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Title: Essentials of Diseases of the Skin - Including the Syphilodermata Arranged in the Form of Questions and Answers Prepared Especially for Students of Medicine
Author: Stelwagon, Henry Weightman, 1853-1919
Language: English
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ESSENTIALS OF DISEASES OF THE SKIN

Including the Syphilodermata

Arranged in the Form of Questions and Answers Prepared Especially
for Students of Medicine

by

HENRY W. STELWAGON, M.D., PH.D.

        *       *       *       *       *

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                              DORLAND'S

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              W. B. SAUNDERS COMPANY, 925 Walnut St., Phila.
               London: 9, Henrietta Street, Covent Garden

        *       *       *       *       *


ESSENTIALS OF DISEASES OF THE SKIN.

   Since the issue of the first volume of the
   #Saunders Question-Compends#,

   OVER 290,000 COPIES

   of these unrivalled publications have been sold.
   This enormous sale is indisputable evidence of
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   physicians.


Saunders' Question-Compends. No. 11.

ESSENTIALS OF DISEASES OF THE SKIN

Including the Syphilodermata

Arranged in the Form of Questions and Answers Prepared Especially
for Students of Medicine

by

HENRY W. STELWAGON, M.D., PH.D.

Professor of Dermatology in the Jefferson Medical College, Philadelphia;
Dermatologist to the Howard and Philadelphia Hospitals, etc.

Seventh Edition, Thoroughly Revised

Illustrated



Philadelphia and London
W. B. Saunders Company
1909

Set up, electrotyped, printed, 1890. Reprinted July, 1891.
Revised, reprinted, June, 1894. Reprinted March, 1897.
Revised, reprinted, August, 1899. Reprinted
September, 1901, May, 1902, September, 1903.
Revised, reprinted January, 1905.
Reprinted March, 1906. Revised,
reprinted March, 1909.

Printed in America

Press of
W. B. Saunders Company
Philadelphia



PREFACE TO SEVENTH EDITION.


In the present--seventh--edition the subject matter, especially as
regards the practical part, has been gone over carefully and the
necessary corrections and additions made. Nineteen new illustrations
have been added, a few of the old ones being eliminated. It is hoped
that the continued demand for this compend means a widening interest in
the study of diseases of the skin, sufficiently keen as to lead to the
desire for a still greater knowledge.

                                                           H.W.S.


PREFACE TO FIRST EDITION.


Much of the present volume is, in a measure, the outcome of a thorough
revision, remodelling and simplification of the various articles
contributed by the author to Pepper's System of Medicine, Buck's
Reference Handbook of the Medical Sciences, and Keating's Cyclopædia of
the Diseases of Children. Moreover, in the endeavor to present the
subject as tersely and briefly as compatible with clear understanding,
the several standard treatises on diseases of the skin by Tilbury Fox,
Duhring, Hyde, Robinson, Anderson, and Crocker, have been freely
consulted, that of the last-named author suggesting the pictorial
presentation of the "Anatomy of the Skin." The space allotted to each
disease has been based upon relative importance. As to treatment, the
best and approved methods only--those which are founded upon the
aggregate experience of dermatologists--are referred to.

For general information a statistical table from the Transactions of the
American Dermatological Association is appended.

                                                           H.W.S.


CONTENTS.


                                               PAGE
ANATOMY OF THE SKIN                              17
    The Epidermis                                18
    The Blood-vessels                            19
    The Nervous and Vascular Papillæ             20
    The Hair and Hair-follicle                   21

SYMPTOMATOLOGY                                   22
    Primary Lesions                              22
    Secondary Lesions                            23
    Distribution and Configuration               24
  Relative Frequency                             26
  Contagiousness                                 27
  Rapidity of Cure                               27
  Ointment Bases                                 27

CLASS I.--DISORDERS OF THE GLANDS                28
    Hyperidrosis                                 28
    Sudamen                                      30
    Hydrocystoma                                 31
    Anidrosis                                    31
    Bromidrosis                                  32
    Chromidrosis                                 32
    Uridrosis                                    33
    Phosphoridrosis                              33
    Seborrh[oe]a (Eczema Seborrhoicum)           33
    Comedo                                       38
    Milium                                       42
    Steatoma                                     43

CLASS II.--INFLAMMATIONS                         44
  Erythema Simplex                               44
  Erythema Intertrigo                            45
  Erythema Multiforme                            46
  Erythema Nodosum                               50
  Erythema Induratum                             51
  Urticaria                                      52
  Urticaria Pigmentosa                           56
  Dermatitis                                     58
  Dermatitis Medicamentosa                       60
  X-Ray Dermatitis                               63
  Dermatitis Factitia                            64
  Dermatitis Gangrænosa                          65
  Erysipelas                                     66
  Phlegmona Diffusa                              68
  Furunculus                                     68
  Carbunculus                                    70
  Pustula Maligna                                72
  Post-mortem Pustule                            73
  Framb[oe]sia                                   73
  Verruga Peruana                                73
  Equinia                                        74
  Miliaria                                       74
  Pompholyx                                      76
  Herpes Simplex                                 78
  Hydroa Vacciniforme                            80
  Epidermolysis Bullosa                          80
  Dermatitis Repens                              81
  Herpes Zoster                                  81
  Dermatitis Herpetiformis                       83
  Psoriasis                                      86
  Pityriasis Rosea                               95
  Dermatitis Exfoliativa                         96
  Lichen Planus                                  98
  Pityriasis Rubra Pilaris                       99
  Lichen Scrofulosus                            100
  Eczema                                        100
  Prurigo                                       118
  Acne                                          119
  Acne Rosacea                                  126
  Sycosis                                       130
  Dermatitis Papillaris Capillitii              135
  Impetigo Contagiosa                           136
  Impetigo Herpetiformis                        138
  Ecthyma                                       138
  Pemphigus                                     140

CLASS III.--HEMORRHAGES                         144
  Purpura                                       144
  Scorbutus                                     146

CLASS IV.--HYPERTROPHIES                        148
  Lentigo                                       148
  Chloasma                                      149
  Keratosis Pilaris                             151
  Keratosis Follicularis                        153
  Molluscum Epitheliale                         153
  Callositas                                    155
  Clavus                                        156
  Cornu Cutaneum                                158
  Verruca                                       160
  Nævus Pigmentosus                             162
  Ichthyosis                                    165
  Onychauxis                                    167
  Hypertrichosis                                168
  [OE]dema Neonatorum                           170
  Sclerema Neonatorum                           171
  Scleroderma                                   172
  Elephantiasis                                 174
  Dermatolysis                                  176

CLASS V.--ATROPHIES                             177
  Albinismus                                    177
  Vitiligo                                      178
  Canities                                      180
  Alopecia                                      181
  Alopecia Areata                               183
  Atrophia Pilorum Propria                      187
  Atrophia Unguis                               188
  Atrophia Cutis                                189

CLASS VI.--NEW GROWTHS                          191
  Keloid                                        191
  Fibroma                                       192
  Neuroma                                       194
  Xanthoma                                      195
  Myoma                                         196
  Angioma                                       196
  Telangiectasis                                197
  Lymphangioma                                  198
  Rhinoscleroma                                 198
  Lupus Erythematosus                           199
  Lupus Vulgaris                                203
  Tuberculosis Cutis                            209
  Ainhum                                        212
  Mycetoma                                      212
  Perforating Ulcer of the Foot                 213
  Syphilis Cutanea                              213
  Lepra                                         231
  Pellagra                                      235
  Epithelioma                                   236
  Paget's Disease of the Nipple                 240
  Sarcoma                                       241
  Granuloma Fungoides                           242

CLASS VII.--NEUROSES                            244
  Hyperæsthesia                                 244
  Dermatalgia                                   244
  Anæsthesia                                    244
  Pruritus                                      244

CLASS VIII.--PARASITIC AFFECTIONS               247
  Tinea Favosa                                  247
  Tinea Trichophytina                           251
  Tinea Imbricata                               261
  Tinea Versicolor                              262
  Erythrasma                                    265
  Actinomycosis                                 266
  Blastomycetic Dermatitis                      266
  Scabies                                       267
  Pediculosis                                   271
  Pediculosis Capitis                           272
  Pediculosis Corporis                          274
  Pediculosis Pubis                             275
  Cysticercus Cellulosæ                         276
  Filaria Medinensis                            277
  Ixodes                                        277
  Leptus                                        277
  [OE]strus                                     278
  Pulex Penetrans                               278
  Cimex Lectularius                             278
  Culex                                         279
  Pulex Irritans                                279

TABLE showing Relative Frequency of the Various
  Diseases of the Skin                          280



DISEASES OF THE SKIN.

#ANATOMY OF THE SKIN.#


[Illustration: Fig. I.
  Vertical section of the skin--Diagrammatic. (_After Heitsmann._)]



                            #The Epidermis.#


[Illustration: Fig. 2.
  _c_, corneous (horny) layer; _g_, granular layer; _m_, mucous layer
  (rete Malpighii).
  The stratum lucidum is the layer just above the granular layer.
  Nerve terminations--_n_, afferent nerve; _b_, terminal nerve bulbs;
  _l_, cell of Langerhans. (_After Ranvier._)]



                           #The Blood-vessels.#


[Illustration: Fig. 3.
  _C_, epidermis; _D_, corium; _P_, papillæ; _S_, sweat-gland duct.
  _v_, arterial and venous capillaries (superficial, or papillary plexus)
  of the papillæ. Deep plexus is partly shown at lower margin of the
  diagram; _vs_--an intermediate plexus, an outgrowth from the deep
  plexus, supplying sweat-glands, and giving a loop to hair papilla.
  (_After Ranvier._)]



                   #The Nervous and Vascular Papillæ.#


[Illustration: Fig. 4.
  _a_, a vascular papilla; _b_, a nervous papilla; _c_, a blood-vessel;
  _d_, a nerve fibre; _e_, a tactile corpuscle. (_After Biesiadecki._)]



                      #The Hair and Hair-Follicle.#


[Illustration: Fig. 5. _A_, shaft of the hair; _B_, root of the hair;
_C_, cuticle of the hair; _D_, medullary substance of the hair. _E_,
external layer of the hair-follicle; _F_, middle layer of the
hair-follicle; _G_, internal layer of the hair-follicle; _H_, papilla of
the hair; _I_, external root-sheath; _J_, outer layer of the internal
root-sheath; _K_, internal layer of the internal root-sheath. (_After
Duhring._)]



#SYMPTOMATOLOGY.#


The symptoms of cutaneous disease may be objective, subjective or both;
and in some diseases, also, there may be systemic disturbance.


#What do you mean by objective symptoms?#

Those symptoms visible to the eye or touch.


#What do you understand by subjective symptoms?#

Those which relate to sensation, such as itching, tingling, burning,
pain, tenderness, heat, anæsthesia, and hyperæsthesia.


#What do you mean by systemic symptoms?#

Those general symptoms, slight or profound, which are sometimes
associated, primarily or secondarily, with the cutaneous disease, as,
for example, the systemic disturbance in leprosy, pemphigus, and purpura
hemorrhagica.


#Into what two classes of lesions are the objective symptoms commonly
divided?#

    Primary (or elementary), and
    Secondary (or consecutive).



                          #Primary Lesions.#


#What are primary lesions?#

Those objective lesions with which cutaneous diseases begin. They may
continue as such or may undergo modification, passing into the secondary
or consecutive lesions.


#Enumerate the primary lesions.#

Macules, papules, tubercles, wheals, tumors, vesicles, blebs and
pustules.


#What are macules (maculæ)?#

Variously-sized, shaped and tinted spots and discolorations, without
elevation or depression; as, for example, freckles, spots of purpura,
macules of cutaneous syphilis.


#What are papules (papulæ)?#

Small, circumscribed, solid elevations, rarely exceeding the size of a
split-pea, and usually superficially seated; as, for example, the
papules of eczema, of acne, and of cutaneous syphilis.


#What are tubercles (tubercula)?#

Circumscribed, solid elevations, commonly pea-sized and usually
deep-seated; as, for example, the tubercles of syphilis, of leprosy, and
of lupus.


#What are wheals (pomphi)?#

Variously-sized and shaped, whitish, pinkish or reddish elevations, of
an evanescent character; as, for example, the lesions of urticaria, the
lesions produced by the bite of a mosquito or by the sting of a nettle.


#What are tumors (tumores)?#

Soft or firm elevations, usually large and prominent, and having their
seat in the corium and subcutaneous tissue; as, for example, sebaceous
tumors, gummata, and the lesions of fibroma.


#What are vesicles (vesiculæ)?#

Pin-head to pea-sized, circumscribed epidermal elevations, containing
serous fluid; as, for example, the so-called fever-blisters, the lesions
of herpes zoster, and of vesicular eczema.


#What are blebs (bullæ)?#

Rounded or irregularly-shaped, pea to egg-sized epidermic elevations,
with fluid contents; in short, they are essentially the same as vesicles
and pustules except as to size; as, for example, the blebs of pemphigus,
rhus poisoning, and syphilis.


#What are pustules (pustulæ)?#

Circumscribed epidermic elevations containing pus; as, for example, the
pustules of acne, of impetigo, and of sycosis.



                        #Secondary Lesions.#


#What are secondary lesions?#

Those lesions resulting from accidental or natural change, modification
or termination of the primary lesions.


#Enumerate the secondary lesions.#

Scales, crusts, excoriations, fissures, ulcers, scars and stains.


#What are scales (squamæ)?#

Dry, laminated, epidermal exfoliations; as, for example, the scales of
psoriasis, ichthyosis, and eczema.


#What are crusts (crustæ)?#

Dried effete masses of exudation; as, for example, the crusts of
impetigo, of eczema, and of the pustular and ulcerating syphilodermata.


#What are excoriations (excoriationes)?#

Superficial, usually epidermal, linear or punctate loss of tissue; as,
for example, ordinary scratch-marks.


#What are fissures (rhagades)?#

Linear cracks or wounds, involving the epidermis, or epidermis and
corium; as, for example, the cracks which often occur in eczema when
seated about the joints, the cracks of chapped lips and hands.


#What are ulcers (ulcera)?#

Rounded or irregularly-shaped and sized loss of skin and subcutaneous
tissue resulting from disease; as, for example, the ulcers of syphilis
and of cancer.


#What are scars (cicatrices)?#

Connective-tissue new formations replacing loss of substance.


#What are stains?#

Discolorations left by cutaneous disease, which stains may be transitory
or permanent.



                     #Distribution and Configuration.#


#What do you mean by a patch of eruption?#

A single group or aggregation of lesions or an area of disease.


#When is an eruption said to be limited or localized?#

When it is confined to one part or region.


#When is an eruption said to be general or generalized?#

When it is scattered, uniformly or irregularly, over the entire surface.


#When is an eruption universal?#

When the whole integument is involved, without any intervening healthy
skin.


#When is an eruption said to be discrete?#

When the lesions constituting the eruption are isolated, having more or
less intervening normal skin.


#When is an eruption confluent?#

When the lesions constituting the eruption are so closely crowded that a
solid sheet results.


#When is an eruption uniform?#

When the lesions constituting the eruption are all of one type or
character.


#When is an eruption multiform?#

When the lesions constituting the eruption are of two or more types or
characters.


#When are lesions said to be aggregated?#

When they tend to form groups or closely-crowded patches.


#When are lesions disseminated?#

When they are irregularly scattered, with no tendency to form groups or
patches.


#When is a patch of eruption said to be circinate?#

When it presents a rounded form, and usually tending to clear in the
centre; as, for example, a patch of ringworm.


#When is a patch of eruption said to be annular?#

When it is ring-shaped, the central portion being clear; as, for
example, in erythema annulare.


#What meaning is conveyed by the term "iris"?#

The patch of eruption is made up of several concentric rings. Difference
of duration of the individual rings, usually slight, tends to give the
patch variegated coloration; as, for example, in erythema iris and
herpes iris.


#What meaning is conveyed by the term "marginate"?#

The sheet of eruption is sharply defined against the healthy skin; as,
for example, in erythema marginatum, eczema marginatum.


#What meaning is conveyed by the qualifying term "circumscribed"?#

The term is applied to small, usually more or less rounded, patches,
when sharply defined; as, for example, the typical patches of psoriasis.


#When is the qualifying term "gyrate" employed?#

When the patches arrange themselves in an irregular winding or
festoon-like manner; as, for instance, in some cases of psoriasis. It
results, usually, from the coalescence of several rings, the eruption
disappearing at the points of contact.


#When is an eruption said to be serpiginous?#

When the eruption spreads at the border, clearing up at the older part;
as, for instance, in the serpiginous syphiloderm.



                         #RELATIVE FREQUENCY.#


#Name the more common cutaneous diseases and state approximately their
frequency.#

Eczema, 30.4%; syphilis cutanea, 11.2%; acne, 7.3%; pediculosis, 4%;
psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies, 2.6%;
urticaria, 2.5%; pruritus, 2.1%; seborrh[oe]a, 2.1%; herpes simplex,
1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%; verruca, 1.1%;
tinea versicolor, 1%. Total: eighteen diseases, representing 81 per
cent. of all cases met with.

(These percentages are based upon statistics, public and private, of the
American Dermatological Association, covering a period of ten years. In
private practice the proportion of cases of pediculosis, scabies, favus,
and impetigo is much smaller, while acne, acne rosacea, seborrh[oe]a,
epithelioma, and lupus are relatively more frequent.)



                           #CONTAGIOUSNESS.#


#Name the more actively contagious skin diseases.#

Impetigo contagiosa, ringworm, favus, scabies and pediculosis; excluding
the exanthemata, erysipelas, syphilis and certain rare and doubtful
diseases.

[At the present time when most diseases are presumed to be due to
bacteria or parasites the belief in contagiousness, under certain
conditions, has considerably broadened.]



                          #RAPIDITY OF CURE.#


#Is the rapid cure of a skin disease fraught with any danger to the
patient?#

No. It was formerly so considered, especially by the public and general
profession, and the impression still holds to some extent, but it is not
in accord with dermatological experience.



                           #OINTMENT BASES.#


#Name the several fats in common use for ointment bases.#

Lard, petrolatum (or cosmoline or vaseline), cold cream and lanolin.


#State the relative advantages of these several bases.#

_Lard_ is the best all-around base, possessing penetrating properties
scarcely exceeded by any other fat.

_Petrolatum_ is also valuable, having little, if any, tendency to
change; it is useful as a protective, but is lacking in its power of
penetration.

_Cold Cream_ (ungt. aquæ rosæ) is soothing and cooling, and may often be
used when other fatty applications disagree.

_Lanolin_ is said to surpass in its power of penetration all other
bases, but this is not borne out by experience. It is an unsatisfactory
base when used alone. It should be mixed with another base in about the
proportion of 25% to 50%.

These several bases may, and often with advantage, be variously
combined.


#What is to be added to these several bases if a stiffer ointment is
required?#

Simple cerate, wax, spermaceti, or suet; or in some instances, a
pulverulent substance, such as starch, boric acid, and zinc oxide.



#CLASS I.--DISORDERS OF THE GLANDS.#


                           #Hyperidrosis.#


[Illustration: Fig. 6.
  A normal sweat-gland, highly magnified. (_After Neumann._)
  _a_, Sweat-coil: _b_, sweat-duct; _c_, lumen of duct; _d_,
  connective-tissue capsule; _e_ and _f_, arterial trunk and
  capillaries.]


#What is hyperidrosis?#

Hyperidrosis is a functional disturbance of the sweat-glands,
characterized by an increased production of sweat. This increase may be
slight or excessive, local or general.


#As a local affection, what parts are most commonly involved?#

The hands, feet, especially the palmar and plantar surfaces, the axillæ
and the genitalia.


#Describe the symptoms of the local forms of hyperidrosis.#

The essential, and frequently the sole symptom, is more or less profuse
sweating.

If the hands are the parts involved, they are noted to be wet, clammy
and sometimes cold.

If involving the soles, the skin often becomes more or less macerated
and sodden in appearance, and as a result of this maceration and
continued irritation they may become inflamed, especially about the
borders of the affected parts, and present a pinkish or pinkish-red
color, having a violaceous tinge. The sweat undergoes change and becomes
offensive.


#Is hyperidrosis acute or chronic?#

Usually chronic, although it may also occur as an acute affection.


#What is the etiology of hyperidrosis?#

Debility is commonly the cause in general hyperidrosis; the local forms
are probably neurotic in origin.


#What is the prognosis?#

The disease is usually persistent and often rebellious to treatment; in
many instances a permanent cure is possible, in others palliation.
Relapses are not uncommon.


#What systemic remedies are employed in hyperidrosis?#

Ergot, belladonna, gallic acid, mineral acids, and tonics.
Constitutional treatment is rarely of benefit in the local forms of
hyperidrosis, and external applications are seldom of service in general
hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is also
well spoken of, combined, if necessary, with an astringent.


#What external remedies are employed in the local forms?#

Astringent lotions of zinc sulphate, tannin and alum, applied several
times daily, with or without the supplementary use of dusting-powders.
Weak solutions of formaldehyde, one to one hundred, are sometimes of
value.

Dusting-powders of boric acid and zinc oxide, to which may be added from
ten to thirty grains of salicylic acid to the ounce, to be used freely
and often:--

  [Rx] Pulv. ac. salicylici ................. gr. x-xxx.
       Pulv. ac. borici ..................... [dram]v.
       Pulv. zinci oxidi .................... [dram]iij     M.

Diachylon ointment, and an ointment containing a drachm of tannin to the
ounce; more especially applicable in hyperidrosis of the feet. The parts
are first thoroughly washed, rubbed dry with towels and dusting-powder,
and the ointment applied on strips of muslin or lint and bound on; the
dressing is renewed twice daily, the parts each time being rubbed dry
with soft towels and dusting-powder, and the treatment continued for ten
days to two weeks, after which the dusting-powder is to be used alone
for several weeks. No water is to be used after the first washing until
the ointment is discontinued. One such course will occasionally suffice,
but not infrequently a repetition is necessary.

Faradization and galvanization are sometimes serviceable. Repeated mild
exposures to the Röntgen rays have a favorable influence in some
instances.



                              #Sudamen.#
                 (_Synonym:_ Miliaria crystallina.)


#What is sudamen?#

Sudamen is a non-inflammatory disorder of the sweat-glands,
characterized by pin-point to pin-head-sized, discrete but thickly-set,
superficial, translucent whitish vesicles.


#Describe the clinical characters.#

The lesions develop rapidly and in great numbers, either irregularly or
in crops, and are usually to be seen as discrete, closely-crowded,
whitish, or pearl-colored minute elevations, occurring most abundantly
upon the trunk. In appearance they resemble minute dew-drops. They are
non-inflammatory, without areola, never become purulent, and evince no
tendency to rupture, the fluid disappearing by absorption, and the
epidermal covering by desquamation.


#Give the course and duration of sudamen.#

New crops may appear as the older lesions are disappearing, and the
affection persist for some time, or, on the other hand, the whole
process may come to an end in several days or a week. In short, the
course and duration depend upon the subsidence or persistence of the
cause.


#What is the anatomical seat of sudamen?#

The lesions are formed between the lamellæ of the corneous layer,
usually the upper part; and are thought to be due to some change in the
character of the epithelial cells of this layer, probably from high
temperature, giving rise to a blocking up of the surface outlet.


#What is the cause of sudamen?#

Debility, especially when associated with high fever. The eruption is
often seen in the course of typhus, typhoid and rheumatic fevers.


#How would you treat sudamen?#

By constitutional remedies directed against the predisposing factor or
factors, and the application of cooling lotions of vinegar or alcohol
and water, or dusting-powders of starch and lycopodium.



                            #Hydrocystoma.#


#Describe hydrocystoma.#

Hydrocystoma is a cystic affection of the sweat-gland ducts, seated upon
the face. The lesions may be present in scant numbers or in more or less
profusion. They have the appearance of boiled sago grains imbedded in
the skin; the larger lesions may have a bluish color, especially about
the periphery. It is not common, and is usually seen in washerwomen and
laundresses, or those exposed to moist heat. In some cases it tends to
disappear during the winter months. There are no subjective symptoms.

Treatment consists of puncturing the lesions and application of
dusting-powder. Avoidance of the exciting cause (moist heat) is
important.



                             #Anidrosis.#


#Describe anidrosis.#

It is the opposite condition of hyperidrosis, and is characterized by
diminution or suppression of the sweat secretion. It occurs to some
extent in certain systemic diseases and also in some affections of the
skin, such as ichthyosis; nerve-injuries may give rise to localized
sweat-suppression.

Treatment is based upon general principles; friction, warm and hot-vapor
baths, electricity and similar measures are of service.



                             #Bromidrosis.#
                        (_Synonym:_ Osmidrosis.)


#Describe bromidrosis.#

Bromidrosis is a functional disturbance of the sweat-glands
characterized by a sweat secretion of an offensive odor. The sweat
production may be normal in quantity or more or less excessive, usually
the latter. The condition may be local or general, commonly the former.
It is closely allied to hyperidrosis, and may often be considered
identical, the odor resulting from rapid decomposition of the sweat
secretion. The decomposition and resulting odor have been thought due to
the presence of bacteria.


#What parts are most commonly affected in bromidrosis?#

The feet and the axillæ.


#What is the treatment of bromidrosis?#

It is essentially the same as that of hyperidrosis (_q. v._), consisting
of applications of astringent lotions, dusting-powders, especially those
containing boric acid and salicylic acid, and the continuous application
of diachylon ointment. In obstinate cases weak formaldehyde solutions,
Röntgen rays, and high-frequency currents can be tried.



                              #Chromidrosis.#


#Describe chromidrosis.#

This is a functional disorder of the sweat-glands characterized by a
secretion variously colored, and usually increased in quantity. It is,
as a rule, limited to a circumscribed area. The most common color is
red. The condition is probably of neurotic origin and tends to recur.
(True chromidrosis is extremely rare; most of the cases formerly thought
to be such are now known to be examples of pseudochromidrosis.)

Treatment should be invigorating and tonic, with special reference
toward the nervous system. The various methods of local electrization
should also be resorted to.

Mild antiseptic and astringent lotions or dusting powders should also be
advised.

_Red chromidrosis_ or _Pseudochromidrosis_ is a condition in which the
coloring of the sweat occurs after its excretion and is due to the
presence of chromatogenous bacteria which are found attached to the
hairs of the part in agglutinated masses. The axilla is the favorite
site. Treatment consists of frequent soap-and-water washings, and the
application of boric acid, resorcin, and corrosive sublimate lotions.



                              #Uridrosis.#


#Describe uridrosis.#

Uridrosis is a rare condition in which the sweat secretion contains the
elements of the urine, especially urea. In marked cases the salt may be
noticeable upon the skin as a colorless or whitish crystalline deposit.
In most instances it has been preceded or accompanied by partial or
complete suppression of the renal functions.



                            #Phosphoridrosis.#


#Describe phosphoridrosis.#

Phosphoridrosis is a rare condition, in which the sweat is
phosphorescent. It has been observed in the later stages of phthisis, in
miliaria, and in those who have eaten of putrid fish.



                   #Seborrh[oe]a (Eczema Seborrhoicum).#
 _Synonyms:_ (Steatorrh[oe]a; Acne sebacea; Ichthyosis sebacea; Dandruff.)


#What is seborrh[oe]a?#

Seborrh[oe]a is a disease of the sebaceous glands, characterized by an
excessive and abnormal secretion of sebaceous matter, appearing on the
skin as an oily coating, crusts, or scales.

In many cases the sweat-glands are likewise implicated, and the process
may also be distinctly, although usually mildly, inflammatory.


#At what age is seborrh[oe]a usually observed?#

Between fifteen and forty. It may, however, occur at any age.


#Name the parts most commonly affected.#

The scalp, face, and (less frequently) the sternal and interscapular
regions of the trunk. It is sometimes seen on other parts.


#What varieties of seborrh[oe]a are encountered?#

Seborrh[oe]a oleosa and seborrh[oe]a sicca; not infrequently the disease
is of a mixed type.


#What are the symptoms of seborrh[oe]a oleosa?#

The sole symptom is an unnatural oiliness, variable as to degree. Its
most common sites are the regions of the scalp, nose, and forehead. In
many instances mild rosacea coexists with oily seborrh[oe]a of the nose.


#Give the symptoms of seborrh[oe]a sicca.#

A variable degree of greasy scalines, which may be seated upon a pale,
hyperæmic or mildly inflammatory surface.

The parts affected are covered scantily or more or less abundantly with
somewhat greasy, grayish, or brownish-gray scales. If upon the scalp
(_dandruff_, _pityriasis capitis_), small particles of scales are found
scattered through the hair, and when the latter is brushed or combed,
fall over the shoulders. If upon the face, in addition to the scaliness,
the sebaceous ducts are usually seen to be enlarged and filled with
sebaceous matter.


#Describe the symptoms of the ordinary or mixed type.#

It is common upon the scalp. The skin is covered with irregularly
diffused, greasy, grayish or brownish scales and crusts, in some cases
moderate in quantity, in others so great that large irregular masses are
formed, pasting the hair to the scalp. If removed, the scales and crusts
rapidly re-form. The skin beneath is found slate-colored, hyperæmic or
mildly inflammatory, and exceptionally it has in places an eczematous
aspect (_eczema seborrhoicum_). Extraneous matter, such as dust and
dirt, collects upon the parts, and the whole mass may become more or
less offensive. There is a strong tendency to falling-out of the hair.
Itching may or may not be present.

[Illustration: Seborrh[oe]a (Eczema Seborrhoicum).]


#Describe the symptoms of seborrh[oe]a of the trunk and other parts.#

[Illustration: Fig. 7.
  A normal sebaceous gland in connection with a lanugo hair.
  (_After Neumann._)
  _a_, Capsule; _b_, fatty secretion; _c_, _h_, secreting cells; _d_, root
  of lanugo hair; _e_, hair-sac; _f_, hair-shaft; _g_, acini of sebaceous
  gland.]

Seborrh[oe]a corporis differs in a measure, in its symptoms, from
seborrh[oe]a of the scalp and is usually illustrative of the variety
known as eczema seborrhoicum; it occurs as one or several irregular or
circinate, slightly hyperæmic or moderately inflammatory patches,
covered with dirty or grayish-looking greasy scales or crusts, usually
moderate in quantity, and upon removal are found to have projections
into the sebaceous ducts. It is commonly seen upon the sternal and
interscapular regions. It rarely exists independently in these regions,
being usually associated with and following the disease on the scalp. It
may also invade the axillæ, genitocrural, and other regions.


#What is the usual course of seborrh[oe]a?#

Essentially chronic, the disease varying in intensity from time to time.
In occasional instances it disappears spontaneously.


#Give the cause or causes of seborrh[oe]a.#

General debility, anæmia, chlorosis, dyspepsia, and similar conditions
are to be variously looked upon as predisposing.

In some instances, however, the disease seems to be purely local in
character, and to be entirely independent of any constitutional or
predisposing condition. The view recently advanced that the disease is
of parasitic nature and contagious has been steadily gaining ground.


#What is the pathology of seborrh[oe]a?#

Seborrh[oe]a is a disease of the sebaceous glands, and probably often
involving the sweat-glands also; its products, as found upon the skin,
consisting of the sebaceous secretion, epithelial cells from the glands
and ducts, and more or less extraneous matter. Not infrequently
evidences of superficial inflammatory action are also to be found, and
it is especially for this type that the name eczema seborrhoicum is most
appropriate. In long-continued and neglected cases slight atrophy of the
gland-structures may occur.


#With what diseases are you likely to confound seborrh[oe]a?#

Upon the scalp, with eczema and psoriasis; upon the face, with lupus
erythematosus and eczema; and upon the trunk, with psoriasis and
ringworm.

As a rule, the clinical features of seborrh[oe]a are sufficiently
characteristic to prevent error.


#What are the differential points?#

Eczema, psoriasis, and lupus erythematosus are diseases in which there
are distinct _inflammatory symptoms_, such as thickening and
infiltration and redness; moreover, psoriasis, and this holds true as to
ringworm also, occurs in sharply-defined, circumscribed patches, and
lupus erythematosus has a peculiar violaceous tint and an elevated and
marginate border. A microscopic examination of the epidermic scrapings
would be of crucial value in differentiating from ringworm.

Quite frequently, especially in the interscapular and sternal regions,
the segmental configuration constitutes an important feature of
seborrh[oe]a--of the eczema seborrhoicum variety.


#What is the prognosis in seborrh[oe]a?#

Favorable. All types are curable, and when upon the non-hairy regions,
usually readily so; upon the scalp it is often obstinate. Relapses are
not uncommon.

In those cases of seborrh[oe]a capitis which have been long-continued or
neglected, and attended with loss of hair, this loss may be more or less
permanent, although ordinarily much can be done to promote a regrowth
(see _Treatment of Alopecia_).


#How would you treat seborrh[oe]a of the scalp?#

By constitutional (if indicated) and local remedies; the former having
in view correction or modification of the predisposing factor or
factors, and the latter removal of the sebaceous accumulations and the
application of mildly stimulating antiseptic ointments or lotions.


#What constitutional remedies are commonly employed?#

The various tonics, such as iron, quinine, strychnia, cod-liver oil,
arsenic, the vegetable bitters, laxatives, malt and similar
preparations. The line of treatment is to be based upon indications.


#How do you free the scalp of the sebaceous accumulations?#

In mild types of the disease shampooing with simple Castile soap (or any
other good toilet soap) and hot water will suffice; in those cases in
which there is considerable scale-and crust-formation the tincture of
green soap (tinct. saponis viridis) is to be employed in place of the
toilet soap, and in some of these latter cases it may be necessary to
soften the crusts with a previous soaking with olive oil.

The frequency of the shampoo depends upon the conditions. In mild cases
once in five or ten days will be sufficiently frequent to keep the parts
clean, but in those cases in which there is rapid scale-or
crust-production once daily or every second day may at first be
demanded.


#Name the most effectual applications in seborrh[oe]a capitis.#

Sulphur, ammoniated mercury, salicylic acid, resorcin, and carbolic
acid.

Sulphur is used in the form of an ointment, from twenty grains to one
drachm in the ounce. Ammoniated mercury, in the form of an ointment, ten
to sixty grains to the ounce. Salicylic acid, either alone as an
ointment, ten to thirty grains to the ounce; or it may often be added
with advantage, in the same proportion, to the sulphur or ammoniated
mercury ointment above named. Resorcin, either as an ointment, ten to
thirty grains to the ounce, or as an alcoholic or aqueous lotion, as the
following:--

  [Rx] Resorcini ............................ [dram]j-[dram]iss.
       Ol. ricini ........................... [minim]xxx-f[dram]ij.
       Alcoholis ............................ f[Oz]iv.                M.

Carbolic acid, to the amount of ten to thirty grains, can be added to
this. If an aqueous lotion is desirable, then in the above formula the
oleum ricini is replaced with glycerine, and the alcohol with water;
three to five minims of glycerine in each ounce is usually sufficient,
as a greater quantity makes the resulting lotion sticky. Petrolatum
alone, or with 10 to 30 per cent. lanolin, is usually the most
satisfactory base for the ointments. In some cases of the inflammatory
variety the skin is found quite irritable, and the mildest applications
are at first only admissible.


#How are the remedies to be applied?#

A small quantity of the lotion, ointment, or oil is gently applied to
the skin; when to the scalp, a lotion or oil can be conveniently applied
by means of an eye-dropper. In the beginning of the treatment an
application once or twice daily is ordered; later, as the disease
becomes less active, once every second or third day.


#How is seborrh[oe]a upon other parts to be treated?#

In the same general manner as seborrh[oe]a of the scalp, except that the
local applications must be somewhat weaker. The several sulphur lotions
employed in the treatment of acne (_q. v._) may also be used when the
disease is upon these parts. In obstinate patchy cases occasional
paintings with a 20 to 50 per cent alcoholic solution of resorcin is
curative; following the painting a mild salve should be used.



                               #Comedo.#
                 (_Synonyms:_ Blackheads; Flesh-worms.)


#What is comedo?#

Comedo is a disorder of the sebaceous glands, characterized by yellowish
or blackish pin-point or pin-head-sized puncta or elevations
corresponding to the gland-orifices.


#At what age and upon what parts are comedones found?#

Usually between fifteen and thirty, and upon the face and upper part of
the trunk, where they may exist sparsely or in great numbers. They are
occasionally associated with oily seborrh[oe]a, the parts presenting a
greasy or soiled appearance.

Exceptionally they occur as distinct, and usually symmetrical, groups
upon the forehead or the cheeks. On the upper trunk so-called double and
multiple comedo have been noted--the two, three, or even four
closely-contiguous blackheads are, beneath the surface,
intercommunicable, the dividing duct-walls having apparently disappeared
by fusion.


#Describe an individual lesion.#

It is pin-point to pin-head in size, dark yellowish, and usually with a
central blackish point (hence the name _blackheads_). There is scarcely
perceptible elevation, unless the amount of retained secretion is
excessive. Upon pressure this may be ejected, the small, rounded orifice
through which it is expressed giving it a thread-like shape (hence the
name _flesh-worms_).


#What is the usual course of comedo?#

Chronic. The lesions may persist indefinitely or the condition may be
somewhat variable. In many instances, either as a result of pressure or
in consequence of chemical change in the sebaceous plugs or of the
addition of a microbic factor, inflammation is excited and acne results.
The two conditions are, in fact, usually associated.

[Illustration: Fig. 8.
  Demodex Folliculorum, X 300. Ventral surface. (_After Simon._)]


#To what may comedo often be ascribed?#

To disorders of digestion, constipation, chlorosis, menstrual
disturbance, lack of tone in the muscular fibres of the skin, the
infrequent use of soap, and working in a dirty or dusty atmosphere.

A small parasite (_demodex folliculorum_, _acarus folliculorum_) is
sometimes found in the sebaceous mass, but its presence is without
etiological significance, as it is also found in healthy follicles. A
microbacillus has been found by several observers, and credited with
etiological influence.


#What is the pathology of comedo?#

The sebaceous ducts or glands, or both, become blocked up with retained
secretion and epithelial cells. The dark points which usually mark the
lesions are probably due to accumulation of dirt, but may, as some
writers maintain, be due to the presence of pigment-granules resulting
from chemical change in the sebaceous matter.


#Is there any difficulty in the diagnosis of comedo?#

No. It can scarcely be confounded with milium, as in this latter disease
the lesion has no open outlet, no black point, and the contents cannot
be squeezed out.


#Give the prognosis of comedo.#

The result of treatment is usually favorable, although the disease is
often rebellious. Relapses are not uncommon.


#How would you treat a case of comedo?#

By systemic (if indicated) and local measures.

The constitutional treatment aims at correction or palliation of the
predisposing conditions, and the external applications have in view a
removal of the sebaceous plugs and stimulation of the glands and skin to
healthy action.

[Illustration: Fig. 9. Comedo Extractor.]


#Name the systemic remedies commonly employed.#

Cod-liver oil, iron, quinine, arsenic, nux vomica and other tonics;
ergot in those cases in which there is lack of muscular tone, salines
and aperient pills in constipation. The digestion is to be looked after
and the bowels kept regular; indigestible food of all kinds is to be
interdicted. Hygienic measures, such as general and local bathing, local
massage, calisthenics, and open-air exercise, are of service.


#Describe the local treatment.#

Steaming the face or prolonged applications of hot water; washing with
ordinary toilet soap and hot water, or, in sluggish cases, using
tincture of green soap (tinct. saponis viridis) instead of the toilet
soap; removal of the sebaceous plugs by mechanical means, such as
lateral pressure with the finger ends or perpendicular pressure with a
watch-key with rounded edges, or with an instrument specially contrived
for this purpose; and after these preliminary measures, which should be
carried out every night, a stimulating sulphur ointment or lotion, such
as employed in the treatment of acne (_q. v._), is to be thoroughly
applied. The following is valuable:--

  [Rx] Zinci sulphatis,
       Potassi sulphureti, . [=a][=a] ....... [dram]j-[dram]iv.
       Alcoholi ............................. f[Oz]ss.
       Aquæ, ................. q.s. ad ...... f[Oz]iv.            M.

Should slight scaliness or a mild degree of irritation of the skin be
brought about, active external treatment is to be discontinued for a few
days and soothing applications made. Resorcin, in lotion, 3 to 25 per
cent strength, is through the exfoliation it provokes, frequently of
value; the resorcin paste referred to in acne can also be used for this
purpose.

Moderately strong applications of the Faradic current, repeated once or
twice weekly, are sometimes of service; also weak to moderately strong
applications of the continuous and high-frequency currents. Röntgen-ray
treatment can also be resorted to in extremely obstinate cases.

In occasional instances sulphur preparations not only fail to do good,
but materially aggravate the condition. In such cases, if resorcin
preparations also fail, the mercurial lotion and ointment employed in
acne may be prescribed. Mercurial and sulphur applications should not be
used, it need scarcely be said, within a week or ten days of each other,
otherwise an increase in the comedones and a slight darkening of the
skin result from the formation of the black sulphuret of mercury.



                             #Milium.#
             (_Synonyms:_ Grutum; Strophulus Albidus.)


#What is milium?#

Milium consists in the formation of small, whitish or yellowish,
rounded, pearly, non-inflammatory elevations situated in the upper part
of the corium.


#Describe the clinical appearances.#

The lesions are usually pin-head in size, whitish or yellowish,
seemingly more or less translucent, rounded or acuminated, without
aperture or duct, are superficially seated in the skin, and project
slightly above the surface.

They appear about the face, especially about the eyelids; they may occur
also, although rarely, upon other parts. But one or several may be
present, or they may exist in numbers.


#What is the course of milium?#

The lesions develop slowly, and may then remain stationary for years.
Their presence gives rise to no disturbance, and, unless they are large
in size or exist in numbers, causes but slight disfigurement.

[Illustration: Fig. 10. Milium Needle.]

In rare instances they may undergo calcareous metamorphosis,
constituting the so-called _cutaneous calculi_.


#What is the anatomical seat of milium?#

The sebaceous gland (probably one or several of the
superficially-situated acini), the duct of which is in some manner
obliterated, the sebaceous matter collects, becomes inspissated and
calcareous, forming the pin-head lesion. The epidermis is the external
covering.


#What is the treatment?#

The usual plan is to prick or incise each lesion and press out the
contents. In some milia it may be necessary also, in order to prevent a
return, to touch the base of the excavation with tincture of iodine or
with silver nitrate. Electrolysis is also effectual. In those cases
where the lesions are numerous the production of exfoliation of the
epiderm by means of resorcin applications (see acne) is a good plan.



                             #Steatoma.#
          (_Synonyms:_ Sebaceous Cyst; Sebaceous Tumor; Wen.)


#Describe steatoma.#

Steatoma, or sebaceous cyst, appears as a variously-sized, elevated,
rounded or semi-globular, soft or firm tumor, freely movable and
painless, and having its seat in the corium or subcutaneous tissue. The
overlying skin is normal in color, or it may be whitish or pale from
distention; in some a gland-duct orifice may be seen, but, as a rule,
this is absent.


#What are the favorite regions for the development of steatoma?#

The scalp, face and back. One or several may be present.


#What is the course of sebaceous cysts?#

Their growth is slow, and, after attaining a variable size, may remain
stationary. They may exist indefinitely without causing any
inconvenience beyond the disfigurement. Exceptionally, in enormously
distended growths, suppuration and ulceration result.


#What is the pathology?#

A steatoma is a cyst of the sebaceous gland and duct, produced by
retained secretion. The contents may be hard and friable, soft and
cheesy, or even fluid, of a grayish, whitish or yellowish color, and
with or without a fetid odor; the mass consisting of fat-drops,
epidermic cells, cholesterin, and sometimes hairs.


#Are sebaceous cysts likely to be confounded with gummata?#

No. Gummata grow more rapidly, are usually painful to the touch, are not
freely movable, and tend to break down and ulcerate.


#Describe the treatment of steatoma.#

A linear incision is made, and the mass and enveloping sac dissected
out. If the sac is permitted to remain, reproduction almost invariably
takes place.



#CLASS II.--INFLAMMATIONS.#


                           #Erythema Simplex.#


#What do you understand by erythema simplex?#

Erythema simplex is a hyperæmic disorder characterized by redness,
occurring in the form of variously-sized and shaped, diffused or
circumscribed, non-elevated patches.


#Name the two general classes into which the simple erythemata are
divided.#

Idiopathic and symptomatic.


#What do you include in the idiopathic class?#

Those erythemas due to external causes, such as cold and heat (_erythema
caloricum_), the action of the sun (_erythema solare_), traumatism
(_erythema traumaticum_), and the various poisons or chemical irritants
(_erythema venenatum_).


#What do you include in the symptomatic class?#

Those rashes often preceding or accompanying certain of the systemic
diseases, and those due to disorders of the digestive tract, stomachic
and intestinal toxins, to the ingestion of certain drugs, and to use of
the therapeutic serums.


#Describe the symptoms of erythema simplex.#

The essential symptom is redness--simple hyperæmia--without elevation or
infiltration, disappearing under pressure, and sometimes attended by
slight heat or burning; it may be patchy or diffused. In the idiopathic
class, if the cause is continued, dermatitis may result.


#What is to be said about the distribution of the simple erythemata?#

The idiopathic rashes, as inferred from the nature of the causes, are
usually limited.

The symptomatic erythemas are more or less generalized; desquamation
sometimes follows.


#Describe the treatment of the simple erythemata.#

A removal of the cause in idiopathic rashes is all that is needed, the
erythema sooner or later subsiding. The same may be stated of the
symptomatic erythemata, but in these there is at times difficulty in
recognizing the etiological factor; constitutional treatment, if
necessary, is to be based upon general principles. Intestinal
antiseptics are useful in some instances.

Local treatment, which is rarely needed, consists of the use of
dusting-powders or mild cooling and astringent lotions, such as are
employed in the treatment of acute eczema (q. v.).



                        #Erythema Intertrigo.#
                         (_Synonym:_ Chafing.)


#What do you understand by erythema intertrigo?#

Erythema intertrigo is a hyperæmic disorder occurring on parts where the
natural folds of the skin come in contact, and is characterized by
redness, to which may be added an abraded surface and maceration of the
epidermis.


#Describe the symptoms of erythema intertrigo.#

The skin of the involved region gradually becomes hyperæmic, but is
without elevation or infiltration; a feeling of heat and soreness is
usually experienced. If the condition continue, the increased
perspiration and moisture of the parts give rise to maceration of the
epidermis and a mucoid discharge; actual inflammation may eventually
result.


#What is the course of erythema intertrigo?#

The affection may pass away in a few days or persist several weeks, the
duration depending, in a great measure, upon the cause.


#Mention the causes of erythema intertrigo.#

The causes are usually local. It is seen chiefly in children, especially
in fat subjects, in whom friction and moisture of contiguous parts of
the body, usually the region of the neck, buttocks and genitalia, are
more common; in such, uncleanliness or the too free use of soap washings
will often act as the exciting factor. Disorders of the stomach or
intestinal canal apparently have a predisposing influence.


#What treatment would you advise in erythema intertrigo?#

The folds or parts are to be kept from contact by means of lint or
absorbent cotton; thin, flat bags of cheese cloth or similar material
partly filled with dusting-powder, and kept clean by frequent changes,
are excellent for this purpose, and usually curative. Cleanliness is
essential, but it is to be kept within the bounds of common sense.
Dusting-powders and cooling and astringent lotions, such as are employed
in the treatment of acute eczema (_q. v._), can also be advised. The
following lotion is valuable:--

  [Rx] Pulv. calaminæ,
       Pulv. zinci oxidi, .. [=a][=a] ...... [dram]iss.
       Glycerinæ, .......................... [minum]xxx
       Alcoholis, .......................... f[dram]ij
       Aquæ, ............................... Oss.   M.

Exceptionally a mild ointment, alone or supplementary to a lotion, acts
more satisfactorily.

In persistent or obstinate cases attention should also be directed to
the state of the general health, especially as regards the digestive
tract.



                          #Erythema Multiforme.#


#What is erythema multiforme?#

Erythema multiforme is an acute, inflammatory disease, characterized by
reddish, more or less variegated macules, papules, and tubercles,
occurring as discrete lesions or in patches of various size and shape.


#Upon what parts of the body does the eruption appear?#

Usually upon the extremities, especially the dorsal aspect, from the
knees and elbows down, and about the face and neck; it may, however, be
more or less general.


#Describe the symptoms of erythema multiforme.#

With or without precursory symptoms of malaise, gastric uneasiness or
rheumatic pains, the eruption suddenly makes its appearance, assuming an
erythematous, papular, tubercular or mixed character; as a rule, one
type of lesion predominates. The lesions tend to increase in size and
intensity, remain stationary for several days or a week, and then
gradually fade; during this time there may have been outbreaks of new
lesions. In color they are pink, red, or violaceous. Slight itching may
or may not be present. Exceptionally, in general cases, the eruption
partakes of the nature of both urticaria and erythema multiforme, and
itching may be quite a decided symptom. In some instances there is
preceding and accompanying febrile action, usually slight in character;
in others there may be some rheumatic swelling of one or more joints.

[Illustration: Fig. 11.
  Erythema Multiforme, in which many of the lesions have become
  bullous--Erythema Bullosum.]


#What type of the eruption is most common?#

The papular, appearing usually upon the backs of the hands and forearms,
and not infrequently, also, upon the face, legs and feet. The papules
are usually pea-sized, flattened, and of a dark red or violaceous color.


#Describe the various shapes which the erythematous lesions may assume.#

Often the patches are distinctly ring-shaped, with a clear
centre--_erythema annulare_; or they are made up of several concentric
rings, presenting variegated coloring--_erythema iris_; or a more or
less extensive patch may spread with a sharply-defined border, the older
part tending to fade--_erythema marginatum_; or several rings may
coalesce, with a disappearance of the coalescing parts, and serpentine
lines or bands result--_erythema gyratum_.


#Does the eruption of erythema multiforme ever assume a vesicular or
bullous character?#

Yes. In exceptional instances, the inflammatory process may be
sufficiently intense to produce vesiculation, usually at the summits of
the papules--_erythema vesiculosum_; and in some instances, blebs may be
formed--_erythema bullosum_. A vesicular or bullous lesion may become
immediately surrounded by a ring-like vesicle or bleb, and outside of
this another form; a patch may be made up of as many as several such
rings--_herpes iris_. In the vesicular and bullous cases the lips and
the mucous membranes of the mouth and nose also may be the seat of
similar lesions.


#What is the course of erythema multiforme?#

Acute, the symptoms disappearing spontaneously, usually in one to three
or four weeks. In some instances the recurrences take place so rapidly
that the disease assumes a chronic aspect; it is possible that such
cases are midway cases between this disease and dermatitis
herpetiformis.


#Mention the etiological factors in erythema multiforme.#

The causes are obscure. Digestive disturbance, rheumatic conditions, and
the ingestion of certain drugs are at times influential. Intestinal
toxins are doubtless important etiological factors in some cases.
Certain foods, such as are apt to undergo rapid putrefactive or
fermentative change, especially pork meats, oysters, fish, crabs,
lobsters, etc., are, therefore, not infrequently of apparent causative
influence. It is most frequently observed in spring and autumn months,
and in early adult life. The disease is not uncommon.


#What is the pathology of erythema multiforme?#

It is a mildly inflammatory disorder, somewhat similar to urticaria, and
presumably due to vasomotor disturbance; the amount of exudation, which
is variable, determines the character of the lesions.


#Name the diagnostic points of erythema multiforme.#

The multiformity of the eruption, the size of the papules, often its
limitation to certain parts, its course and the entire or comparative
absence of itching.

It resembles urticaria at times, but the lesions of this latter disease
are evanescent, disappearing and reappearing usually in the most
capricious manner, are commonly seated about the trunk, and are
exceedingly itchy.

In the vesicular and bullous types the acute character of the outbreak,
the often segmental and ring-like shape, their frequent origin from
erythematous papules, and the distribution and association with the more
common manifestations, are always suggestive.


#What prognosis would you give in erythema multiforme?#

Always favorable; the eruption usually disappears in ten days to three
weeks, although in rare instances new crops may appear from day to day
or week to week, and the process last one or two months. One or more
recurrences in succeeding years are not uncommon. Those rare cases in
which vesicular or bullous lesions are also seen on the lips and in the
mouth, are more prone to longer duration and to more frequent
recurrences.


#What remedies are commonly prescribed in erythema multiforme?#

Quinin, and, if constipation is present, saline laxatives. Calcined
magnesia is valuable as a laxative. Intestinal antiseptics, such as
salol, thymol, and sodium salicylate, are valuable in cases probably due
to intestinal toxins. In those exceptional instances in which there may
be associated febrile action and rheumatic swelling of the joints, the
patient should be kept in bed till these symptoms subside. Local
applications are rarely required, but in those exceptional cases in
which itching or burning is present, cooling lotions of alcohol and
water or vinegar and water are to be prescribed. The vesicular and
bullous types demand mild protective applications, such as used in
eczema and pemphigus.



                          #Erythema Nodosum.#
                (_Synonym:_ Dermatitis contusiformis.)


#What is erythema nodosum?#

Erythema nodosum is an inflammatory affection, of an acute type,
characterized by the formation of variously-sized, roundish, more or
less elevated erythematous nodes.


#Is there any special region of predilection for the eruption of erythema
nodosum?#

Yes. The tibial surfaces, to which the eruption is often limited; not
infrequently, however, other parts may be involved, more especially the
arms and forearms.


#Describe the symptoms of erythema nodosum.#

The eruption makes its appearance suddenly, and is usually ushered in
with febrile disturbance, gastric uneasiness, malaise, and rheumatic
pains and swelling about the joints. The lesions vary in size from a
cherry to a hen's egg, are rounded or ovalish, tender and painful, have
a glistening and tense look, and are of a bright red, erysipelatous
color which merges gradually into the sound skin. At first they are
somewhat hard, but later they soften and appear as if about to break
down, but this, however, never occurs, absorption invariably taking
place. In occasional instances they are hemorrhagic. Exceptionally the
lesions of erythema multiforme are also present. Lymphangitis is
sometimes observed. In rare instances symptoms pointing to visceral
involvement, to cerebral invasion, and to heart complications have been
observed.


#Are the lesions in erythema nodosum usually numerous?#

No. As a rule not more than five to twenty nodes are present.


#What is the course of erythema nodosum?#

Acute. The disease terminating usually in one to three weeks. As the
lesions are disappearing they present the various changes of color
observed in an ordinary bruise.


#What is known in regard to the etiology?#

The affection is closely allied to erythema multiforme, and is, indeed,
by some considered a form of that disease. It occurs most frequently in
children and young adults, and usually in the spring and autumn months.
Intestinal toxins are thought responsible in some cases. Digestive
disturbance and rheumatic pain and swellings are often associated with
it. By many the malady is thought to be a specific infection.


#What is the pathology of erythema nodosum?#

The disease is to be viewed as an inflammatory [oe]dema, probably
resulting, in some instances at least, from an inflammation of the
lymphatics or an embolism of the cutaneous vessels.


#What diseases may erythema nodosum resemble?#

Bruises, abscesses, and gummata.


#How are the lesions of erythema nodosum to be distinguished from these
several conditions?#

By the bright red or rosy tint, the apparently violent character of the
process, the number, situation and course of the lesions.


#State the prognosis of erythema nodosum.#

Favorable, recovery usually taking place in ten days to several weeks.


#State the treatment to be advised in erythema nodosum.#

Rest, relative or absolute, depending upon the severity of the case, and
an unstimulating diet; internally intestinal antiseptics, quinin and
saline laxatives, and locally applications of lead-water and laudanum.



                           #Erythema Induratum.#
              (_Synonym:_ Erythema induratum scrofulosorum.)


#What do you understand by erythema induratum?#

A rare disease characterized in the beginning by one or more usually
deep-seated nodules, and, as a rule, seated in the legs, especially the
calf region. The nodules gradually enlarge, the skin becomes reddish,
violaceous or livid in color. Absorption may take place slowly, or the
indurations may break down, resulting in an indolent, rather deep-seated
ulcer, closely resembling a gummatous ulcer. The disease is slow and
persistent, and is commonly met with in girls and young women, usually
of strumous type. It suggests a tuberculous origin.

Treatment consists in administration of cod-liver oil, phosphorus and
other tonics. Rest is of service. Locally antiseptic applications, and
support with roller bandage are to be advised.



                              #Urticaria.#
                   (_Synonyms:_ Hives; Nettlerash.)


#Give a definition of urticaria.#

Urticaria is an inflammatory affection characterized by evanescent
whitish, pinkish or reddish elevations, or wheals, variable as to size
and shape, and attended by itching, stinging or pricking sensations.


#Describe the symptoms of urticaria.#

The eruption, erythematous in character and consisting of isolated pea
or bean-sized elevations or of linear streaks or irregular patches,
limited or more or less general, and usually intensely itchy, makes its
appearance suddenly, with or without symptoms of preceding gastric
derangement. The lesions are soft or firm, reddish or pinkish-white,
with the peripheral portion of a bright red color, and are fugacious in
character, disappearing and reappearing in the most capricious manner.
In many cases simply drawing the finger over the skin will bring out
irregular and linear wheals. In exceptional cases this peculiar property
is so pronounced and constant that at any time letters and other symbols
may be produced at will, even when such subjects are free from the
ordinary urticarial lesions (_urticaria factitia_, _dermatographism_,
_autographism_).

The mucous membrane of the mouth and throat may also be the seat of
wheals and urticarial swellings.


#What is the ordinary course of urticaria?#

Acute. The disease is usually at an end in several hours or days.


#Does urticaria always pursue an acute course?#

No. In exceptional instances the disease is chronic, in the sense that
new lesions continue to appear and disappear irregularly from time to
time for months or several years, the skin rarely being entirely free
(_chronic urticaria_).


[Illustration: Fig. 12.
  Dermatographism. (_After C.N. Davis._)]


#Are subjective symptoms always present in urticaria?#

Yes. Itching is commonly a conspicuous symptom, although at times
pricking, stinging or a feeling of burning constitutes the chief
sensation.


#In what way may the eruption be atypical?#

Exceptionally the wheals, or lesions, are peculiar as to formation, or
another condition or disease may be associated, hence the varieties
known as urticaria papulosa, urticaria hæmorrhagica, urticaria tuberosa,
and urticaria bullosa.


#Describe urticaria papulosa.#

Urticaria papulosa (formerly called _lichen urticatus_) is a variety in
which the lesions are small and papular, developing usually out of the
ordinary wheals. They appear as a rule suddenly, rarely in great
numbers, are scattered, and after a few hours or, more commonly, days
gradually disappear. The itching is intense, and in consequence their
apices are excoriated. Sometimes the papules are capped with a small
vesicle (vesicular urticaria). It is seen more particularly in ill-cared
for and badly-nourished young children.


#Describe urticaria hæmorrhagica.#

Urticaria hæmorrhagica is characterized by lesions similar to ordinary
wheals, except that they are somewhat hemorrhagic, partaking, in fact,
of the nature of both urticaria and purpura.


#Describe urticaria tuberosa.#

In urticaria tuberosa the lesions, instead of being pea- or bean-sized,
as in typical urticaria, are large and node-like (also called _giant
urticaria_).


#What is acute-circumscribed [oe]dema?#

In rare instances there occurs, along with the ordinary lesions of the
disease or as its sole manifestation, sudden and evanescent swelling of
the eyelids, ears, lips, tongue, hands, fingers, or feet (_urticaria
[oe]dematosa_, _acute_ _circumscribed [oe]dema_, _angioneurotic [oe]dema_).
One or several of these parts only may be affected at the one attack; in
recurrences, so usual in this variety, the same or other parts may
exhibit the manifestation.

(These [oe]dematous swellings occurring alone might be looked upon, as
they are by most observers, as an independent affection, but its close
relationship to ordinary urticaria is often evident.)


#Describe urticaria bullosa.#

Urticaria bullosa is a variety in which the inflammatory action has been
sufficiently great to give rise to fluid exudation, the wheals resulting
in the formation of blebs.


#What is the etiology of urticaria?#

Any irritation from disease, functional or organic, of any internal
organ, may give rise to the eruption in those predisposed. Gastric
derangement from indigestible or peculiar articles of food, intestinal
toxins, and the ingestion of certain drugs are often provocative. The
so-called "shell-fish" group of foods play an important etiological part
in some cases. Idiosyncrasy to certain articles of food is also
responsible in occasional instances. Various rheumatic and nervous
disorders are not infrequently associated with it, and are doubtless of
etiological significance. External irritants, also, in predisposed
subjects, are at times responsible.


#What is the pathology of urticaria?#

Anatomically a wheal is seen to be a more or less firm elevation
consisting of a circumscribed or somewhat diffused collection of
semi-fluid material in the upper layers of the skin. The vasomotor
nervous system is probably the main factor in its production; dilatation
following spasm of the vessels results in effusion, and in consequence,
the overfilled vessels of the central portion are emptied by pressure of
the exudation and the central paleness results, while the pressed-back
blood gives rise to the bright red periphery.


#From what diseases is urticaria to be differentiated?#

From erythema simplex, erythema multiforme, erythema nodosum, and
erysipelas.


#Mention the diagnostic points of urticaria.#

The acuteness, character of the lesions, their evanescent nature, the
irregular or general distribution, and the intense itching.


#What is the prognosis in urticaria?#

The acute disease is usually of short duration, disappearing
spontaneously or as the result of treatment, in several hours or days;
it may recur upon exposure to the exciting cause. The prognosis of
chronic urticaria is to be guarded, and will depend upon the ability to
discover and remove or modify the predisposing condition.


#What systemic measures are to be prescribed in acute urticaria?#

Removal of the etiological factor is of first importance. This will be
found in most cases to be gastric disturbance from the ingestion of
improper or indigestible food, and in such cases a saline purgative is
to be given, probably the best for this purpose being the laxative
antacid, magnesia; or if the case is severe and food is still in the
stomach, an emetic, such as mustard or ipecac, will act more promptly.
Alkalies, especially sodium salicylate, and intestinal antiseptics are
useful. Calcium chloride in doses of five to twenty grains should be
tried in obstinate cases. The diet should be, for the time, of a simple
character.


#What systemic measures are to be prescribed in chronic and recurrent
urticaria?#

The cause must be sought for and treatment directed toward its removal
or modification. Treatment will, therefore, depend upon indications. In
obscure cases, quinine, sodium salicylate, arsenic, pilocarpine,
_atropia_, potassium bromide, calcium chloride, and ichthyol are to be
variously tried; general galvanization is at times useful, as is also a
change of scene and climate. A proper dietary and the maintenance of
free action of the bowels, preferably, as a rule, with a saline
laxative, is of great importance in these chronic cases.

In acute circumscribed [oe]dema treatment is essentially that of
urticaria, the diet being given special attention.


#What external applications would you advise for the relief of the
subjective symptoms?#

Cooling lotions of alcohol and water or vinegar and water; lotions of
carbolic acid, one to three drachms to the pint; of thymol, one-fourth
to one drachm to the pint of alcohol and water; of liquor carbonis
detergens, one to three ounces to the pint of water, or the following:--

  [Rx] Acidi carbolici, ..................... [dram]j-[dram]iij
       Acidi borici, ........................ [dram]iv
       Glycerinæ, ........................... f[dram]j
       Alcoholis, ........................... f[Oz]ij
       Aquæ, ................................ f[Oz]xiv. M.

Alkaline baths are also useful, and may advantageously be followed by
dusting-powders of starch and zinc oxide.



                        #Urticaria Pigmentosa.#
                     (_Synonym:_ Xanthelasmoidea.)


#Describe urticaria pigmentosa.#

Urticaria pigmentosa is a rare disease, variously viewed as an unusual
form of urticaria and as an urticaria-like eruption in which there is an
element of new growth in the lesions. It begins usually in infancy or
early childhood and continues for months or years, and is characterized
by slightly, moderately, or intensely itchy, wheal-like elevations,
which are more or less persistent and leave yellowish, orange-colored,
greenish or brownish stains. Exceptionally subjective symptoms are
almost entirely absent. Anatomical studies show that the lesion has in
some respects the structure of an ordinary wheal, with [oe]dema and
pigment deposit in the epidermal portion, and cellular infiltration made
up principally of mast-cells.

[Illustration: Fig. 13.
  Urticaria Pigmentosa.]

The nature of the disease is obscure and treatment unsatisfactory.
Ordinarily as early youth or adult life is reached it spontaneously
disappears. The treatment advised is usually on the same lines as that
of chronic urticaria.



                         #Dermatitis.#


#What is implied by the term dermatitis?#

Dermatitis, or inflammation of the skin, is a term employed to designate
those cases of cutaneous disturbance, usually acute in character, which
are due to the action of irritants.


#Mention some examples of cutaneous disturbance to which this term is
applied.#

The dermatic inflammation due to the action of excessive heat or cold,
to caustics and other chemical irritants, and to the ingestion of
certain drugs.


#What several varieties are commonly described?#

Dermatitis traumatica, dermatitis calorica, dermatitis venenata, and
dermatitis medicamentosa.


#Describe dermatitis traumatica.#

Under this head are included all forms of cutaneous inflammation due to
traumatism. To the dermatologist the most common met with is that
produced by the various animal parasites and from continued scratching;
in such, if the cause has been long-continued and persistent, a variable
degree of inflammatory thickening of the skin and pigmentation result,
the latter not infrequently being more or less permanent. The
inflammation due to tight-fitting garments, bandages, to constant
pressure (as bed-sores), etc., also illustrates this class.


#What is the treatment of dermatitis traumatica?#

Removal of the cause, and, if necessary, the application of soothing
ointments or lotions; in bed-sores, soap plaster, plain or with one to
five per cent. of ichthyol.


#What is dermatitis calorica?#

Cutaneous inflammation, varying from a slight erythematous to a
gangrenous character, produced by excessive heat (_dermatitis
ambustionis_, _burns_) or cold (_dermatitis congelationis_,
_frostbite_).


#Give the treatment of dermatitis calorica.#

In burns, if of a mild degree, the application of sodium bicarbonate, as
a powder or saturated solution, is useful; in the more severe grade, a
two- to five-per-cent. solution will probably be found of greater
advantage. Other soothing applications may also be employed. In recent
years a one-per-cent. solution of picric acid has been commended for the
slighter burns of limited extent. Upon the whole, there is nothing yet
so generally useful and soothing in these cases as the so-called Carron
oil; in some cases more valuable with 1/2 to 1 minim of carbolic acid
added to each ounce.

In frostbite, seen immediately after exposure, the parts are to be
brought gradually back to a normal temperature, at first by rubbing with
snow or applying cold water. Subsequently, in ordinary chilblains,
stimulating applications, such as oil of turpentine, balsam of Peru,
tincture of iodine, ichthyol, and strongly carbolized ointments are of
most benefit. If the frostbite is of a vesicular, pustular, bullous, or
escharotic character, the treatment consists in the application of
soothing remedies, such as are employed in other like inflammatory
conditions.


#What do you understand by dermatitis venenata?#

All inflammatory conditions of the skin due to contact with deleterious
substances such as caustic, chemical irritants, iodoform, etc., are
included under this head, but the most common causes are the rhus
plants--_poison ivy_ (or _poison oak_) and _poison sumach_ (_poison
dogwood_). Mere proximity to these plants will, in some individuals,
provoke cutaneous disturbance (_rhus poisoning_, _ivy poisoning_),
although they may be handled by others with impunity.

Many other plants are also known to produce cutaneous irritation in
certain subjects; among these may be mentioned the nettle, primrose,
cowhage, smartweed, balm of Gilead, oleander, and rue.

The local action of iodoform (_iodoform dermatitis_) in some individuals
is that of a decided irritant, bringing about a dermatitis, which often
spreads much beyond the parts of application, and which in those
eczematously inclined may result in a veritable and persistent eczema.


#Describe the symptoms of rhus poisoning.#

The symptoms appear usually soon after exposure, and consist of an
inflammatory condition of the skin of an eczematous nature, varying in
degree from an erythematous to a bullous character, and with or without
[oe]dema and swelling. As a rule, marked itching and burning are
present. The face, hands, forearms and genitalia are favorite parts,
although it may in many instances involve a greater portion of the whole
surface.


#What is the course of rhus poisoning?#

It runs an acute course, terminating in recovery in one to six weeks. In
those eczematously inclined, however, it may result in a veritable and
persistent form of that disease.


#How would you treat rhus poisoning?#

By soothing and astringent applications, such as are employed in acute
eczema (_q. v._), which are to be used freely. Among the most valuable
are: a lotion of fluid extract of grindelia robusta, one to two drachms
to four ounces of water; lotio nigra, either alone or followed by the
oxide-of-zinc ointment; a saturated solution of boric acid, with a half
to two drachms of carbolic acid to the pint; a lotion of zinc sulphate,
a half to four grains to the ounce; weak alkaline lotions; cold cream,
petrolatum, and oxide-of-zinc ointments.


#How would you treat the dermatitis due to other deleterious substances
of this class?#

By applications of a soothing and protective character, similar to those
used in eczema and burns.



                       #Dermatitis Medicamentosa.#


#What do you understand by dermatitis medicamentosa?#

Under this head are included all eruptions due to the ingestion or
absorption of certain drugs.

In rare instances one dose will have such effect; commonly, however, it
results only after several days' or weeks' continued administration.
With some drugs such effect is the rule, with others it is exceptional,
nor are all individuals equally susceptible.


#How is the eruption produced in dermatitis medicamentosa?#

In some instances it is probably due to the elimination of the drug
through the cutaneous structures; in others, to the action of the
drug upon the nervous system. The view that the drug acts as a toxin or
generates some toxin or irritant material in the blood, to which the
eruptive phenomena may be due, has also been advanced.

[Illustration: Dermatitis medicamentosa.
  Bullous dermatitis from iodide of potassium.]


#What is the character of the eruption in dermatitis medicamentosa?#

It may be erythematous, papular, urticarial, vesicular, pustular or
bullous, and, if the administration of the drug is continued, even
gangrenous.


#Name the more common drugs having such action.#

Antipyrin, arsenic, atropia (or belladonna), bromides, chloral, copaiba,
cubebs, digitalis, iodides, mercury, opium (or morphia), quinine,
salicylic acid, stramonium, acetanilid, sulphonal, phenacetin,
turpentine, many of the new coal-tar derivatives, etc.


#State frequency and types of eruption due to the ingestion of antipyrin.#

Not uncommon. _Erythematous_, morbilliform and erythemato-papular;
itching is usually present and moderate desquamation may follow.
Acetanilid, sulphonal, phenacetin, and other drugs of this class may
provoke like eruptions.


#Mention frequency and types of eruption due to the ingestion of arsenic.#

Rare. Erythematous, erythemato-papular; exceptionally, herpetic, and
pigmentary. Herpes zoster has been thought to follow its use. Keratosis
of the palms and soles has also been occasionally observed, which, in
rare instances, has developed into epithelioma.


#Mention frequency and types of eruption due to the ingestion of atropia
(or belladonna).#

Not uncommon. _Erythematous_ and _scarlatinoid_; usually no febrile
disturbance, and desquamation seldom follows.


#Give frequency and types of cutaneous disturbance following the
administration of the bromides (bromine).#

Common. _Pustular_, sometimes furuncular and carbuncular and
superficially ulcerative. In exceptional instances papillomatous or
vegetating lesions have been observed. Co-administration of arsenic or
potassium bitartrate is thought to have a preventive influence in some
cases.


#State frequency and types of cutaneous disturbance due to the
administration of chloral.#

Occasional. Scarlatinoid and urticarial, and exceptionally purpuric; in
rare instances, if drug is continued, eruption becomes vesicular,
hemorrhagic, ulcerative and even gangrenous.


#State frequency and types of eruption following the administration of
copaiba.#

Not uncommon. _Urticarial_, erythemato-papular and _scarlatinoid_.


#Mention frequency and types of eruption resulting from the ingestion of
cubebs.#

Uncommon. Erythematous and small papular.

[Illustration: Fig. 14.
  A somewhat rare form of eruption from the ingestion of iodine compounds.
  (_After J.C. McGuire._)]


#Mention frequency and types of eruption resulting from the
administration of digitalis.#

Exceptional. Scarlatinoid and papular.


#State frequency and types of eruption resulting from the iodides
(iodine).#

Common. _Pustular_, but may be erythematous, papular, vesicular,
bullous, tuberous, purpuric and hemorrhagic. Co-administration of
arsenic or potassium bitartrate is thought to have a preventive
influence in some cases.


#Give the frequency and types of eruption observed to follow the
administration of mercury.#

Exceptional. Erythematous and erysipelatous.


#Give the frequency and types of the cutaneous disturbance following the
ingestion of opium (or morphia).#

Not uncommon. Erythematous and _scarlatinoid_, and sometimes urticarial.


#Mention the frequency and the types of eruption following the
administration of quinine.#

Not infrequent. Usually _erythematous_, but may be urticarial,
erythemato-papular, and even purpuric. There is, in some instances,
preceding or accompanying systemic disturbance. Furfuraceous or lamellar
desquamation often follows.


#State frequency and types of eruption resulting from the ingestion of
salicylic acid.#

Not common. Erythematous and urticarial; exceptionally, vesicular,
pustular, bullous, and ecchymotic.


#Give frequency and type of cutaneous disturbance due to the
administration of stramonium.#

Not common. Erythematous.


#State frequency and types of eruption resulting from the administration
of turpentine.#

Not uncommon. _Erythematous_, and small-papular; exceptionally
vesicular.



                         #X-Ray Dermatitis.#


#What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray burns)
are observed?#

Three grades are usually described: erythema, superficial vesication,
and necrosis. The first and second may come on shortly--a few hours to
several days--after exposure; occasionally later. The third grade may
present also in the first several days, but in many cases one to several
weeks may elapse before it appears; it is quite commonly preceded by
erythema and vesication. The necrosis may be superficial or deep, and
quite usually results in a persistent ulcer covered by a leathery
coating; it is usually painful.

[Illustration: Fig. 15. _x_-ray burn]


#Give the prognosis and treatment of x-ray dermatitis.#

The first grade--the erythematous--usually disappears in one to ten
days; the second grade requires one to several weeks, and may be quite
sore and tender; the severe or necrotic burns are persistent, sometimes
lasting for months and several years, with little tendency to
spontaneous disappearance, and rebellious to treatment.

Treatment of the milder types is that of erythema (_q. v._); the necrotic
type occasionally demands thorough curetting and skin-grafting before it
will heal.


                         #Dermatitis Factitia.#
                     (_Synonym:_ Feigned Eruptions.)


#What do you understand by feigned eruptions?#

Feigned, or artificial, eruptions, occasionally met with in hysterical
females and in others, are produced, for the purpose of exciting
sympathy or of deception, by the action of friction, cantharides, acids
or strong alkalies; the cutaneous disturbance may, therefore, be
erythematous, vesicular, bullous, or gangrenous. It is usually limited
in extent, and, as a rule, seen only on parts easily reached by the
hands.

[Illustration: Fig. 16.
  Dermatitis Factitia--note the unusually uniform and regular character
  and arrangement of the lesions.]



                         #Dermatitis Gangrænosa.#


#What do you understand by dermatitis gangrænosa?#

Dermatitis gangrænosa (_erythema gangrænosum_, _Raynaud's disease_,
_spontaneous gangrene_) is an exceedingly rare affection, characterized
by the formation of gangrenous spots and patches. It may be idiopathic
or symptomatic. Some of these cases, especially in hysterical subjects,
belong under the "feigned eruptions," being self-produced.

As an idiopathic disease, it begins as erythematous, dark-red
spots--usually preceded and accompanied by mild or grave systemic
disturbance--which gradually pass into gangrene and sloughing; the
eventual termination may be fatal, or recovery may take place. As a
symptomatic disease, it is occasionally met with in diabetes and in
grave cerebral and spinal affections.

In Raynaud's disease (symmetric gangrene) the parts affected are the
extremities, such as fingers and toes, the ears and nose, only
occasionally other parts. The first symptoms observed are coldness and
paleness of the part; followed sooner or later by congestion of a dark
red, livid, or bluish color, with sometimes swelling, and tenderness and
shooting pains. The termination is usually in gangrene of a dry
character, with, in some instances, vesicles and blebs along the edges;
in other cases the parts become atrophied, withered, and indurated.

Treatment is based upon general principles.



                           #Erysipelas.#


#What is erysipelas?#

Erysipelas is an acute specific inflammation of the skin and
subcutaneous tissue, commonly of the face, characterized by shining
redness, swelling, [oe]dema, heat, and a tendency in some cases to
vesicle- and bleb-formation, and accompanied by more or less febrile
disturbance.


#Describe the symptoms and course of erysipelas.#

A decided rigor or a feeling of chilliness followed by febrile action
usually ushers in the cutaneous disturbance. The skin at a certain point
or part, commonly where there is a lesion of continuity, becomes bright
red and swollen; this spreads by peripheral extension, and in the course
of several hours involves a portion or the whole region. The parts are
shining red, swollen, of an elevated temperature, and sharply defined
against the sound skin. After several days or a week, during which time
there is usually continued mild or severe febrile action, the process
begins to subside, and is followed by epidermic desquamation.

In some cases vesicles and blebs may be present; in other cases the
disease seriously involves the deeper parts, and is accompanied by grave
constitutional symptoms. In exceptional instances sloughing takes place.

A mild, transitory, limited, and often recurrent erysipelatous condition
of the outlet and immediate neighborhood of one or both nostrils is met
with, taking its origin from an inflammation of the hair-follicles just
inside the margin of the nose; constitutional symptoms are usually
wanting. Somewhat similar, doubtless, is the erysipelatous inflammation
(_erysipeloid_) observed on the fingers and hands of butchers, etc.,
starting from a wound, apparently as a result of infection from putrid
meat or fish.


#What is erysipelas migrans (or erysipelas ambulans)?#

A variety of erysipelas which, after a few hours or days, disappears at
one region and appears at another, and so continues for one or several
weeks.


#What is the cause of erysipelas?#

The disease is due to a specific streptococcus--the streptococcus of
Fehleisen. Depression of the vital forces and local abrasions are
predisposing factors.


#State the diagnostic points.#

The character of the onset, the shining redness and swelling, the
sharply-defined border, and the accompanying febrile disturbance.


#What is the prognosis in erysipelas?#

In most instances the disease runs a favorable course, terminating in
recovery in one to three weeks. Exceptionally, in severe cases, a fatal
termination ensues.


#What is the treatment of erysipelas?#

_Internally_, a purge, followed by the tincture of the chloride of iron
and quinia, and stimulants if needed. _Locally_, one to three per cent.
carbolic-acid lotion or ointment, a saturated solution of boric acid, or
a ten- to twenty-per-cent. aqueous solution or ointment of ichthyol may
be employed.

In some cases the spread of the disease is apparently controlled by
painting the bordering healthy skin with a ring of tincture of iodine or
strong solution of nitrate of silver.



                          #Phlegmona Diffusa.#


#What do you understand by phlegmona diffusa?#

Phlegmona diffusa is a more or less extensive inflammation of the
cutaneous and subcutaneous tissues presenting symptoms partaking of the
nature of both deep erysipelas and flat carbuncles, and usually attended
with varying constitutional disturbance. Suppuration at several points
takes place, and sloughing may ensue. Recovery usually finally results,
but a fatal issue is possible.

Treatment is based upon general principles.



                             #Furunculus.#
                     (_Synonyms:_ Furuncle; Boil.)


#Define furunculus.#

Furunculus, or boil, is an acute, deep-seated, inflammatory,
circumscribed, rounded or more or less acuminated, firm, painful
formation, usually terminating in central suppuration.


#Describe the symptoms and course.#

A boil begins as a small, rounded or imperfectly defined reddish spot,
or as a small, superficial pustule; it increases in size, and when well
advanced appears as a pea or cherry-sized, circumscribed, reddish
elevation, with more or less surrounding hyperæmia and swelling; it is
painful and tender, and ends, in the course of several days or a week,
in the formation of a central slough or "_core_," which finally involves
the central overlying skin (_pointing_). One or several may be present,
gradually maturing and disappearing. Insignificant scarring may remain.

In some cases sympathetic constitutional disturbance is noticed.


#What is a blind boil?#

A sluggish boil exhibiting little, if any, tendency to point or break.


#What is furunculosis?#

Furunculosis is that condition in which boils, singly or in crops,
continue to appear, irregularly, for weeks or months.


#State the etiology of furuncle.#

A depraved state of the general health is often to be considered as a
predisposing factor. Persistent furunculosis is not infrequent in
diabetes mellitus. The immediate exciting cause is the entrance into the
follicle of a microbe, the staphylococcus pyogenes aureus. It is not
improbable, however, that boils may also be due to other pus-producing
organisms.

Workmen in paraffin oils or other petroleum products often present
numerous furuncles and cutaneous abscesses. Conditions favoring a
persistent miliaria have also a causative influence, especially observed
in infants and young children. In these latter, especially among the
poorer classes, sluggish boils or subcutaneous abscesses about the scalp
in hot weather, are not at all infrequent.


#What is the pathology of furuncle?#

A boil is an inflammatory formation having its starting point in a
sebaceous-gland, sweat-gland, or hair-follicle. The core, or central
slough, is composed of pus and of the tissue of the gland in which it
had its origin.


#How would you distinguish a boil from a carbuncle?#

A boil is comparatively small, rounded or acuminate, and has but one
point of suppuration; a carbuncle is large, flattened, intensely
painful, often with grave systemic disturbance, and has, moreover,
several centres of suppuration.


#State the prognosis.#

When occurring in crops (furunculosis) the affection is often
rebellious; recovery, however, finally resulting.


#What is the method of treatment of furunculus?#

If there be but one lesion, with no tendency to the appearance of
others, local treatment alone is usually employed. If, however, several
or more are present, or if there is a tendency to successive
development, both constitutional and local measures are demanded.


#Name the internal remedies employed.#

Such nutrients and tonics as cod-liver oil, malt, quinine, strychnia,
iron and arsenic; in some instances calx sulphurata, one-tenth- to
one-fourth-grain doses every three or four hours has been thought to be
of service. Brewers' yeast has been recently again brought forward as a
remedy of value.


#What is the external treatment?#

Local treatment consists in the beginning, with the hope of aborting the
lesion, of the application of carbolic acid to the central portion, or
the use of a twenty-five-per-cent. ointment of ichthyol applied as a
plaster:--

  [Rx] Ichthyol, ............................ [dram]j
     Emp. plumbi, ........................... [dram]ij
     Emp. resinæ, ........................... [dram]j.   M.

Or the injection of a five-per-cent. solution of carbolic acid into the
apex of the boil may be tried if the formation is more advanced. If
suppuration is fully established, evacuation of the contents, followed
by antiseptic applications, constitutes the best method.

A saturated solution of boric acid or a lotion of corrosive sublimate
(one to three grains to the ounce) applied to the immediate neighborhood
of the boil or boils tends to prevent the formation of new lesions.
Frequent washing of the parts with soap and water or tincture of green
soap and water is also a preventive measure of value. In repeatedly
infected areas, mild exposures to _x_-rays, at intervals of a few days,
will often prove of curative value.



                           #Carbunculus.#
                  (_Synonyms:_ Anthrax; Carbuncle.)


#What is carbuncle?#

A carbuncle is an acute, usually egg to palm-sized, circumscribed,
phlegmonous inflammation of the skin and subcutaneous structures,
terminating in a slough.


#At what age and upon what parts is carbuncle usually observed?#

In middle and advanced life, and more commonly in men.

It is seen most frequently at the nape of the neck and upon the upper
part of the back.


#What are the symptoms and course of carbuncle?#

There is rarely more than one lesion present. It begins, usually with
preceding and accompanying malaise, chilliness and febrile disturbance,
as a firm, flat, inflammatory infiltration in the deeper skin and
subcutaneous tissue, spreading laterally and finally involving an area
of one to several inches in diameter. The infiltration and swelling
increase, the skin becomes of dark red color, and sooner or later,
usually at the end of ten days or two weeks, softening and suppuration
begin to take place, the skin finally giving away at several points,
through which sanious pus exudes; the whole mass finally sloughs away
either in portions or in its entirety, resulting in a deep ulcer, which
slowly heals and leaves a permanent cicatrix.

In some cases, especially in old people, constitutional disturbance of a
grave character is noted, septicæmia is developed, and a fatal result
may ensue.


#What is the cause of carbuncle?#

The same causes are considered to be operative in carbunculus as in
furuncle; general debility and depression, from whatever cause,
predisposing to its formation, and the introduction of a microbe,
probably the same as in furunculus, being at present looked upon as the
exciting factor.


#What is the pathology?#

The inflammation starts simultaneously from numerous points, from the
hair-follicles, sweat-glands or sebaceous glands. The inflammatory
centres break down, and the pus finds its way to the surface; finally
the process ends in gangrene of the whole area.


#How would you distinguish carbuncle from a boil?#

By its flat character, greater size, and multiple points of suppuration.


#What is the prognosis of carbuncle?#

Occurring in those greatly debilitated or in late life, and in those
cases in which two or more lesions exist, or when seated about the head,
the prognosis is always to be guarded, as a fatal result is not
uncommon. In fact, in every instance the disease is to be considered of
possible serious import.


#What constitutional treatment is usually employed in carbuncle?#

A full nutritious diet, the use of such remedies as iron, quinia, nux
vomica, with malt and stimulants, if indicated. Calx sulphurata,
one-tenth to one-fourth grain every two or three hours, appears, in some
instances, to have a beneficial effect. If the pain is severe, morphia
or chloral should be given.


#What external measures are employed?#

In the early part of the formation, injection of a five or ten per cent.
carbolic acid solution, or covering the whole area with a twenty-five
per cent. ichthyol ointment, may be employed. When it has broken down
the pus may be drawn out with a cupping-glass, and carbolized glycerine
or carbolized water introduced into each opening, and the ichthyol
ointment superimposed. If the whole part has sloughed, it should be
removed as rapidly as possible, and antiseptic dressings used. Or, if
its progress is slow, and grave systemic disturbance be present, the
whole part may be incised and curetted, and then treated antiseptically.
Mild exposure to the _x_-rays is also to be commended.



                           #Pustula Maligna.#
                (_Synonyms:_ Anthrax; Malignant Pustule.)


#What is malignant pustule?#

Malignant pustule is a furuncle- or carbuncle-like lesion resulting from
inoculation of the virus generated in animals suffering from splenic
fever, or "charbon," and is accompanied by constitutional symptoms of
more or less gravity. A fatal termination is not unusual.


#What is the cause of pustula maligna?#

The disease is due to the presence of the bacillus anthracis.


#What is the treatment of malignant pustule?#

Early excision or destruction with caustic potash, with subsequent
antiseptic dressings; and internally the free use of stimulants and
tonics.



                         #Post-mortem Pustule.#
                     (_Synonym:_ Dissection Wound.)


#Describe post-mortem pustule.#

Post-mortem pustule develops at the point of inoculation, beginning as
an itchy red spot, becoming vesico-pustular, and later pustular, with
usually a broad inflammatory base, and accompanied with more or less
pain and redness and not infrequently lymphangitis, erysipelatous
swelling, and slight or severe sympathetic constitutional disturbance.


#What is the treatment of post-mortem pustule?#

Treatment consists in opening the pustule and thorough cauterization,
and the subsequent use of antiseptic applications or dressings.
_Internally_ quinia and stimulants if indicated.



                            #Framb[oe]sia.#
                       (_Synonyms:_ Yaws; Pian.)


#Describe framb[oe]sia.#

Framb[oe]sia is an endemic, contagious disease met with in tropical
countries, characterized by the appearance of variously-sized papules,
tubercles, and tumors, which, when developed, resemble currants and
small raspberries, and finally break down and ulcerate. It is
accompanied by constitutional symptoms of variable severity.

Hygienic measures, good food, tonics, and antiseptic and stimulating
applications are curative.


                          #Verruga Peruana.#
      (_Synonyms:_ Peruvian Warts; Carrion's Disease; Oroya Fever.)


#Describe verruga peruana.#

A specific inoculable affection endemic in some valleys of the Western
Andes, in Peru, and characterized by a prodromal febrile period and
subsequent outbreak of peculiar pin-head- to pea-sized, or larger,
bright reddish, rounded, wart-like elevations. The prodromal symptoms,
of an irregular malarial or typhoid type, with associated rheumatic and
muscular pains, may last for weeks or several months, usually abating
when eruption presents. The lesions may be crowded together in great
bunches. The face and limbs are favorite localities. The disease is
inoculable and thought to be due to a bacillus.

The fatality varies between 10 and 20 per cent. Tonics and stimulants
are prescribed.



                             #Equinia.#
                   (_Synonyms:_ Farcy; Glanders.)


#What is equinia, or glanders?#

A rare contagious specific disease of a malignant type, derived from the
horse, and characterized by grave constitutional symptoms, inflammation
of the nasal and respiratory passages, and a deep-seated
papulo-pustular, or tubercular, nodular (_farcy buds_), ulcerative
eruption. A fatal issue is not uncommon. It is due to a micro-organism.

Treatment, both local and constitutional, is based upon general
principles.



                              #Miliaria.#
      (_Synonyms:_ Prickly Heat; Heat Rash; Lichen Tropicus; Red Gum;
                              Strophulus.)


#What do you understand by miliaria?#

An acute mildly inflammatory disorder of the sweat-glands, characterized
by the appearance of minute, discrete but closely crowded papules,
vesico-papules, and vesicles.


#Describe the symptoms of miliaria.#

The eruption, consisting of pin-point to millet-seed-sized papules,
vesico-papules, vesicles, or a mixture of these lesions, discrete but
usually numerous and closely crowded, appears suddenly, occurring upon a
limited portion of the surface, or, as commonly observed, involving a
greater part or the whole integument. The trunk is a favorite locality.
The papular lesions are pinkish or reddish, and the vesicles whitish or
yellowish, surrounded by inflammatory areola, thus giving the whole
eruption a bright red appearance--_miliaria rubra_. Later, the areolæ
fade, the transparent contents of the vesicles become somewhat opaque
and yellowish-white, and the eruption has a whitish or yellowish
cast--_miliaria alba_. In long-continued cases, especially in children,
boils and cutaneous abscesses sometimes develop; and it may also develop
into a true eczema.

Itching, or a feeling of burning, slight or intense, is usually present.


#What is the course of the eruption?#

The vesicles show no disposition to rupture, but dry up in a few days or
a week, disappearing by absorption and with slight subsequent
desquamation; the papular lesions gradually fade away, and the
affection, if the exciting cause has ceased to act, terminates.


#What is the cause of miliaria?#

Excessive heat. Debilitated individuals, especially children, are more
prone to an attack. Being too warmly clad is often causative.


#What is the nature of the disease?#

The affection is considered to be due to sweat-obstruction, with mild
inflammatory symptoms as a cause or consequence, congestion and
exudation taking place about the ducts, giving rise to papules or
vesicles, according to the intensity of the process.


#How would you distinguish miliaria from papular and vesicular eczema,
and from sudamen?#

The papules of eczema are larger, more elevated, firmer, slower in their
evolution, of longer duration, and are markedly itchy.

The vesicles of eczema are usually larger, tend to become confluent, and
also to rupture and become crusted; there is marked itchiness, and the
inflammatory action is usually severe and persistent.

In sudamen there is absence of inflammatory symptoms.


#What is the prognosis of miliaria?#

The affection, under favorable circumstances, disappears in a few days
or weeks. If the cause persists, as for instance, in infants or young
children too warmly clad, it may result in eczema.


#What is the treatment of miliaria?#

Removal of the cause, and in debilitated subjects the administration of
tonics; together with the application of cooling and astringent lotions,
as the following:--

  [Rx] Aeidi carbolici, ..................... [dram]ss-[dram]j
       Acidi borici, ........................ [dram]iv
       Glycerinæ, ........................... f[dram]j
       Alcoholis, ........................... f[Oz]ij
       Aquæ, ................................ [Oz]xiv.  M.


This is sometimes more efficient if zinc oxide, six to eight drachms, is
added.

Lotions of alcohol and water or vinegar and water, and also the various
lotions used in acute eczema, are often employed with relief.

Dusting-powders of starch, boric acid, lycopodium, talc, and zinc oxide
are also valuable; the following combination is satisfactory:--

  [Rx] Pulv. acidi borici,
       Pulv. talci veneti,
       Pulv. zinci oxidi,
       Pulv. amyli, .............[=a][=a].....[dram]ij.  M.

Probably the best plan is to use a lotion and a dusting-powder
conjointly; dabbing on the wash freely, allowing it to dry, and then
dusting over with the powder.



                            #Pompholyx.#
             (_Synonyms:_ Dysidrosis; Cheiro-pompholyx.)


#What is pompholyx?#

Pompholyx is a rare disease of the skin of a vesicular and bullous
character, and limited to the hands and feet.


#Describe the symptoms of pompholyx.#

In most instances the hands only are affected. It begins usually with a
feeling of burning, tingling or tenderness of the parts, followed
rapidly by the appearance of deeply-seated vesicles, especially between
the fingers and on the palmar aspect. These beginning lesions look not
unlike sago grains imbedded in the skin. In some instances the disease
does not extend beyond this stage, the vesicles disappearing after a few
days or weeks by absorption, and usually without desquamation.
Ordinarily, however, the lesions increase in size, new ones arise,
become confluent, and blebs result, the skin in places appearing as if
undermined with serous exudation. The parts are commonly inflamed to a
slight or marked degree. The skin comes off in flakes, new lesions may
appear for several days or two or three weeks, and the process then
declines, recovery gradually taking place.

There are no constitutional symptoms, although it is usually noticed
that the general health is below par.


#What is the character of the subjective symptoms in pompholyx?#

The subjective symptoms consist of a feeling of tension, burning and
tenderness, and sometimes itching. Not infrequently, also there is
neuralgic pain.


#What is the cause of pompholyx?#

The eruption is thought to be due to a depressed state of the nervous
system. It is more common in women, and is met with chiefly in adult and
middle life.


#What is the pathology?#

Opinion is divided; some considering it a disease of the sweat-glands
and others an inflammatory disease independent of these structures.


#State the diagnostic features of pompholyx.#

The distribution and the peculiar characters and course of the eruption.

It is to be differentiated from eczema.


#What is the prognosis?#

For the immediate attack, favorable, recovery taking place in several
weeks or a few months. Recurrences at irregular intervals are not
uncommon.


#What is the treatment of pompholyx?#

The general health is to be looked after, and the patient placed under
good hygienic conditions. Remedies of a tonic nature, directed
especially toward improving the state of the nervous system, are to be
prescribed. _Locally_, soothing and anodyne applications, such as
lead-water and laudanum, boric-acid lotion, oxide-of-zinc, boric-acid
and diachylon ointments, are most suitable; or the parts may be
enveloped with the following:--

  [Rx] Pulv. ac. salicylici, ................ gr. x
       Pulv. ac. borici,
       Pulv. amyli, .......... [=a][=a] ..... [dram]ij
       Petrolati, ........................... [dram]iv.    M.

In fact, the external treatment is similar to that employed in acute
eczema.



                           #Herpes Simplex.#
                      (_Synonym:_ Fever Blisters.)


#What is herpes simplex?#

An acute inflammatory disease, characterized by the formation of
pin-head to pea-sized vesicles, arranged in groups, and occurring for
the most part about the face and genitalia.


#Describe the symptoms of herpes simplex.#

In severe cases, malaise and pyrexia may precede the eruption, but
usually it appears without any precursory or constitutional symptoms. A
feeling of heat and burning in the parts is often complained of. The
vesicles, which are commonly pin-head in size, are usually upon a
hyperæmic or inflammatory base, and tend to occur in groups or clusters.
Their contents are usually clear, subsequently becoming more or less
milky or puriform. There is no tendency to spontaneous rupture, but
should they be broken a superficial excoriation results. In a short time
they dry to crusts which soon fall off, leaving no permanent trace.


#Is the eruption in herpes simplex abundant?#

No. As a rule not more than one or two clusters or groups are observed.


#Upon what parts does the eruption occur?#

Usually about the face (_herpes facialis_), and most frequently about
the lips (_herpes labialis_); on the genitalia (_herpes progenitalis_),
the lesions are commonly found on the prepuce (_herpes præputialis_) in
the male, and on the labia minora and labia majora in the female.


#State the causes of herpes simplex.#

Herpes facialis is often observed in association with colds and febrile
and lung diseases. Malaria, digestive disturbance, and nervous disorders
are not infrequently predisposing factors. Herpes progenitalis is said
to occur more frequently in those who have previously had some venereal
disease, especially gonorrh[oe]a, but this is questionable. It is
probably often purely neurotic.


#What are the diagnostic points?#

The appearance of one or several vesicular groups or clusters about the
face, and especially about the lips, is usually sufficiently
characteristic. The same holds true ordinarily when the eruption is seen
on the prepuce or other parts of the genitalia; it is only when the
vesicles become rubbed or abraded and irritated that it might be
mistaken for a venereal sore, but the history, course and duration will
usually serve to differentiate.


#Give the prognosis.#

The eruption will usually disappear in several days or one or two weeks
without treatment. Remedial applications, however, exert a favorable
influence. Herpes progenitalis exhibits a strong disposition to
recurrence.


#What is the treatment of herpes facialis?#

Anointing the parts with camphorated cold cream, with spirits of camphor
or similar evaporating and stimulating applications will at times afford
relief to the burning, and shorten the course.


#What is the treatment of herpes progenitalis?#

In herpes about the genitalia cleanliness is of first importance. A
saturated solution of boric acid, a dusting-powder of calomel or oxide
of zinc, and the following lotion, containing calamine and oxide of
zinc, are valuable:--

  [Rx] Zinci oxidi,
       Calaminæ, .......... [=a][=a] ........ gr. v
       Glycerinæ,
       Alcoholis, ......... [=a][=a] ........ [minim]vj
       Aquæ, ................................ [Oz]j      M.

In obstinate recurrent cases, frequent applications of a mild galvanic
current will have a favorable influence.



                         #Hydroa Vacciniforme.#
         (_Synonyms:_ Recurrent Summer Eruption; Hydroa Puerorum; Hydroa
                              Aestivale.)


#Describe hydroa vacciniforme.#

It is a rare vesicular disease usually seen in boys (only two or three
exceptions), occurring upon uncovered parts, especially the nose,
cheeks, and ears. The lesions begin as red spots, discrete or in groups,
rapidly exhibit vesiculation, and later umbilication; the contents
become milky, dry to crusts, which fall off and leave small pit-like
scars. Fresh outbreaks may take place almost continuously, and the
process go on indefinitely, at least up to youth or manhood, when the
tendency subsides. Its activity is usually limited to the warm season.
Arthritic symptoms and general disturbance are sometimes noted in severe
cases.

It is doubtless a vasomotor neurosis. Exposure to sun and wind is an
important, if not essential, etiological factor. Primarily the lesion
begins in the rete middle layers, and is purely vesicular in character;
later, necrosis of the rete and extending deep in the corium is
observed.

Treatment so far has only been palliative, consisting of the
applications employed in similar conditions. Constitutional medication
is based upon general principles. The patient should avoid exposure to
the sun, strong wind and excessive artificial heat.



                       #Epidermolysis Bullosa.#


#Describe epidermolysis bullosa.#

This is a rare, usually hereditary, disease or condition, characterized
by the formation of vesicles and blebs on any part subjected to slight
rubbing or irritation. No scarring is left, and no pigmentation noted.
The predisposition to these lesions persists indefinitely. The general
health is not involved. The nature of the disease is obscure.

Treatment has no influence in modifying or lessening this tendency. The
vulnerable parts should so far as possible be protected from knocks and
undue friction.



                         #Dermatitis Repens.#


#What do you understand by dermatitis repens?#

It is a rare spreading dermatitis starting from an injury, extending by
a serous undermining of the epidermis, and usually occurring upon the
upper extremities.

It usually begins shortly after an injury, and, as a rule, presents
itself by redness and serous exudation. The overlying epidermis breaks,
and the area of disease gradually progresses by an extension of the
serous undermining process, the denuded part looking red and raw, with
usually an oozing surface. As the disease spreads the oldest part
becomes dry and heals, the new epidermal covering being thin and
atrophic in appearance. Its most usual beginning is on some part of the
hand, and from here it may spread up the arm and involve considerable
area.

The injury from which it starts may be extremely insignificant,
apparently affording an opening for the introduction of the causative
factor, doubtless parasitic. Beyond a feeling of soreness there seem to
be no special subjective symptoms.


#Give the prognosis and treatment.#

The malady shows but little tendency to spontaneous cure. The frequent
or constant application of a mild antiseptic lotion, such as boric acid
and resorcin, or of a mild parasiticide ointment will generally bring
the disease gradually to an end.



                          #Herpes Zoster.#
                (_Synonyms:_ Zoster; Zona; Shingles.)


#Give a definition of herpes zoster.#

Herpes zoster is an acute, self-limited, inflammatory disease,
characterized by groups of vesicles upon inflammatory bases, situated
over or along a nerve tract.


#Upon what parts of the body may the eruption appear?#

It may appear upon any part, following the course of a nerve; it is
therefore always limited in extent, and confined to one side of the
body. It is probably most common about the intercostal, lumbar and
supra-orbital regions. In rare instances the eruption has been observed
to be bilateral.


#Are there any subjective or constitutional symptoms?#

Yes; there is, as a rule, neuralgic pain preceding, during and following
the eruption; and in some cases, also, there may be in the beginning
mild febrile disturbance. There is also a variable degree of tenderness
and pain.


#What are the characters of the eruption?#

Several or more hyperæmic or inflammatory patches over a nerve course
appear, upon which are seated vesico-papules irregularly grouped; these
vesico-papules become distinct vesicles, of size from a pin-head to a
pea, and soon dry and give rise to thin, yellowish or brownish crusts,
which drop off, leaving in most instances no permanent trace, in others
more or less scarring. In some cases the lesions may become pustular
and, on the other hand, the eruption may be abortive, stopping short of
full vesiculation.


#What is known in regard to the nature of the disease?#

An inflamed and irritable state of the spinal ganglia, nerve tract, or
peripheral branches is directly responsible for the eruption, and this
state may be due to atmospheric changes, cold, nerve-injuries and
similar influences. The view has also been advanced that the disease is
of specific and infectious character.


#Give the chief diagnostic features of herpes zoster.#

The prodromic neuralgic pain, the appearance of grouped vesicles upon
inflammatory bases following the course of a nerve tract, and the
limitation of the eruption to one side of the body.


#What is the prognosis?#

Favorable; the symptoms usually disappearing in two to four weeks. In
some instances, however, the neuralgic pains may be persistent, and in
zoster of the supra-orbital region the eye may suffer permanent damage.


#How would you treat herpes zoster?#

_Constitutional treatment_, usually tonic in character, is to be based
upon general principles; moderate doses of quinia, with one-sixth grain
of zinc phosphide, four or five times daily, appear in some cases to
have a special value. The accompanying neuralgic pain may be so intense
as to require anodynes. _Local treatment_ should be of a soothing and
protective character. A dusting-powder of oxide of zinc and starch (to
the ounce of which twenty to thirty grains of camphor may be added)
proves useful; and over this, in order that the parts be further
protected, a bandage or a layer of cotton batting. Oxide-of-zinc
ointment, and in those cases in which there is much pain, ointments
containing powdered opium or belladonna, or orthoform, may be used. A
mild galvanic current applied daily to the parts is often of great
advantage, both in its influence upon the course of the eruption and
upon the neuralgic pain. The plan, so often advised, of painting the
parts with flexible collodion is not to be commended.



                        #Dermatitis Herpetiformis.#
     (_Synonyms:_ Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis
              (Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)


#Give a definition of dermatitis herpetiformis.#

Dermatitis herpetiformis is a somewhat rare inflammatory disease,
characterized by an eruption of an erythematous, papular, vesicular,
pustular, bullous or mixed type, with a decided disposition toward
grouping, accompanied by itching and burning sensations, with, as a
rule, more or less consequent pigmentation, and pursuing usually a
chronic course with remissions.


#Describe the erythematous type of dermatitis herpetiformis.#

The character of the eruption in the erythematous type resembles closely
that of erythema multiforme and of urticaria, especially the former. The
efflorescences usually make their appearance in crops, and are more or
less persistent; fading sooner or later, however, and giving place to
new outbreaks. Vesicles are often intermingled, developing from
erythematous and erythemato-papular lesions or arising from apparently
normal skin.

It may continue in the same type, or change to the vesicular, bullous or
other variety.


#Describe the papular type of dermatitis herpetiformis.#

This is rarely seen as consisting purely of papular lesions, but is
commonly associated with the erythematous and vesicular varieties. In a
measure it resembles the papular manifestations of erythema multiforme,
with a distinct disposition toward group formation. The papules tend,
sooner or later, to develop into vesicles, new papular outbreaks
occurring from time to time; or the whole eruption changes to the
vesicular or other type of the disease. It is not a common type.


#Describe the vesicular type of dermatitis herpetiformis.#

This is the common clinical type of the disease, and is characterized by
pin-head to pea-sized, rounded or irregularly-shaped, distended or
flattened and stellate vesicles, occurring, for the most part, in
irregular and segmental groups of three or more lesions, seated either
upon apparently normal integument or upon hyperæmic or inflammatory
skin. They exhibit no tendency to spontaneous rupture, but after
remaining a shorter or longer time, are broken or disappear by
absorption. The lesions tend to appear in crops. It may, as it not
infrequently does, continue in the same type, or it may become more or
less erythematous or bullous in character. In not a few instances
pustules, few or in numbers, are at times intermingled.


#Describe the pustular type of dermatitis herpetiformis.#

This is rare. It is similar in its clinical characters to the vesicular
type, except that the lesions are pustular. It is met with, as a rule,
in association with the vesicular and bullous varieties of the disease.


#Describe the bullous type of dermatitis herpetiformis.#

The bullous expression of the disease is usually of a markedly
inflammatory nature, often innumerable blebs, small and large, appearing
almost continuously, and in some instances involving the greater part of
the surface. The lesions arise from erythematous skin, from preëxisting
vesicles or vesicular groups, or from apparently normal integument.
There is a marked disposition to appear in clusters. A change of type to
the erythematous or vesicular varieties is not unusual.


#Describe the mixed type of dermatitis herpetiformis.#

In this type the eruption is made up of erythematous patches, vesicles,
bullæ, and often with pustules intermingled, appearing irregularly or in
crops, and with a tendency to patch or group formation.


#Describe the characters of the vesicles, pustules and blebs.#

As a rule, these several lesions, especially the vesicles and blebs, are
somewhat peculiar: they are usually of a strikingly irregular outline,
oblong, stellate, quadrate, and when drying are apt to have a puckered
appearance. They are herpetic in that they show little disposition to
spontaneous rupture, occur in groups, and are usually seated upon
erythematous or inflammatory skin--in some respects similar to the
groups of simple herpes and herpes zoster.


#What is to be said in regard to the subjective symptoms?#

The subjective symptoms are usually the most troublesome feature of the
disease, consisting of intense and persistent itching and a feeling of
heat and burning.


#Are there any constitutional symptoms in dermatitis herpetiformis?#

As a rule, not, excepting the distress and depression necessarily
consequent upon the intense itchiness and loss of sleep. In the pustular
and bullous varieties there may be mild or grave systemic symptoms, but
even in these types the constitutional involvement is, in most
instances, slight in comparison to the intensity of the cutaneous
disturbance.


#What is the course of dermatitis herpetiformis?#

Extremely chronic, in most instances lasting, with remissions,
indefinitely. The skin is rarely entirely free. From time to time the
type of the disease may undergo change. From the continued irritation
and scratching more or less pigmentation results.


#What is to be said in regard to the etiology?#

The disease is in many instances essentially neurotic, and in
exceptional instances septicæmic. Pregnancy and the parturient state are
factors in some instances (so-called herpes gestationis). It is possible
in some instances that the eruption may be an expression of a mild
toxemia of gastro-intestinal origin. In some cases no cause can be
assigned. In the majority of patients the general health, considering
the violence of the eruptive phenomena, remains comparatively
undisturbed.

Nervous shock and mental worry are factors in some cases. Polyuria,
with sugar in the urine, has occasionally been noted. Eosinophile
cells have been found both in the vesicles and the blood. In some
instances--exceptionally, it is true--the disease has appeared shortly
after vaccination.


#Mention the diagnostic features of dermatitis herpetiformis.#

The multiformity of the eruption, the characters of the lesions, the
disposition to grouping, the absence of tendency to form solid sheets of
eruption (as in eczema), the intense itching, history, chronicity and
course. In doubtful cases, an observation of several weeks will always
suffice to distinguish it from eczema, erythema multiforme, herpes iris
and pemphigus, diseases to which it at times bears strong resemblance.


#Give the prognosis of dermatitis herpetiformis.#

An opinion as to the outcome of the disease should be guarded. It is
exceedingly rebellious to treatment, and relapses are the rule.
Exceptionally the bullous and pustular varieties prove eventually fatal.
The erythematous and vesicular varieties are the most favorable.


#State the treatment to be advised.#

There are no special remedies. Constitutional treatment must be
conducted upon general principles. A free action of the bowels is to be
maintained. In occasional instances arsenic in progressive doses seems
of value. Externally protective and antipruritic applications, such as
are employed in the treatment of eczema and pemphigus, are to be
employed:--

  [Rx] Ac. carbolici, ....................... [dram]j-[dram]ij
       Thymol, .............................. gr. xvj.
       Glycerinæ, ........................... [Oz]ss-[Oz]j
       Alcoholis, ........................... f[Oz]ij
       Aquæ, q.s., ......... ad ............. Oj.   M.

Other valuable applications are: lotions of carbolic acid, of liquor
carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment
and carbolized oxide-of-zinc ointment, and dusting-powders of starch,
zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion
or ointment is sometimes of advantage; thiol employed in the same manner
has also been commended.



                             #Psoriasis.#


#Give a definition of psoriasis.#

Psoriasis is a chronic, inflammatory disease, characterized by dry,
reddish, variously-sized, rounded, sharply-defined, more or less
infiltrated, scaly patches.

[Illustration: Psoriasis.]


#At what age does psoriasis usually first make its appearance?#

Most commonly between the ages of fifteen and thirty. It is rarely seen
before the tenth year, and a first attack is uncommon after the age of
forty.


#Has psoriasis any special parts of predilection?#

The extensor surfaces of the limbs, especially the elbows and knees, are
favorite localities, and even when the eruption is more or less general,
these regions are usually most conspicuously involved. The face often
escapes, and the palms and soles, likewise the nails, are rarely
involved. In exceptional instances, the eruption is limited almost
exclusively to the scalp.


#Are there any constitutional or subjective symptoms in psoriasis?#

There is no systemic disturbance; but a variable amount of itching may
be present, although, as a rule, it is not a troublesome symptom.


#Describe the clinical appearances of a typical, well developed case.#

Twenty or a hundred or more lesions, varying in size from a pin-head to
a silver dollar, are usually present. They are sharply defined against
the sound skin, are reddish, slightly elevated and infiltrated, and more
or less abundantly covered with whitish, grayish or mother-of-pearl
colored scales. The patches are usually scattered over the general
surface, but are frequently more numerous on the extensor surfaces of
the arms and legs, especially about the elbows and knees. Several
closely-lying lesions may coalesce and a large, irregular patch be
formed; some of the patches, also, may be more or less circinate, the
central portion having, in a measure or completely, disappeared.


#Give the development and history of a single lesion.#

Every single patch of psoriasis begins as a pin-point or pin-head-sized,
hyperæmic, scaly, slightly-elevated lesion; it increases gradually, and
in the course of several days or weeks usually reaches the size of a
dime or larger, and then may remain stationary; or involution begins to
take place, usually by a disappearance, partially or completely, of the
central portion, and finally of the whole patch.


#Describe the so-called clinical varieties of psoriasis.#

As clinically met with, the patches present are, as a rule, in all
stages of development. In some instances, however, the lesions, or the
most of them, progress no further than pin-head in size, and then remain
stationary, constituting _psoriasis punctata_; in other cases, they
may stop short after having reached the size of drops--_psoriasis
guttata_; in others (and this is the usual clinical type) the patches
develop to the size of coins--_psoriasis nummularis_. In some cases
there is a strong tendency for the central part of the lesions to
disappear, and the process then remain stationary, the patches being
ring-shaped--_psoriasis circinata_; and occasionally several such rings
coalesce, the coalescing portions disappearing and the eruption be more
or less serpentine--_psoriasis gyrata_. Or, in other instances, several
large contiguous lesions may coalesce and a diffused, infiltrated patch
covering considerable surface results--_psoriasis diffusa, psoriasis
inveterata_.

[Illustration: Fig. 17. Psoriasis.]


#Is the eruption of psoriasis always dry?#

Yes.


#What course does psoriasis pursue?#

As a rule, eminently chronic. Patches may remain almost indefinitely, or
may gradually disappear and new lesions appear elsewhere, and so the
disease may continue for months and, sometimes, for years; or, after
continuing for a longer or shorter period, may subside and the skin
remain free for several months or one or two years, and, in rare
instances, may never return.

[Illustration: Fig. 18. Psoriasis.]


#Is the course of psoriasis influenced by the seasons?#

As a rule, yes; there is a natural tendency for the disease to become
less active or to disappear altogether during the warm months.


#What is known in regard to the etiology of psoriasis?#

The causes of the disease are always more or less obscure. There is
often a hereditary tendency, and the gouty and rheumatic diathesis must
occasionally be considered potential. In some instances it is apparently
influenced by the state of the general health. It is a rather common
disease and is met with in all walks of life.


#Is psoriasis contagious?#

No. In recent years the fact of its exhibiting a family tendency has
been thought as much suggestive of contagiousness as of heredity.


#What is the pathology?#

According to modern investigations, it is an inflammation induced by
hyperplasia of the rete mucosum; and it is beginning to be believed that
this hyperplasia may have a parasitic factor as the starting-cause.


#With what diseases are you likely to confound psoriasis?#

Chiefly with squamous eczema and the papulo-squamous syphiloderm; and on
the scalp, also with seborrh[oe]a. It can scarcely be confounded with
ringworm.


#How is psoriasis to be distinguished from squamous eczema?#

By the sharply-defined, circumscribed, scattered, scaly patches, and by
the history and course of the individual lesions.


#In what respects does the papulo-squamous syphiloderm differ from
psoriasis?#

The scales of the squamous syphilide are usually dirty gray in color and
more or less scanty; the patches are coppery in hue, and usually several
or more characteristic scaleless, infiltrated papules are to be found.
The face, palms, and soles are often the seat of the syphilitic
eruption; and, moreover, _concomitant symptoms of syphilis_, such as
sore throat, mucous patches, glandular enlargement, rheumatic pains,
falling out of the hair, together with the history of the initial
lesion, are one, several, or all usually present.


#How does seborrh[oe]a differ from psoriasis?#

Seborrh[oe]a of the scalp is usually diffused, with but little redness
and no infiltration; moreover, the scales of seborrh[oe]a are greasy,
dirty gray or brownish, while those of psoriasis are dry and comonly
whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists
independently of other patches elsewhere on the general surface.

That variety of seborrh[oe]a, commonly known as eczema seborrhoicum,
presents at times, both on scalp and general surface, a strong
resemblance to psoriasis, but the character of the scales and
distribution of psoriasis, as above stated, are distinguishing points;
seborrh[oe]a, moreover, favors hairy surfaces and in extensive examples
the scalp, eyebrows, sternal, and pubic regions rarely escape.


#How does psoriasis differ from ringworm?#

By its greater scaliness, by its higher degree of inflammatory action,
and by its larger number of patches, as also by its history. In ringworm
_all_ the patches tend to clear up in the centre; in psoriasis this is
rarely, if ever, so. If there is still any doubt, microscopic
examination of the scrapings will determine.


#Give the prognosis of psoriasis.#

The prognosis is usually favorable, so far as concerns the immediate
eruption, but as to recurrences, nothing positive can be stated. In rare
instances, however, the cure remains permanent.


#How is psoriasis treated?#

Both constitutional and local remedies are demanded in most cases.


#Do dietary measures exert any influence?#

As a rule, no; but the food should be plain, and an excess of meat
avoided.


#Name the important constitutional remedies usually employed in
psoriasis.#

_Arsenic_ is of first importance. It is not suitable in acute or
markedly inflammatory types; but is most useful in the sluggish, chronic
forms of the disease. The dose should never be pushed beyond slight
physiological action. It may be given as arsenious acid in pill form,
one-fiftieth to one-tenth of a grain three times daily, or as Fowler's
solution, three to ten minims at a dose.

_Alkalies_, of which liquor potassæ is the most eligible. It is to be
given in ten to twenty minim doses, largely diluted. It is valuable in
robust, plethoric, rheumatic or gouty individuals with psoriasis of an
acute or markedly inflammatory type; it is not to be given to
debilitated or anæmic subjects.

_Salicin_, sodium salicylate, and salophen in moderately full doses act
well in some cases. Occasionally thyroid preparations have a good
effect.

_Potassium Iodide_, in doses of thirty to one hundred grains, t.d., acts
favorably in some instances; there are no special indications pointing
toward its selection, unless it be the existence of a gouty or rheumatic
diathesis.

Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper,
and other diuretics are valuable in some instances, and, while often
failing, sometimes exert a rapid influence, especially in those cases in
which the disease is extensive and inflammatory. Wine of antimony, given
cautiously, is also sometimes of service in the acute inflammatory type
in robust subjects.


#Are such remedies as iron, quinine, nux vomica and cod-liver oil ever
useful in psoriasis?#

Yes. In debilitated subjects the administration of such remedies is at
times attended with improvement in the cutaneous eruption.


#What are the indications as regards the external measures?#

Removal of the scales, and the use of soothing or stimulating
applications, according to the individual case.


#How are the scales removed?#

In ordinary cases, either by warm, plain, or alkaline baths, or
hot-water-and-soap washings; in those cases in which the scaling is
abundant and adherent, washing with sapo viridis and hot water may be
required. Baths of sal ammoniac, two to six ounces to the bath are also
valuable in removing the scaliness. The tincture of green soap (tinctura
saponis viridis) is especially valuable for cleansing purposes in
psoriasis of the scalp. The hot vapor bath once or twice weekly is
serviceable in keeping the scaliness in abeyance, and has, moreover, in
some cases, a therapeutic value.

The frequency of the baths or washings will depend upon the rapidity
with which the scales are reproduced.


#Are soothing applications often demanded in psoriasis?#

In exceptional cases; in those in which the disease is acute, markedly
inflammatory and rapidly progressing, mild, soothing applications must
be temporarily employed, such as plain or bran baths, with the use of
some bland oil or ointment. As a rule, however, the conditions, when
coming under observation, are such as to permit of stimulating
applications from the start. The most efficient soothing applications
are the mild lotions and ointments employed in eczema of acute type.


#How are the stimulating remedies employed in psoriasis applied?#

As ointments, oils, and paints (pigmenta).

An ointment, if employed, is to be thoroughly rubbed in the diseased
areas once or twice daily. The same may be said of the oily
applications. The paints (medicated collodion and gutta-percha solution)
are applied with a brush, once daily, or every second or third day,
depending mainly upon the length of time the film remains intact and
adherent.


#Name the several important external remedies.#

Chrysarobin, pyrogallol, tar, ammoniated mercury, [beta]-naphthol,
and resorcin.


#Are these several external remedies equally serviceable in all cases?#

No. Their action differs slightly or greatly according to the case and
individual. A change from one to another is often necessary.


#In what forms and strength are these remedies to be applied?#

_Chrysarobin_ is applied in several ways: as an ointment, twenty to
sixty grains to the ounce, rubbed in once or twice daily; this is the
most rapid but least cleanly and eligible method. As a pigment, or
paint, as in the following:--

  [Rx] Chrysarobini, ........................ [dram]j
       Acidi salicylici, .................... gr. xx
       Etheris, ............................. f[dram]j
       Ol. ricini, .......................... [minim]x
       Collodii, ............................ f[dram]vij.  M.

Or it may be used in liquor gutta-perchæ (traumaticin), a drachm to the
ounce. It may also be employed in chloroform, a drachm to the ounce; this
is painted on, the chloroform evaporating, leaving a thin film of
chrysarobin; over this is painted flexible collodion. If the patches are
few and large, chrysarobin rubber-plaster may be used.

Chrysarobin is usually rapid in its effect, but it has certain
disadvantages; it may cause an inflammation of the surrounding skin,
and, if used near the eyes, may give rise to conjunctivitis. As a rule,
it should not be employed about the head. Moreover, it stains the linen
permanently and the skin temporarily.

_Pyrogallol_ is valuable, and is employed in the same manner and
strength as chrysarobin. In collodion it should at first not be used of
greater strength than three to four per cent., as in this form
pyrogallol sometimes acts with unexpected energy. It is less rapid than
chrysarobin, but it rarely inflames the surrounding integument. It
stains the linen a light brown, however, and is not to be used over an
extensive surface for fear of absorption and toxic effect. Oxidized
pyrogallic acid, a somewhat milder drug in its effect, has been highly
commended, and has the alleged advantage of being free from toxic
action.

_Tar_ is, all things considered, the most important external remedy. It
is comparatively slow in its action, but is useful in almost all cases.
As employed usually it is prescribed in ointment form, either as the
official tar ointment, full strength or weakened with lard or
petrolatum. It may also be used as pix liquida, with equal part of
alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch
(ol. rusci) may be employed, either as oily applications or incorporated
with ointment or with alcohol. Liquor carbonis detergens, in ointment,
one to three drachms to the ounce of simple cerate and lanolin is a mild
tarry application which is often useful. In stubborn patches an
occasional thorough rubbing with a mixture of equal parts of liquor
carbonis detergens and Vleminckx's solution, followed by a mild
ointment, sometimes proves of value. In whatsoever form tar is employed
it should be thoroughly rubbed in, once or twice daily, the excess wiped
off, and the parts then dusted with starch or similar powder.

_Ammoniated mercury_ is applied in ointment form, twenty to sixty grains
to the ounce. Compared to other remedies it is clean and free from
staining, although, as a rule, not so uniformly efficacious. It is
especially useful for application to the scalp and exposed parts. It
should not be used over extensive surface for fear of absorption.

_[beta]-Naphthol_ and _resorcin_ are applied as ointments, thirty to
sixty grains to the ounce, and as they are (especially the former)
practically free from staining, may be used for exposed surfaces.

Gallacetophenone and aristol also act well in some cases, applied in
five- to ten-per-cent. strength, as ointments.

In obstinate patches the _x_-ray may be resorted to, employing it with
caution and in the same manner as in other diseases.



                      #Pityriasis Rosea.#
          (_Synonym:_ Pityriasis Maculata et Circinata.)


#What do you understand by pityriasis rosea?#

Pityriasis rosea is a disease of a mildly inflammatory nature,
characterized by discrete, and later frequently confluent, variously
sized, slightly raised scaly macules of a pinkish to rosy-red, often
salmon-tinged, color.


#Upon what part of the body is the eruption usually found?#

The trunk is the chief seat of the eruption, although not infrequently
it is more or less general.


#Describe the symptoms of pityriasis rosea.#

The lesions, which appear rapidly or slowly, are but slightly elevated,
somewhat scaly, usually rounded, except when several coalesce, when an
irregularly outlined patch results. At first they are pale or bright
pink or reddish, later a salmon tint (which is often characteristic) is
noticed. The scaliness is bran-like or flaky, of a dirty gray color,
and, as a rule, less marked in the central portion; it is never
abundant. The skin is rarely thickened, the process being usually
exceedingly superficial.


#What course does pityriasis rosea pursue?#

The eruption makes its appearance, as a rule, somewhat rapidly, usually
attaining its full development in the course of one or two weeks, and
then begins gradually to decline, the whole process occupying one or two
months.


#To what is pityriasis rosea to be attributed?#

The cause is not known; it is variously considered as allied to
seborrh[oe]a (eczema seborrhoicum), as being of a vegetable-parasitic
origin, and as a mildly inflammatory affection somewhat similar to
psoriasis. It is not a frequent disease.


#How is pityriasis rosea distinguished from ringworm, psoriasis and the
squamous syphiloderm?#

From ringworm, by its rapid appearance, its distribution, the number of
patches, and, if necessary, by microscopic examination of the scrapings.

Psoriasis is a more inflammatory disease, is seen usually more
abundantly upon the limbs, the scales are profuse and silvery, and the
underlying skin is red and has a glazed look; moreover, psoriasis, as a
rule, appears slowly and runs a chronic course.

The squamous syphiloderm differs in its history, distribution, and above
all, by the presence of concomitant symptoms of syphilis, such as
glandular enlargement, sore throat, mucous patches, rheumatic pains, and
falling out of the hair.


#State the prognosis of pityriasis rosea.#

It is favorable, the disease tending to spontaneous disappearance,
usually in the course of several weeks or one or two months.


#What treatment is to be advised in pityriasis rosea?#

Laxatives and intestinal antiseptics, and ointments of salicylic acid
(5-15 grains to the ounce), of sulphur (10-40 grains to the ounce); or a
compound ointment containing both these ingredients can be prescribed.
The ointment base can be equal parts of white vaselin and cold cream; in
some instances Lassar's paste (starch powder, zinc oxid powder, each,
[dram]ij; vaselin, [dram]iv) seems more satisfactory.



                       #Dermatitis Exfoliativa.#
       (_Synonyms:_ General Exfoliative Dermatitis; Recurrent Exfoliative
         Dermatitis; Desquamative Scarlatiniform Erythema; Acute General
          Dermatitis; Recurrent Exfoliative Erythema; Pityriasis Rubra.)


#Describe dermatitis exfoliativa.#

Dermatitis exfoliativa is an inflammatory disease of an acute type,
characterized by a more or less general erythematous inflammation, in
exceptional instances vesicular or bullous, with epidermic desquamation
or exfoliation accompanying or following its development. Constitutional
disturbance, which may be of a serious character, is sometimes present.
It is a rare and obscure affection, running its course usually in
several weeks or months, but exhibiting a decided tendency to relapse
and recurrence. In many cases it is persistently chronic, with
exacerbations and remissions. In some instances it develops from a
long-continued and more or less generalized eczema or psoriasis, and in
exceptional cases it is started by the careless use of mercurial
ointment and of chrysarobin ointment.

[Illustration: Fig. 19. Dermatitis Exfoliativa.]

In another type of the disease, formerly described as _pityriasis
rubra_, the skin is pale red or violaceous-red, but is rarely thickened,
continued exfoliation in the form of thin plates taking place. Its
course is variable, lasting for years, with remissions.

An exfoliating generalized dermatitis is exceptionally observed in the
first weeks of life (_dermatitis exfoliativa neonatorum_), lasting some
weeks, and in most cases followed by recovery. There are no special
constitutional symptoms, the fatal cases usually dying of marasmus.

As will be seen dermatitis exfoliativa varies considerably in degree; it
may be extremely mild, resembling in appearance the scarlet-fever
eruption (erythema scarlatiniforme) and running a rapid course; or the
skin-condition and the systemic symptoms may be of grave and persistent
character.


#Give the treatment of dermatitis exfoliativa.#

General treatment is based upon indications, and externally soothing
applications, such as are employed in acute and subacute eczema, are to
be used.



                        #Lichen Planus.#


#What is lichen planus?#

Lichen planus is an inflammatory disease characterized by small, flat
and angular, smooth and shining, or scaly, discrete or confluent, red or
violaceous-red papules, having a distinctly papular or papulo-squamous
course, and attended with more or less itching.


#Describe the symptoms of lichen planus.#

The eruption, as a rule, begins slowly, usually showing itself upon the
extremities; the forearms, wrists and legs being favorite localities. It
may appear as one or more groups or in the form of short or long bands.
Occasionally its evolution is rapid and a considerable part of the
surface may be invaded. The lesions are pin-head to small pea-sized,
irregularly grouped or so closely crowded together as to form solid
patches; they are quadrangular or polygonal in shape, usually flat, with
central depression or umbilication, and are reddish or violaceous in
color. At first they have a glazed or shining appearance; later,
becoming slightly scaly, the scaliness being more marked where solid
patches have resulted. New papules may appear from time to time, the
older lesions disappearing and leaving persistent reddish or brownish
pigmentation. Exceptionally the eruption presents in bands or lines,
like rows of beads (_lichen moniliformis_). Very exceptionally a
vesicular or bleb tendency in some of the lesions has been noted;
doubtless, in most instances at least, this has been due to the arsenic
so generally administered in this disease. In rare instances lichen
planus lesions are also seen on the glans penis and on the buccal mucous
membrane. In some cases, especially in the region of the ankle, the
papules become quite large (_lichen planus hypertrophicus_), and in
occasional cases there is a tendency in some of the lesions or patches
to clear up centrally. There is, as a rule, considerable itching. There
are no constitutional symptoms.


#What is the etiology of lichen planus?#

In some cases the disease is distinctly neurotic in character, in others
no cause can be assigned. It is more especially met with at middle age,
and among the wealthier, professional, and luxurious classes.

Pathologically the first change noted in the epidermis is thought to be
an acanthosis, followed by epithelial atrophy, and a hyperkeratosis,
intercellular edema, and colloid degeneration of the prickle cells.


#Does the disease bear any resemblance to the miliary papular syphilide,
psoriasis, and papular eczema?#

In some instances it does, but the irregular and angular outline, the
slightly-umbilicated, flattened, smooth or scaly summits, and the
dull-red or violaceous color, the history and course, of lichen planus,
will serve to differentiate.


#State the prognosis.#

Under proper management the eruption, although often obstinate, yields
to treatment.


#What treatment would you prescribe in lichen planus?#

A general tonic plan of medication is indicated in most cases, with such
remedies as iron, quinine, nux vomica, and cod-liver oil and other
nutrients. In many instances arsenic exerts a special influence, and
should always be tried. Mercurials in moderate dosage have also a
favorable action in most cases. Locally, antipruritic and stimulating
applications, such as are used in the treatment of eczema, are to be
employed, alkaline baths and tarry applications deserving special
mention. Liquor carbonis detergens, applied weakened with several parts
water, is a valuable application. In some cases, particularly if the
disease is limited, external applications alone often suffice to bring
about a cure.



                     #Pityriasis Rubra Pilaris.#
          (_Synonyms:_ Lichen Ruber; Lichen Ruber Acuminatus.)


#Describe pityriasis rubra pilaris.#

Pityriasis rubra pilaris is an extremely rare disease, usually of a
mildly inflammatory nature, characterized by grayish, pale-red or
reddish-brown follicular papules with somewhat hard or horny centres;
discrete and confluent, and covering a part or the entire surface. The
skin is harsh, dry and rough, feeling to the touch somewhat like the
surface of a nutmeg-grater or a coarse file. More or less scaliness is
usually present in the confluent patches and on the palms and soles; in
these latter regions the papules are rarely seen. The duration of the
disease is variable, and relapses are common. It bears resemblance at
times to keratosis pilaris, ichthyosis, dermatitis exfoliativa; it is
considered identical with the lichen ruber acuminatus of Kaposi, and by
many also with the lichen ruber of Hebra. The etiology is obscure.

Treatment, both constitutional and local, is to be based upon general
principles; stimulating applications, with frequent baths, such as are
advised in psoriasis, are the most satisfactory. It is rebellious, and
not much more than palliation can be effected in some cases, in others
the outlook is more hopeful.



                         #Lichen Scrofulosus.#


#Describe lichen scrofulosus.#

Lichen scrofulosus is a chronic, inflammatory disease, characterized by
millet-seed-sized, rounded or flat, reddish or yellowish, more or less
grouped, desquamating papules. The lesions have their start about the
hair-follicles, occur usually upon the trunk, tend to group and form
patches, and sooner or later become covered with minute scales. As a
rule, there is no itching. It is a rare disease, and but seldom met with
in America; it is seen chiefly in children and young people of a
scrofulous diathesis. Scarring, slight in character, may or may not
follow.


#What is the treatment of lichen scrofulosus?#

The condition responds to tonics and anti-strumous remedies.



                              #Eczema.#
                  (_Synonym:_ Tetter; Salt Rheum.)


#What is eczema?#

An acute, subacute or chronic inflammatory disease, characterized in the
beginning by the appearance of erythema, papules, vesicles or pustules,
or a combination of these lesions, with a variable amount of
infiltration and thickening, terminating either in discharge with the
formation of crusts, in absorption, or in desquamation, and accompanied
by more or less intense itching and a feeling of heat or burning.


#What are the several primary types of eczema?#

Erythematous, papular, vesicular and pustular; all cases begin as one or
more of these types, but not infrequently lose these characters and
develop into the common clinical or secondary types--eczema rubrum and
eczema squamosum.

[Illustration: Fig. 20. Papular Eczema (leg).]


#What other types are met with clinically?#

Eczema rubrum, eczema squamosum, eczema fissum, eczema sclerosum and
eczema verrucosum. Eczema seborrhoicum is probably a closely allied
disease, occupying a middle position between ordinary eczema and
seborrh[oe]a.


#Describe the symptoms of erythematous eczema.#

Erythematous eczema (_eczema erythematosum_) begins as one or more small
or large, irregularly outlined hyperæmic macules or patches, with or
without slight or marked swelling, and with more or less itching or
burning. At first it may be ill-defined, but it tends to spread and its
features to become more pronounced. It may be limited to a certain
region, or it may be more or less general. When fully developed, the
skin is harsh and dry, of a mottled, reddish or violaceous color,
thickened, infiltrated and usually slightly scaly, with, at times, a
tendency toward the formation of oozing areas. Punctate and linear
scratch-marks may usually be seen scattered over the affected region.

[Illustration: Fig. 21. Eczema Rubrum.]

Its most common site is the face, but it is not infrequent upon other
parts.


#What course does erythematous eczema pursue?#

It tends to chronicity, continuing as the erythematous form, or the skin
may become considerably thickened and markedly scaly, constituting
eczema squamosum; or a moist oozing surface, with more or less crusting,
may take its place--eczema rubrum.


#Describe the symptoms of papular eczema.#

Papular eczema (_eczema papulosum_) is characterized by the appearance,
usually in numbers, of discrete, aggregated or closely-crowded, reddish,
pin-head-sized acuminated or rounded papules. Vesicles and
vesico-papules are often intermingled. The itching is commonly intense,
as often attested by the presence of scratch-marks and blood crusts.

[Illustration: Fig. 22. Eczema Squamosum et tissum.]

It is seen most frequently upon the extremities, especially the flexor
surfaces.


#What course does papular eczema pursue?#

The lesions tend, sooner or later, to disappear, but are usually
replaced by others, the disease thus persisting for weeks or months; in
places where closely crowded, a solid, thickened, scaly sheet of
eruption may result--eczema squamosum.


#Describe the symptoms of vesicular eczema.#

Vesicular eczema (_Eczema vesiculosum_) usually appears, on one or
several regions, as more or less diffused inflammatory reddened patches,
upon which rapidly develop numerous closely-crowded pin-point to
pin-head-sized vesicles, which tend to become confluent and form a solid
sheet of eruption. The vesicles soon mature and rupture, the discharge
drying to yellowish, honeycomb-like crusts. The oozing is usually more
or less continuous, or the disease may decline, the crusts be cast off,
to be quickly followed by a new crop of vesicles. In those cases in
which the process is markedly acute, considerable swelling and [oe]dema
are present. Scattered papules, vesico-papules and pustules may usually
be seen upon the involved area or about the border.

The face in infants (_crusta lactea_, or _milk crust_, of older
writers), the neck, flexor surfaces and the fingers are its favorite
localities.


#What course does vesicular eczema pursue?#

Usually chronic, with acute exacerbations. Not infrequently it passes
into eczema rubrum.


#Describe the symptoms of pustular eczema.#

Pustular eczema (_eczema pustulosum_, _eczema impetiginosum_) is probably
the least common of all the varieties. It is similar, although usually
less actively inflammatory, in its symptoms to eczema vesiculosum, the
lesions being pustular from the start or developing from preëxisting
vesicles; not infrequently the eruption is mixed, the pustules
predominating. There is a marked tendency to rupturing of the lesions,
the discharge drying to thick, yellowish, brownish or greenish crusts.

Its most common sites are the scalp and face, especially in young people
and in those who are ill-nourished and strumous.


#What course does pustular eczema pursue?#

Usually chronic, continuing as the same type, or passing into eczema
rubrum.


#Describe the symptoms of squamous eczema.#

Squamous eczema (_eczema squamosum_) may be defined as a clinical
variety, the chief symptoms of which are a variable degree of scaliness,
more or less thickening, infiltration, and redness, with commonly a
tendency to cracking or fissuring of the skin, especially when the
disease is seated about the joints. It is developed, as a rule, from the
erythematous or papular type. Itching is slight or intense.

The disease is not uncommon upon the scalp.


#What is the course of squamous eczema?#

Essentially chronic.

[Illustration: Fig. 23. Eczema of the Face and Scalp.]


#Describe the symptoms of eczema rubrum.#

Eczema rubrum is characterized by a red, raw-looking, weeping, oozing or
discharging surface, attended with more or less inflammatory thickening,
infiltration and swelling; the exudation, consisting of serum, sometimes
bloody, dries into thick yellowish or reddish-brown crusts. At one time
the whole diseased area may be hidden under a mass of crusting, at other
times a red, raw-looking, weeping surface (_eczema madidans_) is the
most striking feature. Itching is slight or intense, or the subjective
symptom may be a feeling of burning. It is an important clinical type,
usually developing from the vesicular, pustular or other primary
variety.

It is common about the face and scalp in children, and the middle and
lower part of the leg in elderly people.


#What is the course of eczema rubrum?#

Chronic, varying in intensity from time to time.


#Describe the symptoms of fissured eczema.#

The conspicuous symptom is a marked tendency to fissuring or cracking of
the skin (_eczema fissum_; _eczema rimosum_). This tendency is usually a
part of an erythematous or squamous eczema, the fissuring constituting
the most conspicuous and troublesome symptom. _Chapping_ is an extremely
mild but familiar example of this type.

It is especially common about the hands and fingers.


#What is the course of fissured eczema?#

It is more or less persistent, the tendency to fissuring varying
considerably according to the state of the weather, often disappearing
spontaneously in the summer months.


#Describe eczema sclerosum and eczema verrucosum.#

In eczema sclerosum the skin is thickened, infiltrated, hard, and almost
horny. Eczema verrucosum presents similar conditions, but, in addition,
displays a tendency to papillary or wart-like hypertrophy. In both
varieties the disease is usually seated about the ankle or the foot,
developing from the papular or squamous type. They are uncommon, and
obstinately chronic.


#State the nature of the subjective symptoms in eczema.#

Itching, commonly intense, is usually a conspicuous symptom; it may be
more or less paroxysmal. In some cases burning and heat constitute the
main subjective phenomena.


#Is eczema accompanied by febrile or systemic symptoms?#

No. In rare instances, in acute universal eczema, slight febrile action,
or other systemic disturbance, may be noted at the time of the outbreak.


#Is the eczematous eruption (patch or patches) sharply defined against
the neighboring sound skin?#

No. In almost all instances the diseased area merges gradually and
imperceptibly into the surrounding healthy integument.


#What is the character of eczema as regards the degree of inflammatory
action?#

The inflammatory action may be acute, subacute or sluggish in character,
and may be so from the start and so continue throughout its whole
course; or it may, as is usually the case, vary in intensity from time
to time.


#State the character of eczema as regards duration.#

As a rule, it is a persistent disease, showing little, if any, tendency
to spontaneous disappearance.


#Is eczema influenced by the seasons?#

Yes. With comparatively few exceptions the disease is most common and
much worse in cold, windy, winter weather.


#To what may eczema be ascribed?#

Eczema may be due to constitutional or local causes, or to both. It may
be considered, in fact, as a reaction of the skin tissues against some
irritant, and the latter may have its origin from within or without.


#Name some of the important constitutional or predisposing causes.#

Gouty diathesis, rheumatic diathesis, disorders of the digestive tract,
general debility or lack of tone, an exhausted state of the nervous
system, dentition and struma.


#Is a constitutional cause sufficient to provoke an attack?#

Yes; but often the attack is brought about in those so predisposed by
some local or external irritant.


#Mention some of the external causes.#

Heat and cold, sharp, biting winds, excessive use of water, strong
soaps, vaccination, dyes and dyestuffs, chemical irritants, and the
like. There is a growing belief that some cases presenting eczematous
aspects are probably parasitic in origin. In fact, some observers hold
to the microbic view of all cases of eczema.

Contact with the rhus plants, while producing a peculiar dermatitis,
usually running an acute course terminating in recovery, may, in those
predisposed, provoke a veritable and persistent eczema. In fact, in our
examination as to causes in a given case, especially of the hands and face,
all possible exciting factors should be inquired into, such as the handling
of plants, chemicals, dyes, etc.

[Illustration: Fig. 24. Eczema of Face.]


#Is eczema contagious?#

No. The acceptance of a parasitic cause for the disease, however,
necessarily carries with it the possibility of contagiousness under
favoring conditions. Such is not supported, however, by practical
experience.


#What is the pathology?#

The process is an inflammatory one, characterized in all cases by
hyperæmia and exudation, varying in degree according to the intensity
and duration of the disease. The rete and papillary layer are especially
involved, although in severe and chronic cases the lower part of the
corium and even the subcutaneous tissue may share in the process.


#Do the cutaneous manifestations of the eruptive fevers bear resemblance
to the erythematous type of eczema?#

Scarlatina and erysipelas may, to a slight extent, but the presence or
absence of febrile and other constitutional symptoms will usually serve
to differentiate.


#What common skin diseases resemble some phases of eczema?#

Psoriasis, seborrh[oe]a, sycosis, scabies and ringworm.


#How would you exclude psoriasis in a suspected case of eczema (squamous
eczema)?#

Psoriasis occurs in variously-sized, rounded, _sharply-defined_ patches,
usually scattered irregularly over the general surface, with special
predilection for the elbows and knees. They are covered more or less
abundantly with whitish, silvery or mother-of-pearl colored imbricated
scales. The patches are always dry, and itching is, as a rule, slight,
or may be entirely absent. Eczema, on the contrary, is often localized,
appearing as one or more large, irregularly diffused patches; it merges
imperceptibly into the sound skin, and there is often a history of
characteristic serous or gummy oozing; the scaling is usually slight and
itching almost invariably a prominent symptom.


#How would you exclude seborrh[oe]a (eczema seborrhoicum) in a suspected
case of eczema?#

Seborrh[oe]a of the scalp is more commonly over the whole of that region
and is relatively free from inflammatory symptoms; the scales are of a
greasy character and the itching is usually slight or nil. On the other
hand, in eczema of this region the parts are rarely invaded in their
entirety; there may be at times the characteristic serous or gummy
oozing; inflammatory symptoms are usually well-marked, the scales are
dry and the itching is, as a rule, a prominent symptom. These same
differences serve to differentiate the diseases in other regions.


#How does scabies differ from eczema?#

Scabies differs from eczema in its peculiar distribution, the presence
of the burrows, the absence of any tendency to patch formation, and
usually by a clear history of contagion.


#How would you exclude ringworm in a suspected case of eczema?#

Ringworm is to be distinguished by its circular form, its fading in the
centre, and in doubtful cases by microscopic examination of the
scrapings.


#How does eczema differ from sycosis?#

Sycosis is limited to the hairy region of the face, is distinctly a
follicular inflammation, and is rarely very itchy; eczema is diffused,
usually involves other parts of the face, and itching is an annoying
symptom.


#State the general prognosis of eczema.#

The disease is, under favorable circumstances, curable, some cases
yielding more or less readily, others proving exceedingly rebellious.
The length of time to bring about a result is always uncertain, and an
opinion on this point should be guarded.


#Upon what would you base your prognosis in the individual case?#

The extent of disease, its duration and previous behavior, the
removability of the exciting and predisposing causes, and the attention
the patient can give to the treatment.

In eczema involving the lips, face, scrotum, and leg, and especially
when this last-named exhibits a varicose condition of the veins, a cure
is effected, as a rule, only through persistent and prolonged treatment.


#Does eczema ever leave scars?#

No. Upon the legs, in long-continued cases, more or less pigmentation
usually remains.


#How is eczema treated?#

As a rule, eczema requires for its removal both constitutional and
external treatment.

Certain cases, however, seem to be entirely local in their nature, and
in these cases external treatment alone will have satisfactory results.


#What general measures as to hygiene and diet are commonly advisable?#

Fresh air, exercise, moderate indulgence in calisthenics, regular
habits, a plain, nutritious diet; abstention from such articles of food
as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese,
pickles, condiments, excessive coffee or tea drinking, etc. As a rule,
also, beer, wine, and other stimulants are to be interdicted.


#Upon what grounds is the line or plan of constitutional treatment to be
based?#

Upon indications in the individual case. A careful examination into the
patient's general health will usually give the cue to the line of
treatment to be adopted.


#Mention the important remedies variously employed in the constitutional
treatment.#

_Tonics_--such as cod-liver oil, quinine, nux vomica, the vegetable
bitters, iron, arsenic, malt, etc.

_Alkalies_--sodium salicylate, potassium bicarbonate, liquor potassæ,
and lithium carbonate.

_Alteratives_--calomel, colchicum, arsenic, and potassium iodide.

_Diuretics_--potassium acetate, potassium citrate, and oil of copaiba.

_Laxatives_--the various salines, aperient spring waters, castor oil,
cascara sagrada, aloes and other vegetable cathartics.

_Digestives_--pepsin, pancreatin, muriatic acid and the various bitter
tonics.


#Are there any remedies which have a specific influence?#

No; although arsenic, in exceptional instances, seems to exert a special
action. Cod-liver oil is also of great value in some cases.

Upon the whole the most important remedies are those which keep in view
the maintenance of a proper and healthful condition of the
gastro-intestinal tract, and especially with regular and rather free
action of the bowels.


#In what class of cases does arsenic often prove of service?#

In the sluggish, dry, erythematous, scaly and papular types.


#In what cases is arsenic usually contraindicated?#

It should never be employed in acute cases; nor in any instance (unless
its action is watched), in which the degree of inflammatory action is
marked, as an aggravation of the disease usually results.


#What should be the character of the external treatment?#

It depends mainly upon the degree of inflammatory action; but the stage
of the disease, the extent involved, and the ability of the patient to
carry out the details of treatment, also have a bearing upon the
selection of the plan to be advised.


#What is to be said about the use of soap and water in eczema?#

In acute and subacute conditions soap and water are to be employed, as a
rule, as infrequently and as sparingly as possible, as the disease is
often aggravated by their too free use. Washing is necessary, however,
for cleanliness and occasionally, also, for the removal of the crusts.
On the other hand, in chronic, sluggish types the use of soap and water
frequently has a therapeutic value.


#How often should remedial applications be made?#

Usually twice daily, although in some case, and especially those of an
acute type, applications should be made every few hours.


#Mention several remedies or plans of treatment to be used in the acute
or actively inflammatory cases.#

Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly
dabbed on, allowed to dry, the parts gently smeared with ointment; or
the ointment may be applied spread on lint as a plaster.

Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment,
applied in the same manner as the above.

A lotion containing calamine and zinc oxide, the sediment drying and
coating over the affected surface:--

  [Rx] Calaminæ,
          Zinci oxidi, ... [=a][=a] ......... [dram]ij-[dram]iij
          Glycerinæ,
          Alcoholis, ..... [=a][=a] ......... f[dram]ss
          Liq. calcis, ...................... f[Oz]ij
          Aquæ, .......... q.s. ad .......... f[Oz]vj.            M.

Another excellent lotion somewhat similar to the last, but of oily
character, is made up of three drachms each of calamine and zinc oxide,
one drachm of boric acid, ten to thirty drops of carbolic acid, and
three ounces each of lime-water and oil of sweet almonds.

Carbolic-acid lotion, about two drachms to the pint of water, to which
may be added two or three drachms each of glycerin and alcohol; or, if
there is intense itching, carbolic acid may be added to the several
washes already mentioned.

A lotion made of one or two drachms of liquor carbonis detergens[A] to
four ounces of water.

The following wash, especially in the dry form of the disease:--

  [Rx] Ac. borici, .......................... [dram]iv
       Ac. carbolici, ....................... [dram]j
       Glycerinæ, ........................... [dram]ij
       Alcoholis, ........................... [dram]ij
       Aquæ, ............. q.s. ad .......... Oj.          M.

[Footnote A: Liquor carbonis detergens is made by mixing together nine
  ounces of tincture soap bark and four ounces of coal tar, allowing to
  digest for eight days, and filtering. The tincture of soap bark used is
  made with one pound of soap bark to one gallon of 95 per cent. alcohol,
  digesting for a week or so. Instead of the proprietary name above, Prof.
  Duhring has suggested that of tinctura picis mineralis comp.]

Dusting-powders, of starch, zinc oxide and Venetian talc, alone or
severally combined, applied freely and often, so as to afford protection
to the inflamed surface:--

  [Rx] Talci venet,
       Zinci oxidi, ....... [=a][=a] ........ [dram]iv
       Amyli, ............................... [Oz]j        M.

If washes or dusting-powders should disagree or are not desirable or
practicable, ointments may be employed, such as--

Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated,
diachylon ointment (if fresh and well prepared), and a paste-like
ointment, as the following, usually called "salicylic-acid paste"; in
markedly itchy cases, five to fifteen grains of carbolic may be added to
each ounce:

  [Rx] Ac. salicylici, ...................... gr. v-x
       Pulv. amyli,
       Pulv. zinci oxidi, .... [=a][=a] ..... [dram]ij
       Petrolati, ........................... [dram]iv      M.

Or the following ointment:--

  [Rx] Calaminæ, ............................ [dram]j
       Ungt. zinci oxidi, ................... [dram]vij.    M.


#Name several external remedies and combinations useful in eczema of a
subacute or mildly inflammatory type.#

The various remedies and combinations useful when the symptoms are acute
or markedly inflammatory (mentioned above), and more especially the
several following:--

  [Rx] Zinci oxidi, ......................... [dram]ij
       Liq. plumbi subacetat. dilut., ....... f[dram]vj
       Glycerinæ, ........................... f[dram]ij
       Infus. picis liq., ................... f[Oz]iij       M.

A lotion containing resorcin, five to thirty grains to the ounce.

Solution of zinc sulphate, one-half to three grains to the ounce.

An ointment containing calomel or ammoniated mercury, as in the annexed
formula:--

  [Rx] Hydrargyri ammoniat. seu Hydrargyri
           chloridi mit., ................... gr. x-xxx
         Ac. carbolici, ..................... gr. v-x
         Ungt. zinci oxidi, ................. [Oz]j         M.

Another formula, more especially useful in eczema of the hands and legs,
is the following:--

  [Rx] Ac. salicylici, ...................... gr. xxx
       Emp. plumbi,
       Emp. saponis,
       Petrolati, ...... [=a][=a] ........... [Oz]j.        M.

(This is to be applied as a plaster, spread on strips of lint, and
changed every twelve or twenty-four hours.)

The paste-like ointment, referred to as useful in acute eczema, may also
be used with a larger proportion (20 to 60 grains to the ounce) of
salicylic acid.

The following, containing tar, may often be employed with advantage:--

  [Rx] Ungt. picis liq., .................... [dram]j
       Ungt. zinci oxidi, ................... [dram]vij.    M.


#What is to be said in regard to the use of tarry applications?#

Ointments or lotions containing tar should always be tried at first upon
a limited surface, as occasionally skins are met with upon which this
remedy acts as a more or less violent irritant. The coal tar lotion
(liquor carbonis detergens) is the least likely to disagree and may be
used as a mild ointment, one or two drachms to the ounce, or it may be
diluted and used as a weak lotion as already referred to.


#What external remedies are to be employed in eczema of a sluggish type?#

The various remedies and combinations (mentioned above) useful in acute
and subacute eczema may often be employed with benefit, but, as a rule,
stronger applications are necessary, especially in the thick and
leathery patches. The following are the most valuable:--

An ointment of calomel or ammoniated mercury; forty to sixty grains to
the ounce.

Strong salicylic-acid ointment; a half to one drachm of salicylic acid
to the ounce of lard.

Tar ointment, official strength; or the various tar oils, alone or with
alcohol, as a lotion, or in ointment form.

Liquor picis alkalinus[B] is a valuable remedy in chronic _thickened_,
_hard_ and _verrucous_ patches, but is a strong preparation and must be
used with caution. It is applied diluted, one part with from eight to
thirty-two parts of water; or in ointment, one or two drachms to the
ounce. In such cases, also, the following is useful:--

  [Rx] Saponis viridis,
       Picis liq.,
       Alcoholis, .......... [=a][=a] ....... [dram]iij.    M.

  SIG. To be well rubbed in.

[Footnote B:
  [Rx] Potassæ, ............................. [dram]j
       Picis liq., .......................... [dram]ij
       Aquæ, ................................ [dram]v.

  Dissolve the potash in the water, and gradually add to the tar in a
  mortar, with thorough stirring.]

In similar cases, also, the parts may be thoroughly washed or scrubbed
with sapo viridis and hot water until somewhat tender, rinsed off,
dried, and a mild ointment applied as a plaster.

Lactic acid, applied with one to ten or more parts of water is also of
value in the sclerous and verrucous types. Caustic potash solutions,
used cautiously, may also be occasionally employed to advantage in these
cases.

Another remedy of value in these cases, as well as in others of more or
less limited nature, is the _x_-ray. Exposures every few days, of short
duration and 4 to 10 inches distance, with medium vacuum tube. This
method has served me well in occasional cases; caution is necessary, and
it should not be pushed further than the production of the mildest
reaction. The repeated application of a high-frequency current, by means
of the vacuum electrodes, is a safer and sometimes an equally beneficial
method.


#Is there any method of treating eczema with fixed dressings?#

Several plans have been advised from time to time; some are costly, and
some require too great attention to details, and are therefore
impracticable for general employment. The following are those in more
common use:--

The _gelatin dressing_, as originally ordered, is made by melting over a
water-bath one part of gelatin in two parts of water--quickly painting
it over the diseased area; it dries rapidly, and to prevent cracking
glycerine is brushed over the surface. Or the glycerine may be
incorporated with the gelatin and water in the following proportion:
glycerine, one part; gelatin, four parts, and water eight parts.
Medicinal substances may be incorporated with the gelatin mixture.

A good formula is the following:--

  [Rx] Gelatin, ............................. [Oz]j
       Zinci oxidi, ......................... [Oz]ss
       Glycerini, ........................... [Oz]iss
       Aquæ, ................................ [Oz]ii-[Oz]iij.

This should be prepared over a water-bath, and two per cent. ichthyol
added. A thin gauze bandage can be applied to the parts over which this
dressing is painted, before it is completely dry; it makes a comfortable
fixed dressing and may remain on several days.

_Plaster-mull_ and _gutta-percha plaster_. The plaster-mull, consisting
of muslin incorporated with a layer of stiff ointment, and the
gutta-percha plaster, consisting of muslin faced with a thin layer of
India-rubber, the medication being spread upon the rubber coating.

_Rubber plasters._ These are medicated with the various drugs used in
the external treatment of skin diseases, and are often of service in
chronic patches.

Two new excipients for fixed dressings have recently been
introduced--bassorin and plasment; the former is made from gum
tragacanth, and the latter from Irish moss.

The following is a satisfactory formula for a tragacanth dressing:

  [Rx] Tragacanth, .......................... gr. lxxv
       Glycerini, ........................... [minim] xxx
       Ac. carbolici, ....................... gr. x-xx
       Zinci oxidi, ......................... [dram]iss-[dram]iiss.    M.

This is painted over the parts and allowed to dry, and a mild dusting
powder sprinkled over. It cannot be used in warm weather or in folds, as
it is apt to get sticky. The following is a bassorin paste which may be
variously medicated.

  [Rx] Bassorin, ............................ [dram]x
       Dextrin, ............................. [dram]vj
       Glycerini, ........................... [Oz]ij.
       Aquæ, ....................... q.s. ad. [Oz]iij.

It should be prepared cold.

Another "drying dressing" which may be used in cool weather is:

  [Rx] Zinci oxidi, ......................... [Oz]j
       Glycerini, ........................... [Oz]ss
       Mucilag. acaciæ, ..................... [Oz]ii-[Oz]iv.

It may be variously medicated.

The plaster-mull is used in all types, especially the acute; the gelatin
dressing, and the gutta-percha plaster, in the subacute and chronic; and
the rubber plaster in chronic, sluggish patches only. Acacia,
tragacanth, bassorin and plasment applications are used in cases of a
subacute and chronic character.



                             #Prurigo.#


#Define prurigo.#

Prurigo is a chronic, inflammatory disease, characterized by discrete,
pin-head- to small pea-sized, solid, firmly-seated, slightly raised,
pale-red papules, accompanied by itching and more or less general
thickening of the affected skin.


#Describe the symptoms and course of prurigo.#

The disease first appears upon the tibial regions, and its earliest
manifestation may be urticarial, but there soon develop the
characteristic small, millet-seed-sized, or larger, firm elevations,
which may be of the natural color of the skin or of a pinkish tinge. The
lesions, whilst discrete, are in great numbers, and closely crowded. The
overlying skin is dry, rough and harsh; itching is intense, and, as a
result of the scratching, excoriations and blood crusts are commonly
present. In consequence of the irritation, the inguinal glands are
enlarged. Sooner or later the integument becomes considerably thickened,
hard and rough. Eczematous symptoms may be superadded. In severe cases
the entire extensor surfaces of the legs and arms, and in some instances
the trunk also, are invaded. It is worse in the winter season.


#What is known in regard to etiology and pathology?#

It is a disease of the ill-fed and neglected, usually developing in
early childhood, and persisting throughout life. It is extremely rare,
even in its milder types, in this country. Clinically and pathologically
it bears some resemblance to papular eczema.


#Give the prognosis and treatment of prurigo.#

The disease, in its severer types is, as a rule, incurable, but much can
be done to alleviate the condition. Good, nourishing food, pure air and
exercise are of importance. Tonics and cod-liver oil are usually
beneficial. The local management is similar to that employed in chronic
eczema. An ointment of [beta]-naphthol, one-half to five per cent.
strength, is highly extolled.


                                 #Acne.#


#Give a definition of acne.#

Acne is an inflammatory, usually chronic, disease of the sebaceous
glands, characterized by papules, tubercles, or pustules, or a mixture
of these lesions, and seated usually about the face.


#At what age does acne usually occur?#

Between the ages of fifteen and thirty, at which time the glandular
structures are naturally more or less active.


#Describe the symptoms of acne.#

Irregularly scattered over the face, and in some cases also over the
neck, shoulders and upper part of the trunk, are to be seen several,
fifty or more, pin-head- to pea-sized papules, tubercles or pustules;
commonly the eruption is of a mixed type (_acne vulgaris_), the several
kinds of lesions in all stages of evolution and subsidence presenting in
the single case. Interspersed may generally be seen blackheads, or
comedones. The lesions may be sluggish in character, or they may be
markedly inflammatory, with hard and indurated bases. In the course of
several days or weeks, the papules and tubercles tend gradually to
disappear by absorption; or, and as commonly the case, they become
pustular, discharge their contents, or dry and slowly or rapidly
disappear, with or without leaving a permanent trace, new lesions
arising, here and there, to take their place. In exceptional instances
the eruption is limited to the back, and in these cases the eruption is
usually extensive and persistent, and not infrequently leaves scars.


#What do you understand by acne punctata, acne papulosa, acne pustulosa,
acne indurata, acne atrophica, acne hypertrophica, and acne
cachecticorum?#

These several terms indicate that the lesions present are, for the most
part, of one particular character or variety.


#Describe the lesions giving rise to the names of these various types.#

Blocking up of the outlet of the sebaceous gland (comedo), which is
usually the beginning of an acne lesion, may cause a moderate degree of
hyperæmia and inflammation, and a slight elevation, with a central
yellowish or blackish point results--the lesion of _acne punctata_; if
the inflammation is of a higher grade or progresses, the elevation is
reddened and more prominent--_acne papulosa_; if the inflammatory action
continues, the interior or central portion of the papule suppurates and
a pustule results--_acne pustulosa_; the pustule, in some cases, may
have a markedly inflammatory and hard base--_acne indurata_; and not
infrequently the lesions in disappearing may leave a pit-like atrophy or
depression--_acne atrophica_; or, on the contrary, connective-tissue new
growth may follow their disappearance--_acne hypertrophica_; and, in
strumous or cachectic individuals, the lesions may be more or less
furuncular in type, often of the nature of dermic abscesses, usually of
a cold or sluggish character, and of more general distribution--_acne
cachecticorum_.


#What is acne artificialis?#

Acne artificialis is a term applied to an acne or acne-like eruption
produced by the ingestion of certain drugs, as the bromides and iodides,
and by the external use of tar; this is also called _tar acne_.


#What course does acne pursue?#

Essentially chronic. The individual lesions usually run their course in
several days or one or two weeks, but new lesions continue to appear
from time to time, and the disease thus persists, with more or less
variation, for months or years. In many cases there is, toward the age
of twenty-five or thirty, a tendency to spontaneous disappearance of the
disease.

[Illustration: Acne.]


#Is the eruption in acne usually abundant?#

It varies in different cases and at different periods in the same case.
In some instances, not more than five or ten papules and pustules are
present at one time; in others they may be numerous. Not infrequently
several lesions make their appearance, gradually run their course, and
the face continues free for days or one or two weeks.


#Does the eruption in acne disappear without leaving a trace?#

In many instances no permanent trace remains, but in others slight or
conspicuous scarring is left to mark the site of the lesions.


#Are there any subjective symptoms in acne?#

As a rule, not; but markedly inflammatory lesions are painful.


#State the immediate or direct cause of an acne lesion.#

Hypersecretion or retention of sebaceous matter. Recent investigations
point to the possibility of a special bacillus being the exciting cause,
in some instances at least. The pyogenic cocci are added factors in the
pustular and furuncular cases.


#Name the indirect or predisposing causes of acne.#

Digestive disturbance, constipation, menstrual irregularities,
chlorosis, general debility, lack of tone in the muscular fibres of the
skin, scrofulosis; and medicinal substances such as the iodides and
bromides internally, and tar externally.

Working in a dusty or dirty atmosphere is often influential, resulting
in a blocking-up of the gland ducts. Workmen in paraffin oils or other
petroleum products often present a furuncle-like acne.

The disease is more common in individuals of light complexion.


#Is there any difficulty in the diagnosis of acne?#

Not if it be remembered that acne eruption is limited to certain parts
and is always follicular, and that the several stages, from the comedo
to the matured lesion, are usually to be seen in the individual case.


#In what respect does the pustular syphiloderm differ from acne?#

By its general distribution, the longer duration of the individual
lesions, the darker color, and the presence of concomitant symptoms of
syphilis.


#What is the pathology of acne?#

Primarily, acne is a folliculitis, due to retention or decomposition of
the sebaceous secretion or to the introduction of a micro-organism;
subsequently, the tissue immediately surrounding becoming involved, with
the possible destruction of the sebaceous follicle as a result. The
degree of inflammatory action determines the character of the lesions.


#State the prognosis of acne.#

It is usually an obstinate disease, but curable. Some cases yield
readily, others are exceedingly rebellious, especially acne of the back.
Success depends in a great measure upon a recognition and removal of the
predisposing condition. Treatment is ordinarily a matter of months.


#What measures of treatment are usually demanded in acne?#

Constitutional and local measures; the former when indicated, the latter
always.


#Upon what is the constitutional treatment based?#

Upon indications. Diet and hygienic measures are important.

In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin,
saline and vegetable laxatives, are variously prescribed. Special
mention may be made of the following:--

  [Rx] Ext. rhamni pursh. fl., .............. f[dram]ij-f[dram]iv
       Tinct. nucis vom., ................... f[dram]iij
       Tinct. cardamomi comp., .......q.s. ad [Oz]iij.     M.

  SIG.--f[dram]t.d.

Or Hunyadi Janos or Friedrichshall water may be employed for a laxative
purpose.

In chlorotic and anæmic cases the ferruginous preparations are of
advantage. Cod-liver oil is often a remedy of great value, and is
especially useful in strumous and debilitated subjects. Calx sulphurata
in pill form, one-tenth to one-fourth grain four or five times daily, is
said, acts well in the pustular variety. In some instances, more
particularly in sluggish papular acne, arsenic, especially the sulphide
of arsenic, acts favorably. Upon the whole, the line of treatment
that keeps in view proper and healthy action of the gastro-intestinal
canal is the most successful.

[Illustration: Acne of back.]

In inflammatory cases occurring in robust individuals the following is
often of service:--

  [Rx] Potassii acetat., .................... [dram]iv
       Liq. potassæ, ........................ f[dram]ij
       Liq. ammonii acetat., .... q.s. ad ... f[Oz]iij.      M.

  SIG.--f[dram]j-f[dram]ij t.d., largely diluted.


#State the character of the local treatment in acne.#

This must vary somewhat with the local conditions. Cases which are acute
in character, in the sense that the lesions are markedly hyperæmic,
tender and painful, require milder applications, and in exceptional
instances soothing remedies are to be prescribed. As a rule, however,
stimulating applications may be employed from the start.

The remedies are, for obvious reasons, most conveniently applied at
bedtime.


#What preliminary measures are to be advised in ordinary acne cases?#

Washing the parts gently or vigorously, according to the irritability of
the skin, with warm water and soap; subsequently rinsing, and sponging
for several minutes with hot water, and rubbing dry with a soft towel;
after which the remedial application is made. In sluggish and
non-irritable cases sapo viridis or its tincture may often be
advantageously used in place of the ordinary toilet soap.

The blackheads, so far as practicable, are to be removed by pressure
with the fingers or with a suitable instrument (see Comedo), and the
superficial pustules punctured and the contents pressed out. Scraping
the affected parts with a blunt curette is a valuable measure, but is
temporarily disfiguring. As a rule, however, cases do just as well
without puncturing and scraping, and these methods sometimes leave
behind scarring.


#State the methods of external medication commonly employed.#

By ointments and lotions. If an ointment is used, it is to be thoroughly
rubbed in, in small quantity; if a lotion is employed, it is to be well
shaken, the parts freely dabbed with it for several minutes and then
allowed to dry on.


#State the object in view in local medication.#

To hasten the maturation and disappearance of the existing lesions, and
to stimulate the skin and glands to healthy action.

If slight irritation or scaliness results, the application is to be
intermitted one or two nights; in the meantime nothing except the
hot-water sponging, with or without the application of a mild soothing
ointment, is to be employed.


#Is it usually necessary to change from one external remedy to another in
the course of treatment?#

Yes. After a certain time one remedy, as a rule, loses its effect, and a
change from lotion to ointment or the reverse, and from one lotion or
ointment to another, will often be found necessary in order to bring
about continuous improvement.


#Name the various important remedies and combinations employed in the
external treatment of acne.#

Sulphur is the most valuable. It may often be applied with benefit as a
simple ointment:--

  [Rx] Sulphur, præcip., .................... [dram]ss-[dram]j
       Adipis benz.
       Lanolin, ............ [=a][=a] ....... [dram]ij.

Or it may be used as a lotion, as in the annexed formula:--

  [Rx] Sulphur, præcip., .................... [dram]iss
       Pulv. tragacanthæ, ................... gr. x1
       Pulv. camphoræ, ...................... gr. xx
       Liq. calcis, ........ q.s. ad ........ f[Oz]iv.       M.

Another lotion, especially useful in those cases in which an oily
condition of the skin is present, is the following:--

  [Rx] Sulphur, præcip., .................... [dram]iss
       Etheris, ............................. f[dram]iv
       Alcoholis, ........................... f[Oz]iijss.    M.

A compound lotion containing sulphur in one of its combinations is also
valuable in many cases:--

  [Rx] Zinci sulphatis,
       Potassii sulphureti, .... [=a][=a] ... [dram]ss-[dram]iv
       Aquæ, ................................ [Oz]iv.       M.

(The salts should be dissolved separately and then mixed; reaction takes
place and the resulting lotion, when shaken, is milky in appearance, and
free from odor; allowed to stand the particles settle, the sediment
constituting about one-fourth to three-fourths of the whole bulk).

At times the addition to this formula of several drachms of alcohol and
of five to ten minims of glycerin is of advantage.

An external remedy, often valuable, is ichthyol. It is thus
prescribed:--

  [Rx] Ichthyol, ............................ [dram]ss-[dram]j
       Cerat. simp., ........................ [dram]iv.     M.

The various mercurial ointments, especially one of white precipitate,
five to fifteen per cent. strength, are sometimes beneficial.

A compound lotion, containing mercury, which frequently proves
serviceable, is:--

  [Rx] Hydrarg. chlorid. corros., ........... gr. ii-viij
       Zinci sulphatis, ..................... gr. x-xx
       Tinct. benzoini, ..................... f[dram]ij
       Aquæ, ............ q.s. ad ........... f[Oz]iv.

In extremely sluggish cases the following, used cautiously, is of
value:--

  [Rx] Ichthyol,
       Saponis viridis,
       Sulphur, præcip.,
       Lanolin, ............. [=a][=a] ...... [dram]j.

In such instances the application of a strong alcoholic resorcin lotion,
ten to twenty-five per cent. strength, repeated several times daily till
marked irritation and exfoliation occur (a matter usually of one to
three days), will sometimes be followed by marked improvement. Acne of
the back is treated with the same applications, but usually stronger; in
this region applications of Vleminckx's solution and formaldehyde
solution, weakened considerably, at first at least, prove of value.

_Obstinate and indurated lesions_ may be incised, the contents pressed
out, and the interior touched with carbolic acid by means of a pointed
stick. The _x_-ray has proved a most valuable addition to our resources
in the treatment of acne, and is especially serviceable in extensive and
obstinate cases. An exposure should be made about twice weekly, at a
distance of five to ten inches and for from three to ten minutes, and a
tube of medium vacuum used. It must be used with great caution and never
beyond the production of the mildest erythema. The hair, eyes, and lips
should be protected. The _x_-ray treatment is best reserved for
obstinate cases, and then used mildly, and rather as an adjuvant to the
ordinary methods than as the sole measure.


#What precaution is to be taken in advising a change from a sulphur to a
mercurial preparation or the reverse?#

Several days should be allowed to intervene, otherwise a disagreeable,
although temporary, staining or darkening of the skin results--from the
formation of the black sulphuret of mercury.



                           #Acne Rosacea.#


#Give a descriptive definition of acne rosacea.#

Acne rosacea is a chronic, hyperæmic or inflammatory disease, limited to
the face, especially to the nose and cheeks, characterized by redness,
dilatation and enlargement of the bloodvessels, more or less acne and
hypertrophy.


#Describe the symptoms of acne rosacea.#

The disease may be slight or well-marked. Redness, capillary dilatation,
and acne lesions seated on the nose and cheeks, and sometimes on chin
and forehead also, constitute in most cases the entire symptomatology.

A mild variety consists in simple redness or hyperæmia, involving the
nose chiefly and often exclusively, and is to be looked upon as a
passive congestion; this is not uncommon in young adults and is
often associated with an oily seborrh[oe]a of the same parts. In many
cases the condition does not progress beyond this stage. In other
cases, however, sooner or later the dilated capillaries become
permanently enlarged (_telangiectasis_) and acne lesions are often
present--constituting the middle stage or grade of the disease; this is
the type most frequently met with. In exceptional instances, still
further hypertrophy of the bloodvessels ensues, the glands are enlarged,
and a variable degree of connective-tissue new growth is added; this
latter is usually slight, but may be excessive, the nose presenting an
enlarged and lobulated appearance (_rhinophyma_).

[Illustration: Fig. 25. Acne Rosacea.]


#Are there any subjective symptoms in acne rosacea?#

As a rule, no. Some of the acne lesions may be tender and painful, and
at times there is a feeling of heat and burning.


#What do you know in regard to the etiology?#

In many cases the causes are obscure. Chronic digestive and intestinal
disorders, anæmia, chlorosis, continued exposure to heat or cold,
menstrual and uterine irregularities, and the too free use of spirituous
liquors, tea, etc. are often responsible factors.

It is essentially a disease of adult life, common about middle age,
occurring in both sexes, but rarely reaching the same degree of
development in women as observed at times in men.


#Is acne rosacea easily recognized?#

Yes. The redness, acne lesions, dilated capillaries, and, at times, the
glandular and connective-tissue hypertrophy; the limitation of the
eruption to the face, especially the region of the nose; the evident
involvement of the sebaceous glands, the absence of ulceration, taken
with the history of the case, are characteristic.

It is to be distinguished from the tubercular syphiloderm and lupus
vulgaris, diseases to which it may bear rough resemblance.


#State the prognosis of acne rosacea.#

All cases may be favorably influenced by treatment; the mild and
moderately-developed types are, as a rule, curable, but usually
obstinate. It is a persistent disease, showing little, if any, tendency
to disappear spontaneously.


#What is the method of treatment?#

Both constitutional and local measures are demanded in most cases.


#Upon what is the constitutional treatment to be based?#

The constitutional treatment, beyond a regulation of the diet, is to be
based upon a correct appreciation of the etiological factors in the
individual case. There are no special remedies. Iron, cod-liver oil,
tonics, ergot, alkalies, saline laxatives, and similar drugs are to be
variously prescribed.


#What is the external treatment?#

In many respects, both as to the preliminary measures and remedies,
essentially the same as that employed in the treatment of simple acne
(_q. v._). The _x_-ray treatment is not so efficient in this disease,
however, as in acne. In addition to the treatment there found, several
other applications deserve mention:--

In many cases _Vleminckx's solution_[C] is valuable, applied diluted
with one to ten parts of water. Also, a mucilaginous paste containing
sulphur:--

  [Rx] Mucilag. acaciæ, ..................... f[dram]iij
       Glycerinæ, ........................... f[dram]ij
       Sulphur, præcip., .................... [dram]iij.    M.

[Footnote C:
  [Rx] Calcis, .............................. [Oz]ss
       Sulph. sublimat., .................... [Oz]j
       Aquæ, ................................ [Oz]x.

  To be boiled down to [Oz]vj and filtered.]

Or a similar paste with the glycerine in the foregoing replaced with
ichthyol may be used.


#In what manner are the dilated bloodvessels and connective-tissue
hypertrophy to be treated?#

The enlarged capillaries are to be destroyed by incision or by
electrolysis. Properly managed the vessels may be thus destroyed, but
unless the predisposing causes have disappeared or have been remedied, a
new growth may take place.

If the knife is employed, the vessels are either slit in their length or
cut transversely at several points. The method by electrolysis is the
same as used in the removal of superfluous hair (_q. v._).; the needle
may, if the vessel is short, be inserted along its calibre, or if long,
may be inserted at several points in its length.

Excessive connective-tissue growth, exceptionally met with, is to be
treated by ablation with the scissors or knife.



                       #Acne Varioliformis.#
   (_Synonyms:_ Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne;
                        Necrotic Granuloma.)


#Describe acne varioliformis.#

Acne varioliformis is characterized by lesions of a moderately
superficial papulo-pustular type, which in disappearing leave slight or
pit-like scars. The forehead and scalp are the favorite sites, but they
may also occur elsewhere. The eruption is rather scanty as a rule,
consisting usually of ten to thirty lesions. They begin as small
maculo-papules, as papules, or as minute nodules in or on the skin, and
gradually become small pea-sized, with a tendency to slight vesiculation
or pustulation at the central part. The lesion is sluggish in its
course, drying to a thin crust, which finally falls off, leaving a
depressed variola-like scar. New lesions arise from time to time, and
the disease thus continues almost indefinitely. There may or may not be
itching. In what appears to be a variety of this disease, known usually
as _acne urticata_, there is considerable itching just at the time the
lesion is appearing. The malady is not frequent, but occurs in both
sexes, usually in those between the ages of twenty and fifty. It seems
probable that the eruption is parasitic in origin.

The maladies variously known as hydradenitis suppurativa, acnitis,
spiradenitis, folliclis, granuloma necroticum, etc., in which the
lesions, primarily at least, are somewhat deeper seated, sluggish in
their course, and followed by scarring, could be also included under
this head.

#Give the prognosis and treatment.#

The disease is rebellious and tends to recur. The most efficient
applications are those of sulphur and resorcin, the same as prescribed
in ordinary acne.



                            #Sycosis.#
  (_Synonyms:_ Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis
                   Barbæ; Sycosis Coccogenica.)


#What do you understand by sycosis?#

Sycosis is a chronic, inflammatory affection involving the
hair-follicles, usually of the moustache and bearded regions only, and
characterized by papules, tubercles, and pustules perforated by hairs.


#Describe the symptoms of sycosis.#

Sycosis begins by the formation of papules and pustules about the
hair-follicles; the lesions occur in numbers, in close proximity,
and together with the accompanying inflammation, make up a small or large
area. The pustules are small, rounded, flat or acuminated, discrete, and
yellowish in color; they are perforated by hairs, show no tendency to
rupture, and are apt to occur in crops, drying to thin yellowish or
brownish crusts. Papules and tubercles are often intermingled. More or
less swelling and infiltration are noticeable.

[Illustration: Fig. 26.
  Sycosis--not infrequently begins in, and sometimes limited to, this
  region.]

The disease is seen, as a rule, only on the bearded part of the face,
either about the cheeks, chin or upper lip, involving a small portion or
the whole of these parts. It is also sometimes met with involving the
hair follicles just within the nasal orifice, and may even be limited to
this region.

Occasionally a sycosiform eruption, usually of the side of the bearded
region, leaves behind a smooth or keloidal scar, the disease gradually
extending--_ulerythema sycosiforme_ (lupoid sycosis).

An inflammation of the hair-follicles of the scalp apparently sycosiform
in character, occurring as discrete or aggregated lesions, is sometimes
observed, the follicles being destroyed and atrophy or slight scarring
resulting--_folliculitis decalvans_.


#Does conspicuous hair loss occur in sycosis?#

Ordinarily not; the hairs are, especially at first, usually firmly
seated, but in those cases in which suppuration is active, and has
involved the follicles, they may, as a rule, be easily extracted. In
some cases destruction of the follicles ensues and slight scarring and
permanent hair loss result.


#State the character of the subjective symptoms.#

Pain and itching and a sense of burning, variable as to degree, may be
present.


#What is the course of the disease?#

Essentially chronic, the inflammatory action being of a subacute or
sluggish character, with acute exacerbations.


#State the causes of sycosis.#

Upon the upper lip it may have its origin in a nasal catarrh. Entrance
into the follicles of pyogenic micrococci is now regarded as the
essential factor. This view being accepted, carries with it the
possibility of contagiousness.

It is seen in the male sex only, usually in those between the ages of
twenty-five and fifty; and is met with in those in good and bad health,
and among rich and poor. It is comparatively infrequent.


#What is the pathology of sycosis?#

The disease is primarily a perifolliculitis, the follicle and its sheath
subsequently becoming involved in the inflammatory process.


#How would you distinguish sycosis from eczema?#

Eczema is rarely sharply limited to the bearded region, but is apt to
involve other parts of the face; moreover, the lesions are usually
confluent, and there is either an oozing, red crusted surface, or it is
dry and scaly.


#How would you exclude tinea sycosis in the diagnosis?#

In tinea sycosis, or ringworm sycosis, the history of the case is
different. The parts are distinctly lumpy and nodular; the hairs are
soon involved and become dry, brittle, loose, and fall out, or they may
be readily extracted. The superficial type of ringworm sycosis is
readily distinguished by the ring-like character of the patches. In
doubtful cases, microscopic examination of the hairs may be resorted to.


#Give the prognosis of sycosis.#

The disease is curable, but almost invariably obstinate and rebellious
to treatment. The duration, extent, and character of the inflammatory
process must all be considered. An expression of an opinion as to the
length of time required for a cure should always be guarded.

Ulerythema sycosiforme is extremely obstinate. Folliculitis decalvans is
also rebellious.


#How is sycosis to be treated?#

Mainly, and often exclusively, by external applications.

[Illustration: Fig. 27. Sycosis.]


#Is constitutional treatment of no avail in sycosis?#

In some instances; but, as a rule, it is negative. If indicated, such
remedies as tonics, alteratives, cod-liver oil and the like are to be
prescribed.


#Describe the external treatment.#

Crusting, if present, is to be removed by warm embrocations. If the
inflammation is of a high grade, and the parts tender and painful,
soothing applications, such as bland oils, black wash and oxide-of-zinc
ointment, cold cream and petrolatum, are to be used; boric-acid
solution, fifteen grains to the ounce, may be advised in place of black
wash.

In most cases, however, astringent and stimulating remedies are demanded
from the start, such as: diachylon ointment, alone or with ten to thirty
grains of calomel to the ounce; oleate of mercury, as a five- to
twenty-per-cent. ointment; precipitated sulphur, one to three drachms to
the ounce of benzoated lard, or lard and lanolin; a ten- to
twenty-five-per-cent. ichthyol ointment; and resorcin lotion or
ointment, ten to twenty per cent. strength.

[Illustration: Fig. 28. Sycosis.]

A change from one application to another will be found necessary in
almost all cases.

In obstinate cases the x-ray treatment can be used, as it has proved
itself valuable in some instances; as in other diseases, it should be
employed cautiously.


#What would you advise in regard to shaving?#

When bearable (and after a few days' application of soothing remedies it
almost always is), it is to be advised in all cases, as it materially
aids in the treatment. After a cure is effected it should be continued
for some months, until the healthy condition of the parts is thoroughly
established.


#When is depilation advisable as a therapeutic measure?#

When the suppurative process is active, in order to save the follicles
from destruction; incising or puncturing the pustules will often
accomplish the same end.

Depilation is in all cases a valuable therapeutic measure, but it is
painful; as a routine practice, shaving is less objectionable and, upon
the whole, is probably as satisfactory. Those who make free use of the
x-ray commonly push it to the point of producing depilation.



                #Dermatitis Papillaris Capillitii.#
                     (_Synonym:_ Acne Keloid.)

[Illustration: Fig. 29. Dermatitis Papillaris Capillitii.]


#Describe dermatitis papillaris capillitii.#

This is a peculiar, mildly inflammatory, sycosiform, keloidal, acne-like
disease of the hairy border of the back of the neck, often extending
upward to the occipital region; partaking, especially later in its
course, somewhat of the nature of keloid. Several or more acne-like
lesions, papular and pustular, closely grouped or bunched, appear,
developing slowly, usually to the size of peas; are red, pale red, or
whitish, often enveloping small tufts of hair, and attended with more or
less hair loss. Its course is gradual and persistent. It is an
exceedingly rare condition, the exact nature of which is still obscure.


#Give the treatment.#

Treatment, which is usually unsatisfactory, consists of stimulating
applications--the same, in fact, as employed in sycosis, sulphur and
ichthyol deserving special mention. Depilation is essential.



                     #Impetigo Contagiosa.#


#Give a descriptive definition of impetigo contagiosa.#

Impetigo contagiosa is an acute, contagious, inflammatory disease,
characterized by the formation of discrete, superficial, flat, rounded,
or ovalish vesicles or blebs, soon becoming vesico-pustular, and drying
to thin yellowish crusts.


#Upon what parts does the eruption commonly appear?#

Upon the face, scalp, and hands, and exceptionally upon other regions.


#Describe the symptoms of impetigo contagiosa.#

One, several or more small pin-head-sized papulo-vesicles or vesicles
make their appearance, usually upon the face and fingers. In the male
adult the region of the neck and beard is a favorite situation. They
increase in size by extending peripherally, but are more or less
flattened and umbilicated, and are without conspicuous areola. The
lesions may attain the size of a dime or larger, and when close together
may coalesce and form a large patch. In some cases distinct blebs
result, and a picture of pemphigus eruption presented; it is probable
that many of the cases of "contagious pemphigus" belong to this class.
New lesions may appear for several days, but finally, in the course of a
week or ten days, they have all dried to thin, wafer-like crusts, of a
straw or light-yellow color, but slightly adherent, and appearing as if
stuck on; these soon drop off, leaving faint reddish spots, which
gradually fade. In some cases there is so decided a tendency to clear
and dry up centrally while spreading peripherally that the eruption has
a ring-like aspect; this seems especially so in the bearded region of
the male adult.

Instead of presenting as described, it may occur as one or more pea- or
finger-nail-sized, rounded and elevated, usually firm, discrete
pustules, scattered over one part, or more commonly over various
regions, such as the face, hands, feet and lower extremities. The
pustules are such from the beginning, and when developed are usually of
the size of a pea or finger-nail, elevated, semi-globular or rounded,
with somewhat thick and tough walls, and of a whitish or yellowish
color; at first there may be a slight inflammatory areola, but as the
lesion matures this almost, if not entirely, disappears. The pustules
show no disposition to umbilication, rupture or coalescence; drying in
the course of several days or a week to yellowish or brownish crusts,
which soon drop off, leaving no permanent trace. This variety was
formerly thought to be a distinct disease, and was described under the
name of _impetigo simplex_.

As a rule there are no constitutional symptoms, but in the more severe
cases the eruption may be preceded by febrile disturbance and malaise.
Itching may or may not be present.


#State the cause of the disease.#

It is contagious, the contents of the lesions being inoculable and
auto-inoculable. At times it seems to prevail in epidemic form. Pyogenic
microörganisms are now regarded as causative. A relationship to
vaccination has been alleged by some observers. It is more commonly
observed in infants and young children.


#From what diseases is impetigo contagiosa to be differentiated?#

From eczema, pemphigus, and ecthyma.


#How does impetigo contagiosa differ from these several diseases?#

By the character of the lesions, their growth, their superficial nature,
their course, the absence of an inflammatory base and areola, the thin,
yellowish, wafer-like crusts, and usually a history of contagion.


#State the prognosis.#

The effect of treatment is usually prompt. The disease, indeed, tends to
spontaneous disappearance in two to four weeks; in exceptional
instances, more especially in those cases in which itching is present,
the excoriations or scratch-marks become inoculated, and in this way it
may persist several weeks.


#What is the treatment of impetigo contagiosa?#

Treatment consists in the destruction of the auto-inoculable properties
of the contents of the lesions; this is effected by removing the crusts
by means of warm water-and-soap washings, and subsequently rubbing in an
ointment of ammoniated mercury, ten to twenty grains to the ounce. Some
cases respond more rapidly to the use of a drying ointment, such as
Lassar's paste, with ten to twenty grains of white precipitate or
sulphur to the ounce. In itching cases, a saturated solution of boric
acid, or a carbolic-acid lotion, one to two drachms to the pint, is to
be employed for general application.



                     #Impetigo Herpetiformis.#


#Describe impetigo herpetiformis.#

Impetigo herpetiformis is an extremely rare disease, observed usually in
pregnant women, and is characterized by the appearance of numerous
isolated and closely-crowded pin-head-sized superficial pustules, which
show a decided disposition to the formation of circular groups or
patches. The central portion of these groups dries to crusts, while new
pustules appear at the peripheral portion. They tend to coalesce, and in
this manner a greater part of the whole surface may, in the course of
weeks or months, become involved. Profound constitutional disturbance,
usually of a septic character, precedes and accompanies the disease; in
almost every instance a fatal termination sooner or later results.

It is possibly a grave type of dermatitis herpetiformis.



                            #Ecthyma.#


#Give a descriptive definition of ecthyma.#

Ecthyma is a disease characterized by the appearance of one, several or
more discrete, finger-nail-sized, flat, usually markedly inflammatory
pustules.


#Describe the symptoms and course of ecthyma.#

The lesions begin as small, usually pea-sized, pustules; increase
somewhat in area, and when fully developed are dime-sized, or larger,
somewhat flat, with a markedly inflammatory base and areola. At first
yellowish they soon become, from the admixture of blood, reddish, and
dry to brownish crusts, beneath which will be found superficial
excoriations. The individual pustules are usually somewhat acute in
their course, but new lesions may continue to appear from day to day or
week to week. As a rule, not more than five to twenty are present at one
time, and in most cases they are seated on the legs. More or less
pigmentation, and sometimes superficial scarring, may remain to mark the
site of the lesions.

Itching is rarely present, but there may be more or less pain and
tenderness.


#What is the cause of ecthyma?#

It is essentially a disease of the poorly cared-for and ill-fed; the
direct exciting cause is the introduction of pyogenic microörganisms
into the follicular openings. It is closely allied to impetigo
contagiosa, and may in fact be regarded as a markedly inflammatory form
of the latter affection. It seems much less contagious, however. It is
commonly observed in male adults.


#From what diseases is ecthyma to be differentiated?#

From impetigo contagiosa, and the flat pustular syphiloderm.


#How is it distinguished from these several diseases?#

The size, shape, inflammatory action, and the depraved general
condition, the distribution and lesser-contagiousness will distinguish
it from impetigo contagiosa; and the absence of concomitant symptoms of
syphilis, and of positive ulceration, as well as its distribution and
more rapid and inflammatory course, will exclude the pustular
syphiloderm.


#State the prognosis.#

The disease is readily curable, disappearing upon the removal of the
predisposing cause and the employment of local antiseptic applications.


#What treatment is to be advised?#

Good food, proper hygiene and tonic remedies; and, locally, removal of
the crusts and stimulation of the underlying surface with an ointment of
ammoniated mercury, ten to thirty grains to the ounce.

The following mild antiseptic lotion, which materially lessens the
tendency to the formation of new lesions, may be applied to the affected
region two or three times daily:--

  [Rx] Acidi borici, ........................ [dram]iv
       Resorcini, ........................... [dram]ij
       Glycerinæ, ........................... f[dram]ij
       Alcoholis, ........................... f[Oz]j
       Aquæ, ........... q.s. ad ............ Oj.           M.

A weak lotion of thymol, corrosive sublimate or ichthyol would doubtless
be equally effectual.



                             #Pemphigus.#


#What do you understand by pemphigus?#

Pemphigus is an acute or chronic disease characterized by the successive
formation of irregularly-scattered, variously-sized blebs.


#Name the varieties met with.#

Two varieties are usually described--pemphigus vulgaris and pemphigus
foliaceus.


#Describe the symptoms and course of pemphigus vulgaris.#

With or without precursory symptoms of systemic disturbance, irregularly
scattered blebs, few or in numbers, make their appearance, arising from
erythematous spots or from apparently normal skin. They vary in size
from a pea to a large egg, are rounded or ovalish, usually distended,
and contain a yellowish fluid which, later, becomes cloudy or puriform.
If ruptured, the rete is exposed, but the skin soon regains its normal
condition; if undisturbed, the fluid usually disappears by absorption.
Each lesion runs its course in several days or a week.

A grave type of pemphigus is exceptionally observed in the
newborn--_pemphigus neonatorum_.


#What course does pemphigus vulgaris pursue?#

Usually chronic. The disease may subside in several months and the
process come to an end, constituting the acute type. As a rule, however,
the disease is chronic, new blebs continuing to appear from time to time
for an indefinite period.

[Illustration: Fig. 30. Pemphigus (mulatto).]


#In what respects does the severe form of pemphigus vulgaris differ from
the ordinary type?#

In the severe or malignant type the eruption is more profuse; there is
marked, and often grave, systemic depression, and the lesions are
attended with ulcerative action.


#Describe the symptoms and course of pemphigus foliaceus.#

In this, the grave type of the disease, the blebs are loose and flaccid,
with milky or puriform contents, rupturing and drying to crusts, which
are cast off, disclosing the reddened corium. New blebs appear on the
sites of disappearing or half-ruptured lesions, and the whole surface
may be thus involved and the disease continue for years, compromising
the general health and eventually ending fatally.

In some cases of pemphigus (pemphigus vegetans) a vegetating or
papillomatous condition develops from the base of the lesion, with an
offensive discharge; it is usually a grave type of the malady.

Exceptionally cases (dermatitis vegetans) are met with which have a
close similarity in their symptoms to pemphigus vegetans, but in which
the eruption is more or less limited to the genitocrural region. The
disorder is not malignant and usually yields to cleanliness and
antiseptics.


#What is the character of the subjective symptoms in pemphigus?#

The subjective symptoms consist variously of heat, tenderness, pain,
burning and itching, and may be slight or troublesome.


#What is known in regard to the etiology of pemphigus?#

The causes are obscure; general debility, overwork, shock, nervous
exhaustion, and septic conditions (microörganisms) are thought to be of
influence. There seems no doubt that those who have to do with cattle
products, especially butchers, are subjects of acute and usually grave
pemphigus. Vaccination has exceptionally been responsible for the
disease, probably through some coincidental infection. The disease is
not contagious, nor is it due to syphilis. It may occur at any age.

It is a rare disease, especially in this country. Most of the cases
diagnosed as pemphigus by the inexperienced are examples of bullous
urticaria, bullous erythema multiforme, and impetigo contagiosa.


#What is the pathology?#

The lesions are superficially seated, usually between the horny layer
and upper part of the rete. Round-cell infiltration and dilated blood
vessels are found about the papillæ and in the subcutaneous tissue. The
contents of the blebs, always of alkaline reaction, are at first serous,
later containing blood corpuscles, pus, fatty-acid crystals, epithelial
cells, and occasionally uric acid crystals and free ammonia.


#From what diseases is pemphigus to be differentiated?#

From herpes iris, the bullous syphiloderm, impetigo contagiosa and
dermatitis herpetiformis.


#How do these several diseases differ from pemphigus?#

The acute course, small lesions, concentric arrangement, variegated
colors, and distribution, in herpes iris; the thick, bulky, greenish
crusts, the underlying ulceration, the course, history, and the presence
of concomitant symptoms of syphilis, in the bullous syphiloderm; the
history, course, distribution, the character of the crusting, and the
contagious and auto-inoculable properties of the contents of the
lesions, in impetigo contagiosa; the tendency to appear in groups, the
smaller lesions, the intense itchiness, course, multiform characters of
the eruption and the disposition to change of type in dermatitis
herpetiformis,--will serve as differential points.


#State the prognosis of pemphigus.#

Its duration is uncertain, and the issue may in severe cases be fatal.
In the milder types, after months or several years, recovery may take
place.

The extent and severity of the disease and the general condition of the
patient are always to be considered before an opinion is expressed.

Pemphigus neonatorum usually ends fatally.


#Give the treatment of pemphigus.#

Both constitutional and local measures are demanded. Good nutritious
food and hygienic regulations are essential. Arsenic and quinia are the
most valuable remedies. The former, in occasional instances, seems to
have a specific influence, and should always be tried, beginning with
small doses and increasing gradually to the point of tolerance and
continued for several weeks or longer. The remedy should not be set
aside as long as there are signs of improvement, unless the supervention
of stomachic, intestinal or other disturbance demand its discontinuance.
Other tonics, such as iron, strychnia and cod-liver oil, are also at
times of service.

The blebs should be opened and the parts anointed or covered with a mild
ointment. In more general cases bran, starch and gelatin baths, and in
severe cases the continuous bath, if practicable, are to be used.



#CLASS III.--HEMORRHAGES.#


                              #Purpura.#


#Define purpura.#

Purpura is a hemorrhagic affection characterized by the appearance of
variously-sized, usually non-elevated, smooth, reddish or purplish spots
or patches, not disappearing under pressure.


#Name the several varieties met with.#

Three--purpura simplex, purpura rheumatica and purpura hæmorrhagica;
denoting, respectively, the mild, moderate and severe grade of the
disease. The division is, to a great extent, an arbitrary one.


#Describe the clinical appearance and course of an individual lesion of
purpura.#

The spot, which may be pin-head, pea-, bean-sized or larger, appears
suddenly, and is of a bright red or purplish red color. Its brightness
gradually fades, the color changing to a bluish, bluish-green, bluish-
or greenish-yellow, dirty yellowish, yellowish-white, and finally
disappearing; varying in duration from several days to several weeks.


#Describe the symptoms of purpura simplex.#

Purpura simplex, or the mild form, shows itself as pin-point to pea- or
bean-sized, bright or dark-red spots, limited, as a rule, to the limbs,
especially the lower extremities; fading gradually away and coming to an
end in a few weeks, or new crops appearing irregularly for several
months. There is rarely any systemic disturbance, and, as a rule, no
subjective symptoms; in exceptional cases an urticarial element is
added--_purpura urticans_.


#Describe the symptoms of purpura rheumatica.#

Purpura rheumatica (also called _peliosis rheumatica_) is usually
preceded by symptoms of malaise, rheumatic pains and sometimes
swelling about the joints; these phenomena abate and frequently disappear
upon the outbreak of the eruption. The lesions are pea- to dime-sized,
smooth, non-elevated, or slightly raised, and of a reddish or purplish
color; the eruption may be more or less generalized, most abundant upon
the limbs, or it may be limited to these parts. It may end in a few weeks,
or may persist for several months, new spots appearing irregularly or in
the form of crops.

As somewhat allied to this is another form (_Schönlein's disease_),
quite alarming in its symptoms. It is rare. It is characterized by
symptoms partaking of the nature of rheumatism, purpuric spots, blotches
and ecchymoses, erythema multiforme, and often associated with
considerable edema. The throat is also usually invaded, and indeed the
first symptom is commonly in this region. Considerable constitutional
disturbance, of a threatening character, is commonly observed. Recovery
usually takes place.

_Henoch's purpura_, observed chiefly in children, resembles the above,
with the erythema multiforme character and the [oe]dematous swellings
more pronounced, while the actual purpuric symptoms are less
conspicuous. Gastric and intestinal symptoms and hemorrhages from the
mucous membrane are commonly noted. It is fatal in about 20 per cent. of
the cases.


#Describe the symptoms of purpura hæmorrhagica.#

Purpura hæmorrhagica (also called _land scurvy_) is characterized
usually by premonitory, and frequently accompanying, symptoms of general
distress, and by the appearance of coin to palm-sized, red or purplish
hemorrhagic spots or patches, smooth, non-elevated or raised. Hemorrhage
from the mouth, gums and other parts, slight or serious in character,
may occur. New lesions continue to appear for several days or weeks; and
in exceptional instances, repeated relapses take place, and the disease
thus persists for months. It may end fatally.


#State the etiology of purpura.#

In most instances no cause can be assigned. The disease occurs at all
ages from childhood to advanced life, and in individuals, apparently, in
good and bad health alike. The hemorrhagic type is oftener seen in
subjects debilitated or in a depraved state of health. A microörganism
is also looked upon as a factor by some observers, especially in the
grave type of disease.


#State the diagnostic characters of purpura.#

The appearance, irregularly or in crops, of bright-red or purplish
spots, evidently of hemorrhagic nature, and not _disappearing upon
pressure_, and as they are fading, going through the several changes of
color usually observed in any ecchymosis.


#How does scurvy (scorbutus) differ from purpura?#

Scurvy, which may resemble the severe grade of purpura, has a different
history, a recognizable cause, usually a peculiar distribution, and is
accompanied with general weakness and a spongy, soft and bleeding
condition of the gums.


#What is the pathology of purpura?#

The lesion of purpura consists essentially of a hemorrhage into the
cutaneous tissues. The blood is subsequently absorbed, the hæmatin
undergoing changes of color from a red to greenish and pale yellow, and
finally fading away.


#State the prognosis#

The milder varieties disappear in the course of several weeks or months,
and are rarely of serious import; the outcome of purpura hæmorrhagica is
somewhat uncertain; although usually favorable, a fatal result from
internal hemorrhage is possible. The variety known as Schönlein's
disease is alarming, but seldom fatal. Henoch's disease is, however,
always of grave import.


#What is the treatment of purpura?#

Hygienic and dietary measures, the administration of tonics and
astringents, and, in severe cases, by relative or absolute rest.

The drugs commonly prescribed are: ergot, oil of erigeron, oil of
turpentine, quinia, strychnia, iron, mineral acids, and gallic acid.
_External_ treatment is rarely called for, but if deemed advisable,
astringent lotions may be employed.



                             #Scorbutus.#
          (_Synonyms:_ Scurvy; Sea Scurvy; Purpura Scorbutica.)


#Describe scorbutus.#

Scurvy is a peculiar constitutional state, developed in those living
under bad hygienic conditions, and is characterized by emaciation,
general febrile and asthenic symptoms, a more or less swollen, turgid
and spongy and even gangrenous condition of the gums; and concomitantly,
or sooner or later, by the appearance, usually upon the lower portion of
the legs only, of dark-colored hemorrhagic patches or blotches. The skin
of the affected part may become brawny and slightly scaly, and not
infrequently may break down and ulcerate. Hemorrhages from the various
mucous surfaces, slight or grave, may also take place.


#State the etiology of scurvy.#

It is due to long-continued deprivation of proper food, especially of
fruits and vegetables. Other bad hygienic conditions favor its
development. It is seen most commonly in sailors and others taking long
voyages.


#How is scurvy to be distinguished from purpura?#

By the asthenic and emaciated general condition and the peculiar puffy,
spongy state of the gums. The cutaneous manifestation is more diffused,
forming usually large palm-sized patches, and, as a rule, limited to the
region of the ankles or lower part of the legs.


#Give the prognosis of scurvy.#

The disease is remediable, and usually rapidly so. In those instances in
which the same bad hygienic conditions and the ingestion of improper
food are continued, death finally results.


#What treatment would you advise in scurvy?#

Proper food, with an abundance of fruit and vegetables. Lemon or lime
juice is especially valuable, and is to be taken freely. If indicated,
tonics and stimulants are also to be prescribed. For the relief of the
tumid, spongy condition of the gums, astringent and antiseptic mouth
washes are to be employed.

The cutaneous manifestations, when tending to ulceration, are to be
treated upon general principles.



#CLASS IV.--HYPERTROPHIES.#


                               #Lentigo.#
                         (_Synonym:_ Freckle.)


#Describe lentigo.#

Lentigo, or freckle, is characterized by round or irregular, pin-head to
pea-sized, yellowish, brownish or blackish spots, occurring usually
about the face and the backs of the hands. It is a common affection,
varying somewhat in the degree of development; the freckles present may
be few and insignificant, or they may exist in profusion and be quite
disfiguring. Heat and exposure favor their development. Those of light
complexion, especially those with red hair, are its most common
subjects. The color of the lesion is usually a yellowish-brown.

It is common to all ages, but is generally seen in its greatest
development during adolescence, the disposition to its appearance
becoming less marked as age advances.


#What is the pathology of lentigo?#

Lentigo consists simply of a circumscribed deposit of pigment
granules--merely a localized increase of the normal pigment, differing
from chloasma (_q. v._) only in the size and shape of the pigmentation.


#State the prognosis.#

The blemishes can be removed by treatment, but their return is almost
certain.


#Name the several applications commonly employed for their removal.#

An aqueous or alcoholic solution of corrosive sublimate, one-half to
three grains to the ounce; lactic acid, one part to from six to twenty
parts of water; and an ointment containing a drachm each of bismuth
subnitrate and ammoniated mercury to the ounce.

The applications, which act by removing the epidermal and rete cells and
with them the pigment, are made two or three times daily, and their use
intermitted for a few days as soon as the skin becomes irritated or
scaly.

Touching each freckle for a few seconds with the electric needle, just
pricking the epidermis, will occasionally remove the blemish.



                             #Chloasma.#


#What do you understand by chloasma?#

Chloasma consists of an abnormal deposit of pigment, occurring as
variously-sized and shaped, yellowish, brownish or blackish patches.


#Describe the clinical appearances of chloasma.#

Chloasma appears either in ill-defined patches, as is commonly the case,
or as a diffuse discoloration. Its appearance is rapid or gradual,
generally the latter. The patches are rounded or irregular, and usually
shade off into the sound skin. One, several or more may be present, and
coalescence may take place, resulting in a large irregular pigmented
area. The color is yellowish, or brownish, and may even be blackish
(_melasma_, _melanoderma_). The skin is otherwise normal. The face is the
most common site.


#Into what two general classes may the various examples of chloasma be
grouped?#

Idiopathic and symptomatic.


#What cases of chloasma are included in the idiopathic group?#

All those cases of pigmentation caused by external agents, such as the
sun's rays, sinapisms, blisters, continued cutaneous hyperæmia from
scratching or any other cause, etc.


#What cases of chloasma are included in the symptomatic group?#

All forms of pigment deposit which occur as a consequence of various
organic and systemic diseases, as the pigmentation, for instance, seen
in association with tuberculosis, cancer, malaria, Addison's disease,
uterine affections, and the like. In such cases, with few exceptions,
the pigmentation is usually more or less diffuse.


#What is chloasma uterinum?#

Chloasma uterinum is a term applied to the ill-defined patches of
yellowish-brown pigmentation appearing upon the faces of women, usually
between the ages of twenty-five and fifty. It is most commonly seen
during pregnancy, but may occur in connection with any functional or
organic disease of the utero-ovarian apparatus.


#What is argyria?#

Argyria is the term applied to the slate-like discoloration which
follows the prolonged administration of silver nitrate.


#State the pathology of chloasma.#

The sole change consists in an increased deposit of pigment.


#Give the prognosis of chloasma.#

Unless a removal of the exciting or predisposing cause is possible, the
prognosis is, as a rule, unfavorable, and the relief furnished by local
applications usually but temporary.


#If constitutional treatment is advisable, upon what is it to be based?#

Upon general principles; there are no special remedies.


#How do external remedies act?#

Mainly by removing the rete cells and with them the pigmentation; and
partly, also, by stimulating the absorbents.


#Are all external remedies which tend to remove the upper layers of the
skin equally useful for this purpose?#

No; on the contrary some such applications are followed by an increase
in the pigment deposit.


#Name the several applications commonly employed.#

Corrosive sublimate in solution, in the strength of one to four grains
to the ounce of alcohol and water; a lotion made up as follows:--

  [Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
       Ac. acet. dilut., .................... f[dram]ij
       Sodii borat., ........................ [scruple]ij
       Aquæ rosæ, ........................... f[Oz]iv.       M.

And also the following:--

  [Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
       Zinci sulphat.,
       Plumbi acetat., ...... [=a][=a] ...... [dram]ss
       Aquæ, ................................ f[Oz]iv.       M.

And lactic acid, with from five to twenty parts of water; and an
ointment containing a drachm each of bismuth subnitrate and white
precipitate to the ounce. Hydrogen peroxide occasionally acts well.
Trichloracetic acid, usually weakened with one or two parts water, may
be cautiously tried. The application of a strong alcoholic solution of
resorcin, twenty to fifty per cent. strength, is also valuable, as is
also a two to ten per cent. alcoholic solution of salicylic acid.

(Applications are made two or three times daily, and as soon as slight
scaliness or irritation is produced are to be discontinued for one or
two days.)

_Tattoo-marks_ are difficult to remove. Excision is the surest method.
Electrolysis, applying the needle at various points, somewhat close
together, and using a fairly strong current--three to eight
milliampères--will exceptionally, especially when repeated several
times, produce a reactive inflammation and casting-off of the tissue
containing the pigment; a scar is left.

Several writers claim good results with glycerole of papain, pricking it
in in the same manner as in tattooing.

_Gun-powder marks._ If recent, but a day or so after their occurrence,
the larger specks may be picked or scraped out. Later, electrolysis,
using a fairly strong current, may result in their removal. Their
removal may also be satisfactorily effected with a minute cutaneous
trephine.



                         #Keratosis Pilaris.#
            (_Synonyms:_ Pityriasis Pilaris; Lichen Pilaris.)


#What is meant by keratosis pilaris?#

Keratosis pilaris may be defined as a hypertrophic affection
characterized by the formation of pin-head-sized, conical, epidermic
elevations seated about the apertures of the hair follicles.


#Describe the clinical appearances of keratosis pilaris.#

The lesions are usually limited to the extensor surfaces of the thighs
and arms, especially the former. They appear as pin-head-sized, whitish
or grayish elevations, consisting of accumulations of epithelial matter
about the apertures of the hair follicles. Each elevation is pierced by
a hair, or the hair may be twisted and imprisoned within the epithelial
mass; or it may be broken off just at the point of emergence at the apex
of the papule, in which event it may be seen as a dark, central speck.
The skin is usually dry, rough and harsh, and in marked cases, to the
hand passing over it, feels not unlike a nutmeg-grater. The disease
varies in its development, in most cases being so slight as to escape
attention. As a rule, it is free from itching.


#What course does keratosis pilaris pursue?#

It is sluggish and chronic.


#Mention some of the etiological factors.#

It is not an uncommon disease, and is seen usually in those who are
unaccustomed to frequent bathing, being most frequently met with during
the winter months. It is chiefly observed during early adult life.


#Is there any difficulty in the diagnosis?#

No. It is thought at times to bear some resemblance to goose-flesh
(cutis anserina), the miliary papular syphiloderm in its desquamating
stage, and lichen scrofulosus. In goose-flesh the elevations are
evanescent and of an entirely different character; the papules of the
syphiloderm are usually generalized, of a reddish color, tend to group,
are more solid and deeply-seated, less scaly and are accompanied with
other symptoms of syphilis; in lichen scrofulosus the papules are
larger, incline to occur in groups, and appear usually upon the abdomen.


#State the prognosis.#

The disease yields readily to treatment.


#Give the treatment of keratosis pilaris.#

Frequent warm baths, with the use of a toilet soap or sapo viridis, will
usually be found curative. Alkaline baths are also useful. In obstinate
cases the ordinary mild ointments, glycerine, etc., are to be advised in
conjunction with the baths.



                         #Keratosis Follicularis.#


#Describe keratosis follicularis.#

Keratosis follicularis (_Darier's disease_, _ichthyosis follicularis_,
_ichthyosis sebacea cornea_, _psorospermosis_) is a rare disease
characterized by pin-head to pea-sized pointed, rounded, or
irregularly-shaped grayish, brownish, red or even black, horny papules
or elevations, arising from the sebaceous or hair-follicles. They are,
for the most part, discrete, with a tendency here and there to form
solid aggregations or areas. Many of them contain projecting cornified
plugs which may be squeezed out, leaving pit-like depressions. The face,
scalp, lower trunk, groins and flanks are the parts chiefly affected.
The view advanced by Darier, that the malady was due to psorosperms, is
now denied, the bodies thought to be such having been demonstrated to be
due to cell transformation.

As to treatment, in one instance the induction of a substitutive
dermatic inflammation had a favorable influence.


                         #Molluscum Epitheliale.#
    (_Synonyms:_ Molluscum Contagiosum; Molluscum Sebaceum; Epithelioma
                                Molluscum.)


#Give a definition of molluscum epitheliale.#

Molluscum epitheliale is characterized by pin-head to pea-sized,
rounded, semi-globular, or flattened, pearl-like elevations, of a
whitish or pinkish color.


#Describe the symptoms and course of molluscum epitheliale.#

The usual seat is the face; not infrequently, however, the growths occur
on other parts. The lesions begin as pin-head, waxy-looking, rounded or
acuminated elevations, gradually attaining the size of small peas. They
have a broad base or occasionally may tend to become pedunculated. They
rarely exist in profusion, in most cases three to ten or twelve lesions
being present. When fully developed they are somewhat flattened and
umbilicated, with a central, darkish point representing the mouth of the
follicle. They are whitish or pinkish, and look not unlike drops of wax
or pearl buttons. At first they are firm, but eventually, in most cases,
tend to become soft and break down. Not infrequently, however, the
lesions disappear slowly by absorption, without apparent previous
softening. Their course is usually chronic. The contents, a
cheesy-looking mass, may commonly be pressed out without difficulty.


#What is the cause of molluscum epitheliale?#

It is now generally accepted that the disease is mildly contagious. It
occurs chiefly in children, and especially among the poorer classes. The
belief in the parasitic nature of the disease is gaining ground;
recently the opinion has been advanced that it is due to psorosperms
(psorospermosis); but further investigations have indicated that these
bodies were degenerated epithelia.


#State the pathology.#

[Illustration: Fig. 31. Molluscum Epitheliale.]

According to recent investigations, molluscum epitheliale is to be
regarded as a hyperplasia of the rete, the growth probably beginning in
the hair-follicles; the so-called molluscum bodies--peculiar, rounded or
ovoidal, sharply-defined, fatty-looking bodies found in microscopical
examination of the growth--are to be viewed as a form of epithelial
degeneration.


#What are the diagnostic points in molluscum epitheliale?#

The size of the lesions, their waxy or glistening appearance, and the
presence of the central orifice.

It is to be differentiated from molluscum fibrosum, warts and acne.


#State the prognosis.#

The growths are amenable to treatment. In some instances the disease,
after existing some weeks, tends to disappear spontaneously.


#What is the treatment of molluscum epitheliale?#

Incision and expression of the contents, and touching the base of the
cavity with silver nitrate. Pedunculated growths may be ligated. In some
cases an ointment of ammoniated mercury, twenty to forty grains to the
ounce, applied, by gently rubbing, once or twice daily, will bring about
a cure.



                             #Callositas.#
    (_Synonyms:_ Tylosis; Tyloma; Callus; Callous; Callosity; Keratoma.)


#What do you understand by callositas?#

A hard, thickened, horny patch made up of the corneous layers of the
epidermis.


#Describe the clinical appearances.#

Callosities are most common about the hands and feet, and consist of
small or large patches of dry, grayish-yellow looking, hard, slight or
excessive epidermic accumulations. They are somewhat elevated,
especially at the central portion, and gradually merge into the healthy
skin. The natural surface lines are in a great measure obliterated, the
patches usually being smooth and horn-like.

_Keratosis palmaris et plantaris_ (symmetric keratodermia), as regards
the local condition, is a somewhat similar affection. It consists of
hypertrophy of the corneous layer of the palm and soles, usually of a
more or less horny and plate-like character, but is congenital or
hereditary, and not necessarily dependent upon local friction or
pressure.


#Are there any inflammatory symptoms in callositas?#

No; but exceptionally, from accidental injury, the subjacent corium
becomes inflamed, suppurates, and the thickened mass is cast off.


#State the causes of callositas.#

Pressure and friction; for example, on the hands, from the use of
various tools and implements, and on the feet from ill-fitting shoes. It
is, indeed, often to be looked upon as an effort of nature to protect
the more delicate corium.

In exceptional instances it arises without apparent cause.


#What is the pathology?#

The epidermis alone is involved; it consists, in fact, of a hyperplasia
of the horny layer.


#State the prognosis of callositas.#

If the causes are removed, the accumulation, as a rule, gradually
disappears. The effect of treatment is always rapid and positive, but
unless the etiological factors have ceased to act, the result is usually
but temporary.


#How is callositas treated?#

When treatment is deemed advisable, it consists in softening the parts
with hot-water soakings or poultices, and subsequently shaving or
scraping off the callous mass. The same result may also be often
effected by the continuous application, for several days or a week, of a
10 to 15 per cent. salicylated plaster, or the application of a
salicylated collodion, same strength; it is followed up by hot-water
soaking, the accumulation, as a rule, coming readily away.



                             #Clavus.#
                       (_Synonym:_ Corn.)


#What is clavus?#

Clavus, or corn, is a small, circumscribed, flattened, deep-seated,
horny formation usually seated about the toes.


#Describe the clinical appearances.#

Ordinarily a corn has the appearance of a small callosity; the skin is
thickened, polished and horny. Exceptionally, however, occurring on
parts that are naturally more or less moist, as between the toes,
maceration takes place, and the result is the so-called _soft corn_. The
dorsal aspect of the toes is the common site for the ordinary variety.
The usual size is that of a small pea. They are painful on pressure,
and, at times, spontaneously so.


#State the causes.#

Corns are caused by pressure and friction, and may usually be referred
to improperly fitting shoes.


#What is the pathology of clavus?#

It is a hypertrophy of the epiderm. Its shape is conical, with the base
external and the apex pressing upon the papillæ. It is, in fact, a
peculiarly-shaped callosity, the central portion and apex being dense
and horny, forming the so-called core.


#Give the treatment of clavus.#

A simple method of treatment consists in shaving off, after a
preliminary hot-water soaking, the outer portion, and then applying a
ring of felt or like material, with the hollow part immediately over the
site of the core; this should be worn for several weeks. It is also
possible in some cases to extract the whole corn by gently dissecting it
out; the after-treatment being the same as the above.

Another method is by means of a ten- to fifteen-per-cent. solution of
salicylic acid, in alcohol or collodion, or the following:--

  [Rx] Ac. salicylici, ...................... gr. xxx
       Ext. cannabis Ind., .................. gr. x
       Collodii, ............................ f[dram]iv.   M.

This is painted on the corn night and morning for several days, at the
end of which time the parts are soaked in hot water, and the mass or a
greater part of it, will be found, as a rule, to come readily away; one
or two repetitions may be necessary. Lactic acid, with one to several
parts of water, applied once or twice daily, acts in a similar manner.

Soft corns, after the removal of pressure, may be treated with the solid
stick of nitrate of silver, or by any of the methods already mentioned.

In order that treatment be permanently successful, the feet are to be
properly fitted. If pressure is removed, corns will commonly disappear
spontaneously.



                           #Cornu Cutaneum.#
              (_Synonyms:_ Cornu Humanum; Cutaneous Horn.)


#What is cornu cutaneum?#

A cutaneous horn is a circumscribed hypertrophy of the epidermis,
forming an outgrowth of horny consistence and of variable size and
shape.


#At what age and upon what parts are cutaneous horns observed?#

They are usually met with late in life, and are mostly seated upon the
face and scalp.

[Illustration: Fig. 32.
  Cutaneous Horns. Showing beginning epitheliomatous degeneration of the
  base. (_After Pancoast._)]


#Describe the clinical appearances.#

In appearance cutaneous horns resemble those seen in the lower animals,
differing, if at all, but slightly. They are hard, solid, dry and
somewhat brittle; usually tapering, and may be either straight, curved
or crooked. Their surface is rough, irregular, laminated or fissured,
the ends pointed, blunt or clubbed. The color varies; it is usually
grayish-yellow, but may be even blackish. As commonly seen they are
small in size, a fraction of an inch or an inch or thereabouts in
length, but exceptionally attain considerable proportions. The base,
which rests directly upon the skin, may be broad, flattened, or concave,
with the underlying and adjacent tissues normal or the papillæ
hypertrophied; and in some cases there is more or less inflammation,
which may be followed by suppuration. They are usually solitary
formations. They are not, as a rule, painful, unless knocked or
irritated.


#What course do cutaneous horns pursue?#

Their growth is usually slow, and, after having attained a certain size,
they not infrequently become loose and fall off; they are almost always
reproduced.


#What is the cause of these horny growths?#

The cause is not known; appearing about the genitalia, they usually
develop from acuminated warts. They are rare formations.


#State the pathology of cornu cutaneum.#

Horns consist of closely agglutinated epidermic cells, forming small
columns or rods; in the columns themselves the cells are arranged
concentrically. In the base are found hypertrophic papillæ and some
bloodvessels. They have their starting-point in the rete mucosum, either
from that lying above the papillæ or that lining the follicles and
glands.


#Does epitheliomatous degeneration of the base ever occur?#

Yes.


#State the prognosis.#

Cutaneous horns may be readily and permanently removed.


#What is the treatment?#

Treatment consists in detachment, and subsequent destruction of the
base; the former is accomplished by dissecting the horn away from the
base or forcibly breaking it off, the latter by means of any of the
well-known caustics, such as caustic potash, chloride of zinc and the
galvano-cautery.

Another method is to excise the base, the horn coming away with it; this
necessitates, however, considerable loss of tissue.



                              #Verruca.#
                          (_Synonym:_ Wart.)


#What is verruca?#

Verruca, or wart, is a hard or soft, rounded, flat, acuminated or
filiform, circumscribed epidermal and papillary growth.


#Name the several varieties of warts met with.#

Verruca vulgaris, verruca plana, verruca plana juvenilis, verruca
digitata, verruca filifortnis and verruca acuminata.


#Describe verruca vulgaris.#

This is the common wart, occurring mostly upon the hands. It is rounded,
elevated, circumscribed, hard and horny, with a broad base, and usually
the size of a pea. At first it is smooth and covered with slightly
thickened epidermis, but later this disappears to some extent, the
hypertrophied papillæ, appearing as minute elevations, making up the
growth. One, several or more may be present.


#Describe verruca plana.#

This is the so-called flat wart, and occurs commonly upon the back,
especially in elderly people (_verruca senilis_, _keratosis pigmentosa_).
It is, as a rule, but slightly elevated, is usually dark in color, and
of the size of a pea or finger-nail.


#Describe verruca plana juvenilis.#

The warts are mostly pin-head in size, flat, but slightly elevated,
rounded, irregular or square-shaped, and of a light yellowish-brown
color. They bear resemblance to lichen planus papules. They are apt to
be numerous, often becoming aggregated or fused, and occur usually in
young children, and, as a rule, on the face and hands.


#Describe verruca filiformis.#

This is a thread-like growth about an eighth or fourth of an inch long,
and occurring commonly about the face, eyelids and neck. It is usually
soft to the touch and flexible.


#Describe verruca digitata.#

This is a variety of wart, which, especially about the edges, is marked
by digitations, extending nearly or quite down to the base. It is
commonly seen upon the scalp.


#Describe verruca acuminata.#

This variety (_venereal wart_, _pointed wart_, _pointed condyloma_),
usually occurs about the genitalia, especially upon the mucous and
muco-cutaneous surfaces. It consists of one or more groups of
acuminated, pinkish or reddish, raspberry-like elevations, and,
according to the region, may be dry or moist; if the latter, the
secretion, which is usually yellowish and puriform, from rapid
decomposition, develops an offensive and penetrating odor. The formation
may be the size of a small pea, or may attain the dimensions of a fist.


#What is the cause of warts?#

The etiology is not known. They are more common in adolescent and early
adult life. Irritating secretions are thought to be causative in the
acuminated variety. It is highly probable that a parasitic factor will
finally be demonstrated. They are doubtless mildly contagious.

[Illustration: Fig. 33.
  Verruca Acuminata--about the anus. (_After Ashton._)]


#State the pathology of warts.#

A wart consists of both epidermic and papillary hypertrophy, the
interior of the growth containing a vascular loop. In the acuminated
variety there are marked papillary enlargement, excessive development of
the mucous layer, and an abundant vascular supply.


#Give the treatment of warts.#

For ordinary warts, excision or destruction by caustics. The repeated
application of a saturated alcoholic solution of salicylic acid is often
curative, the upper portion being pared off from time to time. The
filiform and digitate varieties may be snipped off with the scissors,
and the base touched with nitrate of silver; or a ligature may be used.
Curetting is a valuable operative method. The growths may also be
removed by electrolysis. When warts are numerous and close together
parasiticide applications can be daily made to the whole affected
region. For this purpose a boric acid solution, containing five to
thirty grains of resorcin to the ounce, and Vleminckx's solution, at
first diluted, prove the most valuable.

Verruca acuminata is to be treated by maintaining absolute cleanliness,
and the application of such astringents as liquor plumbi subacetatis,
tincture of iron, powdered alum and boric acid. The salicylic acid
solution may also be used. In obstinate cases, glacial acetic acid or
chromic acid may be cautiously employed.



                         #Nævus Pigmentosus.#
                          (_Synonym:_ Mole.)


#Describe nævus pigmentosus.#

Nævus pigmentosus, commonly known as mole, may be defined as a
circumscribed increase in the pigment of the skin, usually associated
with hypertrophy of one or all of the cutaneous structures, especially
of the connective tissue and hair. It occurs singly or in numbers; is
usually pea-, bean-sized or larger, rounded or irregular, smooth or
rough, flat or elevated, and of a color varying from a light brown to
black; the hair found thereon may be either colorless or deeply
pigmented, coarse and of considerable length. It is, as a rule, a
permanent formation.


#Name the several varieties of nævus pigmentosus met with.#

Nævus spilus, nævus pilosus, nævus verrucosus, and nævus lipomatodes.
So-called linear nævus might also be considered as belonging in this
group.


#What is nævus spilus?#

A smooth and flat nævus, consisting essentially of augmented
pigmentation alone.

[Illustration: Fig. 34. Linear Nævus.]


#What is nævus pilosus?#

A nævus upon which there is an abnormal growth of hair, slight or
excessive.


#What is nævus verrucosus?#

A nævus to which is added hypertrophy of the papillæ, giving rise to a
furrowed and uneven surface.


#What is linear nævus?#

Linear nævus is a formation usually of a verrucous character, more or
less pigmented, sometimes slightly scaly, occurring in band-like or
zoster-like areas, and, as a rule, unilaterally.


#What is nævus lipomatodes?#

A nævus with excessive fat and connective-tissue hypertrophy.


#State the etiology of nævus pigmentosus.#

The causes are obscure. The growths are usually congenital; but the
smooth, non-hairy moles may be acquired.


#Give the pathology of nævus pigmentosus.#

Microscopical examination shows a marked increase in the pigment in the
lowest layers of the rete mucosum, as well as more or less pigmentation
in the corium usually following the course of the bloodvessels; in the
verrucous variety the papillæ are greatly hypertrophied, in addition to
the increased pigmentation. There is, as a rule, more or less
connective-tissue hypertrophy.


#What is the treatment of nævus pigmentosus?#

In many instances interference is scarcely called for, but when demanded
consists in the removal of the formation either by the knife, by
caustics, or by electrolysis. This last is, in the milder varieties at
least, perhaps the best method, as it is less likely to be followed by
disfiguring cicatrices. In nævus pilosus the removal of the hairs alone
by electrolysis is not infrequently followed by a decided diminution of
the pigmentation. In recent years both liquid air and carbon dioxide
have also been used successfully in the removal of these growths.
Pigmented nævi, which show the least tendency to growth or degenerative
change, should be radically removed, as they not infrequently lead to
carcinomatous and sarcomatous growths.



                             #Ichthyosis.#
                    (_Synonym:_ Fish-skin Disease.)


#Give a descriptive definition of ichthyosis.#

Ichthyosis is a chronic, hypertrophic disease, characterized by dryness
and scaliness of the skin, with a variable amount of papillary growth.


#At what age is ichthyosis first observed?#

It is first noticed in infancy or early childhood. In rare instances it
is congenital (ichthyosis congenita), and in such cases it is usually
severe, and of a grave type; the children are, as a rule, prematurely
born, and frequently do not survive many days or weeks.


#What extent of surface is involved?#

Usually the whole surface, but it is most marked upon the extensor
surfaces of the arms and legs, especially at the elbows and knees; the
face and scalp, in mild cases, often remain free.


#Name the two varieties of ichthyosis usually described.#

Ichthyosis simplex and ichthyosis hystrix, terms commonly employed to
designate the mild and severe forms respectively.


#Describe the clinical appearances of ichthyosis.#

The milder forms of the disease may be so slight as to give rise to
simple dryness or harshness of the skin (_xeroderma_); but as commonly
met with it is more developed, more or less marked scaliness in the form
of thin or somewhat thick epidermal plates being present. The papillæ of
the skin are often slightly hypertrophied. In slight cases the color of
the scales is usually light and pearly; in the more marked examples it
is dark gray, olive green or black.

In the severe variety--ichthyosis hystrix--in addition to scaliness
there is marked papillary hypertrophy, forming warty or spinous patches.
This type is rare, and, as a rule, the surface involved is more or less
limited.


#Are there any inflammatory symptoms in ichthyosis?#

No. In fact, beyond the disfigurement, the disease causes no
inconvenience; in those well-marked cases, however, in which the scales
are thick and more or less immovable, the natural mobility of the parts
is compromised and fissuring often occurs. In the winter months, in the
severer cases, exposed parts may become slightly eczematous.


#Does ichthyosis vary somewhat with the season?#

Yes. In all cases the disease is better in the warm months, and in the
mild forms may entirely disappear during this time. This favorable
change is purely mechanical--due to the maceration to which the
increased activity of the sweat glands gives rise.


#Is the general health affected in ichthyosis?#

No.


#What course does ichthyosis pursue?#

Chronic. Beginning in early infancy or childhood, it usually becomes
gradually more marked until adult age, after which time it, as a rule,
remains stationary.


#What is the etiology?#

Beyond a hereditary influence, which is often a positive factor, the
causes are obscure. It is not a common disease.


#State the pathology.#

Anatomically the essential feature is epidermic hypertrophy, with
usually a varying degree of papillary hypertrophy also.


#Mention the diagnostic features of ichthyosis.#

The harsh, dry skin, epidermic and papillary hypertrophy, the
furfuraceous or plate-like scaliness, the greater development upon the
extensor surfaces, a history of the affection dating from early
childhood, and the absence of inflammatory symptoms.


#How is ichthyosis to be distinguished from eczema, psoriasis, and other
scaly inflammatory diseases?#

By the absence of the inflammatory element.


#What is the outlook for a case of ichthyosis?#

The prognosis is unfavorable as regards a cure, but the process may
usually be kept in abeyance or rendered endurable by proper measures.


#What treatment would you prescribe for ichthyosis?#

Treatment that has in view removal of the scaliness and the maintenance
of a soft and flexible condition of the skin.

In mild cases frequent warm baths, simple or alkaline, will suffice; in
others an application of an oily or fatty substance, such as the
ordinary oils or ointments, made several hours or immediately before the
bath may be necessary. In moderately developed cases the skin is to be
washed energetically with sapo viridis and hot water, followed by a warm
bath, after which an oily or fatty application is made. In some of the
more severe cases the following plan is often useful: The parts are
first rubbed with a soapy ointment consisting of one part of
precipitated sulphur and seven parts of sapo viridis; a bath is then
taken, the skin wiped dry, and a one to five per cent. ointment of
salicylic acid gently rubbed in.

Glycerine lotions, one or two drachms to the ounce of water, are also
beneficial; as also the following:--

  [Rx] Ac. salicylici, ...................... gr. x-xl
       Glycerini, ........................... [dram]ss-[dram]j
       Lanolin,
       Petrolati, .................. [=a][=a] [Oz]ss

In severe cases of ichthyosis hystrix it may be necessary, also, to
employ caustics or the knife.


#What systemic treatment would you prescribe?#

Constitutional remedies are practically powerless; occasionally some
good is accomplished by the internal administration of linseed oil and
jaborandi.



                               #Onychauxis.#
                  (_Synonym:_ Hypertrophy of the Nail.)


#Describe onychauxis.#

Onychauxis, or hypertrophy of the nail, may take place in one or all
directions, and this increase may be, and often is, accompanied by
changes in shape, color, and direction of growth. One or all the nails
may share in the process. As the result of lateral deviation of growth,
the nail presses upon the surrounding tissues, producing a varying
degree of inflammation--_paronychia_.


#What is the etiology of hypertrophy of the nail?#

The condition may be either congenital or acquired. In the latter
instances it is usually the result of the extension to the matrix of
such cutaneous diseases as psoriasis and eczema; or it is produced by
constitutional maladies, such as syphilis.


#Give the treatment of hypertrophy of the nail.#

Treatment consists in the removal of the redundant nail-tissue by means
of the knife or scissors; and, when dependent upon eczema or psoriasis,
the employment of remedies suitable for these diseases. When it is the
result of syphilis, the medication appropriate to this disease is to be
employed.

In paronychia the nail should be frequently trimmed and a pledget of
lint or cotton be interposed between the edge of the nail and the
adjacent soft parts; astringent powders and lotions may often be
employed with advantage; and in severe and persistent cases excision of
the nail, partial or complete, may be found necessary.



                          #Hypertrichosis.#
    (_Synonyms:_ Hirsuties; Hypertrophy of the Hair; Superfluous Hair.)


#What is meant by hypertrichosis?#

Hypertrichosis is a term applied to excessive growth of hair, either as
regards region, extent, age or sex.


#Describe the several conditions met with.#

The unnatural hair growth may be slight, as, for instance, upon a nævus
(_nævus pilosus_); or it may be excessive, as in the so-called hairy
people (_homines pilosi_); or it may also appear on the face, arms and
other parts in females, resulting from a hypertrophy of the natural
lanugo hairs.


#State the causes of hypertrichosis.#

Hereditary influence is often a factor; the condition may also be
congenital.

If acquired, the tendency manifests itself usually toward middle life.
In women, it is not infrequently associated with diseases of the
utero-ovarian system; in many instances, however, there is no apparent
cause. Local irritation or stimulation has at times a causative
influence.


#How is hypertrichosis to be treated?#

For general hypertrichosis there is no remedy. Small hairy nævi may be
excised, or, as also in the larger hairy moles, the hairs may be removed
by electrolysis.

On the faces of women, if the hairs are coarse or large, electrolysis
constitutes the only satisfactory method; if the hairs are small and
lanugo-like, the operation is not to be advised. It is somewhat painful,
but never unbearable. In the past several years the _x_-ray has been
advocated by several writers, but it requires usually numerous exposures
pushed to the point of producing erythema; it is not without risk, and
the hairs are said to return in some months.


#What temporary methods are usually resorted to for the removal of
superfluous hair?#

Shaving, extraction of the hairs and the use of depilatories. As a
depilatory, a powder made up of two drachms of barium sulphide and three
drachms each of zinc oxide and starch, is commonly (and cautiously)
employed; at the time of application enough water is added to the powder
to make a paste, and it is then spread thinly upon the parts, allowed to
remain five to fifteen minutes, or until heat of skin or a burning
sensation is felt, washed off thoroughly, and a soothing ointment
applied. This preparation must be well prepared to be efficient.


#Describe the method of removal of superfluous hair by electrolysis.#

A fine needle in a suitable handle is attached to the _negative_ pole of
a _galvanic_ battery, introduced into the hair-follicle to the depth of
the papilla, and the circuit completed by the patient touching the
positive electrode; in several seconds slight blanching and frothing
usually appear at the point of insertion; a few seconds later the
current is broken by release of the positive electrode, and the needle
is then withdrawn. Sometimes a wheal-like elevation arises, remains
several minutes or hours, and then disappears; or occasionally, probably
from secondary infection, it develops into a pustule.

A strength of current of a half to two milliamperes is usually
sufficient; the time necessary for the destruction of the papilla
varying from several to thirty seconds.


#How are you to know if the papilla has been destroyed?#

The hair will readily come out with but little, if any, traction.


#What is the result if the current has been too strong or too long
continued?#

The follicle suppurates and a scar results.


#Why should contiguous hairs not be operated upon at the same sitting?#

In order that the chances of marked inflammatory action and scarring
(always possibilities) may be reduced to a minimum.


#In case of failure to destroy an individual papilla, should a second
attempt be made at the same sitting?#

As a rule not, in order to avoid the possibility of too much destructive
action, and consequent scarring.


#Can scarring always be prevented?#

In the average case, with skill and care, the use of an exceedingly fine
needle and the avoidance of too strong a current, _perceptible_ scarring
(scarring perceptible to the ordinary observer or at ordinary distance)
need rarely occur.


#What measures are to be advised for the irritation produced by the
operation?#

Hot-water applications and the use of an ointment made of two drachms
cold cream and ten grains of boric acid are of advantage not only in
reducing the resulting hyperæmia, but also in preventing suppuration and
consequent scarring. To lessen the chances of the latter, cleansing the
parts with alcohol just before and after the operation is also of
service.



                        #[OE]dema Neonatorum.#


#Describe [oe]dema neonatorum.#

The essential symptoms are [oe]dema and a variable degree of hardness
and induration. It develops in the first few days of life, and usually
upon the extremities, especially the lower. It may remain more or less
limited to these parts, but, as a rule, slowly extends. The skin is of a
yellowish, dusky, or livid color, and sometimes glossy or shining. There
are general symptoms of drowsiness, subnormal temperature, weakened
circulation, and impaired respiration, which gradually increase, and in
eighty to ninety per cent. of the cases lead to death. It is believed to
be similar to anasarca in the adult and to be due to like causes.

Treatment consists in maintaining the body-heat, sufficient and proper
nourishment and stimulation.



                           #Sclerema Neonatorum.#
       (_Synonyms:_ Scleroderma Neonatorum; Sclerema of the Newborn.)


#What is sclerema neonatorum?#

Sclerema neonatorum is a disease of infancy, showing itself usually at
or shortly after birth, and is characterized by a diffuse stiffness and
rigidity of the integument, accompanied by coldness, [oe]dema,
discoloration, lividity and general circulatory disturbance.


#Describe the symptoms, course, nature and treatment of sclerema
neonatorum.#

As a rule the disease first manifests itself upon the lower extremities,
and then gradually, but usually rapidly, invades the trunk, arms and
face. The surface is cold. The skin, which is noted to be reddish,
purplish or mottled, is [oe]dematous, stiff and tense; in consequence
the infant is unable to move, respires feebly and usually perishes in a
few days or weeks. In extremely exceptional instances the disease, after
involving a small part, may retrogress and recovery take place.

The disease is rare, and in most cases is found associated with
pneumonia and with affections of the circulatory apparatus.

Treatment should be directed toward maintaining warmth and proper
alimentation.



                               #Scleroderma.#
  (_Synonyms:_ Sclerema; Scleriasis; Dermatosclerosis; Morph[oe]a; Keloid
                                of Addison.)


#What is scleroderma?#

Scleroderma is an acute or chronic disease of the skin characterized by
a localized or general, more or less diffuse, usually pigmented, rigid,
stiffened, indurated or hide-bound condition.

Morph[oe]a, by some formerly thought to be a distinct affection, is now
believed to be a form of scleroderma; as typically met with it is
characterized by one or more rounded, oval, or elongate, coin- to
palm-sized, pinkish, or whitish ivory-looking patches. In some instances
such patches are seen in association with the more classic type of
scleroderma just defined.


#Describe the symptoms of ordinary scleroderma.#

The disease may be acute or chronic, usually the latter. A portion or
almost the entire surface may be involved, or it may occupy variously
sized and shaped areas. The integument becomes more or less rigid and
indurated, hard to the touch, hide-bound, and in marked cases immobile.
[OE]dema may, especially in the more acute cases, precede the
induration. Pigmentation, of a yellowish or brownish color, is often a
precursory and accompanying symptom. The skin feels tight and
contracted, and in some instances numbness and cramp-like pains are
complained of.


#Describe the variety known as morph[oe]a.#

The patches (one, several, or more), occurring most frequently about the
trunk, are in the beginning usually slightly hyperæmic, later becoming
pale-yellowish or white, and having a pinkish or lilac border made up of
minute capillaries. They are, as a rule, sharply defined, with a smooth,
often shining and atrophic-looking surface; are soft, fine or leathery
to the touch, on a level or somewhat depressed, and appearing not unlike
a piece of bacon or ivory laid in the skin. Occasionally the patches are
noted to occur over nerve-tracts. The adjacent skin may be normal or
there may be more or less yellowish or brownish mottling. The subjective
symptoms of tingling, itching, numbness, and even pain, may or may not
be present.


#What is the course of the disease?#

Sooner or later, usually after months or years, the disease ends in
resolution and recovery, or in marked atrophic changes, causing
contraction and deformity. As a rule, the general health remains good.


#State the causes of scleroderma.#

The condition is to be considered as probably of neurotic origin.
Exposure and shock to the nervous system are to be looked upon as
influential. It is a rare disease, observed usually in early adult or
middle life, and is more frequent in women than in men.


#What is the pathology?#

In typical and advanced cases both the true skin and the subcutaneous
connective tissue show a marked increase of connective tissue-element,
with thickening and condensation of the fibers.


#Is there any difficulty in reaching a diagnosis in scleroderma?#

As a rule, no. The characters--rigidity, stiffness, hardness, and
hide-bound condition of the skin--are always distinctive.

The peculiar appearance, the course and character of the patches, of
morph[oe]a are quite distinctive.


#Give the prognosis of scleroderma.#

It should always be guarded. In many instances recovery takes place,
whilst in others the disease is rebellious, lasting indefinitely. The
prognosis of the variety known as morph[oe]a is less unfavorable than
general scleroderma, and recovery more frequent.


#What is the treatment of scleroderma?#

Tonics, such as arsenic, quinia, nux vomica, and cod-liver oil;
conjointly with the local employment of stimulating, oily or fatty
applications, friction, and electricity. Röntgen-ray treatment is often
of value, more especially in the morph[oe]a type.



                             #Elephantiasis.#
  (_Synonyms:_ Elephantiasis Arabum; Pachydermia; Barbadoes Leg; Elephant
                                   Leg.)


#Give a descriptive definition of elephantiasis.#

Elephantiasis is a chronic hypertrophic disease of the skin and
subcutaneous tissue characterized by enlargement and deformity,
lymphangitis, swelling, [oe]dema, thickening, induration, pigmentation,
and more or less papillary growth.

[Illustration: Fig. 35. Elephantiasis of moderate development.]


#What parts are commonly involved in elephantiasis?#

Usually one or both legs; occasionally the genitalia; other parts are
seldom affected.


#Describe the symptoms of elephantiasis.#

The disease usually begins with recurrent (at intervals of months or
years) erysipelatous inflammation, with swelling, pain, heat, redness
and lymphangitis; after each attack the parts remain somewhat increased
in size, although at first not noticeably so. After months or one or two
years the enlargement or hypertrophy becomes conspicuous, the part is
chronically swollen, [oe]dematous and hard; the skin is thickened, the
normal lines and folds exaggerated, the papillæ enlarged and prominent,
and with more or less fissuring and pigmentation.


#What is the further course of the disease?#

There is gradual increase in size, the parts in some instances reaching
enormous proportions; the skin becomes rough and warty, eczematous
inflammation is often superadded, and, sooner or later, ulcers,
superficial or deep, form--which, together with the crusting and
moderate scaliness, present a striking picture. There may be periods of
comparative inactivity, or, after reaching a certain development, the
disease may, for a time at least, remain stationary.


#Are there any subjective symptoms?#

A variable degree of pain is often noted, especially marked during the
inflammatory attacks. The general health is not involved.


#State the cause of elephantiasis.#

The etiology is obscure. The disease rarely occurs before puberty. It is
most common in tropical countries, more especially among the poor and
neglected. It is not hereditary, nor can it be said to be contagious.
Inflammation and obstruction of the lymphatics, probably due, according
to late investigations, to the presence of large numbers of filaria
(microscopic thread-worms) in the lymph channels and bloodvessels, is to
be looked upon as the immediate cause.


#What is the pathology?#

All parts of the skin and subcutaneous connective-tissue are
hypertrophied, the lymphatic glands are swollen, the lymph channels and
bloodvessels enlarged, and there is more or less inflammation, with
[oe]dema. Secondarily, from pressure, atrophy and destruction of the
skin-glands, and atrophic degeneration of the fat and muscles result.


#What are the diagnostic characters of beginning elephantiasis?#

Recurrent erysipelatous inflammation, attended with gradual enlargement
of the parts.

The appearances, later in the course of the disease, are so
characteristic that a mistake is scarcely possible.


#Give the prognosis of elephantiasis.#

If the case comes under treatment in the first months of its
development, the process may probably be checked or held in abeyance;
when well established, rarely more than palliation is possible.


#What is the treatment of elephantiasis?#

The inflammatory attacks are to be treated on general principles.
Quinia, potassium iodide, iron and other tonics are occasionally useful;
and, especially in the earlier stages, climatic change is often of
value. Between the inflammatory attacks the parts are to be rubbed with
an ointment of iodine or mercury, together with galvanization of the
involved part.

In elephantiasis of the leg, a roller or rubber bandage, or the gum
stocking, is to be worn; compression and ligation of the main artery,
and even excision of the sciatic nerve, have all been employed, with
more or less diminution in size as a result. In elephantiasis of the
genitalia, if the disease is well advanced, excision or amputation of
the parts is to be practised.

Eczematous inflammation, if present, is to be treated with the ordinary
remedies.



                           #Dermatolysis.#
                    (_Synonym:_ Cutis Pendula.)


#Give a descriptive definition of dermatolysis.#

Dermatolysis is a rare disease, consisting of hypertrophy and looseness
of the skin and subcutaneous connective tissue, with a tendency to hang
in folds.


#Describe the symptoms and course of dermatolysis.#

It may be congenital or acquired, and maybe limited to a small or large
area, or develop simultaneously at several regions. All parts of the
skin, including the follicles, glands and subcutaneous connective and
areolar tissue, share in the hypertrophy; and this in exceptional
instances may be so extensive that the integument hangs in folds. The
enlargement of the follicles, natural folds and rugæ gives rise to an
uneven surface, but the skin remains soft and pliable. There is also
increased pigmentation, the integument becoming more or less brownish.


#What course does dermatolysis pursue?#

Its development is slow and usually progressive. It gives rise to no
further inconvenience than its weight and consequent discomfort.


#Give the etiology.#

The etiology is obscure. It is considered by some authors as allied to
molluscum fibrosum, and, in fact, as a manifestation of that disease,
ordinary molluscum tumors sometimes being associated with it. It is not
malignant.


#What is the pathology?#

The disease consists of a simple hypertrophy of all the skin structures
and the subcutaneous connective tissue.


#What is the treatment of dermatolysis?#

Excision when advisable and practicable.



#CLASS V.--ATROPHIES.#


                        #Albinismus.#


#What do you understand by albinismus?#

Congenital absence, either partial or complete, of the pigment normally
present in the skin, hair and eyes.


#Describe complete albinismus.#

In complete albinismus the skin of the entire body is white, the hair
very fine, soft and white or whitish-yellow in color, the irides are
colorless or light blue, and the pupils, owing to the absence of pigment
in the choroid, are red; this absence of pigment in the eyes gives rise
to photophobia and nystagmus. _Albinos_--a term applied to such
individuals--are commonly of feeble constitution, and may exhibit
imperfect mental development.


#Describe partial albinismus.#

Partial albinismus is met with most frequently in the colored race. In
this form of the affection the pigment is absent in one, several or more
variously-sized patches; usually the hairs growing thereon are likewise
colorless.


#Is there any structural change in the skin?#

No. The functions of the skin are performed in a perfectly natural
manner, and microscopical examination shows no departure from normal
structure save the complete absence of pigment.


#What is known in regard to the etiology?#

Nothing is known of the causes producing albinismus beyond the single
fact that it is frequently hereditary.


#Does albinismus admit of treatment?#

No; the condition is without remedy.



                          #Vitiligo.#
              (_Synonyms:_ Leucoderma; Leucopathia.)


#Give a definition of vitiligo.#

Vitiligo may be defined as a disease involving the pigment of the skin
alone, characterized by several or more progressive, milky-white patches
surrounded by increased pigmentation.


#Describe the symptoms of vitiligo.#

The disease may begin at one or more regions, the backs of the hands,
trunk and face being favorite parts; its appearance is usually
insidious, and the spots may not be especially noticeable until they are
the size of a pea or larger. The patches grow slowly, are milky or dead
white, smooth, non-elevated, and of rounded outline; the bordering skin
is darker than normal, showing increased pigmentation. Several
contiguous spots may coalesce and form a large, irregularly-shaped
patch. Hair growing on the involved skin may or may not be blanched.

There are no subjective symptoms.


#What course does vitiligo pursue?#

The course of the disease is slow, months and sometimes years elapsing
before it reaches conspicuous development. It may after a time remain
stationary, or, in rare instances, retrogress; as a rule, however, it is
progressive. Exceptionally, the greater part, or even the whole surface
may eventually be involved.


#Give the etiology of vitiligo.#

Disturbed innervation is thought to be influential. The disease develops
often without apparent cause. Alopecia areata and morph[oe]a have been
observed associated with it.

[Illustration: Fig. 36. Vitiligo.]


#State the pathology of vitiligo.#

The disease consists, anatomically, of both a diminution and increase of
the pigment--the white patch resulting from the former, and the
pigmented borders from the latter. There is no textural change, the skin
in other respects being normal.


#From what diseases is vitiligo to be differentiated?#

From morph[oe]a and from the anæsthetic patches of leprosy.


#In what respects do these diseases differ from vitiligo?#

In morph[oe]a there is textural change, and in leprosy both textural
change and constitutional or other symptoms.


#What prognosis is to be given?#

It should always be guarded, the disease in almost all cases being
irresponsive to treatment.


#What is the treatment of vitiligo?#

The general health is to be looked after, and remedies directed
especially toward the nervous system to be employed. Arsenic, in small
and continued doses, seems at times to have an influence; when there is
lack of general tone it may be prescribed as follows:--

  [Rx] Liq. potassii arsenitis, ............. f[dram]j
       Tinct. nucis vom., ................... f[dram]iij
       Elix. calisayæ, ....... q. s. ad ..... f[Oz]iv.    M.

  SIG.--f[dram]j t. d.

Suprarenal-gland preparations in moderate dosage long continued has
appeared in a few instances to be of some benefit.

When upon exposed parts, stimulation of the patches, with the view of
producing hyperæmia and consequent pigment deposit; conjoined with
suitable applications to the surrounding pigmented skin, with a view to
lessen the coloration (see _treatment of chloasma_), will be of aid in
rendering the disease less conspicuous. Or the condition may be, in a
measure, masked by staining the patches with walnut juice or similar
pigment.



                               #Canities.#
                  (_Synonym:_ Grayness of the Hair.)


#Describe canities.#

Canities, or graying of the hair, may occur in localized areas or it may
be more or less general; the blanching may be slight, scarcely amounting
to slight grayness, or it may be complete. It is common to advancing
years (_canities senilis_); it is seen also exceptionally in early life
(_canities præmatura_). The condition is usually permanent. The loss of
pigment takes place, as a rule, slowly, but several apparently authentic
cases have been reported in which the change occurred in the course of a
night or in a few days.


#What is the etiology of canities?#

The causes are obscure. Heredity is usually an influential factor, and
conditions which impair the general nutrition have at times an
etiological bearing. Intense anxiety, fright, and other profound nervous
shock are looked upon as causative in sudden graying of the hair.


#Give the treatment.#

Canities is without remedy. Dyeing, although not to be advised, is often
practised, and the condition thus masked.



                           #Alopecia.#
                     (_Synonym:_ Baldness.)


#What do you understand by alopecia?#

By alopecia is meant loss of hair, either partial or complete.


#Name the several varieties of alopecia.#

The so-called varieties are based mainly upon the etiology, and are
named congenital alopecia, premature alopecia and senile alopecia.


#Describe congenital alopecia.#

Congenital alopecia is a rare condition, in which the hair-loss is
usually noted to be patchy, or the general hair-growth may simply be
scanty. In rare instances the hair has been entirely wanting; in such
cases there is usually defective development of other structures, such
as the teeth.


#Describe premature alopecia.#

Loss of hair occurring in early and middle adult life is not uncommon,
and may consist of a simple thinning or of more or less complete
baldness of the whole or greater part of the scalp. It usually develops
slowly, some months or several years passing before the condition is
well established. It is often idiopathic, and without apparent cause
further than probably a hereditary predisposition. It may also be
symptomatic, as, for example, the loss of hair, usually rapid
(_defluvium capillorum_), following systemic diseases, such as the
various fevers, and syphilis; or as a result of a long-continued
seborrh[oe]a or seborrh[oe]ic eczema (_alopecia furfuracea_).


#Describe senile alopecia.#

This is the baldness so frequently seen developing with advancing years,
and may consist merely of a general thinning, or, more commonly a
general thinning with a more or less complete baldness of the temporal
and anterior portion or of the vertex of the scalp.


#What is the prognosis in the various varieties of alopecia?#

In those cases in which there is a positive cause, as, for instance, in
symptomatic alopecia, the prognosis is, as a rule, favorable, especially
if no family predisposition exists. In the congenital and senile
varieties the condition is usually irremediable. In idiopathic premature
alopecia, the prognosis should be extremely guarded.


#How would you treat alopecia?#

By removing or modifying the predisposing factors by appropriate
constitutional remedies, and by the external use of stimulating
applications.


#Name several remedies or combinations usually employed in the local
treatment.#

Sulphur ointment, full strength or weakened with lard or vaseline; a
lotion of resorcin consisting of one or two drachms to four ounces of
alcohol, to which is added ten to thirty minims of castor oil; and a
lotion made up as follows:--

  [Rx] Tinct. cantharidis, .................. f[dram]iv
       Tinct. capsici, ...................... f[Oz]j
       Ol. ricini, .......................... f[dram]ss-f[dram]j
       Alcoholis, .... q. s. ad ............. f[Oz]iv.            M.

The following is sometimes beneficial:--

  [Rx] Resorcin, ............................ gr. lxxx
       Quininæ (alkaloid), .................. gr. xv
       Ol. ricini, .......................... [minim]v-[minim]xx
       Alcoholis, ........................... f[Oz]iv.--M.

Another excellent formula is:

  [Rx] Resorcin, ............................ gr. lxxx-cxx
       Ac. carbolici cryst., ................ gr. xx
       Spts. myrciæ, ........................ f[Oz]iv.--M.

And also the various other stimulating applications employed in alopecia
areata (_q. v._).

Other measures of value are: Faradic electricity applied daily for five
minutes with a metallic brush or comb; daily massage, with the object of
loosening the skin and giving more freedom to cutaneous and subcutaneous
circulation; and the application, two or three times weekly, of static
electricity by means of the static crown electrode.

(The application selected should be gently--not rubbing--applied daily
or every second or third day, according to the case; if a lotion,
moistening the parts with it; if an ointment, merely greasing the parts.
Shampooing every one to three weeks, according to circumstances.)



                         #Alopecia Areata.#
           (_Synonyms:_ Area Celsi; Alopecia Circumscripta.)


#What do you understand by alopecia areata?#

[Illustration: Fig. 37. Alopecia Areata.]

Alopecia areata is an affection of the hairy system, in which occur one
or more circumscribed, round or oval patches of complete baldness
unattended by any marked alteration in the skin.


#Upon what parts and at what age does the disease occur?#

In the large majority of cases the disease is limited to the scalp; but
it may invade other portions of the body, as the bearded region,
eyebrows, eyelashes, and, in rare instances, the entire integument.

It is most common between the ages of ten and forty.


#Describe the symptoms of alopecia areata.#

The disease begins either suddenly, without premonitory symptoms, one or
several patches being formed in a few hours; or, and as is more usually
the case, several days or weeks elapse before the bald area or areas are
sufficiently large to become noticeable. The patches continue to extend
peripherally for a variable period, and then remain stationary, or
several gradually coalesce and form a large, irregular area involving
the entire or a greater portion of the scalp. The skin of the affected
regions is smooth, faintly pink or milky white, and at first presents no
departure from the normal; sooner or later, however, the follicles
become less prominent, and slight atrophy or thinning may occur, the
bald plaques being slightly depressed.

[Illustration: Fig. 38. Alopecia Areata--complete hair loss.]

Occasionally, usually about the periphery and in the early stages, a few
hair-stumps may be seen.


#What course does alopecia areata pursue?#

Almost invariably chronic. After the lapse of a variable period the
patches cease to extend, the hairs at the margins of the bald areas
being firmly fixed in the follicles; sooner or later a fine, colorless
lanugo or down shows itself, which may continue to grow until it is
about a half-inch or so in length and then drop out; or it may remain,
become coarser and pigmented, and the parts resume their normal
condition. Not infrequently, however, after growing for a time, the new
hair falls out, and this may happen several times before the termination
of the disease.


#Are there any subjective symptoms in alopecia areata?#

As a rule, not; but occasionally the appearance of the patches is
preceded by severe headache, itching or burning, or other manifestations
of disturbed innervation.


#State the cause of alopecia areata.#

The etiology is obscure. Two theories as to the cause of the disease
exist: one of these regards it as parasitic, and the other considers it
to be trophoneurotic. Doubtless both are right, as a study of the
literature would indicate that there are, as regards etiology, really
two varieties--the contagious and the non-contagious. In America
examples of the contagious variety are uncommon.


#Does the skin undergo any alterative or destructive changes?#

Microscopical examination of the skin of the diseased area shows little
or no alteration in its structure beyond slight thinning.


#How do you distinguish alopecia areata from ringworm?#

The plaques of alopecia areata are smooth, often completely devoid of
hair, and free from scales; while those of ringworm show numerous broken
hairs and stumps, desquamation, and usually symptoms of mild
inflammatory action. In doubtful cases recourse should be had to the
microscope.


#What is the prognosis in alopecia areata?#

The disease is often rebellious, but in children and young adults the
prognosis is almost invariably favorable, permanent loss of hair being
uncommon. The same holds true, but to a much less extent, with the
disease as occurring in those of more advanced age. In extensive
cases--those in which the hair of the entire scalp finally entirely
disappears, and sometimes involves all hairy parts--the prognosis is
unfavorable. Only exceptionally does recovery ensue in such instances.

The uncertain duration, however, must be borne in mind; months, and in
some instances several years, may elapse before complete restoration of
hair takes place. Relapses are not uncommon.


#How is alopecia areata treated?#

By both constitutional and local measures, the former having in view the
invigoration of the nervous system, and the latter a stimulating and
parasiticidal action of the affected areas.


#Give the constitutional treatment.#

Arsenic is perhaps the most valuable remedy, while quinine, nux vomica,
pilocarpine, cod-liver oil and ferruginous tonics may, in suitable
cases, often be administered with benefit.


#Name several remedies or combinations employed in the external treatment
of alopecia areata.#

Ointments of tar and sulphur of varying strength; the various mercurial
ointments; the tar oils, either pure or with alcohol; stimulating
lotions, containing varying proportions, singly or in combination, of
tincture of capsicum, tincture of cantharides, aqua ammoniæ, and oil of
turpentine. The following is a safe formula, especially in dispensary
and ignorant class practice:

  [Rx] [beta]-naphthol, ..................... [dram]ss-[dram]j
       Ol. cadini, .......................... [dram]j
     Ungt. sulphuris, .......... q. s. ad ... [Oz]j             M.

The cautious use of a five to twenty per cent. chrysarobin ointment is
of value. Painting the patches with pure carbolic acid or trikresol
every ten days or two weeks sometimes acts well; it should not be
applied over large areas nor used in young children. Galvanization or
faradization of the affected parts may also be employed, and with,
occasionally, beneficial effect. Stimulation with the high-frequency
current by means of the vacuum electrode is also of value. When
practicable, the Finsen light can be applied with hope of benefit and
cure.



                        #Atrophia Pilorum Propria.#
                    (_Synonym:_ Atrophy of the Hair.)


#What do you understand by atrophy of the hair?#

An atrophic, brittle, dry condition of the hair, and which may be either
symptomatic or idiopathic.


#Describe the several conditions met with.#

As a symptomatic affection, the dry, brittle condition of the hair met
with in seborrh[oe]a, in severe constitutional diseases, and in the
various vegetable parasitic affections, may be referred to.

As an idiopathic disease it is rare, consisting simply of a brittleness
and an uneven and irregular formation of the hair-shaft, with a tendency
to split up into filaments (_fragilitas crinium_); or there may be
localized swelling and bursting of the hair-shaft, the nodes thus
produced having a shining, semi-transparent appearance (_trichorrhexis
nodosa_). This latter usually occurs upon the beard and moustache.


#State the causes of atrophy of the hair.#

The causes of the symptomatic variety are usually evident; the etiology
of idiopathic atrophy is obscure, but by many is thought due to
parasitism.

[Illustration: Fig. 39. Trichorrhexis Nodosa. (_After Michelson._)]


#What would be your prognosis and treatment in atrophy of the hair?#

Symptomatic atrophy usually responds to proper measures, but always
slowly; treatment is based upon the etiological factors.

For the idiopathic disease little, as a rule, can be done; repeated
shaving or cutting the hair has, in exceptional instances, been followed
by favorable results.



                            #Atrophia Unguis.#
             (_Synonyms:_ Atrophy of the Nails; Onychatrophia.)


#Describe atrophy of the nails.#

The nails are soft, thin and brittle, splitting easily, and are often
opaque and lustreless, and may have a worm-eaten appearance. Several or
more are usually affected.


#State the causes of atrophy of the nails.#

The condition may be congenital or acquired, usually the latter. It may
result from trauma, or be produced by certain cutaneous diseases,
notably eczema and psoriasis; or it may follow injuries or diseases of
the nerves. Syphilis and chronic wasting constitutional diseases may
also interfere with the normal growth of the nail-substance, producing
varying degrees of atrophy. The fungi of tinea trichophytina and tinea
favosa at times invade these structures and lead to more or less
complete disintegration--_onychomycosis_.

[Illustration: Fig. 40. Atrophy of the Nails.]


#What is the treatment of atrophy of the nails?#

Treatment will depend upon the cause. When it is due to eczema or
psoriasis, appropriate constitutional and local remedies should be
prescribed. If it is the result of syphilis, mercury and potassium
iodide are to be advised. In onychomycosis--an exceedingly obstinate
affection--the nails should be kept closely cut and pared, and a one- to
five-grain solution of corrosive sublimate applied several times a day;
a lotion of sodium hyposulphite, a drachm to the ounce, is also a
valuable and safe application.



                         #Atrophia Cutis.#
            (_Synonyms:_ Atrophoderma; Atrophy of the Skin.)


#What do you understand by atrophy of the skin?#

By atrophy of the skin is meant an idiopathic or symptomatic wasting or
degeneration of its component elements.


#State the several conditions met with.#

Glossy skin, general idiopathic atrophy of the skin, parchment skin,
atrophic lines and spots, senile atrophy, and the atrophy following
certain cutaneous diseases.


#Describe glossy skin (atrophoderma neuriticum), and state the treatment.#

Glossy skin is a rare condition following an injury or disease of the
nerve. It is usually seen about the fingers. The skin is hairless,
faintly reddish, smooth and shining, with a varnished and thin
appearance, and with a tendency to fissuring. More or less severe and
persistent burning pain precedes and accompanies the atrophy.

Protective applications are called for, the disease tending slowly to
spontaneous disappearance.


#Describe general idiopathic atrophy of the skin, and give the treatment.#

General idiopathic atrophy of the skin is extremely rare, and is
characterized by a gradual, more or less general, degenerative and
quantitative atrophy of the skin structures, accompanied usually with
more or less discoloration and pigmentation.

Treatment is palliative and based upon indications.


#Describe parchment skin, and state the treatment.#

Parchment skin (_xeroderma pigmentosum_, _angioma pigmentosum et
atrophicum_) is a rare disease, the exact nature of which is not
understood. It is characterized by the appearance of numerous
disseminated, freckle-like pigment-spots, telangiectases, atrophied
muscles, more or less shrinking and contraction of the integument, and
followed, in most instances, by epitheliomatous tumors and ulceration,
and finally death. It is usually slow in its course, beginning in
childhood and lasting for years. It is not infrequently seen in several
children of the same family.

Treatment is palliative, consisting, if necessary, of the use of
protective applications and of the administration of tonics and
nutrients.


#Describe atrophic lines and spots.#

Atrophic lines and spots (_striæ et maculæ atrophicæ_) may be idiopathic
or symptomatic, the lesions consisting of scar-like or atrophic-looking,
whitish lines and macules, most commonly seen on the trunk. They are
smooth and glistening. Slight hyperæmia usually precedes their
formation. As an idiopathic disease its course is insidious and slow,
and its progress eventually stayed. The so-called _lineæ albicantes_,
resulting from the stretching of the skin produced by pregnancy or
tumors, and from rapid development of fat, may be mentioned as
illustrating the symptomatic variety.

In course of time the atrophy becomes less conspicuous.


#Describe senile atrophy.#

Senile atrophy is not uncommon, the atrophy resulting, as the name
inferentially implies, from advancing age. It is characterized by
thinning and wasting, dryness, and a wrinkled condition, with more or
less pigmentation and loss of hair. Circumscribed pigmentary deposits
and seborrh[oe]a, with degeneration, are also noted.


#What several diseases of the skin are commonly followed by atrophic
changes?#

Favus, lupus, syphilis, leprosy, scleroderma and morph[oe]a.



#CLASS VI.--NEW GROWTHS.#


                              #Keloid.#
                (_Synonyms:_ Keloid of Alibert; Cheloid.)


#Give a descriptive definition of keloid.#

Keloid is a fibro-cellular new growth of the corium appearing as one or
several variously-sized, irregularly-shaped, elevated, smooth, firm,
pinkish or pale-reddish cicatriform lesions.


#Describe the clinical appearance of keloid.#

The growth begins as a small, hard, elevated, pinkish or reddish
tubercle, increasing gradually, several months or years usually elapsing
before the tumor reaches conspicuous size. When developed, it is one or
more inches in diameter, is sharply defined, elevated, hard, rounded or
oval, fungoid or crab-shaped, and firmly implanted in the skin. It is
usually pinkish, pearl-white, or reddish, commonly devoid of hair, with
no tendency to scaliness, and with, usually, several vessels coursing
over it. In some instances it is tender, and it may be spontaneously
painful.

The breast, especially over the sternal region, is a favorite site for
its appearance. One, several or more may be present in the single case.


#What course does keloid pursue?#

Chronic; usually lasting throughout life. In rare instances spontaneous
involution takes place.


#State the etiology of keloid.#

The causes are obscure. The growth usually takes its start from some
injury or lesion of continuity; for instance, at the site of burns,
cuts, acne and smallpox scars, etc.--_cicatricial keloid, false keloid_;
or it may also, so it is thought, originate in normal skin--_spontaneous
keloid, true keloid_.


#What is the pathology of keloid?#

The lesion is a connective-tissue new growth having its seat in the
corium.


#Is there any difficulty in the diagnosis of keloid?#

No. It resembles hypertrophic scar; but this latter, which is
essentially keloidal, never extends beyond the line of injury.


#Give the prognosis.#

The growth is persistent and usually irresponsive to treatment. In some
cases, however, there is eventually a tendency to spontaneous
retrogression, up to a certain point at least.


#What is the treatment of keloid?#

Usually palliative, consisting of the continuous application of an
ointment such as the following:--

  [Rx] Acidi salicylici, .................... gr. x-xx
       Emplast. plumbi,
       Emplast. saponis, ... [=a][=a] ....... [dram]iij
       Petrolati, ........................... [dram]ij.     M.

An ointment of ichthyol, twenty-five per cent. strength, rubbed in once
or twice daily, is sometimes beneficial.

Operative measures, such as punctate and linear scarification,
electrolysis and excision, are occasionally practised, but the results
are rarely satisfactory and permanent; not infrequently, indeed, renewed
activity in the progress of the growth is noted to follow. The _x_-ray
can be tried with some hope of improvement. The administration of
thyroid has been thought to have a possible influence in some instances.



                              #Fibroma.#
         (_Synonyms:_ Molluscum Fibrosum; Fibroma Molluscum.)


#What do you understand by fibroma?#

Fibroma is a connective-tissue new growth characterized by one or more
sessile or pedunculated, pea- to egg-sized or larger, soft or firm,
rounded, painless tumors, seated beneath and in the skin.


#Describe the clinical appearances of fibroma.#

The growth may be single, in which case it is apt to be pedunculated or
pendulous, and attain considerable dimensions; as a result of weight or
pressure surface-ulceration may occur. Or, as commonly met with, the
lesions are numerous, scattered over large surface, and vary in size
from a pea to a cherry; the overlying skin being normal, pinkish or
reddish, loose, stretched, hypertrophied or atrophied.

The tumors are painless. The general health is not involved.

[Illustration: Fig. 41. Fibroma. (_After Octerlony._)]


#What is the course of fibroma?#

Chronic and persistent.


#What is the etiology of fibroma?#

The cause is not known. Heredity is often noted. The affection is not
common.


#State the pathology of fibroma.#

The growths are variously thought to have their origin in the connective
tissue of the corium, or in that of the walls of the hair-sac, or in the
connective-tissue framework of the fatty tissue. Recent tumors are
composed of gelatinous, newly-formed connective tissue, and the older
growths of a dense, firmly-packed, fibrous tissue.


#From what growths is fibroma to be differentiated?#

From molluscum contagiosum, neuroma and lipoma; the first is
differentiated by its central aperture or depression, neuroma by its
painfulness, and lipoma by its lobulated character and soft feel.


#Give the prognosis of fibroma.#

The disease is persistent, and irresponsive to all treatment save
operative measures.


#What is the treatment of fibroma?#

Treatment consists, when desired and practicable, in the removal of the
growths by the knife, or in large and pedunculated tumors by the
ligature or by the galvano-cautery.



                               #Neuroma.#


#Describe neuroma.#

Neuroma of the skin is an exceedingly rare disease, characterized by the
formation of variously-sized, usually numerous, firm, immovable and
elastic fibrous tubercles containing new nerve-elements, and accompanied
by violent, paroxysmal pain. Their growth is slow and usually
progressive. Later they are painful upon pressure. They are limited to
one region.

The tumors are seated in the corium, extending into the deeper
structure, and consist of nerve-fibres, yellow elastic tissue, blood
vessels and lymphoid cells.

In the two cases reported, excision of the nerve-trunk gave, in one
instance, permanent relief; in the other the effect was only temporary.



                              #Xanthoma.#
               (_Synonyms:_ Vitiligoidea; Xanthelasma.)


#What is xanthoma?#

Xanthoma is a connective-tissue new growth characterized by the
formation of yellowish, circumscribed, irregularly-shaped,
variously-sized, non-indurated, flat or raised patches or tubercles.


#Name the two varieties met with.#

The macular or flat (_xanthoma planum_) and the tubercular (_xanthoma
tuberculatum_ or _tuberosum_). In some instances both varieties
(_xanthoma multiplex_) are seen in the same individual.


#Describe the clinical appearances of xanthoma planum.#

The macular or flat variety is usually seen about the eyelids. It
consists of one, several or more small or large, smooth, opaque,
sharply-defined, often slightly raised, yellowish patches, looking not
unlike pieces of chamois-skin implanted in the skin.


#Describe the clinical appearances of xanthoma tuberosum.#

The tubercular variety is commonly met with upon the neck, trunk and
extremities. It occurs as small, raised, isolated, yellowish nodules, or
as patches made up of aggregations of millet-seed-sized or larger
tubercles. The lesions may be few or they may exist in great numbers.


#What is the course of xanthoma?#

Extremely slow; after reaching a certain development the growths may
remain stationary.


#State the etiology of xanthoma.#

The causes are obscure. Jaundice not infrequently precedes and
accompanies its development, especially in the tubercular variety. The
disease is uncommon, and is usually seen in middle and advanced life,
and more frequently in women. In some cases (_xanthoma diabeticorum_) of
general xanthoma diabetes is the causative factor.


#What is the pathology of xanthoma?#

It is a benign, connective-tissue new growth, with concomitant or
subsequent, but usually partial, fatty degeneration.


#Give the prognosis of xanthoma.#

The condition is persistent, and usually irresponsive to all treatment
save destructive or operative measures.

#What is the treatment of xanthoma?#

Treatment consists, in suitable cases, of excision; in some instances,
electrolysis is serviceable. Applications of trichloracetic acid
cautiously made are sometimes of value. In that form of general xanthoma
due to diabetes the treatment of this latter condition will materially
and sometimes completely remove the eruption.



                              #Myoma.#
       (_Synonyms:_ Myoma Cutis; Dermatomyoma; Liomyoma Cutis.)


#Describe myoma.#

The disease is rare, and consists usually of one or several
(exceptionally numerous), variously-sized tumors of the skin, made up of
smooth muscular fibres. They are flat, rounded, oval or pedunculated,
and have a smooth surface and a pale-red color; as a rule, they are
painless.

The growth is benign, and consists essentially of a new formation of
unstriped muscular fibres; but it may also be composed largely of
connective tissue (_fibromyoma_); or it may contain an abundance of
bloodvessels (_myoma telangiectodes_, _angiomyoma_); or there may be
lymphatic involvement (_lymphangiomyoma_).



                             #Angioma.#
           (_Synonyms:_ Nævus Vasculosus; Nævus Sanguineus.)


#Give a definition of angioma.#

Angioma is a congenital hypertrophy of the vascular tissues of the
corium and subcutaneous tissue. Exceptionally it makes its appearance a
few weeks or a month after birth.


#Into what two classes may angiomata be roughly grouped?#

The flat (or non-elevated) and the prominent (or elevated).


#Describe the flat, or non-elevated, variety of angioma.#

The flat, or non-elevated, angioma (_nævus flammeus_, _nævus simplex_,
_angioma simplex_, _capillary nævus_) may be pin-head- to bean-sized; or
it may involve an area of several inches in diameter, and, exceptionally,
a whole region. It is of a bright- or dark-red color, and is met with
most frequently about the face. In some instances it extends after birth,
reaches a certain size and then remains stationary; occasionally, when
involving a small area, it undergoes involution and disappears.

The so-called _port-wine mark_ is included in this group.


#Describe the prominent, or elevated, variety of angioma.#

The prominent variety (_venous n[oe]vus_, _angioma cavernosum_, _n[oe]vus
tuberosus_) is variously-sized, often considerably elevated,
clearly-defined, compressible, smooth or lobulated, and of a dark,
purple color; it may, also, be erectile and pulsating. The growth is
usually a single formation, and is met with upon all parts of the body.


#What is the pathology of angioma?#

It is a new growth, consisting of a variable hypertrophy of the
cutaneous and subcutaneous arterial and venous bloodvessels, with or
without an increase of the connective tissue.


#Give the treatment of angioma.#

In some instances, especially in infants, painting the parts repeatedly
with collodion or liquor plumbi subacetatis will act favorably. For
well-established, small, capillary nævi electrolysis or puncturing with
a red-hot needle or with a needle charged with nitric acid may be
employed; for "port-wine mark" frequent and closely contiguous
electrolytic punctures are occasionally followed by a slight diminution
in color. For the _prominent growths_, vaccination, the ligature,
puncturing with the galvano-cautery, and excision are variously resorted
to.

In recent years applications of liquid air and carbon dioxide have proved
of service in some cases.



                           #Telangiectasis.#


#Describe telangiectasis.#

Telangiectasis consists of a new growth or enlargement of the cutaneous
capillaries, usually appearing during middle adult life, and seated, for
the most part, about the face.


#To what extent may telangiectasis develop?#

It may be limited to a red dot or point, with several small radiating
capillaries (_nævus araneus_, _spider nævus_), or a whole region, usually
the face, may show numerous scattered or closely-set capillary
enlargements or new formations (_rosacea_). The latter is frequently
associated with acne (_acne rosacea_).

The etiology is obscure.


#What is the treatment of telangiectasis?#

Destruction of the vessels by electrolysis or by the knife. (See
treatment of acne rosacea.)



                            #Lymphangioma.#
                    (_Synonym:_ Lymphangiectodes.)


#Describe lymphangioma.#

Lymphangioma is a rare disease, consisting of localized dilatations of
the lymphatic vessels, appearing as discrete or aggregated pin-head or
pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish
or faint lilac color, and occurring for the most part about the trunk.
It is of slow but usually progressive development, and is unaccompanied
by subjective symptoms.

A rare condition, Kaposi described as lymphangioma tuberosum multiplex,
characterized by more or less solid, somewhat cystic, pearly to pinkish
red, sometimes crowded lesions, is now known to be "benign cystic
epithelioma"; its most common site is the face. While called "benign,"
ulcerative action may eventually ensue.

Treatment, when demanded, consists of operative measures.



                          #Rhinoscleroma.#


#Describe rhinoscleroma.#

Rhinoscleroma is a rare and obscure disease, slow but progressive in its
course, characterized by the development of an irregular, dense and
hard, flattened, tubercular, non-ulcerating, cellular new growth, having
its seat about the nose and contiguous parts. The overlying skin is
normal in color, or it may be light- or dark-brown or reddish. Marked
disfigurement and closure, partial or complete, of the nasal orifices
gradually results. It is met with chiefly in Austria and Germany.

Treatment, consisting of partial or complete extirpation, is rarely
permanent in its results, the disease tending to recur.



                          #Lupus Erythematosus.#
      (_Synonyms:_ Lupus Erythematodes; Lupus Sebaceus; Seborrh[oe]a
                                 Congestiva.)


#What is lupus erythematosus?#

Lupus erythematosus may be roughly defined as a mildly to moderately
inflammatory superficial new-growth formation, characterized by one,
several, or more circumscribed, variously sized and shaped, pinkish or
dark red patches, covered slightly, and more or less irregularly, with
adherent grayish or yellowish scales.


#Upon what parts is lupus erythematosus observed?#

Its common site is the face, usually the nose and cheeks, with a
tendency toward symmetry; it is often limited to these parts, but may
occasionally be seen upon other regions, more especially the lips, ears,
and scalp. In rare instances a great part of the general surface may
become involved.


#Describe the symptoms of lupus erythematosus.#

Usually the disease begins as one or several rounded, circumscribed,
pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and
of a pinkish, reddish or violaceous color. They slowly, or somewhat
rapidly, increase in area, and after attaining variable size remain
stationary; or they may progress and coalesce, and in this manner sooner
or later involve considerable surface. The patches are sharply defined
against the sound skin by an elevated border, while the central portion
is somewhat depressed and usually atrophic. More or less thickening and
infiltration are observed. _There is no tendency to ulceration_. The
scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous
or plugged with sebaceous and epithelial matter.

The subjective symptoms of burning and itching are usually slight and
often wanting.


#What course does lupus erythematosus pursue?#

As a rule, the disease is persistent, although somewhat variable. At
times the patches retrogress, involution taking place with or without
slight sieve-like atrophy or scarring.


#State the causes of lupus erythematosus.#

The etiology is obscure. Some observers believe it to be a variety of
cutaneous tuberculosis. It is essentially a disease of adult and middle
age; is more common in women, and more frequent in those having a
tendency to disorders of the sebaceous glands. It may, in fact, begin as
a seborrh[oe]a.


#What is the pathology?#

It was formerly considered a new growth, but recent opinion tends toward
regarding it as a chronic inflammation of the cutis, superinducing
degenerative and atrophic changes. Variable [oe]dema of the prickle
layer and of the cutis is found. There is no tendency to pus formation.

[Illustration: Fig. 42. Lupus Erythematosus.]


#Is there any difficulty in the diagnosis of lupus erythematosus?#

As a rule, not, as the features of the disease--the sharply
circumscribed outline, the reddish or violaceous color, the elevated
border, the tendency to central depression and atrophy, the plugged up
or patulous sebaceous ducts, the adherent grayish or yellowish scales,
together with the region attacked (usually the nose and cheeks)--are
characteristic.


#State the prognosis of lupus erythematosus.#

The disease is often capricious and extremely rebellious to treatment;
some cases, up to a certain point at least, yield readily, and
occasionally a tendency to spontaneous disappearance is observed; a
complete cure is, however, it must be confessed, rather rare. The
disease in nowise compromises the general health. In those rare
instances of generalized disease the patient has usually died from an
intercurrent tuberculosis.


#How is lupus erythematosus to be treated?#

The general health is to be looked after and systemic treatment
prescribed, if indicated. As a rule, constitutional remedies exert
little, if any, influence, but exceptionally, cod-liver oil, arsenic,
phosphorus, salicin, quinine, or potassium iodide proves of service.

Locally, according to the case, soothing remedies, stimulating
applications and destruction of the growth by caustics or operative
measures are to be employed. (_Try the milder applications first._)


#Mention the stimulating applications commonly employed.#

Washing the parts energetically with tincture of sapo viridis, rinsing
and applying a soothing ointment, such as cold cream or vaseline.

A lotion containing zinc sulphate and potassium sulphuret thoroughly
dabbed on the parts morning and evening:--

  [Rx] Zinci sulphatis,
       Potassii sulphurati, .... [=a][=a] ... [dram]i-[dram]iv
       Glycerinæ, ........................... [minim]iv
       Aquæ, ................................ f[Oz]iv.       M.

The calamine-and-zinc oxide lotion used in acute eczema is also often
extremely valuable.

Lotions of ichthyol and of resorcin, five to sixty grains to the ounce;
ichthyol in ointment, five- to twenty-per-cent. strength, is also
useful.

Painting the patches with pure carbolic acid; repeating a day or two
after the crusts have fallen off.

The continuous application of mercurial plaster.

Sulphur and tar ointments, officinal strength or weakened with lard, and
also the following:--

  [Rx] Ol. cadini,
       Alcoholis,
       Saponis viridis, ..... [=a][=a] ...... [dram]iiss.   M.

(This is to be rubbed in, in small quantity, once or twice daily, and
later a soothing remedy applied.)

In recent years both the _x_-ray and Finsen light have been used with
variable success. Repeated applications of the high-frequency current,
with the vacuum electrode, have also proved serviceable. Cautious
applications of liquid air or carbon dioxide have also been used with
some success in the past few years.


#When are destructive and operative measures justifiable?#

In obstinate, sluggish, and long-persistent patches, and then only after
other methods of treatment have failed. (Remember that a patch or
patches of the disease _may_ disappear in course of time spontaneously,
and occasionally _without leaving a scar_.)


#State the methods of treatment commonly used in obstinate, sluggish and
persistent patches of lupus erythematosus.#

Cauterization--with nitrate of silver, with applications of pyrogallic
acid in ointment or in liquor gutta-perchæ, fifteen to thirty per cent.
strength, and with solutions (cautiously employed) of caustic potash,
and exceptionally with the galvano-cautery.

[Illustration: Fig. 43. Single Scarifier.]

[Illustration: Fig. 44. Multiple Scarifier.
  (_As modified by Van Harlingen._)]

Operative--scarification, either punctate or linear, and erosion with the
curette. (See treatment of lupus vulgaris.)



                            #Lupus Vulgaris.#
    (_Synonyms:_ Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the
                                  Skin.)


#What do you understand by lupus vulgaris?#

Lupus vulgaris is a cellular new growth, characterized by
variously-sized, soft, reddish-brown, papular, tubercular and
infiltrated patches, usually terminating in ulceration and scarring.


#Upon what region is lupus vulgaris usually observed?#

The face, especially the nose, but any part may be invaded. The area
involved may be small or quite extensive, usually the former.


#At what age is the disease noted?#

In many cases it begins in childhood or early adult life, but as it is
persistent and tends to relapse, it may be met with at any age.


#Describe the earlier symptoms of lupus vulgaris.#

The disease begins by the development of several or more pin-head to
small pea-sized, deep-seated, brownish-red or yellowish tubercles,
having their seat in the deeper part of the corium, and which are
somewhat softer and looser in texture than normal tissue. As the disease
progresses, variously-sized and shaped aggregations or patches result,
covered with thin and imperfectly-formed epidermis.


#What changes do the lupus tubercles or infiltrations undergo?#

The lesions, having attained a certain size or development, may remain
so for a time, but sooner or later retrogressive changes occur: the
matured papules or tubercles, or infiltrated patches, slowly disappear
by absorption, fatty degeneration, and exfoliation, leaving a yellowish
or brownish pigmentation, usually with more or less atrophy or
cicatricial-tissue formation--_lupus exfoliativus_; or disintegration
and destruction result, terminating in ulceration--_lupus exedens, lupus
exulcerans_. This latter is the more usual course.


#Describe the clinical appearances and behavior of the lupus ulcerations.#

They are rounded, shallow excavations, with soft and reddish borders. In
exceptional instances exuberant granulations appear--_lupus
hypertrophicus_; or papillary outgrowths are noted--_lupus verrucosus_.
The ulcerations secrete a variable amount of pus, usually slight in
quantity, which leads to more or less crust formation; later, however,
cicatricial tissue, generally of a _firm and fibrous_ character,
results.

[Illustration: Fig. 45. Lupus of Arm.]


#In what manner does the disease spread?#

The patches spread by the appearance of new tubercles, or infiltrations
at the peripheral portion. New islets and areas of disease may continue
to make their appearance from time to time, usually upon contiguous
parts.


#Are the mucous membranes of the mouth, throat and larynx ever involved?#

In some instances, and either primarily or secondarily.

[Illustration: Lupus Vulgaris.]

[Illustration: Lupus Vulgaris.]


#Is the bone tissue ever involved in lupus vulgaris?#

No.


#What course does lupus vulgaris pursue?#

It is slowly but, as a rule, steadily progressive. Several years or more
may elapse before the area of disease is conspicuous.


#What is the cause of lupus vulgaris?#

It is now known to be due to the invasion of the cutaneous structures by
the tubercle bacillus; in short, a tuberculosis of the skin. It is not
infrequently observed in the strumous and debilitated. It is entirely
independent of syphilis.


#What is the pathology of lupus vulgaris?#

According to recent investigations, the infiltrations of lupus are due
chiefly to cell-proliferation and outgrowth from the protoplasmic walls
and adventitia of the bloodvessels and lymphatics. The fibrous-tissue
network, vessels and a portion of the cell infiltration are thus
produced, the fixed and wandering connective-tissue cells of the
inflamed stroma of the cutis being responsible for the other portion of
the new growth (Robinson).


#State the diagnostic features of lupus vulgaris.#

In a typical, developed patch of lupus are to be seen:--cicatricial
formation, usually of a fibrous and tough character; ulcerations; the
yellowish-brown tubercles and infiltration; and the characteristic soft,
small, yellowish or reddish-brown, cutaneous and subcutaneous points and
tubercles.


#How does the tubercular syphiloderm differ from lupus vulgaris?#

The tubercular syphiloderm is much more rapid in its course, the
ulceration is deeper and the discharge copious and often offensive; the
scarring is soft, and, compared to the amount of ulceration, but
slightly disfiguring; and it is, for obvious reasons, a disease of adult
or late life. The history, together with other evidences of previous or
concomitant symptoms of syphilis, will often aid in the differentiation.


#How does epithelioma differ from lupus vulgaris?#

The edges of the epitheliomatous ulcer are hard, elevated and waxy; the
base is uneven, the secretion thin, scanty and apt to be streaked with
blood; the ulceration usually starts from one point, and is often
painful; the tissue destruction may be considerable; there is little, if
any, tendency to the formation of cicatricial tissue; and, finally, it
is usually a disease of advanced age.


#In what respects does lupus erythematosus differ from lupus vulgaris?#

Lupus erythematosus has no papules, tubercles or ulceration.


#How does acne rosacea differ from lupus vulgaris?#

Acne rosacea is characterized by hyperæmia, dilated vessels, papules,
pustules, the absence of ulceration, and a different history.


#State the prognosis of lupus vulgaris.#

Lupus vulgaris is always a chronic disease, often exceedingly rebellious
to treatment, and one that calls for a guarded opinion. Relapses are not
uncommon.

[Illustration: Fig. 46.
  Galvano-cautery Needle, Knife and Spiral Points. (_As devised by
  Bésnier._)]

The general health usually remains good, but in some instances death by
tuberculosis of the lungs has been noted.


#Is external or internal treatment called for in lupus vulgaris?#

Always external, and not infrequently constitutional also.


#What is the constitutional treatment?#

The general health must be cared for; good, nutritious food, fresh air
and out-door exercise, together with, in many cases, the administration
of such remedies as cod-liver oil, potassium iodide, iron and quinine,
are of therapeutic importance. Tuberculin may be tried in severe and
obstinate cases, but its use is not without danger.


#State the object of local treatment.#

The destruction or removal of the diseased tissue.


#May milder methods of treatment sometimes prove beneficial and even
curative?#

Exceptionally, mercurial plaster, corrosive-sublimate lotion and
ointment (gr. j to [Oz]j), a plaster containing five to fifteen per
cent. of salicylic acid and creasote, repeated paintings with carbolic
acid, and the constant application of lead plaster containing twenty per
cent. of ichthyol, are valuable.

[Illustration: Fig. 47. Double Curette.]

Of the milder methods, those most in vogue to-day are the _Finsen light_
and _x-ray_. Either proves extremely valuable in some cases, but the
Finsen method is the favorite method.


#What methods are commonly employed for the rapid removal or destruction
of lupus tissue?#

Cauterization, scarification, erasion and excision are variously
practised; the particular method depending, in great measure, upon the
extent of the disease, the part involved, and other circumstances.


#Name the several caustics, and state how they are employed.#

_Pyrogallic acid_, used as an ointment:--

  [Rx] Ac. pyrogallici, ..................... [dram]ij
       Emplast. plumbi, ..................... [dram]j
       Cerat. resinsæ, ...................... [dram]v.      M.

It is applied for one or two weeks. Every several days the parts are
poulticed, the slough thus removed, and the ointment reapplied, and so
on until the diseased tissue has been destroyed. It is useful in those
cases in which a mild and comparatively painless caustic is advisable.
In most cases several repetitions of this plan are necessary.

_Arsenious acid_, employed as an ointment--

  [Rx]  Ac. arseniosi, ...................... gr. xx
        Hydrarg. sulphid. rub., ............. gr. lx
        Ungt. aquæ rosæ, .................... [Oz]i.--M.

It is painful but thorough; it is spread on lint and renewed daily. The
action is usually sufficient in three days, and the parts are then
poulticed until the slough comes away, after which a simple dressing is
employed. Its application is advisable for a small area only--not more
than four square inches--as absorption is possible.

_Galvano-cautery._--The diseased tissue is destroyed by numerous
punctures with a red-heated point or by linear incision with a
red-heated knife. It is often a practicable and satisfactory method. The
Paquelin cautery and liquid air and carbon dioxide also have their
advocates.


#Describe the operative measures employed in the removal of lupus tissue.#

_Linear Scarification._--The parts are thoroughly cross-tracked, cutting
through the diseased tissue, and subsequently a simple salicylated
ointment applied. The operation is repeated from time to time, and as a
result the new growth undergoes retrogressive changes, and cicatrization
takes place.

_Punctate Scarification._--By means of a simple or multiple-pointed
instrument numerous closely-set punctures are made, and repeated from
time to time, usually with the same action and result as from linear
scarification.

_Erasion._--The parts are thoroughly scraped with a curette, and a
supplementary caustic application made, either with caustic potash or
several days' use of the pyrogallic-acid ointment. The result is usually
satisfactory.

The dental-burr is also useful in breaking up discrete tubercles.

_Excision._--This is an effective method if the disease consists of a
small pea- or bean-sized circumscribed patch.

Of these various operative methods those now most favored are erasion
and excision, punctate and linear scarification methods are now rarely
employed.



                       #Tuberculosis Cutis.#[D]
                      (_Synonym:_ Scrofuloderma.)

[Footnote D: The most important clinical variety of this class is lupus
  vulgaris, which is considered above, separately, at some length.]


#What do you understand by tuberculosis cutis?#

The term is applied to those peculiar suppurative and ulcerative
conditions of the skin due to the tubercle bacilli.


#How does the common type of tuberculosis cutis begin?#

The most common type of tuberculous ulceration or involvement of the
skin usually results by extension from an underlying caseating and
suppurating lymphatic gland; or it may have its origin as subcutaneous
tubercles independently of these structures. It tends to spread, and may
involve an area of one or several inches.

[Illustration: Fig. 48. Tuberculosis Verrucosa Cutis (Negro).]


#What are the clinical appearances and behavior of this type of
tuberculous ulceration?#

It is usually superficial, has thin, red, undermined edges of a
violaceous color, and an irregular base with granulations covered
scantily with pus. As a rule, it spreads gradually as a simple
ulceration, with but slight, if any, outlying infiltration. Subjective
symptoms of a painful or troublesome character are rarely present. Its
course is usually progressive but slow and chronic.

Other symptoms of tuberculosis are commonly to be found.


#Are other forms of tuberculosis cutis met with?#

A papulo-pustular eruption is sometimes observed, especially on the
upper extremities and face; sluggish and chronic in character and
leaving small pit-like scars; has been known as the _small pustular
scrofuloderma_.

[Illustration: Fig. 49.
  Tuberculosis Verrucosa Cutis (patient had a coexistent pulmonary
  tuberculosis).]

An ulcerative papillomatous or verrucous tuberculosis of the skin
(tuberculosis verrucosa cutis) is also occasionally noted, most commonly
seated upon the lower leg or the back of the hand. It may be slight or
extensive. Its mildest phase is the so-called verruca necrogenica.


#Describe verruca necrogenica.#

Verruca necrogenica is a rare, localized, papillary or wart-like
formation, occurring usually about the knuckles or other parts of the
hand.

It begins, as a rule, as a small, papule-like growth, increasing
gradually in area, and when well advanced appears as a pea, dime-sized
or larger, somewhat inflammatory, elevated, flat, warty mass, with
usually a tendency to slight pus-formation between the hypertrophied
papillæ; the surface may be horny or it may be crusted. It tends to
enlarge slowly and is usually persistent, but it at times undergoes
involution.

[Illustration: Fig. 50.
  Tuberculosis Cutis (Verruca Necrogenica). (_After Model in Guy's
  Museum._)]


#State the etiology.#

Heredity, insufficient and unwholesome food, impure air, and the like
are predisposing. The tubercle bacillus is the immediate exciting cause.

The disease usually appears in childhood or early adult life, and not
infrequently follows in the wake of some severe systemic disease.
Etiologically it is identical in nature with lupus.


#How is the tuberculous ulcer to be differentiated from syphilis?#

By the peculiar character of the tuberculous ulceration, the absence of
outlying tubercles and infiltration, together with its history, course,
and often the presence of other tuberculous symptoms.


#State the prognosis.#

These various types of tuberculosis cutis are, as a rule, more amenable
to treatment than that form known as lupus vulgaris (_q. v._).


#What is the treatment of these forms of tuberculosis cutis?#

Constitutional remedies, such as cod-liver oil, iodide of iron or other
ferruginous tonics, together with good food and pure air; phosphorus
one-hundredth to one-fiftieth of a grain three times daily is also of
benefit in some cases.

The local treatment consists in thorough curetting and the subsequent
application of a mildly stimulating ointment. The several other plans of
external treatment employed in lupus (_q. v._) are also variously
practised. In recent years the _x_-ray and Finsen light plans have, in a
measure, supplanted the previous methods of treatment. They are slow,
however, and might be, especially the _x_-ray, more satisfactorily
employed as a supplementary measure.



                              #Ainhum.#


#Describe ainhum.#

Ainhum is a disease of the African race, met with chiefly in Brazil, the
West Indies, and Africa, and consists of a slow but gradual linear
strangulation of one or more of the toes, especially the smallest,
resulting, eventually, in spontaneous amputation. The affected toes
themselves undergo fatty degeneration, often with increase in size, and
are, when strangulation is well advanced, considerably misshapen. The
nature of the disease is obscure.

_Treatment_ consists, in the early stages, of incision through the
constricting band; when the disease is well advanced, amputation is the
sole recourse.



                             #Mycetoma.#
       (_Synonyms:_ Fungous Foot of India; Madura Foot; Podelcoma.)


#Decribe mycetoma.#

It is a disease involving usually the foot, and is met with chiefly in
India. It is characterized by swelling and the formation of tubercular
or nodular lesions which break down and form the external openings of
sinuses which lead to the interior of the affected part. These
discharge, and are studded with, whitish granules or black, roe-like
masses, mixed with a sanious or sero-purulent fluid. The whole part is
gradually disintegrated, the process lasting indefinitely. Its nature is
obscure; it is thought to be due to a fungus.

_Treatment_ consists in the early stages, when the disease is limited,
of thorough curetting and cauterization; later, after the part is more
or less involved, amputation, at a point well up beyond the disease,
becomes necessary. Potassium iodide internally may exert a favorable
influence.



                    #Perforating Ulcer of the Foot.#


#Describe perforating ulcer of the foot.#

Perforating ulcer of the foot is a rare disease, consisting of an
indolent and usually painless sinus leading down to diseased bone. The
external opening, which is through the centre of a corn-like formation,
is small, and may or may not show the presence of granulations. The
affected part is commonly more or less anæsthetic and of subnormal
temperature. One or several may be present, either on one or both feet.
The most common site is over the articulation of the metatarsal bone
with the phalanx of the first or last toe. The disease is dependent upon
impairment or degeneration of the central, truncal or peripheral nerves.


#What is to be said in regard to the prognosis and treatment?#

Treatment, which is, as a rule, unsatisfactory, consists in the
maintenance of absolute rest, and the use of antiseptic and stimulating
applications. Amputation is also resorted to, but even this is at times
futile, as a new sinus may appear upon the stump.



                        #Syphilis Cutanea.#
    (_Synonyms:_ Syphiloderma; Dermatosyphilis; Syphilis of the Skin.)


#In what various types may syphilis manifest itself upon the integument?#

Syphilis may show itself as a macular, papular (rarely vesicular),
pustular, bullous, tubercular and gummatous eruption; or the eruption
may be, in a measure, of a mixed type.


#In what respects do the early (or secondary) eruptions of syphilis
differ from those following several years or more after the contraction
of the disease?#

The early or secondary eruptions are more or less generalized, with
rarely any attempt at special configuration. Their appearance is often
preceded by symptoms of systemic disturbance, such as fever, loss of
appetite, muscular pains and headache; and accompanied by concomitant
signs of the disease, such as enlargement of the lymphatic glands, sore
throat, mucous patches, falling of the hair and rheumatic pains.


#State the distinguishing characters of the late eruptions.#

The late eruptions (those following one or more years after the
contraction of the disease) are usually of tubercular, gummatous or
ulcerative type; are limited in extent, and have a marked tendency to
appear in circular, semicircular or crescentic forms or groups. Pain in
the bones, bone lesions and other symptoms may or may not be present.


#What is the color of syphilitic lesions?#

Usually, a dull brownish-red or ham-red, with at times a yellowish cast.


#Are there any subjective symptoms in syphilitic eruptions?#

As a rule, no; but in exceptional instances of the generalized
eruptions, more especially in negroes, there may be slight itching.


#Describe the macular, or erythematous, eruption of syphilis.#

The _macular syphiloderm_ is a general eruption, showing itself usually
six or eight weeks after the appearance of the chancre. It consists of
small or large, commonly pea- or bean-sized, rounded or
irregularly-shaped, not infrequently slightly raised, macules. When well
established they do not entirely disappear under pressure. At first a
pale-pink or dull, violaceous red, they later become yellowish or
coppery. The eruption is generally profuse; the face, backs of the hands
and feet may escape. It persists several weeks or one or two months; as
a rule, it is rapidly responsive to treatment.


#How would you distinguish the macular syphiloderm from measles, rötheln
and tinea versicolor?#

Measles is to be differentiated by its catarrhal symptoms, fever, form
and situation of the eruption; rötheln, by its small, roundish,
confluent pinkish or reddish patches, its precursory pyrexic symptoms,
its epidemic nature, and short duration; tinea versicolor by its
scaliness, peripheral growth, distribution and history.

And, finally, by the absence or presence of other symptoms of syphilis.

[Illustration: Fig. 51. Macular Syphiloderm.]


#What several varieties of the papular eruption of syphilis are met with?#

There are two forms of the papular eruption--the small and large; those
of the latter type may undergo various modifications.


#Describe the small-papular eruption of syphilis.#

The _small-papular syphiloderm_ (_miliary papular syphiloderm_) usually
shows itself in the third or fourth month of the disease, and consists
of a more or less generalized eruption of disseminated or grouped, firm,
rounded or acuminated pin-head to millet-seed-sized papules, with smooth
or slightly scaly summits, and in some lesions showing pointed
pustulation. Scattered minute pustules and some large papules are
usually present. The eruption is profuse, most abundant upon the trunk
and limbs; and in the early part of the outbreak is of a bright- or
dull-red color, later assuming a violaceous or brownish tint. It runs a
chronic course, is somewhat rebellious to treatment, and displays a
tendency to relapse.

[Illustration: Fig. 52. Moist Papules. (_After Miller._)]


#How would you distinguish the small-papular syphiloderm from keratosis
pilaris, psoriasis punctata, papular eczema, and lichen ruber?#

The distribution and extent of the eruption, the color, the grouping,
with usually the presence of pustules and large papules and other
concomitant symptoms of syphilis, are points of difference. Pustules
never occur in the several diseases named, except in eczema.


#Describe the large-papular eruption of syphilis.#

The _large-papular syphiloderm_ (or _lenticular syphiloderm_) is a
common form of cutaneous syphilis, appearing usually in the first six or
eight months, and consists of a more or less generalized eruption of
pea- to dime-sized or larger, flat, rounded or oval, firmly seated,
more or less raised, dull-red papules; with at first a smooth surface,
which later usually becomes covered with a film of exfoliating
epidermis. The papules, as a rule, develop slowly, remain stationary
several weeks or a few months, and then pass away by absorption, leaving
slight pigmentation, which gradually fades; or they may undergo certain
modifications. In most cases it responds rapidly to treatment.

[Illustration: Small-papular Syphiloderm.]

[Illustration: Fig. 53. Palmar Syphiloderm.]


#What modifications do the papules of the large-papular syphiloderm
sometimes undergo?#

They may change into the moist papule and squamous papule.


#Describe the moist papule of syphilis.#

The change into the moist papule (also called _mucous patch, flat
condyloma_) is not uncommon where opposing surfaces and natural folds of
skin are subjected to more or less contact, as about the anus, the
scroto-femoral regions, umbilicus, axillæ and beneath the mammæ. The
dry, flat papules gradually become moist and covered with a grayish,
sticky, mucoid secretion; several may coalesce and form large, flat
patches. They may so remain, or they may become hypertrophic, warty or
papillomatous, with more or less crust formation (_vegetating
syphiloderm_).

[Illustration: Fig. 54. Annular Syphiloderm. (_After I.E. Atkinson._)]


#Describe the squamous papule of syphilis.#

This tendency of the large-papular eruption to become scaly, when
exhibited, is more or less common to all papules, and constitutes the
_squamous_ or _papulo-squamous syphiloderm_ (improperly called
_psoriasis syphilitica_). The papules become somewhat flattened and are
covered with dry, grayish or dirty-gray, somewhat adherent scales. The
scaling, as compared to that of psoriasis, is, as a rule, relatively
slight. The eruption may be general, as usually the case in the earlier
months of the disease, or it may appear as a relapse or a later
manifestation, and be limited in extent.

As a limited eruption it is most frequently seen on the palms and
soles--the _palmar and plantar syphiloderm_. Occurring on these parts it
is often rebellious to treatment.

[Illustration: Maculo-papular syphiloderm.]


#How are you to distinguish the papulo-squamous syphiloderm from
psoriasis?#

In psoriasis the eruption is more inflammatory, and usually bright red;
the scales whitish or pearl-colored and, as a rule, abundant. It is
generally seen in greater profusion upon certain parts, as, for
instance, the extensor surfaces, especially of the elbows and knees. It
is not infrequently itchy, and, moreover, presents a different history.

In the syphilitic eruption some of the papules almost invariably remain
perfectly free from any tendency to scale formation; there is distinct
deposit or infiltration, and the lesions are of a dark, sluggish red or
ham tint; and, moreover, concomitant symptoms of syphilis are usually
present.


#Describe the annular eruption of syphilis.#

The _annular syphiloderm_ (_circinate syphiloderm_) is observed usually
in association with the large-papular eruption, and consists of several
or more variously sized, ring-like lesions, with a distinctly elevated
solid ridge or wall peripherally and a more or less flattened centre. It
is commonly seen about the mouth, forehead and neck. The lesion appears
to have its origin from an ordinary, usually scaleless or slightly
scaly, large papule, the central portion of which has been incompletely
formed or has become sunken and flattened. The manifestation is rare,
and is seen most frequently in the negro.


#What several varieties of the pustular syphiloderm are met with?#

The small acuminated-pustular syphiloderm, the large acuminated-pustular
syphiloderm, the small flat-pustular syphiloderm, and the large
flat-pustular syphiloderm.


#Describe the small acuminated-pustular eruption of syphilis.#

The _small acuminated-pustular syphiloderm_ (_miliary pustular
syphiloderm_) is an early or late secondary eruption, commonly
encountered in the first six or eight months of the disease. It
consists of a more or less generalized, disseminated or grouped,
millet-seed-sized, acuminated pustules, usually seated upon dull-red,
papular elevations. The eruption is, as a rule, profuse, and usually
involves the hair-follicles. The pustules dry to crusts, which fall off
and are often followed by a slight, fringe-like exfoliation around the
base, constituting a grayish ring or collar. Minute pin-point atrophic
depressions or stains are left, which gradually become less distinct.
Scattered large pustules, and sometimes papules, are not infrequently
present.


#Describe the large acuminated-pustular eruption of syphilis.#

The _large acuminated-pustular syphiloderm_ (_acne-form syphiloderm_,
_variola-form syphiloderm_) is a more or less generalized eruption,
occurring usually in the first six or eight months of the disease. It
consists of small or large pea-sized, disseminated or grouped,
acuminated or rounded pustules, resembling the lesions of acne and
variola. They develop slowly or rapidly, and at first may appear more or
less papular. They dry to somewhat thick crusts, and are seated upon
superficially ulcerated bases.

It pursues, as a rule, a comparatively rapid and benign course. In
relapses the eruption is usually more or less localized.


#How would you distinguish the large acuminated-pustular syphiloderm from
acne and variola?#

In acne the usual limitation of the lesions to the face or face and
shoulders, the origin, more rapid formation and evolution of the
individual lesions, and the chronic character of the disease, are
usually distinctive points.

In variola, the intensity of the general symptoms, the shot-like
beginning of the lesions, their course, the umbilication, and the
definite duration, are to be considered.

The presence or absence of other symptoms of syphilis has, in obscure
cases, an important diagnostic bearing.


#Describe the small flat-pustular eruption of syphilis.#

The _small flat-pustular syphiloderm_ (_impetigo-form syphiloderm_)
consists of a more or less generalized, pea-sized, flat or raised,
discrete, irregularly-grouped, or in places confluent, pustules,
appearing usually in the first year of the disease. The pustules dry
rapidly to yellow, greenish-yellow, or brownish, more or less adherent,
thick, uneven, somewhat granular crusts, beneath which there may be
superficial or deep ulceration; where the lesions are confluent a
continuous sheet of crusting forms. The eruption is often scanty. It is
most frequently observed about the nose, mouth, hairy parts of the face
and scalp, and about the genitalia, frequently in association with
papules on other parts.


#Are you likely to mistake the small flat-pustular syphiloderm for any
other eruption?#

Scarcely; but when upon the scalp, it may bear rough resemblance to
pustular eczema, but the erosion or ulceration will serve to
differentiate. Moreover, concomitant symptoms of syphilis are to be
looked for.


#Describe the large flat-pustular eruption of syphilis.#

The _large flat-pustular syphiloderm_ (_ecthyma-form syphiloderm_)
consists of a more or less generalized, scattered eruption, of large
pea- or dime-sized, flat pustules. They dry rapidly to crusts. The bases
of the lesions are a deep-red or copper color. Two types of the eruption
are met with.

In one type--the superficial variety--the crust is flat, rounded or
ovalish, of a yellowish-brown or dark-brown color, and seated upon a
superficial erosion or ulcer. The lesions are usually numerous, and most
abundant on the back, shoulders and extremities. It appears, as a rule,
within the first year, and generally runs a benign course.

[Illustration: Fig. 55. Rupia. (_After Tilbury Fox._)]

In the other type--the deep variety--the crust is greenish or blackish,
is raised and more bulky, often conical and stratified, like an oyster
shell--_rupia_; beneath the crusts may be seen rounded or
irregular-shaped ulcers, having a greenish-yellow, puriform secretion.
It is usually a late and malignant manifestation.


#How would you differentiate the large flat-pustular syphiloderm from
ecthyma?#

The syphilitic lesions are more numerous, are scattered, are attended
with superficial or deep ulceration, and followed by more or less
scar-formation. Moreover, the history, and presence or absence of other
symptoms of syphilis have an important diagnostic value.

[Illustration: Fig. 56. Ulcerating Tubercular Syphiloderm.]


#Describe the bullous eruption of syphilis.#

The _bullous syphiloderm_, (of acquired syphilis) is a rare and usually
late eruption, appearing in the form of discrete, disseminated, rounded
or ovalish, pea- to walnut-sized, partially or fully distended, blebs.
The serous contents soon become cloudy and puriform. In some cases the
lesions are distinctly pustular from the beginning. The crust, which
soon forms, is of a yellowish-brown or dark green color, and may be
thick and stratified (_rupia_), as in the deep variety of the large
flat-pustular syphiloderm. The erosions or ulcers beneath the crusts
secrete a greenish-yellow fluid. It is a malignant type of eruption, and
is usually seen in broken-down subjects.

It is not an uncommon manifestation of hereditary syphilis (_q. v._) in
the newborn.

[Illustration: Fig. 57. Tubercular Syphiloderm.]


#How is the bullous syphiloderm to be differentiated from other
pemphigoid eruptions?#

By the gravity of the disease, the accompanying ulceration, the course
and history; and by other evidences, past or present, of syphilis.


#Describe the tubercular eruption of syphilis.#

The _tubercular syphiloderm_ (_syphiloderma tuberculosum_) may
exceptionally occur within the first year as a more or less generalized
eruption. As a rule, however, it is a late manifestation, at times
appearing many years after the initial lesion; is limited in extent, and
shows a decided tendency to occur in groups, often forming segments of
circles and circular areas, clearing in the centre and spreading
peripherally.

It consists (as a late, limited manifestation) of several or more firm,
circumscribed, deeply-seated, smooth, glistening or slightly scaly
elevations; rounded or acuminated in shape, of a yellowish-red,
brownish-red or coppery color and usually of the size of small or large
peas. Several groups may coalesce, and a serpiginous tract result
(_serpiginous tubercular syphiloderm_). The lesions develop slowly, and
are sluggish in their course, remaining, at times, for weeks or months,
with but little change. As a rule, however, they terminate sooner or
later, either by absorption, leaving a more or less permanent pigment
stain with or without slight atrophy (_non-ulcerating tubercular
syphiloderm_), or by ulceration (_ulcerating tubercular syphiloderm_).

[Illustration: Fig. 58. Ulcerating Tubercular Syphiloderm.]


#Describe the ulcerating tubercular syphiloderm.#

The ulceration may be superficial or deep in character, and involve
several or all of the lesions forming the group. The patch may consist,
therefore, of small, discrete, punched-out ulcers, or of one or more
continuous ulcers, segmented, crescentic or serpiginous in shape. They
are covered with a gummy, grayish-yellow deposit or they may be crusted.
As the ulcerative changes take place, new lesions, especially about the
periphery of the group or patch, may appear from time to time.

[Illustration: Tubercular Syphiloderm.]

[Illustration: Large-pustular Syphiloderm.]

In some instances, more especially about the scalp, the surface of the
ulcerations becomes papillary or wart-like, with an offensive,
yellowish, puriform secretion (_syphilis cutanea papillomatosa_).


#From what diseases is the tubercular syphiloderm to be differentiated?#

From tubercular leprosy, epithelioma and lupus vulgaris, especially the
last-named.


#What are the chief diagnostic characters of the tubercular syphiloderm?#

The tendency to form segments, crescents and circles, the color, the
pigmentation and ulceration, the history, and not infrequently marks or
scars of former eruptions.

[Illustration: Fig. 59. Tubercular Syphiloderm.]


#Describe the gummatous eruption of syphilis.#

The _gummatous syphiloderm_ (_syphiloderma gummatosum_, _gumma_,
_syphiloma_) is usually a late manifestation, showing itself as one,
several or more painless or slightly painful, rounded or flat, more or
less circumscribed tumors; they are slightly raised, moderately firm,
and have their seat in the subcutaneous tissue. They tend to break down
and ulcerate.

The lesion begins usually as a pea-sized deposit or infiltration, and grows
slowly or rapidly; when fully developed it may be the size of a walnut,
or even larger. The overlying skin becomes gradually reddish. At first
firm, it is later soft and doughy. It may, even when well advanced,
disappear by absorption, but usually tends to break down, terminating in
a small or large, deep, punched-out ulcer.

[Illustration: Fig. 60. Tubercular Syphiloderm.]


#Does the gummatous syphiloderm invariably appear as a rounded
well-defined tumor?#

No. Exceptionally, instead of a well-defined tumor, it may appear as a
more or less diffused patch of infiltration, leading eventually to
extensive superficial or deep ulceration.


#From what formations is the gummatous syphiloderm to be differentiated?#

From furuncle, abscess, and sebaceous, fatty and fibroid tumors.

Attention to the origin, course, and behavior of the lesion, together
with a history, must all be considered in doubtful cases.

[Illustration: Fig. 61. Large Pustular Syphiloderm.]


#What is to be said in regard to the character and time of appearance of
the cutaneous manifestations of hereditary syphilis?#

In a great measure the cutaneous manifestations of hereditary syphilis
are essentially the same as observed in acquired syphilis. They are
usually noted to occur within the first three months of extra-uterine
life. The macular, papular, and bullous eruptions are most common.


#Describe these several cutaneous manifestations of hereditary syphilis.#

The _macular_ (erythematous) eruption begins as large or small, bright-
or dark-red macules, later presenting a ham or café-au-lait appearance.
At first they disappear upon pressure. The lesions are more or less
numerous, usually become confluent, especially about the folds of the
neck, about the genitalia and buttocks; in these regions resembling
somewhat erythema intertrigo.

The _papular_ eruption is observed in conjunction with the erythematous
manifestation, or it occurs alone. The lesions are but slightly
elevated, and seem to partake of the nature of both macules and papules.
They are usually discrete, and rarely abundant; they may become decked
with a film-like scale, and at the various points of junction of skin
and mucous membrane, and in the folds, they become abraded and
macerated, developing into _moist papules_.

The _bullous_ eruption consists of variously-sized, more or less
purulent blebs, and is usually met with at or immediately following
birth. It is most abundant about the hands and feet. Macules and papules
are often interspersed. There may be superficial or deep ulceration
underlying the bullæ.


#What other symptoms in addition to the cutaneous manifestations are
noted in hereditary syphilis in the newborn?#

Mucous patches, and sometimes ulcers, in the mouth and throat;
hoarseness, as shown by the peculiar cry, and indicating involvement of
the larynx; snuffles, a sallow and dirty appearance of the skin, loss of
flesh and often a shriveled or senile look.


#What is the pathology of cutaneous syphilis?#

The syphilitic deposit consists of round-cell infiltration. The mucous
layer, the corium, and in the deep lesions the subcutaneous connective
tissues also, are involved in the process. The infiltration disappears
by absorption or ulceration. The factor now believed to be responsible
for the disease and the pathological changes is the Spirochæta pallida,
discovered by Schaudinn and Hoffmann, and usually found in numbers in
the tissues.


#Give the prognosis of cutaneous syphilis.#

In _acquired syphilis_, favorable; sooner or later, unless the whole
system is so profoundly affected by the syphilitic poison that a fatal
ending ensues, the cutaneous manifestations disappear, either
spontaneously or as the result of treatment. The earlier eruptions will
often pass away without medication, but treatment is of material aid in
moderating their severity and hastening their disappearance, and is to
be looked upon as essential; in the late syphilodermata treatment is
indispensable. In the large pustular, the tubercular and gummatous
lesions, considerable destruction of tissue may take place, and in
consequence scarring result. Ill-health from any cause predisposes to a
relapse, and also adds to the gravity of the case.

In _hereditary infantile syphilis_, the prognosis is always uncertain:
the more distant from the time of birth the manifestations appear the
more favorable usually is the outcome.


#How is cutaneous syphilis to be treated?#

Always with constitutional remedies; and in the graver eruptions, and
especially in those more or less limited, with local applications also.


#What constitutional and local remedies are commonly employed in
cutaneous syphilis?#

_Constitutional Remedies._--Mercury and potassium iodide; tonics and
nutrients are necessary in some cases.

_Local Remedies._--Mercurial ointments, lotions and baths, and iodol in
ointment or in (and also calomel) powder form.


#Give the constitutional treatment of the earlier, or secondary,
eruptions of syphilis.#

In secondary or early eruptions mercury alone in almost every case; with
tonics, if called for. If mercury is contraindicated (extremely rare),
potassium iodide may be substituted.


#How is mercury usually administered in the eruptions of secondary
syphilis?#

By the mouth, chiefly as the protiodide, calomel and blue mass, in
dosage just short of mild physiological action; by _inunction_, in the
form of blue ointment; by _hypodermic injection_, usually as corrosive
sublimate solution. The method by _fumigation_, with calomel or
bisulphuret, is now rarely employed.

The method by the mouth is the common one, and it is only in rare
instances that any other method is necessary or advisable.


#What local applications are usually advised in the eruptions of
secondary syphilis?#

If the eruption is extensive, and more especially in the pustular types,
baths of corrosive sublimate ([dram ii-dram-iv] to Cong. xxx) may be
used; and ointment of ammoniated mercury, twenty to sixty grains to the
ounce, blue ointment, and the ten per cent. oleate of mercury alone or
with an equal quantity of any ointment base.

The same applications or a dusting powder of calomel may also be used on
moist papules.


#How long is mercury to be actively continued in cases of early
(secondary) syphilis?#

Until one or two months after all manifestations (cutaneous or other)
have disappeared, and then, as a general rule, continued, as a small
daily dose (about one-quarter to one-third of that prescribed during the
active treatment) for a period of two or three months; then another
cycle of the active dosage for a period of four to six weeks; then a
resumption of the smaller daily dose for another two or three months;
and so on, for a period of at least two years.

(Almost all authorities are agreed as to the importance of prolonged
treatment, but differ somewhat on the question of intermittent or
uninterrupted administration.)


#Give the constitutional treatment of the late, or localized,
syphilodermata.#

Mercury always, usually in small or moderate dosage, as the biniodide or
corrosive chloride, and potassium iodide; the latter in dose varying
from two grains to two drachms or more, t.d., depending upon its action
and the urgency of the case.


#How long is constitutional treatment to be continued in cases of the
late syphilodermata?#

Actively for several weeks after the disappearance of all symptoms, and
then (especially the mercury) continued in smaller dosage (about
one-third) for several months longer.


#What applications are usually advised in the late, or localized,
syphilodermata?#

Ointment of ammoniated mercury, twenty to sixty grains to the ounce;
oleate of mercury, five to ten per cent. strength; mercurial plaster,
full strength or weakened with lard or petrolatum; a two to twenty per
cent. ointment of iodol; resorcin, twenty to sixty grains to the ounce
of ointment base; and lotions of corrosive sublimate, one-half to three
grains to the ounce.

The following is valuable in offensive and obstinate ulcerations:--

  [Rx] Hydrarg. chlorid. corros., ........... gr. iv-gr. viij
       Ac. carbolici, ....................... gr. x-xx
       Alcoholis, ........................... f[dram]iv
       Glycerinæ, ........................... f[dram]j
       Aquæ, ............ q.s. ad ........... [Oz]iv.       M.

Ointments are to be rubbed in or applied as a plaster; lotions, employed
chiefly in ulcers and ulcerations, are to be thoroughly dabbed on, and
usually supplemented by the application of an ointment. Iodol may also be
applied to ulcers as a dusting-powder, usually mixed with one to several
parts of zinc oxide or boric acid.


#Give the treatment of hereditary infantile syphilis.#

It is essentially the same (but much smaller dosage) as employed in
acquired syphilis. Attention to proper feeding and hygiene is of first
importance.

Mercury may be given by the mouth, as mercury with chalk (gr. ss-gr. ij,
t.d.); as calomel (gr. 1/20-gr. 1/6, t.d.); and as a solution of
corrosive sublimate (gr. ss-[Oz]vj, [dram]j, t.d.). If mercury is not
well borne by the stomach, it may be administered by inunction; for this
purpose, blue ointment is mixed with one or two parts of lard and spread
(about a drachm) upon an abdominal bandage and applied, being renewed
daily. Treatment by means of baths (gr. x-xxx to the bath) of corrosive
sublimate is, at times, a serviceable method.

Potassium iodide, if exceptionally deemed preferable, may be given in
the dose of a fractional part of a grain to two or three grains three
times daily.


#What local measures are to be advised in cutaneous syphilis of the
newborn?#

If demanded, applications similar to those employed in eruptions of
acquired syphilis, but not more than one-third to one-half the strength.



                               #Lepra.#
              (_Synonyms:_ Leprosy; Elephantiasis Græcorum.)


#What do you understand by leprosy?#

Lepra, or leprosy, is an endemic, chronic, malignant constitutional
disease, characterized by alterations in the cutaneous, nerve, and bone
structures; varying in its morbid manifestations according to whether
the skin, nerves or other tissues are predominantly involved.


#What is the nature of the premonitory symptoms of leprosy?#

In some instances the active manifestations appear without premonition,
but in the majority of cases symptoms, slight or severe in character,
pointing toward profound constitutional disturbance, such as mental
depression, malaise, chills, febrile attacks, digestive derangements and
bone pains, are noticed for weeks, months, or several years preceding
the outbreak.


#What several varieties of leprosy are observed?#

Two definite forms are usually described--the tubercular and the
anæsthetic. A sharp division-line cannot, however, always be drawn; not
infrequently the manifestations are of a mixed type, or one form may
pass into or gradually present symptoms of the other.

[Illustration: Fig. 62. Tubercular Leprosy. (_After Stoddard._)]


#Describe the symptoms of tubercular leprosy.#

The formation of tubercles and tubercular masses of infiltration,
usually of a yellowish-brown color, with subsequent ulceration,
constitute the important cutaneous symptoms. Along with, or preceding
these characteristic lesions, blebs and more or less infiltrated,
hyperæsthetic or anæsthetic, pinkish, reddish or pale-yellowish macules
make their appearance from time to time; subsequently fading away or
remaining permanently (_lepra maculosa_).

When well advanced, the tubercular or nodular masses give rise to great
deformity; the face, a favorite locality, becomes more or less leonine
in appearance (_leontiasis_). The tubercles persist almost indefinitely
without material change, or undergo absorption or ulceration; this last
takes place most commonly about the fingers and toes. The mucous
membrane of the mouth, pharynx and other parts may also become involved.

[Illustration: Fig. 63. Anæsthetic Leprosy.]


#Describe the symptoms of anæsthetic leprosy.#

Following or along with precursory symptoms denoting general systemic
disturbance, or independently of any prodromal indications, a
hyperæsthetic condition, in localized areas or more or less general, is
observed. Lancinating pains along the nerves and an irregular pemphigoid
eruption are also commonly noted. There soon follows the special
eruption, coming out from time to time, and consisting of several or
more, usually non-elevated, well-defined, pale-yellowish patches, one or
two inches in diameter. As a rule, they are at first neither
hyperæsthetic nor anæsthetic, but may be the seat of slight burning or
itching. They spread peripherally, and tend to clear in the centre. The
patches eventually become markedly anæsthetic, and the overlying skin,
and the skin on other parts as well, becomes atrophic and of a brownish
or yellowish color. The subcutaneous tissues, muscle, hair and nails
undergo atrophic or degenerative changes, and these changes are
especially noted about the hands and feet. These parts become crooked,
the bone tissues are involved, the phalanges dropping off or
disappearing by disintegration or absorption (_lepra mutilans_). Sooner
or later various paralytic symptoms, showing more active involvement of
the nerve trunks, present themselves.


#State the cause of leprosy.#

Present knowledge points to a peculiar bacillus as the active factor,
while climate, soil, heredity, food and habits exert a predisposing
influence.


#Is leprosy contagious?#

The consensus of opinion points to the acceptance of the possible
contagiousness of leprosy; probably by inoculation, but only under
certain unknown favoring conditions.


#What are the pathological changes?#

The lesions consist essentially of a new growth, made up of numerous
small, more or less aggregated round cells, beginning in the walls of
the bloodvessels. In this way the tubercular masses and various other
lesions are formed. As yet, positive involvement ot the central nervous
system has not been shown, but some of the nerve trunks are found to be
inflamed and swollen, with a tendency toward hardening.


#What several diseases are to be eliminated in the diagnosis of leprosy?#

Syphilis, morph[oe]a, vitiligo, lupus, and syringomyelia.

When well advanced, the aggregate symptoms of leprosy form a picture
which can scarcely be confused with that of any other disease. In
doubtful cases microscopical examinations of the involved tissues, for
the bacilli, should be made.


#State the prognosis of leprosy.#

Unfavorable; a fatal termination is the rule, but may not be reached for
a number of years. The tubercular form is the most grave, the mixed
variety next, and the anæsthetic the least. Patients are not
infrequently carried off by intercurrent disease. Proper management will
often delay the fatal ending, and exceptionally, in the anæsthetic
variety, stay the progress of the disease.


#What is the treatment of leprosy?#

Hygienic measures are important. Chaulmoogra oil and gurjun oil
internally and externally are in some instances of service. Strychnia
alone, or with either of these oils, is ofttimes beneficial. Ichthyol
internally, and external applications of the same drug, and of resorcin,
chrysarobin, and pyrogallic acid, have been extolled. Change of climate,
especially to a region where the disease does not prevail, is often of
great advantage.



                               #Pellagra.#
                    (_Synonym:_ Lombardian Leprosy.)


#Describe pellagra.#

Pellagra is a slow but usually progressive disease occurring chiefly in
Italy, due, it is thought, to the continued ingestion of decomposed or
fermented maize. It is characterized by cutaneous symptoms, at first
upon exposed parts, of an erythematous, desquamative, vesicular and
bullous character, and by general constitutional disturbance of a
markedly neurotic type. A fatal ending, if the disease is at all severe
or advanced, is to be expected.

Treatment is based upon general principles.



                              #Epithelioma.#
     (_Synonyms:_ Skin Cancer; Epithelial Cancer; Carcinoma Epitheliale.)


#What several varieties of epithelioma are met with?#

Three--the superficial, the deep-seated, and the papillomatous.


#Describe the clinical appearances and course of the superficial variety
of epithelioma.#

The superficial, or flat variety (_rodent ulcer_), begins, usually on
the face, as a minute, firm, reddish or yellowish tubercle, as an
aggregation of such, as a warty excrescence, or as a localized
degenerative seborrh[oe]ic patch. The latter lesion (known also as
keratosis senilis, old-age atrophic patches), consisting of a yellowish
or yellowish-brown greasy or hardened scurfy spot or patch is quite
frequently the starting-point of epithelial growths. Sooner or later,
commonly after months or several years, the surface becomes slightly
excoriated, and an insignificant, yellowish or brownish crust is formed.
The excoriation gradually develops into superficial ulceration, and the
diseased area becomes slowly larger and larger. New lesions may
continue, from time to time, to appear about the edges and go through
the same changes.

[Illustration: Fig. 64. Epithelioma. (_After D. Lewis._)]

The ulcer has usually an uneven surface, secretes a thin, scanty, viscid
fluid, which dries to a firm, adherent crust. It is usually defined
against the healthy skin by a slightly elevated, hard, roll-like,
waxy-looking border. In rare instances there is a disposition, at
points, to spontaneous involution and scar formation; as a rule,
however, the ulcerative action slowly progresses.

The general health is unimpaired, the neighboring lymphatic glands are
not involved, and the local condition, beyond the disfigurement, gives
rise to little trouble, unless, as occasionally happens, it passes into
the more malignant, deep-seated variety.


#Describe the clinical appearances and course of the deep-seated variety
of epithelioma.#

The deep-seated variety starts from the superficial form, or it begins
as a tubercle or nodule in the skin. When typically developed, a
reddish, shining tubercle or nodule, or area of infiltration, forms in
the skin or subcutaneous tissue. In the course of weeks or months
superficial or deep-seated ulceration takes place; the ulcer having
hardened, and, as a rule, everted edges. The surface is reddish and
granular, and secretes an ichorous discharge. The infiltration spreads,
the ulcer enlarges both peripherally and in depth--muscle, cartilage and
bone often becoming invaded. The neighboring lymphatic gland may become
implicated, pains of a burning or neuralgic type are experienced, and
from septicæmia, marasmus, or involvement of vital parts, death
eventually ensues.


#Describe the clinical appearances and course of the papillomatous
variety of epithelioma.#

The papillomatous type usually arises from the superficial or
deep-seated variety, or it may begin as a papillary or warty growth.
When fully developed, it presents an ulcerated, fissured and
papillomatous surface, with an ichorous discharge which dries to crusts.
It is slowly progressive, and sooner or later may develop a malignant
tendency.


#Upon what parts is epithelioma commonly observed?#

About the face, especially the nose, eyelids and lips; and also about
the genitalia. It may involve any part.


#At what age is epithelioma usually noted?#

It is essentially a disease of middle and late life, although it is
exceptionally met with in the young.


#What is the cause of epithelioma?#

The etiology is obscure. It is not, as a rule, inherited. Any locally
irritated tissue may be the starting point of the disease.


#State the pathology.#

The process consists in the proliferation of epithelial cells from the
mucous layer; the cell-growth takes place downward, in the form of
finger-like prolongations or columns, or it may spread out laterally, so
as to form rounded masses, the centres of which usually undergo horny
transformation, resulting in the formation of onion-like bodies, the
so-called cell-nests or globes. The rapid cell-growth requires increased
nutriment, and hence the bloodvessels become enlarged; moreover, the
pressure of the cell-masses gives rise to irritation and inflammation,
with corresponding serous and round-cell infiltration.


#How would you distinguish epithelioma from syphilitic ulceration, wart,
and lupus vulgaris?#

From syphilis it is to be differentiated by the history, duration,
character of the base and edges, its comparative slow progress, its
usually slight, viscid discharge, often streaked with blood, and, if
necessary, by the therapeutic test.

Wart or warty growths are to be differentiated by attention to their
history and course. Long-continued observation may be necessary before a
positive opinion is warrantable. The appearance of any tendency to
crusting, to break down or ulcerate is significant of epitheliomatous
degeneration.

In lupus vulgaris the deposits are peculiar and multiple, the
ulcerations are of different character, the tendency to scar-formation
constant; and, with few exceptions, it has, moreover, its beginning in
childhood or early adult life.


#What factors are to be considered in giving a prognosis in epithelioma?#

The variety, extent, and rapidity of the process. The superficial form
may exist for years, and give rise to no alarm; whereas the
deeper-seated varieties are always to be viewed as serious, and are,
indeed, often fatal. Involving the genitalia, its course is often
strikingly rapid. Relapses, after removal, are not uncommon.


#What is the special object in view in the treatment of epithelioma?#

Thorough destruction or removal of the epitheliomatous tissue.


#How is the destruction or removal of the epitheliomatous tissue
effected?#

By the use of such caustics as caustic potash, chloride-of-zinc paste,
pyrogallic acid, arsenic, and the galvano-cautery; and by operative
measures, such as excision and erasion with the dermal curette, and by
the _x_-ray. (See treatment of lupus vulgaris.)

In small lesions the use of an arsenical paste is a most admirable
method of treatment, although somewhat painful. The paste is made of one
part powdered acacia and one to two parts arsenious acid; at the time of
application sufficient water is added to make a paste. This is applied
thickly, and a piece of lint superimposed. A good deal of pain and
inflammatory swelling ensue; at the end of twenty-four hours the part is
poulticed till the slough comes away; the ulcer is then treated as a
simple ulcer, under which healing takes place. Occasionally a second
application is found necessary.

Upon the whole, the best method in the average case is to curette
thoroughly, and supplement with momentary cauterization, with caustic
potash, or with several days' use of the pyrogallic acid ointment.
During the healing process, short exposures to the Röntgen ray--about
every three to five days--is good practice.

The degenerative changes in the beginning of scurfy, seborrh[oe]ic spots
or patches seen in old people can frequently be lessened or wholly
stopped by the daily application of an ointment containing 5 to 10 per
cent. of sulphur and 2 to 5 per cent. of salicylic acid.


#What can be said of the value of the x-ray in epithelioma?#

The _x_-ray method is now much in vogue, and proves curative in many
superficial cases, and of benefit in some of the deeper-seated
varieties. In most cases it must be pushed to the point of producing a
mild _x_-ray erythema; and in some instances benefit or cure only occurs
after more active exposure, sufficient to cause an _x_-ray burn of the
second degree. The method is not attended with much risk if properly
used. The healthy parts should be protected by lead-foil. Exposure
should be two to five times weekly, at a distance of three to eight
inches, and from five to twenty minutes, employing a tube of medium
vacuum. Unfortunately the method is usually slow. The radium treatment
is essentially similar to that by the _x_-ray.

The much better plan, as already intimated, is to employ one of the
several operative or caustic methods, and supplementing, while healing,
with the _x_-ray.



                  #Paget's Disease of the Nipple.#
    (_Synonyms:_ Malignant Papillary Dermatitis; Paget's Disease.)


#What do you understand by Paget's disease of the nipple?#

Paget's disease is a rare, inflammatory-looking, malignant disease of
the nipple and areola in women, usually of advancing years, eventually
terminating in cancerous involvement of the entire gland.


#Describe the symptoms of Paget's disease.#

The first symptoms, which usually last for months or years, are
apparently eczematous, accompanied with more or less burning, itching
and tingling. Gradually, the diseased area, which is sharply-defined,
and feels like a thin layer of indurated tissue, presents a florid,
intensely red, very finely-granular, raw surface, attended with a more
or less copious viscid exudation. Sooner or later retraction and
destruction of the nipple, followed by gradual scirrhous involvement of
the whole breast, takes place.


#What is the pathology of Paget's disease?#

Although it was thought at one time to be a cancerous disease resulting
from a continued eczematous inflammation of the parts, there is now but
little doubt that it is of malignant nature from the earliest stages.
The psorosperm-like bodies found, to the presence of which the disease
has by some authorities been attributed (psorospermosis), are now known
to be merely changed and degenerated epithelia. The morbid changes
consist of an inflammation of the papillary region of the derma, leading
to [oe]dema and vacuolation of the constituent cells of the epidermis,
followed by their complete destruction in places and their abnormal
proliferation in others (Fordyce).


#State the diagnostic features of Paget's disease.#

The age of the patient; the sharp limitation; the well-defined,
indurated film of infiltration; the peculiar, red, raw, granulating
appearance; and, later, the retraction of the nipple; and, finally, the
involvement of the deeper parts.


#What is the prognosis?#

If the disease is recognized early, and properly treated, a cure may be
anticipated; later the outlook is that of scirrhus of the breast.


#What is the treatment of Paget's disease?#

Thorough cauterization by means of caustic potash or the
galvano-cautery; or, its extirpation by means of the curette or
excision. After extirpation or cauterization, supplementary treatment by
the _x_-ray is advisable as an additional measure of precaution against
relapse.

Until the diagnosis is thoroughly established, soothing applications,
such as are employed in acute eczema, are to be advised.



                              #Sarcoma.#
             (_Synonyms:_ Sarcoma Cutis; Sarcoma of the Skin.)


#Describe the several varieties of sarcoma.#

Sarcoma of the skin is a more or less malignant new growth, of rapid or
slow progress, characterized by the appearance of single or multiple,
variously-shaped, discrete, non-pigmented or pigmented tubercles or
tumors, of size varying from that of a shot to a hazelnut or larger. As
a rule the growths are smooth, firm and elastic, somewhat painful upon
pressure, and exhibit a tendency to ulcerate. The overlying skin is at
first normal and somewhat movable, but as the growths approach the
surface it becomes reddened and adherent; or, if the disease is of the
pigmented variety, it acquires a bluish-black color. It is now generally
believed that the most of the pigmented cases formerly thought to be of
sarcomatous nature are really carcinomatous in character.

The multiple pigmented sarcoma (_melano-sarcoma_) appears first, usually
on the soles and dorsal surfaces of the feet, and later on the hands.
There is more or less diffuse thickening of the integument. The lesions
themselves manifest a disposition to bleed.


#State the prognosis and treatment of sarcoma.#

The disease is always more or less malignant and, as a rule, sooner or
later a fatal termination takes place. It is usually slow in its course.

Excision or extirpation, _x_-ray exposures, and the administration of
arsenic in increasing dosage (preferably by hypodermic injection) now
are generally considered the most promising in this usually hopeless
malady.



                         #Granuloma Fungoides.#


#Describe granuloma fungoides.#

A rare form of disease, heretofore looked upon as sarcomatous, but now
generally recognized as granuloma, and formerly described under the
names _mycosis fungoides_, _inflammatory fungoid neoplasm_, and several
others. It is characterized usually by symptoms of an eczematous,
urticarial, and erysipelatous nature, and by the sudden or gradual
appearance of pinkish or reddish, tubercular, nodular, lobulated, or
furrowed tumors or flat infiltrations, which may disappear by involution
or may be followed by ulceration; several or a larger number of the
growths present a mushroom, papillomatous, or fungoid appearance,
sometimes roughly resembling the cut part of a tomato. In most cases the
tumor stage of the malady is not reached for two or more years; in
exceptional instances, however, they appear in the first few months. The
lesions, especially in their early stages, are, as a rule, accompanied
with more or less burning and itching.


#State the prognosis and treatment of granuloma fungoides.#

The malady may last for several years or much longer, a fatal
termination, with rare exceptions, sooner or later taking place. After
the tumor stage is well established, the patient usually succumbs in
from several months to one or two years.

[Illustration: Fig. 65. Granuloma Fungoides.]

Treatment consists of tonics, if indicated, and the administration of
arsenic, preferably hypodermically, and Röntgen-ray exposures, along
with the application of mild antiseptics, and operative interference
when necessary or advisable.



#CLASS VII.--NEUROSES.#


                            #Hyperæsthesia.#


#What is hyperæsthesia?#

By hyperæsthesia is meant increased cutaneous sensibility. It is usually
more or less localized, and is met with as a symptom in functional and
organic nervous diseases.


                             #Dermatalgia.#
  (_Synonyms:_ Neuralgia of the Skin; Rheumatism of the Skin; Dermalgia.)


#What do you understand by dermatalgia?#

By dermatalgia is meant a tender or painful condition of the skin
unattended by structural change. It is commonly limited to a small area,
and is usually symptomatic of functional or organic nervous disease. As
an idiopathic affection it is looked upon as of a rheumatic origin.

Treatment depends upon the cause.


                             #Anæsthesia.#


#What is anæsthesia?#

Anæsthesia is a diminution, comparative or complete, of cutaneous
sensibility. It is usually localized, and is met with in the course of
certain nervous affections. It is also encountered in leprosy,
morph[oe]a and like diseases.



                             #Pruritus.#


#What do you understand by pruritus?#

Pruritus is a functional disease of the skin, the sole symptom of which
is itching, there being no structural change.


#Describe the symptoms of pruritus.#

The sole and essential symptom is itchiness, usually more or less
paroxysmal, and worse at night. There are no primary structural lesions,
but in severe and persistent cases the parts become so irritated by
continued scratching that secondary lesions, such as papules and slight
thickening and infiltration, may result. It is much more common in
advanced life--_pruritus senilis_. In such cases, as well as in those
cases in younger and middle-aged individuals in which the itchiness
develops at the approach of cold weather and disappears upon the coming
of the warm season (_pruritus hiemalis_), the pruritus is usually more
or less generalized, although not infrequently in the latter the legs
are specially involved.

In some individuals an attack of pruritus, of variable intensity,
lasting from five to thirty minutes, comes on immediately after a bath
(_bath-pruritus_). It is usually confined to the legs from the hips
down.


#Is pruritus always more or less generalized?#

No; not infrequently the itching is limited to the genital region
(_pruritus scroti_, _pruritus vulvæ_) or to the anus (_pruritus ani_).


#To what may pruritus often be ascribed?#

To digestive and intestinal derangements, hepatic disorders, the uric
acid diathesis, gestation, diabetes mellitus, and a depraved state of
the nervous system.

Pruritus vulvæ is at times due to irritating discharges, and pruritus
ani occasionally to hemorrhoids and seat-worms.


#Is there any difficulty in the diagnosis of pruritus?#

No. The subjective symptom of itching without the presence of structural
lesions is diagnostic. In those severe and persistent cases in which
excoriations and papules have resulted from the scratching, the history
of the case, together with its course, must be considered. Care should
be taken not to confound it with pediculosis. In this latter the
excoriations usually have a somewhat peculiar distribution, being most
abundant on those parts of the body with which the clothing lies closely
in contact. (See Pediculosis corporis.)

In pruritus of the genitocrural region the possibility of pediculi being
the cause must be kept in mind; an examination of the parts for the
parasite or for ova (attached to the hairs) would prevent error. (See
Pediculosis pubis.)


#What prognosis would you give in pruritus?#

In the majority of cases the condition responds to proper treatment, but
in others it proves rebellious. The prognosis depends, in fact, upon the
removability of the cause. Temporary relief may always be given by
external applications.


#How would you treat pruritus?#

With systemic remedies directed toward a removal or modification of the
etiological factors, and, for the temporary relief of the itching,
suitable antipruritic applications. In obscure cases, quinia, salophen,
lithia salts, calcium chloride, belladonna, nux vomica, arsenic,
pilocarpine, and general galvanization may be variously tried. Alkalies
prove useful in many cases.

Exceptionally, the relief furnished by external treatment is more or
less permanent.


#Name the important antipruritic applications.#

Alkaline baths; lotions of carbolic acid ([dram]j-[dram]iij to Oj), of
resorcin ([dram]j-[dram]iv to Oj), of liquor carbonis detergens
([Oz]j-[Oz]iv to Oj), and liquor picis alkalinus ([dram]j-[dram]iv to
Oj), used cautiously. One or several ounces of alcohol and one or two
drachms of glycerin in each pint of these lotions will often be of
advantage, as the following:--

  [Rx] Ac. carbolici, ....................... [dram]j-[dram]iij
       Gylcerinæ, ........................... f[dram]ij
       Alcoholis, ........................... f[oz]ij
       Aquæ, ......... q.s. ad .............. Oj.            M.

Various dusting-powders, alone or in conjunction with the lotions.

And in some cases, especially those in which the skin is unnaturally
dry, ointments may be used, such as equal parts of lard, lanolin, and
petrolatum, to the ounce of which may be added from five to thirty
grains of carbolic acid, three to twenty grains of thymol, ten to thirty
minims of chloroform, or two to ten grains of menthol.


#What external applications are to be used in the local varieties of
pruritus?#

In _pruritus ani_ and _pruritus vulvæ_, in addition to the various
applications above, a cocaine ointment, one to ten grains to the ounce,
a strong solution of the same (gr. v-xx to [Oz]j), and an ointment
containing ten to thirty minims of the oil of peppermint to the ounce;
sponging with hot water, often affords temporary relief.

In pruritus vulvæ, moreover, astringent applications and injections of
zinc sulphate, alum, tannic or acetic acid, in the strength commonly
employed for vaginal injections, are at times curative.

In bath-pruritus weak glycerine lotions, and an ointment containing a
few grains of thymol and menthol to the ounce sometimes give moderate
relief. Turkish baths are sometimes free from subsequent pruritus.



#CLASS VIII.--PARASITIC AFFECTIONS.#


                             #Tinea Favosa.#
                           (_Synonym:_ Favus.)

#What is tinea favosa?#

Tinea favosa, or favus, is a contagious vegetable-parasitic disease of
the skin, characterized by pin-head to pea-sized, friable, umbilicated,
cup-shaped yellow crusts, each usually perforated by a hair.


#Upon what parts and at what age is favus observed?#

It is usually met with upon the scalp, but it may occur upon any part of
the integument. Occasionally the nails are invaded. It is seen at all
ages, but is much more common in children.


#Describe the symptoms of favus of the scalp.#

The disease begins as a superficial inflammation or hyperæmic spot, more
or less circumscribed, slightly scaly, and which is soon followed by the
formation of yellowish points about the hair follicles, surrounding the
hair shaft. These yellowish points or crusts increase in size, become
usually as large as small peas, are cup-shaped, with the convex side
pressing down upon the papillary layer, and the concave side raised
several lines above the level of the skin; they are umbilicated,
friable, sulphur-colored, and usually each cup or disc is perforated by
a hair. Upon removal or detachment, the underlying surface is found to
be somewhat excavated, reddened, atrophied and sometimes suppurating. As
the disease progresses the crusting becomes more or less confluent,
forming irregular masses of thick, yellowish, mortar-like crusts or
accumulations, having a peculiar, characteristic odor--that of mice, or
stale, damp straw. The hairs are involved early in the disease, become
brittle, lustreless, break off and fall out. In some instances,
especially near the border of the crusts, are seen pustules or
suppurating points. _Atrophy_ and more or less actual _scarring_ are
sooner or later noted.

Itching, variable as to degree, is usually present.


#What is the course of favus of the scalp?#

Persistent and slowly progressive.

[Illustration: Fig. 66.
  Achorion Schönleinii X 450. (_After Duhring._) Showing simple mycelium,
  in various stages of development, and free spores.]


#What are the symptoms of favus when seated upon the general surface?#

The symptoms are essentially similar to those upon the scalp, modified
somewhat by the anatomical differences of the parts.

The _nails_, when affected, become yellowish, more or less thickened,
brittle and opaque (_tinea favosa unguium_, _onychomycosis favosa_).


#To what is favus due?#

Solely to the invasion of the cutaneous structures, especially the
epidermal portion, by the vegetable parasite, the _achorion
Schönleinii_. It is contagious. It is a somewhat rare disease in the
native-born, being chiefly observed among the foreign poor. The nails
are rarely affected primarily.

It is also met with in the lower animals, from which it is doubtless not
infrequently communicated to man.


#What are the diagnostic features of favus?#

The yellow, and often cup-shaped, crusts, brittleness and loss of hair,
atrophy, and the history.

[Illustration: Fig. 67. Epilating Forceps.]


#How would you distinguish favus from eczema and ringworm?#

From eczema by the condition of the affected hair, the atrophic and
scar-like areas, the odor, and the history. From ringworm by the
crusting and the atrophy. In this latter disease there is usually but
slight scaliness, and rarely any scarring.

Finally, if necessary, a microscopic examination of the crusts may be
made.


#State the method of examination for fungus.#

A portion of the crust is moistened with liquor potassæ and examined
with a power of three to five hundred diameters. The fungus, (achorion
Schönleinii), consisting of mycelium and spores, is luxuriant and is
readily detected.


#State the prognosis of favus.#

Upon the scalp, favus is extremely chronic and rebellious to treatment,
and a cure in six to twelve months may be considered satisfactory; in
neglected cases permanent baldness, atrophy, and scarring sooner or
later result. Although favus of the scalp persists into adult life, it
becomes less active and, finally, as a rule, gradually disappears,
leaving behind scarred or atrophic bald areas.

Upon the general surface it usually responds readily to treatment,
excepting favus of the nails, which is always obstinate.


#How is favus of the scalp treated?#

Treatment is entirely local and consists in keeping the parts free from
crusts, in epilation and applications of a parasiticide.

The crusts are removed by oily applications and soap-and-water washings.
The hair on and around the diseased parts is to be kept closely cut,
and, when practicable, depilation, or extraction of the affected hairs,
is advised; this latter is, in most cases, essential to a cure. Remedial
applications--the so-called parasiticides--are, as a rule, to be made
twice daily. If an ointment is used, it is to be thoroughly rubbed in;
if a lotion, it is to be dabbed on for several minutes and allowed to
soak in.


#Name the most important parasiticides.#

Corrosive sublimate, one to four grains to an ounce of alcohol and
water; carbolic acid, one part to three or more parts of glycerine; a
ten per cent. oleate of mercury; ointments of ammoniated mercury,
sulphur and tar; and sulphurous acid, pure or diluted. The following is
valuable:--

  [Rx] Sulphur, præcip., .................... [dram]ij
       Saponis viridis,
       Ol. cadini, ....... [=a][=a] ......... [dram]j
       Adipis, .............................. [Oz]ss.        M.

Chrysarobin is a valuable remedy, but must be used with caution; it may
be employed as an ointment, five to ten per cent. strength, as a rubber
plaster, or as a paint, a drachm to an ounce of gutta-percha solution.
Formalin, weakened or full strength, has been extolled. Some observers
have experimentally tried the effect of _x_-ray exposure with alleged
good results, pushing the treatment to the point of producing
depilation; if used great caution should be exercised.


#How is favus upon the general surface to be treated?#

In the same general manner as favus of the scalp, but the remedies
employed should be somewhat weaker. In favus of the nail frequent and
close paring of the affected part and the application, twice daily, of
one of the milder parasiticides, will eventually lead to a good result.


#Is constitutional treatment of any value in favus?#

It is questionable, but in debilitated subjects tonics, especially
cod-liver oil, may be prescribed with the hope of aiding the external
applications.



                          #Tinea Trichophytina.#
                          (_Synonym:_ Ringworm.)


#What is tinea trichophytina?#

Tinea trichophytina, or ringworm, is a contagious, vegetable-parasitic
disease due to the invasion of the cutaneous structures by the vegetable
parasite, the trichophyton, or the microsporon Audouinii.


#Do the clinical characters of ringworm vary according to the part
affected?#

Yes, often considerably; thus upon the scalp, upon the general surface,
and upon the bearded region, the disease usually presents totally
different appearances.


#Describe the symptoms of ringworm as it occurs upon non-hairy portions
of the body.#

Ringworm of the general surface (_tinea trichophytina corporis_, _tinea
circinata_) appears as one or more small, slightly-elevated,
sharply-limited, somewhat scaly, hyperæmic spots, with, rarely, minute
papules, vesico-papules, or vesicles, especially at the circumference.
The patch spreads in a uniform manner peripherally, is slightly scaly,
and tends to clear in the centre, assuming a ring-like appearance. When
coming under observation, the patches are usually from one-half to one
inch in diameter, the central portion pale or pale red, and the outer
portion more or less elevated, hyperæmic and somewhat scaly. As commonly
noted one, several or more patches are present. After reaching a certain
size they may remain stationary, or in exceptional cases may tend to
spontaneous disappearance. At times when close together, several may merge
and form a large, irregular, gyrate patch.

Itching, usually slight, may or may not be present.

Exceptionally ringworm appears as a markedly inflammatory pustular
circumscribed patch, formerly thought to be a distinct affection and
described under the name of _conglomerate pustular folliculitis_. It
consists of a flat carbuncular or kerion-like inflammation, somewhat
elevated, and usually a dime to silver dollar in area. The most common
seats are the back of the hands and the buttocks. The surface is
cribriform, and a purulent secretion may be pressed out from follicular
openings.

[Illustration: Fig. 68.
  Tinea trichophytina cruris--so-called eczema marginatum--of unusually
  extensive development. (_After Piffard._)]


#Describe the symptoms of ringworm when occurring about the thighs and
scrotum.#

In adults, more especially males, the inner portion of the upper part of
the thighs and scrotum (_tinea trichophytina cruris_, so-called _eczema
marginatum_) may be attacked, and here the affection, favored by heat
and moisture, develops rapidly and may soon lose its ordinary clinical
appearances, the inflammatory symptoms becoming especially prominent.
The whole of this region may become involved, presenting all the
symptoms of a true eczema; the border, however, is sharply defined, and
usually one or more outlying patches of the ordinary clinical type of
the disease may be seen.


#Describe the symptoms of ringworm when involving the nails.#

In ringworm of the nails (_tinea trichophytina unguium_) these
structures become soft or brittle, yellowish, opaque and thickened the
changes taking place mainly about the free borders. Ringworm on other
parts usually coexists.


#Describe the symptoms of ringworm as it occurs upon the scalp.#

Ringworm of the scalp (_tinea trichophytina capitis_, _tinea tonsurans_)
begins usually in the same manner as that upon the general surface, but,
as a rule, much more insidiously. Sooner or later, however, the hair and
follicles are invaded by the fungus, and in consequence the hair falls
out or becomes brittle and breaks off. The follicles, except in
long-standing cases, are slightly elevated and prominent, and the patch
may have a puffed or goose-flesh appearance. In addition, there is
slight scaliness.


#Describe the appearances of a typical patch of ringworm of the scalp.#

The patch is rounded, grayish, somewhat scaly, and slightly elevated;
the follicles are somewhat prominent; there is more or less alopecia,
with here and there broken, gnawed-off-looking hairs, some of which may
be broken off just at the outlet of the follicles and more or less
surrounded by a whitish or grayish-white dust. This type is produced by
the small-spore fungus--microsporon.


#Does ringworm of the scalp always present typical appearances?#

Not invariably. In some cases the patch or patches may become almost
completely bald, and in others a tendency to the formation of pustules,
with more or less crust-formation, may be seen. The affection may also
appear as small scattered spots or points.

[Illustration: Fig. 69.
  Ringworm (rather inflammatory type, and produced by the trichophyton).]

The markedly inflammatory and pustular types are produced by the
large-spore fungus--trichophyton.


#What is tinea kerion?#

Tinea kerion (_kerion_) is a markedly inflammatory type of ringworm of
the scalp involving the deeper tissues, appearing as a more or less
bald, rounded, inflammatory, [oe]dematous, boggy, honeycombed tumor,
discharging from the follicular openings a mucoid secretion.


#Does ringworm of the scalp ever occur in adults?#

No. (Extremely rare exceptions.)

[Illustration: Fig. 70.
  Ringworm Fungus (Trichophyton) x 450. (_After Duhring._) As found in
  epidermic scrapings of ringworm, showing mycelium and spores.]


#Describe the symptoms of ringworm of the bearded region.#

Ringworm of the bearded region (_tinea trichophytina barbæ_, _tinea
sycosis_, _parasitic sycosis_, _barber's itch_) begins usually in the
same manner as ringworm on other parts, as one or more rounded, slightly
scaly, hyperæmic patches. In rare instances the disease may persist as
such, with very little tendency to involve the hairs and follicles; but,
as a rule, the hairy structures are soon invaded, many of the hairs
breaking off, and many falling out. From involvement of the follicles,
more or less subcutaneous swelling ensues, the parts assuming a
distinctly _lumpy and nodular_ condition. The skin is usually
considerably reddened, often having a glossy appearance, and studded
with few or numerous pustules. The nodules tend, ordinarily, to break
down and discharge, at one or more of the follicular openings, a glairy,
glutinous, purulent material, which may dry to thick, adherent crusts.

[Illustration: Fig. 71.
  Ringworm Fungus (Microsporon) x 500. (_After Duhring._) Short,
  broken-off hair of scalp invaded with masses of free spores.]

The disease may be limited to one patch, or a large area, even to the
extent of the whole bearded region, becomes involved. The upper lip is
rarely invaded. Ringworm of the bearded region is due to the trichophyton.

[Illustration: Fig. 72.
  Ringworm Fungus (Trichophyton) x 300. (_After Duhring._) Short, stout
  hair of beard, with the root-sheath attached, showing free spores and
  chains of spores.]


#To what is ringworm due?#

To the presence and growth in the cutaneous structures of a vegetable
parasite. Although the disease is contagious, individuals differ
considerably as to susceptibility. It is much more common in children
than in those past the age of puberty, ringworm of the scalp being
limited to the former (rare exceptions), and tinea sycosis being a
disease of the male adult.

Until recently the ringworm was thought to be due to but one fungus--the
trichophyton; it is now known that there are several forms of fungi, the
main forms being the small-spored (microsporon Audouini) and the
large-spored (trichophyton). Of this latter there are two main
subvarieties--endothrix and ectothrix. The small-spored fungus is found
as the cause in the majority of scalp cases; the endothrix also commonly
invades the scalp integument. The ectothrix variety is usually derived
directly or indirectly from domestic animals, and is chiefly responsible
for body-ringworm, and for suppurative ringworm, whether upon the
bearded region or elsewhere.


#What is the pathology of ringworm?#

On the general surface the fungus has its seat in the epidermis,
especially in the corneous layer; upon the scalp and bearded region the
epidermis, hair-shaft, root and follicle are invaded. The inflammatory
action may vary considerably in different cases, and at different times
in the same case.

The fungus consists of mycelium and spores. In the epidermic scrapings
it is never to be found in abundance, and the mycelium predominates,
while in affected hairs the spores and chains of spores are almost
exclusively seen, and are usually present in great profusion.


#How do you examine for the fungus?#

The scrapings or hair should be moistened with liquor potassæ, and
examined with a power from three hundred diameters upward.


#How is ringworm of the general surface to be distinguished from eczema,
psoriasis and seborrh[oe]a?#

By the growth and characters of the patch, the slight scaliness, the
tendency to disappear in the centre, by the history, and, if necessary,
by a microscopic examination of the scales.


#How is ringworm of the scalp to be distinguished from alopecia areata,
favus, eczema, seborrh[oe]a, and psoriasis?#

By the peculiar clinical features of ringworm on this region--the slight
scaliness, broken hair and hair stumps, with a certain amount of
baldness--and in doubtful cases by a microscopical examination of the
hairs.

In favus, although the same condition of the hair is noted, the yellow,
cup-shaped crusts, and the presence of the atrophic areas in that
disease are pathognomonic.


#How is ringworm of the bearded region to be distinguished from eczema
and sycosis?#

By the peculiar lumpiness of the parts, the brittleness of the hair,
more or less hair loss, and the history.

The superficial type of ringworm sycosis--those cases in which the
disease remains a surface disease--is readily distinguished, as the
symptoms are essentially the same as ringworm of non-hairy parts, except
that some of the hairs in the areas may become invaded and break off or
fall out.

In doubtful cases recourse may be had to microscopical examination.


#What is the prognosis of ringworm of these several parts?#

When upon the general surface, the disease usually responds rapidly to
therapeutical applications; upon the scalp it is always a stubborn
affection, and, as a rule, requires several months to a year of
energetic treatment to effect a cure. In this latter region the disease
will disappear spontaneously as the age of fifteen or sixteen is
reached. Tinea sycosis yields in most instances in the course of several
weeks or a few months.


#Is ringworm of these several parts treated with the same remedies?#

As a rule, yes; but the strength must be modified. The scalp will stand
strong applications, as will likewise the bearded region; upon non-hairy
portions the remedies should be used somewhat weaker. They should be
applied twice daily; ointments, if used, being well rubbed in, and
lotions thoroughly dabbed on.


#How would you treat ringworm of the general surface?#

By applications of the milder parasiticides, such as a ten to fifteen
per cent. solution of sodium hyposulphite; carbolic acid, five to thirty
grains to the ounce of water, or lard; a saturated solution of boric
acid; ointments of tar, sulphur and mercury, official strength or
weakened with lard; and tincture of iodine, pure or diluted.

When occurring upon the upper and inner part of the thighs (so-called
eczema marginatum), the same remedies are to be employed, but usually
stronger. Deserving of special mention is a lotion of corrosive
sublimate, one to four grains to the ounce; or the same remedy, in the
same proportion, may be used in tincture of myrrh or benzoin, and
painted on the parts.


#How would you treat ringworm of the scalp?#

By occasional soap-and-hot-water washing; by extraction of the involved
hairs, when practicable; by carbolic acid or boric acid lotions to the
whole scalp, so as to limit, as much as possible, the spread of the
disease; and by daily (or twice daily) applications to the patches and
involved areas of a parasiticide. The following are the most valuable:
the oleate of mercury, with lard or lanolin, in varying strength, from
ten to twenty per cent.; carbolic acid, with one to three or more parts
of glycerine or oil; corrosive sublimate, in solution in alcohol and
water, one to four grains to the ounce; sulphur ointment; and citrine
ointment, with one or two parts of lard. Chrysarobin is a valuable
remedy, but is to be employed with care; it may be prescribed as a
rubber plaster, or in a solution of gutta-percha, or as an ointment, ten
to fifteen per cent. strength. [beta]-naphthol in ointment form, five
to fifteen per cent. strength, is also useful. An excellent application
for beginning areas on the scalp is a solution of the red iodide of
mercury in iodine tincture, one to three grains to an ounce.

A compound ointment, containing several of the active remedies named, is
convenient for dispensary practice, such as:--

  [Rx]  [beta]-naphthol, ................. [dram]ss-[dram]j
        Ol. cadini, ......................... [dram]j
        Ungt. sulphuris, ............ q.s. ad [Oz]j.         M.

In that form known as tinea kerion mild applications are demanded at
first; later the same treatment as in the ordinary type.


#How is ringworm of the bearded region to be treated?#

On the same general plan and with the same remedies (excepting
chrysarobin) as in ringworm of the scalp. Depilation is to be practised
as an essential part of the treatment. Special mention may be made of an
ointment of oleate of mercury, sulphur ointment, a lotion of sodium
hyposulphite ([dram]j-[Oz]j), and a lotion of corrosive sublimate (gr.
j-iv to [Oz]j). The _x_-ray has been used in ringworm of this region
with alleged success, pushing it to the production of a mild erythema
and depilation. The above methods are, however, usually successful, and
are without risk of damage.


#How is the certainty of an apparent cure in ringworm of the scalp or
bearded region to be determined?#

By the continued absence of roughness and of broken hairs and stumps,
and by microscopical examination of the new-growing hairs from time to
time for several weeks after discontinuance of treatment.

Cure of ringworm of the general surface is usually self-evident.


#Is systemic treatment of aid in the cure of ringworm?#

It is doubtful, although in children in a depraved state of health the
disease is often noted to be especially stubborn, and in such cod-liver
oil and similar remedies may at times prove of benefit.



                           #Tinea Imbricata.#
                    (_Synonym:_ Tokelau Ringworm.)


#What is tinea imbricata?#

A vegetable parasitic disease of moist tropical countries, characterized
by the formation of patches composed of concentrically arranged,
imbricated, scaly rings. It may begin at one or several points as a
brownish, slightly raised spot, spreading peripherally; the renewed
epidermis of the central part of the patch goes again through the same
process; the result is a small or large area of concentrically arranged,
imbricated, slightly scaly eruption. Several such areas fusing together
may cover a large part of the surface, the ring-like arrangement being
sometimes more or less completely lost. The malady is chronic. There may
be a variable degree of itching. The cause of the disease, which is of a
contagious nature, is a vegetable parasite closely similar to the
trichophyton. The treatment is by the parasiticides, being essentially
the same, in fact, as ringworm.



                          #Tinea Versicolor.#
           (_Synonyms:_ Pityriasis Versicolor; Chromophytosis.)


#What is tinea versicolor?#

Tinea versicolor is a vegetable-parasitic disease of the skin,
characterized by variously-sized and shaped, slightly scaly, macular
patches of a yellowish-fawn color, and occurring for the most part upon
the upper portion of the trunk.


#Describe the symptoms of tinea versicolor.#

The disease begins as one or more yellowish macular points; these, in
the course of weeks or months, gradually extend, and, together with
other patches that arise, may form a more or less continuous sheet of
eruption. There is slight scaliness, always insignificant and
furfuraceous in character, and at times, except upon close inspection,
scarcely perceptible. The color of the patches is pale or
brownish-yellow; in rare instances, in those of delicate skin, there may
be more or less hyperæmia, and in consequence the eruption is of a
reddish tinge. The number of patches varies; there may be but a few, or,
on the other hand, a profusion. Slight itching, especially when the
parts are warm, is usually present.


#Does the eruption of tinea versicolor show predilection for any special
region?#

Yes; the upper part of the trunk, especially anteriorly, is the usual
seat of the eruption, but in exceptional instances the neck, axillæ, the
arms, the whole trunk, the genitocrural region and poplitea, and in rare
cases even the lower part of the face, may become invaded.


#What course does tinea versicolor pursue?#

Persistent, but somewhat variable; as a rule, however, slowly
progressive and lasting for years.


#To what is tinea versicolor due?#

To a vegetable fungus--the _microsporon furfur_.

The affection is tolerably common, and occurs in all parts of the world.
With rare exceptions, it is a disease of adults, and while looked upon
as contagious, must be so to an extremely slight degree.

[Illustration: Fig. 73.
  Microsporon Furfur x 400. (_After Duhring._) Showing mycelium in various
  stages of development, groups of spores and free spores.]


#What is the pathology?#

The fungus, consisting of mycelium and spores, the latter showing a
marked tendency to aggregate, invades the superficial portion of the
epidermis.


#Is tinea versicolor readily diagnosticated?#

Yes; if the color, peculiar characters and distribution of the eruption
are kept in mind.

It is not to be confounded with vitiligo, chloasma, or the macular
syphiloderm. If in doubt, have recourse to the microscope.


#State the method of examination for fungus.#

The scrapings are taken from a patch, moistened with liquor potassæ, and
examined with a power of three to five hundred diameters.


#State the prognosis of tinea versicolor.#

With proper management the disease is readily curable. Relapses are not
uncommon.

[Illustration: Fig. 74. Tinea versicolor.]


#What is the treatment of tinea versicolor?#

It consists in daily washing with soap and hot water (and in obstinate
cases with sapo viridis instead of the ordinary soap) and application
of a lotion of--sulphite or hyposulphite of sodium, a drachm to the
ounce; sulphurous acid, pure or diluted; carbolic acid, or resorcin,
ten to twenty grains to the ounce of water and alcohol; or corrosive
sublimate, one to three grains to the ounce of water. Sulphur and
ammoniated-mercury ointments are also serviceable. The following used
alone, simply as a soap, or in conjunction with a lotion, is often of
special value:--

  [Rx] Sulphur, præcip., .................... [dram]iv
       Saponis viridis, ..................... [dram]xii.    M.

After the disease is apparently cured, an occasional remedial application
should be made for several months, in order to guard against the
possibility of a relapse.



                              #Erythrasma.#


#Describe erythrasma.#

Erythrasma is an extremely rare disease, due to the presence and growth
in the epidermic structures of the vegetable parasite--the _microsporon
minutissimum_. It is characterized by small and large, slightly
furfuraceous, reddish-yellow or reddish-brown patches, occurring usually
on warm and moist parts, such as the axillary, inguinal, anal and
genitocrural regions. It is slowly progressive and persistent, but is
without disturbing symptoms other than occasional slight itching.

[Illustration: Fig. 75.
  Microsporon Minutissimum x 1000. (_After Riehl._)]

Treatment, which is rapidly effective, is the same as that employed in
tinea versicolor.



                             #Dhobie Itch.#

Dhobie itch is a name used in certain tropical countries to designate a
somewhat peculiar itching eruption of the genitocrural and axillary
regions, and by some also a similar eruption about the feet. It consists
of a dermatitis of variable degree, usually with a festooned, irregular
border, with considerable itching. It is believed that such cases are
variously due to the trichophyton of ringworm, to the microsporon furfur
of tinea versicolor, to the microsporon minutissimus of erythrasma, and
to other parasites.



                             #Actinomycosis.#


#Describe actinomycosis.#

Actinomycosis of the skin is an affection due to the ray fungus, and
characterized by a sluggish, red, nodular, or lumpy infiltration,
usually with a tendency to break down and form sinuses. The affection
may involve almost any part, but its most common site is about the jaw,
neck, and face. As a rule, the first evidence is a hard subcutaneous
swelling or infiltration, which may increase slightly or considerably.
The overlying skin gradually becomes of a sluggish or dark-red color.
Softening ensues, and the diseased area breaks down at one or more
points, from which there oozes a discharge of a sero-purulent, purulent,
or sanguinolent character. In this discharge can be usually noted
minute, friable, yellowish or yellowish-gray bodies representing
conglomerate collections of the causative fungus.

The course of the malady is commonly slow and insidious. Unless systemic
pyemic infection occurs or the fungus elements find their way to the
deeper organs or structures the general health remains apparently
undisturbed.


#What is the treatment?#

The administration of moderate to large doses of potassium iodide,
conjointly with curetting or excision of the diseased mass. Local
applications of iodine solution can also be tried.



                     #Blastomycetic Dermatitis.#


#What do you understand by blastomycetic dermatitis?#

Blastomycetic dermatitis is a rare disease beginning usually as a small
papule or nodule, enlarging slowly, breaking down and developing into a
verrucous or papillomatous-looking area, similar in appearance to
tuberculosis cutis verrucosa. A muco-purulent or purulent secretion can
visually be pressed out from between the papillomatous elevations. It
may also present the appearance of a serpiginous lupus vulgaris or
syphiloderm. As a rule it is slow in its course. Furuncular or
abscess-like formations may develop, usually from secondary infection.
The disease is due to the invasion of the cutaneous tissues by the
blastomyces.

[Illustration: Blastomycetic dermatitis.]

Treatment consists in administration of moderate to large doses of
potassium iodide, and in the employment of antiseptic and parasiticide
applications; usually, however, radical treatment, such as employed in
lupus vulgaris, may be necessary.



                                 #Scabies.#
                           (_Synonym:_ The Itch.)


#What is scabies?#

Scabies, or itch, is a contagious animal-parasitic disease characterized
by a multiform eruption of a somewhat peculiar distribution, attended by
intense itching.


#Describe the symptoms of scabies.#

The penetration and presence of the parasites within the cutaneous
structures besides often giving rise to several or more complete or
imperfectly formed _burrows_, excite varying degrees of irritation, and
in consequence the formation of vesicles, papules and pustules,
accompanied with more or less intense itching. Secondarily, crusting,
and at times a mild or severe grade of dermatitis, may be brought about.
The parasite seeks preferably tender and protected situations, as
between the fingers, on the wrists, especially the flexor surface, in
the folds of the axilla, on the abdomen, about the anal fissure, about
the genitalia, and in females also about the nipples, and hence the
eruption is most abundant about these regions. The inside of the thighs
and the feet are also attacked, as, indeed, may be almost every portion
of the body. The scalp and face are not involved; exceptionally,
however, these parts are invaded in infants and young children.


#Is the grade of cutaneous irritation the same in all cases of scabies?#

No; in those of great cutaneous irritability, especially in children,
the skin being more tender, the type of the eruption is usually much
more inflammatory. In those predisposed a true eczema may arise, and
then, in addition to the characteristic lesions of scabies, eczematous
symptoms are superadded; in long-persistent cases, indeed, the burrows
and other consequent lesions may be more or less completely masked by
the eczematous inflammation, and the true nature of the disease be
greatly obscured.


#What do you mean by burrows?#

Burrows, or _cuniculi_, are tortuous, straight or zigzag, dotted,
slightly elevated, dark-gray or blackish thread-like linear formations,
varying in length from an eighth to a half an inch.

[Illustration: Fig. 76.
  Burrow, or cuniculus, greatly magnified. (_After Kaposi._) Showing the
  mite, ova, empty shells and excrement.]


#How is a burrow formed?#

By the impregnated female parasite, which penetrates the epidermis
obliquely to the rete, depositing as it goes along ten or fifteen ova,
forming a minute passage or burrow.


#Upon what parts are burrows most commonly to be found?#

In the interdigital spaces, on the flexor surface of the wrists, about
the mammæ in the female, and on the shaft of the penis in the male.


#Are burrows usually present in numbers?#

No. Several may be found in a single case, but they are rarely numerous,
as the irritation caused by the penetration of the parasites leads
either to violent scratching and their destruction, or gives rise to the
formation of vesicles and pustules, and consequently their formation is
prevented.


#What course does scabies pursue?#

Chronic and progressive, showing no tendency to spontaneous
disappearance.


#To what is scabies due?#

To the invasion of the cutaneous structures by an animal parasite, the
sarcoptes scabiei (_acarus scabiei_). The male mite is never found in
the skin and apparently takes no direct part in the production of the
symptoms.

[Illustration: Fig. 77. Fig. 78.
  Sarcoptes scabiei x 100.
  (_After Duhring._) Female. Ventral surface. Male.]

The disease is contagious to a marked degree, and is most commonly
contracted by sleeping with those affected, or by occupying a bed in
which an affected person has slept. It occurs, for obvious reasons,
usually among the poor, although it is now quite frequently met with
among the better classes.


#State the diagnostic features of scabies.#

The burrows, the peculiar distribution and the multiformity of the
eruption, the progressive development, and usually a history of
contagion.


#How do vesicular and pustular eczema differ from scabies?#

Eczema is usually limited in extent, or irregularly distributed, is
distinctly patchy, with often the formation of large diffused areas; it
is variable in its clinical behavior, better and worse from time to
time, and differs, moreover, in the absence of burrows and of a history
of contagion.


#How does pediculosis corporis differ from scabies?#

In the distribution of the eruption. The pediculi live in the clothing
and go to the skin solely for nourishment, and hence the eruption in
that condition is upon covered parts, especially those parts with which
the clothing lies closely in contact, as around the neck, across the
upper part of the back, about the waist and down the outside of the
thighs; _the hands are free_.


#State the prognosis of scabies.#

It is favorable. The disease is readily cured, and, as soon as the
parasites and their ova are destroyed, the itching and the secondary
symptoms, as a rule, rapidly disappear.


#How is scabies treated?#

Treatment is entirely external, and consists of a preliminary
soap-and-hot-water bath, an application, twice daily for three days, of
a remedy destructive to the parasites and ova, and finally another bath.

Inquiry as to others of the family should be made, and, if affected,
treated at the same time. The wearing apparel should be looked
after--boiled, baked, or sulphur-fumigated.


#What remedial applications are employed in scabies?#

Sulphur, balsam of Peru, styrax, and [beta]-naphthol, singly or
severally combined. In children, or in those of sensitive skin, the
following:--

  [Rx] Sulphur. præcip., .................... [dram]iv
       Balsam. Peruv., ...................... [dram]ij
       Adipis,
       Petrolati, ......... [=a][=a] ........ [Oz]iss.       M.

And in adults, or those of non-irritable skin:--

  [Rx] Sulphur, præcip., .................... [Oz]j
       Balsam. Peruv., ...................... [Oz]ss
       [beta]-Naphthol, ..................... [dram]ij
       Adipis,
       Petrolati, ... [=a][=a] ... q.s. ad .. [Oz]iv.       M.

Styrax is a remedy of value and is commonly employed as an ointment in
the strength of one part to two or three parts of lard.


#Is one such course of treatment sufficient to bring about a cure?#

Yes, in ordinary cases, if the applications have been carefully and
thoroughly made; exceptionally, however, some parasites and ova escape
destruction, and consequently itching will again begin to show itself at
the end of a week or ten days, and a repetition of the treatment become
necessary.


#Does the secondary dermatitis which is always present in severe cases
require treatment?#

Only when it is unusually persistent or severe; in such cases the
various soothing applications, lotions or ointments employed in acute
eczema are to be prescribed.


#Is a dermatitis due to too active and prolonged treatment ever mistaken
for persistence of the scabies?#

Yes.



                              #Pediculosis.#
                  (_Synonyms:_ Phtheiriasis; Lousiness.)


#Define pediculosis.#

Pediculosis is a term applied to that condition of local or general
cutaneous irritation due to the presence of the animal parasite, the
pediculus, or louse.


#Name the several varieties met with.#

Three varieties are presented, named according to the parts involved,
pediculosis capitis, pediculosis corporis, and pediculosis pubis; the
parasite in each being a distinct species of pediculus.



                           #Pediculosis Capitis.#


#Describe the symptoms of pediculosis capitis.#

Pediculosis capitis (_pediculosis capillitii_), due to the presence of
the pediculus capitis, occurs much more frequently in children than in
adults. It is characterized by marked itching, and the formation of
various inflammatory lesions, such as papules, pustules and
excoriations--resulting from the irritation produced by the parasites
and from the scratching to which the intense pruritus gives rise. In
fact, an eczematous eruption of the pustular type soon results, attended
with more or less crust formation. In consequence of the cutaneous
irritation the neighboring lymphatic glands may become inflamed and
swollen, and in rare cases suppurate. The occipital region is the part
which is usually most profusely infested, more especially in young girls
and women. In those of delicate skin, especially in children, scattered
papules, vesico-papules, pustules, and excoriations may often be seen
upon the forehead and neck. In some instances, however, especially in
boys, there may be many pediculi present, with but little cutaneous
disturbance, the itching being the sole symptom.

[Illustration: Fig. 79.
  Pediculus Capitis x 25. (_After Duhring._) Female. Dorsal surface.]

In addition to the pediculi, which, as a rule, may be readily found, their
_ova_, or _nits_, are always to be seen upon the shaft of the hairs,
quite firmly attached.


#Describe the appearance of the ova.#

They are dirty-white or grayish looking, minute, pear-shaped bodies,
visible to the naked eye, and fastened upon the shaft of the hairs with
the small end toward the root.

[Illustration: Fig. 80.
  Ova of the head-louse attached to a hair. Magnified. (_After Kaposi._)]


#Is there any difficulty in the diagnosis of pediculosis capitis?#

No. The diagnosis is readily made, as the pediculi are usually to be
found without difficulty, and even when they exist in small numbers and
are not readily discovered, _the presence of the ova_ will indicate the
nature of the affection.

Pustular eruptions upon the scalp, especially posteriorly, should always
arouse a suspicion of pediculosis. The possibility of the pediculosis
being secondary to eczema must not be forgotten.


#What is the treatment of pediculosis capitis?#

Treatment consists in the application of some remedy destructive to the
pediculi and their ova. Crude petroleum is effective, one or two
thorough applications over night being usually sufficient; in order to
lessen its inflammability, and also to mask its somewhat disagreeable
odor, it may be mixed with an equal part of olive oil and a small
quantity of balsam of Peru added.

Tincture of cocculus indicus, pure or diluted, may also be applied with
good results.

When the parts are markedly eczematous, an ointment of ammoniated
mercury or [beta]-naphthol, thirty to sixty grains to the ounce may
be used.

Daily shampooing with soap and water, and the twice daily application of
a five per cent. carbolic acid lotion, together with the use of a
fine-toothed comb, is a safe and efficient method for dispensary
practice; as it is, indeed, for any class of patients.


#How are the ova or their shells to be removed from the hair?#

By the frequent use of acid or alkaline lotions, such as dilute acetic
acid and vinegar, or solutions of sodium carbonate and borax.



                         #Pediculosis Corporis.#


#Describe the symptoms of pediculosis corporis.#

Pediculosis corporis is dependent upon the presence of the pediculus
corporis (_pediculus vestimenti_), a larger variety than that infesting
the scalp. It is characterized by more or less general itching, together
with various inflammatory lesions and excoriations. As the parasites are
to be found chiefly in the folds and seams of the clothing, visiting the
skin for the purpose of feeding, the various symptoms--the minute
hemorrhagic puncta showing the points at which they have been sucking,
and the consequent papules, pustules and excoriations--are, therefore,
to be found most abundantly on those parts with which the clothing comes
closely in contact, as, for instance, around the neck, across the
shoulders, around the waist, and down the outside of the thighs. It is
uncommon in children.

[Illustration: Fig. 81.
  Pediculus Corporis x 25. (_After Duhring._) Female. Dorsal surface.]


#State the diagnostic characters of pediculosis corporis.#

The presence of the minute hemorrhagic puncta, the multiform character
and peculiar distribution of the eruption. Careful search will almost
invariably disclose one or more pediculi.


#What is the treatment of pediculosis corporis?#

The clothing and bed-coverings are to be thoroughly baked or boiled, the
pediculi and their ova being in this manner destroyed; a thymol or
carbolized boric-acid lotion may be used to relieve the cutaneous
irritation.

When attention to the wearing apparel is not immediately practicable,
ointments of sulphur and staphisagria, and lotions of carbolic acid, may
be advised as temporary measures. The wearing of a bag of loosely woven
texture containing some lump sulphur next to the skin is useful in such
cases; at the temperature of the body the sulphur undergoes slow
oxidation. In hairy individuals the malady is often persistent, due to
the fact that ova have become attached to the hair and a new progeny
soon hatched out. Continued treatment over a few weeks will usually
suffice to rid the patient of their presence.



                         #Pediculosis Pubis.#


#Describe the symptoms of pediculosis pubis.#

Pediculosis pubis is a condition due to the presence of the pediculus
pubis, or crab-louse. It is characterized by more or less itching about
the genitalia, together with papules, excoriations, and other
inflammatory lesions. The amount of irritation varies; it may be slight,
or, on the other hand, severe. The parasite, which is the smallest of
the three varieties, may be discovered upon close examination seated
near the roots of the hairs, clutching the hair, with its head downward
and buried in the follicle. The ova may be seen attached to the
hair-shafts.

It infests adults chiefly, being in many instances probably contracted
through sexual intercourse.


#Is the pediculus pubis found upon any other part of the body?#

Yes. Although its favorite habitat is the region of the pubes, it may,
in exceptional instances, also infest the axillæ, the sternal region of
the male, the beard, eyebrows, and even the eyelashes.


#State the diagnostic characters of pediculosis pubis.#

The region involved, itching, variable amount of irritation, and, above
all, the presence of the pediculi and their ova.

[Illustration: Fig. 82.
  Pediculus Pubis x 25. (_After Duhring._) Female. Dorsal surface.]


#Name several applications prescribed for pediculosis pubis.#

A lotion of corrosive sublimate, one to four grains to the ounce;
infusion of tobacco; a ten to twenty per cent. ointment of oleate of
mercury; ammoniated mercury ointment, and a five to ten per cent.
[beta]-naphthol ointment. Repeated washings with vinegar or dilute
acetic acid, or with alkaline lotions, will free the hairs of the ova.



                        #Cysticercus Cellulosæ.#


#Describe the cutaneous disturbance produced by the cysticercus
cellulosæ.#

The presence of cysticerci in the skin and subcutaneous tissue gives
rise to pea to hazelnut-sized, rounded, firm, movable tumors which, when
developed, may remain unchanged for months. The parasites are disclosed
by microscopic examination.

Most of the cases have been observed in Germany.



                           #Filaria Medinensis.#
                         (_Synonym:_ Guinea-worm.)


#State the character of the lesions produced by the filaria medinensis.#

The young microscopic worm penetrates the skin or deeper tissue, where
it grows gradually, finally reaching several inches or more in length
and about a half-line in thickness; inflammation is excited and a
tumor-like swelling makes its appearance, which, sooner or later,
breaks, disclosing the worm. It may also present a cord-like appearance.
It is rarely met with outside of tropical countries.

Treatment consists in gradual extraction, or in the injection of a
corrosive sublimate solution (1:1000) into the forming tumor. Asafetida
internally has been found to be curative, the parasite being destroyed
and subsequently absorbed or discharged.



                                 #Ixodes.#
                          (_Synonym:_ Wood-tick.)


#State the character of the cutaneous disturbance produced by the ixodes.#

The tick sticks its proboscis into the skin and sucks blood until it is
several times its natural size, and then falls off; an urticarial lesion
results. If caught in the act the animal should not be forcibly
extracted, as its proboscis may be thus broken off and remain in the
skin, and give rise to pain and inflammation. It may be made to
relinquish its hold by placing on it a drop of an essential oil.

A thymol or carbolized boric-acid lotion will relieve the irritation.



                                 #Leptus.#
                        (_Synonym:_ Harvest-mite.)


#State the characters of the lesion produced by the leptus.#

This minute brick-red mite buries itself in the skin, especially about
the ankles and feet, giving rise to papules, vesicles and pustules.

Treatment consists of the use of a mild sulphur ointment or of a
carbolic-acid lotion.



                               #[OE]strus.#
                       (_Synonym:_ Gad, or Bot-fly.)


#Describe the cutaneous disturbance produced by the [oe]strus.#

The ova are deposited in the skin, develop and give rise to the
formation of furuncle-like tumors with central aperture, through which a
sanious discharge exudes; or as the result of the burrowing of the
larvæ, irregular serpiginous lines or wheals are produced.

It is chiefly met with in Central and South America.

_Larva migrant_, or _creeping disease_, is doubtless in this same class.
It is characterized by a thread-like linear formation of an
erythematous, erythemato-papular, or vesicular nature that gradually
extends, the older part disappearing; considerable surface may be
covered before the parasite disappears or dies. The treatment consists
in endeavoring to destroy the organism by means of excision or caustic
applications at the point of its suspected site which is just ahead of
the extending line.



                             #Pulex Penetrans.#
                     (_Synonyms:_ Sand Flea; Jigger.)


#Describe the cutaneous disturbance produced by the pulex penetrans.#

This microscopic animal penetrates the skin, especially about the toes,
producing an inflammatory swelling, vesicle or pustule, or even
ulceration. It is met with in warm and tropical countries.

Treatment consists in extraction. Essential oils are used as a
preventive. A carbolic-acid or alkaline lotion relieves irritation.



                            #Cimex Lectularius.#
                           (_Synonym:_ Bed-bug.)


#Describe the characters of a bed-bug bite.#

An inflammatory papule or wheal-like lesion results, somewhat
hemorrhagic; the purpuric or hemorrhagic point or spot remains after the
swelling subsides, but finally, in the course of several days or a few
weeks, disappears.

Treatment consists in the application of alkaline or acid lotions.



                                #Culex.#
                      (_Synonym:_ Gnat; Mosquito.)


#Describe the cutaneous disturbance produced by the culex.#

It consists of an erythematous spot or a wheal-like lesion.

Alkaline or acid lotions usually give relief.



                            #Pulex Irritans.#
                        (_Synonym:_ Common Flea.)


#Describe the cutaneous disturbance produced by the pulex irritans.#

It consists of an erythematous spot with a minute central hemorrhagic
point. In irritable skin, a wheal-like lesion may result.

Treatment consists of applications of camphor or ammonia-water; carbolic
acid and thymol lotions are also useful.



RELATIVE FREQUENCY OF THE VARIOUS DISEASES OF SKIN AS SHOWN BY THE
STATISTICS (123,746 CASES) OF THE AMERICAN DERMATOLOGICAL ASSOCIATION
FOR TEN YEARS, 1878-87.


-------------------------+-------+-------+
    CLASSIFICATION OF    |  No.  |   %   |
         DISEASES.       | Cases | Cases |
-------------------------+-------+-------+
Class I. Disorders of the|       |       |
  Glands.                |       |       |
  1. OF THE SWEAT GLANDS.|       |       |
    Hyperidrosis         |   328 |  .265 |
    Sudamen              |   268 |  .216 |
    Anidrosis            |    11 |  .009 |
    Bromidrosis          |   112 |  .090 |
    Chromidrosis         |     7 |  .005 |
    Uridrosis            |   ... |  .... |
  2. OF THE SEBACEOUS    |       |       |
    GLANDS               |   238 |  .193 |
    Seborrh[oe]a:        |  1812 | 1.47  |
      a. oleosa          |   367 |  .296 |
      b. sicca           |   395 |  .319 |
    Comedo               |  1225 |  .989 |
    Cyst:                |     6 |  .004 |
      a. Milium          |   225 |  .183 |
      b. Steatoma        |   151 |  .122 |
    Asteatosis           |     8 |  .006 |
                         |       |       |
Class II. Inflammations. |       |       |
    Exanthemata          |  1770 | 1.43  |
    Erythema simplex     |  1064 |  .859 |
    Erythema multiforme: |   915 |  .730 |
      a. papulosum       |   325 |  .262 |
      b. bullosum        |    37 |  .029 |
      c. nodosum         |    82 |  .066 |
    Urticaria            |  2994 | 2.47  |
      pigmentosa         |     1 |  .0008|
    [E]Dermatitis:       |  1720 | 1.39  |
      a. traumatica      |   468 |  .378 |
      b. venenata        |   616 |  .498 |
      c. calorica        |   224 |  .187 |
      d. medicamentosa   |   108 |  .087 |
      e. gangrænosa      |     8 |  .006 |
    Erysipelas           |  1026 |  .829 |
    Furunculus           |  2129 | 1.72  |
    Anthrax              |   252 |  .203 |
    Phlegmona diffusa    |   265 |  .215 |
    Pustula maligna      |   197 |  .159 |
    Herpes simplex       |  2057 | 1.66  |
    Herpes zoster        |  1428 | 1.15  |
    Dermatitis           |       |       |
      herpetiformis      |    41 |  .033 |
    Psoriasis            |  4131 | 3.34  |
    Pityriasis maculuta  |       |       |
      et circinata       |    71 |  .057 |
    Dermatitis           |       |       |
      exfoliativa        |    16 |  .012 |
    Pityriasis rubra     |    44 |  .032 |
    Lichen:              |   144 |  .116 |
      a. planus          |   154 |  .124 |
      b. ruber           |    27 |  .021 |
    Eczema:              | 37661 |30.43  |
      a. erythematosum   |  .... |  .... |
      b. papulosum       |  .... |  .... |
      c. vesiculosum     |  .... |  .... |
      d. madidans        |  .... |  .... |
      e. pustulosum      |  .... |  .... |
      f. rubrum          |  .... |  .... |
      g. squamosum       |  .... |  .... |
    Prurigo              |    34 |  .027 |
    Acne                 |  9077 | 7.34  |
    Acne rosacea         |   398 |  .321 |
    Sycosis              |   227 |  .185 |
    Impetigo             |  1769 | 1.43  |
    Impetigo contagiosa  |   600 |  .485 |
    Impetigo             |       |       |
      herpetiformis      |    10 |  .009 |
    Ecthyma              |   726 |  .587 |
    Pemphigus            |   183 |  .148 |
    Ulcers               |  3021 | 2.44  |
                         |       |       |
Class III. Hemorrhages.  |       |       |
    Purpura:             |   341 |  .275 |
      a. simplex         |   181 |  .145 |
      b. hæmorrhagica    |    49 |  .039 |
                         |       |       |
Class IV. Hypertrophies. |       |       |
  1. OF PIGMENT.         |       |       |
    Lentigo              |   127 |  .103 |
    Chloasma             |   560 |  .452 |
  2. OF EPIDERMAL AND    |       |       |
    PAPILLARY LAYERS.    |       |       |
    Keratosis:           |    94 |  .076 |
      a. pilaris         |   103 |  .083 |
      b. senilis         |    68 |  .055 |
    Molluscum epitheliale|   172 |  .139 |
    Callositas           |   110 |  .090 |
    Clavus               |    84 |  .068 |
    Cornu cutaneum       |    42 |  .034 |
    Verruca              |  1252 | 1.09  |
    Verruca necrogenica  |     2 |  .001 |
    Nævus pigmentosus    |    88 |  .064 |
    Xerosis              |   100 |  .080 |
    Ichthyosis           |   309 |  .249 |
    Onychauxis           |    70 |  .056 |
    Hypertrichosis       |   515 |  .416 |
  3. OF CONNECTIVE       |       |       |
    TISSUE.              |       |       |
    Sclerema neonatorum  |  .... |  .... |
    Scleroderma          |    38 | 0.030 |
    Morph[oe]a           |    39 | 0.031 |
    Elephantiasis        |    57 | 0.046 |
    Rosacea:             |   785 | 0.634 |
      a. erythematosa    |   381 | 0.308 |
      b. hypertrophica   |    58 | 0.047 |
    Framb[oe]sia         |    22 | 0.018 |
                         |       |       |
Class V. Atrophies.      |       |       |
  1. OF PIGMENT.         |       |       |
    Leucoderma           |    77 | 0.062 |
    Albinismus           |     9 | 0.008 |
    Vitiligo             |   191 | 0.155 |
    Canities             |    43 | 0.035 |
  2. OF HAIR.            |       |       |
    Alopecia             |   926 | 0.749 |
    Alopecia furfuracea  |   830 | 0.670 |
    Alopecia areata      |   794 | 0.641 |
    Atrophia pilorum     |       |       |
      propria            |    23 | 0.019 |
    Trichorexis nodosa   |     3 | 0.002 |
  3. OF NAIL             |    26 | 0.021 |
    Atrophia unguis      |    19 | 0.015 |
  4. OF CUTIS            |     6 | 0.005 |
    Atrophia senilis     |    15 | 0.013 |
    Atrophia maculosa et |       |       |
      striata            |    23 | 0.019 |
                         |       |       |
Class VI. New Growths.   |       |       |
  1. OF CONNECTIVE       |       |       |
    TISSUE.              |     1 | 0.0008|
    Keloid               |   152 | 0.124 |
    Cicatrix             |    89 | 0.065 |
    Fibroma              |    93 | 0.075 |
    Neuroma              |    11 | 0.009 |
    Xanthoma             |    69 | 0.056 |
  2. OF MUSCULAR TISSUE. |       |       |
    Myoma                |     1 | 0.0008|
  3. OF VESSELS.         |       |       |
    Angioma              |   462 | 0.373 |
    Angioma pigmentosum  |       |       |
      et atrophicum      |    13 | 0.010 |
    Angioma cavernosum   |    22 | 0.018 |
    Lymphangioma         |    16 |  .012 |
  4. Mycosis fongoide    |     1 |  .0008|
    Rhinoscleroma        |     3 |  .002 |
    Lupus erythematosus  |   477 |  .385 |
    Lupus vulgaris       |   536 |  .433 |
    Scrofuloderma        |   663 |  .536 |
    Syphiloderma:        | 13888 |11.22  |
      a. erythematosum   |  .... |  .... |
      b. papulosum       |  .... |  .... |
      c. pustulosum      |  .... |  .... |
      d. tuberculosum    |  .... |  .... |
      e. gummatosum      |  .... |  .... |
    Lepra:               |    24 |  .020 |
      a. tuberosa        |     7 |  .005 |
      b. maculosa        |     4 |  .003 |
      c. anæsthetica     |     6 |  .004 |
    Carcinoma            |  1068 |  .863 |
    Sarcoma              |    55 |  .044 |
                         |       |       |
Class VII. Neuroses.     |       |       |
    Hyperæsthesia:       |     4 |  .003 |
      a. Pruritus        |  2716 | 2.12  |
      b. Dermatalgia     |    11 |  .009 |
    Anæsthesia           |    22 |  .018 |
                         |       |       |
Class VIII. Parasitic    |       |       |
    Affections.          |       |       |
  1. VEGETABLE.          |       |       |
    Tinea favosa         |   354 |  .286 |
    Tinea trichophytina: |  2289 | 1.85  |
      a. circinata       |   705 |  .569 |
      b. tonsurans       |   675 |  .545 |
      c. sycosis         |   365 |  .295 |
    Tinea versicolor     |  1263 | 1.02  |
  2. ANIMAL.             |       |       |
    Scabies              |  3192 | 2.58  |
    Pediculosis          |       |       |
      capillitii         |  2579 | 2.09  |
    Pediculosis corporis |  1704 | 1.38  |
    Pediculosis pubis    |   436 |  .352 |
-------------------------+-------+-------+
    Total                 123746

[Footnote E: Indicating affections of this class not properly included
  under other titles.]



                            #INDEX.#

Acarus folliculorum, 40
  scabiei, 269

Achorion Schönleinii, 249

Acne, 115-126
  artificialis, 120
  atrophica, 120
  cachecticorum, 120
  frontalis, 129
  hypertrophica, 120
  indurata, 120
  keloid, 135
  lupoid, 129
  necrotica, 129
  papulosa, 120
  punctata, 120
  pustulosa, 120
  rodens, 129
  rosacea, 126-129, 198
  sebacea, 33
  tar, 120
  urticata, 130
  varioliformis, 129
  vulgaris, 119

Acnitis, 130

Actinomycosis, 266

Addison's disease, pigmentation of the skin in, 149
  keloid, 172

Ainhum, 212

Albinismus, 177

Albinos, 177

Alopecia, 181-183
  areata, 183-186
  circumscripta, 183
  congenital, 181
  furfuracea, 181
  premature, 181
  senile, 181

Anæsthesia, 244

Anatomy of the skin, 17-21, 28

Angioma, 196, 197
  cavernosum, 197
  pigmentosum et atrophicum, 190
  simplex, 196

Angiomyoma, 196

Angioneurotic [oe]dema, 54

Anidrosis, 31

Anthrax, 70, 72

Antipruritic applications, 246

Antipyrin, eruptions from, 61

Area Celsi, 183

Argyria, 150

Arsenic, eruptions from, 61

Artificial eruptions (feigned eruptions), 64

Atrophia cutis, 189, 190
  pilorum propria, 187
  unguis, 188, 189

Atrophic lines and spots, 190

Atrophies, 177-190

Atrophoderma, 189
  neuriticum, 189

Atrophy of the hair, 187
  of the nails, 188
  of the skin, 189
    general idiopathic, 189
  senile, 190

Atropia, eruptions from, 61

Autographism, 52


Baldness, 181

Barbadoes leg, 174

Barbers' itch, 255

Bath-pruritis, 245

Bed-bug, 278

Bed-sores, 58

Belladonna, eruptions from, 61

Blackheads, 38-41

Blanching of the hair, 180

Blastomycetic dermatitis, 266

Blebs, 23

Blood-vessels, 19

Boil, 68

Bot-fly, 278

Bromides, eruptions from, 61

Bromidrosis, 32

Bullæ, 23

Burns, 58

Burrows, 268


Calculi, cutaneous, 42

Callositas, 155, 156

Callosity, 155

Callous, 155

Callus, 155

Cancer, epithelial, 236
  skin, 236

Canities, 180
  prematura, 180
  senilis, 180

Carbuncle, 70

Carbunculus, 70-72

Carcinoma epitheliale, 236

Carrion's disease, 73

Chafing, 45

Chapping, 106

Charbon, 72

Cheiro-pompholyx, 76

Cheloid, 191

Chloasma, 149-151
  uterinum, 149

Chloral, eruptions from, 62

Chromidrosis, 32
  red, 33

Chromophytosis, 262

Chrysarobin, 93

Chrysophanic acid (chrysarobin), 93

Cicatrices, 24

Cimex lectularius, 278

Clavus, 156, 157

Comedo, 38-41
  extractor, 40

Condyloma, flat (or broad), 217
  pointed, 161

Configuration, 24

Conglomerate pustular folliculitis, 252

Contagious impetigo, 136

Contagiousness, 27

Copaiba, eruptions from, 62

Corn, 156

Cornu cutaneum, 158, 159
  humanum, 159

Crab-louse, 275

Creeping disease, 278

Crusta lactea, 104

Crustæ, 24

Crusts, 24

Cubebs, eruptions from, 62

Culex, 279

Cuniculus, 268

Curette, 208

Cutaneous calculi, 42
  horn, 158

Cutis anserina, 152
  pendula, 176

Cyst, sebaceous, 43

Cysticercus cellulosæ, 276


Dandruff, 33, 34

Darier's disease, 153

Defluvium capillorum, 181

Demodex folliculorum, 40

Depilatories, 169

Dermalgia, 244

Dermatalgia, 244

Dermatitis, 58-64
  acute general, 96
  ambustionis, 58
  blastomycetic, 266
  calorica, 58
  congelationis, 58
  contusiformis, 50
  exfoliativa, 96, 97
    general, 96
    neonatorum, 97
    recurrent, 96
  factitia, 64
  gangrænosa, 65
  herpetiformis, 83-86
  iodoform, 59
  malignant papillary, 240
  medicamentosa, 60
  papillaris capillitii, 135
  repens, 81
  traumatica, 58
  vegetans, 142
  venenata, 59
  _x_-ray, 63

Dermatographism, 52

Dermatolysis, 176

Dermatomyoma, 196

Dermatosclerosis, 172

Dermatosyphilis, 213

Dhobi itch, 265

Digitalis, eruptions from, 62

Disorders of the glands, 28-44

Dissection wound, 73

Distribution and configuration, 24-26

Drug eruptions (dermatitis medicamentosa), 60

Duhring's disease, 83

Dysidrosis, 76


Ecthyma, 138, 139

Eczema, 100-119
  erythematosum, 102
  fissum, 106
  impetiginosum, 104
  madidans, 105
  marginatum, 253
  papulosum, 103
  pustulosum, 104
  rimosum, 106
  rubrum, 105
  sclerosum, 106
  seborrhoicum, 33, 34, 91, 95, 109
  squamosum, 104
  verrucosum, 106
  vesiculosum, 104

Electrolysis in removal of hair, 169

Elephant leg, 174

Elephantiasis, 174-176
  Arabum, 174
  Græcorum, 231

Epidermis, 18

Epidermolysis bullosa, 80

Epilating forceps, 249

Epithelial cancer, 236

Epithelioma, 236-240
  benign cystic, 198
  molluscum, 153

Equinia, 74

Erasion, 208

Eruptions, feigned (artificial), 64
  medicinal (dermatitis medicamentosa), 60

Erysipelas, 66, 67
  ambulans, 67
  migrans, 67

Erysipeloid, 67

Erythema, 44
  annulare, 48
  bullosum, 48
  caloricum, 44
  desquamative scarlatiniform, 96
  gangrenosum, 65
  gyratum, 48
  induratum, 51
    scrofulosorum, 51
  intertrigo, 45, 46
  iris, 48
  marginatum, 48
  multiforme, 46
  nodosum, 50, 51
  recurrent exfoliative, 96
  simplex, 44
  solare, 44
  traumaticum, 44
  venenatum, 44
  vesiculosum, 48

Erythrasma, 265

Excessive sweating (hyperidrosis), 28

Excoriationes, 24

Excoriations, 24


Farcy, 74

Favus, 247
  of general surface, 248
  of nails, 249
  of scalp, 247

Feigned eruptions, 64

Fever blisters, 78

Fibroma, 192-194
  molluscum, 192

Fibromyoma, 196

Filaria, 175
  medinensis, 277

Fish-skin disease, 165

Fissures, 24

Flea, common, 279
  sand, 278

Flesh worms, 38-41

Folliclis, 130

Folliculitis barbæ, 130
  decalvans, 131
  pustular, conglomerate, 252

Forceps, epilating, 249

Fragilitas crinium, 187

Framb[oe]sia, 73

Freckle, 148

Frost-bite, 58

Fungous foot of India, 212

Furuncle, 68

Furunculosis, 69

Furunculus, 68-70


Gad-fly, 278

Galvano-cautery, 208
  instruments, 206

Gangrene of the skin (dermatitis gangrænosa), 65
  spontaneous, 65
  symmetric, 66

Gelatin dressing, 116

Giant urticaria, 54

Glanders, 74

Glands, sebaceous, 33
  sweat, 28

Glossy skin, 189

Gnat, 279

Goose-flesh, 152

Granuloma fungoides, 242
  necroticum, 129

Grayness of the hair, 180

Grutum, 42

Guinea-worm, 277

Gumma, 225

Gun-powder marks, 151

Gutta-percha plaster, 117


Hair, 21
  atrophy of, 187
  graying of, 180
  hypertrophy of, 168
  superfluous, 168

Hair-follicle, 21

Hairy people, 168

Harvest mite, 277

Heat rash, 74

Hemorrhages, 144-146

Henoch's purpura, 145, 146

Hereditary infantile syphilis, 228
  cutaneous manifestations of, 221

Herpes, 78
  facialis, 78
  gestationis, 83
  iris, 48
  labialis, 78
  præputialis, 79
  progenitalis, 78
  simplex, 78-80
  zoster, 81-83

Hirsuties, 168

Hives, 52

Homines pilosi, 168

Horn, cutaneous, 158

Hydradenitis suppurativa, 130

Hydroa æstivale, 80
  herpetiforme, 83
  puerorum, 80
  vacciniforme, 80

Hydrocystoma, 31

Hyperesthesia, 244

Hyperidrosis, 28-30

Hypertrichosis, 168-170

Hypertrophic scar, 192

Hypertrophies, 148-177

Hypertrophy of the hair, 168
  of the nail, 167


Ichthyosis, 165-167
  congenita, 165
  follicularis, 153
  hystrix, 165
  sebacea, 33
    cornea, 153
  simplex, 165

Impetigo contagiosa, 136, 138
  herpetiformis, 138
  simplex, 137

Infantile syphilis, hereditary, 228

Inflammations, 44-143

Inflammatory fungoid neoplasm, 242

Iodides, eruptions from, 62

Iodoform dermatitis, 59

Itch, 267
  barbers', 255
  dhobie, 265
  mite, 269

Ivy poisoning, 59

Ixodes, 277


Jigger, 278


Keloid, 172, 192
  cicatricial, 191
  false, 191
  of Addison, 172
  of Alibert, 191
  spontaneous, 191
  true, 191

Keratodermia, symmetric, 155

Keratoma, 155

Keratosis follicularis, 153
  palmaris et plantaris, 155
  pigmentosa, 160
  pilaris, 151, 152
  senilis, 236

Kerion, 255


Land scurvy, 145

Larva nigrans, 278

Lentigo, 148

Leontiasis, 233

Lepra, 231-235

Leprosy, 231
  anæsthetic, 233
  Lombardian, 235
  tubercular, 232

Leptus, 277

Lesions, 22
  configuration of, 24
  consecutive, 23
  distribution of, 24
  elementary, 22
  primary, 22
  secondary, 23

Leucoderma, 178

Leucopathia, 178

Lichen moniliformis, 98
  pilaris, 151
  planus, 98
    hypertrophicus, 98
  ruber, 99
    acuminatus, 99
  scrofulosus, 100
  tropicus, 74
  urticatus, 53

Linæ albicantes, 190

Linear nævus, 163
  scarification, 208

Liomyoma cutis, 196

Liquor carbonic detergens, 113
  picis alkalinus, 116

Lombardian leprosy, 235

Louse, body (pediculus corporis), 274
  clothes (pediculus corporis), 274
  crab, 275
  head (pediculus capitis), 272

Lousiness, 271

Lupoid acne, 129
  sycosis, 131

Lupus, 203
  erythematodes, 199
  erythematosus, 199-203
  exedens, 203
  exfoliativus, 203
  exulcerans, 203
  hypertrophicus, 204
  sebaceous, 199
  ulcerations, 203
  verrucosus, 204
  vorax, 203
  vulgaris, 203-208

Lymphangiectodes, 198

Lymphangioma, 198
  tuberosum multiplex, 198

Lymphangiomyoma, 196


Maculæ, 22
  et striæ atrophicæ, 190

Macules, 22

Madura foot, 212

Malignant papillary dermatitis, 240
  pustule, 72

Medicinal eruptions (dermatitis medicamentosa), 60

Melanoderma, 149

Melanosarcoma, 242

Melasma, 149

Mercury, eruptions from, 62

Microsporon audouini, 258

Microsporon furfur, 262
  minutissimum, 265

Miliaria, 74-76
  alba, 75
  crystallina, 30
  rubra, 74

Milium, 42, 43
  needle, 42

Milk crust, 104

Mite, harvest, 277
  itch, 269

Moist papule, 216, 217

Mole, 162

Molluscum contagiosum, 153
  epitheliale, 153-155
  fibrosum, 192
  sebaceum, 153

Morphia, eruptions from, 63

Morph[oe]a, 172

Mosquito, 279

Mucous patch, 217

Mycetoma, 212

Mycosis fungoides, 242

Myoma, 196
  cutis, 196
  telangiectodes, 196


Nævus araneus, 198
  capillary, 196
  flammeus, 196
  linear, 163
  lipomatodes, 164
  pigmentosus, 162
  pilosus, 163, 168
  sanguineus, 196
  simplex, 196
  spider, 198
  spilus, 163
  tuberosus, 197
  vasculosus, 196
  venous, 197
  verrucosus, 163

Nail, atrophy of, 188
  hypertrophy of, 167

Necrotic granuloma, 129

Neoplasm, inflammatory fungoid, 242

Neoplasmata (new growths), 191, 241

Nettlerash, 52

Neuralgia of the skin, 244

Neuroma, 194

Neuroses, 244-247

New growths, 191-243

Nits, 273


Objective symptoms, 22

[OE]dema, acute circumscribed, 54
  neonatorum, 170

[OE]strus, 278

Ointment bases, 27

Onychatrophia, 188

Onychauxis, 167, 168

Onychomycosis, 188
  favosa, 249

Opium, eruptions from, 63

Oroya fever, 73

Osmidrosis, 32

Ova of pediculi, 273


Pachydermia, 174

Paget's disease of the nipple, 240

Papillæ, nervous and vascular, 20

Papulæ, 23

Papule, moist, 216, 217

Papules, 23

Parasitic affections, 247-279
  sycosis, 255

Parasiticides, 250, 259

Parchment skin, 190

Paronychia, 167

Patch, mucous, 217

Pediculosis, 271
  capillitii, 272
  capitis, 272, 273
  corporis, 274, 275
  pubis, 275, 276

Pediculus capitis, 272
  corporis, 274
  pubis, 275
  vestimenti, 274

Peliosis rheumatica, 144

Pellagra, 235

Pemphigus, 140-144
  foliaceus, 141
  neonatorum, 140
  pruriginosus, 83
  vegetans, 142
  vulgaris, 140

Perforating ulcer of the foot, 213

Peruvian warts, 73

Phlegmona diffusa, 68

Phosphorescent sweat, 33

Phosphoridrosis, 33

Phtheiriasis, 271

Plan, 73

Pityriasis capitis, 34
  maculata et circinata, 95
  pilaris, 151
  rosea, 95, 96
  rubra, 97

Pityriasis rubra pilaris, 99
  versicolor, 261

Plasment, 117

Plaster-mull, 117

Podelcoma, 212

Poison dogwood, dermatitis from, 59
  ivy, dermatitis from, 59
  sumach, dermatitis from, 59
  vine, dermatitis from, 59

Pomphi, 23

Pompholyx, 76-78

Port-wine mark, 197

Post-mortem pustule, 73

Prickly heat, 74

Primary lesions, 22, 23

Prurigo, 118, 119

Pruritus, 244-247
  ani, 245
  hiemalis, 245
  scroti, 245
  senilis, 245
  vulvæ, 245

Pseudochromidrosis, 33

Psoriasis, 86-95
  circinata, 88
  diffusa, 88
  guttata, 88
  gyrata, 88
  inveterata, 88
  nummularis, 88
  punctata, 88
  syphilitica, 218

Psorospermosis, 153, 154, 240

Pulex irritans, 279
  penetrans, 278

Punctate scarification, 208

Purpura, 144-146
  hæmorrhagica, 145
  Henoch's, 145, 146
  rheumatica, 144
  scorbutica, 146
  simplex, 144
  urticans, 144

Pustula maligna, 72

Pustulæ, 23

Pustules, 23


Quinine, eruptions from, 63


Rapidity of cure, 27

Raynaud's disease, 66

Recurrent summer eruption, 80

Red chromidrosis, 33
  gum, 74

Relative frequency, 26

Rhagades, 24

Rheumatism of the skin, 244

Rhinophyma, 127

Rhinoscleroma, 198, 199

Rhus poisoning, 59

Ringworm, 251
  of bearded region, 255
  of general surface, 251
  of the nail, 253
  of the scalp, 253
  of the thighs and scrotum, 252
  Tokelau, 261

Rodent ulcer, 236

Rosacea, 198
  acne, 126

Rubber plaster, 117

Rupia, 221, 222


Salicylic acid, eruptions from, 63
  paste, 113

Salt rheum, 100

Sand flea, 278

Sarcoma, 241, 242
  cutis, 241

Sarcoptes scabiei, 269

Scabies, 267-271

Scales, 24

Scarification, linear, 208
  punctate, 208

Scarifier, multiple, 202
  single, 202

Scars, 24
  hypertrophic, 192

Schönlein's disease, 145, 146

Sclerema, 172
  neonatorum, 171
  of the newborn, 171

Scleriasis, 172

Scleroderma, 172, 173
  neonatorum, 171

Scorbutus, 146

Scrofuloderma, 209
  pustular, small, 210

Scurvy, 146
  land, 145
  sea, 146

Sebaceous cyst, 43
  gland, 33
  tumor, 43

Seborrh[oe]a, 33-38
  congestiva, 199
  oleosa, 34
  sicca, 34

Secondary lesions, 23, 24

Shingles, 81

Skin, anatomy of, 17
  cancer, 236
  general idiopathic atrophy of, 189
  glossy, 189
  looseness of, 176

Skin, parchment, 190

Spider nævus, 198

Spiradenitis, 130

Spontaneous gangrene, 65

Spots, 22

Squamæ, 24

Stains, 24

Statistics, 280, 281

Steatoma, 43

Steatorrh[oe]a, 33

Stramonium, eruptions from, 63

Striæ et maculæ atrophicæ, 190

Strophulus, 74
  albidus, 42

Subjective symptoms, 22

Sudamen, 30, 31

Superfluous hair, 168

Sweat, colored (chromidrosis), 32
  glands, 28
    phosphorescent, 33

Sweating, excessive, 28

Sycosis, 130-135
  coccogenica, 130
  non-parasitica, 130
  parasitic, 255
  vulgaris, 130

Symmetric gangrene, 66
  keratodermia, 155

Symptomatology, 22-26

Symptoms, objective, 22
  subjective, 22
  systemic, 22

Syphilis cutanea, 213-231
    early eruptions of, 213
    late eruptions of, 214
    papillomatosa, 225
  hereditary, 227
    eruptions of, 227
  of the skin, 213-231

Syphiloderm, 213
  acne-form, 220
  annular, 219
  bullous, 222, 228
  circinate, 219
  ecthyma-form, 221
  erythematous, 214, 227
  gummatous, 225
  impetigo-form, 220
  large acuminated-pustular, 220
    flat-pustular, 221
    papular, 216
  lenticular, 216
  macular, 214, 227
  miliary papular, 215
    pustular, 219
  non-ulcerating tubercular, 224
  palmar, 217, 218
  papular, 215, 227
  papulo-squamous, 218
  plantar, 218
  pustular, 219
  serpiginous tubercular, 224
  small acuminated-pustular, 219
    flat-pustular, 220
    papular, 215
  squamous, 218
  tubercular, 223, 224
  ulcerating tubercular, 224
  variola-form, 220
  vegetating, 218

Syphiloderma, 213

Syphiloma, 225


Tar acne, 120

Tattoo-marks, removal of, 151

Telangiectasis, 127, 197, 198

Tetter, 100

Tinea circinata, 251
  favosa, 247-251
    fungus of, 249
    unguium, 249
  imbricata, 261
  kerion, 255
  sycosis, 255
  tonsurans, 253
  trichophytina, 251-261
    barbæ, 255
    capitis, 253
    corporis, 251
    cruris, 252
    fungus of, 258
    unguium, 253
  versicolor, 262-265
    fungus of, 262

Tokelau ringworm, 261

Traumaticin, 94

Trichophyton, 258

Trichorrhexis nodosa, 187

Tubercles, 23

Tubercula, 23

Tuberculosis cutis, 209-211
  of the skin, 203

Tuberculosis verrucosa cutis, 209, 210

Tumor, sebaceous, 43

Tumors, 23

Turpentine, eruptions from, 63

Tyloma, 155

Tylosis, 155


Ulcer, perforating, of foot, 213
  rodent, 236

Ulcera, 24

Ulerythema sycosiforme, 131

Uridrosis, 33

Urticaria, 52-56
  bullosa, 54
  chronic, 53
  factitia, 52
  hæmorrhagica, 54
  [oe]dematosa, 54
  papulosa, 54
  tuberosa, 54
  giant, 54
  pigmentosa, 59
  vesicular, 54


Venereal wart, 161

Verruca, 160-162
  acuminata, 161
  digitata, 160
  filiformis, 160
  necrogenica, 211
  plana, 160
    juvenilis, 160
  senilis, 160
  vulgaris, 160

Verruga peruana, 73

Vesicles, 23

Vesiculæ, 23

Vitiligo, 178-180

Vitiligoidea, 195

Vleminckx's solution, 129


Wart, 160
  Peruvian, 73
  pointed, 161
  venereal, 161

Wen, 43

Wheals, 23

Wood-tick, 277

Wound dissection, 73


Xanthelasma, 195

Xanthelasmoidea, 56

Xanthoma, 195, 196
  diabeticorum, 195
  multiplex, 195
  planum, 195
  tuberculatum, 195
  tuberosum, 195

Xeroderma, 165

Xeroderma pigmentosum, 190

_X_-ray dermatitis, 63


Yaws, 73


Zona, 81

Zoster, 81



                         SAUNDERS' BOOKS

                      --------- on ---------

                            GYNECOLOGY

                               and

                            OBSTETRICS

                   *       *       *       *       *

                        W. B. SAUNDERS COMPANY

925 Walnut Street                                            Philadelphia

9, Henrietta Street                                 Covent Garden, London

=========================================================================

                 SAUNDERS' TEXT-BOOKS CONTINUE TO GAIN

The list of text-books recommended in the various colleges again shows a
#decided gain for the Saunders publications#. During the present college
year, in the list of recommended books published by 164 colleges (the
other 23 have not published lists), the Saunders books are mentioned
3278 times, as against 3054 the previous year--#an increase of 224#. In
other words, in each of the medical colleges in this country an average
of 20 (18-2/5 the previous year) of the teaching books employed are
publications issued by W. B. Saunders Company. That this increase is not
due alone to the publication of new text-books, but rather to a most
gratifying increase in the recommendation of text-books recognized as
standards, is at once evident from the following: Ashton's Gynecology
shows an increase of 19; DaCosta's Surgery, an increase of 12; Hirst's
Obstetrics, 14; Howell's Physiology, 25; Jackson on the Eye, 16; Sahli's
Diagnostic Methods, 11; Scudder's Fractures, 11; Stengel's Pathology,
13; Stelwagon on the Skin, 11. These are but examples of similar
remarkable gains throughout the entire list, and is undoubted evidence
that the #Saunders text-books are recognized as the best#.

 #A Complete Catalogue of our Publications will be Sent upon Request#



                               Bandler's

                          Medical Gynecology

                   *       *       *       *       *

#Medical Gynecology#. By S. Wyllis Bandler, M.D., Adjunct. Professor of
Diseases of Women, New York Post-Graduate Medical School and Hospital.
Octavo of 680 pages, with 135 original illustrations. Cloth, $5.00 net;
Half Morocco, $6.50 net.


               #JUST READY--EXCLUSIVELY MEDICAL GYNECOLOGY#


This new work by Dr. Bandler is just the book that the physician engaged
in general practice has long needed. It is truly _the practitioner's
gynecology_--planned for him, written for him, and illustrated for him.
There are many gynecologic conditions that do not call for operative
treatment; yet, because of lack of that special knowledge required for
their diagnosis and treatment, the general practitioner has been unable
to treat them intelligently. This work gives just the information the
practitioner needs. It not only deals with those conditions amenable to
non-operative treatment, but it also tells how to recognize those
diseases demanding operative treatment, so that the practitioner will be
enabled to advise his patient at a time when operation will be attended
with the most favorable results. The chapter on Pessaries is especially
full and excellent, the proper manner of introducing the pessary being
clearly described and illustrated with original pictures that show
plainly the correct technic of this procedure. The chapters on Vaginal
and Abdominal Massage, and particularly that on Artificial Hyperemia and
Anemia, are extremely valuable to the practitioner. They express the
very latest advances in these methods of treatment. Hydrotherapy,
especially the Ferguson and Nauheim baths, are treated _in extenso_, and
Electrotherapy receives the full consideration its importance merits.
Pain as a symptom and its alleviation is dealt with in an unusually
practical way, its value as an aid in diagnosis being emphasized.
Gonorrhea and Syphilis and their many complications are treated in
detail, every care being taken to have these sections--of special
interest to the practitioner--complete in every particular. Other
chapters of great importance are those on Constipation, Sterility,
Associated Nervous Conditions in Gynecology, and Pregnancy and Abortion.



                      Kelly and Noble's Gynecology

                          and Abdominal Surgery

#Gynecology and Abdominal Surgery#. Edited by Howard A. Kelly, M.D.,
Professor of Gynecology in Johns Hopkins University; and Charles P.
Noble, M.D., Clinical Professor of Gynecology in the Woman's Medical
College, Philadelphia. Two imperial octavo volumes of 900 pages each,
containing 650 illustrations, mostly original. Per volume: Cloth, $8.00
net; Half Morocco, $9.50 net.


                        BOTH VOLUMES NOW READY

             WITH 650 ORIGINAL ILLUSTRATIONS BY HERMANN BECKER

                            AND MAX BRÖDEL


In view of the intimate association of gynecology with abdominal surgery
the editors have combined these two important subjects in one work. For
this reason the work will be doubly valuable, for not only the
gynecologist and general practitioner will find it an exhaustive
treatise, but the surgeon also will find here the latest technic of the
various abdominal operations. It possesses a number of valuable features
not to be found in any other publication covering the same fields. It
contains a chapter upon the bacteriology and one upon the pathology of
gynecology, dealing fully with the scientific basis of gynecology. In no
other work can this information, prepared by specialists, be found as
separate chapters. There is a large chapter devoted entirely to _medical
gynecology_, written especially for the physician engaged in general
practice. Heretofore the general practitioner was compelled to search
through an entire work in order to obtain the information desired.
_Abdominal surgery_ proper, as distinct from gynecology, is fully
treated, embracing operations upon the stomach, upon the intestines,
upon the liver and bile-ducts, upon the pancreas and spleen, upon the
kidney, ureter, bladder, and the peritoneum. Special attention has been
given to _modern technic_ and illustrations of the very highest order
have been used to make clear the various steps of the operations.
Indeed, the illustrations are truly magnificent, being the work of _Mr.
Hermann Becker_ and _Mr. Max Brödel_, of the Johns Hopkins Hospital.



                                Ashton's

                        Practice of Gynecology

                    *       *       *       *       *

#The Practice of Gynecology#. By W. Easterly Ashton, M.D., LL.D.,
Professor of Gynecology in the Medico-Chirurgical College, Philadelphia.
Handsome octavo volume of 1096 pages, containing 1057 original line
drawings. Cloth, $6.50 net; Half Morocco, $8.00 net.


                   RECENTLY ISSUED--NEW (3d) EDITION

                   THREE EDITIONS IN EIGHTEEN MONTHS

Three editions of this work have been demanded in eighteen months. Among
the new additions are: Colonic lavage and flushing, Hirst's treatment
for vaginismus, Dudley's treatment of cystocele, Montgomery's round
ligament operation, Chorio-epithelioma of the Uterus, Passive
Incontinence of the Urine, and Moynihan's methods in Intestinal
Anastomosis. Nothing is left to be taken for granted, the author not
only telling his readers in every instance what should be done, but also
precisely _how to do it_. A distinctly original feature of the book is
the illustrations, numbering about one thousand line drawings made
especially under the author's personal supervision from actual
apparatus, living models, and dissections on the cadaver. These line
drawings show in detail the procedures and operations without obscuring
their purpose by unnecessary and unimportant anatomic surroundings.


#Howard A. Kelly, M.D.#

_Professor of Gynecology, Johns Hopkins University._

"It is different from anything that has as yet appeared. The
illustrations are particularly clear and satisfactory. One specially
good feature is the pains with which you describe so many _details_ so
often left to the imagination."


#Charles B. Penrose, M.D.,#

_Formerly Professor of Gynecology, University of Pennsylvania._

"I know of no book that goes so thoroughly and satisfactorily into all
the _details_ of everything connected with the subject. In this respect
your book differs from the others."


#George M. Edebohls, M.D.#

_Professor of Diseases of Women, New York Post-Graduate Medical School._
"I have looked it through and must congratulate you upon having produced
a text-book most admirably adapted to _teach_ gynecology to those who
must get their knowledge, even to the minutest and most elementary
details, from books."



                                Webster's

                           Diseases _of_ Women

                     *       *       *       *       *

#Diseases of Women.# By J. Clarence Webster, M.D. (Edin.), F.R.C.P.E.,
Professor of Gynecology and Obstetrics in Rush Medical College. Octavo
of 712 pages, with 372 illustrations. Cloth, $7.00 net; Half Morocco,
$8.50 net.


                   RECENTLY ISSUED--FOR THE PRACTITIONER


Dr. Webster has written this work _especially for the general
practitioner_, discussing the clinical features of the subject in their
widest relations to general practice rather than from the standpoint of
specialism. The magnificent illustrations, three hundred and seventy-two
in number, are nearly all original. Drawn by expert anatomic artists
under Dr. Webster's direct supervision, they portray the anatomy of the
parts and the steps in the operations with rare clearness and exactness.


#Howard A. Kelly, M.D.#, _Professor of Gynecology, Johns Hopkins
University._

"It is undoubtedly one of the best works which has been put on the
market within recent years, showing from start to finish Dr. Webster's
well-known thoroughness. The illustrations are also of the highest
order."

                    *       *       *       *       *

#Webster's Obstetrics#

#A Text-Book of Obstetrics#. By J. Clarence Webster, M.D. (Edin.),
Professor of Obstetrics and Gynecology in Rush Medical College. Octavo
of 767 pages, illustrated. Cloth, $5.00 net; Half Morocco, $6.50 net.


                          RECENTLY ISSUED


#Medical Record, New York#

"The author's remarks on asepsis and antisepsis are admirable, the
chapter on eclampsia is full of good material, and ... the book can be
cordially recommended as a safe guide."



                              Cullen's

                         Uterine Adenomyoma

                  *       *       *       *       *

#Uterine Adenomyoma#. By Thomas S. Cullen, M.D., Associate Professor of
Gynecology, Johns Hopkins University. Octavo of 275 pages, with original
illustrations by Hermann Becker and August Horn. Cloth, $5.00 net.


                             JUST READY

Dr. Cullen's large clinical experience and his extensive original work
along the lines of gynecologic pathology have enabled him to present his
subject with originality and precision. The work gives the early
literature on adenomyoma, traces the disease through its various stages,
and then gives the detailed findings in a large number of cases
personally examined by the author. Formerly the physician and surgeon
were unable to determine the cause of uterine bleeding, but after
following closely the clinical course of the disease, Dr. Cullen has
found that the majority of these cases can be diagnosed clinically. The
results of these observations he presents in this work. The entire
subject of adenomyoma is dealt with from the standpoint of the
pathologist, the clinician, and the surgeon. The superb illustrations
are the work of Mr. Hermann Becker and Mr. August Horn, of the Johns
Hopkins Hospital.

                    *       *       *       *       *

                               The American

                        Text-Book _of_ Obstetrics


                    Recently Issued--New (2d) Edition


#The American Text-Book of Obstetrics#. In two volumes. Edited by Richard
C. Norris, M.D.; Art Editor, Robert L. Dickinson, M.D. Two octavos of
about 600 pages each; nearly 900 illustrations, including 49 colored and
half-tone plates. Per volume: Cloth, $3.50 net; Half Morocco, $4.50 net.


#American Journal of the Medical Sciences#

"As an authority, as a book of reference, as a 'working book' for the
student or practitioner, we commend it because we believe there is no
better."



                                Hirst's

                           Diseases of Women

                    *       *       *       *       *

#A Text-Book of Diseases of Women#. By Barton Cooke Hirst, M.D., Professor
of Obstetrics, University of Pennsylvania; Gynecologist to the Howard,
the Orthopedic, and the Philadelphia Hospitals. Octavo of 745 pages, 701
illustrations, many in colors. Cloth, $5.00 net; Half Morocco, $6.50
net.


                   RECENTLY ISSUED--NEW (2d) EDITION

                    WITH 701 ORIGINAL ILLUSTRATIONS


The new edition of this work has just been issued after a careful
revision. As diagnosis and treatment are of the greatest importance in
considering diseases of women, particular attention has been devoted to
these divisions. To this end, also, the work has been magnificently
illuminated with 701 illustrations, for the most part original
photographs and water-colors of actual clinical cases accumulated during
the past fifteen years. The palliative treatment, as well as the radical
operative, is fully described, enabling the general practitioner to
treat many of his own patients without referring them to a specialist.
The author's extensive experience renders this work of unusual value.


                    *       *       *       *       *

                      OPINIONS OF THE MEDICAL PRESS

                    *       *       *       *       *


#Medical Record, New York#

"Its merits can be appreciated only by a careful perusal.... Nearly one
hundred pages are devoted to technic, this chapter being in some
respects superior to the descriptions in many text-books."


#Boston Medical and Surgical Journal#

"The author has given special attention to diagnosis and treatment
throughout the book, and has produced a practical treatise which should
be of the greatest value to the student, the general practitioner, and
the specialist."


#Medical News, New York#

"Office treatment is given a due amount of consideration, so that the
work will be as useful to the non-operator as to the specialist."



                                Hirst's

                        Text-Book of Obstetrics

                      New (5th) Edition, Revised

                   *       *       *       *       *

#A Text-Book of Obstetrics#. By Barton Cooke Hirst, M.D., Professor of
Obstetrics in the University of Pennsylvania. Handsome octavo, 899
pages, with 746 illustrations, 39 in colors. Cloth, $5.00 net; Sheep or
Half Morocco, $6.50 net.


                            RECENTLY ISSUED


Immediately on its publication this work took its place as the leading
text-book on the subject. Both in this country and abroad it is
recognized as the most satisfactorily written and clearly illustrated
work on obstetrics in the language. The illustrations form one of the
features of the book. They are numerous and the most of them are
original. In this edition the book has been thoroughly revised. More
attention has been given to the diseases of the genital organs
associated with or following childbirth. Many of the old illustrations
have been replaced by better ones, and there have been added a number
entirely new. The work treats the subject from a clinical standpoint.


                   *       *       *       *       *

                     OPINIONS OF THE MEDICAL PRESS

                   *       *       *       *       *


#British Medical Journal#

"The popularity of American text-books in this country is one of the
features of recent years. The popularity is probably chiefly due to the
great superiority of their illustration over those of the English
text-books. The illustrations in Dr. Hirst's volume are far more
numerous and far better executed, and therefore more instructive, than
those commonly found in the works of writers on obstetrics in our own
country."


#Bulletin of Johns Hopkins Hospital#

"The work is an admirable one in every sense of the word, concisely but
comprehensively written."


#The Medical Record, New York#

"The illustrations are numerous and are works of art, many of them
appearing for the first time. The author's style, though condensed, is
singularly clear, so that it is never necessary to re-read a sentence in
order to grasp the meaning. As a true model of what a modern text-book
on obstetrics should be, we feel justified in affirming that Dr. Hirst's
book is without a rival."



                              Penrose's

                          Diseases of Women

                        Sixth Revised Edition

                  *       *       *       *       *

#A Text-Book of Diseases of Women#. By Charles B. Penrose, M.D., Ph.D.,
formerly Professor of Gynecology in the University of Pennsylvania;
Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 550
pages, with 225 fine original illustrations. Cloth $3.75 net.


                            JUST ISSUED


Regularly every year a new edition of this excellent text-book is called
for, and it appears to be in as great favor with physicians as with
students. Indeed, this book has taken its place as the ideal work for
the general practitioner. The author presents the best teaching of
modern gynecology, untrammeled by antiquated ideas and methods. In every
case the most modern and progressive technique is adopted, and the main
points are made clear by excellent illustrations. The new edition has
been carefully revised, much new matter has been added, and a number of
new original illustrations have been introduced. In its revised form
this volume continues to be an admirable exposition of the present
status of gynecologic practice.


                  *       *       *       *       *

                     PERSONAL AND PRESS OPINIONS

                  *       *       *       *       *

#Howard A. Kelly, M.D.,#

_Professor of Gynecology and Obstetrics, Johns Hopkins University,
Baltimore._

"I shall value very highly the copy of Penrose's 'Diseases of Women'
received. I have already recommended it to my class as The Best book."


#L.E. Montgomery, M.D.,#

_Professor of Gynecology, Jefferson Medical College, Philadelphia._

"The copy of 'A Text-Book of Diseases of Women' by Penrose received
to-day. I have looked over it and admire it very much. I have no doubt
it will have a large sale, as it justly merits."


#Bristol Medico-Chirurgical Journal#

"This is an excellent work which goes straight to the mark.... The book
may be taken as a trustworthy exposition of modern gynecology."



  GET                                                            THE NEW
THE BEST                     American                            STANDARD

                      Illustrated Dictionary

                 Recently Issued--New (4th) Edition

                  *       *       *       *       *

#The American Illustrated Medical Dictionary#. A new and complete
dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy,
Chemistry, and kindred branches; with over 100 new and elaborate tables
and many handsome illustrations. By W.A. Newman Dorland, M.D., Editor of
"The American Pocket Medical Dictionary." Large octavo, 850 pages, bound
in full flexible leather. Price, $4.50 net; with thumb index, $5.00 net.


    Gives a Maximum Amount of Matter in a Minimum Space, and at the
                        Lowest Possible Cost


                        WITH 2000 NEW TERMS


The immediate success of this work is due to the special features that
distinguish it from other books of its kind. It gives a maximum of
matter in a minimum space and at the lowest possible cost. Though it is
practically unabridged, yet by the use of thin bible paper and flexible
morocco binding it is only 1-1/4 inches thick. In this new edition the
book has been thoroughly revised, and upward of two thousand new terms
have been added, thus bringing the book absolutely up to date. The book
contains hundreds of terms not to be found in any other dictionary, over
100 original tables, and many handsome illustrations.


                  *       *       *       *       *

                          PERSONAL OPINIONS

                  *       *       *       *       *

#Howard A. Kelly, M.D.,#

_Professor of Gynecology, Johns Hopkins University, Baltimore._

"Dr. Borland's dictionary is admirable. It is so well gotten up and of
such convenient size. No errors have been found in my use of it."


#J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.)#

_Professor of Surgery, Harvard Medical School._

"I regard it as a valuable aid to my medical literary work. It is very
complete and of convenient size to handle comfortably. I use it in
preference to any other."



                             Garrigues'

                          Diseases of Women


                  Third Edition, Thoroughly Revised

                  *       *       *       *       *

#A Text-Book of Diseases of Women#. By Henry J. Garrigues, A.M., M.D.,
Gynecologist to St. Mark's Hospital and to the German Dispensary, New
York City. Handsome octavo, 756 pages, with 367 engravings and colored
plates. Cloth, $4.50 net; Sheep or Half Morocco, $6.00 net.

The first two editions of this work met with a most appreciative
reception by the medical profession both in this country and abroad. In
this edition the entire work has been carefully and thoroughly revised,
and considerable new matter added, bringing the work precisely down to
date. Many new illustrations have been introduced, thus greatly
increasing the value of the book both as a text-book and book of
reference.


#Thad. A. Reamy, M.D.,# _Professor of Gynecology, Medical College of
Ohio._

"One of the best text-books for students and practitioners which has
been published in the English language; it is condensed, clear, and
comprehensive. The profound learning and great clinical experience of
the distinguished author find expression in this book."

                  *       *       *       *       *

                              American

                     Text-Book of Gynecology

#American Text-Book of Gynecology#. Medical and Surgical. Edited by J.M.
Baldy, M.D., Professor of Gynecology, Philadelphia Polyclinic. Imperial
octavo of 718 pages, with 341 text-illustrations and 38 plates. Cloth,
$6.00 net; Half Morocco, $7.50 net.


                      SECOND REVISED EDITION


This volume is thoroughly practical in its teachings, and is intended to
be a working text-book for physicians and students. Many of the most
important subject are considered from an entirely new standpoint, and
are grouped together in a manner somewhat foreign to the accepted
custom.


#Boston Medical and Surgical Journal#

"The most complete exponent of gynecology that we have. No subject seems
to have been neglected."



                             Dorland's

                        Modern Obstetrics

                  *       *       *       *       *

#Modern Obstetrics: General and Operative#. By W.A. Newman Dorland, A.M.,
M.D., Assistant Instructor in Obstetrics, University of Pennsylvania;
Associate in Gynecology in the Philadelphia Polyclinic. Handsome octavo
volume of 797 pages, with 201 illustrations. Cloth, $4.00 net.

             Second Edition, Revised and Greatly Enlarged

In this edition the book has been entirely rewritten and very greatly
enlarged. Among the new subjects introduced are the surgical treatment
of puerperal sepsis, infant mortality, placental transmission of
diseases, serum-therapy of puerperal sepsis, etc.


#Journal of the American Medical Association#

"This work deserves commendation, and that it has received what it
deserves at the hands of the profession is attested by the fact that a
second edition is called for within such a short time. Especially
deserving of praise is the chapter on puerperal sepsis."

                  *       *       *       *       *

                        Davis' Obstetric and

                        Gynecologic Nursing


#Obstetric and Gynecologic Nursing#. By Edward P. Davis, A.M., M.D.,
Professor of Obstetrics in the Jefferson Medical College and
Philadelphia Polyclinic; Obstetrician and Gynecologist, Philadelphia
Hospital. 12mo of 436 pages, illustrated. Buckram, $1.75 net.


                  JUST ISSUED--THIRD REVISED EDITION


This volume gives a very clear and accurate idea of the manner to meet
the conditions arising during obstetric and gynecologic nursing. The
third edition has been thoroughly revised.


#The Lancet, London#

"Not only nurses, but even newly qualified medical men, would learn a
great deal by a perusal of this book. It is written in a clear and
pleasant style, and is a work we can recommend."



                       Schäffer _and_ Edgar's

                   Labor and Operative Obstetrics

                  *       *       *       *       *

#Atlas and Epitome of Labor and Operative Obstetrics#. By Dr. O. Schäffer,
of Heidelberg. _From the Fifth Revised and Enlarged German Edition._
Edited, with additions, by J. Clifton Edgar, M.D., Professor of
Obstetrics and Clinical Midwifery, Cornell University Medical School,
New York. With 14 lithographic plates in colors, 139 other
illustrations, and 111 pages of text. Cloth, $2.00 net. _In Saunders'
Hand-Atlas Series._

This book presents the act of parturition and the various obstetric
operations in a series of easily understood illustrations, accompanied
by a text treating the subject from a practical standpoint.


#American Medicine#

"The method of presenting obstetric operations is admirable. The
drawings, representing original work, have the commendable merit of
illustrating instead of confusing."

                  *       *       *       *       *

    Schäffer _and_ Edgar's Obstetric Diagnosis and Treatment


#Atlas and Epitome of Obstetric Diagnosis and Treatment#. By Dr. O.
Schäffer, of Heidelberg. _From the Second Revised German
Edition._Edited, with additions, by J. Clifton Edgar, M.D., Professor of
Obstetrics and Clinical Midwifery, Cornell University Medical School,
N.Y. With 122 colored figures on 56 plates, 38 text-cuts, and 315 pages
of text. Cloth, $3.00 net. _In Saunders' Hand-Atlas Series._

This book treats particularly of obstetric operations, and, besides the
wealth of beautiful lithographic illustrations, contains an extensive
text of great value. This text deals with the practical, clinical side
of the subject.


#New York Medical Journal#

"The illustrations are admirably executed, as they are in all of these
atlases, and the text can safely be commended, not only as elucidatory
of the plates, but as expounding the scientific midwifery of to-day."



                         Schäffer and Norris'

                             Gynecology

                  *       *       *       *       *

#Atlas and Epitome of Gynecology#. By Dr. O. Schäffer, of Heidelberg.
_From the Second Revised and Enlarged German Edition._ Edited, with
additions, by Richard C. Norris, A.M., M.D., Assistant Professor of
Obstetrics in the University of Pennsylvania. 207 colored figures on 90
plates, 65 text-cuts, and 308 pages of text. Cloth, $3.50 net. _In
Saunders' Hand-Atlas Series._


American Journal of the Medical Sciences

"Of the illustrations it is difficult to speak in too high terms of
approval. They are so clear and true to nature that the accompanying
explanations are almost superfluous. We commend it most earnestly."

                  *       *       *       *       *

                             Galbraith's

                     Four Epochs of Woman's Life


               Second Revised Edition--Recently Issued


#The Four Epochs of Woman's Life:# A Study in Hygiene. By Anna M.
Galbraith, M.D., Fellow of the New York Academy of Medicine, etc. With
an Introductory Note by John M. Musser, M.D. Professor of Clinical
Medicine, University of Pennsylvania. 12 mo of 247 pages. Cloth $1.50
net.


              MAIDENHOOD, MARRIAGE, MATERNITY, MENOPAUSE


In this instructive work are stated, in a modest, pleasing, and
conclusive manner, those truths of which every woman should have a
thorough knowledge. Written, as it is, for the laity, the subject is
discussed in language readily grasped even by those most unfamiliar with
medical subjects.


#Birmingham Medical Review, England#

"We do not as a rule care for medical books written for the instruction
of the public. But we must admit that the advice in Dr. Galbraith's work
is in the main wise and wholesome."



                        Schäffer and Webster's

                         Operative Gynecology


#Atlas and Epitome of Operative Gynecology#. By Dr. O. Schäffer, of
Heidelberg. Edited, with additions, by J. Clarence Webster, M.D.
(Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in Rush
Medical College, in affiliation with the University of Chicago. 42
colored lithographic plates, many text-cuts, a number in colors, and 138
pages of text. _In Saunders' Hand-Atlas Series._ Cloth, $3.00 net.


                            RECENTLY ISSUED


Much patient endeavor has been expended by the author, the artist, and
the lithographer in the preparation of the plates for this Atlas. They
are based on hundreds of photographs taken from nature, and illustrate
most faithfully the various surgical situations. Dr. Schäffer has made a
specialty of demonstrating by illustrations.


#Medical Record, New York#

"The volume should prove most helpful to students and others in grasping
details usually to be acquired only in the amphitheater itself."

                  *       *       *       *       *

                    DeLee's Obstetrics for Nurses

#Obstetrics for Nurses#. By Joseph B. DeLee, M.D., Professor of
Obstetrics in the Northwestern University Medical School, Chicago;
Lecturer in the Nurses' Training Schools of Mercy, Wesley, Provident,
Cook County, and Chicago Lying-in Hospitals. 12mo of 512 pages, fully
illustrated.
                                                     Cloth, $2.50 net.


                    JUST ISSUED--NEW (3d) EDITION


While Dr. DeLee has written his work especially for nurses, the
practitioner will also find it useful and instructive, since the duties
of a nurse often devolve upon him in the early years of his practice.
The illustrations are nearly all original and represent photographs
taken from actual scenes. The text is the result of the author's many
years' experience in lecturing to the nurses of five different training
schools.


#J. Clifton Edgar, M.D.,#

_Professor of Obstetrics and Clinical Midwifery, Cornell University, New
York._

"It is far and away the best that has come to my notice, and I shall
take great pleasure in recommending it to my nurses, and students as
well."



#American Pocket Dictionary#                     Recently issued--5th Ed.

The American Pocket Medical Dictionary. Edited by W.A. Newman Dorland,
A.M., M.D., Assistant Obstetrician to the Hospital of the University of
Pennsylvania; Fellow of the American Academy of Medicine. With 578
pages. Full leather, limp, with gold edges, $1.00 net; with patent thumb
index, $1.25 net.


#James W. Holland. M.D.,#

_Professor of Chemistry and Toxicology, at the Jefferson Medical
College, Philadelphia._

"I am struck at once with admiration at the compact size and attractive
exterior. I can recommend it to our students without reserve."


#Cragin's Gynecology#                    Recently Issued--New (6th) Ed.

Essentials of Gynecology. By Edwin B. Cragin, M.D., Professor of
Obstetrics, College of Physicians and Surgeons, New York. Crown octavo,
240 pages, 62 illustrations. Cloth, $1.00 net. _In Saunders'
Question-Compend Series._


#The Medical Record, New York#

"A handy volume and a distinct improvement on students' compends in
general. No author who was not himself a practical gynecologist could
have consulted the student's needs so thoroughly as Dr. Cragin has
done."


#Boisliniere's Obstetric Accidents, Emergencies, and Operations#

Obstetric Accidents, Emergencies, and Operations. By the late L. Ch.
Boisliniere, M.D., Emeritus Professor of Obstetrics, St. Louis Medical
College; Consulting Physician, St. Louis Female Hospital. 381 pages,
illustrated. Cloth, $2.00 net.


#British Medical Journal#

"It is clearly and concisely written, and is evidently the work of a
teacher and practitioner of large experience. Its merit lies in the
judgment which comes from experience."


#Ashton's Obstetrics#                      Recently Issued--New (6th) Ed.

Essentials of Obstetrics. By W. Easterly Ashton, M.D., Professor of
Gynecology in the Medico-Chirurgical College, Philadelphia. Crown
octavo, 252 pages, 75 illustrations. Cloth, $1.00 net. _In Saunders'
Question-Compend Series._


#Southern Practitioner#

"An excellent little volume, containing correct and practical knowledge.
An admirable compend, and the best condensation we have seen."


#Barton and Wells' Medical Thesaurus#

A Thesaurus of Medical Words and Phrases. By Wilfred M. Barton, M.D.,
Assistant to Professor of Materia Medica and Therapeutics, Georgetown
University, Washington, D.C.; and WALTER A. WELLS, M.D., Demonstrator
of Laryngology, Georgetown University, Washington, D.C. 12mo of 534
pages. Flexible leather, $2.50 net; with thumb index, $3.00 net.



        *       *       *       *       *



Transcriber's note:

   Changed "dioxid" to "dioxide" in several places

   Made hyphenation of various words consistent

   Page 74: Corrected misspelling of Phlegmona

   Page 135: Corrected misspelling of quantity

   Page 138: changed ',' to '.' at end of sentence

   Page 208: aquæ rosae changed to aquæ rosæ

   Page 210: Fixed typographical error "symptyms" into "symptoms"

   Page 212: Fixed typographical error "Decribe mycetoma" into
             "Describe mycetoma"

   Page 213: Fixed typographical error "iodid" into "iodide"





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