A system of practical medicine. By American authors. Vol. 4

by Unknown

DISEASES OF THE SKIN.

DISEASES OF THE SKIN.¹

BY LOUIS A. DUHRING, M.D., AND HENRY W. STELWAGON, M.D.

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¹ In the general arrangement and order of diseases the classification adopted by the American Dermatological Association has been followed.

For obvious reasons, personal references are almost entirely omitted in the text, but the authors desire to acknowledge valuable suggestions derived from the writings of J. C. White, R. W. Taylor, L. D. Bulkley, J. N. Hyde, W. A. Hardaway, A. R. Robinson, H. G. Piffard, A. Van Harlingen, G. H. Fox, and others.

CLASS I.—DISORDERS OF SECRETION.

Hyperidrosis.

Hyperidrosis, or excessive sweating, is a functional disturbance of the sweat-glands characterized by an increased flow of sweat. It may be local or general, slight or excessive. As a local affection, the form which mainly interests the dermatologist, it occurs usually about the hands and feet, especially the palmar and plantar surfaces, and also about the axillæ and genitalia. If the secretion is excessive, maceration of the epidermis results, with tenderness, and even inflammation, of the parts as a consequence: this is not infrequently the result when the feet are involved, a sodden appearance of the parts being not unusual. The affection may be acute or chronic, the latter usually being the case. It is purely a functional disorder, no anatomical changes taking place in the glands or surrounding tissues. There is no change in the nature of the secretion. Debility is usually the fault in general hyperidrosis. The causes of the local varieties are in many cases obscure. Faulty innervation is doubtless frequently an important factor. The nervous system possesses a powerful control over this secretion. The diagnosis presents no difficulties, as there is no other affection with which it could be confounded. Prickly heat and oily seborrhoea are considered to bear some resemblance, but confusion is not likely to occur. Although some cases are readily relieved, the majority prove obstinate. The duration, locality, and extent of the affection, as well as the condition of the general health, are to be considered in pronouncing a prognosis. The disease is liable to relapse.

Concerning treatment, in addition to quinine and the ordinary tonic remedies, belladonna and ergot may be referred to as being useful, particularly the former. Local treatment is always demanded. Dusting-powders are useful, such as starch or lycopodium powder, to which from ten to thirty grains of salicylic acid to the ounce may be added with benefit. They are to be applied freely, so as to absorb the secretions. Astringent lotions are also of value, and constitute the most agreeable method of treatment. One drachm of tannic acid to six ounces of alcohol will be found of service. Solutions of alum and of zinc sulphate may also be employed. Boric acid, either in powder or in the form of a saturated solution, and tincture of belladonna as a lotion, full strength or diluted with alcohol, are both useful. A successful plan of treatment is that by diachylon ointment (unguentum diachyli) as recommended by Hebra. The parts are first cleansed and dried, and then the ointment applied on strips of muslin as a plaster. It is to be renewed twice daily, the parts on each occasion being rubbed dry with lint or a soft towel and lycopodium or starch powder. Water is not to be employed. The treatment must be continued one or two weeks, and then the ointment omitted, and a dusting-powder used night and morning for several weeks. In many cases relief results from one such course; others may require several repetitions. If a good diachylon ointment is not procurable, the same plan may be followed out with an ointment made by melting together equal parts of lead plaster and cosmoline, or with an ointment of tannic acid, a drachm to the ounce.

Anidrosis.

Anidrosis is a functional disorder of the sweat-glands characterized by a diminution or suppression of the secretion. It is the opposite condition of hyperidrosis, and occurs to a slight extent in certain general diseases, and also in some affections of the skin, as ichthyosis. It sometimes occurs as an idiopathic disorder, and may cause much discomfort. Occasionally in nerve-injury localized areas of diminished or suppressed secretion occur. The treatment should be conducted upon general principles, including warm or vapor baths and friction.

Bromidrosis.

Bromidrosis is a functional disorder of the sweat-glands in which the secretion, which may be either normal or excessive in quantity, is of an offensive odor. The quantity is usually excessive, as in hyperidrosis, but occasionally it is normal in amount, while the odor is heavy, strong-smelling, offensive, and disgusting. It may be universal or local in character, more frequently the latter; in either case the odor is rendered more marked by heat and increased perspiration. In smallpox, measles, typhus and relapsing fevers, and in some nervous affections peculiar odors are noticed. Certain drugs, as sulphur, asafoetida, and like substances, taken internally, may be detected in the odor of the sweat. It is as a localized disorder, however, that the affection usually comes under observation, the axillæ, genitalia, and feet being favored localities, the last named being the most common region affected. It occurs about the soles and between the toes, and is generally symmetrical. The sweating, if excessive, causes after a time more or less maceration, and sometimes hyperæmia or inflammation; the skin becomes whitish and sodden, the affected area having a pinkish margin. Both Hebra and Thin consider the socks and soles of the shoes—which become thoroughly permeated by the secretion—and not the feet, the source of the odor. The latter observer states that he has found innumerable bacteria (Bacterium foetidum) in the fluid in which the sock is soaked. The etiology of the disease is not well understood, but it is without doubt due to some nervous derangement.

The treatment is about the same as that advised for hyperidrosis. In addition, however, to the remedies named for that disorder, there are several other local remedies that have been found useful in this disease, among which may be mentioned a wash of potassium permanganate, two or three grains to the ounce, and chloral, twenty or thirty grains to the ounce of water or dilute alcohol. Thin recommends the use of cork soles, which (and also the socks) are first to be soaked in a boric-acid solution and dried.

Chromidrosis.

Chromidrosis is a functional disorder of the sweat-glands, the secretion being variously colored and generally increased in quantity. The color may be blackish, bluish, reddish, greenish or yellowish, bluish and reddish being the most common. The affection is usually local, occurring in the form of patches, the face, neck, arms, backs of the hands and feet, chest, and abdomen being the favorite localities. The disease is rare. Ferrocyanide of iron, copper, and other substances have been detected in the secretion, to the presence of which doubtless the colors are due. It is generally observed in nervous and excitable persons, chiefly in unmarried women; but it has also been noted in strong men. It tends to recur, and may appear on different parts of the body with each manifestation. The treatment should be directed against the suspected cause, with especial reference to the nervous system.

Uridrosis.

Uridrosis, or urinous sweat, is a functional disorder of the sweat-glands, the secretion containing the elements of the urine, especially urea. This latter is occasionally detected in the sweat of persons apparently in good health. In some cases, however, it exists in such quantity as to be noticeable on the skin, appearing usually on the face and hands as a colorless or whitish saline crystalline deposit or coating. In most of the marked cases reported partial or complete suppression of the renal function has preceded or accompanied the condition.

Phosphoridrosis.

Phosphoridrosis is the rare condition in which sweat is phosphorescent. It is sometimes seen in the later stages of phthisis, also in miliaria, and occasionally in persons who have eaten of putrid fish.

Sudamen.

Sudamen (syn. miliaria crystallina) is a non-inflammatory disorder of the sweat-glands characterized by pinpoint- to pinhead-sized, isolated, superficial, translucent, whitish vesicles. The lesions make their appearance on any portion of the body, but have a predilection for certain regions of the trunk, especially where the epidermis is thin. They show themselves as numerous, closely-crowded, discrete, whitish or pearl-colored minute elevations, in appearance not unlike dew-drops. They form rapidly, remaining discrete, never becoming puriform, and evince no tendency to rupture. They are non-inflammatory, never reddish in color, and are without areolæ. The fluid disappears by absorption and the epidermal covering by subsequent desquamation. The lesions may appear in successive crops or new vesicles may show themselves irregularly from time to time. On the other hand, the first outbreak may disappear rapidly, and no further manifestation show itself. Sudamina occupying the face are usually seen in middle-aged females. The vesicles here are larger, deeper-seated, and more persistent.

Constitutional debility is a predisposing cause of the disease. Diseases accompanied with a high temperature—such, for example, as typhus and typhoid fevers, tuberculosis, and acute articular rheumatism—are frequently responsible for the eruption. The vesicles are produced by the collection of sweat in some part of the sweat-duct or epidermis, usually the latter. As ordinarily seen, the vesicles are situated between the lamellæ of the horny layer, the sweat having made its way from a rupture in an obstructed duct. In those exceptional cases of deep-seated and more persistent sudamina occurring about the face, the vesicles are situated in the corium, and are caused by a dilatation of the duct. The affection is to be distinguished from miliaria by the absence of inflammatory symptoms.

The course and duration of the disease depend upon the cause. In the treatment, removal of the etiological factor is of first importance. For external use some simple dusting-powder, such as equal parts of starch and lycopodium, or frequent bathing of the parts with an evaporating lotion, such as alcohol and water or vinegar and water, may be employed.

Seborrhoea.

Seborrhoea 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. Although most commonly seated on the scalp and face, other parts of the general surface may also be attacked. Upon the trunk the sternal and intrascapular regions are the parts most frequently affected. It may occur at any period of life, although more common in adolescent and early adult age. In newly-born infants it constitutes the vernix caseosa, in which case, however, it is physiological rather than pathological. The course of the disease varies, at times disappearing spontaneously or with simple remedies, and in other cases being rebellious even to judicious treatment. It is in most cases influenced by the tone of the general health. In the majority of instances the disease is non-inflammatory; some cases, on the other hand, show intense hyperæmia and even inflammatory signs, while not infrequently the disease varies from time to time in the activity of the process. Itching and burning in a varying degree are sometimes present; the subjective symptoms are, however, rarely marked. The disease is usually better in warm than in cold weather.

There are two clinical varieties of the disease, depending upon the character of the secretion—seborrhoea oleosa and seborrhoea sicca. Seborrhoea oleosa appears as an oily, greasy coating upon the skin, and is seen most frequently about the nose and forehead. The oiliness may be slight or excessive. Seborrhoea sicca is the more common form of the disease, and is seen usually on the scalp and face, and occasionally on other parts of the body. It consists in the formation of dry sebaceous crusts, usually of a grayish-yellow color, which are slightly adherent. Frequently both varieties are seen together, and present products of a mixed character.

Occurring upon the scalp, constituting seborrhea capitis, popularly known as dandruff, the disease is commonly of the dry or mixed variety, and usually involves the whole of that region. Sometimes it occurs in disseminate patches. It appears as small, dry, and pulverulent scales, detached and loose, or as thin or thick, greasy, crust-like, adherent masses. In the latter condition the hairs may be matted or pasted to the scalp. The hair sooner or later becomes affected, and in consequence is dry and lustreless, and gradually falls out. The disease, if neglected, finally causes more or less structural change in the follicles, with permanent alopecia as a result. The skin beneath the crusts in chronic cases is often of a dull, grayish or bluish-gray color; sometimes, however, it is hyperæmic. Occurring on other hairy parts, as the bearded region and eyebrows, the same characters are presented, but ordinarily they are less marked. At times a condition is seen on the scalp in which there is a mild degree of inflammation, with the formation of fine, dry epithelial scales, with slight or marked itching and burning.

Seborrhoea when occurring about the nose and face—seborrhoea faciei—is characterized by more or less redness, oiliness, and sometimes with a moderate amount of scaling and crusting. The follicular openings are enlarged and patulous, and are either free or contain sebaceous plugs. On the trunk—seborrhoea corporis—the disease tends to form circular and confluent scaly patches on a pale or hyperæmic base, with the sebaceous covering extending into the follicles in the form of projections. Or the skin may be slightly reddened, the follicles open and enlarged, the scales having been detached by the rubbing of the clothing. Seborrhoea when involving the genital region—seborrhoea genitalium—presents characters somewhat different. The inner surface of the prepuce, the glans penis, and the sulcus in the male, and the labia and clitoris of the female, are the parts commonly affected. A soft, cheesy mass collects about the parts, which, unless frequently removed, rapidly undergoes decomposition. If neglected or if the disease is marked, inflammatory symptoms may arise.

The disease is functional in character, the increased and usually changed oily secretion, with the epithelial scales from the glands and ducts, forming its products. There is no alteration in the gland structure except in long-continued cases, in which there may be slight atrophy. The affection depends usually upon an impairment of the general health. Chlorosis and anæmia are frequently the predisposing causes. Stomachic, intestinal, and uterine derangements are also, not infrequently, factors. Persons of light complexion are more prone to the dry form, while those of a dark complexion usually show the oily variety. It is also to be noted that the affection is not infrequently seen in persons apparently in perfect health, yielding, however, in such cases to simple external treatment.

Seborrhoea occurring on the scalp must be distinguished from eczema and from psoriasis. In eczema the skin is somewhat infiltrated, thickened, and reddened, and rarely involves the whole scalp; there is less scaliness, and at times more or less of the characteristic gummy exudation and marked itching of that disease. Psoriasis occurs usually in well-defined, circumscribed inflammatory patches, and in most cases shows signs of the disease upon other regions. These same points are of value in differentiating when the disease is upon non-hairy parts. From lupus erythematosus, which it may at times, on the face, closely resemble, it is to be distinguished by the absence of infiltration and thickening, of the sharply-defined border and violaceous or reddish color of that disease, as well as by the absence of atrophic scarring. Seborrhoea differs from ringworm, which it occasionally resembles, especially on the trunk, by its history, slow course, and by the greasiness of the scales. In obscure cases the microscope will determine the question.

TREATMENT.—It is a curable disease, but in the majority of cases proves obstinate. The rapidity of the cure depends in a great measure upon the removal of the predisposing causes. In seborrhoea of the scalp, if the process be allowed to continue through a long period, more or less marked permanent alopecia, especially of the vertex, may result. Even in unfavorable cases, however, much may be done toward promoting a regrowth of hair.

Treatment consists in both constitutional and local measures. The former is frequently of importance, with a view of securing, if possible, permanent relief. Iron, quinine, cod-liver oil, and arsenic are useful. In some cases one-tenth to one-quarter grain doses of calx sulphurata, three or four times daily, will prove of benefit. Dyspepsia, if present, is to be relieved. Fresh air and healthful exercise will sometimes aid considerably in effecting a cure.

External treatment is demanded in every case. The crusts and scales are to be removed. If in abundance, oily applications, such as olive or almond oil, are to be made to the parts, and after remaining on for six or twelve hours to be washed off with soap and hot water. In severe cases several repetitions may be found necessary. On the other hand, in mild cases simply washing with castile or ordinary toilet soap and warm water, or with a decoction of soap-bark, will suffice. If scaling and crusting are marked, instead of the plain soap sapo viridis should be used, either alone or in the form of the spiritus saponatus kalinus, consisting of two parts of sapo viridis in one of alcohol, perfumed with an essential oil. A tablespoonful of this poured on the scalp, and then a small quantity of hot water added and the parts rubbed briskly, wall produce considerable lather; the scalp is then to be rinsed with warm water, the hair dried, and an oily or fatty substance applied. If after a removal of the crusts the skin is found to be irritated, a bland ointment, such as petroleum ointment, will be the best application. Glycerin and alcohol, one to four, will be of service if the skin is dry and hyperæmic. Subsequently more stimulating applications may be made; in the greater number of cases these are indicated from the start. Chloral, as in the following prescription, may sometimes be used with benefit:

Rx.	Chloralis,	scruple ij;
	Glycerinæ,	minim xx;
	Aquæ rosæ,	fluidounce iv. M.

Gentle friction should be employed in making the application. If the lotion is too drying, more glycerin may be added. An excellent application in many cases is the following:

Rx.	Acidi carbolici,	minim xxx;
	Olei ricini,	fluidrachm ij;
	Alcoholis,	fluidounce j drachm vj. M.

This may be perfumed with a few drops of any essential oil. If greater stimulation is required, then to this last combination one to three drachms each of tincture of cantharides and tincture of capsicum may be added. Liquid applications may be made as follows: An eye-dropper is filled and introduced between the hairs at different points of the scalp, and a few drops pressed out, and subsequently rubbed in by means of a piece of flannel rag; in this manner the application is brought into intimate association with the skin without to any extent soiling the hair.

Ointments are also useful. Sulphur, one or two drachms to the ounce, is one of the best. Ammoniated mercury, twenty to sixty grains to the ounce, red precipitate, five to twenty grains to the ounce, are both valuable. In some cases tannic acid, one or two drachms to the ounce, acts well; also a naphthol ointment, twenty or thirty grains to the ounce. Tar is also of decided value, and may be added to any of the above ointments or be prescribed alone in ointment, one or two drachms to the ounce. The tarry oils, as oil of white birch and oil of cade, used pure or in the form of tincture, one or two drachms to the ounce of alcohol, are also valuable. They may also be used with ointments. The treatment of seborrhoea of other parts of the body than the scalp is essentially the same, but the applications should be somewhat weaker. The sulphur preparations are the most useful.

The frequency of applications in seborrhoea will depend upon the activity of the process. Once or twice daily in the beginning may gradually be changed to once every other day, or later even less frequently. The soap-and-water washing is to be regulated in the same manner. It is advisable to intermit external treatment occasionally to see if the disease is entirely removed or merely in abeyance.

Comedo.

Comedo is a disorder of the sebaceous glands, consisting of retention of sebaceous matter, characterized by yellowish or blackish pinpoint- to pinhead-sized elevations corresponding to the orifices of the glands. The affection is seated, for the most part, about the face, neck, and upper part of the trunk; it may occur, however, wherever there are sebaceous glands. Each lesion is pinpoint to pinhead in size, whitish or yellowish, and usually with a central blackish point. There is very little elevation unless the amount of retained sebaceous matter is excessive. They may exist sparsely or in great numbers. Not infrequently the regions of the forehead, nose, and chin are studded with the lesions, other parts of the face and the shoulders showing them in smaller numbers. They may be disseminated or grouped. If they exist in profusion they give the face a soiled, greasy look, as if dirty and unwashed. Lateral pressure forces out the sebaceous matter in a thread-like form closely resembling a worm, hence the popular terms flesh-worms and grub-worms. From collection of dust and from other causes the outer ends of the sebaceous plugs become blackened, and this appearance has given rise to the term black-heads. This coloring may possibly, to some extent at least, as has been suggested, be dependent upon a chemical change caused by the action of the air on the exposed portion of the sebaceous collection. According to Unna, it is due to pigment matter, either free or contained within epidermal cells. Krause states that the bluish granules described by Unna are from extraneous sources. Seborrhoea oleosa is often seen to coexist. At times the retained secretion, either as a result of pressure or in consequence of chemical changes in the mass, excites inflammation, and acne results. It is not uncommon to find comedones and acne lesions associated together.

The affection is seen most frequently between the ages of fifteen and thirty. The lesions are sluggish, and are apt to disappear and reappear from time to time, depending upon the activity of the predisposing cause. As the patient advances in age the affection tends to spontaneous disappearance. The causes of the disorder are essentially the same as give rise to acne, a disease to which it is, as may be inferred, closely allied. Thus, disorders of digestion, constipation, chlorosis, scrofulous conditions and menstrual disturbances are often predisposing causes. In addition, the unstriped muscular fibres of the skin lack tone and contract sluggishly. The infrequent use of soap, especially in those with oily skins (seborrhoea oleosa), favors their formation. Working in a dirty or dusty atmosphere may cause mechanical obstruction of the ducts, and in consequence the formation of comedones.

Pathologically, the affection has its seat in the sebaceous glands and ducts, consisting essentially of retained secretion and epithelial cells within either the gland or duct or both. The accumulation gives rise to more or less dilatation, which usually increases the longer the comedo exists. The mass consists of epidermic cells, sebaceous matter, and sometimes cholesterin crystals, and one or more lanugo hairs. At times, also, the parasite Demodex folliculorum is found within the mass, but is not responsible in any way for the production of the lesion; it is also often found in healthy follicles. The dark points which usually mark the lesions are due to the accumulation of dirt. The process is an inactive one, occasioning usually no disturbance. The accumulation may increase until a papule is formed, or, on the other hand, may gradually relieve itself. The affection is to be distinguished from acne punctata and milium. Acne is a closely-allied disease, but is inflammatory in its nature; comedo is functional in character: the presence or absence of inflammation, therefore, is a decisive differential point between the two diseases. Milium differs from comedo in the facts that it has no open duct, no black point, and the contents cannot be squeezed out.

The result of treatment is usually favorable, several months sufficing for its removal. On the other hand, occasionally cases are met with which prove rebellious. The aim of constitutional treatment should be to remove the predisposing condition. For this purpose cod-liver oil, iron, quinine, arsenic, and various other tonics, and ergot in full doses, are variously prescribed. At times, small doses (about a tenth to a fourth of a grain) of calx sulphurata have a good effect. Saline aperients are often valuable. An aperient tonic pill of iron, aloes, and strychnia is sometimes serviceable. Open-air exercise and other hygienic measures are to be advised.

External treatment is of great importance,—is in fact indispensable. The condition may in many cases be relieved by local applications alone. Removal of the plugs by mechanical means is to be advised. Lateral pressure with the finger-ends, or perpendicular pressure with a watch-key or similar instrument, will be found effectual. Washing the parts with sapo viridis and hot water, with considerable friction and a kneading motion, will aid in dislodging the sebaceous collections. Instead of the sapo viridis its solution in alcohol, two parts of the soap to one of alcohol (spiritus saponatus kalinus), may be employed. Steaming the face or the application of hot water from ten to twenty minutes will aid in softening the secretion, and with friction and kneading will often have a good effect. Friction with sand soap is also valuable. A soap made of equal parts of green soap (sapo viridis) and finely-pulverized marble may also be used. The use of the dermal curette is at times of service, scraping off the tops of the comedones, rendering their expulsion more easy. After the soap-washing and hot-water application ointments or lotions containing sulphur, such as prescribed in acne, may be applied. The following lotion is often valuable:

Rx.	Sulphuris præcipitati,	drachm ij;
	Ætheris,	fluidounce ss;
	Alcoholis,	fluidounce iijss. M.

S. Shake before using: dab on with a mop for several minutes, allowing it to dry on.

Alkaline lotions containing borax or sodium bicarbonate, ten to twenty grains to the ounce, are often useful. The following paste has been highly spoken of for loosening and dislodging the sebaceous plugs:

Rx.	Aceti,	drachm ij;
	Glycerinæ,	drachm iij;
	Kaolini,	drachm iv. M.

S. Apply over the surface at night. If applied near the eyes, the lids should be kept closed for a few moments, on account of the pungent fumes of the vinegar. The lotion containing zinc sulphate and potassium sulphide, the formula of which is given in the treatment of acne, is of value. Corrosive-sublimate lotions, one-half to two grains to the ounce, are useful in some cases. In changing from a sulphur to a mercurial application, treatment should be suspended for several days, so that the formation of the black sulphuret of mercury, which may darken the skin and comedo plugs to an annoying degree, may be avoided. If treatment brings about considerable irritation of the parts, a result often desirable, it should be omitted temporarily and soothing applications made.

Milium.

Milium, described also as grutum and strophulus albidus, consists in the formation of small, whitish, roundish, pearly, non-inflammatory elevations situated in the upper part of the corium. The lesions are usually pinhead in size, whitish or yellowish, seemingly more or less translucent, rounded or acuminated, without aperture or duct, and appear for the most part about the face, especially about the eyelids, and occasionally elsewhere. One, several, or great numbers may be present; ordinarily, however, but several are to be seen, usually near the eyes. In our experience the affection is observed most frequently in middle-aged women. The lesions develop slowly, and after a certain size is reached may remain stationary for years. Their presence causes no disturbance, and unless large and numerous the affection is but slightly noticeable. Acne and comedo are often found associated with it. The cutaneous calculi occasionally met with are milia which have undergone calcareous metamorphosis. The etiology of the disease, in a great majority of cases, is not known. In some cases, however, the same causes as are operative in the production of comedo and acne seem to have an influence.

Anatomically, the affection is found to have its seat in the sebaceous glands. The duct from some cause is obliterated and the secretion cannot escape. The retained mass consists of sebaceous matter which tends to become inspissated and calcareous, and, as the lesion is without aperture, it cannot be squeezed out. The epidermis constitutes the external covering. It has also been shown by several authorities that the covering proper is either the gland itself or the wall of the hair-follicle, and that in the larger lesions connective-tissue septa are found. According to the investigations of Robinson, two different conditions have been described as milia—one which evidently has its origin in the sebaceous glands or ducts, and the other in which there is no connection whatever with these structures. The lesions are characteristic and the diagnosis easy. The absence of the duct-opening and black point of comedo serves to distinguish it from that disease. The small lesions of xanthoma—a disease which usually has its seat about the eyelids—may resemble it, but can scarcely be confounded with it, as its nature is entirely different.

As regards treatment, it is usually necessary in all cases to incise the lesions and squeeze out or scrape out their contents; in some, touching the base of the excavation with a minute drop of iodine tincture or nitrate of silver may be required to prevent a reappearance. Electrolysis has also been recommended.

Steatoma.

Steatoma—or, as commonly called, sebaceous cyst, sebaceous tumor, or wen—appears as a variously-sized, elevated, roundish, or semi-globular firm or soft tumor having its seat in the corium or subcutaneous tissue. One or several may be present. They are cysts of the sebaceous glands, and may exist wherever these structures occur, but are seen most frequently about the scalp, face, back, and scrotum. They develop slowly, are variable as to size, and may exist indefinitely without causing any inconvenience except disfigurement. The overlying skin is either normal in color or whitish from stretching; on the scalp it is usually devoid of hair. Cysts are usually firm, but may be doughy or soft. As a rule, they are freely movable and painless. In some a gland-duct orifice can be seen; in the majority it is absent. Spontaneous suppuration and ulceration may occasionally take place in enormously distended tumors. Anatomically, steatoma is a cyst of the sebaceous gland and duct, produced by retention of secretion. It is in fact an enormously distended duct and gland whose walls have become thickened into a tough sac. The contents vary, in some being hard and friable, in others soft and cheesy or even fluid, with or without a fetid odor, and of a grayish, whitish or yellowish color. The mass consists of fat-drops, epidermic cells, cholesterin, and sometimes hairs. As a rule, the diagnosis is made without difficulty. Gummata, which may have some resemblance, grow more rapidly, are usually painful to the touch, are not freely movable, and tend to break down and ulcerate. Sebaceous cysts can scarcely be mistaken for fatty tumors and osteomata.

In the treatment excision is radical and most satisfactory. A linear incision is made, and the mass and enveloping sac dissected out. A removal of the sac is necessary, or a reproduction usually takes place. As the scalp wound especially should be treated on antiseptic principles, injecting the tumor with a small quantity of tincture of iodine or other irritant has been successfully employed.

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CLASS II.—INFLAMMATIONS.

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. The affection is due to various causes, which may be external or internal. Hence it is usual to divide the affection into two classes—idiopathic and symptomatic. Under the head of idiopathic erythema are described the erythemas due to cold, heat, traumatism, poison, etc. Erythema caloricum arises from the action of heat or cold. If the degree of heat or cold is sufficient, a dermatitis, or even gangrene, may result. In a mild degree, however, simple congestion of the skin—erythema—is produced. It is usually bright red in color, later becoming somewhat darker, and at times is followed by slight desquamation. If produced by the action of the sun—erythema solare—the uncovered parts only are affected. Erythema traumaticum is usually seen as a result of the pressure of tightly-fitting clothes, corsets, bandages, etc. It disappears rapidly upon removal of the cause, without scaling. If the cause is long continued, a dermatitis may be produced. Erythema venenatum is a term applied to the form of hyperæmia resulting from the action of substances poisonous to the skin: such are all irritating chemicals, the ordinary rubefacients, various dyestuffs, acids, alkalies, and the like. The symptomatic erythemas are the more important. The rashes often preceding or accompanying certain of the systemic diseases, such as smallpox, diphtheria, and vaccinia, belong to this class. Disorders of the digestive tract, especially in children, are responsible for many cases. Roseola is a term sometimes applied to the symptomatic rashes. The division-line between simple erythema and dermatitis is often ill-defined.

The indications for treatment in the various erythemata are usually self-evident. A removal of the cause in idiopathic rashes is all that is needed. The same may be stated of the symptomatic erythemata; but here there is at times difficulty in recognizing the etiological factor. Local treatment is rarely necessary. Dusting-powders, mild lotions, or ointments such as used in acute eczema may be prescribed.

ERYTHEMA INTERTRIGO.—Erythema intertrigo—known popularly as chafing—is a hyperæmic disorder occurring on parts where the natural folds of the skin come in contact, characterized by redness and at times an abraded surface and maceration of the epidermis. The causes are usually local. Thus it appears chiefly about the folds of the neck in fat subjects, the nates, groin, perineum, and axillæ. It is seen usually in hot weather in infants and others whose skin is tender. The skin becomes red from chafing, and if long continued or untreated the perspiration of the parts causes more or less maceration of the epiderm and a mucoid discharge. If the condition continues, actual inflammation may be developed. The affection may pass away in a few days or last several weeks. There is a feeling of heat and soreness about the affected parts. Occurring between the nates in infants, a favorite locality, from the friction of the parts, and the action of the feces and urine, it is often persistent. As a rule, it yields readily to treatment. The predisposition to its development, and its continuance are often due in children to derangement of the stomach or intestinal canal.

In the treatment undue moisture and friction of the parts are to be prevented or counteracted. Washing with castile soap and cool water, and cleanliness, should be advised. The folds or parts are to be separated or kept apart with lint, cloth, or absorbent cotton. Dusting-powders are to be used freely, as they constitute the best method of treatment. The following is a good formula:

Rx.	Pulv. zinci oxidi,	drachm ij;
	Pulv. talci Veneti,	drachm ij;
	Pulv. amyli,	drachm iv. M.

Simple starch and lycopodium powder, alone or together, will both prove efficacious. If the affection prove rebellious to this plan of treatment, astringent and alcoholic lotions may be used. Black wash, diluted, dabbed on the parts several times daily, followed by oxide-of-zinc ointment or a dusting-powder, will be found useful in obstinate cases. A weak solution of corrosive sublimate, a fraction of a grain to the ounce, may also prove valuable in some instances. Lotions of zinc sulphate or of acetate of lead, two or three grains to the ounce, and a weak solution of alum, may also be mentioned. A lotion we have often found of service is the following:

Rx.	Pulv. calaminæ, Pulv. zinci oxidi, aa.	drachm iss;
	Alcoholis,	fluidrachm ij;
	Aquæ rosæ,	fluidounce iv. M.

Sig. Shake before using. Apply several times daily. The local treatment of rebellious cases is, in fact, that which is found efficacious in acute erythematous eczema.

Erythema Multiforme.

Erythema multiforme is an acute inflammatory disease characterized by reddish, more or less variegated macules, papules, and tubercles, occurring discretely or in patches of various size and shape. Certain regions of the body, such as the backs of the hands and feet and the arms and legs, are the parts mainly invaded. The eruption, as the name signifies, is usually marked by the multiformity of its lesions, although, as a rule, one of the forms is generally predominant. Peculiarities which the lesions assume have given rise to the qualifying terms annulare, iris, and marginatum, etc. Thus, when the erythematous patch is circular, fading in the centre, it is called erythema annulare. At times concentric rings, presenting variegated colors, are formed, giving rise to the term erythema iris. When the eruption consists of sharply-defined marginate patches, it is designated erythema marginatum. Most commonly, the eruption appears in the form of papules and tubercles. Erythema papulosum is the form of the disease usually met with. It consists of discrete or aggregated patches of flat papules, variable as to size and shape. In color they are bright red, violaceous, or purplish, disappearing partly under pressure. They fade rapidly, rarely lasting longer than a few weeks. Erythema tuberculosum is a form of the disease occasionally encountered in which the lesions are larger, but of the same general character as in the papular variety.

Erythema multiforme varies as regards duration, averaging about two weeks. During its course new lesions are apt to develop as the older eruption fades away. As the lesions disappear slight pigmentation and desquamation are noticeable. In addition to the parts already named as commonly invaded, the face is sometimes the seat of the eruption. It may, moreover, attack the mucous membranes. The subjective symptoms are rarely marked: usually slight burning and itching are complained of. There may be evidences of constitutional disturbance, such as malaise, headache, rheumatic pains, and gastric derangement, especially at the beginning; as a rule, however, general symptoms are not observed. Relapses, especially from year to year, are not uncommon. The causes of the disease are in most cases obscure. It is most frequent in early adult age. Spring and autumn seem to be predisposing factors, although it is also seen at other periods of the year. Gastric disturbance may give rise to the eruption in some instances. Rheumatism is occasionally associated with it. The affection is more common in the female.

Anatomically, the affection is an exudative disease, resembling urticaria. It is generally regarded as a vaso-motor disturbance. It is closely related to herpes iris and erythema nodosum, and by some these are looked upon as varieties. In regard to the diagnosis, it is to be differentiated from urticaria. In the latter affection itching and burning are prominent and constant symptoms, the lesions are fugacious, and the duration of the disease shorter. It can scarcely be confounded with eczema, in which disease the lesions are smaller and intensely itchy, and the eruption does not assume the different shapes seen in erythema multiforme. Erythema nodosum and herpes iris are also to be differentiated. The prognosis is always favorable, as the affection runs a definite course, usually disappearing at the end of a few weeks. It is rarely influenced by treatment.

Saline laxatives, alkalies, and the bromides may be given and the diet regulated. In the beginning of the attack large doses of quinine may be useful. Locally, applications of alcohol or vinegar and water, or a lotion of carbolic acid, five or ten grains to the ounce of water, will be found of advantage if itching or burning is present. As a rule, active external treatment is not required.

Erythema Nodosum.

Erythema nodosum (syn., dermatitis contusiformis) is an acute inflammatory affection characterized by the formation of variously-sized, roundish or ovalish, more or less elevated erythematous nodes. Febrile disturbance usually ushers in the eruption, often accompanied with gastric derangement, malaise, and rheumatic pains. The efflorescence appears rapidly, having special predilection for the arms and legs, particularly the tibial surfaces. The lesions vary in size, being rarely smaller than a cherry and often as large as an egg, and are ovalish or roundish in shape. They are reddish in color, with a bluish or purplish tinge, which becomes more decided as they grow older. Later, as they are disappearing, yellowish, greenish, and bluish coloration manifests itself, as in the case of a bruise. Not infrequently the lesions are hemorrhagic. When at its height a node has a shining, tense appearance, indicative apparently of beginning suppuration; this latter process, however, does not occur, absorption invariably taking place. Firm and hard at first, as they begin to decline they become softer. They are apt to appear in crops. The lesions are rarely present in large numbers, from five to twenty being the average; occasionally, however, they are much more numerous. The mucous membranes may, as in erythema multiforme, be invaded. They are tender and more or less painful, and are usually accompanied with a sense of burning. Lymphangitis is at times observed. At the end of two or three weeks the affection has usually run its course.

The causes of the disease are not known. It is closely allied to erythema multiforme, and by many observers is regarded as merely a manifestation of that disease. It is generally encountered in the spring and autumn months, and occurs most frequently in children and young persons. It is usually associated with rheumatic pains, and not infrequently with digestive derangement. It is not a common disease. It is regarded by Lewin as an angio-neurosis. According to Hebra, in most cases it is essentially an inflammation of the lymphatics. Bohn regards it as due to embolism of the cutaneous vessels giving rise to inflammatory infarctions. The process is an inflammatory oedema. There is considerable serous transudation, with some blood-corpuscles, and not infrequently with more or less hemorrhage. The lesions usually bear resemblance to bruises, abscesses, and gummata. The rosy hue, the apparently violent character of the process, the number, course, and situation of the lesions, will serve to distinguish it. The prognosis is favorable, as the affection tends to disappear in a few weeks, rarely lasting more than a month.

As spontaneous recovery results, treatment should be conservative. Rest, the more complete the better, sedative applications, as of lead-water and laudanum or of carbolic acid, with the use of saline laxatives and full doses of quinia, are the measures indicated. The diet should be regulated according to the case.

Urticaria.

Urticaria, hives, or nettlerash, is an erythematous affection characterized by the development of wheals of a whitish, pinkish, or reddish color, accompanied by stinging, pricking, and tingling sensations. The advent of the efflorescence is usually sudden; not infrequently symptoms of gastric derangement precede its appearance. The wheals are of variable size, shape, and color. Ordinarily they are of the size of a coffee-grain or bean, rounded or ovoidal in shape, and whitish, pinkish, or reddish in color. They occur isolated or in the form of patches caused by a coalescence of several lesions, and vary in elevation from half a line to several lines. Instead of the ovoidal or rounded form, the eruption may appear in streaks or irregularly-shaped patches. To the touch the lesions may be soft or firm.

The efflorescence disappears, as a rule, without leaving a trace. Pigment-stains are in some cases left which may be slow to disappear. Burning, tingling, stinging, and itching are prominent subjective symptoms. The individual lesions are fugacious, inclining to disappear at one part and to show themselves at another. They are more apt to appear on parts subjected to pressure by contact of clothes, although no region is exempt. No age is spared, but the disease, especially in its acute form, is more common in the young. Ordinarily, urticaria is an acute disorder, lasting a few hours to several days, in which time frequent exacerbations may take place. On the other hand, it may be chronic in the sense that relapses occur successively, the skin, in fact, rarely being entirely free of the lesions.

At times the wheals are peculiar as to formation or are complicated with another condition, and hence arise the so-called varieties of the disease. The most common of these is urticaria papulosa, which was formerly known as lichen urticatus. The lesions have the form of a papule with most of the characteristics of a wheal. They appear, as a rule, suddenly, and after a few hours or days gradually disappear; they rarely occur in numbers, and are generally scattered over the trunk and limbs, especially over the latter. They are intensely itchy, and hence their apices are usually excoriated and covered with blood-crusts. The itching usually becomes more marked toward night. This form of the affection is observed particularly in badly-nourished or in ill-cared-for young children. The occurrence of the disease in association with purpura, or as a complication of the latter, has given rise to the names urticaria hæmorrhagica and purpura urticans or urticata. The lesion is of a mixed character—purpuric and urticarial. Sometimes the wheal formation is of such a nature as to give rise to fluid exudation, producing a bulla; hence the name urticaria bullosa. In rare instances large walnut- or even egg-sized nodes or tumors are formed, constituting urticaria tuberosa, or giant urticaria.

The causes of urticaria are numerous. Two that are well known may be classed under the heads of external and internal irritants. Under the former may be mentioned stinging nettle, jelly-fish, caterpillars, fleas, bedbugs, and mosquitoes; among the latter, whatever produces gastric and intestinal derangements. These latter are responsible for most instances of acute urticaria. With some persons indulgence in certain articles of food, as fish, oysters, clams, crabs, lobsters, pork, strawberries, and similar articles, almost invariably calls forth the efflorescence. A number of medicinal substances, such as copaiba, cubebs, turpentine, valerian, chloral, salicylic acid, iodide of potassium, quinine, and others, taken internally, may provoke an attack. Malaria, functional and organic diseases of the uterus, a weak or irritable state of the nervous system, and impaired digestion are common causes of both the acute and chronic forms of the disease. Various nervous, hemorrhagic, and rheumatic diseases are also sometimes associated with urticaria. In fact, an irritation from disease of any internal organ, functional or organic in character, may give rise to the eruption.

Anatomically, a wheal is seen to be a more or less firm elevation, consisting of a circumscribed collection of semi-fluid material exuded into the upper layers of the skin. It has its seat for the most part in the papillary layer. The vaso-motor nervous system is probably the main factor in the production of the wheal. Dilatation following a spasm of the vessels results in effusion; in consequence, the overfilled vessels of the wheal are emptied by the pressure of the exudation, and the central paleness produced, while the pressed-back blood gives rise to the red border.

The features of the disease are so characteristic that there is, as a rule, no difficulty in distinguishing it from other affections. Erythema simplex, erythema multiforme, erythema nodosum, and erysipelas are to be differentiated. Erythema simplex is a simple hyperæmia, while urticaria is a peculiar inflammatory exudation—a point sufficient to distinguish the two. The papular and tubercular forms of erythema multiforme are to be differentiated by their more persistent character, the locality affected, and the absence usually of marked itching and burning. Erythema nodosum may resemble urticaria tuberosa, but the nodes in the former are usually encountered upon the tibial surfaces, are of much longer duration, and are free from itching. It is only when several wheals coalesce, causing swelling and burning, and then only when occurring about the face, that it may be mistaken for erysipelas; but the evanescent character of the eruption in urticaria, its rapid formation, the itching, and the absence of constitutional symptoms usual in erysipelas, are points of difference.

TREATMENT.—Most cases of acute urticaria may be speedily relieved. Relapses may occur, however, upon repeated exposure to the exciting cause. The prognosis of chronic urticaria, on the other hand, is not always so favorable, and will depend in a great measure upon the ability to remove or modify the predisposing condition. The first essential in the management of a case, therefore, is an investigation into its etiological cause.

In the acute disease, where, as in the majority of cases, gastric disturbance is the exciting factor, a purgative—preferably a saline—should be given. In severe cases, if food is still in the stomach, an emetic will be of service, sulphate of zinc, ipecacuanha, and mustard being the best. The diet should be of the simplest kind. Aperients are generally indicated until recovery takes place. In chronic urticaria, where faulty digestion is the exciting cause, remedies appropriate to that condition are to be prescribed. In all cases attention is to be directed to the state of the general health. If there is a suspicion of malaria, quinine and arsenic may be administered. Functional and organic affections should receive proper management, as they may prove to be the active cause of the disorder. If diuretics are called for, acetate of potassium will often best serve the purpose. The alkaline and laxative natural mineral waters are sometimes useful. In obstinate cases, especially in those in which no assignable cause can be detected, pilocarpine, atropia, tincture of belladonna, chloride of ammonium, bromide of potassium, and arsenic may be tried. Change of climate is at times advisable.

On account of the great distress usually attending the affection, local treatment is demanded in almost all cases. Baths and lotions are the most serviceable methods of applying external remedies. Sponging the surface with vinegar or alcohol, pure or diluted, may afford relief. A lotion of carbolic acid, two to four drachms to the pint of water, will frequently give prompt ease. The latter lotion may be improved by the addition of two or three ounces of alcohol and a small quantity (one to two drachms) of glycerin to the pint. A lotion of thymol, one grain to the ounce of alcohol and water, is likewise of value. Benzoic acid and borax, each five to ten grains to the ounce of water; chloral, ten to twenty grains to the ounce; dilute hydrocyanic acid, one to three drachms to the pint; and diluted ammonia-water,—may also be mentioned. Alkaline baths made with carbonate of sodium or potassium, three or six ounces to the bath, are sometimes serviceable. Starch, gelatin, and bran baths may in like manner be used; and acid baths, half an ounce of hydrochloric or nitric acid to the bath, have been recommended. Dusting-powders, especially when applied after baths, will in some cases prove acceptable.

URTICARIA PIGMENTOSA, called also zanthelasmoidea, is an unusual form of the disease, cases of which during the past few years have been reported. It begins usually in infancy, and may continue for a period of months or years. The wheals are intensely itchy, are more or less persistent, and leave yellowish, orange-colored, greenish, or brownish stains. Its nature is obscure: by some observers it is regarded as an urticaria; by others it is claimed that there is a new-growth element in the lesions. Most cases certainly show urticarial lesions and run the course of this affection. It is more than probable that the different cases reported are not examples of one disease. Treatment is, as a rule, unsatisfactory.

Dermatitis.

Dermatitis, although in its general meaning signifying any inflammation of the skin from whatever cause or character, is a term usually applied to those forms which are directly traceable to the action of irritants. Such irritants may act from without, as cold, heat, caustics, etc., or through the medium of the blood, as in the eruptions following the ingestion of certain drugs. The intensity of the inflammation varies from a simple erythematous condition to actual gangrene. Redness, heat, pain, swelling, and at times itching, the common clinical signs of inflammation, are present, but are variable as to degree. The inflammation may be confined to a small area or may be diffused, depending usually upon the cause. The forms of dermatitis are designated according to the causes which produce them.

DERMATITIS TRAUMATICA.—Under this head are included all those inflammations of the skin which are due to traumatism. Contusions and similar injuries, abrasions and inflammation from the pressure of tight-fitting garments, bandages, etc., excoriations, and the like, are common examples of this form. The excoriations from scratching in pediculosis, scabies, pruritus, eczema, and other itchy diseases are to the dermatologist the most frequent examples of traumatic dermatitis. They subside on removal of the cause, leaving often, especially if the scratching has been at all violent and the cause long continued, thickening of the skin and pigmentation, both of which, notably the latter, may be more or less permanent.

DERMATITIS VENENATA.—All inflammatory conditions of the skin due to contact with deleterious substances are classified in this group. Apart from chemical irritants, certain plants, notably those of the rhus family, are capable in some individuals of producing inflammation of the skin. The two well-known plants of this group are the poison ivy or oak and the poison sumach or dogwood. The majority of persons are not affected by these plants, but in many contact, or in some mere proximity to the plant, will be followed by a dermatitis, variable as to degree. The inflammation may simply be of an erythematous character with slight swelling, or, on the other hand, it may be vesicular, pustular, or bullous, with marked hyperæmia, oedema, and swelling. As a rule, the inflammation appears soon after exposure or contact, sometimes within a few hours; not infrequently, however, several days will elapse before the symptoms present themselves. Itching is commonly a prominent symptom, as also heat and burning.

The eruption usually begins as an erythema with heat, swelling, oedema, and itching, remaining for several days, and then subsiding, or, as is frequently the case, vesicles or even blebs are developed, and the affection then is, as a rule, slower in disappearing. Oedema and swelling may be slight, or, as often occurs, so great as to cause marked temporary disfigurement. The face, hands, and genitalia are the parts generally involved, although the disease may extend to other regions, at times involving large areas or even the greater portion of the whole surface. The lesions, either spontaneously or through violence, rupture, and dry to crusts, and subsequently fall off, leaving erythematous spots, which in turn gradually fade. The affection runs an acute course, lasting from one to six weeks. In some cases, especially in those with a tendency to eczema, its duration may be prolonged. The poisonous principle has been found to be toxicodendric acid, and is exceedingly volatile in character.

The eruption is influenced by treatment. Bland astringent lotions or ointments are most serviceable. The fluid extract of grindelia robusta, two to four drachms to the pint of water, dabbed on frequently, or cloths wet with it kept constantly applied, will usually have a remarkably beneficial effect. Black wash, either alone or followed by the oxide-of-zinc ointment, as in acute eczema, and lead-water, are both serviceable. A saturated solution of sodium hyposulphite, a lotion of sodium bicarbonate, one of carbolic acid, one or two drachms to the pint of water, a weak ammonia lotion, and other applications of a similar nature, may also be advised, frequently with good result.

Other substances which at times act on the skin somewhat similarly to the rhus plants are the aniline dyes, mezereon, arnica, and certain other drugs, as savin, croton oil, tartar emetic, mercurials, etc.

DERMATITIS CALORICA.—Both heat and cold are capable of producing serious disturbances of the skin. The condition varies from a simple erythematous inflammation to a state of actual gangrene, depending upon the degree and duration of the cause, and to some extent upon the recuperative power of the exposed parts. Whether due to heat (dermatitis combustionis, combustio, burns) or to cold (dermatitis congelationis, congelatio, frost-bite, chilblain), the clinical symptoms are about the same. Treatment is generally of a soothing character.

In cases of dermatitis due to cold which are seen immediately after exposure, the parts should gradually be brought back to a normal temperature, at first being rubbed with snow or cold water applied. In ordinary chilblains stimulating applications are most serviceable, such as tincture of iodine and frictions with oil of turpentine. Balsam of Peru, camphor, lead plaster, carbolic acid, twenty to sixty grains to the ounce of ointment, camphor, and similar remedies may also be mentioned.

In burns where the inflammation is of a mild degree, sodium bicarbonate, either as a powder or in saturated solution, is effective; while in those of a more severe grade a solution of 2 to 5 per cent. will be of greater advantage. In burns or frost-bites in which the inflammation is vesicular, bullous, pustular, or escharotic the measures advisable in ordinary inflammation are to be employed.

DERMATITIS MEDICAMENTOSA.—Medicinal eruptions are due to the ingestion of certain drugs, some of which produce in a large proportion of individuals, sooner or later, well-defined cutaneous manifestations; on the other hand, many drugs are only exceptionally noted as giving rise to cutaneous disturbance. Of the former, the iodides and the bromides stand conspicuous; while of the latter class, arsenic and quinine may be cited. The glandular structures of the skin are frequently involved, especially in the iodide and bromide eruptions, and apparently the inflammation and resulting pustules are due to the effort at elimination through these structures. In other instances, especially the erythematous and urticarial eruptions, the effects of the drug seem to be due to some action upon the nervous system.

Arsenic.—Exceptionally eruptions are seen to follow the continued administration of arsenic. They are of an erythematous type, resembling the macular syphiloderm and measles; or papular, somewhat similar to the papular manifestation of erythema multiforme. Vesicles, herpetic in character, and pustules have also been observed. An urticarial-like eruption has occasionally been noted. In several instances arsenic has seemed to hold a causative relationship to an attack of herpes zoster. Arsenical dermatitis is most frequently seen about the face, neck, and hands, and lasts usually from a few days to two weeks. Workmen in arsenic-works are occasionally observed to have a pustular, ulcerative, and even gangrenous eruption, due to the local action of the drug.

Atropia or Belladonna.—A scarlatinoid rash is a frequent result of ingestion of belladonna, even a small dose at times sufficing to provoke the eruption. It is seen most frequently in children, face, neck, and chest being usually involved. Dryness of the throat and general malaise may be present. Usually there is no febrile disturbance, and desquamation seldom if ever follows, the rash usually passing away within a few hours or days after the drug has been discontinued.

Bromides.—The eruption from the bromides is usually pustular in type, occasionally furuncular, and at times giving rise to purulent accumulations of a carbuncular character. In some individuals a single dose suffices to call out the eruption; usually, however, it is only after a few weeks' administration that the cutaneous lesions are observed. In rare instances even its prolonged use is unaccompanied by any disturbance of the skin. The face, neck, shoulders, and back are most prone to its effects. The pustules have their seat in and about the sebaceous glands. A small dose of arsenic or bitartrate of potassium with each dose of the bromide will sometimes prevent the eruption caused by the latter.

Cannabis Indica.—An eruption of a vesico-papular type, the lesions pinpoint- to pea-sized, scattered over the entire surface, accompanied with considerable pruritus, has been recorded, following within twelve hours after a full dose of the drug, and disappearing in a few days.

Chloral.—A scarlatinoid or urticarial eruption, dusky-red in color, somewhat itchy, occurring especially about the face, neck, and extremities, occasionally follows the administration of chloral. In some instances, if the drug is long continued, glandular enlargement, vesicles, petechiæ, ulceration, and sloughing, and rarely death with symptoms of purpura hæmorrhagica, result. In a few cases the drug has produced simple purpuric lesions.

Copaiba.—The copaiba eruption is well known. It may follow a single dose, or, as is more often the case, after several days' or a few weeks' use of the drug. It is maculo-papular or papular in type, itchy, and resembles urticaria and erythema multiforme. The extremities are usually invaded, although not infrequently the whole surface is attacked. A scarlatinoid rash has also been observed. The disturbance usually disappears in a few days.

Cubebs.—A diffused erythematous eruption, with milletseed-sized papules, coalescent here and there, occurring over the face and trunk, and to a less extent the extremities, disappearing with furfuraceous desquamation, is occasionally observed.

Digitalis.—A few cases of scarlatinoid and papular eruptions have been recorded as following the administration of digitalis.

Iodides.—Eruptions from the ingestion of the preparations of iodine are not uncommon. They may be erythematous, papular, vesicular, pustular, bullous, or purpuric in character. The erythematous type is not uncommon, appearing in patches chiefly about the forearms, face, and neck. The papular and vesicular forms are rarer, the latter occurring usually about the chest, limbs, scalp, and scrotum. A markedly eczematous eruption, occupying the greater portion of the entire surface, with copious secretion, has been occasionally noted. A pustular eruption, acne-like in character, resembling that seen following the bromides, is the most frequent. It is seen commonly about the face, shoulders, back, and arms. Iodine has been found in the contents of the lesions. A bullous eruption, occurring chiefly about the head and neck, has also been noted. This form is rare. The lesions usually begin as small vesicles or vesico-papules, and develop to blebs, containing a serous, puriform, or sanguinolent fluid. In some cases the eruption does not go beyond the vesicular or vesico-papular formation. Purpura has also, although rarely, been observed, the lesions being small, simple in character, and occurring mainly about the legs; or exceptionally assuming a grave hemorrhagic type, which may terminate fatally. All of the eruptions of the iodides disappear rapidly after the drug has been discontinued.

Mercury.—An eruption of an erysipelatous character, beginning about the face and extending to other parts, has been occasionally noted to follow this drug. The skin is smooth, shining, red, dry, and itchy.

Opium, Morphia.—An erythematous eruption, scarlatinoid in type, favoring the chest and flexor surfaces of the limbs, with or without itching, is in some individuals caused by even the smallest dose of opium or its alkaloid morphia. It may disappear in a few days or be prolonged and followed by marked desquamation. In some persons one or two doses will give rise to intense itching without any eruption, or if the drug is continued the erythematous condition described is developed. Opium has also rarely caused profuse sweating and sudamina.

Phosphoric Acid.—An instance of a bullous eruption has been recorded as following the administration of this drug.

Quinine.—Quinine rashes are not infrequent, appearing usually first on the face and neck, and then invading other parts. The eruption may be patchy or confluent. The type is generally erythematous. Chill, nausea, and other symptoms of malaise precede its development. There may be oedema and injection of the conjunctivæ, and redness and dryness of the naso-pharyngeal passages. Itching and burning are almost constant symptoms. Desquamation, furfuraceous or lamellar, follows. Eruptions resembling urticaria and erythema multiforme have been observed. A purpuric type has also been noted.

Salicylic Acid.—Dermatitis of an erythematous and urticarial type, with symptoms of general disturbance, is sometimes seen in patients taking salicylic acid or its salts. An efflorescence of vesicles and pustules about the hands and feet, with profuse sweating, has been recorded. A case in which ecchymotic patches about the back and neighboring regions appeared from the use of this drug has been reported.

Santonine.—An instance of an urticarial outbreak with oedema of the eyelids and swelling of the face has been observed following the ingestion of this drug.

Stramonium,—An erythematous efflorescence has been recorded as following this drug.

Strychnia.—A case is on record in which a rash of a scarlatinoid type followed a dose of one-twenty-fourth of a grain of strychnia.

Turpentine.—Both erythematous and papular eruptions, usually itchy, have appeared as the result of large doses of turpentine, occurring principally about the face and upper trunk, the papules being minute in character. A vesicular eruption has also been noticed somewhat similar to vesicular eczema.

DERMATITIS FACTITIA.—Feigned diseases of the skin are not uncommon. Erythema, vesicles, bullæ, and gangrene have been brought about, chiefly in hysterical females, to gain sympathy, or, as also in other individuals, for the purpose of deception, by the action of friction, acids, or strong alkalies.

Dermatitis Gangrænosa.

Dermatitis gangrænosa, or gangrene of the skin, is a rare affection. It may be idiopathic or symptomatic. As an idiopathic disease it begins usually as circular, erythematous, dark-red spots, tending to appear symmetrically, either painful and hyperæsthetic or without sensation. Malaise, fever, and symptoms of debility usually precede and accompany its development. The lesions go on to gangrene and sloughing, recovery taking place or a fatal termination gradually resulting. There may be several or as many as thirty or forty patches. The progress of the disease, whether terminating fatally or in recovery, is slow, usually of several months' duration. Gangrene of the skin as a symptomatic affection is occasionally seen in grave cerebral and spinal diseases, and also in diabetes.

Furunculus.

Furunculus, or boil, is a deep-seated, inflammatory disease, characterized by one or more variously-sized, circumscribed, rounded, more or less acuminated, firm, painful formations, usually terminating in central suppuration.

In the beginning the lesion appears as a reddish spot, small, rounded, imperfectly defined, inflammatory, and painful to the touch, having its seat in the corium; it gradually becomes larger, raised, and with marked tendency to central suppuration, usually maturing in from one to two weeks, when it appears as a painful, deep-red, rounded, pointed, inflammatory formation, varying in size from a pea to a walnut, exhibiting central suppuration, the so-called core. In some cases there is no tendency to core-formation, such lesions being popularly designated blind boils.

A furuncle is usually painful, of a throbbing nature, which persists until suppuration has taken place and the contents discharged. The intensity of the inflammation gives rise to considerable areolar swelling and hyperæmia. There may be but one lesion present, or, as more frequently happens, several may exist at the same time scattered over different regions. In the latter case, after a partial or complete disappearance of the first crop, a second outbreak frequently occurs, to be followed later by a third, and so on, constituting furunculosis. The lesions are usually isolated. No region of the body is exempt; the face, neck, back, and buttocks are favorite localities. Sympathetic constitutional disturbance, more or less marked in severe cases, is usually present. Boils sometimes occur in association with eczema. In general, they are the result of a depressed state of the system. Friction, a contusion, or similar local irritation is often the exciting cause. They are met with in association with diabetes, pyæmia, uræmia, chlorosis, fevers, and like conditions. Although observed at all periods of life, they are more common during adolescence and in old age. The view has been advanced that a furuncle is due to the presence of a microbe (Torula pyogenica). According to Pasteur, this bacterium is identical with that of abscesses of the soft parts, etc.

The lesion usually has its starting-point in a sebaceous gland in the upper part of the corium, or, deeper, in a sweat-gland or hair-follicle. Beginning in a sweat-gland in the deeper structures it constitutes the so-called connective-tissue furuncle, or hydroadenitis of some authors. The core, or central suppuration, is usually made up of the tissue of the gland in which the boil had its origin, and pus, and when cast off appears as a whitish, tough, pultaceous mass. A more or less permanent cicatrix usually results. There is only one affection with which a furuncle is likely to be confounded—namely, carbuncle. In this latter, however, the lesion is considerably larger, flattened instead of rounded and pointed, the pain of an intense character and in a measure independent of touch or injury. Moreover, a carbuncle has several points of suppuration, the boil having but one, and the former, moreover, is rarely multiple.

When occurring in crops, the affection is often rebellious to treatment. Both constitutional and local measures, especially the former, are demanded. Functional disorders are to be regulated, and any faulty condition of the general health corrected. Tonics, such as quinine, iron, strychnia, mineral acids, and arsenic, are not infrequently of service. The last remedy usually proves of most value in those cases in which the lesions appear in crops. The preparations of sulphur are of positive service in many cases of the disease; hyposulphite of sodium, ten or fifteen grains three or four times daily, is one of the most valuable remedies we possess, and with the same view calx sulphurata, one-tenth to one-half grain five or six times daily, may be prescribed. Alkalies, especially liquor potassæ in ten or fifteen minim doses, are not infrequently beneficial. The compound syrup of the hypophosphites may also be employed with the hope of obtaining relief. In regard to the diet, the most nutritious food, liberally partaken of, is, as a rule, to be advised. At times change of air and scene will act most happily.

Concerning the local treatment, the lesion in the first stage may possibly be aborted, or at least modified in its course, by the application to the forming core of a strong solution or of a crystal of carbolic acid. This procedure is preferable to the actual cautery. If the lesion be farther advanced, a drop of carbolic acid and glycerin, equal parts, will often give instantaneous relief and arrest the progress of the boil. A few drops of a 5 per cent. carbolic-acid solution may also be injected into the apex of the boil with good results. For the same purpose painting the parts with tincture of camphor or tincture of iodine is advised. An ointment of carbolic acid—as, for example, resin cerate an ounce, carbolic acid from fifteen to thirty grains—applied as a plaster will be found useful. The application of poultices affords ease in some cases. As soon as suppuration has been fully established evacuation of the contents will shorten the course of the process. If the boil is open and discharging, boric acid in powder, freely applied, has been recommended.

ALEPPO BOUTON, BOIL, OR EVIL, DELHI BOIL, AND BISKRA BOUTON.—The first of these diseases, the Aleppo bouton, boil, or evil, is observed at Aleppo, Bagdad, and the neighboring regions. Delhi boil is not uncommon in India, and the Biskra bouton is found in Algeria and elsewhere along the African coast. In fact, these diseases are more or less epidemic in these countries. They have been considered as allied to furuncle, but their true nature is somewhat obscure. The three affections are probably examples of the same disease, modified, it may be, by climate, habits, etc. They begin as a papule or tubercle, soon becoming a pustule, and then ulcerate, leaving a cicatrix.

Carbunculus.

Carbunculus (anthrax, carbuncle) is a firm, more or less circumscribed, painful, deep-seated inflammation of the skin and subcutaneous structures, variable as to size, terminating in a slough. General malaise, slight fever, and chilliness precede and usher in the disease. Locally, there appears at first a more or less circumscribed, circular redness, with swelling, tenderness, and pain. Soon a phlegmonous inflammation develops, the surface at times showing vesiculation, the lesion involving an area several inches in diameter and of considerable depth. The progress of the disease is not uniform. At the end of a week or two suppuration is fully established, the first signs of this process appearing about the hair-follicles. The tissues are now soft and boggy; the skin becomes gangrenous, breaking down at numerous points, disclosing centres of suppuration, giving the lesion a cribriform appearance. Finally, the whole mass sloughs away either as an entirety or in portions, and results in an open, deep ulcer with hard and raised edges, which gradually granulates and heals, leaving a pigmented cicatrix. The area involved varies, and may be extensive, sometimes as much as six or eight inches in diameter. The favorite localities for its development are the nape of the neck, shoulders, back, and buttocks. As a rule, the process ends in three to six weeks. Usually only one lesion exists. When there are several or where they follow each other in succession, the general condition is apt to become markedly depressed, and even a fatal result is not at all uncommon.

The causes which give rise to the affection are similar to those which predispose to furuncle. It is generally observed in those whose health is impaired or broken down. It is more common in men, and is usually encountered in those past middle age. The inflammation starts simultaneously at numerous points, usually from the hair-follicles, sweat and sebaceous glands, extends in all directions, and eventually terminates in gangrene of the whole area. The inflammatory centres break down rapidly, from each of which the collected pus finds its way to the surface, thus producing the cribriform appearance. According to Warren, the pus ascends by way of the columnæ adiposæ to the hair-follicles, and thence to the surface. The process may involve fascia, muscles, and even periosteum and bone. The disease is to be distinguished from furuncle by its greater size, flatness, and the multiple points of suppuration. From erysipelas, to which in the beginning it may have some resemblance, it is to be differentiated by the hardness, painfulness, and circumscribed character of the lesion. It is also to be distinguished from malignant pustule. It is always to be looked upon as a serious affection, especially when occurring in those past the age of fifty or sixty and in those in a debilitated condition. Carbuncle when occurring about the face terminates in a large proportion of the cases fatally.

The treatment is both local and general. The local measures are in the main the same as advised for furuncle. In the early stages the actual cautery may arrest the process. Injections of from eight to twelve drops of a 5 or 10 per cent. solution of carbolic acid will be found valuable, often affording speedy relief. Frequently-repeated paintings with tincture of iodine in the early stage may prove of service. Poultices are of value, and will often diminish the tension and the pain. A dressing of white lead, laid on thick, is highly spoken of by Milton and other English observers. When the purulent collections have broken through the skin the application of a cupping-glass to draw out the pus has been advised. The wound should be dressed with carbolized oil. The use of the moist-sponge dressing, with the view of absorbing the pus, as recommended by McClellan, may be advised. Compression may also be resorted to with good results. The weight of authority is against the practice of incision, although in some cases it is to be recommended, the operation being preceded by hypodermic injections of cocaine. The general treatment should be of a tonic character. Iron—preferably the tincture of the chloride—and quinine in large doses are to be advised. A liberal diet of nourishing food, with a moderate amount of stimulants, is indicated in almost every case.

Herpes Simplex.

Herpes simplex is an acute, non-contagious, inflammatory disease, characterized by the formation of pinhead- to pea-sized vesicles arranged in groups and occurring for the most part about the face and genitalia. Malaise and pyrexia in severe cases may precede the eruption. Usually, however, the efflorescence appears without any systemic disturbance. The lesions are rarely numerous, and appear in the form of one or more clusters. Sense of heat in the part usually signalizes the outbreak. The vesicles show no tendency to rupture. The contents are at first clear, but later become cloudy or puriform, and dry to yellowish or brownish crusts, which subsequently fall off, leaving the skin normal. If broken or rubbed, a superficial excoriation results. The affection is acute, ordinarily running its course, if unirritated, in a week or ten days. It is liable to recur from time to time. Occurring about the face, it is designated herpes facialis. It is usually seen about the lips (herpes labialis), frequently about the alæ of the nose, and occasionally on other regions of the face. The mucous membrane of the mouth may also be invaded. The lesions may remain discrete or may coalesce, forming small blebs.

When the affection shows itself upon the genitalia, it is termed herpes progenitalis; and when on the prepuce, a common site, herpes præputialis. In the female, in whom it occurs here much less frequently, the labia majora and labia minora, as well as the skin about the vulva, are the parts usually invaded. It is seen most commonly in the young and middle-aged. Burning, slight itching, sometimes darting pain, and more or less oedema, may be present. As a rule, the lesions are not numerous, the average number being five or six. They incline to group, and ordinarily but one group is seen. Unless irritated they run the same favorable course as when on other regions. If, however, as often happens, especially when occurring about the inner surface of the prepuce or the glans, or on the inner surface of the labia, the vesicles break down and excoriations resembling ulcers result. The disease is even more prone to recur than when on other parts.

Herpes of the face is often observed in association with lung and febrile diseases. Malaria is sometimes the cause, and digestive and nervous disorders frequently predispose to it. Herpes of the genitalia, it is stated, is seen most frequently in those who have previously had gonorrhoea, chancroid, or chancre, especially the first. It may be that, occurring in such persons, it excites solicitude, and hence medical relief is sought, and the relative frequency of such causes unduly increased. A long prepuce is a predisposing factor.

The characters of the eruption, as it occurs about the face, are so well marked as to preclude an error in diagnosis. About the genitalia, however, the lesions may become abraded or irritated, and may simulate chancroids. The history, course, and character of the two affections should in doubtful cases be carefully considered before expressing a positive opinion.

In herpes facialis, flexible collodion, camphorated cold cream, or the lotion of zinc sulphate and potassium sulphide (see treatment of acne for formula) may be prescribed. In herpes progenitalis cleanliness is of great importance. Liquor gutta-perchæ, a paste composed of equal parts of mucilage of acacia, glycerin, and oxide of zinc, lotions of sulphate of zinc, a few grains to the ounce, and of ammonia-water, may be prescribed. A saturated solution of boric acid and a dressing of borated absorbent cotton are likewise useful, while in some cases dusting the parts with calomel will prove beneficial. Where the affection recurs, if the prepuce is long, circumcision may afford future immunity.

Herpes Iris.

Herpes iris is an acute non-contagious disease, consisting of one or more groups of inflammatory vesicles or blebs, arranged usually in the form of more or less complete concentric rings, the whole efflorescence being somewhat variegated in color.

The eruption most frequently appears on the backs of the hands and feet, especially the former. It begins as a simple papule or vesicle, which soon disappears, a ring of discrete or confluent vesicles now appearing around the periphery. The process may be arrested at this stage, the lesions soon undergoing involution, or still another ring may form. The vesicles may be discrete or confluent, but usually they coalesce, forming small or large blebs. The number of groups or patches in most cases is not large, three or four usually being present at one period; but sometimes as many as a dozen or more exist. The eruption is usually symmetrical. The difference in the age of the several rings that go to form a single patch gives rise to the variegated colors which characterize the disease. In size the vesicles vary from a pinhead to a pea, and the patches from a fraction of an inch to several inches in diameter. They contain a yellowish, clear, or puriform fluid which rapidly dries to crusts. New patches, as a rule, continue to appear in crops for a few weeks, when the process gradually subsides, leaving slight pigmentation, which soon fades away. Variations in the type of the efflorescence are not uncommon. In some instances the lesions barely reach vesiculation, being rather papulo-vesicular, while in others blebs may appear at the beginning in the place of vesicles. The subjective symptoms of itching and burning are either lacking or are not marked. Malaise or slight febrile action may usher in the disease, or, as is usually the case, constitutional disturbance is not observed. The affection is comparatively rare. Recurrences may take place, usually at intervals of a year or more.

It is seen chiefly in spring and autumn, and is met with in both sexes, but is more common in children and young persons. Its nature is obscure. It is probably due to the same causes that are responsible for erythema multiforme, a disease to which it is very closely allied. The process also is intimately identical with that affection, it being, apparently, merely an advanced stage or modification of that disease. It is to be distinguished from ringworm, erythema multiforme, herpes zoster, pemphigus, and dermatitis herpetiformis. In ringworm the process is more superficial, and usually is less inflammatory, the papules or vesico-papules being scarcely distinguishable; in doubtful cases the microscope will decide. Vesiculation will serve to differentiate from erythema multiforme. The absence of neuralgic pain, the distribution, location, and arrangement of the vesicles, are sufficient to exclude herpes zoster. In pemphigus the size, distribution, arrangement, mode of formation, and course of the lesions are different from herpes iris.

The affection tends to spontaneous disappearance in the course of a week or two; nor does treatment seem to influence materially its course. The bowels should be opened with saline laxatives, and other symptoms treated on general principles. Tonics, especially quinine, are in some cases of value. Locally, dusting-powders, such as oxide of zinc, starch, and lycopodium, may be frequently applied. Cooling, antipruritic, or astringent lotions—such, for example, as those used in acute vesicular eczema—will generally prove grateful.

Herpes Zoster.

Herpes zoster, or zoster, popularly known as shingles, is an acute, self-limited, inflammatory disease, characterized by groups of vesicles with inflammatory bases situated along or over a nerve-tract, and accompanied by more or less neuralgic pain.

As a rule, the cutaneous lesions are preceded, usually for several days, by neuralgic or burning pains in the part, and in some cases mild febrile disturbance. An inflamed state of the skin, in the form of one or several patches, is seen, which is soon followed by the formation of vesico-papules, which rapidly become distinct vesicles. They vary in size from a pinhead to a pea, are situated on inflamed bases, and are irregularly grouped. They may occur in small numbers, or, as is usual, be numerous, in which case they are crowded together. In the latter event they may coalesce here and there, forming larger lesions or irregular patches. They continue to appear for five or six days, remain stationary a short time, and then begin to subside. One or more groups may be present; usually a half dozen or more are seen in the one case. The vesicles contain a clear yellowish liquid, which gradually becomes puriform; those that appear last rarely reach full development. They show no tendency to rupture, are distended, subsequently becoming slightly umbilicated, and by the end of two weeks have gradually dried to thin yellowish or brownish crusts, which soon drop off. Except in severe cases, especially the hemorrhagic form, scarring rarely results. A tendency to group is characteristic of the eruption. The disease is acute, and runs its course usually in from ten to twenty days.

In some instances the lesions run an abortive course, barely arriving at the point of vesiculation. On the other hand, small blebs and pustules may be formed. In severe cases the vesicles may become hemorrhagic. The neuralgic pain may accompany the disease, and in severe cases, especially in persons advanced in years, may persist long after the eruption has subsided. In some cases burning is the only subjective symptom complained of. The disease is not confined to any age or sex. It is more common in the winter season. As a rule, it is limited to one side of the body. Moreover, it is rarely seen in the same individual twice. The intercostal and lumbar regions show the eruption most frequently. In zoster of the orbital region the eye becomes involved, and the disease may in some instances terminate in loss of sight, and even in destruction of the eyeball. Any nerve-tract or part of the body may be the seat of the eruption, hence the names zoster capitis, facialis, brachialis, pectoralis, etc. The disease is not uncommon.

The eruption is dependent upon an irritable and inflamed state of the ganglia or nerves—a neuritis. Hence any agent that may bring about this condition is capable of producing the eruption. Among such may be included atmospheric changes, sudden checking of the perspiration, compression, nerve-injuries, operations, and similar influences. In some instances the eruption is noted to follow the administration of arsenic. The primary seat of the affection is usually in the spinal ganglia; they are found softened and altered in structure and the nerves inflamed and thickened. It may, however, have its beginning along the tract of a nerve or in the peripheral branches. In fact, it may be spinal, ganglionic, or peripheral in origin. The vesicles are found to have their seat in the lower strata of the rete. The surrounding corium and papillæ show more or less round-cell infiltration, with dilatation of the papillary blood-vessels. A perineuritis, with cell-infiltration in and about the neurilemma, is also usually observed. The vesicles contain rete-cells, pus-corpuscles, and serum.

The diagnosis is usually unattended with difficulty. The premonitory pain, the appearance of grouped vesicles upon inflammatory bases, with no tendency to rupture, and the limitation of the eruption to one side of the body, are sufficiently characteristic. The vesicles are larger than those of eczema, and lack the well-known tendency of the latter to break and discharge a gummy fluid which rapidly forms to crusts. In erysipelas the line of demarcation, the deep-reddish color, and the constitutional symptoms will serve to differentiate the diseases. It is to be distinguished from simple herpes by its location, number of groups, unilateral distribution, and absence of relapses. The prognosis is favorable, as the eruption usually disappears at the end of two or three weeks; severe cases, however, may last a month or more. When involving the eye, the possibility of its destroying the same, and even of a fatal result, is to be kept in mind. In elderly subjects the neuralgic symptoms are apt to prove persistent.

Treatment is mainly expectant. The disease is self-limited, and hence severe measures are to be avoided. Internal treatment has, so far as experience shows, very little influence upon its course. Phosphide of zinc, in one-third grain doses every three hours, at times seems to have a beneficial effect. Morphia, hypodermically or by the mouth, is required if the neuralgia is severe. The galvanic current, applied once or twice daily, will sometimes quiet the pain and favorably influence the course of the disease. Locally, the parts are to be protected from irritation. For this purpose dusting-powders, to which a small quantity of morphia and camphor may be added, may be employed. The parts should be further protected with a bandage. Oxide-of-zinc ointment, and anodyne ointments containing powdered opium or belladonna, may also be used. Painting the efflorescence with oil of peppermint or with solutions of menthol, thymol, or carbolic acid will be found to relieve the burning and pain; so also, flexible collodion, containing ten grains of morphia to the ounce, will sometimes afford relief. The parts subsequently may be covered with a layer of cotton batting.

Dermatitis Herpetiformis.

This disease is multiform and protean in character, consisting in the formation of herpetic, erythematous, vesicular, pustular, and bullous lesions, occurring separately or in various combinations, accompanied with itching and burning sensations and pursuing usually a chronic course with relapses.

This affection, which until recently has been confounded with other cutaneous diseases, is rare, although as its peculiar features become belter known numerous cases will doubtless be reported. It was first described by one of us (Duhring) in a paper read before the American Medical Association in 1884. It is an inflammatory disease of an herpetic character, the various lesions showing more or less tendency to group. In some of its forms it bears likeness to erythema multiforme and herpes iris, while in other cases it is allied to pemphigus. It varies greatly in the degree of development. The causes are varied, though in many cases they are neurotic in their nature; thus, the disease may follow shock to the nervous system. It is also met with accompanying the parturient state. In some cases it is septicæmic in origin. It is also at times due to irregular menstruation. As to sex, while more frequent in women, it is also encountered in men. In severe cases there is more or less constitutional disturbance, consisting of malaise, slight fever, and constipation, accompanying the onset of the disease or its relapses and exacerbations. Increased heat of skin, itching, and burning are also prominent symptoms at such periods.

The disease manifests itself in the erythematous, vesicular, bullous, pustular, and multiform varieties. The erythematous variety is characterized by patches or a diffuse efflorescence of an urticarial or erythema-multiforme-like nature, the similarity to the latter process being sometimes marked. The disease may remain in this form, or, as is usually the case, may pass into other varieties, especially the vesicular. This latter is the usual form of the disease. It is characterized by variously-sized, flat or raised, irregularly-shaped or stellate, glistening vesicles, as a rule without marked areolæ. They are usually firm and distended, are often difficult to detect, and have an herpetic look, being grouped into clusters of two, three, or more. Here and there they are aggregated into patches. When in close proximity they tend to coalesce, forming large irregularly-shaped, oblong, or lobulated vesicles, or even blebs. The eruption is usually profuse. The most striking symptom is the itching, which in most cases is severe or even intense. The vesicles make their appearance, as a rule, slowly, several days or a week being required for their complete development. This variety of dermatitis herpetiformis (formerly described with the name herpes gestationis) is liable to be confounded with vesicular eczema, but the irregularity in the size and shape of the vesicles; their angular or stellate outline, giving them a puckered look; their firm, tense walls, showing no disposition to spontaneous rupture,—will all serve in the diagnosis. In some cases the constitutional disturbance and the magnitude of the eruption, as regards profusion, distribution, and multiformity, will also be apparent.

In the bullous variety the lesions are more or less typical blebs, variable as to size and shape, seated upon a slightly inflamed or non-inflammatory base. They tend to group into small clusters, in which case the skin between them will be red, as occurs in herpes zoster. Together with the blebs, vesicles and small or even minute whitish pustules will usually be found, the combination of these varied lesions being sometimes remarkable. The blebs generally rupture or are broken by injury, and become the seat of yellowish or brownish crusts. This variety of the disease is liable to be confounded with pemphigus, but differs in its marked herpetic and more inflammatory aspect.

The pustular variety is generally less clearly defined than the vesicular, because the lesions are usually intermingled with vesicles, vesico-pustules, and blebs. The pustules are acuminate, rounded, or flat, are variable as to size, and are whitish or yellowish in color. The smallest are generally flat, sometimes being no larger than a pinpoint or pinhead, while those that attain the size of a pea are rounded or acuminate, and are surrounded with a marked red areola. The largest are flat, and incline to spread out and to run together, forming patches which later become covered with greenish crusts. Grouping occurs here as in the other varieties, and is sometimes peculiar in that a central pustule may be surrounded by a variable number of smaller pustules in a circinate form, as in herpes iris. This variety of the disease is the same condition described by Hebra with the title impetigo herpetiformis.

The papular manifestation is an ill-defined form of disease, consisting of small reddish, firm, more or less grouped papules, resembling in general appearance the papular lesions sometimes met with in abortive herpes zoster. They resemble at times also certain phases of relapsing chronic papular eczema. Owing to itching and scratching they are generally excoriated.

Finally, there remains to be described the multiform variety, which consists of several of the foregoing varieties occurring in combination, a phase of the disease which is not infrequent. It comprises erythematous, sometimes slightly raised, urticarial patches of variable size and shape, often marginate or confluent, and of a reddish, yellowish, or variegated color. In addition, there may be present more or less well-defined irregularly-shaped or rounded maculo-papules and flat patches of infiltration, papules, and papulo-vesicles in various stages of evolution. Vesicles, blebs, and pustules may also exist, together with pigmentation. Thus it will be noted there exists a mixture or combination of lesions, calling to mind the peculiarities of eczema, although the process is both more capricious and varied in its behavior.

It must also be stated that the disease may at any period change its type; thus the vesicular variety may exist for weeks or months, to be followed by a crop of blebs or of pustules. The mingling of several varieties at one or another period in the course of the affection is usually a marked feature. It is variable in its course, but is in most cases chronic, and not infrequently is of many years' duration. It inclines to persist and to show itself in distinct crops or attacks at irregular intervals, the patient in the mean time being comparatively free of eruption. Relapses are common. It is in most cases very rebellious to treatment. The prognosis should be guarded. The pustular and bullous varieties are the most grave, and at times may prove fatal, especially in connection with the parturient state.

Concerning the treatment, with the knowledge now at hand but little encouragement can be given. The general state of the patient should receive attention, and the cause inquired into and modified or remedied if possible. The therapeutics must be conducted on general principles. Arsenic and its preparations do not seem to be of value, at least in the cases that have fallen under our observation. Locally, the remedies most useful are those usually employed in chronic eczema and in pemphigus.

Psoriasis.

Psoriasis may be defined as a chronic disease of the skin, characterized by reddish, dry, inflammatory, infiltrated patches, variable as to size, shape, and number, covered usually with abundant whitish, mother-of-pearl-colored, imbricated scales. It varies considerably in the degree of its development, but as a rule the lesions are numerous and their features clearly defined. It is the most uniform in its symptoms of all the diseases of the skin. It is therefore easy to recognize. In the first stage it appears as a small reddish spot, as large as a pinhead or a pea; it grows rapidly or slowly, and from the beginning shows signs of scaling, the scales being whitish, imbricated, and easily detached by scraping. They are reproduced readily, so that the lesion is usually well covered. In their early stages the lesions usually develop rapidly until their determinate size has been attained. The usual course is for the lesion to begin as a pinhead-sized spot, and grow to the size of a small or large coin. Several may appear side by side in close proximity, in which event they tend to coalesce, and to form larger, rounded, ovoidal, or figure-of-eight-shaped patches. Thus in time large surfaces of disease, the size of a hand or larger, may result. In other cases the lesions remain small, but through their great number may involve a considerable portion of the whole integument.

When typically developed, the lesions are of a bright- or dull-red color, and are covered with whitish, grayish, or pale-yellowish scales. The degree of inflammation varies with the case; at times it is slight, causing the lesions to assume merely a pale-pinkish, slightly inflammatory look; at other times it is more active, producing a decidedly inflammatory, strawberry- or raspberry-red hue. The majority of cases show a well-defined dull pinkish-red color of a cold inflammatory hue. The scaling, while usually active and abundant, is likewise variable; where the lesions are numerous and large it is constant, the scales being formed and shed rapidly from day to day; where the process is active, they are large, laminated, of a whitish, silvery, or mother-of-pearl-colored or slightly yellowish hue, varying somewhat with the locality involved. Sometimes they are heaped up. They are, moreover, easily detached, and can be readily picked or scraped off, leaving beneath a dry or very little excoriated, reddish surface. When deeply scratched, minute drops or points of blood, sometimes appear. They never exude serum. The lesions are, as a rule, circumscribed and sharply defined from the surrounding healthy integument, differing in this respect from similar patches of eczema. The skin between the lesions is perfectly healthy. In markedly inflammatory cases they occasionally possess a slightly raised border, and sometimes, especially in certain localities, as the hands, fissures form, as in eczema and syphilis.

The disease pursues an eminently chronic course, often lasting years or even throughout life, disappearing and recurring from time to time. Relapses at intervals of months or years are the rule, sometimes slight, at other times severe. It is a capricious disease. Usually it is better in summer than in winter, and in some cases it makes its appearance only during the latter season. It is generally unaccompanied by marked subjective symptoms, although this depends largely upon the degree of inflammatory action. In most chronic cases the itching and burning are either absent or slight, and when present are generally most annoying during the period that new lesions are appearing or old ones spreading. On the other hand, where the affection is highly inflammatory and running an acute, rapid course, both sensations, especially burning, may exist to an annoying degree. The disease is not contagious.

The eruption takes on different appearances according to the size and outline of the lesions, some of which require mention. They constitute the so-called varieties of the disease, but, strictly speaking, are forms rather than varieties. Thus, when the lesions are pinhead in size the form is termed punctata; when larger, the size of peas, guttata, from their resemblance to a drop of mortar; when still larger, the size of coins, they are designated nummularis, this being the form generally encountered. Sometimes the last-named lesions become more or less clear in the centre, and spread on their circumference after the manner of ringworm of the general surface, the condition being called circinata; at other times, more rarely, they assume a figured or ribbon-like form, causing them to have a serpentine, gyrate, or festooned appearance, termed gyrata. Commonly, however, when they grow to a large size they form, by the coalition of two or more lesions, irregularly-rounded patches, covering, it may be, a considerable area, the condition being called diffusa. The disease shows preference for certain regions, among which may be mentioned the extensor surfaces of the limbs, the elbows and knees, the scalp, and the trunk. The palms and soles and nails may also be invaded alone, or, as is usually the case, in connection with the disease upon other regions. It is usually symmetrical.

The causes of the disease seem to be varied, and are by no means well understood. It is met with, as a rule, in subjects whose general health is of the best, and who have hearty and strong constitutions, with no other ailment than the cutaneous manifestation. But cases are also encountered where the general condition is at fault: sometimes the system is below standard, as during lactation; in other cases the nervous system is depressed, as from some long-continued cause like mental worry. It occurs in both sexes, and usually makes its appearance in early adult life. It is seldom met with before the age of eight, and does not show itself in infants. In some cases it is inherited, but more frequently such is not the case. It occurs in all walks of life, being found among the rich and the poor in about like proportions. Statistics show it to be one of the most common diseases of the skin. It is of more frequent occurrence in some countries than in others. According to White's report of 5000 consecutive cases of skin disease observed in Boston, 152 cases of psoriasis were recorded, while Anderson in Glasgow reports 725 cases among 10,000 cases of skin disease, the difference being more than two to one in favor of Scotland. Diet in the majority of cases possesses but little influence over the disease.

The pathological process is one of the most defined and constant in cutaneous medicine. It is well marked throughout its course, and is subject to little variation. According to the most recent and reliable observations, it is held to be an inflammation induced by a hyperplasia of the rete mucosum. The views put forth by Auspitz and by Tilbury Fox have been substantiated by more recent observers. A. R. Robinson, and later Jamieson and Thin, have investigated the pathological anatomy of the disease with care, and have shown that the disease consists essentially of a hyperplasia of the rete mucosum, the increase taking place in the interpapillary portion of the layer. The growth extends downward, pressing upon the papillæ and corium, and setting up a variable degree of inflammation. In the later stages the superficial blood-vessels become dilated, more or less emigration of corpuscular elements occurring, the connective tissue especially in the neighborhood of the vessels becoming the seat of a round-cell infiltration. Effusion of serum, moreover, takes place, separating the connective-tissue bundles and fibres into an open meshwork. As the disease is vanishing there is a gradual return to the normal state, the hyperplasia, dilatation, and infiltration disappearing without traces. The hair is affected from the beginning in the form of hyperplasia of the external root-sheath, but the sebaceous and sweat glands are not found to be involved.

DIAGNOSIS.—The diagnosis, as a rule, offers no difficulties. The characteristic features are so constant and are usually so well marked that in ordinary cases errors are not likely to occur. When localized, as upon the scalp or upon the hands, it may be, however, readily confounded with other diseases. The general aspect of the eruption, the form of the lesions, the peculiar character of the scaling, the localities invaded, and the course of the process must be kept in view. It may be confounded with squamous eczema, especially where only one or two lesions are present, but the scales are usually more abundant, larger, and whiter than in eczema. The patches of psoriasis, moreover, are circumscribed, often sharply defined, and are always dry. In eczema there is not infrequently a history of moisture; itching is also generally an annoying symptom, much more marked than in psoriasis.

The papulo-squamous syphiloderm at times closely resembles psoriasis, especially as it occurs upon the palms and soles. Symmetry usually exists in psoriasis, but in syphilis it is often lacking, even in connection with disease of the palms and soles. Apart from the question of a history of syphilis, it will be found that psoriasis generally involves more surface, and in a more disseminate form, than the syphilitic eruption; also, that the scales are whiter, larger, and more copious than in syphilis. The color of the lesions in both diseases is similar, but in psoriasis it is pinker or redder, and free from the yellowish, brownish, ham-colored tint that generally characterizes the later syphilitic eruptions. The infiltration and thickening of the skin in a psoriatic patch are less than in syphilis, this observation being a valuable point in the diagnosis. The character of the inflammatory product in the diseases is different, that of psoriasis being simpler and less dense and firm. Finally, the course of psoriasis is peculiar, the lesions always manifesting the same general characters, often disappearing spontaneously and again reappearing.

Seborrhoea, especially of the scalp, sometimes simulates psoriasis, but the patches in the former disease are ill defined, are not so marginate, and are covered with finer, looser, and fatty scales. The lesions of psoriasis are redder and more infiltrated, and will usually be found to exist also in other localities. The disease may also be mistaken for lupus erythematosus in its early stage. The involvement of the sebaceous glands in almost all cases in the latter affection, the character of the scaling, and the fact that the face is the usual locality attacked, will aid in the diagnosis. Ringworm of the general surface may also bear resemblance to psoriasis, especially to the circular form, but the parasitic disease is more superficial and more marginate, is less scaly, and runs a more acute course. In doubtful cases the microscope should always be employed to determine the question.

TREATMENT.—The disease is rebellious to treatment, sometimes even where the lesions are few and small. It must be regarded as one of the most stubborn and persistent of the inflammatory diseases of the skin, for, while many cases yield readily to either internal or external remedies, the majority will often resist the best-directed therapeutics looking toward a permanent cure. It may often be happily dissipated for the time being, but immunity from relapses is a difficult task. To relieve the patient of the lesions, and, secondly, to prevent, if possible, relapses, should be the aim. To accomplish this demands usually both external and internal treatment. Before entering upon therapeutic measures the case should be viewed from a general standpoint. The condition of the general health should be inquired into, and the cause, if possible, determined. The history of the disease in chronic cases should be learned, and, if a relapse, the behavior of the lesions on former occasions. The influence of the several well-known remedies, such as arsenic internally, and tar, chrysarobin, and the mercurials locally, should also be ascertained. Finally, the acuteness or chronicity of the attack, the activity of the process, the amount of disease present, the locality invaded, and the general circumstances of the patient and the time that can be devoted to the treatment, should all receive consideration.

Among internal remedies, arsenic and its preparations occupy the most prominent position. For the majority of cases this remedy will be found valuable, and, if administered when indicated and in suitable doses for sufficient length of time, good results may be expected. It is not indicated in every case, as is shown by the fact that sometimes, instead of relieving, it aggravates the disease. It should be used tentatively at first, with the view of determining its tolerance and effect, not only upon the skin, but on the general system and alimentary canal. It is a powerful remedy, and should always be employed with due caution. At the same time, there need be no hesitation in prescribing it, or even in employing it for a long period, if attention be directed to its effects. Toxic symptoms should never be permitted to occur. In acute stages, whether in first attacks or in relapses, where the process is active, characterized by marked redness, inflammation, and heat, it should be withheld. At these periods it usually aggravates the disease. The more chronic the process, the more useful will the remedy probably prove.

The drug is generally administered in the form of arsenious acid, liquor potassii arsenitis, and liquor sodii arsenitis. A dose of arsenious acid varies from one-fortieth to one-fifteenth of a grain thrice daily, administered in pill form. The dose of the liquor potassii arsenitis—or Fowler's solution of arsenic, as it is generally termed—varies from one to five minims three times a day, the average dose being two or three minims. It is best to begin with a small dose and gradually to increase the quantity until the maximum dose is ascertained; after which the regular dose may be instituted. Patients, it will be found, vary as to the amount they can safely and beneficially take: in most cases two or three minims continued for a length of time will prove a full dose, while in others four or five minims will be tolerated. It may be given with water, elixir of calisaya, or wine of iron. The practice of prescribing it pure, directing a certain number of drops to be taken at each dose, is objectionable; it does not ensure an accurate quantity or proper dilution, and, moreover, gives the patient unnecessary trouble. A prescription such as the following possesses practical advantages:

Rx.	Liq. potassii arsenitis,	fluidrachm iss;
	Elix. calisayæ,	fluidounce iv.

M.—Sig. One teaspoonful with a wineglassful of water thrice daily, after meals. The dose here is three minims; should it prove too strong, a half teaspoonful of the mixture may be ordered. The toxic effects of arsenic should be borne in mind. Some persons are very susceptible to the remedy, half-minim or one-minim doses sometimes causing unpleasant symptoms. The usual ill effects consist of erythema of the fauces, oedema of the eyelids, injection of the conjunctivæ, watering of the eyes, pains in the head, nausea, sharp pains in the bowels, and diarrhoea, coming on within a few days or a fortnight after beginning treatment. As a rule, they pass away in a few days after ceasing the use of the remedy.

The length of time that arsenic should be given will depend upon its effects upon the general system and upon the disease. In most cases improvement is noticeable within a fortnight, though its use from one to three months is generally necessary to bring about complete recovery; and it is best to continue the medicine in small doses for a month or two longer. Arsenic is a nervine tonic. It acts as a stimulant to the skin, exerting a decided impression upon the cells of the rete mucosum; doing this, without doubt, directly through the nerves, which, as is well known, are abundantly supplied to this structure.

Phosphorus has been used by several dermatologists, but with varying results. It is liable to produce gastric disturbance, and is a disagreeable remedy. Tar, in capsule or pill form, will sometimes prove of value where arsenic and other remedies have failed. From one to three capsules, containing from three to five grains each, may be given for a dose. Carbolic acid has also been extolled by some, especially in chronic cases with slight infiltration. Anderson speaks well of it, and gives the following formula for its administration:

Rx.	Acidi carbolici,	drachm iij;
	Glycerinæ,	fluidounce j;
	Aquæ,	fluidounce v.

M.—Sig. One teaspoonful in a large wineglassful of water before meals.

In some cases, more particularly in strong, hearty, plethoric persons, and in those having a rheumatic or gouty habit, the free use of alkalies proves of great value. In these cases arsenic often aggravates rather than improves the condition, whereas the alkali acts most happily. It may be recommended in acute stages of the disease when the lesions are red, heated, and growing. Liquor potassæ, in from ten to twenty drop doses, diluted with a large wineglassful of water, thrice daily, is the form generally prescribed. Improvement is sometimes noted within a few days. Anderson calls attention also to the value of carbonate of ammonium, in from ten to thirty grain doses, in like cases. The acetate of potassium, in thirty-grain doses, may also be referred to as being sometimes useful.

Local treatment may now be considered. This is of great value, and should be instituted in all cases, either alone or in conjunction with internal remedies, according to the case. Sometimes it may be directed alone with good results, more particularly in chronic, sluggish cases where the lesions undergo but little change from time to time and are unaccompanied by subjective symptoms. Before prescribing certain points should be ascertained. The duration of the disease; the extent of the eruption, including the number and size of the lesions, and their acuteness or chronicity; the locality involved; the circumstances and the age of the patient; and the time that can be given to the treatment,—should all be taken into consideration. In this connection it should be remembered that whatever plan of treatment is adopted, the remedies should be applied thoroughly. The disease at best yields stubbornly, and to secure satisfactory results the importance of employing the agents properly should be insisted upon. This requires in most instances considerable time once, and, in some cases, twice a day. The scales are to be removed first. Where they are thick and adherent, inunction with some simple oil, as olive oil, followed by the use of soap and water, may be employed. Ordinarily, soft soap alone, well rubbed into the lesions with a piece of wet flannel and rinsed off with water, will be found sufficient. A 5 or 8 per cent. alcoholic solution of salicylic acid may be employed for the same purpose. The bath, simple or alkaline—the latter containing, for example, borax—is also frequently of service.

In acute, highly inflammatory cases, where the skin is red, hot, scaling profusely, and the lesions spreading from day to day, soothing applications, as of olive oil, will generally prove most valuable. Instances are sometimes encountered where the use of the simple bath, followed by inunctions of olive oil or one of the petroleum ointments, will prove to be the only treatment tolerated. The majority of cases, however, seeking advice show the disease already well developed and in the chronic stage, and here stimulating remedies are demanded.

One of the most valuable and generally useful remedies is tar, employed in the form of ointment or tincture or in combination with other substances, as, for example, the mercurials or sulphur. The tarry products in common use are pix liquida, or common tar, oil of tar, oil of cade, and oleum rusci (oil of white birch). The chief objection to their employment is the penetrating odor, which is almost impossible to banish. The oil of birch is probably the least objectionable in the list. Officinal tar ointment, full strength or weakened, will be found serviceable. It should be applied with a piece of cloth or stiff brush, well rubbed into the skin, and should be used twice daily, the scales having been previously removed by one or another of the methods indicated. Similar ointments, one or two drachms to the ounce, may in like manner be prepared from any of the other preparations of tar, as, for instance, the oil of white birch. Where an ointment is not desired, the oil of tar, oil of cade, or oil of white birch may be employed, the remedy being thoroughly rubbed or worked into the skin. Attention to the mode of application should always be insisted upon.

Other tarry preparations, such as liq. picis alkalinus, liq. carbonis detergens (the formulæ for which have been given in speaking of the treatment of eczema), diluted, may also be prescribed in some cases with benefit. Hebra's modification of Wilkinson's ointment may be referred to as an energetic and useful compound:

Rx.	Sulphuris sublimati, Ol. cadini, aa.	drachm iv;
	Saponis viridis, Adipis, aa.	ounce j;
	Cretæ præparatæ,	drachm ijss.
M. Ft. ugt.

Another method of using tar consists in the so-called tar bath: the patches are deprived of scales by means of soft soap, after which tar ointment or one of the tarry oils is rubbed in, and the patient then placed in a warm bath for several hours. A stimulating tarry mixture, especially useful in circumscribed, infiltrated, obstinate patches, is composed of equal parts of tar, soft soap, and alcohol. Tar should not be applied over extensive surfaces without cautioning the patient that systemic disturbance, produced by absorption, may possibly occur. In ordinary cases, however, such an accident is very rarely noted. Creasote, turpentine, and acetic acid, remedies similar to tar in their action on the skin, may also be mentioned. The first-named may be used in the form of an ointment, from one to four drachms to the ounce. Turpentine may be applied pure or with oil, one to two or three parts. In some cases thymol in the form of an ointment, from five to thirty grains to the ounce, proves of service. The mercurials may also be referred to, but it may be stated that they are not as valuable in this disease as they are in eczema. The most useful is white precipitate in the form of ointment, from forty to eighty grains to the ounce, which is especially valuable in psoriasis of the scalp and of the face. Lotions of corrosive sublimate will also sometimes be found of service.

The treatment of psoriasis by chrysarobin—or chrysophanic acid, as it was originally termed—may now be referred to. It is a very valuable method of treatment. Care should be exercised in the selection of a reliable preparation, there being considerable difference in the strength, and therefore in the results obtained, of the remedy as found in the shops. Its disadvantages must be mentioned: It is liable to irritate and inflame the skin, causing sometimes an acute dermatitis or a follicular or furuncular inflammation and a variegated purplish or mahogany-colored staining of the skin. The hair, nails, and the linen of the patient also become stained. It may be prescribed in the form of an ointment, from ten grains to one drachm to the ounce of lard or petroleum ointment. The most desirable mode of application, that which is least objectionable, is in the form of a pigment, with flexible collodion or liquor gutta-perchæ, in the same strength as the ointment mentioned. It should be applied with a brush daily or every other day. The following formula, suggested by G. H. Fox, may be given: Chrysarobin and salicylic acid, each ten parts; ether, fifteen parts; collodion, enough to make one hundred parts. Another valuable remedy, having a similar action, to be used in the same manner as chrysarobin, is pyrogallic acid. Like chrysarobin, it stains the skin (a brownish hue), but it possesses the advantage over that substance in not being so irritating. Neither of these remedies, especially the pyrogallic acid, should be applied over extensive surfaces, on account of liability to absorption and systemic poisoning.

Where the patches are not numerous a solution of sulphide of lime may sometimes be used with excellent results, as according to the following formula, known as Vleminckx's solution:

Rx.	Calcis,	ounce ss;
	Sulphuris sublimati,	ounce j;
	Aquæ,	fluidounce x.
Coque ad fluidounce vj, deinde filtra.

This may be perfumed with oil of anise, five or ten drops to the ounce. It may be applied diluted with two or four parts of water or full strength, and is to be rubbed into the skin with a flannel rag, after which the parts are to be bathed with water and some emollient oil or ointment applied.

Treatment is usually effective in removing the lesions, but, unfortunately, in the majority of cases, relapses sooner or later occur. It may be said relapses are the rule. The prognosis will depend upon the case.

Pityriasis Rosea.

Pityriasis rosea, known also as pityriasis maculata et circinata, is an inflammatory disease, occupying chiefly the trunk, characterized by discrete or confluent pinkish or reddish macular or slightly raised lesions varying in size from a small to a large coin. They are rounded in form, but by coalescence may assume irregular shapes and considerable size, as in the case of psoriasis. They are circumscribed, usually clearly defined, superficially seated, of a bright rosy, pinkish, or reddish hue, which sooner or later fades and is followed by yellowish, salmon-colored, or rusty tints. The surface of the lesions is from the beginning dry, and as the process advances furfuraceous or flaky scaling sets in, similar to that observed in tinea versicolor and in tinea circinata. This feature is more marked about the border, the process inclining to recover in the centre and to spread on the periphery, after the manner of tinea circinata. The skin is only slightly, if at all, thickened. At times there is slight burning or itching, but more frequently subjective symptoms are altogether wanting.

The course of the affection is variable, in many instances lasting from one to several months, while in exceptional cases it is more acute. It tends to spontaneous recovery, and is to be viewed as a mild disease, notwithstanding that the lesions at times, by their redness and size, indicate considerable cutaneous disturbance. It is met with in all ages, in our own experience more frequently in adults than in children, and occurs in both sexes and in those possessing average general health. It is one of the rarer cutaneous diseases, and is not contagious.

It is to be distinguished from ringworm of the body, from tinea versicolor, and from the macular syphiloderm, all three of which diseases it at times closely resembles. It possesses some of the peculiar features which characterize the vegetable parasitic diseases, but in some respects it differs from them in its behavior. The microscope fails to reveal fungus. Concerning treatment there is but little to be said, as the process inclines in most cases to spontaneous disappearance. Mildly stimulating ointments or baths, as in eczema, may be prescribed. When involution sets in recovery usually takes place rapidly.

Pityriasis Rubra.

Pityriasis rubra is an inflammatory disease, usually pursuing a chronic course, characterized by redness and abundant and continuous epidermic exfoliation. It usually develops rapidly, beginning as small, red, scaly patches. It may make its appearance on one or more regions, the spots increasing in size rapidly, and coalescing to form large patches. In a variable time the whole or a large portion of the entire surface is involved, the skin being of a pale or violaceous red color and covered with thin whitish or grayish lamellar scales. These are abundant, and are rapidly formed, cast off and replaced by new, the exfoliation being, as a rule, in the form of flakes. Thickening of the skin seldom occurs. The surface when deprived of the scales is hyperæmic and shining in appearance. The disease usually involves the whole surface. Oedema, especially of the limbs, and stiffness of the joints are sometimes observed. The disease is superficial in character, rarely involving more than the upper cutaneous layers, and is always dry. Fissuring is only exceptionally seen.

As a rule, the subjective symptoms are slight, burning and itching, if present, seldom being violent. Symptoms of constitutional disturbance may or may not be present, but chilliness is often complained of. The disease generally occurs in adults, is acute or chronic, usually the latter, with a tendency to relapses. Being a rare affection, the etiology is obscure. Anatomically, there is found more or less marked cell-infiltration of the cutaneous tissues, especially noticeable in the rete and upper layer of the corium. In severe cases the papillæ are not distinguishable; the same may be said of the sweat and sebaceous glands.

Erythematous and squamous eczema and psoriasis bear resemblance to the disease. Its superficial nature, wide or universal distribution, absence of infiltration, character and rapid formation of the scales, and the slight itching or burning will serve to differentiate it from eczema. In psoriasis the whole surface is rarely if ever involved, while there is more or less thickening of the corium, and the scales are thicker and imbricated. It can scarcely be confounded with lichen ruber or with pemphigus foliaceus.

The disease pursues a variable course. It may last for years, with exacerbations, or outbreaks may occur from time to time. Treatment is, as a rule, unsatisfactory. For external treatment applications of a bland or soothing character afford the most relief. Vaseline, cold cream, and oily substances are generally of most service. Stimulating applications seldom prove useful—in fact, will in most cases give rise to discomfort and positive aggravation. In regard to constitutional remedies general indications are to be followed. There is no drug that seems to exert a specific influence.

Dermatitis Exfoliativa.

This term is employed to designate certain cases in which more or less exfoliation is the prominent characteristic, and which cannot be classified under the head of any of the other diseases in which this symptom is noted. These cases have been variously described under the names of general exfoliative dermatitis, recurring exfoliative dermatitis, desquamative scarlatiniform erythema, recurrent acute eczema, acute general dermatitis, and recurrent exfoliative erythema. The affection is characterized by an erythematous inflammation, rarely vesicular or bullous, acute in type, with desquamation or exfoliation of the epidermis accompanying or following its development. There is also usually more or less marked constitutional disturbance, in some instances of a serious nature, and a tendency to relapse and recurrence. It is possible that in some instances the disease could be properly classified under the head of eczema, psoriasis, pityriasis rubra or pemphigus foliaceus.

Lichen Ruber.

Lichen ruber is an inflammatory disease, characterized by small flat and angular or acuminated, smooth and shining or scaly, discrete or confluent red papules, having a distinctly papular or papulo-squamous course, attended with a variable degree of itching. Two varieties are met with—the plane (lichen ruber planus) and the acuminate (lichen ruber acuminatus), the first of which occurs much the more frequently in this country. The acuminate variety is met with chiefly in Austria, where it was first described by Hebra: it is very rare in the United States, only a few authentic cases being on record. In lichen ruber planus the papules vary in size from a pinhead to a pea, and are peculiar in that they are not rounded, but are quadrangular or polygonal in shape. In their early stage they have a smooth, glazed surface, and are free of scales, but later they become papulo-squamous. They are more or less flattened on their summits, and show slight umbilication with whitish puncta. They are of a dull pinkish, reddish or violaceous color, the hue varying with the individual, age, and locality. As a rule, they are numerous, and occur in variously-sized aggregations, the distribution scarcely amounting to grouping. They tend to coalesce and form patches, which are slightly elevated, flattened, and uneven, the lesions when crowded together having a mosaic pattern. In lichen ruber acuminatus the papules are smaller, pointed, scaly, and disseminated, showing no disposition to group. This variety of the disease spreads rapidly, pursues a chronic course, and is a more serious affection, sometimes terminating fatally.

Lichen ruber planus usually presents itself upon the extremities, especially upon the flexor surfaces, the forearms and wrists and backs of the feet being favorite localities. Not infrequently it appears in the form of short or long narrow bands, following the natural lines of the skin, and sometimes nerve-tracts. The course of the disease is generally slow, extending over months. Occasionally, however, especially where the lesions are acute and very numerous, it is comparatively rapid. New papules continue to show themselves from to time, the older ones disappearing by absorption, leaving persistent marked reddish or brownish pigmentation, which is to be regarded as a characteristic symptom.

The etiology of the disease is at times obscure, although, according to our experience, patients usually show signs of impaired nutrition or nervous depression, arising from varied causes, as, for example, overwork or shock. It occurs at all periods of life, but is usually met with at middle age, and is more common in women than in men. Pathologically, the process is considered an inflammation of a chronic character, accompanied by more or less alterative changes in the structure of the skin, involving the several layers as well as the follicles. The lesion is always of a papular type. Later investigations (Robinson) into the anatomy of the lesions of lichen ruber acuminatus and lichen ruber planus are apparently indicative of the distinct nature of the two varieties, the former being considered a paratypical keratosis, leading to retrograde changes and atrophy, and the latter an inflammatory process occurring in and about the papillæ and upper part of the corium.

In the diagnosis of lichen ruber the papular syphiloderm, lichen scrofulosus, psoriasis, and papular eczema are to be excluded. The irregular and angular outlines of the lesions of the plane variety, taken with their flattened, slightly umbilicated, smooth, or scaly summits and the dull-red or violaceous hue, are sufficiently characteristic. The evolution of a patch of psoriasis is entirely different from that of this disease, the former appearing as small spots and enlarging by peripheral growth, the patches of the latter resulting from aggregations of lesions. In papular eczema the papules are rounded, bright-red in color, intensely itchy, and have a different history and course. The prognosis of lichen ruber planus is generally favorable, although some cases are exceedingly rebellious. According to Hebra, in the severe forms of lichen ruber acuminatus, if neglected or improperly treated, a fatal result may ensue.

A general tonic plan of treatment is almost always indicated, such remedies as iron, quinia, strychnia, and the mineral acids proving of benefit. Arsenic exercises in many cases a specific influence. When the general health is much reduced arsenic fails, as a rule, to benefit until the patient's condition is brought back to its normal tone. The remedy should be given in tolerably large doses, and continued until the lesions have entirely disappeared. On account of the itching and discomfort experienced, external applications are demanded. The various antipruritic remedies mentioned in the treatment of eczema may be employed. Alkaline baths are useful. Unna has reported a few instances of cure of well-developed cases of the disease by the use of an ointment composed of two ounces of oxide-of-zinc ointment, forty grains of carbolic acid, and from one to two grains of corrosive sublimate. Tarry applications, especially in the form of lotions, often prove of service, the liquor picis alkalinus and the liquor carbonis detergens being the preparations commonly employed.

Lichen Scrofulosus.

Lichen scrofulosus is a chronic disease characterized by milletseed-sized, flat, reddish or yellowish, more or less grouped, desquamating papules, unaccompanied by itching and occurring in those of a scrofulous disposition. The lesions, of a pale red or yellowish color, are usually numerous, are seated about the hair-follicles, and show a decided tendency to group, giving rise to patches of variable size and of a rounded or crescentic shape, which sooner or later become covered with minute scales. They are always small; are seen usually about the abdomen and chest, and exceptionally about the limbs; are chronic in character; and as a rule, are unaccompanied by itching. Pit-like, atrophic depressions may or may not follow the disappearance of the lesions.

The affection is not uncommon in Austria, but in this country it is practically unknown. It was first described by Hebra. It is more common in males, and is seen chiefly in children and young people. Symptoms of a scrofulous habit, such as glandular enlargements, ulcers, bone disease, or lung complaint, are found associated in almost all cases. According to Kaposi, the process is an inflammation and cell-infiltration in and about the hair-follicles, the sebaceous glands, and papillæ around the apertures of the follicles. Each papule, as may be seen on close examination, has its seat about the opening of a follicle, the inflammation beginning around the vessels and at the bases of the follicles and glands, and subsequently the cellular infiltration invading the interior of these structures to such an extent as to give rise to distension and elevation into papules.

It is to be differentiated from papular eczema, lichen ruber, the miliary papular syphiloderm, and keratosis pilaris. According to Hebra, cod-liver oil, employed internally and externally, is the remedy to which the disease readily yields.

Eczema.

SYMPTOMS.—Eczema, known popularly as tetter, is the most important and the commonest of the diseases of the skin. It may be defined as an inflammatory, non-contagious disease of the skin, characterized in the beginning by erythema, papules, vesicles or pustules, or a combination of these lesions, pursuing an acute or chronic course, accompanied by infiltration and itching, terminating either in discharge with the formation of crusts, in absorption, or in desquamation. The disease is multiform in character, and is capable of manifesting itself in a great variety of forms; and for this reason any definition that is attempted must be broad enough to comprise all of its essential features. It may begin as a circumscribed or diffuse small or large erythematous patch, which may remain dry and become scaly, or may pass into a state of moist exudation with crusting. It may also begin with vesicles or pustules, which soon rupture, giving rise to a red, moist, oozing, weeping, excoriated surface pouring forth a scanty or abundant fluid, gummy discharge, which rapidly dries to crusts. Instead of a moist discharging surface the skin may become dry, scaly, thickened, and more or less fissured. In other cases small papules, discrete or confluent, in patches or disseminated, form, constituting papular eczema. Finally, several or all of these lesions may occur together or in the course of the process. Thus, it will be observed, the disease is markedly multiform and protean. Not infrequently it is capricious in its manifestations both as to the nature of the lesions and as to the evolution. Several varieties of the disease may appear simultaneously on one or on different regions.

Infiltration is one of the most marked features, and is present in varying degree. In the discharging varieties the fluid exuded is generally considerable and often excessive, giving rise to abundant crusting. In the papular variety the exudation is plastic in character, causing thickening of the skin, followed by more or less induration. Scaling is also frequently a prominent symptom, giving to the condition known as squamous eczema its peculiar features. Itching, usually marked, is an almost constant symptom, varying in degree. As a rule, it is an annoying feature of the disease, causing the patient to scratch in spite of good resolutions. In some cases, as in the erythematous variety, the sensation is of burning rather than itching, or it may be a combination of the two. Occasionally the locality affected is the seat of pain. The course of the disease is extremely variable. As a rule, it inclines to chronicity. Relapses are common, especially in adults and elderly persons. There are many cases on record, however, where, recovery having taken place, the individual remains free of the disease. The several varieties may now be considered.

Eczema Erythematosum.—This begins as an erythematous spot or macule, or as a patch, variable as to color, size and outline. It is most frequently met with upon the face, occupying a portion or the greater part of this region, usually in the form of several discrete or confluent patches. It generally begins as a coin-sized, ill-defined lesion, rounded or irregular in outline, of a pale-red hue, accompanied by itching and burning. The patch at first may be insignificant, but from time to time it spreads and becomes redder, thicker, and the surface slightly scaly. When fully developed, as is perhaps most frequently encountered upon the forehead, it consists of a more or less broken-up patch of considerably thickened somewhat swollen skin of a mottled or streaked pale-reddish, yellowish-red or violaceous hue. The surface is dry or excoriated and very slightly moist in places, and is covered with a thin film of dried, ragged epidermis or with thin adherent scales. The disease varies from time to time, being paler and less marked one week than another. Scratch-marks and excoriations, punctate or linear, are generally present, indicative of the scratching and rubbing to which the skin has been subjected. As stated, several patches generally exist, the disease tending to symmetry. The forehead, sides of the nose, and cheeks are the localities most frequently invaded, but other regions, as the back of the neck, axillæ, and flexures, are all common seats.

Its course is variable. As a rule, it inclines to assume chronicity, varying in intensity from time to time, or even disappearing and reappearing at irregular intervals. It is exceedingly liable to relapse, perhaps more so than any other variety. Having established itself, it may remain erythematous in character or may pass into other varieties of the disease. Thus, a moist or weeping surface may take the place of the erythema, followed by crusting, giving rise to eczema madidans, or eczema rubrum. Not infrequently the patch becomes markedly scaly, and continues in this form, producing eczema squamosum. When it occurs in regions where two opposing surfaces come in contact, as under the mammæ, between the nates, and about the genitalia, an excoriated moist condition is produced known as eczema intertrigo, or eczema mucosum.

Eczema Vesiculosum.—This may be regarded as the typical and perfect expression of the disease. It is characterized in the beginning by a diffuse redness with puncta, which rapidly become small pinpoint- to pinhead-sized, more or less perfect vesicles, accompanied with heat and usually intense itching. As a rule, the lesions are small and are discrete or confluent. They soon mature and burst, the fluid oozing forth on and over the surface, forming yellowish honeycomb-like scanty or abundant crusts. The skin of such a patch is generally slightly swollen, and at times considerably infiltrated with serum (eczema oedematosum). The disease may thus develop upon a small surface, or, as is oftener the case, over an extensive area, as, for example, the flexor surface of the forearm. There is no disposition for the lesions to group, but they incline to appear in areas, a large patch being usually composed of several smaller patches. The amount of serous fluid poured forth is often great, large bulky crusts forming which in time completely mask the skin beneath. The exudation may take place rapidly in the course of a few days and cease, or it may continue, oozing slowly from day to day or with intermissions from time to time indefinitely, constituting acute, subacute or chronic vesicular eczema. The amount will, moreover, depend somewhat upon the locality involved and whether the disease be properly treated or irritated.

Vesicular eczema may show itself typically, the whole of the affected skin taking on vesicular formation, or, as frequently happens, it may be associated with other varieties of the disease, more particularly pustules and papules. Abortive vesicles and vesico-pustules and vesico-papules are common, occurring here and there mixed with the vesicles and about the circumference of the patch. The amount of surface invaded varies. The disease often manifests itself in different regions simultaneously, as, for example, upon the neck and flexor surfaces of the forearms or upon the trunk and the thighs. In infants the face is the locality usually attacked, constituting the so-called crusta lactea, or milk-crust, of former writers. While the disease tends to manifest itself upon the thin skin of the flexor surfaces of the extremities and upon the face, such is not always the case, for the hands and fingers are also often invaded.

Eczema Pustulosum.—This variety of the disease (designated by some writers eczema impetiginosum) is closely allied to the preceding variety. The lesions may develop as pustules or may become pustular from pre-existing vesicles; both lesions are not infrequently found together, although one of the two will usually predominate. In pustular eczema the swelling, heat, and itching are seldom so marked as in the vesicular variety, and the lesions are generally larger and firmer. As in the case of the vesicles, they rupture and dry, forming yellowish or greenish bulky crusts. This variety is most frequently encountered about the face and scalp, and in those—especially young people—who are strumous, ill-nourished, or in a depraved state of health.

Eczema Papulosum.—Eczema papulosum is characterized by small, rounded or acuminated papules about the size of a pinhead. Sometimes they are well defined and circumscribed, but more frequently they possess no sharply-marked outline or form. They are reddish in color, the tint varying with the individual and with other circumstances, and are usually discrete, although not infrequently they are so numerous and so crowded together as to coalesce and form patches or aggregations of disease, which often show considerable infiltration. They begin as papules, and usually preserve this character throughout their course. Vesicles or vesico-papules not infrequently coexist. Sooner or later the lesions disappear, but are usually replaced by others, the process in this manner continuing its course for weeks or months. The itching is in almost all cases severe and persistent, the patient generally scratching himself to the extent of producing excoriations and blood-crusts. Papular eczema shows a preference for certain regions, notably the extremities, especially the flexor surfaces. The face is seldom attacked. It is one of the most obstinate varieties of the disease.

In addition to the principal varieties of eczema, just described, there are other forms of the disease which on account of their peculiar features require mention. Of these eczema rubrum, or eczema madidans, may first be spoken of. It is to be viewed as a secondary condition resulting from one or another of the primary varieties. Thus it usually follows eczema vesiculosum or pustulosum. It is characterized by a reddish, moist or discharging surface, the serum, sometimes bloody, usually exuding freely and forming thick yellowish or brownish crusts, together with more or less thickening of the skin and other secondary changes. In other cases discharge is wanting. The condition varies with the stage of the process and with other circumstances: at one time the red, inflammatory dry or oozing skin is the most striking feature, while in other cases this is completely obscured by large, diffuse masses of crust. It may occur upon any region, but it is most frequently met with on the legs, especially in adults, and more particularly in elderly people. It is usually chronic in its course, and may continue for years, better and worse from time to time, but usually evincing no disposition to spontaneous recovery.

Another clinical form of the disease is known as eczema squamosum, which frequently has been preceded by the erythematous variety, and in many cases is to be viewed as a stage of that variety. It may also follow other varieties. It appears in the form of reddish, dry, more or less infiltrated, scaly patches, the amount of scaling being variable. The scales are usually small or fine, and as a rule are scanty. The condition is generally chronic, and is often met with on the scalp.

Fissures, superficial or deep, are not infrequently met with in eczema, usually in the chronic or recurrent forms of the disease, and may be so pronounced as to give rise to the so-called eczema fissum. This is often seen about the fingers and hands, especially the palms. In localized infiltrated patches of chronic eczema a peculiar warty condition is occasionally met with, which is known as eczema verrucosum; or if simply hard, rather than wart-like, eczema sclerosum.

Eczema is divided into acute and chronic, the several forms of the disease being so different in their clinical pictures as to demand such a division, which relates rather to the pathological changes than to time. Thus the disease may show acute symptoms throughout its course, or, on the other hand, may in the beginning take on a chronic action. As a rule, it tends to chronicity, secondary changes in the skin usually manifesting themselves early in the course of the process.

ETIOLOGY.—Eczema is the commonest of the cutaneous diseases, and seems to be of more frequent occurrence in this country than in Europe. It is met with among all classes of society and at all ages. Individuals with light hair and florid complexions are more often subjects of the disease than those of the opposite temperament. Not infrequently the disease is hereditary, although examples are very common in which no such history obtains. So-called eczematous subjects, in which at longer or shorter intervals throughout life and under variable conditions the disease manifests itself, are of frequent occurrence in practice. The state, though well known clinically, is difficult to define, consisting of a peculiar inherent condition of the system at large and of the skin itself which under favorable circumstances permits the disease to assert itself from time to time. The association in some cases of chronic bronchitis and allied affections of the respiratory tract with eczema, and the clinical observation that as one disease improves the other becomes worse, has led some dermatologists to regard eczema as being catarrhal in its nature.

The constitutional causes which may produce the disease are numerous, and are worthy of careful study as bearing directly upon the treatment. Disorders of the digestive tract, including dyspepsia in its many forms and constipation, are not infrequently found to be the exciting cause of an attack, while faulty excretion through the several emunctories, and the existence of a gouty or rheumatic disposition, may all prove potent factors. Deterioration in the tone of the system, arising from varied causes, with impaired nutrition—as seen, for example, during pregnancy and lactation—is sometimes accompanied with an outbreak of the disease, while nervous exhaustion and other neurotic states, as is now well established, are not infrequently active causes.

In some cases excitants, external or internal—as, for example, cutaneous irritants and intestinal worms—may determine an outbreak. In like manner, dentition and vaccination may call forth the disease. Among the local causes producing the so-called artificial eczemas the preparations of mercury, sulphur, croton oil and tincture of arnica are most notable. Contact with the several varieties of the rhus plant, though usually producing a peculiar dermatitis, may in eczematous subjects provoke a genuine eczema. Heat and cold, especially the rays of the sun, are also factors to be considered, while it is well known that the disease in many instances is influenced by the seasons, being, as a rule, worse in winter than in summer. There are many subjects who suffer only in winter. In sensitive skins water, soap, alkalies and acids, all prove more or less injurious, giving rise to harshness or chapping of the skin, and sometimes to eczema. In the same manner the presence of parasites and the consequent scratching are productive of more or less simple dermatitis, and in eczematous subjects the disease under discussion. Eczema is not contagious, a question which is frequently asked by the patient.

PATHOLOGY.—The changes which occur in the skin in the various eczematous conditions are somewhat different as the process is of short or long duration and mild or intense in character. In all cases hyperæmia and exudation, constant symptoms of all inflammations, are present, varying according to the activity and duration of the process. The rete mucosum is also involved in all cases, being oedematous and infiltrated. In the erythematous form the blood-vessels of the papillary layer are dilated, exudation and congestion as well as increasing activity of the rete taking place. In the papular variety the process is mainly limited, primarily at least, to the follicles. The exudation is confined to small circumscribed areas and gives rise to papular elevations. In the vesicular variety fluid exudation occurs in the upper strata of the corium and in the rete, and the formation of vesicles results. The contents of the vesicles consist of a clear liquid containing a few rete-cells and later some pus-corpuscles. In the pustular form the process is more intense in character, and the cell-emigration and multiplication increased. In the chronic forms of the disease the infiltration involves the deeper parts of the corium and even the subcutaneous tissues, which, in addition to the new connective-tissue formation sometimes taking place, gives rise to considerable thickening. The papillæ are enlarged, and at times are considerably hypertrophied, as exemplified by the so-called verrucous eczema. The exudation and cell-infiltration are especially marked along the blood-vessels. In squamous eczema the blood-vessels of the corium and papillæ are dilated, and these parts infiltrated with round cells and changed connective-tissue corpuscles. Pigmentation may take place in the deeper layers of the rete and in the corium, especially about the vessels. The pathological process in eczema seems to have its starting-point in disturbance of the capillary circulation, the origin and nature of which it is difficult to determine.

DIAGNOSIS.—It must be remembered that the disease is capable of appearing in a multitude of forms, some of which are so dissimilar in their clinical features as sometimes to occasion embarrassment in the diagnosis. No other disease except syphilis manifests itself in such a variety of forms. In all cases where the lesions are varied or where they are ill defined the eruption should be viewed as a whole, when the characters of the process will usually be apparent. Thus a variable amount of infiltration, with swelling or thickening, is almost always present, the skin being more or less red and inflammatory. Moisture or positive discharge, with slight or extensive crusting, is a frequent though by no means a constant symptom, and when present is characteristic. Itching is experienced in almost all cases, and is generally a marked symptom. In some cases heat and burning are complained of.

Cases are occasionally met with in which the eruption bears some resemblance to erysipelas and scarlatina, but the absence of systemic symptoms in eczema would prevent an error in diagnosis. Papular eczema may at times simulate the papular manifestations of urticaria, especially in children, but in ordinary cases there is no likelihood of confounding the diseases. Herpes zoster in its early stage may bear a resemblance to a patch of vesicular or papular eczema, but the grouping of the lesions and the burning or pain in the former disease will generally prove sufficient to distinguish them. Seborrhoea, especially as it occurs upon the scalp, may be mistaken for squamous eczema, but in seborrhoea the scales are greasy, containing more or less sebaceous matter, and the distribution of the disease is usually more uniform than in eczema; and, finally, in the latter affection the skin is reddish, inflamed, often thickened, and usually itchy.

Psoriasis and squamous eczema frequently simulate each other, and in some instances the resemblance is so close that error in diagnosis may readily occur. Both diseases are common, and are liable to invade all regions. In eczema the patches usually fade away into the healthy skin, whereas in psoriasis their margins are generally sharply defined. In eczema the scales are usually scanty, thin and small; in psoriasis they are abundant, whitish or silvery, large and imbricated. These points, taken in connection with the history of the case, will serve to aid in the diagnosis.

The rare disease pityriasis rubra may be confounded with squamous eczema, but the peculiar abundant, thin, papery scaling of this affection is not met with in eczema. Sometimes papular eczema resembles lichen ruber, but with attention to the characteristics of the lesions in the latter disease the diagnosis in most cases offers no difficulty. The resemblance of tinea circinata to eczema in some cases is to be borne in mind, but in the latter disease there is wanting the tendency to circular and marginate forms so characteristic of the parasitic disease. The microscope should always be employed in doubtful cases. Both tinea sycosis and sycosis may be confounded with eczema of the hairy portion of the face, but the follicular involvement in the former affections is the diagnostic point to be remembered. Scabies in its early stages often looks much like papular, vesicular, or pustular eczema, and care should in all cases be taken to make a correct diagnosis. The history of scabies, the regions involved, the distribution and multiformity of the lesions, and the presence of the parasite, as shown by the extraction of the mite or by the burrow, are all points to be duly inquired into. Eczema seldom simulates syphilis. They are most likely to be confounded one with the other when occurring in chronic forms about the scalp and the hands and feet.

PROGNOSIS.—Under favorable circumstances eczema is always a curable disease. In the prognosis of the affection as regards the probable length of time required to remove it an opinion should be guardedly expressed. It depends upon the extent of the disease, the duration, the attention the patient can give to the treatment, and the ease with which the exciting causes can be removed. Where the disease is the result of nervous prostration, as seen in those who have been mentally overworked from whatever cause, the cure will take place slowly, and many relapses will probably occur before positive recovery sets in.

Where the exciting causes cannot be entirely removed recovery is slow, and a complete or permanent cure is sometimes impossible. Thus in eczema about the hands in those who are obliged to wet or wash the parts frequently, to handle chemicals, dyestuffs, or otherwise expose the parts to the action of deleterious substances, a cure of the affection is exceedingly difficult. The same may be said in regard to eczema of the scrotum and neighboring regions, where the natural heat and moisture are constant and exciting, and to a certain extent irremovable, causes. In eczema of the lower limbs depending upon a condition of varicose veins the disease is obstinate. On the other hand, there are many cases of acute eczema met with which run a rapid course and end favorably. Eczema of the face, lips, and other exposed parts is, for evident reasons, apt to prove rebellious. In each case, then, all these points are to be taken into consideration in rendering an opinion upon the probable duration and termination of the disease.

TREATMENT.—There is no other disease of the skin which requires so thorough a knowledge of general medicine for its successful management as does eczema. The exciting cause of the affection is to be ascertained and to be properly treated. It is the specialist who has as the groundwork a comprehensive knowledge of general medicine who is best able to cope successfully with the disease under consideration. In the management of eczema both constitutional and local treatment will be necessary. It is true that some authorities depend upon external applications alone, but, judging from our own experience, a combination of external and internal treatment promises decidedly better results. In those cases in which the exciting cause has disappeared and the eczema persists from habit, as it were, the simplest local treatment may bring about a cure. But these are, unfortunately, exceptional instances. In almost all cases external treatment is indispensable.

Constitutional Treatment.—There are no specific remedies for eczema. Arsenic, it is true, acts in some cases admirably, but these instances are rather exceptional; the proportion of cases in which it may be prescribed with the hope of advantage is not very large. It not infrequently proves positively injurious. It is in the dry, scaly, and papular forms of the disease, and especially those in which the inflammation is of a low grade, that it acts most happily. The drug is to be given in sufficiently large doses to obtain slight evidences of its physiological action; toxic effects are to be avoided. It should never be given in acute cases. In small doses (one or two minims of Fowler's solution) arsenic is frequently of value as a tonic, acting then in the same manner as other tonics. When the physiological effects of the drug are desirable the dose should be gauged accordingly, beginning with two or three minims three times daily, and increasing gradually up to five or six or even more minims; as soon as the action of the drug becomes evident, as shown by a slight conjunctival injection and puffiness about the eyelids, the dose should be diminished and its administration continued for an extended period.

In the management of eczema attention should be given to the subject of diet. The food should be nutritious but plain, avoiding such articles as pork, salted meats, pastry, cabbage, gravies and sauces, pickles, cheese, condiments, beer and wine, etc. In anæmic and debilitated individuals a moderate use of stimulants may prove useful. Fresh air and exercise are often of aid in the treatment. The various remedies to be employed internally will depend upon the cause or causes which have brought about the attack. In robust persons and those of full habit laxatives or purgatives will prove of positive service. A useful formula for such cases, and also for those in whom constipation is present, is the following:

Rx.	Magnesii sulphatis,	ounce iss;
	Potassii bitartratis,	drachm iv;
	Sulphuris præcip.,	drachm ij;
	Glycerinæ,	fluidrachm ij;
	Aquæ menthæ pip., q. s. ad	fluidounce iv.

M.—S. A tablespoonful in a tumblerful of water a half hour before breakfast. If this dose of the mixture fails to produce one or two free evacuations daily, then as much as double the quantity may be taken or a dose may be taken morning and evening. In many cases an aperient combined with a tonic is indicated. This is the case in those who are dyspeptic and debilitated, and in whom there is more or less constipation present. The following formula is available for such cases:

Rx.	Magnesii sulphatis,	ounce iss;
	Ferri sulphatis,	gr. iv;
	Acidi sulphurici dilut.,	fluidrachm ij;
	Aquæ menthæ pip.,	fluidounce iv.

M.—S. A tablespoonful in a tumblerful of water a half hour before the morning meal. In some cases the acid is contraindicated, and then the mixture may be prescribed without this ingredient. Although this formula is found to agree with most individuals, there are some who are either not able to take it or in whom it is found to aggravate the dyspepsia or to cause more or less gastric disturbance. In these cases the following formula has proved of value:

Rx.	Ext. cascaræ sagradæ fl.,	fluidrachm iv;
	Acidi muriatici dilut.,	fluidrachm ij;
	Elix. calisayæ,	fluidounce iij drachm ij.

M.—S. A teaspoonful in a large wineglassful of water before or after meals. The laxative effect of the mixture is more marked when it is taken twenty or thirty minutes before meals. In some cases it will be found necessary to increase the proportion of the cascara sagrada, while, on the other hand, not infrequently a less quantity may be sufficiently active. In acute eczema laxatives, especially the salines, are of great service. The various mineral-spring waters may also be mentioned as useful. Of these Friedrichshall, Hunyadi Janos, the Hathorn and Geyser Springs of Saratoga, are the most serviceable. A tonic aperient where there is only slight constipation is the following:

Rx.	Sodii phosphatis,	drachm vj;
	Acidi phosphorici dilut.,	fluidrachm iij;
	Syr. zingiberis,	fluidounce j;
	Infus. gentianæ comp.,	fluidounce iiss.

M.—S. A tablespoonful in a wineglassful of water three times daily.

The following aperient mixtures may be prescribed for children:

Rx.

Syr. rhei aromat., Olei ricini, aa.

fluidounce ij.

M.—S. A teaspoonful two or three times daily, according to the effect.

Rx.	Ext. cascaræ sagradæ fl.,	fluidrachm ij;
	Syr. aurantii cort.,	fluidrachm vj.

M.—S. A teaspoonful in water at bed-time.

Occasional laxative doses of calomel are often valuable both in children and adults. Dyspepsia, if present, should receive appropriate treatment. The bitter tonics, mineral acids, alkalies, and the various artificial aids to digestion may be employed as seem indicated. Where malaria is suspected, full doses of quinine and small doses of arsenic should be prescribed. In these cases, as also in those in which there may be anæmia or chlorosis, the preparations of iron may be prescribed. If a gouty diathesis appears to be at the foundation of the attack, purgatives, the alkalies, and colchicum are to be advised. In these cases, if of an acute or subacute type, the following formula is serviceable:

Rx.	Potassii acetatis,	ounce j;
	Liquor, potassæ,	fluidrachm vj;
	Aquæ menthæ pip.,	fluidounce iij drachm ij.

M.—S. A teaspoonful in a half gobletful of water an hour before meals. In cases of a chronic type the following may sometimes prove of benefit:

Rx.	Potassii iodidi,	drachm v gr. xx;
	Liquor. potassii arsenit.,	fluidrachm iss;
	Liquor. potassæ,	fluidrachm vss;
	Aquæ,	fluidounce iij.

M.—S. A teaspoonful in a half gobletful of water after meals.

In some gouty and rheumatic cases wine of colchicum may be added to the above two prescriptions with advantage. Where a scrofulous tendency exists cod-liver oil is a valuable remedy; also in all cases of impaired nutrition, in moderate doses, long continued, it will often prove useful, especially in children.

External Treatment.—The local treatment of eczema is based upon the pathological conditions present. The acute disease requires entirely different management from that employed in chronic cases. The stage of the disease and the amount of skin involved, whether in the form of a circumscribed patch or as a diffuse eruption, are points to be taken into consideration in the selection of a remedy and the mode of its application. The several varieties, the erythematous, papular, vesicular, pustular and squamous, and also the secondary forms rubrum, fissum and verrucosum, all demand applications appropriate to the condition. In acute erythematous or vesicular eczema caution is to be exercised in the selection of remedies. Only the milder applications, as a rule, are tolerated. That which will agree with one may not agree with another. It is advisable to try the remedy upon a small portion of the diseased surface to see if it is acceptable to the skin. In these varieties also soap and water should, as much as possible, be avoided.

For the average case, especially of the vesicular variety, the most successful plan of treatment is with lotio nigra and oxide-of-zinc ointment. The lotion is to be dabbed on by means of a sponge or cloth every three or four hours, ten or fifteen minutes at a time; as soon as dry a small quantity of oxide-of-zinc ointment is to be gently smeared over. In many instances this method furnishes immediate relief to the itching, and under its use the inflammation is soon relieved. Powdering the surface with dusting-powder will sometimes afford ease, starch or lycopodium powder, either alone or together, equal parts, being useful. Subnitrate of bismuth is also of value, proving a more stimulating powder. In some cases a half drachm of finely-powdered camphor to the ounce may be advantageously added to one or another of the simple powders. Powdered Venetian talc is also sometimes useful alone or in combination with starch, a drachm or two of the former to the ounce of the latter. Dusting-powders should in all cases be used freely and often, their chief object being to afford protection to the inflamed surfaces.

Another lotion frequently employed in acute cases of vesicular eczema with free discharge, especially in cases where there is oedema or where the skin is irritable, is one containing calamine and zinc oxide; for example,

Rx.	Pulv. zinci oxidi, Pulv. calaminæ, aa.	drachm iiss;
	Glycerinæ,	fluidrachm j;
	Liq. calcis, Aquæ rosæ, aa.	fluidounce iij.

The following may also be mentioned as being useful in similar cases:

Rx.	Pulv. calaminæ, Cretæ præparatæ, aa.	drachm j;
	Acidi hydrocyanici dilut.,	fluidrachm ss;
	Glycerinæ,	fluidrachm ij;
	Aquæ, Liq. calcis, aa.	fluidounce iij.

These lotions, as will be seen, contain more or less insoluble powder, and they are to be applied in the same manner as advised when speaking of the use of black wash.

There are other lotions which are often of service. Carbolic acid, one or two drachms to the pint of water, to which may be added a like quantity of glycerin, is in many cases of value, especially in those in which itching is marked. A saturated solution of boric acid, with or without the addition of glycerin, may also be employed in these cases, especially in erythematous eczema. It is one of the most useful of the milder remedies. In this variety, particularly when confined to the flexures, constituting eczema intertrigo, the following formula containing acetate of lead may be prescribed in some cases with benefit:

Rx.	Plumbi acetatis,	drachm ss;
	Acidi acetici dil.,	fluidrachm ij;
	Glycerinæ,	fluidrachm iv;
	Aquæ, q. s. ad	fluidounce vi. M.

In those cases where lotions do not seem to act happily a mild ointment of salicylated suet (2 or 3 per cent. strength) will often relieve the condition. The fluid extract of grindelia robusta, one or two drachms to six ounces of water, seems to suit some cases, but it should be applied cautiously, as in some instances it tends to aggravate. Weak alkaline lotions, a drachm of the bicarbonate of sodium or borate of sodium to the pint of water, and a drachm of the solution of subacetate of lead to the pint, may be also mentioned. Tarry lotions of weak strength are sometimes useful. A drachm of the liquor carbonis detergens to two or four ounces of water, or the liquor picis alkalinus, a drachm to the half pint of water, may afford relief. The former tarry preparation is made by mixing together nine ounces of tincture of soap-bark² and four ounces of coal-tar, allowing to digest for eight days and filtering. The formula for the liquor picis alkalinus, the other tarry preparation referred to, is as follows:

Rx.	Potassæ,	drachm j;
	Picis liquidæ,	drachm ij;
	Aquæ,	fluidrachm v. M.

A lotion made up of two drachms of zinc oxide, two drachms of glycerin, six drachms of lead-water, and three ounces of infusion of tar is sometimes valuable in the erythematous form.

² Tincture of soap-bark is made by digesting for eight days one pound of soap-bark in one gallon of alcohol.

As a rule, ointments are not so well borne in acute eczema as lotions, but as soon as the more acute symptoms have subsided, and in some instances even during the acute stage, they may be used with benefit. The oxide-of-zinc ointment is well known, and is one of the most soothing; sometimes it is well to reduce the proportion of zinc oxide. Oleate of zinc, in the proportion of one or two drachms to the ounce of vaseline or lard, is somewhat similar to oxide-of-zinc ointment, but is more astringent and stimulating. The oleate of bismuth, pure or with an equal part of vaseline or other fatty base, is also at times of service. The same may be said of the oleate of lead melted with an equal part of lard or vaseline, in this form constituting a soothing and astringent application similar to the well-known diachylon ointment. The latter ointment, if properly prepared, is in the subacute stage often exceedingly valuable. The same objection to this holds as with the different oleates named—that is, the difficulty of securing properly-made preparations. Many are vaunted as such, but our experience is that good preparations are exceptional, and those furnished, instead of acting as expected, often give rise to irritation or marked aggravation. For the acute and subacute stages of the disease the ordinary cold-cream ointment may be in some cases advantageously prescribed. An ointment of equal parts of diachylon plaster and one of the petroleum ointments, as vaseline, constitutes an elegant preparation, useful when a mild, soothing application is called for.

A paste made up as follows may also be recommended for the subacute condition, and at times suits even during the active inflammatory stage:

Rx.	Pulv. zinci oxidi,	ounce ss;
	Mucilag. acaciæ, Glycerinæ, aa.	fluidounce j.

M.—S. Apply with a brush two or three times daily. To this formula, if there is considerable itching present, carbolic acid or salicylic acid in the proportion of 2 per cent. may be added. Glycerite of tannic acid sometimes proves of value, especially in the erythematous varieties of the disease, more particularly when occurring about the face. In like cases glycerite of subacetate of lead may be prescribed. The following is Squire's formula: Acetate of lead, 5 parts; litharge, 3½ parts; glycerin, 20 parts, by weight. Mix and expose to a temperature of 350° F., and filter through a hot-water funnel. The fluid resultant contains 129 grains of the subacetate of lead to the ounce, which is to be diluted with from two to six parts of glycerin or with water. This preparation may sometimes be used with benefit in chronic eczema of the legs applied on strips bound on with a bandage. In these cases the following paste, suggested by Unna, proves useful:

Rx.	Kaolini, Ol. lini, aa.	drachm vj;
	Zinci oxidi,	ounce ss;
	Liq. plumbi subacetat.,	fluidounce ss. M.

This is painted on and allowed to dry, and then bandaged for twenty-four hours. In some skins, however, glycerin invariably irritates.

In the papular form the tarry lotions named and carbolic-acid lotion are of most benefit. These cases are from the beginning inclined to take on the chronic type, and the more stimulating applications are well borne. Thymol, one or two grains to the ounce of alcohol and water, is also useful.

In chronic eczema, and, in fact, in all cases of eczema, after the active inflammatory symptoms have more or less subsided—which usually takes place soon after the beginning of the outbreak—stimulating applications are to be resorted to. In fact, the dividing-line between acute and chronic eczema is difficult to define. The products of the disease, be they crusts or scales, must be removed in order that the remedial application may be brought in contact with the diseased surface. Thoroughly saturating the part with oil, and subsequently washing with warm water and soap, will usually suffice to remove the accumulations. On the non-hairy surface a bland oil, lard, or a non-irritating ointment thickly spread on the parts, will soon be followed by softening and removal of the crusts or scales. If these more simple measures are not sufficient, washings with sapo viridis and warm water are to be advised for this purpose, immediately afterward applying a mild unguent. On the scalp, instead of the pure green soap, the spiritus saponatus kalinus is more satisfactory. In patches which are covered with thickened epidermic masses, as in eczema of the palms, strong applications are necessary to remove the accumulations. For this purpose green soap or salicylic acid may be used. Of these, salicylic acid is in most cases to be preferred. It may be applied as an alcoholic solution, 5 or 8 per cent. strength, or in ointment form, fifteen to forty grains to the ounce.

After a removal of the products of the disease the remedies proper are to be applied. The various ointments already named for the treatment of the acute and subacute types may also be employed in the chronic cases. In some instances they may prove sufficient, but in the majority it will be found necessary to have immediate recourse to the stronger ointments and lotions. In small patches washing the parts with green soap and hot water and following with unguentum diachlyi or a similar ointment will be sufficient.

The mercurials are of great value in the treatment of eczema, used either alone or in combination with various other remedies. An ointment of the mild chloride of mercury, twenty to eighty grains to the ounce, is valuable in many cases. Citrine ointment, weakened, and ammoniated mercury, in the same proportion as calomel, are also well-known and very useful preparations, likewise acceptable in many cases. To these ointments tar may often be advantageously added, in the strength of one or two drachms to the ounce. Carbolic acid in ointment, ten to twenty grains to the ounce, may also be mentioned as often proving serviceable. A compound ointment, prized in the Blackfriars Hospital for Skin Diseases, London, is composed of acetate of lead, ten grains; oxide of zinc, twenty grains; calomel, ten grains; citrine ointment, twenty grains; palm oil, half an ounce; benzoated lard, enough to make one ounce. Another mildly stimulating preparation is composed of bisulphide of mercury and red precipitate, each six grains; lard, one ounce.

Tarry preparations constitute the most generally efficacious applications in the treatment of all forms of chronic eczema, where this remedy is at all tolerated by the skin, especially in the squamous variety of the disease. A good formula, and one that is often of service even in the subacute variety, is the following:

Rx.	Picis liquidæ, Zinci oxidi, aa.	drachm j;
	Ugt. aquæ rosæ,	drachm vj.

M. Ft. ugt.—This is to be gently but thoroughly rubbed into the diseased skin. There are three preparations of tar that may be interchangeably employed: these are the ordinary pix liquida, oleum cadinum, and oleum rusci. The oleum rusci is the least unpleasant. They may be employed in the strength of 10 to 50 per cent., either in ointment form or with alcohol. If used upon the scalp, the lotion form, with alcohol, is to be preferred. In the use of a tarry preparation, to be efficient it is to be gently but thoroughly worked into the patches, so that it permeates the skin; the excess may be wiped off. The liquor picis alkalinus, already mentioned in speaking of the treatment of acute eczema, may be used either in the form of an ointment, in the strength of one or two drachms to the ounce, or in the form of a lotion, in the strength of two to eight drachms to the half pint. This tarry preparation may even be employed in full strength to small and thickened patches, applying carefully and using no other treatment, or following the application immediately with a simple or tarry ointment. In cases of verrucous eczema or in patches of thickened papular or squamous eczema, used in the manner described, it is often curative. It is a strong remedy, and is to be employed with caution. The liquor carbonis detergens, in the strength of one or two drachms to the ounce of water, is also valuable in these chronic cases. It is a safe plan in the use of these tarry preparations to begin with a mild strength and then increase if advisable. An equally efficacious formula for the thick, leathery patches of chronic eczema is the following:

Rx.

Saponis viridis, Picis liquidæ, Alcoholis, aa.

drachm iv.

M.—S. Rub in twice daily. There is another mildly alkaline tarry preparation, the goudron de Guyot, somewhat similar in composition to the liquor picis alkalinus, which at times seems to suit when the other tarry applications fail to benefit.

In the treatment of eczema rubrum of the legs Hebra was in the habit of employing the following method: A small quantity of the green soap is to be rubbed into the parts with a flannel rag, employing considerable friction, until all the soap has apparently disappeared; then warm or hot water is to be added and rubbed in in the same manner, an abundant lather being the result. The parts after being rubbed for from five to fifteen minutes, according to the effect, are to be thoroughly rinsed off with simple warm water, and a mild ointment, spread upon cloths, applied. The best ointment for this purpose is the unguentum diachyli, but any mild ointment may be employed. This treatment is to be repeated once or twice daily. In most cases improvement sets in after a few applications. It is an excellent method of treatment, and can be recommended. It requires considerable time and trouble, however, and is therefore not suitable in all cases, for unless the details are properly carried out it may fail.

Salicylic acid is another remedy that is often useful. In thick, leathery patches, an ointment of the strength of thirty to sixty grains to the ounce, applied on cloths or rubbed in, will often produce marked benefit. In the form of a paste it may be used in many cases of subacute and chronic eczema with good effects:

Rx.	Acidi salicylici,	gr. xx;
	Ugt. petrolei,	drachm iv;
	Amyli, Zinci oxidi, aa.	drachm ij.

M.—S. Apply once or twice daily. If it is used upon the scalp, it should be used with petroleum ointment or lard, the starch and zinc oxide being omitted. Boric acid in the form of a saturated solution, as advised in acute eczema, or in ointment of the strength of a drachm to the ounce, will prove useful in some instances. Sulphur in the form of ointment may also be mentioned as being frequently of value in cases of chronic eczema, especially of the leg. In some cases of subacute and chronic eczema the lotion containing zinc sulphate and potassium sulphide, diluted, mentioned in acne, will be found serviceable. In circumscribed and chronic patches blistering with cantharides is sometimes advisable. In these cases tincture of iodine is also employed. In thickened patches, rebellious to the usual remedies, chrysarobin or pyrogallic acid, as used in psoriasis, may sometimes be applied with benefit.

Mention may here be made of vulcanized india-rubber, used in the form of bandages, the method proving of most value in eczema of the lower extremities, especially in those cases which are due to a condition of varicose veins. It is not suitable in all cases, as in some the disease is aggravated. Reference may also be made to the use of the so-called gelatin dressing. The medicinal substance is incorporated with the gelatin basis, which is made by melting together over a water-bath two parts of water and one of gelatin; and when the application is made the gelatin compound is melted over a water-bath and applied while in the fluid condition; it rapidly hardens and forms an impermeable coating to the diseased part. The dressing is liable to crack, to avoid which, in a measure, a small quantity of glycerin is mixed with the gelatin and water. Another plan is, after the dressing has dried, to brush over the surface a few minims of glycerin. It has, however, cleanliness in its favor, and it is undoubtedly of service in many instances. A good basis formula for the gelatin dressing consists of eight parts of water, four of gelatin, and one of glycerin.

Another form of fixed dressing for scaly patches is with collodion. This may often be made use of when tar is employed, the addition of one or two drachms of pix liquida or one of the tar oils to enough collodion to make an ounce. Such a preparation may be applied to dry and scaly patches, and constitutes an excellent method of application; but tar so applied is not as efficient as when used in solution or in ointment. The gutta-percha and muslin plasters³ constitute excellent methods of applying remedies; they are cleanly, easily applied, comfortable to the patient, and efficacious.

³ These plasters were devised by Unna, and are made by Beiersdorf, an apothecary of Hamburg, Germany. The muslin plasters consist of muslin incorporated with a layer of stiff ointment; the gutta-percha plasters consist of muslin faced with a thin layer of india-rubber, the medication being spread upon the rubber coating.

Prurigo.

Prurigo is a chronic inflammatory disease, characterized by discrete pinhead- to small pea-sized, solid, firmly-seated papules, slightly raised, of a pale-red color, accompanied by general thickening of the skin and itching. The disease manifests itself by the development of small firm elevations, which at first are scarcely perceptible; but they may be distinctly felt by passing the hand over the surface. Later, they may be seen as slightly-raised papules, varying in size from a milletseed to a small pea, of the same color as the surrounding skin or of a pinkish hue, and to the touch are found to be well-defined inflammatory deposits. The lesions are discrete, may be present in great numbers and in close proximity, and show no tendency to group, being irregularly distributed. There is rarely distinct scale-formation, but the papules are usually covered with roughened, dry epidermis, and are frequently perforated with hairs.

Itching, usually intense, is a constant symptom, giving rise to scratching, and as a consequence many of the lesions are covered with blood-crusts and the skin is markedly excoriated. In course of time, either as a symptom of the disease or as a result of the scratching and consequent hyperæmia, or more probably resulting from both, the skin becomes thickened and the surface harsh or rough. The extensor surfaces of the legs, especially the tibial regions, and later the forearms and arms, and in marked cases the trunk, are the regions usually invaded. The palms and soles escape, and only in rare cases is the head involved. As a result of strong local remedies or scratching, or of both, a simple dermatitis or an eczema may develop as a complication. In consequence also of the cutaneous irritation the lymphatic glands, especially the inguinal, may become engorged—prurigo buboes (Hebra).

The causes of the disease are obscure. It is common in Austria, and is occasionally met with in France and England, but it is almost unknown in the United States. It is met with, as Hebra states, almost exclusively in poor subjects and those ill nourished in childhood, and so most often in foundlings and beggars' children. The disease is not hereditary. It usually develops, however, in early childhood, and is worse in winter than in summer. Anatomically, the lesions differ but slightly from those of papular eczema. The papillæ and rete show a moderate amount of cell and serous infiltration. Later, as a result of the chronic inflammation, thickening, increased cell-infiltration, atrophied sweat and sebaceous glands, and pigmentation are observed. The process, according to various authorities, begins in the papillary layer.

Prurigo has been, and is still, erroneously confounded with pruritus and pediculosis, diseases which have nothing in common with that affection except the itching and resulting excoriations—symptoms, as is well known, common to many diseases. In pruritus there is no structural change in the skin except that produced by scratching, a point of difference that is diagnostic. The thickening of the skin and the harsh, rough surface encountered in prurigo are absent in pruritus. The latter disease is usually one of middle or old age; prurigo, on the other hand, dates from childhood. In pediculosis the lesions, punctate or papular in form, are consequent upon the wounds of the pediculus, and are most numerous about the trunk, especially the shoulders and hips. Between simple eczema and prurigo the diagnosis is not difficult. It is to be remembered, however, that eczema may exist as a complication, in which case, after its disappearance, the characteristics of prurigo become evident.

Severe cases are said to be incurable, according to Hebra and others, but in the milder forms of the disease a cure may be effected. Good food, hygiene, and tonic remedies, and systematic local treatment similar to that generally employed in chronic eczema, are the measures indicated. Naphthol, in the form of a 5 per cent. ointment for adults and a ½ per cent. ointment for children, has been found by Kaposi to be of value.

Acne.

Acne, or acne vulgaris, is an inflammatory, usually chronic, disease of the sebaceous glands, characterized by papules, tubercles or pustules, or a combination of these lesions, occurring for the most part about the face. There are several so-called varieties of acne, although examples of all these forms may be seen usually in an individual case, and instances in which all the lesions are of the same type or character are practically not encountered. Other disorders of the sebaceous glands, as comedo and seborrhoea, are often seen associated with this affection. In fact, hypersecretion or retention of the sebaceous matter is the exciting cause of the inflammation.

If the retained sebaceous mass causes a moderate degree of hyperæmia or inflammation, a slight elevation with a central whitish or blackish point results, constituting the lesion of acne punctata. If the inflammation is of a higher grade, the elevation is more marked, reddened, and papular, the lesion being known as acne papulosa. If the process is still more active, the central portion of the papule suppurates and acne pustulosa results. The surrounding inflammation of this form is often of a violent type, and the lesion may be situated upon a hard and inflamed base, and then is designated acne indurata. In some cases of acne the disappearing lesions leave more or less atrophy about the gland-ducts in the form of pit-like depressions—acne atrophica. On the other hand, at times there results connective-tissue hypertrophy about the glands—acne hypertrophica. In strumous, cachectic individuals the lesions, which are usually pustular in type, or at times furuncular, almost of the nature of dermic abscesses, may be more general in distribution, and are, moreover, usually of a more sluggish character, constituting the so-called acne cachecticorum. The efflorescence which follows the prolonged ingestion of the iodides and bromides is usually of a more inflammatory type, the glands and follicles being sometimes seriously and irreparably involved. This form of acne, as well as that resulting from the external action of tar, characterized by the formation of all kinds of lesions with a minute central blackish deposit of tar and more or less inflammation of the surrounding skin, constitutes acne artificialis.

The most common form of acne is that in which the pustule predominates. The lesions, in all the varieties, are usually confined to the face, the forehead, cheeks, and chin being favorite localities; not infrequently, however, the eruption also involves the shoulders and upper part of the back. They are irregularly distributed and tend to appear in crops. Sometimes the face and shoulders are spared, and the lesions, being confined to the back, extend as far down as the lumbar region or even to the thighs. In these cases the lesions are usually of a papulo-pustular character and are sluggish in their evolution. As a rule, an acne papule or pustule runs an acute course, disappearing in the course of one or two weeks, and a new lesion appearing at another point to supply its place. The disease is essentially chronic, in the sense that the parts are never or seldom free, new lesions forming and old ones disappearing from time to time, in some cases indefinitely. As a rule, there are no subjective symptoms, but in some markedly inflammatory cases the lesions are painful; in other exceptional instances there is slight itching.

The disease is common about the age of puberty, and occurs in both sexes. Chronic derangement of the digestive apparatus is a frequent factor. Those of a light complexion are more liable to its development, while menstrual difficulties, chlorosis, scrofulosis, and general debility may all predispose to the disease. Medicinal substances, such as the iodides and bromides, and tar externally, are also prone to produce acne-form lesions. The retention of the secretion within the sebaceous gland is the first step in the formation of an acne lesion, and its presence—or it may be its decomposition—gives rise to inflammation, which usually involves the gland-structure and the surrounding tissue. Primarily, it is a folliculitis, the tissue immediately about the follicle subsequently becoming involved, constituting a perifolliculitis. As a result of this latter process, or from inflammation and changes within the gland without much surrounding inflammation, the destruction of the sebaceous follicles may ensue. The hair-follicles at times are also involved in the process. The degree of inflammation determines the character of the lesion; if mild in character, the simple papule or pustule results; if of a severe grade, the lesion of the indurated and hypertrophied forms follows.

Acne resembles at times the papular and pustular syphiloderms. In syphilis the distribution of the eruption, the history of the case, the color, the duration of the individual lesions, the tendency of the papules or pustules to group, and usually the presence of other evidence of the disease, will serve to distinguish it from acne. Tar acne may be recognized by the history, the black points at the follicular openings, and usually evidence of the presence of tar about the patient. Acne resulting from the ingestion of the bromides and iodides is almost always of an acute and markedly inflammatory type, the lesions being scattered over the general surface, and are usually larger and more virulent in character than those of acne vulgaris. From acne rosacea it may be known by the characters referred to in speaking of that disease.

TREATMENT.—Cases of acne vary considerably as to their course and curability. There is in almost every case a natural inclination toward disappearance of the eruption at the age of twenty or thirty. Although the lesions are at any age of the patient generally easily removable by treatment, relapses are the rule; but the older the patient the less probability is there of a recurrence. Even in young subjects, however, the cure may be permanent, depending upon the ability to discover and remove the cause. The disease requires both constitutional and local treatment. For the removal of the existing eruption local applications alone are usually sufficient, but the disposition to the development of new lesions in most cases yields only to appropriate internal treatment.

Each case of acne for its successful management demands careful investigation with a view of discovering the etiological factors. If these can be ascertained and removed, a successful result is assured. As already intimated, disorders of digestion play a most important part in the etiology of this disease, and in a large proportion of cases remedies appropriate to such conditions are required. The diet is to be strictly regulated: all indigestible articles of food, such as pork, salt meats, pastry, cheese, pickles, etc., should be interdicted. If constipation exists, laxatives are to be prescribed. As a rule, salines are more serviceable than vegetable preparations for plethoric individuals, while for others the latter, especially for long-continued administration, are to be preferred. A change from one to the other is often advisable. The dose should be sufficient to produce a free evacuation daily. An excellent tonic aperient mixture is the following:

Rx.	Magnesii sulphatis,	ounce iss;
	Ferri sulphatis,	gr. viij;
	Acidi sulphurici diluti,	fluidrachm ij;
	Aquæ menthæ piperitæ,	fluidounce iij drachm vi.

M.—S. A tablespoonful in a tumblerful of water a half hour before breakfast. The tonic effect of such a mixture is best obtained by prescribing one or two teaspoonfuls in a large wineglassful of water before each meal: as a rule, however, when thus given its laxative property is not so well marked. The mint-water may be replaced by a bitter infusion, such as quassia, but the mixture, unpalatable at the best, is not improved by such a substitution. In some cases the acid in the above mixture is contraindicated, and the following, also a valuable formula, may be prescribed:

Rx.	Magnesii sulphatis,	ounce iss;
	Potassii bitart.,	drachm iv;
	Sulphuris præcip.,	drachm ij;
	Glycerinæ,	fluidrachm ij;
	Aquæ menthæ pip.,	fluidounce iv.

M.—S. Tablespoonful in a tumblerful of water a half hour before breakfast. Hunyadi Janos water, in the dose of a large wineglassful thirty or forty minutes before the morning meal, is a useful saline, and is not especially disagreeable. Friedrichshall water is an efficient laxative and cathartic, but has a nauseous taste and odor. The ordinary mixture of rhubarb and soda is of value, not only for its laxative effect, but also for its antacid property where such is indicated. The following formula, containing cascara sagrada, is of service:

Rx.	Ext. cascaræ sagradæ fl.,	fluidrachm iv;
	Acidi muriatici diluti,	fluidrachm ij;
	Tincturæ gentianæ comp.,	fluidounce iij drachm ij.

M.—S. Teaspoonful in a large wineglassful of water before meals. At times this proportion of cascara sagrada is too large, and, on the other hand, in some cases it must be increased. A laxative pill, as the following, containing aloin, belladonna, and strychnia, may be given:

Rx.	Aloin,	gr. iij;
	Ext. belladonnæ,	gr. ij;
	Strychniæ sulphatis,	gr. ¼.

M. Ft. pilul. No. xv.—S. One or two at night. If there is torpor of the liver, an occasional dose of blue mass or calomel may be prescribed. When there is flatulence or other symptoms of fermentative indigestion, a mixture such as the following will be found useful:

Rx.	Sodii hyposulphitis,	drachm ijss-ounce j;
	Ext. nucis vomicæ fl.	fluidrachm ij;
	Aquæ menthæ piperitæ,	fluidounce iv.

M.—S. Teaspoonful in a large wineglassful of water a half hour before meals. The hyposulphite of sodium contained in the mixture may have a laxative effect in addition to its antifermentative action.

If there is anæmia or chlorosis, a preparation of iron, combined with aloes if there is tendency to constipation, is to be prescribed, the wine of iron being one of the most eligible ferruginous preparations. Ergot in the dose of a half drachm of the fluid extract has been recommended in the acne of females, especially where it seems probable that uterine disturbance is the exciting cause. Possibly its effect is, as has been suggested, due to its action on the unstriped muscular fibres of the skin. After one or two weeks' administration it is apt to cause gastric disturbance and, directly or indirectly, vertiginous symptoms. Calx sulphurata in the dose of one-tenth to one-half grain every three or four hours is of value in some cases, usually proving of most service in the pustular type. In strumous individuals, and in those whose nutrition is below the average, cod-liver oil is a valuable remedy. In like cases glycerin in similar doses may be prescribed, although its action is not so certain.

Arsenic is of decided value in some cases, but proves powerless in others. The sluggish papular forms are often influenced favorably by its continued administration. The alterative effect of mercury is sometimes beneficial, corrosive sublimate in small doses being the most available preparation. Where the inflammation is of a high grade, potassium acetate and other alkalies may be prescribed, as in the following formula:

Rx.	Potassii acetatis,	drachm v gr. xx;
	Liq. potassæ,	fluidrachm ijss;
	Liq. ammonii acetatis,	fluidounce iij drachm v.

M.—Sig. Teaspoonful in a large wineglassful of water one hour before meals.

Local Treatment.—This is of great importance and is demanded in every case. In acute acne, rarely encountered, mildly astringent applications are to be advised. The disease, as generally met with, however, is of a subacute or chronic character, requiring stimulating measures. External treatment in these cases has for its object the production of hyperæmia and the removal of the superficial layers of the epidermis, thus stimulating the glands and circulation and assisting in the excretion of the sebaceous matter. For this purpose washing the parts energetically with sapo viridis and hot water every night, using a sponge or preferably a piece of flannel, may be advised. After the soap-washing the parts are to be sponged with hot water for several minutes, or the face held over a basin containing steaming hot water. Subsequently, the comedones are to be pressed out by means of pressure with the fingers, or, better, by a watch-key with rounded edges so as not to injure the skin. An application of a simple emollient, such as cold cream or vaseline, may then be made and allowed to remain on over night. This plan of treatment is to be repeated nightly or every other night.

In many simple cases of acne the above method of external treatment, combined with appropriate constitutional medication, will bring about marked improvement and sometimes permanent relief. In the majority of cases, however, a more stimulating plan of treatment is called for. In almost all cases the soap-washing, either with the sapo viridis or a milder soap, and the sponging with hot water, are to precede the nightly remedial applications. Among the external remedies for acne sulphur preparations stand first. Properly managed, they rarely fail to benefit, and often prove curative. Precipitated sulphur is the preparation generally employed, and in many cases the most suitable. It may be prescribed as a powder, in ointment, or in lotion. As a powder it may be applied pure or mixed with starch, and as an ointment the following formula can be recommended:

Rx.	Sulphuris præcipitati,	drachm iss;
	Adipis benzoati,	drachm iv;
	Ugt. petrolei,	drachm ijss;
	Olei rosæ,	gtt. iij.

M. Ft. ugt.—Sig. To be rubbed thoroughly into the skin at night. Or, instead of the precipitated sulphur in the above ointment, the sulphur hypochloride may be substituted. As a mild stimulant sulphur soap may often be ordered with advantage in connection with other remedies.

In sluggish, non-inflammatory cases the following may be used:

Rx.

Sulphuris præcipitati, Potassii carbonatis, Glycerinæ, Ugt. petrolei, aa.

drachm ij.

M. Ft. ugt.—Sig. Apply at night, rubbing it into the skin. In the above formula the petroleum ointment may be replaced with the same quantity of alcohol. In the form of a lotion precipitated sulphur at times acts more decidedly than as an ointment. There are several useful formulæ which, as a rule, answer equally well, although in some cases differing in their beneficial effects. In the average case the following seems most certain in its results:

Rx.	Sulphuris præcipitati,	drachm ij;
	Pulv. camphoræ,	gr. xx;
	Pulv. tragacanthæ,	gr. xxx;
	Aquæ aurantii flor., Liq. calcis, aa.	fluidounce ij.

M.—S. Dab on with a mop or rag; shake before using.

A similar mixture in the form of a paste may be made with equal parts of mucilage of acacia, glycerin, and sulphur, and is to be applied with a brush, being allowed to remain on the skin over night.

Another sulphur lotion is the following:

Rx.	Sulphuris præcipitati,	drachm ij;
	Glycerinæ,	fluidrachm j;
	Alcoholis,	fluidounce j;
	Liq. calcis,	fluidounce ij;
	Aquæ aurantii flor.,	fluidounce j.

M.—Sig. Apply with a sponge or rag, shaking well before using.

The annexed is also a good stimulating lotion:

Rx.	Sulphuris præcipitati,	drachm ij;
	Ætheris,	fluidrachm iv;
	Aquæ cologniensis,	fluidrachm iv;
	Alcoholis,	fluidounce iij.

M.—Sig. Shake well and dab on with a rag.

Potassium sulphide is a preparation of sulphur which often acts admirably in this disease. It may be employed as an ointment, or, preferably, as a lotion. An excellent formula, containing the sulphide, which can be prescribed with advantage in many cases, is the following:

Rx.	Potassii sulphidi, Zinci sulphatis, aa.	drachm j;
	Aquæ rosæ,	fluidounce iv.

M.—S. Apply with a sponge or rag. The resulting lotion from this mixture is a complex one, a double reaction taking place. The salts should be separately dissolved, and then mixed. If properly made, the lotion when shaken is of a milky color and free from odor; upon standing the particles sink and form a white sediment, the liquid above being clear. If improperly prepared, as is often the case, it is of a yellowish tinge with a decided odor of the potassium sulphide, and has an entirely different effect. Vleminckx's solution,⁴ perfumed with an essential oil, is often of service; it is to be diluted with three to six parts of water and dabbed on every night, the strength gradually increased if necessary.

⁴ See treatment of Psoriasis for formula.

Another class of external remedies found of service in the treatment of this disease are the mercurials. They are not so valuable as the sulphur preparations. Corrosive sublimate, white precipitate, and calomel are the mercurials commonly used. If sulphur has been previously employed, several days should intervene and the parts be repeatedly cleansed before using a mercurial, otherwise the skin is darkened temporarily by the formation of the black sulphuret of mercury. Corrosive sublimate is prescribed in the form of a lotion, from one-half to two grains to the ounce of alcohol and water, or as in the following formula:

Rx.	Hydrargyri chloridi corros.,	gr. ij;
	Zinci sulphatis,	gr. xv;
	Alcoholis,	fluidounce ij;
	Aquæ rosæ,	fluidounce ij.

M.—S. Apply with a rag. The zinc sulphate renders the lotion astringent, and is often a valuable addition. Ammoniated mercury, thirty to sixty grains to the ounce of benzoated lard or cold cream, will frequently prove serviceable. If the lesions are numerous and are seated close together, the application is to be made to the entire surface of the part; on the other hand, if they are sparse, it may be made to the spots only. The same may be said also in regard to the sulphur preparations. A 5 or 10 per cent. ointment of oleate of mercury, rubbed thoroughly into sluggish and indurated lesions, will often shorten their course by promoting suppuration. In many cases puncturing the lesions with a sharp knife or scraping with a curette before applying the hot water will be of assistance in the treatment. In obstinate indurated lesions, in addition to puncturing the lesions, the apices may be treated with carbolic acid. The protiodide of mercury, in the strength of five to fifteen grains to the ounce of ointment, is well spoken of by some authorities; it is to be used with care, as it is actively stimulant. In some cases rubbing energetically over the parts a mixture of sapo viridis and sulphur, adding enough hot water to make a lather, and allowing it to remain on over night, will, if repeated nightly until the skin becomes slightly inflamed and then followed subsequently by a mild ointment, produce a decided effect.

Acne Rosacea.

Acne rosacea, or rosacea, is a chronic, hyperæmic or inflammatory disease of the face, invading especially the nose and cheeks, characterized by redness, dilatation and enlargement of the blood-vessels, more or less acne, and hypertrophy. The course of the disease divides itself naturally into three stages. There is at first simply a hyperæmia, due to passive congestion. In young subjects the affection is seen in this stage, and rarely passes beyond it. In other cases, however, sooner or later, dilatation and enlargement of the vessels (telangiectasis) take place, and acne papules and pustules are scattered over the parts, constituting the second stage of the disease. This stage is frequently met with, and illustrates the acne rosacea usually seen. Exceptionally, however, the disease progresses, the vessels increase in calibre, the glands are enlarged, and there is more less hypertrophy of the connective tissue and the third stage is developed. The nose may become much enlarged, even lobulated, and in some portions pendulous (rhinophyma). The nose and its immediate neighborhood are the favorite localities for the development of acne rosacea, but it is not infrequently confined to the cheeks, and sometimes is localized upon the forehead, while all these parts are not infrequently affected simultaneously. As a rule, there are no marked subjective symptoms, although in some instances burning or a sense of fulness is complained of.

It is seen in both sexes, but is more frequent in males; in women it rarely, if ever, reaches the same degree of development as in men. It is most common about middle life. The causes are varied. Chronic stomachic and intestinal derangements, anæmia, and chlorosis are common causes. The habitual use of spirituous liquors is not infrequently a source of the disease. Long-continued exposure to excessive cold or heat is in some cases a causative agent. In women, menstrual and uterine difficulties are often the responsible factors; hence in this sex it is much more common at the climacteric period. When occurring in the young about the period of adolescence, it is frequently associated with seborrhoea, and rarely advances beyond a condition of hyperæmia. Pathologically, in the first stage of the disease there is simply a hyperæmia—a stasis; in the second, hypertrophy and dilatation of the vessels are superadded, together with acne and slight hypertrophy of the sebaceous glands; in the third stage there is, in addition, hypertrophy of the connective tissue of the corium.

Acne rosacea is to be distinguished from the tubercular syphiloderm, lupus vulgaris, and acne vulgaris, to which affections it at times bears resemblance. The tubercular syphiloderm is comparatively more rapid in its course; does not necessarily involve the sebaceous glands; has frequently as a consequence ulceration and crusting; is usually confined to a part of the nose; and is unaccompanied with dilatation and enlargement of the blood-vessels. Its history, the firmer consistence, and the more dusky color of the tubercles, and frequently the presence of other evidences of syphilis, are also points of difference. In lupus vulgaris the characteristic soft, yellowish-red papules, the absence of the hypertrophied blood-vessels, the degeneration, ulceration, and cicatricial-tissue formation, the more or less limited character of the eruption, and the history of the case, will serve to distinguish it. A simple case of acne vulgaris can scarcely be confounded with acne rosacea: in many cases, however, the dividing-line is far from being marked; in fact, the disease under consideration is often acne with hyperæmia and dilated blood-vessels superadded.

TREATMENT.—The affection may in all cases be more or less favorably influenced by treatment. The milder cases, although at times obstinate, are curable; but when the disease has advanced to marked dilatation and hypertrophy of the blood-vessels and connective tissue, the prognosis is not so favorable. In all stages of the affection, however, as stated, a great deal can be accomplished by appropriate remedies. External and internal treatment are required in the majority of cases. The former usually proves the more valuable.

Concerning internal remedies, there is no drug that exerts a specific influence. The guide to constitutional treatment should be a study of the etiological causes of the disease. Constipation is frequently present, and hence laxatives, especially the salines, are indicated. Chlorosis in the female is often the predisposing cause, and such remedies as iron, quinine, and strychnia will be found useful. Dyspepsia is one of the most frequent causes, and treatment directed toward a removal of that condition will often be of considerable aid in curing the disease. Menstrual irregularities should be inquired into and the appropriate remedies employed.

There are mainly two classes of external remedies which are used in the treatment—namely, the mercurials and the sulphur preparations. The latter are by far the more valuable, precipitated and sublimed sulphur, the hypochloride of sulphur, and the sulphuret of potassium being the most serviceable. They are prescribed either in the form of lotions or ointments. The officinal sulphur ointment, an ointment of the precipitated sulphur and of the hypochloride of sulphur, of the strength of one or two drachms to the ounce, may be referred to as valuable applications. Sulphur may also be used as a dusting-powder or in the form of a paste, as in the following formula:

Rx.	Mucilag. acaciæ,	fluidrachm ij;
	Glycerinæ,	fluidrachm ij;
	Sulphur, præcip.,	drachm iij.

M.—Sig. Use with a brush as a paint.

A lotion containing one to four drachms of precipitated sulphur, twenty or thirty grains of camphor, thirty to sixty grains of tragacanth, in two ounces each of lime-water and orange-flower water, or one of the same quantity of sulphur, two or three drachms of ether, and three and a half ounces of alcohol, will in many cases prove serviceable. A lotion of one or two drachms each of sulphide of potassium and sulphate of zinc, in four ounces of water, is one of great value.

Concerning the mercurials, corrosive sublimate, calomel, and white precipitate are in some cases of service. Corrosive sublimate is prescribed as a lotion of the strength of one-half to four grains to the ounce of water or water and alcohol. Calomel and white precipitate are prescribed in ointment, twenty grains to two drachms of either to the ounce, or they may be used in the form of a powder, full strength or weakened with starch powder, dusted over the surface.

To a great extent, the treatment of acne rosacea is the same as simple acne, and for other formulæ and for the method of applying the various remedies the reader is referred to that disease. When dilated blood-vessels are present, however, other measures, in addition to those advised above, are to be adopted. There are two methods of destroying the blood-vessels. One plan is by the knife, cutting across the vessels at several points or slitting their whole length, permitting them to bleed; subsequently cold water may be applied. The other method is by means of electrolysis, according to the procedure fully described in the treatment of hypertrichosis. If the vessel is long, inserting the needle at several points along its length will be necessary; if short, insertion at one or two points will suffice. While either of these methods will, if properly managed, destroy the vessels, neither will prevent the growth of new vessels. In those cases, however, in which the cause has long ceased to operate destruction of the existing vessels may not be followed by new growth. Excessive connective-tissue hypertrophy may require ablation by the knife.

Sycosis.

Sycosis (syn., sycosis non-parasitica, folliculitis barbæ) is a chronic inflammatory, non-contagious affection, involving the hair-follicles, appearing generally upon the bearded region, and characterized by papules, tubercles and pustules perforated by hairs. 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. The hairy portion of the neck may also be invaded. The disease may begin by the formation of papules and pustules about the hair-follicles on previously healthy skin, or chronic hyperæmia, or even eczema, may have preceded. The lesions generally occur in numbers, in close proximity, and, together with the accompanying inflammation, make up a patch of disease involving a greater or less area. The pustules are discrete, flat or acuminated, small in size, yellowish in color, perforated by hairs, show no disposition to rupture, and are, as a rule, apt to appear in crops. They dry to thin yellowish-brown crusts. There is more or less swelling and infiltration. Papules and tubercles may usually be seen intermingled with the pustules, or the former may constitute the greater part of the eruption. At first the hairs are firmly seated, but later, when suppuration has involved the follicles, they may be easily extracted. Not infrequently the hair-follicles are completely destroyed, in which case scarring and alopecia result. The process is chronic, it being of a subacute or chronic character, with, usually, acute exacerbations. Burning sensations, and at times pain or itching, accompany the disease.

According to Robinson, the affection is primarily a perifolliculitis, the first changes, which are those usually observed in vascular connective-tissue inflammations, taking place around the follicle. Later, the follicle and its sheath become involved, the pus and transuded serum finding their way into these structures. At times pus does not enter within the follicle, the changes observed therein being due to the transuded serum. The pus reaches the surface by forcing its way through the epidermis close to the hair. The causes of the disease are not understood. It is usually seen in those between the ages of twenty-five and fifty, in all classes of society, and in those in good or bad health. Persons with eczematous skin and those having thick and stiff hair are especially predisposed to the disease. Local irritation may serve as the exciting cause. The affection is not common. It is not contagious.

The disease is to be distinguished from tinea sycosis and eczema. Tinea sycosis usually begins as a circular scaly patch—in fact, as simple ringworm—later invading the hairs and follicles and giving rise to papules and tubercles. These lesions are larger than in simple sycosis, and appear and feel like lumps and nodules. Moreover, the changes in the hairs in the parasitic disease are characteristic: they become opaque, brittle, loose, and can be readily extracted. If necessary, a microscopical examination of the hairs may be resorted to. In eczema there is either an oozing, red, crusted surface, or it is dry and scaly; the lesions, as a rule, do not remain discrete, are not perforated by hairs, and the eruption is apt to involve other parts of the face. It is scarcely possible to confound the disease with syphilis.

The disease is essentially a chronic one, and under the best management is often rebellious. Relapses are not uncommon. The treatment consists mainly of external measures. Suitable internal remedies are, however, in some cases, as in plethoric or in broken-down subjects, of value. The digestive apparatus is to be looked after. The extremes of heat and cold are to be, as far as possible, avoided. Clipping the hair, or shaving if not too painful, will permit a more thorough application of remedies. If the disease be of an acute type, soothing applications are at first to be advised. If there is crusting, it should be removed by poultices or oily applications. The use of lotio nigra, and subsequently a cloth spread with oxide-of-zinc ointment, as in acute vesicular eczema, may be advised to allay inflammation. Cold cream, vaseline, or applications of lead-water and like remedies, will also be found useful in the acute stage. As a rule, however, astringent and stimulating ointments may be prescribed when the case first comes under observation. As an astringent ointment there is in the average case nothing superior to a good unguentum diachyli. It should be spread thickly on muslin and bound down to the parts, renewing every six or twelve hours. If stimulation is permissible, twenty grains to a drachm of ammoniated mercury or calomel to the ounce of ointment may be prescribed.

If the process be chronic in character, the parts may be washed with sapo viridis and water, and then diachylon ointment applied, repeating the washing every day and the application of the ointment twice or thrice daily. Sulphur, one to three drachms to the ounce of ointment, is a valuable stimulating remedy, and should be applied thoroughly twice daily; citrine ointment, two or three drachms to the ounce of lard or cold cream, will sometimes have a good effect. Shaving will be found useful in many cases. In some instances epilation proves a valuable adjunct to the treatment. In acute stages the hairs should be extracted from the pustules only—in the chronic stage both from papules and pustules. The operation will be rendered less painful by previously steaming or applying hot water to the parts. After the operation the surface should be dressed with a mild ointment. Epilation at the proper time will often save follicles from irreparable destruction; if for any reason it is not advisable, the pustules should be incised, so that free egress may be given to the pus.

Impetigo.

Impetigo is an acute inflammatory disease, characterized by the formation of one or more pea- or finger-nail-sized, rounded and elevated, usually firm, discrete pustules, seated upon an inflammatory base. The affection is at times preceded by slight malaise. The lesion is pustular from the beginning, and when well advanced may be of the size of a pea or finger-nail, is rounded, or semiglobular, markedly elevated, yellowish or whitish in color, with at first a more or less pronounced areola, which as the lesion matures becomes less and less marked, and finally almost entirely subsides. The pustule is usually distended, shows no disposition to rupture nor to umbilication, and is characterized by but little surrounding infiltration, and even where several exist close together they show no tendency to coalesce. Ten, twenty, or more lesions are usually present, and are most common about the face, hands, feet, and lower extremities. They dry to crusts of a yellowish or brownish color, which are usually thin and drop off, no pigmentation or scar remaining. The process is of brief duration, is benign in character, and is rarely attended with subjective symptoms. It is commonly seen in children under the age of ten.

The disease, apparently, is not related to eczema; occurs, as a rule, in well-nourished subjects, and is not contagious. The lesion is a typical pustule, the process being distinctly circumscribed. The walls are somewhat thick, and are probably made up of both the horny and mucous layers. There is no inflammatory base. Microscopically, the contents are found to be composed of pus-corpuscles, a few red blood-corpuscles, epithelial cells, and cellular débris. The disease is to be distinguished from pustular eczema, impetigo contagiosa, and erythema. The pustules of eczema are numerous, closely crowded together, small in size, tend to coalesce, with a decided disposition to rupture, and are accompanied by itching. The lesions of impetigo contagiosa are vesicular or vesico-pustular, flattened, superficial, thin-walled, often umbilicated; if close together they tend to coalesce, and dry to lamellar crusts of a yellowish color, and the affection is distinctly contagious. The pustules of ecthyma are flat, with an inflammatory base and areola; the crusts are brownish or blackish, and seated upon a deep excoriation; and the affection is, moreover, usually seen in adults and in those whose general health is markedly below the standard.

The affection rarely calls for treatment, as it tends to spontaneous recovery. Incision and evacuation of the matured lesions and a simple protective dressing of a mild ointment, such as oxide-of-zinc ointment, may be advised. If slight stimulation is desirable, ten or twenty grains of ammoniated mercury may be added to the ounce of the ointment.

Impetigo Contagiosa.

Impetigo contagiosa is an acute, inflammatory, contagious disease, characterized by the formation of discrete, superficial, flat, rounded or ovalish vesicles or blebs, which soon become vesico-pustular and pass into crusts. Precursory febrile symptoms, especially in young children, frequently usher in the eruption. The lesions begin as discrete vesicles, small in size, becoming vesico-pustular and increasing by extension peripherally, reaching the size of a pea or developing into blebs as large as a dime or silver quarter dollar. They are flat, slightly or markedly umbilicated, the umbilication being more marked in the older lesions. Several or a few dozen such vesicles or blebs may be present, and if situated close together may coalesce and form patches. There is very little areola, and the covering of the lesion is thin and withered-looking. The superficial character of the process is a striking feature. In a few days the lesions dry to crusts, thin, granular, wafer-like in character, light-yellowish or straw-colored, and but slightly adherent. If the vesicular or bleb wall or the crust is removed, a slightly excoriated surface is disclosed, resembling a superficial burn, secreting a thin fluid. The lesions are seen most commonly about the face and hands, although they frequently occur on other parts. In some cases one or two dozen lesions are scattered over the general surface. In these instances the resemblance of the whole process to an acute contagious systemic disease with cutaneous manifestations is striking. The lesions of the affection as ordinarily encountered appear simultaneously or in crops. As a rule, there is very little itching, and when it exists is usually present only in the beginning of the disease or at night. The affection is contagious and auto-inoculable, and at times apparently epidemic; is seen most frequently in the warm months, and is confined almost exclusively to children. When occurring in adults it is usually of an abortive type. In addition to the cutaneous covering, the mucous membranes of the mouth and conjunctiva are sometimes affected. As a rule, it runs an acute course, lasting ten days or two weeks. In exceptional instances the disease is anomalous, as regards not only its course, but the character and type of the individual lesions.

The causes of the disease are not understood. Some authorities consider it due to the presence of a parasite,—a view in which we are not prepared to coincide. A fungus—in fact, several varieties—may be found in microscopic examinations of the crusts, but the same may be found in crusts of other diseases, and their presence may be considered as accidental. There seem to be two varieties of the disease, in one of which the lesions are for the most part confined to the face and hands, and in the other the lesions are scattered over the general surface. The affection is encountered most frequently among the poor and ill-cared-for. A relationship to vaccination has at times been noted.

In the diagnosis eczema and simple impetigo are to be excluded. The history, course, and characters of the lesions of contagious impetigo are entirely different from those of these two diseases. The size, growth, isolated character, the non-inclination to rupture, and the comparative absence of itching will serve to distinguish it from eczema. The pustule of simple impetigo is prominently raised; that of contagious impetigo is flat and usually umbilicated; the contents of the former are distinctly pustular, and the crusts thicker, smaller, and usually yellowish-brown; of the latter the contents are rarely more than vesico-pustular, the crust thin, light-yellowish or straw-colored, and has the appearance of being stuck on. Those cases which resemble an exanthem may in the early stages be confounded with varicella, but later the lesions are much larger than seen in that disease. In exceptional instances the resemblance to the blebs of pemphigus is more or less pronounced.

As a rule, but little treatment is necessary, as the affection tends to spontaneous disappearance. In some cases, however, in which there is more or less itching, auto-inoculation at the excoriated points takes place, and in this manner the affection may persist. An ointment of ammoniated mercury, ten or fifteen grains to the ounce, rubbed in the lesions, will have a curative effect; likewise an ointment or lotion of carbolic acid, ten grains to the ounce.

Ecthyma.

Ecthyma is characterized by the formation of one or more discrete finger-nail-sized, flat, inflammatory pustules. The pustules are usually few in number, vary in size from that of a pea to a large finger-nail, roundish or ovalish in shape, and are situated on an inflammatory base, with a marked areola of a bright-red color. In the beginning they are yellowish, but later, from an admixture of more or less blood, they become reddish, subsequently drying to brownish but slightly adherent crusts. If the crust is removed, a superficial excoriation, secreting a yellowish fluid, is disclosed. The lesions pursue an acute course, but new pustules are apt to form from time to time. The lower extremities, shoulders and back are favorite localities. The subjective symptoms are usually slight, but burning and pain may be complained of. More or less pigmentation is left to mark the site of the lesions, which sooner or later disappears. The affection is seen in both sexes and at all ages, but is more frequently met with in men.

It is a disease of the poorly-nourished and debilitated; hence it is chiefly seen in the lower walks of life. All causes that tend to reduce the tone of the general health are indirectly responsible for the disease. In such persons external irritants, such as pediculi, bed-bugs, and similar parasites, may provoke the formation of ecthymatous lesions. The affection is not contagious. The process is of a markedly inflammatory type, and tends rapidly to pus-formation. The lesion is a typical pustule, and the excoriation does not extend deeper than the papillary layer. Permanent scarring never results. In the negro, instead of increased pigmentation, loss of pigment results.

The disease is to be distinguished from simple impetigo, contagious impetigo, and the flat pustular syphiloderm. It differs from impetigo in the flat form of the lesion and the character of its crust, and in the more inflammatory nature of the process. The non-contagiousness of the affection, the character and color of the crust, the regions involved, and the course will serve to differentiate it from impetigo contagiosa. In exceptional cases of this latter disease some of the lesions bear considerable resemblance to ecthyma. A striking similarity to the large flat pustule of syphilis is often noticed in ecthyma, and it is here that difficulty in the diagnosis is most likely to be experienced. The local disturbance, such as pain and heat, is generally more marked in ecthyma. The syphiloderm is usually of slower development and runs a more chronic course; moreover, positive ulceration beneath the crusts does not occur in ecthyma. The crusts of syphilis are darker in color, and usually have a greenish hue. Concomitant symptoms of syphilis are almost always present, and are valuable in the diagnosis. Ecthyma can scarcely be confounded with pustular eczema, as the size and discrete character of the pustules and the absence of marked itching are sufficiently distinctive.

Where it is possible for the patient to follow out treatment the result is always favorable. The importance of good food and proper hygiene cannot be overestimated. Tonics may be prescribed as efficient adjuvants. Iron, quinine, nux vomica, and the mineral acids are valuable. As a rule, simple measures are sufficient in the external treatment. If the lesions are numerous and are markedly inflammatory, alkaline baths, six ounces of sodium bicarbonate or of a similar alkaline salt to the bath, will be of service. The crusts are to be removed by poultices or hot-water applications, and the excoriations dressed with an ointment of ten to twenty grains of ammoniated mercury in an ounce of oxide-of-zinc ointment. In some cases a more stimulating ointment is required. Where active stimulation is demanded, touching the parts with nitrate of silver, diluted carbolic acid or a similar agent will prove serviceable.

Miliaria.

Miliaria—popularly known as prickly heat or heat-rash—is an acute inflammatory disorder of the sweat-glands, characterized by pinpoint to milletseed-sized papules or vesicles, attended usually by sensations of pricking, tingling, or burning. In some cases the eruption is almost entirely made up of papular lesions, and constitutes the form of the affection known as miliaria papulosa. In other cases the lesions are vesicular in nature, and miliaria vesiculosa is typified. It is chiefly the papular form to which the name of prickly heat has been applied. This variety begins with the formation of minute elevated, acuminated, bright-red papules, occurring usually in great numbers, more or less crowded together; the individual lesions, however, remain discrete. The affection may be localized, or, as is usually the case, may involve considerable surface. In miliaria vesiculosa the lesions are in the form of vesicles the same in size as the papules, and appear as whitish or yellowish points surrounded with inflammatory areolæ. They are usually crowded so closely together as to give the skin a bright-red look (miliaria rubra). At first the vesicles are transparent and contain a clear fluid, but as they become older they appear opaque and yellowish-white (miliaria alba), and instead of the bright-red appearance the eruption has then a yellowish cast. As in the papular form of the eruption, small areas may be involved or the greater part of the entire surface. The trunk is a favorite locality. The vesicles dry up in a few days, showing no tendency to rupture, and terminate in slight desquamation. In the majority of cases the eruption consists of papular, vesico-papular, and vesicular lesions interspersed. They make their appearance suddenly, usually accompanied with considerable sweating, and if the cause has ceased to act terminate in the course of a few days. As a rule, the subjective symptoms are mild in character, nothing more than slight tingling, burning, being noted; in others, however, these may be so marked as to give rise to considerable annoyance. Individuals who are debilitated seem most prone to an outbreak. Hot weather predisposes to it; in fact, excessive heat from whatever cause is apt to provoke an attack. It is especially common in children. The affection as usually met with is essentially an inflammatory disorder of the sweat-glands, congestion and exudation taking place about the ducts, giving rise to papules or vesicles, according to the intensity of the process.

It is to be distinguished from eczema and sudamen. The papules of eczema are larger, more elevated, firmer, make their appearance more slowly, and are of much longer duration; moreover, the itching of papular eczema is usually marked. Vesicular eczema differs from miliaria vesiculosa by the larger size of the lesions, their disposition to rupture, their tendency to become confluent, and their greater itchiness, and by the general features of the eruption both as regards its appearance and duration. It is to be noted that miliaria occurring in children from the conjoint effects of warm weather and superfluous clothing may, if the exciting causes are continued, result in eczema. Sudamen may be differentiated by the absence of inflammatory symptoms.

The affection under favorable circumstances runs a rapid course, disappearing in a few days or weeks. A removal of the exciting cause will in all cases have a favorable effect. Too active treatment is to be avoided, not only as being useless but prejudicial. Undue perspiration should be guarded against. The patient is for the time to avoid exercise and to be properly clad. Refrigerating diuretics, as citrate or the acetate of potassium or simple lemon-juice diluted, may be prescribed. When the eruption is kept up or frequently recurs as a result of impaired health, tonics, as quinine, iron, and the mineral acids, will be useful. In the majority of cases local treatment alone is necessary. Dusting-powders and cooling or astringent lotions are of most value. Starch and lycopodium powder, equal quantities or with 20 to 30 per cent. of oxide of zinc added, may be used; the surface is to be kept freely powdered. Astringent lotions may be employed in place of the dusting-powder, or, what is often advisable, may immediately precede the latter, the lotion being first applied, allowed to dry on the surface, and then the powder freely dusted over. A lotion of alcohol and water and sponging with vinegar and water may be prescribed.

Pompholyx.

Under this head (and also that of Dysidrosis) a rare disease of the skin has been described, characterized by peculiar vesicles and blebs and an excoriated state of the skin, with subsequent exfoliation of the epidermis. It consists at first of deep-seated vesicular lesions, which resemble small boiled sago-grains implanted in the skin, accompanied by a variable degree of inflammation. As the lesions grow they incline to coalesce, thus forming small or large blebs showing but little if any disposition to rupture. Sooner or later the fluid is reabsorbed or exudes, the epidermis peeling off, usually in large flakes or pieces, sometimes in the form of a cast of the fingers or hand. In most cases burning sensations, tenderness, and soreness are complained of. The disease pursues a variable course. Ordinarily, the process lasts from two to eight weeks. Relapses as well as recurrences of the disease may take place. It attacks by preference the hands, more especially the palms and the sides of the fingers, from which circumstance it was originally designated cheiro-pompholyx; but it may invade the feet and also other regions.

The same disease has been described with the two names given, some observers regarding it as being due to a disordered state of the sweat apparatus, others as being an inflammatory affection. We incline to the latter view, looking upon true dysidrosis as a form of miliaria. The disease under consideration is without question neurotic in origin. It occurs chiefly in those suffering from nervous debility or prostration arising from varied causes. It is due to impaired, faulty innervation. It is most liable to be mistaken for vesicular eczema or pemphigus. The treatment should be general, consisting of such remedies as quinine and arsenic, together with good food and proper hygiene. Local treatment may be prescribed as in the case of eczema, but the result in most cases is not as satisfactory as in that disease.

Pemphigus.

Pemphigus is an acute or chronic bullous disease, characterized by the successive formation of variously sized and shaped blebs. Two varieties are met with—pemphigus vulgaris and pemphigus foliaceus—the symptoms of which differ considerably. Pemphigus vulgaris, the usual form of the disease, appears with or without precursory symptoms. In marked cases headache and fever may precede the cutaneous outbreak. All portions of the body may suffer, but the extremities are more commonly the seat of the eruption. The mucous membrane of the mouth and vagina may also be involved. The lesions, as a rule, are rarely seen in large numbers, a dozen or so usually being present at one time. They vary in size from a pea to a large egg, and are generally rounded or ovalish, fully distended, and according to the size are elevated from a few lines to an inch above the surrounding skin. There is but little inflammation attending their formation. In some cases the blebs arise from erythematous spots or wheals, but generally from apparently normal skin. The fluid is yellowish, later often becoming cloudy or puriform. At times slight hemorrhage occurs, giving the lesions a reddish or purplish color. Spontaneous rupture of the lesions seldom occurs, the contents usually disappearing by absorption. Each bleb runs its course in from two to eight days. Itching and burning are rarely prominent symptoms, in some cases being scarcely noticeable or absent, in others present to a marked degree, constituting pemphigus pruriginosus. In children pemphigus vulgaris is usually attended with systemic disturbance; in adults, as a rule, only in severe cases. The disease may be acute or chronic. Acute pemphigus is rare, and occurs, as a rule, only in children. It usually runs a favorable course, except in ill-nourished children, in whom it may take on a malignant type and have a fatal termination. Chronic pemphigus may be benign or malignant. In the benign form the eruption may persist several months by successive outbreaks, and then disappear, or the blebs may form irregularly and indefinitely. In the former case there may be but the one attack, or, as commonly occurs, relapses may follow after months or years. In the malignant form the disease is more violent, with marked systemic depression and ulcerative action, and may frequently have an unfavorable termination.

Pemphigus foliaceus, the other variety of the disease, is rare. The blebs are loose and flaccid, with milky or puriform contents, rupture, and the oozing liquid dries to crusts, which are cast off, disclosing the reddened corium beneath. The blebs may coalesce and involve considerable surface, and may appear in rapid succession on other regions and on the sites of disappearing or half-ruptured lesions; even the whole surface may become involved, the process continuing for years, undermining the general health and eventually destroying the patient.

Pemphigus is a rare disease, and seems to be of even less frequent occurrence in this country than abroad. It is not contagious, nor is it due to syphilis, the so-called syphilitic pemphigus being a bullous syphiloderm and not a true pemphigus. General debility, overwork, shock, and nervous prostration are influential in producing the disease. Occasionally an hereditary tendency is traceable.

The contents of blebs are at first colorless or yellowish, consisting of serum,—later containing blood-corpuscles, pus, fatty-acid crystals, and epithelial cells, and occasionally uric-acid crystals and free ammonia. The reaction is alkaline, becoming more markedly so as the contents grow older. The lesions are superficially seated, between the horny layer and upper part of the rete and the lengthened cells of the rete and the corium. The papillæ and subcutaneous tissues show round-cell infiltration and dilated blood-vessels.

Herpes iris and the bullous syphiloderm are to be excluded in the diagnosis. In herpes iris the acute course, small lesions, variegated colors, the usually marked areola, the decided tendency to concentric arrangement of the lesions, the seat of the disease,—all tend to distinguish it from pemphigus. The thick, bulky, greenish crusts of the bullous syphilide, with the underlying ulceration, its course, and the presence of concomitant symptoms of that disease, taken with the history of the case, are points of difference. Impetigo contagiosa may at times strikingly resemble pemphigus, but the history of the case, its distribution, the contagious and auto-inoculable properties of the contents of the lesions, and the characteristic crusting of the former disease,—are all available in the differential diagnosis. The blebs of pemphigus are to be distinguished also from the accidental blebs of urticaria and of erythema multiforme. It is to be remembered also that cases sometimes come under observation in which blebs are, for the sake of feigning disease, produced artificially, the subjects being usually hysterical women.

Pemphigus is in most cases a grave disease. The unfavorable symptoms are the presence of numerous bullæ, the rapid and successive development of new lesions, flabby walls, frequent febrile attacks, loss of strength, and marasmus. It is injudicious, even in mild cases, to express an opinion as to the probable duration of the disease. Both constitutional and local treatment, especially the former, are demanded. The general health should receive careful study and faulty conditions corrected. Good food, milk, wine, or ale, eggs and meat are in most cases to be advised. Suitable hygienic regulations should also receive attention. Arsenic in appropriate doses, long continued, has in some cases almost a specific action: on the whole, it must be regarded as our most valuable remedy. Quinine in full doses, cod-liver oil, iron, and the mineral acids are also of service. External treatment is of importance, and is in many cases demanded for the comfort of the patient. The blebs are to be opened as soon as developed, and the parts anointed with oxide-of-zinc ointment. Lotio nigra, used as in eczema, will sometimes be found soothing, as also lotions containing liquor carbonis detergens or liquor picis alkalinus. Dusting-powders of zinc oxide with talc and starch are likewise useful. Baths containing bran, starch, or gelatin sometimes afford ease. Corrosive-sublimate baths, one or two drachms to the bath, and alkaline baths in some cases prove of service. After the bath an application of an ointment or mild dusting-powder may be made to advantage. Where baths prove unsuitable or are impracticable, mild ointments may be used, such as diachylon ointment, vaseline, cold cream, or zinc ointment, spread upon cloth and bound down with bandages.

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CLASS IV.—HYPERTROPHIES.⁵

⁵ Purpura, constituting Class III., appears in Vol. II. p. 186, as a separate article by I. E. Atkinson.

Lentigo.

Lentigo, or freckle, is characterized by irregularly-shaped, rounded or angular, pinhead- or pea-sized, yellowish or brownish spots of pigment deposit, occurring for the most part upon the face and the backs of the hands. They may appear as blemishes scarcely perceptible to the casual observer, or to such an extent and with such intensity of color as to be disfiguring. They may show themselves as discrete or as confluent lesions, and in the latter event the skin presents a spotted, rusty, or dirty appearance. As stated, the face and the backs of the hands are usually attacked, but other regions may also be invaded. They are encountered at all ages, but usually in young persons, especially in those of light complexion, and more particularly in red-haired subjects. They pursue a chronic course, lasting, as a rule, a lifetime, being, however, in most cases much paler in winter than in summer. Sometimes the lesions are blackish rather than brownish, and cases are on record where such were numerous and occupying the general surface. Blackish freckles are also met with in connection with certain rare forms of atrophy of the skin proper complicated with telangiectases, as in the cases reported by Hebra and Kaposi, Taylor, and one of us (Duhring), an account of which may be found under atrophy of the skin.

The affection consists of a circumscribed deposit of pigment, which in the majority of cases is due to the influence of the sun's rays, but there are cases in which the lesions cannot be assigned to this cause, as, for example, where they occur upon the trunk or other regions not exposed to light. The treatment will be referred to in connection with chloasma.

Chloasma.

Chloasma may be described as a pigmentary affection, consisting of variously sized and shaped, more or less defined, smooth patches of a yellowish, brownish, or blackish color. The affection is one merely of coloration, the structure of the skin proper being normal. The spots or patches vary much as to size and shape. As a rule, they are irregular in outline, and not infrequently they are angular. They vary in size from a small coin to a hand or larger. At times the affection may develop as a diffuse or even as a universal discoloration. The distribution of the pigment may be uniform, but more frequently it is mottled, giving the skin a thick, muddy, or dirty appearance. Under idiopathic chloasma are included the forms of pigmentation due to various external agencies, as, for example, chemicals, sinapisms, heat, and long-continued scratching. The symptomatic group comprises uterine chloasma and the discolorations occurring in connection with certain general maladies, among which cancer, tuberculosis, Addison's disease, and malaria may be mentioned. Chloasma is also met with as a symptom in certain diseases of the skin proper, as scleroderma, morphoea, leprosy, and syphilis.

Chloasma uterinum, the commonest form, appears in all degrees from a duskiness or swarthiness of the complexion to pronounced patches of mottled yellowish or brownish discoloration, occurring on the face usually of pregnant women. But the same condition is met with also in single women, and at times in men. In women it usually appears as a more or less broken patch invading the forehead, extending from temple to temple, but the nose, cheeks, and chin are likewise very frequently attacked. It is due both to physiological and to pathological changes in the uterus, and also to various disorders of the menstrual function. The nervous system in many cases is without doubt at fault, and to this cause must be assigned those cases occurring in men. It is encountered, as a rule, between the ages of twenty-five and fifty. Its course is variable, depending upon the cause, but, as a rule, it is persistent, and it may continue for a long period. It is liable to be confounded with tinea versicolor, from which, however, it may be readily distinguished by the observation that in the latter disease the surface of the skin is the seat of more or less furfuraceous desquamation, which becomes more evident by scraping. In chloasma the skin is normal in structure. The patches of tinea versicolor are usually more numerous than those of chloasma, and occupy the trunk, a region seldom invaded by the latter affection. The face is the common seat of chloasma, a region practically exempt from tinea versicolor.

The treatment consists in removing the cause where this is possible, or in modifying it by such general remedies as appear indicated. Among the various local remedies corrosive sublimate is one of the most valuable, used in the form of a lotion with water, alcohol, or almond emulsion. Its strength should vary from half a grain to five grains to the ounce, according to the region, size of the spot, sensitiveness of the skin, and the effect produced. Two or three grains to the ounce will generally be found of sufficient strength; and this may be applied, dabbed on lightly for five or ten minutes, twice daily, until irritation or desquamation appears. A lotion recommended by Hardy is the following:

Rx.	Hydrargyri chlor. corros.,	gr. viiss;
	Zinci sulphatis,	drachm ss;
	Plumbi acetatis,	drachm ss;
	Aquæ,	fluidounce iv. M.

Ammoniated mercury, from forty to eighty grains to the ounce of ointment, may also be referred to as of positive value.

The following formula may also be given:

Rx.	Hydrargyri ammoniati,	drachm j;
	Bismuthi magist.,	drachm ss;
	Ugt. aquæ rosæ,	ounce j.

M.—Sig. Apply at night.

Sulphur ointments, as of precipitated sulphur one or two drachms to the ounce, are also at times useful. The applications may be suspended from time to time should irritation occur. The treatment in some cases is followed by good results, while in others it is unsatisfactory. The discoloration, having been removed, may remain away, or, as often happens, may recur. The treatment recommended for chloasma is that which will be found of most service in lentigo.

There are other discolorations, of a different nature, which may be referred to here, as the staining due to the coloring matter of the bile, and that sometimes following the internal use of nitrate of silver, known as argyria, where the skin assumes a bluish-gray, bronze, or blackish shade. Neumann states that reduced silver is found in all parts of the skin except the lining epithelia of the glands and the cells of the mucous layer of the epidermis. The deposit also occurs in the internal organs.

Keratosis Pilaris.

Keratosis pilaris (also called lichen pilaris and pityriasis pilaris) is an hypertrophy of the epidermis about the apertures of the hair-follicles, forming pinhead-sized, conical epidermic elevations. The lesions are met with usually about the extensor surfaces of the thighs and arms, especially the former, but they may also occur on other parts. They are whitish, grayish, or blackish in color, are rarely larger than a pinhead, each being pierced by a hair, around which are accumulated, in the form of strata, the horny cells of the epidermis. In some lesions the hair is broken off at the apex, appearing as a black central point; in others the hair is not visible, but is found coiled or twisted up within the papules. The skin is dry, harsh, or rough, and together with the papules may feel like a nutmeg-grater. The skin at the base of each papule is of a normal color or slightly reddened. The elevations consist of an accumulation of epidermic cells and sebaceous matter about the orifices of the hair-follicles. The affection in its milder forms is not uncommon, and is encountered usually in cold weather, and especially in those who bathe infrequently. It may occur at any age, but is most common in early adult life. Slight itching is occasionally present. As ordinarily observed, it is a slight disorder, but shows a tendency to persist. It resembles somewhat cutis anserina, the miliary papular syphiloderm in the desquamating stage, and also lichen scrofulosus. In goose-flesh (cutis anserina) the elevations are of a different nature, being due to cold, heat, or nervous excitement. The papules of the syphiloderm tend to group, are firmer, more deeply seated, less scaly, and of a reddish color. In lichen scrofulosus the papules are more solid in character, incline to group, are less scaly, and usually appear about the abdomen.

The disease is readily removable by treatment. Hot baths with the free use of strong soap, as sapo viridis, will usually suffice in ordinary cases; alkaline baths are also serviceable. In rebellious cases oily applications, such as the petroleum preparations, lard, and glycerin, or sulphur ointment, may be used in conjunction with the baths.

Molluscum Epitheliale.

Molluscum epitheliale, also called molluscum contagiosum and molluscum sebaceum, is characterized by rounded, semiglobular, flattened, or verrucous papules or tubercles of a whitish or pinkish color, varying in size from a pinhead to a pea. As generally met with, they are the size and shape of a small split pea; in other cases they are more acuminated or are in the form of a very small pearl button. They have a broad base and are seated close to the general surface. As a rule, they are multiple, three or six or more being present in different stages of evolution. They are unaccompanied by subjective symptoms. The skin covering them is stretched, and they have a glistening or waxy look, and at times resemble a drop of wax. In consistence they are usually firm, becoming soft with age. Their summits are sometimes flattened and umbilicated, with a central darkish point representing the mouth of the follicle. Their usual seat is the face, especially the eyelids, cheeks, and chin, but the neck, breast, and genitalia may also be invaded. They grow slowly in most cases, and are unaccompanied by inflammatory symptoms. Later, they become soft and tend to break down, with at times ulceration.

The disease is rare in this country, and is seldom encountered in our experience either in dispensary or in private practice. It occurs chiefly in children, and more especially among the poorer classes. Its cause is obscure. By some authorities it is considered to be contagious, this view being more generally entertained in England (where the disease seems to be more frequently encountered than elsewhere) than in other countries. The evidence for believing it to be contagious, however, does not seem sufficient to warrant such a conclusion. Inoculation has failed to develop the disease. Some observers consider that the process has its origin in the sebaceous glands, while others—ourselves among the number—hold that it is a disease of the rete mucosum. It is to be regarded as a hyperplasia of the rete. If the tumor be cut into, the contents may usually be expressed in the form of a whitish or yellowish rounded mass of a thick or thin cheesy consistence. Under the microscope it is seen to be composed of epithelial cells with nuclei and of peculiar rounded or ovoidal, sharply-defined, fatty-looking bodies—the so-called molluscum bodies, which are to be viewed as a form of epithelial degeneration. The growth probably begins in the hair-follicles, as originally stated by Virchow and more recently confirmed by Thin.

The disease is to be distinguished from molluscum fibrosum, from papillary warts, and from acne. Local treatment, consisting of incision and expression of the contents, with subsequent cauterization with nitrate of silver, is the best procedure. They may also be ligated. As the disease tends to spontaneous cure, the remedies employed should be simple in character.

Callositas.

Callositas (syn., tylosis, tyloma, callus) is characterized by the formation of a hard or horny thickened patch of epidermis, variously sized and shaped, and of a grayish, yellowish, or brownish color. The patches are usually coin-sized, more or less rounded in shape, grayish, yellowish, or brownish in color, somewhat elevated, and of a dense and firm texture. They are most common about the hands and feet, and in a measure are protective to the more sensitive corium beneath. The ordinary surface lines are less distinct than on the surrounding healthy skin, into which the patch gradually merges. The thickening and elevation may be slight or excessive, and are most marked at the centre. The process rarely gives rise to any annoyance or pain, but when excessive the more delicate movements of the parts are restricted. Occasionally, from accidental injury, the underlying corium becomes inflamed, suppurates, and as a result the thickened mass is cast off. When occurring about the joints from motion of the parts, it may, moreover, become fissured and painful. Pressure and friction are the main factors in the production of a callosity—on the hands from the use of tools and implements, and on the feet from ill-fitting shoes. But cases are seen exceptionally in which there has been no apparent external cause; moreover, the same amount of pressure or friction in different individuals may give rise to different degrees of callosity; hence there must in some cases be other causes which at times enter into its production, as, for example, altered nerve-supply. The epidermis is the only part involved; fissuring and suppuration, it is true, involve the deeper structures, but these conditions are accidental and secondary. A section of a callosity shows a thickening of the horny layer, the corium remaining normal.

Unless the callosity is excessive or gives rise to inconvenience, treatment is rarely demanded. When advisable, the parts are to be softened by means of hot-water applications or poultices, solutions of caustic potash, or sapo viridis used as an ointment; after which the callus may be removed by scraping with a dermal curette or shaving with a sharp knife. An excellent method of treatment consists in the continuous application for some days of a plaster of salicylic acid of 10 or 12 per cent. strength, the same to be renewed every few days; at the end of a week or two the parts should be soaked in hot water, and the mass will readily come away. A solution of salicylic acid in collodion of the same strength or stronger, applied frequently for five or six days, will often act in like manner.

Clavus.

Clavus, or corn, is a small, circumscribed hypertrophy of the horny layer of the epidermis, painful upon pressure, situated usually about the feet. As commonly met with, it is about the size of a pea, with a smooth and shining surface, having a hard and horny feel. Corns are seen most frequently upon the outer surface of the little toe, but are often met with also upon the other toes and on the soles of the feet. Occurring between the toes, the moisture and friction of the part have a softening effect, and as a result the corns are soft and spongy, constituting soft corns. One, several, or more may be present. When slightly developed they cause very little disturbance or discomfort, but if large or irritated they may become sensitive and render walking painful. Continued pressure and friction, as from badly-fitting shoes, are the active factors in their production. Anatomically, a corn is a localized epidermal hypertrophy, consisting of a horny mass, cone-shaped, with the base externally and the apex pressing upon the rete and corium; the cone being made up of concentrically-arranged, closely-packed layers of epidermic cells. The corium upon which this cone-shaped mass presses may be atrophied or hypertrophied.

The first essential in the treatment is a removal of the cause. The feet should be properly fitted. The corn is to be softened by means of continuous or repeated soaking in hot water or by poulticing, after which it may be pared down or extracted. Salicylic acid, either in solution or in the form of a plaster, 15 or 20 per cent. strength, applied for several nights, will often give relief. A well-known and efficient formula is the following:

Rx.	Acidi salicylici,	gr. xxx;
	Ext. cannabis Indicæ,	gr. x;
	Collodii,	fluidounce ss. M.

Sig. Paint on every night and morning. At the end of several days or a week the part is soaked in warm water and the epidermic mass, or greater portion of it, is readily detached. Nitrate of silver is useful after softening of the growth has been brought about, and is also of advantage in the treatment of soft corns. Caustic potash, thirty to sixty grains to the ounce of water or alcohol, is also of service, but is to be employed cautiously. Considerable relief to the soft formation is obtained by separating the toes with a thin layer of raw cotton. A ring of rubber, wadding or felt should be employed to prevent pressure and friction upon a corn, and, as this removes the exciting cause, permanent relief may follow.

Cornu Cutaneum.

Cornu cutaneum (syn., cornu humanum, horny tumor) is characterized by the development of a true horny formation of variable size and shape, arising from the skin. The growth bears a striking similarity to the horns of the lower animals. It is a solid, dry, harsh, somewhat brittle formation, usually more or less tapering, conical, or rounded, crooked or twisted, with a laminated, irregular, and fissured surface, and of a grayish-yellow or brownish color. Horns vary as to size and form, being a few lines or several inches in length, with a broad base, and tapering toward the end. They may be broad and flat or elongate. They have a flattened or concave base resting directly upon the skin, with the underlying and surrounding tissue normal, slightly elevated, or inflamed and undergoing epithelial degeneration. In some cases the papillæ are much enlarged and extend up into the growth. Ordinarily, there is present but one growth, but in some instances several or a dozen or more have been observed in a single case. The face and scalp are favorite regions, and to a less degree the male genitalia. As a rule, the horns are painless, but if injured more or less pain is usually experienced about the base. They rarely develop before middle age, attain a certain size, and then tend to loosen and fall off, disclosing an ulcerating base, from which a new growth is usually reproduced. Epitheliomatous degeneration is not an uncommon sequela.

Anatomically, the growth has its origin in the deeper layers of the stratum mucosum, either from that lying directly over the papillæ or from that lining the follicles and glands. It is essentially an epidermic hypertrophy, similar or closely related to warty formation. A variable degree of papillary hypertrophy, the papillæ running up into the base of the horn, is invariably present, and precedes, doubtless, the horny outgrowth. The horny cells are massed together to form columns, and in the columns themselves are concentrically arranged. Blood-vessels also appear in the base of the growth. There can be no difficulty in the diagnosis. In regard to prognosis the possibility of degeneration into epithelioma is to be kept in view. If the horn becomes detached or is knocked off, it is almost invariably reproduced. Properly managed, horns are easily removed and permanent freedom assured. The possibility of epitheliomatous degeneration, as well as their unsightliness, demands active treatment. The formation is to be detached and the base thoroughly scraped with the dermal curette, and pyrogallic acid or arsenious acid applied, as in epithelial cancer; or it may be cauterized with zinc chloride or caustic potash. The galvano-cautery is also efficient, while in some cases excision may prove the best method of treatment. If the base is properly treated, a return of the growth rarely occurs.

Verruca.

Verruca, or wart, is a hard or soft, rounded, flat, or acuminated, circumscribed epidermal and papillary formation. There are several forms of warts. The most common variety, verruca vulgaris, is seen mostly upon the hands. It is usually split-pea-sized, elevated, circumscribed, rounded, with a broad base. At first there may be epidermal hypertrophy, but later this in a measure disappears, and the hypertrophic papillæ constitute the growth and are seen as minute elevations. It is firm, hard, or horny, and the color is ordinarily the same as the surrounding skin, but at times it is darker. The papillæ forming a wart are sometimes so irregularly developed as to make it appear lobulated, causing a cauliflower-like form. One, several, or great numbers may be present. Another form is verruca plana, or flat wart, differing from the ordinary wart described above in being flat and broad. It is usually the size of a split pea or finger-nail; occurs most frequently upon the back, especially in elderly people; and is usually brownish or blackish in color, constituting verruca senilis and keratosis pigmentosa. Verruca filiformis, a third variety, is a thread-like formation, usually about an eighth of an inch in length, occurring singly or in groups, and generally about the face, eyelids, and neck. Verruca digitata, another form, is mostly observed upon the scalp, and occurs as a slightly elevated formation, varying in size from a pea to a finger-nail, and marked by digitations, especially noticeable about the border.

Verruca acuminata (syn., venereal wart, pointed wart, moist wart, fig wart, pointed condyloma, cauliflower excrescence; verruca elevata) consists of one or more groups of acuminated or irregularly-shaped elevations, usually so closely packed together as to form a more or less solid mass of vegetations. At times they present an appearance of granulation tissue. In color they are usually pinkish or reddish, and are seen mainly about the genitalia, more particularly about the glans penis, on the inner side of the prepuce, and about the labia, and more rarely about the arms, axillæ, umbilicus, and toes. They are dry or moist according to the regions about which they occur and to other circumstances. The secretion from the moist formation is yellowish and of a puriform character, undergoing rapid decomposition and giving rise to a penetrating and often disgusting odor. They are seen both in men and women, especially in young people; develop rapidly, at times attaining the size of a fist; and variously resemble the cauliflower, cock's-comb, fungi, or raspberries.

The etiology of warts is not known. They are common to both sexes, and are much more frequent in the young. The various causes which, in the popular mind, are capable of producing these growths are merely conjectural, and in most instances have no foundation in fact. The acuminated wart is usually caused by irritating secretions. Anatomically, a wart consists of a connective-tissue growth as a basis, with papillary and slight epidermic hypertrophy, the interior of the growth containing vascular loops. In the acuminated or venereal wart there is considerable connective-tissue growth, the papillæ being markedly enlarged, the cells of the mucous layer highly developed, and the vascular supply abundant.

There is rarely any difficulty in the diagnosis, as the formations are well known and their characters pronounced. Prognosis is favorable; as a rule, the growths respond rapidly to treatment; at times, however, they prove obstinate. When they exist in numbers it is best to remove a part only of the whole manifestation at a time. Occasionally removal of several will be followed by spontaneous disappearance of the others. In some cases, indeed, after existing a shorter or longer period, they tend to disappear without treatment.

Excision by means of the curved scissors or a knife in some cases will be found the best method of dealing with them, their bases immediately after the operation being touched with nitrate of silver. Caustics, such as potassa, chromic acid, nitric acid, and acetic acid, may be employed, but strong remedies should be applied with care. Touching the growths frequently with a 10 to 20 per cent. solution of salicylic acid or a salicylic-acid plaster of the same strength, constantly applied, will be found useful. Multiple flat warts may be treated with a paste of precipitated sulphur and equal parts of acetic acid and glycerin, prepared at the time of using. In obstinate and relapsing cases the internal use of arsenic has been recommended. Stimulating powders and lotions, such as calomel, burnt alum, powdered savine, solution of chlorinated soda, and carbolic acid, may be used in the acuminated variety.

Nævus Pigmentosus.

Nævus pigmentosus, commonly called mole, is a circumscribed pigmentary deposit in the skin. In addition to hypertrophy of pigment there may also be hypertrophy of one or of all of the other cutaneous structures, especially of the hair. When the surface of the nævus is normal and smooth it is termed nævus spilus; if there is a growth of hair upon it, nævus pilosus; if the connective tissue is increased, forming growths of variable dimensions, it is designated nævus lipomatodes; if the surface is rough and warty, nævus verrucosus. Moles may be congenital or acquired, usually the former. As ordinarily met with, they are rounded, of the size of a coffee-grain, the color varying from a light yellowish-brown to a chocolate or black. The trunk, neck, back and face are favorite localities. One or more may be present, usually upon different parts of the body, or in exceptional cases following nerve-tracts. When once formed there is little tendency to change. They occur with equal frequency in both sexes. Anatomically, there is found an increase in the natural coloring-matter of the skin, and in almost all cases variable degrees of connective-tissue hypertrophy. Enlargement of the papillæ gives rise to nævus verrucosus, and an increase in size and numerically of the hair-bulbs constitutes nævus pilosus.

Treatment of a nævus consists in its removal by means of caustics or the knife. The small and flat lesions may be removed with potassa or the ethylate of sodium; a 1 per cent. solution of corrosive sublimate, applied for a few hours by means of compresses, causes blistering and usually the removal of the pigment. Excision or thorough cauterization may be employed for nævus verrucosus and nævus lipomatodes. The galvano-caustic has also been advocated.

Ichthyosis.

Ichthyosis, also called xeroderma and fish-skin disease, is a chronic, hypertrophic disease, usually occupying the whole surface, characterized by dryness or scaliness of the skin, with a variable amount of papillary growth. There are two varieties of the disease,—ichthyosis simplex and ichthyosis hystrix, arbitrary divisions, however, employed to designate the milder and more severe forms respectively.

The milder variety is that which is usually encountered. In this form the disorder may be so trifling in character as to give rise to simple dryness or harshness of the integument,—a condition to which the term xeroderma has been given. In others the process may be more developed, and the scales somewhat thick, having a polygonal or plate-like form. When the latter is the case, the form and size of the plates are usually determined by the natural lines or furrows of the parts. The scaling may be merely thin and bran-like or thick and horny, resembling fish-scales. In the milder forms of this variety the color of the scales may be light and pearly; when more or less thickly developed, may be dark, even olive-green or blackish. This color cannot be attributed entirely to extraneous matter, pigment-granules having been demonstrated in the scales. The amount of scaling depends somewhat upon the age of the patient, the severity of the disease, and also the frequency of ablutions. If the scales are allowed to accumulate, they may become enormously thickened. The disease is found most developed upon the extensor surfaces of the upper and lower extremities, especially the latter, the flexor surfaces in mild cases being free. The scales are firmly attached, but can usually be removed without injury to the underlying parts.

In the other variety of the disease—ichthyosis hystrix—in addition to excessive formation of scales there is marked papillary hypertrophy, at times the papillary outgrowths reaching several lines, bearing resemblance to the quills of a porcupine. This resemblance has given rise to the qualifying term hystrix. This variety of the disease is not apt to be so generalized as the milder variety. It is not infrequently seen to occur as one or more rounded, irregular or linear patches, solid, corrugated, warty or spinous in character. The patches may exist close together or widely separated or along nerve-tracts, and the other parts of the surface may exhibit the milder variety.

Ichthyosis is usually first noticed in the early months of childhood, from which time it becomes progressively worse until it reaches a certain point, and then usually remains stationary throughout life. It is common to both sexes. The scalp and face usually escape. The condition is affected favorably by warm weather, so much so that the milder forms of the disease disappear entirely during the summer, to reappear as soon as the cold season begins. Even the severer forms of the affection disappear to some extent during the warm months. This change is due to the activity of the glands in the summer, the secretions macerating the epidermis, rendering the removal easy and thus relieving the patient. Unless the affection is well marked subjective symptoms rarely exist, but slight itching is sometimes present. In the well-developed cases, however, the scales may become so thick and the hypertrophy so marked as to interfere with the natural mobility of the parts, or as a result of motion fissures may occur. The general health of patients suffering with ichthyosis is usually noted to be good.

The causes of the disease are not clearly understood. An hereditary tendency is frequently traceable. The affection is to be looked upon more in the light of a deformity than as a disease. Although it does not manifest itself, as a rule, until the end of the first or second year, it is nevertheless to be considered, in most instances at least, as born with the individual. The disease is so slight in the beginning that in view of the repeated ablutions that infants are subjected to it might exist slightly in the first months of life without being noted. Race and climate have been stated as important factors in its production. It will be found, however, that where it exists in any great proportion, as in Paraguay and in the Moluccas, for various reasons intermarrying among the natives is the practice, and it is unquestionably a natural consequence that a distinctly hereditary disease should become frequent under such conditions. In this country the disease in its marked form is comparatively rare.

Anatomically, a constant feature of the disease is epidermic hypertrophy. This may be slight or marked according to the severity of the process. There is usually also considerable hypertrophy of the papillæ. In some cases, in addition to these conditions the rete may found hypertrophied, the blood-vessels dilated, the hair-follicles and the sweat and sebaceous glands more or less involved. The features of the disease—the harsh, dry skin, the hypertrophy of the epidermis and papillæ, the furfuraceous or plate-like scaliness, the greater development of the affection upon the extensor surfaces, and the history—are so characteristic that a diagnosis is a matter of no difficulty. From psoriasis, scaly eczema, and the other inflammatory scaly disorders it may be distinguished by the absence of inflammation.

The prognosis of the affection, as already intimated, is unfavorable as regards its cure. In only a few cases has a cure been noted. Hebra reports two such cases, the disappearance of the affection having followed an attack of one of the exanthematous fevers. Internal treatment is very rarely, if at all, of any benefit. Some good has been stated to follow the administration of linseed oil. In a few cases under observation jaborandi in moderate doses has temporarily influenced the disease favorably, probably by increasing the action of the sweat-glands. Although the prospect of a cure is entirely unfavorable, the affection may be, in almost all cases, kept in abeyance by external measures. Oily applications, soaps, and frequent bathing are the measures to be advised. In mild cases simple baths, frequently repeated, will suffice. In others it may be necessary to make the bath alkaline by the addition of bicarbonate of sodium, three to six ounces to the bath: the patient should soak in the bath for thirty minutes or longer. Where the alkaline baths seem unsuitable or fail to benefit sufficiently, the hot bath and washing with sapo viridis may be employed. The vapor bath is particularly serviceable in these cases. Rubbing in some mild ointment, allowing it to remain a few hours or longer, and then following it with a hot bath and green-soap washing, subsequently rinsing with simple warm or hot water, and then again anointing the surface with the ointment, will be found valuable in the more severe cases. An ointment such as the following may be employed for this purpose:

Rx.	Adipis benz.,	ounce j;
	Glycerinæ,	drachm j;
	Ugt. petrolei,	ounce j.

M. Ft. ugt.—Apply after bathing.

Or,

Rx.	Potassii iodidi,	scruple j;
	Glycerinæ,	drachm j;
	Adipis benz., Ol. bubuli, aa.	ounce ss.

M. Ft. ugt.—Apply once daily.

Or any simple oil or salve may be substituted. In the more severe cases of the hystrix variety, in addition to the measures already described, it may be necessary to employ caustics, or even the knife, for the removal of the horny patches which form. For localized patches a 10 to 20 per cent. salicylic-acid plaster will be found useful. For the general scaliness the same drug in ointment form, 5 to 10 per cent., will prove of benefit.

Onychauxis.

Onychauxis (syn., onychogryphosis, hypertrophy of the nail) is seen as an idiopathic affection and also as a consequence or accompaniment of other diseases. The hypertrophy may consist in excessive length, width, thickness, or all combined. In addition to the increase in size, the nails may be abnormal as regards their shape, being twisted, conical or curved, their surface roughened, uneven or furrowed, and may also be attended with changes in color and consistence. If the hypertrophy increases the width to any marked extent, the parts encroached upon become irritated and inflamed, resulting in paronychia. At times the matrix may be the seat of inflammation, giving rise to structural changes in the nail-substance,—onychia. One, several, or all the nails, both of the fingers and toes, more frequently the latter, may be involved. Hypertrophy of the nail is met with in eczema, psoriasis, ichthyosis, leprosy and syphilis, and also as a result of the invasion of the vegetable parasites of tinea trichophytina and favus. The rare diseases lichen ruber and pityriasis rubra may also involve the nails. In syphilis infiltration of the matrix gives rise to the changes in the nail-substance. The nails in eczema and psoriasis are thickened and brittle, with an uneven surface. In some cases, especially those due to the vegetable parasites (onychomycosis) softening occurs.

Treatment depends upon the cause. Both constitutional and local means are in most cases employed. The nail should be softened and trimmed by means of the scissors or knife. Inflammation of the surrounding tissues is to be combated by the ordinary methods, and all sources of irritation avoided. Ingrowing nails should be cut transversely and not rounded, and the soft parts may be relieved of pressure and irritation by placing a piece of lint or cotton between the nail and skin-fold. In hypertrophy due to syphilis, psoriasis, and like diseases appropriate constitutional treatment is essential. In onychomycosis the parasiticides are to be applied.

Hypertrichosis.

Hypertrichosis (hirsuties), or hypertrophy of the hair, is a term applied to unnatural growth of hair, either as regards region, extent, age, or sex. It may be slight or excessive; thus, it may be universal, as in the so-called hairy people (homines pilosi), or limited, as upon a wart or nævus (nævus pilosus). The hairs themselves may be fine, coarse or of the average thickness. The hair of the scalp, eyebrows, axillæ, pubes, and beard in men may show excessive development either in thickness or length. Increased activity of hair-growth may take place in the fine downy hairs present over the greater portion of the surface. It may occur in the very young—in fact, may be congenital—and the growth may also appear on the face, arms, and other parts of females, resulting, of course, from a hypertrophy of the natural lanugo hairs.

It is difficult to give any definite or satisfactory explanation of the causes which give rise to unnatural growth of the hair. It is seen more frequently in persons of dark complexion, and may be congenital or acquired; if the latter, the tendency to excessive development manifesting itself, as a rule, toward middle life. It is frequently associated in women with other masculine peculiarities, appearing especially at the climacteric period, and also noted in connection with the diseases of the uterus and ovaries. It is sometimes seen in sterile women, also on the faces of insane women. Local stimulation or irritation will at times have a curative influence.

For general hirsuties there is no remedy. Hairy nævi, if small, may be treated by excision, or, if large, the hairs may be removed by electrolysis, as described below. The excessive growth seen about the faces of women is an annoying disfigurement, and such patients will submit to almost any treatment with the hope of relief. Extraction of hairs and shaving are frequently employed, but give only temporary relief. The method of removal by electrolysis is the only plan which promises permanent success. A fine needle in a suitable handle is attached to the negative pole of a galvanic battery, introduced into the hair-follicle alongside of the hair to the depth of the papilla, and the circuit made by the patient touching the sponge electrode attached to the positive pole. At the point of insertion the parts become blanched, and frothing appears at the aperture of the follicle, a result of the decomposition of the tissues at the point of the needle. The action should be continued for several seconds or longer, and then the circuit broken by the patient removing the hand from the sponge electrode, after which the needle is to be withdrawn. If the papilla has been destroyed, the hair may be readily extracted by the forceps with very little traction. In most cases, after the needle is withdrawn, or at times even before this, a wheal-like elevation appears at the point of insertion. In some cases the follicles may suppurate. Scarring, which is liable to take place, is to be guarded against. It occurs more markedly in some subjects than in others. Noticeable scarring, however, may generally be prevented if the operator is skilful. The operation is somewhat painful, the amount of pain varying with different persons, in some being slight, while in others it is severe. A current from four to twelve cells of a freshly-charged battery usually suffices.

Removal of hairs by the use of depilatories is considerably practised, but, as they are caustic in their nature, they should be employed with care. If prescribed, one made up of two drachms of barium sulphide and three drachms each of oxide of zinc and starch may be recommended. Enough water is added to the powder to make a paste, which is thinly laid on the parts for ten or fifteen minutes. Heat of skin or a burning sensation soon occurs, upon the advent of which the paste is immediately to be scraped off, the parts thoroughly cleansed, and a mild ointment applied. As with extraction and shaving, this method is only temporary in its effects.

Sclerema Neonatorum.

Sclerema neonatorum, or sclerema of the new-born, is a disease of infancy manifesting itself usually at birth, characterized by a diffuse stiffness, rigidity or hardness of the integument, accompanied by coldness, oedema, discoloration, lividity, and general circulatory disturbance. Frequently it is congenital. It usually begins on the lower extremities, extending upward and invading the trunk, arms, and face. The skin is reddish, purplish or brownish, glossy, and tense or stretched, causing more or less rigidity and stiffness. The surface is usually cold, and upon pressure oedema, together with an infiltrated state of the tissues, is noted. When the disease is general the body bears resemblance to a half-frozen corpse. The child is unable to move, respires feebly, and usually perishes in a few days. The disease is very rare. It is in most cases found associated with pneumonia or with affections of the circulatory apparatus. The causes are obscure. After death the condition of the skin undergoes but little change, the induration remaining; on incision a considerable quantity of serous fluid is poured out, when the tissues become softer and resemble ordinary oedematous tissue. The treatment should consist of warm applications, frictions, and like measures. The prognosis is unfavorable.

Scleroderma.

Scleroderma, known also as sclerema and scleriasis, is an acute or chronic disease, characterized by a diffuse, more or less pigmented, rigid, stiffened or hardened, hide-bound condition of the skin. It was first described by Alibert with the name sclérèmie des adultes, since which time many cases have been recorded. The first symptoms consist of more or less rigidity or induration of the integument, which may increase rapidly, or, as is usually the case, slowly, until the region affected becomes hard and bound down to the tissues beneath. In some cases febrile symptoms, oedema, and pigmentation precede the induration, but usually the process asserts itself insidiously, the first symptom noted by the patient being the sclerosis. In marked cases the skin is rigid, tight, or immovable, and is firm or positively hard to the touch, as though frozen, but without the sensation of cold. In some cases it may seem wooden or as though undergoing petrifaction. It is hide-bound, and cannot be made to glide over the structures beneath, nor can it be taken up between the fingers. The skin, owing to the immobility, becomes set or fixed, the natural lines and wrinkles disappearing, causing persons to look younger. The induration is diffuse, being neither circumscribed nor defined, and generally occupies a considerable area, the face, neck, back, chest, and upper extremities being the regions most frequently involved. It may occupy variously sized and shaped areas, for the most part irregular in outline, or it may appear in the form of narrow or broad bands or elongated patches, which usually become more or less shrunken and sunken atrophic lesions.

The surface of the integument in scleroderma is usually on a level with the neighboring healthy skin, except in the later stages where atrophy has occurred, and is generally smooth and shining. Pigmentation is in most cases a marked symptom, being yellowish or brownish, in the form of patches, giving a dirty, chloasmic appearance to the part. Subjective symptoms are usually wanting, although there may be numbness or cramp-like pains, especially when the limbs are the seat of the disease. The skin in all cases feels contracted, tightly stretched or too short. The disease may be limited, as is generally the case, or it may occupy the greater portion, or even the whole, of the body. It is usually symmetrical. It pursues a variable course, at times acute, but more frequently chronic, extending over a period of years or throughout life. Sooner or later resolution and recovery set in, or atrophic changes take place, characterized by a wasting or a condensation of the integument and of the subjacent tissues, causing contraction and deformity, which are especially marked when occurring about joints. As a rule, the general health remains good. The disease in some cases is accompanied by patches of morphoea, which affection is regarded by some authors as being merely a circumscribed variety of scleroderma.

The causes are obscure. The disease is rare, and is encountered oftener in women than in men, and occurs usually in early adult or middle life. Sudden changes of temperature, exposure to wet or cold, and violent impressions on the nervous system have been cited as causes. The anatomy of the disease has been studied by various observers, but with different results, in the majority of cases slight structural changes only having been found. Both the true skin and the subcutaneous connective tissue are the seat of the process, showing a marked increase of the connective tissue, with thickening and condensation of the fibres. The disease may be viewed as a tropho-neurosis. The diagnosis, as a rule, presents no difficulty. From morphoea, to which it is closely allied, it may be distinguished by its tendency to involve large areas, occupying sometimes the greater portion or the whole of the integument, whereas morphoea usually appears in smaller lesions. Scleroderma manifests itself diffusely and without lines of demarcation; morphoea is circumscribed, and in its early stage is surrounded by a pinkish border. Scleroderma is always characterized by stiffness or hardness, whereas morphoea is usually soft or firm. In scleroderma the skin is merely rigid or hard in the beginning, whereas in morphoea there is hyperæmia and only slight induration.

Concerning the treatment of this disease there is but little to be said. Constitutional remedies, such as arsenic, quinine, and cod-liver oil, together with the employment of stimulating oily or fatty applications, frictions, and electricity are indicated, though it is difficult to state their intrinsic value. The course and termination of the disease varies. In some cases spontaneous involution sets in sooner or later, while in other instances the process continues to progress, and lasts throughout life.

Morphoea.

Morphoea, formerly known as keloid of Addison, is characterized by one or more rounded, ovalish or elongate, coin-sized patches, which, as a rule, are circumscribed and clearly defined. At first they are hyperæmic and pinkish, becoming as the process advances pale yellowish or whitish, with a faint pinkish or lilac border made up of very minute injected capillaries. The patch may be slightly elevated or puffed in the beginning, but later is on a level with the surrounding skin, or even somewhat depressed. When typically developed it is either soft or firm to the touch, or, more rarely, leathery or brawny. The surface is usually smooth, and may be shining and have an atrophic appearance. Not infrequently it resembles in color and in look a piece of cut bacon or ivory laid in the skin. Around the patch there is usually, in addition to the hyperæmic border, more or less diffuse, mottled yellowish or brownish pigmentation. The disease exhibits no disposition to symmetry, but not infrequently it manifests itself over nerve-tracts. The regions commonly invaded are the face, neck, chest, mammæ, back, abdomen, arms, and thighs. The lesions pursue a variable though usually chronic course, lasting, as a rule, years. There is always a marked tendency to varied atrophic changes, which in most cases appear early, the skin becoming thin, shrivelled, or parchment-like, later being bound down to the tissues beneath, forming cicatriform, keloidal lesions, which may cause contraction and deformity, with, in some cases, wasting and general atrophy, more particularly of the extremities.

In addition to the usual characteristic circumscribed patches described, there may exist distinctly atrophic lesions consisting of small pit-like depressions resembling scars; also, reddish or bluish, tortuous, short or long, large and minute, dilated, superficial cutaneous blood-vessels and telangiectases, together with smooth, glazed, whitish, slightly-depressed spots or grooved streaks—true maculæ et striæ atrophicæ. Accompanying these various lesions there is usually considerable diffuse or patchy yellowish or brownish pigmentation. The process in some cases is simple as regards the lesions, but not infrequently it is complex, being characterized, as indicated, by a variety of lesions in different stages of evolution. The course is chronic, extending in the majority of cases over years. The disease in some cases eventually tends to spontaneous recovery; and this is all the more remarkable considering that atrophy has existed. The disease is met with more frequently in females than in males. Impaired nerve-power is without doubt the important factor in its production. Concerning the relation of morphoea to scleroderma, it may be said that these affections are closely allied, and that they may occur together. The pathological anatomy of the characteristic patches varies with the stage of the disease. In the early stages there is shrinkage or atrophy of the papillary layer, with condensation of the connective tissue of the corium. Crocker further noted marked cell-infiltration around the sebaceous glands, hair-follicles, and vessels, and in the later stages the transformation of these cells into fibrillar tissue, its contraction, and the consequent obliteration of blood-vessels, with atrophy of the sebaceous and sweat glands.

Morphoea is to be distinguished from scleroderma, from vitiligo, and from the anæsthetic patches of leprosy. In appearance morphoea and leprosy possess features in common, and it is probable that they are both due to the same cause—namely, perverted innervation. As a rule, no difficulty will arise in the diagnosis, for the reason that in leprosy other symptoms of that disease will almost invariably be present.

To be viewed as a variety or form of morphoea, we may mention hemi-atrophia facialis, or unilateral atrophy of the face, which affection consists of a variable degree of atrophy of the skin and deeper structures, the cutaneous lesions being the same as those in morphoea. The neurotic origin of the disease in this case is plain.

A general tonic treatment, with the long-continued use of such remedies as arsenic, quinine, cod-liver oil, iodide of potassium, and electricity, is called for, most reliance being placed upon arsenic. Good results sometimes follow its administration. The prognosis should always be guarded.

Elephantiasis.

Elephantiasis, or elephantiasis arabum (also called pachydermia, Barbadoes leg, elephant leg), is a chronic hypertrophic disease of the skin and subcutaneous tissue, characterized by enlargement and deformity of the part affected, accompanied by lymphangitis, swelling, oedema, thickening, induration, pigmentation, and more or less papillary growth. The legs and genitalia, especially the former, are favorite localities for its development; about the latter, the penis, scrotum, and clitoris are most frequently involved. It begins with an inflammation of the parts, erysipelatous in character, attended with febrile disturbance, swelling, pain, heat, redness, and lymphangitis. The inflammation may have its starting-point in a local lesion, as a wound or scar, or, as is usually the case, manifests itself without any apparent cause. Similar attacks occur more or less frequently, after each of which the part remains increased in size. After a year or longer, during which time repeated attacks may have taken place, considerable increase in size is noted: the part is swollen, oedematous, and hard, and the skin hypertrophied, fissured, pigmented, and the papillæ enlarged and prominent. Later, the hypertrophy becomes still more marked; the part is often enormously enlarged and swollen, the skin rough, fissured, and warty. In Eastern countries the disease assumes huge proportions. Eczematous inflammation may coexist and complicate the appearance. The fissures may be slight or large and deep, the normal lines and folds of the surface exaggerated, with more or less maceration of the epidermis taking place, especially about the folds. Ulcers sooner or later tend to form, developing usually from varicose veins, while scales and crusts may also be present. Pain varies, being usually marked during the inflammatory attacks.

Elephantiasis is met with in all parts of the world, but much more frequently in tropical climates, especially about the West Coast of Africa, Brazil, the West Indies, and particularly India, and to less extent in Mediterranean regions and Arabia. In our own country, and also in Europe, it is not common. It rarely occurs before puberty. Heredity has no influence, nor is it contagious. It is commonly observed among the poor and neglected.

The immediate cause of the disease is to be found in inflammation and obstruction of the lymphatics. This obstruction is, according to late investigations, probably due to the presence in the lymphatic vessels of the parasite filaria and its ova. The filaria—a microscopic thread-worm—has been found in large numbers adhering to the walls of the lymphatics and blood-vessels, but is discoverable only during certain hours of the day. The parasite has also been found in lymph-scrotum, a disease closely related to, if not identical with, elephantiasis.

The great mass of the growth in the disease is made up of hypertrophic connective tissue and connective-tissue new growth. All parts of the skin and the subcutaneous tissues share in the hypertrophy. Papillary enlargement is usually a marked feature. The lymphatic glands are swollen and enlarged and the lymphatic vessels prominent. There is marked oedematous infiltration, lymphatic in character. As a result of pressure, the glandular structures of the skin are atrophied or destroyed, the fat atrophied, and the muscles degenerated. The walls of the blood-vessels are thickened.

In well-developed cases of elephantiasis the symptoms are so characteristic that the disease is readily recognized. Recurrent attacks of erysipelatous inflammation of the leg or genitalia will point, with probability, to a development of the disease, even before marked hypertrophy or the clinical features are developed. As regards the outcome of the disease, if the case comes under treatment in the early months of its development the process may be checked or held in abeyance; later, after the affection has become well established, but little more than palliation can be effected.

The inflammatory attacks are to be treated with rest in bed, hot or cold applications, lead-water, and similar measures. Quinine and iron internally, especially the former, are of value. Potassium iodide has also been well spoken of. Climatic change, especially in the early stages, may prove of marked advantage. After the acute symptoms of the erysipelatous attacks have subsided inunctions of iodine or mercurial ointments may be employed to soften the skin and promote absorption. The parts should also be firmly bandaged, either the roller bandage, or, preferably, one of rubber, being used. Instrumental compression and ligation of the main artery of the limb have been employed, at times, with diminution in the size of the part; also excision of a portion of the sciatic nerve was practised in a single case by Morton with reduction in the size of the limb, but these methods of treatment are not to be recommended. Lately, the use of the strong, constant current has been extolled as having a beneficial effect. Elephantiasis involving the genitalia is, if the disease is well advanced, to be treated by the knife, amputation of the parts being practised.

Dermatolysis.

Dermatolysis consists of a more or less circumscribed hypertrophy of the cutaneous and subcutaneous structures, characterized by softness and looseness of the skin and a tendency to hang dependently. It may be slight or extensive, and may be limited to a certain region or show itself simultaneously in several different parts. The integument is thickened, bulky, superabundant, and to a greater or less extent hangs down in folds. The hypertrophy is general over the area affected; the glandular structures, connective tissue, muscular fibres, pigment, and the subcutaneous areolar tissue share in the process. The surface is usually soft and pliable to the touch, but is uneven, in consequence of the hypertrophy of the follicles and the natural folds and rugæ. As a result of the increase in pigment the skin is more or less brownish in color. The tissues may develop to an enormous size, and the redundant parts may hang down in several folds, overlapping one another and forming a cloak to the parts below.

Dermatolysis may be congenital or may not develop until after puberty. It is a simple hypertrophy involving the integument and all its component parts, especially the subcutaneous connective tissue. The causes which bring about this condition are not known. It appears to be closely allied to molluscum fibrosum, the two diseases sometimes occurring together. It is not malignant, but its presence impedes locomotion and its weight is a discomfort.

The affection is classified under the head of elephantiasis by German writers, but the clinical features and course of the two diseases are entirely different. Elephantiasis telangiectodes is a term that has been given to a form of simple hypertrophy of the skin in which a marked new growth of vascular tissue takes place. In connection with this disease mention may be made of the condition characterizing the so-called rubber or elastic-skin man. In this condition there is no hypertrophy. The mobility and elasticity of the skin are probably due to a peculiar and abnormal looseness of the subcutaneous areolar tissue. It is to be looked upon as a congenital deformity. The treatment of dermatolysis is by excision when this operation is practicable.

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CLASS V.—ATROPHIES.

Albinismus.

Albinismus is a term employed to designate that condition in which there is congenital absence of the normal pigment. It may be localized (albinismus partialis) or general (albinismus universalis). Persons in whom it is universal are called albinos. They are characterized by more or less complete absence of pigment in the skin, hair, iris, and choroid. The skin is milky-white, with, usually, a pinkish tint; the hair is white or yellowish, fine, thin, soft, and silky. The eyes are sensitive to light, the pupils appear red and contract and dilate continuously; oscillation of the eyeballs is noted, and also rapid and constant winking. These individuals are usually physically and mentally deficient, with a tendency to pulmonary disease.

Partial albinismus is seen more frequently in the negro. There may be one or more whitish or pinkish-white patches, variable as to size and shape, occurring upon any region. The skin is normal with the exception of loss of pigment. The hairs existing upon the spots are blanched. The eyes show no loss of pigment. The negroes in whom the patches occur are termed pied, or piebald. In exceptional instances a redeposit of pigment has been observed. Albinismus is not confined to any race or climate, and is comparatively rare. Its causes are not known. It is frequently inherited.

Vitiligo.

Vitiligo (known also as acquired leucoderma or leucopathia) is a disease consisting of one or more usually sharply-defined, rounded or irregularly-shaped, variously-sized and distributed, smooth, whitish spots, whose borders usually show an increase in the normal amount of pigmentation. The patches may appear on any region, the backs of the hands and the trunk being favorite localities. The disease begins by the appearance of small pale spots, which gradually increase in size, new patches showing themselves from time to time. They are well defined in outline, the pale milky whiteness of the patches contrasting markedly with the surrounding pigmented skin. The increased pigmentation of the borders is almost an invariable accompaniment of the disease, and may be slight or excessive, gradually becoming less intense as the healthy skin is approached. The patches are smooth, on a level with the surrounding skin, rounded, ovalish, or irregular. They may be small or large, depending upon their age and also upon the rapidity of their growth. If several coalesce, as is frequently the case, large irregular patches are formed. The secretion of the sweat and sebaceous glands and the sensibility of the skin are not disturbed. With the exception of the loss of color the skin is normal. Hairs included in the patches may or may not be whitened. There are no subjective symptoms.

As a rule, the progress of the disease is slow, years frequently elapsing before the patches attain a large area. In some instances, after reaching a certain size, they remain stationary, either for a time or permanently. In most cases, however, the disease is progressive. In rare instances the skin has been known to become normal again. The sole annoyance the disease occasions is the disfigurement, and this is often striking. The spots are but little, if at all, affected by the sun, except that they are rendered more conspicuous by the bronzing of the normal skin which its rays cause. As a rule, the affection first shows itself in early adult life, although it may appear earlier or later. Both sexes, whether of a light or dark complexion, are attacked. The general health is usually good. It is attributed to a disturbance of innervation. Alopecia areata and morphoea have been seen in association with it.

Anatomically, it consists of both an atrophy and a hypertrophy of the normal pigment of the skin, the pale patch resulting from the former, and the pigmented border from the latter. There is no textural change in the skin. It may be mistaken for chloasma, tinea versicolor, and morphoea. In the former diseases, when several patches are close together, the normal skin between appears, in comparison, pale, and if cursorily examined might be mistaken for the pale patches of vitiligo, while the surrounding yellowish patches of tinea versicolor or chloasma may appear as the pigmented borders. In tinea versicolor the patches are slightly scaly. In morphoea there is always structural change.

Treatment in most cases is unsatisfactory. The functions and the state of the general health must receive attention. In some cases arsenic long continued proves of benefit. It is the only known remedy of any value. The disfigurement produced by the patches can in a measure be removed. For this purpose the darkened border should receive appropriate applications, such as are used in the removal of patches of chloasma. The white spots sometimes may be made darker by the application of cantharides, promoting capillary congestion.

Canities.

Canities is a term applied to grayness or blanching of the hair. Loss of pigment in the hair may be partial or general. It may occur early in life or, as is commonly the case, as the result of old age. The change in color may take place throughout the entire hair or in parts. The color varies from slight blanching to white. It is usually grayish. In rare instances the color is to a moderate degree regained in summer. Grayness of the hair in the young—canities præmatura—is exceptional; in the old—canities senilis—it is constant, individuals differing considerably, however, as to the time of life at which the change begins. After the hair has become gray it rarely recovers its coloring matter, although occasionally in the young, after the lapse of years, the hair may again become dark. In those of a dark complexion the loss of pigment occurs, as a rule, much earlier than in those whose hair is of the lighter shades. Usually considerable time is required in the complete change to gray or white, but authentic cases are on record in which the change has taken place in the course of a night or within a few days. The pathology is obscure.

Canities, as may be readily inferred, depends upon a deficient production of pigment. The causes which gives rise to this deficiency are not understood. Hereditary influence is often noticeable. Conditions which impair the general nutrition, such as chlorosis, anæmia, fevers, etc., and those that hinder the local nutrition, as seborrhoea and inflammatory diseases of the parts, may possibly have some influence. In sudden blanching of the hair fright, intense anxiety, and the like are the usual causes. Treatment, whether internal or external, has no effect in preventing the loss of pigment or in restoring it. Dyeing, however, may be practised, and the condition masked; but it is not to be recommended, as the skin of the scalp becomes discolored and the nutrition of the hair interfered with.

Alopecia.

Alopecia consists of partial or complete deficiency of hair, irrespective of cause. There are several varieties, named according to the causes which have produced the affection. Thus, congenital alopecia consists of a partial or complete absence of hair, either over the entire surface or confined to a portion. In some instances there is scantiness or irregular development. In rare cases there is complete absence of the hair, microscopical examination failing to show the existence of hair-bulbs. In cases of congenital deficiency there usually exists an hereditary predisposition.

Senile alopecia and senile calvities are terms applied to the baldness of advanced years. With the loss of hair there is usually atrophy of the other cutaneous structures. In these cases the hairs, as a rule, first turn gray, become dry and thin, and fall out, with no tendency to a new growth. The condition is seen upon the scalp, beginning usually at the crown; in occasional instances other parts of the body may also sooner or later show more or less atrophy of the hairy appendage. Upon the scalp, the skin, which is more or less free of the hair, becomes atrophied, smooth and glossy. The alterations in the cutaneous structures in senile baldness consist of marked atrophy of the sebaceous glands, of the hair-follicles and of the skin itself. The affection is common in men, but is comparatively infrequent in women. No satisfactory reason can be assigned for this. Idiopathic premature alopecia is the term applied to the baldness which begins to manifest itself about the age of twenty-five or thirty. The hairs may fall out rapidly or the loss may take place slowly. In these cases the normal hairs are usually replaced with finer, thinner, and shorter hairs, but finally even these eventually cease to be reproduced, and more or less alopecia results. There is no seborrhoea, and the skin shows no other atrophic change. As a rule, several years elapse before the condition becomes marked. The location affected is the same as in senile alopecia, and the same statement may be made as to its frequency in the two sexes. According to microscopical examination, there is an increase in the connective tissue, compressing the blood-vessels, and thus interfering with the blood-supply of the parts.

Symptomatic premature alopecia includes all those forms of alopecia which are the result of disease, either local or general. Falling of the hair is frequent after fevers and other systemic diseases. Mental anxiety, nervous exhaustion, and depraved conditions of the general health may also cause varying degrees of alopecia. In these cases the shedding of the hair usually takes place rapidly, constituting defluvium capillorum. With a disappearance of the exciting cause there is usually a regrowth, but this is not always the case, as not infrequently the baldness is permanent. Among local diseases which give rise to baldness, chronic seborrhoea is the most important. As a result of the seborrhoea, atrophy of the glands occurs, and alopecia sooner or later sets in. Many other local affections, as lupus erythematosus, erysipelas, variola, tinea tonsurans, and tinea favosa, are at times attended with loss of hair. Syphilitic alopecia may occur at two different periods of that disease. It is noted as one of the early symptoms, and later as the result of the general cachexia, or in localized patches as the result of ulceration and destruction of the skin. The alopecia appearing as a secondary symptom of the disease may be slight or complete baldness may take place, but in either case the loss is rarely permanent if the patient is under proper treatment. As a rule, in the course of a few months the hair is reproduced. The alopecia resulting from ulcerative lesions is permanent.

The treatment of the various varieties of alopecia named depends, as will be readily inferred, upon the etiological causes. Senile alopecia is rarely amenable to treatment. Idiopathic premature alopecia may frequently be benefited by therapeutic measures. The general health is to be looked after. In these cases arsenic in moderate doses long continued may prove of some value. The external treatment has in view the promotion of the nutrition of the skin, which is attained by the use of stimulating applications for the purpose of increasing the vascular supply. The treatment of symptomatic premature alopecia is that of the primary disease. The external remedies and formulæ which are employed in cases of alopecia for their stimulating effects will be found in detail under the head of alopecia areata.

Alopecia Areata.

Alopecia areata (syn. area celsi, alopecia circumscripta, porrigo decalvans, tinea decalvans) is an atrophic disease of the hairy system, characterized by the more or less sudden appearance of one or more circumscribed, variously sized and shaped, whitish bald patches. The scalp is the region most frequently the seat of the disease, but other hairy parts, especially the face in the male, are often invaded, and even the whole surface may be involved. Occurring upon the scalp, one or several patches may be present, which are usually rounded and circumscribed. The hair may fall out suddenly without any previous signs of weakening, the individual awaking in the morning to discover an area of partial or complete baldness on the scalp; or, as is usually the case, the loss of hair takes place insidiously or more gradually, several days or weeks elapsing before the bald patch is of sufficient size to attract observation. The parietal region is perhaps most frequently involved. In most cases but a single patch appears at first, but this usually is followed by others. The areas incline to grow larger and larger, and, as a rule, finally coalesce, eventually the whole scalp, with possibly the exception of a tuft or patch here and there, being bald. In most cases, however, the patches, after reaching a certain size, remain stationary.

The skin of the affected areas has a smooth, whitish, polished, atrophied appearance, and is usually entirely devoid of hair or with a few straggling long or short hairs scattered over it. The orifices of the follicles become less appreciable, and the skin is thin, and resembles that seen in the baldness of advanced years. The hairs surrounding the affected area are usually found to be firmly seated in their follicles, but if the patch has not ceased enlarging they may be loose and readily extracted. In some cases about the border are noted a few short atrophied hairs, resembling the short, broken-off hairs of tinea tonsurans. At first the skin may be slightly puffed, but usually it is on a level with the surrounding parts; later, it may be somewhat depressed, as though atrophied. It is neither scaly nor inflamed. Slight anæsthesia may be present. There are, as a rule, no subjective symptoms. Involving the regions of the moustache and eyebrows, the clinical phenomena are essentially the same as when affecting the scalp. In those cases in which universal loss of hair results, the process usually begins in the same way, first appearing as well-marked areas, which rapidly increase in size; new patches are added, coalescence results, and eventually the entire surface is involved. After the disease has come to a standstill it may so remain indefinitely, or lanugo hairs may appear from time to time, reach an inch or a fraction thereof in length, may become slightly darkened, and then fall out. Finally, in favorable cases, instead of falling out, their growth continues; they become dark, and recovery takes place. In these latter cases the disease may have existed several months before signs of a permanent regrowth show themselves; on the other hand, several years may have elapsed.

The disease is met with in both sexes, in children and adults, and among the wealthy and the poor. It is not a rare disease, nor is it common. Impaired nutrition as the result of functional nerve-disturbance is probably the important etiological factor, leading to the view that the affection is a trophoneurosis. It is often seen to follow neuralgias, nervous shock, and debility. Morphoea and vitiligo, both diseases of a neurotic character, are occasionally seen in association with it. In the greater number of cases no appreciable cause is discoverable. It is not parasitic, nor is it contagious. Microscopic examinations have given negative results, the skin remaining normal and the glandular structures unchanged. Atrophy of the hair shafts and bulbs, and occasionally breaking and bulging of the hairs, are usually noted. The atrophic condition of the bulbs is similar to that seen in hairs which have reached the end of their normal life.

The disease with which alopecia areata may, by the inexperienced, be sometimes confounded is tinea tonsurans, and yet the incomplete baldness, the short, stumpy, split, gnawed-off-looking hairs, the scaliness, the increased prominence of the follicular openings, and the history and course which characterize ringworm, are entirely different from the clinical signs of alopecia areata. Where there is doubt the microscope is to be employed. It is to be remembered, also, that ringworm of the scalp is not seen in individuals past the age of puberty. The peculiar clinical features of the disease will distinguish it from other forms of baldness.

TREATMENT.—The uncertainty of the duration and ultimate termination of the disease is to be kept in view in expressing an opinion. It may be stated, with a degree of positiveness, however, that in young individuals the eventual result is, as a rule, good; but occurring in persons past adult age, the prognosis as to a regrowth is not so favorable, and becomes less so as age increases. The length of time elapsing in favorable cases before the hair reappears, as already mentioned, is uncertain: it may be several months, or on the other hand, as many years. On both points proper and persevering treatment has sometimes a material influence.

Local and general measures are called for. Of the two, the general treatment is the more important, and among remedies employed arsenic stands prominent. It should be continued for months. In addition, such tonics as iron, quinine, cod-liver oil are to be advised as the case demands. In some instances potassium iodide in moderate doses is of service.

External treatment is of value, and is in most cases to be advised. The object in view is a stimulation of the vascular supply, and through this an improvement in the nutrition of the papillæ and hairs. The same remedies in various combinations are employed as in the treatment of other forms of alopecia. Rubefacients and irritants, such as alcohol, the essential oils, sulphur, tar, cantharides, corrosive sublimate and other salts of mercury, carbolic acid, iodine, turpentine, ammonia, chrysarobin, and spiritus saponatus kalinus, are variously used. They are, as a rule, employed either in alcoholic or ethereal fluids or in the form of oils or ointments. It is to be borne in mind that the scalp tolerates strong remedies. The applications are to be made once or twice daily, according to the demands of the case, and with considerable friction, employing for the application a flannel rag or mop. Such remedies as iodine, corrosive sublimate, are usually to be painted or dabbed on.

Sulphur, two to four drachms to the ounce; corrosive sublimate, one to four grains to the ounce of alcohol; tar, ol. cadini, or ol. rusci, one to four drachms to the ounce of alcohol or ointment,—are all serviceable remedies. Cantharides and capsicum are stimulating, and may be prescribed as in the following formula:

Rx.	Tinct. cantharidis, Tinct. capsici, aa.	fluidounce iss;
	Olei ricini,	fluidrachm ij;
	Alcoholis,	fluidrachm vj;
	Spts. rosmarini,	fluidrachm ij. M.

The following, containing the oil of mace, is also serviceable:

Rx.	Olei myristicæ exp.,	fluidrachm ij;
	Alcoholis, Spiritus lavandulæ, aa.	fluidounce ij. M.

Carbolic acid may be used as follows:

Rx.	Acidi carbolici cryst.,	drachm ij;
	Alcoholis,	fluidounce iij;
	Olei ricini,	fluidrachm iv;
	Spts. rosmarini,	fluidrachm iv. M.

Aqua ammoniæ may sometimes be employed with benefit, as in the formula recommended by Wilson:

Rx.	Olei amygdalæ dulc., Aquæ ammoniæ fort., aa.	fluidounce ss;
	Spiritus rosmarini,	fluidounce ij;
	Olei limonis,	fluidrachm ss. M.

Blistering the affected areas by means of a cantharidal vesicating fluid, frequently repeated, sometimes proves of advantage. Friction with oil of turpentine once or twice daily may in some cases be practised with benefit; when the skin becomes sensitive it should be discontinued for a few days. Chrysarobin in ointment, 5 to 15 per cent. strength, is an active irritant which may be cautiously employed. Oleate of mercury, 10 to 30 per cent. strength, rubbed in once or twice daily, is useful in some cases, and the same may be said of the other mercurial ointments, such as citrine and white precipitate ointments. Electricity sometimes proves of service, and may be tried in obstinate cases.

Atrophia Pilorum Propria.

Atrophia pilorum propria, or atrophy of the hair, may be either symptomatic or idiopathic. As a symptomatic affection it is seen as a result of such diseases of the scalp as seborrhoea and the parasitic affections, and also following various constitutional diseases, such as syphilis and fevers, in consequence of impaired nutrition. The hairs become dry, brittle, atrophied, and exhibit a marked disposition to split up. Idiopathic atrophy of the hair is characterized in one of its forms (fragilitas crinium) by a brittle state of the hair-shaft, an irregular and uneven formation of its structure, and a tendency to separate into its filaments. It is seen about the scalp and beard, and may be slight or markedly developed. A somewhat similar condition of the hair of the beard has been described (Duhring), in which the bulb is atrophied and the shaft split up, fission taking place within the follicles, causing irritation of the skin. Another form (trichorexis nodosa) of the idiopathic affection is characterized by shining, semi-transparent, rounded swellings of the hair-shaft, seen usually upon the beard and moustache. At first sight they look not unlike the ova of pediculi; one or several may be present upon a single hair. Upon close inspection they are seen to be localized swellings of the hair-structure. At these points the hairs readily break off, leaving a brush-like end; if many of these are present, which is usually the case, they give the impression that the hair has been singed. The medullary as well as the cortical substance, as determined by microscopical examination, is swollen, and in consequence of the swelling of the medullary portion the cortex is burst and split into filaments. In regard to the cause of idiopathic atrophy of the hair nothing is known, and but little can be done in the way of treatment. Shaving and cutting the hair have exceptionally been followed by a normal growth.

Atrophia Unguis.

Atrophy of the nail is commonly an acquired affection. It is characterized by deficient development or growth of the nail-substance, as shown by a thin, brittle, soft, crumbly or worm-eaten condition. The nail may be pale, opaque or dark in color. It may occur in consequence of injury or disease of the nerves of the part, or as a result of some general disease, as syphilis, or from general debility. Eczema, psoriasis, and allied diseases, which may be productive of hypertrophy of the nails, may also cause atrophic changes. Treatment of atrophy of the nail depends upon the cause. In simple atrophy, and also in that due to eczema and psoriasis, arsenic is of value.

Atrophia Cutis.

Atrophy of the skin, or atrophia cutis propria, in its various forms is not infrequently encountered. It may occur as an idiopathic affection, or as a symptom in connection with other well-known diseases. Thus, as an example of the former condition the well-known striæ atrophicæ may be cited, while lupus, syphilis, and tinea favosa are sometimes followed by symptomatic atrophy. Injuries to nerves are also at times followed by more or less cutaneous atrophy, usually in connection with wasting of the subcutaneous structures, the skin becoming thin, dry, shrivelled, and yellowish or brownish in color. Atrophy of the skin may be general, as in the senile form, or localized, as in morphoea. Where degenerative atrophy exists the skin is usually somewhat hardened, yellowish or whitish in color, and has a waxy, fatty appearance. In the condition known as glossy skin, generally seen upon the fingers, the skin is reddish, smooth, and shining as though varnished, the affection resembling chilblains. The hairs are usually shed, and excoriations or fissures often exist. It is accompanied with pain of a burning character.

Cases of general idiopathic atrophy of the skin have from time to time been reported, the disease in almost all instances being more marked in some localities than in others, occurring in the form of more or less extensive patches. The disease originally described by Hebra and Kaposi with the name xeroderma, or parchment-skin disease, may here be referred to. The lesions consist of numerous disseminated pigment-spots, resembling freckles; telangiectases, or minute congeries of blood-vessels; atrophic macules of variable size; with more or less shrinking and contraction of skin, followed in most cases by epitheliomatous tumors and ulceration. The disease almost invariably begins in early years, is prone to show itself in several children of the same family, and lasts during life. The advanced stages of scleroderma and morphoea likewise show marked atrophic changes, which, however, will be considered in speaking of those diseases.

Senile Atrophy.—This form of atrophy, taking place as the result of old age, may be simple or degenerative, both usually occurring together. The integument becomes thin and wasted, the surface being dry, wrinkled and more or less discolored by pigmentation, with loss of hair. In degenerative atrophy the connective tissue of the corium becomes changed into a fine or coarse granular matter or into a homogeneous vitreous mass. Fatty metamorphosis and marked pigmentary deposits are also common.

Maculæ et Striæ Atrophicæ.—Atrophic streaks and spots may occur idiopathically or symptomatically. The idiopathic form is that most frequently encountered, and occurs without known cause, generally making its appearance insidiously. It is characterized by lines or streaks constituting the so-called linear atrophy, striæ atrophicæ; or by spots, maculæ atrophicæ. The streaks are more frequently met with, and consist of irregular curved or tortuous lesions, usually about a line in width and of variable length, running parallel with one another. The macules are rounded or ovalish, varying in size from a pinhead to a finger-nail. Both are smooth and glistening, and the skin is thinned and scar-like. They are slightly depressed or grooved, and possess a pinkish, whitish, or bluish-gray color. They may appear upon any region, but the abdomen, buttocks, and thighs are the favorite localities. They pursue a slow course over a period of years or a lifetime, occasioning no inconvenience. The first stage of either variety of the disease is characterized by erythema, the lesion being reddish, hyperæmic, and slightly raised or puffed. This sooner or later disappears, followed by depression and atrophy.

The symptomatic form of the affection is usually noted to take place as the result of extreme distension of the cutaneous structures. It occurs sometimes in obese subjects, and in the latter stages of pregnancy upon the abdomen and mammæ, and over large abdominal and other tumors where the skin is greatly stretched, constituting the so-called lineæ albicantes.

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CLASS VI.—NEW GROWTHS.⁶

⁶ Lepra (leprosy), an important disease of this class, appears, in Vol. I. p. 785, as a separate article by J. C. White.

Keloid.

Keloid is a connective-tissue new growth, characterized by one or more irregularly-shaped, variously-sized, elevated, smooth, firm, somewhat elastic, pale-reddish, cicatriform lesions. It ordinarily begins as a nodule or tubercle, pea- or bean-sized, which slowly, usually in the course of years, increases in dimension. When fully developed, the growth appears as an ovalish, elongated, cylindrical, fungoid or crab-shaped patch, occupying usually an area of one or several inches, distinctly elevated, sharply defined, and firmly implanted in the skin. In some cases the lesion does not exceed the size of a pea or a bean. The color is usually pinkish-white. The surface is smooth, shining, and commonly devoid of hair, with no tendency to scaliness or ulceration, and generally marked by ramifying vessels. It is firm and elastic to the touch. The disease sometimes appears in the form of streaks or lines. It is seen most frequently upon the sternum, although other regions, as the neck, mamma, ear, sides of the trunk, or back are often invaded. It is more common in the colored race. The lesion is usually single, though several may coexist. Itching to a slight degree is sometimes present, and more or less pain, especially on pressure, may also exist. Depending upon the origin of the growth, whether arising spontaneously or upon the site of various injuries of the skin, keloid is termed, respectively, spontaneous, or true, and cicatricial, or false. Clinically and pathologically, both varieties are the same.

It is often met with as the result of burns, cuts, flogging, and all ulcerative affections. Not infrequently it takes its origin in the scars of acne and variola; occasionally it is seen to develop on the lobe of the ear, taking its start at the point where the ear has been pierced. Pathologically, the lesion is a connective-tissue new growth, made up of a dense, fibrous mass of tissue, whitish in color, having its seat in the corium. The clinical features of keloid are so characteristic that no difficulty is experienced in recognizing it. The course of the disease is chronic, usually lasting throughout life; in exceptional instances spontaneous involution has been noted.

Treatment is usually negative. Removal by excision or caustics is, as a rule, followed by a return of the growth, and sometimes in an aggravated form. If its destruction or extirpation is decided upon, it should not be done while the growth is still progressive. Improvement has been reported by Vidal from multiple linear scarification. If the formation is painful, various anodyne applications may be made. Iodine, mercurial, and lead plasters may be tried with the object of promoting absorption. Painting the growth with a solution composed of potassium iodide one drachm, and an ounce each of soft soap and alcohol, followed by the application of lead plaster spread on a piece of soft leather, has been advised by Wilson. The use of lead plaster alone, applied continuously as a plaster, is sometimes followed by softening and diminution in size.

Fibroma.

Fibroma (molluscum fibrosum, fibroma molluscum) is a connective-tissue new growth, characterized by sessile or pedunculated, soft or firm, rounded, painless tumors, varying in size from a pea to an egg or larger, seated beneath and in the skin. A single growth may occur, or, as is more commonly the case, they are present in large numbers, and usually scattered over the greater portion of the body, having a preference for the softer tissues,—for example, the trunk. They may be of various shapes, rounded and sunken in the skin itself or in the subcutaneous tissue, or club- or pear-shaped and pedunculated. They usually begin as soft masses in the skin. If but one tumor exists, it is apt to be pedunculated or pendulous, and to attain considerable dimensions, in some cases weighing several pounds. In these instances surface-ulceration is occasionally noted as the result of mere weight or pressure. As commonly met with, however, the growths are numerous, several hundreds existing, varying from a pea to a cherry in size, with larger ones scattered here and there. The overlying skin is normal, pinkish or reddish, or may be loose or stretched, hypertrophied or atrophied. They are unattended with pain. They may make their appearance at any age, often in childhood, and grow as a rule slowly. After reaching a certain size they are apt to remain stationary; in rare instance spontaneous involution of some of the growths has been noted to take place. The affection is not common. It is often inherited, and may show itself in several members of the same family. Those in whom it is observed are usually noted to be stunted in their physical and mental development. The general health is not involved. Opinions are divided as to whether the growths take their origin in the connective-tissue framework of the fatty tissue, in the connective tissue of the corium, or in that of the walls of the hair-sac. The developed tumors consist of a connective-tissue capsule enclosing a whitish fibrous mass, with the central portion more or less soft and pulpy, out of which may be squeezed a small quantity of yellowish fluid. Small, recent tumors are composed of gelatinous, newly-formed connective tissue, while old growths consist entirely of a dense, firmly-packed fibrous tissue.

They are to be distinguished from the tumors of molluscum epitheliale by the absence of an aperture or depression upon their summits. They can scarcely be confounded with multiple neuromata or with lipomata, as the accompanying pain of the former and the lobulated structure and soft feel of the latter are sufficiently distinctive. Their removal, if desired, may be effected by the knife, or in the case of the large and pedunculated growth by the ligature or by the galvano-cautery.

Neuroma.

Neuroma cutis, or neuroma of the skin, is characterized by the formation of variously-sized fibrous tubercles, containing new nerve-elements, having their seat primarily in the corium, and accompanied in their development by violent paroxysmal pain. It is exceedingly rare, there being but few cases recorded. It appears on the shoulders, arms, thighs or buttocks in the form of numerous, disseminated, pinhead to hazelnut in size, round or ovalish tubercles or nodules, which at the outset may be either painful or painless; in the later stages, however, pain, both spontaneous and upon pressure, is a constant symptom. The growths are firm, immovable, and elastic, and are seated in the corium, extending into the deeper structures. They may be covered scantily with fine, laminated, glistening scales, as in the case reported by one of us. Anatomically, the tumors are composed of nerve-fibres, yellow elastic tissue, blood-vessels, and lymphoid cells. Excision of a portion of the nerve-trunk leading to the affected area has been practised in one case (Kosinski's) reported, with permanent relief; in another (Duhring's) the relief was merely temporary.

Xanthoma.

Xanthoma (also called vitiligoidea and xanthelasma) 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. Two varieties are met with. The macular, or flat form (xanthoma planum) is commonly seen upon the eyelids, looking not unlike pieces of chamois-skin inserted in the lids. This form may also be encountered occasionally on other parts of the face, as well as upon the body. The patches are smooth, opaque, usually sharply defined, and to the touch soft and apparently normal in texture; they are on a level with the surrounding integument or slightly raised, and of a creamy or yellowish color. They vary in size and shape, and may coalesce, forming a band extending across the eyelids, especially the upper lids. The tubercular form (xanthoma tuberosum) is usually met with upon the neck, trunk, and extremities, the eyelids seldom being invaded. It occurs as small, isolated nodules, or in patches slightly raised above the level of the skin, consisting of aggregations of tubercles of the size of a milletseed or larger. Both forms of the disease not infrequently occur in the same individual. After reaching a certain development it is apt to remain stationary throughout life, and with no involvement of the general health. As a rule, the lesions are few in numbers; on the other hand, rarely they may be numerous (xanthoma multiplex). The affection is usually encountered in middle and advanced life, although it is occasionally met with in the young. It is more common in women than in men. Jaundice has been frequently noticed as preceding or accompanying it, especially the tubercular variety. Pathologically, it is a connective-tissue new growth with fatty degeneration. Excision, where practicable, constitutes the sole method of treatment.

Myoma.

Myoma cutis, or dermato-myoma (known also as liomyoma cutis), is a rare affection, consisting of tumors of the skin composed of muscular fibres. They occur either as single or multiple tumors, varying in size from a lentil to an egg, localized in a special region, as the nipple, scrotum, labia majora, thigh, hand, or foot; or, more rarely, numerous, and scattered over the greater portion of the whole body. They are either flat or pedunculated, rounded or oval in form, pale-red in color, with a smooth surface; although generally painless, they are sometimes tender upon pressure, The growth consists essentially of a new formation of unstriped muscular fibres. At times it is composed largely of connective tissue (fibromyoma), or it may contain an abundance of blood-vessels, giving rise to cavernous erectile tumors (myoma telangiectodes). The disease is benign.

Angioma.

Angioma, or nævus vasculosus, is a congenital formation composed chiefly of blood-vessels and having its seat in the skin and subcutaneous tissue. Several forms of the affection are met with, all of which, however, may be grouped under two heads—non-elevated and prominent. The former (nævus flammeus, nævus simplex, angioma simplex) is illustrated by the so-called port-wine mark, or claret-stain, known in German as feuermal, and in French as tache de feu. The prominent variety (angioma cavernosum, nævus tuberosus) may be turgescent, erectile, pulsating, tumor-like, circumscribed growths, with an uneven or rugous surface. In shape nævi are usually roundish, but may be irregular; in color, bright or dark red, violaceous, or bluish; and in size as large as a pea or a bean, or in some cases involving areas several inches in diameter. As a rule, they are single formations. They may occur on any part of the body, but are most frequently seen about the face. Their course varies. In many instances, after attaining a certain size, they remain stationary, or in some cases may retrograde or undergo spontaneous involution, this remark applying more particularly to the flat variety in early life. Ordinarily, they are permanent deformities. They become pale under pressure, and the more prominent growths are markedly compressible. Anatomically, the growth consists of a dilatation and hypertrophy of the arterial and venous blood-vessels of the corium and subcutaneous tissues, and in some instances there is increase in connective tissue. In some cases the connective-tissue hypertrophy is made up mainly from the adipose layer (angioma lipomatodes). Occasionally there may be more or less pigmentation.

In the treatment, the extent, form, and region involved are to be considered. Various methods have been advised for their removal. For pinhead-sized nævi puncturing with a red-hot needle, or with a needle charged with nitric or chromic acid, may be employed. Those of pea size may be treated by caustic applications. Sodium ethylate, as recommended by Richardson, is an efficient caustic for the more superficial forms: it should be pure and applied with a glass rod; a dry dressing is to be employed and the crust permitted to loosen itself. Painting a nævus with liquor plumbi subacetatis will, if repeated daily for several weeks or months, sometimes succeed. Caustic potash in solution, from one to two drachms in the ounce, and nitric acid, may both be cautiously used. An ointment of a drachm of adhesive plaster and nine grains of tartar emetic applied to small nævi will, according to Neumann, cause free suppuration and healing. A solution of eight grains of corrosive sublimate in a drachm of collodion is sometimes effective. Injections of astringent and irritating liquids, such as the tincture of the chloride of iron and cantharidine, as formerly practised, possess no advantage over safer methods. Linear and punctate scarifications—in the latter the needles being charged with a 50 per cent. solution of carbolic acid or a 25 per cent. solution of chromic acid—have been recommended. In small formations vaccinating the nævus is often successful. The galvano-cautery and the actual cautery are both serviceable in treating the smaller nævi. Electrolysis constitutes a valuable plan of treatment. A current of from six to twelve cells is usually required. One or more platinum needles are attached to the negative pole and a single needle or charcoal point to the positive pole. Slight frothing at the points of insertion indicates that the action has been sufficient. Suppuration and sloughing should not occur if proper care is exercised. If the nævus is extensive, only a small portion is to be treated at the one sitting. In the port-wine mark this method promises the best results; the color is made much lighter, and exceptionally is made to disappear entirely. In prominent, and especially in pedunculated, tumors a ligature may be employed.

Lymphangioma.

Lymphangioma (also described as lymphangioma tuberosum multiplex) is a rare disease, characterized by numerous, scattered, pea- or bean-sized, ovalish or rounded, brownish-red, glistening, smooth, slightly-elevated tubercles, having a somewhat translucent look, occurring for the most part about the trunk. They are firm and elastic to the touch; are situated in the cutis, but are not sharply defined; they can be readily made to sink below the level of the surrounding integument, owing to their marked compressibility. At times they have a lilac or bluish tinge. The growths bear some resemblance to the large papular syphiloderm. They are generally congenital or appear in childhood. Anatomically, they consist of immensely dilated and hypertrophied lymphatic vessels. The course of the disease is slow, and evinces no disposition to malignancy. The general health is not involved.

Lupus Erythematosus.

Lupus erythematosus (also known as lupus erythematodes, seborrhoea congestiva, and lupus sebaceus) is a small-celled new growth, characterized by one or more circumscribed, variously sized and shaped, reddish patches, more or less covered with adherent grayish or yellowish scales. The affection usually begins as a rounded, circumscribed, pinhead- to pea-sized, slightly elevated lesion, which increases in size by peripheral extension until considerable surface is involved; or, as is often the case, the disease starts with several such spots, which grow and generally coalesce, sooner or later involving considerable surface. The spots are at first erythematous and slightly scaly, with but little elevation, later becoming thickened, with a more or less raised border sharply defined against the healthy skin, covered with small, firmly adherent yellowish or grayish scales, with enlarged and plugged or patulous follicles, the centre of the patch being somewhat depressed. The color is pinkish, reddish, or violaceous. In the beginning the disease often closely resembles seborrhoea,—so much so that it was originally described by Hebra as seborrhoea congestiva. The scaling is usually scanty, but in exceptional instances may be abundant. At times the lesions show little tendency to peripheral growth, the large areas of disease resulting from the continuous appearance of new patches in proximity which run together. Occasionally the patches are small, discrete, and numerous, when the disease is apt to be disseminated over considerable surface.

Lupus erythematosus is seen most frequently about the face, one or several patches, varying in size from a pea to a silver dollar, ordinarily being present. The nose and the cheeks are favorite localities, and, seated here, the disease is apt to be symmetrical, extending from one cheek across the nose to the other cheek, in shape representing rudely the outline of a bat or butterfly with outstretched wings. The lips, ears, scalp, and other parts of the body are often affected. The progress of the disease is variable; the patches, as a rule, reach a certain size, and then remain stationary or retrogress, or, as generally happens, the central portion becomes depressed and more or less atrophied. The resulting scar is whitish, usually soft, punctate, and superficial. As old patches disappear it is not uncommon to see new patches appearing close by. It is essentially a chronic disease: the individual lesions may be acute in their course, and when such is noted, as a rule new areas of disease continue to appear in rapid succession. Ordinarily, however, the individual patches themselves are chronic in their course. The disease is not attended with ulceration. The subjective symptoms of itching and burning are usually mild in character, and sometimes are entirely wanting.

The condition of the general health is, as a rule, good. The disease is seen more frequently in women than in men, and is rarely observed before puberty, being chiefly encountered in early adult and middle age. The causes are not known. It frequently begins as a seborrhoea, but it may occur (although rarely) upon the palms of the hands, where sebaceous glands are not to be found. It is a notable fact, however, that the disease is most commonly encountered in those who are subject to disorder of these glands. It is observed more often in persons of light complexion. It is comparatively rare. The condition of the general health apparently exercises no causative influence.

Pathologically, the process is essentially a chronic inflammation of the cutis, superinducing degenerative and atrophic changes. In the majority of cases the disease originates in the sebaceous glands, but later all parts of the skin become affected. It is even authoritatively stated that it may in some instances take its start in the subcutaneous connective tissue. In some respects it has the character of a new growth, which until late years it has been considered. In the light of recent investigations, however, it seems possible that it may be a chronic inflammation leading to degenerative changes. The process never ends in the formation of pus. There is small-celled infiltration about the follicles and glands, the blood-vessels are dilated, the surrounding tissue is infiltrated with embryonic corpuscles, and the sebaceous glands are enlarged and their walls infiltrated with small cells. The whole affected area is, in fact, infiltrated with a small-celled inflammatory new growth. If retrograde changes occur, the infiltration may disappear by absorption without leaving a trace. On the other hand, and as is usually the case, degenerative metamorphosis, resulting in absorption and atrophy, takes place.

There is very little difficulty in recognizing a fully-developed patch of lupus erythematosus, as its features are usually characteristic. The sharply circumscribed outline, the reddish or violaceous patch with 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 (generally the nose and cheeks), are characters which, when taken together, are common to no other disease. Lupus vulgaris may be excluded by the absence of papules, tubercles, and ulceration. The sebaceous involvement and the peculiar atrophy and superficial scarring are, moreover, not seen in lupus vulgaris. Erythematous lupus begins, as a rule, during adult life; lupus vulgaris usually in childhood. In psoriasis the course and symptoms peculiar to that disease will distinguish it from lupus erythematosus. It is scarcely possible to confound the disease with eczema or syphilis. In some cases in the beginning of the affection it may resemble seborrhoea; in fact, it often has its starting-point in that disease. The inflammation, infiltration, sharply-defined characters, atrophy, and scarring are absent in seborrhoea.

TREATMENT.—The prognosis of lupus erythematosus, as regards the general health and welfare of the patient, is good, but respecting the disappearance and cure of the disease an opinion should always be guarded. Occasionally the patches yield readily, but, on the other hand, cases are frequently met with that prove exceedingly rebellious, responding only after long-continued treatment. Constitutional remedies are in most cases of but little value. Occasionally arsenic and cod-liver oil, used continuously for a long period, prove serviceable. Iodized starch, in the dose of one or two teaspoonfuls three times daily, has been recommended, and in some cases potassium iodide has a favorable influence.

It is to the external treatment, however, we look for positive effects. In the selection of remedial applications it is to be remembered that the patches of disease sometimes disappear spontaneously, occasionally with little or no scarring, and therefore treatment that would have as an effect marked scarring or disfigurement is to be avoided. The simplest remedy, at times useful, is soft soap, the sapo viridis of the shops. This may be used as such or in solution in alcohol, two parts of the soap to one of alcohol, constituting the well-known spiritus saponatus kalinus. It is to be energetically rubbed into the diseased parts once or twice daily. The application of the sapo viridis as a plaster is a more energetic method. After several days the soap is to be discontinued and a soothing ointment applied. In addition to its therapeutic properties, sapo viridis—or, better, its alcoholic solution—may be advantageously employed to cleanse the parts preparatory to other remedial applications. Mercurial plaster constantly applied to the patches will in some cases effect a cure. A 10 to 25 per cent. oleate-of-mercury ointment, rubbed on the parts once or twice daily, is sometimes of value.

In almost every case where the inflammatory symptoms are marked the following lotion will prove palliative, and in some cases of the mild and superficial form of the disease it has in time effected a cure:

Rx.	Zinci sulphatis, Potassii sulphidi, aa.	drachm ij;
	Aquæ,	fluidounce iij;
	Alcoholis,	fluidounce j.

The salts are to be dissolved separately in the water, and then mixed, and after reaction the alcohol is to be added. Properly made, the resulting lotion is without odor, contains a whitish sediment, which when agitated gives the lotion a milky appearance. It is to be shaken, and the parts dabbed with it for from fifteen to thirty minutes twice daily, allowing it to dry on. Sulphur ointment and alcoholic sulphur lotion, such as are used in the treatment of acne, are also sometimes serviceable. Tincture of iodine, either alone or with an equal part of glycerin, painted over the parts once or twice daily until a coating forms, in some cases proves useful. The same may be said of the following formula:

Rx.	Iodinii, Potassii iodidi, aa.	drachm iv;
	Glycerinæ,	drachm j.

M.—Sig. Paint over the part until a coating is produced. Painting pure carbolic acid over the patches is sometimes followed by good results. A mixture that is serviceable as a stimulant is the following:

Rx.

Olei cadini, Alcoholis, Saponis viridis, aa.

drachm iij.

M.—Sig. Rub into the patches night and morning.

Stronger applications are often necessary if the disease fails to yield to the simpler remedies. Pyrogallic acid in ointment, from forty to ninety grains to the ounce, and chrysarobin in the same strength, are serviceable. The latter is a dangerous remedy to use about the face, occasioning at times a violent conjunctivitis with oedema. Pyrogallic acid is safer, and sometimes proves more satisfactory when applied in flexible collodion or liquor gutta-perchæ than in ointment form, as in the following formula:

Rx.	Acidi pyrogallici,	drachm j;
	Liquor. gutta-perchæ,	fluidrachm iv.

M.—S. Apply with a brush. This is to be painted over the patches several times daily until considerable reaction takes place or a crust forms, then discontinued, and as soon as the crust is removed or falls off the application is to be repeated. If there is much scaling, thirty grains of salicylic acid may be added to the above formula. In most cases it is advisable as soon as the crust forms to remove it, and immediately to resume the pyrogallic-acid painting. Cantharidal blistering fluid, repeatedly applied, has been recommended. Nitrate of silver, either in stick or strong solution, is a comparatively safe caustic, and is at times useful. Treatment by linear scarifications, especially in obstinate, sluggish, and infiltrated patches, is often valuable. The scar left is, as a rule, insignificant. Erasion with the curette is a method that sometimes proves of advantage in the severer and deeper-seated forms of the disease. Although in almost all instances stimulating or active treatment is demanded and well borne, there are cases occasionally met with in which, on account of the inflammation and pain, soothing applications must, for a time at least, be employed. These cases, it will be found, are aggravated by stimulating remedies.

Lupus Vulgaris.

Lupus vulgaris (known also as lupus exedens, lupus vorax) is a cellular new growth, characterized by variously-sized, soft, reddish-brown patches, consisting of papules, tubercles, and flat infiltrations, eventually terminating in ulceration and cicatrization. The disease appears differently as seen in the several forms and stages of its development. All the varieties usually begin in one and the same way.

The primary lesions are pinhead- to small pea-sized, deep-seated, brownish-red or yellowish papules, having their seat in the deeper part of the corium. They are softer and looser in texture than normal tissue, and as the disease progresses form variously sized and shaped patches. They may be so closely aggregated as to form flat infiltrations. The patches tend to be round, serpiginous, or ill defined. As the papules increase in size they may be distinctly recognized both by the eye and by passing the finger over the surface; later even reaching the size of small peas. The lesions having attained a certain size or development and being covered with imperfectly-formed epidermis, may so remain for a time, or retrogressive changes may immediately occur. They may disappear by absorption, fatty degeneration taking place, leaving a desquamating, atrophic or cicatricial tissue—lupus exfoliativus—or disintegration and destruction of the diseased skin may occur, resulting in ulceration—lupus exedens, or exulcerans. This latter is the usual course of the disease. The ulcerations are rounded, shallow excavations with soft and reddish borders. If the ulcerations are the seat of exuberant granulations, the condition is known as lupus hypertrophicus. Papillary outgrowths may occur in the healing ulcers, and a rough, verrucous condition results—lupus verrucosus.

The lesions of lupus are seldom painful. The ulcers secrete a slight or moderate amount of pus which forms crusts. Soft or firm cicatricial tissue finally results. In almost all cases of long standing the several stages of the disease may be recognized, each lesion, whether the first or the last, going through a similar course, either of absorption and exfoliation or ulceration and cicatrization. The deeper parts may be involved in the process, subcutaneous connective tissue, cartilage, and mucous membrane being liable to invasion. The mucous membrane of the mouth, gums, velum and larynx may even be primarily the seat of the lupus infiltration, considerable destruction eventually resulting. The face, especially the nose, is the most common site of the disease. Occurring about the eye, the process may eventually destroy that organ. The ears are likewise frequently attacked. Not infrequently the extremities, and occasionally the trunk, are invaded. The disease begins, as a rule, in childhood. It is always a destructive process, usually resulting in disfiguring cicatrices.

The causes of the disease are obscure. Although it usually appears in early life, it is never congenital. Heredity has little if any influence. It is comparatively rare in this country, less so in England and Ireland, but is more common in Austria, Germany and France. It is most generally observed among the strumous and debilitated, but is also frequently seen in those who enjoy all the advantages of life and who are otherwise in average health. It is entirely distinct and independent of syphilis. The French consider it a scrofuloderm (scrofulide), and yet in many cases there is clinically a considerable difference. On the other hand, cases are met with in which its close relationship, if not identity, with the scrofulodermata is not to be questioned. The view that it is a tuberculosis of the skin due to the same cause as at present advanced for tuberculosis of the lungs—the bacillus—has lately been suggested. The disease attacks both sexes, but is somewhat more common in women than in men.

Anatomically, the process is a chronic inflammation, consisting essentially of small-cell infiltration, affecting primarily the corium, eventually spreading to other parts. The epithelial structures are usually involved in the first stages of the disease. Recent lesions are rich in vessels, the vascularity when retrogressive changes take place rapidly decreasing, beginning at the centre of the nodule. The cutaneous tissues undergo cicatricial contraction, a part, however, being organized into coarse connective tissue. In addition to the formation of the nodular mass, the cell-infiltration is found to spread along the vessels of the corium and papillæ, and also into the deeper portions of the skin. The papules may be so close and the cell-infiltration so extensive that a large area of disease results and undergoes the same changes as an individual lesion. The sweat and sebaceous glands are involved. Sometimes epithelial hyperplasia takes place, the epithelial outgrowth from the rete dipping down and joining similar outgrowths from the cells of the sweat-glands and hair root-sheaths, forming an epithelial network which may become a histological basis for the development of epithelioma. The occurrence of this latter disease in lupus tissue, in association or as a sequela, has been noted by several observers. According to the latest investigations the infiltration of lupus is due chiefly to cell-proliferation and outgrowth from the protoplasmic walls and adventitia of the blood-vessels 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.

DIAGNOSIS.—Ordinarily, the features of lupus vulgaris are so distinctive as to render a diagnosis a matter of no difficulty. The characteristic soft, small, reddish-brown subcutaneous papule—the primary efflorescence of the disease—is generally to be found, especially about the periphery of the patch, and when present is diagnostic. At times, however, it bears resemblance to syphilis, epithelioma, lupus erythematosus, and acne rosacea.

It is chiefly in the serpiginous forms of the late tubercular and ulcerative syphilodermata that the resemblance to lupus vulgaris is sometimes very close. There are several points of difference. Syphilis is much more rapid in its course, marked ulceration following frequently within a few weeks or months of its appearance. With lupus, on the other hand, years may elapse before the same amount of destruction results. In lupus there are usually several points of ulceration; in syphilis, one or several, which incline to coalesce. The ulcers of lupus are apt to be superficial, whereas those of syphilis are usually deep, with a punched-out appearance. Lupus papules are small, soft and but slightly elevated, and frequently reappear in the scars left by the disease; the papules or tubercles of syphilis are larger, more elevated, firm and harder, and are seldom seen in the scar or track of the disease. The secretion of the syphilitic ulcer is abundant, purulent and offensive, and the crusts thick, often oystershell-like, and of a greenish or blackish color; the secretion of lupus ulceration is slight, odorless, the crusts thin and scanty and of a reddish or reddish-brown color. The scar of lupus is generally hard, shrunken, yellowish, and more or less distorted, while that of syphilis is soft and, compared to the amount of ulceration, but slightly disfiguring. The bone-structures are not involved in lupus; they may be in syphilis. The two diseases have different histories: lupus generally begins in childhood and runs a slow and chronic course; syphilis is usually seen after adolescence or adult age, and progresses more rapidly. In syphilis, moreover, other evidences of the disease may usually be found.

Lupus vulgaris differs from epithelioma in several important points. The edges of the epitheliomatous ulcer are hard, elevated, and waxy; the base is uneven, and the secretion is thin, scanty, and apt to be streaked with blood; the ulceration usually starts from a single point; it is often painful; the tissue-destruction may be considerable; and, finally, epithelioma is, as a rule, a disease of advanced age. Lupus vulgaris differs essentially in all these particulars.

As a rule, there is no difficulty in differentiating lupus vulgaris from lupus erythematosus. The absence of papules, tubercles and ulceration is sufficiently distinctive. Lupus erythematosus is, moreover, a superficial disease, pinkish or violaceous in color, showing itself in circumscribed patches covered with thin adherent scales, and with usually evident involvement of the sebaceous glands. It rarely begins before adult age, whereas lupus vulgaris, as a rule, first appears in childhood. Attention to the ordinary characters of acne rosacea—the hyperæmia, the dilated vessels, comedones, acne papules and pustules, its advent at or after maturity, and the history—will prevent an error in diagnosis.

TREATMENT.—Lupus vulgaris is always a chronic disease, and one that calls for a guarded opinion as to treatment. Although it be removed, relapses are prone to occur, and new papules may show themselves even about the scar resulting from treatment. If it is localized the chances of permanent cure are more favorable. The deformity attending and following the disease is often great,—contraction of joints, destruction of cartilages, and sometimes partial closure of the orifices resulting. The general health is usually good. Death by tuberculosis of the lungs has been noticed in some cases.

Treatment has in the main two objects,—to limit the development or spread of the disease and to remove the morbid tissue that is already present. In accomplishing the former constitutional treatment is occasionally useful; although much cannot usually be attained in this way, yet from our own observations we are convinced that in some cases the disease may be favorably influenced and its spread limited. Cod-liver oil, administered in full doses and for a long period, is sometimes of decided value. Potassium iodide is another remedy which at times proves serviceable. Iodoform in half-grain doses three times daily has been recommended, as have also muriate of lime, in the dose of twenty grains three times a day, and calx sulphurata, in small doses. Hygienic measures are to be enforced, and a generous, nutritious diet advised.

External remedies are essential in every case, and constitute the only plan of treatment to be relied upon. Removal of the diseased tissues by caustics or operation is the method practised. In the earlier stages of the disease or before adopting radical measures it is advisable to make an attempt to bring about absorption by the employment of stimulating applications. Equal parts of tincture of iodine and glycerin, or one part each of iodine and potassium iodide and two parts of glycerin, may be painted over the parts daily or every other day. Mercurial plaster, renewed once or twice a day and kept constantly applied, is valuable in some cases. Corrosive sublimate in the form of a lotion or ointment, one-half to two grains to the ounce, has lately been advised. Cashew-nut oil applied with friction has been recommended for the non-ulcerative form. Tar and sulphur ointments may also be employed. Chrysarobin, either in the form of an ointment or as a solution in liquor gutta-perchæ, has also been advised.

For the radical treatment of the disease there are numerous caustics in use, but there are some which are more positive in their effect and whose action may be controlled. Nitrate of silver, pyrogallic acid, arsenic, caustic potash, the curette, scarifier, and the actual and galvano-cautery are all valuable. Nitrate of silver is best used in stick form. The lesions are forcibly pierced and bored with the stick, and thoroughly cauterized. The operation is to be repeated every three or four days. It is a safe remedy, and is especially useful about the face, as the scars left are soft and smooth. Pyrogallic acid in the form of an ointment or plaster, from 15 to 25 per cent. strength, is often of great value. It is a mild and safe caustic; it is usually painless and leaves a smooth, soft scar. The ointment should be stiff and adhesive, and kept applied constantly for several days or more, renewing twice daily. The following formula serves well:

Rx.	Acidi pyrogallici,	drachm ij;
	Emplastri plumbi,	drachm j;
	Cerati resinæ comp.,	drachm v.

M.—Sig. Apply as a plaster. In winter the lead plaster may be omitted. The remedy may also be applied in liquor gutta-perchæ, but is not so satisfactory. The tissues become soft and blackish, and then the parts are to be poulticed and the slough removed; and if the diseased tissue is not sufficiently destroyed the dressing is to be renewed. Subsequently the ulcer is dressed with mercurial ointment or a simple salve. Healing should take place in the course of a few weeks. Iodoform is well spoken of. In deep-seated infiltration the upper epidermic layers should first be removed by a solution of caustic potassa. The iodoform is then put on and a layer of cotton is applied over it, and the dressing remains undisturbed for a week. The lupus nodules are soon destroyed. Several repetitions of the remedy may be necessary. Excepting the preliminary application of the potassa the method is painless.

A solution of caustic potash is sometimes employed for the destruction of the lupus deposit. It is thorough in its action, but is painful and must be used with great caution. The cicatrices left after the use of this caustic are apt to be large and hard. In the application, as soon as the diseased tissue has been thoroughly destroyed by the caustic, the further action may be stopped by neutralizing the alkali with diluted acetic acid. Arsenic in the form of paste is another valuable caustic. It has the advantage of sparing the healthy, and even the cicatricial, tissues. Hebra's modification of Cosme's paste is an eligible formula:

Rx.	Acidi arseniosi,	scruple j;
	Hydrargyri sulphuret. rub.,	drachm j;
	Ugt. simplicis,	ounce j.

M. Ft. ugt.—Sig. Spread upon a piece of kid or cloth and apply as a plaster. The paste is to be applied for two or three days consecutively, at the end of which time the parts are somewhat swollen and painful. The lupus nodules are seen as black, necrosed spots. Poultices are then applied until the slough comes away, usually in a day or two; subsequently a mild, stimulating ointment is employed. Rapid cicatrization usually takes place, and the cicatrices are, as a rule, satisfactory. The chief objection to arsenical applications is the intense pain that usually develops soon after the remedy is applied. In other respects the method has its advantages.

Acetate of zinc in crystal form, repeatedly applied to the lesions, has been advised. It is painful at the time of application, but the pain may be somewhat relieved by washing the parts with water. Red iodide of mercury in the form of a strong ointment (equal parts of the salt and a fatty base), applied upon a piece of kid or cloth, will have a speedy caustic effect. There are other caustic remedies which may be mentioned. Chloride of zinc, with an equal part of chloride of antimony and sufficient hydrochloric acid to dissolve the zinc chloride, and enough powdered licorice added to make a paste, and applied as a plaster, is an efficient caustic. It produces an eschar in twelve to twenty-four hours. The parts are then dressed with a simple ointment, and healing allowed to take place. It is a strong caustic, and is destructive to healthy as well as diseased tissue. The same may be said of Vienna paste, consisting of equal parts of lime and potassa. The latter mixture is made into a paste at the time of application by adding alcohol. It is not to be applied more than five to ten minutes, and its further effects are to be counteracted by the application of acetic acid. In the application of such powerful and destructive caustics it is advisable to protect the adjacent skin with strips of adhesive plaster. Salicylic acid has lately been recommended in the form of an ointment of the strength of one to two drachms to the ounce. It is thickly spread on linen and applied continuously. The remedy is a mild one and acts slowly. Mention may also be made of lactic acid, applications of which, it is stated, have been productive of beneficial results.

Of late years the mechanical removal of the lupus deposits has been largely practised. In small patches excision of the entire diseased area has been recommended, but as considerable healthy tissue is necessarily removed with it, and the resulting scar is deep and disfiguring, it is not to be advised. Excision followed by transplantation of healthy skin has also been advocated. An excellent method of removal is by means of the dermal curette, or scraping-spoon. It is one that answers well in many cases. The diseased tissue should be thoroughly scraped out. It is painful, and it is often necessary to operate under ether. The healthy tissues are unyielding and cannot be readily scraped away, so that only the morbid deposit is removed. As it is difficult to remove the new growth from the interstitial spaces, we are in the habit of supplementing the operation with a caustic, either cauterizing lightly with caustic potash, or, what is advisable in the greater number of cases, applying the pyrogallic-acid ointment for several days following the curetting. This method—the curetting and subsequent cauterization—has, on the whole, proved satisfactory.

Linear or punctate scarification is another method of treatment that is often valuable. It is of most service in the non-ulcerating forms. Linear scarification is the more satisfactory. The parts are thoroughly cross-tracked and a simple ointment applied. If the bleeding is marked, cold compresses may be applied. Anæmia of the parts results, the papules are disturbed, and the new growth rapidly undergoes retrogressive changes. If the area to be operated upon is large, the patient should be anæsthetized. Charging the knife, or if punctiform scarifications are practised the pointed instrument, with iodized glycerin (one part iodine to twenty of glycerin) has been advised, as rendering a successful result the more certain. The scar following the curette and linear and punctate scarification is usually soft and white, much less disfiguring, as a rule, than that following the action of the stronger caustics. Destruction of the new growth by means of the galvano-cautery or by the actual cautery has from time to time had its advocates. Piercing the individual lesions with a platinum needle-point heated to dull red by means of the battery has been strongly advised; comparative absence of pain, rapidity, and good results are claimed for it.

Scrofuloderma.

Scrofuloderma is a term employed to designate certain morbid conditions of the skin which are dependent upon that state of the system known as scrofula, or struma. The most common form of the cutaneous manifestation is that which has its beginning in one or more of the lymphatic glands. The gland slowly increases in size, without any of the ordinary signs of inflammation, and after reaching the dimensions of an almond may so remain or undergo fatty or cheesy degeneration. As a rule, however, sooner or later the gland grows much larger, the new-cell growth breaks down, the superjacent skin becomes hyperæmic, thin, sensitive, and of a violaceous or purplish color. Finally, the tumor breaks, and a thick, cheesy pus mixed with blood is discharged; sinuses are apt to form, the skin ulcerates, and the process may so continue for months, partial cicatrization taking place, and then again breaking down. The resulting ulcers are irregular or ovalish in shape, with undermined edges, and the surrounding thin and chronically inflamed skin of a violaceous color. Their bases are uneven and covered with pale, unhealthy-looking granulations. If there is crust-formation, it is seen to be thin, grayish or brownish. The process is slow and chronic. The scars are irregular, knotty, contracted, and often hypertrophic. The affection is seen most frequently about the neck, especially under the lower jaw. Other evidences of scrofula are usually present.

A less frequent cutaneous manifestation consists of one or several large, rounded, ovalish or irregularly-shaped, flat pustules upon an inflamed or violaceous base. The crust forms slowly, is thin and flat, and of a brownish color. The ulceration beneath has the peculiar scrofulous characters. The scars which follow are soft, flat, and superficial.

A scrofuloderm occasionally met with consists of one or several papillary or fungoid growths of a bright or dull violaceous red color, with an ulcerated and discharging surface. They occur perhaps most frequently about the hands, are chronic, and often lead to deep-seated ulceration, which may involve the bones and give rise to deformity. The disease resembles the verrucous and hypertrophic varieties of lupus vulgaris.

Another variety of disease, seen usually in scrofulous subjects, described by one of us (Duhring), manifests itself as small pinhead- to pea-sized, disseminated, yellowish, flat papulo-pustules upon a red or violaceous base, which slowly dry to crusts, and leave punched-out-looking scars resembling those of variola. The lesions are irregularly distributed, occurring for the most part about the face and extremities. The process may continue for years. The lesions resemble those of the small pustular syphiloderm.

The manifestations of scrofula are at the present time supposed to be due to the specific infecting agent, the bacillus. Other conditions which have been considered influential, and which are unquestionably important predisposing causes, are heredity, blood-marriages, insufficient and unwholesome food, continued exposure to wet and cold and impure air. It generally develops in childhood, often after measles, scarlatina, and similar diseases. Negroes are especially predisposed to it. The scrofulodermata are, as a rule, readily distinguished by their peculiar clinical characters. Other symptoms of scrofula are, moreover, usually present and aid in the diagnosis. It is to be differentiated from the gummatous ulcerations of syphilis by its history, course, locality, the absence of the specific infiltration at the borders of the ulceration, and the violaceous tint.

The constitutional treatment is the same as employed in other scrofulous affections—cod-liver oil, syrup of the iodide of iron, sulphide or muriate of lime, phosphorus, and iodine preparations being the most reliable remedies. The diet should be liberal, consisting of a large proportion of animal food. Hygienic measures are active adjuvants. The external treatment of scrofulous ulcerations consists in the use of stimulating applications. Mercurial ointments, corrosive sublimate in alcohol, one-fourth to one grain to the ounce, and yellow wash, are serviceable applications. Iodoform, in powder or ointment, is often of benefit. A 1 or 2 per cent. nitrate-of-silver-ointment may also be mentioned. Curetting, as in lupus vulgaris, is one of the most valuable methods of treatment, especially useful in the fungoid variety. Milton has had good results with calomel or gray powder, taken at night two or three times weekly for a few weeks, and a saline every morning in sufficient dose to produce a daily evacuation. The mercurial is then intermitted for two or three weeks. Bitters and mineral acids are given if the appetite fails. A simple ointment is used locally.

Syphilis Cutanea.

Syphilis (syphiloderma, dermatosyphilis, syphilis of the skin) manifests itself in various forms upon the integument. Preceding or ushering in the early eruptions there is sometimes considerable systemic disturbance, such as slight fever, loss of appetite, muscular pains, and headache. In the greater number of cases, however, general symptoms are wanting. Along with the cutaneous manifestations there are usually other signs of the disease. In the early eruptions the lymphatic glands are enlarged, and sore throat and mucous patches may exist. Sometimes there is loss of hair. In the later syphilodermata pains in the bones, bone lesions, and other symptoms may be observed. The early eruptions are generalized; the later manifestations are usually limited in extent, and have a tendency to appear in circular, semicircular or crescentic forms. There are rarely any subjective symptoms. The color of established syphilitic lesions is usually a dull brownish-red or yellowish-red.

Syphilis may show itself as a macular, papular, vesicular, pustular, bullous, tubercular or gummatous form of disease. In many instances, although a particular efflorescence may predominate, lesions of other varieties may be found intermingled.

SYPHILODERMA ERYTHEMATOSUM (syn., exanthematous syphilide, syphilis cutanea maculosa, roseola syphilitica, macular syphiloderm) is a general eruption, showing itself usually six to eight weeks after the appearance of the chancre. The appearance of the eruption is retarded by treatment. It consists of macules of various sizes and shapes, for the most part the size of a pea or small bean and rounded, on a level with the surrounding skin or slightly raised, giving the skin a mottled or marbled look. At first the spots disappear under pressure, but later, owing to the presence of more or less pigmentation, they persist. Their outline, which is ill defined, is usually brought out more distinctly on exposure. They vary in color from a pale pink to a dull violaceous red, depending upon their duration and also upon the natural complexion of the individual, and as they fade away become yellowish or coppery. As a rule, they exist in profusion, so much so as to cover not infrequently almost the entire surface, appearing without order of distribution; exceptionally they exist sparsely and faintly, in which case the eruption may be overlooked. The face, backs of the hands, and feet frequently escape. Subjective symptoms are wanting. The efflorescence may appear with or without systemic disturbance, but malaise and slight fever frequently precede it. The chancre or its scar, enlarged inguinal and cervical glands, erythema of the fauces, rheumatic pains, and more or less falling of the hair usually accompany its development. It may manifest itself slowly and insidiously, a week or two elapsing before its height is reached, or the invasion may be sudden, taking place in the course of twenty-four or forty-eight hours. This syphiloderm probably occurs in the majority of cases of syphilis, but in many instances is so faint as to escape observation. As a rule, it responds rapidly to treatment.

It is to be distinguished from measles, rötheln, urticaria, simple erythema, tinea versicolor, and certain medicinal eruptions. The catarrhal symptoms, the fever, form, and situation of the eruption of measles; the rapid formation and disappearance of the patches of simple erythema; the wheals and intense itchiness of urticaria; the slight scaliness, peripheral growth, and distribution of tinea versicolor; the small roundish, confluent pinkish or reddish patches, precursory pyrexic symptoms, the epidemic nature, short duration of rötheln; and the history, fever, form, and duration of the medicinal rashes,—are points of difference which serve to distinguish these diseases from the syphiloderm.

So-called Syphiloderma Pigmentosum, or pigmentary syphilide, may here be referred to. It is a rare manifestation, and is characterized by rounded, ovalish or irregularly-shaped, variously-sized, discrete or confluent, pale grayish, yellowish, or brownish, usually ill-defined faint macules. It occurs most frequently about the neck, is seen almost exclusively in women, and is encountered during the latter half of the first and in the second year of the disease. It develops slowly, and may continue one or two months or as many years, and is uninfluenced by antisyphilitic treatment. It is a simple pigmentary affection, similar, apparently, to chloasma, from which and tinea versicolor it is to be differentiated.

SYPHILODERMA PAPULOSUM (syn., syphilis cutanea papulosa, papular syphilide, papular syphiloderm) is characterized by the formation of variously-sized papules. The lesions are small or large, and in some cases undergo various modifications.

The Small Papular Syphiloderm (syn., miliary papular syphiloderm, lichen syphiliticus) consists in an eruption of disseminated or grouped, more or less confluent, firm, small or minute, rounded or acuminated papules, the size of a pinhead or milletseed. Their summits may be smooth or covered with fine scales, or may show pointed pustulation; this last symptom occurring especially in those through which a hair protrudes. Miliary pustules, scattered here and there over the surface, may also be present. At first the eruption is bright- or dull-red, but later it generally assumes a violaceous or brownish tint. In some cases the lesions are numerous and grouped, forming patches. The eruption is seen most frequently about the trunk and upon the limbs. It may appear during the third or fourth month or later. Large flat papules or moist papules may exist simultaneously. It has a chronic course, with a tendency to relapse, and is usually rebellious to treatment. It is to be distinguished from keratosis pilaris, lichen scrofulosus, psoriasis punctata, papular eczema, and lichen ruber. The extent of the eruption, the color, grouping, with usually the presence of pustules and large papules and other concomitant symptoms of syphilis, are points of differentiation.

The Large Papular Syphiloderm (syn., lenticular syphiloderm) is characterized by the formation of large, flat, circular or ovalish, firmly-seated, more or less raised pale- or dull-red papules, varying in size from a small split pea to a dime. In their early stage they are usually smooth, but they subsequently become covered with exfoliating epidermis. The forehead, region of the mouth, neck, back, flexor surfaces of the extremities, scrotum, labia, perineum, and margin of the anus are all favorite localities. The lesions, as a rule, develop slowly, and, having attained various sizes, remain for weeks or months. It is one of the commonest forms of cutaneous syphilis; it may be an early or late eruption, and shows a disposition to relapse. As a rule, it yields readily to treatment. The lesions may undergo more or less modification, due either to the locality in which they exist or to other influences. Ordinarily, they persist as typical papules, and gradually pass away by absorption. At times they become soft and spongy, while occasionally they become excoriated, with slight moisture and crusting. This latter condition is usually observed about the junctures of the mucous membrane and the skin.

A common change is into the Moist Papule (syn., mucous papule, mucous patch, broad, or flat, condyloma; Fr. plaques muquese). This takes place upon those regions where opposing surfaces and natural folds of skin are subjected to more or less contact, as about the nates, umbilicus, axillæ, beneath the mammæ, etc. The lesions are more or less moist, covered with a grayish, sticky, mucoid secretion consisting of macerated epidermis. They are usually flat, and may coalesce, and so form large patches. They may become hypertrophic, warty, and papillary, constituting the vegetating syphiloderm (syphilis cutanea vegetans). In this form the lesions become elevated, more or less circumscribed, and may assume a warty character, resembling the cauliflower formation, with a contagious secretion which dries to yellowish-brown crusts. Heat, moisture, friction, and uncleanliness favor their development. They usually disappear rapidly under local treatment.

Another modification which the papule frequently undergoes is into the squamous papule, forming the Papulo-squamous Syphiloderm (syn. squamous syphiloderm, syphilis cutanea squamosa, psoriasis syphilitica). The papules become somewhat flattened, and are covered with dry, grayish, adherent scales. The scaling may be slight or relatively abundant, but is rarely as luxuriant as in psoriasis. On removing the scales the papular character of the lesion may readily be detected. As a rule, the eruption is not extensive; it may show itself on any part, and is exceedingly persistent. It is most frequently encountered on the palms and soles, where, on account of the peculiarities in the structure of the skin, the lesions are somewhat modified. Occurring on these parts, it is known as the palmar or plantar syphiloderm. The lesions partake more of the nature of macules than papules; they are slightly raised and are irregular in outline, and, as a rule, ill defined, varying in size from a pea to a finger-nail. They may coalesce and form roundish serpiginous or crescentic patches covered with dry, scanty, semi-detached, grayish flakes of epidermis, which are most abundant about the edges; at times the exfoliation is marked, and then the patches are distinctly squamous, as in psoriasis. It is, as a rule, symmetrical, and is frequently observed in the centre of the palms or soles and upon the ball of the thumb and about the volar surfaces of the fingers. It is rebellious to treatment. It may be an early or late manifestation, but is usually the latter.

The papulo-squamous form of the syphiloderm may resemble eczema and psoriasis. In eczema heat, itching, and sometimes discharge, together with the history and course, will be sufficient points of distinction. Psoriasis upon the palms rarely occurs except as a part of a general eruption; the character and abundance of the scales, their lamellar arrangement, the red rete beneath, and the absence of infiltration are diagnostic. The differential diagnosis of the papulo-squamous syphiloderm and psoriasis when occurring on the other parts of the body are fully given in treating of the latter disease.

SYPHILODERMA VESICULOSUM (syn., vesicular syphilide, syphilis cutanea vesiculosa) is an exceedingly rare form of cutaneous syphilis, and in the majority of cases may be more properly classed under the head of the pustular variety. The lesions vary in size from a pinhead to a split pea. If small, they are more or less acuminated, disseminated, or grouped, usually involving the hair-follicles; if large, semiglobular or flat, with or without a tendency to umbilication. The vesicles, as a rule, pass into pustules. It is an early eruption, occurring usually within the first six or eight months; is rarely extensive, pursues a rapid course, and is generally associated with other symptoms of the disease.

SYPHILODERMA PUSTULOSUM (syn., pustular syphilide, syphilis cutanea pustulosa) is an important manifestation, although not so common as the macular and papular varieties. The lesions assume one of several forms, although not infrequently they are found intermingled.

The Small Acuminated Pustular Syphiloderm (syn., miliary pustular syphiloderm) is characterized by the formation of milletseed-sized acuminated pustules, usually seated upon minute reddish papular elevations. The puriform contents dry to crusts, which fall off and are followed by a slight fringe-like exfoliation around the base, constituting a grayish ring or collar. The lesions commonly involve the hair-follicles, are present in great numbers and scattered over the whole surface, and may be either disseminated or in groups; in relapses the eruption is usually localized. Variously-sized larger papules are sometimes seen scattered sparsely over the surface. It may be an early or a late secondary eruption. Minute pinpoint atrophic depressions and stains are left, which gradually become less distinct. Other symptoms of syphilis are usually present. The diagnosis is rarely difficult.

The Large Acuminated Pustular Syphiloderm (syn., acne-form syphiloderm, acne syphilitica, variola-form syphiloderm) consists of small or large split-pea-sized pustules, more or less acuminated, resembling the lesions of simple acne or variola. The resulting crusts are yellowish or brownish, usually thick and bulky, and are seated upon ulcerated bases. The lesions may develop slowly or rapidly, with or without malaise or febrile symptoms, are disseminated or grouped, at first looking more or less papular. In the subacute or relapsing cases the eruption is apt to be localized. It pursues a rapid and usually a benign course, and is to be distinguished from acne, from the potassium-iodide eruption, and from variola. The usual limitation of acne lesions to the face and shoulders, their rapid formation, and the chronic character of the disease, together with the absence of the concomitant symptoms of syphilis, are points which may be utilized in the diagnosis. Variola differs in the intensity of the general symptoms, the umbilicated pustules, and the definite duration of the disease. The acute character, bright color, course, and history of the potassium-iodide eruption are generally sufficiently characteristic.

The Small Flat Pustular Syphiloderm (syn., impetigo-form syphiloderm, impetigo syphilitica) shows itself in the form of pea-sized, flat or raised, discrete, irregularly-grouped, or confluent pustules. The crusts, which form rapidly, are a yellow, greenish-yellow, or brownish-yellow color, more or less adherent, thick, bulky, uneven, with a tendency to become granular and to crumble. Where the lesions are confluent there results a continuous sheet of crust. Beneath the crusts there may be superficial or deep ulceration. The eruption is most frequently observed about the nose, mouth, and hairy parts of the face, on the scalp, and also about the genitalia. When upon the scalp it is apt to resemble pustular eczema; the erosion or ulceration beneath, however, will serve to differentiate it.

The Large Flat Pustular Syphiloderm (syn., ecthyma-form syphiloderm, ecthyma syphiliticum) appears in the form of large pea- or dime-sized, flat pustules, with a deep red base. Crusting usually follows immediately. There are two forms of the lesion—a superficial and a deep. In the superficial variety the crust is flat, rounded, or ovalish, yellowish-brown or dark brown, and seated upon a superficial erosion or ulcer, having a grayish or yellowish secretion. It may occur upon any region, but is most common on the back, shoulders, and extremities; the lesions are sometimes numerous. It appears, as a rule, within the first year and runs a benign course. In the deep variety the crust is raised and more bulky, dark-greenish or blackish, inclining to become conical and stratified, like an oyster-shell, constituting what is designated rupia. A crust of the same character occurs in the bullous syphiloderm. If the crust is removed, an excavated ulcer is seen, having a defined or irregular outline and a greenish-yellow, puriform secretion. It is a late and a malignant manifestation, and is not infrequently met with in hospital and dispensary practice.

SYPHILODERMA TUBERCULOSUM (syn., tubercular syphilide, syphilis cutanea tuberculosa) is characterized by one or more firm, circumscribed, rounded, acuminated, or semiglobular, deeply-seated, smooth, glistening or slightly scaly elevations, yellowish-red, brownish-red, or coppery in color, varying in size from a split pea to a hazelnut. They rarely occur in great numbers, and are, as a rule, confined to certain regions, and show a decided tendency to occur in groups, often forming segments of circles. When several such groups coalesce, the result is a serpiginous tract, the so-called serpiginous tubercular syphiloderm. The face, back, and extremities are favorite localities. The lesions develop slowly, are unaccompanied by subjective symptoms, and usually occur as a late manifestation, at times appearing many years after the initial lesion. A history of earlier symptoms of the disease is usually obtainable.

The eruption terminates or disappears either by absorption or by ulceration. If the former, a pigment-stain, which is usually persistent, and in some cases slight atrophy, mark the site of the lesions, and there may be also a slight amount of exfoliation. If ulceration results, it may be superficial or deep, more frequently the latter. It begins on the summit or in the interior, and the result is a deep, punched-out, more or less crescentic ulcer with a gummy, grayish-yellow deposit or covered with a crust. If the ulcerative process takes place in a patch of grouped tubercles, an extensive excavated ulcer may result. Sometimes the ulceration occurs in a crescentic or serpiginous course. In some instances from the ulcerating surface spring up papillary, wart-like, or cauliflower excrescences, with a yellowish, offensive, puriform secretion, the so-called syphilis cutanea papillomatosa. This condition is most frequently encountered upon the scalp.

Tubercular syphiloderm is to be differentiated from lupus vulgaris, leprosy, and cancer—especially the first, to which it at times bears a close resemblance. In syphilis the lesions are firmer and deeper, and form more rapidly, than in lupus; moreover, the disease is usually one of adult life and middle age, whereas lupus appears, as a rule, first in childhood.

SYPHILODERMA GUMMATOSUM (syn., gummatous syphilide, syphilis cutanea gummatosa) consists in the formation of a rounded or flat, slightly raised, moderately firm, more or less circumscribed tumor, having its seat in the subcutaneous tissue, which later shows a tendency to break down. As a rule, only one or two tumors are present. The growth is variously known as a gumma, gummy tumor, and syphiloma. The lesion, which is usually a late manifestation, begins as a small, pea-sized deposit beneath the skin, which gradually increases in size; the overlying skin, which is at first of a natural color, becoming pinkish or reddish. It may eventually attain the size of a walnut or may be even larger. It is firm or soft and doughy to the touch, is usually painless, and tends to break down, disappearing by absorption or ulceration, the ulcer being usually deep with perpendicular edges. It is to be distinguished from furuncle, abscess, and fatty and fibrous tumors. In most cases other symptoms of syphilis are present.

SYPHILODERMA BULLOSUM (syn., bullous syphilide, syphilis cutanea bullosa, pemphigus syphiliticus) appears in the form of discrete, disseminated, rounded or ovalish blebs, varying in size from a pea to a walnut, and containing a serous fluid which rapidly becomes cloudy or thick. In some cases the process is distinctly pustular from the beginning. The blebs, which are, as a rule, partially or fully distended, after a variable time dry to crusts of a yellowish-brown or dark-greenish color, which may be thick and raised or conical and stratified, the latter constituting rupia, as in the case of the large, flat pustular syphiloderm. They are easily removed, and cover erosions or ulcers which secrete a greenish-yellow fluid. It is a rare manifestation, occurring late, is variable in its course, and is seen usually in broken-down individuals. It is not infrequent in hereditary syphilis in the new-born.⁷

⁷ For the cutaneous manifestations of hereditary syphilis see article by J. William White on that subject in Vol. II. p. 254.

ANATOMY.—Anatomically, the syphilitic deposit consists of a round-cell infiltration. It is most typically shown in the papule and tubercle; in the macule there is hyperæmia, with beginning tissue-cell proliferation, but the specific cell-infiltration is not distinguishable. The process usually involves the mucous layer of the epidermis, the corium, and, in the deep lesions, the subcutaneous connective tissue. The extent and depth of the infiltration depend upon the size and form of the growth.

TREATMENT.—Cutaneous syphilis, as in the case of all other manifestations of this disease, requires constitutional treatment, and generally local medication also. In order that relapses may in a great measure be obviated, prolonged treatment by appropriate remedies is essential. Even with such management and under the best circumstances relapses will frequently occur. The advantage of temperate and regular living and hygienic influences in promoting a disappearance of the manifestations and keeping the disease in abeyance cannot be too strongly urged. In syphilitic subjects anæmia, dyspepsia, malaria, or any similar condition is apt to render the syphilis more violent, and, if present, should receive appropriate treatment. Ill health from any cause predisposes to a relapse.

The remedies which, in a sense, may be considered to exert a specific action in syphilis are mercury and potassium iodide. They are indispensable in the treatment of the disease. Both are important, although the former is the more valuable. As a rule, mercury is the remedy to be given in the first stages of the disease, and the cases are exceptional in which its use is not permissible. In such instances potassium iodide is to be prescribed. As the later stages of the disease approach the iodide of potassium becomes relatively more important. Even in the late syphilodermata, however, mercury in small doses holds a prominent place in the treatment, as it seems to possess a greater influence in preventing relapses. In the administration of mercury salivation is to be carefully guarded against, as its occurrence is detrimental to the health of the patient, and indirectly as well as directly it exerts an unfavorable influence on the course of the disease. Beyond slight tenderness of the gums its action should never be pushed.

There are several methods of administering mercury, but that by the mouth is for many reasons the best. For this purpose various preparations, such as blue mass, calomel, corrosive sublimate, the protiodide and biniodide, as well as other mercurials, are used. In the average case the protiodide is one of the best, and is probably in most general use. It is given in pill form in the dose of one-fourth or one-half a grain three times daily. If gastric or intestinal disturbance, such as pain and diarrhoea, is produced by its use, as is occasionally the case with this and all other preparations of mercury, a small proportion of opium may be added to each pill. Blue mass is an important mercurial in the early syphilodermata, and is given in doses of two or three grains three times daily. For bringing the system rapidly under the influence of the mineral, an important consideration in some cases, calomel in doses of one or two grains combined with opium, three or four times a day, is the most active. Corrosive sublimate is slow in its action, but is usually well borne and shows but slight disposition to salivate. The dose is one-twenty-fourth to one-eighth of a grain in pill or solution three times daily. It is rarely employed in early syphilis, but is a useful mercurial for long-continued administration, and also in the later stages of the disease.

Inunction is another method of introducing mercury into the system, and is especially useful in treating the disease in the infant. For this purpose two preparations are used—blue ointment and oleate of mercury. The latter, 5 to 20 per cent. strength, has lately been somewhat extensively employed, but it is not comparable in value for this purpose to the blue ointment. The sole advantage of the oleate is its light color. The blue ointment may always be prescribed with confidence as to its effect; the same cannot be said of the oleate. Various regions are selected for the inunctions—the arms, axillæ, thighs, abdomen, chest, and back being taken in turn, so as to obviate as far as possible local irritation. About a drachm of the blue ointment suffices for an inunction. For infants the preparation should be weakened. By means of inunctions the system may rapidly be brought under the influence of the remedy.

Another method of introducing mercury is by hypodermic injections. Corrosive sublimate is the preparation commonly employed; about one-tenth of a grain, with about the same quantity of morphia, dissolved in fifteen minims of water, constitutes the average amount for an injection, one being made daily. The back, especially the lateral regions, is the part usually selected. The method has the advantage of rapidity of action, twenty to thirty injections sufficing, as a rule, to remove the lesions. At the same time potassium iodide, if indicated, may be given by the mouth. The method, however, is objectionable, the injections producing pain, inflammatory swelling, and induration, and not infrequently abscesses. Ptyalism, a possible accident also, is to be guarded against.

The mercurial vapor bath is in many cases of value. Calomel or the black oxide of mercury is commonly used, about thirty grains of either to the bath. A vaporizing apparatus, containing the mineral and water required, is placed beneath the stool or chair, and the patient enveloped in a sleeveless flannel gown and covered over with a rubber blanket, the bath lasting about thirty minutes. The patient remains covered until cooled off, and then goes to bed in the flannel gown. The plan has cleanliness and simplicity as well as effectiveness to commend it. The corrosive-sublimate water bath is another method that is useful, especially for infants—ten to thirty grains to the bath for an infant, and two to four drachms for an adult. From fifteen minutes to half an hour should be passed in the bath.

Potassium iodide is, as already stated, indispensable in the treatment of late manifestations. The average dose is ten to twenty grains three times daily, but in many obstinate cases much larger doses may be necessary. It is usually given after meals, but it may be taken largely diluted half an hour before eating to greater advantage. Mercury should be, for reasons already stated, prescribed with it, the two remedies constituting the so-called mixed treatment. Another remedy frequently of use in the treatment of syphilis, especially in obstinate cases of ulceration, is opium in the dose of one or two grains three times daily, which in some cases possesses the power of arresting the activity of the process.

Local treatment remains to be considered. In the macular and small papular eruptions it is rarely called for, but in the more severe syphilodermata their disappearance may be hastened by external applications. The mercurial vapor and water baths already mentioned are serviceable; also an ointment of ammoniated mercury, a drachm to the ounce, a 5 to 20 per cent. oleate-of-mercury ointment, and citrine ointment with two to four parts of lard, constitute excellent local remedies. Mercurial plaster is frequently of value, especially in reducing infiltrations. In the palmar and plantar syphilides strong ointments are necessary, and should be well worked into the skin. Moist papules always require treatment; cleanliness is of great importance. Applications of solutions of chlorinated soda, corrosive-sublimate lotion, and a lotion of carbolic acid, followed by a dusting-powder of calomel, oxide of zinc, or starch, may be advised. The ulcerative lesions, after the removal of crusts by means of hot water or oily applications, are to be treated with the ointments or lotions named above.

Epithelioma.

There are three varieties of epithelioma or skin cancer—superficial, deep-seated, and papillomatous. The superficial, or flat, form begins as a minute, firm, reddish or yellowish prominence, or it may begin as an aggregation of such lesions. The process may remain in this stage for months or years; sooner or later, however, the summit of the growth becomes slightly scaly and shows a softened or excoriated centre. From this central point a small quantity of fluid oozes, which forms a yellowish or brownish crust. This scale or crust becomes detached from time to time, either intentionally or by accident, and is followed by another similar in character, but possibly larger than that which had preceded. At the same time the underlying nodule or nodules slowly increase in size.

In this condition it may remain for months or years, but sooner or later the process becomes more active. New nodules form about the edges of the patch, and in a variable period go through the same steps as those forming the original lesions. The excoriation or ulcer becomes more marked, being as large as a pea or a dime, irregular in outline, more or less crusted. It is defined against the surrounding healthy skin by a flat or slightly elevated, more or less hardened, infiltrated border. The ulcer, which has usually an uneven surface, secretes a scanty, thin, viscid fluid, which dries to a firm, adherent crust. At points there may be a disposition to spontaneous involution, the epithelial growth being cast off by suppuration, depressed scar-tissue taking its place. The ulcerative process, however, generally progresses until often a sore of considerable size may form. The general health remains unaffected. The superficial variety may form as described, and may so continue its course, or it may at any stage pass into the more malignant, deep-seated variety.

This latter variety may begin as a tubercle or nodule in the normal skin, or it may, as already stated, start from the superficial or other variety. Where it develops typically a pea-sized, reddish, shining tubercle or nodule, or an area of infiltration, forms in the skin, or even in the subcutaneous connective tissue, which grows slowly or rapidly, usually from six months to a year or more elapsing before exciting solicitude. Sooner or later, depending on the virulence of the process, ulceration takes place, superficial or deep-seated in character, depending upon the amount of infiltration. The surface of the ulcer is granular and reddish and secretes an ichorous discharge, and the edges are indurated and, as a rule, everted. As the infiltration spreads the ulcer enlarges peripherally, and at the same time involves the deeper parts, muscle, cartilage, and bone often becoming implicated. The glands also become involved, burning or neuralgic pains are felt, and the strength gradually declines, until from septicæmia, marasmus, or implication of vital parts death results.

The third variety, the papillomatous, may arise in the form of a papillary or warty growth, or it may develop, as is more commonly the case, from either the superficial or the deep-seated variety. At an advanced period its surface is papillomatous or warty, is ulcerated and fissured, bleeds easily, and discharges an ichorous fluid, which dries and forms a brownish crust.

Epithelioma is most frequently encountered about the face; the nose, eyelids, and cheek all being favorite localities. The neck, the hands, and the genitalia also suffer frequently. If seated about the genitals, its course is apt to be more rapid and destructive. The predisposing causes are not well understood. The disease rarely shows itself before middle life, and is much more common in men than in women. It is not, as a rule, inherited. The exciting causes are frequently to be found in long-continued alterations in the epithelial structures, such as, for example, occur in warts. Any locally irritated tissue may be the starting-point of the disease. 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 onion-like bodies, the so-called cell-nests or globes. The rapid cell-growth requires increased nutriment, and hence the blood-vessels become enlarged; moreover, the pressure of the cell-masses gives rise to irritation and inflammation, with corresponding serous and round-cell infiltration.

Epithelioma is to be differentiated from syphilis, wart, and lupus. Occurring about the genitals, it may be confounded with chancre, but the history, duration, character of the base and edges will serve to differentiate the diseases. The syphilitic lesion, wherever occurring, runs a much more rapid course than epithelioma. In tubercular syphilis several points of ulceration are usually seen; in epithelioma usually only one. The secretion from syphilitic ulcerations is generally abundant and of a yellowish, creamy character; in cancer it is scanty, viscid, stringy, and streaked with blood. The ulcer of syphilis rarely has the elevated, infiltrated border usually seen in epithelioma. Warts or warty growths must be distinguished by attention to their history and course; observation extending over months may at times be necessary before a positive opinion as to the existence of epithelial degeneration is warrantable. In lupus vulgaris the deposits are peculiar and are multiple, while in epithelioma the lesion is usually a single formation. The former generally begins in early life; the latter is a disease of the middle-aged and old. It remains to be stated that occasionally cancer and lupus occur combined, the former usually following the latter.

TREATMENT.—The variety, extent, and rapidity of the process are always to be duly considered in the prognosis. The superficial form may exist for many years without causing alarm. The deep-seated variety is always to be viewed as a serious disease, and is often fatal. Relapses after operation, even where this has been well performed, are frequent. The treatment is in most cases—for the time, at all events—successful. If the diseased tissue is thoroughly removed, the relief may be permanent or may at the least extend over several years. If, however, cauterization or operation is not thorough, the parts are scarcely healed before symptoms of a recurrence manifest themselves. Internal treatment does not seem to exert any beneficial effect upon the disease. In regard to local treatment, whatever operation or remedy is capable of removing or destroying the growth may be employed, caustics, the curette, and the knife all being available for this purpose.

Among the caustic agents, potassa in stick or in solution is one of the most valuable. Chloride of zinc in paste or stick form may also be mentioned as being of service, but it is a painful caustic. Arsenical pastes are efficient, and have the advantage of sparing the healthy tissues; one consisting of equal parts of powdered acacia and arsenic, to which a small proportion of morphia may be added, will be found serviceable; it should kept applied in the form of a plaster for from six to twenty-four hours, or until the pain, which is apt to be severe, becomes unbearable, and then poultices applied. Pyrogallic acid, from one to four drachms to the ounce of resin cerate, is a very valuable remedy. Its action is slow; it should be renewed twice daily, and its application continued for a week or longer. As a rule, it is painless.

One of the best plans of treatment is that with the dermal curette. The diseased tissue is thoroughly scraped away, the wound dressed with some simple ointment, and healing allowed to take place. Sometimes after the use of the curette it is advisable to cauterize lightly with caustic potash or to apply an ointment of pyrogallic acid for a few days to ensure complete destruction of the disease. There are other cases in which excision constitutes the most useful method of treatment. In cases in which there is much loss of tissue a plastic operation may be performed, being preceded by a thorough removal of the diseased tissues. The galvano-cautery is another method which may be resorted to.

Sarcoma.

Sarcoma cutis, or sarcoma of the skin, is a rare affection, consisting of shot-, pea-, hazelnut-, or larger-sized, variously-shaped, discrete, non-pigmented or pigmented tubercles or tumors. They are smooth, firm, and elastic, are not markedly painful upon pressure, and show a tendency to reach the surface and ulcerate. The overlying skin is at first normal and somewhat movable, but as the lesions approach the surface it becomes reddened and adherent, or if of the pigmented variety the skin acquires a bluish-black color. The multiple pigmented sarcoma (melano-sarcoma) appears, as a rule, first on the soles and dorsal surfaces of the feet, and later on the hands, the lesions manifesting a disposition to bleed.

The disease described by Geber and one of us (Duhring) under the name of inflammatory fungoid neoplasm is doubtless a form of, or closely allied to, sarcoma. It manifests itself by the formation of several distinct kinds of lesions, the more important consisting of flat or slightly-raised coin- to palm-sized, rounded or ovalish, superficial or deep-seated, smooth, scaly, or crusted patches of a pale-pinkish or deep-reddish color; and prominent, rounded, or ovalish, soft, firm, or solid, furrowed or lobulated, tubercular or fungoid tumors, varying in size from a pea to an egg, somewhat depressed in the centre, and pale-red, deep raspberry-red, or violaceous in color. The flat patches with involution assume a mottled or streaked purplish, yellowish, or salmon color. The tumors may appear suddenly within a few hours or a day, or gradually in the course of weeks or months. After reaching a certain size they tend to soften, diminish in size, and undergo spontaneous involution or ulcerate. Itching and burning are usually complained of, but are variable. All regions may be attacked. It is rare. The so-called lymphadenoma, lymphadénie cutanée, and mycosis fungoide of the French may also, doubtless, be properly classified as a variety of sarcoma.

The disease is to be distinguished from the papular, tubercular, and gummative syphilodermata, lupus, leprosy, and carcinoma. As a rule, sooner or later, a fatal termination takes place. Treatment is palliative. Surgical interference may be of service in particular situations. Hypodermic injections of Fowler's solution in increasing doses have, it is stated, influenced the disease favorably.

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CLASS VII.—NEUROSES.

Dermatalgia.

Dermatalgia, or neuralgia of the skin, is characterized by pain having its seat solely in the skin, unattended by structural change, and associated usually with a morbidly sensitive condition of the part. The symptoms are purely subjective, as in pruritus. The skin shows no alteration. It is usually a local disorder, confined to a small area, and is met with, as a rule, in adult age. It consists in a highly-sensitive state of the integument, with a feeling of positive pain having its seat in the superficial layers of the skin, which is remarkably sensitive to external impressions; the touch, contact of the clothing, and even the air, exciting more or less pain. In character the sensation is burning, pricking or darting, or like electric shocks. It is generally worse at night. The affection may exist idiopathically or symptomatically, the latter being the more common and accompanying lesions of the nervous centres. Its frequent connection with rheumatism has been pointed out by Beau and other writers, from which fact it is sometimes called rheumatism of the skin; but in other cases it occurs in persons apparently in good health. Hysteria has also been noted as a cause. The general treatment depends upon the exciting cause, but local measures may be demanded to relieve the disagreeable or painful sensations, among which the galvanic current, applications containing belladonna, aconite, or iodine and blistering may be tried.

Pruritus.

Pruritus is a functional disease of the skin, characterized solely by the sensation of itching, without the existence of structural change. The affection must be clearly separated from the many other cutaneous diseases accompanied by itching. In pruritus the single symptom is itching, varying in kind and degree. There are no primary structural lesions, but secondary lesions, resulting from scratching and local irritation, are not infrequently present. The sensation is variously described by the sufferers, being often likened to the crawling of small insects over the surface. The desire to rub or scratch is irresistible. In other cases the sensation is a tingling, or as though some irritating substance, as flannel, was in contact with the surface. It exists in all degrees of severity, and frequently proves a source of great distress. It may occur at any age, but is most often met with in middle life and in old age, constituting so-called pruritus senilis. The itching may be constant or intermittent, but is usually the latter, occurring in most cases paroxysmally, and being almost invariably worse at night.

The disease may be local or general, but it seldom invades large portions of the surface at one time. In most cases it is a local disorder, the common regions being the genitalia and anus. The trunk, especially in elderly persons, is also not infrequently invaded. Occurring about the female genital organs, it constitutes the pruritus vulvæ of writers, having its seat in the labia or in the vagina. It is a very distressing form of disease, and is met with, as a rule, in middle life and old age. In the male the anus and the scrotum are the regions generally attacked, the perineum sometimes also being involved simultaneously. The anus in either sex is liable to invasion, the disease occurring here in children as well as in adults. All of these local varieties, as stated, are worse at night, and sometimes prove so harassing as to interfere greatly with sleep.

The causes which give rise to the affection are varied. Thus it is sometimes called forth by gestation and by the various disorders of menstruation, and in other instances, in either sex, by organic diseases of the genito-urinary tract. Diseases of the kidney and of the liver, especially jaundice, are frequently accompanied by pruritus. The nervous system is not infrequently at fault. Gastro-intestinal derangement, the ingestion of certain medicines (as opium), intestinal parasites, and hemorrhoids, are all well-known causes. The disease is strictly functional in nature, and is due to reflex nervous action.

The diagnosis rests with the subjective symptoms as given by the sufferer. There are no primary lesions; the secondary lesions, however, are sometimes so extensive as to suggest other diseases, especially prurigo and eczema, but there should be no difficulty in differentiating these diseases if their clinical features are kept in mind. Prurigo—a disease, practically speaking, unknown in this country—it will be remembered, is characterized by well-defined papules, and moreover shows predilection for the lower extremities. The subjective symptoms of pruritus often simulate those due to the presence of lice. In all cases these parasites, whether of the head, body, or pubes, should be carefully excluded in the diagnosis, for it sometimes happens that pediculosis is looked upon and treated as pruritus, the true nature of the affection being unsuspected. Pediculosis, it must not be forgotten, is occasionally met with in the upper walks of life, where it is at times extremely difficult to account for the source of contagion. Inspection of the skin and of the underclothing should be made in all suspected cases.

The treatment naturally varies with the determined or probable cause. The local origin of the affection should, in the first place, be inquired into. The internal remedies are to be selected with the view of meeting the requirements of the case. The various functions of the body should receive due attention, the bowels, in all cases tending to constipation, being kept open by laxatives, preferably saline preparations. The diet should be directed, all stimulating or injurious food and drink being interdicted. Quinine, arsenic, belladonna, strychnine, carbolic acid, tincture of gelsemium, and pilocarpine are remedies which may be tried in obstinate cases. In all cases the cause should be diligently sought for, for until this is discovered and removed there can be but little hope of complete recovery. External remedies, though extremely grateful to the patient, and of course very useful, as a rule are only palliative. There are cases, however, in which they prove curative. Water in the form of very hot or cold douches, and alkaline and sulphur lotions and baths, are sometimes serviceable, employed either alone or in connection with other remedies. In the local varieties of the disease antipruritic and stimulating lotions are especially serviceable. One of the most valuable remedies is carbolic acid, in the strength of from fifteen to forty grains to the ounce, to which may be added small quantities of glycerin and alcohol. A strong lotion consists of carbolic acid, one drachm and a half; potassa, twenty grains; water, eight ounces. The tarry preparations considered in eczema, especially liquor carbonis detergens and liquor picis alkalinus, are useful, as are likewise thymol, a few grains to the ounce of glycerin and alcohol, and oil of peppermint. The latter remedy, pure or mixed with glycerin, may be applied with a brush. Sometimes a simple chloral lotion is efficacious. In like manner lotions of acetate of lead, ten to thirty grains to the ounce; dilute hydrocyanic acid, a few drachms to the pint; hyposulphite of sodium; chloroform; chloroform and alcohol; diluted acetic acid; diluted ammonia-water; diluted nitric-acid; and corrosive sublimate,—may be tried. R. W. Taylor recommends the following:

Rx.	Fol. belladonnæ, Fol. hyoscyami, aa.	drachm ij;
	Fol. aconiti,	drachm ss;
	Acidi acetici,	fluidounce j. M.

This may be diluted with water a drachm to the ounce, or may be used with equal parts of glycerin, painted on the skin or in the form of an ointment, a drachm or two to the ounce. Tobacco, used as an infusion, two or three drachms to the pint, is often efficacious, especially in pruritus vulvæ. The fluid extract of conium, applied with a brush, and iodoform in ethereal solution, applied as a spray, may likewise be resorted to where the disease involves this region. Camphor and borax may be mentioned as being sometimes of service, as in the following formula:

Rx.	Sodii boratis,	drachm ij;
	Glycerinæ,	fluidrachm iv;
	Spts. camphoræ,	fluidounce ss;
	Aquæ rosæ,	ounce v. M.

Another lotion, containing borax and morphia, may be given:

Rx.	Sodii boratis,	drachm iv;
	Morphiæ sulph.,	gr. xv;
	Glycerinæ,	fluidounce ss;
	Aquæ, q. s. ad	fluidounce viij. M.

In some cases ointments prove more acceptable than lotions. Tar, carbolic acid, thymol, and the mercurials are all valuable used in this form, varying in strength with the locality and amount of surface to be treated. The smaller the area, as a rule, the stronger the remedy. Chloroform, chloral, and camphor also may be used in the form of ointments. About one drachm each of chloral and camphor to the ounce constitutes a good antipruritic remedy; the active ingredients are to be rubbed together and then added to the ointment.

In pruritus of the anus one of the most valuable and neatest remedies is carbolic acid with glycerin or olive oil, in the strength of from fifteen to forty grains to the ounce. Very hot water applied with a soft linen compress or sponge will usually afford temporary ease, and may be employed from time to time in connection with other more active remedies. In some cases we have had rapid and good results from an ointment of balsam of Peru, a drachm and a half to the ounce. Equal parts of belladonna ointment and mercurial ointment, and a solution of corrosive sublimate, about a quarter of a grain to the ounce, may also be mentioned; and where there are fissures occasional pencilling with a solution of nitrate of silver will afford relief, the latter application, made with a piece of sponge fastened on a stick, being also useful in pruritus vulvæ.

A long list of formulæ have been vaunted for the relief of pruritus of the female genitalia, a few of which may be given. In addition to the remedies already mentioned the following formulæ will sometimes prove valuable. The fluid preparations may be used as vaginal injections or may be applied by means of a brush, tampon or cloth, according to their nature. Hyposulphite of sodium, a drachm to the ounce; sulphurous acid, sufficiently diluted; alum, sulphate of zinc, tannic acid, acetic acid, borax, and boric acid, may all be made use of in the form of injections. In this variety of the disease, as well as in pruritus of the anus, a 6 per cent. solution of cocaine, applied with a brush, or the oleate used as an ointment in the same strength, may be prescribed.

The prognosis should in all cases be guarded, the ability to relieve the disorder depending mainly upon the nature of the cause. The majority of cases, due to no evident cause, prove obstinate. But in all instances the patient should be encouraged to persevere in the treatment, and the hope of an ultimate cure extended to him.

PRURITUS HIEMALIS.—This is a peculiar form of pruritus, characterized by a somewhat harsh and dry state of the skin, accompanied with smarting and burning, unattended primarily by structural change, dependent upon atmospheric influences, and occurring chiefly in winter. It makes its appearance usually in the late autumn, becoming worse with the colder weather, and disappearing in the spring. The disease manifests predilection for certain regions, notably the extremities, especially the inner surfaces of the thighs, the popliteal spaces, and the calves; but in a less degree it may also invade other localities. In its milder form it is a common affection in cold climates. At times the itching is severe, leading to scratching and excoriations, while in other cases it merely amounts to an annoyance. It possesses the peculiarity of manifesting itself chiefly at night, coming on during the evening or shortly after bed is entered. The symptoms usually vary with the weather, being better and worse as the temperature is mild or cold. The affection in most instances repeats itself each year, and may thus continue indefinitely or it may partly or wholly disappear. As stated, the disorder is due to atmospheric influences, but is aggravated by irritating underwear and scratching. It occurs in both sexes, at all ages after puberty, and in those who bathe freely as well as in those who make sparing use of water. It does not seem to be influenced by the state of the general health, nor does internal treatment affect it favorably. Among the various external remedies, preparations containing glycerin, the petroleum ointment, carbolic acid and tar in the form of ointments and lotions, as in eczema, and alkaline lotions and baths,—may be mentioned as being most useful. The simple vapor bath is also in some cases beneficial.

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CLASS VIII.—PARASITES.

Tinea Favosa.

Tinea Favosa, or favus, is a contagious, vegetable parasitic disease, due to the achorion Schönleinii, characterized by discrete or confluent pea-sized, circular, pale-yellow, friable, cup-shaped crusts, usually perforated by hairs. It is seen commonly upon the scalp, and at times on other hairy regions, involving the hairs and hair-follicles (tinea favosa pilaris), or the non-hairy portions of the integument may be attacked (tinea favosa epidermidis), and cases are occasionally met with in which the nails are the seat of the disease (tinea favosa unguium). The scalp is the usual seat. It begins as a more or less circumscribed, superficial inflammation, with slight scaling, followed by the appearance of one or more yellowish points underneath the superficial epidermis and surrounding hair-shafts. They increase in size, and reach the dimensions of small peas, constituting the so-called favus cups, favi, or favus scutula. They are sulphur-colored, friable, circumscribed, round or oval, with depressed centres, and each pierced with a hair. In their early stage they are bound down to the skin by a layer of epidermis, which surrounds and envelops their periphery. The crusts are elevated from a half to several lines above the surrounding skin, distinctly umbilicated, and if detached an excavated, reddened, atrophied or suppurating surface is disclosed.

The crusts are composed of closely-packed, concentrically-arranged layers, and although they are at first discrete, sooner or later, from increase in number and size, they coalesce, and then their peculiar features are scarcely, if at all, distinguishable, irregular masses of thick, yellowish-white, mortar-like crusts taking their place. If removed, the surface is usually found atrophied, dry or inflamed and moist, and hairless. The hair-shafts are soon involved, the nutrition of these structures impaired, and in consequence the hairs become dry, lustreless, brittle, break off or fall out, and eventually the papillæ are entirely destroyed. Pustules and suppuration are in some instances noted about the borders and beneath the crusts. The pressure of the growing fungus gives rise to atrophy of the skin, which may be seen as depressed, firm, shining, cicatricial-looking areas. The general surface may also be attacked, either together with the scalp or alone. On non-hairy regions, however, the disease is rarely persistent. If the nails are invaded, they become thickened, yellowish, opaque, and brittle. Favus is usually attended with itching, especially when occurring upon the scalp. The odor of the crusts is peculiar, and may be likened to that of mice or stale straw. Upon the scalp the disease is always chronic, if untreated lasting indefinitely.

It is more common in children than in adults, and is seen almost exclusively among the poor. It is comparatively rare in this country. It is contagious. The disease is also encountered in the lower animals, from which doubtless it is not infrequently contracted. The affection is due solely to the growth in the upper layers of the skin of the achorion Schönleinii. This vegetable parasite grows luxuriantly, and constitutes almost entirely the whole mass of the crusts. It can be readily seen by subjecting a small portion of the crust, moistened with diluted liquor potassæ, to microscopical examination, a power of three to five hundred diameters sufficing. It consists of both spores and mycelium. The mycelium is composed of pale-grayish or pale-greenish narrow, flat threads or tubes branching and anastomosing in all directions. The spores are small, variable as to size, round, oval, flask- or dumb-bell-shaped, and are to be seen in abundance in the meshes of the mycelium. Intermediate forms between the spores and mycelium are always present. The hair-follicles and hair-shafts are found to be more or less invaded. If the nails are attacked, the fungus can be easily detected in a section or in scrapings, the mycelium predominating.

As a rule, favus is easily recognized. The small, pale, yellow, friable cup- or saucer-shaped crusts and the peculiar odor are sufficiently characteristic. In some chronic cases, where the crusts are merged into a mass, perhaps mixed with dirt and pus, it resembles pustular eczema; but the condition of the hair, the atrophic patches, and the odor will serve as distinguishing points. Tinea tonsurans can scarcely be confounded with this disease, as it is wanting in the peculiar crust-formation and the tendency to scarring. In doubtful cases the microscope is to be employed.

Favus of the scalp is not only a chronic disease, but is also rebellious to treatment. In neglected cases permanent baldness, atrophy, and scarring sooner or later occur. On the non-hairy portions of the body it is rarely obstinate; involving the nails, it is slow to yield. The first step in the treatment of a case of favus of the scalp, the common seat of the disease, is a removal of the crusts. This is readily accomplished by saturating the parts with simple or carbolized oil, and subsequently washing with soap and hot water. The hair on and around the patches is to be clipped as a preliminary measure; keeping the hair of the entire scalp cut short facilitates treatment, but is not essential. The hairs in the diseased areas are then to be carefully extracted by means of the broad-bladed forceps. This part of the treatment, epilation or extraction of the hairs, is indispensable if the eventual result is to be successful and permanent. Before epilating, the surface to be operated upon is to be anointed with a simple oil. After the operation a parasiticide is to be thoroughly applied, so that it may penetrate the hair-follicles. The whole surface involved is thus treated. Another plan of epilation is that in which the hair is drawn with some force between the thumb and an ordinary tongue-spatula, those that are diseased and loose coming out, while those that are sound remain. In this method the hair is not clipped. The plan is more simple and less tedious than forceps epilation, but is not so satisfactory, as the hairs are more likely to break off, and, moreover, many that are diseased are left unextracted.

Whatever parasiticide is used should be well and thoroughly applied to the affected areas. Those that have the greatest penetrating power are to be selected. Corrosive sublimate, three or four grains to the ounce of alcohol or ether; a 25 per cent. oleate-of-mercury ointment; carbolic acid and glycerin, one part of the former to three or more of the latter,—may be mentioned as among the most useful. Tar, sulphur, and ammoniated mercury and citrine ointments, of officinal strength or weakened; sulphurous acid; a solution of hyposulphite of sodium, a drachm to the ounce,—are also efficient parasiticides. Chrysarobin, in ointment or in chloroform, a drachm to the ounce, has been well spoken of, but must be used cautiously. After several weeks' treatment applications may be suspended for a week or more, so that the condition may again be determined. In ordinary well-developed cases from three to six months' active treatment is required for a removal of the disease.

Favus of the non-hairy portions of the surface requires, after a removal of the crusts, the application of a mild parasiticide, the disease, as a rule, readily yielding. In favus of the nail as much as possible of the affected portion is to be pared or cut away, and a simple parasiticide applied once or twice daily. In those who are debilitated and ill-nourished favus may possibly be rendered less obstinate by suitable internal treatment, with proper nourishment and pure air.

Tinea Trichophytina.

Tinea trichophytina, or ringworm, is a contagious vegetable parasitic disease, due to the trichophyton, its clinical characters varying according to the part invaded. It is a common disease, more frequent in children than in adults, and is met with to a varying extent in all countries. It is contagious, but individuals vary as regards susceptibility. The fungus (the trichophyton) consists of spores and mycelium. The latter consists of long, slender, delicate, sharply-contoured, pale-grayish, straight or crooked, branching, ribbon-like threads, containing spores and granules. They are remarkable for their length. The spores are round, small, highly refractive, grayish or pale-greenish bodies, and are either single or arranged in rows, which may be isolated or joined to mycelium. The appearances of the disease, and to a certain extent its treatment, are so different when affecting the general surface, the scalp or the bearded region that separate descriptions are called for. When seated upon the general surface the disease is commonly known as tinea circinata (tinea trichophytina corporis); on the scalp, tinea tonsurans (tinea trichophytina capitis); on the bearded region, tinea sycosis (tinea trichophytina barbæ).

TINEA CIRCINATA, or ringworm of the body, is characterized by one or more circular or irregularly-shaped, variously-sized, inflammatory, slightly vesicular or squamous patches. It usually begins by the formation of one or more roundish, slightly-elevated, sharply-limited, somewhat scaly, hyperæmic spots, which in some cases show minute papules or vesicles, especially about the periphery. As the process advances, usually in the course of a few days, the inflammation is more marked and the scaliness increased. The patches assume, as a rule, a distinctly annular character, and as they grow by extending peripherally, their centres clear up, so that when fully developed they are usually about an inch in diameter, and consist of a more or less normal central area, then an intermediate pale-reddish scaly portion, and the red, elevated, and scaly or papulo-vesicular or vesicular border defined against the healthy skin. In rare instances vesico-pustules may form. There may be one, several, or many patches present, but as a rule they are not numerous. After attaining a certain size they may remain stationary for a short time or may begin to disappear spontaneously. Where two or more are in close proximity, they may increase in size, gradually coalesce, and form gyrate or irregularly-shaped lesions. At times, instead of the typical annular patches, the disease may appear in the form of disseminated, small, reddish, slightly scaly, ill-defined spots, which may appear and disappear rapidly, the patient rarely being free of lesions. Although any portion of the general surface may be invaded, there are certain regions of predilection, as the face, neck, and backs of the hands. It is commoner in children than in adults.

Involving surfaces that are in close contact, as the axillæ, between the buttocks, and the inner surfaces of the thighs, it tends to spread extensively, is more inflammatory, and often proves rebellious to treatment. Invading these parts, the condition, under the impression that it was an eczema, was described by Hebra as eczema marginatum. It is most common, however, about the thighs, and seated here is termed tinea circinata cruris. It begins usually in the same manner as ringworm on other regions, but on account of the heat, moisture, and friction of the parts its characters become changed. The patch becomes inflamed, slightly elevated, coalescing with similar patches, until the greater part of the inner surface of the thighs and buttocks may be involved. The groins and mons veneris may also be invaded. When fully developed it is characterized by extensive, irregularly-shaped, inflammatory patches, with at times a slightly moist surface, and is usually well defined against the surrounding healthy skin by a more or less raised border, which may show papules or vesicles. Sometimes beyond the general area involved may be seen more or less typical ringworm patches. As met with in this country, it is usually mild in character. In Southern Europe it is encountered more frequently, is of a severer type, and is often intractable. It is met with usually in adults. Relapses are not uncommon.

The course of ringworm of the general surface may be acute or chronic. It may disappear in a few weeks, or, on the other hand, may continue indefinitely. As commonly met with in this country, it is, as a rule, readily responsive to treatment. It is frequently seen in association with ringworm of the scalp. Itching in variable degree is usually present. Invading the nails, the affection is designated tinea trichophytina unguium. These structures become dry, opaque, dirty white or yellowish, thickened, of irregular shape, bent, soft, or brittle and laminated, the changes taking place especially about the free border. The nails of the toes are seldom affected. As a rule, not more than two or three of the finger-nails are attacked. It is commonly associated with chronic ringworm on other parts of the body.

The fungus (trichophyton) in tinea circinata has its seat in the epidermis, especially in the corneous layer. The first effect of its invasion is hyperæmia, subsequently inflammation, usually mild in character, with more or less scaling. A microscopical examination, with a power of two to five hundred diameters, of scales from the periphery of a patch, moistened with liquor potassæ, will show both mycelium and spores, the latter comparatively few in number. In fact, the fungus in ringworm of the body is rarely to be found in abundance. In tinea trichophytina unguium the substance of the nail is invaded, scrapings of which will show the fungus, usually the mycelium, generally but few spores being present.

The affection is to be recognized by its peculiar clinical features, and, if necessary, by means of the microscope. This instrument should always be employed in cases of doubt. At times it bears resemblance to eczema and seborrhoea, and to psoriasis. From eczema it may be distinguished by its circular or annular form, its sharply-defined margins, its tendency to clear up in the centre, its slight desquamation, and its history and course; the itching is usually less marked than in eczema. Seborrhoea, when occurring on the chest and back, often consists of circular patches similar in general features to ringworm, but the scales are greasy, and are seated upon non-inflamed skin; the scaliness of ringworm is the result of inflammation, while that of seborrhoea consists of dried sebaceous matter. Moreover, in the latter affection the sebaceous follicular openings are perceptibly enlarged, and are indicative of the nature of the disease. In psoriasis at times the patches clear up in the centre, and in such instances a mistake in diagnosis might occur. The scaliness of psoriasis, however, is always a marked feature; it is usually insignificant in ringworm. Moreover, the characters of the scales are different. Occasionally the circinate tubercular syphiloderm has been confounded with ringworm, but the nature of the patch in the former disease, consisting of an irregular and incomplete ring of elevated tubercles or infiltrations, with, at times, ulceration, is so entirely different from the latter affection that an error should not occur. It can scarcely be confounded with favus if the peculiar yellowish, cup-shaped crusts of that disease are kept in mind; the clinical features of the two affections are also in other respects dissimilar.

The treatment consists in the application of the milder parasiticides, the disease rarely proving obstinate. In exceptional cases, where the affection is persistent, it will sometimes be found that the general nutrition is below the standard; and in such instances constitutional remedies of a tonic nature, as cod-liver oil, iron, quinine, and arsenic, are serviceable. In children the skin is delicate and strong remedies are not well borne; nor are they, as a rule, necessary. The parts should be first washed with soap and water, and then the remedial applications made; the lotion or ointment should be applied two or three times daily. If a lotion, it should be dabbed on thoroughly; if an ointment, it should be thoroughly rubbed into the patches. The sulphite or hyposulphite of sodium, in lotion or ointment form, a drachm to the ounce; sulphurous acid, full strength or diluted; ammoniated mercury, thirty to sixty grains to the ounce of lard or vaseline; corrosive sublimate, two to four grains to an ounce of alcohol or water; an ointment of sulphur, a drachm or two to the ounce; tar ointment, a drachm or two to the ounce; carbolic acid, ten to thirty grains to the ounce of water or lard,—are all parasiticides of value which may be employed in this disease. In obstinate cases chrysarobin, five to thirty grains to the ounce of lard, may be cautiously used, or it may be applied in collodion or gutta-percha solution, 5 to 10 per cent. strength. In tinea circinata cruris applications such as the above, but stronger, are serviceable. R. W. Taylor speaks well of a solution of corrosive sublimate in tincture of benzoin, two to four grains to the ounce, painted over the parts. The chrysarobin ointment or solution already mentioned may also be especially referred to. Hebra's modification of Wilkinson's ointment (see Scabies for formula) is useful in these cases. In tinea trichophytina unguium the nail should be pared or scraped, and one of the parasiticides applied.

TINEA TONSURANS.—Tinea tonsurans, or ringworm of the scalp, is characterized by circular or irregularly-shaped, variously-sized, scaly, more or less bald patches, showing the hair to be diseased and usually broken off close to the scalp. It is met with in children, especially in those under the age of twelve years; it is rarely seen after puberty. It begins as one or more small, round, erythematous, scaly spots, which may be minutely papulo-vesicular or vesicular about the periphery. Soon by peripheral growth typical circular patches of various sizes are formed, averaging about an inch in diameter. More or less itching is usually complained of. A typical patch is circumscribed, slightly elevated, reddish, grayish or slate-colored, with more or less scaling, usually thin or bran-like in character, with the hairs broken off close to the scalp. The color varies with the complexion of the individual; in marked blondes it has usually an inflammatory tint, while in those of dark hair and skin it is bluish-gray or the color of slate. The hairs on the affected areas are involved early in the disease, becoming lustreless, dry, brittle, twisted, breaking off close to the skin, with their free extremities ragged and uneven, having a gnawed or nibbled look. They are easily extracted, or often break off within the follicles, appearing then as blackish dots. A variable degree of baldness occurs, which, however, is rarely permanent. In some instances the patch is non-inflammatory and free of scales, the loss of hair, which is more or less complete, taking place rapidly, such cases bearing resemblance to alopecia areata. As a rule, several patches varying in duration and size are present. They may remain discrete, or coalesce and form irregular areas. The vertex and parietal regions are favorite localities, although any region of the scalp may be invaded. It is not uncommon to see patches of the disease on the non-hairy portions of the body at the same time.

In some cases, especially in those ill nourished and scrofulous, the inflammation may be of a higher grade, resulting in the production of discrete or grouped pustules, terminating in crusting; or the disease may assume the condition known as tinea kerion. This latter is seen most commonly in scrofulous subjects. Beginning ordinarily as a simple patch of ringworm, the affected area soon becomes inflamed, swollen, oedematous, elevated, red, shining and boggy, covered with a mucoid secretion which is poured out from the openings of the hair-follicles. The stubby hairs soon fall out, leaving the patch more or less bald. The surface is uneven and studded with the foramina, or small cavities, containing the mucoid or sero-purulent secretion, corresponding to the dilated hair-follicles. It bears resemblance to abscess and carbuncle. An analogous condition is not uncommon in tinea sycosis. It may occur with the usual form of tinea tonsurans or alone. Occasionally the disease cures itself in this way. It may, however, be chronic. Its causes are not understood: it may be due to the presence of the fungus in the deeper portions of the hair-follicles, or at times to over-treatment. It is a rare manifestation.

Other unusual forms of the disease are occasionally noted. The spots may in the early stages be merely scaly, with or without inflammatory symptoms, and the hairs long and firmly seated, resembling eczema or seborrhoea. Later, however, the hairs break and the characteristic stumps are the result. As ringworm becomes chronic (its usual course) the clinical features become different. The disease exists in irregular areas—as a rule, non-inflammatory and more or less scaly, especially about the follicles. The hairs are short, stubby, and broken off near the skin or in the apertures of the follicles; in the latter case the skin has a punctate or dotted appearance. This condition is noted especially in brunettes; in blondes the hairs are somewhat longer and apt to drop out insidiously. Or, the disease may be disseminated, involving here and there over the scalp small groups of follicles, the hairs being short, the follicles slightly enlarged, with a tendency to scaliness; in these cases the disease may be easily overlooked.

Ringworm of the scalp is a common affection, and is observed among the rich as well as the poor, but is most frequent in those suffering from malnutrition. It may be communicated by means of caps, combs, brushes, and the like. It is frequently seen in schools and children's asylums, sometimes affecting a large proportion of the inmates. The fungus (trichophyton) invades the epidermis, hair-follicle, bulb, and shaft. The follicle becomes distended and raised; the hairs are permeated with the fungus (spores markedly predominating), are disintegrated, and destroyed. The perifollicular tissue may, in severe cases, be invaded. The spores are present in great abundance, the mycelium existing scantily.

As a rule, there is no difficulty in recognizing the disease. The presence of stumps of hair having a gnawed or nibbled look, the prominent follicles, more or less baldness, and slight or decided scaliness, together with the history and course, constitute a clinical picture that is scarcely mistakable. If necessary, microscopical examination of the hair will give positive information. For this purpose one or two of the short, stubby hairs should be selected, placed upon a slide, a drop of liquor potassæ added, allowed to stand a few minutes, and then examined with a power of two to five hundred diameters; the hairs will be found full of spores, the shafts being completely disintegrated. If a few drops of chloroform are poured upon a patch of ringworm of the scalp and allowed to evaporate, the hairs and follicular openings affected become whitish or light-yellow, which, according to Duckworth, is pathognomonic. It is to be differentiated from squamous eczema, seborrhoea, psoriasis, and alopecia areata. The history of eczema is different: it rarely begins as circular spots, spreading peripherally; the margins are always more or less irregular; the hairs are not involved, but remain seated firmly in the follicles; the itching is marked, whereas in ringworm it is usually slight. Seborrhoea is non-inflammatory; the scales are greasy; the hairs are not broken off; and the margins of the patch are ill defined. In psoriasis the scaling is a marked feature; the hairs are not involved; and the disease is usually to be found typically expressed on other parts of the body. From alopecia areata ringworm may be differentiated by its clinical features; in the former disease the baldness is usually complete, the skin devoid of scales, non-inflamed, smooth, shining, and the follicles, as a rule, less prominent than normal; the absence of the characteristic stumps of ringworm may also be noted. In obscure cases the microscope is to be employed.

An opinion regarding the length of time required to cure ringworm of the scalp should always be guarded; while some cases respond in several weeks, in others several months or more may be required. Relapses are liable to occur. External remedies are, as a rule, alone required. In chronic cases, however, where a condition of malnutrition exists, proper food, fresh air, and suitable internal remedies, as cod-liver oil, iron, and arsenic, are to be advised; cleanliness is of importance. The patches should be washed frequently with warm water and castile soap or sapo viridis, the frequency depending upon the scaling and the amount of disease, and also somewhat upon the remedies employed. Occasional washing of the entire scalp is also to be advised. Remedial applications should be, as a rule, made twice daily. In acute or recent cases, in which the fungus has not penetrated deeply into the hair-follicles, it often yields to the ordinary parasiticides, without the necessity of epilation. In cases commonly encountered, however, the disease has already lasted some length of time, and epilation becomes essential. The main difficulty in the treatment of tinea tonsurans is to bring the remedy in contact with the fungus; otherwise the affection would be as easily curable as that occurring on the general surface. To a great extent epilation aids in overcoming this difficulty, as the parasiticide is then able to permeate the emptied follicle; and in addition to this advantage the extracted hairs take with them the fungus contained within their structures. The hair within and around the affected areas should be clipped short, or, if the patches are numerous, the hair of the entire scalp should be cut, or, what is preferable in many cases, shaved. If the scalp is shaved, a few days elapse before epilation is possible. On a shaved head there is no chance for any diseased area, however small, to escape observation; in the treatment of the disease as met with in institutions this procedure is almost essential. In epilation the loose hairs on the patches and about the borders should first receive attention. For this purpose a small, broad-bladed, short forceps may be employed, a few hairs at a time being seized. A portion of the diseased area should be carefully gone over each day until all are removed. After each epilation the parasiticide is to be applied.

Corrosive sublimate, two to four grains to the ounce of alcohol or water, is a reliable remedy; also oleate of mercury, in the form preferably of a 25 per cent. ointment. An ointment such as the following is serviceable in many cases:

Rx.	Ugt. picis liquidæ, Ugt. hydrarg. nitrat., aa.	drachm ij;
	Ugt. sulphuris,	drachm iv.
M. Ft. ugt.

Or, in place of the tar ointment in the formula, carbolic acid in the same or less quantity may be substituted. The officinal tar, sulphur, and ammoniated mercury ointments may also be referred to as useful. In small disseminated patches carbolic acid in glycerin, one to three drachms of the former with enough of the latter to make an ounce, will often prove serviceable. Thymol sometimes proves of value, and may be prescribed as advised by Malcolm Morris:

Rx.	Thymolis,	drachm ss;
	Chloroformis,	drachm ij;
	Olei olivæ,	drachm vj. M.

Coster's paste is also serviceable:

Rx.	Iodinii,	drachm ij;
	Olei picis,	ounce j. M.

This is painted on the patch, and permitted to remain on until the crust comes off, then is reapplied: a few applications are sometimes sufficient. In tinea kerion the hairs are extracted and a mild parasiticide applied: sulphurous acid, a weak solution of corrosive sublimate, carbolic acid, ten to twenty grains to the ounce of water, or a weak ointment of the oleate of mercury or of white precipitate, may be employed.

If the disease proves obstinate, resisting the above treatment, it may be necessary to adopt stronger applications with a view of producing an acute inflammation in the part. To be efficacious the inflammatory action should be marked. For this purpose croton oil is used. It should never be employed when the disease is extensive; or if used in such cases a small area only, not exceeding that of a quarter dollar, should be treated at one time. Although valuable, the remedy is severe, and must be used cautiously. It may be applied pure or weakened with two or three parts of olive oil. An application requires but a small quantity, as it is apt to involve the skin beyond the area of application. In some cases a single application is sufficient; in others several or more are necessary before the requisite amount of follicular inflammation and suppuration results. The applications should be made by the physician, as it is not a safe remedy to entrust to attendants. After the application the part should be poulticed, and subsequently epilation practised and mild parasiticides employed. Instead of using croton oil, the patches may be painted with glacial acetic acid or cantharidal collodion once a week, and mild parasiticides, as sulphurous acid, carbolic-acid lotion, or sulphur ointment, applied in the interval. From time to time in the treatment of the disease, usually at intervals of from three to four weeks, applications should be discontinued a few days, and a microscopic examination of the scales and hairs made: if fungus is found, treatment is to be resumed.

TINEA SYCOSIS.—Tinea sycosis, or parasitic sycosis, is a disease confined to the hairy portions of the face and neck in the adult male, involving the hair and hair-follicles, with inflammation of the skin and subcutaneous connective tissue, and the formation of tubercles and pustules. It is popularly known under the name of barber's itch. It usually begins as one or more small, red, scaly spots, similar, in fact, to ringworm on the non-hairy portions of the surface. The redness and scaliness increase, and swelling and induration are noticed. In a short time the hairs are involved, become dry, brittle, inclined to break, and begin to fall out, the same changes occurring as noted in ringworm of the scalp. The fungus passes to the hair-follicles; perifollicular inflammation is set up, and results in the formation of deep-seated tubercles, varying in size from a pea to that of a cherry, giving the part a distinct nodular appearance. These coalesce and give rise to lumpy patches. The surface is of a deep reddish or purplish color; pustulation is noted about the openings of the hair-follicles. More or less crusting may take place; if removed, the hairs may come away with it. The amount of suppuration depends upon the grade of inflammation. Sometimes the hair-follicles are destroyed and permanent alopecia results.

The disease may involve a small area, appearing as a sharply-circumscribed, prominently-raised, deep-seated, nodular, coin-sized patch, with or without a purulent discharge from the emptied hair-follicles or with crusting; or the whole bearded region of the neck and chin may be invaded. It is not common on the upper lip or the upper bearded portion of the cheeks. Burning and itching are usually present, but are variable as to degree. The disease tends to chronicity. It is not uncommon at the same time to see patches of ringworm on other portions of the body. It is markedly contagious, although individuals differ as to susceptibility. It is often contracted at the hands of a barber. The fungus (trichophyton) which gives rise to the disease invades the same parts as when seated upon the scalp—the epidermis and the hair and hair-follicles; the latter are usually found permeated with spores, the mycelium being scanty.

The affection is not common, its frequency varying in different countries. It is to be distinguished from simple (non-parasitic) sycosis, pustular eczema, and the vegetating syphiloderm. In simple sycosis the process is comparatively superficial and confined to the hair-follicles; the hairs are not involved, and in the beginning, at least, are seated firmly in the follicles. In tinea sycosis the skin and subcutaneous connective tissue are extensively involved, resulting in the formation of nodular masses—a condition that is characteristic; the hairs are affected, are loose, and often fall out. In doubtful cases the microscope will determine. From pustular eczema it may be differentiated by its history and course: its clinical features are entirely dissimilar. Eczema is never attended with the nodular and tubercular formation peculiar to this disease, nor are the hairs affected. The absence of ulceration will distinguish the disease from the vegetating syphiloderm. Tinea sycosis when occurring as a circumscribed patch may sometimes resemble carbuncle.

In the treatment epilation with the use of parasiticides is employed; as a rule, the disease yields readily to treatment. Crusts, if present, are to be removed by means of oily applications and washings with castile soap (or if necessary sapo viridis) and warm water. The parts should be clipped or shaved, preferably the latter. Although this operation is painful at first, later it may be accomplished without much discomfort; shaving every second or third day is frequent enough. In the interval epilation is to be practised. The milder parasiticides, as sulphite or hyposulphite of sodium, a drachm to the ounce of water or ointment; sulphurous acid, full strength or diluted; citrine ointment, two or three drachms to the ounce of vaseline or lard; and a weak sulphur ointment,—are all useful. A 10 to 30 per cent. ointment of oleate of mercury is a valuable remedy; the same may be said of a solution of corrosive sublimate, two to four grains to the ounce of water or alcohol. In addition, the other parasiticides mentioned in the treatment of ringworm of the body or scalp may be referred to. The applications should be made twice daily; together with epilation they should be continued until microscopical examinations of the hairs give negative results.

Tinea Versicolor.

Tinea versicolor is a vegetable parasitic disease due to the microsporon furfur, characterized by variously-sized, irregularly-shaped, dry, slightly furfuraceous, yellowish, macular patches, occurring for the most part upon the trunk and in adults. The affection may be slight, consisting of several small patches on the upper part of the chest, or so extensive as to involve the greater part of the trunk, neck, axillæ, flexures of the elbows, groins, and in very rare instances the face. It never occurs on the scalp, hands, or feet. As commonly met with, it is a disease of the trunk, especially the anterior portion of the thorax. It begins as small yellowish or brownish, fawn-colored, furfuraceous spots scattered over the region affected. These gradually increase in size, new spots may appear, and considerable surface may be invaded. In size they vary from a pea to large irregular patches, and are scarcely, if at all, elevated. The larger patches are irregular, and usually formed by coalescence of several smaller spots. Rarely patches may clear up in the centre and assume an annular form.

The number of patches varies; as a rule, a half dozen or more are present; in other cases they may be numerous. They show more or less furfuraceous scaling, varying with the amount of perspiration and the frequency with which the parts are washed. The scaling, even when it is insignificant or when the patches are apparently smooth, may be easily detected by scratching or scraping the surface. Slight itching is ordinarily present, especially when the parts are unusually warm; it is rarely marked. The color is usually a pale or brownish yellow. In sensitive skins at times the affection causes more or less hyperæmia, and the spots have a reddish hue. The course of the disease is variable, sometimes spreading rapidly, while in most cases its progress is slow. It is, as a rule, persistent, existing years. Relapses are not uncommon.

The cause of the disease is the vegetable fungus, the microsporon furfur. It invades the superficial portion of the epidermis. The affection is but slightly contagious. Those between the ages of twenty and forty, of either sex indifferently, are most frequently the subjects of the disease; it rarely if ever occurs in children or in elderly people. It is commonly observed in those whose nutrition is below the standard, especially in persons having pulmonary phthisis. It is a common affection, and occurs, in varying proportions, in all parts of the world. Scrapings or scales moistened with liquor potassæ may be examined with a power of three to five hundred diameters, and the peculiar features of the fungus well brought out, as the fungus exists in abundance. It consists of mycelium and spores, the former appearing as short, slender, variously-sized, straight or curved, twisted, wavy, or angular threads, crossing one another in all directions. In appearance they are homogeneous or granular, and often contain spores, especially about the joints. The spores are ovalish or round, sharply contoured, small in size, with a nucleus and slightly granular plasma. They show a marked tendency to aggregate and form groups—an arrangement which is characteristic of this fungus. The growth is found in every stage of development from mycelium to spores.

There should be no difficulty in recognizing the disease if its characters and distribution are kept in mind. In doubtful cases the microscope will prevent error. It is at times confounded with chloasma, vitiligo, and the macular syphilide. In chloasma, in which there is merely an increase of pigment in the rete, there is no scaling, the outlines are ill defined, and it is usually seen about the face—a region that is practically exempt in tinea versicolor. Moreover, the coloration in the parasitic disease is due to the fungus, which has its seat in the superficial epidermis and can be readily scraped off. With ordinary care it is impossible to mistake vitiligo for the disease in question. The macular syphiloderm is to be distinguished by attention to the distribution, character, and size of the lesions. Tinea versicolor is practically a disease of the trunk; the macular syphiloderm is usually distributed over the whole surface; and if it is the latter disease concomitant symptoms of syphilis are almost invariably present.

The disease is readily curable; any simple parasiticide properly and thoroughly applied will soon effect its removal. Lotions, as a rule, are to be preferred, inasmuch as they are more cleanly and more satisfactory. Washing the parts involved frequently with green soap (sapo viridis) and warm water is to be advised as an adjuvant, and will in some cases suffice to remove the disease. Alkaline baths, three or four ounces of carbonate of sodium or potassium to thirty gallons of water, are also useful. Various parasiticides are employed. Sulphite or hyposulphite of sodium, a drachm to the ounce; corrosive sublimate, two or four grains to the ounce of alcohol and water; sulphurous acid, pure or diluted; a saturated solution of boric acid; Vleminckx's solution, diluted with three to six parts of water,—are among the most useful. Sulphur and ammoniated mercury ointments, carbolic acid, ten to twenty grains to the ounce of lard, may be mentioned as serviceable. The frequency of application depends upon the extent and obstinacy of the disease, once or twice daily usually sufficing. After the disease is apparently cured treatment should be continued, although less actively, for a few weeks or a month, in order that a relapse may be avoided.

Scabies.

Scabies, or itch, is a contagious animal parasitic disease, due to the Sarcoptes scabiei, characterized by the formation of cuniculi, papules, vesicles, and pustules, followed by excoriations, crusts, and general cutaneous inflammation, and accompanied with itching. The amount of disturbance depends upon the duration of the disease and the sensitiveness of the skin. The itch mite (Acarus scabiei, Sarcoptes scabiei, or Sarcoptes hominis) through contagion finds its way upon the skin, and begins to burrow its way through the upper layers of the epidermis. The female only is found within the epidermis, the male, as generally supposed, never penetrating the skin. As the female burrows she lays a varying number of eggs, a dozen or more; by this time the burrow, or cuniculus, has usually attained its full length of several lines. It is to be seen as a narrow whitish or yellowish linear epidermic elevation, as a rule irregular and tortuous, and with a dotted or speckled look. It contains the female, its excrement, and a variable number of eggs. In a short time the ova are hatched, and the mites are rapidly multiplied. New burrows appear and are to be seen in all stages of development, and thus the disease progresses.

According to the sensitiveness of the skin will the lesions produced in consequence of the irritation of the mite vary. Usually, inflammatory points, papules, vesicles, pustules, and excoriations are to be seen scattered over the regions involved. The hands, especially the sides of the fingers, are almost invariably the parts first attacked, the mite gradually invading other parts of the body, as the anterior surfaces of the wrists, forearms, elbows, and arms, the axillary folds, about the mammæ in females, between the buttocks, about the penis, the inner sides of the thighs. The face and scalp are never invaded, except in infants. Itching is a marked symptom, usually worse at night. In well-advanced cases the secondary symptoms, such as papular elevations, vesicles, impetiginous and ecthymatous pustules, which are often torn by the scratching invoked, the crusts and excoriations of various characters, and a variable amount of cutaneous inflammation, with infiltration and pigmentation, taken together with the presence of burrows, constitute a clinical picture of the disease. In many cases the cuniculi are in a great measure obliterated by the scratching; their remains, however, may usually be detected. In persons with eczematous skin true eczema may be developed.

The disease is due solely to the presence of the itch mite. It is met with in persons of all ages and in every station of life, but for obvious reasons is more common and its ravages more marked among the poor. It is encountered in all parts of the world, but is especially frequent in the various European countries. In the United States it is comparatively infrequent, and is seen chiefly in the seaboard cities, and many of the cases can be traced to direct importation from abroad. It is markedly contagious. The Sarcoptes scabiei is almost microscopic in size, appearing as a yellowish-white rounded body. The male is but half the size of the female, and is rarely met with, apparently having no direct part in producing the cutaneous disturbance seen in the disease. The full-grown female, as may be determined by microscopical examination, is ovoid or crab-shaped, the dorsal surface convex and the ventral surface flattened, the back being studded with a varying number of short, thick spines and several long spike-shaped processes, all with their points directed backward. The head is small, rounded, or oval, without eyes, and closely set in the body, and is provided with palpi and mandibles. There are eight legs, four situated close to the head and four posteriorly. The entire parasite scarcely exceeds a fifth of a line in length. The female mite is to be looked for at the blind end of a burrow or at the roof of a vesicle.

Scabies when fully developed may usually be recognized without difficulty. The pathognomonic symptom is the presence of the parasites or the burrows. In the early stage cuniculi are not yet fully formed, but often the mite may be extracted from a recent vesicle. Burrows are usually most typically seen upon the sides of the fingers. The distribution of the eruption, however, is, in most cases, a sufficient basis for a diagnosis, the fingers, hands, flexor surface of the wrists, elbows, axillæ, buttocks, penis, mammæ in females, being especially invaded. It may be remembered also that the face and scalp, except in infants, are not involved. The multiform nature of the eruption is one of its prominent characteristics. It is a progressive disease. A history of contagion is often obtainable. It is to be distinguished from vesicular and pustular eczema and pediculosis. The more or less discrete vesicles and pustules of scabies, the localities affected, its progressive course, and the presence of burrows and a history of contagion will serve to differentiate from eczema. Pediculosis corporis involves the covered portions of the surface only, and the regions usually involved are different from those invaded in scabies. In scabies the hands are almost invariably the parts first and most markedly involved. The characters of the lesions are also different.

The disease yields rapidly to proper treatment. Various remedies are employed for the destruction of the parasite and its ova. The most common, and one that is thoroughly efficient, is sulphur. It is usually prescribed in ointment, one to four drachms to the ounce. In irritable skins, or where the secondary dermatitis is marked, the weaker proportions are advisable. A proportion of two drachms to the ounce is the average strength, and will be found suitable for the majority of cases. For children a drachm to the ounce is sufficiently strong; in these cases a half drachm of balsam of Peru may be added. This latter remedy is of itself a parasiticide. A compound sulphur ointment, known as Hebra's modification of Wilkinson's ointment, frequently employed abroad, is made up as follows:

Rx.	Sulphuris sublimatis, Olei cadini, aa.	drachm ij;
	Cretæ præparatæ,	drachm iiss;
	Saponis viridis, Adipis, aa.	ounce j.

Styrax is another balsam that is destructive to the itch mite, used in the proportion of one part to two of lard. Naphthol, a drachm to the ounce of ointment, is, according to Kaposi and others, an especially reliable remedy, possessing the advantages of being without color or odor, and also favorably influencing the dermatitis. Usually, especially in sensitive skins, it may be prescribed in rose-water ointment; in others the following formula, which has been well spoken of by Kaposi, may be employed: Rx. Naphthol, 15 parts; pulv. cretæ alb., 10 parts; saponis viridis, 50 parts; adipis, 100 parts.

Before beginning the remedial applications the patient is to take a soap-and-warm-water bath. The ointment is then rubbed into every portion of the body with the exception, in adults, of the head. The localities favored by the parasite should receive special attention. About an ounce of ointment is required for an application. It is to be so applied twice daily for three days, and then a soap-and-water-bath is to be taken. The itching becomes less marked after the first application, but may persist in a mild degree for several days after the ointment has been discontinued. The secondary dermatitis produced by the parasite and the scratching usually subsides soon after the removal of the cause; if slow, it is to be treated with mild and soothing applications, such as are employed in the treatment of eczema.

Pediculosis.

Pediculosis, phtheiriasis, or lousiness, is a contagious animal affection, characterized by the presence of pediculi and the lesions which they produce, together with scratch-marks and excoriations. Three varieties of pediculi, or lice, infest the human body, differing both in their male and female forms, and each variety inhabiting a different portion of the body. The three varieties are—pediculus capitis, pediculus corporis, and pediculus pubis. They obtain nourishment by a process of suction, in so doing giving rise to a minute wound, in consequence of which a small amount of blood and serum exudes; more or less hyperæmia and infiltration may occur, giving rise to marked itching, and the scratching induced results in excoriations. The varieties of pediculosis are designated according to the names of the species of pediculi.

PEDICULOSIS CAPITIS.—This is a condition due to the presence of the pediculus capitis, or head louse. This pediculus is seen, as a rule, upon the scalp only; in feeble and bedridden individuals it is, at times, seen upon other parts of the body. It is an insect of a grayish color, and varies in length from one and a half to three millimeters, the female being larger than the male. It is oval in shape, consisting of head, thorax, and abdomen, the last named occupying more than half its length and made up of seven clearly-defined segments, marked off from one another by deep notches. The thorax is broad, and from its sides project six legs, each one hairy and provided with a crab-like hook at its extremity. The head is somewhat triangular, with a pair of short, five-jointed antennæ and two black, prominent eyes, and furnished with a sucking apparatus. They are extremely prolific, the progeny of a single louse numbering several thousands in about eight weeks. The eggs, or nits, are deposited upon the hairs near the roots; several may often be found on a single shaft. If seen on the hair some distance from the scalp, it is due to the fact of the hairs having grown since the nits were deposited. They are pyriform, whitish bodies, about one-fourth of a line in length, securely glued to the hairs, hatching out in five or six days. The young become capable of reproduction in three weeks. According to the duration of the affection and the habits of the individual, they are to be seen in small or large numbers. They may be found upon the scalp or crawling over the hair, the occipital region being especially favored. Pediculosis capitis is commonly seen in children, and it is also not infrequent in women; it is met with usually among the poorer classes. The irritation from the attacks of the pediculi upon the scalp gives rise to scratching, resulting in serous and purulent oozing, which, mixed with blood and dirt, mats the hair and forms crusts. In marked cases the hair soon acquires a disgusting odor. An eczematous condition is soon brought about. Excoriations, vesicles, and pustules may often be seen beyond the limits of the scalp, upon the back of the neck and shoulders, and upon the forehead. From the constant irritation, intolerable itching, loss of sleep, etc. the general health may finally suffer. Pediculosis capitis may be recognized without difficulty. The ova, or nits, may be seen even at a distance, and the parasites themselves may always be detected if a search is made. An eczematous eruption of the occipital region in children and women, especially of the poorer classes, should always give rise to suspicion and an examination. This condition is often a result of pediculosis, but it is to be remembered also that an eczema of the scalp may have at first existed, furnishing a favorable habitat for the parasites.

Treatment is satisfactory; with ordinary care the condition may soon be removed. Cutting the hair, though facilitating treatment, is not necessary. The main object is the removal or destruction of the parasites and their ova; this accomplished, the irritation and excoriations will soon disappear or yield to simple treatment. The best plan is with ordinary petroleum. The parts should be saturated with it and then bandaged, care being taken to prevent the oil from running down the neck or on to the face. The dressing is to be allowed to remain on about twelve hours, usually over night, and the scalp washed with soap and water in the morning. One or two applications, if thoroughly made, are sufficient. An oily solution of naphthol, 5 per cent. strength, has been well spoken of. Tincture of cocculus Indicus is also a reliable application. Ointments may be employed in place of lotions, but are not so cleanly or, as a rule, so satisfactory. In some cases, however, where an eczematous condition exists, especially if the hair is short, they may be employed with good results. An ointment of staphisagria, or one of white precipitate, twenty to sixty grains to the ounce, may be referred to. Oleate of mercury, in solution or ointment, 20 to 30 per cent. strength, is also serviceable. The parasites and nits are usually destroyed by any of these applications; the latter, however, remain clinging to the hair. Their removal may soon be brought about by applications of alcoholic lotions, diluted acetic acid or vinegar, alkaline lotions, and the use of a fine comb.

PEDICULOSIS CORPORIS.—Pediculosis corporis is due to the presence of the pediculus corporis, or body louse (more properly pediculus vestimenti, or clothes louse), resembling in its shape and anatomical structure the head louse, but is larger, measuring from one to four millimeters: the female is also larger than the male. Its period of growth and reproductive powers are also as great. In color, when devoid of blood, it is dirty white or grayish. The eggs are similar to, but larger than, those of the pediculus capitis. It dwells in the clothing, trespassing upon the integument only to obtain nourishment, where it may, when existing in numbers, often be surprised in the act of drawing blood or crawling over the surface. The ova are deposited in the folds and seams of the clothing, in which localities also the parasites are usually found. The excoriations, therefore, are to be seen especially about those portions of the body which are closest to these parts of the clothing, as, for example, about the neck and shoulders, the waist, hips, thighs, etc. The primary lesions consist of minute reddish puncta with slight areolæ, the points at which the pediculi have drawn blood. Not infrequently, instead of simple hemorrhagic points, a wheal marks the site of attack; at times also papules, pustules, and even furuncles, result. Intense itching is set up, and as a consequence excoriations, scratch-marks of various kinds, and blood-crusts are to be seen. Eventually, from the long-continued irritation and hyperæmia, a brownish or blackish pigmentation results. The affection is met with chiefly among the poorer classes, in the middle-aged and elderly; children are seldom attacked. It is not common in this country. The presence of the ova or the pediculi in the seams and folds, the characteristic reddish puncta, and the multiform lesions and excoriations upon the regions above named are sufficiently diagnostic. It is not to be confounded with pruritus and scabies, in which diseases the distribution and causes of the lesions are altogether different.

As the pediculi live in the clothing, treatment consists in their destruction, by baking or boiling of the wearing apparel, and in ordinary attention to cleanliness. Repeated examinations should be made, so that no pediculi or ova are permitted to remain. Alkaline baths, three to four ounces of sodium bicarbonate to the bath, and lotions similar to those employed in the treatment of pruritus, will allay the itching and aid in the removal of the secondary lesions. In those cases where the patient cannot immediately subject the clothes to the above treatment an ointment of staphisagria, made by digesting two drachms of the powder in an ounce of hot lard and straining, may be applied to the skin.

PEDICULOSIS PUBIS.—Pediculosis pubis is a condition due to the presence of the pediculus pubis, or crab louse. It is the smallest of the three varieties, measuring from one to two millimeters. It has a short, rounded, flat body, and an oval head, which is furnished with two long, five-jointed antennæ and a pair of inconspicuous eyes. The thorax, which is small and imperceptibly merged into the abdomen, is provided with six jointed, hairy legs with hooked claws. The margins of the abdomen are slightly indented, and from it projects eight stubby, prehensile feet armed with bristles. It is more or less translucent, and of a yellowish-gray color. As in the other varieties, the female is larger than the male. It is liable to escape detection on account of its translucency, and the fact that it is apt to remain seated near the roots of the hairs, clutching the hair with its head downward and buried deep in the follicles. The ova are similar in construction, but smaller than those of the other varieties; they may be readily seen attached to the hairs in the same manner. The excrement, minute reddish particles, may be detected lying around the bases of the hairs. It infests adults chiefly, being usually contracted through sexual intercourse. Although its favorite habitat is the region of the pubes, it may also infest the axillæ, the sternal region of the male, the beard, eyebrows, and even eyelashes. The amount of irritation varies—at times insignificant, while in other cases it is severe. Pediculosis pubis may be mistaken for pruritus or eczema, but an examination will disclose the ova, and if carefully sought for the pediculi may always be found, usually near the roots of the hair, looking not unlike dirt-specks or freckles; the excrement may also be detected. For their removal any of the lotions or ointments mentioned in the treatment of the other varieties may be employed. A lotion of corrosive sublimate, two to four grains to the ounce of alcohol or water; infusion of tobacco; 10 to 20 per cent. ointment of oleate of mercury; ammoniated mercury ointment; a 5 to 10 per cent. oily solution or ointment of naphthol,—are all efficient. The parts should be washed with soap and water twice daily, and the remedy applied after each washing. In order to ensure complete destruction of the ova the applications should be continued for some days after the pediculi have been destroyed.

LEPTUS.—Two species of leptus are met with as attacking man: Leptus Americanus (American harvest mite) and Leptus irritans (irritating harvest mite, harvest bug, mower's mite). The former is a minute, brick-red colored, elongate, pyriform creature with six legs, barely visible to the naked eye. Its favorite sites of attack are the scalp and axillæ, partly burying itself in the skin, giving rise to a small inflammatory papule. The latter species is more common, differing from the former merely in having a roundish oval form. It buries itself in the skin, giving rise to inflammatory papules, vesicles, and pustules. Its sites of predilection are the ankles and legs. The minute red mite met with especially about blackberry-bushes in the low grounds of Pennsylvania, New Jersey, and Delaware is probably the same species. Both varieties are common, during the summer, in our South-western States. For treatment a weak sulphur ointment or ointments of the other mild parasiticides may be employed.

PULEX PENETRANS, OR RHINOCHOPRION PENETRANS.—This creature—the sand-flea, known also as chigoe, chigger, and jigger—is almost microscopic in size, closely similar to the common flea, but has a proboscis as long as its body. It is common in tropical countries, and also met with in our Southern States. It (the impregnated female) burrows into the skin, depositing the ova, resulting in inflammatory swelling, large vesicles or pustules, and even ulceration. The toes, especially beneath and alongside of the nail, and other parts of the feet are the regions attacked. The treatment consists in extraction; it usually comes away in the form of a sac about the size of a small pea, its size due to the distension of the abdomen with ova. As a preventive the essential oils are used about the feet.

FILARIA MEDINENSIS.—This parasite, the guinea-worm, known also as dracunculus, is only encountered in tropical countries. The young bore into the skin and subcutaneous tissue, in which their growth takes place; sooner or later marked inflammation is produced, resulting in painful furuncular tumors, which finally break, showing the presence of the worms. The lower extremities, especially the feet, are the favorite regions of attack. The worm varies from several inches to three feet in length, according to its age, and is one-half or three-fourths of a line in thickness. The treatment consists in extracting the worm inch by inch, from day to day, as soon as discovered, care being exercised not to break it. Poultices may be applied.

CYSTICERCUS CELLULOSÆ.—This affection is characterized by rounded or ovalish, smooth, elastic, firm or hard, movable, pea- to hazelnut-sized tumors, more or less numerous, usually seated just beneath the skin, new tumors showing themselves from time to time. After reaching a certain size they may remain stationary. Although not painful upon pressure, spontaneous pains may be complained of. Microscopical examination reveals the cysticerci.

OESTRUS.—This parasite (known also as breeze, gad-fly, and bot-fly) is met with in Central and South America, and also in other countries. The neck, back, and extremities especially are liable to be attacked. The ova are deposited in the skin, and there result inflammatory, boil-like tumors or swellings with a central opening, from which issues a sanious fluid; or the lesion may assume a linear, tortuous, or serpiginous form. Sooner or later the grub is detected, and may be easily squeezed out or extracted.

DEMODEX FOLLICULORUM.—This microscopic parasite (also known as steatozoon, entozoon, acarus, and Simonea, folliculorum) is to be found in the sebaceous follicles. It is harmless, giving rise to no disturbance. It is worm-like in form, made up of a head, thorax, and a long abdomen. It is more apt to be found in those with thick, greasy skins. Several of them often exist in a single follicle.

CIMEX LECTULARIUS, OR ACANTHIA LECTULARIA.—This insect (the common bed-bug) and its various residing-places are well known. It gives rise to a cutaneous lesion of the nature of an urticarial wheal, with a central hemorrhagic point which remains after the swelling has subsided. As a result of the scratching to which the irritation and itching give rise excoriations are often observed. A larger species (Conorhinus sauguisuga), known as the blood-sucking cone-nose and big bed-bug, has been met with in Southern Illinois and Ohio; its bite is said to produce severe inflammation of the skin. For the relief of bed-bug bites lotions containing alcohol, vinegar, lead-water, ammonia-water, and similar remedies may be sponged upon the parts. Pyrethrum powder and corrosive sublimate are the best preventives against bugs in beds.

PULEX IRRITANS.—This, the common flea, is found universally, especially in hot and warm climates. As a result of its bite erythematous spots with minute central hemorrhagic points are seen. The presence of the areola distinguishes the lesions from those of simple purpura, which at times they may resemble. The cutaneous disturbance is usually slight, but in some individuals, and especially in tropical countries, the discomfort to which these creatures give rise is often considerable.

CULEX.—Gnats, or mosquitoes, are often productive of considerable cutaneous irritation, the typical lesion being a wheal-like elevation. The itching is best relieved with ammonia-water.

IXODES.—There are several species of wood-ticks met with in our woods which are liable to attach themselves to the human skin. Inserting their proboscis and head deeply into the tissues, they suck blood until often they swell up several times their natural size. They should be induced to relinquish their firm hold by dropping olive oil or one of the essential oils upon the skin; they should never be extracted with violence.