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T> c o 03w jo Aavaan ivnouvn 3noiq3w jo Aavaan ivnouvn 3noiq3w jo Aavaan i NAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ° V i]w ir\ ixv^oil iwmpi /^ ESSENTIALS DISEASES OF THE SKIN, Since the issue of the first volume of the Saunders Question=Compends, OVER 175,000 COPIES of these unrivalled publications have been sold. This enormous sale is indisputable evidence of the value of these self-helps to students and physicians. SAUNDERS' QUESTION-COMPENDS. No. II. ESSENTIALS DISEASES OF THE SKIN INCLUDING THE SYPHILODERMATA ARRANGED IN THE FORM OF QUESTIONS AND ANSWERS ritEl'AUED ESPECIALLY FOR STUDENTS OF MEDICINE HENRY W. STELWAGON, M.D., Ph.D. Clinical Professor of Dermatology in the Jefferson Medical College ; Physician to the Department for Skin Diseases, Howard Hospital; Der- matologist to the Philadelphia Hospital, etc. FOURTH EDITION, THOROUGHLY REVISED ILLUSTRATED PH: W. B. 925 ^ '.adMiBRARY suf8bk3n bfjneral's office alnut Street. ■ s99 0CT-418S9 U*rh Copyright, 1899, by W. B. Saunders. PRESS OF W. B. SAUNDERS. PREFACE TO FOURTH EDITION. In this fourth edition the entire book has been subjected to a careful scrutiny and revision, and the text has undergone numerous small but important changes, in order that the subject-matter might reflect our present knowledge of cutaneous diseases. Besides this, several of the more rare affections have been briefly described. Among the latter are Hydroa Vacciniforme, Blastomycetic Derma- titis, Erythema Induratum, Hydrocystoma, Phlegmonosa Diffusa, Hydradenitis Suppurativa, Epidermolysis Bullosa, and Conglom- erative Pustular Perifolliculitis. . The author ventures to hope that in its present improved condi- tion the book may continue to meet with the favor of students and practitioners. H. W. S. PREFACE TO FIRST EDITION. Much of the present volume is, in a measure, the outcome of a thorough revision, remodelling and simplification of the various articles contributed by tlie author to Pepper's System of Medicine, Buck's Reference Handbook of the Medical Sciences, and Keating's Cyclopaedia of the Diseases of Children. Moreover, in the endeavor to present tlie subject as tersely and briefly as compatible with clear understanding, the several standard treatises on diseases of the skin by Tilbury Pox, Duhring, Hyde, Robinson, Anderson, and Crocker, have been freely consulted, that of the last-named author sug- gesting the pictorial presentation of the " Anatomy of the Skin." The space allotted to each disease has been based upon relative importance. As to treatment, the best and approved methods only—those which are founded upon the aggregate experience of dermatologists—are referred to. For general information a statistical table from the Transactions of the American Dennatological Association is appended. H. W. S. CONTENTS. PAGE Anatomy op the Skin..................17 The Epidermis.....................18 The Blood-vessels...................19 The Nervous and Vascular Papillae............20 The Hair and Hair-follicle ...............21 « Symptomatology.....................22 Primary Lesions....................22 Secondary Lesions...................23 Distribution and Configuration..............24 Relative Frequency....................26 Contagiousness......................27 Rapidity of Cure.....................27 Ointment Bases......................27 Classification.......................28 Class I.—Disorders of the Glands............31 Hyperidrosis...................... 31 Sudamen.................. .....33 Hydrocystoma.....................34 Anidrosis........................34 Bromidrosis......................35 Chromidrosis......•...............35 Uridrosis .......................36 Phosphoridrosis.....................36 Seborrhoea.......................36 Comedo........................41 Milium.................... . 44 Steatoma.......................45 11 12 CONTENTS. Class II.—Inflammations . .................46 Erythema Simplex...................46 Erythema Intertrigo..................47 Erythema Multiforme.......... ......48 Erythema Nodosum................ 51 Erythema Induratum................ 52 Urticaria................... 53 Urticaria Pigmentosa................. 57 Dermatitis................... 57 Feigned Eruptions................... 63 Dermatitis Gangraenosa.............. 63 Erysipelas .................... gg Phlegmonosa Diflusa................ 65 Furunculus.................. 65 Carbunculus ................. gy Conglomerative Pustular Perifolliculitis ......... 69 Pustula Maligna................ 70 Post-mortem Pustule................. 70 Framboesia................... ^q Equinia.................... i-j Miliaria................. 71 Pompholyx..................... 70 Hydradenitis Suppurativa .............. 75 Herpes Simplex................. 75 Hydroa Vacciniforme................ 77 Epidermolysis Bullosa ... ............ 78 Herpes Zoster................... 78 Herpes Iris..................... 80 Dermatitis Herpetiformis . ............... 81 Psoriasis...................... g^ Pityriasis Rosea...... ............. 93 Dermatitis Exfoliativa................. 04 Pityriasis Rubra Pilaris................. 95 Lichen Ruber.................... og Lichen Scrofulosus................... 98 Eczema..................... qo Prurigo ........................114 Acne.........................115 Acne Rosacea................... 109 Sycosis........................225 CONTENTS. 13 PAGE Inflammations—Continued. Dermatitis Papillaris Capillitii...........128 Impetigo.....................129 Impetigo Contagiosa.................130 Impetigo Herpetiformis.................132 Ecthyma...................... 132 Pemphigus......................134 Class III.—Hemorrhages ...............136 Purpura.....................136 Scorbutus......................139 Class IV.—Hypertrophies................140 Lentigo .....................140 Chloasma.......................141 Keratosis Pilaris....................143 Keratosis Follicularis..................145 Molluseum Epitheliale................145 Callositas......................147 Clavus.............. .........148 Cornu Cutaneum...................150 Verruca.......................152 Verruca Necrogenica..................154 Nievus Pigmentosus................155 Ichthyosis......................157 Onychauxis...................159 Hypertrichosis....................160 Sclerema Neonatorum.................163 Scleroderma ...................164 Morphcea......................165 Elephantiasis................. ... 167 Dermatolysis.....................170 Class V.— Atrophies...................171 Albinismus......................171 Vitiligo........................172 Canities .......................175 Alopecia........................ 175 Alopecia Areata....................177 Atrophia Pilorum Propria ...............181 Atrophia Unguis....................182 Atrophia Cutis...................183 14 contents. PAGE Class VI.—New Growths...............185 Keloid......................185 Fibroma......................180 Neuroma....... .............188 Xanthoma ........189 Myoma........V . .........190 Angioma...................190 Telangiectasis...................191 Lymphangioma...................192 Rhinoscleroma.................192 Lupus Erythematosus..................193 Lupus Vulgaris....................197 Scrofuloderma....................204 Ainhum.......................206 Podelcoma..................... 206 Perforating Ulcer of the Foot..............207 Syphilis Cutanea .,................... 207 Lepra......................222 Pellagra.......................226 Epithelioma................. 227 Paget's Disease of the Nipple..............230 Sarcoma......................231 Class VII.—Neuroses . ...............233 Hyperesthesia....................233 Dermatalgia......................233 Anaesthesia......................234 Pruritus ......................234 Class VIII.—Parasitic Affections..........237 Tinea Favosa....................237 Tinea Trichophytina..................240 Tinea Versicolor............. ......249 Erythrasma......................251 Blastomycetic Dermatitis................252 Scabies.......................253 Pediculosis.....................257 Pediculosis Capitis...................257 Pediculosis Corporis...... ..........259 Pediculosis Pubis ...................261 Cysticercus Cellulosae..................262 contents. 15 PAGE Parasitic Affections—Continued. Filaria Medinensis.....■..............262 Ixodes..........:.............263 Leptus........................263 (Estrus........................264 Pulex Penetrans..........-...."......264 Cimex Lectularius...................264 Culex........................264 Pulex Irritans.....................265 DISEASES OF THE SKIN ANATOMY OF THE SKIN. Fig. 1. Vertical section of the skia—Diagrammatic. (After Heitzmann.) I 17 18 DISEASES OF THE SKIN. The Epidermis. Fig. 2. c, corneous (horny) layer; g, granular layer; m, mucous layer (rete Malpighii). The stratum lucidum is the layer just above the granular layer. Nerve terminations—n, afferent nerve; 6, terminal nerve bulb3; I, cell of Langerhaus. (After Ranvier.) ANATOMY OF THE SKIN. 19 The Blood-vessels. Fig. 3. C, epidermis; D, corium ; P, papillae; S, sweat-gland duct. t», arterial and venous capillaries (superficial, or papillary plexus) of the papillae. Deep plexus is partly shown at lower margin of the diagram ; vs—an interme- diate plexus, an outgrowth from the deep plexus, supplying sweat-glands, and giving a loop to hair papilla. (After Ranvier.) 20 DISEASES OF THE SKIN. The Nervous and Vascular Papillae. a, a vascular papilla; &, a nervous papilla; c, a blood-vessel; d, a nerve fibre; e, a tactile corpuscle. (After Biesiadecki.) ANATOMY OF THE SKIN. 21 The Hair and Hair-Follicle. A, shaft of the hair; B, root of the hair; C, cuticle of the hair; D, medullary sub- stance of the hair. E, external layer of the hair-follicle; F, middle layer of the hair-follicle ; G, internal layer of the hair-follicle; H, papilla of the hair; 2, external root-sheath; J, outer layer of the internal root-sheath ; IC, internal layer of the internal root- sheath. (After Duhring.) 22 DISEASES OF THE SKIN. SYMPTOMATOLOGY. The symptoms of cutaneous disease may he objective, subjective or both ; and in some diseases, also, there may be systemic disturb- ance. What do you mean by objective symptoms ? Those symptoms visible to the eye or touch. What do you understand by subjective symptoms ? Those which relate to sensation, such as itching, tingling, burn- ing, pain, tenderness, heat, anaesthesia, and hyperesthesia. What do you mean by systemic symptoms ? Those general symptoms, slight or profound, which are sometimes associated,primarily or secondarily, with the cutaneous disease, as, for example, the systemic disturbance in leprosy, pemphigus, and purpura hemorrhagica. Into what two classes of lesions are the objective symptoms commonly divided ? Primary (or elementary), and Secondary (or consecutive). Primary Lesions. What are primary lesions ? Those objective lesions with which cutaneous diseases begin. They may continue as such or may undergo modification, passing into the secondary or consecutive lesions. Enumerate the primary lesions. Macules, papules, tubercles, wheals, tumors, vesicles, blebs and pustules. What are macules (maculae) ? Variously-sized, shaped and tinted spots and discolorations, with- out elevation or depression ; as, for example, freckles, spots of purpura, macules of cutaneous syphilis. SYMPTOMATOLOGY. 23 What are papules (papulae) ? Small, circumscribed, solid elevations, rarely exceeding the size of a split-pea, and usually superficially seated ; as, for example, the papules of eczema, of acne, and of cutaneous syphilis. What are tubercles (tubercula) ? Circumscribed, solid elevations, commonly pea-sized and usually deep-seated ; as, for example, the tubercles of syphilis, of leprosy, and of lupus. What are wheals (pomphi) ? Variously-sized and shaped, whitish, pinkish or reddish elevations, of an evanescent character ; as, for example, the lesions of urticaria, the lesions produced by the bite of a mosquito or by the sting of a nettle. What are tumors (tumores) ? Soft or firm elevations, usually large and prominent, and having their seat in the corium and subcutaneous tissue ; as, for example, sebaceous tumors, gummata, and the lesions of fibroma. What are vesicles (vesiculae) ? Pin-head to pea-sized, circumscribed epidermal elevations, contain- ing serous fluid ; as, for example, the so-called lever-blisters, the lesions of herpes zoster, and of vesicular eczema. What are blebs (bullae) ? Pounded or irregularly-shaped, pea to egg-sized epidermic eleva- tions, with fluid contents; in short, they are essentially the same as vesicles and pustules except as to size; as, for example, the blebs of pemphigus, rims poisoning, and syphilis. What are pustules (pustulae) ? Circumscribed epidermic elevations containing pus; as, for ex- ample, the pustules of acne, of impetigo, and of sycosis. Secondary Lesions. What are secondary lesions ? Those lesions resulting from accidental or natural change, modifi- cation or termination of the primary lesions. 24 DISEASES OF THE SKIN. Enumerate the secondary lesions. Scales, crusts, excoriations, fissures, ulcers, sears and stains. What are scales (squamae) ? Dry, laminated, epidermal exfoliations; as, for example, the scales of psoriasis, ichthyosis, and eczema. What are crusts (crustae)? Dried effete masses of exudation ; as, for example, the crusts of impetigo, of eczema, and of the pustular and ulcerating syphiloder- mata. What are excoriations (excoriationes) ? Superficial, usually epidermal, linear or punctate loss of tissue ; as, for example, ordinary scratch-marks. What are fissures (rhagades) ? Linear cracks or wounds, involving the epidermis, or epidermis and corium; as, for example, the cracks which often occur in eczema when seated about the joints, the cracks of chapped lips and hands. What are ulcers (ulcera) ? Rounded or irregularly-shaped and sized loss of skin and sub- cutaneous tissue resulting from disease ; as, for example, the ulcers of syphilis and of cancer. What are scars (cicatrices) ? Connective-tissue new formations replacing loss of substance. What are stains ? Discolorations left by cutaneous disease, which stains may be tran- sitory or permanent. Distribution and Configuration. What do you mean by a patch of eruption ? A single group or aggregation of lesions or an area of disease. When is an eruption said to be limited or localized ? When it is confined to one part or region. SYMPTOMATOLOGY. 25 When is an eruption said to be general or generalized ? ^ hen it is scattered, uniformly or irregularly, over the entire surface. When is an eruption universal ? When the whole integument is involved, without any intervening healthy skin. When is an eruption said to be discrete ? When the lesions constituting the eruption are isolated, having more or less intervening normal skin. When is an eruption confluent ? When the lesions constituting the eruption are so closely crowded that a solid sheet results. When is an eruption uniform ? When the lesions constituting the eruption are all of one type or character. When is an eruption multiform ? When the lesions constituting the eruption are of two or more types or characters. When are lesions said to be aggregated ? When they tend to form groups or closely-crowded patches. When are lesions disseminated ? When they are irregularly scattered, with no tendency to form groups or patches. When is a patch of eruption said to be circinate ? When it presents a rounded form, and usually tending to clear in the centre ; as, for example, a patch of ringworm. When is a patch of eruption said to be annular ? When it is ring-shaped, the central portion being clear; as, for example, in erythema annulare. What meaning is conveyed by the term "iris" ? The patch of eruption is made up of several concentric rings. Difference of duration of the individual rings, usually slight, tends to give the patch variegated coloration ; as, for example, in erythema iris and herpes iris. 2G DISEASES OF THE SKIN. What meaning is conveyed by the term " marginate " ? The sheet of eruption is sharply defined against the healthy skin; as, for example, in erythema marginatum, eczema, margi- natum. What meaning is conveyed by the qualifying term " circum- scribed"? The term is applied to small, usually more or less rounded, patches, when sharply defined ; as, for example, the typical patches of psori- asis. When is the qualifying term " gyrate " employed ? When the patches arrange themselves in an irregular winding or festoon-like manner; as, for instance, in some cases of psoriasis. It results, usually, from the coalescence of several rings, the eruption disappearing at the points of contact. When is an eruption said to be serpiginous ? When the eruption spreads at the border, clearing up at the older part; as, for instance, in the serpiginous syphiloderm. RELATIVE FREQUENCY. Name the more common cutaneous diseases and state their frequency. Eczema, 30.4% ; syphilis cutanea, 11.2% ; acne, 7.3% ; pediculosis, 4%; psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies, 2.6 % ; urticaria, 2.5%; pruritus, 2.1 % ; seborrhoea, 2.1 % ; herpes simplex, 1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%; verruca, 1.1%; tinea versicolor, 1%. Total: eighteen diseases, representing 81 per cent, of all cases met with. (These percentages are based upon statistics, public and private, of the American Dermatological Association, covering a period of ten years. In private practice the proportion of cases of pedicu- losis, scabies, favus and impetigo, are almost nil, whilst acne, acne rosacea, seborrhoea, epithelioma and lupus, are relatively more fre- quent.) CONTAiilOl SNESS—KAP1D1TY OF CURE—OINTMENT BASES. 27 CONTAGIOUSNESS. Name the more actively contagious skin diseases. Impetigo contagiosa, ringworm, favus, scabies and pediculosis; excluding the exanthemata, erysipelas, syphilis and certain rare and doubtful diseases. [ At the present time when most diseases are presumed to be due to Iiaeteria or parasites the belief in contagiousness, under certain ronditions, has considerably broadened. J RAPIDITY OF CURE. Is the rapid cure of a skin disease fraught with any danger to the patient ? jtfo. It was formerly so considered, especially by the public and general profession, and the impression still holds to some extent, but it is not in accord with dermatological experience. OINTMENT BASES. Name the several fats in common use for ointment bases. Lard, petrolatum (or cosmoline or vaseline), cold cream and lanolin. State the relative advantages of these several bases. Lard is the best all-around base, possessing penetrating proper- ties scarcely exceeded by any other fat. Petrolatum is also valuable, having little, if any, tendency to change ; it is useful as a protective, but is lacking in its power of penetration. Cold ("ream (ungt. aquae rosro) is soothing and cooling, and may often be used when other fatty applications disagree. Lanolin is said to surpass in its power of penetration all other bases, but this is not borne out by experience. It is an unsatis- factory base when used alone. It should be mixed with another base in about the proportion of 25% to 50%. These several bases may, and often with advantage, be variously combined. 28 DISEASES OF THE SKIN. What is to be added to these several bases if a stiffer oint- ment is required ? Simple cerate, wax, spermaceti, or suet; or in some instances^ a pulverulent substance, such as starch, boric acid, and zinc oxide. CLASSIFICATION. Upon what basis are diseases of the skin commonly classified ? Mainly upon pathological and anatomical grounds. A permanent classification is, in the present state of knowledge, impossible. (The classification here given is that adopted by the American Dermatological Association ; at present it is, however, undergoing a remodelling.) Name the classes into which diseases of the skin are com- monly divided. There are eight classes :— Class I. Disorders of the Glands. 1. Of the Sweat-Glands. Hyperidrosis. Bromidrosis. Sudamen. Chromidrosis. Anidrosis. Uridrosis. 2. Of the Sebaceous Glands. Seborrhoea : Cyst: a. oleosa. a. Milium. b. sicca. b. Steatoma. Comedo. Asteatosis. Class II. Inflammations. Exanthemata. Erythema simplex. Erythema multiforme : a. papulosum. b. bullosum. c. nodosum. Urticaria. pigmentosa. ♦Indicating affections of this class not properly included under other titles. * Dermatitis : a. traumatica. b. venenata. c. calorica. d. medicamentosa. c. gangrenosa. Erysipelas. Furunculus. CLASSIFICATION. 29 Class II. Inflammations— Continued Anthrax. Phlegmona diffusa, Pustula maligna. Herpes simplex. Herpes zoster. Dermatitis herpetiformis Psoriasis. Pityriasis maculata et nata. Dermatitis exfoliativa. Pityriasis rubra pilaris. Lichen : a. planus. b. ruber. Class III. Hemorrhages. Purpura. a. simplex. hczema : a. erythematosum. b. papulosum. c. vesiculosum. d. madidans. e. pustulosum. /. rubrum.« g. squamosum. Prurigo. Acne. Acne rosacea. Sycosis. Impetigo. Impetigo contagiosa. Impetigo herpetiformis. Ecthyma. Pemphigus. b. hemorrhagica. Class IV. Hypertrophies. 1. Of Pigment. Lentigo. 2. Of Epidermal and Papillary Keratosis pilaris. Keratosis follicularis. Molluscum epitheliale. Callositas. Clavus. Cornu cutaneum. Verruca. 3. Of Connect ire Tissue. Sclerema neonatorum. Scleroderma. Morphcea. Elephantiasis. Chloasma. Layers. Verruca necrogenica. Nievus pigmentosus. Xerosis. Ichthyosis. Onychauxis. Hypertrichosis. Rosacea : a. erythematosa. b. hypertrophica. Frambcesia. 30 diseases of the skin. Class V. Atrophies. 1. Of Pigment. Leucoderma. Albinismus. 2. Of Hair. Alopecia. Alopecia furfuracea. Alopecia areata. 3. Of Nail Atrophia unguis. 4- Of Cutis. Atrophia senilis. Class VI. New Growths. 1. Of Connective Tissue. Keloid. Cicatrix. Fibroma. 2. Of Muscular Tissue. Myoma. 3. Of Vessels. Angioma. Angioma pigmentosum et atrophicum. 4- Rhinoscleroma. Lupus erythematosus. Lupus vulgaris. Scrofuloderma. Syphiloderma. a. erythematosum. b. papulosum. c. pustulosum. Class VII. Neuroses. Hyperesthesia : a. Pruritus. b. Dermatalgia. Vitiligo. Canities. Atrophia pilorum propria. Trichorexis nodosa. Atrophia maculosa et striata. Neuroma. Xanthoma. Angioma cavernosum. Lymphangioma. d. tuberculosum. e. gummatosum. Lepra : a. tuberosa. b. maculosa. c. anaesthetica. Carcinoma. Sarcoma. Anaesthesia. DISOKDEKS of the glands. 31 Class VIII. Parasitic Affections. 1. Vegetable. Tinea favosa. Tinea trichophytina : a. circinata. 2. Animal. Scabies. Pediculosis capillitii. b. tonsurans. c. sycosis. Tinea versicolor. Pediculosis corporis, Pediculosis pubis. CLASS I.—DISORDERS OF THE GLANDS. Hyperidrosis. Fig. 6. A normal sweat-gland, highly magnified. (After Neumann.) a, Sweat-coil: 6, sweat-duct; c, lumen of duct; rf, connective-tissue capsule; e and /, arterial trunk and capillaries. What is hyperidrosis ? Hyperidrosis is a functional disturbance of the sweat-glands, char- 32 DISEASES OF THE SKIN. acterized by an increased production of sweat. This increase may be slight or excessive, local or general. As a local affection, what parts are most commonly involved ? The hands, feet, especially the palmar and plantar surfaces, the axillae and the genitalia. Describe the symptoms of the local forms of hyperidrosis. The essential, and frequently the sole symptom, is more or less profuse sweating. If the hands are the parts involved, they are noted to be wet, clammy and sometimes cold. If involving the soles, the skin often becomes more or less ma- cerated and sodden in appearance, and as a result of this maceration and continued irritation they may become inflamed, especially about the borders of the affected parts, and present a pinkish or pinkish- red color, having a violaceous tinge. The sweat undergoes change and becomes offensive. Is hyperidrosis acute or chronic ? Usually chronic, although it may also occur as an acute affection. What is the etiology of hyperidrosis ? Debility is commonly the cause in general hyperidrosis ; the local forms are probably neurotic in origin. What is the prognosis ? The disease is usually persistent and often rebellious to treatment; in many instances a permanent cure is possible, in others palliation. Relapses are not uncommon. What systemic remedies are employed in hyperidrosis ? Ergot, belladonna, gallic acid, mineral acids, and tonics. Consti- tutional treatment is rarely of benefit in the local forms of hyperi- drosis, and external applications are seldom of service in general hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is also well spoken of, combined, if necessary, with an astringent.. What external remedies are employed in the local forms ? Astringent lotions of zinc sulphate, tannin and alum, applied sev- eral times daily, with or without the supplementary use of dusting- powders. Weak solutions of formaldehyde, one to one hundred, are sometimes of value. DISORDERS OF THE GLANDS. 33 Dusting-powders of starch and boric acid, to which may be added from ten to twenty grains of salicylic acid to the ounce, to be used freely and often :— R. Pulv. ac. salicylici,.........gr. x-xx Pulv. ae. borici,...........3 ij Pulv. amyli,............gvj. M. Diachylon ointment, and an ointment containing a drachm of tan- nin to the ounce ; more especially applicable in hyperidrosis of the feet. The parts are first thoroughly washed, rubbed dry with towels and dusting-powder, and the ointment applied on strips of muslin or lint and bound on; the dressing is renewed twice daily, the parts each time being rubbed dry with soft towels and dusting-powder, and the treatment continued for ten days to two weeks, after which the dusting-powder is to be used alone for several weeks. No water is to be used after the first washing until the ointment is discontinued. One such course will occasionally suffice, but not infrequently a repe- tition is necessary. Faradization and galvanization are sometimes serviceable. Sudamen. (Synonym: Miliaria crystallina.) What is sudamen ? Sudamen is a non-inflammatory disorder of the sweat-glands, char- acterized by pin-point to pin-head-sized, discrete but thickly-set, superficial, translucent whitish vesicles. Describe the clinical characters. The lesions develop rapidly and in great numbers, either irregu- larly or in crops, and are usually to be seen as discrete, closely-crowded, whitish, or pearl-colored minute elevations, occurring most abun- dantly upon the trunk. In appearance they resemble minute dew- drops. They aiv non-inflammatory, without areola, never become purulent, and evince no tendency to rupture, the fluid disappearing by absorption, and the epidermal covering by desquamation. 34 DISEASES OF THE SKIN. Give the course and duration of sudamen. New crops may appear as the older lesions are disappearing, and the affection persist for some time, or, on the other hand, the whole process may come to an end in several days or a week. In short, the course and duration depend upon the subsidence or persistence of the cause. What is the anatomical seat of sudamen ? The vesicles are due to collection of sweat in some part of the sweat-gland duct or epidermis. What is the cause of sudamen ? Debility, especially when associated with high fever. The erup- tion is often seen in the course of typhus, typhoid and rheumatic fevers. How would you treat sudamen? By constitutional remedies directed against the predisposing factor or factors, and the application of cooling lotions of vinegar or alcohol and water, or dusting-powders of starch and lycopodium. Hydrocystoma. Describe hydrocystoma. Hydrocystoma is a cystic affection of the sweat-gland ducts, seated upon the face. The lesions may be present in scant numbers or in more or less profusion. They have the appearance of boiled sago grains imbedded in the skin ; the larger lesions may have a bluish color, especially about the periphery. It is not common, and is usually seen in washerwomen and laundresses, or those exposed to moist heat. In some cases it tends to disappear during the winter months. There are no subjective symptoms. Treatment consists of puncturing the lesions and application of dusting-powder. Avoidance of the exciting cause (moist heat) is important. Anidrosis. Describe anidrosis. It is the opposite condition of hyperidrosis, and is characterized DISORDERS OF THE GLANDS. 35 by diminution or suppression of the sweat secretion. It occurs to some extent in certain systemic diseases and also in some affections of the skin, such as ichthyosis; nerve-injuries may give rise to local- ized sweat-suppression. Treatment is based upon general principles; friction, warm and hot-vapor baths, electricity and similar measures are of service. Bromidrosis. (Synonym: Osmidrosis.) Describe bromidrosis. Bromidrosis is a functional disturbance of the sweat-glands charac- terized by a sweat secretion of an offensive odor. The sweat produc- tion may be normal in quantity or more or less excessive, usually the latter. The condition may be local or general, commonly the former. It is closely allied to hyperidrosis, and may.often be considered identical, the odor resulting from rapid decomposition of the sweat secretion. What parts are most commonly affected in bromidrosis ? The feet and the axillae. What is the treatment of bromidrosis ? It is essentially the same as that of hyperidrosis (q. v.), con- sisting of applications of astringent lotions, dusting-powders, espe- cially those containing boric acid and salicylic acid, and the continu- ous application of diachylon ointment. Chromidrosis. Describe chromidrosis. This is a rare functional disorder of the sweat-glands characterized by a secretion variously colored, and usually increased in quantity. It is, as a rule, limited to a circumscribed area. The most common color is red. The condition is probably of neurotic origin, and tends to recur. According to recent investigations the color would seem, in many eases at least, to be due to bacteria. Treatment should be invigorating and tonic, with special reference toward the nervous system. 36 DISEASES OF THE SKIN. Mild antiseptic and astringent lotions or dusting powders should also be advised. Uridrosis. Describe uridrosis. Uridrosis is a rare condition in which the sweat secretion contains the elements of the urine, especially urea. In marked cases the salt may be noticeable upon the skin as a colorless or whitish crystalline deposit. In most instances it has been preceded or accompanied by partial or complete suppression of the renal functions. Phosphoridrosis. Describe phosphoridrosis. Phosphoridrosis is a rare condition, in which the sweat is phos- phorescent. It has been observed in the later stages of phthisis, in miliaria, and in those who have eaten of putrid fish. Seborrhoea. (Synonyms: Steatorrhea; Acne sebacea; Ichthyosis sebacea; Dandruff.) What is seborrhoea ? Seborrhoea is a functional disease of the sebaceous glands, charac- terized by an excessive, and perhaps abnormal, secretion of sebaceous matter, appearing on the skin as an oily coating, crusts or scales. At what age is seborrhoea usually observed ? Between fifteen and forty. It may, however, occur at any age. Name the parts most commonly affected. The scalp, face, and (less frequently) the sternal and interscapular regions of the trunk. It is rarely seen on other parts. What varieties of seborrhoea are encountered ? Seborrhoea oleosa and seborrhoea sicca ; not infrequently the dis- ease is of a mixed type. What are the symptoms of seborrhoea oleosa ? The sole symptom is an unnatural oiliness, variable as to degree. Its most common site is the region of the nose and forehead. In occasional instances mild rosacea coexists. r» Seborrhoea (Eczema Seborrhoicum). DISORDERS OF THE GLANDS. 37 Give the symptems of seborrhoea sicca. A variable degree of greasy scaliness, usually seated upon a pale or non-inflammatory surface. The parts affected are covered scantily or more or less abundantly with somewhat greasy, grayish, or brownish-gray scales. If upon the scalp (dandruff, pityriasis capitis), small particles of scales are found scattered through the hair, and when the latter is brushed or combed, A normal .sebaceous gland in connection with a lanugo hair. (After Neumann.) a, Capsule; b, fatty secretion ; c, h, secreting cells; d, root of lanugo hair; e, hair- sac; /, hair-shaft; g, acini of sebaceous gland. fall over the shoulders. If upon the face, in addition to the scaliness, the sebaceous ducts are usually seen to be enlarged and filled with sebaceous matter, and in some instances the skin is more or less hyperacute; and even mild inflammatory action may be present (eczema seborrhoicum). 38 DISEASES OF THE SKIN. Describe the symptoms of the ordinary or mixed type. It is common upon the scalp. The skin is covered with irregularly diffused, greasy, grayish or brownish scales and crusts, in some cases moderate in quantity, in others so great that large irregular masses are formed, pasting the hair to the scalp. If removed, the scales and crusts rapidly re-form. The skin beneath is found pale or slate-col- ored ; exceptionally it has in places an eczematous aspect (eczema seborrhoicum). Extraneous matter, such as dust and dirt, collects upon the parts, and the whole mass may become more or less offen- sive. There is a strong tendency to falling out of the hair. Itch- ing may or may not be present. Describe the symptoms of seborrhoea of the trunk. Seborrhoea corporis differs in a measure, in its symptoms, from seborrhoea of other parts; it occurs as one or several irregular or cir- cinate, pale or slightly hyperaemic patches, covered with dirty or grayish-looking greasy scales or crusts, usually moderate in quantity, and upon removal are found to have projections into the sebaceous ducts. It is commonly seen upon the sternal and interscapular regions. What is the usual course of seborrhoea ? Essentially chronic, the disease varying in intensity from time to time. In occasional instances it disappears spontaneously. Give the cause or causes of seborrhoea. There is no single responsible factor. General debility, anaemia, chlorosis, dyspepsia, and similar conditions are to be variously looked upon as causative. In some instances, however, the disease seems to be due to loss of tone in the glands and skin, and to be entirely independent of any constitutional or predisposing condition. The view recently ad- vanced that the disease is of parasitic nature and contagious has been steadily gaining ground. What is the pathology of seborrhoea ? Seborrhoea is a functional disease of the sebaceous glands, its products, as found upon the skin, consisting of the sebaceous se- cretion, epithelial cells from the glands and ducts, and more or less extraneous matter. Not infrequently evidences of superficial in- flammatory action are also to be found {eczema seborrhoicum). In DISORDERS OF THE GLANDS. 39 long-continued and neglected cases slight atrophy of the gland- structures may occur. Kccent investigations would hold the sweat-glands as partly or chiefly responsible. With what diseases are you likely to confound seborrhoea ? Upon the scalp, with eczema and psoriasis; upon the face, with lupus erythematosus and eczema ; and upon the trunk, with psori- asis and ringworm. As a rule, the clinical features of seborrhoea are sufficiently charac- teristic to prevent error. What are the differential points ? Kczeina, psoriasis, and lupus erythematosus are diseases in which there are distinct inflammatory symptoms, such as thickening and infiltration and redness; moreover, psoriasis, and this holds true as to ringworm also, occurs in sharply-defined, circumscribed patches, and lupus erythematosus has a peculiar violaceous tint and an elevated and marginate border. A microscopic examination of the epidermic scrapings would be of crucial value in differentiating from ringworm. What is the prognosis in seborrhoea ? Favorable. All types are curable, and when upon the non-hairy regions, usually readily so; upon the scalp it is often obstinate. Relapses are not uncommon. In those cases of seborrhoea capitis which have been long-con- tinued or neglected, and attended with loss of hair, this loss may be more or less permanent, although ordinarily much can be done to promote a regrowth (see Treatment of Alopecia). How would you treat seborrhoea of the scalp ? By constitutional (if indicated) and local remedies ; the former having in view correction or modification of the predisposing factor or factors, and the latter removal of the sebaceous accumulations and the application of mildly stimulating antiseptic ointments or lotions. What constitutional remedies are commonly employed ? The various tonics, such as iron, quinine, strychnia, cod-liver oil arsenic, the vegetable bitters, laxatives, malt and similar prepa- rations. The line of treatment is to be based upon indications. 40 DISEASES OF THE SKIN. How do you free the scalp of the sebaceous accumulations ? In mild types of the disease shampooing with simple Castile soap (or any other good toilet soap) and hot water will suffice; in those cases in which there is considerable scale- and crust-formation the tincture of green soap (tinct. saponis viridis) is to be employed in place of the toilet soap, and in some of these latter cases it may be necessary to soften the crusts with a previous soaking with olive oil. The frequency of the shampoo depends upon the conditions. In mild cases once in five or ten days will be sufficiently frequent to keep the parts clean, but in those cases in which there is rapid scale- or crust-production once daily or every second day may at first be demanded. Name the most effectual applications in seborrhoea capitis. Sulphur, ammoniated mercur}', salicylic acid and resorcin; petro- leum ointment, liquid petrolatum, water with five to ten minims of glycerine and alcohol to the ounce, and alcohol with a few minims of castor oil to the ounce, are the most desirable vehicles for the remedial applications. Sulphur is used in the form of an ointment, one to three drachms in the ounce. Ammoniated mercur}7, in the form of an ointment, twenty to sixty grains to the ounce. Salicylic acid, either alone as an ointment, ten to thirty grains to the ounce; or it may often be added with advantage, in the same proportion, to the sulphur or ammoniated mercury ointment above named. Resorcin, either as an ointment, twenty to sixty grains to the ounce, or as an alcoboUc or aqueous lotion, as the following :— R. Resorcini,..............^j-.^iss 01. ricini,.............TTLv-xxx. Alcobolis,.............I^iv. M. If an aqueous lotion is desirable, then in the above formula the oleum ricini is replaced with glycerine and the alcohol with water. How are the remedies to be applied ? A small quantity of the lotion, ointment, or oil is gently but thor- oughly rubbed into the skin; in the beginning of the treatment, once or twice daily, later, as the disease becomes less active, once every second or third day. DISORDERS OF THE GLANDS. 41 How is seborrhoea upon other parts to be treated ? In the same general manner as seborrhoea of the scalp, except that the local applications must be somewhat weaker. The several sul- phur lotions employed in the treatment of acne (q. v.) may also be used when the disease is upon these parts. Comedo. (Synonyms: Blackheads; Flesh-worms.) What is comedo ? Comedo is a disorder of the sebaceous glands, characterized by yellowish or blackish pin-point or pin-head-sized puncta or elevations corresponding to the gland-orifices. At what age and upon what parts are comedones found? Usually between fifteen and thirty, and upon the face and upper part of the trunk, where they may exist sparsely or in great num- bers. They are occasionally associated with oily seborrhoea, the parts presenting a greasy or soiled appearance. Exceptionally they occur as distinct, and usually symmetrical, groups upon the forehead or the cheeks. On the upper trunk so- called double and multiple comedo have been noted—the two, three, or even four closely-contiguous blackheads are, beneath the surface, intercommunicable, the dividing duet-walls having appa- rently disappeared by fusion. Describe an individual lesion. It is pin-point to pin-head in size, dark yellowish, and usually with a central blackish point (hence the name blackheads). There is scarcely perceptible elevation, unless the amount of retained secre- tion is excessive. Upon pressure this may be ejected, the small, rounded orifice through which it is expressed giving it a thread-like shape (hence the name flesh-worms). What is the usual course of comedo ? Chronic. The lesions may persist indefinitely or the condition may be somewhat variable. In many instances, either as a result of pressure or in consequence of chemical change in the sebaceous 42 DISEASES OF THE SKIN plugs, inflammation is excited and acne results. The two conditions are, in fact, usually associated. Fig. 8. Demodex Folliculorum, X 300. Ventral surface. (After Simon.) To what may comedo often be ascribed ? To disorders of digestion, constipation, chlorosis, menstrual dis- turbance, lack of tone in the muscular fibres of the skin, the infre- quent use of soap, and working in a dirty or dusty atmosphere. A small parasite (demodex folliculorum, acarus folliculorum) is sometimes found in the sebaceous mass, but its presence is without etiological significance, as it is also found in healthy follicles. What is the pathology of comedo ? The sebaceous ducts or glands, or both, become blocked up with retained secretion and epithelial cells. The dark points which usually mark the lesions are probably due to accumulation of dirt, but may, as some writers maintain, be due to the presence of pigment- granules resulting from chemical change in the sebaceous matter. Is there any difficulty in the diagnosis of comedo ? No. It can scarcely be confounded with milium, as in this latter disease the lesion has no open outlet, no black point, and the con- tents cannot be squeezed out. Give the prognosis of comedo. The result of treatment is usually favorable, although the disease is often rebellious. Relapses are not uncommon. How would you treat a case of comedo ? By systemic (if indicated) and local measures. The constitutional treatment aims at correction or palliation of the predisposing conditions, and the external applications have in view DISORDERS OF THE GLANDS. 43 a removal of the sebaceous plugs and stimulation of the glands and skiu to healthy action. Fig. 9. Comedo Extractor. Name the systemic remedies commonly employed. Cod-liver oil, iron, quinine, arsenic, nux vomica and other tonics : ergot in those cases in which there is lack of muscular tone, salines and aperient pills in constipation. The digestion is to be looked after and the bowels kept regular; indigestible food of all kinds is to be interdicted. Hygienic measures, such as general and local bathing, calisthenics, and open-air exercise, are of service. Describe the local treatment. Steaming the face or prolonged applications of hot water ; wash- ing with ordinary toilet soap and hot water, or, in sluggish cases, using tincture of green soap (tinct. saponis viridis) instead of the toilet soap ; removal of the sebaceous plugs by mechanical means, such as lateral pressure with the finger ends or perpendicular pres- sure with a watch-key with rounded edges, or with an instrument specially contrived for this purpose ; and after these preliminary measures, which should be carried out every night, a stimulating sulphur or mercurial ointment or lotion, such as employed in the treatment of acne (q. v.), is to be thoroughly applied. The follow- ing is valuable :— R. Zinci sulphatis, Potassii sulphureti, . ... aa .... ^j Aqme rosa3,.............% iv. M. Should slight scaliness .or a mild degree of irritation of the skin be brought about, external treatment is to be discontinued for a few days and soothing applications made. Moderately strong applications of the Faradic current, repeated once in- twice weekly, are sometimes of service. In occasional instances sulphur preparations not only fail to do good, but materially aggravate the condition. Mercurial and sul- 44 DISEASES OF THE SKIN. phur applications should not be used, it need scarcely be said, within a week or ten days of each other, otherwise an increase in the comedones and a slight darkening of the skin result from the formation of the black sulphuret of mercury. Milium. {Synonyms: Grutum; Strophulus Albidus.) What is milium ? Milium consists in the formation of small, whitish or yellowish. rounded, pearly, non-inflammatory elevations situated in the upper part of the corium. Describe the clinical appearances. The lesions are usually pin-head in size, whitish or yellowish, seem - ingly more or less translucent, rounded or acuminated, without aperture or duct, are superficially seated in the skin, and project slightly above the surface. They appear about the face, especially about the eyelids; they may occur also, although rarely, upon other parts. But one or several may be present, or they may exist in numbers. What is the course of milium ? The lesions develop slowly, and may then remain stationary for years. Their presence gives rise to no disturbance, and, unless they are large in size or exist in numbers, causes but slight disfigurement. Fig. 10. Milium Needle. In rare instances they may undergo calcareous metamorphosis, con- stituting the so-called cutaneous calculi. What is the anatomical seat of milium ? The sebaceous gland (probably one or several of the superficially- situated acini), the duct of which is in some manner obliterated, the sebaceous matter collects, becomes inspissated and calcareous, form- ing the pin-head lesion. The epidermis is the external covering. DISORDERS OF THE GLANDS 45 What is the treatment ? The usual plan is to prick or incise each lesion and press out the contents. In some milia it may be necessary also, in order to pre- vent a return, to touch the base of the excavation with tincture of iodine or with silver nitrate. Electrolysis is also effectual. Steatoma. (Synonyms: Sebaceous Cyst; Sebaceous Tumor; Wen.) Describe steatoma. Steatoma, or sebaceous cyst, appears as a variously-sized, elevated, rounded or semi-globular, soft or firm tumor, freely movable and painless, and having its seat in the corium or subcutaneous tissue. The overlying skin is normal in color, or it may be whitish or pale from distention ; in some a gland-duct orifice may be seen, but, as a rule, this is absent. What are the favorite regions for the development of stea- toma? The scalp, face and back. One or several may be present. What is the course of sebaceous cysts ? Their growth is slow, and, after attaining a variable size, may re- main stationary. They may exist indefinitely without causing any inconvenience beyond the disfigurement. Exceptionally, in enor- mously distended growths, suppuration and ulceration result. What is the pathology ? A steatoma is a cyst of the sebaceous gland and duct, produced by retained secretion. The contents may be hard and friable, soft and cheesy, or even fluid, of a grayish, whitish or yellowish color, and with or without a fetid odor ; the mass consisting of fat-drops, epidermic cells, cholesterin, and sometimes hairs. Are sebaceous cysts likely to be confounded with gummata ? No. Gummata grow more rapidly, are usually painful to the touch, are not freely movable, and tend to break down and ulcerate. Describe the treatment of steatoma. A linear incision is made, and the mass and enveloping sac dis- 46 DISEASES OF THE SKIN. sected out. If the sac is permitted to remain, reproduction almost invariably takes place. CLASS II.—INFLAMMATIONS. Erythema Simplex. What do you understand by erythema simplex ? Erythema simplex is a hyperaemic disorder characterized by red- ness, occurring in the form of variously-sized and shaped, diffused or circumscribed, non-elevated patches. Name the two general classes into which the simple erythe- mata are divided. Idiopathic and symptomatic. What do you include in the idiopathic class ? Those erythemas due to external causes, such as cold and heat (erythema caloricum), the action of the sun (erythema sola re), trau- matism (erythema traumatic am), and the various poisons or chemical irritants (erythema venenatum). What do you include in the symptomatic class ? Those rashes often preceding or accompanying certain of the sys- temic diseases, and those due to disorders of the digestive tract, stomachic and intestinal toxins, and to the ingestion of certain drugs. Describe the symptoms of erythema simplex. The essential symptom is redness—simple hyperaemia—without elevation or infiltration, disappearing under pressure, and sometimes attended by slight heat or burning ; it may be patchy or diffused. In the idiopathic class, if the cause is continued, dermatitis may result. What is to be said about the distribution of the simple erythe- mata? The idiopathic rashes, as inferred from the nature of the causes, are usually limited. The symptomatic erythemas are more or less generalized ; desqua- mation sometimes follows. INFLAMMATIONS. 47 Describe the treatment of the simple erythemata. A removal of the cause in idiopathic rashes is all that is needed, the erythema sooner or later subsiding. The same may be stated of the symptomatic erythemata, but in these there is at times difficulty in recognizing the etiological factor; constitutional treatment, if necessary, is to be based upon general principles. Intestinal anti- septics are useful in some instances. Local treatment, which is rarely needed, consists of the use of dusting-powders or mild cooling and astringent lotions, such as are employed in the treatment of acute eczema (q. v.). Erythema Intertrigo. (Synonym: Chafing.) What do you understand by erythema intertrigo ? Erythema intertrigo is a hyperaamic disorder occurring on parts where the natural folds of the skin come in contact, and is charac- terized by redness, to which may be added an abraded surface and maceration of the epidermis. Describe the symptoms of erythema intertrigo. The skin of the involved region gradually becomes hyperaemic, but is without elevation or infiltration ; a feeling of heat and soreness is usually experienced. If the condition continue, the increased perspiration and moisture of the parts give rise to maceration of the epidermis and a mucoid discharge ; actual inflammation may event- ually result. What is the course of erythema intertrigo ? The affection may pass away in a few days or persist several weeks, the duration depending, in a great measure, upon the cause. Mention the causes of erythema intertrigo. The causes are usually local. It is seen chiefly in children, espe- cially in fat subjects, in whom friction and moisture of contiguous parts of the body, usually the region of the neck, buttocks and geni- talia, are more common ; in such, uncleanliness or the too free use of soap washings will often act as the exciting factor. Disorders of 4S DISEASES OF THE SKIN. the stomach or intestinal canal apparently have a predisposing influ- ence. What treatment would you advise in erythema intertrigo ? The folds or parts are to be kept from contact by means of lint or absorbent cotton. Cleanliness is essential, but it is to be kept within the bounds of common sense. Dusting-powders and cooling and astringent lotions, such as are employed in the treatment of acute eczema (q. v.), are to be advised. The following lotion is valuable :— R. Pulv. calaminae, Pulv. zinci oxidi,.....aa . . . . ^iss. Glycerinae,.............tt\,xxx Alcoholis,.............f^ij Aquse,...............Oss. M. Exceptionally a mild ointment, alone or supplementary to a lotion, acts more satisfactorily. In persistent or obstinate cases attention should also be directed to the state of the general health, especially as regards the digestive tract. Erythema Multiforme. What is erythema multiforme ? Erythema multiforme is an acute, inflammatory disease, character- ized by reddish, more or less variegated macules, papules, and tuber- cles, occurring as discrete lesions or in patches of various size and shape. Upon what parts of the body does the eruption appear ? Usually upon the extremities, especially the dorsal aspect, from the knees and elbows down ; it may, however, be more or less general. Describe the symptoms of erythema multiforme. With or without precursory symptoms of malaise, gastric uneasi- ness or rheumatic pains, the eruption suddenly makes its appearance, assuming an erythematous, papular, tubercular or mixed character ; as a rule, one type of lesion predominates. The lesions tend to increase in size and intensity, remain stationary for several days or a INFLAMMATIONS. 49 week, and then gradually fade ; during this time there may have been outbreaks of new lesions. In color they are pink, red, or violaceous. Slight itching may or may not be present. Exception- ally, in general cases, the eruption partakes of the nature of both urticaria and erythema multiforme, and itching may be quite a m decided symptom. In some instances there is preceding and ac- companying febrile action, usually slight in character; in others there may be some rheumatic swelling of one or more joints. What type of the eruption is most common ? The papular, appearing usually upon the backs of the hands and forearms, and not infrequently, also, upon the face, legs and feet. The papules are usually pea-sized, flattened, and of a dark red or violaceous color. Describe the various shapes which the erythematous lesions may assume. Often the patches are distinctly ring-shaped, with a clear centre— erythema annulare; or they are made up of several concentric rings, presenting variegated coloring—erythema iris; or a more or less extensive patch may spread with a sharply-defined border, the older part tending to fade—erythema marginatum; or several rings may coalesce, with a disappearance of the coalescing parts, and ser- pentine lines or bands result—erythema gyratum. Does the eruption of erythema multiforme ever assume a vesicular or bullous character ? Yes. In exceptional instances, the inflammatory process may be sufficiently intense to produce vesiculation, usually at the summits of the papules—en/thema vesiculosum; and in some instances, blebs may be formed—erythfma bullosnm. (Sec Herpes iris. ) In these cases the lips and the mucous membranes of the mouth and nose may be the seat of similar lesions. What is the course of erythema multiforme ? Acute, the symptoms disappearing spontaneously, usually in one to three or four weeks. In some instances the recurrences take place so rapidly that the disease assumes a chronic aspect; it is possible that such eases are midway cases between this disease and dermatitis herpetiformis. -l 50 DISEASES OF THE SKIN. Mention the etiological factors in erythema multiforme. The causes are obscure. Digestive disturbance, rheumatic condi- tions, and the ingestion of certain drugs are at times influential. Intestinal toxins are doubtless important etiological factors in some cases. It is most frequently observed in spring and autumn months, and in early adult life. The disease is not uncommon. What is the pathology of erythema multiforme ? It is a mildly inflammatory disorder, somewhat similar to urticaria, and presumably due to vasomotor disturbance; the amount of exuda- tion, which is variable, determines the character of the lesions. Name the diagnostic points of erythema multiforme. The multiformity of the eruption, the size of the papules, often its limitation to certain parts, its course and the entire or com- parative absence of itching. It resembles urticaria at times, but the lesions of this latter disease are evanescent, disappearing and reappearing usually in the most capricious manner, are commonly seated about the trunk, and are exceedingly itchy. What prognosis would you give in erythema multiforme ? Always favorable ; the eruption usually disappears in ten days to three weeks, although in rare instances new crops may appear from day to day or week to week, and the process last one or two months. One or more recurrences in succeeding years are not uncommon. What remedies are commonly prescribed in erythema multi- forme ? Quinin, and, if constipation is present, saline laxatives. Intes- tinal antiseptics, such as salol, thymol, and sodium salicylate, are valuable in cases probably due to intestinal toxins. Local applica- tions are rarely required, but in those exceptional cases in which itching or burning is present, cooling lotions of alcohol and water or vinegar and water are to be prescribed. INFLAMMATIONS. 51 Erythema Nodosum. (Synonym: Dermatitis contusiformis.) What is erythema nodosum ? Erythema nodosum is an inflammatory affection, of an acute type, characterized by the formation of variously-sized, roundish, more or less elevated erythematous nodes. Is there any special region of predilection for the eruption of erythema nodosum ? Yes. The tibial surfaces, to which the eruption is often limited ; not infrequently, however, other parts may be involved, more espe- cially the arms and forearms. Describe the symptoms of erythema nodosum. The eruption makes its appearance suddenly, and is usually ushered in with febrile disturbance, gastric uneasiness, malaise, and rheumatic pains and swelling about the joints. The lesions vary in size from a cherry to a hen's egg, are rounded or ovalish, tender and painful, have a glistening and tense look, and are of a bright red, erysipelatous color which merges gradually into the sound skin. At first they are somewhat hard, but later they soften and appear as if about to break down, but this, however, never occurs, absorption invariably taking place. In occasional instances they are hemor- rhagic. Kxeeptionally the lesions of erythema multiforme are also present. Lymphangitis is sometimes observed. Are the lesions in erythema nodosum usually numerous ? No. As a rule not more than five to twenty nodes are present. What is the course of erythema nodosum ? Acute; the disease terminating usually in one to three weeks. As the lesions are disappearing they present the various changes of color observed in an ordinary braise. What is known in regard to the etiology ? The affection is closely allied to erythema multiforme, and may, indeed, be considered as a form of that disease. It occurs most frequently in children and young adults, and usually in the spring 52 DISEASES OF THE SKIN. and autumn months. Intestinal toxins are thought responsible in some cases. Digestive disturbance and rheumatic pains and swel- lings are often associated with it. What is the pathology of erythema nodosum ? The disease is to be viewed as an inflammatory oedema, probably resulting, in some instances at least, from an inflammation of the lymphatics or an embolism of the cutaneous vessels. What diseases may erythema nodosum resemble ? Bruises, abscesses, and gummata. How are the lesions of erythema nodosum to be distinguished from these several conditions ? By the bright red or rosy tint, the apparently violent character of the process, the number, situation and course of the lesions. State the prognosis of erythema nodosum. Favorable, recovery usually taking place in ten days to several weeks. State the treatment to be advised in erythema nodosum. Rest, relative or absolute, depending upon the severity of the case, and an unstimulating diet; internally intestinal antiseptics, quinin and saline laxatives, and locally applications of lead-water and laudanum. Erythema Induratum. What do you understand by erythema induratum ? A rare disease characterized in the beginning by one or more usually deep-seated nodules, and as a rule seated in the legs, especially the calf region. The nodules gradually enlarge, the skin becomes reddish, violaceous or livid in color. Absorption may take place slowly, or the indurations may break down, resulting in an indolent, rather deep-seated ulcer, closely resembling a gummatous ulcer. The disease is slow and persistent, and is commonly met with in girls and young women, usually of strumous type. It sug- gests a tuberculous origin. Treatment consists in administration of cod-liver oil, phosphorus and other tonics. Rest is of service. Locally antiseptic applica- tions, and support with roller bandage are of benefit. [NEI.AMMATIONS. 53 Urticaria. (Synonyms : Hives ; Nettlerash.) Give a definition of urticaria. Urticaria is an inflammatory affection characterized by evanescent whitish, pinkish or reddish elevations, or wheals, variable as to size and shape, and attended by itching, stinging or pricking sensations. Describe the symptoms of urticaria. The eruption, erythematous in character and consisting of isolated pea or bean-sized elevations or of linear streaks or irregular patches. Dermatoirrnphia. (After ('. X. ])avis.) limited or more or less general, and usually intensely itchy, makes its appearance suddenly, with or without symptoms of preceding gastric derangement. The lesions are soft or firm, reddish or' pinkish-white, with the peripheral portion of a bright red color, 54 DISEASES OF THE SKIN. and are fugacious in character, disappearing and reappearing in the most capricious manner. In many eases simply drawing the finger over the skin will bring out irregular and linear wheals, so much so that letters and other symbols may be produced at will (urticaria factitia, dermatographism, autographism). The mucous mem- brane of the mouth and throat may also be the seat of wheals an 1 urticarial swellings. What is the ordinary course of urticaria ? Acute. The disease is usually at an end in several hours or days. Does urticaria always pursue an acute course ? No. In exceptional instances the disease is chronic, in the sense that new lesions continue to appear and disappear irregularly from time to time for months or several years, the skin rarely being entirely free (chronic urticaria). Are subjective symptoms always present in urticaria? Yes. Itching is commonly a conspicuous symptom, although at times pricking, stinging or a feeling of burning constitutes the chief sensation. In what way may the eruption be atypical? Exceptionally the wheals, or lesions, are peculiar as to formation, or another condition or disease may be associated, hence the varieties known as urticaria papulosa, urticaria haemorrhagica, urticaria tube- rosa, and urticaria bullosa. Describe urticaria papulosa. Urticaria papulosa (formerly called lichen urticatus) is a variety in which the lesions are small and papular, developing usually out of the ordinary wheals. They appear as a rule suddenly, rarely in numbers, are scattered, and after a few hours, or more commonly, days, gradually disappear. The itching is intense, and in conse- quence their apices are excoriated. It is seen more particularly in ill-cared for and badly-nourished young children. Describe urticaria haemorrhagica. Urticaria haemorrhagica is characterized by lesions similar to ordi- nary wheals, except that they are somewhat hemorrhagic, partaking, in fact, of the nature of both urticaria and purpura. INFLAMMATIONS. 51 Describe urticaria tuberosa. In urticaria tuberosa the lesions, instead of being pea- or bean- sized, as in typical urticaria, are large and node-like (also called f/iaut urticaria). Tn rare instances there occurs, along with the ordinary lesions of the disease or as its sole manifestation, sudden and evanescent swelling of the eyelids, ears, lips, tongue, hands, fingers, or feet (urticaria aidematosa.. acute circumscribed a-dema, angioneurotic a ken a superficial excoriation results. In a short time they dry to crusts which soon fall off, leav- ing no permanent trace. Is the eruption in herpes simplex abundant? No. As a rule not more than one or two clusters or groups are observed. Upon what parts does the eruption occur ? Usually about the face (herpes facialis), and most frequently about the lips {herpes labialis); on the genitalia (herpes progcuitalis), the lesions are commonly found on the prepuce (Jierpespraputialis) in the male, and on the labia minora and labia majora in the female. State the causes of herpes simplex. Herpes facialis is often observed in association with colds and febrile and lung diseases. Malaria, digestive disturbance, and nerv- ous disorders are not infrequently predisposing factors. Herpes progenitalis is said to occur more frequently in those who have pre- viously had some venereal disease, especially gonorrhoea, but this is questionable. It is probably often purely neurotic. What are the diagnostic points ? The appearance of one or several vesicular groups or clusters about the face, and especially about the lips, is usually sufficiently charac- teristic. The same holds true ordinarily when the eruption is seen on the prepuce or other parts of the genitalia ; it is only when the vesi- cles become rubbed or abraded and irritated that it might be mis- taken for a venereal sore, but the history, course and duration will usually serve to differentiate. Give the prognosis. The eruption will usually disappear in several days or one or two weeks without treatment. Remedial applications, however, exert INFLAMMATIONS. 77 a favorable influence. Herpes progenitalis exhibits a strong disposi- tion to recurrence. What is the treatment of herpes facialis ? Anointing the parts with camphorated cold cream, with spirits of camphor or similar evaporating and stimulating applications will at times afford relief to the burning, and shorten the course. What is the treatment of herpes progenitalis ? In herpes about the genitalia cleanliness is of first importance, A saturated solution of boric acid, a dusting-powder of calomel or oxide of zinc, and the following lotion, containing calamine and oxide of zinc, are valuable :— R. Zinci oxidi, Calaminae,......aa ...... gr. v Glycerinoc, Alcoholis,......aa ..... . niyj Aqua?,...............Jj M. In obstinately recurrent cases, frequent applications of a mild galvanic current will have a favorable influence. Hydroa Vacciniforme. (Synonyms: Recurrent Summer Eruption; Hydroa Pueroruni; Hydroa Aestivale.) Describe hydroa vacciniforme. It is a rare vesicular disease usually seen in boys (only two or three exceptions), occurring upon uncovered parts, and as a rule, after exposure to sun or wind. The lesions begin as red spots, discrete or in groups, rapidly exhibit vesiculation, and later umbilication; the contents become milky, dry to crusts, which fall off and leave small pit-like scars. Fresh outbreaks may take place almost continuously, and the process go on indefinitely, at least up to youth or manhood, when the tendency subsides. It is usually limited to the warm season. Arthritic symptoms and general disturbance are sometimes noted in severe cast's. It is doubtless a vasomotor neurosis. Primarily the lesion begins 78 DISEASES OF THE SKIN. in the rete middle layers, and is purely vesicular in character; later necrosis of the rete and extending deep in the corium is observed. Treatment so far has only been palliative, consisting of the appli- cations employed in similar conditions. Constitutional medication is based upon general principles. The patient should avoid exposure to the sun, strong wind and excessive artificial heat. Epidermolysis Bullosa. Describe epidermolysis bullosa. This is a rare, usually hereditary, disease or condition, character- ized by the formation of vesicles and blebs on any part subjected to slight rubbing or irritation. No scarring is left, and no pigmenta- tion noted. The predisposition to these lesions persists indefinitely. The general health is not involved. The nature of the disease is obscure. Treatment has no influence in modifying or lessening this ten- dency. Herpes Zoster. (Synonyms : Zoster; Zona; Shingles.) Give a definition of herpes zoster. Herpes zoster is an acute, self-limited, inflammatory disease, char- acterized by groups of vesicles upon inflammatory bases, situated over or along a nerve tract. Upon what parts of the body may the eruption appear ? It may appear upon any part, following the course of a nerve ; it is therefore always limited in extent, and confined to one side of the body. It is probably most common about the intercostal, lumbar and supra-orbital regions. In rare instances the eruption has been observed to be bilateral. Are there any subjective or constitutional symptoms ? Yes; there is, as a rule, neuralgic pain preceding, during and following the eruption ; and in some cases, also, there may be in the 1 Herpes Facialis. Herpes Zoster INFLAMMATIONS. 79 beginning mild febrile disturbance. There is also a variable degree of tenderness and pain. What are the characters of the eruption ? Several or more hyperaemic or inflammatory patches over a neive course appear, upon which are seated vesico-papules irregularly grouped ; these vesico-papules become distinct vesicles, of size from a pin-head to a pea, and soon dry and give rise to thin, yellowish or brownish crusts, which drop off, leaving in most instances no per- manent trace, in others more or less scarring. In some cases the lesions may become pustular and, on the other hand, the eruption may be abortive, stopping short of full vesiculation. What is known in regard to the nature of the disease ? An inflamed and irritable state of the spinal ganglia, nerve tract, or peripheral branches is directly responsible for the eruption, and this state may be due .to atmospheric changes, cold, nerve-injuries and similar influences. The view has also been advanced that the disease is of specific and infectious character. Give the chief diagnostic features of herpes zoster. The prodromic neuralgic pain, the appearance of grouped vesicles upon inflammatory bases following the course of a nerve tract, and the limitation of the eruption to one side of the body. What is the prognosis ? Favorable; the symptoms usually disappearing in two to four weeks. In some instances, however, the neuralgic pains may be per- sistent, and in zoster of the supra-orbital region the eye may suffer permanent damage. How would you treat herpes zoster ? • Constitutional treatment, usually tonic in character, is to be based upon general principles; moderate doses of quinia, with one-sixth grain of zinc phosphide, four or five times daily, appear in some cases to have a special value. The accompanying neuralgic pain may be so intense as to require anodynes. Local treatment should be of a soothing and protective char- acter. A dusting-powder of oxide of zinc and starch (to the ounce of which twenty to thirty grains of camphor may be added) proves useful; and over this, in order that the parts be further protected, a bandauc or a layer of cotton batting. Oxide-of-zinc ointment, 80 DISEASES OF THE SKIN. and in those cases in which there is much pain, ointments containing powdered opium or belladonna, or orthoform, may be used. A mild galvanic current applied daily to the parts is often of great advantage, both in its influence upon the course of the eruption and upon the neuralgic pain. In abortive cases protecting the parts by painting on flexible collodion is satisfactory. Herpes Iris. What do you understand by herpes iris ? Herpes iris is an acute inflammatory disease characterized by one or more groups of vesicles or blebs arranged usually in the form of more or less complete concentric rings, the whole efflorescence being somewhat variegated in color. Describe the symptoms of herpes iris. A patch of herpes iris usually begins as a simple vesicle or papule; this partly disappears, while around the periphery a ring of discrete or confluent vesicles makes its appearance; the process may stop here, or one, two or more such rings may be added. Several or more patches are usually present, and when fully formed present variegated colors due to the difference in age of the individual rings making up the eruption ; new patches may continue to appear one or two weeks, or longer, and the disease come to an end, the lesions drying to crusts, which, falling off, leave transitory redness and pigmentation. The subjective symptoms, of heat, burning, and sometimes itch- ing, are rarely troublesome. Upon what parts of the body is the eruption commonly ob- served ? Upon the backs of the bands and forearms; it may, however, be seen upon other parts, more especially the face, neck, legs, and feet. Exceptionally a variable number of lesions may be seen in the mouth, especially in recurrent cases. Are blebs ever produced in herpes iris ? Yes. In exceptional instances the inflammatory action is suffi- ciently severe to give rise to bleb formation. What is the nature of the disease ? It is closely allied, in its cause, distribution, and course, to ery- INFLAMMATIONS. SI thema multiforme, and is indeed to be looked upon as a variety or modification of that disease. It is somewhat rare. May herpes iris be confounded with other diseases ? It might possibly bear resemblance to ringworm, herpes zoster and pemphigus, but its characters, mode of formation, distribution and course are different, and will serve to prevent error. Derma- titis herpetiformis may at times present an eruption of the same character, but the chronicity of this disease is a distinguishing factor. What prognosis is to be given in herpes iris? Favorable. The disease, while at times markedly inflammatory, usually subsides at the end of one to three weeks. One or more recurrences, usually at yearly intervals, are not uncommon. Ex- ceptionally the disease recurs at short intervals, the eruption being usually scanty, and seated about the hands, wrists, and in the mouth. What treatment is to be advised ? The stomach and intestinal canal should receive attention; qui- nine, strychnia, salol. sodium salicylate and other intestinal anti- septics are to be advised if indicated. Arsenic and intestinal anti- septics are the most valuable remedies in the recurrent eases. Locally, soothing and protective applications should be made; oxide-of-zinc ointment, calamine lotion as prescribed in eczema (q. v.), cold cream or the like may be used for this purpose. Dermatitis Herpetiformis. (Synonyms: Hydroa Herpetifonne (Tilbury Fox); Herpes OJestationis (Bulkley) ; Pemphigus Pruriginosus : Duhring's Disease.) Give a definition of dermatitis herpetiformis. Dermatitis herpetiformis is a somewhat rare inflammatory disease, characterized by an eruption of an erythematous, papular, vesicular, pustular, bullous or mixed type, with a decided disposition toward grouping, accompanied by itching and burning sensations, with, as a rule more or less consequent pigmentation, and pursuing usually a chronic course with remissions. 6 82 DISEASES OF THE SKIN. Describe the erythematous type of dermatitis herpetiformis. The character of the eruption in the erythematous type resembles closely that of erythema multiforme and of urticaria, especially the former. The efflorescences usually make their appearance in crops, and are more or less persistent; fading sooner or later, however, and giving place to new outbreaks. Aresicles are often intermingled, developing from erythematous and erythemato-papular lesions or arising from apparently normal skin. It may continue in the same type, or change to the vesicular, bul- lous or other variety. Describe the papular type of dermatitis herpetiformis. This is rarely seen as consisting purely of papular lesions, but is com- monly associated with the erythematous and vesicular varieties. In a measure it resembles the papular manifestations of erythema mul- tiforme, with a distinct disposition toward group formation. The papules tend, sooner or later, to develop into vesicles, new papular outbreaks occurring from time to time; or the whole eruption changes to the vesicular or other type of the disease. It is not a common type. Describe the vesicular type of dermatitis herpetiformis. This is the common clinical type of the disease, and is character- ized by pin-head to pea-sized, rounded or irregularly-shaped, dis- tended or flattened and stellate vesicles, occurring, for the most part, in irregular and segmental groups of three or more lesions, seated either upon apparently normal integument or upon hyperaemic or inflammatory skin. They exhibit no tendency to spontaneous rupture, but after remaining a shorter or longer time, are broken or disappear by absorption. The lesions tend to appear in crops. It may, as it not infrequently does, continue in the same type, or it may become more or less erythematous or bullous in character. In not a few instances pustules, few or in numbers, are at times intermingled. Describe the pustular type of dermatitis herpetiformis, This is rare. It is similar in its clinical characters to the vesicular type, except that the lesions are pustular. It is met with, as a rule, in association with the vesicular and bullous varieties of the disease. INFLAMMATIONS. 83 Describe the bullous type of dermatitis herpetiformis. The bullous expression of tlie disease is usually of a markedly inflammatory nature, often innumerable blebs, small and large, appearing almost continuously, and in some instances involving the greater part of the surface. The lesions arise from erythematous skin, from preexisting vesicles or vesicular groups, or from appa- rently normal integument. There is a marked disposition to appear in clusters. A change of type to the erythematous or vesicular varieties is not unusual. Describe the mixed type of dermatitis herpetiformis. In this type the eruption is made up of erythematous patches, vesicles, bullae, and often with pustules intermingled, appearing irregularly or in crops, and with a tendency to patch or group for- mation. Describe the characters of the vesicles, pustules and blebs. As a rule, thesu several lesions, especially the vesicles and blebs, are somewhat peculiar: they are usually of a strikingly irregular outline, oblong, stellate, quadrate, and when drying are apt to have a puckered appearance. They are herpetic in that they show little disposition to spontaneous rupture, occur in groups, and are usually seated upon erythematous or inflammatory skin—in some respects similar to the groups of simple herpes and herpes zoster. What is to be said in regard to the subjective symptoms? The subjective symptoms are usually the most troublesome feature of the disease, consisting of intense and persistent itching and a feeling of heat and burning. Are there any constitutional symptoms in dermatitis herpeti- formis ? As a rale, not, excepting the distress and depression necessarily consequent upon the intense itchiness and loss of sleep. In the pustular and bullous varieties there may be mild or grave systemic symptoms, but even in these types the constitutional involvement is, in most instances, slight in comparison to the intensity of the cutaneous disturbance. 84 DISEASES OF THE SKIN. What is the course of dermatitis herpetiformis ? Extremely chronic, in most instances lasting, with remissions, indefinitely. The skin is rarely entirely free. From time to time the type of the disease may undergo change. From the continued irritation and scratching more or less pigmentation results. What is to be said in regard to the etiology ? The disease is in many instances essentially neurotic, and in excep- tional instances septicaemic. Pregnancy and the parturient state are factors in some instances (so-called herpes gestationis). In other cases no cause can be assigned. In the majority of patients the general health, considering the violence of the eruptive phenomena, remains comparatively undisturbed. Nervous shock and mental worry are factors in some cases. Polyuria, with sugar in the urine, has occasionally been noted. Eosinophile cells have been found both in the vesicles and the blood. Mention the diagnostic features of dermatitis herpetiformis. The multiformity of the eruption, the characters of the lesions, the disposition to grouping, the absence of tendency to form solid sheets of eruption (as in eczema), the intense itching, history, chronicity and course. In doubtful cases, an observation of several weeks will always suffice to distinguish it from eczema, erythema multiforme, herpes iris and pemphigus, diseases to which it at times bears strong resemblance. Give the prognosis of dermatitis herpetiformis. An opinion as to the outcome of the disease should be guarded. It is exceedingly rebellious to treatment, and relapses are the rule. Exceptionally the bullous and pustular varieties prove eventually fatal. The erythematous and vesicular varieties are the most favorable. State the treatment to be advised. There are no special remedies. Constitutional treatment must be conducted upon general principles. Externally protective and anti- pruritic applications, such as are employed in the treatment of eczema and pemphigus, are to be employed :— INFLAMMATIONS. 85 R. Ac. carbolioi............3J~3ij Thymol,.............gr. xvj. Glycerinae,.............Iss-^j Alcoholis,............fgij Aquae, q. s.,.......ad .... Oj. M. Other valuable applications are : lotions of carbolic acid, of liquor carbonis detergens, of boric acid; alkaline baths, mild sulphur oint- ment and carbolized oxide-ofzinc ointment, and dusting-powders of starch, zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion or ointment is sometimes of advantage; thiol em- ployed in the same manner has also been commended. Psoriasis. Give a definition of psoriasis. Psoriasis is a chronic, inflammatory disease, characterized by dry, reddish, variously-sized, rounded, sharply-defined, more or less infiltrated, scaly patches. At what age does psoriasis usually first make its appearance ? Most commonly between the ages of fifteen and thirty. It is rarely seen before the tenth year, and a first attack is uncommon after the age of forty. Has psoriasis any special parts of predilection ? The extensor surfaces of the limbs, especially the elbows and knees, are favorite localities, and even when the eruption is more or less general, these regions are usually most conspicuously involved. The face often escapes, and the palms and soles, likewise the nails, are rarely involved. In exceptional instances, the eruption is limited almost exclusively to the scalp. Are there any constitutional or subjective symptoms in psoriasis ? There is no systemic disturbance ; but a variable amount of itch- ing may be present, although, as a rule, it is not a troublesome symptom. SO DISEASES OF THE SKIN. Describe the clinical appearances of a typical, well devel- oped case. Twenty or a hundred or more lesions, varying in size from a pin- head to a silver dollar, are usually present. They are sharply defined against the sound skin, are reddish, slightly elevated and infiltrated, and more or less abundantly covered with whitish, grayish or mother-of-pearl colored scales. The patches are usually scattered over the general surface, but are frequently more numer- ous on the extensor surfaces of the arms and legs, especially about the elbows and knees. Several closely-lying lesions may coalesce and a large, irregular patch be formed; some of the patches, also, may be more or less circinate, the central portion having, in a measure or completely, disappeared. Give the development and history of a single lesion. Every single patch of psoriasis begins as a pin-point or pin-bead- sized, hyperaemic, scaly, slightly-elevated lesion; it increases gradually, and in the course of several days or weeks usually reaches the size of a dime or larger, and then may remain stationary; or involution begins to take place, usually by a disappearance, partially or com- pletely, of the central portion, and finally of the whole patch. Describe the so-called clinical varieties of psoriasis. As clinically met with, the patches present are, as a rule, in all stages of development. In some instances, however, the lesions, or the most of them, progress no further than pin-head in size, and then remain stationary, constituting psoriasis punctata; in other cases, they may stop short after having reached the size of drops— psoriasis guttata; in others (and this is the usual clinical type) the patches develop to the size of coins—psoriasis nummularis. In some cases there is a strong tendency for the central part of the lesions to disappear, and the process then remain stationary, the patches being ring-shaped—psoriasis circinata; aud occasionally several such rings coalesce, the coalescing portions disappearing and the eruption be more or less serpentine—psoriasis gyrata. Or, in other instances, several large contiguous lesions may coalesce and a diffused, infiltrated patch covering considerable surface results— psoriasis diffusa, psoriasis inveterata. Psoriasis. INFLAMMATIONS. 87 Is the eruption of psoriasis always dry ? Yes. What course does psoriasis pursue ? As a rule, eminently chronic. Patches may remain almost indefi- nitely, or may gradually disappear and new lesions appear elsewhere, and so the disease may continue for months and, sometimes, for years; or, after continuing for a longer or shorter period, may subside and the skin remain free for several months or one or two years, and, in rare instances, may never return. Fig. 13. Vertical section of a psoriasis papule of a few days' duration; sbowing marked increase of the rete mucosum, especially the interpapillary portion. (After Robinson.) Is the course of psoriasis influenced by the seasons ? As a rule, yes; there is a natural tendency for the disease to become less active or to disappear altogether during the warm months. What is known in regard to the etiology of psoriasis ? The causes of the disease are always more or less obscure. Therp 88 DISEASES OF THE SKIN. is often a hereditary tendency, and the gouty and rheumatic diathe- sis must occasionally be considered potential. In some instances it is apparently influenced by the state of the general health. It is a rather common disease and is met with in all walks of life. Fig. 14. Vertical section of skin from a patch of psoriasis of long standing. (After Jamieson.) MP, Malpighian (rete mucosum) prolongation ; C, corium; L, leucocytes. Is psoriasis contagious ? No. What is the pathology ? According to modern investigations, it is an inflammation induced by hyperplasia of the rete mucosum. With what diseases are you likely to confound psoriasis ? Chiefly with squamous eczema and the papulosquamous syphilo- derm; and on the scalp, also with seborrhoea. It can scarcely be confounded with ringworm. INFLAMMATIONS. 89 How is psoriasis to be distinguished from squamous eczema ? By the sharply-defined, circumscribed, scattered, scaly patches, and by the history and course of the individual lesions. In what respects does the papulo-squamous syphiloderm dif- fer from psoriasis ? The scales of the squamous syphilide are usually dirty gray in color and more or less scanty; the patches are coppery in hue, and usually several or more characteristic scaleless, infiltrated papules arc to be found. The face, palms, and soles are often the seat of the syph- ilitic eruption; and, moreover, concomitant symptoms of syphilis, such as sore throat, mucous patches, glandular enlargement, rheu- matic pains, falling out of the hair, together with the history of the initial lesion, are one, several, or all usually present. How does seborrhoea of the scalp differ from psoriasis ? Seborrhoea is usually diffused, with no redness and infiltration; moreover, the scales of seborrhoea are greasy, dirty gray or brown- ish, while those of psoriasis are dry and commonly whitish or mother- of-pearl colored. Psoriasis of the scalp rarely exists independently of other patches elsewhere on the general surface. How does psoriasis differ from ringworm ? By its greater scaliness, by its higher degree of inflammatory action, and by its larger number of patches, as also by its history. In ringworm all the patches tend to clear up in the centre; in psoriasis this is rarely, if ever, so. If there is still any doubt, microscopic examination of the scrapings will determine. Give the prognosis of psoriasis. The prognosis is usually favorable, so far as concerns the immedi- ate eruption, but as to recurrences, nothing positive can be stated. In some instances, however, the cure remains permanent. How is psoriasis treated ? Both constitutional and local remedies are demanded in most cases. Do dietary measures exert any influence ? As a rale, no ; but the food should be plain, and an excess of meat avoided. 90 DISEASES OF THE SKIN. Name the important constitutional remedies usually em- ployed in psoriasis. Arsenic is of first importance. It is not suitable in acute or markedly inflammatory types ; but is most useful in the sluggish, chronic forms of the disease. The dose should never be pushed beyond slight physiological action. It may be given as arsenious acid in pill form, one-fiftieth to one-tenth of a grain three times daily, or as Fowler's solution, three to ten minims at a dose. Alkalies, of which liquor potassae is the most eligible. It is to be given in ten to twenty minim doses, largely diluted. It is valuable in robust, plethoric, rheumatic or gouty individuals with psoriasis of an acute or markedly inflammatory type; it is not to be given to debilitated or anaemic subjects. Potassium Iodide, in doses of ten to sixty grains, t. d., acts favor- ably in some instances ; there are no special indications pointing toward its selection, unless it be the existence of a gouty or rheu- matic diathesis. Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper, and other diuretics are valuable in some instances, and, while often failing, sometimes exert a rapid influence, especially in those cases in which the disease is extensive and inflammatory. Wine of anti- mony, given cautiously, is also sometimes of service in the acute inflammatory type in robust subjects. Sodium salicylate, salicin, and salophen in moderately full doses act well in some cases. Occasionally thyroid preparations have a good effect. Are such remedies as iron, quinine, nux vomica and cod-liver oil ever useful in psoriasis ? Yes. In debilitated subjects the administration of such remedies is at times attended with improvement in the cutaneous eruption. What are the indications as regards the external measures ? Removal of the scales, and the use of soothing or stimulating applications, according to the individual case. How are the scales removed ? In ordinary cases, either by warm, plain, or alkaline baths, or hot- water-and-soap washings; in those cases in which the scaling is INFLAMMATIONS. 91 abundant and adherent, washing with sapo viridis and hot water may be required. Baths of sal ammoniac, two to six ounces to the bath are also valuable in removing the scaliness. The tincture of green soap (tinctura saponis viridis) is especially valuable for cleans- ing purposes in psoriasis of the scalp. The hot vapor bath once or twice weekly is serviceable in keeping the scaliness in abeyance, and has, moreover, in some cases, a therapeutic value. The frequency of the baths or washings will depend upon the rapidity with which the scales are reproduced. Are soothing applications often demanded in psoriasis ? In exceptional cases ; in those in which the disease is acute, markedly inflammatory and rapidly progressing, mild, soothing appli- cations must be temporarily employed, such as plain or bran baths, with the use of some bland oil or ointment. As a rule, however, the conditions, when coming under observation, are such as to permit of stimulating applications from the start. How are the stimulating remedies employed in psoriasis applied ? As ointments, oils, and paints (pigmenta). An ointment, if employed, is to be thoroughly rubbed in the dis- eased areas once or twice daily. The same may be said of the oily applications. The paints (medicated collodion and gutta-percha solution) are applied with a brush, once daily, or every second or third day, depending mainly upon the length of'time the film remains intact and adherent. Name the several important external remedies. Chrysarobin, pyrogallic acid, tar, ammoniated mercury, /3-naphthol and resorcin. Are these several external remedies equally serviceable in all cases ? No. Their action differs slightly or greatly according to the case and individual. A change from one to another is often necessary. In what forms and strength are these remedies to be applied? Chrysarobin is applied in several ways: as an ointment, twenty to sixty grains to the ounce, rubbed in once or twice daily ; this is 92 DISEASES OF THE SKIN. the most rapid but least cleanly and eligible method. As a pigment, or paint, as in the following :— R. Chrysarobini,............3 j Acidi sal icylici,...........gr. xx Etheris,..............fgj 01. ricini, .............rr^x Collodii,..............f^vij. M. Or it may be used in liquor gutta-perchae (traumaticin), a drachm to the ounce. It may also be employed in chloroform, a drachm to the ounce; this is painted on, the chloroform evaporating, leaving a thin film of chrysarobin; over this is painted flexible collodion. If the patches are few and large, chrysarobin rubber-plaster may be used. Chrysarobin is usually rapid in its effect, but it has certain disad- vantages ; it may cause an inflammation of the surrounding skin, and, if used near the eyes, may give rise to conjunctivitis. As a rule, it should not be employed about the head. Moreover, it stains the linen permanently and the skin temporarily. Pyrogallic acid is also valuable, and is employed in the same manner and strength as chrysarobin. It is less rapid than that remedy, but it rarely inflames the surrounding integument. It stains the linen a light brown, however, and is not to be used over an extensive surface for fear of absorption and toxic effect, Oxi- dized pyrogallic acid, a somewhat milder drug in its effect, has been highly commended, and has the alleged advantage of being free from toxic action. Tar is, all things considered, the most important external remedy. It is comparatively slow in its action, but is useful in almost all cases. As employed usually it is prescribed in ointment form, either as the official tar ointment, full strength or weakened with lard or petrolatum. It may also be used as pix liquida, with equal part of alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch (ol. rusci) maybe employed, either as oily applications or incorporated with ointment or with alcohol. Liquor carbonis detergens, in oint- ment, one to three drachms to the ounce of simple cerate and lanolin is a mild tarry application which is often useful. In stub- born patches an occasional thorough rubbing with a mixture of equal parts of liquor carbonis detergens and Yleminckx's solution, INFLAMMATIONS. 93 followed by a mild ointment, sometimes proves of value. In what- soever form tar is employed it should be thoroughly rubbed in, once or twice daily, the excess wiped off, and the parts then dusted with starch or similar powder. Ammoniated mercury \$ applied in ointment form, twenty to sixty grains to the ounce. Compared to other remedies it is clean and free from staining, although, as a rule, not so uuiformly efficacious. It is especially useful for application to the scalp and exposed parts. ft-Naphthol and resorcin are applied as ointments, thirty to sixty grains to the ounce, and as they are (especially the former) practi- cally free from staining, may be used for exposed surfaces. (Jallacetophenonc and aristol also act well in some cases, applied in five- to ten-per-cent, strength, as ointments. Pityriasis Rosea. (Synonym : Pityriasis Maculata et Circinata.) What do you understand by pityriasis rosea ? Pityriasis rosea is a disease of a mildly inflammatory nature, char- acterized by discrete or confluent, pinkish or rosy-red, variously- sized, slightly raised scaly macules. Upon what part of the body is the eruption usually found ? The trunk is the chief seat of the eruption, although not infre- quently it is more or less general. Describe the symptoms of pityriasis rosea. The lesions, which appear rapidly or slowly, are but slightly elevated, somewhat scaly, usually rounded, except when several co- alesce, when an irregularly outlined patch results. At first they are pale or bright pink or reddish, later a salmon tint (which is often characteristic) is noticed. The scaliness is bran-like or flaky, of a dirty gray color, and, as a rule, less marked in the central portion ; it is never abundant. The skin is rarely thickened, the process being usually exceedingly superficial. What course does pityriasis rosea pursue ? The eruption makes its appearance, as a rule, somewhat rapidly, usually attaining its full development in the course of one or two weeks, and then begins gradually to decline, the whole .process occu- pying one or two months. 94 DISEASES OF THE SKIN. To what is pityriasis rosea to be attributed ? The cause is not known; it is variously considered as allied to seborrhoea (eczema seborrhoicum), as being of a vegetable-parasitic origin, and as a mildly inflammatory affection somewhat similar to psoriasis. It is not a frequent disease. How is pityriasis rosea distinguished from ringworm, psori- asis and the squamous syphiloderm ? From ringworm, by its rapid appearance, its distribution, the number of patches, and, if necessary, by microscopic examination of the scrapings. Psoriasis is a more inflammatory disease, is seen usually more abundantly upon the limbs, the scales are profuse and silvery, and the underlying skin is red and has a glazed look ; moreover, psoriasis, as a rule, appears slowly and runs a chronic course. The squamous syphiloderm differs in its history, distribution, and above all, by the presence of concomitant symptoms of syphilis, such as glandular enlargement, sore throat, mucous patches, rheumatic pains, and falling out of the hair. State the prognosis of pityriasis rosea. It is favorable, the disease tending to spontaneous disappearance, usually in the course of several weeks or one or two months. What treatment is to be advised in pityriasis rosea ? Treatment is rarely required. In severe cases, simple ointments or ointments containing a half to one drachm of precipitated sulphur to the ounce of lard or petrolatum may be used. Saline laxatives, and, if indicated, quinine and tonics, may also be prescribed. Dermatitis Exfoliativa. (Synonyms: General Exfoliative Dermatitis; Recurrent Exfoliative Derma- titis; Desquamative Scarlatiniform Erythema; Acute General Derma- titis; Recurrent Exfoliative Erythema; Pityriasis Rubra.) Describe dermatitis exfoliativa. Dermatitis exfoliativa is an inflammatory disease of an acute type, characterized by a more or less general erythematous inflammation, in exceptional instances vesicular or bullous, with epidermic desqua- INFLAMMATIONS. 90 mation or exfoliation accompanying or following its development. Constitutional disturbance, which may be of a serious character, is usually present. It is a rare and obscure affection, running its course usually in several weeks or months, but exhibiting a decided tendency to relapse and recurrence. In some instances it develops from a long-continued and more or less generalized eczema or psoriasis. In another type of the disease, formerly described as pityriasis rubra, the skin is pale red or violaceous-red, but is rarely thickened, continued exfoliation in the form of thin plates taking place. Its course is variable, lasting for years, with remissions. An exfoliating generalized dermatitis is exceptionally observed in the first weeks of life (dermatitis exfoliativa neonatorum), lasting some weeks, and in most cases followed by recovery. There are no special constitutional symptoms, the fatal cases usually dying of marasmus. Give the treatment of dermatitis exfoliativa. General treatment is based upon indications, and externally sooth- ing applications, such as are employed in acute and subacute eczema, are to be used. Pityriasis Rubra Pilaris. Describe pityriasis rubra pilaris. Pityriasis rubra pilaris is an extremely rare disease, usually of a mildly inflammatory nature, characterized by grayish, pale red or reddish-brown follicular papules with somewhat hard or horny centres; discrete and confluent, and covering a part or the entire surface. The skin is harsh, dry and rough, feeling to the touch somewhat like the surface of a nutmeg-grater or a coarse file. More or less scaliness is usually present in the confluent patches and on the palms and soles; in these latter regions the papules are rarely seen. The duration of the disease is variable, and relapses are common. Tt bears resemblance at times to keratosis pilaris, ichthy- osis, dermatitis exfoliativa, and lichen ruber acuminatum; it is indeed considered by many as identical with the last-named disease. The etiology is obscure. 06 DISEASES OF THE SKIN. Treatment, both constitutional and local, is to be 1 ased upon general principles; stimulating applications, with frequent balhs, such as are advised in psoriasis, arc the most satisfactory. Lichen Ruber. What is 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 or violaceous-red papules, having a distinctly papular or papulosquamous course, and attended with more or less itching. What two varieties of lichen ruber are met with ? The acuminate (lichen ruber acuminatus, lichen ruber) and the plane (lichen ruber planus, lichen planus). The former is ex- tremely rare; the latter, while not frequent, is not uncommon. The pathological identity of these varieties is at present questioned ; and it is believed by some observers that the lichen ruber acuminatus is identical with pityriasis ruber pilaris (q. v.). Describe the symptoms of lichen ruber acuminatus. The acuminate variety is characterized by the appearance of small, pin-point or pin-head, pointed or rounded, reddish, scaly, dis- seminated or closely-crowded, solid papules, showing no disposition to group; spreading rapidly, pursuing a chronic course, and attended with more or less serious involvement of the general health, with, sometimes, a fatal termination. Describe the symptoms of lichen ruber planus. The plane variety, as a rule, begins slowly, usually showing itself upon the extremities; the forearms, wrists and legs being favorite localities. It may appear as one or more groups or in the form of short or long bands. Occasionally its evolution is rapid, and a con- siderable part of the surface may be invaded. The lesions are pin- head to small pea-sized, irregularly grouped or so closely crowded together as to form solid patches; they are quadrangular or poly- gonal in shape, usually flat, with central depression or umbilication, and are reddish or violaceous in color. At first they have a glazed or shining appearance; later, becoming slightly scaly, the scaliness INFLAMMATIONS. 97 being more marked where solid patches have resulted. New papules may appear from time to time, the older lesions disappearing and leaving persistent reddish or brownish pigmentation. Exceptionally the eruption presents in bands or lines, like rows of beads (lichen moniliformis). There is, as a rule, considerable itching. There are no constitutional symptoms. What is the etiology of lichen ruber ? In some cases the disease is distinctly neurotic in character, in others no cause can be assigned. It is more especially met with at middle age. Does the disease bear any resemblance to the miliary papular syphilide, psoriasis, and papular eczema ? In some instances it does, but the irregular and angular outline, the slightly-umbilicated, flattened, smooth or scaly summits, and the dull-red or violaceous color, the history and course, of lichen ruber planus, will serve to differentiate. Lichen ruber acuminatus can scarcely be confounded, if its clinical appearances, history and course are kept in mind. State the prognosis. Under proper management both varieties, although often obstinate, yield to treatment. What treatment would you prescribe in lichen ruber ? A general tonic plan of medication is indicated in most cases, with such remedies as iron, quinine, nux vomica, and cod-liver oil and other nutrients. In many instances arsenic exerts a special influ- ence, and should always be tried. Mercurials in small or moderate dosage have a favorable action in some cases. Locally, antipruritic and stimulating applications, such as are used in the treatment of eczema, are to be employed, alkaline baths and tarry applications deserving special mention. In the plane variety, particularly if the disease is limited, external applications alone often suffice to bring about a cure. 7 98 DISEASES OF THE SKIN. Lichen Scrofulosus. Describe lichen scrofulosus. Lichen scrofulosus is a chronic, inflammatory disease, characterized by millet-seed-sized, rounded or flat, reddish or yeilowish, more or less grouped, desquamating papules. The lesions have their start about the hair-follicles, occur usually upon the trunk, tend to group and form patches, and sooner or later become covered with minute scales. As a rule, there is no itching. It is a rare disease, and but seldom met with in America; it is seen chiefly in children and young people of a scrofulous diathesis. Scarring, slight in character, may or may not follow. What is the treatment of lichen scrofulosus ? The condition responds to tonics and anti-strumous remedies. Eczema. (Synonym: Tetter; Salt Rheum.) What is eczema ? An acute, subacute or chronic inflammatory disease, characterized in the beginning by the appearance of erythema, papules, vesicles or pustules, or a combination of these lesions, with a variable amount of infiltration and thickening, terminating either in discharge with the formation of crusts, in absorption, or in desquamation, and accompanied by more or less intense itching and a feeling of heat or burning. What are the several primary types of eczema ? Erythematous, papular, vesicular and pustular ; all cases begin as one or more of these types, but not infrequently lose these charac- ters and develop into the common clinical or secondary types—eczema rabruni and eczema squamosum. What other types are met with clinically ? Eczema rubrum, eczema squamosum, eczema fissum, -eczema scle- rosum and eczema verrucosum. Eczema seborrhoicum is probably a closely allied disease, occupying a middle position between ordinary eczema and seborrhoea. INFLAMMATIONS. 99 Describe the symptoms of erythematous eczema. Erythematous eczema (eczema erythematoswm) begins as one or more small or large, irregularly outlined hyperaemic macules or patches, with or without slight or marked swelling, and with more or less itching or burning. At first it may be ill-defined, but it tends to spread and its features to become more pronounced. It may be limited to a certain region, or it may be more or less general. When fully developed, the skin is harsh and dry, of a mottled, red- dish or violaceous color, thickened, infiltrated and usually slightly scaly, with, at times, a tendency toward the formation of oozing areas. Punctate and linear scratch-marks may usually be seen scat- tered over the affected region. Its most common site is the face, but it is not infrequent upon other parts. What course does erythematous eczema pursue ? It tends to chronicity, continuing as the erythematous form, or the skin may become considerably thickened and markedly scaly, constituting eczema squamosum; or a moist oozing surface, with more or less crusting, may take its place—eczema rubruni. Describe the symptoms of papular eczema. Papular eczema (eczema papillosum) is characterized by the ap- pearance, usually in numbers, of discrete, aggregated or closely- crowded, reddish, pin-head-sized acuminated 6r rounded papules. Yesicles and vesico-papules are often intermingled. The itching is commonly intense, as often attested by the presence of scratch- marks and blood crusts. It is seen most frequently upon the extremities, especially the flexor surfaces. What course does papular eczema pursue ? The lesions tend, sooner or later, to disappear, but are usually re- placed by others, the disease thus persisting for weeks or months; in places where closely crowded, a solid, thickened, scaly sheet of eruption may result—eczema squamosum. Describe the symptoms of vesicular eczema. A'esicular eczema (eczema vesiculosum) usually appears, on one or several regions, as more or less diffused inflammatory red- 100 DISEASES OF THE SKIN. dened patches, upon which rapidly develop numerous closely- crowded pin-point to pin-head-sized vesicles, which tend to become confluent and form a solid sheet of eruption. The vesicles soon mature and rupture, the discharge drying to yellowish, honeycomb- like crusts. The oozing is usually more or less continuous, or the disease may decline, the crusts be cast off, to be quickly followed by a new crop of vesicles. In those cases in which the process is markedly acute, considerable swelling and oedema are present. Scattered papules, vesico-papules and pustules may usually be seen upon the involved area or about the border. The face in infants (crusta lactea, or milk crust, of older writers), the neck, flexor surfaces and the fingers are its favorite localities. What course does vesicular eczema pursue ? Usually chronic, with acute exacerbations. Not infrequently it passes into eczema rubrum. Describe the symptoms of pustular eczema. Pustular eczema (eczema pustulosum, eczema impetiginosum) is probably the least common of all the varieties. It is similar, although usually less actively inflammatory, in its symptoms to eczema vesiculosum, the lesions being pustular from the start or developing from preexisting vesicles; not infrequently the eruption is mixed, the pustules predominating. There is a marked tendency to rup- turing of the lesions, the discharge drying to thick, yellowish, brown- ish or greenish crusts. Its most common sites are the scalp and face, especially in young people and in those who are ill-nourished and strumous. What course does pustular eczema pursue ? Usually chronic, continuing as the same type, or passing into eczema rubrum. Describe the symptoms of squamous eczema. Squamous eczema (eczema squamosum) may be defined as a clinical variety, the chief symptoms of which are a variable degree of scaliness, more or less thickening, infiltration and redness, with commonly a tendency to cracking or fissuring of the skin, especially when the disease is seated about the joints. It is developed, as a INFLAMMATIONS. 101 rule, from the erythematous or papular type. Itching is slight or intense. The disease is not uncommon upon the scalp. What is the course of squamous eczema ? Essentially chronic. Describe the symptoms of eczema rubrum. Eczema rubrum is characterized by a red, raw-looking, weeping, oozing or discharging surface, attended with more or less inflamma- FlG. 15. Eczema of the Face and Scalp. (After Piffard.) tory thickening, infiltration and swelling; the exudation, consisting of scram, sometimes bloody, dries into thick yellowish or reddish- brown crasts. At one time the whole diseased area may be hidden under a mass of crusting, at other times a red, raw-looking, weeping surface (eczema madidans) is the most striking feature. Itching is slight or intense, or the subjective symptom may be a feeling of 102 DISEASES OF THE SKIN. burning. It is an important clinical type, usually developing from the vesicular, pustular or other primary variety. It is common about the face and scalp in children, and the middle and lower part of the leg in elderly people. What is the course of eczema rubrum? Chronic, varying in intensity from time to time. Describe the symptoms of fissured eczema. The conspicuous symptom is a marked tendency to fissuring or cracking of the skin (eczema fissum; eczema rimosum). This ten- dency is usually a part of an erythematous or squamous eczema, the fissuring constituting the most conspicuous and troublesome symptom. Chapping is an extremely mild but familiar example of this type. It is especially common about the hands and fingers. What is the course of fissured eczema ? It is more or less persistent, the tendency to fissuring varying con- siderably according to the state of the weather, often disappearing spontaneously i*2ftfe. summer months. Describe eczemani™rosum and eczema verrucosum. In eczema sclerosuni^|^kin is thickened, infiltrated, hard, and almost horny. Eczema vernW||um presents similar conditions, but, in addition, displays a tendency to papillary or wart-like hyper- trophy. In both varieties the disease is usually seated about the ankle or the foot, developing from the papular or squamous type. They are uncommon, and obstinately chronic. What do you understand by eczema seborrhoicum ? A cutaneous inflammation of both seborrheic and eczematous aspects, for which a parasitic cause has been assumed. As yet, howeyer, the propriety or advisability of its recognition as a distinct disease is not generally admitted. The group of cases constituting this class is made up of many of the cases heretofore considered as examples of seborrhoea, of psori- asis, and of eczema; more especially those cases of seborrhoea in which there is an inflammatory element, and those cases of eczema of a greasy, scaly, or crusted character. Those rare examples of INFLAMMATIONS. 103 eczema occurring in rather sharply defined, rounded, and circum- scribed patches or areas have also been included in this group; these cases are sometimes spoken of as " parasitic eczema." State the nature of the subjective symptoms in eczema. Itching, commonly intense, is usually a conspicuous symptom ; it may be more or less paroxysmal. In some cases burning and heat constitute the main subjective phenomena. Is eczema accompanied by febrile or systemic symptoms ? No. In rare instances, in acute universal eczema, slight febrile action, or other systemic disturbance, may be noted at the time of the outbreak. Is the eczematous eruption (patch or patches) sharply denned against the neighboring sound skin ? No. In almost all instances the diseased area merges gradually and imperceptibly into the surrounding healthy integument. What is the character of eczema as regards the degree of inflammatory action? The inflammatory action may be acute, subacute or sluggish in character, and may be so from the start and so continue throughout its whole course ; or it may, as is usually the case, vary in intensity from time to time. State the character of eczema as regards duration. As a rule, it is a persistent disease, showing little, if any, tendency to spontaneous disappearance. Is eczema influenced by the seasons ? Yes. With comparatively few exceptions the disease is most com- mon and much worse in cold, windy, winter weather. To what may eczema be ascribed ? Eczema may be due to constitutional or local causes, or to both. Name some of the important constitutional or predisposing causes. Gouty diathesis, rheumatic diathesis, disorders of the digestive tract, general debility or lack of tone, an exhausted state of the nerv- ous system, dentition and struma. 104 DISEASES OF THE SKIN. Is a constitutional cause sufficient to provoke an attack ?" Yes; but often the attack is brought about in those so predis- posed by some local or external irritant. Mention some of the external causes. Heat and cold, sharp, biting winds, excessive use of water, strong soaps, vaccination, dyes and dyestuffs, chemical irritants, and the Fig. 16. Vertical section of a recent vesicle of eczema. (Af/e>- Robinson.) a, Corneous layer; b, rete mucosum ; c, corium ; d, vesicle ; e, dilated bloodvessels. like. There is a growing belief that some cases presenting eczemat- ous aspects are probably parasitic in origin. Contact with the rhus plants, while producing a peculiar dermatitis, usually running an acute course terminating in recovery, may, in those predisposed, provoke a veritable and persistent eczema. Is eczema contagious ? No. The acceptance of a parasitic cause for the disease, however. necessarily carries with it the possibility of contagiousness. What is the pathology ? The process is an inflammatory one, characterized in all cases by hypememia and exudation, varying in degree according to the INFLAMMATIONS. 105 intensity and duration of the disease. The rete and papillary layer are especially involved, although in severe and chronic cases the lower part of the corium and even the subcutaneous tissue may share in the process. Fig. 17. Chronic eczema—vertical section of the skin of the forearm. (After Kaposi.) a, Epidermis; 6, thickened rete; c, hyper-pigraented layer of rete; d, enlarged papillae; e, atrophied sebaceous gland; /, atrophied hair-follicle; g, infiltrated corium. Do the cutaneous manifestations of the eruptive fevers bear resemblance to the erythematous type of eczema ? Scarlatina and erysipelas may, to a slight extent, but the presence or absence of febrile and other constitutional symptoms will usually serve to differentiate. What common skin diseases resemble some phases of eczema ? Psoriasis, seborrhoea, sycosis, scabies and ringworm. How would you exclude psoriasis in a suspected case of ec- zema (squamous eczema) ? Psoriasis occurs in variously-sized, rounded, sharply-defined 106 DISEASES OF THE SKIN. patches, usually scattered irregularly over the general surface, with special predilection for the elbows and knees. They are covered more or less abundantly with whitish, silvery or mother-of-pearl col- ored imbricated scales. The patches are always dry, and itching is, as a rule, slight, or may be entirely absent. Eczema, on the con- trary, is often localized, appearing as one or more large, irregularly diffused patches ; it merges imperceptibly into the sound skin, and there is often a history of characteristic serous or gummy oozing; the scaling is usually slight and itching almost invariably a promi- nent symptom. How would you exclude seborrhoea in a suspected case of eczema ? Seborrhoea of the scalp (in which locality it may resemble eczema) is commonly over the whole of that region and is free from inflamma- tory symptoms ; the scales are of a greasy character and the itching is usually slight or nil. On the other hand, in eczema of this region the parts are rarely invaded in their entirety ; there may be at times the characteristic serous or gummy oozing ; inflammatory symptoms are usually well-marked, the scales are dry and the itch- ing is, as a rule, a prominent symptom. How does scabies differ from eczema ? Scabies differs from eczema in its peculiar distribution, the pre- sence of the burrows, the absence of any tendency to patch for- mation, and usually by a clear history of contagion. How would you exclude ringworm in a suspected case of eczema ? Kingworm is to be distinguished by its circular form, its fading in the centre, and in doubtful cases by microscopic examination of the scrapings. How does eczema differ from sycosis ? Sycosis is limited to the hairy region of the face, is distinctly a follicular inflammation, and is rarely very itchy ; eczema is diffused, usually involves other parts of the face, and itching is an annoying symptom. State the general prognosis of eczema. The disease is, under favorable circumstances, curable, some cases INFLAMMATIONS. 107 yielding more or less readily, others proving exceedingly rebellious. The length of time to bring about a result is always uncertain, and an opinion on this point should be guarded. Upon what would you base your prognosis in the individual case? The extent of disease, its duration and previous behavior, the removability of the exciting and predisposing causes, and the atten- tion the patient can give to the treatment. In eczema involving the lips, face, scrotum, and leg, and especially when this last-named exhibits a varicose condition of the veins, a cure is effected, as a rale, only through persistent and prolonged treatment. Does eczema ever leave scars ? No. Upon the legs, in long-continued cases, more or less pigmen- tation usually remains. How is eczema treated ? As a rale, eczema requires for its removal both constitutional and external treatment. Certain cases, however, seem to be entirely local in their nature, or the predisposing factors may have disappeared and the disease persist, as it were, from force of habit. Such instances are not uncommon, and in these cases external treatment alone will have satisfactory results. What general measures as to hygiene and diet are commonly advisable ? Fresh air, exercise, moderate indulgence in calisthenics, regular habits, a plain, nutritious diet; abstention from such articles of food as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese, pickles, condiments, excessive coffee or tea drinking, etc. As a rule, also, beer, wine, and other stimulants are to be interdicted. Upon what grounds is the line or plan of constitutional treat- ment to be based ? Upon indications in the individual case. A careful examination into the patient's general health will usually give the cue to the line of treatment to be adopted. 108 DISEASES OF THE SKIN. Mention the important remedies variously employed in the constitutional treatment. Tonics—such as cod-liver oil, quinine, nux vomica, the vegetable bitters, iron, arsenic, malt, etc. Alkalies—sodium salicylate, potassium bicarbonate, liquor po- tassae, and lithium carbonate. Alteratives—calomel, colchicum, arsenic, and potassium iodide. Diuretics—potassium acetate, potassium citrate, and oil of copaiba. Laxatives—the various salines, aperient spring waters, castor oil, cascara sagrada, aloes and other vegetable cathartics. Digestives—pepsin, pancreatin, muriatic acid and the various bitter tonics. Are there any remedies which have a specific influence ? No; although arsenic, in exceptional instances, seems to exert a special action. Cod-liver oil is also of great value in some cases. In what class of cases does arsenic often prove of service ? In the sluggish, dry, erythematous, scaly and papular types. In what cases is arsenic usually contraindicated ? It should never be employed in acute cases ; nor in any instance (unless its action is watched), in which the degree of inflammatory action is marked, as an aggravation of the disease usually results. What should be the character of the external treatment ? It depends mainly upon the degree of inflammatory action; but the stage of the disease, the extent involved, and the ability of the patient to carry out the details of treatment, also have a bearing upon the selection of the plan to be advised. What is to be said about the use of soap and water in eczema ? In acute and subacute conditions soap and water are to be em- ployed, as a rule, as infrequently and as sparingly as possible, as the disease is often aggravated by their too free use. Washing is necessary, however, for cleanliness and occasionally, also, for the removal of the crusts. On the other hand, in chronic, sluggish types the use of soap and water frequently has a therapeutic value. INFLAMMATIONS. 109 How often should remedial applications be made ? Usually twice daily, although in some cases, and especially those of an acute type, applications should be made every few hours. Mention several remedies or plans of treatment to be used in the acute or actively inflammatory cases. Black wash and oxide-of-zinc ointment conjointly, the wash being thoroughly dabbed on, allowed to dry, and the parts then gently smeared with the ointment; or the ointment may be applied spread on lint as a plaster. Boric-acid wash (15 grains to the ounce) and oxide-of-zinc oint- ment, applied in the same manner as the above. A. lotion containing calamine and zinc oxide, the sediment drying and coating over the affected surface :— R. Calaminae, Zinci oxidi,......aa......3 ij- 3 iij Glycerinae, Alcobolis, ......aa...... f^j Liq. calcis,.............f^ij Aquae,......q. s. ad.....f^vj- M- Carbolic-acid lotion, about two drachms to the pint of water, to which may be added two or three drachms each of glycerin and alcohol; or, if there is intense itching, carbolic acid may be added to the several washes already mentioned. A lotion made of one or two drachms of liquor carbonis detergens * to four ounces of water. The following wash, especially in the dry form of the disease :— R. Ac. borici,.............giv Ac. carbolici,............jj Glycerinae,.............3 ij Alcobolis, .............3 ij Aquie,......q. s. ad.....Oj. M. Dusting-powders, of starch, zinc oxide and Venetian talc, alone or * Liquor carbonis detergens is made by mixing togetber nine ounces of tincture of soap bark and four ounces of coal tar, allowing to digest for eight days, and filtering. 110 DISEASES OF THE SKIN. severally combined, applied freely and often, so as to afford protec- tion to the inflamed surface :— R. Talci venet, Zinci oxidi, Amyli, . . If washes or dusting-powders should disagree or are not desirable or practicable, ointments may be employed, such as— Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbo- lated, diachylon ointment (if fresh and well prepared), and a paste- like ointment, as the following, usually called " salicylic-acid paste "; in markedly itchy cases, five to fifteen grains of carbolic may be added to each ounce: R. Ac. salicylic!,............gr. v-x Pulv. amyli, Pulv. zinci oxidi, . . . . aa.....3 ij Petrolati, .............^iv M. Or the following ointment:— R. Calaminae,.............3j Ungt. zinci oxidi,..........3vij. M. Name several external remedies and combinations useful in eczema of a subacute or mildly inflammatory type. The various remedies and combinations useful when the symptoms are acute or markedly inflammatory (mentioned above), and more especially the several following :— R. Zinci oxidi,............zij Liq. plumbi subacetat. dilut., . . . . fgvj Glycerinse,...... ......f^ij Infus. picis liq.,..........f^iij M. A lotion containing resorcin, five to thirty grains to the ounce. Solution of zinc sulphate, one-half to three grains to the ounce. An ointment containing calomel or ammoniated mercury, as in the annexed formula :— 3iv M. INFLAMMATIONS. Ill R. Hydrargyri ammoniat. sen Hydrargyri chloridi mit.,...........gr. x-xxx Ac. carbolici,............gr. v-x Ungt. zinci oxidi,..........^j. M. Another formula, more especially useful in eczema of the hands and legs, is the following :— R. Ac. salicylici,............gr. xxx Emp. plumbi, Emp. saponis, Petrolati,......aa.......gj. M. (This is to be applied as a plaster, spread on strips of lint, and changed every twelve or twenty-four hours.) The paste-like ointment, referred to as useful in acute eczema, may also be used with a larger proportion (20 to 60 grains to the ounce) of salicylic acid. Painting on twice daily a saturated solution of picric acid for three or four days, and then allowing pellicle thus formed to come off; or an emollient may be applied and exfoliation hastened. This treatment is useful in some cases; it should not be applied to ex- tensive areas for fear of absorption. The following, containing tar, may often be employed with advan- tage :— R. Ungt. picis liq.,...........3j Ungt. zinci oxidi,...........^vij- M. What is to be said in regard to the use of tarry applications ? Ointments or lotions containing tar should always be tried at first upon a limited surface, as occasionally skins are met with upon which this remedy acts as a more or less violent irritant. The coal tar lotion (liquor carbonis detergens) is the least likely to disagree and may be used as a mild ointment, one or two drachms to the ounce, or it may be diluted and used as a weak lotion as already referred to. What external remedies are to be employed in eczema of a sluggish type ? The various remedies and combinations (mentioned above) useful 112 DISEASES OF THE SKIN. in acute and subacute eczema may often be employed with benefit, but, as a rule, stronger applications are necessary, especially in the thick and leathery patches. The following are the most valuable :— An ointment of calomel or ammoniated mercury ; forty to sixty grains to the ounce. Strong salicylic-acid ointment; a half to one drachm of salicylic acid to the ounce of lard. Tar ointment, official strength; or the various tar oils, alone or with alcohol, as a lotion, or in ointment form. Liquor picis alkalinus * is a valuable remedy in chronic thickened, hard and verrucous patches, but is a strong preparation and must be used with caution. It is applied diluted, one part with from eight to thirty-two parts of water ; or in ointment, one or two drachms to the ounce. In such cases, also, the following is useful:— R. Saponis viridis, Picis liq., Alcobolis,....., aa......^iij. M. SlG. To be well rubbed in. In similar cases, also, the parts may be thoroughly washed or scrubbed with sapo viridis and hot water until somewhat tender, rinsed off, dried, and a mild ointment applied as a plaster. Lactic acid, applied with one to ten or more parts of water is also of value in the sclerous and verrucous types. Caustic potash solu- tions, used cautiously, may also be occasionally employed to advan- tage in these cases. Is there any method of treating eczema with fixed dressings ? Several plans have been advised from time to time; some are costly, and some require too great attention to details, and arc therefore impracticable for general employment. The following are those in more common use :— The gelatin dressing, as originally ordered, is made by melting over *R. Potassae,..............gj Picis liq.,.............3 ij Aquae,...............3 v. Dissolve the potash in the water, and gradually add to tbe tar in a mortar, with thorough stirring. INFLAMMATIONS. 113 a water-bath one part of gelatin in two parts of water—quickly paint- ing it over the diseased area; it dries rapidly, and to prevent crack- ing glycerine is brushed over the surface. Or the glycerine may be incorporated with the gelatin and water in the following propor- tion: glycerine, one part; gelatin, four parts, and water eight parts. Medicinal substances may be incorporated with the gelatin mixture. A goo 1 formula is the following:— R. Gelatin..............3j Zinci oxidi, ............5 as Glycerini,..............^ iss Aquae,...............gii-^iij. This should be prepared over a water-bath, and two per cent. ichthyol added. A thin gauze bandage can be applied to the parts over which this dressing is painted, before it is completely dry; it makes a comfortable fixed dressing and may remain on several days. Plaster-mull and gutta-percha plaster. The plaster-mull, con- sisting of muslin incorporated with a layer of stiff ointment, and the gutta-percha plaster, consisting of muslin faced with a thin layer of India-rubber, the medication being spread upon the rubber coating. Rubber plasters. These are medicated with the various drugs used in the external treatment of skin diseases, and are often of great service. Two new excipients for fixed dressings have recently been intro- duced—bassorin and plasment ; the former is made from gum trag- acanth, and the latter from Irish moss. The following is a satisfactory formula for a tragaeanth dressing: R. Tragaeanth,............ gr. lxxv Glycerini,.............rr^xxx Ac. carbolici, ...........gr. x-xx Zinci oxidi,..........3 iss-3 iiss.—M. This is painted over the parts and allowed to dry, and a mild dust- ing powder sprinkled over. It cannot be usel in warm weather or in folds, as it is apt to get sticky. The following is a bassorin paste which may be variously medicated. 114 DISEASES OP THE SKIN. R. Bassorin,..............3 x Dextrin,..............3 vj Glycerini,.............3 ij Aquae,............q. s. ad. g iij. It should be prepared cold. Another "drying dressing" which may be used in cool weather is: R. Zinci oxidi,............§"j Glycerini,............% ss Mucilag. acaeise,..........3 ii- 3 iv. It may be variously medicated. The plaster-mull is used in all types, especially the acute ; the gel- atin dressing, and the gutta-percha plaster, in the subacute and chronic; and the rubber plaster in chronic, sluggish patches only. Acacia, tragaeanth, bassorin and plasment applications are used in cases of a subacute and chronic character. Prurigo. Define prurigo. Prurigo is a chronic, inflammatory disease, characterized by dis- crete, pin-head- to small pea-sized, solid, firmly-seated, slightly raised, pale-red papules, accompanied by itching and more or less general thickening of the affected skin. Describe the symptoms and course of prurigo. The disease first appears upon the tibial regions, and its earliest manifestation may be urticarial, but there soon develop the char- acteristic small, millet-seed-sized, or larger, firm elevations, which may be of the natural color of the skin or of a pinkish tinge. The lesions, whilst discrete, are in great numbers, and closely crowded. The overlying skin is dry, rough and harsh ; itching is intense, and, as a result of the scratching, excoriations and blood crusts are com- monly present. In consequence of the irritation, the inguinal glands are enlarged. Sooner or later the integument becomes considerably thickened, hard and rough. Eczematous symptoms may be super- added. In severe cases the entire extensor surfaces of the legs and arms, and in some instances the trunk also, are invaded. It is worse in the winter season. INFLAMMATIONS. 115 What is known in regard to etiology and pathology ? It is a disease of the ill-fed and neglected, usually developing in early childhood, and persisting throughout life. It is extremely rare, even in its milder types, in this country. Clinically and pathologi- cally it bears some resemblance to papular eczema. Give the prognosis and treatment of prurigo. The disease, in its severer types is, as a rule, incurable, but much can be done to alleviate the condition. Good, nourishing food, pure air and exercise are of importance. Tonics and cod-liver oil are usually beneficial. The local management is similar to that employed in chronic eczema. An ointment of /3-naphthol, one-half to five per cent, strength, is highly extolled. Acne. Give a definition of acne. Acne is an inflammatory, usually chronic, disease of the sebaceous glands, characterized by papules, tubercles, or pustules, or a mixture of these lesions, and seated usually about the face. At what age does acne usually occur ? Between the ages of fifteen and thirty, at which time the glandu- lar structures are naturally more or less active. Describe the symptoms of acne. Irregularly scattered ovei the face, and in some cases also over the neck, shoulders and upper part of the trunk, are to be seen several, fifty or more, pin-head- to pea-sized papules, tubercles or pustules ; commonly the eruption is of a mixed type (acne vulgaris), the several kinds of lesions in all stages of evolution and subsidence presenting in the single case. Interspersed may generally be seen blackheads, or comedones. The lesions may be sluggish in character, or they may be markedly inflammatory, with hard and indurated bases. In the course of several days or weeks, the papules and tubercles tend gradually to disappear by absorption; or, and as commonly the case, they become pustular, discharge their contents, or dry and slowly or rapidly disappear, with or without leaving a permanent trace, new lesions arising, here and there, to take their place. In excep- tional instances the eruption is limited to the back, and in these 116 DISEASES OF THE SKIN. cases the eruption is usually extensive and persistent, and not infre- quently leaves scars. Acne varioliformis is a term applied to an eruption of scattered or grouped pea- to bean-sized, reddish or reddish brown firm pap- ules, becoming capped with a pustule at their. apices, running a sluggish course, and leaving variola-like sears. The lesions are usually seen on upper part of forehead, and on the scalp. The disease is chronic, and entirely distinct, apparently, from ordinary acne. What do you understand by acne punctata, acne papulosa, acne pustulosa, acne indurata, acne atrophica, acne hypertrophica, and acne cachecticorum ? These several terms indicate that the lesions present are, for the most part, of one particular character or variety. Describe the lesions giving rise to the names of these various types. Blocking up of the outlet of the sebaceous gland (comedo), which is usually the beginning of an acne lesion, may cause a moderate degree of hyperaemia and inflammation, and a slight elevation, with a cen- tral yellowish or blackish point results—the lesion of acne punctata; if the inflammation is of a higher grade or progresses, the elevation is reddened and more prominent—acne papulosa; if the inflamma- tory action continues, the interior or central portion of the papule sup ■ purates and a pustule results—acne pustulosa; the pustule, in some cases, may have a markedly inflammatory and hard base—acne indu- rata; and not infrequently the lesions in disappearing may leave a pit-like atrophy or depression—acne atrophica ; or, on the contrary, connective-tissue new growth may follow their disappearance—acne hypertrophica ; and, in strumous or cachectic individuals, the lesions may be more or less furuncular in type, often of the nature of dermic abscesses, usually of a cold or sluggish character, and of more general distribution—acne cachecticorum. What is acne artificialis ? Acne artificialis is a term applied to an acne or acne-like eruption produced by the ingestion of certain drugs, as the bromides and iodides, and by the external use of tar; this is also called tar acne. INFLAMMATIONS. 117 What course does acne pursue ? Essentially chronic. The individual lesions usually run their course in several days or one or two weeks, but new lesions continue to ap- pear from time to time, and the disease thus persists, with more or less variation, for months or years. In many cases there is, toward the age of twenty-five or thirty, a tendency to spontaneous dis- appearance of the disease. Is the eruption in acne usually abundant ? It varies in different cases and at different periods in the same case. In some instances, not more than five or ten papules and pustules are present at one time ; in others they may be numerous. Not infrequently several lesions make their appearance, gradually run their course, and the face continues free for days or one or two weeks. Does the eruption in acne disappear without leaving a trace? In nifmy instances no permanent trace remains, but in others slight or conspicuous scarring is left to mark the site of the lesions. Are there any subjective symptoms in acne ? As a rale, not; but markedly inflammatory lesions are painful. State the immediate or direct cause of an acne lesion. Hypersecretion or retention of sebaceous matter. Name the indirect or predisposing causes of acne. Digestive disturbance, constipation, menstrual irregularities, chlo- rosis, general debility, lack of tone in the muscular til ties of the skin, scrofulosis; and medicinal sul istances such as the iodides and bromides internally, and tar externally. The introduction of a microorganism is alleged as a conjoint factor in some cases, especially the papulo- pustule and pustular varieties. AVorking in a dusty or dirty atmosphere is often influential, result- ing in a bfocking-up of the gland ducts. Workmen in paraffin oils orother petroleum products often present a furuncle-like acne. The disease is more common in individuals of light complexion. Is ttfere any difficulty in the diagnosis of acne ? Not if it be remembered that acne eruption is limited to certain parts and is alwavs follicular, and that the several stages, from the 118 DISEASES OF THE SKIN. comedo to the matured lesion, are usually to be seen in the individual case. In what respect does the pustular syphiloderm differ from acne? By its general distribution, the longer duration of the individual lesions, the darker color, and the presence of concomitant symptoms of syphilis. What is the pathology of acne ? Primarily, acne is a folliculitis, due to retention or decomposition of the sebaceous secretion; subsequently, the tissue immediately surrounding becoming involved, with the possible destruction of the sebaceous follicle as a result. The degree of inflammatory action determines the character of the lesions. State the prognosis of acne. It is usually an obstinate disease, but curable. Some cases yield readily, others are exceedingly rebellious, especially acne of the back. Success depends in a great measure upon a recognition and removal of the predisposing condition. Treatment is ordinarily a matter of months. What measures of treatment are usually demanded in aerie ? Constitutional and local measures; the former when indicated, the latter always. Upon what is the constitutional treatment based ? Upon indications. Diet and hygienic measures are important. In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin, saline and vegetable laxatives, are variously prescribed. Special mention may be made of the following :— R. Ext. rhamni pursh. fl., .......f3ij-f3iv Tinct. nucisvom.,..........f 3 iij Elix. calisayae,.....q.s. ad . . . f^iij. M. Sig.—f3j t. d. Or Hunyadi Janos or Friedrichshall water may be employed for a laxative purpose. In chlorotic and anaemic cases the ferruginous preparations are of INFLAMMATIONS. 119 advantage. Cod-liver oil is often a remedy of great value, and is especially useful in strumous and debilitated subjects. Calx sulphu- rata in pill form, one-tenth to one-fourth grain four or five times daily, occasionally acts well in the pustular variety. Ergot is also of benefit in a small proportion of cases—in those cases due to uterine disturbance or lack of tone in the muscular fibres of the skin. In some instances, more particularly in sluggish papular acne, arsenic, especially the sulphide of arsenic, acts favorably. In inflammatory cases occurring in robust individuals the follow- ing is often of service :— R. Potassii acetat.,...........3 iv Liq. potassae,............f3ij Liq. ammonii acetat., . . . q.s. ad . . f^iij. M. SiG.—f3j-f 3 ij t. d., largely diluted. State the character of the local treatment in acne. This must vary somewhat with the local conditions. Cases which are acute in character, in the sense that the lesions are markedly hyperaemic, tender and painful, require milder applications, and in exceptional instances soothing remedies are to be prescribed. As a rule, however, stimulating applications may be employed from the start. The remedies are, for obvious reasons, most conveniently applied at bedtime. Fig. 18. Fig. 19. Acne Lances. Guarded with a shoulder, and thus made safer for patient's own use. Fig. 18 folds up. What preliminary measures are to be advised in ordinary acne cases ? Washing the parts gently or vigorously, according to the irrita- 120 DISEASES OF THE SKIN. bility of the skin, with warm water and soap ; subsequently rinsing, and sponging for several minutes with hot water, and rubbing dry with a soft towel; after which the remedial application is made. In sluggish and non-irritable cases sapo viridis or its tincture may often be advantageously used in place of the ordinary toilet soap. The blackheads, so far as practicable, are to be removed by pres- sure with the fingers or with a suitable instrument (see Comedo), and the pustules punctured and the contents pressed out, Scraping the affected parts with a Hunt curette is a valuable measure, but is tem- porarily disfiguring. State the methods of external medication commonly em- ployed. By ointments and lotions. If an ointment is used, it is to be thoroughly rubbed in, in small quantity ; if a lotion is employed, it is to be well shaken, the parts freely dabbed with it for several minutes and then allowed to dry on. State the object in view in local medication. To hasten the maturation and disappearance of the existing lesions, and to stimulate the skin and glands to healthy action. If slight irritation or scaliness results, the application is to be intermitted one or two nights; in the meantime nothing except the hot-water sponging, with or without the application of a mild soothing ointment, is to be employed. Is it usually necessary to change from one external remedy to another in the course of treatment ? Yes. After a certain time one remedy, as a rule, loses its effect, and a change from lotion to ointment or the reverse, and from one lotion or ointment to another, will often be found necessary in order to bring about continuous improvement. Name the various important remedies and combinations em- ployed in the external treatment of acne. Sulphur is the most valuable. It may often be applied with benefit as a simple ointment:— R. Sulphur, prsecip.,..........3ss~3J Adipis benz. Lanolin,......aa.......3 ij. INFLAMMATIONS. 121 Or it may be used as a lotion, as in the annexed formula :— R. Sulphur, praecip.,..........3 iss Pulv. tragacanthae,......... . gr. xx Spts. camphors}, ..........f3'J Liq. calcis, . . . . q. s. ad.....fSiv- ^° Another lotion, especially useful in those cases in which an oily condition of the skin is present, is the following :— R . Sulphur, praecip.,..........3 i^ Etheris,..............f 3 iv Alcoholis,.............f ^ iijss. M. A compound lotion containing sulphur in one of its combinations is also valuable in many cases :— R. Zinci sulphatis, Potassii sulphureti, .... ila ... , 3ss_3ij Aquae,...............§iv. M. (The salts should be dissolved separately and then mixed ; reaction takes place and the resulting lotion, when shaken, is milky in appear- ance, and free from odor; allowed to stand the particles settle, the sediment constituting about one-fourth of the whole bulk). At times the addition to this formula of several drachms of alco- hol or of ten to thirty minims of glycerin is of advantage. An external remedy, often valuable, is ichthyol. It is thus pre- scribed :— R. Ichthyol,..............3SS~3J Cerat. simp.,............3iv. M. Resorcin as a lotion, ten to sixty grains to the ounce, is useful in some cases. The various mercurial ointments, especially one of white precipi- tate, five to fifteen per cent, strength, are sometimes beneficial. A compound lotion, containing mercury, which frequently proves serviceable, is :— R. Hydrarg. chlorid. corros.,......gr. ii-viij Zinci sulphatis,...........gr. x-xx Tinct. benzoini, ..........f 3 ij Aquse,.......q. s. ad . . . . f ^ iv. 122 DISEASES OF THE SKIN. In extremely sluggish cases the following, used cautiously, is of value:— R. Ichthyol, Saponis viridis, Sulphur, praecip., Lanolin,......aa.......3j. Acne of the back is treated with the same applications, but usually stronger; in this region applications of Vleminckx's solu- tion and formaldehyde solution, weakened considerably, at first at least, prove of value. Obstinate and indurated lesions may be incised, the contents pressed out, and the interior touched with carbolic acid by means of a pointed stick. What precaution is to be taken in advising a change from a sulphur to a mercurial preparation or the reverse ? Several days should be allowed to intervene, otherwise a disagree- able, although temporary, staining or darkening of the skin results —from the formation of the black sulphuret of mercury. Acne Rosacea. Give a descriptive definition of acne rosacea. Acne rosacea is a chronic, hyperaemic or inflammatory disease, limited to the face, especially to the nose and cheeks, characterized by redness, dilatation and enlargement of the bloodvessels, more or less acne and hypertrophy. Describe the symptoms of acne rosacea. The disease may be slight or well-marked. Redness, capillary dilatation, and acne lesions seated on the nose and cheeks, and some- times on chin and forehead also, constitute in most cases the entire sym ptomatology. A mild variety consists in simple redness or hyperaemia, involving the nose chiefly and often exclusively, and is to be looked upon as a passive congestion; this is not uncommon in young adults and is often associated with an oily seborrhoea of the same parts. In many INFLAMMATIONS. 123 cases the condition does not progress beyond this stage. In other cases, however, sooner or later, the dilated capillaries become per- manently enlarged (telangiectasis) and acne lesions are often present— constituting the middle stage or grade of the disease; this is the type most frequently met with. In exceptional instances, still further hypertrophy of the blood-vessels ensues, the glands are enlarged, and a variable degree of connective-tissue new growth is added; this latter is usually slight, but may be excessive, the nose presenting an enlarged and lobulated appearance (rhinophyma). Are there any subjective symptoms in acne rosacea? As a rule, no. Some of the acne lesions may be tender and pain- ful, and at times there is a feeling of heat and burning. What do you know in regard to the etiology ? In many cases the causes are obscure. Chronic digestive and in- tcsiinal disorders, anaemia, chlorosis, continued exposure to heat or cold, menstrual and uterine irregularities, and the too free use of spirituous liquors, tea, etc. are often responsible factors. It is essentially a disease of adult life, common about middle age, occurring in both sexes, but rarely reaching the same degree of de- velopment in women as observed at times in men. Is acne rosacea easily recognized ? Yes. The redness, acne lesions, dilated capillaries, and, at times, the glandular and connective-tissue hypertrophy; the limitation of the eruption to the face, especially the region of the nose; the evident involvement of the sebaceous glands, the absence of ulceration, taken with the history of the case, are characteristic. It is to be distinguished from the tubercular syphiloderm and lupus vulgaris, diseases to which it may bear rough resemblance. State the prognosis of acne rosacea. All cases may be favorably influenced by treatment; the mild and moderately-developed types are, as a rule, curable, but dually obstinate. It is a persistent disease, showing little, if any, tendency to disappear spontaneously. What is the method of treatment ? Both constitutional and local measures are demanded in most cases. 124 DISEASES OF THE SKIN. Upon what is the constitutional treatment to be based ? The constitutional treatment, beyond a regulation of the diet, is to be based upon a correct appreciation of the etiological factors in the individual case. There are no special remedies. Iron, cod-liver oil, tonics, ergot, alkalies, saline laxatives, and similar drugs are to be variously prescribed. What is the external treatment ? In many respects, both as to the preliminary measures and reme- dies, essentially the same as that employed in the treatment of sim- ple acne (q. v.). In addition to the treatment there found, however, several other applications deserve mention:— In many cases Vleminckx's solution* is valuable, applied diluted with one to ten parts of water. Also, a mucilaginous paste con- taining sulphur :— R. Mucilag. acaciae,..........f^iij Glycerinae, ............f ^ ij Sulphur, praecip.,..........3iij- M. Or a similar paste with the glycerine in the foregoing replaced with ichthyol may be used. In what manner are the dilated blood-vessels and connective- tissue hypertrophy to be treated ? The enlarged capillaries are to be destroyed by incision or by elec- trolysis. Properly managed the vessels may be thus destroyed, but unless the predisposing causes have disappeared or have been reme- died, a new growth may take place. If the knife is employed, the vessels are either slit in their length or cut transversely at several points. The method by electrolysis is the same as used in the removal of superfluous hair (q. v.). ; the needle may, if the vessel is short, be inserted along its calibre, or if long, may be inserted at several points in its length. Excessive connective-tissue growth, exceptionally met with, is to be treated by ablation with the scissors or knife. * R. Calcis,...............5; ss Sulph. sublimat.,..........3jj Aquae,...............^x. To be boiled down to ^ vj and filtered. INFLAMMATIONS. 125 Sycosis. (Synonyms : Sycosis Non-parasitba ; Folliculitis Barbae.) What do you understand by sycosis ? Sycosis is a chronic, inflammatory affection involving the hair- follicles, usually of the bearded region only, and characterized by papules, tubercles and pustules perforated by hairs. Describe the symptoms of sycosis. Sycosis begins by the formation of papules and pustules about the hair-follicles ; the lesions occur in numbers, in close proximity, and together with the accompanying inflammation, make up a small or large area. The pustules are small, rounded, flat or acuminated, discrete, and yellowish in color ; they are perforated by hairs, show no tendency to rupture, and are apt to occur in crops, drying to thin yellowish or brownish crusts. Papules and tubercles are often intermingled. More or less swelling and infiltration are noticeable. 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. Occasionally a sycosiform eruption, usually of the side of the bearded region, leaves behind a smooth or keloidal scar, the disease gradually extending—ulerythema sycosiforme (lupoid sycosis). An inflammation of the hair-follicles of the scalp apparently S3rcosiform in chaVacter, occurring as discrete or aggregated lesions, is sometimes observed, the follicles being destroyed and atrophy or slight scarring resulting—folliculitis decalvans. Does conspicuous hair loss occur in sycosis ? Ordinarily not; the hairs are, especially at first, usually firmly seated, but in those cases in which suppuration is active, and has involved the follicles, they may, as a rule, be easily extracted. In some cases destruction of the follicles ensues and slight scarring and permanent hair loss result. State the character of the subjective symptoms. Pain and itching and a sense of burning, variable as to degree, may be present. 126 DISEASES OF THE SKIN. What is the course of the disease ? Essentially chronic, the inflammatory action being of a subacute or sluggish character, with acute exacerbations. State the causes of sycosis. The etiology is obscure. It is not contagious. Local irritation may act as an exciting cause. Upon the upper lip it may have its origin in a nasal catarrh. Entrance into the follicles of a peculiar microorganism is suggested as the essential factor. It is seen in the male sex only, usually in those between the ages of twenty-five and fifty ; and is met with in those in good and bad health, and among rich and poor. It is comparatively infrequent. What is the pathology of sycosis ? The disease is primarily a perifolliculitis, the follicle and its sheath subsequently becoming involved in the inflammatory process. How would you distinguish sycosis from eczema ? Eczema is rarely sharply limited to the bearded region, but is apt to involve other parts of the face ; moreover, the lesions are usually confluent, and there is either an oozing, red crusted surface or it is dry and scaly. How would you exclude tinea sycosis in the diagnosis ? In tinea sycosis, or ringworm, the history of the case is different. The parts are distinctly lumpy and nodular ; the hairs are soon in- volved and become dry, brittle, loose and fall out, or they may be readily extracted. In doubtful cases, microscopic examination of the hairs may be resorted to. Give the prognosis of sycosis. The disease is curable, but almost invariably obstinate and rebel- lious to treatment. The duration, extent and character of the in- flammatory process must all be considered. An expression of an opinion as to the length of time required for a cure should always be guarded. Ulerythema sycosiforme is extremely obstinate. Folliculitis decal- vans is also rebellious. How is sycosis to be treated ? Mainly, and often exclusively, by external applications. INFLAMMATIONS. 127 Is constitutional treatment of no avail in sycosis ? In some instances; but, as a rule, it is negative. If indicated, such remedies as tonics, alteratives, cod-liver oil and the like are to be prescribed. Calx sulphurata, in one-tenth to one-fourth grain doses,- every three or four hours, is sometimes of service. Describe the external treatment. Crusting, if present, is to be removed by warm embrocations. If the inflammation is of a high grade, and the parts tender and pain- ful, soothing applications, such as bland oils, black wash and oxide- of-zinc ointment, cold cream and petrolatum, are to be used; boric- acid solution, fifteen grains to the ounce, may be advised in place of black wash. In most cases, however, astringent and stimulating remedies are demanded from the start, such as: diachylon ointment, alone or with ten to thirty grains of calomel to the ounce; oleate of mercury, as a five- to twenty-per-cent. ointment; precipitated sulphur, one to three drachms to the ounce of benzoated lard, or lard and lanolin; a ten- to twenty-five-per-cent. ichthyol ointment; and resorcin lotion or ointment, ten to twenty per cent, strength. A change from one application to another will be found necessary in almost all cases. What would you advise in regard to shaving ? When bearable (and after a few days' application of soothing remedies it almost always is), it is to be advised in all cases, as it materially aids in the treatment. After a cure is effected it should be continued for some months, until the healthy condition of the parts is thoroughly established. When is depilation advisable as a therapeutic measure ? When the suppurative process is active, in order to save the folli- cles from destruction; incising or puncturing the pustules will often accomplish the same end. Depilation is in all cases a valuable therapeutic measure, but it is painful; as a routine practice, shaving is less objectionable and, upon the whole, is probably as satisfactory. 128 DISEASES OF THE SKIN. Dermatitis Papillaris Capillitii. (Synonym : Acne Keloid.) Describe dermatitis papillaris capillitii. This is a peculiar, mildly inflammatory, syeosiform, keloidal. Fig. 20. Derm-titis Papillaris Capillitii acne-like disease of the hairy border of the back of the neck, often extending upward to the occipital region; partaking, especi- ally later in its course, somewhat of the nature of keloid. Several or more acne-like lesions, papular and pustular, closely grouped or bunched, appear, developing slowly, usually to the size of peas; are red, pale red, or whitish, often enveloping small tufts of hair, and • attended with more or less hair loss. Its course is gradual and persistent. It is an exceedingly rare condition, the exact nature of which is still obscure. - Give the treatment. Treatment, which is usually unsatisfactory, consists of stimulating applications—the same, in fact, as employed in S3Tcosis, sulphur and ichthyol deserving special mention. Depilation is valuable. INFLAMMATIONS. 129 Impetigo. (Synonym: Impetigo Simplex.) What is 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. Describe the symptoms and course of impetigo. The affection is sometimes preceded by slight malaise. Several or more lesions may be present, scattered over one part, or more commonly over various regions, such as the face, hands, feet and lower extremities. The pustules are such from the beginning, and when developed are usually of the size of a pea or finger-nail, ele- vated, semi-globular or rounded, with somewhat thick and tough walls, and of a whitish or yellowish color; at first there may be a slight inflammatory areola, but as the lesion matures this almost, if not entirely, disappears. The pustules show no disposition to umbilication, rupture or coalescence ; drying in the course of several days or a week to yellowish or brownish crusts, which soon drop off, leaving no permanent trace. The disease is benign in character and usually of short duration, and, as a rule, without subjective symptoms. What is the cause of the disease ? The cause is not known. It may possibly be due to the presence of microorganisms. Its subjects, commonly young children, are often well-nourished. Microscopically the contents of the lesions are found to be composed of pus-corpuscles, a few red blood-cor- puscles, epithelial cells and cellular debris. The individuality of this disease is questioned; the consensus of opinion seems to be in the direction of viewing these cases as anom- alous examples of impetigo contagiosa. In what respects do impetigo contagiosa and ecthyma differ from impetigo ? The lesions of impetigo contagiosa are vesicular or vesico-pustular, flattened, thin-walled, supeiflcial and often umbihcated, and, if close 9 130 DISEASES OF THE SKIN. together, tend to coalesce, drying, in the course of a fow days or a week, to thin, wafer-like, light yellowish crusts. The lesions of ecthyma are markedly inflammatory, having a hard and often extensive base, and a distinct areola, drying to brownish or blackish crasts, beneath which will be found deep excoriations. It is, moreover, usually seen in adults, in those who are in a depraved condition of health. State the prognosis of impetigo. Favorable. The disease tends to rapid and spontaneous disappear- ance, rarely lasting more than a few weeks. Give the treatment. Treatment is seldom demanded ; but the lesions may be incised, the contents pressed out, and a simple protective dressing of carbol- ized oxide-of-zinc ointment applied. For sluggish lesions, the same ointment, with ten to twenty grains of white precipitate, may be used. Impetigo Contagiosa. Give a descriptive definition of impetigo contagiosa. Impetigo contagiosa is an acute, contagious, inflammatory dis- ease, characterized by the formation of discrete, superficial, flat, rounded, or ovalish vesicles or blebs, soon becoming vesico-pustular, and drying to thin yellowish crusts. Upon what parts does the eruption commonly appear ? Upon the face, scalp, and hands, and exceptionally upon other regions. Describe the symptoms of impetigo contagiosa. One, several or more small pin-head-sized papulo-vesicles or vesicles make their appearance, usually upon the face and fingers. They increase in size by extending peripherally, but are more or less flat- tened and umbihcated, and are without conspicuous areola. The lesions may attain the size of a dime or larger, and when close together may coalesce and form a large patch. In some cases dis- tinct blebs result, and a picture of pemphigus eruption presented; it is probable that many of the cases of "contagious pemphigus" INFLAMMATIONS. 131 belong to this class. New lesions may appear for several days, but finally, in the course of a week or ten days, they have all dried to thin, wafer-like crusts, of a straw or light-yellow color, but slightly adherent, and appearing as if stuck on; these soon drop off, leaving faint reddish spots, which gradually fade. As a rule there are no constitutional symptoms, but in the more severe cases the eruption may be preceded by febrile disturbance and malaise. Itch- ing may or may not be present. State the cause of the disease. The etiology is not known. It is contagious, the contents of the lesions being inoculable and auto-inoculable. At times it seems to prevail in epidemic form. Microorganisms are now looked upon as causative. A relationship to vaccination has been noted in some instances. It is commonly observed in infants and young children. From what diseases is impetigo contagiosa to be differ- entiated? From eczema, simple impetigo, pemphigus, and ecthyma. How does impetigo contagiosa differ from these several dis- eases? By the character of the lesions, their growth, their supeiflcial nature, their course, the absence of an inflammatory base and areola, the thin, yellowish, wafer-like crasts, and usually a history of con- tagion. State the prognosis. The effect of treatment is usually prompt. The disease, indeed, tends to spontaneous disaxtpearauce in one to two weeks ; in excep- tional instances, more especially in those cases in which itching is present, the excoriations or scratch-marks become inoculated, and in this way it may persist several weeks. What is the treatment of impetigo contagiosa ? Treatment consists in the destruction of the auto-inoculable prop- erties of the contents of the lesions; this is effected by removing the crusts by means of warm water-and-soap washings, and sub- sequently rubbing in an ointment of ammoniated mercury, ten to twenty grains to the ounce. In itching cases, a saturated solution of boric acid, or a carbolic-acid lotion, one to two drachms to the pint, is to be employed for general application. 132 DISEASES OF THE SKIN. Impetigo Herpetiformis. Describe impetigo herpetiformis. Impetigo herpetiformis is an extremely rare disease, observed usually in pregnant women, and is characterized by the appearance of numerous isolated and closely-crowded pin-head-sized superficial pustules, which show a decided disposition to the formation of circu- lar groups or patches. The central portion of these groups dries to crasts, while new pustules appear at the peripheral portion. They tend to coalesce, and in this manner a greater part of the whole sur- face may, in the course of weeks or months, become involved. Pro- found constitutional disturbance, usually of a septic character, pre- cedes and accompanies' the disease ; in almost every instance a fatal termination sooner or later results. It is possibly a grave type of dermatitis herpetiformis. Ecthyma. Give a descriptive definition of ecthyma. Ecthyma is a disease characterized by the appearance of one, sev- eral or more discrete, finger-nail-sized, flat, usually markedly inflam- matory pustules. Describe the symptoms and course of ecthyma. The lesions begin as small, usually pea-sized, pustules; increase somewhat in area, and when fully developed are dime-sized, or larger, somewhat flat, with a markedly inflammatory base and areola. At first yellowish they soon become, from the admixture of blood, red- dish, and dry to brownish crasts, beneath which will be found super- ficial excoriations. The individual pustules are usually somewhat acute in their course, but new lesions may continue to appear from day to day or week to week. As a rule, not more than five to twenty are present at one time, and in most cases they are seated on the legs. More or less pigmentation, and sometimes superficial scarring, may remain to mark the site of the lesions. Itching is rarely present, but there may be more or less pain and tenderness. INFLAMMATIONS. '133 What is the cause of ecthyma ? It is essentially a disease of the poorly cared-for and ill-fed, and, according to present prevailing views regarding suppurative pro- cesses, the direct exciting cause may be the introduction of micro- organisms into the follicular openings. It is commonly observed in male adults. From what diseases is ecthyma to be differentiated? From simple impetigo, impetigo contagiosa, and the flat pustular syphiloderm. How is it distinguished from these several diseases ? The size, shape, inflammatory action, and the depraved general condition will serve to differentiate it from simple impetigo; the same characters, the distribution and non-contagiousness will distinguish it from impetigo contagiosa ; and the absence of concomitant symp- toms of syphilis, and of positive ulceration, as well as its distribu- tion and more rapid and inflammatory course, will exclude the pus- tular syphiloderm. State the prognosis. The disease is readily curable, disappearing upon the removal of the predisposing cause. What treatment is to be advised ? Good food, proper hygiene and tonic remedies; and, locally, re- moval of the crusts and stimulation of the underlying surface with an ointment of ammoniated mercury, ten to thirty grains to the ounce. The following mild antiseptic lotion, which materially lessens the tendency to the formation of new lesions, may be applied to the affected region two or three times daily:— R. Acidi borici,............3iv Resorcini,.............3U Glycerinse,............f^ij Alcoholis,............f5J Aqua1,......q. s. ad.....Oj. M. A weak lotion of thymol, corrosive sublimate or ichthyol would doubtless be euually effectual. 134 DISEASES OF THE SKIN. Pemphigus. What do you understand by pemphigus ? Pemphigus is an acute or chronic disease characterized by the suc- cessive formation of irregularly-scattered, variously-sized blebs. Name the varieties met with. Two varieties are usually described—pemphigus vulgaris and pemphigus foliaceus. Describe the symptoms and course of pemphigus vulgaris. With or without precursory symptoms of systemic disturbance, irregularly scattered blebs, few or in numbers, make their appear- ance, arising from erythematous spots or from apparently normal skin. They vary in size from a pea to a large egg, are rounded or ovalish, usually distended, and contain a yellowish fluid which, later, becomes cloudy or puriform. If raptured, the rete is exposed, but the skin soon regains its normal condition ; if undisturbed, the fluid usually disappears by absorption. Each lesion runs its course in several days or a week. A grave type of pemphigus is exceptionally observed in the new- born—pemphigus neonatorum. What course does pemphigus vulgaris pursue ? Usually chronic. The disease may subside in several months and the process come to an end, constituting the acute type. As a rule, however, the disease is chronic, new blebs continuing to appear from time to time for an indefinite period. In what respects does the severe form of pemphigus vul- garis differ from the ordinary type ? In the severe or malignant type the eruption is more profuse; there is marked, and often grave, systemic depression, and the lesions are attended with ulcerative action. Describe the symptoms and course of pemphigus foliaceus. In this, the grave type of the disease, the blebs are loose and flaccid, with milky or puriform contents, rupturing and drying to crusts, which are cast off, disclosing the reddened corium. New blebs appear on the sites of disappearing or half-ruptured lesions, and the whole surface may be thus involved and the disease con- INFLAMMATIONS. 135 tinue for years, compromising the general health and eventually ending fatally. What is the character of the subjective symptoms in pem- phigus ? The subjective symptoms consist variously of beat, tenderness, pain, burning and itching, and may be slight or troublesome.. What is known in regard to the etiology of pemphigus ? The causes are obscure; general debility, overwork, shock, nerv- ous exhaustion, and septic conditions (microorganisms) are thought to be of influence. The disease is not contagious, nor is it due to syphilis. It may occur at any age. It is a rare disease, especially in this country. What is the pathology ? The lesions are superficially seated, usually between the horny layer and upper part of the rete. Round-cell infiltration and dilated blood vessels are found about the papillae and in the subcutaneous tissue. The contents of the blebs, always of alkaline reaction, are at first serous, later containing blood corpuscles, pus, fatty-acid crystals, epithelial cells, and occasionally uric acid crystals and free ammonia. From what diseases is pemphigus to be differentiated? From herpes iris, the bullous syphiloderm, impetigo contagiosa and dermatitis herpetiformis. How do these several diseases differ from pemphigus ? The acute course, small lesions, concentric arrangement, variegated colors, and distribution, in herpes iris; the thick, bulky, greenish crasts, the underlying ulceration, the course, history, and the pres- ence of concomitant symptoms of syphilis, in the bullous syphilo- derm ; the history, course, distribution, the character of the crusting, and the contagious and auto-inoculable properties of the contents of the lesions, in impetigo contagiosa ; the tendency to appear in groups, the smaller lesions, the intense itchiness, course, multiform characters of the eruption and the disposition to change of type in dermatitis herpetiformis,—will serve as differential points. 136 DISEASES OF THE SKIN. State the prognosis of pemphigus. Its duration is uncertain, and the issue may in severe cases be fatal. In the milder types, after months or several years, recovery may take place. The extent and severity of the disease and the general condition of the patient are always to be considered before an opinion is expressed. Pemphigus neonatorum usually ends fatally. Give the treatment of pemphigus. Both constitutional and local measures are demanded. Good nutritious food and hygienic regulations are essential. Arsenic and quinia are the most valuable remedies. The former, in occasional instances, seems to have a specific influence, and should always be tried, beginning with small doses and increasing gradually to the point of tolerance and continued for several weeks or longer. The remedy should not be set aside as long as there are signs of improve- ment, unless the supervention of stomachic, intestinal or other dis- turbance demand its discontinuance. Other tonics, such as iron, strychnia and cod-liver oil, are also at times of service. The blebs should be opened and the parts anointed or covered with a mild ointment. In more general cases bran, starch and gelatin baths, and in severe cases the continuous bath, if practi- cable, are to be used. CLASS III.—HEMORRHAGES. Purpura. Define purpura. Purpura is a hemorrhagic affection characterized by the appear- ance of variously-sized, usually non-elevated, smooth, reddish or purplish spots or patches, not disappearing under pressure. Name the several varieties met with. Three—purpura simplex, purpura rhcumatica and purpura haem- orrhagica; denoting, respectively, the mild, moderate and severe grade of the disease. The division is, to a great extent, an arbitrary one. HEMORRHAGES. 137 Describe the clinical appearance and course of an individual lesion of purpura. The spot, which may be pin-head, pea-, bean-sized or larger, appears suddenly, and is of a bright red or purplish red color. Its brightness gradually fades, the color changing to a bluish, bluish- green, bluish- or greenish-yellow, dirty yellowish, yellowish-white, and finally disappearing; varying in duration from several days to several weeks. Describe the symptoms of purpura simplex. Purpura simplex, or the mild form, shows itself as pin-point to pea- or bean-sized, bright or dark-red spots, limited, as a rule, to the limbs, esjiecially the lower extremities ; fading gradually away and coming to an end in a few weeks, or new crops appearing irregularly for several months. There is rarely any systemic disturbance, and, as a rule, no subjective symptoms ; in exceptional cases an urticarial element is added—purpura urticans. Describe the symptoms of purpura rheumatica. Purpura rheumatica (also called peliosis rheumatica) is usually preceded by symptoms of malaise, rheumatic pains and sometimes swelling about the joints; these phenomena abate and frequently disappear upon the outbreak of the eruption. The lesions are pea- to dime-sized, smooth, non-elevated, or slightly raised, and of a red- dish or purplish color ; the eruption may be more or less generalized, most abundant upon the limbs, or it may be limited to these parts. It may end in a few weeks, or may persist for several months, new spots appearing irregularly or in the form of crops. Describe the symptoms of purpura haemorrhagica. Purpura haemorrhagica (also called land scurvy) is characterized usually by premonitory, and frequently accompanying, symptoms of general distress, and by the appearance of coin to palm-sized, red or purplish hemorrhagic spots or patches, smooth, non-elevated or raised. Hemorrhage from the mouth, gums and other parts, slight or serious in character, may occur. New lesions continue to appear for several days or weeks; and in exceptional instances, repeated relapses take place, and the disease thus persists for months. It may end fatally. 138 DISEASES OF THE SKIN. State the etiology of purpura. In most instances no cause can be assigned. The disease occurs at all ages from childhood to advanced life, and in individuals, appar- ently, in good and bad health alike. The hemorrhagic type is oftener seen in subjects debilitated or in a depraved state of health. A microorganism is also looked upon as a factor by some observers, especially in the grave type of disease. State the diagnostic characters of purpura. The appearance, irregularly or in crops, of bright-red or purplish spots, evidently of hemorrhagic nature, and not disappearing upon pressure, and as they are fading, going through the several changes of color usually observed in any ecchymosis. How does scurvy (scorbutus) differ from purpura ? Scurvy, which may resemble the severe grade of purpura, has a different history, a recognizable cause, usually a peculiar distribution, and is accompanied with general weakness and a spongy, soft and bleeding condition of the gums. What is the pathology of purpura ? The lesion of purpura consists essentially of a hemorrhage into the cutaneous tissues. The blood is subsequently absorbed, the haematin undergoing changes of color from a red to greenish and pale yellow, and finally fading away. State the prognosis The milder varieties disappear in the course of several weeks or months, and are rarely of serious import; the outcome of purpura haemorrhagica is somewhat uncertain ; although usually favorable, a fatal result from internal hemorrhage is possible. What is the treatment of purpura ? Hygienic and dietary measures, the administration of tonics and astringents, and, in severe cases, by relative or absolute rest. The drags commonly prescribed are : ergot, oil of erigeron, oil of turpentine, quinia, strychnia, iron, mineral acids, and gallic acid. External treatment is rarely called for, but if deemed advisable, as- tringent lotions may be employed. HEMORRHAGES. 139 Scorbutus. (Synonyms: Scurvy; Sea Scurvy; Purpura Scorbutica.) Describe scorbutus. Scurvy is a peculiar constitutional state, developed in those living under bad hygienic conditions, and is characterized by emaciation, general febrile and asthenic symptoms, a more or less swollen, turgid and spongy and even gangrenous condition of the gums; and con- comitantly, or sooner or later, by the appearance, usually upon the lower portion of the legs only, of dark-colored hemorrhagic patches or blotches. The skin of the affected part may become brawny and slightly scaly, and not infrequently may break down and ulcerate. Hemorrhages from the various mucous surfaces, slight or grave, may also take place. State the etiology of scurvy. It is due to long-continued deprivation of proper food, especially of fruits and vegetables. Other bad hygienic conditions favor its development. It is seen almost exclusively in sailors and others taking long voyages. How is scurvy to be distinguished from purpura ? By the asthenic and emaciated general condition and the peculiar puffy, spongy state of the gums. The cutaneous manifestation is more diffused, forming usually large palm-sized patches, and, as a rule, limited to the region of the ankles or lower part of the legs. Give the prognosis of scurvy. The disease is remediable, and usually rapidly so. In those in- stances in which the same bad hygienic conditions and the ingestion of improper food are continued, death finally results. What treatment would you advise in scurvy ? Proper food, with an abundance of fruit and vegetables. Lemon or lime juice is especially valuable, and is to be taken freely. If indi- cated, tonics and stimulants are also to be prescribed. For the relief of the tumid, spongy condition of the gums, astringent and antiseptic mouth washes are to be employed. The cutaneous manifestations, when tending to ulceration, are to be treated upon general principles. 140 DISEASES OF THE SKIN. CLASS IV.—HYPERTROPHIES. Lentigo. (Synonym: Freckle.) Describe lentigo. Lentigo, or freckle, is characterized by round or irregular, pin- head to pea-sized, yellowish, brownish or blaemsh spots, occurring usually about the face and the backs of the hands. It is a com- mon affection, varying somewhat in the degree of development; the freckles present may be few and insignificant, or they may exist in profusion and be quite disfiguring. Heat and exposure favor their development. Those of light complexion, especially those with red hair, are its most common subjects. The color of the lesion is usually a yellowish-brown. It is common to all ages, but is generally seen in its greatest development during adolescence, the disposition to its appearance becoming less marked as age advances. What is the pathology of lentigo ? Lentigo consists simply of a circumscribed deposit of pigment granules—merely a localized increase of the normal pigment, differing from chloasma (q. v.) only in the size and shape of the pigmentation. State the prognosis. The blemishes can be removed by treatment, but their return is almost certain. Name the several applications commonly employed for their removal, An aqueous or alcoholic solution of corrosive sublimate, one-half to three grains to the ounce; lactic acid, one part to from six to twenty parts of water ; and an ointment containing a drachm each of bismuth subnitrate and ammoniated mercury to the ounce. The applications, which act by removing the epidermal and rete cells and with them the pigment, are made two or three times daily, and their use intermitted for a few days as soon as the skin becomes irritated or scaly. Touching each freckle for a few seconds with the electric needle, just pricking the epidermis, will occasionally remove the blemish. HYPERTROPHIES. 141 Chloasma. What do you understand by chloasma ? Chloasma consists of an abnormal deposit of pigment, occurring as variously-sized and shaped, yellowish, brownish or blackish patches. Describe the clinical appearances of chloasma. Chloasma appears either in ill-defined patches, as is commonly the case, or as a diffuse discoloration. Its appearance is rapid or gradual, generally the latter. The patches are rounded or irregular, and usually shade off into the sound skin. One, several or more may be present, and coalescence may take place, resulting in a large irreg- ular pigmented area. The color is yellowish, or brownish, and may even be blackish (melasma, melanoderma). The skin is otherwise normal. The face is the most common site. Into what two general classes may the various examples of chloasma be grouped ? Idiopathic and symptomatic. What cases of chloasma are included in the idiopathic group? All those cases of pigmentation caused by external agents, such as the sun's rays, sinapisms, blisters, continued cutaneous hyper- aemia from scratching or any other cause, etc. What cases of chloasma are included in the symptomatic group ? All forms of pigment deposit which occur as a consequence of various organic and systemic diseases, as the pigmentation, for in- stance, seen in association with tuberculosis, cancer, malaria, Addi- son's disease, uterine affections, and the like. In such cases, with few exceptions, the pigmentation is usually more or less diffuse. What is chloasma uterinum ? Chloasma uterinum is a term applied to the ill-defined patches of yellowish-brown pigmentation appearing upon the faces of women, usually between the ages of twenty-five and fifty. It is most com- monly seen during pregnancy, but may occur in connection with any functional or organic disease of the utero-ovarian apparatus. 142 DISEASES OF THE SKIN. What is argyria ? Argyria is the term applied to the slate-like discoloration which follows the prolonged administration of silver nitrate. State the pathology of chloasma. The sole change consists in an increased deposit of pigment. Give the prognosis of chloasma. Unless a removal of the exciting or predisposing cause is possible, the prognosis is, as a rule, unfavorable, and the relief furnished by local applications usually but temporary. If constitutional treatment is advisable, upon what is it to be based? Upon general principles ; there are no special remedies. How do external remedies act ? Mainly by removing the rete cells and with them the pigmenta- tion ; and partly, also, by stimulating the absorbents. Are all external remedies which tend to remove the upper layers of the skin equally useful for this purpose ? No; on the contrary some such applications are followed by an in- crease in the pigment deposit. Yame the several applications commonly employed. Corrosive sublimate in solution, in the strength of one to four grains to the ounce of alcohol and water; a lotion made up as fol- lows :— R. Hydrargyri chlorid. corros.,.....gr. iij-viij Ac. acet. dilut., ..........f 3 ij Sodii borat.,............Q ij A quae rosae,............f^iv. M. And also the following :— R. Hydrargyri chlorid. corros., .....gr. iij-viij Zinci sulphat., Plumbi acetat.,.....aa.....3 ss Aquas,...............f^iv. M. And lactic acid, with from five to twenty parts of water ; and an HYPERTROPHIES. 143 ointment containing a drachm each of bismuth subnitrate and white precipitate to the ounce. Hydrogen peroxide occasionally acts well. (Applications are made two or three times daily, and as soon as slight scaliness or irritation is produced are to be discontinued for one or two days.) Tattoo-macks are difficult to remove. Excision is the surest method. Electrolysis, applying the needle at various points, some- what close together, and using a fairly strong current—three to eight milliampores—will exceptionally, especially when repeated several times, produce a reactive inflammation and casting-off of the tissue containing the pigment; a scar is left. Several writers claim good results with glycerole of papain, prick- ing it in in the same manner as in tattooing. Gun-poiodc.r marks. If recent, but a day or so after their occur- rence, the larger specks may be picked or scraped out. Later, electrolysis, using a fairly strong current, may result in their re- moval. Their removal may also be satisfactorily effected with a minute cutaneous trephine. Keratosis Pilaris. 'Synonyms: Pityriasis Pilaris; Lichen Pilaris.) What is meant by keratosis pilaris ? Keratosis pilaris may be defined as a hypertrophic affection characterized by the formation of pin-head-sized, conical, epidermic elevations seated about the apertures of the hair follicles. Describe the clinical appearances of keratosis pilaris. The lesions are usually limited to the extensor surfaces of the thighs and arms, especially the former. They appear as pin-head- sized, whitish or grayish elevations, consisting of accumulations of epithelial matter about the apertures of the hair follicles. Each ele- vation is pierced by a hair, or the hair may be twisted and impris- oned within the epithelial mass ; or it may be broken off just at the point of emergence at the apex of the papule, in which event it may be seen as a dark, central speck. The skin is usually dry, rough and harsh, and in marked cases, to the hand passing over it, feels not 144 DISEASES OF THE SKIN. unlike a nutmeg-grater. The disease varies in its development, in most cases being so slight as to escape attention. As a rule, it is free from itching. What course does keratosis pilaris pursue ? It is sluggish and chronic. Mention some of the etiological factors. It is not an uncommon disease, and is seen usually in those who are unaccustomed to frequent bathing, being most frequently met with during the winter months. It is chiefly observed during early adult life. Is there any difficulty in the diagnosis ? No. It is thought at times to bear some resemblance to goose- flesh (cutis anserina), the miliary papular syphiloderm in its desqua- mating stage, and lichen scrofulosus. In goose-flesh the elevations are evanescent and of an entirely different character; the papules of the syphiloderm are usually generalized, of a reddish color, tend to group, are more solid and deeply-seated, less scaly and are accom- panied with other symptoms of syphilis; in lichen scrofulosus the papules are larger, incline to occur in groups, and appear usually upon the abdomen. State the prognosis. The disease yields readily to treatment. Give the treatment of keratosis pilaris. Frequent warm baths, with the use of a toilet soap or sapo viridis, will usually be found curative. Alkaline baths are also useful. In obstinate cases the ordinary mild ointments, glycerine, etc., are to be advised in conjunction with the baths. HYPERTROPHIES. 145 Keratosis Follicularis. Describe keratosis follicularis. Keratosis follicularis (Dariers disease, ichthyosis follicularis, ich- thyosis sebacea cornea, psorospermosis) is a rare disease characterized by pin-head to pea-sized pointed, rounded, or irregularly-shaped grayish, brownish, red or even black, horny papules or elevations, arising from the sebaceous or hair-follicles. They are, for the most part, discrete, with a tendency here and there to form solid aggre- gations or areas. Many of them contain projecting cornified plugs which may be squeezed out, leaving pit-like depressions. The face, scalp, lower trunk, groins and flanks are the parts chiefly affected. It is both affirmed and denied that psorosperms are to be found in the lesions, and to be considered causative. As to treatment, in one instance the induction of a substitutive dermatic inflammation had a favorable influence. Molluscum Epitheliale. (Synonyms: Molluscum Contagiosum; Molluscum Sebaceum; Epithelioma Molluscum.) Give a definition of molluscum epitheliale. Molluscum epitheliale is characterized by pin-head to pea-sized, rounded, semi-globular, or flattened, pearl-like elevations, of a whitish or pinkish color. Describe the symptoms and course of molluscum epitheliale. The usual seat is the face ; not infrequently, however, the growths occur on other parts. The lesions begin as pin-head, waxy-looking, rounded or acuminated elevations, gradually attaining the size of small peas. They have a broad base or occasionally may tend to be- come pedunculated. They rarely exist in profusion, in most cases three to ten or twelve lesions being present. When fully developed they are somewhat flattened and umbihcated, with a central, darkish point representing the mouth of the follicle. They are whitish or pinkish, and look not unlike drops of wax or pearl buttons. At first they are firm, but eventually, in most cases, tend to become soft and break down. Not infrequently, however, the lesions disappear slowly by absorption, without apparent previous softening. Their course 10 146 DISEASES OF THE SKIN. is usually chronic. The contents, a cheesy-looking mass, may com- monly be pressed out without difficulty. What is the cause of molluscum epitheliale ? It is now generally accepted that the disease is mildly contagious. It occurs chiefly in children, and especially among the poorer classes. The belief in the parasitic nature of the disease is gaining ground; recently the opinion has been advanced that it is due to psorosperms (psorospermosis). State the pathology. According to recent investigations, molluscum epitheliale is to be Fig. 21. Molluscum Epitheliale. (After Alien.) regarded as a hyperplasia of the rete, the growth probably beginning in the hair-follicles; the so-called molluscum bodies—peculiar, rounded or ovoidal, sharply-defined, fatty-looking bodies found in microscopical examination of the growth—are to be viewed as a form of epithelial degeneration. HYPERTROPHIES. 147 What are the diagnostic points in molluscum epitheliale? The size of the lesions, their waxy or glistening appearance, and the presence of the central orifice. It is to be differentiated from molluscum fibrosum, warts and acne. State the prognosis, The growths are amenable to treatment. In some instances the disease, after existing some weeks, tends to disappear spontaneously. What is the treatment of molluscum epitheliale ? Incision and expression of the contents, and touching the base of the cavity with silver nitrate. Pedunculated growths may be ligated. In some cases an ointment of ammoniated mercury, twenty to forty grains to the ounce, applied, by gently rubbing, once or twice daily, will bring about a cure. Callositas. (Synonyms: Tylosis; Tyloma; Callus; Callous; Callosity; Keratoma.) What do you understand by callositas ? A hard, thickened, horny patch made up of the corneous layers of the epidermis. Describe the clinical appearances. Callosities are most common about the hands and feet, and con- sist of small or large patches of dry, grayish-yellow looking, hard, slight or excessive epidermic accumulations. They are somewhat elevated, especially at the central portion, and gradually merge into the healthy skin. The natural surface lines are in a great measure obliterated, the patches usually being smooth and horn-like. Are there any inflammatory symptoms in callositas ? No; but exceptionally, from accidental injury, the subjacent corium becomes inflamed, suppurates, and the thickened mass is cast off. State the causes of callositas. Pressure and friction ; for example, on the hands, from the use of various tools and implements, and on the feet from ill-fitting shoes. 148 DISEASES OF THE SKIN. It is, indeed, often to be looked upon as an effort of nature to protect the more delicate corium. In exceptional instances it arises without apparent cause. What is the pathology ? The epidermis alone is involved ; it consists, in fact, of a hyper- plasia of the horny layer. State the prognosis of callositas. If the causes are removed, the accumulation, as a rule, gradually disappears. The effect of treatment is always rapid and positive, but unless the etiological factors have ceased to act, the result is usually but temporary. How is callositas treated ? When treatment is deemed advisable, it consists in softening the parts with hot-water soakings or poultices, and subsequently shaving or scraping off the callous mass. The same result may also be often effected by the continuous application, for several days or a week, of a 10 to 15 per cent, salicylated plaster, or the application of a sali- cylated collodion, same strength; it is followed up by hot-water soaking, the accumulation, as a rule, coming readily away. Clavus. (Synonym: Corn.) What is clavus ? Clavus, or corn, is a small, circumscribed, flattened, deep-seated, horny formation usually seated about the toes. Describe the clinical appearances. Ordinarily a corn has the appearance of a small callosity ; the skin is thickened, polished and horny. Exceptionally, however, occur- ring on parts that are naturally more or less moist, as between the toes, maceration takes place, and the result is the so-called soft corn. The dorsal aspect of the toes is the common site for the ordinary variety. The usual size is that of a small pea. They are painful on pressure, and, at times, spontaneously so. HYPERTROPHIES. 149 State the causes. Corns are caused by pressure and friction, and may usually be re- ferred to improperly fitting shoes. What is the pathology of clavus? It is a hypertrophy of the epiderm. Its shape is conical, with the base external and the apex pressing upon the papillae. It is, in fact, a peculiarly-shaped callosity, the central portion and apex being dense and horny, forming the so-called core. Give the treatment of clavus. A simple method of treatment consists in shaving off, after a pre- liminary hot-water soaking, the outer portion, and then applying a ring of felt or like material, with the hollow part immediately over the site of the core ; this should be worn for several weeks. It is also possible in some cases to extract the whole corn by gently dis- secting it out; the after-treatment being the same as the above. Another method is by means of a ten- to fifteen-per-cent. solution of salicylic acid, in alcohol or collodion, or the following :— R. Ac. salicylici,............gr. xxx Ext. cannabis Ind.,.........gr. x Gollodii,..............f 3 iv. M. This is painted on the corn night and morning for several days, at the end of which time the parts are soaked in hot water, and the mass or a greater part of it, will be found, as a rule, to come readily away; one or two repetitions may be necessary. Lactic acid, with one to several parts of water, applied once or twice daily, acts in a similar manner. Soft corns, after the removal of pressure, may be treated with the solid stick of nitrate of silver, or by any of the methods already mentioned. In order that treatment be permanently successful, the feet are to be properly fitted. If pressure is removed, corns will commonly disappear spontaneously. 150 DISEASES OF THE SKIN. Cornu Cutaneum. (Synonyms: Cornu Humanum; Cutaneous Horn.) What is cornu cutaneum ? A cutaneous horn is a circumscribed hypertrophy of the epidermis, forming an outgrowth of horny consistence and of variable size and shape. At what age and upon what parts are cutaneous horns ob- served ? They are usually met with late in life, and are mostly seated upon the face and scalp. Fig. 22. Cutaneous Horns. Showing beginning epitheliomatous degeneration of the base. (After Pancoasi.) Describe the clinical appearances. In appearance cutaneous horns resemble those seen in the lower animals, differing, if at all, but slightly. They are hard, sohd, dry and somewhat brittle ; usually tapering, and may be either straight, curved or crooked. Their surface is rough, irregular, laminated or HYPERTROPHIES 151 fissured, the ends pointed, blunt or clubbed. The color varies ; it is usually grayish-yellow, but may be even blackish. As commonly seen they are small in size, a fraction of an inch or an inch or there- abouts in length, but exceptionally attain considerable proportions. The base, which rests directly upon the skin, may be broad, flat- tened, or concave, with the underlying and adjacent tissues normal or the papillae hypertrophied; and in some cases there is more or less inflammation, which may be followed by suppuration. They are usually solitary formations. They are not, as a rule, painful, unless knocked or irritated. What course do cutaneous horns pursue ? Their growth is usually slow, and, after having attained a certain size, they not infrequently become loose and fall off; they are almost always reproduced. What is the cause of these horny growths ? The cause is not known; appearing about the genitalia, they usually develop from acuminated warts. They are rare formations. State the pathology of cornu cutaneum. Horns consist of closely agglutinated epidermic cells, forming small columns or rods ; in the columns themselves the cells are arranged concentrically. In the base are found hypertrophic papil- lae and some bloodvessels. They have their starting- point in the rete mucosum, either from that lying above the papillae or that lining the follicles and glands. Does epitheliomatous degeneration of the base ever occur ? Yes. State the prognosis. Cutaneous horns may be readily and permanently removed. What is the treatment ? Treatment consists in detachment, and subsequent destruction of the base ; the former is accomplished by dissecting the horn away from the base or forcibly breaking it off, the latter by means of any of the well-known caustics, such as caustic potash, chloride of zinc and the galvano-cautery. Another method is to excise the base, the horn coming away with it; this necessitates, however, considerable loss of tissue. 152 DISEASES OF THE SKIN. Verruca. (Synonym : Wart.) What is verruca ? Verruca, or wart, is a hard or soft, rounded, flat, acuminated or filiform, circumscribed epidermal and papillary growth. Name the several varieties of warts met with. Verruca vulgaris, verruca plana, verruca digitata, verruca filiformis and verruca acuminata. Describe verruca vulgaris. This is the common wart, occurring mostly upon the hands. It is rounded, elevated, circumscribed, hard and horny, with a broad base. and usually the size of a pea. At first it is smooth and covered with slightly thickened epidermis, but later this disappears to some ex- tent, the hypertrophied papillae, appearing as minute elevations, making up the growth. One, several or more may be present. Describe verruca plana. This is the so-called flat wart, and occurs commonly upon the back, especially in elderly people (cerruca senilis, keratosis pigmen- tosa). It is, as a rule, but slightly elevated, is usually dark in color, and of the size of a pea or finger-nail. Describe verruca filiformis. This is a thread-like growth about an eighth or fourth of an inch long, and occurring commonly about the face, eyelids and neck. It is usually soft to the touch and flexible. Describe verruca digitata. This is a variety of wart, which, especially about the edges, is marked by digitations, extending nearly or quite down to the base. It is commonly seen upon the scalp. Describe verruca acuminata. This variety (venereal wart, pointed wart, pointed condyloma), usually occurs about the genitalia, especially upon the mucous and muco-cutaneous surfaces. It consists of one or more groups of acuminated, pinkish or reddish, raspberry-like elevations, and, accord- HYPERTROPHIES. 153 ing to the region, may be dry or moist; if the latter, the secretion, which is usually yellowish and puriform, from rapid decomposition, develops an offensive and penetrating odor. The formation may be the size of a small pea, or may attain the dimensions of a fist. What is the cause of warts ? The etiology is not known, They are more common in adolescent and early adult life. Irritating secretions are thought to be causa- tive in tlie acuminated variety. Contagiousness has been asserted. Fig. 23. Verruca Acuminata—about the anus. (After Ashlon.) ' State the pathology of warts. A wart consists of both epidermic and papillary hypertrophy, the interior of the growth containing a vascular loop. In the acuminated variety there are marked papillary enlargement, excessive develop- ment of the mucous layer, and an abundant vascular supply. Give the treatment of warts. For ordinary warts, excision or destruction by caustics. The re- peated application of a saturated alcoholic solution of salicylic acid is often curative, the upper portion being pared off from time to tune. The filiform and digitate varieties may be snipped off with the 154 DISEASES OF THE SKIN. scissors, and the base touched with nitrate of silver; or a ligature may be used. Curetting is a valuable operative method. The growths may also be removed by electrolysis. Verruca acuminata is to be treated by maintaining absolute clean- liness, and the application of such astringents as liquor plumbi subacetatis, tincture of iron, powdered alum and boric acid. The salicylic acid solution may also be used. In obstinate cases, glacial acetic acid or chromic acid may be cautiously employed. Verruca Necrogenica. (Synonyms: Post-mortem Wart; Anatomical Tubercle; Tuberculosis Verru- cosa Cutis.) What is verruca necrogenica ? Verruca necrogenica is a rare, localized, papillary or wart-like for- Fig. 24. Verruca Necrogenica. (After Model in Guy's Museum.) mation, resulting from contact with decomposing animal matter, and occurring usually about the knuckles or other parts of the hand. Describe the symptoms. It begins, as a rule, as a small, papule-like growth, increasing HYPERTROPHIES. 155 gradually in area, and when well advanced appears as a pea, dime- sized or larger, somewhat inflammatory, elevated, flat, warty mass, with usually a tendency to slight pus formation between the hypertrophied papillae. The surface may be horny or it may be crusted. It tends to enlarge slowly and is usually persistent, but it at times undergoes involution. What is the etiology of verruca necrogenica ? Through recent investigations, it is now known to be due to inocu- lation of the tubercle bacillus—analogous, in fact, in its etiology, to lupus and other forms of tuberculosis of the skin. Give the prognosis. It is usually persistent, and may be progressive ; exceptionally, it tends, after a time, to spontaneous disappearance. What is the treatment of verruca necrogenica ? Treatment consists in its removal by means of such caustics as caustic potash, chromic and nitric acid; or by means of thorough curetting and subsequent cauterization of the base with nitrate of silver or other caustic. In some cases the continuous application of a strong (25 per cent.) salicylic-acid plaster will bring about a cure. Naevus Pigmentosus. (Synonym : Mole.) Describe naevus pigmentosus. Naevus pigmentosus, commonly known as mole, may be defined as a circumscribed increase in the pigment of the skin, usually asso- ciated with hypertrophy of one or all of the cutaneous structures, especially of the connective tissue and hair. It occurs singly or in numbers ; is usually pea-, bean-sized or larger, rounded or irregular, smooth or rough, flat or elevated, and of a color varying from a light brown to black; the hair found thereon may be either colorless or deeply pigmented, coarse and of considerable length. It is, as a rule, a permanent formation. 150 DISEASES OF THE SKIN. Name the several varieties of naevus pigmentosus met with. Naevus spilus, naevus pilosus, naevus verrucosus, and naevus lipo- matodes. What is naevus spilus ? A smooth and flat naevus, consisting essentially of augmented pigmentation alone. What is naevus pilosus ? A naevus upon which there is an abnormal growth of hair, slight or excessive. What is naevus verrucosus ? A naevus to which is added hypertrophy of the papillae, giving rise to a furrowed and uneven surface. What is naevus lipomatodes ? A naevus with excessive fat and connective-tissue hypertrophy. State the etiology of naevus pigmentosus. The causes are obscure. The growths are usually congenital; but the smooth, non-hairy moles may be acquired. Give-the pathology of naevus pigmentosus. Microscopical examination shows a marked increase in the pig- ment in the lowest layers of the rete mucosum, as well as more or less pigmentation in the corium usually following the course of the bloodvessels; in the verrucous variety the papillae are greatly hy- pertrophied, in addition to the increased pigmentation. There is, as a rule, more or less connective-tissue hypertrophy. What is the treatment of naevus pigmentosus ? In many instances interference is scarcely called for, but when de- manded consists in the removal of the formation either by the knife, by caustics, or by electrolysis. This last is, in the milder varieties at least, perhaps the best method, as it is less likely to be followed by disfiguring cicatrices. In naevus pilosus the removal of the hairs alone by electrolysis is not infrequently followed by a decided diminu- tion of the pigmentation. HYPERTROPHIES. 157 Ichthyosis. (Synonym: Fish-skin Disease.) Give a descriptive definition of ichthyosis. Ichthyosis is a chronic, hypertrophic disease, characterized by dry- ness and scaliness of the skin, with a variable amount of papillary growth. At what age is ichthyosis first observed ? It is first noticed in infancy or early childhood. What extent of surface is involved ? Usually the whole surface, but it is most marked upon the ex- tensor surfaces of the arms and legs, especially at the elbows and knees; the face and scalp, in mild cases, often remain free. Name the two varieties of ichthyosis usually described. Ichthyosis simplex and ichthyosis hystrix, terms commonly em- ployed to designate the mild and severe forms respectively. Describe the clinical appearances of ichthyosis. The milder forms of the disease may be so slight as to give rise to simple dryness or harshness of the skin (xeroderma); but as commonly met with it is more developed, more or less marked scaliness in the form of thin or somewhat thick epidermal plates being present. The papillae of the skin are often slightly hypertrophied. In slight cases the color of the scales is usually light and pearly ; in the more marked examples it is dark gray, olive green or black. In the severe variety—ichthyosis hystrix—in addition to scaliness there is marked papillary hypertrophy, forming warty or spinous patches. This type is rare, and, as a rale, the surface involved is more or less limited. Are there any inflammatory symptoms in ichthyosis ? No. In fact, beyond the disfigurement, the disease causes no incon- venience ; in those well-marked cases, however, in which the scales are thick and more or less immovable, the natural mobility of the parts is compromised and fissuring often occurs. In the winter months, in the severer cases, exposed parts may become slightly eczematous. 158 DISEASES OF THE SKIN. Does ichthyosis vary somewhat with the season ? Yes. In all cases the disease is better in the warm months, and in the mild forms may entirely disappear during this time. This favor- able change is purely mechanical—due to the maceration to which the increased activity of the sweat glands gives rise. Is the general health affected in ichthyosis ? No. What course does ichthyosis pursue ? Chronic. Beginning in early infancy or childhood, it usually becomes gradually more marked until adult age, after which time it, as a rule, remains stationary. What is the etiology ? Beyond a hereditary influence, which is often a positive factor, the causes are obscure. It is not a common disease. State the pathology. Anatomically the essential feature is epidermic hypertrophy, with usually a varying degree of papillary hypertrophy also. Mention the diagnostic features of ichthyosis. The harsh, dry skin, epidermic and papillary hypertrophy, the furfuraceous or plate-like scaliness, the greater development upon the extensor surfaces, a history of the affection dating from early childhood, and the absence of inflammatory symptoms. How is ichthyosis to be distinguished from eczema, psoriasis, and other scaly inflammatory diseases ? By the absence of the inflammatory element. What is the outlook for a case of ichthyosis ? The prognosis is unfavorable as regards a cure, but the process may usually be kept in abeyance or rendered endurable by proper measures. What treatment would you prescribe for ichthyosis ? Treatment that has in view removal of the scaliness and the maintenance of a soft and flexible condition of the skin. In mild cases frequent warm baths, simple or alkaline, will suffice ; in others an application of an oily or fatty substance, such as the HYPERTROPHIES. 159 ordinary oils or ointments, made several hours or immediately before the bath may be necessary. In moderately developed cases the skin is to be washed energetically with sapo viridis and hot water, fol- lowed by a warm bath, after which an oily or fatty application is made. In some of the more severe cases the following plan is often useful : The parts are first rubbed with a soapy ointment con- sisting of one part of precipitated sulphur and seven parts of sapo viridis ; a bath is then taken, the skin wiped dry, and a one to five per cent, ointment of salicylic acid gently rubbed in. Glycerine lotions, one or two drachms to the ounce of water, are also beneficial; as also the following :— R. Ac. salicylici, ...........gr. x-xl Glycerini,......-......3SS-3J Lanolin, Petrolati, ............aa. ^ ss In severe cases of ichthyosis hystrix it may be necessary, also, to employ caustics or the knife. What systemic treatment would you prescribe ? Constitutional remedies are practically powerless; occasionally some good is accomplished by the internal administration of linseed oil and jaborandi. Onychauxis. (Synonym : Hypertrophy of the Nail.) Describe onychauxis. Onychauxis, or hypertrophy of the nail, may take place in one or all directions, and this increase may be, and often is, accompanied by changes in shape, color, and direction of growth. One or all the nails may share in the process. As the result of lateral deviation of growth, the nail presses upon the surrounding tissues, producing a varying degree of inflammation—paronychia. What is the etiology of hypertrophy of the nail ? The condition may be either congenital or acquired. In the latter instances it is usually the result of the extension to the matrix of 160 DISEASES OF THE SKIN. such cutaneous diseases as psoriasis and eczema; or it is produced by constitutional maladies, such as syphilis. Give the treatment of hypertrophy of the nail. Treatment consists in the removal of the redundant nail-tissue by means of the knife or scissors; and, when dependent upon eczema or psoriasis, the employment of remedies suitable for these diseases. When it is the result of syphilis, the medication appropriate to this disease is to be employed. In paronychia the nail should be frequently trimmed and a pledget of lint or cotton be interposed between the edge of the nail and the adjacent soft parts; astringent powders and lotions may often be employed with advantage; and in severe and persistent cases excision of the nail, partial or complete, may be found necessary. Hypertrichosis. [Synonyms: Hirsuties ; Hypertrophy of the Hair ; Superfluous Hair.) What is meant by hypertrichosis ? Hypertrichosis is a term applied to excessive growth of hair, either as regards region, extent, age or sex. Describe the several conditions met with. The unnatural hair growth may be slight, as, for instance, upon a naevus (nacus pilosus); or it may be excessive, as in the so-called hairy people (homines pilosi) ; or it may also appear on the face, arms and other parts in females, resulting from a hypertrophy of the natural lanugo hairs. State the causes of hypertrichosis. Hereditary influence is often a factor ; the condition may also be congenital. If acquired, the tendency manifests itself usually toward middle life. In women, it is not infrequently associated with diseases of the utero-ovarian system ; in many instances, however, there is no appa- rent cause. Local irritation or stimulation has at times a causative influence. HYPERTROPHIES. 161 How is hypertrichosis to be treated. For general hypertrichosis there is no remedy. Small hairy naevi may be excised, or, as also in the larger hairy moles, the hairs may be removed by electrolysis. On the faces of women, if the hairs are coarse or large, electrolysis constitutes the only satisfactory method ; if the hairs are small and lanugo-like, the operation is not to be advised. It is somewhat painful, but never unbearable. Ftg. 25. The Russian " Dog-faced Man "—an example of excessive hypertrichosis. What temporary methods are usually resorted to for the removal of superfluous hair ? Shaving, extraction of the hairs and the use of depilatories. As a depilatory, a powder made up of two drachms of barium sulphide and three drachms each of zinc oxide and starch, is commonly (and cautiously) employed ; at the time of application enough water is addeil to the powder to make a paste, and it is then spread thinly upon the parts, allowed to remain five to fifteen minutes, or until it DISEASES OF THE SKIN. heat of skin or a burning sensation is felt, washed off thoroughly, and a soothing ointment applied. This preparation must be well pre- pared to be efficient. Describe the method of removal of super- fluous hair by electrolysis. A fine needle in a suitable handle is attached to the negative pole of a galvanic battery, intro- duced into the hair-follicle to the depth of the papilla, and the circuit completed by the patient touching the positive electrode; in several seconds slight blanching and frothing usually appear at the point of insertion ; a few seconds later the current is broken by release of the positive electrode, and the needle is then with- drawn. Sometimes a wheal-like elevation arises, remains several minutes or hours, and then disappears : or occasionally (rarely if the opera- tor is practiced and skillful) it develops into a pustule. A strength of current of a half to two milli- amperes is usually sufficient; the time necessary for the destruction of the papilla varying from several to thirty seconds. How are you to know if the papilla has been destroyed ? The hair will readily come out with but little, if any, traction. What is the result if the current has been too strong or too long continued ? The follicle suppurates and a scar results. Why should contiguous hairs not be operated upon at the same sitting ? In order that the chances of marked inflam- matory action and scarring (always possibilities) may be reduced to a minimum. HYPERTROPHIES. 163 In case of failure to destroy an individual papilla, should a second attempt be made at the same sitting ? As a rule not, in order to avoid the possibility of too much destruc- tive action, and consequent scarring. Can scarring always be prevented ? In the average case, with skill and care, the use of an exceedingly fine needle, and the avoidance of too strong a current, perceptible scarring (scarring perceptible to the ordinary observer or at ordinary distance) need rarely occur. What measures are to be advised for the irritation produced by the operation ? Hot-water applications and the use of an ointment made of two drachms cold cream and ten grains of boric acid are of advantage not only in reducing the resulting hyperaemia, but also in preventing suppuration and consequent scarring. To lessen the chances of the latter, cleansing the parts with alcohol just before and after the operation is also of service. Sclerema Neonatorum. (Synonyms : Scleroderma Neonatorum; Sclerema of the Newborn.) What is sclerema neonatorum ? Sclerema neonatorum is a disease of infancy, showing itself usually at or shortly after birth, and is characterized by a diffuse stiffness and rigidity of the integument, accompanied by coldness, oedema, discoloration, lividity and general circulatory disturbance. Describe the symptoms, course, nature and treatment of sclerema neonatorum. As a rale the disease first manifests itself upon the lower extremi- ties, and then gradually, but usually rapidly, invades the trunk, arms and face. The surface is cold. The skin, which is noted to be reddish, purplish or mottled, is oedematous, stiff and tense ; in con- sequence the infant is unable to move, respires feebly and usually perishes in a few days or weeks. In extremely exceptional instances the disease, after involving a small part, may retrogress and recovery take place. 164 DISEASES OF THE SKIN. * The disease is rare, and in most cases is found associated with pneumonia and with affections of the circulatory apparatus. Treatment should be directed toward maintaining warmth and proper alimentation. Scleroderma. (Synonyms: Sclerema; Scleriasis; Dermatosclerosis.) What is scleroderma ? Scleroderma is an acute or chronic disease of the skin characterized by a localized or general, more or less diffuse, usually pigmented, rigid, stiffened, indurated or hide-bound condition. Describe the symptoms of scleroderma. The disease may be acute or chronic, usually the latter. A portion or almost the entire surface may be involved, or it may occupy variously-sized and shaped areas. The integument becomes more or less rigid and indurated, hard to the touch, hide-bound and in marked cases immobile. (Edema may, especially in the more acute cases, precede the induration. Pigmentation, of a yellowish or brown- ish color, is often a precursory and accompanying symptom. The skin feels tight and contracted, and in some instances numbness and cramp-like pains are complained of. In exceptional cases patches of morphcea are present. The general health, as a rule, remains good. What is the course of the disease ? Sooner or later, usually after months or years, the disease ends in resolution and recovery, or in marked atrophic changes, causing con- traction and deformity. State the causes of scleroderma. The condition is to be considered as probably of neurotic origin. Exposure and shock to the nervous system are to be looked upon as influential. It is a rare disease, observed usually in early adult or middle life, and is more frequent in women than in men. It is closely allied to morphoea, and is by some observers considered identical. What is the pathology ? . In typical and advanced cases, both the true skin and the subcu- HYPERTROPHIES. icn taneous connective tissue show a marked increase of connective-tissue element, with thickening and condensation of the fibres. Is there any difficulty in reaching a diagnosis in scleroderma ? Asa rule, no. The characters—rigidity, stiffness, hardness and hide-bound condition of the skin—are always distinctive. Give the prognosis of scleroderma. It should always be guarded. In many instances recovery takes place, whilst in others the disease is rebellious, lasting indefi- nitely. What is the treatment of scleroderma ? Tonics, such as arsenic, quinia, nux vomica and cod-liver oil ; con- jointly with the local employment of stimulating, oily or fatty appli- cations, friction and electricity. Morphcea. (Synonyms: Keloid of Addison; Circumscribed Scleroderma.) What is morphcea ? Morphoea, as typically met with, is characterized by one or more rounded, oval or elongate, coin- to palm-sized, pinkish or whitish, ivory-looking patches. Describe the clinical appearances. The patches (one, several or more), occurring most frequently about the trunk, are in the beginning usually slightly hyperaemic, later becoming pale-yellowish or white, and having a pinkish or lilac border made up of minute capillaries. They are, as a rule, sharply defined, with a smooth, often shining and atrophic-looking surface ; are soft, fine or leathery to the touch, on a level or somewhat de- pressed, and appearing not unlike a piece of bacon or ivory laid in the skin. Occasionally the patches are noted to occur over nerve- tracts. The adjacent skin may be normal, or there may be more or less yellowish or brownish mottling. 166 DISEASES OF THE SKIN. The subjective symptoms of tingling, itching, numbness, and even pain, may or may not be present. What course does morphcea pursue? Its progress is slow, and the disease may last for months or years, the patches undergoing degenerative atrophic change, in some instances with a tendency to keloidal formation and consequent deformity. In other cases retrogression takes place, a spontaneous cure resulting without leaving a trace. What other cutaneous lesions are occasionally seen in asso- ciation with morphcea ? True sclerodermic areas, pit-like depressions or atrophy, telangi- ectasis and atrophic spots and lines. State the etiology of morphoea. The causes are obscure. Impaired nerve-power is probably influ- ential. It is rare, and is more common in women. It is closely allied to scleroderma. These two affections are thought by many authorities to be essentially the same disease. What is the pathology ? In the early stages there is atrophy of the papillary layer and con- nective-tissue of the corium, with cell-infiltration about the sebaceous glands, hair-follicles and bloodvessels. Later atrophy of all the skin structures takes place, the cell-infiltration changing to fibrillar tissue. From what diseases is morphcea to be differentiated? From scleroderma, vitiligo and the anaesthetic patches of leprosy. How is morphcea to be distinguished from these several dis- eases? By the peculiar appearance, the course and characters of the patches; in leprosy other symptoms are commonly present. What is the prognosis in morphoea ? The prognosis should always be guarded; the disease is uncer- tain in its duration and course, as well as rebellious to treatment, often lasting indefinitely. What treatment would you prescribe for morphoea ? Tonic, with special reference toward the nervous system; arsenic, HYPERTROPHIES. 167 quinine, cod-liver oil, and general and local galvanization or faradi- zation, deservjng special mention. Massage and friction and the use of stimulating oily applications are also serviceable. Elephantiasis. (Synonyms : Elephantiasis Arabum ; Pachydermia; Barbadoes Leg; Elephant Leg.) Give a descriptive definition of elephantiasis. Elephantiasis is a chronic hypertrophic disease of the skin and subcutaneous tissue characterized by enlargement and deformity, lymphangitis, swelling, oedema, thickening, induration, pigmenta- tion, and more or less papillary growth. Fig. 27. Elephantiasis of moderate development. (After Slurgis.) What parts are commonly involved in elephantiasis ? Usually one or both legs; occasionally the genitalia ; other parts are seldom affected. Describe the symptoms of elephantiasis. The disease usually begins with recurrent (at intervals of months 168 DISEASES OF THE SKIN. or years) erysipelatous inflammation, with swelling, pain, heat, red- ness and lymphangitis; after each attack the parts remain somewhat increased in size, although at first not noticeably so. After months or one or two years the enlargement or hypertrophy becomes con- spicuous, the part is»chronically swollen, oedematous and hard; the skin is thickened, the normal lines and folds exaggerated, the papillae enlarged and prominent, and with more or less fissuring and pigmen- tation. Fig. 28. Elephantiasis of enormous development. (After Smith.) What is the further course of the disease ? There is gradual increase in size, the parts in some instances reaching enormous proportions; the skin becomes rough and warty, eczematous inflammation is often superadded, and, sooner or later, ulcers, superficial or deep, form—which, together with the crusting and moderate scaliness, present a striking picture. There may be periods of comparative inactivity, or, after reaching a certain de- velopment, the disease may, for a time at least, remain stationary. HYPERTROPHIES. 169 Are there any subjective symptoms ? A variable degree of pain is often noted, especially marked during the inflammatory attacks. The general health is not involved. State the cause of elephantiasis. The etiology is obscure. The disease rarely occurs before puberty. It is most common in tropical countries, more especially among the poor and neglected. It is not hereditary, nor can it be said to be contagious. Inflammation and obstruction of the lymphatics, prob- ably due, according to late investigations, to the presence of large numbers of filaria (microscopic thread-worms) in the lymph channels and bloodvessels, is to be looked upon as the immediate cause. What is the pathology ? All parts of the skin and subcutaneous connective-tissue are hy- pertrophied, the lymphatic glands are swollen, the lymph channels and bloodvessels enlarged, and there is more or less inflammation, with oedema. Secondarily, from pressure, atrophy and destruction of the skin-glands, and atrophic degeneration of the fat and muscles result. What are the diagnostic characters of beginning elephan- tiasis ? Recurrent erysipelatous inflammation, attended with gradual en- largement of the parts. The appearances, later in the course of the disease, are so charac- teristic that a mistake is scarcely possible. Give the prognosis of elephantiasis. If the case comes under treatment in the first months of its devel- opment, the process may probably be checked or held in abeyance ; when well established, rarely more than palliation is possible. What is the treatment of elephantiasis ? The inflammatory attacks are to be treated on general principles. Quinia, potassium iodide, iron and other tonics are occasionally use- ful ; and, especially in the earlier stages, climatic change is often of value. Between the inflammatory attacks the parts are to be rubbed with an ointment of iodine or mercury, together with gal- vanization of the involved part. In elephantiasis of the leg, a roller or rubber bandage, or the gum stocking, is to be worn; compression and ligation of the main 170 DISEASES OF THE SKIN. artery, and even excision of the sciatic nerve, have all been em- • ployed, with more or less diminution in size as a result. In elephantiasis of the genitalia, if the disease is well advanced, excision or amputation of the parts is to be practised. Eczematous inflammation, if present, is to be treated with the ordinary remedies. Dermatolysis. (Synonym: Cutis Pendula.) Give a descriptive definition of dermatolysis. Dermatolysis is a rare disease, consisting of hypertrophy and loose- ness of the skin and subcutaneous connective tissue, with a tendency to hang in folds. Describe the symptoms and course of dermatolysis. It may be congenital or acquired, and may be limited to a small or large area, or develop simultaneously at several regions. All parts of the skin, including the follicles, glands and subcutaneous connect- ive and areolar tissue, share in the hypertrophy ; and this in excep- tional instances may be so extensive that the integument hangs in folds. The enlargement of the follicles, natural folds and rugae gives rise to an uneven surface, but the skin remains soft and pliable. There is also increased pigmentation, the integument becoming more or less brownish. What course does dermatolysis pursue ? Its development is slow and usually progressive. It gives rise to no further inconvenience than its weight and consequent discomfort. , Give the etiology. The etiology is obscure. It is considered by some authors as allied to molluscum fibrosum, and, in fact, as a manifestation of that dis- ease, ordinary molluscum tumors sometimes being associated with it. It is not malignant. What is the pathology ? The disease consists of a simple hypertrophy of all the skin struc tures and the subcutaneous connective tissue. What is the treatment of dermatolysis ? Excision when advisable and practicable. ATROPHIES. 171 CLASS V—ATROPHIES. Albinismus. What do you understand by albinismus ? Congenital absence, either partial or complete, of the pigment normally present in the skin, hair and eyes. Describe complete albinismus. In complete albinismus the skin of the entire body is white, the hair very fine, soft and white or whitish-yellow in color, the irides are colorless or light blue, and the pupils, owing to the absence of pigment in the choroid, are red; this absence of pigment in the eyes gives rise to photophobia and nystagmus. Albinos—a term applied to such individuals—are commonly of feeble constitution, and may exhibit imperfect mental development. Describe partial albinismus. Partial albinismus is met with most frequently in the colored race. In this form of the affection the pigment is absent in one, several or more variously-sized patches; usually the hairs growing thereon are likewise colorless. Is there any structural change in the skin? No. The functions of the skin are performed in a perfectly natural manner, and microscopical examination shows no departure from normal structure save the complete absence of pigment. What is known in regard to the etiology ? Nothing is known of the causes producing albinismus beyond the single fact that it is frequently hereditary. Does albinismus admit of treatment? No ; the condition is without remedy. 172 DISEASES OF THE SKIN. Vitiligo. (Synonyms: Leucoderma; Leucopathia.) Give a definition of vitiligo. Vitiligo may be defined as a disease involving the pigment of the skin alone, characterized by several or more progressive, milky-white patches surrounded by increased pigmentation. Fig. 29. Fig. 30. Vitiligo—in the Caucasian. Showing, also, the increased pigmentation of the sur- rounding skin. (After Lesser.) Describe the symptoms of vitiligo. The disease may begin at one or more regions, the backs of the hands, trunk and face being favorite parts ; its appearance is usually insidious, and the spots may not be especially noticeable until they are the size of a pea or larger. The patches grow slowly, are milky or dead white, smooth, non-elevated, and of rounded outline; the ATROPHIES. 173 bordering skin is darker than normal, showing increased pigmenta- tion. Several contiguous spots may coalesce and form a large, irregularly-shaped patch. Hair growing on the involved skin may or may not be blanched. There are no subjective symptoms. What course does vitiligo pursue ? The course of the disease is slow, months and sometimes years Fig. 31. Vitiligo—in the Negro. (After Taylor.) elapsing before it reaches conspicuous development. It may after a time remain stationary, or, in rare instances, retrogress ; as a rule, however, it is progressive. Exceptionally, the greater part, or even the whole surface may eventually be involved. Give the etiology of vitiligo. Disturbed innervation is thought to be influential. The disease 174 DISEASES OF THE SKIN. develops often without apparent cause. Alopecia areata and mor- ■ phcea have been observed associated with it. State the pathology of vitiligo. The disease consists, anatomically, of both a diminution and in- crease of the pigment—the white patch resulting from the former, and the pigmented borders from the latter. There is no textural change, the skin in other respects being normal. From what diseases is vitiligo to be differentiated ? From morphoea and fi'om the anaesthetic patches of leprosy. In what respects do these diseases differ from vitiligo ? In morphoea there is textural change, and in leprosy both textural change and constitutional or other symptoms. What prognosis is to be given ? It should always be guarded, the disease in almost all cases being irresponsive to treatment. What is the treatment of vitiligo ? The general health is to be looked after, and remedies directed especially toward the nervous system to be employed. Arsenic, in email and continued doses, seems at'times to have an influence ; when there is lack of general tone it may be prescribed as follows:— R. Liq. potassii arsenitis,........f^j Tinct. nucisvom.,.........f3 iij Elix. calisayse, . . . . q. s. ad . . . f^iv. M. ff Wa.-fsj t. d. When upon exposed parts, stimulation of the patches, with the view of producing hypersemia and consequent pigment deposit; con- joined with suitable applications to the surrounding pigmented skin, with a view to lessen the coloration (see treatment of chloasma), will be of aid in rendering the disease less conspicuous. Or the condition may be, in a measure, masked by staining the patches with walnut juice or similar pigment. ATROPHIES. 17.") Canities. (Synonym : Grayness of the Hair.) Describe canities. Canities, or graying of the hair, may occur in localized areas or it may be more or less general; the blanching may be slight, scarcely amounting to slight grayness, or it may be complete. It is common to advancing years (canities senilis); it is seen also exceptionally in early life (canities praiuatura). The condition is usually perma- nent. The loss of pigment takes place, as a rule, slowly, but several apparently authentic cases have been reported in which the change occurred in the course of a night or in a few days. What is the etiology of canities ? The causes are obscure. Heredity is usually an influential factor, and conditions which impair the general nutrition have at times an etiological bearing. Intense anxiety, fright, and other profound ner- vous shock are looked upon as causative in sudden graying of the hair. Give the treatment. Canities is without remedy. Dyeing, although not to be advised, is often practised, and the condition thus masked. Alopecia. (Synonym: Baldness.) What do you understand by alopecia ? By alopecia is meant loss of hair, either partial or complete. Name the several varieties of alopecia. The so-called varieties are based mainly upon the etiology, and are named congenital alopecia, premature alopecia and senile alopecia. Describe congenital alopecia. Congenital alopecia is a rare condition, in which the hair-loss is usually noted to be patchy, or the general hair-growth may simply be scanty. In rare instances the hair has been entirely wanting; in such cases there is usually defective development of other structures, such as the teeth. 176 DISEASES OF THE SKIN. Describe premature alopecia. Loss of hair occurring in early and middle adult life is not uncom- mon, and may consist of a simple thinning or of more or less com- plete baldness of the whole or greater part of the scalp. It usually develops slowly, some months or several years passing before the condition is well established. It is often idiopathic, and without apparent cause further than probably a hereditary predisposition. It may also be symptomatic, as, for example, the loss of hair, usually rapid (defluvium capillorum), following systemic diseases, such as the various fevers, and syphilis; or as a result of a long-continued sebor- rhoea or seborrhoeic eczema (alopecia furfuracea). Describe senile alopecia. This is the baldness so frequently seen developing with advancing years, and may consist merely of a general thinning, or, more com- monly, a general thinning with a more or less complete baldness of the temporal and anterior portion or of the vertex of the scalp. What is the prognosis in the various varieties of alopecia? In those cases in which there is a positive cause, as, for instance, in symptomatic alopecia, the prognosis is, as a rale, favorable, especially if no family predisposition exists. In the congenital and senile vari- eties the condition is usually irremediable. In idiopathic premature alopecia, the prognosis should be extremely guarded. How would you treat alopecia ? By removing or modifying the predisposing factors by appro- priate constitutional remedies, and by the external use of stimulating applications. Name several remedies or combinations usually employed in the local treatment. Sulphur ointment, full strength or weakened with lard or vaseline ; a lotion of resorcin consisting of one or two drachms to four ounces of alcohol, to which is added ten to thirty minims of castor oil; and a lotion made up as follows :— R. Tinct. cantbaridis,.........f^iv Tinct. capsici,...........i"3J 01. ricini,.............f^ss-f^j Alcoholis, .... q. s. ad.....f 5 iv. M. ATROPHIES. 177 The following is sometimes beneficial: — R. Resorcin..............^ i Quinina? (alkaloid),.........gr. xv 01. ricini,.............TTLv-n\.xx Alcobolis,.............f ^ iv.—M. And also the various other stimulating applications employed io alopecia areata (q. v.). (The application selected should be thoroughly rubbed in daily or every second or third day, according to the case.) Alopecia Areata. (Synonyms : Area Celsi; Alopecia Circumscripta.) What do you understand by alopecia areata ? Alopecia areata is an affection of the hahy system, in which occur Fig. 33. Alopecia Areata. (After Robinson.) one or more circumscribed, round or oval patches of complete bald- ness unattended by any marked alteration in the skin. 12 178 DISEASES OF THE SKTN. Upon what parts and at what age does the disease occur ? In the large majority of cases the disease is limited to the scalp ; but it may invade other portions of the body, as the bearded region, eyebrows, eyelashes, and, in rare instances, the entire integument. It is most common between the ages of ten and forty. Describe the symptoms of alopecia areata. The disease begins either suddenly, without premonitory symp- toms, one or several patches being formed in a few hours ; or, and as is more usually*the case, several days or weeks elapse before the bald area or areas are sufficiently large to become noticeable. The patches continue to extend peripherally for a variable period, and then remain -stationary, or several gradually coalesce and form a large, irregular area involving the entire or a greater portion of the scalp. The skin of the affected regions is smooth, faintly pink or milky white, and Flu. 34. Alopecia Areata—resulting in complete hair loss. (After Michelson.) at first presents no departure from the normal; sooner or later, how- ever, the follicles become less prominent, and slight atrophy or thinning may occur, the bald plaques being slightly depressed. Occasionally, usually about the periphery and in the early stages, a few hair-stumps may be seen. * ATROPHIES. 179 What course does alopecia areata pursue ? Almost invariably chronic. After the lapse of a variable period the patches cease to extend, the hairs at the margins of the bald areas being firmly fixed in the follicles; sooner or later a fine, colorless lanugo or down shows itself, which may continue to grow until it is about a half-inch or so in length and then drop out; or it may remain, become coarser'and pigmented, and the parts resume their normal condition. Not infrequently, however, after growing for a time, the new hair falls out, and this may happen several times before the termination of the disease. Are there any subjective symptoms in alopecia areata ? As a rule, not; but occasionally the appearance of the patches is preceded by severe headache, itching or burning, or other manifes- tations of disturbed innervation. State the cause of alopecia areata. The etiology is obscure. Two theories as to the cause of the dis- ease exist: one of these regards it as parasitic, and the other con- siders it to be trophoneurotic. Doubtless both are right, as a study of the literature would indicate that there are, as regards etiology, really two varieties—the contagious and the non-contagious. In America examples of the contagious variety are uncommon. Does the skin undergo any alterative or destructive changes ? Microscopical examination of the skin of the diseased area shows little or no alteration in its structure beyond slight thinning. How do you distinguish alopecia areata from ringworm ? The plaques of alopecia areata are smooth, often completely devoid of hair, and free from scales; while those of ringworm show numerous broken hairs and stumps, desquamation, and usually symptoms of mild inflammatory action. In doubtful cases recourse should be bad to the microscope. What is the prognosis in alopecia areata ? The disease is often rebellious, but in children and young adults the prognosis is almost invariably favorable, permanent loss of hair being uncommon. The same holds true, but to a much less extent, with the disease as occurring in those of more advanced age. In extensive cases—those in which the hair of the entire scalp finally 180 DISEASES OF THE SKIN. entirely disappears, and sometimes involves all hairy parts—the prognosis is unfavorable. Only exceptionally does recovery ensue in such instances. The uncertain duration, however, must be borne in mind; months, and in some instances several years, may elapse before complete restoration of hair takes place. Relapses are not uncommon. How is alopecia areata treated? By both constitutional and local measures, the former having in View the invigoration of the nervous system, and the latter stimu- lation of the affected areas. Give the constitutional treatment. Arsenic is perhaps the most valuable remedy, while quinine, nux vomica, pilocarpine, cod-liver oil and ferruginous tonics may, in suit- able cases, often be administered with benefit. Name several remedies or combinations employed in the external treatment of alopecia areata. Ointments of tar and sulphur of varying strength; the various mercurial ointments; the tar oils, either pure or with alcohol; stimulating lotions, containing varying proportions, singly or in combination, of tincture of capsicum, tincture of cantharides, aqua ammoniae, and oil of turpentine, as in the following :— R. Tinct. capsici, Tinct. cantharidis, 01. terebinthinae, . . . . aa.....sjiiss. M. In obstinate patches repeated blistering, or the cautious use of a five to twenty per cent, chrysarobin ointment, is of value. Painting the patches with pure carbolic acid or trikresol every ten days or two weeks sometimes acts well; it should not be applied over large areas, nor used in young children, (lalvanization or faradization of the affected parts may also be employed, and with, occasionally, beneficial effect. (The strength of the applications will depend upon circumstances, a mild degree of irritation being desirable; they are to be thor- oughly rubbed in, the friction employed being not without value). ATROPHIES. 181 Atrophia Pilorum Propria. (Synonym : Atrophy of the Hair.) What do you understand by atrophy of the hair ? An atrophic, brittle, dry condition of the hair, and which may be either symptomatic or idiopathic. Describe the several conditions met with. As a symptomatic affection, the dry, brittle condition of the hair met with in seborrhoea, in severe constitutional diseases, and in the various vegetable parasitic affections, may be referred to. As an idiopathic disease it is rare, consisting simply of a brittle:- ness and an uneven and irregular formation of the hair-shaft, with a tendency to split up into filaments (fragilitas crinium); or there may be localized swelling and bursting of the hair-shaft, the nodes thus produced having a shining, semi-transparent appearance (trichorexis nodosa). This latter usually occurs upon the beard and moustache. State the causes of atrophy of the hair. The causes of the symptomatic variety are usually evident; the etiology of idiopathic atrophy is obscure. Trichorexis Nodosa. (After Michelson.) What would be your prognosis and treatment in atrophy of the hair ? Symptomatic atrophy usually responds to proper measures, but always slowly ; treatment is based upon the etiological factors. For the idiopathic disease little, as a rule, can be done ; repeated shaving or cutting the hair has, in exceptional instances, been fol- lowed by favorable results. 182 DISEASES OF THE SKIN. Atrophia Unguis. (Synonyms: Atrophy of the Nails; Onychatrophia.) Describe atrophy of the nails. The nails are soft, thin and brittle, splitting easily, and are often opaque and lustreless, and may have a worm-eaten appearance. Several or more are usually affected. State the causes of atrophy of the nails. The condition may be congenital or acquired, usually the latter. It may result from trauma, or be produced by certain cutaneous diseases, notably eczema and psoriasis ; or it may follow injuries or diseases of the nerves. Syphilis and chronic wasting constitutional diseases may also interfere with the normal growth of the nail-sub- stance, producing varying degrees of atrophy. The fungi of tinea trichopbytina and tinea favosa at times invade these structures and lead to more or less complete disintegration—onychomycosis. Fig. 36. Atrophy of the Nails. What is the treatment of atrophy of the nails ? Treatment will depend upon the cause. When it is due to eczema ATROPHIES. 183 or psoriasis, appropriate constitutional and local remedies should be prescribed. If it is the result of syphilis, mercury and potassium iodide are to be advised. In onychomycosis—an exceedingly obsti- nate affection—the nails should be kept closely cut and pared, and a one- to five-grain solution of corrosive sublimate applied several times a day ; a lotion of sodium hyposulphite, a drachm to the ounce, is also a valuable and safe application. Atrophia Cutis. (Synonyms: Atrophoderma; Atrophy of the Skin.) What do you understand by atrophy of the skin ? By atrophy of the skin is meant an idiopathic or symptomatic wasting or degeneration of its component elements. State the several conditions met with. Glossy skin, general idiopathic atrophy of the skin, parchment skin, atrophic lines and spots, senile atrophy, and the atrophy fol- lowing certain-cutaneous diseases. Describe glossy skin (atrophoderma neuriticum), and state the treatment. Glossy skin is a rare condition following an injury or disease of the nerve. It is usually seen about the fingers. The skin is hairless, faintly reddish, smooth and shining, with a varnished and thin appearance, and with a tendency to fissuring. More or less severe and persistent burning pain precedes and accompanies the atrophy. Protective applications are called for, the disease tending slowly to spontaneous disappearance. Describe general idiopathic atrophy of the skin, and give the treatment. (! eneral idiopathic atrophy of the skin is extremely rare, and is characterized by a gradual, more or less general, degenerative and quantitative atrophy of the skin stractures, accompanied usually with more or less discoloration and pigmentation. Treatment is palliative and based upon indications. 184 DISEASES OF THE SKIN. Describe parchment skin, and state the treatment. Parchment skin (xeroderma pigmentosum^ angioma pigmentosum et atrophicum) is a rare disease, the exact nature of which is not understood. It is characterized by the appearance of numerous disseminated, freckle-like pigment-spots, telangiectases, atrophied muscles, more or less shrinking and contraction of the integument, and followed, in most instances, by epitheliomatous tumors and ulceration, and finally death. It is usually slow in its course, begin- ning in childhood and lasting for years. It is not infrequently seen in several children of the same family. Treatment is palliative, consisting, if necessary, of the use of protective applications and of the administration of tonics and nutrients. Describe atrophic lines and spots. Atrophic lines and spots (strive et macula; atrophica) may be idio- pathic or symptomatic, the lesions consisting of scar-like or atrophic- looking, whitish lines and macules, most commonly seen on the trunk. They are smooth and glistening. Slight hyperaemia usually precedes their formation. As an idiopathic disease its course is insidious and slow, and its progress eventually stayed. The so-called lincce albican tes, resulting from the stretching of the skin produced by pregnancy or tumors, and from rapid development of fat, may be mentioned as illustrating the symptomatic variety. In course of time the atrophy becomes less conspicuous. Describe senile atrophy. Senile atrophy is not uncommon, the atrophy resulting, as the name inferentially implies, from advancing age. It is characterized by thinning and wasting, dryness, and a wrinkled condition, with more or less pigmentation and loss of hair. Circumscribed pigment- ary deposits and seborrhoea, with degeneration, are also noted. What several diseases of the skin are commonly followed by atrophic changes ? Favus, lupus, syphilis, leprosy, scleroderma and morphoea. NEW GROWTHS. 185 CLASS VI—NEW GROWTHS. Keloid. (Synonyms: Keloid of Alibert; Cheloid.) Give a descriptive definition of keloid. Keloid is a fibro-cellular new growth of the corium appearing as one or several variously-sized, irregularly-shaped, elevated, smooth, firm, pinkish or pale-reddish cicatriform lesions. Describe the clinical appearance of keloid. The growth begins as a small, hard, elevated, pinkish or reddish tubercle, increasing gradually, several months or years usually elaps- ing before the tumor reaches conspicuous size. AVhen developed, it is one or more inches in diameter, is sharply defined, elevated, hard, rounded or oval, fungoid or crab-shaped, and firmly implanted in the skin. It is usually pinkish, pearl-white, or reddish, commonly devoid of hair, with no tendency to scaliness, and with, usually, several vessels coursing over it. In some instances it is tender, and it may be spontaneously painful. The breast, especially over the sternal region, is a favorite site for its appearance. One, several or more may be present in the single case. What course does keloid pursue ? Chronic; usually lasting throughout life. In rare instances spon- taneous involution takes place. State the etiology of keloid. The causes are obscure. The growth usually takes its start from some injury or lesion of continuity; for instance, at the site of burns, cuts, acne and smallpox scars, etc.—cicatricial keloid, false keloid; or it may also, so it is thought, originate in normal skin—sponta- neous keloid, true keloid. What is the pathology of keloid ? The lesion is a connective-tissue new growth having its seat in the corium. 186 DISEASES OF THE SKIN. Is there any difficulty in the diagnosis of keloid? No. It resembles hypertrophic scar; but this latter, which is essentially keloidal, never extends beyond the line of injury. Give the prognosis. The growth is persistent and usually irresponsive to treatment. What is the treatment of keloid ? Usually palliative, consisting of the continuous application of an ointment such as the following :— R. Acidi salicylici,...........gr. x-xx Emplast. plumbi, Emplast. saponis,.....aa . . . . ^iij _ Petrolati, .............^ij. M. An ointment of ichthyol, twenty-five per cent, strength, rubbed in pnce or twice daily, is sometimes beneficial. Operative measures, such as punctate and linear scarification, electrolysis and excision, are occasionally practised, but the results are rarely satisfactory and permanent; not infrequently, indeed, renewed activity in the progress of the growth is noted to follow. Fibroma. (Synonyms: Molluscum Fibrosum; Fibroma Molluscum.) What do you understand by fibroma ? Fibroma is a connective-tissue new growth characterized by one or more sessile or pedunculated, pea- to egg-sized or larger, soft or firm, rounded, painless tumors, seated beneath and in the skin. Describe the clinical appearances of fibroma. The growth may be single, in which case it is apt to be peduncu- lated or pendulous, and attain considerable dimensions; as a result of weight or pressure surface-ulceration may occur. Or, and as commonly met with, the lesions are numerous, scattered over large surface, and vary in size from a pea to a cherry ; the overlying skin being normal, pinkish or reddish, loose, stretched, hypertrophied or atrophied. Tbe tumors are painless. The general health is not involved. NEW GROWTHS. 187 What is the course of fibroma ? Chronic and persistent. FIG. 37. Fibroma. (After Octerlony.) What is the etiology of fibroma ? The cause is not known. Heredity is often noted. The affection is not common. 188 DISEASES OF THE SKIN. State the pathology of fibroma. The growths are variously thought to have their origin in the connective tissue of the corium, or in that of the wails of the hair- sac, or in the connective-tissue framework of the fatty tissue. Recent tumors are composed of gelatinous, newly-formed connective tissue, and the older growths of a dense, firmly-packed, fibrous tissue. From what growths is fibroma to be differentiated ? From molluscum contagiosuni, neuroma and lipoma ; the first is differentiated by its central aperture or depression, neuroma by its painfullness, and lipoma by its lobulated character and soft feel. Give the prognosis of fibroma. The disease is persistent, and irresponsive to all treatment save operative measures. What is the treatment of fibroma ? Treatment consists, when desired and practicable, in the removal of the growths by the knife, or in large and pedunculated tumors by the ligature or by the galvano-cautery. Neuroma. Describe neuroma. Neuroma of the skin is an exceedingly rare disease, characterized by the formation of variously-sized, usually numerous, firm, immovable, and elastic fibrous tubercles containing new nerve-elements, and ac- companied by violent, paroxysmal pain. Their growth is slow and usually progressive. Later they are painful upon pressure. They are limited to one region. The tumors are seated in the corium, extending into the deeper structure, and consist of nerve-fibres, yellow elastic tissue, blood ves- sels and lymphoid cells. In the two cases reported, excision of the nerve-trunk gave, in one instance, permanent relief; in the other the effect was only temporaiy. NEW (iKOWTIIS. 189 Xanthoma. (Synonyms : Vitiligoidea ; Xanthelasma.) What is xanthoma ? Xanthoma is a connective-tissue new growth characterized by the formation of yellowish, circumscribed, irregularly-shaped, variously- sized, non-indurated, flat or raised patches or tubercles. Name the two varieties met with. The macular or flat (xanthoma planum) and the tubercular (xanthoma tuberculatum or tuberosum). In some instances both varieties (xanthoma multiplex) are seen in the same individual. Describe the clinical appearances of xanthoma planum. The macular or flat variety is usually seen about the eyelids. It consists of one, several or more small or large, smooth, opaque, sharply-defined, often slightly raised, yellowish patches, looking not unlike pieces of chamois-skin implanted in the skin. Describe the clinical appearances of xanthoma tuberosum. The tubercular variety is commonly met with upon the neck, trunk and extremities. It occurs as small, raised, isolated, yellowish nodules, or as patches made up of aggregations of millet-seed-sized or larger tubercles. The lesions may be few or they may exist in great numbers. What is the course of xanthoma ? Extremely slow; after reaching a certain development the growths may remain stationary. State the etiology of xanthoma. The causes are obscure. Jaundice not infrequently precedes and accompanies its development, especially in the tubercular variety. The disease is uncommon, and is usually seen in middle and advanced life, and more frequently in women. What is the pathology of xanthoma ? It is a benign, connective-tissue new growth, with concomitant or subsequent, but usually partial, fatty degeneration. 190 DISEASES OF THE SKIN. Give the prognosis of xanthoma. The condition is persistent, and usually irresponsive to all treat- ment save destructive or operative measures. What is the treatment of xanthoma ? Treatment consists, in suitable cases, of excision; in some in- stances, electrolysis is serviceable. Myoma. (Synonyms: Myoma Cutis; Dermatomyoma; Liomyoma Cutis.) Describe myoma. The disease is rare, and consists usually of one or several (excep- tionally numerous), variously-sized tumors of the skin, made up of smooth muscular fibres. They are flat, rounded, oval or peduncu- lated, and have a smooth surface and a pale-red color; as a rale, they are painless. The growth is benign, and consists essentially of a new formation of unstriped muscular fibres; but it may also be composed largely of connective tissue (fibromyoma); or it may contain an abundance of bloodvessels (myoma telangiectodes, angiomyoma) ; or there may be lymphatic involvement (Jymphangiomyoma). Angioma. (Synonyms: Na>vus Vasculosus; Naevus Sanguineus.) Give a definition of angioma. Angioma is a congenital hypertrophy of the vascular tissues of the corium and subcutaneous tissue. Exceptionally it makes its appear- ance a few weeks or a month after birth. Into what two classes may angiomata be roughly grouped ? The flat (or non-elevated) and the prominent (or elevated). Describe the flat, or non-elevated, variety of angioma. The flat, or non-elevated, angioma (merits flammeus, ncevus sim- plex, angioma simplex, capillary ntvvus) may be pin-head- to bean- sized ; or it may involve an area of several inches in diameter, and, NEW GROWTHS. 191 exceptionally, a whole region. It is of a bright- or dark-red color, and is met with most frequently about the face. In some instances it extends after birth, reaches a certain size and then remains station- ary ; occasionally, when involving a small area, it undergoes involu- tion and disappears. The so-called port-wine mark is included in this group. Describe the prominent, or elevated, variety of angioma. The prominent variety (venous noevus, angioma cavernosum, ncevus tuberosus) is variously-sized, often considerably elevated, clearly- defined, compressible, smooth or lobulated, and of a dark, purple color ; it may, also, be erectile and pulsating. The growth is usually a single formation, and is met with upon all parts of the body. What is the pathology of angioma ? It is a new growth, consisting of a variable hypertrophy of the cutaneous and subcutaneous arterial and vein ais bloodvessels, with or without an increase of the connective tissue. Give the treatment of angioma. In some instances, especially in infants, painting the parts repeat- edly with collodion or liquor plumbi subacetatis will act favorably. For well-established, small, capillary naevi electrolysis or puncturing with a red-hot needle or with a needle charged with nitric acid may be employed; for '' port-wine mark'' frequent and closely contiguous electrolytic punctures are occasionally followed by a slight diminution in color. For the prominent growths, vaccination, the ligature, puncturing with the galvano-cautery and excision are variously resorted to. Telangiectasis. Describe telangiectasis. Telangiectasis consists of a new growth or enlargement of the cutaneous capillaries, usually appearing during middle adult life, and seated, for the most part, about the face. To what extent may telangiectasis develop ? It may be limited to a red dot or point, with several small radiat- 192 DISEASES OF THE SKIN. ing capillaries (nacus araneus, spider navus), or a whole region, usually the face, may show numerous scattered or closely-set capillary enlargements or new formations (rosacea). The latter is frequently associated with acne (acne rosacea). The etiology is obscure. What is the treatment of telangiectasis ? Destruction of the vessels by electrolysis or by the knife. (See treatment of acne rosacea.) Lymphangioma. (Synonym : Lymphangiectodes.) Describe lymphangioma. Lymphangioma is a rare disease, consisting of localized dilatations of the lymphatic vessels, appearing as discrete or aggregated pin- head or pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish or faint lilac color, and occurring for the most part about the trunk. It is of slow but usually progressive development, and is unaccompanied by subjective symptoms. A rare condition, probably a variety of this affection, with some- what similar general features, but in which the lesions are more or less solid and somewhat painful, has been described under the name of lymphangioma tubeirjsum multiplec. Treatment, when demanded, consists of operative measures. Rhinoscleroma. Describe rhinoscleroma. Rhinoscleroma is a rare and obscure disease, slow but progressive in its course, characterized by the development of an irregular, dense and hard, flattened, tubercular, non-ulcerating, cellular new growth, having its seat about the nose and contiguous parts. The overlying skin is normal in color, or it may be light- or dark-brown or reddish. Marked disfigurement and closure, partial or complete, of the nasal NEW GROWTHS. 193 orifices gradually results. It is met with chiefly iu Austria and Germany. Treatment, consisting of partial or complete extirpation, is rarely permanent iu its results, the disease tending to recur. Fig. 38. Rhinoscleroma. (After Bebra.) Lupus Erythematosus. (Synonyms: Lupus Erythematodes; Lupus Sebaceus; Seborrhoea Congestiva.) What is lupus erythematosus ? Lupus erythematosus may be roughly defined as a small-celled new growth, characterized by one, several or more circuinscribed, variously-sized and shaped, pinkish or dark red patches, covered slightly, and more or less irregularly, with adherent grayish or yel- lowish scales. Upon what parts is lupus erythematosus observed ? Its common site is the face, usually the nose and cheeks, with a tendency toward symmetry; it is often limited to these parts, but may occasionally be seen upon other regions, more especially the lips, ears, and scalp. In rare instances a great part of the general surface may become involved. 13 67 194 DISEASES OF THE SKIN. Describe the symptoms of lupus erythematosus. Usually the disease begins as one or several rounded, circuinscribed, pin-head- to pea-sized lesions ; slightly scaly, somewhat elevated, and of a pinkish, reddish or violaceous color. They slowly, or somewhat rapidly, increase in area, and after attaining variable size remain stationary; or they may progress and coalesce, and in this manner sooner or later involve considerable surface. The patches are sharply defined against the sound skin by an elevated border, while the central portion is somewhat depressed and usually atrophic. More or less thickening and infiltration are observed. There is no tendency to ulceration. The scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous or plugged with sebaceous and epithelial matter. The subjective symptoms of burning and itching are usually slight and often wanting. What course does lupus erythematosus pursue ? As a rule, the disease is persistent, although somewhat variable. At times the patches retrogress, involution taking place with or without slight sieve-like atrophy or scarring. State the causes of lupus erythematosus. The etiology is obscure. Some observers believe it to be a variety of cutaneous tuberculosis. It is essentially a disease of adult and middle age; is more common in women, and more frequent in those having a tendency to disorders of the sebaceous glands. It may, in fact, begin as a seborrhoea. What is the pathology ? It was formerly considered a new growth, but recent opinion tends toward regarding it as a chronic inflammation of the cutis, superin- ducing degenerative and atrophic changes. The disease in many cases originates in the sebaceous glands. There is no tendency to pus formation. Is there any difficulty in the diagnosis of lupus erythematosus? As a rule, not, as the features of the disease—the sharply circum- scribed outline, the reddish or violaceous color, the elevated border, the tendency to central depression and atrophy, the plugged up or patulous sebaceous ducts, the adherent grayish or yellowish .scales, together with the region attacked (usually the nose and cheeks)— are characteristic. NEW GROWTHS. 195 State the prognosis of lupus erythematosus. The disease is often capricious and extremely rebellious to treat- ment; on the other hand, some cases yield readily, and occasionally Fig. 39. Vertical section of skin from a patch of Lupus Erythematosus. (AfterNeumann.) a,enlarged papillae, with cell-infiltration; b, collection of cells; e, hair (cut off); d, sebaceous gland, with infiltration; e, arrector pili. a tendency to spontaneous disappearance is observed. The disease in no wise compromises the general health. In those rare instances of generalized disease the patient has usually died from an inter- current tuberculosis. 196 DISEASES OF THE SKIN. How is lupus erythematosus to be treated ? The general health is to be looked after and systemic treatment prescribed, if indicated. As a rule, constitutional remedies exert little, if any, influence, but exceptionally, cod-liver oil, arsenic, phosphorus, salicin, quinine, or potassium iodide proves of ser- vice. Locally, according to the case, soothing remedies, stimulating ap- plications and destruction of the growth by caustics or operative measures are to be employed. (Try the milder applications first.) Mention the stimulating applications commonly employed. Washing the parts energetically with tincture of sapo viridis, rins- ing and applying a soothing ointment, such as.cold cream or vaseline. A lotion containing zinc sulphate and potassium sulphuret thoroughly dabbed on the parts morning and evening :— R. Zinci sulphatis, Potassii sulphureti, . . . . aa . . . Sss-ijij Alcoholis,.............f^j Glycerinse,.............f^ss Aquae, ..............f3uJ- M. The calamine-and-zinc oxide lotion used in acute eczema is also often extremely valuable. Lotions of ichthyol and of resorcin, five to sixty grains to the ounce; ichthyol in ointment, five- to twenty-per-cent. strength, is also useful. Painting the patches with pure carbolic acid ; repeating a day or two after the crusts have fallen off. The continuous application of mercurial plaster. Sulphur and tar ointments, officinal strength or weakened with lard, and also the following :— R. 01. cadini, Alcoholis, Saponis -viridis,.....aa.....giiss. M. (This is to be rubbed in, in small quantity, once or twice daily, and later a soothing remedy applied.) NEW GROWTHS. 197 When are destructive and operative measures justifiable? In obstinate, sluggish and long persistent patches, and then only after other methods of treatment have failed. (Remember that the disease may disappear in course of time spontaneously, and occa- sionally without leaving a scar.) State the methods of treatment commonly used in obstinate, sluggish and persistent patches of lupus erythematosus. Cauterization—with nitrate of silver, with a {(plications of pyro- gallic acid in ointment or in liciuor gutta-perchae, fifteen to thirty Fig. 40. Single Scarifier. per cent, strength, and with solutions (cautiously employed) of caus- tic potash, and exceptionally with the galvano-cautery. Operative—scarification, either punctate or linear, and erasiouwith the curette. (See treatment of lupus vulgaris.) Fio. 41. 3 Multiple Scarifier. (As modified by Van Harlingen.) What operative method of treatment promises the best re- sult with the least amount of scarring ? The method by linear scarification. It is a tedious one, but the results, especially in a cosmetic sense, are gratifying. Lupus Vulgaris. (Synonyms : Lupus; Lupus Exedens; Lupus Yorax; Tuberculosis of the Skin.) What do you understand by lupus vulgaris ? Lupus vulgaris is a cellular new growth, characterized by variously- 198 DISEASES OF THE SKIN. sized, soft, reddish-brown, papular, tubercular and infiltrated patches, usually terminating in ulceration and scarring. Upon what region is lupus vulgaris usually observed ? The face, especially the nose, but any part may be invaded. The area involved may be small or quite extensive, usually the former. At what age is the disease noted ? In many cases it begins in childhood or early adult life, but as it is persistent and tends to relapse, it may be met with at any age. Describe the earlier symptoms of lupus vulgaris. The disease begins by the development of several or more pin-head to small pea-sized, deep-seated, brownish-red or yellowish tubercles, having their seat in the deeper part of the corium, and which are somewhat softer and looser in texture than normal tissue. As the disease progresses, variously-sized and shaped aggregations or patches result, covered with thin and imperfectly-formed epidermis. What changes do the lupus tubercles or infiltrations undergo ? The lesions, having attained a certain size or development, may remain so for a time, but sooner or later retrogressive changes occur: the matured papules or tubercles, or infiltrated patches, slowly dis- appear by absorption, fatty degeneration taking place, leaving an exfoliating, atrophic or cicatricial tissue—lupus exfoliatives ; or dis- integration and destruction result, terminating in ulceration—lupus exedens, lupus exulcerans. This latter is the usual course. Describe the clinical appearances and behavior of the lupus ulcerations. They are rounded, shallow excavations, with soft and reddish borders. In exceptional instances exuberant granulations appear— lupus hypertrophicus; or papillary outgrowths are noted—lupus ver- rucosus. The ulcerations secrete a variable amount of pus, usually slight in quantity, which leads to more or less crust formation ; later, however, cicatricial tissue, generally of a firm and fibrous character, results. In what manner does the disease spread ? The patches spread by the appearance of new papules, or infiltra- tions at the peripheral portion. New islets and areas of disease may Lupus Vulgaris. * 1 Lupus Vulgaris. NEW GROWTHS. 199 continue to make their appearance from time to time, usually upon contiguous parts. Are the mucous membranes of the mouth, throat and larynx ever involved ? In some instances, and either primarily or secondarily. Fig. 42. Vertical section of a lupus tubercle, greatly magnified. (After Neumann.) a rete mucosum ; b, cell-infiltration in the papillae ; c, and d, accumulations of cells ' in the upper and lower layers of the corium; e, cell-infiltration iu the pan niculus adiposus. Is the bone tissue ever involved in lupus vulgaris? 200 DISEASES OF THE SKIN. What course does lupus vulgaris pursue ? It is slowly but, as a rule, steadily progressive. Several years or more may elapse before the area of disease is conspicuous. What is the cause of lupus vulgaris ? It is now known to be due to the invasion of the cutaneous struct- ures by the tubercle bacillus; in short, a tuberculosis of the skin. It is not infrequently observed in the strumous and debilitated. It is entirely independent of syphilis. What is the pathology of lupus vulgaris ? According to recent investigations, the infiltrations of lupus are due chiefly to cell-proliferation and outgrowth from the protoplasmic walls and adventitia of the bloodvessels and lymphatics. The fibrous-tissue network, vessels and a portion of the cell infiltration are thus produced, the fixed and wandering connective-tissue cells of the inflamed stroma of the cutis being responsible for the other portion of the new growth (Robinson). State the diagnostic features of lupus vulgaris. In a typical, developed patch of lupus are to be seen :—cicatricial formation, usually of a fibrous and tough character; ulcerations ; the yellowish-brown tubercles and infiltration; and the characteristic soft, small, yellowish or reddish-brown, cutaneous and subcutaneous points and papules. How does the tubercular syphiloderm differ from lupus vul- . garis ? The tubercular syphiloderm is much more rapid in its course, the ulceration is deeper and the discharge copious and often offen- sive ; the scarring is soft, and, compared to the amount of ulceration, but slightly disfiguring ; and it is, for obvious reasons, a disease of adult or late life. The history, together with other evidences of previous or concomitant symptoms of syphilis, will often aid in the differentiation. How does epithelioma differ from lupus vulgaris ? The edges of the epitheliomatous ulcer are hard, elevated and waxy ; the base is uneven, the secretion thin, scanty and apt to be streaked with blood ; the ulceration usually starts from one point, NEW GROWTHS. 201 and is often painful; the tissue destruction may be considerable; there is little, if any, tendency to the formation of cicatricial tissue; and, finally, it is usually a disease of advanced age. In what respects does lupus erythematosus differ from lupus vulgaris ? Lupus erythematosus has no papules, tubercles or ulceration. How does acne rosacea differ from lupus vulgaris ? Acne rosacea is characterized by hyperaeniia, ddated vessels, papules, pustules, the absence of ulceration, and a different history. State the prognosis of lupus vulgaris. Lupus vulgaris is always a chronic disease, often exceedingly Fig. 43. Galvano-cautery Needle, Knife and Spiral Points. (As devised by Bisnier.) rebellious to treatment, and one that calls for a guarded opinion. Relapses are not uncommon. The general health usually remains good,, but in some instances death by tuberculosis of the lungs has been noted. Holder for Galvano-cautery Instruments. Is external or internal treatment called for in lupus vulgaris ? Always external, and not infrequently constitutional also. 202 DISEASES OF THE SKIN. What is the constitutional treatment ? The general health must be cared for; good, nutritious food, fresh air and out-door exercise, together with, in many cases, the administration of such remedies as cod-liver oil, potassium iodide, iron and quinine, are of therapeutic importance. Tuberculin may be tried in severe and obstinate cases, but its use is not without danger. Fig. 45. Cautery Battery. State the object of local treatment. The destruction or removal of the diseased tissue. May milder methods of treatment sometimes prove beneficial and even curative ? Exceptionally, mercurial plaster, corrosive-sublimate lotion and ointment (gr. j to ^j), a plaster containing five to fifteen per cent. �999999999999999999� NEW GROWTHS. 203 of salicylic acid and creasote, repeated paintings with carbolic acid, and the constant application of lead plaster containing twenty per cent, of ichthyol, are valuable. What methods are commonly employed for the removal or destruction of lupus tissue ? Cauterization, scarification, erasion and excision are variously prac- tised; the particular method depending, in great measure, upon the extent of the disease, the part involved, and other circumstances. Name the several caustics, and state how they are employed. Nitrate of silver stick; this is applicable to small areas or discrete lesions, and is thoroughly bored into the parts. The operation is repeated every several days. Pi/rogallic acid, used as an ointment:— R . Ac. pyrogallici,...........Z ij Emplast. plumbi,..........3J Cerat. resime.............3 v. M. It is applied for one or two weeks. Every several days the parts are poulticed, the slough thus removed, and the ointment reapplied, and so on until the diseased tissue has been destroyed. It is useful in those cases in which a mild and comparatively painless caustic is advisable. Fig. 4f>. Double Curette. Arsenions acid, employed as an ointment— R. Ac. arseniosi,............gr. xx Hydrarg. sulphid. rub.,.......gr. lx Ungt. aqure rosae...........5 i.—M. It is painful but thorough ; it is spread on lint and renewed daily. The action is usually sufficient in three days, and the parts are then 204 DISEASES OF THE SKIN. poulticed until the slough comes away, after which a simple dressing is employed. Its application is advisable for a small area only— not more than four square inches—as absorption is possible. Galea no-cautery.—The diseased tissue is destroyed by numerous punctures with a red-heated point or by linear incision with a red- heated knife. It is often a practicable and satisfactory method. Describe the operative measures employed in the removal of lupus tissue. Linear Scarification.—The parts are thoroughly cross-tracked, cutting through the diseased tissue, and subsequently a simple salic- ylated ointment applied. The operation is repeated from time to time, and as a result the new growth undergoes retrogressive changes, and cicatrization takes place. Punctate Scarification.—Ry means of a simple or multiple-pointed instrument numerous closely-set punctures are made, and repeated from time to time, usually with the same action and result as from linear scarification. Erasion.—The parts are thoroughly scraped with a curette, and a supplementary caustic application made, either with caustic potash or several days' use of the pyrogallic-acid ointment. The result is usually satisfactory. The dental-burr is also useful in breaking up discrete tubercles. Excision.—This is an effective method if the disease consists of a small pea- or bean-sized circumscribed patch. Scrofuloderma. (Synonym : Tuberculosis cutis.) What do you understand by scrofuloderma? The term scrofuloderma is applied to those peculiar suppurative and ulcerative conditions of the skin occurring in strumous subjects. How does the common type of scrofuloderma begin? The most common type of scrofulous ulceration or involvement of the skin usually results by extension from an underlying caseating and suppurating lymphatic gland; or it may have its origin as sub- NEW GROWTHS. 205 cutaneous tubercles independently of these stractures. It tends to spread, and may involve an area of one or several inches. What are the clinical appearances and behavior of scrofu- lous ulceration? It is usually superficial, has thin, red, undermined edges of a viola- ceous color, and an irregular base with granulations covered scantily with pus. As a rule, it spreads gradually as a simple ulceration, with but slight, if any, outlying infiltration. Subjective symptoms of a painful or troublesome character are rarely present. Its course is usually progressive but slow and chronic. Other symptoms of a scrofulous nature are commonly to be found. Are other forms of scrofuloderma met with ? A papulo-pustular eruption is sometimes observed, especially on the upper extremities and face; sluggish and chronic in character and leaving small pit-like scars. An ulcerative papillomatous or verrucous tuberculosis of the skin is also occasionally noted, most commonly seated upon the lower leg or the back of the hand. It may be slight or extensive. Its mildest phase is the so-called verruca necrogenica (q. v.). State the etiology of scrofuloderma. Heredity, insufficient and unwholesome food, impure air, and the like are predisposing. The tubercle bacillus is-the immediate excit- ing cause. The disease usually appears in childhood or early adult life, and not infrequently follows in the wake of some severe systemic disease. Etiologically it is identical in nature with lupus. How is scrofuloderma to be differentiated from lupus vulgaris and syphilis ? By the peculiar character of the scrofulous ulceration, the absence of outlying tubercles and infiltration, together with its history, course, and often the presence of other strumous symptoms. State the prognosis of scrofuloderma. It usually responds to appropriate measures of treatment. As a rule, there is but little, if any, tendency to spontaneous cure. What is the treatment of scrofuloderma ? Constitutional remedies, such as cod-liver oil, iodide of iron or other 206 DISEASES OF THE SKIN. ferruginous tonics, together with good food and pure air ; calx sul- phurata, in one-tenth grain doses every three hours, and phosphorus one-hundredth to one-fiftieth of a grain three times daily, are also of benefit in some cases. The local treatment consists in thorough curetting and the sub- sequent application of a mildly stimulating ointment. The several other plans of external treatment employed in lupus (q. v.) are also variously practised. Ainhum. Describe ainhum. Ainhum is a disease of the African race, met with chiefly in Brazil, the West Indies, and Africa, and consists of a slow but gradual linear strangulation of one or more of the toes, especially Jj^mallest, resulting, eventually, in spontaneous amputation. The affected toes themselves undergo fatty degeneration, often with increase in size, and are, when strangulation is well advanced, con- siderably misshapen. The nature of the disease is obscure. Treatment consists, in the early stages, of incision through the constricting band ; when the disease is well advanced, amputation is the sole recourse. Podelcoma. (Synonyms: Fungous Foot of India; Madura Foot; Mycetoma.) Describe podelcoma. It is a disease involving usually the foot, and is met with chiefly in India. It is characterized by swelling and the formation of tuber- cular or nodular lesions which break down and form the external openings of sinuses which lead to the interior of the affected part. These discharge, and are studded with, whitish granules or black, roe-like masses, mixed with a sanious or sero-purulent fluid. The whole part is gradually disintegrated, the process lasting indefinitely. Its nature is obscure ; it is thought to be due to a fungus. Treatment consists in the early stages, when the disease is lim- ited, of thorough curetting and cauterization; later, after the part is more or less involved, amputation, at a point well up beyond the disease becomes necessary. NEW GROWTHS. 207 Perforating Ulcer of the Foot. Describe perforating ulcer of the foot. Perforating ulcer of the foot is a rare disease, consisting of an indolent and usually painless sinus leading down to diseased bone. The external opening, which is through the centre of a corn-like formation, is small, and may or may not show the presence of granu- lations. The affected part is commonly more or less anaesthetic and of subnormal temperature. One or several may be present, either on one or both feet. The most common site is over the articulation of the metatarsal bone with the phalanx of the first or last toe. The disease is dependent upon impairment or degeneration of the central, truncal or peripheral nerves. What is to be said in regard to the prognosis and treatment ? Treatment, which is, as a rule, unsatisfactory, consists in the makf* tenance of absolute rest, and the use of antiseptic and stimula- ting applications. Amputation is also resorted to, but even this is at times futile, as a new sinus may appear upon the stump. Syphilis Cutanea. (Synonyms : Syphiloderma; Dermatosyphilis; Syphilis of the Skin.) In what various types may syphilis manifest itself upon the integument ? Syphilis may show itself as a macular, papular (rarely vesicular), pustular, bullous, tubercular and gummatous eruption; or the erup- tion may be, in a measure, of a mixed type. In what respects do the early (or secondary) eruptions of syphilis differ from those following several years or more after the contraction of the disease ? The early or secondary eruptions are more or less generalized, with rarely any attempt at special configuration. Their appearance is often preceded by symptoms of systemic disturbance, such as fever, loss of appetite, muscular pains and headache ; and accompanied by concomitant signs of the disease, such as enlargement of the lym 208 DISEASES OF THE SKIN. phatic glands, sore throat, mucous patches, falling of the hair and rheumatic pains. State the distinguishing characters of the late eruptions. , The late eruptions (those following one or more years after /the contraction of the disease) are usually of tubercular, gummatous or ulcerative type ; are limited in extent, and have a marked tendency to appear in circular, semicircular or crescentic forms or groups, Pain in the bones, bone lesions and other symptoms may or may not be present. What is the color of syphilitic lesions ? Usually, a dull brownish-red or ham-red, with at times a yellowish cast. Are there any subjective symptoms in syphilitic eruptions? As a rule, no; but in exceptional instances of the generalized eruptions, more especially in negroes, there may be slight itching. Describe the macular, or erythematous, eruption of syphilis. The macular syphiloderm is a general eruption, showing itself usually six or eight weeks after the appearance of the chancre. It consists of small or large, commonly pea- or bean-sized, rounded or irregularly-shaped, not infrequently slightly raised, macules. When well established they do not entirely disappear under pressure. At first a pale-pink or dull, violaceous red, they later become yellowish or coppery. The eruption is generally profuse ; the face, backs of the hands and feet may escape. It persists several weeks or one or two months ; as a rule, it is rapidly responsive to treatment. How would you distinguish the macular syphiloderm from measles, rbtheln and tinea versicolor ? Measles is to be differentiated by its catarrhal symptoms, fever, form and situation of the eruption ; rbtheln, by its small, roundish, confluent pinkish or reddish patches, its precursory pyrexic symp- toms, its epidemic nature, and short duration; tinea versicolor by its scaliness, peripheral growth, distribution and history. And, finally, by the absence or presence of other symptoms of syphilis. i^£ Small-papular Syphiloderm. NEW GROAVTHS. 209 What several varieties of the papular eruption of syphilis are met with ? There are two forms of the papular eruption—the small and large; those of the latter type may undergo various modifications. Describe the small-papular eruption of syphilis. The small-papular syphiloderm {miliary papular syphiloderm) usually shows itself in the third or fourth month of the disease, and consists of a more or less generalized eruption of disseminated or grouped, firm, rounded or acuminated pin-head to millet-seed-sized papules, with smooth or slightly scaly summits, and in some lesions showing pointed pustulation. Scattered minute pustules and some large papules are usually present. The eruption is profuse, most abun- dant upon the trunk and limbs; and in the early part of the out- break is of a bright- or dull-red color, later assuming a violaceous or Fig. 47. Moist Papules. (After Miller.) brownish tint. It runs a chronic course, is somewhat rebellious to treatment, and displays a tendency to relapse. How would you distinguish the small-papular syphiloderm from keratosis pilaris, psoriasis punctata, papular ec- zema, and lichen ruber ? The distribution and extent of the eruption, the color, the group- 14 210 DISEASES OF THE SKIN. ing, with usually the presence of pustules and large papules and other concomitant symptoms of syphilis, are points of difference. Pus- tules never occur in the several diseases named, except in eczema. Describe the large-papular eruption of syphilis. The large-papular syphiloderm (or lenticular syphiloderm) is a common form of cutaneous syphilis, appearing usually in the first six or eight months, and consists of a more or less generalized erup- tion of pea- to dime-sized or larger, flat, rounded or oval, firmly- seated, more or less raised, dull-red papules ; with at first a smooth surface, which later usually becomes covered with a film of exfolia- ting epidermis. The papules, as a rale, develop slowly, remain sta- tionary several weeks or a few months, and then pass away by absorption, leaving slight pigmentation, which gradually fades; or they may undergo certain modifications. In most cases it responds rapidly to treatment. Fig. 48. Palmar Syphiloderm. (After Keyes.) What modifications do the papules of the large-papular syphi- loderm sometimes undergo ? They may change into the moist papule and squamous papule. Describe the moist papule of syphilis. The change into the moist papule (also called mucous patch, flat condyloma) is not uncommon where opposing surfaces and natural folds of skin are subjected to more or less contact, as about the nates, the scroto-femoral regions, umbilicus, axillae and beneath the NEW GROWTHS. 211 mammae. The dry, flat papules gradually become moist and cov- ered with a grayish, sticky, mucoid secretion ; several may coalesce and form large, flat patches. They may so remain, or they may become hypertrophic, warty or papillomatous, with more or less crust formation (vegetating syphiloderm). Fig. 49. Annular Syphiloderm. (After I. E. Atkinson.) Describe the squamous papule of syphilis. This tendency of the large-papular eruption to become scaly, when exhibited, is more or less common to all papules, and constitutes the squamous or papulosquamous syphiloderm (improperly called pso- riasis syphilitica). The papules become somewhat flattened and are covered with dry, grayish or dirty-gray, somewhat adherent scales. The scaling, as compared to that of psoriasis, is, as a rule, relatively slight. The eruption may be general, as usually the case in the earlier months of the disease, or it may appear as a relapse or a later manifestation, and be limited in extent. As a limited eruption it is most frequently seen on the palms and soles—the j^'dmar and plantar syphiloderm. Occurring on these parts it is often rebellious to treatment. 212 DISEASES OF THE SKIN. How are you to distinguish the papulo-squamous syphilodenn from psoriasis ? In psoriasis the eruption is more inflammatory, and usually bright red; the scales whitish or pearl-colored and, as a rule, abundant. It is generally seen in greater profusion upon certain parts, as, for instance, the extensor surfaces, especially of the elbows and knees. It is not infrequently itchy, and, moreover, presents a different history. In the syphilitic eruption some of the papules almost invariably remain perfectly free from any tendency to scale formation ; there is distinct deposit or infiltration, and the lesions are of a dark, sluggish red or ham tint; and, moreover, concomitant symptoms of syphilis are usually present. Describe the annular eruption of syphilis. The annular syphiloderm (circinate syphiloderm) is observed usu- ally in association with the large-papular eruption, and consists of several or more variously- sized, ring-like lesions, with a distinctly elevated solid ridge or wall peripherally and a more or less flattened centre. It is commonly seen about the mouth, forehead and neck. The lesion appears to have its origin from an ordinary, usually scale- less or slightly scaly, large papule, the central portion of which has been incompletely formed or has become sunken and flattened. The manifestation is rare, and is seen most frequently in the negro. What several varieties of the pustular syphiloderm are met with? The small acuminated-pustular syphiloderm, the large acuminated- pustular syphiloderm, the small flat-pustular syphiloderm, and the large flat-pustular syphiloderm. Describe the small acuminated-pustular eruption of syphilis. The small acuminated-pustular syphiloderm (miliary pustular syphiloderm) is an early or late secondary eruption, commonly en- countered in the first six or eight months of the disease. It con- sists of a more or less generalized, disseminated or grouped, millet- seed-sized, acuminated pustules, usually seated upon dull-red, papular elevations. The eruption is, as a rule, profuse, and usu- ally involves the hair-follicles. The pustules dry to crusts, which fall off and are often followed by a slight, fringe-like exfoliation NEW GROWTHS. 213 around the base, constituting a grayish ring or collar. Minute pin- point atrophic depressions or stains are left, which gradually become less distinct. Scattered large pustules, and sometimes papules, are not infrequently present. Describe the large acuminated-pustular eruption of syphilis. The large acuminated-pustular syphiloderm (acne-form syphilo- derm, variola-form syphiloderm) is a more or less generalized erup- tion, occurring usually in the first six or eight months of the disease. It consists of small or large pea-sized, disseminated or grouped, acuminated or rounded pustules, resembling the lesions of acne and variola. They develop slowly or rapidly, and at first may appear more or less papular. They dry to somewhat thick crusts, and are seated upon superficially ulcerated bases. It pursues, as a rale, a comparatively rapid and benign course. In relapses the eruption is usually more or less localized. How would you distinguish the large acuminated-pustular syphiloderm from acne and variola ? In acne the usual limitation of the lesions to the face or face and shoulders, the origin, more rapid formation and evolution of the individual lesions, and the chronic character of the disease, are usually distinctive points. In variola, the intensity of the general symptoms, the shot-like beginning of the lesions, their course, the umbilication, and the definite duration, are to be considered. The presence or absence of other symptoms of syphilis has, in obscure cases, an important diagnostic bearing. Describe the small flat-pustular eruption of syphilis. The small flat-pustular syphiloderm (impetigo-form syphiloderm) consists of a more or less generalized, pea-sized, flat or raised, discrete, irregularly-grouped, or in places confluent, pustules, appearing usually in the first year of the disease. The pustules dry rapidly to yellow, greenish-yellow, or brownish, more or less adherent, thick, uneven, somewhat granular crusts, beneath which there may be superficial or deep ulceration ; where the lesions are confluent a continuous sheet of crusting forms. The eruption is often scanty. It is most fre- quently observed about the nose, mouth, hairy parts of the face and 214 DISEASES OF THE SKIN. scalp, and about the genitalia, frequently in association with papules on other parts. Are you likely to mistake the small flat-pustular syphilo- derm for any other eruption ? Scarcely; but when upon the scalp, it may bear rough resem- blance to pustular eczema, but the erosion or ulceration will serve to differentiate. Moreover, concomitant symptoms of syphilis are to be looked for. Describe the large flat-pustular eruption of syphilis. The large flat-pustular syphiloderm (ecthyma-form syphiloderm) consists of a more or less generalized, scattered eruption, of large pea- or dime-sized, flat pustules. They dry rapidly to crasts. The bases of the lesions are a deep-red or copper color. Two types of the eruption are met with. In one type—the superficial variety—the crust is flat, rounded or ovalish, of a yellowish-brown or dark-brown color, and seated upon Fig. 50. Rupia. (After Tilbury Fox ) a superficial erosion or ulcer. The lesions are usually numerous, and most abundant on the back, shoulders anil extremities. It appears, as a rule, within the first year, and generally runs a benign course. NEW (1R0WTHS. 215 In the other type—the deep variety—the crust is greenish or blackish, is raised and more bulky, often conical and stratified, like an oyster shell—rupia; beneath the crusts may be seen rounded or irregular-shaped ulcers, having a greenish-yellow, puriform secre- tion. It is usually a late and malignant manifestation. How would you differentiate the large flat-pustular syphilo- derm from ecthyma? The syphilitic lesions are more numerous, are scattered, are attended with superficial or deep ulceration, and followed by more or less scar-formation. Moreover, the history, and presence or absence of other symptoms of syphilis have an important diagnostic value. Describe the bullous eruption of syphilis. The bullous syphiloderm (of acquired syphilis) is a rare and usually late eruption, appearing in the form of discrete, disseminated, rounded or ovalish, pea- to walnut-sized, partially or fully distended, blebs. The serous contents soon become cloudy and puriform. In some cases the lesions are distinctly pustular from the beginning. The crust, which soon forms, is of a yellowish-brown or dark green color, and may be thick and stratified (rupia), as in the deep variety of the large flat-pustular syphiloderm. The erosions or ulcers be- neath the crasts secrete a greenish-yellow fluid. It is a malignant type of eruption, and is usually seen in broken-down subjects. It is not an uncommon manifestation of hereditary syphilis (q. v.) in the newborn. How is the bullous syphiloderm to be differentiated from other pemphigoid eruptions ? By the gravity of the disease, the accompanying ulceration, the course and history; and by other evidences, past or present, of syphilis. Describe the tubercular eruption of syphilis. The tubercular syphiloderm (syphiloderma tuberculosum) may ex- ceptionally occur within the first year as a more or less generalized eruption. As a rule, however, it is a late manifestation, at times appearing many years after the initial lesion; is limited in extent, and shows a decided tendency to occur in groups, often forming seg- ments of circles and circular areas, clearing in the centre and spread- ing peripherally. 216 DISEASES OF THE SKIN. It consists (as a late, limited manifestation) of several or more firm, circumscribed, deeply-seated, smooth, glistening or slightly scaly elevations ; rounded or acuminated in shape, of a yellowish-red, brownish-red or coppery color and usually of the size of small or large peas. Several groups may coalesce, and a serpiginous *ract result (serpiginous tubercular syphiloderm). The lesions develop slowly, and are sluggish in their course, remaining, at times, for weeks or months, with but little change. As a rule, however, they termi- nate sooner or later, either by absorption, leaving a more or less permanent pigment stain with or without slight atrophy (non-ulcera- ting tubercular syphiloderm), or by ulceration (ulcerating tubercu- lar syphiloderm). Describe the ulcerating tubercular syphiloderm. The ulceration may be superficial or deep in character, and involve Fig. 51. Ulcerating Tubercular Syphiloderm. (After Keyes.) several or all of the lesions forming the group. The patch may consist, therefore, of small, discrete, punched-out ulcers, or of one or more continuous ulcers, segmental, crescentic or serpiginous in *».. .»».•«'**•* Tubercular Syphiloderm. Large-pustular Syphiloderm. NEW GROWTHS. 217 shape. They arc covered with a gummy, grayish-yellow deposit or they may be crusted. As the ulcerative changes take place, new lesions, especially about the periphery of the group or patch, may appear from time to time. In some instances, more especially about the scalp, the surface of the ulcerations becomes papillary or wart-like, with an offensive, yel- lowish, puriform secretion (syphilis cutanea popdlomatosa). From what diseases is the tubercular syphiloderm to be differentiated ? From tubercular leprosy, epithelioma and lupus vulgaris, especially the last-named. What are the chief diagnostic characters of the tubercular syphiloderm ? Tlie tendency to form segments, crescents and circles, the color, the pigmentation and ulceration, the history, and not infrequently marks or scars of former eruptions. Describe the gummatous eruption of syphilis. The gummatous syphiloderm (syphiloderma gummatosum, gum- ma, syphiloma) is usually a late manifestation, showing itself as one, several or more painless or slightly painful, rounded or flat, more or less circumscribed tumors ; they are slightly raised, moderately firm, and have their seat in the subcutaneous tissue. They tend to break down and ulcerate. The lesion begins usually as a pea-sized deposit or infiltration, and grows slowly or rapidly ; when fully developed it may be the size of a walnut, or even larger. The overlying skin becomes gradually reddish. At first firm, it is later soft and doughy. It may, even when well advanced, disappear by absorption, but usually tends to break down, terminating in a small or large, deep, punched-out ulcer. Does the gummatous syphiloderm invariably appear as a rounded well-defined tumor ? No. Exceptionally, instead of a well-defined tumor, it may ap- pear as a more or less diffused patch of infiltration, leading eventu- ally to extensive superficial or deep ulceration. 218 DISEASES OF THE SKIN. From what formations is the gummatous syphiloderm to be differentiated? From furuncle, abscess, and sebaceous, fatty and fibroid tumors. Attention to the origin, course, and behavior of the lesion, to- gether with a history, must all be considered in doubtful cases. Fig. 52. Gummata. (After Jullien.) What is to be said in regard to the character and time of appearance of the cutaneous manifestations of heredi- tary syphilis ? In a great measure the cutaneous manifestations of hereditary syphilis are essentially the same as observed in acquired syphilis. They are usually noted to occur within the first three months of extra-uterine life. The macular, papular, and bullous eruptions are most common. Describe these several cutaneous manifestations of hereditary syphilis. The macular (erythematous) eruption begins as large or small, bright- or dark-red macules, later presenting a ham or cafe-au-lait appearance. At first they disappear upon pressure. The lesions are NEW GROWTHS. 219 more or less numerous, usually become confluent, especially about the folds of the neck, about the genitalia and buttocks; in these regions resembling somewhat erythema intertrigo. The papular eruption is observed in conjunction with the erythe- matous manifestation, or it occurs alone. The lesions are but slightly elevated, and seem to partake of the nature of both macules and papules. They are usually discrete, and rarely abundant; they may become decked with a film-like scale, and at the various points of junction of skin and mucous membrane, and in the folds, they become abraded and macerated, developing into moist papules. The bullous eruption consists of variously-sized, more or less puru- lent blebs, and is usually met with at or immediately following birth. It is most abundant about the hands and feet Macules and papules are often interspersed. There may be superficial or deep ulceration underlying the bullae. What other symptoms in addition to the cutaneous manifes- tations are noted in hereditary syphilis in the new- born? Mucous patches, and sometimes ulcers, in the mouth and throat; hoarseness, as shown by the peculiar cry, and indicating involve- ment of the larynx ; snuffles, a sallow and dirty appearance of the skin, loss of flesh and often a shriveled or senile look. What is the pathology of cutaneous syphilis ? The syphilitic deposit' consists of round-cell infiltration. The mucous layer, the corium, and in the deep lesions the subcutaneous connective tissues also, are involved in the process. The infiltration disappears by absorption or ulceration. Give the prognosis of cutaneous syphilis. In acquired syphilis, favorable ; sooner or later, unless the whole system is so profoundly affected by the syphilitic poison that a fatal ending ensues, the cutaneous manifestations disappear, either spon- taneously or as the result of treatment. The earlier eruptions will often pass away without medication, but treatment is of material aid in moderating their severity and hastening their disappearance, and is to be looked upon as essential; in the late syphilodermata treatment is indispensable. In the large pustular, the tubercular and gummatous lesions, considerable destraction of tissue may take 220 DISEASES OF THE SKIN. place, and in consequence scarring result. Ill-health from any cause predisposes to a relapse, and also adds to the gravity of the case. In hereditary infantile syphilis, the prognosis is always uncertain : the more distant from the time of birth the manifestations appear the more favorable usually is the outcome. How is cutaneous syphilis to be treated ? Always with constitutional remedies ; and in the graver eruptions, and especially in those more or less limited, with local applications also. What constitutional and local remedies are commonly em- ployed in cutaneous syphilis ? Constitutional Remedies.—Mercury and potassium iodide; tonics and nutrients are necessary in some cases. Local Remedies.—Mercurial ointments, lotions and baths, and iodol in ointment or in (and also calomel) powder form. Give the constitutional treatment of the earlier, or secondary, eruptions of syphilis. In secondary or early eruptions mercury alone in almost every case; with tonics, if called for. If mercury is contraindicated (extremely rare), potassium iodide may be substituted. How is mercury usually administered in the eruptions of sec- ondary syphilis ? By the mouth, chiefly as the protiodide, calomel and blue mass, in dosage just short of mild physiological action ; by inunction, in the form of blue ointment; by hypodermic injection, usually as corrosive sublimate solution ; and by fumigation, with calomel and the bisulphuret. The method by the mouth is the common one, and it is only in rare instances that any other method is necessary or advisable. What local applications are usually advised in the eruptions of secondary syphilis ? If the eruption is extensive, and more especially in the pustular types, baths of corrosive sublimate (3ij-3iv to Cong, xxx) may be used ; and ointment of ammoniated mercury, twenty to sixty grains to the ounce, blue ointment, and the ten per cent, oleate of mercury alone or with an equal quantity of any ointment base. NEW GKOWTHS. 221 The same applications or a dusting powder of calomel may also be used on moist papules. How long is mercury to be actively continued in cases of early (secondary) syphilis ? Until one or two months after all manifestations (cutaneous or other) have disappeared, and then, as a general rale, continued, as a small daily dose, for one to two years—unless there should be some contraindication. (Almost all authorities arc agreed as to the importance of pro- longed treatment, but differ somewhat on the question of intermittent or uninterrupted administration.) Give the constitutional treatment of the late, or localized, syphilodermata. Mercury always, usually in small or moderate dosage, as the binio- dide or corrosive chloride, and potassium iodide ; the latter in dose varying from two grains to two drachms or more, t. d., depending upon its action and the urgency of the case. How long is constitutional treatment to be continued in cases of the late syphilodermata ? Actively for several weeks after the disappearance of all symptoms, and then (especially the mercury) continued in smaller dosage (about one-third) for one or two months longer. What applications are usually advised in the late, or localized, syphilodermata ? Ointment of ammoniated mercury, twenty to sixty grains to the ounce ; oleate of mercury, five to ten per cent, strength ; mercurial plaster, full strength or weakened with lard or petrolatum ; a two to twenty per cent, ointment of iodol; resorcin, twenty to sixty grains to the ounce of ointment base ; and lotions of corrosive sublimate, one-half to three grains to the ounce. The following is valuable in offensive and obstinate ulcerations :— R. Hydrarg. chlorid. corros.,......gr. iv-gr. viij Ac. carbolici,............gr. x-xx Alcoholis,.............f5>iv Glycerinse,.............fgj Aquae.......q. s. ad.....^ iv. M. 222 DISEASES OF THE SKIN. Ointments are to be rubbed in or applied as a plaster ; lotions, em- ployed chiefly in ulcers and ulcerations, are to be thoroughly dabbed on, and usually supplemented by the application of an ointment. Iodol may also be applied to ulcers as a dusting-powder, usually mixed with one to several parts of zinc oxide or boric acid. Give the treatment of hereditary infantile syphilis. It is essentially the same (but much smaller dosage) as employed in acquired syphilis. Attention to proper feeding and hygiene is of first importance. Mercury may be given by the mouth, as mercury with chalk (gr. ss-gr. ij, t. d.); as calomel (gr. ^-gr. £, t. d.); and as a solution of corrosive sublimate (gr. ss-^vj, 3j, t. d.). If mercury is not well borne by the stomach, it may be administered by inunction ; for this purpose, blue ointment is mixed with one or two parts of lard and spread (about a drachm) upon an abdominal bandage and applied, being renewed daily. Treatment by means of baths (gr. x-xxx to the bath) of corrosive sublimate is, at times, a serviceable method. Potassium iodide, if exceptionally deemed preferable, may be given in the dose of a fractional part of a grain to two or three grains three times daily. What local measures are to be advised in cutaneous syphilis of the newborn ? If demanded, applications similar to those employed in eruptions of acquired syphilis, but not more than one-third to one-half the strength. Lepra. (Synonyms : Leprosy ; Elephantiasis Graecorum.) What do you understand by leprosy ? Lepra, or leprosy, is an endemic, chronic, malignant constitutional disease, characterized by alterations in the cutaneous, nerve, and bone structures ; varying in its morbid manifestations according to whether the skin, nerves or other tissues are predominantly involved. What is the nature of the premonitory symptoms of leprosy ? In some instances the active manifestations- appear without pre- NEW GROWTHS. 223 monition, but in the majority of cases symptoms, slight or severe in character, pointing toward profound constitutional disturbance, such as mental depression, malaise, chills, febrile attacks, digestive derangements and bone pains, are noticed for weeks, months, or several years preceding the outbreak. What several varieties of leprosy are observed ? Two definite forms are usually described—the tubercular and the anaesthetic. A sharp division-line cannot, however, always be drawn ; not infrequently the manifestations are of a mixed type, or one form may pass into or gradually present symptoms of-the other. Tubercular Leprosy. (After Stoddard.) Describe the symptoms of tubercular leprosy. The formation of tubercles and tubercular masses of infiltration, usually of a yellowish-brown color, with subsequent ulceration, constitute the important cutaneous symptoms. Along with, or pre- ceding these characteristic lesions, blebs and more or less infiltrated, hyperajsthetic or anaesthetic, pinkish, reddish or pale-yellowish 224 DISEASES OF THE SKIN. macules make their appearance from time to time; subsequently fading away or remaining permanently (lepra maculosa). When well advanced, the tubercular or nodular masses give rise to great deformity; the face, a favorite locality, becomes more or less leonine in appearance (leontiasis). The tubercles persist almost indefinitely without material change, or undergo absorption or ulcer- ation ; this last takes place most commonly about the fingers and toes. The mucous membrane of the mouth, pharynx and other parts may also become involved. Fig. 54. Anaesthetic Leprosy. (After A.C.W. Beecher.) Describe the symptoms of anaesthetic leprosy. Following or along with precursory symptoms denoting general systemic disturbance, or independently of any prodromal indications, a hyperassthetic condition, in localized areas or more or less general, is observed. Lancinating pains along the nerves and an irregular NEW GROWTHS. 225 pemphigoid eruption are also commonly noted. There soon follows the special eruption, coming out from time to time, and consisting of several or more, usually non-elevated, well-defined, pale-yellowish patches, one or two inches in diameter. As a rule, they are at first neither hyperaesthetic nor anaesthetic, but may be the seat of slight burning or itching. They spread peripherally, and tend to clear in the centre. The patches eventually become markedly anaesthetic, and the overlying skin, and the skin on other parts as well, becomes atrophic and. of a brownish or yellowish color. The subcutaneous tissues, muscle, hair and nails undergo atrophic or degenerative changes, and these changes are especially noted about the hands and feet. These parts become crooked, the bone tissues are involved, the phalanges dropping off or disappearing by disintegration or absorption (lepra mutilans). Sooner or later various paralytic symptoms, showing more active involvement of the nerve trunks, present themselves. State the cause of leprosy. Present knowledge points to a peculiar bacillus as the active factor, while climate, soil, heredity, food and habits exert a predis- posing influence. Is leprosy contagious ? 'The consensus of opinion points to the acceptance of the possible contagiousness of leprosy; probably by inoculation, but only under certain unknown favoring conditions. What are the pathological changes ? The lesions consist essentially of a new growth, made up of numerous small, more or less aggregated round cells, beginning in the walls of the bloodvessels. In this way the tubercular masses •>nd various other lesions are formed. As yet, positive involvement ot the central nervous system has not been shown, but some of the nerve trunks are found to be inflamed and swollen, with a tendency toward hardening. What several diseases are to be eliminated in the diagnosis of leprosy ? Syphilis, morphoea, vitiligo, lupus, and syringomyelia. When well advanced, the aggregate symptoms of leprosy form a 15 226 DISEASES OF THE SKIN. picture which can scarcely be confused with that of any other dis- ease. In doubtful cases microscopical examinations of the involved tissues, for the bacilli, should be made. State the prognosis of leprosy. Unfavorable; a fatal termination is almost invariable, but may not be reached for a number of years. The tubercular form is the most grave, the mixed variety next, and the anaesthetic the least. Pa- tients are not infrequently carried off by intercurrent disease. Proper management will often delay the fatal ending, and exceptionally, in the anaesthetic variety, stay the progress of the disease. What is the treatment of leprosy ? Hygienic measures are important. Chaulmoogra oil and gurjun oil internally and externally are in some instances of service. Strychnia alone, or with either of these oils, is ofttimes beneficial. Ichthyol internally, and external applications of the same drug, and of resorcin, chrysarobin, and pyrogallic acid, have been extolled. Change of climate, especially to a region where the disease does not prevail, is often of great advantage. Pellagra. (Synonym: Lombardian Leprosy.) Describe pellagra. Pellagra is a slow but usually progressive disease occurring chiefly in Italy, due, it is thought, to the continued ingestion of decom- posed or fermented maize. It is characterized by cutaneous symp- toms, at first upon exposed parts, of an erythematous, desquamative, vesicular and bullous, character, and by general constitutional dis- turbance of a markedly neurotic type. A fatal ending, if the dis- ease is at all severe or advanced, is to be expected. Treatment is based upon general principles. NEW GROWTHS. 227 Epithelioma. (Synonyms: Skin Cancer; Epithelial Cancer; Carcinoma Epitheliale.) What several varieties of epithelioma are met with ? Three—the superficial, the deep-seated, and the papillomatous. Describe the clinical appearances and course of the superficial variety of epithelioma. The superficial, or flat variety (rodent ulcer), begins, usually on the face, as a minute, firm, reddish or yellowish tubercle, as an Fig. 55. Epithelioma. (After D. Lewis.) aggregation of such, as a warty excrescence, or as a localized degen- erative seborrhoeic patch. Sooner or later, commonly after months or several years, the surface becomes slightly excoriated, and an in- significant, yellowish or brownish crust is formed. The excoriation gradually develops into superficial ulceration, and the diseased area 228 DISEASES OF THE SKIN. becomes slowly larger and larger. New lesions may continue, from time to time, to appear about the edges and go through the same changes. The ulcer has usually an uneven surface, secretes a thin, scanty, viscid fluid, which dries to a firm, adherent crust. It is usually defined against the healthy skin by a slightly elevated, hard, roll-like, waxy-looking border. In rare instances there is a disposition, at points, to spontaneous involution and scar formation ; as a rule. however, the-ulcerative action slowly progresses. The general health is unimpaired, the neighboring lymphatic glands are not involved, and the local condition, beyond the disfig- urement, gives rise to little trouble, unless, as occasionally happens, it passes into the more malignant, deep-seated variety. Describe the clinical appearances and course of the deep- seated variety of epithelioma. The deep-seated variety starts from the superficial form, or it begins as a tubercle or nodule in the skin. When typically developed, a reddish, shining tubercle or nodule, or area of infiltration, forms in the skin or subcutaneous tissue. In the course of weeks or months superficial or deep-seated ulceration takes place; the ulcer having hardened, and, as a rale, everted edges. The surface is red- dish and granular, and secretes an ichorous discharge. The infil- tration spreads, the ulcer enlarges both peripherally and in depth— muscle, cartilage and bone often becoming invaded. The neighbor- ing lymphatic glands are finally implicated, pains of a burning or neuralgic type are experienced, and from septicaemia, marasmus or involvement of vital parts, death eventually ensues. Describe the clinical appearances and course of the papillo- matous variety of epithelioma. The papillomatous type usually arises from the superficial or deep-seated variety, or it may begin as a papillary or warty growth. When fully developed, it presents an ulcerated, fissured and papillo- matous surface, with an ichorous discharge which dries to crusts. It is slowly progressive, and sooner or later may develop a malignant tendency. Upon what parts is epithelioma commonly observed ? About the face, especially the nose, eyelids and lips; and also about the genitalia. It may involve any part. NEW GROWTHS. 229 &.t what age is epithelioma usually noted ? It is essentially a disease of middle and late life, although it is exceptionally met with in the young. What is the cause of epithelioma ? The etiology is obscure. It is not, as a rule, inherited. Any locally irritated tissue may be the starting point of the disease. State the pathology. The process consists in the proliferation of epithelial cells from the mucous layer; the cell-growth takes place downward, in the form of finger-like prolongations or columns, or it may spread out laterally, so as to form rounded masses, the centres of which usually undergo horny transformation, resulting in the formation of onion-like bodies, the so-called cell-nests or globes. The rapid cell-growth requires increased nutriment, and hence the bloodvessels become enlarged; moreover, the pressure of the cell-masses gives rise to irritation and inflammation, with corresponding serous and round-cell infiltration. How would you distinguish epithelioma from syphilitic ulceration, wart, and lupus vulgaris ? From syphilis it is to be differentiated by the history, duration, character of the base and edges, its comparative slow progress, its usually slight, viscid discharge, often streaked with blood, and, if necessary, by the therapeutic test. Wart or warty growths are to be differentiated by attention to their history and course. Long-continued observation may be necessary before a positive opinion is warrantable. The appearance of any tendency to crusting, to break down or ulcerate is significant of epi- theliomatous degeneration. In lupus vulgaris the deposits are peculiar and multiple, the ulcerations are of different character, the tendency to scar-formation constant; and, with few exceptions, it has, moreover, its beginning in childhood or early adult life. What factors are to be considered in giving a prognosis in epithelioma ? The variety, extent, and rapidity of the process. The superficial form may exist for years, and give rise to no alarm ; whereas the 230 DISEASES OF THE SKIN. deeper-seated varieties are always to be viewed as serious, and are, indeed, often fatal. Involving the genitalia, its course is often strikingly rapid. Relapses, after removal, are not uncommon. What is the special object in view in the treatment of epi- thelioma ? Thorough destruction or removal of the epitheliomatous tissue. How is the destruction or removal of the epitheliomatous tissue effected ? By the use of such caustics as caustic potash, chloride-of-zinc paste, pyrogallic acid, arsenic, and the galvano-cautery; and by operative measures, such as excision and erasion with the dermal curette. (See treatment of lupus vulgaris.) In small lesions the use of an arsenical paste is a most admirable method of treatment, although somewhat painful. The paste is made of one part powdered acacia and one to two parts arsenious acid; at the time of application sufficient water is added to make a paste. This is applied thickly, and a piece of lint superimposed. A good deal of pain and inflammatory swelling ensue ; at the end of twenty- four hours the part is poulticed till the slough comes away; the ulcer is then treated as a simple ulcer, under which healing takes place. Occasionally a second application is found necessary. Of these several methods, those with the arsenical paste, the curette, and by excision in suitable cases, are the most convenient and satisfactory. Paget's Disease of the Nipple. (Synonyms: Malignant Papillary Dermatitis; Paget's Disease.) What do you understand by Paget's disease of the nipple ? Paget's disease is a rare, inflammatory-looking, malignant disease of the nipple and areola in women, eventually terminating in can- cerous involvement of the entire gland. Describe the symptoms of Paget's disease. The first symptoms, which usually last for months or years, are apparently eczematous, accompanied with more or less burning, itching and tingling. Gradually, the diseased area, which is sharply- NEW GROWrTHS. 231 defined, and feels like a thin layer of indurated tissue, presents a florid, intensely red, very finely-granular, raw surface, attended with a more or less copious viscid exudation. Sooner or later retraction and destraction of the nipple, followed by gradual scirrhous involve- ment of the whole breast, takes place. What is the pathology of Paget's disease ? It is thought, on the one hand, to be a cancerous disease result- ing from a continued eczematous inflammation of the parts, and by others it is considered to be of a cancerous nature from the very beginning. Psorosperms have been found, to the presence of which the disease has by some authorities been attributed (psorospermosis). It is usually met with in women between the ages of forty and sixty. State the diagnostic features of Paget's disease. The age of the patient; the sharp limitation ; the well-defined, indurated film of infiltration ; the peculiar, red, raw, granulating appearance ; and, later, the retraction of the nipple ; and, finally, the involvement of the deeper parts. What is the prognosis ? If the disease is recognized early, and properly treated, a cure may be anticipated; later the outlook is that of scirrhus of the breast. What is the treatment of Paget's disease ? Thorough cauterization by means of caustic potash or the galvano- cautery ; or, its extirpation by means of the curette or excision. Until the diagnosis is thoroughly established, soothing applications, such as are employed in acute eczema, are to be advised. Sarcoma. [Synonyms: Sarcoma Cutis; Sarcoma of the Skin.) Describe the several varieties of sarcoma. Sarcoma of the skin is a more or less malignant new growth, of rapid or slow progress, characterised by the appearance of single or multiple, variously-shaped, discrete, non-pigmented or pigmented tubercles or tumors, of size varying from that of a shot to a hazel- nut or larger. As a rale the growths are smooth, firm and elastic, somewhat painful upon pressure, and exhibit a tendency to ulcerate. 232 DISEASES OF THE SKIN. The overlying skin is at first normal and somewhat movable, but as the growths approach the surface it becomes reddened and adherent; or, if the disease is of the pigmented variety, it acquires a bluish- black color. Fig. 56. Granuloma Fungoides. (After Duhring.) The multiple pigmented sarcoma (melano-sarcoma) appears first, usually on the soles and dorsal surfaces of the feet, and later on the hands. There is more or less diffuse thickening of the integument. The lesions themselves manifest a disposition to bleed. A rare form of disease, heretofore looked upon as sarcomatous, but now generally recognized as granuloma, has been described under the names mycosis fungoides, inflammatory fungoid neo- plasm, and granuloma fungoides. It is characterized usually by symptoms of an eczematous, urticarial, and erysipelatous nature, and by the sudden or gradual appearance of pinkish or reddish, tubercular, nodular, lobulated or furrowed tumors or flat infil- NEUROSES. 233 trations, which may disappear by involution or may be followed by ulceration; several, or a larger number, of the growths present a mushroom, papillomatous, or fungoid appearance, sometimes roughly resembling the cut part of a tomato. The lesions, especially in their early stages, are, as a rule, accompanied with more or less burning and itching. State the prognosis of sarcoma. The disease is always more or less malignant, and, as a rule, sooner or later a fatal termination takes place. It is usually slow in its course. The outlook for cases of granuloma fungoides is scarcely less unfavorable. What is the treatment of sarcoma ? Treatment is palliative. Surgical interference may be of service in particular situations. A favorable influence has been noted, in a few instances, to follow hypodermic injections of Fowler's solution in increasing dosage. CLASS VII.—NEUROSES. Hyperesthesia. What is hyperaesthesia ? By hyperesthesia is meant increased cutaneous sensibility. It is usually more or less localized, and is met with as a symptom in func- tional and organic nervous diseases. Dermatalgia. (Synonyms : Neuralgia of the Skin; Rheumatism of the Skin; Dermalgia.) What do you understand by dermatalgia ? By dermatalgia is meant a tender or painful condition of the skin unattended by structural change. It is commonly limited to a small area, and is usually symptomatic of functional or organic nervous 234 DISEASES OF THE SKIN. disease. As an idiopathic affection it is looked upon as of a rheu- matic origin. Treatment depends upon the cause. Anaesthesia. What is anaesthesia ? Anaesthesia is a diminution, comparative or complete, of cutaneous sensibility. It is usually localized, and is met with in the course of certain nervous affections. It is also encountered in leprosy, morphoea and like diseases. Pruritus. What do you understand by pruritus ? Pruritus is a functional disease of the skin, the sole symptom of which is itching, there being no structural change. Describe the symptoms of pruritus. The sole and essential symptom is itchiness, usually more or less paroxysmal, and worse at night. There are no primary structural lesions, but in severe and persistent cases the parts become so irri- tated by continued scratching that secondary lesions, such as papules and slight thickening and infiltration, may result. It is much more common in advanced life—pruritus senilis. In such cases, as well as in those cases in younger and middle-aged individuals in which the itchiness develops at the approach of cold weather and disappears upon the coming of the warm season (pruritus hiemalis), the pru- ritus is usually more or less generalized, although not infrequently in the latter the legs are specially involved. In some individuals an attack of pruritus, of variable intensity, lasting from five to thirty minutes, comes on immediately after a bath (bath-pruritus). It is usually confined to the legs from the hips down. Is pruritus always more or less generalized ? No ; not infrequently the itching is limited to the genital region (pruritus scroti, pruritus vulva-) or to the anus (pruritus ani). NEUROSES. 235 To what may pruritus often be ascribed ? To digestive and intestinal derangements, hepatic disorders, the uric acid diathesis, gestation, diabetes mellitus, and a depraved state of the nervous system. Pruritus vulvas is at times due to irritating discharges, and pruritus ani occasionally to seat worms. Is there any difficulty in the diagnosis of pruritus ? No. The subjective symptom of itching without the presence of structural lesions is diagnostic. In those severe and persistent cases in which excoriations and papules have resulted from the scratching, the history of the case, together with its course, must be considered. Care should be taken not to confound it with pedicu- losis. In this latter the excoriations usually have a somewhat pecu- liar distribution, being most abundant on those parts of the body with which the clothing lies closely in contact. (See pediculosis corporis.) What prognosis would you give in pruritus ? In the majority of cases the condition responds to proper treat- ment, but in others it proves rebellious. The prognosis depends, in fact, upon the removability of the cause. Temporary relief may always be given by external applications. How would you treat pruritus ? With systemic remedies directed toward a removal or modification of the etiological factors, and, for the temporary relief of the itch- ing, suitable antipruritic applications. In obscure cases, quinia, salophen, lithia salts, calcium chloride, belladonna, nux vomica, arsenic, pilocarpine, and general galvanization may be variously tried. Alkalies prove useful in many cases. Exceptionally, the relief furnished by external treatment is more or less permanent. Name the important antipruritic applications. Alkaline baths ; lotions of carbolic acid (3j-3iij to Oj), of thymol (gr. xviij-gr. xxxij to Oj alcohol and water), of resorcin (3j-3iv to Oj), of liquor carbonis detergens (£j-1 iv to Oj), and liquor picis alka- linus (3j-3iv to Oj) used cautiously. One or several ounces of 236 DISEASES OF THE SKIN. alcohol and one or two drachms of glycerine in each pint of these lotions will often be of advantage, as the following :— R. Ac. carbolici,............3j_3iij Gylcerinse,.............f^ij Alcoholis,............: f^ij Aquae,......q. s. ad..... Oj. M. Various dusting-powders, alone or in conjunction with the lotions. And in some cases, especially those in which the skin is unnaturally dry, ointments may be used, such as equal parts of lard, lanolin, and petrolatum, to the ounce of which may be added from five to thirty grains of carbolic acid, three to twenty grains of thymol, ten to thirty minims of chloroform, or two to ten grains of menthol. Liquid petro- latum is also a useful excipient for these remedies. What external applications are to be used in the local varie- ties of pruritus ? In pruritus ani and pruritus vulvae, in addition to the various ap- plications above, a cocaine ointment, one to ten grains to the ounce, a strong solution of the same (gr. v-xx to 3j), and an ointment containing ten to thirty minims of the oil of peppermint to the ounce ; sponging with hot water, often affords temporary relief. In pruritus vulvae, moreover, astringent applications and injections of zinc sulphate, alum, tannic or acetic acid, in the strength com- monly employed for vaginal injections, are at times curative. In bath-pruritus weak glycerine lotions, and an ointment contain- ing a few grains of thymol and menthol to the ounce sometimes give moderate relief. Turkish baths are sometimes free from sub- sequent pruritus. PARASITIC AFFECTIONS. 237 CLASS VIII—PARASITIC AFFECTIONS. Tinea Favosa. (Synonym: Favus.) What is tinea favosa ? Tinea favosa, or favus, is a contagious vegetable-parasitic disease of the skin, characterized by pin-head to pea-sized, friable, umbili- cated, cup-shaped yellow crusts, each usually perforated by a hair. Upon what parts and at what age is favus observed ? It is usually met with upon the scalp, but it may occur upon any part of the integument. Occasionally the nails are invaded. It is seen at all ages, but is much more common in children. Describe the symptoms of favus of the scalp. The disease begins as a superficial inflammation or hyperaemic spot, more or less circumscribed, slightly scaly, and which is soon fol- lowed by the formation of yellowish points about the hair follicles, surrounding the hair shaft. These yellowish points or crusts increase in size, become usually as large as small peas, are cup-shaped, with the convex side pressing down upon the papillary layer, and the con- cave side raised several lines above the level of the skin ; they are umbihcated, friable, sulphur-colored, and usually each cup or disc is perforated by a hair. Upon removal or detachment, the underlying surface is found to be somewhat excavated, reddened, atrophied and sometimes suppurating. As the disease progresses the crusting be- comes more or less confluent, forming irregular masses of thick, yellowish, mortar-like crasts or accumulations, having a peculiar, characteristic odor—that of mice, or stale, damp straw. The hairs are involved early in the disease, become brittle, lustreless, break off and fall out. In some instances, especially near the border of the crusts, are seen pustules or suppurating points. Atrophy and more or less actual scarring are sooner or later noted. Itching, variable as to degree, is usually present. What is the course of favus of the scalp ? Persistent and slowly progressive. 238 DISEASES OF THE SKIN. What are the symptoms of favus when seated upon the gen- eral surface? The symptoms are essentially similar to those upon the scalp, modified somewhat by the anatomical differences of the parts. The nails, when affected, become yellowish, more or less thick- ened, brittle and opaque (tinea facosa unguium, onychomycosis favosa). To what is favus due ? Solely to the invasion of the cutaneous structures, especially the Fig. 57. Achorion Schonleinii X 450. (After Duhring.) Showing simple mycelium, in various stages of development, and free spores. epidermal portion, by the vegetable parasite, the achorion Schonleinii. It is contagious. It is a somewhat rare disease in the native-born, being chiefly observed among the foreign poor. The nails are rarely affected primarily. It is also met with in the lower animals, from which it is doubtless not infrequently communicated to man. What are the diagnostic features of favus ? The yellow, and often cup-shaped, crusts, brittleness and loss of hair, atrophy, and the history. PARASITIC AFFECTIONS. 239 How would you distinguish favus from eczema and ring- worm? From eczema by the condition of the affected hair, the atrophic and scar-like areas, the odor, and the history. From ringworm by the crusting and the atrophy. In this latter disease there is usually but slight scaliness, and rarely any scarring. Finally, if necessary, a microscopic examination of the crusts may be made. State the method of examination for fungus. A portion of the crust is moistened with liquor potassae and exam- ined with a power of three to five hundred diameters. The fungus, (achorion Schonleinii), consisting of mycelium and spores, is luxuriant and is readily detected. State the prognosis of favus. Upon the scalp, favus is extremely chronic and rebellious to treat- FlG. 58. Epilating Forceps. ment. and a cure in six to twelve months may be considered satisfactory; in neglected cases permanent baldness, atrophy, and scarring sooner or later result. Upon the general surface it usually responds readily—excepting favus of the nails, which is always obstinate. How is favus of the scalp treated ? Treatment is entirely local and consists in keeping the parts free from crusts, in epilation and applications of a parasiticide. The crusts are removed by oily applications and soap-and-water washings. The hair on and around the diseased parts is to be kept closely cut, and, when practicable, depilation, or extraction of the affected hairs, is advised; this latter is, in most cases, essen- tial to a cure. Remedial applications—the so-called parasiti- cides—are, as a rule, to be made twice daily. If an ointment is 240 DISEASES OF THE SKIN. used, it is to be thoroughly rubbed in; if a lotion, it is to be dabbed on for several minutes and allowed to soak in. Name the most important parasiticides. Corrosive sublimate, one to four grains to an ounce of alcohol and water; carbolic acid, one part to three or more parts of glycerine ; a ten percent, oleate of mercury; ointments of ammoniated mer- cury, sulphur and tar; and sulphurous acid, pure or diluted. The following is valuable :— R. Sulphur, praecip.,..........£ij Saponis viridis, 01. cadini,......aa......gj Adipis,...............^ss. M. Chrysarobin is a valuable remedy, but must be used with caution; it may be employed as an ointment, five to ten per cent, strength, as a rubber plaster, or as a paint, a drachm to an ounce of gutta- percha solution. How is favus upon the general surface to be treated? In the same general manner as favus of the scalp, but the remedies employed should be somewhat weaker. In favus of the nail frequent and close paring of the affected part and the appli- cation, twice daily, of one of the milder parasiticides, will eventually lead to a good result. Is constitutional treatment of any value in favus ? It is questionable, but in debilitated subjects tonics, especially cod- liver oil, may be prescribed with the hope of aiding the external applications. Tinea Trichophytina. (Synonym: Ringworm.) What is tinea trichophytina ? Tinea trichophytina, or ringworm, is a contagious, vegetable-para- sitic disease due to the invasion of the cutaneous structures by the vegetable parasite, the trichophyton. PARASITIC AFFECTIONS. 241 Do the clinical characters of ringworm vary according to the part affected ? Yes, often considerably; thus upon the scalp, upon the general surface, and upon the bearded region, the disease usually presents totally different appearances. Describe the symptoms of ringworm as it occurs upon non- hairy portions of the body. Hingworm of the general surface (tinea trichophytina corporis, tinea circinata) appears as one or more small, slightly-elevated, sharply-limited, somewhat scaly, hyperaemic spots, with, rarely, minute papules, vesico-papules, or vesicles, especially at the circum- ference. The patch spreads in a uniform manner peripherally, is slightly scaly, and tends to clear in the centre, assuming a ring-like appearance. When coming under observation, the patches are usually from one-half to one inch in diameter, the central portion pale or pale red, and the outer portion more or less elevated, hyperaemic and somewhat scaly. As commonly noted one, several or more patches are present. After reaching a certain size they may remain stationary, or in exceptional cases may tend to spontaneous disappearance. At times when close together, several may merge and form a large, irregular, gyrate patch. Itching, usually slight, may or may not be present. Describe the symptoms of ringworm when occurring about the thighs and scrotum. In adults, more especially males, the inner portion of the upper part of the thighs and scrotum (tinea trichophytina cruris, so-called eczema marginatum) may be attacked, and here the affection, favored by heat and moisture, develops rapidly and may soon lose its ordi nary clinical appearances, the inflammatory symptoms becoming especially prominent. The whole of this region may become in- volved, presenting all the symptoms of a true eczema; the border, however, is sharply defined, and usually one or more outlying patches of the ordinary clinical type of the disease may be seen. Describe the symptoms of ringworm when involving the nails. In ringworm of the nails (tinea trichophytina unguium) these structures become soft or brittle, yellowish, opaque and thickened 16 242 DISEASES OF THE SKIN. the changes taking place mainly about the free borders. Ringworm on other parts usually coexists. Describe the symptoms of ringworm as it occurs upon the scalp. Ringworm of the scalp (tinea trichophytina capitis, tinea tonsu- rans) begins usually in the same manner as that upon the general surface, but, as a rule, much more insidiously. Sooner or later, Fig. 59. Tinea trichophytina cruris—so-called eczema marginatum—of unusually extensive development. (After Piffard.) however, the hair and follicles are invaded by the fungus, and in consequence the hair falls out or becomes brittle and breaks off. The follicles, except in long-standing cases, are slightly elevated and prominent, and the patch may have a puffed or goose-flesh appear- ance. In addition, there is slight scaliness. Describe the appearances of a typical patch of ringworm of the scalp. The patch is rounded, grayish, somewhat scaly, and slightly ele- *$?%m V 1 / fV Ringworm. PARASITIC AFFECTIONS. 243 vated ; the follicles are somewhat prominent; there is more or less alopecia, with here and there broken, gnawed-off-looking hairs, some of which may be broken off just at the outlet of the foUicles and appear as black specks. Does ringworm of the scalp always present typical appear- ances ? Not invariably. In some cases the patch or patches may become almost completely bald, and in others a tendency to the formation of pustules, with more or less crust-formation, may be seen. The affection may also appear as small, scattered spots or points. What is tinea kerion? Tinea kerion (kerion) is a markedly inflammatory type of ringworm of the scalp involving the deeper tissues, appearing as a more or less bald, rounded, inflammatory, oedematous, boggy, honeycombed tumor, discharging from the follicular openings a mucoid secretion. Does ringworm of the scalp ever occur in adults ? No. (Extremely rare exceptions.) Describe the symptoms of ringworm of the bearded region. Ringworm of the bearded region (tinea trichophytina barbae, tinea sycosis, parasitic sycosis, barber s itch) begins usually in the same manner as ringworm on other parts, as one or more rounded, slightly scaly, hyperaemic patches. In rare instances the disease may per- sist as such, with very little tendency to involve the hairs and follicles; but, as a rule, the hairy structures are soon invaded, many of the hairs breaking off, and many falling out. From involvement of the follicles, more or less subcutaneous swelling ensues, the parts assum- ing a distinctly lumpy and nodular condition. The skin is usually considerably reddened, often having a glossy appearance, and studded with few or numerous pustules. The nodules tend, ordi- narily, to break down and discharge, at one or more of the follicular openings, a glairy, glutinous, purulent material, which may dry to thick, adherent crusts. The disease may be limited to one patch, or a large area, even to the extent of the whole bearded region, becomes involved. The upper lip is rarely invaded. 244 DISEASES OF THE SKIN To what is ringworm due ? To the presence and growth in the cutaneous structures of a vegetable parasite. Although the disease is contagious, individuals differ considerably as to susceptibility. It is much more common in children than in those past the age of puberty, ringworm of the scalp being limited to the former (rare exceptions), and tinea syco- sis being a disease of the male adult. Until recently the ringworm was thought to be due to but one fungus—the trichophyton; it is now known that there are several Fig. 60. Trichophyton X 450. {After Duhring.) As found in epidermic scrapings of ringworm, showing mycelium and spores. forms of fungi, the main forms being the small-spored (microsporon Audouini) and the large-spored (trichophyton). Of this latter there are two main subvarieties—endothrix and ectothrix. The small-spored fungus is found as the cause in the majority of scalp cases; the endothrix also commonly invades the scalp integument. The ectothrix variety is usually derived directly or indirectly from domestic animals, and is chiefly responsible for body-ringworm, and for suppurative ringworm, whether upon the bearded region or elsewhere. PARASITIC AFFECTIONS. 245 What is the pathology of ringworm ? On the general surface the fungus has its seat in the epidermis, Flo, 61. Trichophyton X 350. (After Duhring.) Short, broken-off hair of scalp invaded with free spores and chains of spores. especially in the corneous layer ; upon the scalp and bearded region the epidermis, hair-shaft, root and follicle are invaded. The inflam- matory action may vary considerably in different cases, and at dif- ferent times in the same *case. 246 DISEASES OF THE SKIN. The fungus consists of mycelium and spores. In the epidermic scrapings it is never to be found in abundance, and the mycelium predominates, while in affected hairs the spores and chains of spores are almost exclusively seen, and are usually present in great pro- fusion. Trichophyton X 300. (After Duhring) Short, stout hair of beard, with the root-sheath attached, showing free spores and chains of spores. How do you examine for the fungus ? The scrapings or hair should be moistened with liquor potassae, and examined with a power from three hundred diameters upward. PARASITIC AFFECTIONS. 247 How is ringworm of the general surface to be distinguished from eczema, psoriasis and seborrhoea ? By the growth and characters of the patch, the slight scaliness the tendency to disappear in the centre, by the history, and, if necessary, by a microscopic examination of the scales. How is ringworm of the scalp to be distinguished from alo- pecia areata, favus, eczema, seborrhoea, and psoriasis ? By the peculiar clinical features of ringworm on this region—the sfight scaliness, broken hair and hair stumps, with a certain amount of baldness—and in doubtful cases by a microscopical examination of the hairs. In favus, although the same condition of the hair is noted, the yellow, cup-shaped crusts, and the presence of the atrophic areas in that disease are pathognomonic. How is ringworm of the bearded region to be distinguished from eczema and non-parasitic sycosis ? By the peculiar lumpiness of the parts, the brittleness of the hair, more or less hair-loss, the history, and finally, in doubtful cases, by microscopical examination. What is the prognosis of ringworm of these several parts ? When upon the general surface, the disease usually responds rap- idly to therapeutical applications; upon the scalp it is always a stub- born affection, and, as a rule, requires several months to a year of energetic treatment to effect a cure. In this latter region the disease will disappear spontaneously as the age of fifteen or sixteen is reached. Tinea sycosis yields in most instances in the course of several weeks or a few months. Is ringworm of these several parts treated with the same remedies ? As a rule, yes; but the strength must be modified. The scalp will stand strong applications, as will likewise the bearded region ; upon non-hairy portions the remedies should be used somewhat weaker. They should be applied twice daily; ointments, if used, being well rubbed in, and lotions thoroughly dabbed on. How would you treat ringworm of the general surface ? By applications of the milder parasiticides, such as a ten to fifteen 248 DISEASES OF THE SKIN. per cent, solution of sodium hyposulphite; carbolic acid, five to thirty grains to the ounce of water, or lard ; a saturated solution of boric acid; ointments of tar, sulphur and mercury, ofiicial strength or weakened with lard; and tincture of iodine, pure or diluted. When occurring upon the upper and inner part of the thighs (so-called eczema marginatum), the same remedies are to be em- ployed, but usually stronger. Deserving of special mention is a lotion of corrosive sublimate, one to four grains to the ounce ; or the same remedy, in the same proportion, may be used in tincture of myrrh or benzoin, and painted on the parts. How would you treat ringworm of the scalp ? By occasional soap-and-bot-water washing ; by extraction of the involved hairs, when practicable; by carbolic acid or boric acid lotions to the whole scalp, so as to limit, as much as possible, the spread of the disease; and by daily (or twice daily) applications to the patches and involved areas of a parasiticide. The following are the most valuable: the oleate of mercury, with lard or lanolin, in varying strength, from ten to twenty per cent.; carbolic acid, with one to three or more parts of glycerine or oil; corrosive sublimate, in solu- tion in alcohol and water, one to four grains to the ounce; sulphur ointment; and citrine ointment, with one or two parts of lard; Cos- ter's paint of iodine and oil of tar (iodine 3ij, tar 3vj). Chrysarobin is a valuable remedy, but is to be employed with care; it may be pre- scribed as a rubber plaster, or in a solution of gutta-percha, or as an ointment, ten to fifteen per cent, strength. /3-naphthol in ointment form, five to fifteen per cent, strength, is also useful. An excellent application for beginning areas on the scalp is a solution of the red iodide of mercury in iodine tincture, one to three grains to an ounce. A compound ointment, containing several of the active remedies named, is convenient for dispensary practice. And also:— R. Hydrarg. oleat.,..........3J-iij Ac. carbolici,...........3J Adipis,.......q. s. ad . . . . ^j. M. In that form known as tinea kerion mild applications are de- manded at first; later the same treatment as in the ordinary type. PARASITIC AFFECTIONS. 249 How is ringworm of the bearded region to be treated ? On the same general plan and with the same remedies (excepting chrysarobin) as in ringworm of the scalp. Depilation is to be prac- tised as an essential part of the treatment. Special mention may be made of an ointment of oleate of mercury, sulphur ointment, a lotion of sodium hyposulphite (3j~5j) and a lotion of corrosive sub- limate (gr. j-iv to ^j). How is the certainty of an apparent cure in ringworm of the scalp or bearded region to be determined? By the continued absence of roughness and of broken hairs and stumps, and by microscopical examination of the new-growing hairs from time to time for several weeks after discontinuance of treatment. Cure of ringworm of the general surface is usually self-evident. Is systemic treatment of aid in the cure of ringworm ? It is doubtful, although in children in a depraved state of health the disease is often noted to be especially stubborn, and in such cod-liver oil and similar remedies may at times prove of benefit. Tinea Versicolor. (Synonyms: Pityriasis Versicolor; Chromophytosis.) What is tinea versicolor ? Tinea versicolor is a vegetable-parasitic disease of the skin, characterized by variously-sized and shaped, slightly scaly, macular patches of a yellowish-fawn color, and occurring for the most part upon the upper portion of the trunk. Describe the symptoms of tinea versicolor. The disease begins as one or more yellowish macular points ; these, in the course of weeks or months, gradually extend, and, together with other patches that arise, may form a more or less continuous sheet of eruption. There is slight scaliness, always insignificant and furfuraceous in character, and at times, except upon close inspection, scarcely perceptible. The color of the patches is pale or brownish- yellow ; in rare instances, in those of delicate skin, there may be more or less hyperaemia, and in consequence the eruption is of a 250 DISEASES OF THE SKIN. reddish tinge. The number of patches varies ; there may be but a few, or, on the other hand, a profusion. Slight itching, especially when the parts are warm, is usually present. Does the eruption of tinea versicolor show predilection for any special region ? Yes; the upper part of the trunk, especially anteriorly, is the usual seat of the eruption, but in exceptional instances the neck, axillae, the arms, the whole trunk, the genito-crural region and poplitea, and in rare cases even the lower part of the face, may become invaded. Fig. 63. Microsporon Furfur X 400. (After Duhring.) Showing mycelium in various stages of development, groups of spores and free spores. What course does tinea versicolor pursue ? Persistent, but somewhat variable ; as a rule, however, slowly pro- gressive and lasting for years. To what is tinea versicolor due ? To a vegetable fungus—the microsporon furfur. The affection is tolerably common, and occurs in all parts of the world. With rare exceptions, it is a disease of adults, and while looked upon as contagious, must be so to an extremely slight degree. k. Tinea Versicolor. PARASITIC AFFECTIONS. 251 What is the pathology ? The fungus, consisting of mycelium and spores, the latter showing a marked tendency to aggregate, invades the superficial portion of the epidermis. Is tinea versicolor readily diagnosticated ? Yes; if the color, peculiar characters and distribution of the erup- tion are kept in mind. It is not to be confounded with vitiligo, chloasma, or the macular syphiloderm. If in doubt, have recourse to the microscope. State the method of examination for fungus. The scrapings are taken from a patch, moistened with liquor po- tassae, and examined with a power of three to five hundred diameters. State the prognosis of tinea versicolor. With proper management the disease is readily curable. Re- lapses are not uncommon. What is the treatment of tinea versicolor ? It consists in daily washing with soap and hot water (and in obstinate cases with sapo viridis instead of the ordinary soap) and application of a lotion of—sulphite or hyposulphite of sodium, a drachm to the ounce ; sulphurous acid, pure or diluted ; carbolic acid, or resorcin, ten to twenty grains to the ounce of water and alcohol; or corrosive sublimate, one to three grains to the ounce of water. Sulphur and ammoniated-mercury ointments are also serviceable. The following used alone, simply as a soap, or in conjunction with a lotion, is often of special value :— R. Sulphur, praecip.,..........giv Saponis viridis,...........3 xii. M. After the disease is apparently cured, an occasional remedial ap- plication should be made for a few weeks or a month, in order to guard against the possibility of a relapse. Erythrasma. Describe erythrasma. Erythrasma is an extremely rare disease, due to the presence and 252 DISEASES OF THE SKIN. growth in the epidermic stractures of the vegetable parasite—the microsporon minutissimum. It is characterized by small and large, Fig. 64. Microsporon Minutissimum X 1000. (After Riehl.) slightly furfuraceous, reddish-yellow or reddish-brown patches, oc- curring usually on warm and moist parts, such as the axillary, inguinal, anal and genito-crural regions. It is slowly progressive and persistent, but is without disturbing symptoms other than occa- sional slight itching. Treatment, which is rapidly effective, is the same as that employed in tinea versicolor. Blastomycetic Dermatitis. What do you understand by blastomycetic dermatitis? Blastomycetic dermatitis is a rare disease beginning usually as a small papule or nodule, enlarging slowly, breaking down and develop- ing into a verrucous or papillomatous-looking area, similar in appear- ance to tuberculosis cutis verrucosa. A niuco-purulent or purulent secretion can usually be pressed out from between the papillomatous elevations. It may also present the appearance of a serpiginous PARASITIC AFFECTIONS. 253 lupus vulgaris or syphiloderm. As a rule it is slow in its course. Furunrular or abscess-like formations may develop, usually from secondary infection. The disease is due to the invasion of the cutaneous tissues by the blastomyces. Treatment consists in the employment of antiseptic and parasiti- cide applications; usually, however, radical treatment such as em- ployed in lupus vulgaris may be necessary. Scabies. (Synonym: The Itch.) What is scabies ? Scabies, or itch, is a contagious animal-parasitic disease character- ized by a multiform eraption of a somewhat peculiar distribution, attended by intense itching. Describe the symptoms of scabies. The penetration and presence of the parasites within the cutaneous structures besides often giving rise to several or more complete or imperfectly formed burrows, excite varying degrees of irritation, and in consequence the formation of vesicles, papules and pustules, accompanied with more or less intense itching. Secondarily, crust- ing, and at times a mild or severe grade of dermatitis, may be brought about. The parasite seeks preferably tender and protected situa- tions, as between the fingers, on the wrists, especially the flexor sur- face, in the folds of the axillae, on the abdomen, about the anal fissure, about the genitalia, and in females also about the nipples, and hence the eruption is most abundant about these regions. The inside of the thighs and the feet are also attacked, as, indeed, may be almost every portion of the body. The scalp and face are not in- volved ; exceptionally, however, these parts are invaded in infants and young children. Is the grade of cutaneous irritation the same in all cases of scabies ? No ; in those of great cutaneous irritability, especially in children, the skin being more tender, the type of the eruption is usually much more inflammatory. In those predisposed a true eczema may arise, and then, in addition to the characteristic lesions of scabies, ecze- 254 DISEASES OF THE SKIN. matous symptoms are superadded; in long-persistent cases, indeed, the burrows and other consequent lesions may be more or less com- pletely masked by the eczematous inflammation, and the true nature of the disease be greatly obscured. What do you mean by burrows ? Burrows, or cuniculi, are tortuous, straight or zigzag, dotted, slightly elevated, dark-gray or blackish thread-like linear formations, varying in length from an eighth to a half an inch. Fig. 65. Burrow, or cuniculus, greatly magnified. (After Kaposi.) Showing the mite, ova, empty shells and excrement. How is a burrow formed ? By the impregnated female parasite, which penetrates the epi- dermis obliquely to the rete, depositing as it goes along ten or fifteen ova, forming a minute passage or burrow. Upon what parts are burrows most commonly to be found? In the interdigital spaces, on the flexor surface of the wrists, about the mammae in the female, and on the shaft of the penis in the male. Are burrows usually present in numbers ? No. Several may be found in a single case, but they are rarely numerous, as the irritation caused by the penetration of the para- sites leads either to violent scratching and their destruction, or gives rise to the formation of vesicles and pustules, and consequently their formation is prevented. PARASITIC AFFECTIONS. 255 What course does scabies pursue ? Chronic and progressive, showing no tendency to spontaneous disappearance. To what is scabies due ? To the invasion of the cutaneous stractures by an animal parasite, the sarcoptes scabiei (acarus scabiei). The male mite is never found in the skin and apparently takes no direct part in the production of the symptoms. Fig. 66. Fig. 67. Sarcoptes scabiei X 100. (After Duhring.) Female. Ventral surface. Male. The disease is contagious to a marked degree, and is most com- monly contracted by sleeping with those affected, or by occupying a bed in which an affected person has slept. It occurs, for obvious reasons, usually among the poor, although it is occasionally met with among the better classes. State the diagnostic features of scabies. The burrows, the peculiar distribution and the multiformity of the eruption, the progressive development, and usually a history of contagion. How do vesicular and pustular eczema differ from scabies ? Eczema is usually limited in extent or irregularly distributed, is 256 DISEASES OF. THE SKIN. distinctly patchy, with often the formation of large diffused areas ; it is variable in its clinical behavior, better and worse from time to time, and differs, moreover, in the absence of burrows and of a history of contagion. How does pediculosis corporis differ from scabies ? In the distribution of the eruption. The pediculi live in the clothing and go to the skin solely for nourishment, and hence the eruption in that condition is upon covered parts, especially those parts with which the clothing lies closely in contact, as around the neck, across the upper part of the back, about the waist and down the outside of the thighs ; the hands are free. State the prognosis of scabies. It is favorable. The disease is readily cured, and, as soon as the parasites and their ova are destroyed, the itching and the secondary symptoms, as a rale, rapidly disappear. How is scabies treated ? Treatment is entirely external, and consists of a preliminary soap- and-hot-water bath, an application, twice daily for three days, of a remedy destructive to the parasites and ova, and finally another bath. Inquiry as to others of the family should be made, and, if affected, treated at the same time. The wearing apparel should be looked after—boiled, baked, or sulphur-fumigated. What remedial applications are employed in scabies ? Sulphur, balsam of Peru, styrax, and /3-naphthol, singly or severally combined. In children, or in those of sensitive skin, the following :— R. Sulphur, prsecip..........5 iv Balsam. Peru v.,..........giv Adipis, Petrolati,......aa.......^iss. M. And in adults, or those of non-irritable skin :— R. Sulphur, praecip.,.........^j Balsam. Peruv.,..........^ss j3-Naphthol,............3 ij Adipis, Petrolati, . . . aa. . . q. s. ad . . . §iv. M. PARASITIC AFFECTIONS. 257 Styrax is a remedy of value and is commonly employed as an ointment in tlie strength of one part to two or three parts of lard. Is one such course of treatment sufficient to bring about a cure? Yes, in ordinary cases, if the applications have been carefully and thoroughly made ; exceptionally, however, some parasites and ova escape destruction, and consequently itching will again begin to show itself at the end of a week or ten days, and a repetition of the treatment become necessary. Does the secondary dermatitis which is always present in severe cases require treatment ? Only when it is unusually persistent or severe ; in such cases the various soothing applications, lotions or ointments employed in acute eczema are to be prescribed. Is a dermatitis due to too active and prolonged treatment ever mistaken for persistence of the scabies? Yes. Pediculosis. (Synonyms: Phtheiriasis; Lousiness.) Define pediculosis. Pediculosis is a term applied to that condition of local or general cutaneous irritation due to the presence of the animal parasite, the pediculus, or louse. Name the several varieties met with. Three varieties are presented,named according to the parts involved, pediculosis capitis, pediculosis corporis, and pediculosis pubis ; the parasite in each being a distinct species of pediculus. Pediculosis Capitis. Describe the symptoms of pediculosis capitis. Pediculosis capitis (pediculosis capillitii), due to the presence of the pediculus capitis, occurs much more frequently in children than 17 258 DISEASES OF THE SKIN. in adults. It is characterized by marked itching, and the formation of various inflammatory lesions, such as papules, pustules and excori- ations—resulting from the irritation produced by the parasites and from the scratching to which the intense pruritus gives rise. In fact, an eczematous eruption of the pustular type soon results, attended with more or less crust formation. In consequence of the cutaneous irritation the neighboring lymphatic glands may become inflamed and swollen, and in rare cases suppurate. The occipital region is the part which is usually most profusely infested. In those of delicate skin, especially in children, scattered papules, Fig. 68. Pediculus Capitis X 25. (After Duhring.) Female. Dorsal surface. vesico-papules, pustules and excoriations may often be seen upon the forehead and neck. In addition to the pediculi, which, as a rule, may be readily found, their ova, or nits, are always to be seen upon the shaft of the hairs, quite firmly attached. Describe the appearance of the ova. They are dirty-white or grayish-looking, minute, pear-shaped bodies, visible to the naked eye, and fastened upon the shaft of the hairs with the small end toward the root. PARASITIC AFFECTIONS. 259 Is there any difficulty in the diagnosis of pediculosis capitis ? No. The diagnosis is readily made, as the pedi- culi are usually to be found without difficulty, and even when they exist in small numbers and are not readily discovered, the presence of the oca will in- dicate the nature of the affection. Pustular eruptions upon the scalp, especially posteriorly, should always arouse a suspicion of pediculosis. The possibility of the pediculosis being secondary to eczema must not be forgotten. What is the treatment of pediculosis capitis ? Treatment consists in the application of some remedy destructive to the pediculi and their ova. Crude petroleum is effective, one or two thorough applications over night being usually sufficient; in order to lessen its inflammability, and also to mask its somewhat disagreeable odor, it may be mixed with an equal part of olive oil and a small quantity of balsam of Peru added. Tincture of cocculus indicus, pure or diluted, may also be applied with good results. When the parts are markedly eczematous, an ointment of ammoniated mercury or /?-naphthol, thirty to sixty grains to the ounce may be used. How are the ova or their shells to be removed from the hair ? By the frequent use of acid or alkaline lotions, such as dilute acetic acid and vinegar, or solutions of sodium carbonate and borax. Fig. 69. ;- " Ova of the head- louse attached to a hair. Magnified. (After Kaposi.) Pediculosis Corporis. Describe the symptoms of pediculosis corporis. Pediculosis corporis is dependent upon the presence of the pedicu- lus corporis (pedicilus vcstimenti), a larger variety than that infest- ing the scalp. It is characterized by more or less general itching, 260 DISEASES Ol' THE SKIN. together with various inflammatory lesions and excoriations. As the parasites are to be found chiefly in the folds and seams of the clothing, visiting the skin for the purpose of feeding, the various symptoms—the minute hemorrhagic puncta showing the points at which they have been sucking, and the consequent papules, pustules and excoriations—are, therefore, to be found most abundantly on those parts with which the clothing comes closely in contact, as, for Fig. 70. Pediculus Corporis X 25. (After Duhring.) Female. Dorsal surface. instance, around the neck, across the shoulders, around the waist, and down the outside of the thighs. It is uncommon in children. State the diagnostic characters of pediculosis corporis. The presence of the minute hemorrhagic puncta, the multiform character and peculiar distribution of the eruption. Careful search will almost invariably disclose one or more pediculi. What is the treatment of pediculosis corporis ? The clothing and bed-coverings are to be thoroughly baked or PARASITIC AFFECTIONS. 2f,l boiled, the pediculi and their ova being in this manner destroyed; a thymol or carbolized boric-acid lotion may be used to relieve the cutaneous irritation. When attention to the wearing apparel is not immediately practi- cable, ointments of sulphur and staphisagria, and lotions of carbolic acid, may be advised as temporary measures. The wearing of a bag of loosely woven texture containing some lump sulphur next to the skin is useful in such cases; at the temperature of the body the sulphur undergoes slow oxidation. Pediculosis Pubis. Describe the symptoms of pediculosis pubis. Pediculosis pubis is a condition due to the presence of the pediculus pubis, or crab-louse. It is characterized by more or less itching about the genitalia, together with papules, excoriations, and other inflammatory lesions. The amount of irritation varies; Fig. 71. Pediculus Pubis X 25. (After Duhring.) Female. Dorsal surface. it may be slight, or, on the other hand, severe. The parasite, which is the smallest of the three varieties, may be discovered upon close examination seated near the roots of the hairs, clutching the hair, with its head downward and buried in the follicle. The ova may be seen attached to the hair-shafts. It infests adults chiefly, being in most instances probably con- tracted through sexual intercourse. 262 DISEASES OF THE SKIN. Is the pediculus pubis found upon any other part of the body? Yes. Although its favorite habitat is the region of the pubes, it may, in exceptional instances, also infest the axillae, the sternal region of the male, the beard, eyebrows, and even the eyelashes. State the diagnostic characters of pediculosis pubis. The region involved, itching, variable amount of irritation, and. above all, the presence of the pediculi and their ova. Name several applications prescribed for pediculosis pubis. A lotion of corrosive sublimate, one to four grains to the ounce; infusion of tobacco; a ten to twenty per cent, ointment of oleate of mercury; ammoniated mercury ointment, and a five to ten per cent. /3-naphthol ointment. Repeated washings with vinegar or dilute acetic acid, or with alkaline lotions, will free the hairs of the ova. Cysticercus Cellulosae. Describe the cutaneous disturbance produced by the cysti- cercus cellulosae. The presence of cysticerci in the skin and subcutaneous tissue gives rise to pea to hazelnut-sized, rounded, firm, movable tumors which, when developed, may remain unchanged for months. The parasites are disclosed by microscopic examination. Most of the cuses have been observed in Germany. Filaria Medinensis. (Synonym : Guinea-worm.) State the character of the lesions produced by the filaria medinensis. The young microscopic worm penetrates the skin or deeper tissue, where it grows gradually, finally reaching several inches or more in length and about a half-line in thickness ; inflammation is excited and a tumor-like swelling makes its appearance, which, sooner or later, breaks, disclosing the worm. It may also present a cord-like appear- ance. It is rarely met with outside of tropical countries. Treatment consists in gradual extraction. Asafoetida internally has been found to be curative, the parasite being destroyed and sub- sequently absorbed or discharged. PARASITIC AFFECTIONS. 263 Ixodes. (Synonym : Wood-tick.) State the character of the cutaneous disturbance produced by the ixodes. The tick sticks its proboscis into the skin and sucks blood until it is several times its natural size, and then falls off; an urticarial lesion results. If caught in the act the animal should not be forcibly extracted, as its proboscis may be thus broken off and remain in the skin, and give rise to pain and inflammation. It may be made to relinquish its hold by placing on it a drop of an essential oil. A thymol or carbolized boric-acid lotion will relieve the irritation. Leptus. (Synonym: Harvest-mite.) State the characters of the lesion produced by the leptus. This minute brick-red mite buries itself in the skin, especially Fig. 72. Leptus. Magnified. (After Kilchenmeister.) about the ankles and feet, giving rise to papules, vesicles and pustules. Treatment consists of the use of a mild sulphur ointment or of a carbolic-acid lotion. 264 DISEASES OF THE SKIN. (Estrus. (Synonym : Gad, or Bot-fly.) Describe the cutaneous disturbance produced by the oestrus. The ova are deposited in the skin, develop and give rise to the formation of furuncle-like tumors with central aperture, through which a sanious discharge exudes; or as the result of the burrowing of the larvae, irregular serpiginous lines or wheals are produced. It is chiefly met with in Central and South America. Pulex Penetrans. (Synonyms : Sand Flea; Jigger.) Describe the cutaneous disturbance produced by the pulex penetrans. This microscopic animal penetrates the skin, especially about the toes, producing an inflammatory swelling, vesicle or pustule, or even ulceration. It is met with in warm and tropical countries. Treatment consists in extraction. Essential oils are used as a preventive. A carbolic-acid or alkaline lotion relieves irritation. Cimex Lectularius. (Synonym : Bed-hug.) Describe the characters of a bed-bug bite. An inflammatory papule or wheal-like lesion results, somewhat hemorrhagic; the purpuric or hemorrhagic point or spot remains after the swelling subsides, but finally, in the course of several days or a few weeks, disappears. Treatment consists in the application of alkaline or acid lotions. Culex. (Synonym: Gnat; Mosquito.) Describe the cutaneous disturbance produced by the culex, It consists of an erythematous spot or a wheal-like lesion. Alkaline or acid lotions usually give relief. PARASITIC AFFECTIONS. 265 Pulex Irritans. (Synonym : Common Flea.) Describe the cutaneous disturbance produced by the pulex irritans. It consists of an erythematous spot with a minute central hemor- rhagic point. In irritable skin, a wheal-like lesion may result. Treatment consists of applications of camphor or ammonia-water; carbolic acid and thymol lotions are also useful. 266 DISEASES OF THE SKIN. RELATIVE FREQUENCY OF THE VARIOUS DISEASES OF SKIN AS SHOWN P.Y THE STATISTICS (123,746 CASES) OF THE AMERICAN DERMATOLOGICAL ASSOCIATION FOR TEN YEARS, 1878-87. Classification of Diseases. Class I. Disorders of the Glands. 1. Of the Sweat Glands. Hyperidrosis ............... Sudamen.................... Anidrosis .................... Bromidrosis................. Chromidrosis............. Uridrosis..................... 2. Of the Sebaceous Glands .................. Seborrhoea: ................ a. oleosa ................. b. sicca.................. Comedo...................... Cyst:.......................... a. Milium.............. 6. Steatoma ............. Asteatosis.................. Class II. Inflammations. Exanthemata............. Erythema simplex...... Erythema multiforme a. papulosum......... b. bullosum............. c. nodosum.............. Urticaria.................... pigmentosa............. * Dermatitis :................ a. traumatica........... b. venenata.............. c. calorica................ d. medicamentosa.... e. gangrenosa.......... Erysipelas.................. Kuruuculus .............. Anthrax..................... Phlegmona diffusa...... Pustula maligna......... Herpes simplex........... Herpes zoster............. Dermatitis h e r p e t i ■ formis...................... Psoriasis....................., Pityriasis maculata et circinata................. Dermatitis exfoliativa.. 3J8 208 11 112 7 238 1812 3(57 395 1225 6 225 lol 1770 1064 915 325 37 82 2991 1 1720 468 616 224 108 8 1026 2129 252 265 197 2057 1428 41 4131 71 16 .265 .216 .0H9 .09J .005 .193 1.47 .296 .319 .989 .004 .181 .122 .006 1.43 .859 .730 .262 .029 .066 2.47 .0008 1.39 .378 .498 .187 .087 .006 .829 172 .203 .215 .159 1.66 1.15 .033 3.34 .057 .012 Classification of Diseases. Pityriasis rubra............ Lichen :....................... a. planus.................. 6. ruber.................... Eczema:...................... a. erythematosus .... 6. papillosum........... c. vesiculosum.......... d. madidans.............. e. pustulosum........... /. rubrum................ g. squamosum........... Prurigo....................... Acne........................... Acne rosacea............... Sycosis....................... Impetigo.................. Impetigo contagiosa..... Impetigo herpetiformis Ecthyma..................... Pemphigus.................. Dicers......................... Class III. Hemorrhages. Purpura:..................... a. simplex................ 6. hemorrhagica...... Class IV. Hypertrophies. 1. Of Pigment. Lentigo.................... Chloasma.................... 2. Of Epidermal and Papillary Layers. Keratosis:.................... a. pilaris.................. b. senilis............. ... Molluscum epiiheliale.. Callositas..................... Clavus......................... Cornu cutaneum.......... Verruca....................., Verruca necrogenica.... Nevus pigmentosus..... Xerosis........................ Ichthyosis................... Onychauxis................ Hypertrichosis............ 44 .03 144 .11 154 .12 27 .02 37661 30.43 34 .02 9077 7.34 398 .32 227 .18, 1769 1.43 6u0 .48 10 .00 726 .58 183 .14 3021 2.44 341 .27 181 .14 49 .03 127 .10 560 .45 94 .07 103 .08 68 .05 172 .13 110 .09 84 .06 42 .03 1252 1.09 2 .00 88 .06 100 .08 309 .21 70 .05 515 .41 * Indicating affections of this class not properly included under other titles. STATISTICS. STATISTICS—(Continued.) 2c>: Classification of Diseases. 3. Of Connective Tissue Sclerema neonatorum... Scleroderma........... ..... Morphcea.................... Elephantiasis............... Rosacea :.................... a. erythematosa........ 6. hypertrophica___ Frambcesia.................. Class V. Atrophias. 1. Of PlfiMKNT. Leucoderma................ Albinismus................ Vitiligo...................... Canities...................... 2. Of Hair. Alopecia..................... Alopecia furfuracea..... Alopecia areata .......... Atrophia pilorum pro- pria........................., Trichorexis nodosa..... 3. Of Nail..................... Atrophia unguis.......... 4. Of Cutis..................., Atrophia senilis........... Atrophia maculosa et striata....................... Class VI. New Growths. 1. OfConnkctivkTissue. Keloid........................ Cicatrix.......,............... Fibroma...................... Neuroma..................... Xanthoma.................. 2. Of Muscular Tissue. Myoma........................ 3. Of Vessels. Angioma..................... Angioma pigmentosum et atrophicum........... 38 39 57 785 381 58 22 77 9 19! 43 926 830 794 23 3 26 19 6 15 23 1 152 89 93 II 69 0.030 0.031 0.046 0.634 0.308 0.047 0.018 0.062 0.008 0.155 0.035 0.749 0.670 0.641 0.019 0.002 0.021 0.015 0.005 0.013 0.019 0.0008 0.124 0.065 0.075 0.009 0.056 1 0.0008 462 0.373 13 0.010 Classification of Diseases. Angioma cavernosura.. Lymphangioma.......... Mycosis fongoide....... Rhinoscleroma........... Lupus erythematosus.. Lupus vulgaris........... Scrofuloderma............. Syphiloderma:............ a. erythematosum.... 6. papillosum........... c. pustulosum........... d. tuberculosum....... e. gummatosum...... Lepra:...................... a. tuberosa............... 6. maculosa.............., c. ansesthetica.......... Carcinoma................... Sarcoma...................... Class VII. Neuroses. Hyperesthesia:___ a. Pruritus......... 6. Dermatalgia... Anesthesia........... Class VIII. Parasitic Affections. 1. Vegetable. Tinea favosa............... Tinea trichophytina:... a. circinata............... 6. tonsurans.............. c. sycosis................. Tinea versicolor.......... Animal. Sc abies...................... Pediculosis capillitii. ... Pediculosis corporis..... Pediculosis pubis........ 22 16 1 3 477 536 663 13888 Total 24 7 4 6 1068 55 4 2716 11 22 354 2289 705 675 365 12u3 3192 2579 1704 436 123746 INDEX. Acarus folliculorum, 42 scabei, 255 Achorion Schonleinii, 238 Acne, 115-122 artificialis, 116 atrophica, 116 Ciichccticorum, 116 hypertrophica, 116 indurata, 116 keloid, 128 lances, 119 papulosa, 116 punctata, 116 pustulosa, 116 rosacea, 122-124, 192 sebacea, 36 tar, 116 varioliformis, 116 vulgaris, 115 Addison's disease, pigmentation of the skin in, 141 Ainhum, 206 Albinismus, 171 Albinos, 171 Alopecia, 175-177 areata, 177-180 circumscripta, 177 congenital, 175 furfuraeea, 176 premature, 176 senile, 176 Anaesthesia, 234 Anatomical tubercle, 154 Anatomy of the skin, 17-21, 31, 36 Angioma, 190-191 cavernosum, 191 pigmentosum et atrophieum, 184 simplex, 190 Angiomyoma, 190 Angioneurotic oedema, 55 Anidrosis, 34 Anthrax, 67, 70 Antipruritic applications, 235 Antipyrin, eruptions from, 60 Area Celsi, 177 Argyria, 142 Arsenic, eruptions from, 60 Artificial eruptions (feigned erup- tions), 63 Atrophia cutis, 183-184 pilorum propria, 181 unguis, 182-183 Atrophic lines and spots, 184 Atrophies, 30, 171-184 Atrophoderma, 183 neuriticum, 183 Atrophy of the hair, 181 nails, 182 skin, 183 general idiopathic, 183 senile, 184 Atropia, eruptions from, 61 Autograph ism, 54 Baldness, 175 Barbadoes leg, 167 Barber's itch, 243 Bath-pruritus, 234 Bed-bug, 2<>4 Bed-sores, 58 Belladonna, eruptions from, 61 Blanching of tlie hair, 175 Blackheads, 40-42 Blastomycetic dermatitis, 252 Blebs, 23 Bloodvessels, 19 Boil, 65 Bot-fly, 264 Bromides, eruptions from, 61 Bromidrosis, 35 Bullae, 23 Burns, 58 Burrows, 254 269 270 Calculi, cutaneous, 44 Callositas, 147-148 Callosity, 147 Callous, 147 Callus, 147 Cancer, epithelial, 227 skin, 227 Canities, 175 prematura, 175 senilis, 175 Carbuncle, 67 Carbunculus, 67-69 Carcinoma epitheliale, 227 Chafing, 47 Chapping, 102 Charbon, 70 Cheiro-pompholyx, 73 Cheloid, 185 Chloasma, 141-143 uterinum, 141 Chloral, eruptions from, 61 Chromidrosis, 35 Chromophytosis, 249 Chrysarobin, 91 Chrysophauic acid (chrysarobin), 91 Cicatrices, 24 Cimex lectularius, 264 Classification, 28-31 Clavus, 148-149 Comedo, 41-44 extractor, 43 Condyloma, flat (or broad), 210 pointed, 152 Configuration, 24 Conglomerative pustular perifollic- ulitis, 69 Contagious impetigo, 130 Contagiousness, 27 Copaiba, eruptions from, 62 Corn, 148 Cornu cutaneum, 150-151 humanum, 150 Crab-louse, 261 Crusta lactea, 100 Crustae, 24 Crusts, 24 Cubebs, eruptions from, 62 Culex, 264 Cuniculus, 254 Curette, 203 Cutaneous calculi, 45 horn, 150 Cutis anserina, 144 pendula, 170 Cyst, sebaceous, 44 Cysticercus cellulosae, 262 Dandruff, 36, 37 Darier's disease, 145 Defluvium capillorum, 176 Demodex folliculorum, 42 Depilatories, 161 Dermalgia, 233 Dermatalgia, 233 Dermatitis, 57-62 acute general, 94 ambustionis, 58 blastomycetic, 252 calorica, 58 congelationis, 58 contusiformis, 51 exfoliativa, 94-95 general, 94 recurrent, 94 neonatorum, 95 gau green osa, 63 herpetiformis, 81-85 iodoform, 59 medicamentosa, 60 papillaris capillitii, 128 traumatica, 58 venenata, 59 malignant papillary, 230 Dermatographism, 54 Dermatolysis, 170 Dermatomyoma, 190 Dermatosclerosis, 164 Dermatosyphilis, 207 Digitalis, eruptions from, 62 Disorders of the glands, 28, 31-45 Dissection wound, 70 Distribution and configuration, 24- 26 Drug eruptions (dermatitis medica- mentosa), 60 Duhring's disease, 81 Dysidrosis, 73 Ecthyma, 132-133 Eczema, 98-113 erythematosum, 99 fissum, 102 impetiginosum, 100 madidans, 101 marginatum, 241 papulosum, 100 parasitic, 103 pustulosum, 100. rubrum, 101 INDEX. 271 Eczema selerosum, 102 seborrhceicum, 37, 38, 94, 102 squamosum, 100 verrucosum, 102 vesiculosum, 99 Electrolysis in removal of hair, 162 Elephant leg, 167 Elephantiasis, 167-170 Arabum, 167 Graecorum, 222 Endemic verrugas, 70 Epidermis, 18 Epidermolysis bullosa, 78 Epilating forceps, 239 Epithelial cancer, 227 Epithelioma, 227-230 molluscum, 145 Equinia, 71 Erasion, 204 Eruptions, feigned (artificial), 63 medicinal (dermatitis medica- mentosa), 60 Erysipelas, 63-65 ambulans, 64 migrans, 64 Erysipeloid, 64 Erythema, 46 annulare, 49 bullosum, 49 caloricum, 46 desquamative scarlatiniform, 94 gangraenosum, 63 gyratum, 49 induratum, 52 intertrigo, 47, 48 iris, 49 marginatum, 49 multiforme, 48 nodosum, 51-52 recurrent exfoliative, 94 simplex, 46 solare, 46 traumaticum, 46 venenatum, 46 vesiculosum, 49 Erythrasma, 251-252 Excessive sweating (hyperidrosis), 31 Excoriationes, 24 Excoriations, 24 Farcy, 71 Favus, 237 Favus of general surface, 238 of nails, 238 Favus of scalp, 237 Feigned eruptions, 63 Fever blisters, 75 Fibroma, 186-188 molluscum, 186 Fibromyoma, 190 Filaria, 169 medinensis, 262 Fish-skin disease, 157 Fissures, 24 Flea, common, 265 Flea', sand, 264 Flesh worms, 41, 42 Folliculitis barbae, 125 decalvans, 125 Forceps, epilating, 239 Fragilitas crinium, 181 Frambcesia, 70 Freckle, 140 Frost-bite, 58 Fungous foot of India, 206 Furuncle, 65 Furunculosis, 66 Furunculus, 65-67 Gad-fly, 264 Galvano-cautery, 204 battery, 202 handle, 201 instruments, 201 Gangrene of the skin, (dermatitis gangrsenosa), 63 spontaneous, 63 Gelatin dressing, 112 Giant urticaria, 55 Glanders, 71 Glands, sebaceous, 36 sweat, 31 Glossy skin, 183 Gnat, 264 Goose-flesh, 144 Granuloma fungoides, 232 Grayness of the hair, 175 Grutum, 44 Guinea-worm, 262 Gumma, 217, 218 Gun-powder marks, 143 Gutta-percha plaster, 113 Hair, 21 atrophy of, 181 graying of, 175 hypertrophy of, 160 superfluous, 160 Hair-follicle, 21 272 INI Hairy people, 160 Harvest mite, 263 Heat rash, 71 Hemorrhages, 29, 136-139 Hereditary infantile syphilis, 219 cutaneous manifestations of, 213 Herpes, 75 facialis, 76 gestationis, 81 iris, 80, 81 labialis, 76 praeputialis, 76 progenitalis, 76 simplex, 75-77 zoster, 78, 80 Hirsuties, 160 Hives, 52 Homines pilosi, 160 Horn, cutaneous, 150 Hydradenitis suppurativa, 75 Hydroa aestivale, 77 herpetiforme, 81 pulsorum, 77 vacciniforme, 77 Hydrocystoma, 34 Hyperaesthesia, 233 Hyperidrosis, 31-33 Hypertrichosis, 160-163 Hypertrophies, 29, 140-170 Hypertrophic scar, 186 Hypertrophy of the hair, 160 of the nail, ,159 Ichthyosis, 157-159 follicularis, 145 hystrix, 157 sebacea, 36 cornea, 145 simplex, 157 Impetigo, 129, 130 contagiosa, 130-131 herpetiformis, 132 simplex, 129 Infantile syphilis, hereditary, 219 Inflammations, 28, 29, 46-136 Inflammatory fungoid neoplasm, 232 Iodides, eruptions from, 62 Iodoform dermatitis, 59 Itch, 253 barbers', 243 mite, 263 Ivy poisoning, 59 Ixodes, 263 Jigger, 264 Keloid, 185, 186 cicatricial, 185 false, 185 of Addison, 165 of Alibert, 185 spontaneous, 185 true, 185 Keratoma, 147 Keratosis follicularis, 145 pigmentosa, 152 pilaris, 143, 144 Kerion, 243 Land scurvy, 137 Lanugo, 169 Lentigo, 140 Leontiasis, 224 Lepra, 222-226 Leprosy, 222 anaesthetic, 224 Lombardian, 226 tubercular, 223 Leptus, 263 , Lesions, 22 configuration of, 24 consecutive, 23 distribution of, 24 elementary, 22 primary, 22 secondary, 23 Leucoderma, 172 Leucopathia, 172 Lichen moniliformis, 97 pilaris, 143 planus, 96 ruber, 96 acuminatus, 96 planus, 96 scrofulosus, 98 tropicus, 71 urticatus, 54 Lineae albicantes, 184 Linear scarification, 204 Liomyoma cutis, 190 Liquor carbonis detergens, 109 picis alkalinus, 112 Lombardian leprosy, 226 Louse, body (pediculus corporis), 260 clothes (pediculus corporis), 260 crab, 261 head (pediculus capitis), 257 Lousiness, 257 Lupoid sycosis, 125 Lupus, 197 INDEX. 273 Lupus erythematodes, 193 erythematosus, 193-197 exedens, 197, 198 exfoliativa, 198 exulcerans, 198 hypertrophicus, 199 sebaceus, 193 ulcerations, 198 verrucosus, 198 vorax, 197 vulgaris, 197-204 Lymphangiectodes, 192 Lymphangioma, 192 tuberosum multiplex, 192 Lymphangiomyoma, 190 Macule, 22 et striae atrophicae, 184 Macules, 22 Madura foot, 206 Malignant pustule, 69 papillary dermatitis, 230 Medicinal eruptions (dermatitis medicamentosa), 60 Melanoderma, 141 Melano-sarcoma, 232 Melasma, 150 Mercury, eruptions from, 62 Microsporon audouini, 244 furfur, 250 minutissimum, 252 Miliaria, 71, 72 alba, 71 crystal lina, 33 rubra, 71 Milium, 44, 45 needle, 44 Milk crust, 100 Mite, harvest, 263 itch, 255 Moist papule, 209, 210 Mole, 155 Molluscum contagiosum, 145 epitheliale, 145-147 fibrosum, ISO sebaceum, 145 Morphia, eruptions from, 62 Morphcea, 165-167 Mosquito, 264 Mucous patch, 210 Mycetoma, 206 Mvcosis fungoides, 232 Myoma, 190 cutis. 190 telangiectodes, 190 N.evus araneus, 192 capillary, 190 flammeus, 190 lipomatodes, 156 pigmentosus, 155-156 pilosus, 156, 160 sanguineus, 190 simplex, 190 spider, 192 spilus, 156 tuberosus, 191 vasculosus, 190 venous, 191 verrucosus, 156 Nail, atrophy of, 182 hypertrophy of, 159 Needle-holder for electrolysis, 162 Neoplasm, inflammatory fungoid, 232 Neoplasmata (new growths), 30,185, 232 Nettle-rash, 52 Neuralgia of the skin, 233 Neuroma, 188 Neuroses, 30, 233-236 New growths, 30, 185-233 Nits, 258 Objective symptoms, 22 CEdema, acute circumscribed, 55 (Estrus, 264 Ointment bases, 27 Onychatrophia, 182 Onychauxis, 159, 160 Onychomycosis, 182 favosa, 238 Opium, eruptions from, 62 Osmidrosis, 35 Ova of pediculi, 258 Papilla, nervous and vascular, 20 Pachydermia, 167 Paget's disease of the nipple, 230 Papulae, 23 Papule, moist, 209, 210 Papules, 23 Parasitic affections, 31, 237-265 sycosis, 243 Parasiticides, 240, 247, 248 Parchment skin, 184 Paronychia, 159 Patch, mucous, 209, 210 Pediculosis, 257 capillitii, 257 capitis, 257-259 IS 274 INDEX. Pediculosis corporis, 259-261 pubis, 261-262 Pediculus capitis, 258 corporis, 260 pubis, 261 vestimenti, 259 Peliosis rheumatica, 137 Pellagra, 226 Pemphigus, 134-136 foliaceus, 134 neonatorum, 134 pruriginosus, 81 vulgaris, 134 Perforating ulcer of the foot, 207 Perifolliculitis, conglomerative pus- tular, 69 Phlegmonosa diffusa, 65 Phosphorescent sweat, 36 Phosphoridrosis, 36 Phtheiriasis, 257 Pian, 70 Pityriasis capitis, 37 maculata et circinata, 93 pilaris, 143 rosea, 93-94 rubra, 95 pilaris, 95 versicolor, 249 Plasment, 113 Plaster-mull, 113 Podelcoma, 206 Poison dogwood, dermatitis from, 59 ivy, dermatitis from, 59 sumach, dermatitis from, 59 vine, dermatitis from, 59 Pom phi, 23 Pompholyx, 73-75 Port-wine mark, 191 Post-mortem pustule, 70 tubercle, 154 wart, 154 Prickly heat, 71 Primary lesions, 22-23 Prurigo, 113-115 Pruritus, 234-236 ani, 234 hiemalis, 234 scroti, 234 senilis, 234 vulvae, 234 Psoriasis, 85-93 circinata, 86 diffusa, 86 guttata, 86 Psoriasis gyrata, 86 invcterata, 86 nummularis, 86 punctata, 86 syphilitica, 211 Psorospermosis, 145, 146, 231 Pulex irritans, 265 penetrans, 264 Punctate scarification, 204 Purpura, 136-138 haemorrhagica, 137 rheumatica, 137 scorbutica, 139 simplex, 137 urticans, 137 Pustula maligna, 70 Pustuhe, 23 Pustules, 23 Quinine, eruptions from, 62 Rapidity of cure, 27 Raynaud's disease, 63 Recurrent summer eruption, 77 Red gum, 71 Relative frequency, 26 Rhagades, 24 Rheumatism of the skin, 233 Rhinophyma, 123 Rhinoscleroma, 192, 193 Rhus poisoning, 59 Ringworm, 240 of bearded region, 243 of general surface, 241 of the nails, 241 of the scalp, 242 of the thighs and scrotum, 241 Rodent ulcer, 227 Rosacea, 192 acne, 122 Rubber plaster, 113 Rupia, 214, 215 Salicylic acid, eruptions from, 62 paste, 110 Salt rheum, 98 Sand flea, 264 Sarcoma. 231-233 cutis, 231 Sarcoptes scabiei, 245 Scabies, 253-257 ' Scales, 24 Scarification, linear, 204 punctate, 204 Scarifier, multiple, 197 INDEX. 275 Scarifier, single, 197 Scars, 24 hypertrophic, 186 Sclerema, 164 neonatorum, 163-164 of the newborn, 163 Scleriasis, 164 Scleroderma, 164-165 circumscribed, 165 neonatorum, 163 Scorbutus, 139 Scrofuloderma, 204-206 Scurvy, 139 land, 137 sea, 139 Sebaceous cyst, 45 gland, 36 tumor, 45 Seborrhoea, 36-41 congestiva, 193 oleosa, 36 sicca, 37 Secondary lesions, 23-24 Shingles, 77 Skin, anatomy of, 17 cancer, 227 general idiopathic atrophy of, 183 glossy, 183 looseness of, 170 parchment, 184 Spider naevus, 192 Spontaneous gangrene, 63 Spots, 22 Squamae, 24 Stains, 24 Statistics, 266. 267 Steatoma, 45 Steatorrhea, 36 Stramonium, eruptions from, 62 Strise et maculae atrophicae, 181 Strophulus, 71 albidus, 44 Subjective symptoms, 22 Sudamen, 33-34 Superfluous hair, 160 Sweat colored (chromidrosis), 35 glands, 31 phosphorescent, 36 Sweating, excessive, 31 Sycosis, 125-127 non-parasitica, 125 parasitic, 243 Symptomatology, 22-26 Symptoms, objective, 22 Symptoms, subjective, 22 systemic, 22 Syphilis cutanea, 207-222 early eruptions of, 207 late eruptions of, 208 papillomatosa, 217 hereditary, 218 eruptions of, 218 of the skin, 207-222 Syphiloderm, 207-209 acne-form, 213 annular, 211, 212 bullous, 215, 219 circinate, 212 ecthyma-form, 214 erythematous, 208, 218 gummatous, 217 impetigo-form, 213 large acuminated-pustular, 213 large flat-pustular, 214 large papular, 210 lenticular, 210 macular, 208, 218 miliary papular, 209 pustular, 212 non-ulcerating tubercular, 216 palmar, 210, 211 papular, 209, 219 papulo-squamous, 211 plautar, 211 pustular, 212 serpiginous tubercular, 216 small acuminated-pustular, 212 flat-pustular, 213 papular, 209 squamous, 211 tubercular, 215, 216 ulcerating tubercular, 216 variola-form, 213 vegetating, 211 Syphiloderma, 207 Syphiloma, 217 Tar acne, 116 Tattoo-marks, removal of, 143 Telangiectasis, 123, 191-192 Tetter, 98 Tinea circinata, 241 cruris, 241 favosa, 237-240 fungus of, 238 kerion, 243 sycosis, 243 tonsurans, 242 trichophytina, 240-249 276 INDEX. Tinea tricophytina barbae, 243 capitis, 242 corporis, 241 cruris, 241 fungus of, 244 unguium, 241 unguium, 238 versicolor, 249-251 fungus of, 251 Traumaticin, 92 Trichophyton, 244 Trichorexis nodosa, 181 Tubercle, anatomical, 154 Tubercles, 23 Tubercula, 23 Tuberculosis cutis, 204 of the skin, 197 verrucosa cutis, 154. Tumor, sebaceous, 45 Tumors, 23 Turpentine, eruptions from, 63 Tyloma, 147 Tylosis, 147 Ulcer, rodent, 227 Ulcera, 24 Ulerythema sycosi forme, 125 Uridrosis, 36 Urticaria, 52-57 bullosa, 55 chronic, 54 factitia, 54 haemorrhagica, 54 cedematosa, 55 papulosa, 54 tuberosa, 55 giant, 55 pigmentosa, 57 Venereal wart, 152 Verruca, 152-154 acuminata, 152 digitata, 152 filiformis, 152 necrogenica, 154,155 plana, 152 senilis, 152 vulgaris, 152 Verrugas, endemic, 70 Vesicles, 23 Vesiculae, 23 Vitiligo, 172-174 Vitiligoidea, 189 Vleminckx's solution, 124 Wart, 152 pointed, 152 post-mortem, 154 venereal, 152 Wen, 45 Wheals, 23 Wood-tick, 263 Wound, dissection, 70 Xanthelasma, 189 Xanthelasmoidea, 57 Xanthoma, 189-190 multiplex, 189 planum, 189 tuberculatum, 189 tuberosum, 189 Xeroderma, 157 pigmentosum, 184 Yaws, 70 Zona, 77 Zoster, 77 Medical and Surgical Works PUBLISHED BY W. B. SAUNDERS, 925. Walnut Street, Philadelphia, Pa. 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The same careful and competent editorial supervision has been secured in the English edition as in the originals; The translations have been edited by the leading American specialists in the different subjects. The volumes are of a uniform and convenient size (5 X 1% inches), and are substantially bound. (For List of Volumes in this Series, see next page.) 3 SAUNDERS' MEDICAL HAND-ATLASES. VOLUMES NOW READY. Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine Philadelphia Polyclinic. 68 colored plates, 64 text illustrations, and 259 pages of text. Cloth, $3.00 net. " The charm of the book is its clearness, conciseness, and the accuracy and beauty of its illustrations. It deals with facts. It vividly illustrates those facts. It is a scientific work put together for ready reference."—Brooklyn Medical Journal. Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peterson, M. D., Clinical Professor of Mental Diseases, Woman's Medical College, New York; Chief of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, #3.50 net. " Hot'mann's 'Atlas of Legal Medicine' is a unique work. This immense field finds in this book a pictorial presentation that far excels anything with which we are familiar in any other work."—Philadelphia Medical Journal. Atlas of Diseases of the Larynx. By Dr. L. Gr'unwald, of Munich. Edited by Charles P. Grayson, M. D., Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-illustrations, and 103 pages of text. Cloth, $2.50 net. "Aided as it is by magnificently executed illustrations in color, it cannot fail of being of the greatest advantage to students, general practitioners, and expert laryngologists."—St. Louis Medical and Surgical Journal. Atlas of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers DaCosta, M. D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia. With 24 colored plates, 217 text-illus- trations, and 395 pages of text. Cloth, $3.00 net. " We know of no other work that combines such a wealth of beautiful illustrations with clearness and conciseness of language, that is so entirely abreast of the latest achievements, and so useful both for the beginner and for one who wishes to increase his knowledge of oper- ative surgery."—Miinchener medicinische Wochenschrift. Atlas of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, University and Bellevue Hospital Medical College, New York. With 71 colored plates from original water-colors, 16 black- and-white illustrations, and 122 pages of text. Cloth, $3.50 net. "A glance through the book is almost like actual attendance upon a famous clinic."— Journal of the American Medical Association. Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia With 76 colored illustrations on 40 plates, and 228 pages of text. Cloth, $3.00 net. Atlas of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by Henry W. Stelwagon, M. D., Clinical Professor of Derma- tology, Jefferson Medical College, Philadelphia. With 63 colored plates, 39 beautiful half-tone illustrations, and 200 pages of text. Cloth, #3.50 net. IN PREPARATION. Atlas of Pathological Histology. Atlas of Operative Gynecology. Atlas of Orthopedic Surgery. Atlas of Psychiatry. Atlas of General Surgery. Atlas of Diseases of the Ear. CATALOGUE OF MEDICAL .WORKS. 5 *AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by William H. Howell, Ph.D., M. D., Professor of Physiology in the Johns Hopkins University, Baltimore, Md. One handsome octavo volume of 1052 pages, fully illustrated. Prices : Cloth, $6.00 net; Sheep or Half- Morocco, $7.00 net. This work is the most notable attempt yet made in America to combine in rme volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they write. The completed work represents the present status of the science of Physiology, particularly from the standpoint of the student of medicine and of the medical practitioner. The collaboration of several teachers in the preparation of an elementary text- book of physiology is unusual, the almost invariable rule heretofore having been for a single author to write the entire book. One of the advantages to be derived from this collaboration method is that the more limited literature necessary for consultation by each author has' enabled him to base his elementary account upon a comprehensive knowledge of the subject assigned to him; another, and perhaps the most important, advantage is that the student gains the point of view of a number of teachers. In a measure he reaps the same benefit as would be obtained by following courses of instruction under different teachers. The different standpoints assumed, and the differences in emphasis laid upon the various lines of procedure, chemical, physical, and anatomical, should give the student a better insight into the methods of the science as it exists to-day. The work will also be found useful to many medical practitioners who may wish to keep in touch with the development of modern physiology. TOXTRIBIITORS: WARREN P. LOMBARD, M. D., Professor of Physiology, University of Michigan. GRAHAM LUSK, Ph. D., Professor of Physiology, Vale Medica) School. W. T. PORTER, M.D., Assistant Professor of Physiology, Har- vard Medical School. EDWARD T. REICHERT, M. D., Professor of Physiology, University of Pennsylvania. HENRY SEWALL, Ph.D., M. D., Professorof Physiology, Medical Depart- ment, University of Denver. " We can commend it most heartily, not only to all students of physiology, but to every physician and pathologist, as a valuable and comprehensive work of reference, written by men who are of eminent authority in their own special subjects." — London Lancet. " To the practitioner of medicine and to the advanced student this volume constitutes, we believe, the best exposition of the present status of the science of physiology in the Eng- lish language."—American Journal of the Medical Sciences. HMKI r. BUWIMTUri, Ol. U., Professor of Physiology, Harvard Medi- cal School. JOHN G. CURTIS, M. D., Professor of Physiology, Columbia Uni- versity, N. Y. (College of Physicians and Surgeons). HENRY H. DONALDSON, Ph.D., Head-Professor of Neurology, Univer- sity of Chicago. W. H. HOWELL, Ph. D., M. D., Professor of Physiology, Johns Hopkins University. FREDERIC S. LEE, Ph. D., Adjunct Professorof Physiology, Colum- bia University, N. Y. (College of Pllviirinn*: anH Sni-cr«»r»nQ^ 6 W. B. SAUNDERS' *AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- TICS. For the Use of Practitioners and Students. Edited by James C. Wilson, M. D., Professor of the Practice of Medicine and of Clinical Medicine in the Jefferson Medical College. One handsome octavo volume of 1326 pages. Illustrated. Prices: Cloth, $7.00 net; Sheep or Half-Morocco, $8.00 net. The arrangement of this volume has been based, so far as possible, upon modern pathologic doctrines, beginning with the intoxications, and following with infections, diseases due to internal parasites, diseases of undetermined origin, and finally the disorders of the several bodily systems—digestive, re- spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to include also a consideration of the disorders of pregnancy. The articles, with two exceptions, are the contributions of American writers. Written from the standpoint of the practitioner, the aim of the work is to facili- tate the application of knowledge to the prevention, the cure, and the allevia- tion of disease. The endeavor throughout has been to conform to the title of the book—Applied Therapeutics—to indicate the course of treatment to be pursued at the bedside, rather than to name a list of drugs that have been used at one time or another. The list of contributors comprises the names of many who have acquired dis- tinction as practitioners and teachers of practice, of clinical medicine, and of the specialties. CONTRIBUTORS: Dr. I. E. Atkinson, Baltimore, Md. Sanger Brown, Chicago, 111. . John B. Chapin, Philadelphia, Pa. William C. Dabney, Charlottesville, Va. John Chalmers DaCosta, Philada., Pa. I. N. Danforth, Chicago, 111. John L. Dawson, Jr., Charleston, S. C. F. X. Dercum, Philadelphia, Pa. George Dock, Ann Arbor, Mich. Robert T. Edes, Jamaica Plain, Mass. Augustus A. Eshner, Philadelphia, Pa. J. T. Eskridge, Denver, Col. F. Forchheimer, Cincinnati, O. Carl Frese, Philadelphia, Pa. Edwin E. Graham, Philadelphia, Pa. John Guiteras, Philadelphia, Pa. Frederick P. Henry, Philadelphia, Pa. Guy Hinsdale, Philadelphia, Pa. Orville Horwitz, Philadelphia, Pa. W. W. Johnston, Washington, D. C. Ernest Laplace, Philadelphia, Pa. A. Laveran, Paris, France. Dr. James Hendrie Lloyd, Philadelphia, Pa. John Noland Mackenzie, Baltimore, Md. J. W. McLaughlin, Austin, Texas. A. Lawrence Mason, Boston, Mass. Charles K. Mills, Philadelphia, Pa. John K. Mitchell, Philadelphia, Pa. W. P. Northrup, New York City. William Osier, Baltimore, Md. Frederick A. Packard, Philadelphia, Pa. Theophilus Parvin, Philadelphia, Pa. . Beaven Rake, London, England. E. O. Shakespeare, Philadelphia, Pa. Wharton Sinkler, Philadelphia, Pa. Louis Starr, Philadelphia, Pa. Henry W. Stelwagon, Philadelphia, Pa. James Stewart, Montreal, Canada. Charles G. Stockton, Buffalo, N. Y. James Tyson, Philadelphia, Pa. Victor C. Vaughan, Ann Arbor, Mich. James T. Whittaker, Cincinnati, O. J. C. Wilson, Philadelphia, Pa. " As a work either for study or reference it will be of great value to the practitioner, as it is virtually an exposition of such clinical therapeutics as experience has taught to be of the most value. Taking it all in all, no recent publication on therapeutics can be compared with this one in practical value to the working physician."—Chicago Clinical Review. "The whole field of medicine has been well covered. The work is thoroughly practical, and while it is intended for practitioners and students, it is a better book for the general practitioner than for the student. The young practitioner especially will find it extremely suggestive and helpful."—The Indian Lancet. CATALOGUE OF MEDICAL WORKS. 7 *AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Richard C. Norjlis, M. D.; Art Editor, Robert L. Dickinson, M. D. One handsome octavo volume of over iooo pages, with nearly 900 colored and half-tone illustrations. Prices : Cloth, $7.00; Sheep or Half-Morocco, SS.oo. The advent of each successive volume of the series of the American Text- Books has been signalized by the most nattering comment from both the Press and the Profession. The high consideration received by these text-books, and their attainment to an authoritative position in current medical literature, have been matters of deep international interest, which finds its fullest expression in the demand for these publications from all parts of the civilized world. In the preparation of the "American Text-Book of Obstetrics" the editor has called to his aid proficient collaborators whose professional prominence entitles them to recognition, and whose disquisitions exemplify Practical Obstetrics. While these writers were each assigned special themes for dis- cussion, the correlation of the subject-matter is, nevertheless, such as ensures logical connection in treatment, the deductions of which thoroughly represent the latest advances in the science, and which elucidate the best modern methods of procedure. The more conspicuous feature of the treatise is its wealth of illustrative matter. The production of the illustrations had been in progress for several years, under the personal supervision of Robert L. Dickinson, M. D., to whose artistic judgment and professional experience is due the most sumptuously illustrated work of the period. By means of the photographic art, combined with the skill of the artist and draughtsman, conventional illustration is super- seded by rational methods of delineation. Furthermore, the volume is a revelation as to the possibilities that may be reached in mechanical execution, through the unsparing hand of its publisher. < ovnt11:1 TOKS : Dr. James C. Cameron. Edward P. Davis. Robert L. Dickinson. Charles Warrington Earle. James H. Etheridge. Henry J. Garrigues. Barton Cooke Hirst. Charles Jewett. Dr. Howard A. Kelly. Richard C. Norris. Chauncey D. Palmer. Theophilus Parvin. George A. Piersol. Edward Reynolds. Henry Schwarz. "At first glance we are overwhelmed by the magnitude of this work in several respects, viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- ment who have taken part in its production, then by the profuseness and character of the illustrations, and last, but not least, the conciseness and clearness with which the text is ren- dered. This is an entirely new composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy the front rank in their specialty, and there are many of them. We cannot turn over these pages without being struck by the superb illustrations which adorn so many of them. We are confident that this most practical work will find instant appreciation by practitioners as well as students."—New York Medical Times. Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that 1 have ever seen. I congratulate you and thank you for this superb work, which alone is sufficient to place you first in the ranks of medical publishers. With profound respect I am sincerely yours, Alex. J. C. Skene. 8 W. B. SAUNDERS' *AN AMERICAN TEXT-BOOK OF THE THEORY AND PRACTICE OF MEDICINE. By American Teachers. Edited by William Pepper, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Complete in two handsome royal-octavo volumes of about iooo pages each, with illustrations to elucidate the text wherever necessary. Price per Volume: Cloth, #5.00 net; Sheep or Half-Morocco, $6.00 net. VOLUME I. CONTAINS: Hygiene.—Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing).—Scarla- tina, Measles, Rotheln, Variola, Varioloid, Vaccinia,Varicella, Mumps,Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actino- mycosis, Glanders, and Tetanus.—Tubercu- losis, Scrofula, Syphilis, Diphtheria, Erysipe- las, Malaria, Cholera, and Yellow Fever.— Nervous, Muscular, and Mental Diseases etc. VOLUME II. CONTAINS! Urine (Chemistry and Microscopy).—Kid- ney and Lungs.—Air-passages (Larynx and Bronchi) and Pleura.—Pharynx, CEsophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins. —Peritoneum, Liver,and Pancreas.—Diathet- ic Diseases (Rheumatism, Rheumatoid Ar- thritis, Gout, Lithaemia, and Diabetes.)— Blood and Spleen.—Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. The articles are not written as though addressed to students in lectures, but are exhaustive descriptions of diseases, with the newest facts as regards Causa- tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number of approved formulae. The recent advances made in the study of the bacterial origin of various diseases are fully described, as well as the bearing of the knowledge so gained upon prevention and cure. The subjects of Bacteriology as a whole and of Immunity are fully considered in a separate section. Methods of diagnosis are given the most minute and careful attention, thus enabling the reader to learn the very latest methods of investigation without consulting works specially devoted to the subject. CONTRIBUTORS: Dr. J. S. Billings, Philadelphia. Francis Delafield, New York. Reginald H. Fitz, Boston. James W. Holland, Philadelphia. Henry M. Lyman, Chicago. William Osier, Baltimore. Dr. William Pepper, Philadelphia. W. Gilman Thompson, New York. W. H. Welch, Baltimore. James T. Whittaker, Cincinnati. James C. Wilson, Philadelphia. Horatio C. Wood, Philadelphia. " We reviewed the first volume of this work, and said: ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second a.nd last volume leads us to modify that verdict and to say that the completed work is, in our opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of what the modern text-book should be."—New York Medical Journal. " A library upon modern medical art. The work must promote the wider diffusion of sound knowledge."—American Lancet. " A trusty counsellor for the practitioner or senior student, on which he may implicitly rely."—Edinburgh Medical Journal. CATALOGUE OF MEDICAL WORKS. 9 *AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam W. Keen, M.D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal octavo volume of 1230 pages (10 x 7 inches), with 496 wood-cuts in text, and 37 colored and half-tone plates, many of them engraved from original photographs and drawings furnished by the authors. Price : Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. THIRD EDITION, THOROUGHLY REVISED. The want of a text-book which could be used by the practitioner and at the same time be recommended to the medical student has been deeply felt, espe- cially by teachers of surgery; hence, when it was suggested to a number of these that it would be well to unite in preparing a text-book of this description, great unanimity of opinion was found to exist, and the gentlemen below named gladly consented to join in its production. While there is no distinctive Amer- ican Surgery, yet America has contributed very largely to the progress of modern surgery, and among the foremost of those who have aided in developing this art and science will be found the authors of the present volume. All of them are teachers of surgery in leading medical schools and hospitals in the United States and Canada. Especial prominence has been given to Surgical Bacteriology, a feature which is believed to be unique in a surgical text-book in the English language. Asep- sis and Antisepsis have received particular attention. The text is brought well up to date in such important branches as cerebral, spinal, intestinal, and pelvic surgery, the most important and newest operations in these departments being described and illustrated. The text of the entire book has been submitted to all the authors for their mutual criticism and revision—an idea in book-making that is entirely new and original. The book as a whole, therefore, expresses on all the important sur- gical topics of the day the consensus of opinion of the eminent surgeons who have joined in its preparation. One of the most attractive features of the book is its illustrations. Very many of them are original and faithful reproductions of photographs taken directly from patients or from specimens. CONTRIBUTORS: . Phineas S. Conner, Cincinnati. Frederic S. Dennis, New York William W. Keen, Philadelphia. Charles B. Nancrede, Ann Arbor, Mich. Roswell Park, Buffalo, New York. Lewis S. Pilcher, New York. Dr. Nicholas Senn, Chicago. Francis J. Shepherd, Montreal, Canada. Lewis A. Slimson, New York. J. Collins Warren, Boston. J. William White, Philadelphia. If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very h.gh order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice "— London Lancet. IO W. B. SAUNDERS1 *AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL, for the use of Students and Practitioners. Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume of 718 pages, with 341 illustrations in the text and 38 colored and half- tone plates. Prices : Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. SECOND EDITION, THOROUGHLY REVISED. In this volume all anatomical descriptions, excepting those essential to a clear understanding of the text, have been omitted, the illustrations being largely de- pended upon to elucidate the anatomy of the parts. This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for physicians and students. A clear line of treatment has been laid down in every case, and although no attempt has been made to dis- cuss mooted points, still the most important of these have been noted and ex- plained. The operations recommended are fully illustrated, so that the reader, having a picture of the procedure described in the text under his eye, cannot fail to grasp the idea. All extraneous matter and discussions have been carefully excluded, the attempt being made to allow no unnecessary details to cumber the text. The subject-matter is brought up to date at every point, and the work is as nearly as possible the combined opinions of the ten specialists who figure as the authors. In the revised edition much new material has been added, and some of the old eliminated or modified. More than forty of the old illustrations have been replaced by new ones, which add very materially to the elucidation of the text, as they picture methods, not specimens. The chapters on technique and after-treatment have been considerably enlarged, and the portions devoted to plastic work have been so greatly improved as to be practically new. Hyste- rectomy has been rewritten, and all the descriptions of operative procedures have been carefully revised and fully illustrated. CONTRIBUTORS: Dr. Henry T. Byford. John M. Baldy. Edwin Cragin. ). H. Etheridge. William Goodell. Dr. Howard A. Kelly. Florian Krug. E. E. Montgomery. William R. Pryor. George M. Tuttle. " The most notable contribution to gynecological literature since 1887, .... and the most complete exponent of gynecology which we have. No subject seems to have been neglected, .... and the gynecologist and surgeon, and the general practitioner who has any desire to practise diseases of women, will find it of practical value. In the matter of illustrations and plates the book surpasses anything we have seen."—Boston Medical and Surgical Journal. " A thoroughly modern text-book, and gives reliable and well-tempered advice and in- struction."—Edinburgh Medical Journal. " The harmony of its conclusions and the homogeneity of its style give it an individuality which suggests a single rather than a multiple authorship."—Annals of Surgery. " It must command attention and respect as a worthy representation of our advanced clinical teaching."—American Journal of Medical Sciences. CATALOGUE OF 'MEDICAL WORKS. II *AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- DREN. By American Teachers. Edited by Louis Starr, M. D., assisted by Thompson S. Westcott, M. D. In one handsome royal-8vo volume of 1244 pages, profusely illustrated with wood-cuts, half-tone and colored plates. Net Prices: Cloth, $7.00; Sheep or Half-Morocco, $8.00. SECOND EDITION, REVISED AND ENLARGED. The plan of this work embraces a series of original articles written by some sixty well-known podiatrists, representing collectively the teachings of the most prominent medical schools and colleges of America. The work is intended to be a practical book, suitable for constant and handy reference by the practi- tioner and the advanced student. Especial attention has been given to the latest accepted teachings upon the etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- dren, with the introduction of many special formulae and therapeutic procedures. In this new edition the whole subject matter has been carefully revised, new articles added, some original papers emended, and a number entirely rewritten. The new articles include "Modified Milk and Percentage Milk-Mixtures," " Lithemia," and a section on " Orthopedics." Those rewritten are " Typhoid Fever," "Rubella," "Chicken-pox," "Tuberculous Meningitis," "Hydroceph- alus," and "Scurvy;" while extensive revision has been made in "Infant Feeding," " Measles," " Diphtheria," and " Cretinism." The volume has thus been much increased in size by the introduction of fresh material. CONTRI Dr. S. S. Adams, Washington. John Ashhurst, Jr., Philadelphia. A. D. Blackader, Montreal, Canada David Bovaird, New York. Dillon Brown, New York. Edward M. Buckingham, Boston. Charles W. Burr, Philadelphia. W. E. Casselberry, Chicago. Henry Dwight Chapin, New York. W. S. Christopher, Chicago. Archibald-Church, Chicago. Floyd M. Crandall, New York. Andrew F. Currier, New York. Roland G. Curtin, Philadelphia J. M. DaCosfa, Philadelphia. I. N. Danforth, Chicago. Edward P. Davis, Philadelphia. John B. Deaver, Philadelphia. G. E. de Schweinitz, Philadelphia. John Doming, New York. Charles Warrington Earle, Chicago. Wm. A. Edwards, San Diego, Cal. F. Forchheimer, Cincinnati. J. Henry Fruitnight, New York. J. P. Crozer Griffith, Philadelphia. W. A. Hardaway. St. Louis. M. P Hatfield, Chicago. Barton Cooke Hirst, Philadelphia. H. Illoway, Cincinnati. Henry Jackson, Boston. Charles G. Jennings, Detroit. Henry Koplik. New York. BUTORS) Dr. Thomas S. Latimer, Baltimore. Albert R. Leeds, Hoboken, N. J. J. Hendrie Lloyd, Philadelphia. George Roe Lockwood, New York. Henry M. Lyman, Chicago. Francis T. Miles, Baltimore. Charles K Mills, Philadelphia. James E Moore, Minneapolis. F. Gordon Morrill, Boston. John H. Musser, Philadelphia. Thomas R. Neilson, Philadelphia, W. P. Northrup, New York. William Osier, Baltimore. Frederick A. Paekard, Philadelphia. William Pepper, Philadelphia. Frederick Peterson, New York. W. T. Plant, Syracuse, New York William M. Powell. Atlantic City. B. K. Rachford, Cincinnati. B. Alexander Randall, Philadelphia. Edward O. Shakespeare, Philadelphia F. C. Shattuck, Boston. J. Lewis Smith, New York. Louis Starr, Philadelphia. M. Allen Starr, New York. Charles W. Townsend, Boston. James Tyson, Philadelphia. W. S. Thayer, Baltimore. Victor C. Vaughan, Ann Arbor, Mich Thompson S. Westcott, Philadelphia. Henry R. Wharton, Philadelphia. J William White, Philadelphia. 1 C Wilson, Philadelphia. 12 W. B. SAUNDERS' *AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND SKIN DISEASES. By 47 Eminent Specialists and Teachers. Edited by L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, Uni- versity and Bellevue Hospital Medical College, New York; and W. A. Hardaway, M. D., Professor of Diseases of the Skin, Missouri Medical College. Imperial octavo volume of 1229 pages, with 300 engravings and 20 full-page colored plates. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. This addition to the series of " American Text-Books," it is confidently be- lieved, will meet the requirements of both students and practitioners, giving, as it does, a comprehensive and detailed presentation of the Diseases of the Genito-Urinary Organs, of the Venereal Diseases, and of the Affections of the Skin. Having secured the collaboration of well-known authorities in the branches represented in the undertaking, the editors have not restricted the contributors ii. regard to the particular views set forth, but have offered every facility for the free expression of their individual opinions. The work will therefore be found to be original, yet homogeneous and fully representative of the several depart- ments of medical science with which it is concerned. CONTRIBUTORS : Dr. Chas. W. Allen, New York. I. E. Atkinson, Baltimore. L Bolton Bangs, New York. P. R. Bolton, New York. Lewis C. Bosher, Richmond, Va. John T. Bowen, Boston. J. Abbott Cantrell, Philadelphia. William T. Corlett, Cleveland, Ohio. B. Farquhar Curtis, New York. Condict W. Cutler, New York. Isadore Dyer, New Orleans. Christian Fenger, Chicago. John A. Fordyce, New York. Eugene Fuller, New York. R. H. Greene, New York. Joseph Grindon, St. Louis. Graeme M. Hammond, New York. W. A. Hardaway, St. Louis. M. B. Hartzell, Philadelphia. Louis Heitzmann, New York. James S. Howe, Boston. George T. Jackson, New York. Abraham Jacobi, New York. James C. Johnston, New York. Dr. Hermann G. Klotz, New York, J. H. Linsley, Burlington, Vt. G. F. Lydston, Chicago. Hartwell N. Lyon, St. Louis. Edward Martin, Philadelphia. D. G. Montgomery, San Francisco. James Pedersen, New York. S. Pollitzer, New York. Thomas R. Pooley, New York. A. R. Robinson, New York. A. E. Regensburger, San Francisco. Francis J. Shepherd, Montreal, Can. S. C. Stanton, Chicago, 111. Emmanuel J. Stout, Philadelphia. Alonzo E. Taylor, Philadelphia. Robert W. Taylor, New York. Paul Thorndike, Boston. H. Tuholske, St. Louis. Arthur Van Harlingen, Philadelphia. Francis S. Watson, Boston. J. William White, Philadelphia. J. McF. Winfield, Brooklyn. Alfred C. Wood, Philadelphia. "This voluminous work is thoroughly up to date, and the chapters on genito-urinary dis- eases are especially valuable. The illustrations are fine and are mostly original. The section on dermatology is concise and in every way admirable."—Journal of the American Medical Association. " This volume is one of the best yet issued of the publisher's series of ' American Text- Books.' The list of contributors represents an extraordinary array of talent and extended experience. The book will easily take the place in comprehensiveness and value of the half dozen or more costly works on these subjects which have hitherto been necessary to a well-equipped library."—New York Polyclinic. CATALOGUE OF MEDICAL WORKS. 13 * AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT. Edited by George E. de Schweinitz, A. M., M. D., Professor of Ophthalmology, Jefferson Medical College; and B. Alexander Randall, A. M., M. D., Clinical Professor of Diseases of the Ear, University of Pennsylvania. One handsome imperial octavo volume of 1251 pages; 766 illustrations, 59 of them colored. Prices: Cloth, $7.00 net; Sheep or Half-Morocco, $8.00 net. Just Issued. The present work is the only book ever published embracing diseases of the intimately related organs of the eye, ear, nose, and throat. Its special claim to favor is based on encyclopedic, authoritative, and practical treatment of the subjects. Each section of the book has been entrusted to an author who is specially identified with the subject on which he writes, and who therefore presents his case in the manner of an expert. Uniformity is secured and overlapping pre- vented by careful editing and by a system of cross-references which forms a special feature of the volume, enabling the reader to come into touch with all that is said on any subject in different portions of the book. Particular emphasis is laid on the most approved methods of treatment, so that the book shall be one to which the student and practitioner can refer for information in practical work. Anatomical and physiological problems, also, are fully discussed for the benefit of those who desire to investigate the more abstruse problems of the subject. CONTRIBUTORS: Dr. Henry A. Alderton, Brooklyn. Harrison Allen, Philadelphia. Frank Allport, Chicago. Morris J. Asch, New York. S. C. Ayres, Cincinnati. R. O. Beard, Minneapolis. Clarence J. Blake, Boston. Arthur A. Bliss, Philadelphia. Albert P. Brubaker, Philadelphia. J. H. Bryan, Washington, D. C. Albert H. Buck, New York. F. Buller, Montreal, Can. Swan M. Burnett, Washington, D. C. Flemming Carrow, Ann Arbor, Mich. W. E. Casselberry, Chicago. Colman W. Cutler, New York. Edward B. Dench, New York. William S. Dennett, New York. George E. de Schweinitz, Philadelphia. Alexander Duane, New York. John W. Farlow, Boston, Mass. Walter J. Freeman, Philadelphia. H. Gifford, Omaha, Neb. W. C. Glasgow, St. Louis. J. Orne Green, Boston. Ward A. Holden, New York. Christian R. Holmes, Cincinnati. William E. Hopkins, San Francisco. F. C. Hotz, Chicago. Lucien Howe, Buffalo, N. Y. Dr. Alvin A. Hubbell, Buffalo, N. Y. Edward Jackson, Philadelphia. J. Ellis Jennings, St. Louis. Herman Knapp, New York. Chas. W. Kollock, Charleston, S. C. G. A. Leland, Boston. J. A. Lippincott, Pittsburg, Pa. G. Hudson Makuen, Philadelphia. John H. McCollom, Boston. H. G. Miller, Providence, R. I. B. L. Milliken, Cleveland, Ohio. Robert C. Myles, New York. James E. Newcomb, New York. R. J. Phillips, Philadelphia. George A. Piersol, Philadelphia. W. P. Porcher, Charleston, S. C. B. Alex. Randall, Philadelphia. Robert L. Randolph, Baltimore. John O. Roe, Rochester, N. Y. Charles E. de M. Sajous, Philadelphia. J. E. Sheppard, Brooklyn, N. Y. E. L. Shurly, Detroit, Mich. William M. Sweet, Philadelphia. Samuel Theobald, Baltimore, Md. A. G. Thomson, Philadelphia. Clarence A. Veasey, Philadelphia. John E. Weeks, New York. Casey A. Wood, Chicago, 111. Jonathan Wright, Brooklyn. H. V. Wurdemann, Milwaukee, Wis. 14 W. B. SAUNDERS' *AN AMERICAN YEAR-BOOK OF MEDICINE AND SUR- GERY. A Yearly Digest of Scientific Progress and Authoritative Opmion in all branches of Medicine and Surgery, drawn from journals, monographs, and text-books of the leading American and Foreign authors and investigators. Collected and arranged, with critical editorial com- ments, by eminent American specialists and teachers, under the general editorial charge of George M. Gould, M.D. One handsome imperial octavo volume of about 1200 pages. Uniform in style, size, and general make-up with the "American Text-Book" Series. Cloth, $6.50 net; Half-Morocco, $7.50 net. Now Beady, Volumes for 1896, 1897, 1898, 1899. Notwithstanding the rapid multiplication of medical and surgical works, still these publications fail to meet fully the requirements of the general physician, inasmuch as he feels the need of something more than mere text-books of well- known principles of medical science. This deficiency would best be met by current journalistic literature, but most practitioners have scant access to this almost unlimited source of information, and the busy practiser has but little time to search out in periodicals the many interesting cases whose study would doubtless be of inestimable value in his practice. Therefore, a work which places before the physician in convenient form an epitomization of this literature by persons competent to pronounce upon The Value of a Discovery or of a Method of Treatment cannot but command his highest appreciation. It is this critical and judicial function that is assumed by the Editorial staff of the " American Year-Book of Medicine and Surgery." CONTRIBUTORS : Dr. Samuel W. Abbott, Boston. John J. Abel, Baltimore. J. M. Baldy, Philadelphia. Charles H. Burnett, Philadelphia. Archibald Church, Chicago. J. Chalmers DaCosta, Philadelphia. W. A. N. Dorland, Philadelphia. Louis A. Duhring, Philadelphia. D. L. Edsall, Philadelphia. Virgil P. Gibney, New York. Henry A. Griffin, New York. John Guiteras, Philadelphia. C. A. Hamann, Cleveland. Alfred Hand, Jr., Philadelphia. Dr. Howard E. Hansell, Philadelphia. M. B. Hartzell, Philadelphia. Barton Cooke Hirst, Philadelphia. E. Fletcher lngals, Chicago. Wyatt Johnston, Montreal, W. W. Keen, Philadelphia. Henry G. Ohls, Chicago. Wendell Reber, Philadelphia. David Riesman, Philadelphia. Louis Starr, Philadelphia. Alfred Stengel, Philadelphia. G. N. Stewart. Cleveland. J. R. Tillinghast, New York. J. Hilton Waterman, New York. "It is difficult to know which to admire most—the research and industry of the distin- guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the wealth and abundance of the contributions to every department of science that have been deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for, as each section is entrusted to experienced and able contributors, the reader has the advan- tage of certain critical commentaries and expositions . . . proceeding from writers fully qualified to perform these tasks. ... It is emphatically a book which should find a place in every medical library, and is in several respects more useful than the famous ' jahrbiicher' of Germany."—London Lancet. CATALOGUE OF MEDICAL WORKS. 15 * ANOMALIES AND CURIOSITIES OF MEDICINE. By George M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collec- tion of are and extraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an ex- haustive research of medical literature from its origin to the present day, abstracted, classified, annotated, and indexed. Handsome imperial octavo volume of 968 pages, with 295 engravings in the text, and 12 full-page plates. Cloth, $6.00 net; Half-Morocco, $7.00 net. Several years of exhaustive research have been spent by the authors in the great medical libraries of the United States and Europe in collecting the mate- rial for this work. Medical literature of all ages and all languages has been carefully searched, as a glance at the Bibliographic Index will show. The facts, which will be of extreme value to the author and lecturer, have been arranged and annotated, and full reference footnotes given, indicating whence they have been obtained. In view of the persistent and dominant interest in the anomalous and curious, a thorough and systematic collection of this kind (the first of which the authors have knowledge) must have its own peculiar sphere of usefulness. As a complete and authoritative Book of Reference it will be of value not only to members of the medical profession, but to all persons interested in gen- eral scientific, sociologic, and medico-legal topics; in fact, the general interest of the subject and the dearth of any complete work upon it make this volume one of the most important literary innovations of the day. " One of the most valuable contributions ever made to medical literature. It is, so far as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the medical profession has this volume value : it will serve as a book of reference for all who are interested in general scientific, sociologic, or medico-legal topics."—Brooklyn Medical Jour- nal. NERVOUS AND MENTAL DISEASES. By Archibald Church, M. D., Professor of Clinical Neurology, Mental Diseases, and Medical Jurisprudence, Northwestern University Medical School; and Frederick Peterson, M. D., Clinical Professor of Mental Diseases, Woman's Medi- cal College, New York. Handsome octavo volume of 843 pages, with over 300 illustrations. Prices: Cloth, $5.00 net; Half-Morocco, $6.00 net. Just Issued. This book is intended to furnish students and practitioners with a practical, working knowledge of nervous and mental diseases. Written by men of wide experience and authority, it presents the many recent additions to the subject. The book is not filled with an extended dissertation on anatomy and pathology, but, treating these points in connection with special conditions, it lays particular stress on methods of examination, diagnosis, and treatment. In this respect the work is unusually complete and valuable, laying down the definite courses of procedure which the authors have found to be most generally satisfactory. i6 W. B. SAUNDERS' A TEXT-BOOK OF PATHOLOGY. By Alfred Stengel, M. D., Professor of Clinical Medicine in the University of Pennsylvania; Physi- cian to the Philadelphia Hospital; Physician to the Children's Hospital, Philadelphia. Handsome octavo volume of 848 pages, with 362 illustra- tions, many of which are in colors. Prices: Cloth, #4.00 net; Half- Morocco, $5.00 net. Second Edition. In this work the practical application of pathological facts to clinical medicine is considered more fully than is customary in works on pathology. While the subject of pathology is treated in the broadest way consistent with the size of the book, an effort has been made to present the subject from the point of view of the clinician. The general relations of bacteriology to pathology are dis- cussed at considerable length, as the importance of these branches deserves. It will be found that the recent knowledge is fully considered, as well as older and more widely-known facts. " I consider the work abreast of modern pathology, and useful to both students and prac- titioners. It presents in a concise and well-considered form the essential facts of general and special pathological anatomy, with more than usual emphasis upon pathological physiology." —William H. Welch, Professor of Pathology, Johns Hopkins University, Baltimore, Md. " I regard it as the most serviceable text-book for students on this subject yet written by an American author."—L. Hektoen, Professor of Pathology, Rush Medical College, Chicago, III. A TEXT-BOOK OF OBSTETRICS. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. Handsome oc- tavo volume of 846 pages, with 618 illustrations and seven colored plates. Prices : Cloth, $5.00 net; Half-Morocco, $6.00 net. This work, which has been in course of preparation for several years, is in- tended as an ideal text-book for the student no less than an advanced treatise for the obstetrician and for general practitioners. It represents the very latest teaching in the practice of obstetrics by a man of extended experience and recognized authority. The book emphasizes especially, as a work on obstetrics should, the practical side of the subject, and to this end presents an unusually large collection of illustrations. A great number of these are new and original, and the whole collection will form a complete atlas of obstetrical practice. An extremely valuable feature of the book is the large number of refer- ences to cases, authorities, sources, etc., forming, as it does, a valuable bib- liography of the most recent and authoritative literature on the subject of obstetrics. As already stated, this work records the wide practical ex- perience of the author, which fact, combined with the brilliant presentation of the subject, will doubtless render this one of the most notable books on obstetrics that has yet appeared. " The illustrations are numerous and are works of art, many of them appearing for the first time. The arrangement of the subject-matter, the foot-notes, and index are beyond criticism. The author's style, though condensed, is singularly clear, so that it is never necessary to re-read a sentence in order to grasp its meaning. As a true model of what a modern text-book in obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a rival."—New York Medical Record. CATALOGUE OF MEDICAL WORKS. 17 A TEXT-BOOK OF THE PRACTICE OF MEDICINE. By James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadel- phia. In one handsome octavo volume of 1287 pages, fully illustrated. Cloth, $5.50 net; Sheep or Half-Morocco, $6.50 net. THIRD EDITION, THOROUGHLY REVISED. This work gives in a comprehensive manner the results of the latest scientific studies bearing upon medical affections, and portrays with rare force and clear- ness the clinical pictures of the different diseases considered. The practical points, particularly with reference to diagnosis and treatment, are completely stated and are presented in a most convenient form; for example, the differ- ential diagnosis has in many instances been tabulated, no less than fifty-six diagnostic tables being given. The first edition of this work having been exhausted in so short a time, the author has not found it necessary to make an extensive revision, but has simply availed himself of the opportunity to make a few changes of minor importance. " It is an excellent book—concise, comprehensive, thorough, and up to date. It is a credit to you; but, more than that, it is a credit to the profession of Philadelphia—to us." —James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jeffer- son Medical College, Philadelphia. " I consider Dr. Anders' book not only the best late work on Medical Practice, but by far the best that has ever been published. It is concise, systematic, thorough, and fully up to date in everything. I consider it a great credit to both the author and the publisher."—A. C. Cowperthwaite, President of the Illinois Homeopathic Medical Association. DISEASES OF THE STOMACH. By William W. Van Valzah, M. D., Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic; and J. Douglas Nisbet, M. D., Adjunct Professor of General Medicine and Diseases of the Digestive Sys- tem and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, $3.50 net. An eminently practical book, intended as a guide to the student, an aid to the physician, and a contribution to scientific medicine. It aims to give a complete description of the modern methods of diagnosis and treatment of diseases of the stomach, and to reconstruct the pathology of the stomach in keeping with the revelations of scientific research. The book is clear, practical, and complete, and contains the results of the authors' investigations and of their extensive ex- perience as specialists. Particular attention is given to the important subject of dietetic treatment. The diet-lists are very complete, and are so arranged that selections can readily be made to suit individual cases. "This is the most satisfactory work on the subject in the English language."—Chicago Medical Recorder. " The article on diet and general medication is one of the most valuable in the book, and should be read by every practising physician."—New York Medical Journal. i8 W. B. SAUNDERS' SURGICAL DIAGNOSIS AND TREATMENT. By J. W. Mac- donald, M. D., Edin., F. R. C. S., Edin., Professor of the Practice of Sur- gery and of Clinical Surgery in Hamline University; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 pages, profusely illustrated. Cloth, $5.00 net; Half-Morocco, $6.00 net. This work aims in a comprehensive manner to furnish a guide in matters of surgical diagnosis. It sets forth in a systematic way the necessities of examina- tions and the proper methods of making them. The various portions of the body are then taken up in order and the diseases and injuries thereof succinctly considered and the treatment briefly indicated. Practically all the modern and approved operations are described with thoroughness and clearness. The work concludes with a chapter on the use of the R5ntgen rays in surgery. "The work is brimful of just the kind of practical information that is useful alike to students and practitioners. It is a pleasure to commend the'book because of its intrinsic value to the medical practitioner."—Cincinnati Lancet-Clinic. PATHOLOGICAL TECHNIQUE. A Practical Manual for Laboratory Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on Post-Mortem Technique and the Performance of Autopsies. By Frank B. Mallory, A. M., M. D., Assistant Professor of Pathology, Harvard University Medical Schoo'l, Boston; and James H. Wright, A. M.,M.D., Instructor in Pathology, Harvard University Medical School, Boston. Oc- tavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. This book is designed especially foi practical use in pathological laboratories, both as a guide to beginners and as a source of reference for the advanced. The book will also meet the wants of practitioners who have opportunity to do general pathological work. Besides the methods of post-mortem examinations and of bacteriological and histological investigations connected with autopsies, the special methods employed in clinical bacteriology and pathology have been fully discussed. " One of the most complete works on the subject, and one which should be in the library of every physician who hopes to keep pace with the great advances made in pathology."— Journal of American Medical Association. THE SURGICAL COMPLICATIONS AND SEQUELS OF TY- PHOID FEVER. By Wm. W. Keen, M. D., LL.D., Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia. Octavo volume of 386 pages, illustrated. Cloth, #3.00 net. This monograph is the only one in any language covering the entire subject of the Surgical Complications and Sequels of Typhoid Fever. The work will prove to be of importance and interest not only to the general surgeon and phy- sician, but also to many specialists—laryngologists, ophthalmologists, gynecolo- gists, pathologists, and bacteriologists—as the subject has an important bearing upon each one of their spheres. The author's conclusions are based on reports of over 1700 cases, including practically all those recorded in the last fifty years. Reports of cases have been brought down to date, many having been added while the work was in press. " This is probably the first and only work in the English language that gives the reader a clear view of what typhoid fever really is, and what it does and can do to the human organ- ism. This book should be in the possession of every medical man in America."—American Medico-Surgical Bulletin. CATALOGUE OF MEDICAL WORKS. 19 MODERN SURGERY, GENERAL AND OPERATIVE. By John Chalmers DaCosta, M.D., Clinical Professorof Surgery, Jefferson Medi- cal College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Handsome octavo volume of 911 pages, profusely illustrated. Cloth, $4.00 net; Half-Morocco, $5.00 net. Second Edition, Rewritten and Greatly Enlarged. The remarkable success attending DaCosta's Manual of Surgery, and the general favor with which it has been received, have led the author in this revision to produce a complete treatise on modern surgery along the same lines that made the former edition so successful. The book has been entirely re- written and very much enlarged. The old edition has long been a favorite not only with students and teachers, but also with practising physicians and sur- geons, and it is believed that the present work will find an even wider field of usefulness. " We know of no small work on surgery in the English language which so well fulfils the requirements of the modern student."—Medico-Chirurgical Journal, Bristol, England. " The author has presented concisely and accurately the principles of modern surgery. The book is a valuable one which can be recommended to students and is of great value to the general practitioner."—American Journal of the Medical Sciences. A MANUAL OF ORTHOPEDIC SURGERY. By James E. Moore, M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo volume of 356 pages, with 177 beautiful illustrations from photographs made spec- ially for this work. Cloth, $2.50 net. A practical book based upon the author's experience, in which special stress is laid upon early diagnosis and treatment such as can be carried out by the general practitioner. The teachings of the author are in accordance with his belief that true conservatism is to be found in the middle course between the surgeon who operates too frequently and the orthopedist who seldom operates. "A very demonstrative work, every illustration of which conveys a lesson. The work is a most excellent and commendable one, which we can certainly endorse with pleasure."— St. Louis Medical and Surgical Journal. ELEMENTARY BANDAGING AND SURGICAL DRESSING. With Directions concerning the Immediate Treatment of Cases of Emer- gency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 illustrations. Cloth, flexible covers, 75 cents net. This little book is chiefly a condensation of those portions of Pye's " Surgical Handicraft" which deal with bandaging, splinting, etc., and of those which treat of the management in the first instance of cases of emergency. The directions given are thoroughly practical, and the book will prove extremely use- ful to students, surgical nurses, and dressers. " The author writes well, the diagrams are clear, and the book itself is small and portable, although the paper and type are good."—British Medical Journal. 20 W. B. SAUNDERS' A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS AND PHARMACOLOGY. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc Octavo, 860 pages, illustrated. Cloth, $4.00 net; Sheep, #5.00 net. Third Edition, Thoroughly Revised. A clear, concise, and practical text-book, adapted for permanent reference no less than for the requirements of the class-room. The recent important additions made to our knowledge of the physiological action of drugs are fully discussed in the present edition. Many alterations also have been made in the chapters on Diuretics and Cathartics. " Taken as a whole, the book may fairly be considered as one of the most satisfactory of any single-volume works on materia medica in the market."—Journal of the American Medical Association. TUBERCULOSIS OF THE GENITO-URINARY ORGANS, MALE AND FEMALE. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated_ Cloth, #3.00 net. Tuberculosis of the male and female genito-urinary organs is such a frequent, distressing, and fatal affection that a special treatise on the subject appears to fill a gap in medical literature. In the present work the bacteriology of the sub- ject has received due attention, the modern resources employed in the differen- tial diagnosis between tubercular and other inflammatory affections are fully described, and the medical and surgical therapeutics are discussed in detail. "An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day."—Clinical Reporter. "A work which adds another to the many obligations the profession owes the talented author."—Chicago Medical Recorder. A TEXT-BOOK OF DISEASES OF WOMEN. By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 529 pages, with 217 illustrations, nearly all from drawings made for this work. Cloth, $3.50 net. Second Edition, Revised. In this work, which has been written for both the student of gynecology and the general practitioner, the author presents the best teaching of modern gyne- cology untrammelled by antiquated theories or methods of treatment. In most instances but one plan of treatment is recommended, to avoid confusing the student or the physician who consults the book for practical guidance. " I shall value very highly the copy of Penrose's ' Diseases of Women' received. I have already recommended it to my class as THE BEST book."—Howard A. Kelly, Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. " The book is to be commended without reserve, not only to the student but to the general practitioner who wishes to have the latest and best modes of treatment explained with absolute clearness."— Therapeutic Gazette. CATALOGUE OF MEDICAL WORKS. 21 SURGICAL PATHOLOGY AND THERAPEUTICS. By John Collins Warren, M. D., LL.D., Professorof Surgery, Medical Depart- ment Harvard University; Surgeon to the Massachusetts General Hospital, etc. A handsome octavo volume of 832 pages, with 136 relief and litho- graphic illustrations, 33 of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Prices : Cloth, $6.00 net; Half-Morocco, $7.00 net. Without Exception, the Illustrations are the Best ever Seen in a Work of this Kind. "A most striking and very excellent feature of this book is its illustrations. Without ex- ception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. * * * Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section."—Annals of Surgery, Philadelphia. " It is the handsomest specimen of book-making * * * that has ever been issued from the American medical press."—American Journal of the Medical Sciences, Philadelphia. PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and of Clinical Surgery, Rush Medical College; Professor of Surgery, Chicago Polyclinic; Attending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 engravings, including full-page colored plates. Price?: Cloth, $6.00 net; Half-Morocco, $7.00 net. Books specially devoted to this subject are few, and in our text-books and systems of surgery this part of surgical pathology is usually condensed to a de- gree incompatible with its scientific and clinical importance. The author spent many years in collecting the material for this work, and has taken great pains to present it in a manner that should prove useful as a text-book for the student, a work of reference for the practitioner, and a reliable guide for the surgeon. " The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, .... and the author has given a notable and lasting contribution to surgery."—Journal of the American Medical Association, Chicago. LECTURES ON RENAL AND URINARY DISEASES. By Robert Saundby, M. D., Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society; Physician to the General Hospital. Octavo volume of 434 pages, with numerous illustra- tions and 4 colored plates. Cloth, $2.50 net. " The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book maybe cordially recommended."—British Medical Journal. " The work represents the present knowledge of renal and urinary diseases. It is ad- mirably written and is accurately scientific."—Medical News. 22 W. B. SAUNDERS' A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- delphia; Vice-President of the American Psediatric Society; Ex-President of the Association of Life Insurance Medical Directors; Editor " Cyclo- paedia of the Diseases of Children," etc.; and Henry Hamilton, author of " A New Translation of Virgil's yEneid into English Rhyme;" co- author of " Saunders' Medical Lexicon," etc.; with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. With an Appendix containing important Tables of Bacilli, Micrococci, Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- gery, Poisons and their Antidotes, Weights and Measures, Thermometric Scales, New Official and Unofficial Drugs, etc. One very attractive volume of over 800 pages. Second Revised Edition. Prices: Cloth, $5.00 net; Sheep or Half-Morocco, $6.00 net; with Denison's Patent Ready-Refer- ence Index; without patent index, Cloth, $4.00 net; Sheep or Half- Morocco, #5.00 net. PROFESSIONAL OPINIONS. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my classes." Henry M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. Lindsley, M. D., Professor of Theory and Practice of Medicine, Medical Dept. Yale University: Secretary Connecticut State Board of Health, New Haven, Conn, AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- fessor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per Volume, $2.50 net. 1 his autobiography, which was continued by the late eminent surgeon until within three months of his death, contains a full and accurate history of his early struggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men—surgeons, physicians, divines, lawyers, states- men, scientists, etc.—with whom he was brought in contact in America and in Europe; the whole forming a retrospect of more than three-quarters of a century. CATALOGUE OF MEDICAL WORKS. 2$ PRACTICAL POINTS IN NURSING. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated with 73 engravings in the text, and 9 colored and half-tone plates. Cloth. Price, $1.75 net. SECOND EDITION, THOROUGHLY REVISED. In this volume the author explains, in popular language and in the shortest possible form, the entire range of private nursing as distinguished from hospital nursing, and the nurse is instructed how best to meet the various emergencies of medical and surgical cases when distant from medical or surgical aid or when thrown on her own resources. An especially valuable feature of the work will be found in the diractions to the nurse how to improvise everything ordinarily needed in the sick-room, where the embarrassment of the nurse, owing to the want of proper appliances, is fre- quently extreme. The work has been logically divided into the following sections: I. The Nurse : her responsibilities, qualifications, equipment, etc. II. The Sick-Room: its selection, preparation, and management. III. The Patient: duties of the nurse in medical, surgical, obstetric, and gyne- cologic cases. IV. Nursing in Accidents and Emergencies. V. Nursing in Special Medical Cases. VI. Nursing of the New-born and Sick Children. VII. Physiology and Descriptive Anatomy. The Appendix contains much information in compact form that will be found of great value to the nurse, including Rules for Feeding the Sick; Recipes for Invalid Foods and Beverages; Tables of Weights and Measures; Table for Computing the Date of Labor; List of Abbreviations; Dose-List; and a full and complete Glossary of Medical Terms and Nursing Treatment. "This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise and how to prepare everything ordinarily needed in the illness of her patient."—American Journal of Obstetrics and Diseases of Women and Children, Aug., 1896. A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and Prevention of Infective Diseases and an account of Yeasts and Moulds, Hsematozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- fessor of Comparative Pathology and Bacteriology, King's College, London. A handsome octavo volume of 700 pages, with 273 engravings in the text, and 22 original and colored plates. Price, $6.50 net. This book, though nominally a Fourth Edition of Professor Crookshank's " Manual of Bacteriology," is practically a new work, the old one having been reconstructed, greatly enlarged, revised throughout, and largely rewritten, forming a text-book for the Bacteriological Laboratory, for Medical Ofncers of Health, and for Veterinary Inspectors. 24 W. B. SAUNDERS' MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Fifth Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume of 600 pages. 194 fine wood-cuts in the text, many of them in colors. Prices: Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net. FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND ENLARGED GERMAN EDITION. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. The present edition of this highly successful work has been translated from the fifth German edition. Many alterations have been made throughout the book, but especially in the sections on Gastric Digestion and the Nervous System. It will be found that all the qualities which served to make the earlier editions so acceptable have been developed with the evolution of the work to its present form. THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- LITIC AFFECTIONS. (American Edition.) Translation from the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- sician to, and Physician to the department for Diseases of the Skin at, the Middlesex Hospital, London. Photo-lithochromes from the famous models of dermatological and syphilitic pases in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, at $3.00 per Part. " Of all the atlases of skin diseases which have been published in recent years, the present one promises to be of greatest interest and value, especially from the standpoint of the general practitioner."—American Medico-Surgical Bulletin, Feb. 22, 1896. " The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit."—New York Medical Journal, Feb. 15, 1896. " An interesting feature of the Atlas is the descriptive text, which is written for each picture by the physician who treated the case or at whose instigation the models have been made. We predict for this truly beautiful work a large circulation in all parts of the medical world where the names St. Louis and Baretta have preceded it."—Medical Record, N. Y., Feb. 1, 1896. A TEXT-BOOK OF MECHANO-THERAPY (MASSAGE AND MEDICAL GYMNASTICS). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in the Royal Swedish Army; late House Physi- cian, City Hospital, Blackwell's Island, New York. i2mo, 139 pages, illustrated. Cloth, $1.00 net. CATALOGUE OF MEDICAL WORKS. 2$ DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- tice. By G. E. de Schweinitz, M. D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. A handsome royal- octavo volume of 696 pages, with 255 fine illustrations, many of which are original, and 2 chromo-lithographic plates. Prices: Cloth, #4.00 net; Sheep or Half-Morocco, $5.00 net. THIRD EDITION, THOROUGHLY REVISED. In the third edition of this text-book, destined, it is hoped, to meet the favor- able reception which has been accorded to its predecessors, the work has been revised thoroughly, and much new matter has been introduced. Particular attention has been given to the important relations which micro-organisms bear to many ocular diseases. A number of special paragraphs on new subjects have been introduced, and certain articles, including a portion of the chapter on Operations, have been largely rewritten, or at least materially changed. A number of new illustrations have been added. The Appendix contains a full description of the method of determining the corneal astigmatism with the ophthalmometer of Javal and Schiotz, and the rotation of the eyes with the tropometer of Stevens. " A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D. Provost and Professor of Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. "A clearly written, comprehensive manual. . . . One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science."—British Medical Journal. r\"u\}\ hardly to° much to say that for tr»e student and practitioner beginning the study of Ophthalmology, it is the best single volume at present published."—Medical News. " It is a very useful, satisfactory, and safe guide for the student and the practitioner, and one of the best works of this scope in the English language."—Annals of Ophthalmology. DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M. D., B.Sc, Lond., F.R.C.S., Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. Cloth, #2.50 net. The authors have placed in the hands of the physician and student a concise yet comprehensive guide to tke study of gynecology in its most modern develop- ment. It has been their aim to relate facts and describe methods belonging to the science and art of gynecology in a way that will prove useful to students for examination purposes, and which will also enable the general physician to prac- tice this important department of surgery with advantage to his patients and with satisfaction to himself. " The book is very well prepared, and is certain to be well received by the medical public." —British Medical Journal. "The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the day."—Journal of the American Medical Association. 26 W. B. SAUNDERS' TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- cially written for Students of Medicine. By Joseph McFarland, M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia, etc. 497 pages, finely illustrated. Price, Cloth, $2.50 net. SECOND EDITION, REVISED AND GREATLY ENLARGED. The work is intended to be a text-book for the medical student and for the practitioner who has had no recent laboratory training in this department of medi- cal science. The instructions given as to needed apparatus, cultures, stainings, microscopic examinations, etc. are ample for the student's needs, and will afford to the physician much information that will interest and profit him relative to a subject which modern science shows to go far in explaining the etiology of many diseased conditions. In this second edition the work has been brought up to date in all depart- ments of the subject, and numerous additions have been made to the technique in the endeavor to make the book fulfil the double purpose of a systematic work upon bacteria and a laboratory guide. " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable, and the book should prove useful to those for whom it is written.—London Lancet, Aug. 29, 1896. " The author has succeded admirably in presenting the essential details of bacteriological technics, together with a judiciously chosen summary of our present knowledge of pathogenic bacteria. . . . The work, we think, should have a wide circulation among English-speaking students of medicine."—N. Y. Medical Journal, April 4, 1896. " The book will be found of considerable use by medical men who have not had a special bacteriological training, and who desire to understand this important branch of medical science."—Edinburgh Medical Journal, July, 1896. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- nary Science, Sheffield Scientific School, Yale University. Illustrated. Price, Cloth, 75 cents. The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laboratory work " It is a convenient and useful little work, and will more than repay the outlay necessary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages."—American Med.- Surg. Bulletin. FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. Bound in limp cloth, flush edges. Price, 25 cents net. Synopsis : Analyses of Milk—Importance of the Subject of Feeding in Early Infancy—Proportion of Casein and Sugar in Human Milk—Time to Begin Arti- ficial Feeding of Infants—Amount of Food to be Administered at Each Feed- ing—Intervals between Feedings—Increase in Amount of Food at Different Periods of Infant Development—Unsuitableness of Condensed Milk as a Sub- stitute for Mother's Milk—Objections to Sterilization or " Pasteurization " of Milk—Advances made in the Method of Artificial Feeding of Infants. CATALOGUE OF MEDICAL WORKS. 27 MATERIA MEDICA FOR NURSES. By Emily A. M. Stoney, Graduate of the Training-school for Nurses, Lawrence, Mass.; late Superintendent of the Training-school for Nurses, Carney Hospital, South Boston, Mass. Handsome octavo, 300 pages. Cloth, $1.50 net. The present book differs from other similar works in several features, all of which are introduced to render it more practical and generally useful. The general plan of contents follows the lines laid down in training-schools for nurses, but the book contains much useful matter not usually included'iu works of this character, such as Poison-emergencies, Ready Dose-list, Weiglits and Measures, etc., as well as a Glossary, defining all the terms in Materia Medica, and describing all the latest drugs and remedies, which have been generally neglected by other books of the kind. ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- CAL DISSECTION, containing " Hints on Dissection." By Chari.es B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition, lost 8vo, over 500 pages, with handsome full-page lithographic plates in coiors, and over 200 illustrations. Price: Extra Cloth or Oilcloth for the dissection-room, $2.00 net. Neither pains nor expense has been spared to make this work the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles arteries, veins, and nerves. The wood-cuts have all been specially drawn and. engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy. A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. D., Instructor in Physical Diagnosis in the University of Penn- sylvania, and Professor of Pathology in the Woman's Medical College of Pennsylvania. Specially intended for students preparing for graduation and hospital examinations. Post 8vo, 519 pages. Numerous illustrations and selected formula?. Price, bound in flexible leather, $2.00 net. FIFTH EDITION, REVISED AND ENLARGED. Contributions to the science of medicine have poured in so rapidly during the last quarter of a century that it is well-nigh impossible for the student, with the limited time at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teaching, the author has been enabled, by classification, to group allied symp- toms, and by the judicious elimination of theories and redundant explanations to bring within a comparatively small compass a complete outline of the prac- tice of medicine. 28 W. B. SAUNDERS MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsylvania, and Professor of Pathology in the Woman's Medical College of Pennsylvania. 445 pages. Price, bound in flexible leather, $2.25. SECOND EDITION, REVISED. This wholly new volume, which is based on the last edition of the Pharma- copoeia, comprehends the following sections: Physiological Action of Drugs; Drugs; Remedial Measures other than Drugs; Applied Therapeutics; Incom- patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of Diseases; the treatment being elucidated by more than two hundred formulae. " The author is to be congratulated upon having presented the medical student with as accurate a manual of therapeutics as it is possible to prepare."— Therapeutic Gazette. " Far superior to most of its class; in fact, it is very good. Moreover, the book is reliable and accurate."—New York Medical Journal. " The author has faithfully presented modern therapeutics in a comprehensive work, . . . and it will be found a reliable guide."—University Medical Magazine. NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- plications and Modes of Administration. By David Cerna, M. D., Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. Post-octavo, 253 pages. Price, #1.25. SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chemical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. Chemists are so multiplying compounds, that, if each compound is to be thor- oughly studied, investigations must be carried far enough to determine the prac- tical importance of the new agents. " Especially valuable because of its completeness, its accuracy, its systematic consider- ation of the properties and therapy of many remedies of which doctors generally know but little, expressed in a brief yet terse manner."—Chicago Clinical Review. TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 8x13^ inches. Price, per pad of 25 charts, 50 cents. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. CATALOGUE OF MEDICAL WORKS. 29 A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- TICAL. For the Use of Students. By Arthur Clarkson, M. B., C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in the Yorkshire College, Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 beautifully colored original illustrations. Price, strongly bound in Cloth, $6.00 net. The purpose of the writer in this work has been to furnish the student of His- tology, in one volume, with both the descriptive and the practical part of the science. The first two chapters are devoted to the consideration of the general methods of Histology; subsequently, in each chapter, the structure of the tissue or organ is first systematically described, the student is then taken tutorially over the specimens illustrating it, and, finally, an appendix affords a short note of the methods of preparation. " The work must be considered a valuable addition to the list of available text-books, and is to be highly recommended."—New York Medical Journal. " One of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students."—Chicago Medical Recorder. THE PATHOLOGY AND TREATMENT OF SEXUAL IM- POTENCE. By Victor G. Vecki, M. D. From the second Ger- man edition, revised and rewritten. Demi-octavo, about 300 pages. Cloth, $2.00 net. The subject of impotence has but seldom been treated in this country in the truly scientific spirit that it deserves, and this volume will come to many as a revelation of the possibilities of therapeusis in this important field. Dr. Vecki's work has long been favorably known, and the German book has received the highest consideration. This edition is more than a mere translation, for, although based on the German edition, it has been entirely rewritten by the author in English. '* The work can be recommended as a scholarly treatise on its subject, and it can be read with advantage by many practitioners."—Journal of the American Medical Association. ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, B. A., Camb. A series of collotype illustrations, with descriptive text, illustrating the applications of the New Photography to Medicine and Sur- gery. Price, per Part, $1.00. Parts I. to V. now ready. The object of this publication is to put on record in permanent form some of the most striking applications of the new photography to the needs of Medicine and Surgery. The progress of this new art has been so rapid that, although Prof. Rontgen's discovery is only a thing of yesterday, it has already taken its place among the approved and accepted aids to diagnosis. 3° W. B. SAUNDERS' DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M. D., Professor of Gynecology in the New York School of Clinical Medicine; Gynecologist to St. Mark's Hospital and to the German Dispensary, New York City. In one handsome octavo volume of 728 pages, illustrated by 335 engravings and colored plates. Prices: Cloth, £4.00 net; Sheep or Half-Morocco, $5.00 net. A practical work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough know- ledge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chap- ters on Operations and on Treatment are thoroughly modern, and are based upon the large hospital and private practice of the author. The text is eluci- dated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying embryology and the anatomy of the female genitalia, besides exemplifying, whenever needed, morbid condi- tions, instruments, apparatus, and operations. Second Edition, Thoroughly Revised. The first edition of this work met with a most appreciative reception by the medical press and profession both in this country and abroad, and was adopted as a text-book or recommended as a book of reference by nearly one hundred colleges in the United States and Canada. The author has availed himself of the opportunity afforded by this revision to embody the latest approved advances in the treatment employed in this important branch of Medicine. He has also more extensively expressed his own opinion on the comparative value of the different methods of treatment employed. " One of the best text-books for students and practitioners which has been published in the English language; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners, to whom experienced consultants may not be available, will find in this book invaluable counsel and help." Thad. A. Reamy, M. D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio ; Gynecologist to the Good Samaritan and Cincinnati Hospitals. A SYLLABUS OF GYNECOLOGY, arranged in conformity witri " An American Text-Book of Gynecology." By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. Price, Cloth (interleaved), $1.00 net. Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already possess the text-book it will also have an independent value as an aid to the practitioner in gynecological work, and to the student as a guide in the lecture- room, as the subject is [.resented in a manner at once systematic, clear, succinct, pnd practical. CATALOGUE OF MEDICAL WORKS. 3* THE AMERICAN POCKET MEDICAL DICTIONARY. Edited by W. A. Newman Dorland, M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania; Fellow of the American Academy of Mwdicine. Containing the pronunciation and definition of over 26,000 words used in medicine and the kindred sciences, with 64 extensive tables. Handsomely bound in flexible leather, limp, with gold edges and patent thumb index. Price, $1.25 net. SECOND EDITION, REVISED. Orer >6,000 Words, 64 Valuable Tables. This is the ideal pocket lexicon. It is an absolutely new book, and not a re- vision of any old work. It is complete, defining all the terms of modern medi- cine and forming a vocabulary of over 26,000 words. It gives the pronunciation of all the terms. It makes a special feature of the newer words neglected by other dictionaries. It contains a wealth of anatomical tables of special value to students. It forms a handy volume, indispensable to every medical man. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1800 Formulae, selected from several hundred of the best-known authorities. Forming a handsome and con- venient pocket companion of nearly 300 printed pages, with blank leaves for Additions; with an Appendix containing Posological Table, Formulae and Doses for Hypodermatic Medication, Poisons and their Antidotes, Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in morocco, with side index, wallet, and flap. Price, $1.75 net. FIFTH EDITION, THOROUGHLY REVISED. "This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and as the name of the author of each prescription is given,is unusually reliable."—Neiu York Medical Record. A COMPENDIUM OF INSANITY. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physician- Superintendent ofthe Willard State Hospital, New York; Honorary Mem- ber of the Medico-Psychological Society of Great Britain, of the Society of Mental Medicine of Belgium. i2mo, 234 pages, illust. Cloth, $1.25 net. The author has given, in a condensed and concise form, a compendium of Diseases of the Mind, for the convenient use and aid of physicians and students. It contains a clear, concise statement of the clinical aspects of the various ab- normal mental conditions, with directions as to the most approved methods of managing and treating the insane. " The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We desire especially, however, to call attention to the fact that in the subject ofthe therapeutics of insanity the work is exceedingly valuable. The author has made a distinct addition to the literature of his specialty."—Philadelphia Medical Journal. 32 W. B. SAUNDERS'< AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. SECOND EDITION, REVISED FORM. A convenient blank, suitable for all operations, giving complete instructions regarding necessary preparation of patient, etc., with a full list of dressings and medicines to be employed. On the back of each blank is a list of instruments used—viz. general instru ments, etc., required for all operations; and special instruments for surgery of the brain and spine, mouth and throat, abdomen, rectum, male and female genito-urinary organs, the bones, etc. The whole forming a neat pad, arranged for hanging on the wall of a sur- geon's office or in the hospital operating-room. " Will serve a useful purpose for the surgeon in reminding him of the details of prepa- ration for the patient and the room as well as for the instruments, dressings, and antiseptics needed "—New York Medical Record " Covers about all that can be needed in any operation."—American Lancet. " The plan is a capital one."—Boston Medical and Surgical Journal. LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, Cloth, #2.50. This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. Illustra- tions have freely been used to elucidate the text, and a complete index to facil- itate reference has been added. " There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation."—American Journal of Pharmacy. DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women; with an Introduction by Sir Henry Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, Cloth, 11.50. Useful to those who have to nurse, feed, and prescribe for the sick. In each case the accepted causation of the disease and the reasons for the special diet prescribed are briefly described. Medical men will find the dietaries and recipes practically useful, and likely to save them trouble in directing the dietetic treatment of patients. CATALOGUE OF MEDICAL WORKS. 33 P MANUAL OF PHYSIOLOGY, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Handsome octavo volume of 848 pages, with 300 illustrations in the text, and 5 colored plates. Price, Cloth, $3-75 net. THIRD EDITION, REVISED. " It will make its way by sheer force of merit, and amply deserves to do so. It is one oj the very best English text-books on the subject."—London Lancet. " Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Professor Stewart's volume."—British Medical Journal. ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- sis in the Rush Medical College, Chicago; Attending Physician to the Central Free Dispensary, Department of Rhinology, Laryngology, and Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers. Price, $1.25 net. SECOND EDITION, THOROUGHLY REVISED AND ENLARGED. SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, $2.00 net. " This work is so far superior to others on the same subject that we take pleasure in call- ing attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- tions given. No details are regarded as unimportant; no minor matters omitted. We ven- ture to say that even the old practitioner will find useful hints in this direction which he can- not afford to despise."—New York Medical Record. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with " An American Text-Book of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rusl Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. This work by so eminent an author, himself one of the contributors to " An American Text-Book of Surgery," will prove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome of or supplement to the larger work. " The author has evidently spared no pains in making his Syllabus thoroughly comprehen- sive, and har. added new matter and alluded to the most recent authors and operations. Full references are also given to all requisite details of surgical anatomy and pathology."—British Medical Journal, London. 34 W. B. SAUNDERS' THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children, University of Pennsylvania; Physician to the Children's Hospital, Philadelphia, etc. 404 pages, with 67 illustrations in the text, and 5 plates. i2mo. Price, $1.50. SECOND EDITION, REVISED. A reliable guide not only for mothers, but also for medical students and practitioners whose opportunities for observing children have been limited. " The whole book is characterized by rare good sense, and is evidently written by a mas. ter hand. It can be read with benefit not only by mothers, but by medical students and by any practitioners who have not had large opportunities for observing children."—American Journal of Obstetrics. THE NURSE'S DICTIONARY of Medical Terms and Nursing Treatment, containing Definitions of the Principal Medical and Nursing Terms, Abbreviations, and Physiological Names, and Descriptions of the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or the sick-room. By Honnor Morten, author of "How to Become a Nurse," "Sketches of Hospital Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. This little volume is intended for use merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, M. D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home; Assistant Visiting Physician to the Kings County Hospital; Assistant Bacteriologist, Brooklyn Health Department. Price, Cloth, $1.50 (Send for specimen List.) One hundred and sixty detachable (perforated) diet lists for Albuminuria, Anaemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, Gout or Uric-Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable sheets of Sick-Room Dietary, containing full instructions for preparation of easily-digested foods necessary for invalids. Each list is numbered only, the disease for which it is to be used in no case being mentioned, an index key being reserved vfor the physician's private use. DIETS FOR INFANTS AND CHILDREN IN HEALTH AND IN DISEASE. By Louis Starr, M. D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. Price, $1.25 net. The first series of blanks are prepared for the first seven months of infanl life; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formula foj tne preparation of diluents and foods are appended. CATALOGUE OF MEDICAL WORKS. 35 HOW TO EXAMINE FOR LIFE INSURANCE. By Joi*N M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Paediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections; also, numerous cuts to elucidate the text. Third edition. Price, Cloth, $2.00 net. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. As the proofs of these instructions were corrected by the directors.of the companies, they form the latest instructions obtainable. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science."—The Medical News, Philadelphia. NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital; Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md.; late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome i2mo volume of 512 pages, illustrated. Price, Cloth, $2.00 net. SECOND EDITION, REVISED AND ENLARGED. This original work on the important subject of nursing is at once comprehensive and systematic. It is written in a clear, accurate, and readable style, suitable alike to the student and the lay reader. Such a work has long been a desidera- tum with those entrusted with the management of hospitals and the instruction of nurses in training-schools. It is also of especial value to the graduated nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- TIONS. By L. Ch. Boisi.iniere, M. D., late Emeritus Professor of Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- trated. Price, $2.00 net. " For the use of the practitioner who, when away from home, has not the opportunity of consulting a library or of calling a friend in consultation. He then, being thrown upon his own resources, will find this book of benefit in guiding and assisting him in emergencies." INFANT'S WEIGHT CHART. Designed by J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children in the University of Peni\ sylvania. 25 charts in each pad. Price per pad, 50 cents net. A convenient blank for keeping a record of the child's weight during the first two years of life. Printed on each chart is a curve representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected Saunders^ &» students New Series ™* of Manuals ^^ THAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NEW SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press. These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively written and exhaustive in detail, without being encumbered with the introduction of "cases," which so largely expand the ordinary text- book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner: to the latter, too busy to search through page after page of elaborate treatises for what he wants to know, they will prove of inestimable value ; to the former they will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OK MANUALS are conceded to be superior to any similar books now on the market. No other manuals afford so much information in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion ofthe work worthy of the high literary standard attained by these books. Any of these Manuals will be mailed on receipt of price (see next page 'or List). SAUNDERS' NEW SERIES OF MANUALS. VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A. M., M. D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital, etc. Price, jfSl.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M. D., Professor of Clinical Surgery, Jefferson Medical College, Philadel- phia. Second edition, revised and greatly enlarged. Octavo, 911 pages, 386 illustrations. Cloth, 34.00 net; Half-Morocco, $5.00 net. DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Price, $1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- son Medical College of Philadelphia, etc, Price, #1.50 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the German Poliklinik; Instructor in Surgery, New York Post-Graduate Medical School, etc. Price, $1.25 net. MANUAL OF ANATOMY. By Irving S. Haynes, M. D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. Price, $2.50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M. D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- urinary Diseases in Rush Medical College, Chicago. Price, $2.50 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. Price, $2.50 net. OBSTETRICS. By W. A. Newman Dorland, M. D., Assistant Demon- strator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispensary, Pennsylvania Hospital. Price, $2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital for Women, London; and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. Edin., Assistant Surgeon to the Chelsea Hospital for Women, London. 436 pages, handsomely illustrated. Price, $2.50 net. IN PREPARATION. NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Profes- sor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. *** There will be published in the same series, at short intervals, carefully prepared works on various subjects, by prominent specialists. 37 SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature WITH Students and Practitioners in every City of the United States and Canada. THE REASON WHY. They are the advance guard of " Student's Helps "—that DO help; they are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- come Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-four subjects, has been kept thoroughly revised and enlarged when necessary, many of them/being in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- ket, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence: 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. *** Any of these Compends will be mailed on receipt of price (see next page for List). 38 SAUNDERS' QUESTION-COMPEND SERIES. Price, Cloth, $1.00 per copy, except when otherwise noted. i. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Revised and enlarged By H. A. Hare, M. D. (Price, $1.00 net.) 2. ESSENTIALS OF SURGERY. 6th edition, with an Appendix on Antiseptic Sur- gery. 90 illustrations. By Edward Martin, M. D. 3. ESSENTIALS OF ANATOMY. 6th edition, thoroughly revised. 151 illustrations. By Charles B. Nancrede, M. D. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 5th edition, revised, with an Appendix. By Lawrence Wolff, M. D. 5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and enlarged. 75 illustra- tions. By VV. Easterly Ashton, M. D. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 7th thousand. 46 illustrations. By C. E. Armand Semple, M. D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTION-WRITING. 5th edition. By Henry Morris, M. D. 8, g. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.J) Am Appendix on Ukine Examin ation. Illustrated. By Lawrence Wolff, 1YI. D. ;d edition, enlarged by some 300 Essential Formulae, selected from eminent authori- ties, by W11. M. Powell, M. D. (Double number, price #2.00.) 10. ESSENTIALS OF GYNAECOLOGY. 4th edition, revised. With 62 illustrations. By Edwin B. Cragin, M. D. 11. ESSENTIALS OF DISEASES OF THE SKIN. 4th edition, revised and enlar^/d 71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M.D. (Price, J1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward Martin, M. D. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 130 illustrations. By C. E. Armand Semi'I.e, M. D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 illustrations. j1 edition, revised. By Edward Jackson, M. D., and E. Baldwin Gleason, M. D. 15. ESSENTIALS OF DISEASES OF CHILDREN. 2d edition. By William M. Powell, M. D 16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale," and numerous illustrations. By Lawrence Wolff, MD. (Price, 75 cents.) 17. ESSENTIALS OF DIAGNOSIS, ss illustrations, some in colors. By S. Solis- Cohen, M. D., and A. A. Eshner, M D. (Price, $1.50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. 2d edition, revised. By L. E. Sayre. 20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustrations. By M. V. Ball, M. D. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 3d edition, revised. By John C. Shaw, M. D. 22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised By Fred J. Brockway, M. D. (Price, $1.00 net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. Stewart, M. D., and Edward S. Lawrance, M. D. 24. ESSENTIALS OF DISEASES OF THE EAR. 114 illustrations. 2d edition, re- vised and enlarged. By E. Baldwin Gleason, M. D. 39 IN PRESS FOR PUBLICATION EARLY IN THE FALL OF 1899. THE INTERNATIONAL TEXT-BOOK OF SURGERY. In two vols. By American and British authors. Edited by J. Collins Warren, M. D.; LL.D., Professor of Surgery, Harvard Medical School, Boston; Surgeon to the Massachusetts General Hospital; and A. Pearce Gould, M. S., F. R. C. S., Eng., Lecturer on Practical Surgery and Teacher of Operative Surgery, Middlesex Hospital Medical School; Surgeon to the Middlesex Hospital, London, England. Vol. I. Handsome octavo volume of about 950 pages, with over 400 beautiful illustrations in the text, and 9 litho- graphic plates. HEISLER'S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M. D., Pro- fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. i2mo volume of about 325 pages, handsomely illustrated. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Professor of Laryngology and Rhinology, Jefferson Medical Col- lege, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital. Octavo volume of about 630 pages, with over 150 illustrations and 6 lithographic plates. PRYOR PELVIC INFLAMMATIONS. The Treatment of Pelvic Inflammations through the Vagina. By W. R. Pryor, M. D., Professor of Gynecology in the New York Poly- clinic. i2mo volume of about 250 pages, handsomely illustrated. ABBOTT ON TRANSMISSIBLE DISEASES. The Hygiene of Transmissible Diseases: their Causation, Modes of Dissemination, and Methods of Prevention. By A. C. Abbott, M. D., Professor of Hygiene in the University of Pennsyl- vania ; Director of the Laboratory of Hygiene. Octavo volume of about 325 pages, containing a number of charts and maps, and numerous illus- trations. JACKSON-DISEASES OF THE EYE. A Manual of Diseases of the Eye. By Edward Jackson, A. M., M. D., late Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine. l2mo volume of over 500 pages, with about 175 beautiful illustrations from drawings by the author. SAUNDERS' MEDICAL HAND-ATLASES. ----.o^o«---- The series of books included under this title are authorized translations into English of the world-famous Lehmann Medicinische Handatlanten, which for scientific accuracy, pictorial beauty, compactness, and cheapness surpass any similar volumes ever published. Each volume contains from 50 to 100 colored plates, besides numer- ous illustrations in the text. The colored plates have been executed by the most skilful German lithographers, in some cases more than twenty im- pressions being required to obtain the desired result. Each plate is accom- panied by a full and appropriate description, and each book contains a con- densed but adequate outline of the subject to which it is devoted. One of the most valuable features of these atlases is that they offer a ready and satisfactory substitute for clinical observation. Such ob- servation, of course, is available only to the residents in large medical centers; and even then the requisite variety is seen only after long years of routine hospital work. To those unable to attend important clinics these books will be absolutely indispensable, as presenting in a complete and con- venient form the most accurate reproductions of clinical work, interpreted by the most competent of clinical teachers. While appreciating the value of such colored plates, the profession has heretofore been practically debarred from purchasing similar works because of their extremely high price, made necessary by a limited sale and an enormous expense of production. Now, however, by reason of their pro- jected universal translation and reproduction, affording international dis- tribution, the publishers have been enabled to secure for these atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unapproached in cheapness. The great success of the undertaking is demonstrated by the fact that the volumes have already appeared in nine different languages—German, English, French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. The same careful and competent editorial supervision has been secured in the English edition as in the originals. The translations have been edited by the leading American specialists in the different sub- jects. The volumes are of a uniform and convenient size (5 x "J}i inches), and are substantially bound in cloth. (For List of Books, Prices, etc. see next page.) Pamphlet containing specimens of the Colored Plates sent free on application. VOLUMES NOW READY. Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited by Augustus A, Eshner, M.D., Professor of Clinical Medicine in the Phila- delphia Polyclinic; Attending Physician to the Philadelphia Hospital. 68 colored plates. Cloth, $3.00 net. Atlas of Legal Medicine. By Dr. E.- von Hofmann, of Vienna. Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York ; Chief of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates, and 193 half-tone illustrations. Cloth, #3.50 net. Atlas of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited by Charles P. Grayson, M.D., Lec- turer on Laryngology and Rhinology in the University of Pennsylvania ; Physician-in-Charge, Throat and Nose Depart- ment, Hospital of the University of Penna. With 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net. Atlas of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital. With 24 colored plates, and 217 illustrations in the text. Cloth, $3.00 net. Atlas of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by L. Bolton Bangs, M.D., late Professor of Genito-Urinary and Venereal Diseases, New York Post-Graduate Medical School and Hos- pital. With 71 colored plates from original water-colors by A. Schmitson. Cloth, $3.50 net. Atlas of External Diseases of the Eye.—By Dr. O. Haar, of Zurich. Edited by G. K. de Schweinitz, M. D., Profes- sor of Ophthalmology, Jefferson Medical College, Philadel- phia. With 76 colored illustrations on 40 plates. Cloth, #53.00 net. Atlas of Skin Diseases.—By Prof. Dr. Franz Mracek, of Vienna. Edited by Henry W. Stelwagon, M. D., Clinical Professor of Dermatology, Jefferson Medical College, Phila- delphia. With 63 colored plates and 39 beautiful half-tone illustrations. Cloth, $3.50 net. IN PREPARATION. Atlas of Pathological Histology. Atlas of Operative Gynecology. Atlas of Orthopedic Surgery. Atlas of Psychiatry. Atlas of General Surgery. Atlas of Diseases of the Ear. 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