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PHOTOGRAPHIC  ILLUSTRATIONS
OF
/
SKIN    DISEASES.
BY
f
           GEORGE HENRY  FOX, A.M., M.D.,
Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the Ne7v York Dispensary, Department
    of Skin and Venereal Diseases; Fellow of the American Academy of Medicine; Member of the New York
           Dermatological Society, the American Dermatological Association, etc.
FORTY-EIQHT fl-ATES FROM J-IFE.
COLORED BY HAND.
    {  NEW  YORK:

E. B. TREAT, No. 757  Broadway,

           1880. 
"\X
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Won.  (Y)ui.
F'(01fh
vsrao
    COPYRIGHT,

GEORGE HENRY FOX,

      1879.

 [ali rights reserved.]
   Artotype,
UOBROUN it BREI8TODT,
   New York..
 Samckl Stoddkb,
   Stereotyper,
W Akn Stkekt, N. Y. 
 
 
PREFACE.
     The study  of  Skin Diseases without cases  or  colored plates  is like the study of
 osteology without bones, or the study of geography without maps.   However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is next best, its faithful  representation.  A
 systematic  course of clinical  study is  only possible in our large  cities, and yet the
 physician in any remote  locality may be called  upon to treat the rarest forms of skin
 disease.  As succes's must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations of skin diseases.   Photographs, though  serving a good purpose in portraying
 the characteristic location  and configuration of the various affections of  the skin, have
 generally lacked an essential element of diagnosis, viz., the color, or have been disfigured
 by careless  daubing, and colored lithographs have not only been expensive, but in too
 many instances lacked fidelity to nature both in form and color.
     In the series of illustrations now offered to the profession, advantage has been taken
 of a process recently devised for  the  reproduction  of pictures  from  photographic
 negatives.  These pictures  not only possess the  sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.  The negatives which serve as a basis for the plates of this series have been selected
 from a very large number, most of which were taken under the  immediate supervision
 of the editor. A few have been collected from other sources.  The coloring has been
 entrusted to  a skilful artist, who was formerly a physician, and, having studied skin
 diseases in the General Hospital at Vienna, is peculiarly fitted for the work.  The text
 accompanying the plates is designed to call attention to the diagnostic characters of
 the various diseases, and to give in brief some practical suggestions  for their treatment.
 The notes of cases  have been made  very brief, as a rule, inasmuch as it has seemed
 unnecessary to give full particulars  of a case except where it has possessed points of
 special interest.   No systematic  order has been  followed  in the arrangement of dis-
 eases, although certain ones have been  placed  together with a view to their contrast.
 On a number of the plates  will be found a double illustration, showing different stages
 or phases of  the same disease.
    It has been the aim of  the author to represent in this series  nearly all of the rare
as well as the common affections of the skin, with  the exception of the Syphilodermata ;
to present their features with photographic accuracy, and to employ color with the ut-
most care to render  the illustrations as life-like as possible.  The cutaneous manifesta-
tions  of Syphilis are so varied  and important that merely one or two illustrations
would be of little value.  It has  therefore been deemed advisable to reserve this field
for a second work, and to make the present one a more complete  series of non-syphilitic
affections.
                                                     GEORGE HENRY  FOX. 
              CONTENTS
                          AND

LIST   OF   ILLUSTRATIONS,

              WITH  SYNONYMOUS TERMS.
                                                                                       PAGB
 ACNE VULGARIS,     ................9
 ALOPECIA areata,......(Tinea decalvans,)......97
 CHROMOPKYTOSIS,.....(Pityriasis or Tinea versicolor,)     ...  33
 COMEDO,........(Acne punctata,)......7
 CORNUA cutanea,................95
 ECZEMA barbae,................47
 ECZEMA cruris,................37
 ECZEMA ichorosum,  ......  (Eczema madidans or rubrum,)     .     .    .43
 ECZEMA infantile,................39
 ECZEMA manum,................49
 ECZEMA papulosum,.....(Lichen simplex,)......41
 ECZEMA pustttlosum,.....(Impetigo.—Eczema impetiginosum,)     .    .  43
 ECZEMA squamosum,...............45
 ECZEMA universale,...............29
 ECZEMA e venis  varicosis,..............51
 ELEPHANTIASIS,......(Elephantiasis Arabum,).....18
 EPITHELIOMA,     ......(Carcinoma epitheliomatosum,)     .     .    .61
 EPITHELIOMA rodens,...............59
 EPITHELIOMA superficiale,      .    .     .  (Ulcusrodens,).......59
 ERYTHEMA circinatum,       ....  (Erythema annulare^).....91
 ERYTHEMA exfoliativum,    ....  (E. desquamativum scarlati?iiforme,)      .    .  91
 ERYTHEMA multiforme,      ....  (Erythema exsudativum,).....77
 FAVUS capitis,      ................35
FAVUS corporis,................35
FIBROMA pendulum,.....(Dermatolysis.—Pachydermatocele,)      .    .  23
HERPES  facialis,......(Herpes febrilis,)......87 
                                        CONTENTS.
                                                                                          *AGE
HYDROA buixosum,      ...............89
ICHTHYOSIS simplex,...............21
KELOID,..................15
KERION,........(Tinea Jeer ion,)      ......71
LEPRA  maculosa,......(Elephantiasis Grazcorum,)     .    .     .    .73
LEPRA  tuberosa,......(Elephantiasis Grcecorum,)     .    .     .    .11
LEUCODERMA,      ......(Vitiligo,)       .......31
LICHEN planus,................67
LICHEN ruber,      ................69
LUPUS  erythematosus,.....(L. erythematodes,)......57
LUPUS  vulgaris,......(L. non-exedens.—L. tuberculosus,)   .     .    .55
MOLLUSCUM,.......(Molluscum contagiosimi or sebaceum,)     .    .  75
MORPHCEA,.......(Addison's keloid,)......99
PORRIGO e pediculis,.....(Porrigo or impetigo contagiosa,)    .     .    .85
PHTHEIRIASIS capitis,.....(Pediculosis capitis,)      .....79
PHTHEIRIASIS corporis,      ....   (Pediculosis corporis,).....81
PSORIASIS  ANNULATA................53
PSORIASIS  NUMMULATA,...............19
PURPURA  simplex,................93
ROSACEA,      .......(Acne rosacea.— Gutta rosea,)   .    .     .    .17
SARCOMA pigmentosum,.....(Melanosis.—Melanosarcoma,)  .    .     .     .101
SCABIES,..................83
SCLERODERMA,................99
TRICHOPHYTOSIS capitis,    ....   (Tinea trichophytina tonsurans,)    .     .     .  63
TRICHOPHYTOSIS corporis,  ....   (Tinea trichophytina circinata,)     ...  65
ULCUS  varicosum,................51
VARICELLA,.................25
ZOSTER PECTORALIS,................27
ZOSTER lumbalis,......(Herpes zoster.—Zona,).....27 
CLASSIFICATION  &  NOMENCLATURE OF DISEASES OF THE  SKIN.
10.
n.
12.
13-
14.



17-
18.
19.
20.
22.
23-
24.
Class     I. Glandular Affections.
  «*      II. Inflammatory Affections.
  "    III. Hemorrhagic      "
  "     IV. Hypertrophic      "

    Class I.—Glandular Affections.
  A.  Sebaceous.
Seborrhoea.  a. oleosa.
           b. sicca.
Comedo.
Milium.
Cystis sebacea.
       B.  Sudoriparous.
1.  Hyperidrosis.
2.  Anidrosis.
3.  Bromidrosis.
4.  Chromidrosis.
5.  Dysidrosis.
6.  Sudamina.
   Class II.--Inflammatory Affections.
Rubeola (or Measles).       4.  Variola.
Rubella (or Rotheln).       5.  Varicella.
Scarlatina.                6.  Vaccinia.
Erythema,  a. simplex.
Intertrigo.
Erythema multiforme.
(or E. exsudativum).
Urticaria.
Dermatitis.
Eczema.
b.  exfoliativum.

a.  papulosum.
b.  tuberculosum.
c.  circinatum.
d.  nodosum.
 a. calorica.  b. venenata,  c. traumatica.
 a. erythematosum.
 b. papulosum (or Lichen simplex).
 c. vesiculosum.
 d. pustulosum (or  Impetigo).
 e. ichorosum (or E. rubrum).
f. squamosum.
Pityriasis
Dermatitis exfoliativa.
Psoriasis.
Lichen sestivus
   (or Lichen tropicus).
Lichen planus.
Lichen ruber.
Lichen scrofulosus.
Prurigo,  a. mitis.
        b. ferox.
        a. facialis.
        b. progenitalis
21.  Herpes.
Zoster.
Hydroa.
Pemphigus.
25.  Pompholyx.
a. vulgaris.
b. foliaceus.
26.
27.
28.
29.
30-
3i-
32-
33-
34
Acne.  a. vulgaris.
      b. indurata.

Sycosis.
Porrigo.
Ecthyma.
Pustula maligna.
Erysipelas.
Furunculus.
Anthrax.
Ulcus.
35.  Onychia.
   Class. III.—Hemorrhagic Affections.
Purpura,  a.  simplex.
         b.  papulosa.
         c.  rheumatica.
         d.  hemorrhagica.
Scorbutus.
Hematidrosis.

   Class IV.—Hypertrophic  Affections.

 A.  Of Pigment.
Lentigo.
Chloasma.
Melanoderma.
Nsevus pigmentosus.
Morbus Addisonii.
B.  Of Epidermis and Papillae.
1.   Callositas.
2.   Clavus.
3.   Verruca.
4.   Molluscum.
5.   Cornu cutaneum.
6.   Keratosis pilaris.
7.   Ichthyosis.
Class    V. Atrophic Affections.
  "     VI. Neoplastic      "
  "    VII. Neurotic       "
  "  VIII. Parasitic       "
C.  Of Corium.
1.  Sclerema.
2.  Scleroderma.
3.  Morphoea.
4.  Elephantiasis.
5.  Rosacea.
         D.  Of Hair.

1.   Hirsuties.  a. partialis.
             b. universalis.
2.   Naevus pilosus.
     E.  Of Nail.
1.   Onychogryphosis.
2.   Onychauxis.
Class V.—Atrophic  Affections.
	A. Of Pigment.	B. Of Hair
I. 2. 3-	Albinismus. a. universalis. 1. b. partialis. 2. Leucoderma (or Vitiligo). 3. Canities.	Alopecia. Alopecia areata. Trichorexis nodosa.
	C. Of Corium.	D. Of Nail.
I. 2.	Atrophia cutis, a. propria. I. b. liniaris. c. maculosa. Atrophia senilis.	Onychatrophia.
Class VI.—Neoplastic Affections.
 A.  Of Connective Tissue.

1.  Keloid.
2.  Fibroma.
3.  Xanthoma.
4.  Neuroma.

     B.   Of  Vessels.
I.  Nsevus vasculosus.
2.  Angioma.
3.  Telangiectasis.
4.  Lymphangioma.
  C.  Of Granulation Tissue.

1. Lupus.
2. Scrofuloderma.
3. Syphiloderma.
4. Lepra,  a. tuberosa.
           b. maculosa
           c. anaesthetica.
5. Rhinoscleroma.
6. Epithelioma.
7. Sarcoma.
Class VII.—Neurotic Affections.
I.  Pruritus.
2.  Dermatalgia.
3.   Hypersesthesia.
4.   Anaesthesia.
      .  Class VIII.—Parasitic Affections.

             A.  From Vegetable Parasites.

I.  Favus (or Tinea favosa).  {Parasite—Achorion.)
2.  Trichophytosis (or Tinea trichophytina).  a.  capitis.
                                      b.  barbae.
                {Parasite—Trichophyton.) c.  corporis.
                                      d.  cruris.
                                      e.  unguium.
3.  Chromophytosis (or Tinea versicolor).  {Parasite—Microsporon.)

              B.  From Animal Parasites.

1.  Scabies {Parasite—Acarus).
2.  Phtheiriasis (or Pediculosis) capitis {Parasite—Pediculus capitis).
3-                   "     corporis (  "   —    "   corporis).
4-      "            "     pubis (   "   —    ««   pubis). 
COMEDO. 
 
COMEDO.
  Case.—C. D., set. 16, U. S.  Patient at the New York Dispensary.  A typical specimen of  the  lym-
          phatic temperament.  In  fair health, but addicted to tobacco-chewing and  other untidy
          habits.  The skin of the face was thick and doughy, the circulation inactive, and the secretion
          of the sebaceous glands notably in excess.  The nose was large and greasy, and its sides as
          well as the forehead were dotted with patulous ducts.  Upon the cheeks comedos of unusually
          large  size were  abundant, but there was very little tendency to  the development of Acne.
          The treatment in this case consisted solely of local measures.  In three visits, during the first
          week of his attendance at the Dispensary, the sebaceous ducts were  emptied by means  of a
          comedo-presser and the free use of  soap was  enjoined.  A  most marked improvement  took
          place  immediately, and in three weeks, no other treatment being employed, the patient was
          discharged as cured.   I have rarely if ever seen a case of this affection so well marked  and
          possessing at the same time so little tendency to follicular congestion.

     Comedo is an affection of the sebaceous glands, occurring alone or associated with Acne.   It  con-
 sists in an excessive secretion of sebaceous matter,  which becoming hardened, produces a distension of
 the sebaceous ducts.  The skin may be tolerably smooth and dotted with numerous dirty specks, which
 indicate the gaping mouths of distended ducts, or as is usually the case, small conical  papules arc
 seen with black dots  at their summits.  The dark color  of these  " black heads " is owing  to the
 adherence of particles of dirt to the exposed end of the fatty plug which occupies the follicle.   In
 patients who work in dusty rooms, and especially among such as are sparing in the use of soap, these
 black dots increase in number and prominence,  until the face looks as  though it had been exposed to
 an explosion of gunpowder.  When pressure is  applied to opposite sides  of a comedo, an inspissated
 mass composed of sebum  and epithelial cells  can be  extruded in the  shape of a  curdy or cheesy
 " worm."
     The affection  is commonly observed upon the face, although the upper portion of the back  is
 almost as frequently its seat.  Not infrequently a few.comedos (or comedones) are seen upon the  ster-
 nal region and upon the sides of the neck.  The sebaceous glands of the nose, which are numerous and
 normally of large size, are not apt to be  greatly distended, although in nearly every case of this affec-
 tion white plugs or threads of sebum, an eighth of an inch or more in length, can be expressed from
 the follicles, both upon  the tip and alae nasi.  In the concha of the ear the black ends of a group of
 comedos are  frequently seen.   In this location they are firmly imbedded  and  pressed out with diffi-
 culty.  Upon the  forehead and temples comedos do not attain as large  a size nor  are  they as
 numerous as upon  the cheeks.   They may be  soft, whitish, and curdy, curling  as they are extruded
from the sebaceous ducts, or in  cases of long standing they may be more or less hardened, of a yellow-
                                                7 
COMEDO.
isb color and pyriform shape, and when pressure is exerted upon the walls  of the follicle by means
of a silver  tube or comedo-presser, they pop out with an audible sound.  Frequently the comedo  is
found, upon examination, to be composed of three parts, a  black end corresponding to the mouth of
the follicle, a yellowish  or horny mould  of the duct, and  a soft whitish extremity representing the
fresh  secretion of the gland.   Microscopical examination  of the sebaceous matter composing  the
comedo will sometimes reveal the presence of an animal parasite called the steatozoon or acarus fob-
liculorum.  Several of these microscopic insects  may be found in one  follicle.   They are perfectly
harmless, and occur in healthy follicles as well as in those which are  distended by an  accumulation
of sebum.
    The treatment of comedo is usually restricted to local measures, although attention to the  state of
the general health is necessary in most  cases to check the tendency to the disorder.   Our first aim
should be to evacuate  the distended ducts.  This is frequently accomplished  by the patient, by means
of the thumb-nails.  The use of a watch-key is a better plan of treatment, but since, on account  of its
square bore and rough end, it is liable to wound the skin, several little comedo-pressers have been de-
vised  as  a substitute.  The simplest instrument is a silver tube, five or six centimetres in length, with
rounded extremities, and  a calibre of knitting-needle size.   By placing the end of  this  tube over the
summit of  the comedo, and exerting a quick, firm pressure, the sebaceous plug  can  be expressed with
the least amount of discomfort.  In pressing out  comedos over bony prominences, such as the cheek-
bone  or margin of the  jaw, or upon  the nose, care must  be exercised lest the tube  slip  and tear
the surface of the  skin.   After the follicles have been evacuated, the face may be bathed  with very hot
water to lessen the congestion, which, in a greater  or  less degree results  from the use of the in-
strument.  The daily use of soap should be prescribed, both  for  the sake of its  stimulant action
on the glands,  and for  the purpose of removing a portion of the fatty matter  from ducts which
are not  sufficiently distended  to warrant the  use of the  comedo  presser.   Soap  will  also  remove
from  the follicular orifices the  numerous  black  specks which, in young  persons  with over-active
glands, are apt to dot the face  in  spite  of unremitting attention  to  bathing.  When there is any
tendency to  glandular inflammation, and the use of soap  is found to aggravate this, it is well to
bathe  the  face  in  warm water,  to  which a little borax or bran may be added.  Ladies sometimes
object to the use  of  soap in bathing the face,  on account of the tense and shiny  condition of the
skin  which is sometimes left.   This  is easily  remedied by slight friction with  a piece  of flannel
or chamois-skin, and if   necessary by  the  application  of  a  little rice powder or lycopodium.  As
a lotion  to be used in cases of  comedo, the following is mildly  astringent and  conducive to the
normal action of the glands;
                #.  Zinci Sulphatis,......4 grams (3 i).
                    Aquse Aurant. flor.,......200   "   (f 3 vi).
                M.
                                               8 
rr  '
n
ACNE    VULGARIS. 
 
ACNE.
 Case.—C R, set. 20, U. S.  A case contrasting strongly with the foregoing one.  The patient was of
         fair complexion, with a naturally delicate skin.   He suffered from dyspepsia, but in other re-
         spects  was strong and well.  The cheeks were  hypersemic  and nearly  covered  with dark-
         red papules and pustules.  A few of the latter situated near the angle of the jaw had slightly
         indurated  bases,  but there  were none  of  those  hard,  deep-seated tubercles  which, when
         numerous, produce that lumpy form of the disease  to which is applied the term Acne indu-
         rata. A few comedos were interspersed among the inflammatory papules,  and about the zygo-
         matic region  were numerous pin-head sized, whitish elevations,  due to the  distension "of
         glands of small size,  seated in the upper portion of the corium.  A marked flushing of  the
         face ensued upon mental excitement or slight external irritation.  The local treatment in this
         case was necessarily of a soothing nature.  The irritation produced  by carefully pressing out
         the comedos occasioned patches of congestion which would last an  hour or more, and lead to
         the development of fresh pustules.  The mildest stimulating applications invariably aggravated
         the condition,  and it was only after the gastric derangement  had been nearly cured, and the
         irritability of the skin lessened by the most soothing treatment that an improvement began to
         manifest itself.

     Acne is an inflammatory affection of  the sebaceous follicles, characterized by three distinct lesions,
 viz.: papules, pustules, and tubercles.  The term has been  applied by some  writers to nearly all affec-
 tions of the sebaceous glands,  whether inflammatory or not, and in this broad application has included
 comedo, milium, seborrhcea  and  molluscum.  These  affections depend   upon  pathological  con-
 ditions  which are  not  essential elements of acne.  It is a fact, however, that excessive secretion of
 the glands and accumulation of sebaceous matter in the ducts are conditions which  very  frequently
 exist in connection with follicular inflammation.
     Acne, even  in the restricted sense in which  the term is now used, may be regarded as the most
 common of all cutaneous affections.  It may be asserted that the majority of  adults, male or female,
 have  not passed through the period of adolescence without  having at least  a mild form of acne upon
 either the face or upper portion of  the back.  These are the  regions upon which the affection is most
 apt to appear.  In cases where the face is affected in a marked degree the back, shoulders  and breast
 may be slightly affected, or remain perfectly free; while, on the other hand, in cases where the back
is covered with the lesions of acne, the face may be nearly or wholly exempt.   The pustules of second-
ary syphilis are usually disseminated over the greater portion of the body and are sometimes erroneously
termed Acne syphilitica.   These are not true acne pustules, however, and should be spoken of as  the
pustular syphilide or syphiloderm.
     Other eruptions of  pustules occurring on various portions of the body result from the ingestion of
                                                9 
                                             ACNE.

 certain drugs, or from certain forms of external irritation.  These again are not true acne, even though
 produced by follicular inflammation.   They differ in their causation, run a different course, and never
 demand the same treatment as does acne.   The affection which has been  called Acne Rosacea is also of
 distinct nature  and  pathology, as will be seen in connection with  the illustration of Rosacea.  For
 practical purposes the only necessary division of acne is into two varieties, viz :  Acne vulgaris and Acne
 indurata.  The former, or common form of the affection, is so  well known  as to require no detailed
 description.   It appears in one patient upon the forehead or cheek in  the form of a few small red pap-
 ules or " blotches," which may disappear in a week and return when the  same  dietary error, menstrual
 irregularity or other  exciting cause is repeated.  In another  patient the  papules resulting from simple
 follicular congestion  may suppurate and form pustules.   These  may  increase  in number through new
 ones coming faster than the old ones disappear.  Month after month  the skin becomes more and more
 thickened by the products of inflammation; soaps and ointments, lotions and balms, are used by the pa-
 tient with no perceptible effect, and finally the disease reaches the chronic and disfiguring stage which
 is represented in  the illustration.  In time the disease disappears,  even  without treatment,  as it is
 rarely met with in  middle life, but often deep pits remain on the site  of  former pustules and resemble
 the marks left by variola.
     The causes  of acne reside mainly in impaired digestion and menstrual irregularity, and in its treat-
 ment a high degree of diagnostic skill is of ten necessary to detect the cause, and a thorough knowledge
 of general medicine required to remove it.   My limited space will not  allow extended remarks on inter
 nal treatment, but  I must exhort the reader not to rely wholly upon sulphur pastes, corrosive subli-
 mate lotions or medicated soaps,  but to  do everything  possible to improve the general health of the
 patient, and if then the skin does not speedily get well of itself, the simplest local measures will suffice.
 In most cases of acne there is great irritability of the skin, and the error  is frequently made of using
 applications  which are unnecessarily stimulating.  If the patient steams the face at night by  holding
 it over a pitcher of very hot water, and afterwards  sponges it with equal parts of  bay rum and water,
 the improvement will often be  greater than with more active treatment.  A useful lotion in these irri-
 table cases is the following:
                  #.   Acidi Acetici,    ....
                       Glycerinse purse, ....
                       Aquae Cologniens.,
                  M.   Sig.  Dilute with water and apply night and morning.
     At the outset  all comedos should be pressed out, even though the acne is temporarily aggravated
by so doing.   Pustules  should be lanced as often  as  they form, and  hot cloths applied  to lessen the
inflammation. Indolent tubercles which show little tendency to disappear may be lightly touched with
a glass rod dipped in nitric acid or the acid nitrate of mercury.   When  the cheeks are comparatively
smooth, but still reddened, sulphur in one form or another is of service.  I have seen excellent results
ensue from the use of the following:
                  $.   Sulphuris Sublimati,
                       Acidi Tannici,    .    .     .        aa 1  gram     (gr. xv).
                       Unguenti Petrolei,    .     .     .     30   "       (§"i).
                 M.                            10
16 grams	(f|ss).
48 "	(f 1 iss),
64 "	(ffii).
 
LEPRA   TUBEROSA. 
 
LEPRA.
Case.—A. B., set. 54, U. S.  Born in New York, of healthy parents.  In 1855 he went to Cuba, where
         he remained nine years and then removed to Baltimore, being at that time in apparently good
         health.  About  two years ago he first  felt  a  sensation upon the forehead  as  though
         ants were crawling over the skin.   At this time the skin of this part began to assume a light-
         brownish color, and groups of tubercles appeared upon eyebrows, cheeks, nose, hands, feet and
         ears.  He suffered from occasional febrile attacks until February, 1878, when he was admitted
         to the Baltimore  City Hospital.  According to notes of this case published by Dr. George H.
         Rohe in a paper on Leprosy (Maryland Medical Journal, July, 1878), the patient at this time
         was broken down in health.  His face was of a smoky yellow hue, resembling dirty chamois
         skin.  The eyebrows, nose, cheeks and  chin were  lumpy, and the lobes  of  the ears were
         elongated and thickened.   The anterior and posterior surfaces of the trunk,  together with  the
         extremities, presented a bronzed discoloration.  The left side was more affected by the disease
         than the right.  His voice was husky, sight impaired, and smell diminished.   The hands felt
         numb, and locomotion was impeded on account of ulceration of the feet.   In May, when he
         left Baltimore and came to me with a letter from  Dr.  Rohe, his  condition was pretty much
         as above described.  He was but a very short time under my care, and is, at the present time,
         a patient in Charity Hospital.  In the illustration may be seen the lumpy condition of the eye-
         brows, the pits produced on the cheek by absorption of tubercles, and the ulcerations attacking
         the finger ends and phalangeal joints.  The white streaks on the arm resulted from drawing
         the finger nail over the thickened and discolored skin.  The change in the expression of  the
         face could doubtless be better appreciated by comparing a  portrait taken before the disease
         began.

     The leprosy of the present day, occurring in Oriental countries and elsewhere, undoubtedly afflicted
the  children of Israel  in the time of Moses.   The Scriptural account of the disease,  however, as
recorded in Leviticus, is for the most part unintelligible, and it is probable that at the  time when it was
written a number of  chronic and contagious affections were confounded with true leprosy.  In later
centuries this mistake Has been repeatedly made, and the numerous leper-houses established throughout
Europe at the time of the crusades, doubtless contained a large  proportion of syphilitic, psoriatic and
other patients.  In glancing at the  history of leprosy, we find not only a confusion of  diseases, but a
confusion of names.  Suffice it to say that the term Elephantiasis Groecorum is now discarded, and the
term Lepra (unfortunately applied by some writers to a form of psoriasis), is generally adopted in Ger-
many, France and America as the synonym of leprosy.
     Lepra is endemic at  the  present day in various quarters of the globe.  It is common along  the
shores of the  Mediterranean, in India and China, in the  West Indies, Central America and  Brazil.
                                              11 
LEPRA.
Although occurring chiefly in warm climates, it is also prevalent in Norway, Iceland and Kamtschatka.
In the Sandwich Islands leprosy abounds.  On one island (Molokai) there is an asylum to which nearly
two thousand cases have been admitted since its foundation in 1865.  In  certain localities of  the
United  States and Canada there are families or generations of lepers, descended  from immigrants who
were affected by the disease.   In  Minnesota there is a Norwegian community comprising a number of
lepers who  contracted  the disease in the old country.  In California the disease prevails to a limited
extent among the Chinese.  At Tracadie, a small French settlement in New Brunswick, Canada, there
is  a lazaretto  containing a  dozen or more leprous patients who, with  other  cases residing in  the
vicinity, are nearly all descendants of a leprous woman who introduced the disease into the community
near the beginning of this century.  In New York and other large cities of the Atlantic States, cases
of leprosy are  occasionally met with, but the disease almost invariably occurs in sailors, or men who
have spent some time in countries where it is common.  There is no doubt about the hereditary trans-
mission of the disease, although a difference of opinion prevails regarding its contagious nature.   Cases
are reported where a husband has been leprous and the wife healthy, and vice versa, but it is quite
probable that  the  disease is  inoculable, and that in  some cases it  has been transferred directly from
one to another.
     There are three forms of leprosy based upon  the  predominance of certain lesions or symptoms,
viz.:  the tuberose, the macular, and the anaesthetic.   Frequently both macules and protuberances co-
exist  in the same  patient.  Anaesthesia in greater or less degree is rarely absent in advanced cases,  but
it  may  occur,  as  the sole cutaneous lesion, neither macules  nor tubercles being present.  In some
text-books but two forms are described ; the macular and the tubercular.
     Like syphilis, lepra is a  constitutional disease, the cutaneous manifestations of  which, though
highly interesting, are of but secondary importance.  A gradual decline in health usually precedes the
earliest  characteristic indications, which may be faint brownish patches of discoloration or small aggre-
gated tubercles.   In a  case of tuberose leprosy the first unmistakable signs are usually seen upon  the
face.  Tubercular thickening invades  the  lower half of the forehead, and as the tubercles increase in
size  and become tuberous, the patient's face assumes a very characteristic leonine  expression.  The
nose and ears are very apt to be the seat of similar protuberances.
     The nerves undergo a remarkable  change in lepra, the larger trunks of the extremities, as well
as the finer branches  supplying  the skin, becoming thickened and degenerate.   The ulnar nerve, in
particular, can usually be felt enlarged and hardened.  The fingers and toes and  other portions of skin
supplied by these affected nerves  suffer as a natural consequence.  In an early stage of the disease they
are hyperaesthetic, but as changes in the nerves progress, they become numb and  almost lifeless. Ulcers
form, which  are healed with difficulty.  In  severe cases the bones of  the extremities become carious,
and one by one the rotting  phalanges fall off  and  leave disgusting stumps.   The tubercles upon the
face and elsewhere develop  slowly, and though  generally permanent, they sometimes  decrease in size
and disappear by absorption.  New  ones in greater number usually take  their place, and the disease
goes from bad to worse, until the strength of the patient fails.   Remarks on the diagnosis and treat-
ment of lepra will accompany a plate illustrating the macular form.
                                               12 
ELEPHANTIASIS. 
H
> 
ELEPHANTIASIS.
Case.—A. C, set. 19, U. S.  Patient of Dr. Chas. Jewett of Brooklyn, notes furnished by Dr. P. L.
        Schenck of  Kings County Hospital.  The lower limbs have  been enlarged since childhood.
        Patient had Scarlatina at eight years of age, which was followed by general oedema.   From
        about that time the limbs have been increasing in size.   Has  been subject to attacks of chills
        followed by high fever, lasting three or four days.   These have occurred at intervals of three
        or four months and have been followed by a marked increase in the size of the limbs.   On
        the anterior aspect of the legs there are  now (Dec. '78) several patches of thickened  and
        roughened epidermis.   On  the  posterior  surface of the right leg ulceration began about
        eighteen  months  ago.   Sloughing occurred about a month  ago, and there is now an
        excavation four inqhes in diameter and four and a half  inches in depth.  There are one or
        two patches of superficial ulceration, oozing a large quantity of clear serous fluid.  Since  this
        oozing began the legs have diminished in circumference.  The general health is failing.

     Elephantiasis is a disease which  is entirely distinct from leprosy.  Hitherto much confusion has
been occasioned  by the use  of  the term  Elephantiasis  Arabum  to designate the  disease under
consideration, and Elephantiasis Graecorum to designate leprosy.   These  qualifying  adjectives have
now been pretty generally discarded in this country,  and while the term lepra is applied to leprosy, the
term elephantiasis is employed solely in connection with the elephantine disease.
     This disease consists in a hypertrophic growth of  skin and sub cutaneous tissue, and affects chiefly
the lower extremities and genitals.  The leg and foot are  most frequently attacked. It is unusual for
the  disease to extend above the knee, and extremely rare  for both lower extremities  to be wholly
affected, as in  the remarkable case portrayed in the illustration.  Cases  have  been  reported of the
disease  occurring upon the  cheeks, breast and  upper  extremities.  Fibromatous tumors and  that
peculiar relaxed condition of the  skin known as Dermatolysis or Cutis  pendula may occur upon these
parts and  assume elephantine proportions, but they are  to be  carefully  distinguished  from  true
elephantiasis.
     The disease  is chronic in its course, does not affect the health in any marked degree, and the patient
suffers principally from interference with locomotion,  depending upon  the weight of the affected limb.
It is met with in all parts of the world, but abounds  in tropical climates, where it attacks by preference
those whose constitutions have been impaired by improper diet, excessive exposure and other causes.
In the West Indies it is so common that Barbadoes Leg has come to be a well-known synonym.
     The disease is intimately connected with conditions which produce obstruction of the lymphatics.
(Edema plays  a  most important part  in the production and  development of the disease, and recurrent
                                              13 
ELEPHANTIASIS.
inflammatory attacks of an erysipelatous nature characterize its progress.   Each attack leaves the skin
more swollen and harder, and the attacks continue  at  a variable interval until the part affected  has
attained  an immoderate size.  The scrotum, for instance,  may hang nearly to the  floor and weigh
upwards of a hundred pounds.   In the  female the  labia and clitoris may be similarly affected.  The
skin of an affected leg is darkened in color and either smooth and oedematous or  fissured and  scaly.
Its sensibility is  lessened by reason  of the great  thickening, but there are no ansesthetic patches as in
leprosy.  In severe cases portions of skin  become pendulous and deep creases  are formed between
them.  Upon the dorsum of the foot and anterior aspect of the leg it is not uncommon for the skin to
present  a verrucous surface, covered with dry and blackened  papillary elevations.   Eczema  often
appears upon the  surface of the skin,  and fissures occur at  the bottom  of  the furrows.  Slight
ulceration is present in  many cases, and  from the  denuded patches  a large  quantity of  lymph is
poured out.   Sloughing may take place, especially when the  strength  has  failed  and the  patient is
unable to leave the bed.
     Elephantiasis is neither contagious nor transmitted through hereditary influence.   Its causes are
obscure, but are doubtless connected with the patient's manner of living.   Malaria has been  cited as a
cause, but proof is lacking as to its influence.  Varicose veins, cicatrices, gummy deposits, bone  callus
and other local conditions  inducing obstruction of the venous and lymphatic  circulation have been
alleged to act as exciting causes.  A very  interesting and plausible theory has been advanced that  the
disease is of parasitic origin, and that, furthermore, the mosquito is responsible  for its existence.    Dr.
Manson,  a British surgeon, resident in China, has discovered  the filaria sanguinis in the blood of
clephantiasic patients, as also in  the blood of  patients affected by the so-called lymph-scrotum  and
chyluria.   He believes with others that this parasite has its habitat in the lymphatics and by causing
obstruction  and distal fullness of these vessels, gives rise to elephantiasis.   As in the case  of tape-worm
ova, the  immature filarial  can  only become developed outside  of the human  body and the mosquito
is accused of being  their intermediate host.   In the stomach of  this insect the undeveloped filaria is
supposed to undergo a metamorphosis, and being discharged with the young of  the mosquito upon  the
water, finds its way  again into human lymphatics and occasions elephantiasis.
     The treatment of this disease, though often gratifying, is not always attended with the desired suc-
cess.  In the early stage, rest, poulticing and other antiphlogistic remedies should be employed during
the erysipelatous attacks.   Later, bandaging is of service, as it tends to lessen,  though  seldom perma-
nently, the size of the leg.   Hebra recommends elevation of the limb and inunction of mercurial oint-
ment.  Compression and ligation  of the femoral artery has been practiced in a number of cases with
partial success.   The improvement which  follows this method  of treatment is  due to the removal of
arterial pressure, which interferes with the function of the lymphatics.   This pressure  being removed,
a, rapid absorption of the effused serum often takes place, and in some cases the decrease of the infiltration
is permanent.  When the genitals are affected in  a marked degree  the knife  is the remedy most in
vogue, and by its skillful use most brilliant results have been achieved.
                                               14 
KELOID.
 
 
KELOID.
 Case.—H., set. 27. Patient of Dr. Wm. T. Bull.  About eighteen months before the photograph was
         taken this patient had a severe attack of variola, which left considerable pitting of  rh°. face.
         About the time  of  leaving hospital  tumors appeared on either cheek,  which have  slowly
         increased in size.   A small one was excised, but the growth reappeared almost as soon a* the
         wound had  healed.   The disease  as it occurs in this patient would be commonly termed
         spurious or cicatricial keloid.  In appearance, however, it differs in no material respect from
         the spontaneous  form, and presents  a strong  contrast  to the  reticulated cicatricial  hyper-
         trophy which  is frequently observed upon the face as a sequel of variola.    The  bifurcated
         process extending forward upon the cheek is decidedly characteristic, and no stretch  of imag-
         ination is required to detect a close resemblance to the claw of a crab.   The  growth will be
         noted upon the scalp where it assumes the form of linear ridges, as upon the side of  the nose.
         The lobe of the  ear, which is sometimes the seat of  cicatricial keloid, is unaffected in this
         case, although it has been pierced to hold a ring.

     Keloid is a cutaneous tumor which usually develops upon the site of a cicatrix.  It results from a
 new growth of connective  tissue, and may affect various portions of the body.  It is variable in size, and
 though usually small, it may in  rare  cases assume immense proportions.  It  is generally  a  single
 growth, but may occur in the form of  multiple tumors, especially when it arises from cicatrices.   Its
 shape is usually oval or  irregular, and  more or  less  flattened, and one or more straight or  bifurcated
 processes  are seen projecting in  every typical case.  These have given  origin to the name  keloid
 (like the claw of  a crab).  In some instances the growth rises abruptly from the surrounding healthy
 skin and forms a plump convex tumor, while in other cases it  is reticulated  in appearance,  from the
 interlacing  of cicatricial ridges.   The margins of the growth are sometimes elevated and  inclose a
 central depressed area.  Its surface is smooth, of a whitish or dull pinkish hue, and is frequently streaked
 with a fine network of small dilated vessels.  The  growth is firm and elastic to the touch, usually ten-
 der when pressed upon or squeezed, and in some instances gives rise to severe  intermittent  pain even
 when carefully protected.  The processes  radiating from the growth tend  to  contract and produce a
 puckered condition, such as surrounds the cicatrix of an extensive burn.    A favorite site of  keloid is
 the sternal  region, where it appears as  an  elongated flattened tumor  crossing the median line in a
 transverse direction.   It occurs frequently upon the back and sides and also upon the scalp and face.
 It is slow in its development and is never associated with  any constitutional symptoms.   It neither
ulcerates nor tends as a rule  to spontaneous disappearance, but after reaching a certain size remains
in the same  condition for many years,
                                               15 
KELOID.
    The cause of keloid is unknown. Observation teaches that in the vast majority of cases it develops
at some point where cutaneous injury has taken place.  The cicatrices of acne upon the back, of boils or
carbuncles upon the nape of the neck, of  variola upon the face, and of vaccination upon  the arm are
frequently observed to be the site of keloidal growths.  Negroes appear to be more frequently affected
by keloid than white persons.   Whether  this is due to a peculiarity of the race or to the fact  that
their  skins are more frequently  pitted with variola, scarred by strumous abscesses, and disfigured by
the lash, may be a question.  The disease is never hereditary.  A division of keloid has been made into
a spontaneous and a cicatricial variety, the former embracing those cases of idiopathic origin, the latter
comprising those which develop  upon cicatrices.  As it is well known  that keloidal tumors of consid-
erable size and attended by pain result from the most trifling injury to the  skin, it seems quite prob-
able that every case of keloid is  of  traumatic origin, and that the so-called idiopathic cases have been
produced by the prick of  a pin or some other insignificant injury of which the patient took little or
no notice at the time.   The term spurious  keloid might be  advantageously abandoned or  applied to a
form  of hypertrophic development  of cicatricial tissue sometimes met with, and which differs from  true
keloid.
    The name keloid, like many other dermatological terms, has been diverted from its original  sig-
nification and applied to distinct affections.   We hear accordingly of Alibert's keloid  and Addison's
keloid.  Concerning the nature of the latter affection, or Morphoea, there is much doubt  existing among
dermatologists, but one thing is certain, it is  not  keloid.   The diagnosis of  the disease is usually an
easy matter.   The firm, elastic tumor, the processes (which  however  are not  invariably present), the
puckering of  the surrounding  skin, the long duration of the growth and the unimpaired  health  of
the patient are  characteristic  features  which  will  serve  to distinguish  it  from other affections.
The diagnosis of genuine  from  spurious  keloid depends, according  to  writers who make the distinc-
tion, upon the idiopathic or traumatic origin.  The origin, as has been remarked, is often uncertain and
the distinction is unnecessary.  It must be remembered, however, that cicatrices often become thickened
and lumpy through condensation of tissue and are with difficulty distinguished from keloid.
    In the treatment of the disease success seems to depend in great measure upon idiosyncracy on
the part of the patient. A method which will succeed admirably in one case will fail utterly in another,
and caution must be observed in stating beforehand what the result of treatment will be.   Excision of
the tumor or destruction by caustics usually does more harm than good, as  the growth usually reap-
pears  even before the wound is healed, and  soon reaches  a  greater  size than before the operation.
This is  especially the case when  the growth is  progressive.   When there has been no increase in size
for several years, caustic potash  or glacial  acetic acid may be cautiously used.   I have  recently seen a
case of  reticulated keloid following variola, which was greatly improved by parallel incisions and  the
use of the concentrated acid.   An ointment  of iodide of lead or of iodide of potassium or elastic
collodion may be applied with a certainty of at least doing no harm.   Where excessive pain is present
hypodermic injections  of morphia or anodyne lotions are required.
                                               16 
ROSACEA. 
 
ROSACEA.
Case.—Margaret K., set. 45,  Ireland.   Patient at the Skin Clinic of the Woman's  Medical College.
         The eruption had troubled her more or less for six years and had been much  worse than usual
         during the last month.   Menopause occurred two years before.   She complained greatly of
         discomfort after eating and often vomited her food.  This gastric irritability having subsided
         under a restricted diet, together with the use of pepsin and bismuth, she was ordered Aug.
         6, 1878, a mixture containing sulphate of  iron and sulphate  of magnesia, and for local ap-
         plication  an ointment of sulphur,  four parts, tannic Scid, four parts, cosmoline, ninety-two
         parts.  This was followed by a rapid improvement, and when seen  on Sept. 17, all trace of
         eruption had disappeared, and she felt much stronger and better.

     Rosacea is a chronic disease of the middle  period of life, occurring upon the face, and resulting
from a dilatation of blood-vessels and an increased growth of connective tissue.  Its chief features are
redness and a tendency to the development of tubercles and pustules.  The affection has  been de-
scribed by writers on  dermatology as a form  of acne, and even  those who have believed it to be a
distinct affection have generally employed the term Acne-Rosacea.   Some writers, in order to distin-
guish the affection from acne, as should be done, have  employed the old but expressive term Gutta
Rosea or Gutta Rosacea. Recently rosacea has been disjoined from acne in name as well as in nature,
and this usage will doubtless tend to  dissipate  the  erroneous idea  that they  are forms of  the same
disease.
     Rosacea is common in both sexes and is most frequently met with between the ages of thirty and
fifty.  Its site is characteristic.  If the face were mapped out into vertical  thirds the middle section
would include nearly all cases of rosacea.   The parts most frequently affected are those portions of the
cheeks below the infra-orbital ridges.  In  severe cases a fiery triangle may be seen  on either cheek,
lying between this ridge and the zygomatic minor and labio-nasal muscles.  A  milder form of the
disease often exists upon the central portion of the forehead, just  above the bridge  of  the nose, and at
a short distance from the angles of  the mouth isolated rosy drops are frequently observed.
     The simplest form of rosacea is that which appears in the  form of dull red macules or slightly-
elevated papules, resulting from  chronic  congestion or dilatation of the superficial vascular plexus
around the mouth of a follicle.  These " rosy drops " sometimes  present a central point of a somewhat
darker hue, more elevated and at times surmounted by a scale or the thin crust of a  minute pustule.
The  confluence of these  circular "drops" forms a purplish-red patch, presenting.a swollen  and uneven
surface dotted with patulous follicles and somewhat resembling the skin of an orange  in texture.    As
the disease advances the patch  becomes studded with  tubercles which usually tend to suppuration.
                                              17 
ROSACEA.
 The rounded summit of the tubercle assumes a yellowish-white appearance  and a minute superficial
 drop of  pus, evacuated when the patient is washing or wiping the face, gives place to a thin, dark col-
 ored crust.   In many of the tubercles a more decided form of suppuration occurs, and in a case of long
 standing numerous hemispherical pustules or abscesses are accordingly present.   These pustules are not
 of  glandular  origin,  as in acne, and may be  easily distinguished from  true acne pustules by their
 rounded summits and the absence of a central comedo.   Similar pustules or small superficial abscesses
 not unfrequently occur in acne, especially in the indurated form, and are not connected with the se-
 baceous glands.
     Dilatation of the superficial blood-vessels, though commonly occurring in rosacea, is not an essen-
 tial element of the  disease.  Where the condition is marked, as it often is upon the wings of the nose,
 constituting the most striking feature of the affection, the term Rosacea varicosa has been employed.
     The most remarkable form of the  disease is that known as Rosacea hypertrophica.    It is a late
 stage of the affection and occurs chiefly on the  nose.  The tumid or lumpy condition  of the skin which
 is characteristic of the disease in its common  form, becomes exaggerated to such an extent that the nose
 assumes astonishing proportions.  A  number of  tumors project from the sides or tip, varying in size
 from a large pea to a small egg, and frequently become pedunculated.  The nose may attain the size of
 the fist, and either  partially obstruct  vision or  hang down  in front of the mouth.  This condition is,
 fortunately, so rare, as to constitute a  dermatological curiosity.
     Rosacea resembles acne, in being largely dependent upon disturbance of gastric and uterine func-
 tions.   The  treatment in most cases consists of a  combination  of internal and local  remedies.   To
 achieve success with the former we must ferret out all predisposing  and  exciting causes.   Abnormal
 states of internal organs must be rectified.   Injurious  habits must be abandoned by the patient and
 strict attention paid to hygienic rules.   To derive benefit from local  applications it is necessary to de-
 termine the amount of stimulation required  by each individual  case.  In mild  cases, where there is
 much irritability and little thickening of the skin, the  following lotion may be used  while  the cure is
 being effected by internal treatment:
              $   Sodii boratis,.......4 grams  (31)
                  Glycerinse purse,......8  "    (f 3 ii)
                  Aquae rosse,.......128  "    (fliv)
              M.   Sig. Use as a lotion for the face ad lib.
     Where a little  more stimulation  is desired the following may be applied  to the affected  part at
 night and the powder allowed  to remain until morning.
              fy  Sulphur, precip.,       .....10 grams  (3 iii)
                 Spirit. Lavandul.,.....90   "   (f § iii)
             M.  Sig.  Shake before using.
     Equal parts of  the oxide of zinc and ammoniated mercury ointments  are  useful where  more stim-
ulation is required;  and when there is marked infiltration of the skin a course of nightly frictions with
green soap is almost indispensable.  Dilated-blood vessels should be well scarified, and after the blood
has ceased flowing a thick coating of  elastic  collodion  painted  over them.   In the hypertrophic form
of the disease surgical treatment is indispensable.
                                               18 
</
fc**'
PSORIASIS.  NUMMULATA 
 
PSORIASIS.
Case.—J. S.,  set. 40.  The eruption in  this patient was  of about five years' standing, and although
         some  patches had disappeared  and new ones  taken their place,  it had been characterized
         throughout its course by  a  few discrete  circular  patches covered  with  thick scales.   No
         especial change had  taken place, as usually happens,  at certain seasons of the year.  The
         patient was a large, strongly-built man, and seemingly enjoyed the best of health.   At times
         the eruption itched   slightly, especially  when heated by  fast walking  or other physical
         exertion.  The  scalp was  but slightly affected, and the nails presented  a peculiar condition
         occasionally met with in this disease.  Upon a few  of his fingers,  and upon nearly all of
         his toes, the free margin of the nail was raised  from its bed  by  a  hard yellowish mass of
         horny epidermic scales.  This produced a lateral  curving  of the nails and a splitting of the
         free  ends.   The treatment  adopted  at first  in  this case consisted of Fowler's solution
         internally with oil  of cade rubbed  daily into the affected  skin  after the scales had been
         completely removed  by means  of a  curette.  Improvement  followed, but  treatment  was
         discontinued during  absence from the city.    Later  a ten per cent, ointment  of  chryso-
         phanic acid was used with excellent result.

     This very common affection  consists in  circumscribed  patches of red and  thickened skin, covered
usually  with  whitish or  yellowish-white  scales.   The   patches  may be   isolated  or   confluent.
In  the former case  they vary  in size from  a pin-head to  a saucer, and are  circular in form.
In  the  latter  case  they  give rise  to  large  irregular  patches,  with  scolloped  borders,  and   fre-
quently  with  inclosed  areas  of normal  or  slightly pigmented  skin.   In some cases  the  entire
body and especially the  trunk may be affected, and appear reddened, thickened, and more  or  less
scaly.   The patches  always begin  in  the  form of small red papules, surmounted  by a thin scale.
These  may be scattered abundantly over the  body,  and  show  little  or no tendency to increase
in  size (P. punctata).   They are  more apt,  however, to assume the size of a cent or quarter-
dollar, and when numerous  and aggregated they appear as  though  a  handful  of thin  mortar
had been   spattered  over  the  skin  (P.  guttata).    In a  small number   of  cases  the patches
are  few  and  large, and, as  in  the illustration,  appear  like   silver  coins  of  large   size  (P.
nummulata).  Generally  the  patches  tend  to  coalesce  as  they increase in  size, and  lose their
circular outline (P. diffusa).  In  nearly  all  cases the  central  portion of  the patch is the first  to
disappear,  and in  consequence  scaly rings  are  produced  (P.  annulata)  and  in   rare  instances
crescentic and  serpentine lines  (P. gyrata).  The scales  of psoriasis are imbricated, and in most cases
easily removed.  In  appearance they have  been compared to  silver and to  mother  of  pearl.
Theic  thickness is  usually  in proportion   to  the  amount of infiltration of the  subjacent skin.
                                              19 
PSORIASIS.
In  diffused patches  they are often  branny in character, while in chronic cases they  become thick
and  hard, like plates of armor.  The extensor surfaces of the extremities, the back and the scalp,
are the favorite sites of the affection.   Upon the elbows  and knees and along the frontal margin
of  the  scalp  it commonly occurs, although it  is not  invariably present upon these  parts.
     The  etiology of psoriasis, in  spite of much investigation and more discussion, is  still  obscure.
While some  writers connect  it  with a dartrous or rheumic diathesis, or insist  upon  its  depend-
ence  upon malaria,  others regard it as a  purely local  disease, and claim for it a traumatic origin.
The majority of psoriatic patients seem as strong and  hearty as the average of mortals, and if not
in perfect health apart from their cutaneous blemish, they at least believe themselves to be so.
     The  diagnosis  is  generally  easy, especially  in  typical  cases.   It  must be constantly borne in
mind, however, that  the  eruption  may be in its declining stage or modified  by previous treatment,
in which case it differs greatly in appearance from  the eruption  when seen at its height and before
treatment.  If a psoriatic patient is stripped sufficiently to reveal the greater portion of  the eruption,
a  diagnosis can readily be made  by observing the characteristic configuration of  the  patches even
when viewed at a considerable  distance.   When the eruption  is  seen in its incipient stage,  and
only  a  few scaly points or  drops are present, a diagnosis can often be  arrived at  by observing the
ease with  which the scale can be removed  by the finger  nail, and the  bleeding  corium which  is
exposed beneath  it.  Too much  stress, however, is often  laid upon this point, as in some  cases of
eczema, where the eruption is recent and accompanied by slight  scaling  and little  or no infiltration
of the true skin, the finger nail may remove the epidermis as readily as in psoriasis, and a number
of bleeding  points  will  be seen  springing  from the lacerated papillae.   If the  condition of the
eruption,  together  with its  location, does not  settle  the diagnosis, the  history of  the case  will
generally furnish the necessary clue.  Its occurrence at certain seasons of the year, and its partial
or  complete  disappearance  at others, its   absolute  and  persistent dryness,  and  its  tendency to
relapse  after being apparently cured, are features of  the case which point  only to psoriasis.
     The  treatment   of  the disease  is simple  as far  as regards  the removal of  the  eruption.  It
is a much more difficult matter to prevent its relapse.  Psoriatic patients are not usually  in need
of tonics.   Some errors  in  digestion may be discovered and require to be corrected.   An  alkaline
plan  of treatment may be called for by the  association of the disease  with  a rheumatic or gouty
habit, and  should  be our  chief reliance  whenever  the  patches  are  hyperaemic   and  irritable.
The  acetate  or citrate  of potassium may  be given  in from  one  to  two gram  doses, in a  half
glass  of water,  a short  time before  meals.  In  chronic cases arsenic  is  an   old,  a  well-tested and
an  efficient remedy.   It may be given in  the  form of the liq.  potassii arsenitis,  the liq. ferri
chloridi, or the so-called Asiatic pills converted into a powder (Piffard).
              $  Acid,  arseniosi,.......2 parts.
                  Piper  nig.,........18    "
              M. Sacch. lactis,........80    "
    From one to  five  grains of this  powder may  be  taken  with  each  meal, being sprinkled
on  the  food  in place of salt, if  agreeable  to the patient.   The local  treatment  of  the disease
will  be  discussed in  connection  with another plate.
                                                20 
(
r~
*
4

t

ICHTHYOSIS  simplex. 
 
ICHTHYOSIS.
 Case.—A boy about  10 years  of age ;  a  patient from the  Children's Department of  the New
         York Dispensary, under the  care of  Dr. G. W. Robinson.   At  birth, and  for some time
         after, the skin was normal, according to the  mother's  statement, and  only within the
         last  two years  did  it attain  the degree of  roughness which  is shown in the illustration.
         No other member of his family had  ever  been affected in  like manner.  Cod liver oil
         was  used in  this case,  both internally  and  by inunction, and its constant  use kept the
         patient's skin in an  almost  normal  condition.   The  photograph of  this case was taken
         in the  sunlight, the  patient lying upon his back.   The polygonal scales, with   raised
         edges, may be  noted upon  the outer  surface of  the   thigh, and  characteristic parallel
         wrinkles are  seen encircling  the elbow.
     Ichthyosis is a chronic disease of the skin, characterized by dryness and roughness.  It varies in
 severity from cases in  which  the abnormal condition of  the  skin  is so  slight as  to  be perceptible
 to the  touch rather  than   to   the  eye,  to cases in  which  large polygonal  scales or blackened
 horny  projections  take  the  place of  the  normal  epidermis.   This  variable degree of  severity
 has  led  to  a   division  of  the  disease into  forms   to which  the names  xeroderma,  ichthyosis
 simplex, and icthyosis hystrix have been applied.  These terms are convenient for descriptive purposes
 but  it  should not be inferred that xeroderma and ichthyosis are distinct affections.   Nor  is ichthyosis
 hystrix  to be  understood  as meaning anything  but a peculiar  form of ordinary ichthyosis.
     In  the mildest cases of the disease, very frequently observed in infants  and young children,
 there is a deficiency  of  the sebaceous  secretion as well as of perspiration and  a harsh  or  mealy
 condition of  the  epidermis.    The skin is a trifle darker than normal,  and  suggests the idea of a
 lack of soap and water.  In  other  cases,  or in these same cases at a  later period,  the epidermis
 becomes hypertrophied, and  cracks in a characteristic manner.  Small lozenge-shaped or pentagonal
 scales result, which are slightly raised at  their margins.  In a  more severe or further advanced  condi-
 tion  these hypertrophied epidermic plates become darker in color, and assume a yellowish or greenish
 hue,  while the furrows between them appear like  a network of  white interlacing lines.  The plates,
 though  horny and sometimes  glistening, are never found lapping one over another, as might possibly
 be inferred from the  name of the disease or its common synonym of " fish-skin disease."  In  cases
of unusual severity one or more  patches of  skin may  become covered with  black papillary  projec-
tions, presenting  an appearance   which  is suggestive of the  bark  of a  tree.  These patches are
similar  to  those warty  growths which appear upon the  skin  in  elephantiasis.   When   these
 papillary projections,  which  are  always thickly  crowded together and  usually  flattened, become
elongated and pointed, the term ichthyosis hystrix  has been  applied  to  the condition, from the
                                               21 
                                           ICHTHYOSIS.

   fancied resemblance  of  the spines to  the  quills of  a porcupine.   Cases presenting this form
   of the disease have  been on  exhibition as "Porcupine  men."   "The man-fish of Tennessee" is a
   marked case of ichthyosis,  now traveling through the  country.   An excellent description of this
   medical curiosity by Dr. Yandell, may be found in the Louisville Medical  News (Nov. 30, 1878).
       The disease affects the greater  portion of the  skin.  The palms and  soles are  always free,
   and the flexures of the joints are devoid of scales, although abnormal dryness of the  skin is present.
   Around  the elbows  and knees  the epidermis  is broken  up  into  smaller  plates,  and numerous
   elliptical wrinkles or folds  of skin  occupy these parts.   The disease usually begins  in infancy and
   never  in adult life.   In the  majority of cases the mild or  xerodermatous  form tends  to remain
   through  life, while in some instances the affection increases in severity  from  year  to  year.  It is
   sometimes  hereditary.   Two or more children in  one family may be affected, while others  in the
   same  family show no  tendency whatever to the affection.  It is attended with little or  no discom-
   fort  beyond the consciousness,  on the part of the patient, that his skin is not as it  should  be,
   and it exerts no influence on the patient's general health.   Mild cases are often temporarily cured
   in hot weather, when the perspiratory glands are active, and even the most  aggravated cases are
   considerably better in  summer than  in winter.  In the latter season ich thy otic patients usually suffer
   considerably from  the cold,  and when  exposed to  high winds the face and hands are unusually
   prone  to become chapped and painful.
       The diagnosis of  the  disease  is  easy,  when its  extensive  distribution  over the body,  its
   absence of  redness and  itching,  and its chronicity are taken into account.   Pityriasis simplex is the
   only  affection  to which it  bears any  resemblance, but  in  pityriasis  the skin is not so generally
   affected,  there  is hyperaemia  beneath  the  scales,  and these are  constantly falling, or  are  easily
   rubbed off, while in ichthyosis there is  no hypersemia, and  the scales remain upon the skin.
       The treatment of ichthyosis, or at least  its cure, is not easy.  The  skin may be  made quite
   smooth by   appropriate applications,  but as soon as  these  are laid aside, the roughening and scal-
   ing tend quickly to  reappear.  Inunction  is  the  chief  remedy in the  treatment  of  mild  cases.
t  Cosmoline,   vaseline, benzoated  lard, almond,  linseed, and  cod-liver oils  are  useful, and  as each
   accomplishes the  object in  view, viz.,  the lubrication of the preternaturally  dry  skin,  it matters
   little  which  one is  selected.   Balmanno  Squire  thinks  that glycerine  diluted with  three  times
   its quantity of  water is more effectual  than oil in keeping the skin in good condition.
       In severe  cases,  where the epidermic plates are  thick and  horny,  inunction may  still  be
   advantageously  employed,  but  greater  dependence   must  now  be  placed  upon   soap  frictions
   and constant bathing.   Some  patches on the  extensor surface of  the  extremities may  be  so hard
   as  to  require blistering.  The  Turkish bath  renders excellent  service  in all cases of ichthyosis.
   The profuse sweating  is  useful, as  is  shown by  the improvement  which naturally  takes  place
   in  hot weathei*, and  the  shampooing  removes the  superfluous epidermis.  The body  should  be
   thoroughly  anointed  immediately after each   bath.   Jaborandi  has been  given internally in this
   affection,  and  has  produced a  rapid  improvement in the  condition  of  the  skin,   but  there  are
   objections to the use, and the Turkish  bath is to be  preferred.
                                                 22
fir
K 
ai*, ...«
V
Vk1
FIBROMA PENDULUM. 
 
FIBROMA.
Case.—M. K., set. 48, Ireland.   Patient of Dr. James R. Wood.   The  pendulous growth upon the
        right side of this patient's head, and a number of small and soft tumors on various parts of
        the body, were congenital.  During childhood, and even until thirty years of age, the tumor
        of the scalp steadily increased in size, from year to year.   Since coming to this country, sixteen
        years ago, patient thinks there has been no permanent change. At times, however, the growth
        feels heavier and warmer than at others, and there is an increase in size, due to a temporary
        afflux of blood.  Patient suffers more inconvenience from the weight of the tumor in summer
        than in winter.  When  exposed to a  low temperature in winter, the lax tissue becomes icy
        cold, but has never been at all benumbed.  About five years ago, while at work,  a shovelful
        of gravel was accidentally thrown against the right side of his head,  on account  of which
        accident he entered Bellevue Hospital, April, 1874.   The growth was injured, several slight
        wounds continued to discharge, and an attack of erysipelas supervened.  Since  then he has
        been employed in hospital and has suffered again from erysipelas, to  which affection he seems
        unusually prone.  The small tumors found elsewhere on the body have  undergone no change
        since childhood.  Upon examination, the tumor of the  scalp is found  to be  soft, and  com-
        posed of a flaccid and pendulous fold of skin and subjacent  tissue.  It has a broad  base line
        extending  from  the vertex posteriorly around to the forehead anteriorly, and occupying the
        line of  the usual parting of  the hair.  From the side of the head where it naturally hangs,
        it can be raised and carried over the top of  the head.  By grasping either extremity of the
        base of  the tumor with the thumb and fingers, the two layers of  scalp can be felt sliding one
        over the other and forming a fold about one and a half inches thick.   The free edge of the
        fold which hangs down over the right ear, and as low as the angle  of the  jaw, is somewhat
        thicker than the base, and is notched as though resulting from the confluence of four or five
        pendulous  tumors  arranged side by side.  On  the outer surface of the growth are several
        vertical linear depressions terminating  in these notches.  The  ear, though pressed by the
        tumor, is of normal shape, but above the right zygoma  there is  a  marked depression.   The
        bones of the temporal fossa are extremely thin, and yield on pressure.  The scalp involved
        in  this pendulous fold  is thin, and of a dull reddish hue.  On  the under side of the tumor,
        the scalp is nearly as white as  it is on the normal side of the head.  There is no pigmentation
        of the growth, although the patient's complexion is quite dark.  Its sensibility is unimpaired,
        a touch being felt on the pendulous scalp as readily as on the other side of the head.  The
        hair growrs  sparsely,  but is as soft as on the normal scalp.  The follicles are apparently
        normal in number and structure, but  the stretching of the scalp, produced  by the  excessive
        growth  of  connective tissue,  has separated them, and  they  average a quarter  of an  inch
        apart.  The hairs can be pulled out more readily than elsewhere.   There are a half dozen
        small tumors on the face and  head, varying from a pea to a walnut in size, and not diffen'ug
                                             23 
FIBROMA.
         in any essential regard from the large growth.   On the right hip and  left leg are  two soft
         sessile fibro-areolar tumors nearly as large as a lien's egg.   Scattered over the body and ex-
         tremities are nearly one hundred of the same, varying in size from a pea to a walnut, some
         appearing like prominent pouches of skin, others  more deeply seated,  merely producing
         hemispherical elevations of the skin.

     In applying a name to the pendulous tumor represented in the illustration, I might  refer to the
 literature of cutaneous tumors and  choose from a long list of names which have been applied to similar
 growths.  Molluscum pendulum, Molluscum fibrosum, Fibroma  molluscum, Pachydermatocele,  Cutis
 pendula,  Dermatolysis, Elephantiasis Arabum,  and Elephantiasis mollusca, are  terms  employed  by
 various writers.  I prefer the term Fibroma pendulum.
     Fibroma consists in a hyperplasia or new growth of connective tissue, and occurs in various organs
 of the body.  The growth may be single or multiple, firm or lax in structure, and is always benignant
 in character.  Occurring in the skin, it  involves the  corium and the  reticulated subjacent tissue, and
 produces circumscribed tumors of variable  form and dimensions, usually soft and flaccid, and either
 small  and sessile (fibroma  simplex), larger and  pedunculated (fibroma pyriformis), or  plicated, i. a,
 hanging in one or more folds from a  broad base  (fibroma pendulum seu plicatum).   It is sometimes
 congenital, increasing gradually in size up to a certain variable limit, and sometimes presents  itself as
 an acquired growth.  In many instances it seems to be hereditary and  affects two or more members of
 a family.  In its most  common form, fibroma occurs as a small, soft, pouch-like  tumor, or polypus of
 the  skin, connected by a pedicle and usually seated on the neck, breast, or  back (Acrochordon).
 The trunk  and extremities may be studded with a  countless number of these  small, soft tumors,
 varying in size from a pea to a walnut and producing a most striking appearance,  although exerting no
 influence upon the health and general condition of the patient.
     Occasionally a single fibroma will become large, pendulous and pedunculated.  One of my  series
 of Photographs of Skin Diseases (No. 18) represents a woman with a  pyriform  tumor about the size
 of her fist hanging by a long slender pedicle from between the left breast and the axillary region.  In
 most of these cases the skin is nearly normal in structure and appearance, being merely stretched by
 the increased growth of fibrous and areolar tissue beneath.  Finally we come to a series of rare cases in
 which the fibrous growth hangs in one or more folds as is seen in the illustration.   This growth differs
 in no essential regard from  the pedunculated tumor, although the corium is apt to be specially involved.
 The sebaceous ducts are sometimes distended and white cheesy threads can be extruded  by pressure.
 This pendulous form, whether occurring  in folds or as  a  large pedunculate tumor, generally co-exists
 with a number of  small sessile fibromata, and is identical in nature though differing  in shape and
 appearance.  Under the name of Dermatolysis it has been described as  an hypertrophy of the skin, an
 affection distinct from fibroma.  The skin, indeed, may be thickened in  some cases and appear  coarse in
 texture, but in others it is atrophied from tension and appears smootli and fine.
    The treatment of fibroma is not imperative, as the affection occasions no discomfort.  When the
 tumors are small they may be let alone, when large and  pedunculated, they may be removed by the
knife, galvano-caustic loop, or elastic ligature.  In the pendulous form,  the  liability to erysipelas must
be considered before attempting an  operation, but such growths have been successfully removed.
                                              24 
/
VARICELLA. 
 
VARICELLA.
    Varicella, or chicken-pox, is a well-known exanthematous  affection of infancy and  childhood.
The  name  suggests a  relationship to variola, or small-pox, and there exists indeed a  resemblance
between  the  two.   Until the  inoculation of small-pox prevailed in Europe, varicella was regarded as
a mild form of  this disease, and its history is intimately associated with that of variola.
    At the beginning of  the eighteenth century, Lady Wortley Montagu, the wife of the British
Ambassador at  Constantinople, became acquainted with the practice of inoculating small-pox  in order
to lessen the severity of the disease, and having subjected her own children to the operation, advocated
the practice with such earnestness that it soon prevailed not  only  in England but throughout Europe.
It was at this time that the attention of physicians  became directed to the study of varicella, and the
question  of its  specific nature assumed  a vital  importance  in  determining the value of inoculation.
This practice, so  startling an  innovation upon established custom, naturally met with opposition.   Its
opponents,  observing that patients after having contracted the disease by inoculation were subsequently
attacked  with what they considered to be small-pox, claimed that  inoculation possessed no prophylactic
value.  Its supporters, on the  other hand, claimed that the pustular and vesicular eruptions sometimes
occurring after  small-pox were not cases of true variola, but distinct affections, to which  they gave the
names varioloid and varicella.  After Jcnner's discovery of vaccination the controversy respecting the
identity of variola and varicella raged more fiercely than ever.  At the present day there are none  in
the medical profession who claim that varioloid, or the modified form of small-pox which sometimes
occurs after vaccination, is distinct from variola.  As to varicella, however, the majority of physicians,
who are able  to pass judgment on the question, are agreed that it  is a distinct specific disease.
     Varicella is  pre-eminently a disease of childhood and is never met  with in adult  life.  It is
rarely  if ever seen  twice upon the same individual, although an attack of mild small-pox or varioloid
may either precede or follow the eruption.   The serum contained in the vesicles is not readily inocul
able, and the eruption has no prophylactic or modifying influence over future attacks of small-pox.
     Varicella occurs sporadically and in epidemic form.  In large cities cases are always to be found,
and  epidemics  of this disease occur with far greater frequency  than do those of small-pox.  Some
claim that  the  disease  is not  contagious  and assert that  its occurrence  among several children  of a
family is merely the result of epidemic influence.  It certainly  does not appear  to be  as contagious
as the other exanthemata.  I have known three out of five young children  to be affected in one
household  while  the  other  two  escaped.    The  period  of  inoculation  is supposed to be longer
than that of small-pox or measles.  During this period the child may evince some signs  of languor,
                                               23 
                                        VARICELLA.

but generally there  is only  a slight fever of  a few hours' duration preceding the  eruption, and
very frequently the eruption itself is the  first  indication that the  child is not in perfect health.
The eruption at the outset presents small red macules  or slightly-elevated  papules upon the body,
and shortly after upon the face and extremities.   In a few hours a minute vesicle is noted in the center
of each red macule, its shape varying in different cases, being either conical or hemispherical,  and
usually from a pin-head to a small pea in  size.   The vesicles are disseminated and vary in number from
a few score to several hundred.  They are quite superficial, covered by a tense layer of epidermis, and
surrounded usually by a narrow zone of inflammatory redness.   The contained fluid is clear,  colorless, or
slightly tinged with yellow, and of an alkaline reaction, differing in this regard from the acid serum of
sudamina.   The vesicles after the first day may appear cloudy, but they never become purulent.   The
fever subsides on the third or  fourth day, unless  kept up, as is often the case, by successive crbps of
vesicles.   These may become flaccid through absorption of their contents when one or two  days old, or
they may burst from excessive distension or be scratched by the patient, in which case they dry in the
centre and  form yellowish or brownish  thin horny crusts.  At this  stage new papular lesions  may
appear, and aborting in their  course, fail to  become vesicular.   Some of the vesicles enlarge by  per-
ipheral extension and form bullae, which  are umbilicated when  the centre of  the vesicle has begun to
dry.   The crusts fail in a few days or are scratched  off by the patient in his endeavors  to alleviate
the  pruritus or burning of the skin, which is always present in greater or less degree.  Beneath is left
a small, circular and slightly-depressed patch  of reddened skin.   Scars sometimes remain through  life,
presenting a characteristic form and a peculiar whiteness and softness.
     The diagnosis of varicella is easily made if the eruption is seen at the outset.  The red papules
noticed on the child's body or neck on the first day are suggestive of mosquito bites and are frequently
mistaken for them.  The development of vesicles, however, shows that the eruption is either  chicken-
pox or the vesicular stage of mild small-pox.   If an epidemic of variola is in progress the diagnosis of
the case becomes a matter of considerable importance, and  an  error may prove  unfortunate  for  both
patient and physician.  Although variola is as a rule a far  more severe  disease than varicella, it  may
run  an extremely mild course, and  does  so frequently when  modified by a previous vaccination.  In
such a case the differential diagnosis is not always easy, but the chief points  upon which it may be
established will be seen by reference to the following  comparative table.

                  Varicella.                               Mild Vaeiola or Varioloid.
  Is not inoculable as a rule.                         Is readily inoculable.
  Attacks children recently vaccinated.                Rarely occurs until years after vaccination.
  Is unaffected by previous vaccination.               Is modified, if not prevented by vaccination.
  Vaccination will succeed after varicella.             Vaccination will not succeed after  small-pox.
  No prodromal fever of any consequence.            Initial fever lasting two or three days.
  Fever begins with the outbreak of the eruption.      Fever abates when the eruption appears.
  Eruption  spreads  rapidly over  the  body  and      Eruption spreads slowly from face to extremi
Vesiculation takes place on the first day.             ties and the vesicles develop gradually.
  Vesicles are superficial,  and have no hard base.      Papules are deep-seated and feel "shotty."
  Occurs always in children.                         Occurs chiefly in adults.
    The treatment of Varicella consists  simply in judicious nursing.
                                               26 
*s
ZOSTER  PECTORALIS.
ZOSTER   LUMBALIS. 
 
ZOSTER.
Case I.—Johnny G., set. 3K.  A patient from the Children's  Department of the N. Y. Dispensary,
         kindly placed under my observation by Dr. G. W. Robinson.   On September 30th, according
         to the mother's account, the child was as well as ever and  had been in usual health of late.
         October 1st.  Dull and uneasy in the afternoon, and at night feverish.  October 2d.  A patch
         of fine vesicles was noticed  on the left side  of the dorsal vertebrae, with patches of hyper-
         emia on the side of thorax.  During this night  and the succeeding one, the child was very
         restless, and complained during the day of the eruption hurting him, although he was able to
         keep playing about the house.   When seen by me on  October 4th, the vesicles  on the side
         had  coalesced and  formed large  tense  bullse of  the size of pigeon's eggs.   Bromide  of
         potassium was  ordered.  On the 5th, after  suffering  much  and sleeping little during the
         previous  night, the bullse were found to be  less  tense  than on  the preceding day.  The
         vesicles of  the patch near spine, which  first appeared, were now flattened  and  contained  a
         cloudy or sero-purulent fluid.   It was at this  stage of the  eruption  that  the photograph was
         taken.  The mother was instructed to dust the eruption freely with starch powder, and small,
         frequently-repeated  doses of the tincture of mezereum was given.  October 7th.  Has slept
         better for two nights, and to-day is quite good-natured.  Near spine the eruption consists of
         small, confluent, purulent vesicles, the whitish patches  tending to become dark in the  center.
         The eruption on breast is rapidly drying.  There arc two thin, blackish scabs where  the bullae
         were, one of them being depressed, and suggesting the  possibility  of its leaving a scar.
Case II.—P.  T., set. 24.   The eruption on right side was first noticed upon arising  in the  morning,
         the patient having been somewhat feverish, and perspired  freely during the  preceding night.
         The eruption, photographed on  the third day, was beginning to fade, and  a few groups of
         small vesicsle had coalesced and flattened.  Patient was pale, and had a tired, anxious  expres-
         sion, although claiming to be as strong and well as usual.   There was a constant burning in
         the affected skin, and tenderness on pressure  on the right side of spine.

     The name Herpes has been used by dermatological writers,  as a generic term  to  include all erup-
tions in which groups of vesicles are present.   This use of the term associates Zoster with Herpes  of
the lips and  prepuce, and with  other rarer affections, which differ widely in their  clinical features.
It is advisable therefore,  to class Zoster as an  affection sui generis.  The  characteristics  which serve
to distinguish Zoster from Herpes may be concisely stated as follows.   Zoster is almost invariably
unilateral, and rarely occurs more than  once in  a lifetime.  It  presents large isolated patches of
tense vesicles, seated on a  highly-congested  base, and  usually following  the course of  a cutaneous
nerve for a  considerable distance.  It is associated with neuralgic pain and a lancinating sensation in
the affected  skin.  It usually runs a regular course of from two to  four weeks and occasionally leaves
                                               27 
                                            ZOSTER.
 cicatrices.  Herpes is usually bilateral if at all extensive, and may be tolerably symmetrical.   It occurs
 many times in the same patient.  There is no tendency to distribution  along the course of a single
 nerve for any distance.   The  pain  is  not of a neuralgic character.   There is a great variation in the
 severity and course of the affection and no scars are left.
     Zoster may be defined therefore, as a vesicular eruption, remarkable  for its unilateral occurrence
 and its limitation to the cutaneous distribution of one or  more nerves.  Though  not a very common
 affection it is one easily recognized, and is generally known among the laity by the  name of " shingles.'
 The eruption usually  occurs upon one side of the chest or waist, forming  a  portion  of a girdle, from
 which circumstance is derived  the name.  It may also occur upon  the head or  limbs, following in
 every instance the course of a nerve.   It is only in extremely rare cases that the eruption is  bilateral.
 The sexes are about equally  liable to  attacks and the eruption occurs at almost any age.  In children
 it is annoying while it lasts, but no neuralgia is left behind, as is often the case in  the aged.
     The eruption usually begins after a short  febrile  attack, appearing in the form  of one or more
 patches of  intense hypersemia.   A pricking or tingling sensation sometimes calls the patient's attention
 to the  part  before the vesicles have appeared, but usually the  patch when  first  seen  is dotted with
 pearly vesicles which rapidly attain the size of hemp-seed.   Frequently the vesicles vary in  size upon
 different patches in the same case, the least developed patch bearing pin-head sized  vesicles, while those
 upon another patch have reached the size of small peas and are distended by a  clear, yellowish serum.
 The vesicles usually reach their maximum development in four days,  remain tense for a day or more,
 and then gradually flatten.   The inflammatory base changes in color  from a  bright scarlet  to a dull
 crimson, and the amber-hued contents of the vesicles become cloudy and even pustular.  In the second
 week, blackish crusts or  scabs form,  which  gradually fall during  the third or fourth week.  The
 eruption may fail to reach its full development and begin dry on the second or third day.
     There are, strictly speaking, no varieties of Zoster, the same characteristics appearing wherever the
 eruption majr be situated.  Regional  adjectives  are  conveniently used,  such as Z. capitis, Z. faciei,
 Z. nucha?, Z.  brachialis, Z.pectoralis, Z. dbdominalis,  Z. lumbalis, and  Z. femoralis.  The term
 Zoster bullosa might be  applied to one of the cases illustrated, in which we  find an  accidental eleva-
 tion of the epidermis by a rapid exudation of serum and a resulting confluence of the vesicles.
     The cause of Zoster is to be found in some abnormal condition of the nervous system in general,
 or in some injury or disease of the nerve supplying the affected portion of skin.  The occurrence of
 the disease is usually a surprise and no conditions exist which would lead  one to anticipate an attack.
 The diagnosis  is generally an easy matter, although when  imperfectly developed,  as  it may be upon
 the scalp or extremities, its recognition may be difficult.
     Zoster will always run its course  without special treatment.  It is useless to attempt to abort the
 vesicles with nitrate of silver or  blisters.   The part should be protected against the friction of the cloth-
 ing by a soft linen cloth, and starch powder may be dusted  on to  absorb the fluid when the vesicles
 rupture.  When severe pain is present, fifty centigrams of sulphate of morphia may be added to fifty
grams of elastic collodion and painted over the patches.  Internally,  the phosphide of zinc, two centi-
grams every three hours, has been praised.  As  the course of the  disease is variable, it is difficult
to judge of the effect of an internal remedy except from observation of numerous cases.
                                               28 
mr
~<&i
>***--
1:. ,  r'.-*-.






































■ ■ ■
t
ECZEMA UNIVERSALE. 
 
ECZEMA.
Case.—S. J. W., set. 57.  The eruption in this patient had begun five years before, on  the abdomen,
         had gradually spread, and for a  year or more had been universal.  The skin was everywhere
         reddened, more or less thickened,  and where  not covered with large  adherent flakes of
         exfoliating epidermis, as on the arms and  thighs, it presented a fine branny desquamation
         which may be seen  in  the  illustration  upon the patient's back.  Removal of the  clothing
         always occasioned a shower of  fine scales.  Upon the inner  aspect  of the  thighs, in the
         axillary region, and  around  the  neck were  several  aggravated patches which now and then
         became moist.  These patches were badly excoriated, and the itching of the whole body was
         almost intolerable.  The case was a type of  no single form of eczema, but the  erythematous,
         exuding  and squamous  forms of the affection were all present  at one time upon different
         portions of  the body.   The patient was first ordered a  gram of acetate of  potassium, three
         times a day, while diachylon ointment was applied to the exuding patches.   He was then put
         upon the linseed-oil treatment, recommended by Sherwell, a pint being well rubbed  into the
         skin morning and night, and as much of the large East  Indian seed given internally as the
         patient could conveniently chew and swallow.  Under this treatment the  itching abated, and
         the skin grew paler and  smoother.  After a few weeks, however, he returned to his home in
         a neighboring State, and here my notes of the case cease.

    Eczema is the proteus  of cutaneous affections.  It is  capable  of  assuming such  a variety of
appearances that there is scarcely an affection of the skin to which it may not bear  a  resemblance, and
with which it may not be confounded.  It attacks every part of the  body, and presents peculiarities
dependent upon  its location, as  well as upon  the age, occupation, habits and  general condition
of the patient.
    The term eczema (from ek and Ceu),  meaning " to boil out," or " effervesce,"  implies a catarrhal
condition of the  skin.  A moist surface, or at  least a tendency of the affected skin to become moist
through exudation of a gummy, albuminous serum,  is the chief characteristic of  the disease.  It has
been claimed that a  moist surface is always present at some  time in the course of the disease, but
clinical experience shows that cases of erythematous and papular eczema may remain dry from begin-
ning to end.   Even  these cases, however, evince a  tendency to  develop a moist surface upon slight
external  irritation, and moist patches are  not infrequently found upon an extensive eruption which
elsewhere is perfectly dry.  Frequently patients will state  that their eczema,  now in its decline, has
always been dry, and the thickened patch of skin may appear to be due to  increased cellular growth
or some  cause other than infiltration of  the skin with  a serous fluid.   If  the scaling epidermis be
rubbed briskly with  soap and a  piece of  rough  cloth it will be readily removed, and the catarrhal,
and hence the eczematous nature  of the patch, will be revealed by the minute  pearly beads of serum,
                                              29 
ECZEMA.
which ooze out on the surface of the partially denuded corium.   It is this  tendency to exudation upon
the surface of the skin which distinguishes a patch of eczema from simple  inflammation or dermatitis.
    The exudation in  eczema  varies in amount, being so slight in some cases as not to appear upon
the surface, while in others it is poured out so abundantly that the whole epidermis is washed away
and a smooth, red, moist patch is exposed.  It varies also in character.   In some cases  the  exudation
is plastic, and being retained in the cutaneous tissue produces papulation on the surface, and infiltration
and hardening of the subcutaneous cellular tissue,  while in other cases it readily permeates the cells of
the rete, and elevates the horny layer in the form of  vesicles.  Upon  the surface of the skin the exu-
dation feels sticky, and' cloths or bandages soaked by  it stiffen upon drying, and appear stained.   In
strumous and ill-conditioned subjects, the exudation assumes a purulent character.  This variation in
the character of the exudation results in a variety of lesions, no  one  of  which has any claim to  be
regarded as the special lesion of eczema.  The disease is not merely  a vesicular affection,  as it was
classed  by the earlier dermatologists, but  is frequently papular and  pustular as well, and in many
instances there is no vesiculation from beginning to end.   When the surface exudation is profuse the
Berum dries and forms crusts.  The crust of typical eczema is thin and dark, cracking, and allowing the
exudation to  ooze from the cracks.  Often it is composed partly of dried blood, the result of scratch-
ing.  When the exudation is purulent the crusts are lighter in color and thicker, increasing in bulk  by
augmentation from beneath.  The exudation  is sometimes of a thick,  honey-like character,  producing
a bright yellow crust.
    The thickening of the skin in eczema is most marked in chronic cases.  It is partly due  to cellular
infiltration, and partly to the exudation of plastic  serum into the  subjacent areolar tissue.  In  acute
cases and  in parts of the  body liable to passive  congestion, e. g., the  legs, a temporary oedema often
increases the thickness of the integument.
    The itching of a patch of eczema is a feature which is rarely absent, but, on the contrary, usually
present in  a  marked degree.  In  adults it  is apt to be  most troublesome in the erythematous and
papular forms of the disease.  In children  it is usually severe,  although, in  the pustular form which
occurs so often in those  of a strumous diathesis, the symptom is always  mild.
    The pathological process which takes place in the affected skin consists  mainly in  congestion and
cell-proliferation.  In some cases the congestion  is the  main  feature, and  the affection is  only to be
distinguished  from erythema  by the characteristic  pruritus  and desquamation.    In  most  cases,
however, there are marked  cellular changes, as has been shown by microscopical examination.   The
disease in its mildest form may begin as a  simple hyperaemia.  The skin  becomes  slightly  thickened,
itches more or less, and finally desquamates.  Usually, however, the initial hyperaemia  is followed by
the development of papules, vesicles or pustules.   Pruritus and exudation become prominent features,
and eventually the affected skin  desquamates, as in the former instance.   The disease, then, always
begins in hyperaemia and ends in desquamation.   It is characterized by a tendency  to moisture of the
surface, which may result in crusting, by infiltration of the deeper tissues which produces thickening,
by the development usually of papules, vesicles or pustules, and by slight or severe itching.
    The differential diagnosis and  the treatment of  eczema will   be  given in connection  with
other  plates.
                                               30 
LEUCODERMA.
> 
 
LEUCODERMA.
 Case.—Mrs. B., set. 68, Scotch, widow.  A patient of Dr. E. B. Bronson.  The affection began two
         years ago, in the form of white spots on the hands.   Has always been healthy, and is in good
         condition now.  The skin of the face, neck, and arms is, for the most part, of a decidedly
         darker hue than normal, looking as though tanned from out-door exposure.  It is marked by
         irregular, sharply-defined patches which, appear bleached, and are most noticeable on the
         nape of the neck, backs of  hands, along the frontal border of the hair, on the lower eyelids,
         beneath the ears, and upon  the arms.  Patient thinks a brother was similarly affected.

     Leucoderma,  or Vitiligo, as the affection is sometimes termed, is an  acquired loss of pigment,
 occurring in spots or patches on various portions of the body.  It is a rare affection, occurring gener-
 ally in the middle  period of life, and often  in persons who are seemingly in good health.  The spots
 of leucoderma, unlike the white piebald skin of  partial albinismus, tend  to a gradual increase in size,
 although  in many cases they may remain  stationary for years, and sometimes there is noted a spon-
 taneous return of  pigmentation.   The spots are  always round at the beginning, become oval as they
 increase  in  size, until, coalescing, they form large and irregular patches, of a  milk-white  color, or
 slightly roseate where there  is  an active circulation of  blood  in the part.  The  skin adjacent  to the
 leucodermatous patch is usually somewhat darker than normal, thereby  rendering the affection more
 striking in  appearance  by contrast.  This  increased  pigmentation is most marked in a narrow zone,
 just beyond the advancing edge of the white patch,  which it sharply defines.  It shades gradually off
 as it recedes from the patch, and at the distance of an inch or less the skin presents its normal hue.
     The affection consists in an abnormal distribution of pigment, that which is taken from the affected
 patch being apparently deposited  in the immediate  vicinity.  At the outset  there are usually a number
 of small, isolated  spots, which  naturally become  fewer as they increase in  size and coalesce.  The
 favorite starting-point of leucoderma seems  to be  the  face, neck  and hands.   From these  parts the
 affection  may  spread indefinitely, and eventually affect  the greater portion of the body.   Hebra
 mentions  a case of long standing, in which the  white  patches had coalesced  and covered nearly the
 whole body, the normal pigment remaining only in small broken patches upon  the backs of the hands
 and feet, the elbows and the face.
     Since the affection is simply due to an absence of pigment in the cells of  the rete, it follows that
the patch is neither elevated nor sunken, neither thicker nor thinner, neither harder nor softer than the
normal skin.  In  some  cases the leucodermatous patches  appear  to be  unusually  susceptible  to the
action of the sun  and  other external irritants.  There is  never any desquamation,  and  to the touch
alone, this, unlike the majority of skin affections,  imparts no  information.  The patient suffers  no in-
                                              31 
                                      LEUCODERMA.
convenience, or at least experiences none of the subjective sensations of cutaneous disease, such as pain,
hypersesthesia, anaesthesia or pruritus, and the  affection has no influence upon his general condition.
When hairs exist  upon  the patches  their growth  is unimpaired, although  they  are usually lighter
in color, if not quite devoid of pigment.  The affection sometimes affects the scalp.
    It is sometimes difficult, in glancing at a case of leucoderma, when the loss of pigment is extensive,
to say at once which is the normal skin—the dark or the light patches.  A fact to bear in mind is this.
The advancing margin of a  leucodermatous patch is always rounded  or convex, and the edge of  the
normal skin is of necessity concave.  Accordingly, if in a given case where doubt at first glance might
exist, it is noticed that the whiter skin has a convex  or  scolloped margin, it is  evident that we have
either a patch of leucoderma or partial albinismus, i. e., an affection characterized by loss of pigment;
while, on  the other hand, should the whiter portions of skin be found to have  a concave border, or to
be indented, as  it were, by  the dark patches, it is  evident, in that case, that the white parts are  the
normal skin, and that we have a case of  chloasma or pigmentary nsevus to deal with ; in other words,
an affection characterized not by loss, but by increase  of pigment.   At the outset  the  round spots of
leucoderma  can be  readily recognized as  such, but when the skin is affected to  such  a degree that
neither the normal nor the affected skin is greatly in excess of the other,'the diagnosis may be difficult.
It is  simplified, however, when the peculiarity of  the  development of  the affection, viz.: its always
presenting a convex or scolloped margin, is borne in mind.  From partial albinismus, which in the
negro race it very much  resembles, it can be distinguished by the fact of its not being congenital, but
developing in adult life, and from the  additional feature  of its not being stationary, but usually
tending to indefinite  extension.   In leprosy, circular white patches are met with which  resemble
leucoderma.  They do not result simply from  absence of pigment, however, and can be distinguished
by the atrophic changes and loss of sensibility.
    Of the treatment  of leucoderma not much that  is encouraging can  be  said.   By some it is pro-
nounced incurable, and there is a difference of opinion among writers as to the spontaneous return of
pigment  to  leucodermatous patches.  Arsenic, iron, phosphorus, cod-liver  oil, and other  remedies
likely to  exert  an  influence upon the nutrition of the  skin may be  tried, with  the conviction that
they will act as well, if not  better, than anything else that  might be given internally.   Locally,  an
attempt may be made to lessen the pigmentation surrounding the white patches by painting  the  dark
border with  strong acetic acid, or a one per cent, solution of corrosive sublimate, or by blistering it
lightly.  This will not tend to cure the actual disease,  but may lessen the  unpleasant contrast existing
between the white  patch and the surrounding skin, and thus render the affection less  striking in
appearance.   The same result might possibly be attained by applying mustard or other irritants to the
white patches, in the faint hope  of inducing inflammation,  and a subsequent pigmentation, such as
is so often seen after eczema and other chronic skin affections.  When the patches are extensive the
following lotion may be tried :

                  #   Zinci Acetatis,  .     .    .     .     .     .6 grams (3 iss)
                      Glycerinse,......2   "   (f3ss)
                      Spiritus Limonis,.....92   "   (f § iii)
                 M
                                               32 
CHROMOPHYTOSIS 
 
CHROMOPHYTOSIS.
 Case.—D. M., set. 25.  A patient at the New York Dispensary.   The fungous growth in this case
         was extremely luxuriant, and though not covering the skin as extensively as it frequently
         does, the spots were more elevated and more striking in appearance than in any case which I
         have ever seen.   To the left side of the trunk the tincture of iodine was applied every second
         day.   This, while producing  the  characteristic yellowish-brown staining of the normal skin,
         gave to the affected patches a very dark brown color, and rendered the contrast far more
         striking than before.  To the right side  was applied a twenty-five per cent, solution of car-
         bolic acid.  This produced no immediate change, but being rubbed in thoroughly three times
         a day, removed the disease more rapidly than did the iodine.  The patient  was ordered to
         have his back rubbed daily with ordinary kerosene, which proved an efficient remedy.

     Chromophytosis is one of the three important affections of the skin which owe their origin to the
 growth of  a vegetable parasite or fungus.  The other two are Trichophytosis (or common ringworm)
 and Favus.  It is contagious, though not in a marked degree, and patients seldom have any idea of the
 manner in which they contracted the affection.   The trunk and upper extremities are its favorite and
 almost  its  sole seat.  It sometimes extends upon the neck, and even upon the cheeks, and may be
 found, in rare instances, upon the thighs.  It usually commences upon the upper portion of  the breast,
 and in many cases is quite symmetrical in its development.   Although, at the beginning, the eruption
 may be one-sided in respect to situation, in nearly all cases  of long standing, where the whole trunk
 is more or less affected, the symmetrical distribution of the eruption is a marked feature.
     The affection begins  in the form of a few pin-head-sized, yellowish, scaly spots, which gradually
 increase in size  and number.  When  first noticed  by the patient, there may be a score or more of
 isolated, brownish-yellow, pea-sized circular patches, showing very distinctly upon  the  background of
 normal skin, or there  may be a small  irregular patch of  the  same color, variable in size, with  a few
 isolated circular spots scattered near its margin.   As the eruption increases in  extent, it spreads over
 the upper portion of the  chest and follows down the median line as a  rule towards the pubis.  The
 back likewise becomes affected, though  not  generally in  so  marked a  degree  as the breast.
 The  sternal region, though  often the  first to  present the  eruption, frequently becomes free in
 an advanced  stage.  The  groins are usually exempt, and the axillae and sides of  the chest are not as
 thickly covered as the breast and  back.
    The circular discs are usually slightly elevated, but the diffused  patches are less so, and sometimes
can with difficulty be distinguished from  normal skin.  The  margin may be quite abrupt, or it may
shade off so imperceptibly that it  is difficult to say exactly where the affected skin begins.
         3                                    33 
CHROMOPHYTOSIS.
    Itching is present in a moderate degree in some cases, but generally there is nothing to attract the
patient's attention to the  trouble, and in patients who bathe little, the affection may exist for a long
time,  and  then be  accidentally  discovered.   Though occurring often among those who  pay due
attention to personal cleanliness, and hence met with in private practice, it is far more common in that
class of persons who perspire freely and bathe seldom.   In Dispensary practice patients rarely apply
for treatment, unless a guilty conscience leads them to mistake the eruption for a manifestation of
syphilis; and yet, where patients with  syphilis and other affections are stripped for  examination,
chromophytosis in greater or less extent is very frequently observed.
    The disease  may persist  for the  greater portion of a lifetime if nothing be done to remove it.
In some cases a small patch or number of patches show no tendency whatever to spread, while" in other
cases  portions of  the  body become quickly covered, and  the eruption shows a marked tendency to
return  after  treatment.  The  disease is  only  met  with in adults,  and occurs  with  nearly  equal
frequency in  either sex.  It is common in early adult life, and rarely if ever seen upon the aged.
    The affection is generally recognized with ease, by the color, the peculiar configuration of the
patches, and the scaling of the epidermis when  scratched lightly with the finger nail.  In cases where
the patient has  bathed and used soap freely, the disease may be extensive, and yet be only recognized
by the yellowish  or  tawny hue  which it imparts to the skin.  In case of  doubt, the  microscope will
settle the question at once.
    As the disease  is a  strictly local  one, local measures will  effect a cure.  Care  must be taken,
however, that the treatment is faithfully  carried out by the patient, else the disease will only be appar-
ently  cured, and in a short time will reappear.   Two points should always be borne in mind.   Firstly,
that the affection is  confined to the epidermis,  and whatever means  will  remove  the outer  layers of
epidermic  cells will necessarily remove  the disease.   Secondly, that  it is useless  to cure nine-tenths
of the  dibease, for if a single spot be  left,  or even if the same underclothing be worn again, without
being thoroughly cleaned, the eruption is almost certain to return.
    Soap will cure a great many cases, if the skin be scrubbed, rather  than rubbed with it, or if it be
rubbed into the affected patches  daily, and allowed  to remain for a week.  A bath taken  then will
remove considerable dead  epidermis, and with it the spores and mycelium of the parasite.   Common
soft soap may be  used  when the  sapo  viridis, or green soap, is  not easily obtained.  The tincture of
iodine, painted  over  the patches, and daubed on the small circular spots, will cause the  epidermis to
peel off, and  thus remove the disease.   This remedy, even diluted, changes the color of the affected
patches to a much darker brown than the normal skin, and  hence is of advantage in revealing the
presence of minute  spots which might  readily be overlooked.  An ointment of chrysophanic acid
quickly cures the affection, but is objectionable on account of its tendency to inflame the skin, and to
stain the clothing.  When the  patient is apparently free  from  the eruption, it  is  well to  apply for
several  weeks a  lotion of carbolic acid of five pjr cent, strength, or the following more  agreeable
preparation:

                  $.  Sodii Hyposulphit.,      ....     8grams(3ii)
                      Aquae Rosse,......192   "   (f 5 vi)
                  M.
84 
^4i,
FAVUS  capitis

* '.?

"■air
*fc>V<
FAVUS  CORPORIS 
 
FAVUS.
Case I.—Favus capitis.  The patient was a little girl in the Children's Dept. at the N. Y. Dispensary,
         and under care of Dr. E.  P. Williams.   The case was of long standing, and the crusts were
         thick, light in color and friable.  The child was brought only once to the Dispensary, and
         two years later, when I accidentally ran across the case again, I found that the mother had
         spent the  meantime  in  taking the  child from one  public charity to another, without ever
         following the advice given at any one.
Case II.—Favus  corporis.   From the  collection  of  O. G. Mason, Photographic Dept. of Bellevue
         Llospital.  The illustration shows the characteristic  bright  yellow, cup-shaped crusts which
         are seen in an early stage of the affection.

     Favus is a parasitic disease occurring upon the scalp or on  non-hairy parts, and is characterized
by the development of sulphur-colored cup-shaped crusts.   These are not met with at all stages of the
disease, although they are  generally present.  At the beginning  there may be  simply  a circular
furfuraceous  patch, which on the body cannot be  distinguished from trichophytosis or ringworm.
Soon, however, bright  yellow specks are seen, and as the cup-shaped crusts rapidly develop, it will be
noted on the scalp that each one is seated at the mouth of a hair follicle, and that its centre is generally
perforated by a hair.   As these " cups"  become numerous they tend to coalesce, and a thick, irregular
crust of lighter color is formed, and the  original  cup-shaped crusts can  be found only about hairs at
the margin of the large patch.
     If, in any case of incipient  favus, the  crusts be removed and  the hair shaven, the  scalp
will appear  smooth and in a  tolerably healthy condition, and the development of the disease may
be conveniently studied.   In about two  weeks the  parasitic growth which has remained in the follicles
will show itself on the surface of the  scalp in  the form of  minute yellow  crusts around some of
the  growing hairs.  These crusts being covered with a layer of  epidermis are not, strictly speaking,
upon the surface.  When in a few days  they have  reached the size of a  split pea, the margin becomes
elevated, and the centre depressed, forming the favus " cup."  This is concave on the upper surface, and
convex beneath, fitting into a corresponding depression in the scalp, which is covered with a very thin
layer of epidermis.   The peculiar form  of the cup arises in the following manner.   The spores of the
parasite grow between  the layers of the epidermis,  at the funnel-shaped mouth of the hair follicle.  As
the fungous mass increases in bulk, it raises the superficial layer at the periphery of  the disc above the
surface of  the skin, while  in  the  centre, where  the epidermis is in  connection with the hair, and
immovable, a  pit is consequently formed.  On the under  surface  nothing hinders  the mass in its
growth from  pressing  down upon the succulent ce.Ws of the rete, and the  convexity of the inferior
surface of the cup, and the corresponding depression of the scalp, is thus produced.  When a case of
                                               35 
FA VUS.
favus goes untreated the crusts invade a large portion of the scalp, increase in bulk while fading in
color, and finally, becoming quite friable, break and tend to fall off in piecemeal.  The pressure of the
cups causes atrophy of the  hair  roots, and  bald spots of a dull,  purplish-red hue, and cicatricial
appearance are seen after the fall of the crusts.  The hair never grows with its normal luxuriance after
a severe attack  of favus, but the scalp is covered with a sparse growth of wiry and curling  hairs.
The disease, untreated, persists until the whole scalp is affected, and the hair very nearly destroyed.
     The disease presents somewhat different features according to  its seat.   On the  head, where it
usually  appears,  it  is  not often  seen by the  physician at  the outset,  but  only when, through
ignorance or willful  neglect  or  mismanagement, it has  been allowed  to  extend over considerable
ground.  Favus epidermidis,  or favus corporis, as  it is more appropriately termed, is  not apt to  be as
severe  as favus  capitis.   It  does not present the accumulation of friable  crust,  and  is far more
amenable to treatment, on  account of the inability of the spores to  take root in deep follicles.   The
reddened and scaly circular patches which precede the development of the cups, and present a notable
similarity to patches of  ringworm, can be well studied in these cases.  Sometimes favus co-exists upon
the  scalp. and  non-hairy  parts, but  in a number of  cases of favus  corporis coming  under  my
observation, the scalp has been free.   It has been reported as attacking the  finger-nails, and from the
itching  of the affected scalp  its  transference  to the nails would not appear strange.
     Favus occurs chiefly in  childhood, although, from  lack of proper  treatment, it may persist upon
the scalp and be observed in  middle life.  It is rare in this country, as compared with its occurrence in
some parts of Europe.  The disease is contagious, and as it is transferred directly from one person to
another, those most  liable  to contract it are  children  in schools and  crowded tenements.  Though
a local disease, it seems  to flourish best upon the scalp and skin of those who are poorly fed and cared
for,  and those in  impaired health.  Family pets are often a source of the disease, and in every case of
its occurrence in  a household, it  is well to examine the dog and the cat.   Mice seem  peculiarly subject
to favus, and are often caught  with large, yellow crusts upon their  heads.   Through the cat they
transmit the disease to some member of the family.  In spontaneous cases, it is probable that the
spores have been carried through the air, and found a favorable nidus upon  a moist  scalp or patch of
skin. A well-marked case of favus of the scalp exhales a peculiar odor, which has been likened to  that
of mice.  To me, the odor is more like that of an ill-kept menagerie.
     The treatment  is simple, although it requires much time and  patience to cure a case in  wdiich
the  scalp is extensively affected.   Favus of non-hairy parts  can be readily  cured  by softening and
scraping off the  crusts and  applying one of  the numerous parasiticide remedies.   A few weeks, at
most, suffice for a cure.  Upon the scalp the  spores of the parasite have usually invaded the deepest
portion  of the follicles, and consequently no superficial applications  can effect  a radical  cure, at
least, until  the  hairs have been pulled  out.   This must be done  over the whole of  the  affected
surface, and in  obstinate cases, repeated a number of times.   After  the  epilation, a one-half per cent.
lotion of corrosive sublimate, or a three per cent, ointment of chrysophanic acid may be well rubbed
into the scalp several times  a day, and continued until  both  scalp and hairs have apparently assumed
a tendency to  healthy growth.  Even now, however, it  cannot be  asserted that the disease is  cured,
without a microscopical examination of some  of  the new hairs from  different portions of the scalp.
                                                36 

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ECZEMA  cruris, 
 
ECZEMA.
 Case.—W. II., set. 25.  A patient  at  the  New York Dispensary.   The disease was of one  month's
         standing, situated on the legs, and on the backs of the hands.   It was a typical specimen of
         the moist and crusted form of eczema.   A poultice applied over night removed the crust,
         which was in great part loosened by the copious exudation beneath, and a reddened and moist
         surface was exposed.  The patient was ordered a mixture of acetate of potassium, internally,
         and the oxide of zinc  ointment to be spread  thickly on soft cloths, and  applied constantly
         over the affected skin.  This produced a marked improvement, but the patient  being care-
         less in following  out directions, and unable to  abstain wholly from liquor, the cure was  not
         particularly rapid.  In  six weeks, however, the legs were  dry  and slightly scaling, when he
         was ordered a mixture of sulphate of iron and magnesia, with the ungt. cadini  locally.

     According to the German school, eczema is a local  disease, and  independent of any constitutional
vice or humor.   External  treatment is, therefore, of the greatest curative value.  The  idea of " driv-
ing in" the eruption, or of its possible metastasis to some internal organ is rejected, and  the relapse
which so often occurs in eczematous patients is referred to a perverted cell-growth of  the affected part
rather than to any disposition to the affection existing throughout the economy.
     The French school  has always  been the champion of the constitutional nature of  eczema.  The
dartrous diathesis which, emigrating to America, appears as the rheumic  diathesis, is a term employed
to indicate that general condition of which the eruption in eczema (and psoriasis as well) is  believed to
be a mere outward  expression.   The local  treatment, according  to  the  supporters  of this view, is of
minor importance, and a  radical cure is only to be obtained by remedies aimed at the constitutional
defect.
     The English  writers  on  dermatology, while  not  generally  accepting this view  of the diathetic
nature of  eczema, lay great stress upon its association  with and  dependence upon  gout, rheumatism,
dyspepsia, etc., in a large proportion of cases, and are more disposed  to favor a judicious combination
of internal and external remedies.  In America, these' opposing views meet on a common ground, and
time will undoubtedly declare the " survival of the fittest."
     The predisposing causes of eczema are not thoroughly understood.   There are plenty to be found
outside of the profession who satisfy themselves by saying that it arises from "heat in  the  blood,"
or "bad humor,"  or "scurvy," and  there are many able  writers in the profession, who  delude
themselves into  the belief that  everything is clear  when the  disease  is ascribed  to "assimilative
debility,"  "perverted innervation,"  or to some  favorite  "diathes's."    We know that eczema is
frequently associated with  a rheumatic tendency, and with some of the many phases of  dyspepsia, and
that  it is  aggravated  by  poor food, intemperate habits, care, and overwork.   Its  association with
                                               37 
                                          ECZEMA.

dentition, gestation, worms, diabetes, etc., has been noticed so  often  as to suggest a relationship, and
the fact should not be lost sight of when called upon to treat the disease.  If not hereditary in many
instances, it is certainly more prone to occur among those who inherit the delicate and irritable skin,
and the  rheumatic  and gouty tendencies of  their eczematous progenitors.   The  exciting  causes are
mostly local.   Any  continued irritant of mechanical or chemical nature will produce an eczema  upon
almost any skin, and all the more readily when some of the predisposing causes exist. The use of over-
stimulating ointments in other skin affections—as sulphur  in scabies,  mercurial ointment in phtheiriasis
pubis—often evokes an eczema.  Grocers, bakers, bricklayers, and others engaged in peculiar occupations,
often acquire an eczema upon the hands and other parts exposed to the irritating action of sugar, lime,
brick-dust,  etc.  Persistent moisture favors the development of the  disease, and hence  infants and
corpulent adults are often affected where the folds of the skin come in contact.  Washerwomen are
very  prone to a severe eczema of the hands, which is often incurable so long as the  hands are
frequently  in water.
     The constitutional treatment of eczema may be  summed up in the advice to improve the patient's
health in every possible way.  There is no routine plan  to pursue, or at least  there  should be none.
Give tonics when needed, regulate the diet, improve the digestion, when impaired,  relieve existing
constipation,  and rectify,  if  possible,  all errors  of  hygiene.  There is  no  specific treatment in
eczema,  no single  remedy of pre-eminent value.  The administration of arsenic, as a first and last
resort in  every case,  is  a prevalent  custom  which I must emphatically condemn.  Arsenic is a
valuable remedy in pemphigus and psoriasis,  and indeed in some  cases of eczema;  but  of so little
value is it in the  latter disease,   as compared with  other  remedies, that  I very  rarely find any
occasion to prescribe it.
     The  value  of purgation  in eczema is  debated.  While  not  accepting  the  old  idea  of a
materies morbi  being  carried out of  the system  in this way,  I  must say that clinical  experience
demonstrates  that in many cases  of  both  acute and chronic eczema, particularly of  the  erythema-
tous  variety,  the administration  of  purgatives for a few days will  be  followed by an  immediate
and a permanent improvement, and this, too, in cases  which are not  being treated locally,  or in
which local  applications  have  had comparatively little effect.   Diuretics, by stimulating the kid-
neys, and  thus  relieving the  skin  of some  of  its  functional  duties,  certainly produce  a most
decided  improvement  in  many  cases  of  eczema, and  are  almost  indispensable when treating
patients  with  gouty or rheumatic tendencies.
     Our natural mineral waters  have  a  very beneficial  effect in  most cases of chronic and  obsti-
nate  eczema,  and  the  Ballston  waters,  which contain a large  amount  of  lithia,  I can especially
recommend.   Of the  alkaline  salts, either the acetate  or the citrate of  potassium, in one or two-
grain  doses  (gr. xv.—xxx.), will  be  found of  great  service.  This  should always be  taken well
diluted, and either a half-hour before or an  hour after each  meal.   In children  and in  ill-nourished
adults cod-liver  oil is  of  great value,  and when ansemia is  present,  or  the  system of  the patient
indicates a general lack of vigor,  iron may be given alone  or in  combination.
     The forms  of eczema  and  their  local  treatment  will  be discussed in connection with later
illustrations.
                                                33                             /^5^0lli:L
 



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ECZEMA.
 Case  of Eczema  infantile.—W. K., aged  seven  months.  Skin Clinic of the Woman's  Medical
         College.   The eruption, which was a  typical instance of the exuding and crusted form of
         eczema (E. ichorosum), so commonly met with in  infancy, was of about six weeks' standing
         when first seen by me.  It had begun upon the scalp, and from there had spread rapidly over
         the face.  There was  a most severe  itching, and enlargement of the  cervical glands.  The
         mother was in poor  health, giving a clear history of syphilis, contracted eight years  before,
         and followed by two miscarriages.   The infant was only partly nursed, and was cutting its
         third and fourth (upper incisor) teeth.  The mother was  directed to dilute  the  child's milk
         with lime-water, to refrain from washing the  face, and to apply the oxide of zinc ointment
         freely spread on soft rags kept in place  by means of a  mask.   Under this treatment the erup-
         tion quickly improved, but soon returned again upon neglect in its continuance.  An emulsion
         of oleum lini (33 per cent.) was now  prescribed, to be rubbed well into the  skin, and a half-
         teaspoonful to be given internally three times daily.   In less than a week the face was much
         less inflamed, appearing paler and smoother.  The  mother thought  that the emulsion was
         superior, as a local application, to the zinc  oxide ointment; and as  to its internal use, I can
         only say that it  was  taken  as readily  as cod-liver oil, and the  child got well very quickly.
         The  illustration shows the highly inflamed condition of the skin,  with scattered greenish-
         yellow crusts, and here and there a blackish  scab where the skin  has been excoriated  by
         the nails.

     Following Willan, the  illustrious pioneer of  English Dermatology, some  writers have  divided
 eczema into a mild variety (E.  simpUx),  an inflammatory variety  (E. rubrum),  and  a purulent
 variety (E. impetiginodes).  This division  is rather  broad and indefinite, and  as many cases  do not
 fall  naturally  into one of the  three  classes it is of  little practical value. As a guide in the study
 of the disease, an aid in the  description of cases, and a hint  as to the  requisite mode of treatment,
 it is a better  plan  to divide eczema into stages through which the majority  of cases pass in their
 progress toward  recovery, and to  classify  all cases in accordance with  certain well-marked  clinical
 forms  or phases assumed  by the eruption, and  to which a spec'al nomenclature is applicable.
     The stages of eczema are three.  The  initial stage is  characterized  mainly by Irvpersemia, with
 slight interstitial exudation, and in most cases by an  eruption of papules, vesicles, or pustules.  This
 lasts but a  few days or  weeks at the most before  passing into the second  stage,  which is  charac-
 terized by  exudation and  crusting.  The  exudation  may  be  serous  or sero-purulent in character,
and  the inflammatory symptoms  are  usually  well-marked.   The  surface  exudation destroys the
integrity of the epidermis  and dries into  light-colored  crusts  when not mingled  with blood, which 
ECZEMA.
often flows freely  from numerous excoriations.  The second stage of eczema is of indefinite dura-
tion ; but sooner or later the  exudation subsides, the crusts fall, leaving a thin,  newly-formed epi-
dermis, and we have then the third or terminal stage, characterized by desquamation and  a  certain
amount of induration of the affected part.  In some instances the initial stage passes directly into
the terminal  stage, without the  occurrence of exudation upon the surface  or the development of
any  lesion besides the  erythematous patch, and  not infrequently  the third stage  relapses into the
second,  the scaling surface again becoming moist.  Very often  a  case of eczema will  exhibit  the
three stages on  different portions of skin at the same time.  At the spreading margin  of an exud-
ing patch (second  stage) we see hyperaemia and vesiculation (first stage), while a neighboring patch
may have become dry and scaly (third stage).   The terms  "acute" and "chronic," as applied to
eczema, are conveniently used in describing  cases, and  are  always suggestive of the appropriate
plan of  treatment;  but it must be borne  in  mind that these terms,  as  commonly employed,  do
not refer so much to the length of time which the eruption has existed as to the grade  of  inflam-
mation  which  it  presents.  An eczema  of  thirty years'  standing might, therefore, during  an
exacerbation, be regarded as an  acute  eczema,  and treated as such until the inflammatory symp-
toms have subsided.
     The  clinical forms of eczema are numberless, and scores of expressive terms  have  been coined
and  applied to them.  It is simply a question of convenience  whether we shall employ  five terms
or fifty for purposes of description.  Certain it is, however, that there are six  striking phases assumed
by eczema, and in accord with  Wilson, the most admirable writer on this disease, the following clinical
forms will be described :
                      1.  Eczema erythematosum  (Pityriasis).
                      2.  Eczema papulosum        (Lichen simplex).
                      3.  Eczema vesiculosum.
                      4.  Eczema ichorosum        (E. madidans.  E. rubrum).
                      5.  Eczema pustulosum       (E. impetiginosum).
                      6.  Eczema squamosum.

     The  first two and last of these forms are always dry (E siccum), while the remaining three  are
more or less moist (E humldum), although the moist surface is sometimes concealed  by a crust.   These
forms of eczema may be accompanied by exceptional peculiarities, such as a  circumscribed border,  the
existence of oedema, and the development of tubercles, fissures or a warty surface.   The term Eczema
marginatum is applied to an erythematous or papular patch which does not shade off at its  borders, as
is commonly the case in eczema.   The condition is frequently seen about the genito-crural folds, and is
likely to be confounded with trichophytosis of this region, of which it  is sometimes  a  sequel.  The
term Eczema rimosum  (seufissum) is used when a squamous or ichorous eczema of the hand or of  the
flexure of joints is accompanied by the development of numerous fissures (see plate of E.  squamosum).
Eczema verrucosum indicates  a warty condition, most frequently seen near the ankle, and generally in
connection with ulceration.  These accidental features are of little importance, and cases of eczema
exhibiting them will be found to fall naturally into one of the six divisions.
                                              -10 
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ECZEMA   PAPULOSUM 
» 
ECZEMA.
 Case of Eczema papulosum.—Mary J., set. 8.   This girl was overgrown, pale, and poorly nourished.
         The eruption consisted of aggregated  patches of small  yellowish-red  papules, with flattened,
         glistening summits, each dotted by a follicular opening.   There was no tendency to exudation
         upon the surface of the skin, except from the papules which had just been excoriated by her
         finger-nails.   The itching was  annoying, and most of the papules were surmounted by dark,
         pinhead-sized crusts of dried blood.

     Although eczema presents itself under innumerable  phases, it can generally be recognized with
 ease when we bear in mind  that its  characteristic  features  are redness, itching, moisture, and scaling,
 two or more of which features are invariably present.
     Erythematous eczema, as the name  implies, is characterized mainly by hyperaemia.  There  are  no
 vesicles,  pustules,  or well-marked papules, no  moisture—nothing but a  tolerably smooth,  reddened
 surface, with a moderate amount of fine desquamation.  In its incipient form it is merely a persistent
 erythema, with slight infiltration of the skin and consequent pruritus.   By scratching, or other external
 irritation, the skin  may  become  considerably thickened and covered with  fine branny scales.   This
 form (classed with E. squamosum by Hebra, and described  as pityriasis by older writers) is frequently
 met with on the face, and usually predominates when the disease extends over the greater portion of the
 body.  In  the plate of  E.  universale  it is seen, together  with patches  of  the ichorous and  of the
 squamous form.
     When the  hypersemia, which  is the  distinguishing feature of both erythematous  and papular
 eczema, is not merely confined to the superficial network of blood-vessels, as in the erythematous form,
 but involves  also the  follicular plexuses, we  have  discrete  congested papules developed upon  a
 reddened patch of skin.  This papular eczema may be transitory when produced by external agencies
 (a poultice or water-dressing, e. g.), but it is often chronic and obstinate.  When the congested follicles
 are  not  seated  upon  a hypersemic and  infiltrated  patch but  are  scattered in groups  upon  the
 normal skin, the term lichen simplex has been  used to denote the condition.   While it is convenient
 for purposes of description to use the old  terms lichen, impetigo, and pityriasis, it must be borne in
 mind that  they  are  not  distinct affections, but merely modifications of the papular, pustular, and
 squamous forms of eczema.
     Vesicular eczema was formerly regarded as  the type of  the disease.  Vesicles, however, are rarely
present  in  cases of  eczema when  seen by the physician, and hence are of  little use in diagnosis.   In
many cases there has been  neither vesiculation nor even a moist surface throughout the course of the
disease.   The vesicular form of  eczema  is quite  uncommon.  It consists of numerous small  acuminate
                                               41 
ECZEMA.
vesicles, crowded together upon a highly-congested base.  It may run an acute course, and terminate in
a week or  ten  days (and this is usually the case when it  is due to the action of some severe local
irritant),  or the exudation may continue after a rupture of the vesicles, and the disease then assume the
ichorous form.   Vesicular eczema attacking the face  is often mistaken for erysipelas, especially when
its outbreak is accompanied by slight fever.  The smooth, tense skin, with an  abrupt  margin of  the
patch, is  not seen, however, in  eczema, and the speedy development of fine vesicles, or an exuding
surface, dispels all doubt.
     In  the ichorous, or moist form of eczema, we have the condition of most frequent occurrence.
The affected  part is swollen and tender, and  the surface either  presents a reddened, raw appearance
(E. rubrum), or is covered by a thin, dark crust, through which and  beneath which the characteristic
gummy exudation appears.   Vesiculation may or may not have preceded this condition.  The exuda-
tion may have permeated  the  epidermic  cells and  washed them  away en masse.  Indeed, a moist
surface may be present in some cases without even destruction of  the epidermis.  When folds of  skin
lie  in contact, as they do about the neck and joints of fat babies, and beneath  the breasts and in the
inguinal  region of obese females,  the  epidermis becomes macerated, and frequently assumes  the
character of epithelium.  For a short time the skin  may appear as though converted into  a mucous
membrane, and discharge a viscid serum (E. mucosum).  Eczema ichorosum, in  which the disease  is at
its height, cannot be well confounded with  any other affection of the skin.
     The pustular form is  in  some  cases not readily distinguished from the ichorous  form.   The
exuding serum, instead of being clear and watery, may be of a thicker, honey-like consistence, and dry
into yellowish  crusts.  The contents of the vesicles may assume a sero-purulent character, or pustules
may be  scattered over the surface along with  vesicles, while in either case  yellowish or slightly
brownish  crusts  are  formed, which increase  in thickness from  additions to the under surface.
Pustular eczema is common in  strumous and  poorly-nourished subjects.  It is  very apt to appear  in
connection  with scabies and with phtheiriasis both of the body and of the head.   Isolated  pustules are
frequently  developed when external irritation coincides with impaired vital energy, e. g., after a season
of intensely hot weather, but it  is an open question as to whether these are justly regarded as being
eczematous  in  nature.  Though eczema  commonly  leaves  no scars, this  pustular form, the " milk-
crust " of infancy, sometimes pits the cheeks, and, even in  later years, the child shows marks  which
might be mistaken for the effect of  variola.
     The squamous form is the terminal stage of one of the other forms.  It is  but an exaggeration of
the  erythematous form—the acute  hypersemia and  branny desquamation giving place to thickening
and induration of the skin and subjacent tissue, with exfoliation  of the epidermis.  It sometimes occurs
in patches upon the extensor surface  of the extremities, when it is with difficulty distinguished from
psoriasis.  The gradual shading off of the patches at their margins, contrasting with the circumscribed
border of psoriatic scales, and the existence  of moisture beyond that condition which exists in psoriasis
when the scale is removed and the corium exposed, are features which will usually determine the diag-
nosis.  Squamous eczema, when universal, resembles  Dermatitis exfoliativa; but in this rare affection
the flakes of epidermis are much more abundant, there is no thickening of the  skin, no moist patches,
no severe itching, and frequently there is a  high grade of fever and great prostration.
                                               42 
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ECZEMA.
Case I., Eczema ichorosum.—C. M., set.  6.  This boy seemed to be in fair health, although eczema
         in a more or less aggravated form covered  the  greater portion of his body.  His skin,
         where it was  normal, was soft  and delicate, and he  manifested  unmistakable signs of a
         strumous diathesis.   The eruption began upon the head when  he was only three months old,
         soon  appeared on  the  trunk and  extremities, and since that time had  never  entirely dis-
         appeared.  This unusual extent  and persistence of the eruption was chiefly owing to neglect
         on the part of his parents, who had been told by wiseacres in their neighborhood that the
         eruption could not be cured (all of their remedies having failed), that it would be injurious
         to cure it, and that it would go  away of itself when the boy  was seven  years old, &c, &c.
         With iron and cod-liver oil internally, and emollient applications to the skin after removal of
         the crusts, a cure was effected in a few months.

Case II., Eczema pustulosum.—An infant  with a recent and comparatively mild form  of  eczema.
         This  began as a pustular eruption, the yellowish, honey-like contents of  the pustules rapidly
         developing a crust which increased  in  thickness from below, while the surface grew darker in
         color from exposure to the air.   This thick crust, which ought  never to have been allowed  to
         develop, was easily removed by the application of a poultice,  and the skin beneath, though
         somewhat inflamed, and denuded of its epidermis, was tending to recover its normal state; and
         needed but a simple dressing, to exclude the air and allow recovery to take place.


     The success of local treatment in eczema depends upon its adaptation to the case in hand.  In-
numerable are the remedies which have been recommended, but without a knowledge of the principles
which govern its use, no remedy can be of much service.  I will  venture to assert, that so far as local
applications are concerned, the great majority of  cases  of eczema can  be successfully treated with two
simple ones, wrhich are always on  hand, or very easily obtained, viz.,  sweet oil  and soft soap.   Of
course, I do not advise the reader to use  these, since  there are various  emollient applications superior
to the former,  and stimulating remedies which may advantageously supplant the latter, but I hold that
it  is far better to know how and when  to  use even the two remedies mentioned, which typify two
opposite modes of treatment, than  to have a well-stocked  drug store at command, and to use  its
contents without definite purpose.   What will a bland oil  or an  emollient ointment accomplish in the
treatment of eczema ?  It will soften and  remove any crusts which may be present, it will soothe the
inflamed parts, and alleviate the  itching, and it will protect the  denuded corium  from the desiccating
influence of the air and the irritating action of  water, and thus allow the growth of a new and healthy
                                              43 
ECZEMA.
epidermis.   In the acute eczema of infancy, and in the acute  form of the disease, at whatever age it
may bejnet with, it matters little what oil or ointment or lotion be employed so long as it is the most
soothing application that can be made.   What will soap accomplish in  the treatment of eczema ?  It
will free the surface of the skin from a mass of dead epidermis, it will  give  exit to confined serum, it
will stimulate the circulation of blood in the diseased skin, and thereby promote the absorption of the
infiltrated products of inflammation.   In chronic cases, where there is thickening and induration of the
skin, with  persistent desquamation and  annoying pruritus, cases in which emollient applications are
utterly  inefficacious, soap frictions will change the character of the  eczema from a chronic to a sub-
acute form, a condition tending naturally to recovery.  In fact,  as quinine in the treatment of  malaria,
so is sapo viridis, or ordinary soft soap, in the treatment of chronic eczema.
     The most common mistake made  in  the local treatment of eczema is in the application  of over-
stimulating ointments and irritating lotions to parts which demand the most soothing measures, and in
the application on the other hand, of the oxide of zinc, or some other slightly astringent ointment, to
cases in which nothing short of soap frictions or some equally harsh remedy will prove of  the slightest
benefit.  At the risk of repetition, let me say again, that the grade of inflammation determines the
selection of a soothing  or a  stimulating plan of treatment.  If the affected part  is swollen and hot,
pouring forth a  profuse discharge,  and accompanied  by an  intense, burning  pruritus, the  local
applications cannot be of too soothing a nature.  If the skin  is dry,  thickened, indurated and scaly,
the local treatment can hardly be too severe.   Where the disease is extensive, as in Eczema universale,
it is generally necessary to vary the character of the treatment upon  different portions of the body.
     Such, briefly stated, are the principles which govern the local treatment of eczema.  As, in general
treatment, the habit and  idiosyncrasies of the patient must be borne in mind, so in local treatment must
the character of the lesions be  studied and  routine practice avoided.  The reader must cast aside the
vulgar notion  that a wonderful therapeutic power dwells in the remedy which  is used, and learn that suc-
cess in treatment is wholly due to the skillful adaptation of remedies to the requirements of each case.
     The question as to whether the rapid cure of eczema may prove  prejudicial to the patient has been
freely discussed.   The experience  of nearly all dermatologists answers this with an emphatic negative.
No peccant matter is ever eliminated from  the system  in the form of an eczematous discharge, and
under  no circumstances can the  disease be regarded as salutary.  It is true  that the eruption, in rare
instances, seems to alternate with affections of the respiratory apparatus ; but this merely shows that
inflammation of the skin is not apt to co-exist with inflammation of an internal organ.   If a child under
treatment for eczema is exposed to cold or injured by a fall, and contracts pneumonia or meningitis, the
eruption naturally subsides, in consequence of the determination of blood to lungs or brain.  The rapid
cure of the eczema, instead of being the cause, is rather the result of the internal phlegmasia.  In this
way an eruption may be said to be  drawn in,  but it is impossible for local treatment to drive it in.   I
have no doubt but that in  some  cases of infantile eczema harm has resulted from the application of
strong mercurial ointments to a large extent of skin ;  but it has been  the mercury and not the disease
which  has been driven in.  Death or severe illness, from whatever cause, is preceded by the subsidence
of any eczematous discharge which  has  pre-existed, and  illogical friends  of the patient are not only
liable,  but  often disposed, to mistake the cause for the effect.
                                                44 
ECZEMA    SQUAMOSUM. 
* 
ECZEMA.
Case of Eczema squamosum.—J. Z., set. 20.  The eruption in this, case began as an acute eczema.   The
         inflammation rapidly subsided into a sub-acute condition.   Painful cracks resulted from motion
         of the arm, and the epidermis peeled  off in large flakes, as seen in the illustration.   A mixture
         of lime-water and linseed oil, equal parts, was freely applied, and the arm placed in a sling.

     The local  treatment of eczema, while depending upon  the clinical form and stage of the disease,
must be greatly modified in accordance with peculiarities of the region which is affected.
     Eczema of the scalp, particularly in children, is prone to assume the ichorous form, and to become
crusted.  A poultice applied over night will remove the crust, when benzoated oxide of zinc ointment
freely applied to the scalp, night  and morning, will  soon effect a cure.   It is hardly necessary to say
that a thin layer of ointment, smeared over a thick crust, will have no  effect upon the diseased  skin
beneath.   Cutting the hair short facilitates treatment; but in the case of women and young girls, who
are reluctant to be cropped, it is never absolutely necessary.  In the chronic cases, occurring chiefly in
adults, the  scalp is sometimes reddened, thickened, and covered with tine white scales.  A shampoo,
consisting of  aromatic  spirit of ammonia, one part, and  water, four to six parts, will cleanse the scalp,
after which perfumed cosmoline may be freely used as a  pomade.  When  there  is no tendency to
moisture, ten per cent,  of ammoniated mercury  ointment may be added.
     Eczema of the face, so common  among infants, can often  be cured, after numerous  applications
have failed, by using any one of them which is unirritating,  and instructing the mother or nurse to
cease washing the child's face.   The  diachylon ointment or the oleate of zinc ointment are satisfactory
applications ; but it is of little use to  merely grease the face with them.  The ointment must be spread
thickly on soft rags or pieces of impermeable  lint, re-applied  twice daily, and held in  close contact  with
the skin by means of  a mask or  piece of stout linen cut to  fit the face, with  holes  for eyes, nose and
mouth, and tapes to fasten  beneath the occiput.  The custom  of  tying an infant's hands or muffling
them in stockings, in order to prevent the scratching during sleep, is cruel.  A soothing ointment and
a well-fitting mask which the child cannot pull off, will quickly  subdue the itching and give both infant
and attendant a good night's rest.
     Eczema of the lips is usually one of  the most intractable forms.  I have had good success with an
ointment of thymol (one to three per cent.)  where a dry, wrinkled and scaly condition surrounds the
mouth.   A case of long-continued scaling of the opposing surface of the lips in a gentleman still under
my care lias resisted every remedy, internal and external, which  has been used, and the affection, though
by no means a serious one, appears to be practically incurable.
                                              ' 45 
ECZEMA.
    Eczema of the anterior  nasal passages may exist with or without an eruption upon the face.  It
occasions redness, swelling, and soreness of the nose, and interferes with normal respiration.   The accu-
mulated crusts should be removed by spraying the nostrils with a weak solution of borax or common
salt in water, after which a pledget of lint, smeared with vaseline or diluted citrine ointment, may be
inserted in one or both nostrils.
    Eczema of the external auditory canal is usually regarded by aurists as extremely obstinate in most
cases.  The frequent syringing of  the  ear  for purposes of  cleanliness  tends  to aggravate the disease.
By reducing the zinc oxide ointment to a fluid consistence by the admixture of glycerine, and applying
it frequently  by means of  a camel's-hair brush, the canal may be kept clean and the eczema cured.
    Eczema occurs beneath the breasts of corpulent women, and where folds of skin rub together.  It
is the result of continued  heat and moisture.  In  the intertrigo or  subsequent  genito-crural eczema
of infants, the so-called "sprew" of nurses, the breech-cloths must be instantly removed when soiled
or wet.   In all cases, the red or raw surfaces should be washed occasionally with bran-water, dusted
often with lycopodium, and kept separate by the interposition of soft linen.
    In eczema of the scrotum and perineal region in males, and of the vulva in females, the itching is
always intense and annoying, and the condition is  only aggravated by scratching.   An ointment of
thymol (three to five per cent.) or  a lotion of carbolic acid in glycerin (fifteen to twenty per cent.), used
with caution,  will generally afford relief when weaker applications have failed.
    Eczema manifests a decided disposition to attack the flexor surface of joints, and is frequently seen
in the axilla, bend of elbow and  popliteal space.  In recent cases it is important to prevent drying of
the skin and the consequent formation of painful fissures on motion of the part.
    Eczema of the lower portion of the legs is common in middle life and old age.  It is usually of
long standing, and requires stimulation.  When the eruption is dry, as in the erythematous and papular
forms, the skin is simply reddened, harsh, itchy, and  more or less excoriated.   Daily frictions with
green soap will soften the skin and relieve the itching.   After using the soap, the legs should be care-
fully  dried, and a slightly astringent  ointment applied.   In the squamous form, the soap frictions will
remove the scales and often cause an  exuding surface to appear.  This temporary aggravation, how-
ever,  by stimulating the flow of the  blood through the  part and promoting absorption, will speedily
reduce the thickening of the skin.   In the ichorous form of eczema (well shown in the plate of Eczema
cruris), and in the squamous form  when there is any tendency to a discharge, the application of vulcan-
ized rubber cloth is one of the best plans of treatment.   It cleanses  and cools  the surface, promotes a
copious flow of serum, and quickly lessens pain  and swelling.   The cloth should envelop the leg with
the rubber surface next to  the skin, and be held  in  position by a roller bandage.   When the ankle is
affected, the cloth may be gored or cut  so  as to fit smoothly.   The rubber bandages, to be described
later in the treatment of varicose conditions, are sometimes preferable, though more likely to irritate
the healthy skin.   When the  leg has  returned to its normal size, and the exudation has nearly ceased,
the rubber is no longer of service, and the cure may be completed by applying the nitrate  of mercury
ointment, one or two parts, to the  oxide of zinc ointment, eight or nine parts.  When the skin is infil-
trated, itchy and  scaly, but  only  to a  slight extent, the preparations of tar can  be advantageously
employed.  Where there is an exuding surface the use of tar is contra-indicated.
                                               46 
ECZEMA   BARBAE. 
 
ECZEMA   OF  THE   BEARD.
 Case.—J. G., aet. 21.  Patient at the New York Dispensary.  The eruption was of six months' stand-
         ing,  although it had been preceded  by blotches upon the face since puberty.  It had  be-
         gun  upon the chin, where it existed in a most aggravated form, thick, blood-stained crusts
         being held  by the closely cut hairs of  the beard.   Near the angle of the jaw the exudation
         had  ceased, the crusts  had partly  fallen, and given place to  a patch of whitish scales (E.
         squamosum).  The  upper portion of the  beard, in  front  of the  ears, was but  very
         slightly affected, while the upper lip  was covered with dark, granular crusts.  The disease
         existed behind  the ears, and along the margin of the eyelids.   There were patches with a
         yellowish crust on the  hairy portion of the abdomen and pubic region, and the scalp was
         slightly affected.  The patient had never suffered from severe eczema on non-hairy parts.

     The bearded portion of the face  is the seat of several skin affections, chief of which are eczema,
sycosis and trichophytosis.  These affections, when attacking the beard, present no important features
which are not present when they occur upon the scalp or elsewhere.  Eczema of the beard, though
naturally occurring only in adult males, tends to assume a severe grade of inflammation, but differs in
no essential regard from eczema of the scalp.   Sycosis is an affection which generally attacks the beard,
but  in rare instances it occurs on hairy parts elsewhere, and presents the characteristic features of the
disease, viz., suppurating nodules, developing about the roots of the hairs.  Trichophytosis or " ring-
worm " of the beard has, in the great  majority of cases, the same features as when met with upon the
scalp and non-hairy  parts, and does not deserve  a different name.   Indeed, much confusion has been
introduced into dermatology  by the application of different names  to the same disease  occurring on
different portions of  the body.
     In order  to show the points in  the diagnosis of eczema of the beard,  it will be convenient to
describe briefly the features of these other affections.
     Trichophytosis barbse, or ringworm of the  beard, is a  tolerably common affection, which  begins
usually with one or several small circular patches,  which are reddened, slightly scaly, and which tend to
increase steadily in circumference.  Sometimes  the affected patch  becomes  swollen, and the surface
assumes a lumpy appearance.  It  rarely, if ever, affects the whole beard, as does eczema, and is generally
present in its characteristic circular form upon the face, neck or other non-hairy parts.  It is generally
a dry eruption, although, in the lumpy form (Kerion), there may be a yellowish, honey-like discharge
from the hair follicles.  Unlike eczema, it does not usually present a moist or crusted surface.
     Sycosis is a term which is often loosely applied to nearly every affection of the bearded portion of
the face (S. parasitica, S. non-par asitica).  Its use should be restricted to that inflammatory condition
                                              47 
ECZEMA  OF  THE   BEARD.
of the hair follicles and adjacent cellular tissue which is  characterized by pustules perforated by hairs
which in time become so loosened that they can be extracted by the gentlest traction of the epilatory
forceps.  The affection involves  the  deeper tissues of the skin, and causes a painful swelling of the
part.   It is often associated with eczema, and by some is  regarded as  nothing more nor less than a
pustular form of  this disease.
    Eczema of the beard is characterized by the  symptoms of  eczema in general, redness, burning or
itching, exudation, with a tendency to the  formation of  crusts, and finally, thickening of the skin and
desquamation.  Some writers claim that a pustular eczema of the beard, which of all the forms of
eczema bears the closest resemblance to sycosis, can be distinguished from the  latter by its extending
beyond the hairy parts, upon the cheeks and neck, whereas, sycosis is strictly limited  to the hairy parts.
This point is not  always to be relied upon.   In the accompanying illustration, the eczematous nature of
the eruption is clearly shown by its  occurrence upon those favorite localities, the ear and eyelids, but
its tendency to attack and confine itself, like sycosis, to the hairy parts, is shown by its presence in the
pubic region, and its conspicuous absence beneath the corners of the mouth, where the growth of the
beard has not begun.
    The first step to take in the treatment of eczema of the bearded portion of the face is to dispose
of the  beard.  This  may be  clipped  very closely  with  fine scissors, shaved, or  pulled out, as the
necessities of the case  demand.  When the eruption  is crusted, or the skin acutely inflamed, and
exuding freely, shaving is for the time almost impossible.  The hairs should be cut  as short as possible
with  scissors, when, by a poultice or repeated inunction of oil, the crusts can be removed.  If now the
skin is tender, and shaving proves to be a painful operation, it is well to continue the use of the scissors
in preference to the razor.   In the majority of  cases, however, shaving can and should be performed at
least  thrice weekly, while the ordinary treatment for eczema is carried out.  When the  affected part is
hot, swollen, and discharging serum, I have seen  excellent  results follow moderate purgation kept up
for two or three  days, combined with hot fomentations, or the application of the zinc  oxide ointment
spread  on soft rags, and held in place  by a  bandage.   An infusion of senna or viola  tricolor, or the
compound  jalap  powder may be used as  a purgative.   When the acute inflammation has subsided
under the influence of  emollient applications and due attention to the patient's general health, ? Ld
the eruption has  assumed the character of a dry, reddeued  and scaly patch, the officinal ointment  of
sulphur or of the nitrate of mercury may be used, diluted with from three to five parts of cold crefrni.
When the morbid process  shows a tendency to extend from  the surface to  the deeper portion of  the
hair  follicles, the skin usually  assumes a lumpy appearance  resembling sycosis, and pustules develop
around the  hairs.   In  such  a  case, the treatment  already  mentioned is of  but  little  benefit, and
epilation is called for.   The hairs  are usually firm, and consequently extracted with pain.  A small
drop  of blood occasionally follows the epilation of certain hairs, but this  only acts as an antiphlogistic,
and the improvement within twenty-fours  is often as surprising as it is pleasing.  To allay the pain I
have  in some cases held a piece of ice in contact with the skin for a fev/ minutes before extracting the
hairs.   When the inflammation  has attacked the  deeper parts, the  hairs are loosened,  come out with
gentle traction, the root sheaths being bathed in pus.   In such cases the excessive suppuration is  apt to
destroy the follicles, and lead to permanent baldness of the part.
                                                48 
">■<-
X
v
*
4
ECZEMA
M A N U M 
 
ECZEMA    OF   THE    HANDS.
     Although eczema may attack either the palmar or the dorsal surface of the hands, it rarely occurs
in a marked degree upon both at the same time.   One hand only may be affected, although the disease
is commonly found on both, and is sometimes quite symmetrical.   On the back of the hand, eczema is
more apt to be of internal origin, and to co-exist with patches on the arm or elsewhere.   When of long
standing it  may be papular or squamous, but it usually assumes the ichorous  form.   On  the palm,
eczema differs in many respects from the disease as it occurs elsewhere, and demands a peculiar mode of
treatment.   As met with in practice it is usually dry, and characterized by horny scales, and by deep,
painful fissures  occurring in the  lines of flexion.   Sometimes the whole palm is affected.  More fre-
quently the  disease occupies but a portion, and appears as a single diffused patch or a number of  isolated
scaly patches of a more or less circular form.   Eczema of the palm  is usually chronic (in one sense of
the term) from the very  outset.  It begins  at one or more  points with redness and itching, and after
much gentle scratching or rubbing with the other hand it develops into a somewhat thickened and
scaly patch.   This increases  in  size by peripheral extension, or creeps over the palm with a cir-
cumscribed  and curving border, very much like a squamous  syphilide.   There is a wide variation
in the appearance  of  different  cases.   Upon a soft-skinned palm, the redness, infiltration and des-
quamation of typical eczema are seen, while in another  case nothing is apparent but whitish  patches
of horny epidermis, which  the  patient is  constantly picking or  digging with the  finger-nails of the
other hand.  Where much inflammation  is present of an  acute grade, the  palms become swollen,
and numerous fissures result from flexion and extension of the hands,  until the  latter become too
painful to be used, and are held  by the patient like claws, in a rigid and semi-flexed position.  In
old cases, where the outer layers of  epidermis have been  gradually removed, the  skin  of the palms
is notably reddened, feels harsh  and dry, though  quite smooth, and the natural lines and  furrows
are greatly  exaggerated. When  the fingers in  such a  case are forcibly extended, the blanching of
the palm, which occurs to a slight degree in a healthy hand, is well marked and characteristic.
     The diagnosis of eczema  of the hands is usually simple.  Palmar  eczema, however,  may bear
such a strong  resemblance to scaling  syphilitic  patches that experienced  dermatologists are  often
unable to  make a  positive  diagnosis from a mere study of  the  lesions.  According to  text-books,
eczema presents irregular patches, covering  perhaps  the  whole palm  and  itching  severely, while
syphilis is characterized by  smaller circular patches, with  more  infiltration  of the skin, a  circum-
scribed border,  and an absence of  itching.   But there are very many exceptions to this rule.   Eczema
may occur  in the  form  of small  circular  patches and  in the  center of the palm, may have a well-
defined border  and spread over the palm in  a serpiginous manner, while a palmar syphiloderm may
                                              49 
                              ECZEMA  OF  THE  HANDS.
itch and crack  and be  aggravated by putting  the hands in water, and, in short, appear exactly
like an eczema.  I know of  but  one infallible rule to apply.  If a number of  small scaly spots
are arranged in a semicircular or  horse-shoe form,  with  an inclosed area of  healthy skin, or if  a
spreading circular patch exhibits  an  infiltrated margin and a healthy or  healing  center, the  patch
is of syphilitic origin.   In a doubtful case the  history of  the  patient is of  little value, as the palmar
syphiloderm, liable  to  be  confounded with  eczema, is a late manifestation  of  the disease, and so
many syphilitic persons, particularly females, are unaware of  ever having contracted  the disease.   The
scaling papules, accompanying or following the  early secondary eruption, ought never to be mistaken.
Even with a clear history of syphilis, eczema may oacur as  an independent affection.   " Psoriasis" is a
term  applied  by many to every scaly palmar patch, irrespective of its etiology.  I have never yet
met with a case of  true  psoriasis  upon the palms, either  occurring  alone  or  in  connection  with
psoriasis upon other parts, and am convinced that  nearly all, if  not quite  all cases  reported as
psoriasis of the palms  have been syphilitic or  eczematous.
     The local treatment  of eczema  occurring on the backs of the  hands  requires no special  direc-
tions.   Soap  frictions  are  useful  in the papular form,  accompanied with  induration  of the skin,
and even in the case of  moist  patches, soap, though a harsh remedy, may  be  used once or  twice
to remove the dried  exudation  and dead epidermis in  order to give a  free exit to  the confined
serum.   The diachylon ointment may then  be  spread  thickly on  pieces of  soft  cloth, and  kept
constantly applied to the  moist, reddened  surface.  The affected fingers may be bandaged separately
and tightly, and the  hands must  be kept out of  water  until a new epidermis  has  formed  and
there are no more fine beads of exuding  serum.
     Eczema of the palm  requires a  method of treatment  quite different from that of eczema else-
where.   The thickened epidermis must be removed, the  painful cracks  healed,  and the infiltration
of  the corium  absorbed.   The skin  must  then be kept  in a soft pliable state, by  applications,
until  the redness has in great measure faded and there is little tendency  to itching and scaling.
     Though the occasional dipping of the hands in water is harmful, there is scarcely a better mode of
lessening the inflammation, and at the same time macerating the epidermis than by ordering the patient
to place the palms in a shallow vessel containing a little more than  enough water to cover the bottom.
The water should be as hot  as can  be borne, and the palms kept in it for at least fifteen minutes at  a
time.  Where  there are horny patches, unaffected by the water, glacial acetic acid,  or liquor potassii
applied on  a  glass rod will be  found to  soften them quickly. These strong applications must be
handled with  care, lest severe pain be caused by their getting into the  cracks.  But the cracks are
merely the result of the thickened and indurated epidermis, and it is useless to heal them and have
them break open again.  If their cause, viz., the thickened epidermis, be removed,  they  will heal of
themselves and remain healed.   Rubber  gloves worn  constantly (with the rubber  side next to the
skin)  act beneficially in most  chronic and  obstinate cases.   After  the thickened  epidermis has been
removed and the cracks healed, the  palms may remain for  a  long time reddened, dry and harsh, with
a constant tendency to  become worse again.  An ointment containing ten  per cent, of oil of cade in
vaseline  does  well  in  such cases, but success will depend less upon local measures than upon the
internal treatment adapted to eczematous cases in general and to this patient in particular.
                                               50 
s
ECZEMA  E VENIS VARICOSIS.
ULCUS  VARTCOSUM. 
 
VARICOSE  ECZEMA:   VARICOSE  ULCERS.
Case I.—M. H., set. 60.  Patient at the New York Dispensary.   For thirty years the superficial veins
         of both legs had been varicose, and during the past four years he had suffered more or less
         from eczema in this region.   At the time of  sitting for  the photograph, the disease, through
         neglect or mismanagement, had assumed the ichorous form.  It was mostly covered by a dark-
         greenish or blackish crust, which had split after drying  and contracting.   The curling up of
         the edges of this rent showed the red, raw skin beneath bathed in an ichorous discharge.

Case II.—B. R., set.  55.  This patient had a moderate varicosity of the  superficial veins of the leg,
         with an ulcer near the inner malleolus of  four  months' standing.  The skin around the ulcer
         was congested and  extremely sensitive to pressure. It had been gradually growing worse,
         though under treatment.  An elastic tubular bandage was applied to the calf, and adhesive
         straps  to the ulcer, under which treatment  the redness and soreness about the ulcer rapidly
         disappeared, and healing began at once.

     The permanent dilatation of veins to which the term varicose is applied begins usually in early or
middle life, and affects chiefly the internal saphenous and its branches.  The enlarged vein may be
simply distended, or it may be hypertrophied, and  either form a tumor by doubling on itself, or run a
serpentine course for a short distance.  About the  ankle and on  the dorsal  surface of the foot,  it is
common to find the venous twigs dilated, and  appearing as numerous  purplish blue dots  or streaks.
The cause of varicose veins is not always apparent, although ill health, standing occupations, pregnancy,
tight garters, &c, doubtless exert an influence in their  production.  The result of their presence, how-
ever, rather than their causes, renders them of importance from a  dermatological standpoint.  In many
persons varicose veins of the lower extremities exist for years without producing any effect upon the
skin, or even inducing any feeling of discomfort.  Given,  however, a tendency to eczema in such a
case, and it will not be long before some external irritation will provoke an eruption which will prove
rebellious to ordinary treatment, on account of the oedema and infiltration of the skin, which in time
becomes associated with varicose veins of the leg.
     The treatment of varicose eczema involves the  ordinary  therapeutic measures adapted to the cure
of the disease, with the addition of a support for the enlarged veins.   So long as the limb is allowed to
swell daily from the pressure of a column  of  blood, so long will lotions and ointments fail to effect a
cure.  Where the limb cannot be maintained in a  horizontal position (and exercise  is as  desirable in
many cases as it is unavoidable), some form of a bandage or elastic stocking is required.  The ordinary-
roller, if smoothly applied, answers a two-fold purpose  in compressing the limb and keeping the dress- 
ECZEMA.
 ings  in  place.  But  rarely do we  find a  patient who can make the  reverse turns properly, and a
 bandage twisted around the leg and drawn tight to keep it from sliding down will do more harm than
 good. A flannel roller is preferable to one made of cotton cloth, on account of its greater elasticity and
 softness, and when applied moist it will produce a. tolerably firm compression of the leg.   As for the
 elastic stockings in the market it may be said that the cheap  ones are useless, while the good  ones are
 too expensive for a large class of patients.   The rubber bandage introduced  by Dr. Martin has of late
 become widely known and deservedly popular.  It not only supports the dilated veins and thus tends
 to remove a cause of the eruption, but by its local action it macerates the epidermis, and facilitates
 the escape of serum  confined  in the skin and subcutaneous  tissue.  By its elasticity  it exerts a con-
 stant pressure on the leg, and induces a rapid absorption of  the products of inflammation.   It is, in
 fact,  a happy combination of the impermeable rubber dressing  and the elastic stocking.  It can be
 applied by any patient of average  intelligence, as no reverse turns are needed, it can be tightened or
 loosened with  ease,  and, unlike  the ordinary  roller, which  speedily becomes loose, it maintains its
 pressure even  when  the leg decreases in size by subsidence of the  oedema.   The rubber  bandage
 should be applied in the morning before the patient gets out of bed.   At night, after its removal, both
 leg and bandage should be washed and carefully dried.  The bandage may now be re-applied,  or if the
 infiltration has nearly disappeared, and especially if the skin is much irritated, it  is better  to dress the
 leg with an  emollient ointment  and to wait until morning before re-applying the bandage.  In cases
 where the bandage is applied for  an  eczema of  the ankle or lower part of the leg, the healthy skin
 above may become irritated.   This can  be prevented by dusting the sound skin night and  morning
 with  powder of starch, oxide of zinc or bismuth, but it indicates an eczematous tendency on  the  part
 of the patient and suggests greater reliance on internal medication.
    Varicose veins play an important part in the causation of  ulcers of the legs, but they are rarely the
 sole cause.  In many persons they exist for years, without causing either eczema or ulceration,  and,
 indeed, an ulcer  may co-exist with varicose veins, without there being  any relation  between  the two.
 It is  therefore a mistake to call  every ulceration  on the leg  a varicose ulcer, simply because  enlarged
 veins  are present.   The  true varicose ulcer develops usually upon an eczematous base, but  it may  be a
 simple, traumatic ulcer resulting from a fall, a kick, or a  scratch, and aggravated or kept from healing
 by  the presence of varicose veins.  A simple ulcer occurring about  the ankle, where oedema is so
 common, is very apt to be aggravated by the pressure of blood in dilated veins.  It may be irritable or
 indolent, and in time  it may become callous.   The applications which have failed to cure it, will often
 succeed, when the blood  pressure, and consequent  congestion,  is removed.  The ordinary rubber band-
age is of excellent service in these  cases, and nothing does so well  in the treatment of an ulcer with
thickened edges.   In  other cases I have used with  success a  device which  I term the elastic tubular
bandage.  This can be made of rubber sheeting, just thick enough to be sufficiently  strong, and of
varying size  to suit various legs.   When drawn upon the leg, it is like an  extra skin,  fitting closely,
though pressing less upon the lower part of the leg  than  upon the calf, where the pressure is desired.
It can be worn for a month  or more at a time, rolling it up from the bottom  halfway, then down from
the top, when ablution of the skin is called for.  It is far lighter, and consequently much more com-
f ortable than the  ordinary rubber bandage.
                                                52 
r*\  \
K
*
^i
PSORIASIS ANNULATA. 
 
PSORIASIS.
 Case of Psoriasis Annulata.—O. H., set. 22.  Three years ago  this patient was first attacked, a scaly
         spot appearing upon the scalp near the vertex.   This was in the spring, and before the follow-
         ing winter  the  eruption had  developed to about as marked a  degree  as  is shown in the
         illustration.  Under different physicians  a variety of remedies were employed, including cod-
         liver  oil,  alkalies  and arsenic  internally,  and  glycerine, iodine, acetic acid,  Vlemingkx'
         solution, tar, etc., locally.  When first seen by me, he had for over a year been  taking large
         doses  of liquor potassii, and  his health was considerably impaired. The eruption, which had
         varied in form  and severity at different  seasons, though never  manifesting  a  tendency to
         disappear, was now present upon the greater portion of the body.   Upon the breast and back
         were scaly ridges forming circles of varying size, many of which were confluent and embraced
         areas of smooth and slightly reddened or pigmented skin.   On the  extremities and particularly
         on the hands were guttate or nummular spots of recent appearance.  The eruption upon the
         scalp  was quite noticeable along the margin of the hair on the forehead and neck.  On the
         face were irregular patches of a very faint red color and free from scales.
             The first  step in  the treatment of this case was to  stop the heroic internal  medication.
         Then, with Turkish baths three times a week, and a moderate amount of exercise, to which the
         patient had long been  unaccustomed, his  health began to improve, and  the eruption began to
         subside.  An ointment of ammoniated mercury  (U. S. P.) applied to the head, improved the
         condition of the scalp, and removed the eruption from the face, while the oleum rusci rubbed
         into the patches upon the body, rapidly caused the rings to break  up  into small isolated spots
         of infiltrated skin.  In three weeks there was a decided change for the better in the condition
         of the skin.  The liquor potassii arsenitis  was now given  in doses, varying from  three to ten
         drops (as large as he  could tolerate), and  the tar  superseded by  a 20  per  cent,  ointment of
         chrysophanic acid applied  at first on only one-half  of the body.  This proved  to be far
         more  efficacious  than the tar, and in two months the patient left  the city for his home with
         only a few reddish papules remaining as a relic of the eruption.

     In nearly every case of psoriasis there is undoubtedly a morbid condition of the economy, an ill-
defined something, deeper  than  the  scaly  patches.  Some call  this  the disease,  and  regard the
cutaneous affection as a mere symptom.  Others apply the term psoriasis solely to  the cutaneous lesions,
and  look upon  internal morbid conditions as predisposing  causes.   The supporters of the diathetic
nature of psoriasis assert that local measures cannot cure the disease, while others claim that when the
skin is restored to its normal condition  the disease is cured for the  time  being, although the imper-
fectly understood causes still existing may induce its return.   This is a mere quibble.   Local applica-
tions will restore the  skin to its  normal state in  nearly all  cases, while in many it is extremely
                                              53 
PSORIASIS.
difficult to prevent relapses, even with internal treatment.  Most cases  of  psoriasis demand a combina-
tion of internal and  external treatment, but  where  the  general health is good, local treatment is of
chief importance.  In  estimating the  value  of any local application  or plan of treatment it must
always be borne in mind that  psoriasis is rarely stationary, but tends to improve  or to completely dis-
appear at certain seasons of the year.   The  value of a remedy can only be determined, therefore, by
observation of its effect in a large number of cases.
     In the local treatment of psoriasis, our aim should be three-fold, viz., to soothe the skin, to soften
and remove the scales, and to promote absorption of the infiltrated patches.  In no disease of the skin
is bathing of more  importance than  in psoriasis.  The Turkish bath fulfills each of the three indica-
tions above mentioned, and  often does more  to improve  the general  health  of  the  patient than the
administration of drugs.  When  the psoriatic patches are red, itchy and irritable, as they frequently
are, the mistake is too often  made of giving  arsenic internally, and applying  stimulating applications
to the diseased  skin.  It is far better, in such cases, to prescribe a daily bath with inunction of cosmo-
line, or  vaseline, until the acute inflammatory symptoms have subsided. Intense  itching may be
allayed by means of a lotion of carbolic acid  (10-15 per cent.) in glycerine.  The irritability of  the
patches being subdued, soap frictions may be added to the bath  to  remove the accumulated epidermis,
although, when the scales  are but moderately thick, they are  quickly softened  and  removed by the
stimulating ointment employed  to lessen the infiltration of  the skin. When in inveterate cases the
scales are like plates of  horny armor, they need to be softened by painting them with acetic acid  and
scraping them off with a curette, or by enveloping the limb, or even the body, in a closely-fitting gar-
ment of  vulcanized rubber cloth, worn with the smooth side  next to the skin.   To  the red  and
thickened  patches now exposed  may be  applied one of numerous  stimulating  remedies of variable
strength.   Tar  has been most extensively employed, and its most convenient form, the  oil of  cade, is a
serviceable application.   It should be rubbed  into the patches in its pure state, as it is of little service
when diluted.  The mercurial preparations used in the form of ointments are scarcely inferior to tar in
their effect, and vastly superior as regards  the  cleanliness and comfort of the patient.  I rarely use
anything but the ointment of  ammoniated mercury upon  the  face  and  scalp, while for patches on the
body I have used with satisfaction an ointment of calomel (10 per cent.)  in  cosmoline.  Recently a
remedy has come into use which acts  with surprising  effect in many cases of  psoriasis.  And it is in
those inveterate cases which have heretofore resisted treatment that goa powder,  or its active constitu-
ent, chrysophanic acid, displays its brilliant curative powers. In the irritable cases  it fails, or aggravates
the disease, and in those cases which yield readily to  the other applications already mentioned,  chryso-
phanic acid  cannot be recommended, on account of its objectionable qualities, viz., its  liability to
inflame the skin and to stain the clothing.   It is best employed  in  the  form of an ointment, made by
dissolving  the  acid in  hot lard  or  vaseline.   The strength  may vary from five to twenty per cent.
according to the severity of the disease and the susceptibility  of the healthy skin to its action.
                                                54 
LUPUS  VULGARI'
%RA^y 
1 
LUPUS   VULGARIS.
Case.—G. W., set.  30.—Patient at the clinic of the University Medical College.   The  disease had
         existed  for twenty-one years.  It began, according to  patient, in the form of a small scaly
         pimple  midway  between right eye and ear, a region now occupied by cicatricial tissue.  It
         spread very gradually, in  spite of the endeavors of several physicians, who  employed both
         internal remedies and caustics.  Four years before the photograph was taken a  patch appeared
         upon  the  scalp near the vertex.  This has not been treated  as yet, and is  slowly enlarging.
         At the college clinic Dr. Piffard scraped with the dermal curette a portion  of  the patch near
         the ear.  On a subsequent occasion he scraped and cauterized a portion  of the lower edge of
         the patch, the patient being under the influence of chloroform.  The patient now  being trans-
         ferred to my care, I  endeavored to check the spread of  the patch, and particularly to prevent
         its further extension upon the eyelid.   Caustic potassa in solid stick was applied  successively
         to portions of the edge of the patch.  Absorbent  cotton wrapped about a probe and dipped in
         the liquefied potassa  was used when working upon the  eyelids.   By means of these applica-
         tions, frequently repeated, the elevated margin of the patch was soon reduced to a level with
         the adjacent  healthy skin, the ridge  of  lupus infiltration being converted into  a cicatricial
         belt.  The patch was then covered with adhesive mercurial plaster for a few weeks.  It is
         now  quite smooth, of a dull  reddish  hue, looking at a distance  somewhat like  a faint port-
         wine  mark.   The center, composed mainly of old cicatricial tissue, is  comparatively white.
         There are neither tubercles, pustules nor scales at present.  The lower  portion of the patch,
         to which the thermo-cautery was applied, is remarkably smooth, and the edge of the patch
         can hardly be made out, as the redness of the burn shades off into the surrounding healthy
         skin.

     Lupus is a chronic affection, presenting circumscribed, dull reddish patches of diseased skin, which
tend to ulcerate,  and invariably leave a scar.   Except  in  its severe forms there is a notable absence
of pain, itching and other subjective sensations.  The disease runs a variable course in different  cases,
and  presents variations in appearance  at different stages.  The most characteristic lesion is a  small
yellowish-red papule, which  can frequently  be noted at  the margin or  in  the vicinity  of  a patch.
It is not  present in all cases.  Sometimes the disease begins as a dull reddish macule,  which becomes
slightly elevated  and scaly as it increases  in size.   This  mild or erythemato-squamous form of the
disease may occur in one  or  in several patches of irregular form.  It creeps slowly over the surface
attacked, and in many cases disappears  without ulceration.  The  cellular infiltration, however, usually
produces a certain amount of atrophy of the skin, and being absorbed, leaves a more or less distinct
cicatrix.   When, as is commonly the case, the disease develops by  the  aggregation  of  small, solid
papules, the patches usually  present an elevated, crescentic and sometimes a scalloped border.   Not
infrequently a prominent  ridge of  infiltrated skin will  be seen  surrounding a  tolerably smooth, and
                                               55 
LUPUS   VULGARIS.
in some cases a cicatricial center.  As the papules of lupus increase in size and become tubercular they
evince a  marked  tendency to soften, and to form small ulcers, especially at the advancing border of
the patch.  This now will present a  reddened and scaly surface, with numerous small  crusts near the
periphery and areas of cicatricial tissue in the center.  When the cellular growth invades the  deeper
portion of the skin ulceration is likely to occur, sometimes assuming  a serpiginous form, and often
proving difficult to heal.  The face  is  the favorite seat of the disease, and the cheeks, upper  lip and
wings of the nose are affected with great frequency. It also occurs on the scalp, trunk, and particularly
on the backs of the hands and fingers.  The mucous membrane of the oral and nasal cavities may be
affected coincidently with the skin.
     The  disease  is  never congenital, and  rarely, if  ever,  hereditary.  It  generally  develops iD
childhood or early life, although I have  noted its first appearance in a man  of sixty.  The sexes
suffer with about equal frequency.
     Lupus is regarded by some writers as being invariably a cutaneous manifestation of  scrofula.  It
surely occurs in  some patients who  are far from presenting signs of  a strumous diathesis.   On the
other hand, scrofulous abscesses often lead to an ulcerative process in the skin  (scrofuloderma), which
surely ought not to be designated as lupus.
     The diagnosis of lupus is generally easy, but the  tubercular  and ulcerative  forms of the  disease
sometimes bear such a strong resemblance to syphilis that nothing but experience in  the  treatment of
the two diseases will enable  one to decide as to the  nature of the case.   The age of  the eruption
is of  the  greatest importance in  arriving at  a  conclusion, since lupus is  a disease of slow progress,
while the cutaneous  manifestations of  syphilis  develop with  considerable  rapidity.   If a patch
of tubercles  or an ulcer on  the  face  is of doubtful nature, it may be considered syphilitic  if it is
extensive  and  has developed within a few months,  while, if it has existed  without much  change
for several years, it is assuredly lupus.
     Lupus  is  by no means the obstinate or incurable disease which the majority of  physicians
think it to  be, provided the patient  will submit gracefully to the proper treatment.   This is  simple,
though in many cases  it is of necessity somewhat heroic.  The quickest way to cure the  disease
is to destroy it, and the scar resulting from treatment will probably be much  less unsightly than that
which would, in  time, result from the ravages of the disease.   Scarring indeed, is  inevitable in
all  cases  save  the most  superficial.    These  mild   cases may be   successfully treated  by  the
employment cf  vigorous  soap  frictions,  and the  application  of highly  stimulating  ointments.
But when the patch is deep-seated, the speediest, surest, and even the  pleasantest plan of treatment
is  to excise it while it is small.   Much destruction of tissue and consequent disfiguration might  have
been spared in hundreds of cases by a timely use of the knife.
     Where tubercles  are  scattered  over a considerable extent of surface,  an arsenical paste,  or a
fifteen per cent, ointment of pyrogallic acid may be applied to  the patch, or each tubercle  may be
bored out with a solid conical-pointed stick of fused nitrate of silver.   In cases of extensive ulceration
healing may sometimes be induced by the use of acetate, sulphate or chloride of zinc, caustic  potash,
nitric acid,  or  the acid  nitrate  of  mercury, but it  is  usually advisable to destroy  the diseased
tissue by scraping  the  ulcer thoroughly,  and  then applying the actual  cautery.
                                               53 
LUPUS  frythe y. 
 
LUPUS    ERYTHEMATOSUS.
Case.—V. W., set. 45.—Patient of Dr. Weisse, presented at a meeting of the N. Y. Dermatological
         Society.  The disease, which was of eighteen years' standing, began as a red patch on the right
         cheek, and extended gradually until it invaded the forehead, ear and neck.  The affected skin
         was red  and hot, rather smooth, but scaling slightly in circles extending  peripherally from
         the  nose.  It  appeared tightly drawn, was moderately thickened and but slightly elevated.
         The margins of the eruption were sharply defined.

    Lupus erythematosus, though described in most text-books apart  from lupus vulgaris, is  not to
be considered as a distinct affection.  It is  merely a peculiar variety of lupus, in which the cellular
infiltration  is quite  superficial, involving in a characteristic manner the  sebaceous follicles.   Unlike
the common  lupus  already described, this comparatively  rare  form   does  not  tend to  ulceration,
although, when the infiltration is sufficient  to produce atrophy of  the skin, a cicatricial surface results.
The name lupus  erythematosus is  an unfortunate one, since  the common lupus (L. vulgaris)  is
frequently superficial and erythematous, and confusion has arisen from a restricted use of the adjective.
The distinctive  peculiarity of  the variety  of  lupus now under consideration being the involvement
of the sebaceous  glands, it would be far  better  to employ a  term such  as  lupus sebaceous or lupus
acneiformis.  Hebra, who first described this peculiar  affection of the skin  in  1845, gave to it the
name Seborrhcea congestiva, but later saw fit to class it as a form of lupus.
    The course of  the disease is notably  chronic. In rare instances  it  has been observed to attack
a large extent of cutaneous surface like an acute eruption, and to be accompanied  with severe consti-
tutional symptoms.   Frequently injudicious treatment or some other cause may induce a patch of long
standing to become acutely congested.   Such an exacerbation of  the disease  is often coincident with
the development of new lesions.  As a rule the affection exerts no perceptible influence on the general
health of the patient.   It is far more likely than the common form  of lupus to be accompanied by
subjective sensations, such as burning or even a slight itching.  The disease usually makes  its  appear-
ance in  the  form of small, red, pinhead-sized macules, which will not  quite disappear on pressure.
They present slight depressions in  the center, where the sebaceous follicles open upon the surface
of the skin, or, as is usually the case, these  minute  pits are filled with fine, adherent, fatty scales.
These characteristic primary lesions may be disseminated or grouped.   In the latter case  they form
patches of a dull reddish or violaceous hue, dotted with numerous whitish points, or covered with fine
adherent scales, which, when gently raised,  show prolongations from the under surface corresponding
to the sebaceous  follicles.  The patches, of which there may be one or several,  are usually sharply
                                              57 
LUPUS  ERYTHEMATOSUS.
defined.   They may have an irregular outline, with primary efflorescences scattered about the margin,
or be circular in form, in which case they are apt to become depressed as the disease progresses.  The
disease almost invariably attacks  the face.  Occurring, as it frequently does, upon the bridge of the
nose, and extending laterally  upon  either cheek,  the configuration of the  patch  is suggestive  of a
butterfly with outspread wings.
    .Like the vulgar form,  lupus erythematosus is sometimes  associated with  indications of struma.
It is more frequently met  with  in  females, and in this sex is more apt to run a severe course.  It
does not develop in childhood, as  does lupus vulgaris.
     It is often quite difficult  to  distinguish lupus erythematosus from the superficial  or erythemato-
squamous form of  lupus  vulgaris.  But  since the  nature of these two varieties  is essentially
the  same, and  a  similar treatment required in  either  case, the  differential diagnosis is of  little
practical importance.  Still, it is well  to  bear in mind, that,  whereas one  variety  has numerous
white specks, or in some cases  minute horny projections upon  the  diseased  surface,  the other
variety  presents small  papules,  and at a  more  advanced stage,  tubercules, pustules and  ulcers.
The age  of the patient may furnish  a clew, as only the common variety  of lupus is met with before
the age of adolescence.   A  patch of chronic eczema of the face, or a rosacea, might  be  mistaken for
erythematous lupus,  and  harm  result from  the  unnecessary use  of caustic  applications.  But
these affections have not the sharp border of lupus, and while the former differs in being quite
itchy, and perhaps moist, at  times, the latter may be  recognized by its development of  tubercles and
pustules.
     In the treatment of  this affection,  I know of  no indications for any particular remedy, although
whatever will  improve  the general health  of  the  patient should  naturally be given; it  may
be  iron  in  one case, cod-liver  oil  in  another, and   arsenic,  strychnia,  or  phosphorus in  others.
The internal use of  the  iodide of starch  in lupus erythematosus lias recently been  recommended
upon such  good authority  (Anderson), that I mention it, though without  experience in its use.
The local treatment is  of the  highest importance.    Frictions with  green  soap may be at first
used  to  remove the scales and  to  promote absorption of  the  diseased  tissue.    Tar, sulphur,
and  other stimulating applications may now be used with  more or  less effect, but  my experience
has  led   me  to rely  far  more  upon  the  constant application  of adhesive  mercurial  plaster.
In  some mild cases this  will  effect  a  cure.   Generally,  however, stronger  applications  are
called for.   A  tincture of iodine  of  double  strength combined with an  equal part of  collodion,
may be  used  as a varnish,  and renewed as  often  as  it  peels.
     Where   the  infiltration  is  deep,  a  strong  solution  of  caustic  potash  may be  applied  to
successive portions of the patch.   In severe  cases  the dermal  curette may be employed to scrape
away the diseased tissue,  and the raw surface  very  lightly  touched  with  the galvano cautery.
When active congestion is  present, caustics should  be withheld until  after  a course  of soothing
applications has put the  skin in a less  irritable condition.  Otherwise, a mild  caustic may stimulate
rather than  decrease the  affection.
                                              58 
EPITHELIOMA  superficial
EPITHELIOMA  kodfns 
 
EPITHELIOMA.
I.—Case  of Epithelioma rodens.—Negative from the Bellevue collection.  The disease in this case
         probably began upon the lid, gradually invaded the conjunctiva and destroyed the eye.  The
         peculiar elevated and sinuous border of the ulcer is well shown in the illustration.
II.—Case of Epithelioma  superficial^.—Patient  at  the skin clinic of the  University Medical
         College.  The  circular form of the patch, with its nodular margin and central depression, is
         quite characteristic.   The growth was removed by Prof. Piffard in the presence of the class,
         and the wound healed quickly.

     The term cancer implies a malignant growth  which tends to invade and  destroy  certain  tissues
(notably the cutaneous  and glandular), which is prone  to  recur after excision, and  which induces a
peculiar diathetic condition  frequently ending  in death.   Epithelioma is one of the least malignant
forms of cancer, and  develops primarily on a cutaneous or mucous surface.
     Like  other affections of the skin, epithelioma presents a variable appearance in different subjects,
in different parts of the body and at  different stages of its growth.  Four clinical forms may be
described, viz., a superficial, a rodent, a deep-seated and a papillomatous form.   These forms or  phases
may present themselves in a single case as successive stages in the progress of the  disease.
     The superficial  form appears at  first  as a small, roundish, slightly-elevated patch of  colorless
infiltration.   It  may remain in  this condition for three or four years, scarcely noticed by the patient.
Slowly one or more flattened  papules of a yellowish-white or waxy hue are developed,  forming a rather
prominent and dense growth, usually of circular or oval form.   Arriving at the size of a three or five-
cent piece  the  central  portion becomes depressed,  while  the  border  remains smooth and glossy or
assumes a nodular aspect.  Frequently the growth is composed of  three or four nodules grouped so as
to resemble the crown of a molar tooth, with fine blood-vessels running between them,  and ramifying in
the central depression.   When superficial ulceration develops a thin scab in this central pit, the growth
bears some resemblance  in form and appearance to a well-developed vaccine vesicle.
    The rodent  form, i. e., a rodent ulcer, may begin, as has been intimated, in the  center of  the
superficial, button-like epithelioma, and, by extending in depth and circumference, gradually convert
this  into a circular, polygonal or irregular  ulcer with a sharp-cut border, an elevated,  indurated and
flattened margin, and a clean  glazed surface.  By the growth of dense waxy nodules at the periphery,
and the necrosis  of  the  inner surface  of the wall, this ulcer increases in size, and in a few years
becomes as  large as  a  silver dollar, or  larger.  It is remarkably slow in its growth, and may exict for
fifteen or twenty years without affecting the general health of the patient, or involving the neighboring
lymphatic glands.  The rodent epithelioma often  originates in an insignificant "pimple" or " wart," 
EPITHELIOMA.
which  becomes scratched or injured,  and forms  a blackish  scab.   This,  when  removed,  discovers
a small ulcer of  trifling appearance, but which shows little tendency to heal.   If, under treatment, it
cicatrizes, it is only to break out again  and to form a larger  sore.   This ulcer may be annular, and
inclose an island of cicatricial tissue, or crescentic in form, or serpiginous in its character, creeping over
the surface  and leaving a superficial scar in its track.  The induration is  so superficial as not to be..
always readily distinguishable, destruction of tissue seeming to keep pace with the  new growth.
    The deep-seated or infiltrating form of epithelioma may follow the superficial or rodent form,
and its clinical features will depend  upon its  location.  When  the eyelid is attacked  the  disease
usually begins as a superficial nodule.   In a few years or sooner the whole palpebral opening becomes
affected,  and the  disease  assumes the rodent form.  Destructive  ulceration  may  now  attack the
conjunctiva and quickly  destroy both lids and  eye.   Indeed, the  disease often progresses  in depth,
destroys the bones of the orbit, and produces a most frightful cavity.   A similar destructive process
sometimes ensues  when the disease is situated near the nasal  orifice or the oral commissure.  When
the infiltrating form begins as such, which is usually  the case upon the lower lip, there is developed
a hard tumor of  pea  or marble size, slightly  elevated  above the surface.  It is at first  movable,
but later adheres  to the  subjacent tissues.  This  tumor is almost invariably  single, and  eventually
becomes  an ulcer, through necrosis of the central portion of the mass and the formation of an abscess.
It runs a more rapid course  usually than the  rodent ulcer, and differs from this form of  epithelioma
chiefly in  its tendency  to implicate adjacent glands.   The  papillomatous  form  is' uncommon,
and may be regarded as a peculiar warty development of the superficial or rodent form.
    Epithelioma  usually  attacks the  face, thirty  per cent,  of all  cases  appearing upon the lip.
It occasionally occurs  upon  the  genitals, particularly in the male, and may occur elsewhere.  The
superficial or rodent form occurs usually about the eyes  and nose,  while  the favorite seat  of the
infiltrating form is the lower lip.   On the scrotum  the growth is at first superficial, but soon progresses
in depth.   On the  glans penis, and  especially  the coronal  portion, the  superficial or papillomatous
form  is  most apt to occur,  frequently  with swelling and  induration  of  the lymphatic vessels of
the dorsum  penis.  Epithelioma usually  occurs  in  patients  over fifty,  but it  may occur  before
that age.   Seventy-five per cent, of  cases occur in  males.  In  old persons  subject  to epithelioma,
a peculiar atrophic whiteness of the  skin over the  temples is  sometimes  observed, with  various
indications of degeneration, such as numerous small specks of  xanthelasma and patches of seborrhcea
covered by horny and blackened scales.   The etiology of the disease  is obscure, and  in  most  cases
neither patient nor physician  can assign  any reasonable cause for its  development.   In a  small
percentage of cases  a  family history  of cancer can be  traced.  Local  irritation  undoubtedly  acts
as a predisposing cause, but  its influence  has  been  greatly overrated.   For  instance, the  term
smoker's  cancer has been used as a synonym for epithelioma of the lip,  and where a  patient, like
the subject of our illustration, has for years performed his daily labor  with pipe in  mouth, the
name might seem to be  warranted.   But other men smoke  constantly at their work  and  do not
have epithelioma,  while the  disease frequently attacks women,  and men who never  smoke.   In like
manner the  chimney-sweeper's  cancer, or epithelioma  of  the scrotum, occurs  in  countries where
the construction of houses is such as  to furnish no  occupation for this  class  of  laborers.
                                               60 
EPITHELIOMA 
 
EPITHELIOMA.
Case of  Epithelioma of  Lip.—P. D., set,  73.—This  patient came from  a long-lived ancestry,
        his father having died at the age of 105.   He  had always  been  a  strong, healthy, hard-
        working  man before  the development of  the epithelioma, and  had  worked  generally
        with a pipe in his mouth.  Two  and a  half  years before  the photograph was  taken, a
        small  lump  began  to be felt  on  the  left side of the  lower lip.   This became hard,
        superficially  eroded, and  covered with a scab.  Gradually the growth invaded the greater
        portion of the lip, although  it was  over two  years  before destructive ulceration began.
        When  applying for treatment at the Northwestern Dispensary, the  lower lip presented a
        deep irregular ulceration with a marked degree of induration.   Near the oral commissure,
        the borders  of the ulcer  were quite protuberant and everted.   In  the  central portion of
        the lip there had been loss of tissue, and there was such a continual dribbling of saliva
        that the  patient usually   kept  a  handkerchief  pressed upon his  chin, and in sitting for
        his photograph it was necessary to put  a rubber  cloth  over his  breast to  protect his
        clothing.   On  upper lip, beneath one nostril,  there was a  pea-sized, whitish,  indurated
        nodule.   At the junction of  the wing of  the  nose and lip there was  a slit-like ulcer,
        with a  slightly indurated edge  and  bottom, nearly healed.  This is  not  seen  in  the
        illustration, being  in  the shadow  of the nose.    Patient stated that ten  years before he
        was cut  at  this spot by  a barber.  The  narrow,  depressed  cicatrix  had  only  become
        indurated and slightly eroded  during the  past three months.

     The  treatment  of epithelioma  usually  demands  prompt  and  active  measures.  When  the
disease  is evidently   increasing  in  extent  by involving  adjacent  tissue,  there should  be  no
temporizing.   The earlier the  patch can be destroyed the better,  and it is as well to destroy a little
healthy skin at the  margin  of  a  small patch as  to allow the  disease to  invade and destroy it.
When progress is very rapid, the immediate removal of the diseased  part, or  its complete destruction
by means  of  a powerful caustic, is the  only treatment worthy of being considered.   As to value of
tonics, good food, and fresh air, I  need not  speak, as no  one will doubt  their indirect  influence in
lessening the  spread of  the  disease, and in  augmenting the beneficial effects  of an operation.   But
while internal treatment  may be advantageously employed to put  the patient in the  best  possible
condition  before attempting to remove the growth, no  time should be lost  in  the  endeavor to
eradicate  it by internal medication whenever  it evinces  a  disposition toward active growth.   The
question as to  whether internal medication  can possibly  have a direct  effect upon the growth of
epithelioma is sub judice.  Although the results  following  the use  of  most  of  the  anti-cancerous
remedies which have  enjoyed  a widespread  though transient reputation, are either  disappointing or
                                              61 
EPITHELIOMA.
 delusive, it by no means follows that a specific remedy, or one acting as decidedly as  does quinine in
 intermittent fever, may not exist.  The majority of writers agree in rejecting the idea that any direct
 influence  can  be  exerted  on epithelioma  by the  use of  internal  remedies.   A  certain number
 of  experienced physicians claim, on the other hand, that the disease is amenable to internal treatment.
 Neligan, who describes the rodent form of  epithelioma under the  head of lupus devorans, lays
 stress upon the importance of administering iodine, iodide of potassium, and cod-liver oil  in small
 doses continued for a  length of  time.  He regards the employment of topical agents as auxiliary to
 the constitutional treatment, which  he  claims should  engage the chief attention of the physician.   I
 have not  such  confidence in the  efficacy  of these drugs, but  in  cases  where the disease  is  not
 progressive, and especially where the patient objects to the use of the knife or cautery, I would advise
 the administration of the remedies mentioned, or preferably arsenic, in small and long-continued doses.
 Fowler's Solution might be advantageously used both internally and externally, since in  some cases of
 epithelioma with slight ulceration, healing has'been observed to follow a daily penciling of the sore
 with ten to twenty drops of the solution (Anderson).
     In the use  of caustics in  epithelioma failure  and  even  harm  often  results  from an insufficient
 application of the  caustic, through  fear of going  too  deeply,  or  occasioning  too  much pain.  The
 growth, instead  of being totally  destroyed, merely becomes inflamed, and is  stimulated to a further
 increase in extent.   As a rule the burning must be thoroughly done or not done at all.  The  choice
 between the  knife and caustic  depends upon  the extent, location and  character of the growth, when
 there is no whim or prejudice on  the part of the patient.  When the  growth is large, it is usually
 advisable to scrape  or excise as thoroughly as possible, and to apply the  deliquesced  chloride of zinc
to the raw  surface, especially when  fears are entertained of  a recurrence of the disease.  When  the
growth is superficial, one or two applications of a caustic paste will  answer the purpose.  Hebra's
arsenical paste (arsenious acid,  one part, red sulphuret of mercury, three parts,  and cold cream, twenty-
four parts), though a painful application, acts merely upon the diseased tissue, sparing the healthy skin.
It should be  applied on a piece of linen, and allowed to  remain for twenty-four hours, being renewed
if necessary.  Marsden's paste is prepared as follows :  To equal parts of arsenious acid and  powdered
acacia add  sufficient water to moisten and  make a thick paste.   This is to  be spread over the cleansed
surface of  the part to be destroyed,  and covered with absorbent cotton.   A slough forms, dries, and
falls in a week  or more.  As a  rule, the best caustic  is  the one with which the operator is most
familiar.  I prefer  the caustic potassa,  either solid or liquefied.  This forms a blackish slough, small or
 large, as is  desired.   Its action can be readily checked by applying vinegar or  dilute acetic acid.  The
 pain resulting is not very severe, and quickly  ceases, having  this great advantage over an  arsenical
 paste.   An ointment of pyrogallic acid  (20 per cent.) applied  as  a paste has recently  been  highly
 recommended.
     The removal of an extensive epithelioma, occurring upon the lip or elsewhere, frequently involves
 a plastic operation  to restore the lost parts.  In  such cases, the  knife is far preferable to caustics
 as the removal  of the disease and the  restoration of the part can be combined in one operation.   In
 excising a  small growth from the neighborhood of the eye the  rule is  commonly laid down that  the
 line of the cicatrix  should radiate from the center of the pupil, to prevent distortion of the lids.
                                               63 
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TRICHOPHYTOSIS.
     Trichophytosis is an affection of the skin resulting from the growth of a microscopic plant called
 the  Trichophyton.   It is quite familiar to the laity  as " ringworm."   In dermatological literature it
 appears  under a confusing variety of  titles, the most  common  of which arc  Herpes tonsurans and
 Tinea tricophytina.  It is one of the  three vegetable  parasitic  diseases  of  the skin, the other  two,
 chromophytosis and favus, having already been illustrated and described.  Like these, trichophytosis is
 contagious, possessing  the quality in a far more marked degree than chromophytosis.   Children are
 more susceptible than adults to contagion, and when  once  introduced  into a  family or school the
 disease  is apt to be conveyed from one to another until nearly all  are affected.  It  is sometimes
 observed in horses, cows, cats, and other domestic animals.
     From the peculiarities presented by trichophytosis, according to its location, five regional  forms of
 the disease may be conveniently described.  These are  given below in  the order of their importance,
 and  with their most frequent synonyms appended.

                    Trichophytosis  capitis.  . . . Tinea tricophytina tonsurans.
                          "        barbae. . . , Tinea sycosis.   Sycosis parasitica.
                          "        corporis.  . . Tinea tricophytina circinata.
                          "        cruris.  .  . .  Eczema  marginatum.
                          "        unguium.. .  Onychomycosis.

     On  the general surface of the body (T. corporis), where the eruption can  be most  satisfactorily
 observed, the disease begins either in the form of a group of minute  vesicles, or  a  small, reddened,
 scaly macule, which, increasing in size, presents  a circular  outline and  a slightly  elevated margin.
 The skin is but slightly inflamed as a rule, and at the advancing border of a typical  patch a circle of
 minute  vesicles may  be sometimes  discovered upon close examination.  The patch extends  at the
 periphery, and  as the elevated margin creeps over the  healthy skin, the central portion  becomes but
 slightly,  if at all elevated, and far  less scaly than  the border,   hi many cases  the  inclosed  area
 becomes quite  normal or remains somewhat  pigmented,  and the eruption  presents a characteristic
 annular appearance.  There is rarely but a single focus of disease, and  in many instances a score or
 more of  circular patches may be counted.  Where these  are near  each other  they coalesce as  they
increase in size, and large patches of irregular outline  result.
     Trichophytosis of non-hairy parts (T.  corporis) occurs  in  both sexes, and at  almost  all ages.
It has been reported as occurring upon  an infant six hours old.
     In  the genito-crural region (T. cruris) the parasite  grows luxuriantly, owing  to the  heat and
                                              63 
TRICHOPHYTOSIS.
frequent moisture of  the parts affected, and the eruption extends upon the buttocks and inner surface
of the thighs.   It  produces  in this region an unusual amount  of  dermatitis, and  in many subjects a
pronounced eczema,  In the  tropics this form of the disease is common and obstinate.
     On the scalp (T.  capitis) or bearded portion of the face (T. barbae) the disease begins in the form
of one or several small, scaly  patches.   After having existed a short time  without  treatment, the hairs
springing from  the patch lose their luster, become brittle, and finally break off very near the surface
of the skin.  The  patch, which has now perhaps reached the size of a cent or quarter dollar, appears
bald at first glance, but on close inspection is found  to be covered with white powdery scales, through
which the broken  hairs  project like stubble.   Trichophytosis capitis is never seen in adults, although
the  occurrence  of the disease upon the bearded  portion  of  the face is by no  means uncommon.
Trichophytosis of  the beard  may be contracted in the barber's chair, and constitutes one form of the
so-called " barber's itch," which term is usually made to include eczema and sycosis.   It does not arise
from the use of  an unclean razor, as is commonly imagined, but from the  use of a damp, soiled  towel,
which furnishes  a most excellent nidus for the growth of any vegetable parasite.
     Trichophytosis affecting  the nails (T. unguium) is extremely rare, but it may occur either alone or
in connection with rings of the disease upon  the hands or other portions of the body.   The nails, one
or more of which may be affected, become thickened, discolored and friable.  Those of the fingers are
more likely to suffer than those of the toes.
     The diagnosis of  trichophytosis is generally so simple that  it can be made by the patient.  When
the eruption, however, has been  treated and partially cured, or when, on the other hand, it has been
maltreated or overtreated, so that it has become obscured by a secondary eczema, the physician must be
cautious  in venturing an opinion until  a  microscopic  examination  has determined the presence or
absence of  the  parasite.   The diseases with which it is most likely to be  confounded  are  favus,
psoriasis and eczema,  In the  early  stage  of  favus, before   the characteristic  yellow  crusts have
developed, the appearance presented is very similar to ringworm, and a diagnosis can only be based  on
a microscopic examination of  the  hairs.   Psoriasis sometimes appeavs in the form of circular, reddened
patches,  with a  very  moderate amount of scaling, closely resembling the patches of trichophvtosis
and when on the wane they tend moreover to heal in the center, and form  rings which have often been
mistaken for ringworm by physician as well  as  patient.   The peculiar location and  symmetry of  the
eruption in psoriasis will generally serve as a guide in diagnosis.
     Eczema may simulate every skin disease.  In its dry and scaly stage,  especially when occurring as
one or more small  roundish patches, such as may be met with on the face, breast or hands, it resembles
trichophytosis in being hypersemic, scaly and itchy in a moderate  degree.   The patch of  eczema
however, is rarely circular, and generally shades off into the surrounding skin instead of presenting an
abrupt margin.  Furthermore, there is never any tendency toward healing in the central portion of the
patch.  Trichophytosis capitis is often confounded with eczema, but the  circular  form of  the  patch
the absence of moisture, and particularly, the mealy epidermis  and the short, broken hairs ouo-ht to
reveal the nature of the  affection in most cases.  In  all doubtful  cases  of  skin disease  where
trichophytosis or one of the other parasitic  diseases is suspected, microscopical examination of a few
scales or hairs must be resorted to in order to  settle the question of diagnosis.
                                               64 
TRICHOPHYTOSIS
CORPORIS 
 
TRICHOPHYTOSIS.
 Case.—An infant  with  an acutely inflamed patch upon  the  wrist.   The  motion of the hand had
         produced one or two painful cracks.  The disease had been transferred to the forearm of the
         mother, where it  appeared in the  form of a typical, orbicular, scaly patch, consisting of two
         well-marked concentric rings.

     As trichophytosis is essentially a dermatitis of greater  or less severity, resulting from the growth
 of  a parasitic fungus in or  upon the skin, its  treatment must consist mainly in the use  of local
 measures.  As the trichophyton will take root and thrive upon a perfectly healthy skin, it is evident
 that internal treatment cannot  effect a cure.  At the same time, clinical observation  teaches that  in
 certain  conditions of the system the skin affords a more  favorable soil for the  development of the
 fungus.  The affection appears  to be more  disposed to spread, and to be less easily checked by  the
 action of parasiticides, when the patient is ill-nourished or  physically depraved.   Internal remedies
 may, therefore, in a slight degree at least, prove conducive to a cure, and in the majority of cases it is
 advisable to look well after the general health  while carrying out the local treatment.  Cod-liver oil,
 by promoting nutrition of the skin, and bathing, by  rousing  into activity  the cutaneous functions,
 produce  a  beneficial effect, and are especially called for by the class of patients affected, many of
 whom are of a lymphatic temperament, averse  to fatty food, and with  a dull, torpid, pasty skin.
     The main objects of  local treatment should be, (1) to reduce any undue amount of  inflammation,
 should such be present, and (2), to destroy the  very last germ of the parasite.  Success depends upon
 the  appropriateness of the  remedy.  Failure may result from  the use of  one which is too weak, or
 from the too long continued use of  one which is unnecessarily strong. In most cases vigorous  local
 treatment may be instituted at once, but on the soft skin of childhood, and on certain regions in the
 adult where the skin is thin and easily inflamed, it is preferable to  employ the milder  parasiticide
 remedies for a greater length of time, than  to risk the  production of a severe dermatitis or eczema.
 To  destroy the parasite it is  usually necessary to  destroy the epidermis and hairs which are  invaded.
Where the  disease  occurs on non-hairy parts, it is commonly superficial and easily cured.   As the
spores and  mycelium  grow between the cells of the horny layer  of the epidermis it is evident that
whatever will remove this layer will carry away with  it the parasitic growth.  When  this, however,
has grown  down into the hair follicles, and even penetrated the hairs themselves, the disease is not
 readily cured.   It may indeed prove  exceedingly intractable, and recur after it is apparently well.
     On the general surface  of  the  body,  where the hairs  are fine  or  absent, the disease can be
 removed mechanically by scrubbing the affected part  daily  with sapo  viridis.   This  alone  will
                                              65 
TRICHOPHYTOSIS.
usually suffice, but the patient is apt to be more contented, and indeed, the cure  may be hastened, it
he applies an ointment or a lotion to the  affected part  between the soap frictions.   An ointment of
thymol  (three to five  per cent.), or  of carbolic acid  (ten  to  fifteen  per cent.),  or a lotion  of  the
hyposulphite of sodium (twenty per cent.), will be found very useful.  These remedies have the power
to arrest the development of vegetable spores, if not to utterly  destroy them, but to secure their
beneficial action they  must be applied with great frequency, as  the parasitic spores  multiply with
amazing rapidity, and no time  should be  lost between the applications.   Most  of  the so-called
parasiticides, however,  merely  have an astringent or slight caustic action, and would  be more properly
termed epidermicides.  Common ink, and a copper cent dipped in vinegar, are valued remedies among
the laity, and not wholly without effect;  but the physician will do better to paint  the  patches with
acetic acid or the tincture of iodine.  The latter is objectionable when the affection is on the face or
hands, owing to the staining of the skin.  If decolorized, the tincture loses much of its efficacy.   A
still better application is a five per cent, ointment of chrysophanic acid, or one of the remedies already
spoken of as acting in  a truly parasiticidal manner.   Blistering a patch with cantharidal collodion, or
some  other epispastic, is a most efficacious plan of removing the disease, but is rarely called for.
    In  the  genito-crural form of the disease the parasitic growth is rather difficult to  get  rid of, as
strong applications  must be used with caution.  But  the chief difficulty in treating this form arises
from  the fact that it is so frequently associated with an  erythematous eczema,   The skin is reddened,
thickened and itchy, and even when  the  parasite has been destroyed  by the use  of pure sulphurous
acid,  or the remedies already suggested, the outline  of the  patches and their  general  appearance
remain pretty much the same.  In other words, the eczema still remains to be treated.
    The treatment of  trichophytosis  capitis is similar to the treatment of favus, after the crusts have
been  removed, and  consists mainly in epilation.  In trichophytosis the hairs are more  difficult to
extract  than in  favus, since, owing to the penetration of spores into the fibrous portion of  the shaft,
the hairs break, and a patch  has to be epilated  repeatedly before  the  scalp is left smooth and clean.
The prognosis in this affection is much better than in favus of equal extent, since the hair  bulbs are
not so apt to be  destroyed, and consequently the bald, depressed spots and the sparse, wiry hair, which
usually  result from a severe attack of favus,  do not follow. After trichophytosis of the  greater
portion of the scalp, the hair may in time grow as thick and strong  as ever.
    Epilation may be performed in various ways.   I have  made some  use  of an epilating paste,
composed of resin, wax and balsam of tolu, molded into the form of a convenient stick,  about an inch
in diameter. One end of this being  melted  by heat and pressed upon  the patch, a sudden twist and
jerk  wrill extract a large number of hairs at once ; but the epilating forceps are almost universally
used  for this purpose.  They should be carefully made, with broad, accurately-closing and slightly-
roughened blades.  If too stiff they are certain to tire the fingers of the operator where a patch of any
size is to be epilated.  When  the scalp or beard is recently affected,  the patches  small, and the hairs
normal,  epilation is not necessary.    The  patches  may be  shaved, and parasiticide applications
vigorously applied for a  considerable length of time.   If, now, the microscope shows no indications
of a parasitic disease after repeated examination  of the hairs and epidermic scales,  the shaving  may be
discontinued, but the patches must be closely watched for a month or two, lest the disease reappear. 
LICHEN flanus
«
LICHEN planus 
 
LICHEN   PLANUS.
 I.—Case of disseminated lichen planus.—M. A., set. 35.—Patient of Dr. Sherwell.  The eruption,
         which was of about three  months' standing, covered an unusually large amount of surface,
         being well marked upon the neck and back, where  the papules had  coalesced and formed
         large  tracts  of  diseased skin.    Both  upper and lower extremities presented  numerous
         disseminate papules, with the characteristic flattened summit and central pit.   The itching,
         which was at first distressing, decreased under treatment, and  the  papules  soon became
         reduced to macules, appearing as though they had been  ironed smooth, though still  retaining
         their glistening appearance.   The  internal  treatment in  this  case  consisted of quinia,
         strychnia  and nitro-muriatic acid,  while the bichloride of mercury and dilute hydrocyanic
         acid in emulsion of bitter almond was employed as a lotion, being rubbed into the skin after
         frequent bathing.   The patient had also  frequent  inunctions of  linseed oil, and at  last
         accounts was nearly well, having grown much stouter and improved in general appearance.
 II.—Case of aggregated lichen planus.—C. F., set. 50.—Patient of Dr. Bronson.  The  eruption,
         of about three months' standing, began as small red and itchy papules on the anterior surface
         of the forearms.   Similar lesions developed  elsewhere, and when photograph was taken,
         there were papules scattered over the legs, thighs and chest, presenting a shiny, glistening
         appearance, with a flattened summit, and a slight umbilication.  On the anterior surface of
         the wrists the papules had coalesced into large red, or purplish-red,  patches, with branny
         scales, and numerous striations, or little fissures, through the  epidermis.  The eruption at all
         points itched excessively.   The patient was ordered five-drop doses of Fowler's Solution, to
         be gradually increased, and, externally, a soothing lotion.  The patient was not  seen for four
         months, during which time the disease  had  continued, with occasional eruptions of new
         papules, while old ones disappeared.  Of the  confluent patches on the  wrists there remained
         only dark discolorations.

     Lichen is  a name which was  applied by  the older dermatologists to all diseases of the  skin,  the
lesions of which consist of persistent papules.  Several varieties of lichen were described,  but as a
more careful study of the natural history of skin diseases has shown that these are not varieties of one
disease, but papular stages or forms of widely different diseases, most of them have become obsolete as
forms of lichen, being known at present under  different and more appropriate names.  Lichen simplex,
according to many writers, is nothing more nor less than a papular  form of eczema (See plate of E.
papulosum).   Lichen lividus is Purpura papulosa; Lichen urticatus is Urticaria papulosa; while
Lichen syphiliticus is Syphiloderma papulosum, a name  expressing the nature of the disease, which is,
of course, of vastly more importance than the form and  appearance of the cutaneous lesion. There
still  occur, however, papular eruptions which cannot be considered as mere papular forms of any
disease otherwise named, and to such  the term " Lichen " is justly applied.
                                              67 
LICHEN  PLANUS.
     Lichen  planus  consists  in an  eruption  of peculiar papules,  which  may be  disseminated  or
 aggregated,  and either occupy a limited region,  or extend over a  large  extent of the  general
 surface of the skin.   The  chief peculiarity of  the papules, and one which gives rise to the name, is
 their flattened summit.   They are but slightly elevated, and though rising abruptly from the healthy
 skin, they do not possess the conical or rounded summit of ordinary papules, but appear as though
 they had  been shaved  off  or pressed down.   The  summit  is smooth and horny,  and sometimes
 presents a glistening appearance.   Usually a  punctate  depression, or umbilication,  is seen  m  the
 center of this flattened surface.  The base of the papule is often angular in its outline.  In size, the
 papules  vary greatly in  different cases, and slightly upon different  portions of  the body.   They are
 usually of the size of a  pin's head, but may be considerably  larger.  As in the case of the  papular
 syphilide, both a miliary and  a lenticular form of  Lichen planus may occur.  The  color is a pale
 yellowish-red when  the papules  are  small, and  " dull  crimson,"  or violaceous,  when  they  are
 larger, the center being somewhat lighter than the rim of the papule.   The papules may be regularly
 disseminated  over a given surface,  or strewn in groups, even  when  not coalescing.  The papules,
 when  once  developed,  persist as  such,  never evincing  the  slightest tendency  to  vesiculation  or
 pustulation.   They "do not  increase  in  size, and patches are formed by the  springing up  of new
 papules among the older ones.  The isolated  papules are not scaly ; but when they become aggregated
 they lose their peculiarities of  form  and appearance, and irregular patches of thickened  skin result,
 with a dry, harsh, horny surface, which to the touch  feels  like a file, or even a nutmeg-grater.  At the
 border of such a patch the typical papules may sometimes be observed.   The  disease is attended with
 a certain amount of itching  in every case, and the utmost distress is sometimes occasioned by this
symptom.  It develops with variable rapidity, requiring but a few weeks in some cases to produce an
 extensive eruption.   Limited patches, on  the other  hand, often  remain for months without  change.
 The disease is chronic in most cases, and shows little disposition to yield readily to treatment.
     The cause of the affection is obscure.   It  is certain,  however, that those  affected by it are far
from being in perfect  health.  The  debilitated condition of  the  system in  this disease  is more
noticeable than in eczema, and far more so than in psoriasis.   The eruption may occur in either sex,
in the young as well as the old, and upon  almost any portion of the body.  It occurs far more
 frequently in females, according to my experience, and usually  in middle life.  The anterior surface
 of the forearm and wrist is, perhaps, the most favorite locality.
     The diagnosis of Lichen planus is not generally difficult for one who has  had the opportunity of
 seeing a well-marked case of the affection.  But, as  the disease is comparatively rare, the reader may
 be  called upon  to diagnose  and treat a case without this advantage.   If  the  case is typical it will
 correspond with the description given, and with that of no  other disease.  The papular syphilide
 ought not to be  mistaken for it, owing to the regular  distribution of papules  over the body, and the
 absence of itching in the former affection.  The papules of eczema are itchy,  often affect a limited
 region, may be both  disseminate and  grouped, and resemble Lichen planus at first glance.  They are
brighter in color, however,  conical in form, and never present the angular base, flattened summit, and
 central depression, which characterize the papules  of  the latter affection.
                                               68 
LICHEN    BUBEF 
 
LICHEN   RUBER.
 Case.—C. T., set. 35.—Patient of Dr. Sherwell.   The eruption first appeared  at the age of seven, in
          the form of discrete papules on the backs of the hands, and successively invaded the extensor
          surface of  arms, the neck and shoulders, dorsum of feet, knees, and finally the trunk.   The
          eruption has remained distinctly papular from the outset, and of a dull red hue, spreading
          through development of fresh papules.  When  photograph was taken, the patient was in a
          poorly nourished condition.  The  itching of the eruption was generally  slight, though at
          times  of  an  intense  character.   The  mucous membrane of tongue  and  pharynx  was
          roughened.   The  nails,  which from the commencement were thin  and  brittle, were all
          affected, the  matrix  being rugose  and  shallow.  The patient has  been under intermittent
          treatment by tonics, alteratives  and soothing applications externally for  two years.   The
          improvement has been slow but decided.  She had previously taken arsenic, with little or no
          effect.   Has  seemed to improve the most under inunctions of oleum lini, with the crushed
          seed and milk taken internally.

     Lichen ruber was  first  recognized as  a  distinct affection of the skin  by Hebra,  who selected the
 name on  account of the development of papules, and  the dull red  line which  they present when not
 whitened  by a slight desquamation of the epidermis.  The disease, as described by Hebra, is one of the
 rarest of  cutaneous  affections.   The subject of our illustration, together with a case reported by Dr.
 White of  Boston, are, as far as I know, the only instances of the disease which  have been met with in
 this country.  Cases of extensive Lichen planus I have seen, but these seem to me to differ  in their
 nature from the  Lichen ruber of the Germans.  From my recollection of cases of the latter disease seen
 in the  hospital at Vienna, from the descriptions given by Hebra, Neumann and others, and  from my
 examinations of  Dr. Sherwell's case, I should not be inclined to associate Lichen ruber with the Lichen
 planus described first by Wilson, and later by other English dermatologists.  I must defer, however,
 to the  unanimous opinion of Wilson, Tilbury Fox, Kaposi, Taylor, Bulkley and Dubring, who declare
 the identity of the two affections.  Piffard is  inclined  to believe that they are distinct, and writes as
 follows: " This view, that L. planus  and ruber are identical, supported by such eminent authority, is
 very plausible, and might be accepted as definitive, were it not for certain prominent facts which its
 advocates  fail  to satisfactorily explain.  In the first place, Wilson  observed fifty cases of L. planus
 characterized by umbilicated papules and pigment stains, and which pursued a benign course.   Hebra
 observed fourteen cases without umbilicated papules or stains, most of which terminated  fatally.  It is
 hardly supposable that  a careful observer  like Hebra would  have overlooked the umbilications, if
present, or that Wilson should have met with mild cases  only, and Hebra with severe ones.  Now,
                                               69 
                                    LICHEN  RUBER.

subsequent to Wilson's publication, Hebra and Kaposi  have observed a number of examples of a
benign, umbilicated, papular eruption,  which they have  included under their old name of 'ruber?
It does not follow, however, that because they have  done this, that  the two are the same disease.
Neumann, in 1868, described the microscopical appearances of the original L. ruber, and Biesiadecki,
in 1872, those of the umbilicated eruption.  As will be seen later, these differ widely.  Lastly, no one,
so far as I am aware, has seen the transition of a typical L. planus into L. ruber P
    In many respects Lichen ruber resembles Lichen planus, and it is only necessary to refer briefly to
certain points of difference, without deciding the question  as to whether the two are distinct affections,
or forms of  the same disease.  The papules at the outset are of a brighter red color, conical  in shape,
and  surmounted  by a  thin, adherent  scale.  When aggregated,  as is usually the case, the same
roughened surface is produced as in L. planus.
    The eruption affects no particular locality, but tends  to  become general.   The nails  suffer in  a
characteristic manner, becoming thickened, with an uneven surface and a  broken  extremity.   This
condition, together with the  infiltration of the skin, interferes considerably with the free use of the
hands and feet.  When the disease has existed for some time, the patient tends to become emaciated,
and in time the strength fails, and death ensues.  The different  prognosis given by different writers
results evidently from the fact that some confound  the general  eruption of L. planus with the true
L. ruber.  Whereas, a cure may confidently be expected in  the one case,  it can only be hoped for in
the other.
    The treatment of Lichen planus and Lichen ruber may be discussed together, as whatever will
benefit the former will most likely prove of some service in the latter.
    The general  health in all cases being impaired in a marked degree, the strictest attention should
be paid to dietary and hygienic measures.  The digestive organs must .be kept in as normal a condition
as possible, and the most nourishing  and  easily digested food prescribed.  Of  internal remedies, the
alkaline diuretics seem  to be  productive  of the  best results  by  relieving the  cutaneous  congestion.
In many cases of either of the  diseases in question, and  indeed  in any case of chronic skin disease
where  an imperfect oxygenation of the blood exists,  it  is advisable  to  administer a gram or more
of chlorate  of potassium, well diluted,  fifteen  minutes after  each  meal,  and twenty  drops  of
dilute nitric acid in water,  fifteen minutes later.  Wilson recommends  quinine, nitro-muriatic acid
and chalybeates.  In Lichen ruber,  a long continued  course  of  arsenic is advised by Hebra,  while
the effect of  the linseed oil  treatment of Dr.  Sherwell in the case illustrated, would suggest its
trial in other cases.   Locally, baths and other  soothing measures  are called  for when the amount of
congestion  is  extreme,  but  as a  rule,  cases  of  Lichen planus will stand mild stimulation by soap
frictions and the preparations of tar.
                                               70 
KEPvION.
 
 
KERION.
Case.—D. M., set. 15.—Patient at the New York Dispensary.  This boy was of diminutive stature,
        pale and strumous in appearance.  At four years of age he had had an abscess in the axilla,
        which continued to discharge  for more  than a  year.  The present  affection  was of six
        months' standing, and had begun in the form of small " boils," which did not suppurate, but
        resulted in a circumscribed alopecia.  When first  seen by  me the vertex  capitis presented
        a group of  small tumors, each  about  as large as half a  marble, crowded together, or rather
        heaped upon each other, giving the affected part a lumpy or mountainous  appearance.  The
        elevated portion of  scalp was  of  a dull, purplish-red hue,  and for the most  part devoid of
        hair.   No hairs had been pulled out, according to the patient's statement, although there was
        a white margin of bald scalp skirting  the  upper or anterior and oldest  portion of the patch.
        The hairs springing from the occipital edge, and from the furrows between the hemispherical
        tumors, were surrounded by a gummy  exudation which oozed from the follicles. Each tumor,
        or  mound,  presented a  bald, dry, and shiny summit, and bore  a striking resemblance to
        a thin-walled superficial abscess.  As the tumors were found  on palpation to be  rather soft,
        it seemed almost certain  that they contained pus or other fluid demanding evacuation.  Upon
        puncture, however, only a drop  of bloody serum escaped ;  and when, at a meeting  of the New
        York Dermatological Society, where the patient was shown, an experienced surgeon declared
        unhesitatingly that pus was present, a free incision was  made  with only a scanty discharge
        of  blood and serum.  On  other portions of the scalp there were a few pea-sized bald spots,
        each one  indicating, according  to  the patient's account, the  site of a  former " boil."  The
        disease in this case was considered to have had a parasitic  origin, although  a  microscopic
        examination made at the time the photograph was taken  (November 30) revealed no fungus.
        The treatment consisted in the  administration of the syrup of the iodide of iron  in cod-liver
        oil, with epilation of the hairs upon and around the elevated patch.  Two weeks  after begin-
        ning the epilation, a circular patch of scalp, on the  right margin of the  epilated area, became
        suddenly inflamed, and  occasioned a  sharp, pricking and painful sensation.  In three days
        this patch increased a trifle  in size, and the pain  lessened.  On December 18, the  color of
        the large  epilated patch had faded considerably, and the mounds were scarcely  perceptible.
        There  still existed  some deep-seated  fluctuation, but an  exploring needle merely evacuated
        blood  and serum.   The  inflamed patch was as large as a, half dollar, elevated, and with an
        abrupt margin and a reddened  surface, dotted with one or  two small pustules and crusts of
        dried exudation.   The dark yellowish, honey-like  serum, which had been  exuding in abun-
        dance, had now ceased to flow, and the pain had disappeared.   The hairs were loosened, and
        came out with gentle traction.  The hair bulbs were somewhat swollen, and to some the root
        sheaths were attached.   The mother of  the boy was instructed to continue the epilation,
        which  she failed  to do in a satisfactory manner, and the cure  progressed very  slowly.  In
        February the scalp was nearly though  not entirely well.
                                              71 
KERION.
     Kerion is regarded by  most writers  who  have described the affection as an  unusual form of
trichophytosis, or ringworm of the scalp (Tinea kerion).  In this series of illustrations I have placed it
apart from trichophytosis, as I do not regard it  as  essentially parasitic  in its  nature, although there is
no doubt that the trichophyton acts with extreme frequency as an exciting cause of the affection.  The
disease usually begins with the development of one or several small, pea-sized tumors, which are always
reddened and "boggy," and which often present a deceptive feeling of  fluctuation which is apt to lead
one to declare them abscesses.  In spite of the appearance presented by these little tumors, it  is a
noteworthy fact that they rarely if ever suppurate.   The fluid contained in the deeper portion of the
corium, and which gives to  the  swollen part its  soft,  spongy feeling, is a highly albuminous serum,
which appears in the form of viscid, honey-like drops, at the dilated orifices of  the follicles, especially
after the hairs have loosened and fallen.  This loss of hair, which usually takes  place  soon after the
affection has developed, is  limited to the portion of scalp affected.  The little  tumor remains for an
indefinite period of a livid red hue, and then tends to gradually fade  and flatten, unless  similar lesions
develop in  its immediate vicinity.  Sometimes,  especially in young children, it enlarges peripherally,
and forms a soft, flattened, and but slightly elevated disk, as  large as a half dollar.  Generally, a group
of closely packed tumors, or  mounds, develope, and the symptoms already described as pertaining to
a single small tumor present themselves in  an exaggerated form.
     The diagnosis of so well-marked a case of kerion as the subject of our illustration is attended with
no difficulty.  The bald and lumpy condition of the scalp is  not seen in any other affection.  In the
earlier stage of kerion a mistake might readily occur.  Where there are a number of  scattered red  and
soft  tubercles upon the scalp, they might  be mistaken  for boils, abscesses, or  for syphilis.  The latter
disease would not be likely to occur at the age when kerion  is commonly met with,  unless it were
hereditary, in which  case it  would not  manifest itself  in the form  of tubercles limited to the scalp.
Boils would be recognized by their more  conical form, indurated base, and tendency to suppuration,
while a number of  small  equal-sized abscesses would  not be  apt to  occur  upon the  scalp without
apparent cause.  After the hair has fallen  from  the little  tumors, and  the boggy feeling lessened, they
might be  regarded as indications of  incipient alopecia areata; but in this affection the bald patches
show no signs whatever of past  or present inflammation, the affected scalp being white, smooth,  and
not at all elevated.   Where a portion of scalp is suddenly attacked, and a copious discharge  of gummy
serum takes place, the affection bears a resemblance to an acute eczema.  It will be noted, however,
that  the hairs are loosened, and pull easily, which is never the case  in eczema of the scalp.
     The treatment of kerion consists in improving the  general tone of the patient, and in thoroughly
epilating the affected part.  Whether the disease is of parasitic origin or not, epilation is demanded by
the condition of the hairs, which  are not broken off, but lie, as in case of sycosis, like foreign bodies in
the inflamed follicles.  Their extraction removes a source of irritation,  and the free discharge of viscid
serum through the follicles lessens the boggy condition of the scalp and promotes the subsidence of
inflammation.  It must not be expected that epilation  will effect a speedy cure of the  affection, even
when the trichophytic fungus is  present as an  exciting cause.  As the fungus, in this case, is not the
sole  cause  of  the  peculiar phlegmonous  condition,  its removal with the hairs, will not produce as
striking an improvement as in cases of ordinary trichophytosis capitis.
                                                72 

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LEPRA   MACULOSA.
Case.—F. W. F., about 35 years of age, born in Prussia.  Four years before the photograph was taken
        he noticed a painful swelling of left leg, while residing in Central America.  The ankle joint
        became stiff.   This was followed by a loss of sensation at  the tip of nose, edge of lower jaw,
        and other portions of the face. During the first  year red spots appeared on the trunk and
        extremities.   During the second year the hands became painful, the finger  ends  swelled, and
        the nails fell off.  In the third year the spots changed to a light-brownish hue, and anaesthesia
        of various portions of  the body developed.  Bullae had frequently made their appearance on
        his toes, and he could only use his fingers with difficulty.  The treatment in this case was
        not systematic, but arsenic seemed to produce a better result than gurjon oil.

    The diagnosis of a  case of leprosy is more  or less easy, according as the disease is more  or
less developed.  In an  advanced stage, its peculiar features proclaim the diagnosis at a glance, but in
its incipiency it may pass  unsuspected for  months  or years, especially when  met with in a country or
region where it does not prevail. The earliest symptoms are usually a  gradual loss of  strength from
no apparent cause, chilly sensations, vague pains, and numbness of  the extremities.  Later, the disease
is  characterized by the development of numerous brownish patches upon the  extremities, nodules
above the  eyebrows or about the ears, and  tracts of ansesthetic skin particularly on the hands and feet.
The diseases with which  leprosy might be most  readily confounded are syphilis, lupus, leucoderma,
scleroderma, and morphcea; but the features of a case, if at  all well marked, will usually proclaim its
nature as soon as the diagnosis of leprosy is suggested.
    Lepra tuberosa may bear a resemblance, at first glance, to tubercular syphilis, the forehead being
a favorite seat  of either  disease.  But the infiltration of the skin in  leprosy is more  diffused, the
protuberances are of variable size, often larger in the center of the patch, and always of a dull, bronzed
hue.  The syphiloderm in this locality presents small, hard tubercles of  a brownish-red color, arranged
often in  a circular or  crescentic form, tending  to ulceration and sometimes enclosing a smooth area.
Lepra maculosa may simulate leucoderma,  both in form and  color, but  the patches  in the  former are
never perfectly smooth as in the latter affection.
    Leprosy is a  disease which may be regarded as practically incurable, since there is no remedy or
plan of treatment which can be adopted with any certainty  of restoring the patient  to perfect health.
And yet many cases improve to a greater or less extent under treatment, and some have been reported
in which an apparent cure of the disease has been  effected.  The first step in the treatment of  leprosy
is  to remove the patient, if possible, from the  locality in which  the disease has  been contracted.
Hutchinson has reported the case of a woman whose parents had always resided in England, and who
contracted the disease  in a  severe form  during  a  twelve  years' sojourn in Jamaica.  She  became
                                              73
j 
LEPRA  MACULOSA.
apparently free from all symptoms after her return to England, and  during a period of twenty years
there was  no return of the disease, and the woman  considered herself as perfectly well.  A mere
change of residence could not be expected to effect a cure, since leprosy is known to run its  course to
a fatal termination in almost every climate;  but a change of diet and habits is doubtless a factor of far
greater importance.   In this case,  Hutchinson attributed the cure mainly to  a  cessation of a diet
composed largely of  unwholesome fish, which in leprous countries is supposed by many to be an active
cause of the disease.  The next step is to place the patient under the best hygienic  conditions, and to
treat the symptoms of the disease on  general principles.  Where ulceration of  the  extremities has
taken place, the sores should be kept scrupulously clean, and dressed with some  slightly stimulating
application, such as balsam of Peru.   For the pain, which is usually annoying in an  advanced stage of
the disease, morphia may be given.   Stretching of the ulnar nerve  under ansesthesia has been resorted
to in  some cases of  leprosy, with  a view to restore  its function.   This operation  seems to  have
produced at least a temporary benefit in a considerable number of cases.   The thickening of the nerve
has  been  lessened,  and  the ansesthetic portions  of  skin  supplied  by it have  been  restored  to
sensibility.  As regards internal treatment, many  remedies have been vaunted, but as yet no specific
has  been found.  There  are certain balsams  and oils, which, if used for a length of time, produce
a favorable change in the condition of the patient, though it cannot be said that they have the power
to cure the disease.   Chief among these are gnrjon balsam and cashew  and chaulmoogra oils.  The
former is  used by British  surgeons in India  and other  tropical  localities, with good results.  For
internal  use, an emulsion is made of equal parts of the oil and lime-water, and administered in half-
ounce doses, twice daily.  As an external application, the oil is mixed with three parts of lime-water,
and  with this  the whole body is thoroughly rubbed.  Under this  plan  of treatment  patients in  an
advanced stage of leprosy improve in health, the  ulcers heal, the tubercles  soften and disappear, and
the ansesthetic parts  resume their sensibility.  Chaulmoogra oil (expressed from  the seeds  of Gymno-
cardia odorata) has of late been highly recommended,  and is given in doses of from five to  twenty
drops, three times daily.  One case of macular leprosy, in a boy of  nine, which I have recently had
the  repeated opportunity of  seeing, has manifested a considerable  degree of improvement  under  an
ordinary anti-syphilitic course of treatment.
     In most regions where leprosy abounds, the spread of the disease  is checked by the segregation of
all  leprous patients, under governmental  authority.   The wisdom  of this plan, as  a prophylactic
measure, cannot be impugned, although the question of  the  contagiousness of the disease is still mooted.
     The  prognosis of leprosy, as is evident from the foregoing,  is decidedly unfavorable.  In the .
tuberose, which is the most grave form, death may be expected to take place  in  from three to nine
years after the first symptoms of the disease are noted.  Very frequently pyaemia  sets in, and carries
off  the patient with  unexpected  suddenness.  The case  of Lepra  tuberosa illustrated  in the first
number of this work died shortly after its  publication, or  in less than three years  after the develop-
ment of the disease, according to his statement.   The  macular or the ansesthetic  form of the disease
may  develop gradually, and exist for a long time without any very marked impairment of the patient's
health.   Twenty-four years has been fixed as the extreme limit of the disease by physicians who have
had the opportunity of observing it where it is endemic.
                                               74 

#
MOLLUSCUM
MOLLUSCUM. 
 
MOLLUSCUM.
Case I.—Joanna E., set. 5.—This patient was a red-cheeked, chubby little girl.   Examined April 8,
         1876.   There were six or eight mollusca on left thigh, of a year's standing.  She was brought
         to me for treatment on account of a group of the larger ones having inflamed,  suppurated and
         formed a dark crust.  In this case there was no history or evidence of contagion.   Her little
         brothers and  sisters,  though playing with her by day and sleeping with her  at night, had
         never been affected, nor had any of the neighbors' children.   One sister had ordinary warts
         on her hands.
Case II.—Fannie W., set. 1%.—This child exhibited nearly one  hundred mollusca of varying size,
         mostly located beneath the chin.  A  bean-sized tumor resulted from the close proximity of
         several.  There were  a few scattered on neck, breast and about the eyes.   Although an older
         sister had nothing of the kind, the little patient lived next door to a little girl whom  I had
         treated months before for the same  affection.   The mollusca  in this case  were rapidly
         removed with a pair of curved scissors,  the child  being under the influence of a few whiffs of
         ether.

     The term  molluscum  has long  been applied to two distinct  affections, viz., one which will  be
presently described (Molluscum contagiosum of Bateman), and one which has already been illustrated
and described in this work (Fibroma, or  the Molluscum fibrosum of certain writers).  The affection to
which the term molluscum should be  limited consists of little soft tumors, varying  in size from a pin's
head  to  a  small  pea,  with  constricted  base,  a  central depressed orifice and whitish, curdy contents.
They are not of very infrequent occurrence among children, and are as interesting  to the dermatologist
as they are harmless to the patient.  The affection commonly attacks children, and the face  and neck
is its most common seat.  The  tumors exhibit a tendency in many cases to congregate  about the eyes,
and occasionally about the mouth.  I have met with them  exceptionally upon the scalp, ears and tip
of nose.  In adults the genitals are the part usually affected, although the mollusca sometimes occur on
nearly all parts of the body.
    Each individual tumor is of slow development  and  indefinite duration.  It begins as  a pin-head
sized  whitish  elevation of  the epidermis, with a minute central depression,  which becomes more
prominent as the growth increases in size.  When it is as large  as  a  hemp-seed the summit becomes
flattened, the base more or less constricted, the center of the growth  appears whiter than the wall of
the tumor which is usually of normal skin-color, and lateral pressure causes a whitish, cheesy substance
to exude.  Under the microscope this is  found to be composed mainly of peculiar  round or oval bodies
known as the " molluscum corpuscles."   The tumors have usually a waxy, transparent aspect, although,
when they have attained  the  size of a large pea, the walls are often traversed by fine blood-vessels,
                                              75 
MOLLUSCUM.
 and present a pinkish appearance.   No pain  or  other  subjective sensation accompanies the growth,
 which may persist for a year or more, never getting larger than a large pea,  and finally withering  or
 undergoing a process of destructive inflammation.
     In a large proportion of cases the hands of the patient will be found to be the seat of ordinary warts.
     The etiology of molluscum is obscure.   Its occurrence in several members of one family, and the
 fact  that it has been observed to affect suddenly a number of children in a hospital ward, have led to a
 belief in its contagious nature.  But this is by no means proven.  Although  the disease occurs with
 much greater frequency among the poorer classes, it cannot be considered  as the offspring of poverty
 and uncleanliness.   Damp and crowded dwellings may  favor its development, and  I have  known a
 number of  cases to occur in such a locality.   Ill  health is not  always a factor in its production, for
 while most of the molluscous children I  have examined were strumous or weakly,  there have been
 some upon  whose faces not even the dirt could conceal the glow of health.
     The diagnosis is very simple, the tumors being so peculiar in appearance that, when once seen and
 recognized, they could  hardly be mistaken when met with a  second time.   I  have seen  numerous
 mollusca upon the face of a young woman, which, on account of their whitish, flattened  summits and
 central depression, bore a striking resemblance, when observed at a distance, to the umbilicated pustules
 of variola.  A mistake in diagnosis, however, could scarcely occur.
     Fibromata, when small, might be mistaken for mollusca, and especially as the sebaceous  glands in
 the former  tumors frequently contain an accumulation of sebum, which can  be pressed out in the form
 of cheesy threads.   They do not present, however, a central depression, do not occur in groups, do not
 have the plump feeling of mollusca, but, on  the  other hand, are apt to  be quite flaccid, and finally,
 when multiple,  as  they usually are,  they vary considerably in  size, and  usually become  much  larger
 than mollusca.
     The treatment of molluscum is simple, the object being to remove the excrescence  and to  excite
 as little inflammation as possible in so doing.  When the mollusca are so  situated as to admit of
 abscission, the most  advisable plan of treatment is to shave them off with a razor, or a long, thin-bladed
 knife, at a level with the surrounding skin.  The hemorrhage occasioned  scarcely amounts to  more
 than a drop, and it is quickly checked by touching the freshly-cut surface with nitrate of silver.  When
 the mollusca  are not seated  upon  a projecting, or at least upon a convex part, but occur in certain
 localities where, especially in the case of struggling children, a knife could not  be handled with safety,
 a pair of curved  scissors may be used in its stead.   For  very small mollusca, nothing more than slight
 cauterization is required to arrest their growth and  to hasten their disappearance.  They may be bored
 very gently with a conical stick of nitrate of silver, or touched with a tine glass rod dipped  in-strong
 acetic  acid.   When a  cluster of  tumors have coalesced  and undergone a process of destructive
 inflammation, the hard crust should be removed by a poultice  or dressing-of  cosmoline, and a  little
 balsam  of  Peru  applied to  heal  the superficial ulceration.  When a molluscum,  however large,  is
removed, no scar is left, under ordinary circumstances, since the  growth  is epidermic in character, and
can scarcely be said to involve the coram, or true skin.   When an inflamed molluscum is scratched or
irritated to the degree of purulent secretion, a slight pit may be expected to result.
                                               70 
ERYTHEMA  multiforme. 
 
ERYTHEMA   MULTIFORME.
 Case.—C. R., set. 57.—Patient of Dr. N. G. McMaster.  This patient, born in Bohemia, and a silk
         weaver by occupation, was spare and sallow, but had a good previous history, and manifested
         no tendency to constitutional disease of any kind.   The eruption  began about a week before
         the photograph wras taken,  as a small, bright-red and itchy spot on the inner side  of the right
         wrist.  A few hours  later  a chain of similar lesions extended up  the  inner  side of  forearm
         and arm.  Then a spot appeared on inner side  of  right ankle, followed rapidly by others,
         extending up  leg  and thigh to groin.  These* differed  from those  on upper extremity in
         being larger, in having a more livid color, and  in being  accompanied by considerable oedema
         of the limb.   Toward evening the opposite, or left extremity, became attacked  in a similar
         manner.  In short, the eruption, within a space of fifteen hours, appeared on the inner aspect
         of both upper  and lower extremities, in the form of circular elevated macules, which were
         extremely itchy for the first twenty-four hours after their development, and which gradually
         increased in size and coalesced.   When  seen by Dr. M. at the University College Clinic, the
         eruption presented a large  number of discolored disks or rings, mostly confluent, and forming
         patches  with a scalloped  margin.   At  the shoulder the rings were about three inches  in
         diameter, and their size gradually decreased in approaching the wrist, where  they measured
         about an inch.  The rings were vejy striking in appearance, being of a bright, purplish-red color,
         shading  off through  hues  of red and dull  yellow, and inclosing a central area of apparently
         normal skin.  On the lower extremities the patches were more confluent and of a deeper hue.
         The treatment prescribed in this case was a recumbent position, a moderate dose of castor oil,
         a light diet and frequent bathing of the limbs with vinegar  and tepid water.   In about two
         weeks the lesions began to  fade, and in a month there was no trace of  it, save a slight oedema
         of legs, which persisted for several weeks.  The patient stated that  the eruption disappeared
         in an inverse order to that  in which it appeared, leaving the right wrist last.

     The term erythema indicates a pathojogical congestion of the skin.   When  hypersemic redness is
the sole lesion in any case, the affection is called Erythema simplex.  When the congestion of  the skin
is  accompanied by a  peculiar  plastic exudation, we have  an  entirely different affection, and one to
which Hebra has applied the distinctive title of  Erythema exsudatwum multiforme.   Although the
generic term  erythema, adopted by Willan in his lesional classification, is still in use, the reader must
bear in mind that Erythema simplex and Erythema multiforme are not mere varieties of one cutaneous
disease, but that they are quite independent affections, according to a classification based on etiology or
pathology.
    Erythema multiforme is an  acute inflammatory affection, characterized by a marked degree  of
superficial plastic exudation.  This leads to the rapid development of either papules, tubercles, elevated
                                              77 
ERYTHEMA   MULTIFORME.
rings  or  diffused  marginate  patches.   The varying  character of  the eruption  has led  to the
establishment of a number of clinical forms which differ from one another only in external appearance.
Erythema papulatmm, which may be taken as the type of the affection, is the most common form, and
occurs chiefly on the backs of the hands and forearms, and, in some cases, on  the feet and legs as well.
The lower extremities are rarely affected alone.  In E. tuberculatum the papules are  simply larger
and firmer.  They present at times a whitish summit and  appear  like bullse containing  gelatinous
contents.   In a case which I recently saw, the tubercles  on the  backs of the  fingers were dark and
purpuric in character.  In E. annulatum a large flat papule or disk of exudation  presents a depressed
central  area, and in rare instances,  one or more outer  circles  form,  and by  exhibiting a variation in
color  give rise to the name E. iris.   E. marginatum is  applied  to  the  eruption when  it appears in
the form of diffused  patches with  an abrupt  and elevated border which is usually  scalloped from the
coalition of smaller circular patches.   E. nodosum is a peculiar form, in which  one or more large,
painful  swellings appear upon the limbs or elsewhere.  Although this form  is  almost always met with
alone and is usually described as an affection .distinct from E. multiforme, I  have,  in one case, seen  it
coexisting with the papular and marginate  forms.  In rare instances, the eruption becomes vesicular
and even bullous, and to such cases the terms  Herpes iris and Hydroa have been applied.
    The eruption, in the beginning, whether papular or of whatever form, is seated upon a slightly
swollen  and reddened base.  Within twenty-four hours the encircling hypersemia subsides, and leaves
the eruption contrasting strongly with the normal  skin.  The color  changes  gradually from a  bright
red to a dull, livid  or purplish hue, and the affection runs its course in from one to six weeks, according
to the  intensity of  the  exudative process.  An  average  case will last from two to three weeks.
Frequently the lesions develop successively, and the attack is  thereby prolonged.  Recurrent attacks at
a certain season  of the year are not uncommon.  The outbreak of the eruption is often associated with
malaise  and slight fever,  and according to my experience the eruption is usually quite annoying on
account of the burning sensation or pruritus,  which is nearly always/ present.  Most writers, however,
speak of the subjective symptoms as being insignificant.
    The causes  of erythema multiforme are rarely apparent.   It is  frequently met  with  in the  spring
and autumn, and the sudden changes of temperature so common in this climate seem to me to be an
etiological factor of importance.  In dispensary practice I have  had  occasion to note that immigrants
are a  class peculiarly liable to be affected.  In many cases a lowered  tone of the system is evident, but
the disease does  not seem,  like urticaria, to be attributable to dietetic errors.   It is  generally met with
in youth and middle age, and neither sex is exempt.
    The treatment of the  affection  may be expectant or consist chiefly in good  nursing.  Frequent
warm baths are beneficial.   A teacupful of carbonate of  sodium may be  added to the water when the
eruption is extensive and accompanied by pruritus.   There is nothing to be gained by applying
ointments or even dustkig  powders.   A linen cloth saturated with a lead lotion may be applied to the
affected skin at the outset, when the inflammatory symptoms are very acute.
                                              78 
PHTHEIRIASIS capitis.
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PHTHEIRIASIS.
Case of Phtheiriasis  Capitis.—This was a little girl who " caught lice " at school, a circumstance not
        always avoidable.  Being neglected by her parents, or those who were supposed to care for
        her, she was allowed to suffer unnecessarily.  The illustration shows the characteristic indica-
        tions  of  the  presence of lice, viz., the occipital eczema glueing  the  hairs together, the
        swollen cervical glands and the porrigo or eruption of contagious pustules upon the neck.

     Phtheiriasis, or Pediculosis, or, in plain English, " lousiness," is a term  which includes both the
presence of lice and the cutaneous lesions to which their presence  gives rise.   In some cases, where an
eczematous tendency on the part of the patient exists, the external irritation and consequent scratching
is sufficient to occasion patches of typical eczema.   The older writers  regarded  the affection in the
light of a specific dyscrasia, of which the pediculi were  a natural result, and among the laity at the
present time it is a common belief  that the lice come out of the skin, where they are supposed to  be
bred by the disease.
     Pediculi are insects belonging to  the group of hemiptera.   They  are without wings,  possess a
sucking mouth, and undergo no metamorphosis.   There are three members of the family which are
parasites of the human body, viz.,  the pediculus capitis or head-louse, the  pediculus corporis or
body-louse and the  pediculus  pubis  or crab-louse.  These  occasion the three affections known as
Phtheiriasis capitis, Phtheiriasis corporis and Phtheiriasis pubis.
     The pediculus capitis is of a whitish color,  and varies in  size from one to three  millimetres in
length.  Attached to  its thorax  are six hairy, jointed and clawed legs, with which  it is enabled to
travel rapidly along and among the hairs.   It is only met with upon the scalp.   The lice  deposit their
ova either singly or in  groups upon the hairs.  These ova or " nits " are found, upon close examination,
to be whitish, pyriform bodies, glued to the hairs with the smaller end close to the  shaft  and pointing
toward the scalp.  They are always deposited near the root  of  the hair,  and accordingly,  when
observed near  the free extremity, it is an indication  that the affection has existed for a considerable
length of time.
     The  pediculus  corporis  bears a  strong resemblance to the pediculus capitis,  although it is
somewhat larger.  Its  habits are quite peculiar.  It does not burrow  in the skin like the acarus or
itch-mite,  nor is it ever found in the hair, like the other species of pediculi.  It inhabits  the clothing
and merely pastures upon the skin.  It does not bite, but sucks the blood of its victim  through  a
haustellnm or proboscis which it inserts into the skin.  Its appetite is  voracious,  and when  observed
beneath a watch-glass,  during meal-time, its body may be seen to increase in size and assume a darker
or reddish color.  When numerous the pediculi may  be seen  traveling over the  free surface of the
                                               79 
PHTHEIRIASIS.
patient's apparel, but when a strict search is necessary to discover them, they will generally be found
secreted in the folds and seams of the various garments.  In  cheap lodging-houses, police stations and
wherever lousy persons are in the habit of sleeping, the bed-ticks  and woollen  blankets may  become
infested.
    Phtheiriasis capitis is  an extremely common affection  among the lower classes.   Though most
frequently attacking  children, and especially those who associate with a number of others in  schools,
asylums  and  similar institutions,  it  is not  infrequent  among adults.   Filth and  neglect act as
predisposing causes, but at the same time, children who have every possible attention  paid them are
often affected, and even ladies of wealth and refinement sometimes  discover that they  have been
unconsciously harboring  a large number of the unwelcome and disgusting vermin.  Men,  on  account
of their short hair, are much less likely to be attacked.   It is a notable fact that certain individuals are
peculiarly liable to become affected whenever exposed, and, in case  of some children whose heads are
carefully washed  and cared for,  it is a puzzling matter to  account for the  repeated presence of the
insects in  the hair.
     The first symptom  produced by the presence of  the pediculi  is an unpleasant itching of the scalp.
In children, the continued scratching produces excoriations, and a serous or sero-purulent discharge
soon  appears, which  tends to mat the hairs.   An  eczema,  especially upon the occipital region,  is
frequently evoked, and this is  so characteristic that, when limited to this region, it should always lead
to a  search for pediculi as its  probable  cause.  An eruption of contagious pustules, as  in the case
illustrated, may appear upon the neck and shoulders.  In strumous  children the irritation of the scalp
may lead to a marked swelling of the lymphatic glands of the neck.
     The diagnosis of the  affection is readily made if the pediculi are found, but the presence of nits
upon the hairs is alone sufficient to establish it, since they indicate that there have been, and probably
will be, pediculi in  the hair, even though none may have been discovered by a careful investigation.
     When eczema of the scalp exists the presence of pediculi is often overlooked, and the affection
may  be unsuccessfully  treated  until its  parasitic origin  is  discovered.   As  above stated, occipital
eczema is an almost certain sign of phtheiriasis.
     The treatment varies with the extent of the affection  and the social condition of the patient.  In
dispensary practice  it is usually advisible to have the child's hair cut close,  especially in warm weather.
If no eczema is  present  the  lice and  nits may be destroyed by rubbing the scalp night and morning
with ordinary kerosene.   Caution should be given respecting the danger of setting the child's  head on
fire by rubbing in the oil in too close proximity to a gas-jet or candle.  When severe eczema is present
this must  be treated by means of a soothing ointment, although it is sometimes advisable to  destroy the
parasitic cause of the eczema at the outset, even though  the treatment should aggravate the  eczematous
condition.   In private practice it is not necessary to have  the hair cut, and, with proper attention, it
will  be found easy  to  cure  the affection by careful  combing  and  the nightly inunction of the
ammoniated mercury ointment.   The nits  are  sometimes  difficult to  remove,  but  this   may be
accomplished by  rubbing each affected hair  from root to tip with a sponge or  soft  cloth dipped in
alcohol or cologne-water.
                                                80 
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PHTHEIRIASIS  corporis. 
 
PHTHEIRIASIS.
 Case of Phtheiriasis Corporis.—A patient at the New York Dispensary.   This was a tramp, who
         for some time had been a nightly guest in a crowded police station-house, and whose clothes
         had probably not been removed for months.   They were  infested with pediculi, and his body
         was covered with excoriated papules and scratch marks.  The illustration shows the character-
         istic location of the eruption between the shoulders and the parallel scratches, produced by a
         vigorous use of the finger-nails.

     Phtheiriasis corporis implies the presence of lice in the clothing, together with the existence, to a
 greater or less degree, of  certain cutaneous  lesions.  The  affection is a common, and  often a chronic
 one among the poor and  miserable, and under certain circumstances, the possessor of wealth and refine-
 ment is not protected against an acute attack.  As Professor  Hebra  once remarked to his students, it
 is not always a disgrace to have lice, but it is a disgrace not to get rid of them speedily.
     The lesions constituting the eruption in Phtheiriasis corporis are: (1)  peculiar hemorrhagic specks
 or so-called  " bites," (2) small wheals or inflammatory papules,  (3) excoriations,  either presenting a raw
 surface, or covered with  a crust of dried blood, (4) scratch marks of parallel direction, such as are not
 met with upon the skin,  except as a result  of phtheiriasic irritation, and (5)  pustules, furuncles, and
 superficial ulcerations.
     The eruption is observed chiefly upon  the body and thighs.  It is always  most marked in certain
 localities which correspond to the seams and folds of the clothing, where the pediculi secrete themselves,
 and deposit, in  great numbers, their small, white, and shining eggs.   A tract of skin that can be almost
 covered by the palm, lying between the upper portion of  the  scapulae, is a spot most likely to present
 excoriations, since it is a favorite habitat of the lice, and  quite accessible to the hands of the patient.
 The eruption in this locality usually presents a striking appearance, the skin being  frequently pig-
 mented, and showing old  cicatrices  scattered among the recent excoriations.   The  eruption is also apt
 to be well marked around the  loins, presenting a  distribution which might be termed  the phtheiriasic
 girdle.  This is commonly observed when the  trousers are  supported by  a belt.  Excoriations are
 common about  the  trochanteric region and outer  aspect of the thighs, when the trousers are chiefly
 infested.  I have seen a patient with dark stripes running down the1 thighs and legs, and corresponding
 to the seams, which were swarming with pediculi and their ova.
     The diagnosis of phtheiriasis corporis can usually be made by observing the patient at a respectful
distance—a very fortunate circumstance for the  physician, who in charity practice has to treat a large
number of cases.   When the patient strips, the nature  of the affection, if it be  of long standing and
                                               81 
PHTHEIRIASIS.
well marked, is evident from the characteristic location of the  scratch marks, and from the fact that
the patient finds it impossible to keep his hands still.  There is no other disease in which the pruritus is
so intense as in a severe case of phtheiriasis.   Exposure of the body to the cool air seems to excite  the
desire to scratch.   If the patient is  requested to stand perfectly  still, with his hands hanging, he may
retain this soldier-like  position for  a few seconds, when he will probably begin, with both hands, to
rub and scratch, and even to tear the skin, until it is  bleeding at numerous points.  The pruritic char-
acter of the eruption being thus manifest, we are led at  once to exclude  a diagnosis of  syphiloderma
and every other non-pruritic skin affection, and to think of urticaria, prurigo, eczema, or scabies, erup-
tions which are always accompanied by severe itching.   The irritability of the skin, shown by the
parallel pink streaks which follow in the wake of the finger-nails, and the  rapidly developing white
ridges or small  wheals, is a striking  feature of urticaria, and might lead to the diagnosis of this affection.
But in urticaria the severe excoriations  are lacking, and the eruption is usually of recent and  sudden
development.   Prurigo in the severe form, which is seen in the skin clinic of Vienna, is rarely, if ever,
met with in this country.  In a mild  form  it  is occasionally encountered, and can be  distinguished
from phtheiriasis by  its  attacking chiefly  the extremities,  and being invariably a disease of long
standing.
     A case of phtheiriasis might be diagnosed as one of papular or pustular eczema, the difference in
the appearance of these  eruptions  not  always being very marked; but the  characteristic location of
excoriations across the back of  the  shoulders, around  the waist, and upon the outer surface of the hips
and thighs, should point at once to  their parasitic origin.  Scabies, when affecting the body extensively,
may resemble phtheiriasis, but it manifests a strong  preference  for the hands, forearms, lower part of
abdomen, genitals, and the inner aspect of  the thighs, while avoiding the  favorite seats of phtheiriasic
lesions.  It is intensely pruritic, as  the common name of " the  itch " suggests, but the patient scratches
with comparative gentleness, and never digs  the skin  with fury, as in case  of phtheiriasis.
     It will thus be seen  that the diagnosis  is easy, in a severe form of  the affection, but frequently
cases occur in which only a moderate pruritus, with very few excoriations, is  present.  Here it may be
impossible to discover  any pediculi, and it is sometimes extremely difficult to distinguish the affection
from the Pruritus cutaneus, which is a neurotic affection, depending  upon some  internal disorder.
The hemorrhagic points produced by  the haustellum of the pediculus  can generally be discovered,
however, and serve an excellent purpose in pointing  out the parasitic origin of  the trouble.   When in
private practice there exists a suspicion  of pediculi (and phtheiriasis  is not wholly confined to dispens-
ary patients), it is far preferable to  quietly hunt for these characteristic lesions of the disease, than to
give offense to a patient by instituting a fruitless search through the clothing.
     The treatment will be given in connection with the illustration of " Porrigo epedicuUs."
                                               82 
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SCABIES.
     Scabies, or " the itch," is  an affection of the skin,  resulting primarily from the  burrowing of
minute insects called " acari."  The presence of these parasites in the skin occasions a severe pruritus,
and evokes a characteristic eruption, which cannot be duly appreciated and rationally treated without
a certain knowledge of their anatomical structure and peculiar habits.
     The Acarus Scabiei, or itch-mite,  is a minute and almost  microscopic insect.  It can  be readily
seen with the naked eye when extracted from its burrow or cuniculus by means  of a needle, but its
features can only be studied beneath the microscope.  The mature acarus is of oval shape, and provided
with eight legs.   The male is smaller than the female, does not burrow as does the latter,  and is not
readily found.  The young acari possess but six legs (two posteriorly), and these are in time  thrown off
with  its  skin,  when  the  mature  eight-legged  insect appears.   If a  female, she becomes  speedily
impregnated by the male, who roams at night upon the free surface of  the skin.   She then proceeds
to burrow, and deposits her ova to the number of a dozen or more beneath the epidermis.  At the end
of this burrow  she dies, unless  prematurely removed by the finger nail of  her unwilling host.  The
ova are hatched  within fourteen days,  and find their way to the surface of the skin.  Here the maiden
acari  are  wooed,  become impregnated, and  the  burrowing and hatching process is repeated.  The
burrows are generally found where the skin is thin and warm, as between the fingers, upon the penis
in the male, and the nipple in the female.   They appear as dotted, slightly elevated and curving lines.
Vesicles  and pustules are  frequently observed in their vicinity, but  the extensive eruption which,
in some severe cases, covers  the body and  extremities, is not a direct effect of the burrowing of the
acari, but results from the free use of the finger-nails.  The  itching is almost intolerable, especially in
the night, when the patient is warm in bed.
     The eruption in scabies is localized in great  measure  according to  the character of the patient's
clothing, and differs in this respect in men,  women and children.  Upon the hands and wrists it is
common in all, but its prevalence about the breasts in women, and upon the  genitals in men and boys
seems to depend upon the ease with which they can scratch in those localities, especially at  night.  In
young children, who  wear long, close-fitting night-dresses,  the  ankles, which  alone  are  exposed, are
usually the seat of an eruption.  The  face and  scalp are usually free from eruption, even in the most
severe cases of scabies.  A secondary eczema, however, may be  found  upon the head, as well as on the
body.  The disease is usually contracted at night, from some affected bedfellow.   The physician may
handle the hands of a patient with impunity, according to my experience.  Nevertheless, one writer
has stated that  he contracted the disease " from  incautiously handling  and hunting for the mite on a
child's arm."
                                              83 
SCABIES.
    The diagnosis of scabies may be based upon the discovery of burrows, or, in the event of not find-
ing them, upon  the  characteristic  locality  of  the  excoriated papules which constitute  the eruption.
The burrows are more apt to be found in mild and recent cases than in severe cases, where the hands
are covered with vesicles and  pustules.   When the occupation  of the patient causes the hands to be
kept very much in water, they may appear perfectly free  from the disease, and yet a characteristic
eruption exist on the body.
    The treatment of scabies depends upon the age  of the patient, the chronicity of the disease, and
the presence or absence of a secondary eczema. In infants, whose tender skin would certainly become
inflamed from use of the ordinary stimulating  sulphur ointment, equal parts of vaseline and balsam of
Peru may be employed with a  satisfactory result.  In children and adults  stronger applications may
be made, although it must be  remembered that some  skins  can bear what others cannot.  Styrax
balsam, in the form of a liniment, made by adding  twenty per cent, of olive oil, or as an ointment,
made with an equal part of cosmoline, is an agreeable and effective application.   Sulphur, however,
has long been the chief remedy in scabies, and although others may be  equally good, there seems to
be none more efficacious in the majority of cases.   It is frequently combined with carbonate of potas-
sium, mercury, tar, chalk, &c, but as far as my experience goes, these compound ointments possess no
marked advantage over  a simple sulphur ointment, which, if applied in strength  suitable  to the case
and to the various parts of the body, will leave nothing to be desired.  The Ungt. Sulphuris (U. S. P.)
consisting of one part of sulphur to two parts of lard, is rather stronger than is necessary, especially
when its application is to be repeated, and combined with baths and soap frictions.   A twenty, or even
a  ten  per cent, ointment is  preferable in most cases, for the patient generally prefers to be cured
pleasantly and permanently, to  being cured quickly.  In a recent case of  the affection, smearing the
hands at night with the ointment  may  suffice to effect a cure ; but when the disease is of  long stand-
ing, the whole body with the exception of  the head, should be anointed.   Before going  to bed, the
patient may remain for a quarter of an  hour in a warm bath.   This macerates the epidermis upon the
hands and other affected parts to such a degree, that  a brisk friction with soap will doubtless exhume
some of the acari, and certainly increase the effect of the  ointment which is to be subsequently applied.
Hebra warns against the injudicious use of frequent warm baths, but the effect of bathing, in predis-
posing the  skin  to  eczematous inflammation is only noticed when one  employs the very strong
applications which he recommends.   If the eruption is  seated on a delicate skin, and especially if an
eczematous  tendency manifests itself, baths may be  discarded, while the ointment is used with great
care, and not continued but for a few days at a time.
     Disinfection of the clothing is unnecessary in most cases, if not in all.   It is important, however
to treat not only the patient who applies for treatment, but also the bed-fellows, playmates or associates
who may be similarly affected.   Otherwise the disease will be re-contracted as soon as it is fairly cured.
     The duration of the treatment must necessarily vary.   Ordinary cases  can be cured in from five
to ten days.  It is always difficult to say just when the patient is cured, and when, therefore the treat-
ment should cease.  Too often the treatment is continued on account of an eruption which is not due
to the acari, but to the irritating applications which are being employed,
                                               84 
PORRIGO   E  PEDICULIS. 
 
PORRIGO    E   PEDICULIS.
Case.—A  patient  at  the  New  York  Dispensary.  He had suffered,  for several  months,  from
         phtheiriasis, and the pustular eruption shown  in  the  illustration had  developed recently.
         The crusts were thick, of a greenish-yellow color, and most of  them presented a central
         depression, similar  to that observed in a vaccine pustule.   Many had fallen spontaneously,
         and others were but lightly adherent, and when picked off, left  circular  pinkish macules.
         Those which  had  been violently removed by scratching, had left a raw surface or ulceration
         of the most superficial character.  It was quite evident that wherever the skin was excoriated
         by the finger-nails,  the pustules were liable to develop.  An auto-inoculation being made, a
         small  vesico-pustule formed within twenty-four hours, and, in the course of three or four
         days, developed a typical, thick yellow crust.

     The name  Porrigo has been  applied, by the older writers on skin diseases, to so many pustular, as
well as non-pustular affections of widely different nature,  that, at the present day, it is scarcely able to
retain a  position  in dermatological nomenclature.  As  there exists, however, a contagious pustular
affection of the skin, which is neither eczematous nor unmistakably parasitic, and to which no settled
name is  attached, I am disposed to follow the example  of Startin, Nayler, and Hutchinson, and to
apply to  it the old and  misused term, Porrigo.
     The affection is an acute one, and is characterized by the rapid development of  one or many flat,
vesico-pustules, which spring from an apparently normal skin.  These  are quite superficial, tend to
enlarge peripherally though  remaining flattened, and usually attain the size of a ten-cent piece.  The
crusts which form are thick, friable, varying from a straw color to a greenish-yellow,  or brownish hue,
and  often  presenting a central depression, like a vaccine  crust.   They are lightly adherent, and when
forcibly removed, expose a  raw, purulent surface,  but no deep ulcer.  When allowed to dry and fall,
a thin, reddened epidermis  remains for a short time, and disappears without leaving  any scar.  The
chief peculiarity of  the pustules is their contagious character.  When occurring, as they frequently do
in connection with  phtheiriasis, it  is quite apparent that they tend  to develop  wherever the skin is
excoriated, and it appears quite probable  that  the  pus partakes of an infectious nature, and is carried
from one point to another by the finger-nails.  New pustules may be  readily produded by intentional
auto-inoculation.  The  affection  is quite common among children, but it  also  attacks adults.  Fre-
quently several members of a household are successively affected, and epidemics have been reported to
occur.  The  pustules  are most  frequently  met  with upon  the scalp  and  face.   The  trunk and
extremities, and particularly  the fingers, may also be  its seat.  It occasionally develops when no appar-
ent cause exists.  Local irritation  of some sort, however, can generally be detected, and to the irritating
                                              85 
PORRIGO  E  PEDICULIS.
presence of pediculi the affection is frequently attributable.   A  fungus has been described as existing
in the crusts, but it has not been proven to be the essential cause of the affection.
    The diagnosis is  easy, although some confusion arises from the varying descriptions  of  Impetigo
and Eczema impel iginosum which are found in the text-books.   The term Impetigo  is  regarded, by
most  recent  writers, as a 6ynonym of  pustular eczema, " an eczema,"  according  to Tilbury Fox,
" occurring  in  a pyogenic habit of body."   The  Impetigo contagiosa, described by this late writer,
appears to me to be  simply a' form of Porrigo which  occurs  largely among children, and is usually
accompanied, at the outset, by slight febrile symptoms.  Such cases I have had  repeated opportunities
of studying, and  have  verified  the admirable description of the eminent  English author.   I see no
reason,  however, why the name  which is applied to these cases (be it Porrigo or Impetigo contagiosa),
should not also be applied  to an eruption of isolated,  contagious, vesico-pustules in adults, although
unaccompanied  by  febrile symptoms, and  occurring  as a complication  of  phtheiriasis.  Between
Porrigo and Eczemapustulosum, there are essential differences in respect to etiology,  clinical appear-
ance, and amenability to treatment.  Eczema is generally associated with  a condition of the system
which predisposes to a catarrhal inflammation of the skin.  It involves the corium to a greater depth
than do the superficial pustules of Porrigo.   It is never contagious, and is, as a rule, not readily cured.
Porrigo, on the contrary, is almost wholly local in its nature, tends to run a rapid course,  and yields to
the simplest  treatment.
     To cure the affection it is first necessary to  remove the crusts, which can be done without violence
after the application of a poultice or folded cloth wrung out of hot water.   A  five per cent, ointment
of carbolic acid may then be applied to the affected skin for a few days.
     The  treatment of Phtheiriasis corporis, with which affection  Porrigo is frequently  associated,
consists in getting rid of the pediculi, and soothing the irritation of  the skin, which their attacks have
occasioned.   In dispensary practice, I  might say that the first aim of treatment should be to convince
the patient that the eruption is not due to "  heat "  or " humor " in the  blood, but that  it is the natural
result of lice in his clothing.  The patient may be ignorant of the existence of lice, though generally
he is conscious of their presence, but yet so thoroughly possessed with the idea that  they are  the
effect, rather than the cause, of  the eruption, that' it is in vain  to argue the point, and hopeless to give
directions for treatment.  Such cases can only be  treated  satisfactorily in  hospitals, where enforced
cleanliness is possible.  When the patient appreciates the fact that the lice cause the eruption, he may
be directed  to change his clothing throughout, with a fair prospect of his doing so.  It  is not sufficient,
as many patients imagine,  to put on a clean shirt  once or  twice in the week, or even oftener.  The
patient must be told and shown, if necessary, that the outer garments are  infested, and that it  is
essential to change these as well  as  the  underclothes.   While  the latter are being boiled, the former
may be baked in a hot oven, with the probable result of destroying both lice and ova.   It may not be
superfluous, however, after the  clothes have been  thoroughly baked, to sprinkle the seams, where the
ova were  most numerous, with  sulphur, pyrethrum or  staphisagria.  As regards the eruption on the
body, this will quickly disappear when its  cause is  removed.  A daily warm bath will  prove agreeable
and  beneficial  when the skin is greatly  irritated.  For dispensary  patients I  usually prescribe an
ointment or lotion of carbolic acid, which tends to allay the itching, and to repel the parasite.
                                                86 
m
if
HERPES FACIALIS. 
 
HERPES.
 Case.—John B., set.  9.—After  four days  of fever, the eruption suddenly appeared (June 7) in the
         form of erythematous and vesiculated patches  upon the face.   The illustration shows its
         appearance upon the following  day, at which time the vesicles had become larger and partly
         confluent.   The patient now had considerable fever.   His mother stated that he had been
         very restless during the preceding night, and that his body had been  very red.   He  was
         ordered a drop of the tincture of  rhus every three hours, and on the following day (June 9)
         was better.   On June 10 the eruption was drying into thin crusts.  On  the 11th the patient
         was doing well, but, as the mother expressed it, still felt " droopy."  He  complained  of some
         abdominal pain, although his bowels were  free.   The eruption was attended by some itching,
         and the face had been scratched in  several places.  No reason  could be assigned  for  this
         attack.   The mother stated that the J)oy had suffered repeatedly from a similar eruption of
         blisters upon the nose,  mouth, and cheeks, but never before in  such a marked degree.  The
         attacks had always been preceded and  accompanied by more or less fever.

     Herpes, a term old enough to have been used by Hippocrates, has  been  applied, by writers in
 times past, to numerous and varied affections.   Even at the present time there are some who apply it,
 with varying adjectives,  to both  vesicular and bullous, as well as to parasitic, affections.  The tendency
 of modern dermatology has  been toward a limited application of the term to acute affections, charac-
 terized by the development of vesicles in groups.   From a clinical point of view, I deem it convenient
 and advisable to regard zoster and hydroa,  two  vesicular or vesiculo-bullous affections, as distinct from
 the ordinary herpes, so frequently met with upon the  lips and prepuce.   The  reasons for separating
 zoster from herpes have  already  been stated in connection with a former illustration, and the relations
 of herpes to hydroa will be given later, in connection with a plate representing the latter affection.
     Herpes may be defined  as  an acute inflammatory affection, consisting of one  or more groups of
 vesicles, occurring on the face or external genitals, and in the former location accompanied frequently
 by fever.   This definition limits the application of the term to two comparatively insignificant forms
 of vesicular eruption, called in accordance with  the regions affected, H. facialis and H. progenitalis.
     Herpes facialis, in its most  frequent form, is met with upon the margin of the lips, constitutino-
 what is  commonly termed a cold  sore  (H. lahialis).  The vesicles, in such a case, are not  usually
distinct, and the person affected  may note but  one or more slight swellings of the lip, attended by an
unpleasant burning sensation, and the  rapid development  of a thin crust or scab.   The affection  may
result from  no apparent cause, but the patient is frequently conscious of having "caught a cold."  The
eruption often extends from the  vermilion border of the lip upon the  cutaneous  surface, and groups
                                               87 
HERPES.
 of vesicles are seen upon the side of the nose and  cheeks.   When  developed to this extent, the erup-
 tion, particularly in children, is apt to  be associated with more or less  fever.  In  rare instances, the
 forehead, eyelids, ears, as well  as the mucous surface of the  tongue and buccal cavity become the seat
 of  the  eruption.  However numerous may  be the  groups of vesicles,  they are  usually developed
 simultaneously, the affection differing in this respect from  zoster and hydroa.   The vesicles develop
 upon an erythematous base, are rounded and tense, and though larger than the vesicles of eczema, are
 not equal in size to those which are seen in  cases  of  hydroa.  An uncomfortable,  burning sensation
 accompanies their outbreak, but subsides  as soon as the eruption has attained its maximum develop-
 ment.  There is never any of  the neuralgic pain which is so common a feature of zoster.  The vesicles
 rarely rupture when protected from external irritation, but dry speedily, in the course of a week, to
 thin, dark crusts, which fall and leave a slightly reddened surface.   In certain patients, as, for example,
 in the subject of  our illustration, there is a marked tendency of the eruption to recur at intervals.
      The etiology of facial herpes is not thoroughly understood.   That  it  is frequently due to reflex
 nervous irritation is quite apparent from the fact of its common occurrence  in the early stage  of pneu-
 monia,  and in the urethral  fever following internal urethrotomy.   The old idea that  its occurrence is a
 favorable prognostic sign appears to have no scientific basis.
      The treatment of the affection is mainly expectant.  A dusting powder is the best external appli-
 cation when the eruption is extensive.  Spirit  of  camphor,  or some similar stimulating liquid may be
 applied frequently to an incipient " cold sore " in the hope of checking its development.  If it fails,
. as it generally does, cold cream  may be  applied with  good effect, for the purpose of softening the
 crust which forms.
      Herpes progenitalis consists in  the eruption of one or two small groups of vesicles on an ery-
 thematous base, and is  unaccompanied  by fever.  In the male the sheath of the penis, the prepuce or
 the glans may be its seat, while in the female it may be found upon the labia and pubes.   When upon
 a cutaneous surface, it  is  usually recognized without  difficulty, but upon the mucous surface  of the
 genitalia the vesicles become  quickly macerated, and a mere erosion results.  Herpes of the internal
 surface of  the prepuce is  a quite common  affection, and  one which is frequently regarded by both
 patient and physician, as being of venereal origin.   This may be the case, as the irritation of the sexual
 act may evoke the eruption, especially in one predisposed to herpes of this part.   Moreover, it  may be
  the result of direct contagion, since the serum contained in the vesicles has been successfully inoculated.
 But usually herpes of the  prepuce is an innocent affair.  The affection frequently occurs in those who
 have never had any venereal  disease, nor  indulged in impure intercourse.  The vesicles are  usually
 accompanied by slight soreness, and in some  cases by a decided  pruritus.   If the  part is in a cleanly
 condition,  the eruption runs  a rapid course and disappears in four or five days.  A tendency to recur
 is noted in certain  patients, as was seen in the case of herpes of the face.   Those who have suffered
 from venereal disease are especially liable to recurrent attacks, some patients suffering in this way for
 years.   Shortly after the healing of a chancroid, herpes is  prone to occur,  in which case it is very apt
 to be erroneously regarded as  a relapse, or as a fresh infection.
      The treatment of this form of herpes is simple.   Keep the part clean  and dry.
                                                 88 

1
HYDROA  BULLOSUM. 
 
HYDROA.
i/ASE.—Henry B., aet. 15.—The eruption in this case was limited to the parts shown in the illustration.
         The photograph was  taken  about the tenth day, at which time the bullse were becoming
         flatter, their contents  somewhat turbid, and  the  epidermis over the confluent patches was
         wrinkled from  absorption of serum.   The arms  felt stiff  and sore.  There was  no marked
         itching,  and little or no constitutional  disturbance.  Iron and quinine were given internally,
         and powdered starch  applied locally  as an absorbent.  The eruption disappeared  in about
         three weeks.  Two  and a half years  later the patient came to  me again with a somewhat
         similar eruption  upon the hands,  face, and  scrotum.   The  palms were affected this time as
         well  as  the backs of the hands.   This attack was  more  severe than the former, and was
         accompanied  by soreness of  the  joints.  Its duration  wras also about three weeks.  Small
         doses of the tincture of the rhus toxicodendron were given,  with an apparent effect in lessen-
         ing the local pain and checking the development of the bullse.  (A fuller description of these
         two attacks may be found in  the Archives of Dermatology, Vol. III., p. 25, and Vol. IV., p.
         211.)

     Hydroa, a term first employed by Bazin, has gradually come into use during the past twenty years.
It has hardly acquired, as yet, a definite signification,  but  is applied to certain cases of vesicular  or
vesiculo-bullous eruption, possessing clinical features which serve to distinguish them from herpes
and  from pemphigus, with which affections they were formerly confounded.   The  disease is not a
common one, and while the cases met with present salient features which mark  their identity, they
vary in their clinical aspect to such an  extent  that a  concise  definition cannot be given,  which will
include all forms  of  the affection.  The leading characteristics of hydroa are its symmetrical distribu-
tion  its peculiar locality, its tendency to recur at longer or  shorter intervals, and the constitutional
derangement which usually accompanies the eruption.   It begins, as a rule, by the sudden development
of erythematous  papules or patches, upon  the  central  portion of which a single vesicle or  group of
vesicles is rapidly formed.   These are usually of large size and  hemispherical.  They contain at first
clear serum  which in a few days becomes  cloudy and gives to the patches  a whitish or even a yellow-
ish aspect.   There are generally some  isolated  vesicles  or bullse,  and these do not always spring from
an erythematous base.  They may attain the size of a pemphigus  bulla, and become surrounded as they
mature  by a narrow zone of inflammation.   The groups of vesicles tend to become depressed in  the
center and  sometimes an advancing vesicular  margin is noted.  A tendency to successive crops of
vesicles is common, and when  the eruption is subsiding at one  point, a relapse may take place upon
some other portion of the body.
    The serous contents of the  vesicles and  bullse  tend  to become absorbed,  and leave  merely a
                                               89 
HYDROA.
desquamating epidermis, but when the lesions are ruptured by scratching or other external violence, a
yellowish crust or a dark scab may form.   The subjective  symptoms, in a mild  case, consist chiefly in
a burning sensation, but in  many cases, and especially in  those which run  a more chronic course, the
itching may be intense.  There is generally a marked impairment of the general health preceding the
attack, and while the eruption is present, the patient is usually  wholly unfitted for his customary
duties.  There occur now and then rheumatic complications, and effusion into the knee joint has been
reported.  The disease commonly runs an acute course, the successive crops of vesicles disappearing in
a few weeks or  months, but  it may persist for years.  It  is  non-contagious, and though in many
instances a severe affection, it is rarely, if ever, fatal.
    The favorite seat of hydroa is upon the extensor surface  of  the forearms and hands, the face and
ears, the genitals, knees and feet.  In many cases  the oral cavity  is likewise affected, the uvula and soft
palate being frequently the  seat of vesicles, or presenting an inflamed  or eroded appearance.  The
affection is apt to attack young persons, and appears to be most common in the early winter and early
summer.   Some may have a  number of attacks during the year, and cases have been reported where an
annual attack has occurred since childhood.  The  causes of hydroa are obscure, but it is evident that
the eruption is due to derangement of the  nerve-centers, and  not dependent upon any blood changes.
    The diagnosis is not difficult, but as there are no sharp  boundary lines between herpes, hydroa, and
pemphigus, cases often occur which illustrate the relationship of hydroa to one of the other affections
named, and a question might arise as to  the most appropriate term  for a given case.  The main fea-
tures of the three affections may be contrasted as follows:
Lesion.
Location.
Course.
Treatment.
  Herpes.
Vesicles  in
  groups.

Face and genitals
  only.
Acute, lasting but
  a few days.

None required.
       Hydroa.
Large vesicles or bullse,
  isolated or grouped.

Face, forearms, scrotum,
  knees and feet. Rarely
  general.

Acute or chronic, lasting
  a few weeks or longer.

Treatment may  hasten
  the cure.
  Pemphigus.
Bullse, always iso-
  lated.

All  portions of
   the body.
Chronic,  lasting
 for years.

Is rarely cured,
  and often fatal.
    The chief aim of treatment in a case of hydroa should be to restore to the patient his natural
degree of health of mind and body, taking little  account, in most cases, of the eruption upon the skin.
The nervine tonics, such as arsenic, quinine, and cod-liver oil, are highly recommended, and with these,
and the beneficial effects of a complete cessation from work and  worry, with perhaps a change of scene
when it is practicable, a speedy cure may be expected.  When the patches are in a highly inflammatory
condition, the  common lead and opium wash is of service, and when itching is a prominent  symptom,
the parts may  be rubbed with camphorated oil.
                                               00 
ERYTHEMA  circinatum
ERYTHEMA  exfoliativa 
 
   ERYTHEMA    CIRCINATUM.
ERYTHEMA   EXFOLIATIVUM.
Case of Erythema circinatum.—W. R., set. 34, American.—By occupation, a  pilot.—This patient
        was sent by Dr. Robert Abbe to a  meeting of the New York Dermatological Society, and
        afterward kindly placed under  my observation.  Lie was <a large  and powerful man, appar-
        ently in  perfect health.  A searching examination made by Dr. Abbe failed to reveal any
        history or evidence of syphilis.   He had never had any eruption elsewhere upon the skin, and
        with the exception  of a slight attack  of rheumatism, had  never been  ill.  His tongue was
        clean, his appetite good, his bowels slightly constipated, and  his urine clear.  He stated that,
        six weeks previously, a small, itchy red spot appeared in the center of his left  palm, and
        gradually increased in  size.  A few  days  later  two similar spots appeared in right palm.
        About six months before this, the patient had suffered from a  similar, though milder attack.
        There were, at that  time, two or three circular, non-elevated patches  in  each palm, which
        itched exceedingly, and disappeared in  about a  month without treatment.  No scaling fol-
        lowed.  Upon examination of  the  palms during the second attack,  the center of  each was
        found to be the seat of a nearly circular,  purplish-red ring.  The circle  in the  left  palm
      •  (apparently the right in  the illustration), presented an irregular border, and appeared as though
        one or two small rings  had coalesced with  the central circle by centrifugal extension.  On
        the right palm were three small  lesions, in addition  to the central circle, two being near the
        latter, and one on the long finger, near its base.   These small  lesions were just beginning to
        grow annular by a fading of the color  in the center.  The central circles were of  half dollar
        size, and not  at all elevated, although  Dr.  Abbe assures me that they were so at the outset.
        Their most striking feature consisted  in a double border, the inner one  being of a purplish-
        red color, and evidently indicating the height of  the exudative process, the  outer one appear-
        ing whitish, like the epidermis  raised by a blister.   The lesions were not very striking in
        appearance, especially the incipient ones.  But the purple band of the central circles showed
        very plainly when the fingers were forcibly extended, so  as to blanch  the surrounding tissue,
        or when the palm was rubbed briskly for a few seconds with  the corner of a dampened towel.
        The eruption was accompanied by a severe and annoying itching, which kept the patient rub-
        bing or picking at the palms, but the epidermis was  not at all excoriated.
            The treatment adopted at  first in this case wras purely expectant, but as the eruption
        showed no tendency to  disappear of its own accord, as it had  done six  months before, the
        patient was ordered nightly frictions with  green soap, to be  followed  by the inunction of
        mercurial ointment.  This appeared to have no effect, and on January 6,  two weeks after the
        photograph was taken, the rings were increasing in size, and very itchy, especially after wash-
        ing the  hands.  Rochelle salts internally and  chrysophanic acid ointment locally  were
        ordered,  and the eruption disappeared after a duration of  ten weeks.
                                             91 
 ERYTHEMA  CIRCINATUM-ERYTHEMA  EXFOLIATIVUM.

Erythema  ExroLiATivuM.-Chas. O., at  23,  German.-By occupation  a  Porte£-™e
patient had a sallow complexion,  but was strong and apparently m good condition  He gave
the following history.   In his youth, from the age of  four to fourteen, he had suffered every
summer from a general " peeling of  the skin."  The attack  would usually confine him to his
bed for five or six weeks, and he remembers that large sheets of  skin could be loosened and
removed entire from his body. At the close of each attack,  the thick skin of the soles of the
feet would  separate in two portions, one from the ball of the foot and one from  the heel.
His four brothers and one sister were all healthy, as was the patient himself, between  these
annual attacks.  From  the age of fourteen to twenty-two he  was in good health, and  tree ±rom
his early trouble, with the exception of a single mild attack,  which occurred when about nine-
teen.  During the  past six months he has had at least  six  mild attacks, in such rapid succes-
sion that the erythema  would sometimes  appear upon the  body before the palms had finished
scaling  as  the result of a former attack.  When first  seen  by me (January 20),  the  patient
stated that  on the morning of the previous day he had awoke to find his body and extremities
reddened, as was usual at the beginning  of an attack.  An  examination  revealed  a vivid
erythema upon the sides  of  the trunk, the neck, arms, and  thighs.  The skin  on the palms
was dry and harsh, and apparently beginning to separate.   (This condition resulted  from a
previous attack, which  occurred a few weeks before.)   It began to exfoliate shortly  after, and
presented the appearance shown in the illustration.  The erythema quickly became  universal,
with the exception of the face, penis, and backs of hands, and was immediately  followed by a
desquamation of the epidermis.   On the  scalp it occasioned  an acute attack of pityriasis.
On January 26 the attack was waning ; it had been severer than his recent attacks, but did
not compare in severity with those which he had  as a boy.   The skin of the body appeared
of a dusky red hue, indicative of  venous congestion.  The skin on the inner side of the thighs
and gluteal region was quite dark, and  on close  examination presented a  slightly powdery
surface.  Drawing the finger nail rapidly over it a number of times produced at first whitish,
chalky lines, which rapidly assumed a bright red color, contrasting strongly with the surround-
ing livid hue.  There was no evidence of  urticaria, and this irritation of the skin was  unac-
companied  by itching.  The  knees  appeared whitish from the  presence  of thin, adherent
scales, and  there was a certain amount of pityriasis on various portions of the body.
     On March  2, patient came to me with another attack.  Two days before he had felt
perfectly well.  He slept well that night, but awoke on the following morning with the red-
ness of whole body, excluding head, hands and feet.  The skin was hot as well as red, and he
experienced a burning sensation, especially at the flexures of the joints.   He felt weak during
the day, and complained of nausea, but again  slept well.   When seen by me the brightness of
the erythema was already fading, and the skin appeared like that of an Indian, or as it some-
times appears after staining with chrysophanic acid.  His  red flannel underclothing, which
had lost  its  brightness by long  use, very  nearly matched the shade  of the skin.  The
hypersemia was intense, but  of a passive  character, and the body  contrasted strongly with the
face, which was pale and sallow.   On March 5 the purplish redness had faded,  and  where the
skin was naturally thin,  the  desquamation was beginning at numerous points, in  the form of
small siliquose elevations of the epidermis.  From these points the desquamation proceeded cen-
trifugally, leaving patches of normal skin, surrounded by an irregular white line of exfoliating
epidermis.   On March 7 there  were islands, not of denuded  skin,  as before, but of old
epidermis.   These  remaining patches appeared of a  dirty, yellowish-brown color, and were
dotted  by  the siliquose  elevations  of epidermis, and small circular spots,  from  which the
epidermis had fallen.   The patient was feeling perfectly well.
93 
#*„
PURPURA SIMPLEX. 
 
PURPURA.
Case.—Mrs.  J. H.,  set. 31, widow.—Occupation, a cook.   Patient at the New  York Dispensary,
         under the care of Dr. G. W. Robinson.  At the age of 21 she first menstruated, and again a
         year later.   Since  that time there has been no menstruation.  Has  suffered from dyspepsia
         for  twelve  years.   In May, 1875, she had an apoplectic seizure, and was paralyzed and in
         hospital for four months.  Upon her dismissal she went into service, but kept her place but
         two days on account of a purpuric attack affecting the legs, which disappeared in  about a
         week without treatment.  She had repeated attacks during the succeeding  year, and  in June,
         1876,  upon  applying  for  treatment  at the dispensary,  the following notes were made :
         Appearance very stupid.  Uncertainty of speech.  Right arm and  side not as strong as the
         left.   Tongue coated.  Craving appetite.   Bowels constipated.   Confluent  patches of pur-
         pura below  the knees, with oedema and tenderness  of  the  legs.   Small discrete spots  above
         the knees.   She was given a mixture of  iron and ergot, and the lower limbs were bandaged,
         under which treatment she  grew well and  strong in about six weeks.  A month later she
         returned, with a slight attack, from which she recovered in a week, under similar treatment.

     An  effusion of  blood  from the cutaneous capillaries may take place from three causes, viz.,
external violence, increased blood-pressure, and weakness of the vascular walls.  To all of these forms
of cutaneous hemorrhage some writers have applied the term purpura, which is manifestly wrong,
since it places  a flea-bite or a " black-eye "  in the same  category with scurvy.  The  term  purpura
should be used in  a restricted sense, and  applied only to an independent disease, in which cutaneous
hemorrhages occur as a primary lesion.   This excludes the hemorrhage resulting from a blow, fall, or
the bite of an insect, as also that which is  clue to obstruction of the venous circulation. It  excludes
the hemorrhage which occurs secondarily in the  course of the exanthematous  fevers (e.  g., Variola
hemorrhagica), and in certain inflammatory skin affections, such as erythema, urticaria, and pemphigus.
Finally it excludes scorbutus  (or scurvy), as being  an affection due to a definite  and well-known
cause.
     It is customary to describe four forms of purpura.  In  the  most  common  form, or  purpura
simplex,  numerous  small spots,  of a bright purplish-red or claret color,  appear suddenly on the
lower extremities, and in  rare instances on other portions of the body.   They  occur spontaneously,
and  are usually unaccompanied by any marked general symptoms.   The bright  color changes  in the
course of a few days to a dull  red, and after assuming the greenish and yellowish hues so frequently
noted after an ordinary bruise, the spots gradually disappear.  Fresh  extravasations often  appear
from time to time during  the  course of the affection, and thus a contrast of colors may  result.
                                              93 
PURPURA.
The spots commonly vary  in size from a pinhead to a small pea, are  not at all elevated, and do not
disappear on pressure.  Sometimes they are slightly prominent at the outset, and  sometimes large
livid patches develop, as may be seen in the illustration.
    Purpura hemorrhagica is a  more  aggravated form of  the disease, in  which  largo cutaneous
extravasations are  seen, not only on the skin, but also upon the mucous membranes.  Hemorrhages
from  the nose  and  gums occur,  as also bloody stools and urine.  The constitutional  symptoms are
marked, and the weakness resulting from a continued loss of blood may lead to a fatal termination.
    Purpura (or peliosis) rheumatica is  a peculiar affection (conveniently regarded at present as a
form  of purpura), in which  arthritic pains and fever  precede an eruption of  small hemorrhagic
macules upon both trunk and extremities.   The disease usually runs a brief course, although a repeated
onset of  fever and rheumatic  pains, followed by cutaneous hemorrhages, may protract  it for  months.
It commonly attacks those who have a rheumatic tendency, but  are otherwise apparently well.
    The diagnosis of  the simple and hemorrhagic forms of  purpura is  unattended with difficulty.
To the practiced eye the cutaneous lesions are characteristic,  but their hemorrhagic  nature can  be
easily verified by  noting  the  fact that  they do not change in color  under pressure  of  the finger,
a circumstance  which  enables the tyro  to distinguish them  from inflammatory lesions.  Scorbutus,
or sea-scurvy, is  regarded  as distinct from  purpura hemorrhagica, on account of its  gradual develop-
ment, the marked  swelling of  the gums, with loosening  of the teeth, and the extreme debility, which
are its prominent  features; and from the fact  that it  occurs  so frequently among  sailors and those
who cannot or do not eat  fresh vegetables.  Purpura  rheumatica may be  readily mistaken for  rheu-
matism  during   the few days  which  precede  the  outbreak of  the  characteristic eruption.   Tilbury
Fox regarded this form as simply an erythema, complicated by hemorrhage.
    The treatment of purpura consists chiefly in removing any cause which may be ascertainable, and
in enjoining absolute rest where the hemorrhages are severe and frequent.  Iron, ergot, the mineral acids,
and quinine are remedies of value, although too much reliance may be placed upon  their action, and
too little thought given to the question of rest, proper diet,  and the hygienic influences which surround
the patient.  In mild cases of  purpura simplex a moderate amount of  exercise is rather advantageous
than otherwise,  and often  the  treatment need  not interfere with the daily duties of the patient.  No
remedy can be  given  to  hasten the disappearance of the hemorrhagic spots,  but full doses of the
tincture of  the  chloride of iron will usually check the development of new lesions, and improve tho
general  condition  of  the  patient.    In  purpura  rheumatica  the patient usually recovers  speedily
under good nursing, although  an  anodyne  may be necessary to relieve pain, and a  tonic of iron or
quinine prove serviceable  at  the close of the  attack.   In purpura hemorrhagica the patient must
be kept  as quiet as possible.  Ergot  may be given by the mouth or  by hypodermic injection.  For
the latter purpose dissolve five centigrams  of  ergotin in  warm water and glycerine.   This, with tho
use of ice, will promptly control the hemorrhage from  the  mucous  membranes.  A diet  of fresh
vegetables,  which invariably produces  such a beneficial change  in scorbutus (sea scurvy) is of no value
in the treatment of purpura hemorrhagica.
                                              94 

/  \  > '
*&>-&'
CORNUA CUTANEA.
a 
 
CORNUA    CUTANEA.
Case.—E. H. C, set. 58.—Patient of  Dr. Geo. F. French, of Minneapolis, Minn.  About three years
         ago a lesion appeared on the  edge  of the lower lip, near the angle of the mouth, which, in a
         few weeks, bore a resemblance to a rupial crust.  In three months it had assumed a horny con-
         sistence, and at the end of a  year was one half an inch in length.  About this time two more
         horns appeared on the opposite side of the lip, and in six months attained the size of the first.
         Six months later these  three horns were cut off close to  the lip, but in a year they grew to
         three or four times their former dimensions.  Two months ago, while in the woods, and
         pushing his way through the brush, the horns were torn apart, and  the lacerated wound,
         which has never healed, discharges, at the present time, a foul, unhealthy pus, and the sore
         presents an epitheliomatous appearance.  The horns from this patient, which Dr. French was
         kind  enough to  send me with a photograph, are three in  number; the smallest one is about
         an inch in length, of a dull yellowish white color, tolerably smooth, quite dense, and sharply
         curved near its apex.  The  others are over two inches in length, of a  brownish-yellow hue,
         and rugose  in appearance.   They are also curved, but  not so sharply as the smaller one, are
         slightly twisted, and  present a bifurcation a little  more than an inch from the base.  The
         apices of one horn lie  close  together, one  being shorter than the other, while those of the
         other horn tend  to diverge.   The basic portion of the  larger horns is hollow, and readily
         crumbles, now that they have become dry.

    In medical literature we find many accounts of human horns springing  from various portions of
the body.  These cases create surprise and wonder  at first thought, but when  we consider that the
outer layer of the epidermis, together  with the nails, is a natural growth of horny character, we become
far less surprised by these unnatural horny growths.  The favorite seat of horns  may be said to be the
head, although there is scarcely a portion of the whole body which  has been spared.  They have been
reported  as occurring on the scalp, forehead, temple, nose, cheek, lip, jaw, breast, back, pubes, glans
penis, scrotum, praeputium clitoridis, thigh,  knee, leg, hand and foot.  Though usually occurring in the
aged, they have been met with in young  children.  In  size and shape they vary considerably, some
beino- short and stumpy, others conical, and  many long, curving, and somewhat spiral.   Rayer mentions
the case of an old woman with a conoidal horn springing from the forehead, which  was six or seven
inches in diameter at the base, and which projected six inches.   Nayler speaks of a horn ten inches in
length, and curved  like a ram's horn. The shorter  horns, with  a rounded extremity,  are  usually
thicker at the base than those of greater length.   The long ones are always curved when a few inches
in length, and often twisted.  The surface is always rough, and usually ridged transversely.  When of
a marked horny character the horn may present longitudinal striae, and show a tendency to split in
                                              95 
CORNUA   CUTANEA.
this direction.   The color of a horn varies from a yellowish to a dark brown or blackish hue, and is
lighter at the apex than at the base.  The consistence of the growth also varies, some horns being soft
and friable, and others quite dense.  The outer  portion is  always harder than the inner.   The base of
a horn, like the base or youngest portion of a nail, is often surrounded with a thin layer of epidermis.
When removed,  the  horn presents  a conical  cup-like depression, which fits over a fungoid mass
projecting above the level of  the skin.   When cut across, it may be found to be cylindrical or flattened
from  side to side.  Microscopical examination shows it to be composed  chiefly of epidermic cells,
usually arranged in a  concentric manner.  The horn  may spring from the free surface  of the skin, or
originate in one of the larger sebaceous follicles.  It may therefore be regarded  as being  either an
exaggerated wart, having a soft, pulpy, papillomatous base, surmounted by a cone of dense epidermis,
or as  being a dried and hardened sebaceous or epidermic mass, which derives its shape from being
slowly extruded from  a sebaceous cyst.  In some cases the nail, especially that of the great toe, becomes
greatly thickened and rounded and finally assumes the shape and other characteristics of a horn.
    Cutaneous horns develop  slowly, and are painless when unirritated.   The  base may become
inflamed from injury  done to it by violent movement of the growth.  A horn may continue to grow,
whatever size it has attained, but the  longer it is, the greater is its  liability to become accidentally
knocked or torn off.  When it falls  in this way, or is merely cut off on a level with the surrounding
skin,  the growth is reproduced,  and a succession of  horns may occupy a given site.   Not  infrequently
two horns take the place of a preceding one.
    The diagnosis of  a case is easy when the  horn  is present.  The base from which it springs might
be  mistaken for an epithelioma or malignant growth of some kind.  On the lip, indeed, epithelioma
has been observed to follow a horny growth.
    The treatment called for in the case of a cutaneous horn consists in not only removing the growth,
but in destroying the  base from which it springs, in order to prevent its reproduction.  The horn itself,
being frequently quite movable, can be readily torn from  the  skin with  a  slight  amount of violence,
especially when the part has been previously softened.   The base should now  be scraped  with the
curette, and  cauterized lightly with caustic  potassa, or the chloride of zinc.   This will produce a
radical cure, and leave but a trifling  scar in place of the unsightly excrescence.  When  the horn
springs from  a distended follicle  or cyst, extirpation of  this with  the horny growth  is  usually
recommended.
                                              96 
-'■ "H.
ALOPECIA   AREATA 
 
ALOPECIA    AREATA.
***
 Case.—J. L., set. 46.—A patient of a marked nervous temperameut, but apparently in perfect  health.
         He states that his father was bald, that an elder brother has thick hair, and that a younger
         sister had a single bald spot on her scalp two years ago, which  recovered without treatment.
         His own baldness began nearly a }rear ago, at which time, after having  his hair cut, his
         wife noticed three small bald spots  on side of head and  occiput.   Since then numerous
         bald spots have appeared upon the scalp,  cheeks and upper lip.  These have coalesced, and
         at times  formed long patches or streaks of baldness, especially upon the scalp.  There is a
         single spot on the posterior ulnar  aspect of  the left forearm.  On the upper part and side
         of the  head there are a number of spots which are quite bald, and others which present  a
         growth of sparse white hairs.  To the left of the sagittal suture is a  line of closely cut dark
         hairs which have not fallen.  The vertex, though practically bald, is covered with very fine
         hairs,. and the occiput presents, at a distance,  a peculiar piebald appearance,  there  being
         fifteen or twenty areas, varying in size from a ten cent piece to a silver dollar.  These leave
         an intermediate net-work of dark hair, which represents the original growth.  The back of
         the neck  is unusually hairy, while on the lower portion of the  occiput a transverse patch of
         baldness extends from ear to ear, broken by a narrow vertical line of hair on the left side.
         The eye-brows are unaffected.  The beard, which had always been of  a dark brown  color,
         beo-an to be streaked with white on either side of chin  shortly after the bald spots appeared
         on the scalp.  The patient has noticed no change in  his health, either before or since the
         development of the baldness.  He asserts that he feels as well now as  he ever did.

     Alopecia areata is a form of baldness, which begins suddenly, at one or more points, and rapidly
produces  smooth, white patches of  circular  shape and variable size.   These  tend   to increase
peripherally to  a greater or less extent, and often  run together in such a manner as to  form large
irregular patches, or long streaks of baldness.  The disease not only attacks the scalp and beard, but
also  the pubes and axillse, and in rare instances not a single hair  remains upon any portion  of the
body.  It has no relation whatever to ordinary baldness, occurs very frequently in young persons,
and may attack those who have naturally a luxuriant growth of hair.   It is unaccompanied by itching
or other subjective sensations.  After a  variable length of time a new growth of fine downy hair
appears upon the bald spots.  This  new growth is frequently white at first, but gradually becomes
pigmented  and in  time no trace of  the affection is to be  seen.  When  the bald spots are numerous
some will  be found to recover far  more quickly than others,  and in some cases, when  the  hair is
apparently ^rowing normally once more, a relapse  may suddenly occur.  Concerning the  etiology  of
                                              97 
                                  ALOPECIA  AREATA.

the disease, very little can  be positively asserted.  It appears  to  be dependent upon a trophoneurosis
or functional nerve derangement.  A parasitic  origin has been claimed for it, but the claim is by no
means established.   Two or more cases frequently occur in a family, and seem to indicate an hereditary
tendency or predisposition.
    The diagnosis of the affection is easy.   Trichophytosis of the scalp may bear a resemblance, but
in the latter affection the hairs  break off instead of falling out,  and leave rough, scaly patches, quite
different from  the smooth, velvety areas of the former.   The two affections, however, may co-exist in
some  cases.
    The treatment of alopecia  areata is, to a certain extent, empirical, and the results obtained  are
exceedingly variable.  In  some  cases there is a tendency to spontaneous recovery, and hair may grow
again upon the bald  spots in the course of a few months, even without treatment.  Indeed, nearly
every case will get well in time, but it often requires a long time, one  or two  years, perhaps, and
though, in  many cases which recover spontaneously, the credit  is unjustly awarded to the remedies
employed, it is, nevertheless, certain  that judicious treatment tends to  hasten a cure.   In every case a
guarded prognosis should  be given as to the time required to  effect a cure.  Otherwise the result may
bring discredit to the physician and disappointment to the patient.
    As nervous debility,  headaches,  and ether ills, often precede or accompany the  affection, it is
important that these be detected and appropriately treated.  If  the general condition of the patient is
not what it ought to be, attention should be directed to this point rather than to the baldness.  There
is no  special internal remedy which can be recommended above others, although on theoretical grounds
the various  nervine  tonics would seem  to  be indicated.  The local treatment  consists in epilation of
the loose hairs surrounding the bald  patch; in occasional blistering of  the denuded scalp ; in frequent
shaving of the new growth of hair, and in the persistent  use of  various strongly stimulating remedies.
Blistering and  shaving are remedies highly esteemed by some, but it is a question whether they are as
beneficial as they are disagreeable.   I  have  usually dispensed with them, and relied mainly on  the
use of local stimulants, of which the strong solution of ammonia is one of the  most efficient.   If  the
odor of the ammonia is objectionable, a lotion of equal  parts of the tincture of cantharadis and bay-
rum may be applied morning and night.  A host  of other  stimulating remedies  have been recom-
mended, but they all act in the same way.  There is no benefit  to be derived from changing from one
to another, except as it may amuse the patient or curb his impatient desire for a  speedy cure.
                                               98 
1
MORPHCEA.                            SCLERODERMA. 
 
MORPHCEA.-SCLERODERMA.
 Case oe Morphcea.—Alice D., set. 35.—Patient at the New York Dispensary, under the care of Dr.
         P. A. Morrow.  The patch  upon the upper part of the right arm had developed within a
         year.   It occasioned no  pain or inconvenience, and her attention was attracted to it by
         accident.  The patch had a hard horny feeling, and could be pinched up from the underlying
         tissues.  It  presented a  white  waxy appearance,  like the surface of leaf-lard, and had a
         glazed and shiny aspect.   Its upper and outer borders were marked by a broad margin of a
         mottled brownish pigmentation, interspersed with  numerous milky white spots.  Upon the
         right  cheek  there was  a circumscribed  patch, which appeared to be undergoing the  first
         changes of the  disease, and which might have been  mistaken for a patch of  leucoderma.
         The patches on the arm were very itchy, but no other subjective symptoms existed.  In four
         months, during which time  I had  repeated opportunities of studying the case, through the
         kindness of Dr. Morrow, no  material change took jjlace.  The dead white color of the large
         patch assumed a yellow or yellowish white hue.

 Case of Scleroderma.—Mary M., set. 10.—Patient of Dr. V. P. Gibney.  The affection  began at
         the age of three years.  The progress had been steady and gradual, not marked by pain or
         tenderness.   The lower half of the left side of the face presented a  typical hemiatrophia
        facialis, and an examination of  the scalp revealed a patch of canities and another of alopecia
         areata.  (For a complete report of the above cases see Archives of  Dermatology, April, 1879.)

     It is convenient to speak of morphcea and scleroderma together, as there is a kinship between the
 two affections, and, according to several recent writers, a pathological identity.  But whether they are
 forms or stages  of the same disease or not, a clinical differentiation is generally easy, and until a fuller
 knowledge of their nature has been acquired, it appears advisable to retain both terms in use.
     Morphcea is a circumscribed  affection.  When first noticed there are usually one or  more round
 or oval whitish patches of skin, with a faintly marked border, of a darker hue.  When  multiple,
 these patches vary in size, and are usually distributed  along the course of a nerve.   They increase but
 slowly in size, and assume either an alabaster whiteness or a dull, creamy tint, which has been aptly
 compared to the color of an old billiard ball.   They are seldom raised, but, on the contrary, they may
 be slightly depressed below the surface of the skin, and appear atrophic in character.  The  surface
 may be smooth and waxy, or roughened by numerous fine wrinkles, which give to it a peculiar shriveled
 appearance.  Sometimes a patch is quite firm to the touch, although the hardness, when present, is
 always superficial.  On the other hand, it may differ little to the touch from the  surrounding  normal
skin.  The narrow border frequently assumes  a dull  red  or lilac hue, and constitutes a  conspicuous
                                             99 
                             MORPHCEA-SCLERODERMA.

feature of the affection.  Dark macules, of a similar tint, are  often noted as preceding the develop-
ment of the small white patches.  The affection is most common on the extremities, though met with
also on the neck and  trunk.  There is no pain or discomfort produced by the presence of the patches,
and after a lapse of years they may tend to disappear spontaneously.
    Scleroderma is a diffused induration of a tract of skin and its  subjacent connective tissue   The
affected part at first becomes stiff, and later assumes a  certain density  and  tension,  which is  well
expressed by the serai "hide-bound."  The skin itself presents no lesions to the eye, save in some cases
a decided pigmentation.  The  affected part may appear shrunken, but the peculiarity of the affection
is best revealed to the touch.  There is usually no margin to a patch of scleroderma.   The hardness
gradually shades off into the surrounding normal skin.   Large tracts of  skin are often involved by the
disease—the whole side of a limb, for example.   Like morphcea, it progresses slowly, lasts indefinitely,
and in rare instances subsides spontaneously.
    From the above brief description a striking difference is  seen to  exist between typical cases  of
morphcea and  scleroderma.    But in some cases the  patient presents lesions characteristic of  each
affection.   The diagnosis is  consequently  uncertain, and the  conviction  is fostered that the two
affections are identical in nature.  Both morphcea and scleroderma have been observed more frequently
in women than in men.  Cases occur infrequently in childhood.   No known cause  exists, and the
patients affected may in other  respects appear in average health.
    Morphcea, in  its incipient stage, is to be distinguished from scleroderma, to which it may bear a
resemblance.  The marked change in  the character of the skin, apart from its  mere loss of pigment,
and the partial anaesthesia which usually exists, are points of diagnostic  value.  The whitish anaesthetic
macules  which sometimes occur in leprosy resemble morphcea, but their  nature is generally revealed
by the co-existing indications of the leprous diathesis.   Scleroderma can hardly be confounded  with
other cutaneous affections.  It should be  remarked, however, that there exists an acute affection  of
the skin, in which hardening  of the integument takes place rapidly over a large portion of  the body,
and  disappears in a short  time.  This must be  distinguished from  scleroderma, and may be  con-
veniently called scleriasis or sclerema, the  latter of which  terms has  been usually  applied to a similar
affection occuring  in infants (Sclerema neonatorum).
    Little can be said as to the benefit to be expected from treatment in cases  of  morphcea or sclero-
derma.  Under arsenic internally and the local application of the constant galvanic  current there seems
to be the best prospect of achieving success.  The use of the galvanic  battery in cases of scleroderma
has been followed  by very good results.   The progress of these affections is slow and the prognosis is
uncertain.  A marked improvement, if not a perfect cure, is  always a possibility, and  since the  local
condition is more  or less dependent upon the general health of the patient, nothing in the shape of
tonic and hygienic treatment should be neglected.
100 
SARCOMA   PIGMENTOSA 
 
SARCOMA   PIGMENTOSUM.
Case.—William R., set. 22, American, driver.—This patient was successively under the care of Dr.
        Geo. K. Smith and Dr. S. Sherwell, of Brooklyn, and Dr. L. D. Bulkley, of New York.  To
        Drs. Sherwell and Bulkley I am indebted for a complete history of the case, and to the latter
        for the negatives used.  The patient had always been healthy as a child, with the exception
        of a few convulsions.  Six years before the photographs were taken he received a blow on the
        outer side of the right eye-ball.   Shortly after a minute  black speck appeared on the site of
        the bruise, which steadily, though slowly, increased in size.  Small tumors appeared later on
        various portions of the body, none  of which caused any pain.   In June, 1874, there were
        about forty or  fifty tumors, varying from a slight nodosity to a large  horse-chestnut in size.
        Dr. Matthewson examined the deeper tissues of the eye ophthalmoscopically without finding
        any  evidence of lesion there (vide Trans. Amer. Ophthalmological Soc, July, 1874).   At
        this time only one of the tumors, one situated on  the breast, presented any ulcerative change,
        and this was merely abraded as a result of friction.   There was no region of the body exempt,
        nor any especially favored in the distribution of the tumors.  One of  hazel-nut size on the
        right  temple was excised  by Drs.  Smith and Sherwell,  to relieve the  deformity and  for
        microscopical examination.  The tumor was friable in structure, and almost  black in color.
        Microscopically a great excess of pigment matter was found, and many large  cells, with two
        or even three nuclei.  The urine was of smoky color, and  microscopical examination showed
        the uric acid crystals to have a  blue  refraction, and  there were minute granules of pigment
        present of a dark blue color.  The  patient's general health seemed fair, although the prog-
        nosis which had been made in his case rendered him despondent.
           From this time forward the development of the tumors was  pretty  rapid, new ones being
        discovered almost daily.  Some disappeared wholly, or in part.   The general  surface of the
        skin grew darker,  and the face resembled the  appearance seen in Addison's disease.   In
        December, 1874, when coming  under the care of Dr. Bulkley, the following condition was
        noted by  him:  The whole surface, from  head  to foot, is more or less covered with a
        development of sub-cutaneous tumors of various sizes and shapes, varying from that of  a very
        small split pea, to an inch and even two inches in  diameter.  Most of the masses are circular,
        but some are oval, and occasionally a long one is observed, as on the  right forearm, where
        there is one two inches long by three-quarters of an inch wide.  Some of the  lumps appear
        to be made up of several tumors closely set together.  Most of the tumors are distinctly raised
        above the skin to various heights, some being round on top, others quite flat; even those of
        an inch or more in transverse diameter may be elevated only a quarter of an inch or so above
        the level, and be quite flat on top.  These appear  to be such as have reached their height of
        development, and are undergoing absorption.  All of the tumors are decidedly hard and firm
        to the feel. Some of them are  colored, of various shades, from a greenish brown  to a deep
                                            101 
SARCOMA  PIGMENTOS UM.
blue-black, but most of the tumors externally appear of the color of the skin.   Over  these
latter the skin is quite freely movable, but over those of a dark color, which are  really those
undergoing atrophy and flattening, the skin is thick, hard, and united with the tumor.  It is
impossible to give the exact number of  the separate masses, so many smaller ones are deeply
imbedded beneath the skin, and can be  found  only by palpation.   When stripped, the body
appeared  to be  very thickly sprinkled  with them.    Last  week his brother counted ^ one
hundred and fifty by the eye.  As previously remarked, some of the tumors are  now disap-
pearing.  After having attained a certain size, or rather height, as apparently sub-cutaneous
tumors  covered with skin of a normal  color, they become first  of a purplish color, which
deepens until of a deep  black.  While  this is going  on  the tumors seem to flatten, then
absorption appears to take place, the surface sinking  and the color  fading somewhat, until
now some of the older ones on  the  chest and abdomen are seen only as flat discolorations,
presenting a hue much  like that of a nitrate of silver stain.   The  patient  states  that
all of those tumors which have undergone this change  have previously bled spontaneously, or
from friction of the clothing.   Some of the lumps  showed  signs  of  recent hemorrhage.
     A very curious condition develops  in connection with some of  the tumors, notably in
those upon the chest and abdomen.  During the process  of absorption, when the mass has
flattened considerably, there appears a ring or collar around the tumor, which is very distinctly
marked in a number of places at the present time.  This ring is about a quarter of an inch in
width, and, in some  instances, hard and  slightly elevated, and of a  bluish-black color.  In
other places the ring appears simply as a colored band, not elevated, around the  central pig-
mented spot, separated from it by a very narrow portion of healthy skin.  In some instances
this ring is seen around tumors over which the integument  is slightly, if at all colored.  The
patient asserts that this circle is always formed around a tumor which has become discolored,
and also that those which become discolored on the surface always bleed  at some time.
     The subsequent history of the  case can be told in a few words.   The patient  rapidly lost
in strength and  flesh, and the tumors continued to develop anew, and  also to undergo the
processes of absorption and disappearance before described, only the  total mass of cutaneous
tumors was steadily on the increase.  Tumors reappeared in the site of those excised.
     In six weeks he was in a greatly depressed state.   Swelling  of the legs  had appeared.
These were bandaged, but on account of his weakness he entered Roosevelt Hospital.
     He remained in the hospital about three weeks, and died there on May 16.  During this
period the urine was acid, specific  gravity 1.018, was dark colored and  contained a trace of
albumen.   He failed rapidly, becoming more and more bronzed, until, at the time of death,
the general melasmic state of the skin was very striking.
     Autopsy by Dr. Delafield, May 17, 1875.   The entire skin is of a dark color.  On the
surface of the body, just beneath and in the skin, are  seen a great number of tumors,  from
the size of a pea to that of a lien's egg;  many of them of a  dark  purplish-black color.
The  dura mater is grayish, and on its inner surface coated with a  thin layer of fibrin.  The
pia mater is normal, except for one small pigment nodule.  The substance of the brain is not
pigmented, and appears normal   On  the right eye, in the sclerotic, close to the outer edo-e of
the cornea, is a small black nodule, the size of half a  grape  seed.  The lungs are  not pig-
mented ; the left lower lobe is ©edematous, and partly hepatized.   The pericardium is dis-
tended with clear serum; heart normal.  The peritoneal cavity  contains  purulent serum.
The  liver and spleen are pigmented, and  black nodules  are  found in the liver.  The cervical
bronchial, and mesenteric glands are all large and black.
                                     102 
Part i.                              Price, $2

           COMPLETE IN TWELVE PARTS.
-»v°
-qjuis IJJ0sfr
OF
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'#
SKIN   DISEASES
BY
          GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
      Diseases; Fellow of the American Academy of Medicine; Member of the New»York Dermatological Society,
              the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
COMEDO.


ACNE VULGARIS.


LEPRA TUBEROSA.


ELEPHANTIASIS.
■*v.
.:*S&.


IE. IB.
          NEW YORK:

TIRE^T,  JSTo. 805 B^oac3_-v^a,^r.
 9---_--------------

[Copyright, 1879, by George Henry Fox.] 
PREFACE.
      The study of Skin Diseases without cases or colored plates is like the study of
  osteology without bones, or  the  study of geography without maps.  However compre-
  hensive^ practical a text-book may be, its verbal descriptions cannot compare in value
  with a sight of the thing described, or, what is next best, its faithful  representation.   A
  systematic  course  of clinical study  is only possible  in our large  cities,  and yet the
  physician in any remote locality may be called upon to treat the rarest forms of skin
  disease.   As success must depend in great measure upon the correctness of his diagnosis,
  it is hardly necessary to argue the value of a complete series of well-executed plates.
      Of late the steadily increasing interest in dermatology has led to  a demand for illus-
  trations  of skin diseases.  Photographs, though serving a good  purpose in portraying
"  the characteristic location and configuration of the various affections of the skin, have
  generally lacked an essential element  of diagnosis, viz., the color, or have been disfigured
  by careless daubing, and colored lithographs have not only been  expensive, but  in too
  many instances lacked fidelity to nature both in form and color.
      In the series of illustrations now offered to the profession, advantage has been taken
  of a process  recently  devised  for  the reproduction of  pictures  from  photographic
  negatives.  These pictures not only  possess the sharpness of detail and brilliancy of
  ordinary photographs, but, unlike the latter,  will not fade through age and exposure to
  light. The negatives which serve as a basis for the plates of this series have been selected
  from a very large number, most of which were  taken under the immediate supervision
  of the editor.   A few have  been collected from other sources.  The coloring has been
  entrusted to a skilful artist, who was formerly a physician,  and, having studied skin
  diseases  in the General Hospital  at Vienna, is peculiarly fitted for the work.  The text
  accompanying  the plates is  designed to call attention to  the diagnostic  characters of
  the various diseases, and to give in brief some practical suggestions for their treatment.
  The notes of cases have been made very brief, as a  rule,  inasmuch as it has seemed
  unnecessary to give full particulars of a  case except where it has possessed points of
  special interest.   No systematic  order has been followed in the arrangement of  dis-
  eases, although certain ones have been placed together with a view to their contrast.
      It has  been the aim of  the editor to represent in this series nearly all of the rare as
  well  as  the common  affections of the skin, to present their features  with photographic
  accuracy, and  to employ color with  the utmost care  to render the illustrations as life-
  like as possible.
                                                      GEORGE HENRY FOX.
      New York, May,  1879. 
A list of photographic negatives, taken from life, from which most of the plates of the series will be selected.
1.	Epithelioma (lip).	68.	Leucoderma post syph. (side).	160.
2.	Lepra tuberosa (face).	69.	Ulcus fungosum (leg).	161.
3.	Syphiloderma pustulosum (back).	70.	Syph. ulcerativum (elbow).	162.
4.	Leucoplakia linguae.	71.	Syph. papulo-squam. (neck).	163.
5.	Hydroa (forearms). ,	72.	Epithelioma (nose).	164.
6.	Syphiloderma pustulosum (face and arms).	73.	Syph. papulo-squamosum (palm).	165.
7.	Syphiloderma pustulosum (legs).	74	Syph. papulosum annulare (forehead).	166,
8.	Psoriasis diffusa (side).	75.	Ulcera eczematosa (leg).	168,
9.	Eczema madidans (universal). >	76.	Eczema squamosum (forearm).	170,
10.	Scabies (fiand).	77.	Syph. squam. serpig. (foot).	174
11.	Alopecia areata syph. (infant's head).	78.	Syph. squam. serpig. (sole).	175,
12.	Trichophytosis (wrist).	79.	Psoriasis (trunk).	179.
13.	Purpura (legs).	80.	Ulcera syphilitica (leg).	181.
14.	Lichen planus (forearm).	81.	Kerion (scalp).	182.
15.	Eczema rimosum (palm).	82.	Lichen ruber (ant. view).	183.
16.	Eczema squamosum (palm).	83.	Eczema—Vena varicosa (leg).	184,
17.	Lepra maculosa (body).	84.	Syph. tuberculosum (leg).	188.
18.	Fibroma (breast).	85.	Favus (arm).	189.
19.	Syphiloderma pustulosum (arms and thighs).	86.	Fibroma (ear).	190.
20.	Alopecia areata (head).	87.	Lepra tuberosa ( face).	191.
21.	Epithelioma (cheek).	88.	Psoriasis annulata (breast).	192.
22.	Phtheiriasis capitis.	89.	Psoriasis annulata (back).	193.
23.	Eczema madidans (face).	90.	Trichophytosis capitis.	194
24.	Eczema impetiginosum (face).	91.	Rosacea (face).	195,
25.	Lupus vulgaris (face).	92.	Syph. papulosum miliare (anterior).	197.
26.	Favus (Jfead).	93.	Syph. papulosum miliare (posterior).	198,
27.	Syphiloderma rupiale (forearm).	94.	Psoriasis—chrys. acid stain (side).	200.
28.	Ulcus fungosuiu (leg).	95.	Acne indurata (face).	201.
29.	Condylomata syphilitica.	96.	Prurigo (thigh).	202.
30.	Phtheiriasis corporis (back).	97.	Papilloma corneum (cheek).	203.
31.	Favus (back).	98.	Zoster pectoralis.	204.
32.	Lichen simplex (back).	99.	Xeroderma (of Hebra) (face and arms).	205.
33.	Psoriasis guttata (back).	100.	Xeroderma (of Hebra) (face and arms).	206.
34.	Chromophytosis (breast).	101,	102. Syphiloderma papulosum.	207.
85.	Lentigo (abdomen).	ioa	Syphiloderma papulo-squamosum.	208.
36.	Phtheiriasis corporis (back).	104	Syphiloderma papulosum (negro).	209.
37.	Syphiloderma rupiale (legs).	105.	Syphiloderma squamosum.	210.
38.	Syphiloderma ecthymaforme (face).	106,	107,108. Syphiloderma tuberculosum.	211.
39.	Syphiloderma tuberculosum (neck).	109.	Syphiloderma tuberc-ulcerativum.	212.
40.	Syphiloderma ulcerativum (neck).	110.	Syphiloderma serpiginosum.	213.
41.	Epithelioma linguae.	Ill,	112. Syphiloderma ulcerativum.	214
42.	Sycosis (chin).	113.	Syphiloderma gummatosum.	215.
43.	Scabies (hand).	114,	115. Syphilis bursae patellae.	216.
44.	Dermatitis bullosa (hands).	116,	117. Syphilis nasi.	217.
45.	Trichophytosis (hand).	118.	Chancre of nose.	218.
46.	Lupus verrucosus (hand).	119,	120. Lepra tuberosa.	219.
47.	Molluscum (thigK).	121,	122. Elephantiasis.	220.
48.	Psoriasis (legs).	123,	124. Lupus erythematosus.	221.
49.	Vesiculae (from Zoster) (side).	125.	Lupus vulgaris.	222.
50.	Zoster lumbo iuguinalis.	126.	Lupus verrucosus.	223.
51.	Comedo (face).	127.	Lupus hypertrophicus.	224.
52.	Vesiculae (poison ivy eruption) (forearm).	128.	129, 130. Lupus exedens.	225.
53.	Eczema barbae.	131,	132. Lupus.	226.
54.	Dactylitis.	133.	Lupus exedens.	227.
55.	Pemphigus foliaceous.	134,	135, 136, 137, 138, 139, 140, 141, 142, 143,	228.
56.	Eczema rubrum et squamosum (legs).		144. Epithelioma.	229.
57.	Acne vulgaris (back).	145.	Keloid.	230.
58.	Eczema squamosum (elbow).	146.	Sarcoma.	231.
59.	Erythema exudativum (neck).	147.	Sarcoma pigmentosum.	232.
60.	Ulcus syphiliticum (leg).	148.	Naevus vascularis.	233.
61.	Keloid (cJitek).	149.	Rosacea hypertrophica.	234
62.	Lupus tuberculosus (face).	150.	Verrucae.	235.
63.	Albinismus partialis (sid*).	151,	152. Lipoma.	236.
64.	Molluscum (neck).	153,	154, 155, 156. Fibroma.	237.
65.	Ulcera syphilitica (leg).	157.	Dermatolysis.	238.
66.	Syph. ulcerativ. hered. (thigh).	158.	Keloid.	239.
67.	Cicatrix ustionis (elbow). 1	159.	Naevus pilosus.	240.
  Hirsuties.
  Anthrax.
  Pustular eruption from tart. emet. ointment.
.' Abscesses from hypodermic syringe.
  Frostbite—gangrene.
  Cicatrix of burn.
 167.  Eczema.
 169.  Psoriasis.
 171,  172, 173. Psoriasis and eczema.
  Eczema universale.
 176,  177, 178. Ichthyosis.
 180.  Favus.
 Chromophytosis.
  Keloid.
  Lupus erythematosus.
 185,  186, 187. Skin grafts.
  Scratch marks.
  Pityriasis.
  Syphiloderma faciei.
  Syph.  condylomata.
  Epithelioma of hand.
 Ven. wart 8.
  Cancrum oris.
 196.  Ven. warts.
  Syphiloderma papulosum.
 199.  Syphiloderma serpiginosum.
  Syphiloderma ulcerativum.
  Folliculitis calorica (face).
  Morphcea (arm).
  Syphiloderma tuberc. (side).
  Papilloma (lip).
  Leucoderma (face and arms).
  Lepra tuberculosa (face and arms).
  Chromophytosis (body).
  Acne vulgaris (face).
  Impetigo (face).
  Eczema barbae.
  Eczema universale (side view).
  Ichthyosis (side and tMgh).
  Epithelioma (lip).
  Eczema madidans (legs).
  Onychia syphilitica.
  Eczema papulosum (hand).
  Impetigo e pediculis (back).
  Syph. tuberc.  Bursitis (knee).
  Syph.  tuberculosum (face and arms).
  Psoriasis nummulata (back).
  Syph. pustulosum serpig. (thigh).
  Ulcus gangrenosum (thigh).
  Syph. tuberc. squamosum (face and arms).
  Erythema exfoliativum (palm).
 Syph. papulo-squam. (arm and breast).
  Syph.  papulo-squam. (shoulder).
  Scabies (hand).
  Favus (scalp). 
.  ANNOUNCEMENT.
    The undersigned respectfully  announces  to  the  medical .profession that he has
undertaken the publication of a series of Photographic Illustrations  of  Skin Diseases,
from negatives taken from  life, accompanied by a descriptive text calling  attention to
the diagnostic character of the various diseases,  and giving practical suggestions for their
treatment.
               BY GEORGE HENRY  FOX, M.D., OF  NEW YORK.

    The enterprise is  one that will commend itself to Physicians in general practice,
whose opportunity for the study of Dermatology has been necessarily limited, and who
appreciate  the  fact that  the successful treatment of diseases of the skin depends upon
their accuracy in diagnosis.  The large experience and reputation of Dr. Fox in this depart-
ment eminently qualify him for the preparation of so important a work.
    As one of  the Surgeons  to the New York Dispensary, in charge of the Skin and
Venereal Department, where upwards of five thousand cases are  treated annually, he
has had an ample amount of clinical material from which to select  cases.  Through the
kindness of physicians in charge of the Skin clinics he has had the advantage of drawing
largely from other Dispensaries and Hospitals both in New York and Brooklyn.
    By permission of  Mr. O. G. Mason, of  the  Bellevue Hospital  Photographic De-
partment,  the  author has  had access to a collection of several thousand negatives,
taken by Mr. Mason from patients in various Hospitals and private practice during the
past ten years,  and which include some remarkable cases of rare and well-marked skin
disease.
    Of this vast amount of material only  the most typical cases have been selected
for photography.  From  many of these cases good sharp pictures  could  not be taken,
owing to inability on the part of the patient  to sit sufficiently still.  Of the negatives
taken many have  been rejected,  and of the approved ones, constituting the author's
extensive collection, only the choice ones have been selected for this work.
    The Coloring is a special feature of the work, which has been entrusted to a .skilful
anatomical artist, J. Gaertner, M.D., formerly a physician and student under. Hebra, in
the General Hospital of Yienna.
    It is proposed  to complete the work within one year from the publication of Part I.,
issuing the succeeding.parts monthly.  As a guarantee to subscribers that the work will
be issued promptly and regularly, the  publisher asserts that the entire list of negatives
composing  the series are  now in his  possession, also a large portion of the Author's
manuscript.  This  announcement has  been withheld until such a  statement could be
truthfully made;

    CONDITIONS.—The work will  be complete in  Twelve Monthly Parts, each, part
consisting of four plates printed from the original  photographic-negatives, by a new and
indelible process, on the  finest quality of heavy  card-board, 10 x 12 inches, colored by
hand, giving in  each case  the characteristic and life-like effects of the disease.   Two pages
of text, in detail, will accompany each  plate.
    This work will be sold only by  our duly authorized Canvassing Agents.          Dk-!««  ^«m n~„*   (f *
    No Subscriber's name will be taken for less than the entire work.             "NCB  DBf "flU   J>1
    InLT^ir ^ ^ ^ f°7? d°IiVery' thC Can'ier n0t behl* *,mnitted to Sive creditor *> receive money in advance
    bubscnbers removmg or not being regularly supplied will please advise the Publisher by mail or otherwise

              E.  B. TREAT,  PUBLISHER, 805 Broadway,  New York.
Parts I. and II. are now Ready. 
Part 2.
Price, $2
COMPLETE IN TWELVE PARTS.
w>
t4¥te I1J8^
OF
*°4
<y
SKIN   DISEASES
BY
          GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
      Diseases; Feliow of the American Academy of Medicine; Member of the New York Dermatological Society,
               the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE
KELOID,  v/


ROSACEA, v


PSORIASIS NUMMULATA. ,


ICHTHYOSIS simplex, y
                NEW YORK:

IE. IB. TttEJ^-T, JSTo. 805  IB:r?oa,cL-w-a,;5r-
[Copyright, 1879, by George Henry Fox.] 
•
PREFACE.
    The study  of  Skin Diseases  without cases or colored  plates is like t^e study of
osteology without bones, or the study of geography without maps.  However Compre-
hensive or practical a text-book may be, its verbal descriptions cannot compare in value
with a sight of the thing described, or, what is next best, its faithful representation.  A
systematic course of clinical  study is  only possible in our large cities, and  yet the
physician in any remote  locality  may be called upon to treat the rarest forms  of skin
disease.  As success must depend in great measure upon the correctness of his diagnosis,
it is hardly necessary to argue the  value of a complete series of well-executed plates.
    Of late the steadily increasing  interest in dermatology has led to a demand for illus-
trations of skin diseases.   Photographs, though serving a good purpose in portraying
the characteristic location  and configuration of the various affections of  the skin, have
generally lacked an essential element of diagnosis, viz., the color, or have been disfigured
by careless daubing, and colored lithographs have  not only been expensive, but in too
many instances lacked fidelity to nature both in form and color.
    In the series of illustrations now offered to the profession, advantage has been taken
of a  process  recently devised for  the  reproduction of  pictures from photographic
negatives.  These pictures not only possess the sharpness of detail and brilliancy of
ordinary photographs, but, unlike  the latter, will not  fade  through age and exposure to
light.  The negatives which serve as a basis for the plates of this, series have been selected
from a very large number, most of which were  taken  under the immediate  supervision
of the editor.  A few have been collected from other sources.  The  coloring has been
entrusted  to  a skilful artist, who was formerly a physician,  and, having studied  skin
diseases in the General Hospital at Vienna, is peculiarly fitted for the work.  The text
accompanying the plates is designed to call attention to  the diagnostic characters of
the various diseases, and to give in brief some practical suggestions for their treatment.
The notes of cases  have been made very brief, as  a rule, inasmuch as it has  seemed
unnecessary to give full particulars  of a case except where  it has possessed points of
special interest.  No systematic order has been followed  in the arrangement  of dis-
eases, although certain ones have  been  placed together with a view to their contrast.
    It has been the aim of the editor to represent in this series nearly all of the rare as
well as the common affections of  the skin, to present their features with 'photographic
accuracy,  and to employ color with the utmost  care to  render the illustrations as life-
like as possible.
                                                    GEORGE HENRY  FOX.
    New  York,  May, 1879. 
A list of photographic negatives, taken from life, from which most of the plates of the series will be selected.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
2G.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
Epithelioma (lip).
Lepra tuberosa (face).
Syphiloderma pustulosum (back).
Leucoplakia linguse.
Hydroa (forearms).
Syphiloderma pustulosum (face and arms).
Syphiloderma pustulosum (legs).
Psoriasis diffusa (side).
Eczema madidans (universal).
Scabies (hand).
Alopecia a reata syph. (infant's Jiead).
Trichophytosis (wrist).
Purpura (legs).
Lichen planus (forearm).
Eczema rimosum ipalm).
Eczema squamosum (palm).
Lepra maculosa (body).
Fibroma (breast).
Syphiloderma pustulosum (arms and thighs).
Alopecia areata (head).
Epithelioma (cheek).
Phtheiriasis capitis.
Eczema madidans (face).
Eczema impetiginosum (face).
Lupus vulgaris (fact).
Favus (head).
Syphiloderma rupiale (forearm).
Ulcus fungosum  (leg).
Condylomata syphilitica.
Phtheiriasis corporis (back).
Favus (back).
Lichen simplex (back).
Psoriasis guttata (back).
Chromophytosis  (breast).
 Lentigo (abdomen).
 Phtheiriasis corporis (back).
 Syphiloderma rupiale (legs).
 Syphiloderma eefchymaforme (face).
 Syphiloderma tuberculosum (neck).
 Syphiloderma ulcerativum (neck).
 Epithelioma linguae.
 Sycosis (chin).
 Scabies (hand).
 Dermatitis bullosa (hands).
 Trichophytosis (hand).
 Lupus verrucosus (hand).
 Molluscum  (thigh).
 Psoriasis (legs).
 Vesieulae (from Zoster) (side).
 Zoster lumbo iuguinalis.
 Comedo (face).
 Vesiculae (poison ivy eruption) (forearm).
 Eczema barbae.
 Dactylitis.
 Pemphigus foliaceous.
 Eczema rubrum  et squamosum (legs).
 Acne vulgaris (back).
 Eczema squamosum (elbow).
 Erythema exudativum (neck).
 Ulcus syphiliticum (leg).
 Keloid (cheek).
 Lupus tuberculosus (face).
 Albinismus partialis (sid*).
 Molluscum (neck).
 Ulcera syphilitica (leg).
 Syph. ulcerativ.  hered. (thigh).
Cicatrix ustionis (elbow).
68. Leucoderma post syph. (side).
69. Ulcus fungosum (leg).
70. Syph. ulcerativum (elbow).
71. Syph. papulo-squam. (neck).
72. Epithelioma (nose).
73. Syph. papulo-squamosum (palm).
74. Syph. papulosum annulare (forehead).
75. Ulcera eczematosa (leg).
76. Eczema squamosum (forearm).
77. Syph. squam. serpig. (foot).
78. Syph. squam. serpig. (sole).
79. Psoriasis (trunk).
80. Ulcera syphilitica (leg).
81. Kerion (scalp).
82. Lichen ruber (ant. view).
83. Eczema—Vena  varicosa (leg).
84. Syph. tuberculosum (leg).
85. Favus (arm).
86. Fibroma (ear).
87. Lepra tuberosa ( face).
88. Psoriasis annulata (breast).
89. Psoriasis annulata (back).
90. Trichophytosis capitis.
91. Rosacea (face).
92. Syph. papulosum miliare (anterior).
93. Syph. papulosum miliare (posterior).
94. Psoriasis—chrys.  acid stain (side).
95. Acne indurata (face).
96. Prurigo (thigh),
97. Papilloma corneum (cheek).
98. Zoster pectoralis.
99. Xeroderma (of  Hebra) (face and arms).
100. Xeroderma (of  Hebra) (face and arms).
101, 102. Syphiloderma papulosum.
103; Syphiloderma papulo-squamosum.
104 Syphiloderma papulosum (negro).
105. Syphiloderma squamosum.
106, 107,108. Syphiloderma tuberculosum.
109. Syphiloderma tuberc-ulcerativum.
110. Syphiloderma  serpiginosum.
Ill, 112. Syphil derma ulcerativum.
113. Syphiloderma gummatosum.
114, 115. Syphilis bursse patellae.
116, 117. Syphilis nasi.
118. Chancre of nose.
119, 120. Lepra tuberosa.
121, 122. Elephantiasis.
123, 124. Lupus erythematosus.
125. Lupus  vulgaris.
126. Lupus verrucosus.
127. Lupus  hypertrophicus.
128. 129, 130. Lupus exedens.
131, 132. Lupus.
133. Lupus  exedens.
134,  135, 136, 137,  138, 139, 140, 141,  142,
      144. Epithelioma.
145. Keloid.
146. Sarcoma.
147. Sarcoma pigmentosum.
148. Naevus vascularis.
149. Rosacea hypertrophica.
150. Verrucae.
151, 152. Lipoma.
153, 154, 155, 156. Fibroma.
157. Dermatolysis.
158. Keloid.
159. Naevus pilosua.
143,
160.  Hirsuties.
161.  Anthrax.
162.  Pustular eruption from tart. emet. ointment.
163.  Abscesses from hypodermic syringe.
164.  Frostbite—gangrene.
165.  Cicatrix of burn.
166,  167. Eczema.
168,  169. Psoriasis.
170,  171, 172, 173. Psoriasis and eczema.
174.  Eczema universale.
175,  176, 177, 178. Ichthyosis.
179,180. Favus.
181.  Chromophytosis.
182.  Keloid.
183.  Lupus erythematosus.
184,  185, 186, 187. Skin grafts.
188.  Scratch marks.
189.  Pityriasis.
190.  Syphiloderma  faciei.
191.  Syph. condylomata.
192.  Epithelioma of hand.
193.  Ven. warts.
194.  Cancruni oris.
195,196. Ven. warts.
197.  Syphiloderma papulosum.
198, 199. Syphiloderma serpiginosum.
200.  Syphiloderma  ulcerativum.
201. Folliculitis calorica (face).
202.  Morphcea (arm).
203. Syphiloderma  tuberc (side).
204. Papilloma (lip).
205. Leucoderma (face and arms).
206. Lepra tuberculosa (face and arms).
207. Chromophytosis (body).
208. Acne vulgaris  (face).
209. Impetigo (face).
210. Eczema barbae.
211. Eczema universale (side view).
212. Ichthyosis (side ana thigh).
213. Epithelioma (lip).
214. Eczema madidans (legs).
215. Onychia syphilitica.
216. Eczema papulosum (hand).
217. Impetigo e pediculis (back).
218. Syph. tuberc.   Bursitis (knee).
219. Syph. tuberculosum (face and arms).
220. Psoriasis nummulata (back).
221. Syph. pustulosum serpig. (thigh).
     Ulcus  gangrenosum (thigh).
     Syph. tuberc.  squamosum (face and arms).
     Erythema exfoliativum (palm).
     Syph. papulo squam. (arm and breast).
     Syph.  papulo-squam. (shoulder).
     Scabies (hand).
     Favus (scalp).
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
238.
239.
240. 
ANNOUNCEMENT.
i
    The undersigned  respectfully announces to the medical  profession that he has
undertaken the publication of a series of Photographic Illustrations of Skin Diseases,
from negatives taken from life, accompanied by a descriptive  text  calling attention to
the diagnostic character of the various diseases, and giving practical suggestions for their
treatment.                                                                -

               BY GEORGE HENRY FOX,  M.D.,  OF  NEW YORK.

    The enterprise is one that will commend itself  to Physicians in general practice,
whose opportunity for the study of Dermatology has been necessarily limited, and who
appreciate  the fact that the successful treatment of diseases of the skin depends upon
their accuracy in diagnosis. The large  experience and reputation of Dr. Fox in this depart-
ment eminently qualify him for the preparation of so important a work.
    As one of the Surgeons  to the New York Dispensary, in charge of the Skin and
Venereal Department, where upwards of five thousand cases are treated annually, he
has had an ample amount of clinical material from which to select cases.   Through the
kindness of physicians in charge of the Skin clinics he has had the  advantage of drawing
largely from other Dispensaries and Hospitals both in New York and Brooklyn.
    By permission of  Mr. O. G.  Mason,  of the Bellevue Hospital Photographic De-
partment,  the author has had  access to a collection of  several  thousand negatives,
taken by Mr.  Mason from patients in various Hospitals and private practice during the
past ten years, and which include some remarkable cases of rare and well-marked skin
disease.
    Of this vast amount of material only  the most  typical cases  have been selected
for photography.  From many of  these cases good sharp pictures could  not be taken,
owing to inability on the part of the  patient to sit sufficiently  still.  Of the negatives
taken  many have been rejected,  and of the approved ones, constituting the  author's
extensive collection,  only the choice ones have been selected for this work.
    The Coloring is a special feature of the work, which has been entrusted to a skilful
anatomical  artist, J. Gaertner, M.D.,  formerly a physician and  student under Hebra, in
the General Hospital of Vienna,
    It is proposed to complete the work within  one year from the publication of Part I.
issuing the succeeding  parts monthly.   As a guarantee to subscribers that the work will
be issued promptly and regularly,  the publisher asserts that the  entire list of negatives
composing  the series are now in his  possession, also  a large portion of the Author's
manuscript.  This announcement  has been  withheld until such a statement could  be
truthfully made.

    CONDITIONS.-The work will be complete in Twelve Monthly Parts, each part
consisting of four plates printed from the original photographic negatives, by a new and
indelible process, on the finest quality of heavy card-board, 10 x 12 inches,  colored by
hand, giving in each case the characteristic and life-like effects of the disease.  Two pa°-es
of text, in detail, will accompany each plate.                                       *
    This work will be sold only by our duly authorized Canvassing Agents.          D*i««   m    PI       tf *\
    No Subscriber's name will be taken for less than the entire work.            11106   DGr  iB\\    J)Z
    The part,  are to be paid for on delivery, the Carrier not being permitted to give credit or to receive money in advancT
    subscribers removing or not being regularly supplied will please advise the Publisher by mail or otherwise

              E. B.  TREAT,  PUBLISHER, 805 Broadway,  New  York.
Parts I. and II. are now Ready. 
/
Part 3.
Price, $2.
COMPLETE IN TWELVE PARTS.
SKIN   DISEASES
BY
           GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
      Diseases; Fellow of the American Academy of Medicine; Member of the New York Dermatological Society,
                the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES  TAKEN FROM LIFE.
FIBROMA PENDULUM.


VARICELLA. /


ZOSTER PECTORALIS. 1 /

ZOSTER LUMBALIS. \j


ECZEMA UNIVERSALE. V
                  NEW YORK:

IE. IB- TIRIE^-T,  ISTo.  805 IB:coa,cl-s*7-a,;y-'.
[Copyright, 1879, by George Henry Fox.] 
PREFACE.
     The study of Skin  Diseases without cases or colored plates is like the study of
 osteology without  bones, or the study of geography without maps.  However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is  next best, its faithful representation.  A
 systematic  course  of clinical study is  only possible  in  our large  cities,  and yet the
 physician in any remote locality may be called upon to treat the rarest forms of skin
 disease.  As success must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations of  skin diseases.   Photographs, though serving a good ^purpose in portraying
 ,the characteristic location and  configuration of the various affections of  the skin, have
 generally lacked an essential element of diagnosis, viz., the color, or have been disfigured
 by careless  daubing,  and colored lithographs have not only been  expensive, but in too
 many instances lacked fidelity to nature both in form and color.
     In the series of illustrations now offered to the profession, advantage has been taken
 of  a process recently  devised  for the  reproduction  of  pictures from  photographic
 negatives.  These pictures not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.   The negatives  which serve as a basis for the plates of this series have been selected
 from a very large number, most of  which were taken under the immediate supervision
 of  the  editor.  A few have been collected from other sources.  The  coloring has been
 entrusted to a skilful artist, who was formerly a physician, and, having studied skin
 diseases in the General Hospital at Vienna, is peculiarly fitted for the work.  The text
 accompanying the  plates is designed  to call attention to  the diagnostic characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
 The notes of cases have been made very brief, as a rule,  inasmuch as it has seemed
 unnecessary to give full particulars of a case  except where it has possessed points of
 special  interest.  No systematic order has been followed  in the arrangement of dis-
 eases, although certain ones have been placed together with a view to their contrast.
    It has been the aim of  the editor to represent in this series nearly all of the rare as
well as the  common  affections of the  skin, to  present their features with photographic
accuracy, and to employ color with the  utmost care to render the illustrations as life-
like as possible.
                                                     GEORGE HENRY FOX.
    New York,  May,  1879.
V. 
         A list of photographic negatives,

 1. Epithelioma (lip).
 2. Lepra tuberosa (face).
 3. Syphiloderma pustulosum (back).
 4. Leucoplakia linguae.
 5. Hydroa (forearms).
 6. Syphiloderma pustulosum (face and arms).
 7. Syphiloderma pustulosum (legs).
 8. Psoriasis diffusa (side).
 9. Eczema madidans (universal).
10. Scabies (hand).
11. Alopecia areata syph. (infant's head).
12. Trichophytosis (wrist).
13. Purpura (legs).
14. Lichen planus (forearm).
15. Eczema rimosum (palm).
16. Eczema squamosum (palm).
17. Lepra maculosa (body).
18. Fibroma (breast).
19. Syphiloderma pustulosum (arms and thighs).
20. Alopecia areata (Iiead).
21. Epithelioma (cheek).
22. Phtheiriasis capitis.
23. Eczema madidans (face).
24. Eczema impetiginosum (face).
25. Lupus vulgaris (face).
26. Favus (head).
27. Syphiloderma rupiale (forearm).
28. Ulcus fungosum (leg).
29. Condylomata syphilitica.
30. Phtheiriasis corporis (back).
31. Favus (back).
32. Lichen simplex (back).
33. Psoriasis guttata (back).
34. Chromophytosis (breast).
35. Lentigo (abdomen).
36. Phtheiriasis corporis (back).
37. Syphiloderma rupiale (fe£tt).
38. Syphiloderma ecthymaforme (face).
39. Syphiloderma tuberculosum (neck).
40. Syphiloderma ulcerativum (neck).
41. Epithelioma linguae.
42. Sycosis (chin).
43. Scabies (hand).
44. Dermatitis bullosa (hands).
45. Trichophytosis (fiand).
46. Lupus verrucosus  (hand).
47. Molluscum (thigh).
48. Psoriasis (Ze^a).
49. Vesiculae (from Zoster)  (aide).
50. Zoster lumbo inguinalis.
51. Comedo (/ace).
52. Vesiculae (poison ivy eruption) (forearm).
53. Eczema barbae.
54. Dactylitis.
55. Pemphigus foliaceous.
56. Eczema rubrum et squamosum (legs).
57. Acne vulgaris (back).
58. Eczema squamosum (elbow).
59. Erythema exudativum (neck).
60. Ulcus syphiliticum (leg).
61. Keloid (cheek).
62. Lupus tuberculosus (face).
63. Albinismus partialis (sid>).
64. Molluscum (neck).
65. Ulcera syphilitica (leg).
66. Syph. ulcerativ. hered. (thigh).
67. Cicatrix ustionis (elbow).
taken from life, from which most of 1

  68. Leucoderma post syph. (side).
  69. Ulcus fungosum (leg).
  70. Syph. ulcerativum (elbow).
  71. Syph. papulo-squam. (neck).
  72. Epithelioma (nose).
  73. Syph. papulo-squamosum (palm).
  74. Syph. papulosum annulare (forehead).
  75. Ulcera eczematosa (leg).
  76. Eczema squamosum (forearm).
  77. Syph. squam. serpig. (foot).
  78. Syph. squam. serpig. (sole).
  79. Psoriasis (trunk).
  80. Ulcera syphilitica (fe^).'
  81. Kerion (scalp).
  82. Lichen ruber (ant. view).
  83. Eczema—Vena varicosa (leg).
  84. Syph. tuberculosum (leg).
  85. Favus (arm).
  86. Fibroma  (ear).
  87. Lepra tuberosa (face).
  88. Psoriasis annulata (breast).
  89. Psoriasis annulata (back).
  90. Trichophytosis capitis.
  91. Rosacea.(face).
  92. Syph. papulosum miliare (anterior).
  93. Syph. papulosum miliare (posterior).
  94. Psoriasis—chrys. acid stain (side).
  95. Acne indurata (face).
  96. Prurigo (thigh).
  97. Papilloma corneum (cheek).
  98. Zoster pectoralis.
  99. Xeroderma (of Hebra) (face and arms).
  100. Xeroderma (of Hebra) (face and arms).
  101, 102.  Syphiloderma papulosum.
  103; Syphiloderma papulo-squamosum.
  104. Syphiloderma papulosum (negro).
  105. Syphiloderma squamosum.
  106, 107,108.  Syphiloderma tuberculosum.
  109. Syphiloderma tuberc-ulcerativum.
  110. Syphiloderma serpiginosum.
  Ill, 112.  Syphiloderma ulcerativum.
  113. Syphiloderma gummatosum.
  114, 115.  Syphilis bursae patellae.
  116, 117.  Syphilis nasi.
  118. Chancre  of noBe.
  119, 120.  Lepra tuberosa.
  121, 122.  Elephantiasis.
  123, 124.  Lupus erythematosus.
  125. Lupus vulgaris.
  126. Lupus verrucosus.
  127. Lupus hypertrophicus.
  128,129, 130.  Lupus exedenB.
  131, 132.  Lupus.
  133. Lupus exedens.
  134, 135,  136, 137, 138, 189,  140, 141,  142, 143
        144. Epithelioma.
  145. Keloid.
  146. Sarcoma.
  147. Sarcoma pigmentosum.
  148. Naevus vascularis.
  149. Rosacea hypertrophies.
  150. Verrucae.
  151, 152.  Lipoma.
  153, 154, 155, 156. Fibroma.
  157. Dermatolysis.
  158. Keloid.
  159. Naevus pilosus.
plates of the series will be selected.

  160. Hirsuties.
  161. Anthrax.
  162. Pustular eruption from tart. emet. ointment.
  163. Abscesses from hypodermic syringe.
  164. Frostbite—gangrene.
  165. Cicatrix of burn.
  166, 167. Eczema.
  168, 169. Psoriasis.
  170, 171, 172, 173.  Psoriasis and eczema.
  174. Eczema universale.
  175, 176,177, 178.  Ichthyosis.
  179.180. Favus.
  181. Chromophytosis.
  182. Keloid.
  183. Lupus erythematosus.
  184, 185, 186, 187.  Skin grafts.
  188. Scratch marks.
  189. Pityriasis.
  190. Syphiloderma faciei.
  191. Syph. condylomata.
  192. Epithelioma of hand.
  193. Ven. warts.
  194. Cancrum oris.
  195,196. Ven. warts.
  197. Syphiloderma papulosum.
  198, 199. Syphiloderma serpiginosum.
  200. Syphiloderma ulcerativum.
  201. Folliculitis calorica (face).
  202. Morphcea (arm).
  203. Syphiloderma tuberc. (side).
  204. Papilloma (lip).
  205. Leucoderma (face and arms).
  206. Lepra tuberculosa (face and arms).
  207. Chromophytosis (body).
  208. Acne vulgaris (face).
  209. Impetigo (face).
  210. Eczema barbae.
  211. Eczema universale (side view).
  212. Ichthyosis (side and thigh).
  213. Epithelioma  (lip).
  214. Eczema madidans (legs).
  215. Onychia syphilitica.
  216. Eczema papulosum (hand).
  217. Impetigo e pediculis (back).
  218. Syph. tuberc.  Bursitis  (knee).
  219. Syph. tuberculosum (face and arms).
  220. Psoriasis nummulata (back).
  221. Syph. pustulosum serpig. (thigh).
  222. Ulcus gangrenosum {thigh).
  223. Syph. tuberc. squamosum (face and arms).
  224. Erythema exfoliativum (palm)-
  225. Syph. papulo-squam. (arm and breast).
  226. Syph. papulo-squam. (shoulder).
   227. Scabies (hand).
   228. Favus (scalp).
   229.
   230.
  231.                              r
   232.
   233.
   234.
   235.
   236.
   237.
   238.
   239.
   240. 
        OPINIONS   OF  DERMATOLOGISTS
                             CONCERNING THE
   "Photographic JUustrations  of  Skin   Diseases."
    I am  exceedingly  pleased .with  the  Photographic Illustrations  of Skin
Diseases   They are, without exception, the most life-like representations that
I  have ever seen                    HENRY G. P1FFARD, M.D.,
I  have ever seen.            Prof. of Dermatology, Med. Dept. of N. Y. Univ.

    I know the photographs of  Dr.  Fox well,  and use them continually in
teaching.   Many of the series are taken from cases presented before the New
York  Dermatological Society, and of the accuracy and  truthfulness of the
representations 1 can bear witness.    L. DUNCAN  BULKLEY, M.D.,
  r                                     Editor of "Archives of Dermatology.

    1 can hardly  imagine  anything better that  art could  produce  on  paper
than these pictures.   The  coloring is admirable, and  the clinical features of
the various maladies  so strikingly  portrayed that they proclaim the diagnosis to
the  eye  instantly.   I  am  not   acquainted with  any  plates  that  please
me so well, or seem so true to life.     E. L. KEYES, M.D.,
                    Prof, of Dermatology, Bellevue Hospital Medical College.
     Hitherto  photographs of cutaneous affections have failed to reproduce to
the eye  the exact appearances of disease. These plates are a wonderful success,
and will commend themselves to all who want faithful and artistic  representa-
tions of diseases of the skin.          JAMES C. WHITE,  M.D.,
                     Professor of Dermatology, Harvard Univ. Medical Dept.
     In  my judgment, nothing in the way of Illustration of Skin Diseases, that
has ever been placed before the Profession, has at all approached these  in life-
like appearance, and this I think  must be concurred in by every Dermatologist.
                                S. SHERWELL,  M.D.,
      Lecturer on  Dermatology, Long  Island College  Hospital, Brooklyn. N. Y.
     They are marvelously successful  representations  of Skin Diseases, well
calculated to accomplish all that is possible in the way of teaching Dermatology
pictorially.  The accompanying text,  also, is worthy of all praise.
                              FRANK P.  FOSTER,  M.D.,
   Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
     The  illustrations are truly admirable representations, and give  a life-like
picture of each disease portrayed which it would be indeed difficult to surpass.
They will be the indispensable requisites of the teacher and of the student  in
 Dermatology, and should  be in  the  hands of every practitioner who devotes
 any attention  to diseases of the skin.   I commend them most heartily.
                            JAMES NEVINS HYDE, M.D.,
                Professor of Dermatology, Rush  Medical College, Chicago, 111.
     I consider the illustrations in this work by one of the foremost specialists in
 his department to be admirably executed,  accurate and life-like in  appearance.
 The text is simple and concise, and I cannot too highly recommend this valua-
 ble work to students of medicine as well as to experienced  practitioners.
                          JOHN V. SHOEMAKER,  M.D.,
                  Lecturer on Dermatology, Philadelphia School of Anatomy.
     I have examined the "Illustrations of Skin Diseases," byG. H. Fox, M.D.
 They are true to life, and altogether the most useful plates I have yet seen. I am
 convinced that thfese photographs give a more correct idea of the minute appear-
 ances of  Skin Diseases than can  be  obtained by any other kind of pictorial
 representation.                      J. E.  GRAHAM, M.D.,
                  Lecturer on Dermatology, Toronto General Hospital, Canada.
     The Photographic Illustrations  of Dr.  G. H. Fox are admirable, being in
 every particular wonderfully life-like.   A series of forty-eight such illustrations
 will form agallery of Dermatology of the greatest  value  to both  student and
 teacher.  The tinting of the various lesions is perfect. The accompanying text is
 of great supplementary advantage, as it gives a clear idea of the various diseases
 with excellent directions for their treatment.     R.  w. TAYLOR, M.D.,
      Professor of Diseases of the Skin, University of Vermont, Physician to the
          Class of Skin Diseases at Bellevue Hospital (Out-Door Department). 
Part 4.
Price, $2
COMPLETE IN TWELVE PARTS.
-«v>
%t^c mUstin
OF
%
#
SKIN   DISEASES
BY
          GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
     Diseases; Fellow of the American Academy of Medicine; Member of the New York Dermatological Society,
              the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
LEUCODERMA.

CHROMOPHYTOSIS.

FAVUS capitis. ) <
FAVUS corporis. J {

ECZEMA cruris.
IE. IB-
         NEW YORK:

TIRIE-A-T, JSTo. 805 ^j?oeb<3L^?v~a&--
[Copyright, 1879, by George Henry Fox.] 
                              PREFACE.
                                    ——• • •---

     The study of Skin Diseases without cases or colored plates  is like the study of
 osteology without bones, or the study of geography without maps.   However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is  next best,  its faithful  representation.  A
 systematic  course  of  clinical  study is only possible  in  our large  cities,  and yet the
 physician in any remote locality may be called upon to treat the rarest forms of skin
 disease.   As success must depend in great measure  upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations  of skin  diseases.   Photographs, though serving a good  purpose in portraying
 the  characteristic location and configuration of the various affections of the skin, have
 generally lacked  an essential element of diagnosis, viz., the color, or have been disfigured
 by careless daubing, and colored lithographs have not only been  expensive, but in too
 many instances lacked fidelity to nature both in form and color.
     In the series  of illustrations now offered to the  profession, advantage has been taken
 of a process  recently  devised for the  reproduction  of pictures  from  photographic
 negatives.  These pictures not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.  The negatives which serve as a basis for  the plates of this series have been selected
 from a very large number, most of  which were taken under the immediate supervision
 of the editor.  A few have been collected from other sources.  The coloring has been
 entrusted to a skilful artist, who was formerly a physician, and, having studied  skin
 diseases  in the General Hospital at A'ienna, is  peculiarly fitted for the work.   The text
 accompanying the plates is  designed to  call attention to the diagnostic  characters of
 the various diseases, and to give in brief some practical suggestions  for their treatment.
 The  notes of cases have been made very brief, as a rule,  inasmuch as  it has seemed
 unnecessary to give full particulars of a case  except where it has possessed points of
 special interest.  No systematic order has been followed  in the arrangement of dis-
 eases, although certain ones have been placed together with a view to their contrast.
    It has been  the aim of the editor to represent  in this series nearly all of the rare as-
well as the common affections of the skin, to  present their features with photographic
accuracy, and to employ color with the  utmost care to render the illustrations as life-
like as possible.
                                                     GEORGE HENRY FOX.
    New York,  May,  1879. 
  1.
  2.
  3.
  4.
  5.
  6.
  7.
  8.
  9.
 10.
 11.
 12.
 13.
 14.
 15.
 16.
 17.
 18.
 19.
 20.
 21.
 22.
 23.
 24.
 25.
 26.
 27.
 28.
 29.
 30.
 31.
 32.
 33.
 34.
 35.
 36.
 37.
 38.
 39.
 40.
 41.
 42.
 43.
 44.
 45.
 46.
 47.
 48.
 49.
 50.
 51.
 52.
 53.
 54.
 55.
 56.
 57.
 58.
 59.
 60.
 61.
 62.
 63.
 64.
 65.
66.
67.
A list of photographic negatives, taken from life, from which most of the plates of the series  will be selected.
 Epithelioma (Up).
 Lepra tuberosa (face).
 Syphiloderma pustulosum (back).
 Leucoplakia linguze.
 Hydroa (forearms).
 Syphiloderma pustulosum (face and arms).
 Syphiloderma pustulosum (legs).
 Psoriasis diffusa (side).
 Eczema madidans (universal).
 Scabies (hand).
 Alopecia areata syph. (infant's head).
 Trichophytosis (wrist).
 Purpura (legs).
 Lichen planus (forearm).
 Eczema rimosum (palm).
 Eczema squamosum (palm).
 Lepra maculosa (body).
 Fibroma (breast).
 Syphiloderma pustulosum (arms and thighs).
 Alopecia areata (head).
 Epithelioma (cheek). •
 Phtheiriasis capitis.
 Eczema madidans (face).
 Eczema impetiginosum (face).
 Lupus vulgaris (face).
 Favus (head).
 Syphiloderma rupiale (forearm).
 Ulcus fungosum (leg).
 Condylomata syphilitica.
 Phtheiriasis corporis (back).
 Favus (back).
 Lichen simplex (back).
 Psoriasis guttata (back).
 Chromophytosis (breast).
 Lentigo (abdomen).
 Phtheiriasis corporis (back).
 Syphiloderma rupiale (legs).
 Syphiloderma ecthymaforme (face).
 Syphiloderma tuberculosum (neck).
 Syphiloderma ulcerativum (neck).
 Epithelioma linguae.
 Sycosis (chin).
 Scabies (hand).
 Dermatitis bullosa (hands).
 Trichophytosis (hand).
 Lupus verrucosus (hand).
 Molluscum (thigh).
 Psoriasis (legs).
 Vesiculae (from Zoster) (side).
 Zoster lumbo inguinal is.
 Comedo (face).
 Vesiculae (poison ivy eruption) (forearm).
 Eczema barbae.
 Dactylitis.
 Pemphigus foliaceous.
 Eczema rubrum et squamosum (legs).
 Acne vulgaris  (back).
 Eczema squamosum (elbow).
 Erythema exudativum (neck).
 Ulcus syphiliticum (leg).
 Keloid (cheek).
 Lupus tuberculosus (face).
 Albinismus partialis (sid<).
Molluscum (neck).
 Ulcera syphilitica (leg).
Syph. ulcerativ. hered. (thigh).
Cicatrix ustionis (elbow).
68.	Leucoderma post syph. (aide).	160.
69.	Ulcus fungosum (leg).	161.
70.	Syph. ulcerativum (elbow).	162.
71.	Syph. papulo-squam. (neck).	163.
72.	Epithelioma (nose).	164.
73.	Syph. papulo-squamosum (palm).	165.
74.	Syph. papulosum annulare (forehead).	166,
75.	Ulcera eczematosa (leg).	168,
76.	Eczema squamosum (forearm).	170,
77.	Syph. squam. serpig. (foot).	174.
78.	Syph. squam. serpig. (sole).	175,
79.	Psoriasis (trunk).	179,
80.	Ulcera syphilitica (leg).	181.
81.	Kerion (scalp).	182.
82.	Lichen ruber (ant. view).	183.
83.	Eczema—Vena varicosa (leg).	184,
84.	Syph. tuberculosum (leg).	188.
85.	Favus (arm).	189.
86.	Fibroma (ear).	190.
87.	Lepra tuberosa (face).	191.
88.	Psoriasis annulata (breast).	192.
89.	Psoriasis annulata (back).	193.
90.	Trichophytosis capitis.	194.
91.	Rosacea (face).	195,
92.	Syph. papulosum miliare (anterior).	197.
93.	Syph. papulosum miliare (posterior).	198,
94.	Psoriasis—chrys. acid stain (side).	200.
95.	Acne indurata (face).	201.
96.	Prurigo (thigh).	202.
97.	Papilloma corneum (cheek).	203.
98.	Zoster pectoralis.	204.
99.	Xeroderma (of Hebra) (face and arms).	205.
100.	Xeroderma (of Hebra) (face and arms).	206.
101,	102. Syphiloderma papulosum.	207.
ioa	Syphiloderma papulo-squamosum.	208.
104.	Syphiloderma papulosum (negro).	209.
105.	Syphiloderma squamosum.	210.
106,	107,108. Syphiloderma tuberculosum.	211.
109.	Syphiloderma tuberc-ulcerativum.	212.
110.	Syphiloderma serpiginosum.	213.
HI,	112. Syphiloderma ulcerativum.	214.
113.	Syphiloderma gummatosuni.	215.
114,	115. Syphilis bursae patellae.	216.
116,	117. Syphilis nasi.	217.
118.	Chancre of nose.	218.
119,	120. Lepra tuberosa.	219.
121,	122. Elephantiasis.	220.
123,	124. Lupus erythematosus.	221.
125.	Lupus vulgaris.	222.
126.	Lupus verrucosus.	223.
127.	Lupus hypertrophicus.	224.
128,	129, 130. Lupus exedens.	225.
131,	132. Lupus.	226.
133.	Lupus exedens.	227.
134,	135, 136, 137, 138, 139, 140, 141, 142, 143,	228.
	144. Epithelioma.	229.
145.	Keloid.	230.
146.	Sarcoma.	231.
147.	Sarcoma pigmentosum.	232.
148.	Naevus vascularis.	233.
149.	Rosacea hypertrophica.	234.
150.	Verrucae.	235.
151,	152. Lipoma.	236.
153,	154, 155, 156. Fibroma.	237.
157.	Dermatolysis.	238.
158.	Keloid.	239.
159.	Naevus pilosus.	240.
 Hirsuties.
 Anthrax.
 Pustular eruption from tart. emet. ointmei
 Abscesses from hypodermic syringe.
 Frostbite—gangrene.
 Cicatrix of burn.
167.  Eczema.
169.  Psoriasis.
171,  172, 173. Psoriasis and eczema.
 Eczema universale.
176,  177, 178. Ichthyosis.
180.  Favus.
Chromophy tosi s.
 Keloid.
 Lupus erythematosus.
185,  186, 187. Skin grafts.
 Scratch marks.
 Pityriasis.
 Syphiloderma faciei.
 Syph.  condylomata.
 Epithelioma of hand.
Ven. warts.
 Cancrum oris.
196.  Ven. warts.
 Syphiloderma papulosum.
199.  Syphiloderma serpiginosum.
 Syphiloderma ulcerativum.
 Folliculitis calorica  (face).
 Morphcea (arm).
 Syphiloderma tuberc. (side).
 Papilloma \lip).
 Leucoderma (face and arms).
 Lepra tuberculosa (face and arms).
 Chromophytosis (body).
 Acne vulgaris (face).
 Impetigo (face).
 Eczema barbae.
 Eczema universale (side view).
 Ichthyosis (side and thigh).
 Epithelioma (lip).
 Eczema madidans (legs).
 Onychia syphilitica.
 Eczema papulosum  (hand).
 Impetigo e pediculis (back).
 Syph. tuberc.  Bursitis (knee).
 Syph. tuberculosum (face and arms).
 Psoriasis nummulata (back).
 Syph. pustulosum serpig. (thigh).
 Ulcus gangrenosum (thigh).
 Syph. tuberc. squamosum (face and arms).
Erythema exfoliativum (palm).
Syph. papulo-squam. (arm and breast).
 Syph. papulo-squam. (shoulder).
 Scabies (hand).
 Favus (scalp). 
        OPINIONS   OF   DERMATOLOGISTS
                             CONCERNING the
   " Photographic  Illustrations  of  Skin   Diseases."

    I  am  exceedingly  pleased  with  the Photographic Illustration's  of Skin
Diseases.   They are, without exception, the most life-like representations  that'
I have ever seen.                   HENRY G. P1FFARD, M.D.,
                            Prof, of Dermatology, Med. Dept. of N. Y. Univ.
    I  know the photographs of Dr.  Fox  well,  and use them continually in
teaching.   Many of the series are taken from cases presented before  the New
York  Dermatological Society, and of the accuracy and  truthfulness of the
representations 1 can bear witness.    L. DUNCAN BULKLEY,  M.D.,
                                        Editor of "Archives of Dermatology."
    1  can  hardly imagine  anything better that  art could  produce on paper
than these  pictures.   The  coloring is admirable, and  the clinical features of
the various maladies  so strikingly portrayed that they proclaim the diagnosis to
the eye instantly.   I  am  not acquainted  with  any  plates  that please
me so well, or  seem so true to life.    E. L. KEYES, M.D.,
                    Prof, of  Dermatology, Bellevue Hospital Medical College.
    Hitherto photographs  of cutaneous affections have failed to  reproduce to
the eye the exact appearances of disease. These plates are a wonderful success,
and will commend themselves to all who want faithful and artistic representa-
tions of diseases of the skin.          JAMES  C. WHITE, M.D.,
                     Professor of Dermatology, Harvard Univ. Medical Dept.
    In my judgment, nothing in the way of Illustration of Skin Diseases,  that
has ever been placed before the  Profession, has at all approached these in life-
like appearance, and this I think must be concurred in by every Dermatologist.
                                S. SHERWELL, M.D.,
      Lecturer on Dermatology, Long Island College Hospital, Brooklyn. N.  Y.
    They are marvelously successful  representations  of  Skin  Diseases,  well
calculated to accomplish all that is possible in the way of teaching  Dermatology
pictorially.  -The accompanying  text, also, is worthy of all  praise.
                              FRANK  P.  FOSTER,  M.D.,
  Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
    The illustrations are  truly admirable representations, and give a life-like
picture of each disease portrayed which it would be indeed difficult to surpass.
They  will be the indispensable requisites of the teacher and  of the student in
Dermatology, and should be in the hands  of every practitioner  who devotes
any attention to diseases of the skin.  I commend them most heartily.
                            JAMES  NEVINS  HYDE, M.D.,
                Professor of  Dermatology, Rush Medical College, Chicago, 111.
    I consider the illustrations in this work by one of the foremost specialists in
his department  to be admirably executed, accurate and  life-like in appearance.
The text is simple and concise, and I cannot too highly recommend this valua-
ble work to students of medicine as well as to experienced  practitioners.
                          JOHN V.  SHOEMAKER, M.D.,
                 Lecturer on Dermatology, Philadelphia School of Anatomy.
    I have examined the "Illustrations of Skin Diseases," by G. H. Fox, M.D.
They  are true to life, and altogether the most useful plates I have yet seen. I am
convinced that these photographs give a more correct idea of the minute appear-
ances of Skin Diseases than can be obtained by any other kind of  pictorial
representation.                      j. e. GRAHAM, M.D.,
                Lecturer on Dermatology, Toronto General Hospital, Canada.
    The Photographic Illustrations of Dr. G. H. Fox are admirable,  being in
every  particular wonderfully life-like.  A series of forty-eight such illustrations
will form a  gallery of Dermatology of  the greatest value  to both  student  and
teacher. The tinting of the various lesions is perfect. The accompanying text is
of great supplementary advantage, as it gives a clear id.'a of the various diseases
with excellent directions for their treatment.     R. w.  TAYLOR, M D
     Professor of Diseases of the Skin, University of Vermont, Physician to the
         Class of Skin Diseases at Bellevue Hospital (Out-Door Department). 
Part  5.                                Price,  $2.
            COMPLETE IN TWELVE PARTS.










SKIN   DISEASES
BV
           GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
      Diseases; Fellow of the American Academy of Medicine; Member of the New York Dermatological Society,
                the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
ECZEMA INFANTILE. /


ECZEMA PAPULOsUM. V
ECZEMA ichokosu

ECZEMA pustulos

ECZEMA squamosum.
UM. k .
/
                  NEW YORK:

IE. IB. TIRIE^T,  IsTo 805  Broad^ray.
[Copyright, 1879, by Georce Henry Fox.l 
PREFACE.
     The study of Skin  Diseases without cases or colored plates is like the study of
 osteology without  bones, or the study of geography without maps.   However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is  next best, its faithful  representation.   A
 systematic  course  of clinical study is  only possible  in  our large cities,  and yet the
 physician in any remote locality may be called upon to treat the rarest forms of skin
 disease.  As success must depend in great measure  upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations of  skin  diseases.   Photographs, though serving a good purpose in portraying
 the  characteristic location and  configuration of the various affections of the skin, have
 generally lacked an essential element of diagnosis, viz., the color,  or have been disfigured
 by careless  daubing,  and colored lithographs have not only been expensive, but in too
 many instances lacked fidelity to nature both in form and color.
     In the series of illustrations now offered to the profession, advantage has been taken
 of a process recently  devised  for  the  reproduction  of  pictures  from  photographic
 negatives.  These pictures not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.   The negatives which serve as a basis for the plates of this series have been selected
 from a very large number, most of which were taken under the  immediate supervision
 of the  editor.  A few have  been collected from other sources.   The coloring has been
 entrusted to a skilful artist, who was formerly a physician, and,  having studied skin
 diseases in the General Hospital at Vienna, is peculiarly fitted for the work.  The text
 accompanying the  plates is  designed to call attention to  the  diagnostic  characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
 The  notes of cases have been made  very brief, as a rule,  inasmuch as it has seemed
 unnecessary to give full particulars of a case  except where it has possessed points of
 special interest.  No systematic order has been followed  in the arrangement of dis-
 eases, although certain ones have been placed together with a view to their contrast.
    It has been  the aim of  the editor to represent in this series nearly all  of the rare as
 well as the  common  affections of the skin, to  present their features with photographic
 accuracy, and to employ color with  the  utmost care to render the illustrations as life-
like as possible.
                                                     GEORGE  HENRY FOX.
    New York,  May,  1871). 
2.
3.
4.
  9.
 10.
 11.
 12.
 13.
 14.
 15.
 16.
 17.
 18.
 19.
 20.
 21.
 22.
 23.
 24.
 25.
 26.
 27.
 28.
 29.
 30.
 31.
 32,
 o'o.
 34.
 35.
 36.
 37.
 38.
 39.
 40.
 41.
 42.
 43.
 44.
 45.
 46.
 47.
 48.
 49.
 50.
 51.
 52.
 53.
 54.
 55.
 56.
 57.
 58.
 59.
 60.
 61.
 62.
 63.
 64.
 65.
 66.
87.
     A list of photographic negatives, taken from life, from which most of the plates of the series will be selected.
 Epithelioma (Up).
 Lepra tuberosa (face).
 Syphiloderma pustulosum (back).
 Leucoplakia linguae.
 Hydroa (forearms).
 Syphiloderma puatulosum (face and arms).
 Syphiloderma pustulosum (legs).
 Psoriasis diffusa (side).
 Eczema madidans (universal).
 Scabies (hand).
 Alopecia areata syph. (infant's head).
 Trichophytosis (wrist).
 Purpura (legs).
 Lichen planus (forearm).
 Eczema rimosuuv (palm).
 Eczema squamosum (palm).
 Lepra maculosa (body).
 Fibroma  (breast).
 Syphiloderma pustulosum (arms and thighs).
 Alopecia areata (head).
 Epithelioma (cheek).
 Phtheiriasis capitis.
 Eczema madidans (face).
 Eczema impetiginosum (face).
 Lupus vulgaris (face).
 Favus (head).
 Syphiloderma rupiale (forearm).
 Ulcus fungosum (leg).
 Condylomata syphilitica.
 Phtheiriasis corporis (back).
 Favus (back).
 Lichen simplex (back).
 Psoriasis guttata (back).
 Chromophytosis (breast).
 Lentigo (abdomen).'
 Phtheiriasis corporis (back). '
 Syphiloderma rupiale (legs).
 Syphiloderma ecthymaforme (face).
 Syphiloderma tuberculosum (neck).
 Syphiloderma ulcerativum (neck).
 Epithelioma linguae.
 Sycosis (chin)-
 Scabies (hand).
 Dermatitis bullosa (hands).
 Trichophytosis (hand).
 Lupus verrucosus (hand).
 Molluscum (thigh).
 Psoriasis (legs).
 Vesiculae (from Zoster) (side).
 Zoster lurnbo inguinalis.
 Comedo (face).
 Vesiculae (poison ivy eruption) (forearm).
 Eczema barbae.
 Dactylitis.
 Pemphigus foliaceous.
 Eczema rubrum et squamosum (legs).
 Acne vulgaris (back).
 Eczema squamosum (elbow).
 Erythema exudativum (neck).
 Ulcus  syphiliticum (leg).
 Keloid (cheek).
 Lupus tuberculosus (face).
 Albinismus partialis (sid>).
Molluscum (neck).
 Ulcera syphilitica (leg).
Syph.  uloerativ. hered. (thigh).
Cicatrix ustionis (elbow).
68.	Leuc<»derma post syph. (tide).	160.	Hirsuties.
69.	Ulcus fungosum (leg).	161.	Anthrax.
70.	Syph. ulcerativum (elbow).	162.	Pustular eruption from tart. emet. ointment
71.	Syph. papulo-squam. (neck).	163.	Abscesses from hypodermic syringe.
72.	Epithelioma (not).	164.	Frostbite—gangrene.
73.	Syph. papulo-squamosum (palm).	165.	Cicatrix of burn.
74.	Syph. papulosum annulare (forehead).	166,	167. Eczema.
75.	Ulcera eczematosa (leg).	168,	169. Psoriasis.
76.	Eczema squamosum (forearm).	170,	171, 172, 173. Psoriasis and eczema.
77.	Syph. squam. serpig. (foot).	174.	Eczema universale.
78.	Syph.. squam. serpig. (sole).	175,	176, 177, 178. Ichthyosis.
79.	Psoriasis (trunk).	179.	180. Favus.
80.	Ulcera syphilitica (leg).	181.	Chromophytosis.
81.	Keriou (scalp).	182.	Keloid.
82.	Lichen ruber (ant. view).	183.	Lupus erythematosus.
83.	Eczema—Venn varicosa (leg).	184,	185, 186, 187. Skin grafts.
84.	Syph. tuberculosum (leg).	188.	Scratch marks.
85.	Favus (arm).	189.	Pityriasis.
86.	Fibroma (ear).	190.	Syphiloderma faciei.
87.	Lepra tuberosa (face).	191.	Syph. condylomata.
88.	Psoriasis annulata (breast).	192.	Epithelioma of hand.
89.	Psoriasis annulata (back).	193.	Ven. warts.
90.	Trichophytosis capitis.	194.	Cancrum oris.
91.	Rosacea (face).	195,	196. Ven. warts.
92.	Syph. papulosum miliare (anterior).	197.	Syphiloderma papulosum.
93.	Syph. papillosum miliare (posterior).	198,	199. Syphiloderma serpiginosum.
94.	Psoriasis—chrys. acid stain (side).	200.	Syphiloderma ulcerativum.
95.	Acne indurata (face).	201.	Folliculitis calorica (face).
96.	Prurigo (thigh)'.	202.	Morphcea (arm).
97.	Papilloma corneum (cheek).	203.	Syphiloderma tuberc. (side).
98.	Zoster pectoralis.	204.	Papilloma (lip).
99.	Xeroderma (of Hebra) (face and arms).	205.	Leucoderma (face and arms).
100.	Xeroderma (of Hebra) (face and arms).	206.	Lepra tuberculosa (face and arms).
101,	102. Syphiloderma papulosum.	207.	Chromophytosis (body).
ioa	Syphiloderma papulo-squamosuin.	208.	Acne vulgaris (face).
10i	Syphiloderma papulosum (negro).	209.	Impetigo (face).
105.	Syphiloderma squamosum.	210.	Eczema barbae.
106,	107, 108. Syphiloderma tuberculosum.	211.	Eczema universale (side view).
109.	Syphiloderma tuberc.ulcerativum.	212.	Ichthyosis (side ana thigh).
110.	Syphiloderma serpiginosum.	213.	Epithelioma (lip).
Ill,	112. Syphiloderma ulcerativum.	214.	Eczema madidans (legs).
113.	Syphiloderma gummatosum.	215.	Onychia syphilitica.
114,	115. Syphilis bursae patellae.	216.	Eczema papulosum (hand).
116,	117. Syphilis nasi.	217.	Impetigo e pediculis (back).
118.	Chancre of nose.	218.	Syph. tuberc. Bursitis (knee).
119,	120. Lepra tuberosa.	219.	Syph. tuberculosum (face and arms).
121,	122. Elephantiasis.	220.	Psoriasis nummulata (back).
123,	124. Lupus erythematosus.	221.	Syph. pustulosum serpig. (thigh).
125.	Lupus vulgaris.	222.	Ulcus gangrenosum (thigh).
126.	Lupus verrucosus.	223.	Syph. tuberc. squamosum (face and arms).
127.	Lupus hyperirophicus.	224.	Erythema exfoliativum (palm).
128,	129, 130. Lupus exedens.	225.	Syph. papulo-squam. (arm and breast).
131,	132. Lupus.	226.	Syph. papulo-squam. (shoulder).
133.	Lupus exedens.	227.	Scabies (hand).
134,	135, 136, 137, 138, 139, 140, 141, 142, ^43,	228.	Favus (scalp).
	144. Epithelioma.	229.	
145.	Keloid.	230.	.^-'7 ».
146.	Sarcoma.	231.	
147.	Sarcoma pigmentosum.	232.	
148.	Naevus vascularis.	233.	
149.	Rosacea hypertrophica.	234.	
150.	Verrucse.	235.	
151,	152. Lipoma.	236.	
153,	154, 155, 156. Fibroma.	237.	
157.	Dermatolysis.	238.	
158.	Keloid.	239.	
159.	Naevus pilosus.	240.	
 
OPINIONS   OF  DERMATOLOGISTS
                              CONCERNING THE
    'Photographic   Illustrations  of  Skin  Diseases."

     1  am  exceedingly pleased with the Photographic  Illustrations of Skin
Diseases.  They are, without exception, the most life-like representations that
I have ever seen.                   HENRY G. PIFFARD,  M.D.,
                            Prof, of Dermatology, Med. Dept.  of N. Y. Univ.
     I  know the photographs of Dr. Fox  well, and  use them continually  in
teaching.  Many of the series  are taken from cases presented before the New
York Dermatological  Society,  and of the accuracy  and  truthfulness of the
representations 1 can bear witness.    L. DUNCAN BULKLEY,  M.D.,
                                        Editor of "Archives of Dermatology."
     1  can  hardly  imagine anything better that art could produce  on paper
than these pictures.  The coloring is  admirable, and the clinical features  of
the various maladies so strikingly portrayed that they proclaim  the diagnosis  to
the  eye  instantly.   I am  not acquainted  with  any  plates  that please
me so well, or seem so true to life.    E. L. KEYES, M.D.,
                    Prof, of  Dermatology, Bellevue Hospital Medical College.
   " Hitherto photographs of cutaneous affections have failed to  reproduce  to
the eye the exact appearances of disease. These plates are a wonderful success,
and will commend themselves to all who want faithful and artistic representa-
tions of diseases of the skin.         JAMES C. WHITE, M.D.,
                     Professor of Dermatology, Harvard Univ.  Medical Dept.
     In my judgment, nothing in the way of Illustration of Skin Diseases, that
has ever been placed before the Profession, has at all  approached these in life-
like appearance, and this I think must be concurred in by every Dermatologist.
                                S. SHERWELL,  M.D.,
      Lecturer on Dermatology, Long Island College Hospital, Brooklyn. N. Y.
     They are marvelously successful representations of Skin Diseases, well
calculated to accomplish all that is possible in the way of teaching  Dermatology
pictorially.   The accompanying text, also, is  worthy of all praise.
                              FRANK  P. FOSTER, M.D.,
  Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
     The illustrations are  truly admirable representations, and give a life-like
picture of each disease portrayed which it would be indeed difficult to surpass.
They will be the indispensable requisites of the teacher and of the  student in
Dermatology, and should be in the hands of every practitioner  who devotes
any attention to diseases of the skin.  I commend them most heartily.
                            JAMES NEVINS HYDE,  M.D.,
                Professor of Dermatology, Rush Medical College, Chicago, 111.
     I consider the illustrations in this work by one of the foremost specialists in
his department to be admirably executed, accurate and life-like in  appearance.
The text is simple and  concise,  and I cannot too highly recommend  this valua-
ble work to students of medicine as well as to experienced practitioners
                          JOHN V. SHOEMAKER, M.D.,
                 Lecturer on Dermatology, Philadelphia School of Anatomy.
     I have examined the "Illustrations of Skin Diseases," byG. H.Fox,M.D.
They are true to life, and altogether the most useful plates I have yet seen.'  I km
convinced that these photographs give a more correct idea of the minute appear-
ances of Skin Diseases than can  be obtained by any other kind of  pictorial
representation.                      j.  e.  GRAHAM, M.D.,
                 Lecturer on Dermatology, Toronto General Hospital, Canada.
    The Photographic Illustrations of  Dr." G. H. Fox are admirable, being in
every particular wonderfully life-like. A series of forty-eight such illustrations
will form a gallery  of Dermatology of the greatest value  to both  student and
teacher.  The tinting of the various lesions is perfect. The  accompanying text  is
of great supplementary advantage, as it gives a clearid.-a of the  various diseases
with excellent directions for their treatment.     R. w  TAYLOR  M D
     Professor of Diseases of the Skin, University of Vermont, Physician to'the
         Class of Skin Diseases at Bellevue Hospital (Out-Door Department) 
Part 6.                             Price, $2.

           COMPLETE IN TWELVE PARTS.
ic I,J88X
'&
SKIN   DISEASES
BV
          GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
     Diseases; Fellow of the American Academy of Medicine; Member of the New York Dermatological Society,
              the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
ECZEMA bareue.


ECZEMA MANUM. V


ECZEMA E VENIS VARICOSIS. )*

ULCUS VARICOSUM.    £,


PSORIASIS ANNULATA. y'
y
               NEW YORK:

El. IB. TIRIE-A-T, IsTo.. 805 JBiooSbAr^rsb'^'.
[Copyright, 1879, by George Henry Fox.l 
PREFACE.
   -.. The study of Skin Diseases  without cases  or  colored plates is like the study of
 osteology without bones, or the study of geography without maps.  However compre-
vhensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is next best, its faithful representation.   A
 systematic  course of clinical  study is  only possible in our large cities,  and yet the
 physician in any remote locality may be called  upon to treat the rarest forms of skin
 disease.  As success must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations of skin diseases.   Photographs, though  serving a good purpose in portraying
 the  characteristic location and configuration of the various affections of the skin, have
 generally lacked an essential element of diagnosis, viz., the color,  or have been disfigured
 by careless  daubing,  and colored lithographs have not only been expensive, but  in too
 many instances lacked fidelity to nature both in form and color.
     In the series of illustrations now offered to the profession, advantage has been taken
 of a process recently  devised for the  reproduction  of pictures from  photographic
 negatives.  These pictures not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike  the latter, will not fade through age and exposure to
 light.  The negatives  which serve as a basis for the plates of this series have been selected
 from a very large number, most of  which were taken under the  immediate  supervision
 of the  editor.  A few have been collected from other sources.   The coloring has been
 entrusted to a skilful artist, who was formerly a physician, and,  having studied skin
 diseases in the General Hospital at Vienna, is peculiarly fitted for the work. The text
 accompanying the plates is designed to call attention to the diagnostic  characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
The  notes of cases have been  made  very brief, as a rule,  inasmuch as it has seemed
unnecessary to give full particulars of a case except where it has possessed points of
special  interest.   No systematic order has been followed  in the  arrangement of dis-
eases, although certain  ones  have been placed together with a view to their contrast.
    It has been the aim of the editor to represent in this series nearly all of the rare as
well  as the common  affections of the skin, to present their features with photographic
accuracy, and to  employ color with  the  utmost care to render the illustrations as life-
like as possible.
                                                     GEORGE  HENRY FOX.
    New York,  May,  1879. 
A list of photographic negatives, taken from life, from which most of the plates of the series will be selected.
  3.
  4.
  5.
  6.
  7.
  8.
  9.
 10.
 11.
 12.
 13.
 14.
 15.
 16.
 17.
 18.
 19.
 20.
 21.
 22.
 23.
 24.
 25.
 26.
 27.
 28.
 29.
 30.
 31.
 32.
 33.
 34.
 35.
 36.
 37.
 38.
 39.
 40.
 41.
 42.
 43.
 44.
 45.
 46.
 47.
 48.
 49.
 50.
 51.
 52.
 53.
 54.
 55.
 56.
 57.
 58.
 59.
 60.
 61.
 62.
 63.
 64.
 65.
 66.
67.
 Epithelioma (lip).
 Lepra tuberosa (face).
 Syphiloderma pustulosum (back).
 Leucoplakia lingua?.
 Hydroa (forearms).
 Syphiloderma pustulosum (face and arms).
 Syphiloderma pustulosum (legs).
 Psoriasis diffusa (side).
 Eczema madidans (universal).
 Scabies (hand).
 Alopecia  areata syph. (infant's head).
 Trichophytosis (wrist).
 Purpura (legs).
 Lichen planus (forearm).
 Eczema rimosum (palm).
 Eczema squamosum (palm).
 Lepra maculosa (body).
 Fibroma  (breast).
 Syphiloderma puBtulosum (arms and thighs).
 Alopecia  areata (head).
 Epithelioma (cheek).
 Phtheiriasis capitis.
 Eczema madidans (face).
 Eczema impetiginosum (face).
 Lupus vulgaris (face).
 Favus (head).
 Syphiloderma rupiale (forearm).
 Ulcus fungosum (leg).
 Condylomata syphilitica.
 Phtheiriasis corporis (back).
 Favus (back).
 Lichen simplex (back).
 Psoriasis guttata (back).
 Chromophytosis (breast).
 Lentigo (abdomen).
 Phtheiriasis corporis (back).
 Syphiloderma rupiale (legs).
 Syphiloderma ecthymaforme (face).
 Syphiloderma tuberculosum (neck).
 Syphiloderma ulcerativum (neck).
 Epithelioma lingua?.
 Sycosis (chin).
 Scabies (hand).
 Dermatitis bullosa (hands).
 Trichophytosis (hand).
 Lupus verrucosus (hand).
 Molluscum (thigh).
 Psoriasis  (legs).
 Vesiculae  (Irom Zoster) (side).
 Zoster lumbo iuguinalis.
 Comedo (face).
 Vesiculae  (poison ivy eruption) (forearm).
 Eczema barbae.
 Dactylitis.
 Pemphigus foliaceous.
 Eczema rubrum et squamosum (legs).
 Acne vulgaris  (back).
 Eczema squamosum (elbow).
 Erythema exudativum (neck).
 Ulcus syphiliticum (leg).
 Keloid  (cheek).
 Lupus tuberculosus (face).
 Albinismus partialis (sid*).
 Molluscum (neck).
 Ulcera syphilitica (leg).
Sypb. ulcerativ. hered. (thigh).
Cicatrix ustionis (elbow).
  68. Leucoderma post syph. (side).
  69. Ulcus fungosum (leg).
  70. Syph. ulcerativum (elbow).
  71. Syph. papulo-squam. (neck).
  72. Epithelioma (nosr).
  73. Syph. papulo-squamosum (palm).
  74. Syph. papulosum annulare (forehead).
  75. Ulcera eczematosa (leg).
  76. Eczema squamosum (forearm).
  77. Syph. squam. serpig. (foot).
  78. Syph. squam. serpig. (sole).
  79. Psoriasis (trunk).
  80. Ulcera syphilitica (leg).
  81. Keriou (scalp).
  82. Lichen ruber (ant. view).
  83. Eczema—Vena varicosa (leg).
  84. Syph. tuberculosum (leg).
  85. Favus (arm).
  86. Fibroma (ear).
  87. Lepra tuberosa ( face).
  88. Psoriasis annulata (breast).
  89. Psoriasis annulata (back).
  90. Trichophytosis capitis.
  91. Rosacea (face).
  92. Syph. papulosum miliare (anterior).
  93. Syph. papulosum miliare (posterior).
  94. Psoriasis—chrys. acid stain (side).
  95. Acne indurata (face).
  96. Prurigo (thigh).
  97. Papilloma corneum (cheek).
  98. Zoster pectoralis.
  99. Xeroderma (of Hebra) (face and arms).
 100. Xeroderma (of Hebra) (face and arms).
 101, 102.  Syphiloderma papulosum.
 103; Syphiloderma papulo-squamosum.
 104. Syphiloderma papulosum (negro).
 105. Syphiloderma squamosum,
 106, 107, 108.  Syphiloderma tuberculosum.
 109. Syphiloderma tuberc-ulcerativum.
 110. Syphiloderma serpiginosum.
 Ill, 112.  Syphiloderma ulcerativum.
 113. Syphiloderma gummatosum.
 114, 115.  Syphilis bursae patella?.
 116, 117.  Syphilis nasi.
 118. Chancre of nose.
 119, 120.  Lepra tuberosa.
 121, 122.  Elephantiasis.
 123, 124.  Lupus erythematosus.
 125. Lupus vulgaris.
 126. Lupus verrucosus.
 127. Lupus hypertrophicus.
 128. 129, 130. Lupus exedens.
 131, 132.  Lupus.
 133. Lupus exedens.
 134, 135,  136, 137, 138, 139, 140,  141, 142, 143,
      144. Epithelioma.
 145. Keloid.
 146. Sarcoma.
 147. Sarcoma pigmentosum.
 148. Naevus vascularis.
 149. Rosacea hypertrophic*
150. Verruca?.
151, 152.  Lipoma.
153, 154, 155, 156. Fibroma.
157. Dermatolysis.
158. Keloid.
159. Naevus pilosus.
160.
161.
162.
1G3.
164.
165.
166,
168,
170,
174.
175,
179.
181.
182.
183.
184,
188.
189.
100.
191.
192.
193.
194.
195,
197.
198,
200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
238.
239.
240.
 Hirsuties.
 Anthrax.
 Pustular eruption from tart. emet. ointment
 Abscesses from hypodermic syringe.
 Frostbite—gangrene.
 Cicatrix of burn.
 167.  Eczema.
 169.  Psoriasis.
 171,  172, 173. Psoriasis and eczema.
 Eczema universale.
 176,  177, 178. Ichthyosis.
180.  Favus.
 Chromophytosis.
 Keloid.
 Lupus erythematosus.
 185,  186, 187. Skin grafts.
 Scratch marks.
 Pityriasis.
 Syphiloderma faciei.
 Syph.  condylomata.
 Epithelioma of hand.
 Ven. warts.
 Cancrum oris.
196.  Ven.  warts.
 Syphiloderma papulosum.
 199.  Syphiloderma serpiginosum.
 Syphiloderma ulcerativum.
 Folliculitis calorica (face).
 Morphcea (arm).
 Syphiloderma tuberc. (side).
 Papilloma (lip).
 Leucoderma (face and arms).
 Lepra tuberculosa (face and arms).
 Chromophytosis (body).
 Acne vulgaris (face).
 Impetigo (face).
 Eczema barbae.
 Eczema universale (side-view).
 Ichthyosis (side ana thigh).
 Epithelioma (lip).
 Eczema madidans (legs).
 Onychia syphilitica.
 Eczema papulosum (hand).
 Impetigo e pediculis (back).
 Syph.  tuberc.   Bursitis (knee).
 Syph.  tuberculosum (face and arms).
 Psoriasis nummulata (back).
 Syph.  pustulosum serpig. (thigh).
 Ulcus gangrenosum (thigh).
 Syph.  tuberc. squamosum (face and arms).
 Erythema exfoliativum (palm).
 Syph.  papulo-squam. (arm and breast).
 Syph.  papulo-squam. (shoulder).
 Scabies (hand).
 Favus (scalp). 
        OPINIONS   OF  DERMATOLOGISTS
                             CONCERNING THE
    1 Photographic _l I lustrations  of   Skin   Diseases."

    I  am  exceedingly  pleased  with  the Photographic Illustrations  of Skin
Diseases.   They are, without exception, the most life-like representations  that
I have ever seen.                   HENRY G. PIFFARD, M.D.,
                            Prof, of Dermatology, Med. Dept. of N. Y. Univ.
    I  know the photographs of Dr.  Fox  well,  and use them continually in
teaching.   Many of the series are taken from cases presented before  the New
York  Dermatological Society, and of the accuracy and  truthfulness of the
representations 1 can bear witness.    L. DUNCAN BULKLEY, M.D.,
                                        Editor of "Archives of Dermatology."
    1  can  hardly imagine  anything better that  art could  produce on paper
than these  pictures.   The  coloring is admirable, and  the clinical features of
the various maladies  so strikingly portrayed that they proclaim  the diagnosis to
the eye instantly.   I  am  not  acquainted with  any  plates  that please
me so well, or  seem so true to life.    E.  L. KEYES, M.D.,
                    Prof,  of Dermatology, Bellevue Hospital Medical College.
   ^ Hitherto photographs of cutaneous affections have failed to reproduce to
the eye the exact appearances of disease. These plates are a wonderful success,
and will commend themselves to all who want faithful and artistic  representa-
tions of diseases of the skin.          JAMES C. WHITE, M.D.,
                     Professor of Dermatology, Harvard Univ.  Medical Dept.
    In my judgment, nothing in the way of Illustration of Skin Diseases,  that
has ever been placed before the  Profession, has at all approached these in life-
like appearance, and this I think must be concurred in by every Dermatologist.
                                S. SHERWELL, M.D.,
       Lecturer on Dermatology, Long Island College Hospital, Brooklyn. N.  Y.
    They  are marvelously successful  representations  of  Skin Diseases,  well
calculated to accomplish all that is possible in the way of teaching Dermatology
pictorially.   The accompanying  text,  also, is worthy of all praise.
                             FRANK  P. FOSTER,  M.D.,
  Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
    The illustrations are  truly admirable representations, and give a life-like
picture of each disease portrayed which it would be indeed difficult to surpass.
They will be the indispensable requisites of the teacher and of the student in
Dermatology,  and should be in  the hands of every practitioner who devotes
any attention to diseases of the skin.   I commend them most heartily. " 7'
                            JAMES NEVINS  HYDE,  M.D.,
                Professor of Dermatology, Rush Medical College, Chicago, 111.
    I consider the illustrations in this work by one of the foremost specialists in
his department to be admirably executed, accurate and life-like in appearance.
The text is simple and concise, and I  cannot too highly recommend this valua-
ble work to students of medicine as well as to experienced  practitioners.
                          JOHN V.  SHOEMAKER, M.D.,
                 Lecturer on Dermatology, Philadelphia School of Anatomy.
    I have examined the "Illustrations of Skin Diseases," by G. H. Fox, M.D.
They are true to life, and altogether the most useful plates I have yet seen.  I am
convinced that these photographs give a more correct idea of the minute appear-
ances of Skin Diseases than  can be  obtained by any other kind of  pictorial
representation.                      j. e. GRAHAM, M.D.,
                 Lecturer on Dermatology, Toronto General Hospital, Canada.
    The Photographic Illustrations of Dr. G. H.  Fox are admirable, being in
every particular wonderfully life-like.  A series of  forty-eight such illustrations
will form a gallery of Dermatology of the greatest value to both  student and
teacher. The tinting of the various lesions is perfect. The accompanying text is
of great supplementary advantage, as it gives a clear idea of the various diseases
with excellent directions for their treatment.    R. W. TAYLOR,  M.D.,  -
      Professor of Diseases of the Skin, University of Vermont,  Physician to the
         Class of Skin Diseases at Bellevue Hospital (Out-Door Department). 
Part  7.                                 Price, $2.

            COMPLETE IN TWELVE PARTS.
OF
SKIN    DISEASES
BY
           GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
      Diseases; Fellow of the American Academy of Medicine; Member of the New York Dermatological Society,
                the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
LUPUS VULGARIS. v

LUPUS ERYTHEMATOSUS. v

EPITHELIOMA svpekf.cialk

EPITHELIOMA »»ns.

EPITHELIOMA
\:
4/BTTK^"'
                  NEW YORK:

IE. IB. TIRIE^-T,  2sTo..  805 Broad^ray.
[Copyright, 1879, by George Henry Fox.] 
PREFACE.
     The study of Skin Diseases  without cases  or  colored plates is like the study of
 osteology without bones, or the study of geography without maps.   However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is next best, its faithful  representation.   A
 systematic  course of clinical  study is  only possible in our large cities,  and yet the
 physician in any remote  locality may be called  upon to treat the rarest forms of skin
 disease.  As success must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations of skin diseases.   Photographs, though  serving a good purpose in portraying
 the characteristic location  and configuration of the various affections of the skin, have
.generally lacked an essential element of diagnosis, viz., the color,  or have been disfigured
 by careless  daubing, and colored lithographs have not only been expensive, but  in too
 many instances lacked fidelity to nature both in form and color.
     In the series of illustrations now offered to the profession, advantage has been taken
 of  a process recently  devised for the  reproduction  of pictures from  photographic
 negatives.  These pictures  not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.   The negatives which serve as a basis for the plates of this series have been selected
 from a very large number, most of  which were taken under the  immediate  supervision
 of  the  editor.  A few have been collected from other sources.   The coloring has been
 entrusted to a skilful artist, who was formerly a physician, and, having studied skin
 diseases in the General Hospital at Vienna, is peculiarly fitted for the work. The text
 accompanying the plates is designed to call attention to the diagnostic  characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
 The notes of cases have been made  very brief, as a rule, inasmuch as it has seemed
 unnecessary to give full particulars of a case except where it has possessed points of
 special interest.   No systematic order has been followed  in the arrangement of dis-
 eases, although certain ones have been placed together with a.view to their contrast.
    It has been the aim of the editor to represent in this series nearly all  of the rare as
 well as the common  affections of the skin, to present their features with photographic
 accuracy, and to  employ color with  the  utmost care to render the illustrations as life-
 like as possible.
                                                     GEORGE  HENRY FOX.
    New York, May,  1879. 
         A list of pliotographic negatives,

  1. Epithelioma (Up).
  2. Lepra tuberosa (face).
  3. Syphiloderma pustulosum (back).
  4. Leucoplakia lingua?.
  5. Hydroa (forearms).
  6. Syphiloderma pustulosum (face and arms).
  7. Syphiloderma pustulosum (legs).
  8. Psoriasis diffusa (side).
  9. Eczema madidans (universal).
 10. Scabies (hand).
 11. Alopecia areata syph. (infant's head).
 12. Trichophytosis (icrist).
 13. Purpura (legs).
 14. Lichen planus (forearm).
 15. Eczema rimosum (palm).
 16. Eczema squamosum (palm).
 17. Lepra maculosa (body).
 18. Fibroma (breast).
 19. Syphiloderma pustulosum (arms and thighs).
 20. Alopecia areata (head).
 21. Epithelioma (cheek).
 22. Phtheiriasis capitis.
 23. Eczema madidans (face).
 24. Eczema impetiginosum (face).
 25. Lupus vulgaris (face).
 26. Favus (head).
 27. Syphiloderma rupiale (forearm).
 28. Ulcus fungosum (leg).
 29. Condylomata syphilitica.
 30. Phtheiriasis corporis (back).
 31. Favus (back).
 32. Lichen simplex (back).
 33. Psoriasis .guttata (back).
 34. Chromophytosis (preast).
 35. Lentigo (abdomen).
 30. Phtheiriasis corporis (back).
 37. Syphiloderma rupiale (legs).
 38. Syphiloderma ecthymaforme (face).
 39. Syphiloderma tuberculosum (neck).
 40. Syphiloderma ulcerativum (neck).
 41. Epithelioma lingua?.
 42. Sycosis (chin).
 43. Scabies (hand).
 44. Dermatitis bullosa (hands).
 45. Trichophytosis (hand).
 46. Lupus verrucosus (hand).
 47. Molluscum (thigh).
 48. Psoriasis (fe#s).
 49. Vesiculae (from Zoster) (siYfe).
 50. Zoster lumbo inguinalis.
 51. Comedo (face).
 52. Vesiculae (poison ivy eruption) (forearm).
 53. Eczema barbae.
 54. Dactylitis.
 55. Pemphigus foliaceous.
 56. Eczema rubrum et squamosum (legs).
 57. Acne vulgaris (back).
 58. Eczema squamosum (elbow).
 59. Erythema exudativum (neck).
 60. Ulcus syphiliticum  (leg).
 61. Keloid (cheek).
 62. Lupus tuberculosus (face).
 63. Albinismus partialis («*).
 64. Molluscum (»«•£).
65. Ulcera syphilitica (leg).
66. Syph. ulcerativ. hered. (thigh).
B7.  Cicatrix ustionis (elboic).
taken from life, from which most of

   68. Leucoderma post syph. (side).
   69. Ulcus fungosum (leg).
   70. Syph. ulcerativum (elbow).
   71. Syph. papulo-squam. (neck).
   72. Epithelioma (n<>se).
   73. Syph. papulo-squamosum (palm).
   74. Syph. papulosum annulare (foreJiead).
   75. Ulcera eczematosa (leg).
   76. Eczema squamosum (forearm).
   77. Syph. i^quam. serpig. (foot).
   78. Syph. squam. serpig. (sole).
   79. Psoriasis (trunk).
   80. Ulcera syphilitica (leg).
   81. Kerion (scalp).
   82. Lichen ruber (an£.  view).
   83. Eczema—Vena varicosa (leg).
   84. Syph. tuberculosum (leg).
   85. Favus  (arm).
   86. Fibroma (ear).
   87. Lepra tuberosa (face).
   88. Psoriasis annulata  (breast).
   89. Psoriasis annulata  (back).
   90. Trichophytosis capitis.
   9i. Rosacea (face).
   92. Syph. papulosum miliare (anterior).
   93. Syph. papulosum miliare (posterior).
   9^. Psoriasis—chrys. acid stain (side).
   95. Acne indurata (face).
   96. Prurigo (£/%/*).
   97. Papilloma corneum (cheek).
   98. Zoster pectoralis.
   99. Xeroderma (of Hebra) (face and arms).
  100. Xeroderma (of Hebra) (face and arms).
  101, 102.  Syphiloderma papulosum.
  103; Syphiloderma papulo-squamosum.
  104. Syphiloderma papulosum (negro).
  105. Syphiloderma squamosum,
  106, 107, 108.  Syphiloderma tuberculosum.
  109. Syphiloderma tuberc-ulcerativum.
  110. Syphiloderma serpiginosum.
  Ill, 112.  Syphiloderma ulcerativum.
  113. Syphiloderma gummatosum.
  114, 115.  Syphilis bursse patella?.
  116, 117.  Syphilis nasi.
  118. Chancre of nose.
  119, 120.  Lepra tuberosa.
  121, 122.  Elephantiasis.
  123, 124.  Lupus erythematosus.
  125. Lupus vulgaris.
  126. Lupus verrucosus.
  127. Lupus hypertrophicus.
  128, 129, 130.  Lupus exedens.
  131, 132.  Lupus.
  133. Lupus exedens.
  134, 135, 136, 137, 138, 139, 140,  141,  142,
       144. Epithelioma.
  145. Keloid.
  146. Sarcoma.
  147. Sarcoma  pigmentosum.
  148. Naevus vascularis.
  149. Rosacea hypertrophica.
  150. Verrucae.
  151, 152.  Lipoma.
  153, 154, 155,  156. Fibroma.
  157. Dermatolysis.
  158. Keloid.
1  159. Naevus pilosus.
 plates of the series will bo selected.

  ! 160.  Hirsuties.
   161.  Anthrax.
   162.  Pustular eruption from tart. emet. ointment.
   163.  Abscesses from hypodermic syringe.
   164.  Frostbite—gangrene.
   165.  Cicatrix of burn.
   166, 167.  Eczema.
   168, 109.  Psoriasis.
   170, 171,  172, 173. Psoriasis and eczema.
   174.  Eczema universale.
   175, 176,  177, 178. Ichthyosis.
   179,180.  Favus.
   181. Chromophytosis.
   182.  Keloid.
   183.  Lupus erythematosus.
   184, 185,  186, 187. Skin grafts.
   188.  Scratch marks.
   189.  Pityriasis.
   190.  Syphiloderma faciei.
   191.  Syph.. condylomata.
   192.  Epithelioma of hand.
   193. Ven. warts.
   194.  Cancrum oris.
   195, 196.  Ven. warts.
   197.  Syphiloderma papulosum.
   198, 199.  Syphiloderma serpiginosum.
   200.  Syphiloderma ulcerativum.
   201.  Folliculitis calorica (face).
   202.  Morphcea (arm).
   203.  Syphiloderma tuberc. (side).
   204.  Papilloma (lip).
   205.  Leucoderma (face and arms).
   206.  Lepra tuberculosa (face and arms).
   207.  Chromophytosis (body).
   208.  Acne vulgaris (face).
   209.  Impetigo (face).
   210.  Eczema barbae.
   211.  Eczema universale (side view).
   212.  Ichthyosis (side ana  thigh).
   213.  Epithelioma (lip).
   214.  Eczema madidans (legs).
   215.  Onychia syphilitica.
   216.  Eczema papulosum (hand).
   217.  Impetigo e pediculis (back).
   218.  Syph. tuberc.  Bursitis (knee).
   219.  Syph. tuberculosum (face and arms).
   220. Psoriasis nummulata (back).
   221.  Syph. pustulosum  serpig. (thigh).
   222.  Ulcus gangrenosum (thigh).
   223.  Syph. tuberc. squamosum (face and arms).
   224. Erythema exfoliativum (palm).
   225. Syph. papulo-squam. (arm and breast).
   226. Syph. papulo-squam. (shoulder).
   227.  Scabies (hand).
!,  228.  Favus (scalp).
   229.
   230.
   231.                       ,._____
   232.
   233.
   234.
   235.
   236.
   237.
   238.
   239.
   240. 
        OPINIONS   OF  DERMATOLOGISTS
                             CONCERNING THE
     Photographic  Illustrations  of  Skin   Diseases."
    I  am  exceedingly  pleased  with  the Photographic Illustrations  of Skin
Diseases.   They are, without exception, the most life-like representations  that
I have ever seen.                   HENRY G. PIFFARD, M.D.,
                            Prof, of Dermatology, Med. Dept. of N. Y. Univ.
    I  know  the photographs of Dr.  Fox  well,  and use them continually in
teaching.   Many of the series are taken from cases presented before  the New
York  Dermatological Society, and of the accuracy and  truthfulness of the
representations 1 can bear witness.    L. DUNCAN BULKLEY, M.D.,
                                        Editor of "Archives of Dermatology."
    I  can  hardly  imagine  anything better that  art could  produce on paper
than these  pictures.   The  coloring is admirable, and  the clinical features of
the various maladies so strikingly portrayed that  they proclaim  the diagnosis to
the  eye instantly.   I  am  not  acquainted with any  plates  that please
me so well, or seem so true to life.    E.  L. KEYES, M.D.,
                    Prof, of Dermatology, Bellevue Hospital Medical College.
   -' Hitherto photographs of cutaneous affections have failed to reproduce to
the eye the exact appearances of disease. These  plates are a wonderful success,
and will commend themselves to all who want faithful and artistic  representa-
tions of diseases of the skin.          JAMES C. WHITE, M.D.,
                     Professor of Dermatology,  Harvard Univ.  Medical Dept.
    In my judgment, nothing in the way of Illustration of Skin Diseases,  that
has ever been placed before the  Profession, has at all approached these in life-
like appearance, and this I think must be concurred in by every Dermatologist.
                                S. SHERWELL, M.D.,
       Lecturer on Dermatology, Long Island College Hospital, Brooklyn, N.  Y.
    They  are marvelously successful representations  of  Skin Diseases,  well
calculated to accomplish all that is possible in the way of teaching Dermatology
pictorially.   The accompanying  text, also,  is worthy of all praise.
                              FRANK  P. FOSTER,  M.D.,
  Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
    The illustrations are  truly admirable representations, and give a life-like
picture of each disease portrayed which it would be indeed difficult to surpass.
They will be  the indispensable requisites of the teacher and of the  student in
Dermatology, and should be in  the hands of every practitioner who devotes
any attention to diseases of the skin.   I commend them most heartily.
                            JAMES NEVINS  HYDE,  M.D.,
                Professor of Dermatology, Rush  Medical College, Chicago, 111.
     I consider the illustrations in this work by one of the foremost specialists in
his department to be admirably executed, accurate and life-like in appearance.
The text is simple and concise, and I cannot too highly recommend this valua-
ble work to students of medicine as well as to experienced  practitioners.
                          JOHN V. SHOEMAKER, M.D.,
                 Lecturer on Dermatology, Philadelphia School of Anatomy.
     I have examined the "Illustrations of Skin Diseases," byG. H. Fox, M.D.
They are true to life, and altogether the most useful plates I have yet seen. I am
convinced that these photographs give a more correct idea of the minute appear-
ances of Skin Diseases than  can be obtained by any other kind of  pictorial
representation.                     J. E. GRAHAM, M.D.,
                 Lecturer on Dermatology, Toronto General Hospital, Canada.
    The Photographic Illustrations of Dr. G. H. Fox are admirable, being in
every particular wonderfully life-like.  A series of forty-eight such  illustrations
will form a gallery of Dermatology of the greatest value to both  student  and
teacher. The tinting of the various lesions is perfect. The accompanying text is
of great supplementary advantage, as it gives a clear idea of the various diseases
with excellent directions for  their treatment. -   R. w. TAYLOR,  M.D.,
      Professor of Diseases of the Skin, University of Vermont,  Physician to the
         Class of Skin Diseases at Bellevue Hospital (Out-Door Department). 
Part  8.                           Price. $2.

          COMPLETE IN TWELVE PARTS.
W>
#&$& l^mfat.
OF
°4
'S
SKIN  DISEASES
BY
         GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
     Diseases; Fellow of the American Academy of Medicine; Member of the New York Dermatological Society,
             the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
TRICHOPHYTOSIS owns. >

TRICHOPHYTOSIS corporis .

LICHEN planus
LICHEN planus

LICHEN ruber.
:f:
               NEW YORK:

IE. IB. TBEAT,  IsTo. 80S Broad^ray.
[Copyright, 1879, by Georce Henry Fox.] 
PREFACE.
     The study of Skin Diseases without  cases or colored plates is like  the study of
 osteology without bones, or the study of geography without maps.  However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is next best, its faithful representation.  A
 systematic  course of  clinical study is  only possible  in our large cities, and  yet the
 physician in any remote locality may be called upon to treat the rarest forms  of skin
 disease.   As success must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of.a complete  series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations  of skin  diseases.   Photographs, though serving a good purpose in portraying
 the  characteristic location and  configuration of the various affections of  the skin, have
 generally lacked an essential element of diagnosis, viz., the color, or have been disfigured
 by careless  daubing, and colored lithographs have not only been  expensive, but in too
 many  instances lacked fidelity to nature both in form and color.
     In the series of illustrations now offered to the profession, advantage has been taken
 of a process  recently  devised  for the reproduction of  pictures from photographic
 negatives.  These pictures not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.  The negatives which serve as a basis for the plates of this series have been selected
 from a very large number, most of  which were  taken under the immediate  supervision
 of the editor.  A few have  been collected  from other sources.  The  coloring has been
 entrusted to a skilful artist, who was formerly a physician, and, having studied  skin
 diseases  in the General Hospital at Vienna, is peculiarly fitted for the work.  The text
 accompanying the plates is  designed  to call attention to  the diagnostic characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
 The  notes of cases have been made very brief, as a rule, inasmuch as it  has  seemed
 unnecessary to give  full particulars of a case except where  it has possessed points of
 special interest.  No systematic order has been followed in the arrangement  of dis-
 eases, although certain ones have been placed together with a view to their contrast.
    It  has been  the aim of  the editor  to represent in this series nearly all of the rare as
 well as the common affections of the skin, to present their features with photographic
 accuracy^ and to employ color with the utmost care  to render the illustrations as life-
like as possible.
                                                     GEORGE HENRY FOX.
    New York,  May,  1879. 
A list of photographic negatives, taken from life, from which most of the plates of the series will bo selected.
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
Epithelioma (Up).
Lepra tuberosa (face).
Syphiloderma pustulosum (back).
Leucoplakia lingaae.
Hydroa (forearms).
Syphiloderma pustulosum (face and arms).
Syphiloderma pustulosum (legs).
Psoriasis diffusa (side).
Eczema madidans (universal).
Scabies (hand).
Alopecia areata syph. (infant's head).
Trichophytosis (wrist).
Purpura (legs).
Lichen planus (forearm).
Eczema rimosum (palm).
Eczema squamosum (palm).
Lepra maculosa (body).
Fibroma (breast).
Syphiloderma pustulosum (arms and thighs).
Alopecia areata (head).
Epithelioma (cheek).
Phtheiriasis capitis.
Eczema madidans  (face).
Eczema impetiginoeum (face).
Lupus vulgaris (face).
Favus (head).
Syphiloderma rupiale (forearm).
Ulcus fungosum '(teg).
Condylomata syphilitica.
Phtheiriasis corporis (back).
Favus (back).
Lichen simplex (back).
Psoriasis guttata (back).
Chromophytosis (breast).
Lentigo (abdomen).
Phtheiriasis corporis (back).
Syphiloderma rupiale (legs).
Syphiloderma ecthymaforme (face):
Syphiloderma tuberculosum (neck).
Syphiloderma ulcerativum (neck).
Epithelioma linguae.
Sycosis (eMri).
Scabies (hand).
Dermatitis bullosa (hands).
Trichophytosis (hand).
Lupus verrucosus (hand).
Molluscum (thigh).
Psoriasis {legs).
Vesiculae (from Zoster)  (side).
Zoster lumbo inguinalis.
Comedo (face).
Vesiculae (poison ivy eruption) (forearm).
Eczema barbae.
Dactylitis.
Pemphigus foliaceous.
Eczema rubrum et squamosum (legs).
Acne vulgaris (back).
Eczema squamosum (elbow).
Erythema exudativum (neck).
Ulcus syphiliticum (leg).
Keloid (cheek).
Lupus tuberculosus (face).
Albinismus partialis (sicU).
Molluscum (neck).
Ulcera syphilitica (leg).
Syph. ulcerativ. hered. (thigh).
Cicatrix ustionis (elbow).
68.	Leucoderma post syph. (side).	160.
69.	Ulcus fungosum (leg).	161.
70.	Syph. ulcerativum (elbow).	162.
71.	Syph. papulo-squajm. (neck).	163.
.72.	Epithelioma (nose).	164.
78.	Syph. papulo-squamosum (palm).	165.
74.	Syph. papulosum annulare (forehead).	166,
75.	Ulcera eczematosa (leg).	168,
76.	Eczema squamosum (forearm).	170,
77.	Syph. squam. serpig. (foot).	174.
78.	Syph. squam. serpig. (sole).	175,
79.	Psoriasis (trunk).	179.
80.	Ulcera syphilitica (leg).	181.
81.	Kerion (scalp).	182.
82.	Lichen ruber (ant. view).	183.
83.	Eczema—■Vena varicosa (leg).	184,
84.	Syph. tuberculosum (leg).	188.
85.	Favus (arm).	189.
86.	Fibroma (ear).	190.
87.	Lepra tuberosa (face).	191.
' 88.	Psoriasis annulata (breast).	192.
89.	Psoriasis annulata (back).	193.
90.	Trichophytosis capitis.	194.
91.	Rosacea (face).	195,
92.	Syph. papulosum miliare (anterior).	197.
93.	Syph. papillosum miliare (posterior).	198,
94.	Psoriasis—chrys. acid stain (side).	200.
95.	Acne indurata (face).	201.
96.	Prurigo (thigh).	202.
97.	Papilloma corneum (cheek),	203..
98.	Zoster pectoralis.	204.
99.	Xeroderma (of Hebra) (face and arms).	205.
100.	Xeroderma (of Hebra) (face and arms).	206.
101,	102. Syphiloderma papulosum.	207.
ioa	Syphiloderma papulo-squamosum.	208.
104.	Syphiloderma papulosum (negro).	309.
105.	Syphiloderma squamosum.	210.
106,	107, 108. Syphiloderma tuberculosum.	211.
109.	Syphiloderma tuberc-ulcerativum.	212.
110.	Syphiloderma serpiginosum.	213.
Ill,	112. Syphiloderma ulcerativum.	214.
113.	Syphiloderma gummatosum.	215.
114,	115. Syphilis bursae patellae.	216.
116,	117. Syphilis nasi.	217.
118.	Chancre of nose.	218.
119,	120. -Lepra tuberosa.	219.
121,	122. Elephantiasis.	220.
123,	124. Lupus erythematosus.	221.
"125.	Lupus vulgaris.	222.
126.	Lupus verrucosus.	223.
127.	Lupus hypertrophicus.	224.
128.	129, 130. Lupus exedens.	225.
131,	132. Lupus.	226.
133.	Lupus exedens.	227.
134,	135, 136, 137, 138, 139, 140, 141, 142, 143,	228.
	144. Epithelioma.	229.
145.	Keloid.	230.
146.	Sarcoma.	231.
147.	Sarcoma pigmentosum.	232.
148.	Naevus vascularis.	233.
149.	Rosacea hypertrophies.	234.
150.	Verrucae.	235.
151,	152. Lipoma.	236.
153,	154, 155, 156. Fibroma.	237.
157.	Dermatolysis.	238.
158.	Keloid.	239.
i 159.	N;pvus pilosus.	240.
 Hirsuties.
 Anthrax.
 Pustular eruption from tart. emet. ointment.
 Abscesses from hypodermic syringe.
 Frostbite—gangrene.
 Cicatrix of burn.
 167.  Eczema.
 169.  Psoriasis.             »
 171,  172, 173. Psoriasis and eczema.
 Eczema universale.
 176,  177, 178. Ichthyosis.
180.  Favus.
 Chromophytosis.
 Keloid.
 Lupus erythematosus.
 185,  186, 187. Skin grafts.
 Scratch marks.
 Pityriasis.
 Syphiloderma faciei.
 Syph.  condylomata.
 Epithelioma of hand.
 Ven. warts.
 Cancrum oris.
196.  Ven. warts.
 Syphiloderma papulosum.
 199.  Syphiloderma serpiginosum.
 Syphiloderma ulcerativum.
 Folliculitis calorica (face).
 Morphcea (arm).
 Syphiloderma tuberc. (side).
 Papilloma (lip).
 Leucoderma (face and arms).
 Lepra tuberculosa (face and arms).
 Chromophytosis (body).
 Acne vulgaris (face).
 Impetigo (face).
 Eczema barbae.
 Eczema universale (side view).
 Ichthyosis (side ana thigh).
 Epithelioma (lip).
 Eczema madidans (legs).
 Onychia syphilitica.
 Eczema papulosum (hand).
 Impetigo e pediculis (back).
 Syph.  tuberc.  Bursitis (knee).
 Syph.  tuberculosum (face and arms).
 Psoriasis nummulata (back).
 Syph.  pustulosum serpig. (thigh).
 Ulcus gangrenosum (thig7i).
 Syph.  tuberc. squamosum (face and arms).
 Erythema exfoliativum (palm).
 Syph.  papulo-squam. (arm and breast).
 Syph.  papulo-squam. (shoulder).
 Scabies (hand).
 Favus (scalp). 
        OPINIONS   OF  DERMATOLOGISTS
                             CONCERNING THE
     Photographic  Illustrations  of   Skin   Diseases."

    I  am  exceedingly  pleased  with  the Photographic Illustrations  of  Skin
Diseases.   They are, without exception, the most life-like representations that
I have ever seen.                   HENRY G. PIFFARD, M.D.,
                            Prof, of Dermatology, Med. Dept. of N. Y. Univ.
    I  know the photographs of Dr.  Fox well,  and use them continually in
teaching.   Many of the series are taken from cases presented before the New
York  Dermatological Society, and of the accuracy and  truthfulness of the
representations I can bear witness.    L. DUNCAN BULKLEY, M.D.,
                                        Editor of "Archives of Dermatology."
    I  can hardly  imagine  anything better that  art could produce on  paper
than these pictures.   The  coloring is admirable, and  the clinical features of
the various maladies  so strikingly portrayed that they proclaim  the diagnosis to
the  eye  instantly.   I  am  not  acquainted with  any  plates  that  please
me so well, or  seem so true to life.    E. L. KEYES, M.D.,
                    Prof, of Dermatology, Bellevue Hospital  Medical College.
   J Hitherto photographs of cutaneous affections have failed to reproduce to
the eye the exact appearances of disease. These plates are a  wonderful success,
and will commend therriselves to all who want faithful and artistic  representa-
tions of diseases of the skin.          JAMES C. WHITE,  M.D.,
                     Professor of Dermatology, Harvard Univ.  Medical Dept.
    In my judgment, nothing in the way of  Illustration of Skin Diseases, that
has ever been placed before the  Profession, has at all approached these in life-
like appearance, and this I think must be concurred in by every Dermatologist.  >
                                S. SHERWELL, M.D.,
       Lecturer on Dermatology, Long Island College Hospital, Brooklyn. N. Y.
    They  are marvelously successful representations  of  Skin Diseases, well
calculated to accomplish all that is possible in the way of teaching Dermatology
pictorially.  The accompanying  text, also, is worthy of all  praise.
                              FRANK  P.  FOSTER,  M.D.,
  Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
    The illustrations are truly admirable representations, and give a life-like
picture of each disease portrayed which it would be indeed difficult to surpass.
They will be the indispensable requisites of the teacher and  of the student in
Dermatology,  and should be in  the hands  of every practitioner who devotes
any attention to diseases of the skin.   I commend them most heartily.
                            JAMES NEVINS  HYDE, M.D.,
                Professor of Dermatology, Rush Medical College, Chicago, 111.
     I consider the illustrations in this work by one of the foremost specialists in
his department to be admirably executed, accurate and life-like in appearance.
The text is simple and concise, and I cannot  too highly recommend this valua-
ble work to students of medicine as well as to experienced practitioners.
                          JOHN V. SHOEMAKER, M.D.,
                 Lecturer on Dermatology, Philadelphia School of Anatomy.
     I have examined the "Illustrations of Skin Diseases," byG. H. Fox, M.D.
They are true to life, and altogether the most useful plates I have yet seen.  I am
convinced that these photographs give a more correct idea of the minute appear-
ances of Skin Diseases than  can be  obtained by any other kind of  pictorial
representation.                      J. e. GRAHAM, M.D.,
                 Lecturer on Dermatology, Toronto General Hospital, Canada.
    The Photographic Illustrations of Dr. G. H.  Fox are admirable, being in
every particular wonderfully life-like.  A series of  forty-eight such illustrations
will form a gallery of Dermatology of the greatest value to  both student and
teacher. The tinting of the various lesions is  perfect. The accompanying text is
of great supplementary advantage, as it gives a clear id?a of the various diseases
with excellent directions for their treatment.  -   R. W. TAYLOR,  M.D.,
      Professor of Diseases of the Skin, University of Vermont, Physician to  the
         Class of Skin Diseases at Bellevue Hospital (Out-Door Department). 
Part  9.                              Price, $2.

            COMPLETE IN TWELVE PARTS.
W>
ta¥fe IJJ«^
OF
°4
V
SKIN   DISEASES
BY
           GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
      Diseases; Feliow of the American Academy of Medicine; Member of the New York Dermatological Society,
               the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.

             X
KERION. v^

LEPRA MACULOSA. v

MOLLUSCUM.)

MOLLUSCUM. j  ✓

ERYTHEMA multiforme, v
IE. IB
            NEW YORK:

. TEEAT,  JSTo.. 805 Broad-^ray.
[Copyright, 1879, by George Henry Fox.] 
                              PREFACE.
                                    .-----•-»•----.

     The study of Skin Diseases without  cases or colored plates is like the study of
 osteology without bones, or the study of geography without maps.  However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is next best, its faithful representation.  A
 systematic  course of  clinical  study is  only possible  in  our large cities,  and yet the
 physician in any remote locality may  be called upon to treat the rarest forms of skin
 disease.  As success must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete  series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations of  skin  diseases.   Photographs, though serving a good  purpose in portraying
 the  characteristic location and configuration of the various affections of  the skin, have
 generally lacked an essential element of diagnosis, viz., the color, or have been disfigured
 by careless  daubing, and colored lithographs have not only been  expensive, but in too
 many  instances lacked fidelity to nature both in form and color.
     In the series of illustrations now offered to the profession, advantage has been taken
 of a process  recently  devised for the  reproduction of  pictures from  photographic
 negatives.  These pictures not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.  The negatives which serve as  a basis for the plates of this series have been selected
 from a very large number, most of which were  taken under the immediate supervision
 of the editor.  A few have  been collected from other sources.  The  coloring has been
 entrusted to a skilful artist, who was formerly a physician, and, having studied skin
 diseases in the General Hospital at Vienna,  is peculiarly fitted for the work.  The text
 accompanying the plates is  designed to call attention to the  diagnostic characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
 The  notes of cases have been made very brief, as a rule,  inasmuch as it has seemed
 unnecessary to give  full particulars of  a case except where it has possessed points of
 special interest.  No systematic order  has been followed  in the arrangement of dis-
 eases, although certain ones have been placed together with a view to their contrast.
    It  has been  the aim of  the editor to represent in this series nearly all of the rare as
well as the common affections of the skin, to present their features with photographic
accuracy, and to employ color with the  utmost care to render the illustrations as life-
like as possible.
                                                     GEORGE HENRY FOX.
 »  New York,  May,  1879.
\ 
A list of photographic negatives, taken from life, from which most of the plates of the series  will be selected.
  9.
 10.
 11.
 12.
 13.
 14.
 15.
 16.
 17.
 18.
 19.
 20.
 21.
 22.
 23.
 24.
 25.
 26.
 27.
 28.
 29.
 30.
 81.
 32.
 33.
 34.
 35.
 36.
 37.
 38.
 39.
 40.
 41.
 42.
 43.
 44.
 45.
 46.
 47.
 48.
 49.
 50.
 51.
 52.
 53.
 54.
 55.
 56.
 57.
 58.
 59.
 60.
 61.
 62.
 63.
 64.
 65.
66.
67.
Epithelioma (Up).
Lepra tuberosa (face).
Syphiloderma pustulosum (back).
Leucoplakia linguze.
Hydroa (forearms).
Syphiloderma pustulosum (face and anns).
Syphiloderma pustulosum (legs).
Psoriasis diffusa (side).
Eczema madidans (universal).
Scabies (Jiand).
Alopecia areata syph. (infant's head).
Trichophytosis (wrist).
Purpura (legs).
Lichen planus (forearm).
Eczema rirnosum (palm).
Eczema squamosum (palm).
Lepra maculosa (body).
Fibroma  (breast).
Syphiloderma pustulosum (arms and thighs).
Alopecia areata (head).
Epithelioma (cJieek).
Phtheiriasis capitis.
Eczema madidans (face).
Eczema impetiginosum (face).
Lupus vulgaris (face).
Favus (head).
Syphiloderma rupiale (forearm).
Ulcus fungosum (leg).
Condylomata syphilitica.
Phtheiriasis corporis (back).
Favus (back).
Lichen simplex (back).
Psoriasis guttata (back).
Chromophytosis (breast).
Lentigo (abdomen).
Phtheiriasis corporis (back).
Syphiloderma rupiale (legs).
Syphiloderma eclhymaforme (face).
Syphiloderma tuberculosum (neck).
Syphiloderma ulcerativum (neck).
Epithelioma linguae.
Sycosis (chin).
Scabies (hand).
Dermatitis bullosa (hands).
Trichophytosis (hand).
Lupus verrucosus (hand).
Molluscum (thigh).
Psoriasis (legs).
Vesiculae  (Irom Zoster) (side).
Zoster lumbo inguinalis.
Comedo (face).
Vesiculae  (poison ivy eruption) (forearm).
Eczema barbae.
Dactylitis.
Pemphigus foliaceous.
Eczema rubrum et squamosum (legs).
Acne vulgaris (back).
Eczema squamosum (elbow).
Erythema exudativum (neck).
Ulcus syphiliticum (leg).
Keloid (cheek).
Lupus tuberculosus (face).
Albinismus partialis (aid*).
Molluscum (neck).
Ulcera syphilitica (leg).
Syph.  ulcerativ. hered. (thigh).
Cicatrix ustionis (elbow).
 G8. Leucoderma post syph. (side).
 69. Ulcus fungosum (leg).
 70. Syph. ulcerativum (elbow).
 71. Syph. papulo-squam: (neck).
 72. Epithelioma (nose).
 73. Syph. papulo-squamosum (palm).
 74. Syph. papulosum annulare (forehead).
 75. Ulcera eczematosa (leg).
 76. Eczema squamosum (forearm).
 77. Syph. squam. serpig. (foot).
 78. Syph. squam. serpig.  (sole).
 79. Psoriasis (trunk).
 80. Ulcera syphilitica (leg).
 81. Kerion (scalp).
 82. Lichen ruber (ant. view).
 83. Eczema—Vena varicosa (leg).
 84. Syph. tuberculosum (leg).
 85. Favus (arm).
 86. Fibroma (ear).
 87. Lepra tuberosa (face).
 88. Psoriasis annulata (breast).
 89. Psoriasis annulata (back).
 90. Trichophytosis capitis.
 91. Rosacea (face).
 92. Syph. papulosum  miliare (anterior).
 93. Syph. papulosum  miliare (posterior).
 94. Psoriasis—chrys. acid stain (side).
 95. Acne indurata (face).
 96. Prurigo (thigh).
 97. Papilloma corneum (cheek).
 98. Zoster pectoralis.
 99. Xeroderma (of Hebra) (face and ai'ms).
100. Xeroderma (of Hebra) (face and arms).
101, 102. Syphiloderma papulosum.
103. Syphiloderma papulo-squamosum.
104. Syphiloderma papulosum (negro).
105. Syphilodeiina squamosum.
106, 107,108. Syphiloderma tuberculosum.
109. Syphiloderma tuberc-ulcerativum.
110. Syphiloderma serpiginosum.
Ill, 112. Syphili derma ulcerativum.
113. Syphiloderma gummatosum.
114, 115. Syphilis bursae patellae.
116, 117. Syphilis nasi.
118. Chancre of nose.
119, 120. Lepra tuberosa.
121, 122. Elephantiasis.
123, 124. Lupus erythematosus.
125. Lupus vulgaris.
126. Lupus verrucosus.
127. Lupus hypertrophicus.
128.129,130. Lupus" exedens.
131, 132. Lupus.
133. Lupus exedens.
134, 135,  136, 137, 138, 139, 140,  141, 142,
      144.  Epithelioma.
145. Keloid.
146. Sarcoma.
147. Sarcoma pigmentosum.
148. Naevus vascularis.
149. Rosacea hypertrophica.
150. Verrucae.
151, 152. Lipoma.
153, 154, 155, 156. Fibroma.
157. Dermatolysis.
158. Keloid.
159. Nievus pilosus.
143,
160.
161.
162.
163.
164.
165.
166,
168,
170,
174.
175,
179,
181.
182.
183.
184,
188.
189.
190.
191.
192.
193.
194.
195,
197.
198,
200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
238.
239.
240.
Hirsuties.
Anthrax.
Pustular eruption from tart. emet. ointment,
Abscesses from hypodermic syringe.
Frostbite—gangrene.
Cicatrix of burn.
167.  Eczema.
169.  Psoriasis.
171,  172, 173. Psoriasis and eczema.
Eczema universale.
176,  177, 178. Ichthyosis.
180.  Favus.
Chromophy tosi s.
Keloid.
Lupus erythematosus.
185,  186, 187. Skin grafts.
Scratch marks.
Pityriasis.
Syphiloderma faciei.
Syph. condylomata.
Epithelioma of hand.
Ven. warts.
Cancrum oris.
196.  Ven. warts.
Syphiloderma papulosum.
199.  Syphiloderma serpiginosum.
Syphiloderma ulcerativum.
Folliculitis calorica (face).
Morphcea (arm).
Syphiloderma tuberc. (side).
Papilloma (lip).
Leucoderma (face and arms).
Lepra tuberculosa (face and arms).
Chromophytosis (body).
Acne vulgaris (face)..
Impetigo (face).
Eczema barbae.
Eczema universale (side view).
Ichthyosis (side ana thigh).
Epithelioma (lip).
Eczema madidans (legs).
Onychia syphilitica.
Eczema papulosum (hand).
Impetigo e pediculis (back).
Syph. tuberc.   Bursitis (knee).
Syph. tuberculosum (face and arms).
Psoriasis nummulata (back).
Syph. pustulosum serpig. (thigh).
Ulcus gangrenosum (thigh).
Syph. tuberc. squamosum (face and arms).
Erythema exfoliativum (palm).
Syph. papulo-squam.  (arm and breast).
Syph. papulo-squam. (shoulder).
Scabies (Jiand).
Favus (scalp).
&K-.. 
        OPINIONS   OF  DERMATOLOGISTS
                             CONCERNING THE
     Photographic  Illustrations  of   Skin   Diseases."

    I  ain  exceedingly  pleased  with  the  Photographic Illustrations  of Skin
Diseases.   They are, without exception, the most lite-like representations that
I have ever seen.                   HENRY G.  PIFFARD, M.D.,
                            Prof, of Dermatology, Med. Dept. of N. Y. Univ.
    I  know the photographs of Dr.  Fox well, and use them  continually in
teaching.   Many of the series are taken from cases presented before the New
York  Dermatological Society, and  of the accuracy and  truthfulness of the
representations 1 can bear witness.    L. DUNCAN BULKLEY, M.D.,
                                        Editor of •«Archives of Dermatology."
    I  can  hardly imagine  anything better that art could  produce on  paper
than these  pictures.   The  coloring is admirable, and  the clinical features of
the various maladies  so strikingly portrayed that they proclaim the diagnosis to
the eye instantly.   I  am  not acquainted with any plates  that  please
me so well, or  seem so true to life.     E. L. KEYES, M.D.,
                    Prof, of Dermatology, Bellevue Hospital Medical College.
    Hitherto photographs  of cutaneous affections have failed to reproduce to
the eye the exact appearances of disease. These plates are a wonderful success,
and will commend themselves to all who want faithful and artistic  representa-
tions of diseases of the skin.          JAMES C.  WHITE, M.D.,
                     Professor of Dermatology, Harvard Univ. Medical Dept.
    In my judgment, nothing in the way of  Illustration of Skin Diseases, that
has ever been placed before the  Profession, has at all approached these in life-
like appearance, and this I  think must be concurred in  by every Dermatologist.
                                S. SHERWELL, M.D.,
      Lecturer on Dermatology, Long Island College Hospital, Brooklyn. N. V.
    They are marvelously successful  representations  of Skin  Diseases, well
calculated to accomplish all that is possible in the way of teaching Dermatology
pictorially.   The accompanying  text, also, is worthy of all praise.
                             FRANK P.  FOSTER,  M.D.,
  Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
    The illustrations are truly admirable  representations, and give a life-like
picture of each disease portrayed which it would be indeed  difficult to surpass.
They  will be the indispensable requisites of the teacher and  of the student in
Dermatology,  and should be in the hands  of every practitioner who devotes
any attention to diseases of the skin.   I commend them most heartily.
                            JAMES  NEVINS HYDE, M.D.,
                Professor of Dermatology, Rush Medical College, Chicago, 111.
    I  consider the illustrations in this work by one of the foremost specialists in
his department to be admirably executed, accurate and  life-like in appearance.
The text is simple and concise, and I cannot  too highly recommend this valua-
ble work to students of medicine as well as to experienced  practitioners.
                          JOHN V.  SHOEMAKER,  M.D.,
                 Lecturer on Dermatology, Philadelphia School of Anatomy.
    I have examined the "Illustrations of Skin Diseases," byG. H. Fox, M.D.
They  are true to life, and altogether the most useful plates I have yet seen. I am
convinced that these photographs give a more correct idea of the minute appear-
ances of Skin Diseases than  can be  obtained by any  other kind  of pictorial
representation.                      J. e. GRAHAM,  M.D.,
                Lecturer on Dermatology, Toronto General Hospital, Canada.
    The Photographic Illustrations  of Dr. G. H. Fox  are admirable,  being in
every  particular wonderfully life-like.   A series of forty-eight such illustrations
will form a  gallery of Dermatology of  the greatest value  to both student and
teacher. The tinting of the various lesions is perfect. The accompanying text is
of great supplementary advantage, as it gives a clear idea of the various diseases
with excellent directions for their treatment.     R. w.  TAYLOR,  M D.
     Professor of Diseases of the Skin, University  of Vermont, Physician to the
         Class of Skin Diseases at Bellevue Hospital (Out-Door Department). 
Part 10.                           Price, $2.

           COMPLETE IN TWELVE PARTS.
\V»
*&$** llh8t?m
OF
%
'S
SKIN   DISEASES
BY
          GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
     Diseases; Fellow of the American Academy of Medicine; Member of the New York Dermatological Society,
              the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
PHTHEIRIASIS capitis. J <

PHTHEIRIASIS corporis./

SCABIES.

SCABIES.

PORRIGO e pedicul||is. tf
El. IB-
         NEW YORK:*

TDRIE-A-T, JSTo.. 805 ^jooe3b<3L-™ra&-.
[Copyright, 1879, by George Henry Fox.] 
                             PREFACE.
                                        ♦• •-------

     The  study of Skin Diseases without  cases or colored plates is like the study of
 osteology without bones, or the study of geography without maps.  However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is next best, its faithful representation.  A
 systematic  course of  clinical study  is  only possible  in our large cities, and  yet the
 physician in any remote locality may be called upon to treat the rarest forms  of skin
 disease.   As success must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations of  skin  diseases.   Photographs, though serving a good purpose in portraying
 the  characteristic location and  configuration of the various affections of  the skin, have
 generally lacked  an essential element of diagnosis, viz., the color, or have been disfigured
 by careless  daubing, and colored lithographs have not only been  expensive, but in too
 many instances lacked fidelity to nature both in form and color.
     In the series  of illustrations now offered to the profession, advantage has been taken
 of a process  recently  devised  for the reproduction of  pictures from photographic
 negatives.  These pictures not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.  The negatives which serve as a basis for the plates of this series have been selected
 from a very large number, most of  which were  taken under the immediate  supervision
 of the editor.  A few have  been collected  from other sources.  The  coloring has been
 entrusted to a skilful artist, who was formerly a physician, and, having studied  skin
 diseases in the General Hospital at Vienna, is peculiarly fitted for the work.  The text
 accompanying the plates is  designed  to call attention to  the diagnostic characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
 The  notes of cases have been made very brief, as a rule, inasmuch as it has  seemed
 unnecessary to give  full particulars of a case except where  it has possessed points of
 special interest.  No systematic order has been followed in the arrangement  of dis-
 eases, although certain ones have been  placed together with a view to their contrast.
    It  has been  the aim of  the editor  to represent in this series nearly all of the rare as
well  as the common affections of the skin, to present their features with photographic
accuracy, and to employ color with the utmost care  to render the illustrations as life-
like as possible.
                                                     GEORGE HENRY  FOX.
    New  York,  May,  1879. 
        A list of pliotographic negatives,

 1.  Epithelioma (Up).
 2.  Lepra tuberosa (face).
 3.  Syphiloderma pustulosum (back).
 4.  Leucoplakia linguae.
 5.  Hydroa (forearms).
 6.  Syphiloderma pustulosum (face and arms).
 7.  Syphiloderma pustulosum (legs).,
 8.  Psoriasis diffusa (side).
 9.  Eczema madidans (universal).
10.  Scabies (hand).
11.  Alopecia  areata syph. (infant's head).
12.  Trichophytosis  (wrist).
13.  Purpura (legs).
14.  Lichen planus (forearm).
15.  Eczema rimosum (palm).
16.  Eczema squamosum (palm).
17.  Lepra maculosa (body).
18.  Fibroma  (breast).
19.  Syphiloderma pustulosum (arms and thighs).
20.  Alopecia  areata (head).
21.  Epithelioma (cheek).
22.  Phtheiriasis capitis.
23.  Eczema madidans (face).
24.  Eczema impetiginosum (face).
25.  Lupus vulgaris (face).
26.  Favus (head).
27.  Syphiloderma rupiale (forearm).
28.  Ulcus fungosum (leg).
29.  Condylomata syphilitica.
30.  Phtheiriasis corporis (back).
31.  Favus (back).
32.  Lichen simplex (back).
33.  Psoriasis guttata (back).
34.  Chromophytosis (breast).
35.  Lentigo (abdomen).
36.  Phtheiriasis corporis (back).
37.  Syphiloderma rupiale (fcgv).
38.  Syphiloderma ecthy-maforme (face).
39.  Syphiloderma tuberculosum (neck).
40.  Syphiloderma ulcerativum (/iec&).
41.  Epithelioma linguae.
42.  Sycosis (chin).
43.  Scabies (hand).
44.  Dermatitis bullosa (hands).
45.  Trichophytosis (hand).
46.  Lupus verrucosus (hand).
47.  Molluscum  (thigh).
48.  Psoriasis (te#s).
49.  Vesiculae (from  Zoster) (aide).
50.  Zoster lumbo inguinalis.
51.  Comedo (face).
52.  Vesicuhe (poison ivy eruption) (forearm).
53.  Eczema barbae.
54.  Dactylitis.
55.  Pemphigus foliaceous.
56.  Eczema rubrum et squamosum (legs).
57.  Acne vulgaris (back).
58.  Eczema squamosum (elbow).
59.  Erythema exudativum (neck).
60.  Ulcus syphiliticum (leg).
61.  Keloid (cJieek).
62.  Lupus tuberculosus (face).
63.  Albinismus partialis (aid*).
64.  Molluscum (neck).
65.  Ulcera syphilitica (leg).
66.  Syph. ulcerativ. hered. (thigh).
67.  Cicatrix ustionis (elbow).
taken from life,  from which most of

  68. Leucoderma post syph. (side).
  69. Ulcus fungosum (leg).
  70. Syph. ulcerativum (elbow).
  71. Syph. papulo-squam. (neck).
  72. Epithelioma  (nose).
  73. Syph. papulo-squamosum (palm).
  74. Syph. papulosum annulare (forehead).
  75. Ulcera eczematosa (leg).
  76. Eczema squamosum (forearm).
  77. Syph. squam. 6erpig. (foot).
  78. Syph. squam. serpig. (sole).
  79. Psoriasis (trunk).
  80. Ulcera syphilitica (leg).
  81. Kerion (sculp).  ■
  82. Lichen ruber (ant. view).
  83. Eczema—Vena varicosa (leg).
  84. Syph. tuberculosum (leg).
  85. Favus (arm).
  86. Fibroma (ear).
  87. Lepra tuberosa (face).
  88. Psoriasis annulata (breast).
  89. Psoriasis annulata (back).
  90. Trichophytosis capitis.
  91. Rosacea (face).
  92. Syph. papulosum  miliare (anterior).
  93. Syph. papulosum  miliare (posterior).
  94. Psoriasis—chrys. acid stain (side).
  95. Acne indurata (face).
  96. Prurigo (thigh).
  97. Papilloma corneum (cAefA;).
  98. Zoster pectoralis.
  99. Xeroderma (of Hebra) (face and arms).
  100. Xeroderma (of Hebra) (face and arms).
  101, 102.  Syphiloderma papulosum.
  103; Syphiloderma papulo-squamosum.
  104. Syphiloderma papulosum (negro).
  105. Syphiloderma squamosum.
  106, 107,108. Syphiloderma tuberculosum.
  109. Syphiloderma tuberc-ulcerativum.
  110. Syphiloderma serpiginosum.
  Ill, 112.  Syphib derma ulcerativum.
  113. Syphiloderma gummatosum.
  114, 115.  Syphilis bursa? patellae.
  116, 117.  Syphilis nasi.
  118. Chancre of nose.
  119, 120.  Lepra tuberosa.
  121, 122.  Elephantiasis.
  123, 124.  Lupus erythematosus.
  125. Lupus vulgaris.
  126. Lupus verrucosus.
  127. Lupus hypertrophicus.
  128. 129, 130. Lupus exedens.
  131, 132.  Lupus.
  133. Lupus «*edens.
  134, 135, 136, 137, 138, 139, 140,  141, 142, 143,
       144. Epithelioma.
  145. Keloid.
  146. Sarcoma.
  147. Sarcoma pigmentosum.
  148. Naevus vascularis.
  149. Rosacea hypertrophica.
  150. Verruca?.
  151, 152.  Lipoma.
  153, 154, 155, 156. Fibroma.
  157. Dermatolysis.
  158. Keloid.
  159. Naevus pilostis
3 plates of the series will be selected.

   I 160.  Hirsuties.
    161.  Anthrax.
    162.  Pustular eruption from tart, emet, ointment..
    163.  Abscesses from hypodermic syringe.
    164.  Frostbite—gangrene.
    165.  Cicatrix of burn.
    166,  167. Eczema.
    168,  169. Psoriasis.
    170,  171, 172, 173.  Psoriasis and eczema.
    174.  Eczema universale.
    175,  176, 177, 178. Ichthyosis.
    179,180. Favus.
    181.  Chromophytosis.
    182.  Keloid.
    183.  Lupus erythematosus.
    184,  185, 186, 187.  Skin grafts.
    188.  Scratch marks.
    189.  Pityriasis.
    190.  Syphiloderma faciei.
    191.  Syph. condylomata.
    192.  Epithelioma of hand.
    193.  Ven. warts.
    194.  Cancrum oris.
    195,196. Ven. warts.
    197.  Syphiloderma papulosum.
    198,  199. Syphiloderma serpiginosum.
    200.  Syphiloderma ulcerativum.
    201.  Folliculitis calorica (face).
    202.  Morphcea (arm).
    203.  Syphiloderma tuberc. (side).
    204.  Papilloma (Up).
    205.  Leucoderma (face and arms).
    206.  Lepra tuberculosa (face and arms).
    207.  Chromophytosis (body).
    208.  Acne vulgaris (face).
    209.  Impetigo (face).
    210.  Eczema barbae.
    211.  Eczema universale (side view).
    212.  Ichthyosis (side ana thigh).
    213.  Epithelioma (lip).
    214.  Eczema madidans (legs).
    215.  Onychia syphilitica.
    216.  Eczema papulosum (hand).
    217.  Impetigo e pediculis (back).
    218.  Syph. tuberc.   Bursitis (knee).
    219.  Syph. tuberculosum (face and arms).
    220.  Psoriasis nummulata (back).
    221.  Syph. pustulosum serpig. (thigh).
    222.  Ulcus gangrenosum (thigh).
    223.  Syph. tuberc.  squamosum (face and arms).
    224.  Erythema exfoliativum (palm).
    225.  Syph. papulo-squam. (arm and breast).
    226.  Syph. papulo-squam. (shoulder).
    227.  Scabies (hand).
    228.  Favus (scalp).
    229.
    230.
    231.
    232.
    233.
    234.
    235.
    236.
    237.
    238.
    239.
    240. 
        OPINIONS   OF  DERMATOLOGISTS
                             CONCERNING THE
     Photographic  Illustrations  of   Skin   Diseases."

     I  am  exceedingly  pleased  with  the  Photographic Illustrations  of Skin
Diseases.   They are, without exception, the most lite-like representations  that
I have ever seen.                   HENRY G.  PIFFARD, M.D.,
                            Prof, of Dermatology, Med. Dept. of N. Y. Univ.
     I  know the photographs of Dr.  Fox well, and use them continually in
teaching.   Many of the series are taken from cases presented before  the New
York Dermatological Society, and  of the accuracy and  truthfulness of the
representations 1 can bear witness.    L. DUNCAN BULKLEY, M.D.,
                                        Editor of "Archives of Dermatology."
     1  can  hardly imagine anything better that art could  produce on  paper
than these  pictures.   The coloring is admirable, and  the clinical features of
the various maladies  so strikingly portrayed that they proclaim the diagnosis to
the  eye instantly.   I  am  not acquainted  with  any  plates  that please
me so well, or  seem so true to life.     E. L. KEYES, M.D.,
                    Prof, of Dermatology, Bellevue Hospital Medical College.
     Hitherto photographs of cutaneous affections have failed  to reproduce to
the eye the exact appearances of disease. These plates are a wonderful success,
and will commend themselves ta.all who want faithful and artistic  representa-
tions of diseases of the skin.           JAMES  C.  WHITE, M.D.,
                     Professor of Dermatology, Harvard Univ. Medical Dept.
                            « .--------------
     In my judgment, nothing in  the way of  Illustration of Skin Diseases,  that
has ever been placed before the  Profession, has at all approached these in life-
like appearance, and this I think must be concurred in by every Dermatologist.
                                S. SHERWELL, M.D.,
      Lecturer on Dermatology, Long Island College Hospital, Brooklyn. N.  Y.
     They  are marvelously successful representations  of  Skin  Diseases,  well
calculated to accomplish all  that  is possible in the way of teaching Dermatology
pictorially. • The accompanying  text, also, is worthy of all  praise.
                             FRANK P.  FOSTER,  M.D.,
  Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
     The illustrations are truly admirable  representations, and give a life-like
picture of each disease portrayed which it would be indeed difficult to surpass.
They will be the indispensable requisites of the teacher and  of the student in
Dermatology,  and should be in the hands  of every practitioner who devotes
any attention to diseases of the skin.   I commend them most heartily.
                            JAMES NEVINS HYDE, M.D.,
                Professor of Dermatology, Rush Medical College, Chicago, 111.
     I consider the illustrations in this work by one of the foremost specialists in
his department to be admirably executed, accurate and life-like in appearance.
The text is simple and concise, and I cannot too highly recommend this valua-
ble work to students of medicine as well as to experienced  practitioners.
                          JOHN V. SHOEMAKER, M.D.,
                 Lecturer on Dermatology, Philadelphia School of Anatomy.
     I have examined the "Illustrations of Skin Diseases," by G. H. Fox, M.D.
They are true to life, and altogether the most useful plates I have yet seen. I am
convinced that these photographs give a more correct idea of the minute appear-
ances of Skin Diseases than  can be  obtained by any other kind  of pictorial
representation.                      j. e. GRAHAM, M.D.,
                 Lecturer on Dermatology, Toronto General Hospital, Canada.
     The Photographic Illustrations of Dr. G. H. Fox are admirable,  being in
every particular wonderfully  life-like.   A series of forty-eight such illustrations
will form a gallery of Dermatology of the greatest value  to  both student  and
teacher. The tinting of the various lesions is perfect. The accompanying text is
of great supplementary advantage, as it gives a clear idea of the various diseases
with excellent directions for their treatment.     R. w. TAYLOR,  M.D.
      Professor of Diseases of the Skin, University  of Vermont, Physician to the
         Class of Skin Diseases at Bellevue Hospital (Out-Door Department). 
JLfi
Part n.                               Price, $2

            COMPLETE IN TWELVE PARTS.
t*«
^jjbie  II]8sfr
OF
0H
'S
SKIN    DISEASES
BY
           GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
      Diseases; Feliow of the American Academy of Medicine; Member of the New York Dermatological Society,
               the Amencan Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
HERPES facialis. >/

HYDROA buixosum. \/

ERYTHEMA circinatum.

ERYTHEMA exfoliativum.

PURPURA simplex, y
,/
E. IB-
NEW YORK:
[Copyright, 1879, by Georok. Hknry Fox.] 
PREFACE.
     The study of Skin Diseases without  cases or colored plates is like the study of
 osteology without bones, or the study of geography without maps.  However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is next best, its faithful representation.  A
 systematic  course of  clinical study is  only possible  in  our large cities, and yet the
 physician in any remote locality may be called upon to treat the rarest forms of skin
 disease.  As success must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete  series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations of  skin  diseases.   Photographs, though serving a good purpose in portraying
 the  characteristic location and  configuration of the various affections of  the skin, have
 generally lacked an essential element of diagnosis, viz., the color, or have been disfigured
 by careless  daubing, and colored lithographs have not only been  expensive, but in too
 many instances lacked fidelity to nature both in form and color.
     In the series of illustrations now offered to the profession, advantage has been taken
 of a process  recently  devised  for the  reproduction of  pictures from  photographic
 negatives.  These pictures not  only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.  The negatives which serve as a basis for the plates of this series have been selected
 from a very large number, most of which were  taken under the immediate supervision
 of the editor.  A few have  been collected from other sources.  The  coloring has been
 entrusted to a skilful artist, who was formerly a physician, and, having studied skin
 diseases in the General Hospital at Vienna,  is peculiarly fitted for the work.  The  text
 accompanying the plates is  designed  to call attention to the diagnostic characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
 The  notes of cases have been made very brief, as a rule,  inasmuch as it has seemed
 unnecessary to give  full particulars of a case except where it has possessed points of
 special interest.  No systematic order has been followed  in the arrangement of  dis-
 eases, although certain ones have been placed together with a view to their contrast.
    It has been  the aim of  the  editor to represent in this series nearly all of the rare as
 well as the common *affections of the skin,  to present their features with photographic
 accuracy, and to employ color with the  utmost care to render the illustrations as life-
like as possible.
                                                     GEORGE HENRY FOX.
    New York,  May,  1879. 
  1.
  2.
  3.
  4.
  5.
  G.
  7.
  8.
  9.
 10.
 11.
 12.
 13.
 14.
 15.
 16.
 17.
 18.
 19.
 20.
 21.
 22.
 23.
 24.
 25.
 26.
 27.
 28.
 29.
 30.
 31.
 32.
 33.
 34.
 35.
 36.
 37.
 38.
 39.
 40.
 41.
 42.
 43.
 44.
 45.
 46.
 47.
 48.
 49.
 50.
 51.
 52.
 53.
 54.
 55.
 56.
 57.
 58.
 59.
 60.
 61.
 62.
 63.
 64.
 65.
 66.
67.
A list of photographic negatives, taken from life, from which most of the plates of the series will be selected.
 Epithelioma (lip).
 Lepra tuberosa (face).
 Syphiloderma pustulosum (back).
 Leucoplakia linguae.
 Hydroa (forearms).
 Syphiloderma pustulosum (face and arms).
 Syphiloderma pustulosum (legs).
 Psoriasis diffusa (side).
 Eczema madidans (universal).
 Scabies (hand).
 Alopecia areata syph. (infant's head).
 Trichophytosis (wrist).
 Purpura (legs).
 Lichen planus (forearm).
 Eczema rimosum (palm).
 Eczema squamosum (palm).
 Lepra maculosa (body).
 Fibroma (breast).
 Syphiloderma pustulosum (arms and thighs).
 Alopecia areata (head).  '
 Epithelioma (cheek).
 Phtheiriasis capitis.
 Eczema madidans (face).
 Eczema impetiginosum (face).
 Lupus vulgaris (face).
 Favus (head).
 Syphiloderma rupiale (forearm).
 Ulcus fungosum (leg).
 Condylomata syphilitica.
 Phtheiriasis corporis (back).
 Favus (back).
 Lichen simplex (back).
 Psoriasis guttata (back).
 Chromophytosis (breast).
 Lentigo (abdomen).
 Phtheiriasis corporis (back).
 Syphiloderma rupiale (legs).
 Syphiloderma ecthymaforme (face).
 Syphiloderma tuberculosum (neck).
 Syphiloderma ulcerativum (neck).
 Epithelioma linguae.
 Sycosis (chin).
 Scabies (hand).
 Dermatitis bullosa (hands).
 Trichophytosis (hand).
 Lupus verrucosus (hand).
 Molluscum (thigh).
 Psoriasis (legs).
 Vesiculae (from Zoster)  (side).
 Zoster lumbo inguinalis.
 Comedo (face).
 Vesiculre (poison ivy eruption) (forearm).
 Eczema barbae.
 Dactylitis.
 Pemphigus foliaceous.
 Eczema rubrum et squamosum (legs).
 Acne vulgaris  (back).
 Eczema squamosum (elbow).
 Erythema exudativum  (neck).
 Ulcus syphiliticum (leg).
 Keloid  (cheek).
 Lupus tuberculosus (face).
 Albinismus partialis (sid«).
 Molluscum (neck).
 Ulcera syphilitica (leg).
 Sypb. ulcerativ. hered.  (thigh).
Cicatrix ustionis (elbow).
  68. Leucoderma post syph. (side).
  69. Ulcus fungosum (leg).
  70. Syph. ulcerativum (elbow).
  71. Syph. papulo-squam. (neck).
  72. Epithelioma  (nose).
  73. Syph. papulo-squamosum (palm).
  74. Syph. papulosum annulare (forehead).
  75. Ulcera eczematosa (leg).
  76. Eczema squamosum (forearm).
  77. Syph. squam. 6erpig. (foot).
  78. Syph. squam. serpig. (sole).
  79. Psoriasis (trunk).
  80. Ulcera syphilitica (leg).
  81. Kerion (scalp).
  82. Lichen ruber (ant.  view).
  83. Eczema—Vena varicosa (leg).
  84. Syph. tuberculosum (leg).
  85. Favus  (arm).
  86. Fibroma (ear).
  87. Lepra tuberosa (face).
  88. Psoriasis annulata  (breast).
  89. Psoriasis annulata  (back).
  90. Trichophytosis,capitis.
  91. Rosacea (face).
  92. Syph. papulosum miliare (anterior).
  93. Syph. papulosum miliare (posterior).
  94. Psoriasis—chrys. acid stain (side).
  95. Acne indurata (face).
  96. Prurigo (thigh).
  97. Papilloma corneum (cheek).
  98. Zoster pectoralis.
  99. Xeroderma (of Hebra) (face and arms).
 100. Xeroderma (of Hebra) (face and arms).
 101, 102.  Syphiloderma papulosum.
 103; Syphiloderma papulo-squamosum.
 104. Syphiloderma papulosum (negro).
 105. Syphiloderma squamosum.
 106, 107, 108.  Syphiloderma tuberculosum.
 109. Syphiloderma tuberc-ulcerativum.
 110. Syphiloderma serpiginosum.
 Ill, 112.  Syphiloderma ulcerativum.
 113. Syphiloderma gummatosum.
 114, 115.  Syphilis bursae patellae.
 116, 117.  Syphilis  nasi.
 118. Chancre of nose.
 119, 120.  Lepra tuberosa.
 121, 122.  Elephantiasis.
 123, 124.  Lupus erythematosus.
 125. Lupus vulgaris.
 126. Lupus verrucosus.
 127. Lupus hypertrophicus.
 128, 129, 130.  Lupus exedens.
 131, 132.  Lupus.
 133. Lupua exedens.
 134, 135, 136, 137, 138, 139, 140,  141, 142.  143,
      144. Epithelioma.
 145. Keloid.
 146. Sarcoma.
 147. Sarcoma pigmentosum.
 148. Naevus vascularis.
 149. Rosacea hypertrophica.
150. Verruca?.
151, 152. Lipoma.
153, 154, 155, 156.  Fibroma.
157. Dermatolysis.
158. Keloid.
159. Naevus pilosus.
160.
161.
162.
163.
164.
165.
166,
168,
170,
174.
175,
179.
181.
182.
183.
184,
188.
189.
190.
191.
192.
193.
194.
195,
197.
198,
200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235,
236.
237.
238.
239.
240.
 Hirsuties.
 Anthrax.
 Pustular eruption from tart. emet. ointment.
 Abscesses from hypodermic syringe.
 Frostbite—gangrene.
 Cicatrix of burn.
167.  Eczema.
169.  Psoriasis.
171,  172, 173. Psoriasis and eczema.
 Eczema universale.
170,  177, 178. Ichthyosis.
180.  Favus.
Chromophy tosi s.
 Keloid.
 Lupus erythematosus.
185,  186, 187. Skin grafts.
 Scratch marks.
 Pityriasis.
 Syphiloderma faciei.
 Syph.  condylomata.
 Epithelioma of hand.
Ven. warts.
 Cancrum oris.
196.  Ven. warts.
 Syphiloderma papulosum.
199.  Syphiloderma serpiginosum.
 Syphiloderma ulcerativum.
 Folliculitis calorica (face).
 Morphcea (arm).
 Syphiloderma tuberc. (side).
 Papilloma (lip).
 Leucoderma (face and arms).
 Lepra tuberculosa (face and arms).
 Chromophytosis (body).
 Acne vulgaris (face).
 Impetigo (face).
 Eczema barbae.
 Eczema universale (side view).
 Ichthyosis (side ana thigh).
 Epithelioma (lip).
 Eczema madidans  (legs).
 Onychia syphilitica.
 Eczema papulosum (hand).
 Impetigo e pediculis (back).
 Syph. tuberc.  Bursitis (knee).
 Syph. tuberculosum (face and arms).
 Psoriasis nummulata (back).
 Syph. pustulosum serpig. (thigh).
 Ulcus gangrenosum (thigh).
 Syph. tuberc. squamosum (face and arms).
 Erythema exfoliativum (palm).
Syph. papulo-squam. (arm and breast).
 Syph. papulo-squam. (shoulder).
 Scabies (hand).
 Favus (scalp). 
        OPINIONS   OF   DERMATOLOGISTS
                             CONCKHNING TUE
     Photographic  Illustrations  of  Skin  Diseases."

    1  am  exceedingly  pleased  with the Photographic  Illustrations  fcf Skin
Diseases.   They are, without exception, the most lite-like representations that
I have ever seen.                   HENRY G. P1FFARD,  M.D.,
                            Prof, of Dermatology, Med. Dept.  of N. Y. Univ.
    I  know  the photographs of Dr. Fox well,  and  use them continually in
teaching.   Many of the series are taken from cases presented before  the New
York  Dermatological Society, and of the accuracy  and truthfulness of the
representations 1 can bear witness.    L. DUNCAN BULKLEY,  M.D.,
                                        Editor of "Archives of Dermatology."
    1  can  hardly  imagine  anything better that  art could produce on paper
than these  pictures.   The  coloring  is admirable, and the clinical features of
the various maladies  so strikingly portrayed that  they proclaim  the diagnosis to
the eye instantly.   I  am  not  acquainted with  any  plates  that please
me so well, or seem so true to life.    E. L. KEYES, M.D.,
                    Prof, of Dermatology, Bellevue Hospital Medical College.
    Hitherto photographs of cutaneous affections have failed to  reproduce to
the eye the exact appearances of disease.  These  plates are a wonderful success,
and will commend themselves to all  who want faithful and artistic representa-
tions of diseases of the skin.          JAMES C. WHITE, M.D.,
                     Professor of Dermatology,  Harvard  Univ.  Medical Dept.
    In my judgment, nothing in the way of Illustration of Skin Diseases, that
has ever been placed before the  Profession, has at all  approached these in life-
like appearance, and this I think must be  concurred in by every Dermatologist.
                                S.  SHERWELL, M.D.,
       Lecturer on Dermatology, Long Island College Hospital, Brooklyn. N. Y.
    They  are marvelously successful representations of Skin Diseases, well
calculated to accomplish all that is possible in the way of teaching  Dermatology
pictorially.    The accompanying  text, also, is worthy of all praise.
                              FRANK  P.  FOSTER, M.D.,
  Clinical Assistant, Diseases of the Skin, College of Physicians and Surgeons, N. Y
    The illustrations are  truly admirable representations, and give a life-like
picture of each disease portrayed which it would be indeed difficult to surpass.
They will be  the indispensable requisites of the teacher and of the  student in
Dermatology, and should be in  the hands  of every  practitioner  who devotes
any attention to diseases of the skin.  I commend them most heartily.
                            JAMES NEVINS  HYDE,  M.D.,
                Professor of Dermatology, Rush  Medical College, Chicago, 111.
    I consider the illustrations in this work by one of the  foremost specialists in
his department to be admirably executed,  accurate and life-like in appearance.
The text is simple and concise, and I cannot top highly recommend this valua-
ble work to students of medicine as well as to experienced practitioners.
                          JOHN V. SHOEMAKER, M.D.,
                 Lecturer on Dermatology, Philadelphia School of Anatomy.
    I have examined the "Illustrations of Skin Diseases," by G. H. Fox, M.D.
They are true to life, and altogether the most useful plates  I have yet seen.  I am
convinced that these photographs give a more correct idea of the minute appear-
ances^of Skin Diseases^han  can be obtained by any other kind of  pictorial
representation.                     j. e. GRAHAM, M.D.,
                 Lecturer on Dermatology,  Toronto General Hospital, Canada.
    The Photographic Illustrations  of Dr. G. H. Fox are admirable, being in
every particular wonderfully life-like.  A series of forty-eight such illustrations
will form a gallery of Dermatology of the greatest value   to both  student and
teacher. The tinting of the various lesions  is perfect. The accompanying text is
of great supplementary advantage, as it gives a clearid?a of the various diseases
with excellent directions for  their treatment.      R. w. TAYLOR, M  D.
      Professor of Diseases of the Skin, University of Vermont,  Physician  to the
         Class of Skin Diseases at Bellevue Hospital (Out-Door Department). 
      See Announcement 4th Page of Cover.

Part i2.                             Price, $2.

           COMPLETE IN TWELVE PARTS.
w>
%T^ic IIJ«^
OF
%
'$
SKIN    DISEASES
BY
          GEORGE HENRY FOX, A. M., M. D.


Clinical Professor of Dermatology, Starling Medical College, Columbus, O.; Surgeon to the New York Dispensary, Department of Skin and Venereal
     Diseases; Feliow of the American Academy of Medicine; Member of the New York Dermatological Society,
              the American Dermatological Association, etc.
FORTY-EIGHT COLORED PLATES TAKEN FROM LIFE.
CORNUA cutanea. ✓-

ALOPECIA AREATA. ^

MORPHCEA.   {

SCLERODERMA, j v

SARCOMA PIGMENTOSUM
/
IE- IB-
          NEW YORK:

TIR^E^JT,  JSTo. 805 ZB:coa,clT*7-a,;5r.
[Copyright, 1879, by Georck Henry Fox.l 
PREFACE.
     The study of Skin Diseases without  cases or colored plates is like the study of
 osteology without bones, or the study of geography without maps.  However compre-
 hensive or practical a text-book may be, its verbal descriptions cannot compare in value
 with a sight of the thing described, or, what is next best, its faithful representation.  A
 systematic  course of  clinical study is  only possible  in  our large cities, and  yet the
 physician in any remote locality may be called upon to treat the rarest forms  of skin
 disease.   As success must depend in great measure upon the correctness of his diagnosis,
 it is hardly necessary to argue the value of a complete  series of well-executed plates.
     Of late the steadily increasing interest in dermatology has led to a demand for illus-
 trations  of  skin  diseases.   Photographs, though serving a good purpose in portraying
 the  characteristic location and  configuration of the various affections of  the skin, have
 generally lacked  an essential element of diagnosis, viz., the color, or have been disfigured
 by careless  daubing, and colored lithographs have not only been  expensive, but in too
 many instances lacked fidelity to nature both in form and color.
     In the series  of illustrations now offered to the profession, advantage has been taken
 of a process  recently  devised  for the reproduction of  pictures from photographic
 negatives.  These pictures not only possess the sharpness of detail and brilliancy of
 ordinary photographs, but, unlike the latter, will not fade through age and exposure to
 light.  The negatives which serve as a basis for the plates of. this series have been selected
 from a very large number, most of  which were  taken under the immediate  supervision
 of the editor.  A few have been collected  from other sources.  The  coloring has been
 entrusted to a skilful artist, who was formerly a physician, and, having studied  skin
 diseases  in the General Hospital at Vienna, is peculiarly fitted for the work.  The text
 accompanying the plates is  designed  to call attention to the diagnostic characters of
 the various diseases, and to give in brief some practical suggestions for their treatment.
 The  notes of cases have been made very brief, as a rule, inasmuch as it  has  seemed
 unnecessary to give  full particulars of a case except where  it has possessed points of
 special interest.  No systematic order has been followed in the arrangement  of dis-
 eases, although certain ones have been placed together with a view to their contrast.
    It  has been  the aim of the editor  to represent in this series nearly all of the rare as
 well as the common affections of the skin, to present their features with photographic
accuracy, and to employ color with the utmost  care to render the illustrations as life-
like as possible.
                                                     GEORGE HENRY FOX
    New York,  Mav,  1879. 
A list of photographic negatives, taken from life, from which most of the plates of the series will bo selected.
 1. Epithelioma (Up).
 2. Lepra tuberosa (face).
 3. Syphiloderma pustulosum (back).
 4. Leucoplakia linguae.
 5. Hydroa (forearms).
 6. Syphiloderma pustulosum (face and arms).
 7. Syphiloderma pustulosum (legs).
 8. Psoriasis diffusa (side).
 9. Eczema madidans (universal).
10. Scabies (hand).
11. Alopecia areata syph. (infant's Jiead).
12. Trichophytosis (wrist).
13. Purpura (legs).
14. Lichen planus (forearm).
15. Eczema rimosuin (p<dn\).
16. Eczema squamosum (palm).
17. Lepra' maculosa (body).
18. Fibroma (breast).
19. Syphiloderma pustulosum (arms and thighs).
20. Alopecia areata (head).
21. Epithelioma (cheek).
22. Phtheiriasis capitis.
23. Eczema madidans (face).
24. Eczema impetigiuosum (face).
25. Lupus vulgaris (face).
26. Favus (head).
27. Syphiloderma rupiale (forearm).
28. Ulcus fungosum (leg).
29. Condylomata syphilitica.
30. Phtheiriasis corporis (back).
31. Favus (back).
32. Lichen simplex (back),
33. Psoriasis guttata (back).
34.•Chromophytosis (breast).
35. Lentigo (abdomen).
36. Phtheiriasis corporis (back).
37. Syphiloderma rupiale (legs).
38. Syphiloderma ecthymaforme (face).
39. Syphiloderma tuberculosum (neck).
40. Syphiloderma ulcerativum (neck).
41. Epithelioma linguae.
42. Sycosis (chin).
43. Scabies (hand).
44. Dermatitis bullosa (hands).
45. Trichophytosis (Jiand).
46. Lupus verrucosus (hand).
47. Molluscum (thigh).
48. Psoriasis (fe^a).
49. Vesiculae (from Zoster) (side).
50. Zoster lumbo inguinalis.
51. Comedo (face).
52. Vesiculae (poison ivy eruptipn) (forearm).
53. Eczema barbae.
54. Dactylitis.
55. Pemphigus foliaceous.
56. Eczema rubrum et squamosum (legs).
57. Acne vulgaris (back).
58. Eczema squamosum (elbow).
59. Erythema exudativum (neck).
60. Ulcus syphiliticum (leg).
61. Keloid (cheek).
62. Lupus tuberculosus (face).
63. Albinismus partialis (sid«).
64. Molluscum (neck).
65. Ulcera syphilitica (leg).
66. Syph. ulcerativ. hered. (thigh).
67.  Cicatrix ustionis (elbow).
 68.  Leucoderma post syph. (side).
 09.  Ulcus fungosum (leg).
 70.  Syph. ulcerativum (elbow).
 71.  Syph. papulo-squam. (/jecA;).
 72.  Epithelioma (nose),
 73.  Syph. papulo-squamosum (palm).
 74.  Syph. papulosum annulare (forehead).
 75.  Ulcera eczematosa (tefl*).
 76.  Eczema squamosum (forearm).
 77.  Syph. squam. serpig. (foot).
 78.  Syph. squam. serpig. (sole).
 79.  Psoriasis (trunk).
 80.  Ulcera syphilitica (Irg).
 81.  Kerion (scalp).
 82.  Lichen ruber (««£. new).
 83.  Eczema—Venn varicosa (leg).
 84.  Syph. tuberculosum (leg).
 85.  Favus (arm).
 86.  Fibroma (ear).
 87.  Lepra tuberosa (face).
 88.  Psoriasis annulata (breast).
 89.  Psoriasis annulata (back).
 90.  Trichophytosis capitis.
 91.  Rosacea (face).
 92.  Syph. papulosum miliare (anterior).
 93.  Syph. papulosum miliare (posterior).
 94.  Psoriasis—chrys. acid stain (side).
 95.  Acne indurata (face).
 96.  Prurigo (thigh).
 97.  Papilloma corueum (clieek).
 98.  Zoster pectoralis.
 99.  Xeroderma (of Hebra)  (face and arms).
100.  Xeroderma (of Hebra)  (face and arms).
101,  102. Syphiloderma papulosum.
103;  Syphiloderma papulo-squamosum.
104.  Syphiloderma papulosum (negro).
105.  Syphiloderma squamosum.
106,  107, 108. Syphiloderma tuberculosum.
109.  Syphiloderma tuberc-ulcerativum.
110.  Syphiloderma serpiginosum.
Ill,  112. Syphiloderma ulcerativum.
113.  Syphiloderma gummatosum.
114,  115. Syphilis bursae patellae.
116,117. Syphilis nasi.
118.  Chancre of nose.
119,  120. Lepra tuberosa.
121,  122. Elephantiasis.
123,  124. Lupus erythematosus.
125.  Lupus vulgaris.
126.  Lupus verrucosus.
127.  Lupus hypertrophicus.
128,  129, 130. Lupus exedens.
131,  132. Lupus.
133.  Lupus exedens.
134,  135, 136, 137,  138, 139, 140, 141, 142, 143,
      144. Epithelioma.
145.  Keloid.
146.  Sarcoma.
147.  Sarcoma pigmentosum.
148.  Naevus vascularis.
149.  Rosacea hypertrophica. ,
150.  Verrucae.
151,  152. Lipoma.
153,  154, 155, 156. Fibroma.
157.  Dermatolysis.
158.  Keloid.
159.  Naevus pilosus.
160.
161.
162.
163.
164.
165.
166,
168,
170,
174.
175,
179.
181.
182.
183.
184,
188.
189.
190.
191.
192.
193.
194.
195,
197.
198,
200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
238.
239.
240.
Hirsuties.
Anthrax.
Pustular eruption from tart. emet. ointment.
Abscesses from hypodermic syringe.
Frostbite—gangrene.
Cicatrix of burn.
167.  Eczema.
169.  Psoriasis.
171,  172, 173. Psoriasis and eczema.
Eczema universale.
176,  177, 178. Ichthyosis.
180.  Favus.
Chromophy tosi s.
Keloid.
Lupus erythematosus.
185,  186, 187. Skin grafts.
Scratch marks.
Pityriasis.
Syphiloderma faciei.
Syph. condylomata.
Epithelioma of hand.
Ven. warts.
Cancrum oris.
19G.  Ven. warts.
Syphiloderma papulosum.
199.  Syphiloderma serpiginosum.
Syphiloderma ulcerativum.
Folliculitis calorica (face).
Morphcea (arm).
Syphiloderma tuberc. (side).
Papilloma (lip).
Leucoderma (face and arms).
Lepra tuberculosa (face and arms).
Chromophytosis (body).
Acne vulgaris (face).
Impetigo (face).
Eczema barbae.
Eczema universale (side view).
Ichthyosis (side ana thigh).
Epithelioma (lip).
Eczema madidans (legs).
Onychia syphilitica.
Eczema papulosum (hand).
Impetigo e pediculis (back).
Syph. tuberc.   Bursitis (knee).
Syph. tuberculosum (face and arms).
Psoriasis nummulata (back).
Syph. pustulosum serpig. (thigh).
Ulcus gangrenosum (thigh).
Syph. tuberc. squamosum (face and arms).
Erythema exfoliativum (palm).
Syph. papulo-squam. (arm and breast).
Syph. papulo-squamt (shoulder).
 Scabies (hand).
 Favus (scalp). 
             ANNOUNCEMENT!

      The very flattering reception accorded by the Medical Tro-
fession  to  the  "Photographic Illustrations  of  Skin Diseases."  a
work which is ?iow complete, has demonstrated that photographs
reproduced by an indelible process and colored by hand, constitute
tlie most successful illustrations of diseases of the skin.
      In this work, plates of cutaneous syphilis were omitted, in
order to make the illustration of important non-syphilitic diseases
as complete as possible.
      The publis tier now announces to the profession a  companion
work, entitled
       "Photographic Illustrations of CUTA1TE0US SYPHILIS,"
which will appear shortly.   In this tlie aut7ior enters a new field,
and it will be his earnest endeavor, as well as that of the unde?-
signed, to make the forthcoming work sustain the reputation of its
predecessor.
             E. B. TREAT, Publisher, 805 Broadway, N. Y.
    "V^ill remove May 1st to ,73,7 Broad\7ray. 
 
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