Volume 4 — DISEASES OF THE SKIN. (continued 4)

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

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

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

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

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

Dermatolysis.

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

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

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

CLASS V.—ATROPHIES.

Albinismus.

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

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

Vitiligo.

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

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

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

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

Canities.

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

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

Alopecia.

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

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

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

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

Alopecia Areata.

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

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

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

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

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

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

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

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

Rx. Tinct. cantharidis, Tinct. capsici, aa. fluidounce iss;

Olei ricini, fluidrachm ij;

Alcoholis, fluidrachm vj;

Spts. rosmarini, fluidrachm ij. M.

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

Rx. Olei myristicæ exp., fluidrachm ij;

Alcoholis, Spiritus lavandulæ, aa. fluidounce ij. M.

Carbolic acid may be used as follows:

Rx. Acidi carbolici cryst., drachm ij;

Alcoholis, fluidounce iij;

Olei ricini, fluidrachm iv;

Spts. rosmarini, fluidrachm iv. M.

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

Rx. Olei amygdalæ dulc., Aquæ ammoniæ fort., aa. fluidounce ss;

Spiritus rosmarini, fluidounce ij;

Olei limonis, fluidrachm ss. M.

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

Atrophia Pilorum Propria.

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

Atrophia Unguis.

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

Atrophia Cutis.

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

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

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

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

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

CLASS VI.—NEW GROWTHS.⁶

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

Keloid.

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

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

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

Fibroma.

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

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

Neuroma.

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

Xanthoma.

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

Myoma.

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

Angioma.

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

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

Lymphangioma.

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

Lupus Erythematosus.

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

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

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

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

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

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

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

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

Rx. Zinci sulphatis, Potassii sulphidi, aa. drachm ij;

Aquæ, fluidounce iij;

Alcoholis, fluidounce j.

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

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

Glycerinæ, drachm j.

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

Rx. Olei cadini, Alcoholis, Saponis viridis, aa. drachm iij.

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

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

Rx. Acidi pyrogallici, drachm j;

Liquor. gutta-perchæ, fluidrachm iv.

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

Lupus Vulgaris.

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

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

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

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

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

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

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

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

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

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

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

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

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

Rx. Acidi pyrogallici, drachm ij;

Emplastri plumbi, drachm j;

Cerati resinæ comp., drachm v.

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

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

Rx. Acidi arseniosi, scruple j;

Hydrargyri sulphuret. rub., drachm j;

Ugt. simplicis, ounce j.

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

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

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

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

Scrofuloderma.

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

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

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

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

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

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

Syphilis Cutanea.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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