Volume 4 — DISEASES OF THE SKIN. (continued 5)

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

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

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

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

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

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

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

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

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

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

Epithelioma.

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

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

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

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

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

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

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

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

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

Sarcoma.

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

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

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

CLASS VII.—NEUROSES.

Dermatalgia.

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

Pruritus.

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

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

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

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

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

Rx. Fol. belladonnæ, Fol. hyoscyami, aa. drachm ij;

Fol. aconiti, drachm ss;

Acidi acetici, fluidounce j. M.

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

Rx. Sodii boratis, drachm ij;

Glycerinæ, fluidrachm iv;

Spts. camphoræ, fluidounce ss;

Aquæ rosæ, ounce v. M.

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

Rx. Sodii boratis, drachm iv;

Morphiæ sulph., gr. xv;

Glycerinæ, fluidounce ss;

Aquæ, q. s. ad fluidounce viij. M.

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

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

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

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

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

CLASS VIII.—PARASITES.

Tinea Favosa.

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

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

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

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

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

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

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

Tinea Trichophytina.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rx. Ugt. picis liquidæ, Ugt. hydrarg. nitrat., aa. drachm ij;

Ugt. sulphuris, drachm iv.

M. Ft. ugt.

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

Rx. Thymolis, drachm ss;

Chloroformis, drachm ij;

Olei olivæ, drachm vj. M.

Coster's paste is also serviceable:

Rx. Iodinii, drachm ij;

Olei picis, ounce j. M.

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

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

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

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

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

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

Tinea Versicolor.

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

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

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

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

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

Scabies.

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

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

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

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

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

Rx. Sulphuris sublimatis, Olei cadini, aa. drachm ij;

Cretæ præparatæ, drachm iiss;

Saponis viridis, Adipis, aa. ounce j.

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

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

Pediculosis.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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