Volume 4 — DISEASES OF THE SKIN.

DISEASES OF THE SKIN.¹

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

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

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

CLASS I.—DISORDERS OF SECRETION.

Hyperidrosis.

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

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

Anidrosis.

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

Bromidrosis.

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

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

Chromidrosis.

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

Uridrosis.

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

Phosphoridrosis.

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

Sudamen.

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

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

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

Seborrhoea.

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

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

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

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

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

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

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

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

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

Rx. Chloralis, scruple ij;

Glycerinæ, minim xx;

Aquæ rosæ, fluidounce iv. M.

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

Rx. Acidi carbolici, minim xxx;

Olei ricini, fluidrachm ij;

Alcoholis, fluidounce j drachm vj. M.

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

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

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

Comedo.

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

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

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

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

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

Rx. Sulphuris præcipitati, drachm ij;

Ætheris, fluidounce ss;

Alcoholis, fluidounce iijss. M.

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

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

Rx. Aceti, drachm ij;

Glycerinæ, drachm iij;

Kaolini, drachm iv. M.

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

Milium.

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

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

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

Steatoma.

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

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

CLASS II.—INFLAMMATIONS.

Erythema Simplex.

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

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

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

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

Rx. Pulv. zinci oxidi, drachm ij;

Pulv. talci Veneti, drachm ij;

Pulv. amyli, drachm iv. M.

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

Rx. Pulv. calaminæ, Pulv. zinci oxidi, aa. drachm iss;

Alcoholis, fluidrachm ij;

Aquæ rosæ, fluidounce iv. M.

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

Erythema Multiforme.

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

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

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

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

Erythema Nodosum.

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

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

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

Urticaria.

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

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

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

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

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

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

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

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

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

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

Dermatitis.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dermatitis Gangrænosa.

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

Furunculus.

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

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

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

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

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

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

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

Carbunculus.

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

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

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

Herpes Simplex.

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

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

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

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

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

Herpes Iris.

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

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

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

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

Herpes Zoster.

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

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

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

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

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

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

Dermatitis Herpetiformis.

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

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

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

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

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

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

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

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

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

Psoriasis.

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