As a limited eruption it is most frequently seen on the palms and soles—the palmar and plantar syphiloderm. Occurring on these parts it is often rebellious to treatment.



How are you to distinguish the papulo-squamous syphiloderm from psoriasis?

In psoriasis the eruption is more inflammatory, and usually bright red; the scales whitish or pearl-colored and, as a rule, abundant. It is generally seen in greater profusion upon certain parts, as, for instance, the extensor surfaces, especially of the elbows and knees. It is not infrequently itchy, and, moreover, presents a different history.

In the syphilitic eruption some of the papules almost invariably remain perfectly free from any tendency to scale formation; there is distinct deposit or infiltration, and the lesions are of a dark, sluggish red or ham tint; and, moreover, concomitant symptoms of syphilis are usually present.

Describe the annular eruption of syphilis.

The annular syphiloderm (circinate syphiloderm) is observed usually in association with the large-papular eruption, and consists of several or more variously sized, ring-like lesions, with a distinctly elevated solid ridge or wall peripherally and a more or less flattened centre. It is commonly seen about the mouth, forehead and neck. The lesion appears to have its origin from an ordinary, usually scaleless or slightly scaly, large papule, the central portion of which has been incompletely formed or has become sunken and flattened. The manifestation is rare, and is seen most frequently in the negro.

What several varieties of the pustular syphiloderm are met with?

The small acuminated-pustular syphiloderm, the large acuminated-pustular syphiloderm, the small flat-pustular syphiloderm, and the large flat-pustular syphiloderm.

Describe the small acuminated-pustular eruption of syphilis.

The small acuminated-pustular syphiloderm (miliary pustular syphiloderm) is an early or late secondary eruption, commonly encountered in the first six or eight months of the disease. It consists of a more or less generalized, disseminated or grouped, millet-seed-sized, acuminated pustules, usually seated upon dull-red, papular elevations. The eruption is, as a rule, profuse, and usually involves the hair-follicles. The pustules dry to crusts, which fall off and are often followed by a slight, fringe-like exfoliation around the base, constituting a grayish ring or collar. Minute pin-point atrophic depressions or stains are left, which gradually become less distinct. Scattered large pustules, and sometimes papules, are not infrequently present.

Describe the large acuminated-pustular eruption of syphilis.

The large acuminated-pustular syphiloderm (acne-form syphiloderm, variola-form syphiloderm) is a more or less generalized eruption, occurring usually in the first six or eight months of the disease. It consists of small or large pea-sized, disseminated or grouped, acuminated or rounded pustules, resembling the lesions of acne and variola. They develop slowly or rapidly, and at first may appear more or less papular. They dry to somewhat thick crusts, and are seated upon superficially ulcerated bases.

It pursues, as a rule, a comparatively rapid and benign course. In relapses the eruption is usually more or less localized.

How would you distinguish the large acuminated-pustular syphiloderm from acne and variola?

In acne the usual limitation of the lesions to the face or face and shoulders, the origin, more rapid formation and evolution of the individual lesions, and the chronic character of the disease, are usually distinctive points.

In variola, the intensity of the general symptoms, the shot-like beginning of the lesions, their course, the umbilication, and the definite duration, are to be considered.

The presence or absence of other symptoms of syphilis has, in obscure cases, an important diagnostic bearing.

Describe the small flat-pustular eruption of syphilis.

The small flat-pustular syphiloderm (impetigo-form syphiloderm) consists of a more or less generalized, pea-sized, flat or raised, discrete, irregularly-grouped, or in places confluent, pustules, appearing usually in the first year of the disease. The pustules dry rapidly to yellow, greenish-yellow, or brownish, more or less adherent, thick, uneven, somewhat granular crusts, beneath which there may be superficial or deep ulceration; where the lesions are confluent a continuous sheet of crusting forms. The eruption is often scanty. It is most frequently observed about the nose, mouth, hairy parts of the face and scalp, and about the genitalia, frequently in association with papules on other parts.

Are you likely to mistake the small flat-pustular syphiloderm for any other eruption?

Scarcely; but when upon the scalp, it may bear rough resemblance to pustular eczema, but the erosion or ulceration will serve to differentiate. Moreover, concomitant symptoms of syphilis are to be looked for.

Describe the large flat-pustular eruption of syphilis.

The large flat-pustular syphiloderm (ecthyma-form syphiloderm) consists of a more or less generalized, scattered eruption, of large pea- or dime-sized, flat pustules. They dry rapidly to crusts. The bases of the lesions are a deep-red or copper color. Two types of the eruption are met with.

In one type—the superficial variety—the crust is flat, rounded or ovalish, of a yellowish-brown or dark-brown color, and seated upon a superficial erosion or ulcer. The lesions are usually numerous, and most abundant on the back, shoulders and extremities. It appears, as a rule, within the first year, and generally runs a benign course.



In the other type—the deep variety—the crust is greenish or blackish, is raised and more bulky, often conical and stratified, like an oyster shell—rupia; beneath the crusts may be seen rounded or irregular-shaped ulcers, having a greenish-yellow, puriform secretion. It is usually a late and malignant manifestation.

How would you differentiate the large flat-pustular syphiloderm from ecthyma?

The syphilitic lesions are more numerous, are scattered, are attended with superficial or deep ulceration, and followed by more or less scar-formation. Moreover, the history, and presence or absence of other symptoms of syphilis have an important diagnostic value.



Describe the bullous eruption of syphilis.

The bullous syphiloderm, (of acquired syphilis) is a rare and usually late eruption, appearing in the form of discrete, disseminated, rounded or ovalish, pea- to walnut-sized, partially or fully distended, blebs. The serous contents soon become cloudy and puriform. In some cases the lesions are distinctly pustular from the beginning. The crust, which soon forms, is of a yellowish-brown or dark green color, and may be thick and stratified (rupia), as in the deep variety of the large flat-pustular syphiloderm. The erosions or ulcers beneath the crusts secrete a greenish-yellow fluid. It is a malignant type of eruption, and is usually seen in broken-down subjects.

It is not an uncommon manifestation of hereditary syphilis (q. v.) in the newborn.



How is the bullous syphiloderm to be differentiated from other pemphigoid eruptions?

By the gravity of the disease, the accompanying ulceration, the course and history; and by other evidences, past or present, of syphilis.

Describe the tubercular eruption of syphilis.

The tubercular syphiloderm (syphiloderma tuberculosum) may exceptionally occur within the first year as a more or less generalized eruption. As a rule, however, it is a late manifestation, at times appearing many years after the initial lesion; is limited in extent, and shows a decided tendency to occur in groups, often forming segments of circles and circular areas, clearing in the centre and spreading peripherally.

It consists (as a late, limited manifestation) of several or more firm, circumscribed, deeply-seated, smooth, glistening or slightly scaly elevations; rounded or acuminated in shape, of a yellowish-red, brownish-red or coppery color and usually of the size of small or large peas. Several groups may coalesce, and a serpiginous tract result (serpiginous tubercular syphiloderm). The lesions develop slowly, and are sluggish in their course, remaining, at times, for weeks or months, with but little change. As a rule, however, they terminate sooner or later, either by absorption, leaving a more or less permanent pigment stain with or without slight atrophy (non-ulcerating tubercular syphiloderm), or by ulceration (ulcerating tubercular syphiloderm).



Describe the ulcerating tubercular syphiloderm.

The ulceration may be superficial or deep in character, and involve several or all of the lesions forming the group. The patch may consist, therefore, of small, discrete, punched-out ulcers, or of one or more continuous ulcers, segmented, crescentic or serpiginous in shape. They are covered with a gummy, grayish-yellow deposit or they may be crusted. As the ulcerative changes take place, new lesions, especially about the periphery of the group or patch, may appear from time to time.



In some instances, more especially about the scalp, the surface of the ulcerations becomes papillary or wart-like, with an offensive, yellowish, puriform secretion (syphilis cutanea papillomatosa).

From what diseases is the tubercular syphiloderm to be differentiated?

From tubercular leprosy, epithelioma and lupus vulgaris, especially the last-named.

What are the chief diagnostic characters of the tubercular syphiloderm?

The tendency to form segments, crescents and circles, the color, the pigmentation and ulceration, the history, and not infrequently marks or scars of former eruptions.



Describe the gummatous eruption of syphilis.

The gummatous syphiloderm (syphiloderma gummatosum, gumma, syphiloma) is usually a late manifestation, showing itself as one, several or more painless or slightly painful, rounded or flat, more or less circumscribed tumors; they are slightly raised, moderately firm, and have their seat in the subcutaneous tissue. They tend to break down and ulcerate.

The lesion begins usually as a pea-sized deposit or infiltration, and grows slowly or rapidly; when fully developed it may be the size of a walnut, or even larger. The overlying skin becomes gradually reddish. At first firm, it is later soft and doughy. It may, even when well advanced, disappear by absorption, but usually tends to break down, terminating in a small or large, deep, punched-out ulcer.



Does the gummatous syphiloderm invariably appear as a rounded well-defined tumor?

No. Exceptionally, instead of a well-defined tumor, it may appear as a more or less diffused patch of infiltration, leading eventually to extensive superficial or deep ulceration.

From what formations is the gummatous syphiloderm to be differentiated?

From furuncle, abscess, and sebaceous, fatty and fibroid tumors.

Attention to the origin, course, and behavior of the lesion, together with a history, must all be considered in doubtful cases.



What is to be said in regard to the character and time of appearance of the cutaneous manifestations of hereditary syphilis?

In a great measure the cutaneous manifestations of hereditary syphilis are essentially the same as observed in acquired syphilis. They are usually noted to occur within the first three months of extra-uterine life. The macular, papular, and bullous eruptions are most common.

Describe these several cutaneous manifestations of hereditary syphilis.

The macular (erythematous) eruption begins as large or small, bright- or dark-red macules, later presenting a ham or cafe-au-lait appearance. At first they disappear upon pressure. The lesions are more or less numerous, usually become confluent, especially about the folds of the neck, about the genitalia and buttocks; in these regions resembling somewhat erythema intertrigo.

The papular eruption is observed in conjunction with the erythematous manifestation, or it occurs alone. The lesions are but slightly elevated, and seem to partake of the nature of both macules and papules. They are usually discrete, and rarely abundant; they may become decked with a film-like scale, and at the various points of junction of skin and mucous membrane, and in the folds, they become abraded and macerated, developing into moist papules.

The bullous eruption consists of variously-sized, more or less purulent blebs, and is usually met with at or immediately following birth. It is most abundant about the hands and feet. Macules and papules are often interspersed. There may be superficial or deep ulceration underlying the bullae.

What other symptoms in addition to the cutaneous manifestations are noted in hereditary syphilis in the newborn?

Mucous patches, and sometimes ulcers, in the mouth and throat; hoarseness, as shown by the peculiar cry, and indicating involvement of the larynx; snuffles, a sallow and dirty appearance of the skin, loss of flesh and often a shriveled or senile look.

What is the pathology of cutaneous syphilis?

The syphilitic deposit consists of round-cell infiltration. The mucous layer, the corium, and in the deep lesions the subcutaneous connective tissues also, are involved in the process. The infiltration disappears by absorption or ulceration. The factor now believed to be responsible for the disease and the pathological changes is the Spirochaeta pallida, discovered by Schaudinn and Hoffmann, and usually found in numbers in the tissues.

Give the prognosis of cutaneous syphilis.

In acquired syphilis, favorable; sooner or later, unless the whole system is so profoundly affected by the syphilitic poison that a fatal ending ensues, the cutaneous manifestations disappear, either spontaneously or as the result of treatment. The earlier eruptions will often pass away without medication, but treatment is of material aid in moderating their severity and hastening their disappearance, and is to be looked upon as essential; in the late syphilodermata treatment is indispensable. In the large pustular, the tubercular and gummatous lesions, considerable destruction of tissue may take place, and in consequence scarring result. Ill-health from any cause predisposes to a relapse, and also adds to the gravity of the case.

In hereditary infantile syphilis, the prognosis is always uncertain: the more distant from the time of birth the manifestations appear the more favorable usually is the outcome.

How is cutaneous syphilis to be treated?

Always with constitutional remedies; and in the graver eruptions, and especially in those more or less limited, with local applications also.

What constitutional and local remedies are commonly employed in cutaneous syphilis?

Constitutional Remedies.—Mercury and potassium iodide; tonics and nutrients are necessary in some cases.

Local Remedies.—Mercurial ointments, lotions and baths, and iodol in ointment or in (and also calomel) powder form.

Give the constitutional treatment of the earlier, or secondary, eruptions of syphilis.

In secondary or early eruptions mercury alone in almost every case; with tonics, if called for. If mercury is contraindicated (extremely rare), potassium iodide may be substituted.

How is mercury usually administered in the eruptions of secondary syphilis?

By the mouth, chiefly as the protiodide, calomel and blue mass, in dosage just short of mild physiological action; by inunction, in the form of blue ointment; by hypodermic injection, usually as corrosive sublimate solution. The method by fumigation, with calomel or bisulphuret, is now rarely employed.

The method by the mouth is the common one, and it is only in rare instances that any other method is necessary or advisable.

What local applications are usually advised in the eruptions of secondary syphilis?

If the eruption is extensive, and more especially in the pustular types, baths of corrosive sublimate ([dram ii-dram-iv] to Cong. xxx) may be used; and ointment of ammoniated mercury, twenty to sixty grains to the ounce, blue ointment, and the ten per cent. oleate of mercury alone or with an equal quantity of any ointment base.

The same applications or a dusting powder of calomel may also be used on moist papules.

How long is mercury to be actively continued in cases of early (secondary) syphilis?

Until one or two months after all manifestations (cutaneous or other) have disappeared, and then, as a general rule, continued, as a small daily dose (about one-quarter to one-third of that prescribed during the active treatment) for a period of two or three months; then another cycle of the active dosage for a period of four to six weeks; then a resumption of the smaller daily dose for another two or three months; and so on, for a period of at least two years.

(Almost all authorities are agreed as to the importance of prolonged treatment, but differ somewhat on the question of intermittent or uninterrupted administration.)

Give the constitutional treatment of the late, or localized, syphilodermata.

Mercury always, usually in small or moderate dosage, as the biniodide or corrosive chloride, and potassium iodide; the latter in dose varying from two grains to two drachms or more, t.d., depending upon its action and the urgency of the case.

How long is constitutional treatment to be continued in cases of the late syphilodermata?

Actively for several weeks after the disappearance of all symptoms, and then (especially the mercury) continued in smaller dosage (about one-third) for several months longer.

What applications are usually advised in the late, or localized, syphilodermata?

Ointment of ammoniated mercury, twenty to sixty grains to the ounce; oleate of mercury, five to ten per cent. strength; mercurial plaster, full strength or weakened with lard or petrolatum; a two to twenty per cent. ointment of iodol; resorcin, twenty to sixty grains to the ounce of ointment base; and lotions of corrosive sublimate, one-half to three grains to the ounce.

The following is valuable in offensive and obstinate ulcerations:—

[Rx] Hydrarg. chlorid. corros., ........... gr. iv-gr. viij Ac. carbolici, ....................... gr. x-xx Alcoholis, ........................... f[dram]iv Glycerinae, ........................... f[dram]j Aquae, ............ q.s. ad ........... [Oz]iv. M.

Ointments are to be rubbed in or applied as a plaster; lotions, employed chiefly in ulcers and ulcerations, are to be thoroughly dabbed on, and usually supplemented by the application of an ointment. Iodol may also be applied to ulcers as a dusting-powder, usually mixed with one to several parts of zinc oxide or boric acid.

Give the treatment of hereditary infantile syphilis.

It is essentially the same (but much smaller dosage) as employed in acquired syphilis. Attention to proper feeding and hygiene is of first importance.

Mercury may be given by the mouth, as mercury with chalk (gr. ss-gr. ij, t.d.); as calomel (gr. 1/20-gr. 1/6, t.d.); and as a solution of corrosive sublimate (gr. ss-[Oz]vj, [dram]j, t.d.). If mercury is not well borne by the stomach, it may be administered by inunction; for this purpose, blue ointment is mixed with one or two parts of lard and spread (about a drachm) upon an abdominal bandage and applied, being renewed daily. Treatment by means of baths (gr. x-xxx to the bath) of corrosive sublimate is, at times, a serviceable method.

Potassium iodide, if exceptionally deemed preferable, may be given in the dose of a fractional part of a grain to two or three grains three times daily.

What local measures are to be advised in cutaneous syphilis of the newborn?

If demanded, applications similar to those employed in eruptions of acquired syphilis, but not more than one-third to one-half the strength.



Lepra. (Synonyms: Leprosy; Elephantiasis Graecorum.)

What do you understand by leprosy?

Lepra, or leprosy, is an endemic, chronic, malignant constitutional disease, characterized by alterations in the cutaneous, nerve, and bone structures; varying in its morbid manifestations according to whether the skin, nerves or other tissues are predominantly involved.

What is the nature of the premonitory symptoms of leprosy?

In some instances the active manifestations appear without premonition, but in the majority of cases symptoms, slight or severe in character, pointing toward profound constitutional disturbance, such as mental depression, malaise, chills, febrile attacks, digestive derangements and bone pains, are noticed for weeks, months, or several years preceding the outbreak.

What several varieties of leprosy are observed?

Two definite forms are usually described—the tubercular and the anaesthetic. A sharp division-line cannot, however, always be drawn; not infrequently the manifestations are of a mixed type, or one form may pass into or gradually present symptoms of the other.



Describe the symptoms of tubercular leprosy.

The formation of tubercles and tubercular masses of infiltration, usually of a yellowish-brown color, with subsequent ulceration, constitute the important cutaneous symptoms. Along with, or preceding these characteristic lesions, blebs and more or less infiltrated, hyperaesthetic or anaesthetic, pinkish, reddish or pale-yellowish macules make their appearance from time to time; subsequently fading away or remaining permanently (lepra maculosa).

When well advanced, the tubercular or nodular masses give rise to great deformity; the face, a favorite locality, becomes more or less leonine in appearance (leontiasis). The tubercles persist almost indefinitely without material change, or undergo absorption or ulceration; this last takes place most commonly about the fingers and toes. The mucous membrane of the mouth, pharynx and other parts may also become involved.



Describe the symptoms of anaesthetic leprosy.

Following or along with precursory symptoms denoting general systemic disturbance, or independently of any prodromal indications, a hyperaesthetic condition, in localized areas or more or less general, is observed. Lancinating pains along the nerves and an irregular pemphigoid eruption are also commonly noted. There soon follows the special eruption, coming out from time to time, and consisting of several or more, usually non-elevated, well-defined, pale-yellowish patches, one or two inches in diameter. As a rule, they are at first neither hyperaesthetic nor anaesthetic, but may be the seat of slight burning or itching. They spread peripherally, and tend to clear in the centre. The patches eventually become markedly anaesthetic, and the overlying skin, and the skin on other parts as well, becomes atrophic and of a brownish or yellowish color. The subcutaneous tissues, muscle, hair and nails undergo atrophic or degenerative changes, and these changes are especially noted about the hands and feet. These parts become crooked, the bone tissues are involved, the phalanges dropping off or disappearing by disintegration or absorption (lepra mutilans). Sooner or later various paralytic symptoms, showing more active involvement of the nerve trunks, present themselves.

State the cause of leprosy.

Present knowledge points to a peculiar bacillus as the active factor, while climate, soil, heredity, food and habits exert a predisposing influence.

Is leprosy contagious?

The consensus of opinion points to the acceptance of the possible contagiousness of leprosy; probably by inoculation, but only under certain unknown favoring conditions.

What are the pathological changes?

The lesions consist essentially of a new growth, made up of numerous small, more or less aggregated round cells, beginning in the walls of the bloodvessels. In this way the tubercular masses and various other lesions are formed. As yet, positive involvement ot the central nervous system has not been shown, but some of the nerve trunks are found to be inflamed and swollen, with a tendency toward hardening.

What several diseases are to be eliminated in the diagnosis of leprosy?

Syphilis, morph[oe]a, vitiligo, lupus, and syringomyelia.

When well advanced, the aggregate symptoms of leprosy form a picture which can scarcely be confused with that of any other disease. In doubtful cases microscopical examinations of the involved tissues, for the bacilli, should be made.

State the prognosis of leprosy.

Unfavorable; a fatal termination is the rule, but may not be reached for a number of years. The tubercular form is the most grave, the mixed variety next, and the anaesthetic the least. Patients are not infrequently carried off by intercurrent disease. Proper management will often delay the fatal ending, and exceptionally, in the anaesthetic variety, stay the progress of the disease.

What is the treatment of leprosy?

Hygienic measures are important. Chaulmoogra oil and gurjun oil internally and externally are in some instances of service. Strychnia alone, or with either of these oils, is ofttimes beneficial. Ichthyol internally, and external applications of the same drug, and of resorcin, chrysarobin, and pyrogallic acid, have been extolled. Change of climate, especially to a region where the disease does not prevail, is often of great advantage.



Pellagra. (Synonym: Lombardian Leprosy.)

Describe pellagra.

Pellagra is a slow but usually progressive disease occurring chiefly in Italy, due, it is thought, to the continued ingestion of decomposed or fermented maize. It is characterized by cutaneous symptoms, at first upon exposed parts, of an erythematous, desquamative, vesicular and bullous character, and by general constitutional disturbance of a markedly neurotic type. A fatal ending, if the disease is at all severe or advanced, is to be expected.

Treatment is based upon general principles.



Epithelioma. (Synonyms: Skin Cancer; Epithelial Cancer; Carcinoma Epitheliale.)

What several varieties of epithelioma are met with?

Three—the superficial, the deep-seated, and the papillomatous.

Describe the clinical appearances and course of the superficial variety of epithelioma.

The superficial, or flat variety (rodent ulcer), begins, usually on the face, as a minute, firm, reddish or yellowish tubercle, as an aggregation of such, as a warty excrescence, or as a localized degenerative seborrh[oe]ic patch. The latter lesion (known also as keratosis senilis, old-age atrophic patches), consisting of a yellowish or yellowish-brown greasy or hardened scurfy spot or patch is quite frequently the starting-point of epithelial growths. Sooner or later, commonly after months or several years, the surface becomes slightly excoriated, and an insignificant, yellowish or brownish crust is formed. The excoriation gradually develops into superficial ulceration, and the diseased area becomes slowly larger and larger. New lesions may continue, from time to time, to appear about the edges and go through the same changes.



The ulcer has usually an uneven surface, secretes a thin, scanty, viscid fluid, which dries to a firm, adherent crust. It is usually defined against the healthy skin by a slightly elevated, hard, roll-like, waxy-looking border. In rare instances there is a disposition, at points, to spontaneous involution and scar formation; as a rule, however, the ulcerative action slowly progresses.

The general health is unimpaired, the neighboring lymphatic glands are not involved, and the local condition, beyond the disfigurement, gives rise to little trouble, unless, as occasionally happens, it passes into the more malignant, deep-seated variety.

Describe the clinical appearances and course of the deep-seated variety of epithelioma.

The deep-seated variety starts from the superficial form, or it begins as a tubercle or nodule in the skin. When typically developed, a reddish, shining tubercle or nodule, or area of infiltration, forms in the skin or subcutaneous tissue. In the course of weeks or months superficial or deep-seated ulceration takes place; the ulcer having hardened, and, as a rule, everted edges. The surface is reddish and granular, and secretes an ichorous discharge. The infiltration spreads, the ulcer enlarges both peripherally and in depth—muscle, cartilage and bone often becoming invaded. The neighboring lymphatic gland may become implicated, pains of a burning or neuralgic type are experienced, and from septicaemia, marasmus, or involvement of vital parts, death eventually ensues.

Describe the clinical appearances and course of the papillomatous variety of epithelioma.

The papillomatous type usually arises from the superficial or deep-seated variety, or it may begin as a papillary or warty growth. When fully developed, it presents an ulcerated, fissured and papillomatous surface, with an ichorous discharge which dries to crusts. It is slowly progressive, and sooner or later may develop a malignant tendency.

Upon what parts is epithelioma commonly observed?

About the face, especially the nose, eyelids and lips; and also about the genitalia. It may involve any part.

At what age is epithelioma usually noted?

It is essentially a disease of middle and late life, although it is exceptionally met with in the young.

What is the cause of epithelioma?

The etiology is obscure. It is not, as a rule, inherited. Any locally irritated tissue may be the starting point of the disease.

State the pathology.

The process consists in the proliferation of epithelial cells from the mucous layer; the cell-growth takes place downward, in the form of finger-like prolongations or columns, or it may spread out laterally, so as to form rounded masses, the centres of which usually undergo horny transformation, resulting in the formation of onion-like bodies, the so-called cell-nests or globes. The rapid cell-growth requires increased nutriment, and hence the bloodvessels become enlarged; moreover, the pressure of the cell-masses gives rise to irritation and inflammation, with corresponding serous and round-cell infiltration.

How would you distinguish epithelioma from syphilitic ulceration, wart, and lupus vulgaris?

From syphilis it is to be differentiated by the history, duration, character of the base and edges, its comparative slow progress, its usually slight, viscid discharge, often streaked with blood, and, if necessary, by the therapeutic test.

Wart or warty growths are to be differentiated by attention to their history and course. Long-continued observation may be necessary before a positive opinion is warrantable. The appearance of any tendency to crusting, to break down or ulcerate is significant of epitheliomatous degeneration.

In lupus vulgaris the deposits are peculiar and multiple, the ulcerations are of different character, the tendency to scar-formation constant; and, with few exceptions, it has, moreover, its beginning in childhood or early adult life.

What factors are to be considered in giving a prognosis in epithelioma?

The variety, extent, and rapidity of the process. The superficial form may exist for years, and give rise to no alarm; whereas the deeper-seated varieties are always to be viewed as serious, and are, indeed, often fatal. Involving the genitalia, its course is often strikingly rapid. Relapses, after removal, are not uncommon.

What is the special object in view in the treatment of epithelioma?

Thorough destruction or removal of the epitheliomatous tissue.

How is the destruction or removal of the epitheliomatous tissue effected?

By the use of such caustics as caustic potash, chloride-of-zinc paste, pyrogallic acid, arsenic, and the galvano-cautery; and by operative measures, such as excision and erasion with the dermal curette, and by the x-ray. (See treatment of lupus vulgaris.)

In small lesions the use of an arsenical paste is a most admirable method of treatment, although somewhat painful. The paste is made of one part powdered acacia and one to two parts arsenious acid; at the time of application sufficient water is added to make a paste. This is applied thickly, and a piece of lint superimposed. A good deal of pain and inflammatory swelling ensue; at the end of twenty-four hours the part is poulticed till the slough comes away; the ulcer is then treated as a simple ulcer, under which healing takes place. Occasionally a second application is found necessary.

Upon the whole, the best method in the average case is to curette thoroughly, and supplement with momentary cauterization, with caustic potash, or with several days' use of the pyrogallic acid ointment. During the healing process, short exposures to the Roentgen ray—about every three to five days—is good practice.

The degenerative changes in the beginning of scurfy, seborrh[oe]ic spots or patches seen in old people can frequently be lessened or wholly stopped by the daily application of an ointment containing 5 to 10 per cent. of sulphur and 2 to 5 per cent. of salicylic acid.

What can be said of the value of the x-ray in epithelioma?

The x-ray method is now much in vogue, and proves curative in many superficial cases, and of benefit in some of the deeper-seated varieties. In most cases it must be pushed to the point of producing a mild x-ray erythema; and in some instances benefit or cure only occurs after more active exposure, sufficient to cause an x-ray burn of the second degree. The method is not attended with much risk if properly used. The healthy parts should be protected by lead-foil. Exposure should be two to five times weekly, at a distance of three to eight inches, and from five to twenty minutes, employing a tube of medium vacuum. Unfortunately the method is usually slow. The radium treatment is essentially similar to that by the x-ray.

The much better plan, as already intimated, is to employ one of the several operative or caustic methods, and supplementing, while healing, with the x-ray.



Paget's Disease of the Nipple. (Synonyms: Malignant Papillary Dermatitis; Paget's Disease.)

What do you understand by Paget's disease of the nipple?

Paget's disease is a rare, inflammatory-looking, malignant disease of the nipple and areola in women, usually of advancing years, eventually terminating in cancerous involvement of the entire gland.

Describe the symptoms of Paget's disease.

The first symptoms, which usually last for months or years, are apparently eczematous, accompanied with more or less burning, itching and tingling. Gradually, the diseased area, which is sharply-defined, and feels like a thin layer of indurated tissue, presents a florid, intensely red, very finely-granular, raw surface, attended with a more or less copious viscid exudation. Sooner or later retraction and destruction of the nipple, followed by gradual scirrhous involvement of the whole breast, takes place.

What is the pathology of Paget's disease?

Although it was thought at one time to be a cancerous disease resulting from a continued eczematous inflammation of the parts, there is now but little doubt that it is of malignant nature from the earliest stages. The psorosperm-like bodies found, to the presence of which the disease has by some authorities been attributed (psorospermosis), are now known to be merely changed and degenerated epithelia. The morbid changes consist of an inflammation of the papillary region of the derma, leading to [oe]dema and vacuolation of the constituent cells of the epidermis, followed by their complete destruction in places and their abnormal proliferation in others (Fordyce).

State the diagnostic features of Paget's disease.

The age of the patient; the sharp limitation; the well-defined, indurated film of infiltration; the peculiar, red, raw, granulating appearance; and, later, the retraction of the nipple; and, finally, the involvement of the deeper parts.

What is the prognosis?

If the disease is recognized early, and properly treated, a cure may be anticipated; later the outlook is that of scirrhus of the breast.

What is the treatment of Paget's disease?

Thorough cauterization by means of caustic potash or the galvano-cautery; or, its extirpation by means of the curette or excision. After extirpation or cauterization, supplementary treatment by the x-ray is advisable as an additional measure of precaution against relapse.

Until the diagnosis is thoroughly established, soothing applications, such as are employed in acute eczema, are to be advised.



Sarcoma. (Synonyms: Sarcoma Cutis; Sarcoma of the Skin.)

Describe the several varieties of sarcoma.

Sarcoma of the skin is a more or less malignant new growth, of rapid or slow progress, characterized by the appearance of single or multiple, variously-shaped, discrete, non-pigmented or pigmented tubercles or tumors, of size varying from that of a shot to a hazelnut or larger. As a rule the growths are smooth, firm and elastic, somewhat painful upon pressure, and exhibit a tendency to ulcerate. The overlying skin is at first normal and somewhat movable, but as the growths approach the surface it becomes reddened and adherent; or, if the disease is of the pigmented variety, it acquires a bluish-black color. It is now generally believed that the most of the pigmented cases formerly thought to be of sarcomatous nature are really carcinomatous in character.

The multiple pigmented sarcoma (melano-sarcoma) appears first, usually on the soles and dorsal surfaces of the feet, and later on the hands. There is more or less diffuse thickening of the integument. The lesions themselves manifest a disposition to bleed.

State the prognosis and treatment of sarcoma.

The disease is always more or less malignant and, as a rule, sooner or later a fatal termination takes place. It is usually slow in its course.

Excision or extirpation, x-ray exposures, and the administration of arsenic in increasing dosage (preferably by hypodermic injection) now are generally considered the most promising in this usually hopeless malady.



Granuloma Fungoides.

Describe granuloma fungoides.

A rare form of disease, heretofore looked upon as sarcomatous, but now generally recognized as granuloma, and formerly described under the names mycosis fungoides, inflammatory fungoid neoplasm, and several others. It is characterized usually by symptoms of an eczematous, urticarial, and erysipelatous nature, and by the sudden or gradual appearance of pinkish or reddish, tubercular, nodular, lobulated, or furrowed tumors or flat infiltrations, which may disappear by involution or may be followed by ulceration; several or a larger number of the growths present a mushroom, papillomatous, or fungoid appearance, sometimes roughly resembling the cut part of a tomato. In most cases the tumor stage of the malady is not reached for two or more years; in exceptional instances, however, they appear in the first few months. The lesions, especially in their early stages, are, as a rule, accompanied with more or less burning and itching.

State the prognosis and treatment of granuloma fungoides.

The malady may last for several years or much longer, a fatal termination, with rare exceptions, sooner or later taking place. After the tumor stage is well established, the patient usually succumbs in from several months to one or two years.



Treatment consists of tonics, if indicated, and the administration of arsenic, preferably hypodermically, and Roentgen-ray exposures, along with the application of mild antiseptics, and operative interference when necessary or advisable.



CLASS VII.—NEUROSES.

Hyperaesthesia.

What is hyperaesthesia?

By hyperaesthesia is meant increased cutaneous sensibility. It is usually more or less localized, and is met with as a symptom in functional and organic nervous diseases.

Dermatalgia. (Synonyms: Neuralgia of the Skin; Rheumatism of the Skin; Dermalgia.)

What do you understand by dermatalgia?

By dermatalgia is meant a tender or painful condition of the skin unattended by structural change. It is commonly limited to a small area, and is usually symptomatic of functional or organic nervous disease. As an idiopathic affection it is looked upon as of a rheumatic origin.

Treatment depends upon the cause.

Anaesthesia.

What is anaesthesia?

Anaesthesia is a diminution, comparative or complete, of cutaneous sensibility. It is usually localized, and is met with in the course of certain nervous affections. It is also encountered in leprosy, morph[oe]a and like diseases.



Pruritus.

What do you understand by pruritus?

Pruritus is a functional disease of the skin, the sole symptom of which is itching, there being no structural change.

Describe the symptoms of pruritus.

The sole and essential symptom is itchiness, usually more or less paroxysmal, and worse at night. There are no primary structural lesions, but in severe and persistent cases the parts become so irritated by continued scratching that secondary lesions, such as papules and slight thickening and infiltration, may result. It is much more common in advanced life—pruritus senilis. In such cases, as well as in those cases in younger and middle-aged individuals in which the itchiness develops at the approach of cold weather and disappears upon the coming of the warm season (pruritus hiemalis), the pruritus is usually more or less generalized, although not infrequently in the latter the legs are specially involved.

In some individuals an attack of pruritus, of variable intensity, lasting from five to thirty minutes, comes on immediately after a bath (bath-pruritus). It is usually confined to the legs from the hips down.

Is pruritus always more or less generalized?

No; not infrequently the itching is limited to the genital region (pruritus scroti, pruritus vulvae) or to the anus (pruritus ani).

To what may pruritus often be ascribed?

To digestive and intestinal derangements, hepatic disorders, the uric acid diathesis, gestation, diabetes mellitus, and a depraved state of the nervous system.

Pruritus vulvae is at times due to irritating discharges, and pruritus ani occasionally to hemorrhoids and seat-worms.

Is there any difficulty in the diagnosis of pruritus?

No. The subjective symptom of itching without the presence of structural lesions is diagnostic. In those severe and persistent cases in which excoriations and papules have resulted from the scratching, the history of the case, together with its course, must be considered. Care should be taken not to confound it with pediculosis. In this latter the excoriations usually have a somewhat peculiar distribution, being most abundant on those parts of the body with which the clothing lies closely in contact. (See Pediculosis corporis.)

In pruritus of the genitocrural region the possibility of pediculi being the cause must be kept in mind; an examination of the parts for the parasite or for ova (attached to the hairs) would prevent error. (See Pediculosis pubis.)

What prognosis would you give in pruritus?

In the majority of cases the condition responds to proper treatment, but in others it proves rebellious. The prognosis depends, in fact, upon the removability of the cause. Temporary relief may always be given by external applications.

How would you treat pruritus?

With systemic remedies directed toward a removal or modification of the etiological factors, and, for the temporary relief of the itching, suitable antipruritic applications. In obscure cases, quinia, salophen, lithia salts, calcium chloride, belladonna, nux vomica, arsenic, pilocarpine, and general galvanization may be variously tried. Alkalies prove useful in many cases.

Exceptionally, the relief furnished by external treatment is more or less permanent.

Name the important antipruritic applications.

Alkaline baths; lotions of carbolic acid ([dram]j-[dram]iij to Oj), of resorcin ([dram]j-[dram]iv to Oj), of liquor carbonis detergens ([Oz]j-[Oz]iv to Oj), and liquor picis alkalinus ([dram]j-[dram]iv to Oj), used cautiously. One or several ounces of alcohol and one or two drachms of glycerin in each pint of these lotions will often be of advantage, as the following:—

[Rx] Ac. carbolici, ....................... [dram]j-[dram]iij Gylcerinae, ........................... f[dram]ij Alcoholis, ........................... f[oz]ij Aquae, ......... q.s. ad .............. Oj. M.

Various dusting-powders, alone or in conjunction with the lotions.

And in some cases, especially those in which the skin is unnaturally dry, ointments may be used, such as equal parts of lard, lanolin, and petrolatum, to the ounce of which may be added from five to thirty grains of carbolic acid, three to twenty grains of thymol, ten to thirty minims of chloroform, or two to ten grains of menthol.

What external applications are to be used in the local varieties of pruritus?

In pruritus ani and pruritus vulvae, in addition to the various applications above, a cocaine ointment, one to ten grains to the ounce, a strong solution of the same (gr. v-xx to [Oz]j), and an ointment containing ten to thirty minims of the oil of peppermint to the ounce; sponging with hot water, often affords temporary relief.

In pruritus vulvae, moreover, astringent applications and injections of zinc sulphate, alum, tannic or acetic acid, in the strength commonly employed for vaginal injections, are at times curative.

In bath-pruritus weak glycerine lotions, and an ointment containing a few grains of thymol and menthol to the ounce sometimes give moderate relief. Turkish baths are sometimes free from subsequent pruritus.



CLASS VIII.—PARASITIC AFFECTIONS.

Tinea Favosa. (Synonym: Favus.)

What is tinea favosa?

Tinea favosa, or favus, is a contagious vegetable-parasitic disease of the skin, characterized by pin-head to pea-sized, friable, umbilicated, cup-shaped yellow crusts, each usually perforated by a hair.

Upon what parts and at what age is favus observed?

It is usually met with upon the scalp, but it may occur upon any part of the integument. Occasionally the nails are invaded. It is seen at all ages, but is much more common in children.

Describe the symptoms of favus of the scalp.

The disease begins as a superficial inflammation or hyperaemic spot, more or less circumscribed, slightly scaly, and which is soon followed by the formation of yellowish points about the hair follicles, surrounding the hair shaft. These yellowish points or crusts increase in size, become usually as large as small peas, are cup-shaped, with the convex side pressing down upon the papillary layer, and the concave side raised several lines above the level of the skin; they are umbilicated, friable, sulphur-colored, and usually each cup or disc is perforated by a hair. Upon removal or detachment, the underlying surface is found to be somewhat excavated, reddened, atrophied and sometimes suppurating. As the disease progresses the crusting becomes more or less confluent, forming irregular masses of thick, yellowish, mortar-like crusts or accumulations, having a peculiar, characteristic odor—that of mice, or stale, damp straw. The hairs are involved early in the disease, become brittle, lustreless, break off and fall out. In some instances, especially near the border of the crusts, are seen pustules or suppurating points. Atrophy and more or less actual scarring are sooner or later noted.

Itching, variable as to degree, is usually present.

What is the course of favus of the scalp?

Persistent and slowly progressive.



What are the symptoms of favus when seated upon the general surface?

The symptoms are essentially similar to those upon the scalp, modified somewhat by the anatomical differences of the parts.

The nails, when affected, become yellowish, more or less thickened, brittle and opaque (tinea favosa unguium, onychomycosis favosa).

To what is favus due?

Solely to the invasion of the cutaneous structures, especially the epidermal portion, by the vegetable parasite, the achorion Schoenleinii. It is contagious. It is a somewhat rare disease in the native-born, being chiefly observed among the foreign poor. The nails are rarely affected primarily.

It is also met with in the lower animals, from which it is doubtless not infrequently communicated to man.

What are the diagnostic features of favus?

The yellow, and often cup-shaped, crusts, brittleness and loss of hair, atrophy, and the history.



How would you distinguish favus from eczema and ringworm?

From eczema by the condition of the affected hair, the atrophic and scar-like areas, the odor, and the history. From ringworm by the crusting and the atrophy. In this latter disease there is usually but slight scaliness, and rarely any scarring.

Finally, if necessary, a microscopic examination of the crusts may be made.

State the method of examination for fungus.

A portion of the crust is moistened with liquor potassae and examined with a power of three to five hundred diameters. The fungus, (achorion Schoenleinii), consisting of mycelium and spores, is luxuriant and is readily detected.

State the prognosis of favus.

Upon the scalp, favus is extremely chronic and rebellious to treatment, and a cure in six to twelve months may be considered satisfactory; in neglected cases permanent baldness, atrophy, and scarring sooner or later result. Although favus of the scalp persists into adult life, it becomes less active and, finally, as a rule, gradually disappears, leaving behind scarred or atrophic bald areas.

Upon the general surface it usually responds readily to treatment, excepting favus of the nails, which is always obstinate.

How is favus of the scalp treated?

Treatment is entirely local and consists in keeping the parts free from crusts, in epilation and applications of a parasiticide.

The crusts are removed by oily applications and soap-and-water washings. The hair on and around the diseased parts is to be kept closely cut, and, when practicable, depilation, or extraction of the affected hairs, is advised; this latter is, in most cases, essential to a cure. Remedial applications—the so-called parasiticides—are, as a rule, to be made twice daily. If an ointment is used, it is to be thoroughly rubbed in; if a lotion, it is to be dabbed on for several minutes and allowed to soak in.

Name the most important parasiticides.

Corrosive sublimate, one to four grains to an ounce of alcohol and water; carbolic acid, one part to three or more parts of glycerine; a ten per cent. oleate of mercury; ointments of ammoniated mercury, sulphur and tar; and sulphurous acid, pure or diluted. The following is valuable:—

[Rx] Sulphur, praecip., .................... [dram]ij Saponis viridis, Ol. cadini, ....... āā ......... [dram]j Adipis, .............................. [Oz]ss. M.

Chrysarobin is a valuable remedy, but must be used with caution; it may be employed as an ointment, five to ten per cent. strength, as a rubber plaster, or as a paint, a drachm to an ounce of gutta-percha solution. Formalin, weakened or full strength, has been extolled. Some observers have experimentally tried the effect of x-ray exposure with alleged good results, pushing the treatment to the point of producing depilation; if used great caution should be exercised.

How is favus upon the general surface to be treated?

In the same general manner as favus of the scalp, but the remedies employed should be somewhat weaker. In favus of the nail frequent and close paring of the affected part and the application, twice daily, of one of the milder parasiticides, will eventually lead to a good result.

Is constitutional treatment of any value in favus?

It is questionable, but in debilitated subjects tonics, especially cod-liver oil, may be prescribed with the hope of aiding the external applications.



Tinea Trichophytina. (Synonym: Ringworm.)

What is tinea trichophytina?

Tinea trichophytina, or ringworm, is a contagious, vegetable-parasitic disease due to the invasion of the cutaneous structures by the vegetable parasite, the trichophyton, or the microsporon Audouinii.

Do the clinical characters of ringworm vary according to the part affected?

Yes, often considerably; thus upon the scalp, upon the general surface, and upon the bearded region, the disease usually presents totally different appearances.

Describe the symptoms of ringworm as it occurs upon non-hairy portions of the body.

Ringworm of the general surface (tinea trichophytina corporis, tinea circinata) appears as one or more small, slightly-elevated, sharply-limited, somewhat scaly, hyperaemic spots, with, rarely, minute papules, vesico-papules, or vesicles, especially at the circumference. The patch spreads in a uniform manner peripherally, is slightly scaly, and tends to clear in the centre, assuming a ring-like appearance. When coming under observation, the patches are usually from one-half to one inch in diameter, the central portion pale or pale red, and the outer portion more or less elevated, hyperaemic and somewhat scaly. As commonly noted one, several or more patches are present. After reaching a certain size they may remain stationary, or in exceptional cases may tend to spontaneous disappearance. At times when close together, several may merge and form a large, irregular, gyrate patch.

Itching, usually slight, may or may not be present.

Exceptionally ringworm appears as a markedly inflammatory pustular circumscribed patch, formerly thought to be a distinct affection and described under the name of conglomerate pustular folliculitis. It consists of a flat carbuncular or kerion-like inflammation, somewhat elevated, and usually a dime to silver dollar in area. The most common seats are the back of the hands and the buttocks. The surface is cribriform, and a purulent secretion may be pressed out from follicular openings.



Describe the symptoms of ringworm when occurring about the thighs and scrotum.

In adults, more especially males, the inner portion of the upper part of the thighs and scrotum (tinea trichophytina cruris, so-called eczema marginatum) may be attacked, and here the affection, favored by heat and moisture, develops rapidly and may soon lose its ordinary clinical appearances, the inflammatory symptoms becoming especially prominent. The whole of this region may become involved, presenting all the symptoms of a true eczema; the border, however, is sharply defined, and usually one or more outlying patches of the ordinary clinical type of the disease may be seen.

Describe the symptoms of ringworm when involving the nails.

In ringworm of the nails (tinea trichophytina unguium) these structures become soft or brittle, yellowish, opaque and thickened the changes taking place mainly about the free borders. Ringworm on other parts usually coexists.

Describe the symptoms of ringworm as it occurs upon the scalp.

Ringworm of the scalp (tinea trichophytina capitis, tinea tonsurans) begins usually in the same manner as that upon the general surface, but, as a rule, much more insidiously. Sooner or later, however, the hair and follicles are invaded by the fungus, and in consequence the hair falls out or becomes brittle and breaks off. The follicles, except in long-standing cases, are slightly elevated and prominent, and the patch may have a puffed or goose-flesh appearance. In addition, there is slight scaliness.

Describe the appearances of a typical patch of ringworm of the scalp.

The patch is rounded, grayish, somewhat scaly, and slightly elevated; the follicles are somewhat prominent; there is more or less alopecia, with here and there broken, gnawed-off-looking hairs, some of which may be broken off just at the outlet of the follicles and more or less surrounded by a whitish or grayish-white dust. This type is produced by the small-spore fungus—microsporon.

Does ringworm of the scalp always present typical appearances?

Not invariably. In some cases the patch or patches may become almost completely bald, and in others a tendency to the formation of pustules, with more or less crust-formation, may be seen. The affection may also appear as small scattered spots or points.



The markedly inflammatory and pustular types are produced by the large-spore fungus—trichophyton.

What is tinea kerion?

Tinea kerion (kerion) is a markedly inflammatory type of ringworm of the scalp involving the deeper tissues, appearing as a more or less bald, rounded, inflammatory, [oe]dematous, boggy, honeycombed tumor, discharging from the follicular openings a mucoid secretion.

Does ringworm of the scalp ever occur in adults?

No. (Extremely rare exceptions.)



Describe the symptoms of ringworm of the bearded region.

Ringworm of the bearded region (tinea trichophytina barbae, tinea sycosis, parasitic sycosis, barber's itch) begins usually in the same manner as ringworm on other parts, as one or more rounded, slightly scaly, hyperaemic patches. In rare instances the disease may persist as such, with very little tendency to involve the hairs and follicles; but, as a rule, the hairy structures are soon invaded, many of the hairs breaking off, and many falling out. From involvement of the follicles, more or less subcutaneous swelling ensues, the parts assuming a distinctly lumpy and nodular condition. The skin is usually considerably reddened, often having a glossy appearance, and studded with few or numerous pustules. The nodules tend, ordinarily, to break down and discharge, at one or more of the follicular openings, a glairy, glutinous, purulent material, which may dry to thick, adherent crusts.



The disease may be limited to one patch, or a large area, even to the extent of the whole bearded region, becomes involved. The upper lip is rarely invaded. Ringworm of the bearded region is due to the trichophyton.



To what is ringworm due?

To the presence and growth in the cutaneous structures of a vegetable parasite. Although the disease is contagious, individuals differ considerably as to susceptibility. It is much more common in children than in those past the age of puberty, ringworm of the scalp being limited to the former (rare exceptions), and tinea sycosis being a disease of the male adult.

Until recently the ringworm was thought to be due to but one fungus—the trichophyton; it is now known that there are several forms of fungi, the main forms being the small-spored (microsporon Audouini) and the large-spored (trichophyton). Of this latter there are two main subvarieties—endothrix and ectothrix. The small-spored fungus is found as the cause in the majority of scalp cases; the endothrix also commonly invades the scalp integument. The ectothrix variety is usually derived directly or indirectly from domestic animals, and is chiefly responsible for body-ringworm, and for suppurative ringworm, whether upon the bearded region or elsewhere.

What is the pathology of ringworm?

On the general surface the fungus has its seat in the epidermis, especially in the corneous layer; upon the scalp and bearded region the epidermis, hair-shaft, root and follicle are invaded. The inflammatory action may vary considerably in different cases, and at different times in the same case.

The fungus consists of mycelium and spores. In the epidermic scrapings it is never to be found in abundance, and the mycelium predominates, while in affected hairs the spores and chains of spores are almost exclusively seen, and are usually present in great profusion.

How do you examine for the fungus?

The scrapings or hair should be moistened with liquor potassae, and examined with a power from three hundred diameters upward.

How is ringworm of the general surface to be distinguished from eczema, psoriasis and seborrh[oe]a?

By the growth and characters of the patch, the slight scaliness, the tendency to disappear in the centre, by the history, and, if necessary, by a microscopic examination of the scales.

How is ringworm of the scalp to be distinguished from alopecia areata, favus, eczema, seborrh[oe]a, and psoriasis?

By the peculiar clinical features of ringworm on this region—the slight scaliness, broken hair and hair stumps, with a certain amount of baldness—and in doubtful cases by a microscopical examination of the hairs.

In favus, although the same condition of the hair is noted, the yellow, cup-shaped crusts, and the presence of the atrophic areas in that disease are pathognomonic.

How is ringworm of the bearded region to be distinguished from eczema and sycosis?

By the peculiar lumpiness of the parts, the brittleness of the hair, more or less hair loss, and the history.

The superficial type of ringworm sycosis—those cases in which the disease remains a surface disease—is readily distinguished, as the symptoms are essentially the same as ringworm of non-hairy parts, except that some of the hairs in the areas may become invaded and break off or fall out.

In doubtful cases recourse may be had to microscopical examination.

What is the prognosis of ringworm of these several parts?

When upon the general surface, the disease usually responds rapidly to therapeutical applications; upon the scalp it is always a stubborn affection, and, as a rule, requires several months to a year of energetic treatment to effect a cure. In this latter region the disease will disappear spontaneously as the age of fifteen or sixteen is reached. Tinea sycosis yields in most instances in the course of several weeks or a few months.

Is ringworm of these several parts treated with the same remedies?

As a rule, yes; but the strength must be modified. The scalp will stand strong applications, as will likewise the bearded region; upon non-hairy portions the remedies should be used somewhat weaker. They should be applied twice daily; ointments, if used, being well rubbed in, and lotions thoroughly dabbed on.

How would you treat ringworm of the general surface?

By applications of the milder parasiticides, such as a ten to fifteen per cent. solution of sodium hyposulphite; carbolic acid, five to thirty grains to the ounce of water, or lard; a saturated solution of boric acid; ointments of tar, sulphur and mercury, official strength or weakened with lard; and tincture of iodine, pure or diluted.

When occurring upon the upper and inner part of the thighs (so-called eczema marginatum), the same remedies are to be employed, but usually stronger. Deserving of special mention is a lotion of corrosive sublimate, one to four grains to the ounce; or the same remedy, in the same proportion, may be used in tincture of myrrh or benzoin, and painted on the parts.

How would you treat ringworm of the scalp?

By occasional soap-and-hot-water washing; by extraction of the involved hairs, when practicable; by carbolic acid or boric acid lotions to the whole scalp, so as to limit, as much as possible, the spread of the disease; and by daily (or twice daily) applications to the patches and involved areas of a parasiticide. The following are the most valuable: the oleate of mercury, with lard or lanolin, in varying strength, from ten to twenty per cent.; carbolic acid, with one to three or more parts of glycerine or oil; corrosive sublimate, in solution in alcohol and water, one to four grains to the ounce; sulphur ointment; and citrine ointment, with one or two parts of lard. Chrysarobin is a valuable remedy, but is to be employed with care; it may be prescribed as a rubber plaster, or in a solution of gutta-percha, or as an ointment, ten to fifteen per cent. strength. [beta]-naphthol in ointment form, five to fifteen per cent. strength, is also useful. An excellent application for beginning areas on the scalp is a solution of the red iodide of mercury in iodine tincture, one to three grains to an ounce.

A compound ointment, containing several of the active remedies named, is convenient for dispensary practice, such as:—

[Rx] [beta]-naphthol, ................. [dram]ss-[dram]j Ol. cadini, ......................... [dram]j Ungt. sulphuris, ............ q.s. ad [Oz]j. M.

In that form known as tinea kerion mild applications are demanded at first; later the same treatment as in the ordinary type.

How is ringworm of the bearded region to be treated?

On the same general plan and with the same remedies (excepting chrysarobin) as in ringworm of the scalp. Depilation is to be practised as an essential part of the treatment. Special mention may be made of an ointment of oleate of mercury, sulphur ointment, a lotion of sodium hyposulphite ([dram]j-[Oz]j), and a lotion of corrosive sublimate (gr. j-iv to [Oz]j). The x-ray has been used in ringworm of this region with alleged success, pushing it to the production of a mild erythema and depilation. The above methods are, however, usually successful, and are without risk of damage.

How is the certainty of an apparent cure in ringworm of the scalp or bearded region to be determined?

By the continued absence of roughness and of broken hairs and stumps, and by microscopical examination of the new-growing hairs from time to time for several weeks after discontinuance of treatment.

Cure of ringworm of the general surface is usually self-evident.

Is systemic treatment of aid in the cure of ringworm?

It is doubtful, although in children in a depraved state of health the disease is often noted to be especially stubborn, and in such cod-liver oil and similar remedies may at times prove of benefit.



Tinea Imbricata. (Synonym: Tokelau Ringworm.)

What is tinea imbricata?

A vegetable parasitic disease of moist tropical countries, characterized by the formation of patches composed of concentrically arranged, imbricated, scaly rings. It may begin at one or several points as a brownish, slightly raised spot, spreading peripherally; the renewed epidermis of the central part of the patch goes again through the same process; the result is a small or large area of concentrically arranged, imbricated, slightly scaly eruption. Several such areas fusing together may cover a large part of the surface, the ring-like arrangement being sometimes more or less completely lost. The malady is chronic. There may be a variable degree of itching. The cause of the disease, which is of a contagious nature, is a vegetable parasite closely similar to the trichophyton. The treatment is by the parasiticides, being essentially the same, in fact, as ringworm.



Tinea Versicolor. (Synonyms: Pityriasis Versicolor; Chromophytosis.)

What is tinea versicolor?

Tinea versicolor is a vegetable-parasitic disease of the skin, characterized by variously-sized and shaped, slightly scaly, macular patches of a yellowish-fawn color, and occurring for the most part upon the upper portion of the trunk.

Describe the symptoms of tinea versicolor.

The disease begins as one or more yellowish macular points; these, in the course of weeks or months, gradually extend, and, together with other patches that arise, may form a more or less continuous sheet of eruption. There is slight scaliness, always insignificant and furfuraceous in character, and at times, except upon close inspection, scarcely perceptible. The color of the patches is pale or brownish-yellow; in rare instances, in those of delicate skin, there may be more or less hyperaemia, and in consequence the eruption is of a reddish tinge. The number of patches varies; there may be but a few, or, on the other hand, a profusion. Slight itching, especially when the parts are warm, is usually present.

Does the eruption of tinea versicolor show predilection for any special region?

Yes; the upper part of the trunk, especially anteriorly, is the usual seat of the eruption, but in exceptional instances the neck, axillae, the arms, the whole trunk, the genitocrural region and poplitea, and in rare cases even the lower part of the face, may become invaded.

What course does tinea versicolor pursue?

Persistent, but somewhat variable; as a rule, however, slowly progressive and lasting for years.

To what is tinea versicolor due?

To a vegetable fungus—the microsporon furfur.

The affection is tolerably common, and occurs in all parts of the world. With rare exceptions, it is a disease of adults, and while looked upon as contagious, must be so to an extremely slight degree.



What is the pathology?

The fungus, consisting of mycelium and spores, the latter showing a marked tendency to aggregate, invades the superficial portion of the epidermis.

Is tinea versicolor readily diagnosticated?

Yes; if the color, peculiar characters and distribution of the eruption are kept in mind.

It is not to be confounded with vitiligo, chloasma, or the macular syphiloderm. If in doubt, have recourse to the microscope.

State the method of examination for fungus.

The scrapings are taken from a patch, moistened with liquor potassae, and examined with a power of three to five hundred diameters.

State the prognosis of tinea versicolor.

With proper management the disease is readily curable. Relapses are not uncommon.



What is the treatment of tinea versicolor?

It consists in daily washing with soap and hot water (and in obstinate cases with sapo viridis instead of the ordinary soap) and application of a lotion of—sulphite or hyposulphite of sodium, a drachm to the ounce; sulphurous acid, pure or diluted; carbolic acid, or resorcin, ten to twenty grains to the ounce of water and alcohol; or corrosive sublimate, one to three grains to the ounce of water. Sulphur and ammoniated-mercury ointments are also serviceable. The following used alone, simply as a soap, or in conjunction with a lotion, is often of special value:—

[Rx] Sulphur, praecip., .................... [dram]iv Saponis viridis, ..................... [dram]xii. M.

After the disease is apparently cured, an occasional remedial application should be made for several months, in order to guard against the possibility of a relapse.



Erythrasma.

Describe erythrasma.

Erythrasma is an extremely rare disease, due to the presence and growth in the epidermic structures of the vegetable parasite—the microsporon minutissimum. It is characterized by small and large, slightly furfuraceous, reddish-yellow or reddish-brown patches, occurring usually on warm and moist parts, such as the axillary, inguinal, anal and genitocrural regions. It is slowly progressive and persistent, but is without disturbing symptoms other than occasional slight itching.



Treatment, which is rapidly effective, is the same as that employed in tinea versicolor.



Dhobie Itch.

Dhobie itch is a name used in certain tropical countries to designate a somewhat peculiar itching eruption of the genitocrural and axillary regions, and by some also a similar eruption about the feet. It consists of a dermatitis of variable degree, usually with a festooned, irregular border, with considerable itching. It is believed that such cases are variously due to the trichophyton of ringworm, to the microsporon furfur of tinea versicolor, to the microsporon minutissimus of erythrasma, and to other parasites.



Actinomycosis.

Describe actinomycosis.

Actinomycosis of the skin is an affection due to the ray fungus, and characterized by a sluggish, red, nodular, or lumpy infiltration, usually with a tendency to break down and form sinuses. The affection may involve almost any part, but its most common site is about the jaw, neck, and face. As a rule, the first evidence is a hard subcutaneous swelling or infiltration, which may increase slightly or considerably. The overlying skin gradually becomes of a sluggish or dark-red color. Softening ensues, and the diseased area breaks down at one or more points, from which there oozes a discharge of a sero-purulent, purulent, or sanguinolent character. In this discharge can be usually noted minute, friable, yellowish or yellowish-gray bodies representing conglomerate collections of the causative fungus.

The course of the malady is commonly slow and insidious. Unless systemic pyemic infection occurs or the fungus elements find their way to the deeper organs or structures the general health remains apparently undisturbed.

What is the treatment?

The administration of moderate to large doses of potassium iodide, conjointly with curetting or excision of the diseased mass. Local applications of iodine solution can also be tried.



Blastomycetic Dermatitis.

What do you understand by blastomycetic dermatitis?

Blastomycetic dermatitis is a rare disease beginning usually as a small papule or nodule, enlarging slowly, breaking down and developing into a verrucous or papillomatous-looking area, similar in appearance to tuberculosis cutis verrucosa. A muco-purulent or purulent secretion can visually be pressed out from between the papillomatous elevations. It may also present the appearance of a serpiginous lupus vulgaris or syphiloderm. As a rule it is slow in its course. Furuncular or abscess-like formations may develop, usually from secondary infection. The disease is due to the invasion of the cutaneous tissues by the blastomyces.



Treatment consists in administration of moderate to large doses of potassium iodide, and in the employment of antiseptic and parasiticide applications; usually, however, radical treatment, such as employed in lupus vulgaris, may be necessary.



Scabies. (Synonym: The Itch.)

What is scabies?

Scabies, or itch, is a contagious animal-parasitic disease characterized by a multiform eruption of a somewhat peculiar distribution, attended by intense itching.

Describe the symptoms of scabies.

The penetration and presence of the parasites within the cutaneous structures besides often giving rise to several or more complete or imperfectly formed burrows, excite varying degrees of irritation, and in consequence the formation of vesicles, papules and pustules, accompanied with more or less intense itching. Secondarily, crusting, and at times a mild or severe grade of dermatitis, may be brought about. The parasite seeks preferably tender and protected situations, as between the fingers, on the wrists, especially the flexor surface, in the folds of the axilla, on the abdomen, about the anal fissure, about the genitalia, and in females also about the nipples, and hence the eruption is most abundant about these regions. The inside of the thighs and the feet are also attacked, as, indeed, may be almost every portion of the body. The scalp and face are not involved; exceptionally, however, these parts are invaded in infants and young children.

Is the grade of cutaneous irritation the same in all cases of scabies?

No; in those of great cutaneous irritability, especially in children, the skin being more tender, the type of the eruption is usually much more inflammatory. In those predisposed a true eczema may arise, and then, in addition to the characteristic lesions of scabies, eczematous symptoms are superadded; in long-persistent cases, indeed, the burrows and other consequent lesions may be more or less completely masked by the eczematous inflammation, and the true nature of the disease be greatly obscured.

What do you mean by burrows?

Burrows, or cuniculi, are tortuous, straight or zigzag, dotted, slightly elevated, dark-gray or blackish thread-like linear formations, varying in length from an eighth to a half an inch.



How is a burrow formed?

By the impregnated female parasite, which penetrates the epidermis obliquely to the rete, depositing as it goes along ten or fifteen ova, forming a minute passage or burrow.

Upon what parts are burrows most commonly to be found?

In the interdigital spaces, on the flexor surface of the wrists, about the mammae in the female, and on the shaft of the penis in the male.

Are burrows usually present in numbers?

No. Several may be found in a single case, but they are rarely numerous, as the irritation caused by the penetration of the parasites leads either to violent scratching and their destruction, or gives rise to the formation of vesicles and pustules, and consequently their formation is prevented.

What course does scabies pursue?

Chronic and progressive, showing no tendency to spontaneous disappearance.

To what is scabies due?

To the invasion of the cutaneous structures by an animal parasite, the sarcoptes scabiei (acarus scabiei). The male mite is never found in the skin and apparently takes no direct part in the production of the symptoms.



The disease is contagious to a marked degree, and is most commonly contracted by sleeping with those affected, or by occupying a bed in which an affected person has slept. It occurs, for obvious reasons, usually among the poor, although it is now quite frequently met with among the better classes.

State the diagnostic features of scabies.

The burrows, the peculiar distribution and the multiformity of the eruption, the progressive development, and usually a history of contagion.

How do vesicular and pustular eczema differ from scabies?

Eczema is usually limited in extent, or irregularly distributed, is distinctly patchy, with often the formation of large diffused areas; it is variable in its clinical behavior, better and worse from time to time, and differs, moreover, in the absence of burrows and of a history of contagion.

How does pediculosis corporis differ from scabies?

In the distribution of the eruption. The pediculi live in the clothing and go to the skin solely for nourishment, and hence the eruption in that condition is upon covered parts, especially those parts with which the clothing lies closely in contact, as around the neck, across the upper part of the back, about the waist and down the outside of the thighs; the hands are free.

State the prognosis of scabies.

It is favorable. The disease is readily cured, and, as soon as the parasites and their ova are destroyed, the itching and the secondary symptoms, as a rule, rapidly disappear.

How is scabies treated?

Treatment is entirely external, and consists of a preliminary soap-and-hot-water bath, an application, twice daily for three days, of a remedy destructive to the parasites and ova, and finally another bath.

Inquiry as to others of the family should be made, and, if affected, treated at the same time. The wearing apparel should be looked after—boiled, baked, or sulphur-fumigated.

What remedial applications are employed in scabies?

Sulphur, balsam of Peru, styrax, and [beta]-naphthol, singly or severally combined. In children, or in those of sensitive skin, the following:—

[Rx] Sulphur. praecip., .................... [dram]iv Balsam. Peruv., ...................... [dram]ij Adipis, Petrolati, ......... āā ........ [Oz]iss. M.

And in adults, or those of non-irritable skin:—

[Rx] Sulphur, praecip., .................... [Oz]j Balsam. Peruv., ...................... [Oz]ss [beta]-Naphthol, ..................... [dram]ij Adipis, Petrolati, ... āā ... q.s. ad .. [Oz]iv. M.

Styrax is a remedy of value and is commonly employed as an ointment in the strength of one part to two or three parts of lard.

Is one such course of treatment sufficient to bring about a cure?

Yes, in ordinary cases, if the applications have been carefully and thoroughly made; exceptionally, however, some parasites and ova escape destruction, and consequently itching will again begin to show itself at the end of a week or ten days, and a repetition of the treatment become necessary.

Does the secondary dermatitis which is always present in severe cases require treatment?

Only when it is unusually persistent or severe; in such cases the various soothing applications, lotions or ointments employed in acute eczema are to be prescribed.

Is a dermatitis due to too active and prolonged treatment ever mistaken for persistence of the scabies?

Yes.



Pediculosis. (Synonyms: Phtheiriasis; Lousiness.)

Define pediculosis.

Pediculosis is a term applied to that condition of local or general cutaneous irritation due to the presence of the animal parasite, the pediculus, or louse.

Name the several varieties met with.

Three varieties are presented, named according to the parts involved, pediculosis capitis, pediculosis corporis, and pediculosis pubis; the parasite in each being a distinct species of pediculus.



Pediculosis Capitis.

Describe the symptoms of pediculosis capitis.

Pediculosis capitis (pediculosis capillitii), due to the presence of the pediculus capitis, occurs much more frequently in children than in adults. It is characterized by marked itching, and the formation of various inflammatory lesions, such as papules, pustules and excoriations—resulting from the irritation produced by the parasites and from the scratching to which the intense pruritus gives rise. In fact, an eczematous eruption of the pustular type soon results, attended with more or less crust formation. In consequence of the cutaneous irritation the neighboring lymphatic glands may become inflamed and swollen, and in rare cases suppurate. The occipital region is the part which is usually most profusely infested, more especially in young girls and women. In those of delicate skin, especially in children, scattered papules, vesico-papules, pustules, and excoriations may often be seen upon the forehead and neck. In some instances, however, especially in boys, there may be many pediculi present, with but little cutaneous disturbance, the itching being the sole symptom.



In addition to the pediculi, which, as a rule, may be readily found, their ova, or nits, are always to be seen upon the shaft of the hairs, quite firmly attached.

Describe the appearance of the ova.

They are dirty-white or grayish looking, minute, pear-shaped bodies, visible to the naked eye, and fastened upon the shaft of the hairs with the small end toward the root.



Is there any difficulty in the diagnosis of pediculosis capitis?

No. The diagnosis is readily made, as the pediculi are usually to be found without difficulty, and even when they exist in small numbers and are not readily discovered, the presence of the ova will indicate the nature of the affection.

Pustular eruptions upon the scalp, especially posteriorly, should always arouse a suspicion of pediculosis. The possibility of the pediculosis being secondary to eczema must not be forgotten.