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+The Project Gutenberg eBook, Essentials of Diseases of the Skin, by Henry
+Weightman Stelwagon
+
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+
+
+
+Title: Essentials of Diseases of the Skin
+       Including the Syphilodermata Arranged in the Form of Questions and Answers Prepared Especially for Students of Medicine
+
+
+Author: Henry Weightman Stelwagon
+
+
+
+Release Date: July 1, 2008  [eBook #25944]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+
+***START OF THE PROJECT GUTENBERG EBOOK ESSENTIALS OF DISEASES OF THE
+SKIN***
+
+
+E-text prepared by Kevin Handy, Ronnie Sahlberg, cbott, John Hagerson, and
+the Project Gutenberg Online Distributed Proofreading Team
+(https://www.pgdp.net)
+
+
+
+Note: Project Gutenberg also has an HTML version of this
+      file which includes the original illustrations.
+      See 25944-h.htm or 25944-h.zip:
+      (https://www.gutenberg.org/dirs/2/5/9/4/25944/25944-h/25944-h.htm)
+      or
+      (https://www.gutenberg.org/dirs/2/5/9/4/25944/25944-h.zip)
+
+
+Transcriber's note:
+
+      This book contains many characters not displayed by ASCII or
+      iso-8859-1 (Latin1) character sets. In the text file these
+      characters have been denoted by enclosing explanatory text
+      within square brackets. Two of the more commonly occurring
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+      and a-macron (denoted by [=a]. Some, but not all, of the
+      other such characters display properly in the html version.
+
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+      original (#bold face#).
+
+      A detailed transcriber's note is at the end of the e-text.
+
+
+
+
+
+ESSENTIALS OF DISEASES OF THE SKIN
+
+Including the Syphilodermata
+
+Arranged in the Form of Questions and Answers Prepared Especially
+for Students of Medicine
+
+by
+
+HENRY W. STELWAGON, M.D., PH.D.
+
+        *       *       *       *       *
+
+Get the Best                                           The New Standard
+
+
+                              DORLAND'S
+
+                        AMERICAN ILLUSTRATED
+
+                         MEDICAL DICTIONARY
+
+
+                   For Students and Practitioners
+
+
+A New and Complete Dictionary of the terms used in Medicine, Surgery,
+Dentistry, Pharmacy, Chemistry, and kindred branches; together with new
+and elaborate Tables of Arteries, Muscles, Nerves, Veins, etc.; of
+Bacilli, Bacteria, Micrococci, etc.; Eponymic Tables of Diseases,
+Operations, Signs and Symptoms, Stains, Tests, Methods of Treatment,
+etc. By W.A.N. Dorland, M.D., Editor of the American Pocket Medical
+Dictionary. Large octavo, nearly 800 pages, bound in full flexible
+leather. Price, $4.50 net; with thumb index, $5.00 net.
+
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+bound in full flexible leather, and is just the kind of a book that a
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+a special feature of #the newer words#, and defines hundreds of
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+hundred of great practical value, including new tables of Tests, Stains
+and Staining Methods. A new feature is the inclusion of numerous
+handsome illustrations, many of them in colors, drawn and engraved
+specially for this book.
+
+     "I must acknowledge my astonishment at seeing how much he has
+     condensed within relatively small space. I find nothing to
+     criticise, very much to commend, and was interested in finding some
+     of the new words which are not in other recent
+     dictionaries."--Roswell Park, _Professor of Principles and Practice
+     of Surgery and Clinical Surgery, University of Buffalo_.
+
+     "Dr. Dorland's Dictionary is admirable. It is so well gotten up and
+     of such convenient size. No errors have been found in my use of
+     it."--Howard A. Kelly, _Professor of Gynecology, Johns Hopkins
+     University, Baltimore_.
+
+               W. B. SAUNDERS COMPANY, 925 Walnut St., Phila.
+                London: 9, Henrietta Street, Covent Garden
+
+
+Fifth Edition, Just Ready                      With Complete Vocabulary
+
+
+                                 THE
+
+                           AMERICAN POCKET
+
+                         MEDICAL DICTIONARY
+
+
+                              EDITED BY
+
+                    W.A. NEWMAN DORLAND, A.M., M.D.,
+
+    Assistant Demonstrator of Obstetrics, University of Pennsylvania.
+
+
+                        HUNDREDS OF NEW TERMS
+
+   Bound in Full Leather, Limp, with Gold Edges. Price, $1.00 net; with
+                    Patent Thumb Index, $1.25 net.
+
+
+The book is an #absolutely new one#. It is not a revision of any old work,
+but it has been written entirely anew and is constructed on lines that
+experience has shown to be the most practical for a work of this kind.
+It aims to be #complete#, and to that end contains practically all the
+terms of modern medicine. This makes an unusually large vocabulary.
+Besides the ordinary dictionary terms the book contains a wealth of
+#anatomical and other tables#. This matter is of particular value to
+students for memorizing in preparation for examination.
+
+
+     "I am struck at once with admiration at the compact size and
+     attractive exterior. I can recommend it to our students without
+     reserve."--James W. Holland, M.D., _of Jefferson Medical College_.
+
+     "This is a handy pocket dictionary, which is so full and complete
+     that it puts to shame some of the more pretentious
+     volumes."--_Journal of the American Medical Association._
+
+     "We have consulted it for the meaning of many new and rare terms,
+     and have not met with a disappointment. The definitions are
+     exquisitely clear and concise. We have never found so much
+     information in so small a space."--_Dublin Journal of Medical
+     Science._
+
+     "This is a handy little volume that, upon examination, seems fairly
+     to fulfil the promise of its title, and to contain a vast amount of
+     information in a very small space.... It is somewhat surprising
+     that it contains so many of the rarer terms used in
+     medicine."--_Bulletin Johns Hopkins Hospital_, Baltimore.
+
+
+
+              W. B. SAUNDERS COMPANY, 925 Walnut St., Phila.
+               London: 9, Henrietta Street, Covent Garden
+
+        *       *       *       *       *
+
+
+ESSENTIALS OF DISEASES OF THE SKIN.
+
+   Since the issue of the first volume of the
+   #Saunders Question-Compends#,
+
+   OVER 290,000 COPIES
+
+   of these unrivalled publications have been sold.
+   This enormous sale is indisputable evidence of
+   the value of these self-helps to students and
+   physicians.
+
+
+Saunders' Question-Compends. No. 11.
+
+ESSENTIALS OF DISEASES OF THE SKIN
+
+Including the Syphilodermata
+
+Arranged in the Form of Questions and Answers Prepared Especially
+for Students of Medicine
+
+by
+
+HENRY W. STELWAGON, M.D., PH.D.
+
+Professor of Dermatology in the Jefferson Medical College, Philadelphia;
+Dermatologist to the Howard and Philadelphia Hospitals, etc.
+
+Seventh Edition, Thoroughly Revised
+
+Illustrated
+
+
+
+
+
+
+
+Philadelphia and London
+W. B. Saunders Company
+1909
+
+Set up, electrotyped, printed, 1890. Reprinted July, 1891.
+Revised, reprinted, June, 1894. Reprinted March, 1897.
+Revised, reprinted, August, 1899. Reprinted
+September, 1901, May, 1902, September, 1903.
+Revised, reprinted January, 1905.
+Reprinted March, 1906. Revised,
+reprinted March, 1909.
+
+Printed in America
+
+Press of
+W. B. Saunders Company
+Philadelphia
+
+
+
+
+PREFACE TO SEVENTH EDITION.
+
+
+In the present--seventh--edition the subject matter, especially as
+regards the practical part, has been gone over carefully and the
+necessary corrections and additions made. Nineteen new illustrations
+have been added, a few of the old ones being eliminated. It is hoped
+that the continued demand for this compend means a widening interest in
+the study of diseases of the skin, sufficiently keen as to lead to the
+desire for a still greater knowledge.
+
+                                                           H.W.S.
+
+
+PREFACE TO FIRST EDITION.
+
+
+Much of the present volume is, in a measure, the outcome of a thorough
+revision, remodelling and simplification of the various articles
+contributed by the author to Pepper's System of Medicine, Buck's
+Reference Handbook of the Medical Sciences, and Keating's Cyclopædia of
+the Diseases of Children. Moreover, in the endeavor to present the
+subject as tersely and briefly as compatible with clear understanding,
+the several standard treatises on diseases of the skin by Tilbury Fox,
+Duhring, Hyde, Robinson, Anderson, and Crocker, have been freely
+consulted, that of the last-named author suggesting the pictorial
+presentation of the "Anatomy of the Skin." The space allotted to each
+disease has been based upon relative importance. As to treatment, the
+best and approved methods only--those which are founded upon the
+aggregate experience of dermatologists--are referred to.
+
+For general information a statistical table from the Transactions of the
+American Dermatological Association is appended.
+
+                                                           H.W.S.
+
+
+CONTENTS.
+
+
+                                               PAGE
+ANATOMY OF THE SKIN                              17
+    The Epidermis                                18
+    The Blood-vessels                            19
+    The Nervous and Vascular Papillæ             20
+    The Hair and Hair-follicle                   21
+
+SYMPTOMATOLOGY                                   22
+    Primary Lesions                              22
+    Secondary Lesions                            23
+    Distribution and Configuration               24
+  Relative Frequency                             26
+  Contagiousness                                 27
+  Rapidity of Cure                               27
+  Ointment Bases                                 27
+
+CLASS I.--DISORDERS OF THE GLANDS                28
+    Hyperidrosis                                 28
+    Sudamen                                      30
+    Hydrocystoma                                 31
+    Anidrosis                                    31
+    Bromidrosis                                  32
+    Chromidrosis                                 32
+    Uridrosis                                    33
+    Phosphoridrosis                              33
+    Seborrh[oe]a (Eczema Seborrhoicum)           33
+    Comedo                                       38
+    Milium                                       42
+    Steatoma                                     43
+
+CLASS II.--INFLAMMATIONS                         44
+  Erythema Simplex                               44
+  Erythema Intertrigo                            45
+  Erythema Multiforme                            46
+  Erythema Nodosum                               50
+  Erythema Induratum                             51
+  Urticaria                                      52
+  Urticaria Pigmentosa                           56
+  Dermatitis                                     58
+  Dermatitis Medicamentosa                       60
+  X-Ray Dermatitis                               63
+  Dermatitis Factitia                            64
+  Dermatitis Gangrænosa                          65
+  Erysipelas                                     66
+  Phlegmona Diffusa                              68
+  Furunculus                                     68
+  Carbunculus                                    70
+  Pustula Maligna                                72
+  Post-mortem Pustule                            73
+  Framb[oe]sia                                   73
+  Verruga Peruana                                73
+  Equinia                                        74
+  Miliaria                                       74
+  Pompholyx                                      76
+  Herpes Simplex                                 78
+  Hydroa Vacciniforme                            80
+  Epidermolysis Bullosa                          80
+  Dermatitis Repens                              81
+  Herpes Zoster                                  81
+  Dermatitis Herpetiformis                       83
+  Psoriasis                                      86
+  Pityriasis Rosea                               95
+  Dermatitis Exfoliativa                         96
+  Lichen Planus                                  98
+  Pityriasis Rubra Pilaris                       99
+  Lichen Scrofulosus                            100
+  Eczema                                        100
+  Prurigo                                       118
+  Acne                                          119
+  Acne Rosacea                                  126
+  Sycosis                                       130
+  Dermatitis Papillaris Capillitii              135
+  Impetigo Contagiosa                           136
+  Impetigo Herpetiformis                        138
+  Ecthyma                                       138
+  Pemphigus                                     140
+
+CLASS III.--HEMORRHAGES                         144
+  Purpura                                       144
+  Scorbutus                                     146
+
+CLASS IV.--HYPERTROPHIES                        148
+  Lentigo                                       148
+  Chloasma                                      149
+  Keratosis Pilaris                             151
+  Keratosis Follicularis                        153
+  Molluscum Epitheliale                         153
+  Callositas                                    155
+  Clavus                                        156
+  Cornu Cutaneum                                158
+  Verruca                                       160
+  Nævus Pigmentosus                             162
+  Ichthyosis                                    165
+  Onychauxis                                    167
+  Hypertrichosis                                168
+  [OE]dema Neonatorum                           170
+  Sclerema Neonatorum                           171
+  Scleroderma                                   172
+  Elephantiasis                                 174
+  Dermatolysis                                  176
+
+CLASS V.--ATROPHIES                             177
+  Albinismus                                    177
+  Vitiligo                                      178
+  Canities                                      180
+  Alopecia                                      181
+  Alopecia Areata                               183
+  Atrophia Pilorum Propria                      187
+  Atrophia Unguis                               188
+  Atrophia Cutis                                189
+
+CLASS VI.--NEW GROWTHS                          191
+  Keloid                                        191
+  Fibroma                                       192
+  Neuroma                                       194
+  Xanthoma                                      195
+  Myoma                                         196
+  Angioma                                       196
+  Telangiectasis                                197
+  Lymphangioma                                  198
+  Rhinoscleroma                                 198
+  Lupus Erythematosus                           199
+  Lupus Vulgaris                                203
+  Tuberculosis Cutis                            209
+  Ainhum                                        212
+  Mycetoma                                      212
+  Perforating Ulcer of the Foot                 213
+  Syphilis Cutanea                              213
+  Lepra                                         231
+  Pellagra                                      235
+  Epithelioma                                   236
+  Paget's Disease of the Nipple                 240
+  Sarcoma                                       241
+  Granuloma Fungoides                           242
+
+CLASS VII.--NEUROSES                            244
+  Hyperæsthesia                                 244
+  Dermatalgia                                   244
+  Anæsthesia                                    244
+  Pruritus                                      244
+
+CLASS VIII.--PARASITIC AFFECTIONS               247
+  Tinea Favosa                                  247
+  Tinea Trichophytina                           251
+  Tinea Imbricata                               261
+  Tinea Versicolor                              262
+  Erythrasma                                    265
+  Actinomycosis                                 266
+  Blastomycetic Dermatitis                      266
+  Scabies                                       267
+  Pediculosis                                   271
+  Pediculosis Capitis                           272
+  Pediculosis Corporis                          274
+  Pediculosis Pubis                             275
+  Cysticercus Cellulosæ                         276
+  Filaria Medinensis                            277
+  Ixodes                                        277
+  Leptus                                        277
+  [OE]strus                                     278
+  Pulex Penetrans                               278
+  Cimex Lectularius                             278
+  Culex                                         279
+  Pulex Irritans                                279
+
+TABLE showing Relative Frequency of the Various
+  Diseases of the Skin                          280
+
+
+
+
+DISEASES OF THE SKIN.
+
+#ANATOMY OF THE SKIN.#
+
+
+[Illustration: Fig. I.
+  Vertical section of the skin--Diagrammatic. (_After Heitsmann._)]
+
+
+
+
+                            #The Epidermis.#
+
+
+[Illustration: Fig. 2.
+  _c_, corneous (horny) layer; _g_, granular layer; _m_, mucous layer
+  (rete Malpighii).
+  The stratum lucidum is the layer just above the granular layer.
+  Nerve terminations--_n_, afferent nerve; _b_, terminal nerve bulbs;
+  _l_, cell of Langerhans. (_After Ranvier._)]
+
+
+
+
+                           #The Blood-vessels.#
+
+
+[Illustration: Fig. 3.
+  _C_, epidermis; _D_, corium; _P_, papillæ; _S_, sweat-gland duct.
+  _v_, arterial and venous capillaries (superficial, or papillary plexus)
+  of the papillæ. Deep plexus is partly shown at lower margin of the
+  diagram; _vs_--an intermediate plexus, an outgrowth from the deep
+  plexus, supplying sweat-glands, and giving a loop to hair papilla.
+  (_After Ranvier._)]
+
+
+
+
+                   #The Nervous and Vascular Papillæ.#
+
+
+[Illustration: Fig. 4.
+  _a_, a vascular papilla; _b_, a nervous papilla; _c_, a blood-vessel;
+  _d_, a nerve fibre; _e_, a tactile corpuscle. (_After Biesiadecki._)]
+
+
+
+
+                      #The Hair and Hair-Follicle.#
+
+
+[Illustration: Fig. 5. _A_, shaft of the hair; _B_, root of the hair;
+_C_, cuticle of the hair; _D_, medullary substance of the hair. _E_,
+external layer of the hair-follicle; _F_, middle layer of the
+hair-follicle; _G_, internal layer of the hair-follicle; _H_, papilla of
+the hair; _I_, external root-sheath; _J_, outer layer of the internal
+root-sheath; _K_, internal layer of the internal root-sheath. (_After
+Duhring._)]
+
+
+
+
+#SYMPTOMATOLOGY.#
+
+
+The symptoms of cutaneous disease may be objective, subjective or both;
+and in some diseases, also, there may be systemic disturbance.
+
+
+#What do you mean by objective symptoms?#
+
+Those symptoms visible to the eye or touch.
+
+
+#What do you understand by subjective symptoms?#
+
+Those which relate to sensation, such as itching, tingling, burning,
+pain, tenderness, heat, anæsthesia, and hyperæsthesia.
+
+
+#What do you mean by systemic symptoms?#
+
+Those general symptoms, slight or profound, which are sometimes
+associated, primarily or secondarily, with the cutaneous disease, as,
+for example, the systemic disturbance in leprosy, pemphigus, and purpura
+hemorrhagica.
+
+
+#Into what two classes of lesions are the objective symptoms commonly
+divided?#
+
+    Primary (or elementary), and
+    Secondary (or consecutive).
+
+
+
+                          #Primary Lesions.#
+
+
+#What are primary lesions?#
+
+Those objective lesions with which cutaneous diseases begin. They may
+continue as such or may undergo modification, passing into the secondary
+or consecutive lesions.
+
+
+#Enumerate the primary lesions.#
+
+Macules, papules, tubercles, wheals, tumors, vesicles, blebs and
+pustules.
+
+
+#What are macules (maculæ)?#
+
+Variously-sized, shaped and tinted spots and discolorations, without
+elevation or depression; as, for example, freckles, spots of purpura,
+macules of cutaneous syphilis.
+
+
+#What are papules (papulæ)?#
+
+Small, circumscribed, solid elevations, rarely exceeding the size of a
+split-pea, and usually superficially seated; as, for example, the
+papules of eczema, of acne, and of cutaneous syphilis.
+
+
+#What are tubercles (tubercula)?#
+
+Circumscribed, solid elevations, commonly pea-sized and usually
+deep-seated; as, for example, the tubercles of syphilis, of leprosy, and
+of lupus.
+
+
+#What are wheals (pomphi)?#
+
+Variously-sized and shaped, whitish, pinkish or reddish elevations, of
+an evanescent character; as, for example, the lesions of urticaria, the
+lesions produced by the bite of a mosquito or by the sting of a nettle.
+
+
+#What are tumors (tumores)?#
+
+Soft or firm elevations, usually large and prominent, and having their
+seat in the corium and subcutaneous tissue; as, for example, sebaceous
+tumors, gummata, and the lesions of fibroma.
+
+
+#What are vesicles (vesiculæ)?#
+
+Pin-head to pea-sized, circumscribed epidermal elevations, containing
+serous fluid; as, for example, the so-called fever-blisters, the lesions
+of herpes zoster, and of vesicular eczema.
+
+
+#What are blebs (bullæ)?#
+
+Rounded or irregularly-shaped, pea to egg-sized epidermic elevations,
+with fluid contents; in short, they are essentially the same as vesicles
+and pustules except as to size; as, for example, the blebs of pemphigus,
+rhus poisoning, and syphilis.
+
+
+#What are pustules (pustulæ)?#
+
+Circumscribed epidermic elevations containing pus; as, for example, the
+pustules of acne, of impetigo, and of sycosis.
+
+
+
+                        #Secondary Lesions.#
+
+
+#What are secondary lesions?#
+
+Those lesions resulting from accidental or natural change, modification
+or termination of the primary lesions.
+
+
+#Enumerate the secondary lesions.#
+
+Scales, crusts, excoriations, fissures, ulcers, scars and stains.
+
+
+#What are scales (squamæ)?#
+
+Dry, laminated, epidermal exfoliations; as, for example, the scales of
+psoriasis, ichthyosis, and eczema.
+
+
+#What are crusts (crustæ)?#
+
+Dried effete masses of exudation; as, for example, the crusts of
+impetigo, of eczema, and of the pustular and ulcerating syphilodermata.
+
+
+#What are excoriations (excoriationes)?#
+
+Superficial, usually epidermal, linear or punctate loss of tissue; as,
+for example, ordinary scratch-marks.
+
+
+#What are fissures (rhagades)?#
+
+Linear cracks or wounds, involving the epidermis, or epidermis and
+corium; as, for example, the cracks which often occur in eczema when
+seated about the joints, the cracks of chapped lips and hands.
+
+
+#What are ulcers (ulcera)?#
+
+Rounded or irregularly-shaped and sized loss of skin and subcutaneous
+tissue resulting from disease; as, for example, the ulcers of syphilis
+and of cancer.
+
+
+#What are scars (cicatrices)?#
+
+Connective-tissue new formations replacing loss of substance.
+
+
+#What are stains?#
+
+Discolorations left by cutaneous disease, which stains may be transitory
+or permanent.
+
+
+
+                     #Distribution and Configuration.#
+
+
+#What do you mean by a patch of eruption?#
+
+A single group or aggregation of lesions or an area of disease.
+
+
+#When is an eruption said to be limited or localized?#
+
+When it is confined to one part or region.
+
+
+#When is an eruption said to be general or generalized?#
+
+When it is scattered, uniformly or irregularly, over the entire surface.
+
+
+#When is an eruption universal?#
+
+When the whole integument is involved, without any intervening healthy
+skin.
+
+
+#When is an eruption said to be discrete?#
+
+When the lesions constituting the eruption are isolated, having more or
+less intervening normal skin.
+
+
+#When is an eruption confluent?#
+
+When the lesions constituting the eruption are so closely crowded that a
+solid sheet results.
+
+
+#When is an eruption uniform?#
+
+When the lesions constituting the eruption are all of one type or
+character.
+
+
+#When is an eruption multiform?#
+
+When the lesions constituting the eruption are of two or more types or
+characters.
+
+
+#When are lesions said to be aggregated?#
+
+When they tend to form groups or closely-crowded patches.
+
+
+#When are lesions disseminated?#
+
+When they are irregularly scattered, with no tendency to form groups or
+patches.
+
+
+#When is a patch of eruption said to be circinate?#
+
+When it presents a rounded form, and usually tending to clear in the
+centre; as, for example, a patch of ringworm.
+
+
+#When is a patch of eruption said to be annular?#
+
+When it is ring-shaped, the central portion being clear; as, for
+example, in erythema annulare.
+
+
+#What meaning is conveyed by the term "iris"?#
+
+The patch of eruption is made up of several concentric rings. Difference
+of duration of the individual rings, usually slight, tends to give the
+patch variegated coloration; as, for example, in erythema iris and
+herpes iris.
+
+
+#What meaning is conveyed by the term "marginate"?#
+
+The sheet of eruption is sharply defined against the healthy skin; as,
+for example, in erythema marginatum, eczema marginatum.
+
+
+#What meaning is conveyed by the qualifying term "circumscribed"?#
+
+The term is applied to small, usually more or less rounded, patches,
+when sharply defined; as, for example, the typical patches of psoriasis.
+
+
+#When is the qualifying term "gyrate" employed?#
+
+When the patches arrange themselves in an irregular winding or
+festoon-like manner; as, for instance, in some cases of psoriasis. It
+results, usually, from the coalescence of several rings, the eruption
+disappearing at the points of contact.
+
+
+#When is an eruption said to be serpiginous?#
+
+When the eruption spreads at the border, clearing up at the older part;
+as, for instance, in the serpiginous syphiloderm.
+
+
+
+                         #RELATIVE FREQUENCY.#
+
+
+#Name the more common cutaneous diseases and state approximately their
+frequency.#
+
+Eczema, 30.4%; syphilis cutanea, 11.2%; acne, 7.3%; pediculosis, 4%;
+psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies, 2.6%;
+urticaria, 2.5%; pruritus, 2.1%; seborrh[oe]a, 2.1%; herpes simplex,
+1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%; verruca, 1.1%;
+tinea versicolor, 1%. Total: eighteen diseases, representing 81 per
+cent. of all cases met with.
+
+(These percentages are based upon statistics, public and private, of the
+American Dermatological Association, covering a period of ten years. In
+private practice the proportion of cases of pediculosis, scabies, favus,
+and impetigo is much smaller, while acne, acne rosacea, seborrh[oe]a,
+epithelioma, and lupus are relatively more frequent.)
+
+
+
+                           #CONTAGIOUSNESS.#
+
+
+#Name the more actively contagious skin diseases.#
+
+Impetigo contagiosa, ringworm, favus, scabies and pediculosis; excluding
+the exanthemata, erysipelas, syphilis and certain rare and doubtful
+diseases.
+
+[At the present time when most diseases are presumed to be due to
+bacteria or parasites the belief in contagiousness, under certain
+conditions, has considerably broadened.]
+
+
+
+                          #RAPIDITY OF CURE.#
+
+
+#Is the rapid cure of a skin disease fraught with any danger to the
+patient?#
+
+No. It was formerly so considered, especially by the public and general
+profession, and the impression still holds to some extent, but it is not
+in accord with dermatological experience.
+
+
+
+                           #OINTMENT BASES.#
+
+
+#Name the several fats in common use for ointment bases.#
+
+Lard, petrolatum (or cosmoline or vaseline), cold cream and lanolin.
+
+
+#State the relative advantages of these several bases.#
+
+_Lard_ is the best all-around base, possessing penetrating properties
+scarcely exceeded by any other fat.
+
+_Petrolatum_ is also valuable, having little, if any, tendency to
+change; it is useful as a protective, but is lacking in its power of
+penetration.
+
+_Cold Cream_ (ungt. aquæ rosæ) is soothing and cooling, and may often be
+used when other fatty applications disagree.
+
+_Lanolin_ is said to surpass in its power of penetration all other
+bases, but this is not borne out by experience. It is an unsatisfactory
+base when used alone. It should be mixed with another base in about the
+proportion of 25% to 50%.
+
+These several bases may, and often with advantage, be variously
+combined.
+
+
+#What is to be added to these several bases if a stiffer ointment is
+required?#
+
+Simple cerate, wax, spermaceti, or suet; or in some instances, a
+pulverulent substance, such as starch, boric acid, and zinc oxide.
+
+
+
+
+#CLASS I.--DISORDERS OF THE GLANDS.#
+
+
+                           #Hyperidrosis.#
+
+
+[Illustration: Fig. 6.
+  A normal sweat-gland, highly magnified. (_After Neumann._)
+  _a_, Sweat-coil: _b_, sweat-duct; _c_, lumen of duct; _d_,
+  connective-tissue capsule; _e_ and _f_, arterial trunk and
+  capillaries.]
+
+
+#What is hyperidrosis?#
+
+Hyperidrosis is a functional disturbance of the sweat-glands,
+characterized by an increased production of sweat. This increase may be
+slight or excessive, local or general.
+
+
+#As a local affection, what parts are most commonly involved?#
+
+The hands, feet, especially the palmar and plantar surfaces, the axillæ
+and the genitalia.
+
+
+#Describe the symptoms of the local forms of hyperidrosis.#
+
+The essential, and frequently the sole symptom, is more or less profuse
+sweating.
+
+If the hands are the parts involved, they are noted to be wet, clammy
+and sometimes cold.
+
+If involving the soles, the skin often becomes more or less macerated
+and sodden in appearance, and as a result of this maceration and
+continued irritation they may become inflamed, especially about the
+borders of the affected parts, and present a pinkish or pinkish-red
+color, having a violaceous tinge. The sweat undergoes change and becomes
+offensive.
+
+
+#Is hyperidrosis acute or chronic?#
+
+Usually chronic, although it may also occur as an acute affection.
+
+
+#What is the etiology of hyperidrosis?#
+
+Debility is commonly the cause in general hyperidrosis; the local forms
+are probably neurotic in origin.
+
+
+#What is the prognosis?#
+
+The disease is usually persistent and often rebellious to treatment; in
+many instances a permanent cure is possible, in others palliation.
+Relapses are not uncommon.
+
+
+#What systemic remedies are employed in hyperidrosis?#
+
+Ergot, belladonna, gallic acid, mineral acids, and tonics.
+Constitutional treatment is rarely of benefit in the local forms of
+hyperidrosis, and external applications are seldom of service in general
+hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is also
+well spoken of, combined, if necessary, with an astringent.
+
+
+#What external remedies are employed in the local forms?#
+
+Astringent lotions of zinc sulphate, tannin and alum, applied several
+times daily, with or without the supplementary use of dusting-powders.
+Weak solutions of formaldehyde, one to one hundred, are sometimes of
+value.
+
+Dusting-powders of boric acid and zinc oxide, to which may be added from
+ten to thirty grains of salicylic acid to the ounce, to be used freely
+and often:--
+
+  [Rx] Pulv. ac. salicylici ................. gr. x-xxx.
+       Pulv. ac. borici ..................... [dram]v.
+       Pulv. zinci oxidi .................... [dram]iij     M.
+
+Diachylon ointment, and an ointment containing a drachm of tannin to the
+ounce; more especially applicable in hyperidrosis of the feet. The parts
+are first thoroughly washed, rubbed dry with towels and dusting-powder,
+and the ointment applied on strips of muslin or lint and bound on; the
+dressing is renewed twice daily, the parts each time being rubbed dry
+with soft towels and dusting-powder, and the treatment continued for ten
+days to two weeks, after which the dusting-powder is to be used alone
+for several weeks. No water is to be used after the first washing until
+the ointment is discontinued. One such course will occasionally suffice,
+but not infrequently a repetition is necessary.
+
+Faradization and galvanization are sometimes serviceable. Repeated mild
+exposures to the Röntgen rays have a favorable influence in some
+instances.
+
+
+
+                              #Sudamen.#
+                 (_Synonym:_ Miliaria crystallina.)
+
+
+#What is sudamen?#
+
+Sudamen is a non-inflammatory disorder of the sweat-glands,
+characterized by pin-point to pin-head-sized, discrete but thickly-set,
+superficial, translucent whitish vesicles.
+
+
+#Describe the clinical characters.#
+
+The lesions develop rapidly and in great numbers, either irregularly or
+in crops, and are usually to be seen as discrete, closely-crowded,
+whitish, or pearl-colored minute elevations, occurring most abundantly
+upon the trunk. In appearance they resemble minute dew-drops. They are
+non-inflammatory, without areola, never become purulent, and evince no
+tendency to rupture, the fluid disappearing by absorption, and the
+epidermal covering by desquamation.
+
+
+#Give the course and duration of sudamen.#
+
+New crops may appear as the older lesions are disappearing, and the
+affection persist for some time, or, on the other hand, the whole
+process may come to an end in several days or a week. In short, the
+course and duration depend upon the subsidence or persistence of the
+cause.
+
+
+#What is the anatomical seat of sudamen?#
+
+The lesions are formed between the lamellæ of the corneous layer,
+usually the upper part; and are thought to be due to some change in the
+character of the epithelial cells of this layer, probably from high
+temperature, giving rise to a blocking up of the surface outlet.
+
+
+#What is the cause of sudamen?#
+
+Debility, especially when associated with high fever. The eruption is
+often seen in the course of typhus, typhoid and rheumatic fevers.
+
+
+#How would you treat sudamen?#
+
+By constitutional remedies directed against the predisposing factor or
+factors, and the application of cooling lotions of vinegar or alcohol
+and water, or dusting-powders of starch and lycopodium.
+
+
+
+                            #Hydrocystoma.#
+
+
+#Describe hydrocystoma.#
+
+Hydrocystoma is a cystic affection of the sweat-gland ducts, seated upon
+the face. The lesions may be present in scant numbers or in more or less
+profusion. They have the appearance of boiled sago grains imbedded in
+the skin; the larger lesions may have a bluish color, especially about
+the periphery. It is not common, and is usually seen in washerwomen and
+laundresses, or those exposed to moist heat. In some cases it tends to
+disappear during the winter months. There are no subjective symptoms.
+
+Treatment consists of puncturing the lesions and application of
+dusting-powder. Avoidance of the exciting cause (moist heat) is
+important.
+
+
+
+                             #Anidrosis.#
+
+
+#Describe anidrosis.#
+
+It is the opposite condition of hyperidrosis, and is characterized by
+diminution or suppression of the sweat secretion. It occurs to some
+extent in certain systemic diseases and also in some affections of the
+skin, such as ichthyosis; nerve-injuries may give rise to localized
+sweat-suppression.
+
+Treatment is based upon general principles; friction, warm and hot-vapor
+baths, electricity and similar measures are of service.
+
+
+
+                             #Bromidrosis.#
+                        (_Synonym:_ Osmidrosis.)
+
+
+#Describe bromidrosis.#
+
+Bromidrosis is a functional disturbance of the sweat-glands
+characterized by a sweat secretion of an offensive odor. The sweat
+production may be normal in quantity or more or less excessive, usually
+the latter. The condition may be local or general, commonly the former.
+It is closely allied to hyperidrosis, and may often be considered
+identical, the odor resulting from rapid decomposition of the sweat
+secretion. The decomposition and resulting odor have been thought due to
+the presence of bacteria.
+
+
+#What parts are most commonly affected in bromidrosis?#
+
+The feet and the axillæ.
+
+
+#What is the treatment of bromidrosis?#
+
+It is essentially the same as that of hyperidrosis (_q. v._), consisting
+of applications of astringent lotions, dusting-powders, especially those
+containing boric acid and salicylic acid, and the continuous application
+of diachylon ointment. In obstinate cases weak formaldehyde solutions,
+Röntgen rays, and high-frequency currents can be tried.
+
+
+
+                              #Chromidrosis.#
+
+
+#Describe chromidrosis.#
+
+This is a functional disorder of the sweat-glands characterized by a
+secretion variously colored, and usually increased in quantity. It is,
+as a rule, limited to a circumscribed area. The most common color is
+red. The condition is probably of neurotic origin and tends to recur.
+(True chromidrosis is extremely rare; most of the cases formerly thought
+to be such are now known to be examples of pseudochromidrosis.)
+
+Treatment should be invigorating and tonic, with special reference
+toward the nervous system. The various methods of local electrization
+should also be resorted to.
+
+Mild antiseptic and astringent lotions or dusting powders should also be
+advised.
+
+_Red chromidrosis_ or _Pseudochromidrosis_ is a condition in which the
+coloring of the sweat occurs after its excretion and is due to the
+presence of chromatogenous bacteria which are found attached to the
+hairs of the part in agglutinated masses. The axilla is the favorite
+site. Treatment consists of frequent soap-and-water washings, and the
+application of boric acid, resorcin, and corrosive sublimate lotions.
+
+
+
+                              #Uridrosis.#
+
+
+#Describe uridrosis.#
+
+Uridrosis is a rare condition in which the sweat secretion contains the
+elements of the urine, especially urea. In marked cases the salt may be
+noticeable upon the skin as a colorless or whitish crystalline deposit.
+In most instances it has been preceded or accompanied by partial or
+complete suppression of the renal functions.
+
+
+
+                            #Phosphoridrosis.#
+
+
+#Describe phosphoridrosis.#
+
+Phosphoridrosis is a rare condition, in which the sweat is
+phosphorescent. It has been observed in the later stages of phthisis, in
+miliaria, and in those who have eaten of putrid fish.
+
+
+
+                   #Seborrh[oe]a (Eczema Seborrhoicum).#
+ _Synonyms:_ (Steatorrh[oe]a; Acne sebacea; Ichthyosis sebacea; Dandruff.)
+
+
+#What is seborrh[oe]a?#
+
+Seborrh[oe]a 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.
+
+In many cases the sweat-glands are likewise implicated, and the process
+may also be distinctly, although usually mildly, inflammatory.
+
+
+#At what age is seborrh[oe]a usually observed?#
+
+Between fifteen and forty. It may, however, occur at any age.
+
+
+#Name the parts most commonly affected.#
+
+The scalp, face, and (less frequently) the sternal and interscapular
+regions of the trunk. It is sometimes seen on other parts.
+
+
+#What varieties of seborrh[oe]a are encountered?#
+
+Seborrh[oe]a oleosa and seborrh[oe]a sicca; not infrequently the disease
+is of a mixed type.
+
+
+#What are the symptoms of seborrh[oe]a oleosa?#
+
+The sole symptom is an unnatural oiliness, variable as to degree. Its
+most common sites are the regions of the scalp, nose, and forehead. In
+many instances mild rosacea coexists with oily seborrh[oe]a of the nose.
+
+
+#Give the symptoms of seborrh[oe]a sicca.#
+
+A variable degree of greasy scalines, which may be seated upon a pale,
+hyperæmic or mildly inflammatory surface.
+
+The parts affected are covered scantily or more or less abundantly with
+somewhat greasy, grayish, or brownish-gray scales. If upon the scalp
+(_dandruff_, _pityriasis capitis_), small particles of scales are found
+scattered through the hair, and when the latter is brushed or combed,
+fall over the shoulders. If upon the face, in addition to the scaliness,
+the sebaceous ducts are usually seen to be enlarged and filled with
+sebaceous matter.
+
+
+#Describe the symptoms of the ordinary or mixed type.#
+
+It is common upon the scalp. The skin is covered with irregularly
+diffused, greasy, grayish or brownish scales and crusts, in some cases
+moderate in quantity, in others so great that large irregular masses are
+formed, pasting the hair to the scalp. If removed, the scales and crusts
+rapidly re-form. The skin beneath is found slate-colored, hyperæmic or
+mildly inflammatory, and exceptionally it has in places an eczematous
+aspect (_eczema seborrhoicum_). Extraneous matter, such as dust and
+dirt, collects upon the parts, and the whole mass may become more or
+less offensive. There is a strong tendency to falling-out of the hair.
+Itching may or may not be present.
+
+[Illustration: Seborrh[oe]a (Eczema Seborrhoicum).]
+
+
+#Describe the symptoms of seborrh[oe]a of the trunk and other parts.#
+
+[Illustration: Fig. 7.
+  A normal sebaceous gland in connection with a lanugo hair.
+  (_After Neumann._)
+  _a_, Capsule; _b_, fatty secretion; _c_, _h_, secreting cells; _d_, root
+  of lanugo hair; _e_, hair-sac; _f_, hair-shaft; _g_, acini of sebaceous
+  gland.]
+
+Seborrh[oe]a corporis differs in a measure, in its symptoms, from
+seborrh[oe]a of the scalp and is usually illustrative of the variety
+known as eczema seborrhoicum; it occurs as one or several irregular or
+circinate, slightly hyperæmic or moderately inflammatory patches,
+covered with dirty or grayish-looking greasy scales or crusts, usually
+moderate in quantity, and upon removal are found to have projections
+into the sebaceous ducts. It is commonly seen upon the sternal and
+interscapular regions. It rarely exists independently in these regions,
+being usually associated with and following the disease on the scalp. It
+may also invade the axillæ, genitocrural, and other regions.
+
+
+#What is the usual course of seborrh[oe]a?#
+
+Essentially chronic, the disease varying in intensity from time to time.
+In occasional instances it disappears spontaneously.
+
+
+#Give the cause or causes of seborrh[oe]a.#
+
+General debility, anæmia, chlorosis, dyspepsia, and similar conditions
+are to be variously looked upon as predisposing.
+
+In some instances, however, the disease seems to be purely local in
+character, and to be entirely independent of any constitutional or
+predisposing condition. The view recently advanced that the disease is
+of parasitic nature and contagious has been steadily gaining ground.
+
+
+#What is the pathology of seborrh[oe]a?#
+
+Seborrh[oe]a is a disease of the sebaceous glands, and probably often
+involving the sweat-glands also; its products, as found upon the skin,
+consisting of the sebaceous secretion, epithelial cells from the glands
+and ducts, and more or less extraneous matter. Not infrequently
+evidences of superficial inflammatory action are also to be found, and
+it is especially for this type that the name eczema seborrhoicum is most
+appropriate. In long-continued and neglected cases slight atrophy of the
+gland-structures may occur.
+
+
+#With what diseases are you likely to confound seborrh[oe]a?#
+
+Upon the scalp, with eczema and psoriasis; upon the face, with lupus
+erythematosus and eczema; and upon the trunk, with psoriasis and
+ringworm.
+
+As a rule, the clinical features of seborrh[oe]a are sufficiently
+characteristic to prevent error.
+
+
+#What are the differential points?#
+
+Eczema, psoriasis, and lupus erythematosus are diseases in which there
+are distinct _inflammatory symptoms_, such as thickening and
+infiltration and redness; moreover, psoriasis, and this holds true as to
+ringworm also, occurs in sharply-defined, circumscribed patches, and
+lupus erythematosus has a peculiar violaceous tint and an elevated and
+marginate border. A microscopic examination of the epidermic scrapings
+would be of crucial value in differentiating from ringworm.
+
+Quite frequently, especially in the interscapular and sternal regions,
+the segmental configuration constitutes an important feature of
+seborrh[oe]a--of the eczema seborrhoicum variety.
+
+
+#What is the prognosis in seborrh[oe]a?#
+
+Favorable. All types are curable, and when upon the non-hairy regions,
+usually readily so; upon the scalp it is often obstinate. Relapses are
+not uncommon.
+
+In those cases of seborrh[oe]a capitis which have been long-continued or
+neglected, and attended with loss of hair, this loss may be more or less
+permanent, although ordinarily much can be done to promote a regrowth
+(see _Treatment of Alopecia_).
+
+
+#How would you treat seborrh[oe]a of the scalp?#
+
+By constitutional (if indicated) and local remedies; the former having
+in view correction or modification of the predisposing factor or
+factors, and the latter removal of the sebaceous accumulations and the
+application of mildly stimulating antiseptic ointments or lotions.
+
+
+#What constitutional remedies are commonly employed?#
+
+The various tonics, such as iron, quinine, strychnia, cod-liver oil,
+arsenic, the vegetable bitters, laxatives, malt and similar
+preparations. The line of treatment is to be based upon indications.
+
+
+#How do you free the scalp of the sebaceous accumulations?#
+
+In mild types of the disease shampooing with simple Castile soap (or any
+other good toilet soap) and hot water will suffice; in those cases in
+which there is considerable scale-and crust-formation the tincture of
+green soap (tinct. saponis viridis) is to be employed in place of the
+toilet soap, and in some of these latter cases it may be necessary to
+soften the crusts with a previous soaking with olive oil.
+
+The frequency of the shampoo depends upon the conditions. In mild cases
+once in five or ten days will be sufficiently frequent to keep the parts
+clean, but in those cases in which there is rapid scale-or
+crust-production once daily or every second day may at first be
+demanded.
+
+
+#Name the most effectual applications in seborrh[oe]a capitis.#
+
+Sulphur, ammoniated mercury, salicylic acid, resorcin, and carbolic
+acid.
+
+Sulphur is used in the form of an ointment, from twenty grains to one
+drachm in the ounce. Ammoniated mercury, in the form of an ointment, ten
+to sixty grains to the ounce. Salicylic acid, either alone as an
+ointment, ten to thirty grains to the ounce; or it may often be added
+with advantage, in the same proportion, to the sulphur or ammoniated
+mercury ointment above named. Resorcin, either as an ointment, ten to
+thirty grains to the ounce, or as an alcoholic or aqueous lotion, as the
+following:--
+
+  [Rx] Resorcini ............................ [dram]j-[dram]iss.
+       Ol. ricini ........................... [minim]xxx-f[dram]ij.
+       Alcoholis ............................ f[Oz]iv.                M.
+
+Carbolic acid, to the amount of ten to thirty grains, can be added to
+this. If an aqueous lotion is desirable, then in the above formula the
+oleum ricini is replaced with glycerine, and the alcohol with water;
+three to five minims of glycerine in each ounce is usually sufficient,
+as a greater quantity makes the resulting lotion sticky. Petrolatum
+alone, or with 10 to 30 per cent. lanolin, is usually the most
+satisfactory base for the ointments. In some cases of the inflammatory
+variety the skin is found quite irritable, and the mildest applications
+are at first only admissible.
+
+
+#How are the remedies to be applied?#
+
+A small quantity of the lotion, ointment, or oil is gently applied to
+the skin; when to the scalp, a lotion or oil can be conveniently applied
+by means of an eye-dropper. In the beginning of the treatment an
+application once or twice daily is ordered; later, as the disease
+becomes less active, once every second or third day.
+
+
+#How is seborrh[oe]a upon other parts to be treated?#
+
+In the same general manner as seborrh[oe]a of the scalp, except that the
+local applications must be somewhat weaker. The several sulphur lotions
+employed in the treatment of acne (_q. v._) may also be used when the
+disease is upon these parts. In obstinate patchy cases occasional
+paintings with a 20 to 50 per cent alcoholic solution of resorcin is
+curative; following the painting a mild salve should be used.
+
+
+
+                               #Comedo.#
+                 (_Synonyms:_ Blackheads; Flesh-worms.)
+
+
+#What is comedo?#
+
+Comedo is a disorder of the sebaceous glands, characterized by yellowish
+or blackish pin-point or pin-head-sized puncta or elevations
+corresponding to the gland-orifices.
+
+
+#At what age and upon what parts are comedones found?#
+
+Usually between fifteen and thirty, and upon the face and upper part of
+the trunk, where they may exist sparsely or in great numbers. They are
+occasionally associated with oily seborrh[oe]a, the parts presenting a
+greasy or soiled appearance.
+
+Exceptionally they occur as distinct, and usually symmetrical, groups
+upon the forehead or the cheeks. On the upper trunk so-called double and
+multiple comedo have been noted--the two, three, or even four
+closely-contiguous blackheads are, beneath the surface,
+intercommunicable, the dividing duct-walls having apparently disappeared
+by fusion.
+
+
+#Describe an individual lesion.#
+
+It is pin-point to pin-head in size, dark yellowish, and usually with a
+central blackish point (hence the name _blackheads_). There is scarcely
+perceptible elevation, unless the amount of retained secretion is
+excessive. Upon pressure this may be ejected, the small, rounded orifice
+through which it is expressed giving it a thread-like shape (hence the
+name _flesh-worms_).
+
+
+#What is the usual course of comedo?#
+
+Chronic. The lesions may persist indefinitely or the condition may be
+somewhat variable. In many instances, either as a result of pressure or
+in consequence of chemical change in the sebaceous plugs or of the
+addition of a microbic factor, inflammation is excited and acne results.
+The two conditions are, in fact, usually associated.
+
+[Illustration: Fig. 8.
+  Demodex Folliculorum, X 300. Ventral surface. (_After Simon._)]
+
+
+#To what may comedo often be ascribed?#
+
+To disorders of digestion, constipation, chlorosis, menstrual
+disturbance, lack of tone in the muscular fibres of the skin, the
+infrequent use of soap, and working in a dirty or dusty atmosphere.
+
+A small parasite (_demodex folliculorum_, _acarus folliculorum_) is
+sometimes found in the sebaceous mass, but its presence is without
+etiological significance, as it is also found in healthy follicles. A
+microbacillus has been found by several observers, and credited with
+etiological influence.
+
+
+#What is the pathology of comedo?#
+
+The sebaceous ducts or glands, or both, become blocked up with retained
+secretion and epithelial cells. The dark points which usually mark the
+lesions are probably due to accumulation of dirt, but may, as some
+writers maintain, be due to the presence of pigment-granules resulting
+from chemical change in the sebaceous matter.
+
+
+#Is there any difficulty in the diagnosis of comedo?#
+
+No. It can scarcely be confounded with milium, as in this latter disease
+the lesion has no open outlet, no black point, and the contents cannot
+be squeezed out.
+
+
+#Give the prognosis of comedo.#
+
+The result of treatment is usually favorable, although the disease is
+often rebellious. Relapses are not uncommon.
+
+
+#How would you treat a case of comedo?#
+
+By systemic (if indicated) and local measures.
+
+The constitutional treatment aims at correction or palliation of the
+predisposing conditions, and the external applications have in view a
+removal of the sebaceous plugs and stimulation of the glands and skin to
+healthy action.
+
+[Illustration: Fig. 9. Comedo Extractor.]
+
+
+#Name the systemic remedies commonly employed.#
+
+Cod-liver oil, iron, quinine, arsenic, nux vomica and other tonics;
+ergot in those cases in which there is lack of muscular tone, salines
+and aperient pills in constipation. The digestion is to be looked after
+and the bowels kept regular; indigestible food of all kinds is to be
+interdicted. Hygienic measures, such as general and local bathing, local
+massage, calisthenics, and open-air exercise, are of service.
+
+
+#Describe the local treatment.#
+
+Steaming the face or prolonged applications of hot water; washing with
+ordinary toilet soap and hot water, or, in sluggish cases, using
+tincture of green soap (tinct. saponis viridis) instead of the toilet
+soap; removal of the sebaceous plugs by mechanical means, such as
+lateral pressure with the finger ends or perpendicular pressure with a
+watch-key with rounded edges, or with an instrument specially contrived
+for this purpose; and after these preliminary measures, which should be
+carried out every night, a stimulating sulphur ointment or lotion, such
+as employed in the treatment of acne (_q. v._), is to be thoroughly
+applied. The following is valuable:--
+
+  [Rx] Zinci sulphatis,
+       Potassi sulphureti, . [=a][=a] ....... [dram]j-[dram]iv.
+       Alcoholi ............................. f[Oz]ss.
+       Aquæ, ................. q.s. ad ...... f[Oz]iv.            M.
+
+Should slight scaliness or a mild degree of irritation of the skin be
+brought about, active external treatment is to be discontinued for a few
+days and soothing applications made. Resorcin, in lotion, 3 to 25 per
+cent strength, is through the exfoliation it provokes, frequently of
+value; the resorcin paste referred to in acne can also be used for this
+purpose.
+
+Moderately strong applications of the Faradic current, repeated once or
+twice weekly, are sometimes of service; also weak to moderately strong
+applications of the continuous and high-frequency currents. Röntgen-ray
+treatment can also be resorted to in extremely obstinate cases.
+
+In occasional instances sulphur preparations not only fail to do good,
+but materially aggravate the condition. In such cases, if resorcin
+preparations also fail, the mercurial lotion and ointment employed in
+acne may be prescribed. Mercurial and sulphur applications should not be
+used, it need scarcely be said, within a week or ten days of each other,
+otherwise an increase in the comedones and a slight darkening of the
+skin result from the formation of the black sulphuret of mercury.
+
+
+
+                             #Milium.#
+             (_Synonyms:_ Grutum; Strophulus Albidus.)
+
+
+#What is milium?#
+
+Milium consists in the formation of small, whitish or yellowish,
+rounded, pearly, non-inflammatory elevations situated in the upper part
+of the corium.
+
+
+#Describe the clinical appearances.#
+
+The lesions are usually pin-head in size, whitish or yellowish,
+seemingly more or less translucent, rounded or acuminated, without
+aperture or duct, are superficially seated in the skin, and project
+slightly above the surface.
+
+They appear about the face, especially about the eyelids; they may occur
+also, although rarely, upon other parts. But one or several may be
+present, or they may exist in numbers.
+
+
+#What is the course of milium?#
+
+The lesions develop slowly, and may then remain stationary for years.
+Their presence gives rise to no disturbance, and, unless they are large
+in size or exist in numbers, causes but slight disfigurement.
+
+[Illustration: Fig. 10. Milium Needle.]
+
+In rare instances they may undergo calcareous metamorphosis,
+constituting the so-called _cutaneous calculi_.
+
+
+#What is the anatomical seat of milium?#
+
+The sebaceous gland (probably one or several of the
+superficially-situated acini), the duct of which is in some manner
+obliterated, the sebaceous matter collects, becomes inspissated and
+calcareous, forming the pin-head lesion. The epidermis is the external
+covering.
+
+
+#What is the treatment?#
+
+The usual plan is to prick or incise each lesion and press out the
+contents. In some milia it may be necessary also, in order to prevent a
+return, to touch the base of the excavation with tincture of iodine or
+with silver nitrate. Electrolysis is also effectual. In those cases
+where the lesions are numerous the production of exfoliation of the
+epiderm by means of resorcin applications (see acne) is a good plan.
+
+
+
+                             #Steatoma.#
+          (_Synonyms:_ Sebaceous Cyst; Sebaceous Tumor; Wen.)
+
+
+#Describe steatoma.#
+
+Steatoma, or sebaceous cyst, appears as a variously-sized, elevated,
+rounded or semi-globular, soft or firm tumor, freely movable and
+painless, and having its seat in the corium or subcutaneous tissue. The
+overlying skin is normal in color, or it may be whitish or pale from
+distention; in some a gland-duct orifice may be seen, but, as a rule,
+this is absent.
+
+
+#What are the favorite regions for the development of steatoma?#
+
+The scalp, face and back. One or several may be present.
+
+
+#What is the course of sebaceous cysts?#
+
+Their growth is slow, and, after attaining a variable size, may remain
+stationary. They may exist indefinitely without causing any
+inconvenience beyond the disfigurement. Exceptionally, in enormously
+distended growths, suppuration and ulceration result.
+
+
+#What is the pathology?#
+
+A steatoma is a cyst of the sebaceous gland and duct, produced by
+retained secretion. The contents may be hard and friable, soft and
+cheesy, or even fluid, of a grayish, whitish or yellowish color, and
+with or without a fetid odor; the mass consisting of fat-drops,
+epidermic cells, cholesterin, and sometimes hairs.
+
+
+#Are sebaceous cysts likely to be confounded with gummata?#
+
+No. Gummata grow more rapidly, are usually painful to the touch, are not
+freely movable, and tend to break down and ulcerate.
+
+
+#Describe the treatment of steatoma.#
+
+A linear incision is made, and the mass and enveloping sac dissected
+out. If the sac is permitted to remain, reproduction almost invariably
+takes place.
+
+
+
+
+#CLASS II.--INFLAMMATIONS.#
+
+
+                           #Erythema Simplex.#
+
+
+#What do you understand by 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.
+
+
+#Name the two general classes into which the simple erythemata are
+divided.#
+
+Idiopathic and symptomatic.
+
+
+#What do you include in the idiopathic class?#
+
+Those erythemas due to external causes, such as cold and heat (_erythema
+caloricum_), the action of the sun (_erythema solare_), traumatism
+(_erythema traumaticum_), and the various poisons or chemical irritants
+(_erythema venenatum_).
+
+
+#What do you include in the symptomatic class?#
+
+Those rashes often preceding or accompanying certain of the systemic
+diseases, and those due to disorders of the digestive tract, stomachic
+and intestinal toxins, to the ingestion of certain drugs, and to use of
+the therapeutic serums.
+
+
+#Describe the symptoms of erythema simplex.#
+
+The essential symptom is redness--simple hyperæmia--without elevation or
+infiltration, disappearing under pressure, and sometimes attended by
+slight heat or burning; it may be patchy or diffused. In the idiopathic
+class, if the cause is continued, dermatitis may result.
+
+
+#What is to be said about the distribution of the simple erythemata?#
+
+The idiopathic rashes, as inferred from the nature of the causes, are
+usually limited.
+
+The symptomatic erythemas are more or less generalized; desquamation
+sometimes follows.
+
+
+#Describe the treatment of the simple erythemata.#
+
+A removal of the cause in idiopathic rashes is all that is needed, the
+erythema sooner or later subsiding. The same may be stated of the
+symptomatic erythemata, but in these there is at times difficulty in
+recognizing the etiological factor; constitutional treatment, if
+necessary, is to be based upon general principles. Intestinal
+antiseptics are useful in some instances.
+
+Local treatment, which is rarely needed, consists of the use of
+dusting-powders or mild cooling and astringent lotions, such as are
+employed in the treatment of acute eczema (q. v.).
+
+
+
+                        #Erythema Intertrigo.#
+                         (_Synonym:_ Chafing.)
+
+
+#What do you understand by erythema intertrigo?#
+
+Erythema intertrigo is a hyperæmic disorder occurring on parts where the
+natural folds of the skin come in contact, and is characterized by
+redness, to which may be added an abraded surface and maceration of the
+epidermis.
+
+
+#Describe the symptoms of erythema intertrigo.#
+
+The skin of the involved region gradually becomes hyperæmic, but is
+without elevation or infiltration; a feeling of heat and soreness is
+usually experienced. If the condition continue, the increased
+perspiration and moisture of the parts give rise to maceration of the
+epidermis and a mucoid discharge; actual inflammation may eventually
+result.
+
+
+#What is the course of erythema intertrigo?#
+
+The affection may pass away in a few days or persist several weeks, the
+duration depending, in a great measure, upon the cause.
+
+
+#Mention the causes of erythema intertrigo.#
+
+The causes are usually local. It is seen chiefly in children, especially
+in fat subjects, in whom friction and moisture of contiguous parts of
+the body, usually the region of the neck, buttocks and genitalia, are
+more common; in such, uncleanliness or the too free use of soap washings
+will often act as the exciting factor. Disorders of the stomach or
+intestinal canal apparently have a predisposing influence.
+
+
+#What treatment would you advise in erythema intertrigo?#
+
+The folds or parts are to be kept from contact by means of lint or
+absorbent cotton; thin, flat bags of cheese cloth or similar material
+partly filled with dusting-powder, and kept clean by frequent changes,
+are excellent for this purpose, and usually curative. Cleanliness is
+essential, but it is to be kept within the bounds of common sense.
+Dusting-powders and cooling and astringent lotions, such as are employed
+in the treatment of acute eczema (_q. v._), can also be advised. The
+following lotion is valuable:--
+
+  [Rx] Pulv. calaminæ,
+       Pulv. zinci oxidi, .. [=a][=a] ...... [dram]iss.
+       Glycerinæ, .......................... [minum]xxx
+       Alcoholis, .......................... f[dram]ij
+       Aquæ, ............................... Oss.   M.
+
+Exceptionally a mild ointment, alone or supplementary to a lotion, acts
+more satisfactorily.
+
+In persistent or obstinate cases attention should also be directed to
+the state of the general health, especially as regards the digestive
+tract.
+
+
+
+                          #Erythema Multiforme.#
+
+
+#What is erythema multiforme?#
+
+Erythema multiforme is an acute, inflammatory disease, characterized by
+reddish, more or less variegated macules, papules, and tubercles,
+occurring as discrete lesions or in patches of various size and shape.
+
+
+#Upon what parts of the body does the eruption appear?#
+
+Usually upon the extremities, especially the dorsal aspect, from the
+knees and elbows down, and about the face and neck; it may, however, be
+more or less general.
+
+
+#Describe the symptoms of erythema multiforme.#
+
+With or without precursory symptoms of malaise, gastric uneasiness or
+rheumatic pains, the eruption suddenly makes its appearance, assuming an
+erythematous, papular, tubercular or mixed character; as a rule, one
+type of lesion predominates. The lesions tend to increase in size and
+intensity, remain stationary for several days or a week, and then
+gradually fade; during this time there may have been outbreaks of new
+lesions. In color they are pink, red, or violaceous. Slight itching may
+or may not be present. Exceptionally, in general cases, the eruption
+partakes of the nature of both urticaria and erythema multiforme, and
+itching may be quite a decided symptom. In some instances there is
+preceding and accompanying febrile action, usually slight in character;
+in others there may be some rheumatic swelling of one or more joints.
+
+[Illustration: Fig. 11.
+  Erythema Multiforme, in which many of the lesions have become
+  bullous--Erythema Bullosum.]
+
+
+#What type of the eruption is most common?#
+
+The papular, appearing usually upon the backs of the hands and forearms,
+and not infrequently, also, upon the face, legs and feet. The papules
+are usually pea-sized, flattened, and of a dark red or violaceous color.
+
+
+#Describe the various shapes which the erythematous lesions may assume.#
+
+Often the patches are distinctly ring-shaped, with a clear
+centre--_erythema annulare_; or they are made up of several concentric
+rings, presenting variegated coloring--_erythema iris_; or a more or
+less extensive patch may spread with a sharply-defined border, the older
+part tending to fade--_erythema marginatum_; or several rings may
+coalesce, with a disappearance of the coalescing parts, and serpentine
+lines or bands result--_erythema gyratum_.
+
+
+#Does the eruption of erythema multiforme ever assume a vesicular or
+bullous character?#
+
+Yes. In exceptional instances, the inflammatory process may be
+sufficiently intense to produce vesiculation, usually at the summits of
+the papules--_erythema vesiculosum_; and in some instances, blebs may be
+formed--_erythema bullosum_. A vesicular or bullous lesion may become
+immediately surrounded by a ring-like vesicle or bleb, and outside of
+this another form; a patch may be made up of as many as several such
+rings--_herpes iris_. In the vesicular and bullous cases the lips and
+the mucous membranes of the mouth and nose also may be the seat of
+similar lesions.
+
+
+#What is the course of erythema multiforme?#
+
+Acute, the symptoms disappearing spontaneously, usually in one to three
+or four weeks. In some instances the recurrences take place so rapidly
+that the disease assumes a chronic aspect; it is possible that such
+cases are midway cases between this disease and dermatitis
+herpetiformis.
+
+
+#Mention the etiological factors in erythema multiforme.#
+
+The causes are obscure. Digestive disturbance, rheumatic conditions, and
+the ingestion of certain drugs are at times influential. Intestinal
+toxins are doubtless important etiological factors in some cases.
+Certain foods, such as are apt to undergo rapid putrefactive or
+fermentative change, especially pork meats, oysters, fish, crabs,
+lobsters, etc., are, therefore, not infrequently of apparent causative
+influence. It is most frequently observed in spring and autumn months,
+and in early adult life. The disease is not uncommon.
+
+
+#What is the pathology of erythema multiforme?#
+
+It is a mildly inflammatory disorder, somewhat similar to urticaria, and
+presumably due to vasomotor disturbance; the amount of exudation, which
+is variable, determines the character of the lesions.
+
+
+#Name the diagnostic points of erythema multiforme.#
+
+The multiformity of the eruption, the size of the papules, often its
+limitation to certain parts, its course and the entire or comparative
+absence of itching.
+
+It resembles urticaria at times, but the lesions of this latter disease
+are evanescent, disappearing and reappearing usually in the most
+capricious manner, are commonly seated about the trunk, and are
+exceedingly itchy.
+
+In the vesicular and bullous types the acute character of the outbreak,
+the often segmental and ring-like shape, their frequent origin from
+erythematous papules, and the distribution and association with the more
+common manifestations, are always suggestive.
+
+
+#What prognosis would you give in erythema multiforme?#
+
+Always favorable; the eruption usually disappears in ten days to three
+weeks, although in rare instances new crops may appear from day to day
+or week to week, and the process last one or two months. One or more
+recurrences in succeeding years are not uncommon. Those rare cases in
+which vesicular or bullous lesions are also seen on the lips and in the
+mouth, are more prone to longer duration and to more frequent
+recurrences.
+
+
+#What remedies are commonly prescribed in erythema multiforme?#
+
+Quinin, and, if constipation is present, saline laxatives. Calcined
+magnesia is valuable as a laxative. Intestinal antiseptics, such as
+salol, thymol, and sodium salicylate, are valuable in cases probably due
+to intestinal toxins. In those exceptional instances in which there may
+be associated febrile action and rheumatic swelling of the joints, the
+patient should be kept in bed till these symptoms subside. Local
+applications are rarely required, but in those exceptional cases in
+which itching or burning is present, cooling lotions of alcohol and
+water or vinegar and water are to be prescribed. The vesicular and
+bullous types demand mild protective applications, such as used in
+eczema and pemphigus.
+
+
+
+                          #Erythema Nodosum.#
+                (_Synonym:_ Dermatitis contusiformis.)
+
+
+#What is erythema nodosum?#
+
+Erythema nodosum is an inflammatory affection, of an acute type,
+characterized by the formation of variously-sized, roundish, more or
+less elevated erythematous nodes.
+
+
+#Is there any special region of predilection for the eruption of erythema
+nodosum?#
+
+Yes. The tibial surfaces, to which the eruption is often limited; not
+infrequently, however, other parts may be involved, more especially the
+arms and forearms.
+
+
+#Describe the symptoms of erythema nodosum.#
+
+The eruption makes its appearance suddenly, and is usually ushered in
+with febrile disturbance, gastric uneasiness, malaise, and rheumatic
+pains and swelling about the joints. The lesions vary in size from a
+cherry to a hen's egg, are rounded or ovalish, tender and painful, have
+a glistening and tense look, and are of a bright red, erysipelatous
+color which merges gradually into the sound skin. At first they are
+somewhat hard, but later they soften and appear as if about to break
+down, but this, however, never occurs, absorption invariably taking
+place. In occasional instances they are hemorrhagic. Exceptionally the
+lesions of erythema multiforme are also present. Lymphangitis is
+sometimes observed. In rare instances symptoms pointing to visceral
+involvement, to cerebral invasion, and to heart complications have been
+observed.
+
+
+#Are the lesions in erythema nodosum usually numerous?#
+
+No. As a rule not more than five to twenty nodes are present.
+
+
+#What is the course of erythema nodosum?#
+
+Acute. The disease terminating usually in one to three weeks. As the
+lesions are disappearing they present the various changes of color
+observed in an ordinary bruise.
+
+
+#What is known in regard to the etiology?#
+
+The affection is closely allied to erythema multiforme, and is, indeed,
+by some considered a form of that disease. It occurs most frequently in
+children and young adults, and usually in the spring and autumn months.
+Intestinal toxins are thought responsible in some cases. Digestive
+disturbance and rheumatic pain and swellings are often associated with
+it. By many the malady is thought to be a specific infection.
+
+
+#What is the pathology of erythema nodosum?#
+
+The disease is to be viewed as an inflammatory [oe]dema, probably
+resulting, in some instances at least, from an inflammation of the
+lymphatics or an embolism of the cutaneous vessels.
+
+
+#What diseases may erythema nodosum resemble?#
+
+Bruises, abscesses, and gummata.
+
+
+#How are the lesions of erythema nodosum to be distinguished from these
+several conditions?#
+
+By the bright red or rosy tint, the apparently violent character of the
+process, the number, situation and course of the lesions.
+
+
+#State the prognosis of erythema nodosum.#
+
+Favorable, recovery usually taking place in ten days to several weeks.
+
+
+#State the treatment to be advised in erythema nodosum.#
+
+Rest, relative or absolute, depending upon the severity of the case, and
+an unstimulating diet; internally intestinal antiseptics, quinin and
+saline laxatives, and locally applications of lead-water and laudanum.
+
+
+
+                           #Erythema Induratum.#
+              (_Synonym:_ Erythema induratum scrofulosorum.)
+
+
+#What do you understand by erythema induratum?#
+
+A rare disease characterized in the beginning by one or more usually
+deep-seated nodules, and, as a rule, seated in the legs, especially the
+calf region. The nodules gradually enlarge, the skin becomes reddish,
+violaceous or livid in color. Absorption may take place slowly, or the
+indurations may break down, resulting in an indolent, rather deep-seated
+ulcer, closely resembling a gummatous ulcer. The disease is slow and
+persistent, and is commonly met with in girls and young women, usually
+of strumous type. It suggests a tuberculous origin.
+
+Treatment consists in administration of cod-liver oil, phosphorus and
+other tonics. Rest is of service. Locally antiseptic applications, and
+support with roller bandage are to be advised.
+
+
+
+                              #Urticaria.#
+                   (_Synonyms:_ Hives; Nettlerash.)
+
+
+#Give a definition of urticaria.#
+
+Urticaria is an inflammatory affection characterized by evanescent
+whitish, pinkish or reddish elevations, or wheals, variable as to size
+and shape, and attended by itching, stinging or pricking sensations.
+
+
+#Describe the symptoms of urticaria.#
+
+The eruption, erythematous in character and consisting of isolated pea
+or bean-sized elevations or of linear streaks or irregular patches,
+limited or more or less general, and usually intensely itchy, makes its
+appearance suddenly, with or without symptoms of preceding gastric
+derangement. The lesions are soft or firm, reddish or pinkish-white,
+with the peripheral portion of a bright red color, and are fugacious in
+character, disappearing and reappearing in the most capricious manner.
+In many cases simply drawing the finger over the skin will bring out
+irregular and linear wheals. In exceptional cases this peculiar property
+is so pronounced and constant that at any time letters and other symbols
+may be produced at will, even when such subjects are free from the
+ordinary urticarial lesions (_urticaria factitia_, _dermatographism_,
+_autographism_).
+
+The mucous membrane of the mouth and throat may also be the seat of
+wheals and urticarial swellings.
+
+
+#What is the ordinary course of urticaria?#
+
+Acute. The disease is usually at an end in several hours or days.
+
+
+#Does urticaria always pursue an acute course?#
+
+No. In exceptional instances the disease is chronic, in the sense that
+new lesions continue to appear and disappear irregularly from time to
+time for months or several years, the skin rarely being entirely free
+(_chronic urticaria_).
+
+
+[Illustration: Fig. 12.
+  Dermatographism. (_After C.N. Davis._)]
+
+
+#Are subjective symptoms always present in urticaria?#
+
+Yes. Itching is commonly a conspicuous symptom, although at times
+pricking, stinging or a feeling of burning constitutes the chief
+sensation.
+
+
+#In what way may the eruption be atypical?#
+
+Exceptionally the wheals, or lesions, are peculiar as to formation, or
+another condition or disease may be associated, hence the varieties
+known as urticaria papulosa, urticaria hæmorrhagica, urticaria tuberosa,
+and urticaria bullosa.
+
+
+#Describe urticaria papulosa.#
+
+Urticaria papulosa (formerly called _lichen urticatus_) is a variety in
+which the lesions are small and papular, developing usually out of the
+ordinary wheals. They appear as a rule suddenly, rarely in great
+numbers, are scattered, and after a few hours or, more commonly, days
+gradually disappear. The itching is intense, and in consequence their
+apices are excoriated. Sometimes the papules are capped with a small
+vesicle (vesicular urticaria). It is seen more particularly in ill-cared
+for and badly-nourished young children.
+
+
+#Describe urticaria hæmorrhagica.#
+
+Urticaria hæmorrhagica is characterized by lesions similar to ordinary
+wheals, except that they are somewhat hemorrhagic, partaking, in fact,
+of the nature of both urticaria and purpura.
+
+
+#Describe urticaria tuberosa.#
+
+In urticaria tuberosa the lesions, instead of being pea- or bean-sized,
+as in typical urticaria, are large and node-like (also called _giant
+urticaria_).
+
+
+#What is acute-circumscribed [oe]dema?#
+
+In rare instances there occurs, along with the ordinary lesions of the
+disease or as its sole manifestation, sudden and evanescent swelling of
+the eyelids, ears, lips, tongue, hands, fingers, or feet (_urticaria
+[oe]dematosa_, _acute_ _circumscribed [oe]dema_, _angioneurotic [oe]dema_).
+One or several of these parts only may be affected at the one attack; in
+recurrences, so usual in this variety, the same or other parts may
+exhibit the manifestation.
+
+(These [oe]dematous swellings occurring alone might be looked upon, as
+they are by most observers, as an independent affection, but its close
+relationship to ordinary urticaria is often evident.)
+
+
+#Describe urticaria bullosa.#
+
+Urticaria bullosa is a variety in which the inflammatory action has been
+sufficiently great to give rise to fluid exudation, the wheals resulting
+in the formation of blebs.
+
+
+#What is the etiology of urticaria?#
+
+Any irritation from disease, functional or organic, of any internal
+organ, may give rise to the eruption in those predisposed. Gastric
+derangement from indigestible or peculiar articles of food, intestinal
+toxins, and the ingestion of certain drugs are often provocative. The
+so-called "shell-fish" group of foods play an important etiological part
+in some cases. Idiosyncrasy to certain articles of food is also
+responsible in occasional instances. Various rheumatic and nervous
+disorders are not infrequently associated with it, and are doubtless of
+etiological significance. External irritants, also, in predisposed
+subjects, are at times responsible.
+
+
+#What is the pathology of urticaria?#
+
+Anatomically a wheal is seen to be a more or less firm elevation
+consisting of a circumscribed or somewhat diffused collection of
+semi-fluid material in the upper layers of the skin. The vasomotor
+nervous system is probably the main factor in its production; dilatation
+following spasm of the vessels results in effusion, and in consequence,
+the overfilled vessels of the central portion are emptied by pressure of
+the exudation and the central paleness results, while the pressed-back
+blood gives rise to the bright red periphery.
+
+
+#From what diseases is urticaria to be differentiated?#
+
+From erythema simplex, erythema multiforme, erythema nodosum, and
+erysipelas.
+
+
+#Mention the diagnostic points of urticaria.#
+
+The acuteness, character of the lesions, their evanescent nature, the
+irregular or general distribution, and the intense itching.
+
+
+#What is the prognosis in urticaria?#
+
+The acute disease is usually of short duration, disappearing
+spontaneously or as the result of treatment, in several hours or days;
+it may recur upon exposure to the exciting cause. The prognosis of
+chronic urticaria is to be guarded, and will depend upon the ability to
+discover and remove or modify the predisposing condition.
+
+
+#What systemic measures are to be prescribed in acute urticaria?#
+
+Removal of the etiological factor is of first importance. This will be
+found in most cases to be gastric disturbance from the ingestion of
+improper or indigestible food, and in such cases a saline purgative is
+to be given, probably the best for this purpose being the laxative
+antacid, magnesia; or if the case is severe and food is still in the
+stomach, an emetic, such as mustard or ipecac, will act more promptly.
+Alkalies, especially sodium salicylate, and intestinal antiseptics are
+useful. Calcium chloride in doses of five to twenty grains should be
+tried in obstinate cases. The diet should be, for the time, of a simple
+character.
+
+
+#What systemic measures are to be prescribed in chronic and recurrent
+urticaria?#
+
+The cause must be sought for and treatment directed toward its removal
+or modification. Treatment will, therefore, depend upon indications. In
+obscure cases, quinine, sodium salicylate, arsenic, pilocarpine,
+_atropia_, potassium bromide, calcium chloride, and ichthyol are to be
+variously tried; general galvanization is at times useful, as is also a
+change of scene and climate. A proper dietary and the maintenance of
+free action of the bowels, preferably, as a rule, with a saline
+laxative, is of great importance in these chronic cases.
+
+In acute circumscribed [oe]dema treatment is essentially that of
+urticaria, the diet being given special attention.
+
+
+#What external applications would you advise for the relief of the
+subjective symptoms?#
+
+Cooling lotions of alcohol and water or vinegar and water; lotions of
+carbolic acid, one to three drachms to the pint; of thymol, one-fourth
+to one drachm to the pint of alcohol and water; of liquor carbonis
+detergens, one to three ounces to the pint of water, or the following:--
+
+  [Rx] Acidi carbolici, ..................... [dram]j-[dram]iij
+       Acidi borici, ........................ [dram]iv
+       Glycerinæ, ........................... f[dram]j
+       Alcoholis, ........................... f[Oz]ij
+       Aquæ, ................................ f[Oz]xiv. M.
+
+Alkaline baths are also useful, and may advantageously be followed by
+dusting-powders of starch and zinc oxide.
+
+
+
+                        #Urticaria Pigmentosa.#
+                     (_Synonym:_ Xanthelasmoidea.)
+
+
+#Describe urticaria pigmentosa.#
+
+Urticaria pigmentosa is a rare disease, variously viewed as an unusual
+form of urticaria and as an urticaria-like eruption in which there is an
+element of new growth in the lesions. It begins usually in infancy or
+early childhood and continues for months or years, and is characterized
+by slightly, moderately, or intensely itchy, wheal-like elevations,
+which are more or less persistent and leave yellowish, orange-colored,
+greenish or brownish stains. Exceptionally subjective symptoms are
+almost entirely absent. Anatomical studies show that the lesion has in
+some respects the structure of an ordinary wheal, with [oe]dema and
+pigment deposit in the epidermal portion, and cellular infiltration made
+up principally of mast-cells.
+
+[Illustration: Fig. 13.
+  Urticaria Pigmentosa.]
+
+The nature of the disease is obscure and treatment unsatisfactory.
+Ordinarily as early youth or adult life is reached it spontaneously
+disappears. The treatment advised is usually on the same lines as that
+of chronic urticaria.
+
+
+
+                         #Dermatitis.#
+
+
+#What is implied by the term dermatitis?#
+
+Dermatitis, or inflammation of the skin, is a term employed to designate
+those cases of cutaneous disturbance, usually acute in character, which
+are due to the action of irritants.
+
+
+#Mention some examples of cutaneous disturbance to which this term is
+applied.#
+
+The dermatic inflammation due to the action of excessive heat or cold,
+to caustics and other chemical irritants, and to the ingestion of
+certain drugs.
+
+
+#What several varieties are commonly described?#
+
+Dermatitis traumatica, dermatitis calorica, dermatitis venenata, and
+dermatitis medicamentosa.
+
+
+#Describe dermatitis traumatica.#
+
+Under this head are included all forms of cutaneous inflammation due to
+traumatism. To the dermatologist the most common met with is that
+produced by the various animal parasites and from continued scratching;
+in such, if the cause has been long-continued and persistent, a variable
+degree of inflammatory thickening of the skin and pigmentation result,
+the latter not infrequently being more or less permanent. The
+inflammation due to tight-fitting garments, bandages, to constant
+pressure (as bed-sores), etc., also illustrates this class.
+
+
+#What is the treatment of dermatitis traumatica?#
+
+Removal of the cause, and, if necessary, the application of soothing
+ointments or lotions; in bed-sores, soap plaster, plain or with one to
+five per cent. of ichthyol.
+
+
+#What is dermatitis calorica?#
+
+Cutaneous inflammation, varying from a slight erythematous to a
+gangrenous character, produced by excessive heat (_dermatitis
+ambustionis_, _burns_) or cold (_dermatitis congelationis_,
+_frostbite_).
+
+
+#Give the treatment of dermatitis calorica.#
+
+In burns, if of a mild degree, the application of sodium bicarbonate, as
+a powder or saturated solution, is useful; in the more severe grade, a
+two- to five-per-cent. solution will probably be found of greater
+advantage. Other soothing applications may also be employed. In recent
+years a one-per-cent. solution of picric acid has been commended for the
+slighter burns of limited extent. Upon the whole, there is nothing yet
+so generally useful and soothing in these cases as the so-called Carron
+oil; in some cases more valuable with 1/2 to 1 minim of carbolic acid
+added to each ounce.
+
+In frostbite, seen immediately after exposure, the parts are to be
+brought gradually back to a normal temperature, at first by rubbing with
+snow or applying cold water. Subsequently, in ordinary chilblains,
+stimulating applications, such as oil of turpentine, balsam of Peru,
+tincture of iodine, ichthyol, and strongly carbolized ointments are of
+most benefit. If the frostbite is of a vesicular, pustular, bullous, or
+escharotic character, the treatment consists in the application of
+soothing remedies, such as are employed in other like inflammatory
+conditions.
+
+
+#What do you understand by dermatitis venenata?#
+
+All inflammatory conditions of the skin due to contact with deleterious
+substances such as caustic, chemical irritants, iodoform, etc., are
+included under this head, but the most common causes are the rhus
+plants--_poison ivy_ (or _poison oak_) and _poison sumach_ (_poison
+dogwood_). Mere proximity to these plants will, in some individuals,
+provoke cutaneous disturbance (_rhus poisoning_, _ivy poisoning_),
+although they may be handled by others with impunity.
+
+Many other plants are also known to produce cutaneous irritation in
+certain subjects; among these may be mentioned the nettle, primrose,
+cowhage, smartweed, balm of Gilead, oleander, and rue.
+
+The local action of iodoform (_iodoform dermatitis_) in some individuals
+is that of a decided irritant, bringing about a dermatitis, which often
+spreads much beyond the parts of application, and which in those
+eczematously inclined may result in a veritable and persistent eczema.
+
+
+#Describe the symptoms of rhus poisoning.#
+
+The symptoms appear usually soon after exposure, and consist of an
+inflammatory condition of the skin of an eczematous nature, varying in
+degree from an erythematous to a bullous character, and with or without
+[oe]dema and swelling. As a rule, marked itching and burning are
+present. The face, hands, forearms and genitalia are favorite parts,
+although it may in many instances involve a greater portion of the whole
+surface.
+
+
+#What is the course of rhus poisoning?#
+
+It runs an acute course, terminating in recovery in one to six weeks. In
+those eczematously inclined, however, it may result in a veritable and
+persistent form of that disease.
+
+
+#How would you treat rhus poisoning?#
+
+By soothing and astringent applications, such as are employed in acute
+eczema (_q. v._), which are to be used freely. Among the most valuable
+are: a lotion of fluid extract of grindelia robusta, one to two drachms
+to four ounces of water; lotio nigra, either alone or followed by the
+oxide-of-zinc ointment; a saturated solution of boric acid, with a half
+to two drachms of carbolic acid to the pint; a lotion of zinc sulphate,
+a half to four grains to the ounce; weak alkaline lotions; cold cream,
+petrolatum, and oxide-of-zinc ointments.
+
+
+#How would you treat the dermatitis due to other deleterious substances
+of this class?#
+
+By applications of a soothing and protective character, similar to those
+used in eczema and burns.
+
+
+
+                       #Dermatitis Medicamentosa.#
+
+
+#What do you understand by dermatitis medicamentosa?#
+
+Under this head are included all eruptions due to the ingestion or
+absorption of certain drugs.
+
+In rare instances one dose will have such effect; commonly, however, it
+results only after several days' or weeks' continued administration.
+With some drugs such effect is the rule, with others it is exceptional,
+nor are all individuals equally susceptible.
+
+
+#How is the eruption produced in dermatitis medicamentosa?#
+
+In some instances it is probably due to the elimination of the drug
+through the cutaneous structures; in others, to the action of the
+drug upon the nervous system. The view that the drug acts as a toxin or
+generates some toxin or irritant material in the blood, to which the
+eruptive phenomena may be due, has also been advanced.
+
+[Illustration: Dermatitis medicamentosa.
+  Bullous dermatitis from iodide of potassium.]
+
+
+#What is the character of the eruption in dermatitis medicamentosa?#
+
+It may be erythematous, papular, urticarial, vesicular, pustular or
+bullous, and, if the administration of the drug is continued, even
+gangrenous.
+
+
+#Name the more common drugs having such action.#
+
+Antipyrin, arsenic, atropia (or belladonna), bromides, chloral, copaiba,
+cubebs, digitalis, iodides, mercury, opium (or morphia), quinine,
+salicylic acid, stramonium, acetanilid, sulphonal, phenacetin,
+turpentine, many of the new coal-tar derivatives, etc.
+
+
+#State frequency and types of eruption due to the ingestion of antipyrin.#
+
+Not uncommon. _Erythematous_, morbilliform and erythemato-papular;
+itching is usually present and moderate desquamation may follow.
+Acetanilid, sulphonal, phenacetin, and other drugs of this class may
+provoke like eruptions.
+
+
+#Mention frequency and types of eruption due to the ingestion of arsenic.#
+
+Rare. Erythematous, erythemato-papular; exceptionally, herpetic, and
+pigmentary. Herpes zoster has been thought to follow its use. Keratosis
+of the palms and soles has also been occasionally observed, which, in
+rare instances, has developed into epithelioma.
+
+
+#Mention frequency and types of eruption due to the ingestion of atropia
+(or belladonna).#
+
+Not uncommon. _Erythematous_ and _scarlatinoid_; usually no febrile
+disturbance, and desquamation seldom follows.
+
+
+#Give frequency and types of cutaneous disturbance following the
+administration of the bromides (bromine).#
+
+Common. _Pustular_, sometimes furuncular and carbuncular and
+superficially ulcerative. In exceptional instances papillomatous or
+vegetating lesions have been observed. Co-administration of arsenic or
+potassium bitartrate is thought to have a preventive influence in some
+cases.
+
+
+#State frequency and types of cutaneous disturbance due to the
+administration of chloral.#
+
+Occasional. Scarlatinoid and urticarial, and exceptionally purpuric; in
+rare instances, if drug is continued, eruption becomes vesicular,
+hemorrhagic, ulcerative and even gangrenous.
+
+
+#State frequency and types of eruption following the administration of
+copaiba.#
+
+Not uncommon. _Urticarial_, erythemato-papular and _scarlatinoid_.
+
+
+#Mention frequency and types of eruption resulting from the ingestion of
+cubebs.#
+
+Uncommon. Erythematous and small papular.
+
+[Illustration: Fig. 14.
+  A somewhat rare form of eruption from the ingestion of iodine compounds.
+  (_After J.C. McGuire._)]
+
+
+#Mention frequency and types of eruption resulting from the
+administration of digitalis.#
+
+Exceptional. Scarlatinoid and papular.
+
+
+#State frequency and types of eruption resulting from the iodides
+(iodine).#
+
+Common. _Pustular_, but may be erythematous, papular, vesicular,
+bullous, tuberous, purpuric and hemorrhagic. Co-administration of
+arsenic or potassium bitartrate is thought to have a preventive
+influence in some cases.
+
+
+#Give the frequency and types of eruption observed to follow the
+administration of mercury.#
+
+Exceptional. Erythematous and erysipelatous.
+
+
+#Give the frequency and types of the cutaneous disturbance following the
+ingestion of opium (or morphia).#
+
+Not uncommon. Erythematous and _scarlatinoid_, and sometimes urticarial.
+
+
+#Mention the frequency and the types of eruption following the
+administration of quinine.#
+
+Not infrequent. Usually _erythematous_, but may be urticarial,
+erythemato-papular, and even purpuric. There is, in some instances,
+preceding or accompanying systemic disturbance. Furfuraceous or lamellar
+desquamation often follows.
+
+
+#State frequency and types of eruption resulting from the ingestion of
+salicylic acid.#
+
+Not common. Erythematous and urticarial; exceptionally, vesicular,
+pustular, bullous, and ecchymotic.
+
+
+#Give frequency and type of cutaneous disturbance due to the
+administration of stramonium.#
+
+Not common. Erythematous.
+
+
+#State frequency and types of eruption resulting from the administration
+of turpentine.#
+
+Not uncommon. _Erythematous_, and small-papular; exceptionally
+vesicular.
+
+
+
+                         #X-Ray Dermatitis.#
+
+
+#What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray burns)
+are observed?#
+
+Three grades are usually described: erythema, superficial vesication,
+and necrosis. The first and second may come on shortly--a few hours to
+several days--after exposure; occasionally later. The third grade may
+present also in the first several days, but in many cases one to several
+weeks may elapse before it appears; it is quite commonly preceded by
+erythema and vesication. The necrosis may be superficial or deep, and
+quite usually results in a persistent ulcer covered by a leathery
+coating; it is usually painful.
+
+[Illustration: Fig. 15. _x_-ray burn]
+
+
+#Give the prognosis and treatment of x-ray dermatitis.#
+
+The first grade--the erythematous--usually disappears in one to ten
+days; the second grade requires one to several weeks, and may be quite
+sore and tender; the severe or necrotic burns are persistent, sometimes
+lasting for months and several years, with little tendency to
+spontaneous disappearance, and rebellious to treatment.
+
+Treatment of the milder types is that of erythema (_q. v._); the necrotic
+type occasionally demands thorough curetting and skin-grafting before it
+will heal.
+
+
+                         #Dermatitis Factitia.#
+                     (_Synonym:_ Feigned Eruptions.)
+
+
+#What do you understand by feigned eruptions?#
+
+Feigned, or artificial, eruptions, occasionally met with in hysterical
+females and in others, are produced, for the purpose of exciting
+sympathy or of deception, by the action of friction, cantharides, acids
+or strong alkalies; the cutaneous disturbance may, therefore, be
+erythematous, vesicular, bullous, or gangrenous. It is usually limited
+in extent, and, as a rule, seen only on parts easily reached by the
+hands.
+
+[Illustration: Fig. 16.
+  Dermatitis Factitia--note the unusually uniform and regular character
+  and arrangement of the lesions.]
+
+
+
+                         #Dermatitis Gangrænosa.#
+
+
+#What do you understand by dermatitis gangrænosa?#
+
+Dermatitis gangrænosa (_erythema gangrænosum_, _Raynaud's disease_,
+_spontaneous gangrene_) is an exceedingly rare affection, characterized
+by the formation of gangrenous spots and patches. It may be idiopathic
+or symptomatic. Some of these cases, especially in hysterical subjects,
+belong under the "feigned eruptions," being self-produced.
+
+As an idiopathic disease, it begins as erythematous, dark-red
+spots--usually preceded and accompanied by mild or grave systemic
+disturbance--which gradually pass into gangrene and sloughing; the
+eventual termination may be fatal, or recovery may take place. As a
+symptomatic disease, it is occasionally met with in diabetes and in
+grave cerebral and spinal affections.
+
+In Raynaud's disease (symmetric gangrene) the parts affected are the
+extremities, such as fingers and toes, the ears and nose, only
+occasionally other parts. The first symptoms observed are coldness and
+paleness of the part; followed sooner or later by congestion of a dark
+red, livid, or bluish color, with sometimes swelling, and tenderness and
+shooting pains. The termination is usually in gangrene of a dry
+character, with, in some instances, vesicles and blebs along the edges;
+in other cases the parts become atrophied, withered, and indurated.
+
+Treatment is based upon general principles.
+
+
+
+                           #Erysipelas.#
+
+
+#What is erysipelas?#
+
+Erysipelas is an acute specific inflammation of the skin and
+subcutaneous tissue, commonly of the face, characterized by shining
+redness, swelling, [oe]dema, heat, and a tendency in some cases to
+vesicle- and bleb-formation, and accompanied by more or less febrile
+disturbance.
+
+
+#Describe the symptoms and course of erysipelas.#
+
+A decided rigor or a feeling of chilliness followed by febrile action
+usually ushers in the cutaneous disturbance. The skin at a certain point
+or part, commonly where there is a lesion of continuity, becomes bright
+red and swollen; this spreads by peripheral extension, and in the course
+of several hours involves a portion or the whole region. The parts are
+shining red, swollen, of an elevated temperature, and sharply defined
+against the sound skin. After several days or a week, during which time
+there is usually continued mild or severe febrile action, the process
+begins to subside, and is followed by epidermic desquamation.
+
+In some cases vesicles and blebs may be present; in other cases the
+disease seriously involves the deeper parts, and is accompanied by grave
+constitutional symptoms. In exceptional instances sloughing takes place.
+
+A mild, transitory, limited, and often recurrent erysipelatous condition
+of the outlet and immediate neighborhood of one or both nostrils is met
+with, taking its origin from an inflammation of the hair-follicles just
+inside the margin of the nose; constitutional symptoms are usually
+wanting. Somewhat similar, doubtless, is the erysipelatous inflammation
+(_erysipeloid_) observed on the fingers and hands of butchers, etc.,
+starting from a wound, apparently as a result of infection from putrid
+meat or fish.
+
+
+#What is erysipelas migrans (or erysipelas ambulans)?#
+
+A variety of erysipelas which, after a few hours or days, disappears at
+one region and appears at another, and so continues for one or several
+weeks.
+
+
+#What is the cause of erysipelas?#
+
+The disease is due to a specific streptococcus--the streptococcus of
+Fehleisen. Depression of the vital forces and local abrasions are
+predisposing factors.
+
+
+#State the diagnostic points.#
+
+The character of the onset, the shining redness and swelling, the
+sharply-defined border, and the accompanying febrile disturbance.
+
+
+#What is the prognosis in erysipelas?#
+
+In most instances the disease runs a favorable course, terminating in
+recovery in one to three weeks. Exceptionally, in severe cases, a fatal
+termination ensues.
+
+
+#What is the treatment of erysipelas?#
+
+_Internally_, a purge, followed by the tincture of the chloride of iron
+and quinia, and stimulants if needed. _Locally_, one to three per cent.
+carbolic-acid lotion or ointment, a saturated solution of boric acid, or
+a ten- to twenty-per-cent. aqueous solution or ointment of ichthyol may
+be employed.
+
+In some cases the spread of the disease is apparently controlled by
+painting the bordering healthy skin with a ring of tincture of iodine or
+strong solution of nitrate of silver.
+
+
+
+                          #Phlegmona Diffusa.#
+
+
+#What do you understand by phlegmona diffusa?#
+
+Phlegmona diffusa is a more or less extensive inflammation of the
+cutaneous and subcutaneous tissues presenting symptoms partaking of the
+nature of both deep erysipelas and flat carbuncles, and usually attended
+with varying constitutional disturbance. Suppuration at several points
+takes place, and sloughing may ensue. Recovery usually finally results,
+but a fatal issue is possible.
+
+Treatment is based upon general principles.
+
+
+
+                             #Furunculus.#
+                     (_Synonyms:_ Furuncle; Boil.)
+
+
+#Define furunculus.#
+
+Furunculus, or boil, is an acute, deep-seated, inflammatory,
+circumscribed, rounded or more or less acuminated, firm, painful
+formation, usually terminating in central suppuration.
+
+
+#Describe the symptoms and course.#
+
+A boil begins as a small, rounded or imperfectly defined reddish spot,
+or as a small, superficial pustule; it increases in size, and when well
+advanced appears as a pea or cherry-sized, circumscribed, reddish
+elevation, with more or less surrounding hyperæmia and swelling; it is
+painful and tender, and ends, in the course of several days or a week,
+in the formation of a central slough or "_core_," which finally involves
+the central overlying skin (_pointing_). One or several may be present,
+gradually maturing and disappearing. Insignificant scarring may remain.
+
+In some cases sympathetic constitutional disturbance is noticed.
+
+
+#What is a blind boil?#
+
+A sluggish boil exhibiting little, if any, tendency to point or break.
+
+
+#What is furunculosis?#
+
+Furunculosis is that condition in which boils, singly or in crops,
+continue to appear, irregularly, for weeks or months.
+
+
+#State the etiology of furuncle.#
+
+A depraved state of the general health is often to be considered as a
+predisposing factor. Persistent furunculosis is not infrequent in
+diabetes mellitus. The immediate exciting cause is the entrance into the
+follicle of a microbe, the staphylococcus pyogenes aureus. It is not
+improbable, however, that boils may also be due to other pus-producing
+organisms.
+
+Workmen in paraffin oils or other petroleum products often present
+numerous furuncles and cutaneous abscesses. Conditions favoring a
+persistent miliaria have also a causative influence, especially observed
+in infants and young children. In these latter, especially among the
+poorer classes, sluggish boils or subcutaneous abscesses about the scalp
+in hot weather, are not at all infrequent.
+
+
+#What is the pathology of furuncle?#
+
+A boil is an inflammatory formation having its starting point in a
+sebaceous-gland, sweat-gland, or hair-follicle. The core, or central
+slough, is composed of pus and of the tissue of the gland in which it
+had its origin.
+
+
+#How would you distinguish a boil from a carbuncle?#
+
+A boil is comparatively small, rounded or acuminate, and has but one
+point of suppuration; a carbuncle is large, flattened, intensely
+painful, often with grave systemic disturbance, and has, moreover,
+several centres of suppuration.
+
+
+#State the prognosis.#
+
+When occurring in crops (furunculosis) the affection is often
+rebellious; recovery, however, finally resulting.
+
+
+#What is the method of treatment of furunculus?#
+
+If there be but one lesion, with no tendency to the appearance of
+others, local treatment alone is usually employed. If, however, several
+or more are present, or if there is a tendency to successive
+development, both constitutional and local measures are demanded.
+
+
+#Name the internal remedies employed.#
+
+Such nutrients and tonics as cod-liver oil, malt, quinine, strychnia,
+iron and arsenic; in some instances calx sulphurata, one-tenth- to
+one-fourth-grain doses every three or four hours has been thought to be
+of service. Brewers' yeast has been recently again brought forward as a
+remedy of value.
+
+
+#What is the external treatment?#
+
+Local treatment consists in the beginning, with the hope of aborting the
+lesion, of the application of carbolic acid to the central portion, or
+the use of a twenty-five-per-cent. ointment of ichthyol applied as a
+plaster:--
+
+  [Rx] Ichthyol, ............................ [dram]j
+     Emp. plumbi, ........................... [dram]ij
+     Emp. resinæ, ........................... [dram]j.   M.
+
+Or the injection of a five-per-cent. solution of carbolic acid into the
+apex of the boil may be tried if the formation is more advanced. If
+suppuration is fully established, evacuation of the contents, followed
+by antiseptic applications, constitutes the best method.
+
+A saturated solution of boric acid or a lotion of corrosive sublimate
+(one to three grains to the ounce) applied to the immediate neighborhood
+of the boil or boils tends to prevent the formation of new lesions.
+Frequent washing of the parts with soap and water or tincture of green
+soap and water is also a preventive measure of value. In repeatedly
+infected areas, mild exposures to _x_-rays, at intervals of a few days,
+will often prove of curative value.
+
+
+
+                           #Carbunculus.#
+                  (_Synonyms:_ Anthrax; Carbuncle.)
+
+
+#What is carbuncle?#
+
+A carbuncle is an acute, usually egg to palm-sized, circumscribed,
+phlegmonous inflammation of the skin and subcutaneous structures,
+terminating in a slough.
+
+
+#At what age and upon what parts is carbuncle usually observed?#
+
+In middle and advanced life, and more commonly in men.
+
+It is seen most frequently at the nape of the neck and upon the upper
+part of the back.
+
+
+#What are the symptoms and course of carbuncle?#
+
+There is rarely more than one lesion present. It begins, usually with
+preceding and accompanying malaise, chilliness and febrile disturbance,
+as a firm, flat, inflammatory infiltration in the deeper skin and
+subcutaneous tissue, spreading laterally and finally involving an area
+of one to several inches in diameter. The infiltration and swelling
+increase, the skin becomes of dark red color, and sooner or later,
+usually at the end of ten days or two weeks, softening and suppuration
+begin to take place, the skin finally giving away at several points,
+through which sanious pus exudes; the whole mass finally sloughs away
+either in portions or in its entirety, resulting in a deep ulcer, which
+slowly heals and leaves a permanent cicatrix.
+
+In some cases, especially in old people, constitutional disturbance of a
+grave character is noted, septicæmia is developed, and a fatal result
+may ensue.
+
+
+#What is the cause of carbuncle?#
+
+The same causes are considered to be operative in carbunculus as in
+furuncle; general debility and depression, from whatever cause,
+predisposing to its formation, and the introduction of a microbe,
+probably the same as in furunculus, being at present looked upon as the
+exciting factor.
+
+
+#What is the pathology?#
+
+The inflammation starts simultaneously from numerous points, from the
+hair-follicles, sweat-glands or sebaceous glands. The inflammatory
+centres break down, and the pus finds its way to the surface; finally
+the process ends in gangrene of the whole area.
+
+
+#How would you distinguish carbuncle from a boil?#
+
+By its flat character, greater size, and multiple points of suppuration.
+
+
+#What is the prognosis of carbuncle?#
+
+Occurring in those greatly debilitated or in late life, and in those
+cases in which two or more lesions exist, or when seated about the head,
+the prognosis is always to be guarded, as a fatal result is not
+uncommon. In fact, in every instance the disease is to be considered of
+possible serious import.
+
+
+#What constitutional treatment is usually employed in carbuncle?#
+
+A full nutritious diet, the use of such remedies as iron, quinia, nux
+vomica, with malt and stimulants, if indicated. Calx sulphurata,
+one-tenth to one-fourth grain every two or three hours, appears, in some
+instances, to have a beneficial effect. If the pain is severe, morphia
+or chloral should be given.
+
+
+#What external measures are employed?#
+
+In the early part of the formation, injection of a five or ten per cent.
+carbolic acid solution, or covering the whole area with a twenty-five
+per cent. ichthyol ointment, may be employed. When it has broken down
+the pus may be drawn out with a cupping-glass, and carbolized glycerine
+or carbolized water introduced into each opening, and the ichthyol
+ointment superimposed. If the whole part has sloughed, it should be
+removed as rapidly as possible, and antiseptic dressings used. Or, if
+its progress is slow, and grave systemic disturbance be present, the
+whole part may be incised and curetted, and then treated antiseptically.
+Mild exposure to the _x_-rays is also to be commended.
+
+
+
+                           #Pustula Maligna.#
+                (_Synonyms:_ Anthrax; Malignant Pustule.)
+
+
+#What is malignant pustule?#
+
+Malignant pustule is a furuncle- or carbuncle-like lesion resulting from
+inoculation of the virus generated in animals suffering from splenic
+fever, or "charbon," and is accompanied by constitutional symptoms of
+more or less gravity. A fatal termination is not unusual.
+
+
+#What is the cause of pustula maligna?#
+
+The disease is due to the presence of the bacillus anthracis.
+
+
+#What is the treatment of malignant pustule?#
+
+Early excision or destruction with caustic potash, with subsequent
+antiseptic dressings; and internally the free use of stimulants and
+tonics.
+
+
+
+                         #Post-mortem Pustule.#
+                     (_Synonym:_ Dissection Wound.)
+
+
+#Describe post-mortem pustule.#
+
+Post-mortem pustule develops at the point of inoculation, beginning as
+an itchy red spot, becoming vesico-pustular, and later pustular, with
+usually a broad inflammatory base, and accompanied with more or less
+pain and redness and not infrequently lymphangitis, erysipelatous
+swelling, and slight or severe sympathetic constitutional disturbance.
+
+
+#What is the treatment of post-mortem pustule?#
+
+Treatment consists in opening the pustule and thorough cauterization,
+and the subsequent use of antiseptic applications or dressings.
+_Internally_ quinia and stimulants if indicated.
+
+
+
+                            #Framb[oe]sia.#
+                       (_Synonyms:_ Yaws; Pian.)
+
+
+#Describe framb[oe]sia.#
+
+Framb[oe]sia is an endemic, contagious disease met with in tropical
+countries, characterized by the appearance of variously-sized papules,
+tubercles, and tumors, which, when developed, resemble currants and
+small raspberries, and finally break down and ulcerate. It is
+accompanied by constitutional symptoms of variable severity.
+
+Hygienic measures, good food, tonics, and antiseptic and stimulating
+applications are curative.
+
+
+                          #Verruga Peruana.#
+      (_Synonyms:_ Peruvian Warts; Carrion's Disease; Oroya Fever.)
+
+
+#Describe verruga peruana.#
+
+A specific inoculable affection endemic in some valleys of the Western
+Andes, in Peru, and characterized by a prodromal febrile period and
+subsequent outbreak of peculiar pin-head- to pea-sized, or larger,
+bright reddish, rounded, wart-like elevations. The prodromal symptoms,
+of an irregular malarial or typhoid type, with associated rheumatic and
+muscular pains, may last for weeks or several months, usually abating
+when eruption presents. The lesions may be crowded together in great
+bunches. The face and limbs are favorite localities. The disease is
+inoculable and thought to be due to a bacillus.
+
+The fatality varies between 10 and 20 per cent. Tonics and stimulants
+are prescribed.
+
+
+
+                             #Equinia.#
+                   (_Synonyms:_ Farcy; Glanders.)
+
+
+#What is equinia, or glanders?#
+
+A rare contagious specific disease of a malignant type, derived from the
+horse, and characterized by grave constitutional symptoms, inflammation
+of the nasal and respiratory passages, and a deep-seated
+papulo-pustular, or tubercular, nodular (_farcy buds_), ulcerative
+eruption. A fatal issue is not uncommon. It is due to a micro-organism.
+
+Treatment, both local and constitutional, is based upon general
+principles.
+
+
+
+                              #Miliaria.#
+      (_Synonyms:_ Prickly Heat; Heat Rash; Lichen Tropicus; Red Gum;
+                              Strophulus.)
+
+
+#What do you understand by miliaria?#
+
+An acute mildly inflammatory disorder of the sweat-glands, characterized
+by the appearance of minute, discrete but closely crowded papules,
+vesico-papules, and vesicles.
+
+
+#Describe the symptoms of miliaria.#
+
+The eruption, consisting of pin-point to millet-seed-sized papules,
+vesico-papules, vesicles, or a mixture of these lesions, discrete but
+usually numerous and closely crowded, appears suddenly, occurring upon a
+limited portion of the surface, or, as commonly observed, involving a
+greater part or the whole integument. The trunk is a favorite locality.
+The papular lesions are pinkish or reddish, and the vesicles whitish or
+yellowish, surrounded by inflammatory areola, thus giving the whole
+eruption a bright red appearance--_miliaria rubra_. Later, the areolæ
+fade, the transparent contents of the vesicles become somewhat opaque
+and yellowish-white, and the eruption has a whitish or yellowish
+cast--_miliaria alba_. In long-continued cases, especially in children,
+boils and cutaneous abscesses sometimes develop; and it may also develop
+into a true eczema.
+
+Itching, or a feeling of burning, slight or intense, is usually present.
+
+
+#What is the course of the eruption?#
+
+The vesicles show no disposition to rupture, but dry up in a few days or
+a week, disappearing by absorption and with slight subsequent
+desquamation; the papular lesions gradually fade away, and the
+affection, if the exciting cause has ceased to act, terminates.
+
+
+#What is the cause of miliaria?#
+
+Excessive heat. Debilitated individuals, especially children, are more
+prone to an attack. Being too warmly clad is often causative.
+
+
+#What is the nature of the disease?#
+
+The affection is considered to be due to sweat-obstruction, with mild
+inflammatory symptoms as a cause or consequence, congestion and
+exudation taking place about the ducts, giving rise to papules or
+vesicles, according to the intensity of the process.
+
+
+#How would you distinguish miliaria from papular and vesicular eczema,
+and from sudamen?#
+
+The papules of eczema are larger, more elevated, firmer, slower in their
+evolution, of longer duration, and are markedly itchy.
+
+The vesicles of eczema are usually larger, tend to become confluent, and
+also to rupture and become crusted; there is marked itchiness, and the
+inflammatory action is usually severe and persistent.
+
+In sudamen there is absence of inflammatory symptoms.
+
+
+#What is the prognosis of miliaria?#
+
+The affection, under favorable circumstances, disappears in a few days
+or weeks. If the cause persists, as for instance, in infants or young
+children too warmly clad, it may result in eczema.
+
+
+#What is the treatment of miliaria?#
+
+Removal of the cause, and in debilitated subjects the administration of
+tonics; together with the application of cooling and astringent lotions,
+as the following:--
+
+  [Rx] Aeidi carbolici, ..................... [dram]ss-[dram]j
+       Acidi borici, ........................ [dram]iv
+       Glycerinæ, ........................... f[dram]j
+       Alcoholis, ........................... f[Oz]ij
+       Aquæ, ................................ [Oz]xiv.  M.
+
+
+This is sometimes more efficient if zinc oxide, six to eight drachms, is
+added.
+
+Lotions of alcohol and water or vinegar and water, and also the various
+lotions used in acute eczema, are often employed with relief.
+
+Dusting-powders of starch, boric acid, lycopodium, talc, and zinc oxide
+are also valuable; the following combination is satisfactory:--
+
+  [Rx] Pulv. acidi borici,
+       Pulv. talci veneti,
+       Pulv. zinci oxidi,
+       Pulv. amyli, .............[=a][=a].....[dram]ij.  M.
+
+Probably the best plan is to use a lotion and a dusting-powder
+conjointly; dabbing on the wash freely, allowing it to dry, and then
+dusting over with the powder.
+
+
+
+                            #Pompholyx.#
+             (_Synonyms:_ Dysidrosis; Cheiro-pompholyx.)
+
+
+#What is pompholyx?#
+
+Pompholyx is a rare disease of the skin of a vesicular and bullous
+character, and limited to the hands and feet.
+
+
+#Describe the symptoms of pompholyx.#
+
+In most instances the hands only are affected. It begins usually with a
+feeling of burning, tingling or tenderness of the parts, followed
+rapidly by the appearance of deeply-seated vesicles, especially between
+the fingers and on the palmar aspect. These beginning lesions look not
+unlike sago grains imbedded in the skin. In some instances the disease
+does not extend beyond this stage, the vesicles disappearing after a few
+days or weeks by absorption, and usually without desquamation.
+Ordinarily, however, the lesions increase in size, new ones arise,
+become confluent, and blebs result, the skin in places appearing as if
+undermined with serous exudation. The parts are commonly inflamed to a
+slight or marked degree. The skin comes off in flakes, new lesions may
+appear for several days or two or three weeks, and the process then
+declines, recovery gradually taking place.
+
+There are no constitutional symptoms, although it is usually noticed
+that the general health is below par.
+
+
+#What is the character of the subjective symptoms in pompholyx?#
+
+The subjective symptoms consist of a feeling of tension, burning and
+tenderness, and sometimes itching. Not infrequently, also there is
+neuralgic pain.
+
+
+#What is the cause of pompholyx?#
+
+The eruption is thought to be due to a depressed state of the nervous
+system. It is more common in women, and is met with chiefly in adult and
+middle life.
+
+
+#What is the pathology?#
+
+Opinion is divided; some considering it a disease of the sweat-glands
+and others an inflammatory disease independent of these structures.
+
+
+#State the diagnostic features of pompholyx.#
+
+The distribution and the peculiar characters and course of the eruption.
+
+It is to be differentiated from eczema.
+
+
+#What is the prognosis?#
+
+For the immediate attack, favorable, recovery taking place in several
+weeks or a few months. Recurrences at irregular intervals are not
+uncommon.
+
+
+#What is the treatment of pompholyx?#
+
+The general health is to be looked after, and the patient placed under
+good hygienic conditions. Remedies of a tonic nature, directed
+especially toward improving the state of the nervous system, are to be
+prescribed. _Locally_, soothing and anodyne applications, such as
+lead-water and laudanum, boric-acid lotion, oxide-of-zinc, boric-acid
+and diachylon ointments, are most suitable; or the parts may be
+enveloped with the following:--
+
+  [Rx] Pulv. ac. salicylici, ................ gr. x
+       Pulv. ac. borici,
+       Pulv. amyli, .......... [=a][=a] ..... [dram]ij
+       Petrolati, ........................... [dram]iv.    M.
+
+In fact, the external treatment is similar to that employed in acute
+eczema.
+
+
+
+                           #Herpes Simplex.#
+                      (_Synonym:_ Fever Blisters.)
+
+
+#What is herpes simplex?#
+
+An acute inflammatory disease, characterized by the formation of
+pin-head to pea-sized vesicles, arranged in groups, and occurring for
+the most part about the face and genitalia.
+
+
+#Describe the symptoms of herpes simplex.#
+
+In severe cases, malaise and pyrexia may precede the eruption, but
+usually it appears without any precursory or constitutional symptoms. A
+feeling of heat and burning in the parts is often complained of. The
+vesicles, which are commonly pin-head in size, are usually upon a
+hyperæmic or inflammatory base, and tend to occur in groups or clusters.
+Their contents are usually clear, subsequently becoming more or less
+milky or puriform. There is no tendency to spontaneous rupture, but
+should they be broken a superficial excoriation results. In a short time
+they dry to crusts which soon fall off, leaving no permanent trace.
+
+
+#Is the eruption in herpes simplex abundant?#
+
+No. As a rule not more than one or two clusters or groups are observed.
+
+
+#Upon what parts does the eruption occur?#
+
+Usually about the face (_herpes facialis_), and most frequently about
+the lips (_herpes labialis_); on the genitalia (_herpes progenitalis_),
+the lesions are commonly found on the prepuce (_herpes præputialis_) in
+the male, and on the labia minora and labia majora in the female.
+
+
+#State the causes of herpes simplex.#
+
+Herpes facialis is often observed in association with colds and febrile
+and lung diseases. Malaria, digestive disturbance, and nervous disorders
+are not infrequently predisposing factors. Herpes progenitalis is said
+to occur more frequently in those who have previously had some venereal
+disease, especially gonorrh[oe]a, but this is questionable. It is
+probably often purely neurotic.
+
+
+#What are the diagnostic points?#
+
+The appearance of one or several vesicular groups or clusters about the
+face, and especially about the lips, is usually sufficiently
+characteristic. The same holds true ordinarily when the eruption is seen
+on the prepuce or other parts of the genitalia; it is only when the
+vesicles become rubbed or abraded and irritated that it might be
+mistaken for a venereal sore, but the history, course and duration will
+usually serve to differentiate.
+
+
+#Give the prognosis.#
+
+The eruption will usually disappear in several days or one or two weeks
+without treatment. Remedial applications, however, exert a favorable
+influence. Herpes progenitalis exhibits a strong disposition to
+recurrence.
+
+
+#What is the treatment of herpes facialis?#
+
+Anointing the parts with camphorated cold cream, with spirits of camphor
+or similar evaporating and stimulating applications will at times afford
+relief to the burning, and shorten the course.
+
+
+#What is the treatment of herpes progenitalis?#
+
+In herpes about the genitalia cleanliness is of first importance. A
+saturated solution of boric acid, a dusting-powder of calomel or oxide
+of zinc, and the following lotion, containing calamine and oxide of
+zinc, are valuable:--
+
+  [Rx] Zinci oxidi,
+       Calaminæ, .......... [=a][=a] ........ gr. v
+       Glycerinæ,
+       Alcoholis, ......... [=a][=a] ........ [minim]vj
+       Aquæ, ................................ [Oz]j      M.
+
+In obstinate recurrent cases, frequent applications of a mild galvanic
+current will have a favorable influence.
+
+
+
+                         #Hydroa Vacciniforme.#
+         (_Synonyms:_ Recurrent Summer Eruption; Hydroa Puerorum; Hydroa
+                              Aestivale.)
+
+
+#Describe hydroa vacciniforme.#
+
+It is a rare vesicular disease usually seen in boys (only two or three
+exceptions), occurring upon uncovered parts, especially the nose,
+cheeks, and ears. The lesions begin as red spots, discrete or in groups,
+rapidly exhibit vesiculation, and later umbilication; the contents
+become milky, dry to crusts, which fall off and leave small pit-like
+scars. Fresh outbreaks may take place almost continuously, and the
+process go on indefinitely, at least up to youth or manhood, when the
+tendency subsides. Its activity is usually limited to the warm season.
+Arthritic symptoms and general disturbance are sometimes noted in severe
+cases.
+
+It is doubtless a vasomotor neurosis. Exposure to sun and wind is an
+important, if not essential, etiological factor. Primarily the lesion
+begins in the rete middle layers, and is purely vesicular in character;
+later, necrosis of the rete and extending deep in the corium is
+observed.
+
+Treatment so far has only been palliative, consisting of the
+applications employed in similar conditions. Constitutional medication
+is based upon general principles. The patient should avoid exposure to
+the sun, strong wind and excessive artificial heat.
+
+
+
+                       #Epidermolysis Bullosa.#
+
+
+#Describe epidermolysis bullosa.#
+
+This is a rare, usually hereditary, disease or condition, characterized
+by the formation of vesicles and blebs on any part subjected to slight
+rubbing or irritation. No scarring is left, and no pigmentation noted.
+The predisposition to these lesions persists indefinitely. The general
+health is not involved. The nature of the disease is obscure.
+
+Treatment has no influence in modifying or lessening this tendency. The
+vulnerable parts should so far as possible be protected from knocks and
+undue friction.
+
+
+
+                         #Dermatitis Repens.#
+
+
+#What do you understand by dermatitis repens?#
+
+It is a rare spreading dermatitis starting from an injury, extending by
+a serous undermining of the epidermis, and usually occurring upon the
+upper extremities.
+
+It usually begins shortly after an injury, and, as a rule, presents
+itself by redness and serous exudation. The overlying epidermis breaks,
+and the area of disease gradually progresses by an extension of the
+serous undermining process, the denuded part looking red and raw, with
+usually an oozing surface. As the disease spreads the oldest part
+becomes dry and heals, the new epidermal covering being thin and
+atrophic in appearance. Its most usual beginning is on some part of the
+hand, and from here it may spread up the arm and involve considerable
+area.
+
+The injury from which it starts may be extremely insignificant,
+apparently affording an opening for the introduction of the causative
+factor, doubtless parasitic. Beyond a feeling of soreness there seem to
+be no special subjective symptoms.
+
+
+#Give the prognosis and treatment.#
+
+The malady shows but little tendency to spontaneous cure. The frequent
+or constant application of a mild antiseptic lotion, such as boric acid
+and resorcin, or of a mild parasiticide ointment will generally bring
+the disease gradually to an end.
+
+
+
+                          #Herpes Zoster.#
+                (_Synonyms:_ Zoster; Zona; Shingles.)
+
+
+#Give a definition of herpes zoster.#
+
+Herpes zoster is an acute, self-limited, inflammatory disease,
+characterized by groups of vesicles upon inflammatory bases, situated
+over or along a nerve tract.
+
+
+#Upon what parts of the body may the eruption appear?#
+
+It may appear upon any part, following the course of a nerve; it is
+therefore always limited in extent, and confined to one side of the
+body. It is probably most common about the intercostal, lumbar and
+supra-orbital regions. In rare instances the eruption has been observed
+to be bilateral.
+
+
+#Are there any subjective or constitutional symptoms?#
+
+Yes; there is, as a rule, neuralgic pain preceding, during and following
+the eruption; and in some cases, also, there may be in the beginning
+mild febrile disturbance. There is also a variable degree of tenderness
+and pain.
+
+
+#What are the characters of the eruption?#
+
+Several or more hyperæmic or inflammatory patches over a nerve course
+appear, upon which are seated vesico-papules irregularly grouped; these
+vesico-papules become distinct vesicles, of size from a pin-head to a
+pea, and soon dry and give rise to thin, yellowish or brownish crusts,
+which drop off, leaving in most instances no permanent trace, in others
+more or less scarring. In some cases the lesions may become pustular
+and, on the other hand, the eruption may be abortive, stopping short of
+full vesiculation.
+
+
+#What is known in regard to the nature of the disease?#
+
+An inflamed and irritable state of the spinal ganglia, nerve tract, or
+peripheral branches is directly responsible for the eruption, and this
+state may be due to atmospheric changes, cold, nerve-injuries and
+similar influences. The view has also been advanced that the disease is
+of specific and infectious character.
+
+
+#Give the chief diagnostic features of herpes zoster.#
+
+The prodromic neuralgic pain, the appearance of grouped vesicles upon
+inflammatory bases following the course of a nerve tract, and the
+limitation of the eruption to one side of the body.
+
+
+#What is the prognosis?#
+
+Favorable; the symptoms usually disappearing in two to four weeks. In
+some instances, however, the neuralgic pains may be persistent, and in
+zoster of the supra-orbital region the eye may suffer permanent damage.
+
+
+#How would you treat herpes zoster?#
+
+_Constitutional treatment_, usually tonic in character, is to be based
+upon general principles; moderate doses of quinia, with one-sixth grain
+of zinc phosphide, four or five times daily, appear in some cases to
+have a special value. The accompanying neuralgic pain may be so intense
+as to require anodynes. _Local treatment_ should be of a soothing and
+protective character. A dusting-powder of oxide of zinc and starch (to
+the ounce of which twenty to thirty grains of camphor may be added)
+proves useful; and over this, in order that the parts be further
+protected, a bandage or a layer of cotton batting. Oxide-of-zinc
+ointment, and in those cases in which there is much pain, ointments
+containing powdered opium or belladonna, or orthoform, may be used. A
+mild galvanic current applied daily to the parts is often of great
+advantage, both in its influence upon the course of the eruption and
+upon the neuralgic pain. The plan, so often advised, of painting the
+parts with flexible collodion is not to be commended.
+
+
+
+                        #Dermatitis Herpetiformis.#
+     (_Synonyms:_ Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis
+              (Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)
+
+
+#Give a definition of dermatitis herpetiformis.#
+
+Dermatitis herpetiformis is a somewhat rare inflammatory disease,
+characterized by an eruption of an erythematous, papular, vesicular,
+pustular, bullous or mixed type, with a decided disposition toward
+grouping, accompanied by itching and burning sensations, with, as a
+rule, more or less consequent pigmentation, and pursuing usually a
+chronic course with remissions.
+
+
+#Describe the erythematous type of dermatitis herpetiformis.#
+
+The character of the eruption in the erythematous type resembles closely
+that of erythema multiforme and of urticaria, especially the former. The
+efflorescences usually make their appearance in crops, and are more or
+less persistent; fading sooner or later, however, and giving place to
+new outbreaks. Vesicles are often intermingled, developing from
+erythematous and erythemato-papular lesions or arising from apparently
+normal skin.
+
+It may continue in the same type, or change to the vesicular, bullous or
+other variety.
+
+
+#Describe the papular type of dermatitis herpetiformis.#
+
+This is rarely seen as consisting purely of papular lesions, but is
+commonly associated with the erythematous and vesicular varieties. In a
+measure it resembles the papular manifestations of erythema multiforme,
+with a distinct disposition toward group formation. The papules tend,
+sooner or later, to develop into vesicles, new papular outbreaks
+occurring from time to time; or the whole eruption changes to the
+vesicular or other type of the disease. It is not a common type.
+
+
+#Describe the vesicular type of dermatitis herpetiformis.#
+
+This is the common clinical type of the disease, and is characterized by
+pin-head to pea-sized, rounded or irregularly-shaped, distended or
+flattened and stellate vesicles, occurring, for the most part, in
+irregular and segmental groups of three or more lesions, seated either
+upon apparently normal integument or upon hyperæmic or inflammatory
+skin. They exhibit no tendency to spontaneous rupture, but after
+remaining a shorter or longer time, are broken or disappear by
+absorption. The lesions tend to appear in crops. It may, as it not
+infrequently does, continue in the same type, or it may become more or
+less erythematous or bullous in character. In not a few instances
+pustules, few or in numbers, are at times intermingled.
+
+
+#Describe the pustular type of dermatitis herpetiformis.#
+
+This is rare. It is similar in its clinical characters to the vesicular
+type, except that the lesions are pustular. It is met with, as a rule,
+in association with the vesicular and bullous varieties of the disease.
+
+
+#Describe the bullous type of dermatitis herpetiformis.#
+
+The bullous expression of the disease is usually of a markedly
+inflammatory nature, often innumerable blebs, small and large, appearing
+almost continuously, and in some instances involving the greater part of
+the surface. The lesions arise from erythematous skin, from preëxisting
+vesicles or vesicular groups, or from apparently normal integument.
+There is a marked disposition to appear in clusters. A change of type to
+the erythematous or vesicular varieties is not unusual.
+
+
+#Describe the mixed type of dermatitis herpetiformis.#
+
+In this type the eruption is made up of erythematous patches, vesicles,
+bullæ, and often with pustules intermingled, appearing irregularly or in
+crops, and with a tendency to patch or group formation.
+
+
+#Describe the characters of the vesicles, pustules and blebs.#
+
+As a rule, these several lesions, especially the vesicles and blebs, are
+somewhat peculiar: they are usually of a strikingly irregular outline,
+oblong, stellate, quadrate, and when drying are apt to have a puckered
+appearance. They are herpetic in that they show little disposition to
+spontaneous rupture, occur in groups, and are usually seated upon
+erythematous or inflammatory skin--in some respects similar to the
+groups of simple herpes and herpes zoster.
+
+
+#What is to be said in regard to the subjective symptoms?#
+
+The subjective symptoms are usually the most troublesome feature of the
+disease, consisting of intense and persistent itching and a feeling of
+heat and burning.
+
+
+#Are there any constitutional symptoms in dermatitis herpetiformis?#
+
+As a rule, not, excepting the distress and depression necessarily
+consequent upon the intense itchiness and loss of sleep. In the pustular
+and bullous varieties there may be mild or grave systemic symptoms, but
+even in these types the constitutional involvement is, in most
+instances, slight in comparison to the intensity of the cutaneous
+disturbance.
+
+
+#What is the course of dermatitis herpetiformis?#
+
+Extremely chronic, in most instances lasting, with remissions,
+indefinitely. The skin is rarely entirely free. From time to time the
+type of the disease may undergo change. From the continued irritation
+and scratching more or less pigmentation results.
+
+
+#What is to be said in regard to the etiology?#
+
+The disease is in many instances essentially neurotic, and in
+exceptional instances septicæmic. Pregnancy and the parturient state are
+factors in some instances (so-called herpes gestationis). It is possible
+in some instances that the eruption may be an expression of a mild
+toxemia of gastro-intestinal origin. In some cases no cause can be
+assigned. In the majority of patients the general health, considering
+the violence of the eruptive phenomena, remains comparatively
+undisturbed.
+
+Nervous shock and mental worry are factors in some cases. Polyuria,
+with sugar in the urine, has occasionally been noted. Eosinophile
+cells have been found both in the vesicles and the blood. In some
+instances--exceptionally, it is true--the disease has appeared shortly
+after vaccination.
+
+
+#Mention the diagnostic features of dermatitis herpetiformis.#
+
+The multiformity of the eruption, the characters of the lesions, the
+disposition to grouping, the absence of tendency to form solid sheets of
+eruption (as in eczema), the intense itching, history, chronicity and
+course. In doubtful cases, an observation of several weeks will always
+suffice to distinguish it from eczema, erythema multiforme, herpes iris
+and pemphigus, diseases to which it at times bears strong resemblance.
+
+
+#Give the prognosis of dermatitis herpetiformis.#
+
+An opinion as to the outcome of the disease should be guarded. It is
+exceedingly rebellious to treatment, and relapses are the rule.
+Exceptionally the bullous and pustular varieties prove eventually fatal.
+The erythematous and vesicular varieties are the most favorable.
+
+
+#State the treatment to be advised.#
+
+There are no special remedies. Constitutional treatment must be
+conducted upon general principles. A free action of the bowels is to be
+maintained. In occasional instances arsenic in progressive doses seems
+of value. Externally protective and antipruritic applications, such as
+are employed in the treatment of eczema and pemphigus, are to be
+employed:--
+
+  [Rx] Ac. carbolici, ....................... [dram]j-[dram]ij
+       Thymol, .............................. gr. xvj.
+       Glycerinæ, ........................... [Oz]ss-[Oz]j
+       Alcoholis, ........................... f[Oz]ij
+       Aquæ, q.s., ......... ad ............. Oj.   M.
+
+Other valuable applications are: lotions of carbolic acid, of liquor
+carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment
+and carbolized oxide-of-zinc ointment, and dusting-powders of starch,
+zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion
+or ointment is sometimes of advantage; thiol employed in the same manner
+has also been commended.
+
+
+
+                             #Psoriasis.#
+
+
+#Give a definition of psoriasis.#
+
+Psoriasis is a chronic, inflammatory disease, characterized by dry,
+reddish, variously-sized, rounded, sharply-defined, more or less
+infiltrated, scaly patches.
+
+[Illustration: Psoriasis.]
+
+
+#At what age does psoriasis usually first make its appearance?#
+
+Most commonly between the ages of fifteen and thirty. It is rarely seen
+before the tenth year, and a first attack is uncommon after the age of
+forty.
+
+
+#Has psoriasis any special parts of predilection?#
+
+The extensor surfaces of the limbs, especially the elbows and knees, are
+favorite localities, and even when the eruption is more or less general,
+these regions are usually most conspicuously involved. The face often
+escapes, and the palms and soles, likewise the nails, are rarely
+involved. In exceptional instances, the eruption is limited almost
+exclusively to the scalp.
+
+
+#Are there any constitutional or subjective symptoms in psoriasis?#
+
+There is no systemic disturbance; but a variable amount of itching may
+be present, although, as a rule, it is not a troublesome symptom.
+
+
+#Describe the clinical appearances of a typical, well developed case.#
+
+Twenty or a hundred or more lesions, varying in size from a pin-head to
+a silver dollar, are usually present. They are sharply defined against
+the sound skin, are reddish, slightly elevated and infiltrated, and more
+or less abundantly covered with whitish, grayish or mother-of-pearl
+colored scales. The patches are usually scattered over the general
+surface, but are frequently more numerous on the extensor surfaces of
+the arms and legs, especially about the elbows and knees. Several
+closely-lying lesions may coalesce and a large, irregular patch be
+formed; some of the patches, also, may be more or less circinate, the
+central portion having, in a measure or completely, disappeared.
+
+
+#Give the development and history of a single lesion.#
+
+Every single patch of psoriasis begins as a pin-point or pin-head-sized,
+hyperæmic, scaly, slightly-elevated lesion; it increases gradually, and
+in the course of several days or weeks usually reaches the size of a
+dime or larger, and then may remain stationary; or involution begins to
+take place, usually by a disappearance, partially or completely, of the
+central portion, and finally of the whole patch.
+
+
+#Describe the so-called clinical varieties of psoriasis.#
+
+As clinically met with, the patches present are, as a rule, in all
+stages of development. In some instances, however, the lesions, or the
+most of them, progress no further than pin-head in size, and then remain
+stationary, constituting _psoriasis punctata_; in other cases, they
+may stop short after having reached the size of drops--_psoriasis
+guttata_; in others (and this is the usual clinical type) the patches
+develop to the size of coins--_psoriasis nummularis_. In some cases
+there is a strong tendency for the central part of the lesions to
+disappear, and the process then remain stationary, the patches being
+ring-shaped--_psoriasis circinata_; and occasionally several such rings
+coalesce, the coalescing portions disappearing and the eruption be more
+or less serpentine--_psoriasis gyrata_. Or, in other instances, several
+large contiguous lesions may coalesce and a diffused, infiltrated patch
+covering considerable surface results--_psoriasis diffusa, psoriasis
+inveterata_.
+
+[Illustration: Fig. 17. Psoriasis.]
+
+
+#Is the eruption of psoriasis always dry?#
+
+Yes.
+
+
+#What course does psoriasis pursue?#
+
+As a rule, eminently chronic. Patches may remain almost indefinitely, or
+may gradually disappear and new lesions appear elsewhere, and so the
+disease may continue for months and, sometimes, for years; or, after
+continuing for a longer or shorter period, may subside and the skin
+remain free for several months or one or two years, and, in rare
+instances, may never return.
+
+[Illustration: Fig. 18. Psoriasis.]
+
+
+#Is the course of psoriasis influenced by the seasons?#
+
+As a rule, yes; there is a natural tendency for the disease to become
+less active or to disappear altogether during the warm months.
+
+
+#What is known in regard to the etiology of psoriasis?#
+
+The causes of the disease are always more or less obscure. There is
+often a hereditary tendency, and the gouty and rheumatic diathesis must
+occasionally be considered potential. In some instances it is apparently
+influenced by the state of the general health. It is a rather common
+disease and is met with in all walks of life.
+
+
+#Is psoriasis contagious?#
+
+No. In recent years the fact of its exhibiting a family tendency has
+been thought as much suggestive of contagiousness as of heredity.
+
+
+#What is the pathology?#
+
+According to modern investigations, it is an inflammation induced by
+hyperplasia of the rete mucosum; and it is beginning to be believed that
+this hyperplasia may have a parasitic factor as the starting-cause.
+
+
+#With what diseases are you likely to confound psoriasis?#
+
+Chiefly with squamous eczema and the papulo-squamous syphiloderm; and on
+the scalp, also with seborrh[oe]a. It can scarcely be confounded with
+ringworm.
+
+
+#How is psoriasis to be distinguished from squamous eczema?#
+
+By the sharply-defined, circumscribed, scattered, scaly patches, and by
+the history and course of the individual lesions.
+
+
+#In what respects does the papulo-squamous syphiloderm differ from
+psoriasis?#
+
+The scales of the squamous syphilide are usually dirty gray in color and
+more or less scanty; the patches are coppery in hue, and usually several
+or more characteristic scaleless, infiltrated papules are to be found.
+The face, palms, and soles are often the seat of the syphilitic
+eruption; and, moreover, _concomitant symptoms of syphilis_, such as
+sore throat, mucous patches, glandular enlargement, rheumatic pains,
+falling out of the hair, together with the history of the initial
+lesion, are one, several, or all usually present.
+
+
+#How does seborrh[oe]a differ from psoriasis?#
+
+Seborrh[oe]a of the scalp is usually diffused, with but little redness
+and no infiltration; moreover, the scales of seborrh[oe]a are greasy,
+dirty gray or brownish, while those of psoriasis are dry and comonly
+whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists
+independently of other patches elsewhere on the general surface.
+
+That variety of seborrh[oe]a, commonly known as eczema seborrhoicum,
+presents at times, both on scalp and general surface, a strong
+resemblance to psoriasis, but the character of the scales and
+distribution of psoriasis, as above stated, are distinguishing points;
+seborrh[oe]a, moreover, favors hairy surfaces and in extensive examples
+the scalp, eyebrows, sternal, and pubic regions rarely escape.
+
+
+#How does psoriasis differ from ringworm?#
+
+By its greater scaliness, by its higher degree of inflammatory action,
+and by its larger number of patches, as also by its history. In ringworm
+_all_ the patches tend to clear up in the centre; in psoriasis this is
+rarely, if ever, so. If there is still any doubt, microscopic
+examination of the scrapings will determine.
+
+
+#Give the prognosis of psoriasis.#
+
+The prognosis is usually favorable, so far as concerns the immediate
+eruption, but as to recurrences, nothing positive can be stated. In rare
+instances, however, the cure remains permanent.
+
+
+#How is psoriasis treated?#
+
+Both constitutional and local remedies are demanded in most cases.
+
+
+#Do dietary measures exert any influence?#
+
+As a rule, no; but the food should be plain, and an excess of meat
+avoided.
+
+
+#Name the important constitutional remedies usually employed in
+psoriasis.#
+
+_Arsenic_ is of first importance. It is not suitable in acute or
+markedly inflammatory types; but is most useful in the sluggish, chronic
+forms of the disease. The dose should never be pushed beyond slight
+physiological action. It may be given as arsenious acid in pill form,
+one-fiftieth to one-tenth of a grain three times daily, or as Fowler's
+solution, three to ten minims at a dose.
+
+_Alkalies_, of which liquor potassæ is the most eligible. It is to be
+given in ten to twenty minim doses, largely diluted. It is valuable in
+robust, plethoric, rheumatic or gouty individuals with psoriasis of an
+acute or markedly inflammatory type; it is not to be given to
+debilitated or anæmic subjects.
+
+_Salicin_, sodium salicylate, and salophen in moderately full doses act
+well in some cases. Occasionally thyroid preparations have a good
+effect.
+
+_Potassium Iodide_, in doses of thirty to one hundred grains, t.d., acts
+favorably in some instances; there are no special indications pointing
+toward its selection, unless it be the existence of a gouty or rheumatic
+diathesis.
+
+Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper,
+and other diuretics are valuable in some instances, and, while often
+failing, sometimes exert a rapid influence, especially in those cases in
+which the disease is extensive and inflammatory. Wine of antimony, given
+cautiously, is also sometimes of service in the acute inflammatory type
+in robust subjects.
+
+
+#Are such remedies as iron, quinine, nux vomica and cod-liver oil ever
+useful in psoriasis?#
+
+Yes. In debilitated subjects the administration of such remedies is at
+times attended with improvement in the cutaneous eruption.
+
+
+#What are the indications as regards the external measures?#
+
+Removal of the scales, and the use of soothing or stimulating
+applications, according to the individual case.
+
+
+#How are the scales removed?#
+
+In ordinary cases, either by warm, plain, or alkaline baths, or
+hot-water-and-soap washings; in those cases in which the scaling is
+abundant and adherent, washing with sapo viridis and hot water may be
+required. Baths of sal ammoniac, two to six ounces to the bath are also
+valuable in removing the scaliness. The tincture of green soap (tinctura
+saponis viridis) is especially valuable for cleansing purposes in
+psoriasis of the scalp. The hot vapor bath once or twice weekly is
+serviceable in keeping the scaliness in abeyance, and has, moreover, in
+some cases, a therapeutic value.
+
+The frequency of the baths or washings will depend upon the rapidity
+with which the scales are reproduced.
+
+
+#Are soothing applications often demanded in psoriasis?#
+
+In exceptional cases; in those in which the disease is acute, markedly
+inflammatory and rapidly progressing, mild, soothing applications must
+be temporarily employed, such as plain or bran baths, with the use of
+some bland oil or ointment. As a rule, however, the conditions, when
+coming under observation, are such as to permit of stimulating
+applications from the start. The most efficient soothing applications
+are the mild lotions and ointments employed in eczema of acute type.
+
+
+#How are the stimulating remedies employed in psoriasis applied?#
+
+As ointments, oils, and paints (pigmenta).
+
+An ointment, if employed, is to be thoroughly rubbed in the diseased
+areas once or twice daily. The same may be said of the oily
+applications. The paints (medicated collodion and gutta-percha solution)
+are applied with a brush, once daily, or every second or third day,
+depending mainly upon the length of time the film remains intact and
+adherent.
+
+
+#Name the several important external remedies.#
+
+Chrysarobin, pyrogallol, tar, ammoniated mercury, [beta]-naphthol,
+and resorcin.
+
+
+#Are these several external remedies equally serviceable in all cases?#
+
+No. Their action differs slightly or greatly according to the case and
+individual. A change from one to another is often necessary.
+
+
+#In what forms and strength are these remedies to be applied?#
+
+_Chrysarobin_ is applied in several ways: as an ointment, twenty to
+sixty grains to the ounce, rubbed in once or twice daily; this is the
+most rapid but least cleanly and eligible method. As a pigment, or
+paint, as in the following:--
+
+  [Rx] Chrysarobini, ........................ [dram]j
+       Acidi salicylici, .................... gr. xx
+       Etheris, ............................. f[dram]j
+       Ol. ricini, .......................... [minim]x
+       Collodii, ............................ f[dram]vij.  M.
+
+Or it may be used in liquor gutta-perchæ (traumaticin), a drachm to the
+ounce. It may also be employed in chloroform, a drachm to the ounce; this
+is painted on, the chloroform evaporating, leaving a thin film of
+chrysarobin; over this is painted flexible collodion. If the patches are
+few and large, chrysarobin rubber-plaster may be used.
+
+Chrysarobin is usually rapid in its effect, but it has certain
+disadvantages; it may cause an inflammation of the surrounding skin,
+and, if used near the eyes, may give rise to conjunctivitis. As a rule,
+it should not be employed about the head. Moreover, it stains the linen
+permanently and the skin temporarily.
+
+_Pyrogallol_ is valuable, and is employed in the same manner and
+strength as chrysarobin. In collodion it should at first not be used of
+greater strength than three to four per cent., as in this form
+pyrogallol sometimes acts with unexpected energy. It is less rapid than
+chrysarobin, but it rarely inflames the surrounding integument. It
+stains the linen a light brown, however, and is not to be used over an
+extensive surface for fear of absorption and toxic effect. Oxidized
+pyrogallic acid, a somewhat milder drug in its effect, has been highly
+commended, and has the alleged advantage of being free from toxic
+action.
+
+_Tar_ is, all things considered, the most important external remedy. It
+is comparatively slow in its action, but is useful in almost all cases.
+As employed usually it is prescribed in ointment form, either as the
+official tar ointment, full strength or weakened with lard or
+petrolatum. It may also be used as pix liquida, with equal part of
+alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch
+(ol. rusci) may be employed, either as oily applications or incorporated
+with ointment or with alcohol. Liquor carbonis detergens, in ointment,
+one to three drachms to the ounce of simple cerate and lanolin is a mild
+tarry application which is often useful. In stubborn patches an
+occasional thorough rubbing with a mixture of equal parts of liquor
+carbonis detergens and Vleminckx's solution, followed by a mild
+ointment, sometimes proves of value. In whatsoever form tar is employed
+it should be thoroughly rubbed in, once or twice daily, the excess wiped
+off, and the parts then dusted with starch or similar powder.
+
+_Ammoniated mercury_ is applied in ointment form, twenty to sixty grains
+to the ounce. Compared to other remedies it is clean and free from
+staining, although, as a rule, not so uniformly efficacious. It is
+especially useful for application to the scalp and exposed parts. It
+should not be used over extensive surface for fear of absorption.
+
+_[beta]-Naphthol_ and _resorcin_ are applied as ointments, thirty to
+sixty grains to the ounce, and as they are (especially the former)
+practically free from staining, may be used for exposed surfaces.
+
+Gallacetophenone and aristol also act well in some cases, applied in
+five- to ten-per-cent. strength, as ointments.
+
+In obstinate patches the _x_-ray may be resorted to, employing it with
+caution and in the same manner as in other diseases.
+
+
+
+                      #Pityriasis Rosea.#
+          (_Synonym:_ Pityriasis Maculata et Circinata.)
+
+
+#What do you understand by pityriasis rosea?#
+
+Pityriasis rosea is a disease of a mildly inflammatory nature,
+characterized by discrete, and later frequently confluent, variously
+sized, slightly raised scaly macules of a pinkish to rosy-red, often
+salmon-tinged, color.
+
+
+#Upon what part of the body is the eruption usually found?#
+
+The trunk is the chief seat of the eruption, although not infrequently
+it is more or less general.
+
+
+#Describe the symptoms of pityriasis rosea.#
+
+The lesions, which appear rapidly or slowly, are but slightly elevated,
+somewhat scaly, usually rounded, except when several coalesce, when an
+irregularly outlined patch results. At first they are pale or bright
+pink or reddish, later a salmon tint (which is often characteristic) is
+noticed. The scaliness is bran-like or flaky, of a dirty gray color,
+and, as a rule, less marked in the central portion; it is never
+abundant. The skin is rarely thickened, the process being usually
+exceedingly superficial.
+
+
+#What course does pityriasis rosea pursue?#
+
+The eruption makes its appearance, as a rule, somewhat rapidly, usually
+attaining its full development in the course of one or two weeks, and
+then begins gradually to decline, the whole process occupying one or two
+months.
+
+
+#To what is pityriasis rosea to be attributed?#
+
+The cause is not known; it is variously considered as allied to
+seborrh[oe]a (eczema seborrhoicum), as being of a vegetable-parasitic
+origin, and as a mildly inflammatory affection somewhat similar to
+psoriasis. It is not a frequent disease.
+
+
+#How is pityriasis rosea distinguished from ringworm, psoriasis and the
+squamous syphiloderm?#
+
+From ringworm, by its rapid appearance, its distribution, the number of
+patches, and, if necessary, by microscopic examination of the scrapings.
+
+Psoriasis is a more inflammatory disease, is seen usually more
+abundantly upon the limbs, the scales are profuse and silvery, and the
+underlying skin is red and has a glazed look; moreover, psoriasis, as a
+rule, appears slowly and runs a chronic course.
+
+The squamous syphiloderm differs in its history, distribution, and above
+all, by the presence of concomitant symptoms of syphilis, such as
+glandular enlargement, sore throat, mucous patches, rheumatic pains, and
+falling out of the hair.
+
+
+#State the prognosis of pityriasis rosea.#
+
+It is favorable, the disease tending to spontaneous disappearance,
+usually in the course of several weeks or one or two months.
+
+
+#What treatment is to be advised in pityriasis rosea?#
+
+Laxatives and intestinal antiseptics, and ointments of salicylic acid
+(5-15 grains to the ounce), of sulphur (10-40 grains to the ounce); or a
+compound ointment containing both these ingredients can be prescribed.
+The ointment base can be equal parts of white vaselin and cold cream; in
+some instances Lassar's paste (starch powder, zinc oxid powder, each,
+[dram]ij; vaselin, [dram]iv) seems more satisfactory.
+
+
+
+                       #Dermatitis Exfoliativa.#
+       (_Synonyms:_ General Exfoliative Dermatitis; Recurrent Exfoliative
+         Dermatitis; Desquamative Scarlatiniform Erythema; Acute General
+          Dermatitis; Recurrent Exfoliative Erythema; Pityriasis Rubra.)
+
+
+#Describe dermatitis exfoliativa.#
+
+Dermatitis exfoliativa is an inflammatory disease of an acute type,
+characterized by a more or less general erythematous inflammation, in
+exceptional instances vesicular or bullous, with epidermic desquamation
+or exfoliation accompanying or following its development. Constitutional
+disturbance, which may be of a serious character, is sometimes present.
+It is a rare and obscure affection, running its course usually in
+several weeks or months, but exhibiting a decided tendency to relapse
+and recurrence. In many cases it is persistently chronic, with
+exacerbations and remissions. In some instances it develops from a
+long-continued and more or less generalized eczema or psoriasis, and in
+exceptional cases it is started by the careless use of mercurial
+ointment and of chrysarobin ointment.
+
+[Illustration: Fig. 19. Dermatitis Exfoliativa.]
+
+In another type of the disease, formerly described as _pityriasis
+rubra_, the skin is pale red or violaceous-red, but is rarely thickened,
+continued exfoliation in the form of thin plates taking place. Its
+course is variable, lasting for years, with remissions.
+
+An exfoliating generalized dermatitis is exceptionally observed in the
+first weeks of life (_dermatitis exfoliativa neonatorum_), lasting some
+weeks, and in most cases followed by recovery. There are no special
+constitutional symptoms, the fatal cases usually dying of marasmus.
+
+As will be seen dermatitis exfoliativa varies considerably in degree; it
+may be extremely mild, resembling in appearance the scarlet-fever
+eruption (erythema scarlatiniforme) and running a rapid course; or the
+skin-condition and the systemic symptoms may be of grave and persistent
+character.
+
+
+#Give the treatment of dermatitis exfoliativa.#
+
+General treatment is based upon indications, and externally soothing
+applications, such as are employed in acute and subacute eczema, are to
+be used.
+
+
+
+                        #Lichen Planus.#
+
+
+#What is lichen planus?#
+
+Lichen planus is an inflammatory disease characterized by small, flat
+and angular, smooth and shining, or scaly, discrete or confluent, red or
+violaceous-red papules, having a distinctly papular or papulo-squamous
+course, and attended with more or less itching.
+
+
+#Describe the symptoms of lichen planus.#
+
+The eruption, as a rule, begins slowly, usually showing itself upon the
+extremities; the forearms, wrists and legs being favorite localities. It
+may appear as one or more groups or in the form of short or long bands.
+Occasionally its evolution is rapid and a considerable part of the
+surface may be invaded. The lesions are pin-head to small pea-sized,
+irregularly grouped or so closely crowded together as to form solid
+patches; they are quadrangular or polygonal in shape, usually flat, with
+central depression or umbilication, and are reddish or violaceous in
+color. At first they have a glazed or shining appearance; later,
+becoming slightly scaly, the scaliness being more marked where solid
+patches have resulted. New papules may appear from time to time, the
+older lesions disappearing and leaving persistent reddish or brownish
+pigmentation. Exceptionally the eruption presents in bands or lines,
+like rows of beads (_lichen moniliformis_). Very exceptionally a
+vesicular or bleb tendency in some of the lesions has been noted;
+doubtless, in most instances at least, this has been due to the arsenic
+so generally administered in this disease. In rare instances lichen
+planus lesions are also seen on the glans penis and on the buccal mucous
+membrane. In some cases, especially in the region of the ankle, the
+papules become quite large (_lichen planus hypertrophicus_), and in
+occasional cases there is a tendency in some of the lesions or patches
+to clear up centrally. There is, as a rule, considerable itching. There
+are no constitutional symptoms.
+
+
+#What is the etiology of lichen planus?#
+
+In some cases the disease is distinctly neurotic in character, in others
+no cause can be assigned. It is more especially met with at middle age,
+and among the wealthier, professional, and luxurious classes.
+
+Pathologically the first change noted in the epidermis is thought to be
+an acanthosis, followed by epithelial atrophy, and a hyperkeratosis,
+intercellular edema, and colloid degeneration of the prickle cells.
+
+
+#Does the disease bear any resemblance to the miliary papular syphilide,
+psoriasis, and papular eczema?#
+
+In some instances it does, but the irregular and angular outline, the
+slightly-umbilicated, flattened, smooth or scaly summits, and the
+dull-red or violaceous color, the history and course, of lichen planus,
+will serve to differentiate.
+
+
+#State the prognosis.#
+
+Under proper management the eruption, although often obstinate, yields
+to treatment.
+
+
+#What treatment would you prescribe in lichen planus?#
+
+A general tonic plan of medication is indicated in most cases, with such
+remedies as iron, quinine, nux vomica, and cod-liver oil and other
+nutrients. In many instances arsenic exerts a special influence, and
+should always be tried. Mercurials in moderate dosage have also a
+favorable action in most cases. Locally, antipruritic and stimulating
+applications, such as are used in the treatment of eczema, are to be
+employed, alkaline baths and tarry applications deserving special
+mention. Liquor carbonis detergens, applied weakened with several parts
+water, is a valuable application. In some cases, particularly if the
+disease is limited, external applications alone often suffice to bring
+about a cure.
+
+
+
+                     #Pityriasis Rubra Pilaris.#
+          (_Synonyms:_ Lichen Ruber; Lichen Ruber Acuminatus.)
+
+
+#Describe pityriasis rubra pilaris.#
+
+Pityriasis rubra pilaris is an extremely rare disease, usually of a
+mildly inflammatory nature, characterized by grayish, pale-red or
+reddish-brown follicular papules with somewhat hard or horny centres;
+discrete and confluent, and covering a part or the entire surface. The
+skin is harsh, dry and rough, feeling to the touch somewhat like the
+surface of a nutmeg-grater or a coarse file. More or less scaliness is
+usually present in the confluent patches and on the palms and soles; in
+these latter regions the papules are rarely seen. The duration of the
+disease is variable, and relapses are common. It bears resemblance at
+times to keratosis pilaris, ichthyosis, dermatitis exfoliativa; it is
+considered identical with the lichen ruber acuminatus of Kaposi, and by
+many also with the lichen ruber of Hebra. The etiology is obscure.
+
+Treatment, both constitutional and local, is to be based upon general
+principles; stimulating applications, with frequent baths, such as are
+advised in psoriasis, are the most satisfactory. It is rebellious, and
+not much more than palliation can be effected in some cases, in others
+the outlook is more hopeful.
+
+
+
+                         #Lichen Scrofulosus.#
+
+
+#Describe lichen scrofulosus.#
+
+Lichen scrofulosus is a chronic, inflammatory disease, characterized by
+millet-seed-sized, rounded or flat, reddish or yellowish, more or less
+grouped, desquamating papules. The lesions have their start about the
+hair-follicles, occur usually upon the trunk, tend to group and form
+patches, and sooner or later become covered with minute scales. As a
+rule, there is no itching. It is a rare disease, and but seldom met with
+in America; it is seen chiefly in children and young people of a
+scrofulous diathesis. Scarring, slight in character, may or may not
+follow.
+
+
+#What is the treatment of lichen scrofulosus?#
+
+The condition responds to tonics and anti-strumous remedies.
+
+
+
+                              #Eczema.#
+                  (_Synonym:_ Tetter; Salt Rheum.)
+
+
+#What is eczema?#
+
+An acute, subacute or chronic inflammatory disease, characterized in the
+beginning by the appearance of erythema, papules, vesicles or pustules,
+or a combination of these lesions, with a variable amount of
+infiltration and thickening, terminating either in discharge with the
+formation of crusts, in absorption, or in desquamation, and accompanied
+by more or less intense itching and a feeling of heat or burning.
+
+
+#What are the several primary types of eczema?#
+
+Erythematous, papular, vesicular and pustular; all cases begin as one or
+more of these types, but not infrequently lose these characters and
+develop into the common clinical or secondary types--eczema rubrum and
+eczema squamosum.
+
+[Illustration: Fig. 20. Papular Eczema (leg).]
+
+
+#What other types are met with clinically?#
+
+Eczema rubrum, eczema squamosum, eczema fissum, eczema sclerosum and
+eczema verrucosum. Eczema seborrhoicum is probably a closely allied
+disease, occupying a middle position between ordinary eczema and
+seborrh[oe]a.
+
+
+#Describe the symptoms of erythematous eczema.#
+
+Erythematous eczema (_eczema erythematosum_) begins as one or more small
+or large, irregularly outlined hyperæmic macules or patches, with or
+without slight or marked swelling, and with more or less itching or
+burning. At first it may be ill-defined, but it tends to spread and its
+features to become more pronounced. It may be limited to a certain
+region, or it may be more or less general. When fully developed, the
+skin is harsh and dry, of a mottled, reddish or violaceous color,
+thickened, infiltrated and usually slightly scaly, with, at times, a
+tendency toward the formation of oozing areas. Punctate and linear
+scratch-marks may usually be seen scattered over the affected region.
+
+[Illustration: Fig. 21. Eczema Rubrum.]
+
+Its most common site is the face, but it is not infrequent upon other
+parts.
+
+
+#What course does erythematous eczema pursue?#
+
+It tends to chronicity, continuing as the erythematous form, or the skin
+may become considerably thickened and markedly scaly, constituting
+eczema squamosum; or a moist oozing surface, with more or less crusting,
+may take its place--eczema rubrum.
+
+
+#Describe the symptoms of papular eczema.#
+
+Papular eczema (_eczema papulosum_) is characterized by the appearance,
+usually in numbers, of discrete, aggregated or closely-crowded, reddish,
+pin-head-sized acuminated or rounded papules. Vesicles and
+vesico-papules are often intermingled. The itching is commonly intense,
+as often attested by the presence of scratch-marks and blood crusts.
+
+[Illustration: Fig. 22. Eczema Squamosum et tissum.]
+
+It is seen most frequently upon the extremities, especially the flexor
+surfaces.
+
+
+#What course does papular eczema pursue?#
+
+The lesions tend, sooner or later, to disappear, but are usually
+replaced by others, the disease thus persisting for weeks or months; in
+places where closely crowded, a solid, thickened, scaly sheet of
+eruption may result--eczema squamosum.
+
+
+#Describe the symptoms of vesicular eczema.#
+
+Vesicular eczema (_Eczema vesiculosum_) usually appears, on one or
+several regions, as more or less diffused inflammatory reddened patches,
+upon which rapidly develop numerous closely-crowded pin-point to
+pin-head-sized vesicles, which tend to become confluent and form a solid
+sheet of eruption. The vesicles soon mature and rupture, the discharge
+drying to yellowish, honeycomb-like crusts. The oozing is usually more
+or less continuous, or the disease may decline, the crusts be cast off,
+to be quickly followed by a new crop of vesicles. In those cases in
+which the process is markedly acute, considerable swelling and [oe]dema
+are present. Scattered papules, vesico-papules and pustules may usually
+be seen upon the involved area or about the border.
+
+The face in infants (_crusta lactea_, or _milk crust_, of older
+writers), the neck, flexor surfaces and the fingers are its favorite
+localities.
+
+
+#What course does vesicular eczema pursue?#
+
+Usually chronic, with acute exacerbations. Not infrequently it passes
+into eczema rubrum.
+
+
+#Describe the symptoms of pustular eczema.#
+
+Pustular eczema (_eczema pustulosum_, _eczema impetiginosum_) is probably
+the least common of all the varieties. It is similar, although usually
+less actively inflammatory, in its symptoms to eczema vesiculosum, the
+lesions being pustular from the start or developing from preëxisting
+vesicles; not infrequently the eruption is mixed, the pustules
+predominating. There is a marked tendency to rupturing of the lesions,
+the discharge drying to thick, yellowish, brownish or greenish crusts.
+
+Its most common sites are the scalp and face, especially in young people
+and in those who are ill-nourished and strumous.
+
+
+#What course does pustular eczema pursue?#
+
+Usually chronic, continuing as the same type, or passing into eczema
+rubrum.
+
+
+#Describe the symptoms of squamous eczema.#
+
+Squamous eczema (_eczema squamosum_) may be defined as a clinical
+variety, the chief symptoms of which are a variable degree of scaliness,
+more or less thickening, infiltration, and redness, with commonly a
+tendency to cracking or fissuring of the skin, especially when the
+disease is seated about the joints. It is developed, as a rule, from the
+erythematous or papular type. Itching is slight or intense.
+
+The disease is not uncommon upon the scalp.
+
+
+#What is the course of squamous eczema?#
+
+Essentially chronic.
+
+[Illustration: Fig. 23. Eczema of the Face and Scalp.]
+
+
+#Describe the symptoms of eczema rubrum.#
+
+Eczema rubrum is characterized by a red, raw-looking, weeping, oozing or
+discharging surface, attended with more or less inflammatory thickening,
+infiltration and swelling; the exudation, consisting of serum, sometimes
+bloody, dries into thick yellowish or reddish-brown crusts. At one time
+the whole diseased area may be hidden under a mass of crusting, at other
+times a red, raw-looking, weeping surface (_eczema madidans_) is the
+most striking feature. Itching is slight or intense, or the subjective
+symptom may be a feeling of burning. It is an important clinical type,
+usually developing from the vesicular, pustular or other primary
+variety.
+
+It is common about the face and scalp in children, and the middle and
+lower part of the leg in elderly people.
+
+
+#What is the course of eczema rubrum?#
+
+Chronic, varying in intensity from time to time.
+
+
+#Describe the symptoms of fissured eczema.#
+
+The conspicuous symptom is a marked tendency to fissuring or cracking of
+the skin (_eczema fissum_; _eczema rimosum_). This tendency is usually a
+part of an erythematous or squamous eczema, the fissuring constituting
+the most conspicuous and troublesome symptom. _Chapping_ is an extremely
+mild but familiar example of this type.
+
+It is especially common about the hands and fingers.
+
+
+#What is the course of fissured eczema?#
+
+It is more or less persistent, the tendency to fissuring varying
+considerably according to the state of the weather, often disappearing
+spontaneously in the summer months.
+
+
+#Describe eczema sclerosum and eczema verrucosum.#
+
+In eczema sclerosum the skin is thickened, infiltrated, hard, and almost
+horny. Eczema verrucosum presents similar conditions, but, in addition,
+displays a tendency to papillary or wart-like hypertrophy. In both
+varieties the disease is usually seated about the ankle or the foot,
+developing from the papular or squamous type. They are uncommon, and
+obstinately chronic.
+
+
+#State the nature of the subjective symptoms in eczema.#
+
+Itching, commonly intense, is usually a conspicuous symptom; it may be
+more or less paroxysmal. In some cases burning and heat constitute the
+main subjective phenomena.
+
+
+#Is eczema accompanied by febrile or systemic symptoms?#
+
+No. In rare instances, in acute universal eczema, slight febrile action,
+or other systemic disturbance, may be noted at the time of the outbreak.
+
+
+#Is the eczematous eruption (patch or patches) sharply defined against
+the neighboring sound skin?#
+
+No. In almost all instances the diseased area merges gradually and
+imperceptibly into the surrounding healthy integument.
+
+
+#What is the character of eczema as regards the degree of inflammatory
+action?#
+
+The inflammatory action may be acute, subacute or sluggish in character,
+and may be so from the start and so continue throughout its whole
+course; or it may, as is usually the case, vary in intensity from time
+to time.
+
+
+#State the character of eczema as regards duration.#
+
+As a rule, it is a persistent disease, showing little, if any, tendency
+to spontaneous disappearance.
+
+
+#Is eczema influenced by the seasons?#
+
+Yes. With comparatively few exceptions the disease is most common and
+much worse in cold, windy, winter weather.
+
+
+#To what may eczema be ascribed?#
+
+Eczema may be due to constitutional or local causes, or to both. It may
+be considered, in fact, as a reaction of the skin tissues against some
+irritant, and the latter may have its origin from within or without.
+
+
+#Name some of the important constitutional or predisposing causes.#
+
+Gouty diathesis, rheumatic diathesis, disorders of the digestive tract,
+general debility or lack of tone, an exhausted state of the nervous
+system, dentition and struma.
+
+
+#Is a constitutional cause sufficient to provoke an attack?#
+
+Yes; but often the attack is brought about in those so predisposed by
+some local or external irritant.
+
+
+#Mention some of the external causes.#
+
+Heat and cold, sharp, biting winds, excessive use of water, strong
+soaps, vaccination, dyes and dyestuffs, chemical irritants, and the
+like. There is a growing belief that some cases presenting eczematous
+aspects are probably parasitic in origin. In fact, some observers hold
+to the microbic view of all cases of eczema.
+
+Contact with the rhus plants, while producing a peculiar dermatitis,
+usually running an acute course terminating in recovery, may, in those
+predisposed, provoke a veritable and persistent eczema. In fact, in our
+examination as to causes in a given case, especially of the hands and face,
+all possible exciting factors should be inquired into, such as the handling
+of plants, chemicals, dyes, etc.
+
+[Illustration: Fig. 24. Eczema of Face.]
+
+
+#Is eczema contagious?#
+
+No. The acceptance of a parasitic cause for the disease, however,
+necessarily carries with it the possibility of contagiousness under
+favoring conditions. Such is not supported, however, by practical
+experience.
+
+
+#What is the pathology?#
+
+The process is an inflammatory one, characterized in all cases by
+hyperæmia and exudation, varying in degree according to the intensity
+and duration of the disease. The rete and papillary layer are especially
+involved, although in severe and chronic cases the lower part of the
+corium and even the subcutaneous tissue may share in the process.
+
+
+#Do the cutaneous manifestations of the eruptive fevers bear resemblance
+to the erythematous type of eczema?#
+
+Scarlatina and erysipelas may, to a slight extent, but the presence or
+absence of febrile and other constitutional symptoms will usually serve
+to differentiate.
+
+
+#What common skin diseases resemble some phases of eczema?#
+
+Psoriasis, seborrh[oe]a, sycosis, scabies and ringworm.
+
+
+#How would you exclude psoriasis in a suspected case of eczema (squamous
+eczema)?#
+
+Psoriasis occurs in variously-sized, rounded, _sharply-defined_ patches,
+usually scattered irregularly over the general surface, with special
+predilection for the elbows and knees. They are covered more or less
+abundantly with whitish, silvery or mother-of-pearl colored imbricated
+scales. The patches are always dry, and itching is, as a rule, slight,
+or may be entirely absent. Eczema, on the contrary, is often localized,
+appearing as one or more large, irregularly diffused patches; it merges
+imperceptibly into the sound skin, and there is often a history of
+characteristic serous or gummy oozing; the scaling is usually slight and
+itching almost invariably a prominent symptom.
+
+
+#How would you exclude seborrh[oe]a (eczema seborrhoicum) in a suspected
+case of eczema?#
+
+Seborrh[oe]a of the scalp is more commonly over the whole of that region
+and is relatively free from inflammatory symptoms; the scales are of a
+greasy character and the itching is usually slight or nil. On the other
+hand, in eczema of this region the parts are rarely invaded in their
+entirety; there may be at times the characteristic serous or gummy
+oozing; inflammatory symptoms are usually well-marked, the scales are
+dry and the itching is, as a rule, a prominent symptom. These same
+differences serve to differentiate the diseases in other regions.
+
+
+#How does scabies differ from eczema?#
+
+Scabies differs from eczema in its peculiar distribution, the presence
+of the burrows, the absence of any tendency to patch formation, and
+usually by a clear history of contagion.
+
+
+#How would you exclude ringworm in a suspected case of eczema?#
+
+Ringworm is to be distinguished by its circular form, its fading in the
+centre, and in doubtful cases by microscopic examination of the
+scrapings.
+
+
+#How does eczema differ from sycosis?#
+
+Sycosis is limited to the hairy region of the face, is distinctly a
+follicular inflammation, and is rarely very itchy; eczema is diffused,
+usually involves other parts of the face, and itching is an annoying
+symptom.
+
+
+#State the general prognosis of eczema.#
+
+The disease is, under favorable circumstances, curable, some cases
+yielding more or less readily, others proving exceedingly rebellious.
+The length of time to bring about a result is always uncertain, and an
+opinion on this point should be guarded.
+
+
+#Upon what would you base your prognosis in the individual case?#
+
+The extent of disease, its duration and previous behavior, the
+removability of the exciting and predisposing causes, and the attention
+the patient can give to the treatment.
+
+In eczema involving the lips, face, scrotum, and leg, and especially
+when this last-named exhibits a varicose condition of the veins, a cure
+is effected, as a rule, only through persistent and prolonged treatment.
+
+
+#Does eczema ever leave scars?#
+
+No. Upon the legs, in long-continued cases, more or less pigmentation
+usually remains.
+
+
+#How is eczema treated?#
+
+As a rule, eczema requires for its removal both constitutional and
+external treatment.
+
+Certain cases, however, seem to be entirely local in their nature, and
+in these cases external treatment alone will have satisfactory results.
+
+
+#What general measures as to hygiene and diet are commonly advisable?#
+
+Fresh air, exercise, moderate indulgence in calisthenics, regular
+habits, a plain, nutritious diet; abstention from such articles of food
+as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese,
+pickles, condiments, excessive coffee or tea drinking, etc. As a rule,
+also, beer, wine, and other stimulants are to be interdicted.
+
+
+#Upon what grounds is the line or plan of constitutional treatment to be
+based?#
+
+Upon indications in the individual case. A careful examination into the
+patient's general health will usually give the cue to the line of
+treatment to be adopted.
+
+
+#Mention the important remedies variously employed in the constitutional
+treatment.#
+
+_Tonics_--such as cod-liver oil, quinine, nux vomica, the vegetable
+bitters, iron, arsenic, malt, etc.
+
+_Alkalies_--sodium salicylate, potassium bicarbonate, liquor potassæ,
+and lithium carbonate.
+
+_Alteratives_--calomel, colchicum, arsenic, and potassium iodide.
+
+_Diuretics_--potassium acetate, potassium citrate, and oil of copaiba.
+
+_Laxatives_--the various salines, aperient spring waters, castor oil,
+cascara sagrada, aloes and other vegetable cathartics.
+
+_Digestives_--pepsin, pancreatin, muriatic acid and the various bitter
+tonics.
+
+
+#Are there any remedies which have a specific influence?#
+
+No; although arsenic, in exceptional instances, seems to exert a special
+action. Cod-liver oil is also of great value in some cases.
+
+Upon the whole the most important remedies are those which keep in view
+the maintenance of a proper and healthful condition of the
+gastro-intestinal tract, and especially with regular and rather free
+action of the bowels.
+
+
+#In what class of cases does arsenic often prove of service?#
+
+In the sluggish, dry, erythematous, scaly and papular types.
+
+
+#In what cases is arsenic usually contraindicated?#
+
+It should never be employed in acute cases; nor in any instance (unless
+its action is watched), in which the degree of inflammatory action is
+marked, as an aggravation of the disease usually results.
+
+
+#What should be the character of the external treatment?#
+
+It depends mainly upon the degree of inflammatory action; but the stage
+of the disease, the extent involved, and the ability of the patient to
+carry out the details of treatment, also have a bearing upon the
+selection of the plan to be advised.
+
+
+#What is to be said about the use of soap and water in eczema?#
+
+In acute and subacute conditions soap and water are to be employed, as a
+rule, as infrequently and as sparingly as possible, as the disease is
+often aggravated by their too free use. Washing is necessary, however,
+for cleanliness and occasionally, also, for the removal of the crusts.
+On the other hand, in chronic, sluggish types the use of soap and water
+frequently has a therapeutic value.
+
+
+#How often should remedial applications be made?#
+
+Usually twice daily, although in some case, and especially those of an
+acute type, applications should be made every few hours.
+
+
+#Mention several remedies or plans of treatment to be used in the acute
+or actively inflammatory cases.#
+
+Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly
+dabbed on, allowed to dry, the parts gently smeared with ointment; or
+the ointment may be applied spread on lint as a plaster.
+
+Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment,
+applied in the same manner as the above.
+
+A lotion containing calamine and zinc oxide, the sediment drying and
+coating over the affected surface:--
+
+  [Rx] Calaminæ,
+          Zinci oxidi, ... [=a][=a] ......... [dram]ij-[dram]iij
+          Glycerinæ,
+          Alcoholis, ..... [=a][=a] ......... f[dram]ss
+          Liq. calcis, ...................... f[Oz]ij
+          Aquæ, .......... q.s. ad .......... f[Oz]vj.            M.
+
+Another excellent lotion somewhat similar to the last, but of oily
+character, is made up of three drachms each of calamine and zinc oxide,
+one drachm of boric acid, ten to thirty drops of carbolic acid, and
+three ounces each of lime-water and oil of sweet almonds.
+
+Carbolic-acid lotion, about two drachms to the pint of water, to which
+may be added two or three drachms each of glycerin and alcohol; or, if
+there is intense itching, carbolic acid may be added to the several
+washes already mentioned.
+
+A lotion made of one or two drachms of liquor carbonis detergens[A] to
+four ounces of water.
+
+The following wash, especially in the dry form of the disease:--
+
+  [Rx] Ac. borici, .......................... [dram]iv
+       Ac. carbolici, ....................... [dram]j
+       Glycerinæ, ........................... [dram]ij
+       Alcoholis, ........................... [dram]ij
+       Aquæ, ............. q.s. ad .......... Oj.          M.
+
+[Footnote A: Liquor carbonis detergens is made by mixing together nine
+  ounces of tincture soap bark and four ounces of coal tar, allowing to
+  digest for eight days, and filtering. The tincture of soap bark used is
+  made with one pound of soap bark to one gallon of 95 per cent. alcohol,
+  digesting for a week or so. Instead of the proprietary name above, Prof.
+  Duhring has suggested that of tinctura picis mineralis comp.]
+
+Dusting-powders, of starch, zinc oxide and Venetian talc, alone or
+severally combined, applied freely and often, so as to afford protection
+to the inflamed surface:--
+
+  [Rx] Talci venet,
+       Zinci oxidi, ....... [=a][=a] ........ [dram]iv
+       Amyli, ............................... [Oz]j        M.
+
+If washes or dusting-powders should disagree or are not desirable or
+practicable, ointments may be employed, such as--
+
+Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated,
+diachylon ointment (if fresh and well prepared), and a paste-like
+ointment, as the following, usually called "salicylic-acid paste"; in
+markedly itchy cases, five to fifteen grains of carbolic may be added to
+each ounce:
+
+  [Rx] Ac. salicylici, ...................... gr. v-x
+       Pulv. amyli,
+       Pulv. zinci oxidi, .... [=a][=a] ..... [dram]ij
+       Petrolati, ........................... [dram]iv      M.
+
+Or the following ointment:--
+
+  [Rx] Calaminæ, ............................ [dram]j
+       Ungt. zinci oxidi, ................... [dram]vij.    M.
+
+
+#Name several external remedies and combinations useful in eczema of a
+subacute or mildly inflammatory type.#
+
+The various remedies and combinations useful when the symptoms are acute
+or markedly inflammatory (mentioned above), and more especially the
+several following:--
+
+  [Rx] Zinci oxidi, ......................... [dram]ij
+       Liq. plumbi subacetat. dilut., ....... f[dram]vj
+       Glycerinæ, ........................... f[dram]ij
+       Infus. picis liq., ................... f[Oz]iij       M.
+
+A lotion containing resorcin, five to thirty grains to the ounce.
+
+Solution of zinc sulphate, one-half to three grains to the ounce.
+
+An ointment containing calomel or ammoniated mercury, as in the annexed
+formula:--
+
+  [Rx] Hydrargyri ammoniat. seu Hydrargyri
+           chloridi mit., ................... gr. x-xxx
+         Ac. carbolici, ..................... gr. v-x
+         Ungt. zinci oxidi, ................. [Oz]j         M.
+
+Another formula, more especially useful in eczema of the hands and legs,
+is the following:--
+
+  [Rx] Ac. salicylici, ...................... gr. xxx
+       Emp. plumbi,
+       Emp. saponis,
+       Petrolati, ...... [=a][=a] ........... [Oz]j.        M.
+
+(This is to be applied as a plaster, spread on strips of lint, and
+changed every twelve or twenty-four hours.)
+
+The paste-like ointment, referred to as useful in acute eczema, may also
+be used with a larger proportion (20 to 60 grains to the ounce) of
+salicylic acid.
+
+The following, containing tar, may often be employed with advantage:--
+
+  [Rx] Ungt. picis liq., .................... [dram]j
+       Ungt. zinci oxidi, ................... [dram]vij.    M.
+
+
+#What is to be said in regard to the use of tarry applications?#
+
+Ointments or lotions containing tar should always be tried at first upon
+a limited surface, as occasionally skins are met with upon which this
+remedy acts as a more or less violent irritant. The coal tar lotion
+(liquor carbonis detergens) is the least likely to disagree and may be
+used as a mild ointment, one or two drachms to the ounce, or it may be
+diluted and used as a weak lotion as already referred to.
+
+
+#What external remedies are to be employed in eczema of a sluggish type?#
+
+The various remedies and combinations (mentioned above) useful in acute
+and subacute eczema may often be employed with benefit, but, as a rule,
+stronger applications are necessary, especially in the thick and
+leathery patches. The following are the most valuable:--
+
+An ointment of calomel or ammoniated mercury; forty to sixty grains to
+the ounce.
+
+Strong salicylic-acid ointment; a half to one drachm of salicylic acid
+to the ounce of lard.
+
+Tar ointment, official strength; or the various tar oils, alone or with
+alcohol, as a lotion, or in ointment form.
+
+Liquor picis alkalinus[B] is a valuable remedy in chronic _thickened_,
+_hard_ and _verrucous_ patches, but is a strong preparation and must be
+used with caution. It is applied diluted, one part with from eight to
+thirty-two parts of water; or in ointment, one or two drachms to the
+ounce. In such cases, also, the following is useful:--
+
+  [Rx] Saponis viridis,
+       Picis liq.,
+       Alcoholis, .......... [=a][=a] ....... [dram]iij.    M.
+
+  SIG. To be well rubbed in.
+
+[Footnote B:
+  [Rx] Potassæ, ............................. [dram]j
+       Picis liq., .......................... [dram]ij
+       Aquæ, ................................ [dram]v.
+
+  Dissolve the potash in the water, and gradually add to the tar in a
+  mortar, with thorough stirring.]
+
+In similar cases, also, the parts may be thoroughly washed or scrubbed
+with sapo viridis and hot water until somewhat tender, rinsed off,
+dried, and a mild ointment applied as a plaster.
+
+Lactic acid, applied with one to ten or more parts of water is also of
+value in the sclerous and verrucous types. Caustic potash solutions,
+used cautiously, may also be occasionally employed to advantage in these
+cases.
+
+Another remedy of value in these cases, as well as in others of more or
+less limited nature, is the _x_-ray. Exposures every few days, of short
+duration and 4 to 10 inches distance, with medium vacuum tube. This
+method has served me well in occasional cases; caution is necessary, and
+it should not be pushed further than the production of the mildest
+reaction. The repeated application of a high-frequency current, by means
+of the vacuum electrodes, is a safer and sometimes an equally beneficial
+method.
+
+
+#Is there any method of treating eczema with fixed dressings?#
+
+Several plans have been advised from time to time; some are costly, and
+some require too great attention to details, and are therefore
+impracticable for general employment. The following are those in more
+common use:--
+
+The _gelatin dressing_, as originally ordered, is made by melting over a
+water-bath one part of gelatin in two parts of water--quickly painting
+it over the diseased area; it dries rapidly, and to prevent cracking
+glycerine is brushed over the surface. Or the glycerine may be
+incorporated with the gelatin and water in the following proportion:
+glycerine, one part; gelatin, four parts, and water eight parts.
+Medicinal substances may be incorporated with the gelatin mixture.
+
+A good formula is the following:--
+
+  [Rx] Gelatin, ............................. [Oz]j
+       Zinci oxidi, ......................... [Oz]ss
+       Glycerini, ........................... [Oz]iss
+       Aquæ, ................................ [Oz]ii-[Oz]iij.
+
+This should be prepared over a water-bath, and two per cent. ichthyol
+added. A thin gauze bandage can be applied to the parts over which this
+dressing is painted, before it is completely dry; it makes a comfortable
+fixed dressing and may remain on several days.
+
+_Plaster-mull_ and _gutta-percha plaster_. The plaster-mull, consisting
+of muslin incorporated with a layer of stiff ointment, and the
+gutta-percha plaster, consisting of muslin faced with a thin layer of
+India-rubber, the medication being spread upon the rubber coating.
+
+_Rubber plasters._ These are medicated with the various drugs used in
+the external treatment of skin diseases, and are often of service in
+chronic patches.
+
+Two new excipients for fixed dressings have recently been
+introduced--bassorin and plasment; the former is made from gum
+tragacanth, and the latter from Irish moss.
+
+The following is a satisfactory formula for a tragacanth dressing:
+
+  [Rx] Tragacanth, .......................... gr. lxxv
+       Glycerini, ........................... [minim] xxx
+       Ac. carbolici, ....................... gr. x-xx
+       Zinci oxidi, ......................... [dram]iss-[dram]iiss.    M.
+
+This is painted over the parts and allowed to dry, and a mild dusting
+powder sprinkled over. It cannot be used in warm weather or in folds, as
+it is apt to get sticky. The following is a bassorin paste which may be
+variously medicated.
+
+  [Rx] Bassorin, ............................ [dram]x
+       Dextrin, ............................. [dram]vj
+       Glycerini, ........................... [Oz]ij.
+       Aquæ, ....................... q.s. ad. [Oz]iij.
+
+It should be prepared cold.
+
+Another "drying dressing" which may be used in cool weather is:
+
+  [Rx] Zinci oxidi, ......................... [Oz]j
+       Glycerini, ........................... [Oz]ss
+       Mucilag. acaciæ, ..................... [Oz]ii-[Oz]iv.
+
+It may be variously medicated.
+
+The plaster-mull is used in all types, especially the acute; the gelatin
+dressing, and the gutta-percha plaster, in the subacute and chronic; and
+the rubber plaster in chronic, sluggish patches only. Acacia,
+tragacanth, bassorin and plasment applications are used in cases of a
+subacute and chronic character.
+
+
+
+                             #Prurigo.#
+
+
+#Define prurigo.#
+
+Prurigo is a chronic, inflammatory disease, characterized by discrete,
+pin-head- to small pea-sized, solid, firmly-seated, slightly raised,
+pale-red papules, accompanied by itching and more or less general
+thickening of the affected skin.
+
+
+#Describe the symptoms and course of prurigo.#
+
+The disease first appears upon the tibial regions, and its earliest
+manifestation may be urticarial, but there soon develop the
+characteristic small, millet-seed-sized, or larger, firm elevations,
+which may be of the natural color of the skin or of a pinkish tinge. The
+lesions, whilst discrete, are in great numbers, and closely crowded. The
+overlying skin is dry, rough and harsh; itching is intense, and, as a
+result of the scratching, excoriations and blood crusts are commonly
+present. In consequence of the irritation, the inguinal glands are
+enlarged. Sooner or later the integument becomes considerably thickened,
+hard and rough. Eczematous symptoms may be superadded. In severe cases
+the entire extensor surfaces of the legs and arms, and in some instances
+the trunk also, are invaded. It is worse in the winter season.
+
+
+#What is known in regard to etiology and pathology?#
+
+It is a disease of the ill-fed and neglected, usually developing in
+early childhood, and persisting throughout life. It is extremely rare,
+even in its milder types, in this country. Clinically and pathologically
+it bears some resemblance to papular eczema.
+
+
+#Give the prognosis and treatment of prurigo.#
+
+The disease, in its severer types is, as a rule, incurable, but much can
+be done to alleviate the condition. Good, nourishing food, pure air and
+exercise are of importance. Tonics and cod-liver oil are usually
+beneficial. The local management is similar to that employed in chronic
+eczema. An ointment of [beta]-naphthol, one-half to five per cent.
+strength, is highly extolled.
+
+
+                                 #Acne.#
+
+
+#Give a definition of acne.#
+
+Acne is an inflammatory, usually chronic, disease of the sebaceous
+glands, characterized by papules, tubercles, or pustules, or a mixture
+of these lesions, and seated usually about the face.
+
+
+#At what age does acne usually occur?#
+
+Between the ages of fifteen and thirty, at which time the glandular
+structures are naturally more or less active.
+
+
+#Describe the symptoms of acne.#
+
+Irregularly scattered over the face, and in some cases also over the
+neck, shoulders and upper part of the trunk, are to be seen several,
+fifty or more, pin-head- to pea-sized papules, tubercles or pustules;
+commonly the eruption is of a mixed type (_acne vulgaris_), the several
+kinds of lesions in all stages of evolution and subsidence presenting in
+the single case. Interspersed may generally be seen blackheads, or
+comedones. The lesions may be sluggish in character, or they may be
+markedly inflammatory, with hard and indurated bases. In the course of
+several days or weeks, the papules and tubercles tend gradually to
+disappear by absorption; or, and as commonly the case, they become
+pustular, discharge their contents, or dry and slowly or rapidly
+disappear, with or without leaving a permanent trace, new lesions
+arising, here and there, to take their place. In exceptional instances
+the eruption is limited to the back, and in these cases the eruption is
+usually extensive and persistent, and not infrequently leaves scars.
+
+
+#What do you understand by acne punctata, acne papulosa, acne pustulosa,
+acne indurata, acne atrophica, acne hypertrophica, and acne
+cachecticorum?#
+
+These several terms indicate that the lesions present are, for the most
+part, of one particular character or variety.
+
+
+#Describe the lesions giving rise to the names of these various types.#
+
+Blocking up of the outlet of the sebaceous gland (comedo), which is
+usually the beginning of an acne lesion, may cause a moderate degree of
+hyperæmia and inflammation, and a slight elevation, with a central
+yellowish or blackish point results--the lesion of _acne punctata_; if
+the inflammation is of a higher grade or progresses, the elevation is
+reddened and more prominent--_acne papulosa_; if the inflammatory action
+continues, the interior or central portion of the papule suppurates and
+a pustule results--_acne pustulosa_; the pustule, in some cases, may
+have a markedly inflammatory and hard base--_acne indurata_; and not
+infrequently the lesions in disappearing may leave a pit-like atrophy or
+depression--_acne atrophica_; or, on the contrary, connective-tissue new
+growth may follow their disappearance--_acne hypertrophica_; and, in
+strumous or cachectic individuals, the lesions may be more or less
+furuncular in type, often of the nature of dermic abscesses, usually of
+a cold or sluggish character, and of more general distribution--_acne
+cachecticorum_.
+
+
+#What is acne artificialis?#
+
+Acne artificialis is a term applied to an acne or acne-like eruption
+produced by the ingestion of certain drugs, as the bromides and iodides,
+and by the external use of tar; this is also called _tar acne_.
+
+
+#What course does acne pursue?#
+
+Essentially chronic. The individual lesions usually run their course in
+several days or one or two weeks, but new lesions continue to appear
+from time to time, and the disease thus persists, with more or less
+variation, for months or years. In many cases there is, toward the age
+of twenty-five or thirty, a tendency to spontaneous disappearance of the
+disease.
+
+[Illustration: Acne.]
+
+
+#Is the eruption in acne usually abundant?#
+
+It varies in different cases and at different periods in the same case.
+In some instances, not more than five or ten papules and pustules are
+present at one time; in others they may be numerous. Not infrequently
+several lesions make their appearance, gradually run their course, and
+the face continues free for days or one or two weeks.
+
+
+#Does the eruption in acne disappear without leaving a trace?#
+
+In many instances no permanent trace remains, but in others slight or
+conspicuous scarring is left to mark the site of the lesions.
+
+
+#Are there any subjective symptoms in acne?#
+
+As a rule, not; but markedly inflammatory lesions are painful.
+
+
+#State the immediate or direct cause of an acne lesion.#
+
+Hypersecretion or retention of sebaceous matter. Recent investigations
+point to the possibility of a special bacillus being the exciting cause,
+in some instances at least. The pyogenic cocci are added factors in the
+pustular and furuncular cases.
+
+
+#Name the indirect or predisposing causes of acne.#
+
+Digestive disturbance, constipation, menstrual irregularities,
+chlorosis, general debility, lack of tone in the muscular fibres of the
+skin, scrofulosis; and medicinal substances such as the iodides and
+bromides internally, and tar externally.
+
+Working in a dusty or dirty atmosphere is often influential, resulting
+in a blocking-up of the gland ducts. Workmen in paraffin oils or other
+petroleum products often present a furuncle-like acne.
+
+The disease is more common in individuals of light complexion.
+
+
+#Is there any difficulty in the diagnosis of acne?#
+
+Not if it be remembered that acne eruption is limited to certain parts
+and is always follicular, and that the several stages, from the comedo
+to the matured lesion, are usually to be seen in the individual case.
+
+
+#In what respect does the pustular syphiloderm differ from acne?#
+
+By its general distribution, the longer duration of the individual
+lesions, the darker color, and the presence of concomitant symptoms of
+syphilis.
+
+
+#What is the pathology of acne?#
+
+Primarily, acne is a folliculitis, due to retention or decomposition of
+the sebaceous secretion or to the introduction of a micro-organism;
+subsequently, the tissue immediately surrounding becoming involved, with
+the possible destruction of the sebaceous follicle as a result. The
+degree of inflammatory action determines the character of the lesions.
+
+
+#State the prognosis of acne.#
+
+It is usually an obstinate disease, but curable. Some cases yield
+readily, others are exceedingly rebellious, especially acne of the back.
+Success depends in a great measure upon a recognition and removal of the
+predisposing condition. Treatment is ordinarily a matter of months.
+
+
+#What measures of treatment are usually demanded in acne?#
+
+Constitutional and local measures; the former when indicated, the latter
+always.
+
+
+#Upon what is the constitutional treatment based?#
+
+Upon indications. Diet and hygienic measures are important.
+
+In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin,
+saline and vegetable laxatives, are variously prescribed. Special
+mention may be made of the following:--
+
+  [Rx] Ext. rhamni pursh. fl., .............. f[dram]ij-f[dram]iv
+       Tinct. nucis vom., ................... f[dram]iij
+       Tinct. cardamomi comp., .......q.s. ad [Oz]iij.     M.
+
+  SIG.--f[dram]t.d.
+
+Or Hunyadi Janos or Friedrichshall water may be employed for a laxative
+purpose.
+
+In chlorotic and anæmic cases the ferruginous preparations are of
+advantage. Cod-liver oil is often a remedy of great value, and is
+especially useful in strumous and debilitated subjects. Calx sulphurata
+in pill form, one-tenth to one-fourth grain four or five times daily, is
+said, acts well in the pustular variety. In some instances, more
+particularly in sluggish papular acne, arsenic, especially the sulphide
+of arsenic, acts favorably. Upon the whole, the line of treatment
+that keeps in view proper and healthy action of the gastro-intestinal
+canal is the most successful.
+
+[Illustration: Acne of back.]
+
+In inflammatory cases occurring in robust individuals the following is
+often of service:--
+
+  [Rx] Potassii acetat., .................... [dram]iv
+       Liq. potassæ, ........................ f[dram]ij
+       Liq. ammonii acetat., .... q.s. ad ... f[Oz]iij.      M.
+
+  SIG.--f[dram]j-f[dram]ij t.d., largely diluted.
+
+
+#State the character of the local treatment in acne.#
+
+This must vary somewhat with the local conditions. Cases which are acute
+in character, in the sense that the lesions are markedly hyperæmic,
+tender and painful, require milder applications, and in exceptional
+instances soothing remedies are to be prescribed. As a rule, however,
+stimulating applications may be employed from the start.
+
+The remedies are, for obvious reasons, most conveniently applied at
+bedtime.
+
+
+#What preliminary measures are to be advised in ordinary acne cases?#
+
+Washing the parts gently or vigorously, according to the irritability of
+the skin, with warm water and soap; subsequently rinsing, and sponging
+for several minutes with hot water, and rubbing dry with a soft towel;
+after which the remedial application is made. In sluggish and
+non-irritable cases sapo viridis or its tincture may often be
+advantageously used in place of the ordinary toilet soap.
+
+The blackheads, so far as practicable, are to be removed by pressure
+with the fingers or with a suitable instrument (see Comedo), and the
+superficial pustules punctured and the contents pressed out. Scraping
+the affected parts with a blunt curette is a valuable measure, but is
+temporarily disfiguring. As a rule, however, cases do just as well
+without puncturing and scraping, and these methods sometimes leave
+behind scarring.
+
+
+#State the methods of external medication commonly employed.#
+
+By ointments and lotions. If an ointment is used, it is to be thoroughly
+rubbed in, in small quantity; if a lotion is employed, it is to be well
+shaken, the parts freely dabbed with it for several minutes and then
+allowed to dry on.
+
+
+#State the object in view in local medication.#
+
+To hasten the maturation and disappearance of the existing lesions, and
+to stimulate the skin and glands to healthy action.
+
+If slight irritation or scaliness results, the application is to be
+intermitted one or two nights; in the meantime nothing except the
+hot-water sponging, with or without the application of a mild soothing
+ointment, is to be employed.
+
+
+#Is it usually necessary to change from one external remedy to another in
+the course of treatment?#
+
+Yes. After a certain time one remedy, as a rule, loses its effect, and a
+change from lotion to ointment or the reverse, and from one lotion or
+ointment to another, will often be found necessary in order to bring
+about continuous improvement.
+
+
+#Name the various important remedies and combinations employed in the
+external treatment of acne.#
+
+Sulphur is the most valuable. It may often be applied with benefit as a
+simple ointment:--
+
+  [Rx] Sulphur, præcip., .................... [dram]ss-[dram]j
+       Adipis benz.
+       Lanolin, ............ [=a][=a] ....... [dram]ij.
+
+Or it may be used as a lotion, as in the annexed formula:--
+
+  [Rx] Sulphur, præcip., .................... [dram]iss
+       Pulv. tragacanthæ, ................... gr. x1
+       Pulv. camphoræ, ...................... gr. xx
+       Liq. calcis, ........ q.s. ad ........ f[Oz]iv.       M.
+
+Another lotion, especially useful in those cases in which an oily
+condition of the skin is present, is the following:--
+
+  [Rx] Sulphur, præcip., .................... [dram]iss
+       Etheris, ............................. f[dram]iv
+       Alcoholis, ........................... f[Oz]iijss.    M.
+
+A compound lotion containing sulphur in one of its combinations is also
+valuable in many cases:--
+
+  [Rx] Zinci sulphatis,
+       Potassii sulphureti, .... [=a][=a] ... [dram]ss-[dram]iv
+       Aquæ, ................................ [Oz]iv.       M.
+
+(The salts should be dissolved separately and then mixed; reaction takes
+place and the resulting lotion, when shaken, is milky in appearance, and
+free from odor; allowed to stand the particles settle, the sediment
+constituting about one-fourth to three-fourths of the whole bulk).
+
+At times the addition to this formula of several drachms of alcohol and
+of five to ten minims of glycerin is of advantage.
+
+An external remedy, often valuable, is ichthyol. It is thus
+prescribed:--
+
+  [Rx] Ichthyol, ............................ [dram]ss-[dram]j
+       Cerat. simp., ........................ [dram]iv.     M.
+
+The various mercurial ointments, especially one of white precipitate,
+five to fifteen per cent. strength, are sometimes beneficial.
+
+A compound lotion, containing mercury, which frequently proves
+serviceable, is:--
+
+  [Rx] Hydrarg. chlorid. corros., ........... gr. ii-viij
+       Zinci sulphatis, ..................... gr. x-xx
+       Tinct. benzoini, ..................... f[dram]ij
+       Aquæ, ............ q.s. ad ........... f[Oz]iv.
+
+In extremely sluggish cases the following, used cautiously, is of
+value:--
+
+  [Rx] Ichthyol,
+       Saponis viridis,
+       Sulphur, præcip.,
+       Lanolin, ............. [=a][=a] ...... [dram]j.
+
+In such instances the application of a strong alcoholic resorcin lotion,
+ten to twenty-five per cent. strength, repeated several times daily till
+marked irritation and exfoliation occur (a matter usually of one to
+three days), will sometimes be followed by marked improvement. Acne of
+the back is treated with the same applications, but usually stronger; in
+this region applications of Vleminckx's solution and formaldehyde
+solution, weakened considerably, at first at least, prove of value.
+
+_Obstinate and indurated lesions_ may be incised, the contents pressed
+out, and the interior touched with carbolic acid by means of a pointed
+stick. The _x_-ray has proved a most valuable addition to our resources
+in the treatment of acne, and is especially serviceable in extensive and
+obstinate cases. An exposure should be made about twice weekly, at a
+distance of five to ten inches and for from three to ten minutes, and a
+tube of medium vacuum used. It must be used with great caution and never
+beyond the production of the mildest erythema. The hair, eyes, and lips
+should be protected. The _x_-ray treatment is best reserved for
+obstinate cases, and then used mildly, and rather as an adjuvant to the
+ordinary methods than as the sole measure.
+
+
+#What precaution is to be taken in advising a change from a sulphur to a
+mercurial preparation or the reverse?#
+
+Several days should be allowed to intervene, otherwise a disagreeable,
+although temporary, staining or darkening of the skin results--from the
+formation of the black sulphuret of mercury.
+
+
+
+                           #Acne Rosacea.#
+
+
+#Give a descriptive definition of acne rosacea.#
+
+Acne rosacea is a chronic, hyperæmic or inflammatory disease, limited to
+the face, especially to the nose and cheeks, characterized by redness,
+dilatation and enlargement of the bloodvessels, more or less acne and
+hypertrophy.
+
+
+#Describe the symptoms of acne rosacea.#
+
+The disease may be slight or well-marked. Redness, capillary dilatation,
+and acne lesions seated on the nose and cheeks, and sometimes on chin
+and forehead also, constitute in most cases the entire symptomatology.
+
+A mild variety consists in simple redness or hyperæmia, involving the
+nose chiefly and often exclusively, and is to be looked upon as a
+passive congestion; this is not uncommon in young adults and is
+often associated with an oily seborrh[oe]a of the same parts. In many
+cases the condition does not progress beyond this stage. In other
+cases, however, sooner or later the dilated capillaries become
+permanently enlarged (_telangiectasis_) and acne lesions are often
+present--constituting the middle stage or grade of the disease; this is
+the type most frequently met with. In exceptional instances, still
+further hypertrophy of the bloodvessels ensues, the glands are enlarged,
+and a variable degree of connective-tissue new growth is added; this
+latter is usually slight, but may be excessive, the nose presenting an
+enlarged and lobulated appearance (_rhinophyma_).
+
+[Illustration: Fig. 25. Acne Rosacea.]
+
+
+#Are there any subjective symptoms in acne rosacea?#
+
+As a rule, no. Some of the acne lesions may be tender and painful, and
+at times there is a feeling of heat and burning.
+
+
+#What do you know in regard to the etiology?#
+
+In many cases the causes are obscure. Chronic digestive and intestinal
+disorders, anæmia, chlorosis, continued exposure to heat or cold,
+menstrual and uterine irregularities, and the too free use of spirituous
+liquors, tea, etc. are often responsible factors.
+
+It is essentially a disease of adult life, common about middle age,
+occurring in both sexes, but rarely reaching the same degree of
+development in women as observed at times in men.
+
+
+#Is acne rosacea easily recognized?#
+
+Yes. The redness, acne lesions, dilated capillaries, and, at times, the
+glandular and connective-tissue hypertrophy; the limitation of the
+eruption to the face, especially the region of the nose; the evident
+involvement of the sebaceous glands, the absence of ulceration, taken
+with the history of the case, are characteristic.
+
+It is to be distinguished from the tubercular syphiloderm and lupus
+vulgaris, diseases to which it may bear rough resemblance.
+
+
+#State the prognosis of acne rosacea.#
+
+All cases may be favorably influenced by treatment; the mild and
+moderately-developed types are, as a rule, curable, but usually
+obstinate. It is a persistent disease, showing little, if any, tendency
+to disappear spontaneously.
+
+
+#What is the method of treatment?#
+
+Both constitutional and local measures are demanded in most cases.
+
+
+#Upon what is the constitutional treatment to be based?#
+
+The constitutional treatment, beyond a regulation of the diet, is to be
+based upon a correct appreciation of the etiological factors in the
+individual case. There are no special remedies. Iron, cod-liver oil,
+tonics, ergot, alkalies, saline laxatives, and similar drugs are to be
+variously prescribed.
+
+
+#What is the external treatment?#
+
+In many respects, both as to the preliminary measures and remedies,
+essentially the same as that employed in the treatment of simple acne
+(_q. v._). The _x_-ray treatment is not so efficient in this disease,
+however, as in acne. In addition to the treatment there found, several
+other applications deserve mention:--
+
+In many cases _Vleminckx's solution_[C] is valuable, applied diluted
+with one to ten parts of water. Also, a mucilaginous paste containing
+sulphur:--
+
+  [Rx] Mucilag. acaciæ, ..................... f[dram]iij
+       Glycerinæ, ........................... f[dram]ij
+       Sulphur, præcip., .................... [dram]iij.    M.
+
+[Footnote C:
+  [Rx] Calcis, .............................. [Oz]ss
+       Sulph. sublimat., .................... [Oz]j
+       Aquæ, ................................ [Oz]x.
+
+  To be boiled down to [Oz]vj and filtered.]
+
+Or a similar paste with the glycerine in the foregoing replaced with
+ichthyol may be used.
+
+
+#In what manner are the dilated bloodvessels and connective-tissue
+hypertrophy to be treated?#
+
+The enlarged capillaries are to be destroyed by incision or by
+electrolysis. Properly managed the vessels may be thus destroyed, but
+unless the predisposing causes have disappeared or have been remedied, a
+new growth may take place.
+
+If the knife is employed, the vessels are either slit in their length or
+cut transversely at several points. The method by electrolysis is the
+same as used in the removal of superfluous hair (_q. v._).; the needle
+may, if the vessel is short, be inserted along its calibre, or if long,
+may be inserted at several points in its length.
+
+Excessive connective-tissue growth, exceptionally met with, is to be
+treated by ablation with the scissors or knife.
+
+
+
+                       #Acne Varioliformis.#
+   (_Synonyms:_ Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne;
+                        Necrotic Granuloma.)
+
+
+#Describe acne varioliformis.#
+
+Acne varioliformis is characterized by lesions of a moderately
+superficial papulo-pustular type, which in disappearing leave slight or
+pit-like scars. The forehead and scalp are the favorite sites, but they
+may also occur elsewhere. The eruption is rather scanty as a rule,
+consisting usually of ten to thirty lesions. They begin as small
+maculo-papules, as papules, or as minute nodules in or on the skin, and
+gradually become small pea-sized, with a tendency to slight vesiculation
+or pustulation at the central part. The lesion is sluggish in its
+course, drying to a thin crust, which finally falls off, leaving a
+depressed variola-like scar. New lesions arise from time to time, and
+the disease thus continues almost indefinitely. There may or may not be
+itching. In what appears to be a variety of this disease, known usually
+as _acne urticata_, there is considerable itching just at the time the
+lesion is appearing. The malady is not frequent, but occurs in both
+sexes, usually in those between the ages of twenty and fifty. It seems
+probable that the eruption is parasitic in origin.
+
+The maladies variously known as hydradenitis suppurativa, acnitis,
+spiradenitis, folliclis, granuloma necroticum, etc., in which the
+lesions, primarily at least, are somewhat deeper seated, sluggish in
+their course, and followed by scarring, could be also included under
+this head.
+
+#Give the prognosis and treatment.#
+
+The disease is rebellious and tends to recur. The most efficient
+applications are those of sulphur and resorcin, the same as prescribed
+in ordinary acne.
+
+
+
+                            #Sycosis.#
+  (_Synonyms:_ Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis
+                   Barbæ; Sycosis Coccogenica.)
+
+
+#What do you understand by sycosis?#
+
+Sycosis is a chronic, inflammatory affection involving the
+hair-follicles, usually of the moustache and bearded regions only, and
+characterized by papules, tubercles, and pustules perforated by hairs.
+
+
+#Describe the symptoms of sycosis.#
+
+Sycosis begins by the formation of papules and pustules about the
+hair-follicles; the lesions occur in numbers, in close proximity,
+and together with the accompanying inflammation, make up a small or large
+area. The pustules are small, rounded, flat or acuminated, discrete, and
+yellowish in color; they are perforated by hairs, show no tendency to
+rupture, and are apt to occur in crops, drying to thin yellowish or
+brownish crusts. Papules and tubercles are often intermingled. More or
+less swelling and infiltration are noticeable.
+
+[Illustration: Fig. 26.
+  Sycosis--not infrequently begins in, and sometimes limited to, this
+  region.]
+
+The disease is seen, as a rule, only on the bearded part of the face,
+either about the cheeks, chin or upper lip, involving a small portion or
+the whole of these parts. It is also sometimes met with involving the
+hair follicles just within the nasal orifice, and may even be limited to
+this region.
+
+Occasionally a sycosiform eruption, usually of the side of the bearded
+region, leaves behind a smooth or keloidal scar, the disease gradually
+extending--_ulerythema sycosiforme_ (lupoid sycosis).
+
+An inflammation of the hair-follicles of the scalp apparently sycosiform
+in character, occurring as discrete or aggregated lesions, is sometimes
+observed, the follicles being destroyed and atrophy or slight scarring
+resulting--_folliculitis decalvans_.
+
+
+#Does conspicuous hair loss occur in sycosis?#
+
+Ordinarily not; the hairs are, especially at first, usually firmly
+seated, but in those cases in which suppuration is active, and has
+involved the follicles, they may, as a rule, be easily extracted. In
+some cases destruction of the follicles ensues and slight scarring and
+permanent hair loss result.
+
+
+#State the character of the subjective symptoms.#
+
+Pain and itching and a sense of burning, variable as to degree, may be
+present.
+
+
+#What is the course of the disease?#
+
+Essentially chronic, the inflammatory action being of a subacute or
+sluggish character, with acute exacerbations.
+
+
+#State the causes of sycosis.#
+
+Upon the upper lip it may have its origin in a nasal catarrh. Entrance
+into the follicles of pyogenic micrococci is now regarded as the
+essential factor. This view being accepted, carries with it the
+possibility of contagiousness.
+
+It is seen in the male sex only, usually in those between the ages of
+twenty-five and fifty; and is met with in those in good and bad health,
+and among rich and poor. It is comparatively infrequent.
+
+
+#What is the pathology of sycosis?#
+
+The disease is primarily a perifolliculitis, the follicle and its sheath
+subsequently becoming involved in the inflammatory process.
+
+
+#How would you distinguish sycosis from eczema?#
+
+Eczema is rarely sharply limited to the bearded region, but is apt to
+involve other parts of the face; moreover, the lesions are usually
+confluent, and there is either an oozing, red crusted surface, or it is
+dry and scaly.
+
+
+#How would you exclude tinea sycosis in the diagnosis?#
+
+In tinea sycosis, or ringworm sycosis, the history of the case is
+different. The parts are distinctly lumpy and nodular; the hairs are
+soon involved and become dry, brittle, loose, and fall out, or they may
+be readily extracted. The superficial type of ringworm sycosis is
+readily distinguished by the ring-like character of the patches. In
+doubtful cases, microscopic examination of the hairs may be resorted to.
+
+
+#Give the prognosis of sycosis.#
+
+The disease is curable, but almost invariably obstinate and rebellious
+to treatment. The duration, extent, and character of the inflammatory
+process must all be considered. An expression of an opinion as to the
+length of time required for a cure should always be guarded.
+
+Ulerythema sycosiforme is extremely obstinate. Folliculitis decalvans is
+also rebellious.
+
+
+#How is sycosis to be treated?#
+
+Mainly, and often exclusively, by external applications.
+
+[Illustration: Fig. 27. Sycosis.]
+
+
+#Is constitutional treatment of no avail in sycosis?#
+
+In some instances; but, as a rule, it is negative. If indicated, such
+remedies as tonics, alteratives, cod-liver oil and the like are to be
+prescribed.
+
+
+#Describe the external treatment.#
+
+Crusting, if present, is to be removed by warm embrocations. If the
+inflammation is of a high grade, and the parts tender and painful,
+soothing applications, such as bland oils, black wash and oxide-of-zinc
+ointment, cold cream and petrolatum, are to be used; boric-acid
+solution, fifteen grains to the ounce, may be advised in place of black
+wash.
+
+In most cases, however, astringent and stimulating remedies are demanded
+from the start, such as: diachylon ointment, alone or with ten to thirty
+grains of calomel to the ounce; oleate of mercury, as a five- to
+twenty-per-cent. ointment; precipitated sulphur, one to three drachms to
+the ounce of benzoated lard, or lard and lanolin; a ten- to
+twenty-five-per-cent. ichthyol ointment; and resorcin lotion or
+ointment, ten to twenty per cent. strength.
+
+[Illustration: Fig. 28. Sycosis.]
+
+A change from one application to another will be found necessary in
+almost all cases.
+
+In obstinate cases the x-ray treatment can be used, as it has proved
+itself valuable in some instances; as in other diseases, it should be
+employed cautiously.
+
+
+#What would you advise in regard to shaving?#
+
+When bearable (and after a few days' application of soothing remedies it
+almost always is), it is to be advised in all cases, as it materially
+aids in the treatment. After a cure is effected it should be continued
+for some months, until the healthy condition of the parts is thoroughly
+established.
+
+
+#When is depilation advisable as a therapeutic measure?#
+
+When the suppurative process is active, in order to save the follicles
+from destruction; incising or puncturing the pustules will often
+accomplish the same end.
+
+Depilation is in all cases a valuable therapeutic measure, but it is
+painful; as a routine practice, shaving is less objectionable and, upon
+the whole, is probably as satisfactory. Those who make free use of the
+x-ray commonly push it to the point of producing depilation.
+
+
+
+                #Dermatitis Papillaris Capillitii.#
+                     (_Synonym:_ Acne Keloid.)
+
+[Illustration: Fig. 29. Dermatitis Papillaris Capillitii.]
+
+
+#Describe dermatitis papillaris capillitii.#
+
+This is a peculiar, mildly inflammatory, sycosiform, keloidal, acne-like
+disease of the hairy border of the back of the neck, often extending
+upward to the occipital region; partaking, especially later in its
+course, somewhat of the nature of keloid. Several or more acne-like
+lesions, papular and pustular, closely grouped or bunched, appear,
+developing slowly, usually to the size of peas; are red, pale red, or
+whitish, often enveloping small tufts of hair, and attended with more or
+less hair loss. Its course is gradual and persistent. It is an
+exceedingly rare condition, the exact nature of which is still obscure.
+
+
+#Give the treatment.#
+
+Treatment, which is usually unsatisfactory, consists of stimulating
+applications--the same, in fact, as employed in sycosis, sulphur and
+ichthyol deserving special mention. Depilation is essential.
+
+
+
+                     #Impetigo Contagiosa.#
+
+
+#Give a descriptive definition of impetigo contagiosa.#
+
+Impetigo contagiosa is an acute, contagious, inflammatory disease,
+characterized by the formation of discrete, superficial, flat, rounded,
+or ovalish vesicles or blebs, soon becoming vesico-pustular, and drying
+to thin yellowish crusts.
+
+
+#Upon what parts does the eruption commonly appear?#
+
+Upon the face, scalp, and hands, and exceptionally upon other regions.
+
+
+#Describe the symptoms of impetigo contagiosa.#
+
+One, several or more small pin-head-sized papulo-vesicles or vesicles
+make their appearance, usually upon the face and fingers. In the male
+adult the region of the neck and beard is a favorite situation. They
+increase in size by extending peripherally, but are more or less
+flattened and umbilicated, and are without conspicuous areola. The
+lesions may attain the size of a dime or larger, and when close together
+may coalesce and form a large patch. In some cases distinct blebs
+result, and a picture of pemphigus eruption presented; it is probable
+that many of the cases of "contagious pemphigus" belong to this class.
+New lesions may appear for several days, but finally, in the course of a
+week or ten days, they have all dried to thin, wafer-like crusts, of a
+straw or light-yellow color, but slightly adherent, and appearing as if
+stuck on; these soon drop off, leaving faint reddish spots, which
+gradually fade. In some cases there is so decided a tendency to clear
+and dry up centrally while spreading peripherally that the eruption has
+a ring-like aspect; this seems especially so in the bearded region of
+the male adult.
+
+Instead of presenting as described, it may occur as one or more pea- or
+finger-nail-sized, rounded and elevated, usually firm, discrete
+pustules, scattered over one part, or more commonly over various
+regions, such as the face, hands, feet and lower extremities. The
+pustules are such from the beginning, and when developed are usually of
+the size of a pea or finger-nail, elevated, semi-globular or rounded,
+with somewhat thick and tough walls, and of a whitish or yellowish
+color; at first there may be a slight inflammatory areola, but as the
+lesion matures this almost, if not entirely, disappears. The pustules
+show no disposition to umbilication, rupture or coalescence; drying in
+the course of several days or a week to yellowish or brownish crusts,
+which soon drop off, leaving no permanent trace. This variety was
+formerly thought to be a distinct disease, and was described under the
+name of _impetigo simplex_.
+
+As a rule there are no constitutional symptoms, but in the more severe
+cases the eruption may be preceded by febrile disturbance and malaise.
+Itching may or may not be present.
+
+
+#State the cause of the disease.#
+
+It is contagious, the contents of the lesions being inoculable and
+auto-inoculable. At times it seems to prevail in epidemic form. Pyogenic
+microörganisms are now regarded as causative. A relationship to
+vaccination has been alleged by some observers. It is more commonly
+observed in infants and young children.
+
+
+#From what diseases is impetigo contagiosa to be differentiated?#
+
+From eczema, pemphigus, and ecthyma.
+
+
+#How does impetigo contagiosa differ from these several diseases?#
+
+By the character of the lesions, their growth, their superficial nature,
+their course, the absence of an inflammatory base and areola, the thin,
+yellowish, wafer-like crusts, and usually a history of contagion.
+
+
+#State the prognosis.#
+
+The effect of treatment is usually prompt. The disease, indeed, tends to
+spontaneous disappearance in two to four weeks; in exceptional
+instances, more especially in those cases in which itching is present,
+the excoriations or scratch-marks become inoculated, and in this way it
+may persist several weeks.
+
+
+#What is the treatment of impetigo contagiosa?#
+
+Treatment consists in the destruction of the auto-inoculable properties
+of the contents of the lesions; this is effected by removing the crusts
+by means of warm water-and-soap washings, and subsequently rubbing in an
+ointment of ammoniated mercury, ten to twenty grains to the ounce. Some
+cases respond more rapidly to the use of a drying ointment, such as
+Lassar's paste, with ten to twenty grains of white precipitate or
+sulphur to the ounce. In itching cases, a saturated solution of boric
+acid, or a carbolic-acid lotion, one to two drachms to the pint, is to
+be employed for general application.
+
+
+
+                     #Impetigo Herpetiformis.#
+
+
+#Describe impetigo herpetiformis.#
+
+Impetigo herpetiformis is an extremely rare disease, observed usually in
+pregnant women, and is characterized by the appearance of numerous
+isolated and closely-crowded pin-head-sized superficial pustules, which
+show a decided disposition to the formation of circular groups or
+patches. The central portion of these groups dries to crusts, while new
+pustules appear at the peripheral portion. They tend to coalesce, and in
+this manner a greater part of the whole surface may, in the course of
+weeks or months, become involved. Profound constitutional disturbance,
+usually of a septic character, precedes and accompanies the disease; in
+almost every instance a fatal termination sooner or later results.
+
+It is possibly a grave type of dermatitis herpetiformis.
+
+
+
+                            #Ecthyma.#
+
+
+#Give a descriptive definition of ecthyma.#
+
+Ecthyma is a disease characterized by the appearance of one, several or
+more discrete, finger-nail-sized, flat, usually markedly inflammatory
+pustules.
+
+
+#Describe the symptoms and course of ecthyma.#
+
+The lesions begin as small, usually pea-sized, pustules; increase
+somewhat in area, and when fully developed are dime-sized, or larger,
+somewhat flat, with a markedly inflammatory base and areola. At first
+yellowish they soon become, from the admixture of blood, reddish, and
+dry to brownish crusts, beneath which will be found superficial
+excoriations. The individual pustules are usually somewhat acute in
+their course, but new lesions may continue to appear from day to day or
+week to week. As a rule, not more than five to twenty are present at one
+time, and in most cases they are seated on the legs. More or less
+pigmentation, and sometimes superficial scarring, may remain to mark the
+site of the lesions.
+
+Itching is rarely present, but there may be more or less pain and
+tenderness.
+
+
+#What is the cause of ecthyma?#
+
+It is essentially a disease of the poorly cared-for and ill-fed; the
+direct exciting cause is the introduction of pyogenic microörganisms
+into the follicular openings. It is closely allied to impetigo
+contagiosa, and may in fact be regarded as a markedly inflammatory form
+of the latter affection. It seems much less contagious, however. It is
+commonly observed in male adults.
+
+
+#From what diseases is ecthyma to be differentiated?#
+
+From impetigo contagiosa, and the flat pustular syphiloderm.
+
+
+#How is it distinguished from these several diseases?#
+
+The size, shape, inflammatory action, and the depraved general
+condition, the distribution and lesser-contagiousness will distinguish
+it from impetigo contagiosa; and the absence of concomitant symptoms of
+syphilis, and of positive ulceration, as well as its distribution and
+more rapid and inflammatory course, will exclude the pustular
+syphiloderm.
+
+
+#State the prognosis.#
+
+The disease is readily curable, disappearing upon the removal of the
+predisposing cause and the employment of local antiseptic applications.
+
+
+#What treatment is to be advised?#
+
+Good food, proper hygiene and tonic remedies; and, locally, removal of
+the crusts and stimulation of the underlying surface with an ointment of
+ammoniated mercury, ten to thirty grains to the ounce.
+
+The following mild antiseptic lotion, which materially lessens the
+tendency to the formation of new lesions, may be applied to the affected
+region two or three times daily:--
+
+  [Rx] Acidi borici, ........................ [dram]iv
+       Resorcini, ........................... [dram]ij
+       Glycerinæ, ........................... f[dram]ij
+       Alcoholis, ........................... f[Oz]j
+       Aquæ, ........... q.s. ad ............ Oj.           M.
+
+A weak lotion of thymol, corrosive sublimate or ichthyol would doubtless
+be equally effectual.
+
+
+
+                             #Pemphigus.#
+
+
+#What do you understand by pemphigus?#
+
+Pemphigus is an acute or chronic disease characterized by the successive
+formation of irregularly-scattered, variously-sized blebs.
+
+
+#Name the varieties met with.#
+
+Two varieties are usually described--pemphigus vulgaris and pemphigus
+foliaceus.
+
+
+#Describe the symptoms and course of pemphigus vulgaris.#
+
+With or without precursory symptoms of systemic disturbance, irregularly
+scattered blebs, few or in numbers, make their appearance, arising from
+erythematous spots or from apparently normal skin. They vary in size
+from a pea to a large egg, are rounded or ovalish, usually distended,
+and contain a yellowish fluid which, later, becomes cloudy or puriform.
+If ruptured, the rete is exposed, but the skin soon regains its normal
+condition; if undisturbed, the fluid usually disappears by absorption.
+Each lesion runs its course in several days or a week.
+
+A grave type of pemphigus is exceptionally observed in the
+newborn--_pemphigus neonatorum_.
+
+
+#What course does pemphigus vulgaris pursue?#
+
+Usually chronic. The disease may subside in several months and the
+process come to an end, constituting the acute type. As a rule, however,
+the disease is chronic, new blebs continuing to appear from time to time
+for an indefinite period.
+
+[Illustration: Fig. 30. Pemphigus (mulatto).]
+
+
+#In what respects does the severe form of pemphigus vulgaris differ from
+the ordinary type?#
+
+In the severe or malignant type the eruption is more profuse; there is
+marked, and often grave, systemic depression, and the lesions are
+attended with ulcerative action.
+
+
+#Describe the symptoms and course of pemphigus foliaceus.#
+
+In this, the grave type of the disease, the blebs are loose and flaccid,
+with milky or puriform contents, rupturing and drying to crusts, which
+are cast off, disclosing the reddened corium. New blebs appear on the
+sites of disappearing or half-ruptured lesions, and the whole surface
+may be thus involved and the disease continue for years, compromising
+the general health and eventually ending fatally.
+
+In some cases of pemphigus (pemphigus vegetans) a vegetating or
+papillomatous condition develops from the base of the lesion, with an
+offensive discharge; it is usually a grave type of the malady.
+
+Exceptionally cases (dermatitis vegetans) are met with which have a
+close similarity in their symptoms to pemphigus vegetans, but in which
+the eruption is more or less limited to the genitocrural region. The
+disorder is not malignant and usually yields to cleanliness and
+antiseptics.
+
+
+#What is the character of the subjective symptoms in pemphigus?#
+
+The subjective symptoms consist variously of heat, tenderness, pain,
+burning and itching, and may be slight or troublesome.
+
+
+#What is known in regard to the etiology of pemphigus?#
+
+The causes are obscure; general debility, overwork, shock, nervous
+exhaustion, and septic conditions (microörganisms) are thought to be of
+influence. There seems no doubt that those who have to do with cattle
+products, especially butchers, are subjects of acute and usually grave
+pemphigus. Vaccination has exceptionally been responsible for the
+disease, probably through some coincidental infection. The disease is
+not contagious, nor is it due to syphilis. It may occur at any age.
+
+It is a rare disease, especially in this country. Most of the cases
+diagnosed as pemphigus by the inexperienced are examples of bullous
+urticaria, bullous erythema multiforme, and impetigo contagiosa.
+
+
+#What is the pathology?#
+
+The lesions are superficially seated, usually between the horny layer
+and upper part of the rete. Round-cell infiltration and dilated blood
+vessels are found about the papillæ and in the subcutaneous tissue. The
+contents of the blebs, always of alkaline reaction, are at first serous,
+later containing blood corpuscles, pus, fatty-acid crystals, epithelial
+cells, and occasionally uric acid crystals and free ammonia.
+
+
+#From what diseases is pemphigus to be differentiated?#
+
+From herpes iris, the bullous syphiloderm, impetigo contagiosa and
+dermatitis herpetiformis.
+
+
+#How do these several diseases differ from pemphigus?#
+
+The acute course, small lesions, concentric arrangement, variegated
+colors, and distribution, in herpes iris; the thick, bulky, greenish
+crusts, the underlying ulceration, the course, history, and the presence
+of concomitant symptoms of syphilis, in the bullous syphiloderm; the
+history, course, distribution, the character of the crusting, and the
+contagious and auto-inoculable properties of the contents of the
+lesions, in impetigo contagiosa; the tendency to appear in groups, the
+smaller lesions, the intense itchiness, course, multiform characters of
+the eruption and the disposition to change of type in dermatitis
+herpetiformis,--will serve as differential points.
+
+
+#State the prognosis of pemphigus.#
+
+Its duration is uncertain, and the issue may in severe cases be fatal.
+In the milder types, after months or several years, recovery may take
+place.
+
+The extent and severity of the disease and the general condition of the
+patient are always to be considered before an opinion is expressed.
+
+Pemphigus neonatorum usually ends fatally.
+
+
+#Give the treatment of pemphigus.#
+
+Both constitutional and local measures are demanded. Good nutritious
+food and hygienic regulations are essential. Arsenic and quinia are the
+most valuable remedies. The former, in occasional instances, seems to
+have a specific influence, and should always be tried, beginning with
+small doses and increasing gradually to the point of tolerance and
+continued for several weeks or longer. The remedy should not be set
+aside as long as there are signs of improvement, unless the supervention
+of stomachic, intestinal or other disturbance demand its discontinuance.
+Other tonics, such as iron, strychnia and cod-liver oil, are also at
+times of service.
+
+The blebs should be opened and the parts anointed or covered with a mild
+ointment. In more general cases bran, starch and gelatin baths, and in
+severe cases the continuous bath, if practicable, are to be used.
+
+
+
+
+#CLASS III.--HEMORRHAGES.#
+
+
+                              #Purpura.#
+
+
+#Define purpura.#
+
+Purpura is a hemorrhagic affection characterized by the appearance of
+variously-sized, usually non-elevated, smooth, reddish or purplish spots
+or patches, not disappearing under pressure.
+
+
+#Name the several varieties met with.#
+
+Three--purpura simplex, purpura rheumatica and purpura hæmorrhagica;
+denoting, respectively, the mild, moderate and severe grade of the
+disease. The division is, to a great extent, an arbitrary one.
+
+
+#Describe the clinical appearance and course of an individual lesion of
+purpura.#
+
+The spot, which may be pin-head, pea-, bean-sized or larger, appears
+suddenly, and is of a bright red or purplish red color. Its brightness
+gradually fades, the color changing to a bluish, bluish-green, bluish-
+or greenish-yellow, dirty yellowish, yellowish-white, and finally
+disappearing; varying in duration from several days to several weeks.
+
+
+#Describe the symptoms of purpura simplex.#
+
+Purpura simplex, or the mild form, shows itself as pin-point to pea- or
+bean-sized, bright or dark-red spots, limited, as a rule, to the limbs,
+especially the lower extremities; fading gradually away and coming to an
+end in a few weeks, or new crops appearing irregularly for several
+months. There is rarely any systemic disturbance, and, as a rule, no
+subjective symptoms; in exceptional cases an urticarial element is
+added--_purpura urticans_.
+
+
+#Describe the symptoms of purpura rheumatica.#
+
+Purpura rheumatica (also called _peliosis rheumatica_) is usually
+preceded by symptoms of malaise, rheumatic pains and sometimes
+swelling about the joints; these phenomena abate and frequently disappear
+upon the outbreak of the eruption. The lesions are pea- to dime-sized,
+smooth, non-elevated, or slightly raised, and of a reddish or purplish
+color; the eruption may be more or less generalized, most abundant upon
+the limbs, or it may be limited to these parts. It may end in a few weeks,
+or may persist for several months, new spots appearing irregularly or in
+the form of crops.
+
+As somewhat allied to this is another form (_Schönlein's disease_),
+quite alarming in its symptoms. It is rare. It is characterized by
+symptoms partaking of the nature of rheumatism, purpuric spots, blotches
+and ecchymoses, erythema multiforme, and often associated with
+considerable edema. The throat is also usually invaded, and indeed the
+first symptom is commonly in this region. Considerable constitutional
+disturbance, of a threatening character, is commonly observed. Recovery
+usually takes place.
+
+_Henoch's purpura_, observed chiefly in children, resembles the above,
+with the erythema multiforme character and the [oe]dematous swellings
+more pronounced, while the actual purpuric symptoms are less
+conspicuous. Gastric and intestinal symptoms and hemorrhages from the
+mucous membrane are commonly noted. It is fatal in about 20 per cent. of
+the cases.
+
+
+#Describe the symptoms of purpura hæmorrhagica.#
+
+Purpura hæmorrhagica (also called _land scurvy_) is characterized
+usually by premonitory, and frequently accompanying, symptoms of general
+distress, and by the appearance of coin to palm-sized, red or purplish
+hemorrhagic spots or patches, smooth, non-elevated or raised. Hemorrhage
+from the mouth, gums and other parts, slight or serious in character,
+may occur. New lesions continue to appear for several days or weeks; and
+in exceptional instances, repeated relapses take place, and the disease
+thus persists for months. It may end fatally.
+
+
+#State the etiology of purpura.#
+
+In most instances no cause can be assigned. The disease occurs at all
+ages from childhood to advanced life, and in individuals, apparently, in
+good and bad health alike. The hemorrhagic type is oftener seen in
+subjects debilitated or in a depraved state of health. A microörganism
+is also looked upon as a factor by some observers, especially in the
+grave type of disease.
+
+
+#State the diagnostic characters of purpura.#
+
+The appearance, irregularly or in crops, of bright-red or purplish
+spots, evidently of hemorrhagic nature, and not _disappearing upon
+pressure_, and as they are fading, going through the several changes of
+color usually observed in any ecchymosis.
+
+
+#How does scurvy (scorbutus) differ from purpura?#
+
+Scurvy, which may resemble the severe grade of purpura, has a different
+history, a recognizable cause, usually a peculiar distribution, and is
+accompanied with general weakness and a spongy, soft and bleeding
+condition of the gums.
+
+
+#What is the pathology of purpura?#
+
+The lesion of purpura consists essentially of a hemorrhage into the
+cutaneous tissues. The blood is subsequently absorbed, the hæmatin
+undergoing changes of color from a red to greenish and pale yellow, and
+finally fading away.
+
+
+#State the prognosis#
+
+The milder varieties disappear in the course of several weeks or months,
+and are rarely of serious import; the outcome of purpura hæmorrhagica is
+somewhat uncertain; although usually favorable, a fatal result from
+internal hemorrhage is possible. The variety known as Schönlein's
+disease is alarming, but seldom fatal. Henoch's disease is, however,
+always of grave import.
+
+
+#What is the treatment of purpura?#
+
+Hygienic and dietary measures, the administration of tonics and
+astringents, and, in severe cases, by relative or absolute rest.
+
+The drugs commonly prescribed are: ergot, oil of erigeron, oil of
+turpentine, quinia, strychnia, iron, mineral acids, and gallic acid.
+_External_ treatment is rarely called for, but if deemed advisable,
+astringent lotions may be employed.
+
+
+
+                             #Scorbutus.#
+          (_Synonyms:_ Scurvy; Sea Scurvy; Purpura Scorbutica.)
+
+
+#Describe scorbutus.#
+
+Scurvy is a peculiar constitutional state, developed in those living
+under bad hygienic conditions, and is characterized by emaciation,
+general febrile and asthenic symptoms, a more or less swollen, turgid
+and spongy and even gangrenous condition of the gums; and concomitantly,
+or sooner or later, by the appearance, usually upon the lower portion of
+the legs only, of dark-colored hemorrhagic patches or blotches. The skin
+of the affected part may become brawny and slightly scaly, and not
+infrequently may break down and ulcerate. Hemorrhages from the various
+mucous surfaces, slight or grave, may also take place.
+
+
+#State the etiology of scurvy.#
+
+It is due to long-continued deprivation of proper food, especially of
+fruits and vegetables. Other bad hygienic conditions favor its
+development. It is seen most commonly in sailors and others taking long
+voyages.
+
+
+#How is scurvy to be distinguished from purpura?#
+
+By the asthenic and emaciated general condition and the peculiar puffy,
+spongy state of the gums. The cutaneous manifestation is more diffused,
+forming usually large palm-sized patches, and, as a rule, limited to the
+region of the ankles or lower part of the legs.
+
+
+#Give the prognosis of scurvy.#
+
+The disease is remediable, and usually rapidly so. In those instances in
+which the same bad hygienic conditions and the ingestion of improper
+food are continued, death finally results.
+
+
+#What treatment would you advise in scurvy?#
+
+Proper food, with an abundance of fruit and vegetables. Lemon or lime
+juice is especially valuable, and is to be taken freely. If indicated,
+tonics and stimulants are also to be prescribed. For the relief of the
+tumid, spongy condition of the gums, astringent and antiseptic mouth
+washes are to be employed.
+
+The cutaneous manifestations, when tending to ulceration, are to be
+treated upon general principles.
+
+
+
+
+#CLASS IV.--HYPERTROPHIES.#
+
+
+                               #Lentigo.#
+                         (_Synonym:_ Freckle.)
+
+
+#Describe lentigo.#
+
+Lentigo, or freckle, is characterized by round or irregular, pin-head to
+pea-sized, yellowish, brownish or blackish spots, occurring usually
+about the face and the backs of the hands. It is a common affection,
+varying somewhat in the degree of development; the freckles present may
+be few and insignificant, or they may exist in profusion and be quite
+disfiguring. Heat and exposure favor their development. Those of light
+complexion, especially those with red hair, are its most common
+subjects. The color of the lesion is usually a yellowish-brown.
+
+It is common to all ages, but is generally seen in its greatest
+development during adolescence, the disposition to its appearance
+becoming less marked as age advances.
+
+
+#What is the pathology of lentigo?#
+
+Lentigo consists simply of a circumscribed deposit of pigment
+granules--merely a localized increase of the normal pigment, differing
+from chloasma (_q. v._) only in the size and shape of the pigmentation.
+
+
+#State the prognosis.#
+
+The blemishes can be removed by treatment, but their return is almost
+certain.
+
+
+#Name the several applications commonly employed for their removal.#
+
+An aqueous or alcoholic solution of corrosive sublimate, one-half to
+three grains to the ounce; lactic acid, one part to from six to twenty
+parts of water; and an ointment containing a drachm each of bismuth
+subnitrate and ammoniated mercury to the ounce.
+
+The applications, which act by removing the epidermal and rete cells and
+with them the pigment, are made two or three times daily, and their use
+intermitted for a few days as soon as the skin becomes irritated or
+scaly.
+
+Touching each freckle for a few seconds with the electric needle, just
+pricking the epidermis, will occasionally remove the blemish.
+
+
+
+                             #Chloasma.#
+
+
+#What do you understand by chloasma?#
+
+Chloasma consists of an abnormal deposit of pigment, occurring as
+variously-sized and shaped, yellowish, brownish or blackish patches.
+
+
+#Describe the clinical appearances of chloasma.#
+
+Chloasma appears either in ill-defined patches, as is commonly the case,
+or as a diffuse discoloration. Its appearance is rapid or gradual,
+generally the latter. The patches are rounded or irregular, and usually
+shade off into the sound skin. One, several or more may be present, and
+coalescence may take place, resulting in a large irregular pigmented
+area. The color is yellowish, or brownish, and may even be blackish
+(_melasma_, _melanoderma_). The skin is otherwise normal. The face is the
+most common site.
+
+
+#Into what two general classes may the various examples of chloasma be
+grouped?#
+
+Idiopathic and symptomatic.
+
+
+#What cases of chloasma are included in the idiopathic group?#
+
+All those cases of pigmentation caused by external agents, such as the
+sun's rays, sinapisms, blisters, continued cutaneous hyperæmia from
+scratching or any other cause, etc.
+
+
+#What cases of chloasma are included in the symptomatic group?#
+
+All forms of pigment deposit which occur as a consequence of various
+organic and systemic diseases, as the pigmentation, for instance, seen
+in association with tuberculosis, cancer, malaria, Addison's disease,
+uterine affections, and the like. In such cases, with few exceptions,
+the pigmentation is usually more or less diffuse.
+
+
+#What is chloasma uterinum?#
+
+Chloasma uterinum is a term applied to the ill-defined patches of
+yellowish-brown pigmentation appearing upon the faces of women, usually
+between the ages of twenty-five and fifty. It is most commonly seen
+during pregnancy, but may occur in connection with any functional or
+organic disease of the utero-ovarian apparatus.
+
+
+#What is argyria?#
+
+Argyria is the term applied to the slate-like discoloration which
+follows the prolonged administration of silver nitrate.
+
+
+#State the pathology of chloasma.#
+
+The sole change consists in an increased deposit of pigment.
+
+
+#Give the prognosis of chloasma.#
+
+Unless a removal of the exciting or predisposing cause is possible, the
+prognosis is, as a rule, unfavorable, and the relief furnished by local
+applications usually but temporary.
+
+
+#If constitutional treatment is advisable, upon what is it to be based?#
+
+Upon general principles; there are no special remedies.
+
+
+#How do external remedies act?#
+
+Mainly by removing the rete cells and with them the pigmentation; and
+partly, also, by stimulating the absorbents.
+
+
+#Are all external remedies which tend to remove the upper layers of the
+skin equally useful for this purpose?#
+
+No; on the contrary some such applications are followed by an increase
+in the pigment deposit.
+
+
+#Name the several applications commonly employed.#
+
+Corrosive sublimate in solution, in the strength of one to four grains
+to the ounce of alcohol and water; a lotion made up as follows:--
+
+  [Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
+       Ac. acet. dilut., .................... f[dram]ij
+       Sodii borat., ........................ [scruple]ij
+       Aquæ rosæ, ........................... f[Oz]iv.       M.
+
+And also the following:--
+
+  [Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
+       Zinci sulphat.,
+       Plumbi acetat., ...... [=a][=a] ...... [dram]ss
+       Aquæ, ................................ f[Oz]iv.       M.
+
+And lactic acid, with from five to twenty parts of water; and an
+ointment containing a drachm each of bismuth subnitrate and white
+precipitate to the ounce. Hydrogen peroxide occasionally acts well.
+Trichloracetic acid, usually weakened with one or two parts water, may
+be cautiously tried. The application of a strong alcoholic solution of
+resorcin, twenty to fifty per cent. strength, is also valuable, as is
+also a two to ten per cent. alcoholic solution of salicylic acid.
+
+(Applications are made two or three times daily, and as soon as slight
+scaliness or irritation is produced are to be discontinued for one or
+two days.)
+
+_Tattoo-marks_ are difficult to remove. Excision is the surest method.
+Electrolysis, applying the needle at various points, somewhat close
+together, and using a fairly strong current--three to eight
+milliampères--will exceptionally, especially when repeated several
+times, produce a reactive inflammation and casting-off of the tissue
+containing the pigment; a scar is left.
+
+Several writers claim good results with glycerole of papain, pricking it
+in in the same manner as in tattooing.
+
+_Gun-powder marks._ If recent, but a day or so after their occurrence,
+the larger specks may be picked or scraped out. Later, electrolysis,
+using a fairly strong current, may result in their removal. Their
+removal may also be satisfactorily effected with a minute cutaneous
+trephine.
+
+
+
+                         #Keratosis Pilaris.#
+            (_Synonyms:_ Pityriasis Pilaris; Lichen Pilaris.)
+
+
+#What is meant by keratosis pilaris?#
+
+Keratosis pilaris may be defined as a hypertrophic affection
+characterized by the formation of pin-head-sized, conical, epidermic
+elevations seated about the apertures of the hair follicles.
+
+
+#Describe the clinical appearances of keratosis pilaris.#
+
+The lesions are usually limited to the extensor surfaces of the thighs
+and arms, especially the former. They appear as pin-head-sized, whitish
+or grayish elevations, consisting of accumulations of epithelial matter
+about the apertures of the hair follicles. Each elevation is pierced by
+a hair, or the hair may be twisted and imprisoned within the epithelial
+mass; or it may be broken off just at the point of emergence at the apex
+of the papule, in which event it may be seen as a dark, central speck.
+The skin is usually dry, rough and harsh, and in marked cases, to the
+hand passing over it, feels not unlike a nutmeg-grater. The disease
+varies in its development, in most cases being so slight as to escape
+attention. As a rule, it is free from itching.
+
+
+#What course does keratosis pilaris pursue?#
+
+It is sluggish and chronic.
+
+
+#Mention some of the etiological factors.#
+
+It is not an uncommon disease, and is seen usually in those who are
+unaccustomed to frequent bathing, being most frequently met with during
+the winter months. It is chiefly observed during early adult life.
+
+
+#Is there any difficulty in the diagnosis?#
+
+No. It is thought at times to bear some resemblance to goose-flesh
+(cutis anserina), the miliary papular syphiloderm in its desquamating
+stage, and lichen scrofulosus. In goose-flesh the elevations are
+evanescent and of an entirely different character; the papules of the
+syphiloderm are usually generalized, of a reddish color, tend to group,
+are more solid and deeply-seated, less scaly and are accompanied with
+other symptoms of syphilis; in lichen scrofulosus the papules are
+larger, incline to occur in groups, and appear usually upon the abdomen.
+
+
+#State the prognosis.#
+
+The disease yields readily to treatment.
+
+
+#Give the treatment of keratosis pilaris.#
+
+Frequent warm baths, with the use of a toilet soap or sapo viridis, will
+usually be found curative. Alkaline baths are also useful. In obstinate
+cases the ordinary mild ointments, glycerine, etc., are to be advised in
+conjunction with the baths.
+
+
+
+                         #Keratosis Follicularis.#
+
+
+#Describe keratosis follicularis.#
+
+Keratosis follicularis (_Darier's disease_, _ichthyosis follicularis_,
+_ichthyosis sebacea cornea_, _psorospermosis_) is a rare disease
+characterized by pin-head to pea-sized pointed, rounded, or
+irregularly-shaped grayish, brownish, red or even black, horny papules
+or elevations, arising from the sebaceous or hair-follicles. They are,
+for the most part, discrete, with a tendency here and there to form
+solid aggregations or areas. Many of them contain projecting cornified
+plugs which may be squeezed out, leaving pit-like depressions. The face,
+scalp, lower trunk, groins and flanks are the parts chiefly affected.
+The view advanced by Darier, that the malady was due to psorosperms, is
+now denied, the bodies thought to be such having been demonstrated to be
+due to cell transformation.
+
+As to treatment, in one instance the induction of a substitutive
+dermatic inflammation had a favorable influence.
+
+
+                         #Molluscum Epitheliale.#
+    (_Synonyms:_ Molluscum Contagiosum; Molluscum Sebaceum; Epithelioma
+                                Molluscum.)
+
+
+#Give a definition of molluscum epitheliale.#
+
+Molluscum epitheliale is characterized by pin-head to pea-sized,
+rounded, semi-globular, or flattened, pearl-like elevations, of a
+whitish or pinkish color.
+
+
+#Describe the symptoms and course of molluscum epitheliale.#
+
+The usual seat is the face; not infrequently, however, the growths occur
+on other parts. The lesions begin as pin-head, waxy-looking, rounded or
+acuminated elevations, gradually attaining the size of small peas. They
+have a broad base or occasionally may tend to become pedunculated. They
+rarely exist in profusion, in most cases three to ten or twelve lesions
+being present. When fully developed they are somewhat flattened and
+umbilicated, with a central, darkish point representing the mouth of the
+follicle. They are whitish or pinkish, and look not unlike drops of wax
+or pearl buttons. At first they are firm, but eventually, in most cases,
+tend to become soft and break down. Not infrequently, however, the
+lesions disappear slowly by absorption, without apparent previous
+softening. Their course is usually chronic. The contents, a
+cheesy-looking mass, may commonly be pressed out without difficulty.
+
+
+#What is the cause of molluscum epitheliale?#
+
+It is now generally accepted that the disease is mildly contagious. It
+occurs chiefly in children, and especially among the poorer classes. The
+belief in the parasitic nature of the disease is gaining ground;
+recently the opinion has been advanced that it is due to psorosperms
+(psorospermosis); but further investigations have indicated that these
+bodies were degenerated epithelia.
+
+
+#State the pathology.#
+
+[Illustration: Fig. 31. Molluscum Epitheliale.]
+
+According to recent investigations, molluscum epitheliale is to be
+regarded as a hyperplasia of the rete, the growth probably beginning in
+the hair-follicles; the so-called molluscum bodies--peculiar, rounded or
+ovoidal, sharply-defined, fatty-looking bodies found in microscopical
+examination of the growth--are to be viewed as a form of epithelial
+degeneration.
+
+
+#What are the diagnostic points in molluscum epitheliale?#
+
+The size of the lesions, their waxy or glistening appearance, and the
+presence of the central orifice.
+
+It is to be differentiated from molluscum fibrosum, warts and acne.
+
+
+#State the prognosis.#
+
+The growths are amenable to treatment. In some instances the disease,
+after existing some weeks, tends to disappear spontaneously.
+
+
+#What is the treatment of molluscum epitheliale?#
+
+Incision and expression of the contents, and touching the base of the
+cavity with silver nitrate. Pedunculated growths may be ligated. In some
+cases an ointment of ammoniated mercury, twenty to forty grains to the
+ounce, applied, by gently rubbing, once or twice daily, will bring about
+a cure.
+
+
+
+                             #Callositas.#
+    (_Synonyms:_ Tylosis; Tyloma; Callus; Callous; Callosity; Keratoma.)
+
+
+#What do you understand by callositas?#
+
+A hard, thickened, horny patch made up of the corneous layers of the
+epidermis.
+
+
+#Describe the clinical appearances.#
+
+Callosities are most common about the hands and feet, and consist of
+small or large patches of dry, grayish-yellow looking, hard, slight or
+excessive epidermic accumulations. They are somewhat elevated,
+especially at the central portion, and gradually merge into the healthy
+skin. The natural surface lines are in a great measure obliterated, the
+patches usually being smooth and horn-like.
+
+_Keratosis palmaris et plantaris_ (symmetric keratodermia), as regards
+the local condition, is a somewhat similar affection. It consists of
+hypertrophy of the corneous layer of the palm and soles, usually of a
+more or less horny and plate-like character, but is congenital or
+hereditary, and not necessarily dependent upon local friction or
+pressure.
+
+
+#Are there any inflammatory symptoms in callositas?#
+
+No; but exceptionally, from accidental injury, the subjacent corium
+becomes inflamed, suppurates, and the thickened mass is cast off.
+
+
+#State the causes of callositas.#
+
+Pressure and friction; for example, on the hands, from the use of
+various tools and implements, and on the feet from ill-fitting shoes. It
+is, indeed, often to be looked upon as an effort of nature to protect
+the more delicate corium.
+
+In exceptional instances it arises without apparent cause.
+
+
+#What is the pathology?#
+
+The epidermis alone is involved; it consists, in fact, of a hyperplasia
+of the horny layer.
+
+
+#State the prognosis of callositas.#
+
+If the causes are removed, the accumulation, as a rule, gradually
+disappears. The effect of treatment is always rapid and positive, but
+unless the etiological factors have ceased to act, the result is usually
+but temporary.
+
+
+#How is callositas treated?#
+
+When treatment is deemed advisable, it consists in softening the parts
+with hot-water soakings or poultices, and subsequently shaving or
+scraping off the callous mass. The same result may also be often
+effected by the continuous application, for several days or a week, of a
+10 to 15 per cent. salicylated plaster, or the application of a
+salicylated collodion, same strength; it is followed up by hot-water
+soaking, the accumulation, as a rule, coming readily away.
+
+
+
+                             #Clavus.#
+                       (_Synonym:_ Corn.)
+
+
+#What is clavus?#
+
+Clavus, or corn, is a small, circumscribed, flattened, deep-seated,
+horny formation usually seated about the toes.
+
+
+#Describe the clinical appearances.#
+
+Ordinarily a corn has the appearance of a small callosity; the skin is
+thickened, polished and horny. Exceptionally, however, occurring on
+parts that are naturally more or less moist, as between the toes,
+maceration takes place, and the result is the so-called _soft corn_. The
+dorsal aspect of the toes is the common site for the ordinary variety.
+The usual size is that of a small pea. They are painful on pressure,
+and, at times, spontaneously so.
+
+
+#State the causes.#
+
+Corns are caused by pressure and friction, and may usually be referred
+to improperly fitting shoes.
+
+
+#What is the pathology of clavus?#
+
+It is a hypertrophy of the epiderm. Its shape is conical, with the base
+external and the apex pressing upon the papillæ. It is, in fact, a
+peculiarly-shaped callosity, the central portion and apex being dense
+and horny, forming the so-called core.
+
+
+#Give the treatment of clavus.#
+
+A simple method of treatment consists in shaving off, after a
+preliminary hot-water soaking, the outer portion, and then applying a
+ring of felt or like material, with the hollow part immediately over the
+site of the core; this should be worn for several weeks. It is also
+possible in some cases to extract the whole corn by gently dissecting it
+out; the after-treatment being the same as the above.
+
+Another method is by means of a ten- to fifteen-per-cent. solution of
+salicylic acid, in alcohol or collodion, or the following:--
+
+  [Rx] Ac. salicylici, ...................... gr. xxx
+       Ext. cannabis Ind., .................. gr. x
+       Collodii, ............................ f[dram]iv.   M.
+
+This is painted on the corn night and morning for several days, at the
+end of which time the parts are soaked in hot water, and the mass or a
+greater part of it, will be found, as a rule, to come readily away; one
+or two repetitions may be necessary. Lactic acid, with one to several
+parts of water, applied once or twice daily, acts in a similar manner.
+
+Soft corns, after the removal of pressure, may be treated with the solid
+stick of nitrate of silver, or by any of the methods already mentioned.
+
+In order that treatment be permanently successful, the feet are to be
+properly fitted. If pressure is removed, corns will commonly disappear
+spontaneously.
+
+
+
+                           #Cornu Cutaneum.#
+              (_Synonyms:_ Cornu Humanum; Cutaneous Horn.)
+
+
+#What is cornu cutaneum?#
+
+A cutaneous horn is a circumscribed hypertrophy of the epidermis,
+forming an outgrowth of horny consistence and of variable size and
+shape.
+
+
+#At what age and upon what parts are cutaneous horns observed?#
+
+They are usually met with late in life, and are mostly seated upon the
+face and scalp.
+
+[Illustration: Fig. 32.
+  Cutaneous Horns. Showing beginning epitheliomatous degeneration of the
+  base. (_After Pancoast._)]
+
+
+#Describe the clinical appearances.#
+
+In appearance cutaneous horns resemble those seen in the lower animals,
+differing, if at all, but slightly. They are hard, solid, dry and
+somewhat brittle; usually tapering, and may be either straight, curved
+or crooked. Their surface is rough, irregular, laminated or fissured,
+the ends pointed, blunt or clubbed. The color varies; it is usually
+grayish-yellow, but may be even blackish. As commonly seen they are
+small in size, a fraction of an inch or an inch or thereabouts in
+length, but exceptionally attain considerable proportions. The base,
+which rests directly upon the skin, may be broad, flattened, or concave,
+with the underlying and adjacent tissues normal or the papillæ
+hypertrophied; and in some cases there is more or less inflammation,
+which may be followed by suppuration. They are usually solitary
+formations. They are not, as a rule, painful, unless knocked or
+irritated.
+
+
+#What course do cutaneous horns pursue?#
+
+Their growth is usually slow, and, after having attained a certain size,
+they not infrequently become loose and fall off; they are almost always
+reproduced.
+
+
+#What is the cause of these horny growths?#
+
+The cause is not known; appearing about the genitalia, they usually
+develop from acuminated warts. They are rare formations.
+
+
+#State the pathology of cornu cutaneum.#
+
+Horns consist of closely agglutinated epidermic cells, forming small
+columns or rods; in the columns themselves the cells are arranged
+concentrically. In the base are found hypertrophic papillæ and some
+bloodvessels. They have their starting-point in the rete mucosum, either
+from that lying above the papillæ or that lining the follicles and
+glands.
+
+
+#Does epitheliomatous degeneration of the base ever occur?#
+
+Yes.
+
+
+#State the prognosis.#
+
+Cutaneous horns may be readily and permanently removed.
+
+
+#What is the treatment?#
+
+Treatment consists in detachment, and subsequent destruction of the
+base; the former is accomplished by dissecting the horn away from the
+base or forcibly breaking it off, the latter by means of any of the
+well-known caustics, such as caustic potash, chloride of zinc and the
+galvano-cautery.
+
+Another method is to excise the base, the horn coming away with it; this
+necessitates, however, considerable loss of tissue.
+
+
+
+                              #Verruca.#
+                          (_Synonym:_ Wart.)
+
+
+#What is verruca?#
+
+Verruca, or wart, is a hard or soft, rounded, flat, acuminated or
+filiform, circumscribed epidermal and papillary growth.
+
+
+#Name the several varieties of warts met with.#
+
+Verruca vulgaris, verruca plana, verruca plana juvenilis, verruca
+digitata, verruca filifortnis and verruca acuminata.
+
+
+#Describe verruca vulgaris.#
+
+This is the common wart, occurring mostly upon the hands. It is rounded,
+elevated, circumscribed, hard and horny, with a broad base, and usually
+the size of a pea. At first it is smooth and covered with slightly
+thickened epidermis, but later this disappears to some extent, the
+hypertrophied papillæ, appearing as minute elevations, making up the
+growth. One, several or more may be present.
+
+
+#Describe verruca plana.#
+
+This is the so-called flat wart, and occurs commonly upon the back,
+especially in elderly people (_verruca senilis_, _keratosis pigmentosa_).
+It is, as a rule, but slightly elevated, is usually dark in color, and
+of the size of a pea or finger-nail.
+
+
+#Describe verruca plana juvenilis.#
+
+The warts are mostly pin-head in size, flat, but slightly elevated,
+rounded, irregular or square-shaped, and of a light yellowish-brown
+color. They bear resemblance to lichen planus papules. They are apt to
+be numerous, often becoming aggregated or fused, and occur usually in
+young children, and, as a rule, on the face and hands.
+
+
+#Describe verruca filiformis.#
+
+This is a thread-like growth about an eighth or fourth of an inch long,
+and occurring commonly about the face, eyelids and neck. It is usually
+soft to the touch and flexible.
+
+
+#Describe verruca digitata.#
+
+This is a variety of wart, which, especially about the edges, is marked
+by digitations, extending nearly or quite down to the base. It is
+commonly seen upon the scalp.
+
+
+#Describe verruca acuminata.#
+
+This variety (_venereal wart_, _pointed wart_, _pointed condyloma_),
+usually occurs about the genitalia, especially upon the mucous and
+muco-cutaneous surfaces. It consists of one or more groups of
+acuminated, pinkish or reddish, raspberry-like elevations, and,
+according to the region, may be dry or moist; if the latter, the
+secretion, which is usually yellowish and puriform, from rapid
+decomposition, develops an offensive and penetrating odor. The formation
+may be the size of a small pea, or may attain the dimensions of a fist.
+
+
+#What is the cause of warts?#
+
+The etiology is not known. They are more common in adolescent and early
+adult life. Irritating secretions are thought to be causative in the
+acuminated variety. It is highly probable that a parasitic factor will
+finally be demonstrated. They are doubtless mildly contagious.
+
+[Illustration: Fig. 33.
+  Verruca Acuminata--about the anus. (_After Ashton._)]
+
+
+#State the pathology of warts.#
+
+A wart consists of both epidermic and papillary hypertrophy, the
+interior of the growth containing a vascular loop. In the acuminated
+variety there are marked papillary enlargement, excessive development of
+the mucous layer, and an abundant vascular supply.
+
+
+#Give the treatment of warts.#
+
+For ordinary warts, excision or destruction by caustics. The repeated
+application of a saturated alcoholic solution of salicylic acid is often
+curative, the upper portion being pared off from time to time. The
+filiform and digitate varieties may be snipped off with the scissors,
+and the base touched with nitrate of silver; or a ligature may be used.
+Curetting is a valuable operative method. The growths may also be
+removed by electrolysis. When warts are numerous and close together
+parasiticide applications can be daily made to the whole affected
+region. For this purpose a boric acid solution, containing five to
+thirty grains of resorcin to the ounce, and Vleminckx's solution, at
+first diluted, prove the most valuable.
+
+Verruca acuminata is to be treated by maintaining absolute cleanliness,
+and the application of such astringents as liquor plumbi subacetatis,
+tincture of iron, powdered alum and boric acid. The salicylic acid
+solution may also be used. In obstinate cases, glacial acetic acid or
+chromic acid may be cautiously employed.
+
+
+
+                         #Nævus Pigmentosus.#
+                          (_Synonym:_ Mole.)
+
+
+#Describe nævus pigmentosus.#
+
+Nævus pigmentosus, commonly known as mole, may be defined as a
+circumscribed increase in the pigment of the skin, usually associated
+with hypertrophy of one or all of the cutaneous structures, especially
+of the connective tissue and hair. It occurs singly or in numbers; is
+usually pea-, bean-sized or larger, rounded or irregular, smooth or
+rough, flat or elevated, and of a color varying from a light brown to
+black; the hair found thereon may be either colorless or deeply
+pigmented, coarse and of considerable length. It is, as a rule, a
+permanent formation.
+
+
+#Name the several varieties of nævus pigmentosus met with.#
+
+Nævus spilus, nævus pilosus, nævus verrucosus, and nævus lipomatodes.
+So-called linear nævus might also be considered as belonging in this
+group.
+
+
+#What is nævus spilus?#
+
+A smooth and flat nævus, consisting essentially of augmented
+pigmentation alone.
+
+[Illustration: Fig. 34. Linear Nævus.]
+
+
+#What is nævus pilosus?#
+
+A nævus upon which there is an abnormal growth of hair, slight or
+excessive.
+
+
+#What is nævus verrucosus?#
+
+A nævus to which is added hypertrophy of the papillæ, giving rise to a
+furrowed and uneven surface.
+
+
+#What is linear nævus?#
+
+Linear nævus is a formation usually of a verrucous character, more or
+less pigmented, sometimes slightly scaly, occurring in band-like or
+zoster-like areas, and, as a rule, unilaterally.
+
+
+#What is nævus lipomatodes?#
+
+A nævus with excessive fat and connective-tissue hypertrophy.
+
+
+#State the etiology of nævus pigmentosus.#
+
+The causes are obscure. The growths are usually congenital; but the
+smooth, non-hairy moles may be acquired.
+
+
+#Give the pathology of nævus pigmentosus.#
+
+Microscopical examination shows a marked increase in the pigment in the
+lowest layers of the rete mucosum, as well as more or less pigmentation
+in the corium usually following the course of the bloodvessels; in the
+verrucous variety the papillæ are greatly hypertrophied, in addition to
+the increased pigmentation. There is, as a rule, more or less
+connective-tissue hypertrophy.
+
+
+#What is the treatment of nævus pigmentosus?#
+
+In many instances interference is scarcely called for, but when demanded
+consists in the removal of the formation either by the knife, by
+caustics, or by electrolysis. This last is, in the milder varieties at
+least, perhaps the best method, as it is less likely to be followed by
+disfiguring cicatrices. In nævus pilosus the removal of the hairs alone
+by electrolysis is not infrequently followed by a decided diminution of
+the pigmentation. In recent years both liquid air and carbon dioxide
+have also been used successfully in the removal of these growths.
+Pigmented nævi, which show the least tendency to growth or degenerative
+change, should be radically removed, as they not infrequently lead to
+carcinomatous and sarcomatous growths.
+
+
+
+                             #Ichthyosis.#
+                    (_Synonym:_ Fish-skin Disease.)
+
+
+#Give a descriptive definition of ichthyosis.#
+
+Ichthyosis is a chronic, hypertrophic disease, characterized by dryness
+and scaliness of the skin, with a variable amount of papillary growth.
+
+
+#At what age is ichthyosis first observed?#
+
+It is first noticed in infancy or early childhood. In rare instances it
+is congenital (ichthyosis congenita), and in such cases it is usually
+severe, and of a grave type; the children are, as a rule, prematurely
+born, and frequently do not survive many days or weeks.
+
+
+#What extent of surface is involved?#
+
+Usually the whole surface, but it is most marked upon the extensor
+surfaces of the arms and legs, especially at the elbows and knees; the
+face and scalp, in mild cases, often remain free.
+
+
+#Name the two varieties of ichthyosis usually described.#
+
+Ichthyosis simplex and ichthyosis hystrix, terms commonly employed to
+designate the mild and severe forms respectively.
+
+
+#Describe the clinical appearances of ichthyosis.#
+
+The milder forms of the disease may be so slight as to give rise to
+simple dryness or harshness of the skin (_xeroderma_); but as commonly
+met with it is more developed, more or less marked scaliness in the form
+of thin or somewhat thick epidermal plates being present. The papillæ of
+the skin are often slightly hypertrophied. In slight cases the color of
+the scales is usually light and pearly; in the more marked examples it
+is dark gray, olive green or black.
+
+In the severe variety--ichthyosis hystrix--in addition to scaliness
+there is marked papillary hypertrophy, forming warty or spinous patches.
+This type is rare, and, as a rule, the surface involved is more or less
+limited.
+
+
+#Are there any inflammatory symptoms in ichthyosis?#
+
+No. In fact, beyond the disfigurement, the disease causes no
+inconvenience; in those well-marked cases, however, in which the scales
+are thick and more or less immovable, the natural mobility of the parts
+is compromised and fissuring often occurs. In the winter months, in the
+severer cases, exposed parts may become slightly eczematous.
+
+
+#Does ichthyosis vary somewhat with the season?#
+
+Yes. In all cases the disease is better in the warm months, and in the
+mild forms may entirely disappear during this time. This favorable
+change is purely mechanical--due to the maceration to which the
+increased activity of the sweat glands gives rise.
+
+
+#Is the general health affected in ichthyosis?#
+
+No.
+
+
+#What course does ichthyosis pursue?#
+
+Chronic. Beginning in early infancy or childhood, it usually becomes
+gradually more marked until adult age, after which time it, as a rule,
+remains stationary.
+
+
+#What is the etiology?#
+
+Beyond a hereditary influence, which is often a positive factor, the
+causes are obscure. It is not a common disease.
+
+
+#State the pathology.#
+
+Anatomically the essential feature is epidermic hypertrophy, with
+usually a varying degree of papillary hypertrophy also.
+
+
+#Mention the diagnostic features of ichthyosis.#
+
+The harsh, dry skin, epidermic and papillary hypertrophy, the
+furfuraceous or plate-like scaliness, the greater development upon the
+extensor surfaces, a history of the affection dating from early
+childhood, and the absence of inflammatory symptoms.
+
+
+#How is ichthyosis to be distinguished from eczema, psoriasis, and other
+scaly inflammatory diseases?#
+
+By the absence of the inflammatory element.
+
+
+#What is the outlook for a case of ichthyosis?#
+
+The prognosis is unfavorable as regards a cure, but the process may
+usually be kept in abeyance or rendered endurable by proper measures.
+
+
+#What treatment would you prescribe for ichthyosis?#
+
+Treatment that has in view removal of the scaliness and the maintenance
+of a soft and flexible condition of the skin.
+
+In mild cases frequent warm baths, simple or alkaline, will suffice; in
+others an application of an oily or fatty substance, such as the
+ordinary oils or ointments, made several hours or immediately before the
+bath may be necessary. In moderately developed cases the skin is to be
+washed energetically with sapo viridis and hot water, followed by a warm
+bath, after which an oily or fatty application is made. In some of the
+more severe cases the following plan is often useful: The parts are
+first rubbed with a soapy ointment consisting of one part of
+precipitated sulphur and seven parts of sapo viridis; a bath is then
+taken, the skin wiped dry, and a one to five per cent. ointment of
+salicylic acid gently rubbed in.
+
+Glycerine lotions, one or two drachms to the ounce of water, are also
+beneficial; as also the following:--
+
+  [Rx] Ac. salicylici, ...................... gr. x-xl
+       Glycerini, ........................... [dram]ss-[dram]j
+       Lanolin,
+       Petrolati, .................. [=a][=a] [Oz]ss
+
+In severe cases of ichthyosis hystrix it may be necessary, also, to
+employ caustics or the knife.
+
+
+#What systemic treatment would you prescribe?#
+
+Constitutional remedies are practically powerless; occasionally some
+good is accomplished by the internal administration of linseed oil and
+jaborandi.
+
+
+
+                               #Onychauxis.#
+                  (_Synonym:_ Hypertrophy of the Nail.)
+
+
+#Describe onychauxis.#
+
+Onychauxis, or hypertrophy of the nail, may take place in one or all
+directions, and this increase may be, and often is, accompanied by
+changes in shape, color, and direction of growth. One or all the nails
+may share in the process. As the result of lateral deviation of growth,
+the nail presses upon the surrounding tissues, producing a varying
+degree of inflammation--_paronychia_.
+
+
+#What is the etiology of hypertrophy of the nail?#
+
+The condition may be either congenital or acquired. In the latter
+instances it is usually the result of the extension to the matrix of
+such cutaneous diseases as psoriasis and eczema; or it is produced by
+constitutional maladies, such as syphilis.
+
+
+#Give the treatment of hypertrophy of the nail.#
+
+Treatment consists in the removal of the redundant nail-tissue by means
+of the knife or scissors; and, when dependent upon eczema or psoriasis,
+the employment of remedies suitable for these diseases. When it is the
+result of syphilis, the medication appropriate to this disease is to be
+employed.
+
+In paronychia the nail should be frequently trimmed and a pledget of
+lint or cotton be interposed between the edge of the nail and the
+adjacent soft parts; astringent powders and lotions may often be
+employed with advantage; and in severe and persistent cases excision of
+the nail, partial or complete, may be found necessary.
+
+
+
+                          #Hypertrichosis.#
+    (_Synonyms:_ Hirsuties; Hypertrophy of the Hair; Superfluous Hair.)
+
+
+#What is meant by hypertrichosis?#
+
+Hypertrichosis is a term applied to excessive growth of hair, either as
+regards region, extent, age or sex.
+
+
+#Describe the several conditions met with.#
+
+The unnatural hair growth may be slight, as, for instance, upon a nævus
+(_nævus pilosus_); or it may be excessive, as in the so-called hairy
+people (_homines pilosi_); or it may also appear on the face, arms and
+other parts in females, resulting from a hypertrophy of the natural
+lanugo hairs.
+
+
+#State the causes of hypertrichosis.#
+
+Hereditary influence is often a factor; the condition may also be
+congenital.
+
+If acquired, the tendency manifests itself usually toward middle life.
+In women, it is not infrequently associated with diseases of the
+utero-ovarian system; in many instances, however, there is no apparent
+cause. Local irritation or stimulation has at times a causative
+influence.
+
+
+#How is hypertrichosis to be treated?#
+
+For general hypertrichosis there is no remedy. Small hairy nævi may be
+excised, or, as also in the larger hairy moles, the hairs may be removed
+by electrolysis.
+
+On the faces of women, if the hairs are coarse or large, electrolysis
+constitutes the only satisfactory method; if the hairs are small and
+lanugo-like, the operation is not to be advised. It is somewhat painful,
+but never unbearable. In the past several years the _x_-ray has been
+advocated by several writers, but it requires usually numerous exposures
+pushed to the point of producing erythema; it is not without risk, and
+the hairs are said to return in some months.
+
+
+#What temporary methods are usually resorted to for the removal of
+superfluous hair?#
+
+Shaving, extraction of the hairs and the use of depilatories. As a
+depilatory, a powder made up of two drachms of barium sulphide and three
+drachms each of zinc oxide and starch, is commonly (and cautiously)
+employed; at the time of application enough water is added to the powder
+to make a paste, and it is then spread thinly upon the parts, allowed to
+remain five to fifteen minutes, or until heat of skin or a burning
+sensation is felt, washed off thoroughly, and a soothing ointment
+applied. This preparation must be well prepared to be efficient.
+
+
+#Describe the method of removal of superfluous hair by electrolysis.#
+
+A fine needle in a suitable handle is attached to the _negative_ pole of
+a _galvanic_ battery, introduced into the hair-follicle to the depth of
+the papilla, and the circuit completed by the patient touching the
+positive electrode; in several seconds slight blanching and frothing
+usually appear at the point of insertion; a few seconds later the
+current is broken by release of the positive electrode, and the needle
+is then withdrawn. Sometimes a wheal-like elevation arises, remains
+several minutes or hours, and then disappears; or occasionally, probably
+from secondary infection, it develops into a pustule.
+
+A strength of current of a half to two milliamperes is usually
+sufficient; the time necessary for the destruction of the papilla
+varying from several to thirty seconds.
+
+
+#How are you to know if the papilla has been destroyed?#
+
+The hair will readily come out with but little, if any, traction.
+
+
+#What is the result if the current has been too strong or too long
+continued?#
+
+The follicle suppurates and a scar results.
+
+
+#Why should contiguous hairs not be operated upon at the same sitting?#
+
+In order that the chances of marked inflammatory action and scarring
+(always possibilities) may be reduced to a minimum.
+
+
+#In case of failure to destroy an individual papilla, should a second
+attempt be made at the same sitting?#
+
+As a rule not, in order to avoid the possibility of too much destructive
+action, and consequent scarring.
+
+
+#Can scarring always be prevented?#
+
+In the average case, with skill and care, the use of an exceedingly fine
+needle and the avoidance of too strong a current, _perceptible_ scarring
+(scarring perceptible to the ordinary observer or at ordinary distance)
+need rarely occur.
+
+
+#What measures are to be advised for the irritation produced by the
+operation?#
+
+Hot-water applications and the use of an ointment made of two drachms
+cold cream and ten grains of boric acid are of advantage not only in
+reducing the resulting hyperæmia, but also in preventing suppuration and
+consequent scarring. To lessen the chances of the latter, cleansing the
+parts with alcohol just before and after the operation is also of
+service.
+
+
+
+                        #[OE]dema Neonatorum.#
+
+
+#Describe [oe]dema neonatorum.#
+
+The essential symptoms are [oe]dema and a variable degree of hardness
+and induration. It develops in the first few days of life, and usually
+upon the extremities, especially the lower. It may remain more or less
+limited to these parts, but, as a rule, slowly extends. The skin is of a
+yellowish, dusky, or livid color, and sometimes glossy or shining. There
+are general symptoms of drowsiness, subnormal temperature, weakened
+circulation, and impaired respiration, which gradually increase, and in
+eighty to ninety per cent. of the cases lead to death. It is believed to
+be similar to anasarca in the adult and to be due to like causes.
+
+Treatment consists in maintaining the body-heat, sufficient and proper
+nourishment and stimulation.
+
+
+
+                           #Sclerema Neonatorum.#
+       (_Synonyms:_ Scleroderma Neonatorum; Sclerema of the Newborn.)
+
+
+#What is sclerema neonatorum?#
+
+Sclerema neonatorum is a disease of infancy, showing itself usually at
+or shortly after birth, and is characterized by a diffuse stiffness and
+rigidity of the integument, accompanied by coldness, [oe]dema,
+discoloration, lividity and general circulatory disturbance.
+
+
+#Describe the symptoms, course, nature and treatment of sclerema
+neonatorum.#
+
+As a rule the disease first manifests itself upon the lower extremities,
+and then gradually, but usually rapidly, invades the trunk, arms and
+face. The surface is cold. The skin, which is noted to be reddish,
+purplish or mottled, is [oe]dematous, stiff and tense; in consequence
+the infant is unable to move, respires feebly and usually perishes in a
+few days or weeks. In extremely exceptional instances the disease, after
+involving a small part, may retrogress and recovery take place.
+
+The disease is rare, and in most cases is found associated with
+pneumonia and with affections of the circulatory apparatus.
+
+Treatment should be directed toward maintaining warmth and proper
+alimentation.
+
+
+
+                               #Scleroderma.#
+  (_Synonyms:_ Sclerema; Scleriasis; Dermatosclerosis; Morph[oe]a; Keloid
+                                of Addison.)
+
+
+#What is scleroderma?#
+
+Scleroderma is an acute or chronic disease of the skin characterized by
+a localized or general, more or less diffuse, usually pigmented, rigid,
+stiffened, indurated or hide-bound condition.
+
+Morph[oe]a, by some formerly thought to be a distinct affection, is now
+believed to be a form of scleroderma; as typically met with it is
+characterized by one or more rounded, oval, or elongate, coin- to
+palm-sized, pinkish, or whitish ivory-looking patches. In some instances
+such patches are seen in association with the more classic type of
+scleroderma just defined.
+
+
+#Describe the symptoms of ordinary scleroderma.#
+
+The disease may be acute or chronic, usually the latter. A portion or
+almost the entire surface may be involved, or it may occupy variously
+sized and shaped areas. The integument becomes more or less rigid and
+indurated, hard to the touch, hide-bound, and in marked cases immobile.
+[OE]dema may, especially in the more acute cases, precede the
+induration. Pigmentation, of a yellowish or brownish color, is often a
+precursory and accompanying symptom. The skin feels tight and
+contracted, and in some instances numbness and cramp-like pains are
+complained of.
+
+
+#Describe the variety known as morph[oe]a.#
+
+The patches (one, several, or more), occurring most frequently about the
+trunk, are in the beginning usually slightly hyperæmic, later becoming
+pale-yellowish or white, and having a pinkish or lilac border made up of
+minute capillaries. They are, as a rule, sharply defined, with a smooth,
+often shining and atrophic-looking surface; are soft, fine or leathery
+to the touch, on a level or somewhat depressed, and appearing not unlike
+a piece of bacon or ivory laid in the skin. Occasionally the patches are
+noted to occur over nerve-tracts. The adjacent skin may be normal or
+there may be more or less yellowish or brownish mottling. The subjective
+symptoms of tingling, itching, numbness, and even pain, may or may not
+be present.
+
+
+#What is the course of the disease?#
+
+Sooner or later, usually after months or years, the disease ends in
+resolution and recovery, or in marked atrophic changes, causing
+contraction and deformity. As a rule, the general health remains good.
+
+
+#State the causes of scleroderma.#
+
+The condition is to be considered as probably of neurotic origin.
+Exposure and shock to the nervous system are to be looked upon as
+influential. It is a rare disease, observed usually in early adult or
+middle life, and is more frequent in women than in men.
+
+
+#What is the pathology?#
+
+In typical and advanced cases both the true skin and the subcutaneous
+connective tissue show a marked increase of connective tissue-element,
+with thickening and condensation of the fibers.
+
+
+#Is there any difficulty in reaching a diagnosis in scleroderma?#
+
+As a rule, no. The characters--rigidity, stiffness, hardness, and
+hide-bound condition of the skin--are always distinctive.
+
+The peculiar appearance, the course and character of the patches, of
+morph[oe]a are quite distinctive.
+
+
+#Give the prognosis of scleroderma.#
+
+It should always be guarded. In many instances recovery takes place,
+whilst in others the disease is rebellious, lasting indefinitely. The
+prognosis of the variety known as morph[oe]a is less unfavorable than
+general scleroderma, and recovery more frequent.
+
+
+#What is the treatment of scleroderma?#
+
+Tonics, such as arsenic, quinia, nux vomica, and cod-liver oil;
+conjointly with the local employment of stimulating, oily or fatty
+applications, friction, and electricity. Röntgen-ray treatment is often
+of value, more especially in the morph[oe]a type.
+
+
+
+                             #Elephantiasis.#
+  (_Synonyms:_ Elephantiasis Arabum; Pachydermia; Barbadoes Leg; Elephant
+                                   Leg.)
+
+
+#Give a descriptive definition of elephantiasis.#
+
+Elephantiasis is a chronic hypertrophic disease of the skin and
+subcutaneous tissue characterized by enlargement and deformity,
+lymphangitis, swelling, [oe]dema, thickening, induration, pigmentation,
+and more or less papillary growth.
+
+[Illustration: Fig. 35. Elephantiasis of moderate development.]
+
+
+#What parts are commonly involved in elephantiasis?#
+
+Usually one or both legs; occasionally the genitalia; other parts are
+seldom affected.
+
+
+#Describe the symptoms of elephantiasis.#
+
+The disease usually begins with recurrent (at intervals of months or
+years) erysipelatous inflammation, with swelling, pain, heat, redness
+and lymphangitis; after each attack the parts remain somewhat increased
+in size, although at first not noticeably so. After months or one or two
+years the enlargement or hypertrophy becomes conspicuous, the part is
+chronically swollen, [oe]dematous and hard; the skin is thickened, the
+normal lines and folds exaggerated, the papillæ enlarged and prominent,
+and with more or less fissuring and pigmentation.
+
+
+#What is the further course of the disease?#
+
+There is gradual increase in size, the parts in some instances reaching
+enormous proportions; the skin becomes rough and warty, eczematous
+inflammation is often superadded, and, sooner or later, ulcers,
+superficial or deep, form--which, together with the crusting and
+moderate scaliness, present a striking picture. There may be periods of
+comparative inactivity, or, after reaching a certain development, the
+disease may, for a time at least, remain stationary.
+
+
+#Are there any subjective symptoms?#
+
+A variable degree of pain is often noted, especially marked during the
+inflammatory attacks. The general health is not involved.
+
+
+#State the cause of elephantiasis.#
+
+The etiology is obscure. The disease rarely occurs before puberty. It is
+most common in tropical countries, more especially among the poor and
+neglected. It is not hereditary, nor can it be said to be contagious.
+Inflammation and obstruction of the lymphatics, probably due, according
+to late investigations, to the presence of large numbers of filaria
+(microscopic thread-worms) in the lymph channels and bloodvessels, is to
+be looked upon as the immediate cause.
+
+
+#What is the pathology?#
+
+All parts of the skin and subcutaneous connective-tissue are
+hypertrophied, the lymphatic glands are swollen, the lymph channels and
+bloodvessels enlarged, and there is more or less inflammation, with
+[oe]dema. Secondarily, from pressure, atrophy and destruction of the
+skin-glands, and atrophic degeneration of the fat and muscles result.
+
+
+#What are the diagnostic characters of beginning elephantiasis?#
+
+Recurrent erysipelatous inflammation, attended with gradual enlargement
+of the parts.
+
+The appearances, later in the course of the disease, are so
+characteristic that a mistake is scarcely possible.
+
+
+#Give the prognosis of elephantiasis.#
+
+If the case comes under treatment in the first months of its
+development, the process may probably be checked or held in abeyance;
+when well established, rarely more than palliation is possible.
+
+
+#What is the treatment of elephantiasis?#
+
+The inflammatory attacks are to be treated on general principles.
+Quinia, potassium iodide, iron and other tonics are occasionally useful;
+and, especially in the earlier stages, climatic change is often of
+value. Between the inflammatory attacks the parts are to be rubbed with
+an ointment of iodine or mercury, together with galvanization of the
+involved part.
+
+In elephantiasis of the leg, a roller or rubber bandage, or the gum
+stocking, is to be worn; compression and ligation of the main artery,
+and even excision of the sciatic nerve, have all been employed, with
+more or less diminution in size as a result. In elephantiasis of the
+genitalia, if the disease is well advanced, excision or amputation of
+the parts is to be practised.
+
+Eczematous inflammation, if present, is to be treated with the ordinary
+remedies.
+
+
+
+                           #Dermatolysis.#
+                    (_Synonym:_ Cutis Pendula.)
+
+
+#Give a descriptive definition of dermatolysis.#
+
+Dermatolysis is a rare disease, consisting of hypertrophy and looseness
+of the skin and subcutaneous connective tissue, with a tendency to hang
+in folds.
+
+
+#Describe the symptoms and course of dermatolysis.#
+
+It may be congenital or acquired, and maybe limited to a small or large
+area, or develop simultaneously at several regions. All parts of the
+skin, including the follicles, glands and subcutaneous connective and
+areolar tissue, share in the hypertrophy; and this in exceptional
+instances may be so extensive that the integument hangs in folds. The
+enlargement of the follicles, natural folds and rugæ gives rise to an
+uneven surface, but the skin remains soft and pliable. There is also
+increased pigmentation, the integument becoming more or less brownish.
+
+
+#What course does dermatolysis pursue?#
+
+Its development is slow and usually progressive. It gives rise to no
+further inconvenience than its weight and consequent discomfort.
+
+
+#Give the etiology.#
+
+The etiology is obscure. It is considered by some authors as allied to
+molluscum fibrosum, and, in fact, as a manifestation of that disease,
+ordinary molluscum tumors sometimes being associated with it. It is not
+malignant.
+
+
+#What is the pathology?#
+
+The disease consists of a simple hypertrophy of all the skin structures
+and the subcutaneous connective tissue.
+
+
+#What is the treatment of dermatolysis?#
+
+Excision when advisable and practicable.
+
+
+
+
+#CLASS V.--ATROPHIES.#
+
+
+                        #Albinismus.#
+
+
+#What do you understand by albinismus?#
+
+Congenital absence, either partial or complete, of the pigment normally
+present in the skin, hair and eyes.
+
+
+#Describe complete albinismus.#
+
+In complete albinismus the skin of the entire body is white, the hair
+very fine, soft and white or whitish-yellow in color, the irides are
+colorless or light blue, and the pupils, owing to the absence of pigment
+in the choroid, are red; this absence of pigment in the eyes gives rise
+to photophobia and nystagmus. _Albinos_--a term applied to such
+individuals--are commonly of feeble constitution, and may exhibit
+imperfect mental development.
+
+
+#Describe partial albinismus.#
+
+Partial albinismus is met with most frequently in the colored race. In
+this form of the affection the pigment is absent in one, several or more
+variously-sized patches; usually the hairs growing thereon are likewise
+colorless.
+
+
+#Is there any structural change in the skin?#
+
+No. The functions of the skin are performed in a perfectly natural
+manner, and microscopical examination shows no departure from normal
+structure save the complete absence of pigment.
+
+
+#What is known in regard to the etiology?#
+
+Nothing is known of the causes producing albinismus beyond the single
+fact that it is frequently hereditary.
+
+
+#Does albinismus admit of treatment?#
+
+No; the condition is without remedy.
+
+
+
+                          #Vitiligo.#
+              (_Synonyms:_ Leucoderma; Leucopathia.)
+
+
+#Give a definition of vitiligo.#
+
+Vitiligo may be defined as a disease involving the pigment of the skin
+alone, characterized by several or more progressive, milky-white patches
+surrounded by increased pigmentation.
+
+
+#Describe the symptoms of vitiligo.#
+
+The disease may begin at one or more regions, the backs of the hands,
+trunk and face being favorite parts; its appearance is usually
+insidious, and the spots may not be especially noticeable until they are
+the size of a pea or larger. The patches grow slowly, are milky or dead
+white, smooth, non-elevated, and of rounded outline; the bordering skin
+is darker than normal, showing increased pigmentation. Several
+contiguous spots may coalesce and form a large, irregularly-shaped
+patch. Hair growing on the involved skin may or may not be blanched.
+
+There are no subjective symptoms.
+
+
+#What course does vitiligo pursue?#
+
+The course of the disease is slow, months and sometimes years elapsing
+before it reaches conspicuous development. It may after a time remain
+stationary, or, in rare instances, retrogress; as a rule, however, it is
+progressive. Exceptionally, the greater part, or even the whole surface
+may eventually be involved.
+
+
+#Give the etiology of vitiligo.#
+
+Disturbed innervation is thought to be influential. The disease develops
+often without apparent cause. Alopecia areata and morph[oe]a have been
+observed associated with it.
+
+[Illustration: Fig. 36. Vitiligo.]
+
+
+#State the pathology of vitiligo.#
+
+The disease consists, anatomically, of both a diminution and increase of
+the pigment--the white patch resulting from the former, and the
+pigmented borders from the latter. There is no textural change, the skin
+in other respects being normal.
+
+
+#From what diseases is vitiligo to be differentiated?#
+
+From morph[oe]a and from the anæsthetic patches of leprosy.
+
+
+#In what respects do these diseases differ from vitiligo?#
+
+In morph[oe]a there is textural change, and in leprosy both textural
+change and constitutional or other symptoms.
+
+
+#What prognosis is to be given?#
+
+It should always be guarded, the disease in almost all cases being
+irresponsive to treatment.
+
+
+#What is the treatment of vitiligo?#
+
+The general health is to be looked after, and remedies directed
+especially toward the nervous system to be employed. Arsenic, in small
+and continued doses, seems at times to have an influence; when there is
+lack of general tone it may be prescribed as follows:--
+
+  [Rx] Liq. potassii arsenitis, ............. f[dram]j
+       Tinct. nucis vom., ................... f[dram]iij
+       Elix. calisayæ, ....... q. s. ad ..... f[Oz]iv.    M.
+
+  SIG.--f[dram]j t. d.
+
+Suprarenal-gland preparations in moderate dosage long continued has
+appeared in a few instances to be of some benefit.
+
+When upon exposed parts, stimulation of the patches, with the view of
+producing hyperæmia and consequent pigment deposit; conjoined with
+suitable applications to the surrounding pigmented skin, with a view to
+lessen the coloration (see _treatment of chloasma_), will be of aid in
+rendering the disease less conspicuous. Or the condition may be, in a
+measure, masked by staining the patches with walnut juice or similar
+pigment.
+
+
+
+                               #Canities.#
+                  (_Synonym:_ Grayness of the Hair.)
+
+
+#Describe canities.#
+
+Canities, or graying of the hair, may occur in localized areas or it may
+be more or less general; the blanching may be slight, scarcely amounting
+to slight grayness, or it may be complete. It is common to advancing
+years (_canities senilis_); it is seen also exceptionally in early life
+(_canities præmatura_). The condition is usually permanent. The loss of
+pigment takes place, as a rule, slowly, but several apparently authentic
+cases have been reported in which the change occurred in the course of a
+night or in a few days.
+
+
+#What is the etiology of canities?#
+
+The causes are obscure. Heredity is usually an influential factor, and
+conditions which impair the general nutrition have at times an
+etiological bearing. Intense anxiety, fright, and other profound nervous
+shock are looked upon as causative in sudden graying of the hair.
+
+
+#Give the treatment.#
+
+Canities is without remedy. Dyeing, although not to be advised, is often
+practised, and the condition thus masked.
+
+
+
+                           #Alopecia.#
+                     (_Synonym:_ Baldness.)
+
+
+#What do you understand by alopecia?#
+
+By alopecia is meant loss of hair, either partial or complete.
+
+
+#Name the several varieties of alopecia.#
+
+The so-called varieties are based mainly upon the etiology, and are
+named congenital alopecia, premature alopecia and senile alopecia.
+
+
+#Describe congenital alopecia.#
+
+Congenital alopecia is a rare condition, in which the hair-loss is
+usually noted to be patchy, or the general hair-growth may simply be
+scanty. In rare instances the hair has been entirely wanting; in such
+cases there is usually defective development of other structures, such
+as the teeth.
+
+
+#Describe premature alopecia.#
+
+Loss of hair occurring in early and middle adult life is not uncommon,
+and may consist of a simple thinning or of more or less complete
+baldness of the whole or greater part of the scalp. It usually develops
+slowly, some months or several years passing before the condition is
+well established. It is often idiopathic, and without apparent cause
+further than probably a hereditary predisposition. It may also be
+symptomatic, as, for example, the loss of hair, usually rapid
+(_defluvium capillorum_), following systemic diseases, such as the
+various fevers, and syphilis; or as a result of a long-continued
+seborrh[oe]a or seborrh[oe]ic eczema (_alopecia furfuracea_).
+
+
+#Describe senile alopecia.#
+
+This is the baldness so frequently seen developing with advancing years,
+and may consist merely of a general thinning, or, more commonly a
+general thinning with a more or less complete baldness of the temporal
+and anterior portion or of the vertex of the scalp.
+
+
+#What is the prognosis in the various varieties of alopecia?#
+
+In those cases in which there is a positive cause, as, for instance, in
+symptomatic alopecia, the prognosis is, as a rule, favorable, especially
+if no family predisposition exists. In the congenital and senile
+varieties the condition is usually irremediable. In idiopathic premature
+alopecia, the prognosis should be extremely guarded.
+
+
+#How would you treat alopecia?#
+
+By removing or modifying the predisposing factors by appropriate
+constitutional remedies, and by the external use of stimulating
+applications.
+
+
+#Name several remedies or combinations usually employed in the local
+treatment.#
+
+Sulphur ointment, full strength or weakened with lard or vaseline; a
+lotion of resorcin consisting of one or two drachms to four ounces of
+alcohol, to which is added ten to thirty minims of castor oil; and a
+lotion made up as follows:--
+
+  [Rx] Tinct. cantharidis, .................. f[dram]iv
+       Tinct. capsici, ...................... f[Oz]j
+       Ol. ricini, .......................... f[dram]ss-f[dram]j
+       Alcoholis, .... q. s. ad ............. f[Oz]iv.            M.
+
+The following is sometimes beneficial:--
+
+  [Rx] Resorcin, ............................ gr. lxxx
+       Quininæ (alkaloid), .................. gr. xv
+       Ol. ricini, .......................... [minim]v-[minim]xx
+       Alcoholis, ........................... f[Oz]iv.--M.
+
+Another excellent formula is:
+
+  [Rx] Resorcin, ............................ gr. lxxx-cxx
+       Ac. carbolici cryst., ................ gr. xx
+       Spts. myrciæ, ........................ f[Oz]iv.--M.
+
+And also the various other stimulating applications employed in alopecia
+areata (_q. v._).
+
+Other measures of value are: Faradic electricity applied daily for five
+minutes with a metallic brush or comb; daily massage, with the object of
+loosening the skin and giving more freedom to cutaneous and subcutaneous
+circulation; and the application, two or three times weekly, of static
+electricity by means of the static crown electrode.
+
+(The application selected should be gently--not rubbing--applied daily
+or every second or third day, according to the case; if a lotion,
+moistening the parts with it; if an ointment, merely greasing the parts.
+Shampooing every one to three weeks, according to circumstances.)
+
+
+
+                         #Alopecia Areata.#
+           (_Synonyms:_ Area Celsi; Alopecia Circumscripta.)
+
+
+#What do you understand by alopecia areata?#
+
+[Illustration: Fig. 37. Alopecia Areata.]
+
+Alopecia areata is an affection of the hairy system, in which occur one
+or more circumscribed, round or oval patches of complete baldness
+unattended by any marked alteration in the skin.
+
+
+#Upon what parts and at what age does the disease occur?#
+
+In the large majority of cases the disease is limited to the scalp; but
+it may invade other portions of the body, as the bearded region,
+eyebrows, eyelashes, and, in rare instances, the entire integument.
+
+It is most common between the ages of ten and forty.
+
+
+#Describe the symptoms of alopecia areata.#
+
+The disease begins either suddenly, without premonitory symptoms, one or
+several patches being formed in a few hours; or, and as is more usually
+the case, several days or weeks elapse before the bald area or areas are
+sufficiently large to become noticeable. The patches continue to extend
+peripherally for a variable period, and then remain stationary, or
+several gradually coalesce and form a large, irregular area involving
+the entire or a greater portion of the scalp. The skin of the affected
+regions is smooth, faintly pink or milky white, and at first presents no
+departure from the normal; sooner or later, however, the follicles
+become less prominent, and slight atrophy or thinning may occur, the
+bald plaques being slightly depressed.
+
+[Illustration: Fig. 38. Alopecia Areata--complete hair loss.]
+
+Occasionally, usually about the periphery and in the early stages, a few
+hair-stumps may be seen.
+
+
+#What course does alopecia areata pursue?#
+
+Almost invariably chronic. After the lapse of a variable period the
+patches cease to extend, the hairs at the margins of the bald areas
+being firmly fixed in the follicles; sooner or later a fine, colorless
+lanugo or down shows itself, which may continue to grow until it is
+about a half-inch or so in length and then drop out; or it may remain,
+become coarser and pigmented, and the parts resume their normal
+condition. Not infrequently, however, after growing for a time, the new
+hair falls out, and this may happen several times before the termination
+of the disease.
+
+
+#Are there any subjective symptoms in alopecia areata?#
+
+As a rule, not; but occasionally the appearance of the patches is
+preceded by severe headache, itching or burning, or other manifestations
+of disturbed innervation.
+
+
+#State the cause of alopecia areata.#
+
+The etiology is obscure. Two theories as to the cause of the disease
+exist: one of these regards it as parasitic, and the other considers it
+to be trophoneurotic. Doubtless both are right, as a study of the
+literature would indicate that there are, as regards etiology, really
+two varieties--the contagious and the non-contagious. In America
+examples of the contagious variety are uncommon.
+
+
+#Does the skin undergo any alterative or destructive changes?#
+
+Microscopical examination of the skin of the diseased area shows little
+or no alteration in its structure beyond slight thinning.
+
+
+#How do you distinguish alopecia areata from ringworm?#
+
+The plaques of alopecia areata are smooth, often completely devoid of
+hair, and free from scales; while those of ringworm show numerous broken
+hairs and stumps, desquamation, and usually symptoms of mild
+inflammatory action. In doubtful cases recourse should be had to the
+microscope.
+
+
+#What is the prognosis in alopecia areata?#
+
+The disease is often rebellious, but in children and young adults the
+prognosis is almost invariably favorable, permanent loss of hair being
+uncommon. The same holds true, but to a much less extent, with the
+disease as occurring in those of more advanced age. In extensive
+cases--those in which the hair of the entire scalp finally entirely
+disappears, and sometimes involves all hairy parts--the prognosis is
+unfavorable. Only exceptionally does recovery ensue in such instances.
+
+The uncertain duration, however, must be borne in mind; months, and in
+some instances several years, may elapse before complete restoration of
+hair takes place. Relapses are not uncommon.
+
+
+#How is alopecia areata treated?#
+
+By both constitutional and local measures, the former having in view the
+invigoration of the nervous system, and the latter a stimulating and
+parasiticidal action of the affected areas.
+
+
+#Give the constitutional treatment.#
+
+Arsenic is perhaps the most valuable remedy, while quinine, nux vomica,
+pilocarpine, cod-liver oil and ferruginous tonics may, in suitable
+cases, often be administered with benefit.
+
+
+#Name several remedies or combinations employed in the external treatment
+of alopecia areata.#
+
+Ointments of tar and sulphur of varying strength; the various mercurial
+ointments; the tar oils, either pure or with alcohol; stimulating
+lotions, containing varying proportions, singly or in combination, of
+tincture of capsicum, tincture of cantharides, aqua ammoniæ, and oil of
+turpentine. The following is a safe formula, especially in dispensary
+and ignorant class practice:
+
+  [Rx] [beta]-naphthol, ..................... [dram]ss-[dram]j
+       Ol. cadini, .......................... [dram]j
+     Ungt. sulphuris, .......... q. s. ad ... [Oz]j             M.
+
+The cautious use of a five to twenty per cent. chrysarobin ointment is
+of value. Painting the patches with pure carbolic acid or trikresol
+every ten days or two weeks sometimes acts well; it should not be
+applied over large areas nor used in young children. Galvanization or
+faradization of the affected parts may also be employed, and with,
+occasionally, beneficial effect. Stimulation with the high-frequency
+current by means of the vacuum electrode is also of value. When
+practicable, the Finsen light can be applied with hope of benefit and
+cure.
+
+
+
+                        #Atrophia Pilorum Propria.#
+                    (_Synonym:_ Atrophy of the Hair.)
+
+
+#What do you understand by atrophy of the hair?#
+
+An atrophic, brittle, dry condition of the hair, and which may be either
+symptomatic or idiopathic.
+
+
+#Describe the several conditions met with.#
+
+As a symptomatic affection, the dry, brittle condition of the hair met
+with in seborrh[oe]a, in severe constitutional diseases, and in the
+various vegetable parasitic affections, may be referred to.
+
+As an idiopathic disease it is rare, consisting simply of a brittleness
+and an uneven and irregular formation of the hair-shaft, with a tendency
+to split up into filaments (_fragilitas crinium_); or there may be
+localized swelling and bursting of the hair-shaft, the nodes thus
+produced having a shining, semi-transparent appearance (_trichorrhexis
+nodosa_). This latter usually occurs upon the beard and moustache.
+
+
+#State the causes of atrophy of the hair.#
+
+The causes of the symptomatic variety are usually evident; the etiology
+of idiopathic atrophy is obscure, but by many is thought due to
+parasitism.
+
+[Illustration: Fig. 39. Trichorrhexis Nodosa. (_After Michelson._)]
+
+
+#What would be your prognosis and treatment in atrophy of the hair?#
+
+Symptomatic atrophy usually responds to proper measures, but always
+slowly; treatment is based upon the etiological factors.
+
+For the idiopathic disease little, as a rule, can be done; repeated
+shaving or cutting the hair has, in exceptional instances, been followed
+by favorable results.
+
+
+
+                            #Atrophia Unguis.#
+             (_Synonyms:_ Atrophy of the Nails; Onychatrophia.)
+
+
+#Describe atrophy of the nails.#
+
+The nails are soft, thin and brittle, splitting easily, and are often
+opaque and lustreless, and may have a worm-eaten appearance. Several or
+more are usually affected.
+
+
+#State the causes of atrophy of the nails.#
+
+The condition may be congenital or acquired, usually the latter. It may
+result from trauma, or be produced by certain cutaneous diseases,
+notably eczema and psoriasis; or it may follow injuries or diseases of
+the nerves. Syphilis and chronic wasting constitutional diseases may
+also interfere with the normal growth of the nail-substance, producing
+varying degrees of atrophy. The fungi of tinea trichophytina and tinea
+favosa at times invade these structures and lead to more or less
+complete disintegration--_onychomycosis_.
+
+[Illustration: Fig. 40. Atrophy of the Nails.]
+
+
+#What is the treatment of atrophy of the nails?#
+
+Treatment will depend upon the cause. When it is due to eczema or
+psoriasis, appropriate constitutional and local remedies should be
+prescribed. If it is the result of syphilis, mercury and potassium
+iodide are to be advised. In onychomycosis--an exceedingly obstinate
+affection--the nails should be kept closely cut and pared, and a one- to
+five-grain solution of corrosive sublimate applied several times a day;
+a lotion of sodium hyposulphite, a drachm to the ounce, is also a
+valuable and safe application.
+
+
+
+                         #Atrophia Cutis.#
+            (_Synonyms:_ Atrophoderma; Atrophy of the Skin.)
+
+
+#What do you understand by atrophy of the skin?#
+
+By atrophy of the skin is meant an idiopathic or symptomatic wasting or
+degeneration of its component elements.
+
+
+#State the several conditions met with.#
+
+Glossy skin, general idiopathic atrophy of the skin, parchment skin,
+atrophic lines and spots, senile atrophy, and the atrophy following
+certain cutaneous diseases.
+
+
+#Describe glossy skin (atrophoderma neuriticum), and state the treatment.#
+
+Glossy skin is a rare condition following an injury or disease of the
+nerve. It is usually seen about the fingers. The skin is hairless,
+faintly reddish, smooth and shining, with a varnished and thin
+appearance, and with a tendency to fissuring. More or less severe and
+persistent burning pain precedes and accompanies the atrophy.
+
+Protective applications are called for, the disease tending slowly to
+spontaneous disappearance.
+
+
+#Describe general idiopathic atrophy of the skin, and give the treatment.#
+
+General idiopathic atrophy of the skin is extremely rare, and is
+characterized by a gradual, more or less general, degenerative and
+quantitative atrophy of the skin structures, accompanied usually with
+more or less discoloration and pigmentation.
+
+Treatment is palliative and based upon indications.
+
+
+#Describe parchment skin, and state the treatment.#
+
+Parchment skin (_xeroderma pigmentosum_, _angioma pigmentosum et
+atrophicum_) is a rare disease, the exact nature of which is not
+understood. It is characterized by the appearance of numerous
+disseminated, freckle-like pigment-spots, telangiectases, atrophied
+muscles, more or less shrinking and contraction of the integument, and
+followed, in most instances, by epitheliomatous tumors and ulceration,
+and finally death. It is usually slow in its course, beginning in
+childhood and lasting for years. It is not infrequently seen in several
+children of the same family.
+
+Treatment is palliative, consisting, if necessary, of the use of
+protective applications and of the administration of tonics and
+nutrients.
+
+
+#Describe atrophic lines and spots.#
+
+Atrophic lines and spots (_striæ et maculæ atrophicæ_) may be idiopathic
+or symptomatic, the lesions consisting of scar-like or atrophic-looking,
+whitish lines and macules, most commonly seen on the trunk. They are
+smooth and glistening. Slight hyperæmia usually precedes their
+formation. As an idiopathic disease its course is insidious and slow,
+and its progress eventually stayed. The so-called _lineæ albicantes_,
+resulting from the stretching of the skin produced by pregnancy or
+tumors, and from rapid development of fat, may be mentioned as
+illustrating the symptomatic variety.
+
+In course of time the atrophy becomes less conspicuous.
+
+
+#Describe senile atrophy.#
+
+Senile atrophy is not uncommon, the atrophy resulting, as the name
+inferentially implies, from advancing age. It is characterized by
+thinning and wasting, dryness, and a wrinkled condition, with more or
+less pigmentation and loss of hair. Circumscribed pigmentary deposits
+and seborrh[oe]a, with degeneration, are also noted.
+
+
+#What several diseases of the skin are commonly followed by atrophic
+changes?#
+
+Favus, lupus, syphilis, leprosy, scleroderma and morph[oe]a.
+
+
+
+
+#CLASS VI.--NEW GROWTHS.#
+
+
+                              #Keloid.#
+                (_Synonyms:_ Keloid of Alibert; Cheloid.)
+
+
+#Give a descriptive definition of keloid.#
+
+Keloid is a fibro-cellular new growth of the corium appearing as one or
+several variously-sized, irregularly-shaped, elevated, smooth, firm,
+pinkish or pale-reddish cicatriform lesions.
+
+
+#Describe the clinical appearance of keloid.#
+
+The growth begins as a small, hard, elevated, pinkish or reddish
+tubercle, increasing gradually, several months or years usually elapsing
+before the tumor reaches conspicuous size. When developed, it is one or
+more inches in diameter, is sharply defined, elevated, hard, rounded or
+oval, fungoid or crab-shaped, and firmly implanted in the skin. It is
+usually pinkish, pearl-white, or reddish, commonly devoid of hair, with
+no tendency to scaliness, and with, usually, several vessels coursing
+over it. In some instances it is tender, and it may be spontaneously
+painful.
+
+The breast, especially over the sternal region, is a favorite site for
+its appearance. One, several or more may be present in the single case.
+
+
+#What course does keloid pursue?#
+
+Chronic; usually lasting throughout life. In rare instances spontaneous
+involution takes place.
+
+
+#State the etiology of keloid.#
+
+The causes are obscure. The growth usually takes its start from some
+injury or lesion of continuity; for instance, at the site of burns,
+cuts, acne and smallpox scars, etc.--_cicatricial keloid, false keloid_;
+or it may also, so it is thought, originate in normal skin--_spontaneous
+keloid, true keloid_.
+
+
+#What is the pathology of keloid?#
+
+The lesion is a connective-tissue new growth having its seat in the
+corium.
+
+
+#Is there any difficulty in the diagnosis of keloid?#
+
+No. It resembles hypertrophic scar; but this latter, which is
+essentially keloidal, never extends beyond the line of injury.
+
+
+#Give the prognosis.#
+
+The growth is persistent and usually irresponsive to treatment. In some
+cases, however, there is eventually a tendency to spontaneous
+retrogression, up to a certain point at least.
+
+
+#What is the treatment of keloid?#
+
+Usually palliative, consisting of the continuous application of an
+ointment such as the following:--
+
+  [Rx] Acidi salicylici, .................... gr. x-xx
+       Emplast. plumbi,
+       Emplast. saponis, ... [=a][=a] ....... [dram]iij
+       Petrolati, ........................... [dram]ij.     M.
+
+An ointment of ichthyol, twenty-five per cent. strength, rubbed in once
+or twice daily, is sometimes beneficial.
+
+Operative measures, such as punctate and linear scarification,
+electrolysis and excision, are occasionally practised, but the results
+are rarely satisfactory and permanent; not infrequently, indeed, renewed
+activity in the progress of the growth is noted to follow. The _x_-ray
+can be tried with some hope of improvement. The administration of
+thyroid has been thought to have a possible influence in some instances.
+
+
+
+                              #Fibroma.#
+         (_Synonyms:_ Molluscum Fibrosum; Fibroma Molluscum.)
+
+
+#What do you understand by fibroma?#
+
+Fibroma is a connective-tissue new growth characterized by one or more
+sessile or pedunculated, pea- to egg-sized or larger, soft or firm,
+rounded, painless tumors, seated beneath and in the skin.
+
+
+#Describe the clinical appearances of fibroma.#
+
+The growth may be single, in which case it is apt to be pedunculated or
+pendulous, and attain considerable dimensions; as a result of weight or
+pressure surface-ulceration may occur. Or, as commonly met with, the
+lesions are numerous, scattered over large surface, and vary in size
+from a pea to a cherry; the overlying skin being normal, pinkish or
+reddish, loose, stretched, hypertrophied or atrophied.
+
+The tumors are painless. The general health is not involved.
+
+[Illustration: Fig. 41. Fibroma. (_After Octerlony._)]
+
+
+#What is the course of fibroma?#
+
+Chronic and persistent.
+
+
+#What is the etiology of fibroma?#
+
+The cause is not known. Heredity is often noted. The affection is not
+common.
+
+
+#State the pathology of fibroma.#
+
+The growths are variously thought to have their origin in the connective
+tissue of the corium, or in that of the walls of the hair-sac, or in the
+connective-tissue framework of the fatty tissue. Recent tumors are
+composed of gelatinous, newly-formed connective tissue, and the older
+growths of a dense, firmly-packed, fibrous tissue.
+
+
+#From what growths is fibroma to be differentiated?#
+
+From molluscum contagiosum, neuroma and lipoma; the first is
+differentiated by its central aperture or depression, neuroma by its
+painfulness, and lipoma by its lobulated character and soft feel.
+
+
+#Give the prognosis of fibroma.#
+
+The disease is persistent, and irresponsive to all treatment save
+operative measures.
+
+
+#What is the treatment of fibroma?#
+
+Treatment consists, when desired and practicable, in the removal of the
+growths by the knife, or in large and pedunculated tumors by the
+ligature or by the galvano-cautery.
+
+
+
+                               #Neuroma.#
+
+
+#Describe neuroma.#
+
+Neuroma of the skin is an exceedingly rare disease, characterized by the
+formation of variously-sized, usually numerous, firm, immovable and
+elastic fibrous tubercles containing new nerve-elements, and accompanied
+by violent, paroxysmal pain. Their growth is slow and usually
+progressive. Later they are painful upon pressure. They are limited to
+one region.
+
+The tumors are seated in the corium, extending into the deeper
+structure, and consist of nerve-fibres, yellow elastic tissue, blood
+vessels and lymphoid cells.
+
+In the two cases reported, excision of the nerve-trunk gave, in one
+instance, permanent relief; in the other the effect was only temporary.
+
+
+
+                              #Xanthoma.#
+               (_Synonyms:_ Vitiligoidea; Xanthelasma.)
+
+
+#What is xanthoma?#
+
+Xanthoma is a connective-tissue new growth characterized by the
+formation of yellowish, circumscribed, irregularly-shaped,
+variously-sized, non-indurated, flat or raised patches or tubercles.
+
+
+#Name the two varieties met with.#
+
+The macular or flat (_xanthoma planum_) and the tubercular (_xanthoma
+tuberculatum_ or _tuberosum_). In some instances both varieties
+(_xanthoma multiplex_) are seen in the same individual.
+
+
+#Describe the clinical appearances of xanthoma planum.#
+
+The macular or flat variety is usually seen about the eyelids. It
+consists of one, several or more small or large, smooth, opaque,
+sharply-defined, often slightly raised, yellowish patches, looking not
+unlike pieces of chamois-skin implanted in the skin.
+
+
+#Describe the clinical appearances of xanthoma tuberosum.#
+
+The tubercular variety is commonly met with upon the neck, trunk and
+extremities. It occurs as small, raised, isolated, yellowish nodules, or
+as patches made up of aggregations of millet-seed-sized or larger
+tubercles. The lesions may be few or they may exist in great numbers.
+
+
+#What is the course of xanthoma?#
+
+Extremely slow; after reaching a certain development the growths may
+remain stationary.
+
+
+#State the etiology of xanthoma.#
+
+The causes are obscure. Jaundice not infrequently precedes and
+accompanies its development, especially in the tubercular variety. The
+disease is uncommon, and is usually seen in middle and advanced life,
+and more frequently in women. In some cases (_xanthoma diabeticorum_) of
+general xanthoma diabetes is the causative factor.
+
+
+#What is the pathology of xanthoma?#
+
+It is a benign, connective-tissue new growth, with concomitant or
+subsequent, but usually partial, fatty degeneration.
+
+
+#Give the prognosis of xanthoma.#
+
+The condition is persistent, and usually irresponsive to all treatment
+save destructive or operative measures.
+
+#What is the treatment of xanthoma?#
+
+Treatment consists, in suitable cases, of excision; in some instances,
+electrolysis is serviceable. Applications of trichloracetic acid
+cautiously made are sometimes of value. In that form of general xanthoma
+due to diabetes the treatment of this latter condition will materially
+and sometimes completely remove the eruption.
+
+
+
+                              #Myoma.#
+       (_Synonyms:_ Myoma Cutis; Dermatomyoma; Liomyoma Cutis.)
+
+
+#Describe myoma.#
+
+The disease is rare, and consists usually of one or several
+(exceptionally numerous), variously-sized tumors of the skin, made up of
+smooth muscular fibres. They are flat, rounded, oval or pedunculated,
+and have a smooth surface and a pale-red color; as a rule, they are
+painless.
+
+The growth is benign, and consists essentially of a new formation of
+unstriped muscular fibres; but it may also be composed largely of
+connective tissue (_fibromyoma_); or it may contain an abundance of
+bloodvessels (_myoma telangiectodes_, _angiomyoma_); or there may be
+lymphatic involvement (_lymphangiomyoma_).
+
+
+
+                             #Angioma.#
+           (_Synonyms:_ Nævus Vasculosus; Nævus Sanguineus.)
+
+
+#Give a definition of angioma.#
+
+Angioma is a congenital hypertrophy of the vascular tissues of the
+corium and subcutaneous tissue. Exceptionally it makes its appearance a
+few weeks or a month after birth.
+
+
+#Into what two classes may angiomata be roughly grouped?#
+
+The flat (or non-elevated) and the prominent (or elevated).
+
+
+#Describe the flat, or non-elevated, variety of angioma.#
+
+The flat, or non-elevated, angioma (_nævus flammeus_, _nævus simplex_,
+_angioma simplex_, _capillary nævus_) may be pin-head- to bean-sized; or
+it may involve an area of several inches in diameter, and, exceptionally,
+a whole region. It is of a bright- or dark-red color, and is met with
+most frequently about the face. In some instances it extends after birth,
+reaches a certain size and then remains stationary; occasionally, when
+involving a small area, it undergoes involution and disappears.
+
+The so-called _port-wine mark_ is included in this group.
+
+
+#Describe the prominent, or elevated, variety of angioma.#
+
+The prominent variety (_venous n[oe]vus_, _angioma cavernosum_, _n[oe]vus
+tuberosus_) is variously-sized, often considerably elevated,
+clearly-defined, compressible, smooth or lobulated, and of a dark,
+purple color; it may, also, be erectile and pulsating. The growth is
+usually a single formation, and is met with upon all parts of the body.
+
+
+#What is the pathology of angioma?#
+
+It is a new growth, consisting of a variable hypertrophy of the
+cutaneous and subcutaneous arterial and venous bloodvessels, with or
+without an increase of the connective tissue.
+
+
+#Give the treatment of angioma.#
+
+In some instances, especially in infants, painting the parts repeatedly
+with collodion or liquor plumbi subacetatis will act favorably. For
+well-established, small, capillary nævi electrolysis or puncturing with
+a red-hot needle or with a needle charged with nitric acid may be
+employed; for "port-wine mark" frequent and closely contiguous
+electrolytic punctures are occasionally followed by a slight diminution
+in color. For the _prominent growths_, vaccination, the ligature,
+puncturing with the galvano-cautery, and excision are variously resorted
+to.
+
+In recent years applications of liquid air and carbon dioxide have proved
+of service in some cases.
+
+
+
+                           #Telangiectasis.#
+
+
+#Describe telangiectasis.#
+
+Telangiectasis consists of a new growth or enlargement of the cutaneous
+capillaries, usually appearing during middle adult life, and seated, for
+the most part, about the face.
+
+
+#To what extent may telangiectasis develop?#
+
+It may be limited to a red dot or point, with several small radiating
+capillaries (_nævus araneus_, _spider nævus_), or a whole region, usually
+the face, may show numerous scattered or closely-set capillary
+enlargements or new formations (_rosacea_). The latter is frequently
+associated with acne (_acne rosacea_).
+
+The etiology is obscure.
+
+
+#What is the treatment of telangiectasis?#
+
+Destruction of the vessels by electrolysis or by the knife. (See
+treatment of acne rosacea.)
+
+
+
+                            #Lymphangioma.#
+                    (_Synonym:_ Lymphangiectodes.)
+
+
+#Describe lymphangioma.#
+
+Lymphangioma is a rare disease, consisting of localized dilatations of
+the lymphatic vessels, appearing as discrete or aggregated pin-head or
+pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish
+or faint lilac color, and occurring for the most part about the trunk.
+It is of slow but usually progressive development, and is unaccompanied
+by subjective symptoms.
+
+A rare condition, Kaposi described as lymphangioma tuberosum multiplex,
+characterized by more or less solid, somewhat cystic, pearly to pinkish
+red, sometimes crowded lesions, is now known to be "benign cystic
+epithelioma"; its most common site is the face. While called "benign,"
+ulcerative action may eventually ensue.
+
+Treatment, when demanded, consists of operative measures.
+
+
+
+                          #Rhinoscleroma.#
+
+
+#Describe rhinoscleroma.#
+
+Rhinoscleroma is a rare and obscure disease, slow but progressive in its
+course, characterized by the development of an irregular, dense and
+hard, flattened, tubercular, non-ulcerating, cellular new growth, having
+its seat about the nose and contiguous parts. The overlying skin is
+normal in color, or it may be light- or dark-brown or reddish. Marked
+disfigurement and closure, partial or complete, of the nasal orifices
+gradually results. It is met with chiefly in Austria and Germany.
+
+Treatment, consisting of partial or complete extirpation, is rarely
+permanent in its results, the disease tending to recur.
+
+
+
+                          #Lupus Erythematosus.#
+      (_Synonyms:_ Lupus Erythematodes; Lupus Sebaceus; Seborrh[oe]a
+                                 Congestiva.)
+
+
+#What is lupus erythematosus?#
+
+Lupus erythematosus may be roughly defined as a mildly to moderately
+inflammatory superficial new-growth formation, characterized by one,
+several, or more circumscribed, variously sized and shaped, pinkish or
+dark red patches, covered slightly, and more or less irregularly, with
+adherent grayish or yellowish scales.
+
+
+#Upon what parts is lupus erythematosus observed?#
+
+Its common site is the face, usually the nose and cheeks, with a
+tendency toward symmetry; it is often limited to these parts, but may
+occasionally be seen upon other regions, more especially the lips, ears,
+and scalp. In rare instances a great part of the general surface may
+become involved.
+
+
+#Describe the symptoms of lupus erythematosus.#
+
+Usually the disease begins as one or several rounded, circumscribed,
+pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and
+of a pinkish, reddish or violaceous color. They slowly, or somewhat
+rapidly, increase in area, and after attaining variable size remain
+stationary; or they may progress and coalesce, and in this manner sooner
+or later involve considerable surface. The patches are sharply defined
+against the sound skin by an elevated border, while the central portion
+is somewhat depressed and usually atrophic. More or less thickening and
+infiltration are observed. _There is no tendency to ulceration_. The
+scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous
+or plugged with sebaceous and epithelial matter.
+
+The subjective symptoms of burning and itching are usually slight and
+often wanting.
+
+
+#What course does lupus erythematosus pursue?#
+
+As a rule, the disease is persistent, although somewhat variable. At
+times the patches retrogress, involution taking place with or without
+slight sieve-like atrophy or scarring.
+
+
+#State the causes of lupus erythematosus.#
+
+The etiology is obscure. Some observers believe it to be a variety of
+cutaneous tuberculosis. It is essentially a disease of adult and middle
+age; is more common in women, and more frequent in those having a
+tendency to disorders of the sebaceous glands. It may, in fact, begin as
+a seborrh[oe]a.
+
+
+#What is the pathology?#
+
+It was formerly considered a new growth, but recent opinion tends toward
+regarding it as a chronic inflammation of the cutis, superinducing
+degenerative and atrophic changes. Variable [oe]dema of the prickle
+layer and of the cutis is found. There is no tendency to pus formation.
+
+[Illustration: Fig. 42. Lupus Erythematosus.]
+
+
+#Is there any difficulty in the diagnosis of lupus erythematosus?#
+
+As a rule, not, as the features of the disease--the sharply
+circumscribed outline, the reddish or violaceous color, the elevated
+border, the tendency to central depression and atrophy, the plugged up
+or patulous sebaceous ducts, the adherent grayish or yellowish scales,
+together with the region attacked (usually the nose and cheeks)--are
+characteristic.
+
+
+#State the prognosis of lupus erythematosus.#
+
+The disease is often capricious and extremely rebellious to treatment;
+some cases, up to a certain point at least, yield readily, and
+occasionally a tendency to spontaneous disappearance is observed; a
+complete cure is, however, it must be confessed, rather rare. The
+disease in nowise compromises the general health. In those rare
+instances of generalized disease the patient has usually died from an
+intercurrent tuberculosis.
+
+
+#How is lupus erythematosus to be treated?#
+
+The general health is to be looked after and systemic treatment
+prescribed, if indicated. As a rule, constitutional remedies exert
+little, if any, influence, but exceptionally, cod-liver oil, arsenic,
+phosphorus, salicin, quinine, or potassium iodide proves of service.
+
+Locally, according to the case, soothing remedies, stimulating
+applications and destruction of the growth by caustics or operative
+measures are to be employed. (_Try the milder applications first._)
+
+
+#Mention the stimulating applications commonly employed.#
+
+Washing the parts energetically with tincture of sapo viridis, rinsing
+and applying a soothing ointment, such as cold cream or vaseline.
+
+A lotion containing zinc sulphate and potassium sulphuret thoroughly
+dabbed on the parts morning and evening:--
+
+  [Rx] Zinci sulphatis,
+       Potassii sulphurati, .... [=a][=a] ... [dram]i-[dram]iv
+       Glycerinæ, ........................... [minim]iv
+       Aquæ, ................................ f[Oz]iv.       M.
+
+The calamine-and-zinc oxide lotion used in acute eczema is also often
+extremely valuable.
+
+Lotions of ichthyol and of resorcin, five to sixty grains to the ounce;
+ichthyol in ointment, five- to twenty-per-cent. strength, is also
+useful.
+
+Painting the patches with pure carbolic acid; repeating a day or two
+after the crusts have fallen off.
+
+The continuous application of mercurial plaster.
+
+Sulphur and tar ointments, officinal strength or weakened with lard, and
+also the following:--
+
+  [Rx] Ol. cadini,
+       Alcoholis,
+       Saponis viridis, ..... [=a][=a] ...... [dram]iiss.   M.
+
+(This is to be rubbed in, in small quantity, once or twice daily, and
+later a soothing remedy applied.)
+
+In recent years both the _x_-ray and Finsen light have been used with
+variable success. Repeated applications of the high-frequency current,
+with the vacuum electrode, have also proved serviceable. Cautious
+applications of liquid air or carbon dioxide have also been used with
+some success in the past few years.
+
+
+#When are destructive and operative measures justifiable?#
+
+In obstinate, sluggish, and long-persistent patches, and then only after
+other methods of treatment have failed. (Remember that a patch or
+patches of the disease _may_ disappear in course of time spontaneously,
+and occasionally _without leaving a scar_.)
+
+
+#State the methods of treatment commonly used in obstinate, sluggish and
+persistent patches of lupus erythematosus.#
+
+Cauterization--with nitrate of silver, with applications of pyrogallic
+acid in ointment or in liquor gutta-perchæ, fifteen to thirty per cent.
+strength, and with solutions (cautiously employed) of caustic potash,
+and exceptionally with the galvano-cautery.
+
+[Illustration: Fig. 43. Single Scarifier.]
+
+[Illustration: Fig. 44. Multiple Scarifier.
+  (_As modified by Van Harlingen._)]
+
+Operative--scarification, either punctate or linear, and erosion with the
+curette. (See treatment of lupus vulgaris.)
+
+
+
+                            #Lupus Vulgaris.#
+    (_Synonyms:_ Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the
+                                  Skin.)
+
+
+#What do you understand by lupus vulgaris?#
+
+Lupus vulgaris is a cellular new growth, characterized by
+variously-sized, soft, reddish-brown, papular, tubercular and
+infiltrated patches, usually terminating in ulceration and scarring.
+
+
+#Upon what region is lupus vulgaris usually observed?#
+
+The face, especially the nose, but any part may be invaded. The area
+involved may be small or quite extensive, usually the former.
+
+
+#At what age is the disease noted?#
+
+In many cases it begins in childhood or early adult life, but as it is
+persistent and tends to relapse, it may be met with at any age.
+
+
+#Describe the earlier symptoms of lupus vulgaris.#
+
+The disease begins by the development of several or more pin-head to
+small pea-sized, deep-seated, brownish-red or yellowish tubercles,
+having their seat in the deeper part of the corium, and which are
+somewhat softer and looser in texture than normal tissue. As the disease
+progresses, variously-sized and shaped aggregations or patches result,
+covered with thin and imperfectly-formed epidermis.
+
+
+#What changes do the lupus tubercles or infiltrations undergo?#
+
+The lesions, having attained a certain size or development, may remain
+so for a time, but sooner or later retrogressive changes occur: the
+matured papules or tubercles, or infiltrated patches, slowly disappear
+by absorption, fatty degeneration, and exfoliation, leaving a yellowish
+or brownish pigmentation, usually with more or less atrophy or
+cicatricial-tissue formation--_lupus exfoliativus_; or disintegration
+and destruction result, terminating in ulceration--_lupus exedens, lupus
+exulcerans_. This latter is the more usual course.
+
+
+#Describe the clinical appearances and behavior of the lupus ulcerations.#
+
+They are rounded, shallow excavations, with soft and reddish borders. In
+exceptional instances exuberant granulations appear--_lupus
+hypertrophicus_; or papillary outgrowths are noted--_lupus verrucosus_.
+The ulcerations secrete a variable amount of pus, usually slight in
+quantity, which leads to more or less crust formation; later, however,
+cicatricial tissue, generally of a _firm and fibrous_ character,
+results.
+
+[Illustration: Fig. 45. Lupus of Arm.]
+
+
+#In what manner does the disease spread?#
+
+The patches spread by the appearance of new tubercles, or infiltrations
+at the peripheral portion. New islets and areas of disease may continue
+to make their appearance from time to time, usually upon contiguous
+parts.
+
+
+#Are the mucous membranes of the mouth, throat and larynx ever involved?#
+
+In some instances, and either primarily or secondarily.
+
+[Illustration: Lupus Vulgaris.]
+
+[Illustration: Lupus Vulgaris.]
+
+
+#Is the bone tissue ever involved in lupus vulgaris?#
+
+No.
+
+
+#What course does lupus vulgaris pursue?#
+
+It is slowly but, as a rule, steadily progressive. Several years or more
+may elapse before the area of disease is conspicuous.
+
+
+#What is the cause of lupus vulgaris?#
+
+It is now known to be due to the invasion of the cutaneous structures by
+the tubercle bacillus; in short, a tuberculosis of the skin. It is not
+infrequently observed in the strumous and debilitated. It is entirely
+independent of syphilis.
+
+
+#What is the pathology of lupus vulgaris?#
+
+According to recent investigations, the infiltrations of lupus are due
+chiefly to cell-proliferation and outgrowth from the protoplasmic walls
+and adventitia of the bloodvessels and lymphatics. The fibrous-tissue
+network, vessels and a portion of the cell infiltration are thus
+produced, the fixed and wandering connective-tissue cells of the
+inflamed stroma of the cutis being responsible for the other portion of
+the new growth (Robinson).
+
+
+#State the diagnostic features of lupus vulgaris.#
+
+In a typical, developed patch of lupus are to be seen:--cicatricial
+formation, usually of a fibrous and tough character; ulcerations; the
+yellowish-brown tubercles and infiltration; and the characteristic soft,
+small, yellowish or reddish-brown, cutaneous and subcutaneous points and
+tubercles.
+
+
+#How does the tubercular syphiloderm differ from lupus vulgaris?#
+
+The tubercular syphiloderm is much more rapid in its course, the
+ulceration is deeper and the discharge copious and often offensive; the
+scarring is soft, and, compared to the amount of ulceration, but
+slightly disfiguring; and it is, for obvious reasons, a disease of adult
+or late life. The history, together with other evidences of previous or
+concomitant symptoms of syphilis, will often aid in the differentiation.
+
+
+#How does epithelioma differ from lupus vulgaris?#
+
+The edges of the epitheliomatous ulcer are hard, elevated and waxy; the
+base is uneven, the secretion thin, scanty and apt to be streaked with
+blood; the ulceration usually starts from one point, and is often
+painful; the tissue destruction may be considerable; there is little, if
+any, tendency to the formation of cicatricial tissue; and, finally, it
+is usually a disease of advanced age.
+
+
+#In what respects does lupus erythematosus differ from lupus vulgaris?#
+
+Lupus erythematosus has no papules, tubercles or ulceration.
+
+
+#How does acne rosacea differ from lupus vulgaris?#
+
+Acne rosacea is characterized by hyperæmia, dilated vessels, papules,
+pustules, the absence of ulceration, and a different history.
+
+
+#State the prognosis of lupus vulgaris.#
+
+Lupus vulgaris is always a chronic disease, often exceedingly rebellious
+to treatment, and one that calls for a guarded opinion. Relapses are not
+uncommon.
+
+[Illustration: Fig. 46.
+  Galvano-cautery Needle, Knife and Spiral Points. (_As devised by
+  Bésnier._)]
+
+The general health usually remains good, but in some instances death by
+tuberculosis of the lungs has been noted.
+
+
+#Is external or internal treatment called for in lupus vulgaris?#
+
+Always external, and not infrequently constitutional also.
+
+
+#What is the constitutional treatment?#
+
+The general health must be cared for; good, nutritious food, fresh air
+and out-door exercise, together with, in many cases, the administration
+of such remedies as cod-liver oil, potassium iodide, iron and quinine,
+are of therapeutic importance. Tuberculin may be tried in severe and
+obstinate cases, but its use is not without danger.
+
+
+#State the object of local treatment.#
+
+The destruction or removal of the diseased tissue.
+
+
+#May milder methods of treatment sometimes prove beneficial and even
+curative?#
+
+Exceptionally, mercurial plaster, corrosive-sublimate lotion and
+ointment (gr. j to [Oz]j), a plaster containing five to fifteen per
+cent. of salicylic acid and creasote, repeated paintings with carbolic
+acid, and the constant application of lead plaster containing twenty per
+cent. of ichthyol, are valuable.
+
+[Illustration: Fig. 47. Double Curette.]
+
+Of the milder methods, those most in vogue to-day are the _Finsen light_
+and _x-ray_. Either proves extremely valuable in some cases, but the
+Finsen method is the favorite method.
+
+
+#What methods are commonly employed for the rapid removal or destruction
+of lupus tissue?#
+
+Cauterization, scarification, erasion and excision are variously
+practised; the particular method depending, in great measure, upon the
+extent of the disease, the part involved, and other circumstances.
+
+
+#Name the several caustics, and state how they are employed.#
+
+_Pyrogallic acid_, used as an ointment:--
+
+  [Rx] Ac. pyrogallici, ..................... [dram]ij
+       Emplast. plumbi, ..................... [dram]j
+       Cerat. resinsæ, ...................... [dram]v.      M.
+
+It is applied for one or two weeks. Every several days the parts are
+poulticed, the slough thus removed, and the ointment reapplied, and so
+on until the diseased tissue has been destroyed. It is useful in those
+cases in which a mild and comparatively painless caustic is advisable.
+In most cases several repetitions of this plan are necessary.
+
+_Arsenious acid_, employed as an ointment--
+
+  [Rx]  Ac. arseniosi, ...................... gr. xx
+        Hydrarg. sulphid. rub., ............. gr. lx
+        Ungt. aquæ rosæ, .................... [Oz]i.--M.
+
+It is painful but thorough; it is spread on lint and renewed daily. The
+action is usually sufficient in three days, and the parts are then
+poulticed until the slough comes away, after which a simple dressing is
+employed. Its application is advisable for a small area only--not more
+than four square inches--as absorption is possible.
+
+_Galvano-cautery._--The diseased tissue is destroyed by numerous
+punctures with a red-heated point or by linear incision with a
+red-heated knife. It is often a practicable and satisfactory method. The
+Paquelin cautery and liquid air and carbon dioxide also have their
+advocates.
+
+
+#Describe the operative measures employed in the removal of lupus tissue.#
+
+_Linear Scarification._--The parts are thoroughly cross-tracked, cutting
+through the diseased tissue, and subsequently a simple salicylated
+ointment applied. The operation is repeated from time to time, and as a
+result the new growth undergoes retrogressive changes, and cicatrization
+takes place.
+
+_Punctate Scarification._--By means of a simple or multiple-pointed
+instrument numerous closely-set punctures are made, and repeated from
+time to time, usually with the same action and result as from linear
+scarification.
+
+_Erasion._--The parts are thoroughly scraped with a curette, and a
+supplementary caustic application made, either with caustic potash or
+several days' use of the pyrogallic-acid ointment. The result is usually
+satisfactory.
+
+The dental-burr is also useful in breaking up discrete tubercles.
+
+_Excision._--This is an effective method if the disease consists of a
+small pea- or bean-sized circumscribed patch.
+
+Of these various operative methods those now most favored are erasion
+and excision, punctate and linear scarification methods are now rarely
+employed.
+
+
+
+                       #Tuberculosis Cutis.#[D]
+                      (_Synonym:_ Scrofuloderma.)
+
+[Footnote D: The most important clinical variety of this class is lupus
+  vulgaris, which is considered above, separately, at some length.]
+
+
+#What do you understand by tuberculosis cutis?#
+
+The term is applied to those peculiar suppurative and ulcerative
+conditions of the skin due to the tubercle bacilli.
+
+
+#How does the common type of tuberculosis cutis begin?#
+
+The most common type of tuberculous ulceration or involvement of the
+skin usually results by extension from an underlying caseating and
+suppurating lymphatic gland; or it may have its origin as subcutaneous
+tubercles independently of these structures. It tends to spread, and may
+involve an area of one or several inches.
+
+[Illustration: Fig. 48. Tuberculosis Verrucosa Cutis (Negro).]
+
+
+#What are the clinical appearances and behavior of this type of
+tuberculous ulceration?#
+
+It is usually superficial, has thin, red, undermined edges of a
+violaceous color, and an irregular base with granulations covered
+scantily with pus. As a rule, it spreads gradually as a simple
+ulceration, with but slight, if any, outlying infiltration. Subjective
+symptoms of a painful or troublesome character are rarely present. Its
+course is usually progressive but slow and chronic.
+
+Other symptoms of tuberculosis are commonly to be found.
+
+
+#Are other forms of tuberculosis cutis met with?#
+
+A papulo-pustular eruption is sometimes observed, especially on the
+upper extremities and face; sluggish and chronic in character and
+leaving small pit-like scars; has been known as the _small pustular
+scrofuloderma_.
+
+[Illustration: Fig. 49.
+  Tuberculosis Verrucosa Cutis (patient had a coexistent pulmonary
+  tuberculosis).]
+
+An ulcerative papillomatous or verrucous tuberculosis of the skin
+(tuberculosis verrucosa cutis) is also occasionally noted, most commonly
+seated upon the lower leg or the back of the hand. It may be slight or
+extensive. Its mildest phase is the so-called verruca necrogenica.
+
+
+#Describe verruca necrogenica.#
+
+Verruca necrogenica is a rare, localized, papillary or wart-like
+formation, occurring usually about the knuckles or other parts of the
+hand.
+
+It begins, as a rule, as a small, papule-like growth, increasing
+gradually in area, and when well advanced appears as a pea, dime-sized
+or larger, somewhat inflammatory, elevated, flat, warty mass, with
+usually a tendency to slight pus-formation between the hypertrophied
+papillæ; the surface may be horny or it may be crusted. It tends to
+enlarge slowly and is usually persistent, but it at times undergoes
+involution.
+
+[Illustration: Fig. 50.
+  Tuberculosis Cutis (Verruca Necrogenica). (_After Model in Guy's
+  Museum._)]
+
+
+#State the etiology.#
+
+Heredity, insufficient and unwholesome food, impure air, and the like
+are predisposing. The tubercle bacillus is the immediate exciting cause.
+
+The disease usually appears in childhood or early adult life, and not
+infrequently follows in the wake of some severe systemic disease.
+Etiologically it is identical in nature with lupus.
+
+
+#How is the tuberculous ulcer to be differentiated from syphilis?#
+
+By the peculiar character of the tuberculous ulceration, the absence of
+outlying tubercles and infiltration, together with its history, course,
+and often the presence of other tuberculous symptoms.
+
+
+#State the prognosis.#
+
+These various types of tuberculosis cutis are, as a rule, more amenable
+to treatment than that form known as lupus vulgaris (_q. v._).
+
+
+#What is the treatment of these forms of tuberculosis cutis?#
+
+Constitutional remedies, such as cod-liver oil, iodide of iron or other
+ferruginous tonics, together with good food and pure air; phosphorus
+one-hundredth to one-fiftieth of a grain three times daily is also of
+benefit in some cases.
+
+The local treatment consists in thorough curetting and the subsequent
+application of a mildly stimulating ointment. The several other plans of
+external treatment employed in lupus (_q. v._) are also variously
+practised. In recent years the _x_-ray and Finsen light plans have, in a
+measure, supplanted the previous methods of treatment. They are slow,
+however, and might be, especially the _x_-ray, more satisfactorily
+employed as a supplementary measure.
+
+
+
+                              #Ainhum.#
+
+
+#Describe ainhum.#
+
+Ainhum is a disease of the African race, met with chiefly in Brazil, the
+West Indies, and Africa, and consists of a slow but gradual linear
+strangulation of one or more of the toes, especially the smallest,
+resulting, eventually, in spontaneous amputation. The affected toes
+themselves undergo fatty degeneration, often with increase in size, and
+are, when strangulation is well advanced, considerably misshapen. The
+nature of the disease is obscure.
+
+_Treatment_ consists, in the early stages, of incision through the
+constricting band; when the disease is well advanced, amputation is the
+sole recourse.
+
+
+
+                             #Mycetoma.#
+       (_Synonyms:_ Fungous Foot of India; Madura Foot; Podelcoma.)
+
+
+#Decribe mycetoma.#
+
+It is a disease involving usually the foot, and is met with chiefly in
+India. It is characterized by swelling and the formation of tubercular
+or nodular lesions which break down and form the external openings of
+sinuses which lead to the interior of the affected part. These
+discharge, and are studded with, whitish granules or black, roe-like
+masses, mixed with a sanious or sero-purulent fluid. The whole part is
+gradually disintegrated, the process lasting indefinitely. Its nature is
+obscure; it is thought to be due to a fungus.
+
+_Treatment_ consists in the early stages, when the disease is limited,
+of thorough curetting and cauterization; later, after the part is more
+or less involved, amputation, at a point well up beyond the disease,
+becomes necessary. Potassium iodide internally may exert a favorable
+influence.
+
+
+
+                    #Perforating Ulcer of the Foot.#
+
+
+#Describe perforating ulcer of the foot.#
+
+Perforating ulcer of the foot is a rare disease, consisting of an
+indolent and usually painless sinus leading down to diseased bone. The
+external opening, which is through the centre of a corn-like formation,
+is small, and may or may not show the presence of granulations. The
+affected part is commonly more or less anæsthetic and of subnormal
+temperature. One or several may be present, either on one or both feet.
+The most common site is over the articulation of the metatarsal bone
+with the phalanx of the first or last toe. The disease is dependent upon
+impairment or degeneration of the central, truncal or peripheral nerves.
+
+
+#What is to be said in regard to the prognosis and treatment?#
+
+Treatment, which is, as a rule, unsatisfactory, consists in the
+maintenance of absolute rest, and the use of antiseptic and stimulating
+applications. Amputation is also resorted to, but even this is at times
+futile, as a new sinus may appear upon the stump.
+
+
+
+                        #Syphilis Cutanea.#
+    (_Synonyms:_ Syphiloderma; Dermatosyphilis; Syphilis of the Skin.)
+
+
+#In what various types may syphilis manifest itself upon the integument?#
+
+Syphilis may show itself as a macular, papular (rarely vesicular),
+pustular, bullous, tubercular and gummatous eruption; or the eruption
+may be, in a measure, of a mixed type.
+
+
+#In what respects do the early (or secondary) eruptions of syphilis
+differ from those following several years or more after the contraction
+of the disease?#
+
+The early or secondary eruptions are more or less generalized, with
+rarely any attempt at special configuration. Their appearance is often
+preceded by symptoms of systemic disturbance, such as fever, loss of
+appetite, muscular pains and headache; and accompanied by concomitant
+signs of the disease, such as enlargement of the lymphatic glands, sore
+throat, mucous patches, falling of the hair and rheumatic pains.
+
+
+#State the distinguishing characters of the late eruptions.#
+
+The late eruptions (those following one or more years after the
+contraction of the disease) are usually of tubercular, gummatous or
+ulcerative type; are limited in extent, and have a marked tendency to
+appear in circular, semicircular or crescentic forms or groups. Pain in
+the bones, bone lesions and other symptoms may or may not be present.
+
+
+#What is the color of syphilitic lesions?#
+
+Usually, a dull brownish-red or ham-red, with at times a yellowish cast.
+
+
+#Are there any subjective symptoms in syphilitic eruptions?#
+
+As a rule, no; but in exceptional instances of the generalized
+eruptions, more especially in negroes, there may be slight itching.
+
+
+#Describe the macular, or erythematous, eruption of syphilis.#
+
+The _macular syphiloderm_ is a general eruption, showing itself usually
+six or eight weeks after the appearance of the chancre. It consists of
+small or large, commonly pea- or bean-sized, rounded or
+irregularly-shaped, not infrequently slightly raised, macules. When well
+established they do not entirely disappear under pressure. At first a
+pale-pink or dull, violaceous red, they later become yellowish or
+coppery. The eruption is generally profuse; the face, backs of the hands
+and feet may escape. It persists several weeks or one or two months; as
+a rule, it is rapidly responsive to treatment.
+
+
+#How would you distinguish the macular syphiloderm from measles, rötheln
+and tinea versicolor?#
+
+Measles is to be differentiated by its catarrhal symptoms, fever, form
+and situation of the eruption; rötheln, by its small, roundish,
+confluent pinkish or reddish patches, its precursory pyrexic symptoms,
+its epidemic nature, and short duration; tinea versicolor by its
+scaliness, peripheral growth, distribution and history.
+
+And, finally, by the absence or presence of other symptoms of syphilis.
+
+[Illustration: Fig. 51. Macular Syphiloderm.]
+
+
+#What several varieties of the papular eruption of syphilis are met with?#
+
+There are two forms of the papular eruption--the small and large; those
+of the latter type may undergo various modifications.
+
+
+#Describe the small-papular eruption of syphilis.#
+
+The _small-papular syphiloderm_ (_miliary papular syphiloderm_) usually
+shows itself in the third or fourth month of the disease, and consists
+of a more or less generalized eruption of disseminated or grouped, firm,
+rounded or acuminated pin-head to millet-seed-sized papules, with smooth
+or slightly scaly summits, and in some lesions showing pointed
+pustulation. Scattered minute pustules and some large papules are
+usually present. The eruption is profuse, most abundant upon the trunk
+and limbs; and in the early part of the outbreak is of a bright- or
+dull-red color, later assuming a violaceous or brownish tint. It runs a
+chronic course, is somewhat rebellious to treatment, and displays a
+tendency to relapse.
+
+[Illustration: Fig. 52. Moist Papules. (_After Miller._)]
+
+
+#How would you distinguish the small-papular syphiloderm from keratosis
+pilaris, psoriasis punctata, papular eczema, and lichen ruber?#
+
+The distribution and extent of the eruption, the color, the grouping,
+with usually the presence of pustules and large papules and other
+concomitant symptoms of syphilis, are points of difference. Pustules
+never occur in the several diseases named, except in eczema.
+
+
+#Describe the large-papular eruption of syphilis.#
+
+The _large-papular syphiloderm_ (or _lenticular syphiloderm_) is a
+common form of cutaneous syphilis, appearing usually in the first six or
+eight months, and consists of a more or less generalized eruption of
+pea- to dime-sized or larger, flat, rounded or oval, firmly seated,
+more or less raised, dull-red papules; with at first a smooth surface,
+which later usually becomes covered with a film of exfoliating
+epidermis. The papules, as a rule, develop slowly, remain stationary
+several weeks or a few months, and then pass away by absorption, leaving
+slight pigmentation, which gradually fades; or they may undergo certain
+modifications. In most cases it responds rapidly to treatment.
+
+[Illustration: Small-papular Syphiloderm.]
+
+[Illustration: Fig. 53. Palmar Syphiloderm.]
+
+
+#What modifications do the papules of the large-papular syphiloderm
+sometimes undergo?#
+
+They may change into the moist papule and squamous papule.
+
+
+#Describe the moist papule of syphilis.#
+
+The change into the moist papule (also called _mucous patch, flat
+condyloma_) is not uncommon where opposing surfaces and natural folds of
+skin are subjected to more or less contact, as about the anus, the
+scroto-femoral regions, umbilicus, axillæ and beneath the mammæ. The
+dry, flat papules gradually become moist and covered with a grayish,
+sticky, mucoid secretion; several may coalesce and form large, flat
+patches. They may so remain, or they may become hypertrophic, warty or
+papillomatous, with more or less crust formation (_vegetating
+syphiloderm_).
+
+[Illustration: Fig. 54. Annular Syphiloderm. (_After I.E. Atkinson._)]
+
+
+#Describe the squamous papule of syphilis.#
+
+This tendency of the large-papular eruption to become scaly, when
+exhibited, is more or less common to all papules, and constitutes the
+_squamous_ or _papulo-squamous syphiloderm_ (improperly called
+_psoriasis syphilitica_). The papules become somewhat flattened and are
+covered with dry, grayish or dirty-gray, somewhat adherent scales. The
+scaling, as compared to that of psoriasis, is, as a rule, relatively
+slight. The eruption may be general, as usually the case in the earlier
+months of the disease, or it may appear as a relapse or a later
+manifestation, and be limited in extent.
+
+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.
+
+[Illustration: Maculo-papular syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 55. Rupia. (_After Tilbury Fox._)]
+
+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.
+
+[Illustration: Fig. 56. Ulcerating Tubercular Syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 57. Tubercular Syphiloderm.]
+
+
+#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_).
+
+[Illustration: Fig. 58. 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.
+
+[Illustration: Tubercular Syphiloderm.]
+
+[Illustration: Large-pustular Syphiloderm.]
+
+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.
+
+[Illustration: Fig. 59. Tubercular Syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 60. Tubercular Syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 61. Large Pustular Syphiloderm.]
+
+
+#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 café-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 bullæ.
+
+
+#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 Spirochæta 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
+       Glycerinæ, ........................... f[dram]j
+       Aquæ, ............ 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 Græcorum.)
+
+
+#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
+anæsthetic. 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.
+
+[Illustration: Fig. 62. Tubercular Leprosy. (_After Stoddard._)]
+
+
+#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,
+hyperæsthetic or anæsthetic, 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.
+
+[Illustration: Fig. 63. Anæsthetic Leprosy.]
+
+
+#Describe the symptoms of anæsthetic leprosy.#
+
+Following or along with precursory symptoms denoting general systemic
+disturbance, or independently of any prodromal indications, a
+hyperæsthetic 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
+hyperæsthetic nor anæsthetic, 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 anæsthetic, 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 anæsthetic the least. Patients are not
+infrequently carried off by intercurrent disease. Proper management will
+often delay the fatal ending, and exceptionally, in the anæsthetic
+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.
+
+[Illustration: Fig. 64. Epithelioma. (_After D. Lewis._)]
+
+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 septicæmia, 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 Röntgen 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.
+
+[Illustration: Fig. 65. Granuloma Fungoides.]
+
+Treatment consists of tonics, if indicated, and the administration of
+arsenic, preferably hypodermically, and Röntgen-ray exposures, along
+with the application of mild antiseptics, and operative interference
+when necessary or advisable.
+
+
+
+
+#CLASS VII.--NEUROSES.#
+
+
+                            #Hyperæsthesia.#
+
+
+#What is hyperæsthesia?#
+
+By hyperæsthesia 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.
+
+
+                             #Anæsthesia.#
+
+
+#What is anæsthesia?#
+
+Anæsthesia 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 vulvæ_) 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 vulvæ 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
+       Gylcerinæ, ........................... f[dram]ij
+       Alcoholis, ........................... f[oz]ij
+       Aquæ, ......... 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 vulvæ_, 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 vulvæ, 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 hyperæmic 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.
+
+[Illustration: Fig. 66.
+  Achorion Schönleinii X 450. (_After Duhring._) Showing simple mycelium,
+  in various stages of development, and free spores.]
+
+
+#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
+Schönleinii_. 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.
+
+[Illustration: Fig. 67. Epilating Forceps.]
+
+
+#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 potassæ and examined
+with a power of three to five hundred diameters. The fungus, (achorion
+Schönleinii), 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, præcip., .................... [dram]ij
+       Saponis viridis,
+       Ol. cadini, ....... [=a][=a] ......... [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, hyperæmic 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, hyperæmic 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.
+
+[Illustration: Fig. 68.
+  Tinea trichophytina cruris--so-called eczema marginatum--of unusually
+  extensive development. (_After Piffard._)]
+
+
+#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.
+
+[Illustration: Fig. 69.
+  Ringworm (rather inflammatory type, and produced by the trichophyton).]
+
+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.)
+
+[Illustration: Fig. 70.
+  Ringworm Fungus (Trichophyton) x 450. (_After Duhring._) As found in
+  epidermic scrapings of ringworm, showing mycelium and spores.]
+
+
+#Describe the symptoms of ringworm of the bearded region.#
+
+Ringworm of the bearded region (_tinea trichophytina barbæ_, _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, hyperæmic 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.
+
+[Illustration: Fig. 71.
+  Ringworm Fungus (Microsporon) x 500. (_After Duhring._) Short,
+  broken-off hair of scalp invaded with masses of free spores.]
+
+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.
+
+[Illustration: Fig. 72.
+  Ringworm Fungus (Trichophyton) x 300. (_After Duhring._) Short, stout
+  hair of beard, with the root-sheath attached, showing free spores and
+  chains of spores.]
+
+
+#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 potassæ, 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 hyperæmia, 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, axillæ, 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.
+
+[Illustration: Fig. 73.
+  Microsporon Furfur x 400. (_After Duhring._) Showing mycelium in various
+  stages of development, groups of spores and free spores.]
+
+
+#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 potassæ, 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.
+
+[Illustration: Fig. 74. Tinea versicolor.]
+
+
+#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, præcip., .................... [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.
+
+[Illustration: Fig. 75.
+  Microsporon Minutissimum x 1000. (_After Riehl._)]
+
+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.
+
+[Illustration: Blastomycetic dermatitis.]
+
+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.
+
+[Illustration: Fig. 76.
+  Burrow, or cuniculus, greatly magnified. (_After Kaposi._) Showing the
+  mite, ova, empty shells and excrement.]
+
+
+#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 mammæ 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.
+
+[Illustration: Fig. 77. Fig. 78.
+  Sarcoptes scabiei x 100.
+  (_After Duhring._) Female. Ventral surface. Male.]
+
+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. præcip., .................... [dram]iv
+       Balsam. Peruv., ...................... [dram]ij
+       Adipis,
+       Petrolati, ......... [=a][=a] ........ [Oz]iss.       M.
+
+And in adults, or those of non-irritable skin:--
+
+  [Rx] Sulphur, præcip., .................... [Oz]j
+       Balsam. Peruv., ...................... [Oz]ss
+       [beta]-Naphthol, ..................... [dram]ij
+       Adipis,
+       Petrolati, ... [=a][=a] ... 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.
+
+[Illustration: Fig. 79.
+  Pediculus Capitis x 25. (_After Duhring._) Female. Dorsal surface.]
+
+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.
+
+[Illustration: Fig. 80.
+  Ova of the head-louse attached to a hair. Magnified. (_After Kaposi._)]
+
+
+#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.
+
+
+#What is the treatment of pediculosis capitis?#
+
+Treatment consists in the application of some remedy destructive to the
+pediculi and their ova. Crude petroleum is effective, one or two
+thorough applications over night being usually sufficient; in order to
+lessen its inflammability, and also to mask its somewhat disagreeable
+odor, it may be mixed with an equal part of olive oil and a small
+quantity of balsam of Peru added.
+
+Tincture of cocculus indicus, pure or diluted, may also be applied with
+good results.
+
+When the parts are markedly eczematous, an ointment of ammoniated
+mercury or [beta]-naphthol, thirty to sixty grains to the ounce may
+be used.
+
+Daily shampooing with soap and water, and the twice daily application of
+a five per cent. carbolic acid lotion, together with the use of a
+fine-toothed comb, is a safe and efficient method for dispensary
+practice; as it is, indeed, for any class of patients.
+
+
+#How are the ova or their shells to be removed from the hair?#
+
+By the frequent use of acid or alkaline lotions, such as dilute acetic
+acid and vinegar, or solutions of sodium carbonate and borax.
+
+
+
+                         #Pediculosis Corporis.#
+
+
+#Describe the symptoms of pediculosis corporis.#
+
+Pediculosis corporis is dependent upon the presence of the pediculus
+corporis (_pediculus vestimenti_), a larger variety than that infesting
+the scalp. It is characterized by more or less general itching, together
+with various inflammatory lesions and excoriations. As the parasites are
+to be found chiefly in the folds and seams of the clothing, visiting the
+skin for the purpose of feeding, the various symptoms--the minute
+hemorrhagic puncta showing the points at which they have been sucking,
+and the consequent papules, pustules and excoriations--are, therefore,
+to be found most abundantly on those parts with which the clothing comes
+closely in contact, as, for instance, around the neck, across the
+shoulders, around the waist, and down the outside of the thighs. It is
+uncommon in children.
+
+[Illustration: Fig. 81.
+  Pediculus Corporis x 25. (_After Duhring._) Female. Dorsal surface.]
+
+
+#State the diagnostic characters of pediculosis corporis.#
+
+The presence of the minute hemorrhagic puncta, the multiform character
+and peculiar distribution of the eruption. Careful search will almost
+invariably disclose one or more pediculi.
+
+
+#What is the treatment of pediculosis corporis?#
+
+The clothing and bed-coverings are to be thoroughly baked or boiled, the
+pediculi and their ova being in this manner destroyed; a thymol or
+carbolized boric-acid lotion may be used to relieve the cutaneous
+irritation.
+
+When attention to the wearing apparel is not immediately practicable,
+ointments of sulphur and staphisagria, and lotions of carbolic acid, may
+be advised as temporary measures. The wearing of a bag of loosely woven
+texture containing some lump sulphur next to the skin is useful in such
+cases; at the temperature of the body the sulphur undergoes slow
+oxidation. In hairy individuals the malady is often persistent, due to
+the fact that ova have become attached to the hair and a new progeny
+soon hatched out. Continued treatment over a few weeks will usually
+suffice to rid the patient of their presence.
+
+
+
+                         #Pediculosis Pubis.#
+
+
+#Describe the symptoms of pediculosis pubis.#
+
+Pediculosis pubis is a condition due to the presence of the pediculus
+pubis, or crab-louse. It is characterized by more or less itching about
+the genitalia, together with papules, excoriations, and other
+inflammatory lesions. The amount of irritation varies; it may be slight,
+or, on the other hand, severe. The parasite, which is the smallest of
+the three varieties, may be discovered upon close examination seated
+near the roots of the hairs, clutching the hair, with its head downward
+and buried in the follicle. The ova may be seen attached to the
+hair-shafts.
+
+It infests adults chiefly, being in many instances probably contracted
+through sexual intercourse.
+
+
+#Is the pediculus pubis found upon any other part of the body?#
+
+Yes. Although its favorite habitat is the region of the pubes, it may,
+in exceptional instances, also infest the axillæ, the sternal region of
+the male, the beard, eyebrows, and even the eyelashes.
+
+
+#State the diagnostic characters of pediculosis pubis.#
+
+The region involved, itching, variable amount of irritation, and, above
+all, the presence of the pediculi and their ova.
+
+[Illustration: Fig. 82.
+  Pediculus Pubis x 25. (_After Duhring._) Female. Dorsal surface.]
+
+
+#Name several applications prescribed for pediculosis pubis.#
+
+A lotion of corrosive sublimate, one to four grains to the ounce;
+infusion of tobacco; a ten to twenty per cent. ointment of oleate of
+mercury; ammoniated mercury ointment, and a five to ten per cent.
+[beta]-naphthol ointment. Repeated washings with vinegar or dilute
+acetic acid, or with alkaline lotions, will free the hairs of the ova.
+
+
+
+                        #Cysticercus Cellulosæ.#
+
+
+#Describe the cutaneous disturbance produced by the cysticercus
+cellulosæ.#
+
+The presence of cysticerci in the skin and subcutaneous tissue gives
+rise to pea to hazelnut-sized, rounded, firm, movable tumors which, when
+developed, may remain unchanged for months. The parasites are disclosed
+by microscopic examination.
+
+Most of the cases have been observed in Germany.
+
+
+
+                           #Filaria Medinensis.#
+                         (_Synonym:_ Guinea-worm.)
+
+
+#State the character of the lesions produced by the filaria medinensis.#
+
+The young microscopic worm penetrates the skin or deeper tissue, where
+it grows gradually, finally reaching several inches or more in length
+and about a half-line in thickness; inflammation is excited and a
+tumor-like swelling makes its appearance, which, sooner or later,
+breaks, disclosing the worm. It may also present a cord-like appearance.
+It is rarely met with outside of tropical countries.
+
+Treatment consists in gradual extraction, or in the injection of a
+corrosive sublimate solution (1:1000) into the forming tumor. Asafetida
+internally has been found to be curative, the parasite being destroyed
+and subsequently absorbed or discharged.
+
+
+
+                                 #Ixodes.#
+                          (_Synonym:_ Wood-tick.)
+
+
+#State the character of the cutaneous disturbance produced by the ixodes.#
+
+The tick sticks its proboscis into the skin and sucks blood until it is
+several times its natural size, and then falls off; an urticarial lesion
+results. If caught in the act the animal should not be forcibly
+extracted, as its proboscis may be thus broken off and remain in the
+skin, and give rise to pain and inflammation. It may be made to
+relinquish its hold by placing on it a drop of an essential oil.
+
+A thymol or carbolized boric-acid lotion will relieve the irritation.
+
+
+
+                                 #Leptus.#
+                        (_Synonym:_ Harvest-mite.)
+
+
+#State the characters of the lesion produced by the leptus.#
+
+This minute brick-red mite buries itself in the skin, especially about
+the ankles and feet, giving rise to papules, vesicles and pustules.
+
+Treatment consists of the use of a mild sulphur ointment or of a
+carbolic-acid lotion.
+
+
+
+                               #[OE]strus.#
+                       (_Synonym:_ Gad, or Bot-fly.)
+
+
+#Describe the cutaneous disturbance produced by the [oe]strus.#
+
+The ova are deposited in the skin, develop and give rise to the
+formation of furuncle-like tumors with central aperture, through which a
+sanious discharge exudes; or as the result of the burrowing of the
+larvæ, irregular serpiginous lines or wheals are produced.
+
+It is chiefly met with in Central and South America.
+
+_Larva migrant_, or _creeping disease_, is doubtless in this same class.
+It is characterized by a thread-like linear formation of an
+erythematous, erythemato-papular, or vesicular nature that gradually
+extends, the older part disappearing; considerable surface may be
+covered before the parasite disappears or dies. The treatment consists
+in endeavoring to destroy the organism by means of excision or caustic
+applications at the point of its suspected site which is just ahead of
+the extending line.
+
+
+
+                             #Pulex Penetrans.#
+                     (_Synonyms:_ Sand Flea; Jigger.)
+
+
+#Describe the cutaneous disturbance produced by the pulex penetrans.#
+
+This microscopic animal penetrates the skin, especially about the toes,
+producing an inflammatory swelling, vesicle or pustule, or even
+ulceration. It is met with in warm and tropical countries.
+
+Treatment consists in extraction. Essential oils are used as a
+preventive. A carbolic-acid or alkaline lotion relieves irritation.
+
+
+
+                            #Cimex Lectularius.#
+                           (_Synonym:_ Bed-bug.)
+
+
+#Describe the characters of a bed-bug bite.#
+
+An inflammatory papule or wheal-like lesion results, somewhat
+hemorrhagic; the purpuric or hemorrhagic point or spot remains after the
+swelling subsides, but finally, in the course of several days or a few
+weeks, disappears.
+
+Treatment consists in the application of alkaline or acid lotions.
+
+
+
+                                #Culex.#
+                      (_Synonym:_ Gnat; Mosquito.)
+
+
+#Describe the cutaneous disturbance produced by the culex.#
+
+It consists of an erythematous spot or a wheal-like lesion.
+
+Alkaline or acid lotions usually give relief.
+
+
+
+                            #Pulex Irritans.#
+                        (_Synonym:_ Common Flea.)
+
+
+#Describe the cutaneous disturbance produced by the pulex irritans.#
+
+It consists of an erythematous spot with a minute central hemorrhagic
+point. In irritable skin, a wheal-like lesion may result.
+
+Treatment consists of applications of camphor or ammonia-water; carbolic
+acid and thymol lotions are also useful.
+
+
+
+
+RELATIVE FREQUENCY OF THE VARIOUS DISEASES OF SKIN AS SHOWN BY THE
+STATISTICS (123,746 CASES) OF THE AMERICAN DERMATOLOGICAL ASSOCIATION
+FOR TEN YEARS, 1878-87.
+
+
+-------------------------+-------+-------+
+    CLASSIFICATION OF    |  No.  |   %   |
+         DISEASES.       | Cases | Cases |
+-------------------------+-------+-------+
+Class I. Disorders of the|       |       |
+  Glands.                |       |       |
+  1. OF THE SWEAT GLANDS.|       |       |
+    Hyperidrosis         |   328 |  .265 |
+    Sudamen              |   268 |  .216 |
+    Anidrosis            |    11 |  .009 |
+    Bromidrosis          |   112 |  .090 |
+    Chromidrosis         |     7 |  .005 |
+    Uridrosis            |   ... |  .... |
+  2. OF THE SEBACEOUS    |       |       |
+    GLANDS               |   238 |  .193 |
+    Seborrh[oe]a:        |  1812 | 1.47  |
+      a. oleosa          |   367 |  .296 |
+      b. sicca           |   395 |  .319 |
+    Comedo               |  1225 |  .989 |
+    Cyst:                |     6 |  .004 |
+      a. Milium          |   225 |  .183 |
+      b. Steatoma        |   151 |  .122 |
+    Asteatosis           |     8 |  .006 |
+                         |       |       |
+Class II. Inflammations. |       |       |
+    Exanthemata          |  1770 | 1.43  |
+    Erythema simplex     |  1064 |  .859 |
+    Erythema multiforme: |   915 |  .730 |
+      a. papulosum       |   325 |  .262 |
+      b. bullosum        |    37 |  .029 |
+      c. nodosum         |    82 |  .066 |
+    Urticaria            |  2994 | 2.47  |
+      pigmentosa         |     1 |  .0008|
+    [E]Dermatitis:       |  1720 | 1.39  |
+      a. traumatica      |   468 |  .378 |
+      b. venenata        |   616 |  .498 |
+      c. calorica        |   224 |  .187 |
+      d. medicamentosa   |   108 |  .087 |
+      e. gangrænosa      |     8 |  .006 |
+    Erysipelas           |  1026 |  .829 |
+    Furunculus           |  2129 | 1.72  |
+    Anthrax              |   252 |  .203 |
+    Phlegmona diffusa    |   265 |  .215 |
+    Pustula maligna      |   197 |  .159 |
+    Herpes simplex       |  2057 | 1.66  |
+    Herpes zoster        |  1428 | 1.15  |
+    Dermatitis           |       |       |
+      herpetiformis      |    41 |  .033 |
+    Psoriasis            |  4131 | 3.34  |
+    Pityriasis maculuta  |       |       |
+      et circinata       |    71 |  .057 |
+    Dermatitis           |       |       |
+      exfoliativa        |    16 |  .012 |
+    Pityriasis rubra     |    44 |  .032 |
+    Lichen:              |   144 |  .116 |
+      a. planus          |   154 |  .124 |
+      b. ruber           |    27 |  .021 |
+    Eczema:              | 37661 |30.43  |
+      a. erythematosum   |  .... |  .... |
+      b. papulosum       |  .... |  .... |
+      c. vesiculosum     |  .... |  .... |
+      d. madidans        |  .... |  .... |
+      e. pustulosum      |  .... |  .... |
+      f. rubrum          |  .... |  .... |
+      g. squamosum       |  .... |  .... |
+    Prurigo              |    34 |  .027 |
+    Acne                 |  9077 | 7.34  |
+    Acne rosacea         |   398 |  .321 |
+    Sycosis              |   227 |  .185 |
+    Impetigo             |  1769 | 1.43  |
+    Impetigo contagiosa  |   600 |  .485 |
+    Impetigo             |       |       |
+      herpetiformis      |    10 |  .009 |
+    Ecthyma              |   726 |  .587 |
+    Pemphigus            |   183 |  .148 |
+    Ulcers               |  3021 | 2.44  |
+                         |       |       |
+Class III. Hemorrhages.  |       |       |
+    Purpura:             |   341 |  .275 |
+      a. simplex         |   181 |  .145 |
+      b. hæmorrhagica    |    49 |  .039 |
+                         |       |       |
+Class IV. Hypertrophies. |       |       |
+  1. OF PIGMENT.         |       |       |
+    Lentigo              |   127 |  .103 |
+    Chloasma             |   560 |  .452 |
+  2. OF EPIDERMAL AND    |       |       |
+    PAPILLARY LAYERS.    |       |       |
+    Keratosis:           |    94 |  .076 |
+      a. pilaris         |   103 |  .083 |
+      b. senilis         |    68 |  .055 |
+    Molluscum epitheliale|   172 |  .139 |
+    Callositas           |   110 |  .090 |
+    Clavus               |    84 |  .068 |
+    Cornu cutaneum       |    42 |  .034 |
+    Verruca              |  1252 | 1.09  |
+    Verruca necrogenica  |     2 |  .001 |
+    Nævus pigmentosus    |    88 |  .064 |
+    Xerosis              |   100 |  .080 |
+    Ichthyosis           |   309 |  .249 |
+    Onychauxis           |    70 |  .056 |
+    Hypertrichosis       |   515 |  .416 |
+  3. OF CONNECTIVE       |       |       |
+    TISSUE.              |       |       |
+    Sclerema neonatorum  |  .... |  .... |
+    Scleroderma          |    38 | 0.030 |
+    Morph[oe]a           |    39 | 0.031 |
+    Elephantiasis        |    57 | 0.046 |
+    Rosacea:             |   785 | 0.634 |
+      a. erythematosa    |   381 | 0.308 |
+      b. hypertrophica   |    58 | 0.047 |
+    Framb[oe]sia         |    22 | 0.018 |
+                         |       |       |
+Class V. Atrophies.      |       |       |
+  1. OF PIGMENT.         |       |       |
+    Leucoderma           |    77 | 0.062 |
+    Albinismus           |     9 | 0.008 |
+    Vitiligo             |   191 | 0.155 |
+    Canities             |    43 | 0.035 |
+  2. OF HAIR.            |       |       |
+    Alopecia             |   926 | 0.749 |
+    Alopecia furfuracea  |   830 | 0.670 |
+    Alopecia areata      |   794 | 0.641 |
+    Atrophia pilorum     |       |       |
+      propria            |    23 | 0.019 |
+    Trichorexis nodosa   |     3 | 0.002 |
+  3. OF NAIL             |    26 | 0.021 |
+    Atrophia unguis      |    19 | 0.015 |
+  4. OF CUTIS            |     6 | 0.005 |
+    Atrophia senilis     |    15 | 0.013 |
+    Atrophia maculosa et |       |       |
+      striata            |    23 | 0.019 |
+                         |       |       |
+Class VI. New Growths.   |       |       |
+  1. OF CONNECTIVE       |       |       |
+    TISSUE.              |     1 | 0.0008|
+    Keloid               |   152 | 0.124 |
+    Cicatrix             |    89 | 0.065 |
+    Fibroma              |    93 | 0.075 |
+    Neuroma              |    11 | 0.009 |
+    Xanthoma             |    69 | 0.056 |
+  2. OF MUSCULAR TISSUE. |       |       |
+    Myoma                |     1 | 0.0008|
+  3. OF VESSELS.         |       |       |
+    Angioma              |   462 | 0.373 |
+    Angioma pigmentosum  |       |       |
+      et atrophicum      |    13 | 0.010 |
+    Angioma cavernosum   |    22 | 0.018 |
+    Lymphangioma         |    16 |  .012 |
+  4. Mycosis fongoide    |     1 |  .0008|
+    Rhinoscleroma        |     3 |  .002 |
+    Lupus erythematosus  |   477 |  .385 |
+    Lupus vulgaris       |   536 |  .433 |
+    Scrofuloderma        |   663 |  .536 |
+    Syphiloderma:        | 13888 |11.22  |
+      a. erythematosum   |  .... |  .... |
+      b. papulosum       |  .... |  .... |
+      c. pustulosum      |  .... |  .... |
+      d. tuberculosum    |  .... |  .... |
+      e. gummatosum      |  .... |  .... |
+    Lepra:               |    24 |  .020 |
+      a. tuberosa        |     7 |  .005 |
+      b. maculosa        |     4 |  .003 |
+      c. anæsthetica     |     6 |  .004 |
+    Carcinoma            |  1068 |  .863 |
+    Sarcoma              |    55 |  .044 |
+                         |       |       |
+Class VII. Neuroses.     |       |       |
+    Hyperæsthesia:       |     4 |  .003 |
+      a. Pruritus        |  2716 | 2.12  |
+      b. Dermatalgia     |    11 |  .009 |
+    Anæsthesia           |    22 |  .018 |
+                         |       |       |
+Class VIII. Parasitic    |       |       |
+    Affections.          |       |       |
+  1. VEGETABLE.          |       |       |
+    Tinea favosa         |   354 |  .286 |
+    Tinea trichophytina: |  2289 | 1.85  |
+      a. circinata       |   705 |  .569 |
+      b. tonsurans       |   675 |  .545 |
+      c. sycosis         |   365 |  .295 |
+    Tinea versicolor     |  1263 | 1.02  |
+  2. ANIMAL.             |       |       |
+    Scabies              |  3192 | 2.58  |
+    Pediculosis          |       |       |
+      capillitii         |  2579 | 2.09  |
+    Pediculosis corporis |  1704 | 1.38  |
+    Pediculosis pubis    |   436 |  .352 |
+-------------------------+-------+-------+
+    Total                 123746
+
+[Footnote E: Indicating affections of this class not properly included
+  under other titles.]
+
+
+
+                            #INDEX.#
+
+Acarus folliculorum, 40
+  scabiei, 269
+
+Achorion Schönleinii, 249
+
+Acne, 115-126
+  artificialis, 120
+  atrophica, 120
+  cachecticorum, 120
+  frontalis, 129
+  hypertrophica, 120
+  indurata, 120
+  keloid, 135
+  lupoid, 129
+  necrotica, 129
+  papulosa, 120
+  punctata, 120
+  pustulosa, 120
+  rodens, 129
+  rosacea, 126-129, 198
+  sebacea, 33
+  tar, 120
+  urticata, 130
+  varioliformis, 129
+  vulgaris, 119
+
+Acnitis, 130
+
+Actinomycosis, 266
+
+Addison's disease, pigmentation of the skin in, 149
+  keloid, 172
+
+Ainhum, 212
+
+Albinismus, 177
+
+Albinos, 177
+
+Alopecia, 181-183
+  areata, 183-186
+  circumscripta, 183
+  congenital, 181
+  furfuracea, 181
+  premature, 181
+  senile, 181
+
+Anæsthesia, 244
+
+Anatomy of the skin, 17-21, 28
+
+Angioma, 196, 197
+  cavernosum, 197
+  pigmentosum et atrophicum, 190
+  simplex, 196
+
+Angiomyoma, 196
+
+Angioneurotic [oe]dema, 54
+
+Anidrosis, 31
+
+Anthrax, 70, 72
+
+Antipruritic applications, 246
+
+Antipyrin, eruptions from, 61
+
+Area Celsi, 183
+
+Argyria, 150
+
+Arsenic, eruptions from, 61
+
+Artificial eruptions (feigned eruptions), 64
+
+Atrophia cutis, 189, 190
+  pilorum propria, 187
+  unguis, 188, 189
+
+Atrophic lines and spots, 190
+
+Atrophies, 177-190
+
+Atrophoderma, 189
+  neuriticum, 189
+
+Atrophy of the hair, 187
+  of the nails, 188
+  of the skin, 189
+    general idiopathic, 189
+  senile, 190
+
+Atropia, eruptions from, 61
+
+Autographism, 52
+
+
+Baldness, 181
+
+Barbadoes leg, 174
+
+Barbers' itch, 255
+
+Bath-pruritis, 245
+
+Bed-bug, 278
+
+Bed-sores, 58
+
+Belladonna, eruptions from, 61
+
+Blackheads, 38-41
+
+Blanching of the hair, 180
+
+Blastomycetic dermatitis, 266
+
+Blebs, 23
+
+Blood-vessels, 19
+
+Boil, 68
+
+Bot-fly, 278
+
+Bromides, eruptions from, 61
+
+Bromidrosis, 32
+
+Bullæ, 23
+
+Burns, 58
+
+Burrows, 268
+
+
+Calculi, cutaneous, 42
+
+Callositas, 155, 156
+
+Callosity, 155
+
+Callous, 155
+
+Callus, 155
+
+Cancer, epithelial, 236
+  skin, 236
+
+Canities, 180
+  prematura, 180
+  senilis, 180
+
+Carbuncle, 70
+
+Carbunculus, 70-72
+
+Carcinoma epitheliale, 236
+
+Carrion's disease, 73
+
+Chafing, 45
+
+Chapping, 106
+
+Charbon, 72
+
+Cheiro-pompholyx, 76
+
+Cheloid, 191
+
+Chloasma, 149-151
+  uterinum, 149
+
+Chloral, eruptions from, 62
+
+Chromidrosis, 32
+  red, 33
+
+Chromophytosis, 262
+
+Chrysarobin, 93
+
+Chrysophanic acid (chrysarobin), 93
+
+Cicatrices, 24
+
+Cimex lectularius, 278
+
+Clavus, 156, 157
+
+Comedo, 38-41
+  extractor, 40
+
+Condyloma, flat (or broad), 217
+  pointed, 161
+
+Configuration, 24
+
+Conglomerate pustular folliculitis, 252
+
+Contagious impetigo, 136
+
+Contagiousness, 27
+
+Copaiba, eruptions from, 62
+
+Corn, 156
+
+Cornu cutaneum, 158, 159
+  humanum, 159
+
+Crab-louse, 275
+
+Creeping disease, 278
+
+Crusta lactea, 104
+
+Crustæ, 24
+
+Crusts, 24
+
+Cubebs, eruptions from, 62
+
+Culex, 279
+
+Cuniculus, 268
+
+Curette, 208
+
+Cutaneous calculi, 42
+  horn, 158
+
+Cutis anserina, 152
+  pendula, 176
+
+Cyst, sebaceous, 43
+
+Cysticercus cellulosæ, 276
+
+
+Dandruff, 33, 34
+
+Darier's disease, 153
+
+Defluvium capillorum, 181
+
+Demodex folliculorum, 40
+
+Depilatories, 169
+
+Dermalgia, 244
+
+Dermatalgia, 244
+
+Dermatitis, 58-64
+  acute general, 96
+  ambustionis, 58
+  blastomycetic, 266
+  calorica, 58
+  congelationis, 58
+  contusiformis, 50
+  exfoliativa, 96, 97
+    general, 96
+    neonatorum, 97
+    recurrent, 96
+  factitia, 64
+  gangrænosa, 65
+  herpetiformis, 83-86
+  iodoform, 59
+  malignant papillary, 240
+  medicamentosa, 60
+  papillaris capillitii, 135
+  repens, 81
+  traumatica, 58
+  vegetans, 142
+  venenata, 59
+  _x_-ray, 63
+
+Dermatographism, 52
+
+Dermatolysis, 176
+
+Dermatomyoma, 196
+
+Dermatosclerosis, 172
+
+Dermatosyphilis, 213
+
+Dhobi itch, 265
+
+Digitalis, eruptions from, 62
+
+Disorders of the glands, 28-44
+
+Dissection wound, 73
+
+Distribution and configuration, 24-26
+
+Drug eruptions (dermatitis medicamentosa), 60
+
+Duhring's disease, 83
+
+Dysidrosis, 76
+
+
+Ecthyma, 138, 139
+
+Eczema, 100-119
+  erythematosum, 102
+  fissum, 106
+  impetiginosum, 104
+  madidans, 105
+  marginatum, 253
+  papulosum, 103
+  pustulosum, 104
+  rimosum, 106
+  rubrum, 105
+  sclerosum, 106
+  seborrhoicum, 33, 34, 91, 95, 109
+  squamosum, 104
+  verrucosum, 106
+  vesiculosum, 104
+
+Electrolysis in removal of hair, 169
+
+Elephant leg, 174
+
+Elephantiasis, 174-176
+  Arabum, 174
+  Græcorum, 231
+
+Epidermis, 18
+
+Epidermolysis bullosa, 80
+
+Epilating forceps, 249
+
+Epithelial cancer, 236
+
+Epithelioma, 236-240
+  benign cystic, 198
+  molluscum, 153
+
+Equinia, 74
+
+Erasion, 208
+
+Eruptions, feigned (artificial), 64
+  medicinal (dermatitis medicamentosa), 60
+
+Erysipelas, 66, 67
+  ambulans, 67
+  migrans, 67
+
+Erysipeloid, 67
+
+Erythema, 44
+  annulare, 48
+  bullosum, 48
+  caloricum, 44
+  desquamative scarlatiniform, 96
+  gangrenosum, 65
+  gyratum, 48
+  induratum, 51
+    scrofulosorum, 51
+  intertrigo, 45, 46
+  iris, 48
+  marginatum, 48
+  multiforme, 46
+  nodosum, 50, 51
+  recurrent exfoliative, 96
+  simplex, 44
+  solare, 44
+  traumaticum, 44
+  venenatum, 44
+  vesiculosum, 48
+
+Erythrasma, 265
+
+Excessive sweating (hyperidrosis), 28
+
+Excoriationes, 24
+
+Excoriations, 24
+
+
+Farcy, 74
+
+Favus, 247
+  of general surface, 248
+  of nails, 249
+  of scalp, 247
+
+Feigned eruptions, 64
+
+Fever blisters, 78
+
+Fibroma, 192-194
+  molluscum, 192
+
+Fibromyoma, 196
+
+Filaria, 175
+  medinensis, 277
+
+Fish-skin disease, 165
+
+Fissures, 24
+
+Flea, common, 279
+  sand, 278
+
+Flesh worms, 38-41
+
+Folliclis, 130
+
+Folliculitis barbæ, 130
+  decalvans, 131
+  pustular, conglomerate, 252
+
+Forceps, epilating, 249
+
+Fragilitas crinium, 187
+
+Framb[oe]sia, 73
+
+Freckle, 148
+
+Frost-bite, 58
+
+Fungous foot of India, 212
+
+Furuncle, 68
+
+Furunculosis, 69
+
+Furunculus, 68-70
+
+
+Gad-fly, 278
+
+Galvano-cautery, 208
+  instruments, 206
+
+Gangrene of the skin (dermatitis gangrænosa), 65
+  spontaneous, 65
+  symmetric, 66
+
+Gelatin dressing, 116
+
+Giant urticaria, 54
+
+Glanders, 74
+
+Glands, sebaceous, 33
+  sweat, 28
+
+Glossy skin, 189
+
+Gnat, 279
+
+Goose-flesh, 152
+
+Granuloma fungoides, 242
+  necroticum, 129
+
+Grayness of the hair, 180
+
+Grutum, 42
+
+Guinea-worm, 277
+
+Gumma, 225
+
+Gun-powder marks, 151
+
+Gutta-percha plaster, 117
+
+
+Hair, 21
+  atrophy of, 187
+  graying of, 180
+  hypertrophy of, 168
+  superfluous, 168
+
+Hair-follicle, 21
+
+Hairy people, 168
+
+Harvest mite, 277
+
+Heat rash, 74
+
+Hemorrhages, 144-146
+
+Henoch's purpura, 145, 146
+
+Hereditary infantile syphilis, 228
+  cutaneous manifestations of, 221
+
+Herpes, 78
+  facialis, 78
+  gestationis, 83
+  iris, 48
+  labialis, 78
+  præputialis, 79
+  progenitalis, 78
+  simplex, 78-80
+  zoster, 81-83
+
+Hirsuties, 168
+
+Hives, 52
+
+Homines pilosi, 168
+
+Horn, cutaneous, 158
+
+Hydradenitis suppurativa, 130
+
+Hydroa æstivale, 80
+  herpetiforme, 83
+  puerorum, 80
+  vacciniforme, 80
+
+Hydrocystoma, 31
+
+Hyperesthesia, 244
+
+Hyperidrosis, 28-30
+
+Hypertrichosis, 168-170
+
+Hypertrophic scar, 192
+
+Hypertrophies, 148-177
+
+Hypertrophy of the hair, 168
+  of the nail, 167
+
+
+Ichthyosis, 165-167
+  congenita, 165
+  follicularis, 153
+  hystrix, 165
+  sebacea, 33
+    cornea, 153
+  simplex, 165
+
+Impetigo contagiosa, 136, 138
+  herpetiformis, 138
+  simplex, 137
+
+Infantile syphilis, hereditary, 228
+
+Inflammations, 44-143
+
+Inflammatory fungoid neoplasm, 242
+
+Iodides, eruptions from, 62
+
+Iodoform dermatitis, 59
+
+Itch, 267
+  barbers', 255
+  dhobie, 265
+  mite, 269
+
+Ivy poisoning, 59
+
+Ixodes, 277
+
+
+Jigger, 278
+
+
+Keloid, 172, 192
+  cicatricial, 191
+  false, 191
+  of Addison, 172
+  of Alibert, 191
+  spontaneous, 191
+  true, 191
+
+Keratodermia, symmetric, 155
+
+Keratoma, 155
+
+Keratosis follicularis, 153
+  palmaris et plantaris, 155
+  pigmentosa, 160
+  pilaris, 151, 152
+  senilis, 236
+
+Kerion, 255
+
+
+Land scurvy, 145
+
+Larva nigrans, 278
+
+Lentigo, 148
+
+Leontiasis, 233
+
+Lepra, 231-235
+
+Leprosy, 231
+  anæsthetic, 233
+  Lombardian, 235
+  tubercular, 232
+
+Leptus, 277
+
+Lesions, 22
+  configuration of, 24
+  consecutive, 23
+  distribution of, 24
+  elementary, 22
+  primary, 22
+  secondary, 23
+
+Leucoderma, 178
+
+Leucopathia, 178
+
+Lichen moniliformis, 98
+  pilaris, 151
+  planus, 98
+    hypertrophicus, 98
+  ruber, 99
+    acuminatus, 99
+  scrofulosus, 100
+  tropicus, 74
+  urticatus, 53
+
+Linæ albicantes, 190
+
+Linear nævus, 163
+  scarification, 208
+
+Liomyoma cutis, 196
+
+Liquor carbonic detergens, 113
+  picis alkalinus, 116
+
+Lombardian leprosy, 235
+
+Louse, body (pediculus corporis), 274
+  clothes (pediculus corporis), 274
+  crab, 275
+  head (pediculus capitis), 272
+
+Lousiness, 271
+
+Lupoid acne, 129
+  sycosis, 131
+
+Lupus, 203
+  erythematodes, 199
+  erythematosus, 199-203
+  exedens, 203
+  exfoliativus, 203
+  exulcerans, 203
+  hypertrophicus, 204
+  sebaceous, 199
+  ulcerations, 203
+  verrucosus, 204
+  vorax, 203
+  vulgaris, 203-208
+
+Lymphangiectodes, 198
+
+Lymphangioma, 198
+  tuberosum multiplex, 198
+
+Lymphangiomyoma, 196
+
+
+Maculæ, 22
+  et striæ atrophicæ, 190
+
+Macules, 22
+
+Madura foot, 212
+
+Malignant papillary dermatitis, 240
+  pustule, 72
+
+Medicinal eruptions (dermatitis medicamentosa), 60
+
+Melanoderma, 149
+
+Melanosarcoma, 242
+
+Melasma, 149
+
+Mercury, eruptions from, 62
+
+Microsporon audouini, 258
+
+Microsporon furfur, 262
+  minutissimum, 265
+
+Miliaria, 74-76
+  alba, 75
+  crystallina, 30
+  rubra, 74
+
+Milium, 42, 43
+  needle, 42
+
+Milk crust, 104
+
+Mite, harvest, 277
+  itch, 269
+
+Moist papule, 216, 217
+
+Mole, 162
+
+Molluscum contagiosum, 153
+  epitheliale, 153-155
+  fibrosum, 192
+  sebaceum, 153
+
+Morphia, eruptions from, 63
+
+Morph[oe]a, 172
+
+Mosquito, 279
+
+Mucous patch, 217
+
+Mycetoma, 212
+
+Mycosis fungoides, 242
+
+Myoma, 196
+  cutis, 196
+  telangiectodes, 196
+
+
+Nævus araneus, 198
+  capillary, 196
+  flammeus, 196
+  linear, 163
+  lipomatodes, 164
+  pigmentosus, 162
+  pilosus, 163, 168
+  sanguineus, 196
+  simplex, 196
+  spider, 198
+  spilus, 163
+  tuberosus, 197
+  vasculosus, 196
+  venous, 197
+  verrucosus, 163
+
+Nail, atrophy of, 188
+  hypertrophy of, 167
+
+Necrotic granuloma, 129
+
+Neoplasm, inflammatory fungoid, 242
+
+Neoplasmata (new growths), 191, 241
+
+Nettlerash, 52
+
+Neuralgia of the skin, 244
+
+Neuroma, 194
+
+Neuroses, 244-247
+
+New growths, 191-243
+
+Nits, 273
+
+
+Objective symptoms, 22
+
+[OE]dema, acute circumscribed, 54
+  neonatorum, 170
+
+[OE]strus, 278
+
+Ointment bases, 27
+
+Onychatrophia, 188
+
+Onychauxis, 167, 168
+
+Onychomycosis, 188
+  favosa, 249
+
+Opium, eruptions from, 63
+
+Oroya fever, 73
+
+Osmidrosis, 32
+
+Ova of pediculi, 273
+
+
+Pachydermia, 174
+
+Paget's disease of the nipple, 240
+
+Papillæ, nervous and vascular, 20
+
+Papulæ, 23
+
+Papule, moist, 216, 217
+
+Papules, 23
+
+Parasitic affections, 247-279
+  sycosis, 255
+
+Parasiticides, 250, 259
+
+Parchment skin, 190
+
+Paronychia, 167
+
+Patch, mucous, 217
+
+Pediculosis, 271
+  capillitii, 272
+  capitis, 272, 273
+  corporis, 274, 275
+  pubis, 275, 276
+
+Pediculus capitis, 272
+  corporis, 274
+  pubis, 275
+  vestimenti, 274
+
+Peliosis rheumatica, 144
+
+Pellagra, 235
+
+Pemphigus, 140-144
+  foliaceus, 141
+  neonatorum, 140
+  pruriginosus, 83
+  vegetans, 142
+  vulgaris, 140
+
+Perforating ulcer of the foot, 213
+
+Peruvian warts, 73
+
+Phlegmona diffusa, 68
+
+Phosphorescent sweat, 33
+
+Phosphoridrosis, 33
+
+Phtheiriasis, 271
+
+Plan, 73
+
+Pityriasis capitis, 34
+  maculata et circinata, 95
+  pilaris, 151
+  rosea, 95, 96
+  rubra, 97
+
+Pityriasis rubra pilaris, 99
+  versicolor, 261
+
+Plasment, 117
+
+Plaster-mull, 117
+
+Podelcoma, 212
+
+Poison dogwood, dermatitis from, 59
+  ivy, dermatitis from, 59
+  sumach, dermatitis from, 59
+  vine, dermatitis from, 59
+
+Pomphi, 23
+
+Pompholyx, 76-78
+
+Port-wine mark, 197
+
+Post-mortem pustule, 73
+
+Prickly heat, 74
+
+Primary lesions, 22, 23
+
+Prurigo, 118, 119
+
+Pruritus, 244-247
+  ani, 245
+  hiemalis, 245
+  scroti, 245
+  senilis, 245
+  vulvæ, 245
+
+Pseudochromidrosis, 33
+
+Psoriasis, 86-95
+  circinata, 88
+  diffusa, 88
+  guttata, 88
+  gyrata, 88
+  inveterata, 88
+  nummularis, 88
+  punctata, 88
+  syphilitica, 218
+
+Psorospermosis, 153, 154, 240
+
+Pulex irritans, 279
+  penetrans, 278
+
+Punctate scarification, 208
+
+Purpura, 144-146
+  hæmorrhagica, 145
+  Henoch's, 145, 146
+  rheumatica, 144
+  scorbutica, 146
+  simplex, 144
+  urticans, 144
+
+Pustula maligna, 72
+
+Pustulæ, 23
+
+Pustules, 23
+
+
+Quinine, eruptions from, 63
+
+
+Rapidity of cure, 27
+
+Raynaud's disease, 66
+
+Recurrent summer eruption, 80
+
+Red chromidrosis, 33
+  gum, 74
+
+Relative frequency, 26
+
+Rhagades, 24
+
+Rheumatism of the skin, 244
+
+Rhinophyma, 127
+
+Rhinoscleroma, 198, 199
+
+Rhus poisoning, 59
+
+Ringworm, 251
+  of bearded region, 255
+  of general surface, 251
+  of the nail, 253
+  of the scalp, 253
+  of the thighs and scrotum, 252
+  Tokelau, 261
+
+Rodent ulcer, 236
+
+Rosacea, 198
+  acne, 126
+
+Rubber plaster, 117
+
+Rupia, 221, 222
+
+
+Salicylic acid, eruptions from, 63
+  paste, 113
+
+Salt rheum, 100
+
+Sand flea, 278
+
+Sarcoma, 241, 242
+  cutis, 241
+
+Sarcoptes scabiei, 269
+
+Scabies, 267-271
+
+Scales, 24
+
+Scarification, linear, 208
+  punctate, 208
+
+Scarifier, multiple, 202
+  single, 202
+
+Scars, 24
+  hypertrophic, 192
+
+Schönlein's disease, 145, 146
+
+Sclerema, 172
+  neonatorum, 171
+  of the newborn, 171
+
+Scleriasis, 172
+
+Scleroderma, 172, 173
+  neonatorum, 171
+
+Scorbutus, 146
+
+Scrofuloderma, 209
+  pustular, small, 210
+
+Scurvy, 146
+  land, 145
+  sea, 146
+
+Sebaceous cyst, 43
+  gland, 33
+  tumor, 43
+
+Seborrh[oe]a, 33-38
+  congestiva, 199
+  oleosa, 34
+  sicca, 34
+
+Secondary lesions, 23, 24
+
+Shingles, 81
+
+Skin, anatomy of, 17
+  cancer, 236
+  general idiopathic atrophy of, 189
+  glossy, 189
+  looseness of, 176
+
+Skin, parchment, 190
+
+Spider nævus, 198
+
+Spiradenitis, 130
+
+Spontaneous gangrene, 65
+
+Spots, 22
+
+Squamæ, 24
+
+Stains, 24
+
+Statistics, 280, 281
+
+Steatoma, 43
+
+Steatorrh[oe]a, 33
+
+Stramonium, eruptions from, 63
+
+Striæ et maculæ atrophicæ, 190
+
+Strophulus, 74
+  albidus, 42
+
+Subjective symptoms, 22
+
+Sudamen, 30, 31
+
+Superfluous hair, 168
+
+Sweat, colored (chromidrosis), 32
+  glands, 28
+    phosphorescent, 33
+
+Sweating, excessive, 28
+
+Sycosis, 130-135
+  coccogenica, 130
+  non-parasitica, 130
+  parasitic, 255
+  vulgaris, 130
+
+Symmetric gangrene, 66
+  keratodermia, 155
+
+Symptomatology, 22-26
+
+Symptoms, objective, 22
+  subjective, 22
+  systemic, 22
+
+Syphilis cutanea, 213-231
+    early eruptions of, 213
+    late eruptions of, 214
+    papillomatosa, 225
+  hereditary, 227
+    eruptions of, 227
+  of the skin, 213-231
+
+Syphiloderm, 213
+  acne-form, 220
+  annular, 219
+  bullous, 222, 228
+  circinate, 219
+  ecthyma-form, 221
+  erythematous, 214, 227
+  gummatous, 225
+  impetigo-form, 220
+  large acuminated-pustular, 220
+    flat-pustular, 221
+    papular, 216
+  lenticular, 216
+  macular, 214, 227
+  miliary papular, 215
+    pustular, 219
+  non-ulcerating tubercular, 224
+  palmar, 217, 218
+  papular, 215, 227
+  papulo-squamous, 218
+  plantar, 218
+  pustular, 219
+  serpiginous tubercular, 224
+  small acuminated-pustular, 219
+    flat-pustular, 220
+    papular, 215
+  squamous, 218
+  tubercular, 223, 224
+  ulcerating tubercular, 224
+  variola-form, 220
+  vegetating, 218
+
+Syphiloderma, 213
+
+Syphiloma, 225
+
+
+Tar acne, 120
+
+Tattoo-marks, removal of, 151
+
+Telangiectasis, 127, 197, 198
+
+Tetter, 100
+
+Tinea circinata, 251
+  favosa, 247-251
+    fungus of, 249
+    unguium, 249
+  imbricata, 261
+  kerion, 255
+  sycosis, 255
+  tonsurans, 253
+  trichophytina, 251-261
+    barbæ, 255
+    capitis, 253
+    corporis, 251
+    cruris, 252
+    fungus of, 258
+    unguium, 253
+  versicolor, 262-265
+    fungus of, 262
+
+Tokelau ringworm, 261
+
+Traumaticin, 94
+
+Trichophyton, 258
+
+Trichorrhexis nodosa, 187
+
+Tubercles, 23
+
+Tubercula, 23
+
+Tuberculosis cutis, 209-211
+  of the skin, 203
+
+Tuberculosis verrucosa cutis, 209, 210
+
+Tumor, sebaceous, 43
+
+Tumors, 23
+
+Turpentine, eruptions from, 63
+
+Tyloma, 155
+
+Tylosis, 155
+
+
+Ulcer, perforating, of foot, 213
+  rodent, 236
+
+Ulcera, 24
+
+Ulerythema sycosiforme, 131
+
+Uridrosis, 33
+
+Urticaria, 52-56
+  bullosa, 54
+  chronic, 53
+  factitia, 52
+  hæmorrhagica, 54
+  [oe]dematosa, 54
+  papulosa, 54
+  tuberosa, 54
+  giant, 54
+  pigmentosa, 59
+  vesicular, 54
+
+
+Venereal wart, 161
+
+Verruca, 160-162
+  acuminata, 161
+  digitata, 160
+  filiformis, 160
+  necrogenica, 211
+  plana, 160
+    juvenilis, 160
+  senilis, 160
+  vulgaris, 160
+
+Verruga peruana, 73
+
+Vesicles, 23
+
+Vesiculæ, 23
+
+Vitiligo, 178-180
+
+Vitiligoidea, 195
+
+Vleminckx's solution, 129
+
+
+Wart, 160
+  Peruvian, 73
+  pointed, 161
+  venereal, 161
+
+Wen, 43
+
+Wheals, 23
+
+Wood-tick, 277
+
+Wound dissection, 73
+
+
+Xanthelasma, 195
+
+Xanthelasmoidea, 56
+
+Xanthoma, 195, 196
+  diabeticorum, 195
+  multiplex, 195
+  planum, 195
+  tuberculatum, 195
+  tuberosum, 195
+
+Xeroderma, 165
+
+Xeroderma pigmentosum, 190
+
+_X_-ray dermatitis, 63
+
+
+Yaws, 73
+
+
+Zona, 81
+
+Zoster, 81
+
+
+
+
+                         SAUNDERS' BOOKS
+
+                      --------- on ---------
+
+                            GYNECOLOGY
+
+                               and
+
+                            OBSTETRICS
+
+                   *       *       *       *       *
+
+                        W. B. SAUNDERS COMPANY
+
+925 Walnut Street                                            Philadelphia
+
+9, Henrietta Street                                 Covent Garden, London
+
+=========================================================================
+
+                 SAUNDERS' TEXT-BOOKS CONTINUE TO GAIN
+
+The list of text-books recommended in the various colleges again shows a
+#decided gain for the Saunders publications#. During the present college
+year, in the list of recommended books published by 164 colleges (the
+other 23 have not published lists), the Saunders books are mentioned
+3278 times, as against 3054 the previous year--#an increase of 224#. In
+other words, in each of the medical colleges in this country an average
+of 20 (18-2/5 the previous year) of the teaching books employed are
+publications issued by W. B. Saunders Company. That this increase is not
+due alone to the publication of new text-books, but rather to a most
+gratifying increase in the recommendation of text-books recognized as
+standards, is at once evident from the following: Ashton's Gynecology
+shows an increase of 19; DaCosta's Surgery, an increase of 12; Hirst's
+Obstetrics, 14; Howell's Physiology, 25; Jackson on the Eye, 16; Sahli's
+Diagnostic Methods, 11; Scudder's Fractures, 11; Stengel's Pathology,
+13; Stelwagon on the Skin, 11. These are but examples of similar
+remarkable gains throughout the entire list, and is undoubted evidence
+that the #Saunders text-books are recognized as the best#.
+
+ #A Complete Catalogue of our Publications will be Sent upon Request#
+
+
+
+
+                               Bandler's
+
+                          Medical Gynecology
+
+                   *       *       *       *       *
+
+#Medical Gynecology#. By S. Wyllis Bandler, M.D., Adjunct. Professor of
+Diseases of Women, New York Post-Graduate Medical School and Hospital.
+Octavo of 680 pages, with 135 original illustrations. Cloth, $5.00 net;
+Half Morocco, $6.50 net.
+
+
+               #JUST READY--EXCLUSIVELY MEDICAL GYNECOLOGY#
+
+
+This new work by Dr. Bandler is just the book that the physician engaged
+in general practice has long needed. It is truly _the practitioner's
+gynecology_--planned for him, written for him, and illustrated for him.
+There are many gynecologic conditions that do not call for operative
+treatment; yet, because of lack of that special knowledge required for
+their diagnosis and treatment, the general practitioner has been unable
+to treat them intelligently. This work gives just the information the
+practitioner needs. It not only deals with those conditions amenable to
+non-operative treatment, but it also tells how to recognize those
+diseases demanding operative treatment, so that the practitioner will be
+enabled to advise his patient at a time when operation will be attended
+with the most favorable results. The chapter on Pessaries is especially
+full and excellent, the proper manner of introducing the pessary being
+clearly described and illustrated with original pictures that show
+plainly the correct technic of this procedure. The chapters on Vaginal
+and Abdominal Massage, and particularly that on Artificial Hyperemia and
+Anemia, are extremely valuable to the practitioner. They express the
+very latest advances in these methods of treatment. Hydrotherapy,
+especially the Ferguson and Nauheim baths, are treated _in extenso_, and
+Electrotherapy receives the full consideration its importance merits.
+Pain as a symptom and its alleviation is dealt with in an unusually
+practical way, its value as an aid in diagnosis being emphasized.
+Gonorrhea and Syphilis and their many complications are treated in
+detail, every care being taken to have these sections--of special
+interest to the practitioner--complete in every particular. Other
+chapters of great importance are those on Constipation, Sterility,
+Associated Nervous Conditions in Gynecology, and Pregnancy and Abortion.
+
+
+
+
+                      Kelly and Noble's Gynecology
+
+                          and Abdominal Surgery
+
+#Gynecology and Abdominal Surgery#. Edited by Howard A. Kelly, M.D.,
+Professor of Gynecology in Johns Hopkins University; and Charles P.
+Noble, M.D., Clinical Professor of Gynecology in the Woman's Medical
+College, Philadelphia. Two imperial octavo volumes of 900 pages each,
+containing 650 illustrations, mostly original. Per volume: Cloth, $8.00
+net; Half Morocco, $9.50 net.
+
+
+                        BOTH VOLUMES NOW READY
+
+             WITH 650 ORIGINAL ILLUSTRATIONS BY HERMANN BECKER
+
+                            AND MAX BRÖDEL
+
+
+In view of the intimate association of gynecology with abdominal surgery
+the editors have combined these two important subjects in one work. For
+this reason the work will be doubly valuable, for not only the
+gynecologist and general practitioner will find it an exhaustive
+treatise, but the surgeon also will find here the latest technic of the
+various abdominal operations. It possesses a number of valuable features
+not to be found in any other publication covering the same fields. It
+contains a chapter upon the bacteriology and one upon the pathology of
+gynecology, dealing fully with the scientific basis of gynecology. In no
+other work can this information, prepared by specialists, be found as
+separate chapters. There is a large chapter devoted entirely to _medical
+gynecology_, written especially for the physician engaged in general
+practice. Heretofore the general practitioner was compelled to search
+through an entire work in order to obtain the information desired.
+_Abdominal surgery_ proper, as distinct from gynecology, is fully
+treated, embracing operations upon the stomach, upon the intestines,
+upon the liver and bile-ducts, upon the pancreas and spleen, upon the
+kidney, ureter, bladder, and the peritoneum. Special attention has been
+given to _modern technic_ and illustrations of the very highest order
+have been used to make clear the various steps of the operations.
+Indeed, the illustrations are truly magnificent, being the work of _Mr.
+Hermann Becker_ and _Mr. Max Brödel_, of the Johns Hopkins Hospital.
+
+
+
+
+                                Ashton's
+
+                        Practice of Gynecology
+
+                    *       *       *       *       *
+
+#The Practice of Gynecology#. By W. Easterly Ashton, M.D., LL.D.,
+Professor of Gynecology in the Medico-Chirurgical College, Philadelphia.
+Handsome octavo volume of 1096 pages, containing 1057 original line
+drawings. Cloth, $6.50 net; Half Morocco, $8.00 net.
+
+
+                   RECENTLY ISSUED--NEW (3d) EDITION
+
+                   THREE EDITIONS IN EIGHTEEN MONTHS
+
+Three editions of this work have been demanded in eighteen months. Among
+the new additions are: Colonic lavage and flushing, Hirst's treatment
+for vaginismus, Dudley's treatment of cystocele, Montgomery's round
+ligament operation, Chorio-epithelioma of the Uterus, Passive
+Incontinence of the Urine, and Moynihan's methods in Intestinal
+Anastomosis. Nothing is left to be taken for granted, the author not
+only telling his readers in every instance what should be done, but also
+precisely _how to do it_. A distinctly original feature of the book is
+the illustrations, numbering about one thousand line drawings made
+especially under the author's personal supervision from actual
+apparatus, living models, and dissections on the cadaver. These line
+drawings show in detail the procedures and operations without obscuring
+their purpose by unnecessary and unimportant anatomic surroundings.
+
+
+#Howard A. Kelly, M.D.#
+
+_Professor of Gynecology, Johns Hopkins University._
+
+"It is different from anything that has as yet appeared. The
+illustrations are particularly clear and satisfactory. One specially
+good feature is the pains with which you describe so many _details_ so
+often left to the imagination."
+
+
+#Charles B. Penrose, M.D.,#
+
+_Formerly Professor of Gynecology, University of Pennsylvania._
+
+"I know of no book that goes so thoroughly and satisfactorily into all
+the _details_ of everything connected with the subject. In this respect
+your book differs from the others."
+
+
+#George M. Edebohls, M.D.#
+
+_Professor of Diseases of Women, New York Post-Graduate Medical School._
+"I have looked it through and must congratulate you upon having produced
+a text-book most admirably adapted to _teach_ gynecology to those who
+must get their knowledge, even to the minutest and most elementary
+details, from books."
+
+
+
+
+                                Webster's
+
+                           Diseases _of_ Women
+
+                     *       *       *       *       *
+
+#Diseases of Women.# By J. Clarence Webster, M.D. (Edin.), F.R.C.P.E.,
+Professor of Gynecology and Obstetrics in Rush Medical College. Octavo
+of 712 pages, with 372 illustrations. Cloth, $7.00 net; Half Morocco,
+$8.50 net.
+
+
+                   RECENTLY ISSUED--FOR THE PRACTITIONER
+
+
+Dr. Webster has written this work _especially for the general
+practitioner_, discussing the clinical features of the subject in their
+widest relations to general practice rather than from the standpoint of
+specialism. The magnificent illustrations, three hundred and seventy-two
+in number, are nearly all original. Drawn by expert anatomic artists
+under Dr. Webster's direct supervision, they portray the anatomy of the
+parts and the steps in the operations with rare clearness and exactness.
+
+
+#Howard A. Kelly, M.D.#, _Professor of Gynecology, Johns Hopkins
+University._
+
+"It is undoubtedly one of the best works which has been put on the
+market within recent years, showing from start to finish Dr. Webster's
+well-known thoroughness. The illustrations are also of the highest
+order."
+
+                    *       *       *       *       *
+
+#Webster's Obstetrics#
+
+#A Text-Book of Obstetrics#. By J. Clarence Webster, M.D. (Edin.),
+Professor of Obstetrics and Gynecology in Rush Medical College. Octavo
+of 767 pages, illustrated. Cloth, $5.00 net; Half Morocco, $6.50 net.
+
+
+                          RECENTLY ISSUED
+
+
+#Medical Record, New York#
+
+"The author's remarks on asepsis and antisepsis are admirable, the
+chapter on eclampsia is full of good material, and ... the book can be
+cordially recommended as a safe guide."
+
+
+
+
+                              Cullen's
+
+                         Uterine Adenomyoma
+
+                  *       *       *       *       *
+
+#Uterine Adenomyoma#. By Thomas S. Cullen, M.D., Associate Professor of
+Gynecology, Johns Hopkins University. Octavo of 275 pages, with original
+illustrations by Hermann Becker and August Horn. Cloth, $5.00 net.
+
+
+                             JUST READY
+
+Dr. Cullen's large clinical experience and his extensive original work
+along the lines of gynecologic pathology have enabled him to present his
+subject with originality and precision. The work gives the early
+literature on adenomyoma, traces the disease through its various stages,
+and then gives the detailed findings in a large number of cases
+personally examined by the author. Formerly the physician and surgeon
+were unable to determine the cause of uterine bleeding, but after
+following closely the clinical course of the disease, Dr. Cullen has
+found that the majority of these cases can be diagnosed clinically. The
+results of these observations he presents in this work. The entire
+subject of adenomyoma is dealt with from the standpoint of the
+pathologist, the clinician, and the surgeon. The superb illustrations
+are the work of Mr. Hermann Becker and Mr. August Horn, of the Johns
+Hopkins Hospital.
+
+                    *       *       *       *       *
+
+                               The American
+
+                        Text-Book _of_ Obstetrics
+
+
+                    Recently Issued--New (2d) Edition
+
+
+#The American Text-Book of Obstetrics#. In two volumes. Edited by Richard
+C. Norris, M.D.; Art Editor, Robert L. Dickinson, M.D. Two octavos of
+about 600 pages each; nearly 900 illustrations, including 49 colored and
+half-tone plates. Per volume: Cloth, $3.50 net; Half Morocco, $4.50 net.
+
+
+#American Journal of the Medical Sciences#
+
+"As an authority, as a book of reference, as a 'working book' for the
+student or practitioner, we commend it because we believe there is no
+better."
+
+
+
+
+                                Hirst's
+
+                           Diseases of Women
+
+                    *       *       *       *       *
+
+#A Text-Book of Diseases of Women#. By Barton Cooke Hirst, M.D., Professor
+of Obstetrics, University of Pennsylvania; Gynecologist to the Howard,
+the Orthopedic, and the Philadelphia Hospitals. Octavo of 745 pages, 701
+illustrations, many in colors. Cloth, $5.00 net; Half Morocco, $6.50
+net.
+
+
+                   RECENTLY ISSUED--NEW (2d) EDITION
+
+                    WITH 701 ORIGINAL ILLUSTRATIONS
+
+
+The new edition of this work has just been issued after a careful
+revision. As diagnosis and treatment are of the greatest importance in
+considering diseases of women, particular attention has been devoted to
+these divisions. To this end, also, the work has been magnificently
+illuminated with 701 illustrations, for the most part original
+photographs and water-colors of actual clinical cases accumulated during
+the past fifteen years. The palliative treatment, as well as the radical
+operative, is fully described, enabling the general practitioner to
+treat many of his own patients without referring them to a specialist.
+The author's extensive experience renders this work of unusual value.
+
+
+                    *       *       *       *       *
+
+                      OPINIONS OF THE MEDICAL PRESS
+
+                    *       *       *       *       *
+
+
+#Medical Record, New York#
+
+"Its merits can be appreciated only by a careful perusal.... Nearly one
+hundred pages are devoted to technic, this chapter being in some
+respects superior to the descriptions in many text-books."
+
+
+#Boston Medical and Surgical Journal#
+
+"The author has given special attention to diagnosis and treatment
+throughout the book, and has produced a practical treatise which should
+be of the greatest value to the student, the general practitioner, and
+the specialist."
+
+
+#Medical News, New York#
+
+"Office treatment is given a due amount of consideration, so that the
+work will be as useful to the non-operator as to the specialist."
+
+
+
+
+                                Hirst's
+
+                        Text-Book of Obstetrics
+
+                      New (5th) Edition, Revised
+
+                   *       *       *       *       *
+
+#A Text-Book of Obstetrics#. By Barton Cooke Hirst, M.D., Professor of
+Obstetrics in the University of Pennsylvania. Handsome octavo, 899
+pages, with 746 illustrations, 39 in colors. Cloth, $5.00 net; Sheep or
+Half Morocco, $6.50 net.
+
+
+                            RECENTLY ISSUED
+
+
+Immediately on its publication this work took its place as the leading
+text-book on the subject. Both in this country and abroad it is
+recognized as the most satisfactorily written and clearly illustrated
+work on obstetrics in the language. The illustrations form one of the
+features of the book. They are numerous and the most of them are
+original. In this edition the book has been thoroughly revised. More
+attention has been given to the diseases of the genital organs
+associated with or following childbirth. Many of the old illustrations
+have been replaced by better ones, and there have been added a number
+entirely new. The work treats the subject from a clinical standpoint.
+
+
+                   *       *       *       *       *
+
+                     OPINIONS OF THE MEDICAL PRESS
+
+                   *       *       *       *       *
+
+
+#British Medical Journal#
+
+"The popularity of American text-books in this country is one of the
+features of recent years. The popularity is probably chiefly due to the
+great superiority of their illustration over those of the English
+text-books. The illustrations in Dr. Hirst's volume are far more
+numerous and far better executed, and therefore more instructive, than
+those commonly found in the works of writers on obstetrics in our own
+country."
+
+
+#Bulletin of Johns Hopkins Hospital#
+
+"The work is an admirable one in every sense of the word, concisely but
+comprehensively written."
+
+
+#The Medical Record, New York#
+
+"The illustrations are numerous and are works of art, many of them
+appearing for the first time. The author's style, though condensed, is
+singularly clear, so that it is never necessary to re-read a sentence in
+order to grasp the meaning. As a true model of what a modern text-book
+on obstetrics should be, we feel justified in affirming that Dr. Hirst's
+book is without a rival."
+
+
+
+
+                              Penrose's
+
+                          Diseases of Women
+
+                        Sixth Revised Edition
+
+                  *       *       *       *       *
+
+#A Text-Book of Diseases of Women#. By Charles B. Penrose, M.D., Ph.D.,
+formerly Professor of Gynecology in the University of Pennsylvania;
+Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 550
+pages, with 225 fine original illustrations. Cloth $3.75 net.
+
+
+                            JUST ISSUED
+
+
+Regularly every year a new edition of this excellent text-book is called
+for, and it appears to be in as great favor with physicians as with
+students. Indeed, this book has taken its place as the ideal work for
+the general practitioner. The author presents the best teaching of
+modern gynecology, untrammeled by antiquated ideas and methods. In every
+case the most modern and progressive technique is adopted, and the main
+points are made clear by excellent illustrations. The new edition has
+been carefully revised, much new matter has been added, and a number of
+new original illustrations have been introduced. In its revised form
+this volume continues to be an admirable exposition of the present
+status of gynecologic practice.
+
+
+                  *       *       *       *       *
+
+                     PERSONAL AND PRESS OPINIONS
+
+                  *       *       *       *       *
+
+#Howard A. Kelly, M.D.,#
+
+_Professor of Gynecology and Obstetrics, Johns Hopkins University,
+Baltimore._
+
+"I shall value very highly the copy of Penrose's 'Diseases of Women'
+received. I have already recommended it to my class as The Best book."
+
+
+#L.E. Montgomery, M.D.,#
+
+_Professor of Gynecology, Jefferson Medical College, Philadelphia._
+
+"The copy of 'A Text-Book of Diseases of Women' by Penrose received
+to-day. I have looked over it and admire it very much. I have no doubt
+it will have a large sale, as it justly merits."
+
+
+#Bristol Medico-Chirurgical Journal#
+
+"This is an excellent work which goes straight to the mark.... The book
+may be taken as a trustworthy exposition of modern gynecology."
+
+
+
+
+  GET                                                            THE NEW
+THE BEST                     American                            STANDARD
+
+                      Illustrated Dictionary
+
+                 Recently Issued--New (4th) Edition
+
+                  *       *       *       *       *
+
+#The American Illustrated Medical Dictionary#. A new and complete
+dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy,
+Chemistry, and kindred branches; with over 100 new and elaborate tables
+and many handsome illustrations. By W.A. Newman Dorland, M.D., Editor of
+"The American Pocket Medical Dictionary." Large octavo, 850 pages, bound
+in full flexible leather. Price, $4.50 net; with thumb index, $5.00 net.
+
+
+    Gives a Maximum Amount of Matter in a Minimum Space, and at the
+                        Lowest Possible Cost
+
+
+                        WITH 2000 NEW TERMS
+
+
+The immediate success of this work is due to the special features that
+distinguish it from other books of its kind. It gives a maximum of
+matter in a minimum space and at the lowest possible cost. Though it is
+practically unabridged, yet by the use of thin bible paper and flexible
+morocco binding it is only 1-1/4 inches thick. In this new edition the
+book has been thoroughly revised, and upward of two thousand new terms
+have been added, thus bringing the book absolutely up to date. The book
+contains hundreds of terms not to be found in any other dictionary, over
+100 original tables, and many handsome illustrations.
+
+
+                  *       *       *       *       *
+
+                          PERSONAL OPINIONS
+
+                  *       *       *       *       *
+
+#Howard A. Kelly, M.D.,#
+
+_Professor of Gynecology, Johns Hopkins University, Baltimore._
+
+"Dr. Borland's dictionary is admirable. It is so well gotten up and of
+such convenient size. No errors have been found in my use of it."
+
+
+#J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.)#
+
+_Professor of Surgery, Harvard Medical School._
+
+"I regard it as a valuable aid to my medical literary work. It is very
+complete and of convenient size to handle comfortably. I use it in
+preference to any other."
+
+
+
+
+                             Garrigues'
+
+                          Diseases of Women
+
+
+                  Third Edition, Thoroughly Revised
+
+                  *       *       *       *       *
+
+#A Text-Book of Diseases of Women#. By Henry J. Garrigues, A.M., M.D.,
+Gynecologist to St. Mark's Hospital and to the German Dispensary, New
+York City. Handsome octavo, 756 pages, with 367 engravings and colored
+plates. Cloth, $4.50 net; Sheep or Half Morocco, $6.00 net.
+
+The first two editions of this work met with a most appreciative
+reception by the medical profession both in this country and abroad. In
+this edition the entire work has been carefully and thoroughly revised,
+and considerable new matter added, bringing the work precisely down to
+date. Many new illustrations have been introduced, thus greatly
+increasing the value of the book both as a text-book and book of
+reference.
+
+
+#Thad. A. Reamy, M.D.,# _Professor of Gynecology, Medical College of
+Ohio._
+
+"One of the best text-books for students and practitioners which has
+been published in the English language; it is condensed, clear, and
+comprehensive. The profound learning and great clinical experience of
+the distinguished author find expression in this book."
+
+                  *       *       *       *       *
+
+                              American
+
+                     Text-Book of Gynecology
+
+#American Text-Book of Gynecology#. Medical and Surgical. Edited by J.M.
+Baldy, M.D., Professor of Gynecology, Philadelphia Polyclinic. Imperial
+octavo of 718 pages, with 341 text-illustrations and 38 plates. Cloth,
+$6.00 net; Half Morocco, $7.50 net.
+
+
+                      SECOND REVISED EDITION
+
+
+This volume is thoroughly practical in its teachings, and is intended to
+be a working text-book for physicians and students. Many of the most
+important subject are considered from an entirely new standpoint, and
+are grouped together in a manner somewhat foreign to the accepted
+custom.
+
+
+#Boston Medical and Surgical Journal#
+
+"The most complete exponent of gynecology that we have. No subject seems
+to have been neglected."
+
+
+
+
+                             Dorland's
+
+                        Modern Obstetrics
+
+                  *       *       *       *       *
+
+#Modern Obstetrics: General and Operative#. By W.A. Newman Dorland, A.M.,
+M.D., Assistant Instructor in Obstetrics, University of Pennsylvania;
+Associate in Gynecology in the Philadelphia Polyclinic. Handsome octavo
+volume of 797 pages, with 201 illustrations. Cloth, $4.00 net.
+
+             Second Edition, Revised and Greatly Enlarged
+
+In this edition the book has been entirely rewritten and very greatly
+enlarged. Among the new subjects introduced are the surgical treatment
+of puerperal sepsis, infant mortality, placental transmission of
+diseases, serum-therapy of puerperal sepsis, etc.
+
+
+#Journal of the American Medical Association#
+
+"This work deserves commendation, and that it has received what it
+deserves at the hands of the profession is attested by the fact that a
+second edition is called for within such a short time. Especially
+deserving of praise is the chapter on puerperal sepsis."
+
+                  *       *       *       *       *
+
+                        Davis' Obstetric and
+
+                        Gynecologic Nursing
+
+
+#Obstetric and Gynecologic Nursing#. By Edward P. Davis, A.M., M.D.,
+Professor of Obstetrics in the Jefferson Medical College and
+Philadelphia Polyclinic; Obstetrician and Gynecologist, Philadelphia
+Hospital. 12mo of 436 pages, illustrated. Buckram, $1.75 net.
+
+
+                  JUST ISSUED--THIRD REVISED EDITION
+
+
+This volume gives a very clear and accurate idea of the manner to meet
+the conditions arising during obstetric and gynecologic nursing. The
+third edition has been thoroughly revised.
+
+
+#The Lancet, London#
+
+"Not only nurses, but even newly qualified medical men, would learn a
+great deal by a perusal of this book. It is written in a clear and
+pleasant style, and is a work we can recommend."
+
+
+
+
+                       Schäffer _and_ Edgar's
+
+                   Labor and Operative Obstetrics
+
+                  *       *       *       *       *
+
+#Atlas and Epitome of Labor and Operative Obstetrics#. By Dr. O. Schäffer,
+of Heidelberg. _From the Fifth Revised and Enlarged German Edition._
+Edited, with additions, by J. Clifton Edgar, M.D., Professor of
+Obstetrics and Clinical Midwifery, Cornell University Medical School,
+New York. With 14 lithographic plates in colors, 139 other
+illustrations, and 111 pages of text. Cloth, $2.00 net. _In Saunders'
+Hand-Atlas Series._
+
+This book presents the act of parturition and the various obstetric
+operations in a series of easily understood illustrations, accompanied
+by a text treating the subject from a practical standpoint.
+
+
+#American Medicine#
+
+"The method of presenting obstetric operations is admirable. The
+drawings, representing original work, have the commendable merit of
+illustrating instead of confusing."
+
+                  *       *       *       *       *
+
+    Schäffer _and_ Edgar's Obstetric Diagnosis and Treatment
+
+
+#Atlas and Epitome of Obstetric Diagnosis and Treatment#. By Dr. O.
+Schäffer, of Heidelberg. _From the Second Revised German
+Edition._Edited, with additions, by J. Clifton Edgar, M.D., Professor of
+Obstetrics and Clinical Midwifery, Cornell University Medical School,
+N.Y. With 122 colored figures on 56 plates, 38 text-cuts, and 315 pages
+of text. Cloth, $3.00 net. _In Saunders' Hand-Atlas Series._
+
+This book treats particularly of obstetric operations, and, besides the
+wealth of beautiful lithographic illustrations, contains an extensive
+text of great value. This text deals with the practical, clinical side
+of the subject.
+
+
+#New York Medical Journal#
+
+"The illustrations are admirably executed, as they are in all of these
+atlases, and the text can safely be commended, not only as elucidatory
+of the plates, but as expounding the scientific midwifery of to-day."
+
+
+
+
+                         Schäffer and Norris'
+
+                             Gynecology
+
+                  *       *       *       *       *
+
+#Atlas and Epitome of Gynecology#. By Dr. O. Schäffer, of Heidelberg.
+_From the Second Revised and Enlarged German Edition._ Edited, with
+additions, by Richard C. Norris, A.M., M.D., Assistant Professor of
+Obstetrics in the University of Pennsylvania. 207 colored figures on 90
+plates, 65 text-cuts, and 308 pages of text. Cloth, $3.50 net. _In
+Saunders' Hand-Atlas Series._
+
+
+American Journal of the Medical Sciences
+
+"Of the illustrations it is difficult to speak in too high terms of
+approval. They are so clear and true to nature that the accompanying
+explanations are almost superfluous. We commend it most earnestly."
+
+                  *       *       *       *       *
+
+                             Galbraith's
+
+                     Four Epochs of Woman's Life
+
+
+               Second Revised Edition--Recently Issued
+
+
+#The Four Epochs of Woman's Life:# A Study in Hygiene. By Anna M.
+Galbraith, M.D., Fellow of the New York Academy of Medicine, etc. With
+an Introductory Note by John M. Musser, M.D. Professor of Clinical
+Medicine, University of Pennsylvania. 12 mo of 247 pages. Cloth $1.50
+net.
+
+
+              MAIDENHOOD, MARRIAGE, MATERNITY, MENOPAUSE
+
+
+In this instructive work are stated, in a modest, pleasing, and
+conclusive manner, those truths of which every woman should have a
+thorough knowledge. Written, as it is, for the laity, the subject is
+discussed in language readily grasped even by those most unfamiliar with
+medical subjects.
+
+
+#Birmingham Medical Review, England#
+
+"We do not as a rule care for medical books written for the instruction
+of the public. But we must admit that the advice in Dr. Galbraith's work
+is in the main wise and wholesome."
+
+
+
+
+                        Schäffer and Webster's
+
+                         Operative Gynecology
+
+
+#Atlas and Epitome of Operative Gynecology#. By Dr. O. Schäffer, of
+Heidelberg. Edited, with additions, by J. Clarence Webster, M.D.
+(Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in Rush
+Medical College, in affiliation with the University of Chicago. 42
+colored lithographic plates, many text-cuts, a number in colors, and 138
+pages of text. _In Saunders' Hand-Atlas Series._ Cloth, $3.00 net.
+
+
+                            RECENTLY ISSUED
+
+
+Much patient endeavor has been expended by the author, the artist, and
+the lithographer in the preparation of the plates for this Atlas. They
+are based on hundreds of photographs taken from nature, and illustrate
+most faithfully the various surgical situations. Dr. Schäffer has made a
+specialty of demonstrating by illustrations.
+
+
+#Medical Record, New York#
+
+"The volume should prove most helpful to students and others in grasping
+details usually to be acquired only in the amphitheater itself."
+
+                  *       *       *       *       *
+
+                    DeLee's Obstetrics for Nurses
+
+#Obstetrics for Nurses#. By Joseph B. DeLee, M.D., Professor of
+Obstetrics in the Northwestern University Medical School, Chicago;
+Lecturer in the Nurses' Training Schools of Mercy, Wesley, Provident,
+Cook County, and Chicago Lying-in Hospitals. 12mo of 512 pages, fully
+illustrated.
+                                                     Cloth, $2.50 net.
+
+
+                    JUST ISSUED--NEW (3d) EDITION
+
+
+While Dr. DeLee has written his work especially for nurses, the
+practitioner will also find it useful and instructive, since the duties
+of a nurse often devolve upon him in the early years of his practice.
+The illustrations are nearly all original and represent photographs
+taken from actual scenes. The text is the result of the author's many
+years' experience in lecturing to the nurses of five different training
+schools.
+
+
+#J. Clifton Edgar, M.D.,#
+
+_Professor of Obstetrics and Clinical Midwifery, Cornell University, New
+York._
+
+"It is far and away the best that has come to my notice, and I shall
+take great pleasure in recommending it to my nurses, and students as
+well."
+
+
+
+
+#American Pocket Dictionary#                     Recently issued--5th Ed.
+
+The American Pocket Medical Dictionary. Edited by W.A. Newman Dorland,
+A.M., M.D., Assistant Obstetrician to the Hospital of the University of
+Pennsylvania; Fellow of the American Academy of Medicine. With 578
+pages. Full leather, limp, with gold edges, $1.00 net; with patent thumb
+index, $1.25 net.
+
+
+#James W. Holland. M.D.,#
+
+_Professor of Chemistry and Toxicology, at the Jefferson Medical
+College, Philadelphia._
+
+"I am struck at once with admiration at the compact size and attractive
+exterior. I can recommend it to our students without reserve."
+
+
+#Cragin's Gynecology#                    Recently Issued--New (6th) Ed.
+
+Essentials of Gynecology. By Edwin B. Cragin, M.D., Professor of
+Obstetrics, College of Physicians and Surgeons, New York. Crown octavo,
+240 pages, 62 illustrations. Cloth, $1.00 net. _In Saunders'
+Question-Compend Series._
+
+
+#The Medical Record, New York#
+
+"A handy volume and a distinct improvement on students' compends in
+general. No author who was not himself a practical gynecologist could
+have consulted the student's needs so thoroughly as Dr. Cragin has
+done."
+
+
+#Boisliniere's Obstetric Accidents, Emergencies, and Operations#
+
+Obstetric Accidents, Emergencies, and Operations. By the late L. Ch.
+Boisliniere, M.D., Emeritus Professor of Obstetrics, St. Louis Medical
+College; Consulting Physician, St. Louis Female Hospital. 381 pages,
+illustrated. Cloth, $2.00 net.
+
+
+#British Medical Journal#
+
+"It is clearly and concisely written, and is evidently the work of a
+teacher and practitioner of large experience. Its merit lies in the
+judgment which comes from experience."
+
+
+#Ashton's Obstetrics#                      Recently Issued--New (6th) Ed.
+
+Essentials of Obstetrics. By W. Easterly Ashton, M.D., Professor of
+Gynecology in the Medico-Chirurgical College, Philadelphia. Crown
+octavo, 252 pages, 75 illustrations. Cloth, $1.00 net. _In Saunders'
+Question-Compend Series._
+
+
+#Southern Practitioner#
+
+"An excellent little volume, containing correct and practical knowledge.
+An admirable compend, and the best condensation we have seen."
+
+
+#Barton and Wells' Medical Thesaurus#
+
+A Thesaurus of Medical Words and Phrases. By Wilfred M. Barton, M.D.,
+Assistant to Professor of Materia Medica and Therapeutics, Georgetown
+University, Washington, D.C.; and WALTER A. WELLS, M.D., Demonstrator
+of Laryngology, Georgetown University, Washington, D.C. 12mo of 534
+pages. Flexible leather, $2.50 net; with thumb index, $3.00 net.
+
+
+
+
+        *       *       *       *       *
+
+
+
+Transcriber's note:
+
+   Changed "dioxid" to "dioxide" in several places
+
+   Made hyphenation of various words consistent
+
+   Page 74: Corrected misspelling of Phlegmona
+
+   Page 135: Corrected misspelling of quantity
+
+   Page 138: changed ',' to '.' at end of sentence
+
+   Page 208: aquæ rosae changed to aquæ rosæ
+
+   Page 210: Fixed typographical error "symptyms" into "symptoms"
+
+   Page 212: Fixed typographical error "Decribe mycetoma" into
+             "Describe mycetoma"
+
+   Page 213: Fixed typographical error "iodid" into "iodide"
+
+
+
+***END OF THE PROJECT GUTENBERG EBOOK ESSENTIALS OF DISEASES OF THE SKIN***
+
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+<h1>The Project Gutenberg eBook, Essentials of Diseases of the Skin, by Henry
+Weightman Stelwagon</h1>
+<pre>
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at <a href = "http://www.gutenberg.org">www.gutenberg.org</a></pre>
+<p>Title: Essentials of Diseases of the Skin</p>
+<p>       Including the Syphilodermata Arranged in the Form of Questions and Answers Prepared Especially for Students of Medicine</p>
+<p>Author: Henry Weightman Stelwagon</p>
+<p>Release Date: July 1, 2008  [eBook #25944]</p>
+<p>Language: English</p>
+<p>Character set encoding: ISO-8859-1</p>
+<p>***START OF THE PROJECT GUTENBERG EBOOK ESSENTIALS OF DISEASES OF THE SKIN***</p>
+<p>&nbsp;</p>
+<h3>E-text prepared by Kevin Handy, Ronnie Sahlberg, cbott, John Hagerson,<br />
+    and the Project Gutenberg Online Distributed Proofreading Team<br />
+    (http://www.pgdp.net)</h3>
+<p>&nbsp;</p>
+<table border="0" cellpadding="10" style="background-color: #ddddff;">
+  <tr>
+    <td>
+		Transcriber's note:<br />
+		<br />
+		This book contains many characters which might not display if
+		the character is not included in the character sets available
+		to the browser, in which case the reader is likely to see a small
+		square instead of the intended character. Some of these characters
+		are symbols for quantities, such as dram and minim, or the recipe
+		(prescription) sign. Referring to one of the text-file versions
+		might help the reader to identify characters that do not display
+		in the browser.<br />
+		<br />
+		A detailed transcriber's note is at the end of the e-text.
+    </td>
+  </tr>
+</table>
+<p>&nbsp;</p>
+<hr class="full" />
+<p>&nbsp;</p>
+
+<table width='100%'>
+<tr><td style='text-align: left'><strong>Get the Best</strong></td><td></td><td style='text-align: right;'><strong>The New Standard</strong></td></tr>
+</table>
+
+<h3>DORLAND'S</h3>
+
+<h2>AMERICAN ILLUSTRATED</h2>
+
+<h1>MEDICAL DICTIONARY</h1>
+
+<h3>For Students and Practitioners</h3>
+
+<p><b>A New and Complete Dictionary of the terms used in Medicine, Surgery,
+Dentistry, Pharmacy, Chemistry, and kindred branches; together with
+new and elaborate Tables of Arteries, Muscles, Nerves, Veins, etc.;
+of Bacilli, Bacteria, Micrococci, etc.; Eponymic Tables of Diseases,
+Operations, Signs and Symptoms, Stains, Tests, Methods of Treatment,
+etc. By <span class='smcap'>W.A.N. Dorland, M.D.</span>, Editor of the American
+Pocket Medical Dictionary. Large octavo, nearly 800 pages, bound in
+full flexible leather. Price, $4.50 net; with thumb index, $5.00 net</b>.</p>
+
+<p>JUST ISSUED&mdash;NEW (4) REVISED EDITION--2000 NEW WORDS</p>
+
+<p class='center'><i>It contains a maximum amount of matter in a minimum</i></p>
+<p class='center'><i>space and at the lowest possible cost.</i></p>
+
+<p>This book contains <b>double the material in the ordinary students' dictionary</b>,
+and yet, by the use of a clear, condensed type and thin paper of the
+finest quality, is only 1-3/4 inches in thickness. It is bound in full flexible leather,
+and is just the kind of a book that a man will want to keep on his desk for constant
+reference. The book makes a special feature of <b>the newer words</b>, and
+defines hundreds of important terms not to be found in any other dictionary. It
+is especially <b>full in the matter of tables</b>, containing more than a hundred of
+great practical value, including new tables of Tests, Stains and Staining Methods.
+A new feature is the inclusion of numerous handsome illustrations, many of
+them in colors, drawn and engraved specially for this book.</p>
+
+<div class='blockquot'><p>&ldquo;I must acknowledge my astonishment at seeing how much he has condensed within relatively
+small space. I find nothing to criticise, very much to commend, and was interested in
+finding some of the new words which are not in other recent dictionaries.&rdquo;&mdash;<span class='smcap'>Roswell Park</span>,
+<i>Professor of Principles and Practice of Surgery and Clinical Surgery, University of Buffalo</i>.</p>
+
+<p>&ldquo;Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient
+size. No errors have been found in my use of it.&rdquo;&mdash;<span class='smcap'>Howard A. Kelly</span>, <i>Professor of Gynecology,
+Johns Hopkins University, Baltimore</i>.</p></div>
+
+<p class='center'><b>W. B. SAUNDERS COMPANY, 925 Walnut St., Phila.</b></p>
+<p class='center'><b>London: 9, Henrietta Street, Covent Garden</b></p>
+
+
+<hr style='width: 65%;' />
+
+<table width='100%'>
+<tr><td style='text-align: left'><strong>Fifth Edition, Just Ready</strong></td><td></td><td style='text-align: right;'><strong>With Complete Vocabulary</strong></td></tr>
+</table>
+
+
+<h3>THE</h3>
+
+<h2>AMERICAN POCKET</h2>
+
+<h1>MEDICAL DICTIONARY</h1>
+
+
+<p class='center'>EDITED BY</p>
+
+<p class='center'>W.A. NEWMAN DORLAND, A.M., M.D.,</p>
+
+<p class='center'>Assistant Demonstrator of Obstetrics, University of Pennsylvania.</p>
+
+
+<p class='center'>HUNDREDS OF NEW TERMS</p>
+
+<p class='center'><b>Bound in Full Leather, Limp, with Gold Edges. Price, $1.00 net;
+with Patent Thumb Index, $1.25 net.</b></p>
+
+<hr style='width: 35%;' />
+
+<p>The book is an <b>absolutely new one</b>. It is not a revision
+of any old work, but it has been written entirely anew
+and is constructed on lines that experience has shown to be
+the most practical for a work of this kind. It aims to be
+<b>complete</b>, and to that end contains practically all the terms
+of modern medicine. This makes an unusually large vocabulary.
+Besides the ordinary dictionary terms the book contains
+a wealth of <b>anatomical and other tables</b>. This matter is
+of particular value to students for memorizing in preparation
+for examination.</p>
+
+<div class='blockquot'><p>&ldquo;I am struck at once with admiration at the compact size and attractive exterior.
+I can recommend it to our students without reserve.&rdquo;&mdash;<span class='smcap'>James W. Holland</span>,
+M.D., <i>of Jefferson Medical College</i>.</p>
+
+<p>&ldquo;This is a handy pocket dictionary, which is so full and complete that it puts
+to shame some of the more pretentious volumes.&rdquo;&mdash;<i>Journal of the American
+Medical Association</i>.</p>
+
+<p>&ldquo;We have consulted it for the meaning of many new and rare terms, and
+have not met with a disappointment. The definitions are exquisitely clear and
+concise. We have never found so much information in so small a space.&rdquo;&mdash;<i>Dublin
+Journal of Medical Science</i>.</p>
+
+<p>&ldquo;This is a handy little volume that, upon examination, seems fairly to fulfil
+the promise of its title, and to contain a vast amount of information in a very
+small space.... It is somewhat surprising that it contains so many of the rarer
+terms used in medicine.&rdquo;&mdash;<i>Bulletin Johns Hopkins Hospital</i>, Baltimore.</p></div>
+
+
+<p class='center'><b>W. B. SAUNDERS COMPANY, 925 Walnut St., Phila.</b></p>
+
+<p class='center'><b>London: 9, Henrietta Street, Covent Garden</b></p>
+
+
+
+
+<hr style='width: 65%;' />
+<p><br /><br /><br /><br /><br /><br /><br /><br /></p>
+
+<h2><a name='ESSENTIALS' id='ESSENTIALS'></a>ESSENTIALS</h2>
+
+<p class='center'>OF</p>
+
+<h1>DISEASES OF THE SKIN.</h1>
+
+<p><br /><br /><br /><br /><br /><br /><br /><br /><br /></p>
+
+<hr style='width: 65%;' />
+
+<p><br /><br /><br /><br /><br /><br /><br /><br /><br /></p>
+
+<p>Since the issue of the first volume of the
+<b>Saunders Question-Compends</b>,</p>
+
+<p class='center'>OVER 290,000 COPIES</p>
+
+<p>of these unrivalled publications have been sold.
+This enormous sale is indisputable evidence
+of the value of these self-helps to students
+and physicians.</p>
+
+<p><br /><br /><br /><br /><br /><br /><br /><br /><br /></p>
+
+<hr style='width: 65%;' />
+
+
+<p class='center'>SAUNDERS' QUESTION-COMPENDS. No. 11.</p>
+
+
+<h2>ESSENTIALS</h2>
+
+<h3>OF</h3>
+
+<h1>DISEASES OF THE SKIN</h1>
+
+
+<p class='center'>INCLUDING THE</p>
+
+<h3>SYPHILODERMATA</h3>
+
+
+<p class='center'>ARRANGED IN THE FORM OF</p>
+
+<h2>QUESTIONS AND ANSWERS</h2>
+
+
+<p class='center'>PREPARED ESPECIALLY FOR</p>
+
+<h3>STUDENTS OF MEDICINE</h3>
+
+<p class='center'>BY</p>
+
+<p class='center'>HENRY W. STELWAGON, M.D., PH.D.</p>
+
+<p class='center'>Professor of Dermatology in the Jefferson Medical College, Philadelphia;
+Dermatologist to the Howard and Philadelphia Hospitals, etc.</p>
+
+
+<p class='center'><b>SEVENTH EDITION, THOROUGHLY REVISED</b></p>
+
+<p class='center'><b>ILLUSTRATED</b></p>
+<p>&nbsp;</p>
+<p>&nbsp;</p>
+<p>&nbsp;</p>
+
+<p class='center'><b>PHILADELPHIA AND LONDON</b></p>
+
+<p class='center'><b>W. B. SAUNDERS COMPANY</b></p>
+
+<p class='center'><b>1909</b></p>
+<hr style='width: 65%;' />
+
+<p><br /><br /><br /><br /><br /><br /><br /><br /></p>
+
+<p class='center'>Set up, electrotyped, printed, 1890. Reprinted July, 1891.</p>
+<p class='center'>Revised, reprinted, June, 1894. Reprinted March, 1897.</p>
+<p class='center'>Revised, reprinted, August, 1899. Reprinted September,</p>
+<p class='center'>1901, May, 1902, September, 1903. Revised, reprinted</p>
+<p class='center'>January, 1905. Reprinted March,</p>
+<p class='center'>1906. Revised, reprinted</p>
+<p class='center'>March, 1909.</p>
+<hr style='width: 15%;' />
+
+<p><br /><br /><br /><br /><br /></p>
+
+<hr style='width: 15%;' />
+<p class='center'>PRINTED IN AMERICA</p>
+<hr style='width: 15%;' />
+
+
+<p class='center'>PRESS OF</p>
+
+<p class='center'>W. B. SAUNDERS COMPANY</p>
+
+<p class='center'>PHILADELPHIA</p>
+<hr style='width: 65%;' />
+
+<p><br /><br /><br /><br /><br /></p>
+
+<h2><a name='PREFACE_TO_SEVENTH_EDITION' id='PREFACE_TO_SEVENTH_EDITION'></a>PREFACE TO SEVENTH EDITION.</h2>
+
+<hr style='width: 25%;' />
+
+<p>In the present&mdash;seventh&mdash;edition the subject matter, especially
+as regards the practical part, has been gone over carefully and the
+necessary corrections and additions made. Nineteen new illustrations
+have been added, a few of the old ones being eliminated. It
+is hoped that the continued demand for this compend means a
+widening interest in the study of diseases of the skin, sufficiently
+keen as to lead to the desire for a still greater knowledge.</p>
+
+<p class='right'>H.W.S.</p>
+
+<p><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /></p>
+<p><br /><br /><br /><br /><br /></p>
+
+<hr style='width: 65%;' />
+<h2><a name='PREFACE_TO_FIRST_EDITION' id='PREFACE_TO_FIRST_EDITION'></a>PREFACE TO FIRST EDITION.</h2>
+
+<hr style='width: 25%;' />
+
+<p>Much of the present volume is, in a measure, the outcome of a
+thorough revision, remodelling and simplification of the various
+articles contributed by the author to Pepper's System of Medicine,
+Buck's Reference Handbook of the Medical Sciences, and Keating's
+Cyclop&aelig;dia of the Diseases of Children. Moreover, in the endeavor
+to present the subject as tersely and briefly as compatible with clear
+understanding, the several standard treatises on diseases of the skin
+by Tilbury Fox, Duhring, Hyde, Robinson, Anderson, and Crocker,
+have been freely consulted, that of the last-named author suggesting
+the pictorial presentation of the &ldquo;Anatomy of the Skin.&rdquo;
+The space allotted to each disease has been based upon relative
+importance. As to treatment, the best and approved methods
+only&mdash;those which are founded upon the aggregate experience of
+dermatologists&mdash;are referred to.</p>
+
+<p>For general information a statistical table from the Transactions
+of the American Dermatological Association is appended.</p>
+
+<p class='right'>H.W.S.</p>
+
+<p><br /><br /><br /><br /><br /></p>
+
+<hr style='width: 65%;' />
+
+
+<p class='center'><a name='TOC' id='TOC'></a>CONTENTS.</p>
+
+<hr style='width: 15%;' />
+
+<table summary='CONTENTS.'>
+<tr><th></th><th style='text-align: right;'>PAGE</th></tr>
+
+<tr><td><a href='#ANATOMY_OF_THE_SKIN'><span class='smcap'>Anatomy of the Skin</span></a></td><td style='text-align: right;'><a href='#Page_17'>17</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#The_Epidermis'>The Epidermis</a></span></td><td style='text-align: right;'><a href='#Page_18'>18</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#The_Blood_vessels'>The Blood-vessels</a></span></td><td style='text-align: right;'><a href='#Page_19'>19</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#The_Nervous_and_Vascular_Papillae'>The Nervous and Vascular Papill&aelig;</a></span></td><td style='text-align: right;'><a href='#Page_20'>20</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#The_Hair_and_Hair_Follicle'>The Hair and Hair-follicle</a></span></td><td style='text-align: right;'><a href='#Page_21'>21</a></td></tr>
+
+<tr><td><a href='#SYMPTOMATOLOGY'><span class='smcap'>Symptomatology</span></a></td><td style='text-align: right;'><a href='#Page_22'>22</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#Primary_Lesions'>Primary Lesions</a></span></td><td style='text-align: right;'><a href='#Page_22'>22</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#Secondary_Lesions'>Secondary Lesions</a></span></td><td style='text-align: right;'><a href='#Page_23'>23</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#Distribution_and_Configuration'>Distribution and Configuration</a></span></td><td style='text-align: right;'><a href='#Page_24'>24</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#RELATIVE_FREQUENCY'>Relative Frequency</a></span></td><td style='text-align: right;'><a href='#Page_26'>26</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#CONTAGIOUSNESS'>Contagiousness</a></span></td><td style='text-align: right;'><a href='#Page_27'>27</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#RAPIDITY_OF_CURE'>Rapidity of Cure</a></span></td><td style='text-align: right;'><a href='#Page_27'>27</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#OINTMENT_BASES'>Ointment Bases</a></span></td><td style='text-align: right;'><a href='#Page_27'>27</a></td></tr>
+
+<tr><td><a href='#CLASS_I_DISORDERS_OF_THE_GLANDS'><span class='smcap'>Class I.&mdash;Disorders of the Glands</span></a></td><td style='text-align: right;'><a href='#Page_28'>28</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Hyperidrosis'>Hyperidrosis</a></span></td><td style='text-align: right;'><a href='#Page_28'>28</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Sudamen'>Sudamen</a></span></td><td style='text-align: right;'><a href='#Page_30'>30</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Hydrocystoma'>Hydrocystoma</a></span></td><td style='text-align: right;'><a href='#Page_31'>31</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Anidrosis'>Anidrosis</a></span></td><td style='text-align: right;'><a href='#Page_31'>31</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Bromidrosis'>Bromidrosis</a></span></td><td style='text-align: right;'><a href='#Page_32'>32</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Chromidrosis'>Chromidrosis</a></span></td><td style='text-align: right;'><a href='#Page_32'>32</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Uridrosis'>Uridrosis</a></span></td><td style='text-align: right;'><a href='#Page_33'>33</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Phosphoridrosis'>Phosphoridrosis</a></span></td><td style='text-align: right;'><a href='#Page_33'>33</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Seborrhoea_Eczema_Seborrhoicum'>Seborrh&oelig;a (Eczema Seborrhoicum)</a></span></td><td style='text-align: right;'><a href='#Page_33'>33</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Comedo'>Comedo</a></span></td><td style='text-align: right;'><a href='#Page_38'>38</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Milium'>Milium</a></span></td><td style='text-align: right;'><a href='#Page_42'>42</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Steatoma'>Steatoma</a></span></td><td style='text-align: right;'><a href='#Page_43'>43</a></td></tr>
+
+<tr><td><a href='#CLASS_II_INFLAMMATIONS'><span class='smcap'>Class II.&mdash;Inflammations</span></a></td><td style='text-align: right;'><a href='#Page_44'>44</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Erythema_Simplex'>Erythema Simplex</a></span></td><td style='text-align: right;'><a href='#Page_44'>44</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Erythema_Intertrigo'>Erythema Intertrigo</a></span></td><td style='text-align: right;'><a href='#Page_45'>45</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Erythema_Multiforme'>Erythema Multiforme</a></span></td><td style='text-align: right;'><a href='#Page_46'>46</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Erythema_Nodosum'>Erythema Nodosum</a></span></td><td style='text-align: right;'><a href='#Page_50'>50</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Erythema_Induratum'>Erythema Induratum</a></span></td><td style='text-align: right;'><a href='#Page_51'>51</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Urticaria'>Urticaria</a></span></td><td style='text-align: right;'><a href='#Page_52'>52</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Urticaria_Pigmentosa'>Urticaria Pigmentosa</a></span></td><td style='text-align: right;'><a href='#Page_56'>56</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatitis'>Dermatitis</a></span></td><td style='text-align: right;'><a href='#Page_58'>58</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatitis_Medicamentosa'>Dermatitis Medicamentosa</a></span></td><td style='text-align: right;'><a href='#Page_60'>60</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#X_Ray_Dermatitis'>X-Ray Dermatitis</a></span></td><td style='text-align: right;'><a href='#Page_63'>63</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatitis_Factitia'>Dermatitis Factitia</a></span></td><td style='text-align: right;'><a href='#Page_64'>64</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatitis_Gangraenosa'>Dermatitis Gangr&aelig;nosa</a></span></td><td style='text-align: right;'><a href='#Page_65'>65</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Erysipelas'>Erysipelas</a></span></td><td style='text-align: right;'><a href='#Page_66'>66</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Phlegmona_Diffusa'>Phlegmona Diffusa</a></span></td><td style='text-align: right;'><a href='#Page_68'>68</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Furunculus'>Furunculus</a></span></td><td style='text-align: right;'><a href='#Page_68'>68</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Carbunculus'>Carbunculus</a></span></td><td style='text-align: right;'><a href='#Page_70'>70</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pustula_Maligna'>Pustula Maligna</a></span></td><td style='text-align: right;'><a href='#Page_72'>72</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Post_mortem_Pustule'>Post-mortem Pustule</a></span></td><td style='text-align: right;'><a href='#Page_73'>73</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Framboesia'>Framb&oelig;sia</a></span></td><td style='text-align: right;'><a href='#Page_73'>73</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Verruga_Peruana'>Verruga Peruana</a></span></td><td style='text-align: right;'><a href='#Page_73'>73</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Equinia'>Equinia</a></span></td><td style='text-align: right;'><a href='#Page_74'>74</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Miliaria'>Miliaria</a></span></td><td style='text-align: right;'><a href='#Page_74'>74</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pompholyx'>Pompholyx</a></span></td><td style='text-align: right;'><a href='#Page_76'>76</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Herpes_Simplex'>Herpes Simplex</a></span></td><td style='text-align: right;'><a href='#Page_78'>78</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Hydroa_Vacciniforme'>Hydroa Vacciniforme</a></span></td><td style='text-align: right;'><a href='#Page_80'>80</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Epidermolysis_Bullosa'>Epidermolysis Bullosa</a></span></td><td style='text-align: right;'><a href='#Page_80'>80</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatitis_Repens'>Dermatitis Repens</a></span></td><td style='text-align: right;'><a href='#Page_81'>81</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Herpes_Zoster'>Herpes Zoster</a></span></td><td style='text-align: right;'><a href='#Page_81'>81</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatitis_Herpetiformis'>Dermatitis Herpetiformis</a></span></td><td style='text-align: right;'><a href='#Page_83'>83</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Psoriasis'>Psoriasis</a></span></td><td style='text-align: right;'><a href='#Page_86'>86</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pityriasis_Rosea'>Pityriasis Rosea</a></span></td><td style='text-align: right;'><a href='#Page_95'>95</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatitis_Exfoliativa'>Dermatitis Exfoliativa</a></span></td><td style='text-align: right;'><a href='#Page_96'>96</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Lichen_Planus'>Lichen Planus</a></span></td><td style='text-align: right;'><a href='#Page_98'>98</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pityriasis_Rubra_Pilaris'>Pityriasis Rubra Pilaris</a></span></td><td style='text-align: right;'><a href='#Page_99'>99</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Lichen_Scrofulosus'>Lichen Scrofulosus</a></span></td><td style='text-align: right;'><a href='#Page_100'>100</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Eczema'>Eczema</a></span></td><td style='text-align: right;'><a href='#Page_100'>100</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Prurigo'>Prurigo</a></span></td><td style='text-align: right;'><a href='#Page_118'>118</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Acne'>Acne</a></span></td><td style='text-align: right;'><a href='#Page_119'>119</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Acne_Rosacea'>Acne Rosacea</a></span></td><td style='text-align: right;'><a href='#Page_126'>126</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Sycosis'>Sycosis</a></span></td><td style='text-align: right;'><a href='#Page_130'>130</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatitis_Papillaris_Capillitii'>Dermatitis Papillaris Capillitii</a></span></td><td style='text-align: right;'><a href='#Page_135'>135</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Impetigo_Contagiosa'>Impetigo Contagiosa</a></span></td><td style='text-align: right;'><a href='#Page_136'>136</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#Impetigo_Herpetiformis'>Impetigo Herpetiformis</a></span></td><td style='text-align: right;'><a href='#Page_138'>138</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Ecthyma'>Ecthyma</a></span></td><td style='text-align: right;'><a href='#Page_138'>138</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pemphigus'>Pemphigus</a></span></td><td style='text-align: right;'><a href='#Page_140'>140</a></td></tr>
+
+<tr><td><a href='#CLASS_III_HEMORRHAGES'><span class='smcap'>Class III.&mdash;Hemorrhages</span></a></td><td style='text-align: right;'><a href='#Page_144'>144</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Purpura'>Purpura</a></span></td><td style='text-align: right;'><a href='#Page_144'>144</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Scorbutus'>Scorbutus</a></span></td><td style='text-align: right;'><a href='#Page_146'>146</a></td></tr>
+
+<tr><td><a href='#CLASS_IV_HYPERTROPHIES'><span class='smcap'>Class IV.&mdash;Hypertrophies</span></a></td><td style='text-align: right;'><a href='#Page_148'>148</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Lentigo'>Lentigo</a></span></td><td style='text-align: right;'><a href='#Page_148'>148</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Chloasma'>Chloasma</a></span></td><td style='text-align: right;'><a href='#Page_149'>149</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Keratosis_Pilaris'>Keratosis Pilaris</a></span></td><td style='text-align: right;'><a href='#Page_151'>151</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Keratosis_Follicularis'>Keratosis Follicularis</a></span></td><td style='text-align: right;'><a href='#Page_153'>153</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Molluscum_Epitheliale'>Molluscum Epitheliale</a></span></td><td style='text-align: right;'><a href='#Page_153'>153</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Callositas'>Callositas</a></span></td><td style='text-align: right;'><a href='#Page_155'>155</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Clavus'>Clavus</a></span></td><td style='text-align: right;'><a href='#Page_156'>156</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Cornu_Cutaneum'>Cornu Cutaneum</a></span></td><td style='text-align: right;'><a href='#Page_158'>158</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Verruca'>Verruca</a></span></td><td style='text-align: right;'><a href='#Page_160'>160</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Naevus_Pigmentosus'>N&aelig;vus Pigmentosus</a></span></td><td style='text-align: right;'><a href='#Page_162'>162</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Ichthyosis'>Ichthyosis</a></span></td><td style='text-align: right;'><a href='#Page_165'>165</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Onychauxis'>Onychauxis</a></span></td><td style='text-align: right;'><a href='#Page_167'>167</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Hypertrichosis'>Hypertrichosis</a></span></td><td style='text-align: right;'><a href='#Page_168'>168</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Oedema_Neonatorum'>&OElig;dema Neonatorum</a></span></td><td style='text-align: right;'><a href='#Page_170'>170</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Sclerema_Neonatorum'>Sclerema Neonatorum</a></span></td><td style='text-align: right;'><a href='#Page_171'>171</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Scleroderma'>Scleroderma</a></span></td><td style='text-align: right;'><a href='#Page_172'>172</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Elephantiasis'>Elephantiasis</a></span></td><td style='text-align: right;'><a href='#Page_174'>174</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatolysis'>Dermatolysis</a></span></td><td style='text-align: right;'><a href='#Page_176'>176</a></td></tr>
+
+<tr><td><a href='#CLASS_V_ATROPHIES'><span class='smcap'>Class V.&mdash;Atrophies</span></a></td><td style='text-align: right;'><a href='#Page_177'>177</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Albinismus'>Albinismus</a></span></td><td style='text-align: right;'><a href='#Page_177'>177</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Vitiligo'>Vitiligo</a></span></td><td style='text-align: right;'><a href='#Page_178'>178</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Canities'>Canities</a></span></td><td style='text-align: right;'><a href='#Page_180'>180</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Alopecia'>Alopecia</a></span></td><td style='text-align: right;'><a href='#Page_181'>181</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Alopecia_Areata'>Alopecia Areata</a></span></td><td style='text-align: right;'><a href='#Page_183'>183</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Atrophia_Pilorum_Propria'>Atrophia Pilorum Propria</a></span></td><td style='text-align: right;'><a href='#Page_187'>187</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Atrophia_Unguis'>Atrophia Unguis</a></span></td><td style='text-align: right;'><a href='#Page_188'>188</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Atrophia_Cutis'>Atrophia Cutis</a></span></td><td style='text-align: right;'><a href='#Page_189'>189</a></td></tr>
+
+<tr><td><a href='#CLASS_VI_NEW_GROWTHS'><span class='smcap'>Class VI.&mdash;New Growths</span></a></td><td style='text-align: right;'><a href='#Page_191'>191</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#Keloid'>Keloid</a></span></td><td style='text-align: right;'><a href='#Page_191'>191</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Fibroma'>Fibroma</a></span></td><td style='text-align: right;'><a href='#Page_192'>192</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Neuroma'>Neuroma</a></span></td><td style='text-align: right;'><a href='#Page_194'>194</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Xanthoma'>Xanthoma</a></span></td><td style='text-align: right;'><a href='#Page_195'>195</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Myoma'>Myoma</a></span></td><td style='text-align: right;'><a href='#Page_196'>196</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Angioma'>Angioma</a></span></td><td style='text-align: right;'><a href='#Page_196'>196</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Telangiectasis'>Telangiectasis</a></span></td><td style='text-align: right;'><a href='#Page_197'>197</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Lymphangioma'>Lymphangioma</a></span></td><td style='text-align: right;'><a href='#Page_198'>198</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Rhinoscleroma'>Rhinoscleroma</a></span></td><td style='text-align: right;'><a href='#Page_198'>198</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Lupus_Erythematosus'>Lupus Erythematosus</a></span></td><td style='text-align: right;'><a href='#Page_199'>199</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Lupus_Vulgaris'>Lupus Vulgaris</a></span></td><td style='text-align: right;'><a href='#Page_203'>203</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Tuberculosis_Cutis'>Tuberculosis Cutis</a></span></td><td style='text-align: right;'><a href='#Page_209'>209</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Ainhum'>Ainhum</a></span></td><td style='text-align: right;'><a href='#Page_212'>212</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Mycetoma'>Mycetoma</a></span></td><td style='text-align: right;'><a href='#Page_212'>212</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Perforating_Ulcer_of_the_Foot'>Perforating Ulcer of the Foot</a></span></td><td style='text-align: right;'><a href='#Page_213'>213</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Syphilis_Cutanea'>Syphilis Cutanea</a></span></td><td style='text-align: right;'><a href='#Page_213'>213</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Lepra'>Lepra</a></span></td><td style='text-align: right;'><a href='#Page_231'>231</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pellagra'>Pellagra</a></span></td><td style='text-align: right;'><a href='#Page_235'>235</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Epithelioma'>Epithelioma</a></span></td><td style='text-align: right;'><a href='#Page_236'>236</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pagets_Disease_of_the_Nipple'>Paget's Disease of the Nipple</a></span></td><td style='text-align: right;'><a href='#Page_240'>240</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Sarcoma'>Sarcoma</a></span></td><td style='text-align: right;'><a href='#Page_241'>241</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Granuloma_Fungoides'>Granuloma Fungoides</a></span></td><td style='text-align: right;'><a href='#Page_242'>242</a></td></tr>
+
+<tr><td><a href='#CLASS_VII_NEUROSES'><span class='smcap'>Class VII.&mdash;Neuroses</span></a></td><td style='text-align: right;'><a href='#Page_244'>244</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#Hyperaesthesia'>Hyper&aelig;sthesia</a></span></td><td style='text-align: right;'><a href='#Page_244'>244</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Dermatalgia'>Dermatalgia</a></span></td><td style='text-align: right;'><a href='#Page_244'>244</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#Anaesthesia'>An&aelig;sthesia</a></span></td><td style='text-align: right;'><a href='#Page_244'>244</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pruritus'>Pruritus</a></span></td><td style='text-align: right;'><a href='#Page_244'>244</a></td></tr>
+
+<tr><td><a href='#CLASS_VIII_PARASITIC_AFFECTIONS'><span class='smcap'>Class VIII.&mdash;Parasitic Affections</span></a></td><td style='text-align: right;'><a href='#Page_247'>247</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Tinea_Favosa'>Tinea Favosa</a></span></td><td style='text-align: right;'><a href='#Page_247'>247</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Tinea_Trichophytina'>Tinea Trichophytina</a></span></td><td style='text-align: right;'><a href='#Page_251'>251</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Tinea_Imbricata'>Tinea Imbricata</a></span></td><td style='text-align: right;'><a href='#Page_261'>261</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Tinea_Versicolor'>Tinea Versicolor</a></span></td><td style='text-align: right;'><a href='#Page_262'>262</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Erythrasma'>Erythrasma</a></span></td><td style='text-align: right;'><a href='#Page_265'>265</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Actinomycosis'>Actinomycosis</a></span></td><td style='text-align: right;'><a href='#Page_266'>266</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Blastomycetic_Dermatitis'>Blastomycetic Dermatitis</a></span></td><td style='text-align: right;'><a href='#Page_266'>266</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Scabies'>Scabies</a></span></td><td style='text-align: right;'><a href='#Page_267'>267</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pediculosis'>Pediculosis</a></span></td><td style='text-align: right;'><a href='#Page_271'>271</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pediculosis_Capitis'>Pediculosis Capitis</a></span></td><td style='text-align: right;'><a href='#Page_272'>272</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pediculosis_Corporis'>Pediculosis Corporis</a></span></td><td style='text-align: right;'><a href='#Page_274'>274</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pediculosis_Pubis'>Pediculosis Pubis</a></span></td><td style='text-align: right;'><a href='#Page_275'>275</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Cysticercus_Cellulosae'>Cysticercus Cellulos&aelig;</a></span></td><td style='text-align: right;'><a href='#Page_276'>276</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Filaria_Medinensis'>Filaria Medinensis</a></span></td><td style='text-align: right;'><a href='#Page_277'>277</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Ixodes'>Ixodes</a></span></td><td style='text-align: right;'><a href='#Page_277'>277</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Leptus'>Leptus</a></span></td><td style='text-align: right;'><a href='#Page_277'>277</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Oestrus'>&OElig;strus</a></span></td><td style='text-align: right;'><a href='#Page_278'>278</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pulex_Penetrans'>Pulex Penetrans</a></span></td><td style='text-align: right;'><a href='#Page_278'>278</a></td></tr>
+
+<tr><td><span style='margin-left: 2em;'><a href='#Cimex_Lectularius'>Cimex Lectularius</a></span></td><td style='text-align: right;'><a href='#Page_278'>278</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Culex'>Culex</a></span></td><td style='text-align: right;'><a href='#Page_279'>279</a></td></tr>
+
+
+<tr><td><span style='margin-left: 2em;'><a href='#Pulex_Irritans'>Pulex Irritans</a></span></td><td style='text-align: right;'><a href='#Page_279'>279</a></td></tr>
+
+<tr><td><span class='smcap'>Table</span> showing Relative Frequency of the Various Diseases of the Skin</td><td style='text-align: right;'><a href='#Page_280'>280</a></td></tr>
+</table>
+
+
+<p><span class='pagenum'><a name='Page_17' id='Page_17'></a><a href='#TOC'>[Pg 17]</a></span></p>
+<h1><a name='ANATOMY_OF_THE_SKIN' id='ANATOMY_OF_THE_SKIN'></a>DISEASES OF THE SKIN.</h1>
+<h1>ANATOMY OF THE SKIN</h1>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 1.</b></p>
+<div class='figcenter' style='width: 388px;'>
+<a href='images/fullsize_017.jpg'>
+<img src='images/017.jpg' width='388' height='600'
+alt='FIG. 1.'
+title='FIG. 1.' />
+</a>
+</div>
+<p class='center'>Vertical section of the skin&mdash;Diagrammatic. (<i>After Heitsmann.</i>)</p>
+
+
+
+<hr style='width: 65%;' />
+<p><span class='pagenum'><a name='Page_18' id='Page_18'></a><a href='#TOC'>[Pg 18]</a></span></p>
+<h2><a name='The_Epidermis' id='The_Epidermis'></a><b>The Epidermis.</b></h2>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 2.</b></p>
+<div class='figcenter' style='width: 276px;'>
+<a href='images/fullsize_018.jpg'>
+<img src='images/018.jpg' width='276' height='600'
+alt='FIG. 2.'
+title='FIG. 2.' />
+</a>
+</div>
+
+<p class='center'><i>c</i>, corneous (horny) layer; <i>g</i>, granular layer; <i>m</i>, mucous layer (rete Malpighii).<br />
+The stratum lucidum is the layer just above the granular layer.<br />
+
+Nerve terminations&mdash;<i>n</i>, afferent nerve; <i>b</i>, terminal nerve bulbs; <i>l</i>, cell of Langerhans.</p>
+
+<p class='right'>(<i>After Ranvier.</i>)</p>
+
+
+<hr style='width: 65%;' />
+<p><span class='pagenum'><a name='Page_19' id='Page_19'></a><a href='#TOC'>[Pg 19]</a></span></p>
+
+
+<h2><a name='The_Blood_vessels' id='The_Blood_vessels'></a><b>The Blood-vessels.</b></h2>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 3.</b></p>
+<div class='figcenter' style='width: 397px;'>
+<a href='images/fullsize_019.jpg'>
+<img src='images/019.jpg' width='397' height='600'
+alt='FIG. 3.'
+title='FIG. 3.' />
+</a>
+</div>
+
+
+<p class='center'><i>C</i>, epidermis; <i>D</i>, corium; <i>P</i>, papill&aelig;; <i>S</i>, sweat-gland duct.<br />
+
+<i>v</i>, arterial and venous capillaries (superficial, or papillary plexus) of the papill&aelig;.<br />
+
+Deep plexus is partly shown at lower margin of the diagram; <i>vs</i>&mdash;an intermediate<br />
+plexus, an outgrowth from the deep plexus, supplying sweat-glands, and<br />
+giving a loop to hair papilla.</p>
+
+<p class='right'>(<i>After Ranvier</i>).</p>
+
+
+<hr style='width: 65%;' />
+<p><span class='pagenum'><a name='Page_20' id='Page_20'></a><a href='#TOC'>[Pg 20]</a></span></p>
+
+<h2><a name='The_Nervous_and_Vascular_Papillae' id='The_Nervous_and_Vascular_Papillae'></a><b>The Nervous and Vascular Papill&aelig;.</b></h2>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 4.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_020.jpg'>
+<img src='images/020.jpg' width='400' height='457'
+alt='FIG. 4.'
+title='FIG. 4.' />
+</a>
+</div>
+
+
+<p class='center'><i>a</i>, a vascular papilla; <i>b</i>, a nervous papilla; <i>c</i>, a blood-vessel; <i>d</i>, a nerve fibre; <br />
+<i>e</i>, a tactile corpuscle.</p>
+<p class='right'>(<i>After Biesiadecki.</i>)</p>
+
+
+<hr style='width: 65%;' />
+<p><span class='pagenum'><a name='Page_21' id='Page_21'></a><a href='#TOC'>[Pg 21]</a></span></p>
+
+
+
+<h2><a name='The_Hair_and_Hair_Follicle' id='The_Hair_and_Hair_Follicle'></a><b>The Hair and Hair-Follicle.</b></h2>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 5.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_021.jpg'>
+<img src='images/021.jpg' width='400' height='508'
+alt='FIG. 5.'
+title='FIG. 5.' />
+</a>
+</div>
+
+<p class='center'><i>A</i>, shaft of the hair; <i>B</i>, root of the hair; <i>C</i>, cuticle of the hair; <i>D</i>, medullary substance
+of the hair.</p>
+
+<p class='center'><i>E</i>, external layer of the hair-follicle; <i>F</i>, middle layer of the hair-follicle; <i>G</i>, internal
+layer of the hair-follicle; <i>H</i>, papilla of the hair; <i>I</i>, external root-sheath; <i>J</i>,
+outer layer of the internal root-sheath; <i>K</i>, internal layer of the internal root-sheath.</p>
+
+<p class='right'>(<i>After Duhring.</i>)</p>
+
+
+<hr style='width: 65%;' />
+<p><span class='pagenum'><a name='Page_22' id='Page_22'></a><a href='#TOC'>[Pg 22]</a></span></p>
+
+
+<h1><a name='SYMPTOMATOLOGY' id='SYMPTOMATOLOGY'></a><b>SYMPTOMATOLOGY</b>.</h1>
+
+<p>The symptoms of cutaneous disease may be objective, subjective
+or both; and in some diseases, also, there may be systemic disturbance.</p>
+
+<p><b>What do you mean by objective symptoms</b>?</p>
+
+<p>Those symptoms visible to the eye or touch.</p>
+
+
+<p><b>What do you understand by subjective symptoms</b>?</p>
+
+<p>Those which relate to sensation, such as itching, tingling, burning,
+pain, tenderness, heat, an&aelig;sthesia, and hyper&aelig;sthesia.</p>
+
+
+<p><b>What do you mean by systemic symptoms</b>?</p>
+
+<p>Those general symptoms, slight or profound, which are sometimes
+associated, primarily or secondarily, with the cutaneous disease, as, for
+example, the systemic disturbance in leprosy, pemphigus, and purpura
+hemorrhagica.</p>
+
+
+<p><b>Into what two classes of lesions are the objective symptoms
+commonly divided</b>?</p>
+
+<p style='margin-left: 10em;'>Primary (or elementary), and</p>
+<p style='margin-left: 10em;'>Secondary (or consecutive).</p>
+
+
+
+<h2><a name='Primary_Lesions' id='Primary_Lesions'></a><b>Primary Lesions.</b></h2>
+
+
+<p><b>What are primary lesions</b>?</p>
+
+<p>Those objective lesions with which cutaneous diseases begin. They
+may continue as such or may undergo modification, passing into the
+secondary or consecutive lesions.</p>
+
+
+<p><b>Enumerate the primary lesions</b>.</p>
+
+<p>Macules, papules, tubercles, wheals, tumors, vesicles, blebs and
+pustules.</p>
+
+
+<p><b>What are macules (macul&aelig;)</b>?</p>
+
+<p>Variously-sized, shaped and tinted spots and discolorations, without
+elevation or depression; as, for example, freckles, spots of
+purpura, macules of cutaneous syphilis.
+<span class='pagenum'><a name='Page_23' id='Page_23'></a><a href='#TOC'>[Pg 23]</a></span></p>
+
+<p><b>What are papules (papul&aelig;)?</b></p>
+
+<p>Small, circumscribed, solid elevations, rarely exceeding the size of
+a split-pea, and usually superficially seated; as, for example, the
+papules of eczema, of acne, and of cutaneous syphilis.</p>
+
+
+<p><b>What are tubercles (tubercula)?</b></p>
+
+<p>Circumscribed, solid elevations, commonly pea-sized and usually
+deep-seated; as, for example, the tubercles of syphilis, of leprosy,
+and of lupus.</p>
+
+
+<p><b>What are wheals (pomphi)?</b></p>
+
+<p>Variously-sized and shaped, whitish, pinkish or reddish elevations,
+of an evanescent character; as, for example, the lesions of urticaria,
+the lesions produced by the bite of a mosquito or by the sting of a
+nettle.</p>
+
+
+<p><b>What are tumors (tumores)?</b></p>
+
+<p>Soft or firm elevations, usually large and prominent, and having
+their seat in the corium and subcutaneous tissue; as, for example,
+sebaceous tumors, gummata, and the lesions of fibroma.</p>
+
+
+<p><b>What are vesicles (vesicul&aelig;)?</b></p>
+
+<p>Pin-head to pea-sized, circumscribed epidermal elevations, containing
+serous fluid; as, for example, the so-called fever-blisters, the
+lesions of herpes zoster, and of vesicular eczema.</p>
+
+
+<p><b>What are blebs (bull&aelig;)?</b></p>
+
+<p>Rounded or irregularly-shaped, pea to egg-sized epidermic elevations,
+with fluid contents; in short, they are essentially the same as
+vesicles and pustules except as to size; as, for example, the blebs
+of pemphigus, rhus poisoning, and syphilis.</p>
+
+
+<p><b>What are pustules (pustul&aelig;)?</b></p>
+
+<p>Circumscribed epidermic elevations containing pus; as, for example,
+the pustules of acne, of impetigo, and of sycosis.</p>
+
+
+
+<h2><a name='Secondary_Lesions' id='Secondary_Lesions'></a><b>Secondary Lesions.</b></h2>
+
+
+<p><b>What are secondary lesions?</b></p>
+
+<p>Those lesions resulting from accidental or natural change, modification
+or termination of the primary lesions.
+<span class='pagenum'><a name='Page_24' id='Page_24'></a><a href='#TOC'>[Pg 24]</a></span></p>
+
+<p><b>Enumerate the secondary lesions</b>.</p>
+
+<p>Scales, crusts, excoriations, fissures, ulcers, scars and stains.</p>
+
+<p><b>What are scales (squam&aelig;)?</b></p>
+
+<p>Dry, laminated, epidermal exfoliations; as, for example, the scales
+of psoriasis, ichthyosis, and eczema.</p>
+
+<p><b>What are crusts (crust&aelig;)?</b></p>
+
+<p>Dried effete masses of exudation; as, for example, the crusts of
+impetigo, of eczema, and of the pustular and ulcerating syphilodermata.</p>
+
+<p><b>What are excoriations (excoriationes)</b>?</p>
+
+<p>Superficial, usually epidermal, linear or punctate loss of tissue;
+as, for example, ordinary scratch-marks.</p>
+
+<p><b>What are fissures (rhagades)?</b></p>
+
+<p>Linear cracks or wounds, involving the epidermis, or epidermis and
+corium; as, for example, the cracks which often occur in eczema
+when seated about the joints, the cracks of chapped lips and
+hands.</p>
+
+<p><b>What are ulcers (ulcera)?</b></p>
+
+<p>Rounded or irregularly-shaped and sized loss of skin and subcutaneous
+tissue resulting from disease; as, for example, the ulcers
+of syphilis and of cancer.</p>
+
+<p><b>What are scars (cicatrices)?</b></p>
+
+<p>Connective-tissue new formations replacing loss of substance.</p>
+
+<p><b>What are stains</b>?</p>
+
+<p>Discolorations left by cutaneous disease, which stains may be transitory
+or permanent.</p>
+
+
+<h2><a name='Distribution_and_Configuration' id='Distribution_and_Configuration'></a><b>Distribution and Configuration.</b></h2>
+
+<p><b>What do you mean by a patch of eruption</b>?</p>
+
+<p>A single group or aggregation of lesions or an area of disease.</p>
+
+<p><b>When is an eruption said to be limited or localized</b>?</p>
+
+<p>When it is confined to one part or region.
+<span class='pagenum'><a name='Page_25' id='Page_25'></a><a href='#TOC'>[Pg 25]</a></span></p>
+
+<p><b>When is an eruption said to be general or generalized?</b></p>
+
+<p>When it is scattered, uniformly or irregularly, over the entire
+surface.</p>
+
+<p><b>When is an eruption universal?</b></p>
+
+<p>When the whole integument is involved, without any intervening
+healthy skin.</p>
+
+<p><b>When is an eruption said to be discrete?</b></p>
+
+<p>When the lesions constituting the eruption are isolated, having
+more or less intervening normal skin.</p>
+
+<p><b>When is an eruption confluent?</b></p>
+
+<p>When the lesions constituting the eruption are so closely crowded
+that a solid sheet results.</p>
+
+<p><b>When is an eruption uniform?</b></p>
+
+<p>When the lesions constituting the eruption are all of one type or
+character.</p>
+
+<p><b>When is an eruption multiform?</b></p>
+
+<p>When the lesions constituting the eruption are of two or more
+types or characters.</p>
+
+<p><b>When are lesions said to be aggregated?</b></p>
+
+<p>When they tend to form groups or closely-crowded patches.</p>
+
+<p><b>When are lesions disseminated?</b></p>
+
+<p>When they are irregularly scattered, with no tendency to form
+groups or patches.</p>
+
+<p><b>When is a patch of eruption said to be circinate?</b></p>
+
+<p>When it presents a rounded form, and usually tending to clear in
+the centre; as, for example, a patch of ringworm.</p>
+
+<p><b>When is a patch of eruption said to be annular?</b></p>
+
+<p>When it is ring-shaped, the central portion being clear; as, for
+example, in erythema annulare.</p>
+
+<p><b>What meaning is conveyed by the term &ldquo;iris&rdquo;?</b></p>
+
+<p>The patch of eruption is made up of several concentric rings.
+Difference of duration of the individual rings, usually slight, tends to
+give the patch variegated coloration; as, for example, in erythema
+iris and herpes iris.
+<span class='pagenum'><a name='Page_26' id='Page_26'></a><a href='#TOC'>[Pg 26]</a></span></p>
+
+<p><b>What meaning is conveyed by the term &ldquo;marginate&rdquo;?</b></p>
+
+<p>The sheet of eruption is sharply defined against the healthy
+skin; as, for example, in erythema marginatum, eczema marginatum.</p>
+
+<p><b>What meaning is conveyed by the qualifying term &ldquo;circumscribed&rdquo;?</b></p>
+
+<p>The term is applied to small, usually more or less rounded, patches,
+when sharply defined; as, for example, the typical patches of psoriasis.</p>
+
+<p><b>When is the qualifying term &ldquo;gyrate&rdquo; employed?</b></p>
+
+<p>When the patches arrange themselves in an irregular winding or
+festoon-like manner; as, for instance, in some cases of psoriasis. It
+results, usually, from the coalescence of several rings, the eruption
+disappearing at the points of contact.</p>
+
+<p><b>When is an eruption said to be serpiginous?</b></p>
+
+<p>When the eruption spreads at the border, clearing up at the older
+part; as, for instance, in the serpiginous syphiloderm.</p>
+
+
+<h2><a name='RELATIVE_FREQUENCY' id='RELATIVE_FREQUENCY'></a><b>RELATIVE FREQUENCY.</b></h2>
+
+<p><b>Name the more common cutaneous diseases and state approximately
+their frequency.</b></p>
+
+<p>Eczema, 30.4%; syphilis cutanea, 11.2%; acne, 7.3%; pediculosis,
+4%; psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies,
+2.6%; urticaria, 2.5%; pruritus, 2.1%; seborrh&oelig;a, 2.1%; herpes
+simplex, 1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%;
+verruca, 1.1%; tinea versicolor, 1%. Total: eighteen diseases,
+representing 81 per cent. of all cases met with.</p>
+
+<p>(These percentages are based upon statistics, public and private,
+of the American Dermatological Association, covering a period of
+ten years. In private practice the proportion of cases of pediculosis,
+scabies, favus, and impetigo is much smaller, while acne, acne
+rosacea, seborrh&oelig;a, epithelioma, and lupus are relatively more frequent.)
+<span class='pagenum'><a name='Page_27' id='Page_27'></a><a href='#TOC'>[Pg 27]</a></span></p>
+
+
+<h2><a name='CONTAGIOUSNESS' id='CONTAGIOUSNESS'></a><b>CONTAGIOUSNESS.</b></h2>
+
+<p><b>Name the more actively contagious skin diseases.</b></p>
+
+<p>Impetigo contagiosa, ringworm, favus, scabies and pediculosis;
+excluding the exanthemata, erysipelas, syphilis and certain rare and
+doubtful diseases.</p>
+
+<p>[At the present time when most diseases are presumed to be due
+to bacteria or parasites the belief in contagiousness, under certain
+conditions, has considerably broadened.]</p>
+
+
+<h2><a name='RAPIDITY_OF_CURE' id='RAPIDITY_OF_CURE'></a><b>RAPIDITY OF CURE.</b></h2>
+
+<p><b>Is the rapid cure of a skin disease fraught with any danger
+to the patient?</b></p>
+
+<p>No. It was formerly so considered, especially by the public and
+general profession, and the impression still holds to some extent, but
+it is not in accord with dermatological experience.</p>
+
+
+<h2><a name='OINTMENT_BASES' id='OINTMENT_BASES'></a><b>OINTMENT BASES.</b></h2>
+
+<p><b>Name the several fats in common use for ointment bases.</b></p>
+
+<p>Lard, petrolatum (or cosmoline or vaseline), cold cream and
+lanolin.</p>
+
+<p><b>State the relative advantages of these several bases.</b></p>
+
+<p><i>Lard</i> is the best all-around base, possessing penetrating properties
+scarcely exceeded by any other fat.</p>
+
+<p><i>Petrolatum</i> is also valuable, having little, if any, tendency to
+change; it is useful as a protective, but is lacking in its power of
+penetration.</p>
+
+<p><i>Cold Cream</i> (ungt. aqu&aelig; ros&aelig;) is soothing and cooling, and may
+often be used when other fatty applications disagree.</p>
+
+<p><i>Lanolin</i> is said to surpass in its power of penetration all other
+bases, but this is not borne out by experience. It is an unsatisfactory
+base when used alone. It should be mixed with another
+base in about the proportion of 25% to 50%.</p>
+
+<p>These several bases may, and often with advantage, be variously
+combined.
+<span class='pagenum'><a name='Page_28' id='Page_28'></a><a href='#TOC'>[Pg 28]</a></span></p>
+
+<p><b>What is to be added to these several bases if a stiffer ointment
+is required</b>?</p>
+
+<p>Simple cerate, wax, spermaceti, or suet; or in some instances, a
+pulverulent substance, such as starch, boric acid, and zinc oxide.</p>
+
+
+<h1><a name='CLASS_I_DISORDERS_OF_THE_GLANDS' id='CLASS_I_DISORDERS_OF_THE_GLANDS'></a><b>CLASS I.&mdash;DISORDERS OF THE GLANDS.</b></h1>
+
+<h2><a name='Hyperidrosis' id='Hyperidrosis'></a><b>Hyperidrosis.</b></h2>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 6.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_029.jpg'>
+<img src='images/029.jpg' width='400' height='534'
+alt='FIG. 6.'
+title='FIG. 6.' />
+</a>
+</div>
+
+<p class='center'>A normal sweat-gland, highly magnified. <i>(After Neumann.</i>)</p>
+
+<p class='center'><i>a</i>, Sweat-coil: <i>b</i>, sweat-duct; <i>c</i>, lumen of duct; <i>d</i>, connective-tissue capsule;
+<i>e</i> and <i>f</i>, arterial trunk and capillaries.</p>
+
+<p><b>What is hyperidrosis?</b></p>
+
+<p>Hyperidrosis is a functional disturbance of the sweat-glands, characterized
+by an increased production of sweat. This increase may
+be slight or excessive, local or general.
+<span class='pagenum'><a name='Page_29' id='Page_29'></a><a href='#TOC'>[Pg 29]</a></span></p>
+
+<p><b>As a local affection, what parts are most commonly involved?</b></p>
+
+<p>The hands, feet, especially the palmar and plantar surfaces, the
+axill&aelig; and the genitalia.</p>
+
+<p><b>Describe the symptoms of the local forms of hyperidrosis.</b></p>
+
+<p>The essential, and frequently the sole symptom, is more or less
+profuse sweating.</p>
+
+<p>If the hands are the parts involved, they are noted to be wet,
+clammy and sometimes cold.</p>
+
+<p>If involving the soles, the skin often becomes more or less macerated
+and sodden in appearance, and as a result of this maceration
+and continued irritation they may become inflamed, especially about
+the borders of the affected parts, and present a pinkish or pinkish-red
+color, having a violaceous tinge. The sweat undergoes change
+and becomes offensive.</p>
+
+<p><b>Is hyperidrosis acute or chronic?</b></p>
+
+<p>Usually chronic, although it may also occur as an acute affection.</p>
+
+<p><b>What is the etiology of hyperidrosis?</b></p>
+
+<p>Debility is commonly the cause in general hyperidrosis; the local
+forms are probably neurotic in origin.</p>
+
+<p><b>What is the prognosis?</b></p>
+
+<p>The disease is usually persistent and often rebellious to treatment;
+in many instances a permanent cure is possible, in others palliation.
+Relapses are not uncommon.</p>
+
+<p><b>What systemic remedies are employed in hyperidrosis?</b></p>
+
+<p>Ergot, belladonna, gallic acid, mineral acids, and tonics. Constitutional
+treatment is rarely of benefit in the local forms of hyperidrosis,
+and external applications are seldom of service in general
+hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is
+also well spoken of, combined, if necessary, with an astringent.</p>
+
+<p><b>What external remedies are employed in the local forms?</b></p>
+
+<p>Astringent lotions of zinc sulphate, tannin and alum, applied several
+times daily, with or without the supplementary use of dusting-powders.
+Weak solutions of formaldehyde, one to one hundred,
+are sometimes of value.
+<span class='pagenum'><a name='Page_30' id='Page_30'></a><a href='#TOC'>[Pg 30]</a></span></p>
+
+<p>Dusting-powders of boric acid and zinc oxide, to which may be
+added from ten to thirty grains of salicylic acid to the ounce, to be
+used freely and often:&mdash;</p>
+
+<pre>
+  &#8478; Pulv. ac. salicylici, ............................ gr. x-xxx.
+    Pulv. ac. borici, ................................ &#658;v.
+    Pulv. zinci oxidi, ............................... &#658;iij   M.
+</pre>
+
+<p>Diachylon ointment, and an ointment containing a drachm of tannin
+to the ounce; more especially applicable in hyperidrosis of the
+feet. The parts are first thoroughly washed, rubbed dry with towels
+and dusting-powder, and the ointment applied on strips of muslin or
+lint and bound on; the dressing is renewed twice daily, the parts
+each time being rubbed dry with soft towels and dusting-powder,
+and the treatment continued for ten days to two weeks, after which
+the dusting-powder is to be used alone for several weeks. No water
+is to be used after the first washing until the ointment is discontinued.
+One such course will occasionally suffice, but not infrequently a repetition
+is necessary.</p>
+
+<p>Faradization and galvanization are sometimes serviceable. Repeated
+mild exposures to the R&ouml;ntgen rays have a favorable influence
+in some instances.</p>
+
+
+<h2><a name='Sudamen' id='Sudamen'></a><b>Sudamen.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Miliaria crystallina.)</p>
+
+<p><b>What is sudamen</b>?</p>
+
+<p>Sudamen is a non-inflammatory disorder of the sweat-glands, characterized
+by pin-point to pin-head-sized, discrete but thickly-set,
+superficial, translucent whitish vesicles.</p>
+
+<p><b>Describe the clinical characters.</b></p>
+
+<p>The lesions develop rapidly and in great numbers, either irregularly
+or in crops, and are usually to be seen as discrete, closely-crowded,
+whitish, or pearl-colored minute elevations, occurring most abundantly
+upon the trunk. In appearance they resemble minute dew-drops.
+They are non-inflammatory, without areola, never become
+purulent, and evince no tendency to rupture, the fluid disappearing
+by absorption, and the epidermal covering by desquamation.
+<span class='pagenum'><a name='Page_31' id='Page_31'></a><a href='#TOC'>[Pg 31]</a></span></p>
+
+<p><b>Give the course and duration of sudamen.</b></p>
+
+<p>New crops may appear as the older lesions are disappearing, and
+the affection persist for some time, or, on the other hand, the whole
+process may come to an end in several days or a week. In short,
+the course and duration depend upon the subsidence or persistence
+of the cause.</p>
+
+<p><b>What is the anatomical seat of sudamen?</b></p>
+
+<p>The lesions are formed between the lamell&aelig; of the corneous layer,
+usually the upper part; and are thought to be due to some change
+in the character of the epithelial cells of this layer, probably from
+high temperature, giving rise to a blocking up of the surface outlet.</p>
+
+<p><b>What is the cause of sudamen?</b></p>
+
+<p>Debility, especially when associated with high fever. The eruption
+is often seen in the course of typhus, typhoid and rheumatic fevers.</p>
+
+<p><b>How would you treat sudamen?</b></p>
+
+<p>By constitutional remedies directed against the predisposing factor
+or factors, and the application of cooling lotions of vinegar or alcohol
+and water, or dusting-powders of starch and lycopodium.</p>
+
+
+<h2><a name='Hydrocystoma' id='Hydrocystoma'></a><b>Hydrocystoma.</b></h2>
+
+<p><b>Describe hydrocystoma.</b></p>
+
+<p>Hydrocystoma is a cystic affection of the sweat-gland ducts, seated
+upon the face. The lesions may be present in scant numbers or in
+more or less profusion. They have the appearance of boiled sago
+grains imbedded in the skin; the larger lesions may have a bluish
+color, especially about the periphery. It is not common, and is
+usually seen in washerwomen and laundresses, or those exposed to
+moist heat. In some cases it tends to disappear during the winter
+months. There are no subjective symptoms.</p>
+
+<p>Treatment consists of puncturing the lesions and application of
+dusting-powder. Avoidance of the exciting cause (moist heat) is
+important.</p>
+
+
+<h2><a name='Anidrosis' id='Anidrosis'></a><b>Anidrosis.</b></h2>
+
+<p><b>Describe anidrosis.</b></p>
+
+<p>It is the opposite condition of hyperidrosis, and is characterized
+<span class='pagenum'><a name='Page_32' id='Page_32'></a><a href='#TOC'>[Pg 32]</a></span>
+by diminution or suppression of the sweat secretion. It occurs to
+some extent in certain systemic diseases and also in some affections
+of the skin, such as ichthyosis; nerve-injuries may give rise to localized
+sweat-suppression.</p>
+
+<p>Treatment is based upon general principles; friction, warm and
+hot-vapor baths, electricity and similar measures are of service.</p>
+
+
+<h2><a name='Bromidrosis' id='Bromidrosis'></a><b>Bromidrosis.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Osmidrosis.)</p>
+
+
+<p><b>Describe bromidrosis.</b></p>
+
+<p>Bromidrosis is a functional disturbance of the sweat-glands characterized
+by a sweat secretion of an offensive odor. The sweat production
+may be normal in quantity or more or less excessive, usually the
+latter. The condition may be local or general, commonly the former.
+It is closely allied to hyperidrosis, and may often be considered
+identical, the odor resulting from rapid decomposition of the sweat
+secretion. The decomposition and resulting odor have been thought
+due to the presence of bacteria.</p>
+
+<p><b>What parts are most commonly affected in bromidrosis?</b></p>
+
+<p>The feet and the axill&aelig;.</p>
+
+<p><b>What is the treatment of bromidrosis?</b></p>
+
+<p>It is essentially the same as that of hyperidrosis (<i>q. v.</i>), consisting
+of applications of astringent lotions, dusting-powders, especially
+those containing boric acid and salicylic acid, and the continuous
+application of diachylon ointment. In obstinate cases weak formaldehyde
+solutions, R&ouml;ntgen rays, and high-frequency currents can
+be tried.</p>
+
+
+<h2><a name='Chromidrosis' id='Chromidrosis'></a><b>Chromidrosis.</b></h2>
+
+<p><b>Describe chromidrosis.</b></p>
+
+<p>This is a functional disorder of the sweat-glands characterized by
+a secretion variously colored, and usually increased in quantity. It
+is, as a rule, limited to a circumscribed area. The most common
+color is red. The condition is probably of neurotic origin and tends
+to recur. (True chromidrosis is extremely rare; most of the cases
+formerly thought to be such are now known to be examples of
+pseudochromidrosis.)
+<span class='pagenum'><a name='Page_33' id='Page_33'></a><a href='#TOC'>[Pg 33]</a></span></p>
+
+<p>Treatment should be invigorating and tonic, with special reference
+toward the nervous system. The various methods of local electrization
+should also be resorted to.</p>
+
+<p>Mild antiseptic and astringent lotions or dusting powders should
+also be advised.</p>
+
+<p><i>Red chromidrosis</i> or <i>Pseudochromidrosis</i> is a condition in which
+the coloring of the sweat occurs after its excretion and is due to the
+presence of chromatogenous bacteria which are found attached to
+the hairs of the part in agglutinated masses. The axilla is the favorite
+site. Treatment consists of frequent soap-and-water washings,
+and the application of boric acid, resorcin, and corrosive sublimate
+lotions.</p>
+
+
+<h2><a name='Uridrosis' id='Uridrosis'></a><b>Uridrosis.</b></h2>
+
+<p><b>Describe uridrosis.</b></p>
+
+<p>Uridrosis is a rare condition in which the sweat secretion contains
+the elements of the urine, especially urea. In marked cases the salt
+may be noticeable upon the skin as a colorless or whitish crystalline
+deposit. In most instances it has been preceded or accompanied by
+partial or complete suppression of the renal functions.</p>
+
+
+<h2><a name='Phosphoridrosis' id='Phosphoridrosis'></a><b>Phosphoridrosis.</b></h2>
+
+<p><b>Describe phosphoridrosis.</b></p>
+
+<p>Phosphoridrosis is a rare condition, in which the sweat is phosphorescent.
+It has been observed in the later stages of phthisis, in
+miliaria, and in those who have eaten of putrid fish.</p>
+
+
+<h2><a name='Seborrhoea_Eczema_Seborrhoicum' id='Seborrhoea_Eczema_Seborrhoicum'></a><b>Seborrh&oelig;a (Eczema Seborrhoicum).</b></h2>
+
+<p class='center'><i>Synonyms:</i> (Steatorrh&oelig;a; Acne sebacea; Ichthyosis sebacea; Dandruff.)</p>
+
+<p><b>What is seborrh&oelig;a?</b></p>
+
+<p>Seborrh&oelig;a 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.</p>
+
+<p>In many cases the sweat-glands are likewise implicated, and the
+process may also be distinctly, although usually mildly, inflammatory.
+<span class='pagenum'><a name='Page_34' id='Page_34'></a><a href='#TOC'>[Pg 34]</a></span></p>
+
+<p><b>At what age is seborrh&oelig;a usually observed?</b></p>
+
+<p>Between fifteen and forty. It may, however, occur at any age.</p>
+
+<p><b>Name the parts most commonly affected.</b></p>
+
+<p>The scalp, face, and (less frequently) the sternal and interscapular
+regions of the trunk. It is sometimes seen on other parts.</p>
+
+<p><b>What varieties of seborrh&oelig;a are encountered?</b></p>
+
+<p>Seborrh&oelig;a oleosa and seborrh&oelig;a sicca; not infrequently the disease
+is of a mixed type.</p>
+
+<p><b>What are the symptoms of seborrh&oelig;a oleosa?</b></p>
+
+<p>The sole symptom is an unnatural oiliness, variable as to degree.
+Its most common sites are the regions of the scalp, nose, and forehead.
+In many instances mild rosacea coexists with oily seborrh&oelig;a
+of the nose.</p>
+
+<p><b>Give the symptoms of seborrh&oelig;a sicca.</b></p>
+
+<p>A variable degree of greasy scalines, which may be seated upon
+a pale, hyper&aelig;mic or mildly inflammatory surface.</p>
+
+<p>The parts affected are covered scantily or more or less abundantly
+with somewhat greasy, grayish, or brownish-gray scales. If upon the
+scalp (<i>dandruff</i>, <i>pityriasis capitis</i>), small particles of scales are found
+scattered through the hair, and when the latter is brushed or combed,
+fall over the shoulders. If upon the face, in addition to the scaliness,
+the sebaceous ducts are usually seen to be enlarged and filled with
+sebaceous matter.</p>
+
+<p><b>Describe the symptoms of the ordinary or mixed type.</b></p>
+
+<p>It is common upon the scalp. The skin is covered with irregularly
+diffused, greasy, grayish or brownish scales and crusts, in some
+cases moderate in quantity, in others so great that large irregular
+masses are formed, pasting the hair to the scalp. If removed, the
+scales and crusts rapidly re-form. The skin beneath is found slate-colored,
+hyper&aelig;mic or mildly inflammatory, and exceptionally it has
+in places an eczematous aspect (<i>eczema seborrhoicum</i>). Extraneous
+matter, such as dust and dirt, collects upon the parts, and the
+whole mass may become more or less offensive. There is a strong
+tendency to falling-out of the hair. Itching may or may not be
+present.</p>
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_036.jpg'>
+<img src='images/036.jpg' width='400' height='230'
+alt='FIG. 5.'
+title='FIG. 5.' />
+</a>
+</div>
+
+<p class='center'>Seborrh&oelig;a (Eczema Seborrhoicum).</p>
+
+<p><span class='pagenum'><a name='Page_35' id='Page_35'></a><a href='#TOC'>[Pg 35]</a></span></p>
+
+
+<p><b>Describe the symptoms of seborrh&oelig;a of the trunk and other
+parts.</b></p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 7.</b></p>
+<div class='figcenter' style='width: 391px;'>
+<a href='images/fullsize_038.jpg'>
+<img src='images/038.jpg' width='391' height='600'
+alt='FIG. 7.'
+title='FIG. 7.' />
+</a>
+</div>
+
+
+<p class='center'>A normal sebaceous gland in connection with a lanugo hair. (<i>After Neumann.</i>)</p>
+
+<p class='center'><i>a</i>, Capsule; <i>b</i>, fatty secretion; <i>c</i>, <i>h</i>, secreting cells; <i>d</i>, root of lanugo hair; <i>e</i>, hair-sac;
+<i>f</i>, hair-shaft; <i>g</i>, acini of sebaceous gland.</p>
+
+<p>Seborrh&oelig;a corporis differs in a measure, in its symptoms, from
+seborrh&oelig;a of the scalp and is usually illustrative of the variety
+known as eczema seborrhoicum; it occurs as one or several irregular
+or circinate, slightly hyper&aelig;mic or moderately inflammatory patches,
+covered with dirty or grayish-looking greasy scales or crusts, usually
+moderate in quantity, and upon removal are found to have projections
+into the sebaceous ducts. It is commonly seen upon the sternal
+and interscapular regions. It rarely exists independently in these
+regions, being usually associated with and following the disease on the
+scalp. It may also invade the axill&aelig;, genitocrural, and other regions.
+<span class='pagenum'><a name='Page_36' id='Page_36'></a><a href='#TOC'>[Pg 36]</a></span></p>
+
+<p><b>What is the usual course of seborrh&oelig;a?</b></p>
+
+<p>Essentially chronic, the disease varying in intensity from time to
+time. In occasional instances it disappears spontaneously.</p>
+
+<p><b>Give the cause or causes of seborrh&oelig;a.</b></p>
+
+<p>General debility, an&aelig;mia, chlorosis, dyspepsia, and similar conditions
+are to be variously looked upon as predisposing.</p>
+
+<p>In some instances, however, the disease seems to be purely local
+in character, and to be entirely independent of any constitutional or
+predisposing condition. The view recently advanced that the disease
+is of parasitic nature and contagious has been steadily gaining
+ground.</p>
+
+<p><b>What is the pathology of seborrh&oelig;a?</b></p>
+
+<p>Seborrh&oelig;a is a disease of the sebaceous glands, and probably
+often involving the sweat-glands also; its products, as found upon
+the skin, consisting of the sebaceous secretion, epithelial cells from
+the glands and ducts, and more or less extraneous matter. Not
+infrequently evidences of superficial inflammatory action are also to
+be found, and it is especially for this type that the name eczema
+seborrhoicum is most appropriate. In long-continued and neglected
+cases slight atrophy of the gland-structures may occur.</p>
+
+<p><b>With what diseases are you likely to confound seborrh&oelig;a?</b></p>
+
+<p>Upon the scalp, with eczema and psoriasis; upon the face, with
+lupus erythematosus and eczema; and upon the trunk, with psoriasis
+and ringworm.</p>
+
+<p>As a rule, the clinical features of seborrh&oelig;a are sufficiently characteristic
+to prevent error.</p>
+
+<p><b>What are the differential points?</b></p>
+
+<p>Eczema, psoriasis, and lupus erythematosus are diseases in which
+there are distinct <i>inflammatory symptoms</i>, such as thickening and
+infiltration and redness; moreover, psoriasis, and this holds true as to
+ringworm also, occurs in sharply-defined, circumscribed patches, and
+lupus erythematosus has a peculiar violaceous tint and an elevated
+and marginate border. A microscopic examination of the epidermic
+scrapings would be of crucial value in differentiating from ringworm.</p>
+
+<p>Quite frequently, especially in the interscapular and sternal regions,
+the segmental configuration constitutes an important feature
+of seborrh&oelig;a&mdash;of the eczema seborrhoicum variety.
+<span class='pagenum'><a name='Page_37' id='Page_37'></a><a href='#TOC'>[Pg 37]</a></span></p>
+
+<p><b>What is the prognosis in seborrh&oelig;a</b>?</p>
+
+<p>Favorable. All types are curable, and when upon the non-hairy
+regions, usually readily so; upon the scalp it is often obstinate.
+Relapses are not uncommon.</p>
+
+<p>In those cases of seborrh&oelig;a capitis which have been
+long-continued
+or neglected, and attended with loss of hair, this loss may be
+more or less permanent, although ordinarily much can be done to
+promote a regrowth (see <i>Treatment of Alopecia</i>).</p>
+
+<p><b>How would you treat seborrh&oelig;a of the scalp</b>?</p>
+
+<p>By constitutional (if indicated) and local remedies; the former
+having in view correction or modification of the predisposing factor
+or factors, and the latter removal of the sebaceous accumulations and
+the application of mildly stimulating antiseptic ointments or lotions.</p>
+
+<p><b>What constitutional remedies are commonly employed</b>?</p>
+
+<p>The various tonics, such as iron, quinine, strychnia, cod-liver oil,
+arsenic, the vegetable bitters, laxatives, malt and similar preparations.
+The line of treatment is to be based upon indications.</p>
+
+<p><b>How do you free the scalp of the sebaceous accumulations</b>?</p>
+
+<p>In mild types of the disease shampooing with simple Castile soap
+(or any other good toilet soap) and hot water will suffice; in those
+cases in which there is considerable scale-and crust-formation the
+tincture of green soap (tinct. saponis viridis) is to be employed in
+place of the toilet soap, and in some of these latter cases it may be
+necessary to soften the crusts with a previous soaking with olive oil.</p>
+
+<p>The frequency of the shampoo depends upon the conditions. In
+mild cases once in five or ten days will be sufficiently frequent to
+keep the parts clean, but in those cases in which there is rapid
+scale-or crust-production once daily or every second day may at
+first be demanded.</p>
+
+<p><b>Name the most effectual applications in seborrh&oelig;a capitis</b>.</p>
+
+<p>Sulphur, ammoniated mercury, salicylic acid, resorcin, and carbolic
+acid.</p>
+
+<p>Sulphur is used in the form of an ointment, from twenty grains
+to one drachm in the ounce. Ammoniated mercury, in the form of
+an ointment, ten to sixty grains to the ounce. Salicylic acid, either
+alone as an ointment, ten to thirty grains to the ounce; or it may
+<span class='pagenum'><a name='Page_38' id='Page_38'></a><a href='#TOC'>[Pg 38]</a></span></p>
+
+
+<p>often be added with advantage, in the same proportion, to the sulphur
+or ammoniated mercury ointment above named. Resorcin,
+either as an ointment, ten to thirty grains to the ounce, or as an
+alcoholic or aqueous lotion, as the following:&mdash;</p>
+
+<pre>
+  &#8478; Resorcini, ....................................... &#658;j-&#658;iss.
+    Ol. ricini, ...................................... &#9807;xxx-f&#658;ij.
+    Alcoholis, ...................................... f&#8485;iv.   M.
+</pre>
+
+<p>Carbolic acid, to the amount of ten to thirty grains, can be added to
+this. If an aqueous lotion is desirable, then in the above formula
+the oleum ricini is replaced with glycerine, and the alcohol with
+water; three to five minims of glycerine in each ounce is usually
+sufficient, as a greater quantity makes the resulting lotion sticky.
+Petrolatum alone, or with 10 to 30 per cent. lanolin, is usually the
+most satisfactory base for the ointments. In some cases of the
+inflammatory variety the skin is found quite irritable, and the mildest
+applications are at first only admissible.</p>
+
+<p><b>How are the remedies to be applied</b>?</p>
+
+<p>A small quantity of the lotion, ointment, or oil is gently applied
+to the skin; when to the scalp, a lotion or oil can be conveniently
+applied by means of an eye-dropper. In the beginning of the treatment
+an application once or twice daily is ordered; later, as the
+disease becomes less active, once every second or third day.</p>
+
+<p><b>How is seborrh&oelig;a upon other parts to be treated</b>?</p>
+
+<p>In the same general manner as seborrh&oelig;a of the scalp, except that
+the local applications must be somewhat weaker. The several sulphur
+lotions employed in the treatment of acne (<i>q. v.</i>) may also be
+used when the disease is upon these parts. In obstinate patchy
+cases occasional paintings with a 20 to 50 per cent alcoholic solution
+of resorcin is curative; following the painting a mild salve should
+be used.</p>
+
+<h2><a name='Comedo' id='Comedo'></a><b>Comedo.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Blackheads; Flesh-worms.)</p>
+
+<p><b>What is comedo</b>?</p>
+
+<p>Comedo is a disorder of the sebaceous glands, characterized by
+yellowish or blackish pin-point or pin-head-sized puncta or elevations
+corresponding to the gland-orifices.
+<span class='pagenum'><a name='Page_39' id='Page_39'></a><a href='#TOC'>[Pg 39]</a></span></p>
+
+
+<p><b>At what age and upon what parts are comedones found</b>?</p>
+
+<p>Usually between fifteen and thirty, and upon the face and upper
+part of the trunk, where they may exist sparsely or in great numbers.
+They are occasionally associated with oily seborrh&oelig;a, the
+parts presenting a greasy or soiled appearance.</p>
+
+<p>Exceptionally they occur as distinct, and usually symmetrical,
+groups upon the forehead or the cheeks. On the upper trunk
+so-called
+double and multiple comedo have been noted&mdash;the two,
+three, or even four closely-contiguous blackheads are, beneath the
+surface, intercommunicable, the dividing duct-walls having apparently
+disappeared by fusion.</p>
+
+
+<p><b>Describe an individual lesion</b>.</p>
+
+<p>It is pin-point to pin-head in size, dark yellowish, and usually with
+a central blackish point (hence the name <i>blackheads</i>). There is
+scarcely perceptible elevation, unless the amount of retained secretion
+is excessive. Upon pressure this may be ejected, the small,
+rounded orifice through which it is expressed giving it a
+thread-like
+shape (hence the name <i>flesh-worms</i>).</p>
+
+
+<p><b>What is the usual course of comedo</b>?</p>
+
+
+<p>Chronic. The lesions may persist indefinitely or the condition
+may be somewhat variable. In many instances, either as a result of
+pressure or in consequence of chemical change in the sebaceous
+plugs or of the addition of a microbic factor, inflammation is excited
+and acne results. The two conditions are, in fact, usually associated.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 8.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_042.jpg'>
+<img src='images/042.jpg' width='400' height='147'
+alt='FIG. 8.'
+title='FIG. 8.' />
+</a>
+</div>
+<p class='center'>Demodex Folliculorum, X 300. Ventral surface. (<i>After Simon</i>).</p>
+
+<p><b>To what may comedo often be ascribed</b>?</p>
+
+<p>To disorders of digestion, constipation, chlorosis, menstrual disturbance,
+lack of tone in the muscular fibres of the skin, the infrequent
+use of soap, and working in a dirty or dusty atmosphere.
+<span class='pagenum'><a name='Page_40' id='Page_40'></a><a href='#TOC'>[Pg 40]</a></span>
+A small parasite (<i>demodex folliculorum, acarus folliculorum</i>) is
+sometimes found in the sebaceous mass, but its presence is without
+etiological significance, as it is also found in healthy follicles. A
+microbacillus has been found by several observers, and credited
+with etiological influence.</p>
+
+
+<p><b>What is the pathology of comedo?</b></p>
+
+<p>The sebaceous ducts or glands, or both, become blocked up with
+retained secretion and epithelial cells. The dark points which
+usually mark the lesions are probably due to accumulation of dirt,
+but may, as some writers maintain, be due to the presence of pigment-granules
+resulting from chemical change in the sebaceous matter.</p>
+
+
+<p><b>Is there any difficulty in the diagnosis of comedo?</b></p>
+
+<p>No. It can scarcely be confounded with milium, as in this latter
+disease the lesion has no open outlet, no black point, and the contents
+cannot be squeezed out.</p>
+
+
+<p><b>Give the prognosis of comedo.</b></p>
+
+<p>The result of treatment is usually favorable, although the disease
+is often rebellious. Relapses are not uncommon.</p>
+
+
+<p><b>How would you treat a case of comedo?</b></p>
+
+<p>By systemic (if indicated) and local measures.</p>
+
+<p>The constitutional treatment aims at correction or palliation of the
+predisposing conditions, and the external applications have in view
+a removal of the sebaceous plugs and stimulation of the glands and
+skin to healthy action.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 9.</b></p>
+<div class='figcenter' style='width: 600px;'>
+<img src='images/043.jpg' width='600' height='112'
+alt='FIG. 9.'
+title='FIG. 9.' />
+</div>
+<p class='center'>Comedo Extractor.</p>
+
+
+<p><b>Name the systemic remedies commonly employed.</b></p>
+
+<p>Cod-liver oil, iron, quinine, arsenic, nux vomica and other tonics;
+ergot in those cases in which there is lack of muscular tone, salines
+and aperient pills in constipation. The digestion is to be looked
+after and the bowels kept regular; indigestible food of all kinds is
+to be interdicted. Hygienic measures, such as general and local
+bathing, local massage, calisthenics, and open-air exercise, are of
+service.
+<span class='pagenum'><a name='Page_41' id='Page_41'></a><a href='#TOC'>[Pg 41]</a></span></p>
+
+<p><b>Describe the local treatment.</b></p>
+
+<p>Steaming the face or prolonged applications of hot water; washing
+with ordinary toilet soap and hot water, or, in sluggish cases,
+using tincture of green soap (tinct. saponis viridis) instead of the
+toilet soap; removal of the sebaceous plugs by mechanical means,
+such as lateral pressure with the finger ends or perpendicular pressure
+with a watch-key with rounded edges, or with an instrument
+specially contrived for this purpose; and after these preliminary
+measures, which should be carried out every night, a stimulating
+sulphur ointment or lotion, such as employed in the treatment of
+acne (<i>q. v.</i>), is to be thoroughly applied. The following is valuable:&mdash;</p>
+
+<pre>
+  &#8478; Zinci sulphatis,
+    Potassi sulphureti, ...................&#257;&#257;......... &#658;j-&#658;iv.
+    Alcoholi ........................................ f&#8485;ss.
+    Aqu&aelig;, ........................... q.s. ad. ...... f&#8485;iv.   M.
+</pre>
+
+<p>Should slight scaliness or a mild degree of irritation of the skin
+be brought about, active external treatment is to be discontinued for
+a few days and soothing applications made. Resorcin, in lotion, 3
+to 25 per cent strength, is through the exfoliation it provokes, frequently
+of value; the resorcin paste referred to in acne can also be
+used for this purpose.</p>
+
+<p>Moderately strong applications of the Faradic current, repeated
+once or twice weekly, are sometimes of service; also weak to moderately
+strong applications of the continuous and high-frequency
+currents. R&ouml;ntgen-ray treatment can also be resorted to in extremely
+obstinate cases.</p>
+
+<p>In occasional instances sulphur preparations not only fail to do
+good, but materially aggravate the condition. In such cases, if resorcin
+preparations also fail, the mercurial lotion and ointment employed
+in acne may be prescribed. Mercurial and sulphur applications
+should not be used, it need scarcely be said, within a week or
+ten days of each other, otherwise an increase in the comedones and
+a slight darkening of the skin result from the formation of the black
+sulphuret of mercury.
+<span class='pagenum'><a name='Page_42' id='Page_42'></a><a href='#TOC'>[Pg 42]</a></span></p>
+
+
+<h2><a name='Milium' id='Milium'></a><b>Milium.</b></h2>
+<p class='center'>(<i>Synonyms:</i> Grutum; Strophulus Albidus.)</p>
+
+<p><b>What is milium?</b></p>
+
+<p>Milium consists in the formation of small, whitish or yellowish,
+rounded, pearly, non-inflammatory elevations situated in the upper
+part of the corium.</p>
+
+<p><b>Describe the clinical appearances</b>.</p>
+
+<p>The lesions are usually pin-head in size, whitish or yellowish, seemingly
+more or less translucent, rounded or acuminated, without
+aperture or duct, are superficially seated in the skin, and project
+slightly above the surface.</p>
+
+<p>They appear about the face, especially about the eyelids; they
+may occur also, although rarely, upon other parts. But one or
+several may be present, or they may exist in numbers.</p>
+
+<p><b>What is the course of milium</b>?</p>
+
+<p>The lesions develop slowly, and may then remain stationary for
+years. Their presence gives rise to no disturbance, and, unless they
+are large in size or exist in numbers, causes but slight disfigurement.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 10.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/045.jpg' width='400' height='96'
+alt='FIG. 10.'
+title='FIG. 10.' />
+</div>
+<p class='center'>Milium Needle.</p>
+
+<p>In rare instances they may undergo calcareous metamorphosis, constituting
+the so-called <i>cutaneous calculi</i>.</p>
+
+<p><b>What is the anatomical seat of milium</b>?</p>
+
+<p>The sebaceous gland (probably one or several of the superficially-situated
+acini), the duct of which is in some manner obliterated, the
+sebaceous matter collects, becomes inspissated and calcareous, forming
+the pin-head lesion. The epidermis is the external covering.</p>
+
+<p><b>What is the treatment?</b></p>
+
+<p>The usual plan is to prick or incise each lesion and press out the
+contents. In some milia it may be necessary also, in order to prevent
+a return, to touch the base of the excavation with tincture of
+<span class='pagenum'><a name='Page_43' id='Page_43'></a><a href='#TOC'>[Pg 43]</a></span>
+iodine or with silver nitrate. Electrolysis is also effectual. In those
+cases where the lesions are numerous the production of exfoliation
+of the epiderm by means of resorcin applications (see acne) is a
+good plan.</p>
+
+
+<h2><a name='Steatoma' id='Steatoma'></a><b>Steatoma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Sebaceous Cyst; Sebaceous Tumor; Wen.)</p>
+
+<p><b>Describe steatoma.</b></p>
+
+<p>Steatoma, or sebaceous cyst, appears as a variously-sized, elevated,
+rounded or semi-globular, soft or firm tumor, freely movable and
+painless, and having its seat in the corium or subcutaneous tissue.
+The overlying skin is normal in color, or it may be whitish or pale
+from distention; in some a gland-duct orifice may be seen, but, as a
+rule, this is absent.</p>
+
+<p><b>What are the favorite regions for the development of steatoma?</b></p>
+
+<p>The scalp, face and back. One or several may be present.</p>
+
+<p><b>What is the course of sebaceous cysts?</b></p>
+
+<p>Their growth is slow, and, after attaining a variable size, may remain
+stationary. They may exist indefinitely without causing any
+inconvenience beyond the disfigurement. Exceptionally, in enormously
+distended growths, suppuration and ulceration result.</p>
+
+<p><b>What is the pathology?</b></p>
+
+<p>A steatoma is a cyst of the sebaceous gland and duct, produced
+by retained secretion. The contents may be hard and friable, soft
+and cheesy, or even fluid, of a grayish, whitish or yellowish color,
+and with or without a fetid odor; the mass consisting of fat-drops,
+epidermic cells, cholesterin, and sometimes hairs.</p>
+
+<p><b>Are sebaceous cysts likely to be confounded with gummata?</b></p>
+
+<p>No. Gummata grow more rapidly, are usually painful to the
+touch, are not freely movable, and tend to break down and ulcerate.</p>
+
+<p><b>Describe the treatment of steatoma.</b></p>
+
+<p>A linear incision is made, and the mass and enveloping sac
+<span class='pagenum'><a name='Page_44' id='Page_44'></a><a href='#TOC'>[Pg 44]</a></span>
+dissected out. If the sac is permitted to remain, reproduction almost
+invariably takes place.</p>
+
+
+
+<h1><a name='CLASS_II_INFLAMMATIONS' id='CLASS_II_INFLAMMATIONS'></a><b>CLASS II.&mdash;INFLAMMATIONS.</b></h1>
+
+<h2><a name='Erythema_Simplex' id='Erythema_Simplex'></a><b>Erythema Simplex.</b></h2>
+
+
+<p><b>What do you understand by erythema simplex?</b></p>
+
+<p>Erythema simplex is a hyper&aelig;mic disorder characterized by redness,
+occurring in the form of variously-sized and shaped, diffused
+or circumscribed, non-elevated patches.</p>
+
+<p><b>Name the two general classes into which the simple erythemata
+are divided</b>.</p>
+
+<p>Idiopathic and symptomatic.</p>
+
+<p><b>What do you include in the idiopathic class</b>?</p>
+
+<p>Those erythemas due to external causes, such as cold and heat
+(<i>erythema caloricum</i>), the action of the sun (<i>erythema solare</i>), traumatism
+(<i>erythema traumaticum</i>), and the various poisons or chemical
+irritants (<i>erythema venenatum</i>).</p>
+
+<p><b>What do you include in the symptomatic class</b>?</p>
+
+<p>Those rashes often preceding or accompanying certain of the systemic
+diseases, and those due to disorders of the digestive tract,
+stomachic and intestinal toxins, to the ingestion of certain drugs,
+and to use of the therapeutic serums.</p>
+
+<p><b>Describe the symptoms of erythema simplex</b>.</p>
+
+<p>The essential symptom is redness&mdash;simple hyper&aelig;mia&mdash;without
+elevation or infiltration, disappearing under pressure, and sometimes
+attended by slight heat or burning; it may be patchy or diffused. In
+the idiopathic class, if the cause is continued, dermatitis may result.</p>
+
+<p><b>What is to be said about the distribution of the simple erythemata?</b></p>
+
+<p>The idiopathic rashes, as inferred from the nature of the causes,
+are usually limited.</p>
+
+<p>The symptomatic erythemas are more or less generalized; desquamation
+sometimes follows.
+<span class='pagenum'><a name='Page_45' id='Page_45'></a><a href='#TOC'>[Pg 45]</a></span></p>
+
+<p><b>Describe the treatment of the simple erythemata.</b></p>
+
+<p>A removal of the cause in idiopathic rashes is all that is needed,
+the erythema sooner or later subsiding. The same may be stated of
+the symptomatic erythemata, but in these there is at times difficulty
+in recognizing the etiological factor; constitutional treatment, if
+necessary, is to be based upon general principles. Intestinal antiseptics
+are useful in some instances.</p>
+
+<p>Local treatment, which is rarely needed, consists of the use of
+dusting-powders or mild cooling and astringent lotions, such as are
+employed in the treatment of acute eczema (q. v.).</p>
+
+
+
+<h2><a name='Erythema_Intertrigo' id='Erythema_Intertrigo'></a><b>Erythema Intertrigo.</b></h2>
+<p class='center'>(<i>Synonym:</i> Chafing.)</p>
+
+<p><b>What do you understand by erythema intertrigo?</b></p>
+
+<p>Erythema intertrigo is a hyper&aelig;mic disorder occurring on parts
+where the natural folds of the skin come in contact, and is characterized
+by redness, to which may be added an abraded surface and
+maceration of the epidermis.</p>
+
+<p><b>Describe the symptoms of erythema intertrigo.</b></p>
+
+<p>The skin of the involved region gradually becomes hyper&aelig;mic,
+but is without elevation or infiltration; a feeling of heat and soreness
+is usually experienced. If the condition continue, the increased
+perspiration and moisture of the parts give rise to maceration of the
+epidermis and a mucoid discharge; actual inflammation may eventually
+result.</p>
+
+<p><b>What is the course of erythema intertrigo?</b></p>
+
+<p>The affection may pass away in a few days or persist several weeks,
+the duration depending, in a great measure, upon the cause.</p>
+
+<p><b>Mention the causes of erythema intertrigo.</b></p>
+
+<p>The causes are usually local. It is seen chiefly in children, especially
+in fat subjects, in whom friction and moisture of contiguous
+parts of the body, usually the region of the neck, buttocks and genitalia,
+are more common; in such, uncleanliness or the too free use
+of soap washings will often act as the exciting factor. Disorders of
+<span class='pagenum'><a name='Page_46' id='Page_46'></a><a href='#TOC'>[Pg 46]</a></span>
+the stomach or intestinal canal apparently have a predisposing influence.</p>
+
+
+<p><b>What treatment would you advise in erythema intertrigo?</b></p>
+
+<p>The folds or parts are to be kept from contact by means of lint or
+absorbent cotton; thin, flat bags of cheese cloth or similar material
+partly filled with dusting-powder, and kept clean by frequent
+changes, are excellent for this purpose, and usually curative.
+Cleanliness is essential, but it is to be kept within the bounds of
+common sense. Dusting-powders and cooling and astringent lotions,
+such as are employed in the treatment of acute eczema (<i>q. v.</i>), can
+also be advised. The following lotion is valuable:&mdash;</p>
+
+<pre>
+  &#8478; Pulv. calamin&aelig;,
+    Pulv. zinci oxidi, ....................&#257;&#257;......... &#658;iss.
+    Glycerin&aelig;, ....................................... &#9807;xxx
+    Alcoholis, ...................................... f&#658;ij
+    Aqu&aelig;, ............................................ Oss.   M.
+</pre>
+
+<p>Exceptionally a mild ointment, alone or supplementary to a lotion,
+acts more satisfactorily.</p>
+
+<p>In persistent or obstinate cases attention should also be directed to
+the state of the general health, especially as regards the digestive tract.</p>
+
+
+<h2><a name='Erythema_Multiforme' id='Erythema_Multiforme'></a><b>Erythema Multiforme.</b></h2>
+
+
+<p><b>What is erythema multiforme?</b></p>
+
+<p>Erythema multiforme is an acute, inflammatory disease, characterized
+by reddish, more or less variegated macules, papules, and tubercles,
+occurring as discrete lesions or in patches of various size and
+shape.</p>
+
+
+<p><b>Upon what parts of the body does the eruption appear?</b></p>
+
+<p>Usually upon the extremities, especially the dorsal aspect, from
+the knees and elbows down, and about the face and neck; it may,
+however, be more or less general.</p>
+
+
+<p><b>Describe the symptoms of erythema multiforme.</b></p>
+
+<p>With or without precursory symptoms of malaise, gastric uneasiness
+or rheumatic pains, the eruption suddenly makes its appearance,
+<span class='pagenum'><a name='Page_47' id='Page_47'></a><a href='#TOC'>[Pg 47]</a></span>
+assuming an erythematous, papular, tubercular or mixed character;
+as a rule, one type of lesion predominates. The lesions tend to
+increase in size and intensity, remain stationary for several days or a
+week, and then gradually fade; during this time there may have
+been outbreaks of new lesions. In color they are pink, red, or
+violaceous. Slight itching may or may not be present. Exceptionally,
+in general cases, the eruption partakes of the nature of both
+urticaria and erythema multiforme, and itching may be quite a
+decided symptom. In some instances there is preceding and accompanying
+febrile action, usually slight in character; in others
+there may be some rheumatic swelling of one or more joints.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 11.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_050.jpg'>
+<img src='images/050.jpg' width='400' height='414'
+alt='FIG. 11.'
+title='FIG. 11.' />
+</a>
+</div>
+
+<p class='center'>Erythema Multiforme, in which many of the lesions have become bullous&mdash;</p>
+<p class='center'>Erythema Bullosum.</p>
+
+<p><span class='pagenum'><a name='Page_48' id='Page_48'></a><a href='#TOC'>[Pg 48]</a></span></p>
+
+
+<p><b>What type of the eruption is most common?</b></p>
+
+<p>The papular, appearing usually upon the backs of the hands and
+forearms, and not infrequently, also, upon the face, legs and feet.
+The papules are usually pea-sized, flattened, and of a dark red or
+violaceous color.</p>
+
+
+<p><b>Describe the various shapes which the erythematous lesions
+may assume.</b></p>
+
+<p>Often the patches are distinctly ring-shaped, with a clear centre&mdash;
+<i>erythema annulare</i>; or they are made up of several concentric
+rings, presenting variegated coloring&mdash;<i>erythema iris</i>; or a more or
+less extensive patch may spread with a sharply-defined border, the
+older part tending to fade&mdash;<i>erythema marginatum</i>; or several rings
+may coalesce, with a disappearance of the coalescing parts, and serpentine
+lines or bands result&mdash;<i>erythema gyratum</i>.</p>
+
+
+<p><b>Does the eruption of erythema multiforme ever assume a
+vesicular or bullous character?</b></p>
+
+<p>Yes. In exceptional instances, the inflammatory process may be
+sufficiently intense to produce vesiculation, usually at the summits
+of the papules&mdash;<i>erythema vesiculosum</i>; and in some instances, blebs
+may be formed&mdash;<i>erythema bullosum</i>. A vesicular or bullous lesion
+may become immediately surrounded by a ring-like vesicle or bleb,
+and outside of this another form; a patch may be made up of as
+many as several such rings&mdash;<i>herpes iris</i>. In the vesicular and bullous
+cases the lips and the mucous membranes of the mouth and
+nose also may be the seat of similar lesions.</p>
+
+
+<p><b>What is the course of erythema multiforme?</b></p>
+
+<p>Acute, the symptoms disappearing spontaneously, usually in one
+to three or four weeks. In some instances the recurrences take
+place so rapidly that the disease assumes a chronic aspect; it is
+possible that such cases are midway cases between this disease and
+dermatitis herpetiformis.</p>
+
+
+<p><b>Mention the etiological factors in erythema multiforme.</b></p>
+
+<p>The causes are obscure. Digestive disturbance, rheumatic conditions,
+and the ingestion of certain drugs are at times influential.
+Intestinal toxins are doubtless important etiological factors in some
+cases. Certain foods, such as are apt to undergo rapid putrefactive
+<span class='pagenum'><a name='Page_49' id='Page_49'></a><a href='#TOC'>[Pg 49]</a></span>
+or fermentative change, especially pork meats, oysters, fish, crabs,
+lobsters, etc., are, therefore, not infrequently of apparent causative
+influence. It is most frequently observed in spring and autumn
+months, and in early adult life. The disease is not uncommon.</p>
+
+
+<p><b>What is the pathology of erythema multiforme?</b></p>
+
+<p>It is a mildly inflammatory disorder, somewhat similar to urticaria,
+and presumably due to vasomotor disturbance; the amount of exudation,
+which is variable, determines the character of the lesions.</p>
+
+
+<p><b>Name the diagnostic points of erythema multiforme.</b></p>
+
+<p>The multiformity of the eruption, the size of the papules, often
+its limitation to certain parts, its course and the entire or comparative
+absence of itching.</p>
+
+<p>It resembles urticaria at times, but the lesions of this latter disease
+are evanescent, disappearing and reappearing usually in the most
+capricious manner, are commonly seated about the trunk, and are
+exceedingly itchy.</p>
+
+<p>In the vesicular and bullous types the acute character of the outbreak,
+the often segmental and ring-like shape, their frequent origin
+from erythematous papules, and the distribution and association
+with the more common manifestations, are always suggestive.</p>
+
+
+<p><b>What prognosis would you give in erythema multiforme?</b></p>
+
+<p>Always favorable; the eruption usually disappears in ten days to
+three weeks, although in rare instances new crops may appear from
+day to day or week to week, and the process last one or two months.
+One or more recurrences in succeeding years are not uncommon.
+Those rare cases in which vesicular or bullous lesions are also seen
+on the lips and in the mouth, are more prone to longer duration and
+to more frequent recurrences.</p>
+
+
+<p><b>What remedies are commonly prescribed in erythema multiforme?</b></p>
+
+<p>Quinin, and, if constipation is present, saline laxatives. Calcined
+magnesia is valuable as a laxative. Intestinal antiseptics, such as
+salol, thymol, and sodium salicylate, are valuable in cases probably
+due to intestinal toxins. In those exceptional instances in which
+there may be associated febrile action and rheumatic swelling of the
+joints, the patient should be kept in bed till these symptoms
+<span class='pagenum'><a name='Page_50' id='Page_50'></a><a href='#TOC'>[Pg 50]</a></span>
+subside. Local applications are rarely required, but in those exceptional
+cases in which itching or burning is present, cooling lotions of alcohol
+and water or vinegar and water are to be prescribed. The vesicular
+and bullous types demand mild protective applications, such as
+used in eczema and pemphigus.</p>
+
+
+<h2><a name='Erythema_Nodosum' id='Erythema_Nodosum'></a><b>Erythema Nodosum.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Dermatitis contusiformis.)</p>
+
+
+<p><b>What is erythema nodosum?</b></p>
+
+<p>Erythema nodosum is an inflammatory affection, of an acute type,
+characterized by the formation of variously-sized, roundish, more or
+less elevated erythematous nodes.</p>
+
+
+<p><b>Is there any special region of predilection for the eruption
+of erythema nodosum?</b></p>
+
+<p>Yes. The tibial surfaces, to which the eruption is often limited;
+not infrequently, however, other parts may be involved, more especially
+the arms and forearms.</p>
+
+
+<p><b>Describe the symptoms of erythema nodosum.</b></p>
+
+<p>The eruption makes its appearance suddenly, and is usually
+ushered in with febrile disturbance, gastric uneasiness, malaise, and
+rheumatic pains and swelling about the joints. The lesions vary in
+size from a cherry to a hen's egg, are rounded or ovalish, tender and
+painful, have a glistening and tense look, and are of a bright red,
+erysipelatous color which merges gradually into the sound skin.
+At first they are somewhat hard, but later they soften and appear as
+if about to break down, but this, however, never occurs, absorption
+invariably taking place. In occasional instances they are hemorrhagic.
+Exceptionally the lesions of erythema multiforme are also
+present. Lymphangitis is sometimes observed. In rare instances
+symptoms pointing to visceral involvement, to cerebral invasion, and
+to heart complications have been observed.</p>
+
+
+<p><b>Are the lesions in erythema nodosum usually numerous?</b></p>
+
+<p>No. As a rule not more than five to twenty nodes are present.</p>
+
+
+<p><b>What is the course of erythema nodosum?</b></p>
+
+<p>Acute. The disease terminating usually in one to three weeks.
+<span class='pagenum'><a name='Page_51' id='Page_51'></a><a href='#TOC'>[Pg 51]</a></span>
+As the lesions are disappearing they present the various changes of
+color observed in an ordinary bruise.</p>
+
+
+<p><b>What is known in regard to the etiology?</b></p>
+
+<p>The affection is closely allied to erythema multiforme, and is, indeed,
+by some considered a form of that disease. It occurs most
+frequently in children and young adults, and usually in the spring
+and autumn months. Intestinal toxins are thought responsible in
+some cases. Digestive disturbance and rheumatic pain and swellings
+are often associated with it. By many the malady is thought
+to be a specific infection.</p>
+
+
+<p><b>What is the pathology of erythema nodosum?</b></p>
+
+<p>The disease is to be viewed as an inflammatory &oelig;dema, probably
+resulting, in some instances at least, from an inflammation of the
+lymphatics or an embolism of the cutaneous vessels.</p>
+
+
+<p><b>What diseases may erythema nodosum resemble?</b></p>
+
+<p>Bruises, abscesses, and gummata.</p>
+
+
+<p><b>How are the lesions of erythema nodosum to be distinguished
+from these several conditions?</b></p>
+
+<p>By the bright red or rosy tint, the apparently violent character of
+the process, the number, situation and course of the lesions.</p>
+
+
+<p><b>State the prognosis of erythema nodosum.</b></p>
+
+<p>Favorable, recovery usually taking place in ten days to several
+weeks.</p>
+
+
+<p><b>State the treatment to be advised in erythema nodosum.</b></p>
+
+<p>Rest, relative or absolute, depending upon the severity of the
+case, and an unstimulating diet; internally intestinal antiseptics,
+quinin and saline laxatives, and locally applications of lead-water
+and laudanum.</p>
+
+
+<h2><a name='Erythema_Induratum' id='Erythema_Induratum'></a><b>Erythema Induratum.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Erythema induratum scrofulosorum.)</p>
+
+
+<p><b>What do you understand by erythema induratum?</b></p>
+
+<p>A rare disease characterized in the beginning by one or more
+usually deep-seated nodules, and, as a rule, seated in the legs,
+<span class='pagenum'><a name='Page_52' id='Page_52'></a><a href='#TOC'>[Pg 52]</a></span>
+especially the calf region. The nodules gradually enlarge, the skin
+becomes reddish, violaceous or livid in color. Absorption may take
+place slowly, or the indurations may break down, resulting in an
+indolent, rather deep-seated ulcer, closely resembling a gummatous
+ulcer. The disease is slow and persistent, and is commonly met
+with in girls and young women, usually of strumous type. It suggests
+a tuberculous origin.</p>
+
+<p>Treatment consists in administration of cod-liver oil, phosphorus
+and other tonics. Rest is of service. Locally antiseptic applications,
+and support with roller bandage are to be advised.</p>
+
+
+<h2><a name='Urticaria' id='Urticaria'></a><b>Urticaria.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Hives; Nettlerash.)</p>
+
+
+<p><b>Give a definition of urticaria.</b></p>
+
+<p>Urticaria is an inflammatory affection characterized by evanescent
+whitish, pinkish or reddish elevations, or wheals, variable as to size
+and shape, and attended by itching, stinging or pricking sensations.</p>
+
+
+<p><b>Describe the symptoms of urticaria.</b></p>
+
+<p>The eruption, erythematous in character and consisting of isolated
+pea or bean-sized elevations or of linear streaks or irregular patches,
+limited or more or less general, and usually intensely itchy, makes
+its appearance suddenly, with or without symptoms of preceding
+gastric derangement. The lesions are soft or firm, reddish or
+pinkish-white, with the peripheral portion of a bright red color,
+and are fugacious in character, disappearing and reappearing in the
+most capricious manner. In many cases simply drawing the finger
+over the skin will bring out irregular and linear wheals. In exceptional
+cases this peculiar property is so pronounced and constant
+that at any time letters and other symbols may be produced at will,
+even when such subjects are free from the ordinary urticarial lesions
+(<i>urticaria factitia, dermatographism, autographism</i>).</p>
+
+<p>The mucous membrane of the mouth and throat may also be the
+seat of wheals and urticarial swellings.</p>
+
+
+<p><b>What is the ordinary course of urticaria?</b></p>
+
+<p>Acute. The disease is usually at an end in several hours or days.
+<span class='pagenum'><a name='Page_53' id='Page_53'></a><a href='#TOC'>[Pg 53]</a></span></p>
+
+
+<p><b>Does urticaria always pursue an acute course?</b></p>
+
+<p>No. In exceptional instances the disease is chronic, in the sense
+that new lesions continue to appear and disappear irregularly from
+time to time for months or several years, the skin rarely being
+entirely free (<i>chronic urticaria</i>).</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 12.</b></p>
+<div class='figcenter' style='width: 310px;'>
+<a href='images/fullsize_056.jpg'>
+<img src='images/056.jpg' width='310' height='444'
+alt='FIG. 12.'
+title='FIG. 12.' />
+</a>
+</div>
+
+<p class='center'>Dermatographism. (<i>After C.N. Davis.</i>)</p>
+
+<p><b>Are subjective symptoms always present in urticaria?</b></p>
+
+<p>Yes. Itching is commonly a conspicuous symptom, although at
+times pricking, stinging or a feeling of burning constitutes the chief
+sensation.</p>
+
+
+<p><b>In what way may the eruption be atypical?</b></p>
+
+<p>Exceptionally the wheals, or lesions, are peculiar as to formation, or
+another condition or disease may be associated, hence the varieties
+known as urticaria papulosa, urticaria h&aelig;morrhagica, urticaria tuberosa,
+and urticaria bullosa.</p>
+
+
+<p><b>Describe urticaria papulosa.</b></p>
+
+<p>Urticaria papulosa (formerly called <i>lichen urticatus</i>) is a variety in
+<span class='pagenum'><a name='Page_54' id='Page_54'></a><a href='#TOC'>[Pg 54]</a></span>
+which the lesions are small and papular, developing usually out of
+the ordinary wheals. They appear as a rule suddenly, rarely in
+great numbers, are scattered, and after a few hours or, more commonly,
+days gradually disappear. The itching is intense, and in
+consequence their apices are excoriated. Sometimes the papules are
+capped with a small vesicle (vesicular urticaria). It is seen more
+particularly in ill-cared for and badly-nourished young children.</p>
+
+
+<p><b>Describe urticaria h&aelig;morrhagica.</b></p>
+
+<p>Urticaria h&aelig;morrhagica is characterized by lesions similar to ordinary
+wheals, except that they are somewhat hemorrhagic, partaking,
+in fact, of the nature of both urticaria and purpura.</p>
+
+
+<p><b>Describe urticaria tuberosa.</b></p>
+
+<p>In urticaria tuberosa the lesions, instead of being pea- or bean-sized,
+as in typical urticaria, are large and node-like (also called
+<i>giant urticaria</i>).</p>
+
+
+<p><b>What is acute-circumscribed &oelig;dema?</b></p>
+
+<p>In rare instances there occurs, along with the ordinary lesions
+of the disease or as its sole manifestation, sudden and evanescent
+swelling of the eyelids, ears, lips, tongue, hands, fingers, or feet
+(<i>urticaria &oelig;dematosa, acute circumscribed &oelig;dema, angioneurotic
+&oelig;dema</i>). One or several of these parts only may be affected at the
+one attack; in recurrences, so usual in this variety, the same or other
+parts may exhibit the manifestation.</p>
+
+<p>(These &oelig;dematous swellings occurring alone might be looked
+upon, as they are by most observers, as an independent affection,
+but its close relationship to ordinary urticaria is often evident.)</p>
+
+
+<p><b>Describe urticaria bullosa.</b></p>
+
+<p>Urticaria bullosa is a variety in which the inflammatory action has
+been sufficiently great to give rise to fluid exudation, the wheals resulting
+in the formation of blebs.</p>
+
+
+<p><b>What is the etiology of urticaria?</b></p>
+
+<p>Any irritation from disease, functional or organic, of any internal
+organ, may give rise to the eruption in those predisposed. Gastric
+derangement from indigestible or peculiar articles of food, intestinal
+toxins, and the ingestion of certain drugs are often provocative.
+The so-called &ldquo;shell-fish&rdquo; group of foods play an important etiological
+part in some cases. Idiosyncrasy to certain articles of food is
+<span class='pagenum'><a name='Page_55' id='Page_55'></a><a href='#TOC'>[Pg 55]</a></span>
+also responsible in occasional instances. Various rheumatic and
+nervous disorders are not infrequently associated with it, and are
+doubtless of etiological significance. External irritants, also, in predisposed
+subjects, are at times responsible.</p>
+
+
+<p><b>What is the pathology of urticaria?</b></p>
+
+<p>Anatomically a wheal is seen to be a more or less firm elevation
+consisting of a circumscribed or somewhat diffused collection of semi-fluid
+material in the upper layers of the skin. The vasomotor nervous
+system is probably the main factor in its production; dilatation
+following spasm of the vessels results in effusion, and in consequence,
+the overfilled vessels of the central portion are emptied by pressure
+of the exudation and the central paleness results, while the pressed-back
+blood gives rise to the bright red periphery.</p>
+
+
+<p><b>From what diseases is urticaria to be differentiated?</b></p>
+
+<p>From erythema simplex, erythema multiforme, erythema nodosum,
+and erysipelas.</p>
+
+
+<p><b>Mention the diagnostic points of urticaria.</b></p>
+
+<p>The acuteness, character of the lesions, their evanescent nature, the
+irregular or general distribution, and the intense itching.</p>
+
+
+<p><b>What is the prognosis in urticaria?</b></p>
+
+<p>The acute disease is usually of short duration, disappearing spontaneously
+or as the result of treatment, in several hours or days; it
+may recur upon exposure to the exciting cause. The prognosis of
+chronic urticaria is to be guarded, and will depend upon the ability
+to discover and remove or modify the predisposing condition.</p>
+
+
+<p><b>What systemic measures are to be prescribed in acute urticaria?</b></p>
+
+<p>Removal of the etiological factor is of first importance. This will
+be found in most cases to be gastric disturbance from the ingestion
+of improper or indigestible food, and in such cases a saline purgative
+is to be given, probably the best for this purpose being the
+laxative antacid, magnesia; or if the case is severe and food is still
+in the stomach, an emetic, such as mustard or ipecac, will act more
+promptly. Alkalies, especially sodium salicylate, and intestinal antiseptics
+are useful. Calcium chloride in doses of five to twenty
+<span class='pagenum'><a name='Page_56' id='Page_56'></a><a href='#TOC'>[Pg 56]</a></span>
+grains should be tried in obstinate cases. The diet should be, for
+the time, of a simple character.</p>
+
+
+<p><b>What systemic measures are to be prescribed in chronic and
+recurrent urticaria?</b></p>
+
+<p>The cause must be sought for and treatment directed toward its
+removal or modification. Treatment will, therefore, depend upon
+indications. In obscure cases, quinine, sodium salicylate, arsenic,
+pilocarpine, <i>atropia</i>, potassium bromide, calcium chloride, and ichthyol
+are to be variously tried; general galvanization is at times
+useful, as is also a change of scene and climate. A proper dietary
+and the maintenance of free action of the bowels, preferably, as a
+rule, with a saline laxative, is of great importance in these chronic
+cases.</p>
+
+<p>In acute circumscribed &oelig;dema treatment is essentially that of
+urticaria, the diet being given special attention.</p>
+
+
+<p><b>What external applications would you advise for the relief
+of the subjective symptoms?</b></p>
+
+<p>Cooling lotions of alcohol and water or vinegar and water; lotions
+of carbolic acid, one to three drachms to the pint; of thymol, one-fourth
+to one drachm to the pint of alcohol and water; of liquor
+carbonis detergens, one to three ounces to the pint of water, or the
+following:&mdash;</p>
+
+<pre>
+  &#8478; Acidi carbolici, ................................. &#658;j-&#658;iij
+    Acidi borici, .................................... &#658;iv
+    Glycerin&aelig;, ...................................... f&#658;j
+    Alcoholis, ...................................... f&#8485;ij
+    Aqu&aelig;, ........................................... f&#8485;xiv.   M.
+</pre>
+
+<p>Alkaline baths are also useful, and may advantageously be followed
+by dusting-powders of starch and zinc oxide.</p>
+
+
+<h2><a name='Urticaria_Pigmentosa' id='Urticaria_Pigmentosa'></a><b>Urticaria Pigmentosa.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Xanthelasmoidea.)</p>
+
+
+<p><b>Describe urticaria pigmentosa.</b></p>
+
+<p>Urticaria pigmentosa is a rare disease, variously viewed as an
+unusual form of urticaria and as an urticaria-like eruption in which
+<span class='pagenum'><a name='Page_57' id='Page_57'></a><a href='#TOC'>[Pg 57]</a></span>
+there is an element of new growth in the lesions. It begins usually
+in infancy or early childhood and continues for months or years, and
+is characterized by slightly, moderately, or intensely itchy, wheal-like
+elevations, which are more or less persistent and leave yellowish,
+orange-colored, greenish or brownish stains. Exceptionally subjective
+symptoms are almost entirely absent. Anatomical studies
+show that the lesion has in some respects the structure of an ordinary
+wheal, with &oelig;dema and pigment deposit in the epidermal portion,
+and cellular infiltration made up principally of mast-cells.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 13.</b></p>
+<div class='figcenter' style='width: 356px;'>
+<a href='images/fullsize_060.jpg'>
+<img src='images/060.jpg' width='356' height='460'
+alt='FIG. 13.'
+title='FIG. 13.' />
+</a>
+</div>
+<p class='center'>Urticaria Pigmentosa.</p>
+
+
+<p>The nature of the disease is obscure and treatment unsatisfactory.
+Ordinarily as early youth or adult life is reached it spontaneously
+disappears. The treatment advised is usually on the same lines as
+that of chronic urticaria.
+<span class='pagenum'><a name='Page_58' id='Page_58'></a><a href='#TOC'>[Pg 58]</a></span></p>
+
+
+<h2><a name='Dermatitis' id='Dermatitis'></a><b>Dermatitis.</b></h2>
+
+<p><b>What is implied by the term dermatitis?</b></p>
+
+<p>Dermatitis, or inflammation of the skin, is a term employed to
+designate those cases of cutaneous disturbance, usually acute in
+character, which are due to the action of irritants.</p>
+
+
+<p><b>Mention some examples of cutaneous disturbance to which
+this term is applied.</b></p>
+
+<p>The dermatic inflammation due to the action of excessive heat or
+cold, to caustics and other chemical irritants, and to the ingestion of
+certain drugs.</p>
+
+
+<p><b>What several varieties are commonly described?</b></p>
+
+<p>Dermatitis traumatica, dermatitis calorica, dermatitis venenata,
+and dermatitis medicamentosa.</p>
+
+
+<p><b>Describe dermatitis traumatica.</b></p>
+
+<p>Under this head are included all forms of cutaneous inflammation
+due to traumatism. To the dermatologist the most common met
+with is that produced by the various animal parasites and from continued
+scratching; in such, if the cause has been long-continued and
+persistent, a variable degree of inflammatory thickening of the skin
+and pigmentation result, the latter not infrequently being more or
+less permanent. The inflammation due to tight-fitting garments,
+bandages, to constant pressure (as bed-sores), etc., also illustrates
+this class.</p>
+
+
+<p><b>What is the treatment of dermatitis traumatica?</b></p>
+
+<p>Removal of the cause, and, if necessary, the application of soothing
+ointments or lotions; in bed-sores, soap plaster, plain or with
+one to five per cent. of ichthyol.</p>
+
+
+<p><b>What is dermatitis calorica?</b></p>
+
+<p>Cutaneous inflammation, varying from a slight erythematous to
+a gangrenous character, produced by excessive heat (<i>dermatitis
+ambustionis</i>, <i>burns</i>) or cold (<i>dermatitis congelationis</i>, <i>frostbite</i>).</p>
+
+
+<p><b>Give the treatment of dermatitis calorica.</b></p>
+
+<p>In burns, if of a mild degree, the application of sodium bicarbonate,
+as a powder or saturated solution, is useful; in the more severe
+<span class='pagenum'><a name='Page_59' id='Page_59'></a><a href='#TOC'>[Pg 59]</a></span>
+grade, a two- to five-per-cent. solution will probably be found of
+greater advantage. Other soothing applications may also be employed.
+In recent years a one-per-cent. solution of picric acid has
+been commended for the slighter burns of limited extent. Upon the
+whole, there is nothing yet so generally useful and soothing in these
+cases as the so-called Carron oil; in some cases more valuable with
+1/2 to 1 minim of carbolic acid added to each ounce.</p>
+
+<p>In frostbite, seen immediately after exposure, the parts are to be
+brought gradually back to a normal temperature, at first by rubbing
+with snow or applying cold water. Subsequently, in ordinary chilblains,
+stimulating applications, such as oil of turpentine, balsam of
+Peru, tincture of iodine, ichthyol, and strongly carbolized ointments
+are of most benefit. If the frostbite is of a vesicular, pustular,
+bullous, or escharotic character, the treatment consists in the application
+of soothing remedies, such as are employed in other like
+inflammatory conditions.</p>
+
+
+<p><b>What do you understand by dermatitis venenata?</b></p>
+
+<p>All inflammatory conditions of the skin due to contact with deleterious
+substances such as caustic, chemical irritants, iodoform,
+etc., are included under this head, but the most common causes
+are the rhus plants&mdash;<i>poison ivy</i> (or <i>poison oak</i>) and <i>poison sumach</i>
+(<i>poison dogwood</i>). Mere proximity to these plants will, in some
+individuals, provoke cutaneous disturbance (<i>rhus poisoning</i>, <i>ivy
+poisoning</i>), although they may be handled by others with impunity.</p>
+
+<p>Many other plants are also known to produce cutaneous irritation
+in certain subjects; among these may be mentioned the nettle, primrose,
+cowhage, smartweed, balm of Gilead, oleander, and rue.</p>
+
+<p>The local action of iodoform (<i>iodoform dermatitis</i>) in some individuals
+is that of a decided irritant, bringing about a dermatitis,
+which often spreads much beyond the parts of application, and
+which in those eczematously inclined may result in a veritable and
+persistent eczema.</p>
+
+
+<p><b>Describe the symptoms of rhus poisoning.</b></p>
+
+<p>The symptoms appear usually soon after exposure, and consist of
+an inflammatory condition of the skin of an eczematous nature,
+<span class='pagenum'><a name='Page_60' id='Page_60'></a><a href='#TOC'>[Pg 60]</a></span>
+varying in degree from an erythematous to a bullous character, and
+with or without &oelig;dema and swelling. As a rule, marked itching and
+burning are present. The face, hands, forearms and genitalia are
+favorite parts, although it may in many instances involve a greater
+portion of the whole surface.</p>
+
+
+<p><b>What is the course of rhus poisoning?</b></p>
+
+<p>It runs an acute course, terminating in recovery in one to six
+weeks. In those eczematously inclined, however, it may result in
+a veritable and persistent form of that disease.</p>
+
+
+<p><b>How would you treat rhus poisoning?</b></p>
+
+<p>By soothing and astringent applications, such as are employed in
+acute eczema (<i>q. v.</i>), which are to be used freely. Among the most
+valuable are: a lotion of fluid extract of grindelia robusta, one to two
+drachms to four ounces of water; lotio nigra, either alone or followed
+by the oxide-of-zinc ointment; a saturated solution of boric acid, with
+a half to two drachms of carbolic acid to the pint; a lotion of zinc
+sulphate, a half to four grains to the ounce; weak alkaline lotions;
+cold cream, petrolatum, and oxide-of-zinc ointments.</p>
+
+
+<p><b>How would you treat the dermatitis due to other deleterious
+substances of this class?</b></p>
+
+<p>By applications of a soothing and protective character, similar to
+those used in eczema and burns.</p>
+
+
+<h2><a name='Dermatitis_Medicamentosa' id='Dermatitis_Medicamentosa'></a><b>Dermatitis Medicamentosa.</b></h2>
+
+
+<p><b>What do you understand by dermatitis medicamentosa?</b></p>
+
+<p>Under this head are included all eruptions due to the ingestion
+or absorption of certain drugs.</p>
+
+<p>In rare instances one dose will have such effect; commonly, however,
+it results only after several days' or weeks' continued administration.
+With some drugs such effect is the rule, with others it is
+exceptional, nor are all individuals equally susceptible.</p>
+
+
+<p><b>How is the eruption produced in dermatitis medicamentosa?</b></p>
+
+<p>In some instances it is probably due to the elimination of the drug
+through the cutaneous structures; in others, to the action of the
+drug upon the nervous system. The view that the drug acts as a
+toxin or generates some toxin or irritant material in the blood, to
+which the eruptive phenomena may be due, has also been advanced.</p>
+
+<div class='figcenter' style='width: 398px;'>
+<a href='images/fullsize_061.jpg'>
+<img src='images/061.jpg' width='398' height='600'
+alt='FIG. 5.'
+title='FIG. 5.' />
+</a>
+</div>
+
+<p class='center'>Dermatitis medicamentosa. Bullous dermatitis from iodide of
+potassium.</p>
+
+<p><span class='pagenum'><a name='Page_61' id='Page_61'></a><a href='#TOC'>[Pg 61]</a></span></p>
+
+
+<p><b>What is the character of the eruption in dermatitis medicamentosa?</b></p>
+
+<p>It may be erythematous, papular, urticarial, vesicular, pustular
+or bullous, and, if the administration of the drug is continued, even
+gangrenous.</p>
+
+
+<p><b>Name the more common drugs having such action.</b></p>
+
+<p>Antipyrin, arsenic, atropia (or belladonna), bromides, chloral,
+copaiba, cubebs, digitalis, iodides, mercury, opium (or morphia),
+quinine, salicylic acid, stramonium, acetanilid, sulphonal, phenacetin,
+turpentine, many of the new coal-tar derivatives, etc.</p>
+
+
+<p><b>State frequency and types of eruption due to the ingestion of
+antipyrin.</b></p>
+
+<p>Not uncommon. <i>Erythematous</i>, morbilliform and erythemato-papular;
+itching is usually present and moderate desquamation
+may follow. Acetanilid, sulphonal, phenacetin, and other drugs of
+this class may provoke like eruptions.</p>
+
+
+<p><b>Mention frequency and types of eruption due to the ingestion
+of arsenic.</b></p>
+
+<p>Rare. Erythematous, erythemato-papular; exceptionally, herpetic,
+and pigmentary. Herpes zoster has been thought to follow
+its use. Keratosis of the palms and soles has also been occasionally
+observed, which, in rare instances, has developed into epithelioma.</p>
+
+
+<p><b>Mention frequency and types of eruption due to the ingestion
+of atropia (or belladonna).</b></p>
+
+<p>Not uncommon. <i>Erythematous</i> and <i>scarlatinoid</i>; usually no febrile
+disturbance, and desquamation seldom follows.</p>
+
+
+<p><b>Give frequency and types of cutaneous disturbance following
+the administration of the bromides (bromine).</b></p>
+
+<p>Common. <i>Pustular</i>, sometimes furuncular and carbuncular and
+superficially ulcerative. In exceptional instances papillomatous or
+vegetating lesions have been observed. Co-administration of arsenic
+or potassium bitartrate is thought to have a preventive influence in
+some cases.
+<span class='pagenum'><a name='Page_62' id='Page_62'></a><a href='#TOC'>[Pg 62]</a></span></p>
+
+
+<p><b>State frequency and types of cutaneous disturbance due to
+the administration of chloral.</b></p>
+
+<p>Occasional. Scarlatinoid and urticarial, and exceptionally purpuric;
+in rare instances, if drug is continued, eruption becomes
+vesicular, hemorrhagic, ulcerative and even gangrenous.</p>
+
+
+<p><b>State frequency and types of eruption following the administration
+of copaiba.</b></p>
+
+<p>Not uncommon. <i>Urticarial</i>, erythemato-papular and <i>scarlatinoid</i>.</p>
+
+
+<p><b>Mention frequency and types of eruption resulting from the
+ingestion of cubebs.</b></p>
+
+<p>Uncommon. Erythematous and small papular.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 14.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_062.jpg'>
+<img src='images/062.jpg' width='400' height='292'
+alt='FIG. 14.'
+title='FIG. 14.' />
+</a>
+</div>
+
+<p class='center'>A somewhat rare form of eruption from the ingestion of iodine compounds.</p>
+<p class='center'>(<i>After J.C. McGuire.</i>)</p>
+
+
+<p><b>Mention frequency and types of eruption resulting from the
+administration of digitalis.</b></p>
+
+<p>Exceptional. Scarlatinoid and papular.</p>
+
+
+<p><b>State frequency and types of eruption resulting from the
+iodides (iodine).</b></p>
+
+<p>Common. <i>Pustular</i>, but may be erythematous, papular, vesicular,
+bullous, tuberous, purpuric and hemorrhagic. Co-administration of
+arsenic or potassium bitartrate is thought to have a preventive influence
+in some cases.
+<span class='pagenum'><a name='Page_63' id='Page_63'></a><a href='#TOC'>[Pg 63]</a></span></p>
+
+
+<p><b>Give the frequency and types of eruption observed to follow
+the administration of mercury.</b></p>
+
+<p>Exceptional. Erythematous and erysipelatous.</p>
+
+
+<p><b>Give the frequency and types of the cutaneous disturbance
+following the ingestion of opium (or morphia).</b></p>
+
+<p>Not uncommon. Erythematous and <i>scarlatinoid</i>, and sometimes
+urticarial.</p>
+
+
+<p><b>Mention the frequency and the types of eruption following the
+administration of quinine.</b></p>
+
+<p>Not infrequent. Usually <i>erythematous</i>, but may be urticarial,
+erythemato-papular, and even purpuric. There is, in some instances,
+preceding or accompanying systemic disturbance. Furfuraceous or
+lamellar desquamation often follows.</p>
+
+
+<p><b>State frequency and types of eruption resulting from the ingestion
+of salicylic acid.</b></p>
+
+<p>Not common. Erythematous and urticarial; exceptionally, vesicular,
+pustular, bullous, and ecchymotic.</p>
+
+
+<p><b>Give frequency and type of cutaneous disturbance due to the
+administration of stramonium.</b></p>
+
+<p>Not common. Erythematous.</p>
+
+
+<p><b>State frequency and types of eruption resulting from the administration
+of turpentine.</b></p>
+
+<p>Not uncommon. <i>Erythematous</i>, and small-papular; exceptionally
+vesicular.</p>
+
+
+<h2><a name='X_Ray_Dermatitis' id='X_Ray_Dermatitis'></a><b>X-Ray Dermatitis.</b></h2>
+
+
+<p><b>What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray
+burns) are observed?</b></p>
+
+<p>Three grades are usually described: erythema, superficial vesication,
+and necrosis. The first and second may come on shortly&mdash;a
+few hours to several days&mdash;after exposure; occasionally later. The
+third grade may present also in the first several days, but in many
+cases one to several weeks may elapse before it appears; it is quite
+commonly preceded by erythema and vesication. The necrosis may
+be superficial or deep, and quite usually results in a persistent ulcer
+covered by a leathery coating; it is usually painful.
+<span class='pagenum'><a name='Page_64' id='Page_64'></a><a href='#TOC'>[Pg 64]</a></span></p>
+
+
+<p><b>Give the prognosis and treatment of x-ray dermatitis.</b></p>
+
+<p>The first grade&mdash;the erythematous&mdash;usually disappears in one to
+ten days; the second grade requires one to several weeks, and may
+be quite sore and tender; the severe or necrotic burns are persistent,
+sometimes lasting for months and several years, with little tendency
+to spontaneous disappearance, and rebellious to treatment.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 15.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_064.jpg'>
+<img src='images/064.jpg' width='400' height='377'
+alt='FIG. 15.'
+title='FIG. 15.' />
+</a>
+</div>
+<p class='center'><i>x</i>-ray burn</p>
+
+
+<p>Treatment of the milder types is that of erythema (<i>q. v.</i>); the
+necrotic type occasionally demands thorough curetting and skin-grafting
+before it will heal.</p>
+
+
+<h2><a name='Dermatitis_Factitia' id='Dermatitis_Factitia'></a><b>Dermatitis Factitia.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Feigned Eruptions.)</p>
+
+
+<p><b>What do you understand by feigned eruptions?</b></p>
+
+<p>Feigned, or artificial, eruptions, occasionally met with in hysterical
+females and in others, are produced, for the purpose of exciting sympathy
+or of deception, by the action of friction, cantharides, acids or
+<span class='pagenum'><a name='Page_65' id='Page_65'></a><a href='#TOC'>[Pg 65]</a></span>
+strong alkalies; the cutaneous disturbance may, therefore, be erythematous,
+vesicular, bullous, or gangrenous. It is usually limited
+in extent, and, as a rule, seen only on parts easily reached by the
+hands.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 16.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_065.jpg'>
+<img src='images/065.jpg' width='400' height='522'
+alt='FIG. 16.'
+title='FIG. 16.' />
+</a>
+</div>
+
+<p class='center'>Dermatitis Factitia&mdash;note the unusually uniform and regular character and
+arrangement of the lesions.</p>
+
+
+<h2><a name='Dermatitis_Gangraenosa' id='Dermatitis_Gangraenosa'></a><b>Dermatitis Gangr&aelig;nosa.</b></h2>
+<p><b>Dermatitis Gangr&aelig;nosa.</b></p>
+
+
+<p><b>What do you understand by dermatitis gangr&aelig;nosa?</b></p>
+
+<p>Dermatitis gangr&aelig;nosa (<i>erythema gangr&aelig;nosum</i>, <i>Raynaud's disease</i>,
+<i>spontaneous gangrene</i>) is an exceedingly rare affection, characterized
+by the formation of gangrenous spots and patches. It
+<span class='pagenum'><a name='Page_66' id='Page_66'></a><a href='#TOC'>[Pg 66]</a></span>
+may be idiopathic or symptomatic. Some of these cases, especially
+in hysterical subjects, belong under the &ldquo;feigned eruptions,&rdquo; being
+self-produced.</p>
+
+<p>As an idiopathic disease, it begins as erythematous, dark-red
+spots&mdash;usually preceded and accompanied by mild or grave systemic
+disturbance&mdash;which gradually pass into gangrene and sloughing; the
+eventual termination may be fatal, or recovery may take place. As
+a symptomatic disease, it is occasionally met with in diabetes and in
+grave cerebral and spinal affections.</p>
+
+<p>In Raynaud's disease (symmetric gangrene) the parts affected are
+the extremities, such as fingers and toes, the ears and nose, only
+occasionally other parts. The first symptoms observed are coldness
+and paleness of the part; followed sooner or later by congestion of
+a dark red, livid, or bluish color, with sometimes swelling, and tenderness
+and shooting pains. The termination is usually in gangrene
+of a dry character, with, in some instances, vesicles and blebs along
+the edges; in other cases the parts become atrophied, withered, and
+indurated.</p>
+
+<p>Treatment is based upon general principles.</p>
+
+
+<h2><a name='Erysipelas' id='Erysipelas'></a><b>Erysipelas.</b></h2>
+
+
+<p><b>What is erysipelas?</b></p>
+
+<p>Erysipelas is an acute specific inflammation of the skin and subcutaneous
+tissue, commonly of the face, characterized by shining redness,
+swelling, &oelig;dema, heat, and a tendency in some cases to vesicle- and
+bleb-formation, and accompanied by more or less febrile disturbance.</p>
+
+
+<p><b>Describe the symptoms and course of erysipelas.</b></p>
+
+<p>A decided rigor or a feeling of chilliness followed by febrile action
+usually ushers in the cutaneous disturbance. The skin at a certain
+point or part, commonly where there is a lesion of continuity, becomes
+bright red and swollen; this spreads by peripheral extension,
+and in the course of several hours involves a portion or the whole
+region. The parts are shining red, swollen, of an elevated temperature,
+and sharply defined against the sound skin. After several
+days or a week, during which time there is usually continued mild
+or severe febrile action, the process begins to subside, and is followed
+by epidermic desquamation.
+<span class='pagenum'><a name='Page_67' id='Page_67'></a><a href='#TOC'>[Pg 67]</a></span></p>
+
+<p>In some cases vesicles and blebs may be present; in other cases
+the disease seriously involves the deeper parts, and is accompanied
+by grave constitutional symptoms. In exceptional instances sloughing
+takes place.</p>
+
+<p>A mild, transitory, limited, and often recurrent erysipelatous condition
+of the outlet and immediate neighborhood of one or both
+nostrils is met with, taking its origin from an inflammation of the
+hair-follicles just inside the margin of the nose; constitutional symptoms
+are usually wanting. Somewhat similar, doubtless, is the erysipelatous
+inflammation (<i>erysipeloid</i>) observed on the fingers and
+hands of butchers, etc., starting from a wound, apparently as a
+result of infection from putrid meat or fish.</p>
+
+
+<p><b>What is erysipelas migrans (or erysipelas ambulans)?</b></p>
+
+<p>A variety of erysipelas which, after a few hours or days, disappears
+at one region and appears at another, and so continues for one
+or several weeks.</p>
+
+
+<p><b>What is the cause of erysipelas?</b></p>
+
+<p>The disease is due to a specific streptococcus&mdash;the streptococcus
+of Fehleisen. Depression of the vital forces and local abrasions are
+predisposing factors.</p>
+
+
+<p><b>State the diagnostic points.</b></p>
+
+<p>The character of the onset, the shining redness and swelling, the
+sharply-defined border, and the accompanying febrile disturbance.</p>
+
+
+<p><b>What is the prognosis in erysipelas?</b></p>
+
+<p>In most instances the disease runs a favorable course, terminating
+in recovery in one to three weeks. Exceptionally, in severe cases,
+a fatal termination ensues.</p>
+
+
+<p><b>What is the treatment of erysipelas?</b></p>
+
+<p><i>Internally</i>, a purge, followed by the tincture of the chloride of
+iron and quinia, and stimulants if needed. <i>Locally</i>, one to three
+per cent. carbolic-acid lotion or ointment, a saturated solution of
+boric acid, or a ten- to twenty-per-cent. aqueous solution or ointment
+of ichthyol may be employed.</p>
+
+<p>In some cases the spread of the disease is apparently controlled
+by painting the bordering healthy skin with a ring of tincture of
+iodine or strong solution of nitrate of silver.
+<span class='pagenum'><a name='Page_68' id='Page_68'></a><a href='#TOC'>[Pg 68]</a></span></p>
+
+
+<h2><a name='Phlegmona_Diffusa' id='Phlegmona_Diffusa'></a><b>Phlegmona Diffusa.</b></h2>
+
+
+<p><b>What do you understand by phlegmona diffusa?</b></p>
+
+<p>Phlegmona diffusa is a more or less extensive inflammation of
+the cutaneous and subcutaneous tissues presenting symptoms partaking
+of the nature of both deep erysipelas and flat carbuncles,
+and usually attended with varying constitutional disturbance. Suppuration
+at several points takes place, and sloughing may ensue.
+Recovery usually finally results, but a fatal issue is possible.</p>
+
+<p>Treatment is based upon general principles.</p>
+
+
+<h2><a name='Furunculus' id='Furunculus'></a><b>Furunculus.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Furuncle; Boil.)</p>
+
+
+<p><b>Define furunculus.</b></p>
+
+<p>Furunculus, or boil, is an acute, deep-seated, inflammatory, circumscribed,
+rounded or more or less acuminated, firm, painful formation,
+usually terminating in central suppuration.</p>
+
+
+<p><b>Describe the symptoms and course.</b></p>
+
+<p>A boil begins as a small, rounded or imperfectly defined reddish
+spot, or as a small, superficial pustule; it increases in size, and when
+well advanced appears as a pea or cherry-sized, circumscribed, reddish
+elevation, with more or less surrounding hyper&aelig;mia and swelling;
+it is painful and tender, and ends, in the course of several days or a
+week, in the formation of a central slough or &ldquo;<i>core</i>,&rdquo; which finally
+involves the central overlying skin (<i>pointing</i>). One or several may
+be present, gradually maturing and disappearing. Insignificant
+scarring may remain.</p>
+
+<p>In some cases sympathetic constitutional disturbance is noticed.</p>
+
+
+<p><b>What is a blind boil?</b></p>
+
+<p>A sluggish boil exhibiting little, if any, tendency to point or break.</p>
+
+
+<p><b>What is furunculosis?</b></p>
+
+<p>Furunculosis is that condition in which boils, singly or in crops,
+continue to appear, irregularly, for weeks or months.
+<span class='pagenum'><a name='Page_69' id='Page_69'></a><a href='#TOC'>[Pg 69]</a></span></p>
+
+
+<p><b>State the etiology of furuncle.</b></p>
+
+<p>A depraved state of the general health is often to be considered as
+a predisposing factor. Persistent furunculosis is not infrequent in
+diabetes mellitus. The immediate exciting cause is the entrance
+into the follicle of a microbe, the staphylococcus pyogenes aureus.
+It is not improbable, however, that boils may also be due to other
+pus-producing organisms.</p>
+
+<p>Workmen in paraffin oils or other petroleum products often
+present numerous furuncles and cutaneous abscesses. Conditions
+favoring a persistent miliaria have also a causative influence,
+especially observed in infants and young children. In these
+latter, especially among the poorer classes, sluggish boils or subcutaneous
+abscesses about the scalp in hot weather, are not at all
+infrequent.</p>
+
+
+<p><b>What is the pathology of furuncle?</b></p>
+
+<p>A boil is an inflammatory formation having its starting point in a
+sebaceous-gland, sweat-gland, or hair-follicle. The core, or central
+slough, is composed of pus and of the tissue of the gland in which
+it had its origin.</p>
+
+
+<p><b>How would you distinguish a boil from a carbuncle?</b></p>
+
+<p>A boil is comparatively small, rounded or acuminate, and has but
+one point of suppuration; a carbuncle is large, flattened, intensely
+painful, often with grave systemic disturbance, and has, moreover,
+several centres of suppuration.</p>
+
+
+<p><b>State the prognosis.</b></p>
+
+<p>When occurring in crops (furunculosis) the affection is often rebellious;
+recovery, however, finally resulting.</p>
+
+
+<p><b>What is the method of treatment of furunculus?</b></p>
+
+<p>If there be but one lesion, with no tendency to the appearance of
+others, local treatment alone is usually employed. If, however,
+several or more are present, or if there is a tendency to successive
+development, both constitutional and local measures are demanded.</p>
+
+
+<p><b>Name the internal remedies employed.</b></p>
+
+<p>Such nutrients and tonics as cod-liver oil, malt, quinine, strychnia,
+iron and arsenic; in some instances calx sulphurata, one-tenth- to
+<span class='pagenum'><a name='Page_70' id='Page_70'></a><a href='#TOC'>[Pg 70]</a></span>
+one-fourth-grain doses every three or four hours has been thought
+to be of service. Brewers' yeast has been recently again brought
+forward as a remedy of value.</p>
+
+
+<p><b>What is the external treatment?</b></p>
+
+<p>Local treatment consists in the beginning, with the hope of aborting
+the lesion, of the application of carbolic acid to the central portion,
+or the use of a twenty-five-per-cent. ointment of ichthyol
+applied as a plaster:&mdash;</p>
+
+<pre>
+  &#8478; Ichthyol, ........................................ &#658;j
+    Emp. plumbi, ..................................... &#658;ij
+    Emp. resin&aelig;, ..................................... &#658;j.   M.
+</pre>
+
+<p>Or the injection of a five-per-cent. solution of carbolic acid into the
+apex of the boil may be tried if the formation is more advanced.
+If suppuration is fully established, evacuation of the contents,
+followed by antiseptic applications, constitutes the best method.</p>
+
+<p>A saturated solution of boric acid or a lotion of corrosive sublimate
+(one to three grains to the ounce) applied to the immediate
+neighborhood of the boil or boils tends to prevent the formation of
+new lesions. Frequent washing of the parts with soap and water or
+tincture of green soap and water is also a preventive measure of
+value. In repeatedly infected areas, mild exposures to <i>x</i>-rays, at
+intervals of a few days, will often prove of curative value.</p>
+
+
+<h2><a name='Carbunculus' id='Carbunculus'></a><b>Carbunculus.</b></h2>
+<p class='center'>(<i>Synonyms:</i> Anthrax; Carbuncle.)</p>
+
+
+<p><b>What is carbuncle?</b></p>
+
+<p>A carbuncle is an acute, usually egg to palm-sized, circumscribed,
+phlegmonous inflammation of the skin and subcutaneous structures,
+terminating in a slough.</p>
+
+
+<p><b>At what age and upon what parts is carbuncle usually observed?</b></p>
+
+<p>In middle and advanced life, and more commonly in men.</p>
+
+<p>It is seen most frequently at the nape of the neck and upon the
+upper part of the back.
+<span class='pagenum'><a name='Page_71' id='Page_71'></a><a href='#TOC'>[Pg 71]</a></span></p>
+
+
+<p><b>What are the symptoms and course of carbuncle?</b></p>
+
+<p>There is rarely more than one lesion present. It begins, usually
+with preceding and accompanying malaise, chilliness and febrile disturbance,
+as a firm, flat, inflammatory infiltration in the deeper skin
+and subcutaneous tissue, spreading laterally and finally involving an
+area of one to several inches in diameter. The infiltration and swelling
+increase, the skin becomes of dark red color, and sooner or later,
+usually at the end of ten days or two weeks, softening and suppuration
+begin to take place, the skin finally giving away at several points,
+through which sanious pus exudes; the whole mass finally sloughs
+away either in portions or in its entirety, resulting in a deep ulcer,
+which slowly heals and leaves a permanent cicatrix.</p>
+
+<p>In some cases, especially in old people, constitutional disturbance
+of a grave character is noted, septic&aelig;mia is developed, and a fatal
+result may ensue.</p>
+
+
+<p><b>What is the cause of carbuncle?</b></p>
+
+<p>The same causes are considered to be operative in carbunculus as in
+furuncle; general debility and depression, from whatever cause, predisposing
+to its formation, and the introduction of a microbe, probably
+the same as in furunculus, being at present looked upon as the
+exciting factor.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>The inflammation starts simultaneously from numerous points,
+from the hair-follicles, sweat-glands or sebaceous glands. The inflammatory
+centres break down, and the pus finds its way to the surface;
+finally the process ends in gangrene of the whole area.</p>
+
+
+<p><b>How would you distinguish carbuncle from a boil?</b></p>
+
+<p>By its flat character, greater size, and multiple points of suppuration.</p>
+
+
+<p><b>What is the prognosis of carbuncle?</b></p>
+
+<p>Occurring in those greatly debilitated or in late life, and in those
+cases in which two or more lesions exist, or when seated about the
+head, the prognosis is always to be guarded, as a fatal result is not
+uncommon. In fact, in every instance the disease is to be considered
+of possible serious import.
+<span class='pagenum'><a name='Page_72' id='Page_72'></a><a href='#TOC'>[Pg 72]</a></span></p>
+
+
+<p><b>What constitutional treatment is usually employed in carbuncle?</b></p>
+
+<p>A full nutritious diet, the use of such remedies as iron, quinia, nux
+vomica, with malt and stimulants, if indicated. Calx sulphurata,
+one-tenth to one-fourth grain every two or three hours, appears, in
+some instances, to have a beneficial effect. If the pain is severe,
+morphia or chloral should be given.</p>
+
+
+<p><b>What external measures are employed?</b></p>
+
+<p>In the early part of the formation, injection of a five or ten per
+cent. carbolic acid solution, or covering the whole area with a twenty-five
+per cent. ichthyol ointment, may be employed. When it has
+broken down the pus may be drawn out with a cupping-glass, and
+carbolized glycerine or carbolized water introduced into each opening,
+and the ichthyol ointment superimposed. If the whole part has
+sloughed, it should be removed as rapidly as possible, and antiseptic
+dressings used. Or, if its progress is slow, and grave systemic disturbance
+be present, the whole part may be incised and curetted, and
+then treated antiseptically. Mild exposure to the <i>x</i>-rays is also to be
+commended.</p>
+
+
+<h2><a name='Pustula_Maligna' id='Pustula_Maligna'></a><b>Pustula Maligna.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Anthrax; Malignant Pustule.)</p>
+
+
+<p><b>What is malignant pustule?</b></p>
+
+<p>Malignant pustule is a furuncle- or carbuncle-like lesion resulting
+from inoculation of the virus generated in animals suffering
+from splenic fever, or &ldquo;charbon,&rdquo; and is accompanied by constitutional
+symptoms of more or less gravity. A fatal termination is not
+unusual.</p>
+
+
+<p><b>What is the cause of pustula maligna?</b></p>
+
+<p>The disease is due to the presence of the bacillus anthracis.</p>
+
+
+<p><b>What is the treatment of malignant pustule?</b></p>
+
+<p>Early excision or destruction with caustic potash, with subsequent
+antiseptic dressings; and internally the free use of stimulants and
+tonics.
+<span class='pagenum'><a name='Page_73' id='Page_73'></a><a href='#TOC'>[Pg 73]</a></span></p>
+
+
+<h2><a name='Post_mortem_Pustule' id='Post_mortem_Pustule'></a><b>Post-mortem Pustule.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Dissection Wound.)</p>
+
+
+<p><b>Describe post-mortem pustule.</b></p>
+
+<p>Post-mortem pustule develops at the point of inoculation, beginning
+as an itchy red spot, becoming vesico-pustular, and later pustular,
+with usually a broad inflammatory base, and accompanied with
+more or less pain and redness and not infrequently lymphangitis,
+erysipelatous swelling, and slight or severe sympathetic constitutional
+disturbance.</p>
+
+
+<p><b>What is the treatment of post-mortem pustule?</b></p>
+
+<p>Treatment consists in opening the pustule and thorough cauterization,
+and the subsequent use of antiseptic applications or dressings.
+<i>Internally</i> quinia and stimulants if indicated.</p>
+
+
+<h2><a name='Framboesia' id='Framboesia'></a><b>Framb&oelig;sia.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Yaws; Pian.)</p>
+
+
+<p><b>Describe framb&oelig;sia.</b></p>
+
+<p>Framb&oelig;sia is an endemic, contagious disease met with in tropical
+countries, characterized by the appearance of variously-sized papules,
+tubercles, and tumors, which, when developed, resemble currants
+and small raspberries, and finally break down and ulcerate. It is
+accompanied by constitutional symptoms of variable severity.</p>
+
+<p>Hygienic measures, good food, tonics, and antiseptic and stimulating
+applications are curative.</p>
+
+
+<h2><a name='Verruga_Peruana' id='Verruga_Peruana'></a><b>Verruga Peruana.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Peruvian Warts; Carrion's Disease; Oroya Fever.)</p>
+
+
+<p><b>Describe verruga peruana.</b></p>
+
+<p>A specific inoculable affection endemic in some valleys of the
+Western Andes, in Peru, and characterized by a prodromal febrile
+period and subsequent outbreak of peculiar pin-head- to pea-sized, or
+larger, bright reddish, rounded, wart-like elevations. The prodromal
+symptoms, of an irregular malarial or typhoid type, with associated
+rheumatic and muscular pains, may last for weeks or several months,
+<span class='pagenum'><a name='Page_74' id='Page_74'></a><a href='#TOC'>[Pg 74]</a></span>
+usually abating when eruption presents. The lesions may be crowded
+together in great bunches. The face and limbs are favorite localities.
+The disease is inoculable and thought to be due to a bacillus.</p>
+
+<p>The fatality varies between 10 and 20 per cent. Tonics and stimulants
+are prescribed.</p>
+
+
+<h2><a name='Equinia' id='Equinia'></a><b>Equinia.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Farcy; Glanders.)</p>
+
+
+<p><b>What is equinia, or glanders?</b></p>
+
+<p>A rare contagious specific disease of a malignant type, derived
+from the horse, and characterized by grave constitutional symptoms,
+inflammation of the nasal and respiratory passages, and a deep-seated
+papulo-pustular, or tubercular, nodular (<i>farcy buds</i>), ulcerative
+eruption. A fatal issue is not uncommon. It is due to a micro-organism.</p>
+
+<p>Treatment, both local and constitutional, is based upon general
+principles.</p>
+
+
+<h2><a name='Miliaria' id='Miliaria'></a><b>Miliaria.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Prickly Heat; Heat Rash; Lichen Tropicus; Red Gum; Strophulus.)</p>
+
+
+<p><b>What do you understand by miliaria?</b></p>
+
+<p>An acute mildly inflammatory disorder of the sweat-glands, characterized
+by the appearance of minute, discrete but closely crowded
+papules, vesico-papules, and vesicles.</p>
+
+
+<p><b>Describe the symptoms of miliaria.</b></p>
+
+<p>The eruption, consisting of pin-point to millet-seed-sized papules,
+vesico-papules, vesicles, or a mixture of these lesions, discrete but
+usually numerous and closely crowded, appears suddenly, occurring
+upon a limited portion of the surface, or, as commonly observed,
+involving a greater part or the whole integument. The trunk is a
+favorite locality. The papular lesions are pinkish or reddish, and
+the vesicles whitish or yellowish, surrounded by inflammatory areola,
+thus giving the whole eruption a bright red appearance&mdash;<i>miliaria
+rubra</i>. Later, the areol&aelig; fade, the transparent contents of the
+vesicles become somewhat opaque and yellowish-white, and the
+<span class='pagenum'><a name='Page_75' id='Page_75'></a><a href='#TOC'>[Pg 75]</a></span>
+eruption has a whitish or yellowish cast&mdash;<i>miliaria alba</i>. In long-continued
+cases, especially in children, boils and cutaneous abscesses
+sometimes develop; and it may also develop into a true eczema.</p>
+
+<p>Itching, or a feeling of burning, slight or intense, is usually
+present.</p>
+
+
+<p><b>What is the course of the eruption?</b></p>
+
+<p>The vesicles show no disposition to rupture, but dry up in a few
+days or a week, disappearing by absorption and with slight subsequent
+desquamation; the papular lesions gradually fade away, and
+the affection, if the exciting cause has ceased to act, terminates.</p>
+
+
+<p><b>What is the cause of miliaria?</b></p>
+
+<p>Excessive heat. Debilitated individuals, especially children, are
+more prone to an attack. Being too warmly clad is often causative.</p>
+
+
+<p><b>What is the nature of the disease?</b></p>
+
+<p>The affection is considered to be due to sweat-obstruction, with
+mild inflammatory symptoms as a cause or consequence, congestion
+and exudation taking place about the ducts, giving rise to papules
+or vesicles, according to the intensity of the process.</p>
+
+
+<p><b>How would you distinguish miliaria from papular and vesicular
+eczema, and from sudamen?</b></p>
+
+<p>The papules of eczema are larger, more elevated, firmer, slower
+in their evolution, of longer duration, and are markedly itchy.</p>
+
+<p>The vesicles of eczema are usually larger, tend to become confluent,
+and also to rupture and become crusted; there is marked
+itchiness, and the inflammatory action is usually severe and persistent.</p>
+
+<p>In sudamen there is absence of inflammatory symptoms.</p>
+
+
+<p><b>What is the prognosis of miliaria?</b></p>
+
+<p>The affection, under favorable circumstances, disappears in a few
+days or weeks. If the cause persists, as for instance, in infants or
+young children too warmly clad, it may result in eczema.</p>
+
+
+<p><b>What is the treatment of miliaria?</b></p>
+
+<p>Removal of the cause, and in debilitated subjects the administration
+of tonics; together with the application of cooling and astringent
+lotions, as the following:&mdash;
+<span class='pagenum'><a name='Page_76' id='Page_76'></a><a href='#TOC'>[Pg 76]</a></span></p>
+
+<pre>
+<span style='margin-left: 2em;'>
+  &#8478; Aeidi carbolici, ................................. &#658;ss-&#658;j
+    Acidi borici, .................................... &#658;iv
+    Glycerin&aelig;, ...................................... f&#658;j
+    Alcoholis, ...................................... f&#8485;ij
+    Aqu&aelig;, ............................................ &#8485;xiv.   M.
+</span>
+</pre>
+
+<p>This is sometimes more efficient if zinc oxide, six to eight drachms,
+is added.</p>
+
+<p>Lotions of alcohol and water or vinegar and water, and also the
+various lotions used in acute eczema, are often employed with
+relief.</p>
+
+<p>Dusting-powders of starch, boric acid, lycopodium, talc, and zinc
+oxide are also valuable; the following combination is satisfactory:&mdash;</p>
+
+<pre>
+  &#8478; Pulv. acidi borici,
+    Pulv. talci veneti,
+    Pulv. zinci oxidi,
+    Pulv. amyli, ..........................&#257;&#257;......... &#658;ij.   M.
+</pre>
+
+<p>Probably the best plan is to use a lotion and a dusting-powder
+conjointly; dabbing on the wash freely, allowing it to dry, and then
+dusting over with the powder.</p>
+
+
+<h2><a name='Pompholyx' id='Pompholyx'></a><b>Pompholyx.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Dysidrosis; Cheiro-pompholyx.)</p>
+
+
+<p><b>What is pompholyx?</b></p>
+
+<p>Pompholyx is a rare disease of the skin of a vesicular and bullous
+character, and limited to the hands and feet.</p>
+
+
+<p><b>Describe the symptoms of pompholyx.</b></p>
+
+<p>In most instances the hands only are affected. It begins usually
+with a feeling of burning, tingling or tenderness of the parts,
+followed rapidly by the appearance of deeply-seated vesicles, especially
+between the fingers and on the palmar aspect. These beginning
+lesions look not unlike sago grains imbedded in the skin. In some
+instances the disease does not extend beyond this stage, the vesicles
+disappearing after a few days or weeks by absorption, and usually
+<span class='pagenum'><a name='Page_77' id='Page_77'></a><a href='#TOC'>[Pg 77]</a></span>
+without desquamation. Ordinarily, however, the lesions increase in
+size, new ones arise, become confluent, and blebs result, the skin in
+places appearing as if undermined with serous exudation. The
+parts are commonly inflamed to a slight or marked degree. The
+skin comes off in flakes, new lesions may appear for several days or
+two or three weeks, and the process then declines, recovery gradually
+taking place.</p>
+
+<p>There are no constitutional symptoms, although it is usually
+noticed that the general health is below par.</p>
+
+<p><b>What is the character of the subjective symptoms in pompholyx?</b></p>
+
+<p>The subjective symptoms consist of a feeling of tension, burning
+and tenderness, and sometimes itching. Not infrequently, also
+there is neuralgic pain.</p>
+
+
+<p><b>What is the cause of pompholyx?</b></p>
+
+<p>The eruption is thought to be due to a depressed state of the
+nervous system. It is more common in women, and is met with
+chiefly in adult and middle life.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>Opinion is divided; some considering it a disease of the sweat-glands
+and others an inflammatory disease independent of these
+structures.</p>
+
+
+<p><b>State the diagnostic features of pompholyx.</b></p>
+
+<p>The distribution and the peculiar characters and course of the
+eruption.</p>
+
+<p>It is to be differentiated from eczema.</p>
+
+
+<p><b>What is the prognosis?</b></p>
+
+<p>For the immediate attack, favorable, recovery taking place in
+several weeks or a few months. Recurrences at irregular intervals
+are not uncommon.</p>
+
+
+<p><b>What is the treatment of pompholyx?</b></p>
+
+<p>The general health is to be looked after, and the patient placed
+under good hygienic conditions. Remedies of a tonic nature,
+directed especially toward improving the state of the nervous system,
+are to be prescribed. <i>Locally</i>, soothing and anodyne applications,
+<span class='pagenum'><a name='Page_78' id='Page_78'></a><a href='#TOC'>[Pg 78]</a></span>
+such as lead-water and laudanum, boric-acid lotion, oxide-of-zinc,
+boric-acid and diachylon ointments, are most suitable; or the parts
+may be enveloped with the following:&mdash;</p>
+
+<pre>
+  &#8478; Pulv. ac. salicylici, ............................ gr. x
+    Pulv. ac. borici,
+    Pulv. amyli, ..................&#257;&#257;................. &#658;ij
+    Petrolati, ....................................... &#658;iv.   M.
+</pre>
+
+<p>In fact, the external treatment is similar to that employed in acute
+eczema.</p>
+
+
+<h2><a name='Herpes_Simplex' id='Herpes_Simplex'></a><b>Herpes Simplex.</b></h2>
+<p class='center'>(<i>Synonym:</i> Fever Blisters.)</p>
+
+
+<p><b>What is herpes simplex?</b></p>
+
+<p>An acute inflammatory disease, characterized by the formation of
+pin-head to pea-sized vesicles, arranged in groups, and occurring for
+the most part about the face and genitalia.</p>
+
+
+<p><b>Describe the symptoms of herpes simplex.</b></p>
+
+<p>In severe cases, malaise and pyrexia may precede the eruption, but
+usually it appears without any precursory or constitutional symptoms.
+A feeling of heat and burning in the parts is often complained of.
+The vesicles, which are commonly pin-head in size, are usually upon
+a hyper&aelig;mic or inflammatory base, and tend to occur in groups or
+clusters. Their contents are usually clear, subsequently becoming
+more or less milky or puriform. There is no tendency to spontaneous
+rupture, but should they be broken a superficial excoriation
+results. In a short time they dry to crusts which soon fall off, leaving
+no permanent trace.</p>
+
+
+<p><b>Is the eruption in herpes simplex abundant?</b></p>
+
+<p>No. As a rule not more than one or two clusters or groups are
+observed.</p>
+
+
+<p><b>Upon what parts does the eruption occur?</b></p>
+
+<p>Usually about the face (<i>herpes facialis</i>), and most frequently about
+the lips (<i>herpes labialis</i>); on the genitalia (<i>herpes progenitalis</i>), the
+<span class='pagenum'><a name='Page_79' id='Page_79'></a><a href='#TOC'>[Pg 79]</a></span>
+lesions are commonly found on the prepuce (<i>herpes pr&aelig;putialis</i>) in the
+male, and on the labia minora and labia majora in the female.</p>
+
+
+<p><b>State the causes of herpes simplex.</b></p>
+
+<p>Herpes facialis is often observed in association with colds and
+febrile and lung diseases. Malaria, digestive disturbance, and nervous
+disorders are not infrequently predisposing factors. Herpes
+progenitalis is said to occur more frequently in those who have previously
+had some venereal disease, especially gonorrh&oelig;a, but this is
+questionable. It is probably often purely neurotic.</p>
+
+
+<p><b>What are the diagnostic points?</b></p>
+
+<p>The appearance of one or several vesicular groups or clusters about
+the face, and especially about the lips, is usually sufficiently characteristic.
+The same holds true ordinarily when the eruption is seen
+on the prepuce or other parts of the genitalia; it is only when the vesicles
+become rubbed or abraded and irritated that it might be mistaken
+for a venereal sore, but the history, course and duration will
+usually serve to differentiate.</p>
+
+
+<p><b>Give the prognosis.</b></p>
+
+<p>The eruption will usually disappear in several days or one or two
+weeks without treatment. Remedial applications, however, exert
+a favorable influence. Herpes progenitalis exhibits a strong disposition
+to recurrence.</p>
+
+
+<p><b>What is the treatment of herpes facialis?</b></p>
+
+<p>Anointing the parts with camphorated cold cream, with spirits of
+camphor or similar evaporating and stimulating applications will at
+times afford relief to the burning, and shorten the course.</p>
+
+
+<p><b>What is the treatment of herpes progenitalis?</b></p>
+
+<p>In herpes about the genitalia cleanliness is of first importance.
+A saturated solution of boric acid, a dusting-powder of calomel or
+oxide of zinc, and the following lotion, containing calamine and oxide
+of zinc, are valuable:&mdash;</p>
+
+<pre>
+  &#8478; Zinci oxidi,
+    Calamin&aelig;, ..............&#257;&#257;........................ gr. v
+    Glycerin&aelig;,
+    Alcoholis, .............&#257;&#257;........................ &#9807;vj
+    Aqu&aelig;, ............................................ &#8485;j   M.
+</pre>
+
+<p><span class='pagenum'><a name='Page_80' id='Page_80'></a><a href='#TOC'>[Pg 80]</a></span>
+In obstinate recurrent cases, frequent applications of a mild
+galvanic current will have a favorable influence.</p>
+
+
+<h2><a name='Hydroa_Vacciniforme' id='Hydroa_Vacciniforme'></a><b>Hydroa Vacciniforme.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Recurrent Summer Eruption; Hydroa Puerorum; Hydroa Aestivale.)</p>
+
+
+<p><b>Describe hydroa vacciniforme.</b></p>
+
+<p>It is a rare vesicular disease usually seen in boys (only two or three
+exceptions), occurring upon uncovered parts, especially the nose,
+cheeks, and ears. The lesions begin as red spots, discrete or in
+groups, rapidly exhibit vesiculation, and later umbilication; the
+contents become milky, dry to crusts, which fall off and leave small
+pit-like scars. Fresh outbreaks may take place almost continuously,
+and the process go on indefinitely, at least up to youth or manhood,
+when the tendency subsides. Its activity is usually limited to the
+warm season. Arthritic symptoms and general disturbance are
+sometimes noted in severe cases.</p>
+
+<p>It is doubtless a vasomotor neurosis. Exposure to sun and wind
+is an important, if not essential, etiological factor. Primarily the
+lesion begins in the rete middle layers, and is purely vesicular in
+character; later, necrosis of the rete and extending deep in the
+corium is observed.</p>
+
+<p>Treatment so far has only been palliative, consisting of the applications
+employed in similar conditions. Constitutional medication is
+based upon general principles. The patient should avoid exposure
+to the sun, strong wind and excessive artificial heat.</p>
+
+
+<h2><a name='Epidermolysis_Bullosa' id='Epidermolysis_Bullosa'></a><b>Epidermolysis Bullosa.</b></h2>
+
+
+<p><b>Describe epidermolysis bullosa.</b></p>
+
+<p>This is a rare, usually hereditary, disease or condition, characterized
+by the formation of vesicles and blebs on any part subjected to
+slight rubbing or irritation. No scarring is left, and no pigmentation
+noted. The predisposition to these lesions persists indefinitely.
+The general health is not involved. The nature of the disease is
+obscure.</p>
+
+<p>Treatment has no influence in modifying or lessening this tendency.
+The vulnerable parts should so far as possible be protected
+from knocks and undue friction.
+<span class='pagenum'><a name='Page_81' id='Page_81'></a><a href='#TOC'>[Pg 81]</a></span></p>
+
+
+<h2><a name='Dermatitis_Repens' id='Dermatitis_Repens'></a><b>Dermatitis Repens.</b></h2>
+
+
+<p><b>What do you understand by dermatitis repens?</b></p>
+
+<p>It is a rare spreading dermatitis starting from an injury, extending
+by a serous undermining of the epidermis, and usually occurring
+upon the upper extremities.</p>
+
+<p>It usually begins shortly after an injury, and, as a rule, presents
+itself by redness and serous exudation. The overlying epidermis
+breaks, and the area of disease gradually progresses by an extension
+of the serous undermining process, the denuded part looking red
+and raw, with usually an oozing surface. As the disease spreads
+the oldest part becomes dry and heals, the new epidermal covering
+being thin and atrophic in appearance. Its most usual beginning is
+on some part of the hand, and from here it may spread up the arm
+and involve considerable area.</p>
+
+<p>The injury from which it starts may be extremely insignificant,
+apparently affording an opening for the introduction of the causative
+factor, doubtless parasitic. Beyond a feeling of soreness there
+seem to be no special subjective symptoms.</p>
+
+
+<p><b>Give the prognosis and treatment.</b></p>
+
+<p>The malady shows but little tendency to spontaneous cure. The
+frequent or constant application of a mild antiseptic lotion, such as
+boric acid and resorcin, or of a mild parasiticide ointment will generally
+bring the disease gradually to an end.</p>
+
+
+<h2><a name='Herpes_Zoster' id='Herpes_Zoster'></a><b>Herpes Zoster.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Zoster; Zona; Shingles.)</p>
+
+
+<p><b>Give a definition of herpes zoster.</b></p>
+
+<p>Herpes zoster is an acute, self-limited, inflammatory disease, characterized
+by groups of vesicles upon inflammatory bases, situated
+over or along a nerve tract.</p>
+
+
+<p><b>Upon what parts of the body may the eruption appear?</b></p>
+
+<p>It may appear upon any part, following the course of a nerve; it
+is therefore always limited in extent, and confined to one side of the
+body. It is probably most common about the intercostal, lumbar
+and supra-orbital regions. In rare instances the eruption has been
+observed to be bilateral.
+<span class='pagenum'><a name='Page_82' id='Page_82'></a><a href='#TOC'>[Pg 82]</a></span></p>
+
+
+<p><b>Are there any subjective or constitutional symptoms?</b></p>
+
+<p>Yes; there is, as a rule, neuralgic pain preceding, during and
+following the eruption; and in some cases, also, there may be in the
+beginning mild febrile disturbance. There is also a variable degree
+of tenderness and pain.</p>
+
+
+<p><b>What are the characters of the eruption?</b></p>
+
+<p>Several or more hyper&aelig;mic or inflammatory patches over a nerve
+course appear, upon which are seated vesico-papules irregularly
+grouped; these vesico-papules become distinct vesicles, of size from
+a pin-head to a pea, and soon dry and give rise to thin, yellowish
+or brownish crusts, which drop off, leaving in most instances no permanent
+trace, in others more or less scarring. In some cases the
+lesions may become pustular and, on the other hand, the eruption
+may be abortive, stopping short of full vesiculation.</p>
+
+
+<p><b>What is known in regard to the nature of the disease?</b></p>
+
+<p>An inflamed and irritable state of the spinal ganglia, nerve tract,
+or peripheral branches is directly responsible for the eruption, and
+this state may be due to atmospheric changes, cold, nerve-injuries
+and similar influences. The view has also been advanced that the
+disease is of specific and infectious character.</p>
+
+
+<p><b>Give the chief diagnostic features of herpes zoster.</b></p>
+
+<p>The prodromic neuralgic pain, the appearance of grouped vesicles
+upon inflammatory bases following the course of a nerve tract, and
+the limitation of the eruption to one side of the body.</p>
+
+
+<p><b>What is the prognosis?</b></p>
+
+<p>Favorable; the symptoms usually disappearing in two to four
+weeks. In some instances, however, the neuralgic pains may be persistent,
+and in zoster of the supra-orbital region the eye may suffer
+permanent damage.</p>
+
+
+<p><b>How would you treat herpes zoster?</b></p>
+
+<p><i>Constitutional treatment</i>, usually tonic in character, is to be based
+upon general principles; moderate doses of quinia, with one-sixth
+grain of zinc phosphide, four or five times daily, appear in some
+cases to have a special value. The accompanying neuralgic pain
+may be so intense as to require anodynes.</p>
+
+<p><i>Local treatment</i> should be of a soothing and protective
+<span class='pagenum'><a name='Page_83' id='Page_83'></a><a href='#TOC'>[Pg 83]</a></span>
+character. A dusting-powder of oxide of zinc and starch (to the ounce
+of which twenty to thirty grains of camphor may be added) proves
+useful; and over this, in order that the parts be further protected,
+a bandage or a layer of cotton batting. Oxide-of-zinc ointment,
+and in those cases in which there is much pain, ointments containing
+powdered opium or belladonna, or orthoform, may be used. A
+mild galvanic current applied daily to the parts is often of great
+advantage, both in its influence upon the course of the eruption and
+upon the neuralgic pain. The plan, so often advised, of painting
+the parts with flexible collodion is not to be commended.</p>
+
+<h2><a name='Dermatitis_Herpetiformis' id='Dermatitis_Herpetiformis'></a><b>Dermatitis Herpetiformis.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis (Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)</p>
+
+
+<p><b>Give a definition of dermatitis herpetiformis.</b></p>
+
+<p>Dermatitis herpetiformis is a somewhat rare inflammatory disease,
+characterized by an eruption of an erythematous, papular, vesicular,
+pustular, bullous or mixed type, with a decided disposition toward
+grouping, accompanied by itching and burning sensations, with, as
+a rule, more or less consequent pigmentation, and pursuing usually
+a chronic course with remissions.</p>
+
+
+<p><b>Describe the erythematous type of dermatitis herpetiformis.</b></p>
+
+<p>The character of the eruption in the erythematous type resembles
+closely that of erythema multiforme and of urticaria, especially the
+former. The efflorescences usually make their appearance in crops,
+and are more or less persistent; fading sooner or later, however, and
+giving place to new outbreaks. Vesicles are often intermingled,
+developing from erythematous and erythemato-papular lesions or
+arising from apparently normal skin.</p>
+
+<p>It may continue in the same type, or change to the vesicular, bullous
+or other variety.</p>
+
+
+<p><b>Describe the papular type of dermatitis herpetiformis.</b></p>
+
+<p>This is rarely seen as consisting purely of papular lesions, but is commonly
+associated with the erythematous and vesicular varieties. In
+a measure it resembles the papular manifestations of erythema multiforme,
+with a distinct disposition toward group formation. The
+<span class='pagenum'><a name='Page_84' id='Page_84'></a><a href='#TOC'>[Pg 84]</a></span>
+papules tend, sooner or later, to develop into vesicles, new papular
+outbreaks occurring from time to time; or the whole eruption
+changes to the vesicular or other type of the disease. It is not a
+common type.</p>
+
+
+<p><b>Describe the vesicular type of dermatitis herpetiformis.</b></p>
+
+<p>This is the common clinical type of the disease, and is characterized
+by pin-head to pea-sized, rounded or irregularly-shaped, distended
+or flattened and stellate vesicles, occurring, for the most part,
+in irregular and segmental groups of three or more lesions, seated
+either upon apparently normal integument or upon hyper&aelig;mic
+or inflammatory skin. They exhibit no tendency to spontaneous
+rupture, but after remaining a shorter or longer time, are broken or
+disappear by absorption. The lesions tend to appear in crops. It may,
+as it not infrequently does, continue in the same type, or it may
+become more or less erythematous or bullous in character. In not a
+few instances pustules, few or in numbers, are at times intermingled.</p>
+
+
+<p><b>Describe the pustular type of dermatitis herpetiformis.</b></p>
+
+<p>This is rare. It is similar in its clinical characters to the vesicular
+type, except that the lesions are pustular. It is met with, as a rule,
+in association with the vesicular and bullous varieties of the disease.</p>
+
+
+<p><b>Describe the bullous type of dermatitis herpetiformis.</b></p>
+
+<p>The bullous expression of the disease is usually of a markedly
+inflammatory nature, often innumerable blebs, small and large,
+appearing almost continuously, and in some instances involving the
+greater part of the surface. The lesions arise from erythematous
+skin, from pre&euml;xisting vesicles or vesicular groups, or from apparently
+normal integument. There is a marked disposition to appear
+in clusters. A change of type to the erythematous or vesicular
+varieties is not unusual.</p>
+
+
+<p><b>Describe the mixed type of dermatitis herpetiformis.</b></p>
+
+<p>In this type the eruption is made up of erythematous patches,
+vesicles, bull&aelig;, and often with pustules intermingled, appearing
+irregularly or in crops, and with a tendency to patch or group formation.</p>
+
+
+<p><b>Describe the characters of the vesicles, pustules and blebs.</b></p>
+
+<p>As a rule, these several lesions, especially the vesicles and blebs,
+are somewhat peculiar: they are usually of a strikingly irregular
+<span class='pagenum'><a name='Page_85' id='Page_85'></a><a href='#TOC'>[Pg 85]</a></span>
+outline, oblong, stellate, quadrate, and when drying are apt to have
+a puckered appearance. They are herpetic in that they show little
+disposition to spontaneous rupture, occur in groups, and are usually
+seated upon erythematous or inflammatory skin&mdash;in some respects
+similar to the groups of simple herpes and herpes zoster.</p>
+
+
+<p><b>What is to be said in regard to the subjective symptoms?</b></p>
+
+<p>The subjective symptoms are usually the most troublesome feature
+of the disease, consisting of intense and persistent itching and a
+feeling of heat and burning.</p>
+
+
+<p><b>Are there any constitutional symptoms in dermatitis herpetiformis?</b></p>
+
+<p>As a rule, not, excepting the distress and depression necessarily
+consequent upon the intense itchiness and loss of sleep. In the
+pustular and bullous varieties there may be mild or grave systemic
+symptoms, but even in these types the constitutional involvement
+is, in most instances, slight in comparison to the intensity of the
+cutaneous disturbance.</p>
+
+
+<p><b>What is the course of dermatitis herpetiformis?</b></p>
+
+<p>Extremely chronic, in most instances lasting, with remissions,
+indefinitely. The skin is rarely entirely free. From time to time
+the type of the disease may undergo change. From the continued
+irritation and scratching more or less pigmentation results.</p>
+
+
+<p><b>What is to be said in regard to the etiology?</b></p>
+
+<p>The disease is in many instances essentially neurotic, and in exceptional
+instances septic&aelig;mic. Pregnancy and the parturient state are
+factors in some instances (so-called herpes gestationis). It is possible
+in some instances that the eruption may be an expression of a
+mild toxemia of gastro-intestinal origin. In some cases no cause
+can be assigned. In the majority of patients the general health,
+considering the violence of the eruptive phenomena, remains comparatively
+undisturbed.</p>
+
+<p>Nervous shock and mental worry are factors in some cases.
+Polyuria, with sugar in the urine, has occasionally been noted.
+Eosinophile cells have been found both in the vesicles and the
+blood. In some instances&mdash;exceptionally, it is true&mdash;the disease has
+appeared shortly after vaccination.</p>
+
+
+<p><b>Mention the diagnostic features of dermatitis herpetiformis.</b></p>
+
+<p>The multiformity of the eruption, the characters of the lesions,
+<span class='pagenum'><a name='Page_86' id='Page_86'></a><a href='#TOC'>[Pg 86]</a></span>
+the disposition to grouping, the absence of tendency to form solid
+sheets of eruption (as in eczema), the intense itching, history,
+chronicity and course. In doubtful cases, an observation of several
+weeks will always suffice to distinguish it from eczema, erythema
+multiforme, herpes iris and pemphigus, diseases to which it at times
+bears strong resemblance.</p>
+
+
+<p><b>Give the prognosis of dermatitis herpetiformis.</b></p>
+
+<p>An opinion as to the outcome of the disease should be guarded.
+It is exceedingly rebellious to treatment, and relapses are the rule.
+Exceptionally the bullous and pustular varieties prove eventually
+fatal. The erythematous and vesicular varieties are the most
+favorable.</p>
+
+
+<p><b>State the treatment to be advised.</b></p>
+
+<p>There are no special remedies. Constitutional treatment must be
+conducted upon general principles. A free action of the bowels is
+to be maintained. In occasional instances arsenic in progressive
+doses seems of value. Externally protective and antipruritic applications,
+such as are employed in the treatment of eczema and pemphigus,
+are to be employed:&mdash;</p>
+
+<pre>
+  &#8478; Ac. carbolici, ................................... &#658;j-&#658;ij
+    Thymol, .......................................... gr. xvj.
+    Glycerin&aelig;, ....................................... &#8485;ss-&#8485;j
+    Alcoholis, ...................................... f&#8485;ij
+    Aqu&aelig;, q.s., .........ad........................... Oj.   M.
+</pre>
+
+<p>Other valuable applications are: lotions of carbolic acid, of liquor
+carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment
+and carbolized oxide-of-zinc ointment, and dusting-powders
+of starch, zinc oxide, talc and boric acid. A two- to ten-per-cent.
+ichthyol lotion or ointment is sometimes of advantage; thiol employed
+in the same manner has also been commended.</p>
+
+
+<h2><a name='Psoriasis' id='Psoriasis'></a><b>Psoriasis.</b></h2>
+
+
+<p><b>Give a definition of psoriasis.</b></p>
+
+<p>Psoriasis is a chronic, inflammatory disease, characterized by
+dry, reddish, variously-sized, rounded, sharply-defined, more or less
+infiltrated, scaly patches.</p>
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_087.jpg'>
+<img src='images/087.jpg' width='400' height='439'
+alt='Psoriasis.'
+title='Psoriasis.' />
+</a>
+</div>
+<p class='center'>Psoriasis.</p>
+
+<p><span class='pagenum'><a name='Page_87' id='Page_87'></a><a href='#TOC'>[Pg 87]</a></span></p>
+
+<p><b>At what age does psoriasis usually first make its appearance?</b></p>
+
+<p>Most commonly between the ages of fifteen and thirty. It is
+rarely seen before the tenth year, and a first attack is uncommon
+after the age of forty.</p>
+
+
+<p><b>Has psoriasis any special parts of predilection?</b></p>
+
+<p>The extensor surfaces of the limbs, especially the elbows and
+knees, are favorite localities, and even when the eruption is more or
+less general, these regions are usually most conspicuously involved.
+The face often escapes, and the palms and soles, likewise the nails,
+are rarely involved. In exceptional instances, the eruption is limited
+almost exclusively to the scalp.</p>
+
+
+<p><b>Are there any constitutional or subjective symptoms in
+psoriasis?</b></p>
+
+<p>There is no systemic disturbance; but a variable amount of itching
+may be present, although, as a rule, it is not a troublesome
+symptom.</p>
+
+
+<p><b>Describe the clinical appearances of a typical, well developed
+case.</b></p>
+
+<p>Twenty or a hundred or more lesions, varying in size from a pin-head
+to a silver dollar, are usually present. They are sharply
+defined against the sound skin, are reddish, slightly elevated and
+infiltrated, and more or less abundantly covered with whitish,
+grayish or mother-of-pearl colored scales. The patches are usually
+scattered over the general surface, but are frequently more numerous
+on the extensor surfaces of the arms and legs, especially about the
+elbows and knees. Several closely-lying lesions may coalesce and a
+large, irregular patch be formed; some of the patches, also, may be
+more or less circinate, the central portion having, in a measure or
+completely, disappeared.</p>
+
+
+<p><b>Give the development and history of a single lesion.</b></p>
+
+<p>Every single patch of psoriasis begins as a pin-point or pin-head-sized,
+hyper&aelig;mic, scaly, slightly-elevated lesion; it increases gradually,
+and in the course of several days or weeks usually reaches the size
+of a dime or larger, and then may remain stationary; or involution
+begins to take place, usually by a disappearance, partially or completely,
+of the central portion, and finally of the whole patch.
+<span class='pagenum'><a name='Page_88' id='Page_88'></a><a href='#TOC'>[Pg 88]</a></span></p>
+
+
+<p><b>Describe the so-called clinical varieties of psoriasis.</b></p>
+
+<p>As clinically met with, the patches present are, as a rule, in all
+stages of development. In some instances, however, the lesions, or
+the most of them, progress no further than pin-head in size, and
+then remain stationary, constituting <i>psoriasis punctata</i>; in other
+cases, they may stop short after having reached the size of drops&mdash;
+<i>psoriasis guttata</i>; in others (and this is the usual clinical type) the
+patches develop to the size of coins&mdash;<i>psoriasis nummularis</i>. In
+some cases there is a strong tendency for the central part of the
+lesions to disappear, and the process then remain stationary, the
+patches being ring-shaped&mdash;<i>psoriasis circinata</i>; and occasionally
+several such rings coalesce, the coalescing portions disappearing and
+the eruption be more or less serpentine&mdash;<i>psoriasis gyrata</i>. Or, in
+other instances, several large contiguous lesions may coalesce and a
+diffused, infiltrated patch covering considerable surface results&mdash;
+<i>psoriasis diffusa, psoriasis inveterata</i>.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 17.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_088.jpg'>
+<img src='images/088.jpg' width='400' height='378'
+alt='FIG. 17.'
+title='FIG. 17.' />
+</a>
+</div>
+
+<p class='center'>Psoriasis.</p>
+
+<p><span class='pagenum'><a name='Page_89' id='Page_89'></a><a href='#TOC'>[Pg 89]</a></span></p>
+
+
+<p><b>Is the eruption of psoriasis always dry?</b></p>
+
+<p>Yes.</p>
+
+
+<p><b>What course does psoriasis pursue?</b></p>
+
+<p>As a rule, eminently chronic. Patches may remain almost indefinitely,
+or may gradually disappear and new lesions appear elsewhere,
+and so the disease may continue for months and, sometimes, for
+years; or, after continuing for a longer or shorter period, may
+subside and the skin remain free for several months or one or two
+years, and, in rare instances, may never return.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 18.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_089.jpg'>
+<img src='images/089.jpg' width='400' height='366'
+alt='FIG. 18.'
+title='FIG. 18.' />
+</a>
+</div>
+<p class='center'>Psoriasis.</p>
+
+
+<p><b>Is the course of psoriasis influenced by the seasons?</b></p>
+
+<p>As a rule, yes; there is a natural tendency for the disease to
+become less active or to disappear altogether during the warm
+months.
+<span class='pagenum'><a name='Page_90' id='Page_90'></a><a href='#TOC'>[Pg 90]</a></span></p>
+
+
+<p><b>What is known in regard to the etiology of psoriasis?</b></p>
+
+<p>The causes of the disease are always more or less obscure. There
+is often a hereditary tendency, and the gouty and rheumatic diathesis
+must occasionally be considered potential. In some instances it is
+apparently influenced by the state of the general health. It is a rather
+common disease and is met with in all walks of life.</p>
+
+
+<p><b>Is psoriasis contagious?</b></p>
+
+<p>No. In recent years the fact of its exhibiting a family tendency
+has been thought as much suggestive of contagiousness as of heredity.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>According to modern investigations, it is an inflammation induced
+by hyperplasia of the rete mucosum; and it is beginning to be believed
+that this hyperplasia may have a parasitic factor as the starting-cause.</p>
+
+
+<p><b>With what diseases are you likely to confound psoriasis?</b></p>
+
+<p>Chiefly with squamous eczema and the papulo-squamous syphiloderm;
+and on the scalp, also with seborrh&oelig;a. It can scarcely be
+confounded with ringworm.</p>
+
+
+<p><b>How is psoriasis to be distinguished from squamous eczema?</b></p>
+
+<p>By the sharply-defined, circumscribed, scattered, scaly patches, and
+by the history and course of the individual lesions.</p>
+
+
+<p><b>In what respects does the papulo-squamous syphiloderm differ
+from psoriasis?</b></p>
+
+<p>The scales of the squamous syphilide are usually dirty gray in
+color and more or less scanty; the patches are coppery in hue, and
+usually several or more characteristic scaleless, infiltrated papules are
+to be found. The face, palms, and soles are often the seat of the syphilitic
+eruption; and, moreover, <i>concomitant symptoms of syphilis</i>,
+such as sore throat, mucous patches, glandular enlargement, rheumatic
+pains, falling out of the hair, together with the history of the
+initial lesion, are one, several, or all usually present.</p>
+
+
+<p><b>How does seborrh&oelig;a differ from psoriasis?</b></p>
+
+<p>Seborrh&oelig;a of the scalp is usually diffused, with but little redness
+and no infiltration; moreover, the scales of seborrh&oelig;a are greasy,
+dirty gray or brownish, while those of psoriasis are dry and
+<span class='pagenum'><a name='Page_91' id='Page_91'></a><a href='#TOC'>[Pg 91]</a></span>
+commonly whitish or mother-of-pearl colored. Psoriasis of the scalp
+rarely exists independently of other patches elsewhere on the general
+surface.</p>
+
+<p>That variety of seborrh&oelig;a, commonly known as eczema seborrhoicum,
+presents at times, both on scalp and general surface, a strong
+resemblance to psoriasis, but the character of the scales and distribution
+of psoriasis, as above stated, are distinguishing points;
+seborrh&oelig;a, moreover, favors hairy surfaces and in extensive examples
+the scalp, eyebrows, sternal, and pubic regions rarely escape.</p>
+
+
+<p><b>How does psoriasis differ from ringworm?</b></p>
+
+<p>By its greater scaliness, by its higher degree of inflammatory
+action, and by its larger number of patches, as also by its history. In
+ringworm <i>all</i> the patches tend to clear up in the centre; in psoriasis
+this is rarely, if ever, so. If there is still any doubt, microscopic
+examination of the scrapings will determine.</p>
+
+
+<p><b>Give the prognosis of psoriasis.</b></p>
+
+<p>The prognosis is usually favorable, so far as concerns the immediate
+eruption, but as to recurrences, nothing positive can be stated.
+In rare instances, however, the cure remains permanent.</p>
+
+
+<p><b>How is psoriasis treated?</b></p>
+
+<p>Both constitutional and local remedies are demanded in most
+cases.</p>
+
+
+<p><b>Do dietary measures exert any influence?</b></p>
+
+<p>As a rule, no; but the food should be plain, and an excess of
+meat avoided.</p>
+
+
+<p><b>Name the important constitutional remedies usually employed
+in psoriasis.</b></p>
+
+<p><i>Arsenic</i> is of first importance. It is not suitable in acute or
+markedly inflammatory types; but is most useful in the sluggish,
+chronic forms of the disease. The dose should never be pushed
+beyond slight physiological action. It may be given as arsenious
+acid in pill form, one-fiftieth to one-tenth of a grain three times
+daily, or as Fowler's solution, three to ten minims at a dose.</p>
+
+<p><i>Alkalies</i>, of which liquor potass&aelig; is the most eligible. It is to be
+given in ten to twenty minim doses, largely diluted. It is valuable
+<span class='pagenum'><a name='Page_92' id='Page_92'></a><a href='#TOC'>[Pg 92]</a></span>
+in robust, plethoric, rheumatic or gouty individuals with psoriasis of
+an acute or markedly inflammatory type; it is not to be given to
+debilitated or an&aelig;mic subjects.</p>
+
+<p><i>Salicin</i>, sodium salicylate, and salophen in moderately full doses
+act well in some cases. Occasionally thyroid preparations have a
+good effect.</p>
+
+<p><i>Potassium Iodide</i>, in doses of thirty to one hundred grains, t.d.,
+acts favorably in some instances; there are no special indications
+pointing toward its selection, unless it be the existence of a gouty or
+rheumatic diathesis.</p>
+
+<p>Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper,
+and other diuretics are valuable in some instances, and, while often
+failing, sometimes exert a rapid influence, especially in those cases
+in which the disease is extensive and inflammatory. Wine of antimony,
+given cautiously, is also sometimes of service in the acute
+inflammatory type in robust subjects.</p>
+
+
+<p><b>Are such remedies as iron, quinine, nux vomica and cod-liver
+oil ever useful in psoriasis?</b></p>
+
+<p>Yes. In debilitated subjects the administration of such remedies
+is at times attended with improvement in the cutaneous eruption.</p>
+
+
+<p><b>What are the indications as regards the external measures?</b></p>
+
+<p>Removal of the scales, and the use of soothing or stimulating
+applications, according to the individual case.</p>
+
+
+<p><b>How are the scales removed?</b></p>
+
+<p>In ordinary cases, either by warm, plain, or alkaline baths, or hot-water-and-soap
+washings; in those cases in which the scaling is
+abundant and adherent, washing with sapo viridis and hot water
+may be required. Baths of sal ammoniac, two to six ounces to the
+bath are also valuable in removing the scaliness. The tincture of
+green soap (tinctura saponis viridis) is especially valuable for cleansing
+purposes in psoriasis of the scalp. The hot vapor bath once or
+twice weekly is serviceable in keeping the scaliness in abeyance, and
+has, moreover, in some cases, a therapeutic value.</p>
+
+<p>The frequency of the baths or washings will depend upon the
+rapidity with which the scales are reproduced.
+<span class='pagenum'><a name='Page_93' id='Page_93'></a><a href='#TOC'>[Pg 93]</a></span></p>
+
+
+<p><b>Are soothing applications often demanded in psoriasis?</b></p>
+
+<p>In exceptional cases; in those in which the disease is acute,
+markedly inflammatory and rapidly progressing, mild, soothing applications
+must be temporarily employed, such as plain or bran baths,
+with the use of some bland oil or ointment. As a rule, however,
+the conditions, when coming under observation, are such as to permit
+of stimulating applications from the start. The most efficient soothing
+applications are the mild lotions and ointments employed in
+eczema of acute type.</p>
+
+
+<p><b>How are the stimulating remedies employed in psoriasis applied?</b></p>
+
+<p>As ointments, oils, and paints (pigmenta).</p>
+
+<p>An ointment, if employed, is to be thoroughly rubbed in the diseased
+areas once or twice daily. The same may be said of the oily
+applications. The paints (medicated collodion and gutta-percha
+solution) are applied with a brush, once daily, or every second or
+third day, depending mainly upon the length of time the film
+remains intact and adherent.</p>
+
+
+<p><b>Name the several important external remedies.</b></p>
+
+<p>Chrysarobin, pyrogallol, tar, ammoniated mercury, &beta;-naphthol,
+and resorcin.</p>
+
+
+<p><b>Are these several external remedies equally serviceable in all cases?</b></p>
+
+<p>No. Their action differs slightly or greatly according to the case
+and individual. A change from one to another is often necessary.</p>
+
+
+<p><b>In what forms and strength are these remedies to be applied?</b></p>
+
+<p><i>Chrysarobin</i> is applied in several ways: as an ointment, twenty
+to sixty grains to the ounce, rubbed in once or twice daily; this is
+the most rapid but least cleanly and eligible method. As a pigment,
+or paint, as in the following:&mdash;</p>
+
+<pre>
+  &#8478; Chrysarobini, .................................... &#658;j
+    Acidi salicylici, ................................ gr. xx
+    Etheris, ........................................ f&#658;j
+    Ol. ricini, ...................................... &#9807;x
+    Collodii, ....................................... f&#658;vij.   M.
+</pre>
+
+
+
+<p><span class='pagenum'><a name='Page_94' id='Page_94'></a><a href='#TOC'>[Pg 94]</a></span>
+Or it may be used in liquor gutta-perch&aelig; (traumaticin), a drachm to
+the ounce. It may also be employed in chloroform, a drachm to the
+ounce; this is painted on, the chloroform evaporating, leaving a thin
+film of chrysarobin; over this is painted flexible collodion. If the
+patches are few and large, chrysarobin rubber-plaster may be used.</p>
+
+<p>Chrysarobin is usually rapid in its effect, but it has certain disadvantages;
+it may cause an inflammation of the surrounding skin,
+and, if used near the eyes, may give rise to conjunctivitis. As a
+rule, it should not be employed about the head. Moreover, it stains
+the linen permanently and the skin temporarily.</p>
+
+<p><i>Pyrogallol</i> is valuable, and is employed in the same manner and
+strength as chrysarobin. In collodion it should at first not be used
+of greater strength than three to four per cent., as in this form pyrogallol
+sometimes acts with unexpected energy. It is less rapid than
+chrysarobin, but it rarely inflames the surrounding integument. It
+stains the linen a light brown, however, and is not to be used over
+an extensive surface for fear of absorption and toxic effect. Oxidized
+pyrogallic acid, a somewhat milder drug in its effect, has
+been highly commended, and has the alleged advantage of being
+free from toxic action.</p>
+
+<p><i>Tar</i> is, all things considered, the most important external remedy.
+It is comparatively slow in its action, but is useful in almost all
+cases. As employed usually it is prescribed in ointment form, either
+as the official tar ointment, full strength or weakened with lard or
+petrolatum. It may also be used as pix liquida, with equal part of
+alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch (ol.
+rusci) may be employed, either as oily applications or incorporated
+with ointment or with alcohol. Liquor carbonis detergens, in ointment,
+one to three drachms to the ounce of simple cerate and
+lanolin is a mild tarry application which is often useful. In stubborn
+patches an occasional thorough rubbing with a mixture of
+equal parts of liquor carbonis detergens and Vleminckx's solution,
+followed by a mild ointment, sometimes proves of value. In whatsoever
+form tar is employed it should be thoroughly rubbed in, once
+or twice daily, the excess wiped off, and the parts then dusted with
+starch or similar powder.</p>
+
+<p><i>Ammoniated mercury</i> is applied in ointment form, twenty to sixty
+grains to the ounce. Compared to other remedies it is clean and
+free from staining, although, as a rule, not so uniformly efficacious.
+<span class='pagenum'><a name='Page_95' id='Page_95'></a><a href='#TOC'>[Pg 95]</a></span>
+It is especially useful for application to the scalp and exposed parts.
+It should not be used over extensive surface for fear of absorption.</p>
+
+<p><i>&beta;-Naphthol</i> and <i>resorcin</i> are applied as ointments, thirty to sixty
+grains to the ounce, and as they are (especially the former) practically
+free from staining, may be used for exposed surfaces.</p>
+
+<p>Gallacetophenone and aristol also act well in some cases, applied
+in five- to ten-per-cent. strength, as ointments.</p>
+
+<p>In obstinate patches the <i>x</i>-ray may be resorted to, employing it
+with caution and in the same manner as in other diseases.</p>
+
+
+<h2><a name='Pityriasis_Rosea' id='Pityriasis_Rosea'></a><b>Pityriasis Rosea.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Pityriasis Maculata et Circinata.)</p>
+
+
+<p><b>What do you understand by pityriasis rosea?</b></p>
+
+<p>Pityriasis rosea is a disease of a mildly inflammatory nature, characterized
+by discrete, and later frequently confluent, variously sized,
+slightly raised scaly macules of a pinkish to rosy-red, often salmon-tinged,
+color.</p>
+
+
+<p><b>Upon what part of the body is the eruption usually found?</b></p>
+
+<p>The trunk is the chief seat of the eruption, although not infrequently
+it is more or less general.</p>
+
+
+<p><b>Describe the symptoms of pityriasis rosea</b>.</p>
+
+<p>The lesions, which appear rapidly or slowly, are but slightly
+elevated, somewhat scaly, usually rounded, except when several coalesce,
+when an irregularly outlined patch results. At first they are
+pale or bright pink or reddish, later a salmon tint (which is often
+characteristic) is noticed. The scaliness is bran-like or flaky, of a
+dirty gray color, and, as a rule, less marked in the central portion; it
+is never abundant. The skin is rarely thickened, the process being
+usually exceedingly superficial.</p>
+
+
+<p><b>What course does pityriasis rosea pursue?</b></p>
+
+<p>The eruption makes its appearance, as a rule, somewhat rapidly,
+usually attaining its full development in the course of one or two
+weeks, and then begins gradually to decline, the whole process occupying
+one or two months.</p>
+
+
+<p><b>To what is pityriasis rosea to be attributed?</b></p>
+
+<p>The cause is not known; it is variously considered as allied to
+seborrh&oelig;a (eczema seborrhoicum), as being of a vegetable-parasitic
+<span class='pagenum'><a name='Page_96' id='Page_96'></a><a href='#TOC'>[Pg 96]</a></span>
+origin, and as a mildly inflammatory affection somewhat similar to
+psoriasis. It is not a frequent disease.</p>
+
+
+<p><b>How is pityriasis rosea distinguished from ringworm, psoriasis
+and the squamous syphiloderm?</b></p>
+
+<p>From ringworm, by its rapid appearance, its distribution, the
+number of patches, and, if necessary, by microscopic examination
+of the scrapings.</p>
+
+<p>Psoriasis is a more inflammatory disease, is seen usually more
+abundantly upon the limbs, the scales are profuse and silvery, and
+the underlying skin is red and has a glazed look; moreover, psoriasis,
+as a rule, appears slowly and runs a chronic course.</p>
+
+<p>The squamous syphiloderm differs in its history, distribution, and
+above all, by the presence of concomitant symptoms of syphilis, such
+as glandular enlargement, sore throat, mucous patches, rheumatic
+pains, and falling out of the hair.</p>
+
+
+<p><b>State the prognosis of pityriasis rosea.</b></p>
+
+<p>It is favorable, the disease tending to spontaneous disappearance,
+usually in the course of several weeks or one or two months.</p>
+
+
+<p><b>What treatment is to be advised in pityriasis rosea?</b></p>
+
+<p>Laxatives and intestinal antiseptics, and ointments of salicylic
+acid (5-15 grains to the ounce), of sulphur (10-40 grains to the
+ounce); or a compound ointment containing both these ingredients
+can be prescribed. The ointment base can be equal parts of white
+vaselin and cold cream; in some instances Lassar's paste (starch
+powder, zinc oxid powder, each, &#658;ij; vaselin, &#658;iv) seems more satisfactory.</p>
+
+
+<h2><a name='Dermatitis_Exfoliativa' id='Dermatitis_Exfoliativa'></a><b>Dermatitis Exfoliativa.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> General Exfoliative Dermatitis; Recurrent Exfoliative Dermatitis; Desquamative Scarlatiniform Erythema; Acute General Dermatitis; Recurrent Exfoliative Erythema; Pityriasis Rubra.)</p>
+
+
+<p><b>Describe dermatitis exfoliativa.</b></p>
+
+<p>Dermatitis exfoliativa is an inflammatory disease of an acute type,
+characterized by a more or less general erythematous inflammation,
+in exceptional instances vesicular or bullous, with epidermic desquamation
+or exfoliation accompanying or following its development.
+Constitutional disturbance, which may be of a serious character, is
+<span class='pagenum'><a name='Page_97' id='Page_97'></a><a href='#TOC'>[Pg 97]</a></span>
+sometimes present. It is a rare and obscure affection, running its
+course usually in several weeks or months, but exhibiting a decided
+tendency to relapse and recurrence. In many cases it is persistently
+chronic, with exacerbations and remissions. In some instances it
+develops from a long-continued and more or less generalized eczema
+or psoriasis, and in exceptional cases it is started by the careless use
+of mercurial ointment and of chrysarobin ointment.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 19.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_097.jpg'>
+<img src='images/097.jpg' width='400' height='239'
+alt='FIG. 19.'
+title='FIG. 19.' />
+</a>
+</div>
+
+<p class='center'>Dermatitis Exfoliativa.</p>
+
+
+<p>In another type of the disease, formerly described as <i>pityriasis
+rubra</i>, the skin is pale red or violaceous-red, but is rarely thickened,
+continued exfoliation in the form of thin plates taking place. Its
+course is variable, lasting for years, with remissions.</p>
+
+<p>An exfoliating generalized dermatitis is exceptionally observed in
+the first weeks of life (<i>dermatitis exfoliativa neonatorum</i>), lasting
+some weeks, and in most cases followed by recovery. There are no
+special constitutional symptoms, the fatal cases usually dying of
+marasmus.</p>
+
+<p>As will be seen dermatitis exfoliativa varies considerably in degree;
+it may be extremely mild, resembling in appearance the scarlet-fever
+eruption (erythema scarlatiniforme) and running a rapid
+course; or the skin-condition and the systemic symptoms may be
+of grave and persistent character.
+<span class='pagenum'><a name='Page_98' id='Page_98'></a><a href='#TOC'>[Pg 98]</a></span></p>
+
+
+<p><b>Give the treatment of dermatitis exfoliativa.</b></p>
+
+<p>General treatment is based upon indications, and externally soothing
+applications, such as are employed in acute and subacute eczema,
+are to be used.</p>
+
+
+<h2><a name='Lichen_Planus' id='Lichen_Planus'></a><b>Lichen Planus.</b></h2>
+
+
+<p><b>What is lichen planus?</b></p>
+
+<p>Lichen planus is an inflammatory disease characterized by small,
+flat and angular, smooth and shining, or scaly, discrete or confluent,
+red or violaceous-red papules, having a distinctly papular or papulo-squamous
+course, and attended with more or less itching.</p>
+
+
+<p><b>Describe the symptoms of lichen planus</b>.</p>
+
+<p>The eruption, as a rule, begins slowly, usually showing itself upon
+the extremities; the forearms, wrists and legs being favorite localities.
+It may appear as one or more groups or in the form of short
+or long bands. Occasionally its evolution is rapid and a considerable
+part of the surface may be invaded. The lesions are pin-head to
+small pea-sized, irregularly grouped or so closely crowded together
+as to form solid patches; they are quadrangular or polygonal in
+shape, usually flat, with central depression or umbilication, and are
+reddish or violaceous in color. At first they have a glazed or shining
+appearance; later, becoming slightly scaly, the scaliness being
+more marked where solid patches have resulted. New papules may
+appear from time to time, the older lesions disappearing and leaving
+persistent reddish or brownish pigmentation. Exceptionally the
+eruption presents in bands or lines, like rows of beads (<i>lichen moniliformis</i>).
+Very exceptionally a vesicular or bleb tendency in some
+of the lesions has been noted; doubtless, in most instances at least,
+this has been due to the arsenic so generally administered in this
+disease. In rare instances lichen planus lesions are also seen on the
+glans penis and on the buccal mucous membrane. In some cases,
+especially in the region of the ankle, the papules become quite large
+(<i>lichen planus hypertrophicus</i>), and in occasional cases there is a
+tendency in some of the lesions or patches to clear up centrally.
+There is, as a rule, considerable itching. There are no constitutional
+symptoms.</p>
+
+
+<p><b>What is the etiology of lichen planus?</b></p>
+
+<p>In some cases the disease is distinctly neurotic in character, in
+others no cause can be assigned. It is more especially met with at
+<span class='pagenum'><a name='Page_99' id='Page_99'></a><a href='#TOC'>[Pg 99]</a></span>
+middle age, and among the wealthier, professional, and luxurious
+classes.</p>
+
+<p>Pathologically the first change noted in the epidermis is thought
+to be an acanthosis, followed by epithelial atrophy, and a hyperkeratosis,
+intercellular edema, and colloid degeneration of the
+prickle cells.</p>
+
+
+<p><b>Does the disease bear any resemblance to the miliary papular
+syphilide, psoriasis, and papular eczema?</b></p>
+
+<p>In some instances it does, but the irregular and angular outline,
+the slightly-umbilicated, flattened, smooth or scaly summits, and the
+dull-red or violaceous color, the history and course, of lichen planus,
+will serve to differentiate.</p>
+
+
+<p><b>State the prognosis.</b></p>
+
+<p>Under proper management the eruption, although often obstinate,
+yields to treatment.</p>
+
+
+<p><b>What treatment would you prescribe in lichen planus?</b></p>
+
+<p>A general tonic plan of medication is indicated in most cases, with
+such remedies as iron, quinine, nux vomica, and cod-liver oil and
+other nutrients. In many instances arsenic exerts a special influence,
+and should always be tried. Mercurials in moderate dosage
+have also a favorable action in most cases. Locally, antipruritic
+and stimulating applications, such as are used in the treatment of
+eczema, are to be employed, alkaline baths and tarry applications
+deserving special mention. Liquor carbonis detergens, applied
+weakened with several parts water, is a valuable application. In
+some cases, particularly if the disease is limited, external applications
+alone often suffice to bring about a cure.</p>
+
+
+<h2><a name='Pityriasis_Rubra_Pilaris' id='Pityriasis_Rubra_Pilaris'></a><b>Pityriasis Rubra Pilaris.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Lichen Ruber; Lichen Ruber Acuminatus.)</p>
+
+
+<p><b>Describe pityriasis rubra pilaris.</b></p>
+
+<p>Pityriasis rubra pilaris is an extremely rare disease, usually of a
+mildly inflammatory nature, characterized by grayish, pale-red or
+reddish-brown follicular papules with somewhat hard or horny
+centres; discrete and confluent, and covering a part or the entire
+surface. The skin is harsh, dry and rough, feeling to the touch
+somewhat like the surface of a nutmeg-grater or a coarse file. More
+<span class='pagenum'><a name='Page_100' id='Page_100'></a><a href='#TOC'>[Pg 100]</a></span>
+or less scaliness is usually present in the confluent patches and on
+the palms and soles; in these latter regions the papules are rarely
+seen. The duration of the disease is variable, and relapses are
+common. It bears resemblance at times to keratosis pilaris, ichthyosis,
+dermatitis exfoliativa; it is considered identical with the lichen
+ruber acuminatus of Kaposi, and by many also with the lichen ruber
+of Hebra. The etiology is obscure.</p>
+
+<p>Treatment, both constitutional and local, is to be based upon
+general principles; stimulating applications, with frequent baths,
+such as are advised in psoriasis, are the most satisfactory. It is
+rebellious, and not much more than palliation can be effected in
+some cases, in others the outlook is more hopeful.</p>
+
+
+<h2><a name='Lichen_Scrofulosus' id='Lichen_Scrofulosus'></a><b>Lichen Scrofulosus.</b></h2>
+
+
+<p><b>Describe lichen scrofulosus.</b></p>
+
+<p>Lichen scrofulosus is a chronic, inflammatory disease, characterized
+by millet-seed-sized, rounded or flat, reddish or yellowish, more or
+less grouped, desquamating papules. The lesions have their start
+about the hair-follicles, occur usually upon the trunk, tend to group
+and form patches, and sooner or later become covered with minute
+scales. As a rule, there is no itching. It is a rare disease, and
+but seldom met with in America; it is seen chiefly in children and
+young people of a scrofulous diathesis. Scarring, slight in character,
+may or may not follow.</p>
+
+
+<p><b>What is the treatment of lichen scrofulosus?</b></p>
+
+<p>The condition responds to tonics and anti-strumous remedies.</p>
+
+
+<h2><a name='Eczema' id='Eczema'></a><b>Eczema.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Tetter; Salt Rheum.)</p>
+
+
+<p><b>What is eczema?</b></p>
+
+<p>An acute, subacute or chronic inflammatory disease, characterized
+in the beginning by the appearance of erythema, papules, vesicles or
+pustules, or a combination of these lesions, with a variable amount
+of infiltration and thickening, terminating either in discharge with
+the formation of crusts, in absorption, or in desquamation, and
+accompanied by more or less intense itching and a feeling of heat or
+burning.
+<span class='pagenum'><a name='Page_101' id='Page_101'></a><a href='#TOC'>[Pg 101]</a></span></p>
+
+<p><b>What are the several primary types of eczema?</b></p>
+
+<p>Erythematous, papular, vesicular and pustular; all cases begin as
+one or more of these types, but not infrequently lose these characters
+and develop into the common clinical or secondary types&mdash;eczema
+rubrum and eczema squamosum.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 20.</b></p>
+<div class='figcenter' style='width: 275px;'>
+<a href='images/fullsize_101.jpg'>
+<img src='images/101.jpg' width='275' height='600'
+alt='FIG. 20.'
+title='FIG. 20.' />
+</a>
+</div>
+<p class='center'>Papular Eczema (leg).</p>
+
+<p><b>What other types are met with clinically?</b></p>
+
+<p>Eczema rubrum, eczema squamosum, eczema fissum, eczema sclerosum
+and eczema verrucosum. Eczema seborrhoicum is probably
+a closely allied disease, occupying a middle position between ordinary
+eczema and seborrh&oelig;a.
+<span class='pagenum'><a name='Page_102' id='Page_102'></a><a href='#TOC'>[Pg 102]</a></span></p>
+
+
+<p><b>Describe the symptoms of erythematous eczema.</b></p>
+
+<p>Erythematous eczema (<i>eczema erythematosum</i>) begins as one or
+more small or large, irregularly outlined hyper&aelig;mic macules or
+patches, with or without slight or marked swelling, and with more
+or less itching or burning. At first it may be ill-defined, but it
+tends to spread and its features to become more pronounced. It
+may be limited to a certain region, or it may be more or less general.
+When fully developed, the skin is harsh and dry, of a mottled, reddish
+or violaceous color, thickened, infiltrated and usually slightly
+scaly, with, at times, a tendency toward the formation of oozing
+areas. Punctate and linear scratch-marks may usually be seen scattered
+over the affected region.</p>
+
+<p>Its most common site is the face, but it is not infrequent upon
+other parts.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 21.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_102.jpg'>
+<img src='images/102.jpg' width='400' height='290'
+alt='FIG. 21.'
+title='FIG. 21.' />
+</a>
+</div>
+<p class='center'>Eczema Rubrum.</p>
+
+
+
+<p><b>What course does erythematous eczema pursue?</b></p>
+
+<p>It tends to chronicity, continuing as the erythematous form, or
+the skin may become considerably thickened and markedly scaly,
+<span class='pagenum'><a name='Page_103' id='Page_103'></a><a href='#TOC'>[Pg 103]</a></span>
+constituting eczema squamosum; or a moist oozing surface, with
+more or less crusting, may take its place&mdash;eczema rubrum.</p>
+
+<p><b>Describe the symptoms of papular eczema.</b></p>
+
+<p>Papular eczema (<i>eczema papulosum</i>) is characterized by the appearance,
+usually in numbers, of discrete, aggregated or closely-crowded,
+reddish, pin-head-sized acuminated or rounded papules.
+Vesicles and vesico-papules are often intermingled. The itching is
+commonly intense, as often attested by the presence of scratch-marks
+and blood crusts.</p>
+
+<p>It is seen most frequently upon the extremities, especially the
+flexor surfaces.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 22.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_103.jpg'>
+<img src='images/103.jpg' width='400' height='324'
+alt='FIG. 22.'
+title='FIG. 22.' />
+</a>
+</div>
+
+<p class='center'>Eczema Squamosum et tissum.</p>
+
+
+<p><b>What course does papular eczema pursue?</b></p>
+
+<p>The lesions tend, sooner or later, to disappear, but are usually replaced
+by others, the disease thus persisting for weeks or months;
+in places where closely crowded, a solid, thickened, scaly sheet of
+eruption may result&mdash;eczema squamosum.
+<span class='pagenum'><a name='Page_104' id='Page_104'></a><a href='#TOC'>[Pg 104]</a></span></p>
+
+
+<p><b>Describe the symptoms of vesicular eczema</b>.</p>
+
+<p>Vesicular eczema (<i>Eczema vesiculosum</i>) usually appears, on one
+or several regions, as more or less diffused inflammatory reddened
+patches, upon which rapidly develop numerous closely-crowded
+pin-point to pin-head-sized vesicles, which tend to become
+confluent and form a solid sheet of eruption. The vesicles soon
+mature and rupture, the discharge drying to yellowish, honeycomb-like
+crusts. The oozing is usually more or less continuous, or the
+disease may decline, the crusts be cast off, to be quickly followed by
+a new crop of vesicles. In those cases in which the process is
+markedly acute, considerable swelling and &oelig;dema are present.
+Scattered papules, vesico-papules and pustules may usually be seen
+upon the involved area or about the border.</p>
+
+<p>The face in infants (<i>crusta lactea</i>, or <i>milk crust</i>, of older writers),
+the neck, flexor surfaces and the fingers are its favorite localities.</p>
+
+
+<p><b>What course does vesicular eczema pursue?</b></p>
+
+<p>Usually chronic, with acute exacerbations. Not infrequently it
+passes into eczema rubrum.</p>
+
+
+<p><b>Describe the symptoms of pustular eczema.</b></p>
+
+<p>Pustular eczema (<i>eczema pustulosum, eczema impetiginosum</i>) is
+probably the least common of all the varieties. It is similar,
+although usually less actively inflammatory, in its symptoms to eczema
+vesiculosum, the lesions being pustular from the start or developing
+from pre&euml;xisting vesicles; not infrequently the eruption is mixed,
+the pustules predominating. There is a marked tendency to rupturing
+of the lesions, the discharge drying to thick, yellowish, brownish
+or greenish crusts.</p>
+
+<p>Its most common sites are the scalp and face, especially in young
+people and in those who are ill-nourished and strumous.</p>
+
+
+<p><b>What course does pustular eczema pursue?</b></p>
+
+<p>Usually chronic, continuing as the same type, or passing into
+eczema rubrum.</p>
+
+
+<p><b>Describe the symptoms of squamous eczema.</b></p>
+
+<p>Squamous eczema (<i>eczema squamosum</i>) may be defined as a
+clinical variety, the chief symptoms of which are a variable degree
+of scaliness, more or less thickening, infiltration, and redness, with
+<span class='pagenum'><a name='Page_105' id='Page_105'></a><a href='#TOC'>[Pg 105]</a></span>
+commonly a tendency to cracking or fissuring of the skin, especially
+when the disease is seated about the joints. It is developed, as a
+rule, from the erythematous or papular type. Itching is slight or
+intense.</p>
+
+<p>The disease is not uncommon upon the scalp.</p>
+
+
+<p><b>What is the course of squamous eczema?</b></p>
+
+<p>Essentially chronic.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 23.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_105.jpg'>
+<img src='images/105.jpg' width='400' height='387'
+alt='FIG. 23.'
+title='FIG. 23.' />
+</a>
+</div>
+
+<p class='center'>Eczema of the Face and Scalp.</p>
+
+
+<p><b>Describe the symptoms of eczema rubrum.</b></p>
+
+<p>Eczema rubrum is characterized by a red, raw-looking, weeping,
+oozing or discharging surface, attended with more or less inflammatory
+thickening, infiltration and swelling; the exudation, consisting
+of serum, sometimes bloody, dries into thick yellowish or reddish-brown
+crusts. At one time the whole diseased area may be hidden
+under a mass of crusting, at other times a red, raw-looking, weeping
+surface (<i>eczema madidans</i>) is the most striking feature. Itching is
+slight or intense, or the subjective symptom may be a feeling of
+<span class='pagenum'><a name='Page_106' id='Page_106'></a><a href='#TOC'>[Pg 106]</a></span>
+burning, It is an important clinical type, usually developing from
+the vesicular, pustular or other primary variety.</p>
+
+<p>It is common about the face and scalp in children, and the middle
+and lower part of the leg in elderly people.</p>
+
+
+<p><b>What is the course of eczema rubrum?</b></p>
+
+<p>Chronic, varying in intensity from time to time.</p>
+
+
+<p><b>Describe the symptoms of fissured eczema.</b></p>
+
+<p>The conspicuous symptom is a marked tendency to fissuring or
+cracking of the skin (<i>eczema fissum; eczema rimosum</i>). This tendency
+is usually a part of an erythematous or squamous eczema,
+the fissuring constituting the most conspicuous and troublesome
+symptom. <i>Chapping</i> is an extremely mild but familiar example
+of this type.</p>
+
+<p>It is especially common about the hands and fingers.</p>
+
+
+<p><b>What is the course of fissured eczema?</b></p>
+
+<p>It is more or less persistent, the tendency to fissuring varying considerably
+according to the state of the weather, often disappearing
+spontaneously in the summer months.</p>
+
+
+<p><b>Describe eczema sclerosum and eczema verrucosum.</b></p>
+
+<p>In eczema sclerosum the skin is thickened, infiltrated, hard, and
+almost horny. Eczema verrucosum presents similar conditions, but,
+in addition, displays a tendency to papillary or wart-like hypertrophy.
+In both varieties the disease is usually seated about the
+ankle or the foot, developing from the papular or squamous type.
+They are uncommon, and obstinately chronic.</p>
+
+
+<p><b>State the nature of the subjective symptoms in eczema.</b></p>
+
+<p>Itching, commonly intense, is usually a conspicuous symptom; it
+may be more or less paroxysmal. In some cases burning and heat
+constitute the main subjective phenomena.</p>
+
+
+<p><b>Is eczema accompanied by febrile or systemic symptoms?</b></p>
+
+<p>No. In rare instances, in acute universal eczema, slight febrile
+action, or other systemic disturbance, may be noted at the time of
+the outbreak.
+<span class='pagenum'><a name='Page_107' id='Page_107'></a><a href='#TOC'>[Pg 107]</a></span></p>
+
+
+<p><b>Is the eczematous eruption (patch or patches) sharply defined
+against the neighboring sound skin?</b></p>
+
+<p>No. In almost all instances the diseased area merges gradually
+and imperceptibly into the surrounding healthy integument.</p>
+
+
+<p><b>What is the character of eczema as regards the degree of
+inflammatory action?</b></p>
+
+<p>The inflammatory action may be acute, subacute or sluggish in
+character, and may be so from the start and so continue throughout
+its whole course; or it may, as is usually the case, vary in intensity
+from time to time.</p>
+
+
+<p><b>State the character of eczema as regards duration.</b></p>
+
+<p>As a rule, it is a persistent disease, showing little, if any, tendency
+to spontaneous disappearance.</p>
+
+
+<p><b>Is eczema influenced by the seasons?</b></p>
+
+<p>Yes. With comparatively few exceptions the disease is most common
+and much worse in cold, windy, winter weather.</p>
+
+
+<p><b>To what may eczema be ascribed?</b></p>
+
+<p>Eczema may be due to constitutional or local causes, or to both.
+It may be considered, in fact, as a reaction of the skin tissues against
+some irritant, and the latter may have its origin from within or
+without.</p>
+
+
+<p><b>Name some of the important constitutional or predisposing
+causes.</b></p>
+
+<p>Gouty diathesis, rheumatic diathesis, disorders of the digestive
+tract, general debility or lack of tone, an exhausted state of the nervous
+system, dentition and struma.</p>
+
+
+<p><b>Is a constitutional cause sufficient to provoke an attack?</b></p>
+
+<p>Yes; but often the attack is brought about in those so predisposed
+by some local or external irritant.</p>
+
+
+<p><b>Mention some of the external causes.</b></p>
+
+<p>Heat and cold, sharp, biting winds, excessive use of water, strong
+soaps, vaccination, dyes and dyestuffs, chemical irritants, and the
+like. There is a growing belief that some cases presenting eczematous
+aspects are probably parasitic in origin. In fact, some observers
+hold to the microbic view of all cases of eczema.
+<span class='pagenum'><a name='Page_108' id='Page_108'></a><a href='#TOC'>[Pg 108]</a></span>
+Contact with the rhus plants, while producing a peculiar dermatitis,
+usually running an acute course terminating in recovery, may,
+in those predisposed, provoke a veritable and persistent eczema. In
+fact, in our examination as to causes in a given case, especially of
+the hands and face, all possible exciting factors should be inquired
+into, such as the handling of plants, chemicals, dyes, etc.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 24.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_108.jpg'>
+<img src='images/108.jpg' width='400' height='523'
+alt='FIG. 24.'
+title='FIG. 24.' />
+</a>
+</div>
+
+<p class='center'>Eczema of Face.</p>
+
+
+<p><b>Is eczema contagious?</b></p>
+
+<p>No. The acceptance of a parasitic cause for the disease, however,
+necessarily carries with it the possibility of contagiousness under
+favoring conditions. Such is not supported, however, by practical
+experience.
+<span class='pagenum'><a name='Page_109' id='Page_109'></a><a href='#TOC'>[Pg 109]</a></span></p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>The process is an inflammatory one, characterized in all cases
+by hyper&aelig;mia and exudation, varying in degree according to the
+intensity and duration of the disease. The rete and papillary layer
+are especially involved, although in severe and chronic cases the
+lower part of the corium and even the subcutaneous tissue may
+share in the process.</p>
+
+
+<p><b>Do the cutaneous manifestations of the eruptive fevers bear
+resemblance to the erythematous type of eczema?</b></p>
+
+<p>Scarlatina and erysipelas may, to a slight extent, but the presence
+or absence of febrile and other constitutional symptoms will usually
+serve to differentiate.</p>
+
+
+<p><b>What common skin diseases resemble some phases of eczema?</b></p>
+
+<p>Psoriasis, seborrh&oelig;a, sycosis, scabies and ringworm.</p>
+
+
+<p><b>How would you exclude psoriasis in a suspected case of eczema
+(squamous eczema)?</b></p>
+
+<p>Psoriasis occurs in variously-sized, rounded, <i>sharply-defined</i>
+patches, usually scattered irregularly over the general surface, with
+special predilection for the elbows and knees. They are covered
+more or less abundantly with whitish, silvery or mother-of-pearl colored
+imbricated scales. The patches are always dry, and itching is,
+as a rule, slight, or may be entirely absent. Eczema, on the contrary,
+is often localized, appearing as one or more large, irregularly
+diffused patches; it merges imperceptibly into the sound skin, and
+there is often a history of characteristic serous or gummy oozing;
+the scaling is usually slight and itching almost invariably a prominent
+symptom.</p>
+
+
+<p><b>How would you exclude seborrh&oelig;a (eczema seborrhoicum)
+in a suspected case of eczema?</b></p>
+
+<p>Seborrh&oelig;a of the scalp is more commonly over the whole of that
+region and is relatively free from inflammatory symptoms; the scales
+are of a greasy character and the itching is usually slight or nil.
+On the other hand, in eczema of this region the parts are rarely
+invaded in their entirety; there may be at times the characteristic
+serous or gummy oozing; inflammatory symptoms are usually well-marked,
+the scales are dry and the itching is, as a rule, a prominent
+<span class='pagenum'><a name='Page_110' id='Page_110'></a><a href='#TOC'>[Pg 110]</a></span>
+symptom. These same differences serve to differentiate the diseases
+in other regions.</p>
+
+
+<p><b>How does scabies differ from eczema?</b></p>
+
+<p>Scabies differs from eczema in its peculiar distribution, the presence
+of the burrows, the absence of any tendency to patch formation,
+and usually by a clear history of contagion.</p>
+
+
+<p><b>How would you exclude ringworm in a suspected case of
+eczema?</b></p>
+
+<p>Ringworm is to be distinguished by its circular form, its fading
+in the centre, and in doubtful cases by microscopic examination of
+the scrapings.</p>
+
+
+<p><b>How does eczema differ from sycosis?</b></p>
+
+<p>Sycosis is limited to the hairy region of the face, is distinctly a
+follicular inflammation, and is rarely very itchy; eczema is diffused,
+usually involves other parts of the face, and itching is an annoying
+symptom.</p>
+
+
+<p><b>State the general prognosis of eczema.</b></p>
+
+<p>The disease is, under favorable circumstances, curable, some cases
+yielding more or less readily, others proving exceedingly rebellious.
+The length of time to bring about a result is always uncertain, and
+an opinion on this point should be guarded.</p>
+
+
+<p><b>Upon what would you base your prognosis in the individual
+case?</b></p>
+
+<p>The extent of disease, its duration and previous behavior, the
+removability of the exciting and predisposing causes, and the attention
+the patient can give to the treatment.</p>
+
+<p>In eczema involving the lips, face, scrotum, and leg, and especially
+when this last-named exhibits a varicose condition of the veins, a
+cure is effected, as a rule, only through persistent and prolonged
+treatment.</p>
+
+
+<p><b>Does eczema ever leave scars?</b></p>
+
+<p>No. Upon the legs, in long-continued cases, more or less pigmentation
+usually remains.</p>
+
+
+<p><b>How is eczema treated?</b></p>
+
+<p>As a rule, eczema requires for its removal both constitutional and
+external treatment.
+<span class='pagenum'><a name='Page_111' id='Page_111'></a><a href='#TOC'>[Pg 111]</a></span>
+Certain cases, however, seem to be entirely local in their nature,
+and in these cases external treatment alone will have satisfactory
+results.</p>
+
+
+<p><b>What general measures as to hygiene and diet are commonly
+advisable?</b></p>
+
+<p>Fresh air, exercise, moderate indulgence in calisthenics, regular
+habits, a plain, nutritious diet; abstention from such articles of food
+as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese,
+pickles, condiments, excessive coffee or tea drinking, etc. As a rule,
+also, beer, wine, and other stimulants are to be interdicted.</p>
+
+
+<p><b>Upon what grounds is the line or plan of constitutional treatment
+to be based?</b></p>
+
+<p>Upon indications in the individual case. A careful examination
+into the patient's general health will usually give the cue to the line
+of treatment to be adopted.</p>
+
+
+<p><b>Mention the important remedies variously employed in the
+constitutional treatment.</b></p>
+
+<p><i>Tonics</i>&mdash;such as cod-liver oil, quinine, nux vomica, the vegetable
+bitters, iron, arsenic, malt, etc.</p>
+
+<p><i>Alkalies</i>&mdash;sodium salicylate, potassium bicarbonate, liquor potass&aelig;,
+and lithium carbonate.</p>
+
+<p><i>Alteratives</i>&mdash;calomel, colchicum, arsenic, and potassium iodide.</p>
+
+<p><i>Diuretics</i>&mdash;potassium acetate, potassium citrate, and oil of copaiba.</p>
+
+<p><i>Laxatives</i>&mdash;the various salines, aperient spring waters, castor oil,
+cascara sagrada, aloes and other vegetable cathartics.</p>
+
+<p><i>Digestives</i>&mdash;pepsin, pancreatin, muriatic acid and the various bitter
+tonics.</p>
+
+
+<p><b>Are there any remedies which have a specific influence?</b></p>
+
+<p>No; although arsenic, in exceptional instances, seems to exert
+a special action. Cod-liver oil is also of great value in some cases.</p>
+
+<p>Upon the whole the most important remedies are those which
+keep in view the maintenance of a proper and healthful condition
+of the gastro-intestinal tract, and especially with regular and rather
+free action of the bowels.
+<span class='pagenum'><a name='Page_112' id='Page_112'></a><a href='#TOC'>[Pg 112]</a></span></p>
+
+<p><b>In what class of cases does arsenic often prove of service?</b></p>
+
+<p>In the sluggish, dry, erythematous, scaly and papular types.</p>
+
+<p><b>In what cases is arsenic usually contraindicated?</b></p>
+
+<p>It should never be employed in acute cases; nor in any instance
+(unless its action is watched), in which the degree of inflammatory
+action is marked, as an aggravation of the disease usually results.</p>
+
+<p><b>What should be the character of the external treatment?</b></p>
+
+<p>It depends mainly upon the degree of inflammatory action; but
+the stage of the disease, the extent involved, and the ability of the
+patient to carry out the details of treatment, also have a bearing
+upon the selection of the plan to be advised.</p>
+
+<p><b>What is to be said about the use of soap and water in eczema?</b></p>
+
+<p>In acute and subacute conditions soap and water are to be employed,
+as a rule, as infrequently and as sparingly as possible, as
+the disease is often aggravated by their too free use. Washing is
+necessary, however, for cleanliness and occasionally, also, for the
+removal of the crusts. On the other hand, in chronic, sluggish
+types the use of soap and water frequently has a therapeutic value.</p>
+
+<p><b>How often should remedial applications be made?</b></p>
+
+<p>Usually twice daily, although in some case, and especially those
+of an acute type, applications should be made every few hours.</p>
+
+<p><b>Mention several remedies or plans of treatment to be used
+in the acute or actively inflammatory cases.</b></p>
+
+<p>Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly
+dabbed on, allowed to dry, the parts gently smeared with
+ointment; or the ointment may be applied spread on lint as a plaster.</p>
+
+<p>Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment,
+applied in the same manner as the above.</p>
+
+<p>A lotion containing calamine and zinc oxide, the sediment drying
+and coating over the affected surface:&mdash;</p>
+
+<pre>
+  &#8478; Calamin&aelig;,<br />
+    Zinci oxidi, .................&#257;&#257;.................. &#658; ij-&#658; iij
+    Glycerin&aelig;,
+    Alcoholis, ...................&#257;&#257;................. f&#658;ss
+    Liq. calcis, .................................... f&#8485;ij
+    Aqu&aelig;, .............. q.s. ... ad ................ f&#8485;vj.   M.
+</pre>
+
+<p><span class='pagenum'><a name='Page_113' id='Page_113'></a><a href='#TOC'>[Pg 113]</a></span>
+Another excellent lotion somewhat similar to the last, but of
+oily character, is made up of three drachms each of calamine
+and zinc oxide, one drachm of boric acid, ten to thirty drops of
+carbolic acid, and three ounces each of lime-water and oil of sweet
+almonds.</p>
+
+<p>Carbolic-acid lotion, about two drachms to the pint of water, to
+which may be added two or three drachms each of glycerin and
+alcohol; or, if there is intense itching, carbolic acid may be added
+to the several washes already mentioned.</p>
+
+<p>A lotion made of one or two drachms of liquor carbonis detergens<a name='FNanchor_A_1' id='FNanchor_A_1'></a><a href='#Footnote_A_1' class='fnanchor'>[A]</a>
+to four ounces of water.</p>
+
+<p>The following wash, especially in the dry form of the disease:&mdash;</p>
+
+<pre>
+  &#8478; Ac. borici, ...................................... &#658;iv
+    Ac. carbolici, ................................... &#658;j
+    Glycerin&aelig;, ....................................... &#658;ij
+    Alcoholis, ....................................... &#658;ij
+    Aqu&aelig;, ............... q.s. ad. ................... Oj.  M.
+</pre>
+
+<div class='footnote' style='margin-left: 5em;'><p><a name='Footnote_A_1' id='Footnote_A_1'></a><a href='#FNanchor_A_1'><span class='label'>[A]</span></a> Liquor carbonis detergens is made by mixing together nine ounces
+of tincture soap bark and four ounces of coal tar, allowing to digest for
+eight days, and filtering. The tincture of soap bark used is made with
+one pound of soap bark to one gallon of 95 per cent. alcohol, digesting
+for a week or so. Instead of the proprietary name above, Prof. Duhring
+has suggested that of tinctura picis mineralis comp.</p></div>
+
+<p>Dusting-powders, of starch, zinc oxide and Venetian talc, alone or
+severally combined, applied freely and often, so as to afford protection
+to the inflamed surface:&mdash;</p>
+
+<pre>
+  &#8478; Talci venet,
+    Zinci oxidi, ...............&#257;&#257;.................... &#658;iv
+    Amyli, ........................................... &#8485;j.   M.
+</pre>
+
+<p>If washes or dusting-powders should disagree or are not desirable
+or practicable, ointments may be employed, such as&mdash;</p>
+
+<p>Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated,
+diachylon ointment (if fresh and well prepared), and a paste-like<span class='pagenum'><a name='Page_114' id='Page_114'></a><a href='#TOC'>[Pg 114]</a></span>
+ointment, as the following, usually called &ldquo;salicylic-acid paste&rdquo;;
+in markedly itchy cases, five to fifteen grains of carbolic may be
+added to each ounce:</p>
+
+<pre>
+<span style='margin-left: 2em;'>
+  &#8478; Ac. salicylici, .................................. gr. v-x
+    Pulv. amyli,
+    Pulv. zinci oxidi, ...............&#257;&#257;.............. &#658;ij
+    Petrolati, ....................................... &#658;iv   M.
+</span>
+</pre>
+
+<p>Or the following ointment:&mdash;</p>
+
+<pre>
+  &#8478; Calamin&aelig;, ........................................ &#658;j
+    Ungt. zinci oxidi, ............................... &#658;vij.   M.
+</pre>
+
+
+<p><b>Name several external remedies and combinations useful in
+eczema of a subacute or mildly inflammatory type.</b></p>
+
+<p>The various remedies and combinations useful when the symptoms
+are acute or markedly inflammatory (mentioned above), and more
+especially the several following:&mdash;</p>
+
+<pre>
+  &#8478; Zinci oxidi, ..................................... &#658;ij
+    Liq. plumbi subacetat. dilut., .................. f&#658;vj
+    Glycerin&aelig;, ...................................... f&#658;ij
+    Infus. picis liq., .............................. f&#8485;iij   M.
+</pre>
+
+<p>A lotion containing resorcin, five to thirty grains to the ounce.</p>
+
+<p>Solution of zinc sulphate, one-half to three grains to the ounce.</p>
+
+<p>An ointment containing calomel or ammoniated mercury, as in
+the annexed formula:&mdash;</p>
+
+<pre>
+  &#8478; Hydrargyri ammoniat. seu Hydrargyri
+      chloridi mit., ................................. gr. x-xxx
+    Ac. carbolici, ................................... gr. v-x
+    Ungt. zinci oxidi, ............................... &#8485;j.   M.
+</pre>
+
+<p>Another formula, more especially useful in eczema of the hands
+and legs, is the following:&mdash;
+<span class='pagenum'><a name='Page_115' id='Page_115'></a><a href='#TOC'>[Pg 115]</a></span></p>
+
+<pre>
+  &#8478; Ac. salicylici, .................................. gr. xxx
+    Emp. plumbi,
+    Emp. saponis,
+    Petrolati, ...................&#257;&#257;.................. &#8485;j.   M.
+</pre>
+
+<p>(This is to be applied as a plaster, spread on strips of lint, and
+changed every twelve or twenty-four hours.)</p>
+
+<p>The paste-like ointment, referred to as useful in acute eczema,
+may also be used with a larger proportion (20 to 60 grains to the
+ounce) of salicylic acid.</p>
+
+<p>The following, containing tar, may often be employed with advantage:&mdash;</p>
+
+<pre>
+  &#8478; Ungt. picis liq., ................................ &#658;j
+    Ungt. zinci oxidi, ............................... &#658;vij.   M.
+</pre>
+
+
+<p><b>What is to be said in regard to the use of tarry applications?</b></p>
+
+<p>Ointments or lotions containing tar should always be tried at first
+upon a limited surface, as occasionally skins are met with upon
+which this remedy acts as a more or less violent irritant. The coal
+tar lotion (liquor carbonis detergens) is the least likely to disagree
+and may be used as a mild ointment, one or two drachms to the
+ounce, or it may be diluted and used as a weak lotion as already
+referred to.</p>
+
+
+<p><b>What external remedies are to be employed in eczema of a
+sluggish type?</b></p>
+
+<p>The various remedies and combinations (mentioned above) useful
+in acute and subacute eczema may often be employed with
+benefit, but, as a rule, stronger applications are necessary, especially
+in the thick and leathery patches. The following are the
+most valuable:&mdash;</p>
+
+<p>An ointment of calomel or ammoniated mercury; forty to sixty
+grains to the ounce.</p>
+
+<p>Strong salicylic-acid ointment; a half to one drachm of salicylic
+acid to the ounce of lard.</p>
+
+<p>Tar ointment, official strength; or the various tar oils, alone or
+with alcohol, as a lotion, or in ointment form.
+<span class='pagenum'><a name='Page_116' id='Page_116'></a><a href='#TOC'>[Pg 116]</a></span></p>
+
+<p>
+Liquor picis alkalinus<a name='FNanchor_A_2' id='FNanchor_A_2'></a><a href='#Footnote_A_2' class='fnanchor'>[B]</a> is a valuable remedy in chronic <i>thickened,
+hard</i> and <i>verrucous</i> patches, but is a strong preparation and must be
+used with caution. It is applied diluted, one part with from eight
+to thirty-two parts of water; or in ointment, one or two drachms to
+the ounce. In such cases, also, the following is useful:&mdash;</p>
+
+<pre>
+  &#8478; Saponis viridis,
+    Picis liq.,
+    Alcoholis, ....................&#257;&#257;................. &#658;iij.   M.
+  SIG. To be well rubbed in.
+</pre>
+
+<div class='footnote' style='margin-left: 5em;'><p><a name='Footnote_A_2' id='Footnote_A_2'></a><a href='#FNanchor_A_2'><span class='label'>[B]</span></a>
+</p>
+
+<pre>
+  &#8478; Potass&aelig; ,......................................... &#658;j
+    Picis liq., ...................................... &#658;ij
+    Aqu&aelig;, ............................................ &#658;v.
+</pre>
+
+<p>
+Dissolve the potash in the water, and gradually add to the tar in a
+mortar, with thorough stirring.</p></div>
+
+<p>In similar cases, also, the parts may be thoroughly washed or
+scrubbed with sapo viridis and hot water until somewhat tender,
+rinsed off, dried, and a mild ointment applied as a plaster.</p>
+
+<p>Lactic acid, applied with one to ten or more parts of water is also
+of value in the sclerous and verrucous types. Caustic potash solutions,
+used cautiously, may also be occasionally employed to advantage
+in these cases.</p>
+
+<p>Another remedy of value in these cases, as well as in others
+of more or less limited nature, is the <i>x</i>-ray. Exposures every
+few days, of short duration and 4 to 10 inches distance, with
+medium vacuum tube. This method has served me well in
+occasional cases; caution is necessary, and it should not be
+pushed further than the production of the mildest reaction. The
+repeated application of a high-frequency current, by means of the
+vacuum electrodes, is a safer and sometimes an equally beneficial
+method.</p>
+
+
+<p><b>Is there any method of treating eczema with fixed dressings?</b></p>
+
+<p>Several plans have been advised from time to time; some are costly,
+and some require too great attention to details, and are therefore
+impracticable for general employment. The following are those in
+more common use:&mdash;</p>
+
+<p>The <i>gelatin dressing</i>, as originally ordered, is made by melting over<span class='pagenum'><a name='Page_117' id='Page_117'></a><a href='#TOC'>[Pg 117]</a></span>
+a water-bath one part of gelatin in two parts of water&mdash;quickly painting
+it over the diseased area; it dries rapidly, and to prevent cracking
+glycerine is brushed over the surface. Or the glycerine may
+be incorporated with the gelatin and water in the following proportion:
+glycerine, one part; gelatin, four parts, and water eight parts.
+Medicinal substances may be incorporated with the gelatin mixture.</p>
+
+<p>A good formula is the following:&mdash;</p>
+
+<pre>
+  &#8478; Gelatin, ......................................... &#8485;j
+    Zinci oxidi, ..................................... &#8485;ss
+    Glycerini, ....................................... &#8485;iss
+    Aqu&aelig;, ............................................ &#8485;ii-&#8485;iij.
+</pre>
+
+<p>This should be prepared over a water-bath, and two per cent.
+ichthyol added. A thin gauze bandage can be applied to the
+parts over which this dressing is painted, before it is completely
+dry; it makes a comfortable fixed dressing and may remain on
+several days.</p>
+
+<p><i>Plaster-mull</i> and <i>gutta-percha plaster</i>. The plaster-mull, consisting
+of muslin incorporated with a layer of stiff ointment, and the
+gutta-percha plaster, consisting of muslin faced with a thin layer
+of India-rubber, the medication being spread upon the rubber
+coating.</p>
+
+<p><i>Rubber plasters.</i> These are medicated with the various drugs
+used in the external treatment of skin diseases, and are often of
+service in chronic patches.</p>
+
+<p>Two new excipients for fixed dressings have recently been introduced&mdash;bassorin
+and plasment; the former is made from gum tragacanth,
+and the latter from Irish moss.</p>
+
+<p>The following is a satisfactory formula for a tragacanth dressing:</p>
+
+<pre>
+  &#8478; Tragacanth, ...................................... gr. lxxv
+    Glycerini, ....................................... &#9807; xxx
+    Ac. carbolici, ................................... gr. x-xx
+    Zinci oxidi, ..................................... &#658;iss-&#658;iiss.   M.
+</pre>
+
+<p>This is painted over the parts and allowed to dry, and a mild dusting
+powder sprinkled over. It cannot be used in warm weather
+or in folds, as it is apt to get sticky. The following is a bassorin
+paste which may be variously medicated.
+<span class='pagenum'><a name='Page_118' id='Page_118'></a><a href='#TOC'>[Pg 118]</a></span></p>
+
+<pre>
+  &#8478; Bassorin, ........................................ &#658;x
+    Dextrin, ......................................... &#658;vj
+    Glycerini, ....................................... &#8485;ij.
+    Aqu&aelig;, ................................... q.s. ad. &#8485;iij.
+</pre>
+
+<p>It should be prepared cold.</p>
+
+<p>Another &ldquo;drying dressing&rdquo; which may be used in cool weather is:</p>
+
+<pre>
+  &#8478; Zinci oxidi, ..................................... &#8485;j
+    Glycerini, ....................................... &#8485;ss
+    Mucilag. acaci&aelig;, ................................. &#8485;ii-&#8485;iv.
+</pre>
+
+<p>It may be variously medicated.</p>
+
+<p>The plaster-mull is used in all types, especially the acute; the gelatin
+dressing, and the gutta-percha plaster, in the subacute and
+chronic; and the rubber plaster in chronic, sluggish patches only.
+Acacia, tragacanth, bassorin and plasment applications are used in
+cases of a subacute and chronic character.</p>
+
+
+<h2><a name='Prurigo' id='Prurigo'></a><b>Prurigo.</b></h2>
+
+
+<p><b>Define prurigo.</b></p>
+
+<p>Prurigo is a chronic, inflammatory disease, characterized by discrete,
+pin-head- to small pea-sized, solid, firmly-seated, slightly
+raised, pale-red papules, accompanied by itching and more or less
+general thickening of the affected skin.</p>
+
+
+<p><b>Describe the symptoms and course of prurigo.</b></p>
+
+<p>The disease first appears upon the tibial regions, and its earliest
+manifestation may be urticarial, but there soon develop the characteristic
+small, millet-seed-sized, or larger, firm elevations, which
+may be of the natural color of the skin or of a pinkish tinge. The
+lesions, whilst discrete, are in great numbers, and closely crowded.
+The overlying skin is dry, rough and harsh; itching is intense, and,
+as a result of the scratching, excoriations and blood crusts are commonly
+present. In consequence of the irritation, the inguinal glands
+are enlarged. Sooner or later the integument becomes considerably
+thickened, hard and rough. Eczematous symptoms may be superadded.
+In severe cases the entire extensor surfaces of the legs and
+arms, and in some instances the trunk also, are invaded. It is
+worse in the winter season.
+<span class='pagenum'><a name='Page_119' id='Page_119'></a><a href='#TOC'>[Pg 119]</a></span></p>
+
+
+<p><b>What is known in regard to etiology and pathology?</b></p>
+
+<p>It is a disease of the ill-fed and neglected, usually developing in
+early childhood, and persisting throughout life. It is extremely rare,
+even in its milder types, in this country. Clinically and pathologically
+it bears some resemblance to papular eczema.</p>
+
+
+<p><b>Give the prognosis and treatment of prurigo.</b></p>
+
+<p>The disease, in its severer types is, as a rule, incurable, but much
+can be done to alleviate the condition. Good, nourishing food, pure
+air and exercise are of importance. Tonics and cod-liver oil are
+usually beneficial. The local management is similar to that employed
+in chronic eczema. An ointment of &beta;-naphthol, one-half to five
+per cent. strength, is highly extolled.</p>
+
+
+<h2><a name='Acne' id='Acne'></a><b>Acne.</b></h2>
+
+
+<p><b>Give a definition of acne</b>.</p>
+
+<p>Acne is an inflammatory, usually chronic, disease of the sebaceous
+glands, characterized by papules, tubercles, or pustules, or a mixture
+of these lesions, and seated usually about the face.</p>
+
+
+<p><b>At what age does acne usually occur?</b></p>
+
+<p>Between the ages of fifteen and thirty, at which time the glandular
+structures are naturally more or less active.</p>
+
+
+<p><b>Describe the symptoms of acne</b>.</p>
+
+<p>Irregularly scattered over the face, and in some cases also over the
+neck, shoulders and upper part of the trunk, are to be seen several,
+fifty or more, pin-head- to pea-sized papules, tubercles or pustules;
+commonly the eruption is of a mixed type (<i>acne vulgaris</i>), the several
+kinds of lesions in all stages of evolution and subsidence presenting in
+the single case. Interspersed may generally be seen blackheads, or
+comedones. The lesions may be sluggish in character, or they may
+be markedly inflammatory, with hard and indurated bases. In the
+course of several days or weeks, the papules and tubercles tend
+gradually to disappear by absorption; or, and as commonly the case,
+they become pustular, discharge their contents, or dry and slowly
+or rapidly disappear, with or without leaving a permanent trace,
+new lesions arising, here and there, to take their place. In exceptional
+instances the eruption is limited to the back, and in these
+<span class='pagenum'><a name='Page_120' id='Page_120'></a><a href='#TOC'>[Pg 120]</a></span>
+cases the eruption is usually extensive and persistent, and not infrequently
+leaves scars.</p>
+
+
+<p><b>What do you understand by acne punctata, acne papulosa,
+acne pustulosa, acne indurata, acne atrophica, acne
+hypertrophica, and acne cachecticorum?</b></p>
+
+<p>These several terms indicate that the lesions present are, for the
+most part, of one particular character or variety.</p>
+
+
+<p><b>Describe the lesions giving rise to the names of these various
+types.</b></p>
+
+<p>Blocking up of the outlet of the sebaceous gland (comedo), which is
+usually the beginning of an acne lesion, may cause a moderate degree
+of hyper&aelig;mia and inflammation, and a slight elevation, with a central
+yellowish or blackish point results&mdash;the lesion of <i>acne punctata;</i>
+if the inflammation is of a higher grade or progresses, the elevation
+is reddened and more prominent&mdash;<i>acne papulosa;</i> if the inflammatory
+action continues, the interior or central portion of the papule suppurates
+and a pustule results&mdash;<i>acne pustulosa;</i> the pustule, in some
+cases, may have a markedly inflammatory and hard base&mdash;<i>acne indurata;</i>
+and not infrequently the lesions in disappearing may leave a
+pit-like atrophy or depression&mdash;<i>acne atrophica;</i> or, on the contrary,
+connective-tissue new growth may follow their disappearance&mdash;<i>acne
+hypertrophica;</i> and, in strumous or cachectic individuals, the lesions
+may be more or less furuncular in type, often of the nature of dermic
+abscesses, usually of a cold or sluggish character, and of more general
+distribution&mdash;<i>acne cachecticorum</i>.</p>
+
+
+<p><b>What is acne artificialis?</b></p>
+
+<p>Acne artificialis is a term applied to an acne or acne-like eruption
+produced by the ingestion of certain drugs, as the bromides and
+iodides, and by the external use of tar; this is also called <i>tar acne</i>.</p>
+
+
+<p><b>What course does acne pursue?</b></p>
+
+<p>Essentially chronic. The individual lesions usually run their course
+in several days or one or two weeks, but new lesions continue to appear
+from time to time, and the disease thus persists, with more or
+less variation, for months or years. In many cases there is, toward
+the age of twenty-five or thirty, a tendency to spontaneous disappearance
+of the disease.</p>
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_120.jpg'>
+<img src='images/120.jpg' width='400' height='455'
+alt='Acne'
+title='Acne' />
+</a>
+</div>
+<p class='center'>Acne</p>
+
+<p><span class='pagenum'><a name='Page_121' id='Page_121'></a><a href='#TOC'>[Pg 121]</a></span></p>
+
+
+<p><b>Is the eruption in acne usually abundant?</b></p>
+
+<p>It varies in different cases and at different periods in the same
+case. In some instances, not more than five or ten papules and
+pustules are present at one time; in others they may be numerous.
+Not infrequently several lesions make their appearance, gradually
+run their course, and the face continues free for days or one or two
+weeks.</p>
+
+
+<p><b>Does the eruption in acne disappear without leaving a trace?</b></p>
+
+<p>In many instances no permanent trace remains, but in others
+slight or conspicuous scarring is left to mark the site of the lesions.</p>
+
+
+<p><b>Are there any subjective symptoms in acne?</b></p>
+
+<p>As a rule, not; but markedly inflammatory lesions are painful.</p>
+
+
+<p><b>State the immediate or direct cause of an acne lesion.</b></p>
+
+<p>Hypersecretion or retention of sebaceous matter. Recent investigations
+point to the possibility of a special bacillus being the exciting
+cause, in some instances at least. The pyogenic cocci are added
+factors in the pustular and furuncular cases.</p>
+
+
+<p><b>Name the indirect or predisposing causes of acne</b>.</p>
+
+<p>Digestive disturbance, constipation, menstrual irregularities, chlorosis,
+general debility, lack of tone in the muscular fibres of the skin,
+scrofulosis; and medicinal substances such as the iodides and bromides
+internally, and tar externally.</p>
+
+<p>Working in a dusty or dirty atmosphere is often influential, resulting
+in a blocking-up of the gland ducts. Workmen in paraffin oils
+or other petroleum products often present a furuncle-like acne.</p>
+
+<p>The disease is more common in individuals of light complexion.</p>
+
+
+<p><b>Is there any difficulty in the diagnosis of acne?</b></p>
+
+<p>Not if it be remembered that acne eruption is limited to certain
+parts and is always follicular, and that the several stages, from the
+comedo to the matured lesion, are usually to be seen in the individual
+case.</p>
+
+
+<p><b>In what respect does the pustular syphiloderm differ from
+acne?</b></p>
+
+<p>By its general distribution, the longer duration of the individual
+lesions, the darker color, and the presence of concomitant symptoms
+of syphilis.
+<span class='pagenum'><a name='Page_122' id='Page_122'></a><a href='#TOC'>[Pg 122]</a></span></p>
+
+
+<p><b>What is the pathology of acne?</b></p>
+
+<p>Primarily, acne is a folliculitis, due to retention or decomposition
+of the sebaceous secretion or to the introduction of a micro-organism;
+subsequently, the tissue immediately surrounding becoming
+involved, with the possible destruction of the sebaceous follicle as a
+result. The degree of inflammatory action determines the character
+of the lesions.</p>
+
+
+<p><b>State the prognosis of acne.</b></p>
+
+<p>It is usually an obstinate disease, but curable. Some cases yield
+readily, others are exceedingly rebellious, especially acne of the
+back. Success depends in a great measure upon a recognition and
+removal of the predisposing condition. Treatment is ordinarily a
+matter of months.</p>
+
+
+<p><b>What measures of treatment are usually demanded in acne?</b></p>
+
+<p>Constitutional and local measures; the former when indicated,
+the latter always.</p>
+
+
+<p><b>Upon what is the constitutional treatment based?</b></p>
+
+<p>Upon indications. Diet and hygienic measures are important.</p>
+
+<p>In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin,
+saline and vegetable laxatives, are variously prescribed. Special
+mention may be made of the following:&mdash;</p>
+
+<pre>
+  &#8478; Ext. rhamni pursh. fl., ......................... f&#658;ij-f&#658;iv
+    Tinct. nucis vom., .............................. f&#658;iij
+    Tinct. cardamomi comp., ................. q.s. ad. &#8485;iij.   M.
+  SIG.&mdash;f&#658; t.d.
+</pre>
+
+<p>Or Hunyadi Janos or Friedrichshall water may be employed for a
+laxative purpose.</p>
+
+<p>In chlorotic and an&aelig;mic cases the ferruginous preparations are of
+advantage. Cod-liver oil is often a remedy of great value, and is
+especially useful in strumous and debilitated subjects. Calx sulphurata
+in pill form, one-tenth to one-fourth grain four or five times
+daily, is said, acts well in the pustular variety. In some instances,
+more particularly in sluggish papular acne, arsenic, especially the
+sulphide of arsenic, acts favorably. Upon the whole, the line of</p>
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_122.jpg'>
+<img src='images/122.jpg' width='400' height='429'
+alt='Acne of back'
+title='Acne of back' />
+</a>
+</div>
+<p class='center'>Acne of back<span class='pagenum'><a name='Page_123' id='Page_123'></a><a href='#TOC'>[Pg 123]</a></span></p>
+
+<p>treatment that keeps in view proper and healthy action of the gastro-intestinal
+canal is the most successful.</p>
+
+<p>In inflammatory cases occurring in robust individuals the following
+is often of service:&mdash;</p>
+
+<pre>
+  &#8478; Potassii acetat., ................................ &#658;iv
+    Liq. potass&aelig;, ................................... f&#658;ij
+    Liq. ammonii acetat., ............ q.s. ad. ..... f&#8485;iij.   M.
+  SIG.&mdash;f&#658;j-f&#658;ij t.d., largely diluted.
+</pre>
+
+
+<p><b>State the character of the local treatment in acne.</b></p>
+
+<p>This must vary somewhat with the local conditions. Cases which
+are acute in character, in the sense that the lesions are markedly
+hyper&aelig;mic, tender and painful, require milder applications, and in
+exceptional instances soothing remedies are to be prescribed. As a
+rule, however, stimulating applications may be employed from the
+start.</p>
+
+<p>The remedies are, for obvious reasons, most conveniently applied
+at bedtime.</p>
+
+
+<p><b>What preliminary measures are to be advised in ordinary
+acne cases?</b></p>
+
+<p>Washing the parts gently or vigorously, according to the irritability
+of the skin, with warm water and soap; subsequently rinsing,
+and sponging for several minutes with hot water, and rubbing dry
+with a soft towel; after which the remedial application is made. In
+sluggish and non-irritable cases sapo viridis or its tincture may often
+be advantageously used in place of the ordinary toilet soap.</p>
+
+<p>The blackheads, so far as practicable, are to be removed by pressure
+with the fingers or with a suitable instrument (see Comedo), and
+the superficial pustules punctured and the contents pressed out.
+Scraping the affected parts with a blunt curette is a valuable measure,
+but is temporarily disfiguring. As a rule, however, cases do
+just as well without puncturing and scraping, and these methods
+sometimes leave behind scarring.</p>
+
+
+<p><b>State the methods of external medication commonly employed.</b></p>
+
+<p>By ointments and lotions. If an ointment is used, it is to be
+thoroughly rubbed in, in small quantity; if a lotion is employed, it
+<span class='pagenum'><a name='Page_124' id='Page_124'></a><a href='#TOC'>[Pg 124]</a></span>
+is to be well shaken, the parts freely dabbed with it for several
+minutes and then allowed to dry on.</p>
+
+
+<p><b>State the object in view in local medication.</b></p>
+
+<p>To hasten the maturation and disappearance of the existing
+lesions, and to stimulate the skin and glands to healthy action.</p>
+
+<p>If slight irritation or scaliness results, the application is to be
+intermitted one or two nights; in the meantime nothing except
+the hot-water sponging, with or without the application of a mild
+soothing ointment, is to be employed.</p>
+
+
+<p><b>Is it usually necessary to change from one external remedy
+to another in the course of treatment?</b></p>
+
+<p>Yes. After a certain time one remedy, as a rule, loses its effect,
+and a change from lotion to ointment or the reverse, and from one
+lotion or ointment to another, will often be found necessary in order
+to bring about continuous improvement.</p>
+
+
+<p><b>Name the various important remedies and combinations employed
+in the external treatment of acne.</b></p>
+
+<p>Sulphur is the most valuable. It may often be applied with benefit
+as a simple ointment:&mdash;</p>
+
+<pre>
+  &#8478; Sulphur, pr&aelig;cip., ................................ &#658;ss-&#658;j
+    Adipis benz.
+    Lanolin, .....................&#257;&#257;.................. &#658;ij.
+</pre>
+
+<p>Or it may be used as a lotion, as in the annexed formula:&mdash;</p>
+
+<pre>
+  &#8478; Sulphur, pr&aelig;cip., ................................ &#658;iss
+    Pulv. tragacanth&aelig;, ............................... gr. x1
+    Pulv. camphor&aelig;, .................................. gr. xx
+    Liq. calcis,........ q.s. ad. ................... f&#8485;iv.   M.
+</pre>
+
+<p>Another lotion, especially useful in those cases in which an oily
+condition of the skin is present, is the following:&mdash;</p>
+
+<pre>
+  &#8478; Sulphur, pr&aelig;cip., ................................ &#658;iss
+    Etheris, ........................................ f&#658;iv
+    Alcoholis, ...................................... f&#8485;iijss.   M.
+</pre>
+
+<p>A compound lotion containing sulphur in one of its combinations
+is also valuable in many cases:&mdash;
+<span class='pagenum'><a name='Page_125' id='Page_125'></a><a href='#TOC'>[Pg 125]</a></span></p>
+
+<pre>
+  &#8478; Zinci sulphatis,
+    Potassii sulphureti, ................&#257;&#257;........... &#658;ss-&#658;iv
+    Aqu&aelig;, ............................................ &#8485;iv.   M.
+</pre>
+
+<p>(The salts should be dissolved separately and then mixed; reaction
+takes place and the resulting lotion, when shaken, is milky in appearance,
+and free from odor; allowed to stand the particles settle, the
+sediment constituting about one-fourth to three-fourths of the whole
+bulk).</p>
+
+<p>At times the addition to this formula of several drachms of alcohol
+and of five to ten minims of glycerin is of advantage.</p>
+
+<p>An external remedy, often valuable, is ichthyol. It is thus prescribed:&mdash;</p>
+
+<pre>
+  &#8478; Ichthyol, ........................................ &#658;ss-&#658;j
+    Cerat. simp., .................................... &#658;iv.   M.
+</pre>
+
+<p>The various mercurial ointments, especially one of white precipitate,
+five to fifteen per cent. strength, are sometimes beneficial.</p>
+
+<p>A compound lotion, containing mercury, which frequently proves
+serviceable, is:&mdash;</p>
+
+<pre>
+  &#8478; Hydrarg. chlorid. corros., ....................... gr. ii-viij
+    Zinci sulphatis, ................................. gr. x-xx
+    Tinct. benzoini, ................................ f&#658;ij
+    Aqu&aelig;, ................... q.s. ad. .............. f&#8485;iv.
+</pre>
+
+<p>In extremely sluggish cases the following, used cautiously, is of
+value:&mdash;</p>
+
+<pre>
+  &#8478; Ichthyol,
+    Saponis viridis,
+    Sulphur, pr&aelig;cip.,
+    Lanolin, .......................&#257;&#257;................ &#658;j.
+</pre>
+
+<p>In such instances the application of a strong alcoholic resorcin
+lotion, ten to twenty-five per cent. strength, repeated several times
+daily till marked irritation and exfoliation occur (a matter usually
+of one to three days), will sometimes be followed by marked improvement.
+Acne of the back is treated with the same applications,
+but usually stronger; in this region applications of Vleminckx's
+<span class='pagenum'><a name='Page_126' id='Page_126'></a><a href='#TOC'>[Pg 126]</a></span>
+solution and formaldehyde solution, weakened considerably, at first
+at least, prove of value.</p>
+
+<p><i>Obstinate and indurated lesions</i> may be incised, the contents
+pressed out, and the interior touched with carbolic acid by means
+of a pointed stick. The <i>x</i>-ray has proved a most valuable addition
+to our resources in the treatment of acne, and is especially serviceable
+in extensive and obstinate cases. An exposure should be made
+about twice weekly, at a distance of five to ten inches and for from
+three to ten minutes, and a tube of medium vacuum used. It must
+be used with great caution and never beyond the production of the
+mildest erythema. The hair, eyes, and lips should be protected.
+The <i>x</i>-ray treatment is best reserved for obstinate cases, and then
+used mildly, and rather as an adjuvant to the ordinary methods than
+as the sole measure.</p>
+
+
+<p><b>What precaution is to be taken in advising a change from a
+sulphur to a mercurial preparation or the reverse?</b></p>
+
+<p>Several days should be allowed to intervene, otherwise a disagreeable,
+although temporary, staining or darkening of the skin results&mdash;from
+the formation of the black sulphuret of mercury.</p>
+
+
+<h2><a name='Acne_Rosacea' id='Acne_Rosacea'></a><b>Acne Rosacea.</b></h2>
+
+
+<p><b>Give a descriptive definition of acne rosacea.</b></p>
+
+<p>Acne rosacea is a chronic, hyper&aelig;mic or inflammatory disease,
+limited to the face, especially to the nose and cheeks, characterized
+by redness, dilatation and enlargement of the bloodvessels, more or
+less acne and hypertrophy.</p>
+
+
+<p><b>Describe the symptoms of acne rosacea.</b></p>
+
+<p>The disease may be slight or well-marked. Redness, capillary
+dilatation, and acne lesions seated on the nose and cheeks, and sometimes
+on chin and forehead also, constitute in most cases the entire
+symptomatology.</p>
+
+<p>A mild variety consists in simple redness or hyper&aelig;mia, involving
+the nose chiefly and often exclusively, and is to be looked upon as a
+passive congestion; this is not uncommon in young adults and is
+often associated with an oily seborrh&oelig;a of the same parts. In many
+<span class='pagenum'><a name='Page_127' id='Page_127'></a><a href='#TOC'>[Pg 127]</a></span>
+cases the condition does not progress beyond this stage. In other
+cases, however, sooner or later the dilated capillaries become permanently
+enlarged (<i>telangiectasis</i>) and acne lesions are often present&mdash;
+constituting the middle stage or grade of the disease; this is the
+type most frequently met with. In exceptional instances, still further
+hypertrophy of the bloodvessels ensues, the glands are enlarged,
+and a variable degree of connective-tissue new growth is added; this
+latter is usually slight, but may be excessive, the nose presenting an
+enlarged and lobulated appearance (<i>rhinophyma</i>).</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 25.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_127.jpg'>
+<img src='images/127.jpg' width='400' height='579'
+alt='FIG. 25.'
+title='FIG. 25.' />
+</a>
+</div>
+<p class='center'>Acne Rosacea.</p>
+
+
+<p><span class='pagenum'><a name='Page_128' id='Page_128'></a><a href='#TOC'>[Pg 128]</a></span></p>
+
+
+<p><b>Are there any subjective symptoms in acne rosacea?</b></p>
+
+<p>As a rule, no. Some of the acne lesions may be tender and painful,
+and at times there is a feeling of heat and burning.</p>
+
+
+<p><b>What do you know in regard to the etiology?</b></p>
+
+<p>In many cases the causes are obscure. Chronic digestive and intestinal
+disorders, an&aelig;mia, chlorosis, continued exposure to heat or
+cold, menstrual and uterine irregularities, and the too free use of
+spirituous liquors, tea, etc. are often responsible factors.</p>
+
+<p>It is essentially a disease of adult life, common about middle age,
+occurring in both sexes, but rarely reaching the same degree of development
+in women as observed at times in men.</p>
+
+
+<p><b>Is acne rosacea easily recognized?</b></p>
+
+<p>Yes. The redness, acne lesions, dilated capillaries, and, at times,
+the glandular and connective-tissue hypertrophy; the limitation of
+the eruption to the face, especially the region of the nose; the evident
+involvement of the sebaceous glands, the absence of ulceration, taken
+with the history of the case, are characteristic.</p>
+
+<p>It is to be distinguished from the tubercular syphiloderm and
+lupus vulgaris, diseases to which it may bear rough resemblance.</p>
+
+
+<p><b>State the prognosis of acne rosacea.</b></p>
+
+<p>All cases may be favorably influenced by treatment; the mild
+and moderately-developed types are, as a rule, curable, but usually
+obstinate. It is a persistent disease, showing little, if any, tendency
+to disappear spontaneously.</p>
+
+
+<p><b>What is the method of treatment?</b></p>
+
+<p>Both constitutional and local measures are demanded in most
+cases.</p>
+
+
+<p><b>Upon what is the constitutional treatment to be based?</b></p>
+
+<p>The constitutional treatment, beyond a regulation of the diet, is
+to be based upon a correct appreciation of the etiological factors in
+the individual case. There are no special remedies. Iron, cod-liver
+oil, tonics, ergot, alkalies, saline laxatives, and similar drugs are to
+be variously prescribed.</p>
+
+
+<p><b>What is the external treatment?</b></p>
+
+<p>In many respects, both as to the preliminary measures and remedies,
+<span class='pagenum'><a name='Page_129' id='Page_129'></a><a href='#TOC'>[Pg 129]</a></span>
+essentially the same as that employed in the treatment of simple
+acne (<i>q. v.</i>). The <i>x</i>-ray treatment is not so efficient in this disease,
+however, as in acne. In addition to the treatment there found,
+several other applications deserve mention:&mdash;</p>
+
+<p>In many cases <i>Vleminckx's solution</i><a name='FNanchor_A_3' id='FNanchor_A_3'></a><a href='#Footnote_A_3' class='fnanchor'>[C]</a> is valuable, applied diluted
+with one to ten parts of water. Also, a mucilaginous paste containing
+sulphur:&mdash;</p>
+
+<pre>
+  &#8478; Mucilag. acaci&aelig;, ................................ f&#658;iij
+    Glycerin&aelig;, ...................................... f&#658;ij
+    Sulphur, pr&aelig;cip., ................................ &#658;iij.   M.
+</pre>
+
+<div class='footnote' style='margin-left: 5em;'><p><a name='Footnote_A_3' id='Footnote_A_3'></a><a href='#FNanchor_A_3'><span class='label'>[C]</span></a></p>
+
+
+<pre>
+  &#8478; Calcis, .......................................... &#8485;ss
+    Sulph. sublimat., ................................ &#8485;j
+    Aqu&aelig;, ............................................ &#8485;x.
+</pre>
+
+
+<p>To be boiled down to &#8485;vj and filtered.</p></div>
+
+<p>Or a similar paste with the glycerine in the foregoing replaced with
+ichthyol may be used.</p>
+
+
+<p><b>In what manner are the dilated bloodvessels and connective-tissue
+hypertrophy to be treated?</b></p>
+
+<p>The enlarged capillaries are to be destroyed by incision or by electrolysis.
+Properly managed the vessels may be thus destroyed, but
+unless the predisposing causes have disappeared or have been remedied,
+a new growth may take place.</p>
+
+<p>If the knife is employed, the vessels are either slit in their length
+or cut transversely at several points. The method by electrolysis is
+the same as used in the removal of superfluous hair (<i>q. v.</i>).; the
+needle may, if the vessel is short, be inserted along its calibre, or if
+long, may be inserted at several points in its length.</p>
+
+<p>Excessive connective-tissue growth, exceptionally met with, is to
+be treated by ablation with the scissors or knife.</p>
+
+
+<h2><a name='Acne_Varioliformis' id='Acne_Varioliformis'></a><b>Acne Varioliformis.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne;
+Necrotic Granuloma.)</p>
+
+
+<p><b>Describe acne varioliformis.</b></p>
+
+<p>Acne varioliformis is characterized by lesions of a moderately
+superficial papulo-pustular type, which in disappearing leave slight or <span class='pagenum'><a name='Page_130' id='Page_130'></a><a href='#TOC'>[Pg 130]</a></span>
+well-marked pit-like scars. The forehead and scalp are the favorite
+sites, but they may also occur elsewhere. The eruption is rather
+scanty as a rule, consisting usually of ten to thirty lesions. They
+begin as small maculo-papules, as papules, or as minute nodules in
+or on the skin, and gradually become small pea-sized, with a tendency
+to slight vesiculation or pustulation at the central part. The
+lesion is sluggish in its course, drying to a thin crust, which finally
+falls off, leaving a depressed variola-like scar. New lesions arise
+from time to time, and the disease thus continues almost indefinitely.
+There may or may not be itching. In what appears to be a variety
+of this disease, known usually as <i>acne urticata</i>, there is considerable
+itching just at the time the lesion is appearing. The malady is not
+frequent, but occurs in both sexes, usually in those between the ages
+of twenty and fifty. It seems probable that the eruption is parasitic
+in origin.</p>
+
+<p>The maladies variously known as hydradenitis suppurativa, acnitis,
+spiradenitis, folliclis, granuloma necroticum, etc., in which the lesions,
+primarily at least, are somewhat deeper seated, sluggish in their
+course, and followed by scarring, could be also included under this
+head.</p>
+
+<p><b>Give the prognosis and treatment.</b></p>
+
+<p>The disease is rebellious and tends to recur. The most efficient
+applications are those of sulphur and resorcin, the same as prescribed
+in ordinary acne.</p>
+
+
+<h2><a name='Sycosis' id='Sycosis'></a><b>Sycosis.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis Barb&aelig;; Sycosis Coccogenica.)</p>
+
+<p><b>What do you understand by sycosis?</b></p>
+
+<p>Sycosis is a chronic, inflammatory affection involving the
+hair-follicles, usually of the moustache and bearded regions only, and
+characterized by papules, tubercles, and pustules perforated by hairs.</p>
+
+<p><b>Describe the symptoms of sycosis.</b></p>
+
+<p>Sycosis begins by the formation of papules and pustules about
+the hair-follicles; the lesions occur in numbers, in close proximity,
+<span class='pagenum'><a name='Page_131' id='Page_131'></a><a href='#TOC'>[Pg 131]</a></span>
+and together with the accompanying inflammation, make up a small
+or large area. The pustules are small, rounded, flat or acuminated,
+discrete, and yellowish in color; they are perforated by hairs, show
+no tendency to rupture, and are apt to occur in crops, drying to thin
+yellowish or brownish crusts. Papules and tubercles are often intermingled.
+More or less swelling and infiltration are noticeable.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 26.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_131.jpg'>
+<img src='images/131.jpg' width='400' height='291'
+alt='FIG. 26.'
+title='FIG. 26.' />
+</a>
+</div>
+
+<p class='center'>Sycosis&mdash;not infrequently begins in, and sometimes limited to, this region.</p>
+
+<p>The disease is seen, as a rule, only on the bearded part of the face,
+either about the cheeks, chin or upper lip, involving a small portion
+or the whole of these parts. It is also sometimes met with involving
+the hair follicles just within the nasal orifice, and may even be
+limited to this region.</p>
+
+<p>Occasionally a sycosiform eruption, usually of the side of the
+bearded region, leaves behind a smooth or keloidal scar, the disease
+gradually extending&mdash;<i>ulerythema sycosiforme</i> (lupoid sycosis).</p>
+
+<p>An inflammation of the hair-follicles of the scalp apparently
+sycosiform in character, occurring as discrete or aggregated lesions,
+is sometimes observed, the follicles being destroyed and atrophy or
+slight scarring resulting&mdash;<i>folliculitis decalvans</i>.</p>
+
+<p><b>Does conspicuous hair loss occur in sycosis?</b></p>
+
+<p>Ordinarily not; the hairs are, especially at first, usually firmly
+seated, but in those cases in which suppuration is active, and has
+<span class='pagenum'><a name='Page_132' id='Page_132'></a><a href='#TOC'>[Pg 132]</a></span>
+involved the follicles, they may, as a rule, be easily extracted. In
+some cases destruction of the follicles ensues and slight scarring and
+permanent hair loss result.</p>
+
+<p><b>State the character of the subjective symptoms.</b></p>
+
+<p>Pain and itching and a sense of burning, variable as to degree,
+may be present.</p>
+
+<p><b>What is the course of the disease?</b></p>
+
+<p>Essentially chronic, the inflammatory action being of a subacute
+or sluggish character, with acute exacerbations.</p>
+
+<p><b>State the causes of sycosis.</b></p>
+
+<p>Upon the upper lip it may have its origin in a nasal catarrh.
+Entrance into the follicles of pyogenic micrococci is now regarded as
+the essential factor. This view being accepted, carries with it the
+possibility of contagiousness.</p>
+
+<p>It is seen in the male sex only, usually in those between the ages
+of twenty-five and fifty; and is met with in those in good and bad
+health, and among rich and poor. It is comparatively infrequent.</p>
+
+<p><b>What is the pathology of sycosis?</b></p>
+
+<p>The disease is primarily a perifolliculitis, the follicle and its sheath
+subsequently becoming involved in the inflammatory process.</p>
+
+<p><b>How would you distinguish sycosis from eczema?</b></p>
+
+<p>Eczema is rarely sharply limited to the bearded region, but is apt
+to involve other parts of the face; moreover, the lesions are usually
+confluent, and there is either an oozing, red crusted surface, or it is
+dry and scaly.</p>
+
+<p><b>How would you exclude tinea sycosis in the diagnosis?</b></p>
+
+<p>In tinea sycosis, or ringworm sycosis, the history of the case is
+different. The parts are distinctly lumpy and nodular; the hairs
+are soon involved and become dry, brittle, loose, and fall out, or
+they may be readily extracted. The superficial type of ringworm
+sycosis is readily distinguished by the ring-like character of the
+patches. In doubtful cases, microscopic examination of the hairs
+may be resorted to.</p>
+
+<p><b>Give the prognosis of sycosis.</b></p>
+
+<p>The disease is curable, but almost invariably obstinate and rebellious
+to treatment. The duration, extent, and character of the
+<span class='pagenum'><a name='Page_133' id='Page_133'></a><a href='#TOC'>[Pg 133]</a></span>
+inflammatory process must all be considered. An expression of an
+opinion as to the length of time required for a cure should always
+be guarded.</p>
+
+<p>Ulerythema sycosiforme is extremely obstinate. Folliculitis decalvans
+is also rebellious.</p>
+
+<p><b>How is sycosis to be treated?</b></p>
+
+<p>Mainly, and often exclusively, by external applications.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 27.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_133.jpg'>
+<img src='images/133.jpg' width='400' height='294'
+alt='FIG. 27.'
+title='FIG. 27.' />
+</a>
+</div>
+<p class='center'>Sycosis.</p>
+
+<p><b>Is constitutional treatment of no avail in sycosis?</b></p>
+
+<p>In some instances; but, as a rule, it is negative. If indicated,
+such remedies as tonics, alteratives, cod-liver oil and the like are to
+be prescribed.</p>
+
+<p><b>Describe the external treatment.</b></p>
+
+<p>Crusting, if present, is to be removed by warm embrocations. If
+the inflammation is of a high grade, and the parts tender and painful,
+soothing applications, such as bland oils, black wash and oxide-of-zinc
+ointment, cold cream and petrolatum, are to be used;
+<span class='pagenum'><a name='Page_134' id='Page_134'></a><a href='#TOC'>[Pg 134]</a></span>
+boric-acid solution, fifteen grains to the ounce, may be advised in place of
+black wash.</p>
+
+<p>In most cases, however, astringent and stimulating remedies are
+demanded from the start, such as: diachylon ointment, alone or
+with ten to thirty grains of calomel to the ounce; oleate of mercury,
+as a five- to twenty-per-cent. ointment; precipitated sulphur, one
+to three drachms to the ounce of benzoated lard, or lard and lanolin;
+a ten- to twenty-five-per-cent. ichthyol ointment; and resorcin lotion
+or ointment, ten to twenty per cent. strength.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 28.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_134.jpg'>
+<img src='images/134.jpg' width='400' height='357'
+alt='FIG. 28.'
+title='FIG. 28.' />
+</a>
+</div>
+<p class='center'>Sycosis.</p>
+
+
+<p>A change from one application to another will be found necessary
+in almost all cases.</p>
+
+<p>In obstinate cases the x-ray treatment can be used, as it has
+proved itself valuable in some instances; as in other diseases, it
+should be employed cautiously.</p>
+
+<p><b>What would you advise in regard to shaving?</b></p>
+
+<p>When bearable (and after a few days' application of soothing
+remedies it almost always is), it is to be advised in all cases, as it
+<span class='pagenum'><a name='Page_135' id='Page_135'></a><a href='#TOC'>[Pg 135]</a></span>
+materially aids in the treatment. After a cure is effected it should
+be continued for some months, until the healthy condition of the
+parts is thoroughly established.</p>
+
+<p><b>When is depilation advisable as a therapeutic measure?</b></p>
+
+<p>When the suppurative process is active, in order to save the follicles
+from destruction; incising or puncturing the pustules will often
+accomplish the same end.</p>
+
+<p>Depilation is in all cases a valuable therapeutic measure, but it is
+painful; as a routine practice, shaving is less objectionable and, upon
+the whole, is probably as satisfactory. Those who make free use
+of the x-ray commonly push it to the point of producing depilation.</p>
+
+
+<h2><a name='Dermatitis_Papillaris_Capillitii' id='Dermatitis_Papillaris_Capillitii'></a><b>Dermatitis Papillaris Capillitii.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Acne Keloid.)</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 29.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_135.jpg'>
+<img src='images/135.jpg' width='400' height='351'
+alt='FIG. 29.'
+title='FIG. 29.' />
+</a>
+</div>
+<p class='center'>Dermatitis Papillaris Capillitii</p>
+
+<p><b>Describe dermatitis papillaris capillitii.</b></p>
+
+<p>This is a peculiar, mildly inflammatory, sycosiform, keloidal,
+acne-like disease of the hairy border of the back of the neck,
+often extending upward to the occipital region; partaking,
+<span class='pagenum'><a name='Page_136' id='Page_136'></a><a href='#TOC'>[Pg 136]</a></span>
+especially later in its course, somewhat of the nature of keloid. Several
+or more acne-like lesions, papular and pustular, closely grouped or
+bunched, appear, developing slowly, usually to the size of peas; are
+red, pale red, or whitish, often enveloping small tufts of hair, and
+attended with more or less hair loss. Its course is gradual and
+persistent. It is an exceedingly rare condition, the exact nature
+of which is still obscure.</p>
+
+<p><b>Give the treatment.</b></p>
+
+<p>Treatment, which is usually unsatisfactory, consists of stimulating
+applications&mdash;the same, in fact, as employed in sycosis, sulphur and
+ichthyol deserving special mention. Depilation is essential.</p>
+
+
+<h2><a name='Impetigo_Contagiosa' id='Impetigo_Contagiosa'></a><b>Impetigo Contagiosa.</b></h2>
+
+<p><b>Give a descriptive definition of impetigo contagiosa.</b></p>
+
+<p>Impetigo contagiosa is an acute, contagious, inflammatory disease,
+characterized by the formation of discrete, superficial, flat,
+rounded, or ovalish vesicles or blebs, soon becoming vesico-pustular,
+and drying to thin yellowish crusts.</p>
+
+<p><b>Upon what parts does the eruption commonly appear?</b></p>
+
+<p>Upon the face, scalp, and hands, and exceptionally upon other regions.</p>
+
+<p><b>Describe the symptoms of impetigo contagiosa.</b></p>
+
+<p>One, several or more small pin-head-sized papulo-vesicles or vesicles
+make their appearance, usually upon the face and fingers. In the
+male adult the region of the neck and beard is a favorite situation.
+They increase in size by extending peripherally, but are more or less
+flattened and umbilicated, and are without conspicuous areola. The
+lesions may attain the size of a dime or larger, and when close
+together may coalesce and form a large patch. In some cases distinct
+blebs result, and a picture of pemphigus eruption presented;
+it is probable that many of the cases of &ldquo;contagious pemphigus&rdquo;
+belong to this class. New lesions may appear for several days,
+but finally, in the course of a week or ten days, they have all dried
+to thin, wafer-like crusts, of a straw or light-yellow color, but slightly
+adherent, and appearing as if stuck on; these soon drop off, leaving
+faint reddish spots, which gradually fade. In some cases there is
+<span class='pagenum'><a name='Page_137' id='Page_137'></a><a href='#TOC'>[Pg 137]</a></span>
+so decided a tendency to clear and dry up centrally while spreading
+peripherally that the eruption has a ring-like aspect; this seems
+especially so in the bearded region of the male adult.</p>
+
+<p>Instead of presenting as described, it may occur as one or more
+pea- or finger-nail-sized, rounded and elevated, usually firm, discrete
+pustules, scattered over one part, or more commonly over various
+regions, such as the face, hands, feet and lower extremities. The
+pustules are such from the beginning, and when developed are
+usually of the size of a pea or finger-nail, elevated, semi-globular or
+rounded, with somewhat thick and tough walls, and of a whitish or
+yellowish color; at first there may be a slight inflammatory areola,
+but as the lesion matures this almost, if not entirely, disappears.
+The pustules show no disposition to umbilication, rupture or coalescence;
+drying in the course of several days or a week to yellowish
+or brownish crusts, which soon drop off, leaving no permanent trace.
+This variety was formerly thought to be a distinct disease, and
+was described under the name of <i>impetigo simplex</i>.</p>
+
+<p>As a rule there are no constitutional symptoms, but in the more
+severe cases the eruption may be preceded by febrile disturbance
+and malaise. Itching may or may not be present.</p>
+
+
+<p><b>State the cause of the disease.</b></p>
+
+<p>It is contagious, the contents of the lesions being inoculable and
+auto-inoculable. At times it seems to prevail in epidemic form.
+Pyogenic micro&ouml;rganisms are now regarded as causative. A relationship
+to vaccination has been alleged by some observers. It is
+more commonly observed in infants and young children.</p>
+
+
+<p><b>From what diseases is impetigo contagiosa to be differentiated?</b></p>
+
+<p>From eczema, pemphigus, and ecthyma.</p>
+
+
+<p><b>How does impetigo contagiosa differ from these several diseases?</b></p>
+
+<p>By the character of the lesions, their growth, their superficial
+nature, their course, the absence of an inflammatory base and areola,
+the thin, yellowish, wafer-like crusts, and usually a history of contagion.
+<span class='pagenum'><a name='Page_138' id='Page_138'></a><a href='#TOC'>[Pg 138]</a></span></p>
+
+<p><b>State the prognosis.</b></p>
+
+<p>The effect of treatment is usually prompt. The disease, indeed,
+tends to spontaneous disappearance in two to four weeks; in exceptional
+instances, more especially in those cases in which itching is
+present, the excoriations or scratch-marks become inoculated, and
+in this way it may persist several weeks.</p>
+
+
+<p><b>What is the treatment of impetigo contagiosa?</b></p>
+
+<p>Treatment consists in the destruction of the auto-inoculable properties
+of the contents of the lesions; this is effected by removing
+the crusts by means of warm water-and-soap washings, and subsequently
+rubbing in an ointment of ammoniated mercury, ten to
+twenty grains to the ounce. Some cases respond more rapidly to
+the use of a drying ointment, such as Lassar's paste, with ten to
+twenty grains of white precipitate or sulphur to the ounce. In
+itching cases, a saturated solution of boric acid, or a carbolic-acid
+lotion, one to two drachms to the pint, is to be employed for general
+application.</p>
+
+
+<h2><a name='Impetigo_Herpetiformis' id='Impetigo_Herpetiformis'></a><b>Impetigo Herpetiformis.</b></h2>
+
+
+<p><b>Describe impetigo herpetiformis.</b></p>
+
+<p>Impetigo herpetiformis is an extremely rare disease, observed
+usually in pregnant women, and is characterized by the appearance
+of numerous isolated and closely-crowded pin-head-sized superficial
+pustules, which show a decided disposition to the formation of circular
+groups or patches. The central portion of these groups dries to
+crusts, while new pustules appear at the peripheral portion. They
+tend to coalesce, and in this manner a greater part of the whole surface
+may, in the course of weeks or months, become involved. Profound
+constitutional disturbance, usually of a septic character, precedes
+and accompanies the disease; in almost every instance a fatal
+termination sooner or later results.</p>
+
+<p>It is possibly a grave type of dermatitis herpetiformis.</p>
+
+
+<h2><a name='Ecthyma' id='Ecthyma'></a><b>Ecthyma.</b></h2>
+
+
+<p><b>Give a descriptive definition of ecthyma.</b></p>
+
+<p>Ecthyma is a disease characterized by the appearance of one, several
+or more discrete, finger-nail-sized, flat, usually markedly inflammatory
+pustules.
+<span class='pagenum'><a name='Page_139' id='Page_139'></a><a href='#TOC'>[Pg 139]</a></span></p>
+
+
+<p><b>Describe the symptoms and course of ecthyma.</b></p>
+
+<p>The lesions begin as small, usually pea-sized, pustules; increase
+somewhat in area, and when fully developed are dime-sized, or larger,
+somewhat flat, with a markedly inflammatory base and areola. At
+first yellowish they soon become, from the admixture of blood, reddish,
+and dry to brownish crusts, beneath which will be found superficial
+excoriations. The individual pustules are usually somewhat
+acute in their course, but new lesions may continue to appear from
+day to day or week to week. As a rule, not more than five to twenty
+are present at one time, and in most cases they are seated on the
+legs. More or less pigmentation, and sometimes superficial scarring,
+may remain to mark the site of the lesions.</p>
+
+<p>Itching is rarely present, but there may be more or less pain and
+tenderness.</p>
+
+
+<p><b>What is the cause of ecthyma?</b></p>
+
+<p>It is essentially a disease of the poorly cared-for and ill-fed; the
+direct exciting cause is the introduction of pyogenic micro&ouml;rganisms
+into the follicular openings. It is closely allied to impetigo contagiosa,
+and may in fact be regarded as a markedly inflammatory
+form of the latter affection. It seems much less contagious, however.
+It is commonly observed in male adults.</p>
+
+
+<p><b>From what diseases is ecthyma to be differentiated?</b></p>
+
+<p>From impetigo contagiosa, and the flat pustular syphiloderm.</p>
+
+
+<p><b>How is it distinguished from these several diseases?</b></p>
+
+<p>The size, shape, inflammatory action, and the depraved general
+condition, the distribution and lesser-contagiousness will distinguish
+it from impetigo contagiosa; and the absence of concomitant symptoms
+of syphilis, and of positive ulceration, as well as its distribution
+and more rapid and inflammatory course, will exclude the pustular
+syphiloderm.</p>
+
+
+<p><b>State the prognosis.</b></p>
+
+<p>The disease is readily curable, disappearing upon the removal of
+the predisposing cause and the employment of local antiseptic applications.
+<span class='pagenum'><a name='Page_140' id='Page_140'></a><a href='#TOC'>[Pg 140]</a></span></p>
+
+
+<p><b>What treatment is to be advised?</b></p>
+
+<p>Good food, proper hygiene and tonic remedies; and, locally, removal
+of the crusts and stimulation of the underlying surface with an
+ointment of ammoniated mercury, ten to thirty grains to the ounce.</p>
+
+<p>The following mild antiseptic lotion, which materially lessens the
+tendency to the formation of new lesions, may be applied to the
+affected region two or three times daily:&mdash;</p>
+
+<pre>
+  &#8478; Acidi borici, .................................... &#658;iv
+    Resorcini, ....................................... &#658;ij
+    Glycerin&aelig;, ...................................... f&#658;ij
+    Alcoholis, ...................................... f&#8485;j
+    Aqu&aelig;, ....................q.s. ad. ............... Oj.   M.
+</pre>
+
+<p>A weak lotion of thymol, corrosive sublimate or ichthyol would
+doubtless be equally effectual.</p>
+
+
+<h2><a name='Pemphigus' id='Pemphigus'></a><b>Pemphigus.</b></h2>
+
+
+<p><b>What do you understand by pemphigus?</b></p>
+
+<p>Pemphigus is an acute or chronic disease characterized by the successive
+formation of irregularly-scattered, variously-sized blebs.</p>
+
+
+<p><b>Name the varieties met with.</b></p>
+
+<p>Two varieties are usually described&mdash;pemphigus vulgaris and
+pemphigus foliaceus.</p>
+
+
+<p><b>Describe the symptoms and course of pemphigus vulgaris.</b></p>
+
+<p>With or without precursory symptoms of systemic disturbance,
+irregularly scattered blebs, few or in numbers, make their appearance,
+arising from erythematous spots or from apparently normal
+skin. They vary in size from a pea to a large egg, are rounded or
+ovalish, usually distended, and contain a yellowish fluid which, later,
+becomes cloudy or puriform. If ruptured, the rete is exposed, but
+the skin soon regains its normal condition; if undisturbed, the fluid
+usually disappears by absorption. Each lesion runs its course in
+several days or a week.</p>
+
+<p>A grave type of pemphigus is exceptionally observed in the newborn&mdash;<i>pemphigus
+neonatorum</i>.
+<span class='pagenum'><a name='Page_141' id='Page_141'></a><a href='#TOC'>[Pg 141]</a></span></p>
+
+
+<p><b>What course does pemphigus vulgaris pursue?</b></p>
+
+<p>Usually chronic. The disease may subside in several months and
+the process come to an end, constituting the acute type. As a rule,
+however, the disease is chronic, new blebs continuing to appear
+from time to time for an indefinite period.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 30.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_141.jpg'>
+<img src='images/141.jpg' width='400' height='424'
+alt='FIG. 30.'
+title='FIG. 30.' />
+</a>
+</div>
+
+<p class='center'>Pemphigus (mulatto).</p>
+
+
+<p><b>In what respects does the severe form of pemphigus vulgaris
+differ from the ordinary type?</b></p>
+
+<p>In the severe or malignant type the eruption is more profuse;
+there is marked, and often grave, systemic depression, and the
+lesions are attended with ulcerative action.</p>
+
+
+<p><b>Describe the symptoms and course of pemphigus foliaceus.</b></p>
+
+<p>In this, the grave type of the disease, the blebs are loose and
+flaccid, with milky or puriform contents, rupturing and drying to
+<span class='pagenum'><a name='Page_142' id='Page_142'></a><a href='#TOC'>[Pg 142]</a></span>
+crusts, which are cast off, disclosing the reddened corium. New
+blebs appear on the sites of disappearing or half-ruptured lesions,
+and the whole surface may be thus involved and the disease continue
+for years, compromising the general health and eventually
+ending fatally.</p>
+
+<p>In some cases of pemphigus (pemphigus vegetans) a vegetating
+or papillomatous condition develops from the base of the lesion,
+with an offensive discharge; it is usually a grave type of the
+malady.</p>
+
+<p>Exceptionally cases (dermatitis vegetans) are met with which
+have a close similarity in their symptoms to pemphigus vegetans,
+but in which the eruption is more or less limited to the genitocrural
+region. The disorder is not malignant and usually yields to cleanliness
+and antiseptics.</p>
+
+
+<p><b>What is the character of the subjective symptoms in pemphigus?</b></p>
+
+<p>The subjective symptoms consist variously of heat, tenderness,
+pain, burning and itching, and may be slight or troublesome.</p>
+
+
+<p><b>What is known in regard to the etiology of pemphigus?</b></p>
+
+<p>The causes are obscure; general debility, overwork, shock, nervous
+exhaustion, and septic conditions (micro&ouml;rganisms) are thought
+to be of influence. There seems no doubt that those who have to
+do with cattle products, especially butchers, are subjects of acute
+and usually grave pemphigus. Vaccination has exceptionally been
+responsible for the disease, probably through some coincidental infection.
+The disease is not contagious, nor is it due to syphilis. It
+may occur at any age.</p>
+
+<p>It is a rare disease, especially in this country. Most of the cases
+diagnosed as pemphigus by the inexperienced are examples of bullous
+urticaria, bullous erythema multiforme, and impetigo contagiosa.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>The lesions are superficially seated, usually between the horny
+layer and upper part of the rete. Round-cell infiltration and dilated
+blood vessels are found about the papill&aelig; and in the subcutaneous
+tissue. The contents of the blebs, always of alkaline reaction, are
+<span class='pagenum'><a name='Page_143' id='Page_143'></a><a href='#TOC'>[Pg 143]</a></span>
+at first serous, later containing blood corpuscles, pus, fatty-acid
+crystals, epithelial cells, and occasionally uric acid crystals and free
+ammonia.</p>
+
+
+<p><b>From what diseases is pemphigus to be differentiated?</b></p>
+
+<p>From herpes iris, the bullous syphiloderm, impetigo contagiosa
+and dermatitis herpetiformis.</p>
+
+
+<p><b>How do these several diseases differ from pemphigus?</b></p>
+
+<p>The acute course, small lesions, concentric arrangement, variegated
+colors, and distribution, in herpes iris; the thick, bulky, greenish
+crusts, the underlying ulceration, the course, history, and the presence
+of concomitant symptoms of syphilis, in the bullous syphiloderm;
+the history, course, distribution, the character of the crusting,
+and the contagious and auto-inoculable properties of the contents
+of the lesions, in impetigo contagiosa; the tendency to appear in
+groups, the smaller lesions, the intense itchiness, course, multiform
+characters of the eruption and the disposition to change of type in
+dermatitis herpetiformis,&mdash;will serve as differential points.</p>
+
+
+<p><b>State the prognosis of pemphigus.</b></p>
+
+<p>Its duration is uncertain, and the issue may in severe cases be fatal.
+In the milder types, after months or several years, recovery may
+take place.</p>
+
+<p>The extent and severity of the disease and the general condition
+of the patient are always to be considered before an opinion is
+expressed.</p>
+
+<p>Pemphigus neonatorum usually ends fatally.</p>
+
+
+<p><b>Give the treatment of pemphigus.</b></p>
+
+<p>Both constitutional and local measures are demanded. Good
+nutritious food and hygienic regulations are essential. Arsenic and
+quinia are the most valuable remedies. The former, in occasional
+instances, seems to have a specific influence, and should always be
+tried, beginning with small doses and increasing gradually to the
+point of tolerance and continued for several weeks or longer. The
+remedy should not be set aside as long as there are signs of improvement,
+unless the supervention of stomachic, intestinal or other disturbance
+demand its discontinuance. Other tonics, such as iron,
+strychnia and cod-liver oil, are also at times of service.
+<span class='pagenum'><a name='Page_144' id='Page_144'></a><a href='#TOC'>[Pg 144]</a></span>
+The blebs should be opened and the parts anointed or covered
+with a mild ointment. In more general cases bran, starch and
+gelatin baths, and in severe cases the continuous bath, if practicable,
+are to be used.</p>
+
+
+<h1><a name='CLASS_III_HEMORRHAGES' id='CLASS_III_HEMORRHAGES'></a><b>CLASS III.&mdash;HEMORRHAGES.</b></h1>
+
+
+<h2><a name='Purpura' id='Purpura'></a><b>Purpura.</b></h2>
+
+
+<p><b>Define purpura.</b></p>
+
+<p>Purpura is a hemorrhagic affection characterized by the appearance
+of variously-sized, usually non-elevated, smooth, reddish or
+purplish spots or patches, not disappearing under pressure.</p>
+
+
+<p><b>Name the several varieties met with.</b></p>
+
+<p>Three&mdash;purpura simplex, purpura rheumatica and purpura h&aelig;morrhagica;
+denoting, respectively, the mild, moderate and severe
+grade of the disease. The division is, to a great extent, an arbitrary
+one.</p>
+
+
+<p><b>Describe the clinical appearance and course of an individual
+lesion of purpura.</b></p>
+
+<p>The spot, which may be pin-head, pea-, bean-sized or larger,
+appears suddenly, and is of a bright red or purplish red color. Its
+brightness gradually fades, the color changing to a bluish, bluish-green,
+bluish- or greenish-yellow, dirty yellowish, yellowish-white,
+and finally disappearing; varying in duration from several days to
+several weeks.</p>
+
+
+<p><b>Describe the symptoms of purpura simplex.</b></p>
+
+<p>Purpura simplex, or the mild form, shows itself as pin-point to
+pea- or bean-sized, bright or dark-red spots, limited, as a rule, to the
+limbs, especially the lower extremities; fading gradually away and
+coming to an end in a few weeks, or new crops appearing irregularly
+for several months. There is rarely any systemic disturbance, and,
+as a rule, no subjective symptoms; in exceptional cases an urticarial
+element is added&mdash;<i>purpura urticans</i>.</p>
+
+
+<p><b>Describe the symptoms of purpura rheumatica.</b></p>
+
+<p>Purpura rheumatica (also called <i>peliosis rheumatica</i>) is usually
+preceded by symptoms of malaise, rheumatic pains and sometimes
+<span class='pagenum'><a name='Page_145' id='Page_145'></a><a href='#TOC'>[Pg 145]</a></span>
+swelling about the joints; these phenomena abate and frequently
+disappear upon the outbreak of the eruption. The lesions are pea-
+to dime-sized, smooth, non-elevated, or slightly raised, and of a reddish
+or purplish color; the eruption may be more or less generalized,
+most abundant upon the limbs, or it may be limited to these parts.
+It may end in a few weeks, or may persist for several months, new
+spots appearing irregularly or in the form of crops.</p>
+
+<p>As somewhat allied to this is another form (<i>Sch&ouml;nlein's disease</i>),
+quite alarming in its symptoms. It is rare. It is characterized by
+symptoms partaking of the nature of rheumatism, purpuric spots,
+blotches and ecchymoses, erythema multiforme, and often associated
+with considerable edema. The throat is also usually invaded, and
+indeed the first symptom is commonly in this region. Considerable
+constitutional disturbance, of a threatening character, is commonly
+observed. Recovery usually takes place.</p>
+
+<p><i>Henoch's purpura</i>, observed chiefly in children, resembles the
+above, with the erythema multiforme character and the &oelig;dematous
+swellings more pronounced, while the actual purpuric symptoms are
+less conspicuous. Gastric and intestinal symptoms and hemorrhages
+from the mucous membrane are commonly noted. It is fatal in
+about 20 per cent. of the cases.</p>
+
+
+<p><b>Describe the symptoms of purpura h&aelig;morrhagica.</b></p>
+
+<p>Purpura h&aelig;morrhagica (also called <i>land scurvy</i>) is characterized
+usually by premonitory, and frequently accompanying, symptoms of
+general distress, and by the appearance of coin to palm-sized, red or
+purplish hemorrhagic spots or patches, smooth, non-elevated or
+raised. Hemorrhage from the mouth, gums and other parts, slight
+or serious in character, may occur. New lesions continue to appear
+for several days or weeks; and in exceptional instances, repeated
+relapses take place, and the disease thus persists for months. It
+may end fatally.</p>
+
+
+<p><b>State the etiology of purpura.</b></p>
+
+<p>In most instances no cause can be assigned. The disease occurs
+at all ages from childhood to advanced life, and in individuals, apparently,
+in good and bad health alike. The hemorrhagic type is oftener
+seen in subjects debilitated or in a depraved state of health. A
+micro&ouml;rganism is also looked upon as a factor by some observers,
+especially in the grave type of disease.
+<span class='pagenum'><a name='Page_146' id='Page_146'></a><a href='#TOC'>[Pg 146]</a></span></p>
+
+
+<p><b>State the diagnostic characters of purpura.</b></p>
+
+<p>The appearance, irregularly or in crops, of bright-red or purplish
+spots, evidently of hemorrhagic nature, and not <i>disappearing upon
+pressure</i>, and as they are fading, going through the several changes
+of color usually observed in any ecchymosis.</p>
+
+
+<p><b>How does scurvy (scorbutus) differ from purpura?</b></p>
+
+<p>Scurvy, which may resemble the severe grade of purpura, has a
+different history, a recognizable cause, usually a peculiar distribution,
+and is accompanied with general weakness and a spongy, soft and
+bleeding condition of the gums.</p>
+
+
+<p><b>What is the pathology of purpura?</b></p>
+
+<p>The lesion of purpura consists essentially of a hemorrhage into
+the cutaneous tissues. The blood is subsequently absorbed, the
+h&aelig;matin undergoing changes of color from a red to greenish and
+pale yellow, and finally fading away.</p>
+
+<p><b>State the prognosis</b></p>
+
+<p>The milder varieties disappear in the course of several weeks or
+months, and are rarely of serious import; the outcome of purpura
+h&aelig;morrhagica is somewhat uncertain; although usually favorable, a
+fatal result from internal hemorrhage is possible. The variety
+known as Sch&ouml;nlein's disease is alarming, but seldom fatal. Henoch's
+disease is, however, always of grave import.</p>
+
+
+<p><b>What is the treatment of purpura?</b></p>
+
+<p>Hygienic and dietary measures, the administration of tonics and
+astringents, and, in severe cases, by relative or absolute rest.</p>
+
+<p>The drugs commonly prescribed are: ergot, oil of erigeron, oil of
+turpentine, quinia, strychnia, iron, mineral acids, and gallic acid.
+<i>External</i> treatment is rarely called for, but if deemed advisable, astringent
+lotions may be employed.</p>
+
+
+<h2><a name='Scorbutus' id='Scorbutus'></a><b>Scorbutus.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Scurvy; Sea Scurvy; Purpura Scorbutica.)</p>
+
+
+<p><b>Describe scorbutus.</b></p>
+
+<p>Scurvy is a peculiar constitutional state, developed in those living
+under bad hygienic conditions, and is characterized by emaciation,
+<span class='pagenum'><a name='Page_147' id='Page_147'></a><a href='#TOC'>[Pg 147]</a></span>
+general febrile and asthenic symptoms, a more or less swollen, turgid
+and spongy and even gangrenous condition of the gums; and concomitantly,
+or sooner or later, by the appearance, usually upon the
+lower portion of the legs only, of dark-colored hemorrhagic patches
+or blotches. The skin of the affected part may become brawny and
+slightly scaly, and not infrequently may break down and ulcerate.
+Hemorrhages from the various mucous surfaces, slight or grave,
+may also take place.</p>
+
+
+<p><b>State the etiology of scurvy.</b></p>
+
+<p>It is due to long-continued deprivation of proper food, especially
+of fruits and vegetables. Other bad hygienic conditions favor its
+development. It is seen most commonly in sailors and others taking
+long voyages.</p>
+
+
+<p><b>How is scurvy to be distinguished from purpura?</b></p>
+
+<p>By the asthenic and emaciated general condition and the peculiar
+puffy, spongy state of the gums. The cutaneous manifestation is
+more diffused, forming usually large palm-sized patches, and, as a
+rule, limited to the region of the ankles or lower part of the legs.</p>
+
+
+<p><b>Give the prognosis of scurvy.</b></p>
+
+<p>The disease is remediable, and usually rapidly so. In those instances
+in which the same bad hygienic conditions and the ingestion
+of improper food are continued, death finally results.</p>
+
+
+<p><b>What treatment would you advise in scurvy?</b></p>
+
+<p>Proper food, with an abundance of fruit and vegetables. Lemon or
+lime juice is especially valuable, and is to be taken freely. If indicated,
+tonics and stimulants are also to be prescribed. For the relief
+of the tumid, spongy condition of the gums, astringent and antiseptic
+mouth washes are to be employed.</p>
+
+<p>The cutaneous manifestations, when tending to ulceration, are to
+be treated upon general principles.
+<span class='pagenum'><a name='Page_148' id='Page_148'></a><a href='#TOC'>[Pg 148]</a></span></p>
+
+
+
+<h1><a name='CLASS_IV_HYPERTROPHIES' id='CLASS_IV_HYPERTROPHIES'></a><b>CLASS IV.&mdash;HYPERTROPHIES.</b></h1>
+
+
+<h2><a name='Lentigo' id='Lentigo'></a><b>Lentigo.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Freckle.)</p>
+
+
+<p><b>Describe lentigo.</b></p>
+
+<p>Lentigo, or freckle, is characterized by round or irregular, pin-head
+to pea-sized, yellowish, brownish or blackish spots, occurring
+usually about the face and the backs of the hands. It is a common
+affection, varying somewhat in the degree of development;
+the freckles present may be few and insignificant, or they may exist
+in profusion and be quite disfiguring. Heat and exposure favor their
+development. Those of light complexion, especially those with red
+hair, are its most common subjects. The color of the lesion is usually
+a yellowish-brown.</p>
+
+<p>It is common to all ages, but is generally seen in its greatest
+development during adolescence, the disposition to its appearance
+becoming less marked as age advances.</p>
+
+
+<p><b>What is the pathology of lentigo?</b></p>
+
+<p>Lentigo consists simply of a circumscribed deposit of pigment
+granules&mdash;merely a localized increase of the normal pigment, differing
+from chloasma (<i>q. v.</i>) only in the size and shape of the pigmentation.</p>
+
+
+<p><b>State the prognosis.</b></p>
+
+<p>The blemishes can be removed by treatment, but their return is
+almost certain.</p>
+
+
+<p><b>Name the several applications commonly employed for their
+removal.</b></p>
+
+<p>An aqueous or alcoholic solution of corrosive sublimate, one-half
+to three grains to the ounce; lactic acid, one part to from six to
+twenty parts of water; and an ointment containing a drachm each
+of bismuth subnitrate and ammoniated mercury to the ounce.</p>
+
+<p>The applications, which act by removing the epidermal and rete
+cells and with them the pigment, are made two or three times daily,
+and their use intermitted for a few days as soon as the skin becomes
+irritated or scaly.</p>
+
+<p>Touching each freckle for a few seconds with the electric needle,
+just pricking the epidermis, will occasionally remove the blemish.
+<span class='pagenum'><a name='Page_149' id='Page_149'></a><a href='#TOC'>[Pg 149]</a></span></p>
+
+
+<h2><a name='Chloasma' id='Chloasma'></a><b>Chloasma.</b></h2>
+
+
+<p><b>What do you understand by chloasma?</b></p>
+
+<p>Chloasma consists of an abnormal deposit of pigment, occurring as
+variously-sized and shaped, yellowish, brownish or blackish patches.</p>
+
+
+<p><b>Describe the clinical appearances of chloasma.</b></p>
+
+<p>Chloasma appears either in ill-defined patches, as is commonly the
+case, or as a diffuse discoloration. Its appearance is rapid or gradual,
+generally the latter. The patches are rounded or irregular, and
+usually shade off into the sound skin. One, several or more may be
+present, and coalescence may take place, resulting in a large irregular
+pigmented area. The color is yellowish, or brownish, and may
+even be blackish (<i>melasma, melanoderma</i>). The skin is otherwise
+normal. The face is the most common site.</p>
+
+
+<p><b>Into what two general classes may the various examples of
+chloasma be grouped?</b></p>
+
+<p>Idiopathic and symptomatic.</p>
+
+
+<p><b>What cases of chloasma are included in the idiopathic group?</b></p>
+
+<p>All those cases of pigmentation caused by external agents, such
+as the sun's rays, sinapisms, blisters, continued cutaneous hyper&aelig;mia
+from scratching or any other cause, etc.</p>
+
+
+<p><b>What cases of chloasma are included in the symptomatic
+group?</b></p>
+
+<p>All forms of pigment deposit which occur as a consequence of
+various organic and systemic diseases, as the pigmentation, for instance,
+seen in association with tuberculosis, cancer, malaria, Addison's
+disease, uterine affections, and the like. In such cases, with
+few exceptions, the pigmentation is usually more or less diffuse.</p>
+
+
+<p><b>What is chloasma uterinum?</b></p>
+
+<p>Chloasma uterinum is a term applied to the ill-defined patches of
+yellowish-brown pigmentation appearing upon the faces of women,
+usually between the ages of twenty-five and fifty. It is most commonly
+seen during pregnancy, but may occur in connection with any
+functional or organic disease of the utero-ovarian apparatus.
+<span class='pagenum'><a name='Page_150' id='Page_150'></a><a href='#TOC'>[Pg 150]</a></span></p>
+
+
+<p><b>What is argyria?</b></p>
+
+<p>Argyria is the term applied to the slate-like discoloration which
+follows the prolonged administration of silver nitrate.</p>
+
+
+<p><b>State the pathology of chloasma.</b></p>
+
+<p>The sole change consists in an increased deposit of pigment.</p>
+
+
+<p><b>Give the prognosis of chloasma.</b></p>
+
+<p>Unless a removal of the exciting or predisposing cause is possible,
+the prognosis is, as a rule, unfavorable, and the relief furnished by
+local applications usually but temporary.</p>
+
+
+<p><b>If constitutional treatment is advisable, upon what is it to be
+based?</b></p>
+
+<p>Upon general principles; there are no special remedies.</p>
+
+
+<p><b>How do external remedies act?</b></p>
+
+<p>Mainly by removing the rete cells and with them the pigmentation;
+and partly, also, by stimulating the absorbents.</p>
+
+
+<p><b>Are all external remedies which tend to remove the upper
+layers of the skin equally useful for this purpose?</b></p>
+
+<p>No; on the contrary some such applications are followed by an increase
+in the pigment deposit.</p>
+
+
+<p><b>Name the several applications commonly employed.</b></p>
+
+<p>Corrosive sublimate in solution, in the strength of one to four
+grains to the ounce of alcohol and water; a lotion made up as follows:&mdash;</p>
+
+<pre>
+  &#8478; Hydrargyri chlorid. corros., ..................... gr. iij-viij
+    Ac. acet. dilut., ............................... f&#658;ij
+    Sodii borat., .................................... &#8456;ij
+    Aqu&aelig; ros&aelig;, ...................................... f&#8485;iv.   M.
+</pre>
+
+<p>And also the following:&mdash;</p>
+
+<pre>
+  &#8478; Hydrargyri chlorid. corros., ..................... gr. iij-viij
+    Zinci sulphat.,
+    Plumbi acetat., ..................&#257;&#257;.............. &#658;ss
+    Aqu&aelig;, ........................................... f&#8485;iv.   M.
+</pre>
+
+<p>And lactic acid, with from five to twenty parts of water; and an
+<span class='pagenum'><a name='Page_151' id='Page_151'></a><a href='#TOC'>[Pg 151]</a></span>
+ointment containing a drachm each of bismuth subnitrate and white
+precipitate to the ounce. Hydrogen peroxide occasionally acts well.
+Trichloracetic acid, usually weakened with one or two parts water,
+may be cautiously tried. The application of a strong alcoholic solution
+of resorcin, twenty to fifty per cent. strength, is also valuable, as
+is also a two to ten per cent. alcoholic solution of salicylic acid.</p>
+
+<p>(Applications are made two or three times daily, and as soon as
+slight scaliness or irritation is produced are to be discontinued for
+one or two days.)</p>
+
+<p><i>Tattoo-marks</i> are difficult to remove. Excision is the surest
+method. Electrolysis, applying the needle at various points, somewhat
+close together, and using a fairly strong current&mdash;three to
+eight milliamp&egrave;res&mdash;will exceptionally, especially when repeated
+several times, produce a reactive inflammation and casting-off of the
+tissue containing the pigment; a scar is left.</p>
+
+<p>Several writers claim good results with glycerole of papain, pricking
+it in in the same manner as in tattooing.</p>
+
+<p><i>Gun-powder marks.</i> If recent, but a day or so after their occurrence,
+the larger specks may be picked or scraped out. Later,
+electrolysis, using a fairly strong current, may result in their removal.
+Their removal may also be satisfactorily effected with a
+minute cutaneous trephine.</p>
+
+
+<h2><a name='Keratosis_Pilaris' id='Keratosis_Pilaris'></a><b>Keratosis Pilaris.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Pityriasis Pilaris; Lichen Pilaris.)</p>
+
+
+<p><b>What is meant by keratosis pilaris?</b></p>
+
+<p>Keratosis pilaris may be defined as a hypertrophic affection
+characterized by the formation of pin-head-sized, conical, epidermic
+elevations seated about the apertures of the hair follicles.</p>
+
+
+<p><b>Describe the clinical appearances of keratosis pilaris</b>.</p>
+
+<p>The lesions are usually limited to the extensor surfaces of the
+thighs and arms, especially the former. They appear as pin-head-sized,
+whitish or grayish elevations, consisting of accumulations of
+epithelial matter about the apertures of the hair follicles. Each elevation
+is pierced by a hair, or the hair may be twisted and imprisoned
+within the epithelial mass; or it may be broken off just at the
+<span class='pagenum'><a name='Page_152' id='Page_152'></a><a href='#TOC'>[Pg 152]</a></span>
+point of emergence at the apex of the papule, in which event it may
+be seen as a dark, central speck. The skin is usually dry, rough and
+harsh, and in marked cases, to the hand passing over it, feels not
+unlike a nutmeg-grater. The disease varies in its development, in
+most cases being so slight as to escape attention. As a rule, it is
+free from itching.</p>
+
+
+<p><b>What course does keratosis pilaris pursue?</b></p>
+
+<p>It is sluggish and chronic.</p>
+
+
+<p><b>Mention some of the etiological factors.</b></p>
+
+<p>It is not an uncommon disease, and is seen usually in those who are
+unaccustomed to frequent bathing, being most frequently met with
+during the winter months. It is chiefly observed during early adult
+life.</p>
+
+
+<p><b>Is there any difficulty in the diagnosis?</b></p>
+
+<p>No. It is thought at times to bear some resemblance to goose-flesh
+(cutis anserina), the miliary papular syphiloderm in its desquamating
+stage, and lichen scrofulosus. In goose-flesh the elevations
+are evanescent and of an entirely different character; the papules
+of the syphiloderm are usually generalized, of a reddish color, tend
+to group, are more solid and deeply-seated, less scaly and are accompanied
+with other symptoms of syphilis; in lichen scrofulosus the
+papules are larger, incline to occur in groups, and appear usually
+upon the abdomen.</p>
+
+
+<p><b>State the prognosis.</b></p>
+
+<p>The disease yields readily to treatment.</p>
+
+
+<p><b>Give the treatment of keratosis pilaris.</b></p>
+
+<p>Frequent warm baths, with the use of a toilet soap or sapo viridis,
+will usually be found curative. Alkaline baths are also useful. In
+obstinate cases the ordinary mild ointments, glycerine, etc., are to be
+advised in conjunction with the baths.
+<span class='pagenum'><a name='Page_153' id='Page_153'></a><a href='#TOC'>[Pg 153]</a></span></p>
+
+
+<h2><a name='Keratosis_Follicularis' id='Keratosis_Follicularis'></a><b>Keratosis Follicularis.</b></h2>
+
+
+<p><b>Describe keratosis follicularis.</b></p>
+
+<p>Keratosis follicularis (<i>Darier's disease, ichthyosis follicularis, ichthyosis
+sebacea cornea, psorospermosis</i>) is a rare disease characterized
+by pin-head to pea-sized pointed, rounded, or irregularly-shaped
+grayish, brownish, red or even black, horny papules or elevations,
+arising from the sebaceous or hair-follicles. They are, for the most
+part, discrete, with a tendency here and there to form solid aggregations
+or areas. Many of them contain projecting cornified plugs
+which may be squeezed out, leaving pit-like depressions. The face,
+scalp, lower trunk, groins and flanks are the parts chiefly affected.
+The view advanced by Darier, that the malady was due to psorosperms,
+is now denied, the bodies thought to be such having been
+demonstrated to be due to cell transformation.</p>
+
+<p>As to treatment, in one instance the induction of a substitutive
+dermatic inflammation had a favorable influence.</p>
+
+
+<h2><a name='Molluscum_Epitheliale' id='Molluscum_Epitheliale'></a><b>Molluscum Epitheliale.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Molluscum Contagiosum; Molluscum Sebaceum; Epithelioma
+Molluscum.)</p>
+
+
+<p><b>Give a definition of molluscum epitheliale.</b></p>
+
+<p>Molluscum epitheliale is characterized by pin-head to pea-sized,
+rounded, semi-globular, or flattened, pearl-like elevations, of a whitish
+or pinkish color.</p>
+
+
+<p><b>Describe the symptoms and course of molluscum epitheliale.</b></p>
+
+<p>The usual seat is the face; not infrequently, however, the growths
+occur on other parts. The lesions begin as pin-head, waxy-looking,
+rounded or acuminated elevations, gradually attaining the size of
+small peas. They have a broad base or occasionally may tend to become
+pedunculated. They rarely exist in profusion, in most cases
+three to ten or twelve lesions being present. When fully developed
+they are somewhat flattened and umbilicated, with a central, darkish
+point representing the mouth of the follicle. They are whitish or
+pinkish, and look not unlike drops of wax or pearl buttons. At first
+they are firm, but eventually, in most cases, tend to become soft and
+break down. Not infrequently, however, the lesions disappear slowly
+by absorption, without apparent previous softening. Their course
+<span class='pagenum'><a name='Page_154' id='Page_154'></a><a href='#TOC'>[Pg 154]</a></span>
+is usually chronic. The contents, a cheesy-looking mass, may commonly
+be pressed out without difficulty.</p>
+
+
+<p><b>What is the cause of molluscum epitheliale?</b></p>
+
+<p>It is now generally accepted that the disease is mildly contagious.
+It occurs chiefly in children, and especially among the poorer classes.
+The belief in the parasitic nature of the disease is gaining ground;
+recently the opinion has been advanced that it is due to psorosperms
+(psorospermosis); but further investigations have indicated that
+these bodies were degenerated epithelia.</p>
+
+
+<p><b>State the pathology.</b></p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 31.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_154.jpg'>
+<img src='images/154.jpg' width='400' height='495'
+alt='FIG. 31.'
+title='FIG. 31.' />
+</a>
+</div>
+<p class='center'>Molluscum Epitheliale.</p>
+
+<p>According to recent investigations, molluscum epitheliale is to be
+regarded as a hyperplasia of the rete, the growth probably beginning
+in the hair-follicles; the so-called molluscum bodies&mdash;peculiar,
+<span class='pagenum'><a name='Page_155' id='Page_155'></a><a href='#TOC'>[Pg 155]</a></span>
+rounded or ovoidal, sharply-defined, fatty-looking bodies found in
+microscopical examination of the growth&mdash;are to be viewed as a
+form of epithelial degeneration.</p>
+
+
+<p><b>What are the diagnostic points in molluscum epitheliale?</b></p>
+
+<p>The size of the lesions, their waxy or glistening appearance, and
+the presence of the central orifice.</p>
+
+<p>It is to be differentiated from molluscum fibrosum, warts and acne.</p>
+
+
+<p><b>State the prognosis.</b></p>
+
+<p>The growths are amenable to treatment. In some instances the
+disease, after existing some weeks, tends to disappear spontaneously.</p>
+
+
+<p><b>What is the treatment of molluscum epitheliale?</b></p>
+
+<p>Incision and expression of the contents, and touching the base of
+the cavity with silver nitrate. Pedunculated growths may be ligated.
+In some cases an ointment of ammoniated mercury, twenty to forty
+grains to the ounce, applied, by gently rubbing, once or twice daily,
+will bring about a cure.</p>
+
+
+<h2><a name='Callositas' id='Callositas'></a><b>Callositas.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Tylosis; Tyloma; Callus; Callous; Callosity; Keratoma.)</p>
+
+
+<p><b>What do you understand by callositas?</b></p>
+
+<p>A hard, thickened, horny patch made up of the corneous layers
+of the epidermis.</p>
+
+
+<p><b>Describe the clinical appearances.</b></p>
+
+<p>Callosities are most common about the hands and feet, and consist
+of small or large patches of dry, grayish-yellow looking, hard,
+slight or excessive epidermic accumulations. They are somewhat
+elevated, especially at the central portion, and gradually merge into
+the healthy skin. The natural surface lines are in a great measure
+obliterated, the patches usually being smooth and horn-like.</p>
+
+<p><i>Keratosis palmaris et plantaris</i> (symmetric keratodermia), as regards
+the local condition, is a somewhat similar affection. It consists
+of hypertrophy of the corneous layer of the palm and soles,
+usually of a more or less horny and plate-like character, but is congenital
+or hereditary, and not necessarily dependent upon local friction
+or pressure.
+<span class='pagenum'><a name='Page_156' id='Page_156'></a><a href='#TOC'>[Pg 156]</a></span></p>
+
+
+<p><b>Are there any inflammatory symptoms in callositas?</b></p>
+
+<p>No; but exceptionally, from accidental injury, the subjacent corium
+becomes inflamed, suppurates, and the thickened mass is cast off.</p>
+
+
+<p><b>State the causes of callositas.</b></p>
+
+<p>Pressure and friction; for example, on the hands, from the use of
+various tools and implements, and on the feet from ill-fitting shoes.
+It is, indeed, often to be looked upon as an effort of nature to
+protect the more delicate corium.</p>
+
+<p>In exceptional instances it arises without apparent cause.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>The epidermis alone is involved; it consists, in fact, of a hyperplasia
+of the horny layer.</p>
+
+
+<p><b>State the prognosis of callositas.</b></p>
+
+<p>If the causes are removed, the accumulation, as a rule, gradually
+disappears. The effect of treatment is always rapid and positive,
+but unless the etiological factors have ceased to act, the result is
+usually but temporary.</p>
+
+
+<p><b>How is callositas treated?</b></p>
+
+<p>When treatment is deemed advisable, it consists in softening the
+parts with hot-water soakings or poultices, and subsequently shaving
+or scraping off the callous mass. The same result may also be often
+effected by the continuous application, for several days or a week, of
+a 10 to 15 per cent. salicylated plaster, or the application of a salicylated
+collodion, same strength; it is followed up by hot-water
+soaking, the accumulation, as a rule, coming readily away.</p>
+
+
+<h2><a name='Clavus' id='Clavus'></a><b>Clavus.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Corn.)</p>
+
+
+<p><b>What is clavus?</b></p>
+
+<p>Clavus, or corn, is a small, circumscribed, flattened, deep-seated,
+horny formation usually seated about the toes.</p>
+
+
+<p><b>Describe the clinical appearances.</b></p>
+
+<p>Ordinarily a corn has the appearance of a small callosity; the skin
+is thickened, polished and horny. Exceptionally, however,
+<span class='pagenum'><a name='Page_157' id='Page_157'></a><a href='#TOC'>[Pg 157]</a></span>
+occurring on parts that are naturally more or less moist, as between the
+toes, maceration takes place, and the result is the so-called <i>soft corn</i>.
+The dorsal aspect of the toes is the common site for the ordinary
+variety. The usual size is that of a small pea. They are painful
+on pressure, and, at times, spontaneously so.</p>
+
+
+<p><b>State the causes</b>.</p>
+
+<p>Corns are caused by pressure and friction, and may usually be referred
+to improperly fitting shoes.</p>
+
+
+<p><b>What is the pathology of clavus?</b></p>
+
+<p>It is a hypertrophy of the epiderm. Its shape is conical, with
+the base external and the apex pressing upon the papill&aelig;. It is, in
+fact, a peculiarly-shaped callosity, the central portion and apex
+being dense and horny, forming the so-called core.</p>
+
+
+<p><b>Give the treatment of clavus.</b></p>
+
+<p>A simple method of treatment consists in shaving off, after a preliminary
+hot-water soaking, the outer portion, and then applying a
+ring of felt or like material, with the hollow part immediately over
+the site of the core; this should be worn for several weeks. It is
+also possible in some cases to extract the whole corn by gently dissecting
+it out; the after-treatment being the same as the above.</p>
+
+<p>Another method is by means of a ten- to fifteen-per-cent. solution
+of salicylic acid, in alcohol or collodion, or the following:&mdash;</p>
+
+<pre>
+  &#8478; Ac. salicylici, .................................. gr. xxx
+    Ext. cannabis Ind., .............................. gr. x
+    Collodii, ....................................... f&#658;iv.   M.
+</pre>
+
+<p>This is painted on the corn night and morning for several days, at
+the end of which time the parts are soaked in hot water, and the
+mass or a greater part of it, will be found, as a rule, to come readily
+away; one or two repetitions may be necessary. Lactic acid, with
+one to several parts of water, applied once or twice daily, acts in a
+similar manner.</p>
+
+<p>Soft corns, after the removal of pressure, may be treated with the
+solid stick of nitrate of silver, or by any of the methods already
+mentioned.</p>
+
+<p>In order that treatment be permanently successful, the feet are to
+be properly fitted. If pressure is removed, corns will commonly
+disappear spontaneously.
+<span class='pagenum'><a name='Page_158' id='Page_158'></a><a href='#TOC'>[Pg 158]</a></span></p>
+
+
+<h2><a name='Cornu_Cutaneum' id='Cornu_Cutaneum'></a><b>Cornu Cutaneum.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Cornu Humanum; Cutaneous Horn.)</p>
+
+
+<p><b>What is cornu cutaneum?</b></p>
+
+<p>A cutaneous horn is a circumscribed hypertrophy of the epidermis,
+forming an outgrowth of horny consistence and of variable size and
+shape.</p>
+
+
+<p><b>At what age and upon what parts are cutaneous horns observed?</b></p>
+
+<p>They are usually met with late in life, and are mostly seated upon
+the face and scalp.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 32.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_158.jpg'>
+<img src='images/158.jpg' width='400' height='353'
+alt='FIG. 32.'
+title='FIG. 32.' />
+</a>
+</div>
+<p class='center'>Cutaneous Horns. Showing beginning epitheliomatous degeneration of the base.</p>
+<p class='center'>(<i>After Pancoast.</i>)</p>
+
+
+<p><b>Describe the clinical appearances.</b></p>
+
+<p>In appearance cutaneous horns resemble those seen in the lower
+animals, differing, if at all, but slightly. They are hard, solid, dry
+and somewhat brittle; usually tapering, and may be either straight,
+curved or crooked. Their surface is rough, irregular, laminated or
+<span class='pagenum'><a name='Page_159' id='Page_159'></a><a href='#TOC'>[Pg 159]</a></span>
+fissured, the ends pointed, blunt or clubbed. The color varies; it is
+usually grayish-yellow, but may be even blackish. As commonly
+seen they are small in size, a fraction of an inch or an inch or thereabouts
+in length, but exceptionally attain considerable proportions.
+The base, which rests directly upon the skin, may be broad, flattened,
+or concave, with the underlying and adjacent tissues normal
+or the papill&aelig; hypertrophied; and in some cases there is more or
+less inflammation, which may be followed by suppuration. They
+are usually solitary formations. They are not, as a rule, painful,
+unless knocked or irritated.</p>
+
+
+<p><b>What course do cutaneous horns pursue?</b></p>
+
+<p>Their growth is usually slow, and, after having attained a certain
+size, they not infrequently become loose and fall off; they are almost
+always reproduced.</p>
+
+
+<p><b>What is the cause of these horny growths?</b></p>
+
+<p>The cause is not known; appearing about the genitalia, they
+usually develop from acuminated warts. They are rare formations.</p>
+
+
+<p><b>State the pathology of cornu cutaneum.</b></p>
+
+<p>Horns consist of closely agglutinated epidermic cells, forming
+small columns or rods; in the columns themselves the cells are
+arranged concentrically. In the base are found hypertrophic papill&aelig;
+and some bloodvessels. They have their starting-point in the
+rete mucosum, either from that lying above the papill&aelig; or that
+lining the follicles and glands.</p>
+
+
+<p><b>Does epitheliomatous degeneration of the base ever occur?</b></p>
+
+<p>Yes.</p>
+
+
+<p><b>State the prognosis.</b></p>
+
+<p>Cutaneous horns may be readily and permanently removed.</p>
+
+
+<p><b>What is the treatment?</b></p>
+
+<p>Treatment consists in detachment, and subsequent destruction
+of the base; the former is accomplished by dissecting the horn away
+from the base or forcibly breaking it off, the latter by means of any
+of the well-known caustics, such as caustic potash, chloride of zinc
+and the galvano-cautery.</p>
+
+<p>Another method is to excise the base, the horn coming away with
+it; this necessitates, however, considerable loss of tissue.
+<span class='pagenum'><a name='Page_160' id='Page_160'></a><a href='#TOC'>[Pg 160]</a></span></p>
+
+
+<h2><a name='Verruca' id='Verruca'></a><b>Verruca.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Wart.)</p>
+
+
+<p><b>What is verruca?</b></p>
+
+<p>Verruca, or wart, is a hard or soft, rounded, flat, acuminated or
+filiform, circumscribed epidermal and papillary growth.</p>
+
+
+<p><b>Name the several varieties of warts met with.</b></p>
+
+<p>Verruca vulgaris, verruca plana, verruca plana juvenilis, verruca
+digitata, verruca filifortnis and verruca acuminata.</p>
+
+
+<p><b>Describe verruca vulgaris.</b></p>
+
+<p>This is the common wart, occurring mostly upon the hands. It is
+rounded, elevated, circumscribed, hard and horny, with a broad base,
+and usually the size of a pea. At first it is smooth and covered with
+slightly thickened epidermis, but later this disappears to some extent,
+the hypertrophied papill&aelig;, appearing as minute elevations,
+making up the growth. One, several or more may be present.</p>
+
+
+<p><b>Describe verruca plana.</b></p>
+
+<p>This is the so-called flat wart, and occurs commonly upon the
+back, especially in elderly people (<i>verruca senilis, keratosis pigmentosa</i>).
+It is, as a rule, but slightly elevated, is usually dark in color,
+and of the size of a pea or finger-nail.</p>
+
+
+<p><b>Describe verruca plana juvenilis.</b></p>
+
+<p>The warts are mostly pin-head in size, flat, but slightly elevated,
+rounded, irregular or square-shaped, and of a light yellowish-brown
+color. They bear resemblance to lichen planus papules. They are
+apt to be numerous, often becoming aggregated or fused, and occur
+usually in young children, and, as a rule, on the face and hands.</p>
+
+
+<p><b>Describe verruca filiformis.</b></p>
+
+<p>This is a thread-like growth about an eighth or fourth of an inch
+long, and occurring commonly about the face, eyelids and neck. It
+is usually soft to the touch and flexible.</p>
+
+
+<p><b>Describe verruca digitata.</b></p>
+
+<p>This is a variety of wart, which, especially about the edges, is
+marked by digitations, extending nearly or quite down to the base.
+It is commonly seen upon the scalp.
+<span class='pagenum'><a name='Page_161' id='Page_161'></a><a href='#TOC'>[Pg 161]</a></span></p>
+
+
+<p><b>Describe verruca acuminata.</b></p>
+
+<p>This variety (<i>venereal wart, pointed wart, pointed condyloma</i>),
+usually occurs about the genitalia, especially upon the mucous and
+muco-cutaneous surfaces. It consists of one or more groups of
+acuminated, pinkish or reddish, raspberry-like elevations, and, according
+to the region, may be dry or moist; if the latter, the secretion,
+which is usually yellowish and puriform, from rapid decomposition,
+develops an offensive and penetrating odor. The formation may be
+the size of a small pea, or may attain the dimensions of a fist.</p>
+
+
+<p><b>What is the cause of warts?</b></p>
+
+<p>The etiology is not known. They are more common in adolescent
+and early adult life. Irritating secretions are thought to be causative
+in the acuminated variety. It is highly probable that a parasitic
+factor will finally be demonstrated. They are doubtless mildly
+contagious.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 33.</b></p>
+<div class='figcenter' style='width: 399px;'>
+<a href='images/fullsize_161.jpg'>
+<img src='images/161.jpg' width='399' height='600'
+alt='FIG. 33.'
+title='FIG. 33.' />
+</a>
+</div>
+<p class='center'>Verruca Acuminata&mdash;about the anus. (<i>After Ashton.</i>)</p>
+
+
+<p><b>State the pathology of warts.</b></p>
+
+<p>A wart consists of both epidermic and papillary hypertrophy, the
+interior of the growth containing a vascular loop. In the acuminated
+variety there are marked papillary enlargement, excessive development
+of the mucous layer, and an abundant vascular supply.
+<span class='pagenum'><a name='Page_162' id='Page_162'></a><a href='#TOC'>[Pg 162]</a></span></p>
+
+
+<p><b>Give the treatment of warts.</b></p>
+
+<p>For ordinary warts, excision or destruction by caustics. The repeated
+application of a saturated alcoholic solution of salicylic acid is
+often curative, the upper portion being pared off from time to time.
+The filiform and digitate varieties may be snipped off with the
+scissors, and the base touched with nitrate of silver; or a ligature
+may be used. Curetting is a valuable operative method. The
+growths may also be removed by electrolysis. When warts are
+numerous and close together parasiticide applications can be daily
+made to the whole affected region. For this purpose a boric acid
+solution, containing five to thirty grains of resorcin to the ounce,
+and Vleminckx's solution, at first diluted, prove the most valuable.</p>
+
+<p>Verruca acuminata is to be treated by maintaining absolute cleanliness,
+and the application of such astringents as liquor plumbi
+subacetatis, tincture of iron, powdered alum and boric acid. The
+salicylic acid solution may also be used. In obstinate cases, glacial
+acetic acid or chromic acid may be cautiously employed.</p>
+
+<h2><a name='Naevus_Pigmentosus' id='Naevus_Pigmentosus'></a><b>N&aelig;vus Pigmentosus.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Mole.)</p>
+
+
+<p><b>Describe n&aelig;vus pigmentosus.</b></p>
+
+<p>N&aelig;vus pigmentosus, commonly known as mole, may be defined
+as a circumscribed increase in the pigment of the skin, usually associated
+with hypertrophy of one or all of the cutaneous structures,
+especially of the connective tissue and hair. It occurs singly or in
+numbers; is usually pea-, bean-sized or larger, rounded or irregular,
+smooth or rough, flat or elevated, and of a color varying from a light
+brown to black; the hair found thereon may be either colorless or
+deeply pigmented, coarse and of considerable length. It is, as a
+rule, a permanent formation.</p>
+
+
+<p><b>Name the several varieties of n&aelig;vus pigmentosus met with.</b></p>
+
+<p>N&aelig;vus spilus, n&aelig;vus pilosus, n&aelig;vus verrucosus, and n&aelig;vus lipomatodes.
+So-called linear n&aelig;vus might also be considered as
+belonging in this group.
+<span class='pagenum'><a name='Page_163' id='Page_163'></a><a href='#TOC'>[Pg 163]</a></span></p>
+
+
+<p><b>What is n&aelig;vus spilus?</b></p>
+
+<p>A smooth and flat n&aelig;vus, consisting essentially of augmented
+pigmentation alone.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 34.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_163.jpg'>
+<img src='images/163.jpg' width='400' height='561'
+alt='FIG. 34.'
+title='FIG. 34.' />
+</a>
+</div>
+<p class='center'>Linear N&aelig;vus.</p>
+
+
+<p><b>What is n&aelig;vus pilosus?</b></p>
+
+<p>A n&aelig;vus upon which there is an abnormal growth of hair, slight
+or excessive.</p>
+
+
+<p><b>What is n&aelig;vus verrucosus?</b></p>
+
+<p>A n&aelig;vus to which is added hypertrophy of the papill&aelig;, giving
+rise to a furrowed and uneven surface.</p>
+
+
+<p><b>What is linear n&aelig;vus?</b></p>
+
+<p>Linear n&aelig;vus is a formation usually of a verrucous character, more
+<span class='pagenum'><a name='Page_164' id='Page_164'></a><a href='#TOC'>[Pg 164]</a></span>
+or less pigmented, sometimes slightly scaly, occurring in band-like
+or zoster-like areas, and, as a rule, unilaterally.</p>
+
+
+<p><b>What is n&aelig;vus lipomatodes?</b></p>
+
+<p>A n&aelig;vus with excessive fat and connective-tissue hypertrophy.</p>
+
+
+<p><b>State the etiology of n&aelig;vus pigmentosus.</b></p>
+
+<p>The causes are obscure. The growths are usually congenital; but
+the smooth, non-hairy moles may be acquired.</p>
+
+
+<p><b>Give the pathology of n&aelig;vus pigmentosus.</b></p>
+
+<p>Microscopical examination shows a marked increase in the pigment
+in the lowest layers of the rete mucosum, as well as more or
+less pigmentation in the corium usually following the course of the
+bloodvessels; in the verrucous variety the papill&aelig; are greatly hypertrophied,
+in addition to the increased pigmentation. There is,
+as a rule, more or less connective-tissue hypertrophy.</p>
+
+
+<p><b>What is the treatment of n&aelig;vus pigmentosus?</b></p>
+
+<p>In many instances interference is scarcely called for, but when demanded
+consists in the removal of the formation either by the knife,
+by caustics, or by electrolysis. This last is, in the milder varieties
+at least, perhaps the best method, as it is less likely to be followed
+by disfiguring cicatrices. In n&aelig;vus pilosus the removal of the hairs
+alone by electrolysis is not infrequently followed by a decided diminution
+of the pigmentation. In recent years both liquid air and carbon
+dioxide have also been used successfully in the removal of these
+growths. Pigmented n&aelig;vi, which show the least tendency to growth
+or degenerative change, should be radically removed, as they not infrequently
+lead to carcinomatous and sarcomatous growths.
+<span class='pagenum'><a name='Page_165' id='Page_165'></a><a href='#TOC'>[Pg 165]</a></span></p>
+
+
+<h2><a name='Ichthyosis' id='Ichthyosis'></a><b>Ichthyosis.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Fish-skin Disease.)</p>
+
+
+<p><b>Give a descriptive definition of ichthyosis.</b></p>
+
+<p>Ichthyosis is a chronic, hypertrophic disease, characterized by dryness
+and scaliness of the skin, with a variable amount of papillary
+growth.</p>
+
+
+<p><b>At what age is ichthyosis first observed?</b></p>
+
+<p>It is first noticed in infancy or early childhood. In rare instances
+it is congenital (ichthyosis congenita), and in such cases it is usually
+severe, and of a grave type; the children are, as a rule, prematurely
+born, and frequently do not survive many days or weeks.</p>
+
+
+<p><b>What extent of surface is involved?</b></p>
+
+<p>Usually the whole surface, but it is most marked upon the extensor
+surfaces of the arms and legs, especially at the elbows and
+knees; the face and scalp, in mild cases, often remain free.</p>
+
+
+<p><b>Name the two varieties of ichthyosis usually described.</b></p>
+
+<p>Ichthyosis simplex and ichthyosis hystrix, terms commonly employed
+to designate the mild and severe forms respectively.</p>
+
+
+<p><b>Describe the clinical appearances of ichthyosis.</b></p>
+
+<p>The milder forms of the disease may be so slight as to give rise to
+simple dryness or harshness of the skin (<i>xeroderma</i>); but as commonly
+met with it is more developed, more or less marked scaliness in the
+form of thin or somewhat thick epidermal plates being present. The
+papill&aelig; of the skin are often slightly hypertrophied. In slight cases
+the color of the scales is usually light and pearly; in the more marked
+examples it is dark gray, olive green or black.</p>
+
+<p>In the severe variety&mdash;ichthyosis hystrix&mdash;in addition to scaliness
+there is marked papillary hypertrophy, forming warty or spinous
+patches. This type is rare, and, as a rule, the surface involved is
+more or less limited.</p>
+
+
+<p><b>Are there any inflammatory symptoms in ichthyosis?</b></p>
+
+<p>No. In fact, beyond the disfigurement, the disease causes no inconvenience;
+in those well-marked cases, however, in which the scales
+are thick and more or less immovable, the natural mobility of the
+parts is compromised and fissuring often occurs. In the winter
+<span class='pagenum'><a name='Page_166' id='Page_166'></a><a href='#TOC'>[Pg 166]</a></span>
+months, in the severer cases, exposed parts may become slightly
+eczematous.</p>
+
+
+<p><b>Does ichthyosis vary somewhat with the season?</b></p>
+
+<p>Yes. In all cases the disease is better in the warm months, and in
+the mild forms may entirely disappear during this time. This favorable
+change is purely mechanical&mdash;due to the maceration to which
+the increased activity of the sweat glands gives rise.</p>
+
+
+<p><b>Is the general health affected in ichthyosis?</b></p>
+
+<p>No.</p>
+
+
+<p><b>What course does ichthyosis pursue?</b></p>
+
+<p>Chronic. Beginning in early infancy or childhood, it usually becomes
+gradually more marked until adult age, after which time it, as a
+rule, remains stationary.</p>
+
+
+<p><b>What is the etiology?</b></p>
+
+<p>Beyond a hereditary influence, which is often a positive factor, the
+causes are obscure. It is not a common disease.</p>
+
+
+<p><b>State the pathology.</b></p>
+
+<p>Anatomically the essential feature is epidermic hypertrophy, with
+usually a varying degree of papillary hypertrophy also.</p>
+
+
+<p><b>Mention the diagnostic features of ichthyosis.</b></p>
+
+<p>The harsh, dry skin, epidermic and papillary hypertrophy, the
+furfuraceous or plate-like scaliness, the greater development upon
+the extensor surfaces, a history of the affection dating from early
+childhood, and the absence of inflammatory symptoms.</p>
+
+
+<p><b>How is ichthyosis to be distinguished from eczema, psoriasis,
+and other scaly inflammatory diseases?</b></p>
+
+<p>By the absence of the inflammatory element.</p>
+
+
+<p><b>What is the outlook for a case of ichthyosis?</b></p>
+
+<p>The prognosis is unfavorable as regards a cure, but the process
+may usually be kept in abeyance or rendered endurable by proper
+measures.</p>
+
+
+<p><b>What treatment would you prescribe for ichthyosis?</b></p>
+
+<p>Treatment that has in view removal of the scaliness and the
+maintenance of a soft and flexible condition of the skin.
+<span class='pagenum'><a name='Page_167' id='Page_167'></a><a href='#TOC'>[Pg 167]</a></span></p>
+
+<p>In mild cases frequent warm baths, simple or alkaline, will suffice;
+in others an application of an oily or fatty substance, such as the
+ordinary oils or ointments, made several hours or immediately before
+the bath may be necessary. In moderately developed cases the skin
+is to be washed energetically with sapo viridis and hot water, followed
+by a warm bath, after which an oily or fatty application is
+made. In some of the more severe cases the following plan is
+often useful: The parts are first rubbed with a soapy ointment consisting
+of one part of precipitated sulphur and seven parts of sapo
+viridis; a bath is then taken, the skin wiped dry, and a one to five
+per cent. ointment of salicylic acid gently rubbed in.</p>
+
+<p>Glycerine lotions, one or two drachms to the ounce of water, are
+also beneficial; as also the following:&mdash;</p>
+
+<pre>
+  &#8478; Ac. salicylici, .................................. gr. x-xl
+    Glycerini, ....................................... &#658;ss-&#658;j
+    Lanolin,
+    Petrolati, .....................................&#257;&#257; &#8485;ss
+</pre>
+
+<p>In severe cases of ichthyosis hystrix it may be necessary, also, to
+employ caustics or the knife.</p>
+
+
+<p><b>What systemic treatment would you prescribe?</b></p>
+
+<p>Constitutional remedies are practically powerless; occasionally
+some good is accomplished by the internal administration of linseed
+oil and jaborandi.</p>
+
+
+<h2><a name='Onychauxis' id='Onychauxis'></a><b>Onychauxis.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Hypertrophy of the Nail.)</p>
+
+
+<p><b>Describe onychauxis.</b></p>
+
+<p>Onychauxis, or hypertrophy of the nail, may take place in one
+or all directions, and this increase may be, and often is, accompanied
+by changes in shape, color, and direction of growth. One or all the
+nails may share in the process. As the result of lateral deviation
+of growth, the nail presses upon the surrounding tissues, producing
+a varying degree of inflammation&mdash;<i>paronychia</i>.</p>
+
+
+<p><b>What is the etiology of hypertrophy of the nail?</b></p>
+
+<p>The condition may be either congenital or acquired. In the latter
+<span class='pagenum'><a name='Page_168' id='Page_168'></a><a href='#TOC'>[Pg 168]</a></span>
+instances it is usually the result of the extension to the matrix of
+such cutaneous diseases as psoriasis and eczema; or it is produced by
+constitutional maladies, such as syphilis.</p>
+
+
+<p><b>Give the treatment of hypertrophy of the nail.</b></p>
+
+<p>Treatment consists in the removal of the redundant nail-tissue by
+means of the knife or scissors; and, when dependent upon eczema
+or psoriasis, the employment of remedies suitable for these diseases.
+When it is the result of syphilis, the medication appropriate to this
+disease is to be employed.</p>
+
+<p>In paronychia the nail should be frequently trimmed and a pledget
+of lint or cotton be interposed between the edge of the nail and the
+adjacent soft parts; astringent powders and lotions may often be
+employed with advantage; and in severe and persistent cases excision
+of the nail, partial or complete, may be found necessary.</p>
+
+
+<h2><a name='Hypertrichosis' id='Hypertrichosis'></a><b>Hypertrichosis.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Hirsuties; Hypertrophy of the Hair; Superfluous Hair.)</p>
+
+
+<p><b>What is meant by hypertrichosis?</b></p>
+
+<p>Hypertrichosis is a term applied to excessive growth of hair,
+either as regards region, extent, age or sex.</p>
+
+
+<p><b>Describe the several conditions met with.</b></p>
+
+<p>The unnatural hair growth may be slight, as, for instance, upon a
+n&aelig;vus (<i>n&aelig;vus pilosus</i>); or it may be excessive, as in the so-called
+hairy people (<i>homines pilosi</i>); or it may also appear on the face,
+arms and other parts in females, resulting from a hypertrophy of the
+natural lanugo hairs.</p>
+
+
+<p><b>State the causes of hypertrichosis.</b></p>
+
+<p>Hereditary influence is often a factor; the condition may also be
+congenital.</p>
+
+<p>If acquired, the tendency manifests itself usually toward middle
+life. In women, it is not infrequently associated with diseases of the
+utero-ovarian system; in many instances, however, there is no apparent
+cause. Local irritation or stimulation has at times a causative
+influence.
+<span class='pagenum'><a name='Page_169' id='Page_169'></a><a href='#TOC'>[Pg 169]</a></span></p>
+
+
+<p><b>How is hypertrichosis to be treated?</b></p>
+
+<p>For general hypertrichosis there is no remedy. Small hairy n&aelig;vi
+may be excised, or, as also in the larger hairy moles, the hairs may
+be removed by electrolysis.</p>
+
+<p>On the faces of women, if the hairs are coarse or large, electrolysis
+constitutes the only satisfactory method; if the hairs are small and
+lanugo-like, the operation is not to be advised. It is somewhat
+painful, but never unbearable. In the past several years the <i>x</i>-ray
+has been advocated by several writers, but it requires usually numerous
+exposures pushed to the point of producing erythema; it is not
+without risk, and the hairs are said to return in some months.</p>
+
+
+<p><b>What temporary methods are usually resorted to for the
+removal of superfluous hair?</b></p>
+
+<p>Shaving, extraction of the hairs and the use of depilatories. As
+a depilatory, a powder made up of two drachms of barium sulphide
+and three drachms each of zinc oxide and starch, is commonly (and
+cautiously) employed; at the time of application enough water is
+added to the powder to make a paste, and it is then spread thinly
+upon the parts, allowed to remain five to fifteen minutes, or until
+heat of skin or a burning sensation is felt, washed off thoroughly,
+and a soothing ointment applied. This preparation must be well
+prepared to be efficient.</p>
+
+
+<p><b>Describe the method of removal of superfluous hair by electrolysis.</b></p>
+
+<p>A fine needle in a suitable handle is attached to the <i>negative</i> pole
+of a <i>galvanic</i> battery, introduced into the hair-follicle to the depth
+of the papilla, and the circuit completed by the patient touching the
+positive electrode; in several seconds slight blanching and frothing
+usually appear at the point of insertion; a few seconds later the
+current is broken by release of the positive electrode, and the needle
+is then withdrawn. Sometimes a wheal-like elevation arises, remains
+several minutes or hours, and then disappears; or occasionally,
+probably from secondary infection, it develops into a pustule.</p>
+
+<p>A strength of current of a half to two milliamperes is usually
+sufficient; the time necessary for the destruction of the papilla
+varying from several to thirty seconds.
+<span class='pagenum'><a name='Page_170' id='Page_170'></a><a href='#TOC'>[Pg 170]</a></span></p>
+
+
+<p><b>How are you to know if the papilla has been destroyed?</b></p>
+
+<p>The hair will readily come out with but little, if any, traction.</p>
+
+
+<p><b>What is the result if the current has been too strong or too
+long continued?</b></p>
+
+<p>The follicle suppurates and a scar results.</p>
+
+
+<p><b>Why should contiguous hairs not be operated upon at the
+same sitting</b>?</p>
+
+<p>In order that the chances of marked inflammatory action and
+scarring (always possibilities) may be reduced to a minimum.</p>
+
+
+<p><b>In case of failure to destroy an individual papilla, should a
+second attempt be made at the same sitting?</b></p>
+
+<p>As a rule not, in order to avoid the possibility of too much destructive
+action, and consequent scarring.</p>
+
+
+<p><b>Can scarring always be prevented?</b></p>
+
+<p>In the average case, with skill and care, the use of an exceedingly
+fine needle and the avoidance of too strong a current, <i>perceptible</i>
+scarring (scarring perceptible to the ordinary observer or at ordinary
+distance) need rarely occur.</p>
+
+
+<p><b>What measures are to be advised for the irritation produced
+by the operation?</b></p>
+
+<p>Hot-water applications and the use of an ointment made of two
+drachms cold cream and ten grains of boric acid are of advantage not
+only in reducing the resulting hyper&aelig;mia, but also in preventing
+suppuration and consequent scarring. To lessen the chances of the
+latter, cleansing the parts with alcohol just before and after the
+operation is also of service.</p>
+
+
+<h2><a name='Oedema_Neonatorum' id='Oedema_Neonatorum'></a><b>&OElig;dema Neonatorum.</b></h2>
+
+
+<p><b>Describe &oelig;dema neonatorum.</b></p>
+
+<p>The essential symptoms are &oelig;dema and a variable degree of hardness
+and induration. It develops in the first few days of life, and
+usually upon the extremities, especially the lower. It may remain
+more or less limited to these parts, but, as a rule, slowly extends.
+<span class='pagenum'><a name='Page_171' id='Page_171'></a><a href='#TOC'>[Pg 171]</a></span>
+The skin is of a yellowish, dusky, or livid color, and sometimes glossy
+or shining. There are general symptoms of drowsiness, subnormal
+temperature, weakened circulation, and impaired respiration, which
+gradually increase, and in eighty to ninety per cent. of the cases lead
+to death. It is believed to be similar to anasarca in the adult and
+to be due to like causes.</p>
+
+<p>Treatment consists in maintaining the body-heat, sufficient and
+proper nourishment and stimulation.</p>
+
+
+<h2><a name='Sclerema_Neonatorum' id='Sclerema_Neonatorum'></a><b>Sclerema Neonatorum.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Scleroderma Neonatorum; Sclerema of the Newborn.)</p>
+
+
+<p><b>What is sclerema neonatorum?</b></p>
+
+<p>Sclerema neonatorum is a disease of infancy, showing itself usually
+at or shortly after birth, and is characterized by a diffuse stiffness
+and rigidity of the integument, accompanied by coldness, &oelig;dema,
+discoloration, lividity and general circulatory disturbance.</p>
+
+
+<p><b>Describe the symptoms, course, nature and treatment of
+sclerema neonatorum.</b></p>
+
+<p>As a rule the disease first manifests itself upon the lower extremities,
+and then gradually, but usually rapidly, invades the trunk, arms
+and face. The surface is cold. The skin, which is noted to be
+reddish, purplish or mottled, is &oelig;dematous, stiff and tense; in consequence
+the infant is unable to move, respires feebly and usually
+perishes in a few days or weeks. In extremely exceptional instances
+the disease, after involving a small part, may retrogress and recovery
+take place.</p>
+
+<p>The disease is rare, and in most cases is found associated with
+pneumonia and with affections of the circulatory apparatus.</p>
+
+<p>Treatment should be directed toward maintaining warmth and
+proper alimentation.
+<span class='pagenum'><a name='Page_172' id='Page_172'></a><a href='#TOC'>[Pg 172]</a></span></p>
+
+
+<h2><a name='Scleroderma' id='Scleroderma'></a><b>Scleroderma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Sclerema; Scleriasis; Dermatosclerosis; Morph&oelig;a;
+Keloid of Addison.)</p>
+
+
+<p><b>What is scleroderma?</b></p>
+
+<p>Scleroderma is an acute or chronic disease of the skin characterized
+by a localized or general, more or less diffuse, usually pigmented,
+rigid, stiffened, indurated or hide-bound condition.</p>
+
+<p>Morph&oelig;a, by some formerly thought to be a distinct affection, is
+now believed to be a form of scleroderma; as typically met with it
+is characterized by one or more rounded, oval, or elongate, coin- to
+palm-sized, pinkish, or whitish ivory-looking patches. In some
+instances such patches are seen in association with the more classic
+type of scleroderma just defined.</p>
+
+
+<p><b>Describe the symptoms of ordinary scleroderma.</b></p>
+
+<p>The disease may be acute or chronic, usually the latter. A portion
+or almost the entire surface may be involved, or it may occupy
+variously sized and shaped areas. The integument becomes more
+or less rigid and indurated, hard to the touch, hide-bound, and in
+marked cases immobile. &OElig;dema may, especially in the more acute
+cases, precede the induration. Pigmentation, of a yellowish or
+brownish color, is often a precursory and accompanying symptom.
+The skin feels tight and contracted, and in some instances numbness
+and cramp-like pains are complained of.</p>
+
+
+<p><b>Describe the variety known as morph&oelig;a.</b></p>
+
+<p>The patches (one, several, or more), occurring most frequently
+about the trunk, are in the beginning usually slightly hyper&aelig;mic,
+later becoming pale-yellowish or white, and having a pinkish or lilac
+border made up of minute capillaries. They are, as a rule, sharply
+defined, with a smooth, often shining and atrophic-looking surface;
+are soft, fine or leathery to the touch, on a level or somewhat depressed,
+and appearing not unlike a piece of bacon or ivory laid in
+the skin. Occasionally the patches are noted to occur over nerve-tracts.
+The adjacent skin may be normal or there may be more or
+<span class='pagenum'><a name='Page_173' id='Page_173'></a><a href='#TOC'>[Pg 173]</a></span>
+less yellowish or brownish mottling. The subjective symptoms of
+tingling, itching, numbness, and even pain, may or may not be
+present.</p>
+
+
+<p><b>What is the course of the disease?</b></p>
+
+<p>Sooner or later, usually after months or years, the disease ends in
+resolution and recovery, or in marked atrophic changes, causing
+contraction and deformity. As a rule, the general health remains
+good.</p>
+
+
+<p><b>State the causes of scleroderma.</b></p>
+
+<p>The condition is to be considered as probably of neurotic origin.
+Exposure and shock to the nervous system are to be looked upon as
+influential. It is a rare disease, observed usually in early adult or
+middle life, and is more frequent in women than in men.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>In typical and advanced cases both the true skin and the
+subcutaneous connective tissue show a marked increase of connective
+tissue-element, with thickening and condensation of the
+fibers.</p>
+
+
+<p><b>Is there any difficulty in reaching a diagnosis in scleroderma?</b></p>
+
+<p>As a rule, no. The characters&mdash;rigidity, stiffness, hardness, and
+hide-bound condition of the skin&mdash;are always distinctive.</p>
+
+<p>The peculiar appearance, the course and character of the patches,
+of morph&oelig;a are quite distinctive.</p>
+
+
+<p><b>Give the prognosis of scleroderma.</b></p>
+
+<p>It should always be guarded. In many instances recovery takes
+place, whilst in others the disease is rebellious, lasting indefinitely.
+The prognosis of the variety known as morph&oelig;a is less unfavorable
+than general scleroderma, and recovery more frequent.</p>
+
+
+<p><b>What is the treatment of scleroderma?</b></p>
+
+<p>Tonics, such as arsenic, quinia, nux vomica, and cod-liver oil;
+conjointly with the local employment of stimulating, oily or fatty
+applications, friction, and electricity. R&ouml;ntgen-ray treatment is
+often of value, more especially in the morph&oelig;a type.
+<span class='pagenum'><a name='Page_174' id='Page_174'></a><a href='#TOC'>[Pg 174]</a></span></p>
+
+
+<h2><a name='Elephantiasis' id='Elephantiasis'></a><b>Elephantiasis.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Elephantiasis Arabum; Pachydermia; Barbadoes Leg; Elephant
+Leg.)</p>
+
+
+<p><b>Give a descriptive definition of elephantiasis.</b></p>
+
+<p>Elephantiasis is a chronic hypertrophic disease of the skin and
+subcutaneous tissue characterized by enlargement and deformity,
+lymphangitis, swelling, &oelig;dema, thickening, induration, pigmentation,
+and more or less papillary growth.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 35.</b></p>
+<div class='figcenter' style='width: 368px;'>
+<a href='images/fullsize_174.jpg'>
+<img src='images/174.jpg' width='368' height='600'
+alt='FIG. 35.'
+title='FIG. 35.' />
+</a>
+</div>
+<p class='center'>Elephantiasis of moderate development.</p>
+
+
+<p><b>What parts are commonly involved in elephantiasis?</b></p>
+
+<p>Usually one or both legs; occasionally the genitalia; other parts
+are seldom affected.</p>
+
+
+<p><b>Describe the symptoms of elephantiasis.</b></p>
+
+<p>The disease usually begins with recurrent (at intervals of months
+or years) erysipelatous inflammation, with swelling, pain, heat, redness
+and lymphangitis; after each attack the parts remain somewhat
+<span class='pagenum'><a name='Page_175' id='Page_175'></a><a href='#TOC'>[Pg 175]</a></span>
+increased in size, although at first not noticeably so. After months
+or one or two years the enlargement or hypertrophy becomes conspicuous,
+the part is chronically swollen, &oelig;dematous and hard; the
+skin is thickened, the normal lines and folds exaggerated, the papill&aelig;
+enlarged and prominent, and with more or less fissuring and pigmentation.</p>
+
+
+<p><b>What is the further course of the disease?</b></p>
+
+<p>There is gradual increase in size, the parts in some instances
+reaching enormous proportions; the skin becomes rough and warty,
+eczematous inflammation is often superadded, and, sooner or later,
+ulcers, superficial or deep, form&mdash;which, together with the crusting
+and moderate scaliness, present a striking picture. There may be
+periods of comparative inactivity, or, after reaching a certain development,
+the disease may, for a time at least, remain stationary.</p>
+
+
+<p><b>Are there any subjective symptoms?</b></p>
+
+<p>A variable degree of pain is often noted, especially marked during
+the inflammatory attacks. The general health is not involved.</p>
+
+
+<p><b>State the cause of elephantiasis.</b></p>
+
+<p>The etiology is obscure. The disease rarely occurs before puberty.
+It is most common in tropical countries, more especially among the
+poor and neglected. It is not hereditary, nor can it be said to be
+contagious. Inflammation and obstruction of the lymphatics, probably
+due, according to late investigations, to the presence of large
+numbers of filaria (microscopic thread-worms) in the lymph channels
+and bloodvessels, is to be looked upon as the immediate cause.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>All parts of the skin and subcutaneous connective-tissue are hypertrophied,
+the lymphatic glands are swollen, the lymph channels
+and bloodvessels enlarged, and there is more or less inflammation, with
+&oelig;dema. Secondarily, from pressure, atrophy and destruction of the
+skin-glands, and atrophic degeneration of the fat and muscles result.</p>
+
+
+<p><b>What are the diagnostic characters of beginning elephantiasis?</b></p>
+
+<p>Recurrent erysipelatous inflammation, attended with gradual enlargement
+of the parts.
+<span class='pagenum'><a name='Page_176' id='Page_176'></a><a href='#TOC'>[Pg 176]</a></span></p>
+
+<p>The appearances, later in the course of the disease, are so characteristic
+that a mistake is scarcely possible.</p>
+
+
+<p><b>Give the prognosis of elephantiasis.</b></p>
+
+<p>If the case comes under treatment in the first months of its development,
+the process may probably be checked or held in abeyance;
+when well established, rarely more than palliation is possible.</p>
+
+
+<p><b>What is the treatment of elephantiasis?</b></p>
+
+<p>The inflammatory attacks are to be treated on general principles.
+Quinia, potassium iodide, iron and other tonics are occasionally useful;
+and, especially in the earlier stages, climatic change is often of
+value. Between the inflammatory attacks the parts are to be
+rubbed with an ointment of iodine or mercury, together with galvanization
+of the involved part.</p>
+
+<p>In elephantiasis of the leg, a roller or rubber bandage, or the
+gum stocking, is to be worn; compression and ligation of the main
+artery, and even excision of the sciatic nerve, have all been employed,
+with more or less diminution in size as a result. In
+elephantiasis of the genitalia, if the disease is well advanced, excision
+or amputation of the parts is to be practised.</p>
+
+<p>Eczematous inflammation, if present, is to be treated with the
+ordinary remedies.</p>
+
+
+
+<h2><a name='Dermatolysis' id='Dermatolysis'></a><b>Dermatolysis.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Cutis Pendula.)</p>
+
+
+<p><b>Give a descriptive definition of dermatolysis.</b></p>
+
+<p>Dermatolysis is a rare disease, consisting of hypertrophy and looseness
+of the skin and subcutaneous connective tissue, with a tendency
+to hang in folds.</p>
+
+
+<p><b>Describe the symptoms and course of dermatolysis.</b></p>
+
+<p>It may be congenital or acquired, and maybe limited to a small or
+large area, or develop simultaneously at several regions. All parts
+of the skin, including the follicles, glands and subcutaneous connective
+and areolar tissue, share in the hypertrophy; and this in exceptional
+instances may be so extensive that the integument hangs in
+folds. The enlargement of the follicles, natural folds and rug&aelig;
+gives rise to an uneven surface, but the skin remains soft and
+<span class='pagenum'><a name='Page_177' id='Page_177'></a><a href='#TOC'>[Pg 177]</a></span>
+pliable. There is also increased pigmentation, the integument
+becoming more or less brownish.</p>
+
+
+<p><b>What course does dermatolysis pursue?</b></p>
+
+<p>Its development is slow and usually progressive. It gives rise to
+no further inconvenience than its weight and consequent discomfort.</p>
+
+
+<p><b>Give the etiology.</b></p>
+
+<p>The etiology is obscure. It is considered by some authors as allied
+to molluscum fibrosum, and, in fact, as a manifestation of that disease,
+ordinary molluscum tumors sometimes being associated with it.
+It is not malignant.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>The disease consists of a simple hypertrophy of all the skin structures
+and the subcutaneous connective tissue.</p>
+
+
+<p><b>What is the treatment of dermatolysis?</b></p>
+
+<p>Excision when advisable and practicable.</p>
+
+
+
+
+<h1><a name='CLASS_V_ATROPHIES' id='CLASS_V_ATROPHIES'></a><b>CLASS V.&mdash;ATROPHIES.</b></h1>
+
+
+<h2><a name='Albinismus' id='Albinismus'></a><b>Albinismus.</b></h2>
+
+
+<p><b>What do you understand by albinismus?</b></p>
+
+<p>Congenital absence, either partial or complete, of the pigment
+normally present in the skin, hair and eyes.</p>
+
+
+<p><b>Describe complete albinismus.</b></p>
+
+<p>In complete albinismus the skin of the entire body is white, the
+hair very fine, soft and white or whitish-yellow in color, the irides
+are colorless or light blue, and the pupils, owing to the absence of
+pigment in the choroid, are red; this absence of pigment in the
+eyes gives rise to photophobia and nystagmus. <i>Albinos</i>&mdash;a term
+applied to such individuals&mdash;are commonly of feeble constitution,
+and may exhibit imperfect mental development.</p>
+
+
+<p><b>Describe partial albinismus.</b></p>
+
+<p>Partial albinismus is met with most frequently in the colored race.
+In this form of the affection the pigment is absent in one, several or
+<span class='pagenum'><a name='Page_178' id='Page_178'></a><a href='#TOC'>[Pg 178]</a></span>
+more variously-sized patches; usually the hairs growing thereon
+are likewise colorless.</p>
+
+
+<p><b>Is there any structural change in the skin?</b></p>
+
+<p>No. The functions of the skin are performed in a perfectly
+natural manner, and microscopical examination shows no departure
+from normal structure save the complete absence of pigment.</p>
+
+
+<p><b>What is known in regard to the etiology?</b></p>
+
+<p>Nothing is known of the causes producing albinismus beyond the
+single fact that it is frequently hereditary.</p>
+
+
+<p><b>Does albinismus admit of treatment?</b></p>
+
+<p>No; the condition is without remedy.</p>
+
+
+<h2><a name='Vitiligo' id='Vitiligo'></a><b>Vitiligo.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Leucoderma; Leucopathia.)</p>
+
+
+<p><b>Give a definition of vitiligo.</b></p>
+
+<p>Vitiligo may be defined as a disease involving the pigment of the
+skin alone, characterized by several or more progressive, milky-white
+patches surrounded by increased pigmentation.</p>
+
+
+<p><b>Describe the symptoms of vitiligo.</b></p>
+
+<p>The disease may begin at one or more regions, the backs of the
+hands, trunk and face being favorite parts; its appearance is usually
+insidious, and the spots may not be especially noticeable until they
+are the size of a pea or larger. The patches grow slowly, are milky
+or dead white, smooth, non-elevated, and of rounded outline; the
+bordering skin is darker than normal, showing increased pigmentation.
+Several contiguous spots may coalesce and form a large,
+irregularly-shaped patch. Hair growing on the involved skin may
+or may not be blanched.</p>
+
+<p>There are no subjective symptoms.</p>
+
+
+<p><b>What course does vitiligo pursue?</b></p>
+
+<p>The course of the disease is slow, months and sometimes years
+elapsing before it reaches conspicuous development. It may after a
+time remain stationary, or, in rare instances, retrogress; as a rule,
+however, it is progressive. Exceptionally, the greater part, or even
+the whole surface may eventually be involved.
+<span class='pagenum'><a name='Page_179' id='Page_179'></a><a href='#TOC'>[Pg 179]</a></span></p>
+
+
+<p><b>Give the etiology of vitiligo.</b></p>
+
+<p>Disturbed innervation is thought to be influential. The disease
+develops often without apparent cause. Alopecia areata and morph&oelig;a
+have been observed associated with it.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 36.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_179.jpg'>
+<img src='images/179.jpg' width='400' height='422'
+alt='FIG. 36.'
+title='FIG. 36.' />
+</a>
+</div>
+<p class='center'>Vitiligo.</p>
+
+
+<p><b>State the pathology of vitiligo.</b></p>
+
+<p>The disease consists, anatomically, of both a diminution and increase
+of the pigment&mdash;the white patch resulting from the former,
+and the pigmented borders from the latter. There is no textural
+change, the skin in other respects being normal.</p>
+
+
+<p><b>From what diseases is vitiligo to be differentiated?</b></p>
+
+<p>From morph&oelig;a and from the an&aelig;sthetic patches of leprosy.</p>
+
+
+<p><b>In what respects do these diseases differ from vitiligo?</b></p>
+
+<p>In morph&oelig;a there is textural change, and in leprosy both textural
+change and constitutional or other symptoms.
+<span class='pagenum'><a name='Page_180' id='Page_180'></a><a href='#TOC'>[Pg 180]</a></span></p>
+
+<p><b>What prognosis is to be given?</b></p>
+
+<p>It should always be guarded, the disease in almost all cases being
+irresponsive to treatment.</p>
+
+
+<p><b>What is the treatment of vitiligo?</b></p>
+
+<p>The general health is to be looked after, and remedies directed
+especially toward the nervous system to be employed. Arsenic, in
+small and continued doses, seems at times to have an influence; when
+there is lack of general tone it may be prescribed as follows:&mdash;</p>
+
+<pre>
+  &#8478; Liq. potassii arsenitis, ........................ f&#658;j
+    Tinct. nucis vom., .............................. f&#658;iij
+    Elix. calisay&aelig;, ............... q.s. ad. ........ f&#8485;iv.   M.
+  SIG.&mdash;f&#658;j t.d.
+</pre>
+
+<p>Suprarenal-gland preparations in moderate dosage long continued
+has appeared in a few instances to be of some benefit.</p>
+
+<p>When upon exposed parts, stimulation of the patches, with the
+view of producing hyper&aelig;mia and consequent pigment deposit; conjoined
+with suitable applications to the surrounding pigmented skin,
+with a view to lessen the coloration (see <i>treatment of chloasma</i>), will
+be of aid in rendering the disease less conspicuous. Or the condition
+may be, in a measure, masked by staining the patches with walnut
+juice or similar pigment.</p>
+
+
+
+<h2><a name='Canities' id='Canities'></a><b>Canities.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Grayness of the Hair.)</p>
+
+
+<p><b>Describe canities.</b></p>
+
+<p>Canities, or graying of the hair, may occur in localized areas or it
+may be more or less general; the blanching may be slight, scarcely
+amounting to slight grayness, or it may be complete. It is common
+to advancing years (<i>canities senilis</i>); it is seen also exceptionally
+in early life (<i>canities pr&aelig;matura</i>). The condition is usually permanent.
+The loss of pigment takes place, as a rule, slowly, but several
+apparently authentic cases have been reported in which the change
+occurred in the course of a night or in a few days.</p>
+
+
+<p><b>What is the etiology of canities?</b></p>
+
+<p>The causes are obscure. Heredity is usually an influential factor,
+<span class='pagenum'><a name='Page_181' id='Page_181'></a><a href='#TOC'>[Pg 181]</a></span>
+and conditions which impair the general nutrition have at times an
+etiological bearing. Intense anxiety, fright, and other profound nervous
+shock are looked upon as causative in sudden graying of the
+hair.</p>
+
+
+<p><b>Give the treatment.</b></p>
+
+<p>Canities is without remedy. Dyeing, although not to be advised,
+is often practised, and the condition thus masked.</p>
+
+
+
+<h2><a name='Alopecia' id='Alopecia'></a><b>Alopecia.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Baldness.)</p>
+
+
+<p><b>What do you understand by alopecia?</b></p>
+
+<p>By alopecia is meant loss of hair, either partial or complete.</p>
+
+
+<p><b>Name the several varieties of alopecia.</b></p>
+
+<p>The so-called varieties are based mainly upon the etiology, and are
+named congenital alopecia, premature alopecia and senile alopecia.</p>
+
+
+<p><b>Describe congenital alopecia.</b></p>
+
+<p>Congenital alopecia is a rare condition, in which the hair-loss is
+usually noted to be patchy, or the general hair-growth may simply
+be scanty. In rare instances the hair has been entirely wanting; in
+such cases there is usually defective development of other structures,
+such as the teeth.</p>
+
+
+<p><b>Describe premature alopecia.</b></p>
+
+<p>Loss of hair occurring in early and middle adult life is not uncommon,
+and may consist of a simple thinning or of more or less complete
+baldness of the whole or greater part of the scalp. It usually
+develops slowly, some months or several years passing before the
+condition is well established. It is often idiopathic, and without
+apparent cause further than probably a hereditary predisposition. It
+may also be symptomatic, as, for example, the loss of hair, usually
+rapid (<i>defluvium capillorum</i>), following systemic diseases, such as the
+various fevers, and syphilis; or as a result of a long-continued seborrh&oelig;a
+or seborrh&oelig;ic eczema (<i>alopecia furfuracea</i>).</p>
+
+
+<p><b>Describe senile alopecia.</b></p>
+
+<p>This is the baldness so frequently seen developing with advancing
+years, and may consist merely of a general thinning, or, more
+<span class='pagenum'><a name='Page_182' id='Page_182'></a><a href='#TOC'>[Pg 182]</a></span>
+commonly, a general thinning with a more or less complete baldness of
+the temporal and anterior portion or of the vertex of the scalp.</p>
+
+
+<p><b>What is the prognosis in the various varieties of alopecia?</b></p>
+
+<p>In those cases in which there is a positive cause, as, for instance, in
+symptomatic alopecia, the prognosis is, as a rule, favorable, especially
+if no family predisposition exists. In the congenital and senile varieties
+the condition is usually irremediable. In idiopathic premature
+alopecia, the prognosis should be extremely guarded.</p>
+
+
+<p><b>How would you treat alopecia?</b></p>
+
+<p>By removing or modifying the predisposing factors by appropriate
+constitutional remedies, and by the external use of stimulating
+applications.</p>
+
+
+<p><b>Name several remedies or combinations usually employed in
+the local treatment.</b></p>
+
+<p>Sulphur ointment, full strength or weakened with lard or vaseline;
+a lotion of resorcin consisting of one or two drachms to four ounces
+of alcohol, to which is added ten to thirty minims of castor oil; and
+a lotion made up as follows:&mdash;</p>
+
+<pre>
+  &#8478; Tinct. cantharidis, ............................. f&#658;iv
+    Tinct. capsici, ................................. f&#8485;j
+    Ol. ricini, ..................................... f&#658;ss-f&#658;j
+    Alcoholis, ................. q.s. ad. ........... f&#8485;iv.   M.
+</pre>
+
+<p>The following is sometimes beneficial:&mdash;</p>
+
+<pre>
+  &#8478; Resorcin, ........................................ gr. lxxx
+    Quinin&aelig; (alkaloid), .............................. gr. xv
+    Ol. ricini, ...................................... &#9807;v-&#9807;xx
+    Alcoholis, ...................................... f&#8485;iv.  M.
+</pre>
+
+<p>Another excellent formula is:</p>
+
+<pre>
+  &#8478; Resorcin, ........................................ gr. lxxx-cxx
+    Ac. carbolici cryst., ............................ gr. xx
+    Spts. myrci&aelig;, ................................... f&#8485;iv.   M.
+</pre>
+
+<p>And also the various other stimulating applications employed in
+alopecia areata (<i>q. v.</i>).
+<span class='pagenum'><a name='Page_183' id='Page_183'></a><a href='#TOC'>[Pg 183]</a></span></p>
+
+<p>Other measures of value are: Faradic electricity applied daily
+for five minutes with a metallic brush or comb; daily massage,
+with the object of loosening the skin and giving more freedom to
+cutaneous and subcutaneous circulation; and the application, two
+or three times weekly, of static electricity by means of the static
+crown electrode.</p>
+
+<p>(The application selected should be gently&mdash;not rubbing&mdash;applied
+daily or every second or third day, according to the case; if a lotion,
+moistening the parts with it; if an ointment, merely greasing the parts.
+Shampooing every one to three weeks, according to circumstances.)</p>
+
+
+
+<h2><a name='Alopecia_Areata' id='Alopecia_Areata'></a><b>Alopecia Areata.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Area Celsi; Alopecia Circumscripta.)</p>
+
+
+<p><b>What do you understand by alopecia areata?</b></p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 37.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_183.jpg'>
+<img src='images/183.jpg' width='400' height='323'
+alt='FIG. 37.'
+title='FIG. 37.' />
+</a>
+</div>
+<p class='center'>Alopecia Areata.</p>
+
+<p>Alopecia areata is an affection of the hairy system, in which occur
+one or more circumscribed, round or oval patches of complete baldness
+unattended by any marked alteration in the skin.
+<span class='pagenum'><a name='Page_184' id='Page_184'></a><a href='#TOC'>[Pg 184]</a></span></p>
+
+
+<p><b>Upon what parts and at what age does the disease occur?</b></p>
+
+<p>In the large majority of cases the disease is limited to the scalp;
+but it may invade other portions of the body, as the bearded region,
+eyebrows, eyelashes, and, in rare instances, the entire integument.</p>
+
+<p>It is most common between the ages of ten and forty.</p>
+
+
+<p><b>Describe the symptoms of alopecia areata.</b></p>
+
+<p>The disease begins either suddenly, without premonitory symptoms,
+one or several patches being formed in a few hours; or, and as
+is more usually the case, several days or weeks elapse before the bald
+area or areas are sufficiently large to become noticeable. The patches
+continue to extend peripherally for a variable period, and then remain
+stationary, or several gradually coalesce and form a large, irregular
+area involving the entire or a greater portion of the scalp. The skin
+of the affected regions is smooth, faintly pink or milky white,</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 38.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_184.jpg'>
+<img src='images/184.jpg' width='400' height='315'
+alt='FIG. 38.'
+title='FIG. 38.' />
+</a>
+</div>
+
+<p class='center'>Alopecia Areata&mdash;complete hair loss.</p>
+
+<p>and at first presents no departure from the normal; sooner or
+later, however, the follicles become less prominent, and slight
+atrophy or thinning may occur, the bald plaques being slightly
+depressed.</p>
+
+<p>Occasionally, usually about the periphery and in the early stages,
+a few hair-stumps may be seen.
+<span class='pagenum'><a name='Page_185' id='Page_185'></a><a href='#TOC'>[Pg 185]</a></span></p>
+
+
+<p><b>What course does alopecia areata pursue?</b></p>
+
+<p>Almost invariably chronic. After the lapse of a variable period
+the patches cease to extend, the hairs at the margins of the bald
+areas being firmly fixed in the follicles; sooner or later a fine, colorless
+lanugo or down shows itself, which may continue to grow until it
+is about a half-inch or so in length and then drop out; or it may
+remain, become coarser and pigmented, and the parts resume their
+normal condition. Not infrequently, however, after growing for a
+time, the new hair falls out, and this may happen several times
+before the termination of the disease.</p>
+
+
+<p><b>Are there any subjective symptoms in alopecia areata?</b></p>
+
+<p>As a rule, not; but occasionally the appearance of the patches is
+preceded by severe headache, itching or burning, or other manifestations
+of disturbed innervation.</p>
+
+
+<p><b>State the cause of alopecia areata.</b></p>
+
+<p>The etiology is obscure. Two theories as to the cause of the disease
+exist: one of these regards it as parasitic, and the other considers
+it to be trophoneurotic. Doubtless both are right, as a study
+of the literature would indicate that there are, as regards etiology,
+really two varieties&mdash;the contagious and the non-contagious. In
+America examples of the contagious variety are uncommon.</p>
+
+
+<p><b>Does the skin undergo any alterative or destructive changes?</b></p>
+
+<p>Microscopical examination of the skin of the diseased area shows
+little or no alteration in its structure beyond slight thinning.</p>
+
+
+<p><b>How do you distinguish alopecia areata from ringworm?</b></p>
+
+<p>The plaques of alopecia areata are smooth, often completely
+devoid of hair, and free from scales; while those of ringworm
+show numerous broken hairs and stumps, desquamation, and usually
+symptoms of mild inflammatory action. In doubtful cases recourse
+should be had to the microscope.</p>
+
+
+<p><b>What is the prognosis in alopecia areata?</b></p>
+
+<p>The disease is often rebellious, but in children and young adults
+the prognosis is almost invariably favorable, permanent loss of hair
+being uncommon. The same holds true, but to a much less extent,
+with the disease as occurring in those of more advanced age. In
+extensive cases&mdash;those in which the hair of the entire scalp finally
+<span class='pagenum'><a name='Page_186' id='Page_186'></a><a href='#TOC'>[Pg 186]</a></span>
+entirely disappears, and sometimes involves all hairy parts&mdash;the
+prognosis is unfavorable. Only exceptionally does recovery ensue
+in such instances.</p>
+
+<p>The uncertain duration, however, must be borne in mind; months,
+and in some instances several years, may elapse before complete
+restoration of hair takes place. Relapses are not uncommon.</p>
+
+
+<p><b>How is alopecia areata treated?</b></p>
+
+<p>By both constitutional and local measures, the former having in
+view the invigoration of the nervous system, and the latter a stimulating
+and parasiticidal action of the affected areas.</p>
+
+
+<p><b>Give the constitutional treatment.</b></p>
+
+<p>Arsenic is perhaps the most valuable remedy, while quinine, nux
+vomica, pilocarpine, cod-liver oil and ferruginous tonics may, in suitable
+cases, often be administered with benefit.</p>
+
+
+<p><b>Name several remedies or combinations employed in the
+external treatment of alopecia areata.</b></p>
+
+<p>Ointments of tar and sulphur of varying strength; the various
+mercurial ointments; the tar oils, either pure or with alcohol;
+stimulating lotions, containing varying proportions, singly or in
+combination, of tincture of capsicum, tincture of cantharides, aqua
+ammoni&aelig;, and oil of turpentine. The following is a safe formula,
+especially in dispensary and ignorant class practice:</p>
+
+<pre>
+  &#8478; &beta;-naphthol, ...................................... &#658;ss-&#658;j
+      Ol. cadini, .................................... &#658;j
+    Ungt. sulphuris, ................. q.s. ad. ...... &#8485;j   M.
+</pre>
+
+<p>The cautious use of a five to twenty per cent. chrysarobin ointment
+is of value. Painting the patches with pure carbolic acid or trikresol
+every ten days or two weeks sometimes acts well; it should
+not be applied over large areas nor used in young children. Galvanization
+or faradization of the affected parts may also be employed,
+and with, occasionally, beneficial effect. Stimulation with
+the high-frequency current by means of the vacuum electrode is
+also of value. When practicable, the Finsen light can be applied
+with hope of benefit and cure.
+<span class='pagenum'><a name='Page_187' id='Page_187'></a><a href='#TOC'>[Pg 187]</a></span></p>
+
+
+<h2><a name='Atrophia_Pilorum_Propria' id='Atrophia_Pilorum_Propria'></a><b>Atrophia Pilorum Propria.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Atrophy of the Hair.)</p>
+
+
+<p><b>What do you understand by atrophy of the hair?</b></p>
+
+<p>An atrophic, brittle, dry condition of the hair, and which may be
+either symptomatic or idiopathic.</p>
+
+
+<p><b>Describe the several conditions met with.</b></p>
+
+<p>As a symptomatic affection, the dry, brittle condition of the hair
+met with in seborrh&oelig;a, in severe constitutional diseases, and in the
+various vegetable parasitic affections, may be referred to.</p>
+
+<p>As an idiopathic disease it is rare, consisting simply of a brittleness
+and an uneven and irregular formation of the hair-shaft, with a
+tendency to split up into filaments (<i>fragilitas crinium</i>); or there may
+be localized swelling and bursting of the hair-shaft, the nodes thus
+produced having a shining, semi-transparent appearance (<i>trichorrhexis
+nodosa</i>). This latter usually occurs upon the beard and
+moustache.</p>
+
+
+<p><b>State the causes of atrophy of the hair.</b></p>
+
+<p>The causes of the symptomatic variety are usually evident; the
+etiology of idiopathic atrophy is obscure, but by many is thought
+due to parasitism.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 39.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/187.jpg' width='400' height='162'
+alt='FIG. 39.'
+title='FIG. 39.' />
+</div>
+
+<p class='center'>Trichorrhexis Nodosa. (<i>After Michelson.</i>)</p>
+
+
+<p><b>What would be your prognosis and treatment in atrophy of
+the hair?</b></p>
+
+<p>Symptomatic atrophy usually responds to proper measures, but
+always slowly; treatment is based upon the etiological factors.</p>
+
+<p>For the idiopathic disease little, as a rule, can be done; repeated
+shaving or cutting the hair has, in exceptional instances, been followed
+by favorable results.
+<span class='pagenum'><a name='Page_188' id='Page_188'></a><a href='#TOC'>[Pg 188]</a></span></p>
+
+
+<h2><a name='Atrophia_Unguis' id='Atrophia_Unguis'></a><b>Atrophia Unguis.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Atrophy of the Nails; Onychatrophia.)</p>
+
+
+<p><b>Describe atrophy of the nails.</b></p>
+
+<p>The nails are soft, thin and brittle, splitting easily, and are often
+opaque and lustreless, and may have a worm-eaten appearance.
+Several or more are usually affected.</p>
+
+
+<p><b>State the causes of atrophy of the nails.</b></p>
+
+<p>The condition may be congenital or acquired, usually the latter.
+It may result from trauma, or be produced by certain cutaneous
+diseases, notably eczema and psoriasis; or it may follow injuries or
+diseases of the nerves. Syphilis and chronic wasting constitutional
+diseases may also interfere with the normal growth of the nail-substance,
+producing varying degrees of atrophy. The fungi of tinea
+trichophytina and tinea favosa at times invade these structures
+and lead to more or less complete disintegration&mdash;<i>onychomycosis</i>.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 40.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/188.jpg' width='400' height='428'
+alt='FIG. 40.'
+title='FIG. 40.' />
+</div>
+
+<p class='center'>Atrophy of the Nails.</p>
+
+
+<p><b>What is the treatment of atrophy of the nails?</b></p>
+
+<p>Treatment will depend upon the cause. When it is due to eczema
+<span class='pagenum'><a name='Page_189' id='Page_189'></a><a href='#TOC'>[Pg 189]</a></span>
+or psoriasis, appropriate constitutional and local remedies should be
+prescribed. If it is the result of syphilis, mercury and potassium
+iodide are to be advised. In onychomycosis&mdash;an exceedingly obstinate
+affection&mdash;the nails should be kept closely cut and pared, and a
+one- to five-grain solution of corrosive sublimate applied several times
+a day; a lotion of sodium hyposulphite, a drachm to the ounce, is
+also a valuable and safe application.</p>
+
+
+<h2><a name='Atrophia_Cutis' id='Atrophia_Cutis'></a><b>Atrophia Cutis.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Atrophoderma; Atrophy of the Skin.)</p>
+
+
+<p><b>What do you understand by atrophy of the skin?</b></p>
+
+<p>By atrophy of the skin is meant an idiopathic or symptomatic
+wasting or degeneration of its component elements.</p>
+
+
+<p><b>State the several conditions met with.</b></p>
+
+<p>Glossy skin, general idiopathic atrophy of the skin, parchment
+skin, atrophic lines and spots, senile atrophy, and the atrophy following
+certain cutaneous diseases.</p>
+
+
+<p><b>Describe glossy skin (atrophoderma neuriticum), and state
+the treatment.</b></p>
+
+<p>Glossy skin is a rare condition following an injury or disease
+of the nerve. It is usually seen about the fingers. The skin is
+hairless, faintly reddish, smooth and shining, with a varnished
+and thin appearance, and with a tendency to fissuring. More or
+less severe and persistent burning pain precedes and accompanies
+the atrophy.</p>
+
+<p>Protective applications are called for, the disease tending slowly
+to spontaneous disappearance.</p>
+
+
+<p><b>Describe general idiopathic atrophy of the skin, and give the
+treatment.</b></p>
+
+<p>General idiopathic atrophy of the skin is extremely rare, and is
+characterized by a gradual, more or less general, degenerative and
+quantitative atrophy of the skin structures, accompanied usually with
+more or less discoloration and pigmentation.</p>
+
+<p>Treatment is palliative and based upon indications.
+<span class='pagenum'><a name='Page_190' id='Page_190'></a><a href='#TOC'>[Pg 190]</a></span></p>
+
+
+<p><b>Describe parchment skin, and state the treatment.</b></p>
+
+<p>Parchment skin (<i>xeroderma pigmentosum, angioma pigmentosum
+et atrophicum</i>) is a rare disease, the exact nature of which is not
+understood. It is characterized by the appearance of numerous
+disseminated, freckle-like pigment-spots, telangiectases, atrophied
+muscles, more or less shrinking and contraction of the integument,
+and followed, in most instances, by epitheliomatous tumors and
+ulceration, and finally death. It is usually slow in its course, beginning
+in childhood and lasting for years. It is not infrequently seen
+in several children of the same family.</p>
+
+<p>Treatment is palliative, consisting, if necessary, of the use of
+protective applications and of the administration of tonics and
+nutrients.</p>
+
+
+<p><b>Describe atrophic lines and spots.</b></p>
+
+<p>Atrophic lines and spots (<i>stri&aelig; et macul&aelig; atrophic&aelig;</i>) may be idiopathic
+or symptomatic, the lesions consisting of scar-like or atrophic-looking,
+whitish lines and macules, most commonly seen on the
+trunk. They are smooth and glistening. Slight hyper&aelig;mia usually
+precedes their formation. As an idiopathic disease its course is
+insidious and slow, and its progress eventually stayed. The so-called
+<i>line&aelig; albicantes</i>, resulting from the stretching of the skin produced
+by pregnancy or tumors, and from rapid development of fat, may
+be mentioned as illustrating the symptomatic variety.</p>
+
+<p>In course of time the atrophy becomes less conspicuous.</p>
+
+
+<p><b>Describe senile atrophy.</b></p>
+
+<p>Senile atrophy is not uncommon, the atrophy resulting, as the
+name inferentially implies, from advancing age. It is characterized
+by thinning and wasting, dryness, and a wrinkled condition, with
+more or less pigmentation and loss of hair. Circumscribed pigmentary
+deposits and seborrh&oelig;a, with degeneration, are also noted.</p>
+
+
+<p><b>What several diseases of the skin are commonly followed by
+atrophic changes?</b></p>
+
+<p>Favus, lupus, syphilis, leprosy, scleroderma and morph&oelig;a.
+<span class='pagenum'><a name='Page_191' id='Page_191'></a><a href='#TOC'>[Pg 191]</a></span></p>
+
+
+
+<h1><a name='CLASS_VI_NEW_GROWTHS' id='CLASS_VI_NEW_GROWTHS'></a><b>CLASS VI.&mdash;NEW GROWTHS.</b></h1>
+
+
+<h2><a name='Keloid' id='Keloid'></a><b>Keloid.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Keloid of Alibert; Cheloid.)</p>
+
+
+<p><b>Give a descriptive definition of keloid.</b></p>
+
+<p>Keloid is a fibro-cellular new growth of the corium appearing as
+one or several variously-sized, irregularly-shaped, elevated, smooth,
+firm, pinkish or pale-reddish cicatriform lesions.</p>
+
+
+<p><b>Describe the clinical appearance of keloid.</b></p>
+
+<p>The growth begins as a small, hard, elevated, pinkish or reddish
+tubercle, increasing gradually, several months or years usually elapsing
+before the tumor reaches conspicuous size. When developed, it
+is one or more inches in diameter, is sharply defined, elevated, hard,
+rounded or oval, fungoid or crab-shaped, and firmly implanted in
+the skin. It is usually pinkish, pearl-white, or reddish, commonly
+devoid of hair, with no tendency to scaliness, and with, usually,
+several vessels coursing over it. In some instances it is tender, and
+it may be spontaneously painful.</p>
+
+<p>The breast, especially over the sternal region, is a favorite site
+for its appearance. One, several or more may be present in the
+single case.</p>
+
+
+<p><b>What course does keloid pursue?</b></p>
+
+<p>Chronic; usually lasting throughout life. In rare instances spontaneous
+involution takes place.</p>
+
+
+<p><b>State the etiology of keloid.</b></p>
+
+<p>The causes are obscure. The growth usually takes its start from
+some injury or lesion of continuity; for instance, at the site of burns,
+cuts, acne and smallpox scars, etc.&mdash;<i>cicatricial keloid, false keloid</i>;
+or it may also, so it is thought, originate in normal skin&mdash;<i>spontaneous
+keloid, true keloid</i>.</p>
+
+
+<p><b>What is the pathology of keloid?</b></p>
+
+<p>The lesion is a connective-tissue new growth having its seat in the
+corium.
+<span class='pagenum'><a name='Page_192' id='Page_192'></a><a href='#TOC'>[Pg 192]</a></span></p>
+
+
+<p><b>Is there any difficulty in the diagnosis of keloid?</b></p>
+
+<p>No. It resembles hypertrophic scar; but this latter, which is
+essentially keloidal, never extends beyond the line of injury.</p>
+
+
+<p><b>Give the prognosis.</b></p>
+
+<p>The growth is persistent and usually irresponsive to treatment.
+In some cases, however, there is eventually a tendency to spontaneous
+retrogression, up to a certain point at least.</p>
+
+
+<p><b>What is the treatment of keloid?</b></p>
+
+<p>Usually palliative, consisting of the continuous application of an
+ointment such as the following:&mdash;</p>
+
+<pre>
+  &#8478; Acidi salicylici, ................................ gr. x-xx
+    Emplast. plumbi,
+    Emplast. saponis, ....................&#257;&#257;.......... &#658;iij
+    Petrolati, ....................................... &#658;ij.   M.
+</pre>
+
+<p>An ointment of ichthyol, twenty-five per cent. strength, rubbed
+in once or twice daily, is sometimes beneficial.</p>
+
+<p>Operative measures, such as punctate and linear scarification,
+electrolysis and excision, are occasionally practised, but the results
+are rarely satisfactory and permanent; not infrequently, indeed,
+renewed activity in the progress of the growth is noted to follow.
+The <i>x</i>-ray can be tried with some hope of improvement. The administration
+of thyroid has been thought to have a possible influence
+in some instances.</p>
+
+
+<h2><a name='Fibroma' id='Fibroma'></a><b>Fibroma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Molluscum Fibrosum; Fibroma Molluscum.)</p>
+
+
+<p><b>What do you understand by fibroma?</b></p>
+
+<p>Fibroma is a connective-tissue new growth characterized by one or
+more sessile or pedunculated, pea- to egg-sized or larger, soft or firm,
+rounded, painless tumors, seated beneath and in the skin.</p>
+
+
+<p><b>Describe the clinical appearances of fibroma.</b></p>
+
+<p>The growth may be single, in which case it is apt to be pedunculated
+or pendulous, and attain considerable dimensions; as a result
+of weight or pressure surface-ulceration may occur. Or, as commonly
+met with, the lesions are numerous, scattered over large surface, and
+<span class='pagenum'><a name='Page_193' id='Page_193'></a><a href='#TOC'>[Pg 193]</a></span>
+vary in size from a pea to a cherry; the overlying skin being normal,
+pinkish or reddish, loose, stretched, hypertrophied or atrophied.</p>
+
+<p>The tumors are painless. The general health is not involved.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 41.</b></p>
+<div class='figcenter' style='width: 317px;'>
+<img src='images/193.jpg' width='317' height='600'
+alt='FIG. 41.'
+title='FIG. 41.' />
+</div>
+<p class='center'>Fibroma. (<i>After Octerlony.</i>)</p>
+
+
+<p><b>What is the course of fibroma?</b></p>
+
+<p>Chronic and persistent.
+<span class='pagenum'><a name='Page_194' id='Page_194'></a><a href='#TOC'>[Pg 194]</a></span></p>
+
+
+<p><b>What is the etiology of fibroma?</b></p>
+
+<p>The cause is not known. Heredity is often noted. The affection
+is not common.</p>
+
+
+<p><b>State the pathology of fibroma.</b></p>
+
+<p>The growths are variously thought to have their origin in the
+connective tissue of the corium, or in that of the walls of the hair-sac,
+or in the connective-tissue framework of the fatty tissue.
+Recent tumors are composed of gelatinous, newly-formed connective
+tissue, and the older growths of a dense, firmly-packed, fibrous tissue.</p>
+
+
+<p><b>From what growths is fibroma to be differentiated?</b></p>
+
+<p>From molluscum contagiosum, neuroma and lipoma; the first is
+differentiated by its central aperture or depression, neuroma by its
+painfulness, and lipoma by its lobulated character and soft feel.</p>
+
+
+<p><b>Give the prognosis of fibroma.</b></p>
+
+<p>The disease is persistent, and irresponsive to all treatment save
+operative measures.</p>
+
+
+<p><b>What is the treatment of fibroma?</b></p>
+
+<p>Treatment consists, when desired and practicable, in the removal
+of the growths by the knife, or in large and pedunculated tumors
+by the ligature or by the galvano-cautery.</p>
+
+<h2><a name='Neuroma' id='Neuroma'></a><b>Neuroma.</b></h2>
+
+
+<p><b>Describe neuroma.</b></p>
+
+<p>Neuroma of the skin is an exceedingly rare disease, characterized by
+the formation of variously-sized, usually numerous, firm, immovable
+and elastic fibrous tubercles containing new nerve-elements, and accompanied
+by violent, paroxysmal pain. Their growth is slow and
+usually progressive. Later they are painful upon pressure. They
+are limited to one region.</p>
+
+<p>The tumors are seated in the corium, extending into the deeper
+structure, and consist of nerve-fibres, yellow elastic tissue, blood vessels
+and lymphoid cells.</p>
+
+<p>In the two cases reported, excision of the nerve-trunk gave, in
+one instance, permanent relief; in the other the effect was only
+temporary.
+<span class='pagenum'><a name='Page_195' id='Page_195'></a><a href='#TOC'>[Pg 195]</a></span></p>
+
+
+<h2><a name='Xanthoma' id='Xanthoma'></a><b>Xanthoma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Vitiligoidea; Xanthelasma.)</p>
+
+
+<p><b>What is xanthoma?</b></p>
+
+<p>Xanthoma is a connective-tissue new growth characterized by the
+formation of yellowish, circumscribed, irregularly-shaped, variously-sized,
+non-indurated, flat or raised patches or tubercles.</p>
+
+
+<p><b>Name the two varieties met with.</b></p>
+
+<p>The macular or flat (<i>xanthoma planum</i>) and the tubercular
+(<i>xanthoma tuberculatum</i> or <i>tuberosum</i>). In some instances both
+varieties (<i>xanthoma multiplex</i>) are seen in the same individual.</p>
+
+
+<p><b>Describe the clinical appearances of xanthoma planum.</b></p>
+
+<p>The macular or flat variety is usually seen about the eyelids.
+It consists of one, several or more small or large, smooth, opaque,
+sharply-defined, often slightly raised, yellowish patches, looking not
+unlike pieces of chamois-skin implanted in the skin.</p>
+
+
+<p><b>Describe the clinical appearances of xanthoma tuberosum.</b></p>
+
+<p>The tubercular variety is commonly met with upon the neck,
+trunk and extremities. It occurs as small, raised, isolated, yellowish
+nodules, or as patches made up of aggregations of millet-seed-sized
+or larger tubercles. The lesions may be few or they may exist in
+great numbers.</p>
+
+
+<p><b>What is the course of xanthoma?</b></p>
+
+<p>Extremely slow; after reaching a certain development the growths
+may remain stationary.</p>
+
+
+<p><b>State the etiology of xanthoma.</b></p>
+
+<p>The causes are obscure. Jaundice not infrequently precedes and
+accompanies its development, especially in the tubercular variety.
+The disease is uncommon, and is usually seen in middle and advanced
+life, and more frequently in women. In some cases (<i>xanthoma
+diabeticorum</i>) of general xanthoma diabetes is the causative factor.</p>
+
+
+<p><b>What is the pathology of xanthoma?</b></p>
+
+<p>It is a benign, connective-tissue new growth, with concomitant or
+subsequent, but usually partial, fatty degeneration.
+<span class='pagenum'><a name='Page_196' id='Page_196'></a><a href='#TOC'>[Pg 196]</a></span></p>
+
+
+<p><b>Give the prognosis of xanthoma</b>.</p>
+
+<p>The condition is persistent, and usually irresponsive to all treatment
+save destructive or operative measures.</p>
+
+<p><b>What is the treatment of xanthoma?</b></p>
+
+<p>Treatment consists, in suitable cases, of excision; in some instances,
+electrolysis is serviceable. Applications of trichloracetic acid
+cautiously made are sometimes of value. In that form of general
+xanthoma due to diabetes the treatment of this latter condition
+will materially and sometimes completely remove the eruption.</p>
+
+
+<h2><a name='Myoma' id='Myoma'></a><b>Myoma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Myoma Cutis; Dermatomyoma; Liomyoma Cutis.)</p>
+
+
+<p><b>Describe myoma.</b></p>
+
+<p>The disease is rare, and consists usually of one or several (exceptionally
+numerous), variously-sized tumors of the skin, made up of
+smooth muscular fibres. They are flat, rounded, oval or pedunculated,
+and have a smooth surface and a pale-red color; as a rule,
+they are painless.</p>
+
+<p>The growth is benign, and consists essentially of a new formation
+of unstriped muscular fibres; but it may also be composed largely
+of connective tissue (<i>fibromyoma</i>); or it may contain an abundance
+of bloodvessels (<i>myoma telangiectodes, angiomyoma</i>); or there may
+be lymphatic involvement (<i>lymphangiomyoma</i>).</p>
+
+
+<h2><a name='Angioma' id='Angioma'></a><b>Angioma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> N&aelig;vus Vasculosus; N&aelig;vus Sanguineus.)</p>
+
+
+<p><b>Give a definition of angioma.</b></p>
+
+<p>Angioma is a congenital hypertrophy of the vascular tissues of the
+corium and subcutaneous tissue. Exceptionally it makes its appearance
+a few weeks or a month after birth.</p>
+
+
+<p><b>Into what two classes may angiomata be roughly grouped?</b></p>
+
+<p>The flat (or non-elevated) and the prominent (or elevated).</p>
+
+
+<p><b>Describe the flat, or non-elevated, variety of angioma.</b></p>
+
+<p>The flat, or non-elevated, angioma (<i>n&aelig;vus flammeus, n&aelig;vus simplex,
+angioma simplex, capillary n&aelig;vus</i>) may be pin-head- to bean-sized;
+or it may involve an area of several inches in diameter, and,
+<span class='pagenum'><a name='Page_197' id='Page_197'></a><a href='#TOC'>[Pg 197]</a></span>
+exceptionally, a whole region. It is of a bright- or dark-red color,
+and is met with most frequently about the face. In some instances
+it extends after birth, reaches a certain size and then remains stationary;
+occasionally, when involving a small area, it undergoes involution
+and disappears.</p>
+
+<p>The so-called <i>port-wine mark</i> is included in this group.</p>
+
+
+<p><b>Describe the prominent, or elevated, variety of angioma.</b></p>
+
+<p>The prominent variety (<i>venous n&oelig;vus, angioma cavernosum, n&oelig;vus
+tuberosus</i>) is variously-sized, often considerably elevated, clearly-defined,
+compressible, smooth or lobulated, and of a dark, purple
+color; it may, also, be erectile and pulsating. The growth is usually
+a single formation, and is met with upon all parts of the body.</p>
+
+
+<p><b>What is the pathology of angioma?</b></p>
+
+<p>It is a new growth, consisting of a variable hypertrophy of the
+cutaneous and subcutaneous arterial and venous bloodvessels, with
+or without an increase of the connective tissue.</p>
+
+
+<p><b>Give the treatment of angioma.</b></p>
+
+<p>In some instances, especially in infants, painting the parts repeatedly
+with collodion or liquor plumbi subacetatis will act favorably.
+For well-established, small, capillary n&aelig;vi electrolysis or puncturing
+with a red-hot needle or with a needle charged with nitric acid may
+be employed; for &ldquo;port-wine mark&rdquo; frequent and closely contiguous
+electrolytic punctures are occasionally followed by a slight diminution
+in color. For the <i>prominent growths</i>, vaccination, the ligature,
+puncturing with the galvano-cautery, and excision are variously
+resorted to.</p>
+
+<p>In recent years applications of liquid air and carbon dioxide have
+proved of service in some cases.</p>
+
+
+<h2><a name='Telangiectasis' id='Telangiectasis'></a><b>Telangiectasis.</b></h2>
+
+
+<p><b>Describe telangiectasis.</b></p>
+
+<p>Telangiectasis consists of a new growth or enlargement of the
+cutaneous capillaries, usually appearing during middle adult life,
+and seated, for the most part, about the face.</p>
+
+
+<p><b>To what extent may telangiectasis develop?</b></p>
+
+<p>It may be limited to a red dot or point, with several small radiating
+<span class='pagenum'><a name='Page_198' id='Page_198'></a><a href='#TOC'>[Pg 198]</a></span>
+capillaries (<i>n&aelig;vus araneus, spider n&aelig;vus</i>), or a whole region,
+usually the face, may show numerous scattered or closely-set capillary
+enlargements or new formations (<i>rosacea</i>). The latter is frequently
+associated with acne (<i>acne rosacea</i>).</p>
+
+<p>The etiology is obscure.</p>
+
+
+<p><b>What is the treatment of telangiectasis?</b></p>
+
+<p>Destruction of the vessels by electrolysis or by the knife. (See
+treatment of acne rosacea.)</p>
+
+
+<h2><a name='Lymphangioma' id='Lymphangioma'></a><b>Lymphangioma.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Lymphangiectodes.)</p>
+
+
+<p><b>Describe lymphangioma</b>.</p>
+
+<p>Lymphangioma is a rare disease, consisting of localized dilatations
+of the lymphatic vessels, appearing as discrete or aggregated pin-head
+or pea-sized, compressible, hollow, tubercle-like elevations, of
+a pinkish or faint lilac color, and occurring for the most part about
+the trunk. It is of slow but usually progressive development, and
+is unaccompanied by subjective symptoms.</p>
+
+<p>A rare condition, Kaposi described as lymphangioma tuberosum
+multiplex, characterized by more or less solid, somewhat cystic,
+pearly to pinkish red, sometimes crowded lesions, is now known to
+be &ldquo;benign cystic epithelioma&rdquo;; its most common site is the face.
+While called &ldquo;benign,&rdquo; ulcerative action may eventually ensue.</p>
+
+<p>Treatment, when demanded, consists of operative measures.</p>
+
+
+<h2><a name='Rhinoscleroma' id='Rhinoscleroma'></a><b>Rhinoscleroma.</b></h2>
+
+
+<p><b>Describe rhinoscleroma.</b></p>
+
+<p>Rhinoscleroma is a rare and obscure disease, slow but progressive
+in its course, characterized by the development of an irregular, dense
+and hard, flattened, tubercular, non-ulcerating, cellular new growth,
+having its seat about the nose and contiguous parts. The overlying
+skin is normal in color, or it may be light- or dark-brown or reddish.
+Marked disfigurement and closure, partial or complete, of the nasal
+<span class='pagenum'><a name='Page_199' id='Page_199'></a><a href='#TOC'>[Pg 199]</a></span>
+orifices gradually results. It is met with chiefly in Austria and
+Germany.</p>
+
+<p>Treatment, consisting of partial or complete extirpation, is rarely
+permanent in its results, the disease tending to recur.</p>
+
+
+<h2><a name='Lupus_Erythematosus' id='Lupus_Erythematosus'></a><b>Lupus Erythematosus.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Lupus Erythematodes; Lupus Sebaceus; Seborrh&oelig;a Congestiva.)</p>
+
+
+<p><b>What is lupus erythematosus?</b></p>
+
+<p>Lupus erythematosus may be roughly defined as a mildly to moderately
+inflammatory superficial new-growth formation, characterized
+by one, several, or more circumscribed, variously sized and shaped,
+pinkish or dark red patches, covered slightly, and more or less irregularly,
+with adherent grayish or yellowish scales.</p>
+
+
+<p><b>Upon what parts is lupus erythematosus observed?</b></p>
+
+<p>Its common site is the face, usually the nose and cheeks, with a
+tendency toward symmetry; it is often limited to these parts, but
+may occasionally be seen upon other regions, more especially the
+lips, ears, and scalp. In rare instances a great part of the general
+surface may become involved.</p>
+
+
+<p><b>Describe the symptoms of lupus erythematosus.</b></p>
+
+<p>Usually the disease begins as one or several rounded, circumscribed,
+pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and
+of a pinkish, reddish or violaceous color. They slowly, or somewhat
+rapidly, increase in area, and after attaining variable size remain
+stationary; or they may progress and coalesce, and in this manner
+sooner or later involve considerable surface. The patches are sharply
+defined against the sound skin by an elevated border, while the
+central portion is somewhat depressed and usually atrophic. More
+or less thickening and infiltration are observed. <i>There is no tendency
+to ulceration</i>. The scaliness is, as a rule, scanty. The gland-ducts are
+enlarged, patulous or plugged with sebaceous and epithelial matter.</p>
+
+<p>The subjective symptoms of burning and itching are usually slight
+and often wanting.</p>
+
+
+<p><b>What course does lupus erythematosus pursue?</b></p>
+
+<p>As a rule, the disease is persistent, although somewhat variable.
+<span class='pagenum'><a name='Page_200' id='Page_200'></a><a href='#TOC'>[Pg 200]</a></span>
+At times the patches retrogress, involution taking place with or
+without slight sieve-like atrophy or scarring.</p>
+
+
+<p><b>State the causes of lupus erythematosus.</b></p>
+
+<p>The etiology is obscure. Some observers believe it to be a variety
+of cutaneous tuberculosis. It is essentially a disease of adult and
+middle age; is more common in women, and more frequent in those
+having a tendency to disorders of the sebaceous glands. It may, in
+fact, begin as a seborrh&oelig;a.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>It was formerly considered a new growth, but recent opinion tends
+toward regarding it as a chronic inflammation of the cutis, superinducing
+degenerative and atrophic changes. Variable &oelig;dema of the
+prickle layer and of the cutis is found. There is no tendency to
+pus formation.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 42.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_200.jpg'>
+<img src='images/200.jpg' width='400' height='249'
+alt='FIG. 42.'
+title='FIG. 42.' />
+</a>
+</div>
+<p class='center'>Lupus Erythematosus.</p>
+
+
+<p><b>Is there any difficulty in the diagnosis of lupus erythematosus?</b></p>
+
+<p>As a rule, not, as the features of the disease&mdash;the sharply circumscribed
+outline, the reddish or violaceous color, the elevated border,
+the tendency to central depression and atrophy, the plugged up or
+patulous sebaceous ducts, the adherent grayish or yellowish scales,
+<span class='pagenum'><a name='Page_201' id='Page_201'></a><a href='#TOC'>[Pg 201]</a></span>
+together with the region attacked (usually the nose and cheeks)&mdash;
+are characteristic.</p>
+
+
+<p><b>State the prognosis of lupus erythematosus.</b></p>
+
+<p>The disease is often capricious and extremely rebellious to treatment;
+some cases, up to a certain point at least, yield readily, and
+occasionally a tendency to spontaneous disappearance is observed;
+a complete cure is, however, it must be confessed, rather rare. The
+disease in nowise compromises the general health. In those rare
+instances of generalized disease the patient has usually died from
+an intercurrent tuberculosis.</p>
+
+
+<p><b>How is lupus erythematosus to be treated?</b></p>
+
+<p>The general health is to be looked after and systemic treatment
+prescribed, if indicated. As a rule, constitutional remedies exert
+little, if any, influence, but exceptionally, cod-liver oil, arsenic,
+phosphorus, salicin, quinine, or potassium iodide proves of service.</p>
+
+<p>Locally, according to the case, soothing remedies, stimulating applications
+and destruction of the growth by caustics or operative
+measures are to be employed. (<i>Try the milder applications first.</i>)</p>
+
+
+<p><b>Mention the stimulating applications commonly employed.</b></p>
+
+<p>Washing the parts energetically with tincture of sapo viridis, rinsing
+and applying a soothing ointment, such as cold cream or vaseline.</p>
+
+<p>A lotion containing zinc sulphate and potassium sulphuret
+thoroughly dabbed on the parts morning and evening:&mdash;</p>
+
+<pre>
+  &#8478; Zinci sulphatis,
+    Potassii sulphurati, ................&#257;&#257;........... &#658;i-&#658;iv
+    Glycerin&aelig;, ....................................... &#9807;iv
+    Aqu&aelig;, ........................................... f&#8485;iv.   M.
+</pre>
+
+<p>The calamine-and-zinc oxide lotion used in acute eczema is also
+often extremely valuable.</p>
+
+<p>Lotions of ichthyol and of resorcin, five to sixty grains to the
+ounce; ichthyol in ointment, five- to twenty-per-cent. strength, is
+also useful.</p>
+
+<p>Painting the patches with pure carbolic acid; repeating a day or
+two after the crusts have fallen off.</p>
+
+<p>The continuous application of mercurial plaster.
+<span class='pagenum'><a name='Page_202' id='Page_202'></a><a href='#TOC'>[Pg 202]</a></span>
+Sulphur and tar ointments, officinal strength or weakened with
+lard, and also the following:&mdash;</p>
+
+<pre>
+  &#8478; Ol. cadini,
+    Alcoholis,
+    Saponis viridis, ..................&#257;&#257;............. &#658;iiss.   M.
+</pre>
+
+<p>(This is to be rubbed in, in small quantity, once or twice daily, and
+later a soothing remedy applied.)</p>
+
+<p>In recent years both the <i>x</i>-ray and Finsen light have been used
+with variable success. Repeated applications of the high-frequency
+current, with the vacuum electrode, have also proved serviceable.
+Cautious applications of liquid air or carbon dioxide have also been
+used with some success in the past few years.</p>
+
+
+<p><b>When are destructive and operative measures justifiable?</b></p>
+
+<p>In obstinate, sluggish, and long-persistent patches, and then only
+after other methods of treatment have failed. (Remember that a
+patch or patches of the disease <i>may</i> disappear in course of time
+spontaneously, and occasionally <i>without leaving a scar</i>.)</p>
+
+
+<p><b>State the methods of treatment commonly used in obstinate,
+sluggish and persistent patches of lupus erythematosus.</b></p>
+
+<p>Cauterization&mdash;with nitrate of silver, with applications of pyrogallic
+acid in ointment or in liquor gutta-perch&aelig;, fifteen to thirty
+per cent. strength, and with solutions (cautiously employed) of caustic
+potash, and exceptionally with the galvano-cautery.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 43.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/202a.png' width='400' height='113'
+alt='FIG. 43.'
+title='FIG. 43.' />
+</div>
+<p class='center'>Single Scarifier.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 44.</b></p>
+<div class='figcenter' style='width: 600px;'>
+<img src='images/202b.png' width='600' height='97'
+alt='FIG. 44.'
+title='FIG. 44.' />
+</div>
+<p class='center'>Multiple Scarifier. (<i>As modified by Van Harlingen.</i>)</p>
+
+<p><span class='pagenum'><a name='Page_203' id='Page_203'></a><a href='#TOC'>[Pg 203]</a></span>
+Operative&mdash;scarification, either punctate or linear, and erosion
+with the curette. (See treatment of lupus vulgaris.)</p>
+
+
+<h2><a name='Lupus_Vulgaris' id='Lupus_Vulgaris'></a><b>Lupus Vulgaris.</b></h2>
+<p class='center'>(<i>Synonyms:</i> Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the Skin.)</p>
+
+
+<p><b>What do you understand by lupus vulgaris?</b></p>
+
+<p>Lupus vulgaris is a cellular new growth, characterized by variously-sized,
+soft, reddish-brown, papular, tubercular and infiltrated patches,
+usually terminating in ulceration and scarring.</p>
+
+
+<p><b>Upon what region is lupus vulgaris usually observed?</b></p>
+
+<p>The face, especially the nose, but any part may be invaded. The
+area involved may be small or quite extensive, usually the former.</p>
+
+
+<p><b>At what age is the disease noted?</b></p>
+
+<p>In many cases it begins in childhood or early adult life, but as it
+is persistent and tends to relapse, it may be met with at any age.</p>
+
+
+<p><b>Describe the earlier symptoms of lupus vulgaris.</b></p>
+
+<p>The disease begins by the development of several or more pin-head
+to small pea-sized, deep-seated, brownish-red or yellowish tubercles,
+having their seat in the deeper part of the corium, and which are
+somewhat softer and looser in texture than normal tissue. As the
+disease progresses, variously-sized and shaped aggregations or patches
+result, covered with thin and imperfectly-formed epidermis.</p>
+
+
+<p><b>What changes do the lupus tubercles or infiltrations undergo?</b></p>
+
+<p>The lesions, having attained a certain size or development, may
+remain so for a time, but sooner or later retrogressive changes occur:
+the matured papules or tubercles, or infiltrated patches, slowly disappear
+by absorption, fatty degeneration, and exfoliation, leaving a
+yellowish or brownish pigmentation, usually with more or less atrophy
+or cicatricial-tissue formation&mdash;<i>lupus exfoliativus</i>; or disintegration
+and destruction result, terminating in ulceration&mdash;<i>lupus exedens,
+lupus exulcerans</i>. This latter is the more usual course.</p>
+
+
+<p><b>Describe the clinical appearances and behavior of the lupus
+ulcerations.</b></p>
+
+<p>They are rounded, shallow excavations, with soft and reddish
+borders. In exceptional instances exuberant granulations appear&mdash;
+<span class='pagenum'><a name='Page_204' id='Page_204'></a><a href='#TOC'>[Pg 204]</a></span>
+<i>lupus hypertrophicus</i>; or papillary outgrowths are noted&mdash;<i>lupus verrucosus</i>.
+The ulcerations secrete a variable amount of pus, usually
+slight in quantity, which leads to more or less crust formation; later,
+however, cicatricial tissue, generally of a <i>firm and fibrous</i> character,
+results.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 45.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_204.jpg'>
+<img src='images/204.jpg' width='400' height='342'
+alt='FIG. 45.'
+title='FIG. 45.' />
+</a>
+</div>
+
+<p class='center'>Lupus of Arm.</p>
+
+
+<p><b>In what manner does the disease spread?</b></p>
+
+<p>The patches spread by the appearance of new tubercles, or infiltrations
+at the peripheral portion. New islets and areas of disease
+may continue to make their appearance from time to time, usually
+upon contiguous parts.</p>
+
+
+<p><b>Are the mucous membranes of the mouth, throat and larynx
+ever involved?</b></p>
+
+<p>In some instances, and either primarily or secondarily.</p>
+
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_204a.jpg'>
+<img src='images/204a.jpg' width='400' height='249'
+alt='Lupus Vulgaris'
+title='Lupus Vulgaris' />
+</a>
+</div>
+<p class='center'>Lupus Vulgaris.</p>
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_204b.jpg'>
+<img src='images/204b.jpg' width='400' height='335'
+alt='Lupus Vulgaris'
+title='Lupus Vulgaris' />
+</a>
+</div>
+<p class='center'>Lupus Vulgaris.</p>
+
+<p><span class='pagenum'><a name='Page_205' id='Page_205'></a><a href='#TOC'>[Pg 205]</a></span></p>
+
+<p><b>Is the bone tissue ever involved in lupus vulgaris?</b></p>
+
+<p>No.</p>
+
+
+<p><b>What course does lupus vulgaris pursue?</b></p>
+
+<p>It is slowly but, as a rule, steadily progressive. Several years or
+more may elapse before the area of disease is conspicuous.</p>
+
+
+<p><b>What is the cause of lupus vulgaris?</b></p>
+
+<p>It is now known to be due to the invasion of the cutaneous structures
+by the tubercle bacillus; in short, a tuberculosis of the skin.
+It is not infrequently observed in the strumous and debilitated. It
+is entirely independent of syphilis.</p>
+
+
+<p><b>What is the pathology of lupus vulgaris?</b></p>
+
+<p>According to recent investigations, the infiltrations of lupus are
+due chiefly to cell-proliferation and outgrowth from the protoplasmic
+walls and adventitia of the bloodvessels and lymphatics. The
+fibrous-tissue network, vessels and a portion of the cell infiltration
+are thus produced, the fixed and wandering connective-tissue cells
+of the inflamed stroma of the cutis being responsible for the other
+portion of the new growth (Robinson).</p>
+
+
+<p><b>State the diagnostic features of lupus vulgaris.</b></p>
+
+<p>In a typical, developed patch of lupus are to be seen:&mdash;cicatricial
+formation, usually of a fibrous and tough character; ulcerations; the
+yellowish-brown tubercles and infiltration; and the characteristic
+soft, small, yellowish or reddish-brown, cutaneous and subcutaneous
+points and tubercles.</p>
+
+
+<p><b>How does the tubercular syphiloderm differ from lupus vulgaris?</b></p>
+
+<p>The tubercular syphiloderm is much more rapid in its course,
+the ulceration is deeper and the discharge copious and often offensive;
+the scarring is soft, and, compared to the amount of ulceration,
+but slightly disfiguring; and it is, for obvious reasons, a disease of
+adult or late life. The history, together with other evidences of
+previous or concomitant symptoms of syphilis, will often aid in the
+differentiation.</p>
+
+
+<p><b>How does epithelioma differ from lupus vulgaris?</b></p>
+
+<p>The edges of the epitheliomatous ulcer are hard, elevated and
+waxy; the base is uneven, the secretion thin, scanty and apt to be
+<span class='pagenum'><a name='Page_206' id='Page_206'></a><a href='#TOC'>[Pg 206]</a></span>
+streaked with blood; the ulceration usually starts from one point,
+and is often painful; the tissue destruction may be considerable;
+there is little, if any, tendency to the formation of cicatricial tissue;
+and, finally, it is usually a disease of advanced age.</p>
+
+
+<p><b>In what respects does lupus erythematosus differ from lupus vulgaris?</b></p>
+
+<p>Lupus erythematosus has no papules, tubercles or ulceration.</p>
+
+
+<p><b>How does acne rosacea differ from lupus vulgaris?</b></p>
+
+<p>Acne rosacea is characterized by hyper&aelig;mia, dilated vessels,
+papules, pustules, the absence of ulceration, and a different history.</p>
+
+
+<p><b>State the prognosis of lupus vulgaris.</b></p>
+
+<p>Lupus vulgaris is always a chronic disease, often exceedingly
+rebellious to treatment, and one that calls for a guarded opinion.
+Relapses are not uncommon.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 46.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/206.jpg' width='400' height='155'
+alt='FIG. 46.'
+title='FIG. 46.' />
+</div>
+
+<p class='center'>Galvano-cautery Needle, Knife and Spiral Points. (<i>As devised by B&eacute;snier.</i>)</p>
+
+
+<p>The general health usually remains good, but in some instances
+death by tuberculosis of the lungs has been noted.</p>
+
+
+<p><b>Is external or internal treatment called for in lupus vulgaris?</b></p>
+
+<p>Always external, and not infrequently constitutional also.</p>
+
+
+<p><b>What is the constitutional treatment?</b></p>
+
+<p>The general health must be cared for; good, nutritious food,
+fresh air and out-door exercise, together with, in many cases, the
+administration of such remedies as cod-liver oil, potassium iodide, iron
+and quinine, are of therapeutic importance. Tuberculin may be tried
+in severe and obstinate cases, but its use is not without danger.
+<span class='pagenum'><a name='Page_207' id='Page_207'></a><a href='#TOC'>[Pg 207]</a></span></p>
+
+
+<p><b>State the object of local treatment.</b></p>
+
+<p>The destruction or removal of the diseased tissue.</p>
+
+
+<p><b>May milder methods of treatment sometimes prove beneficial
+and even curative?</b></p>
+
+<p>Exceptionally, mercurial plaster, corrosive-sublimate lotion and
+ointment (gr. j to &#8485; j), a plaster containing five to fifteen per cent.
+of salicylic acid and creasote, repeated paintings with carbolic acid,
+and the constant application of lead plaster containing twenty per
+cent. of ichthyol, are valuable.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 47.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/207.jpg' width='400' height='96'
+alt='FIG. 47.'
+title='FIG. 47.' />
+</div>
+
+<p class='center'>Double Curette.</p>
+
+
+<p>Of the milder methods, those most in vogue to-day are the <i>Finsen
+light</i> and <i>x-ray</i>. Either proves extremely valuable in some cases,
+but the Finsen method is the favorite method.</p>
+
+
+<p><b>What methods are commonly employed for the rapid removal
+or destruction of lupus tissue?</b></p>
+
+<p>Cauterization, scarification, erasion and excision are variously practised;
+the particular method depending, in great measure, upon the
+extent of the disease, the part involved, and other circumstances.</p>
+
+
+<p><b>Name the several caustics, and state how they are employed.</b></p>
+
+<p><i>Pyrogallic acid</i>, used as an ointment:&mdash;</p>
+
+<pre>
+  &#8478; Ac. pyrogallici, ................................. &#658;ij
+    Emplast. plumbi, ................................. &#658;j
+    Cerat. resins&aelig;, .................................. &#658;v.   M.
+</pre>
+
+<p>It is applied for one or two weeks. Every several days the parts
+are poulticed, the slough thus removed, and the ointment reapplied,
+and so on until the diseased tissue has been destroyed. It is useful
+in those cases in which a mild and comparatively painless caustic
+is advisable. In most cases several repetitions of this plan are
+necessary.
+<span class='pagenum'><a name='Page_208' id='Page_208'></a><a href='#TOC'>[Pg 208]</a></span>
+<i>Arsenious acid</i>, employed as an ointment&mdash;</p>
+
+<pre>
+  &#8478; Ac. arseniosi, ................................... gr. xx
+    Hydrarg. sulphid. rub., .......................... gr. lx
+    Ungt. aqu&aelig; ros&aelig;, ................................. &#8485;i.   M.
+</pre>
+
+<p>It is painful but thorough; it is spread on lint and renewed daily.
+The action is usually sufficient in three days, and the parts are then
+poulticed until the slough comes away, after which a simple dressing
+is employed. Its application is advisable for a small area only&mdash;not
+more than four square inches&mdash;as absorption is possible.</p>
+
+<p><i>Galvano-cautery.</i>&mdash;The diseased tissue is destroyed by numerous
+punctures with a red-heated point or by linear incision with a red-heated
+knife. It is often a practicable and satisfactory method.
+The Paquelin cautery and liquid air and carbon dioxide also have
+their advocates.</p>
+
+
+<p><b>Describe the operative measures employed in the removal of
+lupus tissue.</b></p>
+
+<p><i>Linear Scarification.</i>&mdash;The parts are thoroughly cross-tracked,
+cutting through the diseased tissue, and subsequently a simple salicylated
+ointment applied. The operation is repeated from time to
+time, and as a result the new growth undergoes retrogressive changes,
+and cicatrization takes place.</p>
+
+<p><i>Punctate Scarification.</i>&mdash;By means of a simple or multiple-pointed
+instrument numerous closely-set punctures are made, and repeated
+from time to time, usually with the same action and result as from
+linear scarification.</p>
+
+<p><i>Erasion.</i>&mdash;The parts are thoroughly scraped with a curette, and a
+supplementary caustic application made, either with caustic potash
+or several days' use of the pyrogallic-acid ointment. The result is
+usually satisfactory.</p>
+
+<p>The dental-burr is also useful in breaking up discrete tubercles.</p>
+
+<p><i>Excision.</i>&mdash;This is an effective method if the disease consists of a
+small pea- or bean-sized circumscribed patch.</p>
+
+<p>Of these various operative methods those now most favored are
+erasion and excision, punctate and linear scarification methods are
+now rarely employed.
+<span class='pagenum'><a name='Page_209' id='Page_209'></a><a href='#TOC'>[Pg 209]</a></span></p>
+
+
+<h2><a name='Tuberculosis_Cutis' id='Tuberculosis_Cutis'></a><b>Tuberculosis Cutis.</b><a name='FNanchor_A_4' id='FNanchor_A_4'></a><a href='#Footnote_A_4' class='fnanchor'>[D]</a></h2>
+
+<p class='center'>(<i>Synonym:</i> Scrofuloderma.)</p>
+
+<div class='footnote' style='margin-left: 5em;'><p><a name='Footnote_A_4' id='Footnote_A_4'></a><a href='#FNanchor_A_4'><span class='label'>[D]</span></a> The most important clinical variety of this class is lupus vulgaris,
+which is considered above, separately, at some length.</p></div>
+
+
+<p><b>What do you understand by tuberculosis cutis?</b></p>
+
+<p>The term is applied to those peculiar suppurative and ulcerative
+conditions of the skin due to the tubercle bacilli.</p>
+
+
+<p><b>How does the common type of tuberculosis cutis begin?</b></p>
+
+<p>The most common type of tuberculous ulceration or involvement
+of the skin usually results by extension from an underlying caseating
+and suppurating lymphatic gland; or it may have its origin as subcutaneous
+tubercles independently of these structures. It tends to
+spread, and may involve an area of one or several inches.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 48.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_209.jpg'>
+<img src='images/209.jpg' width='400' height='364'
+alt='FIG. 48.'
+title='FIG. 48.' />
+</a>
+</div>
+<p class='center'>Tuberculosis Verrucosa Cutis (Negro).</p>
+
+
+<p><span class='pagenum'><a name='Page_210' id='Page_210'></a><a href='#TOC'>[Pg 210]</a></span></p>
+
+
+<p><b>What are the clinical appearances and behavior of this type
+of tuberculous ulceration?</b></p>
+
+<p>It is usually superficial, has thin, red, undermined edges of a
+violaceous color, and an irregular base with granulations covered
+scantily with pus. As a rule, it spreads gradually as a simple
+ulceration, with but slight, if any, outlying infiltration. Subjective
+symptoms of a painful or troublesome character are rarely present.
+Its course is usually progressive but slow and chronic.</p>
+
+<p>Other symptoms of tuberculosis are commonly to be found.</p>
+
+
+<p><b>Are other forms of tuberculosis cutis met with?</b></p>
+
+<p>A papulo-pustular eruption is sometimes observed, especially on
+the upper extremities and face; sluggish and chronic in character
+and leaving small pit-like scars; has been known as the <i>small pustular
+scrofuloderma</i>.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 49.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_210.jpg'>
+<img src='images/210.jpg' width='400' height='250'
+alt='FIG. 49.'
+title='FIG. 49.' />
+</a>
+</div>
+<p class='center'>Tuberculosis Verrucosa Cutis (patient had a coexistent pulmonary tuberculosis).</p>
+
+
+<p>An ulcerative papillomatous or verrucous tuberculosis of the skin
+(tuberculosis verrucosa cutis) is also occasionally noted, most commonly
+seated upon the lower leg or the back of the hand. It may
+be slight or extensive. Its mildest phase is the so-called verruca
+necrogenica.
+<span class='pagenum'><a name='Page_211' id='Page_211'></a><a href='#TOC'>[Pg 211]</a></span></p>
+
+
+<p><b>Describe verruca necrogenica.</b></p>
+
+<p>Verruca necrogenica is a rare, localized, papillary or wart-like formation,
+occurring usually about the knuckles or other parts of the hand.</p>
+
+<p>It begins, as a rule, as a small, papule-like growth, increasing
+gradually in area, and when well advanced appears as a pea, dime-sized
+or larger, somewhat inflammatory, elevated, flat, warty mass,
+with usually a tendency to slight pus-formation between the hypertrophied
+papill&aelig;; the surface may be horny or it may be crusted.
+It tends to enlarge slowly and is usually persistent, but it at times
+undergoes involution.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 50.</b></p>
+<div class='figcenter' style='width: 300px;'>
+<img src='images/211.png' width='300' height='499'
+alt='FIG. 50.'
+title='FIG. 50.' />
+</div>
+
+<p class='center'>Tuberculosis Cutis (Verruca Necrogenica). (<i>After Model in Guy's Museum.</i>)</p>
+
+
+<p><b>State the etiology.</b></p>
+
+<p>Heredity, insufficient and unwholesome food, impure air, and the
+like are predisposing. The tubercle bacillus is the immediate exciting
+cause.</p>
+
+<p>The disease usually appears in childhood or early adult life, and
+not infrequently follows in the wake of some severe systemic disease.
+Etiologically it is identical in nature with lupus.</p>
+
+
+<p><b>How is the tuberculous ulcer to be differentiated from syphilis?</b></p>
+
+<p>By the peculiar character of the tuberculous ulceration, the absence
+of outlying tubercles and infiltration, together with its history,
+course, and often the presence of other tuberculous symptoms.
+<span class='pagenum'><a name='Page_212' id='Page_212'></a><a href='#TOC'>[Pg 212]</a></span></p>
+
+
+<p><b>State the prognosis.</b></p>
+
+<p>These various types of tuberculosis cutis are, as a rule, more amenable
+to treatment than that form known as lupus vulgaris (<i>q. v.</i>).</p>
+
+
+<p><b>What is the treatment of these forms of tuberculosis cutis?</b></p>
+
+<p>Constitutional remedies, such as cod-liver oil, iodide of iron or
+other ferruginous tonics, together with good food and pure air;
+phosphorus one-hundredth to one-fiftieth of a grain three times
+daily is also of benefit in some cases.</p>
+
+<p>The local treatment consists in thorough curetting and the subsequent
+application of a mildly stimulating ointment. The several
+other plans of external treatment employed in lupus (<i>q. v.</i>) are also
+variously practised. In recent years the <i>x</i>-ray and Finsen light
+plans have, in a measure, supplanted the previous methods of treatment.
+They are slow, however, and might be, especially the <i>x</i>-ray,
+more satisfactorily employed as a supplementary measure.</p>
+
+
+<h2><a name='Ainhum' id='Ainhum'></a><b>Ainhum.</b></h2>
+
+
+<p><b>Describe ainhum</b>.</p>
+
+<p>Ainhum is a disease of the African race, met with chiefly in
+Brazil, the West Indies, and Africa, and consists of a slow but
+gradual linear strangulation of one or more of the toes, especially
+the smallest, resulting, eventually, in spontaneous amputation. The
+affected toes themselves undergo fatty degeneration, often with
+increase in size, and are, when strangulation is well advanced, considerably
+misshapen. The nature of the disease is obscure.</p>
+
+<p><i>Treatment</i> consists, in the early stages, of incision through the
+constricting band; when the disease is well advanced, amputation is
+the sole recourse.</p>
+
+
+<h2><a name='Mycetoma' id='Mycetoma'></a><b>Mycetoma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Fungous Foot of India; Madura Foot; Podelcoma.)</p>
+
+
+<p><b>Describe mycetoma.</b></p>
+
+<p>It is a disease involving usually the foot, and is met with chiefly in
+India. It is characterized by swelling and the formation of tubercular
+or nodular lesions which break down and form the external
+openings of sinuses which lead to the interior of the affected part.
+These discharge, and are studded with, whitish granules or black,
+roe-like masses, mixed with a sanious or sero-purulent fluid. The
+<span class='pagenum'><a name='Page_213' id='Page_213'></a><a href='#TOC'>[Pg 213]</a></span>
+whole part is gradually disintegrated, the process lasting indefinitely.
+Its nature is obscure; it is thought to be due to a fungus.</p>
+
+<p><i>Treatment</i> consists in the early stages, when the disease is limited,
+of thorough curetting and cauterization; later, after the part
+is more or less involved, amputation, at a point well up beyond the
+disease, becomes necessary. Potassium iodide internally may exert a
+favorable influence.</p>
+
+
+<h2><a name='Perforating_Ulcer_of_the_Foot' id='Perforating_Ulcer_of_the_Foot'></a><b>Perforating Ulcer of the Foot.</b></h2>
+
+
+<p><b>Describe perforating ulcer of the foot.</b></p>
+
+<p>Perforating ulcer of the foot is a rare disease, consisting of an
+indolent and usually painless sinus leading down to diseased bone.
+The external opening, which is through the centre of a corn-like
+formation, is small, and may or may not show the presence of granulations.
+The affected part is commonly more or less an&aelig;sthetic and
+of subnormal temperature. One or several may be present, either
+on one or both feet. The most common site is over the articulation
+of the metatarsal bone with the phalanx of the first or last toe.
+The disease is dependent upon impairment or degeneration of the
+central, truncal or peripheral nerves.</p>
+
+
+<p><b>What is to be said in regard to the prognosis and treatment?</b></p>
+
+<p>Treatment, which is, as a rule, unsatisfactory, consists in the maintenance
+of absolute rest, and the use of antiseptic and stimulating
+applications. Amputation is also resorted to, but even this is
+at times futile, as a new sinus may appear upon the stump.</p>
+
+
+<h2><a name='Syphilis_Cutanea' id='Syphilis_Cutanea'></a><b>Syphilis Cutanea.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Syphiloderma; Dermatosyphilis; Syphilis of the Skin.)</p>
+
+
+<p><b>In what various types may syphilis manifest itself upon the
+integument?</b></p>
+
+<p>Syphilis may show itself as a macular, papular (rarely vesicular),
+pustular, bullous, tubercular and gummatous eruption; or the eruption
+may be, in a measure, of a mixed type.
+<span class='pagenum'><a name='Page_214' id='Page_214'></a><a href='#TOC'>[Pg 214]</a></span></p>
+
+
+<p><b>In what respects do the early (or secondary) eruptions of
+syphilis differ from those following several years or
+more after the contraction of the disease?</b></p>
+
+<p>The early or secondary eruptions are more or less generalized, with
+rarely any attempt at special configuration. Their appearance is
+often preceded by symptoms of systemic disturbance, such as fever,
+loss of appetite, muscular pains and headache; and accompanied by
+concomitant signs of the disease, such as enlargement of the lymphatic
+glands, sore throat, mucous patches, falling of the hair and
+rheumatic pains.</p>
+
+
+<p><b>State the distinguishing characters of the late eruptions.</b></p>
+
+<p>The late eruptions (those following one or more years after the
+contraction of the disease) are usually of tubercular, gummatous or
+ulcerative type; are limited in extent, and have a marked tendency
+to appear in circular, semicircular or crescentic forms or groups.
+Pain in the bones, bone lesions and other symptoms may or may not
+be present.</p>
+
+
+<p><b>What is the color of syphilitic lesions?</b></p>
+
+<p>Usually, a dull brownish-red or ham-red, with at times a yellowish
+cast.</p>
+
+
+<p><b>Are there any subjective symptoms in syphilitic eruptions?</b></p>
+
+<p>As a rule, no; but in exceptional instances of the generalized
+eruptions, more especially in negroes, there may be slight itching.</p>
+
+
+<p><b>Describe the macular, or erythematous, eruption of syphilis.</b></p>
+
+<p>The <i>macular syphiloderm</i> is a general eruption, showing itself
+usually six or eight weeks after the appearance of the chancre. It
+consists of small or large, commonly pea- or bean-sized, rounded or
+irregularly-shaped, not infrequently slightly raised, macules. When
+well established they do not entirely disappear under pressure. At
+first a pale-pink or dull, violaceous red, they later become yellowish
+or coppery. The eruption is generally profuse; the face, backs of the
+hands and feet may escape. It persists several weeks or one or two
+months; as a rule, it is rapidly responsive to treatment.</p>
+
+
+<p><b>How would you distinguish the macular syphiloderm from
+measles, r&ouml;theln and tinea versicolor?</b></p>
+
+<p>Measles is to be differentiated by its catarrhal symptoms, fever,
+form and situation of the eruption; r&ouml;theln, by its small, roundish,
+<span class='pagenum'><a name='Page_215' id='Page_215'></a><a href='#TOC'>[Pg 215]</a></span>
+confluent pinkish or reddish patches, its precursory pyrexic symptoms,
+its epidemic nature, and short duration; tinea versicolor by
+its scaliness, peripheral growth, distribution and history.</p>
+
+<p>And, finally, by the absence or presence of other symptoms of
+syphilis.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 51.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_215.jpg'>
+<img src='images/215.jpg' width='400' height='568'
+alt='FIG. 51.'
+title='FIG. 51.' />
+</a>
+</div>
+
+<p class='center'>Macular Syphiloderm.</p>
+
+
+<p><b>What several varieties of the papular eruption of syphilis are
+met with?</b></p>
+
+<p>There are two forms of the papular eruption&mdash;the small and large;
+those of the latter type may undergo various modifications.</p>
+
+
+<p><b>Describe the small-papular eruption of syphilis.</b></p>
+
+<p>The <i>small-papular syphiloderm</i> (<i>miliary papular syphiloderm</i>)
+usually shows itself in the third or fourth month of the disease, and
+<span class='pagenum'><a name='Page_216' id='Page_216'></a><a href='#TOC'>[Pg 216]</a></span>
+consists of a more or less generalized eruption of disseminated or
+grouped, firm, rounded or acuminated pin-head to millet-seed-sized
+papules, with smooth or slightly scaly summits, and in some lesions
+showing pointed pustulation. Scattered minute pustules and some
+large papules are usually present. The eruption is profuse, most abundant
+upon the trunk and limbs; and in the early part of the outbreak
+is of a bright- or dull-red color, later assuming a violaceous or
+brownish tint. It runs a chronic course, is somewhat rebellious to
+treatment, and displays a tendency to relapse.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 52.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/216.jpg' width='400' height='309'
+alt='FIG. 52.'
+title='FIG. 52.' />
+</div>
+
+<p class='center'>Moist Papules. (<i>After Miller.</i>)</p>
+
+
+<p><b>How would you distinguish the small-papular syphiloderm
+from keratosis pilaris, psoriasis punctata, papular eczema,
+and lichen ruber?</b></p>
+
+<p>The distribution and extent of the eruption, the color, the grouping,
+with usually the presence of pustules and large papules and
+other concomitant symptoms of syphilis, are points of difference. Pustules
+never occur in the several diseases named, except in eczema.</p>
+
+
+<p><b>Describe the large-papular eruption of syphilis.</b></p>
+
+<p>The <i>large-papular syphiloderm</i> (or <i>lenticular syphiloderm</i>) is a common form of cutaneous syphilis, appearing usually in the first
+six or eight months, and consists of a more or less generalized eruption
+of pea- to dime-sized or larger, flat, rounded or oval, firmly-seated,</p>
+
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_216b.jpg'>
+<img src='images/216b.jpg' width='400' height='582'
+alt='Small-papular Syphiloderm'
+title='Small-papular Syphiloderm' />
+</a>
+</div>
+<p class='center'>Small-papular Syphiloderm.</p>
+
+
+<p><span class='pagenum'><a name='Page_217' id='Page_217'></a><a href='#TOC'>[Pg 217]</a></span></p>
+
+
+<p>more or less raised, dull-red papules; with at first a smooth
+surface, which later usually becomes covered with a film of exfoliating
+epidermis. The papules, as a rule, develop slowly, remain stationary
+several weeks or a few months, and then pass away by
+absorption, leaving slight pigmentation, which gradually fades; or
+they may undergo certain modifications. In most cases it responds
+rapidly to treatment.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 53.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_217.jpg'>
+<img src='images/217.jpg' width='400' height='335'
+alt='FIG. 53.'
+title='FIG. 53.' />
+</a>
+</div>
+<p class='center'>Palmar Syphiloderm.</p>
+
+
+<p><b>What modifications do the papules of the large-papular syphiloderm
+sometimes undergo?</b></p>
+
+<p>They may change into the moist papule and squamous papule.</p>
+
+
+<p><b>Describe the moist papule of syphilis.</b></p>
+
+<p>The change into the moist papule (also called <i>mucous patch, flat
+condyloma</i>) is not uncommon where opposing surfaces and natural
+folds of skin are subjected to more or less contact, as about the
+anus, the scroto-femoral regions, umbilicus, axill&aelig; and beneath the
+<span class='pagenum'><a name='Page_218' id='Page_218'></a><a href='#TOC'>[Pg 218]</a></span>
+mamm&aelig;. The dry, flat papules gradually become moist and covered
+with a grayish, sticky, mucoid secretion; several may coalesce
+and form large, flat patches. They may so remain, or they may
+become hypertrophic, warty or papillomatous, with more or less crust
+formation (<i>vegetating syphiloderm</i>).</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 54.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/218.png' width='400' height='452'
+alt='FIG. 54.'
+title='FIG. 54.' />
+</div>
+
+<p class='center'>Annular Syphiloderm. (<i>After I.E. Atkinson.</i>)</p>
+
+
+<p><b>Describe the squamous papule of syphilis.</b></p>
+
+<p>This tendency of the large-papular eruption to become scaly, when
+exhibited, is more or less common to all papules, and constitutes the
+<i>squamous</i> or <i>papulo-squamous syphiloderm</i> (improperly called <i>psoriasis
+syphilitica</i>). The papules become somewhat flattened and are
+covered with dry, grayish or dirty-gray, somewhat adherent scales.
+The scaling, as compared to that of psoriasis, is, as a rule, relatively
+slight. The eruption may be general, as usually the case in the
+earlier months of the disease, or it may appear as a relapse or a
+later manifestation, and be limited in extent.</p>
+
+<p>As a limited eruption it is most frequently seen on the palms and
+soles&mdash;the <i>palmar and plantar syphiloderm</i>. Occurring on these
+parts it is often rebellious to treatment.</p>
+
+
+<div class='figcenter' style='width: 245px;'>
+<a href='images/fullsize_218b.jpg'>
+<img src='images/218b.jpg' width='245' height='600'
+alt='Maculo-papular syphiloderm'
+title='Maculo-papular syphiloderm' />
+</a>
+</div>
+<p class='center'>Maculo-papular syphiloderm.</p>
+
+
+<p><span class='pagenum'><a name='Page_219' id='Page_219'></a><a href='#TOC'>[Pg 219]</a></span></p>
+
+
+<p><b>How are you to distinguish the papulo-squamous syphiloderm
+from psoriasis?</b></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<p><b>Describe the annular eruption of syphilis.</b></p>
+
+<p>The <i>annular syphiloderm</i> (<i>circinate syphiloderm</i>) 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.</p>
+
+
+<p><b>What several varieties of the pustular syphiloderm are met
+with?</b></p>
+
+<p>The small acuminated-pustular syphiloderm, the large acuminated-pustular
+syphiloderm, the small flat-pustular syphiloderm, and the
+large flat-pustular syphiloderm.</p>
+
+
+<p><b>Describe the small acuminated-pustular eruption of syphilis.</b></p>
+
+<p>The <i>small acuminated-pustular syphiloderm</i> (<i>miliary pustular
+syphiloderm</i>) 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
+<span class='pagenum'><a name='Page_220' id='Page_220'></a><a href='#TOC'>[Pg 220]</a></span>
+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.</p>
+
+
+<p><b>Describe the large acuminated-pustular eruption of syphilis.</b></p>
+
+<p>The <i>large acuminated-pustular syphiloderm</i> (<i>acne-form syphiloderm,
+variola-form syphiloderm</i>) 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.</p>
+
+<p>It pursues, as a rule, a comparatively rapid and benign course.
+In relapses the eruption is usually more or less localized.</p>
+
+
+<p><b>How would you distinguish the large acuminated-pustular
+syphiloderm from acne and variola?</b></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The presence or absence of other symptoms of syphilis has, in
+obscure cases, an important diagnostic bearing.</p>
+
+
+<p><b>Describe the small flat-pustular eruption of syphilis.</b></p>
+
+<p>The <i>small flat-pustular syphiloderm</i> (<i>impetigo-form syphiloderm</i>)
+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
+<span class='pagenum'><a name='Page_221' id='Page_221'></a><a href='#TOC'>[Pg 221]</a></span>
+scalp, and about the genitalia, frequently in association with papules
+on other parts.</p>
+
+
+<p><b>Are you likely to mistake the small flat-pustular syphiloderm
+for any other eruption?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Describe the large flat-pustular eruption of syphilis.</b></p>
+
+<p>The <i>large flat-pustular syphiloderm</i> (<i>ecthyma-form syphiloderm</i>)
+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.</p>
+
+<p>In one type&mdash;the superficial variety&mdash;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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 55.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/221.png' width='400' height='339'
+alt='FIG. 55.'
+title='FIG. 55.' />
+</div>
+
+<p class='center'>Rupia. (<i>After Tilbury Fox.</i>)</p>
+
+<p><span class='pagenum'><a name='Page_222' id='Page_222'></a><a href='#TOC'>[Pg 222]</a></span>
+In the other type&mdash;the deep variety&mdash;the crust is greenish or
+blackish, is raised and more bulky, often conical and stratified, like
+an oyster shell&mdash;<i>rupia</i>; 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.</p>
+
+
+<p><b>How would you differentiate the large flat-pustular syphiloderm
+from ecthyma?</b></p>
+
+<p>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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 56.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_222.jpg'>
+<img src='images/222.jpg' width='400' height='384'
+alt='FIG. 56.'
+title='FIG. 56.' />
+</a>
+</div>
+
+<p class='center'>Ulcerating Tubercular Syphiloderm.</p>
+
+
+<p><b>Describe the bullous eruption of syphilis.</b></p>
+
+<p>The <i>bullous syphiloderm</i>, (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.
+<span class='pagenum'><a name='Page_223' id='Page_223'></a><a href='#TOC'>[Pg 223]</a></span>
+The crust, which soon forms, is of a yellowish-brown or dark green
+color, and may be thick and stratified (<i>rupia</i>), 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.</p>
+
+<p>It is not an uncommon manifestation of hereditary syphilis (<i>q. v.</i>)
+in the newborn.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 57.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_223.jpg'>
+<img src='images/223.jpg' width='400' height='249'
+alt='FIG. 57.'
+title='FIG. 57.' />
+</a>
+</div>
+
+<p class='center'>Tubercular Syphiloderm.</p>
+
+
+<p><b>How is the bullous syphiloderm to be differentiated from
+other pemphigoid eruptions?</b></p>
+
+<p>By the gravity of the disease, the accompanying ulceration, the
+course and history; and by other evidences, past or present, of syphilis.</p>
+
+
+<p><b>Describe the tubercular eruption of syphilis.</b></p>
+
+<p>The <i>tubercular syphiloderm</i> (<i>syphiloderma tuberculosum</i>) 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
+<span class='pagenum'><a name='Page_224' id='Page_224'></a><a href='#TOC'>[Pg 224]</a></span>
+segments of circles and circular areas, clearing in the centre and spreading
+peripherally.</p>
+
+<p>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 (<i>serpiginous tubercular syphiloderm</i>). 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 (<i>non-ulcerating
+tubercular syphiloderm</i>), or by ulceration (<i>ulcerating tubercular
+syphiloderm</i>).</p>
+
+
+<p><b>Describe the ulcerating tubercular syphiloderm.</b></p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 58.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_224.jpg'>
+<img src='images/224.jpg' width='400' height='294'
+alt='FIG. 58.'
+title='FIG. 58.' />
+</a>
+</div>
+
+<p class='center'>Ulcerating Tubercular Syphiloderm.</p>
+
+
+<p>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</p>
+
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_224a.jpg'>
+<img src='images/224a.jpg' width='400' height='314'
+alt='Tubercular Syphiloderm'
+title='Tubercular Syphiloderm' />
+</a>
+</div>
+<p class='center'>Tubercular Syphiloderm.</p>
+
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_224b.jpg'>
+<img src='images/224b.jpg' width='400' height='153'
+alt='Large-pustular Syphiloderm'
+title='Large-pustular Syphiloderm' />
+</a>
+</div>
+<p class='center'>Large-pustular Syphiloderm.</p>
+
+<p><span class='pagenum'><a name='Page_225' id='Page_225'></a><a href='#TOC'>[Pg 225]</a></span></p>
+
+<p>lesions, especially about the periphery of the group or patch, may
+appear from time to time.</p>
+
+<p>In some instances, more especially about the scalp, the surface of
+the ulcerations becomes papillary or wart-like, with an offensive, yellowish,
+puriform secretion (<i>syphilis cutanea papillomatosa</i>).</p>
+
+
+<p><b>From what diseases is the tubercular syphiloderm to be
+differentiated?</b></p>
+
+<p>From tubercular leprosy, epithelioma and lupus vulgaris, especially
+the last-named.</p>
+
+
+<p><b>What are the chief diagnostic characters of the tubercular
+syphiloderm?</b></p>
+
+<p>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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 59.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_225.jpg'>
+<img src='images/225.jpg' width='400' height='206'
+alt='FIG. 59.'
+title='FIG. 59.' />
+</a>
+</div>
+
+<p class='center'>Tubercular Syphiloderm.</p>
+
+
+<p><b>Describe the gummatous eruption of syphilis.</b></p>
+
+<p>The <i>gummatous syphiloderm</i> (<i>syphiloderma gummatosum, gumma,
+syphiloma</i>) 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.
+<span class='pagenum'><a name='Page_226' id='Page_226'></a><a href='#TOC'>[Pg 226]</a></span>
+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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 60.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_226.jpg'>
+<img src='images/226.jpg' width='400' height='377'
+alt='FIG. 60.'
+title='FIG. 60.' />
+</a>
+</div>
+
+<p class='center'>Tubercular Syphiloderm.</p>
+
+
+<p><b>Does the gummatous syphiloderm invariably appear as a
+rounded well-defined tumor?</b></p>
+
+<p>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.</p>
+
+
+<p><b>From what formations is the gummatous syphiloderm to be
+differentiated?</b></p>
+
+<p>From furuncle, abscess, and sebaceous, fatty and fibroid tumors.
+<span class='pagenum'><a name='Page_227' id='Page_227'></a><a href='#TOC'>[Pg 227]</a></span>
+Attention to the origin, course, and behavior of the lesion, together
+with a history, must all be considered in doubtful cases.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 61.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_227.jpg'>
+<img src='images/227.jpg' width='400' height='316'
+alt='FIG. 61.'
+title='FIG. 61.' />
+</a>
+</div>
+
+<p class='center'>Large Pustular Syphiloderm.</p>
+
+
+<p><b>What is to be said in regard to the character and time of
+appearance of the cutaneous manifestations of hereditary
+syphilis?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Describe these several cutaneous manifestations of hereditary
+syphilis.</b></p>
+
+<p>The <i>macular</i> (erythematous) eruption begins as large or small,
+bright- or dark-red macules, later presenting a ham or caf&eacute;-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.</p>
+
+<p>The <i>papular</i> eruption is observed in conjunction with the
+<span class='pagenum'><a name='Page_228' id='Page_228'></a><a href='#TOC'>[Pg 228]</a></span>
+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 <i>moist papules</i>.</p>
+
+<p>The <i>bullous</i> 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 bull&aelig;.</p>
+
+
+<p><b>What other symptoms in addition to the cutaneous manifestations
+are noted in hereditary syphilis in the newborn?</b></p>
+
+<p>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.</p>
+
+
+<p><b>What is the pathology of cutaneous syphilis?</b></p>
+
+<p>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
+Spiroch&aelig;ta pallida, discovered by Schaudinn and Hoffmann, and
+usually found in numbers in the tissues.</p>
+
+
+<p><b>Give the prognosis of cutaneous syphilis.</b></p>
+
+<p>In <i>acquired syphilis</i>, 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.</p>
+
+<p>In <i>hereditary infantile syphilis</i>, the prognosis is always uncertain:
+<span class='pagenum'><a name='Page_229' id='Page_229'></a><a href='#TOC'>[Pg 229]</a></span>
+the more distant from the time of birth the manifestations appear
+the more favorable usually is the outcome.</p>
+
+
+<p><b>How is cutaneous syphilis to be treated?</b></p>
+
+<p>Always with constitutional remedies; and in the graver eruptions,
+and especially in those more or less limited, with local applications
+also.</p>
+
+
+<p><b>What constitutional and local remedies are commonly employed
+in cutaneous syphilis?</b></p>
+
+<p><i>Constitutional Remedies.</i>&mdash;Mercury and potassium iodide; tonics
+and nutrients are necessary in some cases.</p>
+
+<p><i>Local Remedies.</i>&mdash;Mercurial ointments, lotions and baths, and
+iodol in ointment or in (and also calomel) powder form.</p>
+
+
+<p><b>Give the constitutional treatment of the earlier, or secondary,
+eruptions of syphilis.</b></p>
+
+<p>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.</p>
+
+
+<p><b>How is mercury usually administered in the eruptions of secondary
+syphilis?</b></p>
+
+<p>By the mouth, chiefly as the protiodide, calomel and blue mass,
+in dosage just short of mild physiological action; by <i>inunction</i>, in
+the form of blue ointment; by <i>hypodermic injection</i>, usually as
+corrosive sublimate solution. The method by <i>fumigation</i>, with calomel
+or bisulphuret, is now rarely employed.</p>
+
+<p>The method by the mouth is the common one, and it is only in
+rare instances that any other method is necessary or advisable.</p>
+
+
+<p><b>What local applications are usually advised in the eruptions
+of secondary syphilis?</b></p>
+
+<p>If the eruption is extensive, and more especially in the pustular
+types, baths of corrosive sublimate (&#658;ii-&#658;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.</p>
+
+<p>The same applications or a dusting powder of calomel may also be
+used on moist papules.
+<span class='pagenum'><a name='Page_230' id='Page_230'></a><a href='#TOC'>[Pg 230]</a></span></p>
+
+
+<p><b>How long is mercury to be actively continued in cases of
+early (secondary) syphilis?</b></p>
+
+<p>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.</p>
+
+<p>(Almost all authorities are agreed as to the importance of prolonged
+treatment, but differ somewhat on the question of intermittent
+or uninterrupted administration.)</p>
+
+
+<p><b>Give the constitutional treatment of the late, or localized,
+syphilodermata.</b></p>
+
+<p>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.</p>
+
+
+<p><b>How long is constitutional treatment to be continued in cases
+of the late syphilodermata?</b></p>
+
+<p>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.</p>
+
+
+<p><b>What applications are usually advised in the late, or localized,
+syphilodermata?</b></p>
+
+<p>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.</p>
+
+<p>The following is valuable in offensive and obstinate ulcerations:&mdash;</p>
+
+<pre>
+  &#8478; Hydrarg. chlorid. corros., ....................... gr. iv-gr. viij
+    Ac. carbolici, ................................... gr. x-xx
+    Alcoholis, ...................................... f&#658;iv
+    Glycerin&aelig;, ...................................... f&#658;j
+    Aqu&aelig;, ................ q.s. ad. .................. &#8485;iv.   M.
+</pre>
+<p><span class='pagenum'><a name='Page_231' id='Page_231'></a><a href='#TOC'>[Pg 231]</a></span>
+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.</p>
+
+
+<p><b>Give the treatment of hereditary infantile syphilis.</b></p>
+
+<p>It is essentially the same (but much smaller dosage) as employed
+in acquired syphilis. Attention to proper feeding and hygiene is of
+first importance.</p>
+
+<p>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-&#8485;vj, &#658;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.</p>
+
+<p>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.</p>
+
+
+<p><b>What local measures are to be advised in cutaneous syphilis
+of the newborn?</b></p>
+
+<p>If demanded, applications similar to those employed in eruptions
+of acquired syphilis, but not more than one-third to one-half the
+strength.</p>
+
+
+<h2><a name='Lepra' id='Lepra'></a><b>Lepra.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Leprosy; Elephantiasis Gr&aelig;corum.)</p>
+
+
+<p><b>What do you understand by leprosy?</b></p>
+
+<p>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.</p>
+
+
+<p><b>What is the nature of the premonitory symptoms of leprosy?</b></p>
+
+<p>In some instances the active manifestations appear without
+<span class='pagenum'><a name='Page_232' id='Page_232'></a><a href='#TOC'>[Pg 232]</a></span>
+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.</p>
+
+
+<p><b>What several varieties of leprosy are observed?</b></p>
+
+<p>Two definite forms are usually described&mdash;the tubercular and the
+an&aelig;sthetic. 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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 62.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/232.png' width='400' height='456'
+alt='FIG. 62.'
+title='FIG. 62.' />
+</div>
+
+<p class='center'>Tubercular Leprosy. (<i>After Stoddard.</i>)</p>
+
+
+<p><b>Describe the symptoms of tubercular leprosy.</b></p>
+
+<p>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,
+hyper&aelig;sthetic or an&aelig;sthetic, pinkish, reddish or pale-yellowish
+<span class='pagenum'><a name='Page_233' id='Page_233'></a><a href='#TOC'>[Pg 233]</a></span>
+macules make their appearance from time to time; subsequently
+fading away or remaining permanently (<i>lepra maculosa</i>).</p>
+
+<p>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 (<i>leontiasis</i>). 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.</p>
+
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 63.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/233.png' width='400' height='397'
+alt='FIG. 63.'
+title='FIG. 63.' />
+</div>
+<p class='center'>An&aelig;sthetic Leprosy.</p>
+
+
+<p><b>Describe the symptoms of an&aelig;sthetic leprosy.</b></p>
+
+<p>Following or along with precursory symptoms denoting general
+systemic disturbance, or independently of any prodromal indications,
+a hyper&aelig;sthetic condition, in localized areas or more or less general,
+is observed. Lancinating pains along the nerves and an irregular
+<span class='pagenum'><a name='Page_234' id='Page_234'></a><a href='#TOC'>[Pg 234]</a></span>
+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 hyper&aelig;sthetic nor an&aelig;sthetic, 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 an&aelig;sthetic,
+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 (<i>lepra mutilans</i>). Sooner or later various paralytic
+symptoms, showing more active involvement of the nerve trunks,
+present themselves.</p>
+
+
+<p><b>State the cause of leprosy.</b></p>
+
+<p>Present knowledge points to a peculiar bacillus as the active
+factor, while climate, soil, heredity, food and habits exert a predisposing
+influence.</p>
+
+
+<p><b>Is leprosy contagious?</b></p>
+
+<p>The consensus of opinion points to the acceptance of the possible
+contagiousness of leprosy; probably by inoculation, but only under
+certain unknown favoring conditions.</p>
+
+
+<p><b>What are the pathological changes?</b></p>
+
+<p>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.</p>
+
+
+<p><b>What several diseases are to be eliminated in the diagnosis
+of leprosy?</b></p>
+
+<p>Syphilis, morph&oelig;a, vitiligo, lupus, and syringomyelia.</p>
+
+<p>When well advanced, the aggregate symptoms of leprosy form a
+<span class='pagenum'><a name='Page_235' id='Page_235'></a><a href='#TOC'>[Pg 235]</a></span>
+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.</p>
+
+
+<p><b>State the prognosis of leprosy.</b></p>
+
+<p>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 an&aelig;sthetic the least. Patients
+are not infrequently carried off by intercurrent disease. Proper
+management will often delay the fatal ending, and exceptionally, in
+the an&aelig;sthetic variety, stay the progress of the disease.</p>
+
+
+<p><b>What is the treatment of leprosy?</b></p>
+
+<p>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.</p>
+
+
+<h2><a name='Pellagra' id='Pellagra'></a><b>Pellagra.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Lombardian Leprosy.)</p>
+
+
+<p><b>Describe pellagra.</b></p>
+
+<p>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.</p>
+
+<p>Treatment is based upon general principles.
+<span class='pagenum'><a name='Page_236' id='Page_236'></a><a href='#TOC'>[Pg 236]</a></span></p>
+
+
+<h2><a name='Epithelioma' id='Epithelioma'></a><b>Epithelioma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Skin Cancer; Epithelial Cancer; Carcinoma Epitheliale.)</p>
+
+
+<p><b>What several varieties of epithelioma are met with?</b></p>
+
+<p>Three&mdash;the superficial, the deep-seated, and the papillomatous.</p>
+
+
+<p><b>Describe the clinical appearances and course of the superficial
+variety of epithelioma.</b></p>
+
+<p>The superficial, or flat variety (<i>rodent ulcer</i>), begins, usually on
+the face, as a minute, firm, reddish or yellowish tubercle, as an</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 64.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/236.png' width='400' height='487'
+alt='FIG. 64.'
+title='FIG. 64.' />
+</div>
+<p class='center'>Epithelioma. (<i>After D. Lewis.</i>)</p>
+
+
+<p>aggregation of such, as a warty excrescence, or as a localized degenerative
+seborrh&oelig;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
+<span class='pagenum'><a name='Page_237' id='Page_237'></a><a href='#TOC'>[Pg 237]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<p><b>Describe the clinical appearances and course of the deep-seated
+variety of epithelioma.</b></p>
+
+<p>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&mdash;
+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 septic&aelig;mia, marasmus, or
+involvement of vital parts, death eventually ensues.</p>
+
+
+<p><b>Describe the clinical appearances and course of the papillomatous
+variety of epithelioma.</b></p>
+
+<p>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.</p>
+
+
+<p><b>Upon what parts is epithelioma commonly observed?</b></p>
+
+<p>About the face, especially the nose, eyelids and lips; and also
+about the genitalia. It may involve any part.
+<span class='pagenum'><a name='Page_238' id='Page_238'></a><a href='#TOC'>[Pg 238]</a></span></p>
+
+
+<p><b>At what age is epithelioma usually noted?</b></p>
+
+<p>It is essentially a disease of middle and late life, although it is
+exceptionally met with in the young.</p>
+
+
+<p><b>What is the cause of epithelioma?</b></p>
+
+<p>The etiology is obscure. It is not, as a rule, inherited. Any
+locally irritated tissue may be the starting point of the disease.</p>
+
+
+<p><b>State the pathology.</b></p>
+
+<p>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.</p>
+
+
+<p><b>How would you distinguish epithelioma from syphilitic
+ulceration, wart, and lupus vulgaris?</b></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<p><b>What factors are to be considered in giving a prognosis in
+epithelioma?</b></p>
+
+<p>The variety, extent, and rapidity of the process. The superficial
+form may exist for years, and give rise to no alarm; whereas the
+<span class='pagenum'><a name='Page_239' id='Page_239'></a><a href='#TOC'>[Pg 239]</a></span>
+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.</p>
+
+
+<p><b>What is the special object in view in the treatment of epithelioma?</b></p>
+
+<p>Thorough destruction or removal of the epitheliomatous tissue.</p>
+
+
+<p><b>How is the destruction or removal of the epitheliomatous
+tissue effected</b>?</p>
+
+<p>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 <i>x</i>-ray. (See treatment of lupus vulgaris.)</p>
+
+<p>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.</p>
+
+<p>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 R&ouml;ntgen
+ray&mdash;about every three to five days&mdash;is good practice.</p>
+
+<p>The degenerative changes in the beginning of scurfy, seborrh&oelig;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.</p>
+
+
+<p><b>What can be said of the value of the x-ray in epithelioma?</b></p>
+
+<p>The <i>x</i>-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 <i>x</i>-ray erythema; and in some instances benefit or cure only
+<span class='pagenum'><a name='Page_240' id='Page_240'></a><a href='#TOC'>[Pg 240]</a></span>
+occurs after more active exposure, sufficient to cause an <i>x</i>-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 <i>x</i>-ray.</p>
+
+<p>The much better plan, as already intimated, is to employ one of
+the several operative or caustic methods, and supplementing, while
+healing, with the <i>x</i>-ray.</p>
+
+
+<h2><a name='Pagets_Disease_of_the_Nipple' id='Pagets_Disease_of_the_Nipple'></a><b>Paget's Disease of the Nipple.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Malignant Papillary Dermatitis; Paget's Disease.)</p>
+
+
+<p><b>What do you understand by Paget's disease of the nipple?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Describe the symptoms of Paget's disease.</b></p>
+
+<p>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.</p>
+
+
+<p><b>What is the pathology of Paget's disease?</b></p>
+
+<p>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
+<span class='pagenum'><a name='Page_241' id='Page_241'></a><a href='#TOC'>[Pg 241]</a></span>
+degenerated epithelia. The morbid changes consist of an inflammation
+of the papillary region of the derma, leading to &oelig;dema and
+vacuolation of the constituent cells of the epidermis, followed by
+their complete destruction in places and their abnormal proliferation
+in others (Fordyce).</p>
+
+
+<p><b>State the diagnostic features of Paget's disease.</b></p>
+
+<p>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.</p>
+
+
+<p><b>What is the prognosis?</b></p>
+
+<p>If the disease is recognized early, and properly treated, a cure may
+be anticipated; later the outlook is that of scirrhus of the breast.</p>
+
+
+<p><b>What is the treatment of Paget's disease?</b></p>
+
+<p>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
+<i>x</i>-ray is advisable as an additional measure of precaution against
+relapse.</p>
+
+<p>Until the diagnosis is thoroughly established, soothing applications,
+such as are employed in acute eczema, are to be advised.</p>
+
+
+<h2><a name='Sarcoma' id='Sarcoma'></a><b>Sarcoma.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Sarcoma Cutis; Sarcoma of the Skin.)</p>
+
+
+<p><b>Describe the several varieties of sarcoma.</b></p>
+
+<p>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;
+<span class='pagenum'><a name='Page_242' id='Page_242'></a><a href='#TOC'>[Pg 242]</a></span>
+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.</p>
+
+<p>The multiple pigmented sarcoma (<i>melano-sarcoma</i>) 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.</p>
+
+
+<p><b>State the prognosis and treatment of sarcoma.</b></p>
+
+<p>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.</p>
+
+<p>Excision or extirpation, <i>x</i>-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.</p>
+
+
+<h2><a name='Granuloma_Fungoides' id='Granuloma_Fungoides'></a><b>Granuloma Fungoides.</b></h2>
+
+
+<p><b>Describe granuloma fungoides.</b></p>
+
+<p>A rare form of disease, heretofore looked upon as sarcomatous,
+but now generally recognized as granuloma, and formerly described
+under the names <i>mycosis fungoides</i>, <i>inflammatory fungoid neoplasm</i>,
+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.
+<span class='pagenum'><a name='Page_243' id='Page_243'></a><a href='#TOC'>[Pg 243]</a></span></p>
+
+
+<p><b>State the prognosis and treatment of granuloma fungoides.</b></p>
+
+<p>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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 65.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_243.jpg'>
+<img src='images/243.jpg' width='400' height='526'
+alt='FIG. 65.'
+title='FIG. 65.' />
+</a>
+</div>
+
+<p class='center'>Granuloma Fungoides.</p>
+
+
+<p>Treatment consists of tonics, if indicated, and the administration
+of arsenic, preferably hypodermically, and R&ouml;ntgen-ray exposures,
+along with the application of mild antiseptics, and operative interference
+when necessary or advisable.
+<span class='pagenum'><a name='Page_244' id='Page_244'></a><a href='#TOC'>[Pg 244]</a></span></p>
+
+
+<h1><a name='CLASS_VII_NEUROSES' id='CLASS_VII_NEUROSES'></a><b>CLASS VII.&mdash;NEUROSES.</b></h1>
+
+
+<h2><a name='Hyperaesthesia' id='Hyperaesthesia'></a><b>Hyper&aelig;sthesia.</b></h2>
+
+
+<p><b>What is hyper&aelig;sthesia?</b></p>
+
+<p>By hyper&aelig;sthesia 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.</p>
+
+
+<h2><a name='Dermatalgia' id='Dermatalgia'></a><b>Dermatalgia.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Neuralgia of the Skin; Rheumatism of the Skin; Dermalgia.)</p>
+
+
+<p><b>What do you understand by dermatalgia?</b></p>
+
+<p>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.</p>
+
+<p>Treatment depends upon the cause.</p>
+
+
+<h2><a name='Anaesthesia' id='Anaesthesia'></a><b>An&aelig;sthesia.</b></h2>
+
+
+<p><b>What is an&aelig;sthesia?</b></p>
+
+<p>An&aelig;sthesia 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&oelig;a and like diseases.</p>
+
+
+<h2><a name='Pruritus' id='Pruritus'></a><b>Pruritus.</b></h2>
+
+
+<p><b>What do you understand by pruritus?</b></p>
+
+<p>Pruritus is a functional disease of the skin, the sole symptom of
+which is itching, there being no structural change.
+<span class='pagenum'><a name='Page_245' id='Page_245'></a><a href='#TOC'>[Pg 245]</a></span></p>
+
+
+<p><b>Describe the symptoms of pruritus.</b></p>
+
+<p>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&mdash;<i>pruritus senilis</i>. 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 (<i>pruritus hiemalis</i>), the pruritus
+is usually more or less generalized, although not infrequently
+in the latter the legs are specially involved.</p>
+
+<p>In some individuals an attack of pruritus, of variable intensity,
+lasting from five to thirty minutes, comes on immediately after a
+bath (<i>bath-pruritus</i>). It is usually confined to the legs from the
+hips down.</p>
+
+
+<p><b>Is pruritus always more or less generalized?</b></p>
+
+<p>No; not infrequently the itching is limited to the genital region
+(<i>pruritus scroti, pruritus vulv&aelig;</i>) or to the anus (<i>pruritus ani</i>).</p>
+
+
+<p><b>To what may pruritus often be ascribed?</b></p>
+
+<p>To digestive and intestinal derangements, hepatic disorders, the
+uric acid diathesis, gestation, diabetes mellitus, and a depraved state
+of the nervous system.</p>
+
+<p>Pruritus vulv&aelig; is at times due to irritating discharges, and pruritus
+ani occasionally to hemorrhoids and seat-worms.</p>
+
+
+<p><b>Is there any difficulty in the diagnosis of pruritus?</b></p>
+
+<p>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.)
+<span class='pagenum'><a name='Page_246' id='Page_246'></a><a href='#TOC'>[Pg 246]</a></span>
+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.)</p>
+
+
+<p><b>What prognosis would you give in pruritus?</b></p>
+
+<p>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.</p>
+
+
+<p><b>How would you treat pruritus?</b></p>
+
+<p>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.</p>
+
+<p>Exceptionally, the relief furnished by external treatment is more
+or less permanent.</p>
+
+
+<p><b>Name the important antipruritic applications.</b></p>
+
+<p>Alkaline baths; lotions of carbolic acid (&#658;j-&#658;iij to Oj), of resorcin
+(&#658;j-&#658;iv to Oj), of liquor carbonis detergens (&#8485;j-&#8485;iv to Oj), and
+liquor picis alkalinus (&#658;j-&#658;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:&mdash;</p>
+
+<pre>
+  &#8478; Ac. carbolici, ................................... &#658;j-&#658;iij
+    Gylcerin&aelig;, ...................................... f&#658;ij
+    Alcoholis, ...................................... f&#8485;ij
+    Aqu&aelig;, .................. q.s. ad. ................ Oj.   M.
+</pre>
+
+<p>Various dusting-powders, alone or in conjunction with the lotions.</p>
+
+<p>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.
+<span class='pagenum'><a name='Page_247' id='Page_247'></a><a href='#TOC'>[Pg 247]</a></span></p>
+
+<p><b>What external applications are to be used in the local varieties
+of pruritus?</b></p>
+
+<p>In <i>pruritus ani</i> and <i>pruritus vulv&aelig;</i>, 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 &#8485;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.</p>
+
+<p>In pruritus vulv&aelig;, 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.</p>
+
+<p>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.</p>
+
+
+
+<h1><a name='CLASS_VIII_PARASITIC_AFFECTIONS' id='CLASS_VIII_PARASITIC_AFFECTIONS'></a><b>CLASS VIII.&mdash;PARASITIC AFFECTIONS.</b></h1>
+
+
+<h2><a name='Tinea_Favosa' id='Tinea_Favosa'></a><b>Tinea Favosa.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Favus.)</p>
+
+
+<p><b>What is tinea favosa?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Upon what parts and at what age is favus observed?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Describe the symptoms of favus of the scalp.</b></p>
+
+<p>The disease begins as a superficial inflammation or hyper&aelig;mic
+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
+<span class='pagenum'><a name='Page_248' id='Page_248'></a><a href='#TOC'>[Pg 248]</a></span>
+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&mdash;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. <i>Atrophy</i> and more
+or less actual <i>scarring</i> are sooner or later noted.</p>
+
+<p>Itching, variable as to degree, is usually present.</p>
+
+
+<p><b>What is the course of favus of the scalp?</b></p>
+
+<p>Persistent and slowly progressive.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 66.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/248.png' width='400' height='401'
+alt='FIG. 66.'
+title='FIG. 66.' />
+</div>
+
+<p class='center'>Achorion Sch&ouml;nleinii X 450. (<i>After Duhring.</i>)<br />
+Showing simple mycelium, in various stages of development, and free spores.</p>
+
+
+<p><b>What are the symptoms of favus when seated upon the general
+surface?</b></p>
+
+<p>The symptoms are essentially similar to those upon the scalp,
+modified somewhat by the anatomical differences of the parts.
+<span class='pagenum'><a name='Page_249' id='Page_249'></a><a href='#TOC'>[Pg 249]</a></span>
+The <i>nails</i>, when affected, become yellowish, more or less thickened,
+brittle and opaque (<i>tinea favosa unguium, onychomycosis
+favosa</i>).</p>
+
+
+<p><b>To what is favus due?</b></p>
+
+<p>Solely to the invasion of the cutaneous structures, especially the
+epidermal portion, by the vegetable parasite, the <i>achorion Sch&ouml;nleinii</i>.
+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.</p>
+
+<p>It is also met with in the lower animals, from which it is doubtless
+not infrequently communicated to man.</p>
+
+
+<p><b>What are the diagnostic features of favus?</b></p>
+
+<p>The yellow, and often cup-shaped, crusts, brittleness and loss of
+hair, atrophy, and the history.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 67.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/249.jpg' width='400' height='81'
+alt='FIG. 67.'
+title='FIG. 67.' />
+</div>
+
+<p class='center'>Epilating Forceps.</p>
+
+
+<p><b>How would you distinguish favus from eczema and ringworm?</b></p>
+
+<p>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.</p>
+
+<p>Finally, if necessary, a microscopic examination of the crusts may
+be made.</p>
+
+
+<p><b>State the method of examination for fungus.</b></p>
+
+<p>A portion of the crust is moistened with liquor potass&aelig; and examined
+with a power of three to five hundred diameters. The fungus,
+(achorion Sch&ouml;nleinii), consisting of mycelium and spores, is luxuriant
+and is readily detected.</p>
+
+
+<p><b>State the prognosis of favus.</b>.</p>
+
+<p>Upon the scalp, favus is extremely chronic and rebellious to treatment,
+<span class='pagenum'><a name='Page_250' id='Page_250'></a><a href='#TOC'>[Pg 250]</a></span>
+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.</p>
+
+<p>Upon the general surface it usually responds readily to treatment,
+excepting favus of the nails, which is always obstinate.</p>
+
+
+<p><b>How is favus of the scalp treated?</b></p>
+
+<p>Treatment is entirely local and consists in keeping the parts free
+from crusts, in epilation and applications of a parasiticide.</p>
+
+<p>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&mdash;the so-called parasiticides&mdash;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.</p>
+
+
+<p><b>Name the most important parasiticides.</b></p>
+
+<p>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:&mdash;</p>
+
+<pre>
+  &#8478; Sulphur, pr&aelig;cip., ................................ &#658;ij
+    Saponis viridis,
+    Ol. cadini, ....................&#257;&#257;................ &#658;j
+    Adipis, .......................................... &#8485;ss.   M.
+</pre>
+
+<p>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
+<i>x</i>-ray exposure with alleged good results, pushing the treatment to
+the point of producing depilation; if used great caution should be
+exercised.
+<span class='pagenum'><a name='Page_251' id='Page_251'></a><a href='#TOC'>[Pg 251]</a></span></p>
+
+<p><b>How is favus upon the general surface to be treated?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Is constitutional treatment of any value in favus?</b></p>
+
+<p>It is questionable, but in debilitated subjects tonics, especially cod-liver
+oil, may be prescribed with the hope of aiding the external
+applications.</p>
+
+
+<h2><a name='Tinea_Trichophytina' id='Tinea_Trichophytina'></a><b>Tinea Trichophytina.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Ringworm.)</p>
+
+
+<p><b>What is tinea trichophytina?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Do the clinical characters of ringworm vary according to the
+part affected?</b></p>
+
+<p>Yes, often considerably; thus upon the scalp, upon the general
+surface, and upon the bearded region, the disease usually presents
+totally different appearances.</p>
+
+
+<p><b>Describe the symptoms of ringworm as it occurs upon non-hairy
+portions of the body.</b></p>
+
+<p>Ringworm of the general surface (<i>tinea trichophytina corporis,
+tinea circinata</i>) appears as one or more small, slightly-elevated,
+sharply-limited, somewhat scaly, hyper&aelig;mic 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,
+hyper&aelig;mic and somewhat scaly. As commonly noted one, several
+or more patches are present. After reaching a certain size they may
+<span class='pagenum'><a name='Page_252' id='Page_252'></a><a href='#TOC'>[Pg 252]</a></span>
+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.</p>
+
+<p>Itching, usually slight, may or may not be present.</p>
+
+<p>Exceptionally ringworm appears as a markedly inflammatory pustular
+circumscribed patch, formerly thought to be a distinct affection
+and described under the name of <i>conglomerate pustular folliculitis</i>.
+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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 68.</b></p>
+<div class='figcenter' style='width: 367px;'>
+<a href='images/fullsize_252.jpg'>
+<img src='images/252.jpg' width='367' height='600'
+alt='FIG. 68.'
+title='FIG. 68.' />
+</a>
+</div>
+
+<p class='center'>Tinea trichophytina cruris&mdash;so-called eczema marginatum&mdash;of unusually extensive
+development. (<i>After Piffard.</i>)</p>
+
+
+<p><b>Describe the symptoms of ringworm when occurring about
+the thighs and scrotum.</b></p>
+
+<p>In adults, more especially males, the inner portion of the upper
+part of the thighs and scrotum (<i>tinea trichophytina cruris</i>, so-called
+<span class='pagenum'><a name='Page_253' id='Page_253'></a><a href='#TOC'>[Pg 253]</a></span>
+<i>eczema marginatum</i>) 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.</p>
+
+
+<p><b>Describe the symptoms of ringworm when involving the
+nails.</b></p>
+
+<p>In ringworm of the nails (<i>tinea trichophytina unguium</i>) 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.</p>
+
+
+<p><b>Describe the symptoms of ringworm as it occurs upon the
+scalp.</b></p>
+
+<p>Ringworm of the scalp (<i>tinea trichophytina capitis, tinea tonsurans</i>)
+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.</p>
+
+
+<p><b>Describe the appearances of a typical patch of ringworm of
+the scalp.</b></p>
+
+<p>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&mdash;microsporon.</p>
+
+
+<p><b>Does ringworm of the scalp always present typical appearances?</b></p>
+
+<p>Not invariably. In some cases the patch or patches may become
+<span class='pagenum'><a name='Page_254' id='Page_254'></a><a href='#TOC'>[Pg 254]</a></span>
+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.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 69.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_254.jpg'>
+<img src='images/254.jpg' width='400' height='528'
+alt='FIG. 69.'
+title='FIG. 69.' />
+</a>
+</div>
+
+<p class='center'>Ringworm (rather inflammatory type, and produced by the trichophyton).</p>
+
+<p><span class='pagenum'><a name='Page_255' id='Page_255'></a><a href='#TOC'>[Pg 255]</a></span>
+The markedly inflammatory and pustular types are produced by
+the large-spore fungus&mdash;trichophyton.</p>
+
+
+<p><b>What is tinea kerion?</b></p>
+
+<p>Tinea kerion (<i>kerion</i>) is a markedly inflammatory type of ringworm
+of the scalp involving the deeper tissues, appearing as a more or
+less bald, rounded, inflammatory, &oelig;dematous, boggy, honeycombed
+tumor, discharging from the follicular openings a mucoid secretion.</p>
+
+
+<p><b>Does ringworm of the scalp ever occur in adults?</b></p>
+
+<p>No. (Extremely rare exceptions.)</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 70.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/255.png' width='400' height='393'
+alt='FIG. 70.'
+title='FIG. 70.' />
+</div>
+
+<p class='center'>Ringworm Fungus (Trichophyton) x 450. (<i>After Duhring.</i>)<br />
+As found in epidermic scrapings of ringworm, showing mycelium and spores.</p>
+
+
+<p><b>Describe the symptoms of ringworm of the bearded region.</b></p>
+
+<p>Ringworm of the bearded region (<i>tinea trichophytina barb&aelig;, tinea
+sycosis, parasitic sycosis, barber's itch</i>) begins usually in the same
+manner as ringworm on other parts, as one or more rounded, slightly
+scaly, hyper&aelig;mic 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
+<span class='pagenum'><a name='Page_256' id='Page_256'></a><a href='#TOC'>[Pg 256]</a></span>
+follicles, more or less subcutaneous swelling ensues, the parts assuming
+a distinctly <i>lumpy and nodular</i> 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.</p>
+
+<p class='center'><b><span class='smcap'>Fig</span>. 71.</b></p>
+<div class='figcenter' style='width: 269px;'>
+<img src='images/256.jpg' width='269' height='600'
+alt='FIG. 71.'
+title='FIG. 71.' />
+</div>
+
+<p class='center'>Ringworm Fungus (Microsporon) x 500. (<i>After Duhring.</i>)<br />
+Short, broken-off hair of scalp invaded with masses of free spores.</p>
+
+
+<p><span class='pagenum'><a name='Page_257' id='Page_257'></a><a href='#TOC'>[Pg 257]</a></span>
+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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 72.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/257.jpg' width='400' height='573'
+alt='FIG. 72.'
+title='FIG. 72.' />
+</div>
+
+<p class='center'>Ringworm Fungus (Trichophyton) x 300. (<i>After Duhring.</i>)<br />
+Short, stout hair of beard, with the root-sheath attached, showing free spores
+and chains of spores.</p>
+
+
+<p><b>To what is ringworm due?</b></p>
+
+<p>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
+<span class='pagenum'><a name='Page_258' id='Page_258'></a><a href='#TOC'>[Pg 258]</a></span>
+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.</p>
+
+<p>Until recently the ringworm was thought to be due to but one
+fungus&mdash;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&mdash;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.</p>
+
+
+<p><b>What is the pathology of ringworm?</b></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<p><b>How do you examine for the fungus?</b></p>
+
+<p>The scrapings or hair should be moistened with liquor potass&aelig;,
+and examined with a power from three hundred diameters upward.</p>
+
+
+<p><b>How is ringworm of the general surface to be distinguished
+from eczema, psoriasis and seborrh&oelig;a?</b></p>
+
+<p>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.</p>
+
+
+<p><b>How is ringworm of the scalp to be distinguished from alopecia
+areata, favus, eczema, seborrh&oelig;a, and psoriasis?</b></p>
+
+<p>By the peculiar clinical features of ringworm on this region&mdash;the
+<span class='pagenum'><a name='Page_259' id='Page_259'></a><a href='#TOC'>[Pg 259]</a></span>
+slight scaliness, broken hair and hair stumps, with a certain amount
+of baldness&mdash;and in doubtful cases by a microscopical examination of
+the hairs.</p>
+
+<p>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.</p>
+
+
+<p><b>How is ringworm of the bearded region to be distinguished
+from eczema and sycosis?</b></p>
+
+<p>By the peculiar lumpiness of the parts, the brittleness of the hair,
+more or less hair loss, and the history.</p>
+
+<p>The superficial type of ringworm sycosis&mdash;those cases in which
+the disease remains a surface disease&mdash;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.</p>
+
+<p>In doubtful cases recourse may be had to microscopical examination.</p>
+
+
+<p><b>What is the prognosis of ringworm of these several parts?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Is ringworm of these several parts treated with the same
+remedies?</b></p>
+
+<p>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.</p>
+
+
+<p><b>How would you treat ringworm of the general surface?</b></p>
+
+<p>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
+<span class='pagenum'><a name='Page_260' id='Page_260'></a><a href='#TOC'>[Pg 260]</a></span>
+boric acid; ointments of tar, sulphur and mercury, official strength
+or weakened with lard; and tincture of iodine, pure or diluted.</p>
+
+<p>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.</p>
+
+
+<p><b>How would you treat ringworm of the scalp?</b></p>
+
+<p>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.</p>
+
+<p>A compound ointment, containing several of the active remedies
+named, is convenient for dispensary practice, such as:&mdash;</p>
+
+<pre>
+  &#8478; &beta;-naphthol, ...................................... &#658;ss-&#658;j
+    Ol. cadini, ...................................... &#658;j
+    Ungt. sulphuris, ........................ q.s. ad. &#8485;j.   M.
+</pre>
+
+<p>In that form known as tinea kerion mild applications are demanded
+at first; later the same treatment as in the ordinary type.</p>
+
+
+<p><b>How is ringworm of the bearded region to be treated?</b></p>
+
+<p>On the same general plan and with the same remedies (excepting
+<span class='pagenum'><a name='Page_261' id='Page_261'></a><a href='#TOC'>[Pg 261]</a></span>
+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 (&#658;j-&#8485;j), and a lotion of corrosive sublimate
+(gr. j-iv to &#8485;j). The <i>x</i>-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.</p>
+
+
+<p><b>How is the certainty of an apparent cure in ringworm of
+the scalp or bearded region to be determined?</b></p>
+
+<p>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.</p>
+
+<p>Cure of ringworm of the general surface is usually self-evident.</p>
+
+
+<p><b>Is systemic treatment of aid in the cure of ringworm?</b></p>
+
+<p>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.</p>
+
+
+<h2><a name='Tinea_Imbricata' id='Tinea_Imbricata'></a><b>Tinea Imbricata.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Tokelau Ringworm.)</p>
+
+
+<p><b>What is tinea imbricata?</b></p>
+
+<p>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
+<span class='pagenum'><a name='Page_262' id='Page_262'></a><a href='#TOC'>[Pg 262]</a></span>
+vegetable parasite closely similar to the trichophyton. The treatment is
+by the parasiticides, being essentially the same, in fact, as ringworm.</p>
+
+
+<h2><a name='Tinea_Versicolor' id='Tinea_Versicolor'></a><b>Tinea Versicolor.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Pityriasis Versicolor; Chromophytosis.)</p>
+
+
+<p><b>What is tinea versicolor?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Describe the symptoms of tinea versicolor.</b></p>
+
+<p>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 hyper&aelig;mia, 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.</p>
+
+
+<p><b>Does the eruption of tinea versicolor show predilection for
+any special region?</b></p>
+
+<p>Yes; the upper part of the trunk, especially anteriorly, is the usual
+seat of the eruption, but in exceptional instances the neck, axill&aelig;, the
+arms, the whole trunk, the genitocrural region and poplitea, and in
+rare cases even the lower part of the face, may become invaded.</p>
+
+
+<p><b>What course does tinea versicolor pursue?</b></p>
+
+<p>Persistent, but somewhat variable; as a rule, however, slowly progressive
+and lasting for years.</p>
+
+
+<p><b>To what is tinea versicolor due?</b></p>
+
+<p>To a vegetable fungus&mdash;the <i>microsporon furfur</i>.
+<span class='pagenum'><a name='Page_263' id='Page_263'></a><a href='#TOC'>[Pg 263]</a></span>
+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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 73.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/263.png' width='400' height='396'
+alt='FIG. 73.'
+title='FIG. 73.' />
+</div>
+
+<p class='center'>Microsporon Furfur x 400. (<i>After Duhring.</i>)<br />
+Showing mycelium in various stages of development, groups of spores and free spores.</p>
+
+
+<p><b>What is the pathology?</b></p>
+
+<p>The fungus, consisting of mycelium and spores, the latter showing
+a marked tendency to aggregate, invades the superficial portion of
+the epidermis.</p>
+
+
+<p><b>Is tinea versicolor readily diagnosticated?</b></p>
+
+<p>Yes; if the color, peculiar characters and distribution of the eruption
+are kept in mind.</p>
+
+<p>It is not to be confounded with vitiligo, chloasma, or the macular
+syphiloderm. If in doubt, have recourse to the microscope.</p>
+
+
+<p><b>State the method of examination for fungus.</b></p>
+
+<p>The scrapings are taken from a patch, moistened with liquor potass&aelig;,
+and examined with a power of three to five hundred diameters.</p>
+
+
+<p><b>State the prognosis of tinea versicolor.</b></p>
+
+<p>With proper management the disease is readily curable. Relapses
+are not uncommon.
+<span class='pagenum'><a name='Page_264' id='Page_264'></a><a href='#TOC'>[Pg 264]</a></span></p>
+
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 74.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_264.jpg'>
+<img src='images/264.jpg' width='400' height='387'
+alt='FIG. 74.'
+title='FIG. 74.' />
+</a>
+</div>
+
+<p class='center'>Tinea versicolor.</p>
+
+
+<p><b>What is the treatment of tinea versicolor?</b></p>
+
+<p>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&mdash;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:&mdash;</p>
+
+<pre>
+  &#8478; Sulphur, pr&aelig;cip., ................................ &#658;iv
+    Saponis viridis, ................................. &#658;xii.   M.
+</pre>
+
+<p><span class='pagenum'><a name='Page_265' id='Page_265'></a><a href='#TOC'>[Pg 265]</a></span>
+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.</p>
+
+
+<h2><a name='Erythrasma' id='Erythrasma'></a><b>Erythrasma.</b></h2>
+<p><b>Erythrasma.</b></p>
+
+
+<p><b>Describe erythrasma.</b></p>
+
+<p>Erythrasma is an extremely rare disease, due to the presence and
+growth in the epidermic structures of the vegetable parasite&mdash;the
+<i>microsporon minutissimum</i>. 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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 75.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/265.png' width='400' height='395'
+alt='FIG. 75.'
+title='FIG. 75.' />
+</div>
+
+<p class='center'>Microsporon Minutissimum x 1000. (<i>After Riehl.</i>)</p>
+
+<p>Treatment, which is rapidly effective, is the same as that employed
+in tinea versicolor.</p>
+
+
+<h2><a name='Dhobie_Itch' id='Dhobie_Itch'></a><b>Dhobie Itch.</b></h2>
+
+<p>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.
+<span class='pagenum'><a name='Page_266' id='Page_266'></a><a href='#TOC'>[Pg 266]</a></span>
+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.</p>
+
+
+<h2><a name='Actinomycosis' id='Actinomycosis'></a><b>Actinomycosis.</b></h2>
+
+
+<p><b>Describe actinomycosis.</b></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<p><b>What is the treatment?</b></p>
+
+<p>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.</p>
+
+
+<h2><a name='Blastomycetic_Dermatitis' id='Blastomycetic_Dermatitis'></a><b>Blastomycetic Dermatitis.</b></h2>
+
+
+<p><b>What do you understand by blastomycetic dermatitis?</b></p>
+
+<p>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</p>
+
+
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_266.jpg'>
+<img src='images/266.jpg' width='400' height='338'
+alt='Blastomycetic dermatitis'
+title='Blastomycetic dermatitis' />
+</a>
+</div>
+<p class='center'>Blastomycetic dermatitis.</p>
+
+
+<p><span class='pagenum'><a name='Page_267' id='Page_267'></a><a href='#TOC'>[Pg 267]</a></span>
+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.</p>
+
+<p>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.</p>
+
+
+<h2><a name='Scabies' id='Scabies'></a><b>Scabies.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> The Itch.)</p>
+
+
+<p><b>What is scabies?</b></p>
+
+<p>Scabies, or itch, is a contagious animal-parasitic disease characterized
+by a multiform eruption of a somewhat peculiar distribution,
+attended by intense itching.</p>
+
+
+<p><b>Describe the symptoms of scabies.</b></p>
+
+<p>The penetration and presence of the parasites within the cutaneous
+structures besides often giving rise to several or more complete or
+imperfectly formed <i>burrows</i>, 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.
+<span class='pagenum'><a name='Page_268' id='Page_268'></a><a href='#TOC'>[Pg 268]</a></span></p>
+
+
+<p><b>Is the grade of cutaneous irritation the same in all cases of
+scabies?</b></p>
+
+<p>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.</p>
+
+
+<p><b>What do you mean by burrows?</b></p>
+
+<p>Burrows, or <i>cuniculi</i>, 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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 76.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_268.jpg'>
+<img src='images/268.jpg' width='400' height='193'
+alt='FIG. 76.'
+title='FIG. 76.' />
+</a>
+</div>
+
+<p class='center'>Burrow, or cuniculus, greatly magnified. (<i>After Kaposi.</i>)</p>
+<p class='center'>Showing the mite, ova, empty shells and excrement.</p>
+
+
+<p><b>How is a burrow formed?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Upon what parts are burrows most commonly to be found?</b></p>
+
+<p>In the interdigital spaces, on the flexor surface of the wrists,
+about the mamm&aelig; in the female, and on the shaft of the penis in
+the male.
+<span class='pagenum'><a name='Page_269' id='Page_269'></a><a href='#TOC'>[Pg 269]</a></span></p>
+
+
+<p><b>Are burrows usually present in numbers?</b></p>
+
+<p>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.</p>
+
+
+<p><b>What course does scabies pursue?</b></p>
+
+<p>Chronic and progressive, showing no tendency to spontaneous
+disappearance.</p>
+
+
+<p><b>To what is scabies due?</b></p>
+
+<p>To the invasion of the cutaneous structures by an animal parasite,
+the sarcoptes scabiei (<i>acarus scabiei</i>). The male mite is never found
+in the skin and apparently takes no direct part in the production
+of the symptoms.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 77.   FIG. 78.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<a href='images/fullsize_269.jpg'>
+<img src='images/269.jpg' width='400' height='270'
+alt='FIG. 77.  FIG. 78.'
+title='FIG. 77.  FIG. 78.' />
+</a>
+</div>
+
+<p class='center'>Sarcoptes scabiei x 100. (<i>After Duhring.</i>)</p>
+<p class='center'>Female. Ventral surface. Male.</p>
+
+
+<p>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.
+<span class='pagenum'><a name='Page_270' id='Page_270'></a><a href='#TOC'>[Pg 270]</a></span></p>
+
+
+<p><b>State the diagnostic features of scabies.</b></p>
+
+<p>The burrows, the peculiar distribution and the multiformity of
+the eruption, the progressive development, and usually a history of
+contagion.</p>
+
+
+<p><b>How do vesicular and pustular eczema differ from scabies?</b></p>
+
+<p>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.</p>
+
+
+<p><b>How does pediculosis corporis differ from scabies?</b></p>
+
+<p>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; <i>the hands are free</i>.</p>
+
+
+<p><b>State the prognosis of scabies.</b></p>
+
+<p>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.</p>
+
+
+<p><b>How is scabies treated?</b></p>
+
+<p>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.</p>
+
+<p>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&mdash;boiled, baked, or sulphur-fumigated.</p>
+
+
+<p><b>What remedial applications are employed in scabies?</b></p>
+
+<p>Sulphur, balsam of Peru, styrax, and &beta;-naphthol, singly or severally
+combined. In children, or in those of sensitive skin, the following:&mdash;</p>
+
+<pre>
+  &#8478; Sulphur. pr&aelig;cip., ................................ &#658;iv
+    Balsam. Peruv., .................................. &#658;ij
+    Adipis,
+    Petrolati, .....................&#257;&#257;................ &#8485;iss.   M.
+</pre>
+
+
+<p><span class='pagenum'><a name='Page_271' id='Page_271'></a><a href='#TOC'>[Pg 271]</a></span>
+And in adults, or those of non-irritable skin:&mdash;</p>
+
+<pre>
+  &#8478; Sulphur, pr&aelig;cip., ................................ &#8485;j
+    Balsam. Peruv., .................................. &#8485;ss
+    &beta;-Naphthol, ...................................... &#658;ij
+    Adipis,
+    Petrolati, ..............&#257;&#257;......... q.s. ad. .... &#8485;iv.   M.
+</pre>
+
+<p>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.</p>
+
+
+<p><b>Is one such course of treatment sufficient to bring about a
+cure?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Does the secondary dermatitis which is always present in
+severe cases require treatment?</b></p>
+
+<p>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.</p>
+
+
+<p><b>Is a dermatitis due to too active and prolonged treatment
+ever mistaken for persistence of the scabies?</b></p>
+
+<p>Yes.</p>
+
+
+<h2><a name='Pediculosis' id='Pediculosis'></a><b>Pediculosis.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Phtheiriasis; Lousiness.)</p>
+
+
+<p><b>Define pediculosis.</b></p>
+
+<p>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.</p>
+
+
+<p><b>Name the several varieties met with.</b></p>
+
+<p>Three varieties are presented, named according to the parts involved,
+<span class='pagenum'><a name='Page_272' id='Page_272'></a><a href='#TOC'>[Pg 272]</a></span>
+pediculosis capitis, pediculosis corporis, and pediculosis pubis; the
+parasite in each being a distinct species of pediculus.</p>
+
+
+<h2><a name='Pediculosis_Capitis' id='Pediculosis_Capitis'></a><b>Pediculosis Capitis.</b></h2>
+
+
+<p><b>Describe the symptoms of pediculosis capitis.</b></p>
+
+<p>Pediculosis capitis (<i>pediculosis capillitii</i>), 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&mdash;
+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.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 79.</b></p>
+<div class='figcenter' style='width: 300px;'>
+<img src='images/272.png' width='300' height='417'
+alt='FIG. 79.'
+title='FIG. 79.' />
+</div>
+
+<p class='center'>Pediculus Capitis x 25. (<i>After Duhring.</i>)</p>
+<p class='center'>Female. Dorsal surface.</p>
+
+<div class='figright' style='width: 162px;'>
+<p class='center'><b><span class='smcap'>Fig</span>. 80.</b></p>
+<img src='images/273.jpg' width='162' height='600'
+alt='FIG. 80.'
+title='FIG. 80.' />
+<p class='center'>Ova of the headlouse attached to a hair. Magnified. <i>(After Kaposi.)</i></p>
+</div>
+
+
+<p><span class='pagenum'><a name='Page_273' id='Page_273'></a><a href='#TOC'>[Pg 273]</a></span>
+In addition to the pediculi, which, as a rule, may be readily
+found, their <i>ova</i>, or <i>nits</i>, are always to be seen upon the shaft of the
+hairs, quite firmly attached.</p>
+
+
+<p><b>Describe the appearance of the ova.</b></p>
+
+<p>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.</p>
+
+<p><b>Is there any difficulty in the diagnosis of
+pediculosis capitis?</b></p>
+
+<p>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, <i>the presence of the ova</i> will indicate
+the nature of the affection.</p>
+
+<p>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.</p>
+
+
+<p><b>What is the treatment of pediculosis capitis?</b></p>
+
+<p>Treatment consists in the application of some
+remedy destructive to the pediculi and their ova.
+Crude petroleum is effective, one or two thorough
+applications over night being usually sufficient; in
+order to lessen its inflammability, and also to mask
+its somewhat disagreeable odor, it may be mixed
+with an equal part of olive oil and a small quantity
+of balsam of Peru added.</p>
+
+<p>Tincture of cocculus indicus, pure or diluted,
+may also be applied with good results.</p>
+
+<p>When the parts are markedly eczematous, an
+ointment of ammoniated mercury or &beta;-naphthol,
+thirty to sixty grains to the ounce may be used.</p>
+
+<p>Daily shampooing with soap and water, and the
+twice daily application of a five per cent. carbolic
+acid lotion, together with the use of a fine-toothed
+comb, is a safe and efficient method for dispensary practice; as it is,
+indeed, for any class of patients.
+<span class='pagenum'><a name='Page_274' id='Page_274'></a><a href='#TOC'>[Pg 274]</a></span></p>
+
+
+<p><b>How are the ova or their shells to be removed from the hair?</b></p>
+
+<p>By the frequent use of acid or alkaline lotions, such as dilute
+acetic acid and vinegar, or solutions of sodium carbonate and borax.</p>
+
+
+<h2><a name='Pediculosis_Corporis' id='Pediculosis_Corporis'></a><b>Pediculosis Corporis.</b></h2>
+
+
+<p><b>Describe the symptoms of pediculosis corporis.</b></p>
+
+<p>Pediculosis corporis is dependent upon the presence of the pediculus
+corporis (<i>pediculus vestimenti</i>), a larger variety than that infesting
+the scalp. It is characterized by more or less general itching,
+together with various inflammatory lesions and excoriations. As
+the parasites are to be found chiefly in the folds and seams of the
+clothing, visiting the skin for the purpose of feeding, the various
+symptoms&mdash;the minute hemorrhagic puncta showing the points at
+which they have been sucking, and the consequent papules, pustules
+and excoriations&mdash;are, therefore, to be found most abundantly on
+those parts with which the clothing comes closely in contact, as, for
+instance, around the neck, across the shoulders, around the waist,
+and down the outside of the thighs. It is uncommon in children.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 81.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/274.png' width='400' height='537'
+alt='FIG. 81.'
+title='FIG. 81.' />
+</div>
+
+<p class='center'>Pediculus Corporis x 25. (<i>After Duhring.</i>)</p>
+<p class='center'>Female. Dorsal surface.</p>
+
+<p><span class='pagenum'><a name='Page_275' id='Page_275'></a><a href='#TOC'>[Pg 275]</a></span></p>
+
+
+<p><b>State the diagnostic characters of pediculosis corporis.</b></p>
+
+<p>The presence of the minute hemorrhagic puncta, the multiform
+character and peculiar distribution of the eruption. Careful search
+will almost invariably disclose one or more pediculi.</p>
+
+
+<p><b>What is the treatment of pediculosis corporis?</b></p>
+
+<p>The clothing and bed-coverings are to be thoroughly baked or
+boiled, the pediculi and their ova being in this manner destroyed;
+a thymol or carbolized boric-acid lotion may be used to relieve the
+cutaneous irritation.</p>
+
+<p>When attention to the wearing apparel is not immediately practicable,
+ointments of sulphur and staphisagria, and lotions of carbolic
+acid, may be advised as temporary measures. The wearing of a
+bag of loosely woven texture containing some lump sulphur next to
+the skin is useful in such cases; at the temperature of the body the
+sulphur undergoes slow oxidation. In hairy individuals the malady
+is often persistent, due to the fact that ova have become attached to
+the hair and a new progeny soon hatched out. Continued treatment
+over a few weeks will usually suffice to rid the patient of their presence.</p>
+
+
+<h2><a name='Pediculosis_Pubis' id='Pediculosis_Pubis'></a><b>Pediculosis Pubis.</b></h2>
+
+
+<p><b>Describe the symptoms of pediculosis pubis.</b></p>
+
+<p>Pediculosis pubis is a condition due to the presence of the
+pediculus pubis, or crab-louse. It is characterized by more or
+less itching about the genitalia, together with papules, excoriations,
+and other inflammatory lesions. The amount of irritation varies;
+it may be slight, or, on the other hand, severe. The parasite,
+which is the smallest of the three varieties, may be discovered
+upon close examination seated near the roots of the hairs, clutching
+the hair, with its head downward and buried in the follicle. The
+ova may be seen attached to the hair-shafts.</p>
+
+<p>It infests adults chiefly, being in many instances probably contracted
+through sexual intercourse.</p>
+
+
+<p><b>Is the pediculus pubis found upon any other part of the body?</b></p>
+
+<p>Yes. Although its favorite habitat is the region of the pubes, it
+<span class='pagenum'><a name='Page_276' id='Page_276'></a><a href='#TOC'>[Pg 276]</a></span>
+may, in exceptional instances, also infest the axill&aelig;, the sternal
+region of the male, the beard, eyebrows, and even the eyelashes.</p>
+
+
+<p><b>State the diagnostic characters of pediculosis pubis.</b></p>
+
+<p>The region involved, itching, variable amount of irritation, and,
+above all, the presence of the pediculi and their ova.</p>
+
+
+<p class='center'><b><span class='smcap'>Fig</span>. 82.</b></p>
+<div class='figcenter' style='width: 400px;'>
+<img src='images/276.png' width='400' height='357'
+alt='FIG. 82.'
+title='FIG. 82.' />
+</div>
+
+<p class='center'>Pediculus Pubis x 25. (<i>After Duhring.</i>) Female. Dorsal surface.</p>
+
+
+<p><b>Name several applications prescribed for pediculosis pubis.</b></p>
+
+<p>A lotion of corrosive sublimate, one to four grains to the ounce;
+infusion of tobacco; a ten to twenty per cent. ointment of oleate of
+mercury; ammoniated mercury ointment, and a five to ten per cent.
+&beta;-naphthol ointment. Repeated washings with vinegar or dilute
+acetic acid, or with alkaline lotions, will free the hairs of the ova.</p>
+
+
+<hr style='width: 35%;' />
+
+<h2><a name='Cysticercus_Cellulosae' id='Cysticercus_Cellulosae'></a><b>Cysticercus Cellulos&aelig;.</b></h2>
+
+
+<p><b>Describe the cutaneous disturbance produced by the cysticercus
+cellulos&aelig;.</b></p>
+
+<p>The presence of cysticerci in the skin and subcutaneous tissue gives
+rise to pea to hazelnut-sized, rounded, firm, movable tumors which,
+when developed, may remain unchanged for months. The parasites
+are disclosed by microscopic examination.</p>
+
+<p>Most of the cases have been observed in Germany.
+<span class='pagenum'><a name='Page_277' id='Page_277'></a><a href='#TOC'>[Pg 277]</a></span></p>
+
+
+<h2><a name='Filaria_Medinensis' id='Filaria_Medinensis'></a><b>Filaria Medinensis.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Guinea-worm.)</p>
+
+
+<p><b>State the character of the lesions produced by the filaria
+medinensis.</b></p>
+
+<p>The young microscopic worm penetrates the skin or deeper tissue,
+where it grows gradually, finally reaching several inches or more in
+length and about a half-line in thickness; inflammation is excited
+and a tumor-like swelling makes its appearance, which, sooner or later,
+breaks, disclosing the worm. It may also present a cord-like appearance.
+It is rarely met with outside of tropical countries.</p>
+
+<p>Treatment consists in gradual extraction, or in the injection of a
+corrosive sublimate solution (1:1000) into the forming tumor. Asafetida
+internally has been found to be curative, the parasite being
+destroyed and subsequently absorbed or discharged.</p>
+
+
+<h2><a name='Ixodes' id='Ixodes'></a><b>Ixodes.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Wood-tick.)</p>
+
+
+<p><b>State the character of the cutaneous disturbance produced
+by the ixodes.</b></p>
+
+<p>The tick sticks its proboscis into the skin and sucks blood until it
+is several times its natural size, and then falls off; an urticarial
+lesion results. If caught in the act the animal should not be forcibly
+extracted, as its proboscis may be thus broken off and remain in the
+skin, and give rise to pain and inflammation. It may be made to
+relinquish its hold by placing on it a drop of an essential oil.</p>
+
+<p>A thymol or carbolized boric-acid lotion will relieve the irritation.</p>
+
+
+<h2><a name='Leptus' id='Leptus'></a><b>Leptus.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Harvest-mite.)</p>
+
+
+<p><b>State the characters of the lesion produced by the leptus.</b></p>
+
+<p>This minute brick-red mite buries itself in the skin, especially
+about the ankles and feet, giving rise to papules, vesicles and
+pustules.</p>
+
+<p>Treatment consists of the use of a mild sulphur ointment or of a
+carbolic-acid lotion.
+<span class='pagenum'><a name='Page_278' id='Page_278'></a><a href='#TOC'>[Pg 278]</a></span></p>
+
+
+<h2><a name='Oestrus' id='Oestrus'></a><b>&OElig;strus.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Gad, or Bot-fly.)</p>
+
+
+<p><b>Describe the cutaneous disturbance produced by the &oelig;strus.</b></p>
+
+<p>The ova are deposited in the skin, develop and give rise to the
+formation of furuncle-like tumors with central aperture, through
+which a sanious discharge exudes; or as the result of the burrowing
+of the larv&aelig;, irregular serpiginous lines or wheals are produced.</p>
+
+<p>It is chiefly met with in Central and South America.</p>
+
+<p><i>Larva migrant</i>, or <i>creeping disease</i>, is doubtless in this same class.
+It is characterized by a thread-like linear formation of an erythematous,
+erythemato-papular, or vesicular nature that gradually extends,
+the older part disappearing; considerable surface may be covered
+before the parasite disappears or dies. The treatment consists in
+endeavoring to destroy the organism by means of excision or caustic
+applications at the point of its suspected site which is just ahead of
+the extending line.</p>
+
+
+<h2><a name='Pulex_Penetrans' id='Pulex_Penetrans'></a><b>Pulex Penetrans.</b></h2>
+
+<p class='center'>(<i>Synonyms:</i> Sand Flea; Jigger.)</p>
+
+
+<p><b>Describe the cutaneous disturbance produced by the pulex
+penetrans.</b></p>
+
+<p>This microscopic animal penetrates the skin, especially about the
+toes, producing an inflammatory swelling, vesicle or pustule, or
+even ulceration. It is met with in warm and tropical countries.</p>
+
+<p>Treatment consists in extraction. Essential oils are used as a
+preventive. A carbolic-acid or alkaline lotion relieves irritation.</p>
+
+
+<h2><a name='Cimex_Lectularius' id='Cimex_Lectularius'></a><b>Cimex Lectularius.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Bed-bug.)</p>
+
+
+<p><b>Describe the characters of a bed-bug bite.</b></p>
+
+<p>An inflammatory papule or wheal-like lesion results, somewhat
+hemorrhagic; the purpuric or hemorrhagic point or spot remains
+after the swelling subsides, but finally, in the course of several days
+or a few weeks, disappears.</p>
+
+<p>Treatment consists in the application of alkaline or acid lotions.
+<span class='pagenum'><a name='Page_279' id='Page_279'></a><a href='#TOC'>[Pg 279]</a></span></p>
+
+
+<h2><a name='Culex' id='Culex'></a><b>Culex.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Gnat; Mosquito.)</p>
+
+
+<p><b>Describe the cutaneous disturbance produced by the culex.</b></p>
+
+<p>It consists of an erythematous spot or a wheal-like lesion.</p>
+
+<p>Alkaline or acid lotions usually give relief.</p>
+
+
+<h2><a name='Pulex_Irritans' id='Pulex_Irritans'></a><b>Pulex Irritans.</b></h2>
+
+<p class='center'>(<i>Synonym:</i> Common Flea.)</p>
+
+
+<p><b>Describe the cutaneous disturbance produced by the pulex
+irritans.</b></p>
+
+<p>It consists of an erythematous spot with a minute central hemorrhagic
+point. In irritable skin, a wheal-like lesion may result.</p>
+
+<p>Treatment consists of applications of camphor or ammonia-water;
+carbolic acid and thymol lotions are also useful.</p>
+
+<p><span class='pagenum'><a name='Page_280' id='Page_280'></a><a href='#TOC'>[Pg 280]</a></span></p>
+
+<hr style='width: 65%;' />
+<p>
+RELATIVE FREQUENCY OF THE VARIOUS DISEASES OF SKIN AS SHOWN BY THE
+STATISTICS (123,746 CASES) OF THE AMERICAN DERMATOLOGICAL ASSOCIATION
+FOR TEN YEARS, 1878-87.
+</p>
+
+<table border='1'
+ summary='Relative Frequency of Diseases of the skin'>
+<tr><th>CLASSIFICATION OF<br />DISEASES.</th><th>No.<br />Cases.</th><th>%<br />Cases.</th><th></th><th>CLASSIFICATION OF<br />DISEASES.</th><th>No.<br />Cases.</th><th>%<br />Cases.</th></tr>
+
+<tr><td><b>Class I. Disorders of the<br />Glands.</b></td><td></td><td></td><td></td><td>&nbsp; &nbsp; Verruca necrogenica</td><td style='text-align: right;'> 2 </td><td style='text-align: right;'>.001</td></tr>
+
+<tr><td>1. OF THE SWEAT GLANDS.</td><td></td><td></td><td></td><td>&nbsp; &nbsp; N&aelig;vus pigmentosus</td><td style='text-align: right;'>88 </td><td style='text-align: right;'>.064</td></tr>
+
+<tr><td>&nbsp; &nbsp; Hyperidrosis</td><td style='text-align: right;'>328</td><td style='text-align: right;'>.265</td><td></td><td>&nbsp; &nbsp; Xerosis</td><td style='text-align: right;'> 100 </td><td style='text-align: right;'>.080</td></tr>
+
+<tr><td>&nbsp; &nbsp; Sudamen</td><td style='text-align: right;'>268</td><td style='text-align: right;'>.216</td><td></td><td>&nbsp; &nbsp; Ichthyosis </td><td style='text-align: right;'> 309 </td><td style='text-align: right;'>.249</td></tr>
+
+<tr><td>&nbsp; &nbsp; Anidrosis</td><td style='text-align: right;'>11</td><td style='text-align: right;'>.009</td><td></td><td>&nbsp; &nbsp; Onychauxis </td><td style='text-align: right;'>70 </td><td style='text-align: right;'>.056</td></tr>
+
+<tr><td>&nbsp; &nbsp; Bromidrosis</td><td style='text-align: right;'>112</td><td style='text-align: right;'>.090</td><td></td><td>&nbsp; &nbsp; Hypertdichosis </td><td style='text-align: right;'> 515 </td><td style='text-align: right;'>.416</td></tr>
+
+<tr><td>&nbsp; &nbsp; Chromidrosis</td><td style='text-align: right;'>7</td><td style='text-align: right;'>.005</td><td></td><td>3. OF CONNECTIVE TISSUE.</td></tr>
+
+<tr><td>&nbsp; &nbsp; Uridrosis</td><td style='text-align: right;'>....</td><td style='text-align: right;'>....</td><td></td><td>&nbsp; &nbsp; Sclerema neonatorum</td><td style='text-align: right;'>.... </td><td style='text-align: right;'> ....</td></tr>
+
+<tr><td>2. OF  THE SEBACEOUS<br />GLANDS</td><td style='text-align: right;'>238</td><td style='text-align: right;'>.193</td><td></td><td>&nbsp; &nbsp; Scleroderma</td><td style='text-align: right;'>38 </td><td style='text-align: right;'>0.030</td></tr>
+
+<tr><td>&nbsp; &nbsp; Seborrh&oelig;a:</td><td style='text-align: right;'>1812</td><td style='text-align: right;'> 1.47&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Morph&oelig;a </td><td style='text-align: right;'>39 </td><td style='text-align: right;'>0.031</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; a. oleosa</td><td style='text-align: right;'>367</td><td style='text-align: right;'>.296</td><td></td><td>&nbsp; &nbsp; Elephantiasis</td><td style='text-align: right;'>57 </td><td style='text-align: right;'>0.046</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; b. sicca</td><td style='text-align: right;'>395</td><td style='text-align: right;'>.319</td><td></td><td>&nbsp; &nbsp; Rosacea: </td><td style='text-align: right;'> 785 </td><td style='text-align: right;'>0.634</td></tr>
+
+<tr><td>&nbsp; &nbsp; Comedo</td><td style='text-align: right;'>1225</td><td style='text-align: right;'>.989</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; a. erythematosa</td><td style='text-align: right;'> 381 </td><td style='text-align: right;'>0.308</td></tr>
+
+<tr><td>&nbsp; &nbsp; Cyst</td><td style='text-align: right;'>6</td><td style='text-align: right;'>.004</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; b. hypertrophica </td><td style='text-align: right;'>58 </td><td style='text-align: right;'>0.047</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; a. Milium</td><td style='text-align: right;'>225</td><td style='text-align: right;'>.183</td><td></td><td>&nbsp; &nbsp; Framb&oelig;sia </td><td style='text-align: right;'>22 </td><td style='text-align: right;'>0.018</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; b. Steatoma</td><td style='text-align: right;'> 151 </td><td style='text-align: right;'>.122</td><td></td><td><b>Class V. Atrophies.</b></td></tr>
+
+<tr><td>&nbsp; &nbsp; Asteatosis</td><td style='text-align: right;'> 8 </td><td style='text-align: right;'>.006</td><td></td><td>1. OF PIGMENT.</td></tr>
+
+<tr><td><b>Class II. Inflammations.</b></td><td></td><td></td><td></td><td>&nbsp; &nbsp; Leucoderma </td><td style='text-align: right;'>77 </td><td style='text-align: right;'>0.062</td></tr>
+
+<tr><td>&nbsp; &nbsp; Exanthemata</td><td style='text-align: right;'>1770 </td><td style='text-align: right;'> 1.43&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Albinismus </td><td style='text-align: right;'> 9 </td><td style='text-align: right;'>0.008</td></tr>
+
+<tr><td>&nbsp; &nbsp; Erythema simplex</td><td style='text-align: right;'>1064 </td><td style='text-align: right;'>.859</td><td></td><td>&nbsp; &nbsp; Vitiligo </td><td style='text-align: right;'> 191 </td><td style='text-align: right;'>0.155</td></tr>
+
+<tr><td>&nbsp; &nbsp; Erythema multiforme:</td><td style='text-align: right;'> 915 </td><td style='text-align: right;'>.730</td><td></td><td>&nbsp; &nbsp; Canities </td><td style='text-align: right;'>43 </td><td style='text-align: right;'>0.035</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; a. papulosum</td><td style='text-align: right;'> 325 </td><td style='text-align: right;'>.262</td><td></td><td>2. OF HAIR.</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; b. bullosum</td><td style='text-align: right;'>37 </td><td style='text-align: right;'>.029</td><td></td><td>&nbsp; &nbsp; Alopecia </td><td style='text-align: right;'> 926 </td><td style='text-align: right;'>0.749</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; c. nodosum</td><td style='text-align: right;'>82 </td><td style='text-align: right;'>.066</td><td></td><td>&nbsp; &nbsp; Alopecia furfuracea</td><td style='text-align: right;'> 830 </td><td style='text-align: right;'>0.67</td></tr>
+
+<tr><td>&nbsp; &nbsp; Urticaria</td><td style='text-align: right;'>2994 </td><td style='text-align: right;'> 2.47&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Alopecia areata</td><td style='text-align: right;'> 794 </td><td style='text-align: right;'>0.641</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; pigmentosa</td><td style='text-align: right;'> 1 </td><td style='text-align: right;'>.0008</td><td></td><td>&nbsp; &nbsp; Atrophia pilorum propria </td><td style='text-align: right;'>23 </td><td style='text-align: right;'>0.019</td></tr>
+
+<tr><td>&nbsp; &nbsp; <a name='FNanchor_A_5' id='FNanchor_A_5'></a><a href='#Footnote_A_5' class='fnanchor'>[E]</a>Dermatitis:</td><td style='text-align: right;'>    1720 </td><td style='text-align: right;'> 1.39&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Trichorexis nodosa </td><td style='text-align: right;'> 3 </td><td style='text-align: right;'>0.002</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; a. traumatica</td><td style='text-align: right;'> 468 </td><td style='text-align: right;'>.378</td><td></td><td>3. OF NAIL</td><td style='text-align: right;'>      26 </td><td style='text-align: right;'>  0.021</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; b. venenata</td><td style='text-align: right;'> 616 </td><td style='text-align: right;'>.498</td><td></td><td>&nbsp; &nbsp; Atrophia unguis</td><td style='text-align: right;'>19 </td><td style='text-align: right;'>0.015</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; c. calorica</td><td style='text-align: right;'> 224 </td><td style='text-align: right;'>.187</td><td></td><td>4. OF CUTIS</td><td style='text-align: right;'> 6 </td><td style='text-align: right;'>  0.005</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; d. medicamentosa </td><td style='text-align: right;'> 108 </td><td style='text-align: right;'>.087</td><td></td><td>&nbsp; &nbsp; Atrophia senilis </td><td style='text-align: right;'>15 </td><td style='text-align: right;'>0.013</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; e. gangr&aelig;nosa</td><td style='text-align: right;'> 8 </td><td style='text-align: right;'>.006</td><td></td><td>&nbsp; &nbsp; Atrophia maculosa et<br />&nbsp; &nbsp; &nbsp; &nbsp; striata </td><td style='text-align: right;'>23 </td><td style='text-align: right;'>0.019</td></tr>
+
+<tr><td>&nbsp; &nbsp; Erysipelas </td><td style='text-align: right;'>1026 </td><td style='text-align: right;'>.829</td><td></td><td><b>Class VI. New Growths.</b></td></tr>
+
+<tr><td>&nbsp; &nbsp; Furunculus </td><td style='text-align: right;'>2129 </td><td style='text-align: right;'> 1.72&nbsp;&nbsp;</td><td></td><td>1. OF CONNECTIVE TISSUE.</td><td style='text-align: right;'> 1 </td><td style='text-align: right;'> 0.0008</td></tr>
+
+<tr><td>&nbsp; &nbsp; Anthrax</td><td style='text-align: right;'> 252 </td><td style='text-align: right;'>.203</td><td></td><td>&nbsp; &nbsp; Keloid </td><td style='text-align: right;'> 152 </td><td style='text-align: right;'>0.124</td></tr>
+
+<tr><td>&nbsp; &nbsp; Phlegmona diffusa</td><td style='text-align: right;'> 265 </td><td style='text-align: right;'>.215</td><td></td><td>&nbsp; &nbsp; Cicatrix </td><td style='text-align: right;'>89 </td><td style='text-align: right;'>0.065</td></tr>
+
+<tr><td>&nbsp; &nbsp; Pustula maligna</td><td style='text-align: right;'> 197 </td><td style='text-align: right;'>.159</td><td></td><td>&nbsp; &nbsp; Fibroma</td><td style='text-align: right;'>93 </td><td style='text-align: right;'>0.075</td></tr>
+
+<tr><td>&nbsp; &nbsp; Herpes simplex </td><td style='text-align: right;'>2057 </td><td style='text-align: right;'> 1.66&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Neuroma</td><td style='text-align: right;'>11 </td><td style='text-align: right;'>0.009</td></tr>
+
+<tr><td>&nbsp; &nbsp; Herpes zoster</td><td style='text-align: right;'>1428 </td><td style='text-align: right;'> 1.15&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Xanthoma </td><td style='text-align: right;'>69 </td><td style='text-align: right;'>0.056</td></tr>
+
+<tr><td>&nbsp; &nbsp; Dermatitis herpetiformis </td><td style='text-align: right;'>41 </td><td style='text-align: right;'>.033</td><td></td><td>2. OF MUSCULAR TISSUE.</td></tr>
+
+<tr><td>&nbsp; &nbsp; Psoriasis</td><td style='text-align: right;'>4131 </td><td style='text-align: right;'> 3.34&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Myoma</td><td style='text-align: right;'> 1 </td><td style='text-align: right;'>0.0008</td></tr>
+
+<tr><td>&nbsp; &nbsp; Pityriasis maculuta et <br />&nbsp; &nbsp; &nbsp; &nbsp; circinata</td><td style='text-align: right;'>71 </td><td style='text-align: right;'>.057</td><td></td><td>3. OF VESSELS.</td></tr>
+
+<tr><td>&nbsp; &nbsp; Dermatitis exfoliativa </td><td style='text-align: right;'>16 </td><td style='text-align: right;'>.012</td><td></td><td>&nbsp; &nbsp; Angioma</td><td style='text-align: right;'> 462 </td><td style='text-align: right;'>0.373</td></tr>
+
+<tr><td>&nbsp; &nbsp; Pityriasis rubra </td><td style='text-align: right;'>44 </td><td style='text-align: right;'>.032</td><td></td><td>&nbsp; &nbsp; Angioma pigmentosum<br />&nbsp; &nbsp; &nbsp; &nbsp; et atrophicum </td><td style='text-align: right;'>13 </td><td style='text-align: right;'>0.010</td></tr>
+
+<tr><td>&nbsp; &nbsp; Lichen:</td><td style='text-align: right;'> 144 </td><td style='text-align: right;'>.116</td><td></td><td>&nbsp; &nbsp; Angioma cavernosum </td><td style='text-align: right;'> 22 </td><td style='text-align: right;'>0.018</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; a. planus</td><td style='text-align: right;'> 154 </td><td style='text-align: right;'>.124</td><td></td><td>&nbsp; &nbsp; Lymphangioma </td><td style='text-align: right;'>16 </td><td style='text-align: right;'> .012</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; b. ruber </td><td style='text-align: right;'>27 </td><td style='text-align: right;'>.021</td><td></td><td>4. Mycosis fongoide</td><td style='text-align: right;'> 1 </td><td style='text-align: right;'> .0008<br /></td></tr>
+
+<tr><td>&nbsp; &nbsp; Eczema:</td><td style='text-align: right;'> 37661 </td><td style='text-align: right;'>30.43&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Rhinoscleroma</td><td style='text-align: right;'> 3 </td><td style='text-align: right;'> .002</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; a. erythematosum </td><td style='text-align: right;'>.... </td><td style='text-align: right;'>....</td><td></td><td>&nbsp; &nbsp; Lupus erythematosus</td><td style='text-align: right;'> 477 </td><td style='text-align: right;'> .385</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; b. papulosum </td><td style='text-align: right;'>.... </td><td style='text-align: right;'>....</td><td></td><td>&nbsp; &nbsp; Lupus vulgaris </td><td style='text-align: right;'> 536 </td><td style='text-align: right;'> .433</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; c. vesiculosum </td><td style='text-align: right;'>.... </td><td style='text-align: right;'>....</td><td></td><td>&nbsp; &nbsp; Scrofuloderma</td><td style='text-align: right;'> 663 </td><td style='text-align: right;'> .536</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; d. madidans</td><td style='text-align: right;'>.... </td><td style='text-align: right;'>....</td><td></td><td>&nbsp; &nbsp; Syphiloderma:</td><td style='text-align: right;'> 13888 </td><td style='text-align: right;'> 11.22&nbsp;&nbsp;</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; e. pustulosum</td><td style='text-align: right;'>.... </td><td style='text-align: right;'>....</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; a. erythematosum </td><td style='text-align: right;'>.... </td><td style='text-align: right;'> ....</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; f. rubrum</td><td style='text-align: right;'>.... </td><td style='text-align: right;'>....</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; b. papulosum </td><td style='text-align: right;'>.... </td><td style='text-align: right;'> ....</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; g. squamosum </td><td style='text-align: right;'>.... </td><td style='text-align: right;'>....</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; c. pustulosum</td><td style='text-align: right;'>.... </td><td style='text-align: right;'> ....</td></tr>
+
+<tr><td>&nbsp; &nbsp; Prurigo</td><td style='text-align: right;'>34 </td><td style='text-align: right;'>.027</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; d. tuberculosum</td><td style='text-align: right;'>.... </td><td style='text-align: right;'> ....</td></tr>
+
+<tr><td>&nbsp; &nbsp; Acne </td><td style='text-align: right;'>9077 </td><td style='text-align: right;'> 7.34&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; e. gummatosum</td><td style='text-align: right;'>.... </td><td style='text-align: right;'> ....</td></tr>
+
+<tr><td>&nbsp; &nbsp; Acne rosacea </td><td style='text-align: right;'> 398 </td><td style='text-align: right;'>.321</td><td></td><td>&nbsp; &nbsp; Lepra: </td><td style='text-align: right;'>24 </td><td style='text-align: right;'> .020</td></tr>
+
+<tr><td>&nbsp; &nbsp; Sycosis</td><td style='text-align: right;'> 227 </td><td style='text-align: right;'>.185</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; a. tuberosa</td><td style='text-align: right;'> 7 </td><td style='text-align: right;'> .005</td></tr>
+
+<tr><td>&nbsp; &nbsp; Impetigo </td><td style='text-align: right;'>1769 </td><td style='text-align: right;'> 1.43&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; b. maculosa</td><td style='text-align: right;'> 4 </td><td style='text-align: right;'> .003</td></tr>
+
+<tr><td>&nbsp; &nbsp; Impetigo contagiosa</td><td style='text-align: right;'> 600 </td><td style='text-align: right;'>.485</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; c. an&aelig;sthetica </td><td style='text-align: right;'> 6 </td><td style='text-align: right;'> .004</td></tr>
+
+<tr><td>&nbsp; &nbsp; Impetigo herpetiformis </td><td style='text-align: right;'>10 </td><td style='text-align: right;'>.009</td><td></td><td>&nbsp; &nbsp; Carcinoma</td><td style='text-align: right;'>1068 </td><td style='text-align: right;'> .863</td></tr>
+
+<tr><td>&nbsp; &nbsp; Ecthyma</td><td style='text-align: right;'> 726 </td><td style='text-align: right;'>.587</td><td></td><td>&nbsp; &nbsp; Sarcoma</td><td style='text-align: right;'>55 </td><td style='text-align: right;'> .044</td></tr>
+
+<tr><td>&nbsp; &nbsp; Pemphigus</td><td style='text-align: right;'> 183 </td><td style='text-align: right;'>.148</td><td></td><td><b>Class VII. Neuroses.</b></td></tr>
+
+<tr><td>&nbsp; &nbsp; Ulcers </td><td style='text-align: right;'>3021 </td><td style='text-align: right;'> 2.44&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; Hyper&aelig;sthesia:</td><td style='text-align: right;'> 4 </td><td style='text-align: right;'> .003</td></tr>
+
+<tr><td><b>Class III. Hemorrhages.</b></td><td></td><td></td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; a. Pruritus</td><td style='text-align: right;'>2716 </td><td style='text-align: right;'>2.12&nbsp;&nbsp;</td></tr>
+
+<tr><td>&nbsp; &nbsp; Purpura:</td><td style='text-align: right;'> 341 </td><td style='text-align: right;'>.275</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; b. Dermatalgia </td><td style='text-align: right;'>11 </td><td style='text-align: right;'> .009</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; a. simplex</td><td style='text-align: right;'> 181 </td><td style='text-align: right;'>.145</td><td></td><td>&nbsp; &nbsp; An&aelig;sthesia </td><td style='text-align: right;'>22 </td><td style='text-align: right;'> .018</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; b. h&aelig;morrhagica </td><td style='text-align: right;'>49 </td><td style='text-align: right;'>.039</td><td></td><td><b>Class VIII. Parasitic<br />Affections.</b></td></tr>
+
+<tr><td><b>Class IV. Hypertrophies.</b></td><td></td><td></td><td></td><td>1. VEGETABLE.</td></tr>
+
+<tr><td>1. OF PIGMENT.</td><td></td><td></td><td></td><td>&nbsp; &nbsp; Tinea favosa </td><td style='text-align: right;'> 354 </td><td style='text-align: right;'> .286</td></tr>
+
+<tr><td>&nbsp; &nbsp; Lentigo</td><td style='text-align: right;'> 127 </td><td style='text-align: right;'>.103</td><td></td><td>&nbsp; &nbsp; Tinea trichophytina: </td><td style='text-align: right;'>2289 </td><td style='text-align: right;'>1.85&nbsp;&nbsp;</td></tr>
+
+<tr><td>&nbsp; &nbsp; Chloasma </td><td style='text-align: right;'> 560 </td><td style='text-align: right;'>.452</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; a. circinata </td><td style='text-align: right;'> 705 </td><td style='text-align: right;'> .569</td></tr>
+
+<tr><td>2. OF EPIDERMAL AND<br />PAPILLARY LAYERS.</td><td></td><td></td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; b. tonsurans </td><td style='text-align: right;'> 675 </td><td style='text-align: right;'> .545</td></tr>
+
+<tr><td>&nbsp; &nbsp; Keratosis:</td><td style='text-align: right;'>94 </td><td style='text-align: right;'>.076</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; c. sycosis </td><td style='text-align: right;'> 365 </td><td style='text-align: right;'> .295</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; a. pilaris </td><td style='text-align: right; text-align: right;'> 103 </td><td style='text-align: right;'>.083</td><td></td><td>&nbsp; &nbsp; Tinea versicolor </td><td style='text-align: right;'>1263 </td><td style='text-align: right;'>1.02&nbsp;&nbsp;</td></tr>
+
+<tr><td>&nbsp; &nbsp; &nbsp; &nbsp; b. senilis </td><td style='text-align: right;'>68 </td><td style='text-align: right;'>.055</td><td></td><td>2. ANIMAL.</td></tr>
+
+<tr><td>&nbsp; &nbsp; Molluscum epitheliale</td><td style='text-align: right;'> 172 </td><td style='text-align: right;'>.139</td><td></td><td>&nbsp; &nbsp; Scabies</td><td style='text-align: right;'>3192 </td><td style='text-align: right;'>2.58&nbsp;&nbsp;</td></tr>
+
+<tr><td>&nbsp; &nbsp; Callositas </td><td style='text-align: right;'> 110 </td><td style='text-align: right;'>.090</td><td></td><td>&nbsp; &nbsp; Pediculosis capillitii </td><td style='text-align: right;'>2579 </td><td style='text-align: right;'>2.09&nbsp;&nbsp;</td></tr>
+
+<tr><td>&nbsp; &nbsp; Clavus </td><td style='text-align: right;'>84 </td><td style='text-align: right;'>.068</td><td></td><td>&nbsp; &nbsp; Pediculosis corporis </td><td style='text-align: right;'>1704 </td><td style='text-align: right;'>1.38&nbsp;&nbsp;</td></tr>
+
+<tr><td>&nbsp; &nbsp; Cornu cutaneum </td><td style='text-align: right;'>42 </td><td style='text-align: right;'>.034</td><td></td><td>&nbsp; &nbsp; Pediculosis pubis</td><td style='text-align: right;'> 436 </td><td style='text-align: right;'> .352</td></tr>
+
+<tr><td>&nbsp; &nbsp; Verruca</td><td style='text-align: right;'>1252 </td><td style='text-align: right;'> 1.09&nbsp;&nbsp;</td><td></td><td>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Total </td><td style='text-align: right;'>123746 </td><td style='text-align: right;'></td></tr>
+
+</table>
+
+
+
+<div class='footnote' style='margin-left: 5em;'><p><a name='Footnote_A_5' id='Footnote_A_5'></a><a href='#FNanchor_A_5'><span class='label'>[E]</span></a> Indicating affections of this class not properly included under other titles.</p></div>
+
+<hr style='width: 65%;' />
+<h2><a name='INDEX' id='INDEX'></a><b>INDEX.</b></h2>
+
+<p>
+Acarus folliculorum, <a href='#Page_40'>40</a><br />
+<span style='margin-left: 1em;'>scabiei, <a href='#Page_269'>269</a></span><br />
+<br />
+Achorion Sch&ouml;nleinii, <a href='#Page_249'>249</a><br />
+<br />
+Acne, <a href='#Page_115'>115</a>-<a href='#Page_126'>126</a><br />
+<span style='margin-left: 1em;'>artificialis, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>atrophica, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>cachecticorum, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>frontalis, <a href='#Page_129'>129</a></span><br />
+<span style='margin-left: 1em;'>hypertrophica, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>indurata, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>keloid, <a href='#Page_135'>135</a></span><br />
+<span style='margin-left: 1em;'>lupoid, <a href='#Page_129'>129</a></span><br />
+<span style='margin-left: 1em;'>necrotica, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>papulosa, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>punctata, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>pustulosa, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>rodens, <a href='#Page_129'>129</a></span><br />
+<span style='margin-left: 1em;'>rosacea, <a href='#Page_126'>126</a>-<a href='#Page_129'>129</a>, <a href='#Page_198'>198</a></span><br />
+<span style='margin-left: 1em;'>sebacea, <a href='#Page_33'>33</a></span><br />
+<span style='margin-left: 1em;'>tar, <a href='#Page_120'>120</a></span><br />
+<span style='margin-left: 1em;'>urticata, <a href='#Page_130'>130</a></span><br />
+<span style='margin-left: 1em;'>varioliformis, <a href='#Page_129'>129</a></span><br />
+<span style='margin-left: 1em;'>vulgaris, <a href='#Page_119'>119</a></span><br />
+<br />
+Acnitis, <a href='#Page_130'>130</a><br />
+<br />
+Actinomycosis, <a href='#Page_266'>266</a><br />
+<br />
+Addison's disease, pigmentation of the skin in, <a href='#Page_149'>149</a><br />
+<span style='margin-left: 1em;'>keloid, <a href='#Page_172'>172</a></span><br />
+<br />
+Ainhum, <a href='#Page_212'>212</a><br />
+<br />
+Albinismus, <a href='#Page_177'>177</a><br />
+<br />
+Albinos, <a href='#Page_177'>177</a><br />
+<br />
+Alopecia, <a href='#Page_181'>181</a>-<a href='#Page_183'>183</a><br />
+<span style='margin-left: 1em;'>areata, <a href='#Page_183'>183</a>-<a href='#Page_186'>186</a></span><br />
+<span style='margin-left: 1em;'>circumscripta, <a href='#Page_183'>183</a></span><br />
+<span style='margin-left: 1em;'>congenital, <a href='#Page_181'>181</a></span><br />
+<span style='margin-left: 1em;'>furfuracea, <a href='#Page_181'>181</a></span><br />
+<span style='margin-left: 1em;'>premature, <a href='#Page_181'>181</a></span><br />
+<span style='margin-left: 1em;'>senile, <a href='#Page_181'>181</a></span><br />
+<br />
+An&aelig;sthesia, <a href='#Page_244'>244</a><br />
+<br />
+Anatomy of the skin, <a href='#Page_17'>17</a>-<a href='#Page_21'>21</a>, <a href='#Page_28'>28</a><br />
+<br />
+Angioma, <a href='#Page_196'>196</a>, <a href='#Page_197'>197</a><br />
+<span style='margin-left: 1em;'>cavernosum, <a href='#Page_197'>197</a></span><br />
+<span style='margin-left: 1em;'>pigmentosum et atrophicum, <a href='#Page_190'>190</a></span><br />
+<span style='margin-left: 1em;'>simplex, <a href='#Page_196'>196</a></span><br />
+<br />
+Angiomyoma, <a href='#Page_196'>196</a><br />
+<br />
+Angioneurotic &oelig;dema, <a href='#Page_54'>54</a><br />
+<br />
+Anidrosis, <a href='#Page_31'>31</a><br />
+<br />
+Anthrax, <a href='#Page_70'>70</a>, <a href='#Page_72'>72</a><br />
+<br />
+Antipruritic applications, <a href='#Page_246'>246</a><br />
+<br />
+Antipyrin, eruptions from, <a href='#Page_61'>61</a><br />
+<br />
+Area Celsi, <a href='#Page_183'>183</a><br />
+<br />
+Argyria, <a href='#Page_150'>150</a><br />
+<br />
+Arsenic, eruptions from, <a href='#Page_61'>61</a><br />
+<br />
+Artificial eruptions (feigned eruptions), <a href='#Page_64'>64</a><br />
+<br />
+Atrophia cutis, <a href='#Page_189'>189</a>, <a href='#Page_190'>190</a><br />
+<span style='margin-left: 1em;'>pilorum propria, <a href='#Page_187'>187</a></span><br />
+<span style='margin-left: 1em;'>unguis, <a href='#Page_188'>188</a>, <a href='#Page_189'>189</a></span><br />
+<br />
+Atrophic lines and spots, <a href='#Page_190'>190</a><br />
+<br />
+Atrophies, <a href='#Page_177'>177</a>-<a href='#Page_190'>190</a><br />
+<br />
+Atrophoderma, <a href='#Page_189'>189</a><br />
+<span style='margin-left: 1em;'>neuriticum, <a href='#Page_189'>189</a></span><br />
+<br />
+Atrophy of the hair, <a href='#Page_187'>187</a><br />
+<span style='margin-left: 1em;'>of the nails, <a href='#Page_188'>188</a></span><br />
+<span style='margin-left: 1em;'>of the skin, <a href='#Page_189'>189</a></span><br />
+<span style='margin-left: 2em;'>general idiopathic, <a href='#Page_189'>189</a></span><br />
+<span style='margin-left: 1em;'>senile, <a href='#Page_190'>190</a></span><br />
+<br />
+Atropia, eruptions from, <a href='#Page_61'>61</a><br />
+<br />
+Autographism, <a href='#Page_52'>52</a><br />
+<br />
+<br />
+Baldness, <a href='#Page_181'>181</a><br />
+<br />
+Barbadoes leg, <a href='#Page_174'>174</a><br />
+<br />
+Barbers' itch, <a href='#Page_255'>255</a><br />
+<br />
+Bath-pruritis, <a href='#Page_245'>245</a><br />
+<br />
+Bed-bug, <a href='#Page_278'>278</a><br />
+<br />
+Bed-sores, <a href='#Page_58'>58</a><br />
+<br />
+Belladonna, eruptions from, <a href='#Page_61'>61</a><br />
+<br />
+Blackheads, <a href='#Page_38'>38</a>-<a href='#Page_41'>41</a><br />
+<br />
+Blanching of the hair, <a href='#Page_180'>180</a><br />
+<br />
+Blastomycetic dermatitis, <a href='#Page_266'>266</a><br />
+<br />
+Blebs, <a href='#Page_23'>23</a><br />
+<br />
+Blood-vessels, <a href='#Page_19'>19</a><br />
+<br />
+Boil, <a href='#Page_68'>68</a><br />
+<br />
+Bot-fly, <a href='#Page_278'>278</a><br />
+<br />
+Bromides, eruptions from, <a href='#Page_61'>61</a><br />
+<br />
+Bromidrosis, <a href='#Page_32'>32</a><br />
+<br />
+Bull&aelig;, <a href='#Page_23'>23</a><br />
+<br />
+Burns, <a href='#Page_58'>58</a><br />
+<br />
+Burrows, <a href='#Page_268'>268</a><br />
+<br />
+<br />
+Calculi, cutaneous, <a href='#Page_42'>42</a><br />
+<br />
+Callositas, <a href='#Page_155'>155</a>, <a href='#Page_156'>156</a><br />
+<br />
+Callosity, <a href='#Page_155'>155</a><br />
+<br />
+Callous, <a href='#Page_155'>155</a><br />
+<br />
+Callus, <a href='#Page_155'>155</a><br />
+<br />
+Cancer, epithelial, <a href='#Page_236'>236</a><br />
+<span style='margin-left: 1em;'>skin, 236</span><br />
+<br />
+Canities, <a href='#Page_180'>180</a><br />
+<span style='margin-left: 1em;'>prematura, <a href='#Page_180'>180</a></span><br />
+<span style='margin-left: 1em;'>senilis, <a href='#Page_180'>180</a></span><br />
+<br />
+Carbuncle, <a href='#Page_70'>70</a><br />
+<br />
+Carbunculus, <a href='#Page_70'>70</a>-<a href='#Page_72'>72</a><br />
+<br />
+Carcinoma epitheliale, <a href='#Page_236'>236</a><br />
+<br />
+Carrion's disease, <a href='#Page_73'>73</a><br />
+<br />
+Chafing, <a href='#Page_45'>45</a><br />
+<br />
+Chapping, <a href='#Page_106'>106</a><br />
+<br />
+Charbon, <a href='#Page_72'>72</a><br />
+<br />
+Cheiro-pompholyx, <a href='#Page_76'>76</a><br />
+<br />
+Cheloid, <a href='#Page_191'>191</a><br />
+<br />
+Chloasma, <a href='#Page_149'>149</a>-<a href='#Page_151'>151</a><br />
+<span style='margin-left: 1em;'>uterinum, <a href='#Page_149'>149</a></span><br />
+<br />
+Chloral, eruptions from, <a href='#Page_62'>62</a><br />
+<br />
+Chromidrosis, <a href='#Page_32'>32</a><br />
+<span style='margin-left: 1em;'>red, <a href='#Page_33'>33</a></span><br />
+<br />
+Chromophytosis, <a href='#Page_262'>262</a><br />
+<br />
+Chrysarobin, <a href='#Page_93'>93</a><br />
+<br />
+Chrysophanic acid (chrysarobin), <a href='#Page_93'>93</a><br />
+<br />
+Cicatrices, <a href='#Page_24'>24</a><br />
+<br />
+Cimex lectularius, <a href='#Page_278'>278</a><br />
+<br />
+Clavus, <a href='#Page_156'>156</a>, <a href='#Page_157'>157</a><br />
+<br />
+Comedo, <a href='#Page_38'>38</a>-<a href='#Page_41'>41</a><br />
+<span style='margin-left: 1em;'>extractor, 40</span><br />
+<br />
+Condyloma, flat (or broad), <a href='#Page_217'>217</a><br />
+<span style='margin-left: 1em;'>pointed, <a href='#Page_161'>161</a></span><br />
+<br />
+Configuration, <a href='#Page_24'>24</a><br />
+<br />
+Conglomerate pustular folliculitis, <a href='#Page_252'>252</a><br />
+<br />
+Contagious impetigo, <a href='#Page_136'>136</a><br />
+<br />
+Contagiousness, <a href='#Page_27'>27</a><br />
+<br />
+Copaiba, eruptions from, <a href='#Page_62'>62</a><br />
+<br />
+Corn, <a href='#Page_156'>156</a><br />
+<br />
+Cornu cutaneum, <a href='#Page_158'>158</a>, <a href='#Page_159'>159</a><br />
+<span style='margin-left: 1em;'>humanum, <a href='#Page_159'>159</a></span><br />
+<br />
+Crab-louse, <a href='#Page_275'>275</a><br />
+<br />
+Creeping disease, <a href='#Page_278'>278</a><br />
+<br />
+Crusta lactea, <a href='#Page_104'>104</a><br />
+<br />
+Crust&aelig;, <a href='#Page_24'>24</a><br />
+<br />
+Crusts, <a href='#Page_24'>24</a><br />
+<br />
+Cubebs, eruptions from, <a href='#Page_62'>62</a><br />
+<br />
+Culex, <a href='#Page_279'>279</a><br />
+<br />
+Cuniculus, <a href='#Page_268'>268</a><br />
+<br />
+Curette, 208<br />
+<br />
+Cutaneous calculi, <a href='#Page_42'>42</a><br />
+<span style='margin-left: 1em;'>horn, <a href='#Page_158'>158</a></span><br />
+<br />
+Cutis anserina, <a href='#Page_152'>152</a><br />
+<span style='margin-left: 1em;'>pendula, <a href='#Page_176'>176</a></span><br />
+<br />
+Cyst, sebaceous, <a href='#Page_43'>43</a><br />
+<br />
+Cysticercus cellulos&aelig;, <a href='#Page_276'>276</a><br />
+<br />
+<br />
+Dandruff, <a href='#Page_33'>33</a>, <a href='#Page_34'>34</a><br />
+<br />
+Darier's disease, <a href='#Page_153'>153</a><br />
+<br />
+Defluvium capillorum, <a href='#Page_181'>181</a><br />
+<br />
+Demodex folliculorum, <a href='#Page_40'>40</a><br />
+<br />
+Depilatories, <a href='#Page_169'>169</a><br />
+<br />
+Dermalgia, <a href='#Page_244'>244</a><br />
+<br />
+Dermatalgia, <a href='#Page_244'>244</a><br />
+<br />
+Dermatitis, <a href='#Page_58'>58</a>-<a href='#Page_64'>64</a><br />
+<span style='margin-left: 1em;'>acute general, <a href='#Page_96'>96</a></span><br />
+<span style='margin-left: 1em;'>ambustionis, <a href='#Page_58'>58</a></span><br />
+<span style='margin-left: 1em;'>blastomycetic, <a href='#Page_266'>266</a></span><br />
+<span style='margin-left: 1em;'>calorica, <a href='#Page_58'>58</a></span><br />
+<span style='margin-left: 1em;'>congelationis, <a href='#Page_58'>58</a></span><br />
+<span style='margin-left: 1em;'>contusiformis, <a href='#Page_50'>50</a></span><br />
+<span style='margin-left: 1em;'>exfoliativa, <a href='#Page_96'>96</a>, <a href='#Page_97'>97</a></span><br />
+<span style='margin-left: 2em;'>general, <a href='#Page_96'>96</a></span><br />
+<span style='margin-left: 2em;'>neonatorum, <a href='#Page_97'>97</a></span><br />
+<span style='margin-left: 2em;'>recurrent, <a href='#Page_96'>96</a></span><br />
+<span style='margin-left: 1em;'>factitia, <a href='#Page_64'>64</a></span><br />
+<span style='margin-left: 1em;'>gangr&aelig;nosa, <a href='#Page_65'>65</a></span><br />
+<span style='margin-left: 1em;'>herpetiformis, <a href='#Page_83'>83</a>-<a href='#Page_86'>86</a></span><br />
+<span style='margin-left: 1em;'>iodoform, <a href='#Page_86'>86</a></span><br />
+<span style='margin-left: 1em;'>malignant papillary, <a href='#Page_240'>240</a></span><br />
+<span style='margin-left: 1em;'>medicamentosa, <a href='#Page_60'>60</a></span><br />
+<span style='margin-left: 1em;'>papillaris capillitii, <a href='#Page_135'>135</a></span><br />
+<span style='margin-left: 1em;'>repens, <a href='#Page_81'>81</a></span><br />
+<span style='margin-left: 1em;'>traumatica, <a href='#Page_58'>58</a></span><br />
+<span style='margin-left: 1em;'>vegetans, <a href='#Page_142'>142</a></span><br />
+<span style='margin-left: 1em;'>venenata, <a href='#Page_86'>86</a></span><br />
+<span style='margin-left: 1em;'><i>x</i>-ray, <a href='#Page_63'>63</a></span><br />
+<br />
+Dermatographism, <a href='#Page_52'>52</a><br />
+<br />
+Dermatolysis, <a href='#Page_176'>176</a><br />
+<br />
+Dermatomyoma, <a href='#Page_196'>196</a><br />
+<br />
+Dermatosclerosis, <a href='#Page_172'>172</a><br />
+<br />
+Dermatosyphilis, <a href='#Page_213'>213</a><br />
+<br />
+Dhobi itch, <a href='#Page_265'>265</a><br />
+<br />
+Digitalis, eruptions from, <a href='#Page_62'>62</a><br />
+<br />
+Disorders of the glands, <a href='#Page_28'>28</a>-<a href='#Page_44'>44</a><br />
+<br />
+Dissection wound, <a href='#Page_73'>73</a><br />
+<br />
+Distribution and configuration, <a href='#Page_24'>24</a>-<a href='#Page_26'>26</a><br />
+<br />
+Drug eruptions (dermatitis medicamentosa), <a href='#Page_60'>60</a><br />
+<br />
+Duhring's disease, <a href='#Page_83'>83</a><br />
+<br />
+Dysidrosis, <a href='#Page_76'>76</a><br />
+<br />
+<br />
+Ecthyma, <a href='#Page_138'>138</a>, <a href='#Page_139'>139</a><br />
+<br />
+Eczema, <a href='#Page_100'>100</a>-<a href='#Page_119'>119</a><br />
+<span style='margin-left: 1em;'>erythematosum, <a href='#Page_102'>102</a></span><br />
+<span style='margin-left: 1em;'>fissum, <a href='#Page_106'>106</a></span><br />
+<span style='margin-left: 1em;'>impetiginosum, <a href='#Page_104'>104</a></span><br />
+<span style='margin-left: 1em;'>madidans, <a href='#Page_105'>105</a></span><br />
+<span style='margin-left: 1em;'>marginatum, <a href='#Page_253'>253</a></span><br />
+<span style='margin-left: 1em;'>papulosum, <a href='#Page_103'>103</a></span><br />
+<span style='margin-left: 1em;'>pustulosum, <a href='#Page_104'>104</a></span><br />
+<span style='margin-left: 1em;'>rimosum, <a href='#Page_106'>106</a></span><br />
+<span style='margin-left: 1em;'>rubrum, <a href='#Page_105'>105</a></span><br />
+<span style='margin-left: 1em;'>sclerosum, <a href='#Page_106'>106</a></span><br />
+<span style='margin-left: 1em;'>seborrhoicum, <a href='#Page_33'>33</a>, <a href='#Page_34'>34</a>, <a href='#Page_91'>91</a>, <a href='#Page_95'>95</a>, <a href='#Page_109'>109</a></span><br />
+<span style='margin-left: 1em;'>squamosum, <a href='#Page_104'>104</a></span><br />
+<span style='margin-left: 1em;'>verrucosum, <a href='#Page_106'>106</a></span><br />
+<span style='margin-left: 1em;'>vesiculosum, <a href='#Page_104'>104</a></span><br />
+<br />
+Electrolysis in removal of hair, <a href='#Page_169'>169</a><br />
+<br />
+Elephant leg, <a href='#Page_174'>174</a><br />
+<br />
+Elephantiasis, <a href='#Page_174'>174</a>-<a href='#Page_176'>176</a><br />
+<span style='margin-left: 1em;'>Arabum, <a href='#Page_174'>174</a></span><br />
+<span style='margin-left: 1em;'>Gr&aelig;corum, <a href='#Page_231'>231</a></span><br />
+<br />
+Epidermis, <a href='#Page_18'>18</a><br />
+<br />
+Epidermolysis bullosa, <a href='#Page_80'>80</a><br />
+<br />
+Epilating forceps, <a href='#Page_249'>249</a><br />
+<br />
+Epithelial cancer, <a href='#Page_236'>236</a><br />
+<br />
+Epithelioma, <a href='#Page_236'>236</a>-<a href='#Page_240'>240</a><br />
+<span style='margin-left: 1em;'>benign cystic, <a href='#Page_198'>198</a></span><br />
+<span style='margin-left: 1em;'>molluscum, <a href='#Page_153'>153</a></span><br />
+<br />
+Equinia, <a href='#Page_74'>74</a><br />
+<br />
+Erasion, <a href='#Page_208'>208</a><br />
+<br />
+Eruptions, feigned (artificial), <a href='#Page_64'>64</a><br />
+<span style='margin-left: 1em;'>medicinal (dermatitis medicamentosa), <a href='#Page_60'>60</a></span><br />
+<br />
+Erysipelas, <a href='#Page_66'>66</a>, <a href='#Page_67'>67</a><br />
+<span style='margin-left: 1em;'>ambulans, <a href='#Page_67'>67</a></span><br />
+<span style='margin-left: 1em;'>migrans, <a href='#Page_67'>67</a></span><br />
+<br />
+Erysipeloid, <a href='#Page_67'>67</a><br />
+<br />
+Erythema, <a href='#Page_44'>44</a><br />
+<span style='margin-left: 1em;'>annulare, <a href='#Page_48'>48</a></span><br />
+<span style='margin-left: 1em;'>bullosum, <a href='#Page_48'>48</a></span><br />
+<span style='margin-left: 1em;'>caloricum, <a href='#Page_44'>44</a></span><br />
+<span style='margin-left: 1em;'>desquamative scarlatiniform, <a href='#Page_96'>96</a></span><br />
+<span style='margin-left: 1em;'>gangrenosum, <a href='#Page_65'>65</a></span><br />
+<span style='margin-left: 1em;'>gyratum, <a href='#Page_48'>48</a></span><br />
+<span style='margin-left: 1em;'>induratum, <a href='#Page_51'>51</a></span><br />
+<span style='margin-left: 2em;'>scrofulosorum, <a href='#Page_51'>51</a></span><br />
+<span style='margin-left: 1em;'>intertrigo, <a href='#Page_45'>45</a>, <a href='#Page_46'>46</a></span><br />
+<span style='margin-left: 1em;'>iris, <a href='#Page_48'>48</a></span><br />
+<span style='margin-left: 1em;'>marginatum, <a href='#Page_48'>48</a></span><br />
+<span style='margin-left: 1em;'>multiforme, <a href='#Page_46'>46</a></span><br />
+<span style='margin-left: 1em;'>nodosum, <a href='#Page_50'>50</a>, <a href='#Page_51'>51</a></span><br />
+<span style='margin-left: 1em;'>recurrent exfoliative, <a href='#Page_96'>96</a></span><br />
+<span style='margin-left: 1em;'>simplex, <a href='#Page_44'>44</a></span><br />
+<span style='margin-left: 1em;'>solare, <a href='#Page_44'>44</a></span><br />
+<span style='margin-left: 1em;'>traumaticum, <a href='#Page_44'>44</a></span><br />
+<span style='margin-left: 1em;'>venenatum, <a href='#Page_44'>44</a></span><br />
+<span style='margin-left: 1em;'>vesiculosum, <a href='#Page_48'>48</a></span><br />
+<br />
+Erythrasma, <a href='#Page_265'>265</a><br />
+<br />
+Excessive sweating (hyperidrosis), <a href='#Page_28'>28</a><br />
+<br />
+Excoriationes, <a href='#Page_24'>24</a><br />
+<br />
+Excoriations, <a href='#Page_24'>24</a><br />
+<br />
+<br />
+Farcy, <a href='#Page_74'>74</a><br />
+<br />
+Favus, <a href='#Page_247'>247</a><br />
+<span style='margin-left: 1em;'>of general surface, <a href='#Page_248'>248</a></span><br />
+<span style='margin-left: 1em;'>of nails, <a href='#Page_249'>249</a></span><br />
+<span style='margin-left: 1em;'>of scalp, <a href='#Page_247'>247</a></span><br />
+<br />
+Feigned eruptions, <a href='#Page_64'>64</a><br />
+<br />
+Fever blisters, <a href='#Page_78'>78</a><br />
+<br />
+Fibroma, <a href='#Page_192'>192</a>-<a href='#Page_194'>194</a><br />
+<span style='margin-left: 1em;'>molluscum, <a href='#Page_192'>192</a></span><br />
+<br />
+Fibromyoma, <a href='#Page_196'>196</a><br />
+<br />
+Filaria, <a href='#Page_175'>175</a><br />
+<span style='margin-left: 1em;'>medinensis, <a href='#Page_277'>277</a></span><br />
+<br />
+Fish-skin disease, <a href='#Page_165'>165</a><br />
+<br />
+Fissures, <a href='#Page_24'>24</a><br />
+<br />
+Flea, common, <a href='#Page_279'>279</a><br />
+<span style='margin-left: 1em;'>sand, <a href='#Page_278'>278</a></span><br />
+<br />
+Flesh worms, <a href='#Page_38'>38</a>-<a href='#Page_41'>41</a><br />
+<br />
+Folliclis, <a href='#Page_130'>130</a><br />
+<br />
+Folliculitis barb&aelig;, <a href='#Page_130'>130</a><br />
+<span style='margin-left: 1em;'>decalvans, <a href='#Page_131'>131</a></span><br />
+<span style='margin-left: 1em;'>pustular, conglomerate, <a href='#Page_252'>252</a></span><br />
+<br />
+Forceps, epilating, <a href='#Page_249'>249</a><br />
+<br />
+Fragilitas crinium, <a href='#Page_187'>187</a><br />
+<br />
+Framb&oelig;sia, <a href='#Page_73'>73</a><br />
+<br />
+Freckle, <a href='#Page_148'>148</a><br />
+<br />
+Frost-bite, <a href='#Page_58'>58</a><br />
+<br />
+Fungous foot of India, <a href='#Page_212'>212</a><br />
+<br />
+Furuncle, <a href='#Page_68'>68</a><br />
+<br />
+Furunculosis, <a href='#Page_69'>69</a><br />
+<br />
+Furunculus, <a href='#Page_68'>68</a>-<a href='#Page_70'>70</a><br />
+<br />
+<br />
+Gad-fly, <a href='#Page_278'>278</a><br />
+<br />
+Galvano-cautery, <a href='#Page_208'>208</a><br />
+<span style='margin-left: 1em;'>instruments, <a href='#Page_206'>206</a></span><br />
+<br />
+Gangrene of the skin (dermatitis gangr&aelig;nosa), <a href='#Page_65'>65</a><br />
+<span style='margin-left: 1em;'>spontaneous, <a href='#Page_65'>65</a></span><br />
+<span style='margin-left: 1em;'>symmetric, <a href='#Page_66'>66</a></span><br />
+<br />
+Gelatin dressing, <a href='#Page_116'>116</a><br />
+<br />
+Giant urticaria, <a href='#Page_54'>54</a><br />
+<br />
+Glanders, <a href='#Page_74'>74</a><br />
+<br />
+Glands, sebaceous, <a href='#Page_33'>33</a><br />
+<span style='margin-left: 1em;'>sweat, <a href='#Page_28'>28</a></span><br />
+<br />
+Glossy skin, <a href='#Page_189'>189</a><br />
+<br />
+Gnat, <a href='#Page_279'>279</a><br />
+<br />
+Goose-flesh, <a href='#Page_152'>152</a><br />
+<br />
+Granuloma fungoides, <a href='#Page_242'>242</a><br />
+<span style='margin-left: 1em;'>necroticum, <a href='#Page_129'>129</a></span><br />
+<br />
+Grayness of the hair, <a href='#Page_180'>180</a><br />
+<br />
+Grutum, <a href='#Page_42'>42</a><br />
+<br />
+Guinea-worm, <a href='#Page_277'>277</a><br />
+<br />
+Gumma, <a href='#Page_225'>225</a><br />
+<br />
+Gun-powder marks, <a href='#Page_151'>151</a><br />
+<br />
+Gutta-percha plaster, <a href='#Page_117'>117</a><br />
+<br />
+<br />
+Hair, <a href='#Page_21'>21</a><br />
+<span style='margin-left: 1em;'>atrophy of, <a href='#Page_187'>187</a></span><br />
+<span style='margin-left: 1em;'>graying of, <a href='#Page_180'>180</a></span><br />
+<span style='margin-left: 1em;'>hypertrophy of, <a href='#Page_168'>168</a></span><br />
+<span style='margin-left: 1em;'>superfluous, <a href='#Page_168'>168</a></span><br />
+<br />
+Hair-follicle, <a href='#Page_21'>21</a><br />
+<br />
+Hairy people, <a href='#Page_168'>168</a><br />
+<br />
+Harvest mite, <a href='#Page_277'>277</a><br />
+<br />
+Heat rash, <a href='#Page_74'>74</a><br />
+<br />
+Hemorrhages, <a href='#Page_144'>144</a>-<a href='#Page_146'>146</a><br />
+<br />
+Henoch's purpura, <a href='#Page_145'>145</a>, <a href='#Page_146'>146</a><br />
+<br />
+Hereditary infantile syphilis, <a href='#Page_228'>228</a><br />
+<span style='margin-left: 1em;'>cutaneous manifestations of, <a href='#Page_221'>221</a></span><br />
+<br />
+Herpes, <a href='#Page_78'>78</a><br />
+<span style='margin-left: 1em;'>facialis, <a href='#Page_78'>78</a></span><br />
+<span style='margin-left: 1em;'>gestationis, <a href='#Page_83'>83</a></span><br />
+<span style='margin-left: 1em;'>iris, <a href='#Page_48'>48</a></span><br />
+<span style='margin-left: 1em;'>labialis, <a href='#Page_78'>78</a></span><br />
+<span style='margin-left: 1em;'>pr&aelig;putialis, <a href='#Page_79'>79</a></span><br />
+<span style='margin-left: 1em;'>progenitalis, <a href='#Page_78'>78</a></span><br />
+<span style='margin-left: 1em;'>simplex, <a href='#Page_78'>78</a>-<a href='#Page_80'>80</a></span><br />
+<span style='margin-left: 1em;'>zoster, <a href='#Page_81'>81</a>-<a href='#Page_83'>83</a></span><br />
+<br />
+Hirsuties, <a href='#Page_168'>168</a><br />
+<br />
+Hives, <a href='#Page_52'>52</a><br />
+<br />
+Homines pilosi, <a href='#Page_168'>168</a><br />
+<br />
+Horn, cutaneous, <a href='#Page_158'>158</a><br />
+<br />
+Hydradenitis suppurativa, <a href='#Page_130'>130</a><br />
+<br />
+Hydroa &aelig;stivale, <a href='#Page_80'>80</a><br />
+<span style='margin-left: 1em;'>herpetiforme, <a href='#Page_83'>83</a></span><br />
+<span style='margin-left: 1em;'>puerorum, <a href='#Page_80'>80</a></span><br />
+<span style='margin-left: 1em;'>vacciniforme, <a href='#Page_80'>80</a></span><br />
+<br />
+Hydrocystoma, <a href='#Page_31'>31</a><br />
+<br />
+Hyperesthesia, <a href='#Page_244'>244</a><br />
+<br />
+Hyperidrosis, <a href='#Page_28'>28</a>-<a href='#Page_30'>30</a><br />
+<br />
+Hypertrichosis, <a href='#Page_168'>168</a>-<a href='#Page_170'>170</a><br />
+<br />
+Hypertrophic scar, <a href='#Page_192'>192</a><br />
+<br />
+Hypertrophies, <a href='#Page_148'>148</a>-<a href='#Page_177'>177</a><br />
+<br />
+Hypertrophy of the hair, <a href='#Page_168'>168</a><br />
+<span style='margin-left: 1em;'>of the nail, <a href='#Page_167'>167</a></span><br />
+<br />
+<br />
+Ichthyosis, <a href='#Page_165'>165</a>-<a href='#Page_167'>167</a><br />
+<span style='margin-left: 1em;'>congenita, <a href='#Page_165'>165</a></span><br />
+<span style='margin-left: 1em;'>follicularis, <a href='#Page_153'>153</a></span><br />
+<span style='margin-left: 1em;'>hystrix, <a href='#Page_165'>165</a></span><br />
+<span style='margin-left: 1em;'>sebacea, <a href='#Page_33'>33</a></span><br />
+<span style='margin-left: 2em;'>cornea, <a href='#Page_153'>153</a></span><br />
+<span style='margin-left: 1em;'>simplex, <a href='#Page_165'>165</a></span><br />
+<br />
+Impetigo contagiosa, <a href='#Page_136'>136</a>, <a href='#Page_138'>138</a><br />
+<span style='margin-left: 1em;'>herpetiformis, <a href='#Page_138'>138</a></span><br />
+<span style='margin-left: 1em;'>simplex, <a href='#Page_137'>137</a></span><br />
+<br />
+Infantile syphilis, hereditary, <a href='#Page_228'>228</a><br />
+<br />
+Inflammations, <a href='#Page_44'>44</a>-<a href='#Page_143'>143</a><br />
+<br />
+Inflammatory fungoid neoplasm, <a href='#Page_242'>242</a><br />
+<br />
+Iodides, eruptions from, <a href='#Page_62'>62</a><br />
+<br />
+Iodoform dermatitis, <a href='#Page_86'>86</a><br />
+<br />
+Itch, <a href='#Page_267'>267</a><br />
+<span style='margin-left: 1em;'>barbers', <a href='#Page_255'>255</a></span><br />
+<span style='margin-left: 1em;'>dhobie, <a href='#Page_265'>265</a></span><br />
+<span style='margin-left: 1em;'>mite, <a href='#Page_269'>269</a></span><br />
+<br />
+Ivy poisoning, <a href='#Page_86'>86</a><br />
+<br />
+Ixodes, <a href='#Page_277'>277</a><br />
+<br />
+<br />
+Jigger, <a href='#Page_278'>278</a><br />
+<br />
+<br />
+Keloid, <a href='#Page_172'>172</a>, <a href='#Page_192'>192</a><br />
+<span style='margin-left: 1em;'>cicatricial, <a href='#Page_191'>191</a></span><br />
+<span style='margin-left: 1em;'>false, <a href='#Page_191'>191</a></span><br />
+<span style='margin-left: 1em;'>of Addison, <a href='#Page_172'>172</a></span><br />
+<span style='margin-left: 1em;'>of Alibert, <a href='#Page_191'>191</a></span><br />
+<span style='margin-left: 1em;'>spontaneous, <a href='#Page_191'>191</a></span><br />
+<span style='margin-left: 1em;'>true, <a href='#Page_191'>191</a></span><br />
+<br />
+Keratodermia, symmetric, <a href='#Page_155'>155</a><br />
+<br />
+Keratoma, <a href='#Page_155'>155</a><br />
+<br />
+Keratosis follicularis, <a href='#Page_153'>153</a><br />
+<span style='margin-left: 1em;'>palmaris et plantaris, <a href='#Page_155'>155</a></span><br />
+<span style='margin-left: 1em;'>pigmentosa, <a href='#Page_160'>160</a></span><br />
+<span style='margin-left: 1em;'>pilaris, <a href='#Page_151'>151</a>, <a href='#Page_152'>152</a></span><br />
+<span style='margin-left: 1em;'>senilis, <a href='#Page_236'>236</a></span><br />
+<br />
+Kerion, <a href='#Page_255'>255</a><br />
+<br />
+<br />
+Land scurvy, <a href='#Page_145'>145</a><br />
+<br />
+Larva nigrans, <a href='#Page_278'>278</a><br />
+<br />
+Lentigo, <a href='#Page_148'>148</a><br />
+<br />
+Leontiasis, <a href='#Page_233'>233</a><br />
+<br />
+Lepra, <a href='#Page_231'>231</a>-<a href='#Page_235'>235</a><br />
+<br />
+Leprosy, <a href='#Page_231'>231</a><br />
+<span style='margin-left: 1em;'>an&aelig;sthetic, <a href='#Page_233'>233</a></span><br />
+<span style='margin-left: 1em;'>Lombardian, <a href='#Page_235'>235</a></span><br />
+<span style='margin-left: 1em;'>tubercular, <a href='#Page_232'>232</a></span><br />
+<br />
+Leptus, <a href='#Page_277'>277</a><br />
+<br />
+Lesions, <a href='#Page_22'>22</a><br />
+<span style='margin-left: 1em;'>configuration of, <a href='#Page_24'>24</a></span><br />
+<span style='margin-left: 1em;'>consecutive, <a href='#Page_23'>23</a></span><br />
+<span style='margin-left: 1em;'>distribution of, <a href='#Page_24'>24</a></span><br />
+<span style='margin-left: 1em;'>elementary, <a href='#Page_22'>22</a></span><br />
+<span style='margin-left: 1em;'>primary, <a href='#Page_22'>22</a></span><br />
+<span style='margin-left: 1em;'>secondary, <a href='#Page_23'>23</a></span><br />
+<br />
+Leucoderma, <a href='#Page_178'>178</a><br />
+<br />
+Leucopathia, <a href='#Page_178'>178</a><br />
+<br />
+Lichen moniliformis, <a href='#Page_98'>98</a><br />
+<span style='margin-left: 1em;'>pilaris, <a href='#Page_151'>151</a></span><br />
+<span style='margin-left: 1em;'>planus, <a href='#Page_98'>98</a></span><br />
+<span style='margin-left: 2em;'>hypertrophicus, <a href='#Page_98'>98</a></span><br />
+<span style='margin-left: 1em;'>ruber, <a href='#Page_99'>99</a></span><br />
+<span style='margin-left: 2em;'>acuminatus, <a href='#Page_99'>99</a></span><br />
+<span style='margin-left: 1em;'>scrofulosus, <a href='#Page_100'>100</a></span><br />
+<span style='margin-left: 1em;'>tropicus, <a href='#Page_74'>74</a></span><br />
+<span style='margin-left: 1em;'>urticatus, <a href='#Page_53'>53</a></span><br />
+<br />
+Lin&aelig; albicantes, <a href='#Page_190'>190</a><br />
+<br />
+Linear n&aelig;vus, <a href='#Page_163'>163</a><br />
+<span style='margin-left: 1em;'>scarification, <a href='#Page_208'>208</a></span><br />
+<br />
+Liomyoma cutis, <a href='#Page_196'>196</a><br />
+<br />
+Liquor carbonic detergens, <a href='#Page_113'>113</a><br />
+<span style='margin-left: 1em;'>picis alkalinus, <a href='#Page_116'>116</a></span><br />
+<br />
+Lombardian leprosy, <a href='#Page_235'>235</a><br />
+<br />
+Louse, body (pediculus corporis), <a href='#Page_274'>274</a><br />
+<span style='margin-left: 1em;'>clothes (pediculus corporis), <a href='#Page_274'>274</a></span><br />
+<span style='margin-left: 1em;'>crab, <a href='#Page_275'>275</a></span><br />
+<span style='margin-left: 1em;'>head (pediculus capitis), <a href='#Page_272'>272</a></span><br />
+<br />
+Lousiness, <a href='#Page_271'>271</a><br />
+<br />
+Lupoid acne, <a href='#Page_129'>129</a><br />
+<span style='margin-left: 1em;'>sycosis, <a href='#Page_131'>131</a></span><br />
+<br />
+Lupus, <a href='#Page_203'>203</a><br />
+<span style='margin-left: 1em;'>erythematodes, <a href='#Page_199'>199</a></span><br />
+<span style='margin-left: 1em;'>erythematosus, <a href='#Page_199'>199</a>-<a href='#Page_203'>203</a></span><br />
+<span style='margin-left: 1em;'>exedens, <a href='#Page_203'>203</a></span><br />
+<span style='margin-left: 1em;'>exfoliativus, <a href='#Page_203'>203</a></span><br />
+<span style='margin-left: 1em;'>exulcerans, <a href='#Page_203'>203</a></span><br />
+<span style='margin-left: 1em;'>hypertrophicus, <a href='#Page_204'>204</a></span><br />
+<span style='margin-left: 1em;'>sebaceous, <a href='#Page_199'>199</a></span><br />
+<span style='margin-left: 1em;'>ulcerations, <a href='#Page_203'>203</a></span><br />
+<span style='margin-left: 1em;'>verrucosus, <a href='#Page_204'>204</a></span><br />
+<span style='margin-left: 1em;'>vorax, <a href='#Page_203'>203</a></span><br />
+<span style='margin-left: 1em;'>vulgaris, <a href='#Page_203'>203</a>-<a href='#Page_208'>208</a></span><br />
+<br />
+Lymphangiectodes, <a href='#Page_198'>198</a><br />
+<br />
+Lymphangioma, <a href='#Page_198'>198</a><br />
+<span style='margin-left: 1em;'>tuberosum multiplex, <a href='#Page_198'>198</a></span><br />
+<br />
+Lymphangiomyoma, <a href='#Page_196'>196</a><br />
+<br />
+<br />
+Macul&aelig;, <a href='#Page_22'>22</a><br />
+<span style='margin-left: 1em;'>et stri&aelig; atrophic&aelig;, <a href='#Page_190'>190</a></span><br />
+<br />
+Macules, <a href='#Page_22'>22</a><br />
+<br />
+Madura foot, <a href='#Page_212'>212</a><br />
+<br />
+Malignant papillary dermatitis, <a href='#Page_240'>240</a><br />
+<span style='margin-left: 1em;'>pustule, <a href='#Page_72'>72</a></span><br />
+<br />
+Medicinal eruptions (dermatitis medicamentosa), <a href='#Page_60'>60</a><br />
+<br />
+Melanoderma, <a href='#Page_149'>149</a><br />
+<br />
+Melanosarcoma, <a href='#Page_242'>242</a><br />
+<br />
+Melasma, <a href='#Page_149'>149</a><br />
+<br />
+Mercury, eruptions from, <a href='#Page_62'>62</a><br />
+<br />
+Microsporon audouini, <a href='#Page_258'>258</a><br />
+<br />
+Microsporon furfur, <a href='#Page_262'>262</a><br />
+<span style='margin-left: 1em;'>minutissimum, <a href='#Page_265'>265</a></span><br />
+<br />
+Miliaria, <a href='#Page_74'>74</a>-<a href='#Page_76'>76</a><br />
+<span style='margin-left: 1em;'>alba, <a href='#Page_75'>75</a></span><br />
+<span style='margin-left: 1em;'>crystallina, <a href='#Page_30'>30</a></span><br />
+<span style='margin-left: 1em;'>rubra, <a href='#Page_74'>74</a></span><br />
+<br />
+Milium, <a href='#Page_42'>42</a>, <a href='#Page_43'>43</a><br />
+<span style='margin-left: 1em;'>needle, <a href='#Page_42'>42</a></span><br />
+<br />
+Milk crust, <a href='#Page_104'>104</a><br />
+<br />
+Mite, harvest, <a href='#Page_277'>277</a><br />
+<span style='margin-left: 1em;'>itch, <a href='#Page_269'>269</a></span><br />
+<br />
+Moist papule, <a href='#Page_216'>216</a>, <a href='#Page_217'>217</a><br />
+<br />
+Mole, <a href='#Page_162'>162</a><br />
+<br />
+Molluscum contagiosum, <a href='#Page_153'>153</a><br />
+<span style='margin-left: 1em;'>epitheliale, <a href='#Page_153'>153</a>-<a href='#Page_155'>155</a></span><br />
+<span style='margin-left: 1em;'>fibrosum, <a href='#Page_192'>192</a></span><br />
+<span style='margin-left: 1em;'>sebaceum, <a href='#Page_153'>153</a></span><br />
+<br />
+Morphia, eruptions from, <a href='#Page_63'>63</a><br />
+<br />
+Morph&oelig;a, <a href='#Page_172'>172</a><br />
+<br />
+Mosquito, <a href='#Page_279'>279</a><br />
+<br />
+Mucous patch, <a href='#Page_217'>217</a><br />
+<br />
+Mycetoma, <a href='#Page_212'>212</a><br />
+<br />
+Mycosis fungoides, <a href='#Page_242'>242</a><br />
+<br />
+Myoma, <a href='#Page_196'>196</a><br />
+<span style='margin-left: 1em;'>cutis, <a href='#Page_196'>196</a></span><br />
+<span style='margin-left: 1em;'>telangiectodes, <a href='#Page_196'>196</a></span><br />
+<br />
+<br />
+N&aelig;vus araneus, <a href='#Page_198'>198</a><br />
+<span style='margin-left: 1em;'>capillary, <a href='#Page_196'>196</a></span><br />
+<span style='margin-left: 1em;'>flammeus, <a href='#Page_196'>196</a></span><br />
+<span style='margin-left: 1em;'>linear, <a href='#Page_163'>163</a></span><br />
+<span style='margin-left: 1em;'>lipomatodes, <a href='#Page_164'>164</a></span><br />
+<span style='margin-left: 1em;'>pigmentosus, <a href='#Page_162'>162</a></span><br />
+<span style='margin-left: 1em;'>pilosus, <a href='#Page_163'>163</a>, <a href='#Page_168'>168</a></span><br />
+<span style='margin-left: 1em;'>sanguineus, <a href='#Page_196'>196</a></span><br />
+<span style='margin-left: 1em;'>simplex, <a href='#Page_196'>196</a></span><br />
+<span style='margin-left: 1em;'>spider, <a href='#Page_198'>198</a></span><br />
+<span style='margin-left: 1em;'>spilus, <a href='#Page_163'>163</a></span><br />
+<span style='margin-left: 1em;'>tuberosus, <a href='#Page_197'>197</a></span><br />
+<span style='margin-left: 1em;'>vasculosus, <a href='#Page_196'>196</a></span><br />
+<span style='margin-left: 1em;'>venous, <a href='#Page_197'>197</a></span><br />
+<span style='margin-left: 1em;'>verrucosus, <a href='#Page_163'>163</a></span><br />
+<br />
+Nail, atrophy of, <a href='#Page_188'>188</a><br />
+<span style='margin-left: 1em;'>hypertrophy of, <a href='#Page_167'>167</a></span><br />
+<br />
+Necrotic granuloma, <a href='#Page_129'>129</a><br />
+<br />
+Neoplasm, inflammatory fungoid, <a href='#Page_242'>242</a><br />
+<br />
+Neoplasmata (new growths), <a href='#Page_191'>191</a>, <a href='#Page_241'>241</a><br />
+<br />
+Nettlerash, <a href='#Page_52'>52</a><br />
+<br />
+Neuralgia of the skin, <a href='#Page_244'>244</a><br />
+<br />
+Neuroma, <a href='#Page_194'>194</a><br />
+<br />
+Neuroses, <a href='#Page_244'>244</a>-<a href='#Page_247'>247</a><br />
+<br />
+New growths, <a href='#Page_191'>191</a>-<a href='#Page_243'>243</a><br />
+<br />
+Nits, <a href='#Page_273'>273</a><br />
+<br />
+<br />
+Objective symptoms, <a href='#Page_22'>22</a><br />
+<br />
+&oelig;dema, acute circumscribed, <a href='#Page_54'>54</a><br />
+<span style='margin-left: 1em;'>neonatorum, <a href='#Page_170'>170</a></span><br />
+<br />
+&oelig;strus, <a href='#Page_278'>278</a><br />
+<br />
+Ointment bases, <a href='#Page_27'>27</a><br />
+<br />
+Onychatrophia, <a href='#Page_188'>188</a><br />
+<br />
+Onychauxis, <a href='#Page_167'>167</a>, <a href='#Page_168'>168</a><br />
+<br />
+Onychomycosis, <a href='#Page_188'>188</a><br />
+<span style='margin-left: 1em;'>favosa, <a href='#Page_249'>249</a></span><br />
+<br />
+Opium, eruptions from, <a href='#Page_63'>63</a><br />
+<br />
+Oroya fever, <a href='#Page_73'>73</a><br />
+<br />
+Osmidrosis, <a href='#Page_32'>32</a><br />
+<br />
+Ova of pediculi, <a href='#Page_273'>273</a><br />
+<br />
+<br />
+Pachydermia, <a href='#Page_174'>174</a><br />
+<br />
+Paget's disease of the nipple, <a href='#Page_240'>240</a><br />
+<br />
+Papill&aelig;, nervous and vascular, <a href='#Page_20'>20</a><br />
+<br />
+Papul&aelig;, <a href='#Page_23'>23</a><br />
+<br />
+Papule, moist, <a href='#Page_216'>216</a>, <a href='#Page_217'>217</a><br />
+<br />
+Papules, <a href='#Page_23'>23</a><br />
+<br />
+Parasitic affections, <a href='#Page_247'>247</a>-<a href='#Page_279'>279</a><br />
+<span style='margin-left: 1em;'>sycosis, <a href='#Page_255'>255</a></span><br />
+<br />
+Parasiticides, <a href='#Page_250'>250</a>, <a href='#Page_259'>259</a><br />
+<br />
+Parchment skin, <a href='#Page_190'>190</a><br />
+<br />
+Paronychia, <a href='#Page_167'>167</a><br />
+<br />
+Patch, mucous, <a href='#Page_217'>217</a><br />
+<br />
+Pediculosis, <a href='#Page_271'>271</a><br />
+<span style='margin-left: 1em;'>capillitii, <a href='#Page_272'>272</a></span><br />
+<span style='margin-left: 1em;'>capitis, <a href='#Page_272'>272</a>, <a href='#Page_273'>273</a></span><br />
+<span style='margin-left: 1em;'>corporis, <a href='#Page_274'>274</a>, <a href='#Page_275'>275</a></span><br />
+<span style='margin-left: 1em;'>pubis, <a href='#Page_275'>275</a>, <a href='#Page_276'>276</a></span><br />
+<br />
+Pediculus capitis, <a href='#Page_272'>272</a><br />
+<span style='margin-left: 1em;'>corporis, <a href='#Page_274'>274</a></span><br />
+<span style='margin-left: 1em;'>pubis, <a href='#Page_275'>275</a></span><br />
+<span style='margin-left: 1em;'>vestimenti, <a href='#Page_274'>274</a></span><br />
+<br />
+Peliosis rheumatica, <a href='#Page_144'>144</a><br />
+<br />
+Pellagra, <a href='#Page_235'>235</a><br />
+<br />
+Pemphigus, <a href='#Page_140'>140</a>-<a href='#Page_144'>144</a><br />
+<span style='margin-left: 1em;'>foliaceus, <a href='#Page_141'>141</a></span><br />
+<span style='margin-left: 1em;'>neonatorum, <a href='#Page_140'>140</a></span><br />
+<span style='margin-left: 1em;'>pruriginosus, <a href='#Page_83'>83</a></span><br />
+<span style='margin-left: 1em;'>vegetans, <a href='#Page_142'>142</a></span><br />
+<span style='margin-left: 1em;'>vulgaris, <a href='#Page_140'>140</a></span><br />
+<br />
+Perforating ulcer of the foot, <a href='#Page_213'>213</a><br />
+<br />
+Peruvian warts, <a href='#Page_73'>73</a><br />
+<br />
+Phlegmona diffusa, <a href='#Page_68'>68</a><br />
+<br />
+Phosphorescent sweat, <a href='#Page_33'>33</a><br />
+<br />
+Phosphoridrosis, <a href='#Page_33'>33</a><br />
+<br />
+Phtheiriasis, <a href='#Page_271'>271</a><br />
+<br />
+Plan, <a href='#Page_73'>73</a><br />
+<br />
+Pityriasis capitis, <a href='#Page_34'>34</a><br />
+<span style='margin-left: 1em;'>maculata et circinata, <a href='#Page_95'>95</a></span><br />
+<span style='margin-left: 1em;'>pilaris, <a href='#Page_151'>151</a></span><br />
+<span style='margin-left: 1em;'>rosea, <a href='#Page_95'>95</a>, <a href='#Page_96'>96</a></span><br />
+<span style='margin-left: 1em;'>rubra, <a href='#Page_97'>97</a></span><br />
+<br />
+Pityriasis rubra pilaris, <a href='#Page_99'>99</a><br />
+<span style='margin-left: 1em;'>versicolor, <a href='#Page_261'>261</a></span><br />
+<br />
+Plasment, <a href='#Page_117'>117</a><br />
+<br />
+Plaster-mull, <a href='#Page_117'>117</a><br />
+<br />
+Podelcoma, <a href='#Page_212'>212</a><br />
+<br />
+Poison dogwood, dermatitis from, <a href='#Page_86'>86</a><br />
+<span style='margin-left: 1em;'>ivy, dermatitis from, <a href='#Page_86'>86</a></span><br />
+<span style='margin-left: 1em;'>sumach, dermatitis from, <a href='#Page_86'>86</a></span><br />
+<span style='margin-left: 1em;'>vine, dermatitis from, <a href='#Page_86'>86</a></span><br />
+<br />
+Pomphi, <a href='#Page_23'>23</a><br />
+<br />
+Pompholyx, <a href='#Page_76'>76</a>-<a href='#Page_78'>78</a><br />
+<br />
+Port-wine mark, <a href='#Page_197'>197</a><br />
+<br />
+Post-mortem pustule, <a href='#Page_73'>73</a><br />
+<br />
+Prickly heat, <a href='#Page_74'>74</a><br />
+<br />
+Primary lesions, <a href='#Page_22'>22</a>, <a href='#Page_23'>23</a><br />
+<br />
+Prurigo, <a href='#Page_118'>118</a>, <a href='#Page_119'>119</a><br />
+<br />
+Pruritus, <a href='#Page_244'>244</a>-<a href='#Page_247'>247</a><br />
+<span style='margin-left: 1em;'>ani, <a href='#Page_245'>245</a></span><br />
+<span style='margin-left: 1em;'>hiemalis, <a href='#Page_245'>245</a></span><br />
+<span style='margin-left: 1em;'>scroti, <a href='#Page_245'>245</a></span><br />
+<span style='margin-left: 1em;'>senilis, <a href='#Page_245'>245</a></span><br />
+<span style='margin-left: 1em;'>vulv&aelig;, <a href='#Page_245'>245</a></span><br />
+<br />
+Pseudochromidrosis, <a href='#Page_33'>33</a><br />
+<br />
+Psoriasis, <a href='#Page_86'>86</a>-<a href='#Page_95'>95</a><br />
+<span style='margin-left: 1em;'>circinata, <a href='#Page_88'>88</a></span><br />
+<span style='margin-left: 1em;'>diffusa, <a href='#Page_88'>88</a></span><br />
+<span style='margin-left: 1em;'>guttata, <a href='#Page_88'>88</a></span><br />
+<span style='margin-left: 1em;'>gyrata, <a href='#Page_88'>88</a></span><br />
+<span style='margin-left: 1em;'>inveterata, <a href='#Page_88'>88</a></span><br />
+<span style='margin-left: 1em;'>nummularis, <a href='#Page_88'>88</a></span><br />
+<span style='margin-left: 1em;'>punctata, <a href='#Page_88'>88</a></span><br />
+<span style='margin-left: 1em;'>syphilitica, <a href='#Page_218'>218</a></span><br />
+<br />
+Psorospermosis, <a href='#Page_153'>153</a>, <a href='#Page_154'>154</a>, <a href='#Page_240'>240</a><br />
+<br />
+Pulex irritans, <a href='#Page_279'>279</a><br />
+<span style='margin-left: 1em;'>penetrans, <a href='#Page_278'>278</a></span><br />
+<br />
+Punctate scarification, <a href='#Page_208'>208</a><br />
+<br />
+Purpura, <a href='#Page_144'>144</a>-<a href='#Page_146'>146</a><br />
+<span style='margin-left: 1em;'>h&aelig;morrhagica, <a href='#Page_145'>145</a></span><br />
+<span style='margin-left: 1em;'>Henoch's, <a href='#Page_145'>145</a>, <a href='#Page_146'>146</a></span><br />
+<span style='margin-left: 1em;'>rheumatica, <a href='#Page_144'>144</a></span><br />
+<span style='margin-left: 1em;'>scorbutica, <a href='#Page_146'>146</a></span><br />
+<span style='margin-left: 1em;'>simplex, <a href='#Page_144'>144</a></span><br />
+<span style='margin-left: 1em;'>urticans, <a href='#Page_144'>144</a></span><br />
+<br />
+Pustula maligna, <a href='#Page_72'>72</a><br />
+<br />
+Pustul&aelig;, <a href='#Page_23'>23</a><br />
+<br />
+Pustules, <a href='#Page_23'>23</a><br />
+<br />
+<br />
+Quinine, eruptions from, <a href='#Page_63'>63</a><br />
+<br />
+<br />
+Rapidity of cure, <a href='#Page_27'>27</a><br />
+<br />
+Raynaud's disease, <a href='#Page_66'>66</a><br />
+<br />
+Recurrent summer eruption, <a href='#Page_80'>80</a><br />
+<br />
+Red chromidrosis, <a href='#Page_33'>33</a><br />
+<br />
+Relative frequency, <a href='#Page_26'>26</a><br />
+<br />
+Rhagades, <a href='#Page_24'>24</a><br />
+<br />
+Rheumatism of the skin, <a href='#Page_244'>244</a><br />
+<br />
+Rhinophyma, <a href='#Page_127'>127</a><br />
+<br />
+Rhinoscleroma, <a href='#Page_198'>198</a>, <a href='#Page_199'>199</a><br />
+<br />
+Rhus poisoning, <a href='#Page_86'>86</a><br />
+<br />
+Ringworm, <a href='#Page_251'>251</a><br />
+<span style='margin-left: 1em;'>of bearded region, <a href='#Page_255'>255</a></span><br />
+<span style='margin-left: 1em;'>of general surface, <a href='#Page_251'>251</a></span><br />
+<span style='margin-left: 1em;'>of the nail, <a href='#Page_253'>253</a></span><br />
+<span style='margin-left: 1em;'>of the scalp, <a href='#Page_253'>253</a></span><br />
+<span style='margin-left: 1em;'>of the thighs and scrotum, <a href='#Page_252'>252</a></span><br />
+<span style='margin-left: 1em;'>Tokelau, <a href='#Page_261'>261</a></span><br />
+<br />
+Rodent ulcer, <a href='#Page_236'>236</a><br />
+<br />
+Rosacea, <a href='#Page_198'>198</a><br />
+<span style='margin-left: 1em;'>acne, <a href='#Page_126'>126</a></span><br />
+<br />
+Rubber plaster, <a href='#Page_117'>117</a><br />
+<br />
+Rupia, <a href='#Page_221'>221</a>, <a href='#Page_222'>222</a><br />
+<br />
+<br />
+Salicylic acid, eruptions from, <a href='#Page_63'>63</a><br />
+<span style='margin-left: 1em;'>paste, <a href='#Page_113'>113</a></span><br />
+<br />
+Salt rheum, <a href='#Page_100'>100</a><br />
+<br />
+Sand flea, <a href='#Page_278'>278</a><br />
+<br />
+Sarcoma, <a href='#Page_241'>241</a>, <a href='#Page_242'>242</a><br />
+<span style='margin-left: 1em;'>cutis, <a href='#Page_241'>241</a></span><br />
+<br />
+Sarcoptes scabiei, <a href='#Page_269'>269</a><br />
+<br />
+Scabies, <a href='#Page_267'>267</a>-<a href='#Page_271'>271</a><br />
+<br />
+Scales, <a href='#Page_24'>24</a><br />
+<br />
+Scarification, linear, <a href='#Page_208'>208</a><br />
+<span style='margin-left: 1em;'>punctate, <a href='#Page_208'>208</a></span><br />
+<br />
+Scarifier, multiple, <a href='#Page_202'>202</a><br />
+<span style='margin-left: 1em;'>single, <a href='#Page_202'>202</a></span><br />
+<br />
+Scars, <a href='#Page_24'>24</a><br />
+<span style='margin-left: 1em;'>hypertrophic, <a href='#Page_192'>192</a></span><br />
+<br />
+Sch&ouml;nlein's disease, <a href='#Page_145'>145</a>, <a href='#Page_146'>146</a><br />
+<br />
+Sclerema, <a href='#Page_172'>172</a><br />
+<span style='margin-left: 1em;'>neonatorum, <a href='#Page_171'>171</a></span><br />
+<span style='margin-left: 1em;'>of the newborn, <a href='#Page_171'>171</a></span><br />
+<br />
+Scleriasis, <a href='#Page_172'>172</a><br />
+<br />
+Scleroderma, <a href='#Page_172'>172</a>, <a href='#Page_173'>173</a><br />
+<span style='margin-left: 1em;'>neonatorum, <a href='#Page_171'>171</a></span><br />
+<br />
+Scorbutus, <a href='#Page_146'>146</a><br />
+<br />
+Scrofuloderma, <a href='#Page_209'>209</a><br />
+<span style='margin-left: 1em;'>pustular, small, <a href='#Page_210'>210</a></span><br />
+<br />
+Scurvy, <a href='#Page_146'>146</a><br />
+<span style='margin-left: 1em;'>land, <a href='#Page_145'>145</a></span><br />
+<span style='margin-left: 1em;'>sea, <a href='#Page_146'>146</a></span><br />
+<br />
+Sebaceous cyst, <a href='#Page_43'>43</a><br />
+<span style='margin-left: 1em;'>gland, <a href='#Page_33'>33</a></span><br />
+<span style='margin-left: 1em;'>tumor, <a href='#Page_43'>43</a></span><br />
+<br />
+Seborrh&oelig;a, <a href='#Page_33'>33</a>-<a href='#Page_38'>38</a><br />
+<span style='margin-left: 1em;'>congestiva, <a href='#Page_199'>199</a></span><br />
+<span style='margin-left: 1em;'>oleosa, <a href='#Page_34'>34</a></span><br />
+<span style='margin-left: 1em;'>sicca, <a href='#Page_34'>34</a></span><br />
+<br />
+Secondary lesions, <a href='#Page_23'>23</a>, <a href='#Page_24'>24</a><br />
+<br />
+Shingles, <a href='#Page_81'>81</a><br />
+<br />
+Skin, anatomy of, <a href='#Page_17'>17</a><br />
+<span style='margin-left: 1em;'>cancer, <a href='#Page_236'>236</a></span><br />
+<span style='margin-left: 1em;'>general idiopathic atrophy of, <a href='#Page_189'>189</a></span><br />
+<span style='margin-left: 1em;'>glossy, <a href='#Page_189'>189</a></span><br />
+<span style='margin-left: 1em;'>looseness of, <a href='#Page_176'>176</a></span><br />
+<br />
+Skin, parchment, <a href='#Page_190'>190</a><br />
+<br />
+Spider n&aelig;vus, <a href='#Page_198'>198</a><br />
+<br />
+Spiradenitis, <a href='#Page_130'>130</a><br />
+<br />
+Spontaneous gangrene, <a href='#Page_65'>65</a><br />
+<br />
+Spots, <a href='#Page_22'>22</a><br />
+<br />
+Squam&aelig;, <a href='#Page_24'>24</a><br />
+<br />
+Stains, <a href='#Page_24'>24</a><br />
+<br />
+Statistics, <a href='#Page_280'>280</a><br />
+<br />
+Steatoma, <a href='#Page_43'>43</a><br />
+<br />
+Steatorrh&oelig;a, <a href='#Page_33'>33</a><br />
+<br />
+Stramonium, eruptions from, <a href='#Page_63'>63</a><br />
+<br />
+Stri&aelig; et macul&aelig; atrophic&aelig;, <a href='#Page_190'>190</a><br />
+<br />
+Strophulus, <a href='#Page_74'>74</a><br />
+<span style='margin-left: 1em;'>albidus, <a href='#Page_42'>42</a></span><br />
+<br />
+Subjective symptoms, <a href='#Page_22'>22</a><br />
+<br />
+Sudamen, <a href='#Page_30'>30</a>, <a href='#Page_31'>31</a><br />
+<br />
+Superfluous hair, <a href='#Page_168'>168</a><br />
+<br />
+Sweat, colored (chromidrosis), <a href='#Page_32'>32</a><br />
+<span style='margin-left: 1em;'>glands, <a href='#Page_28'>28</a></span><br />
+<span style='margin-left: 2em;'>phosphorescent, <a href='#Page_33'>33</a></span><br />
+<br />
+Sweating, excessive, <a href='#Page_28'>28</a><br />
+<br />
+Sycosis, <a href='#Page_130'>130</a>-<a href='#Page_135'>135</a><br />
+<span style='margin-left: 1em;'>coccogenica, <a href='#Page_130'>130</a></span><br />
+<span style='margin-left: 1em;'>non-parasitica, <a href='#Page_130'>130</a></span><br />
+<span style='margin-left: 1em;'>parasitic, <a href='#Page_255'>255</a></span><br />
+<span style='margin-left: 1em;'>vulgaris, <a href='#Page_130'>130</a></span><br />
+<br />
+Symmetric gangrene, <a href='#Page_66'>66</a><br />
+<span style='margin-left: 1em;'>keratodermia, <a href='#Page_155'>155</a></span><br />
+<br />
+Symptomatology, <a href='#Page_22'>22</a>-<a href='#Page_26'>26</a><br />
+<br />
+Symptoms, objective, <a href='#Page_22'>22</a><br />
+<span style='margin-left: 1em;'>subjective, <a href='#Page_22'>22</a></span><br />
+<span style='margin-left: 1em;'>systemic, <a href='#Page_22'>22</a></span><br />
+<br />
+Syphilis cutanea, <a href='#Page_213'>213</a>-<a href='#Page_231'>231</a><br />
+<span style='margin-left: 2em;'>early eruptions of, <a href='#Page_213'>213</a></span><br />
+<span style='margin-left: 2em;'>late eruptions of, <a href='#Page_214'>214</a></span><br />
+<span style='margin-left: 2em;'>papillomatosa, <a href='#Page_225'>225</a></span><br />
+<span style='margin-left: 1em;'>hereditary, <a href='#Page_217'>217</a></span><br />
+<span style='margin-left: 2em;'>eruptions of, <a href='#Page_217'>217</a></span><br />
+<span style='margin-left: 1em;'>of the skin, <a href='#Page_213'>213</a>-<a href='#Page_231'>231</a></span><br />
+<br />
+Syphiloderm, <a href='#Page_213'>213</a><br />
+<span style='margin-left: 1em;'>acne-form, <a href='#Page_220'>220</a></span><br />
+<span style='margin-left: 1em;'>annular, <a href='#Page_219'>219</a></span><br />
+<span style='margin-left: 1em;'>bullous, <a href='#Page_222'>222</a>, <a href='#Page_228'>228</a></span><br />
+<span style='margin-left: 1em;'>circinate, <a href='#Page_219'>219</a></span><br />
+<span style='margin-left: 1em;'>ecthyma-form, <a href='#Page_221'>221</a></span><br />
+<span style='margin-left: 1em;'>erythematous, <a href='#Page_214'>214</a>, <a href='#Page_217'>217</a></span><br />
+<span style='margin-left: 1em;'>gummatous, <a href='#Page_225'>225</a></span><br />
+<span style='margin-left: 1em;'>impetigo-form, <a href='#Page_220'>220</a></span><br />
+<span style='margin-left: 2em;'>large acuminated-pustular, <a href='#Page_220'>220</a>, <a href='#Page_220'>220</a></span><br />
+<span style='margin-left: 2em;'>flat-pustular, <a href='#Page_221'>221</a></span><br />
+<span style='margin-left: 2em;'>papular, <a href='#Page_216'>216</a></span><br />
+<span style='margin-left: 1em;'>lenticular, <a href='#Page_216'>216</a></span><br />
+<span style='margin-left: 1em;'>macular, <a href='#Page_214'>214</a>, <a href='#Page_217'>217</a></span><br />
+<span style='margin-left: 1em;'>miliary papular, <a href='#Page_215'>215</a></span><br />
+<span style='margin-left: 2em;'>pustular, <a href='#Page_219'>219</a></span><br />
+<span style='margin-left: 1em;'>non-ulcerating tubercular, <a href='#Page_224'>224</a></span><br />
+<span style='margin-left: 1em;'>palmar, <a href='#Page_217'>217</a>, <a href='#Page_218'>218</a></span><br />
+<span style='margin-left: 1em;'>papular, <a href='#Page_215'>215</a>, <a href='#Page_217'>217</a></span><br />
+<span style='margin-left: 1em;'>papulo-squamous, <a href='#Page_218'>218</a></span><br />
+<span style='margin-left: 1em;'>plantar, <a href='#Page_218'>218</a></span><br />
+<span style='margin-left: 1em;'>pustular, <a href='#Page_219'>219</a></span><br />
+<span style='margin-left: 1em;'>serpiginous tubercular, <a href='#Page_224'>224</a></span><br />
+<span style='margin-left: 1em;'>small acuminated-pustular, <a href='#Page_219'>219</a></span><br />
+<span style='margin-left: 2em;'>flat-pustular, <a href='#Page_220'>220</a></span><br />
+<span style='margin-left: 2em;'>papular, <a href='#Page_215'>215</a></span><br />
+<span style='margin-left: 1em;'>squamous, <a href='#Page_218'>218</a></span><br />
+<span style='margin-left: 1em;'>tubercular, <a href='#Page_223'>223</a>, <a href='#Page_224'>224</a></span><br />
+<span style='margin-left: 1em;'>ulcerating tubercular, <a href='#Page_224'>224</a></span><br />
+<span style='margin-left: 1em;'>variola-form, <a href='#Page_220'>220</a></span><br />
+<span style='margin-left: 1em;'>vegetating, <a href='#Page_218'>218</a></span><br />
+<br />
+Syphiloderma, <a href='#Page_213'>213</a><br />
+<br />
+Syphiloma, <a href='#Page_225'>225</a><br />
+<br />
+<br />
+Tar acne, <a href='#Page_120'>120</a><br />
+<br />
+Tattoo-marks, removal of, <a href='#Page_151'>151</a><br />
+<br />
+Telangiectasis, <a href='#Page_127'>127</a>, <a href='#Page_197'>197</a>, <a href='#Page_198'>198</a><br />
+<br />
+Tetter, <a href='#Page_100'>100</a><br />
+<br />
+Tinea circinata, <a href='#Page_251'>251</a><br />
+<span style='margin-left: 1em;'>favosa, <a href='#Page_247'>247</a>-<a href='#Page_251'>251</a></span><br />
+<span style='margin-left: 2em;'>fungus of, <a href='#Page_249'>249</a></span><br />
+<span style='margin-left: 2em;'>unguium, <a href='#Page_249'>249</a></span><br />
+<span style='margin-left: 1em;'>imbricata, <a href='#Page_261'>261</a></span><br />
+<span style='margin-left: 1em;'>kerion, <a href='#Page_255'>255</a></span><br />
+<span style='margin-left: 1em;'>sycosis, <a href='#Page_255'>255</a></span><br />
+<span style='margin-left: 1em;'>tonsurans, <a href='#Page_253'>253</a></span><br />
+<span style='margin-left: 1em;'>trichophytina, <a href='#Page_251'>251</a>-<a href='#Page_261'>261</a></span><br />
+<span style='margin-left: 2em;'>barb&aelig;, <a href='#Page_255'>255</a></span><br />
+<span style='margin-left: 2em;'>capitis, <a href='#Page_253'>253</a></span><br />
+<span style='margin-left: 2em;'>corporis, <a href='#Page_251'>251</a></span><br />
+<span style='margin-left: 2em;'>cruris, <a href='#Page_252'>252</a></span><br />
+<span style='margin-left: 2em;'>fungus of, <a href='#Page_258'>258</a></span><br />
+<span style='margin-left: 2em;'>unguium, <a href='#Page_253'>253</a></span><br />
+<span style='margin-left: 1em;'>versicolor, <a href='#Page_262'>262</a>-<a href='#Page_265'>265</a></span><br />
+<span style='margin-left: 2em;'>fungus of, <a href='#Page_262'>262</a></span><br />
+<br />
+Tokelau ringworm, <a href='#Page_261'>261</a><br />
+<br />
+Traumaticin, <a href='#Page_94'>94</a><br />
+<br />
+Trichophyton, <a href='#Page_258'>258</a><br />
+<br />
+Trichorrhexis nodosa, <a href='#Page_187'>187</a><br />
+<br />
+Tubercles, <a href='#Page_23'>23</a><br />
+<br />
+Tubercula, <a href='#Page_23'>23</a><br />
+<br />
+Tuberculosis cutis, <a href='#Page_209'>209</a>-<a href='#Page_211'>211</a><br />
+<span style='margin-left: 1em;'>of the skin, <a href='#Page_203'>203</a></span><br />
+<br />
+Tuberculosis verrucosa cutis, <a href='#Page_209'>209</a>, <a href='#Page_210'>210</a><br />
+<br />
+Tumor, sebaceous, <a href='#Page_43'>43</a><br />
+<br />
+Tumors, <a href='#Page_23'>23</a><br />
+<br />
+Turpentine, eruptions from, <a href='#Page_63'>63</a><br />
+<br />
+Tyloma, <a href='#Page_155'>155</a><br />
+<br />
+Tylosis, <a href='#Page_155'>155</a><br />
+<br />
+<br />
+Ulcer, perforating, of foot, <a href='#Page_213'>213</a><br />
+<span style='margin-left: 1em;'>rodent, <a href='#Page_236'>236</a></span><br />
+<br />
+Ulcera, <a href='#Page_24'>24</a><br />
+<br />
+Ulerythema sycosiforme, <a href='#Page_131'>131</a><br />
+<br />
+Uridrosis, <a href='#Page_33'>33</a><br />
+<br />
+Urticaria, <a href='#Page_52'>52</a>-<a href='#Page_56'>56</a><br />
+<span style='margin-left: 1em;'>bullosa, <a href='#Page_54'>54</a></span><br />
+<span style='margin-left: 1em;'>chronic, <a href='#Page_53'>53</a></span><br />
+<span style='margin-left: 1em;'>factitia, <a href='#Page_52'>52</a></span><br />
+<span style='margin-left: 1em;'>h&aelig;morrhagica, <a href='#Page_54'>54</a></span><br />
+<span style='margin-left: 1em;'>&oelig;dematosa, <a href='#Page_54'>54</a></span><br />
+<span style='margin-left: 1em;'>papulosa, <a href='#Page_54'>54</a></span><br />
+<span style='margin-left: 1em;'>tuberosa, <a href='#Page_54'>54</a></span><br />
+<span style='margin-left: 1em;'>giant, <a href='#Page_54'>54</a></span><br />
+<span style='margin-left: 1em;'>pigmentosa, <a href='#Page_86'>86</a></span><br />
+<span style='margin-left: 1em;'>vesicular, <a href='#Page_54'>54</a></span><br />
+<br />
+<br />
+Venereal wart, <a href='#Page_161'>161</a><br />
+<br />
+Verruca, <a href='#Page_160'>160</a>-<a href='#Page_162'>162</a><br />
+<span style='margin-left: 1em;'>acuminata, <a href='#Page_161'>161</a></span><br />
+<span style='margin-left: 1em;'>digitata, <a href='#Page_160'>160</a></span><br />
+<span style='margin-left: 1em;'>filiformis, <a href='#Page_160'>160</a></span><br />
+<span style='margin-left: 1em;'>necrogenica, <a href='#Page_211'>211</a></span><br />
+<span style='margin-left: 1em;'>plana, <a href='#Page_160'>160</a></span><br />
+<span style='margin-left: 2em;'>juvenilis, <a href='#Page_160'>160</a></span><br />
+<span style='margin-left: 1em;'>senilis, <a href='#Page_160'>160</a></span><br />
+<span style='margin-left: 1em;'>vulgaris, <a href='#Page_160'>160</a></span><br />
+<br />
+Verruga peruana, <a href='#Page_73'>73</a><br />
+<br />
+Vesicles, <a href='#Page_23'>23</a><br />
+<br />
+Vesicul&aelig;, <a href='#Page_23'>23</a><br />
+<br />
+Vitiligo, <a href='#Page_178'>178</a>-<a href='#Page_180'>180</a><br />
+<br />
+Vitiligoidea, <a href='#Page_195'>195</a><br />
+<br />
+Vleminckx's solution, <a href='#Page_129'>129</a><br />
+<br />
+<br />
+Wart, <a href='#Page_160'>160</a><br />
+<span style='margin-left: 1em;'>Peruvian, <a href='#Page_73'>73</a></span><br />
+<span style='margin-left: 1em;'>pointed, <a href='#Page_161'>161</a></span><br />
+<span style='margin-left: 1em;'>venereal, <a href='#Page_161'>161</a></span><br />
+<br />
+Wen, <a href='#Page_43'>43</a><br />
+<br />
+Wheals, <a href='#Page_23'>23</a><br />
+<br />
+Wood-tick, <a href='#Page_277'>277</a><br />
+<br />
+Wound dissection, <a href='#Page_73'>73</a><br />
+<br />
+<br />
+Xanthelasma, <a href='#Page_195'>195</a><br />
+<br />
+Xanthelasmoidea, <a href='#Page_56'>56</a><br />
+<br />
+Xanthoma, <a href='#Page_195'>195</a>, <a href='#Page_196'>196</a><br />
+<span style='margin-left: 1em;'>diabeticorum, <a href='#Page_195'>195</a></span><br />
+<span style='margin-left: 1em;'>multiplex, <a href='#Page_195'>195</a></span><br />
+<span style='margin-left: 1em;'>planum, <a href='#Page_195'>195</a></span><br />
+<span style='margin-left: 1em;'>tuberculatum, <a href='#Page_195'>195</a></span><br />
+<span style='margin-left: 1em;'>tuberosum, <a href='#Page_195'>195</a></span><br />
+<br />
+Xeroderma, <a href='#Page_165'>165</a><br />
+<br />
+Xeroderma pigmentosum, <a href='#Page_190'>190</a><br />
+<br />
+<i>X</i>-ray dermatitis, <a href='#Page_63'>63</a><br />
+<br />
+<br />
+Yaws, <a href='#Page_73'>73</a><br />
+<br />
+<br />
+Zona, <a href='#Page_81'>81</a><br />
+<br />
+Zoster, <a href='#Page_81'>81</a><br />
+</p>
+
+
+<hr style='width: 100%;' />
+
+<h2>SAUNDERS' BOOKS</h2>
+
+<h4><b>on</b></h4>
+
+<h1>GYNECOLOGY</h1>
+
+<h4>and</h4>
+
+<h1>OBSTETRICS</h1>
+<hr style='width: 100%;' />
+
+<h2>W. B. SAUNDERS COMPANY</h2>
+
+<h3>925 Walnut Street &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Philadelphia</h3>
+
+<h3>9, Henrietta Street &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Covent Garden, London</h3>
+<hr style='width: 75%;' />
+
+<p class='center'><b>SAUNDERS' TEXT-BOOKS CONTINUE TO GAIN</b></p>
+
+<p>The list of text-books recommended in the various colleges again shows a
+<b>decided gain for the Saunders publications</b>. During the present college
+year, in the list of recommended books published by 164 colleges (the other
+23 have not published lists), the Saunders books are mentioned 3278 times,
+as against 3054 the previous year&mdash;<b>an increase of 224</b>. In other words, in
+each of the medical colleges in this country an average of 20 (18-2/5 the previous
+year) of the teaching books employed are publications issued by W. B.
+Saunders Company. That this increase is not due alone to the publication
+of new text-books, but rather to a most gratifying increase in the recommendation
+of text-books recognized as standards, is at once evident from the following:
+Ashton's Gynecology shows an increase of 19; DaCosta's Surgery,
+an increase of 12; Hirst's Obstetrics, 14; Howell's Physiology, 25; Jackson
+on the Eye, 16; Sahli's Diagnostic Methods, 11; Scudder's Fractures, 11;
+Stengel's Pathology, 13; Stelwagon on the Skin, 11. These are but examples
+of similar remarkable gains throughout the entire list, and is undoubted
+evidence that the <b>Saunders text-books are recognized as the best</b>.</p>
+
+<p><b>A Complete Catalogue of our Publications will be Sent upon Request</b></p>
+<hr style='width: 100%;' />
+
+
+<h2>Bandler's</h2>
+<h2>Medical Gynecology</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>Medical Gynecology</b>. By <span class='smcap'>S. Wyllis Bandler</span>, M.D.,
+Adjunct. Professor of Diseases of Women, New York Post-Graduate
+Medical School and Hospital. Octavo of 680 pages,
+with 135 original illustrations. Cloth, $5.00 net; Half Morocco,
+$6.50 net.</p>
+
+
+<h3>JUST READY&mdash;EXCLUSIVELY MEDICAL GYNECOLOGY</h3>
+
+
+<p>This new work by Dr. Bandler is just the book that the physician engaged
+in general practice has long needed. It is truly <i>the practitioner's gynecology</i>&mdash;planned
+for him, written for him, and illustrated for him. There are
+many gynecologic conditions that do not call for operative treatment; yet,
+because of lack of that special knowledge required for their diagnosis and
+treatment, the general practitioner has been unable to treat them intelligently.
+This work gives just the information the practitioner needs. It not only
+deals with those conditions amenable to non-operative treatment, but it also
+tells how to recognize those diseases demanding operative treatment, so that
+the practitioner will be enabled to advise his patient at a time when operation
+will be attended with the most favorable results. The chapter on Pessaries
+is especially full and excellent, the proper manner of introducing the pessary
+being clearly described and illustrated with original pictures that show plainly
+the correct technic of this procedure. The chapters on Vaginal and Abdominal
+Massage, and particularly that on Artificial Hyperemia and Anemia, are
+extremely valuable to the practitioner. They express the very latest advances
+in these methods of treatment. Hydrotherapy, especially the Ferguson and
+Nauheim baths, are treated <i>in extenso</i>, and Electrotherapy receives the full
+consideration its importance merits. Pain as a symptom and its alleviation
+is dealt with in an unusually practical way, its value as an aid in diagnosis
+being emphasized. Gonorrhea and Syphilis and their many complications are
+treated in detail, every care being taken to have these sections&mdash;of special
+interest to the practitioner&mdash;complete in every particular. Other chapters of
+great importance are those on Constipation, Sterility, Associated Nervous
+Conditions in Gynecology, and Pregnancy and Abortion.</p>
+
+<hr style='width: 100%;' />
+
+<h2>Kelly and Noble's Gynecology</h2>
+<h2>and Abdominal Surgery</h2>
+
+<p><b>Gynecology and Abdominal Surgery.</b> Edited by <span class='smcap'>Howard
+A. Kelly</span>, M.D., Professor of Gynecology in Johns Hopkins
+University; and <span class='smcap'>Charles P. Noble</span>, M.D., Clinical Professor of
+Gynecology in the Woman's Medical College, Philadelphia. Two
+imperial octavo volumes of 900 pages each, containing 650 illustrations,
+mostly original. Per volume: Cloth, $8.00 net; Half
+Morocco, $9.50 net.</p>
+
+
+<h3>BOTH VOLUMES NOW READY</h3>
+
+<h3>WITH 650 ORIGINAL ILLUSTRATIONS BY HERMANN BECKER</h3>
+<h3>AND MAX BR&Ouml;DEL</h3>
+
+
+<p>In view of the intimate association of gynecology with abdominal surgery
+the editors have combined these two important subjects in one work. For
+this reason the work will be doubly valuable, for not only the gynecologist and
+general practitioner will find it an exhaustive treatise, but the surgeon also will
+find here the latest technic of the various abdominal operations. It possesses
+a number of valuable features not to be found in any other publication covering
+the same fields. It contains a chapter upon the bacteriology and one upon
+the pathology of gynecology, dealing fully with the scientific basis of gynecology.
+In no other work can this information, prepared by specialists, be
+found as separate chapters. There is a large chapter devoted entirely to
+<i>medical gynecology</i>, written especially for the physician engaged in general
+practice. Heretofore the general practitioner was compelled to search through
+an entire work in order to obtain the information desired. <i>Abdominal surgery</i>
+proper, as distinct from gynecology, is fully treated, embracing operations
+upon the stomach, upon the intestines, upon the liver and bile-ducts, upon the
+pancreas and spleen, upon the kidney, ureter, bladder, and the peritoneum.
+Special attention has been given to <i>modern technic</i> and illustrations of the very
+highest order have been used to make clear the various steps of the operations.
+Indeed, the illustrations are truly magnificent, being the work of <i>Mr. Hermann
+Becker</i> and <i>Mr. Max Br&ouml;del</i>, of the Johns Hopkins Hospital.</p>
+
+
+<hr style='width: 100%;' />
+
+<h2>Ashton's</h2>
+<h2>Practice of Gynecology</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>The Practice of Gynecology.</b> By <span class='smcap'>W. Easterly Ashton</span>,
+M.D., LL.D., Professor of Gynecology in the Medico-Chirurgical
+College, Philadelphia. Handsome octavo volume of 1096
+pages, containing 1057 original line drawings. Cloth, $6.50
+net; Half Morocco, $8.00 net.</p>
+
+
+<h3>RECENTLY ISSUED&mdash;NEW (3d) EDITION</h3>
+<h3>THREE EDITIONS IN EIGHTEEN MONTHS</h3>
+
+<p>Three editions of this work have been demanded in eighteen months.
+Among the new additions are: Colonic lavage and flushing, Hirst's treatment
+for vaginismus, Dudley's treatment of cystocele, Montgomery's round
+ligament operation, Chorio-epithelioma of the Uterus, Passive Incontinence of
+the Urine, and Moynihan's methods in Intestinal Anastomosis. Nothing is left
+to be taken for granted, the author not only telling his readers in every instance
+what should be done, but also precisely <i>how to do it</i>. A distinctly original
+feature of the book is the illustrations, numbering about one thousand line
+drawings made especially under the author's personal supervision from actual
+apparatus, living models, and dissections on the cadaver. These line drawings
+show in detail the procedures and operations without obscuring their
+purpose by unnecessary and unimportant anatomic surroundings.</p>
+
+
+<p><b>Howard A. Kelly, M.D.</b></p>
+
+<p><i>Professor of Gynecology, Johns Hopkins University.</i></p>
+
+<p>&ldquo;It is different from anything that has as yet appeared. The illustrations are particularly
+clear and satisfactory. One specially good feature is the pains with which you
+describe so many <i>details</i> so often left to the imagination.&rdquo;</p>
+
+
+<p><b>Charles B. Penrose, M.D.,</b></p>
+
+<p><i>Formerly Professor of Gynecology, University of Pennsylvania.</i></p>
+
+<p>&ldquo;I know of no book that goes so thoroughly and satisfactorily into all the <i>details</i> of
+everything connected with the subject. In this respect your book differs from the others.&rdquo;</p>
+
+
+<p><b>George M. Edebohls, M.D.</b></p>
+
+<p><i>Professor of Diseases of Women, New York Post-Graduate Medical School.</i>
+&ldquo;I have looked it through and must congratulate you upon having produced a text-book
+most admirably adapted to <i>teach</i> gynecology to those who must get their knowledge,
+even to the minutest and most elementary details, from books.&rdquo;</p>
+
+<hr style='width: 100%;' />
+<h2>Webster's</h2>
+<h2>Diseases <i>of</i> Women</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>Diseases of Women.</b> By <span class='smcap'>J. Clarence Webster</span>, M.D.
+(<span class='smcap'>Edin</span>.), F.R.C.P.E., Professor of Gynecology and Obstetrics
+in Rush Medical College. Octavo of 712 pages, with 372 illustrations.
+Cloth, $7.00 net; Half Morocco, $8.50 net.</p>
+
+
+<h3>RECENTLY ISSUED&mdash;FOR THE PRACTITIONER</h3>
+
+
+<p>Dr. Webster has written this work <i>especially for the general practitioner</i>,
+discussing the clinical features of the subject in their widest relations to
+general practice rather than from the standpoint of specialism. The magnificent
+illustrations, three hundred and seventy-two in number, are nearly all
+original. Drawn by expert anatomic artists under Dr. Webster's direct supervision,
+they portray the anatomy of the parts and the steps in the operations
+with rare clearness and exactness.</p>
+
+
+<p><b>Howard A. Kelly, M.D.</b>, <i>Professor of Gynecology, Johns Hopkins University.</i></p>
+
+<p>&ldquo;It is undoubtedly one of the best works which has been put on the market within
+recent years, showing from start to finish Dr. Webster's well-known thoroughness. The
+illustrations are also of the highest order.&rdquo;</p>
+
+<hr style='width: 45%;' />
+
+<h2>Webster's Obstetrics</h2>
+
+<p><b>A Text-Book of Obstetrics.</b> By <span class='smcap'>J. Clarence Webster</span>,
+M.D. (<span class='smcap'>Edin</span>.), Professor of Obstetrics and Gynecology in Rush
+Medical College. Octavo of 767 pages, illustrated. Cloth,
+$5.00 net; Half Morocco, $6.50 net.</p>
+
+
+<h3>RECENTLY ISSUED</h3>
+
+
+<p><b>Medical Record, New York</b></p>
+
+<p>&ldquo;The author's remarks on asepsis and antisepsis are admirable, the chapter on eclampsia
+is full of good material, and ... the book can be cordially recommended as a safe
+guide.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<h2>Cullen's</h2>
+<h2>Uterine Adenomyoma</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>Uterine Adenomyoma.</b> By <span class='smcap'>Thomas S. Cullen</span>, M.D.,
+Associate Professor of Gynecology, Johns Hopkins University.
+Octavo of 275 pages, with original illustrations by Hermann
+Becker and August Horn. Cloth, $5.00 net.</p>
+
+
+<h3>JUST READY</h3>
+
+<p>Dr. Cullen's large clinical experience and his extensive original work along
+the lines of gynecologic pathology have enabled him to present his subject
+with originality and precision. The work gives the early literature on
+adenomyoma, traces the disease through its various stages, and then gives the
+detailed findings in a large number of cases personally examined by the
+author. Formerly the physician and surgeon were unable to determine the
+cause of uterine bleeding, but after following closely the clinical course of
+the disease, Dr. Cullen has found that the majority of these cases can be
+diagnosed clinically. The results of these observations he presents in this
+work. The entire subject of adenomyoma is dealt with from the standpoint
+of the pathologist, the clinician, and the surgeon. The superb illustrations
+are the work of Mr. Hermann Becker and Mr. August Horn, of the Johns
+Hopkins Hospital.</p>
+
+<hr style='width: 100%;' />
+
+<h2>The American</h2>
+<h2>Text-Book <i>of</i> Obstetrics</h2>
+
+
+<h3>Recently Issued&mdash;New (2d) Edition</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>The American Text-Book of Obstetrics.</b> In two volumes.
+Edited by <span class='smcap'>Richard C. Norris</span>, M.D.; Art Editor, Robert L.
+Dickinson, M.D. Two octavos of about 600 pages each; nearly
+900 illustrations, including 49 colored and half-tone plates. Per
+volume: Cloth, $3.50 net; Half Morocco, $4.50 net.</p>
+
+
+<p><b>American Journal of the Medical Sciences</b></p>
+
+<p>&ldquo;As an authority, as a book of reference, as a 'working book' for the student or practitioner,
+we commend it because we believe there is no better.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<h2>Hirst's</h2>
+<h2>Diseases of Women</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>A Text-Book of Diseases of Women.</b> By <span class='smcap'>Barton Cooke
+Hirst</span>, M.D., Professor of Obstetrics, University of Pennsylvania;
+Gynecologist to the Howard, the Orthopedic, and the
+Philadelphia Hospitals. Octavo of 745 pages, 701 illustrations,
+many in colors. Cloth, $5.00 net; Half Morocco, $6.50 net.</p>
+
+
+<h3>RECENTLY ISSUED&mdash;NEW (2d) EDITION</h3>
+<h3>WITH 701 ORIGINAL ILLUSTRATIONS</h3>
+
+
+<p>The new edition of this work has just been issued after a careful revision.
+As diagnosis and treatment are of the greatest importance in considering diseases
+of women, particular attention has been devoted to these divisions. To
+this end, also, the work has been magnificently illuminated with 701 illustrations,
+for the most part original photographs and water-colors of actual
+clinical cases accumulated during the past fifteen years. The palliative treatment,
+as well as the radical operative, is fully described, enabling the general
+practitioner to treat many of his own patients without referring them
+to a specialist. The author's extensive experience renders this work of unusual
+value.</p>
+
+
+<hr style='width: 45%;' />
+
+<h3>OPINIONS OF THE MEDICAL PRESS</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>Medical Record, New York</b></p>
+
+<p>&ldquo;Its merits can be appreciated only by a careful perusal.... Nearly one hundred pages
+are devoted to technic, this chapter being in some respects superior to the descriptions in
+many text-books.&rdquo;</p>
+
+
+<p><b>Boston Medical and Surgical Journal</b></p>
+
+<p>&ldquo;The author has given special attention to diagnosis and treatment throughout the book,
+and has produced a practical treatise which should be of the greatest value to the student,
+the general practitioner, and the specialist.&rdquo;</p>
+
+
+<p><b>Medical News, New York</b></p>
+
+<p>&ldquo;Office treatment is given a due amount of consideration, so that the work will be as
+useful to the non-operator as to the specialist.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<h2>Hirst's</h2>
+<h2>Text-Book of Obstetrics</h2>
+
+<h3>New (5th) Edition, Revised</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>A Text-Book of Obstetrics.</b> By <span class='smcap'>Barton Cooke Hirst</span>,
+M.D., Professor of Obstetrics in the University of Pennsylvania.
+Handsome octavo, 899 pages, with 746 illustrations, 39 in colors.
+Cloth, $5.00 net; Sheep or Half Morocco, $6.50 net.</p>
+
+
+<h3>RECENTLY ISSUED</h3>
+
+
+<p>Immediately on its publication this work took its place as the leading text-book
+on the subject. Both in this country and abroad it is recognized as the
+most satisfactorily written and clearly illustrated work on obstetrics in the
+language. The illustrations form one of the features of the book. They are
+numerous and the most of them are original. In this edition the book has
+been thoroughly revised. More attention has been given to the diseases of
+the genital organs associated with or following childbirth. Many of the old
+illustrations have been replaced by better ones, and there have been added a
+number entirely new. The work treats the subject from a clinical standpoint.</p>
+<hr style='width: 45%;' />
+
+<h3>OPINIONS OF THE MEDICAL PRESS</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>British Medical Journal</b></p>
+
+<p>&ldquo;The popularity of American text-books in this country is one of the features of recent
+years. The popularity is probably chiefly due to the great superiority of their illustration
+over those of the English text-books. The illustrations in Dr. Hirst's volume are far more
+numerous and far better executed, and therefore more instructive, than those commonly
+found in the works of writers on obstetrics in our own country.&rdquo;</p>
+
+
+<p><b>Bulletin of Johns Hopkins Hospital</b></p>
+
+<p>&ldquo;The work is an admirable one in every sense of the word, concisely but comprehensively
+written.&rdquo;</p>
+
+
+<p><b>The Medical Record, New York</b></p>
+
+<p>&ldquo;The illustrations are numerous and are works of art, many of them appearing for the
+first time. The author's style, though condensed, is singularly clear, so that it is never
+necessary to re-read a sentence in order to grasp the meaning. As a true model of what a
+modern text-book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book
+is without a rival.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<h2>Penrose's</h2>
+<h2>Diseases of Women</h2>
+
+<h3>Sixth Revised Edition</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>A Text-Book of Diseases of Women.</b> By <span class='smcap'>Charles B.
+Penrose</span>, M.D., <span class='smcap'>Ph</span>.D., formerly Professor of Gynecology in
+the University of Pennsylvania; Surgeon to the Gynecean Hospital,
+Philadelphia. Octavo volume of 550 pages, with 225 fine
+original illustrations. Cloth $3.75 net.</p>
+
+
+<h3>JUST ISSUED</h3>
+
+
+<p>Regularly every year a new edition of this excellent text-book is called
+for, and it appears to be in as great favor with physicians as with students.
+Indeed, this book has taken its place as the ideal work for the general practitioner.
+The author presents the best teaching of modern gynecology, untrammeled
+by antiquated ideas and methods. In every case the most modern
+and progressive technique is adopted, and the main points are made clear by
+excellent illustrations. The new edition has been carefully revised, much
+new matter has been added, and a number of new original illustrations have
+been introduced. In its revised form this volume continues to be an admirable
+exposition of the present status of gynecologic practice.</p>
+
+<hr style='width: 45%;' />
+
+<h3>PERSONAL AND PRESS OPINIONS</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>Howard A. Kelly, M.D.,</b></p>
+
+<p><i>Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore.</i></p>
+
+<p>&ldquo;I shall value very highly the copy of Penrose's 'Diseases of Women' received. I
+have already recommended it to my class as <span class='smcap'>the best</span> book.&rdquo;</p>
+
+
+<p><b>L.E. Montgomery, M.D.,</b></p>
+
+<p><i>Professor of Gynecology, Jefferson Medical College, Philadelphia.</i></p>
+
+<p>&ldquo;The copy of 'A Text-Book of Diseases of Women' by Penrose received to-day. I
+have looked over it and admire it very much. I have no doubt it will have a large sale, as
+it justly merits.&rdquo;</p>
+
+
+<p><b>Bristol Medico-Chirurgical Journal</b></p>
+
+<p>&ldquo;This is an excellent work which goes straight to the mark.... The book may be
+taken as a trustworthy exposition of modern gynecology.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<table width='100%'>
+<tr><td style='text-align: left'><strong>GET<br />THE BEST</strong></td><td></td><td style='text-align: right;'><strong>THE NEW<br />STANDARD</strong></td></tr>
+</table>
+
+<h2>American</h2>
+<h2>Illustrated Dictionary</h2>
+
+<h3>Recently Issued&mdash;New (4th) Edition</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>The American Illustrated Medical Dictionary.</b> A new
+and complete dictionary of the terms used in Medicine, Surgery,
+Dentistry, Pharmacy, Chemistry, and kindred branches; with
+over 100 new and elaborate tables and many handsome illustrations.
+By <span class='smcap'>W.A. Newman Dorland</span>, M.D., Editor of &ldquo;The
+American Pocket Medical Dictionary.&rdquo; Large octavo, 850 pages,
+bound in full flexible leather. Price, $4.50 net; with thumb
+index, $5.00 net.</p>
+
+
+<p class='center'><b>Gives a Maximum Amount of Matter in a Minimum Space, and at the
+Lowest Possible Cost</b></p>
+
+
+<h3>WITH 2000 NEW TERMS</h3>
+
+
+<p>The immediate success of this work is due to the special features that
+distinguish it from other books of its kind. It gives a maximum of matter
+in a minimum space and at the lowest possible cost. Though it is practically
+unabridged, yet by the use of thin bible paper and flexible morocco
+binding it is only 1-1/4 inches thick. In this new edition the book has been
+thoroughly revised, and upward of two thousand new terms have been
+added, thus bringing the book absolutely up to date. The book contains
+hundreds of terms not to be found in any other dictionary, over 100
+original tables, and many handsome illustrations.</p>
+
+
+<hr style='width: 45%;' />
+
+<h3>PERSONAL OPINIONS</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>Howard A. Kelly, M.D.,</b></p>
+
+<p><i>Professor of Gynecology, Johns Hopkins University, Baltimore.</i></p>
+
+<p>&ldquo;Dr. Borland's dictionary is admirable. It is so well gotten up and of such convenient
+size. No errors have been found in my use of it.&rdquo;</p>
+
+
+<p><b>J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.)</b></p>
+
+<p><i>Professor of Surgery, Harvard Medical School.</i></p>
+
+<p>&ldquo;I regard it as a valuable aid to my medical literary work. It is very complete and
+of convenient size to handle comfortably. I use it in preference to any other.&rdquo;</p>
+
+
+<hr style='width: 100%;' />
+
+<h2>Garrigues'</h2>
+<h2>Diseases of Women</h2>
+
+
+<h3>Third Edition, Thoroughly Revised</h3>
+
+<hr style='width: 45%;' />
+
+<p><b>A Text-Book of Diseases of Women.</b> By <span class='smcap'>Henry J.
+Garrigues</span>, A.M., M.D., Gynecologist to St. Mark's Hospital
+and to the German Dispensary, New York City. Handsome
+octavo, 756 pages, with 367 engravings and colored plates.
+Cloth, $4.50 net; Sheep or Half Morocco, $6.00 net.</p>
+
+<p>The first two editions of this work met with a most appreciative reception
+by the medical profession both in this country and abroad. In this edition
+the entire work has been carefully and thoroughly revised, and considerable
+new matter added, bringing the work precisely down to date. Many new
+illustrations have been introduced, thus greatly increasing the value of the
+book both as a text-book and book of reference.</p>
+
+
+<p><b>Thad. A. Reamy, M.D.,</b> <i>Professor of Gynecology, Medical College of Ohio.</i></p>
+
+<p>&ldquo;One of the best text-books for students and practitioners which has been published in
+the English language; it is condensed, clear, and comprehensive. The profound learning
+and great clinical experience of the distinguished author find expression in this book.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<h2>American</h2>
+<h2>Text-Book of Gynecology</h2>
+
+
+<p><b>American Text-Book of Gynecology.</b> <span class='smcap'>Medical and
+Surgical</span>. Edited by <span class='smcap'>J. M. Baldy</span>, M.D., Professor of Gynecology,
+Philadelphia Polyclinic. Imperial octavo of 718 pages,
+with 341 text-illustrations and 38 plates. Cloth, $6.00 net; Half
+Morocco, $7.50 net.</p>
+
+
+<h3>SECOND REVISED EDITION</h3>
+
+
+<p>This volume is thoroughly practical in its teachings, and is intended to be
+a working text-book for physicians and students. Many of the most important
+subject are considered from an entirely new standpoint, and are grouped
+together in a manner somewhat foreign to the accepted custom.</p>
+
+
+<p><b>Boston Medical and Surgical Journal</b></p>
+
+<p>&ldquo;The most complete exponent of gynecology that we have. No subject seems to have
+been neglected.&rdquo;</p>
+
+
+<hr style='width: 100%;' />
+
+<h2>Dorland's</h2>
+<h2>Modern Obstetrics</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>Modern Obstetrics: General and Operative.</b> By <span class='smcap'>W. A.
+Newman Dorland</span>, A.M., M.D., Assistant Instructor in Obstetrics,
+University of Pennsylvania; Associate in Gynecology
+in the Philadelphia Polyclinic. Handsome octavo volume of 797
+pages, with 201 illustrations. Cloth, $4.00 net.</p>
+
+<h3>Second Edition, Revised and Greatly Enlarged</h3>
+
+<p>In this edition the book has been entirely rewritten and very greatly
+enlarged. Among the new subjects introduced are the surgical treatment of
+puerperal sepsis, infant mortality, placental transmission of diseases, serum-therapy
+of puerperal sepsis, etc.</p>
+
+
+<p><b>Journal of the American Medical Association</b></p>
+
+<p>&ldquo;This work deserves commendation, and that it has received what it deserves at the
+hands of the profession is attested by the fact that a second edition is called for within such
+a short time. Especially deserving of praise is the chapter on puerperal sepsis.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<h2>Davis' Obstetric and</h2>
+<h2>Gynecologic Nursing</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>Obstetric and Gynecologic Nursing.</b> By <span class='smcap'>Edward P.
+Davis</span>, A.M., M.D., Professor of Obstetrics in the Jefferson
+Medical College and Philadelphia Polyclinic; Obstetrician and
+Gynecologist, Philadelphia Hospital. 12mo of 436 pages, illustrated.
+Buckram, $1.75 net.</p>
+
+
+<h3>JUST ISSUED&mdash;THIRD REVISED EDITION</h3>
+
+
+<p>This volume gives a very clear and accurate idea of the manner to meet
+the conditions arising during obstetric and gynecologic nursing. The third
+edition has been thoroughly revised.</p>
+
+
+<p><b>The Lancet, London</b></p>
+
+<p>&ldquo;Not only nurses, but even newly qualified medical men, would learn a great deal by
+a perusal of this book. It is written in a clear and pleasant style, and is a work we can
+recommend.&rdquo;</p>
+
+
+<hr style='width: 100%;' />
+
+<h2>Sch&auml;ffer <i>and</i> Edgar's</h2>
+<h2>Labor and Operative Obstetrics</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>Atlas and Epitome of Labor and Operative Obstetrics.</b>
+By <span class='smcap'>Dr. O. Sch&auml;ffer</span>, of Heidelberg. <i>From the Fifth Revised
+and Enlarged German Edition.</i> Edited, with additions, by <span class='smcap'>J.
+Clifton Edgar</span>, M.D., Professor of Obstetrics and Clinical Midwifery,
+Cornell University Medical School, New York. With 14
+lithographic plates in colors, 139 other illustrations, and 111 pages
+of text. Cloth, $2.00 net. <i>In Saunders' Hand-Atlas Series.</i></p>
+
+<p>This book presents the act of parturition and the various obstetric operations
+in a series of easily understood illustrations, accompanied by a text
+treating the subject from a practical standpoint.</p>
+
+
+<p><b>American Medicine</b></p>
+
+<p>&ldquo;The method of presenting obstetric operations is admirable. The drawings, representing
+original work, have the commendable merit of illustrating instead of confusing.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+
+<h2>Sch&auml;ffer <i>and</i> Edgar's</h2>
+<h2>Obstetric Diagnosis and Treatment</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>Atlas and Epitome of Obstetric Diagnosis and Treatment.</b>
+By <span class='smcap'>Dr. O. Sch&auml;ffer</span>, of Heidelberg. <i>From the Second
+Revised German Edition.</i>Edited, with additions, by <span class='smcap'>J. Clifton
+Edgar</span>, M.D., Professor of Obstetrics and Clinical Midwifery,
+Cornell University Medical School, N.Y. With 122
+colored figures on 56 plates, 38 text-cuts, and 315 pages of text.
+Cloth, $3.00 net. <i>In Saunders' Hand-Atlas Series.</i></p>
+
+<p>This book treats particularly of obstetric operations, and, besides the wealth
+of beautiful lithographic illustrations, contains an extensive text of great value.
+This text deals with the practical, clinical side of the subject.</p>
+
+
+<p><b>New York Medical Journal</b></p>
+
+<p>&ldquo;The illustrations are admirably executed, as they are in all of these atlases, and the
+text can safely be commended, not only as elucidatory of the plates, but as expounding
+the scientific midwifery of to-day.&rdquo;</p>
+
+
+<hr style='width: 100%;' />
+
+<h2>Sch&auml;ffer and Norris'</h2>
+<h2>Gynecology</h2>
+
+<hr style='width: 45%;' />
+
+<p><b>Atlas and Epitome of Gynecology.</b> By <span class='smcap'>Dr. O. Sch&auml;ffer</span>,
+of Heidelberg. <i>From the Second Revised and Enlarged German
+Edition.</i> Edited, with additions, by <span class='smcap'>Richard C. Norris</span>, A.M.,
+M.D., Assistant Professor of Obstetrics in the University of
+Pennsylvania. 207 colored figures on 90 plates, 65 text-cuts, and 308
+pages of text. Cloth, $3.50 net. <i>In Saunders' Hand-Atlas Series.</i></p>
+
+
+<p><b>American Journal of the Medical Sciences</b></p>
+
+<p>&ldquo;Of the illustrations it is difficult to speak in too high terms of approval. They are so
+clear and true to nature that the accompanying explanations are almost superfluous. We
+commend it most earnestly.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<h2>Galbraith's</h2>
+<h2>Four Epochs of Woman's Life</h2>
+
+<hr style='width: 45%;' />
+
+<h3>Second Revised Edition&mdash;Recently Issued</h3>
+
+
+<p><b>The Four Epochs of Woman's Life:</b> <span class='smcap'>A Study in Hygiene</span>.
+By <span class='smcap'>Anna M. Galbraith</span>, M.D., Fellow of the New
+York Academy of Medicine, etc. With an Introductory Note
+by <span class='smcap'>John M. Musser</span>, M.D. Professor of Clinical Medicine,
+University of Pennsylvania. 12 mo of 247 pages. Cloth $1.50
+net.</p>
+
+
+<h3>MAIDENHOOD, MARRIAGE, MATERNITY, MENOPAUSE</h3>
+
+
+<p>In this instructive work are stated, in a modest, pleasing, and conclusive
+manner, those truths of which every woman should have a thorough knowledge.
+Written, as it is, for the laity, the subject is discussed in language
+readily grasped even by those most unfamiliar with medical subjects.</p>
+
+
+<p><b>Birmingham Medical Review, England</b></p>
+
+<p>&ldquo;We do not as a rule care for medical books written for the instruction of the public.
+But we must admit that the advice in Dr. Galbraith's work is in the main wise and wholesome.&rdquo;</p>
+
+
+<hr style='width: 100%;' />
+
+<h2>Sch&auml;ffer and Webster's</h2>
+<h2>Operative Gynecology</h2>
+
+<p><b>Atlas and Epitome of Operative Gynecology.</b> By <span class='smcap'>Dr.
+O. Sch&auml;ffer</span>, of Heidelberg. Edited, with additions, by <span class='smcap'>J.
+Clarence Webster</span>, M.D. (<span class='smcap'>Edin</span>.), F.R.C.P.E., Professor of
+Obstetrics and Gynecology in Rush Medical College, in affiliation
+with the University of Chicago. 42 colored lithographic
+plates, many text-cuts, a number in colors, and 138 pages of text.
+<i>In Saunders' Hand-Atlas Series.</i> Cloth, $3.00 net.</p>
+
+
+<h3>RECENTLY ISSUED</h3>
+
+
+<p>Much patient endeavor has been expended by the author, the artist, and
+the lithographer in the preparation of the plates for this Atlas. They are based
+on hundreds of photographs taken from nature, and illustrate most faithfully
+the various surgical situations. Dr. Sch&auml;ffer has made a specialty of demonstrating
+by illustrations.</p>
+
+
+<p><b>Medical Record, New York</b></p>
+
+<p>&ldquo;The volume should prove most helpful to students and others in grasping details
+usually to be acquired only in the amphitheater itself.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+<h2>DeLee's Obstetrics for Nurses</h2>
+
+<p><b>Obstetrics for Nurses.</b> By <span class='smcap'>Joseph B. DeLee</span>, M.D.,
+Professor of Obstetrics in the Northwestern University Medical
+School, Chicago; Lecturer in the Nurses' Training Schools of
+Mercy, Wesley, Provident, Cook County, and Chicago Lying-in
+Hospitals. 12mo of 512 pages, fully illustrated.</p>
+
+<p>Cloth, $2.50 net.</p>
+
+
+<h3>JUST ISSUED&mdash;NEW (3d) EDITION</h3>
+
+
+<p>While Dr. DeLee has written his work especially for nurses, the practitioner
+will also find it useful and instructive, since the duties of a nurse often
+devolve upon him in the early years of his practice. The illustrations are
+nearly all original and represent photographs taken from actual scenes. The
+text is the result of the author's many years' experience in lecturing to the
+nurses of five different training schools.</p>
+
+
+<p><b>J. Clifton Edgar, M.D.,</b></p>
+
+<p><i>Professor of Obstetrics and Clinical Midwifery, Cornell University, New York.</i></p>
+
+<p>&ldquo;It is far and away the best that has come to my notice, and I shall take great pleasure
+in recommending it to my nurses, and students as well.&rdquo;</p>
+
+<hr style='width: 100%;' />
+
+
+<table width='100%'>
+<tr><td style='text-align: left'><strong>American Pocket Dictionary</strong></td><td></td><td style='text-align: right;'><strong>Recently issued&mdash;5th Ed.</strong></td></tr>
+</table>
+
+
+<p><span class='smcap'>The American Pocket Medical Dictionary</span>. Edited by <span class='smcap'>W. A. Newman Dorland</span>, A.M., M.D., Assistant Obstetrician to the Hospital
+of the University of Pennsylvania; Fellow of the American Academy
+of Medicine. With 578 pages. Full leather, limp, with gold edges,
+$1.00 net; with patent thumb index, $1.25 net.</p>
+
+
+<p><b>James W. Holland. M.D.,</b></p>
+
+<p><i>Professor of Chemistry and Toxicology, at the Jefferson Medical College,
+Philadelphia.</i></p>
+
+<p>&ldquo;I am struck at once with admiration at the compact size and attractive exterior.
+I can recommend it to our students without reserve.&rdquo;</p>
+
+
+<table width='100%'>
+<tr><td style='text-align: left'><strong>Cragin's Gynecology</strong></td><td></td><td style='text-align: right;'><strong>Recently Issued&mdash;New (6th) Ed.</strong></td></tr>
+</table>
+
+
+<p><span class='smcap'>Essentials of Gynecology</span>. By <span class='smcap'>Edwin B. Cragin</span>, M.D., Professor
+of Obstetrics, College of Physicians and Surgeons, New York.
+Crown octavo, 240 pages, 62 illustrations. Cloth, $1.00 net. <i>In
+Saunders' Question-Compend Series.</i></p>
+
+
+<p><b>The Medical Record, New York</b></p>
+
+<p>&ldquo;A handy volume and a distinct improvement on students' compends in general.
+No author who was not himself a practical gynecologist could have consulted the student's
+needs so thoroughly as Dr. Cragin has done.&rdquo;</p>
+
+
+<p><b>Boisliniere's Obstetric Accidents, Emergencies, and Operations</b></p>
+
+<p><span class='smcap'>Obstetric Accidents, Emergencies, and Operations</span>. By the late
+<span class='smcap'>L. Ch. Boisliniere</span>, M.D., Emeritus Professor of Obstetrics, St. Louis
+Medical College; Consulting Physician, St. Louis Female Hospital.
+381 pages, illustrated. Cloth, $2.00 net.</p>
+
+
+<p><b>British Medical Journal</b></p>
+
+<p>&ldquo;It is clearly and concisely written, and is evidently the work of a teacher and
+practitioner of large experience. Its merit lies in the judgment which comes from
+experience.&rdquo;</p>
+
+
+<table width='100%'>
+<tr><td style='text-align: left'><strong>Ashton's Obstetrics</strong></td><td></td><td style='text-align: right;'><strong>Recently Issued&mdash;New (6th) Ed.</strong></td></tr>
+</table>
+
+
+<p><span class='smcap'>Essentials of Obstetrics</span>. By <span class='smcap'>W. Easterly Ashton</span>, M.D., Professor
+of Gynecology in the Medico-Chirurgical College, Philadelphia.
+Crown octavo, 252 pages, 75 illustrations. Cloth, $1.00 net. <i>In
+Saunders' Question-Compend Series.</i></p>
+
+
+<p><b>Southern Practitioner</b></p>
+
+<p>&ldquo;An excellent little volume, containing correct and practical knowledge. An admirable
+compend, and the best condensation we have seen.&rdquo;</p>
+
+
+<p><b>Barton and Wells' Medical Thesaurus</b></p>
+
+
+<p><span class='smcap'>A Thesaurus of Medical Words and Phrases</span>. By <span class='smcap'>Wilfred M.
+Barton</span>, M.D., Assistant to Professor of Materia Medica and Therapeutics,
+Georgetown University, Washington, D.C.; and <span class='smcap'>Walter A.
+Wells</span>, M.D., Demonstrator of Laryngology, Georgetown University,
+Washington, D.C. 12mo of 534 pages. Flexible leather, $2.50 net;
+with thumb index, $3.00 net.</p>
+
+
+
+
+<hr style='width: 100%;' />
+<pre>Transcriber's note:
+
+   Changed "dioxid" to "dioxide" in several places
+
+   Made hyphenation of various words consistent
+
+   Page 74: Corrected misspelling of Phlegmona
+
+   Page 135: Corrected misspelling of quantity
+
+   Page 138: changed ',' to '.' at end of sentence
+
+   Page 208: aqu&aelig; rosae changed to aqu&aelig; ros&aelig;
+
+   Page 210: Fixed typographical error "symptyms" into "symptoms"
+
+   Page 212: Fixed typographical error "Decribe mycetoma" into
+             "Describe mycetoma"
+
+   Page 213: Fixed typographical error "iodid" into "iodide"
+</pre>
+
+<p>&nbsp;</p>
+<p>&nbsp;</p>
+<hr class="full" />
+<p>***END OF THE PROJECT GUTENBERG EBOOK ESSENTIALS OF DISEASES OF THE SKIN***</p>
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+The Project Gutenberg eBook, Essentials of Diseases of the Skin, by Henry
+Weightman Stelwagon
+
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+
+
+
+Title: Essentials of Diseases of the Skin
+       Including the Syphilodermata Arranged in the Form of Questions and Answers Prepared Especially for Students of Medicine
+
+
+Author: Henry Weightman Stelwagon
+
+
+
+Release Date: July 1, 2008  [eBook #25944]
+
+Language: English
+
+Character set encoding: ISO-646-US (US-ASCII)
+
+
+***START OF THE PROJECT GUTENBERG EBOOK ESSENTIALS OF DISEASES OF THE
+SKIN***
+
+
+E-text prepared by Kevin Handy, Ronnie Sahlberg, cbott, John Hagerson, and
+the Project Gutenberg Online Distributed Proofreading Team
+(https://www.pgdp.net)
+
+
+
+Note: Project Gutenberg also has an HTML version of this
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+      or
+      (https://www.gutenberg.org/dirs/2/5/9/4/25944/25944-h.zip)
+
+
+Transcriber's note:
+
+      This book contains many characters not displayed by ASCII or
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+      such characters are the oe-ligature (denoted by [oe] or [OE])
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+      other such characters display properly in the html version.
+
+      Text enclosed between pound signs was in bold face in the
+      original (#bold face#).
+
+      A detailed transcriber's note is at the end of the e-text.
+
+
+
+
+
+ESSENTIALS OF DISEASES OF THE SKIN
+
+Including the Syphilodermata
+
+Arranged in the Form of Questions and Answers Prepared Especially
+for Students of Medicine
+
+by
+
+HENRY W. STELWAGON, M.D., PH.D.
+
+        *       *       *       *       *
+
+Get the Best                                           The New Standard
+
+
+                              DORLAND'S
+
+                        AMERICAN ILLUSTRATED
+
+                         MEDICAL DICTIONARY
+
+
+                   For Students and Practitioners
+
+
+A New and Complete Dictionary of the terms used in Medicine, Surgery,
+Dentistry, Pharmacy, Chemistry, and kindred branches; together with new
+and elaborate Tables of Arteries, Muscles, Nerves, Veins, etc.; of
+Bacilli, Bacteria, Micrococci, etc.; Eponymic Tables of Diseases,
+Operations, Signs and Symptoms, Stains, Tests, Methods of Treatment,
+etc. By W.A.N. Dorland, M.D., Editor of the American Pocket Medical
+Dictionary. Large octavo, nearly 800 pages, bound in full flexible
+leather. Price, $4.50 net; with thumb index, $5.00 net.
+
+
+JUST ISSUED--NEW (4) REVISED EDITION--2000 NEW WORDS
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+This book contains #double the material in the ordinary students'
+dictionary#, and yet, by the use of a clear, condensed type and thin
+paper of the finest quality, is only 1-3/4 inches in thickness. It is
+bound in full flexible leather, and is just the kind of a book that a
+man will want to keep on his desk for constant reference. The book makes
+a special feature of #the newer words#, and defines hundreds of
+important terms not to be found in any other dictionary. It is
+especially #full in the matter of tables#, containing more than a
+hundred of great practical value, including new tables of Tests, Stains
+and Staining Methods. A new feature is the inclusion of numerous
+handsome illustrations, many of them in colors, drawn and engraved
+specially for this book.
+
+     "I must acknowledge my astonishment at seeing how much he has
+     condensed within relatively small space. I find nothing to
+     criticise, very much to commend, and was interested in finding some
+     of the new words which are not in other recent
+     dictionaries."--Roswell Park, _Professor of Principles and Practice
+     of Surgery and Clinical Surgery, University of Buffalo_.
+
+     "Dr. Dorland's Dictionary is admirable. It is so well gotten up and
+     of such convenient size. No errors have been found in my use of
+     it."--Howard A. Kelly, _Professor of Gynecology, Johns Hopkins
+     University, Baltimore_.
+
+               W. B. SAUNDERS COMPANY, 925 Walnut St., Phila.
+                London: 9, Henrietta Street, Covent Garden
+
+
+Fifth Edition, Just Ready                      With Complete Vocabulary
+
+
+                                 THE
+
+                           AMERICAN POCKET
+
+                         MEDICAL DICTIONARY
+
+
+                              EDITED BY
+
+                    W.A. NEWMAN DORLAND, A.M., M.D.,
+
+    Assistant Demonstrator of Obstetrics, University of Pennsylvania.
+
+
+                        HUNDREDS OF NEW TERMS
+
+   Bound in Full Leather, Limp, with Gold Edges. Price, $1.00 net; with
+                    Patent Thumb Index, $1.25 net.
+
+
+The book is an #absolutely new one#. It is not a revision of any old work,
+but it has been written entirely anew and is constructed on lines that
+experience has shown to be the most practical for a work of this kind.
+It aims to be #complete#, and to that end contains practically all the
+terms of modern medicine. This makes an unusually large vocabulary.
+Besides the ordinary dictionary terms the book contains a wealth of
+#anatomical and other tables#. This matter is of particular value to
+students for memorizing in preparation for examination.
+
+
+     "I am struck at once with admiration at the compact size and
+     attractive exterior. I can recommend it to our students without
+     reserve."--James W. Holland, M.D., _of Jefferson Medical College_.
+
+     "This is a handy pocket dictionary, which is so full and complete
+     that it puts to shame some of the more pretentious
+     volumes."--_Journal of the American Medical Association._
+
+     "We have consulted it for the meaning of many new and rare terms,
+     and have not met with a disappointment. The definitions are
+     exquisitely clear and concise. We have never found so much
+     information in so small a space."--_Dublin Journal of Medical
+     Science._
+
+     "This is a handy little volume that, upon examination, seems fairly
+     to fulfil the promise of its title, and to contain a vast amount of
+     information in a very small space.... It is somewhat surprising
+     that it contains so many of the rarer terms used in
+     medicine."--_Bulletin Johns Hopkins Hospital_, Baltimore.
+
+
+
+              W. B. SAUNDERS COMPANY, 925 Walnut St., Phila.
+               London: 9, Henrietta Street, Covent Garden
+
+        *       *       *       *       *
+
+
+ESSENTIALS OF DISEASES OF THE SKIN.
+
+   Since the issue of the first volume of the
+   #Saunders Question-Compends#,
+
+   OVER 290,000 COPIES
+
+   of these unrivalled publications have been sold.
+   This enormous sale is indisputable evidence of
+   the value of these self-helps to students and
+   physicians.
+
+
+Saunders' Question-Compends. No. 11.
+
+ESSENTIALS OF DISEASES OF THE SKIN
+
+Including the Syphilodermata
+
+Arranged in the Form of Questions and Answers Prepared Especially
+for Students of Medicine
+
+by
+
+HENRY W. STELWAGON, M.D., PH.D.
+
+Professor of Dermatology in the Jefferson Medical College, Philadelphia;
+Dermatologist to the Howard and Philadelphia Hospitals, etc.
+
+Seventh Edition, Thoroughly Revised
+
+Illustrated
+
+
+
+
+
+
+
+Philadelphia and London
+W. B. Saunders Company
+1909
+
+Set up, electrotyped, printed, 1890. Reprinted July, 1891.
+Revised, reprinted, June, 1894. Reprinted March, 1897.
+Revised, reprinted, August, 1899. Reprinted
+September, 1901, May, 1902, September, 1903.
+Revised, reprinted January, 1905.
+Reprinted March, 1906. Revised,
+reprinted March, 1909.
+
+Printed in America
+
+Press of
+W. B. Saunders Company
+Philadelphia
+
+
+
+
+PREFACE TO SEVENTH EDITION.
+
+
+In the present--seventh--edition the subject matter, especially as
+regards the practical part, has been gone over carefully and the
+necessary corrections and additions made. Nineteen new illustrations
+have been added, a few of the old ones being eliminated. It is hoped
+that the continued demand for this compend means a widening interest in
+the study of diseases of the skin, sufficiently keen as to lead to the
+desire for a still greater knowledge.
+
+                                                           H.W.S.
+
+
+PREFACE TO FIRST EDITION.
+
+
+Much of the present volume is, in a measure, the outcome of a thorough
+revision, remodelling and simplification of the various articles
+contributed by the author to Pepper's System of Medicine, Buck's
+Reference Handbook of the Medical Sciences, and Keating's Cyclopaedia of
+the Diseases of Children. Moreover, in the endeavor to present the
+subject as tersely and briefly as compatible with clear understanding,
+the several standard treatises on diseases of the skin by Tilbury Fox,
+Duhring, Hyde, Robinson, Anderson, and Crocker, have been freely
+consulted, that of the last-named author suggesting the pictorial
+presentation of the "Anatomy of the Skin." The space allotted to each
+disease has been based upon relative importance. As to treatment, the
+best and approved methods only--those which are founded upon the
+aggregate experience of dermatologists--are referred to.
+
+For general information a statistical table from the Transactions of the
+American Dermatological Association is appended.
+
+                                                           H.W.S.
+
+
+CONTENTS.
+
+
+                                               PAGE
+ANATOMY OF THE SKIN                              17
+    The Epidermis                                18
+    The Blood-vessels                            19
+    The Nervous and Vascular Papillae             20
+    The Hair and Hair-follicle                   21
+
+SYMPTOMATOLOGY                                   22
+    Primary Lesions                              22
+    Secondary Lesions                            23
+    Distribution and Configuration               24
+  Relative Frequency                             26
+  Contagiousness                                 27
+  Rapidity of Cure                               27
+  Ointment Bases                                 27
+
+CLASS I.--DISORDERS OF THE GLANDS                28
+    Hyperidrosis                                 28
+    Sudamen                                      30
+    Hydrocystoma                                 31
+    Anidrosis                                    31
+    Bromidrosis                                  32
+    Chromidrosis                                 32
+    Uridrosis                                    33
+    Phosphoridrosis                              33
+    Seborrh[oe]a (Eczema Seborrhoicum)           33
+    Comedo                                       38
+    Milium                                       42
+    Steatoma                                     43
+
+CLASS II.--INFLAMMATIONS                         44
+  Erythema Simplex                               44
+  Erythema Intertrigo                            45
+  Erythema Multiforme                            46
+  Erythema Nodosum                               50
+  Erythema Induratum                             51
+  Urticaria                                      52
+  Urticaria Pigmentosa                           56
+  Dermatitis                                     58
+  Dermatitis Medicamentosa                       60
+  X-Ray Dermatitis                               63
+  Dermatitis Factitia                            64
+  Dermatitis Gangraenosa                          65
+  Erysipelas                                     66
+  Phlegmona Diffusa                              68
+  Furunculus                                     68
+  Carbunculus                                    70
+  Pustula Maligna                                72
+  Post-mortem Pustule                            73
+  Framb[oe]sia                                   73
+  Verruga Peruana                                73
+  Equinia                                        74
+  Miliaria                                       74
+  Pompholyx                                      76
+  Herpes Simplex                                 78
+  Hydroa Vacciniforme                            80
+  Epidermolysis Bullosa                          80
+  Dermatitis Repens                              81
+  Herpes Zoster                                  81
+  Dermatitis Herpetiformis                       83
+  Psoriasis                                      86
+  Pityriasis Rosea                               95
+  Dermatitis Exfoliativa                         96
+  Lichen Planus                                  98
+  Pityriasis Rubra Pilaris                       99
+  Lichen Scrofulosus                            100
+  Eczema                                        100
+  Prurigo                                       118
+  Acne                                          119
+  Acne Rosacea                                  126
+  Sycosis                                       130
+  Dermatitis Papillaris Capillitii              135
+  Impetigo Contagiosa                           136
+  Impetigo Herpetiformis                        138
+  Ecthyma                                       138
+  Pemphigus                                     140
+
+CLASS III.--HEMORRHAGES                         144
+  Purpura                                       144
+  Scorbutus                                     146
+
+CLASS IV.--HYPERTROPHIES                        148
+  Lentigo                                       148
+  Chloasma                                      149
+  Keratosis Pilaris                             151
+  Keratosis Follicularis                        153
+  Molluscum Epitheliale                         153
+  Callositas                                    155
+  Clavus                                        156
+  Cornu Cutaneum                                158
+  Verruca                                       160
+  Naevus Pigmentosus                             162
+  Ichthyosis                                    165
+  Onychauxis                                    167
+  Hypertrichosis                                168
+  [OE]dema Neonatorum                           170
+  Sclerema Neonatorum                           171
+  Scleroderma                                   172
+  Elephantiasis                                 174
+  Dermatolysis                                  176
+
+CLASS V.--ATROPHIES                             177
+  Albinismus                                    177
+  Vitiligo                                      178
+  Canities                                      180
+  Alopecia                                      181
+  Alopecia Areata                               183
+  Atrophia Pilorum Propria                      187
+  Atrophia Unguis                               188
+  Atrophia Cutis                                189
+
+CLASS VI.--NEW GROWTHS                          191
+  Keloid                                        191
+  Fibroma                                       192
+  Neuroma                                       194
+  Xanthoma                                      195
+  Myoma                                         196
+  Angioma                                       196
+  Telangiectasis                                197
+  Lymphangioma                                  198
+  Rhinoscleroma                                 198
+  Lupus Erythematosus                           199
+  Lupus Vulgaris                                203
+  Tuberculosis Cutis                            209
+  Ainhum                                        212
+  Mycetoma                                      212
+  Perforating Ulcer of the Foot                 213
+  Syphilis Cutanea                              213
+  Lepra                                         231
+  Pellagra                                      235
+  Epithelioma                                   236
+  Paget's Disease of the Nipple                 240
+  Sarcoma                                       241
+  Granuloma Fungoides                           242
+
+CLASS VII.--NEUROSES                            244
+  Hyperaesthesia                                 244
+  Dermatalgia                                   244
+  Anaesthesia                                    244
+  Pruritus                                      244
+
+CLASS VIII.--PARASITIC AFFECTIONS               247
+  Tinea Favosa                                  247
+  Tinea Trichophytina                           251
+  Tinea Imbricata                               261
+  Tinea Versicolor                              262
+  Erythrasma                                    265
+  Actinomycosis                                 266
+  Blastomycetic Dermatitis                      266
+  Scabies                                       267
+  Pediculosis                                   271
+  Pediculosis Capitis                           272
+  Pediculosis Corporis                          274
+  Pediculosis Pubis                             275
+  Cysticercus Cellulosae                         276
+  Filaria Medinensis                            277
+  Ixodes                                        277
+  Leptus                                        277
+  [OE]strus                                     278
+  Pulex Penetrans                               278
+  Cimex Lectularius                             278
+  Culex                                         279
+  Pulex Irritans                                279
+
+TABLE showing Relative Frequency of the Various
+  Diseases of the Skin                          280
+
+
+
+
+DISEASES OF THE SKIN.
+
+#ANATOMY OF THE SKIN.#
+
+
+[Illustration: Fig. I.
+  Vertical section of the skin--Diagrammatic. (_After Heitsmann._)]
+
+
+
+
+                            #The Epidermis.#
+
+
+[Illustration: Fig. 2.
+  _c_, corneous (horny) layer; _g_, granular layer; _m_, mucous layer
+  (rete Malpighii).
+  The stratum lucidum is the layer just above the granular layer.
+  Nerve terminations--_n_, afferent nerve; _b_, terminal nerve bulbs;
+  _l_, cell of Langerhans. (_After Ranvier._)]
+
+
+
+
+                           #The Blood-vessels.#
+
+
+[Illustration: Fig. 3.
+  _C_, epidermis; _D_, corium; _P_, papillae; _S_, sweat-gland duct.
+  _v_, arterial and venous capillaries (superficial, or papillary plexus)
+  of the papillae. Deep plexus is partly shown at lower margin of the
+  diagram; _vs_--an intermediate plexus, an outgrowth from the deep
+  plexus, supplying sweat-glands, and giving a loop to hair papilla.
+  (_After Ranvier._)]
+
+
+
+
+                   #The Nervous and Vascular Papillae.#
+
+
+[Illustration: Fig. 4.
+  _a_, a vascular papilla; _b_, a nervous papilla; _c_, a blood-vessel;
+  _d_, a nerve fibre; _e_, a tactile corpuscle. (_After Biesiadecki._)]
+
+
+
+
+                      #The Hair and Hair-Follicle.#
+
+
+[Illustration: Fig. 5. _A_, shaft of the hair; _B_, root of the hair;
+_C_, cuticle of the hair; _D_, medullary substance of the hair. _E_,
+external layer of the hair-follicle; _F_, middle layer of the
+hair-follicle; _G_, internal layer of the hair-follicle; _H_, papilla of
+the hair; _I_, external root-sheath; _J_, outer layer of the internal
+root-sheath; _K_, internal layer of the internal root-sheath. (_After
+Duhring._)]
+
+
+
+
+#SYMPTOMATOLOGY.#
+
+
+The symptoms of cutaneous disease may be objective, subjective or both;
+and in some diseases, also, there may be systemic disturbance.
+
+
+#What do you mean by objective symptoms?#
+
+Those symptoms visible to the eye or touch.
+
+
+#What do you understand by subjective symptoms?#
+
+Those which relate to sensation, such as itching, tingling, burning,
+pain, tenderness, heat, anaesthesia, and hyperaesthesia.
+
+
+#What do you mean by systemic symptoms?#
+
+Those general symptoms, slight or profound, which are sometimes
+associated, primarily or secondarily, with the cutaneous disease, as,
+for example, the systemic disturbance in leprosy, pemphigus, and purpura
+hemorrhagica.
+
+
+#Into what two classes of lesions are the objective symptoms commonly
+divided?#
+
+    Primary (or elementary), and
+    Secondary (or consecutive).
+
+
+
+                          #Primary Lesions.#
+
+
+#What are primary lesions?#
+
+Those objective lesions with which cutaneous diseases begin. They may
+continue as such or may undergo modification, passing into the secondary
+or consecutive lesions.
+
+
+#Enumerate the primary lesions.#
+
+Macules, papules, tubercles, wheals, tumors, vesicles, blebs and
+pustules.
+
+
+#What are macules (maculae)?#
+
+Variously-sized, shaped and tinted spots and discolorations, without
+elevation or depression; as, for example, freckles, spots of purpura,
+macules of cutaneous syphilis.
+
+
+#What are papules (papulae)?#
+
+Small, circumscribed, solid elevations, rarely exceeding the size of a
+split-pea, and usually superficially seated; as, for example, the
+papules of eczema, of acne, and of cutaneous syphilis.
+
+
+#What are tubercles (tubercula)?#
+
+Circumscribed, solid elevations, commonly pea-sized and usually
+deep-seated; as, for example, the tubercles of syphilis, of leprosy, and
+of lupus.
+
+
+#What are wheals (pomphi)?#
+
+Variously-sized and shaped, whitish, pinkish or reddish elevations, of
+an evanescent character; as, for example, the lesions of urticaria, the
+lesions produced by the bite of a mosquito or by the sting of a nettle.
+
+
+#What are tumors (tumores)?#
+
+Soft or firm elevations, usually large and prominent, and having their
+seat in the corium and subcutaneous tissue; as, for example, sebaceous
+tumors, gummata, and the lesions of fibroma.
+
+
+#What are vesicles (vesiculae)?#
+
+Pin-head to pea-sized, circumscribed epidermal elevations, containing
+serous fluid; as, for example, the so-called fever-blisters, the lesions
+of herpes zoster, and of vesicular eczema.
+
+
+#What are blebs (bullae)?#
+
+Rounded or irregularly-shaped, pea to egg-sized epidermic elevations,
+with fluid contents; in short, they are essentially the same as vesicles
+and pustules except as to size; as, for example, the blebs of pemphigus,
+rhus poisoning, and syphilis.
+
+
+#What are pustules (pustulae)?#
+
+Circumscribed epidermic elevations containing pus; as, for example, the
+pustules of acne, of impetigo, and of sycosis.
+
+
+
+                        #Secondary Lesions.#
+
+
+#What are secondary lesions?#
+
+Those lesions resulting from accidental or natural change, modification
+or termination of the primary lesions.
+
+
+#Enumerate the secondary lesions.#
+
+Scales, crusts, excoriations, fissures, ulcers, scars and stains.
+
+
+#What are scales (squamae)?#
+
+Dry, laminated, epidermal exfoliations; as, for example, the scales of
+psoriasis, ichthyosis, and eczema.
+
+
+#What are crusts (crustae)?#
+
+Dried effete masses of exudation; as, for example, the crusts of
+impetigo, of eczema, and of the pustular and ulcerating syphilodermata.
+
+
+#What are excoriations (excoriationes)?#
+
+Superficial, usually epidermal, linear or punctate loss of tissue; as,
+for example, ordinary scratch-marks.
+
+
+#What are fissures (rhagades)?#
+
+Linear cracks or wounds, involving the epidermis, or epidermis and
+corium; as, for example, the cracks which often occur in eczema when
+seated about the joints, the cracks of chapped lips and hands.
+
+
+#What are ulcers (ulcera)?#
+
+Rounded or irregularly-shaped and sized loss of skin and subcutaneous
+tissue resulting from disease; as, for example, the ulcers of syphilis
+and of cancer.
+
+
+#What are scars (cicatrices)?#
+
+Connective-tissue new formations replacing loss of substance.
+
+
+#What are stains?#
+
+Discolorations left by cutaneous disease, which stains may be transitory
+or permanent.
+
+
+
+                     #Distribution and Configuration.#
+
+
+#What do you mean by a patch of eruption?#
+
+A single group or aggregation of lesions or an area of disease.
+
+
+#When is an eruption said to be limited or localized?#
+
+When it is confined to one part or region.
+
+
+#When is an eruption said to be general or generalized?#
+
+When it is scattered, uniformly or irregularly, over the entire surface.
+
+
+#When is an eruption universal?#
+
+When the whole integument is involved, without any intervening healthy
+skin.
+
+
+#When is an eruption said to be discrete?#
+
+When the lesions constituting the eruption are isolated, having more or
+less intervening normal skin.
+
+
+#When is an eruption confluent?#
+
+When the lesions constituting the eruption are so closely crowded that a
+solid sheet results.
+
+
+#When is an eruption uniform?#
+
+When the lesions constituting the eruption are all of one type or
+character.
+
+
+#When is an eruption multiform?#
+
+When the lesions constituting the eruption are of two or more types or
+characters.
+
+
+#When are lesions said to be aggregated?#
+
+When they tend to form groups or closely-crowded patches.
+
+
+#When are lesions disseminated?#
+
+When they are irregularly scattered, with no tendency to form groups or
+patches.
+
+
+#When is a patch of eruption said to be circinate?#
+
+When it presents a rounded form, and usually tending to clear in the
+centre; as, for example, a patch of ringworm.
+
+
+#When is a patch of eruption said to be annular?#
+
+When it is ring-shaped, the central portion being clear; as, for
+example, in erythema annulare.
+
+
+#What meaning is conveyed by the term "iris"?#
+
+The patch of eruption is made up of several concentric rings. Difference
+of duration of the individual rings, usually slight, tends to give the
+patch variegated coloration; as, for example, in erythema iris and
+herpes iris.
+
+
+#What meaning is conveyed by the term "marginate"?#
+
+The sheet of eruption is sharply defined against the healthy skin; as,
+for example, in erythema marginatum, eczema marginatum.
+
+
+#What meaning is conveyed by the qualifying term "circumscribed"?#
+
+The term is applied to small, usually more or less rounded, patches,
+when sharply defined; as, for example, the typical patches of psoriasis.
+
+
+#When is the qualifying term "gyrate" employed?#
+
+When the patches arrange themselves in an irregular winding or
+festoon-like manner; as, for instance, in some cases of psoriasis. It
+results, usually, from the coalescence of several rings, the eruption
+disappearing at the points of contact.
+
+
+#When is an eruption said to be serpiginous?#
+
+When the eruption spreads at the border, clearing up at the older part;
+as, for instance, in the serpiginous syphiloderm.
+
+
+
+                         #RELATIVE FREQUENCY.#
+
+
+#Name the more common cutaneous diseases and state approximately their
+frequency.#
+
+Eczema, 30.4%; syphilis cutanea, 11.2%; acne, 7.3%; pediculosis, 4%;
+psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies, 2.6%;
+urticaria, 2.5%; pruritus, 2.1%; seborrh[oe]a, 2.1%; herpes simplex,
+1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%; verruca, 1.1%;
+tinea versicolor, 1%. Total: eighteen diseases, representing 81 per
+cent. of all cases met with.
+
+(These percentages are based upon statistics, public and private, of the
+American Dermatological Association, covering a period of ten years. In
+private practice the proportion of cases of pediculosis, scabies, favus,
+and impetigo is much smaller, while acne, acne rosacea, seborrh[oe]a,
+epithelioma, and lupus are relatively more frequent.)
+
+
+
+                           #CONTAGIOUSNESS.#
+
+
+#Name the more actively contagious skin diseases.#
+
+Impetigo contagiosa, ringworm, favus, scabies and pediculosis; excluding
+the exanthemata, erysipelas, syphilis and certain rare and doubtful
+diseases.
+
+[At the present time when most diseases are presumed to be due to
+bacteria or parasites the belief in contagiousness, under certain
+conditions, has considerably broadened.]
+
+
+
+                          #RAPIDITY OF CURE.#
+
+
+#Is the rapid cure of a skin disease fraught with any danger to the
+patient?#
+
+No. It was formerly so considered, especially by the public and general
+profession, and the impression still holds to some extent, but it is not
+in accord with dermatological experience.
+
+
+
+                           #OINTMENT BASES.#
+
+
+#Name the several fats in common use for ointment bases.#
+
+Lard, petrolatum (or cosmoline or vaseline), cold cream and lanolin.
+
+
+#State the relative advantages of these several bases.#
+
+_Lard_ is the best all-around base, possessing penetrating properties
+scarcely exceeded by any other fat.
+
+_Petrolatum_ is also valuable, having little, if any, tendency to
+change; it is useful as a protective, but is lacking in its power of
+penetration.
+
+_Cold Cream_ (ungt. aquae rosae) is soothing and cooling, and may often be
+used when other fatty applications disagree.
+
+_Lanolin_ is said to surpass in its power of penetration all other
+bases, but this is not borne out by experience. It is an unsatisfactory
+base when used alone. It should be mixed with another base in about the
+proportion of 25% to 50%.
+
+These several bases may, and often with advantage, be variously
+combined.
+
+
+#What is to be added to these several bases if a stiffer ointment is
+required?#
+
+Simple cerate, wax, spermaceti, or suet; or in some instances, a
+pulverulent substance, such as starch, boric acid, and zinc oxide.
+
+
+
+
+#CLASS I.--DISORDERS OF THE GLANDS.#
+
+
+                           #Hyperidrosis.#
+
+
+[Illustration: Fig. 6.
+  A normal sweat-gland, highly magnified. (_After Neumann._)
+  _a_, Sweat-coil: _b_, sweat-duct; _c_, lumen of duct; _d_,
+  connective-tissue capsule; _e_ and _f_, arterial trunk and
+  capillaries.]
+
+
+#What is hyperidrosis?#
+
+Hyperidrosis is a functional disturbance of the sweat-glands,
+characterized by an increased production of sweat. This increase may be
+slight or excessive, local or general.
+
+
+#As a local affection, what parts are most commonly involved?#
+
+The hands, feet, especially the palmar and plantar surfaces, the axillae
+and the genitalia.
+
+
+#Describe the symptoms of the local forms of hyperidrosis.#
+
+The essential, and frequently the sole symptom, is more or less profuse
+sweating.
+
+If the hands are the parts involved, they are noted to be wet, clammy
+and sometimes cold.
+
+If involving the soles, the skin often becomes more or less macerated
+and sodden in appearance, and as a result of this maceration and
+continued irritation they may become inflamed, especially about the
+borders of the affected parts, and present a pinkish or pinkish-red
+color, having a violaceous tinge. The sweat undergoes change and becomes
+offensive.
+
+
+#Is hyperidrosis acute or chronic?#
+
+Usually chronic, although it may also occur as an acute affection.
+
+
+#What is the etiology of hyperidrosis?#
+
+Debility is commonly the cause in general hyperidrosis; the local forms
+are probably neurotic in origin.
+
+
+#What is the prognosis?#
+
+The disease is usually persistent and often rebellious to treatment; in
+many instances a permanent cure is possible, in others palliation.
+Relapses are not uncommon.
+
+
+#What systemic remedies are employed in hyperidrosis?#
+
+Ergot, belladonna, gallic acid, mineral acids, and tonics.
+Constitutional treatment is rarely of benefit in the local forms of
+hyperidrosis, and external applications are seldom of service in general
+hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is also
+well spoken of, combined, if necessary, with an astringent.
+
+
+#What external remedies are employed in the local forms?#
+
+Astringent lotions of zinc sulphate, tannin and alum, applied several
+times daily, with or without the supplementary use of dusting-powders.
+Weak solutions of formaldehyde, one to one hundred, are sometimes of
+value.
+
+Dusting-powders of boric acid and zinc oxide, to which may be added from
+ten to thirty grains of salicylic acid to the ounce, to be used freely
+and often:--
+
+  [Rx] Pulv. ac. salicylici ................. gr. x-xxx.
+       Pulv. ac. borici ..................... [dram]v.
+       Pulv. zinci oxidi .................... [dram]iij     M.
+
+Diachylon ointment, and an ointment containing a drachm of tannin to the
+ounce; more especially applicable in hyperidrosis of the feet. The parts
+are first thoroughly washed, rubbed dry with towels and dusting-powder,
+and the ointment applied on strips of muslin or lint and bound on; the
+dressing is renewed twice daily, the parts each time being rubbed dry
+with soft towels and dusting-powder, and the treatment continued for ten
+days to two weeks, after which the dusting-powder is to be used alone
+for several weeks. No water is to be used after the first washing until
+the ointment is discontinued. One such course will occasionally suffice,
+but not infrequently a repetition is necessary.
+
+Faradization and galvanization are sometimes serviceable. Repeated mild
+exposures to the Roentgen rays have a favorable influence in some
+instances.
+
+
+
+                              #Sudamen.#
+                 (_Synonym:_ Miliaria crystallina.)
+
+
+#What is sudamen?#
+
+Sudamen is a non-inflammatory disorder of the sweat-glands,
+characterized by pin-point to pin-head-sized, discrete but thickly-set,
+superficial, translucent whitish vesicles.
+
+
+#Describe the clinical characters.#
+
+The lesions develop rapidly and in great numbers, either irregularly or
+in crops, and are usually to be seen as discrete, closely-crowded,
+whitish, or pearl-colored minute elevations, occurring most abundantly
+upon the trunk. In appearance they resemble minute dew-drops. They are
+non-inflammatory, without areola, never become purulent, and evince no
+tendency to rupture, the fluid disappearing by absorption, and the
+epidermal covering by desquamation.
+
+
+#Give the course and duration of sudamen.#
+
+New crops may appear as the older lesions are disappearing, and the
+affection persist for some time, or, on the other hand, the whole
+process may come to an end in several days or a week. In short, the
+course and duration depend upon the subsidence or persistence of the
+cause.
+
+
+#What is the anatomical seat of sudamen?#
+
+The lesions are formed between the lamellae of the corneous layer,
+usually the upper part; and are thought to be due to some change in the
+character of the epithelial cells of this layer, probably from high
+temperature, giving rise to a blocking up of the surface outlet.
+
+
+#What is the cause of sudamen?#
+
+Debility, especially when associated with high fever. The eruption is
+often seen in the course of typhus, typhoid and rheumatic fevers.
+
+
+#How would you treat sudamen?#
+
+By constitutional remedies directed against the predisposing factor or
+factors, and the application of cooling lotions of vinegar or alcohol
+and water, or dusting-powders of starch and lycopodium.
+
+
+
+                            #Hydrocystoma.#
+
+
+#Describe hydrocystoma.#
+
+Hydrocystoma is a cystic affection of the sweat-gland ducts, seated upon
+the face. The lesions may be present in scant numbers or in more or less
+profusion. They have the appearance of boiled sago grains imbedded in
+the skin; the larger lesions may have a bluish color, especially about
+the periphery. It is not common, and is usually seen in washerwomen and
+laundresses, or those exposed to moist heat. In some cases it tends to
+disappear during the winter months. There are no subjective symptoms.
+
+Treatment consists of puncturing the lesions and application of
+dusting-powder. Avoidance of the exciting cause (moist heat) is
+important.
+
+
+
+                             #Anidrosis.#
+
+
+#Describe anidrosis.#
+
+It is the opposite condition of hyperidrosis, and is characterized by
+diminution or suppression of the sweat secretion. It occurs to some
+extent in certain systemic diseases and also in some affections of the
+skin, such as ichthyosis; nerve-injuries may give rise to localized
+sweat-suppression.
+
+Treatment is based upon general principles; friction, warm and hot-vapor
+baths, electricity and similar measures are of service.
+
+
+
+                             #Bromidrosis.#
+                        (_Synonym:_ Osmidrosis.)
+
+
+#Describe bromidrosis.#
+
+Bromidrosis is a functional disturbance of the sweat-glands
+characterized by a sweat secretion of an offensive odor. The sweat
+production may be normal in quantity or more or less excessive, usually
+the latter. The condition may be local or general, commonly the former.
+It is closely allied to hyperidrosis, and may often be considered
+identical, the odor resulting from rapid decomposition of the sweat
+secretion. The decomposition and resulting odor have been thought due to
+the presence of bacteria.
+
+
+#What parts are most commonly affected in bromidrosis?#
+
+The feet and the axillae.
+
+
+#What is the treatment of bromidrosis?#
+
+It is essentially the same as that of hyperidrosis (_q. v._), consisting
+of applications of astringent lotions, dusting-powders, especially those
+containing boric acid and salicylic acid, and the continuous application
+of diachylon ointment. In obstinate cases weak formaldehyde solutions,
+Roentgen rays, and high-frequency currents can be tried.
+
+
+
+                              #Chromidrosis.#
+
+
+#Describe chromidrosis.#
+
+This is a functional disorder of the sweat-glands characterized by a
+secretion variously colored, and usually increased in quantity. It is,
+as a rule, limited to a circumscribed area. The most common color is
+red. The condition is probably of neurotic origin and tends to recur.
+(True chromidrosis is extremely rare; most of the cases formerly thought
+to be such are now known to be examples of pseudochromidrosis.)
+
+Treatment should be invigorating and tonic, with special reference
+toward the nervous system. The various methods of local electrization
+should also be resorted to.
+
+Mild antiseptic and astringent lotions or dusting powders should also be
+advised.
+
+_Red chromidrosis_ or _Pseudochromidrosis_ is a condition in which the
+coloring of the sweat occurs after its excretion and is due to the
+presence of chromatogenous bacteria which are found attached to the
+hairs of the part in agglutinated masses. The axilla is the favorite
+site. Treatment consists of frequent soap-and-water washings, and the
+application of boric acid, resorcin, and corrosive sublimate lotions.
+
+
+
+                              #Uridrosis.#
+
+
+#Describe uridrosis.#
+
+Uridrosis is a rare condition in which the sweat secretion contains the
+elements of the urine, especially urea. In marked cases the salt may be
+noticeable upon the skin as a colorless or whitish crystalline deposit.
+In most instances it has been preceded or accompanied by partial or
+complete suppression of the renal functions.
+
+
+
+                            #Phosphoridrosis.#
+
+
+#Describe phosphoridrosis.#
+
+Phosphoridrosis is a rare condition, in which the sweat is
+phosphorescent. It has been observed in the later stages of phthisis, in
+miliaria, and in those who have eaten of putrid fish.
+
+
+
+                   #Seborrh[oe]a (Eczema Seborrhoicum).#
+ _Synonyms:_ (Steatorrh[oe]a; Acne sebacea; Ichthyosis sebacea; Dandruff.)
+
+
+#What is seborrh[oe]a?#
+
+Seborrh[oe]a 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.
+
+In many cases the sweat-glands are likewise implicated, and the process
+may also be distinctly, although usually mildly, inflammatory.
+
+
+#At what age is seborrh[oe]a usually observed?#
+
+Between fifteen and forty. It may, however, occur at any age.
+
+
+#Name the parts most commonly affected.#
+
+The scalp, face, and (less frequently) the sternal and interscapular
+regions of the trunk. It is sometimes seen on other parts.
+
+
+#What varieties of seborrh[oe]a are encountered?#
+
+Seborrh[oe]a oleosa and seborrh[oe]a sicca; not infrequently the disease
+is of a mixed type.
+
+
+#What are the symptoms of seborrh[oe]a oleosa?#
+
+The sole symptom is an unnatural oiliness, variable as to degree. Its
+most common sites are the regions of the scalp, nose, and forehead. In
+many instances mild rosacea coexists with oily seborrh[oe]a of the nose.
+
+
+#Give the symptoms of seborrh[oe]a sicca.#
+
+A variable degree of greasy scalines, which may be seated upon a pale,
+hyperaemic or mildly inflammatory surface.
+
+The parts affected are covered scantily or more or less abundantly with
+somewhat greasy, grayish, or brownish-gray scales. If upon the scalp
+(_dandruff_, _pityriasis capitis_), small particles of scales are found
+scattered through the hair, and when the latter is brushed or combed,
+fall over the shoulders. If upon the face, in addition to the scaliness,
+the sebaceous ducts are usually seen to be enlarged and filled with
+sebaceous matter.
+
+
+#Describe the symptoms of the ordinary or mixed type.#
+
+It is common upon the scalp. The skin is covered with irregularly
+diffused, greasy, grayish or brownish scales and crusts, in some cases
+moderate in quantity, in others so great that large irregular masses are
+formed, pasting the hair to the scalp. If removed, the scales and crusts
+rapidly re-form. The skin beneath is found slate-colored, hyperaemic or
+mildly inflammatory, and exceptionally it has in places an eczematous
+aspect (_eczema seborrhoicum_). Extraneous matter, such as dust and
+dirt, collects upon the parts, and the whole mass may become more or
+less offensive. There is a strong tendency to falling-out of the hair.
+Itching may or may not be present.
+
+[Illustration: Seborrh[oe]a (Eczema Seborrhoicum).]
+
+
+#Describe the symptoms of seborrh[oe]a of the trunk and other parts.#
+
+[Illustration: Fig. 7.
+  A normal sebaceous gland in connection with a lanugo hair.
+  (_After Neumann._)
+  _a_, Capsule; _b_, fatty secretion; _c_, _h_, secreting cells; _d_, root
+  of lanugo hair; _e_, hair-sac; _f_, hair-shaft; _g_, acini of sebaceous
+  gland.]
+
+Seborrh[oe]a corporis differs in a measure, in its symptoms, from
+seborrh[oe]a of the scalp and is usually illustrative of the variety
+known as eczema seborrhoicum; it occurs as one or several irregular or
+circinate, slightly hyperaemic or moderately inflammatory patches,
+covered with dirty or grayish-looking greasy scales or crusts, usually
+moderate in quantity, and upon removal are found to have projections
+into the sebaceous ducts. It is commonly seen upon the sternal and
+interscapular regions. It rarely exists independently in these regions,
+being usually associated with and following the disease on the scalp. It
+may also invade the axillae, genitocrural, and other regions.
+
+
+#What is the usual course of seborrh[oe]a?#
+
+Essentially chronic, the disease varying in intensity from time to time.
+In occasional instances it disappears spontaneously.
+
+
+#Give the cause or causes of seborrh[oe]a.#
+
+General debility, anaemia, chlorosis, dyspepsia, and similar conditions
+are to be variously looked upon as predisposing.
+
+In some instances, however, the disease seems to be purely local in
+character, and to be entirely independent of any constitutional or
+predisposing condition. The view recently advanced that the disease is
+of parasitic nature and contagious has been steadily gaining ground.
+
+
+#What is the pathology of seborrh[oe]a?#
+
+Seborrh[oe]a is a disease of the sebaceous glands, and probably often
+involving the sweat-glands also; its products, as found upon the skin,
+consisting of the sebaceous secretion, epithelial cells from the glands
+and ducts, and more or less extraneous matter. Not infrequently
+evidences of superficial inflammatory action are also to be found, and
+it is especially for this type that the name eczema seborrhoicum is most
+appropriate. In long-continued and neglected cases slight atrophy of the
+gland-structures may occur.
+
+
+#With what diseases are you likely to confound seborrh[oe]a?#
+
+Upon the scalp, with eczema and psoriasis; upon the face, with lupus
+erythematosus and eczema; and upon the trunk, with psoriasis and
+ringworm.
+
+As a rule, the clinical features of seborrh[oe]a are sufficiently
+characteristic to prevent error.
+
+
+#What are the differential points?#
+
+Eczema, psoriasis, and lupus erythematosus are diseases in which there
+are distinct _inflammatory symptoms_, such as thickening and
+infiltration and redness; moreover, psoriasis, and this holds true as to
+ringworm also, occurs in sharply-defined, circumscribed patches, and
+lupus erythematosus has a peculiar violaceous tint and an elevated and
+marginate border. A microscopic examination of the epidermic scrapings
+would be of crucial value in differentiating from ringworm.
+
+Quite frequently, especially in the interscapular and sternal regions,
+the segmental configuration constitutes an important feature of
+seborrh[oe]a--of the eczema seborrhoicum variety.
+
+
+#What is the prognosis in seborrh[oe]a?#
+
+Favorable. All types are curable, and when upon the non-hairy regions,
+usually readily so; upon the scalp it is often obstinate. Relapses are
+not uncommon.
+
+In those cases of seborrh[oe]a capitis which have been long-continued or
+neglected, and attended with loss of hair, this loss may be more or less
+permanent, although ordinarily much can be done to promote a regrowth
+(see _Treatment of Alopecia_).
+
+
+#How would you treat seborrh[oe]a of the scalp?#
+
+By constitutional (if indicated) and local remedies; the former having
+in view correction or modification of the predisposing factor or
+factors, and the latter removal of the sebaceous accumulations and the
+application of mildly stimulating antiseptic ointments or lotions.
+
+
+#What constitutional remedies are commonly employed?#
+
+The various tonics, such as iron, quinine, strychnia, cod-liver oil,
+arsenic, the vegetable bitters, laxatives, malt and similar
+preparations. The line of treatment is to be based upon indications.
+
+
+#How do you free the scalp of the sebaceous accumulations?#
+
+In mild types of the disease shampooing with simple Castile soap (or any
+other good toilet soap) and hot water will suffice; in those cases in
+which there is considerable scale-and crust-formation the tincture of
+green soap (tinct. saponis viridis) is to be employed in place of the
+toilet soap, and in some of these latter cases it may be necessary to
+soften the crusts with a previous soaking with olive oil.
+
+The frequency of the shampoo depends upon the conditions. In mild cases
+once in five or ten days will be sufficiently frequent to keep the parts
+clean, but in those cases in which there is rapid scale-or
+crust-production once daily or every second day may at first be
+demanded.
+
+
+#Name the most effectual applications in seborrh[oe]a capitis.#
+
+Sulphur, ammoniated mercury, salicylic acid, resorcin, and carbolic
+acid.
+
+Sulphur is used in the form of an ointment, from twenty grains to one
+drachm in the ounce. Ammoniated mercury, in the form of an ointment, ten
+to sixty grains to the ounce. Salicylic acid, either alone as an
+ointment, ten to thirty grains to the ounce; or it may often be added
+with advantage, in the same proportion, to the sulphur or ammoniated
+mercury ointment above named. Resorcin, either as an ointment, ten to
+thirty grains to the ounce, or as an alcoholic or aqueous lotion, as the
+following:--
+
+  [Rx] Resorcini ............................ [dram]j-[dram]iss.
+       Ol. ricini ........................... [minim]xxx-f[dram]ij.
+       Alcoholis ............................ f[Oz]iv.                M.
+
+Carbolic acid, to the amount of ten to thirty grains, can be added to
+this. If an aqueous lotion is desirable, then in the above formula the
+oleum ricini is replaced with glycerine, and the alcohol with water;
+three to five minims of glycerine in each ounce is usually sufficient,
+as a greater quantity makes the resulting lotion sticky. Petrolatum
+alone, or with 10 to 30 per cent. lanolin, is usually the most
+satisfactory base for the ointments. In some cases of the inflammatory
+variety the skin is found quite irritable, and the mildest applications
+are at first only admissible.
+
+
+#How are the remedies to be applied?#
+
+A small quantity of the lotion, ointment, or oil is gently applied to
+the skin; when to the scalp, a lotion or oil can be conveniently applied
+by means of an eye-dropper. In the beginning of the treatment an
+application once or twice daily is ordered; later, as the disease
+becomes less active, once every second or third day.
+
+
+#How is seborrh[oe]a upon other parts to be treated?#
+
+In the same general manner as seborrh[oe]a of the scalp, except that the
+local applications must be somewhat weaker. The several sulphur lotions
+employed in the treatment of acne (_q. v._) may also be used when the
+disease is upon these parts. In obstinate patchy cases occasional
+paintings with a 20 to 50 per cent alcoholic solution of resorcin is
+curative; following the painting a mild salve should be used.
+
+
+
+                               #Comedo.#
+                 (_Synonyms:_ Blackheads; Flesh-worms.)
+
+
+#What is comedo?#
+
+Comedo is a disorder of the sebaceous glands, characterized by yellowish
+or blackish pin-point or pin-head-sized puncta or elevations
+corresponding to the gland-orifices.
+
+
+#At what age and upon what parts are comedones found?#
+
+Usually between fifteen and thirty, and upon the face and upper part of
+the trunk, where they may exist sparsely or in great numbers. They are
+occasionally associated with oily seborrh[oe]a, the parts presenting a
+greasy or soiled appearance.
+
+Exceptionally they occur as distinct, and usually symmetrical, groups
+upon the forehead or the cheeks. On the upper trunk so-called double and
+multiple comedo have been noted--the two, three, or even four
+closely-contiguous blackheads are, beneath the surface,
+intercommunicable, the dividing duct-walls having apparently disappeared
+by fusion.
+
+
+#Describe an individual lesion.#
+
+It is pin-point to pin-head in size, dark yellowish, and usually with a
+central blackish point (hence the name _blackheads_). There is scarcely
+perceptible elevation, unless the amount of retained secretion is
+excessive. Upon pressure this may be ejected, the small, rounded orifice
+through which it is expressed giving it a thread-like shape (hence the
+name _flesh-worms_).
+
+
+#What is the usual course of comedo?#
+
+Chronic. The lesions may persist indefinitely or the condition may be
+somewhat variable. In many instances, either as a result of pressure or
+in consequence of chemical change in the sebaceous plugs or of the
+addition of a microbic factor, inflammation is excited and acne results.
+The two conditions are, in fact, usually associated.
+
+[Illustration: Fig. 8.
+  Demodex Folliculorum, X 300. Ventral surface. (_After Simon._)]
+
+
+#To what may comedo often be ascribed?#
+
+To disorders of digestion, constipation, chlorosis, menstrual
+disturbance, lack of tone in the muscular fibres of the skin, the
+infrequent use of soap, and working in a dirty or dusty atmosphere.
+
+A small parasite (_demodex folliculorum_, _acarus folliculorum_) is
+sometimes found in the sebaceous mass, but its presence is without
+etiological significance, as it is also found in healthy follicles. A
+microbacillus has been found by several observers, and credited with
+etiological influence.
+
+
+#What is the pathology of comedo?#
+
+The sebaceous ducts or glands, or both, become blocked up with retained
+secretion and epithelial cells. The dark points which usually mark the
+lesions are probably due to accumulation of dirt, but may, as some
+writers maintain, be due to the presence of pigment-granules resulting
+from chemical change in the sebaceous matter.
+
+
+#Is there any difficulty in the diagnosis of comedo?#
+
+No. It can scarcely be confounded with milium, as in this latter disease
+the lesion has no open outlet, no black point, and the contents cannot
+be squeezed out.
+
+
+#Give the prognosis of comedo.#
+
+The result of treatment is usually favorable, although the disease is
+often rebellious. Relapses are not uncommon.
+
+
+#How would you treat a case of comedo?#
+
+By systemic (if indicated) and local measures.
+
+The constitutional treatment aims at correction or palliation of the
+predisposing conditions, and the external applications have in view a
+removal of the sebaceous plugs and stimulation of the glands and skin to
+healthy action.
+
+[Illustration: Fig. 9. Comedo Extractor.]
+
+
+#Name the systemic remedies commonly employed.#
+
+Cod-liver oil, iron, quinine, arsenic, nux vomica and other tonics;
+ergot in those cases in which there is lack of muscular tone, salines
+and aperient pills in constipation. The digestion is to be looked after
+and the bowels kept regular; indigestible food of all kinds is to be
+interdicted. Hygienic measures, such as general and local bathing, local
+massage, calisthenics, and open-air exercise, are of service.
+
+
+#Describe the local treatment.#
+
+Steaming the face or prolonged applications of hot water; washing with
+ordinary toilet soap and hot water, or, in sluggish cases, using
+tincture of green soap (tinct. saponis viridis) instead of the toilet
+soap; removal of the sebaceous plugs by mechanical means, such as
+lateral pressure with the finger ends or perpendicular pressure with a
+watch-key with rounded edges, or with an instrument specially contrived
+for this purpose; and after these preliminary measures, which should be
+carried out every night, a stimulating sulphur ointment or lotion, such
+as employed in the treatment of acne (_q. v._), is to be thoroughly
+applied. The following is valuable:--
+
+  [Rx] Zinci sulphatis,
+       Potassi sulphureti, . [=a][=a] ....... [dram]j-[dram]iv.
+       Alcoholi ............................. f[Oz]ss.
+       Aquae, ................. q.s. ad ...... f[Oz]iv.            M.
+
+Should slight scaliness or a mild degree of irritation of the skin be
+brought about, active external treatment is to be discontinued for a few
+days and soothing applications made. Resorcin, in lotion, 3 to 25 per
+cent strength, is through the exfoliation it provokes, frequently of
+value; the resorcin paste referred to in acne can also be used for this
+purpose.
+
+Moderately strong applications of the Faradic current, repeated once or
+twice weekly, are sometimes of service; also weak to moderately strong
+applications of the continuous and high-frequency currents. Roentgen-ray
+treatment can also be resorted to in extremely obstinate cases.
+
+In occasional instances sulphur preparations not only fail to do good,
+but materially aggravate the condition. In such cases, if resorcin
+preparations also fail, the mercurial lotion and ointment employed in
+acne may be prescribed. Mercurial and sulphur applications should not be
+used, it need scarcely be said, within a week or ten days of each other,
+otherwise an increase in the comedones and a slight darkening of the
+skin result from the formation of the black sulphuret of mercury.
+
+
+
+                             #Milium.#
+             (_Synonyms:_ Grutum; Strophulus Albidus.)
+
+
+#What is milium?#
+
+Milium consists in the formation of small, whitish or yellowish,
+rounded, pearly, non-inflammatory elevations situated in the upper part
+of the corium.
+
+
+#Describe the clinical appearances.#
+
+The lesions are usually pin-head in size, whitish or yellowish,
+seemingly more or less translucent, rounded or acuminated, without
+aperture or duct, are superficially seated in the skin, and project
+slightly above the surface.
+
+They appear about the face, especially about the eyelids; they may occur
+also, although rarely, upon other parts. But one or several may be
+present, or they may exist in numbers.
+
+
+#What is the course of milium?#
+
+The lesions develop slowly, and may then remain stationary for years.
+Their presence gives rise to no disturbance, and, unless they are large
+in size or exist in numbers, causes but slight disfigurement.
+
+[Illustration: Fig. 10. Milium Needle.]
+
+In rare instances they may undergo calcareous metamorphosis,
+constituting the so-called _cutaneous calculi_.
+
+
+#What is the anatomical seat of milium?#
+
+The sebaceous gland (probably one or several of the
+superficially-situated acini), the duct of which is in some manner
+obliterated, the sebaceous matter collects, becomes inspissated and
+calcareous, forming the pin-head lesion. The epidermis is the external
+covering.
+
+
+#What is the treatment?#
+
+The usual plan is to prick or incise each lesion and press out the
+contents. In some milia it may be necessary also, in order to prevent a
+return, to touch the base of the excavation with tincture of iodine or
+with silver nitrate. Electrolysis is also effectual. In those cases
+where the lesions are numerous the production of exfoliation of the
+epiderm by means of resorcin applications (see acne) is a good plan.
+
+
+
+                             #Steatoma.#
+          (_Synonyms:_ Sebaceous Cyst; Sebaceous Tumor; Wen.)
+
+
+#Describe steatoma.#
+
+Steatoma, or sebaceous cyst, appears as a variously-sized, elevated,
+rounded or semi-globular, soft or firm tumor, freely movable and
+painless, and having its seat in the corium or subcutaneous tissue. The
+overlying skin is normal in color, or it may be whitish or pale from
+distention; in some a gland-duct orifice may be seen, but, as a rule,
+this is absent.
+
+
+#What are the favorite regions for the development of steatoma?#
+
+The scalp, face and back. One or several may be present.
+
+
+#What is the course of sebaceous cysts?#
+
+Their growth is slow, and, after attaining a variable size, may remain
+stationary. They may exist indefinitely without causing any
+inconvenience beyond the disfigurement. Exceptionally, in enormously
+distended growths, suppuration and ulceration result.
+
+
+#What is the pathology?#
+
+A steatoma is a cyst of the sebaceous gland and duct, produced by
+retained secretion. The contents may be hard and friable, soft and
+cheesy, or even fluid, of a grayish, whitish or yellowish color, and
+with or without a fetid odor; the mass consisting of fat-drops,
+epidermic cells, cholesterin, and sometimes hairs.
+
+
+#Are sebaceous cysts likely to be confounded with gummata?#
+
+No. Gummata grow more rapidly, are usually painful to the touch, are not
+freely movable, and tend to break down and ulcerate.
+
+
+#Describe the treatment of steatoma.#
+
+A linear incision is made, and the mass and enveloping sac dissected
+out. If the sac is permitted to remain, reproduction almost invariably
+takes place.
+
+
+
+
+#CLASS II.--INFLAMMATIONS.#
+
+
+                           #Erythema Simplex.#
+
+
+#What do you understand by erythema simplex?#
+
+Erythema simplex is a hyperaemic disorder characterized by redness,
+occurring in the form of variously-sized and shaped, diffused or
+circumscribed, non-elevated patches.
+
+
+#Name the two general classes into which the simple erythemata are
+divided.#
+
+Idiopathic and symptomatic.
+
+
+#What do you include in the idiopathic class?#
+
+Those erythemas due to external causes, such as cold and heat (_erythema
+caloricum_), the action of the sun (_erythema solare_), traumatism
+(_erythema traumaticum_), and the various poisons or chemical irritants
+(_erythema venenatum_).
+
+
+#What do you include in the symptomatic class?#
+
+Those rashes often preceding or accompanying certain of the systemic
+diseases, and those due to disorders of the digestive tract, stomachic
+and intestinal toxins, to the ingestion of certain drugs, and to use of
+the therapeutic serums.
+
+
+#Describe the symptoms of erythema simplex.#
+
+The essential symptom is redness--simple hyperaemia--without elevation or
+infiltration, disappearing under pressure, and sometimes attended by
+slight heat or burning; it may be patchy or diffused. In the idiopathic
+class, if the cause is continued, dermatitis may result.
+
+
+#What is to be said about the distribution of the simple erythemata?#
+
+The idiopathic rashes, as inferred from the nature of the causes, are
+usually limited.
+
+The symptomatic erythemas are more or less generalized; desquamation
+sometimes follows.
+
+
+#Describe the treatment of the simple erythemata.#
+
+A removal of the cause in idiopathic rashes is all that is needed, the
+erythema sooner or later subsiding. The same may be stated of the
+symptomatic erythemata, but in these there is at times difficulty in
+recognizing the etiological factor; constitutional treatment, if
+necessary, is to be based upon general principles. Intestinal
+antiseptics are useful in some instances.
+
+Local treatment, which is rarely needed, consists of the use of
+dusting-powders or mild cooling and astringent lotions, such as are
+employed in the treatment of acute eczema (q. v.).
+
+
+
+                        #Erythema Intertrigo.#
+                         (_Synonym:_ Chafing.)
+
+
+#What do you understand by erythema intertrigo?#
+
+Erythema intertrigo is a hyperaemic disorder occurring on parts where the
+natural folds of the skin come in contact, and is characterized by
+redness, to which may be added an abraded surface and maceration of the
+epidermis.
+
+
+#Describe the symptoms of erythema intertrigo.#
+
+The skin of the involved region gradually becomes hyperaemic, but is
+without elevation or infiltration; a feeling of heat and soreness is
+usually experienced. If the condition continue, the increased
+perspiration and moisture of the parts give rise to maceration of the
+epidermis and a mucoid discharge; actual inflammation may eventually
+result.
+
+
+#What is the course of erythema intertrigo?#
+
+The affection may pass away in a few days or persist several weeks, the
+duration depending, in a great measure, upon the cause.
+
+
+#Mention the causes of erythema intertrigo.#
+
+The causes are usually local. It is seen chiefly in children, especially
+in fat subjects, in whom friction and moisture of contiguous parts of
+the body, usually the region of the neck, buttocks and genitalia, are
+more common; in such, uncleanliness or the too free use of soap washings
+will often act as the exciting factor. Disorders of the stomach or
+intestinal canal apparently have a predisposing influence.
+
+
+#What treatment would you advise in erythema intertrigo?#
+
+The folds or parts are to be kept from contact by means of lint or
+absorbent cotton; thin, flat bags of cheese cloth or similar material
+partly filled with dusting-powder, and kept clean by frequent changes,
+are excellent for this purpose, and usually curative. Cleanliness is
+essential, but it is to be kept within the bounds of common sense.
+Dusting-powders and cooling and astringent lotions, such as are employed
+in the treatment of acute eczema (_q. v._), can also be advised. The
+following lotion is valuable:--
+
+  [Rx] Pulv. calaminae,
+       Pulv. zinci oxidi, .. [=a][=a] ...... [dram]iss.
+       Glycerinae, .......................... [minum]xxx
+       Alcoholis, .......................... f[dram]ij
+       Aquae, ............................... Oss.   M.
+
+Exceptionally a mild ointment, alone or supplementary to a lotion, acts
+more satisfactorily.
+
+In persistent or obstinate cases attention should also be directed to
+the state of the general health, especially as regards the digestive
+tract.
+
+
+
+                          #Erythema Multiforme.#
+
+
+#What is erythema multiforme?#
+
+Erythema multiforme is an acute, inflammatory disease, characterized by
+reddish, more or less variegated macules, papules, and tubercles,
+occurring as discrete lesions or in patches of various size and shape.
+
+
+#Upon what parts of the body does the eruption appear?#
+
+Usually upon the extremities, especially the dorsal aspect, from the
+knees and elbows down, and about the face and neck; it may, however, be
+more or less general.
+
+
+#Describe the symptoms of erythema multiforme.#
+
+With or without precursory symptoms of malaise, gastric uneasiness or
+rheumatic pains, the eruption suddenly makes its appearance, assuming an
+erythematous, papular, tubercular or mixed character; as a rule, one
+type of lesion predominates. The lesions tend to increase in size and
+intensity, remain stationary for several days or a week, and then
+gradually fade; during this time there may have been outbreaks of new
+lesions. In color they are pink, red, or violaceous. Slight itching may
+or may not be present. Exceptionally, in general cases, the eruption
+partakes of the nature of both urticaria and erythema multiforme, and
+itching may be quite a decided symptom. In some instances there is
+preceding and accompanying febrile action, usually slight in character;
+in others there may be some rheumatic swelling of one or more joints.
+
+[Illustration: Fig. 11.
+  Erythema Multiforme, in which many of the lesions have become
+  bullous--Erythema Bullosum.]
+
+
+#What type of the eruption is most common?#
+
+The papular, appearing usually upon the backs of the hands and forearms,
+and not infrequently, also, upon the face, legs and feet. The papules
+are usually pea-sized, flattened, and of a dark red or violaceous color.
+
+
+#Describe the various shapes which the erythematous lesions may assume.#
+
+Often the patches are distinctly ring-shaped, with a clear
+centre--_erythema annulare_; or they are made up of several concentric
+rings, presenting variegated coloring--_erythema iris_; or a more or
+less extensive patch may spread with a sharply-defined border, the older
+part tending to fade--_erythema marginatum_; or several rings may
+coalesce, with a disappearance of the coalescing parts, and serpentine
+lines or bands result--_erythema gyratum_.
+
+
+#Does the eruption of erythema multiforme ever assume a vesicular or
+bullous character?#
+
+Yes. In exceptional instances, the inflammatory process may be
+sufficiently intense to produce vesiculation, usually at the summits of
+the papules--_erythema vesiculosum_; and in some instances, blebs may be
+formed--_erythema bullosum_. A vesicular or bullous lesion may become
+immediately surrounded by a ring-like vesicle or bleb, and outside of
+this another form; a patch may be made up of as many as several such
+rings--_herpes iris_. In the vesicular and bullous cases the lips and
+the mucous membranes of the mouth and nose also may be the seat of
+similar lesions.
+
+
+#What is the course of erythema multiforme?#
+
+Acute, the symptoms disappearing spontaneously, usually in one to three
+or four weeks. In some instances the recurrences take place so rapidly
+that the disease assumes a chronic aspect; it is possible that such
+cases are midway cases between this disease and dermatitis
+herpetiformis.
+
+
+#Mention the etiological factors in erythema multiforme.#
+
+The causes are obscure. Digestive disturbance, rheumatic conditions, and
+the ingestion of certain drugs are at times influential. Intestinal
+toxins are doubtless important etiological factors in some cases.
+Certain foods, such as are apt to undergo rapid putrefactive or
+fermentative change, especially pork meats, oysters, fish, crabs,
+lobsters, etc., are, therefore, not infrequently of apparent causative
+influence. It is most frequently observed in spring and autumn months,
+and in early adult life. The disease is not uncommon.
+
+
+#What is the pathology of erythema multiforme?#
+
+It is a mildly inflammatory disorder, somewhat similar to urticaria, and
+presumably due to vasomotor disturbance; the amount of exudation, which
+is variable, determines the character of the lesions.
+
+
+#Name the diagnostic points of erythema multiforme.#
+
+The multiformity of the eruption, the size of the papules, often its
+limitation to certain parts, its course and the entire or comparative
+absence of itching.
+
+It resembles urticaria at times, but the lesions of this latter disease
+are evanescent, disappearing and reappearing usually in the most
+capricious manner, are commonly seated about the trunk, and are
+exceedingly itchy.
+
+In the vesicular and bullous types the acute character of the outbreak,
+the often segmental and ring-like shape, their frequent origin from
+erythematous papules, and the distribution and association with the more
+common manifestations, are always suggestive.
+
+
+#What prognosis would you give in erythema multiforme?#
+
+Always favorable; the eruption usually disappears in ten days to three
+weeks, although in rare instances new crops may appear from day to day
+or week to week, and the process last one or two months. One or more
+recurrences in succeeding years are not uncommon. Those rare cases in
+which vesicular or bullous lesions are also seen on the lips and in the
+mouth, are more prone to longer duration and to more frequent
+recurrences.
+
+
+#What remedies are commonly prescribed in erythema multiforme?#
+
+Quinin, and, if constipation is present, saline laxatives. Calcined
+magnesia is valuable as a laxative. Intestinal antiseptics, such as
+salol, thymol, and sodium salicylate, are valuable in cases probably due
+to intestinal toxins. In those exceptional instances in which there may
+be associated febrile action and rheumatic swelling of the joints, the
+patient should be kept in bed till these symptoms subside. Local
+applications are rarely required, but in those exceptional cases in
+which itching or burning is present, cooling lotions of alcohol and
+water or vinegar and water are to be prescribed. The vesicular and
+bullous types demand mild protective applications, such as used in
+eczema and pemphigus.
+
+
+
+                          #Erythema Nodosum.#
+                (_Synonym:_ Dermatitis contusiformis.)
+
+
+#What is erythema nodosum?#
+
+Erythema nodosum is an inflammatory affection, of an acute type,
+characterized by the formation of variously-sized, roundish, more or
+less elevated erythematous nodes.
+
+
+#Is there any special region of predilection for the eruption of erythema
+nodosum?#
+
+Yes. The tibial surfaces, to which the eruption is often limited; not
+infrequently, however, other parts may be involved, more especially the
+arms and forearms.
+
+
+#Describe the symptoms of erythema nodosum.#
+
+The eruption makes its appearance suddenly, and is usually ushered in
+with febrile disturbance, gastric uneasiness, malaise, and rheumatic
+pains and swelling about the joints. The lesions vary in size from a
+cherry to a hen's egg, are rounded or ovalish, tender and painful, have
+a glistening and tense look, and are of a bright red, erysipelatous
+color which merges gradually into the sound skin. At first they are
+somewhat hard, but later they soften and appear as if about to break
+down, but this, however, never occurs, absorption invariably taking
+place. In occasional instances they are hemorrhagic. Exceptionally the
+lesions of erythema multiforme are also present. Lymphangitis is
+sometimes observed. In rare instances symptoms pointing to visceral
+involvement, to cerebral invasion, and to heart complications have been
+observed.
+
+
+#Are the lesions in erythema nodosum usually numerous?#
+
+No. As a rule not more than five to twenty nodes are present.
+
+
+#What is the course of erythema nodosum?#
+
+Acute. The disease terminating usually in one to three weeks. As the
+lesions are disappearing they present the various changes of color
+observed in an ordinary bruise.
+
+
+#What is known in regard to the etiology?#
+
+The affection is closely allied to erythema multiforme, and is, indeed,
+by some considered a form of that disease. It occurs most frequently in
+children and young adults, and usually in the spring and autumn months.
+Intestinal toxins are thought responsible in some cases. Digestive
+disturbance and rheumatic pain and swellings are often associated with
+it. By many the malady is thought to be a specific infection.
+
+
+#What is the pathology of erythema nodosum?#
+
+The disease is to be viewed as an inflammatory [oe]dema, probably
+resulting, in some instances at least, from an inflammation of the
+lymphatics or an embolism of the cutaneous vessels.
+
+
+#What diseases may erythema nodosum resemble?#
+
+Bruises, abscesses, and gummata.
+
+
+#How are the lesions of erythema nodosum to be distinguished from these
+several conditions?#
+
+By the bright red or rosy tint, the apparently violent character of the
+process, the number, situation and course of the lesions.
+
+
+#State the prognosis of erythema nodosum.#
+
+Favorable, recovery usually taking place in ten days to several weeks.
+
+
+#State the treatment to be advised in erythema nodosum.#
+
+Rest, relative or absolute, depending upon the severity of the case, and
+an unstimulating diet; internally intestinal antiseptics, quinin and
+saline laxatives, and locally applications of lead-water and laudanum.
+
+
+
+                           #Erythema Induratum.#
+              (_Synonym:_ Erythema induratum scrofulosorum.)
+
+
+#What do you understand by erythema induratum?#
+
+A rare disease characterized in the beginning by one or more usually
+deep-seated nodules, and, as a rule, seated in the legs, especially the
+calf region. The nodules gradually enlarge, the skin becomes reddish,
+violaceous or livid in color. Absorption may take place slowly, or the
+indurations may break down, resulting in an indolent, rather deep-seated
+ulcer, closely resembling a gummatous ulcer. The disease is slow and
+persistent, and is commonly met with in girls and young women, usually
+of strumous type. It suggests a tuberculous origin.
+
+Treatment consists in administration of cod-liver oil, phosphorus and
+other tonics. Rest is of service. Locally antiseptic applications, and
+support with roller bandage are to be advised.
+
+
+
+                              #Urticaria.#
+                   (_Synonyms:_ Hives; Nettlerash.)
+
+
+#Give a definition of urticaria.#
+
+Urticaria is an inflammatory affection characterized by evanescent
+whitish, pinkish or reddish elevations, or wheals, variable as to size
+and shape, and attended by itching, stinging or pricking sensations.
+
+
+#Describe the symptoms of urticaria.#
+
+The eruption, erythematous in character and consisting of isolated pea
+or bean-sized elevations or of linear streaks or irregular patches,
+limited or more or less general, and usually intensely itchy, makes its
+appearance suddenly, with or without symptoms of preceding gastric
+derangement. The lesions are soft or firm, reddish or pinkish-white,
+with the peripheral portion of a bright red color, and are fugacious in
+character, disappearing and reappearing in the most capricious manner.
+In many cases simply drawing the finger over the skin will bring out
+irregular and linear wheals. In exceptional cases this peculiar property
+is so pronounced and constant that at any time letters and other symbols
+may be produced at will, even when such subjects are free from the
+ordinary urticarial lesions (_urticaria factitia_, _dermatographism_,
+_autographism_).
+
+The mucous membrane of the mouth and throat may also be the seat of
+wheals and urticarial swellings.
+
+
+#What is the ordinary course of urticaria?#
+
+Acute. The disease is usually at an end in several hours or days.
+
+
+#Does urticaria always pursue an acute course?#
+
+No. In exceptional instances the disease is chronic, in the sense that
+new lesions continue to appear and disappear irregularly from time to
+time for months or several years, the skin rarely being entirely free
+(_chronic urticaria_).
+
+
+[Illustration: Fig. 12.
+  Dermatographism. (_After C.N. Davis._)]
+
+
+#Are subjective symptoms always present in urticaria?#
+
+Yes. Itching is commonly a conspicuous symptom, although at times
+pricking, stinging or a feeling of burning constitutes the chief
+sensation.
+
+
+#In what way may the eruption be atypical?#
+
+Exceptionally the wheals, or lesions, are peculiar as to formation, or
+another condition or disease may be associated, hence the varieties
+known as urticaria papulosa, urticaria haemorrhagica, urticaria tuberosa,
+and urticaria bullosa.
+
+
+#Describe urticaria papulosa.#
+
+Urticaria papulosa (formerly called _lichen urticatus_) is a variety in
+which the lesions are small and papular, developing usually out of the
+ordinary wheals. They appear as a rule suddenly, rarely in great
+numbers, are scattered, and after a few hours or, more commonly, days
+gradually disappear. The itching is intense, and in consequence their
+apices are excoriated. Sometimes the papules are capped with a small
+vesicle (vesicular urticaria). It is seen more particularly in ill-cared
+for and badly-nourished young children.
+
+
+#Describe urticaria haemorrhagica.#
+
+Urticaria haemorrhagica is characterized by lesions similar to ordinary
+wheals, except that they are somewhat hemorrhagic, partaking, in fact,
+of the nature of both urticaria and purpura.
+
+
+#Describe urticaria tuberosa.#
+
+In urticaria tuberosa the lesions, instead of being pea- or bean-sized,
+as in typical urticaria, are large and node-like (also called _giant
+urticaria_).
+
+
+#What is acute-circumscribed [oe]dema?#
+
+In rare instances there occurs, along with the ordinary lesions of the
+disease or as its sole manifestation, sudden and evanescent swelling of
+the eyelids, ears, lips, tongue, hands, fingers, or feet (_urticaria
+[oe]dematosa_, _acute_ _circumscribed [oe]dema_, _angioneurotic [oe]dema_).
+One or several of these parts only may be affected at the one attack; in
+recurrences, so usual in this variety, the same or other parts may
+exhibit the manifestation.
+
+(These [oe]dematous swellings occurring alone might be looked upon, as
+they are by most observers, as an independent affection, but its close
+relationship to ordinary urticaria is often evident.)
+
+
+#Describe urticaria bullosa.#
+
+Urticaria bullosa is a variety in which the inflammatory action has been
+sufficiently great to give rise to fluid exudation, the wheals resulting
+in the formation of blebs.
+
+
+#What is the etiology of urticaria?#
+
+Any irritation from disease, functional or organic, of any internal
+organ, may give rise to the eruption in those predisposed. Gastric
+derangement from indigestible or peculiar articles of food, intestinal
+toxins, and the ingestion of certain drugs are often provocative. The
+so-called "shell-fish" group of foods play an important etiological part
+in some cases. Idiosyncrasy to certain articles of food is also
+responsible in occasional instances. Various rheumatic and nervous
+disorders are not infrequently associated with it, and are doubtless of
+etiological significance. External irritants, also, in predisposed
+subjects, are at times responsible.
+
+
+#What is the pathology of urticaria?#
+
+Anatomically a wheal is seen to be a more or less firm elevation
+consisting of a circumscribed or somewhat diffused collection of
+semi-fluid material in the upper layers of the skin. The vasomotor
+nervous system is probably the main factor in its production; dilatation
+following spasm of the vessels results in effusion, and in consequence,
+the overfilled vessels of the central portion are emptied by pressure of
+the exudation and the central paleness results, while the pressed-back
+blood gives rise to the bright red periphery.
+
+
+#From what diseases is urticaria to be differentiated?#
+
+From erythema simplex, erythema multiforme, erythema nodosum, and
+erysipelas.
+
+
+#Mention the diagnostic points of urticaria.#
+
+The acuteness, character of the lesions, their evanescent nature, the
+irregular or general distribution, and the intense itching.
+
+
+#What is the prognosis in urticaria?#
+
+The acute disease is usually of short duration, disappearing
+spontaneously or as the result of treatment, in several hours or days;
+it may recur upon exposure to the exciting cause. The prognosis of
+chronic urticaria is to be guarded, and will depend upon the ability to
+discover and remove or modify the predisposing condition.
+
+
+#What systemic measures are to be prescribed in acute urticaria?#
+
+Removal of the etiological factor is of first importance. This will be
+found in most cases to be gastric disturbance from the ingestion of
+improper or indigestible food, and in such cases a saline purgative is
+to be given, probably the best for this purpose being the laxative
+antacid, magnesia; or if the case is severe and food is still in the
+stomach, an emetic, such as mustard or ipecac, will act more promptly.
+Alkalies, especially sodium salicylate, and intestinal antiseptics are
+useful. Calcium chloride in doses of five to twenty grains should be
+tried in obstinate cases. The diet should be, for the time, of a simple
+character.
+
+
+#What systemic measures are to be prescribed in chronic and recurrent
+urticaria?#
+
+The cause must be sought for and treatment directed toward its removal
+or modification. Treatment will, therefore, depend upon indications. In
+obscure cases, quinine, sodium salicylate, arsenic, pilocarpine,
+_atropia_, potassium bromide, calcium chloride, and ichthyol are to be
+variously tried; general galvanization is at times useful, as is also a
+change of scene and climate. A proper dietary and the maintenance of
+free action of the bowels, preferably, as a rule, with a saline
+laxative, is of great importance in these chronic cases.
+
+In acute circumscribed [oe]dema treatment is essentially that of
+urticaria, the diet being given special attention.
+
+
+#What external applications would you advise for the relief of the
+subjective symptoms?#
+
+Cooling lotions of alcohol and water or vinegar and water; lotions of
+carbolic acid, one to three drachms to the pint; of thymol, one-fourth
+to one drachm to the pint of alcohol and water; of liquor carbonis
+detergens, one to three ounces to the pint of water, or the following:--
+
+  [Rx] Acidi carbolici, ..................... [dram]j-[dram]iij
+       Acidi borici, ........................ [dram]iv
+       Glycerinae, ........................... f[dram]j
+       Alcoholis, ........................... f[Oz]ij
+       Aquae, ................................ f[Oz]xiv. M.
+
+Alkaline baths are also useful, and may advantageously be followed by
+dusting-powders of starch and zinc oxide.
+
+
+
+                        #Urticaria Pigmentosa.#
+                     (_Synonym:_ Xanthelasmoidea.)
+
+
+#Describe urticaria pigmentosa.#
+
+Urticaria pigmentosa is a rare disease, variously viewed as an unusual
+form of urticaria and as an urticaria-like eruption in which there is an
+element of new growth in the lesions. It begins usually in infancy or
+early childhood and continues for months or years, and is characterized
+by slightly, moderately, or intensely itchy, wheal-like elevations,
+which are more or less persistent and leave yellowish, orange-colored,
+greenish or brownish stains. Exceptionally subjective symptoms are
+almost entirely absent. Anatomical studies show that the lesion has in
+some respects the structure of an ordinary wheal, with [oe]dema and
+pigment deposit in the epidermal portion, and cellular infiltration made
+up principally of mast-cells.
+
+[Illustration: Fig. 13.
+  Urticaria Pigmentosa.]
+
+The nature of the disease is obscure and treatment unsatisfactory.
+Ordinarily as early youth or adult life is reached it spontaneously
+disappears. The treatment advised is usually on the same lines as that
+of chronic urticaria.
+
+
+
+                         #Dermatitis.#
+
+
+#What is implied by the term dermatitis?#
+
+Dermatitis, or inflammation of the skin, is a term employed to designate
+those cases of cutaneous disturbance, usually acute in character, which
+are due to the action of irritants.
+
+
+#Mention some examples of cutaneous disturbance to which this term is
+applied.#
+
+The dermatic inflammation due to the action of excessive heat or cold,
+to caustics and other chemical irritants, and to the ingestion of
+certain drugs.
+
+
+#What several varieties are commonly described?#
+
+Dermatitis traumatica, dermatitis calorica, dermatitis venenata, and
+dermatitis medicamentosa.
+
+
+#Describe dermatitis traumatica.#
+
+Under this head are included all forms of cutaneous inflammation due to
+traumatism. To the dermatologist the most common met with is that
+produced by the various animal parasites and from continued scratching;
+in such, if the cause has been long-continued and persistent, a variable
+degree of inflammatory thickening of the skin and pigmentation result,
+the latter not infrequently being more or less permanent. The
+inflammation due to tight-fitting garments, bandages, to constant
+pressure (as bed-sores), etc., also illustrates this class.
+
+
+#What is the treatment of dermatitis traumatica?#
+
+Removal of the cause, and, if necessary, the application of soothing
+ointments or lotions; in bed-sores, soap plaster, plain or with one to
+five per cent. of ichthyol.
+
+
+#What is dermatitis calorica?#
+
+Cutaneous inflammation, varying from a slight erythematous to a
+gangrenous character, produced by excessive heat (_dermatitis
+ambustionis_, _burns_) or cold (_dermatitis congelationis_,
+_frostbite_).
+
+
+#Give the treatment of dermatitis calorica.#
+
+In burns, if of a mild degree, the application of sodium bicarbonate, as
+a powder or saturated solution, is useful; in the more severe grade, a
+two- to five-per-cent. solution will probably be found of greater
+advantage. Other soothing applications may also be employed. In recent
+years a one-per-cent. solution of picric acid has been commended for the
+slighter burns of limited extent. Upon the whole, there is nothing yet
+so generally useful and soothing in these cases as the so-called Carron
+oil; in some cases more valuable with 1/2 to 1 minim of carbolic acid
+added to each ounce.
+
+In frostbite, seen immediately after exposure, the parts are to be
+brought gradually back to a normal temperature, at first by rubbing with
+snow or applying cold water. Subsequently, in ordinary chilblains,
+stimulating applications, such as oil of turpentine, balsam of Peru,
+tincture of iodine, ichthyol, and strongly carbolized ointments are of
+most benefit. If the frostbite is of a vesicular, pustular, bullous, or
+escharotic character, the treatment consists in the application of
+soothing remedies, such as are employed in other like inflammatory
+conditions.
+
+
+#What do you understand by dermatitis venenata?#
+
+All inflammatory conditions of the skin due to contact with deleterious
+substances such as caustic, chemical irritants, iodoform, etc., are
+included under this head, but the most common causes are the rhus
+plants--_poison ivy_ (or _poison oak_) and _poison sumach_ (_poison
+dogwood_). Mere proximity to these plants will, in some individuals,
+provoke cutaneous disturbance (_rhus poisoning_, _ivy poisoning_),
+although they may be handled by others with impunity.
+
+Many other plants are also known to produce cutaneous irritation in
+certain subjects; among these may be mentioned the nettle, primrose,
+cowhage, smartweed, balm of Gilead, oleander, and rue.
+
+The local action of iodoform (_iodoform dermatitis_) in some individuals
+is that of a decided irritant, bringing about a dermatitis, which often
+spreads much beyond the parts of application, and which in those
+eczematously inclined may result in a veritable and persistent eczema.
+
+
+#Describe the symptoms of rhus poisoning.#
+
+The symptoms appear usually soon after exposure, and consist of an
+inflammatory condition of the skin of an eczematous nature, varying in
+degree from an erythematous to a bullous character, and with or without
+[oe]dema and swelling. As a rule, marked itching and burning are
+present. The face, hands, forearms and genitalia are favorite parts,
+although it may in many instances involve a greater portion of the whole
+surface.
+
+
+#What is the course of rhus poisoning?#
+
+It runs an acute course, terminating in recovery in one to six weeks. In
+those eczematously inclined, however, it may result in a veritable and
+persistent form of that disease.
+
+
+#How would you treat rhus poisoning?#
+
+By soothing and astringent applications, such as are employed in acute
+eczema (_q. v._), which are to be used freely. Among the most valuable
+are: a lotion of fluid extract of grindelia robusta, one to two drachms
+to four ounces of water; lotio nigra, either alone or followed by the
+oxide-of-zinc ointment; a saturated solution of boric acid, with a half
+to two drachms of carbolic acid to the pint; a lotion of zinc sulphate,
+a half to four grains to the ounce; weak alkaline lotions; cold cream,
+petrolatum, and oxide-of-zinc ointments.
+
+
+#How would you treat the dermatitis due to other deleterious substances
+of this class?#
+
+By applications of a soothing and protective character, similar to those
+used in eczema and burns.
+
+
+
+                       #Dermatitis Medicamentosa.#
+
+
+#What do you understand by dermatitis medicamentosa?#
+
+Under this head are included all eruptions due to the ingestion or
+absorption of certain drugs.
+
+In rare instances one dose will have such effect; commonly, however, it
+results only after several days' or weeks' continued administration.
+With some drugs such effect is the rule, with others it is exceptional,
+nor are all individuals equally susceptible.
+
+
+#How is the eruption produced in dermatitis medicamentosa?#
+
+In some instances it is probably due to the elimination of the drug
+through the cutaneous structures; in others, to the action of the
+drug upon the nervous system. The view that the drug acts as a toxin or
+generates some toxin or irritant material in the blood, to which the
+eruptive phenomena may be due, has also been advanced.
+
+[Illustration: Dermatitis medicamentosa.
+  Bullous dermatitis from iodide of potassium.]
+
+
+#What is the character of the eruption in dermatitis medicamentosa?#
+
+It may be erythematous, papular, urticarial, vesicular, pustular or
+bullous, and, if the administration of the drug is continued, even
+gangrenous.
+
+
+#Name the more common drugs having such action.#
+
+Antipyrin, arsenic, atropia (or belladonna), bromides, chloral, copaiba,
+cubebs, digitalis, iodides, mercury, opium (or morphia), quinine,
+salicylic acid, stramonium, acetanilid, sulphonal, phenacetin,
+turpentine, many of the new coal-tar derivatives, etc.
+
+
+#State frequency and types of eruption due to the ingestion of antipyrin.#
+
+Not uncommon. _Erythematous_, morbilliform and erythemato-papular;
+itching is usually present and moderate desquamation may follow.
+Acetanilid, sulphonal, phenacetin, and other drugs of this class may
+provoke like eruptions.
+
+
+#Mention frequency and types of eruption due to the ingestion of arsenic.#
+
+Rare. Erythematous, erythemato-papular; exceptionally, herpetic, and
+pigmentary. Herpes zoster has been thought to follow its use. Keratosis
+of the palms and soles has also been occasionally observed, which, in
+rare instances, has developed into epithelioma.
+
+
+#Mention frequency and types of eruption due to the ingestion of atropia
+(or belladonna).#
+
+Not uncommon. _Erythematous_ and _scarlatinoid_; usually no febrile
+disturbance, and desquamation seldom follows.
+
+
+#Give frequency and types of cutaneous disturbance following the
+administration of the bromides (bromine).#
+
+Common. _Pustular_, sometimes furuncular and carbuncular and
+superficially ulcerative. In exceptional instances papillomatous or
+vegetating lesions have been observed. Co-administration of arsenic or
+potassium bitartrate is thought to have a preventive influence in some
+cases.
+
+
+#State frequency and types of cutaneous disturbance due to the
+administration of chloral.#
+
+Occasional. Scarlatinoid and urticarial, and exceptionally purpuric; in
+rare instances, if drug is continued, eruption becomes vesicular,
+hemorrhagic, ulcerative and even gangrenous.
+
+
+#State frequency and types of eruption following the administration of
+copaiba.#
+
+Not uncommon. _Urticarial_, erythemato-papular and _scarlatinoid_.
+
+
+#Mention frequency and types of eruption resulting from the ingestion of
+cubebs.#
+
+Uncommon. Erythematous and small papular.
+
+[Illustration: Fig. 14.
+  A somewhat rare form of eruption from the ingestion of iodine compounds.
+  (_After J.C. McGuire._)]
+
+
+#Mention frequency and types of eruption resulting from the
+administration of digitalis.#
+
+Exceptional. Scarlatinoid and papular.
+
+
+#State frequency and types of eruption resulting from the iodides
+(iodine).#
+
+Common. _Pustular_, but may be erythematous, papular, vesicular,
+bullous, tuberous, purpuric and hemorrhagic. Co-administration of
+arsenic or potassium bitartrate is thought to have a preventive
+influence in some cases.
+
+
+#Give the frequency and types of eruption observed to follow the
+administration of mercury.#
+
+Exceptional. Erythematous and erysipelatous.
+
+
+#Give the frequency and types of the cutaneous disturbance following the
+ingestion of opium (or morphia).#
+
+Not uncommon. Erythematous and _scarlatinoid_, and sometimes urticarial.
+
+
+#Mention the frequency and the types of eruption following the
+administration of quinine.#
+
+Not infrequent. Usually _erythematous_, but may be urticarial,
+erythemato-papular, and even purpuric. There is, in some instances,
+preceding or accompanying systemic disturbance. Furfuraceous or lamellar
+desquamation often follows.
+
+
+#State frequency and types of eruption resulting from the ingestion of
+salicylic acid.#
+
+Not common. Erythematous and urticarial; exceptionally, vesicular,
+pustular, bullous, and ecchymotic.
+
+
+#Give frequency and type of cutaneous disturbance due to the
+administration of stramonium.#
+
+Not common. Erythematous.
+
+
+#State frequency and types of eruption resulting from the administration
+of turpentine.#
+
+Not uncommon. _Erythematous_, and small-papular; exceptionally
+vesicular.
+
+
+
+                         #X-Ray Dermatitis.#
+
+
+#What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray burns)
+are observed?#
+
+Three grades are usually described: erythema, superficial vesication,
+and necrosis. The first and second may come on shortly--a few hours to
+several days--after exposure; occasionally later. The third grade may
+present also in the first several days, but in many cases one to several
+weeks may elapse before it appears; it is quite commonly preceded by
+erythema and vesication. The necrosis may be superficial or deep, and
+quite usually results in a persistent ulcer covered by a leathery
+coating; it is usually painful.
+
+[Illustration: Fig. 15. _x_-ray burn]
+
+
+#Give the prognosis and treatment of x-ray dermatitis.#
+
+The first grade--the erythematous--usually disappears in one to ten
+days; the second grade requires one to several weeks, and may be quite
+sore and tender; the severe or necrotic burns are persistent, sometimes
+lasting for months and several years, with little tendency to
+spontaneous disappearance, and rebellious to treatment.
+
+Treatment of the milder types is that of erythema (_q. v._); the necrotic
+type occasionally demands thorough curetting and skin-grafting before it
+will heal.
+
+
+                         #Dermatitis Factitia.#
+                     (_Synonym:_ Feigned Eruptions.)
+
+
+#What do you understand by feigned eruptions?#
+
+Feigned, or artificial, eruptions, occasionally met with in hysterical
+females and in others, are produced, for the purpose of exciting
+sympathy or of deception, by the action of friction, cantharides, acids
+or strong alkalies; the cutaneous disturbance may, therefore, be
+erythematous, vesicular, bullous, or gangrenous. It is usually limited
+in extent, and, as a rule, seen only on parts easily reached by the
+hands.
+
+[Illustration: Fig. 16.
+  Dermatitis Factitia--note the unusually uniform and regular character
+  and arrangement of the lesions.]
+
+
+
+                         #Dermatitis Gangraenosa.#
+
+
+#What do you understand by dermatitis gangraenosa?#
+
+Dermatitis gangraenosa (_erythema gangraenosum_, _Raynaud's disease_,
+_spontaneous gangrene_) is an exceedingly rare affection, characterized
+by the formation of gangrenous spots and patches. It may be idiopathic
+or symptomatic. Some of these cases, especially in hysterical subjects,
+belong under the "feigned eruptions," being self-produced.
+
+As an idiopathic disease, it begins as erythematous, dark-red
+spots--usually preceded and accompanied by mild or grave systemic
+disturbance--which gradually pass into gangrene and sloughing; the
+eventual termination may be fatal, or recovery may take place. As a
+symptomatic disease, it is occasionally met with in diabetes and in
+grave cerebral and spinal affections.
+
+In Raynaud's disease (symmetric gangrene) the parts affected are the
+extremities, such as fingers and toes, the ears and nose, only
+occasionally other parts. The first symptoms observed are coldness and
+paleness of the part; followed sooner or later by congestion of a dark
+red, livid, or bluish color, with sometimes swelling, and tenderness and
+shooting pains. The termination is usually in gangrene of a dry
+character, with, in some instances, vesicles and blebs along the edges;
+in other cases the parts become atrophied, withered, and indurated.
+
+Treatment is based upon general principles.
+
+
+
+                           #Erysipelas.#
+
+
+#What is erysipelas?#
+
+Erysipelas is an acute specific inflammation of the skin and
+subcutaneous tissue, commonly of the face, characterized by shining
+redness, swelling, [oe]dema, heat, and a tendency in some cases to
+vesicle- and bleb-formation, and accompanied by more or less febrile
+disturbance.
+
+
+#Describe the symptoms and course of erysipelas.#
+
+A decided rigor or a feeling of chilliness followed by febrile action
+usually ushers in the cutaneous disturbance. The skin at a certain point
+or part, commonly where there is a lesion of continuity, becomes bright
+red and swollen; this spreads by peripheral extension, and in the course
+of several hours involves a portion or the whole region. The parts are
+shining red, swollen, of an elevated temperature, and sharply defined
+against the sound skin. After several days or a week, during which time
+there is usually continued mild or severe febrile action, the process
+begins to subside, and is followed by epidermic desquamation.
+
+In some cases vesicles and blebs may be present; in other cases the
+disease seriously involves the deeper parts, and is accompanied by grave
+constitutional symptoms. In exceptional instances sloughing takes place.
+
+A mild, transitory, limited, and often recurrent erysipelatous condition
+of the outlet and immediate neighborhood of one or both nostrils is met
+with, taking its origin from an inflammation of the hair-follicles just
+inside the margin of the nose; constitutional symptoms are usually
+wanting. Somewhat similar, doubtless, is the erysipelatous inflammation
+(_erysipeloid_) observed on the fingers and hands of butchers, etc.,
+starting from a wound, apparently as a result of infection from putrid
+meat or fish.
+
+
+#What is erysipelas migrans (or erysipelas ambulans)?#
+
+A variety of erysipelas which, after a few hours or days, disappears at
+one region and appears at another, and so continues for one or several
+weeks.
+
+
+#What is the cause of erysipelas?#
+
+The disease is due to a specific streptococcus--the streptococcus of
+Fehleisen. Depression of the vital forces and local abrasions are
+predisposing factors.
+
+
+#State the diagnostic points.#
+
+The character of the onset, the shining redness and swelling, the
+sharply-defined border, and the accompanying febrile disturbance.
+
+
+#What is the prognosis in erysipelas?#
+
+In most instances the disease runs a favorable course, terminating in
+recovery in one to three weeks. Exceptionally, in severe cases, a fatal
+termination ensues.
+
+
+#What is the treatment of erysipelas?#
+
+_Internally_, a purge, followed by the tincture of the chloride of iron
+and quinia, and stimulants if needed. _Locally_, one to three per cent.
+carbolic-acid lotion or ointment, a saturated solution of boric acid, or
+a ten- to twenty-per-cent. aqueous solution or ointment of ichthyol may
+be employed.
+
+In some cases the spread of the disease is apparently controlled by
+painting the bordering healthy skin with a ring of tincture of iodine or
+strong solution of nitrate of silver.
+
+
+
+                          #Phlegmona Diffusa.#
+
+
+#What do you understand by phlegmona diffusa?#
+
+Phlegmona diffusa is a more or less extensive inflammation of the
+cutaneous and subcutaneous tissues presenting symptoms partaking of the
+nature of both deep erysipelas and flat carbuncles, and usually attended
+with varying constitutional disturbance. Suppuration at several points
+takes place, and sloughing may ensue. Recovery usually finally results,
+but a fatal issue is possible.
+
+Treatment is based upon general principles.
+
+
+
+                             #Furunculus.#
+                     (_Synonyms:_ Furuncle; Boil.)
+
+
+#Define furunculus.#
+
+Furunculus, or boil, is an acute, deep-seated, inflammatory,
+circumscribed, rounded or more or less acuminated, firm, painful
+formation, usually terminating in central suppuration.
+
+
+#Describe the symptoms and course.#
+
+A boil begins as a small, rounded or imperfectly defined reddish spot,
+or as a small, superficial pustule; it increases in size, and when well
+advanced appears as a pea or cherry-sized, circumscribed, reddish
+elevation, with more or less surrounding hyperaemia and swelling; it is
+painful and tender, and ends, in the course of several days or a week,
+in the formation of a central slough or "_core_," which finally involves
+the central overlying skin (_pointing_). One or several may be present,
+gradually maturing and disappearing. Insignificant scarring may remain.
+
+In some cases sympathetic constitutional disturbance is noticed.
+
+
+#What is a blind boil?#
+
+A sluggish boil exhibiting little, if any, tendency to point or break.
+
+
+#What is furunculosis?#
+
+Furunculosis is that condition in which boils, singly or in crops,
+continue to appear, irregularly, for weeks or months.
+
+
+#State the etiology of furuncle.#
+
+A depraved state of the general health is often to be considered as a
+predisposing factor. Persistent furunculosis is not infrequent in
+diabetes mellitus. The immediate exciting cause is the entrance into the
+follicle of a microbe, the staphylococcus pyogenes aureus. It is not
+improbable, however, that boils may also be due to other pus-producing
+organisms.
+
+Workmen in paraffin oils or other petroleum products often present
+numerous furuncles and cutaneous abscesses. Conditions favoring a
+persistent miliaria have also a causative influence, especially observed
+in infants and young children. In these latter, especially among the
+poorer classes, sluggish boils or subcutaneous abscesses about the scalp
+in hot weather, are not at all infrequent.
+
+
+#What is the pathology of furuncle?#
+
+A boil is an inflammatory formation having its starting point in a
+sebaceous-gland, sweat-gland, or hair-follicle. The core, or central
+slough, is composed of pus and of the tissue of the gland in which it
+had its origin.
+
+
+#How would you distinguish a boil from a carbuncle?#
+
+A boil is comparatively small, rounded or acuminate, and has but one
+point of suppuration; a carbuncle is large, flattened, intensely
+painful, often with grave systemic disturbance, and has, moreover,
+several centres of suppuration.
+
+
+#State the prognosis.#
+
+When occurring in crops (furunculosis) the affection is often
+rebellious; recovery, however, finally resulting.
+
+
+#What is the method of treatment of furunculus?#
+
+If there be but one lesion, with no tendency to the appearance of
+others, local treatment alone is usually employed. If, however, several
+or more are present, or if there is a tendency to successive
+development, both constitutional and local measures are demanded.
+
+
+#Name the internal remedies employed.#
+
+Such nutrients and tonics as cod-liver oil, malt, quinine, strychnia,
+iron and arsenic; in some instances calx sulphurata, one-tenth- to
+one-fourth-grain doses every three or four hours has been thought to be
+of service. Brewers' yeast has been recently again brought forward as a
+remedy of value.
+
+
+#What is the external treatment?#
+
+Local treatment consists in the beginning, with the hope of aborting the
+lesion, of the application of carbolic acid to the central portion, or
+the use of a twenty-five-per-cent. ointment of ichthyol applied as a
+plaster:--
+
+  [Rx] Ichthyol, ............................ [dram]j
+     Emp. plumbi, ........................... [dram]ij
+     Emp. resinae, ........................... [dram]j.   M.
+
+Or the injection of a five-per-cent. solution of carbolic acid into the
+apex of the boil may be tried if the formation is more advanced. If
+suppuration is fully established, evacuation of the contents, followed
+by antiseptic applications, constitutes the best method.
+
+A saturated solution of boric acid or a lotion of corrosive sublimate
+(one to three grains to the ounce) applied to the immediate neighborhood
+of the boil or boils tends to prevent the formation of new lesions.
+Frequent washing of the parts with soap and water or tincture of green
+soap and water is also a preventive measure of value. In repeatedly
+infected areas, mild exposures to _x_-rays, at intervals of a few days,
+will often prove of curative value.
+
+
+
+                           #Carbunculus.#
+                  (_Synonyms:_ Anthrax; Carbuncle.)
+
+
+#What is carbuncle?#
+
+A carbuncle is an acute, usually egg to palm-sized, circumscribed,
+phlegmonous inflammation of the skin and subcutaneous structures,
+terminating in a slough.
+
+
+#At what age and upon what parts is carbuncle usually observed?#
+
+In middle and advanced life, and more commonly in men.
+
+It is seen most frequently at the nape of the neck and upon the upper
+part of the back.
+
+
+#What are the symptoms and course of carbuncle?#
+
+There is rarely more than one lesion present. It begins, usually with
+preceding and accompanying malaise, chilliness and febrile disturbance,
+as a firm, flat, inflammatory infiltration in the deeper skin and
+subcutaneous tissue, spreading laterally and finally involving an area
+of one to several inches in diameter. The infiltration and swelling
+increase, the skin becomes of dark red color, and sooner or later,
+usually at the end of ten days or two weeks, softening and suppuration
+begin to take place, the skin finally giving away at several points,
+through which sanious pus exudes; the whole mass finally sloughs away
+either in portions or in its entirety, resulting in a deep ulcer, which
+slowly heals and leaves a permanent cicatrix.
+
+In some cases, especially in old people, constitutional disturbance of a
+grave character is noted, septicaemia is developed, and a fatal result
+may ensue.
+
+
+#What is the cause of carbuncle?#
+
+The same causes are considered to be operative in carbunculus as in
+furuncle; general debility and depression, from whatever cause,
+predisposing to its formation, and the introduction of a microbe,
+probably the same as in furunculus, being at present looked upon as the
+exciting factor.
+
+
+#What is the pathology?#
+
+The inflammation starts simultaneously from numerous points, from the
+hair-follicles, sweat-glands or sebaceous glands. The inflammatory
+centres break down, and the pus finds its way to the surface; finally
+the process ends in gangrene of the whole area.
+
+
+#How would you distinguish carbuncle from a boil?#
+
+By its flat character, greater size, and multiple points of suppuration.
+
+
+#What is the prognosis of carbuncle?#
+
+Occurring in those greatly debilitated or in late life, and in those
+cases in which two or more lesions exist, or when seated about the head,
+the prognosis is always to be guarded, as a fatal result is not
+uncommon. In fact, in every instance the disease is to be considered of
+possible serious import.
+
+
+#What constitutional treatment is usually employed in carbuncle?#
+
+A full nutritious diet, the use of such remedies as iron, quinia, nux
+vomica, with malt and stimulants, if indicated. Calx sulphurata,
+one-tenth to one-fourth grain every two or three hours, appears, in some
+instances, to have a beneficial effect. If the pain is severe, morphia
+or chloral should be given.
+
+
+#What external measures are employed?#
+
+In the early part of the formation, injection of a five or ten per cent.
+carbolic acid solution, or covering the whole area with a twenty-five
+per cent. ichthyol ointment, may be employed. When it has broken down
+the pus may be drawn out with a cupping-glass, and carbolized glycerine
+or carbolized water introduced into each opening, and the ichthyol
+ointment superimposed. If the whole part has sloughed, it should be
+removed as rapidly as possible, and antiseptic dressings used. Or, if
+its progress is slow, and grave systemic disturbance be present, the
+whole part may be incised and curetted, and then treated antiseptically.
+Mild exposure to the _x_-rays is also to be commended.
+
+
+
+                           #Pustula Maligna.#
+                (_Synonyms:_ Anthrax; Malignant Pustule.)
+
+
+#What is malignant pustule?#
+
+Malignant pustule is a furuncle- or carbuncle-like lesion resulting from
+inoculation of the virus generated in animals suffering from splenic
+fever, or "charbon," and is accompanied by constitutional symptoms of
+more or less gravity. A fatal termination is not unusual.
+
+
+#What is the cause of pustula maligna?#
+
+The disease is due to the presence of the bacillus anthracis.
+
+
+#What is the treatment of malignant pustule?#
+
+Early excision or destruction with caustic potash, with subsequent
+antiseptic dressings; and internally the free use of stimulants and
+tonics.
+
+
+
+                         #Post-mortem Pustule.#
+                     (_Synonym:_ Dissection Wound.)
+
+
+#Describe post-mortem pustule.#
+
+Post-mortem pustule develops at the point of inoculation, beginning as
+an itchy red spot, becoming vesico-pustular, and later pustular, with
+usually a broad inflammatory base, and accompanied with more or less
+pain and redness and not infrequently lymphangitis, erysipelatous
+swelling, and slight or severe sympathetic constitutional disturbance.
+
+
+#What is the treatment of post-mortem pustule?#
+
+Treatment consists in opening the pustule and thorough cauterization,
+and the subsequent use of antiseptic applications or dressings.
+_Internally_ quinia and stimulants if indicated.
+
+
+
+                            #Framb[oe]sia.#
+                       (_Synonyms:_ Yaws; Pian.)
+
+
+#Describe framb[oe]sia.#
+
+Framb[oe]sia is an endemic, contagious disease met with in tropical
+countries, characterized by the appearance of variously-sized papules,
+tubercles, and tumors, which, when developed, resemble currants and
+small raspberries, and finally break down and ulcerate. It is
+accompanied by constitutional symptoms of variable severity.
+
+Hygienic measures, good food, tonics, and antiseptic and stimulating
+applications are curative.
+
+
+                          #Verruga Peruana.#
+      (_Synonyms:_ Peruvian Warts; Carrion's Disease; Oroya Fever.)
+
+
+#Describe verruga peruana.#
+
+A specific inoculable affection endemic in some valleys of the Western
+Andes, in Peru, and characterized by a prodromal febrile period and
+subsequent outbreak of peculiar pin-head- to pea-sized, or larger,
+bright reddish, rounded, wart-like elevations. The prodromal symptoms,
+of an irregular malarial or typhoid type, with associated rheumatic and
+muscular pains, may last for weeks or several months, usually abating
+when eruption presents. The lesions may be crowded together in great
+bunches. The face and limbs are favorite localities. The disease is
+inoculable and thought to be due to a bacillus.
+
+The fatality varies between 10 and 20 per cent. Tonics and stimulants
+are prescribed.
+
+
+
+                             #Equinia.#
+                   (_Synonyms:_ Farcy; Glanders.)
+
+
+#What is equinia, or glanders?#
+
+A rare contagious specific disease of a malignant type, derived from the
+horse, and characterized by grave constitutional symptoms, inflammation
+of the nasal and respiratory passages, and a deep-seated
+papulo-pustular, or tubercular, nodular (_farcy buds_), ulcerative
+eruption. A fatal issue is not uncommon. It is due to a micro-organism.
+
+Treatment, both local and constitutional, is based upon general
+principles.
+
+
+
+                              #Miliaria.#
+      (_Synonyms:_ Prickly Heat; Heat Rash; Lichen Tropicus; Red Gum;
+                              Strophulus.)
+
+
+#What do you understand by miliaria?#
+
+An acute mildly inflammatory disorder of the sweat-glands, characterized
+by the appearance of minute, discrete but closely crowded papules,
+vesico-papules, and vesicles.
+
+
+#Describe the symptoms of miliaria.#
+
+The eruption, consisting of pin-point to millet-seed-sized papules,
+vesico-papules, vesicles, or a mixture of these lesions, discrete but
+usually numerous and closely crowded, appears suddenly, occurring upon a
+limited portion of the surface, or, as commonly observed, involving a
+greater part or the whole integument. The trunk is a favorite locality.
+The papular lesions are pinkish or reddish, and the vesicles whitish or
+yellowish, surrounded by inflammatory areola, thus giving the whole
+eruption a bright red appearance--_miliaria rubra_. Later, the areolae
+fade, the transparent contents of the vesicles become somewhat opaque
+and yellowish-white, and the eruption has a whitish or yellowish
+cast--_miliaria alba_. In long-continued cases, especially in children,
+boils and cutaneous abscesses sometimes develop; and it may also develop
+into a true eczema.
+
+Itching, or a feeling of burning, slight or intense, is usually present.
+
+
+#What is the course of the eruption?#
+
+The vesicles show no disposition to rupture, but dry up in a few days or
+a week, disappearing by absorption and with slight subsequent
+desquamation; the papular lesions gradually fade away, and the
+affection, if the exciting cause has ceased to act, terminates.
+
+
+#What is the cause of miliaria?#
+
+Excessive heat. Debilitated individuals, especially children, are more
+prone to an attack. Being too warmly clad is often causative.
+
+
+#What is the nature of the disease?#
+
+The affection is considered to be due to sweat-obstruction, with mild
+inflammatory symptoms as a cause or consequence, congestion and
+exudation taking place about the ducts, giving rise to papules or
+vesicles, according to the intensity of the process.
+
+
+#How would you distinguish miliaria from papular and vesicular eczema,
+and from sudamen?#
+
+The papules of eczema are larger, more elevated, firmer, slower in their
+evolution, of longer duration, and are markedly itchy.
+
+The vesicles of eczema are usually larger, tend to become confluent, and
+also to rupture and become crusted; there is marked itchiness, and the
+inflammatory action is usually severe and persistent.
+
+In sudamen there is absence of inflammatory symptoms.
+
+
+#What is the prognosis of miliaria?#
+
+The affection, under favorable circumstances, disappears in a few days
+or weeks. If the cause persists, as for instance, in infants or young
+children too warmly clad, it may result in eczema.
+
+
+#What is the treatment of miliaria?#
+
+Removal of the cause, and in debilitated subjects the administration of
+tonics; together with the application of cooling and astringent lotions,
+as the following:--
+
+  [Rx] Aeidi carbolici, ..................... [dram]ss-[dram]j
+       Acidi borici, ........................ [dram]iv
+       Glycerinae, ........................... f[dram]j
+       Alcoholis, ........................... f[Oz]ij
+       Aquae, ................................ [Oz]xiv.  M.
+
+
+This is sometimes more efficient if zinc oxide, six to eight drachms, is
+added.
+
+Lotions of alcohol and water or vinegar and water, and also the various
+lotions used in acute eczema, are often employed with relief.
+
+Dusting-powders of starch, boric acid, lycopodium, talc, and zinc oxide
+are also valuable; the following combination is satisfactory:--
+
+  [Rx] Pulv. acidi borici,
+       Pulv. talci veneti,
+       Pulv. zinci oxidi,
+       Pulv. amyli, .............[=a][=a].....[dram]ij.  M.
+
+Probably the best plan is to use a lotion and a dusting-powder
+conjointly; dabbing on the wash freely, allowing it to dry, and then
+dusting over with the powder.
+
+
+
+                            #Pompholyx.#
+             (_Synonyms:_ Dysidrosis; Cheiro-pompholyx.)
+
+
+#What is pompholyx?#
+
+Pompholyx is a rare disease of the skin of a vesicular and bullous
+character, and limited to the hands and feet.
+
+
+#Describe the symptoms of pompholyx.#
+
+In most instances the hands only are affected. It begins usually with a
+feeling of burning, tingling or tenderness of the parts, followed
+rapidly by the appearance of deeply-seated vesicles, especially between
+the fingers and on the palmar aspect. These beginning lesions look not
+unlike sago grains imbedded in the skin. In some instances the disease
+does not extend beyond this stage, the vesicles disappearing after a few
+days or weeks by absorption, and usually without desquamation.
+Ordinarily, however, the lesions increase in size, new ones arise,
+become confluent, and blebs result, the skin in places appearing as if
+undermined with serous exudation. The parts are commonly inflamed to a
+slight or marked degree. The skin comes off in flakes, new lesions may
+appear for several days or two or three weeks, and the process then
+declines, recovery gradually taking place.
+
+There are no constitutional symptoms, although it is usually noticed
+that the general health is below par.
+
+
+#What is the character of the subjective symptoms in pompholyx?#
+
+The subjective symptoms consist of a feeling of tension, burning and
+tenderness, and sometimes itching. Not infrequently, also there is
+neuralgic pain.
+
+
+#What is the cause of pompholyx?#
+
+The eruption is thought to be due to a depressed state of the nervous
+system. It is more common in women, and is met with chiefly in adult and
+middle life.
+
+
+#What is the pathology?#
+
+Opinion is divided; some considering it a disease of the sweat-glands
+and others an inflammatory disease independent of these structures.
+
+
+#State the diagnostic features of pompholyx.#
+
+The distribution and the peculiar characters and course of the eruption.
+
+It is to be differentiated from eczema.
+
+
+#What is the prognosis?#
+
+For the immediate attack, favorable, recovery taking place in several
+weeks or a few months. Recurrences at irregular intervals are not
+uncommon.
+
+
+#What is the treatment of pompholyx?#
+
+The general health is to be looked after, and the patient placed under
+good hygienic conditions. Remedies of a tonic nature, directed
+especially toward improving the state of the nervous system, are to be
+prescribed. _Locally_, soothing and anodyne applications, such as
+lead-water and laudanum, boric-acid lotion, oxide-of-zinc, boric-acid
+and diachylon ointments, are most suitable; or the parts may be
+enveloped with the following:--
+
+  [Rx] Pulv. ac. salicylici, ................ gr. x
+       Pulv. ac. borici,
+       Pulv. amyli, .......... [=a][=a] ..... [dram]ij
+       Petrolati, ........................... [dram]iv.    M.
+
+In fact, the external treatment is similar to that employed in acute
+eczema.
+
+
+
+                           #Herpes Simplex.#
+                      (_Synonym:_ Fever Blisters.)
+
+
+#What is herpes simplex?#
+
+An acute inflammatory disease, characterized by the formation of
+pin-head to pea-sized vesicles, arranged in groups, and occurring for
+the most part about the face and genitalia.
+
+
+#Describe the symptoms of herpes simplex.#
+
+In severe cases, malaise and pyrexia may precede the eruption, but
+usually it appears without any precursory or constitutional symptoms. A
+feeling of heat and burning in the parts is often complained of. The
+vesicles, which are commonly pin-head in size, are usually upon a
+hyperaemic or inflammatory base, and tend to occur in groups or clusters.
+Their contents are usually clear, subsequently becoming more or less
+milky or puriform. There is no tendency to spontaneous rupture, but
+should they be broken a superficial excoriation results. In a short time
+they dry to crusts which soon fall off, leaving no permanent trace.
+
+
+#Is the eruption in herpes simplex abundant?#
+
+No. As a rule not more than one or two clusters or groups are observed.
+
+
+#Upon what parts does the eruption occur?#
+
+Usually about the face (_herpes facialis_), and most frequently about
+the lips (_herpes labialis_); on the genitalia (_herpes progenitalis_),
+the lesions are commonly found on the prepuce (_herpes praeputialis_) in
+the male, and on the labia minora and labia majora in the female.
+
+
+#State the causes of herpes simplex.#
+
+Herpes facialis is often observed in association with colds and febrile
+and lung diseases. Malaria, digestive disturbance, and nervous disorders
+are not infrequently predisposing factors. Herpes progenitalis is said
+to occur more frequently in those who have previously had some venereal
+disease, especially gonorrh[oe]a, but this is questionable. It is
+probably often purely neurotic.
+
+
+#What are the diagnostic points?#
+
+The appearance of one or several vesicular groups or clusters about the
+face, and especially about the lips, is usually sufficiently
+characteristic. The same holds true ordinarily when the eruption is seen
+on the prepuce or other parts of the genitalia; it is only when the
+vesicles become rubbed or abraded and irritated that it might be
+mistaken for a venereal sore, but the history, course and duration will
+usually serve to differentiate.
+
+
+#Give the prognosis.#
+
+The eruption will usually disappear in several days or one or two weeks
+without treatment. Remedial applications, however, exert a favorable
+influence. Herpes progenitalis exhibits a strong disposition to
+recurrence.
+
+
+#What is the treatment of herpes facialis?#
+
+Anointing the parts with camphorated cold cream, with spirits of camphor
+or similar evaporating and stimulating applications will at times afford
+relief to the burning, and shorten the course.
+
+
+#What is the treatment of herpes progenitalis?#
+
+In herpes about the genitalia cleanliness is of first importance. A
+saturated solution of boric acid, a dusting-powder of calomel or oxide
+of zinc, and the following lotion, containing calamine and oxide of
+zinc, are valuable:--
+
+  [Rx] Zinci oxidi,
+       Calaminae, .......... [=a][=a] ........ gr. v
+       Glycerinae,
+       Alcoholis, ......... [=a][=a] ........ [minim]vj
+       Aquae, ................................ [Oz]j      M.
+
+In obstinate recurrent cases, frequent applications of a mild galvanic
+current will have a favorable influence.
+
+
+
+                         #Hydroa Vacciniforme.#
+         (_Synonyms:_ Recurrent Summer Eruption; Hydroa Puerorum; Hydroa
+                              Aestivale.)
+
+
+#Describe hydroa vacciniforme.#
+
+It is a rare vesicular disease usually seen in boys (only two or three
+exceptions), occurring upon uncovered parts, especially the nose,
+cheeks, and ears. The lesions begin as red spots, discrete or in groups,
+rapidly exhibit vesiculation, and later umbilication; the contents
+become milky, dry to crusts, which fall off and leave small pit-like
+scars. Fresh outbreaks may take place almost continuously, and the
+process go on indefinitely, at least up to youth or manhood, when the
+tendency subsides. Its activity is usually limited to the warm season.
+Arthritic symptoms and general disturbance are sometimes noted in severe
+cases.
+
+It is doubtless a vasomotor neurosis. Exposure to sun and wind is an
+important, if not essential, etiological factor. Primarily the lesion
+begins in the rete middle layers, and is purely vesicular in character;
+later, necrosis of the rete and extending deep in the corium is
+observed.
+
+Treatment so far has only been palliative, consisting of the
+applications employed in similar conditions. Constitutional medication
+is based upon general principles. The patient should avoid exposure to
+the sun, strong wind and excessive artificial heat.
+
+
+
+                       #Epidermolysis Bullosa.#
+
+
+#Describe epidermolysis bullosa.#
+
+This is a rare, usually hereditary, disease or condition, characterized
+by the formation of vesicles and blebs on any part subjected to slight
+rubbing or irritation. No scarring is left, and no pigmentation noted.
+The predisposition to these lesions persists indefinitely. The general
+health is not involved. The nature of the disease is obscure.
+
+Treatment has no influence in modifying or lessening this tendency. The
+vulnerable parts should so far as possible be protected from knocks and
+undue friction.
+
+
+
+                         #Dermatitis Repens.#
+
+
+#What do you understand by dermatitis repens?#
+
+It is a rare spreading dermatitis starting from an injury, extending by
+a serous undermining of the epidermis, and usually occurring upon the
+upper extremities.
+
+It usually begins shortly after an injury, and, as a rule, presents
+itself by redness and serous exudation. The overlying epidermis breaks,
+and the area of disease gradually progresses by an extension of the
+serous undermining process, the denuded part looking red and raw, with
+usually an oozing surface. As the disease spreads the oldest part
+becomes dry and heals, the new epidermal covering being thin and
+atrophic in appearance. Its most usual beginning is on some part of the
+hand, and from here it may spread up the arm and involve considerable
+area.
+
+The injury from which it starts may be extremely insignificant,
+apparently affording an opening for the introduction of the causative
+factor, doubtless parasitic. Beyond a feeling of soreness there seem to
+be no special subjective symptoms.
+
+
+#Give the prognosis and treatment.#
+
+The malady shows but little tendency to spontaneous cure. The frequent
+or constant application of a mild antiseptic lotion, such as boric acid
+and resorcin, or of a mild parasiticide ointment will generally bring
+the disease gradually to an end.
+
+
+
+                          #Herpes Zoster.#
+                (_Synonyms:_ Zoster; Zona; Shingles.)
+
+
+#Give a definition of herpes zoster.#
+
+Herpes zoster is an acute, self-limited, inflammatory disease,
+characterized by groups of vesicles upon inflammatory bases, situated
+over or along a nerve tract.
+
+
+#Upon what parts of the body may the eruption appear?#
+
+It may appear upon any part, following the course of a nerve; it is
+therefore always limited in extent, and confined to one side of the
+body. It is probably most common about the intercostal, lumbar and
+supra-orbital regions. In rare instances the eruption has been observed
+to be bilateral.
+
+
+#Are there any subjective or constitutional symptoms?#
+
+Yes; there is, as a rule, neuralgic pain preceding, during and following
+the eruption; and in some cases, also, there may be in the beginning
+mild febrile disturbance. There is also a variable degree of tenderness
+and pain.
+
+
+#What are the characters of the eruption?#
+
+Several or more hyperaemic or inflammatory patches over a nerve course
+appear, upon which are seated vesico-papules irregularly grouped; these
+vesico-papules become distinct vesicles, of size from a pin-head to a
+pea, and soon dry and give rise to thin, yellowish or brownish crusts,
+which drop off, leaving in most instances no permanent trace, in others
+more or less scarring. In some cases the lesions may become pustular
+and, on the other hand, the eruption may be abortive, stopping short of
+full vesiculation.
+
+
+#What is known in regard to the nature of the disease?#
+
+An inflamed and irritable state of the spinal ganglia, nerve tract, or
+peripheral branches is directly responsible for the eruption, and this
+state may be due to atmospheric changes, cold, nerve-injuries and
+similar influences. The view has also been advanced that the disease is
+of specific and infectious character.
+
+
+#Give the chief diagnostic features of herpes zoster.#
+
+The prodromic neuralgic pain, the appearance of grouped vesicles upon
+inflammatory bases following the course of a nerve tract, and the
+limitation of the eruption to one side of the body.
+
+
+#What is the prognosis?#
+
+Favorable; the symptoms usually disappearing in two to four weeks. In
+some instances, however, the neuralgic pains may be persistent, and in
+zoster of the supra-orbital region the eye may suffer permanent damage.
+
+
+#How would you treat herpes zoster?#
+
+_Constitutional treatment_, usually tonic in character, is to be based
+upon general principles; moderate doses of quinia, with one-sixth grain
+of zinc phosphide, four or five times daily, appear in some cases to
+have a special value. The accompanying neuralgic pain may be so intense
+as to require anodynes. _Local treatment_ should be of a soothing and
+protective character. A dusting-powder of oxide of zinc and starch (to
+the ounce of which twenty to thirty grains of camphor may be added)
+proves useful; and over this, in order that the parts be further
+protected, a bandage or a layer of cotton batting. Oxide-of-zinc
+ointment, and in those cases in which there is much pain, ointments
+containing powdered opium or belladonna, or orthoform, may be used. A
+mild galvanic current applied daily to the parts is often of great
+advantage, both in its influence upon the course of the eruption and
+upon the neuralgic pain. The plan, so often advised, of painting the
+parts with flexible collodion is not to be commended.
+
+
+
+                        #Dermatitis Herpetiformis.#
+     (_Synonyms:_ Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis
+              (Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)
+
+
+#Give a definition of dermatitis herpetiformis.#
+
+Dermatitis herpetiformis is a somewhat rare inflammatory disease,
+characterized by an eruption of an erythematous, papular, vesicular,
+pustular, bullous or mixed type, with a decided disposition toward
+grouping, accompanied by itching and burning sensations, with, as a
+rule, more or less consequent pigmentation, and pursuing usually a
+chronic course with remissions.
+
+
+#Describe the erythematous type of dermatitis herpetiformis.#
+
+The character of the eruption in the erythematous type resembles closely
+that of erythema multiforme and of urticaria, especially the former. The
+efflorescences usually make their appearance in crops, and are more or
+less persistent; fading sooner or later, however, and giving place to
+new outbreaks. Vesicles are often intermingled, developing from
+erythematous and erythemato-papular lesions or arising from apparently
+normal skin.
+
+It may continue in the same type, or change to the vesicular, bullous or
+other variety.
+
+
+#Describe the papular type of dermatitis herpetiformis.#
+
+This is rarely seen as consisting purely of papular lesions, but is
+commonly associated with the erythematous and vesicular varieties. In a
+measure it resembles the papular manifestations of erythema multiforme,
+with a distinct disposition toward group formation. The papules tend,
+sooner or later, to develop into vesicles, new papular outbreaks
+occurring from time to time; or the whole eruption changes to the
+vesicular or other type of the disease. It is not a common type.
+
+
+#Describe the vesicular type of dermatitis herpetiformis.#
+
+This is the common clinical type of the disease, and is characterized by
+pin-head to pea-sized, rounded or irregularly-shaped, distended or
+flattened and stellate vesicles, occurring, for the most part, in
+irregular and segmental groups of three or more lesions, seated either
+upon apparently normal integument or upon hyperaemic or inflammatory
+skin. They exhibit no tendency to spontaneous rupture, but after
+remaining a shorter or longer time, are broken or disappear by
+absorption. The lesions tend to appear in crops. It may, as it not
+infrequently does, continue in the same type, or it may become more or
+less erythematous or bullous in character. In not a few instances
+pustules, few or in numbers, are at times intermingled.
+
+
+#Describe the pustular type of dermatitis herpetiformis.#
+
+This is rare. It is similar in its clinical characters to the vesicular
+type, except that the lesions are pustular. It is met with, as a rule,
+in association with the vesicular and bullous varieties of the disease.
+
+
+#Describe the bullous type of dermatitis herpetiformis.#
+
+The bullous expression of the disease is usually of a markedly
+inflammatory nature, often innumerable blebs, small and large, appearing
+almost continuously, and in some instances involving the greater part of
+the surface. The lesions arise from erythematous skin, from preexisting
+vesicles or vesicular groups, or from apparently normal integument.
+There is a marked disposition to appear in clusters. A change of type to
+the erythematous or vesicular varieties is not unusual.
+
+
+#Describe the mixed type of dermatitis herpetiformis.#
+
+In this type the eruption is made up of erythematous patches, vesicles,
+bullae, and often with pustules intermingled, appearing irregularly or in
+crops, and with a tendency to patch or group formation.
+
+
+#Describe the characters of the vesicles, pustules and blebs.#
+
+As a rule, these several lesions, especially the vesicles and blebs, are
+somewhat peculiar: they are usually of a strikingly irregular outline,
+oblong, stellate, quadrate, and when drying are apt to have a puckered
+appearance. They are herpetic in that they show little disposition to
+spontaneous rupture, occur in groups, and are usually seated upon
+erythematous or inflammatory skin--in some respects similar to the
+groups of simple herpes and herpes zoster.
+
+
+#What is to be said in regard to the subjective symptoms?#
+
+The subjective symptoms are usually the most troublesome feature of the
+disease, consisting of intense and persistent itching and a feeling of
+heat and burning.
+
+
+#Are there any constitutional symptoms in dermatitis herpetiformis?#
+
+As a rule, not, excepting the distress and depression necessarily
+consequent upon the intense itchiness and loss of sleep. In the pustular
+and bullous varieties there may be mild or grave systemic symptoms, but
+even in these types the constitutional involvement is, in most
+instances, slight in comparison to the intensity of the cutaneous
+disturbance.
+
+
+#What is the course of dermatitis herpetiformis?#
+
+Extremely chronic, in most instances lasting, with remissions,
+indefinitely. The skin is rarely entirely free. From time to time the
+type of the disease may undergo change. From the continued irritation
+and scratching more or less pigmentation results.
+
+
+#What is to be said in regard to the etiology?#
+
+The disease is in many instances essentially neurotic, and in
+exceptional instances septicaemic. Pregnancy and the parturient state are
+factors in some instances (so-called herpes gestationis). It is possible
+in some instances that the eruption may be an expression of a mild
+toxemia of gastro-intestinal origin. In some cases no cause can be
+assigned. In the majority of patients the general health, considering
+the violence of the eruptive phenomena, remains comparatively
+undisturbed.
+
+Nervous shock and mental worry are factors in some cases. Polyuria,
+with sugar in the urine, has occasionally been noted. Eosinophile
+cells have been found both in the vesicles and the blood. In some
+instances--exceptionally, it is true--the disease has appeared shortly
+after vaccination.
+
+
+#Mention the diagnostic features of dermatitis herpetiformis.#
+
+The multiformity of the eruption, the characters of the lesions, the
+disposition to grouping, the absence of tendency to form solid sheets of
+eruption (as in eczema), the intense itching, history, chronicity and
+course. In doubtful cases, an observation of several weeks will always
+suffice to distinguish it from eczema, erythema multiforme, herpes iris
+and pemphigus, diseases to which it at times bears strong resemblance.
+
+
+#Give the prognosis of dermatitis herpetiformis.#
+
+An opinion as to the outcome of the disease should be guarded. It is
+exceedingly rebellious to treatment, and relapses are the rule.
+Exceptionally the bullous and pustular varieties prove eventually fatal.
+The erythematous and vesicular varieties are the most favorable.
+
+
+#State the treatment to be advised.#
+
+There are no special remedies. Constitutional treatment must be
+conducted upon general principles. A free action of the bowels is to be
+maintained. In occasional instances arsenic in progressive doses seems
+of value. Externally protective and antipruritic applications, such as
+are employed in the treatment of eczema and pemphigus, are to be
+employed:--
+
+  [Rx] Ac. carbolici, ....................... [dram]j-[dram]ij
+       Thymol, .............................. gr. xvj.
+       Glycerinae, ........................... [Oz]ss-[Oz]j
+       Alcoholis, ........................... f[Oz]ij
+       Aquae, q.s., ......... ad ............. Oj.   M.
+
+Other valuable applications are: lotions of carbolic acid, of liquor
+carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment
+and carbolized oxide-of-zinc ointment, and dusting-powders of starch,
+zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion
+or ointment is sometimes of advantage; thiol employed in the same manner
+has also been commended.
+
+
+
+                             #Psoriasis.#
+
+
+#Give a definition of psoriasis.#
+
+Psoriasis is a chronic, inflammatory disease, characterized by dry,
+reddish, variously-sized, rounded, sharply-defined, more or less
+infiltrated, scaly patches.
+
+[Illustration: Psoriasis.]
+
+
+#At what age does psoriasis usually first make its appearance?#
+
+Most commonly between the ages of fifteen and thirty. It is rarely seen
+before the tenth year, and a first attack is uncommon after the age of
+forty.
+
+
+#Has psoriasis any special parts of predilection?#
+
+The extensor surfaces of the limbs, especially the elbows and knees, are
+favorite localities, and even when the eruption is more or less general,
+these regions are usually most conspicuously involved. The face often
+escapes, and the palms and soles, likewise the nails, are rarely
+involved. In exceptional instances, the eruption is limited almost
+exclusively to the scalp.
+
+
+#Are there any constitutional or subjective symptoms in psoriasis?#
+
+There is no systemic disturbance; but a variable amount of itching may
+be present, although, as a rule, it is not a troublesome symptom.
+
+
+#Describe the clinical appearances of a typical, well developed case.#
+
+Twenty or a hundred or more lesions, varying in size from a pin-head to
+a silver dollar, are usually present. They are sharply defined against
+the sound skin, are reddish, slightly elevated and infiltrated, and more
+or less abundantly covered with whitish, grayish or mother-of-pearl
+colored scales. The patches are usually scattered over the general
+surface, but are frequently more numerous on the extensor surfaces of
+the arms and legs, especially about the elbows and knees. Several
+closely-lying lesions may coalesce and a large, irregular patch be
+formed; some of the patches, also, may be more or less circinate, the
+central portion having, in a measure or completely, disappeared.
+
+
+#Give the development and history of a single lesion.#
+
+Every single patch of psoriasis begins as a pin-point or pin-head-sized,
+hyperaemic, scaly, slightly-elevated lesion; it increases gradually, and
+in the course of several days or weeks usually reaches the size of a
+dime or larger, and then may remain stationary; or involution begins to
+take place, usually by a disappearance, partially or completely, of the
+central portion, and finally of the whole patch.
+
+
+#Describe the so-called clinical varieties of psoriasis.#
+
+As clinically met with, the patches present are, as a rule, in all
+stages of development. In some instances, however, the lesions, or the
+most of them, progress no further than pin-head in size, and then remain
+stationary, constituting _psoriasis punctata_; in other cases, they
+may stop short after having reached the size of drops--_psoriasis
+guttata_; in others (and this is the usual clinical type) the patches
+develop to the size of coins--_psoriasis nummularis_. In some cases
+there is a strong tendency for the central part of the lesions to
+disappear, and the process then remain stationary, the patches being
+ring-shaped--_psoriasis circinata_; and occasionally several such rings
+coalesce, the coalescing portions disappearing and the eruption be more
+or less serpentine--_psoriasis gyrata_. Or, in other instances, several
+large contiguous lesions may coalesce and a diffused, infiltrated patch
+covering considerable surface results--_psoriasis diffusa, psoriasis
+inveterata_.
+
+[Illustration: Fig. 17. Psoriasis.]
+
+
+#Is the eruption of psoriasis always dry?#
+
+Yes.
+
+
+#What course does psoriasis pursue?#
+
+As a rule, eminently chronic. Patches may remain almost indefinitely, or
+may gradually disappear and new lesions appear elsewhere, and so the
+disease may continue for months and, sometimes, for years; or, after
+continuing for a longer or shorter period, may subside and the skin
+remain free for several months or one or two years, and, in rare
+instances, may never return.
+
+[Illustration: Fig. 18. Psoriasis.]
+
+
+#Is the course of psoriasis influenced by the seasons?#
+
+As a rule, yes; there is a natural tendency for the disease to become
+less active or to disappear altogether during the warm months.
+
+
+#What is known in regard to the etiology of psoriasis?#
+
+The causes of the disease are always more or less obscure. There is
+often a hereditary tendency, and the gouty and rheumatic diathesis must
+occasionally be considered potential. In some instances it is apparently
+influenced by the state of the general health. It is a rather common
+disease and is met with in all walks of life.
+
+
+#Is psoriasis contagious?#
+
+No. In recent years the fact of its exhibiting a family tendency has
+been thought as much suggestive of contagiousness as of heredity.
+
+
+#What is the pathology?#
+
+According to modern investigations, it is an inflammation induced by
+hyperplasia of the rete mucosum; and it is beginning to be believed that
+this hyperplasia may have a parasitic factor as the starting-cause.
+
+
+#With what diseases are you likely to confound psoriasis?#
+
+Chiefly with squamous eczema and the papulo-squamous syphiloderm; and on
+the scalp, also with seborrh[oe]a. It can scarcely be confounded with
+ringworm.
+
+
+#How is psoriasis to be distinguished from squamous eczema?#
+
+By the sharply-defined, circumscribed, scattered, scaly patches, and by
+the history and course of the individual lesions.
+
+
+#In what respects does the papulo-squamous syphiloderm differ from
+psoriasis?#
+
+The scales of the squamous syphilide are usually dirty gray in color and
+more or less scanty; the patches are coppery in hue, and usually several
+or more characteristic scaleless, infiltrated papules are to be found.
+The face, palms, and soles are often the seat of the syphilitic
+eruption; and, moreover, _concomitant symptoms of syphilis_, such as
+sore throat, mucous patches, glandular enlargement, rheumatic pains,
+falling out of the hair, together with the history of the initial
+lesion, are one, several, or all usually present.
+
+
+#How does seborrh[oe]a differ from psoriasis?#
+
+Seborrh[oe]a of the scalp is usually diffused, with but little redness
+and no infiltration; moreover, the scales of seborrh[oe]a are greasy,
+dirty gray or brownish, while those of psoriasis are dry and comonly
+whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists
+independently of other patches elsewhere on the general surface.
+
+That variety of seborrh[oe]a, commonly known as eczema seborrhoicum,
+presents at times, both on scalp and general surface, a strong
+resemblance to psoriasis, but the character of the scales and
+distribution of psoriasis, as above stated, are distinguishing points;
+seborrh[oe]a, moreover, favors hairy surfaces and in extensive examples
+the scalp, eyebrows, sternal, and pubic regions rarely escape.
+
+
+#How does psoriasis differ from ringworm?#
+
+By its greater scaliness, by its higher degree of inflammatory action,
+and by its larger number of patches, as also by its history. In ringworm
+_all_ the patches tend to clear up in the centre; in psoriasis this is
+rarely, if ever, so. If there is still any doubt, microscopic
+examination of the scrapings will determine.
+
+
+#Give the prognosis of psoriasis.#
+
+The prognosis is usually favorable, so far as concerns the immediate
+eruption, but as to recurrences, nothing positive can be stated. In rare
+instances, however, the cure remains permanent.
+
+
+#How is psoriasis treated?#
+
+Both constitutional and local remedies are demanded in most cases.
+
+
+#Do dietary measures exert any influence?#
+
+As a rule, no; but the food should be plain, and an excess of meat
+avoided.
+
+
+#Name the important constitutional remedies usually employed in
+psoriasis.#
+
+_Arsenic_ is of first importance. It is not suitable in acute or
+markedly inflammatory types; but is most useful in the sluggish, chronic
+forms of the disease. The dose should never be pushed beyond slight
+physiological action. It may be given as arsenious acid in pill form,
+one-fiftieth to one-tenth of a grain three times daily, or as Fowler's
+solution, three to ten minims at a dose.
+
+_Alkalies_, of which liquor potassae is the most eligible. It is to be
+given in ten to twenty minim doses, largely diluted. It is valuable in
+robust, plethoric, rheumatic or gouty individuals with psoriasis of an
+acute or markedly inflammatory type; it is not to be given to
+debilitated or anaemic subjects.
+
+_Salicin_, sodium salicylate, and salophen in moderately full doses act
+well in some cases. Occasionally thyroid preparations have a good
+effect.
+
+_Potassium Iodide_, in doses of thirty to one hundred grains, t.d., acts
+favorably in some instances; there are no special indications pointing
+toward its selection, unless it be the existence of a gouty or rheumatic
+diathesis.
+
+Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper,
+and other diuretics are valuable in some instances, and, while often
+failing, sometimes exert a rapid influence, especially in those cases in
+which the disease is extensive and inflammatory. Wine of antimony, given
+cautiously, is also sometimes of service in the acute inflammatory type
+in robust subjects.
+
+
+#Are such remedies as iron, quinine, nux vomica and cod-liver oil ever
+useful in psoriasis?#
+
+Yes. In debilitated subjects the administration of such remedies is at
+times attended with improvement in the cutaneous eruption.
+
+
+#What are the indications as regards the external measures?#
+
+Removal of the scales, and the use of soothing or stimulating
+applications, according to the individual case.
+
+
+#How are the scales removed?#
+
+In ordinary cases, either by warm, plain, or alkaline baths, or
+hot-water-and-soap washings; in those cases in which the scaling is
+abundant and adherent, washing with sapo viridis and hot water may be
+required. Baths of sal ammoniac, two to six ounces to the bath are also
+valuable in removing the scaliness. The tincture of green soap (tinctura
+saponis viridis) is especially valuable for cleansing purposes in
+psoriasis of the scalp. The hot vapor bath once or twice weekly is
+serviceable in keeping the scaliness in abeyance, and has, moreover, in
+some cases, a therapeutic value.
+
+The frequency of the baths or washings will depend upon the rapidity
+with which the scales are reproduced.
+
+
+#Are soothing applications often demanded in psoriasis?#
+
+In exceptional cases; in those in which the disease is acute, markedly
+inflammatory and rapidly progressing, mild, soothing applications must
+be temporarily employed, such as plain or bran baths, with the use of
+some bland oil or ointment. As a rule, however, the conditions, when
+coming under observation, are such as to permit of stimulating
+applications from the start. The most efficient soothing applications
+are the mild lotions and ointments employed in eczema of acute type.
+
+
+#How are the stimulating remedies employed in psoriasis applied?#
+
+As ointments, oils, and paints (pigmenta).
+
+An ointment, if employed, is to be thoroughly rubbed in the diseased
+areas once or twice daily. The same may be said of the oily
+applications. The paints (medicated collodion and gutta-percha solution)
+are applied with a brush, once daily, or every second or third day,
+depending mainly upon the length of time the film remains intact and
+adherent.
+
+
+#Name the several important external remedies.#
+
+Chrysarobin, pyrogallol, tar, ammoniated mercury, [beta]-naphthol,
+and resorcin.
+
+
+#Are these several external remedies equally serviceable in all cases?#
+
+No. Their action differs slightly or greatly according to the case and
+individual. A change from one to another is often necessary.
+
+
+#In what forms and strength are these remedies to be applied?#
+
+_Chrysarobin_ is applied in several ways: as an ointment, twenty to
+sixty grains to the ounce, rubbed in once or twice daily; this is the
+most rapid but least cleanly and eligible method. As a pigment, or
+paint, as in the following:--
+
+  [Rx] Chrysarobini, ........................ [dram]j
+       Acidi salicylici, .................... gr. xx
+       Etheris, ............................. f[dram]j
+       Ol. ricini, .......................... [minim]x
+       Collodii, ............................ f[dram]vij.  M.
+
+Or it may be used in liquor gutta-perchae (traumaticin), a drachm to the
+ounce. It may also be employed in chloroform, a drachm to the ounce; this
+is painted on, the chloroform evaporating, leaving a thin film of
+chrysarobin; over this is painted flexible collodion. If the patches are
+few and large, chrysarobin rubber-plaster may be used.
+
+Chrysarobin is usually rapid in its effect, but it has certain
+disadvantages; it may cause an inflammation of the surrounding skin,
+and, if used near the eyes, may give rise to conjunctivitis. As a rule,
+it should not be employed about the head. Moreover, it stains the linen
+permanently and the skin temporarily.
+
+_Pyrogallol_ is valuable, and is employed in the same manner and
+strength as chrysarobin. In collodion it should at first not be used of
+greater strength than three to four per cent., as in this form
+pyrogallol sometimes acts with unexpected energy. It is less rapid than
+chrysarobin, but it rarely inflames the surrounding integument. It
+stains the linen a light brown, however, and is not to be used over an
+extensive surface for fear of absorption and toxic effect. Oxidized
+pyrogallic acid, a somewhat milder drug in its effect, has been highly
+commended, and has the alleged advantage of being free from toxic
+action.
+
+_Tar_ is, all things considered, the most important external remedy. It
+is comparatively slow in its action, but is useful in almost all cases.
+As employed usually it is prescribed in ointment form, either as the
+official tar ointment, full strength or weakened with lard or
+petrolatum. It may also be used as pix liquida, with equal part of
+alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch
+(ol. rusci) may be employed, either as oily applications or incorporated
+with ointment or with alcohol. Liquor carbonis detergens, in ointment,
+one to three drachms to the ounce of simple cerate and lanolin is a mild
+tarry application which is often useful. In stubborn patches an
+occasional thorough rubbing with a mixture of equal parts of liquor
+carbonis detergens and Vleminckx's solution, followed by a mild
+ointment, sometimes proves of value. In whatsoever form tar is employed
+it should be thoroughly rubbed in, once or twice daily, the excess wiped
+off, and the parts then dusted with starch or similar powder.
+
+_Ammoniated mercury_ is applied in ointment form, twenty to sixty grains
+to the ounce. Compared to other remedies it is clean and free from
+staining, although, as a rule, not so uniformly efficacious. It is
+especially useful for application to the scalp and exposed parts. It
+should not be used over extensive surface for fear of absorption.
+
+_[beta]-Naphthol_ and _resorcin_ are applied as ointments, thirty to
+sixty grains to the ounce, and as they are (especially the former)
+practically free from staining, may be used for exposed surfaces.
+
+Gallacetophenone and aristol also act well in some cases, applied in
+five- to ten-per-cent. strength, as ointments.
+
+In obstinate patches the _x_-ray may be resorted to, employing it with
+caution and in the same manner as in other diseases.
+
+
+
+                      #Pityriasis Rosea.#
+          (_Synonym:_ Pityriasis Maculata et Circinata.)
+
+
+#What do you understand by pityriasis rosea?#
+
+Pityriasis rosea is a disease of a mildly inflammatory nature,
+characterized by discrete, and later frequently confluent, variously
+sized, slightly raised scaly macules of a pinkish to rosy-red, often
+salmon-tinged, color.
+
+
+#Upon what part of the body is the eruption usually found?#
+
+The trunk is the chief seat of the eruption, although not infrequently
+it is more or less general.
+
+
+#Describe the symptoms of pityriasis rosea.#
+
+The lesions, which appear rapidly or slowly, are but slightly elevated,
+somewhat scaly, usually rounded, except when several coalesce, when an
+irregularly outlined patch results. At first they are pale or bright
+pink or reddish, later a salmon tint (which is often characteristic) is
+noticed. The scaliness is bran-like or flaky, of a dirty gray color,
+and, as a rule, less marked in the central portion; it is never
+abundant. The skin is rarely thickened, the process being usually
+exceedingly superficial.
+
+
+#What course does pityriasis rosea pursue?#
+
+The eruption makes its appearance, as a rule, somewhat rapidly, usually
+attaining its full development in the course of one or two weeks, and
+then begins gradually to decline, the whole process occupying one or two
+months.
+
+
+#To what is pityriasis rosea to be attributed?#
+
+The cause is not known; it is variously considered as allied to
+seborrh[oe]a (eczema seborrhoicum), as being of a vegetable-parasitic
+origin, and as a mildly inflammatory affection somewhat similar to
+psoriasis. It is not a frequent disease.
+
+
+#How is pityriasis rosea distinguished from ringworm, psoriasis and the
+squamous syphiloderm?#
+
+From ringworm, by its rapid appearance, its distribution, the number of
+patches, and, if necessary, by microscopic examination of the scrapings.
+
+Psoriasis is a more inflammatory disease, is seen usually more
+abundantly upon the limbs, the scales are profuse and silvery, and the
+underlying skin is red and has a glazed look; moreover, psoriasis, as a
+rule, appears slowly and runs a chronic course.
+
+The squamous syphiloderm differs in its history, distribution, and above
+all, by the presence of concomitant symptoms of syphilis, such as
+glandular enlargement, sore throat, mucous patches, rheumatic pains, and
+falling out of the hair.
+
+
+#State the prognosis of pityriasis rosea.#
+
+It is favorable, the disease tending to spontaneous disappearance,
+usually in the course of several weeks or one or two months.
+
+
+#What treatment is to be advised in pityriasis rosea?#
+
+Laxatives and intestinal antiseptics, and ointments of salicylic acid
+(5-15 grains to the ounce), of sulphur (10-40 grains to the ounce); or a
+compound ointment containing both these ingredients can be prescribed.
+The ointment base can be equal parts of white vaselin and cold cream; in
+some instances Lassar's paste (starch powder, zinc oxid powder, each,
+[dram]ij; vaselin, [dram]iv) seems more satisfactory.
+
+
+
+                       #Dermatitis Exfoliativa.#
+       (_Synonyms:_ General Exfoliative Dermatitis; Recurrent Exfoliative
+         Dermatitis; Desquamative Scarlatiniform Erythema; Acute General
+          Dermatitis; Recurrent Exfoliative Erythema; Pityriasis Rubra.)
+
+
+#Describe dermatitis exfoliativa.#
+
+Dermatitis exfoliativa is an inflammatory disease of an acute type,
+characterized by a more or less general erythematous inflammation, in
+exceptional instances vesicular or bullous, with epidermic desquamation
+or exfoliation accompanying or following its development. Constitutional
+disturbance, which may be of a serious character, is sometimes present.
+It is a rare and obscure affection, running its course usually in
+several weeks or months, but exhibiting a decided tendency to relapse
+and recurrence. In many cases it is persistently chronic, with
+exacerbations and remissions. In some instances it develops from a
+long-continued and more or less generalized eczema or psoriasis, and in
+exceptional cases it is started by the careless use of mercurial
+ointment and of chrysarobin ointment.
+
+[Illustration: Fig. 19. Dermatitis Exfoliativa.]
+
+In another type of the disease, formerly described as _pityriasis
+rubra_, the skin is pale red or violaceous-red, but is rarely thickened,
+continued exfoliation in the form of thin plates taking place. Its
+course is variable, lasting for years, with remissions.
+
+An exfoliating generalized dermatitis is exceptionally observed in the
+first weeks of life (_dermatitis exfoliativa neonatorum_), lasting some
+weeks, and in most cases followed by recovery. There are no special
+constitutional symptoms, the fatal cases usually dying of marasmus.
+
+As will be seen dermatitis exfoliativa varies considerably in degree; it
+may be extremely mild, resembling in appearance the scarlet-fever
+eruption (erythema scarlatiniforme) and running a rapid course; or the
+skin-condition and the systemic symptoms may be of grave and persistent
+character.
+
+
+#Give the treatment of dermatitis exfoliativa.#
+
+General treatment is based upon indications, and externally soothing
+applications, such as are employed in acute and subacute eczema, are to
+be used.
+
+
+
+                        #Lichen Planus.#
+
+
+#What is lichen planus?#
+
+Lichen planus is an inflammatory disease characterized by small, flat
+and angular, smooth and shining, or scaly, discrete or confluent, red or
+violaceous-red papules, having a distinctly papular or papulo-squamous
+course, and attended with more or less itching.
+
+
+#Describe the symptoms of lichen planus.#
+
+The eruption, as a rule, begins slowly, usually showing itself upon the
+extremities; the forearms, wrists and legs being favorite localities. It
+may appear as one or more groups or in the form of short or long bands.
+Occasionally its evolution is rapid and a considerable part of the
+surface may be invaded. The lesions are pin-head to small pea-sized,
+irregularly grouped or so closely crowded together as to form solid
+patches; they are quadrangular or polygonal in shape, usually flat, with
+central depression or umbilication, and are reddish or violaceous in
+color. At first they have a glazed or shining appearance; later,
+becoming slightly scaly, the scaliness being more marked where solid
+patches have resulted. New papules may appear from time to time, the
+older lesions disappearing and leaving persistent reddish or brownish
+pigmentation. Exceptionally the eruption presents in bands or lines,
+like rows of beads (_lichen moniliformis_). Very exceptionally a
+vesicular or bleb tendency in some of the lesions has been noted;
+doubtless, in most instances at least, this has been due to the arsenic
+so generally administered in this disease. In rare instances lichen
+planus lesions are also seen on the glans penis and on the buccal mucous
+membrane. In some cases, especially in the region of the ankle, the
+papules become quite large (_lichen planus hypertrophicus_), and in
+occasional cases there is a tendency in some of the lesions or patches
+to clear up centrally. There is, as a rule, considerable itching. There
+are no constitutional symptoms.
+
+
+#What is the etiology of lichen planus?#
+
+In some cases the disease is distinctly neurotic in character, in others
+no cause can be assigned. It is more especially met with at middle age,
+and among the wealthier, professional, and luxurious classes.
+
+Pathologically the first change noted in the epidermis is thought to be
+an acanthosis, followed by epithelial atrophy, and a hyperkeratosis,
+intercellular edema, and colloid degeneration of the prickle cells.
+
+
+#Does the disease bear any resemblance to the miliary papular syphilide,
+psoriasis, and papular eczema?#
+
+In some instances it does, but the irregular and angular outline, the
+slightly-umbilicated, flattened, smooth or scaly summits, and the
+dull-red or violaceous color, the history and course, of lichen planus,
+will serve to differentiate.
+
+
+#State the prognosis.#
+
+Under proper management the eruption, although often obstinate, yields
+to treatment.
+
+
+#What treatment would you prescribe in lichen planus?#
+
+A general tonic plan of medication is indicated in most cases, with such
+remedies as iron, quinine, nux vomica, and cod-liver oil and other
+nutrients. In many instances arsenic exerts a special influence, and
+should always be tried. Mercurials in moderate dosage have also a
+favorable action in most cases. Locally, antipruritic and stimulating
+applications, such as are used in the treatment of eczema, are to be
+employed, alkaline baths and tarry applications deserving special
+mention. Liquor carbonis detergens, applied weakened with several parts
+water, is a valuable application. In some cases, particularly if the
+disease is limited, external applications alone often suffice to bring
+about a cure.
+
+
+
+                     #Pityriasis Rubra Pilaris.#
+          (_Synonyms:_ Lichen Ruber; Lichen Ruber Acuminatus.)
+
+
+#Describe pityriasis rubra pilaris.#
+
+Pityriasis rubra pilaris is an extremely rare disease, usually of a
+mildly inflammatory nature, characterized by grayish, pale-red or
+reddish-brown follicular papules with somewhat hard or horny centres;
+discrete and confluent, and covering a part or the entire surface. The
+skin is harsh, dry and rough, feeling to the touch somewhat like the
+surface of a nutmeg-grater or a coarse file. More or less scaliness is
+usually present in the confluent patches and on the palms and soles; in
+these latter regions the papules are rarely seen. The duration of the
+disease is variable, and relapses are common. It bears resemblance at
+times to keratosis pilaris, ichthyosis, dermatitis exfoliativa; it is
+considered identical with the lichen ruber acuminatus of Kaposi, and by
+many also with the lichen ruber of Hebra. The etiology is obscure.
+
+Treatment, both constitutional and local, is to be based upon general
+principles; stimulating applications, with frequent baths, such as are
+advised in psoriasis, are the most satisfactory. It is rebellious, and
+not much more than palliation can be effected in some cases, in others
+the outlook is more hopeful.
+
+
+
+                         #Lichen Scrofulosus.#
+
+
+#Describe lichen scrofulosus.#
+
+Lichen scrofulosus is a chronic, inflammatory disease, characterized by
+millet-seed-sized, rounded or flat, reddish or yellowish, more or less
+grouped, desquamating papules. The lesions have their start about the
+hair-follicles, occur usually upon the trunk, tend to group and form
+patches, and sooner or later become covered with minute scales. As a
+rule, there is no itching. It is a rare disease, and but seldom met with
+in America; it is seen chiefly in children and young people of a
+scrofulous diathesis. Scarring, slight in character, may or may not
+follow.
+
+
+#What is the treatment of lichen scrofulosus?#
+
+The condition responds to tonics and anti-strumous remedies.
+
+
+
+                              #Eczema.#
+                  (_Synonym:_ Tetter; Salt Rheum.)
+
+
+#What is eczema?#
+
+An acute, subacute or chronic inflammatory disease, characterized in the
+beginning by the appearance of erythema, papules, vesicles or pustules,
+or a combination of these lesions, with a variable amount of
+infiltration and thickening, terminating either in discharge with the
+formation of crusts, in absorption, or in desquamation, and accompanied
+by more or less intense itching and a feeling of heat or burning.
+
+
+#What are the several primary types of eczema?#
+
+Erythematous, papular, vesicular and pustular; all cases begin as one or
+more of these types, but not infrequently lose these characters and
+develop into the common clinical or secondary types--eczema rubrum and
+eczema squamosum.
+
+[Illustration: Fig. 20. Papular Eczema (leg).]
+
+
+#What other types are met with clinically?#
+
+Eczema rubrum, eczema squamosum, eczema fissum, eczema sclerosum and
+eczema verrucosum. Eczema seborrhoicum is probably a closely allied
+disease, occupying a middle position between ordinary eczema and
+seborrh[oe]a.
+
+
+#Describe the symptoms of erythematous eczema.#
+
+Erythematous eczema (_eczema erythematosum_) begins as one or more small
+or large, irregularly outlined hyperaemic macules or patches, with or
+without slight or marked swelling, and with more or less itching or
+burning. At first it may be ill-defined, but it tends to spread and its
+features to become more pronounced. It may be limited to a certain
+region, or it may be more or less general. When fully developed, the
+skin is harsh and dry, of a mottled, reddish or violaceous color,
+thickened, infiltrated and usually slightly scaly, with, at times, a
+tendency toward the formation of oozing areas. Punctate and linear
+scratch-marks may usually be seen scattered over the affected region.
+
+[Illustration: Fig. 21. Eczema Rubrum.]
+
+Its most common site is the face, but it is not infrequent upon other
+parts.
+
+
+#What course does erythematous eczema pursue?#
+
+It tends to chronicity, continuing as the erythematous form, or the skin
+may become considerably thickened and markedly scaly, constituting
+eczema squamosum; or a moist oozing surface, with more or less crusting,
+may take its place--eczema rubrum.
+
+
+#Describe the symptoms of papular eczema.#
+
+Papular eczema (_eczema papulosum_) is characterized by the appearance,
+usually in numbers, of discrete, aggregated or closely-crowded, reddish,
+pin-head-sized acuminated or rounded papules. Vesicles and
+vesico-papules are often intermingled. The itching is commonly intense,
+as often attested by the presence of scratch-marks and blood crusts.
+
+[Illustration: Fig. 22. Eczema Squamosum et tissum.]
+
+It is seen most frequently upon the extremities, especially the flexor
+surfaces.
+
+
+#What course does papular eczema pursue?#
+
+The lesions tend, sooner or later, to disappear, but are usually
+replaced by others, the disease thus persisting for weeks or months; in
+places where closely crowded, a solid, thickened, scaly sheet of
+eruption may result--eczema squamosum.
+
+
+#Describe the symptoms of vesicular eczema.#
+
+Vesicular eczema (_Eczema vesiculosum_) usually appears, on one or
+several regions, as more or less diffused inflammatory reddened patches,
+upon which rapidly develop numerous closely-crowded pin-point to
+pin-head-sized vesicles, which tend to become confluent and form a solid
+sheet of eruption. The vesicles soon mature and rupture, the discharge
+drying to yellowish, honeycomb-like crusts. The oozing is usually more
+or less continuous, or the disease may decline, the crusts be cast off,
+to be quickly followed by a new crop of vesicles. In those cases in
+which the process is markedly acute, considerable swelling and [oe]dema
+are present. Scattered papules, vesico-papules and pustules may usually
+be seen upon the involved area or about the border.
+
+The face in infants (_crusta lactea_, or _milk crust_, of older
+writers), the neck, flexor surfaces and the fingers are its favorite
+localities.
+
+
+#What course does vesicular eczema pursue?#
+
+Usually chronic, with acute exacerbations. Not infrequently it passes
+into eczema rubrum.
+
+
+#Describe the symptoms of pustular eczema.#
+
+Pustular eczema (_eczema pustulosum_, _eczema impetiginosum_) is probably
+the least common of all the varieties. It is similar, although usually
+less actively inflammatory, in its symptoms to eczema vesiculosum, the
+lesions being pustular from the start or developing from preexisting
+vesicles; not infrequently the eruption is mixed, the pustules
+predominating. There is a marked tendency to rupturing of the lesions,
+the discharge drying to thick, yellowish, brownish or greenish crusts.
+
+Its most common sites are the scalp and face, especially in young people
+and in those who are ill-nourished and strumous.
+
+
+#What course does pustular eczema pursue?#
+
+Usually chronic, continuing as the same type, or passing into eczema
+rubrum.
+
+
+#Describe the symptoms of squamous eczema.#
+
+Squamous eczema (_eczema squamosum_) may be defined as a clinical
+variety, the chief symptoms of which are a variable degree of scaliness,
+more or less thickening, infiltration, and redness, with commonly a
+tendency to cracking or fissuring of the skin, especially when the
+disease is seated about the joints. It is developed, as a rule, from the
+erythematous or papular type. Itching is slight or intense.
+
+The disease is not uncommon upon the scalp.
+
+
+#What is the course of squamous eczema?#
+
+Essentially chronic.
+
+[Illustration: Fig. 23. Eczema of the Face and Scalp.]
+
+
+#Describe the symptoms of eczema rubrum.#
+
+Eczema rubrum is characterized by a red, raw-looking, weeping, oozing or
+discharging surface, attended with more or less inflammatory thickening,
+infiltration and swelling; the exudation, consisting of serum, sometimes
+bloody, dries into thick yellowish or reddish-brown crusts. At one time
+the whole diseased area may be hidden under a mass of crusting, at other
+times a red, raw-looking, weeping surface (_eczema madidans_) is the
+most striking feature. Itching is slight or intense, or the subjective
+symptom may be a feeling of burning. It is an important clinical type,
+usually developing from the vesicular, pustular or other primary
+variety.
+
+It is common about the face and scalp in children, and the middle and
+lower part of the leg in elderly people.
+
+
+#What is the course of eczema rubrum?#
+
+Chronic, varying in intensity from time to time.
+
+
+#Describe the symptoms of fissured eczema.#
+
+The conspicuous symptom is a marked tendency to fissuring or cracking of
+the skin (_eczema fissum_; _eczema rimosum_). This tendency is usually a
+part of an erythematous or squamous eczema, the fissuring constituting
+the most conspicuous and troublesome symptom. _Chapping_ is an extremely
+mild but familiar example of this type.
+
+It is especially common about the hands and fingers.
+
+
+#What is the course of fissured eczema?#
+
+It is more or less persistent, the tendency to fissuring varying
+considerably according to the state of the weather, often disappearing
+spontaneously in the summer months.
+
+
+#Describe eczema sclerosum and eczema verrucosum.#
+
+In eczema sclerosum the skin is thickened, infiltrated, hard, and almost
+horny. Eczema verrucosum presents similar conditions, but, in addition,
+displays a tendency to papillary or wart-like hypertrophy. In both
+varieties the disease is usually seated about the ankle or the foot,
+developing from the papular or squamous type. They are uncommon, and
+obstinately chronic.
+
+
+#State the nature of the subjective symptoms in eczema.#
+
+Itching, commonly intense, is usually a conspicuous symptom; it may be
+more or less paroxysmal. In some cases burning and heat constitute the
+main subjective phenomena.
+
+
+#Is eczema accompanied by febrile or systemic symptoms?#
+
+No. In rare instances, in acute universal eczema, slight febrile action,
+or other systemic disturbance, may be noted at the time of the outbreak.
+
+
+#Is the eczematous eruption (patch or patches) sharply defined against
+the neighboring sound skin?#
+
+No. In almost all instances the diseased area merges gradually and
+imperceptibly into the surrounding healthy integument.
+
+
+#What is the character of eczema as regards the degree of inflammatory
+action?#
+
+The inflammatory action may be acute, subacute or sluggish in character,
+and may be so from the start and so continue throughout its whole
+course; or it may, as is usually the case, vary in intensity from time
+to time.
+
+
+#State the character of eczema as regards duration.#
+
+As a rule, it is a persistent disease, showing little, if any, tendency
+to spontaneous disappearance.
+
+
+#Is eczema influenced by the seasons?#
+
+Yes. With comparatively few exceptions the disease is most common and
+much worse in cold, windy, winter weather.
+
+
+#To what may eczema be ascribed?#
+
+Eczema may be due to constitutional or local causes, or to both. It may
+be considered, in fact, as a reaction of the skin tissues against some
+irritant, and the latter may have its origin from within or without.
+
+
+#Name some of the important constitutional or predisposing causes.#
+
+Gouty diathesis, rheumatic diathesis, disorders of the digestive tract,
+general debility or lack of tone, an exhausted state of the nervous
+system, dentition and struma.
+
+
+#Is a constitutional cause sufficient to provoke an attack?#
+
+Yes; but often the attack is brought about in those so predisposed by
+some local or external irritant.
+
+
+#Mention some of the external causes.#
+
+Heat and cold, sharp, biting winds, excessive use of water, strong
+soaps, vaccination, dyes and dyestuffs, chemical irritants, and the
+like. There is a growing belief that some cases presenting eczematous
+aspects are probably parasitic in origin. In fact, some observers hold
+to the microbic view of all cases of eczema.
+
+Contact with the rhus plants, while producing a peculiar dermatitis,
+usually running an acute course terminating in recovery, may, in those
+predisposed, provoke a veritable and persistent eczema. In fact, in our
+examination as to causes in a given case, especially of the hands and face,
+all possible exciting factors should be inquired into, such as the handling
+of plants, chemicals, dyes, etc.
+
+[Illustration: Fig. 24. Eczema of Face.]
+
+
+#Is eczema contagious?#
+
+No. The acceptance of a parasitic cause for the disease, however,
+necessarily carries with it the possibility of contagiousness under
+favoring conditions. Such is not supported, however, by practical
+experience.
+
+
+#What is the pathology?#
+
+The process is an inflammatory one, characterized in all cases by
+hyperaemia and exudation, varying in degree according to the intensity
+and duration of the disease. The rete and papillary layer are especially
+involved, although in severe and chronic cases the lower part of the
+corium and even the subcutaneous tissue may share in the process.
+
+
+#Do the cutaneous manifestations of the eruptive fevers bear resemblance
+to the erythematous type of eczema?#
+
+Scarlatina and erysipelas may, to a slight extent, but the presence or
+absence of febrile and other constitutional symptoms will usually serve
+to differentiate.
+
+
+#What common skin diseases resemble some phases of eczema?#
+
+Psoriasis, seborrh[oe]a, sycosis, scabies and ringworm.
+
+
+#How would you exclude psoriasis in a suspected case of eczema (squamous
+eczema)?#
+
+Psoriasis occurs in variously-sized, rounded, _sharply-defined_ patches,
+usually scattered irregularly over the general surface, with special
+predilection for the elbows and knees. They are covered more or less
+abundantly with whitish, silvery or mother-of-pearl colored imbricated
+scales. The patches are always dry, and itching is, as a rule, slight,
+or may be entirely absent. Eczema, on the contrary, is often localized,
+appearing as one or more large, irregularly diffused patches; it merges
+imperceptibly into the sound skin, and there is often a history of
+characteristic serous or gummy oozing; the scaling is usually slight and
+itching almost invariably a prominent symptom.
+
+
+#How would you exclude seborrh[oe]a (eczema seborrhoicum) in a suspected
+case of eczema?#
+
+Seborrh[oe]a of the scalp is more commonly over the whole of that region
+and is relatively free from inflammatory symptoms; the scales are of a
+greasy character and the itching is usually slight or nil. On the other
+hand, in eczema of this region the parts are rarely invaded in their
+entirety; there may be at times the characteristic serous or gummy
+oozing; inflammatory symptoms are usually well-marked, the scales are
+dry and the itching is, as a rule, a prominent symptom. These same
+differences serve to differentiate the diseases in other regions.
+
+
+#How does scabies differ from eczema?#
+
+Scabies differs from eczema in its peculiar distribution, the presence
+of the burrows, the absence of any tendency to patch formation, and
+usually by a clear history of contagion.
+
+
+#How would you exclude ringworm in a suspected case of eczema?#
+
+Ringworm is to be distinguished by its circular form, its fading in the
+centre, and in doubtful cases by microscopic examination of the
+scrapings.
+
+
+#How does eczema differ from sycosis?#
+
+Sycosis is limited to the hairy region of the face, is distinctly a
+follicular inflammation, and is rarely very itchy; eczema is diffused,
+usually involves other parts of the face, and itching is an annoying
+symptom.
+
+
+#State the general prognosis of eczema.#
+
+The disease is, under favorable circumstances, curable, some cases
+yielding more or less readily, others proving exceedingly rebellious.
+The length of time to bring about a result is always uncertain, and an
+opinion on this point should be guarded.
+
+
+#Upon what would you base your prognosis in the individual case?#
+
+The extent of disease, its duration and previous behavior, the
+removability of the exciting and predisposing causes, and the attention
+the patient can give to the treatment.
+
+In eczema involving the lips, face, scrotum, and leg, and especially
+when this last-named exhibits a varicose condition of the veins, a cure
+is effected, as a rule, only through persistent and prolonged treatment.
+
+
+#Does eczema ever leave scars?#
+
+No. Upon the legs, in long-continued cases, more or less pigmentation
+usually remains.
+
+
+#How is eczema treated?#
+
+As a rule, eczema requires for its removal both constitutional and
+external treatment.
+
+Certain cases, however, seem to be entirely local in their nature, and
+in these cases external treatment alone will have satisfactory results.
+
+
+#What general measures as to hygiene and diet are commonly advisable?#
+
+Fresh air, exercise, moderate indulgence in calisthenics, regular
+habits, a plain, nutritious diet; abstention from such articles of food
+as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese,
+pickles, condiments, excessive coffee or tea drinking, etc. As a rule,
+also, beer, wine, and other stimulants are to be interdicted.
+
+
+#Upon what grounds is the line or plan of constitutional treatment to be
+based?#
+
+Upon indications in the individual case. A careful examination into the
+patient's general health will usually give the cue to the line of
+treatment to be adopted.
+
+
+#Mention the important remedies variously employed in the constitutional
+treatment.#
+
+_Tonics_--such as cod-liver oil, quinine, nux vomica, the vegetable
+bitters, iron, arsenic, malt, etc.
+
+_Alkalies_--sodium salicylate, potassium bicarbonate, liquor potassae,
+and lithium carbonate.
+
+_Alteratives_--calomel, colchicum, arsenic, and potassium iodide.
+
+_Diuretics_--potassium acetate, potassium citrate, and oil of copaiba.
+
+_Laxatives_--the various salines, aperient spring waters, castor oil,
+cascara sagrada, aloes and other vegetable cathartics.
+
+_Digestives_--pepsin, pancreatin, muriatic acid and the various bitter
+tonics.
+
+
+#Are there any remedies which have a specific influence?#
+
+No; although arsenic, in exceptional instances, seems to exert a special
+action. Cod-liver oil is also of great value in some cases.
+
+Upon the whole the most important remedies are those which keep in view
+the maintenance of a proper and healthful condition of the
+gastro-intestinal tract, and especially with regular and rather free
+action of the bowels.
+
+
+#In what class of cases does arsenic often prove of service?#
+
+In the sluggish, dry, erythematous, scaly and papular types.
+
+
+#In what cases is arsenic usually contraindicated?#
+
+It should never be employed in acute cases; nor in any instance (unless
+its action is watched), in which the degree of inflammatory action is
+marked, as an aggravation of the disease usually results.
+
+
+#What should be the character of the external treatment?#
+
+It depends mainly upon the degree of inflammatory action; but the stage
+of the disease, the extent involved, and the ability of the patient to
+carry out the details of treatment, also have a bearing upon the
+selection of the plan to be advised.
+
+
+#What is to be said about the use of soap and water in eczema?#
+
+In acute and subacute conditions soap and water are to be employed, as a
+rule, as infrequently and as sparingly as possible, as the disease is
+often aggravated by their too free use. Washing is necessary, however,
+for cleanliness and occasionally, also, for the removal of the crusts.
+On the other hand, in chronic, sluggish types the use of soap and water
+frequently has a therapeutic value.
+
+
+#How often should remedial applications be made?#
+
+Usually twice daily, although in some case, and especially those of an
+acute type, applications should be made every few hours.
+
+
+#Mention several remedies or plans of treatment to be used in the acute
+or actively inflammatory cases.#
+
+Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly
+dabbed on, allowed to dry, the parts gently smeared with ointment; or
+the ointment may be applied spread on lint as a plaster.
+
+Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment,
+applied in the same manner as the above.
+
+A lotion containing calamine and zinc oxide, the sediment drying and
+coating over the affected surface:--
+
+  [Rx] Calaminae,
+          Zinci oxidi, ... [=a][=a] ......... [dram]ij-[dram]iij
+          Glycerinae,
+          Alcoholis, ..... [=a][=a] ......... f[dram]ss
+          Liq. calcis, ...................... f[Oz]ij
+          Aquae, .......... q.s. ad .......... f[Oz]vj.            M.
+
+Another excellent lotion somewhat similar to the last, but of oily
+character, is made up of three drachms each of calamine and zinc oxide,
+one drachm of boric acid, ten to thirty drops of carbolic acid, and
+three ounces each of lime-water and oil of sweet almonds.
+
+Carbolic-acid lotion, about two drachms to the pint of water, to which
+may be added two or three drachms each of glycerin and alcohol; or, if
+there is intense itching, carbolic acid may be added to the several
+washes already mentioned.
+
+A lotion made of one or two drachms of liquor carbonis detergens[A] to
+four ounces of water.
+
+The following wash, especially in the dry form of the disease:--
+
+  [Rx] Ac. borici, .......................... [dram]iv
+       Ac. carbolici, ....................... [dram]j
+       Glycerinae, ........................... [dram]ij
+       Alcoholis, ........................... [dram]ij
+       Aquae, ............. q.s. ad .......... Oj.          M.
+
+[Footnote A: Liquor carbonis detergens is made by mixing together nine
+  ounces of tincture soap bark and four ounces of coal tar, allowing to
+  digest for eight days, and filtering. The tincture of soap bark used is
+  made with one pound of soap bark to one gallon of 95 per cent. alcohol,
+  digesting for a week or so. Instead of the proprietary name above, Prof.
+  Duhring has suggested that of tinctura picis mineralis comp.]
+
+Dusting-powders, of starch, zinc oxide and Venetian talc, alone or
+severally combined, applied freely and often, so as to afford protection
+to the inflamed surface:--
+
+  [Rx] Talci venet,
+       Zinci oxidi, ....... [=a][=a] ........ [dram]iv
+       Amyli, ............................... [Oz]j        M.
+
+If washes or dusting-powders should disagree or are not desirable or
+practicable, ointments may be employed, such as--
+
+Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated,
+diachylon ointment (if fresh and well prepared), and a paste-like
+ointment, as the following, usually called "salicylic-acid paste"; in
+markedly itchy cases, five to fifteen grains of carbolic may be added to
+each ounce:
+
+  [Rx] Ac. salicylici, ...................... gr. v-x
+       Pulv. amyli,
+       Pulv. zinci oxidi, .... [=a][=a] ..... [dram]ij
+       Petrolati, ........................... [dram]iv      M.
+
+Or the following ointment:--
+
+  [Rx] Calaminae, ............................ [dram]j
+       Ungt. zinci oxidi, ................... [dram]vij.    M.
+
+
+#Name several external remedies and combinations useful in eczema of a
+subacute or mildly inflammatory type.#
+
+The various remedies and combinations useful when the symptoms are acute
+or markedly inflammatory (mentioned above), and more especially the
+several following:--
+
+  [Rx] Zinci oxidi, ......................... [dram]ij
+       Liq. plumbi subacetat. dilut., ....... f[dram]vj
+       Glycerinae, ........................... f[dram]ij
+       Infus. picis liq., ................... f[Oz]iij       M.
+
+A lotion containing resorcin, five to thirty grains to the ounce.
+
+Solution of zinc sulphate, one-half to three grains to the ounce.
+
+An ointment containing calomel or ammoniated mercury, as in the annexed
+formula:--
+
+  [Rx] Hydrargyri ammoniat. seu Hydrargyri
+           chloridi mit., ................... gr. x-xxx
+         Ac. carbolici, ..................... gr. v-x
+         Ungt. zinci oxidi, ................. [Oz]j         M.
+
+Another formula, more especially useful in eczema of the hands and legs,
+is the following:--
+
+  [Rx] Ac. salicylici, ...................... gr. xxx
+       Emp. plumbi,
+       Emp. saponis,
+       Petrolati, ...... [=a][=a] ........... [Oz]j.        M.
+
+(This is to be applied as a plaster, spread on strips of lint, and
+changed every twelve or twenty-four hours.)
+
+The paste-like ointment, referred to as useful in acute eczema, may also
+be used with a larger proportion (20 to 60 grains to the ounce) of
+salicylic acid.
+
+The following, containing tar, may often be employed with advantage:--
+
+  [Rx] Ungt. picis liq., .................... [dram]j
+       Ungt. zinci oxidi, ................... [dram]vij.    M.
+
+
+#What is to be said in regard to the use of tarry applications?#
+
+Ointments or lotions containing tar should always be tried at first upon
+a limited surface, as occasionally skins are met with upon which this
+remedy acts as a more or less violent irritant. The coal tar lotion
+(liquor carbonis detergens) is the least likely to disagree and may be
+used as a mild ointment, one or two drachms to the ounce, or it may be
+diluted and used as a weak lotion as already referred to.
+
+
+#What external remedies are to be employed in eczema of a sluggish type?#
+
+The various remedies and combinations (mentioned above) useful in acute
+and subacute eczema may often be employed with benefit, but, as a rule,
+stronger applications are necessary, especially in the thick and
+leathery patches. The following are the most valuable:--
+
+An ointment of calomel or ammoniated mercury; forty to sixty grains to
+the ounce.
+
+Strong salicylic-acid ointment; a half to one drachm of salicylic acid
+to the ounce of lard.
+
+Tar ointment, official strength; or the various tar oils, alone or with
+alcohol, as a lotion, or in ointment form.
+
+Liquor picis alkalinus[B] is a valuable remedy in chronic _thickened_,
+_hard_ and _verrucous_ patches, but is a strong preparation and must be
+used with caution. It is applied diluted, one part with from eight to
+thirty-two parts of water; or in ointment, one or two drachms to the
+ounce. In such cases, also, the following is useful:--
+
+  [Rx] Saponis viridis,
+       Picis liq.,
+       Alcoholis, .......... [=a][=a] ....... [dram]iij.    M.
+
+  SIG. To be well rubbed in.
+
+[Footnote B:
+  [Rx] Potassae, ............................. [dram]j
+       Picis liq., .......................... [dram]ij
+       Aquae, ................................ [dram]v.
+
+  Dissolve the potash in the water, and gradually add to the tar in a
+  mortar, with thorough stirring.]
+
+In similar cases, also, the parts may be thoroughly washed or scrubbed
+with sapo viridis and hot water until somewhat tender, rinsed off,
+dried, and a mild ointment applied as a plaster.
+
+Lactic acid, applied with one to ten or more parts of water is also of
+value in the sclerous and verrucous types. Caustic potash solutions,
+used cautiously, may also be occasionally employed to advantage in these
+cases.
+
+Another remedy of value in these cases, as well as in others of more or
+less limited nature, is the _x_-ray. Exposures every few days, of short
+duration and 4 to 10 inches distance, with medium vacuum tube. This
+method has served me well in occasional cases; caution is necessary, and
+it should not be pushed further than the production of the mildest
+reaction. The repeated application of a high-frequency current, by means
+of the vacuum electrodes, is a safer and sometimes an equally beneficial
+method.
+
+
+#Is there any method of treating eczema with fixed dressings?#
+
+Several plans have been advised from time to time; some are costly, and
+some require too great attention to details, and are therefore
+impracticable for general employment. The following are those in more
+common use:--
+
+The _gelatin dressing_, as originally ordered, is made by melting over a
+water-bath one part of gelatin in two parts of water--quickly painting
+it over the diseased area; it dries rapidly, and to prevent cracking
+glycerine is brushed over the surface. Or the glycerine may be
+incorporated with the gelatin and water in the following proportion:
+glycerine, one part; gelatin, four parts, and water eight parts.
+Medicinal substances may be incorporated with the gelatin mixture.
+
+A good formula is the following:--
+
+  [Rx] Gelatin, ............................. [Oz]j
+       Zinci oxidi, ......................... [Oz]ss
+       Glycerini, ........................... [Oz]iss
+       Aquae, ................................ [Oz]ii-[Oz]iij.
+
+This should be prepared over a water-bath, and two per cent. ichthyol
+added. A thin gauze bandage can be applied to the parts over which this
+dressing is painted, before it is completely dry; it makes a comfortable
+fixed dressing and may remain on several days.
+
+_Plaster-mull_ and _gutta-percha plaster_. The plaster-mull, consisting
+of muslin incorporated with a layer of stiff ointment, and the
+gutta-percha plaster, consisting of muslin faced with a thin layer of
+India-rubber, the medication being spread upon the rubber coating.
+
+_Rubber plasters._ These are medicated with the various drugs used in
+the external treatment of skin diseases, and are often of service in
+chronic patches.
+
+Two new excipients for fixed dressings have recently been
+introduced--bassorin and plasment; the former is made from gum
+tragacanth, and the latter from Irish moss.
+
+The following is a satisfactory formula for a tragacanth dressing:
+
+  [Rx] Tragacanth, .......................... gr. lxxv
+       Glycerini, ........................... [minim] xxx
+       Ac. carbolici, ....................... gr. x-xx
+       Zinci oxidi, ......................... [dram]iss-[dram]iiss.    M.
+
+This is painted over the parts and allowed to dry, and a mild dusting
+powder sprinkled over. It cannot be used in warm weather or in folds, as
+it is apt to get sticky. The following is a bassorin paste which may be
+variously medicated.
+
+  [Rx] Bassorin, ............................ [dram]x
+       Dextrin, ............................. [dram]vj
+       Glycerini, ........................... [Oz]ij.
+       Aquae, ....................... q.s. ad. [Oz]iij.
+
+It should be prepared cold.
+
+Another "drying dressing" which may be used in cool weather is:
+
+  [Rx] Zinci oxidi, ......................... [Oz]j
+       Glycerini, ........................... [Oz]ss
+       Mucilag. acaciae, ..................... [Oz]ii-[Oz]iv.
+
+It may be variously medicated.
+
+The plaster-mull is used in all types, especially the acute; the gelatin
+dressing, and the gutta-percha plaster, in the subacute and chronic; and
+the rubber plaster in chronic, sluggish patches only. Acacia,
+tragacanth, bassorin and plasment applications are used in cases of a
+subacute and chronic character.
+
+
+
+                             #Prurigo.#
+
+
+#Define prurigo.#
+
+Prurigo is a chronic, inflammatory disease, characterized by discrete,
+pin-head- to small pea-sized, solid, firmly-seated, slightly raised,
+pale-red papules, accompanied by itching and more or less general
+thickening of the affected skin.
+
+
+#Describe the symptoms and course of prurigo.#
+
+The disease first appears upon the tibial regions, and its earliest
+manifestation may be urticarial, but there soon develop the
+characteristic small, millet-seed-sized, or larger, firm elevations,
+which may be of the natural color of the skin or of a pinkish tinge. The
+lesions, whilst discrete, are in great numbers, and closely crowded. The
+overlying skin is dry, rough and harsh; itching is intense, and, as a
+result of the scratching, excoriations and blood crusts are commonly
+present. In consequence of the irritation, the inguinal glands are
+enlarged. Sooner or later the integument becomes considerably thickened,
+hard and rough. Eczematous symptoms may be superadded. In severe cases
+the entire extensor surfaces of the legs and arms, and in some instances
+the trunk also, are invaded. It is worse in the winter season.
+
+
+#What is known in regard to etiology and pathology?#
+
+It is a disease of the ill-fed and neglected, usually developing in
+early childhood, and persisting throughout life. It is extremely rare,
+even in its milder types, in this country. Clinically and pathologically
+it bears some resemblance to papular eczema.
+
+
+#Give the prognosis and treatment of prurigo.#
+
+The disease, in its severer types is, as a rule, incurable, but much can
+be done to alleviate the condition. Good, nourishing food, pure air and
+exercise are of importance. Tonics and cod-liver oil are usually
+beneficial. The local management is similar to that employed in chronic
+eczema. An ointment of [beta]-naphthol, one-half to five per cent.
+strength, is highly extolled.
+
+
+                                 #Acne.#
+
+
+#Give a definition of acne.#
+
+Acne is an inflammatory, usually chronic, disease of the sebaceous
+glands, characterized by papules, tubercles, or pustules, or a mixture
+of these lesions, and seated usually about the face.
+
+
+#At what age does acne usually occur?#
+
+Between the ages of fifteen and thirty, at which time the glandular
+structures are naturally more or less active.
+
+
+#Describe the symptoms of acne.#
+
+Irregularly scattered over the face, and in some cases also over the
+neck, shoulders and upper part of the trunk, are to be seen several,
+fifty or more, pin-head- to pea-sized papules, tubercles or pustules;
+commonly the eruption is of a mixed type (_acne vulgaris_), the several
+kinds of lesions in all stages of evolution and subsidence presenting in
+the single case. Interspersed may generally be seen blackheads, or
+comedones. The lesions may be sluggish in character, or they may be
+markedly inflammatory, with hard and indurated bases. In the course of
+several days or weeks, the papules and tubercles tend gradually to
+disappear by absorption; or, and as commonly the case, they become
+pustular, discharge their contents, or dry and slowly or rapidly
+disappear, with or without leaving a permanent trace, new lesions
+arising, here and there, to take their place. In exceptional instances
+the eruption is limited to the back, and in these cases the eruption is
+usually extensive and persistent, and not infrequently leaves scars.
+
+
+#What do you understand by acne punctata, acne papulosa, acne pustulosa,
+acne indurata, acne atrophica, acne hypertrophica, and acne
+cachecticorum?#
+
+These several terms indicate that the lesions present are, for the most
+part, of one particular character or variety.
+
+
+#Describe the lesions giving rise to the names of these various types.#
+
+Blocking up of the outlet of the sebaceous gland (comedo), which is
+usually the beginning of an acne lesion, may cause a moderate degree of
+hyperaemia and inflammation, and a slight elevation, with a central
+yellowish or blackish point results--the lesion of _acne punctata_; if
+the inflammation is of a higher grade or progresses, the elevation is
+reddened and more prominent--_acne papulosa_; if the inflammatory action
+continues, the interior or central portion of the papule suppurates and
+a pustule results--_acne pustulosa_; the pustule, in some cases, may
+have a markedly inflammatory and hard base--_acne indurata_; and not
+infrequently the lesions in disappearing may leave a pit-like atrophy or
+depression--_acne atrophica_; or, on the contrary, connective-tissue new
+growth may follow their disappearance--_acne hypertrophica_; and, in
+strumous or cachectic individuals, the lesions may be more or less
+furuncular in type, often of the nature of dermic abscesses, usually of
+a cold or sluggish character, and of more general distribution--_acne
+cachecticorum_.
+
+
+#What is acne artificialis?#
+
+Acne artificialis is a term applied to an acne or acne-like eruption
+produced by the ingestion of certain drugs, as the bromides and iodides,
+and by the external use of tar; this is also called _tar acne_.
+
+
+#What course does acne pursue?#
+
+Essentially chronic. The individual lesions usually run their course in
+several days or one or two weeks, but new lesions continue to appear
+from time to time, and the disease thus persists, with more or less
+variation, for months or years. In many cases there is, toward the age
+of twenty-five or thirty, a tendency to spontaneous disappearance of the
+disease.
+
+[Illustration: Acne.]
+
+
+#Is the eruption in acne usually abundant?#
+
+It varies in different cases and at different periods in the same case.
+In some instances, not more than five or ten papules and pustules are
+present at one time; in others they may be numerous. Not infrequently
+several lesions make their appearance, gradually run their course, and
+the face continues free for days or one or two weeks.
+
+
+#Does the eruption in acne disappear without leaving a trace?#
+
+In many instances no permanent trace remains, but in others slight or
+conspicuous scarring is left to mark the site of the lesions.
+
+
+#Are there any subjective symptoms in acne?#
+
+As a rule, not; but markedly inflammatory lesions are painful.
+
+
+#State the immediate or direct cause of an acne lesion.#
+
+Hypersecretion or retention of sebaceous matter. Recent investigations
+point to the possibility of a special bacillus being the exciting cause,
+in some instances at least. The pyogenic cocci are added factors in the
+pustular and furuncular cases.
+
+
+#Name the indirect or predisposing causes of acne.#
+
+Digestive disturbance, constipation, menstrual irregularities,
+chlorosis, general debility, lack of tone in the muscular fibres of the
+skin, scrofulosis; and medicinal substances such as the iodides and
+bromides internally, and tar externally.
+
+Working in a dusty or dirty atmosphere is often influential, resulting
+in a blocking-up of the gland ducts. Workmen in paraffin oils or other
+petroleum products often present a furuncle-like acne.
+
+The disease is more common in individuals of light complexion.
+
+
+#Is there any difficulty in the diagnosis of acne?#
+
+Not if it be remembered that acne eruption is limited to certain parts
+and is always follicular, and that the several stages, from the comedo
+to the matured lesion, are usually to be seen in the individual case.
+
+
+#In what respect does the pustular syphiloderm differ from acne?#
+
+By its general distribution, the longer duration of the individual
+lesions, the darker color, and the presence of concomitant symptoms of
+syphilis.
+
+
+#What is the pathology of acne?#
+
+Primarily, acne is a folliculitis, due to retention or decomposition of
+the sebaceous secretion or to the introduction of a micro-organism;
+subsequently, the tissue immediately surrounding becoming involved, with
+the possible destruction of the sebaceous follicle as a result. The
+degree of inflammatory action determines the character of the lesions.
+
+
+#State the prognosis of acne.#
+
+It is usually an obstinate disease, but curable. Some cases yield
+readily, others are exceedingly rebellious, especially acne of the back.
+Success depends in a great measure upon a recognition and removal of the
+predisposing condition. Treatment is ordinarily a matter of months.
+
+
+#What measures of treatment are usually demanded in acne?#
+
+Constitutional and local measures; the former when indicated, the latter
+always.
+
+
+#Upon what is the constitutional treatment based?#
+
+Upon indications. Diet and hygienic measures are important.
+
+In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin,
+saline and vegetable laxatives, are variously prescribed. Special
+mention may be made of the following:--
+
+  [Rx] Ext. rhamni pursh. fl., .............. f[dram]ij-f[dram]iv
+       Tinct. nucis vom., ................... f[dram]iij
+       Tinct. cardamomi comp., .......q.s. ad [Oz]iij.     M.
+
+  SIG.--f[dram]t.d.
+
+Or Hunyadi Janos or Friedrichshall water may be employed for a laxative
+purpose.
+
+In chlorotic and anaemic cases the ferruginous preparations are of
+advantage. Cod-liver oil is often a remedy of great value, and is
+especially useful in strumous and debilitated subjects. Calx sulphurata
+in pill form, one-tenth to one-fourth grain four or five times daily, is
+said, acts well in the pustular variety. In some instances, more
+particularly in sluggish papular acne, arsenic, especially the sulphide
+of arsenic, acts favorably. Upon the whole, the line of treatment
+that keeps in view proper and healthy action of the gastro-intestinal
+canal is the most successful.
+
+[Illustration: Acne of back.]
+
+In inflammatory cases occurring in robust individuals the following is
+often of service:--
+
+  [Rx] Potassii acetat., .................... [dram]iv
+       Liq. potassae, ........................ f[dram]ij
+       Liq. ammonii acetat., .... q.s. ad ... f[Oz]iij.      M.
+
+  SIG.--f[dram]j-f[dram]ij t.d., largely diluted.
+
+
+#State the character of the local treatment in acne.#
+
+This must vary somewhat with the local conditions. Cases which are acute
+in character, in the sense that the lesions are markedly hyperaemic,
+tender and painful, require milder applications, and in exceptional
+instances soothing remedies are to be prescribed. As a rule, however,
+stimulating applications may be employed from the start.
+
+The remedies are, for obvious reasons, most conveniently applied at
+bedtime.
+
+
+#What preliminary measures are to be advised in ordinary acne cases?#
+
+Washing the parts gently or vigorously, according to the irritability of
+the skin, with warm water and soap; subsequently rinsing, and sponging
+for several minutes with hot water, and rubbing dry with a soft towel;
+after which the remedial application is made. In sluggish and
+non-irritable cases sapo viridis or its tincture may often be
+advantageously used in place of the ordinary toilet soap.
+
+The blackheads, so far as practicable, are to be removed by pressure
+with the fingers or with a suitable instrument (see Comedo), and the
+superficial pustules punctured and the contents pressed out. Scraping
+the affected parts with a blunt curette is a valuable measure, but is
+temporarily disfiguring. As a rule, however, cases do just as well
+without puncturing and scraping, and these methods sometimes leave
+behind scarring.
+
+
+#State the methods of external medication commonly employed.#
+
+By ointments and lotions. If an ointment is used, it is to be thoroughly
+rubbed in, in small quantity; if a lotion is employed, it is to be well
+shaken, the parts freely dabbed with it for several minutes and then
+allowed to dry on.
+
+
+#State the object in view in local medication.#
+
+To hasten the maturation and disappearance of the existing lesions, and
+to stimulate the skin and glands to healthy action.
+
+If slight irritation or scaliness results, the application is to be
+intermitted one or two nights; in the meantime nothing except the
+hot-water sponging, with or without the application of a mild soothing
+ointment, is to be employed.
+
+
+#Is it usually necessary to change from one external remedy to another in
+the course of treatment?#
+
+Yes. After a certain time one remedy, as a rule, loses its effect, and a
+change from lotion to ointment or the reverse, and from one lotion or
+ointment to another, will often be found necessary in order to bring
+about continuous improvement.
+
+
+#Name the various important remedies and combinations employed in the
+external treatment of acne.#
+
+Sulphur is the most valuable. It may often be applied with benefit as a
+simple ointment:--
+
+  [Rx] Sulphur, praecip., .................... [dram]ss-[dram]j
+       Adipis benz.
+       Lanolin, ............ [=a][=a] ....... [dram]ij.
+
+Or it may be used as a lotion, as in the annexed formula:--
+
+  [Rx] Sulphur, praecip., .................... [dram]iss
+       Pulv. tragacanthae, ................... gr. x1
+       Pulv. camphorae, ...................... gr. xx
+       Liq. calcis, ........ q.s. ad ........ f[Oz]iv.       M.
+
+Another lotion, especially useful in those cases in which an oily
+condition of the skin is present, is the following:--
+
+  [Rx] Sulphur, praecip., .................... [dram]iss
+       Etheris, ............................. f[dram]iv
+       Alcoholis, ........................... f[Oz]iijss.    M.
+
+A compound lotion containing sulphur in one of its combinations is also
+valuable in many cases:--
+
+  [Rx] Zinci sulphatis,
+       Potassii sulphureti, .... [=a][=a] ... [dram]ss-[dram]iv
+       Aquae, ................................ [Oz]iv.       M.
+
+(The salts should be dissolved separately and then mixed; reaction takes
+place and the resulting lotion, when shaken, is milky in appearance, and
+free from odor; allowed to stand the particles settle, the sediment
+constituting about one-fourth to three-fourths of the whole bulk).
+
+At times the addition to this formula of several drachms of alcohol and
+of five to ten minims of glycerin is of advantage.
+
+An external remedy, often valuable, is ichthyol. It is thus
+prescribed:--
+
+  [Rx] Ichthyol, ............................ [dram]ss-[dram]j
+       Cerat. simp., ........................ [dram]iv.     M.
+
+The various mercurial ointments, especially one of white precipitate,
+five to fifteen per cent. strength, are sometimes beneficial.
+
+A compound lotion, containing mercury, which frequently proves
+serviceable, is:--
+
+  [Rx] Hydrarg. chlorid. corros., ........... gr. ii-viij
+       Zinci sulphatis, ..................... gr. x-xx
+       Tinct. benzoini, ..................... f[dram]ij
+       Aquae, ............ q.s. ad ........... f[Oz]iv.
+
+In extremely sluggish cases the following, used cautiously, is of
+value:--
+
+  [Rx] Ichthyol,
+       Saponis viridis,
+       Sulphur, praecip.,
+       Lanolin, ............. [=a][=a] ...... [dram]j.
+
+In such instances the application of a strong alcoholic resorcin lotion,
+ten to twenty-five per cent. strength, repeated several times daily till
+marked irritation and exfoliation occur (a matter usually of one to
+three days), will sometimes be followed by marked improvement. Acne of
+the back is treated with the same applications, but usually stronger; in
+this region applications of Vleminckx's solution and formaldehyde
+solution, weakened considerably, at first at least, prove of value.
+
+_Obstinate and indurated lesions_ may be incised, the contents pressed
+out, and the interior touched with carbolic acid by means of a pointed
+stick. The _x_-ray has proved a most valuable addition to our resources
+in the treatment of acne, and is especially serviceable in extensive and
+obstinate cases. An exposure should be made about twice weekly, at a
+distance of five to ten inches and for from three to ten minutes, and a
+tube of medium vacuum used. It must be used with great caution and never
+beyond the production of the mildest erythema. The hair, eyes, and lips
+should be protected. The _x_-ray treatment is best reserved for
+obstinate cases, and then used mildly, and rather as an adjuvant to the
+ordinary methods than as the sole measure.
+
+
+#What precaution is to be taken in advising a change from a sulphur to a
+mercurial preparation or the reverse?#
+
+Several days should be allowed to intervene, otherwise a disagreeable,
+although temporary, staining or darkening of the skin results--from the
+formation of the black sulphuret of mercury.
+
+
+
+                           #Acne Rosacea.#
+
+
+#Give a descriptive definition of acne rosacea.#
+
+Acne rosacea is a chronic, hyperaemic or inflammatory disease, limited to
+the face, especially to the nose and cheeks, characterized by redness,
+dilatation and enlargement of the bloodvessels, more or less acne and
+hypertrophy.
+
+
+#Describe the symptoms of acne rosacea.#
+
+The disease may be slight or well-marked. Redness, capillary dilatation,
+and acne lesions seated on the nose and cheeks, and sometimes on chin
+and forehead also, constitute in most cases the entire symptomatology.
+
+A mild variety consists in simple redness or hyperaemia, involving the
+nose chiefly and often exclusively, and is to be looked upon as a
+passive congestion; this is not uncommon in young adults and is
+often associated with an oily seborrh[oe]a of the same parts. In many
+cases the condition does not progress beyond this stage. In other
+cases, however, sooner or later the dilated capillaries become
+permanently enlarged (_telangiectasis_) and acne lesions are often
+present--constituting the middle stage or grade of the disease; this is
+the type most frequently met with. In exceptional instances, still
+further hypertrophy of the bloodvessels ensues, the glands are enlarged,
+and a variable degree of connective-tissue new growth is added; this
+latter is usually slight, but may be excessive, the nose presenting an
+enlarged and lobulated appearance (_rhinophyma_).
+
+[Illustration: Fig. 25. Acne Rosacea.]
+
+
+#Are there any subjective symptoms in acne rosacea?#
+
+As a rule, no. Some of the acne lesions may be tender and painful, and
+at times there is a feeling of heat and burning.
+
+
+#What do you know in regard to the etiology?#
+
+In many cases the causes are obscure. Chronic digestive and intestinal
+disorders, anaemia, chlorosis, continued exposure to heat or cold,
+menstrual and uterine irregularities, and the too free use of spirituous
+liquors, tea, etc. are often responsible factors.
+
+It is essentially a disease of adult life, common about middle age,
+occurring in both sexes, but rarely reaching the same degree of
+development in women as observed at times in men.
+
+
+#Is acne rosacea easily recognized?#
+
+Yes. The redness, acne lesions, dilated capillaries, and, at times, the
+glandular and connective-tissue hypertrophy; the limitation of the
+eruption to the face, especially the region of the nose; the evident
+involvement of the sebaceous glands, the absence of ulceration, taken
+with the history of the case, are characteristic.
+
+It is to be distinguished from the tubercular syphiloderm and lupus
+vulgaris, diseases to which it may bear rough resemblance.
+
+
+#State the prognosis of acne rosacea.#
+
+All cases may be favorably influenced by treatment; the mild and
+moderately-developed types are, as a rule, curable, but usually
+obstinate. It is a persistent disease, showing little, if any, tendency
+to disappear spontaneously.
+
+
+#What is the method of treatment?#
+
+Both constitutional and local measures are demanded in most cases.
+
+
+#Upon what is the constitutional treatment to be based?#
+
+The constitutional treatment, beyond a regulation of the diet, is to be
+based upon a correct appreciation of the etiological factors in the
+individual case. There are no special remedies. Iron, cod-liver oil,
+tonics, ergot, alkalies, saline laxatives, and similar drugs are to be
+variously prescribed.
+
+
+#What is the external treatment?#
+
+In many respects, both as to the preliminary measures and remedies,
+essentially the same as that employed in the treatment of simple acne
+(_q. v._). The _x_-ray treatment is not so efficient in this disease,
+however, as in acne. In addition to the treatment there found, several
+other applications deserve mention:--
+
+In many cases _Vleminckx's solution_[C] is valuable, applied diluted
+with one to ten parts of water. Also, a mucilaginous paste containing
+sulphur:--
+
+  [Rx] Mucilag. acaciae, ..................... f[dram]iij
+       Glycerinae, ........................... f[dram]ij
+       Sulphur, praecip., .................... [dram]iij.    M.
+
+[Footnote C:
+  [Rx] Calcis, .............................. [Oz]ss
+       Sulph. sublimat., .................... [Oz]j
+       Aquae, ................................ [Oz]x.
+
+  To be boiled down to [Oz]vj and filtered.]
+
+Or a similar paste with the glycerine in the foregoing replaced with
+ichthyol may be used.
+
+
+#In what manner are the dilated bloodvessels and connective-tissue
+hypertrophy to be treated?#
+
+The enlarged capillaries are to be destroyed by incision or by
+electrolysis. Properly managed the vessels may be thus destroyed, but
+unless the predisposing causes have disappeared or have been remedied, a
+new growth may take place.
+
+If the knife is employed, the vessels are either slit in their length or
+cut transversely at several points. The method by electrolysis is the
+same as used in the removal of superfluous hair (_q. v._).; the needle
+may, if the vessel is short, be inserted along its calibre, or if long,
+may be inserted at several points in its length.
+
+Excessive connective-tissue growth, exceptionally met with, is to be
+treated by ablation with the scissors or knife.
+
+
+
+                       #Acne Varioliformis.#
+   (_Synonyms:_ Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne;
+                        Necrotic Granuloma.)
+
+
+#Describe acne varioliformis.#
+
+Acne varioliformis is characterized by lesions of a moderately
+superficial papulo-pustular type, which in disappearing leave slight or
+pit-like scars. The forehead and scalp are the favorite sites, but they
+may also occur elsewhere. The eruption is rather scanty as a rule,
+consisting usually of ten to thirty lesions. They begin as small
+maculo-papules, as papules, or as minute nodules in or on the skin, and
+gradually become small pea-sized, with a tendency to slight vesiculation
+or pustulation at the central part. The lesion is sluggish in its
+course, drying to a thin crust, which finally falls off, leaving a
+depressed variola-like scar. New lesions arise from time to time, and
+the disease thus continues almost indefinitely. There may or may not be
+itching. In what appears to be a variety of this disease, known usually
+as _acne urticata_, there is considerable itching just at the time the
+lesion is appearing. The malady is not frequent, but occurs in both
+sexes, usually in those between the ages of twenty and fifty. It seems
+probable that the eruption is parasitic in origin.
+
+The maladies variously known as hydradenitis suppurativa, acnitis,
+spiradenitis, folliclis, granuloma necroticum, etc., in which the
+lesions, primarily at least, are somewhat deeper seated, sluggish in
+their course, and followed by scarring, could be also included under
+this head.
+
+#Give the prognosis and treatment.#
+
+The disease is rebellious and tends to recur. The most efficient
+applications are those of sulphur and resorcin, the same as prescribed
+in ordinary acne.
+
+
+
+                            #Sycosis.#
+  (_Synonyms:_ Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis
+                   Barbae; Sycosis Coccogenica.)
+
+
+#What do you understand by sycosis?#
+
+Sycosis is a chronic, inflammatory affection involving the
+hair-follicles, usually of the moustache and bearded regions only, and
+characterized by papules, tubercles, and pustules perforated by hairs.
+
+
+#Describe the symptoms of sycosis.#
+
+Sycosis begins by the formation of papules and pustules about the
+hair-follicles; the lesions occur in numbers, in close proximity,
+and together with the accompanying inflammation, make up a small or large
+area. The pustules are small, rounded, flat or acuminated, discrete, and
+yellowish in color; they are perforated by hairs, show no tendency to
+rupture, and are apt to occur in crops, drying to thin yellowish or
+brownish crusts. Papules and tubercles are often intermingled. More or
+less swelling and infiltration are noticeable.
+
+[Illustration: Fig. 26.
+  Sycosis--not infrequently begins in, and sometimes limited to, this
+  region.]
+
+The disease is seen, as a rule, only on the bearded part of the face,
+either about the cheeks, chin or upper lip, involving a small portion or
+the whole of these parts. It is also sometimes met with involving the
+hair follicles just within the nasal orifice, and may even be limited to
+this region.
+
+Occasionally a sycosiform eruption, usually of the side of the bearded
+region, leaves behind a smooth or keloidal scar, the disease gradually
+extending--_ulerythema sycosiforme_ (lupoid sycosis).
+
+An inflammation of the hair-follicles of the scalp apparently sycosiform
+in character, occurring as discrete or aggregated lesions, is sometimes
+observed, the follicles being destroyed and atrophy or slight scarring
+resulting--_folliculitis decalvans_.
+
+
+#Does conspicuous hair loss occur in sycosis?#
+
+Ordinarily not; the hairs are, especially at first, usually firmly
+seated, but in those cases in which suppuration is active, and has
+involved the follicles, they may, as a rule, be easily extracted. In
+some cases destruction of the follicles ensues and slight scarring and
+permanent hair loss result.
+
+
+#State the character of the subjective symptoms.#
+
+Pain and itching and a sense of burning, variable as to degree, may be
+present.
+
+
+#What is the course of the disease?#
+
+Essentially chronic, the inflammatory action being of a subacute or
+sluggish character, with acute exacerbations.
+
+
+#State the causes of sycosis.#
+
+Upon the upper lip it may have its origin in a nasal catarrh. Entrance
+into the follicles of pyogenic micrococci is now regarded as the
+essential factor. This view being accepted, carries with it the
+possibility of contagiousness.
+
+It is seen in the male sex only, usually in those between the ages of
+twenty-five and fifty; and is met with in those in good and bad health,
+and among rich and poor. It is comparatively infrequent.
+
+
+#What is the pathology of sycosis?#
+
+The disease is primarily a perifolliculitis, the follicle and its sheath
+subsequently becoming involved in the inflammatory process.
+
+
+#How would you distinguish sycosis from eczema?#
+
+Eczema is rarely sharply limited to the bearded region, but is apt to
+involve other parts of the face; moreover, the lesions are usually
+confluent, and there is either an oozing, red crusted surface, or it is
+dry and scaly.
+
+
+#How would you exclude tinea sycosis in the diagnosis?#
+
+In tinea sycosis, or ringworm sycosis, the history of the case is
+different. The parts are distinctly lumpy and nodular; the hairs are
+soon involved and become dry, brittle, loose, and fall out, or they may
+be readily extracted. The superficial type of ringworm sycosis is
+readily distinguished by the ring-like character of the patches. In
+doubtful cases, microscopic examination of the hairs may be resorted to.
+
+
+#Give the prognosis of sycosis.#
+
+The disease is curable, but almost invariably obstinate and rebellious
+to treatment. The duration, extent, and character of the inflammatory
+process must all be considered. An expression of an opinion as to the
+length of time required for a cure should always be guarded.
+
+Ulerythema sycosiforme is extremely obstinate. Folliculitis decalvans is
+also rebellious.
+
+
+#How is sycosis to be treated?#
+
+Mainly, and often exclusively, by external applications.
+
+[Illustration: Fig. 27. Sycosis.]
+
+
+#Is constitutional treatment of no avail in sycosis?#
+
+In some instances; but, as a rule, it is negative. If indicated, such
+remedies as tonics, alteratives, cod-liver oil and the like are to be
+prescribed.
+
+
+#Describe the external treatment.#
+
+Crusting, if present, is to be removed by warm embrocations. If the
+inflammation is of a high grade, and the parts tender and painful,
+soothing applications, such as bland oils, black wash and oxide-of-zinc
+ointment, cold cream and petrolatum, are to be used; boric-acid
+solution, fifteen grains to the ounce, may be advised in place of black
+wash.
+
+In most cases, however, astringent and stimulating remedies are demanded
+from the start, such as: diachylon ointment, alone or with ten to thirty
+grains of calomel to the ounce; oleate of mercury, as a five- to
+twenty-per-cent. ointment; precipitated sulphur, one to three drachms to
+the ounce of benzoated lard, or lard and lanolin; a ten- to
+twenty-five-per-cent. ichthyol ointment; and resorcin lotion or
+ointment, ten to twenty per cent. strength.
+
+[Illustration: Fig. 28. Sycosis.]
+
+A change from one application to another will be found necessary in
+almost all cases.
+
+In obstinate cases the x-ray treatment can be used, as it has proved
+itself valuable in some instances; as in other diseases, it should be
+employed cautiously.
+
+
+#What would you advise in regard to shaving?#
+
+When bearable (and after a few days' application of soothing remedies it
+almost always is), it is to be advised in all cases, as it materially
+aids in the treatment. After a cure is effected it should be continued
+for some months, until the healthy condition of the parts is thoroughly
+established.
+
+
+#When is depilation advisable as a therapeutic measure?#
+
+When the suppurative process is active, in order to save the follicles
+from destruction; incising or puncturing the pustules will often
+accomplish the same end.
+
+Depilation is in all cases a valuable therapeutic measure, but it is
+painful; as a routine practice, shaving is less objectionable and, upon
+the whole, is probably as satisfactory. Those who make free use of the
+x-ray commonly push it to the point of producing depilation.
+
+
+
+                #Dermatitis Papillaris Capillitii.#
+                     (_Synonym:_ Acne Keloid.)
+
+[Illustration: Fig. 29. Dermatitis Papillaris Capillitii.]
+
+
+#Describe dermatitis papillaris capillitii.#
+
+This is a peculiar, mildly inflammatory, sycosiform, keloidal, acne-like
+disease of the hairy border of the back of the neck, often extending
+upward to the occipital region; partaking, especially later in its
+course, somewhat of the nature of keloid. Several or more acne-like
+lesions, papular and pustular, closely grouped or bunched, appear,
+developing slowly, usually to the size of peas; are red, pale red, or
+whitish, often enveloping small tufts of hair, and attended with more or
+less hair loss. Its course is gradual and persistent. It is an
+exceedingly rare condition, the exact nature of which is still obscure.
+
+
+#Give the treatment.#
+
+Treatment, which is usually unsatisfactory, consists of stimulating
+applications--the same, in fact, as employed in sycosis, sulphur and
+ichthyol deserving special mention. Depilation is essential.
+
+
+
+                     #Impetigo Contagiosa.#
+
+
+#Give a descriptive definition of impetigo contagiosa.#
+
+Impetigo contagiosa is an acute, contagious, inflammatory disease,
+characterized by the formation of discrete, superficial, flat, rounded,
+or ovalish vesicles or blebs, soon becoming vesico-pustular, and drying
+to thin yellowish crusts.
+
+
+#Upon what parts does the eruption commonly appear?#
+
+Upon the face, scalp, and hands, and exceptionally upon other regions.
+
+
+#Describe the symptoms of impetigo contagiosa.#
+
+One, several or more small pin-head-sized papulo-vesicles or vesicles
+make their appearance, usually upon the face and fingers. In the male
+adult the region of the neck and beard is a favorite situation. They
+increase in size by extending peripherally, but are more or less
+flattened and umbilicated, and are without conspicuous areola. The
+lesions may attain the size of a dime or larger, and when close together
+may coalesce and form a large patch. In some cases distinct blebs
+result, and a picture of pemphigus eruption presented; it is probable
+that many of the cases of "contagious pemphigus" belong to this class.
+New lesions may appear for several days, but finally, in the course of a
+week or ten days, they have all dried to thin, wafer-like crusts, of a
+straw or light-yellow color, but slightly adherent, and appearing as if
+stuck on; these soon drop off, leaving faint reddish spots, which
+gradually fade. In some cases there is so decided a tendency to clear
+and dry up centrally while spreading peripherally that the eruption has
+a ring-like aspect; this seems especially so in the bearded region of
+the male adult.
+
+Instead of presenting as described, it may occur as one or more pea- or
+finger-nail-sized, rounded and elevated, usually firm, discrete
+pustules, scattered over one part, or more commonly over various
+regions, such as the face, hands, feet and lower extremities. The
+pustules are such from the beginning, and when developed are usually of
+the size of a pea or finger-nail, elevated, semi-globular or rounded,
+with somewhat thick and tough walls, and of a whitish or yellowish
+color; at first there may be a slight inflammatory areola, but as the
+lesion matures this almost, if not entirely, disappears. The pustules
+show no disposition to umbilication, rupture or coalescence; drying in
+the course of several days or a week to yellowish or brownish crusts,
+which soon drop off, leaving no permanent trace. This variety was
+formerly thought to be a distinct disease, and was described under the
+name of _impetigo simplex_.
+
+As a rule there are no constitutional symptoms, but in the more severe
+cases the eruption may be preceded by febrile disturbance and malaise.
+Itching may or may not be present.
+
+
+#State the cause of the disease.#
+
+It is contagious, the contents of the lesions being inoculable and
+auto-inoculable. At times it seems to prevail in epidemic form. Pyogenic
+microorganisms are now regarded as causative. A relationship to
+vaccination has been alleged by some observers. It is more commonly
+observed in infants and young children.
+
+
+#From what diseases is impetigo contagiosa to be differentiated?#
+
+From eczema, pemphigus, and ecthyma.
+
+
+#How does impetigo contagiosa differ from these several diseases?#
+
+By the character of the lesions, their growth, their superficial nature,
+their course, the absence of an inflammatory base and areola, the thin,
+yellowish, wafer-like crusts, and usually a history of contagion.
+
+
+#State the prognosis.#
+
+The effect of treatment is usually prompt. The disease, indeed, tends to
+spontaneous disappearance in two to four weeks; in exceptional
+instances, more especially in those cases in which itching is present,
+the excoriations or scratch-marks become inoculated, and in this way it
+may persist several weeks.
+
+
+#What is the treatment of impetigo contagiosa?#
+
+Treatment consists in the destruction of the auto-inoculable properties
+of the contents of the lesions; this is effected by removing the crusts
+by means of warm water-and-soap washings, and subsequently rubbing in an
+ointment of ammoniated mercury, ten to twenty grains to the ounce. Some
+cases respond more rapidly to the use of a drying ointment, such as
+Lassar's paste, with ten to twenty grains of white precipitate or
+sulphur to the ounce. In itching cases, a saturated solution of boric
+acid, or a carbolic-acid lotion, one to two drachms to the pint, is to
+be employed for general application.
+
+
+
+                     #Impetigo Herpetiformis.#
+
+
+#Describe impetigo herpetiformis.#
+
+Impetigo herpetiformis is an extremely rare disease, observed usually in
+pregnant women, and is characterized by the appearance of numerous
+isolated and closely-crowded pin-head-sized superficial pustules, which
+show a decided disposition to the formation of circular groups or
+patches. The central portion of these groups dries to crusts, while new
+pustules appear at the peripheral portion. They tend to coalesce, and in
+this manner a greater part of the whole surface may, in the course of
+weeks or months, become involved. Profound constitutional disturbance,
+usually of a septic character, precedes and accompanies the disease; in
+almost every instance a fatal termination sooner or later results.
+
+It is possibly a grave type of dermatitis herpetiformis.
+
+
+
+                            #Ecthyma.#
+
+
+#Give a descriptive definition of ecthyma.#
+
+Ecthyma is a disease characterized by the appearance of one, several or
+more discrete, finger-nail-sized, flat, usually markedly inflammatory
+pustules.
+
+
+#Describe the symptoms and course of ecthyma.#
+
+The lesions begin as small, usually pea-sized, pustules; increase
+somewhat in area, and when fully developed are dime-sized, or larger,
+somewhat flat, with a markedly inflammatory base and areola. At first
+yellowish they soon become, from the admixture of blood, reddish, and
+dry to brownish crusts, beneath which will be found superficial
+excoriations. The individual pustules are usually somewhat acute in
+their course, but new lesions may continue to appear from day to day or
+week to week. As a rule, not more than five to twenty are present at one
+time, and in most cases they are seated on the legs. More or less
+pigmentation, and sometimes superficial scarring, may remain to mark the
+site of the lesions.
+
+Itching is rarely present, but there may be more or less pain and
+tenderness.
+
+
+#What is the cause of ecthyma?#
+
+It is essentially a disease of the poorly cared-for and ill-fed; the
+direct exciting cause is the introduction of pyogenic microorganisms
+into the follicular openings. It is closely allied to impetigo
+contagiosa, and may in fact be regarded as a markedly inflammatory form
+of the latter affection. It seems much less contagious, however. It is
+commonly observed in male adults.
+
+
+#From what diseases is ecthyma to be differentiated?#
+
+From impetigo contagiosa, and the flat pustular syphiloderm.
+
+
+#How is it distinguished from these several diseases?#
+
+The size, shape, inflammatory action, and the depraved general
+condition, the distribution and lesser-contagiousness will distinguish
+it from impetigo contagiosa; and the absence of concomitant symptoms of
+syphilis, and of positive ulceration, as well as its distribution and
+more rapid and inflammatory course, will exclude the pustular
+syphiloderm.
+
+
+#State the prognosis.#
+
+The disease is readily curable, disappearing upon the removal of the
+predisposing cause and the employment of local antiseptic applications.
+
+
+#What treatment is to be advised?#
+
+Good food, proper hygiene and tonic remedies; and, locally, removal of
+the crusts and stimulation of the underlying surface with an ointment of
+ammoniated mercury, ten to thirty grains to the ounce.
+
+The following mild antiseptic lotion, which materially lessens the
+tendency to the formation of new lesions, may be applied to the affected
+region two or three times daily:--
+
+  [Rx] Acidi borici, ........................ [dram]iv
+       Resorcini, ........................... [dram]ij
+       Glycerinae, ........................... f[dram]ij
+       Alcoholis, ........................... f[Oz]j
+       Aquae, ........... q.s. ad ............ Oj.           M.
+
+A weak lotion of thymol, corrosive sublimate or ichthyol would doubtless
+be equally effectual.
+
+
+
+                             #Pemphigus.#
+
+
+#What do you understand by pemphigus?#
+
+Pemphigus is an acute or chronic disease characterized by the successive
+formation of irregularly-scattered, variously-sized blebs.
+
+
+#Name the varieties met with.#
+
+Two varieties are usually described--pemphigus vulgaris and pemphigus
+foliaceus.
+
+
+#Describe the symptoms and course of pemphigus vulgaris.#
+
+With or without precursory symptoms of systemic disturbance, irregularly
+scattered blebs, few or in numbers, make their appearance, arising from
+erythematous spots or from apparently normal skin. They vary in size
+from a pea to a large egg, are rounded or ovalish, usually distended,
+and contain a yellowish fluid which, later, becomes cloudy or puriform.
+If ruptured, the rete is exposed, but the skin soon regains its normal
+condition; if undisturbed, the fluid usually disappears by absorption.
+Each lesion runs its course in several days or a week.
+
+A grave type of pemphigus is exceptionally observed in the
+newborn--_pemphigus neonatorum_.
+
+
+#What course does pemphigus vulgaris pursue?#
+
+Usually chronic. The disease may subside in several months and the
+process come to an end, constituting the acute type. As a rule, however,
+the disease is chronic, new blebs continuing to appear from time to time
+for an indefinite period.
+
+[Illustration: Fig. 30. Pemphigus (mulatto).]
+
+
+#In what respects does the severe form of pemphigus vulgaris differ from
+the ordinary type?#
+
+In the severe or malignant type the eruption is more profuse; there is
+marked, and often grave, systemic depression, and the lesions are
+attended with ulcerative action.
+
+
+#Describe the symptoms and course of pemphigus foliaceus.#
+
+In this, the grave type of the disease, the blebs are loose and flaccid,
+with milky or puriform contents, rupturing and drying to crusts, which
+are cast off, disclosing the reddened corium. New blebs appear on the
+sites of disappearing or half-ruptured lesions, and the whole surface
+may be thus involved and the disease continue for years, compromising
+the general health and eventually ending fatally.
+
+In some cases of pemphigus (pemphigus vegetans) a vegetating or
+papillomatous condition develops from the base of the lesion, with an
+offensive discharge; it is usually a grave type of the malady.
+
+Exceptionally cases (dermatitis vegetans) are met with which have a
+close similarity in their symptoms to pemphigus vegetans, but in which
+the eruption is more or less limited to the genitocrural region. The
+disorder is not malignant and usually yields to cleanliness and
+antiseptics.
+
+
+#What is the character of the subjective symptoms in pemphigus?#
+
+The subjective symptoms consist variously of heat, tenderness, pain,
+burning and itching, and may be slight or troublesome.
+
+
+#What is known in regard to the etiology of pemphigus?#
+
+The causes are obscure; general debility, overwork, shock, nervous
+exhaustion, and septic conditions (microorganisms) are thought to be of
+influence. There seems no doubt that those who have to do with cattle
+products, especially butchers, are subjects of acute and usually grave
+pemphigus. Vaccination has exceptionally been responsible for the
+disease, probably through some coincidental infection. The disease is
+not contagious, nor is it due to syphilis. It may occur at any age.
+
+It is a rare disease, especially in this country. Most of the cases
+diagnosed as pemphigus by the inexperienced are examples of bullous
+urticaria, bullous erythema multiforme, and impetigo contagiosa.
+
+
+#What is the pathology?#
+
+The lesions are superficially seated, usually between the horny layer
+and upper part of the rete. Round-cell infiltration and dilated blood
+vessels are found about the papillae and in the subcutaneous tissue. The
+contents of the blebs, always of alkaline reaction, are at first serous,
+later containing blood corpuscles, pus, fatty-acid crystals, epithelial
+cells, and occasionally uric acid crystals and free ammonia.
+
+
+#From what diseases is pemphigus to be differentiated?#
+
+From herpes iris, the bullous syphiloderm, impetigo contagiosa and
+dermatitis herpetiformis.
+
+
+#How do these several diseases differ from pemphigus?#
+
+The acute course, small lesions, concentric arrangement, variegated
+colors, and distribution, in herpes iris; the thick, bulky, greenish
+crusts, the underlying ulceration, the course, history, and the presence
+of concomitant symptoms of syphilis, in the bullous syphiloderm; the
+history, course, distribution, the character of the crusting, and the
+contagious and auto-inoculable properties of the contents of the
+lesions, in impetigo contagiosa; the tendency to appear in groups, the
+smaller lesions, the intense itchiness, course, multiform characters of
+the eruption and the disposition to change of type in dermatitis
+herpetiformis,--will serve as differential points.
+
+
+#State the prognosis of pemphigus.#
+
+Its duration is uncertain, and the issue may in severe cases be fatal.
+In the milder types, after months or several years, recovery may take
+place.
+
+The extent and severity of the disease and the general condition of the
+patient are always to be considered before an opinion is expressed.
+
+Pemphigus neonatorum usually ends fatally.
+
+
+#Give the treatment of pemphigus.#
+
+Both constitutional and local measures are demanded. Good nutritious
+food and hygienic regulations are essential. Arsenic and quinia are the
+most valuable remedies. The former, in occasional instances, seems to
+have a specific influence, and should always be tried, beginning with
+small doses and increasing gradually to the point of tolerance and
+continued for several weeks or longer. The remedy should not be set
+aside as long as there are signs of improvement, unless the supervention
+of stomachic, intestinal or other disturbance demand its discontinuance.
+Other tonics, such as iron, strychnia and cod-liver oil, are also at
+times of service.
+
+The blebs should be opened and the parts anointed or covered with a mild
+ointment. In more general cases bran, starch and gelatin baths, and in
+severe cases the continuous bath, if practicable, are to be used.
+
+
+
+
+#CLASS III.--HEMORRHAGES.#
+
+
+                              #Purpura.#
+
+
+#Define purpura.#
+
+Purpura is a hemorrhagic affection characterized by the appearance of
+variously-sized, usually non-elevated, smooth, reddish or purplish spots
+or patches, not disappearing under pressure.
+
+
+#Name the several varieties met with.#
+
+Three--purpura simplex, purpura rheumatica and purpura haemorrhagica;
+denoting, respectively, the mild, moderate and severe grade of the
+disease. The division is, to a great extent, an arbitrary one.
+
+
+#Describe the clinical appearance and course of an individual lesion of
+purpura.#
+
+The spot, which may be pin-head, pea-, bean-sized or larger, appears
+suddenly, and is of a bright red or purplish red color. Its brightness
+gradually fades, the color changing to a bluish, bluish-green, bluish-
+or greenish-yellow, dirty yellowish, yellowish-white, and finally
+disappearing; varying in duration from several days to several weeks.
+
+
+#Describe the symptoms of purpura simplex.#
+
+Purpura simplex, or the mild form, shows itself as pin-point to pea- or
+bean-sized, bright or dark-red spots, limited, as a rule, to the limbs,
+especially the lower extremities; fading gradually away and coming to an
+end in a few weeks, or new crops appearing irregularly for several
+months. There is rarely any systemic disturbance, and, as a rule, no
+subjective symptoms; in exceptional cases an urticarial element is
+added--_purpura urticans_.
+
+
+#Describe the symptoms of purpura rheumatica.#
+
+Purpura rheumatica (also called _peliosis rheumatica_) is usually
+preceded by symptoms of malaise, rheumatic pains and sometimes
+swelling about the joints; these phenomena abate and frequently disappear
+upon the outbreak of the eruption. The lesions are pea- to dime-sized,
+smooth, non-elevated, or slightly raised, and of a reddish or purplish
+color; the eruption may be more or less generalized, most abundant upon
+the limbs, or it may be limited to these parts. It may end in a few weeks,
+or may persist for several months, new spots appearing irregularly or in
+the form of crops.
+
+As somewhat allied to this is another form (_Schoenlein's disease_),
+quite alarming in its symptoms. It is rare. It is characterized by
+symptoms partaking of the nature of rheumatism, purpuric spots, blotches
+and ecchymoses, erythema multiforme, and often associated with
+considerable edema. The throat is also usually invaded, and indeed the
+first symptom is commonly in this region. Considerable constitutional
+disturbance, of a threatening character, is commonly observed. Recovery
+usually takes place.
+
+_Henoch's purpura_, observed chiefly in children, resembles the above,
+with the erythema multiforme character and the [oe]dematous swellings
+more pronounced, while the actual purpuric symptoms are less
+conspicuous. Gastric and intestinal symptoms and hemorrhages from the
+mucous membrane are commonly noted. It is fatal in about 20 per cent. of
+the cases.
+
+
+#Describe the symptoms of purpura haemorrhagica.#
+
+Purpura haemorrhagica (also called _land scurvy_) is characterized
+usually by premonitory, and frequently accompanying, symptoms of general
+distress, and by the appearance of coin to palm-sized, red or purplish
+hemorrhagic spots or patches, smooth, non-elevated or raised. Hemorrhage
+from the mouth, gums and other parts, slight or serious in character,
+may occur. New lesions continue to appear for several days or weeks; and
+in exceptional instances, repeated relapses take place, and the disease
+thus persists for months. It may end fatally.
+
+
+#State the etiology of purpura.#
+
+In most instances no cause can be assigned. The disease occurs at all
+ages from childhood to advanced life, and in individuals, apparently, in
+good and bad health alike. The hemorrhagic type is oftener seen in
+subjects debilitated or in a depraved state of health. A microorganism
+is also looked upon as a factor by some observers, especially in the
+grave type of disease.
+
+
+#State the diagnostic characters of purpura.#
+
+The appearance, irregularly or in crops, of bright-red or purplish
+spots, evidently of hemorrhagic nature, and not _disappearing upon
+pressure_, and as they are fading, going through the several changes of
+color usually observed in any ecchymosis.
+
+
+#How does scurvy (scorbutus) differ from purpura?#
+
+Scurvy, which may resemble the severe grade of purpura, has a different
+history, a recognizable cause, usually a peculiar distribution, and is
+accompanied with general weakness and a spongy, soft and bleeding
+condition of the gums.
+
+
+#What is the pathology of purpura?#
+
+The lesion of purpura consists essentially of a hemorrhage into the
+cutaneous tissues. The blood is subsequently absorbed, the haematin
+undergoing changes of color from a red to greenish and pale yellow, and
+finally fading away.
+
+
+#State the prognosis#
+
+The milder varieties disappear in the course of several weeks or months,
+and are rarely of serious import; the outcome of purpura haemorrhagica is
+somewhat uncertain; although usually favorable, a fatal result from
+internal hemorrhage is possible. The variety known as Schoenlein's
+disease is alarming, but seldom fatal. Henoch's disease is, however,
+always of grave import.
+
+
+#What is the treatment of purpura?#
+
+Hygienic and dietary measures, the administration of tonics and
+astringents, and, in severe cases, by relative or absolute rest.
+
+The drugs commonly prescribed are: ergot, oil of erigeron, oil of
+turpentine, quinia, strychnia, iron, mineral acids, and gallic acid.
+_External_ treatment is rarely called for, but if deemed advisable,
+astringent lotions may be employed.
+
+
+
+                             #Scorbutus.#
+          (_Synonyms:_ Scurvy; Sea Scurvy; Purpura Scorbutica.)
+
+
+#Describe scorbutus.#
+
+Scurvy is a peculiar constitutional state, developed in those living
+under bad hygienic conditions, and is characterized by emaciation,
+general febrile and asthenic symptoms, a more or less swollen, turgid
+and spongy and even gangrenous condition of the gums; and concomitantly,
+or sooner or later, by the appearance, usually upon the lower portion of
+the legs only, of dark-colored hemorrhagic patches or blotches. The skin
+of the affected part may become brawny and slightly scaly, and not
+infrequently may break down and ulcerate. Hemorrhages from the various
+mucous surfaces, slight or grave, may also take place.
+
+
+#State the etiology of scurvy.#
+
+It is due to long-continued deprivation of proper food, especially of
+fruits and vegetables. Other bad hygienic conditions favor its
+development. It is seen most commonly in sailors and others taking long
+voyages.
+
+
+#How is scurvy to be distinguished from purpura?#
+
+By the asthenic and emaciated general condition and the peculiar puffy,
+spongy state of the gums. The cutaneous manifestation is more diffused,
+forming usually large palm-sized patches, and, as a rule, limited to the
+region of the ankles or lower part of the legs.
+
+
+#Give the prognosis of scurvy.#
+
+The disease is remediable, and usually rapidly so. In those instances in
+which the same bad hygienic conditions and the ingestion of improper
+food are continued, death finally results.
+
+
+#What treatment would you advise in scurvy?#
+
+Proper food, with an abundance of fruit and vegetables. Lemon or lime
+juice is especially valuable, and is to be taken freely. If indicated,
+tonics and stimulants are also to be prescribed. For the relief of the
+tumid, spongy condition of the gums, astringent and antiseptic mouth
+washes are to be employed.
+
+The cutaneous manifestations, when tending to ulceration, are to be
+treated upon general principles.
+
+
+
+
+#CLASS IV.--HYPERTROPHIES.#
+
+
+                               #Lentigo.#
+                         (_Synonym:_ Freckle.)
+
+
+#Describe lentigo.#
+
+Lentigo, or freckle, is characterized by round or irregular, pin-head to
+pea-sized, yellowish, brownish or blackish spots, occurring usually
+about the face and the backs of the hands. It is a common affection,
+varying somewhat in the degree of development; the freckles present may
+be few and insignificant, or they may exist in profusion and be quite
+disfiguring. Heat and exposure favor their development. Those of light
+complexion, especially those with red hair, are its most common
+subjects. The color of the lesion is usually a yellowish-brown.
+
+It is common to all ages, but is generally seen in its greatest
+development during adolescence, the disposition to its appearance
+becoming less marked as age advances.
+
+
+#What is the pathology of lentigo?#
+
+Lentigo consists simply of a circumscribed deposit of pigment
+granules--merely a localized increase of the normal pigment, differing
+from chloasma (_q. v._) only in the size and shape of the pigmentation.
+
+
+#State the prognosis.#
+
+The blemishes can be removed by treatment, but their return is almost
+certain.
+
+
+#Name the several applications commonly employed for their removal.#
+
+An aqueous or alcoholic solution of corrosive sublimate, one-half to
+three grains to the ounce; lactic acid, one part to from six to twenty
+parts of water; and an ointment containing a drachm each of bismuth
+subnitrate and ammoniated mercury to the ounce.
+
+The applications, which act by removing the epidermal and rete cells and
+with them the pigment, are made two or three times daily, and their use
+intermitted for a few days as soon as the skin becomes irritated or
+scaly.
+
+Touching each freckle for a few seconds with the electric needle, just
+pricking the epidermis, will occasionally remove the blemish.
+
+
+
+                             #Chloasma.#
+
+
+#What do you understand by chloasma?#
+
+Chloasma consists of an abnormal deposit of pigment, occurring as
+variously-sized and shaped, yellowish, brownish or blackish patches.
+
+
+#Describe the clinical appearances of chloasma.#
+
+Chloasma appears either in ill-defined patches, as is commonly the case,
+or as a diffuse discoloration. Its appearance is rapid or gradual,
+generally the latter. The patches are rounded or irregular, and usually
+shade off into the sound skin. One, several or more may be present, and
+coalescence may take place, resulting in a large irregular pigmented
+area. The color is yellowish, or brownish, and may even be blackish
+(_melasma_, _melanoderma_). The skin is otherwise normal. The face is the
+most common site.
+
+
+#Into what two general classes may the various examples of chloasma be
+grouped?#
+
+Idiopathic and symptomatic.
+
+
+#What cases of chloasma are included in the idiopathic group?#
+
+All those cases of pigmentation caused by external agents, such as the
+sun's rays, sinapisms, blisters, continued cutaneous hyperaemia from
+scratching or any other cause, etc.
+
+
+#What cases of chloasma are included in the symptomatic group?#
+
+All forms of pigment deposit which occur as a consequence of various
+organic and systemic diseases, as the pigmentation, for instance, seen
+in association with tuberculosis, cancer, malaria, Addison's disease,
+uterine affections, and the like. In such cases, with few exceptions,
+the pigmentation is usually more or less diffuse.
+
+
+#What is chloasma uterinum?#
+
+Chloasma uterinum is a term applied to the ill-defined patches of
+yellowish-brown pigmentation appearing upon the faces of women, usually
+between the ages of twenty-five and fifty. It is most commonly seen
+during pregnancy, but may occur in connection with any functional or
+organic disease of the utero-ovarian apparatus.
+
+
+#What is argyria?#
+
+Argyria is the term applied to the slate-like discoloration which
+follows the prolonged administration of silver nitrate.
+
+
+#State the pathology of chloasma.#
+
+The sole change consists in an increased deposit of pigment.
+
+
+#Give the prognosis of chloasma.#
+
+Unless a removal of the exciting or predisposing cause is possible, the
+prognosis is, as a rule, unfavorable, and the relief furnished by local
+applications usually but temporary.
+
+
+#If constitutional treatment is advisable, upon what is it to be based?#
+
+Upon general principles; there are no special remedies.
+
+
+#How do external remedies act?#
+
+Mainly by removing the rete cells and with them the pigmentation; and
+partly, also, by stimulating the absorbents.
+
+
+#Are all external remedies which tend to remove the upper layers of the
+skin equally useful for this purpose?#
+
+No; on the contrary some such applications are followed by an increase
+in the pigment deposit.
+
+
+#Name the several applications commonly employed.#
+
+Corrosive sublimate in solution, in the strength of one to four grains
+to the ounce of alcohol and water; a lotion made up as follows:--
+
+  [Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
+       Ac. acet. dilut., .................... f[dram]ij
+       Sodii borat., ........................ [scruple]ij
+       Aquae rosae, ........................... f[Oz]iv.       M.
+
+And also the following:--
+
+  [Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
+       Zinci sulphat.,
+       Plumbi acetat., ...... [=a][=a] ...... [dram]ss
+       Aquae, ................................ f[Oz]iv.       M.
+
+And lactic acid, with from five to twenty parts of water; and an
+ointment containing a drachm each of bismuth subnitrate and white
+precipitate to the ounce. Hydrogen peroxide occasionally acts well.
+Trichloracetic acid, usually weakened with one or two parts water, may
+be cautiously tried. The application of a strong alcoholic solution of
+resorcin, twenty to fifty per cent. strength, is also valuable, as is
+also a two to ten per cent. alcoholic solution of salicylic acid.
+
+(Applications are made two or three times daily, and as soon as slight
+scaliness or irritation is produced are to be discontinued for one or
+two days.)
+
+_Tattoo-marks_ are difficult to remove. Excision is the surest method.
+Electrolysis, applying the needle at various points, somewhat close
+together, and using a fairly strong current--three to eight
+milliamperes--will exceptionally, especially when repeated several
+times, produce a reactive inflammation and casting-off of the tissue
+containing the pigment; a scar is left.
+
+Several writers claim good results with glycerole of papain, pricking it
+in in the same manner as in tattooing.
+
+_Gun-powder marks._ If recent, but a day or so after their occurrence,
+the larger specks may be picked or scraped out. Later, electrolysis,
+using a fairly strong current, may result in their removal. Their
+removal may also be satisfactorily effected with a minute cutaneous
+trephine.
+
+
+
+                         #Keratosis Pilaris.#
+            (_Synonyms:_ Pityriasis Pilaris; Lichen Pilaris.)
+
+
+#What is meant by keratosis pilaris?#
+
+Keratosis pilaris may be defined as a hypertrophic affection
+characterized by the formation of pin-head-sized, conical, epidermic
+elevations seated about the apertures of the hair follicles.
+
+
+#Describe the clinical appearances of keratosis pilaris.#
+
+The lesions are usually limited to the extensor surfaces of the thighs
+and arms, especially the former. They appear as pin-head-sized, whitish
+or grayish elevations, consisting of accumulations of epithelial matter
+about the apertures of the hair follicles. Each elevation is pierced by
+a hair, or the hair may be twisted and imprisoned within the epithelial
+mass; or it may be broken off just at the point of emergence at the apex
+of the papule, in which event it may be seen as a dark, central speck.
+The skin is usually dry, rough and harsh, and in marked cases, to the
+hand passing over it, feels not unlike a nutmeg-grater. The disease
+varies in its development, in most cases being so slight as to escape
+attention. As a rule, it is free from itching.
+
+
+#What course does keratosis pilaris pursue?#
+
+It is sluggish and chronic.
+
+
+#Mention some of the etiological factors.#
+
+It is not an uncommon disease, and is seen usually in those who are
+unaccustomed to frequent bathing, being most frequently met with during
+the winter months. It is chiefly observed during early adult life.
+
+
+#Is there any difficulty in the diagnosis?#
+
+No. It is thought at times to bear some resemblance to goose-flesh
+(cutis anserina), the miliary papular syphiloderm in its desquamating
+stage, and lichen scrofulosus. In goose-flesh the elevations are
+evanescent and of an entirely different character; the papules of the
+syphiloderm are usually generalized, of a reddish color, tend to group,
+are more solid and deeply-seated, less scaly and are accompanied with
+other symptoms of syphilis; in lichen scrofulosus the papules are
+larger, incline to occur in groups, and appear usually upon the abdomen.
+
+
+#State the prognosis.#
+
+The disease yields readily to treatment.
+
+
+#Give the treatment of keratosis pilaris.#
+
+Frequent warm baths, with the use of a toilet soap or sapo viridis, will
+usually be found curative. Alkaline baths are also useful. In obstinate
+cases the ordinary mild ointments, glycerine, etc., are to be advised in
+conjunction with the baths.
+
+
+
+                         #Keratosis Follicularis.#
+
+
+#Describe keratosis follicularis.#
+
+Keratosis follicularis (_Darier's disease_, _ichthyosis follicularis_,
+_ichthyosis sebacea cornea_, _psorospermosis_) is a rare disease
+characterized by pin-head to pea-sized pointed, rounded, or
+irregularly-shaped grayish, brownish, red or even black, horny papules
+or elevations, arising from the sebaceous or hair-follicles. They are,
+for the most part, discrete, with a tendency here and there to form
+solid aggregations or areas. Many of them contain projecting cornified
+plugs which may be squeezed out, leaving pit-like depressions. The face,
+scalp, lower trunk, groins and flanks are the parts chiefly affected.
+The view advanced by Darier, that the malady was due to psorosperms, is
+now denied, the bodies thought to be such having been demonstrated to be
+due to cell transformation.
+
+As to treatment, in one instance the induction of a substitutive
+dermatic inflammation had a favorable influence.
+
+
+                         #Molluscum Epitheliale.#
+    (_Synonyms:_ Molluscum Contagiosum; Molluscum Sebaceum; Epithelioma
+                                Molluscum.)
+
+
+#Give a definition of molluscum epitheliale.#
+
+Molluscum epitheliale is characterized by pin-head to pea-sized,
+rounded, semi-globular, or flattened, pearl-like elevations, of a
+whitish or pinkish color.
+
+
+#Describe the symptoms and course of molluscum epitheliale.#
+
+The usual seat is the face; not infrequently, however, the growths occur
+on other parts. The lesions begin as pin-head, waxy-looking, rounded or
+acuminated elevations, gradually attaining the size of small peas. They
+have a broad base or occasionally may tend to become pedunculated. They
+rarely exist in profusion, in most cases three to ten or twelve lesions
+being present. When fully developed they are somewhat flattened and
+umbilicated, with a central, darkish point representing the mouth of the
+follicle. They are whitish or pinkish, and look not unlike drops of wax
+or pearl buttons. At first they are firm, but eventually, in most cases,
+tend to become soft and break down. Not infrequently, however, the
+lesions disappear slowly by absorption, without apparent previous
+softening. Their course is usually chronic. The contents, a
+cheesy-looking mass, may commonly be pressed out without difficulty.
+
+
+#What is the cause of molluscum epitheliale?#
+
+It is now generally accepted that the disease is mildly contagious. It
+occurs chiefly in children, and especially among the poorer classes. The
+belief in the parasitic nature of the disease is gaining ground;
+recently the opinion has been advanced that it is due to psorosperms
+(psorospermosis); but further investigations have indicated that these
+bodies were degenerated epithelia.
+
+
+#State the pathology.#
+
+[Illustration: Fig. 31. Molluscum Epitheliale.]
+
+According to recent investigations, molluscum epitheliale is to be
+regarded as a hyperplasia of the rete, the growth probably beginning in
+the hair-follicles; the so-called molluscum bodies--peculiar, rounded or
+ovoidal, sharply-defined, fatty-looking bodies found in microscopical
+examination of the growth--are to be viewed as a form of epithelial
+degeneration.
+
+
+#What are the diagnostic points in molluscum epitheliale?#
+
+The size of the lesions, their waxy or glistening appearance, and the
+presence of the central orifice.
+
+It is to be differentiated from molluscum fibrosum, warts and acne.
+
+
+#State the prognosis.#
+
+The growths are amenable to treatment. In some instances the disease,
+after existing some weeks, tends to disappear spontaneously.
+
+
+#What is the treatment of molluscum epitheliale?#
+
+Incision and expression of the contents, and touching the base of the
+cavity with silver nitrate. Pedunculated growths may be ligated. In some
+cases an ointment of ammoniated mercury, twenty to forty grains to the
+ounce, applied, by gently rubbing, once or twice daily, will bring about
+a cure.
+
+
+
+                             #Callositas.#
+    (_Synonyms:_ Tylosis; Tyloma; Callus; Callous; Callosity; Keratoma.)
+
+
+#What do you understand by callositas?#
+
+A hard, thickened, horny patch made up of the corneous layers of the
+epidermis.
+
+
+#Describe the clinical appearances.#
+
+Callosities are most common about the hands and feet, and consist of
+small or large patches of dry, grayish-yellow looking, hard, slight or
+excessive epidermic accumulations. They are somewhat elevated,
+especially at the central portion, and gradually merge into the healthy
+skin. The natural surface lines are in a great measure obliterated, the
+patches usually being smooth and horn-like.
+
+_Keratosis palmaris et plantaris_ (symmetric keratodermia), as regards
+the local condition, is a somewhat similar affection. It consists of
+hypertrophy of the corneous layer of the palm and soles, usually of a
+more or less horny and plate-like character, but is congenital or
+hereditary, and not necessarily dependent upon local friction or
+pressure.
+
+
+#Are there any inflammatory symptoms in callositas?#
+
+No; but exceptionally, from accidental injury, the subjacent corium
+becomes inflamed, suppurates, and the thickened mass is cast off.
+
+
+#State the causes of callositas.#
+
+Pressure and friction; for example, on the hands, from the use of
+various tools and implements, and on the feet from ill-fitting shoes. It
+is, indeed, often to be looked upon as an effort of nature to protect
+the more delicate corium.
+
+In exceptional instances it arises without apparent cause.
+
+
+#What is the pathology?#
+
+The epidermis alone is involved; it consists, in fact, of a hyperplasia
+of the horny layer.
+
+
+#State the prognosis of callositas.#
+
+If the causes are removed, the accumulation, as a rule, gradually
+disappears. The effect of treatment is always rapid and positive, but
+unless the etiological factors have ceased to act, the result is usually
+but temporary.
+
+
+#How is callositas treated?#
+
+When treatment is deemed advisable, it consists in softening the parts
+with hot-water soakings or poultices, and subsequently shaving or
+scraping off the callous mass. The same result may also be often
+effected by the continuous application, for several days or a week, of a
+10 to 15 per cent. salicylated plaster, or the application of a
+salicylated collodion, same strength; it is followed up by hot-water
+soaking, the accumulation, as a rule, coming readily away.
+
+
+
+                             #Clavus.#
+                       (_Synonym:_ Corn.)
+
+
+#What is clavus?#
+
+Clavus, or corn, is a small, circumscribed, flattened, deep-seated,
+horny formation usually seated about the toes.
+
+
+#Describe the clinical appearances.#
+
+Ordinarily a corn has the appearance of a small callosity; the skin is
+thickened, polished and horny. Exceptionally, however, occurring on
+parts that are naturally more or less moist, as between the toes,
+maceration takes place, and the result is the so-called _soft corn_. The
+dorsal aspect of the toes is the common site for the ordinary variety.
+The usual size is that of a small pea. They are painful on pressure,
+and, at times, spontaneously so.
+
+
+#State the causes.#
+
+Corns are caused by pressure and friction, and may usually be referred
+to improperly fitting shoes.
+
+
+#What is the pathology of clavus?#
+
+It is a hypertrophy of the epiderm. Its shape is conical, with the base
+external and the apex pressing upon the papillae. It is, in fact, a
+peculiarly-shaped callosity, the central portion and apex being dense
+and horny, forming the so-called core.
+
+
+#Give the treatment of clavus.#
+
+A simple method of treatment consists in shaving off, after a
+preliminary hot-water soaking, the outer portion, and then applying a
+ring of felt or like material, with the hollow part immediately over the
+site of the core; this should be worn for several weeks. It is also
+possible in some cases to extract the whole corn by gently dissecting it
+out; the after-treatment being the same as the above.
+
+Another method is by means of a ten- to fifteen-per-cent. solution of
+salicylic acid, in alcohol or collodion, or the following:--
+
+  [Rx] Ac. salicylici, ...................... gr. xxx
+       Ext. cannabis Ind., .................. gr. x
+       Collodii, ............................ f[dram]iv.   M.
+
+This is painted on the corn night and morning for several days, at the
+end of which time the parts are soaked in hot water, and the mass or a
+greater part of it, will be found, as a rule, to come readily away; one
+or two repetitions may be necessary. Lactic acid, with one to several
+parts of water, applied once or twice daily, acts in a similar manner.
+
+Soft corns, after the removal of pressure, may be treated with the solid
+stick of nitrate of silver, or by any of the methods already mentioned.
+
+In order that treatment be permanently successful, the feet are to be
+properly fitted. If pressure is removed, corns will commonly disappear
+spontaneously.
+
+
+
+                           #Cornu Cutaneum.#
+              (_Synonyms:_ Cornu Humanum; Cutaneous Horn.)
+
+
+#What is cornu cutaneum?#
+
+A cutaneous horn is a circumscribed hypertrophy of the epidermis,
+forming an outgrowth of horny consistence and of variable size and
+shape.
+
+
+#At what age and upon what parts are cutaneous horns observed?#
+
+They are usually met with late in life, and are mostly seated upon the
+face and scalp.
+
+[Illustration: Fig. 32.
+  Cutaneous Horns. Showing beginning epitheliomatous degeneration of the
+  base. (_After Pancoast._)]
+
+
+#Describe the clinical appearances.#
+
+In appearance cutaneous horns resemble those seen in the lower animals,
+differing, if at all, but slightly. They are hard, solid, dry and
+somewhat brittle; usually tapering, and may be either straight, curved
+or crooked. Their surface is rough, irregular, laminated or fissured,
+the ends pointed, blunt or clubbed. The color varies; it is usually
+grayish-yellow, but may be even blackish. As commonly seen they are
+small in size, a fraction of an inch or an inch or thereabouts in
+length, but exceptionally attain considerable proportions. The base,
+which rests directly upon the skin, may be broad, flattened, or concave,
+with the underlying and adjacent tissues normal or the papillae
+hypertrophied; and in some cases there is more or less inflammation,
+which may be followed by suppuration. They are usually solitary
+formations. They are not, as a rule, painful, unless knocked or
+irritated.
+
+
+#What course do cutaneous horns pursue?#
+
+Their growth is usually slow, and, after having attained a certain size,
+they not infrequently become loose and fall off; they are almost always
+reproduced.
+
+
+#What is the cause of these horny growths?#
+
+The cause is not known; appearing about the genitalia, they usually
+develop from acuminated warts. They are rare formations.
+
+
+#State the pathology of cornu cutaneum.#
+
+Horns consist of closely agglutinated epidermic cells, forming small
+columns or rods; in the columns themselves the cells are arranged
+concentrically. In the base are found hypertrophic papillae and some
+bloodvessels. They have their starting-point in the rete mucosum, either
+from that lying above the papillae or that lining the follicles and
+glands.
+
+
+#Does epitheliomatous degeneration of the base ever occur?#
+
+Yes.
+
+
+#State the prognosis.#
+
+Cutaneous horns may be readily and permanently removed.
+
+
+#What is the treatment?#
+
+Treatment consists in detachment, and subsequent destruction of the
+base; the former is accomplished by dissecting the horn away from the
+base or forcibly breaking it off, the latter by means of any of the
+well-known caustics, such as caustic potash, chloride of zinc and the
+galvano-cautery.
+
+Another method is to excise the base, the horn coming away with it; this
+necessitates, however, considerable loss of tissue.
+
+
+
+                              #Verruca.#
+                          (_Synonym:_ Wart.)
+
+
+#What is verruca?#
+
+Verruca, or wart, is a hard or soft, rounded, flat, acuminated or
+filiform, circumscribed epidermal and papillary growth.
+
+
+#Name the several varieties of warts met with.#
+
+Verruca vulgaris, verruca plana, verruca plana juvenilis, verruca
+digitata, verruca filifortnis and verruca acuminata.
+
+
+#Describe verruca vulgaris.#
+
+This is the common wart, occurring mostly upon the hands. It is rounded,
+elevated, circumscribed, hard and horny, with a broad base, and usually
+the size of a pea. At first it is smooth and covered with slightly
+thickened epidermis, but later this disappears to some extent, the
+hypertrophied papillae, appearing as minute elevations, making up the
+growth. One, several or more may be present.
+
+
+#Describe verruca plana.#
+
+This is the so-called flat wart, and occurs commonly upon the back,
+especially in elderly people (_verruca senilis_, _keratosis pigmentosa_).
+It is, as a rule, but slightly elevated, is usually dark in color, and
+of the size of a pea or finger-nail.
+
+
+#Describe verruca plana juvenilis.#
+
+The warts are mostly pin-head in size, flat, but slightly elevated,
+rounded, irregular or square-shaped, and of a light yellowish-brown
+color. They bear resemblance to lichen planus papules. They are apt to
+be numerous, often becoming aggregated or fused, and occur usually in
+young children, and, as a rule, on the face and hands.
+
+
+#Describe verruca filiformis.#
+
+This is a thread-like growth about an eighth or fourth of an inch long,
+and occurring commonly about the face, eyelids and neck. It is usually
+soft to the touch and flexible.
+
+
+#Describe verruca digitata.#
+
+This is a variety of wart, which, especially about the edges, is marked
+by digitations, extending nearly or quite down to the base. It is
+commonly seen upon the scalp.
+
+
+#Describe verruca acuminata.#
+
+This variety (_venereal wart_, _pointed wart_, _pointed condyloma_),
+usually occurs about the genitalia, especially upon the mucous and
+muco-cutaneous surfaces. It consists of one or more groups of
+acuminated, pinkish or reddish, raspberry-like elevations, and,
+according to the region, may be dry or moist; if the latter, the
+secretion, which is usually yellowish and puriform, from rapid
+decomposition, develops an offensive and penetrating odor. The formation
+may be the size of a small pea, or may attain the dimensions of a fist.
+
+
+#What is the cause of warts?#
+
+The etiology is not known. They are more common in adolescent and early
+adult life. Irritating secretions are thought to be causative in the
+acuminated variety. It is highly probable that a parasitic factor will
+finally be demonstrated. They are doubtless mildly contagious.
+
+[Illustration: Fig. 33.
+  Verruca Acuminata--about the anus. (_After Ashton._)]
+
+
+#State the pathology of warts.#
+
+A wart consists of both epidermic and papillary hypertrophy, the
+interior of the growth containing a vascular loop. In the acuminated
+variety there are marked papillary enlargement, excessive development of
+the mucous layer, and an abundant vascular supply.
+
+
+#Give the treatment of warts.#
+
+For ordinary warts, excision or destruction by caustics. The repeated
+application of a saturated alcoholic solution of salicylic acid is often
+curative, the upper portion being pared off from time to time. The
+filiform and digitate varieties may be snipped off with the scissors,
+and the base touched with nitrate of silver; or a ligature may be used.
+Curetting is a valuable operative method. The growths may also be
+removed by electrolysis. When warts are numerous and close together
+parasiticide applications can be daily made to the whole affected
+region. For this purpose a boric acid solution, containing five to
+thirty grains of resorcin to the ounce, and Vleminckx's solution, at
+first diluted, prove the most valuable.
+
+Verruca acuminata is to be treated by maintaining absolute cleanliness,
+and the application of such astringents as liquor plumbi subacetatis,
+tincture of iron, powdered alum and boric acid. The salicylic acid
+solution may also be used. In obstinate cases, glacial acetic acid or
+chromic acid may be cautiously employed.
+
+
+
+                         #Naevus Pigmentosus.#
+                          (_Synonym:_ Mole.)
+
+
+#Describe naevus pigmentosus.#
+
+Naevus pigmentosus, commonly known as mole, may be defined as a
+circumscribed increase in the pigment of the skin, usually associated
+with hypertrophy of one or all of the cutaneous structures, especially
+of the connective tissue and hair. It occurs singly or in numbers; is
+usually pea-, bean-sized or larger, rounded or irregular, smooth or
+rough, flat or elevated, and of a color varying from a light brown to
+black; the hair found thereon may be either colorless or deeply
+pigmented, coarse and of considerable length. It is, as a rule, a
+permanent formation.
+
+
+#Name the several varieties of naevus pigmentosus met with.#
+
+Naevus spilus, naevus pilosus, naevus verrucosus, and naevus lipomatodes.
+So-called linear naevus might also be considered as belonging in this
+group.
+
+
+#What is naevus spilus?#
+
+A smooth and flat naevus, consisting essentially of augmented
+pigmentation alone.
+
+[Illustration: Fig. 34. Linear Naevus.]
+
+
+#What is naevus pilosus?#
+
+A naevus upon which there is an abnormal growth of hair, slight or
+excessive.
+
+
+#What is naevus verrucosus?#
+
+A naevus to which is added hypertrophy of the papillae, giving rise to a
+furrowed and uneven surface.
+
+
+#What is linear naevus?#
+
+Linear naevus is a formation usually of a verrucous character, more or
+less pigmented, sometimes slightly scaly, occurring in band-like or
+zoster-like areas, and, as a rule, unilaterally.
+
+
+#What is naevus lipomatodes?#
+
+A naevus with excessive fat and connective-tissue hypertrophy.
+
+
+#State the etiology of naevus pigmentosus.#
+
+The causes are obscure. The growths are usually congenital; but the
+smooth, non-hairy moles may be acquired.
+
+
+#Give the pathology of naevus pigmentosus.#
+
+Microscopical examination shows a marked increase in the pigment in the
+lowest layers of the rete mucosum, as well as more or less pigmentation
+in the corium usually following the course of the bloodvessels; in the
+verrucous variety the papillae are greatly hypertrophied, in addition to
+the increased pigmentation. There is, as a rule, more or less
+connective-tissue hypertrophy.
+
+
+#What is the treatment of naevus pigmentosus?#
+
+In many instances interference is scarcely called for, but when demanded
+consists in the removal of the formation either by the knife, by
+caustics, or by electrolysis. This last is, in the milder varieties at
+least, perhaps the best method, as it is less likely to be followed by
+disfiguring cicatrices. In naevus pilosus the removal of the hairs alone
+by electrolysis is not infrequently followed by a decided diminution of
+the pigmentation. In recent years both liquid air and carbon dioxide
+have also been used successfully in the removal of these growths.
+Pigmented naevi, which show the least tendency to growth or degenerative
+change, should be radically removed, as they not infrequently lead to
+carcinomatous and sarcomatous growths.
+
+
+
+                             #Ichthyosis.#
+                    (_Synonym:_ Fish-skin Disease.)
+
+
+#Give a descriptive definition of ichthyosis.#
+
+Ichthyosis is a chronic, hypertrophic disease, characterized by dryness
+and scaliness of the skin, with a variable amount of papillary growth.
+
+
+#At what age is ichthyosis first observed?#
+
+It is first noticed in infancy or early childhood. In rare instances it
+is congenital (ichthyosis congenita), and in such cases it is usually
+severe, and of a grave type; the children are, as a rule, prematurely
+born, and frequently do not survive many days or weeks.
+
+
+#What extent of surface is involved?#
+
+Usually the whole surface, but it is most marked upon the extensor
+surfaces of the arms and legs, especially at the elbows and knees; the
+face and scalp, in mild cases, often remain free.
+
+
+#Name the two varieties of ichthyosis usually described.#
+
+Ichthyosis simplex and ichthyosis hystrix, terms commonly employed to
+designate the mild and severe forms respectively.
+
+
+#Describe the clinical appearances of ichthyosis.#
+
+The milder forms of the disease may be so slight as to give rise to
+simple dryness or harshness of the skin (_xeroderma_); but as commonly
+met with it is more developed, more or less marked scaliness in the form
+of thin or somewhat thick epidermal plates being present. The papillae of
+the skin are often slightly hypertrophied. In slight cases the color of
+the scales is usually light and pearly; in the more marked examples it
+is dark gray, olive green or black.
+
+In the severe variety--ichthyosis hystrix--in addition to scaliness
+there is marked papillary hypertrophy, forming warty or spinous patches.
+This type is rare, and, as a rule, the surface involved is more or less
+limited.
+
+
+#Are there any inflammatory symptoms in ichthyosis?#
+
+No. In fact, beyond the disfigurement, the disease causes no
+inconvenience; in those well-marked cases, however, in which the scales
+are thick and more or less immovable, the natural mobility of the parts
+is compromised and fissuring often occurs. In the winter months, in the
+severer cases, exposed parts may become slightly eczematous.
+
+
+#Does ichthyosis vary somewhat with the season?#
+
+Yes. In all cases the disease is better in the warm months, and in the
+mild forms may entirely disappear during this time. This favorable
+change is purely mechanical--due to the maceration to which the
+increased activity of the sweat glands gives rise.
+
+
+#Is the general health affected in ichthyosis?#
+
+No.
+
+
+#What course does ichthyosis pursue?#
+
+Chronic. Beginning in early infancy or childhood, it usually becomes
+gradually more marked until adult age, after which time it, as a rule,
+remains stationary.
+
+
+#What is the etiology?#
+
+Beyond a hereditary influence, which is often a positive factor, the
+causes are obscure. It is not a common disease.
+
+
+#State the pathology.#
+
+Anatomically the essential feature is epidermic hypertrophy, with
+usually a varying degree of papillary hypertrophy also.
+
+
+#Mention the diagnostic features of ichthyosis.#
+
+The harsh, dry skin, epidermic and papillary hypertrophy, the
+furfuraceous or plate-like scaliness, the greater development upon the
+extensor surfaces, a history of the affection dating from early
+childhood, and the absence of inflammatory symptoms.
+
+
+#How is ichthyosis to be distinguished from eczema, psoriasis, and other
+scaly inflammatory diseases?#
+
+By the absence of the inflammatory element.
+
+
+#What is the outlook for a case of ichthyosis?#
+
+The prognosis is unfavorable as regards a cure, but the process may
+usually be kept in abeyance or rendered endurable by proper measures.
+
+
+#What treatment would you prescribe for ichthyosis?#
+
+Treatment that has in view removal of the scaliness and the maintenance
+of a soft and flexible condition of the skin.
+
+In mild cases frequent warm baths, simple or alkaline, will suffice; in
+others an application of an oily or fatty substance, such as the
+ordinary oils or ointments, made several hours or immediately before the
+bath may be necessary. In moderately developed cases the skin is to be
+washed energetically with sapo viridis and hot water, followed by a warm
+bath, after which an oily or fatty application is made. In some of the
+more severe cases the following plan is often useful: The parts are
+first rubbed with a soapy ointment consisting of one part of
+precipitated sulphur and seven parts of sapo viridis; a bath is then
+taken, the skin wiped dry, and a one to five per cent. ointment of
+salicylic acid gently rubbed in.
+
+Glycerine lotions, one or two drachms to the ounce of water, are also
+beneficial; as also the following:--
+
+  [Rx] Ac. salicylici, ...................... gr. x-xl
+       Glycerini, ........................... [dram]ss-[dram]j
+       Lanolin,
+       Petrolati, .................. [=a][=a] [Oz]ss
+
+In severe cases of ichthyosis hystrix it may be necessary, also, to
+employ caustics or the knife.
+
+
+#What systemic treatment would you prescribe?#
+
+Constitutional remedies are practically powerless; occasionally some
+good is accomplished by the internal administration of linseed oil and
+jaborandi.
+
+
+
+                               #Onychauxis.#
+                  (_Synonym:_ Hypertrophy of the Nail.)
+
+
+#Describe onychauxis.#
+
+Onychauxis, or hypertrophy of the nail, may take place in one or all
+directions, and this increase may be, and often is, accompanied by
+changes in shape, color, and direction of growth. One or all the nails
+may share in the process. As the result of lateral deviation of growth,
+the nail presses upon the surrounding tissues, producing a varying
+degree of inflammation--_paronychia_.
+
+
+#What is the etiology of hypertrophy of the nail?#
+
+The condition may be either congenital or acquired. In the latter
+instances it is usually the result of the extension to the matrix of
+such cutaneous diseases as psoriasis and eczema; or it is produced by
+constitutional maladies, such as syphilis.
+
+
+#Give the treatment of hypertrophy of the nail.#
+
+Treatment consists in the removal of the redundant nail-tissue by means
+of the knife or scissors; and, when dependent upon eczema or psoriasis,
+the employment of remedies suitable for these diseases. When it is the
+result of syphilis, the medication appropriate to this disease is to be
+employed.
+
+In paronychia the nail should be frequently trimmed and a pledget of
+lint or cotton be interposed between the edge of the nail and the
+adjacent soft parts; astringent powders and lotions may often be
+employed with advantage; and in severe and persistent cases excision of
+the nail, partial or complete, may be found necessary.
+
+
+
+                          #Hypertrichosis.#
+    (_Synonyms:_ Hirsuties; Hypertrophy of the Hair; Superfluous Hair.)
+
+
+#What is meant by hypertrichosis?#
+
+Hypertrichosis is a term applied to excessive growth of hair, either as
+regards region, extent, age or sex.
+
+
+#Describe the several conditions met with.#
+
+The unnatural hair growth may be slight, as, for instance, upon a naevus
+(_naevus pilosus_); or it may be excessive, as in the so-called hairy
+people (_homines pilosi_); or it may also appear on the face, arms and
+other parts in females, resulting from a hypertrophy of the natural
+lanugo hairs.
+
+
+#State the causes of hypertrichosis.#
+
+Hereditary influence is often a factor; the condition may also be
+congenital.
+
+If acquired, the tendency manifests itself usually toward middle life.
+In women, it is not infrequently associated with diseases of the
+utero-ovarian system; in many instances, however, there is no apparent
+cause. Local irritation or stimulation has at times a causative
+influence.
+
+
+#How is hypertrichosis to be treated?#
+
+For general hypertrichosis there is no remedy. Small hairy naevi may be
+excised, or, as also in the larger hairy moles, the hairs may be removed
+by electrolysis.
+
+On the faces of women, if the hairs are coarse or large, electrolysis
+constitutes the only satisfactory method; if the hairs are small and
+lanugo-like, the operation is not to be advised. It is somewhat painful,
+but never unbearable. In the past several years the _x_-ray has been
+advocated by several writers, but it requires usually numerous exposures
+pushed to the point of producing erythema; it is not without risk, and
+the hairs are said to return in some months.
+
+
+#What temporary methods are usually resorted to for the removal of
+superfluous hair?#
+
+Shaving, extraction of the hairs and the use of depilatories. As a
+depilatory, a powder made up of two drachms of barium sulphide and three
+drachms each of zinc oxide and starch, is commonly (and cautiously)
+employed; at the time of application enough water is added to the powder
+to make a paste, and it is then spread thinly upon the parts, allowed to
+remain five to fifteen minutes, or until heat of skin or a burning
+sensation is felt, washed off thoroughly, and a soothing ointment
+applied. This preparation must be well prepared to be efficient.
+
+
+#Describe the method of removal of superfluous hair by electrolysis.#
+
+A fine needle in a suitable handle is attached to the _negative_ pole of
+a _galvanic_ battery, introduced into the hair-follicle to the depth of
+the papilla, and the circuit completed by the patient touching the
+positive electrode; in several seconds slight blanching and frothing
+usually appear at the point of insertion; a few seconds later the
+current is broken by release of the positive electrode, and the needle
+is then withdrawn. Sometimes a wheal-like elevation arises, remains
+several minutes or hours, and then disappears; or occasionally, probably
+from secondary infection, it develops into a pustule.
+
+A strength of current of a half to two milliamperes is usually
+sufficient; the time necessary for the destruction of the papilla
+varying from several to thirty seconds.
+
+
+#How are you to know if the papilla has been destroyed?#
+
+The hair will readily come out with but little, if any, traction.
+
+
+#What is the result if the current has been too strong or too long
+continued?#
+
+The follicle suppurates and a scar results.
+
+
+#Why should contiguous hairs not be operated upon at the same sitting?#
+
+In order that the chances of marked inflammatory action and scarring
+(always possibilities) may be reduced to a minimum.
+
+
+#In case of failure to destroy an individual papilla, should a second
+attempt be made at the same sitting?#
+
+As a rule not, in order to avoid the possibility of too much destructive
+action, and consequent scarring.
+
+
+#Can scarring always be prevented?#
+
+In the average case, with skill and care, the use of an exceedingly fine
+needle and the avoidance of too strong a current, _perceptible_ scarring
+(scarring perceptible to the ordinary observer or at ordinary distance)
+need rarely occur.
+
+
+#What measures are to be advised for the irritation produced by the
+operation?#
+
+Hot-water applications and the use of an ointment made of two drachms
+cold cream and ten grains of boric acid are of advantage not only in
+reducing the resulting hyperaemia, but also in preventing suppuration and
+consequent scarring. To lessen the chances of the latter, cleansing the
+parts with alcohol just before and after the operation is also of
+service.
+
+
+
+                        #[OE]dema Neonatorum.#
+
+
+#Describe [oe]dema neonatorum.#
+
+The essential symptoms are [oe]dema and a variable degree of hardness
+and induration. It develops in the first few days of life, and usually
+upon the extremities, especially the lower. It may remain more or less
+limited to these parts, but, as a rule, slowly extends. The skin is of a
+yellowish, dusky, or livid color, and sometimes glossy or shining. There
+are general symptoms of drowsiness, subnormal temperature, weakened
+circulation, and impaired respiration, which gradually increase, and in
+eighty to ninety per cent. of the cases lead to death. It is believed to
+be similar to anasarca in the adult and to be due to like causes.
+
+Treatment consists in maintaining the body-heat, sufficient and proper
+nourishment and stimulation.
+
+
+
+                           #Sclerema Neonatorum.#
+       (_Synonyms:_ Scleroderma Neonatorum; Sclerema of the Newborn.)
+
+
+#What is sclerema neonatorum?#
+
+Sclerema neonatorum is a disease of infancy, showing itself usually at
+or shortly after birth, and is characterized by a diffuse stiffness and
+rigidity of the integument, accompanied by coldness, [oe]dema,
+discoloration, lividity and general circulatory disturbance.
+
+
+#Describe the symptoms, course, nature and treatment of sclerema
+neonatorum.#
+
+As a rule the disease first manifests itself upon the lower extremities,
+and then gradually, but usually rapidly, invades the trunk, arms and
+face. The surface is cold. The skin, which is noted to be reddish,
+purplish or mottled, is [oe]dematous, stiff and tense; in consequence
+the infant is unable to move, respires feebly and usually perishes in a
+few days or weeks. In extremely exceptional instances the disease, after
+involving a small part, may retrogress and recovery take place.
+
+The disease is rare, and in most cases is found associated with
+pneumonia and with affections of the circulatory apparatus.
+
+Treatment should be directed toward maintaining warmth and proper
+alimentation.
+
+
+
+                               #Scleroderma.#
+  (_Synonyms:_ Sclerema; Scleriasis; Dermatosclerosis; Morph[oe]a; Keloid
+                                of Addison.)
+
+
+#What is scleroderma?#
+
+Scleroderma is an acute or chronic disease of the skin characterized by
+a localized or general, more or less diffuse, usually pigmented, rigid,
+stiffened, indurated or hide-bound condition.
+
+Morph[oe]a, by some formerly thought to be a distinct affection, is now
+believed to be a form of scleroderma; as typically met with it is
+characterized by one or more rounded, oval, or elongate, coin- to
+palm-sized, pinkish, or whitish ivory-looking patches. In some instances
+such patches are seen in association with the more classic type of
+scleroderma just defined.
+
+
+#Describe the symptoms of ordinary scleroderma.#
+
+The disease may be acute or chronic, usually the latter. A portion or
+almost the entire surface may be involved, or it may occupy variously
+sized and shaped areas. The integument becomes more or less rigid and
+indurated, hard to the touch, hide-bound, and in marked cases immobile.
+[OE]dema may, especially in the more acute cases, precede the
+induration. Pigmentation, of a yellowish or brownish color, is often a
+precursory and accompanying symptom. The skin feels tight and
+contracted, and in some instances numbness and cramp-like pains are
+complained of.
+
+
+#Describe the variety known as morph[oe]a.#
+
+The patches (one, several, or more), occurring most frequently about the
+trunk, are in the beginning usually slightly hyperaemic, later becoming
+pale-yellowish or white, and having a pinkish or lilac border made up of
+minute capillaries. They are, as a rule, sharply defined, with a smooth,
+often shining and atrophic-looking surface; are soft, fine or leathery
+to the touch, on a level or somewhat depressed, and appearing not unlike
+a piece of bacon or ivory laid in the skin. Occasionally the patches are
+noted to occur over nerve-tracts. The adjacent skin may be normal or
+there may be more or less yellowish or brownish mottling. The subjective
+symptoms of tingling, itching, numbness, and even pain, may or may not
+be present.
+
+
+#What is the course of the disease?#
+
+Sooner or later, usually after months or years, the disease ends in
+resolution and recovery, or in marked atrophic changes, causing
+contraction and deformity. As a rule, the general health remains good.
+
+
+#State the causes of scleroderma.#
+
+The condition is to be considered as probably of neurotic origin.
+Exposure and shock to the nervous system are to be looked upon as
+influential. It is a rare disease, observed usually in early adult or
+middle life, and is more frequent in women than in men.
+
+
+#What is the pathology?#
+
+In typical and advanced cases both the true skin and the subcutaneous
+connective tissue show a marked increase of connective tissue-element,
+with thickening and condensation of the fibers.
+
+
+#Is there any difficulty in reaching a diagnosis in scleroderma?#
+
+As a rule, no. The characters--rigidity, stiffness, hardness, and
+hide-bound condition of the skin--are always distinctive.
+
+The peculiar appearance, the course and character of the patches, of
+morph[oe]a are quite distinctive.
+
+
+#Give the prognosis of scleroderma.#
+
+It should always be guarded. In many instances recovery takes place,
+whilst in others the disease is rebellious, lasting indefinitely. The
+prognosis of the variety known as morph[oe]a is less unfavorable than
+general scleroderma, and recovery more frequent.
+
+
+#What is the treatment of scleroderma?#
+
+Tonics, such as arsenic, quinia, nux vomica, and cod-liver oil;
+conjointly with the local employment of stimulating, oily or fatty
+applications, friction, and electricity. Roentgen-ray treatment is often
+of value, more especially in the morph[oe]a type.
+
+
+
+                             #Elephantiasis.#
+  (_Synonyms:_ Elephantiasis Arabum; Pachydermia; Barbadoes Leg; Elephant
+                                   Leg.)
+
+
+#Give a descriptive definition of elephantiasis.#
+
+Elephantiasis is a chronic hypertrophic disease of the skin and
+subcutaneous tissue characterized by enlargement and deformity,
+lymphangitis, swelling, [oe]dema, thickening, induration, pigmentation,
+and more or less papillary growth.
+
+[Illustration: Fig. 35. Elephantiasis of moderate development.]
+
+
+#What parts are commonly involved in elephantiasis?#
+
+Usually one or both legs; occasionally the genitalia; other parts are
+seldom affected.
+
+
+#Describe the symptoms of elephantiasis.#
+
+The disease usually begins with recurrent (at intervals of months or
+years) erysipelatous inflammation, with swelling, pain, heat, redness
+and lymphangitis; after each attack the parts remain somewhat increased
+in size, although at first not noticeably so. After months or one or two
+years the enlargement or hypertrophy becomes conspicuous, the part is
+chronically swollen, [oe]dematous and hard; the skin is thickened, the
+normal lines and folds exaggerated, the papillae enlarged and prominent,
+and with more or less fissuring and pigmentation.
+
+
+#What is the further course of the disease?#
+
+There is gradual increase in size, the parts in some instances reaching
+enormous proportions; the skin becomes rough and warty, eczematous
+inflammation is often superadded, and, sooner or later, ulcers,
+superficial or deep, form--which, together with the crusting and
+moderate scaliness, present a striking picture. There may be periods of
+comparative inactivity, or, after reaching a certain development, the
+disease may, for a time at least, remain stationary.
+
+
+#Are there any subjective symptoms?#
+
+A variable degree of pain is often noted, especially marked during the
+inflammatory attacks. The general health is not involved.
+
+
+#State the cause of elephantiasis.#
+
+The etiology is obscure. The disease rarely occurs before puberty. It is
+most common in tropical countries, more especially among the poor and
+neglected. It is not hereditary, nor can it be said to be contagious.
+Inflammation and obstruction of the lymphatics, probably due, according
+to late investigations, to the presence of large numbers of filaria
+(microscopic thread-worms) in the lymph channels and bloodvessels, is to
+be looked upon as the immediate cause.
+
+
+#What is the pathology?#
+
+All parts of the skin and subcutaneous connective-tissue are
+hypertrophied, the lymphatic glands are swollen, the lymph channels and
+bloodvessels enlarged, and there is more or less inflammation, with
+[oe]dema. Secondarily, from pressure, atrophy and destruction of the
+skin-glands, and atrophic degeneration of the fat and muscles result.
+
+
+#What are the diagnostic characters of beginning elephantiasis?#
+
+Recurrent erysipelatous inflammation, attended with gradual enlargement
+of the parts.
+
+The appearances, later in the course of the disease, are so
+characteristic that a mistake is scarcely possible.
+
+
+#Give the prognosis of elephantiasis.#
+
+If the case comes under treatment in the first months of its
+development, the process may probably be checked or held in abeyance;
+when well established, rarely more than palliation is possible.
+
+
+#What is the treatment of elephantiasis?#
+
+The inflammatory attacks are to be treated on general principles.
+Quinia, potassium iodide, iron and other tonics are occasionally useful;
+and, especially in the earlier stages, climatic change is often of
+value. Between the inflammatory attacks the parts are to be rubbed with
+an ointment of iodine or mercury, together with galvanization of the
+involved part.
+
+In elephantiasis of the leg, a roller or rubber bandage, or the gum
+stocking, is to be worn; compression and ligation of the main artery,
+and even excision of the sciatic nerve, have all been employed, with
+more or less diminution in size as a result. In elephantiasis of the
+genitalia, if the disease is well advanced, excision or amputation of
+the parts is to be practised.
+
+Eczematous inflammation, if present, is to be treated with the ordinary
+remedies.
+
+
+
+                           #Dermatolysis.#
+                    (_Synonym:_ Cutis Pendula.)
+
+
+#Give a descriptive definition of dermatolysis.#
+
+Dermatolysis is a rare disease, consisting of hypertrophy and looseness
+of the skin and subcutaneous connective tissue, with a tendency to hang
+in folds.
+
+
+#Describe the symptoms and course of dermatolysis.#
+
+It may be congenital or acquired, and maybe limited to a small or large
+area, or develop simultaneously at several regions. All parts of the
+skin, including the follicles, glands and subcutaneous connective and
+areolar tissue, share in the hypertrophy; and this in exceptional
+instances may be so extensive that the integument hangs in folds. The
+enlargement of the follicles, natural folds and rugae gives rise to an
+uneven surface, but the skin remains soft and pliable. There is also
+increased pigmentation, the integument becoming more or less brownish.
+
+
+#What course does dermatolysis pursue?#
+
+Its development is slow and usually progressive. It gives rise to no
+further inconvenience than its weight and consequent discomfort.
+
+
+#Give the etiology.#
+
+The etiology is obscure. It is considered by some authors as allied to
+molluscum fibrosum, and, in fact, as a manifestation of that disease,
+ordinary molluscum tumors sometimes being associated with it. It is not
+malignant.
+
+
+#What is the pathology?#
+
+The disease consists of a simple hypertrophy of all the skin structures
+and the subcutaneous connective tissue.
+
+
+#What is the treatment of dermatolysis?#
+
+Excision when advisable and practicable.
+
+
+
+
+#CLASS V.--ATROPHIES.#
+
+
+                        #Albinismus.#
+
+
+#What do you understand by albinismus?#
+
+Congenital absence, either partial or complete, of the pigment normally
+present in the skin, hair and eyes.
+
+
+#Describe complete albinismus.#
+
+In complete albinismus the skin of the entire body is white, the hair
+very fine, soft and white or whitish-yellow in color, the irides are
+colorless or light blue, and the pupils, owing to the absence of pigment
+in the choroid, are red; this absence of pigment in the eyes gives rise
+to photophobia and nystagmus. _Albinos_--a term applied to such
+individuals--are commonly of feeble constitution, and may exhibit
+imperfect mental development.
+
+
+#Describe partial albinismus.#
+
+Partial albinismus is met with most frequently in the colored race. In
+this form of the affection the pigment is absent in one, several or more
+variously-sized patches; usually the hairs growing thereon are likewise
+colorless.
+
+
+#Is there any structural change in the skin?#
+
+No. The functions of the skin are performed in a perfectly natural
+manner, and microscopical examination shows no departure from normal
+structure save the complete absence of pigment.
+
+
+#What is known in regard to the etiology?#
+
+Nothing is known of the causes producing albinismus beyond the single
+fact that it is frequently hereditary.
+
+
+#Does albinismus admit of treatment?#
+
+No; the condition is without remedy.
+
+
+
+                          #Vitiligo.#
+              (_Synonyms:_ Leucoderma; Leucopathia.)
+
+
+#Give a definition of vitiligo.#
+
+Vitiligo may be defined as a disease involving the pigment of the skin
+alone, characterized by several or more progressive, milky-white patches
+surrounded by increased pigmentation.
+
+
+#Describe the symptoms of vitiligo.#
+
+The disease may begin at one or more regions, the backs of the hands,
+trunk and face being favorite parts; its appearance is usually
+insidious, and the spots may not be especially noticeable until they are
+the size of a pea or larger. The patches grow slowly, are milky or dead
+white, smooth, non-elevated, and of rounded outline; the bordering skin
+is darker than normal, showing increased pigmentation. Several
+contiguous spots may coalesce and form a large, irregularly-shaped
+patch. Hair growing on the involved skin may or may not be blanched.
+
+There are no subjective symptoms.
+
+
+#What course does vitiligo pursue?#
+
+The course of the disease is slow, months and sometimes years elapsing
+before it reaches conspicuous development. It may after a time remain
+stationary, or, in rare instances, retrogress; as a rule, however, it is
+progressive. Exceptionally, the greater part, or even the whole surface
+may eventually be involved.
+
+
+#Give the etiology of vitiligo.#
+
+Disturbed innervation is thought to be influential. The disease develops
+often without apparent cause. Alopecia areata and morph[oe]a have been
+observed associated with it.
+
+[Illustration: Fig. 36. Vitiligo.]
+
+
+#State the pathology of vitiligo.#
+
+The disease consists, anatomically, of both a diminution and increase of
+the pigment--the white patch resulting from the former, and the
+pigmented borders from the latter. There is no textural change, the skin
+in other respects being normal.
+
+
+#From what diseases is vitiligo to be differentiated?#
+
+From morph[oe]a and from the anaesthetic patches of leprosy.
+
+
+#In what respects do these diseases differ from vitiligo?#
+
+In morph[oe]a there is textural change, and in leprosy both textural
+change and constitutional or other symptoms.
+
+
+#What prognosis is to be given?#
+
+It should always be guarded, the disease in almost all cases being
+irresponsive to treatment.
+
+
+#What is the treatment of vitiligo?#
+
+The general health is to be looked after, and remedies directed
+especially toward the nervous system to be employed. Arsenic, in small
+and continued doses, seems at times to have an influence; when there is
+lack of general tone it may be prescribed as follows:--
+
+  [Rx] Liq. potassii arsenitis, ............. f[dram]j
+       Tinct. nucis vom., ................... f[dram]iij
+       Elix. calisayae, ....... q. s. ad ..... f[Oz]iv.    M.
+
+  SIG.--f[dram]j t. d.
+
+Suprarenal-gland preparations in moderate dosage long continued has
+appeared in a few instances to be of some benefit.
+
+When upon exposed parts, stimulation of the patches, with the view of
+producing hyperaemia and consequent pigment deposit; conjoined with
+suitable applications to the surrounding pigmented skin, with a view to
+lessen the coloration (see _treatment of chloasma_), will be of aid in
+rendering the disease less conspicuous. Or the condition may be, in a
+measure, masked by staining the patches with walnut juice or similar
+pigment.
+
+
+
+                               #Canities.#
+                  (_Synonym:_ Grayness of the Hair.)
+
+
+#Describe canities.#
+
+Canities, or graying of the hair, may occur in localized areas or it may
+be more or less general; the blanching may be slight, scarcely amounting
+to slight grayness, or it may be complete. It is common to advancing
+years (_canities senilis_); it is seen also exceptionally in early life
+(_canities praematura_). The condition is usually permanent. The loss of
+pigment takes place, as a rule, slowly, but several apparently authentic
+cases have been reported in which the change occurred in the course of a
+night or in a few days.
+
+
+#What is the etiology of canities?#
+
+The causes are obscure. Heredity is usually an influential factor, and
+conditions which impair the general nutrition have at times an
+etiological bearing. Intense anxiety, fright, and other profound nervous
+shock are looked upon as causative in sudden graying of the hair.
+
+
+#Give the treatment.#
+
+Canities is without remedy. Dyeing, although not to be advised, is often
+practised, and the condition thus masked.
+
+
+
+                           #Alopecia.#
+                     (_Synonym:_ Baldness.)
+
+
+#What do you understand by alopecia?#
+
+By alopecia is meant loss of hair, either partial or complete.
+
+
+#Name the several varieties of alopecia.#
+
+The so-called varieties are based mainly upon the etiology, and are
+named congenital alopecia, premature alopecia and senile alopecia.
+
+
+#Describe congenital alopecia.#
+
+Congenital alopecia is a rare condition, in which the hair-loss is
+usually noted to be patchy, or the general hair-growth may simply be
+scanty. In rare instances the hair has been entirely wanting; in such
+cases there is usually defective development of other structures, such
+as the teeth.
+
+
+#Describe premature alopecia.#
+
+Loss of hair occurring in early and middle adult life is not uncommon,
+and may consist of a simple thinning or of more or less complete
+baldness of the whole or greater part of the scalp. It usually develops
+slowly, some months or several years passing before the condition is
+well established. It is often idiopathic, and without apparent cause
+further than probably a hereditary predisposition. It may also be
+symptomatic, as, for example, the loss of hair, usually rapid
+(_defluvium capillorum_), following systemic diseases, such as the
+various fevers, and syphilis; or as a result of a long-continued
+seborrh[oe]a or seborrh[oe]ic eczema (_alopecia furfuracea_).
+
+
+#Describe senile alopecia.#
+
+This is the baldness so frequently seen developing with advancing years,
+and may consist merely of a general thinning, or, more commonly a
+general thinning with a more or less complete baldness of the temporal
+and anterior portion or of the vertex of the scalp.
+
+
+#What is the prognosis in the various varieties of alopecia?#
+
+In those cases in which there is a positive cause, as, for instance, in
+symptomatic alopecia, the prognosis is, as a rule, favorable, especially
+if no family predisposition exists. In the congenital and senile
+varieties the condition is usually irremediable. In idiopathic premature
+alopecia, the prognosis should be extremely guarded.
+
+
+#How would you treat alopecia?#
+
+By removing or modifying the predisposing factors by appropriate
+constitutional remedies, and by the external use of stimulating
+applications.
+
+
+#Name several remedies or combinations usually employed in the local
+treatment.#
+
+Sulphur ointment, full strength or weakened with lard or vaseline; a
+lotion of resorcin consisting of one or two drachms to four ounces of
+alcohol, to which is added ten to thirty minims of castor oil; and a
+lotion made up as follows:--
+
+  [Rx] Tinct. cantharidis, .................. f[dram]iv
+       Tinct. capsici, ...................... f[Oz]j
+       Ol. ricini, .......................... f[dram]ss-f[dram]j
+       Alcoholis, .... q. s. ad ............. f[Oz]iv.            M.
+
+The following is sometimes beneficial:--
+
+  [Rx] Resorcin, ............................ gr. lxxx
+       Quininae (alkaloid), .................. gr. xv
+       Ol. ricini, .......................... [minim]v-[minim]xx
+       Alcoholis, ........................... f[Oz]iv.--M.
+
+Another excellent formula is:
+
+  [Rx] Resorcin, ............................ gr. lxxx-cxx
+       Ac. carbolici cryst., ................ gr. xx
+       Spts. myrciae, ........................ f[Oz]iv.--M.
+
+And also the various other stimulating applications employed in alopecia
+areata (_q. v._).
+
+Other measures of value are: Faradic electricity applied daily for five
+minutes with a metallic brush or comb; daily massage, with the object of
+loosening the skin and giving more freedom to cutaneous and subcutaneous
+circulation; and the application, two or three times weekly, of static
+electricity by means of the static crown electrode.
+
+(The application selected should be gently--not rubbing--applied daily
+or every second or third day, according to the case; if a lotion,
+moistening the parts with it; if an ointment, merely greasing the parts.
+Shampooing every one to three weeks, according to circumstances.)
+
+
+
+                         #Alopecia Areata.#
+           (_Synonyms:_ Area Celsi; Alopecia Circumscripta.)
+
+
+#What do you understand by alopecia areata?#
+
+[Illustration: Fig. 37. Alopecia Areata.]
+
+Alopecia areata is an affection of the hairy system, in which occur one
+or more circumscribed, round or oval patches of complete baldness
+unattended by any marked alteration in the skin.
+
+
+#Upon what parts and at what age does the disease occur?#
+
+In the large majority of cases the disease is limited to the scalp; but
+it may invade other portions of the body, as the bearded region,
+eyebrows, eyelashes, and, in rare instances, the entire integument.
+
+It is most common between the ages of ten and forty.
+
+
+#Describe the symptoms of alopecia areata.#
+
+The disease begins either suddenly, without premonitory symptoms, one or
+several patches being formed in a few hours; or, and as is more usually
+the case, several days or weeks elapse before the bald area or areas are
+sufficiently large to become noticeable. The patches continue to extend
+peripherally for a variable period, and then remain stationary, or
+several gradually coalesce and form a large, irregular area involving
+the entire or a greater portion of the scalp. The skin of the affected
+regions is smooth, faintly pink or milky white, and at first presents no
+departure from the normal; sooner or later, however, the follicles
+become less prominent, and slight atrophy or thinning may occur, the
+bald plaques being slightly depressed.
+
+[Illustration: Fig. 38. Alopecia Areata--complete hair loss.]
+
+Occasionally, usually about the periphery and in the early stages, a few
+hair-stumps may be seen.
+
+
+#What course does alopecia areata pursue?#
+
+Almost invariably chronic. After the lapse of a variable period the
+patches cease to extend, the hairs at the margins of the bald areas
+being firmly fixed in the follicles; sooner or later a fine, colorless
+lanugo or down shows itself, which may continue to grow until it is
+about a half-inch or so in length and then drop out; or it may remain,
+become coarser and pigmented, and the parts resume their normal
+condition. Not infrequently, however, after growing for a time, the new
+hair falls out, and this may happen several times before the termination
+of the disease.
+
+
+#Are there any subjective symptoms in alopecia areata?#
+
+As a rule, not; but occasionally the appearance of the patches is
+preceded by severe headache, itching or burning, or other manifestations
+of disturbed innervation.
+
+
+#State the cause of alopecia areata.#
+
+The etiology is obscure. Two theories as to the cause of the disease
+exist: one of these regards it as parasitic, and the other considers it
+to be trophoneurotic. Doubtless both are right, as a study of the
+literature would indicate that there are, as regards etiology, really
+two varieties--the contagious and the non-contagious. In America
+examples of the contagious variety are uncommon.
+
+
+#Does the skin undergo any alterative or destructive changes?#
+
+Microscopical examination of the skin of the diseased area shows little
+or no alteration in its structure beyond slight thinning.
+
+
+#How do you distinguish alopecia areata from ringworm?#
+
+The plaques of alopecia areata are smooth, often completely devoid of
+hair, and free from scales; while those of ringworm show numerous broken
+hairs and stumps, desquamation, and usually symptoms of mild
+inflammatory action. In doubtful cases recourse should be had to the
+microscope.
+
+
+#What is the prognosis in alopecia areata?#
+
+The disease is often rebellious, but in children and young adults the
+prognosis is almost invariably favorable, permanent loss of hair being
+uncommon. The same holds true, but to a much less extent, with the
+disease as occurring in those of more advanced age. In extensive
+cases--those in which the hair of the entire scalp finally entirely
+disappears, and sometimes involves all hairy parts--the prognosis is
+unfavorable. Only exceptionally does recovery ensue in such instances.
+
+The uncertain duration, however, must be borne in mind; months, and in
+some instances several years, may elapse before complete restoration of
+hair takes place. Relapses are not uncommon.
+
+
+#How is alopecia areata treated?#
+
+By both constitutional and local measures, the former having in view the
+invigoration of the nervous system, and the latter a stimulating and
+parasiticidal action of the affected areas.
+
+
+#Give the constitutional treatment.#
+
+Arsenic is perhaps the most valuable remedy, while quinine, nux vomica,
+pilocarpine, cod-liver oil and ferruginous tonics may, in suitable
+cases, often be administered with benefit.
+
+
+#Name several remedies or combinations employed in the external treatment
+of alopecia areata.#
+
+Ointments of tar and sulphur of varying strength; the various mercurial
+ointments; the tar oils, either pure or with alcohol; stimulating
+lotions, containing varying proportions, singly or in combination, of
+tincture of capsicum, tincture of cantharides, aqua ammoniae, and oil of
+turpentine. The following is a safe formula, especially in dispensary
+and ignorant class practice:
+
+  [Rx] [beta]-naphthol, ..................... [dram]ss-[dram]j
+       Ol. cadini, .......................... [dram]j
+     Ungt. sulphuris, .......... q. s. ad ... [Oz]j             M.
+
+The cautious use of a five to twenty per cent. chrysarobin ointment is
+of value. Painting the patches with pure carbolic acid or trikresol
+every ten days or two weeks sometimes acts well; it should not be
+applied over large areas nor used in young children. Galvanization or
+faradization of the affected parts may also be employed, and with,
+occasionally, beneficial effect. Stimulation with the high-frequency
+current by means of the vacuum electrode is also of value. When
+practicable, the Finsen light can be applied with hope of benefit and
+cure.
+
+
+
+                        #Atrophia Pilorum Propria.#
+                    (_Synonym:_ Atrophy of the Hair.)
+
+
+#What do you understand by atrophy of the hair?#
+
+An atrophic, brittle, dry condition of the hair, and which may be either
+symptomatic or idiopathic.
+
+
+#Describe the several conditions met with.#
+
+As a symptomatic affection, the dry, brittle condition of the hair met
+with in seborrh[oe]a, in severe constitutional diseases, and in the
+various vegetable parasitic affections, may be referred to.
+
+As an idiopathic disease it is rare, consisting simply of a brittleness
+and an uneven and irregular formation of the hair-shaft, with a tendency
+to split up into filaments (_fragilitas crinium_); or there may be
+localized swelling and bursting of the hair-shaft, the nodes thus
+produced having a shining, semi-transparent appearance (_trichorrhexis
+nodosa_). This latter usually occurs upon the beard and moustache.
+
+
+#State the causes of atrophy of the hair.#
+
+The causes of the symptomatic variety are usually evident; the etiology
+of idiopathic atrophy is obscure, but by many is thought due to
+parasitism.
+
+[Illustration: Fig. 39. Trichorrhexis Nodosa. (_After Michelson._)]
+
+
+#What would be your prognosis and treatment in atrophy of the hair?#
+
+Symptomatic atrophy usually responds to proper measures, but always
+slowly; treatment is based upon the etiological factors.
+
+For the idiopathic disease little, as a rule, can be done; repeated
+shaving or cutting the hair has, in exceptional instances, been followed
+by favorable results.
+
+
+
+                            #Atrophia Unguis.#
+             (_Synonyms:_ Atrophy of the Nails; Onychatrophia.)
+
+
+#Describe atrophy of the nails.#
+
+The nails are soft, thin and brittle, splitting easily, and are often
+opaque and lustreless, and may have a worm-eaten appearance. Several or
+more are usually affected.
+
+
+#State the causes of atrophy of the nails.#
+
+The condition may be congenital or acquired, usually the latter. It may
+result from trauma, or be produced by certain cutaneous diseases,
+notably eczema and psoriasis; or it may follow injuries or diseases of
+the nerves. Syphilis and chronic wasting constitutional diseases may
+also interfere with the normal growth of the nail-substance, producing
+varying degrees of atrophy. The fungi of tinea trichophytina and tinea
+favosa at times invade these structures and lead to more or less
+complete disintegration--_onychomycosis_.
+
+[Illustration: Fig. 40. Atrophy of the Nails.]
+
+
+#What is the treatment of atrophy of the nails?#
+
+Treatment will depend upon the cause. When it is due to eczema or
+psoriasis, appropriate constitutional and local remedies should be
+prescribed. If it is the result of syphilis, mercury and potassium
+iodide are to be advised. In onychomycosis--an exceedingly obstinate
+affection--the nails should be kept closely cut and pared, and a one- to
+five-grain solution of corrosive sublimate applied several times a day;
+a lotion of sodium hyposulphite, a drachm to the ounce, is also a
+valuable and safe application.
+
+
+
+                         #Atrophia Cutis.#
+            (_Synonyms:_ Atrophoderma; Atrophy of the Skin.)
+
+
+#What do you understand by atrophy of the skin?#
+
+By atrophy of the skin is meant an idiopathic or symptomatic wasting or
+degeneration of its component elements.
+
+
+#State the several conditions met with.#
+
+Glossy skin, general idiopathic atrophy of the skin, parchment skin,
+atrophic lines and spots, senile atrophy, and the atrophy following
+certain cutaneous diseases.
+
+
+#Describe glossy skin (atrophoderma neuriticum), and state the treatment.#
+
+Glossy skin is a rare condition following an injury or disease of the
+nerve. It is usually seen about the fingers. The skin is hairless,
+faintly reddish, smooth and shining, with a varnished and thin
+appearance, and with a tendency to fissuring. More or less severe and
+persistent burning pain precedes and accompanies the atrophy.
+
+Protective applications are called for, the disease tending slowly to
+spontaneous disappearance.
+
+
+#Describe general idiopathic atrophy of the skin, and give the treatment.#
+
+General idiopathic atrophy of the skin is extremely rare, and is
+characterized by a gradual, more or less general, degenerative and
+quantitative atrophy of the skin structures, accompanied usually with
+more or less discoloration and pigmentation.
+
+Treatment is palliative and based upon indications.
+
+
+#Describe parchment skin, and state the treatment.#
+
+Parchment skin (_xeroderma pigmentosum_, _angioma pigmentosum et
+atrophicum_) is a rare disease, the exact nature of which is not
+understood. It is characterized by the appearance of numerous
+disseminated, freckle-like pigment-spots, telangiectases, atrophied
+muscles, more or less shrinking and contraction of the integument, and
+followed, in most instances, by epitheliomatous tumors and ulceration,
+and finally death. It is usually slow in its course, beginning in
+childhood and lasting for years. It is not infrequently seen in several
+children of the same family.
+
+Treatment is palliative, consisting, if necessary, of the use of
+protective applications and of the administration of tonics and
+nutrients.
+
+
+#Describe atrophic lines and spots.#
+
+Atrophic lines and spots (_striae et maculae atrophicae_) may be idiopathic
+or symptomatic, the lesions consisting of scar-like or atrophic-looking,
+whitish lines and macules, most commonly seen on the trunk. They are
+smooth and glistening. Slight hyperaemia usually precedes their
+formation. As an idiopathic disease its course is insidious and slow,
+and its progress eventually stayed. The so-called _lineae albicantes_,
+resulting from the stretching of the skin produced by pregnancy or
+tumors, and from rapid development of fat, may be mentioned as
+illustrating the symptomatic variety.
+
+In course of time the atrophy becomes less conspicuous.
+
+
+#Describe senile atrophy.#
+
+Senile atrophy is not uncommon, the atrophy resulting, as the name
+inferentially implies, from advancing age. It is characterized by
+thinning and wasting, dryness, and a wrinkled condition, with more or
+less pigmentation and loss of hair. Circumscribed pigmentary deposits
+and seborrh[oe]a, with degeneration, are also noted.
+
+
+#What several diseases of the skin are commonly followed by atrophic
+changes?#
+
+Favus, lupus, syphilis, leprosy, scleroderma and morph[oe]a.
+
+
+
+
+#CLASS VI.--NEW GROWTHS.#
+
+
+                              #Keloid.#
+                (_Synonyms:_ Keloid of Alibert; Cheloid.)
+
+
+#Give a descriptive definition of keloid.#
+
+Keloid is a fibro-cellular new growth of the corium appearing as one or
+several variously-sized, irregularly-shaped, elevated, smooth, firm,
+pinkish or pale-reddish cicatriform lesions.
+
+
+#Describe the clinical appearance of keloid.#
+
+The growth begins as a small, hard, elevated, pinkish or reddish
+tubercle, increasing gradually, several months or years usually elapsing
+before the tumor reaches conspicuous size. When developed, it is one or
+more inches in diameter, is sharply defined, elevated, hard, rounded or
+oval, fungoid or crab-shaped, and firmly implanted in the skin. It is
+usually pinkish, pearl-white, or reddish, commonly devoid of hair, with
+no tendency to scaliness, and with, usually, several vessels coursing
+over it. In some instances it is tender, and it may be spontaneously
+painful.
+
+The breast, especially over the sternal region, is a favorite site for
+its appearance. One, several or more may be present in the single case.
+
+
+#What course does keloid pursue?#
+
+Chronic; usually lasting throughout life. In rare instances spontaneous
+involution takes place.
+
+
+#State the etiology of keloid.#
+
+The causes are obscure. The growth usually takes its start from some
+injury or lesion of continuity; for instance, at the site of burns,
+cuts, acne and smallpox scars, etc.--_cicatricial keloid, false keloid_;
+or it may also, so it is thought, originate in normal skin--_spontaneous
+keloid, true keloid_.
+
+
+#What is the pathology of keloid?#
+
+The lesion is a connective-tissue new growth having its seat in the
+corium.
+
+
+#Is there any difficulty in the diagnosis of keloid?#
+
+No. It resembles hypertrophic scar; but this latter, which is
+essentially keloidal, never extends beyond the line of injury.
+
+
+#Give the prognosis.#
+
+The growth is persistent and usually irresponsive to treatment. In some
+cases, however, there is eventually a tendency to spontaneous
+retrogression, up to a certain point at least.
+
+
+#What is the treatment of keloid?#
+
+Usually palliative, consisting of the continuous application of an
+ointment such as the following:--
+
+  [Rx] Acidi salicylici, .................... gr. x-xx
+       Emplast. plumbi,
+       Emplast. saponis, ... [=a][=a] ....... [dram]iij
+       Petrolati, ........................... [dram]ij.     M.
+
+An ointment of ichthyol, twenty-five per cent. strength, rubbed in once
+or twice daily, is sometimes beneficial.
+
+Operative measures, such as punctate and linear scarification,
+electrolysis and excision, are occasionally practised, but the results
+are rarely satisfactory and permanent; not infrequently, indeed, renewed
+activity in the progress of the growth is noted to follow. The _x_-ray
+can be tried with some hope of improvement. The administration of
+thyroid has been thought to have a possible influence in some instances.
+
+
+
+                              #Fibroma.#
+         (_Synonyms:_ Molluscum Fibrosum; Fibroma Molluscum.)
+
+
+#What do you understand by fibroma?#
+
+Fibroma is a connective-tissue new growth characterized by one or more
+sessile or pedunculated, pea- to egg-sized or larger, soft or firm,
+rounded, painless tumors, seated beneath and in the skin.
+
+
+#Describe the clinical appearances of fibroma.#
+
+The growth may be single, in which case it is apt to be pedunculated or
+pendulous, and attain considerable dimensions; as a result of weight or
+pressure surface-ulceration may occur. Or, as commonly met with, the
+lesions are numerous, scattered over large surface, and vary in size
+from a pea to a cherry; the overlying skin being normal, pinkish or
+reddish, loose, stretched, hypertrophied or atrophied.
+
+The tumors are painless. The general health is not involved.
+
+[Illustration: Fig. 41. Fibroma. (_After Octerlony._)]
+
+
+#What is the course of fibroma?#
+
+Chronic and persistent.
+
+
+#What is the etiology of fibroma?#
+
+The cause is not known. Heredity is often noted. The affection is not
+common.
+
+
+#State the pathology of fibroma.#
+
+The growths are variously thought to have their origin in the connective
+tissue of the corium, or in that of the walls of the hair-sac, or in the
+connective-tissue framework of the fatty tissue. Recent tumors are
+composed of gelatinous, newly-formed connective tissue, and the older
+growths of a dense, firmly-packed, fibrous tissue.
+
+
+#From what growths is fibroma to be differentiated?#
+
+From molluscum contagiosum, neuroma and lipoma; the first is
+differentiated by its central aperture or depression, neuroma by its
+painfulness, and lipoma by its lobulated character and soft feel.
+
+
+#Give the prognosis of fibroma.#
+
+The disease is persistent, and irresponsive to all treatment save
+operative measures.
+
+
+#What is the treatment of fibroma?#
+
+Treatment consists, when desired and practicable, in the removal of the
+growths by the knife, or in large and pedunculated tumors by the
+ligature or by the galvano-cautery.
+
+
+
+                               #Neuroma.#
+
+
+#Describe neuroma.#
+
+Neuroma of the skin is an exceedingly rare disease, characterized by the
+formation of variously-sized, usually numerous, firm, immovable and
+elastic fibrous tubercles containing new nerve-elements, and accompanied
+by violent, paroxysmal pain. Their growth is slow and usually
+progressive. Later they are painful upon pressure. They are limited to
+one region.
+
+The tumors are seated in the corium, extending into the deeper
+structure, and consist of nerve-fibres, yellow elastic tissue, blood
+vessels and lymphoid cells.
+
+In the two cases reported, excision of the nerve-trunk gave, in one
+instance, permanent relief; in the other the effect was only temporary.
+
+
+
+                              #Xanthoma.#
+               (_Synonyms:_ Vitiligoidea; Xanthelasma.)
+
+
+#What is xanthoma?#
+
+Xanthoma is a connective-tissue new growth characterized by the
+formation of yellowish, circumscribed, irregularly-shaped,
+variously-sized, non-indurated, flat or raised patches or tubercles.
+
+
+#Name the two varieties met with.#
+
+The macular or flat (_xanthoma planum_) and the tubercular (_xanthoma
+tuberculatum_ or _tuberosum_). In some instances both varieties
+(_xanthoma multiplex_) are seen in the same individual.
+
+
+#Describe the clinical appearances of xanthoma planum.#
+
+The macular or flat variety is usually seen about the eyelids. It
+consists of one, several or more small or large, smooth, opaque,
+sharply-defined, often slightly raised, yellowish patches, looking not
+unlike pieces of chamois-skin implanted in the skin.
+
+
+#Describe the clinical appearances of xanthoma tuberosum.#
+
+The tubercular variety is commonly met with upon the neck, trunk and
+extremities. It occurs as small, raised, isolated, yellowish nodules, or
+as patches made up of aggregations of millet-seed-sized or larger
+tubercles. The lesions may be few or they may exist in great numbers.
+
+
+#What is the course of xanthoma?#
+
+Extremely slow; after reaching a certain development the growths may
+remain stationary.
+
+
+#State the etiology of xanthoma.#
+
+The causes are obscure. Jaundice not infrequently precedes and
+accompanies its development, especially in the tubercular variety. The
+disease is uncommon, and is usually seen in middle and advanced life,
+and more frequently in women. In some cases (_xanthoma diabeticorum_) of
+general xanthoma diabetes is the causative factor.
+
+
+#What is the pathology of xanthoma?#
+
+It is a benign, connective-tissue new growth, with concomitant or
+subsequent, but usually partial, fatty degeneration.
+
+
+#Give the prognosis of xanthoma.#
+
+The condition is persistent, and usually irresponsive to all treatment
+save destructive or operative measures.
+
+#What is the treatment of xanthoma?#
+
+Treatment consists, in suitable cases, of excision; in some instances,
+electrolysis is serviceable. Applications of trichloracetic acid
+cautiously made are sometimes of value. In that form of general xanthoma
+due to diabetes the treatment of this latter condition will materially
+and sometimes completely remove the eruption.
+
+
+
+                              #Myoma.#
+       (_Synonyms:_ Myoma Cutis; Dermatomyoma; Liomyoma Cutis.)
+
+
+#Describe myoma.#
+
+The disease is rare, and consists usually of one or several
+(exceptionally numerous), variously-sized tumors of the skin, made up of
+smooth muscular fibres. They are flat, rounded, oval or pedunculated,
+and have a smooth surface and a pale-red color; as a rule, they are
+painless.
+
+The growth is benign, and consists essentially of a new formation of
+unstriped muscular fibres; but it may also be composed largely of
+connective tissue (_fibromyoma_); or it may contain an abundance of
+bloodvessels (_myoma telangiectodes_, _angiomyoma_); or there may be
+lymphatic involvement (_lymphangiomyoma_).
+
+
+
+                             #Angioma.#
+           (_Synonyms:_ Naevus Vasculosus; Naevus Sanguineus.)
+
+
+#Give a definition of angioma.#
+
+Angioma is a congenital hypertrophy of the vascular tissues of the
+corium and subcutaneous tissue. Exceptionally it makes its appearance a
+few weeks or a month after birth.
+
+
+#Into what two classes may angiomata be roughly grouped?#
+
+The flat (or non-elevated) and the prominent (or elevated).
+
+
+#Describe the flat, or non-elevated, variety of angioma.#
+
+The flat, or non-elevated, angioma (_naevus flammeus_, _naevus simplex_,
+_angioma simplex_, _capillary naevus_) may be pin-head- to bean-sized; or
+it may involve an area of several inches in diameter, and, exceptionally,
+a whole region. It is of a bright- or dark-red color, and is met with
+most frequently about the face. In some instances it extends after birth,
+reaches a certain size and then remains stationary; occasionally, when
+involving a small area, it undergoes involution and disappears.
+
+The so-called _port-wine mark_ is included in this group.
+
+
+#Describe the prominent, or elevated, variety of angioma.#
+
+The prominent variety (_venous n[oe]vus_, _angioma cavernosum_, _n[oe]vus
+tuberosus_) is variously-sized, often considerably elevated,
+clearly-defined, compressible, smooth or lobulated, and of a dark,
+purple color; it may, also, be erectile and pulsating. The growth is
+usually a single formation, and is met with upon all parts of the body.
+
+
+#What is the pathology of angioma?#
+
+It is a new growth, consisting of a variable hypertrophy of the
+cutaneous and subcutaneous arterial and venous bloodvessels, with or
+without an increase of the connective tissue.
+
+
+#Give the treatment of angioma.#
+
+In some instances, especially in infants, painting the parts repeatedly
+with collodion or liquor plumbi subacetatis will act favorably. For
+well-established, small, capillary naevi electrolysis or puncturing with
+a red-hot needle or with a needle charged with nitric acid may be
+employed; for "port-wine mark" frequent and closely contiguous
+electrolytic punctures are occasionally followed by a slight diminution
+in color. For the _prominent growths_, vaccination, the ligature,
+puncturing with the galvano-cautery, and excision are variously resorted
+to.
+
+In recent years applications of liquid air and carbon dioxide have proved
+of service in some cases.
+
+
+
+                           #Telangiectasis.#
+
+
+#Describe telangiectasis.#
+
+Telangiectasis consists of a new growth or enlargement of the cutaneous
+capillaries, usually appearing during middle adult life, and seated, for
+the most part, about the face.
+
+
+#To what extent may telangiectasis develop?#
+
+It may be limited to a red dot or point, with several small radiating
+capillaries (_naevus araneus_, _spider naevus_), or a whole region, usually
+the face, may show numerous scattered or closely-set capillary
+enlargements or new formations (_rosacea_). The latter is frequently
+associated with acne (_acne rosacea_).
+
+The etiology is obscure.
+
+
+#What is the treatment of telangiectasis?#
+
+Destruction of the vessels by electrolysis or by the knife. (See
+treatment of acne rosacea.)
+
+
+
+                            #Lymphangioma.#
+                    (_Synonym:_ Lymphangiectodes.)
+
+
+#Describe lymphangioma.#
+
+Lymphangioma is a rare disease, consisting of localized dilatations of
+the lymphatic vessels, appearing as discrete or aggregated pin-head or
+pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish
+or faint lilac color, and occurring for the most part about the trunk.
+It is of slow but usually progressive development, and is unaccompanied
+by subjective symptoms.
+
+A rare condition, Kaposi described as lymphangioma tuberosum multiplex,
+characterized by more or less solid, somewhat cystic, pearly to pinkish
+red, sometimes crowded lesions, is now known to be "benign cystic
+epithelioma"; its most common site is the face. While called "benign,"
+ulcerative action may eventually ensue.
+
+Treatment, when demanded, consists of operative measures.
+
+
+
+                          #Rhinoscleroma.#
+
+
+#Describe rhinoscleroma.#
+
+Rhinoscleroma is a rare and obscure disease, slow but progressive in its
+course, characterized by the development of an irregular, dense and
+hard, flattened, tubercular, non-ulcerating, cellular new growth, having
+its seat about the nose and contiguous parts. The overlying skin is
+normal in color, or it may be light- or dark-brown or reddish. Marked
+disfigurement and closure, partial or complete, of the nasal orifices
+gradually results. It is met with chiefly in Austria and Germany.
+
+Treatment, consisting of partial or complete extirpation, is rarely
+permanent in its results, the disease tending to recur.
+
+
+
+                          #Lupus Erythematosus.#
+      (_Synonyms:_ Lupus Erythematodes; Lupus Sebaceus; Seborrh[oe]a
+                                 Congestiva.)
+
+
+#What is lupus erythematosus?#
+
+Lupus erythematosus may be roughly defined as a mildly to moderately
+inflammatory superficial new-growth formation, characterized by one,
+several, or more circumscribed, variously sized and shaped, pinkish or
+dark red patches, covered slightly, and more or less irregularly, with
+adherent grayish or yellowish scales.
+
+
+#Upon what parts is lupus erythematosus observed?#
+
+Its common site is the face, usually the nose and cheeks, with a
+tendency toward symmetry; it is often limited to these parts, but may
+occasionally be seen upon other regions, more especially the lips, ears,
+and scalp. In rare instances a great part of the general surface may
+become involved.
+
+
+#Describe the symptoms of lupus erythematosus.#
+
+Usually the disease begins as one or several rounded, circumscribed,
+pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and
+of a pinkish, reddish or violaceous color. They slowly, or somewhat
+rapidly, increase in area, and after attaining variable size remain
+stationary; or they may progress and coalesce, and in this manner sooner
+or later involve considerable surface. The patches are sharply defined
+against the sound skin by an elevated border, while the central portion
+is somewhat depressed and usually atrophic. More or less thickening and
+infiltration are observed. _There is no tendency to ulceration_. The
+scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous
+or plugged with sebaceous and epithelial matter.
+
+The subjective symptoms of burning and itching are usually slight and
+often wanting.
+
+
+#What course does lupus erythematosus pursue?#
+
+As a rule, the disease is persistent, although somewhat variable. At
+times the patches retrogress, involution taking place with or without
+slight sieve-like atrophy or scarring.
+
+
+#State the causes of lupus erythematosus.#
+
+The etiology is obscure. Some observers believe it to be a variety of
+cutaneous tuberculosis. It is essentially a disease of adult and middle
+age; is more common in women, and more frequent in those having a
+tendency to disorders of the sebaceous glands. It may, in fact, begin as
+a seborrh[oe]a.
+
+
+#What is the pathology?#
+
+It was formerly considered a new growth, but recent opinion tends toward
+regarding it as a chronic inflammation of the cutis, superinducing
+degenerative and atrophic changes. Variable [oe]dema of the prickle
+layer and of the cutis is found. There is no tendency to pus formation.
+
+[Illustration: Fig. 42. Lupus Erythematosus.]
+
+
+#Is there any difficulty in the diagnosis of lupus erythematosus?#
+
+As a rule, not, as the features of the disease--the sharply
+circumscribed outline, the reddish or violaceous color, the elevated
+border, the tendency to central depression and atrophy, the plugged up
+or patulous sebaceous ducts, the adherent grayish or yellowish scales,
+together with the region attacked (usually the nose and cheeks)--are
+characteristic.
+
+
+#State the prognosis of lupus erythematosus.#
+
+The disease is often capricious and extremely rebellious to treatment;
+some cases, up to a certain point at least, yield readily, and
+occasionally a tendency to spontaneous disappearance is observed; a
+complete cure is, however, it must be confessed, rather rare. The
+disease in nowise compromises the general health. In those rare
+instances of generalized disease the patient has usually died from an
+intercurrent tuberculosis.
+
+
+#How is lupus erythematosus to be treated?#
+
+The general health is to be looked after and systemic treatment
+prescribed, if indicated. As a rule, constitutional remedies exert
+little, if any, influence, but exceptionally, cod-liver oil, arsenic,
+phosphorus, salicin, quinine, or potassium iodide proves of service.
+
+Locally, according to the case, soothing remedies, stimulating
+applications and destruction of the growth by caustics or operative
+measures are to be employed. (_Try the milder applications first._)
+
+
+#Mention the stimulating applications commonly employed.#
+
+Washing the parts energetically with tincture of sapo viridis, rinsing
+and applying a soothing ointment, such as cold cream or vaseline.
+
+A lotion containing zinc sulphate and potassium sulphuret thoroughly
+dabbed on the parts morning and evening:--
+
+  [Rx] Zinci sulphatis,
+       Potassii sulphurati, .... [=a][=a] ... [dram]i-[dram]iv
+       Glycerinae, ........................... [minim]iv
+       Aquae, ................................ f[Oz]iv.       M.
+
+The calamine-and-zinc oxide lotion used in acute eczema is also often
+extremely valuable.
+
+Lotions of ichthyol and of resorcin, five to sixty grains to the ounce;
+ichthyol in ointment, five- to twenty-per-cent. strength, is also
+useful.
+
+Painting the patches with pure carbolic acid; repeating a day or two
+after the crusts have fallen off.
+
+The continuous application of mercurial plaster.
+
+Sulphur and tar ointments, officinal strength or weakened with lard, and
+also the following:--
+
+  [Rx] Ol. cadini,
+       Alcoholis,
+       Saponis viridis, ..... [=a][=a] ...... [dram]iiss.   M.
+
+(This is to be rubbed in, in small quantity, once or twice daily, and
+later a soothing remedy applied.)
+
+In recent years both the _x_-ray and Finsen light have been used with
+variable success. Repeated applications of the high-frequency current,
+with the vacuum electrode, have also proved serviceable. Cautious
+applications of liquid air or carbon dioxide have also been used with
+some success in the past few years.
+
+
+#When are destructive and operative measures justifiable?#
+
+In obstinate, sluggish, and long-persistent patches, and then only after
+other methods of treatment have failed. (Remember that a patch or
+patches of the disease _may_ disappear in course of time spontaneously,
+and occasionally _without leaving a scar_.)
+
+
+#State the methods of treatment commonly used in obstinate, sluggish and
+persistent patches of lupus erythematosus.#
+
+Cauterization--with nitrate of silver, with applications of pyrogallic
+acid in ointment or in liquor gutta-perchae, fifteen to thirty per cent.
+strength, and with solutions (cautiously employed) of caustic potash,
+and exceptionally with the galvano-cautery.
+
+[Illustration: Fig. 43. Single Scarifier.]
+
+[Illustration: Fig. 44. Multiple Scarifier.
+  (_As modified by Van Harlingen._)]
+
+Operative--scarification, either punctate or linear, and erosion with the
+curette. (See treatment of lupus vulgaris.)
+
+
+
+                            #Lupus Vulgaris.#
+    (_Synonyms:_ Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the
+                                  Skin.)
+
+
+#What do you understand by lupus vulgaris?#
+
+Lupus vulgaris is a cellular new growth, characterized by
+variously-sized, soft, reddish-brown, papular, tubercular and
+infiltrated patches, usually terminating in ulceration and scarring.
+
+
+#Upon what region is lupus vulgaris usually observed?#
+
+The face, especially the nose, but any part may be invaded. The area
+involved may be small or quite extensive, usually the former.
+
+
+#At what age is the disease noted?#
+
+In many cases it begins in childhood or early adult life, but as it is
+persistent and tends to relapse, it may be met with at any age.
+
+
+#Describe the earlier symptoms of lupus vulgaris.#
+
+The disease begins by the development of several or more pin-head to
+small pea-sized, deep-seated, brownish-red or yellowish tubercles,
+having their seat in the deeper part of the corium, and which are
+somewhat softer and looser in texture than normal tissue. As the disease
+progresses, variously-sized and shaped aggregations or patches result,
+covered with thin and imperfectly-formed epidermis.
+
+
+#What changes do the lupus tubercles or infiltrations undergo?#
+
+The lesions, having attained a certain size or development, may remain
+so for a time, but sooner or later retrogressive changes occur: the
+matured papules or tubercles, or infiltrated patches, slowly disappear
+by absorption, fatty degeneration, and exfoliation, leaving a yellowish
+or brownish pigmentation, usually with more or less atrophy or
+cicatricial-tissue formation--_lupus exfoliativus_; or disintegration
+and destruction result, terminating in ulceration--_lupus exedens, lupus
+exulcerans_. This latter is the more usual course.
+
+
+#Describe the clinical appearances and behavior of the lupus ulcerations.#
+
+They are rounded, shallow excavations, with soft and reddish borders. In
+exceptional instances exuberant granulations appear--_lupus
+hypertrophicus_; or papillary outgrowths are noted--_lupus verrucosus_.
+The ulcerations secrete a variable amount of pus, usually slight in
+quantity, which leads to more or less crust formation; later, however,
+cicatricial tissue, generally of a _firm and fibrous_ character,
+results.
+
+[Illustration: Fig. 45. Lupus of Arm.]
+
+
+#In what manner does the disease spread?#
+
+The patches spread by the appearance of new tubercles, or infiltrations
+at the peripheral portion. New islets and areas of disease may continue
+to make their appearance from time to time, usually upon contiguous
+parts.
+
+
+#Are the mucous membranes of the mouth, throat and larynx ever involved?#
+
+In some instances, and either primarily or secondarily.
+
+[Illustration: Lupus Vulgaris.]
+
+[Illustration: Lupus Vulgaris.]
+
+
+#Is the bone tissue ever involved in lupus vulgaris?#
+
+No.
+
+
+#What course does lupus vulgaris pursue?#
+
+It is slowly but, as a rule, steadily progressive. Several years or more
+may elapse before the area of disease is conspicuous.
+
+
+#What is the cause of lupus vulgaris?#
+
+It is now known to be due to the invasion of the cutaneous structures by
+the tubercle bacillus; in short, a tuberculosis of the skin. It is not
+infrequently observed in the strumous and debilitated. It is entirely
+independent of syphilis.
+
+
+#What is the pathology of lupus vulgaris?#
+
+According to recent investigations, the infiltrations of lupus are due
+chiefly to cell-proliferation and outgrowth from the protoplasmic walls
+and adventitia of the bloodvessels and lymphatics. The fibrous-tissue
+network, vessels and a portion of the cell infiltration are thus
+produced, the fixed and wandering connective-tissue cells of the
+inflamed stroma of the cutis being responsible for the other portion of
+the new growth (Robinson).
+
+
+#State the diagnostic features of lupus vulgaris.#
+
+In a typical, developed patch of lupus are to be seen:--cicatricial
+formation, usually of a fibrous and tough character; ulcerations; the
+yellowish-brown tubercles and infiltration; and the characteristic soft,
+small, yellowish or reddish-brown, cutaneous and subcutaneous points and
+tubercles.
+
+
+#How does the tubercular syphiloderm differ from lupus vulgaris?#
+
+The tubercular syphiloderm is much more rapid in its course, the
+ulceration is deeper and the discharge copious and often offensive; the
+scarring is soft, and, compared to the amount of ulceration, but
+slightly disfiguring; and it is, for obvious reasons, a disease of adult
+or late life. The history, together with other evidences of previous or
+concomitant symptoms of syphilis, will often aid in the differentiation.
+
+
+#How does epithelioma differ from lupus vulgaris?#
+
+The edges of the epitheliomatous ulcer are hard, elevated and waxy; the
+base is uneven, the secretion thin, scanty and apt to be streaked with
+blood; the ulceration usually starts from one point, and is often
+painful; the tissue destruction may be considerable; there is little, if
+any, tendency to the formation of cicatricial tissue; and, finally, it
+is usually a disease of advanced age.
+
+
+#In what respects does lupus erythematosus differ from lupus vulgaris?#
+
+Lupus erythematosus has no papules, tubercles or ulceration.
+
+
+#How does acne rosacea differ from lupus vulgaris?#
+
+Acne rosacea is characterized by hyperaemia, dilated vessels, papules,
+pustules, the absence of ulceration, and a different history.
+
+
+#State the prognosis of lupus vulgaris.#
+
+Lupus vulgaris is always a chronic disease, often exceedingly rebellious
+to treatment, and one that calls for a guarded opinion. Relapses are not
+uncommon.
+
+[Illustration: Fig. 46.
+  Galvano-cautery Needle, Knife and Spiral Points. (_As devised by
+  Besnier._)]
+
+The general health usually remains good, but in some instances death by
+tuberculosis of the lungs has been noted.
+
+
+#Is external or internal treatment called for in lupus vulgaris?#
+
+Always external, and not infrequently constitutional also.
+
+
+#What is the constitutional treatment?#
+
+The general health must be cared for; good, nutritious food, fresh air
+and out-door exercise, together with, in many cases, the administration
+of such remedies as cod-liver oil, potassium iodide, iron and quinine,
+are of therapeutic importance. Tuberculin may be tried in severe and
+obstinate cases, but its use is not without danger.
+
+
+#State the object of local treatment.#
+
+The destruction or removal of the diseased tissue.
+
+
+#May milder methods of treatment sometimes prove beneficial and even
+curative?#
+
+Exceptionally, mercurial plaster, corrosive-sublimate lotion and
+ointment (gr. j to [Oz]j), a plaster containing five to fifteen per
+cent. of salicylic acid and creasote, repeated paintings with carbolic
+acid, and the constant application of lead plaster containing twenty per
+cent. of ichthyol, are valuable.
+
+[Illustration: Fig. 47. Double Curette.]
+
+Of the milder methods, those most in vogue to-day are the _Finsen light_
+and _x-ray_. Either proves extremely valuable in some cases, but the
+Finsen method is the favorite method.
+
+
+#What methods are commonly employed for the rapid removal or destruction
+of lupus tissue?#
+
+Cauterization, scarification, erasion and excision are variously
+practised; the particular method depending, in great measure, upon the
+extent of the disease, the part involved, and other circumstances.
+
+
+#Name the several caustics, and state how they are employed.#
+
+_Pyrogallic acid_, used as an ointment:--
+
+  [Rx] Ac. pyrogallici, ..................... [dram]ij
+       Emplast. plumbi, ..................... [dram]j
+       Cerat. resinsae, ...................... [dram]v.      M.
+
+It is applied for one or two weeks. Every several days the parts are
+poulticed, the slough thus removed, and the ointment reapplied, and so
+on until the diseased tissue has been destroyed. It is useful in those
+cases in which a mild and comparatively painless caustic is advisable.
+In most cases several repetitions of this plan are necessary.
+
+_Arsenious acid_, employed as an ointment--
+
+  [Rx]  Ac. arseniosi, ...................... gr. xx
+        Hydrarg. sulphid. rub., ............. gr. lx
+        Ungt. aquae rosae, .................... [Oz]i.--M.
+
+It is painful but thorough; it is spread on lint and renewed daily. The
+action is usually sufficient in three days, and the parts are then
+poulticed until the slough comes away, after which a simple dressing is
+employed. Its application is advisable for a small area only--not more
+than four square inches--as absorption is possible.
+
+_Galvano-cautery._--The diseased tissue is destroyed by numerous
+punctures with a red-heated point or by linear incision with a
+red-heated knife. It is often a practicable and satisfactory method. The
+Paquelin cautery and liquid air and carbon dioxide also have their
+advocates.
+
+
+#Describe the operative measures employed in the removal of lupus tissue.#
+
+_Linear Scarification._--The parts are thoroughly cross-tracked, cutting
+through the diseased tissue, and subsequently a simple salicylated
+ointment applied. The operation is repeated from time to time, and as a
+result the new growth undergoes retrogressive changes, and cicatrization
+takes place.
+
+_Punctate Scarification._--By means of a simple or multiple-pointed
+instrument numerous closely-set punctures are made, and repeated from
+time to time, usually with the same action and result as from linear
+scarification.
+
+_Erasion._--The parts are thoroughly scraped with a curette, and a
+supplementary caustic application made, either with caustic potash or
+several days' use of the pyrogallic-acid ointment. The result is usually
+satisfactory.
+
+The dental-burr is also useful in breaking up discrete tubercles.
+
+_Excision._--This is an effective method if the disease consists of a
+small pea- or bean-sized circumscribed patch.
+
+Of these various operative methods those now most favored are erasion
+and excision, punctate and linear scarification methods are now rarely
+employed.
+
+
+
+                       #Tuberculosis Cutis.#[D]
+                      (_Synonym:_ Scrofuloderma.)
+
+[Footnote D: The most important clinical variety of this class is lupus
+  vulgaris, which is considered above, separately, at some length.]
+
+
+#What do you understand by tuberculosis cutis?#
+
+The term is applied to those peculiar suppurative and ulcerative
+conditions of the skin due to the tubercle bacilli.
+
+
+#How does the common type of tuberculosis cutis begin?#
+
+The most common type of tuberculous ulceration or involvement of the
+skin usually results by extension from an underlying caseating and
+suppurating lymphatic gland; or it may have its origin as subcutaneous
+tubercles independently of these structures. It tends to spread, and may
+involve an area of one or several inches.
+
+[Illustration: Fig. 48. Tuberculosis Verrucosa Cutis (Negro).]
+
+
+#What are the clinical appearances and behavior of this type of
+tuberculous ulceration?#
+
+It is usually superficial, has thin, red, undermined edges of a
+violaceous color, and an irregular base with granulations covered
+scantily with pus. As a rule, it spreads gradually as a simple
+ulceration, with but slight, if any, outlying infiltration. Subjective
+symptoms of a painful or troublesome character are rarely present. Its
+course is usually progressive but slow and chronic.
+
+Other symptoms of tuberculosis are commonly to be found.
+
+
+#Are other forms of tuberculosis cutis met with?#
+
+A papulo-pustular eruption is sometimes observed, especially on the
+upper extremities and face; sluggish and chronic in character and
+leaving small pit-like scars; has been known as the _small pustular
+scrofuloderma_.
+
+[Illustration: Fig. 49.
+  Tuberculosis Verrucosa Cutis (patient had a coexistent pulmonary
+  tuberculosis).]
+
+An ulcerative papillomatous or verrucous tuberculosis of the skin
+(tuberculosis verrucosa cutis) is also occasionally noted, most commonly
+seated upon the lower leg or the back of the hand. It may be slight or
+extensive. Its mildest phase is the so-called verruca necrogenica.
+
+
+#Describe verruca necrogenica.#
+
+Verruca necrogenica is a rare, localized, papillary or wart-like
+formation, occurring usually about the knuckles or other parts of the
+hand.
+
+It begins, as a rule, as a small, papule-like growth, increasing
+gradually in area, and when well advanced appears as a pea, dime-sized
+or larger, somewhat inflammatory, elevated, flat, warty mass, with
+usually a tendency to slight pus-formation between the hypertrophied
+papillae; the surface may be horny or it may be crusted. It tends to
+enlarge slowly and is usually persistent, but it at times undergoes
+involution.
+
+[Illustration: Fig. 50.
+  Tuberculosis Cutis (Verruca Necrogenica). (_After Model in Guy's
+  Museum._)]
+
+
+#State the etiology.#
+
+Heredity, insufficient and unwholesome food, impure air, and the like
+are predisposing. The tubercle bacillus is the immediate exciting cause.
+
+The disease usually appears in childhood or early adult life, and not
+infrequently follows in the wake of some severe systemic disease.
+Etiologically it is identical in nature with lupus.
+
+
+#How is the tuberculous ulcer to be differentiated from syphilis?#
+
+By the peculiar character of the tuberculous ulceration, the absence of
+outlying tubercles and infiltration, together with its history, course,
+and often the presence of other tuberculous symptoms.
+
+
+#State the prognosis.#
+
+These various types of tuberculosis cutis are, as a rule, more amenable
+to treatment than that form known as lupus vulgaris (_q. v._).
+
+
+#What is the treatment of these forms of tuberculosis cutis?#
+
+Constitutional remedies, such as cod-liver oil, iodide of iron or other
+ferruginous tonics, together with good food and pure air; phosphorus
+one-hundredth to one-fiftieth of a grain three times daily is also of
+benefit in some cases.
+
+The local treatment consists in thorough curetting and the subsequent
+application of a mildly stimulating ointment. The several other plans of
+external treatment employed in lupus (_q. v._) are also variously
+practised. In recent years the _x_-ray and Finsen light plans have, in a
+measure, supplanted the previous methods of treatment. They are slow,
+however, and might be, especially the _x_-ray, more satisfactorily
+employed as a supplementary measure.
+
+
+
+                              #Ainhum.#
+
+
+#Describe ainhum.#
+
+Ainhum is a disease of the African race, met with chiefly in Brazil, the
+West Indies, and Africa, and consists of a slow but gradual linear
+strangulation of one or more of the toes, especially the smallest,
+resulting, eventually, in spontaneous amputation. The affected toes
+themselves undergo fatty degeneration, often with increase in size, and
+are, when strangulation is well advanced, considerably misshapen. The
+nature of the disease is obscure.
+
+_Treatment_ consists, in the early stages, of incision through the
+constricting band; when the disease is well advanced, amputation is the
+sole recourse.
+
+
+
+                             #Mycetoma.#
+       (_Synonyms:_ Fungous Foot of India; Madura Foot; Podelcoma.)
+
+
+#Decribe mycetoma.#
+
+It is a disease involving usually the foot, and is met with chiefly in
+India. It is characterized by swelling and the formation of tubercular
+or nodular lesions which break down and form the external openings of
+sinuses which lead to the interior of the affected part. These
+discharge, and are studded with, whitish granules or black, roe-like
+masses, mixed with a sanious or sero-purulent fluid. The whole part is
+gradually disintegrated, the process lasting indefinitely. Its nature is
+obscure; it is thought to be due to a fungus.
+
+_Treatment_ consists in the early stages, when the disease is limited,
+of thorough curetting and cauterization; later, after the part is more
+or less involved, amputation, at a point well up beyond the disease,
+becomes necessary. Potassium iodide internally may exert a favorable
+influence.
+
+
+
+                    #Perforating Ulcer of the Foot.#
+
+
+#Describe perforating ulcer of the foot.#
+
+Perforating ulcer of the foot is a rare disease, consisting of an
+indolent and usually painless sinus leading down to diseased bone. The
+external opening, which is through the centre of a corn-like formation,
+is small, and may or may not show the presence of granulations. The
+affected part is commonly more or less anaesthetic and of subnormal
+temperature. One or several may be present, either on one or both feet.
+The most common site is over the articulation of the metatarsal bone
+with the phalanx of the first or last toe. The disease is dependent upon
+impairment or degeneration of the central, truncal or peripheral nerves.
+
+
+#What is to be said in regard to the prognosis and treatment?#
+
+Treatment, which is, as a rule, unsatisfactory, consists in the
+maintenance of absolute rest, and the use of antiseptic and stimulating
+applications. Amputation is also resorted to, but even this is at times
+futile, as a new sinus may appear upon the stump.
+
+
+
+                        #Syphilis Cutanea.#
+    (_Synonyms:_ Syphiloderma; Dermatosyphilis; Syphilis of the Skin.)
+
+
+#In what various types may syphilis manifest itself upon the integument?#
+
+Syphilis may show itself as a macular, papular (rarely vesicular),
+pustular, bullous, tubercular and gummatous eruption; or the eruption
+may be, in a measure, of a mixed type.
+
+
+#In what respects do the early (or secondary) eruptions of syphilis
+differ from those following several years or more after the contraction
+of the disease?#
+
+The early or secondary eruptions are more or less generalized, with
+rarely any attempt at special configuration. Their appearance is often
+preceded by symptoms of systemic disturbance, such as fever, loss of
+appetite, muscular pains and headache; and accompanied by concomitant
+signs of the disease, such as enlargement of the lymphatic glands, sore
+throat, mucous patches, falling of the hair and rheumatic pains.
+
+
+#State the distinguishing characters of the late eruptions.#
+
+The late eruptions (those following one or more years after the
+contraction of the disease) are usually of tubercular, gummatous or
+ulcerative type; are limited in extent, and have a marked tendency to
+appear in circular, semicircular or crescentic forms or groups. Pain in
+the bones, bone lesions and other symptoms may or may not be present.
+
+
+#What is the color of syphilitic lesions?#
+
+Usually, a dull brownish-red or ham-red, with at times a yellowish cast.
+
+
+#Are there any subjective symptoms in syphilitic eruptions?#
+
+As a rule, no; but in exceptional instances of the generalized
+eruptions, more especially in negroes, there may be slight itching.
+
+
+#Describe the macular, or erythematous, eruption of syphilis.#
+
+The _macular syphiloderm_ is a general eruption, showing itself usually
+six or eight weeks after the appearance of the chancre. It consists of
+small or large, commonly pea- or bean-sized, rounded or
+irregularly-shaped, not infrequently slightly raised, macules. When well
+established they do not entirely disappear under pressure. At first a
+pale-pink or dull, violaceous red, they later become yellowish or
+coppery. The eruption is generally profuse; the face, backs of the hands
+and feet may escape. It persists several weeks or one or two months; as
+a rule, it is rapidly responsive to treatment.
+
+
+#How would you distinguish the macular syphiloderm from measles, roetheln
+and tinea versicolor?#
+
+Measles is to be differentiated by its catarrhal symptoms, fever, form
+and situation of the eruption; roetheln, by its small, roundish,
+confluent pinkish or reddish patches, its precursory pyrexic symptoms,
+its epidemic nature, and short duration; tinea versicolor by its
+scaliness, peripheral growth, distribution and history.
+
+And, finally, by the absence or presence of other symptoms of syphilis.
+
+[Illustration: Fig. 51. Macular Syphiloderm.]
+
+
+#What several varieties of the papular eruption of syphilis are met with?#
+
+There are two forms of the papular eruption--the small and large; those
+of the latter type may undergo various modifications.
+
+
+#Describe the small-papular eruption of syphilis.#
+
+The _small-papular syphiloderm_ (_miliary papular syphiloderm_) usually
+shows itself in the third or fourth month of the disease, and consists
+of a more or less generalized eruption of disseminated or grouped, firm,
+rounded or acuminated pin-head to millet-seed-sized papules, with smooth
+or slightly scaly summits, and in some lesions showing pointed
+pustulation. Scattered minute pustules and some large papules are
+usually present. The eruption is profuse, most abundant upon the trunk
+and limbs; and in the early part of the outbreak is of a bright- or
+dull-red color, later assuming a violaceous or brownish tint. It runs a
+chronic course, is somewhat rebellious to treatment, and displays a
+tendency to relapse.
+
+[Illustration: Fig. 52. Moist Papules. (_After Miller._)]
+
+
+#How would you distinguish the small-papular syphiloderm from keratosis
+pilaris, psoriasis punctata, papular eczema, and lichen ruber?#
+
+The distribution and extent of the eruption, the color, the grouping,
+with usually the presence of pustules and large papules and other
+concomitant symptoms of syphilis, are points of difference. Pustules
+never occur in the several diseases named, except in eczema.
+
+
+#Describe the large-papular eruption of syphilis.#
+
+The _large-papular syphiloderm_ (or _lenticular syphiloderm_) is a
+common form of cutaneous syphilis, appearing usually in the first six or
+eight months, and consists of a more or less generalized eruption of
+pea- to dime-sized or larger, flat, rounded or oval, firmly seated,
+more or less raised, dull-red papules; with at first a smooth surface,
+which later usually becomes covered with a film of exfoliating
+epidermis. The papules, as a rule, develop slowly, remain stationary
+several weeks or a few months, and then pass away by absorption, leaving
+slight pigmentation, which gradually fades; or they may undergo certain
+modifications. In most cases it responds rapidly to treatment.
+
+[Illustration: Small-papular Syphiloderm.]
+
+[Illustration: Fig. 53. Palmar Syphiloderm.]
+
+
+#What modifications do the papules of the large-papular syphiloderm
+sometimes undergo?#
+
+They may change into the moist papule and squamous papule.
+
+
+#Describe the moist papule of syphilis.#
+
+The change into the moist papule (also called _mucous patch, flat
+condyloma_) is not uncommon where opposing surfaces and natural folds of
+skin are subjected to more or less contact, as about the anus, the
+scroto-femoral regions, umbilicus, axillae and beneath the mammae. The
+dry, flat papules gradually become moist and covered with a grayish,
+sticky, mucoid secretion; several may coalesce and form large, flat
+patches. They may so remain, or they may become hypertrophic, warty or
+papillomatous, with more or less crust formation (_vegetating
+syphiloderm_).
+
+[Illustration: Fig. 54. Annular Syphiloderm. (_After I.E. Atkinson._)]
+
+
+#Describe the squamous papule of syphilis.#
+
+This tendency of the large-papular eruption to become scaly, when
+exhibited, is more or less common to all papules, and constitutes the
+_squamous_ or _papulo-squamous syphiloderm_ (improperly called
+_psoriasis syphilitica_). The papules become somewhat flattened and are
+covered with dry, grayish or dirty-gray, somewhat adherent scales. The
+scaling, as compared to that of psoriasis, is, as a rule, relatively
+slight. The eruption may be general, as usually the case in the earlier
+months of the disease, or it may appear as a relapse or a later
+manifestation, and be limited in extent.
+
+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.
+
+[Illustration: Maculo-papular syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 55. Rupia. (_After Tilbury Fox._)]
+
+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.
+
+[Illustration: Fig. 56. Ulcerating Tubercular Syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 57. Tubercular Syphiloderm.]
+
+
+#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_).
+
+[Illustration: Fig. 58. 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.
+
+[Illustration: Tubercular Syphiloderm.]
+
+[Illustration: Large-pustular Syphiloderm.]
+
+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.
+
+[Illustration: Fig. 59. Tubercular Syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 60. Tubercular Syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 61. Large Pustular Syphiloderm.]
+
+
+#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.
+
+[Illustration: Fig. 62. Tubercular Leprosy. (_After Stoddard._)]
+
+
+#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.
+
+[Illustration: Fig. 63. Anaesthetic Leprosy.]
+
+
+#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.
+
+[Illustration: Fig. 64. Epithelioma. (_After D. Lewis._)]
+
+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.
+
+[Illustration: Fig. 65. Granuloma Fungoides.]
+
+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.
+
+[Illustration: Fig. 66.
+  Achorion Schoenleinii X 450. (_After Duhring._) Showing simple mycelium,
+  in various stages of development, and free spores.]
+
+
+#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.
+
+[Illustration: Fig. 67. Epilating Forceps.]
+
+
+#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, ....... [=a][=a] ......... [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.
+
+[Illustration: Fig. 68.
+  Tinea trichophytina cruris--so-called eczema marginatum--of unusually
+  extensive development. (_After Piffard._)]
+
+
+#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.
+
+[Illustration: Fig. 69.
+  Ringworm (rather inflammatory type, and produced by the trichophyton).]
+
+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.)
+
+[Illustration: Fig. 70.
+  Ringworm Fungus (Trichophyton) x 450. (_After Duhring._) As found in
+  epidermic scrapings of ringworm, showing mycelium and spores.]
+
+
+#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.
+
+[Illustration: Fig. 71.
+  Ringworm Fungus (Microsporon) x 500. (_After Duhring._) Short,
+  broken-off hair of scalp invaded with masses of free spores.]
+
+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.
+
+[Illustration: Fig. 72.
+  Ringworm Fungus (Trichophyton) x 300. (_After Duhring._) Short, stout
+  hair of beard, with the root-sheath attached, showing free spores and
+  chains of spores.]
+
+
+#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.
+
+[Illustration: Fig. 73.
+  Microsporon Furfur x 400. (_After Duhring._) Showing mycelium in various
+  stages of development, groups of spores and free spores.]
+
+
+#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.
+
+[Illustration: Fig. 74. Tinea versicolor.]
+
+
+#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.
+
+[Illustration: Fig. 75.
+  Microsporon Minutissimum x 1000. (_After Riehl._)]
+
+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.
+
+[Illustration: Blastomycetic dermatitis.]
+
+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.
+
+[Illustration: Fig. 76.
+  Burrow, or cuniculus, greatly magnified. (_After Kaposi._) Showing the
+  mite, ova, empty shells and excrement.]
+
+
+#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.
+
+[Illustration: Fig. 77. Fig. 78.
+  Sarcoptes scabiei x 100.
+  (_After Duhring._) Female. Ventral surface. Male.]
+
+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, ......... [=a][=a] ........ [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, ... [=a][=a] ... 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.
+
+[Illustration: Fig. 79.
+  Pediculus Capitis x 25. (_After Duhring._) Female. Dorsal surface.]
+
+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.
+
+[Illustration: Fig. 80.
+  Ova of the head-louse attached to a hair. Magnified. (_After Kaposi._)]
+
+
+#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.
+
+
+#What is the treatment of pediculosis capitis?#
+
+Treatment consists in the application of some remedy destructive to the
+pediculi and their ova. Crude petroleum is effective, one or two
+thorough applications over night being usually sufficient; in order to
+lessen its inflammability, and also to mask its somewhat disagreeable
+odor, it may be mixed with an equal part of olive oil and a small
+quantity of balsam of Peru added.
+
+Tincture of cocculus indicus, pure or diluted, may also be applied with
+good results.
+
+When the parts are markedly eczematous, an ointment of ammoniated
+mercury or [beta]-naphthol, thirty to sixty grains to the ounce may
+be used.
+
+Daily shampooing with soap and water, and the twice daily application of
+a five per cent. carbolic acid lotion, together with the use of a
+fine-toothed comb, is a safe and efficient method for dispensary
+practice; as it is, indeed, for any class of patients.
+
+
+#How are the ova or their shells to be removed from the hair?#
+
+By the frequent use of acid or alkaline lotions, such as dilute acetic
+acid and vinegar, or solutions of sodium carbonate and borax.
+
+
+
+                         #Pediculosis Corporis.#
+
+
+#Describe the symptoms of pediculosis corporis.#
+
+Pediculosis corporis is dependent upon the presence of the pediculus
+corporis (_pediculus vestimenti_), a larger variety than that infesting
+the scalp. It is characterized by more or less general itching, together
+with various inflammatory lesions and excoriations. As the parasites are
+to be found chiefly in the folds and seams of the clothing, visiting the
+skin for the purpose of feeding, the various symptoms--the minute
+hemorrhagic puncta showing the points at which they have been sucking,
+and the consequent papules, pustules and excoriations--are, therefore,
+to be found most abundantly on those parts with which the clothing comes
+closely in contact, as, for instance, around the neck, across the
+shoulders, around the waist, and down the outside of the thighs. It is
+uncommon in children.
+
+[Illustration: Fig. 81.
+  Pediculus Corporis x 25. (_After Duhring._) Female. Dorsal surface.]
+
+
+#State the diagnostic characters of pediculosis corporis.#
+
+The presence of the minute hemorrhagic puncta, the multiform character
+and peculiar distribution of the eruption. Careful search will almost
+invariably disclose one or more pediculi.
+
+
+#What is the treatment of pediculosis corporis?#
+
+The clothing and bed-coverings are to be thoroughly baked or boiled, the
+pediculi and their ova being in this manner destroyed; a thymol or
+carbolized boric-acid lotion may be used to relieve the cutaneous
+irritation.
+
+When attention to the wearing apparel is not immediately practicable,
+ointments of sulphur and staphisagria, and lotions of carbolic acid, may
+be advised as temporary measures. The wearing of a bag of loosely woven
+texture containing some lump sulphur next to the skin is useful in such
+cases; at the temperature of the body the sulphur undergoes slow
+oxidation. In hairy individuals the malady is often persistent, due to
+the fact that ova have become attached to the hair and a new progeny
+soon hatched out. Continued treatment over a few weeks will usually
+suffice to rid the patient of their presence.
+
+
+
+                         #Pediculosis Pubis.#
+
+
+#Describe the symptoms of pediculosis pubis.#
+
+Pediculosis pubis is a condition due to the presence of the pediculus
+pubis, or crab-louse. It is characterized by more or less itching about
+the genitalia, together with papules, excoriations, and other
+inflammatory lesions. The amount of irritation varies; it may be slight,
+or, on the other hand, severe. The parasite, which is the smallest of
+the three varieties, may be discovered upon close examination seated
+near the roots of the hairs, clutching the hair, with its head downward
+and buried in the follicle. The ova may be seen attached to the
+hair-shafts.
+
+It infests adults chiefly, being in many instances probably contracted
+through sexual intercourse.
+
+
+#Is the pediculus pubis found upon any other part of the body?#
+
+Yes. Although its favorite habitat is the region of the pubes, it may,
+in exceptional instances, also infest the axillae, the sternal region of
+the male, the beard, eyebrows, and even the eyelashes.
+
+
+#State the diagnostic characters of pediculosis pubis.#
+
+The region involved, itching, variable amount of irritation, and, above
+all, the presence of the pediculi and their ova.
+
+[Illustration: Fig. 82.
+  Pediculus Pubis x 25. (_After Duhring._) Female. Dorsal surface.]
+
+
+#Name several applications prescribed for pediculosis pubis.#
+
+A lotion of corrosive sublimate, one to four grains to the ounce;
+infusion of tobacco; a ten to twenty per cent. ointment of oleate of
+mercury; ammoniated mercury ointment, and a five to ten per cent.
+[beta]-naphthol ointment. Repeated washings with vinegar or dilute
+acetic acid, or with alkaline lotions, will free the hairs of the ova.
+
+
+
+                        #Cysticercus Cellulosae.#
+
+
+#Describe the cutaneous disturbance produced by the cysticercus
+cellulosae.#
+
+The presence of cysticerci in the skin and subcutaneous tissue gives
+rise to pea to hazelnut-sized, rounded, firm, movable tumors which, when
+developed, may remain unchanged for months. The parasites are disclosed
+by microscopic examination.
+
+Most of the cases have been observed in Germany.
+
+
+
+                           #Filaria Medinensis.#
+                         (_Synonym:_ Guinea-worm.)
+
+
+#State the character of the lesions produced by the filaria medinensis.#
+
+The young microscopic worm penetrates the skin or deeper tissue, where
+it grows gradually, finally reaching several inches or more in length
+and about a half-line in thickness; inflammation is excited and a
+tumor-like swelling makes its appearance, which, sooner or later,
+breaks, disclosing the worm. It may also present a cord-like appearance.
+It is rarely met with outside of tropical countries.
+
+Treatment consists in gradual extraction, or in the injection of a
+corrosive sublimate solution (1:1000) into the forming tumor. Asafetida
+internally has been found to be curative, the parasite being destroyed
+and subsequently absorbed or discharged.
+
+
+
+                                 #Ixodes.#
+                          (_Synonym:_ Wood-tick.)
+
+
+#State the character of the cutaneous disturbance produced by the ixodes.#
+
+The tick sticks its proboscis into the skin and sucks blood until it is
+several times its natural size, and then falls off; an urticarial lesion
+results. If caught in the act the animal should not be forcibly
+extracted, as its proboscis may be thus broken off and remain in the
+skin, and give rise to pain and inflammation. It may be made to
+relinquish its hold by placing on it a drop of an essential oil.
+
+A thymol or carbolized boric-acid lotion will relieve the irritation.
+
+
+
+                                 #Leptus.#
+                        (_Synonym:_ Harvest-mite.)
+
+
+#State the characters of the lesion produced by the leptus.#
+
+This minute brick-red mite buries itself in the skin, especially about
+the ankles and feet, giving rise to papules, vesicles and pustules.
+
+Treatment consists of the use of a mild sulphur ointment or of a
+carbolic-acid lotion.
+
+
+
+                               #[OE]strus.#
+                       (_Synonym:_ Gad, or Bot-fly.)
+
+
+#Describe the cutaneous disturbance produced by the [oe]strus.#
+
+The ova are deposited in the skin, develop and give rise to the
+formation of furuncle-like tumors with central aperture, through which a
+sanious discharge exudes; or as the result of the burrowing of the
+larvae, irregular serpiginous lines or wheals are produced.
+
+It is chiefly met with in Central and South America.
+
+_Larva migrant_, or _creeping disease_, is doubtless in this same class.
+It is characterized by a thread-like linear formation of an
+erythematous, erythemato-papular, or vesicular nature that gradually
+extends, the older part disappearing; considerable surface may be
+covered before the parasite disappears or dies. The treatment consists
+in endeavoring to destroy the organism by means of excision or caustic
+applications at the point of its suspected site which is just ahead of
+the extending line.
+
+
+
+                             #Pulex Penetrans.#
+                     (_Synonyms:_ Sand Flea; Jigger.)
+
+
+#Describe the cutaneous disturbance produced by the pulex penetrans.#
+
+This microscopic animal penetrates the skin, especially about the toes,
+producing an inflammatory swelling, vesicle or pustule, or even
+ulceration. It is met with in warm and tropical countries.
+
+Treatment consists in extraction. Essential oils are used as a
+preventive. A carbolic-acid or alkaline lotion relieves irritation.
+
+
+
+                            #Cimex Lectularius.#
+                           (_Synonym:_ Bed-bug.)
+
+
+#Describe the characters of a bed-bug bite.#
+
+An inflammatory papule or wheal-like lesion results, somewhat
+hemorrhagic; the purpuric or hemorrhagic point or spot remains after the
+swelling subsides, but finally, in the course of several days or a few
+weeks, disappears.
+
+Treatment consists in the application of alkaline or acid lotions.
+
+
+
+                                #Culex.#
+                      (_Synonym:_ Gnat; Mosquito.)
+
+
+#Describe the cutaneous disturbance produced by the culex.#
+
+It consists of an erythematous spot or a wheal-like lesion.
+
+Alkaline or acid lotions usually give relief.
+
+
+
+                            #Pulex Irritans.#
+                        (_Synonym:_ Common Flea.)
+
+
+#Describe the cutaneous disturbance produced by the pulex irritans.#
+
+It consists of an erythematous spot with a minute central hemorrhagic
+point. In irritable skin, a wheal-like lesion may result.
+
+Treatment consists of applications of camphor or ammonia-water; carbolic
+acid and thymol lotions are also useful.
+
+
+
+
+RELATIVE FREQUENCY OF THE VARIOUS DISEASES OF SKIN AS SHOWN BY THE
+STATISTICS (123,746 CASES) OF THE AMERICAN DERMATOLOGICAL ASSOCIATION
+FOR TEN YEARS, 1878-87.
+
+
+-------------------------+-------+-------+
+    CLASSIFICATION OF    |  No.  |   %   |
+         DISEASES.       | Cases | Cases |
+-------------------------+-------+-------+
+Class I. Disorders of the|       |       |
+  Glands.                |       |       |
+  1. OF THE SWEAT GLANDS.|       |       |
+    Hyperidrosis         |   328 |  .265 |
+    Sudamen              |   268 |  .216 |
+    Anidrosis            |    11 |  .009 |
+    Bromidrosis          |   112 |  .090 |
+    Chromidrosis         |     7 |  .005 |
+    Uridrosis            |   ... |  .... |
+  2. OF THE SEBACEOUS    |       |       |
+    GLANDS               |   238 |  .193 |
+    Seborrh[oe]a:        |  1812 | 1.47  |
+      a. oleosa          |   367 |  .296 |
+      b. sicca           |   395 |  .319 |
+    Comedo               |  1225 |  .989 |
+    Cyst:                |     6 |  .004 |
+      a. Milium          |   225 |  .183 |
+      b. Steatoma        |   151 |  .122 |
+    Asteatosis           |     8 |  .006 |
+                         |       |       |
+Class II. Inflammations. |       |       |
+    Exanthemata          |  1770 | 1.43  |
+    Erythema simplex     |  1064 |  .859 |
+    Erythema multiforme: |   915 |  .730 |
+      a. papulosum       |   325 |  .262 |
+      b. bullosum        |    37 |  .029 |
+      c. nodosum         |    82 |  .066 |
+    Urticaria            |  2994 | 2.47  |
+      pigmentosa         |     1 |  .0008|
+    [E]Dermatitis:       |  1720 | 1.39  |
+      a. traumatica      |   468 |  .378 |
+      b. venenata        |   616 |  .498 |
+      c. calorica        |   224 |  .187 |
+      d. medicamentosa   |   108 |  .087 |
+      e. gangraenosa      |     8 |  .006 |
+    Erysipelas           |  1026 |  .829 |
+    Furunculus           |  2129 | 1.72  |
+    Anthrax              |   252 |  .203 |
+    Phlegmona diffusa    |   265 |  .215 |
+    Pustula maligna      |   197 |  .159 |
+    Herpes simplex       |  2057 | 1.66  |
+    Herpes zoster        |  1428 | 1.15  |
+    Dermatitis           |       |       |
+      herpetiformis      |    41 |  .033 |
+    Psoriasis            |  4131 | 3.34  |
+    Pityriasis maculuta  |       |       |
+      et circinata       |    71 |  .057 |
+    Dermatitis           |       |       |
+      exfoliativa        |    16 |  .012 |
+    Pityriasis rubra     |    44 |  .032 |
+    Lichen:              |   144 |  .116 |
+      a. planus          |   154 |  .124 |
+      b. ruber           |    27 |  .021 |
+    Eczema:              | 37661 |30.43  |
+      a. erythematosum   |  .... |  .... |
+      b. papulosum       |  .... |  .... |
+      c. vesiculosum     |  .... |  .... |
+      d. madidans        |  .... |  .... |
+      e. pustulosum      |  .... |  .... |
+      f. rubrum          |  .... |  .... |
+      g. squamosum       |  .... |  .... |
+    Prurigo              |    34 |  .027 |
+    Acne                 |  9077 | 7.34  |
+    Acne rosacea         |   398 |  .321 |
+    Sycosis              |   227 |  .185 |
+    Impetigo             |  1769 | 1.43  |
+    Impetigo contagiosa  |   600 |  .485 |
+    Impetigo             |       |       |
+      herpetiformis      |    10 |  .009 |
+    Ecthyma              |   726 |  .587 |
+    Pemphigus            |   183 |  .148 |
+    Ulcers               |  3021 | 2.44  |
+                         |       |       |
+Class III. Hemorrhages.  |       |       |
+    Purpura:             |   341 |  .275 |
+      a. simplex         |   181 |  .145 |
+      b. haemorrhagica    |    49 |  .039 |
+                         |       |       |
+Class IV. Hypertrophies. |       |       |
+  1. OF PIGMENT.         |       |       |
+    Lentigo              |   127 |  .103 |
+    Chloasma             |   560 |  .452 |
+  2. OF EPIDERMAL AND    |       |       |
+    PAPILLARY LAYERS.    |       |       |
+    Keratosis:           |    94 |  .076 |
+      a. pilaris         |   103 |  .083 |
+      b. senilis         |    68 |  .055 |
+    Molluscum epitheliale|   172 |  .139 |
+    Callositas           |   110 |  .090 |
+    Clavus               |    84 |  .068 |
+    Cornu cutaneum       |    42 |  .034 |
+    Verruca              |  1252 | 1.09  |
+    Verruca necrogenica  |     2 |  .001 |
+    Naevus pigmentosus    |    88 |  .064 |
+    Xerosis              |   100 |  .080 |
+    Ichthyosis           |   309 |  .249 |
+    Onychauxis           |    70 |  .056 |
+    Hypertrichosis       |   515 |  .416 |
+  3. OF CONNECTIVE       |       |       |
+    TISSUE.              |       |       |
+    Sclerema neonatorum  |  .... |  .... |
+    Scleroderma          |    38 | 0.030 |
+    Morph[oe]a           |    39 | 0.031 |
+    Elephantiasis        |    57 | 0.046 |
+    Rosacea:             |   785 | 0.634 |
+      a. erythematosa    |   381 | 0.308 |
+      b. hypertrophica   |    58 | 0.047 |
+    Framb[oe]sia         |    22 | 0.018 |
+                         |       |       |
+Class V. Atrophies.      |       |       |
+  1. OF PIGMENT.         |       |       |
+    Leucoderma           |    77 | 0.062 |
+    Albinismus           |     9 | 0.008 |
+    Vitiligo             |   191 | 0.155 |
+    Canities             |    43 | 0.035 |
+  2. OF HAIR.            |       |       |
+    Alopecia             |   926 | 0.749 |
+    Alopecia furfuracea  |   830 | 0.670 |
+    Alopecia areata      |   794 | 0.641 |
+    Atrophia pilorum     |       |       |
+      propria            |    23 | 0.019 |
+    Trichorexis nodosa   |     3 | 0.002 |
+  3. OF NAIL             |    26 | 0.021 |
+    Atrophia unguis      |    19 | 0.015 |
+  4. OF CUTIS            |     6 | 0.005 |
+    Atrophia senilis     |    15 | 0.013 |
+    Atrophia maculosa et |       |       |
+      striata            |    23 | 0.019 |
+                         |       |       |
+Class VI. New Growths.   |       |       |
+  1. OF CONNECTIVE       |       |       |
+    TISSUE.              |     1 | 0.0008|
+    Keloid               |   152 | 0.124 |
+    Cicatrix             |    89 | 0.065 |
+    Fibroma              |    93 | 0.075 |
+    Neuroma              |    11 | 0.009 |
+    Xanthoma             |    69 | 0.056 |
+  2. OF MUSCULAR TISSUE. |       |       |
+    Myoma                |     1 | 0.0008|
+  3. OF VESSELS.         |       |       |
+    Angioma              |   462 | 0.373 |
+    Angioma pigmentosum  |       |       |
+      et atrophicum      |    13 | 0.010 |
+    Angioma cavernosum   |    22 | 0.018 |
+    Lymphangioma         |    16 |  .012 |
+  4. Mycosis fongoide    |     1 |  .0008|
+    Rhinoscleroma        |     3 |  .002 |
+    Lupus erythematosus  |   477 |  .385 |
+    Lupus vulgaris       |   536 |  .433 |
+    Scrofuloderma        |   663 |  .536 |
+    Syphiloderma:        | 13888 |11.22  |
+      a. erythematosum   |  .... |  .... |
+      b. papulosum       |  .... |  .... |
+      c. pustulosum      |  .... |  .... |
+      d. tuberculosum    |  .... |  .... |
+      e. gummatosum      |  .... |  .... |
+    Lepra:               |    24 |  .020 |
+      a. tuberosa        |     7 |  .005 |
+      b. maculosa        |     4 |  .003 |
+      c. anaesthetica     |     6 |  .004 |
+    Carcinoma            |  1068 |  .863 |
+    Sarcoma              |    55 |  .044 |
+                         |       |       |
+Class VII. Neuroses.     |       |       |
+    Hyperaesthesia:       |     4 |  .003 |
+      a. Pruritus        |  2716 | 2.12  |
+      b. Dermatalgia     |    11 |  .009 |
+    Anaesthesia           |    22 |  .018 |
+                         |       |       |
+Class VIII. Parasitic    |       |       |
+    Affections.          |       |       |
+  1. VEGETABLE.          |       |       |
+    Tinea favosa         |   354 |  .286 |
+    Tinea trichophytina: |  2289 | 1.85  |
+      a. circinata       |   705 |  .569 |
+      b. tonsurans       |   675 |  .545 |
+      c. sycosis         |   365 |  .295 |
+    Tinea versicolor     |  1263 | 1.02  |
+  2. ANIMAL.             |       |       |
+    Scabies              |  3192 | 2.58  |
+    Pediculosis          |       |       |
+      capillitii         |  2579 | 2.09  |
+    Pediculosis corporis |  1704 | 1.38  |
+    Pediculosis pubis    |   436 |  .352 |
+-------------------------+-------+-------+
+    Total                 123746
+
+[Footnote E: Indicating affections of this class not properly included
+  under other titles.]
+
+
+
+                            #INDEX.#
+
+Acarus folliculorum, 40
+  scabiei, 269
+
+Achorion Schoenleinii, 249
+
+Acne, 115-126
+  artificialis, 120
+  atrophica, 120
+  cachecticorum, 120
+  frontalis, 129
+  hypertrophica, 120
+  indurata, 120
+  keloid, 135
+  lupoid, 129
+  necrotica, 129
+  papulosa, 120
+  punctata, 120
+  pustulosa, 120
+  rodens, 129
+  rosacea, 126-129, 198
+  sebacea, 33
+  tar, 120
+  urticata, 130
+  varioliformis, 129
+  vulgaris, 119
+
+Acnitis, 130
+
+Actinomycosis, 266
+
+Addison's disease, pigmentation of the skin in, 149
+  keloid, 172
+
+Ainhum, 212
+
+Albinismus, 177
+
+Albinos, 177
+
+Alopecia, 181-183
+  areata, 183-186
+  circumscripta, 183
+  congenital, 181
+  furfuracea, 181
+  premature, 181
+  senile, 181
+
+Anaesthesia, 244
+
+Anatomy of the skin, 17-21, 28
+
+Angioma, 196, 197
+  cavernosum, 197
+  pigmentosum et atrophicum, 190
+  simplex, 196
+
+Angiomyoma, 196
+
+Angioneurotic [oe]dema, 54
+
+Anidrosis, 31
+
+Anthrax, 70, 72
+
+Antipruritic applications, 246
+
+Antipyrin, eruptions from, 61
+
+Area Celsi, 183
+
+Argyria, 150
+
+Arsenic, eruptions from, 61
+
+Artificial eruptions (feigned eruptions), 64
+
+Atrophia cutis, 189, 190
+  pilorum propria, 187
+  unguis, 188, 189
+
+Atrophic lines and spots, 190
+
+Atrophies, 177-190
+
+Atrophoderma, 189
+  neuriticum, 189
+
+Atrophy of the hair, 187
+  of the nails, 188
+  of the skin, 189
+    general idiopathic, 189
+  senile, 190
+
+Atropia, eruptions from, 61
+
+Autographism, 52
+
+
+Baldness, 181
+
+Barbadoes leg, 174
+
+Barbers' itch, 255
+
+Bath-pruritis, 245
+
+Bed-bug, 278
+
+Bed-sores, 58
+
+Belladonna, eruptions from, 61
+
+Blackheads, 38-41
+
+Blanching of the hair, 180
+
+Blastomycetic dermatitis, 266
+
+Blebs, 23
+
+Blood-vessels, 19
+
+Boil, 68
+
+Bot-fly, 278
+
+Bromides, eruptions from, 61
+
+Bromidrosis, 32
+
+Bullae, 23
+
+Burns, 58
+
+Burrows, 268
+
+
+Calculi, cutaneous, 42
+
+Callositas, 155, 156
+
+Callosity, 155
+
+Callous, 155
+
+Callus, 155
+
+Cancer, epithelial, 236
+  skin, 236
+
+Canities, 180
+  prematura, 180
+  senilis, 180
+
+Carbuncle, 70
+
+Carbunculus, 70-72
+
+Carcinoma epitheliale, 236
+
+Carrion's disease, 73
+
+Chafing, 45
+
+Chapping, 106
+
+Charbon, 72
+
+Cheiro-pompholyx, 76
+
+Cheloid, 191
+
+Chloasma, 149-151
+  uterinum, 149
+
+Chloral, eruptions from, 62
+
+Chromidrosis, 32
+  red, 33
+
+Chromophytosis, 262
+
+Chrysarobin, 93
+
+Chrysophanic acid (chrysarobin), 93
+
+Cicatrices, 24
+
+Cimex lectularius, 278
+
+Clavus, 156, 157
+
+Comedo, 38-41
+  extractor, 40
+
+Condyloma, flat (or broad), 217
+  pointed, 161
+
+Configuration, 24
+
+Conglomerate pustular folliculitis, 252
+
+Contagious impetigo, 136
+
+Contagiousness, 27
+
+Copaiba, eruptions from, 62
+
+Corn, 156
+
+Cornu cutaneum, 158, 159
+  humanum, 159
+
+Crab-louse, 275
+
+Creeping disease, 278
+
+Crusta lactea, 104
+
+Crustae, 24
+
+Crusts, 24
+
+Cubebs, eruptions from, 62
+
+Culex, 279
+
+Cuniculus, 268
+
+Curette, 208
+
+Cutaneous calculi, 42
+  horn, 158
+
+Cutis anserina, 152
+  pendula, 176
+
+Cyst, sebaceous, 43
+
+Cysticercus cellulosae, 276
+
+
+Dandruff, 33, 34
+
+Darier's disease, 153
+
+Defluvium capillorum, 181
+
+Demodex folliculorum, 40
+
+Depilatories, 169
+
+Dermalgia, 244
+
+Dermatalgia, 244
+
+Dermatitis, 58-64
+  acute general, 96
+  ambustionis, 58
+  blastomycetic, 266
+  calorica, 58
+  congelationis, 58
+  contusiformis, 50
+  exfoliativa, 96, 97
+    general, 96
+    neonatorum, 97
+    recurrent, 96
+  factitia, 64
+  gangraenosa, 65
+  herpetiformis, 83-86
+  iodoform, 59
+  malignant papillary, 240
+  medicamentosa, 60
+  papillaris capillitii, 135
+  repens, 81
+  traumatica, 58
+  vegetans, 142
+  venenata, 59
+  _x_-ray, 63
+
+Dermatographism, 52
+
+Dermatolysis, 176
+
+Dermatomyoma, 196
+
+Dermatosclerosis, 172
+
+Dermatosyphilis, 213
+
+Dhobi itch, 265
+
+Digitalis, eruptions from, 62
+
+Disorders of the glands, 28-44
+
+Dissection wound, 73
+
+Distribution and configuration, 24-26
+
+Drug eruptions (dermatitis medicamentosa), 60
+
+Duhring's disease, 83
+
+Dysidrosis, 76
+
+
+Ecthyma, 138, 139
+
+Eczema, 100-119
+  erythematosum, 102
+  fissum, 106
+  impetiginosum, 104
+  madidans, 105
+  marginatum, 253
+  papulosum, 103
+  pustulosum, 104
+  rimosum, 106
+  rubrum, 105
+  sclerosum, 106
+  seborrhoicum, 33, 34, 91, 95, 109
+  squamosum, 104
+  verrucosum, 106
+  vesiculosum, 104
+
+Electrolysis in removal of hair, 169
+
+Elephant leg, 174
+
+Elephantiasis, 174-176
+  Arabum, 174
+  Graecorum, 231
+
+Epidermis, 18
+
+Epidermolysis bullosa, 80
+
+Epilating forceps, 249
+
+Epithelial cancer, 236
+
+Epithelioma, 236-240
+  benign cystic, 198
+  molluscum, 153
+
+Equinia, 74
+
+Erasion, 208
+
+Eruptions, feigned (artificial), 64
+  medicinal (dermatitis medicamentosa), 60
+
+Erysipelas, 66, 67
+  ambulans, 67
+  migrans, 67
+
+Erysipeloid, 67
+
+Erythema, 44
+  annulare, 48
+  bullosum, 48
+  caloricum, 44
+  desquamative scarlatiniform, 96
+  gangrenosum, 65
+  gyratum, 48
+  induratum, 51
+    scrofulosorum, 51
+  intertrigo, 45, 46
+  iris, 48
+  marginatum, 48
+  multiforme, 46
+  nodosum, 50, 51
+  recurrent exfoliative, 96
+  simplex, 44
+  solare, 44
+  traumaticum, 44
+  venenatum, 44
+  vesiculosum, 48
+
+Erythrasma, 265
+
+Excessive sweating (hyperidrosis), 28
+
+Excoriationes, 24
+
+Excoriations, 24
+
+
+Farcy, 74
+
+Favus, 247
+  of general surface, 248
+  of nails, 249
+  of scalp, 247
+
+Feigned eruptions, 64
+
+Fever blisters, 78
+
+Fibroma, 192-194
+  molluscum, 192
+
+Fibromyoma, 196
+
+Filaria, 175
+  medinensis, 277
+
+Fish-skin disease, 165
+
+Fissures, 24
+
+Flea, common, 279
+  sand, 278
+
+Flesh worms, 38-41
+
+Folliclis, 130
+
+Folliculitis barbae, 130
+  decalvans, 131
+  pustular, conglomerate, 252
+
+Forceps, epilating, 249
+
+Fragilitas crinium, 187
+
+Framb[oe]sia, 73
+
+Freckle, 148
+
+Frost-bite, 58
+
+Fungous foot of India, 212
+
+Furuncle, 68
+
+Furunculosis, 69
+
+Furunculus, 68-70
+
+
+Gad-fly, 278
+
+Galvano-cautery, 208
+  instruments, 206
+
+Gangrene of the skin (dermatitis gangraenosa), 65
+  spontaneous, 65
+  symmetric, 66
+
+Gelatin dressing, 116
+
+Giant urticaria, 54
+
+Glanders, 74
+
+Glands, sebaceous, 33
+  sweat, 28
+
+Glossy skin, 189
+
+Gnat, 279
+
+Goose-flesh, 152
+
+Granuloma fungoides, 242
+  necroticum, 129
+
+Grayness of the hair, 180
+
+Grutum, 42
+
+Guinea-worm, 277
+
+Gumma, 225
+
+Gun-powder marks, 151
+
+Gutta-percha plaster, 117
+
+
+Hair, 21
+  atrophy of, 187
+  graying of, 180
+  hypertrophy of, 168
+  superfluous, 168
+
+Hair-follicle, 21
+
+Hairy people, 168
+
+Harvest mite, 277
+
+Heat rash, 74
+
+Hemorrhages, 144-146
+
+Henoch's purpura, 145, 146
+
+Hereditary infantile syphilis, 228
+  cutaneous manifestations of, 221
+
+Herpes, 78
+  facialis, 78
+  gestationis, 83
+  iris, 48
+  labialis, 78
+  praeputialis, 79
+  progenitalis, 78
+  simplex, 78-80
+  zoster, 81-83
+
+Hirsuties, 168
+
+Hives, 52
+
+Homines pilosi, 168
+
+Horn, cutaneous, 158
+
+Hydradenitis suppurativa, 130
+
+Hydroa aestivale, 80
+  herpetiforme, 83
+  puerorum, 80
+  vacciniforme, 80
+
+Hydrocystoma, 31
+
+Hyperesthesia, 244
+
+Hyperidrosis, 28-30
+
+Hypertrichosis, 168-170
+
+Hypertrophic scar, 192
+
+Hypertrophies, 148-177
+
+Hypertrophy of the hair, 168
+  of the nail, 167
+
+
+Ichthyosis, 165-167
+  congenita, 165
+  follicularis, 153
+  hystrix, 165
+  sebacea, 33
+    cornea, 153
+  simplex, 165
+
+Impetigo contagiosa, 136, 138
+  herpetiformis, 138
+  simplex, 137
+
+Infantile syphilis, hereditary, 228
+
+Inflammations, 44-143
+
+Inflammatory fungoid neoplasm, 242
+
+Iodides, eruptions from, 62
+
+Iodoform dermatitis, 59
+
+Itch, 267
+  barbers', 255
+  dhobie, 265
+  mite, 269
+
+Ivy poisoning, 59
+
+Ixodes, 277
+
+
+Jigger, 278
+
+
+Keloid, 172, 192
+  cicatricial, 191
+  false, 191
+  of Addison, 172
+  of Alibert, 191
+  spontaneous, 191
+  true, 191
+
+Keratodermia, symmetric, 155
+
+Keratoma, 155
+
+Keratosis follicularis, 153
+  palmaris et plantaris, 155
+  pigmentosa, 160
+  pilaris, 151, 152
+  senilis, 236
+
+Kerion, 255
+
+
+Land scurvy, 145
+
+Larva nigrans, 278
+
+Lentigo, 148
+
+Leontiasis, 233
+
+Lepra, 231-235
+
+Leprosy, 231
+  anaesthetic, 233
+  Lombardian, 235
+  tubercular, 232
+
+Leptus, 277
+
+Lesions, 22
+  configuration of, 24
+  consecutive, 23
+  distribution of, 24
+  elementary, 22
+  primary, 22
+  secondary, 23
+
+Leucoderma, 178
+
+Leucopathia, 178
+
+Lichen moniliformis, 98
+  pilaris, 151
+  planus, 98
+    hypertrophicus, 98
+  ruber, 99
+    acuminatus, 99
+  scrofulosus, 100
+  tropicus, 74
+  urticatus, 53
+
+Linae albicantes, 190
+
+Linear naevus, 163
+  scarification, 208
+
+Liomyoma cutis, 196
+
+Liquor carbonic detergens, 113
+  picis alkalinus, 116
+
+Lombardian leprosy, 235
+
+Louse, body (pediculus corporis), 274
+  clothes (pediculus corporis), 274
+  crab, 275
+  head (pediculus capitis), 272
+
+Lousiness, 271
+
+Lupoid acne, 129
+  sycosis, 131
+
+Lupus, 203
+  erythematodes, 199
+  erythematosus, 199-203
+  exedens, 203
+  exfoliativus, 203
+  exulcerans, 203
+  hypertrophicus, 204
+  sebaceous, 199
+  ulcerations, 203
+  verrucosus, 204
+  vorax, 203
+  vulgaris, 203-208
+
+Lymphangiectodes, 198
+
+Lymphangioma, 198
+  tuberosum multiplex, 198
+
+Lymphangiomyoma, 196
+
+
+Maculae, 22
+  et striae atrophicae, 190
+
+Macules, 22
+
+Madura foot, 212
+
+Malignant papillary dermatitis, 240
+  pustule, 72
+
+Medicinal eruptions (dermatitis medicamentosa), 60
+
+Melanoderma, 149
+
+Melanosarcoma, 242
+
+Melasma, 149
+
+Mercury, eruptions from, 62
+
+Microsporon audouini, 258
+
+Microsporon furfur, 262
+  minutissimum, 265
+
+Miliaria, 74-76
+  alba, 75
+  crystallina, 30
+  rubra, 74
+
+Milium, 42, 43
+  needle, 42
+
+Milk crust, 104
+
+Mite, harvest, 277
+  itch, 269
+
+Moist papule, 216, 217
+
+Mole, 162
+
+Molluscum contagiosum, 153
+  epitheliale, 153-155
+  fibrosum, 192
+  sebaceum, 153
+
+Morphia, eruptions from, 63
+
+Morph[oe]a, 172
+
+Mosquito, 279
+
+Mucous patch, 217
+
+Mycetoma, 212
+
+Mycosis fungoides, 242
+
+Myoma, 196
+  cutis, 196
+  telangiectodes, 196
+
+
+Naevus araneus, 198
+  capillary, 196
+  flammeus, 196
+  linear, 163
+  lipomatodes, 164
+  pigmentosus, 162
+  pilosus, 163, 168
+  sanguineus, 196
+  simplex, 196
+  spider, 198
+  spilus, 163
+  tuberosus, 197
+  vasculosus, 196
+  venous, 197
+  verrucosus, 163
+
+Nail, atrophy of, 188
+  hypertrophy of, 167
+
+Necrotic granuloma, 129
+
+Neoplasm, inflammatory fungoid, 242
+
+Neoplasmata (new growths), 191, 241
+
+Nettlerash, 52
+
+Neuralgia of the skin, 244
+
+Neuroma, 194
+
+Neuroses, 244-247
+
+New growths, 191-243
+
+Nits, 273
+
+
+Objective symptoms, 22
+
+[OE]dema, acute circumscribed, 54
+  neonatorum, 170
+
+[OE]strus, 278
+
+Ointment bases, 27
+
+Onychatrophia, 188
+
+Onychauxis, 167, 168
+
+Onychomycosis, 188
+  favosa, 249
+
+Opium, eruptions from, 63
+
+Oroya fever, 73
+
+Osmidrosis, 32
+
+Ova of pediculi, 273
+
+
+Pachydermia, 174
+
+Paget's disease of the nipple, 240
+
+Papillae, nervous and vascular, 20
+
+Papulae, 23
+
+Papule, moist, 216, 217
+
+Papules, 23
+
+Parasitic affections, 247-279
+  sycosis, 255
+
+Parasiticides, 250, 259
+
+Parchment skin, 190
+
+Paronychia, 167
+
+Patch, mucous, 217
+
+Pediculosis, 271
+  capillitii, 272
+  capitis, 272, 273
+  corporis, 274, 275
+  pubis, 275, 276
+
+Pediculus capitis, 272
+  corporis, 274
+  pubis, 275
+  vestimenti, 274
+
+Peliosis rheumatica, 144
+
+Pellagra, 235
+
+Pemphigus, 140-144
+  foliaceus, 141
+  neonatorum, 140
+  pruriginosus, 83
+  vegetans, 142
+  vulgaris, 140
+
+Perforating ulcer of the foot, 213
+
+Peruvian warts, 73
+
+Phlegmona diffusa, 68
+
+Phosphorescent sweat, 33
+
+Phosphoridrosis, 33
+
+Phtheiriasis, 271
+
+Plan, 73
+
+Pityriasis capitis, 34
+  maculata et circinata, 95
+  pilaris, 151
+  rosea, 95, 96
+  rubra, 97
+
+Pityriasis rubra pilaris, 99
+  versicolor, 261
+
+Plasment, 117
+
+Plaster-mull, 117
+
+Podelcoma, 212
+
+Poison dogwood, dermatitis from, 59
+  ivy, dermatitis from, 59
+  sumach, dermatitis from, 59
+  vine, dermatitis from, 59
+
+Pomphi, 23
+
+Pompholyx, 76-78
+
+Port-wine mark, 197
+
+Post-mortem pustule, 73
+
+Prickly heat, 74
+
+Primary lesions, 22, 23
+
+Prurigo, 118, 119
+
+Pruritus, 244-247
+  ani, 245
+  hiemalis, 245
+  scroti, 245
+  senilis, 245
+  vulvae, 245
+
+Pseudochromidrosis, 33
+
+Psoriasis, 86-95
+  circinata, 88
+  diffusa, 88
+  guttata, 88
+  gyrata, 88
+  inveterata, 88
+  nummularis, 88
+  punctata, 88
+  syphilitica, 218
+
+Psorospermosis, 153, 154, 240
+
+Pulex irritans, 279
+  penetrans, 278
+
+Punctate scarification, 208
+
+Purpura, 144-146
+  haemorrhagica, 145
+  Henoch's, 145, 146
+  rheumatica, 144
+  scorbutica, 146
+  simplex, 144
+  urticans, 144
+
+Pustula maligna, 72
+
+Pustulae, 23
+
+Pustules, 23
+
+
+Quinine, eruptions from, 63
+
+
+Rapidity of cure, 27
+
+Raynaud's disease, 66
+
+Recurrent summer eruption, 80
+
+Red chromidrosis, 33
+  gum, 74
+
+Relative frequency, 26
+
+Rhagades, 24
+
+Rheumatism of the skin, 244
+
+Rhinophyma, 127
+
+Rhinoscleroma, 198, 199
+
+Rhus poisoning, 59
+
+Ringworm, 251
+  of bearded region, 255
+  of general surface, 251
+  of the nail, 253
+  of the scalp, 253
+  of the thighs and scrotum, 252
+  Tokelau, 261
+
+Rodent ulcer, 236
+
+Rosacea, 198
+  acne, 126
+
+Rubber plaster, 117
+
+Rupia, 221, 222
+
+
+Salicylic acid, eruptions from, 63
+  paste, 113
+
+Salt rheum, 100
+
+Sand flea, 278
+
+Sarcoma, 241, 242
+  cutis, 241
+
+Sarcoptes scabiei, 269
+
+Scabies, 267-271
+
+Scales, 24
+
+Scarification, linear, 208
+  punctate, 208
+
+Scarifier, multiple, 202
+  single, 202
+
+Scars, 24
+  hypertrophic, 192
+
+Schoenlein's disease, 145, 146
+
+Sclerema, 172
+  neonatorum, 171
+  of the newborn, 171
+
+Scleriasis, 172
+
+Scleroderma, 172, 173
+  neonatorum, 171
+
+Scorbutus, 146
+
+Scrofuloderma, 209
+  pustular, small, 210
+
+Scurvy, 146
+  land, 145
+  sea, 146
+
+Sebaceous cyst, 43
+  gland, 33
+  tumor, 43
+
+Seborrh[oe]a, 33-38
+  congestiva, 199
+  oleosa, 34
+  sicca, 34
+
+Secondary lesions, 23, 24
+
+Shingles, 81
+
+Skin, anatomy of, 17
+  cancer, 236
+  general idiopathic atrophy of, 189
+  glossy, 189
+  looseness of, 176
+
+Skin, parchment, 190
+
+Spider naevus, 198
+
+Spiradenitis, 130
+
+Spontaneous gangrene, 65
+
+Spots, 22
+
+Squamae, 24
+
+Stains, 24
+
+Statistics, 280, 281
+
+Steatoma, 43
+
+Steatorrh[oe]a, 33
+
+Stramonium, eruptions from, 63
+
+Striae et maculae atrophicae, 190
+
+Strophulus, 74
+  albidus, 42
+
+Subjective symptoms, 22
+
+Sudamen, 30, 31
+
+Superfluous hair, 168
+
+Sweat, colored (chromidrosis), 32
+  glands, 28
+    phosphorescent, 33
+
+Sweating, excessive, 28
+
+Sycosis, 130-135
+  coccogenica, 130
+  non-parasitica, 130
+  parasitic, 255
+  vulgaris, 130
+
+Symmetric gangrene, 66
+  keratodermia, 155
+
+Symptomatology, 22-26
+
+Symptoms, objective, 22
+  subjective, 22
+  systemic, 22
+
+Syphilis cutanea, 213-231
+    early eruptions of, 213
+    late eruptions of, 214
+    papillomatosa, 225
+  hereditary, 227
+    eruptions of, 227
+  of the skin, 213-231
+
+Syphiloderm, 213
+  acne-form, 220
+  annular, 219
+  bullous, 222, 228
+  circinate, 219
+  ecthyma-form, 221
+  erythematous, 214, 227
+  gummatous, 225
+  impetigo-form, 220
+  large acuminated-pustular, 220
+    flat-pustular, 221
+    papular, 216
+  lenticular, 216
+  macular, 214, 227
+  miliary papular, 215
+    pustular, 219
+  non-ulcerating tubercular, 224
+  palmar, 217, 218
+  papular, 215, 227
+  papulo-squamous, 218
+  plantar, 218
+  pustular, 219
+  serpiginous tubercular, 224
+  small acuminated-pustular, 219
+    flat-pustular, 220
+    papular, 215
+  squamous, 218
+  tubercular, 223, 224
+  ulcerating tubercular, 224
+  variola-form, 220
+  vegetating, 218
+
+Syphiloderma, 213
+
+Syphiloma, 225
+
+
+Tar acne, 120
+
+Tattoo-marks, removal of, 151
+
+Telangiectasis, 127, 197, 198
+
+Tetter, 100
+
+Tinea circinata, 251
+  favosa, 247-251
+    fungus of, 249
+    unguium, 249
+  imbricata, 261
+  kerion, 255
+  sycosis, 255
+  tonsurans, 253
+  trichophytina, 251-261
+    barbae, 255
+    capitis, 253
+    corporis, 251
+    cruris, 252
+    fungus of, 258
+    unguium, 253
+  versicolor, 262-265
+    fungus of, 262
+
+Tokelau ringworm, 261
+
+Traumaticin, 94
+
+Trichophyton, 258
+
+Trichorrhexis nodosa, 187
+
+Tubercles, 23
+
+Tubercula, 23
+
+Tuberculosis cutis, 209-211
+  of the skin, 203
+
+Tuberculosis verrucosa cutis, 209, 210
+
+Tumor, sebaceous, 43
+
+Tumors, 23
+
+Turpentine, eruptions from, 63
+
+Tyloma, 155
+
+Tylosis, 155
+
+
+Ulcer, perforating, of foot, 213
+  rodent, 236
+
+Ulcera, 24
+
+Ulerythema sycosiforme, 131
+
+Uridrosis, 33
+
+Urticaria, 52-56
+  bullosa, 54
+  chronic, 53
+  factitia, 52
+  haemorrhagica, 54
+  [oe]dematosa, 54
+  papulosa, 54
+  tuberosa, 54
+  giant, 54
+  pigmentosa, 59
+  vesicular, 54
+
+
+Venereal wart, 161
+
+Verruca, 160-162
+  acuminata, 161
+  digitata, 160
+  filiformis, 160
+  necrogenica, 211
+  plana, 160
+    juvenilis, 160
+  senilis, 160
+  vulgaris, 160
+
+Verruga peruana, 73
+
+Vesicles, 23
+
+Vesiculae, 23
+
+Vitiligo, 178-180
+
+Vitiligoidea, 195
+
+Vleminckx's solution, 129
+
+
+Wart, 160
+  Peruvian, 73
+  pointed, 161
+  venereal, 161
+
+Wen, 43
+
+Wheals, 23
+
+Wood-tick, 277
+
+Wound dissection, 73
+
+
+Xanthelasma, 195
+
+Xanthelasmoidea, 56
+
+Xanthoma, 195, 196
+  diabeticorum, 195
+  multiplex, 195
+  planum, 195
+  tuberculatum, 195
+  tuberosum, 195
+
+Xeroderma, 165
+
+Xeroderma pigmentosum, 190
+
+_X_-ray dermatitis, 63
+
+
+Yaws, 73
+
+
+Zona, 81
+
+Zoster, 81
+
+
+
+
+                         SAUNDERS' BOOKS
+
+                      --------- on ---------
+
+                            GYNECOLOGY
+
+                               and
+
+                            OBSTETRICS
+
+                   *       *       *       *       *
+
+                        W. B. SAUNDERS COMPANY
+
+925 Walnut Street                                            Philadelphia
+
+9, Henrietta Street                                 Covent Garden, London
+
+=========================================================================
+
+                 SAUNDERS' TEXT-BOOKS CONTINUE TO GAIN
+
+The list of text-books recommended in the various colleges again shows a
+#decided gain for the Saunders publications#. During the present college
+year, in the list of recommended books published by 164 colleges (the
+other 23 have not published lists), the Saunders books are mentioned
+3278 times, as against 3054 the previous year--#an increase of 224#. In
+other words, in each of the medical colleges in this country an average
+of 20 (18-2/5 the previous year) of the teaching books employed are
+publications issued by W. B. Saunders Company. That this increase is not
+due alone to the publication of new text-books, but rather to a most
+gratifying increase in the recommendation of text-books recognized as
+standards, is at once evident from the following: Ashton's Gynecology
+shows an increase of 19; DaCosta's Surgery, an increase of 12; Hirst's
+Obstetrics, 14; Howell's Physiology, 25; Jackson on the Eye, 16; Sahli's
+Diagnostic Methods, 11; Scudder's Fractures, 11; Stengel's Pathology,
+13; Stelwagon on the Skin, 11. These are but examples of similar
+remarkable gains throughout the entire list, and is undoubted evidence
+that the #Saunders text-books are recognized as the best#.
+
+ #A Complete Catalogue of our Publications will be Sent upon Request#
+
+
+
+
+                               Bandler's
+
+                          Medical Gynecology
+
+                   *       *       *       *       *
+
+#Medical Gynecology#. By S. Wyllis Bandler, M.D., Adjunct. Professor of
+Diseases of Women, New York Post-Graduate Medical School and Hospital.
+Octavo of 680 pages, with 135 original illustrations. Cloth, $5.00 net;
+Half Morocco, $6.50 net.
+
+
+               #JUST READY--EXCLUSIVELY MEDICAL GYNECOLOGY#
+
+
+This new work by Dr. Bandler is just the book that the physician engaged
+in general practice has long needed. It is truly _the practitioner's
+gynecology_--planned for him, written for him, and illustrated for him.
+There are many gynecologic conditions that do not call for operative
+treatment; yet, because of lack of that special knowledge required for
+their diagnosis and treatment, the general practitioner has been unable
+to treat them intelligently. This work gives just the information the
+practitioner needs. It not only deals with those conditions amenable to
+non-operative treatment, but it also tells how to recognize those
+diseases demanding operative treatment, so that the practitioner will be
+enabled to advise his patient at a time when operation will be attended
+with the most favorable results. The chapter on Pessaries is especially
+full and excellent, the proper manner of introducing the pessary being
+clearly described and illustrated with original pictures that show
+plainly the correct technic of this procedure. The chapters on Vaginal
+and Abdominal Massage, and particularly that on Artificial Hyperemia and
+Anemia, are extremely valuable to the practitioner. They express the
+very latest advances in these methods of treatment. Hydrotherapy,
+especially the Ferguson and Nauheim baths, are treated _in extenso_, and
+Electrotherapy receives the full consideration its importance merits.
+Pain as a symptom and its alleviation is dealt with in an unusually
+practical way, its value as an aid in diagnosis being emphasized.
+Gonorrhea and Syphilis and their many complications are treated in
+detail, every care being taken to have these sections--of special
+interest to the practitioner--complete in every particular. Other
+chapters of great importance are those on Constipation, Sterility,
+Associated Nervous Conditions in Gynecology, and Pregnancy and Abortion.
+
+
+
+
+                      Kelly and Noble's Gynecology
+
+                          and Abdominal Surgery
+
+#Gynecology and Abdominal Surgery#. Edited by Howard A. Kelly, M.D.,
+Professor of Gynecology in Johns Hopkins University; and Charles P.
+Noble, M.D., Clinical Professor of Gynecology in the Woman's Medical
+College, Philadelphia. Two imperial octavo volumes of 900 pages each,
+containing 650 illustrations, mostly original. Per volume: Cloth, $8.00
+net; Half Morocco, $9.50 net.
+
+
+                        BOTH VOLUMES NOW READY
+
+             WITH 650 ORIGINAL ILLUSTRATIONS BY HERMANN BECKER
+
+                            AND MAX BROEDEL
+
+
+In view of the intimate association of gynecology with abdominal surgery
+the editors have combined these two important subjects in one work. For
+this reason the work will be doubly valuable, for not only the
+gynecologist and general practitioner will find it an exhaustive
+treatise, but the surgeon also will find here the latest technic of the
+various abdominal operations. It possesses a number of valuable features
+not to be found in any other publication covering the same fields. It
+contains a chapter upon the bacteriology and one upon the pathology of
+gynecology, dealing fully with the scientific basis of gynecology. In no
+other work can this information, prepared by specialists, be found as
+separate chapters. There is a large chapter devoted entirely to _medical
+gynecology_, written especially for the physician engaged in general
+practice. Heretofore the general practitioner was compelled to search
+through an entire work in order to obtain the information desired.
+_Abdominal surgery_ proper, as distinct from gynecology, is fully
+treated, embracing operations upon the stomach, upon the intestines,
+upon the liver and bile-ducts, upon the pancreas and spleen, upon the
+kidney, ureter, bladder, and the peritoneum. Special attention has been
+given to _modern technic_ and illustrations of the very highest order
+have been used to make clear the various steps of the operations.
+Indeed, the illustrations are truly magnificent, being the work of _Mr.
+Hermann Becker_ and _Mr. Max Broedel_, of the Johns Hopkins Hospital.
+
+
+
+
+                                Ashton's
+
+                        Practice of Gynecology
+
+                    *       *       *       *       *
+
+#The Practice of Gynecology#. By W. Easterly Ashton, M.D., LL.D.,
+Professor of Gynecology in the Medico-Chirurgical College, Philadelphia.
+Handsome octavo volume of 1096 pages, containing 1057 original line
+drawings. Cloth, $6.50 net; Half Morocco, $8.00 net.
+
+
+                   RECENTLY ISSUED--NEW (3d) EDITION
+
+                   THREE EDITIONS IN EIGHTEEN MONTHS
+
+Three editions of this work have been demanded in eighteen months. Among
+the new additions are: Colonic lavage and flushing, Hirst's treatment
+for vaginismus, Dudley's treatment of cystocele, Montgomery's round
+ligament operation, Chorio-epithelioma of the Uterus, Passive
+Incontinence of the Urine, and Moynihan's methods in Intestinal
+Anastomosis. Nothing is left to be taken for granted, the author not
+only telling his readers in every instance what should be done, but also
+precisely _how to do it_. A distinctly original feature of the book is
+the illustrations, numbering about one thousand line drawings made
+especially under the author's personal supervision from actual
+apparatus, living models, and dissections on the cadaver. These line
+drawings show in detail the procedures and operations without obscuring
+their purpose by unnecessary and unimportant anatomic surroundings.
+
+
+#Howard A. Kelly, M.D.#
+
+_Professor of Gynecology, Johns Hopkins University._
+
+"It is different from anything that has as yet appeared. The
+illustrations are particularly clear and satisfactory. One specially
+good feature is the pains with which you describe so many _details_ so
+often left to the imagination."
+
+
+#Charles B. Penrose, M.D.,#
+
+_Formerly Professor of Gynecology, University of Pennsylvania._
+
+"I know of no book that goes so thoroughly and satisfactorily into all
+the _details_ of everything connected with the subject. In this respect
+your book differs from the others."
+
+
+#George M. Edebohls, M.D.#
+
+_Professor of Diseases of Women, New York Post-Graduate Medical School._
+"I have looked it through and must congratulate you upon having produced
+a text-book most admirably adapted to _teach_ gynecology to those who
+must get their knowledge, even to the minutest and most elementary
+details, from books."
+
+
+
+
+                                Webster's
+
+                           Diseases _of_ Women
+
+                     *       *       *       *       *
+
+#Diseases of Women.# By J. Clarence Webster, M.D. (Edin.), F.R.C.P.E.,
+Professor of Gynecology and Obstetrics in Rush Medical College. Octavo
+of 712 pages, with 372 illustrations. Cloth, $7.00 net; Half Morocco,
+$8.50 net.
+
+
+                   RECENTLY ISSUED--FOR THE PRACTITIONER
+
+
+Dr. Webster has written this work _especially for the general
+practitioner_, discussing the clinical features of the subject in their
+widest relations to general practice rather than from the standpoint of
+specialism. The magnificent illustrations, three hundred and seventy-two
+in number, are nearly all original. Drawn by expert anatomic artists
+under Dr. Webster's direct supervision, they portray the anatomy of the
+parts and the steps in the operations with rare clearness and exactness.
+
+
+#Howard A. Kelly, M.D.#, _Professor of Gynecology, Johns Hopkins
+University._
+
+"It is undoubtedly one of the best works which has been put on the
+market within recent years, showing from start to finish Dr. Webster's
+well-known thoroughness. The illustrations are also of the highest
+order."
+
+                    *       *       *       *       *
+
+#Webster's Obstetrics#
+
+#A Text-Book of Obstetrics#. By J. Clarence Webster, M.D. (Edin.),
+Professor of Obstetrics and Gynecology in Rush Medical College. Octavo
+of 767 pages, illustrated. Cloth, $5.00 net; Half Morocco, $6.50 net.
+
+
+                          RECENTLY ISSUED
+
+
+#Medical Record, New York#
+
+"The author's remarks on asepsis and antisepsis are admirable, the
+chapter on eclampsia is full of good material, and ... the book can be
+cordially recommended as a safe guide."
+
+
+
+
+                              Cullen's
+
+                         Uterine Adenomyoma
+
+                  *       *       *       *       *
+
+#Uterine Adenomyoma#. By Thomas S. Cullen, M.D., Associate Professor of
+Gynecology, Johns Hopkins University. Octavo of 275 pages, with original
+illustrations by Hermann Becker and August Horn. Cloth, $5.00 net.
+
+
+                             JUST READY
+
+Dr. Cullen's large clinical experience and his extensive original work
+along the lines of gynecologic pathology have enabled him to present his
+subject with originality and precision. The work gives the early
+literature on adenomyoma, traces the disease through its various stages,
+and then gives the detailed findings in a large number of cases
+personally examined by the author. Formerly the physician and surgeon
+were unable to determine the cause of uterine bleeding, but after
+following closely the clinical course of the disease, Dr. Cullen has
+found that the majority of these cases can be diagnosed clinically. The
+results of these observations he presents in this work. The entire
+subject of adenomyoma is dealt with from the standpoint of the
+pathologist, the clinician, and the surgeon. The superb illustrations
+are the work of Mr. Hermann Becker and Mr. August Horn, of the Johns
+Hopkins Hospital.
+
+                    *       *       *       *       *
+
+                               The American
+
+                        Text-Book _of_ Obstetrics
+
+
+                    Recently Issued--New (2d) Edition
+
+
+#The American Text-Book of Obstetrics#. In two volumes. Edited by Richard
+C. Norris, M.D.; Art Editor, Robert L. Dickinson, M.D. Two octavos of
+about 600 pages each; nearly 900 illustrations, including 49 colored and
+half-tone plates. Per volume: Cloth, $3.50 net; Half Morocco, $4.50 net.
+
+
+#American Journal of the Medical Sciences#
+
+"As an authority, as a book of reference, as a 'working book' for the
+student or practitioner, we commend it because we believe there is no
+better."
+
+
+
+
+                                Hirst's
+
+                           Diseases of Women
+
+                    *       *       *       *       *
+
+#A Text-Book of Diseases of Women#. By Barton Cooke Hirst, M.D., Professor
+of Obstetrics, University of Pennsylvania; Gynecologist to the Howard,
+the Orthopedic, and the Philadelphia Hospitals. Octavo of 745 pages, 701
+illustrations, many in colors. Cloth, $5.00 net; Half Morocco, $6.50
+net.
+
+
+                   RECENTLY ISSUED--NEW (2d) EDITION
+
+                    WITH 701 ORIGINAL ILLUSTRATIONS
+
+
+The new edition of this work has just been issued after a careful
+revision. As diagnosis and treatment are of the greatest importance in
+considering diseases of women, particular attention has been devoted to
+these divisions. To this end, also, the work has been magnificently
+illuminated with 701 illustrations, for the most part original
+photographs and water-colors of actual clinical cases accumulated during
+the past fifteen years. The palliative treatment, as well as the radical
+operative, is fully described, enabling the general practitioner to
+treat many of his own patients without referring them to a specialist.
+The author's extensive experience renders this work of unusual value.
+
+
+                    *       *       *       *       *
+
+                      OPINIONS OF THE MEDICAL PRESS
+
+                    *       *       *       *       *
+
+
+#Medical Record, New York#
+
+"Its merits can be appreciated only by a careful perusal.... Nearly one
+hundred pages are devoted to technic, this chapter being in some
+respects superior to the descriptions in many text-books."
+
+
+#Boston Medical and Surgical Journal#
+
+"The author has given special attention to diagnosis and treatment
+throughout the book, and has produced a practical treatise which should
+be of the greatest value to the student, the general practitioner, and
+the specialist."
+
+
+#Medical News, New York#
+
+"Office treatment is given a due amount of consideration, so that the
+work will be as useful to the non-operator as to the specialist."
+
+
+
+
+                                Hirst's
+
+                        Text-Book of Obstetrics
+
+                      New (5th) Edition, Revised
+
+                   *       *       *       *       *
+
+#A Text-Book of Obstetrics#. By Barton Cooke Hirst, M.D., Professor of
+Obstetrics in the University of Pennsylvania. Handsome octavo, 899
+pages, with 746 illustrations, 39 in colors. Cloth, $5.00 net; Sheep or
+Half Morocco, $6.50 net.
+
+
+                            RECENTLY ISSUED
+
+
+Immediately on its publication this work took its place as the leading
+text-book on the subject. Both in this country and abroad it is
+recognized as the most satisfactorily written and clearly illustrated
+work on obstetrics in the language. The illustrations form one of the
+features of the book. They are numerous and the most of them are
+original. In this edition the book has been thoroughly revised. More
+attention has been given to the diseases of the genital organs
+associated with or following childbirth. Many of the old illustrations
+have been replaced by better ones, and there have been added a number
+entirely new. The work treats the subject from a clinical standpoint.
+
+
+                   *       *       *       *       *
+
+                     OPINIONS OF THE MEDICAL PRESS
+
+                   *       *       *       *       *
+
+
+#British Medical Journal#
+
+"The popularity of American text-books in this country is one of the
+features of recent years. The popularity is probably chiefly due to the
+great superiority of their illustration over those of the English
+text-books. The illustrations in Dr. Hirst's volume are far more
+numerous and far better executed, and therefore more instructive, than
+those commonly found in the works of writers on obstetrics in our own
+country."
+
+
+#Bulletin of Johns Hopkins Hospital#
+
+"The work is an admirable one in every sense of the word, concisely but
+comprehensively written."
+
+
+#The Medical Record, New York#
+
+"The illustrations are numerous and are works of art, many of them
+appearing for the first time. The author's style, though condensed, is
+singularly clear, so that it is never necessary to re-read a sentence in
+order to grasp the meaning. As a true model of what a modern text-book
+on obstetrics should be, we feel justified in affirming that Dr. Hirst's
+book is without a rival."
+
+
+
+
+                              Penrose's
+
+                          Diseases of Women
+
+                        Sixth Revised Edition
+
+                  *       *       *       *       *
+
+#A Text-Book of Diseases of Women#. By Charles B. Penrose, M.D., Ph.D.,
+formerly Professor of Gynecology in the University of Pennsylvania;
+Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 550
+pages, with 225 fine original illustrations. Cloth $3.75 net.
+
+
+                            JUST ISSUED
+
+
+Regularly every year a new edition of this excellent text-book is called
+for, and it appears to be in as great favor with physicians as with
+students. Indeed, this book has taken its place as the ideal work for
+the general practitioner. The author presents the best teaching of
+modern gynecology, untrammeled by antiquated ideas and methods. In every
+case the most modern and progressive technique is adopted, and the main
+points are made clear by excellent illustrations. The new edition has
+been carefully revised, much new matter has been added, and a number of
+new original illustrations have been introduced. In its revised form
+this volume continues to be an admirable exposition of the present
+status of gynecologic practice.
+
+
+                  *       *       *       *       *
+
+                     PERSONAL AND PRESS OPINIONS
+
+                  *       *       *       *       *
+
+#Howard A. Kelly, M.D.,#
+
+_Professor of Gynecology and Obstetrics, Johns Hopkins University,
+Baltimore._
+
+"I shall value very highly the copy of Penrose's 'Diseases of Women'
+received. I have already recommended it to my class as The Best book."
+
+
+#L.E. Montgomery, M.D.,#
+
+_Professor of Gynecology, Jefferson Medical College, Philadelphia._
+
+"The copy of 'A Text-Book of Diseases of Women' by Penrose received
+to-day. I have looked over it and admire it very much. I have no doubt
+it will have a large sale, as it justly merits."
+
+
+#Bristol Medico-Chirurgical Journal#
+
+"This is an excellent work which goes straight to the mark.... The book
+may be taken as a trustworthy exposition of modern gynecology."
+
+
+
+
+  GET                                                            THE NEW
+THE BEST                     American                            STANDARD
+
+                      Illustrated Dictionary
+
+                 Recently Issued--New (4th) Edition
+
+                  *       *       *       *       *
+
+#The American Illustrated Medical Dictionary#. A new and complete
+dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy,
+Chemistry, and kindred branches; with over 100 new and elaborate tables
+and many handsome illustrations. By W.A. Newman Dorland, M.D., Editor of
+"The American Pocket Medical Dictionary." Large octavo, 850 pages, bound
+in full flexible leather. Price, $4.50 net; with thumb index, $5.00 net.
+
+
+    Gives a Maximum Amount of Matter in a Minimum Space, and at the
+                        Lowest Possible Cost
+
+
+                        WITH 2000 NEW TERMS
+
+
+The immediate success of this work is due to the special features that
+distinguish it from other books of its kind. It gives a maximum of
+matter in a minimum space and at the lowest possible cost. Though it is
+practically unabridged, yet by the use of thin bible paper and flexible
+morocco binding it is only 1-1/4 inches thick. In this new edition the
+book has been thoroughly revised, and upward of two thousand new terms
+have been added, thus bringing the book absolutely up to date. The book
+contains hundreds of terms not to be found in any other dictionary, over
+100 original tables, and many handsome illustrations.
+
+
+                  *       *       *       *       *
+
+                          PERSONAL OPINIONS
+
+                  *       *       *       *       *
+
+#Howard A. Kelly, M.D.,#
+
+_Professor of Gynecology, Johns Hopkins University, Baltimore._
+
+"Dr. Borland's dictionary is admirable. It is so well gotten up and of
+such convenient size. No errors have been found in my use of it."
+
+
+#J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.)#
+
+_Professor of Surgery, Harvard Medical School._
+
+"I regard it as a valuable aid to my medical literary work. It is very
+complete and of convenient size to handle comfortably. I use it in
+preference to any other."
+
+
+
+
+                             Garrigues'
+
+                          Diseases of Women
+
+
+                  Third Edition, Thoroughly Revised
+
+                  *       *       *       *       *
+
+#A Text-Book of Diseases of Women#. By Henry J. Garrigues, A.M., M.D.,
+Gynecologist to St. Mark's Hospital and to the German Dispensary, New
+York City. Handsome octavo, 756 pages, with 367 engravings and colored
+plates. Cloth, $4.50 net; Sheep or Half Morocco, $6.00 net.
+
+The first two editions of this work met with a most appreciative
+reception by the medical profession both in this country and abroad. In
+this edition the entire work has been carefully and thoroughly revised,
+and considerable new matter added, bringing the work precisely down to
+date. Many new illustrations have been introduced, thus greatly
+increasing the value of the book both as a text-book and book of
+reference.
+
+
+#Thad. A. Reamy, M.D.,# _Professor of Gynecology, Medical College of
+Ohio._
+
+"One of the best text-books for students and practitioners which has
+been published in the English language; it is condensed, clear, and
+comprehensive. The profound learning and great clinical experience of
+the distinguished author find expression in this book."
+
+                  *       *       *       *       *
+
+                              American
+
+                     Text-Book of Gynecology
+
+#American Text-Book of Gynecology#. Medical and Surgical. Edited by J.M.
+Baldy, M.D., Professor of Gynecology, Philadelphia Polyclinic. Imperial
+octavo of 718 pages, with 341 text-illustrations and 38 plates. Cloth,
+$6.00 net; Half Morocco, $7.50 net.
+
+
+                      SECOND REVISED EDITION
+
+
+This volume is thoroughly practical in its teachings, and is intended to
+be a working text-book for physicians and students. Many of the most
+important subject are considered from an entirely new standpoint, and
+are grouped together in a manner somewhat foreign to the accepted
+custom.
+
+
+#Boston Medical and Surgical Journal#
+
+"The most complete exponent of gynecology that we have. No subject seems
+to have been neglected."
+
+
+
+
+                             Dorland's
+
+                        Modern Obstetrics
+
+                  *       *       *       *       *
+
+#Modern Obstetrics: General and Operative#. By W.A. Newman Dorland, A.M.,
+M.D., Assistant Instructor in Obstetrics, University of Pennsylvania;
+Associate in Gynecology in the Philadelphia Polyclinic. Handsome octavo
+volume of 797 pages, with 201 illustrations. Cloth, $4.00 net.
+
+             Second Edition, Revised and Greatly Enlarged
+
+In this edition the book has been entirely rewritten and very greatly
+enlarged. Among the new subjects introduced are the surgical treatment
+of puerperal sepsis, infant mortality, placental transmission of
+diseases, serum-therapy of puerperal sepsis, etc.
+
+
+#Journal of the American Medical Association#
+
+"This work deserves commendation, and that it has received what it
+deserves at the hands of the profession is attested by the fact that a
+second edition is called for within such a short time. Especially
+deserving of praise is the chapter on puerperal sepsis."
+
+                  *       *       *       *       *
+
+                        Davis' Obstetric and
+
+                        Gynecologic Nursing
+
+
+#Obstetric and Gynecologic Nursing#. By Edward P. Davis, A.M., M.D.,
+Professor of Obstetrics in the Jefferson Medical College and
+Philadelphia Polyclinic; Obstetrician and Gynecologist, Philadelphia
+Hospital. 12mo of 436 pages, illustrated. Buckram, $1.75 net.
+
+
+                  JUST ISSUED--THIRD REVISED EDITION
+
+
+This volume gives a very clear and accurate idea of the manner to meet
+the conditions arising during obstetric and gynecologic nursing. The
+third edition has been thoroughly revised.
+
+
+#The Lancet, London#
+
+"Not only nurses, but even newly qualified medical men, would learn a
+great deal by a perusal of this book. It is written in a clear and
+pleasant style, and is a work we can recommend."
+
+
+
+
+                       Schaeffer _and_ Edgar's
+
+                   Labor and Operative Obstetrics
+
+                  *       *       *       *       *
+
+#Atlas and Epitome of Labor and Operative Obstetrics#. By Dr. O.
+Schaeffer, of Heidelberg. _From the Fifth Revised and Enlarged German
+Edition._ Edited, with additions, by J. Clifton Edgar, M.D., Professor
+of Obstetrics and Clinical Midwifery, Cornell University Medical School,
+New York. With 14 lithographic plates in colors, 139 other
+illustrations, and 111 pages of text. Cloth, $2.00 net. _In Saunders'
+Hand-Atlas Series._
+
+This book presents the act of parturition and the various obstetric
+operations in a series of easily understood illustrations, accompanied
+by a text treating the subject from a practical standpoint.
+
+
+#American Medicine#
+
+"The method of presenting obstetric operations is admirable. The
+drawings, representing original work, have the commendable merit of
+illustrating instead of confusing."
+
+                  *       *       *       *       *
+
+    Schaeffer _and_ Edgar's Obstetric Diagnosis and Treatment
+
+
+#Atlas and Epitome of Obstetric Diagnosis and Treatment#. By Dr. O.
+Schaeffer, of Heidelberg. _From the Second Revised German
+Edition._Edited, with additions, by J. Clifton Edgar, M.D., Professor of
+Obstetrics and Clinical Midwifery, Cornell University Medical School,
+N.Y. With 122 colored figures on 56 plates, 38 text-cuts, and 315 pages
+of text. Cloth, $3.00 net. _In Saunders' Hand-Atlas Series._
+
+This book treats particularly of obstetric operations, and, besides the
+wealth of beautiful lithographic illustrations, contains an extensive
+text of great value. This text deals with the practical, clinical side
+of the subject.
+
+
+#New York Medical Journal#
+
+"The illustrations are admirably executed, as they are in all of these
+atlases, and the text can safely be commended, not only as elucidatory
+of the plates, but as expounding the scientific midwifery of to-day."
+
+
+
+
+                         Schaeffer and Norris'
+
+                             Gynecology
+
+                  *       *       *       *       *
+
+#Atlas and Epitome of Gynecology#. By Dr. O. Schaeffer, of Heidelberg.
+_From the Second Revised and Enlarged German Edition._ Edited, with
+additions, by Richard C. Norris, A.M., M.D., Assistant Professor of
+Obstetrics in the University of Pennsylvania. 207 colored figures on 90
+plates, 65 text-cuts, and 308 pages of text. Cloth, $3.50 net. _In
+Saunders' Hand-Atlas Series._
+
+
+American Journal of the Medical Sciences
+
+"Of the illustrations it is difficult to speak in too high terms of
+approval. They are so clear and true to nature that the accompanying
+explanations are almost superfluous. We commend it most earnestly."
+
+                  *       *       *       *       *
+
+                             Galbraith's
+
+                     Four Epochs of Woman's Life
+
+
+               Second Revised Edition--Recently Issued
+
+
+#The Four Epochs of Woman's Life:# A Study in Hygiene. By Anna M.
+Galbraith, M.D., Fellow of the New York Academy of Medicine, etc. With
+an Introductory Note by John M. Musser, M.D. Professor of Clinical
+Medicine, University of Pennsylvania. 12 mo of 247 pages. Cloth $1.50
+net.
+
+
+              MAIDENHOOD, MARRIAGE, MATERNITY, MENOPAUSE
+
+
+In this instructive work are stated, in a modest, pleasing, and
+conclusive manner, those truths of which every woman should have a
+thorough knowledge. Written, as it is, for the laity, the subject is
+discussed in language readily grasped even by those most unfamiliar with
+medical subjects.
+
+
+#Birmingham Medical Review, England#
+
+"We do not as a rule care for medical books written for the instruction
+of the public. But we must admit that the advice in Dr. Galbraith's work
+is in the main wise and wholesome."
+
+
+
+
+                        Schaeffer and Webster's
+
+                         Operative Gynecology
+
+
+#Atlas and Epitome of Operative Gynecology#. By Dr. O. Schaeffer, of
+Heidelberg. Edited, with additions, by J. Clarence Webster, M.D.
+(Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in Rush
+Medical College, in affiliation with the University of Chicago. 42
+colored lithographic plates, many text-cuts, a number in colors, and 138
+pages of text. _In Saunders' Hand-Atlas Series._ Cloth, $3.00 net.
+
+
+                            RECENTLY ISSUED
+
+
+Much patient endeavor has been expended by the author, the artist, and
+the lithographer in the preparation of the plates for this Atlas. They
+are based on hundreds of photographs taken from nature, and illustrate
+most faithfully the various surgical situations. Dr. Schaeffer has made
+a specialty of demonstrating by illustrations.
+
+
+#Medical Record, New York#
+
+"The volume should prove most helpful to students and others in grasping
+details usually to be acquired only in the amphitheater itself."
+
+                  *       *       *       *       *
+
+                    DeLee's Obstetrics for Nurses
+
+#Obstetrics for Nurses#. By Joseph B. DeLee, M.D., Professor of
+Obstetrics in the Northwestern University Medical School, Chicago;
+Lecturer in the Nurses' Training Schools of Mercy, Wesley, Provident,
+Cook County, and Chicago Lying-in Hospitals. 12mo of 512 pages, fully
+illustrated.
+                                                     Cloth, $2.50 net.
+
+
+                    JUST ISSUED--NEW (3d) EDITION
+
+
+While Dr. DeLee has written his work especially for nurses, the
+practitioner will also find it useful and instructive, since the duties
+of a nurse often devolve upon him in the early years of his practice.
+The illustrations are nearly all original and represent photographs
+taken from actual scenes. The text is the result of the author's many
+years' experience in lecturing to the nurses of five different training
+schools.
+
+
+#J. Clifton Edgar, M.D.,#
+
+_Professor of Obstetrics and Clinical Midwifery, Cornell University, New
+York._
+
+"It is far and away the best that has come to my notice, and I shall
+take great pleasure in recommending it to my nurses, and students as
+well."
+
+
+
+
+#American Pocket Dictionary#                     Recently issued--5th Ed.
+
+The American Pocket Medical Dictionary. Edited by W.A. Newman Dorland,
+A.M., M.D., Assistant Obstetrician to the Hospital of the University of
+Pennsylvania; Fellow of the American Academy of Medicine. With 578
+pages. Full leather, limp, with gold edges, $1.00 net; with patent thumb
+index, $1.25 net.
+
+
+#James W. Holland. M.D.,#
+
+_Professor of Chemistry and Toxicology, at the Jefferson Medical
+College, Philadelphia._
+
+"I am struck at once with admiration at the compact size and attractive
+exterior. I can recommend it to our students without reserve."
+
+
+#Cragin's Gynecology#                    Recently Issued--New (6th) Ed.
+
+Essentials of Gynecology. By Edwin B. Cragin, M.D., Professor of
+Obstetrics, College of Physicians and Surgeons, New York. Crown octavo,
+240 pages, 62 illustrations. Cloth, $1.00 net. _In Saunders'
+Question-Compend Series._
+
+
+#The Medical Record, New York#
+
+"A handy volume and a distinct improvement on students' compends in
+general. No author who was not himself a practical gynecologist could
+have consulted the student's needs so thoroughly as Dr. Cragin has
+done."
+
+
+#Boisliniere's Obstetric Accidents, Emergencies, and Operations#
+
+Obstetric Accidents, Emergencies, and Operations. By the late L. Ch.
+Boisliniere, M.D., Emeritus Professor of Obstetrics, St. Louis Medical
+College; Consulting Physician, St. Louis Female Hospital. 381 pages,
+illustrated. Cloth, $2.00 net.
+
+
+#British Medical Journal#
+
+"It is clearly and concisely written, and is evidently the work of a
+teacher and practitioner of large experience. Its merit lies in the
+judgment which comes from experience."
+
+
+#Ashton's Obstetrics#                      Recently Issued--New (6th) Ed.
+
+Essentials of Obstetrics. By W. Easterly Ashton, M.D., Professor of
+Gynecology in the Medico-Chirurgical College, Philadelphia. Crown
+octavo, 252 pages, 75 illustrations. Cloth, $1.00 net. _In Saunders'
+Question-Compend Series._
+
+
+#Southern Practitioner#
+
+"An excellent little volume, containing correct and practical knowledge.
+An admirable compend, and the best condensation we have seen."
+
+
+#Barton and Wells' Medical Thesaurus#
+
+A Thesaurus of Medical Words and Phrases. By Wilfred M. Barton, M.D.,
+Assistant to Professor of Materia Medica and Therapeutics, Georgetown
+University, Washington, D.C.; and WALTER A. WELLS, M.D., Demonstrator
+of Laryngology, Georgetown University, Washington, D.C. 12mo of 534
+pages. Flexible leather, $2.50 net; with thumb index, $3.00 net.
+
+
+
+
+        *       *       *       *       *
+
+
+
+Transcriber's note:
+
+   Changed "dioxid" to "dioxide" in several places
+
+   Made hyphenation of various words consistent
+
+   Page 74: Corrected misspelling of Phlegmona
+
+   Page 135: Corrected misspelling of quantity
+
+   Page 138: changed ',' to '.' at end of sentence
+
+   Page 208: aquae rosae changed to aquae rosae
+
+   Page 210: Fixed typographical error "symptyms" into "symptoms"
+
+   Page 212: Fixed typographical error "Decribe mycetoma" into
+             "Describe mycetoma"
+
+   Page 213: Fixed typographical error "iodid" into "iodide"
+
+
+
+***END OF THE PROJECT GUTENBERG EBOOK ESSENTIALS OF DISEASES OF THE SKIN***
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+Project Gutenberg (https://www.gutenberg.org) public repository for
+eBook #25944 (https://www.gutenberg.org/ebooks/25944)