It is proposed here to treat only of those diseases of the skin which may complicate surgical cases or call for surgical treatment.

Dermatitis may be produced by chemicals, caustics, and various irritants; the former, for instance, by the use of strong antiseptics upon sensitive skins, and the latter as when fecal matter or urine is poured over unprotected skin or allowed to remain in contact with it. Ammoniacal urine will prove irritating, as will also that of diabetes. When carbolic acid was in general use it gave rise to great trouble upon the hands of many surgeons, while iodine, iodoform, and other such remedies, as well as the stronger mercurial preparations, will cause local symptoms similar to those produced by poison ivy.

This may be prevented, when the condition has occurred, by applying soothing lotions or mild astringents, with anodynes, in dry dusting powder or in ointment form. Cocaine in small amounts, or preferably orthoform with menthol, may be employed in either of these ways. When an acid discharge is expected the skin should be protected with an ointment or with collodion or rubber cement; the latter by drying will leave a thin film upon the surface. Thus around a fecal fistula the skin will be irritated and more or less macerated, and should always be thus protected when possible.

Between sixty and seventy drugs are known to produce distinct forms of dermatitis, such as copaiba, cubebs, the various preparations of iodine, bromine, and arsenic, some of the aniline preparations, quinine, etc.; while the various antitoxic serums, especially that of diphtheria, will sometimes produce a skin disturbance. In these cases it is only necessary to recognize the source of the trouble and remove the cause by stopping the drug. Should dermatitis produce such restlessness as to interfere with the physiological rest necessary for a wound or fracture an opiate should be administered.

DERMATITIS CALORICA.

Dermatitis calorica means the varying degrees of irritation which may be set up by extremes of heat and cold, continuous or alternate, as in so-called chilblains. These are often seen upon the feet, but occur upon the hands and even the face, i. e., in places most exposed and least supplied with blood. The lesion occurs in patches, often with livid discoloration, and causes sensations varying from discomfort to acute pain, almost always aggravated by warmth; while the skin appears inflamed, though to the touch it usually seems cool.

Treatment.

—Chilblains occur most frequently in the anemic and those with uric-acid diathesis, but may be met at any time. The constitutional treatment should not be overlooked. Much pertains to good care of the feet, especially after exposure. After wetting or chilling they should be dried and then rubbed with boric-acid talcum powder, containing 1 or 2 per cent. of menthol; this may be dusted upon the feet, before going outdoors, upon return, and when there is discomfort.

It will often give relief to immerse the feet in warm water containing sufficient tincture of iodine to give it a mahogany color; or the feet may be simply dipped in this and then allowed to dry without using a towel. The use of hydrogen dioxide diluted two or three times has been highly commended. If this proportion of dioxide be added to four or five parts of hot saturated solution of sodium bicarbonate the efficacy of the measure will be much enhanced. In extreme cases frequent use of the following formula will probably give more relief than anything else: Carbolic acid 1 part, ichthyol and tincture calendula each 4 parts, and glycerin 16 parts. With this the skin may be kept constantly moistened.

The expressions of dermatitis produced by heat may vary from an efflorescent rash to complete destruction, and will be treated of under the following head:

BURNS AND SCALDS.

The term “burn” is applied to lesions produced by flame or dry heat, while moist heat (i. e., boiling materials or steam) causes injuries known as “scalds.” Between the two there is but little essential difference, except that with the latter there is usually loosening of the hair of the part, and sometimes much loosening of the epidermis as well, so that it is easily detached in more or less large patches. Whether heat is relatively feeble but prolonged, or higher in degree and of shorter duration, the results of dry heat are about the same. Some differences will exist according to whether the part is exposed to actual flame or to hot or melted material, sufficiently hot perhaps to cause complete charring or carbonization of a part.

Similar injuries are produced by concentrated caustics, acids, or alkalies, while such materials as phosphorus or sulphur produce deep burns. The burn produced by lightning is rarely deep, although it may be extensive (Fig. 97). Persons coming in contact with live wires sustain burns which partake much of the nature of the electric discharge, and are sometimes of a character to deserve the term “brush-burn.” Formerly burns were divided by Dupuytren into six or seven degrees, but this classification is too cumbersome and artificial to be acceptable. Morton’s classification is now everywhere accepted, by which they are divided into three degrees: (1) Dermatitis without vesication. (2) Vesication even to the formation of bullæ. (3) Destruction of the skin, with or without that of the deeper parts, which may include actual carbonization of a limb.

Burns may vary within the widest imaginable limits. To an extensive burn of the surface may be added the features produced by inhalation of smoke, steam, or flame; accordingly the eyes and the mucous membrane of the nose and mouth suffer, the parts becoming chemotic and disfigured, so as to make the individual unrecognizable. Burns constitute one of the most painful and distressing injuries known to the surgeon, particularly when the area is large and the case is complicated by injuries which necessitate more or less prolonged rest in bed. When the body is burned completely around it is difficult to ensure rest without the use of anodynes.

Shock is a marked feature of every serious case of burn or scald, and albumin quickly appears in the urine in these cases. Ulceration of the duodenum may follow extensive injuries of this kind, and is occasionally the cause of death. It is to be attributed to a toxic action produced by absorption of putrid material connected with the surface sloughing process. A temporary diabetes is sometimes noted. Laryngitis, bronchitis, and pneumonia may occur from inhalation of steam or smoke, while the inhalation of flame may bring about a rapid edema of the glottis, which may necessitate tracheotomy as an early and emergency measure. It is generally stated that a burn of the second degree, which even involves half of the surface of the body, may prove fatal; while this is not invariably the case, it is too frequently true, and may afford aid in prognosis.

Burns of the second degree are always followed by exudation with formation of blebs, usually within a few hours. In the more serious cases the exudate may be bloody. Burns of the third degree are necessarily followed by more or less gangrene, and this fact affords the reason for the radical treatment recommended.

Treatment.

—By the time the surgeon is called to treat a burn the first indications are usually relief of pain, and perhaps stimulation for shock. The circumstances attending such injury generally leave the patient in an excited mental condition, and for several obvious reasons it would be well to use sufficient anodyne to tranquillize and give comfort. An excellent application in emergency cases is a saturated solution of sodium bicarbonate, or it may be dusted over the affected surface.

The unpleasant visceral complications that follow burns are due to absorption of decomposing fluids or tissues, so retained or so in contact with readily absorbing surfaces as to produce a more or less violent degree of toxemia. In this way are to be explained delirium, convulsions, or coma, as well as the ulcerative and toxic intestinal symptoms which constitute the distressing complications.[17] For this reason the radical method of prevention is the best; hence whenever there is any prospect of sloughing, or when even the epidermis is so burned as to make it appear that it will soon separate, the best method of treatment is to anesthetize the patient and then with a stiff brush and antiseptic soap scrub the part and remove everything that is at all loose, if necessary even using a wire brush, scissors, or a razor. Beneath every sloughing area toxic absorption will go on, and it will be far better to have fresh raw and bleeding surfaces than those which cover sources of danger; the resultant scar will not be any greater, while the subsequent course of the case will be favorably influenced. Exquisitely tender surfaces thus have their sensibility blunted, and the comfort of the patient is greatly enhanced by thorough cleansing and sterilization; moreover, dressings will not need to be so frequently changed. A soothing, antiseptic ointment should be applied; there are few better than the ordinary ointment of zinc oxide, to which may be added bismuth subnitrate and orthoform.[18] Treatment of this kind would probably not need to be repeated, and the duration of the trouble would be reduced to one-quarter or one-third of the time which would otherwise be required. When actual carbonization has occurred amputation is generally necessary. Diluted solutions of ichthyol have proved satisfactory, and the dressings should be covered with some impermeable material, so as to exclude the air. Another advantage is that the amount of subsequent discharge is limited, and thus there is less need for frequent change of dressings. In extreme cases there is no method which gives so much comfort and certainty as continuous immersion in warm water; to this may be added common salt or some other antiseptic, but the water alone is sufficient, if changed frequently. In burns covering a great part of the body this treatment is the most serviceable. It should be employed until the sloughs have separated and surfaces are granulating and ready for skin grafting. This implies, of course, immersion of the entire body in a bath-tub, the body lying on a sheet fastened to the sides of the tub. The advantage of brewers’ yeast dressing, when sloughs are present, has been previously emphasized in the chapter on Ulcers and Ulceration.

The disfigurement caused by a superficial burn will fade after a few months. In cases where the skin has sloughed there is a tendency to cicatricial contraction as soon as granulations begin to form, and the tendency then is to the formation of disfiguring scars. About the limbs the flexor muscles will always overcome the extensors, and bridle-like deformities will be formed at flexures of the joints. These are to be prevented so far as possible by two measures—proper splinting and early skin grafting. About the face splints cannot be used, but one of the grafting methods should be used.

A tendency in the scars of old burns is to formation of keloid (see below) and epithelioma. The writer has seen epitheliomatous ulcers covering at least an area of a square foot, which had formed upon the sites of burns received years previously. In one case of this kind it was necessary to remove the entire upper extremity; even then the disease recurred and finally destroyed the patient (Fig. 98).

Burns produced by caustic acids or alkalies call for appropriate chemical antidotes at first and later essentially the same treatment as that already mentioned. In cases of severe burn there is danger of neglecting the ordinary rules of general treatment, which consist in maintaining elimination and nutrition.

FROSTBITE.

Effects similar to those produced by heat are caused also by cold, varying from a superficial dermatitis with its surface irritation, its possible vesication, and, later, desquamation, to complete freezing of an extremity or a part (e. g., the nose, or the ear), which may be followed by gangrene. Portions which are not frozen beyond the point of restoration of vitality undergo a marked reaction and become swollen and discolored, save in rare instances where they shrivel. Gangrene is not so immediate a process as in a severe burn, as it takes a number of hours, sometimes days, for the establishment of the so-called line of demarcation, by which the dead tissue is separated from the living. On one side of this line putrefaction goes on rapidly, as in moist gangrene from any cause; on the other side there is active circulatory disturbance, with phagocytosis, by which the line becomes more marked; no portion of tissue on the distal side of this dead line can be saved. The location of the lesion and the exigencies of the case will indicate where amputation should be made. (See chapter on Gangrene.)

Treatment.

—A rapid restoration of warmth to the part is most undesirable. The thawing-out process in a case of severe freezing should be begun in cold or ice-cold water. Crude petroleum at a temperature of 60° F. has been recommended as a substitute for cold water, and immersion may be continuous for several hours. A rubbing with alcohol and water may be substituted for the cold water, and then a gradual restoration to the ordinary temperature of the air. Unless this treatment be skilfully managed there may be such a rapid reaction as to be painful and even injurious. By the time there is any active exudation, or putrefaction has begun, an absorbent dry dressing and suitable antiseptics may be used.

DERMATITIS OF RADIO-ACTIVE ORIGIN.

The common expression of this form of skin affection is called a burn. This is something more than its name implies, for it is understood that the active factors are the ultraviolet rays, or the rays beyond the color region of the spectrum; that it is not due to the heat rays is shown by the intense burning that is frequently seen in the Arctic regions. In the skin of the young and tender, sunburn is sometimes followed by vesication and desquamation; ordinarily it simply produces the latter. Any soothing ointment or solution is usually sufficient for the treatment of sunburn, which should, however, include avoidance of the exciting cause.

Much more intense actinic effects are produced by the x-rays, leading sometimes to complete destruction of the skin. These phenomena are usually called x-ray dermatitis. They vary from local discomfort, with itching, loss of hair on hairy surfaces, and partial anesthesia, with later a glossy appearance, to edema of the cellular tissue, by which anatomical outlines are effaced. The natural color of the skin, owing to pigmentation, appears dark. If the exciting cause be stopped before or as soon as this stage is reached complete recovery is possible, save that hair does not always grow from the surface which has lost it. The x-ray treatment should be pushed up to this stage. Careful management is now necessary, especially should any surface irritation like chafing occur. That x-ray burn, so called, may result from x-ray exposure made some time previously seems to be established by a case reported to me by Dr. L. L. McArthur, of Chicago, where he had to do skin grafting upon a lesion of this kind which did not appear until fifteen months after the last exposure.

The stage of danger is characterized by extreme itching with multiform eruptions in successive crops, desquamation, formation of minute vesicles, and ulcers; or the process may be more acute and the skin begin to slough. Small lesions will become confluent, and large excavations may be formed. The sloughing process is usually slow, and by it are produced ulcers characterized by extreme pain and discomfort and a lack of tendency to heal.

These ulcers are exquisitely sensitive and applications intended for relief are of themselves most distressing. Everything about such an ulcer seems sluggish, while small areas which have apparently healed break down again; healthy scabs are not formed and granulations are extremely indolent.

Treatment.

—In the treatment of these lesions, so long as they are mild, the surgeon should confine himself to soothing applications and rest; at the same time discontinuance of x-ray exposures and even avoidance of light seem to be essential. Any operator threatened with such trouble should wear thick rubber gloves during all his work. The local treatment of this lesion is not essentially different from that described in the chapter on Ulcers and Ulceration, but the surfaces are often so erethistic as to demand either anodyne applications, containing such remedies as orthoform, anesthesin, or even cocaine, or else they need radical treatment with a sharp spoon.

Sloughing surfaces should be treated with brewers’ yeast until the surface has become healthy. Picric acid in solution has been recommended, a saturated solution being diluted seven or eight times before using.

The writer has rarely seen any more distressing or obstinate lesions than presented in some of these cases. In speaking of epithelioma it has been stated that some of these ulcers are prone to thus degenerate. It seems an extreme contradiction in physics that the agent used so frequently in the treatment of superficial cancers should, when used to excess, produce lesions which themselves become cancerous. It has been the writer’s privilege to witness amputation of all of one hand and a large part of the other, in the case of a well-known colleague, who carried the x-ray treatment to excess, and until he suffered to this extent. Careful and discriminating judgment is therefore necessary in the management of vacuum tubes.

Since radium has come into use it has been found to exercise a deleterious effect upon the skin. The radium emanations are known to influence living cells and tissues, and their inhibiting effect upon the growth of larvae has been well established. The prohibitive price of radium preparations will make these lesions rare. After exposure there appears an erythema followed by an active dermatitis, which so closely resembles lesions above described, in their early stages, that one description will suffice for both. Moreover, the treatment of a radium burn differs in no essential respects from that of an x-ray burn.

ACUTE INFECTIONS OF THE SKIN.

Furuncle or Boil.

—A furuncle is a phlegmon having its origin in a hair follicle and involving a small area of skin and subcutaneous tissue. The infection is produced by one of the ordinary pyogenic organisms, which have easy access to the base of the follicles. Sometimes these organisms are of unusual virulence, but ordinarily there is a local condition which favors the infection, while it may be encouraged by a general diathetic condition, such as diabetes. The lesion is usually single, but may be multiple. Boils appear sometimes in groups or in crops, and when the condition has become chronic it is called furunculosis, which may be local or general. A boil commences as a tender papule, which rapidly enlarges into a conical swelling, sometimes of considerable size. Around it there is an area of dusky discoloration, while the apex becomes quite dark. Pus, travelling in the direction of least resistance, comes more or less readily to the surface, the apex of the boil yielding and pus finally escaping, if not evacuated by incision, usually with a small amount of necrotic tissue, which may be sufficiently large to justify the term “core.” With the escape of pus the throbbing pain is much relieved. A furuncle arising in tissues where swelling is not easily treated, as in the nose, the external meatus, and also in the axilla and the perineum, will produce an abnormal amount of pain.

Treatment.

—The domestic treatment of boils consists of poultices, usually made of hot flaxseed. These are always nauseous applications, and tend to favor the development of similar trouble in adjoining follicles. An equally comforting application can be made with a piece of spongiopiline, or a compress, saturated in an antiseptic solution, and covered with rubber tissues, outside of which, if necessary, a hot-water bottle may be applied. Inasmuch as it is tension which produces pain, early incision, which can be made under a little freezing spray, or with cocaine, will give the greatest relief. This may be practised even before pus has appeared. After such incisions the same moist applications may be applied. Incisions should be made as soon as pus is shown to be present. The appearance of a whitish point at the apex of the furuncle will always indicate the presence of pus beneath.

General furunculosis has almost always an underlying diathesis as a cause, and this should be sought out and treated according to its nature. In the absence of recognized constitutional conditions the writer has never found anything equal to aromatic sulphuric acid, given in 10 or 12-drop doses, with tincture of arnica in teaspoonful doses, to be freely diluted with water.

Carbuncle.

—This differs from a furuncle in the extent of the local infection, involvement of subcutaneous tissue, and the amount of necrosis which it produces. It is in most instances a more serious affair, life often being destroyed by the extent of the resulting necrosis and the amount of toxins produced. It begins as a local process, but always with constitutional disturbance, and sometimes even with a chill. The affected surface rapidly assumes a brawny hardness, and the infiltration is often extensive; pain is severe and throbbing; the surface becomes more dusky in appearance, numerous pustules appear, development of all the features of a serious carbuncle usually taking place in a few days. Later it begins to soften and the skin gives way at several points, at each of which a small drop of pus is discharged, while after removing this there may be seen white necrotic tissue beneath. The sloughing process extends deeply, generally to the deep fascia, and this itself occasionally succumbs. A person may have a distinct carbuncular lesion where the area primarily involved is not much larger than that of a five-cent piece; on the other hand, in debilitated or dissipated subjects, a lesion of this kind may become as large as a dinner plate, while the sloughing process may expose the underlying bone. This is often the case on the back of the neck and trunk. A carbuncle may occur in any part of the body, but is usually seen on the back; when upon a limb it generally involves the extensor surface. It is especially serious and dangerous when occurring upon the face, as septic thrombosis may readily extend to a cranial sinus and rapidly kill. It was formerly believed that carbuncles of the lip always terminated fatally; while this is not necessarily true it will indicate the seriousness of the condition (Figs. 100 and 101).

Treatment.

—There are few lesions where both constitutional and local treatment need to be more judiciously combined. Many of these patients are diabetic, and then it assumes malignant tendencies. Others are syphilitics or alcoholics, whom dissipation has reduced to a condition of serious malnutrition. The urine should always be examined for sugar and albumin, and whatever indications it may afford carefully followed. Septic intoxication and infection may so rapidly depress the already weakened patient as to call for stimulants and tonics, and pain may be so severe as to justify the use of anodynes.

The local treatment should consist of soothing applications until the extent of the plastic exudate has declared itself, after which it should be more radical. It is better, therefore, to excise under an anesthetic, the area which ordinarily would require days or weeks to slough. The most satisfactory treatment is the radical. The knife, the scissors, and the sharp spoon constitute the best means of combating this disease. In other respects the treatment was discussed when dealing with septic infection. Nothing will so hasten the sloughing and cleaning up process as brewers’ yeast. The writer’s custom is to make a thorough excision of the affected area and treat the part with yeast for some days. About the lip and face the sharp spoon should take the place of the knife, but even there, if the case be attacked early, tissue can be saved and disfigurement reduced to a minimum. The method used by some of injecting 5 per cent. carbolic solution is less satisfactory, although the measure above recommended is a rather severe operation and usually requires complete anesthesia.

CHRONIC INFECTIONS OF THE SKIN.

Tuberculosis.

—Most of the skin lesions formerly described as scrofulous are now known to be expressions of tuberculosis. So, also, are some of the papillomatous growths and the chronic ulcers, which do not assume distinctive form.

Lupus vulgaris is perhaps the most common of these cutaneous lesions, especially in certain parts of the world. It is seen more often among the young than the old. The lesions begin with a papule, which becomes the well-known lupus, smaller nodules coalescing and forming eventually a brownish-red patch, whose borders are somewhat elevated and scaly. This lesion usually goes on to ulceration, particularly in those parts of the body where it is kept moist or frequently irritated. It is in these lesions that a healing or cicatrizing tendency is seen at one point and progressive ulceration in another. Ulceration does not always occur, but the papule just described sometimes undergoes spontaneous absorption, the tissue atrophying, losing its peculiar skin functions, and the scar being depressed and scaly.

Lupus vulgaris is to be distinguished from lupus exedens, referred to under Epithelioma. It is often mistaken for the latter, and a differential diagnostic table has already been given. (See p. 293.)

Verruca necrogenica, as it used to be called, is now known as verrucose tuberculosis. It consists of cutaneous warts, surrounded by an erythematous zone or patch, which tend to break down, and covered with scabs, intermixed with pustules. The lesion rarely proceeds to complete ulceration. It occurs especially upon the hands and exposed parts of those who handle cadavers or carcasses. The lesion is usually slow and sometimes disappears spontaneously.

On or about the mucocutaneous borders of individuals suffering from tuberculosis there appear small ulcers, secreting a thin, puruloid material. These are seen especially about the nose, the mouth, the anus, and the vulva. These lesions should be regarded as local infections from a constitutional source. They are often sensitive, show little tendency to heal, and are sources of danger to others. They should receive radical treatment.

Under the term scrofuloderm are included a variety of subcutaneous tuberculous nodules which spread and involve the skin. They begin in the superficial lymph nodes. The overlying skin becomes bluish and gives way, while an ulcer remains which discharges more or less puruloid material. The edges of these ulcers are frequently undermined for a considerable distance. These are ordinarily chronic lesions, which sometimes undergo a spontaneous recovery, leaving disfiguring and discolored scars, usually irregular and more or less striped or banded.

Some of the scrofuloderms are included under the erythema induratum of Bazin, lesions which appear mostly on the calves of the legs of young women, consisting of deep-seated nodules, which break down into deep ulcers, having elevated and overhanging edges. Again, there is the so-called lichen scrofulosorum, i. e., a papular eruption seen in the young, especially those who show other evidences of tuberculosis. It consists of rounded groups of papules, usually on the sides of the trunk, at first bright in color, new papules appearing as the old ones fade. In addition there is the pustular scrofuloderm, which crusts over, heals, and leaves small cicatrices.

In all of these lesions the tubercle bacilli can be usually demonstrated. There are other skin lesions in which no bacilli can be demonstrated, which are supposed to be due to the toxins generated in tuberculous foci elsewhere. Hallopeau suggests calling all tuberculous skin lesions tuberculides and to group them as follows: (a) Those in which bacilli are present, bacillary tuberculides, and (b) those arising from tuberculous toxins, toxic tuberculides.

Among the latter he describes what he calls folliculitis, i. e., small papules, firm, at first red, then elevated, becoming nodules, appearing on the extremities, and gradually producing crater-form ulcers covered with black crusts, leaving small pock-like scars. This condition is chronic, lasting years. In these patients the skin is furfurated, showing a sluggish circulation.

Treatment.

—Inasmuch as tuberculous skin lesions tend to spread and to recur, they need radical treatment—i. e. the sharp spoon, the scissors, and caustic. Ordinarily it is best to scrape the affected surface, to trim away all unhealthy edges, and then to apply a strong caustic for a brief space of time, thereby sterilizing it and searing the mouths of the absorbents which may have been opened by the scraping. Treatment for two or three days with brewers’ yeast will usually suffice to put the surface in a healthy condition, after which it may be skin-grafted or treated by any of the ordinary plastic methods.

Rhinoscleroma.

—The bacillus of rhinoscleroma was described in the chapter on Inflammation, under the heading Pyogenic Organisms. It is a specific infection, primarily of the skin, which appears invariably upon the nose. It begins either in the skin or mucous membrane, or both, and having once thoroughly invaded the tissues grows in all directions. It shows no tendency to heal, but gives to the tissues a distinctive brawny induration. From the nose it extends to the palate, pharynx, and antrum, making steady encroachment upon the parts which it affects, distorting the features, obstructing respiration, and often causing pain by pressure on the sensory nerves. Its first appearance is characterized by nodules, frequently covered with dilated bloodvessels. Unless it can be seen and recognized early it is a wellnigh hopeless condition with which to contend. Extirpation of the affected tissue is the only satisfactory method of dealing with it. It is a different disease from rhinophyma described elsewhere. (See Figs. 7 and 8, p. 55.)

Mycosis Fungoides.

—This form of skin infection, of somewhat uncertain origin, is met in shape of fungoid nodules, and likely to involve the upper part of the body; they tend to increase in number and size, to infiltrate, often to ulcerate, sometimes to disappear by spontaneous absorption, but in severe cases cause death, either by malnutrition or sepsis. Tumors are thus formed which attain the size of a child’s head. As soon as surface infection or ulceration begins the breaking-down process is rapid; there is early involvement of the lymph nodes, and the general health begins to suffer. The tendency in almost every case is to fatal termination. Cases may run from a few months to fifteen years, however, before this stage is reached. By some authors the disease is considered as a peculiar form of sarcoma. It is, however, generally regarded as a granuloma, whose specific organism has not been ascertained.

Actinomycosis, Syphilis, Leprosy, and Glanders

should be included among the chronic infections of the skin, and have been described.

Radesyge.

—Radesyge is a granulomatous involvement of the skin, peculiar to certain parts of Europe, particularly Norway, which has been by some considered to be an expression of leprosy, by others to be a disease by itself. It is generally held that the lesions which have passed under this name are really expressions of cutaneous syphilis.

Framboesia; Yaws.

—This is an endemic tropical disease, of which we see our nearest specimens in the West Indies, and involves especially the negro and Oriental races. It begins with an eruption, papules maturing in fungoid form, being met with most often at mucocutaneous borders, but appearing anywhere upon the surface. It is specific and inoculable, having a period of incubation of about two weeks, and becoming generalized in from fifteen to twenty weeks. The papules increase in size, become covered with yellow crusts, which fall off and expose a rough surface which discharges an offensive puruloid material. After remaining in this condition for an indefinite time the lesions spontaneously improve and may disappear, leaving only pigmented spots to mark their previous sites. Beyond local cleanliness and antiseptic applications the lesions require but little treatment. If anything more is attempted it should be thorough and effected with the cautery or the sharp spoon.

Mycetoma.

—Mycetoma is more commonly known as Madura foot, or sometimes the fungus foot of India. It prevails especially in Southern India and about Madras, and is apparently confined to that part of the globe. Nevertheless it has been reported from Algiers and from South America. It is a specific infection of the foot, beginning in the skin; it rarely occurs on the hands, the scrotum, etc. It leads to the formation of an infectious granuloma, which gradually destroys the texture and identity of the tissues, and finally demands amputation or ablation of the part.

Russian bacteriologists have discovered parasites resembling the protozoa which they have found in the granulations and ulcerations of the Delhi boil. They were also occasionally seen in the leukocytes. By these observers these parasites have been regarded as active agents and have been given the name ovoplasma orientale.

Oriental Boil.-This also is a slow infection of the skin, met with especially in Southern India, where it is known as the Biskra button and the Aleppo or Delhi boil.[19] It appears mainly on the unprotected parts of the body at first as a papule and then a nodule, which enlarges, ulcerates, usually tends to heal spontaneously, and leaves an ineffaceable scar. It is practically a granuloma of the skin, is auto-inoculable, and is best treated by complete excision.

Guinea Worm, or Filaria Medinensis.

—This worm is about one line in diameter and two or three feet long, and is found generally throughout the tropics. The embryo is taken into the intestines with drinking water and migrates to the skin, beneath which it develops. The male worm has never been discovered. What is known of the evidence of its presence pertains only to the female. When fully developed it can be felt in a coil beneath the skin. It produces local inflammation, a vesicle forms, and the head of the worm then protrudes. When it is exposed it can be frequently extracted by gentle traction, removing as much each day as protrudes. Christie has suggested to destroy the worm by electrolysis, and others inject into the vesicle some antiseptic, by which the worm is killed, it being afterward absorbed without difficulty (Fig. 105).

Blastomycetic Dermatitis.

—This is a true protozoan infection of the skin, first described by Wernicke in 1892, which has now become quite generally recognized and described. The parasite is a very small, spheroid protozoan, and is found in the skin elements, as well as in the pus and debris discharged from the lesions. It has been successfully cultivated and inoculated. It is classed among the yeast fungi. It produces lesions very much like some of those met with in syphilis, tuberculosis, and mycosis fungoides. Indeed it may be necessary to use the microscope in order to complete the diagnosis, which is best accomplished by teasing a small portion of tissue on the slide in liquor potassæ (Hardaway).

The lesions begin usually as small papules, which may later coalesce and become covered with a fine scab. Around these there develop thickened borders, with fungus-like projections. Between the little elevations pus may form, or an exudate occur in sufficient quantity to dry into a large-sized crust. Here, as in lupus, cicatrization may be going on at interior points while the lesion is encroaching around the margin. The affection is slow, and the ulcer may attain a size of several inches in diameter.

The treatment consists in radical measures, i. e., strong caustics, curetting or complete extirpation with the knife, which may be followed by more or less plastic work, as required.

Coccidioidal Granuloma.

—Under this name is described a rare form of granulomatous lesion of the skin, whose exciting cause is not one of the ordinary bacteria, but a form of mold—one of the varieties of oidium. The clinical manifestations of this lesion resemble those of blastomycetic dermatitis, save that in the latter the primary focus of infection is always found in the skin and remains there localized, whereas coccidioidal granulomas may occur as well in the deeper tissues or viscera as upon the skin; in fact, the skin lesions of the latter may be described as oidiomycosis in distinction from blastomycosis. It produces miliary skin nodules which closely resemble tuberculous lesions, and may even caseate or assume an acute type and break down rapidly. The lesions are progressive, with a tendency to dissemination, both by the lymph and the blood currents. The lymph nodes are usually early affected and often suppurate.

Cysticercus, or Tænia Solium

, may be found in the subcutaneous tissue in the shape of small nodules, covered by unaffected skin. When young these tumors are tense and elastic, but are subject to calcareous changes. They occur frequently on the back.

Echinococcus Cysts

are also found in the skin, where they may attain a size which will make them fluctuate. The treatment for all such lesions is complete eradication.

Trophoneuroses.

Perforating Ulcer of the Foot.

—This has already been alluded to in the chapter on Ulcers and Ulceration. The lesion apparently begins as a thickening or callosity, usually beneath the head of the first metatarsal bone, at a point where much pressure is made, owing to the natural position of the foot. Beneath the thickened skin there develops an adventitious bursa, in which, or in the skin itself, the first degeneration may take place. The result is a deep ulcer, with overhanging borders, and a thin, often foul discharge. The lesion is not painful, and patients are less likely to spare the foot. It is usually associated with some central spinal disease, or with a peripheral neuritis. It is more common in those patients who have had disease leading to loss of sensation in the foot.

The treatment consists in excision of the ulcer down to healthy tissues, with careful protection. Skin grafting is often found successful.

Ainhum.

—Ainhum is essentially a disease of the negro and of tropical climates. It usually begins in the little toe or little finger, and goes on to spontaneous amputation, the result of an anemia caused by the formation of a sclerotic ring, which encircles the digit and shuts off the blood supply. It is an annular scleroderma, or keloid, which produces the disturbance.

CYSTS OF THE SKIN.

The most common cysts of the skin are the sebaceous, known also as steatomas, which result from obstruction of the ducts of sebaceous follicles, and accumulation therein of sebaceous secretion. They are found where these glands abound, and may attain the size of a hen’s egg or larger. They are frequently infected and suppurate, or their contents may undergo slow change and lose their original characteristics by the time they are evacuated. Peculiar changes occur in rare instances, since they may calcify, or their bases serve even for the development of cutaneous horns, while in the other direction they not infrequently undergo malignant degeneration. In some of these cysts a small opening can be found, through which, on pressure, fatty or butter-like contents can be exposed. When their contents begin to putrefy the odor becomes offensive.

Another variety of the skin cyst is the so-called atheromatous, which is more allied to the cutaneous dermoid, and whose contents are often nearly pure cholesterin. Sometimes they contain hair or other epithelial products. They occur usually in the scalp. These are essentially inclusion cysts and purely epiblastic products. When infected their contents putrefy and smell badly. (See Fig. 88, p. 285.)

Treatment.

—The treatment for any cysts of the skin consists in extirpation of the sac. It is sufficient to split them thoroughly with a sharp, curved bistoury, and then, on either side, to seize the edge of the divided sac with forceps and enucleate it. All this can be done under local anesthesia. The cavity should be thoroughly disinfected and not too tightly closed.

Under the name Cock’s peculiar tumor some English writers have alluded to the offensive ulcerated surface, with raised edges, which is left after the contents of these cysts have undergone putrefaction and escaped by breaking down of the surface. Such a lesion is on the border-land between mere ulceration and malignancy.

HYPERTROPHIES AND BENIGN TUMORS OF THE SKIN.

Corns.

—Clavi, or corns, vary in density. A soft corn differs from a hard one only in that it is located where it is softened by moisture of the parts. A hard corn is a reduplication or callosity, conical in shape, representing great hypertrophy, with condensation of surface epithelium. Beneath old lesions of this kind will frequently be found small cysts, while nerve fibers become entangled, and these little lesions are sometimes exceedingly sensitive. They frequently become inflamed, the process proceeding to suppuration or ulceration.

Bunions.

—When beneath such an indurated area of skin there forms an adventitious bursa, or a natural one becomes involved, the lesion is called a bunion. These are more frequent over the joints of the toes, where they sometimes cause intense discomfort. The bursæ sometimes connect with the joint cavity, and should one suppurate the other necessarily becomes involved. An infection of either of these lesions causes local and possibly fatal disturbance. I have seen death from pyemia follow infection of a bursa beneath a soft corn (Fig. 106).