In walking and during the summer decomposition of the smegma readily takes place, and the decomposed secretion causes irritation of the prepuce and of the glans and excites a balanitis or a balanoposthitis. Under such conditions excoriations, adhesions between the prepuce and the glans, and acuminated condylomata may occur. The marked irritation and itching readily induce onanism. Slight degrees of phimosis should be corrected by retraction of the prepuce upon the glans several times daily, preferably after the evacuation of urine, and maintaining the retraction for some time. More marked degrees of phimosis must be relieved by operative means. The accumulated crusts of fat should then be anointed every two hours with olive-oil until they are exfoliated, the glans and the prepuce be washed with green soup, and then lead-water be applied. In girls and women accumulations of smegma take place upon the clitoris and between the labia, and will require the same treatment as the analogous condition in males.

Universal seborrhea occurs occasionally in the newborn, the active secretion of sebaceous matter that during fetal life gives rise to the formation of the caseous vernix persisting during the first days of life. The skin is covered with large fatty scales, so that it appears as if plowed. The condition is therefore designated also sebaceous ichthyosis, or cutis testea. Often the temperature of the body is abnormally low, food is rejected, and collapse occurs, and may lead to death. The children should be given milk at regular intervals, should be placed twice daily in a warm bath at 42.5° C. (34° R.-108.5° F.), and the skin after the bath should be anointed with olive-oil in order to remove the scales. In bed hot bottles should be placed at the side of the body of the child. In adults universal seborrhea occurs especially in the sequence of debilitating diseases. The skin becomes rough and covered with grayish scales, and the condition is designated pityriasis tabescentium, scrofulosorum, carcinomatosorum, etc., in accordance with the nature of the primary disease. Inunctions of the skin with oil will then render it again pliable and smooth.

DIMINUTION IN THE SEBACEOUS SECRETION (OLIGOSTEATOSIS).

Diminution in the sebaceous secretion is attended with dryness of the skin and a tendency to fissures and the formation of scales. When the skin is covered with epidermic scales the condition is designated also simple pityriasis. The disorder may be congenital or acquired, and develops particularly in the course of a number of chronic diseases of the skin, as, for instance, ichthyosis, psoriasis, and prurigo. Locally it occurs often upon the dorsum of the hands in persons who frequently wash them, particularly during the winter; under such circumstances "chapped hands" result.

The disorder can be relieved by inunctions of the skin with oil, wool-fat, or glycerin. In winter gloves should be worn.

DISORDERS OF SEBACEOUS SECRETION

(PARASTEATOSIS).

COMEDO.

Symptoms and Diagnosis.-Comedones consist in black dots upon the skin, situated in the orifices of the sebaceous follicles, and often projecting somewhat above the level of the skin. If lateral pressure be exerted, the black dot escapes externally, and is followed by a spiral yellow thread, resembling a tiny worm, which consists of inspissated sebaceous matter, and on microscopic examination will be found to contain fat-drops, glandular cells involved in fatty degeneration, cholesterin, leucin, crystals of tyrosin, and, not rarely, acarus of the follicles and bacteria. Comedones are often present in such large number and so closely together that the skin presents a densely mottled appearance. The skin is sometimes elevated like a dise, or a wart, or a nipple. Comedones are especially numerous upon the forehead, the nose, the lips, the chest, and the back, because sebaceous follicles are present in large number in these situations. Comedones are often associated with acne.

Etiology.-Comedones develop with especial frequency at the period of puberty in anemic individuals, perhaps in consequence of deficient activity in the forces that bring about excretion of the sebaceous matter. Occasionally the condition is the result of mechanical obstruction of the orifices of the sebaceous follicles, such as occurs in laborers in tar-works and in oil-works. Sebaceous matter of excessive density also appears to be responsible for the development of comedones.

Prognosis and Treatment.-Comedones are troublesome on account of the disfigurement to which they give rise, but otherwise they represent a wholly innocuous condition, which can be removed by expression between the finger-nails or with the aid of a watch-key. Green soap may be employed to wash the skin, in order to bring about increased exfoliation of the epidermis.

CUTANEOUS SAND (MILIUM).

Milia appear in the form of bright white nodules rather larger than a poppy-seed, over which the epidermis is stretched. If they be incised with a knife, hard, crumbling matter can be expressed containing epidermis-cells arranged like the layers of an onion, but generally without fatty degeneration. These masses have collected in a lobule of a sebaceous follicle, or within the entire

glandular space. Milia are especially common upon the eyelids, the cheeks, and the genitalia. In the coronary sulcus of the glans they are occasionally present in large number, lying close together. They develop with especial readiness at the periphery of cutaneous cicatrices; further, in conjunction with other diseases of the skin, as, for instance, after pemphigus. Occasionally the condition appears to depend upon an abnormal composition of the sebaceous matter. The disorder can be readily relieved by incision with the knife and removal of the contents by pressure.

III. HYPERTROPHIES OF THE SKIN.

HYPERTROPHIES OF THE PIGMENT OF THE SKIN.

NEVUS (MOTHER-MARK).

The designation mother-mark is applied to yellowish, brownish, or even blackish discolorations of the skin that are congenital, but frequently increase progressively in size after birth. On microscopic examination brownish and blackish pigment-granules are found in the lowermost cells of the Malpighian layer, in the cells of the cutis, and often also in obliterated vessels of the cutis. The pigment gains entrance into the cells of the Malpighian layer from the cutis. Mother-marks with a smooth covering of epidermis are designated nævi spili; those with a nodular surface, as verrucose nevi; and those covered with hair, as hairy nevi. Occasionally they are attached to the skin by a pedicle like a tumor, and are then designated mollusciform neri. They vary greatly in number and size. Occasionally they are so densely packed together that the skin presents a spotted appearance. times they follow the course of the nerves upon one or both sides -nerve-neri-and among other structures surround the gluteal and the pubic region like bathing-trunks. Occasionally nevi become carcinomatous at a later period. Their removal can be effected only by operative means.

CHLOASMA.

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The designation chloasma is applied to acquired discolorations of the skin which give rise to a brownish tint. In accordance with the causative factors, several varieties of chloasma are distinguished.

Freckles, ephelides, or lentigenes are roundish, brownish spots which appear especially upon the nose, the adjacent cheek, and

forehead, but also upon covered portions of the body (flexor surfaces of the extremities, the genitalia), and therefore are due not alone to the action of the sun. Freckles usually develop in especially large number in blond and red-haired individuals with a delicate skin. Generally they do not appear before the sixth or after the fortieth year of life. Most frequently they develop at the period of puberty, disappearing spontaneously subsequently. When present in large number they give rise to disfigurement. They can be removed by means of agents that induce active exfoliation of the skin, as, for instance, frictions with green soap, applications of tincture of iodin or of a solution of mercuric chlorid (0.5:50). When present in large number they may be concealed by means of cosmetics.

Traumatic chloasma is attended with dark discoloration of the skin at places where an injury has been inflicted, as, for instance, by the pressure of belts or bands, as a result of scratching for relief from itching cutaneous eruptions, irritating poultices and plasters (mustard-plaster, cantharidal plaster). When pediculi have been present in the clothing for a long time the skin of the trunk especially acquires an almost black color, and this is known as melasma (melanoderma, nigrities), or, if desquamation takes place, as pityriasis nigra.

Caloric chloasma is the designation applied to those dark discolorations of the skin that result from the action of the rays of the sun. Uterine chloasma occurs especially upon the forehead and the cheeks in women suffering from menstrual disorders or uterine or ovarian disease. The chloasma of pregnancy, which develops in gravid women, also belongs in this category.

Cachectic chloasma occurs in cases of pulmonary tuberculosis, carcinoma, malaria, and syphilitic cachexia.

Dark discoloration of the skin is the principal symptom of

Addison's disease.

From the presence of abnormal pigments discoloration of the skin occurs in cases of jaundice; after the use of silver nitrate in the form of argyria; and after the administration of arsenic in the form of arsenical melanosis. Blackish discoloration, particularly of the hands and the forearms has been observed in workers in silver, from the penetration of silver-dust, in stonecutters and millers from iron-dust-siderosis of the skin, and in chimneysweeps and firemen from coal-dust-anthracosis of the skin.

HYPERTROPHY OF THE EPIDERMIS
(KERATOSIS).

ICHTHYOSIS.

Etiology, Symptoms, Diagnosis, and Prognosis.—Ichthyosis is generally an hereditary disease. Cases that are not hereditary are extremely rare, and then occur usually in con

nection with other antecedent disease of the skin. In the last instance the keratosis does not involve the entire skin (total ichthyosis), but only circumscribed portions (partial ichthyosis). Also in the hereditary cases the earliest alterations in the skin do not appear until after the first year of life. In the mildest form of the disease the skin exhibits a tendency to desquamation in large quadrangular areas. At the same time the skin is dry and exceedingly rough-simple ichthyosis. Not rarely the borders of the individual cutaneous scales appear slightly raised, while the center is depressed-scutellate ichthyosis. If the individual areas present a mother-of-pearl appearance, especially toward their free borders, the condition is designated nitid ichthyosis. At times the epidermic scales present a grayish discoloration, so that the appearance of the skin is suggestive of that of the skin of a snakeserpentine or cyprine ichthyosis. In the most marked cases the epidermic scales appear horny, thickened, and curved-corneal ichthyosis; or the epidermis is the seat of thorny, grayish-black projections-histricine ichthyosis. Patients of the latter kind, who are occasionally exhibited in museums as curiosities, have also been designated porcupine-people. Often the different portions of the skin are affected in varying degrees.

The earliest changes in the skin are observed upon the extensor surfaces of the elbows and the knees. The flexures of the joints, the axillary cavities, the palms of the hands, the soles of the feet, and the genitalia remain uninvolved. The face and the scalp also are generally but little affected, although they may desquamate freely. Frequently there is marked loss of hair. Patients with ichthyosis perspire little, complain frequently of distressing itching of the skin, and occasionally suffer from painful fissures. times hypertrophy of the heart, albuminuria, or polyuria has been observed. The disease generally persists throughout the whole of life, although remissions and exacerbations frequently occur. Life is not endangered. Improvement may be effected temporarily. In isolated instances recovery has taken place spontaneously, as, for instance, after recovery from small-pox.

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Anatomic Alterations.-Ichthyosis is attended with excessive proliferation of the cells of the epidermis. In the pricklelayer of the epidermis the marked development of the prickle-processes and the thickness of the intercellular tissues are conspicuous. Processes of division and multiplication also are present in some of the cells. In addition, black pigment occurs, partly within and partly outside of the cells. Proliferation and prolongation of the papillary bodies are encountered in the cutis. The bloodvessels are dilated and the entire cutis is unusually dense. The sudoriferous and the sebaceous glands often are atrophied. The subcutaneous connective tissue is distinctly atrophied.

Treatment.-Temporary improvement and even cure can be