Dermatology.

RINGWORM; PEDICULOSIS AND SCABIES;
ZEMA; PSORIASIS; EPITHELIOMA.

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CLINICAL LECTURE DELIVERED AT THE WOMAN'S MEDICAL COLLEGE OF THE NEW YORK INFIRMARY.

BY GEORGE THOMAS JACKSON, M.D.,

Professor of Dermatology.

RING WORM.

HERE is a little girl who has two circular patches upon the left side of the neck. They are scaly, of a rather pale red, and have a wellmarked elevated border. Their central portions are beginning to clear up, and look as if depressed. They are therefore ring-shaped patches. We also notice that the child has enlarged glands in the neck.

What are the eruptions that occur as circles or rings? It is well, for diagnostic purposes, to group in your minds the various dermatoses according to form, distribution, or some specially-pronounced symptom. Here the most striking element is the circular shape of the lesions, and we remember that erythema multiforme, psoriasis, pityriasis rosea, syphilis, and ringworm are all apt to occur as ringed eruptions.

Is this a case of erythema multiforme? No: because we have not a simple redness that fades away under pressure, to return again when pressure is removed. In this case the border is not only raised, but also decidedly scaly, and if you press upon it you will leave a yellowish stain that soon assumes the red color again. Besides, the eruption occurs on the neck alone, and not on the forearms and backs of the wrists, where an erythema multiforme would be quite sure to appear.

Is it psoriasis? Although the color is somewhat like that of psoriasis, and the patch is scaly, that is about as far as the resemblance goes. It is a localized and not a general eruption; the elbows, knees, and scalp are all spared, locations where we should find lesions were the case one of psoriasis.

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Is it pityriasis rosea? Here, again, the limitation of the disease to one locality throws out the diagnosis of pityriasis rosea. In that disease we find, especially on the trunk, dozens, perhaps scores, of rings and oval lesions which are slightly scaly. These do not clear in the centre, but present a wrinkled condition of the epidermis, looking like old parchment, appearances that are wanting here.

It is said that syphilis must be considered in every diagnosis, it is so protean a disease. There is a form of syphilis that looks somewhat like the eruption under consideration. It is known as the circinate syphilide. While it might occur in a child of this age, it practically is so rare a lesion in children that it should not be given much prominence in the diagnosis. Moreover, the light color of these lesions, the evidence of scratching that we find, and the superficial character of the whole affair, are against syphilis. Syphilides have a dark-red color, are not itchy, and present an infiltrated edge.

Having thrown out the other circinate eruptions, we have left the diagnosis of ringworm. This diagnosis we readily make directly and not by exclusion, because we know that ringworm of the body occurs in the form of superficial, scaly, light-red, round or ring-formed patches that itch slightly. So, then, we have established the diagnosis of the patches on the neck: they are ringworm.

But why should there be these enlarged glands in the neck? Whenever you find glands like these in this child's neck, you should first think of the possibility of there being some inflammatory disease of the scalp, as such diseases are always accompanied by enlarged lymphatic glands. If you should find an eczema capitis, look out for pediculi, as they very commonly are the cause of the eczema. Remember that pediculi are found most easily and abundantly on the occipital and temporal regions of the scalp. The most cursory examination of the scalp in this case shows abundant nits in the favorite regions, and more or less eczema. So the child has both trichophytosis corporis and pediculosis capitis.

Up to this year, it was thought and taught that there was but one trichophyton fungus, and this gave rise to both ringworm of the scalp and ringworm of the body. Sabouraud, of Paris, has upset all this. He has made extensive studies of the disease, and you will find a series of papers by him, on the subject, in the Annales de Dermatologie et de Syphiligraphie for 1893. It seems to me that his work is the most important of the year. He teaches us that we have no longer a single trichophyton fungus, but a number of them. He has found that the variety that causes ringworm of the scalp always breeds true,

and has small spores. This he names the " trichophyton microsporon.” It is the one most constantly found in the ringworm of the scalp that proves so obstinate to treatment. He has also found another variety constant in ringworm of the body, and sometimes found on the scalp. If it occurs on the scalp, the ringworm caused by it is easily cured. Now, we knew, by clinical experience, that there were some cases of ringworm of the scalp which were easy of cure, and others that were very obstinate to treatment. Sabouraud's discovery throws new light upon the subject, and explains the reason why. This second form of fungus has large spores and is named by its discoverer the " trichophyton megalosporon." This large-spored fungus is the one that occurs especially in animals, and has many varieties, one being apparently peculiar to horses, another to cats, another to fowls, and so on.

The case now before us is due to the trichophyton megalosporon, and has probably been derived from some animal. Ringworm is very common in horses, dogs, cats, and other domestic animals. Whenever you find a ringworm in a child, always institute a search of the child's pets. You will frequently find a cat with the hair off its legs, scaly skin, and a generally distressed look.

It is usually as easy to cure ringworm of the body as it is to recognize it. There are nearly as many ringworm cures as there are wart cures, and they are many. You can cure ringworm by almost any antiparasitic application, such as sulphur ointment, painting with tincture of iodine, chrysarobin, or bichloride-of-mercury solution, two grains to the ounce. The objection to the iodine and the chrysarobin is that they both stain the skin. The old women cure cases by the application of common ink, or of vinegar in which an old-fashioned copper cent has been soaked.

SCABIES; PEDICULOSIS CAPITIS.

This little boy has a general eczema of the pustular variety, the pustules forming patches. We note that the crusts are rather greenish. On the neck there are many pustules. We know the disease is itchy, because we see the scratch-marks. It is a pustular eczema, but we must find out if there is anything behind the eczema. We see the hair has been cut off, and that there are large crusts on the scalp. These crusts are always suggestive of pediculosis. We think also of scabies and of urticaria, because those are itchy eruptions, and when they occur over the body pretty generally are apt to cause an artificial eczema. In this case the hands are very much implicated, and we are sure there is something besides pediculosis, because that

does not affect the hands. We also notice that the prepuce is swollen and has upon it a number of scratched lesions.

Whenever you find the penis so much affected as in this case, you may be quite sure that you have scabies to deal with. This is a very important point, because often you will examine a patient all over, and he will show scarcely any decided symptoms of scabies, but if you find the genitals are affected, as in this case, you may suspect scabies. That this child has pediculosis capitis we know from the location of his eczema on the occipital region and by finding nits on the hair. That he has not pediculosis vestimentorum we know, because the eruption here does not occupy the typical location for that form of the disease, that is, over the shoulders and on the outer and inner aspects of the limbs where the seams of the clothing come, and over the buttocks, which is very common, and around the waistband.

On the other hand, scabies occurs on the anterior face of the wrist, between the webs of the fingers, around the umbilicus, and on the genitals of the male and the breast of the female. It is also apt to affect the axillæ, and this child has it quite well marked in that location. Scabies never occurs upon the face, but you may have an eczema on the face with scabies, which is sympathetic. The eruption consists of excoriations, pustules, and eczematous patches. Another diagnostic sign of scabies is the furrow, which is often hard to find. Our patient has therefore two diseases,-pediculosis capitis and scabies. This is the second case to-day with more than one skin-disease.

To cure scabies is easy if you recognize it. Never be content with the simple diagnosis of eczema until you are sure that you have excluded scabies and pediculosis. Sometimes cases of scabies will be treated by the physician for months under the mistaken diagnosis of eczema. Oxide-of-zinc ointment won't cure scabies. Perhaps as efficient a remedy for its cure as any is sulphur ointment. The patient is directed to take a warm bath and scrub his skin thoroughly with soap. He is then to dry the skin with a coarse towel, and rub in sulphur ointment. He is to rub in the ointment each morning and evening for three days, and then take another bath and report to the doctor. Perhaps a second course of treatment may be necessary for a cure. Two courses are almost always enough. At the end of the second course it is always best to suspend treatment for a few days and use only vaseline and corn-starch to the skin, even though itching is still complained of, because sulphur will at times set up an eczema of its own that will be itchy. In small children balsam of Peru will be as efficient as sulphur, and is less objectionable to the attendants.

ECZEMA.

Eczema is the most important of all our skin-diseases. There are six cardinal signs of eczema,-namely, redness, itching, infiltration, moisture, crusting or scaling, and cracking.

This boy has an eruption on the skin. You can see that it itches; you will also notice that it forms patches, and that these patches are not definitely shaped, and have no particular outline. If you look at his right arm, for instance, it would be very hard for you to draw a picture of the outline of the patch on the blackboard and say where it began and where it ended. The skin feels harsh and dry, and also thickened. If you take up a fold of the diseased skin, and then one of the sound skin, you will appreciate that there is a difference in the thickness of the skin. The patches are red. The disease seems to be quite a dry one, but you see a number of lately-torn-off little crusts with excoriated points, and, looking at it closely, you can see here and there the shining of a vesicle, showing that there is a tendency to moisture. So we have here redness, itching, infiltration, and a tendency to moisture. You can see also a certain amount of both scaling and crusting. There is no cracking, because the disease is not located where cracks occur, that is, it is not over the joints.

What sort

This is an excellent illustration of a case of eczema. of eczema shall we call it? There are a variety of eczemas put down in the text-books: which is this? It is sufficient for us to know in the first place that it is an eczema; and after that to know whether it is acute, subacute, or chronic. These are the important points so far as the cure of the case is concerned.

Behind the ears we find little scaly patches. Recollect that behind the ear is the place where eczema is very fond of retiring. A scaly patch behind the ear is indicative of eczema, while one in front of the ear suggests psoriasis. Now, as to treatment. The case is at least subacute, as we find no evidences of much activity. Choose your treatment from what you see, not from the length of time the disease has lasted. We may have an acute outbreak upon a chronic eczematous patch. Remember that in an acute eczema you should use the mildest possible remedies, such as lime-water, or vaseline and corn-starch; in subacute cases astringents and protectives are in order, such as oxide-of-zinc ointment, Lassar's paste, and diachylon ointment. Still later, when the squamous stage is reached, and there is more or less thickening of the skin, we should use stimulating treatment, and our most usual stimulant is some form of tar, especially the oil of cade in the strength of