THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
LOS ANGELES
DR. BOLCSLAW LAPOWSKI,
28 CtNTRAL PARK SOUTH,
NEW YORK.
CUTANEOUS MEDICINE
A SYSTEMATIC TREATISE
ON THE
DISEASES OF THE SKIN
BY
LOUIS A. DUHRING, M.D.
PROFESSOR OF DISEASES OF THE SKIN IN THE UNIVERSITY OF PENNSYLVANIA
AUTHOR OF "A PRACTICAL TREATISE ON DISEASES OF THE SKIN"
AND "ATLAS OF SKIN DISEASES."
DR. BOLESLAW LAPOWSKI,
20 CENTRAL PARK SOUTH,
NEW YORK.
RART I.
Anatomy of the Skin Physiology of the Skin General Symptomatology
General Etiology General Pathology General Diagnosis General
Treatment General Prognosis.
ILLUSTRATED
PHILADELPHIA
J. B. LIPPINCOTT COMPANY
1895.
COPYRIGHT, 1895,
BY
J. B. LIPPINCOTT COMPANY.
ElECTROTYPED AND PRINTED BY J. B. LiPPINCOTT COMPANY, PHILADELPHIA, US A.
Biomedical
Library
/PO
D-
HIS
TO THE MEMBERS
OF THE
AMERICAN DERMATOLOGICAL ASSOCIATION
WHO BY THKIR FAITHFUL SERVICE AND VALUABLE
CONTRIBUTIONS TO THIS
DEPARTMENT OF MEDICINE
THIS
is
H>et>icate&
WITH SENTIMENTS OF HIGHEST ESTEEM AND REGARD
BY
THE AUTHOR
635837
PREFACE.
THE present work has been written to take the place of the author's
former Practical Treatise on Diseases of the Skin, which for several
years has been out of print. The favorable reception accorded to that
work by the medical profession everywhere as attested by the many
thousand copies published, by the press in this country and abroad, and
by its translation into French, Italian, and Russian, has led the author
to believe that a larger and more comprehensive treatise on the same
subject might be equally well received.
The material dealt with in the present volume has on all sides been
approached from a practical stand-point. It has been the aim of the
author to adhere closely to the practical aspect of the subject, supported
by science and by experience. The work, as a whole, rests on clinical
observation supported by pathology and pathological anatomy. The
principles of cutaneous pathology and therapeutics have been put forth
upon conservative lines in the light of modern research and experience.
The rapid strides that Dermatology has taken during the past decade
have produced remarkable changes in the pathology of many of the
diseases of the skin, but clinical observations are on this account none
the less valuable and important.
The author is convinced that the skin occupies a more conspicuous
place in Medicine than has heretofore been accorded to it. It is a large,
complex, important organ of the body, and is by no means a mere pro-
tective covering. It is not only subject to many diseases which are
wholly confined to the skin, but is also intimately connected with
numerous general morbid processes, to describe and to point out the
significance of which is within the province of Cutaneous Medicine. It
occupies a very broad and useful field of observation. No other organ
of the body offers such inducements to the pathologist for study. When
the skin is carefully investigated, and when the signs with which it is
v
vi PREFACE.
marked by disease are properly interpreted, in many instances most
valuable general information is yielded to the clinician as well as to the
pathologist.
The view is taken by the author that the skin and subcutaneous tissue,
composing the integument, should be regarded as a part of the body
rather than as an independent organ. The skin possesses the closest
relations with the general economy, as shown by the observation that
there are comparatively few so-called general diseases in which it
(including naturally the sweat and sebaceous glandular systems) is not
at some period involved in a slight or a marked degree. It may be in
the form merely of general anaemia or hypersemia, but either condition
may be significant of some general pathological process. Hence there
is a great deal to be learned from the close study of this organ in
various diseases other than those in which obvious erythematous,
inflamed, atrophic or hypertrophic lesions (constituting many of the
so-called skin-diseases) exist. In the study of diseases in which this
organ is aifected, taking for example the erythemata as a group, it is
often impossible to determine where the line may be drawn separating
the idiopathic from the symptomatic cutaneous diseases, those which
might properly be designated pure " skin-diseases" from those in
which other organs as well as the skin are involved. The author
is convinced that in many instances such lines cannot be drawn. In
these cases, if attempt be made to adhere strictly to such an arbitrary
decision, confusion must result. For these reasons the systematic study
of cutaneous diseases must embrace not only all the affections involving
the skin, as exemplified by strictly local diseases, but also all morbid
processes in which the integument is in any manner or degree affected.
Dermatology is thus broadened, and its usefulness to General Medicine
becomes obvious.
An accurate knowledge of the anatomy and physiology of the skin
aids greatly the understanding of the diseases which affect this organ.
In like manner a comprehensive view of the general etiology and
pathology of the integument assists the student in comprehending the
meaning of the numerous and diverse manifestations which occur on
the skin. For these reasons considerable attention has been bestowed
on these topics, which may be regarded as the foundation-stones of
Dermatology.
The opinions expressed on therapeutics are in the main the result of
the author's convictions, based upon an extensive clinical experience with
cutaneous diseases at home and abroad, in hospital, dispensary, and
PREFACE. v ii
private practice, extending over a period of nearly thirty years. The
matter has been written in the plainest language, with the view that it
should prove useful to the student as well as to the physician.
The authors and writers of the United States and of foreign countries,
especially of Great Britain, Germany, and France, have been drawn upon
freely, and it has been the endeavor of the author to give credit for all
original investigations. No one appreciates more fully than he the
admirable work that has been done for Dermatology in all parts of the
world. The United States, especially through the medium of the
American Dermatological Association, has contributed a liberal share.
The subject of the skin and all that pertains to it, in health as well as
in disease, has received a great impetus in the way of original investi-
gation and general interest, not only through the medium of bacteriology,
but also in many other directions. Cutaneous Medicine is rapidly as-
suming the elevated position to which it is entitled. It is a natural,
and therefore a legitimate, specialty of General Medicine, and covers
a very extensive, almost limitless, field for the investigator.
Louis A. DUHRING, M.D.
PHILADELPHIA,
1411 SPRUCE STREET.
PAET I.
GENERAL CONSIDERATIONS.
ANATOMY OF THE SKIN.
THE SKIN AS A WHOLE.
A CAREFUL study of the skin as a whole, and of its component parts,
is a matter of the greatest importance to the proper understanding of
its manifold diseases. Without a comprehension of the minute anatomy
of this complex membrane it is impossible to appreciate the pathological
processes and the changes resulting therefrom which constitute the dis-
eases of the skin. The diagnosis of these affections depends to a con-
siderable extent upon close acquaintance with the anatomy of this organ.
The skin is not merely the covering of the organism, but is also the
seat of functional action, in the form of absorption and secretion, and
in the elimination of various products of the economy. It is also a
regulator of the bodily temperature, and an organ of touch. The skin
is a highly vascular and sentient organ, being endowed with special nerve
apparatus, by means of which knowledge of the objects coming in con-
tact with it is obtained. It will be noted, therefore, that an understand-
ing of its physiology is likewise important. Some of the diseases, as, for
example, those of secretion, are mainly or entirely abnormal physiological
processes. The skin has many offices to perform. It is not only the
outer covering of the body, subject to external influences of all kinds,
but it also has relations with various tissues leading to other organs.
To estimate justly the part it plays in the healthy economy and in disease,
therefore, both the anatomy and the physiology must be studied.
GENERAL, CHARACTERISTICS.
The skin, or INTEGUMENTUM COMMUNE, is a covering which com-
pletely invests the body. It is a flexible, tough membrane, possessing
extensibility and elasticity. It offers considerable resistance to external
agencies of all kinds, and thus serves as a protecting organ. This func-
tion is due largely to the subcutaneous adipose tissue, which fills up the
spaces and depressions caused by the several organs and appendages of
the integument. Forces acting from within towards the surface, too,
are regulated by the skin, which acts as a barrier. To the touch the
general surface has a soft, smooth, more or less unctuous feel, especially
1 1
2 ANATOMY OF THE SKIN.
upon those regions devoid of coarse hairs and usually kept covered.
In certain localities, however, and particularly in exposed parts, it is
dry, or may even be harsh, as over joints and on the extremities.
Upon the surface there are numerous lines and markings of various size
and form, which are well denned upon the face, hands, and feet, and larger
and deeper furrows occur about the joints and elsewhere. Numerous
minute depressions, so-called PORES, the orifices of glandular ducts and of
hair-follicles, also exist over the surface. Hairs, coarse and fine, occur
upon almost all regions, more abundantly in some localities than in
others, and serve useful purposes. The color of the skin varies with the
race and with the locality. The thickness is likewise variable, depending
on the region, being thickest on the back, buttocks, palms, and soles, and
thinnest on the eyelids and prepuce. J. Gastreich, 1 who has studied the
subject of the transparency of the human skin by the method of sections,
finds the epidermis more translucent than the corium, and by staining
shows the walls of the veins to be more so than those of the arteries.
The integument viewed anatomically is a complex organization. It
consists of parts, some of which are essential and are everywhere present,
while others are special and exist only in certain regions. To the first
group belong the epidermis, corium, and subcutaneous connective tissue ;
to the second, the sebaceous and sweat glands, hairs, nails, and special
terminal nerve organs, all designated APPENDAGES OF THE SKIN. In
addition to the constituents mentioned, the skin contains blood-vessels,
lymphatics, and medullated and non-medullated nerve fibres.
EARLY DEVELOPMENT OF THE SKIN.
First, the early development of the skin is to be considered, whereby
the order and manner of its formation during intra-uterine life may be
noted. According to the teachings of embryology, two layers only of
the skin are recognized, the epidermis and the corium. The corium is
the foundation of the skin, and is developed from the superficial layer
of the mesoblast, designated by Remak the SKIN-PLATE. The minute
histology of the skin of the embryo has been investigated by Unna, 2 to
whose observations reference will be made, and more recently by Louis
Heitzmann, 3 who has studied a series of sections derived from embryos
1 Monatshefte fur prak. Derm., Bd. xii. S. 495.
2 Anatomy and development of the skin, in Ziemssen's "Hand-Book of Skin Dis-
eases" (translation). New York, 1885. The author takes this opportunity of acknowl-
edging the assistance he has derived from this valuable article.
3 This observer holds to, and has elaborated, the views concerning protoplasm and
basis-substance put forth by Schwann, in 1839, Max Schultze, in 1862, and Carl
Heitzmann, in 1873. The last-named author observed that the basis-substance of all
varieties of connective tissue was not inert but living material. This, as concerned
hyalin cartilage, was confirmed by A. Spina in 1879. Louis Heitzmann has recently
found this to be true for the skin. The view is expressed that the basis-substance in
toto is not living, but that this substance is permeated by a net-work of living matter.
Basis-substance and protoplasm are regarded us of the same structure ; either may at
ANATOMY OF THE SKIN. 3
of all ages, from one to nine months. According to this author, at the
end of the first month the whole product consists of indifferent medullary
or embryonal elements. The surface of the skin shows one or two layers
of epithelium with large nuclei, the corium consisting of shining, struc-
tureless, homogeneous masses surrounded with a protoplasmic net-work
composed of light granular bodies bound together with delicate threads.
Between the second and the third month the indifferent masses undergo
a change into oblong and spindle-form bodies embedded in the proto-
plasm extensions which have assumed a spindle form. The nucleus-like
formations near the surface are closely pressed together, and separated
from one another by scanty protoplasm, while in the deeper layers they
are less numerous and are separated by heavier layers of streaked or
elongated protoplasm, the reticular form of the latter still existing.
PROTOPLASM BECOMES BASIS-SUBSTANCE.
The protoplasm under a high power is noted to have changed into
small, spindle-shaped forms having a close connection with the oblong
nuclei. Here and there are encountered elongated nucleated bodies in
connection with simple, double, or divided prolongations, the " caudate
fibre-plastic cells" of authors, as described originally by Schwann. These
cells L. Heitzmann regards as being artificial productions caused by tear-
ing the preparation, for they are not constant. In the deeper strata of
the future corium delicate bundles of so-called fibrillar connective tissue
are at this period met with. It appears plain that all the fibrillae are
built up from spindles, w T hich differ from the protoplasmic spindles only
in being more shining. Now for the first time the transformation of
protoplasm into basis-substance becomes manifest. Inasmuch as in this
process the reticular structure of the original protoplasm remains intact,
the deduction may be drawn that only the matter in the reticular spaces
which contain fluid undergoes a chemical transformation into collagenous
substance. At this stage of the development are observed masses of
strongly refractive granules of variable sizes and number seated in the
protoplasm. These are the blood-cells of Schwann and the haemato-
blasts of C. Heitzmann, from which result the blood-vessels and the
red blood-corpuscles. An inner layer is now conspicuous, which shows a
deposition of fat and forms the subcutaneous tissue. This latter has been
called the " hypoderm" by Besnier, and really belongs to the corium.
STRUCTURE OF THE EARLY CORIUM.
The entire corium matures from within outwards, and hence the sub-
cutaneous tissue is the first layer and the papillary layer of the corium
any time pass into the other. Protoplasm advances physiologically into basis-substance,
and the latter, on the other hand, in senile atrophy, and especially in pathological
processes, passes into protoplasm. "Die Entwicklunggeschichte der Lederhaut," in
Archiv fur Derm. u. Syph., 1890, p. 621, an article to which the author expresses his
indebtedness.
4 ANATOMY OF THE SKIN.
the last to develop. Between the third and the fourth month the layers
of the epithelium become more numerous, the lower strata sinking into
the corium as button-form prolongations to form future glands, hairs,
and hair-follicles. The whole corium at this stage is made up of myxo-
fibrous structure. In the fifth month the corium again changes, the
myxomatous tissue disappearing and being replaced by a more col-
lagenous basis-substance, which henceforth increases steadily. Between
the seventh and the eighth month the bundles of tissue of the corium
become more marked, and numerous hsematoblasts appear. Heitz-
mann's observations go to show that the red blood-corpuscles occur
primarily in the connective tissue without previous formation of vessels
and independently of them. At this date fine reticular fibrillee, myxo-
matous in nature, characterized by refracting light strongly, make their
appearance, which eventually may become elastic fibres. During fetal
life the subcutaneous tissue develops more than any other portion of
the integument, owing to the deposit in it of fat tissue. After birth
the fat tends to decrease, except at certain points of the body, the sub-
cutaneous tissue becoming a loose net-work.
ARRANGEMENT OF CELLS AND FASCICULI.
As the corium continues to mature, its component cells and bundles
take on a definite plan of arrangement, varying for different regions
and localities. As Unna explains this, the skin, as the outer covering of
the entire body, is forced to follow it in its increased bulk, and is there-
fore kept in a state of permanent tension, thus exerting an influence
upon the long axes of the cells. The trunk and extremities at this stage
of life being short cylindrical bodies, the circular growth of the skin
exceeds that in a longitudinal direction in the proportion of about three
to two. The long axes of the spindle cells naturally yield to the stronger
traction, and consequently arrange themselves at right angles to the long
axes of the trunk and extremities. This course of the cells, having
been established in the foetus, becomes more marked after birth by the
further development of fibrous tissue. In consequence of the extension
of the flexed extremities after birth, and the increased growth in length
which then begins to take place, the direction of many of the connective-
tissue cells and bundles becomes chansred from a transverse into a curved,
o *
spiral, or longitudinal course, such changes occurring chiefly near the
joints, as C. Langer l has shown.
PAPILLARY LAYER.
The papillary layer manifests itself about the fourth month upon
the palms and soles (Unna), produced by the epidermis projecting itself
1 Zur Anat. u Phys. der Haut (I. Die Spaltbarkeit der Cutis ; II. Die Spannung der
Cutis), Sitzungsb. der "Wiener k. Akad. der Wissensch., math.-naturwiss. Classe, xliv.
Bd. I. Abth., Jahrg. 1861, Wien, 1862, und xlv. Bd. I. Abth., Jahrg. 1862, Wien, 1862.
The articles are important contributions, the first being finely illustrated by C. Heitz-
ANATOMY OF THE SKIN. 5
into the corium, giving rise to groove-like depressions. From this date
onward the epidermic and papillary layer are closely connected, the one
dovetailing into the other. But the formation and development of this
luvei- vary with the region, it appearing earlier in some localities and
later in others. Thus, Heitzmann states that it first shows itself upon
the neck, in the form of flat elevations, during the eighth month. Its
formation at an early or a late period depends upon the amount of
epithelial proliferation, and hence it is developed earliest where the
epidermis is naturally thickest.
THE EPIDERMIS A DISTINCT LAYER.
The epidermis is a distinct layer, having no relation genetically with
the papillary layer. It springs from its own matrix, the ectoderm. In
the first month a single layer of cells is present, and in the. second
month a second row between the first row and the corium makes its
appearance, the outer or original stratum becoming flatter, resembling in
shape the subsequent horny layer. From the third to the fifth month
from two to four rows exist, the cells now showing prickles on their
borders, due to the presence of fine connecting threads between the cells.
The horny layer remains thin, and, according to Unna, at the seventh
month has only two rows of cells, the outermost, non-nucleated cells being
mixed with fat and transformed into the vernix caseosa. Granular cells
show themselves between the prickle-cells and the horny cells, and more
complete cornification sets in. The mucous layer is exceedingly active
from the fifth to the eighth month, during which period the hairs and
glands are being formed from this structure by cell division. With the
cornification of the horny layer a barrier to the outward proliferation of
the prickle-cells is established, proliferation in consequence tending to
take place inwardly, thus pressing upon the soft and yielding corium
and forming the papillae.
Having thus considered the general development of the skin before
birth, the anatomy and histology of the mature structure may now be
described. 1
1 Acknowledgment is here made to the " Atlas of Histology," by Klein and Smith,
Phila., 1879; to "Microscopical Morphology of the Animal Body in Health and Dis-
ease," New York, 1883, by C. Heitzmann ; and to A. Biesiadecki's article "Skin," in
Strieker's Hand-Book of Human and Comparative Histology. London, 1872. Also
to essays by C. Remy on the "Histology of the Normal Skin of Man," Gaz. Med.
de Paris, May 4, 1878; abstract in Archives of Derm., 1879, p. 57; by J. Renaut,
" Anatomy of the Skin," in Annales de Derm, et de Syph., 1878; and by Louis Heitz-
mann on the "Anatomy of the Skin," in Morrow's System of Dermatology. New
York, 1894. Special mention remains to be made of the sterling work " Handbuch der
Gewebelehre des Menschen" (sechste umgearbeitete Auflage, Band i., Leipzig, 1889) by
A. Koelliker, from which on many points the author has derived aid. A full bibliog-
raphy up to 1885 of the anatomy of the skin may be found in Diet. Encyclop. des Sci.
Med., art. PEAU. Paris, 1886/
6 ANATOMY OF THE SKIN.
CORIUM.
The corium, called also DERMA, CUTIS, CUTIS VERA, and TRUE SKIN, is
the most important part of the integument. It is a dense and tough
structure, made up mainly of white fibrous tissue. Elastic fibres are
also present, varying in quantity with the locality. It is exceedingly
vascular and sentient, and, besides blood-vessels, nerves, and terminal
nerve organs, contains lymphatics, smooth muscles, hairs, sebaceous and
sweat glands, and fat-cells, which are situated in the interfascicular spaces.
The corium is divided into two portions, an upper and a lower, termed
respectively the PAPILLARY LAYER and the RETICULAR LAYER. These
strata are not separated by any line, but pass gradually into each other.
The upper portion, or papillary layer, is raised into prominences termed
PAPILLAE, to be referred to elsewhere, while the lower portion passes with-
out a line of demarcation into the subcutaneous connective tissue. The
corium, therefore, is not a plane surface, but consists of numerous eleva-
tions and depressions, and of folds and duplicatures, which are obliterated
by traction or by tension of the deeper structures. Linear markings,
wrinkles, and furrows of variable size also occur, further reference to
which will be made elsewhere. Above the corium rests the non-vascular
epidermis, with its epithelial cells fitting closely upon and dovetailed into
the papillary layer.
STRUCTURE OF THE CORIUM.
The framework of the corium is composed largely of white fibrous
connective tissue with a variable amount of elastic tissue, containing but
few cells. The former is present, as shown in excised sections of skin,
in the form of small and large stout bundles, or trabeculse, assuming an
undulating, wavy course ; but, as Unna has pointed out, it is probable
that during life the fibres are in a constant state of tension. The tra-
beculse interlace and cross one another in various directions, forming a
net-work. This is denser and firmer in the upper and looser in the lower
strata of the corium. The so-called connective-tissue corpuscles are
nucleated flattened cells, possessing flat, branched, filamentous processes,
which enter the finer bundles of fibres. They exist in greatest number
in the vicinity of the larger vessels. Louis Heitzmaun 1 regards the so-
called "connective-tissue corpuscles" as unaltered protoplasm, and the
" fibrillse" as protoplasm infiltrated with basis-substance.
The bundles of connective tissue assume a certain regularity of ar-
rangement, crossing and recrossing for the most part obliquely, as
demonstrated by Dupuytren and Malgaigne, but especially by C. Langer. 2
This constitutes the CLEAVAGE OF THE SKIN. Upon puncturing the
1 Der feinere Bau der normalen Lederhaut, Archiv fur Derm. u. Syph., 1890.
2 Loc. cit. This subject had previously been studied by Dupuytren in connection
with wounds made by arms in war (Ueber die Verletzungen durch Kriegswaffen. Aus
der Franz., 1836, p. 27. Quoted by C. Langer). Malgaigne also made similar observe
tions, Traite d'Anatomie chirurgicale, t. i. p 76, 1859.
CORIUM. 7
skin with an awl and withdrawing the instrument, instead of round
holes longitudinal clefts are observed. In certain localities, however,
where the derma is closely attached to the subcutaneous tissues, there is
a felting or matting together of the bundles, when the openings produced
by the instrument are irregular or jagged.
The existence of a cement-substance in the corium, described by
Flemniing l as an ill-defined, cloudy mass enveloping the bundles of fibres,
may be referred to. Its presence does not seem to be proved, though its
existence has been asserted by good observers. Tomsa is of opinion that
it holds the fibrous and other elements of the skin together, and is the
factor of the elasticity in the fresh skin, while Langer believes that the
positive retraction of the skin which often occurs is caused by it.
The boundary between the corium and the epidermis is marked by a
pale, thin, membranous structure, with oval nuclei, the so-called BASE-
MENT or BASAL MEMBRANE, conspicuous in stained preparations. Ac-
cording to E. Klein's 2 observations, it is made up of the basis of the in-
dividual cells which has undergone a chemical and morphological change,
and hence is a product of the deepest layers of the epithelium. Unna,
on the other hand, is opposed to this structure being regarded as a basal
membrane, viewing it rather in the light of a cement-substance than of a
membrane. Balzer and Unna 3 are both of opinion that extremely fine
elastic fibres sometimes penetrate this so-called basal membrane, pushing
themselves between the cylindrical cells of the mucous layer.
ELASTIC FIBRES.
At what period of life elastic fibres ("yellow elastic tissue") first
make their appearance does not seem to be established. Some authors
state that they are not observed in the embryo nor in the new-born. Ac-
cording to the recent studies of Passarge and Kroesing, 4 however, this
tissue in the skin begins to develop between the seventh and the eighth
month of foetal life from the intercellular substance, in the form of gran-
ules arranged in rows and ultimately becoming fibres, or, as it seems,
connective-tissue fibres may be infiltrated and become elastic fibres. The
elastic fibres and net- work of the papilla?, as well as those of the reticular
and subpapillary layers, are formed later.
Elastic fibres vary in number in different individuals, and according
to L. Heitzmann's 5 investigations they occur more sparsely in women
than in men. As F. Balzer, 6 however, has pointed out in his extended
1 Quoted from Unna, loc. cit., p. 5. 2 Atlas of Histology. Phila., 1879.
3 Monatshefte f. prak. Derm., 1883.
4 Schwund und Kegeneration des elastischen Gewebes der Haut unter verschieden
pathologischen Verhaltnissen. Hamburg, 1894.
6 Archiv fur Derm. u. Syph., 1890.
6 Recherches techniques sur le tissu elastique de la Peau. Rapports du tissu mus-
culaire et du tis>u elastique, Archives de Physiol., Oct. 1882, p. 314. See also a lengthy
critical review by Unna in Monatsh. fiir prak. Derm., 1883.
8 ANATOMY OF THE SKIN.
study of these fibres, they are more abundant in general than was formerly
supposed to be the case. They occur in almost all parts of the corium,
especially in the upper strata, though W. Tomsa l and L. Heitzmann state
that they are altogether wanting or sparse in the papillae. They run
parallel with the connective-tissue bundles, and are connected by lateral
branches into a net-work. The fibres are variable in size, and are fine
or coarse, according to the localities where they occur. In the lower
strata they form an open reticulum. Concerning their intimate nature,
L. Heitzmann expresses the view that they do not constitute a tissue sui
generis, but that they are rather fibrillar connective tissue, infiltrated
with an exceedingly firm and persistent basis-substance, the " elastin"
of the chemists. Both A. Spina 2 and L. Heitzmann agree that they
arise from protoplasm.
The relation of the elastic fibres to the extensibility of the skin is
differently interpreted. Tomsa's experiments show that they play an
insignificant part in this function, while Unna considers that the retrac-
tile power of this tissue can only be understood by recognizing its rela-
tions to the involuntary muscles of the skin. When separated from other
structures of the skin they show little retractile power. According to
Ravogli, 3 they increase with advancing years, and with this increase there
is a corresponding decrease of the white fibrous connective-tissue cells.
The elastic tissue of the skin in middle-aged and elderly persons has
been carefully studied by E. Sederholm. 4 This observer confirms the
researches of Schmidt, 5 and especially the following points. The elastic
net-work of the excretory duct of the sudoriparous glands becomes trans-
formed into an elastic membrane, which may serve to explain, perhaps,
the diminution in old persons of the secretion of the sweat glands. The
smooth muscles attached to the fibrous portion of the hair-follicle become
inserted into the elastic net-work of the skin after the atrophy of the
hair. The amount of the elastic substance becomes increased in the
interior and around the smooth muscles. The elastic sheath of the cor-
puscle of Meissner becomes more bulky and more solid. Around the
central mass of the Pacinian body an elastic net-work formed of anas-
tomosing circular fibres is met with, the first traces of which appear
between the ages of forty and fifty.
PAPILLARY LAYER AND PAPILLA.
In the papillary layer of the corium, known also as PAES PAPILLARIS
CORII, which derives its name from the peculiar formation of its upper
1 Beitriige zur Anat. u. Phys. der menschlichen Haul, Archiv fur Derm. u. Syph.,
1873, S. 1.
2 Untersuchungen tiber die Veranderungen der Zellen in entziindeten Sehnen, Med.
Jahrbuch., 1877.
3 Med. Jahrbiicher, Heft 1, 1879.
* Nordiskt Medicinskt Arkiv, Bd. ii. Heft 3, 1892.
5 Virchow's Archiv, Bd. cxxv., 1891.
PAPILLAE OF THE PALM OF THE HAND. VESSELS OF THESE PAPILLAE; TAC-
TILE CORPUSCLES IN SOME OF THE PAPILLAE, AND NERVES WHICH SUPPLY THEM.
1, bifid papilla, containing two vascular loops ; 2, another bifid papilla, presenting
a vascular loop and a tactile corpuscle ; 3, trifid papilla, showing three vascular loops;
4, large papilla divided into two secondary papillae, which are subdivided at their sum-
mit ; one of these secondary papillae receives two vascular loops, the other contains a
loop and a corpuscle ; 5, composite papilla, in which are noted three vascular loops and
two corpuscles ; 6, 6, net- work of blood-vessels from which go off the capillaries that
supply the papillae ; 7, 7, 7, 7, vascular loops of these papillae ; 8, 8, 8, nerves which
contribute to form the subpapillary plexus ; 9, 9, two tactile corpuscles of average
size, receiving each three nerve-fibres ; 10, a larger corpuscle, supplied with four fibres ;
11, small corpuscle, which receives only two fibres. (SAPPEY.)
SURFACE OF THE CORIUM DEPRIVED OF THE EPIDERMIS, showing papillae in
varied shapes. (UNNA.)
SECTION OF SKIN OF THE PULP OF A FINGER, AFTER MACERATION
IN IODIZED SERUM. The epidermis is removed. p, papilla; v, blood-
vessel ; c, ridges on papilla. (RANVIER.)
CORIUM. 9
surface, the bundles of connective tissue are fine, and beneath the papillae
run horizontally, or parallel with the surface of the integument. The
net-work is close, the bundles being small and felted together, forming a
dense structure. The PAPILLAE consist of variously sized and shaped,
nipple like or teat-like prolongations or prominences on the surface of
the corium. They are seated upon ridges, low or high, of the corium.
They are blunt-conical or club-shaped, and are either single or are joined
together by a common base, in which case they receive the name of
" compound papillae." They vary not only in size and shape, but also
in number, according to the region. The largest and most perfectly
formed are found on the palm of the hand, on the inner surfaces of
the fingers and toes, especially on the terminal phalanges, and on the sole
of the foot. Upon these regions they have the form of nipple-shaped
bodies with circular bases. They are upon an average from one and a
half to two times higher than they are broad, and vary in height from
0.05 to 0.02 mm. They are also well defined on the scalp, while upon
the face they are shorter, broader, and flatter. They are placed very
closely together on the labia minora, clitoris, penis, and nipple. Upon
the scrotum, neck, breast, abdomen, and back, and on the extensor sur-
faces of the limbs, they occur sparsely. Where the skin is thin, as on
the flexor surfaces, they are less developed, and in some regions they
exist merely in the form of slight elevations or flattened prominences, or
may be altogether wanting.
They are arranged in the form of irregular, more or less curved rows.
Upon the palms, soles, fingers, and toes they are placed side by side in
striae, two or more rows of them being included within two of the ex-
ternal lines visible to the naked eye. As O. Simon l has shown, their
systematic linear arrangement depends upon the direction of the connec-
tive-tissue bundles of the corium. Upon the ends of the fingers they
are particularly numerous, and here Meissner 2 counted 400 elevations to
one square line (2.116 mm.) of surface, and E. H. Weber, upon the same
space on the palm of the hand, counted 81 compound papillae, or from
150 to 200 smaller papillae. Sappey 3 estimates that there are about 100
papillae to the square millimetre, which would give for the whole surface
of the body about 150,000,000, on the basis of 15,000 square centimetres
to the whole superficial area of the skin.
Papillae are divided into two kinds, according to their internal struc-
ture, termed VASCULAR and SENSORY. The former are well supplied
with blood-vessels, while the latter are made up in great part of con-
nective tissue containing medullated nerves, and possess but a limited
amount of vascularity.
1 Die Localisation der Hautkrankheiten histologisch und klinisch bearbeitet. Mit 6
Tafeln. Berlin, 1873.
2 Beitriige zur Anat. u. Phys. der Haut. Leipzig, 1853.
3 Traite d'Anatomie Descriptive, t. iii. Paris, 1877.
10 ANATOMY OF THE SKIN.
The intimate structure of the papillae is much the same as that of the
corium, the bundles, however, being finer and arranged parallel with the
long axis of the papilla. Elastic fibres are scanty or entirely wanting.
Where the prickle layer cells come in contact with the papillary layer
a more or less well-defined stratum, the so-called basement or basal
membrane, exists, to which reference has already been made.
RELATION OF PAPILLAE TO EPIDERMIS.
The papillary layer and the epidermis viewed together play an im-
portant part in both physiology and pathology, and are the seat of mani-
fold and diverse diseases. The surface of the corium readily adapts
itself to the impression made upon it by the proliferating epidermis, and
the formation of the papillary layer, as to the size and shape of papillae,
is largely under the influence of these epithelial cells. From this state-
ment it will be noted that the papillary layer is by no means a fixed,
rigid formation. It is, on the contrary, a yielding structure, its form
depending upon the activity of the epithelial proliferation, and also
upon the forces acting upon the skin from within. H. Auspitz l was
the first observer to direct attention to this point, and especially to its
importance as a factor in disease. The papillary layer may, as Unna
suggests, be regarded in the light of a cushion and as a filter of nutri-
ment for the epidermis.
ARRANGEMENT OF PAPILLAE.
The fibrous layers of the corium are arranged in definite directions, as
has been shown by C. Langer and Oscar Simon, the ARRANGEMENT OF
THE PAPILLAE being determined by the longitudinal trend of the connec-
tive-tissue bundles ; and, furthermore, the latter govern the arrangement
of the natural furrows of the skin. The disposition of the vessels and
nerves, and even of the glands, is also in part regulated by the same
general controlling influence of the trend of the connective tissue. The
distribution of the papillae exhibits a system, with a well-defined linear
arrangement, which is different for the several regions and localities of
the cutaneous surface. There is, therefore, no irregularity in the distri-
bution of the linear markings, furrows, and folds of the surface : all
follow definite tracks. This will be the more readily understood when
it is remembered that the papillary layer does not begin to form until
the connective tissue is well matured in the later months of intra-uterine
life.
The relations of the epidermis to the papillary layer are important in
connection with the superficial lines upon the surface of the skin, the
subject having been investigated particularly by Blaschko, 2 as well as by
Phillipson.
1 Ueber das Verhaltniss der Oberhaut zur Papillarschicht, Archiv fur Derm. u.
Syph., 1870, p. 31.
2 Beitrage zur Anat. der Oberhaut, Archiv fur Mikr. Anat., Bd. xxx.
CORIUM. 11
A definite scheme of architecture exists for the normal skin, by which
to a certain extent some of the pathological changes that have their seat
in this organ are regulated. This is noted in the general distribution
and in the arrangement or grouping of individual primary lesions, and
also in a more pronounced manner in the healing of wounds and the
mechanism of scars. The latter problem has been worked out carefully
by G. J. Swerchesky. 1
EETICULAR LAYER.
The papillary layer merges into the reticular layer, or PARS RETICU-
LARIS, without line of demarcation, the diiference between these strata
consisting in the arrangement of the connective-tissue bundles. The re-
ticular portion is looser in texture, being made up of fasciculi of con-
nective tissue which decussate more or less obliquely and give it a plexi-
form arrangement. As the bundles ascend towards the surface they
divide into smaller and finer bundles until the papillary layer is reached,
where a close felt-like arrangement of the fibres exists.
THICKNESS OF THE CORIUM.
The thickness of the corium varies greatly, depending on the region
and locality. In the infant it is thin, the subcutaneous tissue being
relatively very thick. In the adult it is thickest upon the soles, palms,
buttocks, and entire back, and thinnest upon the eyelids, prepuce, glans
penis, and inner surface of the labia majora. It is thin also upon the
face, ears, scrotum, perineum, and areola of the nipple. Koelliker 2 esti-
mates it at from \'" (.2645 mm.) to \\'" (3.174 mm.), in most locali-
ties averaging about \'" (.5290 mm.). Landois 3 makes it thicker,
from 2.7 mm. to 3.3 mm. Koelliker's 4 more recent calculations place
the figures at 0.3 to 2.4 mm., with an average of 0.56 to 1.70. It is
remarkably thick in the negro. Constant exposure to wind and weather,
as Krause originally pointed out, has a tendency to thicken the skin.
The development of the epidermis, and especially of the horny layer, as
on the palms and the soles, has much to do with the thickness of the
cutaneous covering.
SUPERFICIAL ARCHITECTURE OF THE SKIN.
Under this heading is to be considered the general superficies of the
skin as concerns its numerous elevations and depressions, including the
folds, furrows, lines, and wrinkles, together with the arrangement of the
elements composing the corium, especially the papillary layer.
1 Contribution to the Physiology and Pathology of Scars, Amer. Jour, of Syph.
and Derm., July, 1871, and July, 1872. Illustrated.
2 Manual of Human Microscopic Anatomy. London, I860, p. 76.
3 Human Physiology, vol. ii. p. 657. 2d English ed., London, 1886.
4 Handbuch der Gewebelehre des Menschen, sechste Auflage. Leipzig, 1889, Bd. i.
p. 161.
12 ANATOMY OF THE SKIN.
The upper surface of the skin, including its covering, the epidermis, is
everywhere marked with lines, furrows, and folds. Some of these are
fine and others coarse, the whole constituting a systematic linear arrange-
ment, which may be designated as the SUPERFICIAL ARCHITECTURE OF
THE SKIN. The direction of these lines and furrows, their form, division,
and symmetry, are well defined and constant for certain regions, as has
been shown by the studies of Bichat, 1 and more recently especially by
C. Langer, 2 and also by O. Simon and Lewinski.
The several forms may be described under the headings of (1) regular
furrows, as those of the palms and soles and the flexor surfaces of the
fingers and toes ; and (2) curved and irregular furrows, which occur over
the whole general surface. The deeper of these assume a spindle form
or diamond shape, and sometimes a three-cornered or a quadrilateral
form. The natural lines of the surface extend down as far as the mucous
layer, and are due to a sinking-in of the horny layer, the linear area
being devoid of papillary prominences.
CLEAVAGE OF THE SKIN.
C. Langer was the first to study carefully the so-called CLEAVAGE OF
THE SKIN, or the direction of the connective-tissue bundles for certain
regions. Allusion has already been made to this subject in considering
the structure of the corium, where it is shown that experiments prove
the existence of a definite arrangement of the fibres and bundles of the
connective tissue of the corium. The great extensibility of the integu-
ment is largely due to this distribution of the fibres. As Langer stated,
the extensibility as well as the retractive power of the skin does not
lie in the physical peculiarities of its elements, but rather in the net-like
arrangement of its tissues. If the skin is stretched, the tissues arrange
themselves in the direction of the traction, and when this ceases the net
returns to its original arrangement.
FURROWS AND FOLDS.
The subject of the FURROWS and FOLDS of the skin has been carefully
studied by Lewinski 3 and also by Phillipson. 4 As Lewinski states, all
the visible lines on the surface are due to the formation of folds, caused
by the motion of the part. The number of the folds hence depends on
the number of motions of which the body is capable. The younger the
individual the more elastic is the skin ; the lines, therefore, are lighter
and the folds flatter, and the surface is more easily smoothed by change
of position. The formation of the marked folds which occur in elderly
persons is by this explanation made clear.
1 Allg. Anat., Uebersetz. von Pfaff. Leipzig, 1803, II. Theil, II. Abth. S. 199.
2 Loc. cit.
3 Ueber Furchen und Fallen der Haut, Archiv fur Path. Anat. und Phys., Bd. xcii.
S. 135 ; and Ueber Hautfurchen und Papillen, Arch, fur Anat. u. Phys., 1882, S. 118.
4 Monatshefte fur prak. Derm.. No. 8, 1889.
LINES INDICATING THE
CLEAVAGE OF THE SKIN.
(C. Heitzmann.)
SUBCUTANEOUS CONNECTIVE TISSUE. 13
Phillipson 1 classifies the furrows into "primary" and "secondary,"
the former being due to proliferation of the mucous layer in the form of
ridges, occasioned by linear depressions of the horny layer. They every-
where form polygonal spaces, but exist deepest on the palms and soles,
and are due to the anatomical relations of the parts. The secondary
furrows develop from stretching and cracking of the skin transversely
over joints, and are physiological.
The movements of the skin have a marked influence in the causation of
the furrows and folds. These exist only where the area of skin is larger
than the space occupied by it ; in the living subject this occurs normally
over joints, and in disease where the corium is thickened by chronic
inflammatory processes, and also near cut wounds of the skin. Folds,
however, may also be produced mechanically, by shoving the skin to-
gether. The number of lines on the surface depends on the retractive
power within the skin. These are removed, as is well known, by stretch-
ing the skin, which is thus made thinner. Lewinski found under the
microscope that the papillae also disappear upon stretching the skin. The
connection between the folds and motion is a double one : whenever the
corium is shortened the papillary layer together with the overlying epi-
dermis is thrown into folds. The folds of emaciation are the result of
the disappearance of fat leaving an excess of skin upon the affected area.
SUBCUTANEOUS CONNECTIVE TISSUE.
The subcutaneous tissue is the first portion of the integument to attain
complete development. During embryonic life it increases in extent
more than any other stratum, the fat being steadily and regularly
deposited, so that at birth it is highly developed. Allowance being
made for extent of surface and bodily weight, it is at this period about
five times as thick as the subcutaneous fat of a stout adult (TJnna). After
birth the fat gradually decreases in quantity, and remains in abundance
only at certain chosen points of the body.
The subcutaneous tissue, or STRATUM STJBCUTANEUM, is to be viewed
as part of the true skin, the latter merging into it. It is made up of
variously sized bundles, or fasciculi, of connective tissue, which cross one
another at different angles, thus forming a rhomboidal net-work. The
meshes, though variable in size, are generally large, the interfascicular
spaces consequently being well defined. It possesses a much looser and
coarser structure than the corium, and contains in most regions an abun-
dance of fat, as noted particularly on the mammary glands, palms, and
soles. In some regions, however, it is wanting, as upon the auricle (ex-
cept the lobule) and the eyelid. Where the fat is abundantly deposited
the structure is designated PANNICULUS ADIPOSUS, or ADIPOSE TISSUE.
1 Ueber die Herstellung von Flachbildern der Oberhaut und der Lederhaut, Monats-
hefte fur prak. Derm., No. 8, 1889.
14 ANATOMY OF THE SKIN.
COLUMNS ADIPOSJE.
J. Collins Warren l describes columnar prolongations of this tissue,
in the form of fat columns, passing in a nearly vertical direction from
the adipose tissue to the bases of the hair-follicles, especially to those of
the fine hairs. The condition is found most highly developed where the
cutis is exceptionally thick, as on the back. The axes of these columns
are nearly parallel to those of the arrector pili muscles. Besides fat the
columns contain a sudoriparous gland, which, as Unna has pointed out,
they help to support. They also serve as channels for blood-vessels and
lymphatics. From the points, whence they ascend from the panniculus a
cone-shaped mass of connective tissue is given off from the lower border
of the cutis, which penetrates the adipose tissue for some distance. These
bundles of fibres have been alluded to by French writers as cdnes fibreux,
and are the attachments of the skin to the parts below. Warren is
of opinion that these " columns adiposa?" afford flexibility to the dense
integument and facilitate the action of the erector muscles, and that they
probably play a part also in the nutrition of the upper layers of the skin
and its glands ; also that in disease they serve as an outlet for morbid
elements pressing up from beneath, examples of which have been seen in
round -celled sarcoma of the subcutaneous connective tissue, in nsevi, and
in carbuncle, the peculiarity of the lesion in the last-named disease being
accounted for by these structures.
FAT-CELLS AND LOBULES.
The collections or lobules of fat, or " fat-glands," as they may be
termed, consist of rounded, oval, or polyhedral fat-cells closely packed
together and enclosed in a net-work. According to Biesiadecki, 2 these
cells possess a very thin membrane, containing a minute droplet of oil,
which keeps the membrane so tightly stretched that it is scarcely discern-
ible during life. The fat may, however, be extracted with ether, when
the thin membrane will be seen, with a round nucleus. Each fat-lobule
is supplied with a fine plexus of blood-vessels, and each cell is further
surrounded by a delicate capillary vessel. Flemming 3 distinguishes three
kinds of collections of fat, which may be described according to their
relations to the cutaneous vascular supply. The " true fat-lobules" are
supplied with large blood-vessels and a system of capillaries surrounding
the fat-cells. The so-called " fat-columns" occur along the larger vas-
cular branches, and have but few capillaries, while the " fat-islands" are
small groups of fat-cells without blood-vessels of their own, being seldom
met with in man. Unna regards the fat-tissue as a dependant of the
coil glands, and as a part of the corium which, owing to the activity
1 Boston Med. and Surg. Jour., April 19, 1877.
2 Strieker's Human and Comparative Histology. London, 1872, vol. ii. p. 219.
3 Monatshefte fur prak. Derm., Bd. i. (1882), p. 81 et seq. See, also, Flemming <( On
the Development of Fat-Cells," Max Schultze's Archiv, vol. vii. Part i.
SUBCUTANEOUS AREOLAR TISSUE. c, c, connective-tissue corpuscles;
w. migratory cells; v, plasma-cells; e, elastic fibres. (PiERSOL.)
FAT-CELLS EMBEDDED IN SUBCUTANEOUS AREOLAR TISSUE./, fat-
cells ; n, nucleus ; c, connective-tissue corpuscles ; w, migratory cells ;
e, elastic fibres ; b, capillary blood-vessels. (PIERSOL.)
BLOOD-VESSELS. 15
of these glands, has undergone a peculiar transformation. Inasmuch as
skin in various regions of the body may be well developed without a
layer of fat beneath it, this tissue cannot be regarded as an essential
constituent of the integument.
RELATION TO OTHER STRUCTURES.
Large blood-vessels pass through the subcutaneous connective tissue,
giving off branches to the corium and the structures contained within
it. Pacinian corpuscles, nerve trunks, lymphatics, sweat glands, and the
lower part of the hair-follicles of deep-seated hairs, are all found here.
Lymphoid cells, especially near the blood-vessels and glands, are also
met with. Above it blends intimately with the corium, while its deeper
layers are connected with the superficial fascia of muscles and the perios-
teum. In regions where the skin is firmly attached by means of coarse,
short bundles, as in the palms, soles, groins, and extensor surfaces of
joints, single or multilocular spaces containing sero-mucous fluid, termed
BURS^E MUCOS^E, exist. Where the skin is firmly attached or is unusu-
ally movable and pliable, and muscular, as on the eyelids, the nose, the
upper portion of the auricle, the external auditory canal, the penis, and
the scrotum, the connective tissue contains few or no fat-lobules in the
adult. When the fat disappears from the subcutaneous tissue, the layer
becomes a loose reticulum. Its presence or absence determines to some
extent the external form of the body.
The subcutaneous tissue plays also a mechanical part in the outer or
external economy of the body. It serves as a pad or cushion, and pro-
tects the blood-vessels, nerves, and delicate parts from external pressure
and injury. It also acts as a regulator of the temperature of the body,
being a poor conductor of heat.
BLOOD-VESSELS.
The blood-vessels of the skin and subcutaneous connective tissue have
been studied by numerous observers, but in particular by Tomsa. 1 They
are subject to great variation. Both the corium and the subcutaneous
tissue are highly vascular, having numerous blood-vessels throughout
their structure in the form of trunks, branches, and capillaries. Arteri-
oles for the sweat and sebaceous glands and for the hair papillae also
exist. They are largest on the palms, soles, and face, and are more
numerous on the flexor than on the extensor surfaces. The arteries are
small in proportion to the size of the veins (Hoyer 2 ). Their form de-
pends largely upon the cleavage of the locality. Mechanical influences
also play an important part in modifying the course of the vessels and
the circulation.
1 Archiv fur Derm. u. Syph., 1873, S. 1.
2 Archiv fur Mikr. Anat , 1877.
16 ANATOMY OF THE SKIN.
ANASTOMOSIS.
There is in all probability a direct passage of the arteries into the veins
of the skin. Sucquet l described in the skin anastomoses of arteries and
veins, which were some years later confirmed by Hoyer 2 with such ac-
curacy in the end of the finger and in the nail-bed that observers are
disposed to accept this view. It may be said, therefore, that the arteries
of the skin never end as terminal vessels, but in the form of multiple
anastomoses. The number of afferent branches and their diameters are
variable, the vessels being more numerous and larger where pressure is
brought to bear, and their length being greater where the skin is very
mobile, as Spalteholz has shown. 3
PLEXUSES.
Two parallel horizontal plexuses exist, one superficial, in the upper
layers of the corium, the other deep, in the subcutaneous tissue. The main
vessels of the corium ascend from the subcutaneous tissue, and give off
branches laterally in all directions, richly supplying the glands and hair-
follicles, as well as the other structure in the corium. In the papillary
layer a delicate and highly organized plexus of capillaries exists, afford-
ing an abundant supply to this region. The papillae receive capillary
loops, which run through their centre or at their sides, parallel to their
long axes. According to G. Thin, 4 the papillae containing developed
nervous structure are supplied with very fine capillary loops, while A. R.
Robinson 5 states that papillae containing tactile corpuscles generally have
no blood-vessels. Upon the scalp, where the papillae are scanty and
undeveloped, the arterioles end in a capillary net- work rather than in
loops. The superficial plexus also supplies the muscles, the ducts of the
sweat glands, and the larger nerves.
LYMPH-VESSELS.
The lymphatics of the skin have been studied by Sappey, 6 Teichmann/
Biesiadecki, 8 Neumann, 9 and Klein, 10 and more recently by Unna. 11 Con-
siderable diversity of opinion exists as to the distribution and arrange-
ment of this system in the skin. In the subcutaneous connective tissue
1 D'une circulation derivative dans les membres et dans la tete de 1'homme. Paris,
1862, avec 6 pi.
2 Archiv fur Mikr. Anat., 1877. 3 La Semaine Medicale, No. 47, 1891.
4 Jour, of Anat. and Phys., vol. viii., 1874, p. 37.
5 Manual of Dermatology. New York, 1884, p. 17.
6 Trailed 'Anatomic Descriptive, t. ii. Paris, 1876.
7 Das Saugadersystem vom anat. Standp. bearb. Leipzig, 1861.
8 Untersuch. aus d. Path. -Anat. Inst. in Krakau. Wien, 1872. See also Strieker's
Human and Comparative Histology, vol. ii. p. 225.
9 Zur Kenntniss der Lymphgefasse der Haut des Menschen und der Saugethiere.
Wien, 1873. Abstract by the author, Phila. Med. Times, vol. iii. No. 43.
10 The Anatomy of the Lymphatic System (for serous membranes and the lung).
London, 1873. " Op. cit.
PERPENDICULAR SECTION OF SLIGHTLY (EDEMATOUS SKIN, SHOWING PAPILLARY
LAYER AND EPIDERMIS, AND INJECTION OF THE LYMPHATIC CHANNELS IN THE
SAME. Gold preparation. (UNNA.)
LYMPH-VESSELS. 17 '
the lymphatics are large vessels, upon which Flemming 1 has demonstrated
the rudiments of a muscular apparatus. In the upper strata of the
corium they form a net-work of denser and much smaller vessels. Valves
oc<tur in the branches coming from the deeper net-work. The direction
of the several plexuses is for the most part horizontal, but vessels also
pass obliquely through the corium. The veins of the skin are of ex-
traordinary width as compared with its arteries, and Unna believes that
the greater part of the lymph which circulates through the skin is taken
up by the veins ; in furtherance of which statement it may be remarked
that oedema of the extremities cannot always be produced by ligating all
the lymphatic trunks, whereas it always follows ligation of the veins.
JUICE-SPACES.
The so-called "juice-spaces'' may be referred to. Unna regards it
as proved that all parts of the skin are supplied with these structures,
which may be denned as those lymphatic channels which do not possess
an absolutely free outflow into distinct lymphatic vessels lined with endo-
thelium, whether they are devoid of independent walls, as is usually the
case, or are provided with them. Lymphatic vessels, on the other
hand, may be denned as those canals from which a free outflow into the
blood takes place. Juice-spaces exist in the epidermis..(a tissue devoid
of blood-vessels), where they occur embedded in the interspinous passages
of the prickle-cell layer. Axel Key and Retzius 2 succeeded in injecting
these spaces from the lymph-spaces of the subcutaneous tissue.
The papillae are freely traversed by juice-spaces, becoming confluent
near their base, at which point the beginning of a lymphatic vessel is
generally formed, which ascends in the axis of the papilla to its upper
third. The excretory ducts of the coil glands, the sebaceous glands,
the prickle-layer of the hair-follicle, and the hair-bed, have the same
interepithelial juice-spaces as the epidermis. The oblique muscles of
the skin and the coils of the coil glands float in distended lymph-spaces.
In the case of the arrectores, these lakes of lymph furnish room for their
movements, and in that of the coil glands they supply material for the
production of this glandular secretion. The connective-tissue bundles and
the fat lobules are all ensheathed by lymph-spaces of various forms.
From these observations it is apparent that the system of juice-spaces is
extensive and complex. The lymph flows to the epidermis mainly from
the apices of the papillae, thence spreading in all directions through the
epidermis and returning to the corium by way of the interpapillary de-
pressions, through the sweat pores of which it may, under some circum-
stances, be discharged externally also (Unna). Kromayer 3 finds that the
pars papillaris cutis possesses its own enclosed lymphatic system, which
explains why most of the cutaneous diseases are seated so superficially.
1 Quoted by Unna, op. cit., p. 63. 2 Quoted by Unna, op. cit., p. 60.
8 Monatshefte fur prak. Derm., Bd. xiii. No. 9.
2
18 ANATOMY OF THE SKIN.
NERVES.
Both medullated and non-medullated nerves exist in the skin, and are
especially abundant in the palms and soles and in the last phalanges of
the fingers and toes. They pass into the corium with the more important
ascending blood-vessels. Bremer found that all the capillaries, even the
smallest, were accompanied by nerves. While Tomsa observed that they
penetrated into the walls of the capillaries, and Klein and Unna hold
that they penetrate into the interior of the capillaries, Bremer takes the
view that they end in swellings on the exterior of the vessels. 1
Medullated nerves terminate, as a rule, in peculiar bodies, so-called
" corpuscles," while the non-medullated fibres pass as delicate filaments
from the papillary layer of the corium into the mucous layer of the
epidermis. In the corium the medullated nerve fibres usually run to
the larger papillae, terminating within the papilla or at its base in the
form of tactile corpuscles or corpuscles of Krause. In the subcutaneous
tissue they terminate in larger bodies, termed Pacinian corpuscles.
The skin and sensory mucous membranes show in certain regions pecu-
liar and remarkable nerve-endings. In man there are three principal
varieties, namely, the Pacinian corpuscles, the corpuscles of Meissner, or
tactile corpuscles, and the corpuscles of Krause. They are similar in
their structure, being constituted for the most part of a connective-tissue
covering with the nerve fibres ending in different forms. Of these the
Pacinian corpuscles were the first to be discovered, by A. Vater ; next
the corpuscles of Meissner, by Meissner and Wagner ; and lastly the
bulb-corpuscles, or corpuscles of Krause, by W. Krause.
The exact ending of the cutaneous nerves and nerve filaments has
been considerably elucidated of late years Krause was the first to
apply the collective name " terminal corpuscles" to the various termina-
tions of sensory peripheral nerves, and enumerated not less than thirteen
varieties in the different classes of vertebrata. 2
MOTOR AND VASO-MOTOR NERVES.
In addition to the sensory nerves, according to Koelliker, 3 the skin
possesses MOTOR NERVES on the smooth muscles of the skin, and on
all glands which have a muscular layer. Of the VASO-MOTOR NERVES
of the skin but little is known with any degree of certainty. They
are probably of two varieties, those connected with the central nervous
system and those connected with gangl ionic plexuses in the immediate
neighborhood of the skin itself. The nerve centre is in the medulla
oblongata. They are particularly abundant around the arterioles of the
skin, and exert an influence upon the vascular, muscular, and glandular
cutaneous systems, causing increase or diminution of the circulation, as
1 Archiv fiir Mikr. Anat., 1882, p. 663.
2 For recent literature of nerves and nerve-endings, see Quain's Elements of Anatomy,
vol. i. Part ii. London, 1891. 3 Op. cit., p. 171.
NERVES. 19
in flushing and blanching of the skin, in contraction of the muscles, as
in cutis anserina, or when the hairs are erected and " stand on end,"
and in profuse sweating, local or, more rarely, general. 1
Medullated Nerves. Under this head are to be considered the cor-
puscles of Krause, the tactile corpuscles, and the Pacinian corpuscles.
CORPUSCLES OF KRAUSE.
The CORPUSCLES OF KRAUSE, or BULB-CORPUSCLES ("Kolbenkorper-
chen" Krause), in their simplest and at the same time their most marked
form, are rounded or elongated bodies composed of a delicate connective-
tissue covering, with flat cells, and a clearer, non-nucleated, inner bulb,
penetrated in the middle by one or more pale nerve fibres. In struc-
ture they resemble closely the innermost parts of the Pacinian body. 2
Numerous other forms, between this and that of the touch corpuscle,
occur, and often much resemble this latter body. They should, however,
be distinguished one from the other, for, as Krause states, they are never
encountered side by side in the same organ. In man these bodies were
first described by Koelliker, in the vermilion of the lips, the glaus
penis, clitoris, and tongue, and designated " papillae fungiformes" This
observer regarded them as undeveloped touch corpuscles. They are met
with especially in the sensory mucous membrane, and abundantly in the
conjunctiva. In man they are usually rounded, and in animals elongate
or club-shaped. Sometimes the nerve fibres are more or less tortuous or
coiled within the corpuscle. According to Koelliker, the nerves upon
which these bodies are seated come from a deeper plexus and give off
finer branches, dividing and subdividing towards the surface. They are
often seated beneath the papillae. On the glans penis and clitoris they
lie deep under the papillae, and on the clitoris are larger, and mul-
berry-shaped, constituting the so-called GEXITAL-NERVE-CORPUSCLES of
Krause. They have been studied by Axel Key and Retzius, and by
Merkel. 3
TACTILE CORPUSCLES.
These bodies are also called TOUCH CORPUSCLES, CORPUSCLES OF
MEISSNER, and CORPUSCLES OF WAGNER. They are fibrous masses,
elongate, ovalish or rounded in form, and are found situated in the papillae
of the corium, or, occasionally, in the papillary layer, attached to medul-
lated nerve fibres. As a rule, they occupy the greater portion of the
papillae, and are visible in prepared sections of skin as large, well-defined,
firm-looking bodies having a markedly transversely striated or corded
1 The subject of these nerves has been studied in particular by Mathias Duval, art.
VASO-MOTEUR, in Dictionnaire de Jaccoud, Paris, 1885, p. 520, to which the author
would refer for further information.
2 Ranvier does not describe these corpuscles specially, regarding them as a variety
of Pacinian corpuscle. Op. cit.
3 See Koelliker, op. cit., and Merkel. (See foot-note under " touch-cells.")
20 ANATOMY OF THE SKIN.
exterior. Two or even three corpuscles occasionally occupy one papilla,
and, as A. R. Robinson l states, frequently a single corpuscle may have
the appearance as if two corpuscles were present, this form being pro-
duced by a constriction caused by the nerve.
The intimate structure of the tactile corpuscles is involved in some
uncertainty. According to the studies of Langerhans * and Thin, 3 the
mass of the body consists of nucleated connective tissue. Medullated
nerve fibres, usually one, sometimes two or even three, penetrate the
corpuscle at its base or side, and, dividing into delicate fibrillse, wind
with a variable course both around and through the structure. The
nerve fibres are seen to advantage stained with gold chloride, the borders
being colored dark. The mode of termination has not been definitely
ascertained. The corpuscles usually occupy those papillae which have no
blood-vessels, but occasionally they are accompanied by a capillary loop.
The number of tactile bodies varies in different regions of the body ;
they are most numerous upon the fingers, especially upon the last
phalanges. They are found also upon the palms and soles, as well as
upon other portions of the body. Meissner, 4 who devoted much time to
their study, ascertained that out of 400 papillae upon a square line of
skin of the last phalanx of the finger, 108 were provided with tactile
bodies. The same investigator states that they vary from -jV" (-1058
mm.) to T V" (-2116 mm.) in length, and that they measure about -fa'"
(.0529 mm.) in width.
PACINIAN CORPUSCLES.
Pacinian corpuscles (so named by Henle and Koelliker after Pacini,
an Italian anatomist, who was the first to describe them fully), also called
" corpuscles of Vater," are well-defined, grayish, ovoidal, elongate or
pear-shaped bodies found upon the cutaneous nerves. In connection
with the tendons in man these bodies assume varied irregularly elongate
shapes, for the most part pear- or flask-shaped bodies, and may be very
numerous, as Sappey 5 has shown. As Langer has proved, they were first
seen by A. Vater and described by him as papittse nervese sen cutanea.
Pacini failed to recognize their relation to nerves (Koelliker). They
occur in various regions, but are most numerous on the fingers and toes,
especially on the last phalanges, and are found also on the palms and
soles. Herbst 6 counted 608 on the whole hand, and nearly as many on
the foot, and upon the index finger 95. They occur sparsely upon the
backs of the hands and feet, and along the nerves of the arm and fore-
arm. They are met with abundantly on the nerves of the joints. The
1 Manual of Dermatology. New York, 1884.
2 Archiv fur Mikroscopische Anat., 1873, p. 730.
3 Jour, of Anat. and Phys., 1874, p. 30.
4 Beitrage zur Anatomie und Physiologic der Haut. Leipzig, 1853.
5 Traite d'Anatomie Generate. Paris, 1894. p. 113.
6 Quoted by Koelliker, op. cit., p. 184.
PAPILLA OF FINGER OF MAN, CON-
TAINING A TACTILE CORPUSCLE COM-
POSED OF Two LOBES. Section after
the successive action of osmic acid and
of alcohol. n, afferent nerve ; a, lower
lobe of the corpuscle ; b, upper lobe ; c,
connective tissue of the papilla ; I, folds
of the basal membrane on the surface of
the papilla ; v, blood-vessel. (KANVIER.)
TACTILE CORPUSCLE FROM SOLE OF
FOOT, treated with gold chloride. Two
dark-bordered nerve-fibres enter, one in
the upper, the other in the lower half of
the corpuscle, and within give rise to
numerous non-medullated winding and
spirally-running fibres, on which dividing
lines and here and there free ends are
visible. (KOELLIKER.)
TACTILE CORPUSCLE OF A PAPILLA
OF PULP OF END OF INDEX FINGER,
treated with osmium. Two dark-bor-
dered afferent nerve-fibres enter the lower
end, which can be followed as such up to
the upper third of the corpuscle and there
disappear. The numerous transverse nu-
clei of the corpuscle belong essentially to
the neurilemma of the medullated and
non-medullated nerve-fibres. (KOELLI-
KER.)
A TACTILE CORPUSCLE, formed of a
single body, but which, by the employ-
ment of reactive agents and under the
influence of compression, has been di-
vided into two parts. Of these two lobes,
the larger appears to be composed of two
lobules superposed and independent but
not separable by compression. (SAPPET.)
Another voluminous TACTILE COR-
PUSCLE, which has been divided into two
lobes ; the larger receives two fibres, the
smaller only one, which on reaching the
inferior extremity turns in a manifestly
spiral form. (SAPPEY.)
A TACTILE CORPUSCLE, much more
voluminous than the preceding, with nu-
clei, and its pedicle composed of five
nerve-fibres. On each of these fibres are
seen the nuclei of the sheath of Schwann.
(SAPPEY.)
LONGITUDINAL VIEW OF A PA-
PILLA. a, cortical layer with connective-
tissue cells and elastic fibres ; b, tactile
corpuscle with its transverse nuclei ; c,
afferent nerve - branch with nucleated
neurilemma; d, nerve-fibres, which wind
around the corpuscle ; e, apparent end of
the same. Treated with acetic acid. 350
diam. (KOELLIKER.)
TRANSVERSE SECTION OF UPPER
PORTION OF A PAPILLA, CONTAINING A
TACTILE CORPUSCLE. a, cortical layer
of papilla with cells ; 6, nerve-fibre ; c,
nucleated covering ; d, tactile corpuscle.
Treated with acetic acid. 350 diam.
(KOTCLLIKKR.)
f-
c
-ff
LONGITUDINAL SECTION OF A PACINIAN CORPUSCLE OF MAN. a,
inner bulb ; b, transverse septa ; c, longitudinal connections ; d, divided
fibres of the capsule ; /, nuclei ; g, outer connective tissue ; h, nerve-fibre
in pedicle; k nerve-fibre in inner bulb; I, end of the same; m, lateral
branches. (KOELLIKER. )
CROSS-SECTION THROUGH MIDDLE OF PACINIAN CORPUSCLE OF A
CHILD. Nerve-fibre in centre, around which is the capsular covering.
The lamellae show punctated places (longitudinal fibrillae) and transverse
fibrillse, which are also present in the interlamellar spaces. (KOELLIKER.)
NERVES. 21
investigations of Rauber 1 show them to be smaller here than in other
regions, and to be especially numerous on the flexor surface of the elbow,
and also on the joints of the fingers and other joints. They are found
typically developed in many animals, and are numerous in the mesentery
of the cat. They are visible to the unaided eye, vary in size, averaging
from %'" (1.058 mm.) to 2'" (4.232 mm.), and have their seat in the sub-
cutaneous connective tissue. According to Krause, these corpuscles serve
as organs of touch, enabling us to appreciate pressure or traction.
Each Pacinian body is connected with a nerve trunk by means of a
medullated nerve fibre, which enters the corpuscle at its lower extremity
and passes through the centre of the structure, terminating in one of
several ways. According to Biesiadecki, 2 a blood-vessel of considerable
size enters the corpuscle in the vicinity of the nerve fibre, and forms a
plexus between the outer layers of the capsular envelope.
INTIMATE STRUCTURE.
The intimate structure of the corpuscle is simple. The outer and
main portion is composed of connective tissue and connective-tissue
corpuscles in the form of a number of concentric, nucleated layers. In
accordance with the observations of Klein, 3 Key and Retzius, 4 Schafer, 5
and others, it may be regarded as consisting of three parts, the " central
nerve fibre," " the core," and the " capsular covering," composed of many
layers. The central fibre, a continuation of the entering nerve, but ap-
parently without medulla, retains a uniform calibre throughout the body
until it reaches its distal extremity, where it usually becomes enlarged,
terminating either in the form of an irregularly sized and shaped enlarge-
ment or with pointed, fork-like processes tipped with bud-like swellings.
The core, situated immediately around the central fibre, consists in its
innermost portion of a clearer, finely granular, softer cord, with delicate
nuclei (or cells), which Koelliker looks upon as a simple connective
tissue. Its outer part is composed of protoplasmic cells, like connective-
tissue corpuscles, with oval nuclei. The capsular envelope which sur-
rounds the core and gives form and bulk to the corpuscle is made up of
a number of capsules, from 20 to 60, according to Koelliker, placed in a
concentric manner around the central elongated clear mass, or core. The
capsule is made up of connective-tissue fibres. These towards the inner
or central portion form a longitudinal layer, and towards the outer por-
tion a circular layer, and these two layers are, moreover, penetrated or
crossed by transverse or " radial" fibres (Ranvier). In the middle por-
tion of the corpuscle the capsule is made up of only a limited number of
1 Quoted by Koelliker, op. cit., p. 185.
* Op. cit., p. 283. 3 Op. cit.
4 Arehiv fur Mikroscop. Anat., Bd. ix., 1873. See also the superb work by Key
and Ketzius, Studien in der Anatomic des Nervensystems und des Bindegewebes.
Zweite Hiilfte. Stockholm, 1876.
5 Quar. Jour, of Micros. Science, April, 1875.
22 ANATOMY OF THE SKIN.
circular fibres. A net-work of fine capillaries exists about the pedicle
of the corpuscle. The layers of the corpuscle are arranged closely one
upon the other, the more external coats being thicker and more loosely
bound together. They are separated by septa into smaller and larger
spaces, lined with a single layer of epithelium, containing a clear serous
fluid, discernible on pricking the corpuscle. Unna l succinctly regards
the corpuscle as consisting of an enormous enlargement of the sheath
of Schwann into concentric lamellae, having nuclei and lined with endo-
thelium.
A special form of touch -corpuscle or touch cell exists in the so called
" corpuscles of Grandry," discovered by Grandry 2 in the bills and other
regions of birds, and minutely described by Merkel. A medullated
nerve is connected with the corpuscle, which on entrance loses its
medulla and is distributed in a peculiar manner.
Non-Medullated Nerves. The researches of Langerhans, 3 Podco-
paew, 4 Klein, 5 Koelliker, 6 Ranvier, 7 and others prove that nerve branches,
containing one, two, or more nerve fibres, when approaching the surface
epithelium are collected into a plexus, the so-called sub-epithelial plexus.
From this small groups of minute varicose elementary fibrils come off,
which lie close to the under surface of the stratum mucosum, and after
having formed a net- work with large meshes the sub-epithelial net-work
enter the stratum mucosum, where they ascend and ramify, between
the epithelial cells, towards the stratum granulosum. They divide and
subdivide between the prickle-cells, and terminate either in free endings
or in minute bud-shaped swellings towards the granular layer. They do
not enter the horny layer. These fibres do not seem to be uniformly
distributed in the epidermis, being more abundant in some specimens
than in others. Frequently they are observed as a rich plexus. Stained
with gold chloride they appear as delicate, filamentous, arborescent struc-
tures, with at times fine varicosities on their surface. Unna and Pfitzner
believe that the nerves end in swellings, or buds, within the cells of the
prickle-layer. This view, however, Koelliker 8 thinks is not proved.
LANGERHANS'S CELLS.
Koelliker, and later Langerhans, found and described peculiar elongate,
irregular or star-shaped bodies or cells, without apparent nuclei, situated
in the deeper strata of the mucous layer. It was at first thought that
they were connected with nerves, but this has been shown not to be the
1 Op. cit.
2 Kecherches sur les corpuscules de Pacini, Journ. de 1'Anatomie, 1869, p. 393.
3 Virchow's Archiv, Bd. xliv., Heft. 2 und 3.
4 Archiv fur Mikroscop. Anat., Bd. v., 1869. 5 Op. cit.
6 Handbuch der Gewebelehre des Menschen. Sechste Auflage, erster Band. Leipzig,
1889. The author desires to express his indebtedness for much assistance from this
authority in the preparation of this article on the nerves of the skin.
'Op. cit. 8 Op. cit., p. 171.
" Vft * V 'V ; / '
WiiM
wilt
fiWiilf
PERPENDICULAR SECTION THROUGH THE SKIN OF THE SOLE OF THE FOOT, WITH
NERVE-BRANCHINGS IN THE Mucous LAYER. The corneous layer is represented
only in its deepest parts. Gold preparation. (KOELLIKER.)
*' d
it
VERTICAL SECTION OF THE EPIDERMIS OF THE PULP OF A CHILD AGED 50 DAYS,
SHOWING NERVES AND NERVE-ENDINGS. Gold chloride preparation. d, corium ;
m, mucous layer; g, granular layer; c, corneous layer; n, nerve supplying the mucous
layer: 6, nerves and nerve-endings; I, Langerhans's cell. (KANVIER.)
NERVES. 23
case. Arnstein * regards them as wandering cells, and Merkel as pigment-
cells devoid of pigment, while Koelliker (who calls them " Langerhans's
cells") believes them to be colorless connective-tissue corpuscles which
differ somewhat from lymphoid cells. 2
TOUCH-CELLS.
Merkel discovered 3 in the epidermis peculiar cells, regarded by him
as connected with nerve-endings and as ganglion-cells. They are known
as " touch-cells," or " Merkel's cells," and are found in man in various
regions, but are more highly developed in some of the lower animals,
especially in the snout of the pig (Merkel, Ranvier 4 ), and in birds. In
specimens stained with osmic acid they are seen as well-defined, oval,
nucleated cells. The connection with nerve fibres is apparent only in
gold-stained sections, which staining renders the cells themselves less
distinct. In man, according to Merkel, they occur in those regions
where tactile corpuscles are sparse, as on the abdomen and the shin, but
Koelliker found them abundant on the tips of the fingers and on the
soles of the feet. As Merkel first pointed out, they are not infrequently
met with in the superficial strata of the corium, an observation that has
been corroborated by Ranvier.
These cells are looked upon differently by observers, and hence it is
difficult to classify them. Merkel believes them to be nerve-cells, while
Krause regards them as epidermis-cells which have undergone mitosis,
and as having no connection with nerve fibres. Ranvier and Koelliker,
however, both incline to the view that they stand in relation to nerve-
endings, the latter authority holding the opinion that they are probably
transformed cells, having a purpose for some mechanical function.
According to Merkel, 5 the tactile corpuscles and the touch-cells are
organs for the finer perceptions, and the bulb corpuscles and Pacinian
bodies for localization and common sensation. The free nerve-endings
in the hairs may subserve touch as well as sensation, and those in the
epidermis both touch and temperature.
MUSCLES.
Both striated and smooth muscles are found in the skin. The former
are met with only in certain regions of the body, particularly the face,
about the lips, alse of the nose, eyebrows, and chin, occurring sparsely.
They arise from the deeper-seated muscles, pass upwards vertically or
obliquely, and terminate in the corium. In many animals the skin is
1 Quoted by Koelliker, op. cit.; p. 172. * Op. cit., p. 171.
3 Arch, fur Mikr. Anat., 1875.
4 Traite technique d'Histologie, Paris, 1890.
5 Archives of Dermatology, vol. vii. No. 2, p. 191. See also Merkel's work, Ueber
die Endigungen der sensiblen Nerven in der Haut der Wirbelthiere, Kostock, 1880.
A complete list of books and papers on the subject of the peripheral distribution and
modes of termination of sensory nerves may be found in this work.
24 ANATOMY OF THE SKIN.
abundantly provided with striped muscles in the form of a cutaneous
layer, the so-called PANNICULUS CARNOSUS, enabling the animal to pro-
duce voluntary movements of the skin.
SMOOTH MUSCLES.
The smooth, or involuntary, muscles exist either as anastomosing
plexuses running horizontally, as occurs in the scrotum, or as fasciculi,
as in connection with the hair-follicles and the sebaceous glands. The
several forms of smooth muscles of the skin call for consideration.
MUSCULAR MEMBRANES.
So-called MUSCULAR MEMBRANES exist in the scrotum, constituting the
fleischhaut, or tunica dartos ; also upon the penis, mammary areola, and
nipple. The bundles of smooth muscular fibres are deposited in strata
in the corium, according to Unna, lying almost perpendicularly to the
direction of the cleavage. In the scrotum the fibres are arranged parallel
to the raph6. On the penis, nipple, and areola they follow a circular
direction, nearly at right angles to that of the cleavage. All these
muscles throw the skin into folds when they contract, the cleavage of
the particular region being thereby indicated. These muscular mem-
branes, therefore, concern the external configuration of the integument
more than they do the fibres of the corium.
SMOOTH MUSCLES OF THE HATR-FOLLTCLES.
The SMOOTH MUSCLES OF THE HAIR-FOLLTCLES, discovered by Koel-
liker, and named arrectores pilorum by Eylandt, are cylindrical or broad,
single or divided bundles, which originate from the papillary layer,
running obliquely, and are inserted into the middle portion of the hair-
follicles, encompassing the sebaceous glands. Tomsa and Unna 1 both
hold the view that we should regard the attachment of the muscles to
the hair as the relatively fixed point, and that to the papillary layer as
the movable one. Unna and Balzer 2 describe these muscles as being
both surrounded and traversed by a net- work of elastic fibres. These
fibres are arranged at both ends of the muscle in large bundles, which
serve as a tendon for the attachment of the muscles to the fibrillae of
the corium. The arrectores pilorum are seen to perfection in the scalp,
mons veneris, scrotum, and perineum. About the areola of the nipple
they are arranged in circular layers, becoming more marked from with-
out inward as far as the base of the nipple, and in the nipple they form
a net-work. While these muscles are widely disseminated, they are
wanting in connection with the hairs in certain regions, as about the
eyelashes, eyebrows, vibrissae, hairs of the lips, and axillae (Koelliker).
The contraction of the muscles produces a general shortening and con-
densation of the corium. The erectile condition of the skin known as
CUTIS ANSERINA, or " goose-skin," is caused by contraction of these
1 Op. cit., p. 7. 2 Op. cit. See " Corium."
SMOOTH MUSCLES OF THE SKIN.
THEIR ATTACHMENT TO THE HAIR-
FOLLICLES, AND THEIR CONNECTION
WITH THE SEBACEOUS GLANDS.
A. Smooth muscles and hair-follicle
of the skin of the thigh. 1, bottom of
the hair-follicle ; 2, its superficial ex-
tremity, or mouth ; 3, sebaceous gland
annexed to the follicle ; 4, 4, 4, smooth
muscles (three) attached to the follicle
immediately below the sebaceous gland.
B. Smooth muscles and hair-follicles
of the skin of the breast. 1, 1, hair-folli-
cles ; 2, 2, sebaceous glands which open
into their cavity ; 3, 3, smooth muscles
which are inserted into the interior ex-
tremities of the hair-follicles. (SAPPEY.)
SMOOTH MUSCLES AND HAIR-FOLLI-
CLE OF THE SCALP. 1, Root of the hair ;
2, its bulb embracing the papilla of the
hair-follicle ; 3, 3, internal sheath of the
root extending to the corneous layer of
the epidermis ; 4, 4, external sheath of
the root extending to the mucous layer
of the epidermis ; 5, tunic with trans-
verse fibres of the follicle with their
nuclei ; 6, tunic with longitudinal fibres ;
7, 7, smooth muscles which are inserted
into this tunic ; 8, 8, their free extremities
which lose' themselves in the superficial
layers of the derma ; 9, sebaceous gland,
multilobular, which opens in to the superior
part of the hair-follicle; 10, excretory
duct of this gland; 11, sebaceous gland
composed of a single utricle ; 12, mouth
of the hair-follicle. (SAPPEY.)
PIGMENT.
muscles acting suddenly upon the hair-follicles. The muscles act, more-
over, not only as erectors of the hair, but as compressors and evacuators of
the sebaceous glands, and also upon the excretory ducts of the sweat glands.
Unna has described diagonal smooth muscles of the corium, uncon-
nected with hair-follicles, on the forehead, cheek, and back, the existence
of which, however, seems not to have been generally confirmed by anato-
mists. 1 He asserts that these possess au importance entirely analogous
to that of the arrectores as regards their action on the corium, and would
regard them together with the erectors of the hairs, under the general
name of " oblique tensors of the corium," irrespective of their connection
with hair-follicles. The elastic tissue is considered to be the real begin-
ning and end of the oblique tensors of the skin through its entire struc-
ture, thus acting upon and regulating all the secretions and fluids of the
integument. Viewed in this light, their function as regulators is a most
important one.
PIGMENT.
The general coloration of the skin depends largely upon a deposition
of pigment, or coloring matter, in the low T er strata of cells of the mucous
layer of the epidermis. It consists in a slight staining of the cells
themselves, with a more intense coloring of the nuclei, and also in the
presence of fine granules of pigment in the cells. It appears as a dark-
ened stratum above the papillary layer of the corium. While in the
white race pigmentation of the skin is due mainly to the deposit of pig-
ment in the mucous layer, the connective tissue of the corium probably
plays the principal part in its production. This observation is particu-
larly noticeable in pathological conditions.
In the white races the horny layer is translucent and grayish or
slightly yellowish, and the mucous layer yellowish-white or brownish.
This latter hue is most expressed in the nipple and areola, and less
marked in the labium majus, scrotum, penis, anus, and axilla. The hue
depends largely upon the natural complexion of the individual, and in
pathological states is diverse and extremely variable both in degree and
in localization. The vascularity of the skin must also be regarded as
influencing the complexion, combining with the natural pigmentation to
produce the so-called flesh tint. The color of the skin of the white races,
according to Kromayer, 2 is due to various circumstances, including the
translucency of the epidermis and corium, the anaemic condition of the ^
papillary layer, and the presence of fat in the subcutaneous connective
tissue. Unna maintains the view that the white race owes its color L
I
largely to the presence of the granular layer.
SEAT OF PIGMENT.
The seat of the pigment of the skin is mainly in the cells of the
1 Koelliker states that he has not been able to verify this assertion. Op. cit., p. 164.
2 Deutsch. Med. Wochenschr., No. 25, 1890.
:
ANATOMY OF THE SKIN.
mucous layer of the epidermis, deposited in the form of finely granular
coloring matter, or true pigment granules (melanin). Where the color-
ation of the skin is not strong, only the deepest stratum of the cells is
pigmented ; but where the coloration is pronounced, from two to four
rows or the whole stratum may be the seat of this deposit. While the
horny layer always remains free from pigment granules, it sometimes
takes on a darker, yellowish hue. In addition to this, so-called pigment
f cells are found in the corium, in the white races mainly in the more
deeply colored regions of the body, but in the colored races more or
less abundantly in all regions.
In the negro and in other colored races the pigment cells are highly
developed, the whole mucous layer being more or less deeply stained, and
even the horny layer discolored. The pigment granules are darker than
in the white races, varying from brown to black. At birth, as is w r ell
^ known, the colored races are comparatively unpigmented, the augmented
coloration taking place shortly afterwards. This latter subject has been
investigated by R. Morison, 1 of Baltimore, who finds that a deposition
1 of pigment in the negro occurs at least as early as one month before
^ birth, as shown by the microscope.
ORIGIN OF PIGMENT.
Concerning the origin of the pigment there has been much discussion,
many investigators, as Riehl, 2 Aeby, 3 and Ehrmann, 4 holding the view
that no pigment is formed in the epidermis, but that it is carried by
leucocytes from the subcutaneous tissue and deposited there. Koelli-
ker's 5 investigations included a number of epithelial structures, from
which he concluded that in epidermis and hair the pigment enters by the
migration of the pigmented cells of the adjacent connective tissue between
the deeper epithelial cells. Koelliker, while he agrees with Aeby in
recognizing the importance of the connective-tissue cell as a means of
conveying pigment, does not regard the origin of pigment within the
epithelium as impossible.
G. A. Piersol's 6 studies lead to the conclusion that in the developing
epidermis the earliest pigment appears within mesoblastic cells which
have entered the epidermis while still uncolored, and that the pigment
is formed within the protoplasm of the cells in loco, being neither trans-
ported to nor taken up by the cell as preformed granules. Later, after
the appearance of pigmented cells within both corium and epidermis,
1 Monatshefte f. prak. Derm., Bd. ix. (1889), S. 485.
2 Zeitschr. f. Kl. Med., Bd. x.
3 Der Herkunft des Pigments im Epithel, Centralb. fur die Med. Wissenschaften,
No. 16, 1885.
* Viertelj. fur Derm. u. Syph., 1885.
5 Woher stammt das Pigment in den Epidermisgebilden, Anatom. Anzeiger, Bd.
ii. No. 15, 1887.
6 Development of Pigment within the Epidermis, Univ. Med. Mag., Aug. 1890.
SECTION OF NEGRO'S SKIN, INCLUDING THE EPIDERMIS (a) AND
THE PAPILLARY LAYER OF THE CORIUM (b) ; the deepest layers of epi-
dermis (c) contain the pigment. (PIERSOL.)
HAIR-BULB OF A HAIR WITH THE SURROUNDING PARTS FROM THE
SCALP, WITH BRANCHED PIGMENT-CELLS IN THE HAIR-BULB. (KOEL-
LIKER.)
EPIDERMIS. 27
the pigment cells of the former send processes into the epithelium, and
thereby contribute additional pigment to the epidermis, the pigment cells
in both localities being identical in nature. This writer holds that there
is no conclusive evidence of the origin of pigment within the epithelial
cells of the epidermis. Caspary, 1 from his investigations, is of opinion
that the presence or absence of foreign pigment cells in the epidermis
stands in no relation to the pigmentation of the basal layer of epithe-
lium, and that probably two independent sources of the pigment of the
epidermis exist. Experiments made by Karg 2 showed that transplan-
tation of white skin upon negro skin was followed by a growing-in of
the pigment cells in a colored man, and that negro skin when grafted on
a white man soon lost its dark color.
It would seem, therefore, from the observations of numerous investi-
gators that many colored cutaneous epithelial structures receive the pig-
ment from peculiar pigmented connective-tissue cells of the underlying
corium.
EPIDERMIS.
The epidermis, CUTICULA, or CUTICLE, is a membrane or layer com-
posed of epithelial cells which covers the corium in all its parts, adapting
itself closely to the various elevations and depressions of this structure.
The relations of the epidermis to the papillary layer of the corium are
most intimate, the former dipping down in the form of prolongations and
forcing itself into the more yielding and plastic true skin. The under
surface of the epidermis fits the papillary layer as the fingers of a glove
fit the fingers of the hand. It is like wax, moulding itself to the
contour of the corium. Where elevations of the corium exist, there
are found corresponding sinkings-in, prolongations, or projections down-
wards of the epithelium. The papillae are due to the pressure of the
epidermis on the surface of the corium.
As has already been pointed out elsewhere, the epithelial layer is
distinct genetically from the true skin, and, while the anatomical and
physiological relations between the tissues are close, they perform their
own functions, each independently of the other. From a dermatological
stand-point the epidermis is a most important structure, playing as it
does so prominent a part in the pathology of numerous and diverse
diseases.
The structure may be viewed in perpendicular or in horizontal sec-
tions, or from its outer or its inner surface, the latter view being obtained
by separating and removing the layer from the pars papittaris com,
as Blaschko 3 has described. Viewing the epidermis according to this
1 Archiv fir Derm. u. Syph., Heft 1, 1891.
2 Ucber Hautpigment und Erniihrung der Epidermis, Anatom. Anzeiger, Bd. ii.
No. 12, 1887.
s Beitrage zur Anat. der Oberhaut, Archiv fur Mikr. Anat., Bd. xxx. (1887) p. 495.
28 ANATOMY OF THE SKIN.
method, an entirely different conception of its form and of the formation
of the papillary stratum is obtained.
Practically, the epidermis is made up of two main layers, the mucous
layer and the corneous, or horny, layer. These layers differ morphologi-
cally and chemically, and are separated from each other by a tolerably
well denned line of demarcation. In addition to these two principal
layers, there remain to be enumerated two of minor importance, namely,
the granular layer and the lucid, or clear, layer.
STRATUM MUCOSUM.
The MUCOUS LAYER, PRICKLE-CELL, LAYER, or GERM LAYER (known
also as the MALPIGHIAN LAYER, RETE MALPIGHII, RETE MUCOSUM,
KEIMSCHICHT (Flemming), STRATUM GERMINATIVUM) may first be con-
sidered, being as it is the living and productive stratum. This layer
has its seat directly upon the papillary layer below, and above is bounded
by the granular layer. It sinks in between the papilla in the form of
interpapillary projections, and where these dip down the layer is of
course much thicker than immediately over the summits of the papillae.
The thickness of the layer, as a whole, varies with the locality and with
individuals, but is subject to less variation than that of other layers. It
presents a slightly undulating surface above, as seen in vertical sections and
where the horny layer has been removed, and shows a grayish or yellow-
ish hue. The mass is soft, moist, and mucoid in character. It is com-
posed of polygonal, nucleated, prickled, or chestnut-burr-like cells, which
differ in form and size in the several strata. In the deepest layer seated
upon the corium they are cylindrical or columnar in form and stand per-
pendicularly. The lower borders of the cells are pointed or elongated,
and give to the line a serrated appearance. The next few layers show
elongated, ovoidal, or rounded cells, the form varying with the locality,
the disposition here being to assume a rounded form, owing to the more
uniform pressure to which they are subjected from below and from above.
As the granular layer is approached, they become more elongate trans-
versely and show indications of stratification. Owing to the irregularity
of the form and position of the cells in the mucous layer, it is impossible
to estimate the precise number of strata of which it is composed. The
cells are protoplasmic in their intimate structure, being made up of a soft
substance, with large oval or rounded nuclei. Around the cells exists a
fluid, occupying the so-called intercellular spaces, which is nutrient in
character.
PRICKLE-CELLS.
From the surface arise innumerable, variably sized, fine, protoplasmic
processes, threads, rays, or prickles, first described, according to Koel-
liker, by Schron in 1863. They were also carefully studieVi by Max
Schultze, who called them PRICKLE-CELLS, and later by Bizzozero.
Schultze believed that the prickles, or processes, fitted closely into each
SECTION OF HUMAN SKIN FROM HAND,
INCLUDING THE PAPILLARY LAYER OF
THE CORIUM AND THE EPIDERMIS. a, b,
c, d, respectively the stratum corneum, stra-
tum lucidum, stratum granulosum, and
stratum mucosum ; e, layer of columnar
cells next the corium ; /, papillary layer of
the corium. (PIERSOL.)
VERTICAL SECTION OF THE CORNEOUS
LAYER OF THE HUMAN EPIDERMIS, ^th
Zeiss's Immersion Lens. (KOELLIKER.)
PRICKLE-CELLS FROM MIDDLE STRATA OF
THE EPIDERMIS. (PIERSOL.)
f-f ?^>'
/-*' v
SECTION THROUGH THE Mucous LAYER OF
THE EPIDERMIS PARALLEL TO THE SURFACE
OF THE SKIN, after injection of blood-vessels
with osmic acid and hardening with gum and
alcohol. c, mucous layer of the epidermis ; t.e,
d, connective tissue of the corium. 1300 diam.
(EANVIER.)
EPIDERMIS. 29
other like the teeth of a cog-wheel, whereas Bizzozero concluded from
his observations that the processes of two adjacent cells fused together
at their points, a view with which Ranvier coincides. Unna regards
them in the light of connecting bridges, which view would permit of
spaces for the flow of lymph and for the nerve threads which are known
to ramify freely through this layer. The existence of a cell-membrane
has been much discussed by histologists, the consensus of opinion seeming
to be opposed to the view that all the cells are so provided. The pro-
cesses serve to hold the cells together, and have intimate attachments, for
they can be isolated only with difficulty, the prickles often breaking off
in the endeavor to separate the cells. This may be done by long im-
mersion in iodized serum, when, as already stated, they resemble in out-
line a chestnut burr. Under the influence of inflammatory conditions
of the corium the intercellular fluid is augmented to a considerable
extent, when the prickles are more separated from one another and are
consequently seen more distinctly. The older the prickle-cells in the
higher layers, the shorter do these processes appear.
As Lewinski l has pointed out, the form of the prickle-cells depends
on mechanical conditions of pressure, caused by their proliferation on the
one hand, and by the counter-pressure of the horny layer on the other.
Owing to these causes, great variation in the form of the cells is met with,
especially in the middle rows of the stratum. Unna believes that the
epithelial cells and their prickles are possessed of independent vitality,
and in this sense cannot be regarded as parts of one continuous mass, for
the continuity of the prickles may be broken and re-established. The
investigations of Flemming 2 show that the epidermic cells always become
segmented after a preceding thread-like, or mitotic, metamorphosis of the
nucleus. These threads, or mitoses, exist only in the deepest stratum of
the mucous layer.
Wandering lymphoid cells are frequently encountered throughout the
mucous layer, especially in the lower strata. The cells, especially the
lower layers, contain pigment granules, to be referred to elsewhere. 3
HERXHEIMER'S SPIRAL FIBRES.
Herxheimer 4 describes peculiar flowing SPIRAL, FIBRES in the human
epidermis and in the epithelium of certain mucous membranes, which
appear to advantage when stained by the method discovered by Weigert
1 Zur Physiologic des Kete Malpighii, Archiv f. Anat. u. Phys., Phys. Abth., 1883.
2 Archiv fur Mikr. Anat., 1884.
R In addition to the authorities cited, these cells have been carefully studied by Hartyn
(Brit. Med. Jour., June 26, 1875; also Monthly Microscopical Jour., Aug. 1875), C.
Heitzmann (Microscopical Morphology of the Human Body in Health and Disease,
New York, 1883), E Oehl (Dennatologischen Studien, Hamburg, 1889), J. Renaut
(Compt.-Rend. Hebd. de 1'Acad. d. Sc., t. civ., 1887), and M. Ide (La Cellule, t. iv.,
1888). See for further references Quain's Elements of Anatomy, vol. i. Part ii.
London, 1891.
4 Archiv f. Derm. u. Syph., 1889, p. 645.
30 ANATOMY OF THE SKIN.
for staining fibrin and micro-organisms. The fibres begin at the junc-
tion of the corium with the epidermis, and are often found in great
numbers between the cells. They occur between the cells, and generally
have a coiled, zigzag, or spiral form, running parallel with the long axes
of the cells, but occasionally run transversely or obliquely. Their form
is extremely variable, all manner of transitions from the straight line
to the spiral being met with. The most irregular course is found in
the middle portion of the epidermis. The fibres divide and branch like
trees, large and small, more or less irregular offshoots of variable calibre
being encountered. They are more abundant in the deeper strata of the
epidermis, and are slightly thicker as the corium is approached, but their
calibre is variable. After excluding the possibility of these fibres being
cell contours, elastic fibres, nerve fibres, or cement-substance, Herx-
heimer suggests that this structure perhaps represents a juice-canal
system. A u Eddowes 1 has substantiated Herxheimer's discovery, and
has added to our knowledge of the subject. According to this investi-
gator, in pathological states the fibres penetrate even into the horny
layer. They seem to be more numerous in inflammatory conditions. A
peculiar granular matter having the same staining reaction as the spirals
is described as existing between the prickle-cells, and where these are
abundant the spirals are almost entirely absent, and vice versa. Eddowes
concludes that these spirals are fibrin in a peculiar form and are con-
tinuous with the fibrin of the corium. Kromayer 2 regards these fibres
as protoplasmic, and designates them " basal filaments." He describes
them as running into the epithelial cells.
STRATUM GEANULOSUM.
The GRANULAR LAYER is to be viewed as the superficial stratum of the
mucous layer, and is composed of two or three strata of coarsely granular
cells. In opposition to Zander, Unna holds that the granular layer exists
in unbroken continuity over the whole surface of the body. It is a
narrow stratum of flattened cells, looking spindle-shaped in vertical
sections, with their long axes parallel with the free surface of the horny
layer. The nuclei are usually not well defined. The cells refract light
very strongly, and therefore seem dark by transmitted and white by
reflected light. The granules which characterize this layer were first
observed by Aufhammer, and later were minutely described by Langer-
hans. 3 The relation of these cells to the process of cornification on free
surfaces was first pointed out by Unna, \vho also demonstrated their
presence in the ducts of the coil glands and in the .mother cells of the
inner root-sheath. Waldeyer 4 proved their existence in the medulla of
1 Brit. Jour, of Derm., Oct. 1890. 2 Monatsh. f. prak. Derm., 1890, ii. 215.
8 Archiv fur Path. Anat. u. Phys., Bd. Iviii.
4 Atlas der menschlichen und thierischen Haare, sowie der ahnlichen Fasergebilde,
mit erklarendem Text. Lahr, 1884.
PERPENDICULAR SECTION THROUGH THE EPIDERMIS.
a, stratum corneum.
b, stratum lucidum, some of the cells of which are filled with drop-
lets of eleidin.
c, stratum granulosum, full of eleidin droplets or granules.
d, stratum mucosum.
e, dentation of deepest cells, for attachment to the corium. (KANVIER.)
,-&- '->*__
PERPKNDICULAR SECTION THROUGH THE SKIN or THE SOLE OF
THE FOOT, WITH NUMEROUS LANGERHANS's CELLS. From an ampu-
tated foot, treated with gold. No nerves visible. (KOELLIKER.)
EPIDERMIS. 31
the hair and in the horny structure of various animals. They stain well
with picroearmine and hsematoxylin, the layer thus treated being readily
distinguished from the other layers of the epidermis.
ELEIDIN AND KERATOHYALIN.
The so-called " granules" are small and large rounded, elongated, or
even rod-like structures, which give the impression of being firm bodies.
Ranvier regarded them as containing droplets of fluid, to which he gave
the name ELEIDIN. These cells were also studied carefully by Waldeyer,
who designated the peculiar substance contained therein KERATOHYA-
LIN, because of the similarity of its chemical behavior with hyalin, a
product of degenerative processes of various tissues. F. Buzzi, 1 who has
investigated the subject, holds the view that eleidin and keratohyalin
should be distinguished from each other, and that they represent two
entirely different substances. One, eleidin, appears in fresh sections on
the cut surface of the basal horny layer in the form of droplets or pools
(flaques) of a fluid fat, free and outside of the cells, which may be
readily wiped away ; the other, keratohyalin, occurs in the form of
granules within the cells of the granular layer, which even by cutting
into them cannot be wiped away. The reaction with staining sub-
stances for the two products is, moreover, different. Both lie in close
proximity, but they are distinct. Keratohyalin is essentially a solid
substance ; eleidin is a fluid. Eleidin is seen best on the sole of the
foot.
The question may be asked, What is eleidin ? Ranvier 2 regarded it
as an ethereal oil (" huile essentielle"), but Buzzi, from its reaction with
staining fluids, looks upon it as a fatty oil, a glycerin fat. It is not a
cholesterin fat (lanolin) ; nor is keratohyalin a cholesterin fat. In this
connection Santi's 3 investigations show that (as opposed to Liebreich's
view) in the human skin no cholesterin fat exists, and that, therefore, no
lanolin occurs.
KERATOHYALIN AND CORNIFICATION.
The following changes, according to Unna, take place simultaneously
in the prickle-cells as they grow old : the nucleus shrinks, the cell becomes
filled with granules of different sizes, composed of keratohyalin, this sub-
stance being peculiar to the process of cornification ; the peripheral zone
of the cell becomes differentiated, as a clear border, from the remainder
of the cell-body, the intercellular connecting bridges become shorter and
stouter, and the cells are in condition to undergo cornification. This
process is peculiar to the granular layer, and is an important function.
The true cornification of the cells affects only the outer layer of the cell,
which is transformed into a horny membrane. The process is confined
1 Monatshefte f. prak. Derm., 1888 and 1889.
2 Archives de Physiol., 1884.
3 Monatshefte fur prak. Derm., 1889.
32 ANATOMY OF THE SKIN.
to the margins of the cells and to their protoplasmic connecting threads.
The changes which take place within the cell are secondary, and have
no bearing on cornification. Zander 1 is of opinion that keratohyalin
and keratin are identical, a view which is strongly opposed by Unna.
True keratin may be defined as horn-substance (as of horn of cattle)
from which the fat has disappeared. Unna 2 and some others view kera-
tohyalin as a degenerative product of albumen, whose existence occurs
simultaneously with that of cornification. According to Behn's 3 studies,
there exists only one kind of cornification for the epidermis, the beginning
of which process occurs with or before the formation of keratohyalin. 4
STRATUM CORNEUM.
The CORNEOUS, or HORNY, layer is the external layer, which serves to
protect the mucous layer as well as the cerium, owing to its resistant
and horny nature. It is a grayish, opaque structure, composed of
polygonal or fusiform cornified cells arranged in strata, which are much
alike. It is generally conceded that remnants of nuclei exist in the
horny layer, but it is not easy to demonstrate their presence. Zander, 5
who has studied these cells, describes two principal forms or types : one
(which is designated type A) found only on the palms and soles and
inner surfaces of the fingers and toes, characterized by a highly refrac-
tive, apparently homogeneous edge ; in the centre a clear, round, or oval
spot (looking like a hole in the tissue), which is regarded as an empty
nuclear space, can generally be seen. Between the edges and the central
cavity a fine net-work exists. Elsewhere over the body the second type
(type B) occurs, the horny layer being composed of flat cornified cells
arranged in lamellae. The horny cells show traces of prickles on their
surfaces, and are still surrounded by fine intercellular spaces, the borders
of the cells having a granular aspect. In sections treated with alcohol or
dilute hyperosmic acid, these spaces look like small bright " streets" be-
tween the cells, with traces of connecting threads (Koelliker). 6 The treat-
ment of the horny cells with caustic solutions shows them to be vesicular,
for they swell up into bladders with a plain limiting membrane. The con-
tents dissolve, and sometimes show a cloudy granular mass. Towards the
surface the cells become flatter, drier, and more shrivelled. Upon the free
surface they exist as dried, horny, more or less wrinkled or crumpled cells,
known as EPIDERMIC SCALES. They measure about -fa'" (.0252 mm.).
1 Archiv f. Anat. u. Phys., 1886 and 1888. See also Monatshefte f. prak. Derm.,
1893, vol. xvi. p. 97.
2 See Jessner's remarks in Monatshefte f. prak. Derm., 1893, vol. xvi. p. 97.
3 Archiv fur Mik. Anat., Bd. xxxiv.
4 See also Blaschko's article, " Ueber den Verhornungsprozess," in Archiv fur
Physiol. (Du Bois-Eeymond), 1889.
6 Untersuchungen iiber den Verhornunajsprozess, His und Braune's Archiv, 1888,
Heft 1.
6 Op. cit., Fig. 152.
EPIDERMIS. 33
Around the apertures of the gland ducts and follicles the cells of the
horny layer assume a circular arrangement, and pass into these depressions
in variable directions. The horny layer varies greatly in thickness, being
most highly developed on the palms and the soles. Where it is thinnest
the cells are flatter.
STRATUM LUCIDUM.
Where the horny layer is thickest, as on the palms and the soles, a deep-
seated, bright, transparent, thin, flattened layer of cells exists, known as
the STRATUM LUCIDUM, first described by Krause, according to Oehl, to
the latter of whom this is generally attributed and who described it more
fully. 1 It is composed of from two to four layers of cells, which differ
mainly from the cells of the horny layer superimposed in being brighter
and more homogeneous. This layer is not always plainly defined, and
is not of much importance. It is really a portion of the horny layer.
Unna designates it the BASAL CORNEOUS LAYER. It surmounts the
granular layer. Zander 2 regards it as being present only in localities
(chiefly the palms and the soles) where his type A of cells is found.
EPITRICHIAL LAYER OF THE EPIDERMIS.
The EPITRICHIAL LAYER of the epidermis so designated and first de-
scribed by Welcker 3 consists of large, polygonal, well-defined cells with
round nuclei much larger than those of the underlying epidermal layers,
which has its prototype in the epitrichium of certain animals. It exists
during a stated period of intra-uterine life as an outer layer of cells.
Minot 4 and Bowen 5 have shown the existence of this layer, which has
not heretofore been universally accepted, Bowen stating that in young
human embryos the outermost epidermic cells constitute a distinct histo-
logical layer, which disappears by the sixth month over most portions of
the body. In certain localities, as the nail, this layer undergoes a kera-
tosis and forms part of the stratum corneum. The nail is a modified
portion of the stratum lucidum, and becomes exposed by the loss of the
epitrichial layer. As Welcker suggested, there are good reasons for con-
sidering this layer homologous with the epitrichium of animals. These
cells are the elements described by Zander as rounded "bladder-cells"
of the epidermis, which he views as having wandered from the deeper
layers of the epidermis to the surface, where they swell in the amniotic
fluid. Koelliker regards them simply as superficial cells of the epidermis
M'hich have not been transformed into horny lamellae, and which by
perishing have become swollen.
1 See " Ueber zwei vergessene Arbeiten der Hautanatomie, " von P. G. Unna. Son-
derabdruck aus " Dermatologischen Studien." Hamburg, 1889.
2 Loc, cit.
3 Ueber die Entwicldung und den Bau der Haut und der Haare bei Bradypus. Halle,
1864.
4 American Naturalist, June, 1886.
6 Anatomischer Anzeiger, IV. Jahrgang (1889), Nr. 13 u. 14.
3
34 ANATOMY OF THE SKIN.
SPIRAL GROWTH OF THE EPIDERMIS.
The investigations of Fischer, 1 Blaschko, 2 and others go to show that
the epithelial cells of the epidermis possess a disposition to grow in a
curved or spiral form. This observation is borne out by the spiral im-
plantation of the hair-root, the spiral turning of the free hair-shaft, the
spiral arrangement of the cuticle of the hair, the spiral winding of the
sweat duct, and the spiral arrangement of the epithelial cells in the
so-called " epitheliomatous pearls," as well as in many other normal and
pathological states of nature. Fischer has also called attention to the
spiral turning of growing organs in general as establishing a law.
SEBACEOUS GLANDS.
The sebaceous glands (glandulee sebacese}, known also as SEBIPAROUS
GLANDS, are racemose, or acinous, in structure, and have their seat in the
corium. They are for the most part connected with hair-follicles, into
which they pour their secretion, the sebaceous matter. They are found
upon all regions of the body where hairs exist, and hence are sometimes
called " hair-follicle glands ;" but they also occur on the border of the red
of the lips, the labia minora, and the glans penis and prepuce, though
they are absent, according to Koelliker, on the glans and prepuce of the
clitoris. Several forms of glands are met with, the simplest being short,
elongated, pear-shaped tubules ; in other places they are composed of two
or three pouches connected with a short pedicle, while in other locali-
ties the pouches are even more clustered, the formation being distinctly
bunched, racemose. Numerous variations of form are encountered.
Accompanying the strong hairs, the glands are seated on the sides of
the hair-follicle, into which they open by means of a short duct. They
may be looked upon as appendages of the hair-follicle. In the case of
lanugo, the duct and gland are often of the same size as, or even larger
than, the hair-follicle. The glands of the nose, occurring here with
lanugo, are highly developed, large, and of unusual form, having some-
times, according to Krause, as many as twenty acini. Those upon the
concha of the ear, the penis, and the areola of the nipple are also large.
The largest, however, exist upon the mons veneris, labia majora, and
scrotum.
The gland is a simple structure, and consists of a secreting portion and
a duct. It possesses a connective-tissue covering which arises from the
hair-follicle or from the corium, lined with a thin membrana propria,
upon which are seated cubical epithelial cells in a variable number of
layers. The cells in the centre of each acinus undergo fatty degenera-
tion, the process of fat-formation taking place in the central portion only
of each cell, which eventually ruptures, the oil being poured out, mixed
1 Das Drehungsgesetz beim Wachsthum der Organismen. Cassel, 1886.
2 Beitrage zur Anat. der Oberhaut, Archiv fur Mikr. Anat., Bd. xxx. (1887).
A, GLAND-VESICLE, OR ACINUS, OF
A COMMON SEBACEOUS GLAND. a, epi-
thelium defined, but without a covering
of membrana propria, and immediately
passing into the cells containing fat, b,
within the tubular gland. (KOELLIKER.)
5, SEBUM CELLS FROM A TUBULAR
GLAND. a, smaller, poor in fat, rather
epithelial, nucleated cells ; b, cells rich in
fat, without visible nuclei ; c, cells in
which the fat has begun to run together ;
d, cells with droplets of fat; 'e, f, cells
the fat of which has in part escaped.
(KOELLIKER.)
SEBACEOUS GLANDS OF THE NOSE.
A, Simple tubular gland without a hair.
B, Composite gland, which has a com-
mon aperture with the hair-follicle ; a,
glandular epithelium, in connection with
&, the mucous layer of the epidermis ; c,
contents of the glands, sebaceous cells
and free fat ; d, single lobes of the gland ;
e, hair-follicle (and root-sheath) with the
hair;/, hair. 50 diam. (KOELLIKER.)
A LARGER SEBACEOUS GLAND OF THE
NOSE, with a small hair-follicle emptying
into it. 50 diarn. (KOELLIKER.)
SECTION OF PORTION OF SEBACEOUS
GLAND FROM HUMAN SCALP, INCLUD-
ING PART OF ACINUS. a, membrana
propria ; 6, peripheral layer of cuboidal
cells ; c, elements in which fatty meta-
morphosis is beginning ; rf, cells filled -with
fatty particles and exhibiting intracellular
net-work; e, nuclei of cells. (PIERSOL.)
D
SEBACEOUS GLANDS or THE SKIN OF THE FACE, SHOWING DIFFERENT DEGREES
OF COMPLICATION. All these varieties occurred in a single thin section of the
integument.
A. GLAND IN A STATE OF SIMPLE VESTIGE. 1, rudimentary hair-follicle; 2,
lanugo contained in this follicle ; 3, gland formed of a single very small pouch open-
ing at the middle portion of the follicle.
B. GLAND ALSO COMPOSED OF A SINGLE POUCH, BUT MORE DEVELOPED THAN
A. 1, 1, hair-follicle; 2, sebaceous gland.
C. GLAND FORMED BY Two UNEQUAL POUCHES. 1, hair-follicle; 2, simple
pouch ; 3, larger pouch, with vestige of segmentation.
D. SEBACEOUS GLAND COMPOSED OF Two LOBULES. 1, hair-follicle; 2, lobule
composed of three pouches ; 3, another lobule, larger, formed of four pouches, of
which two are completely developed and the other two are in a growing state,
E. SEBACEOUS GLAND COMPOSED OF THREE LOBULES. 1, hair-follicle; 2, 2,
first lobule ; 3, second lobule ; 4, 4, third lobule ; 5, two pouches which open by a
common duct into the preceding lobule, of which they are part ; 6, excretory duct.
F. LARGE SEBACEOUS GLAND COMPOSED OF FOUR LOBULES. 1, hair-follicle,
much more highly developed than those of the preceding glands ; 2, 2, first lobule ;
3, second lobule ; 4, third lobule ; 5, fourth lobule ; 6, excretory duct of the gland,
and the hair which traverse? it.
SEBACEOUS GLANDS OF THE FIRST CLASS (SAPPEY).
SEBACEOUS GLANDS OPENING INTO THE CAVITY OF A HAIR-FOLLICLE.
A. Two SEBACEOUS GLANDS OF THE SCALP OF UNEQUAL SIZE. 1, contour of
the hair- follicle, of which the inferior portion has been cut off; 2, 3, the internal and
external sheaths of the root ; 4, a hair ; 5, mouth of the hair-follicle ; 6, unilobular
sebaceous gland; 7, sebaceous gland more complicated than the preceding; 8, 8,
excretory ducts of these glands.
B. A SEBACEOUS GLAND, VERY COMPOSITE, OF THE SKIN OF THE EYELID.
1,1, hair-follicle ; 2, a hair; 3, 3, bilobular sebaceous gland ; 4, its excretory duct.
C. ANOTHER SEBACEOUS GLAND OF THE SKIN OF THE EYELID, EXTREMELY
SIMPLE. 1, 1, hair-follicle; 2, a hair; 3, gland represented by a single utricle.
D. SEBACEOUS GLANDS ANNEXED TO A HAIR-FOLLICLE OF THE EYELID. 1,
1, hair-follicle; 2, eyelid, of which the free extremity has been cut off; 3, 3, very
composite glands opening at a point near the mouth of the hair-follicle.
E. SEBACEOUS GLANDS OF THE ROOT OF THE NOSE. 1, 1, hair-follicle; 2, 2,
two uniutricular glands of the same size, opening on the same level at diametrically
opposite points of the follicle. (SAPPEY.)
'.V
SEBACEOUS GLANDS OF THE SECOND CLASS (SAPPEY).
A. Average sebaceous gland of the ala of the nose, composed of a single lobe, very
complicated. 1, hair-follicle and its hair, both presenting a certain degree of develop-
ment ; 2, 2, rudimentary sebaceous gland, opening into the cavity of the hair-follicle ;
3, sebaceous gland offering the aspect and arrangement of a bunch.
B. Average sebaceous gland of the ala of the nose, composed of three lobes. 1,
hair-follicle ; 2, 2, principal lobe of the gland ; 3, 4, two other lobes more simple.
C. Large sebaceous gland of the areola of the breast. 1, 1, two hair-follicles in a
state of vestige ; 2, 2, large lobe of a very complex structure ; 3, 3, another lobe, of
which the arrangement is a little less complex ; 4, excretory duct of the gland.
D. Nine sebaceous glands of the lachrymal caruncle. 1, hair-follicle of one of these
glands ; 2, hair which it contains ; 3, little lobules of which it is composed. (SAPPEY.)
SEBACEOUS GLANDS OF THE THIRD CLASS (SAPPKY).
THREE GLANDS OF THE NIPPLE. 1, 1, surface of the nipple; 2, sebaceous gland
composed of two lobes, each consisting of two lobules ; 3, another gland, composed also
of two lobes of a complicated arrangement; 4, glandule, very small, and much more
simple than the preceding ; 5, 5, 5, excretory ducts by which the three glands open
upon the surface of the nipple. (SAPPEY.)
SWEAT GLANDS. 35
with more or less epithelial debris, through the excretory duct into the
follicle in the form of SEBUM or SEBACEOUS MATTER. This product of
the glands is an oily, fatty, semi-fluid, amorphous substance, of a whitish
or yellowish color.
The sebaceous glands develop from the outer root-sheath of the hair-
follicle between the fourth and fifth months of intra-uterine life, in the
form of flask-shaped swellings with cavities. Fatty degeneration of the
epithelial cells (the secretion) begins early. Blood-vessels and capillaries
supply the glands, the latter surrounding them as a net- work. The
arrectores pilorum muscles compass the glands and aid in expressing
their contents. The function of the glands is to lubricate the hairs.
MEIBOMIAN AND TYSONIAN GLANDS.
The MEIBOMIAN GLANDS are embedded in the free borders of the eye-
lids, and are the largest sebaceous glands met with. They differ from
other sebaceous glands chiefly in their elongate form. The TYSONIAN
GLANDS are found upon the glans penis and the inner surface of the
prepuce. They are inconstant, sparse or numerous, variable in develop-
ment, and usually may be seen with the naked eye as small whitish points
on a level with the skin. They are unconnected with hairs, opening on
the free surface. The smegma which forms in this locality, and which
was formerly regarded as being a product of these glands, is now known
to be mainly an exfoliation of the horny layer of the epidermis. Upon
the labia minora also exist large glands without hairs, those on the labia
majora being connected with hair-follicles. Koelliker has also described
sebaceous glands on the red border of the lips, especially the upper lip,
and near the angle of the mouth. The glands just referred to may, as
Unna suggests, be grouped and designated "sebaceous glands of the
mucous orifices."
SWEAT GLANDS.
The SWEAT, SUDORIPAROUS, or COIL GLANDS (glandulse sudoriparse,
glandules glomiformes) are convoluted coiled bodies seated in the subcu-
taneous tissue. They are simple tubular glands, coiled into a more or
less globular form, which open upon the free surface by means of a
narrow canal called the EXCRETORY DUCT, which begins within the body
of the coil. Two kinds of glands, large and small, are met with, the
former distinguished by their great thickness and length, and also by
constrictions and irregular dilatations. They are rounded or flattened,
yellowish or yellowish-red, translucent bodies, variable in size. As a
rule, they measure from 0.3 to 0.4 mm. On the eyelids, skin of the
penis, scrotum, the arched, exterior part of the ear, and the nose, they
average from 0.06 to 0.1 mm. In the areola of the nipple and near it,
at the root of the penis between the scrotum and perineum, in the external
auditory canal (ear-wax glands), and in the groin, they measure from 1 to
1.7 mm., and in the anal region (circumaual glands) from 0.6 to 0.7 mm.
36 ANATOMY OF THE SKIN.
in width to 1 to 2 mm. in length. In the axilla they are still larger, and
measure in thickness from 1 to 3 mm. and in width from 2 to 7 mm.
(Koelliker). They have their seat mostly in the reticular layer of the
corium, surrounded by fat and loose connective tissue, and, more rarely,
in the subcutaneous tissue, or at the junction of these two layers, as is
the case in the areolse of the breast, eyelids, penis, axillse, scrotum, palms,
and soles. Upon the palms and soles they are arranged in rows at the
base of the ridges of the corium, tolerably equidistant one from another ;
in other localities they occur, with some exceptions, distributed in a
pretty regular manner, one or two in a reticulum of the corium. In the
axillae they form an almost continuous layer just beneath the true skin,
above which smaller glands in variable number are found. In the
external meatus of the ear (glandulse ceruminosse) they exist between the
skin and the cartilage in dense subcutaneous connective tissue, without
much fat. Around the opening of the anus, Gay first described large,
anuularly arranged glands, called CIRCUMANAL GLANDS. The eyelids
also contain peculiar glands known as GLANDS OF MOLL, which must
be regarded as a variety of sweat gland. They are broad, somewhat con-
voluted tubules, without coils, lined with large cylindrical cells, provided
with muscles, which usually empty into the follicles of the cilia. The
caruncula lachrymalis, according to Waldeyer, exhibits a transitional
form between these modified sweat glands and the usual variety of
sweat glands.
DISTRIBUTION AND NUMBER.
The distribution of the sweat glands is extensive, and, according to
Hoerschelmann, 1 they exist almost everywhere. Klein and Robinson
failed to find them in the glans penis and on the margin of the lips.
Their number is large, and has been estimated by Krause at 2,381,248
for the whole surface. Upon the back and cheek from 400 to 600 co
the square inch have been counted by Krause, and upon the palms and
soles from 2600 to 2736 to the same space. 2 According to the calculation
of Sappey, 3 there exist upon the palm of the hand and the sole of the
foot an average of 106 in a space of 2.5 mm. square. They are three
and a half times as numerous here as on other parts of the body. For
the entire surface of the body Sappey places the number at over 2,000,000.
Hoerschelmann, a more recent observer, gives still larger figures.
STRUCTURE OF THE GLAND.
The sweat gland consists of a single tubule wound or coiled into a
rounded or oval body, the tubule in the case of the smaller glands
having a tolerably uniform calibre, and terminating on the surface or in
the interior of the gland in a swollen blind end. In the larger glands
of the axillae, Koelliker describes the tubules as being divided and sub-
1 Inang. Diss., Dorpat, 1875; Centbl. f. Med., No. 11, 1876.
1 See Koelliker, loc. cit. 3 Traite d'Anat. Descriptive, t. iii. p. 594. Paris, 1877.
SWEAT-DUCT TRAVERSING THE EPIDER-
MIS. BP, papilla of the corium with injected
blood-vessels ; F, interpapillary space ; Z>, duct
in the mucous layer ; E, E, corneous layer ;
PL, granular layer, stained with carmine; P,
excretory duct with corkscrew windings in the
corneous layer. 150 diam. (C. HEITZMANN.)
SECTION OF COILED PART OF SWEAT-
GLAND FROM HUMAN SKIN. , a, secreting
portion of tubule, cut in various directions ;
6, b, parts representing beginning of duct;
c, intertubular connective tissue ; d, layer of
involuntary muscle inside the basement mem-
brane ; e, cubicular border. (PIERSOL.)
SWEAT-GLANDS, SHOWING THE COILS
AND THE ENDINGS.
A, SWEAT-GLAND OF THE PALM OF
THE HAND.
B, SWEAT-GLAND OF THE BACK OF
THE HAND.
C, SWEAT-GLAND OF THE SCALP.
D, SWEAT-GLAND OF THE SKIN OF
THE THIGH.
A. 1, 1, body of the gland; 2, the
initial extremity of the secreting tube ;
3, excretory duct of the gland.
B. 1, 1, body of the gland, more com-
plicated than the preceding, but in great
part, however, also unrolled ; 2, initial
ending of the secreting tube which forms
the glomerule by its superposed flexuosi-
ties ; 3, excretory duct of the gland.
C. 1, 1, body of the gland formed by
the convolutions of the secreting tube
applied one upon another ; the initial ex-
tremity of this tube is hidden from view ;
2, excretory duct of the gland.
D. 1, body of the gland, more volu-
minous and more complicated than the
preceding, because it is formed of a longer
and more flexuous tube ; 2, initial part of
the tube; 3, excretory duct. (SAPPET.)
SWEAT GLANDS. 37
divided into numerous fork-shaped branches terminating in blind sacs.
The secreting tubules of the glands are made up of three distinct layers,
a covering or investing membrane of connective tissue, a layer of smooth
muscle fibres, and epithelium. The first is composed of connective-tissue
fibres and connective-tissue nucleated cells, running parallel with the
long axis of the canal, the inner portion constituting the membrana
propria (Virchow).
The muscular layer exists upon all the glands. It is well defined
upon the larger glands, the elements occurring in the form of spindle
cells with a single nucleus, which are easily isolated, especially in the
glands of the axillae. They are band- or spindle-shaped, with a rounded
or elongated nucleus, which is situated usually to the inner side of the
fibres, from which it is easily loosened. The substance of the fibre-cells
is homogeneous or finely striped, or may possess delicate transverse lines,
and sometimes contains dark, even yellow or brown, fat-granules. The
muscle fibres lie immediately beneath the epithelium, without, according
to Koelliker, an intervening membrana propria.
The epithelial layer, seated directly upon the basis of the muscle layer,
is composed of a single row of cells, usually cylindrical in form, but in
some localities flattened. The cells possess nuclei and one or two nu-
cleoli, the latter being usually in the basal portion of the cells. As Hey-
nold has shown, the cells possess on their free surfaces a delicate, defined
limiting membrane, which in the case of the larger glands is so firm an
investment as to be looked upon as almost an actual cuticle.
The sweat glands are abundantly supplied with blood-vessels, in the
form of a basket-like net-work on the exterior, the vessels penetrating
between the coils, which show well by injection. Tomsa states that these
vessels arise from independent branches of the cutaneous arteries, build
a capillary net-work of their own, and have a separate system from that
of the upper strata of the corium. The excretory duct is supplied with
arterioles from the arteries of the papillary layer. Nerve fibres occur in
a rich net-work around the glands and capillaries, as has been shown in
gold preparations by Ranvier. Some of these fibres penetrate the mem-
brana propria and reach the muscular layer.
The first rudiments of the sweat glands appear in the fifth month of
mtra-uterine life, in the form of conical epithelial processes into the
corium, and develop much like the glands of the hair-follicle. In the
sixth month they have become elongated into slender appendages with
a club- or hook-shaped termination, the beginning of the coil. In the
seventh month the canal appears, extending towards the epidermis, on the
surface of which an opening, the sweat-pore, is formed.
EXCRETORY DUCT.
The EXCRETORY DUCT begins in the interior of the coil, and winds
its way upwards through the corium and between never through the
38 ANATOMY OF THE SKIN.
papillae into the epidermis ; through the epidermis it pursues a winding
spiral course until the surface is reached, where it ends with a rounded
funnel-shaped aperture, the so-called SWEAT-PORE. Occasionally it
opens into the hair- follicle, as in the glands of Moll of the eyelids. The
length of the duct varies with the situation of the gland and with the
thickness of the skin. The duct at its beginning is always narrower
than the secreting tubule, but beyond this point it is of uniform calibre
until the entrance into the mucous layer of the epidermis, where, as a
rule, it doubles in diameter and loses its sharp outline.
The duct possesses up to contact with the mucous layer of the epidermis
or the hair-follicle a connective-tissue investment with elongately placed
nuclei, and a membrana propria, lined with a double row of cells except
in the widened part through the epidermis. The interior is composed of
the continuation of the cylindrical cells of the secreting canal, and con-
sists of pavement epithelium with round nuclei. In the mucous layer
the duct is distinctly lined with cells of the inner cell-layer, but shows
signs of a cuticular covering and a concentric arrangement with flattening.
In this region eleidin granules are also met with in the cells. Above
this point in the horny layer the cells assume a distinctly concentric
arrangement around the openings, or pores, of the ducts. The pores are
regular or irregular in their arrangement according to the region, and
where large, as in the palms and soles, may be seen with a low magnify-
ing power.
HAIR-FOLLICLE.
The hair-follicle is a depression in the corium, adapted to receive the
hair. It is an elongated cylindrical sac, or pouch, dipping down into the
corium, and even into the subcutaneous tissue, and is to be viewed as a
continuation of the corium with its epidermic covering. Its upper por-
tion, termed the MOUTH, is funnel-shaped, and opens directly upon the
free surface. Just below the line of the papillary layer is a constriction,
called the NECK, which is the narrowest part of the follicle and is the
point where the orifice of the sebaceous gland enters. The follicle now
enlarges somewhat, and finally terminates in a bulbous extremity accom-
modating the hair-bulb and the hair-papilla. It is placed more or less
obliquely in the corium, usually pursuing a straight or more or less curved
course, but in some localities, as, for example, the lips and the eyebrows,
it is markedly curved. The depth of the follicle varies greatly in differ-
ent regions, Koelliker estimating it at from 2 to 7 mm. Follicles occur
singly or in groups, the latter being the case especially upon the scalp,
where two or three or even as many as five may exist together. From
the base of the follicle is developed the hair-papilla.
If the connective tissue of the derma and the epidermis covering it
be kept in mind, imagining these two layers of tissue to be pliable, a
sac made by pressing upon them from without inwards and downwards
INSERTION OF THREE ARRECTORES
PILORUM MUSCLES IN A HAIR-FOLLI-
CLE. Transverse section. (KOELLIKER.)
TRANSVERSE SECTION THROUGH THE
SCALP. Treated with acetic acid. a,
interlacing connective-tissue bundles ; 6,
groups of hair-follicles. (KOELLIKER.)
HAIR-FOLLICLE IN LONGITUDINAL
SECTION. a, mouth of the hair-follicle ;
6, its neck ; c, bulbous enlargement ; d, e,
dermic coat (outer and inner layers) ; /, g y
epidermic coat (outer and inner root-
sheaths) ; A, fibrous substance of the
hair; k, medulla; I, hair-bulb; m, fat in
the subcutaneous tissue ; n, arrector pili ;
o, papilla of the cutis ; p, papilla of the
hair-bulb ; s, mucous layer of the epi-
dermis ; ep, horny layer ; t, sebaceous
gland. (BiESiADECKi.)
HAIR-FOLLICLE. 39
would produce the hair-follicle. The innermost layers would represent
the epidermis, and the outermost layer the derma. 1
The hair- follicle may be best comprehended in its relation to the in-
tegument, and, in particular, to the hair, by considering the principal parts,
or coats, of which it is composed, in the following manner : It is made
up of (1) an OUTER, or DERMIC COAT, consisting of a continuation of the
general surface of the derma downwards ; and (2) an INNER, or EPIDERMIC
COAT, which is a continuation of the stratum mucosum of the general
epidermis downwards. 2 The dermic coat consists of three layers, and the
epidermic coat of two layers.
The dermic coat is the outer, fibrous, and vascular coat, constituting
the main part of the hair-follicle in a narrower sense. The epidermic
coat is the inner and the epithelial coat, and covers the fibrous or dermic
coat ; it constitutes the epidermis of the hair-follicle.
DERMIC COAT.
The dermic coat consists of three layers, designated the external, the
middle, and the internal. The EXTERNAL, fibrous layer, which gives form
to the follicle and belongs to the corium, is made up of connective tissue
arranged in longitudinal bundles, together with elastic fibres, occasional
fat-cells, some medullated nerve-fibres, blood-vessels, and a net-work of
capillaries. The MIDDLE LAYER (the " annular fibrous coat" of Koel-
liker) is generally thicker than the external layer, and extends from the
base of the follicle to the point where the sebaceous glands empty into
the follicle. In structure it is made up of an indistinct fibrous basis
with numerous layers of connective-tissue corpuscles, with distinct ovoidal
or rod-shaped nuclei, running transversely, unaccompanied by elastic-
tissue fibres. On account of its resemblance to muscular tissue, this
layer has been regarded by some observers (Klein, Heitzmann, Bonnet)
as muscular ; but Koelliker and Unna both express themselves as opposed
to this view. Capillaries, running for the most part transversely, exist
here, but nerves have not been demonstrated. This layer is the founda-
tion of the hair-follicle, and continues alone into the papilla.
The INTERNAL LAYER, "hyaline," or "vitreous" membrane (Glashaut,
Koelliker), is a clear, homogeneous structure, highly developed only in
the lower third of the follicle. Although homogeneous on section, ac-
cording to Biesiadecki, it shows, when viewed on the flat surface, trans-
verse, oblique, decussating fibres with ill-defined nuclei. It is thin in
the upper portion of the follicle, and arrives at its greatest thickness
at the bulbous extremity, again becoming thinner as it approaches the
papilla, where it exists merely as a very delicate membrane. Upon
tearing out the hair it always remains in the follicle. It is a variable
structure in the degree of its development. Unna is disposed to regard
1 See C. Heitzmann, Chicago Med. Jour, and Exam., Dec. 1881.
2 This division, which seems to the author to be the simplest and most satisfactory,
is adopted in Quain's Elements of Anatomy, 10th ed. London, 1891, vol. i. Part ii.
40 ANATOMY OF THE SKIN.
it as a condensation of the middle fibrous layer inwardly, and not as an
independent membrane.
EPIDERMIC COAT.
The EPIDERMIS OF THE HAIR-FOLLICLE (the " outer root-sheath" of
most authors) is the prolongation of the mucous layer of the epidermis,
and covers the whole follicle. In order to simplify the complexity of
the subject of the sheaths of the hair-follicle, Unna has proposed to
abandon the name " external root-sheath" and to designate the same the
"prickle-cell layer of the hair-follicle." According to this nomencla-
ture, the t( internal root-sheath" of older authors becomes the root-sheath
proper. 1 The epidermis of the hair-follicle in structure corresponds en-
tirely to the mucous layer of the general epidermis. It consists, how-
ever, of different expressions in the several regions of the follicle. In
the funnel-shaped aperture, or mouth of the follicle, it is accompanied as
far as the openings of the sebaceous glands by the granular and horny
layers of the epidermis, at which point these two layers stop. The mucous
layer, contiguous to the vitreous membrane, continues on down alone to
the level of the hair-papilla, at which point it abruptly becomes narrower
and then tapers off, ending at the neck of the hair-papilla often in a
single row of cells. At the base of the hair-follicle it runs without line
of demarcation into the cells of the hair-papilla which covers it. The
mucous layer of the hair-follicle is about from three to five times thicker
than the root-sheath proper of the hair, and attains its greatest thickness
at about the middle of the follicle. The corneous layer of the epidermis
of the hair-follicle is in the beginning thinner than the mucous layer, but
becomes thicker as the mouth of the follicle is approached, and surpasses
the mucous layer at last considerably. As Koelliker remarks, how far it
goes into the hair-follicle it is difficult to say.
ROOT-SHEATH PROPER OF THE HAIR.
The ROOT-SHEATH PROPER OF THE HAIR, so called by Uuna and
Koelliker (the "inner root-sheath" of most authors), is a glass-clear,
translucent, thin but rigid membrane, extending from just below the line
of the opening of the sebaceous glands into the follicle to the hair-bulb.
On its outer surface it borders on the epidermis of the hair-follicle, to
which it is closely bound and united, and on the other side the connec-
tion with the hair i? even more intimate. It is to be regarded as a part
of the hair.
It is composed of two principal layers, the OUTER, or ROOT-SHEATH in
the narrower sense, and the CUTICLE OF THE ROOT-SHEATH PROPER.
The root-sheath in the narrower sense shows two or three layers of
polygonal, elongated, translucent or light-yellowish cells, which all run
parallel with the hair. The outermost layer (the so-called HENLE'S
LAYER) consists of elongated, non-nucleated cells closely bound together,
1 The terms " sheath of Henle" and " sheath of Huxley" Unna regards as superfluous.
>i &-;,tftJA 4n/&i& ; i.\
-' ii
....OH
"*5>--*
1/y
v . -- ._ _ - *?
gffSgp^
LONGITUDINAL SECTION OF A HAIR-FOLLICLE AND A HAIR-ROOT. 6, hair-
follicle ; gl, vitreous membrane (internal layer) of the same, with dentations on
the inner surface; aW, epidermis of the hair-follicle (outer root-sheath); iW, root-
sheath of the hair (inner root-sheath), outer layer (Henle's layer) ; i W, inner layer of
the same (Huxley's layer), with eleidin-granules ; Oi W, cuticle of the root-sheath ; OH,
cuticle of the hair; p, papilla of the hair; HZ, hair-root, with pigment; ///?, cortical
substance of the hair. (KOELLIKER.)
6 aW
TRANSVERSE SECTION OF A HAIR-FOLLICLE AND A HAIR-ROOT. b, hair-follicle ;
clear layer between b and a W vitreous membrane (internal layer) ; aW, epidermis of
the hair-follicle (outer root-sheath); iW, root-sheath of the hair (inner root-sheath),
outer layer (Henle's layer) ; iW, inner layer of the same (Huxley's layer) with eleidin-
granules ; Oi W, cuticle of the root-sheath ; OH, cuticle of the hair j Hr, cortical sub-
stance of the hair. (KOELLIKER.)
HAIR-FOLLICLE. 41
but which under the influence of acetic acid and alkalies and by dissection
show variously sized clefts or openings between the cells, giving a fenes-
trated appearance to the structure, which Koelliker believes to be arti-
ficially produced. Contiguous with and upon the inner surface of the
above coat is encountered another layer (known as HUXLEY'S LAYER),
made up of shorter and broader polygonal nucleated cells. These two
elements of the root-sheath separate in alkalies, but do not swell up, and
undergo but little change in caustics, peculiarities which they share with
the lamellae of the cuticle of the root-sheath proper and of the hair. At
the base of the hair-follicle both layers of the root^sheath proper pass
into soft, still elongated but broader, polygonal cells with peculiar gran-
ular contents, which, becoming more rounded, extend to the deepest parts
of the hair-papilla and there blend with the contiguous layers of the hair.
The "granular contents" referred to, noted first by V. von Ebner, 1 are
eleidin, as described by Ranvier. In the more elongated cells they are large,
mostly rod-shaped, but also rounded, and in the rounded-angular cells,
smaller, and seated in a more rounded and annular form about the nucleus.
On the upper portion of the hair-follicle the root-sheath proper not
infrequently stands off from the hair, terminating close to the point of
opening of the sebaceous gland with a sharply notched edge. Ebner and
Koelliker both found here some loose cells of the root-sheath proper,
from which it may be concluded that this structure, which continues to
grow with the hair, exfoliates, its elements commingling with the seba-
ceous matter. Above the sebaceous glands the epidermis of the follicle
takes the place of the root-sheath proper, the more superficial strata of
which possess all the properties of the horny layer.
CUTICLE OF THE ROOT-SHEATH.
The CUTICLE OF THE ROOT-SHEATH PROPER is closely adherent to the
latter structure, and much resembles the cuticle of the hair, with which
it comes in close contact. It is demonstrated best with alkalies, and,
together with the root-sheath proper itself, may be separated from the
hair, the cuticle of the hair, on the other hand, remaining fixed to that
structure. The membrane is made up of non-nucleated, shingle-like,
broad cells, which are thicker than those of the cuticle of the hair. As
Ebner has shown, the arrangement of the individual cells of the cuticle
of the root-sheath proper in situ is downwards, while that of the cuticle
of the hair with its free edges is upwards, so that the scales of these two
contiguous layers are placed in opposite directions and fit into the serra-
tions of each other. In the extraction of a hair, therefore, the resistance
thereby caused must be overcome, the root-sheath proper often coming
away attached to the hair.
1 Mikr. Studien iiber Wachsthum und Wechsel der Haare, 56 pp., 3 pi. Wien, 1876.
Keprinted from Sitzungsb. d. k. Akad. d. Wissensch., Math.-naturw. Cl., Bd. Ixxiv.
Wien, 1876.
42 ANATOMY OF THE SKIN.
The stratum corneum of the epidermis of the general surface of the
integument, turning in and downwards, produces the root-sheath proper,
while the stratum mucosum forms the epidermis of the hair-follicle (the
" outer root-sheath" of most authors).
HAIR-PAPILLA.
At the base of the follicle rises the HAIR-PAPILLA (papitta pili), an
ovoidal, club-shaped or spherical, well-defined structure (from 110 to
300 w long, and from 50 to 220 nt* broad, Koelliker), connected by a
pedicle with the connective tissue of the corium, of which it is a pro-
jection upwards. It is composed of connective tissue, devoid of fibrillse
and elastic fibres, and contains numerous colorless or pigmented con-
nective-tissue corpuscles. Blood-vessels occur within the structure, and
nerves have been described here ; but Koelliker is of opinion that nothing
is definitely known about the latter. In other localities, however, espe-
cially in connection with the follicle and its membranes, nerves and
nerve-endings are found in abundance, as the observations of Merkel,
Ranvier, and Bonnet have shown. 1 The hair-papilla has its analogue in
the papilla of the corium.
THE HAIR.
EARLY DEVELOPMENT OF THE HAIR.
The rudiments of the hair, according to Unna, first appear on the
face at about the end of the third month, on the backs of the hands in
the seventh month, and about a month later on all parts of the body.
According to Koelliker, the hair-rudiments consist of club-shaped epithe-
lial growths of the mucous layer pressing into the corium, covered with
the horny layer. The follicle takes on shape, and the cells in the interior
resolve into the conical hair and into the root-sheath. The hair-rudiment
lengthens and becomes the " primitive hair-cone," swells out at the bot-
tom of the future follicle, and is fitted to the papilla, which has now
arisen from the corium. The young hair continues to grow, and at about
the end of the fifth month penetrates the horny layer, having, as Esch-
richt 2 has shown, a very regular arrangement, converging and diverging
in certain directions to form curves and "whorls." The embryonal hair
(lanugo) is devoid of medullary substance.
In the beginning of the seventh month the bed-hairs leave the papillae,
their ends having a bulbous form, and ascend to the middle of the folli-
cle, which is here swollen, and where they are arrested, continuing to
grow by accretions received from the epithelium of this region (Unna).
The lower portion of the follicle instead of collapsing becomes possessed
of a more translucent epithelium, which remains a long time, disappears,
1 See Koelliker, loc. cit., p. 239.
2 Ueber die Richtung der Haare am menschlichen Korper, Muller's Archiv, 1837,
p. 37.
THE HAIR. 43
with shortening of the follicle and with atrophy of the papilla, and is
again replaced.
In the eighth month the loosening of the primary hairs takes place
on the scalp, and later upon the trunk and other regions. This hair-
change persists after birth, and occurs over the whole body. As Unna
says, when a child has a very thick, long, erect, and often dark head of
hair at birth, the normal hair-change on the foetal head has been post-
poned until after birth. This growth of hair is made up of old primary
hairs detached from the papillae, seated in shortened follicles, which
have sent downwards from their sides productive epithelial processes.
" They are not ordinary papillary hairs, but ' bed-hairs/ which have been
growing for two months out of the epithelium of the middle follicular
region, the ' hair-bed.' Near the end of intra-uterine life the epithelial
processes produce new young papillary hairs in their interior after the
exact pattern of the primary hair-rudiments, and these, usually before
birth, but often after it, supplant the bed-hairs by loosening them from
below, growing out of the follicle beside them, and finally causing them
to fall out." The hair-change of the new-born is, therefore, an inter-
change between two distinct types of hair.
At birth, normally, a relative degree of absence of hair exists over the
whole body, but the hair of the scalp at once begins to develop, and later
like activity follows in other regions. The formation of new hairs is
preceded or accompanied by a shedding of the old hairs, a process which
continues in a somewhat variable manner throughout life. Sometimes
this shedding of the hair under apparently normal circumstances is peri-
odical, as in the case of Leeuwenhoek, 1 who in his own person, with the
exception of the scalp and beard, lost his thick hairy coat from the gen-
eral surface every spring, the crop being replaced in a remarkably short
time. As was first suggested by Biesiadecki, the smooth muscles of the
hair-follicles play a part in the shedding of the hair, their contraction
causing a neck to be formed around the young hair.
As C. Heitzmann has stated, the new growth of a hair takes place
within the province of the root-sheath proper exclusively. The hair is
a production of the root-sheath proper. It is a solid elongation springing
from this stratum. The epidermis of the hair-follicle (the " outer root-
sheath" of most authors) is not concerned in its production. The young
hair is formed around the old papilla, as has been shown by Koelliker
and C. Langer.
HAIES.
GENERAL OBSERVATIONS.
Hairs are found occupying the greater part of the body, showing
differences in size, number, and distribution, depending upon the sex,
race, age, region, and peculiarities of the individual. They are long,
1 Quoted from Koelliker, op. cit., S. 244.
44 ANATOMY O* THE SKIN.
rounded, compact bodies, having their seat in depressions in the skin,
designated hair-follicles. They occur upon all parts of the body except
upon the palms, soles, eyelids, dorsal aspect of the last phalanges of the
fingers and toes, lips, and inner surface of the prepuce and glans penis.
The number of hairs, even upon the same region, varies with individuals,
depending upon different causes, as, for example, color. Upon scalps
containing the average covering of hair it is found that those with light-
colored hair yield the largest number of individual hairs. A German
observer has counted the hairs upon four different heads, representing
red, black, brown, and light hair, and found that in the red crop there
were 90,000 hairs, in the black 108,000, in the brown 109,000, and in
the light 140,000.* Erasmus Wilson 2 calculates the average number of
hairs of the scalp to be about 1000 to the square inch, or (allowing an
estimate of 120 square inches for the scalp) 120,000 to the whole scalp.
Other calculators estimate the number to be less.
VARIETIES OF HAIR.
There are many kinds of human hair, as represented by the various
races of man. The variations are numerous, depending mainly upon the
degree of straightness or curl, calibre, length, and color. Hair has been
elaborately classified from an ethnological stand-point by P. A. Browne. 3
Charles Stewart, 4 of Edinburgh, in 1873, in comparing the scalp of the
negro with that of the European, found that the portion of the hair and
follicle embedded in the skin is much longer, and is also remarkably
curved. This observation has been verified by T. P. Anderson Stuart, 5
who finds that the curve is about a quarter of a circle, and is of opinion
that this curve of the hair within the follicle accounts for the curl of the
hair outside of the follicle.
Three forms of hair are recognized. (1) LONG HAIR, comprising soft
hairs from two inches to three feet (5 cm. to 1 metre) and more in length,
and from 0.02'" to 0.05'" (50 to 110 /*/*) in thickness, as on the scalp, beard,
chest, armpits, and genital region. (2) BRISTLE-HAIR, short, stiff, and
thicker hairs, from one-quarter to one-half inch (0.6 to 1.3 cm.) in length,
and from 0.03'" to 0.07'" (50 to 120 w) thick, as on the eyebrows,
borders of the eyelids (eyelashes, or cw'ia), nares (vibrissse), and external
auditory canal. (3) FLEECY HAIR ( Wotthaar), DOWNY HAIR, or LA-
NUGO, very short, extremely fine, soft hairs, from 1'" to 6'" (2 to 14
mm.) in length, and from 0.006'" to 0.01'" (13 to 22 ^) in thickness,
1 Med. Kecord, March 12, 1887.
2 Lectures on Dermatology, London, 1878, p. 99.
3 The Classification of Mankind by the Hair and "Wool of their Heads, with the
Nomenclature of Human Hybrids. Philadelphia, 1852.
A collection of hair from all races is preserved in the Mutter Museum of the Col-
lege of Physicians of Philadelphia.
4 Quoted from Jour, of Anat. and Phys., 1882, vol. xvi. p. 362.
5 Jour, of Anat. and Phys., 1882, vol. xvi. p. 362.
THE HAIR. 45
as on the face, buttocks, extremities, caruncula lachrymalis, and labia
minora.
IMPLANTATION OF THE HAIR.
As a rule, there is only one hair in each follicle, but sometimes there
are two or even three. The hairs stand either singly or in groups of
two, three, or even five. Upon the scalp they are generally arranged in
groups. They are usually implanted obliquely in the skin, their direction
depending upon that of the hair-root. Their arrangement is under the
same laws that govern the cleavage of the skin and the papillary forma-
tion of the corium, as has been shown by Blaschko. 1 The direction of
the hairs for the different regions was first elaborated by Eschricht 2 and
later by Voigt. 3 They follow in their course of distribution peculiar
lines and curves, which in certain localities, as the crown of the head,
form segments of circles and circles, or " whorls." The explanation of
this arrangement is found in the direction of the bundles of connective
tissue of the corium, as has been described by C. Langer and Tomsa.*
COLOR OF THE HAIR.
The color of the hair varies with the race and with the individual,
depending upon three factors, namely, (1) pigment granules, (2) soluble
coloring matter affecting the hair-fibres, and (3) the presence of air.
The first, or granular pigment, occurs in all shades from light yellow to
red and from brown to black, and is found surrounding the individual
cells of the cortex of the hair. The general coloring matter imparts,
according to its intensity, a brownish or a dark red color to the hair.
This unites with the pigment granules, one or the other usually pre-
dominating, and produces various shades. The soluble coloring matter
is entirely wanting in white hairs, is sparse in light blonds, and is most
abundant in those of dark brown hair. The coloring of the external
layers of the cortex usually denotes the shade of the hair, for, as Pincus 5
has shown, owing to the presence of air in the cortex the hair may take
on a whitish color in spite of the fact that the central portion is dark.
Absence of the general coloring matter and of pigment granules renders
the hair gray and transparent, and if the presence of air is superadded
the hair becomes white and opaque, as in old age. Black is the almost
.universal color of the hair, the races with blond hair, as the Germans,
Celts, and Finns, being in the minority. Red hair occurs only among
individuals, and is met with exceptionally in all races.
In considering the hair two portions are distinguished, the SHAFT (or
scapus), which is free and protrudes beyond the surface of the skin, and
1 Beitriige zur Anat. der Oberhaut, Archiv fur Mikr. Anat., Bel. xxx. (1887).
2 Miiller's Archiv, 1837, S. 37.
3 Abhandlung uber die Richtung der Haare am menschlichen Korper, Denkschriften
der mathem.-naturw. Cl. der Wiener Akad. d. Wissensch., Bd. xiii. "Wien, 1857, S. 3.
* Archiv fur Derm. u. Syph., 1873, i. 6 Quoted by Unna, loc. cit.
46 ANATOMY OF THE SKIN.
the ROOT (or radix), the portion contained within the skin and seated in
the hair-follicle. The shaft in uncurled hairs is usually long and straight,
rounded or somewhat flattened, and tapers off at its free extremity to a
point. In crisp and woolly hairs it is flattened or ribbed and curled.
The straightest hair is found in the American Indians, Chinese, Japanese,
Polynesians, and Malays, and the curliest in the negroes.
The root terminates in a somewhat curved, bulb-shaped expansion,
called the HAIR-BULB (bulbus pill), seated upon the HAIR-PAPILLA.
(papilla pili). The hair within the follicle is surrounded by the ROOT-
SHEATH PROPER, a clear, thin layer which extends from the hair-bulb
to the duct of the sebaceous glands. The hair consists of the cortical
substance, the cuticle, and the medulla of the hair, which latter, however,
is not constantly present.
CORTICAL SUBSTANCE.
The CORTICAL SUBSTANCE, HAIR-SUBSTANCE, or FIBRE-TISSUE (sfllb-
stantia fibrosa sen, corticalis, cortex), constitutes the bulk of the hair, and
is composed of elongated, narrow, spindle-shaped bundles of fibres, lon-
gitudinally striated, usually colored more or less uniformly, and often
containing pigment granules, which give it a punctate, spotted, or streaked
appearance. The bundles, made up of light- or dark-colored, long, flat
fibres of varied width, are further remarkable in being stiff and brittle,
and in having irregular ragged borders and ends. They are closely bound
together, and are seen to best advantage after separation by treatment with
sulphuric acid.
These bundles are composed of numerous still smaller plates or cells,
the LAMELLA OF THE FIBROUS SUBSTANCE (or FIBRE-CELLS OF THE
CORTEX), which are the ultimate elements of the hair. They are flat and
in general spindle-shaped, with uneven surfaces and irregular borders.
They do not swell in caustic alkalies, and show within very often a darker
streak, and sometimes pigment granules (Koelliker).
The dark points and spots and streaks of the cortical substance con-
sist for the most part of granular pigment, of air or fluid filling up
the space cavities, and of nuclei. The spots due to the presence of air
are more commonly observed in white and light hairs. Moderately dark
small streaks or lines the borders of individual cells or the nuclei of-
these cells are also met with. Koelliker describes, in addition, fine
streaks having their seat in the cortical substance, particularly plain in a
white portion immediately above the bulb, that are produced by uneven-
ness of the surface of the lamellae of the cortex.
In the hair-root, the structures are the same as described for the shaft
until the softer and finer-fibred lower half is reached. The fibre-like
structure here by degrees disappears, and the lamellae now become gradu-
ally changed into softer, elongated, nucleated cells (easily separable with
acetic acid), further down passing into elongate-rounded or rounded cells,
PLATES, OR FIBRE-CELLS, OF THE
CORTICAL SUBSTANCE OF THE HAIR,
from a hair treated with sulphuric acid.
A, isolated plates ; 1, broad surface
view (three single and two bound to-
gether) ; 2, view of side. B, one com-
posed of numerous such plates or fibre-
cells. (KOELLIKER.)
A, HUMAN HAIR. The upper half
shows the superficial corneous cells (h)
constituting the cuticle, the lower half (s)
the cortical substance and the medulla.
E, isolated fibres of the hair : a, cuticular
scales ; b, fibre-cells of cortical substance.
(PlERSOL.)
Two CELLS OF THE CORTICAL SUB-
STANCE OF THE HAIR-ROOT (finely stri-
ated portions of the same from close
over the hair-bulb), with clear nuclei and
striped appearance. 350 diam. ( KOEL-
LIKER.)
A PORTION OF THE KOOT OF A DARK HAIR, LIGHTLY TREATED
WITH SODA. a, medulla still containing air and with tolerably plainly
marked cells ; 6, cortical substance with pigment spots ; c, inner layer of
the cuticle ; d, outer layer of the same ; e, inner layer of the root-sheath
of the hair (Huxley's layer) ; /, outer fenestrated portion of the same
(Henle's layer). 250 diam. (KOELLIKER.)
ELEMENTS OF . THE INNER KOOT-
SHEATH. A, from the outer layer; 1,
isolated lamellae of the same ; #, the same
in coherence, from the upper parts of the
layer in question, after treatment with
soda ; a, openings between the cells b.
ELEMENTS OF THE INNER KOOT-
SHEATH. B, cells of the inner non-per-
forated layer with elongated and slightly
dentated nuclei. C, nucleated cells of the
single-layered, deepest parts of Huxley's
layer. (KOELLIKER.)
Jt ? I f
Ml
A, PORTION OF A WHITE HAIR AFTER
TREATMENT WITH SODA. a, cells of the
medulla containing nuclei without the
presence of air ; b, cortical substance with
fine fibres and distinct linear nuclei ; c,
cuticle with the lamellae standing off' the
hair more markedly than usual. 350
diam. (KOELLIKER.)
BOOT OF A WHITE HAIR. m, medulla
with eleidin-granules ; m', medulla with
air ; W, white places in the cortical sub-
stance of the hair-root. (KOELLIKER.)
B, THREE SINGLE LINEAR NUCLEI
FROM THE CORTICAL SUBSTANCE.
(KOELLIKER.)
ELEIDIN-GRANULES IN THE MKDULLA m OF ROOT OF A WHITE HAIR; r,
cortical substance. (KOELLIKER.)
THE HAIR. 47
with short nuclei, closely pressed together, which continue down to the
papilla. They resemble the cells of the mucous layer of the epidermis,
and contain either colorless granules or so many dark pigment granules as
to be true pigment-cells. In addition to these pigmented cells, the hair-
bulb in its deepest portion contains a variable number of stellate pig-
ment-cells, which Koelliker regards as connective-tissue cells that have
wandered in from the hair-papilla. This observation, made also by
Aeby 1 and Riehl, 2 is important, and aids in explaining the function of
pigment-formation.
MEDULLA.
The MEDULLA, MEDULLARY SUBSTANCE, or PITH (substantia medul-
laris), occurs in the median line of the hair, extending from the bulb to
near the free end of ihe hair in the form of a cord-like structure. It is
usually present in thick, short, and strong hairs, but is often absent in
lanugo and in colored hair of the scalp. After treating the hair with
caustic soda the medullary cells are seen to be rectangular, quadrilateral,
rounded, or spindle-shaped, with here and there dark granules like fat,
and with a rounded, bright spot, probably representing the cell-nucleus.
In fresh hairs the medulla in the shaft is silvery-white by light from
above, and by light from below black, which appearance is produced by
great numbers of rounded or angular so-called " granules" occupying the
medulla cells. These "granules" have been proved by experiment to
be air-vesicles, and not fat or pigment as was formerly supposed. In
the bulb the medulla contains no air-vesicles, but over the entire width
its cells possess peculiar contents, consisting of shining round or ovoidal
structures, like the eleidin of the epidermis. They were first accurately
described by \Valdeyer, 3 and subsequently by Ranvier. 4 The diameter
of the medulla corresponds generally to that of the hair itself as 1 : 3-5,
and is thickest in short thick hairs and thinnest in lanugo and scalp
hairs. Koelliker 5 records having met with a double medullary cord in
the hair of the upper lip, and with four medullary cords in the hair of
a reddish beard.
CUTICLE OF THE HAIR.
The CUTICLE OF THE HAIR is a notably thin, transparent membrane,
which is a complete covering for the whole hair and binds its bundles
together. It is made up of flat, transparent, quadrilateral or rectangular,
non-nucleated lamellae, which on the hair overlap one another, as shingles
upon a roof, the lower overlapping the upper cells. The arrangement of
these cells upon the hair gives it a reticulated or serrated appearance, like
the scales upon a fish. Treated with alkalies they become detached from
the hair and separate into their elements.
J Med. Centrnlbl., 1885, Nr. 16.
2 Viertelj. f. Derm. u. Syph , 1884. p. 83.
8 Op. cit. * Op. cit. 0p. cit., S. 228.
ANATOMY OF THE SKIN.
NAIL.
The NAILS (ungues) are hard, horny, elastic, transparent structures
which are embedded in the corium upon the last phalanges of the fingers
and toes. They are rounded or quadrilateral plates, and are curved
postero-anteriorly and from side to side. They possess four edges, only
one of which, the anterior, is free, the posterior and lateral edges being
sunk in the skin. The uncovered part of the nail is termed the BODY,
terminating anteriorly by a free edge ; and the posterior portion, embedded
in and concealed by the groove, is termed the ROOT. Around the lateral
and posterior edges of the nail, at the line where the true skin joins the
nail, there exists a well-defined groove, designated the NAIL-GROOVE.
That portion of the skin which arises from the groove, and which covers
in the nail as a fold, is known as the NAIL-FOLD, qr NAIL-WALL. The
EPONYCHIUM, or NAIL-SKIN, is a thin layer of cuticle which proceeds
from the nail-fold and, extending forward, covers as a film the beginning
of the body of the nail to a variable, but usually very short, distance.
The epidermis of the skin upon which the under surface of the body of
the nail rests is designated the HYPONYCHIUM, and the epidermis border-
ing the entire nail the PERIONYCHIUM. Upon the outer surface of the
nail, which is smooth and glistening, there exist more or less marked
striae or minute ridges running parallel with the long axis of the nail.
The LUNULA (or SEMILUNULA) is the little whitish, half-moon-shaped
or crescentic spot which exists in front of the nail-fold and extends
on either side to the lateral edges of the nail. It is most distinctly
defined on the thumb, and is often not defined or is wanting on the toes.
The color of the nail when seated in its natural place is, on the free
border grayish or yellowish, and translucent, on the body reddish, and
on the lunula whitish, the two latter colors being due to the vascularity
of the corium beneath showing through.
The nail is a peculiar metamorphosed portion of the epidermis, and is
made up of two layers in the same manner as is the epidermis of the
skin, a soft, mucous layer and a hard, horny layer, the latter composing
the NAIL PROPER. It begins with a narrowed extremity at the bottom
of the nail-fold, becoming thicker and attaining its definite thickness
after leaving this covering, which it usually retains over the entire nail-
bed, except towards the lateral borders and the free edge, which are
thinned.
NAIL-BED.
The NAIL-BED is that portion of the corium anterior to the matrix
upon which the nail-substance rests, and corresponds in form to the nail.
It is divided into two parts : (1) a posterior (matrix unguis), embracing
the root of the nail ; and (2) an anterior part, the bed of the nail proper.
It possesses an elongated, quadrilateral form, and presents a convex sur-
face from the free edge to the root, and, more markedly so, from side
to side. It presents upon its surface peculiar ridges (LAMINA, or
FLOOR OF THE NAIL, lengthwise view (from a to e), divided in half in the median
line. c, d, e, matrix of the nail, e being the posterior portion with smaller pointed
papillae, d the middle portion, showing ridges with papillary elevations, c the field of
the lunula, with feebly expressed ridges, defined by a sharp line from the nail-bed
towards the anterior portion ; b, nail-bed, with smooth elongated ridges terminating
forward in club-shaped enlargements ; a, papillae of the tip of the finger. (H.
HEBRA.)
NAIL.
LAMELLAE), with papillae on their summits, similar to, but smaller than,
those upon the palms and soles, which begin at the bottom of the nail-
groove at the posterior edge of the nail-bed, and from a middle point
proceed obliquely outward, being better marked towards the distal end.
Those in the median line are straight, while those on either side pursue
a curved outward and forward course.
The nail-bed consists of subcutaneous connective tissue, corium, and
mucous layer of the epidermis. The subcutaneous connective tissue is
mainly or entirely without fat, and is further characterized by the course
of the ascending connective-tissue fibres, which arise as separate fasciculi
from the periosteum of the last phalanges, expand in a brush-like manner,
and are directed both upwards and backwards towards the root of the
nail. This arrangement is the RETINACULA UNGUIUM of Koelliker.
Unna 1 finds the papillary layer of the corium over the whole sub-
stratum of the nail exactly as described by H. Hebra. 2 Beginning from
behind occurs a semicircle composed of several (three to six) rows of
very slender papillae. Next to this comes a lenticular space, enclosed
behind and before by slightly curved lines, the anterior border of which
corresponds exactly to the anterior edge of the lunula. This space con-
tains comb-like ridges bearing papillae, which steadily decrease in size
anteriorly, and entirely disappear near the lunula. These ridges do not
all run parallel from behind forward, but converge symmetrically in
their posterior division to a curved border of the nail- fold, those situated
externally adapting themselves to the curved border of the nail-fold.
These two divisions together correspond to the matrix, from which state-
ment it will be seen that the matrix is by no means homogeneous, having
posteriorly a papillary and anteriorly a simple bed-like character (Unna).
MATRIX.
The MATRIX, or germ-layer, of the nail corresponds to the mucous
layer of the epidermis, and is composed of the same cellular elements,
with essentially the same structure, as that membrane. It occupies the
posterior portion of the nail-bed, lying partly or wholly within the nail-
fold, and is the exclusive seat of the formation of the nail. The nail-
bed, other than this portion of it, does not aid in generating the nail.
The lunula does not indicate the entire matrix.
The surface of the matrix, which is seated on a somewhat lower plane
than the nail-bed, is covered with papillae directed forward (as Henle
pointed out) and implanted on low ridge-like elevations of the corium.
Upon the lunular portion of the matrix the papillae are much less de-
veloped than in the rest of the matrix, and possess no regularity of
arrangement.
The ultimate end of the cells of the stratum mucosum varies ; on the
nail- bed proper the cells abruptly pass into flat epidermal scales, as occurs
1 Op. cit., p. 28. a Wiener Med. Jahrb., 1880.
50 ANATOMY OF THE SKIN.
on the general surface of the skin, but on the matrix they pass gradually
into nail-substance. If the nail be divided into two lateral halves by
vertical section, it will be seen that the layer of nucleated flattened cells
over the matrix of the nail is much thicker than over the nail-bed, and
that over the nail-matrix they are continuous, by an oblique furrowed
surface, with the nail-substance (Biesiadecki).
The nail-bed and the matrix are both highly vascular. The blood-
vessels in the forward part of the nail-bed are abundant, but are less so
about the root of the nail. The capillaries are in the form of loops,
which about the larger papillae are coiled or even knotted, and, being
compressed from above, give a peculiar, matted or verrucous appearance
to the surface. Nerves and nerve-endings are not so abundantly supplied
to this region as to the surrounding skin. According to Biesiadecki, 1
the medullated nerves of the subcutaneous connective tissue lose their
medullary sheath at about the level of the corium and run vertically to
the surface.
NAIL PROPER.
The horny layer of the nail, or the NAIL PROPER, upon its under
surface is entirely even at the root, but farther forward shows well-
defined separated ridges which enter the matrix. The intimate structure
of the nail-substance is studied by first preparing the specimen in alka-
lies and acids, in which the cells swell up and by heat may be isolated.
The nail is made up of separate strata composed of polygonal, nucleated
cells, or little plates, much as in the horny layer of the epidermis, except
that the nuclei are more distinct, and are present through nearly all
the strata. The latter are easily seen in soda and acetic acid. In the
lower strata they are thicker and on the periphery somewhat smaller
than in the upper layers. As in the cells of the horny layer of the epi-
dermis, there exist in those of the nail quite distinct remains of prickles,
which are visible in the unchanged elements as well as in those which are
swollen, which appear as little concavities. A peculiar appearance is the
occurrence of air in the nail-substance proper, in the form of larger or
smaller vesicles having their seat in the intercellular spaces and also
in the interior of the plates. The so-called " white spots" not infre-
quently observed in nails, as single or multiple lesions, are due to this
cause.
The arrangement of the lamellae of the nail of the superficial layers
is horizontal or rising with a slight slope. In the deepest strata there
is a disposition for the plates to overlap at their borders. On the
free surface of some nails in the ridges, owing to a certain number of
lamellae here pursuing a concentric course, columnar strings are formed,
which lead to the long, forwardly inclined papillae of the farthest end
of the nail-bed.
1 Op. cit., p. 200.
IMPLANTATION OF THE NAIL AT ITS POSTERIOR BORDER. P, papillae, decreasing
in size towards the middle line, R l ; E, epidermal layer of medium thickness ; N,
plate of the nail. 50 diam. (C. HEITZMANN.)
VERTICAL LONGITUDINAL SUCTION THROUGH THE MATRIX OF THE
NAIL m and the contiguous portions of the corneous layer of the same
n ; h, posterior, f, anterior portions. (KOELLIKER. )
SAGITTAL SECTION THROUGH THE DORSAL PORTION OF UNGUAL PHALANX OP
A HUMAN F<ETUS FOUR MONTHS OLD, showing, ep, eponychium; n, nail-lamellae;
e, cells with eleidin-like granules in the superficial layers of the mucous layer; m,
mucous layer ; c, nail-bed. (KOELLIKER.)
NAIL-LAMELLA, COOKED IN SODA. A, side view, B, surface view;
a, investing membranes of the swollen nail-elements; 6, nuclei of the
same, surface view, c, side view. 350 diam. (KOELLIKER.)
NAIL. 51
LUNULA.
The lunula is only in part the macroscopic expression of the matrix
of the nail. It does not really end at the edge of the covering of the
nail-fold, but extends on either side to the lateral borders of the nail.
Frequently it becomes visible only after the nail-fold has been pushed
back or removed. The difference in color of the lunula and the nail-bed
is due to the fact that the nail-bed is covered by a transparent horny
substance, whereas in the former^there exist positively opaque elements
which dissipate the light. These are the transitional cells, which are
thickly covered with points, which by transmitted light appear darker
and by reflected light whiter than the granular cells. Their presence
marks the exact boundary of the lunula. As Toldt 1 expresses it, the
lunula is caused by a decreased transparency of the nail, due to the
mucous layer producing here a thick, actively proliferating, broad, uni-
formly distributed layer, the cells of which are in active process of
division.
Hans Hebra's 2 studies show that the lunula corresponds to a portion
of the nail-bed which is devoid of papillae, and that it does not take part
in the formation of the nail. The true matrix, he states, lies behind the
lunula, and is entirely hidden by the nail-fold. From the nail-root for-
ward to the lunula the nail lies directly on the germ-cells and papillae.
From the anterior edge of the lunula forward the granular layer inter-
venes between the nail and the mucous layer. The meaning of the
lunula is not plain.
At a point just before the anterior free edge of the nail is reached there
exists in the nail a narrow YELLOWISH BAND, at which line the red
color of the nail-bed abruptly terminates, owing to the presence of opaque
granular cells (Unna).
The eponychium is a partially horny tissue under which the foetal nail
develops. It is, as Unna states, homologous with the epitrichium cover-
ing the hoof in animals, and, according to Bowen, 3 is a part of the epi-
trichial layer. The nail, according to the latter observer's studies, is a
modified portion of the stratum lucidum, and becomes exposed by the
loss of the epitrichial layer. This layer undergoes a keratosis and forms
a part of the stratum corneum.
GROWTH OP THE NAIL.
If the nail is left uncut, it grows to a definite length beyond the end
of the finger or toe, terminating in a narrowed, bent extremity. The
free end wears itself away by natural desquamation of the cells. The
extent of growth varies with the sex and the individual, and depends
upon its thickness and the cohesion of its cells. Among certain Oriental
1 Quoted from Quain, op. cit., p. 417.
2 Med. Jahrbiicher, Wien, 1880. p. 59.
3 Anatom. Anzeiger, IV. Jahrgang, 1889.
52 ANATOMY OF THE SKIN.
peoples it is known in some instances to grow to a length of from one
and a half to two inches (from three to five centimetres), usually bending
or crooking itself upon the fingers. The nails are thickest upon the
great toe of elderly men, and thinnest upon the little finger and little
toe of women. Koelliker estimates the thickness for the thumb at from
0.50 to 0.60 mm. They grow more rapidly hi summer than in winter,
and more rapidly in children than in adults. They require for their
growth from the lunula to the free edge on the fingers, according to
Berthold, from 108 to 161 days ; Dufour gives the time at from 121 to
138 days. On the toes the latter observer makes the time from 180
to 300 days, and Hallux 365 days. 1 The average growth is about -fa of
an inch a week (Quain). The nail grows by the generation of the cells
of the mucous layer at the root. The horny cells are pushed forward by
the new mucous cells, cornification taking place as in the horny layer of
the epidermis of the skin.
The nail begins to form in the third month of intra-uterine life. In
the fifth month the first trace of the definite nail is noted in the form of
a small lenticular collection of prickle-cells at the nail-fold, beneath the
eponychium. This membrane yields to the growth of the nail during
the next two months, and gradually breaks away, remaining only upon
the posterior part of the nail. The remains of this membrane continue
throughout life partly covering the lunula. At birth the granular layer
has appeared between the prickle-layer and the horny layer (Unna).
1 Quoted from Koelliker, op. cit., p. 217.
PHYSIOLOGY OF THE SKIN.
As has been shown in considering the anatomy, the skin is a complex
organization. It fulfils not merely the passive office of encasing and
protecting the organism, but also certain important functions. In struc-
ture it is composed of many parts, closely knitted together so as to form
a compact covering. The functions of those parts remain to be con-
sidered. They may first be viewed as a whole, and then specially. The
protection which the skin affords the body, the skin as an organ of sen-
sation and of touch, and as a regulator of heat, the cutaneous respiratory
function, and the functions of secretion, excretion, and absorption, all call
for special recognition. Some of these are more important than others.
The normal action of these functions is liable to be interfered with in
many ways, and deviations from the normal state produce certain more
or less marked symptoms. Thus, through obstruction of one kind or
another, or through more positive disease, their action may be in part
or wholly disturbed. The welfare of the individual may in this way be
slightly or seriously compromised. These several physiological offices
will be discussed separately.
EPIDERMIS AND EPITHELIUM.
It has been truly said that man, like quadrupeds and birds, consists
of a framework, a covering without, and a lining within. The frame is
composed of bone, muscle, and blood ; the covering, of skin and mucous
membrane. Man has also been with propriety likened to a tube, with a
covering on the outside and a lining on the inside, the outer covering being
the skin, and the inner being that more extensive tract invested with epi-
thelium. In embryology the covering is spoken of as the epiblast, and
the lining as the hypoblast. The outer covering is the ectoderm, the
inner the endoderm, and between the two is the mesoderm, the skeleton,
with its muscular, vascular, and other attachments.
The outer covering with its epidermis and the inner lining with its
epithelium are similarly composed, the former being adapted to resist
light, heat, and external agencies, the latter being constructed to exist in
darkness and moisture. They are united, one being the continuation of
the other, and they complement each other in many ways. Both are
covered with epithelial cells, which in the one case constitute epidermis,
and in the other epithelium.
These coverings play a most important part not only in health but
also in disease. Their numerous involutions of the skin, in the form of
53
54 PHYSIOLOGY OF THE SKIN.
follicles and glands, producing through their functional activity secre-
tions and other products, together with the enormous epithelial surface
within the body, likewise largely follicular and glandular, constitute the
most active and proliferating tissue of the body. They are consequently
the seat of innumerable modifications and alterations in type in their
relation to one another and to the structures contiguous and adjacent,
giving rise to so-called " diseases."
The whole epithelial covering of man, without and within, exposed as
it is to countless influences, gives forth varied products, some normal,
many abnormal. The forms of these products, moreover, are varied,
some being gaseous, as the breath and the exhalations from the skin ;
others fluid, as the sweat and the tears ; some viscid, as saliva, mucus,
and sebum ; others solid, as the epidermis and its modifications, con-
stituting hair, nail, horn, and teeth. 1
THE SKIN A PROTECTING ORGAN.
The skin, as a whole, guards the economy from innumerable external
agencies from without, including heat and cold, and various mechanical and
chemical agents. It also serves as an outer limiting membrane, and thus
acts as a barrier to the subcutaneous structures and to the fluids of the body.
It is a protecting organ, therefore, in a double sense.
The corneous layer of the epidermis performs a most important service
in limiting the evaporation of water from within, without which medium
this process would take place too rapidly. In the performance of this
function the corneous layer is aided materially by the coating of oily
matter from the glands, which is always present in variable quantity.
The presence of this oily matter, moreover, prevents the horny layer
itself from being acted upon too rapidly by fluids. The corneous layer,
which is practically impermeable, also serves as a protective covering
against the absorption of acids, caustics, and other deleterious substances,
whether in a gaseous, a fluid, or a solid state, this protection being aided
by the presence of glandular oily secretions. As has been pointed out
in considering the anatomy of the corneous layer, the epidermis tends to
grow inwardly into the corium, and thus pressure is exerted upon the
cutaneous capillaries, with the result of regulating the flow of the several
fluids of the body,
The corium, or true skin, is an elastic, dense, tough tissue, well adapted
to withstanding shock and injury from without. The hairs, especially
upon the scalp, also aid in strengthening the skin and in shielding it from
the various harmful influences to which it is exposed. These appendages,
moreover, protect the skin from heat as well as from cold.
The subcutaneous connective tissue covers projecting parts, and enters
into various depressions and spaces, giving the general rounded form to
1 See an article on "Skin Products," by Wallace "Wood, of New York, in Jour, of
Nerv. and Ment. Dis., 1888, vol. xv. p. 446, to which the author is indebted.
PHYSIOLOGY OF THE SKIN. 55
the body. In this layer is formed the adipose tissue, so useful and im-
portant to the cutaneous covering, and upon a certain amount of which
depends the beauty of the external form. It acts as a soft and yielding
pad, and protects certain parts, as the palms, the soles, and the nates,
from external pressure. It also acts as a protective covering, and as a
cushion, for the hairs and glands, as well as for the nerves and blood-
vessels.
TACTILE SENSIBILITY.
The skin, being highly endowed with nerves and special nerve-endings,
is an organ of common sensation, conveying feelings or sensations of varied
kinds to the nerve-centres. Thus, through it we distinguish between
heat and cold. It is the seat, moreover, of certain peculiar sensations,
as pain, burning, scalding, smarting, itching, shooting, pricking, creeping,
tingling, and tickling. Another kind of sensibility is that due to direct
touch, known as TACTILE SENSIBILITY, through which knowledge is
obtained of the objects with which we come in contact. The sense of
pressure, and the various degrees of hardness and softness, smoothness
and roughness, and other opposite qualities, are thus recognized. The
sense of touch is exceedingly developed, and may be cultivated far
beyond the normal, as in the case of blind persons. It is noteworthy
that dealers in human hair determine the qualities, and consequently
the commercial value, of the article, chiefly by the touch. Erasmus
Wilson l gives the case of a buyer of silk who by the touch alone
was able to distinguish forty different varieties of texture of that
substance.
Tactile sensibility varies in different parts of the body, being greatest
in the pulps of the fingers and least in the middle of the limbs, as shown
by the experiments of Weber with a pair of compasses. Thus, upon the
pulp of the middle finger the two points are felt when separated from
each other to the extent of only one-third of a line ; on the palmar sur-
face of the same finger it is necessary to separate them two lines ; on the
cheek, five lines ; on the forehead, ten lines ; on the middle of the breast,
twenty lines ; and on the middle of the arm and thigh, thirty lines.
Weber, moreover, noted that the delicacy of perception was greatest in
the direction of the branches of the nerves, as transversely on the face
and longitudinally on the fingers. 2 Thus, the soles and palms, armpits,
and sides of the trunk are the most sensitive regions to tickling ; whereas
the nipple, though highly endowed with the sense of touch, is compara-
tively insensible to the friction of the clothing and to pressure.
The sensibility of the skin may also be tested with the constant or
induced electric current with electrodes of metallic needles. A series
of charts illustrating the relative sensibility of the skin on thirty-nine
different points of the body to the various impressions of electricity,
1 Diseases of the Skin, p. 44. London, 1867.
2 Quoted by Erasmus Wilson, loc. cit., p. 44.
56 PHYSIOLOGY OF THE SKIN.
temperature, and pressure has been prepared by Bernhardt. 1 Tactile
sensibility also varies considerably with the amount of epidermis present,
being increased in proportion to its thinness or absence, as in certain
pathological states.
Abnormal states of the sense of locality are occasionally met with.
Thus, the application of cold water to the scalp produces in some per-
sons a sensation which they refer to the skin of the loins (Stirling) ;
sometimes in pricking the skin, when only two points are applied, three
are felt (Brown-Se'quard) ; and Landois found upon himself that pricking
the skin of the sternum over the angle of Ludovicus was accompanied
by a sensation in the knee. 2 Sometimes when a prick is applied to
the right side the sensation is referred to the left, and vice versa, as
Ferrier has shown. In certain diseases marked modification of sensi-
bility takes place, sensation being either augmented, as in hypersesthesia,
or diminished, as in anaesthesia, or variously modified, as in pruritus and
dermatalgia.
PERIPHERAL NERVES.
The skin is supplied with nerves possessing several distinct functions,
designated MOTOR, connected with striped and smooth muscle ; SECRE-
TORY, governing the secretory cells ; and TROPHIC, controlling tissue-
change and nutrition. In addition to these, the VASO-MOTOR NERVES
are to be referred to.
VASO-MOTOR NERVES.
The VASO-MOTOR, or VASO-CONSTRICTOR, NERVES, which are supplied
to all the non-striped muscles of the arterial system, are under the
control of the medulla oblongata, and possibly the cord, and play an
important part in the physiology and pathology of the skin, their action
being most powerful upon the blood-vessels of peripheral parts. They
regulate the condition of the blood-vessels and the blood-supply. They
possess, therefore, a controlling influence upon temperature. Stimulation
of this centre causes contraction of the arteries and increased blood-
pressure, and paralysis of this centre causes relaxation and dilatation
of the vessels. There is doubt about the existence and mode of action
of trophic nerves in a strict sense ; as Charcot and others have shown,
the nutrition of most of the peripheral parts depends upon the influence
of the spinal cord.
PAIN.
Pain is due to a stronger stimulation than normal of the sensory
nerves. This may be caused by mechanical, chemical, thermal, or elec-
trical action, or may be the result of disease. The intensity depends
upon the region, and upon the excitability of the nerves.
Pain may be produced by stimulating a sensory nerve in any part of
1 Die Sensibilitats-Verhaltnisse der Haut. Berlin, 1874.
2 Human Physiology, by Landois and Sterling, 2d ed. London, 1886.
PHYSIOLOGY OF THE SKIN. 57
its course, but the sensation is always referred to the peripheral end
of the nerve, although the seat of irritation may be at any point along
its course. An example explanatory of this statement is found in the
cicatrix of an amputated extremity, where the pain is referred to the
part removed. When the nerves of the skin are in a state of painful
excitation from inflammation or other form of disease, in which the
slightest touch, or even the contact of air, causes pain, the condition is
designated CUTANEOUS HYPERALGIA.
TEMPERATURE SENSE.
An important function of the skin is that of the temperature sense,
by which we take cognizance of heat and cold and its variations. The
acuteness of the thermal sense varies with different localities. When
the skin is deprived of its blood there is a feeling of coldness of the
part. An increased temperature, on the other hand, gives a sense of
warmth. At certain temperatures pain is felt. Illusions as to the sense
of heat and cold are common : thus, cold weights are judged to be heavier
than warm ones (Landois).
Regarding the sensations of heat and cold, researches conducted with
delicate instruments show that the skin is provided not only with spots
sensitive to touch sensations, but also with "heat spots" and "cold
spots," or minute localities disseminated over the surface, some of which
are sensitive to heat, others to cold. Goldscheider's l experiments show
that the whole of the back is very sensitive to cold, and only moder-
ately so to heat, and that the forehead and the chest manifest a like
peculiarity.
The skin shows remarkable instances of differences in the perception
of temperature : thus, as Weber has shown, if the two hands be im-
mersed in water of the same temperature, that in which the left is placed
will feel the warmest, while the right is the most sensitive to touch. A
weak impression made upon a large surface of skin produces a more
powerful effect upon the nerve centres than a strong impression upon a
small surface. 2 For this reason the hand is better adapted than the
finger to test the temperature of water.
PERIPHERAL TEMPERATURE.
Couty 3 finds that each person has a special palmar temperature, as
determined by the clinical thermometer, varying within a limited range,
and but little affected by external conditions. Digestion causes a rise,
and during the night there is a decrease. The temperature is markedly
1 See review of Goldscheider's article on the "specific energy of the nerves of sensa-
tion of the skin," in Monatsh. fiir prak. Derm., 1884; also a review of the works of
other writers on the same subject by Max Joseph in same journal, Bd. v., 1886, No. 3.
2 Quoted by "Wilson, loc. cit., p. 45.
3 Archives de Physiol. Norm, et Path., 1880, 2e S., t. vii. p. 82.
58 PHYSIOLOGY OF THE SKIN.
affected by variations in the nervous irritability of the individual, from
whatsoever cause. In disease, the changes of the peripheral (palmar)
temperature always give a precise representation of the course of the
process, and often of the extent of its complications. The curve thus
obtained varies more than that for the central temperature. During
fever the palmar temperature rises relatively higher than the axillary,
and the two tend to coincide or even do reach the same height.
The skin temperature in men between the ages of twenty and thirty
has been found by Kunkel 1 to vary from 31 C. (88 F.), the tempera-
ture of the skin of the face, to 24 C. (75 F.) at the tip of the nose
and lobe of the ear. Upon the trunk covered with clothing the skin
shows a temperature of 30 to 32 C. (86 to 90 F.), while the skin
of the foot indicates 26.5 to 28 C. (79J to 84 F.).
HEAT REGULATION.
The skin acts as a regulator of bodily heat, and aids in preserving
a constant temperature of the blood. The tension of the skin, which is
due to the net-work of elastic fibres and to the muscular cutaneous fibres,
to some extent controls the temperature. The action of heat and cold
upon the skin, the one dilating and the other contracting the membrane,
is seen to advantage on the tunica dartos of the scrotum, which is well
supplied with muscles. The contraction of these muscles also takes
place in a conspicuous degree in the hairy portions of the skin in the
nervous condition called " goose-skin." With an increased flow of blood,
as in inflammation, the part becomes warmer than before, but the actual
heat is not greater than that of the body.
Heat passes off from the skin by the evaporation of the secretions, and
also by radiation and conduction. The skin itself is not a good conductor
of heat, but the presence of an increased supply of blood materially aug-
ments the conduction through this structure. The epidermis is likewise
a poor conductor of heat.
The state of the atmosphere, whether moist with vapor or dry, has a
decided effect on the secretion of sweat, moisture favoring the secretion,
while dry air, owing to the rapid evaporation, retards the formation of
sweat.
THE TURKISH BATH.
The action of the Turkish bath may here be referred to. Flemming, 2
from a study of the physiology of this bath, summarizes its effects as
follows. The temperature of the body and the pulse-rate are distinctly
raised. The respiration falls at first, but later is less influenced. The
urine is increased in density, and is deprived of a largo proportion of
its chlorides, while a slight increase in the amount of urea is produced.
1 Phys.-Med. Gesells. z. Wurzburg, 1886 ; abst. in Jour. Cut. and Gen.-Urin. Dis.,
1887, p. 407.
z Jour, of Anat. and Phys., July, 1879. See also Arch, of Derm , vol. vi. p. 74.
PHYSIOLOGY OF THE SKIN. 59
The principal effect upon the arterial tension seems to be an increase pro-
duced by the greater rapidity of the heart's action, combined with the
dilated or gorged condition of the capillary circulation. Hence the most
important effect of the bath is the stimulation of the emunctory action
of the skin. During the bath large quantities of water should be taken.
The elevation of the temperature, pulse-rate, and blood-pressure points to
the necessity of caution in cases where the circulatory system is diseased.
The results obtained by C. Lange l and by J. Byrne Power 2 confirm
Flemming's observations on the effect of the hot-air bath upon the rate
of the pulse and respiration.
DISTURBANCES OF FUNCTION.
Disturbances of the general function of the skin, whereby its several
offices are simultaneously more or less interfered with, may give rise to
grave results. In this case the skin may cease to perform properly its
functions, one or more of these in a measure being taken up by other
organs of the body, especially the kidneys. Thus, when the entire sur-
face is covered with tar, more or less febrile disturbance, malaise, vomiting
of a dark-brown fluid, headache, and greenish-black urine are liable to
result. This may be due partly to disturbed functional power, but in
greater part is the effect of absorption of the tar.
Experiments upon man and animals have been made from time to
time in varnishing the cutaneous surface with various impermeable dress-
ings, such as varnish, oil-paint, adhesive plaster, collodion, and tar.
Socoloff's 3 experiments with animals, covering them with varnish,
asphalt dissolved in turpentine, glue, and acacia, proved the operation
to be fatal in its results. Clonic and tonic spasms in the muscles, a
lowered temperature, albuminous urine, and pareuchymatous inflamma-
tion of the kidneys were noted. The effect is different on different
animals. In rabbits death sooner or later occurs after the application
of varnish to the shaved surface, the symptoms being those of an acute
febrile disease, followed by decrease in temperature, albuminuria, and
convulsions. But rabbits seem to be particularly susceptible to such
influences, for dogs survive varnishing for several weeks.
Senator has performed experiments of this kind upon man, which go
to show that the operation is not so dangerous as was formerly supposed.
In varnishing the skin, according to Miiller's 4 experiments, the secretion
of urine is decreased, rather than increased as might be supposed, which
is explained by both Miiller and Laschkewitch as the result of a general
dilatation of the cutaneous blood-vessels, the pressure on the renal circu-
lation thus being reduced. The question of suppressed glandular secre-
tion will be referred to in considering these secretions.
1 Arch. Gen. de Mod., 1880, t. i. p. 150.
2 Dubl. Jour. Med. Sci., 1882, vol. Ixxiii. p. 372.
3 Archiv fur Derm, u Syph., Heft 1, 1873. * Archiv fur Exp. Path., 1874.
60 PHYSIOLOGY OF THE SKIN.
SECRETION.
The most important function of the skin is that of secretion, which is
to be considered under the heads of (1) sudoriparous and (2) sebaceous
secretions. The products of both sets of glands give moisture and oil
to the skin, whereby the surface is kept soft and supple, besides per-
forming numerous other offices, including the function of excretion.
SWEAT SECRETION.
The secretion of sweat is one of the most important functions of the
skin, and plays an active part in both health and disease. Sweat is
secreted in the coil of the sudoriferous, sweat, or coil gland. When the
fluid occurs on the surface of the skin in an imperceptible degree, evapo-
rating as it appears, it is termed INSENSIBLE PERSPIRATION ; when it
occurs in increased amount, so that drops of sweat form on the surface,
it is spoken of as SENSIBLE PERSPIRATION. The amount normally
poured out in the twenty-four hours varies, but has been estimated at
about two pounds. Koehrig 1 places the amount at less, at one pound
nine ounces troy.
As stated, it varies greatly and depends upon numerous circumstances,
including the external temperature. Under certain conditions the amount
may be greatly increased, so that in a hot bath, for example, as much as
a pound and a half may be thrown off within half an hour. Favre
collected 2560 grammes of sweat in one and a half hours, by placing
a man in a metallic vessel in a warm bath.
The amount of sweat secreted varies on different regions. The palms,
as a rule, give off most, then, in the order named, the soles, face, neck,
axillae, genital region, arms, and forearms.
SWEAT.
Ordinary sweat is a watery or fatty, colorless, clear fluid, with an alka-
line or an acid reaction, according to circumstances. It possesses a salty
taste and a characteristic odor, varying with the individual and with the
region from which it emanates. The odor is due to the presence of
volatile fatty acids.
According to Triimpy and Luchsinger, 2 its reaction is alkaline, although
it frequently is acid owing to the admixture of fatty acids from decom-
posed sebum. In the palm of the hand, where there are no sebaceous
glands, it is constantly alkaline. Triimpy and Luchsinger further state
that during profuse perspiration the reaction becomes neutral and after-
wards alkaline again. The sweat contains volatile fatty acids, chiefly
formic, acetic, butyric, propionic, caproic, and capric, varying in quality
and quantity in different regions of the body. Neutral fats, as palmitin
and stearin, and cholesterin are also present in small amount.
1 Physiologic der Haut. Berlin, 1876. 2 Pfliiger's Archiv, Bd. xviii.
SECRETION. 61
According to Heuss, 1 the sweat of healthy men during rest is normally
acid, but when, after the administration of pilocarpine or boric acid baths,
the sweat becomes profuse, the reaction is neutral or alkaline. The re-
action of the sweat is to be distinguished from the acidity found in the
skin as a tissue, which extends as far as the prickle-cell layer. Even
when the sweat is alkaline the skin may be acid. The normal acidity
of the sweat is the product of the less acid, neutral, or even alkaline
secretion of the sweat glands, and of the acid and cutaneous fluid. In-
crease of alkalinity depends on the relative proportion of the sweat to
the cutaneous fluid.
It seems to be well established that the sweat glands secrete variable
products. One of these is undoubtedly ordinary sweat, which emanates
especially from the smaller glands. In addition to this watery secretion,
an oily, albuminous product is secreted. This, while it is formed typically
in the larger glands, is also secreted by the smaller glands, as by those
on the palm of the hand, where no sebaceous glands exist. The fact
that an oily product is secreted on the palms has been abundantly proved
by numerous investigators. The product of the sweat, or coil, glands is
therefore a mixed secretion, and moreover is variable. The sweat is a
product of secretion, and, as in the case of the saliva, it is under the
control of the nervous system.
Under the microscope sweat contains fine fatty granules and a few epi-
thelial cells. The inorganic constituents of the sweat comprise the alka-
line chlorides, especially sodium chloride, together with traces of earthy
phosphates and sodium phosphate. They average, according to Funke's
analysis, about 0.329 per cent. Traces of albumen have been found,
and also an unknown reddish-yellow pigment, extracted from the residue
of sweat by alcohol.
Cutaneous diseases modify the secretion of sweat. Aubert's 2 observa-
tions show that, as a rule, certain diseases of the skin more or less com-
pletely suppress the perspiratory secretion, and that after their disappear-
ance some time elapses before the secretion reappears. In cicatrices many
of the glands disappear, but those which remain secrete more profusely
than before.
HISTORY OF THE FUNCTION OF THE SWEAT GLANDS.
The function of the sweat, or coil, glands has been the subject of much
discussion, and has been investigated of late, particularly by Koelliker 3
and Unna. 4 Koelliker expresses the view that the coil glands (Kndud-
driisen) produce not only ordinary sweat but also a product rich in fats
1 Monatshefte fur prak Derm., Bd. xiv., Nos. 9, 10, and 12.
2 Le Progres Medical, 1877, p. 679.
3 Handbuch dor Gewebelehre des Menschen, erster Band, p. 259, Leipzig, 1889; also
in his Mikroscopische Anatomic, Leipzig, 1850-54.
4 Ziemssen, Handb. der Spez. Path, und Ther., Bd. xiv. S. 93 ; also Trans. Internat.
Med. Cong., London, 1881 ; and Brit. Jour, of Derm., Sept. 1894.
62 PHYSIOLOGY OF THE SKIN.
and albumen, with grades intermediate between the two extremes. Unna
is also of opinion that all sweat glands contain and secrete fat at times,
which, though similar to that of sebaceous glands, is different from it,
as stearic acid and margaric acid are different from oleic acid. He is of
opinion that the correctness of this observation can at any time be proved
both on sections of the skin and in the sweat of the hand, by means of
treatment by osmic acid.
According to Unna's l historical investigation, F. Simon was the first
to notice fat in sweat. Koelliker, in 1853, found fat in normal skin
only in the sweat glands of the axilla, and in the small sweat glands
yellow granules, this product being comparable to that of the ceruminous
glands of the ear, which contain yellow granules and fat. Koelliker
called attention to the fact that the ordinary sweat glands, the axillary
glands, and the ceruminous glands constituted an unbroken order of
development.
In 1857 G. Meissner put forth the view that the sweat glands gener-
ally were the producers of fat, going further than Krause the elder and
Koelliker in attributing to them the function of fat formation exclu-
sively. He stated that he had " always found fat in considerable quan-
tity in all these glands wherever they might be, and the shining droplet
which often appears in the aperture of the glands of the palm of the
hand on an objective glass consists mainly of fat, which partly crystallizes
when cold." Henle, in 1861, while stating that Meissner's arguments in
proof of the formation in the sweat glands of fat which is destined to
oil the skin were convincing, adopted a more moderate view, in effect
that " the sweat glands as a whole secrete fat, and, besides that, at times
watery sweat without fat." This view is now held by Unna and others,
including the author.
CONDITIONS INFLUENCING SECRETION.
Perspiration varies in different persons, the average secretion being
about double that excreted by the lungs, or about one-sixty-seventh the
body-weight. It is influenced both by reflex and by central stimulation.
The effect of temperature on the secretion is marked. Increased tem-
perature of the surroundings causes the skin to become reddened and to
secrete and pour out sweat profusely ; cold, on the other hand, by pre-
venting the supply of arterial blood, decreases or arrests the secretion.
Vascular and muscular activity, by acting on the blood-pressure of the
cutaneous capillaries, produces an effect similar to that of heat ; while
the internal use of warm water, in the form of copious drinks, as is well
known, increases the secretion.
The action of certain drugs on the secretion is marked ; for example,
pilocarpine, strychnine, muscarine, nicotine, Calabar bean, picrotoxine,
camphor, and ammonia compounds increase the flow, while others, as mor-
1 Brit. Jour, of Derm., Sept. 1894.
SECRETION. 63
phine and atropine, tend to diminish or arrest it. Atropine paralyzes the
nerves of the glands, and morphine acts in like manner to a less degree.
SWEAT GLANDS AND KIDNEYS.
The complementary relation between the sweat glands and the kidneys
may be alluded to, the action of these two sets of organs being in inverse
ratio. When the skin is active, as in summer, the kidneys separate less
water, while in winter, when the cutaneous capillaries are chilled, the
urinary secretion is increased. Upon mechanical grounds there exists,
moreover, a distinct relation between the secretion of the sweat glands,
the urinary secretion, and the movements of the bowels. When the uri-
nary secretion is copious, as in diabetes, and where watery stools occur,
the skin is usually dry. Urea is a normal constituent of sweat, and
exists in the proportion, according to Funke and Picard, 1 of about 0.1
per cent., though variations occur. It has been found from evaporation
of the sweat in a crystallized state on the surface of the skin by Schottin
and Drasche, in certain, especially ursemic, diseases. 2 According to Leube,
when the secretion of sweat is greatly increased the amount of urea in the
urine is lessened, both in health and in uraemia.
J. Byrne Power's 3 experiments show that nitrogen is excreted by the
skin in all cases, but in quantity so small that it is difficult to believe
that the cutaneous excretion can ever act vicariously with the renal to
any appreciable extent, even in cases of gout and in Bright's disease.
Some investigators, as Voit, Ranke, and Purkis, 4 have denied the exist-
ence of nitrogen in the sweat, but some of their experiments were made
upon the lower animals, and hence are not conclusive.
INFLUENCE OF NERVES ON THE SECRETION OF SWEAT.
The researches of Luchsinger 5 show that the dominating sweat centre
is situated in the spinal cord as far up as, or in, the medulla oblongata.
Adamkiewicz 6 has shown that when the medulla oblongata is stimu-
lated in a cat, the hairless soles of all four feet (the only regions on which
the cat sweats) sweat even three-quarters of an hour after death. Ac-
cording to the studies of Vulpian 7 and Adamkiewicz, the peripheral
paths of the sweat nerves follow the rami communicantes to the sympa-
thetic, and then join the mixed nerves of the extremities. P. Coyne 8
has shown the endings of the sweat nerves upon the sweat glands in
the cat.
The secretory nerves control the secretion of sweat, as has been shown
experimentally by stimulation of these nerves upon the lower animals
1 Quoted from Landois, op. cit., p. 668.
2 See Uridrosis for further observations.
3 Dubl. Jour. Med. Sci., 1882, vol. Ixxiii. p. 369.
* Quoted by Power, loc. cit. 5 Pfliig. Arch., 1877, 1878.
6 Die Secretion des Schweisses. Berlin, 1878. 7 Compt.-Rend., 1878.
8 " Sur les terminaisons des nerfs dans les glandes sudoripares de la patte du chat."
Compt.-Rend. Acad. d. Sc., Paris, 1878, 86, p. 1276.
6 4 PHYSIOLOGY OF THE SKIN.
after complete arrest of the circulation. Landois l is of opinion that the
secretory nerves and those for the blood-vessels lie in the same nerve
trunks. The secretory fibres for the head are in the thoracic sympathetic,
pass into the ganglion stellatum, and ascend in the cervical sympathetic.
M. Meyer 2 has shown that cutaneous electrical stimulation of the cervical
sympathetic in man causes sweating of that side of the face and arm.
The secretory fibres of the anterior extremity are found in the ulnar
and median nerves for the fore-limbs of the cat. A sweat centre for
the upper limbs also lies in the lower part of the cervical spinal cord.
Adamkiewicz found that stimulation of the central ends of the brachial
plexus caused a reflex secretion of sweat upon the foot of the other side.
The secretory nerves for the hind limbs of the cat lie in the sciatic nerve,
as shown by the experiments of Luchsinger. The course of the fibres
of secretion to the sciatic nerve is variable, some, according to Vulpian,
passing directly from the spinal cord, others, according to Luchsinger,
Nawrocki, and Ostroumow, 3 passing into the abdominal sympathetic
through the rami communicantes and the anterior spinal roots from the
upper lumbar and lower dorsal spinal cord, where the sweat centre for
the lower limbs is seated.
The sweat centre may be excited directly by a venous state of the
blood, as in dyspnoaa, as seen in the secretion of sweat that sometimes
precedes death ; by overheated blood pouring through the centre ; and
by certain poisons, already referred to. The centre may also be excited
reflexly, though with variable results, as Luchsinger has shown by stimu-
lation of the cervical and peroneal nerves ; while mustard in the mouth
is capable of inducing perspiration on the face. Luchsinger has noted
that the use of pepper in a case caused the formation of drops of sweat
on the forehead and the bridge of the nose. The secretion of sweat
may be induced by psychical conditions, as anxiety and the like.
Sweating must be regarded as a process of true secretion.
SEBACEOUS SECRETION.
The product secreted by the sebaceous glands is designated SEBACEOUS
MATTER, or SEBUM. It is a fatty substance, and in healthy persons
within the glands is a fluid or semi-fluid substance of variable consist-
ence, tending in some instances to become firmer or of cheesy consistence
within the duct. As is well known, in certain localities where the glands
are large it may sometimes be expressed upon the surface as rounded,
worm-like, whitish or yellowish, tallow-like masses or plugs. Commonly
it exists on the surface of the skin as a greasy or oily coating.
In chemical composition the sebum is for the most part fatty, being
chiefly in the form of fluid olein and solid palmitin fats, cholesterin,
soaps, an albuminoid, and the alkaline chlorides and phosphates. Micro-
1 Op. cit. 2 Quoted from Landois, op. cit, p. 671.
3 Quoted from Landois, op. cit., p. 671.
ABSORPTION. 65
scopic examination shows free fat, fatty cells, cell debris, cholesterin
crystals, and epidermic scales. The vernix caseosa and the smegma
prseputialis are similar in composition, and are a fatty mixture of macer-
ated epidermic scales and sebaceous matter and the product of the sweat
glands. Cerumen, or ear-wax, is a mixture of the product of the seba-
ceous and coil glands. The secretion of the Meibomian glands is sebum.
Sebaceous matter in some persons contains a microscopic mite, the DEMO-
DEX FOLLICULORUM, which, so far as is known, is a harmless creature.
The chief function of this secretion is to lubricate the hairs and to
keep the skin normally greased. It is a true secretion, and, as in the
case of that of the sweat, or coil, glands, is under the control of the
nervous system, and is subject to variations. The difference between a
physiological and a pathological process is often ill defined. The general
observations made on the influence of the nerves on the secretion of
sweat apply with almost equal force to the sebaceous secretion. From
clinical studies the author is of opinion that the two sets of glands act
in concert, both in health and in disease, more commonly than is gen-
erally admitted by physiologists and pathologists. Thus, hyperidrosis
of the palms and soles, as well as of the face, sometimes accompanies
severe pustular acne and also seborrhrea of the face, the two secretions
acting abnormally together.
ABSORPTION.
The skin possesses absorptive properties, various substances entering
the system through this medium, especially under favorable conditions.
The channels through which this process takes place are still questioned,
the most plausible theory, however, being that which involves the fol-
licles. There are certain natural barriers to free cutaneous absorption.
Thus, the oily coating arising from the glands, which is always present in
variable degree, covers the whole surface, and acts as a protective coating
against absorption from noxious and other substances. This secretion
also prevents undue evaporation of the fluids of the body. It exists not
only upon the general surface, but also in the hair-follicles and in the
ducts of the glands. If this be removed, as Parisot l showed, absorption
may readily and rapidly occur. The corneous layer of the epidermis,
consisting of a compact mass of stratified corneous cells, likewise acts
as an obstacle to absorption.
The normal intact skin, it may be said, is almost impervious to watery
solutions. Where the corneous layer of the epidermis, however, is defec-
tive or macerated, absorption takes place readily, as numerous experi-
ments and clinical observation prove. The live and succulent cells of
the mucous layer and the papillary layer of the true skin absorb easily,
the juice-spaces and lymphatics taking up fluids very readily, as proved
by experiment upon a blistered or an excoriated surface.
1 Gaz. des Hop., 1863.
5
66 PHYSIOLOGY OF THE SKIN.
The epidermis permits a certain, though extremely small, amount of
fluid to filter through its layers into the skin. The action of water upon
the epidermic cells causes them to swell, through imbibition of the water.
They are also more or less loosened by the process of soaking, the per-
meability of the structure being in this manner increased. Long im-
mersion in the bath gives an increase in body weight, this being the
result of the epidermis taking up water by imbibition rather than of fluid
entering the system.
SUBSTANCES IN SOLUTION.
Medicinal substances in solution, as iodide of potassium, are to some
extent taken up by the epidermic cells, and may subsequently be regained
in part by washing out, as Keller l has shown. Whatever be the avenue,
medicinal substances in solution certainly enter the system in variable
amount under favorable conditions, in proof of which statement there
is abundant experimental and clinical evidence. Keller 2 found that
mineral-water baths were distinctly diuretic, while sweet-water baths were
followed by a decrease of urine ; and that mineral- water baths increased
the chlorides, and sweet-water baths decreased them. The influence of
cold, in the form of cold packing and cold showers, markedly increases
the secretion of urine ; while hot applications, in the form of cloths wrung
out of hot water, lessen it (Miiller 3 ).
The absorption and elimination of iodide of potassium with the urine,
through the vapor bath, take place, according to Bremond, 4 at about two
hours after the bath ; and elimination after a single bath ceases altogether
after twenty-four hours, irrespective of the quantity of the salt in the
vapor or the temperature or duration of the bath. Where, however, ten
baths have been taken, elimination continues for three or four days ; and
where twenty-five or thirty have been taken, it continues ten or twelve
days after the last bath. The importance of having the skin well cleansed
with soap in order to obtain the best results from the absorption of
medicinal substances is well known, as Bremond 5 has pointed out in his
experiments with a vapor obtained from water in which iodide of potas-
sium was dissolved. Unless the skin had been thoroughly cleansed,
absorption did not occur below a temperature of 100.4 F., but if the
skin had been well cleansed, absorption took place at a temperature
varying from 93.2 to 96.8 F. The salt commences to be eliminated
Avith the urine about two hours after the bath.
SUBSTANCES IX OILS OR FATS.
It is a well-recognized fact that the mercury of mercurial ointment is
absorbed into the system through the skin, but there is a difference of
1 Monatsh. fur prak. Derm., Bd. xi , 1890, p. 215.
2 Monatsh. fur prak Derm., Bd. xiii., No. 1, p. 27.
3 Amer. Jour, of Derm, and Syph., vol. v., 1874, p. 318.
4 Jour, of Anat. and Phys., Nov. 1872.
5 Jour, of Anat. and Phys., Nov. 1872.
ABSORPTION. 67
opinion among physiologists as to the manner in which this takes place.
Some believe that the particles pass through the epidermis (Fleischer,
Ilindfleisch) ; others, that they enter through the hair-follicles and seba-
ceous glands (I. Neumann and others). The latter view seems the more
plausible when the structure and form of the epidermic covering are
taken into consideration. V. Voit found globules of mercury between
the layers of the epidermis, and even in the corium, of a person who
was executed, into whose skin mercurial ointment had been previously
rubbed. The mercury globules in mercurial inunction pass into the hair-
follicles and ducts of the glands, where probably they are affected by the
secretion of the glands and transformed into a compound capable of
absorption. 1
Substances dissolved or suspended in oils or fats are absorbed more
readily when mechanical pressure is employed, as is observed when
inunctions are practised. It is recognized that the presence of hair upon
the surface is favorable for absorption, which would favor the view of
this process taking place through the follicles. Lassar's 2 experiments
upon rabbits go to show that fats and the substances contained in them
are readily absorbed, probably, through the hair- follicles. Fleischer, 3
however, opposes Lassar's views as to the permeability of the uninjured
skin for various drugs, dissolved either in water or in oils. He takes
the ground that no absorption occurs where the epidermis is intact, and
that the occurrence of albuminuria after styrax applications for scabies,
and of olive-green urine after inunction with tar ointment, points to a
defective epidermis.
SUBSTANCES IN A DRY STATE.
Certain substances in a dry state and in powder form, as, for example,
sulphur, are taken into the system through the skin. Thus, Bouvard, 4
having wrapped a limb in sulphur powder for the cure of sciatica, found
subsequently the system saturated with the drug, with a strong odor from
the skin and the urine, together with acne and itching, all the symptoms
disappearing in eight days. With the view of testing this observation,
the experiment was repeated with the same results, the symptoms being
slower in disappearing.
GASEOUS SUBSTANCES.
Gases from without pass through the skin with considerable ease, as
proved by experiments, the epidermis not being the same obstacle as in
the case of fluids. Roehrig found that a rabbit whose body was enclosed
in a vessel of sulphuretted hydrogen, in such a manner that the gas
could gain access to the system through the skin only, died with symp-
toms of this poisoning. In a bath containing sulphuretted hydrogen
this gas is absorbed, while carbonic acid gas is given off into the water.
1 Landois, op. cit., p. 673. * Virchow's Archiv, Bd. Ixvii.
3 Virchow's Archiv, Bd. Ixxix. S. 558. * Lond. Med. Kecord, May 20, 1889.
68 PHYSIOLOGY OF THE SKIN.
It is well known that sulphur baths act favorably in lead-poisoning
through the absorption into the system of their gaseous constituents.
VOLATILE SUBSTANCES.
Volatile substances, such as hydrocyanic acid, chloroform, and ether,
also camphor and turpentine, are absorbed by the unbroken skin.
Roehrig l found that after contact of the hand with turpentine until a
feeling of strong burning was experienced (ten minutes), care being taken
that the oil could not gain entrance to the body in any other way, the
urine passed immediately possessed an odor of violets, and when camphor
was employed instead of turpentine, an odor of camphor. Solutions of
iodide of potassium, digitalin, and curarin, under a certain pressure upon
the arm, in from twenty minutes to two hours were found to enter the
body, as determined by their appearance in the secretions or by their
physiological effects. According to Roehrig, all volatile substances which
act upon and destroy the continuity of the epidermis are capable of
absorption.
GALVANIC CONDUCTION.
Galvanic conduction may take place through the skin. The introduc-
tion of dissolved substances through the skin by means of the constant
current is known as the " cataphoric action" of the constant current, so
called by Du Bois-Reymond. The two electrodes are impregnated with
solutions of certain substances (as, for example, iodide of potassium or
quinine) and applied to the skin, the direction of the current being
changed from time to time. In this manner certain substances may enter
the system and be passed in the urine. The introduction into the system
of dissolved substances through cataphoresis takes place, according to
Ehrmann, 2 through the hair-follicles and the mouths of the sebaceous
glands.
RESPIRATORY FUNCTION.
The skin respires to some extent, the process being analogous to that
which takes place through the lungs. The amount of oxygen taken up
by the cutaneous surface is small, according to Gerlach 3 only as 1 to 137
as compared with the lungs. Water and carbonic acid gas are undoubt-
edly excreted, but it seems uncertain whether, even in small amounts, the
same can be said for nitrogen and ammonia.
As Roehrig * states, the greater part of excretion by the skin is in the
form of water. The amount of carbonic acid gas given off during a
stated period varies in proportion to that from the lungs from 1 : 25 to
1 : 92. The reason the excretion by weight from the lungs appears to
be so much less than that by the skin is found in the fact that the lungs
are constantly absorbing oxygen. The actual transpiration through the
1 Archiv fur Derm. u. Syph., Heft 1, 1873, abst. from Archiv der Heilkunde.
2 Wiener Med. Wochenschr., No. 5, 1890. 3 Quoted by Eoehrig, op. cit., p. 36.
4 Die Physiologic der Haut. Berlin, 1876.
ABSORPTION. 69
lungs is more than double that indicated by the loss of weight. Ac-
cording to Regnault and Reiset, 1 the oxygen taken up by the skin is
either equal to or slightly less than the carbonic acid given off. The
carbonic acid excreted by the skin is only ^^ of that excreted by the
lungs, while the oxygen absorbed is y^ of that taken in by the lungs.
Thus it will be noted that the respiratory activity of the skin is slight.
Von Paalzow 2 finds that baths of water rich in carbonic acid gas do not
increase the respiration. Powerful irritation of the skin, such as is pro-
duced by mustard, on the other hand, causes increase both in the amount
of carbonic acid evolved and in that of oxygen taken in. The amount
of carbonic acid gas daily excreted by the skin is placed by Reinhard 3
at 2.23 and by Aubert at 3.87 grammes. It is augmented by exercise
and increased temperature.
The amount of water thrown off daily by the skin, according to
Seguin, 4 is about double that from the lungs, which estimate seems to
be corroborated by more recent investigators. The amount is put down
at about 600 grammes, although this cannot be regarded as fixed, the
process varying greatly with the individual and the conditions, as the
season, temperature, food, drink, and clothing.
It has been estimated that a healthy man loses daily by the skin ^ 7
of his body weight (Seguin), which is greater than the loss by the lungs
in the ratio of 3 to 2 (Valentin). From 150 (Scherling) to 60 (Aubert)
grains of the entire loss is due to carbonic acid, the rest being in the
form of water (from 1J to 2 Ibs.), with a few salts in solution. 5 Sal-
kowski 6 estimates the daily loss of epidermis from a healthy person to
be almost inappreciable.
REGENERATION OF SKIN.
The epidermis and the several epithelial appendages are regenerated
by proliferation from the deeper layer of epithelial cells. The reproduc-
tion of cells is a prolific process, division of the cells and nuclei taking
place actively. The nucleus plays an important part in the division
of the cells, conformably with the process known as karyokinesis, or
indirect division of the nucleus. Cells continue to be reproduced until
the lowest layer and the bed are destroyed, when repair takes place from
the margins. The glands and the hair-follicles also play an important
part in the regeneration of epithelium, a point to which attention has not
been sufficiently directed. This is notable especially in the case of burns
and scalds of the general surface. Skin may be transplanted from one
locality to another, where under favorable conditions the excised portion
1 Quoted by Landoi?, op. cit.
2 Pfluger's Archiv, 1872, p. 492; Jour, of Anat. and Phya., Nov. 1872.
3 Quoted by Ziemssen, Hand-Book of Skin Diseases, p. 67. New York, 1885.
4 Mem. de 1'Acad. de Paris, 1790, et Annales de Chimie, t. xc.
5 Quoted by Landois, op. cit., p. 278. * Virchow's Archiv, Bd. Ixxix. S. 556.
70 PHYSIOLOGY OF THE SKIN.
attaches itself to the tissues beneath and grows, the epithelial tissues in par-
ticular exhibiting a ready disposition to the production of new structure.
According to Donders, 1 the eyelashes are changed in from three to five
months, and the other hairs more slowly. The rate of the growth on
the head is about six lines a month, being more rapid in youth than
in old age. Concerning the influence of the frequency of hair-cutting
on the growth of the hair, Berthold and Moleschott 2 have proved that
the ordinary notion that frequent cutting increases the production is
correct. The oftener it is cut the faster it grows, and the same observa-
tion is true for shaving the beard. The growth of the hair is stronger in
summer than in winter, and more by day than by night. The nail grows
from the root forward. The finger nails attain their full growth in four
or five months, and those of the great toe in about twelve months.
PEOPERTJES OF HAIR.
Hairs are very strong, and are capable of supporting considerable
weight, the hairs of the head supporting at least six ounces without
breaking ; they are, moreover, remarkably elastic and admit of great
extension. This occurs to the extent of nearly a third of their length,
and when stretched out a fifth they contract again so completely that
they remain extended only one-seventeenth beyond their original length
(Koelliker 3 ). They absorb and give off" water readily ; they also take
up fatty and oily substances. They contain no blood-vessels or nerves,
but are nourished from their papillae. In composition they consist of
a nitrogenous substance containing sulphur, fat, pigment, and mineral
salts. According to Von Laer, 4 hair is composed of 47 per cent, carbon,
25 per cent, oxygen, 17 per cent, nitrogen, 6 per cent, hydrogen, and 5
per cent, sulphur. Hair is insoluble in water, but dissolves in alkalies
and in hydrochloric and sulphuric acids. Chlorine first bleaches it and
then converts it into a resinous matter resembling turpentine. When
heated it becomes hard, swells, and emits an odor of burnt horn, and in
the open air takes fire, burns with a bright flame, and leaves a residue
of charcoal (Watts). Many salts and metallic oxides, also certain organic
substances, change the color of red or white hair to black, as nitrate of
silver in ether or in lard. Hairs retain their characteristics unchanged
for a very long time, and are the last portion of the body to give way
to decomposition.
CHOLESTEEIN.
Liebreich 5 in 1885 stated that cholesterin fat, or "lanolin," exists in
the tissues containing keratin, especially in the human epidermis, hairs,
1 Quoted in Landois, op. cit.
2 Untersuchungen zur Naturlehre des Menschen und der Thiere, Bd. xii.
8 Manual of Human Micros. Anat., London, 1860.
4 Quoted from Diet, of Chemistry, by H. Watts, London, 1882.
6 Ueber das Lanolin, eine neue Salbengrundlage, Berl. Klin. Wochen., No. 47, 1885.
GENERAL SYMPTOMATOLOGY. 71
and vernix caseosa, and later repeated this observation. Lewin l expressed
the same opinion. F. Buzzi 2 was the first to oppose these statements of
Liebreich and of Lewin. A. Santi 3 concludes from his investigations
that there is no cholesterin fat, and therefore no lanolin, in human skin.
Lanolin may be said to be found only in sheep wool ; all other horny
tissues contain cholesterin in considerable quantity, but no lanolin.
Cholesterin occurs, however, more extensively in the body than was
formerly supposed, the human subcutaneous fat, the ordinary animal
glycerin fats, and the liver all being rich in this substance.
GENERAL SYMPTOMATOLOGY.
Symptomatology, or semeiology, might be studied with almost equal
propriety in connection with the special pathology of the skin, of which
it is a part or division. For practical purposes, how r ever, it is convenient
to study the subject from the stand-point of mere symptoms, of ab-
normal manifestations, changes, and sensations having their seat in the
integument. Symptomatology viewed thus deals with the various signs
of disease. It is a most important subject, for from a knowledge of the
signs we learn to understand their meaning, and thus are enabled to
recognize and classify diseases. It may be regarded as elementary and
at the same time introductory to special pathology.
The diseases of the skin exhibit themselves in the form of symptoms,
simple or complex in character, which are either objective or subjective
in nature. Objective symptoms consist of certain manifestations which
occur in the skin, and are for the most part the result of structural alter-
ation in the integument. The processes which occasion the lesions need
not be considered here, for it is with their form, shape, distribution, and
the like, and with their general characters and behavior, that semeiology
is concerned. The lesions comprise the external forms to which diseases
give rise, and consequently are capable for the most part of ocular
demonstration. The so-called primary lesions are the external signs of
disease, mainly of inflammation and of new growths, going on in the
several strata of the integument or in connection with the appendages
of the skin. The secondary lesions, as, for example, ulcers and crusts,
1 Microchemischen Nachweis von Cholesterinfett in der Kornerst'hicht der Epi-
dermis. Berl. Klin. Wochensch., 1886, No. 2.
2 Monatsh. fur prak. Derm., Bd. viii., Feb. 15, 1889, No. 4.
3 Monatsh. fur prak. Derm., Bd. ix., Aug. 15, 1889, No. 4.
72 GENERAL SYMPTOMATOLOGY.
represent the results of the pathological processes, and indicate effete
products and altered or destroyed tissue. Subjective symptoms, on the
other hand, relate to sensation, such as pain, itching, and burning, and
their several modifications, of which the patient alone is able to take
cognizance.
Symptoms involving the general economy in connection with the dis-
ease of the skin, as manifested, for example, through the vascular or the
nervous system, must also be referred to. Thus, certain acute and grave
maladies are accompanied by more or less fever, general debility, or
marasmus ; in other instances disordered digestion or menstruation, or
functional disturbance of other organs, is noted ; while sometimes organic
disease of one or another internal organ of the body is found to exist.
All symptoms, indeed, of whatsoever character, should receive attentive
consideration. The symptoms represent the alphabet of dermatology,
and must be learned before the various diseases can be comprehended
and the whole subject understood. The manifestations which occur in
the skin are to be read by the trained observer as a page of a book.
Upon a correct interpretation of the symptoms depend not only the diag-
nosis but also the indications for the treatment. For the diagnosis of
most cutaneous diseases no further information than that furnished by
the integument is required. For the successful treatment of the case,
however, the history and other information may be of great assistance.
OBJECTIVE SYMPTOMS.
The skin is subject to more functional disturbances and alterations of
structure than any other organ of the body. It is attacked not only by
most of the pathological processes that occur in other parts of the body,
but in addition by many that are peculiar to this organ. That the
lesions produced by these numerous processes should be varied in their
character is not remarkable.
Under the head of OBJECTIVE SYMPTOMS are to be studied the various
lesions capable of demonstration which occur in the skin. They com-
prise both the primary and the secondary manifestations, are numerous,
and are, moreover, capable of undergoing innumerable modifications.
It is the many and peculiar modifications of the typical lesions that ren-
der the study of the diseases of the skin so perplexing and difficult of
comprehension. The modifications in many diseases are as common as
the typical expression. On the other hand, the typical lesions are the
rule in some diseases, as, for example, in herpes zoster and psoriasis. They
may be divided into those which show themselves as primary forms of
disease, termed primary lesions, and those which exist either as the result
of primary lesions or from other causes, designated secondary lesions.
The importance of obtaining a just appreciation of these morbid changes
cannot be over-estimated. Upon their recognition depends the ability to
establish correct diagnoses.
OBJECTIVE SYMPTOMS. 73
PEIMAEY LESIONS.
MACULES.
Syn., Maculae; Spots; Germ., Flecke; Fr., Taches.
MACULES ARE VARIOUSLY SIZED, SHAPED, AND COLORED AREAS OP AB-
NORMAL SKIN, DUE TO VARIED CAUSES, UNACCOMPANIED BF ELEVATION OR
DEPRESSION.
The macule is much less sharply defined than most of the other primary
lesions. The term employed to express the macular, or spotted, manifes-
tations which occur upon the skin irrespective of the pathological process
which has caused the lesion. The macule is, therefore, like the other
primary lesions, strictly a clinical expression. The general characteristics
of macules may first be referred to. They are of various sizes. Thus,
they may be as small as a pea or a bean, or as large as a hand. In out-
line they are usually roundish, but they may be irregular or even angular
in shape. They may be ill defined or circumscribed. In color and
tint they vary exceedingly ; they may, in fact, be of any color, the more
common, however, being reddish, yellowish, and brownish. They are the
manifestations of diverse causes, and consequently illustrate numerous
pathological processes. They are the commonest of the elementary lesions.
They are evanescent or permanent, with innumerable intermediate stages,
according to their nature. They disappear or remain under pressure, as
they are of one kind or another, and may or may not be accompanied
by subjective symptoms, depending upon the cause which produces them.
The simplest and commonest variety of macule is that caused by
hyperaemia, or congestion, and called ERYTHEMATOUS MACULE, examples
of which are of constant occurrence in connection with numerous dis-
orders. They occur especially in the hyperaemias and inflammations, but
are of frequent occurrence in the hypertrophies and atrophies, particu-
larly among the pigmentary affections, less so in the neoplasmata. They
very frequently occur as diffused or circumscribed patches or spots of
congestion, with a variable degree of hyperaemia or inflammation.
Macules are generally symptomatic of some disturbance or disease of
the general economy. In some of the specific exanthemata, as measles,
they exist as a marked feature of the disease. When the erythema is
circumscribed and small, the condition is known as ROSEOLA, which,
however, designates merely the form of the lesion, and not the cause ;
thus, roseola may be the manifestation of some slight disorder of the
alimentary canal or of one of the infectious diseases. These spots are
generally symptomatic, as in typhoid fever. They may result from arte-
rial fluxion or from venous stasis. Where inflammatory products are
present the lesion may be circumscribed and slightly raised, taking on
the modification known as the maculo-papule. The macule may also
show signs of inflammatory oedema. The erythematous rings or zones
which often surround other lesions, as pustules, are designated AREOL.E,
or halos, and are usually distinctly inflammatory in character.
74 GENERAL SYMPTOMATOLOGY.
Macules, or stains, may also result secondarily from inflammatory
changes, due to deposit of the coloring matter of the blood or pigment
in the skin, such as occur in syphilis and in lichen planus. They may
also be the result of hemorrhage into the tissues of the skin, when they
occur as reddish, bluish, or purplish marks which do not disappear
under pressure. Such are met with in simple purpura and in various
other diseases in which diapedesis has occurred. Flat vascular or pigmen-
tary growths in the skin, as some nsevi, are also often macular in form.
Alterations in the pigmentary function of the skin likewise give rise
to macules, which may be due to either an increase or a deficiency of the
normal coloring matter. In some diseases macular manifestations due
to both excess and deficiency of pigment deposit occur simultaneously.
Thus, vitiligo presents an instance in which the lesions are due to an
increase and to an absence of the pigment, both atrophy and hypertrophy
taking place side by side. Similar pigmentary changes are met with in
lepra. The yellowish spots termed chloasmata, observed for the most
part about the face in women, occasioned by the presence of an excessive
amount of usually more or less irregularly deposited pigment, may also
be mentioned. Another form, due to the same cause, is found in lentigo,
or freckle ; still another, yellowish or brownish in color (due to a vege-
table growth, the microsporon furfur), in tinea versicolor.
When abnormal coloring of the skin involves the whole or a large
portion of the surface in a uniform manner, the condition is designated
a DISCOLORATION, examples of which are observed in jaundice, Addi-
son's disease, leprosy, and other diseases ; also in the staining of the skin
resulting from the prolonged internal use of nitrate of silver. The pig-
mentary deposits, or so-called STAINS, accompanying or following certain
diseases, such for example as occur in lichen planus and syphilis, and
known as SECONDARY PIGMENTATIONS, may also be referred to ; likewise
chemical stains, as those resulting from the external use of iodine, nitrate of
silver, and other substances.
PAPULES.
Syn., Papulae ; Germ., Knotchen ; Fr., Papules.
PAPULES ARE CIRCUMSCRIBED, SOFT OR FIRM ELEVATIONS OF THE SKIN,
VARYING IN SIZE FROM A PIN-HEAD TO A PEA.
They are of various shapes, some being acuminated, some rounded,
while others are polygonal, flat, and angular. They are encountered in
numerous diseases ; are due to a great number of causes ; and have their
seat in different structures of the skin. Thus, they may be situated in the
corium ; in connection with the sebaceous glands ; or about the hair-folli-
cles. They may be inflammatory, as is usually the case, or may be due to
new growths, hypertrophies, or other processes. In color they are usually
reddish, pale or dark in shade according to the disease and circumstances.
Papules are of many varieties, the more prominent of which are the
following. The commonest is that which consists of a small circum-
OBJECTIVE SYMPTOMS. 75
scribed plastic exudation in the skin. This finds its typical expression
in papular eczema, in lichen planus, in papular acne, and in prurigo.
In some cases papules are more or less umbilicated, as in lichen planus.
Inflammatory papules may or may not undergo metamorphosis into other
lesions ; thus, not infrequently they pass on into vesicles and pustules, as
in eczema and acne, constituting papulo- vesicles and papulo-pustules, or
they may break down and become ulcers, as occurs in syphilis and car-
cinoma. Various inflammatory processes tend to form about the hair-
follicles, giving rise to papular lesions. Another variety is made up of
accumulations of epidermic cells, arranged concentrically around the
entrances of the hair-follicles, forming conical elevations, as in keratosis
pilaris. Closely allied to such formation is that which occurs in comedo,
which may be considered a modified form of papule. Another variety
forms about the sebaceous glands, as in sebaceous cyst and in adenoma
sebaceum. Still another consists of a circumscribed collection of epithe-
lial cells, producing a small, whitish or yellowish, semi-globular eleva-
tion, as observed in m ilium. They may also be formed by hypertrophy
of the normal structures of the skin, as the papillae, examples of which
may be observed in ichthyosis and wart. Finally, hemorrhage into the
skin may give rise to papules, as occurs in purpura papulosa.
The duration of papules varies with their nature, as in the case of
the other cutaneous lesions. They may be acute, chronic, or permanent.
They may disappear by absorption, as in the case of most of the inflam-
matory varieties, or they may disappear spontaneously or be removed by
mechanical or other means, as may take place in epithelial molluscum
and milium. Inflammatory papules are in the course of their evolution
frequently surmounted by accumulations of scales, more particularly
during the stage of decline. When such are present, the lesion receives
the name of a SQUAMOUS PAPULE, a condition of common occurrence
in syphilis and in lichen planus. The disappearance of inflammatory
papules, especially those of long standing, is apt to be followed by
more or less pigmentary deposit, as occurs strikingly in lichen planus
and in syphilis. Papules may or may not be attended by itching, this
symptom, as well as others of a similar kind, depending upon the nature
of the disease. Those of eczema are remarkable for the violence of the
itching which they occasion. In some inflammatory papular diseases
itching is a notably variable symptom, as in lichen planus.
~*2 VESICLES. SW^^UL ^ Tf 90- *
Syn., Vesiculae; Germ., Blaschen ; Fr., Vesicules.
VESICLES ARE CIRCUMSCRIBED, ROUNDED OR ACUMINATED, YELLOWISH,
REDDISH, OR WHITISH ELFVATIOJ4S_OJ^jr^E_^EJP]nDERMIS, VARYING IN SIZE
FROM A PIN-POINT TO A PEA, CONTAINING CLEAR OR OPAQUE FLUID.
They are of different colors, according as their contents are pure serum,
sero-purulent matter, serum mixed with blood, or sweat. When recent,
GENERAL SYMPTOMATOLOGY.
the common inflammatory types have clear contents and a yellowish,
usually glistening hue. They may be either fully or partly distended
with fluid, and their walls may be tense or flaccid. As a rule, they
rupture readily, discharging their contents over the surrounding surface.
Certain vesicles, however, as those of herpes zoster and sudamen, are
tenacious, and do not break unless exposed to violence. In form they
are rounded and circumscribed, and either possess a dome-like roof or are
more or less acuminated. They may have an even, rounded or irregular
surface, or they may have slight depressions on their summits or about
their walls.
Anatomically they have their seat sometimes between the mucous and
horny layers of the epidermis, in other cases within the mucous layer,
and may thus be either superficial or deep-seated. They may also be
due to collections of sweat in connection with the gland ducts. Their
seat varies with the process, and also with the locality and with the
thickness of the epidermis, especially the horny layer. They may be
single or compound, consisting of one or of several chambers : single
vesicles are seen, for example, in sudamen ; compound vesicles in herpes
zoster, and in dermatitis from rhus poisoning. As a rule, they are
inflammatory, the degree of inflammation attending them, however, not
being so marked as in the case of papules or pustules. In many in-
stances they seem to be produced by direct nerve influence, and in this
respect they resemble blebs.
Vesicles, as a rule, do not remain as such for any length of time,
rarely more than a few days, when they either rupture, the fluid be-
coming a crust, or retain their contents, in which case they are absorbed,
or they may pass into a purulent condition and thus become vesico-
pustules or pustules. Sometimes they pass progressively into blebs, a
striking instance of which frequently occurs in dermatitis herpetiformis.
The changes which they undergo vary in different diseases, and even in
the same disease. They may also coalesce, as in eczema, and thus
undermine the horny layer of the epidermis.
Vesicles rarely occur singly. They almost always appear in numbers,
either in the form of aggregations, as in eczema, or in distinct groups, as
in herpes zoster. They may occur upon all parts of the body, more
especially upon those regions where the epidermis is thin and protected ;
but they are also encountered in the palms of the hand, assuming here,
however, a peculiar form, owing to the thickened horny layer. This
structure modifies the vesicle considerably ; thus, where the horny layer
is thick, as on the palms and soles, the exuded fluid tends to undermine
the epidermis in sheet form rather than to form discrete lesions. They
are usually accompanied by burning and itching sensations; but at
times such symptoms are absent.
OBJECTIVE SYMPTOMS.
- BLEBS. ..
Syn., Bullae; Germ., Blasen ; Fr., Bulles.
BLEBS ARE IRREGULARLY SHAPED ELEVATIONS OF THE EPIDERMIS.
VARYING IN SIZE PROM A PEA TO A GOOSE-EGG, CONTAINING CLEAR OE
OPAQUE FLUID.
They vary exceedingly in size, and have no definite form. Large and
small blebs may occur simultaneously side by side. They may appear
either singly or in numbers, but are rarely so numerous as vesicles, nor
do they usually incline to group. When recent they are generally of a
pale yellowish color ; when their contents become turbid they are whitish
or yellowish ; containing blood they are reddish or brownish, and often
are streaked. Their fluid is serous, and offers an alkaline or a neutral
chemical reaction.
They usually possess strong walls, do not tend to rupture spontane-
ously, and, as a rule, consist of a single chamber. They are generally A^
distended, often to their utmost capacity ; in some instances, however,
they are only partly filled and remain flaccid. At times they are
weak and break before they are perfectly formed, leaving their shat-
tered walls attached to the skin in the form of shreds, as noted in pem-
phigus foliaceus. Their bases sometimes show an unhealthy, eroded or
vegetating surface, bloody or purulent secretion, with maceration and
crusting, as in pemphigus vegetans and syphilis. The walls usually f
rise directly from the surface of apparently healthy skin, without, as a (
rule, marked signs of inflammation, but occasionally areolae are present.^
Like vesicles, they have their seat in the superficial or deeper layers of
the epidermis, their intimate structure corresponding to that of vesicles.
They are seldom attended by marked itching or burning sensations. In
some forms of pemphigus, however, these symptoms are positive.
They are encountered in pemphigus, pemphigoid eruptions, dermatitis
herpetiformis, various forms of dermatitis, erysipelas, herpes iris, syphilis,
leprosy, and occasionally as a complication in some other diseases. A
combination of blebs, vesicles, and pustules is occasionally met with, as
in dermatitis herpetiformis. Their presence generally indicates a weak,o
poorly innervated skin, and where they are flaccid a cachectic or de-J
praved condition usually exists. As a result of diseases arising from
within, they must in most cases be regarded as indicative of general
debility or a depressed state. They are not infrequently due to disease
of nerves or to general nervous depression, as in pemphigus.
PUSTULES.
Syn., Pustulae ; Germ., Pusteln ; Fr., Pustules.
PUSTULES ARE CIRCUMSCRIBED, ROUNDED OR IRREGULAR, PLAT OR ACU-
MINATED ELEVATIONS OP THE EPIDERMIS CONTAINING PUS, VARYING IN
SIZE FROM A PIN-POINT TO A FINGER-NAIL.
They are due to varied and diverse causes. They either originate as
pustules or become pustular by transition from vesicles or papules. Thus,
GENERAL SYMPTOMATOLOGY.
all stages from the vesicle to the pustule are frequently encountered, such
lesions being designated vesico-pustules. The transition of papule into
pustule, as in the miliary syphiloderm, is also common, a mixture of
papules, papulo-pustules, and pustules being of frequent occurrence ; and
a similar evolution takes place in variola, constituting the POCK of this
disease. As in the case of the vesicle, the pustule is often multilocular,
or made up of separate chambers, so that when pricked only a portion of
the fluid exudes. The individual cells, moreover, are soaked with the
exudation, the lesion thus being something more than an accumulation
of pus. Pustules are sometimes umbilicated, as seen in variola and in
syphilis. Inasmuch as they always contain puriform fluid, they have a
yellowish-white or yellowish opaque color ; but not infrequently they
also contain blood, when they possess a bright or dull reddish tint, often
streaked.
There are several well-defined varieties of pustule, their chief differ-
ences resting in their seat, mode of development, and structure. The
pustule of acne, for example, has its seat in a sebaceous gland, and that
of sycosis in a hair-follicle. Both of these forms are deep-seated, and
are peculiar, owing to the anatomical relations. The hair-follicle is a
common seat of the lesion in numerous inflammatory diseases. In
ecthyma and pustular eczema the suppuration is chiefly in the mucous
layer. The larger and broader varieties of pustules tend to assume a
flat form, as occurs in ecthyma and in syphilis. As a rule, they are
accompanied with areolse, which are frequently extensive, and character-
ized by active inflammation, as in ecthyma, and at times by induration,
as in furuncle. Pustules are for the most part unaccompanied by
prominent subjective symptoms ; in some cases, however, heat, burning
sensations, and pain are present, as in the highly inflammatory forms of
sycosis and in ecthyma. Much itching is rarely noted. They are often
tender to the touch.
Their course and duration vary according to their nature, but they
usually incline to a rapid termination. They either rupture, forming a
thick, yellowish, greenish, or brownish crust, or desiccate, without break-
ing, leaving a dry, friable, often bulky crust, as in eczema. The crusts
of eczema, especially in infants and on the face, are generally of more
varied color than in any other disease. Excoriated surfaces often take
on suppurative action, crust over, and form pustules ; this is observed in
eczema and also in pediculosis of the scalp and of the body. It will
thus be noted that the skin is particularly liable to suppurative processes,
which are due to a great variety of causes, internal and external.
Pustules may or may not be followed by cicatrices, this termination
V depending upon the nature_of the lesion, and also upon the extent to
which the process has involved the forium. The scars resulting from
variola, as well as from acne, sycosis, and syphilis, are well known.
OBJECTIVE SYMPTOMS. 79
WHEALS.
Syn., Pomphi ; Urticae ; Germ., Quaddeln.
WHEALS ARE CIRCUMSCRIBED, ROUNDED OR FLATTENED, ELONGATE, OR IR-
REGULARLY SHAPED (EDEMATOUS ELEVATIONS OF A FUGITIVE OR EPHEMERAL
CHARACTER.
In size they vary extremely. They may be not larger than peas, the
size of a finger-nail, or as large as the palm of the hand, produced in the
latter case by the confluence of smaller lesions. The average size is that
of a pea or a bean. In rare instances they form discrete hemispherical
elevations of considerable size, occasionally as large as a small hen's-
egg. They may occur singly and discretely, but are apt to appear in
numbers, and when near to one another exhibit a decided inclination to
coalesce. By the process of coalition large surfaces often become more or
less involved in patches or as a continuous sheet. In form they ordi-
narily manifest themselves, as ovalish or bean-shaped elevations, tending
to assume an elongate rather than a rounded shape ; they also occur in
the form of streaks, lines, or bands, irregular in outline. Their color
is usually rosy or reddish pinkish, often with pale or whitish centres, with
more or less marked areolse. Sometimes they present a shining aspect,
owing to the tension of the skin consequent upon the circumscribed oedema.
In duration they are generally fugitive or ephemeral. They usually form
rapidly, often in a few minutes, and, remaining a longer or shorter time,
disappear rapidly or slowly, in most cases much more slowly than they
came. Sometimes they are followed by more or less pigmentation, which
may be slow in disappearing. Their course is generally capricious.
They have their seat in the papillary layer or in the body of the
corium, and are produced by a sudden eifusion of fluid into the meshes
of the corium, followed by immediate contraction of the capillaries, the
vessels being for the time in a state of spasm. Upon relaxation the
fluid is absorbed, the wheal disappearing rapidly or slowly. The process
is peculiar, and is a typical expression of angioneurosis. The lesion
may contain suddenly exuded serous fluid, as in simple urticaria, or a
mixture of serum and blood, as in urticarial purpura. The typical
wheal is seen in the sting of the common nettle, and in urticaria arising
from various internal causes. Wheals are occasioned by many and varied
causes. Their manifestation is accompanied by characteristic tingling,
burning, and itching sensations, which are generally distressing.
TUBERCLES.
Syn., Tubercula; Oerm., Knolen ; Fr., Tubercules.
TUBERCLES ARE FIRM, ROUNDED OR IRREGULARLY-SHAPED, USUALLY CIR-
CUMSCRIBED, PEA-SIZED ELEVATIONS OF THE SKIN, SEATED IN THE CORIUM
OR SUBCUTANEOUS TISSUE.
In shape they are usually circumscribed, but they possess no definite
form ; thus, they may be more or less semi-globular, more or less acumi-
80 GENERAL SYMPTOMATOLOGY.
nated, flat or flattened on their summits, or irregular in outline. Their
color is usually reddish, but this feature depends upon their nature.
Thus, in molluscum fibrosum they are flesh-colored or pinkish. Where
they are due to inflammatory products or to new formations they are apt
to exhibit a yellowish-red, dull-red, or brownish-red color, as occurs in
syphilis, lupus, lepra, and carcinoma. They are ordinarily of firm con-
sistence, and have their seat usually in the corium or in the subcutaneous
connective tissue. In structure they are similar to the inflammatory
varieties of papules, frequently being in reality exaggerated papules in-
volving deeper tissues and a more extended surface. But their presence
has a meaning quite different from that attached to papules. They are
the result of various causes, as in the case of papules, but are produced
mainly by the so-called neoplasmata, new growths due frequently to
specific inflammations. Syphilis, lupus, leprosy, carcinoma, myoma,
neuroma, and xanthoma all give rise to marked examples of tubercle.
They undergo varied changes in their involution, according to their
nature and circumstances. They are either absorbed or break down and
ulcerate and are followed by scars, or establish themselves and remain
permanent, as in molluscum fibrosum. In some of the neoplasmata,
also, they may remain for months or years without undergoing much
change. It will be observed that the term tubercle, as used to express
one of the primary lesions in dermatology, refers only to the form of
the lesion and in no sense to its nature. It must, therefore, not be con-
founded with a more recent meaning of the word as applied to a product
of tuberculosis, with which it has nothing in common.
TUMORS.
Syn. , Tumores ; Phymata; Germ., Knollen; Fr., Tumeurs.
TUMORS ARE VARIOUSLY SIZED, SHAPED, AND CONSTITUTED, FIRM OR SOFT
PROMINENCES HAVING THEIR SEAT IN THE CORIUM OR SUBCUTANEOUS TISSUE.
The definition is vague, but the term is of use clinically. They are
of all sizes, from a pea to an egg and larger ; sometimes they attain the
size of a fist, as in carcinoma, sarcoma, and granuloma fungoides. They
usually tend to assume a rounded or a semi-globular form with a broad
base, as in epithelial molluscum, carcinoma, syphilis, and many other
diseases, or are pedunculated, as in many cases of fibroma molluscum.
They are more or less well defined, or may be vague and ill defined,
according to their nature and expression. Their color may be the same
as that of the contiguous skin, but where due to inflammation, simple or
specific, they are reddish, variable as to shade. The skin covering them
may remain intact or may break down and excoriate, thus giving rise to
suppurating, bleeding, or crusted formations, as in granuloma fungoides
and carcinoma. They usually rise above the surrounding skin to a vari-
able elevation, and, on the other hand, extend more or less deeply into
the tissues beneath; in other cases they are flat or flattened on their
OBJECTIVE SYMPTOMS. 81
summits, as in carbuncle. They are occasioned by a great variety of
causes, as, for example, alterations in the sebaceous glands, various in-
flammations and new formations in the corium and connective tissue,
and new growths of the blood-vessels and lymphatics. They may or
may not be painful, subjective symptoms depending on their nature, as
well as upon other causes.
SECOND AEY LESIONS.
CRUSTS.
Syn., Crustse; Germ., Borken ; Krusten ; Fr., Croutes.
CRUSTS ARE MASSES OP DRIED EFFETE MATERIAL COMPOSED OF THE
PRODUCTS OF CUTANEOUS DISEASE, IRREGULARLY SHAPED AND SIZED, AND
USUALLY YELLOWISH OR BROWNISH IN COLOR.
They are variable as to size and form, their features depending upon
the nature of the process which has occasioned them, as well as fre-
quently upon the length of time during which they have existed ; thus
they may be large, thick and bulky, or thin and flat. They generally
possess a granular, rough, uneven exterior, with clefts, fissures, and ridges
over the surface. In some diseases they tend to assume a shell-like for-
mation. In variola, occasionally, and in some disorders of the sebaceous
glands, the crusts take on a cornified or hard character. They are adhe-
rent to the skin or partially detached, according to their age and the
nature of the disease. Partially detached, or " stuck on," crusts are
observed strikingly in impetigo contagiosa. Being due to serous or
puriform exudation, they are usually yellowish or brownish, but they
may be greenish or blackish, and often are variegated, as in pustular
eczema. They are for the most part formed by the desiccation of exuded
fluids, as serum, pus, and blood, usually by a mixture of these fluids,
together with epithelial debris.
Several distinct varieties are observed. Those resulting from an open,
serous discharging surface are yellowish or brownish-yellow, friable in
consistence, and as a rule without definite outline or bulk, as in vesicular
eczema ; those following the breaking down or drying up of pustules,
especially if there be hemorrhage, are darker, more tenacious, and
thicker, as in ecthyma. The crusts of syphilis are usually firmer and
less friable in structure than in eczema, and frequently have a heaped-
up, shell-like appearance ; they sometimes have a dark greenish tint,
and may be seated upon a superficial or a deep ulcer. Brownish or
blackish crusts always contain more or less blood or its derivative
products. Sebaceous crusts, as those of seborrhosa, are light yellow,
dirty yellow, greenish, or blackish in hue, lamellated, adherent to their
bed, and have a greasy feel and appearance. Another form of crust,
that of tinea favosa, remains to be mentioned ; here the formation is
composed chiefly of epithelial cells, debris, and the fungus, the latter
6
82 GENERAL SYMPTOMATOLOGY.
generally in profusion, and presents a clean or dirty, sulphur-yellow,
umbilicated or cup-shaped, well-formed crust, or, if old, an irregularly
shaped, broken-up crusted mass.
SCALES.
Syn., Squamse; Germ. , Schuppen ; Fr., Squames.
SCALES ARE DRY, LAMINATED MASSES OF EPIDERMIS WHICH HAVE SEPA-
RATED FROM THE TISSUES BENEATH.
They vary greatly in size and form, and may be large and thick or
small and thin, abundant or scanty, laminated or heaped up in the
centre, giving the lesion a shell-like form. In consistence they are
dry and of a horny nature ; they possess a harsh feel, and are more or
less brittle, with a tendency to separate and to break up into their more
minute elements. Such scales are observed in ichthyosis, and in psoriasis
and squamous eczema. In some cases, however, they are m,ore or less
greasy, from admixture with the glandular secretions, as in seborrhoea.
Their color is usually whitish or grayish, either dull and without lustre
or micaceous and glistening, as in psoriasis ; at times they are yellowish
or dirty-yellowish, especially when due to disorder of the sebaceous
glands. The quantity formed and thrown off varies with the morbid
process. In some diseases scales are proliferated and thrown off from
the skin in large quantity ; in pityriasis rubra and in active psoriasis
several handfuls, and even more, may in some cases be gathered daily.
With many inflammatory diseases scaling occurs as a prominent or even
the chief symptom, the nature and activity of the inflammation influ-
encing the degree of desquamation.
Scales are at times formed in large, bulky lamellae, or plates, and in
heaps, as in psoriasis ; sometimes in thin flakes, as in pityriasis rubra ; in
other cases, as in dry seborrhoea or in eczema, they consist of coarse or
fine flakes or of flour-like or bran-like particles; in the latter event
they are known as FURFURACEOUS SCALES, a typical example of which
occurs in tinea versicolor. Modifications of scales are also encountered,
where the product consists of a dried serous or puriform fluid together
with epithelium. Thus, a mixture of scale and crust is not infrequently
found in eczema, and in other diseases. They are due to a variety of
causes, chief among which are the superficial inflammatory diseases and
the vegetable parasitic affections. They are also met with in epithelial
hypertrophies, especially in ichthyosis. They are likely to form in all
cases in which there is want of proper nutrition in the skin arising from
various causes, and therefore may be the product of numerous patho-
logical changes. Scaling in the form of small or large lamellae, con-
stituting sometimes a localized exfoliation of the epidermis, designated
EXFOLIATIVE DESQUAMATION, is met with in impaired nutrition as a
result of nerve injury, such as occurs after section of a nerve.
OBJECTIVE SYMPTOMS. 83
EXCORIATIONS.
Syn., Excoriationes ; Erosions; Germ., Hautabschurfungen ; Fr., Excoriations.
EXCORIATIONS ARE VARIOUSLY SIZED AND SHAPED AREAS CHARACTERIZED
BY LOSSES OF CUTANEOUS TISSUE, CONFINED USUALLY TO THE EPIDERMIS,
GENERALLY THE RESULT OF LOCAL INJURY.
Their seat is usually in the epidermis, extending to the mucous layer,
but not infrequently the latter layer and even the papillary layer of the
corium are involved. They comprise slight wounds, erosions, abrasions
of the skin, lacerations, and scratch-marks. As a rule, they heal readily
and without leaving scars. They present a variety of forms, accord-
ing as they happen to have been produced by one or another cause.
Ordinarily they consist of puncta, lines, or streaks, generally lacerated
and ragged in outline, with shreds of epidermis, variously sized and
shaped, for the most part irregular, showing reddish, moist surfaces,
oozing minute quantities of serum and blood which have a tendency to
dry into crusts. They may be present in connection with an eruption
of an itching nature, or they may exist independently of disease, as
simple wounds of the epidermis produced by mechanical causes of one
kind or another. Into this category falls also the condition known
as "raw skin," in which from any cause the skin has been deprived
of its corneous layer, leaving the mucous layer exposed, in the form
of small or large areas, due to varied causes. Together with or follow-
ing excoriations, especially where the condition has lasted for some
time, more or less suppuration and crusting occur.
Scratching or rubbing, on the part of the patient, is the direct cause
of the vast majority of excoriations. The symptoms which give rise to
the desire for scratching are numerous, and are intimately connected
with a large number of diseases. Most disorders of the skin accompa-
nied by nerve irritation, whether from an internal or an external cause,
occasion more or less itching and consequent scratching. If the itching
be intense, the scratching usually will be violent and the marks propor-
tionally severe and deep ; if slight, as a rule, there will be but little and
the lesions superficial. Excoriations occur most abundantly in eczema,
scabies, and pediculosis, but they occur in some affections in which there
is no itching or scratching, as in the so-called neurotic excoriations, and
in other states where the epidermis is defective. All skins are not
affected to the same extent by the same amount of scratching ; in some
the lesions are readily produced, while in others the tissues resist the
injury. Thus, in otherwise healthy individuals, pruritus may exist and
scratching be vigorously indulged in without causing extensive excoria-
tions, while in other persons, especially those whose systems are in a
debilitated or depraved state from want of food and proper hygiene, as
in vagrants, the epidermis tends to break down readily under even a
moderate degree of scratching.
If violent scratching and rubbing be continued for a long period, the
84 GENERAL SYMPTOMATOLOGY.
skin, if affected with an inflammatory process, as eczema, becomes more
or less inflamed, with or without suppuration, varying in degree in dif-
ferent individuals, generally resulting in considerable infiltration, thick-
ening, and pigmentation. This state of the integument is also frequently
observed in those who have suffered for a long time with pediculosis,
where the skin is usually unhealthy apart from the parasite. Excoria-
tions play an important role in many diseases of the skin, and should in
all cases receive attentive consideration. Their number, form, distribu-
tion, and localization are in themselves often sufficient in certain diseases
to establish the diagnosis. It should be kept in mind that an excoriated
skin is not necessarily the result of injury, scratching, and like causes.
It may be the effect of the natural process of disease, as noted in eczema,
pemphigus, and other diseases with defective epidermis.
FISSURES.
Syn., Kimaa ; Khagades ; Germ., Hautschrunden ; Fr., Fissures.
FlSSUBES ARE VARIOUSLY SIZED AND SHAPED LINEAR CUTANEOUS CRACKS
OR WOUNDS, DUE TO DISEASE IN THE SKIN OR TO EXTERNAL AGENCIES,
HAVING THEIR SEAT MAINLY IN THE EPIDERMIS.
They commonly occur about the well-marked natural furrows of the
skin, as about the palms, soles, fingers, and toes, but they are also en-
countered in other regions. They are liable to appear wherever there
are movement and tension of the tissues, as about the flexures of the
joints, and about the natural apertures of the body, as the mouth, nares,
and anus, especially if nutrition of the part is impaired, as in eczema
or syphilis. In these diseases they are of frequent occurrence. While
they tend to follow the natural lines and furrows of the skin, sometimes
they form elsewhere and at angles or even transversely to these lines
and furrows, as occurs especially in eczema. They assume various sizes,
and appear as elongate, narrow or broad, superficial or deep, reddish,
dry or moist, linear openings or clefts. They may be the result of a
diseased condition of the tissues, as in ichthyosis, eczema, psoriasis, and
syphilis, or may be caused by local irritants, as cold, and chemical
agents, or by other influences acting injuriously upon the epidermis.
They are generally more or less painful, and interfere with the natural
movements of the part.
ULCERS.
Syn., Ulcera ; Germ., Geschwiire ; Fr., Ulceres.
ULCERS OP THE INTEGUMENT ARE IRREGULARLY SIZED AND SHAPED
LOSSES OF SUBSTANCE OR EXCAVATIONS OP THE CUTANEOUS TISSUES, THE
RESULT USUALLY OP SOME PRECEDING DISEASE.
Cutaneous ulcers are characterized by a substantive loss of tissue,
whether this be in the upper or the lower strata of the corium or in
subcutaneous tissue. They are the result of a preceding alteration of the
tissue or tissues involved. In some cases this alteration is of a simple
inflammatory nature, as in the common forms of leg ulcer ; in others it
OBJECTIVE SYMPTOMS. 85
is due to a specific inflammation, as in lupus vulgaris, carcinoma,
syphilis, lepra, and other so-called neoplasmata. The symptomatology
of ulcers occupies an extensive field in dermatology, inasmuch as many
and diverse diseases may at one period or another in their course be
characterized by ulceration. Only the general symptoms of ulcers
can be considered here, and more especially the clinical features of the
commoner forms of these varied lesions.
Ulcers vary extremely as to size and shape ; thus, they may be no
larger than a pin-head or as large as a hand. In outline they incline to
be circular, but they are often irregularly shaped, kidney-shaped, or ser-
piginous. Sometimes they exhibit an excavated or crater-like form, as
seen in carcinoma ; in other cases they have a scooped-out or punched-out
form, as occurs often in syphilis. They may be superficial, shallow, or
deep ; not infrequently they extend into the subcutaneous structures.
They present a more or less moist, bleeding, or discharging surface, which
may or may not be crusted. Their bases are smooth, uneven, or irregu-
lar ; are reddish in color ; and are covered with a grayish, yellowish, or
reddish, inoffensive or offensive secretion, which may be either abundant
or scanty, according to the nature of the morbid process. Their edges
are usually defined ; not infrequently they are abrupt ; at times they are
markedly everted or undermined. Ulcers occur as a symptom in the
course of a large number of diseases, chief among which are syphilis,
lupus, scrofulosis, lepra, carcinoma, sarcoma, carbuncle, and furuncle.
They may also be due to simple or complicated inflammatory processes,
the result of impaired nutrition, venous stasis, and necrosis, as in the
common leg ulcer ; and to animal parasites and other irritants, varied in
character. They occur during the course of certain diseases in which
the nervous system, central or peripheral, is involved, and as a result
of injuries to nerves or of a specific inflammation of nerves, as in lepra.
Ulcers may occur upon any part of the surface, but are most frequently
met with upon the lower extremities, especially the legs. Certain diseases
tending to ulcerate, as syphilis, lupus, lepra, and carcinoma, however,
frequently manifest themselves on the head, trunk, and upper extremities.
Their duration is variable ; they are seldom stationary, but show, on the
contrary, a decided disposition to undergo change. Many tend to enlarge ;
others manifest an inclination to heal. When repair takes place it is in
the form of a cicatricial tissue, which in most cases remains permanently.
While pain is often present, it is a variable symptom.
SCARS.
Syn , Cicatrices ; Germ. , Narben ; Fr., Cicatrices.
SCARS ARE NEW FORMATIONS, CONSISTING MAINLY OP CONNECTIVE TISSUE,
OCCUPYING THE PLACE OF FORMER NORMAL TISSUE, THE RESULT GENERALLY
OF INJURY OR PREVIOUS DISEASE.
While the presence of a scar implies in the vast majority of cases that
86 GENERAL SYMPTOMATOLOGY.
this lesion is the result of an injury of one kind or another, or of an
ulcer, simple or specific in nature, there are cases in which scar tissue
develops independently of such antecedents. To the latter class of
scars belong those which occur in connection with certain hypertrophic
and atrophic diseases, as morphcea and scleroderma, atrophia cutis, and
the like ; with certain diseases of the class neoplasraata, as keloid ; with
simple and specific inflammations of the nerves, as lepra ; and with lupus
erythematosus. The subject of scars, like that of ulcers, covers much
ground, although for obvious reasons it is of less importance than the
latter. Ulcers and scars, the latter being the sequel usually of the
former, should from a pathological stand-point be considered together,
but regarded in the light of mere symptoms they may be discussed
separately.
Scars usually have a shining or glistening, more or less contracted
appearance, and are surrounded by normal skin, into which they blend,
either with a line of demarcation or imperceptibly. They are in most
instances smooth and soft to the feel, but often they are indurated or
firm. They possess different forms or characters, according to the dis-
ease which has occasioned them ; thus, they may be on a level with the
skin, or, as is more often the case, somewhat depressed ; at times, how-
ever, they are raised and hypertrophic. Sometimes they are linear, band-
or cord-like, and in other instances, more frequently, contracted, knotted,
or puckered. Their color is usually whitish, grayish, or silvery ; but
this varies, for if recent they may be rosy, pinkish, or reddish, while
if older, grayish, yellowish, reddish, or brownish. They consist of
fibrous connective-tissue elements, with blood-vessels and nerves, but do
not often contain hairs, glands, and papillae.
Scars in most cases are the result of former disease or of injury.
They are known to follow all the diseases which may be accompanied
by ulceration, and also injuries involving loss of substance, as burns,
scalds, wounds, and caustics ; and sometimes they form where no loss of
tissue has occurred, as the result of simple cuts, punctures, and the like.
The relation of scars of this kind to keloid, and to false keloid in par-
ticular, is intimate. Although resulting from a variety of causes, many
of them are similar in character ; hence they cannot be said to be posi-
tively indicative in all cases of the process which has occasioned them.
At the same time they not infrequently possess certain features as,
for example, outline, number, size, texture, and location which point
unmistakably to the original disease. The experienced clinician will
seldom err in estimating the antecedent history of a well-defined scar
the result of disease. Scars are generally permanent, continuing to exist
through life with little if any alteration. They are for the most part
indolent ; but in rare cases, where nerves become involved, they may be
painful.
GENERAL SYMPTOMS. 87
GENERAL SYMPTOMS.
All the lesions present in a case, especially if inflammatory, viewed
as a whole, constitute what is known as an ERUPTION. An aggregation
of lesions, whether of the same or of different character, goes to make
up what is termed a PATCH of disease. The individual lesions, which
are the expression of the disease of the skin, may all be of the same
kind, as, for example, papules, in which event they are UNIFORM ; or
they may be different, of two or more kinds, macules, papules, and
Vesicles, and their modifications, for example, all being present, when
they are said to be MULTIFORM, or POLYMORPHOUS, exemplified in ery-
thema multiforme, so named on account of the variety of elementary
lesions usually present at one time or another in its course. They may
moreover be isolated or DISCRETE (DISCRETUS), or so numerous as to be
closely crowded, or CONFLUENT (CONFERTUS).
The following expressions, descriptive of peculiar forms of lesion, are
used in connection with certain diseases, more especially in those cases in
which the lesions are both uniform and numerous : when small pin-head
or millet-seed sized, MILIARIS ; when pointed, ACUMINATUS ; when of
the size and shape of a pea or bean, LENTICULARIS, etc. Thus, common
examples are found in the expressions miliary papular syphiloderm, acu-
minated warts, and lenticular papular syphiloderm. The terms NEO-
NATORUM, INFANTILIS, ADULTORUM, SENiLis, etc., are frequently con-
venient to express concisely the time of life at which the disease occurs :
for example, the sclerema of the new-born is called sclerema NEONATO-
RUM ; the eczema of infants, eczema INFANTILE, etc. The terms .ESTI-
VALIS, AUTUMNALIS, HiEMALis, applied to diseases which are peculiar
to certain periods of the year, are obviously indicative of the seasons, as
pruritus hiemalis, eruptio eestivalis, etc.
The terms CAPITIS, FACIALIS, BRACHIALIS, CERVICO-BRACHIALIS,
DORSO-PECTORALIS, FEMORALIS, ABDOMINALIS, DORSO-ABDOMINALIS,
PALMARIS, PLANTARIS, etc., are conveniently used to denote the region
involved : as, for example, eczema capitis, syphiloderma palmaris, herpes
zoster facialis, etc.
Color. This necessarily varies with the nature of the pathological
process, the inflammations, however, producing the most striking color-
ing. It also varies greatly according to the stage of the disorder, a
point which must always be taken into consideration in describing the
disease. In many diseases it is tolerably uniform and constant, as in
psoriasis and tinea versicolor. Reddish colors, of course, prevail, and
they occur in all shades and variegations from pink to vermilion and
crimson. Yellow and brown in innumerable shades are also common.
In some diseases at times unusual and peculiar colors, such as blue,
green, and black, in light or dark shades, are noted. The coloring may
pertain to the corium, to the epidermis, or to effete products, as crusts.
88 GENERAL SYMPTOMATOLOGY.
In some instances it is due to changes taking place in the sweat and
sebaceous secretions, as in chromidrosis and rare forms of seborrhoea.
Different colors and shades, either simultaneously or during the evolu-
tion and involution of the process, are often seen in the several stages
of a disease, as, for instance, in erythema nodosum. The tint is, more-
over, often influenced by external agencies, as by heat or cold, and also
by local treatment. When an affection is characterized by a prominent
and uniform color, whether evanescent or permanent, it is at times
designated by a term descriptive of this peculiarity ; thus, the adjectival
words ALBIDUS, KUBER, FLAVESCENS, NIGRICANS, MELANODES, etc., are
affixed to certain diseases, as, for example, eczema rubrum, sarcoma
melanodes, and seborrhoea nigricans.
Symmetry. This depends largely upon the process, and also upon
the nervous system. The latter has been shown to be the governing
influence in the production of symmetrical manifestations. The inflam-
mations, especially those which pursue an acute course, as the acute infec-
tious diseases, show symmetrical distribution most perfectly. Erythema
multiforme and erythema nodosum both illustrate symmetry. Among
the chronic infectious diseases syphilis in its early cutaneous outbreaks
portrays this distribution strikingly. It is characterized by the simul-
taneous occurrence of the eruption upon the same regions on each lateral
half of the body, as upon both arms or upon both arms and forearms
and hands. More definite regions, as the palms and soles, the elbows,
and the knees, also show this feature in some diseases, as, for example,
eczema and psoriasis. The extremities generally show symmetrical
distribution in the most striking manner. 1
Distribution. Great variation exists in the distribution of lesions ;
they may occupy the whole or the greater part of the surface, or
may be localized to a small circumscribed area. They may further
appear aggregated in patches, AGGREGATUS ; or they may be dissemi-
nated, DISSEMIXATUS. In some diseases the entire general surface
tends to become involved, as in the case of the acute specific inflamma-
tions, dermatitis exfoliativa, and pityriasis rubra. When an eruption
involves the entire surface, it is said to be UNIVERSAL; when various
parts are affected, without regularity of distribution, it is DIFFUSED.
Not infrequently lesions tend to group and cluster in various forms,
notable examples of which are found in herpes simplex, herpes zoster,
herpes iris, tinea circinata, and lichen planus. Eczema, acne, and
scabies, on the other hand, illustrate disseminated lesions. The term
HERPETIFORMIS is used to express the peculiar form of grouping which
is exemplified in the several varieties of herpes, the lesions being papular,
vesicular, pustular, or bullous, as the case may be, and clustered. The
1 For further information on this question the reader is referred to Testut's work " De
la Symetrie dans les Affections de la Peau " Paris, 1877. For abstracts see Annales
de Derm, et de Syph., t. viii. p. 385 ; also Archives of Dermatology, July, 1878.
CONFIGURATION. 89
arrangement is indicative of a peculiar form of peripheral or central
nerve influence.
Streaked, striated, or linear cutaneous manifestations are observed
sometimes in inflammatory affections, as in lichen planus, but more fre-
quently in atrophic diseases depending upon impairment of nerve func-
tion, as in morphcea, maculae et striae atrophicae, alopecia areata, and
ichthyosis hystrix. They generally take the course of the natural lines
of the skin, on the sides of the thorax, for example, running parallel
with the ribs, and not infrequently they follow the course of nerve trunks,
as in some nsevi, ichthyosis hystrix, warty growths, and leprosy, or they
occupy areas innervated by definite segments of the spinal cord rather
than by special nerve trunks, as often noted in herpes zoster. The dis-
tribution to the several organs or appendages of the skin is also impor-
tant, some diseases having their seat in the sebaceous or sweat glands,
some in the follicles, others in the structure of the hair or nails.
Configuration. The lesions of the skin show themselves in a great
variety of forms, and figures or patterns, especially with the inflammatory
affections. Some of these are peculiar, and are characteristic and more
or less constant symptoms of certain diseases, while others are common
to many diseases. In other affections they manifest themselves without
attempt at special configuration, as in eczema. The various forms and
outlines assumed by individual lesions and by patches of disease are des-
ignated by the following suggestive terms. When they occur discretely
in the form of small, pin-head sized points, the condition is termed
PUNCTATUS ; when of the size of drops, GUTTATUS ; if as large as pieces
of coin, NUMMULARIS. As an example, certain of the forms of psoriasis
are known as PUNCTATA, GUTTATA, and NUMMULARIS. When a patch
presents a circumscribed form it is designated CIRCUMSCRIPTUS ; when
rounded and sharply defined, ORBICULARIS or DISCOIDES. If it has a
circular shape, it is called CIRCINATUS ; when in the form of a ring,
ANNULATUS, or ANNUL ARIS, as in tinea circinata and in certain rare
erythemata. The disposition to circular shape, however, shows itself
generally in an incomplete or broken form, producing segments of
circles, often ill defined. The annular shape is usually caused by the
lesion clearing in the centre and at the same time spreading periph-
erally, as -seen in syphilis and psoriasis. The subject will be referred
to again in connection with the mode of spreading of disease. When
the lesions appear in concentric rings with the display of unusual colors,
the condition is expressed by the word IRIS, as, for example, herpes iris.
Patches are sometimes encountered whose margins upon one side appear
unusually sharp and well defined against the sound skin ; to these the
name MARGIN ATUS is given. This condition is often seen markedly
developed in ringworm of the body, and also in pityriasis rosea,
especially of the macular variety.
When the patches are circumscribed and defined by an abrupt line
90 GENERAL SYMPTOMATOLOGY.
of demarcation, as, for example, in psoriasis, the word CIRCUMSCRIPTUS
is used. Sometimes such lesions, owing to their close proximity, run to-
gether and form geometrical shapes, in particular the figure eight. Some
diseases, as eczema, also tend to form circular patches around natural
apertures and depressions, as the anus and the umbilicus. If they arrange
themselves in such a manner as to form winding or gyrate markings,
a form sometimes observed, particularly in psoriasis, the term GYRATUS
is employed. The designation SERPIGINOSUS is applied to those forms
of disease, especially tubercles and ulcers, which pursue their course in
a creeping, serpentine manner ; as an instance, the serpiginous tubercular
syphiloderm may be given. A linear or striate arrangement of the
lesions may also take place, sometimes following nerve trunks, as in
lichen pi anus and striae atrophicse.
The state of an eruption, as to its striking feature, is often denoted as
follows : thus, HYPERTROPHICUS, used especially in connection with
chronic inflammations, hypertrophies, and new growths, is employed to
indicate an exuberant or hypertrophic condition, as in elephantiasic
forms, and in lupus; EXULCERANS, when the process of ulceration is
going on, as often occurs in carcinoma, sarcoma, lupus, and syphilis ;
HUMIDUS or MADIDANS, when moisture is present, as in eczema ; siccus,
when there is absence of moisture, as in seborrhoea ; and INDURATUS,
where induration is pronounced, as occurs often in acne, and in many
other diseases.
Some diseases, as those due to the presence of vegetable growths, are
confined largely to the epidermis, the inflammation of the corium
often present being usually secondary. These affections are for the
most part dry and scaly, as is the case in tinea circinata and tinea versi-
color. The papillary layer, including part of the mucous layer of the
epidermis, constitutes the most active part of the skin, and is the seat
of many pathological changes, notably those which occur in the common
diseases eczema and psoriasis. Here the majority of the superficial
inflammations have their seat, characterized by various superficial ele-
mentary and secondary lesions.
Mode of Extension. The manner of spreading of the disease varies
with the process, and also with the case. In some diseases there is a
tendency to begin as a local lesion and to spread by the multiplication
of lesions through new areas of infection, as in sycosis and lupus
vulgaris. In others the extension takes place on the periphery, as in
tinea circinata, lupus erythematosus, and psoriasis, affections widely differ-
ent in their nature. In connection with the several forms which lesions
in certain diseases are prone to assume, attention must be directed par-
ticularly to the circinate shape, a peculiar and well-known evolution of
which is into the annular form, where the patch having cleared in the
centre continues to spread on the periphery, constituting a ring, complete
or broken, as noted in tinea circinata, and syphilis, especially in the tuber-
EVOLUTION OF LESIONS. 91
cular variety of syphilis, and also not infrequently in psoriasis. 1 An-
other mode of extension is in the form of a series of complete or broken
rings, separated by healthy skin, two or three sometimes occurring, as
seen in herpes iris and in a less marked degree occasionally in tinea
circinata.
Evolution of Lesions. This subject is of practical importance from
a diagnostic point of view as well as from that of pathology. In some
diseases the changes that occur from the earliest formation of the lesions
to their termination are not marked by much change, the lesion, for
example, beginning as a macule or as a papule and remaining such until
its disappearance. Thus, in lichen planus the lesion is almost always a
papule, and in tinea versicolor it is always a macule. But in the vast
majority of diseases, especially those characterized by inflammation or
new growth, the lesions undergo numerous and marked changes during
the evolution of the morbid process. Thus, in eczema they may pass
from vesicles into pustules, while many other changes are common. In
scabies, dermatitis herpetiformis, herpes iris, herpes zoster, granuloma
fungoides, and other diseases, the evolution is not only marked but is
characteristic, thus playing a prominent part in symptomatology. Another
common mode is for macular or papular lesions to become squamous, as
occurs in eczema, syphilis, and other diseases. In brief, it may be stated
that the evolution and involution of cutaneous lesions, primary and
secondary, constitute a most important phase of symptomatology, as may
be noted in connection with the history of most of the diseases.
Locality. The aspect of a disease depends in some cases largely
upon the region and locality invaded, and on the period of time that the
lesions have existed. This observation is shown in many diseases, but
in none more plainly than in eczema and syphilis, where not infrequently
all trace of the original lesions has disappeared, followed by secondary
changes entirely unlike those occurring in the beginning of the disease.
The regions of the body invaded vary with the disease. Certain affec-
tions are peculiar in that they attack only particular localities ; some
possess a decided preference for this or that region, while others exhibit
no elective point of manifestation. Thus, if the several regions of the
general surface be considered, it will be found that the scalp is prone to
develop eczema, alopecia areata, pediculosis capitis, tinea tonsurans, and
tinea favosa ; the face, lupus vulgaris, lupus erytheinatosus, acne, sebor-
rhoea, syphilis, measles, variola, erysipelas, chloasma. Analyzing the
face further, it is observed that the forehead is the usual seat of chloasma ;
the eyelids, of xanthoma, milium, and sebaceous cyst ; the nose, of acne,
acne rosacea, rosacea, lupus, and syphilis ; the bridge of the nose and
the cheeks, of lupus erythematosus ; the upper lip, of herpes simplex ;
the lower lip, of epithelial cancer ; the cheeks and chin in the male, of
1 A report of some examples of "circinate eruption," by Louis Wickham, may be
found in Brit. Jour, of Derm., vol. iii. p. 256.
92 GENERAL SYMPTOMATOLOGY.
sycosis. Tbe neck in front is often invaded with eczema and intertrigo,
especially in infants, and the nucha with acne, furuncle, and carbuncle.
The shoulders and back are liable to carbuncle, acne, and pediculosis
corporis. Upon the chest the acute infectious diseases, as scarlatina
and measles, and the erythematous syphiloderm and tinea versicolor, are
generally well defined. The breasts in the female are subject to eczema
and intertrigo, and the nipples to scabies, eczema, and epithelial cancer.
Upon the sides of the trunk zoster generally manifests itself, and upon
the abdomen the erythematous macules of typhoid fever are seen ; about
the nates are found scabies, furuncle, intertrigo, and congenital syphilis
in infants, and upon the genital organs, eczema, herpes, scabies, pruritus,
and elephantiasis. The forearms and the backs of the hands and fingers
are the usual seats of erythema multiforme, and the sides of the fingers,
interdigits, and wrists, of scabies.
The extensor surfaces of the limbs are prone to manifest psoriasis ; the
flexor surfaces, eczema. The palms and soles favor the papulo-squamous
syphiloderm, and eczema ; the elbows and knees, psoriasis and ichthyosis.
The legs are generally the seat of chronic dermatitis, simple and specific
ulcers, elephantiasis, purpura, and erythema nodosum. 1
LOCALIZATION.
The localization of skin diseases depends upon a variety of causes,
chief among which are the anatomy of the skin, the occupation and
habits of the individual, and the nerve-supply to the skin. Variations
in the thickness of the epidermis, the development of the papillary layer,
the degree of vascularity, the sebaceous and sweat glands, the follicles
and the hairs, all influence the determination of disease to one or another
locality. To these must be added the supply of peculiar nervous struc-
tures to the skin, as in the case of special nerve-endings, and the action
of the central nervous system through the vaso motor system upon special
regions, as the face and the extremities. Owing to this force and to the
fact that the epidermis is thin and not calculated to resist external agencies
nor undue blood-pressure acting from within, and that the glands and
follicles are large and active, the face is specially liable to diseases of
many kinds.
The localization of skin diseases depends to a considerable extent upon
the anatomical structure of the skin, as has been shown by Oscar Simon. 2
The fibrous layer of the corium is arranged in definite directions, the
distribution of the papillae being determined by the longitudinal trend
of the fibrous bundles, which in turn account for the arrangement of the
natural furrows of the skin. The lines of localization, for example, on
1 For further information on this subject, an article by Pye- Smith, Guy's Hosp.
Keports, vol. xxii., 1877, may be consulted.
2 Die Localisation der Hautkrankheiten histologisch und klinisch bearbeitet. Mit 5
Tafeln. Berlin, 1873.
NERVE-SUPPLY TO THE SKIN. 93
the neck and over the superior thoracic region converge from above out-
wards, and from below inwards towards the sternum ; on the back they
run parallel with the ribs ; next to the spine, upwards, and on the outer
portions, downwards ; on the inguinal region they run parallel to Pou-
part's ligament, and on the inner side of the thigh parallel to the sar-
torius muscle.
NERVE-SUPPLY TO THE SKIN.
In connection with the subjects of symmetry, distribution of lesions,
localities and regions prone to be invaded by cutaneous disease in gen-
eral, the influence of the larger nerves innervating the skin may be
considered. That the nerve trunks and branches play an important
part in the localization of many diseases in which the integument is
involved is abundantly shown in such diseases as herpes zoster, as well
as in certain other inflammations, and particularly in morphosa, hemi-
atrophia facialis, and other unilateral atrophies.
A knowledge of the nerves supplying the skin is important to a com-
prehension of the symptoms of many dermatoses, in particular those
which are due to disease of ganglia and nerve-trunks, as, for example,
herpes zoster. In some diseases the nerves play so prominent a part
that the cutaneous manifestations are of secondary importance. The re-
lationship of the central nervous system, ganglia, nerve trunks, branches,
and filaments to the integument is exceedingly close. Many cutaneous
manifestations which we are accustomed to look upon as " diseases of
the skin" may be traced to the nerves and nervous centres. The nerve-
supply to the skin is a subject worthy of study, a knowledge of which
often aids in understanding some diseases. It helps the clinician some-
times in tracing to their source morbid processes which appear on the
surface.
The cutaneous nerve-supply of the human body has been studied
and elaborated in particular by C. A. Voight, 1 Jacob Heiberg, 2 of
Christian ia, and by C. Hasse, 3 of Breslau, all these contributions
1 Ueber ein System neu entdeckter Linien an der Oberflache des menschlichen Korpers
und iiber die Hauptverastlungs-G-ebiete der Hautnerven, nebst der Art der Vertheilung
der Hautnerven in denselben. Sitz. Ber. d. Akad. der Wissenschaften, Math. Naturw.
Cl., xxii. B., S. 240. Wien, 1857. Also, Beitrage zur Dermato-Neurologie nebst der Be-
schreibung eines Systems neu entdecktsr Linien an der Oberflache des menschlichen
Korpers. Mit zwei lith Tafeln in 4to. Denkschriften der Kais. Akad. der Wissen-
schaften, Math. Naturw. Cl., xxii. B., zweite Abth., S. 1. "Wien, 1864.
2 Atlas der Hautnervengebiete. Christiania, 1884. This work has been translated
and edited, with annotations, by W. W. Wagstaffe, of London, with the title " Atlas
of the Cutaneous Nerve Supply of the Human Body." London, 1885.
3 Hand- Atlas der sensiblen und motorischen Gebiete der Hirn Ruckenmarksnerven.
Wiesbaden, 1895.
F. J. Pick, of Prague, has also prepared and had published " Localisations Tabel-
len bei Hautkrankheiten." Prag, 1887. These plates give the outlines of cutaneous
innervation, and are intended for clinical observations in dermato-neurology.
94 GENERAL SYMPTOMATOLOGY.
being of value to the clinician and the pathologist as well as to the
anatomist. 1
There are three nerve territories for the entire body, one being ANTE-
RIOR, one POSTERIOR, and the other LATERAL. The lateral is the
largest of the three to each half of the body.
Anterior Surface of the Entire Body. On the NECK there is no
distribution of lateral branches, but only anterior and posterior. The
line of demarcation between anterior and lateral usually divides the
BREAST into two equal halves. The distribution of the anterior branches
extends in the front to the thigh, but the GENITALIA, with the exception of
the labia majora and scrotum, are supplied by the posterior branches,
namely, superficial branches of the pudic and the small sciatic. The
ARM is entirely supplied by the lateral branches. The great sciatic, or
ischiadic, supplies PART of the SURFACE of the LEG.
Posterior Surface of the Entire Body. The posterior branches of
the spinal nerves take in the OCCIPUT, the BACK of the NECK, and the
MIDDLE PORTION of the BACK down to about the crests of the ilia. Be-
low this occurs the distribution of the small sciatic and the external, or
short, saphenous, with so much of the continuation of the posterior
tibial as supplies the PLANTAR SURFACE of the FOOT. The UPPER EX-
TREMITIES are entirely supplied by the anterior branches of the spinal
nerves.
Head and Pace, Anterior Surface. The nerves of the FRONT of
the HEAD and FACE supplying the skin arise from the trigeminus, or
fifth, nerve, the three divisions of which nerve have a different and un-
equal distribution.
The FIRST, or OPHTHALMIC, supplies the BALL of the EYE with sensory
branches, and by the frontal, through its supra-trochlear and supra-orbital
branches, innervates the entire skin of the FOREHEAD and CROWN of the
HEAD as far as the lambdoidal suture. The infra-trochlear nerve, a
branch of the nasal, and the lachrymal, are distributed to the UPPER
EYELID, and the terminal branches of the nasal to the BRIDGE and TIP
of the NOSE.
The SECOND, or SUPRA-MAXILLARY, supplies the LOWER LID, the
greater part of the CHEEK and of the SIDE of the NOSE, and the WHOLE
of the UPPER LIP. The branches are the infra-orbital, the inferior pal-
pebral, the lateral nasal, and the superior labial.
The THIRD, or INFRA-MAXILLARY, supplies the LOWER PART of the
FACE, corresponding nearly with the LOWER JAW, and by the auriculo-
temporal branch is distributed to the FRONT part of the EAR and the
skin of the adjoining TEMPORAL REGION.
Posterior Surface of the Head. The POSTERIOR SURFACE of the
1 In the description to be given I shall, in the main, follow or quote Heiberg, as
translated by Wagstaffe, but I am also indebted to G. A. Piersol, Professor of Anatomy
in the University of Pennsylvania, for aid and valuable suggestions.
GREAT AURICULAR
IEDIAN
LMAR CUTANEOUS
NERVE-SUPPLY TO THE SKIN.
Anterior Aspect.
GREAT AURICULAR AND
AURICULAR OF PNEUMOGASTRIC
GREAT AURICULAR AND
AURICULAR OF PNEUMOGASTRIC
NERVE-SUPPLY TO THE SKIN.
Posterior Aspect.
NERVE-SUPPLY TO THE SKIN. 95
HEAD is innervated by the upper cervical nerves. The small occipital,
arising from the anterior division of the second cervical nerve, supplies
the skin BEHIND THE EAR, this area ending in a pointed shape towards
the CROWN of the HEAD. The great occipital, representing the internal
branch of the posterior division of the second cervical nerve, innervates
the integument over the OCCIPITAL REGION. The anterior cervical
nerves supply the skin of the FRONT of the NECK. The surface of the
BACK of the NECK is innervated by the posterior divisions of the cervical
nerves.
Anterior Surface of the Arm. The skin of the SUMMIT of the
SHOULDER is fed with sensory nerves arising from the supra-clavicular
branches of the cervical plexus. The ANTERIOR SURFACE of the UPPER
ARM may be divided into two general areas : (1) an outer, supplied by the
cutaneous branches of the circumflex nerve ; (2) an inner, supplied by
the upper branches of the internal cutaneous, together with the lesser in-
ternal cutaneous and the intercosto-humeral nerves.
The FOREARM on its ANTERIOR SURFACE is supplied from two prin-
cipal sources : the musculo-cutaneous, which occupies the OUTER HALF,
and the internal cutaneous, which supplies the INNER HALF of the fore-
arm. Towards the WRIST occur two small nerves, the palmar cutaneous
of the median, and the palmar cutaneous of the ulnar.
Posterior Surface of the Arm. While the anterior surface of the
whole upper extremity is supplied with two main nerves, three exist on
the posterior surface. The circumflex innervates the OUTER SIDE of the
UPPER ARM. The posterior branches of the internal cutaneous, together
with the lesser internal cutaneous, supply the INNER ASPECT. The upper
or internal cutaneous branch of the musculo-spiral is interposed between
the two.
On the FOREARM there are also three nerves distributed cutaneously
throughout its length. The musculo-cutaneous sends branches to the
RADIAL or OUTER SIDE ; the internal cutaneous by its posterior branch
supplies the ULNAR or INNER SURFACE ; the external cutaneous branches
of the musculo-spiral innervate the MIDDLE of the POSTERIOR ASPECT.
Front and Back of the Hand. Three nerve distributions occur on
the HAND. (1) The median supplies the larger half of the PALMAR SUR-
FACE, including the THUMB and the next two and a half FINGERS, and
the limit is indicated by a vertical line from the wrist to the tip of the
fourth, or ring, finger. The median also innervates parts of the FIRST
FOUR FINGERS Oil the DORSAL SURFACE, the MIDDLE FINGER, as far
back as the middle of the first phalanx, receiving almost its entire supply
from the median nerve. (2) The ulnar gives the cutaneous branches to
the INNER SIDE of the PALM as far as the middle line, one and a half
fingers. The distribution of the nerve by means of its dorsal cutaneous
branch extends to the DORSAL SURFACE and includes as far as the middle
line. (3) The radial supplies the skin of the OUTER HALF of the DOR-
96 GENERAL SYMPTOMATOLOGY.
SAL, SURFACE, with the exception of the tips of the first, second, and
third fingers.
Anterior Surface of the Lower Extremity. At the UPPER POR-
TION of the THIGH three nerves exist : (1 ) the external cutaneous ; (2)
the crural branch of the genito-crural ; (3) the superficial branches of
the anterior crural. The anterior crural supplies the greater part of the
ANTERIOR and INNER SURFACE of the THIGH, extending as far as and
even below the PATELLA by its middle and internal cutaneous branches.
The INNER SURFACE of the THIGH is additionally supplied by the
cutaneous branches of the obturator, which extend even farther down-
wards on the posterior aspect of the thigh than on the inner side.
The long, or internal, saphenous nerve, in addition to contributing
filaments to the INNER SIDE of the THIGH, innervates the INNER ASPECT
of the LEG and FOOT. The cutaneous branches derived from the exter-
nal popliteal nerve supply the OUTER SURFACE of the LEG.
Posterior Surface of the Lower Extremity. On the BUTTOCKS
exist the cutaneous branches of the gluteal nerves, but their distribution
does not correspond with the outline of either the nates or the gluteus
maximus.
On the THIGH are three nerve areas : (1) the obturator ; (2) the
posterior cutaneous branches from the small sciatic ; (3) the posterior
branches of the external cutaneous from the lumbar plexus.
On the LEG likewise three nerve areas exist: (1) an internal, supplied
by the long saphenous ; (2) a median, receiving the cutaneous branches
derived from the external popliteal ; (3) an external, supplied by fila-
ments from the external popliteal nerve, largely through the communi-
cans peronei, and lower down, on the OUTER SURFACE of the ANKLE, by
the external saphenous.
The PLANTAR and DORSAL SURFACES of the FOOT are supplied from
several sources. The plantar surface is entirely provided for by the
plantar branches derived from the posterior tibial, the distribution of the
plantar nerves including the DORSAL SURFACE of the TIPS of the TOES.
The BACK of the FOOT is principally supplied by the musculo-cutaneous
branch of the external popliteal nerve, the internal and external borders
being additionally innervated by the long and the short saphenous. The
anterior tibial nerve, a branch of the external popliteal, supplies the
limited area included between the adjacent surfaces of the FIRST and
SECOND TOES.
SUBJECTIVE SYMPTOMS.
Diseases of the skin are generally accompanied by subjective symp-
toms, which are varied in character, consisting of a sense of heat, flush-
ing, burning, itching, smarting, tingling, and pain. Numerous modifi-
cations of these sensations are met with, pain in particular asserting
itself in varied forms. Among the inflammations, new growths, and
SUBJECTIVE SYMPTOMS. 97
neuroses they are of common occurrence ; while among the hypertrophies
and atrophies they either are present in a variable degree or are only
occasionally encountered. They may be trivial, or, as is often the case,
distressing in their severity and persistency.
Disordered sensation occurs either in the form of a diminution of the
normal sensibility, constituting ANESTHESIA, or as an augmentation of
the same, termed HYPER.ESTHESIA. The former occurs in connection
with diseases, functional or organic, in which the nerves are involved,
especially with ascending neuritis, as in lepra, and in allied diseases.
The latter may be simple or perverted in character. More or less
warmth of skin or heat is present in all the hypersemic and inflam-
matory affections, notably in those running an acute course. Sensa-
tions described as itching, burning, tingling, smarting, aud the like
are all common in the same class of diseases.
Itching. This sensation is by far the most prominent of the sub-
jective symptoms, and is present in varying degree in a large number
of disorders. It is a particularly marked symptom .usually in papular
and vesicular eczema, in scabies, in dermatitis herpetiformis, and in
urticaria and urticarial forms of disease. It is a terminal irritation,
due to varied causes, having its seat in the skin, especially in the
mucous layer of the epidermis, and is characterized by sensations which
are sui generis. It is variously described by patients, but is peculiar
in that it provokes in the sufferer a desire to scratch. It may exist in
the form of a tickling or biting sensation or in a sense of formication,
as though insects were crawling over the surface. The latter is common
in pruritus. The itching of pruritus is a sensory manifestation of some
morbid change unaccompanied by any visible alteration in the skin. 1
Itching in general may be due to external causes, as, for example,
the various parasites which attack man, or to varied internal causes,
acting directly upon the nerves of the skin, especially those of the
epidermis, as in local inflammatory processes, or reflexly.
Pain. Pain, varying in kind and degree, occurs in connection with
many and diverse diseases. In most cases the nervous structures, central
or peripheral, are distinctly involved, the latter being often solely or
chiefly implicated. Neuritis, simple or specific in nature, is a common
cause of cutaneous pain, striking examples occurring in herpes zoster and
lepra. The character of the pain varies with the disease, in some cases
being burning, aching, or boring, in others, darting or shooting, while in
still others there may be a combination of some or all of these several
expressions. Pain of a continuous or paroxysmal character, usually the
latter, is met with in neuroma and myoma and in dermatalgia.
1 For further information, see "The Sensation of Itching," by E. B. Bronson.
Medical Record, Oct. 18, 1890.
7
GENERAL ETIOLOGY.
GENEKAL ETIOLOGY.
The subject of the general etiology of cutaneous diseases may be con-
sidered from several points of view. In order to separate it from pathol-
ogy, with which it is intimately associated, and for the purpose of bring-
ing forward its most useful features, the observations to be made will
be confined as much as possible to facts and generally adopted views.
As in the case of symptomatology, it will be approached mainly upon
practical lines.
The causes at work in the production of the various diseases which
affect the skin are manifold. It may with propriety be said that they
are multitudinous. The list of etiological factors has grown immensely
during the last two decades, and is still being lengthened. The causes
are extremely diverse. In order thoroughly to comprehend them it is
of the utmost importance that an expansive view of the subject be taken,
for in many instances it will be found that the manifestations upon the sur-
face are but indexes or direct symptoms of disorder in other portions of the
system. Different causes may produce similar cutaneous lesions : thus,
for example, herpes zoster, herpes iris, and tinea circiriata, all charac-
terized by herpetic lesions, are due to entirely different causes. On the
other hand, the same cause, as, for instance, shock to the nervous system,
may give rise to such dissimilar affections as pemphigus and alopecia
areata.
SYMPTOMATIC DERMATOSES.
A large proportion of the cutaneous diseases are intimately associated
with derangement of the internal economy, and are therefore, strictly
speaking, SYMPTOMATIC DERMATOSES. As examples of such diseases,
the polymorphous erythemata, the exanthemata, numerous inflammatory
affections, some of them ill defined in character, as well as certain pig-
mentary and hemorrhagic affections, may be cited. The subject of the
symptomatic dermatoses covers a wide field, and is intimately associated
with general medicine and in particular with neurotic diseases. In many
instances the skin may be regarded as a mirror in which are reflected
changes due to disease in distant organs. Thus, diseases implicating the
nervous system, especially nerve-centres, frequently cause abnormal states
of the integument. All such affections, of whatsoever form as concerns
the lesions, are to be regarded as examples of symptomatic dermatoses.
The subject has been ably elaborated by Leloir, 1 with whose views the
author would express himself as being in accord.
1 Annales de Derm, et de Syph., 1889. See also abst. in Brit. Jour, of Derm., vol.
ii. (1890), p. 387.
CONDITIONS INFLUENCING DISEASE. 99
IDIOPATHIC DERMATOSES.
On the other hand, a number of diseases have their origin in the skin
itself, and are confined in their action to this organ alone ; these are the
so-called JDIOPATHIC DERMATOSES. To this class belong all the local dis-
eases, as, for example, certain of the hypertrophies and atrophies, as well
as those numerous conditions produced by external agencies, including
parasites. It must never be lost sight of, however, that in the majority
of instances of so-called diseases of the skin the relationship between the
system at large and the skin is extremely close, so much so that very fre-
quently it becomes a most difficult matter to determine to what extent a
disease is local or constitutional. The line of demarcation, except in the
case of diseases obviously local in their origin, can rarely be a strict one.
Etiology may be considered under the three following general heads :
CONDITIONS INFLUENCING DISEASE ; INTERNAL CAUSES, Or those which
act from within the general economy or system ; and EXTERNAL CAUSES,
or those which act from without.
CONDITIONS INFLUENCING DISEASE.
S^Age. The periods of birth, early development, growth, and maturity
are all epochs influencing disease. The tendency to disturbances of the
alimentary tract in early life is a factor in the production of such diseases
as the erythemata and eczema. Later in life such organs as the stomach,
the liver, the kidneys, and the central nervous system are liable to be
aifected in one way or another, and thus become factors of cutaneous dis-
ease. In the production of disease we must take into consideration the
varied circumstances under which the injurious influence occurs. Obser-
vation on this point may elicit facts which will go far towards explaining
the differences in the symptoms often met with.
It is well known that some diseases are prone to make their ap-
pearance at certain periods of life, while others may appear at any time.
A limited number are noted to occur only at stated ages, thus manifesting
a striking peculiarity. Thus, ichthyosis first shows itself during early
life, commonly in the first or second year, occasionally at or soon after
birth. The congenital syphilodermata appear, as a rule, between the first
and third months of life, but at times they are present at or shortly after
birth. Tinea tonsurans is a disease of childhood. Impetigo contagiosa
is likewise principally confined in its origin to the early years of life.
Tinea versicolor, on the other hand, is extremely rarely seen in children.
The vegetable parasitic diseases in general seldom occur in the old, being
met with chiefly from infancy to middle age ; while pediculosis of the
body is only exceptionally observed in children. Carcinoma very rarely
occurs in the young, seldom manifesting itself before adult age, and
frequently not until old age. Pruritus in the majority of cases is an
affection of adult life.
100 GENERAL ETIOLOGY.
is Sex. Some diseases are to a great extent peculiar to one or the other
sex, while others are noted to be more common in one than in the other.
For example, sycosis is met with in the male only ; epithelioma is of
more frequent occurrence in the male ; while Paget's disease of the nipple,
impetigo herpetiformis, and lupus erythematosus are more common in the
female. The most important difference between the sexes in their liability
to disease in general is, that women are much more frequently affected
with diseases of the generative system, and men with diseases of the
urinary system. This is plainly shown by statistics in hospital service. 1
Children, male and female, differ less than adults in liability to disease,
and in their constitution and peculiarities bear more resemblance to the
female than to the male sex.
FREQUENCY OF CERTAIN DISEASES.
According to the figures compiled by Williams, 2 men are more than
twice as subject to carbuncle as women, the mortality returns derived from
the Registrar-General's report for London for twenty-five years showing
3898 deaths from carbuncle in men and 1549 in women. Concerning the
relative frequency of neoplasms in the sexes, it may be stated that the
liability of females is more than twice that of males. Of the 11,000 cases
tabulated by Williams, 3 the percentage is 33 males to 67 females, this
difference being due largely to the great frequency with which in females
the breast, uterus, and ovary are attacked, the corresponding organs in
the male seldom being affected. In females about 70 per cent, of all new
growths attack the reproductive organs, whereas in males statistics show
only about 7 per cent. Males are somewhat more prone to be attacked
with sarcoma than females, but the difference is not great. Cancers
occur more frequently in males than in females, the numbers given by
Williams being 1398 males and 444 females, or 3.14 males to 1 female.
While cancers in general are more common in males than in females
(about 3 to 1), rodent ulcer is about equally distributed between the
sexes.
Climate. The influence of climate in the production of cutaneous
disease cannot be questioned. Observations have established the fact that
certain diseases are almost peculiar to certain countries; as examples,
leprosy, elephantiasis, pellagra, framboesia, and pinta may be mentioned.
To what extent, however, climate alone is to be held accountable cannot be
definitely ascertained ; other agencies, as hygiene, diet, and the habits of
the people, must also receive consideration as probably often having a
share in the causation of the malady. Among climatic influences in the
production of certain skin diseases, reference may be made to the effect of
moisture, which in some regions where it abounds, as in the South Pacific
Islands, is productive of the tineae. The action of high temperature, as in
1 See The Influence of Sex in Disease, by "W. Roger "Williams. London, 1885.
* Loc. cit., p. 9. 3 Loc. cit., p. 15.
SEASONS. 101
equatorial and subtropical countries, causing increased secretion of sweat
and consequent disease, as miliaria and the like, is well known. The
influence of the sun and of the wind must also be referred to. Herpes
zoster is at times due to certain peculiar climatic or local influences, as
shown by the occurrence of small epidemics in communities. Erythema
multiforme, erythema nodosum, and other diseases may appear under
similar influences. Thus, Gifford Nash 1 reports an instance where there
occurred in one family within a period of ten months four cases of ery-
thema nodosum. Here there was probably some unknown local cause
which produced the disease.
VARIATIONS IN PREVALENCE AND TYPE.
Under this head the variations in the prevalence and in the type of
diseases as encountered in different countries may be referred to. Statistics
show that some diseases are much more common in some countries than
in others. According to J. C. White, 2 tinea favosa is less frequently met
with in the United States than in Europe, especially in Scotland. In
Italy, according to general statistics, it is one of the common affections
of the skin. On the other hand, tinea tonsurans and tinea versicolor are
of infrequent occurrence in that country. In the United States lupus is
much rarer than in Europe, while leprosy is met with only occasionally,
and usually as an imported disease. Affections of the glandular system,
especially those intimately connected with the nervous system, are of more
frequent occurrence in the United States than in Europe. The sub-
ject of skin diseases in America was discussed by J. Nevins Hyde
before the Dermatological Congress held in Paris in 1889. 3 My personal
observations derived from travel show that even in the different parts
of one country variations in the kind and type of certain diseases are
met with, dependent not only upon climate, but also upon race and popula-
tion, hygiene, food, and mode of life.
It is well known that immigrants upon landing not infrequently mani-
fest varied and sometimes peculiar forms of cutaneous disturbance, for
the most part inflammatory in nature. As J. C. White 4 has shown, the
diseases of the skin in these cases are probably due to several factors,
the causes being connected not only with climate, but also with mode of
life, food, and the state of the nervous system induced by the new
experience.
Seasons. The seasons exert a marked influence upon many of the
inflammatory affections, as w r ell as upon those of other classes, as, for
example, the corneous epithelial hypertrophies. The majority of the su-
perficial diseases are aggravated by cold weather, as is commonly observed
1 Lancet, July 7, 1894.
2 Variations in Type and in Prevalence of Diseases of the Skin in Different Countries
of Equal Civilization. Proceedings International Medical Congress, Philadelphia, 1876.
3 See Transactions, and also Jour. Cut. and Gen.-Urin. Dis., 1889, p. 433.
4 Immigrant Dermatoses, Jour, of Cut. and Gen.-Urin. Dis., Oct. 1890.
102 GENERAL ETIOLOGY.
in eczema, psoriasis, and ichthyosis. Pruritus hieraalis, as its name
implies, is encountered only during cold weather. Other disorders, again,
occur chiefly during the hot months, as, for instance, prickly heat ; while
still others incline to appear more commonly during the spring and
autumn, as erythema multiforme.
Diathesis. There has been much confusion and question among
medical men generally as to the meaning of the word DIATHESIS. Some
contend that it is capable of being clearly defined, and is expressive of
a definite, recognizable state of the constitution, while others are of
opinion that it is vague in meaning, and that it can occupy no scientific
place in medicine. In the author's opinion, much depends upon the
definition of the term and the sense in which it is employed. Jonathan
Hutchinsoii 1 has discussed the subject with ability from a practical stand-
point, and I am in accord with his views when he defines diathesis to be
" any condition of prolonged peculiarity of health giving proclivity to
definite forms of disease." It is a persisting morbid proclivity, and com-
prises groups of diseases different in their nature. There is a marked dif-
ference between a diathesis and a dyscrasia ; as Hutchinson remarks, the
specific animal poisons cannot become producers of diatheses, and should
be regarded rather as dyscrasiee. The author is also disposed to agree
with Billroth, 2 who, in discussing the advisability of retaining the use of
such words as diathesis, says, " It will do no injury to science if we con-
tinue to use expressions in the accepted sense. It is still convenient to
have a designation for these things, since the latter are not imaginary, but
are founded upon observations verified during centuries, although the inter-
pretation has become variously changed in form in the course of time."
Temperament. Following the views of Halle 3 and Bradley, 4 tem-
perament may be defined as constituting certain differences between men
and men compatible with health, and consisting of differences in the rel-
ative proportions of certain parts of the organism which thereby exer-
cise a preponderating influence upon functions of the economy. Diathe-
ses, on the other hand, signify such hereditary and innate constitu-
tional conditions as may lead to the outbreak of some local or general
disease peculiar to the diathesis. As Bradley states, it may be objected
that this use of the words temperament and diathesis is too arbitrary ;
but while this is true to a certain extent, the terms have distinct prac-
tical advantages if the ideas are not carried to extremes. Temperament
has been defined by Jonathan Hutchinson as " the sum of the physical
peculiarities of an individual, exclusive of all definite tendencies to dis-
ease." It is a physiological condition, and is not the result of influ-
1 Pedigree of Disease, p. 60. London, 1884.
2 Lectures on Surgical Pathology and Treatment, New Syd. Soc. Trans., vol. ii. p.
10'4. London, 1878.
3 Diet, des Sci. Med., tome liv. p. 460.
* Injuries and Diseases of the Lymphatic System, p. 113. London, 1879.
RACE AND COMPLEXION. 103
ences to which the individual has been exposed during his life. Lay-
cock, 1 who gave the subject careful study, views the subject from a
similar stand-point.
Race. The influence of race in the production of disease of the skin
may be referred to. The colored races exhibit a greater tendency than
the white races to the formation of growths containing fibrous tissue, due
to proliferation of cells around the capillaries, constituting true inflam-
matory sclerosis, as occur strikingly in elephantiasis and keloid, and also
in uterine myoma, the three diseases most characteristic of dark-skinned
races. Among the malignant neoplasms the connective-tissue type pre-
dominates in the colored races. These peculiarities, as E. A. Balloch 2
states, constitute a pathological law not heretofore sufficiently recognized.
Complexion. The natural complexion also asserts its influence in
the causation of disease. Blonds, with light hair and eyes and thin
skin, are more prone to glandular disorders and to degeneration of the
epithelial structures than dark-haired and swarthy individuals. The
latter are more ready to develop pigmentary affections, simple and de-
generative, and also connective-tissue growths, especially hypertrophies,
as elephantiasis, fibroma, and keloid.
Natural irritability of skin is sometimes present in individuals in a
marked degree, as evidenced by the ease with which some skins show irri-
tation from the ingestion of certain articles of food, drugs, and especially
local irritants, as woollen clothing, vegetable and mineral poisons, and
the bites and stings of various insects. This happens not infrequently,
and often without an idiosyncrasy existing.
Predisposition. By this term is meant a peculiar, inherent state
of the constitution which inclines to the ready development of some one
disease. The existence of this state of the economy is not uncommon.
The tendency may exhibit itself in one, or, as is often the case, in several
or all of the members of a family. It may be inherited, or it may
originate with the individual. Thus, it is a matter of frequent ob-
servation that certain families manifest more or less of a disposition to
the development, under favorable conditions, of some of the commoner
forms of disease, especially those of an inflammatory character, as, for
example, eczema, and also the keratoses. An hereditary predisposition to
the formation of blebs as the result of any mechanical injury to the skin,
occurring in most instances in several members of a family, is occasion-
ally noted. Kobner, 3 Max Joseph, 4 Lesser, 5 and others, have reported
1 Lectures on Temperament, Med. Times and Gazette, 1861.
2 Medical News, Jan. 13, 1895.
3 Hereditare Anlage zur Blasenbildung (epidermolysisbullosahereditaria), in Deutsch.
Med. "VVochenschr., No. 2, 1886.
4 Monatsh. f. prak. Derm., Bd. v. No. 1, 1886.
5 Monatsh. f. prak. Derm., Bd. xv. (1892), S. 571. Among the first cases reported
were those of Valentin and of Goldscheider. F. Hebra in his work on diseases of the
skin described this condition as "congenital pemphigus."
104 GENERAL ETIOLOGY.
cases where the slightest pressure, and even the contact of the clothing,
under ordinary circumstances and at all times caused blebs to form.
Idiosyncrasy. This plays a part in the production of certain cu-
taneous as well as other diseases. We recognize the results produced,
but are ignorant of the causes which occasion this condition. It is a
peculiarity of the constitution or organization, usually but not always
congenital, characterized by a definite but variable extreme degree of
susceptibility to certain influences. The most striking examples of idio-
syncrasy in the production of cutaneous manifestations are seen as the
results of the ingestion of certain articles of food and drugs. The whole
subject is extensive, and is worthy of attentive consideration in all its
aspects by both the patient and the physician. The long list of the
varied eruptions due to drugs furnishes innumerable instances, many
of which are very striking and singular.
INTERNAL CAUSES.
In this division are to be classed all those causes originating internally,
or of a constitutional nature, which are known to be able in any way,
however remote, to give rise to disturbance or disease of the skin. They
are numerous and call for profound investigation. At times they are very
obscure and far removed in their seat from the skin ; while, on the other
hand, in some cases they are so commonplace as perhaps to be overlooked
by the casual observer.
Heredity. Some diseases are known to be hereditary ; as common ex-
amples of which syphilis, ichthyosis and other keratoses, psoriasis, and
eczema may be cited ; but it must not be supposed that all or any of these
diseases are in every instance hereditary. According to my experience, the
two latter affections are perhaps more frequently found to be developed in
the individual than to have a history of transmission from the parents.
Ichthyosis, likewise, often originates with the individual so affected. In
proof of the hereditability of some of the keratoses may be cited the his-
torical and authenticated instance of the Lambert family, in which, be-
ginning with the father, five generations, all sons, were similarly affected
with ichthyosis hystrix. As Hutchinson 1 states, where there is defect
in development of the skin, it is seldom restricted to one tissue. Those
who have vascular naevi often have moles as well, and, it may be, several
varieties of them. This observer 2 gives the case of a boy who was born
without hair, and almost without subcutaneous fat, and with scars in the
localities of the mammary glands. There were also other defects of the
skin and its appendages, and of the nails and teeth. The condition
seemed to be the result of complete alopecia in the mother, who was in
other respects well developed.
Concerning heredity it may be said, that probably all observers will
1 Archives of Surg., 1890-91, p. 256. 2 Brit. Med. Jour., vol. ii., 1887, p. 231.
FAMILY DISEASES. 105
agree in the view that at least a weak constitution may be inherited. In
such cases the power of the constitution to resist the invasion of the
numerous causes (as, for example, bacteria) of disease is wanting. This
weakness may be general, affecting the whole organism, or special, affect-
ing certain organs or membranes, as the mucous membrane or the skin.
Debility, which leads to other peculiar or unknown states of the tissues,
is a potent factor of disease, the exciting causes, as bacteria, trauma-
tism, and the like, being in perhaps most instances of secondary impor-
tance. The bacilli of certain diseases as, for example, lupus are, prac-
tically speaking, harmful only when they find a soil congenial for their
growth. This condition, unfortunately, often exists, and is to a large
extent in many cases inherited in the form of a weakness of some special
organ, or more often of a set of organs, or of some tissue, as, for example,
the epithelium. But such is not the case with certain other virulent in-
fectious diseases, such, for example, as syphilis, whose contagium takes
root and thrives upon and destroys strong as well as weak tissue. The
agents which produce diseases of the latter kind are potent in all indi-
viduals irrespective of the condition of their tissues, though not to the
same degree in all.
FAMILY DISEASES.
In connection with the subject of heredity the so-called FAMILY DIS-
EASES may be referred to, in which several members of a family are
similarly affected, the disease, however, not necessarily being hereditary.
Examples of such diseases are found in xeroderma pigmentosum (Kaposi),
xanthoma planum, sebaceous cyst, trichorrhexis nodosa, keratosis pal-
maris et plantaris, and ichthyosis. To this list may be added the hered-
itary tendency to bleb-formation, already referred to in considering the
subject of predisposition to cutaneous disease.
There are, however, instances of disease occurring in several members
of a family which are not entitled to be classed as family diseases,
being due to peculiar local or climatic conditions, as, for example, in the
erythema nodosum cases referred to in considering climate.
Constitutional Diseases. These in many instances exert a positive
influence upon the skin. At times the malady is of such a nature that
its existence merely predisposes to some slight cutaneous disorder, such
as chloasma or seborrhoea, as is the case, for example, in chlorosis ; while
in other instances, as in the exanthemata and in syphilis, it is of so viru-
lent a nature that the eruption is but one of a number of prominent
manifestations.
Malaria, the poison which finds its most typical expression in common
fever and ague, must also be referred to as a factor in cutaneous medi-
cine, as L. P. Yandall, 1 of Louisville, pointed out in an article before
the American Dermatological Association, in 1877.
1 American Practitioner, January, 1878.
106 GENERAL ETIOLOGY.
In this connection it may be observed that a depraved state of the gen-
eral health, resulting from a variety of causes, may play a part iu the
causation of certain cutaneous affections. A recognition of this fact will
frequently serve as a guide in the treatment. Thus, it is owing to a
deterioration from the normal state of health of the individual, for ex-
ample, that ecthyma, cachectic acne, and ill-conditioned excoriations often
show themselves. The nature of this deterioration it is not necessary to
consider here. Instances of this kind, especially ecthyma, are frequently
encountered in large hospitals and in almshouses, but are rarely met with
in private practice.
Disorders of Internal Organs. Here may be mentioned a number
of functional and organic diseases capable, under peculiar conditions, of
causing marked cutaneous manifestations. They may act through direct
irritation, reflexly, or indirectly by impairing cutaneous nutrition. Thus,
acute and chronic derangement of the alimentary canal is a productive
source of a number of complaints, among which eczema, urticaria, and acne
stand forth as prominent examples. The relation of certain diseases of the
skin to disturbances of the digestive tract has been closely inquired into by
A. Pick, 1 who regards it as probable that in the alimentary tract of those
individuals in whom the ingestion of certain articles of food gives rise to
urticaria, ferments occur which form poisons out of substances contained
in these foods. A case is related in which an attack of urticaria always
followed the use of potatoes and preserved fruit, and which could be pre-
vented by the administration of small doses of creosote. Affections of
the kidney, as Bright' s disease, albuminuria, and diabetes, occasionally
give rise to oedema, to pruritus, and more rarely to eczema. Diseases of
the liver are known to occasion discolorations, as jaundice, and also to
cause pruritus. Uterine diseases are likewise recognized as frequently
causing pigmentary disturbances, urticaria, eczema, and other cutaneous
manifestations. Finally, derangement of the nervous system is, as is
well recognized, capable of giving rise to a variety of disorders of the
skin ; thus, eczema, herpes, urticaria, pruritus, and alopecia, also certain
hypertrophies and atrophies, may be referred to as being not infre-
quently caused and influenced by both functional and organic disease of
the nervous system.
Some of these topics may be specially referred to.
KIDNEYS AND URINE.
That the urine is not infrequently disordered, as shown by chemical
and microscopical analysis, in connection with various diseases involving
the skin, especially with those of an inflammatory nature, is well known.
How far the abnormal secretion in some cases can be regarded as a cause
of such disease is a question difficult to decide. In many instances it
seems likely that the excretory product of the kidneys, of whatsoever
1 Wiener Med. Presse, No. 31, 1893.
GOUT AND RHEUMATISM. 107
nature, is the result of elimination of deleterious substances from the
system analogous to that taking place from the diseased skin. Both
are excretory organs. In this connection the important supplementary
relation of the kidneys to the skin in health and in disease generally must
be kept in mind. That abnormal urine should in some cases be present
in such cutaneous diseases as generalized eczema involving the greater
part or the whole of the skin, dermatitis exfoliativa, and the like, does not
seem remarkable. Diabetes is sometimes associated with boils, carbuncles,
gangrene, eczema, erythema, urticaria, pruritus, and also with that form
of xanthoma known as xanthoma diabeticorum. The relation of the
kidneys and the urine to various diseases of the skin has been investi-
gated particularly by Bulkley, 1 of New York, Thibierge, 2 of Paris, and
Gamberini, 3 of Italy, all of whom bring forward important observations
showing that in some cases an intimate relationship exists. S. West 4
has also reported cases of acute affections of the skin in the course of
kidney disease.
GOUT AND RHEUMATISM.
The lithsemic, or gouty, state frequently causes manifestations of dis-
ease upon the skin. It influences the general behavior of various cuta-
neous diseases. Such diseases as the erythemata, eczema, and psoriasis
are in some individuals distinctly gouty, sometimes alternating in their
manifestations with gout in other tissues or organs. The skin is to be
viewed as one of the emunctory organs of the body, and as such it assumes
a share in the elimination of deleterious products, often thereby becoming
irritated and diseased in one form or another. In this sense, therefore,
gout, characterized by an altered state of the blood, due to defective
excretion, may be looked upon as a cause of certain diseases, especially
those of an inflammatory nature. It is an irritant to the tissues. The
altered urine, more or less loaded with oxalate of lime, urates, and uric
acid, is the usual index to this condition. It is indicative of the peculiar
changes that have taken place in the blood. It must be kept in mind that
the skin is an organ of excretion as well as are the kidneys ; and that the
two sets of organs are closely correlated, and supplement each other in
such work as the elimination of effete products.
The relation of certain skin diseases to rheumatism has long been es-
tablished. The erythemata, both superficial and deep-seated, are often
preceded and accompanied with rheumatic aching and pain. Erythema
papulosum is the commonest form met with, but erythema nodosum,
scarlatinaform dermatitis, and purpura are also not uncommon. Some-
times such eruptions accompany acute articular rheumatism; in other
1 Archives of Derm., Oct., 1875.
2 Des relations des dermatoses avec les affections des reins et I'albuminurie, Annales
de Derm, et de Syph., 1885, 2 ser. vi. p. 424.
3 Abst. in Monat>hefte f. prak. Derm., 1884, p. 313.
4 St. Earth. Hosp. Eep., 1886, xxii. p. 226.
108 GENERAL ETIOLOGY.
cases the rheumatic symptoms are secondary to the cutaneous manifesta-
tion. They seem in most cases to depend upon a general vitiated state
of the system, due to disorders of the circulation arising from various
causes.
RESPIRATORY SYSTEM.
The relation of the respiratory system, more especially nervous affec-
tions of the same, to certain cutaneous affections, is occasionally made
manifest in such diseases as eczema, psoriasis, and urticaria, which may
be closely associated with spasmodic asthma. L. D. Bulkley 1 has dis-
cussed the subject, with corroborative instances from practice, and Hol-
scher 2 gives the notes of four cases in which psoriasis and asthma occurred
conjointly. In some cases asthma appeared with the eruption of psoriasis
and ceased as the latter vanished ; in other cases the asthma preceded the
psoriasis and disappeared as the eruption developed.
Varied cutaneous affections are also known to accompany or to follow
influenza, or " the grip," in some cases, the most common perhaps being
the polymorphous erythemata, which are often morbilliform in character.
Herpes, purpura, urticaria, eczema, and other manifestations 3 have also
been observed.
SEXUAL SYSTEM.
It is well known that irritating influences existing about the repro-
ductive organs of either sex are capable of provoking such diseases as the
erythemata, urticaria, herpes, acne, and various forms of pigmentation.
Thus, urethral irritation in the male has been shown to be the cause of
acne in some cases, and disordered menstruation may give rise to the
same disease. The eruptions occurring in the course of gonorrhoea may
also be referred to. The latter are polymorphic in character, for the
most part scarlatinaform and morbilliform, and possess no specific char-
acter by which they can be distinguished from the erythemata due to other
causes. 4
The influence of the sexual system in the production of cutaneous dis-
ease is a factor of sufficient importance to be worthy of attentive consider-
ation. 5 The alterations which occur in the skin at puberty are such as to
cause circulatory disorder, and glandular disturbances in particular, as
seen in comedo, acne, seborrhosa, and hyperaemia or anaemia. The influ-
ence of menstruation and of pathological conditions of the uterus in cuta-
1 Brit. Med. Jour., Nov. 21, 1885.
2 Monats. fur prak. Derm., Bd. xvii., No. 9.
8 See, for further information, articles by Barthelemy, abstract in Jour. Cut. and Gen.-
Urin. Dis., 1890, p. 279, and Schwimmer, abstract in Lond. Med Kec., Sept. 20, 189^.
4 For further information, see an article by Leon Perrin, in Annales de Derm, et de
Syph., Nov. 1890.
5 For further information, see an article by the author and M. B. Hartzell, in Keat-
ing and Coe's " Cyclnpasdia of Diseases of Women," Phila., 1895; also a paper by
G. H. Kobe, in Buffalo Med. and Surg. Journ., Feb. 1889.
NERVOUS SYSTEM. 109
neons diseases is well known. The relations of the skin to the uterus at
the menstrual epoch and at the menopause are probably intimately con-
nected with blood-pressure. This would seem to be especially true in
the case of purpura, the skin in most cases, especially if weak, offering the
least resistance to increased blood-pressure. The eruptions of menstrua-
tion are varied, but are for the most part inflammatory and neurotic,
Ii3rpes of the face, lips, and genitalia being one of the commonest mani-
festations. The subject of menstrual herpes has been specially investi-
gated by Bergh, 1 of Copenhagen, who states that it is not due to local
irritation, but that the nervous system is at fault, a view shared by the
author. Eczema, acne, and hyperidrosis (usually localized) are encoun-
tered. Bullous and pemphigoid lesions are also occasionally met with.
Thus, Hardy 2 has applied the term " pemphigus virginum" to a bullous
eruption characterized by the successive appearance of blebs extending
over several months, occurring in young women the subjects of inter-
rupted menstruation. Anomalous forms of eruption are not rare, in
some cases in connection with normal menstruation, in others with
uterine disease of one kind or another. The subject has been elaborated
particularly by L. Grellety. 3 Alterations of the skin at puberty and
at the menopause have also been studied by Deligny. 4
The puerperal state is sometimes a distinct factor in the production
of cutaneous manifestations, among the more striking of which may be
mentioned erythema scarlatiniforme, 5 impetigo herpetiformis, and derma-
titis herpetiformis, more especially the vesicular and bullous varieties of
the latter disease (the so-called " herpes gestationis" of some writers).
Most of the graver eruptions are probably toxic or septicsemic in origin.
Functional disturbance or structural lesions of the sexual organs in
the male must also be referred to as a factor, as observed in progenital
herpes, acne, comedo, and other affections. At times the relation between
the skin and the reproductive organs in either sex is obscure, but the
success in some cases which follows appropriate treatment proves the cor-
rectness of the general observation.
NERVOUS SYSTEM.
The relation of the nervous system to disease of the skin is an im-
portant subject, covering a broad field. Close observation shows plainly
the influence which the nervous centres, the nerve trunks, and the periph-
eral endings possess over various and diverse cutaneous manifestations.
A great deal has been written latterly on the subject by such able authors
1 Abst. in Jour, de Mai. Cut. et Syph , No. G, 1891.
2 Les Maladies de la Peau. Paris, 1886.
3 Influence of Men truation and of the Pathological Conditions of the Uterus in
Cutaneous Diseases. Translation in Wood's Med. and Surg. Monographs, vol. iii.,
No. 1, July, 1889.
4 Jour. Cut. and Gen.-Urin. Dis., 1888, p. 315.
5 Whipham has recorded cases of this kind in Clin. Soc. Trans., vol. xvi.
HO GENERAL ETIOLOGY.
as S. Weir Mitchell, 1 Bulkley, 2 Leloir, 3 Arnozan, 4 Schwimmer, 5 Erb, 6
Crocker/ and Kopp, 8 and the information has been collected and classi-
fied. The subject is capable of still further elaboration, and the author's
experience warrants the opinion that this group of diseases the " neu-
ropathic dermatoses" will continue to grow and in the future to hold
even a more conspicuous place in etiology than at present. The subject
is continually assuming greater proportions.
The many cutaneous diseases which have been shown to be directly
under the influence of the nervous system are extremely diverse as regards
the lesions manifested, hypersemic, inflammatory, and atrophic affections
all being common. Among the inflammations, all the primary lesions
may be produced, singly or in various combinations, through its influ-
ence. The effects of the nervous system upon the integument, therefore,
are extremely variable. While the nervous system is a powerful factor
in the etiology of skin diseases, its action in the production of symptoms
is often uncertain. A variety of lesions may be produced by the same
nerve disorder or disease.
The subject may be considered under the heads of disease of the skin
accompanying or following cerebral disease ; disease of the spinal cord ;
disease of the sympathetic ; peripheral injuries and wounds of nerves ;
and lesions of nerves supplying diseased skin. Eruptions due to disease
of the cord are numerous, especially in connection with locomotor ataxia,
such as erythema, erythema nodosum, urticaria, zoster, pemphigus, ulcers,
and gangrene. The posterior columns play an important part in the
nutrition of the skin, and consequently impairment of their function
may be followed by various cutaneous lesions. Spinal meningitis may
be accompanied with erythematous, vesicular, and bullous eruptions.
Such conditions as hypersemia and anaemia of the skin, pigmentation,
and sweating are sometimes traceable to lesions of the sympathetic.
Lesions due to peripheral injuries of nerves are more common, and
the same may be said of disease of nerves supplying the skin, a striking
example of which occurs in herpes zoster. Multiple neuritis is a well-
known cause of varied peripheral neuroses characterized by sensory
disturbances, as pain, numbness, loss of sensation, and by various vaso-
motor disturbances, hypersemia, inflammation, atrophy, paralysis. The
skin suffers together with the deeper structures, as shown by varied
1 Injuries of Nerves and their Consequences. Phila., 1872.
2 Archives of Electrology and Neurology, Nov. 1874.
3 Kecherches cliniques et anatomo-pathologiques sur les affections cutanees d'origine
nerveuse. Paris, 1881.
4 Lesions trophiques consecutives aux Maladies du Systeme nerveux. Paris, .1880.
5 Die neuropathischen Dermatonosen. Wien, 1883.
8 Diseases of the Peripheral Cerebro-Spinal Nerves, Ziemssen's Cyclopaedia of Pract.
Medicine. New York, 1876.
7 Brain, vol. vii., Oct. 1884, p. 345.
8 Die Trophoneurosen der Haut. Wien, 1886.
PSYCHICAL STATES AND SHOCK. Ill
hyperaemic, inflammatory, and atrophic manifestations, for the most part
peculiar in that they possess a NEURITIC ASPECT. Pigment changes in
the skin and hair are not infrequently met with as the result of some
mental state, as, for example, in sudden blanching of the hair, and in
vitiligo, in epileptics, and in the insane. Eruptions of one kind or
another, especially blebs, are also met with in general paralytics.
The influence of the great sympathetic system of nerves in the production
of manifestations upon the skin is extensive and potent. The subject
has been elaborated by three authors in particular, Eulenburg and Gutt-
mann, 1 C. V. Chapin, 2 and Edward Long Fox, 3 in whose writings the
reader will find much of interest pertaining to the subject.
The influence of the nervous system in the causation of skin diseases is
positive, and is exerted in many ways. The effect of the mind on the
body is at times a potent factor in the production of both functional and
structural disease. The brain and the skin are ever in the closest touch.
The influence of the mind in the etiology of cutaneous diseases has been
shown by the reports of numerous well-authenticated cases. Mental
shock, suddenly impressing the nervous centres, fright, nervous strain,
worry, excitement, fear, grief, and anger, may all provoke cutaneous dis-
order. Shock is a well-recognized cause of numerous functional and
structural cutaneous diseases, of which hyperidrosis, change of color and
other alterations of the hair, alopecia areata, pemphigus, and dermatitis
herpetiformis sometimes serve as striking examples. The influence of
the mind on the body may be exerted in many ways, as has been shown
by observers in numerous well- authenticated cases. The influence may
be injurious or beneficial, the former occurring most frequently and
strikingly. But beneficial results also follow such influence, as is occa-
sionally observed in what are generally designated by the laity as " faith-
cures." This topic has been carefully investigated from a surgical point
of view by J. William White, 4 who concludes, in his article on "the
supposed curative effect of operations per se" based on an extensive
literature, that " there are large numbers of cases of different grades of
severity and varying character which seem to be benefited by operation
alone, some of them by almost any operation."
PSYCHICAL, STATES AND SHOCK.
It is well known that the emotions, in particular fright, grief, and
anxiety, have a positive influence in the production of varied cutaneous
diseases, more especially those of an inflammatory, hypertrophic, and
atrophic nature. Many authentic instances of cases are on record.
1 Physiology and Pathology of the Sympathetic System of Nerves : translated from
the German by A. Napier. London, 1879.
2 The Sympathetic Nerve : its Eelations to Disease. Fisk Fund Prize Essay, 1880.
Providence, 1881.
3 Influence of the Sympathetic in Disease London, 1885.
4 Annals of Surgery, Aug. and Sept. 1891.
112 GENERAL ETIOLOGY.
Leloir l saw a case of polymorphous bullous erythema in a woman sud-
denly follow a violent attack of anger, and R. W. Taylor 2 records a case
of erythematous eczema which appeared on a healthy woman immediately
after hearing of the sudden death of her husband. Tommasoli, 3 of
Italy, has also brought forward cases to emphasize the subject. He cites
the case of a young woman who was suddenly attacked with a pemphi-
goid eruption immediately after receiving the tidings of the death of her
husband ; also another case of a lady who was afflicted with eczema of
the eyelids, neck, arms, and vulva very soon after hearing the sad tidings
that her daughter had committed suicide ; and a third case of a man who,
being threatened with personal injury by a debtor whom he had impor-
tuned for payment, was greatly frightened, and was almost instantly
seized with acute dermatitis accompanied with a pustular eruption cover-
ing the back and the extremities. Such and similar causes, though rare,
are now generally recognized. Diday and Doyon 4 lay considerable
stress upon mental shock as a factor of cutaneous disease, and give cases
of psoriasis, lichen, and other superficial inflammations due to such
causes. F. Mayer 5 also refers to many well-authenticated cases.
Cases are occasionally met with where it is difficult to determine
whether the cause is psychical or physical, or a combination of the two,
as in a severe case of dermatitis herpetiformis with vesicles and blebs
reported by me, 6 occurring in a strong man very shortly after an acci-
dent which exposed him to the fear of imminent death and to physical
exhaustion for many hours. I am of opinion, however, that in almost
all these cases the chief if not the sole factor is mental shock. Not
only may the skin proper be affected, but in like manner the appen-
dages of the skin, as in a case of loss of both the hair and nails from
fright recorded by Foley. 7 A number of cases illustrative of the sub-
ject are on record.
MENTAL IMPRESSIONS UPON THE FCETUS.
As already stated, the part that the mind or the impressionable nervous
matter of the body plays in the production of cutaneous disease is at
times positive. The influence of the mind upon the body is, under certain
conditions, powerful. As part of the body the integument thrives and
suffers with the other organs which go to make up the whole economy.
Striking instances of the mind influencing the skin structurally are ob-
served in the so-called MATERNAL IMPRESSIONS UPON THE FCETUS, the
1 Des Dermatoses par choc moral. Paris, 1887.
2 Recorded in J. William White's article in Annals of Surgery, Aug. and Sept. 1891.
8 Abstract in Med. Record, vol. i., 1887.
4 Thcrapeutique des maladies veneriennes et cutanees. Paris, 1876.
5 De 1 'influence des emotions morales sur le developpement des affections cutanees.
Paris, 1876.
6 Amer. Jour, of the Med. Sci., Jan. 1885.
T Boston Med. and Surg. Jour., Sept. 29, 1887, p. 302.
HYSTERIA.
resulting effects being extremely variable, in some cases slight, in others
grave, while occasionally they are extraordinary. The commoner forms
are pigmentary and vascular nsevi, with all manner of intermediate clini-
cal and pathological formations. That such defective or altered normal
tissue and growths are due to the direct influence of the maternal mind
upon the nutrition of the ftetus, and upon certain structures in particular,
admits of no question. This subject has been discussed fully and ably
by many eminent in the profession, among whom may be mentioned For-
dyce Barker, 1 S. C. Busey, 2 J. W. Ballantyne, 3 W. C. Dabney, 4 and
Arthur Mitchell, 5 all of whom bring forward personal observations in
substantiation of the occurrence, and my own experience is also corrob-
orative. Barker comes to the conclusion that all who disbelieve in the
doctrine base their scepticism on what they regard as physiological reason-
ing, and mainly on the assertion that there is no direct nerve communi-
cation between the maternal and the fetal system, and that therefore
impressions made upon the mother cannot be transmitted to the foetus.
The same observer thinks that the term maternal impressions should not
be restricted to emotional causes alone, but should include those that have
a physical as well as those that have a psychical origin. He cites five
convincing cases from his own practice. Busey reports forty-one collected
cases, and Mitchell records six cases. 6
HYSTERIA.
The so-called " hysterical diseases of the skin" show themselves with
varied lesions, and are mostly obscure in their pathology beyond the ob-
servation that they have an hysterical foundation. In this group may be
placed such cases as the author has reported under the heading of " neuro-
traumatic dermatitis vesiculosa et bullosa," 7 and Kaposi, 3 under the title
"zoster gangrsenosus recidivus atypicus hystericus," and the like. A
remarkable example of hysterical cutaneous disease in the form of a
circumscribed, bulky, epithelial crust of long standing, has been recorded
by S. Weir Mitchell, 9 through whom I had the opportunity of studying
the case.
H. Leloir 10 divides this whole subject as follows : (1) DERMATOXEU-
ROSES CUM MATERIA, these being neurotic affections of the skin second-
1 Amer. Gyn. Soc. Trans., vol. xi. * Ibid.
3 Edinburgh Med. Jour., Jan. 1891.
4 Cyclop. Dis. of Children, edited by Keating, vol. i. p. 191.
5 Trans. Lond. Obstet. Soc., vol. xxvi.
6 Among other authors who believe in the potency of maternal impressions may be
mentioned Geoffroy St.-Hilaire, Montgomery (Signs and Symptoms of Pregnancy, 1856,
pp. 17-22), Martin St.-Auge, Hammond, and Allen Thomson (Cyclop. Anat. and
PhysSol., vol. ii.).
T Internat. Med. Mag., March, 1892.
8 Archiv fur Derm. u. Syph., 1886, p. 179, and 1890, p. 385.
9 Amer. Jour. Med. Sci., March, 1893. With chromo-lithograph.
10 The subject has received careful consideration from this author, to whose works the
114 GENERAL ETIOLOGY.
ary to visible anatomical lesions of the central or peripheral nervous
system; and (2) DERMATONEUROSES SINE MATERIA, embracing the
cutaneous disturbances and diseased states and their modifications, pro-
ceeding from functional disorders of the central or peripheral nervous
system, but where no visible anatomical lesion has been proved up to the
date of the observation. To the first division belong (a) diseases due to
primitive peripheric nervous lesions ; (6) due to ganglionic lesions ; (c)
due to central lesions produced by peripheric nervous alterations ; (d)
due to primitive central lesions ; (e) due to lesions of the great sym-
pathetic.
To the second division belong (a) diseases due to functional disturb-
ances of the peripheral nerves, as the endings, filaments, branches,
trunks, or plexuses of nerves ; (6) due to functional disorder of the ner-
vous ganglia ; (c) due to functional disturbance in the nervous centres
determined by peripheral nervous irritations, spinal or encephalic in
origin (properly called REFLEX DERMATOSES), and (c?) due to functional
disturbance in the primitive nervous centres, as the psychical and emo-
tional dermatoses and the like.
Food. Food is accountable for a number of diseases. Improper
quantity, whether too much or too little, and unsuitable quality, are both
to be regarded as conspicuous factors in the causation of diseases of the
most diverse nature. To keep the economy in a state of perfect equi-
librium it is essential that the proper amount and kind of nutriment be
taken into the system. Many diseases affecting the integument are with-
out doubt indirectly and directly due to insufficient food and improper
diet, viewing the subject in its broadest sense. In support of this view,
one has but to glance at the clinics of hospitals and dispensaries and note
the poor nutrition and general health, and inquire into the average usual
diet of the subjects of these disorders.
Certain kinds of food are particularly liable to occasion cutaneous dis-
turbance. Shell-fish, for example, is in some individuals sufficient to call
forth urticaria every time it is indulged in. Some fruits, especially straw-
berries, are at times followed by the same disease or erythema. Oatmeal
and buckwheat are also known to occasion an erythema or a pruritus in
some individuals. The injurious effects of wine and beer, and of indi-
gestible articles of food, as cheese, pickles, spices, pastry, and the like,
are frequently seen in eczema, urticaria, acne, and other diseases. Alco-
hol in many instances proves distinctly harmful, and numerous cases
might be presented illustrative of its baneful influence upon the skin,
especially in the inflammatory dermatoses. 1 The cause in the matter of
reader is referred for further information. See " Trophonevrose" in Dictionnaire de
Jaccoud, 1884, p. 103, and Annales de Derm, et de Syph., 1886, p. 732 ; also, Kecherches
cliniques et anatomo-pathologiquees sur les affections cutanees d'origine nerveuse.
Paris, 1881 .
1 See an essay by H. Janin, De 1'influence de alcoolisme sur le developpement et
1'evolution des affections cutanees. Paris, 1881.
MEDICINE. 115
food is probably always toxic, acting, by absorption of the poison, upon
the nervous system, as in the case of drugs. Ample latitude, it need
not be said, must be granted in the consideration of this subject, for what
generally or invariably proves injurious or poisonous to one is often a
useful food for another.
Medicine. The ingestion of certain drugs used as medicine is at times
productive of much damage to the skin ; striking instances are observed
in the erythematous or urticarial eruption not infrequently following
the administration of copaiba and of cubebs, and the erythemata from
quinine, chloral, belladonna, and morphine. Arsenic is a potent source
of cutaneous disturbance, through the nerves governing nutrition, and in
particular of pigmentation. Bromide and iodide of potassium are well
known to produce not infrequently peculiar and often severe forms of
cutaneous disturbance. The list of drugs capable of producing cutaneous
disorder is so lengthy and the subject so important that a special chapter
is devoted to the subject. Quinquaud l found by experiment that the
ingestion of uric acid caused various primary lesions of the skin both in
man and in animals, but that it did not produce any of the recognized
so-called skin diseases. In eczematous subjects the itching was increased
by the use of uric acid.
Pregnancy. This state is not infrequently noted to exert a decided
influence upon the skin, which is usually, but not always, injurious. Not
infrequently it is observed to occasion attacks of eczema, herpes, and
pruritus, which disappear in most cases immediately upon the removal of
the cause. Chloasma is likewise frequently observed as an accompani-
ment of pregnancy. On the other hand, chronic affections, as eczema and
psoriasis, are often observed to be better during this period. The period
of lactation may also influence the course of some diseases, as eczema,
psoriasis, and disorders of the sebaceous glands. Some women suffering
with chronic diseases of this kind are sometimes better than usual, or
even free, during this time ; others are worse, the latter being the more
common experience.
Dentition, Vaccination. Dentition may be regarded as an exciting
cause of cutaneous disorder. Its importance viewed etiologically, how-
ever, is secondary, and should not be over-estimated. That both eczema
and urticaria may be aggravated during the eruption of the teeth is
generally recognized. In addition to the usual local disturbance which
vaccination occasions, it is now and then followed by peculiar erythematous,
pustular, or furuncular affections. Such occurrences are comparatively
rare, and usually are benign in their nature. Occasionally, however, the
lesions are deep-seated and complicated, and the disturbance severe, giving
rise to considerable inflammation of the skin and subcutaneous tissue,
variable as to form, aud to marked systemic disturbance. Toxic and sep-
1 Lond. Med. Eecorder, Sept. 20, 1890.
116 GENERAL ETIOLOGY.
tic infections are doubtless the factors in most of these cases. The subject
is more fully considered in the chapter devoted to vaccinal eruptions.
EXTERNAL CAUSES.
The causes of this nature are numerous. Many of them are to be
viewed as exciting causes, giving rise to disorder only under peculiar
conditions, or in those cases where there exists a predisposition to the dis-
ease manifesting itself. Others, however, at all times and upon all sub-
jects act injuriously upon the skin, and are the direct source of the dis-
turbance. To this class belong mechanical injuries, irritation, friction,
poisons, and many other agents.
Occupation. Certain occupations are known to be productive of
harm to the skin, giving rise to hyperaemia, inflammation, or hypertro-
phy. Thus, workers in chemicals, as acids and alkalies, and in dye-
stuffs, especially aniline products and arsenic, are liable to suffer from the
irritating substances with which they come in contact. Washerwomen
exposed to the long-continued influence of water and strong soap, and
masons, may also be referred to as being liable to rough or harsh skins
and fissures, dermatitis, or eczema. Machinists, carpenters, shoemakers,
and others who make constant use of tools, are ordinarily the subjects of
more or less epithelial hypertrophy upon the hands, in the form of cal-
losities.
The influence of occupation in the production of cutaneous disease of
one kind or another is, in fact, of considerable importance. The subject
has been investigated in a thorough manner by J. L. Foley. 1 In addi-
tion to the instances above cited, exposure to wind and weather causes
thickening of the corium, and a tendency to rosacea and erythematous
affections, as seen in policemen, sailors, soldiers, coachmen, and cab-
men. The sedentary life of the student tends to dyspepsia and consequent
acne and eczema. The agricultural class are liable to erythema calorica,
dermatitis venenata, and the ravages of the leptus. Toy-makers are
liable to arsenical eruptions ; gilders, to eczema and alopecia from mer-
curial absorption ; flax-workers, to dermatitis and acne ; butchers and
wool-sorters, to poison wounds, various pustules, and pustula maligna ;
while cooks, bakers, domestics, car-drivers, and typesetters, who are com-
pelled to stand much, tend to develop varicosities, eczema, and leg ulcers.
Heat and Cold. The extremes of heat and cold also act as causes in
the production of disease ; as examples of the former, erythema, derma-
titis, and miliaria, resulting from continued exposure to a high tempera-
ture, may be mentioned. The action of the sun in calling forth several
varieties of disease, as simple dermatitis and pigmentation, is well known.
The influence of solar rays on the skin has been investigated by R. L.
Bowles, 2 who concludes that heat in itself is not the cause of sunburn, but
1 Jour. Cut. and Gen.-Urin. Dis., 1889, p. 170.
2 Brit. Jour, of Derm., August, 1893.
SCRATCHING. 117
that the latter is due probably to reflected violet or ultra-violet rays of
light ; and, moreover, that rays from electric light produce much the
same results as sun-rays reflected from snow. Cold acts in a similar
manner to heat, as observed in frost-bite.
Clothing. Certain kinds of clothing, as well as unsuited modes of
dress, must also be regarded as giving rise to hypersemia and inflamma-
tion of the skin. The coarse flannel worn so persistently next to the
skin by the working classes not infrequently serves as an exciting cause
of erythema and of follicular inflammation. The injurious effects of
such clothing in some cases are noted strikingly in the irritation, hyper-
semia, and inflammation consequent upon wearing next to the skin harsh
\voollen, generally dyed, garments, to which, under the name of " vest-
eruption," Hutchinson, 1 in particular, has directed attention. The influ-
ence of clothing on the skin has been investigated by J. L. Foley, 2 who
points out that it is mainly the inner garments that provoke disease.
Constant friction produced by ill-fitting articles of wear over tender por-
tions of the body, as a stocking or shoe over the instep or about the heel,
will often suffice to give rise to excoriations, ulcers, and other forms of
disease, especially epithelial hypertrophies, as callosities, and the like.
Irritants. Cutaneous irritants are the source of much mischief; for
example, strong external remedies too freely used may prove causes of
hypersemia and inflammation. Among these, as most frequently occa-
sioning disorder, sulphur, croton oil, the preparations of mercury, caus-
tics in general, rubefacients, tartar emetic ointment, and tincture of arnica
may be mentioned.
Uncleanliness. Uncleanliness, or the presence of effete or foreign
matter upon the surface, must likewise be considered as an exciting cause
of disease, though in my opinion it is of less importance than is gener-
ally believed. On the other hand, too much attention to cleanliness may
also be followed by an abnormal condition of the skin ; the injudicious
use of the bath and the constant use of strong soaps are hurtful to the
welfare of the integument, and, moreover, favor contagion by injuring
the epidermis. The frequency of the bath should be regulated by the
condition of the skin, especially as to its natural secretions.
Scratching. This operation brings about material and often exten-
sive lesions upon the surface, especially in affections of an inflammatory
and pruriginous character. It is noted to produce conspicuous lesions,
however, chiefly in those cases in which the skin has previously become
more or less altered by disease, where primary lesions exist. Thus, in
scabies, pediculosis, eczema, and ecthyma, scratching often creates a vast
amount of local disturbance, greatly complicating the primary disease.
In the disorders referred to it is, when protracted, the cause of structural
changes in the skin, as manifested by excoriations, pigment alterations,
1 Archives of Surg., vol. ii., 1890-91. 3 Montreal Med. Jour., 1890.
118 GENERAL ETIOLOGY.
and thickening. The condition of the skin as to its nutrition, the neu-
roses proper, and the presence of contagious elements, vegetable or animal,
have much to do with scratching and its effects.
Traumatism. The fact that eruptions of one kind or another some-
times follow injuries and wounds is well recognized, numerous cases of
the kind being on record. The lesions in some cases are inflammatory r
usually erythematous, vesicular, or bullous, in others atrophic, hypertro-
phic, or neoplastic. They may appear at the seat of injury or at one
point or at several distant points. 1 To this category belong the so-called
" surgical eruptions," those following operations, for the most part scar-
latinaform in character, such as have been described at length by Kidd, 2
Stirling, 3 Hoffa, 4 and others. In some cases they are septicaemic in
nature, and in others angio-neurotic.
Contagion. Among the external causes the most important remains
to be spoken of under this head. The varieties of contagion are numer-
ous and exceedingly prolific sources of disease. Among the infectious
diseases, those which are communicable through the medium of the
atmosphere as well as contact, smallpox, measles, scarlatina, and erysip-
elas, occupy the most conspicuous place ; while the contagious affections,
strictly speaking, those which are transmissible through direct contact
only, comprise especially syphilis, contagious impetigo, vaccinia, certain
low forms of specific inflammation, as equinia, and the so-called parasites.
Many of the cutaneous lesions of syphilis are contagious, and are active
agents in the spread of this common malady in many ways other than
through the genital organs. L. D. Bulkley 5 has directed attention in
an important monograph to the numerous avenues in the walks of life
through which an individual may innocently acquire this insidious dis-
ease. Lepra also may be acquired in ways that are often obscure and
unfathomable in the light of the knowledge of to-day. It is much more
insidious than syphilis in its invasion. Its initial lesion is unrecognizable
and unknown.
The disorders occasioned by the animal and vegetable parasites of the
skin form a distinct group ; they are all contagious, although not equally
so, some being at all times readily communicable, while others manifest
their contagious properties only under certain conditions. Not all indi-
viduals, for example, are to the same extent susceptible to their harmful
influence ; two persons may, under like circumstances, be exposed to the
same vegetable parasite, only one of whom will, in all probability, con-
tract the affection. Some persons, as attendants in hospitals and others
brought into frequent contact witli the contagion, rarely if ever contract
1 For further information consult the monograph of Picaud, " Des Eruptions cu-
tanees consecutive aux lesions traumatiques. " Paris, 1875.
2 Lancet, 1S68, i. p. 9. 3 St. George's Hosp. Kep., 1879.
* Abst. in Lond. Med. Kec., Aug. 1887.
6 Syphilis in the Innocent, New York, 1894.
DANGERS OF CONTAGION. 119
fungous diseases. The author is of opinion, therefore, that these para-
sites usually require a peculiar condition of the skin or soil for their
growth and development. The commonest vegetable parasites (micro-
scopic fungi) are the achorion Schonleiuii, trichophyton and microsporon
furfur. To the group of animal parasites belong the itch mite, head louse,
body louse, and crab louse, together with several other insects of less
importance, as the flea and bed-bug, which under favorable circumstances
commit depredations upon the skin.
DANGERS OF CONTAGION.
Danger of contagion is found in the animal parasites, more especially
in the three forms of pediculosis and in scabies. The latter disease is
often contracted by sleeping in the same bed with an affected person,
and in many cases a history corroborative of this mode of contagion
may be obtained. Of the vegetable parasites, ringworm, due to the tri-
chophyton fungus, is that commonly met with, contracted usually by
contact or through articles of the toilet or wearing apparel. The danger
from tinea versicolor and tinea favosa is not so great, although the latter
disease may be caught from the lower animals, especially mice and cats,
and at times from the most casual exposure.
Among the rare diseases which man is liable to contract, anthrax,
equinia, and actinomycosis, due to micro-organisms, may be mentioned,
all derivable from the lower animals. Of the commoner diseases, syphi-
lis, leprosy, and tuberculosis, likewise due to similar causes, remain to be
referred to, all of which are insidious in their entrance into the system
and are to be guarded against with every precaution. The physician is
especially liable to contract syphilis in the discharge of his professional
duties, particularly in midwifery, many cases of this most unfortunate
accident having from time to time come to the notice of the author. He
should always note whether his epidermis is everywhere intact before
handling or even coming in mere contact with suspicious cases. Ery-
sipelas, gonorrhoea, and diphtheria, as well as the acute infectious diseases
generally, are all to be guarded against, as being diseases liable to be
contracted through contagion and infection.
Contagion by contact may occur in many ways in the ordinary walks
of life, prominent among which is the hazardous custom of hand-
shaking (more prevalent in some countries than in others), whereby
not only the itch but also other parasitic diseases may be communicated
from one person to another. Kissing is a more dangerous act, for grave
diseases (in particular syphilis and tuberculosis) may be readily conveyed
in this way. The entrance into the system of such diseases through the
skin and mucous membrane of the face is commoner than is generally
believed.
The subject of the invasion of the skin by bacteria, micrococci, and
other similar forms of microscopic organisms will be considered in the
chapter on pathology.
120 GENERAL PATHOLOGY.
GENEEAL PATHOLOGY.
GENERAL OBSERVATIONS.
The pathology of the skin may be considered from several stand-points.
A general view of the subject, especially as regards the results, in the
form of tissue changes, of the several pathological processes, it seems to
the author will be in keeping with the practical character of the rest of
this work. The aim, therefore, will be to direct attention to the peculiar
modes in which the skin is invaded by the various pathological processes
concerned in producing diseases, and to point out the common morbid
alterations in the structure of the skin which follow these processes.
The latter topic constitutes the important department of pathological
anatomy. It is upon these general lines that the classification in the
present work rests.
The scheme is of distinctly practical value to the student of dermatol-
ogy. It deals with the tangible aspect of the subject, for the most part
with anatomy and pathological anatomy. It regards the changes which
have occurred in the skin the so-called " diseases " as of paramount
importance for purposes of recognition and further study. It calls for a
knowledge of the morbid changes which have taken place in the integu-
ment and in the several parts of which it is composed. It possesses the
great advantage of resting securely upon the solid ground of anatomy.
Upon this basis the pathology of the diseases is capable of being
elaborated from every stand-point, including the important subject of
etiological factors.
From a strictly practical point of view, what the practitioner desires
to acquire, in order that he may relieve or cure the patient, is a knowledge
of the aggregation of symptoms which go to make up the so-called dis-
ease, and of the meaning of the same. This knowledge is obtained by
dealing primarily with the results of the process rather than with the
causes which have produced it. An understanding of the latter should,
of course, accompany the former, and, as already stated, is most important.
Etiology and pathology are closely related, each being more or less
dependent upon the other. Hence they are to be studied and investigated
together. The importance of acute observation in these two fields, so
intimately related as they are, cannot be overstated. Bacteriology is able
to demonstrate the etiology of many diseases ; pathology informs us of
the morbid processes which have been set up by bacteria and the like ;
while pathological anatomy deals with the structural changes that have
been brought about by morbid processes. Bacteriology, moreover, has
been the means of pointing out new and successful methods of treatment
THE EPIDERMIS. 121
in cutaneous medicine. To view the pathology of the skin aright it
must ever be kept in mind that dermatology is but a department of
general medicine and surgery, and that for the understanding of morbid
processes in the skin the observer must be familiar with general as well
as local pathology.
METHOD OF STUDY.
The pathology of the skin is to be studied in the same light as that
of other parts of the economy. The integument differs from other
membranes chiefly in its anatomy, which on account of its complexity
is subject to a variety of alterations, many of which are peculiar. It is
liable to the same pathological processes, such as hyperaemia, inflamma-
tion, hypertrophy, and atrophy, as take place in other organs, and conse-
quently is to be studied from the broad stand-point of general pathology.
The morbid changes which occur in the skin are very numerous, and
are moreover liable to varied modifications. To comprehend them cor-
rectly, a thorough knowledge of the normal structure is absolutely essen-
tial. A knowledge of the physiology of the skin is likewise important.
THE EPIDERMIS.
All portions of the integument, either separately or together, may be
involved in the various diseases of the skin, but certain parts are more
frequently invaded than others. The epidermis especially partly in
consequence of its serving as the external covering of the body and
therefore being liable to a great variety of influences, partly because it
is a very actively proliferating membrane or layer, and further because
it is intimately associated with the deeper parts is very frequently the
seat of disease. From its position it necessarily plays a more or less
prominent part in the pathology of all cutaneous manifestations. Its
importance as a structure can scarcely be overestimated. Attention may
here be directed to the anatomy of the epidermis, and especially to the
fact that it is genetically a distinct layer. It is composed of two main
strata, the corneous layer and the mucous layer. Of these the mucous
layer, being the germ or living portion, is by far the more important,
not only physiologically but also pathologically. Thus, in eczema,
herpes, psoriasis, and many other superficial inflammatory dermatoses
this layer is chiefly involved primarily, the manifest signs of vesicula-
tion or desquamation being secondary to deeper-seated changes. Even
in those instances in which the pathological process is situated exclusively
in the deeper structures, it shows marked morbid changes, as atrophy or
hypertrophy and its modifications, the result oi'ten of impaired nutrition.
It is a common seat of hypertrophy in varied forms, as seen in callosity,
cornu, wart, ichthyosis, and other keratoses. Various micro-organisms,
including the common so-called vegetable parasites of the skin, also have
their habitat here, the latter not infrequently taking complete possession
of the corneous layer.
122 GENERAL PATHOLOGY.
CORIUM AND SUBCUTANEOUS TISSUE.
In the corium and subcutaneous tissue, however, occur the greater
number of morbid processes. The peculiar structure of these tissues,
consisting of a close net- work of connective tissue, extensive plexuses of
blood-vessels, lymphatics, and nerves, and a complete system of glandular
apparatus, highly endowed with vascular and nervous systems, follicles,
and hairs, renders them particularly liable to disorder. It is, moreover,
through certain organs which have their seat in the integument, the sweat
glands and sebaceous glands, that numerous effete products of the economy
find their exit, -some of which give rise to cutaneous disturbance. The
hypersemias or congestions all have their seat here ; likewise that great
class of diseases, the exudations or inflammations. Hemorrhages also
occur here in both the papillary and the reticular layer, as observed
in purpura. Many hypertrophies and atrophies and new growths of
various kinds are seated mainly in the corium. The grosser parasites,
especially the itch-mite, lice, and the bedbug, also prey upon this tissue.
It is likewise in the corium that certain structural changes of the blood-
vessels, lymphatics, muscles, and nerves take place, as found in angioma,
lymphangioma, myoma, and neuroma Functional disturbances of the
cutaneous nerves, constituting the neuroses proper, manifest themselves
in the papillary layer, a stratum well supplied with nerves, and in the
mucous layer of the epidermis.
APPENDAGES OF THE SKIN.
The sebaceous and sweat glandular systems are attacked by functional
disorders, as seborrhcea and hyperidrosis, and are the seat of varied struc-
tural alterations, either alone, as in sebaceous cyst, or in connection with
disease of other tissues, as in lupus erythematosus. The hair and hair-
follicles and the nails are invaded by numerous pathological processes,
either idiopathically, as in tinea tonsurans, tinea favosa, and the like, or
symptomatically, as in alopecia, eczema, psoriasis ; also as a result of
nervous shock, fevers, and other general diseases.
ANEMIA. /
The subject of anaemia may be conveniently arranged in two di-
visions, the GENERALIZED and the LOCALIZED. Both forms are of
considerable importance in cutaneous medicine. Anaemia does not pro-
duce substantive diseases, as does inflammation, but, like hyperffimia, its
influence upon the skin is marked, and often is significant.
GENERALIZED ANAEMIA.
In this division the first variety to be distinguished is that in which
there exists an alteration in the quantity or the quality of the blood in the
general circulation ; a second variety is that in which the anaemia is con-
fined to the skin and exists in a diffused form. In the first the calibre
of the blood-vessels is in the beginning not at all or but little implicated.
LOCALIZED ANAEMIA. 123
The anaemia may be due to a deficiency in the number of the red corpus-
cles or to an increase of the white corpuscles. Such a deficiency occurs
iu chlorosis, and in the various forms of inanition due to lack of proper
food or to malnutrition, and in certain cachexias, as tuberculosis and
carcinoma ; also in pseudo-leucaemia and in hydraemia. In certain other
morbid processes, as in leucaemia, there is an increase, both relative and
absolute, in the number of the white corpuscles. In poisoning of the
blood, due to varied causes, the quality of this fluid is deteriorated, there
existing usually a deficiency in the red corpuscles.
Universal cutaneous anaemia also precedes and accompanies cerebral
anaemia, as met with in fainting, nausea, sea-sickness, and similar con-
ditions, the skin becoming blanched or of an ashy-gray color. These
colors, also observed in cholera and other diseases, are due to the general
contraction of the blood-vessels of the skin.
The part that the cutaneous blood-vessels play in anaemia of the skin
is worthy of consideration, their general contraction, transient or perma-
nent, under the influence of impaired functional power of the central
nervous system, arising from varied causes, being in certain diseases
marked. General tonic contraction of the peripheral vessels occurs in
the course of the acute infective diseases, due to the circulating poison
acting upon the vaso-motor centres. Fall of peripheral with increase of
internal 'temperature takes place in these instances, the whole economy
being affected. In general hemorrhage from wounds and other causes,
the cutaneous capillaries are not only deprived of their usual amount of
blood, but also contract and become temporarily smaller in calibre, the
skin taking on a yellowish, waxy, or translucent appearance.
The remarks thus far made concern general and diffused anaemia.
LOCALIZED ANAEMIA.
The local or circumscribed anaemias of the skin are the result either
of a primary vascular constriction in the vessels of the skin, or of a
diminished supply of blood to the part, due to a narrowing of the calibre
of the larger vessels supplying the skin. The first may be regarded as
a primary, the latter as a secondary form. Cold applied to the surface
of the skin acts differently according to the degree : thus, the effect
of slight or moderate cold is to produce a congestive hyperaemia, or a
" healthy" flush, but if the cold be carried to an extreme degree it pro-
duces a paralysis of the vessels and anaemia. The effect of prolonged
exposure to cold water, or to alternating cold and hot water, is noted in
washerwomen, whose fingers may become anaemic or cyanotic, and the
disturbed circulation of the parts may be accompanied by pain, heat,
or itching. A similar condition exists in pernio, or frost-bite, in
Raynaud's disease, especially in the early stages of the latter, and iu
some other forms of local asphyxia.
The calibre of the vessels of the integument supplying circumscribed
124 GENERAL PATHOLOGY.
or diffused areas may be diminished through inflammatory changes and
the deposit of connective tissue in their walls. Emboli and thrombi may
also occur in these vessels, producing atrophic, anaemic lesions of one
kind or another, for the most part characterized by condensation of the
connective tissue. Obliterating closure of the blood-vessels (endo-arteritis
obliterans) is productive of a good many anaemic, often atrophic, localized
changes in the skin. Marked examples of patches of anaemic skin, some
small, others large, due to a diminution of the calibre of the vessels from
varied causes, are met with in keloid, morpho3a, scleroderma, maculae et
striae atrophicae, striae gravidarum, certain forms of alopecia, as alopecia
areata, and cicatrices in general. The pale anaemic skin met with over
certain tumors, where the skin is much stretched and the nutrition im-
paired, as in sebaceous cyst and the like, may also be referred to.
The general subject of anaemia of the skin is of special interest from
a diagnostic point, and hence to the clinician. Much is to be learned
from the anaemic conditions of the skin, especially when viewed as
indexes to general pathological processes.
HYPER^EMIA.
Cutaneous hyperaemia consists essentially of an excessive, but not neces-
sarily a large, amount of blood in the vessels and capillaries. Its seat is
mainly in the papillary layer of the corium. It is therefore a well-
defined disturbance of circulation, and, being confined to the vessels, is
comparatively a simple process. It is for the most part an ephemeral or
transitory condition, lasting a variable period, on its subsidence leaving
the skin in a normal state. This observation applies particularly to the
active forms of the process, the passive congestions being often accom-
panied by vascular changes, as seen, for example, in rosacea and telan-
giectasis.
CLINICAL FORMS.
The hyperaemias as a class possess certain characteristic clinical features
whereby they may be recognized. Their existence is always marked by
redness of the skin, varying in color from pink to dark or bluish red,
the tint depending upon the degree of the arterial or of the venous
involvement, and upon the superficiality or the depth of the process.
As a rule, the redness is superficial, and in the active hyperaemias disap-
pears readily under external pressure, but returns instantly. They may
be local and circumscribed, or, on the other hand, diffused or generalized.
Sensations of heat, burning, or tingling often accompany the acute forms,
but such symptoms may be lacking. The temperature of the surface of
the skin is variable. In the active forms it is generally elevated, but in
the passive forms it may be diminished. The acute forms may continue
for hours or days, the period being extremely variable ; not infrequently
they relapse. The passive forms are irregular in their course, and often
are slow or chronic.
ACTIVE AND PASSIVE HYPER^EMI^E. 125
The hyperaemise are met with in connection with a multitude of
pathological conditions, and play a very important part, from a diagnostic
as well as from a pathological stand-point, in cutaneous medicine, espe-
cially in the early stages of disease. They give rise to a great variety
of manifestations upon the surface of the skin, which frequently are
irregular as to size, shape, and outline. Thus, puncta, macules, orbic-
ular, circinate, striate, and gyrate lesions, and reticulated, arborescent, or
marbled patches, often large and wide-spread, are met with. Some of
the so-called erythematous affections belong to the class of hyperaemiae,
but most of them are more properly grouped with the superficial inflam-
mations, being accompanied by a variable, often slight, amount of
exudation.
ACTIVE AND PASSIVE HYPER^MI^.
Hyperaemiae, or congestions, may be ACTIVE or PASSIVE. This divi-
sion is of importance, for their clinical appearances and their significance
are quite different. They must, therefore, be clearly distinguished. The
former constitute the ACTIVE ERYTHEMATA or CONGESTIONS, the latter
the STASIS ERYTHEMATA or CONGESTIONS or the so-called CYANOSES.
The active hypersemise are known clinically by their bright-red color
and their accelerated blood-current, and the passive hyperaemiae by their
dusky-red or bluish-red tint and a retardation of the blood-current.
The arteries, arterioles, and veins all play an important part in this
process, the excess of blood present being due to a decrease in the con-
tractile power of the vessels. The normal tone is lacking, and dilatation
follows. In some cases the arteries are especially implicated ; in others
the veins are at fault.
As Unna J has pointed out, the arterial, active hypersemiae are the result
of a relaxed state of the capillaries, due to inhibiting or paralyzing in-
fluences, owing to which circumstance the current flows more freely and
rapidly. The passive hyperaemiae are due to stagnation, or stasis, charac-
terized by a more or less distinctly marked retardation of the circula-
tion ; but the vessels are by no means inactive in the process. In the
active, or relaxive, hypenemiae the resistance in the walls of the vessels
is impaired and is below normal, the vessels being paralyzed, while the
current is accelerated. In the passive, or obstructive, hypersemiae the
resistance is increased beyond the normal, while the blood current is
retarded. The supply of blood to the part is interfered with ; it is
limited in quantity, while at the same time the return flow from the
affected area is obstructed. There thus results a variable degree of stasis.
Thus these two conditions of the circulation, while they both give rise
to congestions, are the opposite of each other pathologically.
In addition to the dusky-red or bluish-red color noticeable in the
passive hypersemias, there sometimes occurs oedema of the integument,
1 Allgemeines uber Hyperaemien der Haut, Monatsh. f. prak. Derm., Bd. ix.
(1889) No. 2.
126 GENERAL PATHOLOGY.
together with a lowered temperature, either with or independently of
oedema. This diminished temperature indicates faulty innervation gen-
erally, as shown by other changes, as in the altered secretion of the glands
of the skin. A marked example of the latter condition is met with in
acne rosacea and rosacea, especially of the cold or non-inflammatory type
so common in elderly persons. The passive hypersemiee and the venous
congestions, livido and the like, as H. Auspitz l showed by experiments
with the ligature and other mechanical devices, are largely dependent
upon obstructions in the veins, the most varied cutaneous vascular lesions,
both as to color and as to form, being producible by such factors.
CAUSES.
The hypersemias may arise from innumerable and varied, sometimes
directly opposite, causes. Thus, heat and cold, various internal irri-
tants, acting directly or reflexly, systemic disorders due to drugs,
poisons, microbes, and manifold other causes, including local injuries
and irritants, may all give rise to circumscribed or diffused congestions.
The causes may provoke an IRRITATIVE HYPER^EMIA (the "neuro-
tonic congestion" of Recklinghausen), or a PARALYTIC HYPER^EMIA
(a " neuro-paralytic congestion"). The former are so common as not
to require special remark, while the latter may be illustrated by refer-
ence to the erythematous conditions met with after injuries to nerves,
especially of the extremities, as glossy skin and the like. Nerve influ-
ence generally has much to do not only with the production of the con-
gestions of the skin, but also with their form and outline on the surface.
Thus, the circinate and annular erythemata, spreading on the periphery
and clearing away in the centre, are distinctly indicative of irritation
of cutaneous nerve filaments, as illustrated by tinea circinata, due to the
trichophyton fungus. The vaso-motor system is especially involved in
the production of hypersemic cutaneous lesions, especially through the
muscular coat of the arteries.
Cold, especially if long continued in its action, plays an important part
in producing stasis in the vascular system. By causing contraction of
the vessels, the blood-supply and the proper nutrition of the part are inter-
fered with. According to the degree to which the cold is carried, and its
persistence, will the skin become reddened or inflamed, or on the other
hand whitened, with the result possibly of becoming gangrenous. The
cold produces a paralytic angioneurosis in these cases, common examples
of which occur in frost-bite, or pernio, in certain forms of rosacea, and
in telangiectasis, as seen in sailors, cabmen, and others exposed to
wind and cold weather. In this connection the passive congestions which
occur in the legs and feet of persons who stand much, leading frequently
to varicose veins, may be referred to.
1 t^ber Venose Stauung in der Haut. Wien, 1874. Also Viertelj. f. Derm. u. Syph.,
Heft I., 1874.
(EDEMA. 127
COURSE AND TERMINATION.
True hyperaemia is not followed by desquamation, this symptom, when
it occurs, indicating that some cellular exudation from the vessels has
taken place. Pigmentation is a much more common accompaniment or
sequel than desquamation, especially in the passive forms of congestion,
examples of which are common on the legs, particularly about the ankles.
In these cases oedema, especially the inflammatory variety, is also a factor
in the pigmentation. Instead of hypersemia terminating as a simple dis-
turbance of circulation, it may readily proceed further and become in-
flammation. This course, it need not be stated, is of very common
occurrence. Thus, it will be noted that hyperaemia may exist alone,
running its course from beginning to end as hypersemia, but inflamma-
tion cannot exist without having been preceded by hyperaemia. Clin-
ically, the line separating the two processes is generally ill defined, it
being difficult to state when hypersemia ceases and when the inflamma-
tory process begins. At the same time there are many hypersemic
affections pure and simple, and hence the importance of a class devoted
to the hyperaemiae.
CEDEMA.
CEdema is characterized by the presence of serous fluid in the tissues
outside of the vessels, from which latter it has emanated by having oozed
through their walls. The fluid transuded from the blood which con-
stitutes the oedema contains considerably less albumen than the plasma
of the blood. It is always poor in albumen, this constituent being vari-
able in amount. CEdema is a condition which plays a part of considerable
importance in connection with many affections of the skin and the sub-
cutaneous tissue. It is intimately associated with disturbance of the
circulating fluids, especially with venous blood and lymph. It is often
a result of hyperaemia and of inflammation, and is therefore appropriately
considered here. The process which gives rise to oedema is a complicated
one.
It has been shown, in considering the hyperaeimae, that in active con-
gestion the current of the blood is augmented and accelerated, while in
passive congestion it is lowered and retarded. When the current
stagnates or arrives at a stand-still, STASIS is said to occur. But stasis
may result from other causes than mechanical obstruction. Thus, cold
and heat, alcohol, chloroform, and the like, and various other agents
which produce contraction and relaxation of the blood-vessels and dis-
turbances generally of the circulation, may be factors. The relation
of the tone of the veins to that of the arteries is of importance, a
preponderance in the tonicity of the veins, according to Unna, giving
rise to oedema. The existence of O3dema may be regarded as signify-
ing a difference between the arterial and the venous circulation. Spasm
of the veins is caused by a sudden contraction of the muscular coats
]28 GENERAL PATHOLOGY.
of these vessels. This, in order to produce SPASTIC (EDEMA, must be
greater than the corresponding contraction of the arteries. This form
of oedema pursues an extremely variable course, but usually vanishes
gradually, a much longer time almost invariably being required for the
disappearance of the lesion than for its formation.
Two principal varieties of oedema are met with in the integument, one
being mechanical in its origin, the other being due to more or less well
defined inflammatory changes. They are known as MECHANICAL CEDEMA
and INFLAMMATORY GEDEMA.
MECHANICAL (EDEMA.
Unna 1 has called attention to the fact that experimental pathology
teaches that the closure of all the lymphatic channels of a limb does not
cause oedema in it, while, on the other hand, a venous obstruction never
fails to give rise to it, from which observation the conclusion may be
drawn that the lymphatics of the skin are only an occasional channel for
the return of lymph, carrying back to the blood only that portion of the
lymph which does not return by the venous capillaries into the veins.
It is the veins, therefore, rather than the lymphatics that are in the first
place concerned in mechanical cedema. This observation is proved by
the fact that oedema of this nature is produced readily by a bandage
applied tightly to the upper part of an extremity, causing compression
of the veins and arrest of the venous current. In these cases the lymph-
vessels probably take no part in producing the oedema which so soon
follows ; but abnormal distention, stasis, and obstruction in the lymph-
vessels may lead to softening of the tissue and thus to oedema.
It is well known that general venous congestion gives rise to o?dema
of the entire skin, which is usually more pronounced in some localities
than in others, as the eyelids, ankles, and feet ; and venous thrombosis,
especially of the smaller veins, likewise produces a variable amount of
oedema. Unua is of opinion that contraction of the walls of the veins,
giving rise to stagnation of the blood, must be regarded as a factor in
some forms of oedema, as in the circumscribed oedemas and in urticaria.
Gravity is another factor in the production of mechanical oedema.
The degree of elasticity of the skin which is preserved in oedema
determines the amount of pitting on pressure. The longer the oedema
has existed, as a rule, the greater is the loss of the elasticity of the skin.
In certain forms of oedema, especially where the skin is thin or much
distended, as in those due to inflammation, blebs are liable to form in the
epidermis, which break down, giving rise sometimes to a trickling of
serous fluid.
INFLAMMATORY (EDEMA.
Inflammatory cedema may result from acute, subacute, or chronic in-
flammation, and is due to disturbance in the circulation of the lymph.
1 Loc. cit.
ANATOMY OF THE WHEAL. 129
This latter occurs owing to the fact that in inflammation of the skin the
absorptive power of the veins is small, unusual strain thus falling upon
the lymphatics. It is met with, more or less well developed, in many
diseases of the integument. Marked changes occur in the walls of the
blood-vessels in these cases, as noted in elephantiasis and allied forms of
hyperplasia, including certain chronic eczemas of the leg. Inflammatory
oedema is richer than mechanical oedema in soluble albumen and color-
less round cells. It may be due to some of the same general causes that
produce mechanical oedema.
ANATOMY OP THE WHEAL.
The close relation that oedema bears in some cases to inflammation is
seen in the production of the wheal and allied forms of cutaneous tume-
faction. The wheal is an inflammatory oedema, in some cases confined
to the skin, in others involving the subcutaneous connective tissue. It is
a spasmodic or SPASTIC CEDEMA, and is characterized by a tense, elastic
swelling, usually with a defined outline separating it from the surrounding
normal skin. Unna 1 believes that it is caused by a sudden obstruction
to the venous circulation, brought about by abnormal nervous impulses
raising the tone of the veins. It is sharply defined because the normal
lymph-spaces permit only a small amount of the fluid to be carried off.
H. Leloir 2 found in a section of a wheal dilatation of the blood-
vessels and lymph-spaces of the corium ; oedema of the corium ; and the
invasion of the corium by a large number of leucocytes, either isolated
between the meshes of the connective tissue or formed in groups, the
latter being particularly marked about the blood-vessels and lymphatics,
sebaceous and sweat glands. T. C. Gilchrist 3 describes a similar con-
dition, the results being obtained from studies on a number of lesions.
He has shown that in a well-developed wheal of urticaria factitia the
pathological anatomy is that characteristic of inflammation, consisting
of dilated blood-vessels and lymphatics, large numbers of polynuclear
leucocytes, especially inside and around the veins, the presence here and
there of small quantities of fibrin, and an increased number of mono-
nuclear cells (lymphocytes), found particularly around the vessels. The
texture of the tissue is looser than normal, due to the increased exuda-
tion of serum, and sometimes there exists an cedematous condition of
the connective-tissue cells of the papillae.
There are other oedemas to be referred to, depending upon recognized
causes, such as the TOXIC and INFECTIOUS, with changes in the blood,
THERMIC, and TRAUMATIC, all of which may show themselves in varied
forms. The cedemas of kidney disease and scarlatina may be vieAved as
1 " Oedem," Monatsh. f. prak. Derm., Bd. x. (1890), Nos. 3 and 4.
2 Traite Descriptive des Maladies de la Peau, Symptomatologie et Anatomic Patho-
logique, par Leloir et Vidal, Livraison vii. Paris, 1894.
s Paper on the anatomy of the wheal, read before the Section of Dermatology of
the Amer. Med. Assoc., Baltimore, May, 1895.
9
130 GENERAL PATHOLOGY.
probably belonging to the toxic varieties, of which the oedema resulting
from the bites of poisonous serpents may be taken as the type. Another
form is that known as HYDR^EMIC or CACHECTIC, in which the blood
is poor in its solid constituents, differing from the inflammatory form
in the fluid containing less albumen and fewer corpuscular elements.
Unna states that the hyperplastic processes which characterize elephan-
tiasis due to varied causes, including filarise, are the result of the pre-
ceding inflammatory processes (of erysipelas in particular), and not of
the oedema.
The course of oedema in general is variable. In some cases, as in
ordinary urticaria, giant urticaria, and acute circumscribed oedema, it
arises, as a rule, rapidly, and disappears gradually ; while that met with
in connection with renal disease is generally slow in forming.
INFLAMMATION.
DEFINITION AND SYMPTOMS.
It is difficult to present a satisfactory definition of inflammation, for
the reason that the process embraces a whole series of phenomena in
which both the circulation and the tissues are involved. The phenomena
are better understood than is the process. The latter is distinctly com-
plex. There are many changes involved in it. The degree to which
these advance has much to do with the results produced in the tissues.
The causes are both numerous and diverse.
Viewed from a clinical and a pathological point together, it may
be briefly defined as a process characterized by changes in the circu-
latory system, exudation of the fluid and corpuscular elements of the
blood, attended by redness, swelling, heat, and pain. Since the period
of Celsus the latter striking clinical signs (RUBOR, TUMOR, CALOR, et
DOLOR) have been known as the " cardinal symptoms of inflammation."
These signs of inflammation, however, vary considerably according to the
degree and the form of the process, and some of them may be greatly
modified. The changes which take place concern the vessels and the
texture of the tissues invaded, and are intimately connected. Functional
and nutritive disturbances also occur, with perversion of the peripheral,
sensory, and motor apparatus. Pathologists are disposed to attach
considerable importance to the disturbance of function accompanying
inflammation, designating it FUNCTIO L^SA.
The redness is due not only to the dilatation of the vessels and capil-
laries, but also to the exudation of the red corpuscles, and to the pres-
ence of hsemoglobin in a state of solution. The swelling is the result
of the infiltration of the tissues by the fluid exuded from the vessels.
The heat is due to chemical changes Avhich have occurred in the blood,
including augmented oxygenatiori ; while the pain is accounted for by
the tension which the exudation has produced, and by the pressure on the
INFLAMMATION. 131
nerve filaments of the tissues. Chemical changes in the blood must also
be regarded as a factor of pain. Concerning the temperature of an in-
flamed area, observation confirms the doctrine held by Hunter, namely,
that it is in direct proportion to the degree of hyperaemia in the area.
THE PROCESS.
One of the first changes noted is vascular dilatation. Some observers
believe that this is preceded by molecular alteration in the walls of the
vessels. The process may be plainly described as follows. The first
stage is that of hypersemia, an abnormal collection of blood in the
vessels and capillaries. After a variable period this is followed by dila-
tation, with an accelerated blood-current, subsequent retardation, and
contraction in the calibre of the vessels. The corpuscular elements
accumulate, and a condition of stasis results. At this stage the color-
less corpuscles adhere to the sides of the vessels and show increased
activity of movement, embedding themselves in the coats of the vessels
and working their way through the vessels into the tissues beyond. A
var'able, usually large, amount of the liquor sanguinis readily transudes
through the vessels. In high grades of inflammation especially, the red
corpuscles also are forced through the walls, though this occurs passively,
and not actively as in the case of the leucocytes. This process of DIA-
PEDESIS, now so well known, is a very important one in inflammation,
and explains what formerly seemed obscure. The cause of the extrusion
through the walls of the corpuscles was once thought to be blood-
pressure, a point upon which Cohnheim laid much stress when he
said, " without blood-pressure no diapedesis." It is now believed that
this is due to their own active movements. The great activity of the
leucocytes is in strong contrast with the more passive movements of the
red corpuscles. The leucocytes are to be regarded as the principal actors
in inflammation.
According to Metchnikoff 1 and others, the two varieties of leucocytes
which play the principal part in inflammation the mononuclear leuco-
cytes and the neutrophile cells are elements endowed with considerable
chemotactic and physiotactic sensibilities ; are capable of amreboid
movements ; and are prone to englobe and digest different foreign
bodies, especially a number of living microbes.
Next in order after the leucocytes, the vessels and their eudothelium
play the most important part in inflammation, processes, protuberances,
or buds of protoplasm making their appearance, which later often form
loops and vascular channels. Another important factor is the contrac-
tility of the endothelial cells, as shown by the studies of Strieker and
others. While connective-tissue cells proliferate in an inflamed area,
the fixed connective-tissue corpuscles probably take little or no part
in the production of inflammatory cells.
1 Lectures on the Comparative Pathology of Inflammation. London, 1893.
132 GENERAL PATHOLOGY.
THEORIES OF INFLAMMATION.
The various older theories of inflammation (including the CELLULAR,
the VASCULAR, the NEURO-VASCULAR, the NERVOUS, the NEURO-PARA-
LYTIC, and the TROPHIC) are all unsatisfactory in many particulars.
Different views are held by modern observers concerning the pathology
of inflammation, as shown by the varied definitions proposed by distin-
guished observers. B. Sanderson 1 defines it to be "a succession of
changes which occur in a living tissue when it is injured, provided that
the injury is not of such a degree as at once to destroy its structure
and vitality." Ziegler 2 regards it in the light of a pathological exu-
dation from the blood-vessels, produced by harmful agencies, associated
with a local degeneration of the tissues, with a tendency to regeneration
or to hypertrophy of the granulating tissues. J. C. Warren 3 defines
inflammation as " a lesion in the mechanism of nutrition, owing to
which its efficiency is impaired, but which, if not so severe as to cause
death, produces conditions favorable for the protection and repair of the
part."
Metchnikoff 4 has brought forward a theory, which might be termed
the biological or comparative theory of inflammation, since it is founded
on a comparative study of the pathological phenomena presented by
living cells. According to these views, " inflammation generally must
be regarded as a phagocytic reaction on the part of the organism against
irritants. This reaction is carried out by the mobile phagocytes some-
times alone, sometimes with the aid of the vascular phagocytes or of the
nervous system." This observer holds that in the struggle between the
organism and its aggressors some of the combatants by virtue of natural
selection survive, while others, eliminated by the same means, perish.
He concludes that all other phenomena are merely accessory to this
process, and may be looked upon as means to facilitate the access of
phagocytes to the impaired part.
Of late much stress has been laid upon chemotaxis as playing an im-
portant part in inflammation. It consists of an attractile or repellent
power possessed by cells. It includes the various forms of sensibility
of bodies to chemical agents. The studies of pathologists and biologists
show that the phenomena of sensibility play an important part in path-
ological processes, in cryptogams, bacteria, and other forms of life. Two
forms are distinguished. In POSITIVE chemotaxis the bodies approach
the others with which they have to establish relations, whereas in NEGA-
TIVE chemotaxis they are enabled to escape injurious influences.
Both acute and chronic inflammations are due to various causes, which
1 A System of Surgery, edited by T. Holmes, vol. i. London, 1883.
2 Lehrbuch der Allg. Pathologic und Pathologischen Anat., Bd. i. [Allg. Path.],
8te Auflage. Jena, 1895.
3 Surgical Pathology and Therapeutics. Philadelphia, 1895.
4 Op. cit., p. 136.
INFLAMMATION. 133
may be chemical or physical, or, as is more usually the case, biological in
nature. It has been abundantly shown that all factors which tend to
lower the vitality of a part render it more liable to the exciting causes
of inflammation ; and that the kind and the degree of the inflammation
largely depend upon the existing conditions, and upon the infecting
organisms which influence or complicate the process. Experiments show
that the nervous system has a distinct influence on inflammation, serving
to accelerate or to retard its course, but its importance is probably not so
great as was formerly believed.
COURSE AND TERMINATION.
Inflammation may be ACUTE or CHRONIC in its course, depending
upon the nature of the cause and its continuance in relation to the
affected part. These terms apply not so much to the length of time the
process has existed as to the changes that have been produced in the
tissues. The integument, the corium in particular, tends to take on in
a striking manner chronic inflammation. Thus it results that a large
number of the diseases of the skin incline to pursue a long-continued
rather than an acute course, and to undergo gradual rather than sudden
change. The process may terminate in many ways, the commoner being
resolution, or absorption, organization and granulation, serous discharge,
suppuration, desquamation, and hyperplasia. A tendency of the inflam-
matory process is to lead to marked increase in the connective tissue, in
the form of diffused or circumscribed sclerosis. Other forms, the result
for the most part of long-continued irritation, occur especially in connec-
tion with the chronic inflammations, due to varied causes; of these,
nutritional and degenerative states of the tissues, necrosis, ulceration,
and gangrene, may be mentioned. The inflammatory degenerations in-
clude many forms of regressive lesions, some of which are so special as
to be looked upon as diseases. Hypertrophies and atrophies, the latter
in particular, are not infrequently the result of varied chronic forms of
inflammation.
Inflammation and all inflammatory processes tend to destroy tissue.
This is due largely to cellular infiltration, especially in the case of the
connective tissue. Even the elastic tissue suffers. Passarge and Kroe-
sing l have shown that in all inflammations, especially hyperplastic and
degenerative processes, and in various new growths examined by them,
the disappearance of the elastic tissue corresponded with the intensity
and duration of the pathological process. Similar observations have
been made by V. Mibelli. 2 Infiltration is the most damaging of all the
accompanying symptoms of inflammation.
1 Schwund und Regeneration des elastischen Gewebes der Haut unter verschiedenen
pathologischen Verhaltnissen. Hamburg, 1894.
2 Quoted from J. Soffiantini's article on " The Elastic Tissue in the Fibrous Neo-
plasms of the Skin." Archives de Med. Exper. et d'Anat. Path., ler Mars, 1893,
No. 2.
134 GENERAL PATHOLOGY.
PRODUCTS OF INFLAMMATION.
The products of inflammation as met with in the skin consist of fluid,
semi-fluid, or formed materials. Typical fluid exudation occurs in the
vesiculation of eczema and herpes, and in a less pronounced form, ac-
companied with swelling and oedema, in urticaria and erythema multi-
forme. It occurs in the form of blebs in erysipelas, pemphigus, and
other diseases. Bullous formations in general, in almost all cases, are
indicative of greatly disturbed nutrition of the affected area. They are
usually the result of impaired innervation, and in consequence are dis-
tinctly under the direct influence of the nervous system. Pus, in the
form of variously sized and shaped pustules and areas of pustulation, as
in impetigo, ecthyma, and acne, and in cutaneous abscesses, is a common
product of the inflammatory process. In other cases firm, plastic or
fibrinous material, sharply circumscribed or diffused, is formed, giving
rise to firm papules, tubercles, and patches, as in eczema, psoriasis,
lichen planus, and many other diseaess. The various forms of sclerosis,
due fundamentally to an increase of connective tissue, are among the
commonest products of inflammation, as seen in many diseases, for
example, in chronic eczema rubrum of the leg, and in various elephan-
tiasic forms of disease. The lines which separate the several products
of inflammation, however, are often ill defined, intermediate stages and
forms being common upon the same subject. Thus, in eczema, vesicular
and papular lesions are frequently met with together, in combination
with varied intermediate forms.
SEAT OF LESIONS.
The seat of the cutaneous primary lesions due to inflammation de-
pends largely upon the disease, each process having more or less predi-
lection for certain tissues, strata, and parts composing the integument.
The papillary layer, the body of the corium, the subcutaneous tissue, the
sebaceous and sweat glands, the follicles, the blood-vessels, and the
lymph-vessels are all liable to special invasion. Fluid exudation,
especially serous, commonly seeks its outlet between the strata of the
epidermis, occasioning vesicles or blebs or an excoriated surface, as noted
in eczema madidans. In other cases the exuded fluid permeates the
meshes of the corium or subcutaneous tissue as a serous infiltration,
characterized by oedema. Plastic or fibrinous exudation is usually
seated in the corium, giving rise to papules, tubercles, and patches
variable in size and shape. Purulent products tend to form in the
follicles and glands, in the papillary layer of the corium, and in the
subcutaneous tissue. When deeply seated the fluid inclines to find its
outlet through the natural avenues, namely, the follicles and glandular
ducts.
To describe the pathological anatomy of the varied forms of erythema,
vesicles, pustules, papules, tubercles, and other lesions, would be to enter
VARIETIES OF INFLAMMATION. 135
upon the domain of special diseases, inasmuch as there exist many varie-
ties of these lesions, differing in important particulars.
SUPERFICIAL AND DEEP-SEATED FORMS.
In considering the subject of inflammation of the skin distinction must
be made between the superficial and the deep-seated forms. Many affec-
tions of the skin are superficial in their seat from the beginning to the
end of the process; others beginning upon the surface rapidly work
downward through the natural vise (the follicles and ducts) until the
corium and subcutaneous tissue are reached, as in furuncle, sycosis, certain
carcinomata, and many other diseases.
The greater number of inflammatory cutaneous diseases are SUPER-
FICIAL INFLAMMATIONS, characterized by erythema, wheals, papules,
tubercles, vesicles, blebs, and varied modifications of these lesions. In
this division are found eczema, psoriasis, and various other similar affec-
tions marked by the presence of erythema, vesicles, pustules, scales, and
other lesions. The development of these several so-called primary
lesions of the skin and the innumerable modifications which they undergo
constitute a large part of the symptomatology of cutaneous medicine and
surgery. The most common and striking form of superficial inflamma-
tion, whether acute or chronic, is seen in eczema, a disease having its seat
primarily in the papillary layer of the corium and epidermis. It finds
its analogy in catarrhal inflammation of the mucous membranes. DEEP-
SEATED INFLAMMATIONS are illustrated by such diseases as phlegmon,
furuncle, carbuncle, and actinomycosis, in which both the corium and the
subcutaneous tissue are invaded. In various deep-seated inflammations
both the sebaceous and the sudoriparous glands, and the hair-follicles, are
frequently involved.
VARIETIES OF INFLAMMATION.
Two kinds of inflammation may be properly distinguished. The first
of these is known as SIMPLE INFLAMMATION, examples of which are
observed in the healing of healthy wounds, irrespective of their cause.
This form of inflammation runs a course pointing towards repair and
recovery. It shows a disposition to confine itself to the part involved, and
not to spread. It is an uncomplicated and non-infective process, and is
simple, non-destructive in its nature. The second form is that known as
INFECTIVE INFLAMMATION, which is due to the presence of bacteria. It
is a simple inflammation that has become complicated, and constitutes a
graver form of the process. Pyogenic cocci play an important part upon
the skin, being present in many cutaneous diseases, of which abscesses
and boils are common types. Bacteria are, practically speaking, present
in all suppurative diseases, for it is now generally understood that foreign
substances, mechanical irritation, and the like are unable to produce sup-
purative processes without the presence of bacteria.
As distinguished from septic infection from bacteria, must be men-
tioned TOXIC INFECTION, induced by such poisons as the ptomaines and
136 GENERAL PATHOLOGY.
the like, capable of producing local or general disease, especially the
latter. It is probable that these poisons are accountable for certain
angioneurotic dermatoses, as, for example, some forms of urticaria and
oedema.
FORMS OF INFLAMMATION.
The variety of the inflammation is determined by numerous factors,
among which may be mentioned the anatomical seat of the disease, the
nature and character of the irritating agent, and the duration of the
process. The varieties affecting the skin are particularly numerous, are
due to diverse causes, and give rise to a multitude of lesions and modifi-
cations of lesions having certain peculiarities, constituting many of the
diseases of the skin.
All the tissues except the epidermis may be primarily the seat of
inflammation. But the epidermis does not escape damage, being always
more or less involved and altered secondarily, and often in a remarkable
degree, as evidenced by the scaling and vesiculation in such diseases as
psoriasis and eczema. Although the epidermis is not supplied with
blood-vessels, it receives nutrient fluid from the lymphatics and possesses
nerves in abundance, so that in every way it is in the closest touch with
the vascular system of the corium. It occupies, consequently, a very
important place in many inflammatory processes.
The skin is subject especially to oedematous, serous, purulent, fibrinous,
hyperplastic, hemorrhagic, degenerative, and desquamative inflammation,
all of which appear in various modified forms, capable of division and
subdivision into special forms. QEdematous inflammation, or inflamma-
tory oadema, is observed in urticaria and in certain affections complicating
the lymphatic system. The most striking example of serous inflamma-
tion of a catarrhal nature occurs in vesicular and moist eczema, while
the squamous variety of the same disease affords a good illustration
of desquamative inflammation ; but psoriasis is more uniformly desqua-
mative. In serous inflammations the number of leucocytes is small, and
consequently the part they play is not so important as in the catarrhal,
fibrinous, or purulent variety ; but the serous exudations sometimes con-
stitute a congenial fluid for various microbes, which flourish and multiply
in it, while in other forms they are scanty or altogether absent.
The formation of pus, constituting purulent or fibrino-purulent in-
flammation, occurs very frequently both on the general surface of the
skin and throughout its structure and in the subcutaneous tissue, as
noted in various pustular lesions, in excoriated surfaces of the skin, in
ulcers, and in abscesses. Pus occurs in dermatoses quite different in their
nature. Thus, the bacilli of tuberculosis and of anthrax, the virus of
chancroid, the streptococcus pyogenes, and the staphylococcus pyogenes
aureus, albus, etc., all occasion suppurative lesions variable in their
clinical aspects. In the great majority of cases the micro-organisms are
staphylococci or streptococci.
PYJEMIA AND SEPTICAEMIA. 137
The affections of the skin which arise from the inoculation of the
agents of suppuration have been grouped together by H. Leloir l under
the heading of the " pyodermata." They may be divided into two
groups : (1) those produced primarily by the agents of suppuration and
dependent entirely upon these, the pure and simple pyodermata,
examples of which are found in furuncle, carbuncle, certain varieties
of folliculitis, ecthyma, and impetigo ; (2) those in which the action of
the agents of suppuration is superadded to some pre-existent pathogenic
cause, as noted in impetiginous eczema, eczema complicated with ecthyma
or with abscess, and the like. Inoculation may occur directly from the
outside, the common way ; or, more rarely, from the interior, through
toxines formed by microbes, and through impairment of the resisting
power of the individual cells to these destructive agents.
PYAEMIA AND SEPTKLEMIA.
Pyaemia (literally meaning pus in the blood, which it was formerly
supposed to be) is a complication of suppuration. It is a purulent infec-
tion, the system being invaded in most cases from a wound. It generally
occurs through the blood-vessels, sometimes through the lymphatics.
But pyaemia may occur without the existence of a wound. The inter-
mittent type of fever and the chill usually render the diagnosis easy,
especially if there exist a suppurating wound. The micrococci are
staphylococci and streptococci.
Septicaemia (signifying putrid blood), known formerly as " febris
putrida," is a grave, often fatal, type of surgical fever. Billroth 2 has
said that it bears the same relation to surgical or traumatic fever that
pyaamia does to suppurative fever, each being the malignant type of the
corresponding milder affection. It is occasionally encountered in con-
nection with certain well-defined cutaneous diseases, as, for example,
impetigo herpetiformis. The source of infection may be obscure.
INTERSTITIAL, HEMORRHAGIC, AND NECROTIC FORMS.
In interstitial, or fibrinous, inflammation the parts around the blood-
vessels in other words, the connective tissue are involved. This form
of inflammation is seen in many diseases of the skin. It is much more
common in chronic than in acute diseases, lichen planus and other varie-
ties of lichen affording marked examples.
Inflammation in connection with hemorrhage, especially the existence
of the former process in consequence of the latter, is not infrequently
met with, especially in the infective varieties of inflammation. It is
noted in a typical form in erythema nodosum, and in other diseases due
to various causes. There exist in most cases intense congestion, stasis,
diapedesis of the red corpuscles, and sometimes thrombus.
1 Des Pyodermites, Jour, des Mai. Cut. et Syph., No. 7, 1893.
2 Quoted from J. C. Warren's Surgical Pathology and Therapeutics, Phila., 1895,
p. 334.
138 GENERAL PATHOLOGY.
Necrotic inflammation, characterized by the inflammatory products
tending to necrose, sometimes rapidly, in other cases slowly, is met
with in furuncle, carbuncle, and the varied forms of acute and chronic
gangrene. In some cases of localized disease the necrosis is traceable
directly to nerve influence, especially in connection with the hands and
feet, particularly the fingers and toes.
Dermatoses terminating in necrosis, suppuration, ulceration, or gran-
ulation tissue, the latter constituting the so-called " granulomata," in
many instances belong to the class of diseases due to infective poisons,
of which variola, phlegmon, gangrenous bedsores, hospital gangrene,
malignant pustule, anatomical tubercle, tuberculosis, and granuloma
fungoides are striking examples.
PIGMENTATION.
In connection with many forms of inflammation there occurs a variable
degree of pigmentation, the deposit taking place early in the process or
towards the close, in which latter case it may be viewed in the light of a
result of the inflammation. It has been shown in considering the anat-
omy of the pigment that this product emanates from the blood and is
deposited in a variable form in the skin and elsewhere. Pigmentation
being a physiological process as well as a pathological result, intermediate
stages between the two states are common, as seen, for example, in freckle,
in pigmentary mole, in the discoloration of the skin peculiar to pregnancy,
and in other conditions. Certain simple inflammatory diseases of the
skin, as, for example, chronic eczema, especially of the legs, lichen planus,
prurigo, pediculosis corporis, and various forms of dermatitis, as from
sunburn and the like, are accompanied or followed by pigmentation. In
some of these cases the pigment is deposited in abnormal amount as an
essential part of the pathological process, as in lichen planus ; in others
it is deposited as a result of local irritation, as occurs in sunburn and
from scratching.
Pigmentation is also met with very frequently accompanying and
following various forms of passive congestion, the result of extravasa-
tions through diapedesis from the capillaries and larger blood-vessels.
Varicose veins, thrombi, and ulcers, especially about the leg, and other
conditions in which venous congestion occurs, all tend to give rise to this
form of pigmentation. Chronic inflammations, simple and specific, are
also prone to be accompanied by pigment deposit of this kind. Thus,
it occurs conspicuously in syphilis and lepra, and in many other diseases.
In other cases it is directly under the control of the nervous system,
illustrative of which form changes in the color of the hair may be cited.
In the beginning of the disintegration of the red corpuscles the color-
ing matter is haemoglobin. Changes occur rapidly in this product,
giving rise to the derivatives hasmatoidin (identical with bilirubin) and
hsemosiderine, the former containing iron and the latter being free from
iron. Pigmentation disappears by absorption through the vessels.
MICRO-ORGANISMS. 139
CAUSES OF INFLAMMATION.
The causes of inflammation are numerous. They may be considered
under the heads of predisposing and exciting. Both forces are important,
but the latter especially demands attention here. They may be divided
into those which act upon the skin from without and those which exert
their influence from within. To the former belong all manner of me-
chanical and physical injuries, including heat and cold and changes of
temperature ; irritant or corrosive poisons ; animal and vegetable poisons ;
and animal and vegetable parasites, the two latter giving rise to defined
groups of dermatoses. Specific poisons, as, for example, that of chan-
croid, also provoke definite forms of inflammation. Not less numerous
are those causes which act from within, through various natural channels.
Thus, many drugs and poisons entering the circulation find their way to
the skin, there setting up inflammation, variable in form and in degree.
Specific diseases, including acute specific fevers, also play a conspicuous
part in producing cutaneous inflammation.
MICRO-ORGANISMS.
The relation of bacteria, bacilli, micrococci, and the like to inflamma-
tion is now well known. These factors produce both general and local
disturbances, a marked example of which is observed in erysipelas. The
so-called INFECTIVE INFLAMMATIONS, depending upon the action on the
tissues of living organisms, constitute an important group of diseases.
The two chief factors in their production are the micro-organisms, or
germs, and the soil, or the peculiar state of the tissues, in w r hich they
live and multiply. A suitable soil seems in many cases to be necessary
for their growth. This fact has long been recognized in the case of the
vegetable parasites of the skin, as ringworm, which grows or at least
thrives only upon certain kinds of soil. The nature of this peculiarity
of the skin, favorable to the growth of the fungus, we are unable to
define.
The micro-organisms attacking the skin may be specific, as in the case
of the bacilli of leprosy, or non-specific, as in the simple inflammations.
The observations of Metchnikoff and others go to show that the white
corpuscles of the blood are the chief opponents to micro-organisms, and
that the conflict is in the main between these bodies.
Concerning the avenues by which microbes enter the body through the
skin, Wasmuth's 1 experiments upon the lower animals and man with
pure cultures of staphylococcus and with the cocci of erysipelas and car-
buncle indicate that the bacilli tend to enter between the root-sheath and
the hair-shaft, rather than through the unobstructed openings of the
sweat or sebaceous ducts.
Kriloff's 2 experiments with tartar emetic ointment in the form of in-
1 Abstract in Jour. Amer. Med. Assoc., April 22, 1893.
2 Universal Annual of the Med. Sci., edited by Sajous, 1889.
140 GENERAL PATHOLOGY.
unction upon animals point out that pustulation is induced only in those
cases where the ointment is not sterilized, the microscope showing the
staphylococcus pyogenes, which this observer and others regard as the
principal cause of all suppuration. The weight of authority in experi-
mentation with microbically pure mechanical and chemical substances is
in favor of the view that they are not able to produce suppuration.
That pus microbes are the only essential cause of suppuration seems
to be proved by abundant clinical and experimental evidence. The well-
known experiments of Bockhart may be referred to. This observer
inoculated in the skin of his forefinger a mixed cultivation of staphylo-
coccus aureus and albus, which was followed in forty-eight hours by a
small abscess, the pus of which on being opened contained streptococcus
pyogenes aureus. The same author inoculated into the skin a mixture
of staphylococcus pyogenes aureus and albus, which was followed in
fourteen hours at the site of inoculation by twenty-five pustules which
contained the cocci injected.
Finally, mention must be made of the influence of the nerve centres
and nerve trunks and branches in the production of inflammation. The
neurotic inflammatory dermatoses constitute an extensive and important
group, the cutaneous manifestations being due either to functional and
organic disturbances of the central or ganglionic nervous system or to
direct irritation of the nerves supplying the part. This irritation may be
in the form of some palpable injury or may be due to micro-organisms
or other causes.
The subject of the antagonism of micro-organisms is one of in-
terest, especially as it pertains to therapeutics. Thus, observation has
shown that the streptococcus erysipelatis is antagonistic to the bacillus
of anthrax, as demonstrated by the experiments of Watson Cheyne on
rabbits. Neumann and Schwimmer have both noted that the presence
of erysipelas had a marked effect in modifying syphilitic cutaneous
lesions. Babtchinsky's l series of cases of inoculation go to show that
an antagonism exists between erysipelas and diphtheria.
The line separating some of the inflammatory diseases, whether affect-
ing the skin or other organs, and the so-called new growths, or neoplas-
mata, is often indefinite, so much so that certain dermatoses might with
almost equal propriety be arranged in either class, as, for example,
lupus erythematosus and lupus vulgaris. The occurrence of distinct
diseases combining or of one disease supplanting another must be kept
in mind, as happens occasionally with such diseases as lupus and cancer.
Inflammations and hypertrophies are found merging into each other in
some cases, so that not infrequently it becomes difficult to distinguish
between these processes. The varied modifications of a recognized
definite process which may possibly occur should always be borne in
mind. Diseases are not in all cases the entities we have been so long
1 Abst. in Lond. Med. liecord, March 20, 1890.
METASTASIS AND EXCRETION. 141
accustomed to consider them. Frequently they are composed of several
processes, and they may be otherwise complicated.
METASTASIS AND EXCRETION.
The subject of metastasis, or the shifting of the disease-process from
one locality to another, is not difficult to comprehend in the light of
modern pathology. It occurs at times in a striking manner in the
eruptive fevers, and also in other diseases, especially in those of microbic
origin. This question has not received the attention at the hands of
pathologists which it deserves. Perhaps the most generally recognized
manifestation of metastasis occurs in gout, and the correlation between
gout and eczema is generally admitted. A typical eczema may show
itself during an acute attack of general gout, the disease of the skin
being relieved by colchicum, while a general gouty attack may be
relieved by the outbreak of an acute eczema.
These questions, including the subject of excretion, viewed from the
stand-point of cutaneous medicine, have been discussed by Walsh, 1 who,
justly in the author's opinion, directs attention to the importance of
inflammatory irritation of the skin due to excretion. Thus, dermatitis
may be set up in a certain number of cases by the excretion of various
irritant products from the system, which may be chemical or microbic in
nature. Some inflammations may be looked upon as simply expressions
of excretory irritation. The severity of the inflammation and its results
are generally in proportion to the specific action of the irritant on excre-
tory epithelium. Parallels may be drawn between drugs and the poisons
of specific diseases, -both as regards their harmfulness to epithelium and
their channels of elimination. Excretion through the skin not only
affords a key to a certain number of inflammatory dermatoses, but also
accounts for the success of many well-established methods of treatment
which aim at changing the channels of elimination.
CUTANEOUS AND MUCOUS DISEASES.
The relation of cutaneous to mucous diseases, and vice versa, has not
received the consideration it deserves. The subject of " internal cuta-
neous diseases," paradoxical as the term may seem, is of much interest.
It refers to the manifestation upon the mucous membrane of lesions in
nature and in character similar to or identical with those which occur
on the skin. The two coverings of the body, the skin and the " slime-
skin" (Schleimhaut of the Germans) or mucous membrane, have a similar
development and are naturally closely correlated. They are subject to
the same processes, and manifest similar or like changes, modified by
their respective structures. In many instances it is merely the difference
in the structure of the skin and of the mucous membrane that gives rise
to different lesions ; thus, in syphilis upon the skin there is formed a flat
papule, and upon the mucous membrane a so-called mucous papule or
1 Med. Press and Circular, 1890; also Brit. Med. Jour., August 26, 1893.
142 GENERAL PATHOLOGY.
patch. These are the same general expressions of the disease, differing
only in their seat, and modified by the anatomy of the membrane. The
subject of certain cutaneous diseases, especially those of an inflammatory
nature, such as eczema, herpes, psoriasis, pemphigus, and the like, attack-
ing the mucous membrane of the respiratory or alimentary tracts, is in
every way worthy of attention and investigation. That certain processes
may sometimes simultaneously or alternately invade skin and mucous
membrane is an observation that must be admitted. In the case of
pemphigus this occurrence is not uncommon. The pathological correla-
tion of these membranes in such cases admits of no question. When the
disease on the mucous membrane is present, frequently it does not occur
as a defined or obvious lesion or visibly. In the vast majority of cases
of so-called skin diseases, on the other hand, disease of the mucous
membrane is altogether absent, the process being confined strictly to the
cutaneous membrane. From the stand-point of therapeusis, especially
in the consideration of internal versus external treatment, the question
should, in appropriate cases, as, for example, in pemphigus, receive due
attention. 1
HEMORRHAGE.
Cutaneous hemorrhage consists in the extravasation of blood from the
vessels into the surrounding tissues, the result either of the filtration
of the fluid through the walls of the vessels without rupture, known
as DIAPEDESIS, or of rupture of the capillaries, termed RHEXIS. In
hemorrhage from rhexis the determination of blood usually occurs in a
circumscribed area and is pronounced, giving rise to varied lesions,
especially ecchymoses and hsematomata. It is generally the result of
local traumatism. In some cases it is difficult to determine whether the
hemorrhage has occurred by the former or by the latter process. When
it takes place through rhexis, the blood escapes suddenly and rapidly
through the wound in the vessels ; in diapedesis the corpuscular ele-
ments filter through (but not necessarily slowly) the walls of the vessels
together with the serum, the red corpuscles being numerous, in which
particular hemorrhage differs from the inflammatory process.
CLINICAL FORMS.
Hemorrhagic lesions consist of variously sized, diffused or more or
less circumscribed aggregations of blood, or material containing blood,
often commingled with varied pathological products, having their seat
in the corium or the subcutaneous tissue. They possess certain features
by which they may be recognized.
They generally make their appearance suddenly. Having once as-
sumed a definite size and form, they usually retain it until, by the gradual
process of absorption, they fade and finally disappear. They are reddish
1 See a suggestive article by J. Clifford Allbutt, in Arch, of Derm., Oct., 1876, p. 1.
CAUSES OF HEMORRHAGE. 143
in color, varying in shade from bright to dark, according to their nature,
location, extent, and the length of time they have existed. About the
period of their decline they commonly exhibit more or less pronounced
yellowish, bluish, and greenish hues, this coloration being typical in con-
tusion. The variations are due to the changes which the coloring matter
of the blood undergoes. The products of cutaneous hemorrhage are
peculiar in that they do not disappear under pressure. They are usually
upon a level with the surrounding skin, though occasionally they become
elevated in the form of papules, tubercles, or tumors ; this, however,
rarely takes place except in extensive extravasations or in those cases in
which the hemorrhage accompanies other lesions as a secondary symp-
tom, as in hemorrhagic variola. The seat of the process may be in the
papillary layer or in the body of the corium, as in purpura simplex
or in the deeper parts of the integument. It may also occur about
the glands, especially the sweat-glands, and around or in the follicles.
Cutaneous hemorrhage is at times painful, but more often a sense of
soreness or swelling is complained of, and in rare cases more or less itch-
ing or burning. Frequently there are no subjective symptoms. The
lesions, as a rule, disappear slowly by absorption, leaving a variable
amount of discoloration of the skin, which sooner or later passes off.
Hemorrhage through diapedesis occurs as a result of venous engorge-
ment, stasis, or inflammation. In purpura the hemorrhage is mainly
confined to the capillaries and arterioles, and is due chiefly or entirely to
diapedesis. Clinically, as well as pathologically, hemorrhage is found to
complicate various pathological processes, especially inflammation. Its
occurrence in these cases is generally associated with a debilitated or a
depraved state of the tissues or of the blood, as, for example, in scurvy
and in purpura from drugs. Micro-organisms are also at times present,
clogging up the capillaries and causing thrombosis. Various diseased
states of the economy may be accompanied by hemorrhage, as, for
example, poison wounds, scarlatina, morbilli, cerebro-spinal fever, typhus
fever, septicaemia, endocarditis, and other infective and toxsemic processes.
The lesions in the skin are petechial spots or ecchymoses, due to changes
in the blood or in the walls of the vessels, and sometimes, as already
stated, to accumulations of bacteria in the arterioles.
CAUSES OF HEMORRHAGE.
The causes which give rise to hemorrhage are varied. In the first
place, general venous congestion must be regarded as a factor disposing
both to rupture and to diapedesis, as noted in aifections characterized by
paroxysms, as whooping-cough, in which hemorrhagic lesions are liable
to occur. Changes in the walls of the vessels, such as thinning, fatty
and other forms of degeneration, and also thickening (from endarteritis),
are all liable to cause breaking down of the vessels and rupture or
diapedesis. The various forms of purpura are for the most part neurotic
144 GENERAL PATHOLOGY.
or infective processes, the blood filtering through the vessels, the result
of a local or general weakness or stasis. Many infective forms of pur-
pura may be explained on the theory of coagulation thrombi produced by
bacteria. The neurotic hemorrhages are due to perverted or faulty
innervation, and are met with in many diseases. AiFections of the
nervous centres, and certain emotional states of the nervous system, as
exemplified in hsematidrosis, stigmata, and the like, are often accompa-
nied by varied hemorrhagic lesions, particularly petechise. Hemophilia,
in which the general vascular system is involved, is a hemorrhagic
diathesis, and is hereditary. It is characterized by a lack of coagulating
power in the blood and a deficiency in the retractile and contracting
power of the arterioles.
HYPERTROPHY.
DEFINITION AND SYMPTOMS.
Hypertrophy may be succinctly defined as an increase in the amount
of a tissue which already exists. It is characterized by an increase in
bulk and size of the structures invaded. It may take place either by an
increased growth of the already existing elements or by the formation
of new elements of the tissue : thus, a cutaneous capillary may become
enlarged or a series of new capillaries may form. The term is employed
in a broad sense, and takes in the changes which occur not only in the
connective tissue composing the bulk of the skin, but also in the epider-
mis. The appendages of the skin may also be often involved in the
process, either alone or in connection with invasion of the neighboring
structures, as the general epithelial surface or the connective tissue.
Hypertrophy may be LOCALIZED or GENERALIZED, an example of the
former occurring in \vart, and of the latter in ichthyosis. The localized
forms are not usually sharply defined in outline, but rather incline to
spread out, as in callosities and in some of the other keratodermata.
CLINICAL FORMS.
The process may take place as a simple hyperplasia without inflamma-
tion, whether in the epidermis or in the corium. Typical hypertrophy
of the epidermis occurs in callosity. In ichthyosis, corn, horn, and wart
it involves both the epidermis and the papillary layer of the corium.
Hypertrophy of the connective tissue is very common, giving rise to
numerous changes, some being slight or ill defined, while others are ex-
tensive and striking. The latter form is best illustrated by elephanti-
asis and allied elephantiasic affections due to varied causes. As an ex-
ample of simple hyperplasia of the corium and subcutaneous tissue,
without inflammation, acromegalia may be cited. Hypertrophy is in
many instances intimately associated with the inflammatory process, com-
mon examples of which are found in chronic eczema, especially of the
legs, and in elephantiasis. It is also closely connected with cedematous
ATROPHY. 145
processes, many forms of hyperplasia taking their origin in oedema, usu-
ally in inflammatory oedema. Hypertrophy and atrophy sometimes occur
together, further reference to which occurs in the consideration of atrophy.
CAUSES OF HYPERTROPHY.
The causes are found in increased functional activity, pressure, friction,
oedema, and inflammation. Modified forms of the two latter processes,
giving rise to disturbed nutrition, faulty innervation, and obstruction, es-
pecially venous, are frequently the causes of increased growth. The skin,
being an exposed membrane, is subject to the most varied external irri-
tating agencies, many of which act not only upon the epidermis but also
secondarily upon the corium. Certain occupations are directly account-
able for some forms of hypertrophy of the integument. Thus, local
thickenings of the epidermis and even of the entire integument are of
common occurrence in connection with mechanics who use tools, porters,
and others who are compelled to subject certain localities to constant or
interrupted pressure. Friction and pressure are also accountable for the
common corn upon the foot.
HYPERTROPHY OF PIGMENT.
Under the head of hypertrophies in general, the subject of the exces-
sive development of pigment may be referred to. In considering inflam-
mation it was stated that the pigment is derived through complicated
processes from the blood, from which source it is deposited in different
forms in various parts of the body, physiologically and pathologically.
As concerns the skin, abnormal pigmentation has its seat not only in the
mucous layer of the epidermis, but also in the corium. The milder and
commoner expressions of abnormal deposits are encountered on the face
and body in pregnancy (chloasma uterinum), in freckle, and in pigmen-
tary moles and warts ; also in chloasma in general, in Addison's dis-
ease, and the like. The most pronounced forms occur in the malignant,
blackish, bluish, so-called melanotic growths, especially in mel*no-sar-
coma. The pigmentation which occurs as a result of extravasations of
blood into the integument undergoes chemical decomposition accompanied
with variations in color. The haemoglobin is set free from the corpuscles
in solution, but soon takes on a granular or crystalline form, the former
being yellow, orange, brown, or black in color. The darker-colored
granular products are somewhat vaguely designated as MELANIN.
ATROPHY.
DEFINITION AND SYMPTOMS.
The process of atrophy is the opposite of that of hypertrophy. It is
characterized by a decrease in the size or in the number of the histologi-
cal elements which make up the structure. It consists in want of balance
between the nutritive supply and the part to be nourished. Cutaneous
atrophy may appear as a simple, reduced, wasted, thinned, shrunken, pale
10
146 GENERAL PATHOLOGY.
or whitish, dry, smooth or scaly condition of the skin, as is seen in
maculae et striae atrophicae and atrophia cutis propria. It may also take
on peculiar degenerative changes, as occurs in morphoea. It may be
GENERAL, affecting more or less the whole surface, as in senile atrophy,
or PARTIAL, involving circumscribed areas, as in atrophic macules and
streaks, and alopecia areata.
SENILE ATROPHY may be taken as the type of general atrophy of
the cutaneous structures. The skin becomes thinner, owing to the alter-
ation in the papillary layer, the papillae shrinking and flattening. The
vessels become obliterated here and there, and the connective tissue
bundles take on a form of hyaline degeneration. The elastic tissue also
undergoes regressive changes. The epidermis in consequence wastes, the
corneous layer becoming dry, brittle, and scaly. L. Heitzmann's l studies
upon pathological atrophy of the skin in general lead to the conclusion
that the process commonly designated as wasting or atrophy cannot be
explained on the ground of there occurring a direct decrease in size of
the bundles of connective tissue. The observations point rather to a
rejuvenation of the tissues of the corium, occurring through a return to
the embryonic stage of indifferent elements, this taking place, of course,
after a melting-down and fusion of the collagenous substance.
But other and complex changes occur in the skin, a common form
consisting of varied degenerations, often fibrous or fatty, with vascular
involvement. Such changes, as well as certain other forms of atrophy
of the skin, are generally the result of disturbed nerve influence, either
central or in connection with the nerves innervating the region or locali-
ties affected. The appendages of the skin, either in connection with the
corium and subcutaneous tissue or alone, are often affected. The hair in
particular, as in alopecia and in other diseases, is prone to suffer; so also
are the nails. Both the hair and the nails frequently serve as infallible
indexes of disturbed or diminished general as well as local nutrition.
CAUSES OF ATROPHY.
The common causes of atrophy of the skin are diminished blood-
supply, injury to nerves, and impairment of nerve function. As a result
of one or another of these conditions follows naturally disordered nutri-
tion, the immediate cause of the atrophy. As examples of disease due
to faulty nerve-supply and consequently impaired nutrition, morphoea
and hemiatrophy of the face may be cited. Neuritis, especially the
multiple variety, characterized by pain, burning, tingling, pricking sen-
sations, numbness, erythema and other forms of neuritic hyperaemia and
dermatitis, is a common cause of atrophy. Another cause is pressure,
especially when prolonged. Thus, in tinea favosa the fungus grows so
luxuriantly and in such quantity that the pressure downwards on the skin
produced by the growth gives rise to a chronic inflammation and simul-
1 Die Atrophien der Lederhaut, Archiv fur Derm. u. Syph., Bd. xxii. (1890) S 660.
TROPHIC DISEASES. 147
taneous atrophy of the connective tissue of the corium. Certain forms
of suppurative diseases are attended with atrophy, particularly in con-
nection with the hair-follicles and with the glands ; as striking examples,
some forms of folliculitis of the scalp and face, and acne, may be cited.
While hypertrophy and atrophy express diametrically opposite con-
ditions, it is nevertheless true that in certain pathological processes they
occur simultaneously in the same subject, and moreover side by side.
Such pathological processes occur in vitiligo, scleroderma, and morphrea,
and in certain rare affections of the hair. Hence in some diseases it is
difficult, if not impossible, to state whether the process should be regarded
as a hypertrophy or as an atrophy. The proper solution of such ques-
tions is reached by keeping in mind the predominant process, with refer-
ence especially, in the author's opinion, to its ultimate course and termi-
nation. Thus, for example, inasmuch as morphoea tends distinctly to
atrophy, it is proper to regard it as an atrophic rather than as a hyper-
trophic disease. In like manner scleroderma should be grouped with
the atrophic diseases ; for, while it often begins with oedema and increase
in the connective-tissue elements of the integument, the course is towards
condensation and ultimate atrophy. It is proper to state that the corium
is not so prone to take on atrophic as hypertrophic action.
TROPHIC DISEASES.
The so-called trophic diseases of the skin are those which are con-
sidered to be under the influence of nerves governing the normal
metabolism of the tissues, ^he existence of a distinct set of nerves
governing nutrition has not been proved, and it is likely, as Cohnheim l
has stated, that every motor and sensory nerve is at the same time a
trophic one so far as it plays a part in the metabolism and therefore in
the nutrition of the various tissues and organs of the body. Function
and nutrition are probably but different states of the same process. Both
regulate the general metabolism of the body, and both are governed by
the nervous system, which influence plays a particularly conspicuous
part in the production of atrophic diseases of all kinds. Disturbances
of nutrition, or trophic disorders, affecting the cutaneous system are
manifested in their simplest form by such conditions as thin, dry, or
fissured skin, defective nail- or hair-growth, and the like, while the more
advanced stages of faulty innervation are productive of positive atrophies
and hypertrophies of various kinds of the skin and of its component
parts, and of varied forms of neuritic inflammation. Defective nutrition
of the skin plays an important part in dermatology, the visible signs of
which are both numerous and diverse in character.
The vaso-motor disturbances of the skin, following H. Kriege 2 in
the study of the general subject of the " traumatic neuroses," may be
1 General Pathology, vol. ii., New Sydenham Society's translation. London, 1889.
2 Arch, fur Psych. /Bd. xxii., 1890.
148 GENERAL PATHOLOGY.
arranged in three groups, the first including abnormal flushing and
ERYTHEMATOUS conditions ; the second, CEDEM ATOUS and urticaria-like
manifestations, transient, and without the peculiar subjective symptoms
attending true urticaria; and the third, LOCALIZED CYANOSES, which
may attain to such a degree as to be worthy of the name of local
asphyxia (Raynaud's disease), the condition probably being due to vaso-
motor spasm.
NEOPLASMATA.
DEFINITION AND GENERAL CHARACTER.
NEOPLASMS, known also as NEW GROWTHS and NEW FORMATIONS,
consist of a development of tissue which is new or foreign to the struc-
ture in which it occurs. They constitute a large and important class of
diseases. The process producing them differs from that of simple inflam-
mation in several particulars. The ordinary clinical signs of inflamma-
tion are generally wanting in most of the diseases which belong to this
class. The inflammations tend primarily to break down the tissue in
which they occur, whereas the new growths are constructive, building
up new formations, as shown by single or multiple swellings, infiltrated
areas, tubercles, and tumors. They incline to form permanent structures,
in contradistinction to the more transitory formations of simple inflam-
mation. In the neoplasmata the cells thrown out are for the most part
peculiar as to their arrangement, their grouping, the region of the tissue
they attack, and their form, while in the inflammations they are wander-
ing leucocytes, possessing no special peculiarities.
CONNECTIVE-TISSUE AND EPITHELIAL FORMATIONS.
The two great divisions into which most of the new growths fall are
those characterized by CONNECTIVE-TISSUE FORMATIONS and those in
which EPITHELIAL PROLIFERATION prevails. To these groups may be
added a third, the GRANULOMATA. In the first group there exists an
abnormal growth of the connective-tissue elements, as, for example, in
fibroma, with marked development of this tissue in the form of bundles
of fibres. In another variety, xanthoma, a fatty degeneration of the
connective tissue occurs ; in myoma new muscular tissue springs up ;
while in angioma the vessels develop new tissue. New growths of the
epidermis may be typical in their expression, as in the case of cutaneous
horns and warts, with a tendency to proliferate outwards ; or they may
be atypical, with disposition to grow inwards and downwards into the
corium. The former are for the most part innocent, but the latter tend
to malignancy and to destroy the tissues which they invade. In addi-
tion to these forms the glands of the skin not infrequently take on a
simple new growth, constituting the so-called adenomata, of which group
sebaceous adenoma is the most striking illustration. The atypical
epithelial growths comprise the so-called cancers, of which there are two
TUMORS. 149
principal kinds, depending on the variety of epithelium. The squamous
epithelium, as seen iu the epidermis, gives rise to the so-called " epithelial
cancers," or epitheliomata, while the spheroidal epithelium and columnar
epithelium produce the "gland-cancers." It is probable that the clin-
ical form of cancer known as rodent ulcer has its starting-point in the
sebaceous glands. The epithelial new growths have a tendency to begin
about follicular and glandular orifices and at the junction of cutaneous
and mucous surfaces.
GRAN ULOM ATA.
The group of diseases known as the GRANULOMATA or the INFECTIOUS
GRANULOMATA, comprising such diseases as tuberculosis, lupus vulgaris,
syphilis, leprosy, glanders, granuloma fungoides, and malignant pustule,
occupy a position in pathology between the inflammations and the new
growths proper. They are made up of a structure resembling granula-
tion tissue. Some of these diseases pursue an acute course, as malignant
pustule, others, as leprosy, an exceedingly chronic course. They consist
of small cellular elements in an embryonic stage of development, and
have their seat at first mainly in the corium. They undergo involution
by breaking up, becoming cheesy, suppurating, ulcerating, or undergoing
absorption with atrophy and cicatrix. Some of the graiiuloinata are
notable for their resistance to necrobiosis.
CAUSES OF NEOPLASM ATA.
The causes which give rise to new growths are often obscure, but such
factors as mechanical injury, irritation, and friction are well known to be
able to start up some of these processes, as in the case of epithelial cancer
of the lip. In other cases the presence of a bacillus must be regarded
as the cause, as, for example, in such diseases as lupus and leprosy. New
growths are sometimes innocent in their behavior, as in the case of the
fibromata and other connective-tissue formations, but often they tend to
be malignant, characterized by recurring after removal, by destroying
the tissues, by setting up a cachexia, and by ending fatally in exhausting
the system. The two most malignant diseases are cancer and sarcoma,
the first due to excessive and aberrant epithelial proliferation into tissue
other than its own, the second to the development of immature cells,
probably connective-tissue cells, into normal connective tissue.
TUMORS.
A TUMOR may be defined as a mass of new growth character-
ized by enlargement of the purt affected and tending to increase in
growth and to persist. It is usually a neoplasm. It is composed in
almost all instances of some of the natural tissues of the body, which
are either in an embryonic or a developed state. The classification of
tumors resting upon an anatomical basis thus becomes simple, the fibro-
mata (consisting wholly or partly of white fibrous tissue), the lipomata
150 GENERAL PATHOLOGY.
(of fatty tissue), the angiomata (of blood-vessels), the myomata (of mus-
cular tissue), and the sarcomata (having their type in embryonic connec-
tive tissue) serving as common examples of the manner in which such
new formations are designated. In addition to those cited, one of much
importance, carcinoma (finding its origin in epithelium), may be men-
tioned. The anatomical or physiological peculiarity of the tissue from
which a tumor arises is usually plainly marked in the new growth.
Sometimes the elements of the neoplasm are like those of the tissue in
which it occurs, in other cases they differ. The former are known as
HOMOPLASTIC and the latter as HETEROPLASTIC.
The terms " benign" and " malignant" applied so commonly to new
growths possess a meaning which is often relative rather than positive.
While it is often impossible to state where the first-named ends and the
second begins, the common signs of malignancy apply to the integu-
ment much in the same manner as to other organs, especially in the case
of the carcinomata and the sarcomata. The value of the microscope in
determining the benign or the malignant nature of a new growth is great,
and it is remarkable to what degree the work of the clinician and that
of the pathologist may be made to aid and to supplement each other.
The observation applies especially to the diagnosis of growths, including
their probable course, before, and not after, operation ; and also the ad-
visability or not of operative interference, the opinion being founded on
the histological composition of the growth.
INVOLUTION OF DISEASES.
The involution of the products of pathological processes is a topic
worthy of study. Facts have been recorded going to show that many
diseases, some of them even so-called malignant diseases, in some cases
undergo unlooked-for involution, different from that usually attributed
to the history of the disease. Jn some cases this is favorable and in
others unfavorable to the welfare of the patient. The spontaneous dis-
appearance of lesions is occasionally noted in such chronic or malignant
affections as xanthoma, morphoea, scleroderma, vascular nsevus, and sar-
coma. Some diseases tend to recover spontaneously wholly or in part
and then to recur. A striking instance of this behavior of a new growth
came under my observation in a case of granuloma fungoides, 1 in which
large, firm, protuberant formations appeared and disappeared spontane-
ously without leaving a trace behind them. Sarcoma is also a disease
which in some cases inclines to be distinctly capricious as concerns its
involution. Spontaneous withering or disappearance is known to have
occurred. A case of idiopathic pigmented sarcoma of the skin, of the
alveolar variety, is recorded by Hardaway, 2 which underwent complete
spontaneous involution in fifteen years from the beginning of the
1 Archives of Dermatology, Jan. 1879, and Jan. 1880.
2 Jour, of Cut. and Gen.-Urin. Dis., 1890, p. 21.
VEGETABLE PARASITES. 151
disease, leaving behind merely an atrophic condition of the skin. The
general health was always good, and no treatment had ever been used.
The combining or merging of distinct diseases, forming anomalous or
hybrid pathological conditions, also occurs not infrequently, giving rise
to COMPOSITE DISEASES, examples of which are seen in acne rosacea and
seborrhoeic eczema, and among the neoplasmata in fibroma, angioma,
lyinphangioma, and the like.
PARASITES.
Parasites of the skin are those organisms, animal and vegetable, which
prey upon the cutaneous tissues. They produce a variable degree of
disturbance, chiefly in the form of inflammation. In some cases this is
acute, in others chronic. The subject may be considered appropriately
and conveniently under the head of vegetable and animal parasites.
VEGETABLE PARASITES.'
These consist of minute microscopic plants of a low order, which under
certain favorable conditions attach themselves to the surface of the skin
and the epidermic appendages, as the hair- follicle, hair, and nail, and
there vegetate, producing definite structural changes in these tissues.
Primarily the seat of the growth is in almost all cases in the epithelial
tissues, but secondarily, through irritation, disease of the corium is gen-
erally provoked, and occasionally the latter structure itself is invaded by
the parasite. The fungus has its habitat, however, chiefly in the horny
layer of the epidermis, penetrating between the cells, thus causing their
more or less complete destruction, with exfoliation or desquamation.
Hyperaemia or inflammation variable in degree is set up sooner or later,
occasioning desquamation, or vesiculation, pustulation, and crusting. The
symptoms produced by the several fungi are peculiar, and give rise to
different and well-defined lesions. Even the same fungus, attacking one
or another tissue or structure, produces different pathological forms or
lesions.
The fungi belong mostly to the order of hyphomycetse, or moulds, and
have jointed mycelial filaments, or hyphse, and spores, or conidia. They
are a low order of plants, and draw their sustenance chiefly from the epi-
thelial tissues. On some individuals they are barely able to live, causing
but little disturbance in the skin, while on others they thrive luxuriantly,
growing rapidly and giving rise to much disturbance. A certain state
of the epidermis, or soil, the exact nature of which is obscure, is required
for their development, without which favorable condition they fail to
take root and to grow, or at least to thrive. Thus it happens that such
diseases prove contagious for some individuals and not so for others.
Concerning the soil, H. Leslie Roberts, 1 of Liverpool, from his
studies deduces the fundamental principle that "every individual
1 Introduction to the Study of the Mould-Fungi Parasitic on Man. Liverpool, 1893.
152 GENERAL PATHOLOGY."
fungus modifies the soil it thrives in, and every soil may impress some
variation on the fungus it nourishes." Some of the fungi are non-
pathogenetic rather than pathogenetic, as, for example, the aspergilli.
VARIETIES OF FUNGI.
The three common varieties of fungus, occurring widespread in the
world, which invade chiefly the epidermic structures, each producing
disease having distinctive features clinically and pathologically, are the
achorion Schonleinii, causing tinea favosa ; the trichophyton, giving rise
to three common affections, namely, tinea circinata, tinea tonsurans, and
tinea sycosis ; and the microsporon furfur, which produces tinea versi-
color. There is no doubt that there are differences in the form of the
trichophyton fungus, giving rise to distinct varieties, as was first pointed
out by Furthmann and Neebe, 1 who described four. Later, Sabouraud 2
distinguished two, namely, trichophyton microsporon and trichophyton
macrosporon, and expressed the opinion that they belonged to the genus
botrytis. The observations of Rosenbach 3 partly corrojborate the earlier
studies of Furthmann and Neebe 4 and of Sabouraud. 5 Rosenbach is
further of opinion that the superficial and deep-seated cryptogamic affec-
tions of the skin may be produced by a number of different fungi. He
takes exception to the classification of Sabouraud into small and large
spores, and believes that the parasitic form of the fungus is not the
normal form of the growth.
The aspergillus is also met with on man, chiefly in connection with
inflammatory diseases of the ear, but it may occur upon the general
surface, in most cases saprophytically rather than pathogenetically.
Other and different fungi are productive of disease, as actinomyces, or
ray-fungus, causing actinomycosis, also the parasite found in mycetoma,
or fungus-foot of India, the precise nature of which is not fully deter-
mined. Finally, the bacteria causing certain diseases involving the skin,
as erysipelas and variola, may be alluded to, but they constitute another
and a different group of diseases, to be referred to hereafter.
MICRO-ORGANISMS.
The subject of micro-organisms as causes of cutaneous disease is one
which, on account of the difficulties attending its consideration and its
magnitude, must be briefly discussed. The presence of bacilli, cocci, and
the like in connection with many of the diseases of the skin has been
conclusively proved. By the term " diseases of the skin" are meant the
manifestations or evidences of all pathological processes which in any
way, directly or indirectly, affect the skin, either primarily or secondarily.
1 Monatsh. fur prak. Derm., vol. xiii., 1891, p. 477.
2 Annales de Derm, et de Syph., Nov. 1892, p. 1061. See also his work " Les
Trichophyties Humaines. " Paris, 1894.
3 Ueber die tieferen eiternden Schimmelerkrankungen der Haut. Wiesbaden, 1894.
4 Monatsh. fiir prak. Derm., vol. xiii. p. 477.
R Annales de Derm, et de Syph., Nov. 1892, p. 1061.
MICRO-ORGANISMS. 153
In the list are to be included some of the acute and chronic infectious
diseases as well as other diseases which heretofore have been excluded
by most authors from works on dermatology. 1 The question whether
these micro-organisms are causes of the disease or not in all instances
cannot be discussed. In some cases they undoubtedly are the causes, and
these concern this work particularly. Upon the epidermis numerous
micro-organisms have been found, most of which, however, seem to be
harmless. Some, as the trichophyton in ringworm, have long been
known to be productive of disease, while others as factors of disease
occupy positions as yet undetermined. 2 Striking examples of cutaneous
diseases caused by micro-organisms are found in erysipelas, and in suppu-
rative inflammations of the skin, as impetigo contagiosa, ecthyma, sycosis,
furuncle, and carbuncle. Micro-organisms, as Ogstoii first showed, are
always present in acute suppurative processes, but whether they are the
sole cause of the disease is a matter sometimes difficult to determine, for
in some cutaneous diseases they seem rather to complicate the original
process. The degree of the invasion of the cocci, whether superficial or
deep-seated, also plays a part in the production of so-called diseases.
The access of the organisms is usually through a breach in the conti-
nuity of the epidermis or through the root-sheaths, follicles, and glands.
Through these avenues doubtless a number of cocci and bacilli of various
species enter the blood- and lymph-vessels, as well as the structures of
the skin itself and of its appendages. It will thus be noted that the
etiology of cutaneous disease in connection with micro-organisms covers
a broad field. Of late years the subject has assumed great impor-
tance.
To enumerate the micro-organisms in the form of cocci and bacteria
productive of or influencing cutaneous diseases is a task which at the
present epoch cannot be satisfactorily performed. The streptococcus
pyogeues, first distinguished in pus by Ogston, and first cultivated by
Rosenbach, is the organism generally seen in pyaBmic affections. The
staphylococcus pyogenes aureus is the microbe most constantly encoun-
tered in various pustular affections of the skin, in boils, carbuncles,
whitlows, and cutaneous abscesses. Garre's well-known experiments
showed that he was able to produce by inoculation of a staphylococcus
cultivation into the root of the nail of the finger a subcutaneous suppu-
ration, and that with a cultivation of this product carbuncles and boils
were produced by rubbing the matter into the skin of the arm. Of the
pathogenic bacilli which attack the skin, those of anthrax, tuberculosis,
lepra, glanders, and rhinoscleroma may be specially mentioned.
1 See an article on " The Scope of Dermatology" by the author, being the chairman's
address before the Section of Dermatology of the American Medical Association, in
which this idea is more fully elaborated. Jour. Amer. Med. Assoc., 1894.
2 The subject has been studied by Unna and others. See Honatsh. fur prak. Derm.,
1890, p. 185.
154 GENERAL PATHOLOGY.
ANIMAL PARASITES.
The animal parasites all occasion more or less irritation to the skin,
chiefly in the form of acute inflammation, produced by burrowing into
the cutaneous and other tissues, or by biting, stinging, or sucking
blood. The lesions, therefore, are extremely varied. The most promi-
nent among these parasites that burrow is the itch-mite, or sarcoptes
scabiei. It is a true parasite. It can live only on an animal body.
It burrows into the epidermis on a line just above the mucous layer,
and there deposits its ova. Irritation is set up, followed by a variable
degree of inflammation and by the formation of papules, vesicles, pus-
tules, and other lesions. When the process has continued for a long
period the secondary changes in the skin are marked and extensive,
resembling in many respects those of chronic vesicular and papular
eczema.
The leptus autumnalis, or harvest-bug, is another mite that burrows
to some extent in the skin. It does not, however, have its habitat in
the skin, and in this respect it differs from the itch-mite. The demodex
folliculorum is a minute worm-like creature which infests the sebaceous
follicles and glands. It does not set up any irritation in man, and there-
fore cannot be regarded as a producer of disease. It occurs more fre-
quently in some skins than in others. Among the burrowing creatures
met with in the skin (as the worm makes its exit from the body) the
filaria medinensis, or Guinea-worm (dracunculus), remains to be referred
to, as well as the pulex penetrans, or sand flea, both of which excite
inflammation in the cutaneous tissues. Another worm parasite, known
as the filaria sanguinis hominis, has been found in the blood, urine, and
lymphatics. It is chiefly encountered in tropical countries, and it would
seem enters the system by means of drinking-water, being found later
in the blood and lymphatics. By obstructing the circulation it sets up
disease of the lymphatics. It is found in some cases of elephantiasis,
and in lymph-scrotum.
Among the ectozoa, three species of lice infest the human skin, known
as pediculus capitis, pediculus corporis or vestimentorum, and pediculus
pubis, frequenting the 'regions implied in their names. They all derive
their sustenance from the skin by drawing blood. The pathological
changes produced consist of irritation and inflammation, characterized
by hemorrhage, excoriations, and pustules. Scratching also plays a part
in the process. The cimex lectularius, or bedbug, the pulex irritans, or
common flea, and the ixodes ricinus, or common tick, also visit the body
to suck blood, setting up hemorrhagic and inflammatory lesions. Certain
flies, as the bluebottle and others, occasionally deposit their ova in the
skin, and especially in ulcers and wounds, the larvae giving rise to local
inflammation, at times phlegmonous in character.
PROTOZOA AND SPOROZOA. 155
PROTOZOA AND SPOROZOA.
The relations that some of the protophyta bear to disease have been
much elucidated by the observations of Pasteur in France and Koch in
Germany, and by their numerous disciples. In like manner the subject
of the protozoa, and especially one division of them, the sporozoa, and
the part they play in the possible or probable causation of disease, has
recently received much attention from investigators, especially since the
publication of the work of L. Pfeiffer, 1 of Jena, in 1891. Protozoa are
protoplasmic bodies with granular contents. Sometimes they are encysted,
in other cases they show sporulation. The capsules become thinner as the
granular contents become separated and the spores are set free through
the process of sporulation. The line separating the lowest species of
the protozoa from the lowest protophyta is not well defined. Of the
class of sporozoa there are two subclasses of special interest to the pathol-
ogist of cutaneous medicine, namely, the gregarines and the coccidia,
both of which in animal life generally are widely distributed. It is well
known that most full-grown rabbits and other animals contain coccidia
in the liver and in other organs. Pfeiffer in 1885 published the results
of studies upon the bacteriology of vaccine lymph, in which paper were
described certain bodies resembling sporozoa and similar to the amoeboid
bodies previously figured in vaccine lymph by Lionel Beale.
The protozoa considered in relation to cancer, sarcoma, and other
morbid growths have recently received much attention. 2 Thus, K. Tou-
ton 3 describes and figures a number of protozoid formations occurring in
a case of generalized sarcoma of the skin due to leukaemia or pseudo-
leukaemia. Pfeiffer 4 in 1888 was the first to publish a description of
the bodies which he regarded as parasitic protozoa in cancer. As early
as 1865 Virchow and others noted the peculiar "molluscuni bodies"
found in epithelial molluscum (rnolluscum contagiosum), which were
compared to gregarinida, Bellinger maintaining later that they were
parasites and comparable to bodies encountered in a similar affection in
birds. Darier, of Paris, in 1889 described similar bodies in keratosis fol-
licularis (Darier's disease) and in Paget's disease of the nipple. Darier
and others regard the disease as a psorospermosis, and the intra-cellular
cells and bright grains as psorosperms. L. Wickham, 5 of Paris, in the
same year also elaborated the subject, concluding from his studies that
1 Protozoen als Krankheitserreger. Jena, 1891. The reader may also consult the
works of Davaine, " Leqons sur les Sporozoaires," Paris, 1884, and R. Leuckart, " The
Parasites of Man," English trans., Edinb., 1886.
2 An excellent review of the work done in this direction may be found in the Medical
Press and Circular, vol. cvii., 1893, by J. Jackson Clarke, of London, to which the
author is indebted.
3 Miinchener Med. Wochenschr., Jan. 10, 1892.
4 See his work " Untorsuchungen iiber den Krebs," Jena, 1893.
5 Contributions a 1 'etude des Psorospermoses cutanees et de certaines formes de Cancer:
Maladie de la Peau dite Maladie de Paget. Paris, 1890.
156 GENERAL PATHOLOGY.
the bodies found were psorosperms. Other observers, however, differ in
their interpretation of these bodies, some regarding them as cell-inclusions
referable to degeneration or other changes, and not as parasitic. It may
be remarked that as far back as 1 847 Virchow observed certain enclosures
within cancer-cells, which he looked upon as being due to degenerative
processes. Sheridan Delepine, 1 of London, who has done good work on
the psorosperms of the rabbit's liver, states that the evidences he has been
able to collect are against the psorospermial nature of the bodies which
he has observed in epithelial tumors and in Paget's disease of the nipple.
D'Arcy Power 2 expresses the opinion that the majority of the appear-
ances described by Wickham in cases of " psorospermosis" are due to
alterations in epithelial cells, or at any rate that similar appearances may
be produced in epithelium by artificial irritation. The whole subject is
still under investigation, but the author holds the view (in the light of
his examinations of many specimens containing these bodies) that these
organisms are probably not parasitic. Neisser 3 is also of opinion that
there is no proof that these bodies are parasites, and regards them as
abnormal and pathological cell formations ; and in the cases reported by
Darier and others as " psorospermosis follicularis" this observer thinks
it questionable whether the disease may not be looked upon as an in-
herited keratosis.
CASES OF DISEASE WITH SPOROZOA AND SPOROZOID ORGANISMS.
In order to convey a more definite idea of the sporozoa and allied
organisms as they are met with in the human skin, reference will be
made to several well-known cases of peculiar or undescribed forms of
disease in which they have been found. The subject has recently been
investigated by Wernicke, and by Rixford and Gilchrist, but in par-
ticular by Gilchrist, who demonstrated bodies of this kind in specimens
before the American Dermatological Association in 1894, and before the
American Medical Association in 1895. Gilchrist' s researches 4 com-
prise four cases where large numbers of protozoa (subclass sporozoa) or
protozoa-like bodies have been found in diseased skin. The first re-
ported was by Wernicke, 5 of Buenos Ayres, and he described it clinically
as a " doubtful case of -mycosis fungoides." He found the protozoa in
large numbers in the pus which exuded from the lesions, and observed as
many as sixty organisms in one field of the microscope. The next case
recorded was by Rixford and Gilchrist, 6 and was regarded clinically as
1 Trans. Path. Soc. of London, vols. xli. (1890), xlii. (1891).
2 Jour, of Pathology and Bacteriology, 1894, p. 254.
8 Abst. in Jour, of Cut. and Gea.-Urin. Dis., Oct. 1892.
4 The author is indebted to Dr. T. C. Gilchrist, of Baltimore, for the abstract of the
microscopical work here given.
5 Ueber einen Protozoonbefund bei Mycosis Fungoides (?). Centralblatt f. Bakt. u.
Parasitenk., Bd. xii., 1892.
6 Preliminary report read before the American Dermatological Association at Wash-
ington, May, 1894. Also read before the Amer. Med. Assoc., May, 1895.
PROTOZOA AND SPOROZOA. 157
typical " tuberculosis of the skin." The protozoa were similar to those
found by Wernicke, and were just as numerous, but the resulting patho-
logical lesions were almost typical of tuberculosis. The skin lesions
remained local for nearly two years, and then the patient died twelve
months afterwards of almost general protozoic infection. The peculiar
bodies were found in enormous numbers in the lungs, testes, epididymes,
spleen, adrenals, surface of the liver, peritoneum, pleura, etc., and the
lesions, as in the skin, presented the typical picture of tuberculosis. No
tubercle bacilli were found. Successful inoculations were made on dogs
and rabbits.
The third case was also reported by Rixford and Gilchrist, 1 and was
similar in many respects to the second, except that the disease ran a far
more acute course, and the patient died within three months. The pro-
tozoa were present in larger numbers in this third example than in the
first two cases, and the sporulation forms were also far more numerous.
In all these three cases the adult protozoa were easily recognized, stained
or unstained, as circular bodies (1 6 /* to 30 n in diameter) which consisted
of a distinct thick capsule, with granular protoplasmic contents, but no
recognizable nucleus, although a vacuole was sometimes made out. They
developed by sporulation, but only in the second and third cases was the
complete cycle followed out.
The fourth case was recorded by Gilchrist, 2 a unique protozoon-like
body having been discovered in a skin lesion occurring on the back of
the hand of a man. The case had been under the observation of the
author (who furnished the specimen to Dr. Gilchrist), and was regarded
by him as a typical chronic " scrofuloderma verrucosa." The histological
appearances were somewhat similar to those of the second case. The
peculiar bodies were much smaller (10 /* to 15/t in diameter) than the
three other varieties, and developed not by sporulation but by budding.
No tubercle bacilli were found. In the last three cases Gilchrist states
that there was no similarity between these peculiar bodies and the coc-
cidia of rabbits or the protozoa in the helix hortensis. W. H. Welsh 3
regards the bodies in this case as blastomycetes, or yeast fungi.
Comparisons \vere made by Gilchrist between the organisms of the
second, third, and fourth cases and the so-called protozoa or parasites of
cancer (twenty cases of which were examined), of molluscum contagi-
osum (four cases), of herpes zoster (twenty cases), and of psorospermosis,
this observer concluding that there are no justifiable grounds for sup-
posing that the bodies found in these various diseases (including cancer)
are parasites, and that they are various forms of degenerated epithelial
cells.
1 Read before the section on Dermatology of the Amer. Med. Assoc., May, 1895.
2 Preliminary report read before the American Dermatological Association at Wash-
ington, May, 1894. Also read before the Amer. Med. Assoc., May, 1895.
3 Written communication Jo the author.
158 GENERAL DIAGNOSIS.
In some cases the peculiar bodies which so closely resemble protozoa
are blastomycetes, or yeast fungi. Busse 1 found, in a case of chronic
subperiosteal inflammation of the tibia, organisms resembling in form
sporozoa, which he considers to belong to the yeast group. He succeeded
in obtaining a pure culture from animals inoculated with these organ-
isms. After reinoculation with the pure culture similar pathogenic
lesions were produced. Their mode of development was by budding,
and, judging from the drawings in Virchow's Archiv, there is a marked
similarity between these bodies and those found by Gilchrist in the
author's case. Some other bacteriologists, as F. Sanfelice, 2 Maffucci and
Sirleo, 3 Roncali, 4 and Fermi and Aruch, 5 also express the view that
the so called cellular enclosures, sporozoa, fuch sin- bodies, coccidia, etc.,
noted by various observers in tumors are in reality yeast-plants. Fermi
and Aruch believe a species of yeast to be the cause of a disease of
horses in Italy called " farcinoid lymphangitis."
GENEKAL DIAGNOSIS.
GENERAL OBSERVATIONS.
It is unnecessary to devote space to elaborating the statement that the
subject of diagnosis is one of great importance. If satisfactory results
are to be obtained in the treatment of cutaneous diseases, the physician
must know definitely what affection he has before him. Without a full
comprehension of the symptoms and pathology of the disease and of
the course it is likely to pursue, all treatment must be empirical and
attended only with hap-hazard results. With the assistance of a method
for the examination of cases, and of an understanding of the numerous
signs and symptoms encountered, together with a certain amount of
clinical observation, there should remain no great difficulty in the recog-
1 Ueber parasitare Zelleinschlusse und ihre Ziichtung. Centralblatt fur Bakt. u.
Parasitenk., Band xvi., Nos. 4 and 5. Also, Ueber Saccharomycosis hominis, in Vir-
chow's Archiv, Bd. cxl., Heft. I., p. 23, 1895.
2 Ueber eine fur Tiere pathogene Sprosspilzart, etc. Centralb. fur Bakt. u. Para-
sitenk., Bd. xvii., No. 4, 1895.
3 II Policlinico, March 1, 1895, p. 138. Also, Centralb. f. Allgem. Path. u. Path -
Anat., April 30, 1895, Bd. vi., No. 8, and " Neuer Beitrag zur Pathologic eines
Blastomycetes," in Centralb. f. Allg. Path. u. Path.-Anat., June 15, 1895, Bd. vi ,
No. 11.
4 II Policlinico, April 1, 1895.
5 Ueber eine neue pathogene Hefeart, etc. Centralb. fur Bakt u. Parasitenk., May
10, 189"), Bd. xvii., No. 17.
The author is indebted to Prof. W. H. Welsh, of Baltimore, for several of these
references.
HISTORY. 159
nition of these diseases. Unusual varieties of disease and andmalous
cases are not infrequently encountered ; but if the types of the well-
known and accurately described diseases be kept in mind, it will be
found that in most instances the difficulty of classifying cases will be
materially lessened. Not only .should the lesions and symptoms generally
be attentively investigated, but the nature of the pathological process
producing the lesions should be noted. Special and general pathology
should be studied together. One requisite, it may be stated, is indis-
pensable to success in diagnosis, namely, the power of close observation
and scrutiny, without which the student will acquire but a superficial
and unsatisfactory knowledge of the subject.
The following points may be considered :
History. While for the vast majority of the diseases affecting the
skin the trained and experienced dermatologist requires no clinical his-
tory for diagnosis, close observation of the condition of the skin itself
being all-sufficient for this purpose, nevertheless, many instances occur
representing unusual or complex cases in which an account of the begin-
ning and the course of the disease is of great assistance. In such cases
all the information obtainable, and other aid from whatsoever source, are
welcomed. It must be kept in mind, in the study of cutaneous diseases,
that dermatology is a distinctly progressive department of medicine, and
that new diseases are being described and veritable discoveries continually
made by observers. Every source of reliable information, therefore,
should be utilized. The clinical history should, as a rule, be taken before
the inspection of the skin.
Light. To examine a case properly, suitable light should be secured.
Daylight in some cases is important. Artificial light gives to the skin
an unnatural tint, and thus it is easy to fall into an error. A correct
idea of the color and shade of the eruption is an important point, upon
which alone may depend the diagnosis. Various signs of value fre-
quently come to notice under a strong light which might pass unper-
ceived with an uncertain illumination : thus, a faint patch of tinea versi-
color, an early or fading erythematous or a pigmentary syphiloderm,
may readily escape detection with an imperfect light.
Temperature of the Apartment. The patient, whether in bed or
on foot, will of necessity be somewhat exposed to the air during the
examination, and sufficient warmth is needed to preserve the ordinary
temperature of the skin. This is particularly important in the case of
the erythematous manifestations, whether simple or specific. The patient
should, therefore, be examined in a moderately warm room.
Inspection. The patient will generally direct attention to a certain
region or locality, usually to that part of the disease which causes him
the most annoyance. And here, in the first examination, arises an
opportunity for the exercise of tact. The portion offered to view should
160 GENERAL DIAGNOSIS.
be attentively examined, and perhaps at the same time a few questions
asked, with the purpose of gaining the confidence of the patient. The
physician should always endeavor to obtain this as soon as possible.
With women it should be kept in mind that a feeling of diffidence always
exists when called upon to expose to a stranger even a portion of their
person, and that to overcome this their confidence must be obtained. It
may further be asked what other parts of the body are involved, and to
what extent ; and thus by judicious questions it will be ascertained
exactly what regions and localities are affected. If the disease be gen-
eralized, the various parts should be inspected one by one. If the case
be that of a man or a child, it is often advisable to examine the whole or
the greater part of the body. This proceeding is especially important
if the disease manifests a tendency to be disseminated over the general
surface, for, as will be shown presently, much is to be learned from the
distribution of the eruption.
Examination should be thorough. The examination during the first
interview should, if possible, be complete, for it may happen that by the
second visit the lesions will have undergone change and perhaps have lost
in a measure their characteristic features. Cases should always be investi-
gated, as concerns the lesions at least, at the time they first come under
notice. In order to understand a disease, it is essential to be familiar with
all its phases ; hence every change in appearance should be recorded.
The general color of the skin should be noted, in order to determine
its vascularity and vitality. It should be felt, that its temperature,
whether increased or diminished, may be ascertained. In rosacea of the
nose, for example, the skin may have the appearance of being warm or
inflamed, when touch will sometimes reveal a sense of coldness indica-
tive of a state of lowered vitality. Its softness or harshness, suppleness
or firmness or rigidity, should also be noted. Certain diseases may be
diagnosed by the sense of touch alone, as, for instance, ichthyosis and
scleroderma. The peculiar harshness of ichthyosis is characteristic.
Baths influence cutaneous diseases frequently in a striking manner,
especially inflammatory eruptions characterized by scaling and crusting.
The frequency of bathing should be inquired into. It should be noted
whether the body and the skin are fat or lean. It should be observed
particularly whether the hair- follicles and sebaceous gland ducts are
patulous or obstructed, whether the epidermis is normal or dry and
desquamative, and whether the secretion of sweat is scanty, normal, or
profuse.
Constitutional Disturbance. In the majority of the diseases of
the skin little or no constitutional disturbance exists. There are in-
stances, however, where more or less distinct systemic derangement,
as shown by malaise, fever, headache, constipation, and disordered
tongue, is present at some time or other during the course. Symptoms
of this character sometimes prove valuable in aiding to decide between
AGE. 161
affections which resemble one another in external form. The exanthe-
mata, for instance, are always accompanied by elevation of temperature
and by symptoms of general disturbance, and at times in their early
stages it may be these signs alone which permit the diagnosis from other
diseases which they simulate upon the skin. In erythema nodosum
and dermatitis exfoliativa the temperature may be high and the patient
prostrated. Some of the syphilodermata, and other chronic infectious
diseases, as, for example, lepra, are also accompanied by constitutional
disturbance and febrile symptoms.
Age. The age of the patient, whether an infant, a child, an adult, or
an old person, is a point to be taken into consideration. It is known that
certain diseases occur almost exclusively at certain periods of life ; that
some are found only in adult life, and that others are common only to
infants. It is well known, moreover, that infants and young children
are almost exempt from certain diseases ; in questions of diagnosis,
therefore, these may generally be excluded from the list. For example,
psoriasis, one of the most frequent diseases in adult life, is very rarely
found in infants, and, as a rule, we need not look for its occurrence
before the second or fourth year, while usually it does not show itself
until the fifteenth or twentieth year. Epithelioma seldom occurs in
early life ; it is seen now and then at the age of twenty or thirty, but is
not common before forty or fifty.
Sex. The sex of the patient should be taken into account. Males
are more liable to certain affections than females, and vice versa. It is
also to be borne in mind that, owing to peculiarities in the anatomy of
one sex or the other, certain diseases are found in the one which have no
existence in the other, as sycosis, found only in the male. Other diseases
occur chiefly in one sex or the other ; thus, the rare disease impetigo
herpetiformis is met with almost exclusively in females. 1
Temperament. The temperament or natural general organization
of the patient should be noted, and whether the complexion is light
and florid or dark and swarthy. It is well known that certain forms of
disease are prone to come upon those whose natural physical organizations
are of a particular type. Diseases of the sebaceous glands, for example,
especially acne and seborrhoea, are much commoner upon persons of the
florid type. Eczema likewise occurs much oftener, and is generally
more chronic and more obstinate in character, in those of light com-
plexion with flaxen or reddish hair.
Habits. The habits of the patient should be inquired into, and
the ordinary condition of general health ascertained. The state of the
alimentary tract, a region so often the seat of derangement in certain
inflammatory diseases of the skin, especially among those of sedentary
1 See the chapter on " General Etiology." For further information on diseases pecu-
liar to the female sex, the reader may consult an article by the author and M. B. Hart-
zell in Keating and Coe's Cyclopaedia of the Diseases of Women, Phila., 1895.
11
162 GENERAL DIAGNOSIS.
habits, should be searchingly investigated, and not merely the inquiry
made whether the patient suffers from " dyspepsia" or " constipation/'
Questions of this kind are seldom sufficiently definite to elicit the true
condition. The digestive tract should be inquired into attentively. In
some cases it may be assumed that functional derangement probably
exists. In the alimentary canal may often be found the exciting causes
of many of the simpler skin diseases of an erythematous or inflam-
matory type, especially of eczema and of acne. The examination in
this direction should be carefully conducted, no point being slighted or
passed over, for it may be the exciting cause of the disease.
The tongue should always be inspected, and its condition, if whitish,
pinkish, reddish, devoid of normal epithelium, pasty, furred, thickened,
moist, dry, or fissured, noted. This organ, in some of the inflammatory
diseases especially, is worthy of close observation. At the same time,
inquiry into the usual state of the breath may be made, whether heavy
or feverish ; if impure, the cause frequently will be found associated with
digestive or functional nervous disorders. Attention should next be
directed to the stomach ; and here we must question the patient closely,
asking whether he is subject to flatulence, " eructations," " acidity," or
" indigestion," or, using the terms more popular among the working
classes, " heart-burn" and " water-brash." Persons are not infrequently
encountered who will deny all knowledge of dyspepsia or indigestion,
but who will admit suffering from heart-burn. In this connection the
character of the food taken may be inquired into, to ascertain whether
the indigestion is due to certain articles of diet or to other causes, as, for
example, a functionally disturbed nervous system, the result of anxiety,
strain, worriment, and the like. Finally, the state of the bowels must
be investigated, whether normal, temporarily or habitually constipated,
or irregular in action. In many cases, especially in generalized eczema,
pemphigus, psoriasis, furunculosis, and xanthoma, it is of importance to
make an examination of the urine. This procedure should be carried
out in the investigation of any extensive, especially inflammatory, disease.
Occupation. The occupation of the patient sometimes affords a clue
to the cause of the disease. It is well known that various kinds of
work play a part in the production and continuance of certain forms of
disease. An affection perhaps trivial in itself may be aggravated by
exposure to irritating substances. For example, a slight eczema upon a
washerwoman's hand may be much increased by continued exposure to
water and soap, while ultimately a severe eczema rubrum of the arm
may result. Workers in the manufacture of chemicals also suffer at
times from artificially produced diseases : thus, those who work in mer-
cury and arsenic mines are subject to peculiar forms of eruption, while
workers in caustics, acids, iodine, bromine, tar, coal oil and its deriva-
tives, and other substances, may likewise be attacked with simple or
peculiar cutaneous disorders.
GENERAL FEATURES OF THE DISEASE. 163
GENERAL FEATURES OF THE DISEASE.
The disease of the skin itself, including the lesions and their peculi-
arities, may now be considered. The latter should be attentively inves-
tigated, for in most cases they afford the most definite and accurate infor-
mation which it is possible to obtain concerning the nature of the case ;
indeed, they sometimes present the only knowledge which can be relied
upon. One thoroughly familiar with the various cutaneous lesions is in
the majority of cases enabled to comprehend the character of a disease
from simple inspection ; at the same time, the history of the case may
throw much light on the diagnosis, and should always be taken into
consideration with the symptoms.
Acute or Chronic. It is to be noted whether the disease is acute
or chronic in its course ; and, furthermore, the stage in which it exists,
whether upon the increase or upon the decline, is to be observed. In
most cases this can be learned by examining the skin itself and noting
the pathological changes that have occurred. It is also important at
the same time to inquire into the duration of the complaint, and par-
ticularly whether it is a first attack or a relapse ; and, if the latter, into
the behavior of former attacks, and under what general plan of treat-
ment the disease yielded or was aggravated.
Extent of the Disease. The extent of the affection should be ascer-
tained ; whether confined to a certain locality or occurring in various
portions of the body. The regions involved should be noted, for it is
well known that some diseases, as, for example, seborrhrea, acne, and
scabies, have a predilection for certain parts of the body. Other diseases,
as sycosis, are encountered only in definite localities.
Distribution. The distribution of the eruption may often serve as
an aid in diagnosis. The configuration and shape of the patches, and
the grouping and arrangement of the lesions, are to be observed. In
some diseases, as, for instance, in herpes zoster, herpes iris, and the
parasitic diseases, especially scabies, these are peculiar. The tendency
for certain diseases to localize, as, for example, lupus erythematosus upon
the nose and cheeks, is striking. The possible involvement of nerve
trunks and branches, especially in chronic inflammatory and atrophic
affections, should be investigated.
Color. The general color or tint of the disease will almost always
throw considerable light upon the nature of the process, as, for instance,
in many of the syphilitic eruptions, which possess a brownish-red, raw-
ham, or coppery tint, frequently with pigmentation, particularly in the
case of the papular and tubercular formations. Lupus vulgaris is char-
acterized by a similar color, but it usually possesses a more yellowish or
brownish hue, with less pigmentation. The latter point is one often of
service in the differential diagnosis between these diseases. The scrofu-
lodermata, as a rule (as they are met with in the United States), show a
164 GENERAL DIAGNOSIS.
more violaceous tint than lupus vulgaris, and in this respect they re-
semble lupus erythematosus. In xanthoma the color is reddish-yellow
or yellow ; in keloid, pinkish or reddish. In urticaria pigmentosa the
color may be much the same as in xanthoma, but usually it is not so
yellow and is browner. In chloasma it is pale or dark yellow, or
brownish, more or less muddy or mottled. Tinea versicolor is likewise
usually characterized by much the same color as chloasma, but it is more
uniform in distribution, in addition to which the epidermis is the seat
of more or less furfuraceous desquamation. Tinea favosa also shows
a distinctly yellowish coloration of the crusts.
It should be kept in mind that the coloring of the skin may possibly
be due to foreign matter and pigments, as, for example, from the use of
remedies and from chemical changes that have taken place, and also to
drugs taken internally, such as nitrate of silver and arsenic. Variega-
tion is also an aid to diagnosis, some diseases as, for example, erythema
multiforme, herpes iris, and purpura showing, during the evolution of
the lesions, varied colors, shades, and tints.
Individual Lesions. It is to be noted whether the individual lesions
are of one or of several varieties, and whether they are all in the same
or in different stages of development. Their anatomical situation, as
well as their number, is also to be inquired into. It is of the utmost
importance to observe their evolution.
MACULES.
Macules are of very frequent occurrence ; some remain as such through
their entire course, as in chloasma, vitiligo, and tinea versicolor, while
others, beginning as macules, gradually or rapidly pass into other lesions,
as, for example, papules or tubercles, as seen in syphilis, leprosy, granu-
loma fungoides, and sometimes in tinea sycosis. Hypersemic affections,
as the simple erythemata, and discolorations of the skin from various
causes, including pigmentation, all present examples of macules as their
characteristic lesions. Thus, when it is remarked that a disease manifests
itself in a macular form, no intimation is given by this statement as to
its nature, nor is the diagnosis thereby suggested. The knowledge that
it is macular is a vague clue, nothing more. Many diseases diverse in
nature show macular lesions at one period or another in the course of
their evolution.
PAPULES.
Papules are usually multiple, and occur either alone or in connec-
tion with other lesions. Not infrequently they occur alone and remain
papular throughout their evolution, as in lichen planus. In eczema the
lesions may be altogether papular or a mixture of papules and vesicles
in various stages of development, with scales or crusts. In the small
papular syphiloderm, likewise, pustules are often seen intermingled with
the papules. On the other hand, in lichen planus, prurigo, lichen scrof-
VESICLES AND BLEBS. 165
ulosorum, comedo, milium, urticaria pigmentosa, and xanthoma, papules,
possessing for the most part definite form, color, and structure, are ob-
served. Papules are also formed in connection with some of the neo-
plasmata. It will be remembered that papules are of several distinct
varieties, and that some of them are quite unlike not only in form but
in their anatomy. They are, however, less numerous in variety than
macules ; hence if the statement is made that a disease is papular in
type and inflammatory, a probable diagnosis may sometimes be reached
by the process of exclusion.
VESICLES.
Vesicles are common, and occur in a number of diseases. Vesicular
eczema perhaps exhibits the lesion in its most typical state, but it is also
observed perfectly developed in herpes, dermatitis herpetiformis, miliaria,
sndamen, vaccinia, and varicella. Vesico-pustules are seen in the so-called
vesicular syphiloderm, herpes, contagious impetigo, and other affections.
Pustules are met with in diseases too numerous and diverse in nature to
specify. They occur in marked form in variola, pustular eczema, im-
petigo, ecthyma, acne, scabies, the pustular syphilodermata, sycosis,
herpes zoster, dermatitis herpetiformis, and in other diseases. Pustules
and pustular manifestations often occur as complications in various
processes not originally pustular. Cutaneous abscesses and sinuses are
met with especially in connection with diseases of the sebaceous glands.
Vesicles, as has been stated, very frequently pass into pustules, consti-
tuting vesico-pustules.
BLEBS.
Blebs, varying in size from a cherry to a goose-egg, are encountered
chiefly in pemphigus and allied forms of eruption, dermatitis herpeti-
formis, herpes iris, erysipelas, syphilis, and leprosy. They are dependent
largely upon nerve influence for their production. They are also observed
as the result of local irritants, vesicants, scalds, and burns. Wheals are
generally significant of a peculiarly sensitive neurotic state of the skin,
which inclines to their formation usually upon slight provocation. They
are seen most perfectly developed in urticaria resulting from local or
internal irritation ; they also sometimes occur, more or less pronounced
in character, in connection with other diseases, as purpura. They are met
with more frequently in children and young persons than in the middle-
aged and elderly.
TUBERCLES AND TUMORS.
The tubercle is sometimes merely an exaggeration of the papule, but
usually it possesses a life history of its own and is in no way connected
with the papule. Its significance is altogether different from that of the
papule. It occurs frequently in connection with neoplasmata, and its
presence may therefore be indicative of a new growth, benign or malig-
nant in nature. It is seen in tinea sycosis, acne, syphilis, carcinoma,
lepra, rhinoscleroma, sarcoma, neuroma, and in other diseases. Tumors
166 GENERAL DIAGNOSIS.
may be the result of a simple inflammatory process, but oftener they
indicate some new growth, benign or malignant. They may form in
sebaceous cyst, epithelial molluscum, fibrous molluscurn, erythema uodo-
sum, keloid, angioma, lymphangioma, lymphadenoma, neuroma, lipoma,
elephantiasis, syphilis, and in other diseases. In connection with the
subject of tubercles and tumors, the diagnosis of the process producing
them in doubtful cases may generally be cleared up during life by the
microscope. In no other forms of lesions are the results of biopsy, or
section during life, so useful and satisfactory.
SCALES, CRUSTS, AND ULCERS.
Scales differ in size, shape, thickness, color, and in other general
features, as well as in their chemical composition. In some diseases
they are dry, harsh, and brittle, in others soft and greasy. Thus, the
scales of psoriasis in typical cases are characteristic ; so also are those of
seborrho3a of the face, and of tinea versicolor. Scales are exceedingly
common, and are observed in a variety of affections ; psoriasis, sebor-
rhcea, squamous eczema, ichthyosis, erythernatous lupus, and the vegeta-
ble parasitic diseases, all exhibit these products more or less typically.
They form to a greater or less extent in all the inflammatory diseases ;
also in other classes of diseases, as, for example, in some of the hyper-
trophies, as ichthyosis, and in certain atrophies depending on impaired
nutrition. Crusts are found as the product of many diseases. They
constitute striking lesions in eczema, scabies, ecthyma, syphilis, impetigo,
impetigo herpetiformis, dermatitis herpetiformis, herpes, sycosis, leprosy,
carcinoma, and scrofuloderma. Ulcers are met with in many diseases,
and occur as the result chiefly of inflammation, simple, complicated, or
specific. They form in syphilis, lupus vulgaris, carcinoma, leprosy, scro-
fuloderma, herpes zoster, furuncle, carbuncle, etc.
EXCORIATIONS, FISSURES, AND SCARS.
Excoriations are for the most part met with in those affections which
are accompanied by itching and like symptoms ; they are seen chiefly
in eczema, pruritus, pediculosis, and scabies. Fissures form in eczema,
psoriasis, and other inflammatory diseases, and in syphilis and leprosy ;
also in various hypertrophies, as in ichthyosis, wart, and other forms of
epithelial and papillary growth. Cicatrices, slight or extensive, always
follow ulceratiou, the amount of scar tissue depending upon the process
and the accompanying circumstances. They also follow certain new
growths which are unaccompanied by ulceratiou, as lupus erythemato-
sus, and certain atrophic affections, as morphrea.
THE MICROSCOPE AND OTHER AIDS.
Microscopic Examination. The microscope teaches not only the
anatomical part of the integument invaded by the disease, whether epi-
dermis, corium, connective tissue, follicles, ducts, or the appendages of
THE MICROSCOPE AND OTHER AIDS. 167
the skin, but also the nature of the process. Thus, the degree and the
character of the inflammation, whether simple or specific, atrophic, de-
generative, and the like, and the presence or absence of parasites, cocci,
bacteria, and bacilli, are all points that may be determined.
The value of the microscope in the diagnosis of cutaneous diseases can
scarcely be overestimated. The skin is readily accessible to the patholo-
gist, and there is usually no difficulty in obtaining specimens, and in
examining the products of disease in the form of epidermis, scales, and
crusts ; serum, pus, and blood ; and the skin itself taken from the living
subject. This latter operation (termed happily by Besnier BIOPSY),
especially now that cocaine may be employed in the form of hypodermic
injection to render the cut absolutely painless, is a simple one that should
cause no dread on the part of the patient. With care, scarring may
usually be prevented. In doubtful cases of disease the knowledge to be
gained from properly prepared sections is often incalculable, the diag-
nosis frequently becoming clear and certain. This remark is especially
applicable to new growths, about whose nature doubt sometimes exists
prior to microscopic examination. The so-called vegetable parasites, and
other micro-organisms, are made plain to trained eyes under the micro-
scope, and the diagnosis is thus established.
The Magnifying Lens. The aid of a simple magnifying glass,
held in the hand, is in some cases of positive value. The presence
of certain animal parasites and their ova; defects in the epidermis,
hair, and nail ; and various other points, are thereby rendered visible or
plainer. Much escapes the unaided eye that may at a glance be obvious
through a hand-glass.
Touch. The trained hand TACTUS ERUDITUS is of considerable
value in diagnosis. Some diseases may readily be recognized by the
touch. Thus, certain varieties of eczema ; some cases of psoriasis ; acne
and follicular affections ; ichthyosis and other epithelial hypertrophies ;
certain atrophies ; keloid, molluscum fibrosum, and other connective-tissue
growths, such as elephantiasis and the like ; and various other diseases
characterized by papules, tubercles, and tumors, may all be usually recog-
nized by the hand. Certain crusts also present peculiarities of bulk,
consistence, form, shape, outline, distribution, and configuration whereby
their nature may generally be diagnosticated.
Sense of Smell. Some diseases are characterized by peculiar odors,
the cognizance of which may aid in establishing the diagnosis. Thus,
in bromidrosis, in some exanthemata, and in tinea favosa, the odors con-
stitute notable symptoms. In well-developed untreated cases the mousy
smell of the crusts of tinea favosa is usually sufficient to establish the
diagnosis.
Subjective Symptoms. From the character of symptoms of this
kind, their investigation is attended with difficulties. They vary in the
same disease and in different subjects according to circumstances. The
168 GENERAL TREATMENT.
kind of pain or itching, its seat, mode and time of onset, duration, and
other peculiarities, are, however, in some diseases characteristic : thus, the
neuralgic and burning pain preceding and accompanying herpes zoster
is of much diagnostic importance. The pain accompanying many cases
of myoma and neuroma of the skin is a striking symptom. The itching
of scabies and the itching of dermatitis herpetiformis are both peculiar,
and hence are of some value diagnostically. The existence of itching
without structural changes in the skin, as occurs in pruritus due to varied
causes, is of considerable value in diagnosis, this disease being thereby
at once distinguished from eczema, with which it is often confounded.
GENERAL TREATMENT.
GENERAL OBSERVATIONS.
To understand the multitude of manifestations and the diseases affect-
ing the skin requires special study. To treat them successfully calls for
skill in diagnosis and knowledge as to the remedies suitable, not only for
the disease, but also for the particular variety and stage of the disease
present. Upon this latter point I would lay particular stress. This kind
of knowledge can come only from close observation and experience.
In the selection of remedies for the treatment of cutaneous diseases,
especially those of an inflammatory nature, it must be remembered that
the lesions are liable to undergo changes frequently. Sometimes these are
varied, and at times are remarkable. This is particularly true of eczema,
a disease that at one time shows itself as an erythema with an unbroken
epidermis, at another with papular, vesicular, or pustular and interme-
diate lesions, while not infrequently the condition is that of an excoriated,
moist, crusted surface, with varied secondary inflammatory changes, in-
cluding sclerosis of the skin. To relieve or cure such a disease, then, the
different stages and the primary and secondary pathological changes that
have occurred in the skin, as well as the patient, and the probable cause of
the manifestation, must all be taken into consideration. For these reasons
it is impossible to formulate rules for the employment of this or that remedy
or formula. It is necessary to treat not only the symptoms but the dis-
ease itself, viewed from a rational, scientific aspect. In this way only
can satisfactory results be obtained in many diseases. General rules may
be given, and they are useful ; but the remedies and their strength, and
their method of application best adapted for a given case, are matters to
be determined largely by experience, including clinical observation under
the guidance of a master. Many years ago the author drew attention to
GENERAL OBSERVATIONS. 169
the importance of studying cutaneous diseases with the aid of a thorough
master, 1 stating that in this way only could the subject be learned satis-
factorily. The observation applies with equal force to the treatment of
such rebellious diseases as eczema, psoriasis, and acne. The guiding hand
of the master in this class of diseases is almost essential to the student
in therapeutics. Without experience the remedies and the formulae
cannot be prescribed with much hope of meeting the indications that are
obvious to the dermatologist.
It should be the aim of the physician to relieve the disease as rapidly
and as effectually as possible. Every means calculated in any way to
afford relief to the diseased skin should be employed. No fears need be
entertained of curing the disease too soon, or of " driving in the erup-
tion," as this idea is popularly expressed ; the danger is rather in tempo-
rizing with the affection and thus permitting it to obtain the upper hand.
It may be safely stated that the sooner diseases of the skin of all kinds,
including the most acute inflammations, are relieved, the better both for
the comfort of the sufferer and for the credit of the physician. Careful
inquiry and extended experience show that injurious results very seldom
if ever follow the cure of these diseases, whether this takes place rapidly
or slowly. In many cases the time occupied in the treatment unfortu-
nately extends over a long period, even under favorable circumstances,
so that speedy recovery should be regarded with favor. On the other
hand, no attempt should be made to " drive out the eruption," with the
idea that the cutaneous manifestation is a materies morbi which is to be
eliminated through the skin. There are many diseases, as, for example,
those belonging to the group of glandular affections, where such active
remedies as the iodides will readily "drive out," that is, aggravate, the
eruption. In like manner eczema may often be aggravated, or " driven
out," by the injudicious use of arsenic, this remedy in such cases over-
stimulating the cutaneous nerves when rest is required. The disease in
all such cases is invariably made worse by such improper modes of
treatment.
He who would be successful in the treatment of these affections must
first acquire a full knowledge of the principles of general medicine;
without this groundwork his efforts, in the majority of cases, will at best
be rewarded by hap-hazard or unsatisfactory results. Dermatology,
rightly viewed, includes the whole integumentary system, and is a de-
partment of general medicine. Diseases of the skin in many cases are
amenable to the same principles of therapeusis that hold good for dis-
orders of other organs. A simple acute inflammation of the skin calls
for the same general plan of management as an acute inflammation having
its seat in the mucous membrane. The integument is but a part of the
whole organization, and is subject, therefore, to general laws. It is fre-
1 On the Study of Dermatology, Amer. Jour, of Derm, and Syph., 1871.
170 GENERAL TREATMENT.
quently affected manifestly symptomatically, in which case it is an index
to the general state, or to some special organ or part affected, the skin
disorder being of less importance than the primary disease which has
caused it. Diseases of the skin are sometimes reflex in character, and to
relieve or to cure these, remedies, as a rule, must be directed against the
offending organs rather than against the skin.
Before prescribing for a case there are a number of points which should
be taken into consideration, some of which may serve to indicate the
mode of treatment or the remedies likely to prove serviceable or harmful.
These topics may be referred to under the following heads.
Previous History. Not infrequently the previous history will prove
of assistance in determining upon the most suitable method of treatment.
It is to be ascertained whether the present manifestation is a first attack
or a recurrence. If the latter, the course of the former attack, as well
as the nature of the treatment employed, should be inquired into ;
whether external or internal remedies were employed, and whether they
proved successful or otherwise. The preparations used should also, when
practicable, be learned from the patient, for a knowledge of past treat-
ment and its results may save both time and trouble. When, for
example, we are assured by a patient that arsenic taken internally or tar
used externally has on former occasions invariably disagreed, the informa-
tion enables us to be at least cautious as to the manner of prescribing
these remedies should they seem indicated. It will generally be found
that in chronic diseases the statement of the patient is correct on such
points. Idiosyncrasies, too, it must be borne in mind, are occasionally
encountered.
Present General Condition. The general condition of the patient
should be ascertained, and whether there is naturally a tendency to con-
gestion or to pallor of the skin. The state of the circulation should be
inquired into, especially as to the hands and feet ; also the condition of the
glandular systems, if seborrhcea or moist or perspiring palms are present.
The presence or absence of general symptoms, and whether the disease
is strictly local or is diffused, should also be ascertained. The state of
the alimentary canal should be particularly inquired into. The tongue
should be examined, and the patient questioned as to the existence of
dyspeptic symptoms and imperfect assimilation. The state of the bowels
requires special attention, because in certain diseases, as eczema and acne,
the alimentary tract is often at fault and proves by reflex action an
exciting cause of cutaneous disturbance. The biliary and renal secre-
tions call for investigation. The condition of the nervous system, so
frequently impaired in function, should be inquired into : many affections
are well known to be neurotic in origin, and in these cases the treatment
must be directed against this system rather than against the integument,
if satisfactory results are expected. It will thus be seen that the prac-
METHODS OF TREATMENT. 171
titioner must in many cutaneous affections look to the general economy
rather than to the skin for the indications of rational treatment.
Nature of the Disease. Directing attention now to the integument
itself, it is all-important to form a definite idea as to the nature of the
process present ; whether, for example, it is a simple hypersemia, an in-
flammation, an hypertrophy, or a combination of processes. The patho-
logical process being identified in a general way, less difficulty will be
experienced in the diagnosis, and often the treatment will be indicated.
Duration of the Disease. The length of time the disease has existed
should be ascertained ; its natural course studied ; whether confined to a
small area or diffused, and its tendency to localize or to spread, and
whether on the periphery or to crop out at distant points. It is impor-
tant, also, to determine before prescribing whether it is acute, subacute,
or chronic, and, still further, if an acute process, to determine the precise
stage. The subjective symptoms should be learned from the patient;
whether pain, burning, or itching is experienced, and, if present, the degree
of the symptom, and whether continuous, intermittent, or variable.
Cause of the Disease. The importance of forming a correct opinion
as to the cause which has given rise to the affection is so apparent as
scarcely to call for mention. Upon a proper interpretation of this point
will often depend largely the success or the failure of treatment, especially
in such diseases as eczema and acne. It is only by treating the cause,
in many cases of inflammatory disease at least, that permanent relief
may be looked for. Too much study and investigation can scarcely be
devoted to a comprehension of the case as a whole ; and let it be remem-
bered that each case demands special study and a plan of treatment
adapted to its needs. The lesions themselves, except in the case of local
diseases, are often of little consequence compared to the cause, whether
it be local or general, which is continually producing new ones; this
remark applies particularly to acute inflammatory lesions, as in the case
of acne, urticaria, or eczema, depending, it may be, on some internal
source of irritation. It is most important in instituting cutaneous
therapeutics to discriminate, where possible, between idiopathic and
symptomatic disease. When, however, as too frequently occurs, no
cause for the disease can be detected, the lesions themselves should be
vigorously aftacked by every means at hand, with a view of removing
them as soon as possible. Sometimes they will recur, but often they
do not. In those instances in which the affection is known to be
altogether local in its origin, it need hardly be remarked that nothing
further than the treatment of the lesions and the removal of the offending
cause is called for.
Methods of Treatment. For the relief or cure of the diseases of
the skin, both general and local remedies are demanded, which may be
prescribed conjointly or alone, according to the nature of the disorder.
Experience proves that in certain cases constitutional or internal treat-
172 GENERAL TREATMENT.
ment is by far the most effective, while in other instances local measures
offer not only the best, but at times the only, means of relief: such
being the case, it is plain that neither method employed to the exclusion
of the other is capable of yielding the best results which it is possible
to obtain. It may be said, however, that where external means are
sufficient to relieve the disease both promptly and permanently, inter-
nal treatment is not only superfluous, but may be productive of harm,
as is often noted from the injudicious use of such drugs as arsenic and
the iodides. Viewing the subject as a whole, the author is firmly of the
opinion that the most satisfactory results in many cases are to be obtained
from the conjoint employment of both plans. The affections, and more
particularly the individual cases, in which either local or general remedies
are to be prescribed, can be determined only by taking into account both
the nature and the cause of the disease. No positive rules can be given
for the use of either one or another class of remedies, for it will be found
that the skin in a state of disorder is a peculiar and often a sensitive
organ and is subject to no fixed laws of behavior. The remedy suitable
for one stage is frequently not only powerless but often positively in-
jurious in another stage of the disease in the same patient.
Hypodermic Injections. The value of this mode of therapeusis for
the administration of such remedies as arsenic, mercury, antitoxins,
animal extracts, and such substances as thiosiuamine and the like, may
be referred to. In certain diseases where it is desired to make a strong
impression on the general system or on the nervous system, arsenic acts
more effectively administered by this method than by the mouth, the
beneficial results of which, for example, are noted especially in sarcoma
and in lichen planus. The value in grave cases of sarcoma of injections
of toxins derived from pure cultures of the bacillus of erysipelas has
been shown by Coley, 1 of New York, and others. Out of forty-three
cases of inoperable sarcoma treated with the toxins by Coley, eleven were
what may be termed successful ; in some of these relapses occurred in from
one to four years. On the other hand, Senn's experience is adverse to
this method of treatment, but his cases, it wo aid seem, were not selected.
While some carcinomata have yielded to this treatment, in the great
majority of cases the results have been unfavorable.
Anaesthetics, Analgesics. In connection with the topic of hypo-
dermic injections reference may be made to the employment of other
methods and agents for the production of local anesthesia. The con-
dition is brought about for various purposes, but especially for the
relief of pain attendant upon operations upon the integument. Since
the introduction of COCAINE this drug has been made to serve valuable
purposes in preventing and in relieving cutaneous pain, being used
chiefly in solution (1 to 4 per cent.) injected beneath the true skin. A
Proceedings of the Amer. Med. Assoc., meeting held at Baltimore, May, 1895.
INTRACUTANEOUS INJECTIONS. 173
few drops injected well into the subcutaneous tissue, at different points
around the border of the area of skin to be operated upon, suffice
within a minute or two to permit of the removal of a tumor or other
formation absolutely without pain. With this treatment all kinds of
lesions may be operated upon for purposes of cure or diagnosis. Where
the epidermis is defective or wanting, simply brushing the solution or
sprinkling a little of the powder over the mucous layer will in a short
time produce ansesthesia, but, of course, less profound than if injected
into the corium.
Vaporization of ETHER and various mixtures containing ether and
chloroform have long been in use for producing ansesthesia of the skin ;
but if the applications are continued too long there is danger of gan-
grene of Ijie frozen tissues, and there is great pain, especially of inflamed
parts, during the freezing. CHLORIDE OF ETHYL, is a more active
freezing agent than common ether, and often may be used to advantage
painted over the surface where superficial ansesthesia only is required.
Remedies of this kind, including RHIGOLENE, should be applied for the
purpose of benumbing, and not of freezing, the part.
Intracutaneous Injections. Local ansesthesia may also be produced
by making use of various substances in solutions of certain strength
injected intracutaneously, according to the method introduced by
Schleich, of Berlin. 1 It will be noted that the term intracutaneous
is used in contradistinction to subcutaneous. Schleich, as well as
Cholewa, 2 E. Martin, 3 Wiirdemann, 4 and others, has shown that weak
aqueous solutions of cocaine (1 to 5000) are able within the limits of the
infiltration to produce complete anesthesia, so that puncturing, cutting,
and scraping may be performed without causing pain. Similar results
are obtainable in healthy tissue with pure water and solutions of salt,
but with the difference that the process of injecting water into the tissue of
the skin itself, with the formation of water-lesions, is distinctly painful.
Not until from half a minute to a minute after the injection does anses-
thesia occur, when it is similar to that after the injection of cocaine
solution 1 to 5000 or stronger. Water, therefore, used in this manner
produces an " ansesthesia dolorosa," paralysis of the nervous tissue being
preceded by hypersesthesia or pain. Refrigeration of the water to the
freezing point reduces this stage of irritation to a minimum. There
results an oedema, which, according to Schleich, contains the same
amount of common salt (0.6 per cent.) as the serum of the nervous
fluids, and in this fact lies the difference between this and ordinary
1 Schmerzlose Operationen oertliche Betaubung mit indifferenten Fliissigkeiten.
Berlin, 1894.
2 Jour. Amer. Med. Assoc., May 20, 1894.
3 Therapeutic Gazette, Dec. 15, 1892 ; also, oral communication to the author.
4 Jour. Amer. Med. Assoc., Dec. 29, 1894. The author is indebted to Dr. Wiirde-
mann 's article for suggestions.
174 GENERAL TREATMENT.
oedema. As strong a solution of common salt as 0.6 per cent, pro-
duces no anaesthetic effects worth considering ; but a more diluted
solution of common salt, as a 0.2 per cent, solution, especially in lower
degrees of temperature, produces a speedy anaesthesia in the areas of
infiltration. It may also be remarked that what is true of the skin is
applicable also to other tissues of the body, as the subcutaneous tissues
and the muscles. The 0.2 per cent, solution of common salt produces
anaesthesia, proving that it is the infiltration itself that causes the anaes-
thesia, and that the anaesthetizing fluid need not be in itself anaesthetic ;
but the process of injection is painful. According to Schleich and
Cholewa, the proportion of common salt in a solution is important.
Thus, the smallest effective dose of cocaine (weaker injections causing
pain) is 0.2 per cent., or 1 to 5000. This aqueous solution of cocaine
produces anaesthesia and renders other injections painless. The same
dose of cocaine containing 0.6 per cent, of common salt is painful, and
is not able to produce anaesthesia, but the same solution of cocaine
wherein the amount of common salt is not greater than 0.2 per cent,
produces complete anaesthesia. Cocaine and common salt and water are
not the only materials that are able in this way to produce anaesthesia in
normal tissues, a solution of 3 per cent, sugar, 0.1 per cent, morphia, 3
per cent, potassic bromide, 1 per cent, methyl-violet, 2 per cent, caffein,
and others, acting in the same manner, their efficacy being increased by
dissolving them in a 0.2 per cent, solution of common salt.
The cause of anaesthesia by infiltration is not a simple one, several
factors being concerned, the most important of which is removal of
blood from the infiltrated tissues by the pressure of the injected fluid.
It is caused by the anaemia, the compression, and the cooling. After a
properly performed injection the osdematous lesions produced appear
white, the foreign fluid occupying the lymph-vessels and areolar spaces,
the blood being gradually forced into the neighboring vessels.
While the 0.2 per cent. (gr. i ad 3i) solution is sufficient to produce
complete anaesthesia in normal tissues, the addition of cocaine, morphia,
and carbolic acid is demanded where disease exists, but they are em-
ployed several hundred times weaker than as commonly used, so that it
is possible to keep the doses required to produce anaesthesia below the
poisonous limit. The strongest solutions which are used contain only
0.2 per cent, of cocaine and 0.025 per cent, of morphia, so that thirty
syringefuls of this anaesthetizing solution may be employed before the
maximum dose is reached. For an ordinary surgical operation not
more than ten syringefuls are required, and these are used in a manner
different from their administration in a single dose ; moreover, hardly
one-third of this liquid is absorbed. With the cocaine-morphine-salt
solution, Schleich finds that the pain after operation is decidedly less
than after the use of chloroform.
The anaesthetic fluids employed by Schleich for operation upon
CONSTITUTIONAL TREATMENT. 175
highly inflamed or hypersesthetic areas consist of: cocain. mur., gr. iii ;
morphise mur., gr. ss. ; sod. chlorid., gr. iii ; aq. dest., iii. This is
sterilized and two drops of a 5 per cent, carbolic acid solution are added.
For most operations a solution containing less cocaine (gr. iss. to the
same amount of solution) is employed, while for superficial operations
upon nearly normal tissues a solution still weaker in cocaine and mor-
phia ( grain of the former and y 1 ^ grain of the latter to the same amount
(3 iii) of solution) is used. After spraying the surface with ether, the
injections are made side by side until wheal-like lesions are produced
over the line of incision. Only the redematous region is anaesthetic,
and the operation is not to be begun until the artificial rederua is
complete. Anaesthesia occurs at the moment of the completion of
the oadema. Aseptic precautions are to be strictly adhered to. The
solution should be cooled just before the operation by laying the bottle
containing it on ice, and be kept cold during the operation ; the syringe
should also be cooled. As Wiirdemann states, stress must be laid upon
the technique, as localities, however small, that have not been infiltrated
retain their sensibility. A. certain degree of skill is necessary to make
the injections satisfactory, to acquire which experience is required. The
details are to be mastered by application to the subject, and the operator
must accustom himself to working in oadematous tissues. Schleich has
ustd the method in general surgery with success in several thousand
cases, and many others have testified to its efficacy. In excoriated and
spongy lesions, as in many epithelial cancers of the skin, the method
should not be employed ; at least the author has not found it satisfac-
tory in such cases.
Spray. The treatment of the skin and mucous membrane by means
of the spray apparatus is sometimes made use of, and has the advan-
tage of being a neat and clean mode of applying certain remedies. It is
especially useful where the disease occupies regions of the body that are
with difficulty treated by lotions, ointments, or plasters, as in the case
of fissures, where the skin is in folds, and about the mouth, nose, ears,
genitalia, and hands and feet.
The following substances in common use are soluble in both ether and
alcohol : chrysarobin, pyrogallol, creosote, camphor, chloral, camphor-
chloral, iodine, iodoform, salicylic acid, carbolic acid, benzoic acid,
citric acid, acetic acid, trichloracetic acid, and corrosive sublimate. In
alcohol only are soluble arsenous acid, boric acid, nitrate of silver,
acetate of lead, and ethylate of sodium; and in ether only, fats,
cautharidin, and collodion.
CONSTITUTIONAL TREATMENT.
Rest. In some cases rest is an important aid to treatment. In cer-
tain inflammatory diseases, as the erythemata, eczema, and psoriasis, as
well as in diseases characterized by obvious circulatory disturbance, rest
176 GENERAL TREATMENT.
in bed for a few days or weeks will sometimes be followed by good re-
sults, especially where judicious local treatment is employed at the same
time. The value of this measure applies to certain dermatological cases
as forcibly as it does to many cases in general medicine and surgery, the
importance of which is generally recognized. The favorable action is
in most cases through the nervous system, which thereby is relieved of
tension, and the overtaxed vessels are thus permitted to regain strength
and tone.
Hygiene, Climate. The benefits resulting from attention to hygiene
are most strikingly seen in cases where the nervous system is disturbed.
In this category, also, are to be grouped certain conditions of the ali-
mentary canal which may be benefited by following hygienic rules. The
effect of change of climate upon some diseases is occasionally remark-
able. In rebellious cases of urticaria, psoriasis, furunculosis, and eczema,
for example, the change may be followed by decided and at times even
prompt relief. Leprosy and some allied diseases are also benefited by
change of climate and residence.
Diet. The value of a regulated diet in the treatment of certain cuta-
neous diseases is a matter of considerable importance. A well-directed
dietary will be found distinctly useful in some of the inflammatory affec-
tions directly or indirectly due to defective assimilation and impaired nutri-
tion. This remark naturally applies to cases rather than to diseases, for,
while diet positively influences some cases of eczema and acne, for example,
there are other cases, where the disease is dependent upon a neurotic ele-
ment or upon an internal local or general irritation of some kind, that are
not affected by diet. It may, however, be said that the diet should in
most cases be directed by the physician. Whether it shall consist largely
of meat, or of vegetable or farinaceous food, must depend on the patient
rather than on the disease. Upon this point there can be no rule, although
it may be said that with the majority of individuals in the upper walks
of life the disposition is to err on the side of over-indulgence in nitrogenous
food. This is often noted in the case of eczema, psoriasis, and acne in
plethoric or gouty subjects, where the tendency to congestion should be
reduced by every means at command. In such cases regulation of the diet,
including the amount of food consumed, may be essential to a successful
result. The proper nutrition of the individual as a whole, with a view
to restoring and preserving the equilibrium, the disturbance of which
is so often indirectly the cause of disease, should ever be in the mind
of the physician. This I believe to be particularly the case as concerns
the nervous system, so frequently at fault in many dermatoses. While,
therefore, for some cases it may be desirable to restrict such articles as
meat, fats, and oils, and to prescribe starchy food, fruits, and acids, for
others the diet may advantageously be reversed. In all cases the
simplest and most digestible kinds of food should be directed, forbidding
such articles as sausage, shell-fish, pastry, cakes, hot bread, cheese, salads,
ANTIMONY. 177
pickles, condiments, acids, acid fruits, nuts, and sweets. Tea, coffee,
tobacco, and alcohol are all to be interdicted, or used only under the
direction of the physician. Alcohol, especially in the form of fermented
liquors and wines, is positively injurious in many of the inflammatory
diseases. These articles, being stimulants, retard tissue metamorphosis
and functional activity, and hence interfere with nutrition. In some
cases excess of starchy food and sugar, especially in pale or strumous
children, is injurious, a change of diet which includes fatty food often
being beneficial. Good results may sometimes be obtained from a
radical change of diet, as in eczema, psoriasis, urticaria, and purpura.
In the selection of a dietary suitable for a case in any disease involving
nutrition, the needs of the patient should be studied. There can be no
rules laid down on this question. The diet should be directed by the
physician, but not without consultation with the patient.
Cod-Liver Oil. This is valuable in those cases where the general
health has become impaired through improper or insufficient food, bad
hygienic surroundings, and like causes. It is often prescribed to advan-
tage in tuberculous diseases, the scrofulodermata and the like, and in
some forms of eczema. In the eczema of strumous children with glan-
dular involvement and a tendency to abscess, it is of particular value.
Sulphur. This drug, precipitated or sublimed, or in the form of its
several compounds, as calx sulphurata, sulphurous acid, sodium hypo-
sulphite, is of value in many affections, including disorders of the sweat
and sebaceous secretions, acne, acne rosacea, urticaria, and in some
diseases tending to necrosis and suppuration, such as furuncle. SODIUM
HYPOPHOSPHITE is an important remedy in urticaria, furuncle, and
other diseases, and is worthy of special mention. In suitable cases,
especially of the diseases referred to, it is much esteemed by the author
in five- or ten-grain doses three or four times a day. ICHTHYOL. and
THIOL, both containing a certain percentage of sulphur, prove of service
in some cases, especially in those where sulphur is indicated.
Antimony. This drug, used as an alterative in small and repeated
doses, is sometimes useful in both acute and chronic affections. In its
action it somewhat resembles arsenic. In acute inflammations in robust
and congested individuals, especially in such diseases as eczema, psoriasis,
and similar forms of inflammation, it may at times be prescribed bene-
ficially in full doses. In small doses it is sometimes of benefit in such
affections as chronic lichen planus and in true prurigo. It is not infre-
quently of value in cases where arsenic is not tolerated, allaying nerve
irritability and improving nutrition generally. In these cases, in small
doses, it acts as a nerve tonic. Its depressant and toxic effects should
be guarded against. The dose varies with the age and the constitution
of the patient, the average for an adult being one-thirty-second of a
grain of tartarated antimony, equalling about seven and one-half minims
of the wine of antimony. It is advisable to begin with less, and to
12
178 GENERAL TREATMENT.
increase the quantity gradually. But where used for its tonic effect on
the nerves, the author has obtained most benefit from small doses. 1
Jaborandi, Pilocarpine. This drug and its alkaloid are of value
for the stimulating impression they are capable of making on the ner-
vous centres, especially on the nervous matter governing secretion. In
many diseases where this eifect is indicated the drug may be employed,
and with the best results in small doses, as in the case of antimony. It
may be used in some cases of chronic eczema and psoriasis, in sclero-
derma and morphoea, and in other diseases in which nutrition is impaired.
The dose should, as a rule, be less than is demanded to produce the well-
known physiological effects.
Salicylic Acid, Salicylates. This drug and its salts and prepara-
tions, sodium salicylate, salicin, salophen, and salol, may be referred to
here, sodium salicylate in particular being of distinct value in erythema
multiforme, erythema nodosum, urticaria, eczema, psoriasis, and in other
diseases.
Viola tricolor. This drug (wild pansy), much employed at one time
for eczema, has been recommended by Hardy and by Piffard for this
disease, especially for the pustular variety occurring in weakly infante
and children. It is slightly diuretic, diaphoretic, and laxative, and is
best prescribed as an infusion or as a fluid extract. For infants, one
drop of the latter two or three times a day may prove sufficient, but for
an adult the dose may vary from ten drops to a fluidrachm.
Such remedies as ZITTMANN'S DECOCTION, CHAULMOOGRA OIL, GUR-
JUN BALSAM, and HOANG-NAN, are also made use of as alteratives and
nerve tonics in such diseases as chronic syphilis and leprosy, and in
other diseases where a radical change in nutrition is desired.
Ergot. This drug acts by contracting the vessels and thus diminishing
the excessive blood-supply to the part. Administered in doses of twenty
or thirty minims of the fluid extract, it is sometimes useful in acne,
acne rosacea, rosacea, erythema, urticaria, purpura, and pruritus.
Iron. The preparations of iron must receive mention as being in
some cases serviceable. Their administration, alone or in combination
with other remedies, is indicated in affections due to a lowered state of
vitality, as observed not infrequently in anaemic seborrhoea, acne, and
comedo, and in the infectious fevers, as, for example, variola, erysipelas,
and the like. Iron cannot be regarded, however, as of positive value in
many of the strictly cutaneous diseases, and hence alone is not often pre-
scribed by the dermatologist. But in combating such general abnormal
states as anaemia and chlorosis, and to improve the condition of the blood
in erysipelas and similar diseases, it is of course of great value, the
tincture of the chloride being a very serviceable preparation.
1 For further information, see an article by Malcolm Morris, Brit. Med. Jour., 1883.
W. Allan Jamieson and Jonathan Hutchinson have also directed attention to the
value of the drug in cutaneous medicine.
.
ARSENIC. 179
Quinine. This may be given with advantage in many diseases, as,
for example, in certain of the erythematous inflammations, as chronic
urticaria and erythema multi forme, erythema nodosum, erysipelas, and
in elephantiasis, especially in countries where that disease is endemic.
It is of value in the neuroses, as in pruritus, and in other diseases de-
pendent upon or complicated by nervous disturbance, as lichen planus ;
also in diseases accompanied by a malarial element, as in some cases of
urticaria.
Arsenic. As is well known, arsenic has long been held in high esteem
as a remedy in cutaneous medicine. At the present day there exists
some diversity of opinion concerning its worth as a therapeutic agent
against this class of diseases. Many dermatologists believe they derive
a great deal of good from its employment in a number of affections,
while others of equal experience are inclined to place but little reliance
upon its curative powers. The indiscriminate employment of the drug
is to be deplored. To use it in diseases affecting the skin solely because
the skin is diseased, without reference to the nature of the affection, to
the stage of the process, or to the patient, as is so frequently done, is to
be deprecated. The lack of success and the positive injury often done
to the whole system by such injudicious treatment have brought the
drug unjustly into disrepute with some. I hold that it is a remedy of
great value ; that it is, in fact, by far the most valuable of all internal
remedies in the treatment of many dermatoses. The cases, however, in
which it is prescribed must be selected, if successful results are to be
expected. To say that arsenic is of use in " diseases of the skin,"
viewed collectively, is to make an assertion so vague and meaningless
as to be of no practical value. It is necessary to specify not only the
disease, but also the stage of the affection, and, what is even more
important, to select a suitable subject, if we would employ it successfully.
Arsenic should be used to improve the general condition causing the
disease, rather than against the lesions.
MODE OF ACTION.
Its action is through the central nervous system and the nerves. It is
a direct nervine stimulant. Caution should always be observed in its use.
Unless the case be suitable, it will generally aggravate the disease. In
a general way it may be said that it is most useful where the tone of the
nervous system is lowered or depressed.
llinger, Murrell, and Nunn l found that when frogs were poisoned by
arsenic the cuticle could be readily stripped off the whole body within a
few hours after the administration of the drug. The general effect of
arsenous acid upon the epidermis is to cause a degeneration and partial
solution of the protoplasm of the cells, the whole epidermis becoming
loosened from the true skin, and the cells of the rete Malpighii being
1 Jour, of Physiology, vol. i., No. 4.
180 GENERAL TREATMENT.
incoherent, so that the whole layer breaks down. In other cases the
nerves governing the formation of pigment are so over-stimulated that
increased deposit of pigment occurs, characterized by yellowish, brown-
ish, or blackish discoloration in the form of spots and patches, or by
dryness or desquamation of the epidermis.
Arsenic exerts its influence chiefly upon the mucous layer of the epi-
dermis. Hence it is found that diseases involving the more superficial
parts of the skin are, as a rule, most benefited by its administration. It
possesses but little power over many affections w r hich have their seat in
the deeper structures. When administered two or three times a day,
its action upon the skin is often slow, several weeks often being requisite
to produce the desired result. Given in small doses often repeated,
however, say a half or one minim of liquor potassii arsenitis every hour
or two, its effect upon the system may be speedily obtained, sometimes
within forty-eight hours. Improvement once having been obtained, it
is generally expedient to allow the patient to continue its use for some
weeks after all symptoms of disease have disappeared, usually in smaller
doses. It should not be given in the acute inflammatory stage of any
disease of the skin, as a rule. It should not be prescribed when there
is great heat, burning, intense itching, or rapid cell change. It is not
only of no good at this period, but is often positively injurious, tend-
ing to augment the activity of the morbid process. It stimulates the
mucous layer when rest is demanded. In many cases it increases the
congestion of the skin and the itching. Its administration, in whatso-
ever disease, should in almost all cases be withheld until the acute
symptoms have subsided. The more general the cutaneous disease in
its distribution, the more likely is it to prove beneficial. In localized
patches, as of psoriasis, eczema, or lichen planus, dependence for the
cure should be placed mainly upon local remedies. The general condi-
tion of the patient, rather than the particular cutaneous manifestation,
should be the guide for its use.
DISEASES IN WHICH ARSENIC IS USEFUL.
It is unquestionably of great value in psoriasis ; but it is by no means
of benefit in every case, nor should it be directed in all stages of this
disease. Where the process is active and attended with intense hyper-
semia, especially in so-called acute psoriasis, as a rule, it increases the
already highly inflammatory condition. The more active the cell prolif-
eration the less probability is there of its being beneficial. On the other
hand, the paler and the more indolent and sluggish the process the
greater the chance for improvement. It may be stated that in most
cases it should be withheld until the morbid process has become settled
in its course.
It is of service in certain varieties and forms of eczema, especially
papular and squamous manifestations ; particularly in those cases where
PREPARATIONS OF ARSENIC. 181
the primary lesions are ill defined and where there is but slight infil-
tration of the skin. Certain persistent localized papular and abortive
vesicular eczemas, as frequently seen, for example, about the fingers,
sometimes yield to it. Chronic infantile eczemas, unaccompanied by
digestive disturbance, are at times favorably influenced by the remedy.
But in infants it should never be prescribed unless there are good
reasons for its administration. It is a drug capable of doing too much
damage to the nerves and to the economy as a whole to be prescribed
unless plain indications exist for its employment. As is well known,
children tolerate relatively large doses. Viewing the subject in a broad
light, it may be stated that too much should not be expected of arsenic
in eczema. Many cases are in no degree improved by its use, and some,
on the contrary, are unquestionably aggravated.
Pemphigus is often permanently relieved by its judicious use. Ex-
perience has shown it to be of great value in many, but not in all, cases
of this disease. It seems to be less efficacious in the foliaceous than in
the common variety. Discrimination must be made between pemphigus
and pemphigoid eruptions, in which latter forms of disease it may not
be called for. In lichen planus and in lichen ruber it is also often
prescribed with great advantage, but its effects in these diseases are
somewhat variable. It should not be administered in acne unless
distinctly indicated. It is of less value in this disease than in any other
dermatosis against which it is commonly employed. In certain forms
of acne, however, especially in chlorotic or anaemic subjects where the
lesions are very numerous and of a fine papular character, its adminis-
tration is occasionally followed by good results. In chronic urticaria
and in some cases of furunculosis it proves serviceable; likewise in
gangrene, especially in hospital gangrene, beginning with small doses
every two hours and rapidly increasing, combined with alcohol as a
stimulant.
PREPARATIONS OF ARSENIC.
The preparations employed are arsenous acid, bromide of arsenic,
sulphide of arsenic (realgar), arsenite of quinine, liquor arsenici chloridi
("De Valangin's solution"), liquor sodii arsenatis ("Pearson's solution,")
and liquor potassii arsenitis (" Fowler's solution"). Arsenous acid is a
good form in which to administer the drug, given in pill form, usually
combined with sugar of milk. It may also be combined with black
pepper and powdered liquorice, constituting the so-called " Asiatic pill,"
employed more often in Europe than in the United States. The follow-
ing is the formula somewhat modified : Arsenous acid, one grain ; black
pepper and liquorice powder, of each twenty grains, with a sufficient
quantity of mucilage ; mix, and divide into twenty pills. S. One to be
taken two or three times a day, directly after meals. The strength of
the pill may, of course, be varied to suit the case. " Boudin's solution"
(an aqueous solution with white wine) may also be prescribed. The
182 GENERAL TREATMENT.
aqueous solutions do not keep well : hence these preparations should
always be dispensed freshly prepared.
The liquor potassii arsenitis may be given combined with a bitter tinc-
ture, wine of iron, or an elixir of calisaya bark. Prescribed in this way
there is less likelihood of gastric and intestinal derangement, Where
this occurs the drug should be discontinued. Under these circumstances
it may be advisable to change the preparation ; thus, for Fowler's solu-
tion to substitute the solution of arsenate of soda or arsenous acid. The
mode of ordering the solution pure and directing so many drops to
be taken at each dose is objectionable. The average dose suitable for
the majority of individuals is three minims. Four, six, or eight
minims, and even larger doses, will often be tolerated, but out of a num-
ber of persons comparatively few will be able to take more than three
or four minims for any length of time without systemic derangement.
Tolerance of the drug may generally, but not always, be acquired,
sometimes to a remarkable degree, as in confirmed arsenic eaters. The
solution of chloride of arsenic is prescribed in about the same dose
as Fowler's solution. The liquor sodii arsenatis is more stable, milder,
and less irritating to the intestinal tract than Fowler's solution. The
sulphide of arsenic is also well tolerated, and the same may be said of
the arsenite of quinine. Arsenic should always be given either with
the food or directly afterwards. Used hypodermically it has been found
of value especially in lichen plauus, psoriasis, lymphadenoma, sarcoma,
and glandular aifections. The dose at first should be small, say one
minim of Fowler's solution diluted with fifteen minims of water. Anti-
septic precautions should be instituted. Abscesses are liable to occur,
and the operation may cause some pain. The toxic effects of the drug
should always be watched for and guarded against. Occasionally they
appear insidiously, especially in the form of multiple neuritis. Idio-
syncrasies are liable to be met with, some of which are striking. The
author has met with individuals in whom fractional doses of a drop of
Fowler's solution invariably produced marked toxic symptoms. Some
of the injurious effects resulting from the use of arsenic will be referred
to elsewhere, under dermatitis medicamentosa. 1
Phosphorus. The dermatoses in which this drug may be prescribed
are those in which arsenic is indicated. It is a nutritive stimulant to the
nervous system. It is not, however, well tolerated, and it is partly on
this account, probably, that the views of observers as to its efficacy are
1 The value of arsenic in skin diseases has been ably considered by Bulkley, in a
monograph entitled " The Use and Value of Arsenic in the Treatment of Diseases of
the Skin," New York, 1876, and "The History and Therapeutic Value of Arsenic in
Skin Diseases," Practitioner, 1880; also by E. L. Keyes, "The Useful Administra-
tion of Arsenic in Diseases of the Skin," Jour, of Cut. and Ven. Diseases, 1886, p.
230; and by Hardaway, "The Question of the Value of Arsenic in Diseases of the
Skin," Jour, of Cut. and Ven. Diseases, 1886, p. 233.
MERCURY. 183
conflicting. It has been used with success occasionally in psoriasis and
eczema, and in lupus vulgaris and similar diseases. It is best adminis-
tered in the form of tincture or elixir, or of phosphorated oil enclosed
in capsules, the dose being one-hundredth to one-fiftieth of a grain. J.
Ashburton Thompson's solution, which is one of the best formulae for
the administration of phosphorus, is as follows : Take of phosphorus,
grain i ; absolute alcohol, drachms v ; dissolve with the aid of heat and
agitation, and then mix, while still warm, with the following mixture,
also warmed : glycerin, ounces iss. ; alcohol, drachms ii ; spirit of pepper-
mint, minims xl. One fluidrachm of this solution contains one-twentieth
of a grain of phosphorus, and the dose in the beginning is ten drops
three times a day, taken after meals in water quickly added, increasing
daily in dose until thirty or forty drops are reached, if it agrees with
the stomach. L. D. Bulkley, of New York, endorses the formula, and
states that he has derived undoubted benefit from the remedy. The
elixir of phosphorus of the National Formulary of unofficial preparations
is also an eligible preparation. Zinc phosphide, in doses of one-twentieth
to one-eighth of a grain, may be employed with benefit in suitable cases,
as in some cases of herpes zoster. To obtain its effect speedily, the dose
should be given in small doses every hour or two, disturbance of the
alimentary tract and toxic effects being watched for. A pure and fresh
drug should be insisted on.
Tar, Carbolic Acid. Both of these substances are at times employed
internally with good result, as in erysipelas, psoriasis, eczema, and pru-
ritus. Tar, in five- or ten-grain doses, is sometimes useful in chronic
eczema and psoriasis. It should be ordered in pills or capsules. It
is milder in its action than carbolic acid. Carbolic acid, in pill form,
one or two grains three or four times a day, is useful in specific fevers
generally, and in various other microbic diseases. It may also be ad-
ministered in a mixture containing a few drops of chloroform. It tends
to arrest febrile disturbance, and may be given until the urine becomes
smoky or dark.
Mercury. The preparations of mercury are used not only for the
manifestations of syphilis, but also for other dermatoses. Thus, minute
tonic doses of corrosive sublimate, alone or with bark, are sometimes
taken with benefit in certain chronic inflammatory diseases accompanied
with thickening, as, for example, eczema. In syphilitic diseases they
are, of course, invaluable. The corrosive chloride, protiodide, biniodide,
mercurial pill, and gray powder are the forms in which it is commonly
prescribed, the corrosive chloride and the biniodide being preferred
by the author. Its administration by inunction is also of great value.
Mercurial ointment may often be advantageously weakened with petro-
latum. The effect of the mercurials upon the system should always
be carefully noted, and in no case should they be given until active
ptyalism has been produced. Mercury, especially the biniodide, is com-
184 GENERAL TREATMENT.
bined most advantageously with iodide of potassium, not only in syphi-
litic but also in other diseases. Here may be mentioned " Donovan's
solution" (liquor arseni et hydrargyri iodidi), a remedy of repute in the
treatment of syphilitic manifestations, and also in certain chronic non-
syphilitic affections accompanied with infiltration of the skin.
Iodides. These find their chief use in scrofuloderma, lupus vulgaris,
lupus erythematosus, and the syphilodermata, but they are useful in many
other diseases. Not infrequently they are of service in small doses,
half a grain or a grain, as an alterative, when larger doses would prove
injurious. In the aifections mentioned these may be administered, either
alone or in combination with mercury, in doses varying from two to
fifteen or thirty grains, and occasionally even in larger doses, largely
diluted with water. When used in non-syphilitic diseases the dose should
generally be small, although in psoriasis, for which it is sometimes pre-
scribed with benefit, good results, as a rule, do not follow until large
doses have been employed. lodidized starch is a mild preparation, some-
times used in syphilis and in lupus erythematosus, in doses of from one
to four drachms, administered in water or water-gruel. It must be re-
membered that the iodides, as well as the bromides, are capable of pro-
ducing varied forms of eruption.
Analgesics. Such drugs as chloral, bromide of potassium, acetanilide,
and phenacetine are employed to relieve nerve pains, as in herpes zoster
and dermatalgia, and in pruritus. They are also sometimes used in
eczema and lichen planus, and in other diseases accompanied with violent
itching. Opium and morphia are seldom prescribed, because they tend
to bring on itching. They are employed, however, to relieve great or
continuous pain, such as occurs in carcinoma.
Alkalies. These find their employment in the acute and chronic
inflammatory dermatoses, such as the erythemata, eczema, psoriasis, acne,
and acne rosacea, especially in those cases where a manifest rheumatic or
lithsemic state exists. In erythema multiforme and erythema nodosum
they are sometimes distinctly useful, liquor potassse, and the carbonates
of potassium, sodium, and lithium, all being employed.
Diuretics. Remedies exerting an eliminating influence upon the kid-
neys are sometimes administered with advantage in highly inflammatory
diseases complicated with defective excretion, as, for example, in some
cases of eczema and psoriasis. Saline, non-stimulating preparations are
preferable, the citrate, acetate, and bicarbonate of potassium, in from ten-
to twenty-grain doses, being those from which most relief is usually to
be derived. The waters of certain springs that possess but few solid con-
stituents, such as the Poland Spring and the Cresson Magnesia Spring,
may also be used with advantage, in all cases taken on an empty stomach
one-half or three-quarters of an hour before meals. The condition of
the urine, especially in the acute inflammatory diseases, should always
receive attention, not only as to the presence of albumen and sugar, but
NATURAL MINERAL WATERS. 185
also as to the amount of saline constituents. Remarkable deviations
from the normal, indicating the use of diuretics, are sometimes met
with.
Purgatives. This class of remedies is of service in many of the
inflammatory diseases. Saline purgatives, especially the sulphates of
magnesium and sodium, cream of tartar, and Rochelle salt, are to be
recommended, and may be given with marked benefit in the early stages
of many of the acute inflammatory diseases. Magnesium sulphate is
the most valuable of these salts, and is frequently employed in suitable
cases of eczema, acne, and the like, where salines are indicated and well
borne. In some cases they cause considerable general disturbance in the
alimentary tract, when their use should at once be discontinued. The
purgative natural mineral waters, including the so-called " bitter waters,"
may also be employed with advantage. All remedies of this kind, how-
ever, should be used with discretion, and never to the extent of violent
purgation. Magnesium sulphate especially is useful when prescribed
with other substances, as, for example, iron, acids, and barks, in the form
of a draught, as in the " mistura ferri acida" and like preparations.
This mixture, much employed in Great Britain and in the United States,
is variously prescribed, but the following formula is usually well tolerated
by the stomach, and is effective where a tonic acid saline aperient is
indicated : Magnesium sulphate, |iss. ; dilute (or aromatic) sulphuric acid,
3i ; sulphate of iron, gr. viii ; peppermint water, 3iv. The dose is one
tablespoonftil in a gobletful of water half an hour before breakfast. The
effect is laxative, movement occurring usually only once a day, an hour
after taking the mixture. Sometimes syrup of ginger is an ingredient ;
for other cases infusion of quassia may be substituted for the pepper-
mint water. All purgatives and mixtures of this kind should invariably
be administered on an empty stomach, and at least a half-hour before
eating; in many cases they are prescribed most advantageously once
a day, before breakfast, in others three times daily, before each meal, in
smaller doses. The aperient rather than the purgative effect of such
remedies is often indicated.
Natural Mineral "Waters. These, especially those possessing laxa-
tive, diuretic, diaphoretic, and tonic properties, are at times taken with
benefit, but the cases as well as the diseases must be selected if good
results are to be expected. Speaking broadly, it may be remarked that
their value in cutaneous diseases generally cannot be considered great.
But, on the other hand, it must be said that the modus operandi of natural
mineral waters is not well understood, and that consequently they are often
grossly misused. The author holds the belief, based upon experience,
that they should be prescribed generally with the view of operating
against general conditions of the system at large rather than against
definite cutaneous lesions. There are exceptions to this statement, how-
ever, as in psoriasis and in some forms of eczema and the like, in which
186 GENERAL TREATMENT.
cases used iu bathing as well as drinking, but especially in bathing, the
waters may act happily.
Reference may be made to a few of the well-known springs of the
United States and Europe, classifying them according to their chief
constituents or their characteristics. 1
The SULPHUR or SULPHURETTED WATERS contain various sulphur
compounds and gases, especially sulphuretted hydrogen. They vary
considerably in their composition ; some contain large proportions of
calcic carbonates (" calcic-sulphur waters"), others, chloride of sodium
in excess of other salts ("saline-sulphur waters"). Those containing car-
bonate of lime and sulphate of lime are generally constipating ; those
containing sulphate of sodium or of magnesium or large proportions of
sodium chloride are usually cathartic. Richfield Springs, Sharon Springs,
and Avon Springs, in the United States, Harrogate, England, Strath-
peffer, Scotland, Luchou, Aix-les- Bains, and Bareges, France, are all
well-known " sulphur waters." Most sulphur waters are alterative and
diaphoretic; some prove exciting, some sedative, others depressing. Some
of them interfere considerably with digestion and assimilation, and are
otherwise not well tolerated. In many cases they prove more valuable
used as baths than internally. In the Richfield Springs waters the
amount of sulphuretted hydrogen is unusually large, and their efficiency
is probably due to this fact. More dependence is to be placed upon the
external than upon the internal use of these waters. In some cases they
produce disturbance of digestion, and their tendency is to constipate.
The CALCIC WATERS contain the salts of lime, especially the sulphate
(gypsum) or carbonate (limestone), frequently together, with more or less
carbonic acid gas. They are diuretic and diaphoretic. The waters of
Contrexeville, France, are, in addition, laxative and excitant, and are
well tolerated in large doses. The Sweet Springs of West Virginia, and
Waukesha Silurian Spring, Wisconsin, may also be mentioned as ex-
amples of these waters.
Some of this class of waters, especially those showing upon analysis
comparatively few solid constituents, are also DIURETIC WATERS ; but the
1 The natural mineral waters of the United States have been investigated in particular
by a committee of the Amer. Med. Assoc., consisting of Drs. Wm. Pepper (reporter), H.
I. Bowditch, A. N. Bell, S. E. Chaille, and Chas. Denison. See Transactions for 1880.
Excellent work has been done by A. C. Peale, " Lists and Analyses of the Mineral
Springs of the United States," Government Printing Office, Washington, 1886; also
" The Natural Mineral Waters of the United States," Department of the Interior, U. S.
Geological Survey. J. W Powell, Director. Washington, 1895. A fine map showing
the location of the natural mineral-water springs of the United States accompanies the
latter monograph.
The reader may also consult with advantage the well-known treatises on the " Min-
eral Springs of the United States and Canada," by G. E. Walton, Third Edition. New
York, 1883, and the " Mineral Springs of North America," by J. J. Moorman, Phila-
delphia, 1873 ; and an article on " The Real Value of Mineral Waters in Diseases of
the Skin," by L. D. Bulkley, in the Medical Record, Jan. 4, 1890.
NATURAL MINERAL WATERS. 187
latter constitute a group by themselves, their characteristics being the
notable paucity of salts of any kind. They are usually light and agree-
able waters. Some of the calcic waters are markedly diuretic. Thus,
the Poland Spring, of Maine, Cressou Spring, Pennsylvania, and Wau-
kesha Silurian Spring, Wisconsin, are distinctive examples of such
waters, and there are other springs whose waters are similarly consti-
tuted. Because of the small quantity of solid constituents they contain,
they may be designated PURE WATERS. They often serve a useful
purpose in washing out or cleansing the emunctories, and in some cases
may be used to advantage in eczema and psoriasis, as met with in large,
plethoric persons, in those of sedentary habits, and in bon-vivants.
As examples of the ALKALINE WATERS, in which the chief ingre-
dients are the alkaline carbonates, especially sodium carbonate and the
carbonates of calcium and magnesium, and sodium chloride, together
with a variable amount of carbonic acid gas, Vichy (Grande-Grille),
Vals, Royat, Carlsbad, and Ems, in Europe, and Saratoga Vichy, and
Ojo Caliente, New Mexico, in the United States, may be mentioned.
An artificial " Carlsbad salt" may be prepared according to the follow-
ing formula, recommended by Otto Leichteusteru : l Crystallized sodium
sulphate, 3v ; sodium carbonate, 3ii ; sodium chloride, si. Where increased
peristaltic action is desired, a larger proportion of sodium sulphate may
be added to the formula. As a substitute for the well-known alkaline-
saline Ems water, a formula consisting of 2 parts of sodium bicarbonate
and 1 part of sodium chloride, one teaspoonful of which is to be dis-
solved in a quart of water, may be given.
SALINE WATERS contain chiefly sodium chloride, but a special group
contains, in addition, the sulphates of sodium and magnesium in lafge
amounts. The latter are the so-called "bitter waters." To the first
group belong some of the Saratoga waters, especially Congress Spring,
and St. Catherine's Spring in Ontario, Canada, and in Europe, Kreuz-
nach, Homburg, Kissingen, and Wiesbaden. The BITTER WATERS, in
addition to the sodium and magnesium sulphates, contain the carbonates
of lime and magnesium and the sulphate of calcium. The noted Pullna
water of Bohemia, and the Hunyadi-Janos, Franz-Josef, JEsculap,
and Rakoczy of Hungary, may be taken as types. The Franz-Josef
(Ofen) bitter water is very closely represented by equal parts of mag-
nesium sulphate and sodium sulphate. An artificial Hunyadi-Janos
water may be imitated according to the following formula : Magnesium
sulphate, 225 grains ; sodium sulphate, 262 grains ; sodium chloride, 7J
grains ; water, Oi. Friedrichshall water may be imitated as follows :
Sodium sulphate, 105 grains ; magnesium sulphate, 75 grains ; sodium
chloride, 60 grains ; magnesium chloride, 30 grains ; water, Oi. The
Hathorn Spring, Saratoga, and Crab Orchard Spring, Kentucky, belong
1 Ziemssen's Hand-Book of General Therapeutics, vol. iv., London, 1885, p. 440.
188 GENERAL TREATMENT.
to the same group, although they are not so strong in solid constituents
as the foreign waters referred to.
As examples of CHALYBEATE WATEES, those of Rawley Springs,
Virginia, Sharon Chalybeate Spring, New York, Schwalbach, Germany,
and Spa, Belgium, may be mentioned. They prove useful sometimes in
acne and seborrhoea, and in neurotic eczemas occurring in anaemic, spare,
overtaxed women.
Among the strongest of the ARSENICAL WATERS are those of La
Bourboule, in France, and of Levico, in the Austrian Tyrol ; but the
results from their employment, according to my experience, are not so
marked or beneficial as might be expected from such strong waters.
They should be used at the springs rather than from bottles.
Mineral waters should always be taken a half-hour or longer before
meals, and drunk slowly. Much of the benefit accorded to the proper
use of saline mineral waters is probably due to the mild purgation which
accompanies their introduction into the alimentary tract. Laxative and
purgative saline waters stimulate the nerves of the stomach and intes-
tines, and thus excite reflexly peristaltic movements, aid the removal of
accumulated products, and in consequence improve digestion and assimi-
lation.
Animal Extracts. There are other agents of an entirely different
kind which have been found to be of service in various and diverse dis-
eases of the skin, among which are the extracts of certain organs, as the
brain and the various glandular bodies of the lower animals. Of these
the THYROID GLAND of sheep and other animals, variously prepared, in
the form especially of a glycerin or a desiccated extract, may be especially
referred to. It has been proved that this drug acts favorably in some
cases of lupus vulgaris, ichthyosis, psoriasis, and chronic, intractable
eczema ; also in fibroid formations and in scars. The drug, however, as
the author's experience has shown, must be used with caution, on account
not only of the febrile reaction but also of symptoms of other systemic
disturbance, such as flushing, giddiness, forgetfulness, depression, melan-
cholia, and palpitation, and sometimes the insidious formation of deep-
seated abscess. The dose varies from one to five grains once or twice daily
or less frequently. It should in all cases be small at first, the amount
being gradually increased from week to week. Symptoms of general
disturbance should be watched for, and when they occur the use of the
remedy should be suspended for a time.
THIOSINAMINE and TAURINE, administered hypodermically, from half-
to three-grain doses, are occasionally made use of with benefit in such
diseases particularly as lupus, and also in certain cases of the simpler but
intractable inflammatory diseases, such as eczema, psoriasis, and acne. 1
1 Dr. S. G. Dixon has observed several well-known cases of inveterate lupus and
acne where these remedies acted favorably within a short period and with remarkable
efficacy.
LOCAL TREATMENT. 189
Preparations made from the bacillus tuberculosis, such as the so-
called " Koch's lymph" or " tuberculin," and the like, are occasionally
employed hypodermically, therapeutically, and for diagnostic purposes,
in tuberculosis ; but, although decided benefit sometimes follows their
use in lupus vulgaris and other conditions, they are too uncertain and
dangerous in their action to be used for ordinary cases.
LOCAL TREATMENT.
External remedies are used with the view of relieving or of curing
the disease. For the majority of diseases they constitute the most valuable,
and for some the only satisfactory, means. They are especially useful in
the many local and localized affections to which the skin is prone, and are
made use of in one form or another for almost all cutaneous manifesta-
tions. They are, of course, very numerous, and include a great variety
of substances, which are employed either alone or, more often, in com-
bination, and according to certain methods or with special appliances.
There are many drugs that find employment in the local treatment of
cutaneous diseases, some of which are of such importance as to merit
special mention. They are used in a variety of forms, as powders, oint-
ments, pastes, or lotions, and in the form of special media. The subject
of local treatment may be considered under the following captions.
Powders. Simple, innocuous substances, chiefly in powder form, are
employed in ointments, pastes, lotions, and as dusting-powders. Of
these, wheat-starch, corn-starch, rice, Venetian talc, kaolin, oxide of
zinc, oleate of zinc, stearate of zinc, carbonate of zinc, calamine (an im-
pure carbonate of zinc, brownish-pinkish in color), carbonate of mag-
nesium, chalk, silicate of magnesium, subnitrate of bismuth, carbonate of
bismuth, oleate of bismuth, orris root, and lycopodium, may be mentioned.
OXIDE OF ZINC is the most generally useful in this list, and serves as the
basis of the well-known oxide of zinc ointment and oxide of zinc paste.
Carbonate of magnesium is of value especially as an absorbent dusting
powder. Both oxide of zinc and calamine are much used in acute erythe-
matous conditions in the form of aqueous lotions, the powders being held
in suspension. The color of calamine varies, but as ordinarily met with
equal parts of that drug and oxide of zinc produce the flesh tint.
Stimulating and germicidal drugs in powder form may sometimes be
employed with benefit, as, for example, calomel in chancre and other
ulcerative lesions. The fumes of sublimed calomel are also of value in
ulcerative lesions in which mercurials are indicated. Aristol, iodoforni,
acetauilide, and many other drugs may be used for similar purposes.
Pats and Oils. The oils and fats made use of are lard, suet, lano-
lin, adeps lanae, glycerin, cod-liver oil, olive oil, almond oil, walnut oil,
cacao butter, spermaceti, petrolatum, and the numerous other petroleum
products, variable in composition and consistence.
190 GENERAL TREATMENT.
LANOLIN is a useful addition to the list of fats which may be employed
as ointment bases, but its penetrating, peculiar sheepy odor is somewhat
objectionable. This, however, may be in a measure overcome by em-
ploying it with other fats and oils and with perfumes. It contains a large
percentage of water, will take up additional water, and consequently is
of value where an evaporating, cooling ointment is called for. Lanolin
when entirely freed from its water proves irritating in some cases, by
abstracting water from the skin. Lanolin does not dissolve chrysarobin,
nor does it subdivide mercury finely enough to be valuable for employ-
ment with this drug. The different petroleum ointments, as petrolatum,
vaseline, cosmoline, etc., unless properly manufactured and freed of im-
pure paraffin oils, may irritate some skins.
ADEPS LANJE (similar to but different from lanolin) is recommended
by Unna and others as a substitute for lanolin, the writer named pre-
ferring it to lanolin. The objectionable free chlorine which some investi-
gators state to exist in it Unna and Mielck have not been able to find.
The following formula makes a soft, creamy, desirable ointment : Adeps
lanse, 10 parts; oil of sweet almond, 10 parts ; orange flower water, 20
parts. The water of orange flower disguises the odor of the adeps lauae
better than most perfumes, so that this ointment is not objectionable on
this account. The odor of adeps lanae is not so sheepy and penetrating
as that of lanolin. Unna gives the following ointment, which he calls
" cremor refrigerans :" Lanolin, 1 parts ; lard, 20 parts ; rose water, 60
parts. The formula makes a soft, creamy ointment, too soft for most
purposes unless zinc oxide or other powder be incorporated with it.
GLYCERIN is a poor excipient for drugs that are to be absorbed by
the skin. It does not penetrate the skin, and therefore where penetra-
tion is needed it does not take the place of lard or oil. On the other
hand, where only a local effect of the drug is called for, as in the case of
parasiticides, and where systemic effect is to be avoided, as in the use
of corrosive sublimate, it is to be preferred.
Sulphur, Resorcin, Tar. Substances and drugs containing sulphur,
and products derived from the coal and wood tars, such as sublimed
and precipitated sulphur, hypochloride of sulphur, potassium sulphide,
sulphurous acid, sodium hyposulphite, resorcin, ichthyol, thiol, naphtol,
hydronaphtol, tar, oil of tar, oil of cade, oil of birch, creosote, carbolic
acid, oil of turpentine, and creolin, are all used. Some of these may be
considered specially.
SULPHUR is of great value not only as a parasiticide, as in scabies
and tinea versicolor and the like, but also in affections of the sebaceous
glands, particularly in acne, comedo, and seborrhoea, as well as in other
diseases. It is a " keratoplastic," or " reducing," agent, withdrawing
oxygen from the tissues and favoring the cornification of epithelium. In
strong doses, however, it destroys epithelium. Its action is similar to
that of resorcin, pyrogallol, and chrysarobiu. In contradistinction to this
LOCAL TREATMENT. 191
class of remedies the so-called " keratolytic," or " oxidizing," agents, as
typified by corrosive sublimate and the chlorine compounds, may be
referred to.
ICHTHYOL is derived from a bituminous mineral, rich in the fossilized
remains of fish and marine animals (hence its name), found in Southern
Europe, particularly in the Tyrol. The dry distillation of this mineral
yields an oil containing about ten per cent, of sulphur in chemical com-
bination, which by treatment with sulphuric acid becomes a sulphonate.
By neutralization of the latter with alkalies the corresponding ichthyol
salts are obtained, of which the principal are ichthyol-sodium and
ichthyol-ammouium, the former generally passing under the common
name of ichthyol. Ichthyol is of service in burns, erysipelas, lymphan-
gitis, certain forms of eczema, leg and other ulcers, and in other diseases,
employed as a solution or an ointment. THIOL is similar to ichthyol
in its properties, and is comparatively odorless.
RESORCIX. This is a useful remedy, and may be employed in such
diverse conditions as seborrhoea, especially of the scalp, and epithelial
neoplasms. In seborrhoea of the scalp, in the strength of from ten to
twenty grains to the ounce, in ointment or lotion form, with or without
glycerin, it is of value. In sebaceous gland degeneration and in the
milder forms of epithelial cancer which occur so commonly about the
nose, cheeks, and forehead, used as a caustic, twenty-five or fifty per
cent, strength with plaster, it is distinctly valuable. It oxidizes upon
exposure to the air, like pyrogallol and some other substances of this
group, becoming brownish, and stains the skin more or less deeply,
according to the strength employed. It is a stronger and more stimu-
lating remedy than sulphur.
Resorcin, like sulphur, but in a more marked degree, has a double
action on the skin : in weak strength it is keratoplastic, that is, it
tends to harden the skin by favoring cornification of the epidermis ; and
employed in strong solution it is keratolytic, macerating and destroying
the skin. It may be considered in its action on the skin as belonging to
the class of remedies known as " reducing agents," exhibiting that form
of chemical action.
TAR (pix liqnida) is one of the most valuable of remedies in squamous
eczema and psoriasis, acting as a stimulant and constrictor to the cutaneous
capillaries; but it is not tolerated by all skins, and hence it should be
prescribed discreetly, and at first weak. It is employed as an ointment,
from one-half drachm to two drachms to the ounce, and in the form of
lotion and emulsion. The official tar ointment is too strong for most
cases, at least of eczema. A better preparation, useful in subacute patches
of eczema, consists of: Tar ointment, 3ii ; zinc oxide, 3ss. ; cold cream
ointment, 3vi. The oils of tar, as OIL OF CADE and OIL OF BIRCH, may
be used advantageously with alcohol, and with alcohol and ether, as in
the following formula, which dries rapidly upon the skin : Oil of birch,
192 GENERAL TREATMENT.
10 parts ; alcohol and ether, each, 15 parts ; spirit of lavender, 5 parts.
Tar, oil of cade, and oil of birch may be advantageously employed with
collodion, half a drachm or one drachm to the ounce, and in this form
are especially useful in localities where other applications are difficult to
retain in place. In employing tar with collodion, the contractile and not
the flexible must be used, as the latter is too oily and does not adhere
satisfactorily. OLEUM RUSCI is a product of the bark of the white
birch (betula alba) by dry distillation. Its odor resembles that of
Eussia leather, and is less disagreeable than that of oil of cade or of
oleum fagi. The crude oil (oleum rusci crudum) is preferable. The
Russian is quite different from the Dutch and the German oil.
CREOSOTE. This is a product of the distillation of wood-tar. It
much resembles carbolic acid in its properties. It acts upon the cutaneous
sensory nerves as an anaesthetic, and may be used in diseases where
carbolic acid and tar are indicated; but its penetrating, smoky, dis-
agreeable odor is an objection against its use for ordinary cases. It may
be used as an ointment in the strength of from ten grains to one drachm,
or even more, to the ounce ; also in the form of creosote-water, one per
cent, strength, though it does not make a perfectly clear solution. It is
soluble in all proportions in absolute alcohol, ether, chloroform, acetic
acid, benzin, and in the fixed and volatile oils.
Of the BALSAMS, camphor, menthol, thymol, styrax, chaulmoogra oil,
gurjun oil, benzoin, balsam of Peru, Canada balsam, and turpentine may
be quoted.
NAPHTOL, or BETA-NAPHTOL (a phenol occurring in coal-tar, but
usually prepared artificially from naphtalin), and its derivative HYDRO-
NAPHTOL, possess stimulating, antiseptic, and anaesthetic properties, and
find their chief use in chronic inflammations with infiltration of the skin,
as in psoriasis, and in the parasitic affections, especially scabies.
COMPOUND TINCTURE OF COAL-TAR.
COAL-TAR in tincture form is of value in many cases where tar is
indicated, especially in eczema and psoriasis and in pruritus. The
" compound tincture of coal-tar," the formula for which was published
by the author, 1 has been found useful, and is a substitute for similar
proprietary preparations known by the names of " coal-tar saponine,"
" coal-tar Le Boeuf," and " liquor carbonis detergens." With water, it
being always employed diluted, it forms an emulsion. The best results
are obtained by employing it in a much diluted state, five to fifteen
minims to the ounce. The following is the author's formula : Coal-tar
(1 part) should be digested with the tincture of quillaja (6 parts), with
frequent agitation, for not less than eight days, preferably for a longer
period, and finally filtered. The resultant product is a brown-black
tincture, which upon the addition of water forms a cleanly yellowish
1 Amer. Jour, of the Med. Sci., May, 1894.
CHRYSAROBIX, PYROGALLOL. 193
emulsion, the color and certain other characters varying with the variety
of coal-tar used. The strength of the tincture of quillaja should be 1
to 4 with 95 per cent, alcohol.
IODINE, IODOFORM, and the like, bromine, chrysarobin, pyrogallol,
gallanol, anthrarobin, and aristol are all made use of, especially chrysa-
robin and pyrogallol, both valuable drugs. Iodine is useful as a stimu-
lant and as a parasiticide. Preparations, especially ointments, contain-
ing iodine are useful for reducing glandular engorgements and indura-
tions. An ointment composed of equal parts of iodine and mercury
ointment will be found serviceable. lodoform finds its chief use in the
dressing of wounds, as an antiseptic.
Chrysarobin, Pyrogallol. CHRYSAROBIN is a powerful and very
useful remedy. Its action upon the skin is that of a powerful stimulant,
even in moderate strength tending to set up a peculiar, very active
dermatitis accompanied by chemical changes, in particular by staining,
the colors being varied, brownish-red, mahogany, and purplish colors
prevailing. The drug, derived from goa powder, is particularly useful
in removing chronic patches of inflammation, such as occur in psoriasis,
eczema, syphilis, and lepra, in from one to ten per cent, strength in
ointment, plaster, or collodion form, but it must always be applied
discreetly, because of the inflammation of the neighboring skin that it
is liable to provoke. On account of its staining properties, staining
clothing indelibly as well as discoloring the epithelial structures, its use
strong, say from two to ten per cent., is restricted ; but weaker one to
three grains to the ounce it may often be employed to advantage in
chronic eczematous patches and the like. The patient should always be
made aware of its staining properties and of the inflammation it is
liable to produce. Chrysarobin may be combined advantageously with
other active remedies, as in the "compound chrysarobin ointment"
(Unna), employed in psoriasis, in lepra, and in chronic inflammatory
sclerosed patches generally : Chrysarobin, 5 parts ; salicylic acid, 2 parts ;
ichthyol, 5 parts ; petrolatum, 88 parts.
ANTHRAROBIN, which may be regarded as an inferior substitute for
chrysarobin, is produced from alizarin by reduction. It is a yellowish-
white granular powder, almost insoluble in water, but readily soluble in
alcohol and weak alkaline solutions, and mixes readily with fats to form
ointments.
PYROGALLOL is useful in psoriasis, but should not be used over a
large surface, on account of absorption ; it is also of value in carcinoma
of the skin, in fifty per cent, strength, applied as a plaster, in many cases
acting very favorably. Its action is slow, but is not painful. A slough
forms. The drug oxidizes on exposure to the air, turning blackish and
staining the skin.
ARISTOL diminishes suppuration and hastens the cicatrization of
wounds and ulcers. It is said to contain a large percentage of iodine.
13
194 GENERAL TREATMENT.
Chemically it is a dithymol diiodide. It is a substitute for iodoform,
with which it has similar properties, and has the advantage of being
comparatively odorless. In ointment form it is useful in some of
the superficial and pustular forms of eczema and similar dermatoses,
especially in children.
SULPHATE OF ZINC, sulpho-carbolate of zinc, acetate of zinc, alum,
sulphate of copper, and sulphide of barium, are astringents and caustics
occasionally employed, sulphate of zinc being the most useful.
A valuable compound, useful in many inflamed conditions of the skin,
is prepared with sulphate of zinc, sulphide of potassium, and water,
according to the following formula : Sulphate of zinc, gss. ; sulphide of
potassium, 3ss. ; water, iv. The salts are dissolved in water separately,
and are then combined, the resultant being an abundant white, light
precipitate. A double decomposition occurs, resulting in zinc sulphide,
potassium sulphate, and precipitated sulphur. The zinc sulphide thus
formed is a hydrate, and of a white, pulverulent appearance. The
preparation (designated by the author 1 "zinc sulphide lotion") is used
as a lotion with the sediment, and is of value, full strength or diluted,
in acne, seborrhoea, superficial lupus erythematosus, localized erythe-
matous affections, and in some forms of superficial erythematous and
vesicular eczema. The proportion of the two salts used may be varied
to suit the condition. Thus, for sensitive eczemas and the like, the
author frequently prescribes as little as from two to five grains of each
salt to the four ounces. On the other hand, in acne it may often be ad-
vantageously ordered stronger than in the formula given, or one drachm
of each salt to four ounces. It is not a caustic or strong remedy.
Acids. Of the acids, carbolic, salicylic, boric, lactic, acetic, tri-
chloracetic, chromic, tannic, benzoic, nitric, and hydrochloric are those
in common use, and of these carbolic acid, boric acid, and salicylic acid
are particularly valuable. The last-named possesses the property of
acting specially upon the horny layer of the epidermis.
CARBOLIC ACID. This occupies a conspicuous place among the drugs
employed in the treatment of cutaneous diseases. It is an exceedingly
valuable remedy in diverse diseases, but is especially useful as an anti-
pruritic. It benumbs the sensory nerves, acting as a local anaesthetic.
In eczema it is of much value, particularly in the erythematous variety
in middle-aged and elderly subjects, in many cases acting most happily.
In pruritus it is of great service. It is prescribed in the form of oint-
ment, paste, and lotion, most satisfactorily in the latter forms. As an
antipruritic with water or with water and glycerin, it is employed in the
strength of ten or twenty grains to the ounce. It is most efficacious in
the form of compresses, but is generally used as a simple lotion. In
addition to its employment in eczema and pruritus, it is serviceable in
1 Medical News, Nov. 10, 1884.
MERCURIALS. 195
the treatment of ringworm and tinea versicolor, in pernio, in some
hypertrophies, and in wart and warty formations due to varied causes.*
In the latter diseases, as well as in infiltrated patches of eczema, it is
of course used stronger than indicated, sometimes even full strength.
Applied pure it acts powerfully but superficially on the skin, producing a
white film. The oftener it is reapplied on a spot, the deeper its effect
penetrates. It is employed as an antiseptic and germicide in many
diseases, especially in excoriated and ulcerated lesions.
BORIC ACID is a valuable remedy in the treatment of the milder
grades of congestive and exudative erythemata and in some of the more
superficial inflammations generally, especially in erythematous eczema.
Where the skin is naturally thin and sensitive to external impressions,
and in infantile eczema and erythema-intertrigo, it is particularly ser-
viceable. It is often useful in cases where other and stronger drugs are
not tolerated. It possesses a sedative or soothing effect upon the skin,
and is especially useful in the form of an aqueous lotion, to which
sometimes a little glycerin may be added with advantage. It is a drug
that seldom irritates the skin or aggravates the existing disease, and
hence is a safe remedy. It is soluble in 25 parts of cold water, 15
parts of alcohol, and 10 parts of glycerin.
SALICYLIC ACID possesses a peculiar action upon the epidermis,
gradually loosening and separating it from the corium without setting
up inflammation. It is a solvent of the epidermis, but its action is
altogether different from that of caustic potassa. Its effect is compara-
tively slow, considerable time being required to produce this result, but
is perfect, as shown by the complete manner in which a circumscribed
callosity may be removed by the continuous application of a ten or
twenty per cent, plaster. But it is also used weak to advantage for the
opposite effect, as a regenerator of defective epithelium, being employed
for this purpose, usually in ointment or paste form, in such diseases,
for example, as eczema vesiculosum. The more superficially seated the
disease is, the better, as a rule, is the result. Salicylic acid is soluble
in 450 parts of water, in 2 parts of absolute alcohol, and (by careful
heating) in 50 parts of glycerin.
Alkalies and Caustics. Of the alkalies and caustics, potassa,
potassa cum calce, ammonia, arsenic, chloride of zinc, nitrate of silver,
ethylate of sodium, acetate of sodium, lime water, borate of sodium,
liquid, soft, and hard soaps, and quillaja saponaria, may be referred to.
They act upon the natural oils and fats of the skin, and loosen the cells
of the corneous layer of the epidermis, freeing the surface of effete
matter in the form of scales and crusts, thereby preparing the way for
the employment of other agents. In the form of washes and baths they
should be employed weak rather than strong.
Mercurials. The mercurials in common use include mercury, the
white and red precipitates, calomel, black wash, acid nitrate of mercury,
196 GENERAL TREATMENT.
ointment of nitrate of mercury, corrosive sublimate, red iodide, red
sulphide, red oxide, and yellow oxide. The preparations of lead com-
prise litharge, the oleate, acetate, subacetate, carbonate, nitrate, and
iodide.
Among the mercurials, MERCURIAL OINTMENT, CORROSIVE SUBLI-
MATE, CALOMEL, WHITE PRECIPITATE, and BLACK WASH are the most
generally valuable. Corrosive sublimate is employed chiefly as a lotion,
as a germicide, and also as a discutient. Calomel and white precipitate
are used in the form of ointments in eczema and allied diseases, and
in syphilitic manifestations, although for this purpose they are inferior
to mercurial ointment. The latter may sometimes be used, weakened,
especially with oxide of zinc ointment, with benefit in various lesions
other than those due to syphilis. Owing to the readiness with which
mercury is absorbed by the skin through inunction, this ointment should
not be used over large areas of surface for a long-continued period with-
out due precaution.
Two or more mercurials are sometimes'combined with advantage, as in
the following, generally known in London as " Startin's nitric oxide of
mercury ointment," useful especially in subacute eczema : Red (nitric)
oxide of mercury, gr. vi ; bisulphate of mercury, gr. iv ; wax cerate, %i.
An ointment much used in England, known as " unguentum metallo-
rum," is composed of equal parts of ointment of acetate of lead, oint-
ment of nitrate of mercury, and ointment of oxide of zinc. White
precipitate ointment may be substituted for the ointment of nitrate of
mercury.
Some of the mercurials may often be added with advantage to the
sulphur ointments, as in the following formula, long known in France
and Germany, and in the latter country called " the shepherd's salve :"
Red sulphuret of mercury, 1 part ; sublimed sulphur, 24 parts ; lard, 75
parts. It is useful in various pustular affections, especially in those
involving hairy regions.
Such drugs and preparations (some of them analgesic) as ALCOHOL,
ETHER, chloroform, collodion, liquor gutta-perchse, ethyl chloride, opium,
morphine, COCAINE, cannabis indica, belladonna, aconite, atropine, ergot,
cyanide of potassium, witch-hazel, solution of peroxide of hydrogen, per-
manganate of potassium, and chloral, are employed for various purposes.
Cantharides, mustard, croton oil, tartar emetic, and arbor vitse are
occasionally called into requisition.
COLLODION and LIQUOR GUTTA-PERCHA (" traumaticin") both serve
as excellent vehicles for applying many remedies to the non-hairy regions,
as, for example, chrysarobin. The oils of tar may be advantageously
applied with collodion, a half-drachm or more to the ounce. After drying,
an additional coating of pure collodion over the medicament may be ap-
plied, in order to protect the clothing. The compound tincture of ben-
zoin may also be used as a vehicle for applying various medicaments to
THE WET PACK. 197
the skin, such as corrosive sublimate in tinea circiuata, as suggested by
R. W. Taylor.
The mode of employment of some of the drugs and remedies enumer-
ated, especially the forms in which they are commonly used, as well as
the special preparations, may be conveniently considered under the fol-
lowing heads.
MODES OF TREATMENT.
Water, Baths. Water, used for the purpose of cleansing the skin
and removing eifete matter, as scales and crusts, with the view of treating
the skin itself, or in the form of more or less prolonged baths, simple or
medicated, is a most useful therapeutic agent. Its employment, however,
should be directed with judgment, inasmuch as in certain morbid con-
ditions, as many cases of eczema, it is liable to produce mischief rather
than benefit. Where plain water is used, soft or rain water is preferable.
The warm bath is especially serviceable in certain inflammatory diseases,
as psoriasis, and in hypertrophies of the epidermis and the corium, for
example, ichthyosis. The beneficial effect of the continuous applica-
tion of warm baths of simple water in chronic psoriasis is exemplified
strikingly at Leukerbad, Switzerland, where patients (both sexes in
common) remain submerged for hours or for half the day, walking, sit-
ting, talking, and reading in a large pool. The continuous warm bath,
so constructed with mattress and pillows that the patient is enabled to
remain comfortably in the water for days or weeks at a time, may also
be referred to as being useful in the treatment of extensive chronic in-
flammations of the skin, such as pemphigus, psoriasis, and burns. Plain
water, cold or hot, is also used to advantage in the form of douches,
with or without friction, as in acne. The vapor or steam bath is par-
ticularly useful where the skin needs stimulation, as in chronic acne,
comedo, and keratosis pilaris. The stimulating effect locally of a hot
bath at from 100 to 110 F. is generally obtained in from five to ten
minutes : baths prolonged much beyond this duration are usually followed
by general depression.
Hot water (for most cases as hot as can be borne) often acts happily in
relieving local congestion, inflammation, and nerve irritation. Thus, in
some cases of localized eczema, especially circumscribed patches, and in
pruritus, compresses or cloths wrung out of hot water and applied to the
part will generally afford much relief during a paroxysm of itching.
THE WET PACK.
The wet pack, with tepid or cold water, consists of a sheet or pieces
of sheeting wrung out of water, with which the patient is wrapped
closely and then wrapped in and covered with blankets for half an hour or
longer, diaphoresis being thereby induced, after which the skin is rubbed
dry and anointed. This mode of bathing is useful in extensive or uni-
versal inflammations, and especially in psoriasis. It tends to allay heat
198 GENERAL TREATMENT.
and irritation, and to soothe the nerves, especially when the cold pack is
used. The beneficial effects upon the general health of the cold water
pack have been pointed out by numerous observers. The experiments
of Blagoveshchenski l show that in healthy persons cold packs produce
increased nitrogenous metabolism and assimilation of nitrogens, with in-
creased loss by the skin, and that they diminish the quantity of nitrogens
retained in the body. They slow the pulse and respiration and raise the
arterial pressure ; lower the temperature ; augment the appetite ; cause
the person to sleep well ; and give increased strength, with a general
sense of feeling in good health. The effect of the Turkish bath on the
system has been considered in the chapter devoted to the physiology of
the skin.
Under the influence of tepid sweet water baths (temp. 85 to 95 F.)
of from one-half to one hour's duration, the assimilation of fats is aug-
mented in healthy persons, as shown by the gain in weight. But in the
case of saline baths the opposite is noted, the assimilation of fats being
invariably lessened, with a diminution in the secretion of urine. 2
Contrary to the generally accepted opinion, Goldberg 3 found that the
influence of warm baths and sweating upon the elimination of drugs was
to diminish the excretion of the same by the urine.
SULPHUR AND THERMAL WATER BATHS.
The SULPHUR or SULPHURETTED WATERS, as, for example, those of
Richfield, Sharon, and Avon, in New York, as well as many others in
the United States, are useful in varied diseases of the skin. The manner
in which they act upon disease is not always clear, but that cures often
take place through bathing cannot be questioned. At the same time,
the author is of opinion that their value as curative agents is generally
over- rather than under-estimated, and that their indiscriminate employ-
ment often results in no benefit to the patient.
Among the SULPHUR SPRINGS richest in sulphur compounds are
Herculesbad, in Hungary, and Aachen (Aix-la-Chapelle), in Germany.
The former contains about 105 grains to the quart of water, and the
latter 60 grains. As a rule, sulphur wells are poor in solid con-
stituents, and it is probable that, in most cases at least, no specific
action is to be derived from their use. The sulphurous baths of
Aachen, renowned for the treatment of syphilis, doubtless owe their
efficacy as much to the simultaneous free use of mercury and the iodides
as to the strong sulphur compounds in the water. The same remark
applies to the Hot Springs of Arkansas (although these springs are not
sulphurous), where also mercury and the iodides are freely used, and are
1 Lend. Practitioner, Nov. 1889.
2 See the experiments of Zavadsky and Sliitchevsky (Lond. Med. Rec., Nov. 20,
1890) ; also KravkofT, ibid., Oct. 20, 1890.
3 Universal Annual of the Medical Sciences, edited by Sajous, vol. v., Bd. lii., 1890.
MEDICATED BATHS. 199
remarkably well tolerated, in the treatment of various diseases, but
especially of syphilis.
There are many other well-known HOT SPRINGS in the United States,
such as, for example, those of Virginia, North Carolina, and New Mexico
(Las Vegas), as well as others in Colorado, California, and other States.
Many springs of this kind are for the most part simple THERMAL
WATERS, depending for their virtues upon the high temperature and
other peculiarities rather than upon specific salts or gases which they
may contain, often in small amount. The waters of the Hot Springs
of Arkansas resemble in their analysis those of Gastein, Austria, and
PfafFers, Switzerland. The Paso Robles Hot Springs, of California, are
somewhat like those of Aachen, while the Idaho Hot Springs, of Colorado
(near Denver), are alkaline and similar to Carlsbad waters.
The action upon the skin of some baths of this kind (thermal waters),
as the Warm Springs of Virginia and Schlangenbad (the Serpent Bath)
and "VVildbad (near Stuttgart), Germany, is peculiar. A velvety
smoothness is imparted to the skin, as though it had been anointed.
It is probably due to the presence of certain silicates in the water.
MEDICATED BATHS.
The ordinary bath contains from 25 to 30 gallons of water. The tem-
perature for prolonged baths should be from 90 to 100 F., according
to the disease, the patient, and other circumstances. Emollient and
soothing baths are made with starch (1 to 3 Ibs. to the bath) ; bran (2
to 5 Ibs.); linseed (1 ilx); gelatin (1 to 3 Ibs.); and size (I to 3 Ibs.).
The substances should be acted upon by boiling water in a small vessel,
strained through a coarse cloth, and then added to the bath.
ALKALINE BATHS are prepared with carbonate of sodium (2 to 10 oz.)
or potassium (2 to 5 oz.), preferably the latter ; borax (like strength) is
also acceptable ; and a good bath is made by dissolving and using ^ to 1
Ib. of soft soap, which proves serviceable in the papular urticaria of chil-
dren, in some eczemas (with chronic thickening), and in psoriasis. Bran
may be sometimes added with advantage to the alkaline baths.
The SULPHUR BATH is most conveniently made with sulphide of
potassium (3ii to 3iv to the bath), to which may be added bran or
gelatin, prepared as above stated. Startin's compound sulphur bath is
prepared with precipitated sulphur, Sii ; hyposulphite of sodium, Si ;
dilute sulphuric acid, Sss. ; mixed in a pint of water and then added
to the bath. Leichtenstern l gives a formula calling for sulphide of
calcium (3iii to 3iv), with the addition of crude hydrochloric acid (Siii),
to thirty gallons of water. The inhalation of the hydrosulphuric acid
should be prevented by spreading a cloth across the bath.
The TAR BATH is given by tarring the skin and allowing the patient to
1 Ziemssen's Handbook of General Therapeutics, vol. iv. p. 443. London, 1885.
200 GENERAL TREATMENT.
remain in a warm bath for several hours, a procedure which is usually
employed only in desperate cases of psoriasis.
SALT, OR BRINE, BATHS.
The effect of the salt water, or brine, bath upon the skin may be
regarded as stimulating, although it varies locally, as it does generally
with the vigor of the individual, the temperature of the water, and the
duration of the bath. The strength of the average sea water is some-
what over two per cent. The effect of the salt, or brine, bath upon
some diseases of the skin is beneficial. The salt obtained from the
natural brine wells of the interior is well adapted for preparing artificial
salt-water baths, being purer, cleaner, and more readily soluble than sea
salt. In a five per cent, solution, the most generally useful, it cleanses
the skin more thoroughly than soap, and removes odors and exuviae, thus
acting as a deodorizing as well as a cleansing agent. This strength also
leaves the skin soft and supple. Piffard has carefully studied the effect
of the salt-water bath upon the skin in health and in disease, and has
presented his conclusions to the American Dermatological Association. 1
These baths (five per cent, strength, or about 10 Ibs. of salt to 25
gallons of water) are regarded as of service in several cutaneous diseases,
especially in some cases of subacute eczema, in psoriasis, in furuncu-
losis, in urticaria, and in the irritable rashes of hot weather; also in
the pustular and ulcerative syphilodermata, and in the scrofulodermata.
Even in acute moist eczema, where, as is well known, the plain fresh-
water bath, with or without soap, usually aggravates the disease, Piffard
finds a weak brine bath (| Ib. to 1 Ib. of salt to 25 gallons of water)
of service, the patient usually observing that the skin feels better than
it did before the bath. For most cases the water should be as hot as
can be comfortably borne, the immersion lasting about fifteen minutes.
Common salt or brine wells, with accommodations for bathing, exist
at Warsaw, New York, at Mt. Clemens, Michigan, and in Europe at
Kreuznach and Nauheim.
Soaps. The two varieties of soap principally made use of are the
soda, or hard, and the potash, or soft. Both are employed extensively as
therapeutic agents, and are brought into frequent requisition for various
purposes. The hard soaps find their office mainly in cleansing the skin
of ordinary extraneous matter, and as a basis for some of the medicated
soaps.
SOFT SOAP, termed also SAPO MOLLIS and SAPO VIRIDIS, is a soft, yel-
lowish, brownish, or greenish soap, containing an excess (usually about 4
per cent.) of caustic potash. The fatty substance from which it is made
may be an animal fat or a vegetable oil of one kind or another, differences
which, together with the manufacture, account for its variable character
/ O '
1 Salt in Dermal Hygiene and Therapeutics, Jour, of Cut. and Gen.-Urin. Disv,
vol. v. p. 421, 1887.
MEDICATED SOAPS. 201
as to caustic property, consistence, color, and odor. It is a useful agent,
employed alone with water, with alcohol in the form of a tincture, as in the
" spiritus saponatus kalinus" (two parts of soap and one part of alcohol),
or in combination with certain oils, as the tarry oils and other substances.
It is an effective detersive agent, and usually proves sufficient to free the
skin of scales, crusts, and other foreign matter. As its effect upon the
skin is mildly caustic, its employment should be restricted. When applied
for any length of time or repeatedly, this property should be counteracted
by the subsequent application of some bland oil or fat, to prevent rough-
ness and chapping of the epidermis. Through ignorance of the anatomy
and physiology of the epidermis, soaps are very commonly misused by
being employed to excess. In cases where the epidermis is naturally
weak or is slightly diseased, the use of soap may often be restricted or
withheld to advantage.
MEDICATED SOAPS.
Concerning the so-called TOILET SOAPS, for the purpose of cleansing
healthy skill, care should be exercised in selecting one that is superfatted,
neutral, or but slightly alkaline in reaction, according to the demands of
the skin of the individual. Soaps of this kind not infrequently contain
an excess of alkali, and consequently act harshly on the skin. This
remark applies particularly to many of the glycerin and transparent
soaps, most of which will be found when tested to contain free alkali,
sometimes in considerable quantity. To remedy this defect both toilet
and medicated soaps have been produced not only neutral in reaction
but containing an excess of fat, designated " superfatty soaps." Medi-
cated soaps are manufactured extensively and perfectly, and many new
and useful formulae have been published. Their employment as an
adjuvant is of considerable value in the treatment of certain diseases.
Unna, 1 Eichhoff, 2 and Buzzi 3 have introduced a large variety of such
soaps, hard, soft, and liquid, with definite formulae. A basis soap is
prepared, according to Unna and Mielck's formula, by the addition of
two or (in summer) three parts of freshly prepared soda and one part of
potash lye to pure beef tallow, to which (to prevent the drying effect on
the skin common even to neutral soaps) 4 per cent, of olive oil is added
over and above that required for saponification. This simple superfatty
1 Volkmann's Sammlung Klin. Vortr , No. 252.
2 Ibid., Neue Folge, No. 4, 1890.
3 Correspondenz-Blatt f. Schweizer Aerzte, No. 13, 1891. Unna's soaps, elaborated
in conjunction with Dr. Mielck, chemist and apothecary, and manufactured by Douglas,
of Eimsbuttel, near Hamburg, comprise, among others, zinc soap, which has a drying
action on the skin and is useful in the several disorders of secretion ; salicylic acid soap,
of use in subacute and chronic eczema, and in acne ; ichthyol soap, employed in rosacea
and in squamous eczema ; and marble soap, containing 20 per cent, of marble dust, used
in the keratoses and in acne for its mechanical action. EichhofTs formulae are manu-
factured by F. Miihlens, in Cologne, and contain as superfat 2 per cent, lanolin and
3 per cent, olive oil, the soap mass being made of 3 parts of pure tallow and 1 part of
olive oil. A list, comprising many of the active remedies in use, is published.
202 GENERAL TREATMENT.
soap perfumed is in itself useful for ordinary toilet purposes, especially
for those persons whose skin is naturally delicate, dry, and chapped, or
irritable. Potash is used because it acts more effectively than soda on
the horny layer of the epidermis, and the mixture of the two alkalies
gives a better consistence to the soap. The mass in reaction is absolutely
neutral, is of a yellowish-white color and of the consistence of wax, and
is stable. These soaps are applied in different ways, as simply washing
the skin, rubbing the lather in with woollen cloths, or allowing the lather
to dry on the skin.
In cases where the skin is oily and greasy, the ordinary hard, so-called
neutral soaps, medicated with various substances, such as sulphur, birch
tar, boric acid, ichthyol, naphtol and sulphur, salicylic acid and glycerin,
and corrosive sublimate, are useful adjuvants to other treatment. 1 A
superfatted potash soap has also been prepared by Unna and Mielck,
which occupies a position midway between ointments and soaps, and is
designated " sapo unguiuosus." Of medicated soaps of this kind may be
mentioned "sapo cinereus unguinosus," useful for the introduction of
mercury into the system, and " sapo unguiuosus ichthyolatus."
Another advance in soap therapy, in the form of fluid soaps, intro-
duced by Buzzi, 2 may be referred to. A neutral soap basis is first
made, which is either superfatted with lanolin or rendered alkaline by
carbonate of potassium (1 per cent, or more). Of these soaps some
are neutral, others alkaline, and some superfatty. For certain diseases
there are some advantages in fluid over hard soaps.
H. Hebra 3 also speaks well of the " glycerinum saponatum" prepa-
rations. 4 The soap-basis is an absolutely neutral cocoanut oil soda soap,
in cake form, containing a large percentage (80 per cent, and 92 per
cent.) of glycerin, with which the various drugs are incorporated. 5 The
creosote-salicylic-acid preparation (composed of 90 per cent, of an 80
per cent. " glycerinum saponatum" and 5 per cent, each of salicylic
acid and creosote) is highly extolled as a powerful antibaeillary remedy,
especially useful in lepra.
Dusting Powders. These are employed in the management of cer-
tain of the hypersemic and inflammatory disorders, such as erythema,
intertrigo, and eczema, and in some disorders of the sweat glands. They
are composed of one substance, or of several substances mixed in vary-
ing proportions. Wheat-starch, corn-starch, arrow-root, rice flour, oxide
of zinc, carbonate of zinc, stearate of zinc, carbonate of magnesium,
oleate of zinc, bismuth subnitrate, kaolin, boric acid, alum, salicylic acid,
chalk, French chalk, talc, and the silicious earths, reduced to impalpable
1 J. S. Stiefel & Co., of Offenbach-on-the Main, Germany, manufacture such soaps.
2 Monatsh. f. p. Derm., Bd. x., 1890, p 459. Manufactured by Veysser, of Hanover
3 Die Modern e Behandlung der Hautkrankheiten, Wien, 1890.
4 Made by Sarg, the well-known soap-manufacturer of Vienna.
5 The list of soaps manufactured may be found in Hebra's work above referred to.
STIMULATING LOTIONS. 203
powders, are all used for this purpose. They should be prepared with
care and be perfectly smooth and free from grit. The blander sub-
stances serve to protect the surface from the influence of the air, from
irritation and rubbing, and to absorb exuded fluids. The absorptive
powers of the several substances used for dusting powders have been
tested by Gruendler, 1 who finds that magnesium carbonate stands first
on the list, taking up 5| times its weight of water. Infusorial earths
and silicious substances of different kinds (" kieselguhr") take up 3J
times; kaolin, 1J; zinc oxide, 1 ; talc, | ; creta, f ; amylum, 1 ; and
lycopodium, J. As a simple dusting powder for the purpose of absorbing
discharges, magnesium carbonate is unexcelled. Stearate of zinc is also
useful, either alone or as a basis for other substances. It is a fine, white,
soft powder, is light in weight, and is tenaciously adherent to the surface.
It is non-hygroscopic, and does not tend to ball.
Lotions. Lotions constitute a desirable and cleanly means of applying
a large number of remedies. In many instances they are better adapted
for the relief of disease than ointments ; this is particularly the case
when the affection occupies a large amount of surface, as, for example,
often occurs in urticaria and pruritus. In practice it will be found that
the skin of some persons tolerates lotions in general better than oint-
ments. They may be classified for convenience into the soothing, the
stimulating, and the astringent.
SOOTHIXG LOTIONS.
Soothing lotions are usually aqueous or oleaginous preparations con-
taining substances which allay hyperaemia, inflammation, and nerve irri-
tation. Those in common use are lime water, lime water and oil, lead
water, glycerin and water in various proportions, the glyceroles, as of
lead, zinc, and bismuth, weak solutions of tar and carbolic acid, and
boric acid. The last-named in particular is of great value as a lotion in
many conditions. Washes containing in suspension bland powders, such
as oxide of zinc, calamine, and chalk, are particularly soothing in some
of the acute superficial inflammations. They are for the most part made
up with several ingredients with the view of modifying or arresting in-
flammation in its early stage. The following formula, much used by the
author, may be given : powdered prepared calamine, 3i ; oxide of zinc,
3i ; glycer'n, 3ss. ; lime water, Svi. Lotions of this kind find their use
chiefly in the simple erythemata and in acute and subacute erythematous
and vesicular eczema.
STIMULATING LOTIONS.
Stimulating lotions contain alcohol, ether, certain volatile oils, aqua
ammonite, acetic acid, cantharides, carbolic acid, corrosive sublimate,
black wash, tar, alkalies, camphor, menthol, thymol, benzoic acid, chloral,
ichthyol, sulphur, resorcin, sulphide of potassium, and the like ; several of
1 Ueber Fasten : Monatsh. f. prak. Derm., No. 20, 1888.
204 GENERAL TREATMENT.
these substances are not infrequently variously combined with advantage.
They prove of value in affections of the scalp, as in seborrhoea, eczema,
and psoriasis, where oils and ointments may be contra-indicated on
account of the hair. They are also of service in diseases of the seba-
ceous and sweat glands, and in chronic inflammations, as in acne, acne
rosacea, lupus erythematosus, and eczema.
It may be stated here that many of the so-called stimulating lotions
prove sedative and soothing when employed in a weak state, diluted with
water. Thus, black wash, compound zinc sulphide lotion, compound
tincture of coal-tar, all much diluted, often prove soothing. A useful
sedative lotion recommended by Hutchinson is composed of : Solution
of subacetate of lead, njjx ; compound tincture of coal-tar, 3i; water,
Oi. This may be employed in chronic erythematous and squamous eczema
and similar diseases.
ASTRINGENT LOTIONS are made with alcohol, tannic acid, alum, iron,
acetic acid, vinegar, sulphate of zinc, acetate of zinc, ergot, hamamelis,
and like substances, their principal employment being in hemorrhagic
conditions and in disorders of secretion.
Oils. Some of the natural oils are bland, while others are stimulating.
To the first class belong olive oil, oil of sweet almond, linseed oil, walnut
oil, palm oil, cocoanut oil, lard oil, glycerin, castor oil, cod-liver oil, and
some of the petroleum oils. Bland oils are serviceable for softening and
detaching scales and crusts, and for anointing the surface in a variety of
conditions. They also enter largely into the composition of ointments
and lotions. Examples of stimulating oils are found in the derivative
oils from tar, as oil of cade and oil of birch, and in oils derived from
certain woods, nuts, and balsams, as the oil of cashew-nut, and gurjun
oil or balsam, known also as " wood oil."
Ointments. Ointments constitute the usual, the readiest, and in many
cases the most valuable means of applying remedies to the skin. They
are made with various fats, commonly with prepared lard, lanolin, adeps
laufe, or one of the bland petroleum ointments, and usually contain one
or more active substances upon which their chief virtue depends.
Concerning the penetration of different ointment bases, Aubert l experi-
mented with atropine, causing the subjects to sweat through exercise, and
then examining the fluid. With simple inunction, oils and lard pene-
trated best, but when friction was used lanolin did best, probably owing
to erosions of the epidermis or to the pulling out of hairs, absorption
being thus favored. According to Luff's 2 experiments on the absorption
of medicaments from ointments, the petroleum ointments permit of the
most rapid absorption, lanolin being the slowest.
Like the lotions and the oils, they may be divided into those which are
bland and have a soothing, sedative effect, and those which stimulate.
1 Jour. Cut. and Gen.-Urin. Dis., Dec. 1892.
2 Honatsh. f. prak. Derm., Bd. xi., No. 2.
SOOTHING OINTMENTS. 205
While in some cases ointments may be rubbed firmly or vigorously into
the skin with benefit, in most instances they accomplish more good if
they are rubbed in gently, smeared on lightly, or applied spread thinly
on cloths and bound on.
SOOTHING OINTMENTS.
In this class may be placed simple ointments and cerates, "cold
cream," lanolin ointments, glycerin ointments, ointments of cacao butter
and spermaceti, cucumber ointment, petroleum ointments, diachylon and
oxide of zinc ointments, and many other preparations possessing similar
properties. They are for the most part bland in their nature, and are
employed chiefly in inflammatory conditions, with the view of protecting
the surface and of allaying irritation. Diachylon ointment, prepared
from diachylon plaster or from litharge with olive oil, is a useful remedy
in the treatment of eczema. Oxide of zinc, carbonate of zinc, oleate of
zinc, and oleate of bismuth ointments are likewise valuable in ointment
form, finding their principal use in eczema. These ointments are fre-
quently made to serve as vehicles for the application of other remedies,
such as tar, salicylic acid, resorcin, and the mercurials. They are rubbed
gently into the skin or are smeared on lightly, or, still better, in many
cases, where practicable, are spread on cloths or strips of muslin and
bound on to the affected part.
H. Hebra recommends a soothing boric acid ointment that may be
endorsed as an elegant preparation. The formula is : Boric acid, white
wax, and paraffin, of each, 10 parts ; oil of sweet almond, 60 parts. The
product is a very good oily ointment, somewhat softer than cold cream
ointment (U.S.P.). It approaches nearer to the official cold cream oint-
ment, but contains no glycerin, which for many cases is an advantage.
An elegant, soft, oily, clean, odorless ointment, which may be designated
" boroglycerin cream ointment," consists of : Boric acid, 1 part ; glycerin,
24 parts ; lanolin (anhydrous), 5 parts ; vaseline, 70 parts. The boro-
glycerin solution is to be added to the lanolin and vaseline. Another
good boric acid ointment containing glycerin is composed of: Boro-
glycerite, 511 white wax and cetaceum, of each, 31 ; vaseline, 3vi.
A distinctly soothing ointment, useful in superficial inflammations,
especially erythematms and squamous eczema, recommended highly by
McCall Anderson, is composed of: Oxide of bismuth, 3i ; oleic acid, 3i ;
white wax, 3iii ; vaseline, six; oil of rose, njjv. This, however, is not
a true oleate ointment. The oleates of zinc and bismuth are sometimes
made use of, but they do not possess any special advantages, and their
rancid odor is objectionable.
A lanolin-lard-rose-water soft creamy ointment is made of: Lanolin,
10 parts ; lard, 20 parts ; rose water, 30 parts. It possesses the ad-
vantage of keeping well. A very soft, creamy, cooling ointment, with
lanolin as a base, is made as follows : Lanolin, 65 parts ; liquid paraffin,
30 parts ; white wax, 5 parts. Melt together, and add and rub in
20G GENERAL TREATMENT.
water 30 parts, the water to be warmed before adding, and the heat to
be continued for a few minutes.
A thick EMULSION, useful for various purposes, may be made by
mixing equal parts of lard and lime water, with which carbolic acid and
other active remedies may be incorporated. It must be shaken before
being applied, as it is not a permanent emulsion.
STIMULATING OINTMENTS.
These are the most efficacious and generally useful remedies we
possess. They are made with a great variety of substances, which are
employed alone or in combination. Tar and its oils and derivatives,
especially oil of cade, oil of birch (oleum rusci), carbolic acid, and
creosote, may first be mentioned, all particularly valuable in eczema and
psoriasis. The preparations of mercury, including red oxide, yellow
oxide, nitrate, red iodide, red sulphide, mild chloride, corrosive chloride,
and ammoniated mercury, and mercury itself, are all employed and
highly prized for their virtues in numerous and different diseases.
Sulphur, resorcin, ichthyol, thiol, naphtol, and salicylic acid may be
referred to as among the more important remedies of this class. Here
may be mentioned goa powder and its derivative chrysarobin (formerly
known as chrysophanic acid), and also pyrogallol. Chrysarobin is of
great value, and employed weak (from one to five grains to the ounce)
is useful in many diseases. Iodine, iodoform, iodol, and other prepara-
tions containing iodine may be referred to, as well as camphor and
chloral, singly or in combination, thymol, and menthol.
Special Preparations. Some new methods of applying local rem-
edies have been introduced, especially through the labors of Unna,
Lassar, Pick, and others. These may be designated special prepara-
tions, requiring, in most instances, for their manufacture the aid of the
apothecary and the manufacturer. They constitute useful additions to
the dermatological armamentarium. They may be described under the
headings of plasters, salve-muslins, plaster-muslins, glyco-gelatins,
tragacanth jellies and emulsions, pastes, salve-pencils, and paste-pencils.
PLASTERS.
Plasters, made with various adhesive substances, especially wax, resin,
lead plaster, and the like, two or more usually being combined, are
employed chiefly for the purpose of bringing active remedies, particu-
larly mercurials and caustics, in close contact with the skin. I. Neu-
mann gives the following formula for a good adhesive plaster the base
of which is lead plaster. Some drugs, however, on account of their
non-compatibility with lead plaster, cannot be employed with it. It is
composed of oil of turpentine, 1 part ; yellow wax, 1 J parts ; lead
plaster, 6 parts. A mercurial plaster much used in Germany consists
of: Mercury, siv ; turpentine, 3ii ; yellow wax, 3iii ; lead plaster, 3iss.
This may be spread on a cloth and applied. It is useful in syphilitic
SALVE-MUSLINS. 207
scleroses, lupus vulgaris, and sometimes in chronic lupus erythematosus
and localized patches of chronic acne rosacea.
A firm and remarkably adhesive plaster, useful for incorporating
various remedies, particularly such caustics as pyrogallol and resorcin, as
employed in lupus vulgaris and epithelial cancer, can be recommended by
the author, who devised the formula. It consists of: Burgundy pitch,
3x ; resin and yellow wax, each, siv ; oil of turpentine, 3ii ; Canada
balsam, 3ss.
PLASTER-MUSLINS.
These have as a basis gutta-percha and oleate of alum, with which
drugs in varying strengths are incorporated. The mass is spread in a
thin layer on muslin. The gutta-percha forms an impermeable basis,
while the oleate of alum constitutes the adhesive element, and possesses,
moreover, the desirable property of being unirritating to the skin. A great
variety of drugs may be incorporated with the plaster mass. Among the
many preparations the following may be mentioned : carbolic acid, boric
acid, arsenous acid, salicylic acid (in several strengths), chrysarobin, pyro-
gallol, iodoform, mercury, mercury and carbolic acid, mercury and oxide
of zinc, oxide of zinc, tar, litharge, white precipitate, ichthyol, ichthyol
and sublimate, adhesive plaster (with salicylic acid), resorcin, and creosote
and salicylic acid. They are useful in a great many localized affections,
especially in eczema, psoriasis, lupus, acne, acne rosacea, and various
infiltrated patches. They are applied after the manner of other plasters.
They possess the advantages of acting quickly and strongly, of being
adhesive, and of remaining in constant contact with the diseased pan.
They are, moreover, unirritating and cleanly, are readily applied, and
protect the skin from external irritation. To Unna especially is due the
credit of introducing and perfecting these preparations. 1
SALVE-MUSLINS.
These consist of an ointment-mass spread accurately and evenly, by
machinery, on undressed muslin, or mull, and are intended to take the
place of strips of muslin spread with ointment by means of the knife.
They are neater, cleaner, more comfortable, more elegant, and more
readily adaptable to the surface than salves as ordinarily spread.
The salve-mass consists, as a basis, of benzoinated mutton tallow and
wax (the amount of the latter varying with the several preparations),
with which the various drugs are incorporated. The muslin sheets are
dipped into the melted mass, dried, and rolled flat and smooth on both
sides. Another series is prepared, where only one side is so treated.
They are soft and pliable, and, owing to the warmth of the body, adapt
themselves to the skin. Being uniformly spread, they are more efficacious
1 These, as well as the salve-muslins, are manufactured by P. Beiersdorf & Co.,
apothecaries, Hamburg, and may be obtained in most of the large cities of the United
States and other countries.
208 GENERAL TREATMENT.
than the ordinary salves spread on muslin. They prove useful in many
diseases, especially in eczema and other localized inflammatory affections.
Owing to their softness and suppleness, they adapt themselves to the
various depressions and to the joints of the body. Diachylon ointment
and oxide of zinc ointment are both more elegantly and accurately ap-
plied in this manner. The mercurial salves, including white and red
precipitate and mercurial ointment, are advantageously incorporated with
the zinc oxide tallow base, while the tarry and balsamic products mix
well with the lead plaster base. To avoid rancidity, the mass may be
made with wax, petrolatum, and a little lanolin, or with wax and lanolin.
The following medicaments are those in most common use : litharge
plaster, litharge and ichthyol, litharge and carbolic acid, litharge and tar,
oxide of zinc, oxide of zinc and salicylic acid, oxide of zinc and ichthyol,
oxide of zinc and sulphur, and resorcin.
PASTES.
These differ from ointments in being of stiffer consistence and more
adhesive, and in leaving on the skin an adherent coating. They should
be so prepared, and should contain such ingredients as a basis, that they
may be easily spread over the skin in a thin layer and will dry quickly.
Erasmus Wilson many years ago recognized the good to be gained by
the use of stiff ointments of oxide of zinc, which were of the character
of soft pastes. Lassar, 1 however, was the first to call special atten-
tion to the value of this method of treatment, since which time the
subject has been elaborated by Unna, 2 Gruendler, 3 and others. Many
substances have been suggested as the basis for these preparations, chief
among which may be mentioned starch, oxide of zinc, gum arabic,
dextrin, oxide of lead (litharge), and kaolin, made with various fluid
or semi-fluid ingredients, such as glycerin, linseed oil, and petrolatum,
together with the medicament. The formulae for some of these may be
stated.
STARCH. The formula originally suggested by Lassar, consisting of
starch and zinc oxide each 25 parts, petrolatum 50 parts, is a valuable
one, much employed alone and also as a basis in erythematous and ecze-
matous conditions. One slight objection, according to the author's ex-
perience with this paste, is that it adheres to the cloths covering the
skin and to the underclothing as well as to the skin, and after drying
it tends to drop off in particles, lumps, and rolls, and thus to be a
source of annoyance to the patient. The following softer paste the
author has found adheres to the skin rather than to the clothing, and
is preferred by some patients as being a more cleanly preparation :
Boric acid, 9ii ; starch, sii ; zinc oxide, 3n ; vaseline, si. Boric acid
1 Monatsh. f. prakt. Derm., No. 4, 1883.
8 Monatsh. f. prakt. Derm., 1884, p. 38.
8 Monatsh. f. prakt. Derm, 1888, p. 1029.
SALVE-MUSLINS. 209
possesses in a notable degree the property of stiffening pastes and
ointments.
Unna gives a formula of starch 3 parts, glycerin 2 parts, and water 15
parts, to be boiled down to 1 5 parts. This constitutes the basis, to which
may be added half or more, according to the consistence desired, of the
powdered medicament, though if more than half the volume of powder
is required the quantity of glycerin should be increased. Another
formula consists of zinc oxide 50 parts, starch 15 parts, salicylic acid
2 parts, glycerin 15 parts, water 75 parts; to be mixed aud boiled
down to 140 parts. Another formula, suggested by Ihle, is composed
of lanolin, petrolatum, zinc oxide, and starch, of each two drachms.
The following formula makes a very stiff paste, remarkable for its
adherent and drying properties : Lanolin, 65 parts ; paraffin, 30 parts ;
white wax, 5 parts ; mix, and add water 30 parts. Equal parts of zinc
oxide and petrolatum, the author finds, make a clean paste. Zinc oxide
and starch, of each 311, aud cold cream ointment, siv, also make a de-
sirable stiff paste.
GUM. The basis here consists of 1 part of mucilage of gum arabic,
1 part of glycerin, and 2 parts of a powder, such as zinc oxide.
DEXTRIN. The basis consists of equal parts of dextrin, glycerin, and
water, to which a powder, as zinc oxide, may be added as required.
LEAD. Lead pastes are sometimes employed, which may be made
according to the following formula published by Unna : Powdered
litharge, 50 parts ; vinegar, 80 parts ; cook to the consistence of a
paste, and add olive oil, linseed oil, or glycerin, 10 parts. Additional
vinegar may be used from time to time should it become too dry.
KAOLIN. Kaolin, mixed with two parts of olive or linseed oil, has
been recommended by Unna and others for a simple paste, but this earthy
substance varies so much in its composition that from formulae the results
as to consistence cannot be depended upon. The product, moreover, is
oily and doughy, and hence not satisfactory. Unna recommends for
eczema a paste prepared with kaolin 3 parts, oxide of zinc 2 parts,
linseed oil 3 parts, lead water 2 parts. The kaolin and oil must be
mixed before adding the other drugs.
The drugs best adapted to the several pastes mentioned may be re-
ferred to : oxide of zinc with the kaolin, lead, starch, dextrin, and gum
pastes ; lead with the lead or dextrin paste ; sulphur and tar with the
starch, dextrin, and gum pastes ; ichthyol with all except the gum ; sali-
cylic acid with all ; carbolic acid, camphor, and chloral with all ; chrysa-
robin and pyrogallol best with the gum and kaolin ; iodine and iodoform
with the lead, kaolin, aud gum ; and white and red precipitate, calomel,
and sublimate with all. Animal, vegetable, and mineral fats and oils,
as well as soaps, in small quantity, may be incorporated with the pastes
without injuring them.
14
210 GENERAL TREATMENT.
GLYCO-GELATINS.
The basis of these preparations consists of glycerin and gelatin in cer-
tain proportions, together with zinc oxide or other similar substance.
The zinc oxide is the best. Unna ! gives the following formulae for two
forms, a hard and a soft product. The hard is composed of zinc oxide
10 parts, gelatin 30 parts, glycerin 39 parts, water 30 parts ; the soft, of
zinc oxide 15 parts, gelatin 15 parts, glycerin 25 parts, water 45 parts.
Chrysarobin, white precipitate, and iodide of lead are miscible with either,
and are used in from 5 to 10 per cent, strength. lodoform and sulphur,
in from 15 to 30 per cent, strength, are also miscible with either, while
salicylic acid, resorcin, naphtol, potassium sulphide, creosote, and car-
bolic acid exercise an inhibitory influence on the setting of the gelatin,
and should be used with the hard variety only up to 1 per cent. Tars,
balsams, fats, and ichthyol should be incorporated with the hard form,
and not beyond 33 per cent. The solid glyco-gelatin is melted in a
hot-water bath and applied as a coating to the diseased area. Imme-
diately afterwards a strip of muslin or a layer of absorbent cotton may
be applied, which serves as an additional protective covering. In itching
patches this close covering of itself prevents scratching.
Glyco-gelatius are of value chiefly in the acute and chronic inflamma-
tory diseases, as in erythema, dry localized eczema, inflammatory acne,
and localized pruritus. Their action is superficial, but they possess
positive advantages in being protective, in preventing scratching, and
in excluding air, which latter in some cases is a point of importance in
the treatment. They are cleanly and comfortable ; and the base may
be employed as a fixing agent or cement for the salve and plaster muslins
where it is desirable to make of these an impermeable dressing. The
drugs in common use are tar, resorcin, sulphur, ichthyol, and salicylic
acid.
TRAGACANTH JELLY AND EMULSION.
Instead of gelatin, tragacanth may be employed, as suggested by F. J.
Pick, of Prague, which possesses an advantage in that the dressing may be
readily removed with water. A TRAGACANTH-GLYCERIN JELLY (Pick's
formula, called by him " linimentum exsiccans") is made as follows :
Tragacanth, 5 parts ; glycerin, 2 parts ; boiling water, 93 parts. The
tragacanth is to be triturated until a smooth mass results, and the glycerin
then added. To the whole the author adds 2 per cent, of boric acid as a
preservative. This formula is sufficiently soft to be readily smeared
over the surface, upon which it quickly dries, and at the same time is
distinctly cooling. Fifteen or twenty grains of oxide of zinc to the
ounce improves the consistence for most cases. Various active medica-
ments, as salicylic acid, resorcin, carbolic acid, and the like, may be in-
1 Monatsh. f. prakt. Derm , p. 317, 1887.
PASTE-PENCILS. 211
corporated with the mass. It is a cooling and acceptable preparation,
especially for the face, in erythematous eczema and similar affections.
Bassorin, a derivative from gum tragacanth, may be likewise used for
the same purpose, as suggested by G. T. Elliott, of New York.
Tragacanth is useful to make adhesive emulsions, as with lime water,
six grams to the ounce. The author finds emulsions of this kind valu-
able for applying such remedies as zinc oxide, sulphur, and resorcin, and
they possess the advantages of being acceptable and of being easily
removed with water.
SALVE-PENCILS.
As the name implies, these preparations are sticks, or crayons, com-
posed of fatty substances with which the active ingredients are incor-
porated. They are insoluble in water. In consistence they are like the
ordinary cosmetic stick, and are about as thick as the little finger. The
base is composed of wax and olive oil, to which are added in some cases
such substances as oil, soap, and pine or olibanum resin, to produce the
proper consistence and coherence. The salve-pencils are useful for the
treatment of isolated diseased areas where it is desirable to coat the epi-
dermis and to bring a fatty remedy in close contact with the skin, as in
psoriasis, seborrhcea, and dry eczema. The remedies used in this form
comprise boric acid, carbolic acid, salicylic acid, chrysarobin, ichthyol,
creosote, resorcin, soap-tar- ichthyol, corrosive sublimate, sulphur, oxide
of zinc, and various other combinations.
PASTE-PENCILS.
The paste-pencils are devoid of fat, and are easily dissolved by the
aid of moisture. They differ, therefore, from the salve-pencils in being
applicable to surfaces deprived of epidermis, as in excoriations and
ulcers, and in lesions of the mouth, anus, nose, and conjunctiva. They
are useful in chancre, chancroid, and condyloma, also in acne and in
lupus, and in other diseases where it is desirable to bore into the skin
and to act upon or to destroy the diseased tissue. The medicament is thus
brought into the closest contact with the affected skin. According to the
drug used, their base consists of starch, sugar, tragacanth, and gum
arabic, which with the active ingredient is moulded into short, brittle,
cylindrical sticks, of about the thickness of a slate-pencil, which may be
sharpened to a point. The principal drugs thus employed are salicylic
acid (in several strengths), arsenous acid, corrosive sublimate, cocaine,
iodoform, pyrogallol, and resorcin. They constitute a cleanly, convenient,
and ready mode of treating discrete lesions or small patches, and may be
applied by the patient at long or short intervals.
Unna l has conveniently grouped the various diseases and the remedies
in which these salve-pencils (stili unguentes) and paste-pencils (stili dilu-
bilcs] may be employed with advantage. For the allaying of pain and
1 Monatsh. f. prakt. Derm., 1886, p. 157.
212 GENERAL TREATMENT.
itching where the skin is dry (as in pruritus and squamous eczema), the
salve-pencils of belladonna, cocaine, and creosote, and, where the skin is
moist (as in eczema madidans, excoriations, fissures, and superficial
wounds), the paste-pencils of cocaine, may be employed. For the inflam-
matory diseases, pencils of zinc oxide, ichthyol, resorcin, and sulphur
are serviceable; while for the mycotic and bacterial diseases, such as
tinea tonsurans and furuncle, chrysarobin, pyrogallol, and corrosive
sublimate are useful. In the so-called parakeratoses (as lichen planus
and psoriasis), salve-pencils of tar, salicylic-acid-creosote, resorcin, and
chrysarobin may be employed ; and in the hyperkeratoses (as callosity,
corn, and comedo), salve-pencils of salicylic acid and sulphur. The pig-
ment anomalies are particularly suitable for treatment with salve-pencils
of corrosive sublimate, carbolic acid, salicylic acid, and salicylic-creosote.
Small tumors (such as pointed or flat warts, epitheliomata, and nsevi)
may be treated with salve- or paste-pencils of arsenic-sublimate, salicylic-
creosote, pyrogallol, or resorcin.
Caustics. Under this head may be classed those substances and
preparations which are DISCUTIENT in their effect, as well as those which
are truly CAUSTIC. To the former belong iodine, sapo viridis, corrosive
sublimate, salicylic acid, resorcin, acetic acid, trichloracetic acid, lactic
acid, cantharides, and the like. Some of these, as the trichloracetic and
lactic acids, should be employed diluted. Among remedies of this kind
nitrate of silver occupies a conspicuous place, being of service in fissures,
in indolent excoriations and ulcers, and in various epithelial diseases
where a stimulating or a mild caustic effect is desired.
CAUSTIC POTASSA, in stick form or in strong solution, is a potent escha-
rotic. Employed full strength it is a powerful remedy, is exceedingly
rapid in its destructive effects, and should always be used with great
caution. It is applied diluted with good result in some new growths
and hypertrophies, such as epithelioma, hypertrophic lupus vulgaris, and
hypertrophic wart, especially where rapid and thorough destruction is
demanded. It may be employed in its pure state, or, better, weakened
with water or by admixture with other substances, as lime in the prepa-
ration known as POTASSA CUM CALCE. Its employment calls for skill,
and especially for experience, as it is apt to destroy more tissue than
is desired. It forms with the destroyed skin a black eschar, which in
the case of superficial growths becomes detached in a week or ten days,
leaving an open granulating wound. With water, one part to three or
six, it is a safer remedy, and, if sufficient time be allowed, is equally
effective. Caustic potassa, in the form of liquor potassa?, is a discutient
or mild caustic, and may often be employed with advantage for the
purpose of acting rapidly on infiltrated patches of inflammation and in
other conditions.
Potassa in weak solution also serves as an antipruritic, being especially
serviceable when combined with tar or carbolic acid, as in the following
ANTISEPTICS. 213
formula, introduced by L. D. Bulkley, both useful in many diseases
accompanied with itching : Pix liquida, 5i ; potassa, 3i ; water, i. It
should be used freely diluted with w r ater, and in most cases applied weak,
five or ten drops to the ounce. Carbolic acid may be used in the
above formula instead of tar. Chloride of zinc is likewise a strong
caustic, producing its effect slowly, but occasioning great pain both at
the time of the application and for some time after the operation.
ARSENIC may be employed alone or with powdered gum acacia, equal
parts or one to four, with other substances, as the mercurials, in the
form of escharotic powders and plasters, and prescribed especially in
lupus vulgaris and in epithelial cancer. As a caustic it is somewhat slow,
but is destructive in its action, and possesses the peculiarity of tending
to attack diseased tissue in preference to healthy structures.
NITRIC ACID and the acid nitrate of mercury are well adapted for
the treatment of chancroid and chancre, and some cases of nsevi, moles,
and warts. They should always be applied with care. PYROGALLOL,
resorcin, ethylate of sodium, and acetate of sodium may also be referred
to. ACETATE OF zixc, nitrate of zinc, carbolic acid, and corrosive
chloride of mercury are milder, and are occasionally used for purposes
of superficial cauterization.
ACETIC ACID, trichloracetic acid, lactic acid, chromic acid, and sali-
cylic acid are mild caustics, useful in epithelial hypertrophies, as wart,
epithelial molluscum, and like affections.
Parasiticides. These are remedies which act destructively upon both
vegetable and animal parasites. Sulphur and its compounds, including
sulphite of sodium, hyposulphite of sodium, and sulphide of potassium,
in their action safe parasiticides, are deserving of the first mention, being
effectual in both groups of diseases. Styrax and Peruvian balsam are
especially valuable in destroying the itch-mite, while staphisagria, coc-
culus Indicus, white precipitate, mercurial ointment, corrosive sublimate,
and petroleum are the best remedies against the pediculus. The vege-
table parasites are acted upon favorably by a number of other substances,
among which may be mentioned the mercurials, particularly corrosive
sublimate, red iodide, the red and white precipitates, the yellow sulphate,
and the red sulphide. Other drugs serve the same end, as, for example,
goa powder, chrysarobin, veratria, tar, creosote, iodine, carbolic acid,
salicylic acid, resorcin, and boric acid. The most valuable of the reme-
dies mentioned are goa powder and its derivative chrysarobin. The
latter is a powerful and effective remedy, introduced into England from
the East some years ago by Balmanno Squire.
Antiseptics. Among the various drugs used for the purpose of
securing antisepsis in the treatment of wounds and for dressings, car-
bolic acid, corrosive sublimate, boric acid, salicylic acid, iodoform, and
creolin arc the most serviceable. The first two are in common use, and,
if properly employed, are attended with comparatively little risk from
214 GENERAL TREATMENT.
absorption and poisoning. Aqueous solutions of CARBOLIC ACID are
generally employ td in two strengths, 5 per cent. (1 in 20) and 2J per
cent. (1 in 40), the former for the purpose of cleansing infected open
lesions and wounds, the latter to wash out wounds during an operation
and after it, and to wash the operator's hands, sponges, and instruments.
Care should be observed that the solutions be properly prepared, lest
there be globules of undissolved acid floating in the solution. Water
alone takes up all the acid up to about 5 per cent, strength, beyond
which it is less readily dissolved. The addition of a little glycerin facili-
tates the solubility. The purer the acid the less soluble it is in water.
CORROSIVE SUBLIMATE in aqueous solution is used for irrigating
wounds and for disinfecting the hands in the strength of 1 : 1 000 or
1 : 5000, according to the extent of the surface and other circumstances.
Upon sound, unbroken epidermis it may be used 1 : 500 with safety, and
the same strength may be employed for touching or wiping out infected
wounds. Like carbolic acid, it is both irritating and poisonous : care
should, therefore, be observed in its employment.
Phenacetin and acetanilid finely powdered are both useful as applica-
tions in syphilitic and other ulcers, possessing the power of diminishing
suppuration. Among the bactericides and parasiticides serviceable in
venereal ulcers, herpes, and burns, and in the diseases due to mould
fungi, euphorin, europhen, and alumnol may be referred to.
Mechanical Methods. The treatment of cutaneous diseases by me-
chanical means embraces agents of importance. Many procedures are
made use of, some of them simple, others requiring the employment of
instruments. FRICTION, with smooth and rough substances (as prepared
PUMICE-STONE, SAND, SAND-SOAP, and the like), COMPRESSION, and
MASSAGE are all used in one form or another, the two first-named
especially, as with ointments, soaps, plasters, compresses, and bandages.
The knife and lance are used for performing linear, quadrilateral, and
punctate SCARIFICATIONS, as in lupus, in which they are especially valu-
able. Punctate and linear GALVANO-CAUTERIZATIONS are sometimes
employed, but the simple linear and punctate scarifications with the knife
leave a more sightly and superficial scar, with less tendency to hyper-
trophic scar or keloiclal growths than the galvano-cauterizations. Ex-
cision with the knife, except for such new formations as cancer and
various circumscribed growths or tumors, is seldom practised.
For the destruction of hair-follicles, in order to prevent the growth
of hairs, the needle and the electric current (producing electrolysis) are
of the greatest value, although the operation is generally followed by
more or less scarring, the amount depending on the care and skill of
the operator. The same process is also of much service for the removal
of vascular nsevi, telangiectases, and pigmentary and fibrous moles.
CUTANEOUS TREPHINE. 215
DERMAL, CURETTE.
Scraping out localized areas of tissue, by means of the SCRAPING-
SPOON, or DERMAL CURETTE, so useful in lupus, epithelioma, and other
diseases characterized by new formations, is a method of decided value,
and is much used for both small and large diseased areas, especially
with the view of destroying exuberant unhealthy granulation tissue, thus
permitting remedies to be applied to the true skin. In many cases,
however, the operation itself suffices without subsequent applications
other than simple dressings. While this instrument (made of different
sizes and forms) finds its use chiefly in the removal of localized new
growths, such as cancer, the scrofulodermata, and lupus vulgaris, it may
also often be employed with advantage in certain inflammatory lesions,
as in acne with comedo, and in various forms of hypertrophy, as, for
example, in the warty formations and exuberant granulation tissue met
with in many diseases. Its use has a wide application.
In addition to these agents there are certain special surgical instru-
ments which may be mentioned, such as the ACNE LANCE ; the MILIUM
KNIFE or NEEDLE ; the COMEDO EXTRACTOR of Unna, of Hamburg,
and of Piffard, of New York ; the CUTANEOUS PUNCH, or TREPHINE,
for the removal of small growths, devised by Keyes, of New York,
and Mixter, of Boston ; EPILATING FORCEPS ; GRAPPLING FORCEPS ;
SKIN-GRAFTING SCISSORS ; CUTISECTOR, devised by Piffard ; the appa-
ratus for producing SPRAY ; and the NEEDLE-HOLDER for the ELECTRIC
CURRENT.
CUTANEOUS TREPHINE.
The CUTANEOUS TREPHINE, as described by Keyes, 1 is made of sev-
eral sizes and has a sharp cutting edge. By pressing it upon the skin
and rapidly rotating, a circular piece of skin, corresponding to the size
of the instrument used, is cut ; this projects, and is snipped oif with
scissors. The depth of the cut may be varied according to the degree of
pressure used. The wound may be dressed with powdered sulphate of
iron, boric acid, an adhesive plaster, or a cotton and collodion dressing.
The amount of scarring depends upon the size of the instrument and
other circumstances, but with the smallest-sized trephines it is usually
scarcely perceptible. The instrument is useful for the removal of small
epitheliomata, moles, granules of powder, and other blemishes, and in
removing skin for microscopical examination and diagnosis.
Epilation. The extraction of hair from the hair-follicles, particu-
larly when systematically and methodically practised, is of value in some
diseases of the hair and hair-follicles, such as sycosis, tinea sycosis, tinea
tonsurans, tinea favosa, pustular eczema of the hair-follicles, and some
forms of alopecia. Its value in sycosis was pointed out many years ago
1 Jour. Cut. and Gen.-Urin. Dis., March, 1887.
21G GENERAL TREATMENT.
by Wertheim, of Vienna, and more recently by Zeissler, 1 of Chicago.
By the extraction of the hairs a source of irritation to the follicles is
removed, the follicles are rendered patulous, and the walls and the hair-
papillae are stimulated. In parasitic diseases not only is the hair-shaft in
which the fungus is embedded removed, but through the keeping open
of the follicles the parasiticides employed are brought into close contact
with the tissues containing fungus. The forceps should have narrow
blades, and a spring that works easily. In sycosis, if the operation
causes pain, only one hair should be grasped at a time.
Skin Grafting. As Erichsen states, Hunter showed that the spurs
of a young cock could be " made to grow on his comb," and that a
tooth could be successfully transplanted. Reverdin, however, in 1869,
was the first to call special attention to the subject of the GRAFTING OF
EPIDERMIS, or EPIDERMIC GRAFTING, in which operation small bits of
epidermis, including the mucous layer, are transplanted from a healthy
locality to an open granulating surface and there made to grow. Under
favorable conditions this takes place readily, with the result that a layer
of epithelium spreads out from the grafts, beginning at the margins,
and unites with that from other neighboring grafts. A graft the size
of a large pin-head or an oat will continue to grow until it reaches, by
spreading out, the size of a small finger-nail. The growing of epithe-
lium upon an open surface and thus covering the wound, however, does
not constitute cicatrization of the fibrous tissue of the corium and the
prevention of scar tissue. In such cases as wounds from burns epider-
mis grafting does not prevent the formation of a scar, though it probably
lessens the tendency to it.
REVERDIN'S METHOD.
The grafts are to be obtained, where possible, from the individual who
is to receive them. A healthy granulating surface is required. Every
aseptic precaution in the removal of the grafts and in their implantation
is to be employed, but antiseptic applications, such as corrosive sublimate
and carbolic acid, are not to be used. A large piece may be divided and
subdivided, a number of grafts being thus obtained, but the smaller
the grafts the less painful will be their removal. The skin may be
pinched up with a delicate forceps or with a fine sewing-needle inserted
under the epidermis, and the graft snipped off with curved scissors or
knife, removing just enough tissue (including the upper stratum of the
papillary layer) to draw blood. The grafts are picked up on the point
of a needle and thus placed in position. It has been shown that live
grafts may be taken from an amputated limb as long as twenty-four
hours after operation, provided the limb has been kept at a low tem-
perature, just above the freezing-point. The skin of the prepuce, being
devoid of fat, makes desirable material for the purpose. The mode of
1 Jour. Cut. and Gen.-Urin. Dis., 1891, p. 444.
THIERSCH'S METHOD. 217
applying the grafts is much the same as in the Thiersch method, to be
referred to. This method is especially applicable to leg ulcers.
THIERSCH'S METHOD.
Reverdin's method has been largely superseded by that introduced by
Thiersch, of Leipsic, which is a decided improvement on the former.
It consists in removing, by the razor or other instrument, thin slices or
strips composed of true skin and epidermis and transplanting them to an
open granulating surface or wound that has been prepared for their re-
ception. Adhesion takes place, under proper dressings, and the wound
or sore is thus covered in by cutaneous tissue, with the result of less
scarring and contraction than under epidermis grafting, Reverdin's
method. The parts to be grafted are treated aseptically for several days
with a solution of boric acid, and the granulations are cut down with a
sharp knife, the bleeding being allayed by compression and torsion.
Antiseptics are not called for. The strips of skin, which may be from
one to four inches long and from one-half to three-quarters of an inch
wide, taken from the thigh or arm, or from one of the lower animals, as
a young greyhound, are bathed in a six-tenths solution of common salt,
and at once placed on the wound, with the raw surface downward, so
that one strip overlaps the skin and that the edges are covered in.
The strips should be about one-half the thickness of the true skin, or as
thin and at the same time as large as it is possible to cut them. Hem-
orrhage from the wound should be allayed before they are applied. The
dressing to be placed next to the skin should be composed of a substance
which will not adhere to the surface, as sterilized tin- or gold-foil, oiled
silk or rubber tissue in sterilized oil, as proposed by Tillmanns, of
Leipsic, or perforated paraffined paper, over which aseptic cotton com-
presses and a muslin bandage, exerting slight pressure, are laid. The
first dressing should not be removed until the end of from two to four
days. Within a few days after the grafting the corneous layer of the
epidermis becomes detached from the mucous layer and floats away,
leaving the mucous layer raw; but cornificatiou usually soon sets in.
Hemorrhage and suppuration are both liable to interfere with the success
of the operation. The latter may be removed by absorption through
perforations in the dre-sing applied next to the skin. This mode of
treatment has a wide application in general surgery and in dermatology,
especially in the case of wounds with loss of skin and epidermis, burns,
and scalds, and in many diseases in which there is obstinate ulceration
without disposition to heal, such as carcinoma and lupus, and in other
neoplasms. 1
Morrow 2 describes a modification of Thiersch's method, the peculiarity
1 For more complete information on this method the reader is referred to an article
by Urban, of Leipsic, in Deutsche Zeitschrift fur Chirurgie, Bd. xliv., No. 187.
2 Trans. Amer. Derm. Assoc., 1891. See also JS'ew York Med. Jour., Dec. 12, 1891.
218 GENERAL TREATMENT.
consisting in the depth of the graft, which includes the entire thickness
of the skin and in some cases a layer of subcutaneous tissue, and in the
method of procedure, which consists in removing a button of tissue
of any required depth by means of a round, cutting, cutaneous punch,
and immediately inserting it in a receptacle or bed previously made by
the same instrument. It may be employed in the treatment of small
circumscribed malignant and papillary growths occurring on the face,
such as epitheliomata, lupus nodules, moles, warts, and other facial
blemishes. Areas of integument containing hairs may be successfully
transplanted by this method. The punches, or trephines, are manufac-
tured of different sizes. The pain may be mitigated or prevented by
cocaine used through cataphoresis, especially if the skin be punctured
here and there to facilitate the entrance of the cocaine.
Bandages. Appliances of this kind are frequently made use of with
great advantage for the purpose of protection or of affording support to
the skin and subcutaneous tissues. Both acute and chronic conditions
of redema and stasis may be materially relieved by proper bandaging,
especially in cases where the tissues are weakened through debility or
age. In eczema, especially of the lower extremities, in elephantiasis, and
particularly in ulcers, simple or specific in nature, the plain muslin or
the rubber bandage is often employed with great benefit.
Poultices. Preparations of this kind have but a limited use in der-
matology. They are occasionally employed for removing thick, adherent
masses of crust, as in severe and long-standing eczema, and also to relieve
pain and to hasten suppuration in furuncle, carbuncle, and like inflam-
mations. They are usually prepared with flaxseed meal, potato starch,
or bread and milk, care being taken to make them antiseptic by the
addition of suitable drugs, are applied warm or hot, and are repeatedly
renewed.
PARAFFINED and WAXED PAPER serve many useful purposes as a
dressing, taking the place in some cases of cloths for the spreading
of ointments, pastes, and plasters. They protect the skin from the
clothing, and exclude the air. They are employed especially upon
parts where there is but little motion. Where fats or oils of any kind
are spread upon the paper, they should be applied sparingly, in order to
secure adhesion to the skin. Where fatty substances are used on cloths,
the paper may be used to protect the clothing from becoming greased.
Massage. In connection with the subject of mechanical treatment,
the benefit to be derived from massage, in suitable cases, may be referred
to. Certain forms of atrophy and hypertrophy of the integument, as
morphrea, scleroderma, elephantiasis, and allied forms of disease ;
patches of chronic sclerosed inflammatory skin, as eczema, psoriasis,
and lichen planus; prurigo; and affections of the sebaceous glands with
a tendency to the accumulation of the secretion, may be specially men-
tioned.
CATAPHORESIS. 219
Electricity. This therapeutic agent may at times be applied with
good result in certain affections, especially in those in which there is dis-
turbance of the nervous system, as in herpes zoster and in the neuroses,
and also in certain atrophies depending on changes in the nerves, as
morphoea and seleroderma. The galvanic current is that from which the
best effects are usually obtained, but the faradic current is also service-
able. Static electricity is sometimes made use of, especially in morphoea
and seleroderma. The application may be either central or directly to
the disease of the skin.
ELECTROLYSIS.
Electrolysis, or the decomposition of tissues by means of the galvanic
current, is distinctly valuable in the treatment of certain tumors, espe-
cially vascular formations, tubercles, nsevi, warts, moles, hypertrophies,
small fibromata, and connective-tissue growths, as keloid. It is accom-
plished by means of needles (of steel or irido-platinum) in the place of
ordinary electrodes, inserted into the tissues, superficially or deep, through
which the current is discharged. The galvanic current is useful in
eradicating abnormal growth of hair from circumscribed areas, and
superfluous hairs from the face in women, and from moles.
The GALVANO-CAUTERY, especially as used with various pointed and
cutting instruments, as devised by Besnier and Yidal, is of value in such
diseases as lupus, naevus, and other new growths, and in some hypertro-
phies. PAQUELIN'S CAUTERY and its modifications (as the "micro-burner"
of Unna) is made use of to destroy varied pathological formations, espe-
cially such new r growths as angiomata, but, on account of the difficulty
of regulating the depth to which cauterization may extend, it must be
employed with caution.
CATAPHORESIS.
ELECTRIC CATAPHORESIS, or the introduction of drugs into the system
through the action of electricity, especially the galvanic current, is occa-
sionally made use of, but only small doses can be administered in this way
through the skin. The process is a physical one. It is not electrolytic,
no decomposition of the tissues taking place. Various drugs in solution,
such as morphine, cocaine, the salts of mercury, and the iodides, may be
employed, in some cases advantageously. A moderately strong current
is required. The stronger the current the more rapid the effect. From
ten to thirty cells of a Leclanche, Grenet, or chloride of silver battery, or
from five to twenty milliamperes, are required. The solution of the drug
is used on the positive pole (or anode), the negative pole (or cathode) l>eing
placed anywhere. The skin should first be cleansed, and ether used with
the view of dissolving the natural oils and fats on the surface and in
the apertures of the follicles. For cocaine a ten per cent, solution is most
useful, about fifteen milliamperes being required. This may be em-
ployed to advantage in sensitive skins before operating with the needle
and battery for the removal of hair from the face, and also for minor
220 GENERAL PROGNOSIS.
operations upon the skin. Pain may thus be avoided without the danger
of producing constitutional effects. The iodides and the salts of mercury
in solution may be used for the purpose of acting upon superficially seated
diseases. Painful affections of the integument, as ulcers and superficial
neuralgias, may be relieved by analgesics applied in this way. The use
of some drugs, however, is painful : thus, a one per cent, corrosive subli-
mate solution causes a burning pain.
GENEKAL PROGNOSIS.
This subject scarcely permits of being discussed on general grounds.
There is little to be said concerning the prognosis of cutaneous diseases
as a class. In nature the majority are benign ; some are destructive and
semi-malignant ; others, either early or more frequently late during their
course, tend to a fatal termination, this occurring in various ways. The
annoyance, discomfort, disfigurement, or deformity accompanying certain
cutaneous diseases is often great. The subjective symptoms, especially
itching, burning, and pain, frequently cause much distress of body and
mind. In many cases the subjects are truly pitiable, and worthy of the
utmost consideration and attention. In prognoses the question concerns
individual diseases and cases rather than classes. The diseases of the
skin are acute, subacute, or chronic in their course ; some are invariably
acute, as herpes, while others are almost always chronic, as, for example,
psoriasis. It may be said that the majority of the disorders and dis-
eases, taking a view of the whole field, incline to chronicity. Many of
them, as lupus erythematosus and lupus vulgaris, are exceedingly obsti-
nate, lasting years ; others, especially those of a congenital nature, as
vascular nsevus and ichthyosis, in almost all instances continue through-
out life.
The employment of remedies, whether external or internal, it need not
be said, materially influences prognosis. The natural course of the dis-
eases, rather than the influence of these factors, will be dwelt upon in the
present discussion. It may be stated that with the advances in thera-
peutics that are being made from time to time some diseases that for-
merly were regarded as hopeless are now curable. The value of an opinion
in prognosis naturally depends upon the knowledge that is brought to
bear on the subject, and especially upon the experience of the derma-
tologist.
Diseases of secretion, as seborrhoea and hyperidrosis, are often rebellious
to treatment. The active hyperaemias, as long as they remain such, are
GENERAL PROGNOSIS. 221
usually ephemeral or acute disorders ; but it must be remembered that
if the action of the cause is prolonged or is carried beyond a certain
point the process may become inflammatory, and the prognosis, conse-
quently, more uncertain.
Of the inflammatory diseases as a class it is not possible to speak
in general terms ; for, while some always terminate favorably and
within a definite period, others may end fatally, as, for example, chronic
pemphigus. A considerable number of the inflammatory affections tend
to become chronic, lasting not infrequently many years ; as common
instances, eczema, psoriasis, acne, and sycosis may be cited.
Hemorrhages are to be looked upon either in a favorable or in an
unfavorable light, according to their severity and their extent. Hyper-
trophies, as a rule, have a benign character, but they tend to pursue a
slow course, and often continue a lifetime. Some of them are incurable.
The same observations apply to atrophies.
Xeoplasmata, or new growths, inflammatory or otherwise, are benign,
semi-malignant, or malignant. The prognosis of this large group of
diseases will depend upon the disease and the case under consideration.
Thus, lupus, syphilis, lepra, carcinoma, and sarcoma, taken as repre-
sentatives of the new growths, must all receive grave prognoses. Several
of them frequently terminate fatally. On the other hand, certain affec-
tions of this class, as fibrous molluscum, as a rule, give rise merely to
discomfort and disfigurement.
The neuroses, some of which are fugitive, others persistent, are exceed-
ingly variable in their course and duration ; at times they yield readily
to treatment, while in other cases they are very obstinate. The common
vegetable and animal parasitic affections, characterized for the most part
by inflammatory symptoms, are all amenable to treatment, and may
generally be cured in a reasonable time.
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