LIBRARY UNIVERSITY OF CALIFORNIA SAN DIEGO 1 biomedk;al library university of caljf08nw, san diego MAR ; > 1982 rFR 12^^^' rtu CAYLOHD PRiNTtO IN U S A 3 1822 01189 2544 V.l PORTFOLIO OF DERMOCHROMES BY PROFESSOR JAOOBi Of Freiburg^ im Breisgau English Adaptation of Text of the 1st and 2d Editions BY J. J. PRINGLE, M.B., F.R.O.P. Physician to the Department for Diseases of the SKin at the ■Middlesex Hospital, London Fourth Edition, Revised and Enlarged WITH 246 COLORED AND 2 BLACK AND WHITE FIGURES ON 134 PLATES WITH EXPLANATORY TEXT Volume I NEW YORK REBMAN COMPANY 1123 Broadway All Rights Reserved Printed in America DEDICATED TO Geheimrath professor Albert Neisser OF BRESLAU Preface to the English Edition. The process employed in the production of the illus- trations in the following work is that known as CiTocHKOMY, and is the invention of Dr. Albert of Munich. The reproduction of colours by this process is believed to be more perfect than by any other hitherto in use, and is obtained almost entirely by mechanical means apart from manual work. The great majority of the illustrations are taken from models in the Breslau Clinic, executed by Herr Kroner, and are reproduced by kind permission of Professor Neisser, to whom the inception of the work is mainly due, and to whom it is dedicated by his former pupil and assistant. Professor Jacobi. Thanks are also due to Professors Lesser and C. Lassar of Berlin, Dr. Bayet of Brussels, and Dr. Henning of Vienna, for permission to make use of models in their possession. Acknowledgment must also be made of the services rendered by the gentlemen who executed the various models utilized — viz., Herr Kroner of Breslau, Herr Kolbow and Herr Kasten of Berlin, Mons. Baretta and Mons. Tramond of Paris. A few of the models have also been made by Professor Jacobi himself after the method devised by Mr. Cathcart of Edinburgh. The object of the Atlas is not to illustrate the rarer forms of skin disease, but to furnish to medical men, teachers and students a handy and comprehensive series of illustrations of the skin affections most fre- quently met with in practice, in their various phases and at a reasonable price within the reach of all. As no attempt has been made to supplement the necessary systematic treatises on diseases of the skin, the text has been condensed to the greatest possible degree, without, however, omitting any of the essential facts. J. J. P. London. Editor's Preface to the Second Edition. The early and gratifying demand for a second edition of this work testifies to its utility. Two new plates, with text, have been added, \\z. : Plate XVIa, Fig. 28a {Scrofuloderma), and Fig. 29a {Tiiberculide) ; also Plate LXXVni., Fig. 141a {Syphilis circinata) and Fig. 142a {Paronychia syphi- litica). Both plates are taken from models in the collection of Professor Neisser, to whom the renewed thanks of the Editor are gratefully acknowledged. The following figures have been substituted for those which appeared in the first edition, viz.: Plate LIX., Fig. 109; Plate LXXI., Fig. 129; and Plate LXXXIL, Fig. 149. It is hoped that these additions and alterations will enhance the value of the atlas, the price of which re- mains unchanged. J. J. Pringle. vi Preface to the Supplement. The publication of a Supplement to Professor Jacobi's work has been prompted principally by the urgent request of numerous professional friends to fill in certain lacunae in the existing work, so as to render it a practically complete pictorial Atlas of Diseases of the Skin. To these friends Professor Jacobi desires to express his indebtedness. The Supplement contains seventy- six new dermochromes, many of which depict syphi- litic manifestations, the importance of which is uni- versally admitted. But several non-syphilitic diseases not hitherto illustrated are also included, some of which— e.^., Darier's disease. Myiasis linearis— are regarded in most text-books as extreme rarities. This opinion Professor Jacobi does not share, and the trans- lator endorses the author's view. Numerous types or phases of common skin affec- tions not delineated in the work have also been added, and cannot fail to conduce to its increased practical utility both to the student and practitioner. Especial thanks must again be expressed to Pro- fessor Neisser of Breslau, who has placed his entire wealth of material at the author's disposal. A deep debt of gratitude is also due to Professor von Berg- mann. Professor Lassar, Dr. Max Joseph, Dr. Buschke, Dr. Heubner, and Professor Greef, of Berlin ; to Pro- fessor Schlossmann and Dr. Werther of Dresden; to Dr. Henning and Professor Finger of Vienna; to Professor Pospelow of Moscow; and to Professors Fournier and Jullien of Paris, all of whom have per- mitted models in their possession to be utilized. Due recognition must also be acknowledged to the kindly and energetic assistance of Professor Jacobi's former assistant, Dr. von Linck, and to Messrs. Baretta, Jumelin, Kolbow, Kroner, Kasten, Fiweisky, and Johnson, who are responsible for the models from which the dermochromes have been executed under the direct and special supervision of Dr. Albert of Munich, with whom rests the credit of first devising and carry- ing out the method of delineation employed through- out the work with such brilliant success and gratifying results. J. J. Pbingle. London, 1906. viu Preface to the Third Edition. In this edition a number of illustrations are entirely new, others have been more perfected. In the place of some of the pictures contained in the previous editions which were not quite satisfactory, better illustrations have been substituted. The plates of the supplement have been properly classified with the other subjects, and the whole atlas now contains 132 plates with 245 illustrations. The test has been revised and such matter as refers to new illustrations has been added. I wish to express my feelings of gratitude to all those who gave me such splendid aid in the prepara- tion of the previous editions and of the supplement, and who extended their kind offices to me whilst pre- paring this third edition. I wish particularly to thank my I. Assistant, Dr. Lever, for his active co-operation; also Dr. Henning and Mr. Kolbow, who made most of the models ; also Dr. E. Albert of Munich, who made the cliches; like- wise Messrs. Greiner & Pfeiffer, in Stuttgart, and Messrs. Christoph Reisser's Sons, in Vienna, who did the presswork with so much care. Particular thanks are due to my publishers, who have brought great sac- rifices in order to produce this new issue in the same superior and elegant style as the previous editions. E. Jacobi. Fkeibueg I. Br. iz Preface to Fourth Edition. In this edition several figures of superior quality have been substituted. It also contains four new figures of an interesting character. Two of these belong to the article on Sporotrichosis by Dr. de Beurmann, of Paris, with his kind permission. E. Jacobi. Freiburg i./Be. Erythema Exsudativum Multiforme. Plates I., II., Figs. 1, 2, 3, 4. Erytbema multiforme is a skin disease which occurs as part of a general infective malady — es- pecially in spring and antumn — in which macules, papules, vesicles or bullae develop in a few days on typical seats of predilection, especially on the backs of the hands and feet, and extensor surfaces of the fore- arms and legs; it often also appears on the face and other parts of the body, but only in exceptionally severe cases on the palms and soles. Thus, macular and papular erythema (Fig. 3) occur, becoming an- nular or gyrate (Figs. 1, 2) — when involution of the patches takes place in their centre — or vesicular (Fig. 4). The cause is unknown. The colour is bright red in the most infiltrated marginal parts, but livid in the centre, which is fre- quently sunken, especially in cases of old standing and on the lower extremities. The disease is poly- morphous, as different degrees of exudation may be present at the same time. If ring-shaped papules or circles of vesicles in concentric circles are present the affection is called Erythema iris or Herpes iris (a bad name). As the disease progresses the papules soften and pale without scaling, vesicles dry up, and, if no relapses occur — as they are apt to do — the whole 1 Jacobi's Dennochromes. Plate I. No. I. 2. Erythema multiforme. Jacobi's Dermochromes. Plate 11. No. 3. 4. Erythema multiforme. process runs its course in a few weeks. Some partici- pation of the joints is not infrequently observed; implication of internal organs cannot as a rule be laid to the charge of the erythema. On the other hand, toxic erythemata occur in internal disorders, which ought not to be identified with true erythema multiforme. Dlag-nosis can be easily established in typical cases from the acute onset, the general phenomena, the absence of subjective symptoms — apart from slight burning sensations — and the recovery without desqua- mation. The somewhat similar syphilide is different in colour, and usually occurs in different localiza- tions ; eczemas weep and itch ; the occasionally similar urticarial eruptions are much more ephemeral. Eing- worm, which may also occur in concentric forms, is scaly, and never presents the same typical distribution. Prog^nosls is thoroughly favourable. Treatment. — As the disease is a general one and joint affections are often present, salicylate of soda in doses of 30 to 60 grains daily, or similar prepara- tions, are generally prescribed. When there is much burning, compresses of a 1 per cent, solution of acetate of aluminium may be locally applied ; if blebs form, the alcohol spray may be recommended. Figs. 1, 2. Models in Neisser's Clinic in Breslau (Kroner). Fig. 3. Model in Neisser's Clinic in Breslau (Kroner). Fig. 4. Model in Neisser's Clinic in Breslau (Kroner). A repeatedly recurrent vesicular eruption in a tailor- ess, twenty-five years of age, with high fever and joint symptoms. Jacobi's Dermochromes. Plate III. No. 5. Erythema nodosum. No. 6. Purpura haemorrhaqica. Erythema Nodosum. Plate III., Fig. 5. Occasionally associated with Erythema multiforme, but generally alone, there appear nodules as large as a hazel-nut or walnut, with special frequency on the fronts of the legs, but sometimes also on other parts, accompanied by pains and swelling of the joints, which give the impression of a bruise {E. contusiforme), and disappear in two or three weeks. The affection is most probably of infective character. The colour, which is at first bright red, goes gradually through the whole grade of tints which occur in blood pigment un- dergoing absorption. Complications with diseases of internal organs, especially endocarditis, sometimes oc- cur, as well as haemorrhage into mucous membranes. The Diag'nosis may be made without difficulty from the localization and colour of the lesions. Bruises seldom appear in such large numbers and in the same position, while they are generally accompanied by epithelial erosions. Multiple gummata develop insidi- ously, are different in colour, and tend to necrose. The Erythema induratum of Bazin, which affects the same localization is an eminently chronic disease. The Prognosis is favourable in uncomplicated cases, but it must be guarded in presence of endo- carditis. 3 The Treatment consists of rest in bed and the administration of salicylic preparations. Fig. 5. Model in Lesser's Clinic in Berlin (Kolbow). Woman, thirty-six years old, without joint symptoms, treated as an out-patient. Jacobi's Dermochronies. Plate IV c b/. X CO c Purpura Haemorrhagica. Plate III., Fig. 6 ; Plate IV., Fig. 7. Under the name of Purpura are described certain diseases, probably of infective nature, in which haemor- rhages into the skin of varying intensity are observed. Petechise, ecchymoses and vibices are all superficial haemorrhages, characterized by their bright red or dusky colour, not disappearing under pressure with the finger or a glass. The lower extremities of young persons are the most frequent seats of small or large hagmorrhages, which develop — generally with rheu- matic symptoms and rise of temperature — commonly about the knees, and especially in spring and autumn {Purpura vel Peliosis rheumatica) . The number of haemorrhages is often enormously increased by re- peated relapses until, after several weeks, the disease ceases and the effused blood is gradually absorbed, undergoing the well-known changes of colour. Some forms of purpura, such as Werlhof 's disease and scur^^, in which the internal organs and mucous membranes are chiefly involved, differ from this clin- ical picture, and are serious diseases, whereas simple purpura rheumatica is a perfectly harmless affection. The epidermis over single haemorrhages may be raised in form of bullfe. (See Fig. 7.) The Diagnosis can be easily established from the symptoms described. 5 The Prognosis of simple purpura rheumatica is favourable. The Treatment consists of rest in bed with elevation of the extremities, and the administration of haemostatic remedies, such as ergotin, tincture of iron, etc. ; salicylate of soda in doses of 30 to 60 grains daily may be given on the ground of the probable in- fectious nature of the disease. Fig. 6. Model in the Vienna Clinic (Henning). The subject of the illustration was suffering from jaundice. A number of bullae with slightly hsemorrhagic margins are present in addition to the usual purpuric spots. Fig. 7. Model in Neisser's Clinic in Breslau (Kroner). J-. l-$ V en D a 3 00 6 Lupus Erythematosus. Plates XV., XVI. and XVII., Figs. 25, 26, 27, 28, 29. In Lupus erythematosus the skin changes usually begin on the face (Fig. 25), on the ears (Fig. 26), or on the scalp (Fig. 28), more rarely on the ex- tremities (Fig. 27) ; they originate as indeterminate red papules, which develop by peripheral extension to form patches with margins of bright red colour, cov- ered by firmly adlierent scales. These become greenish if of long duration and, if separated, show finger-like processes on their under-surface corresponding to dilated follicular ducts. At the margin comedo-like plugs are also often present which, however, are drier and not so fatty as true comedones. The process ex- tends peripherically with extraordinary slowness, while cicatricial atrophic spots, often traversed by telangiec- tases, develop in the centre without the occurrence of ulceration. A bats-wing configuration frequently re- sults from the favourite localization on the nose and cheeks. On the scalp the cicatricial atrophy gives rise to permanent alopecia. It seldom occurs on the mucous membrane (lips). The redness can be entirely dispelled by pressure; but on pressure with a lens the well-known nodules of Lupus vulgaris, from which this disease must be care- fully distinguished, never appear. Sometimes chilblain- 25 like lesions develop on the fingers, which may form rhagades and fissures, and cause considerable pain; apart from this, the disease causes little or no subjec- tive symptoms. Besides this form, which is called Lupus erythematosus discoides, there also occurs an acute form {Lupus erythematosus disseminatus) , in which numerous efflorescences occur on the face and body, accompanied by violent general symptoms and fever, which involute after a short existence and never extend peripherically, as in the patchy form, but heal with the formation of scars. This last variety may either develop from discoid Lupus erythematosus, or may arise spontaneously, and is always a serious dis- order. The causes of Lupus erythematosus are un- known, but in recent years an attempt has been made to connect the disease with tuberculosis by attributing its existence to the presence of toxins in parts of the body where tubercle bacilli do not exist; no proof of this theory has yet been adduced. (Fig. 29.) The Diagnosis of Lupus erythematosus may be based on its seat, the discoid shape of the lesions, the characteristic scaling, the dilatation of follicles, and the central atrophic scarring. The differential diag- nosis from syphilis and Lupus vulgaris must first be established. The former is distinguished by the copious amount of infiltration and the coppery or burgundy-like colour of its elements, while other mani- festations of syphilis are seldom absent. As regards Lupus vulgaris, the absence of nodules and ulcers is especially to be borne in mind. Psoriasis and mycotic diseases may be at once eliminated by the absence in them of atrophic scars. The Progriiosis must be guarded, as treatment is not always efficacious in the discoid forms; the dis- 26 Jacobi's Dermoclnomc?. Plate XVII. CL, o o 2 v: 3 c > a, 6 -ff,.--a n ■■^ :.'. M }<-■.;■■ C/5 ■r. a, o Jacobi's Derinochromes. Plate XIX. c V o c o U ^0 > 71 Oh 3 O 2 3 > t/1 3 d Jacobi's Dennochromes. Plate XX. to a. d 2 oc t/) D a, a -J 2 J.icol)i's Dermochronies. Plate XXI. -2° > O Z E _o 13 'a, > -J The course of Lupus vulgaris is extremely chronic; the disease usually begins in early childhood, more rarely at more advanced periods of life. It spreads slowly, or gives rise to fresh deposits round about. The general health is often little or not at all impaired, although persons suffering from advanced lupus are more liable to general tubercular infection than healthy individuals. In the course of lupus tubercular infec- tion of lymphatic vessels may occur, as the result of which "cold abscesses" may form at various points, which may break externally, and from this results so- called scrophuloderma without lupus (Gommes scrofu- leux, Fig. 32). The involvement of the afferent lymph channels as the result of erysipelas — which is not an uncommon complication — leads to the formation of elephantiasic growths on the genitals and extremities (Fig. 40), the lupus origin of which can only with difficulty be established after the healing of the lupus. A very malignant form of epithelioma develops in some cases on the top of lupus of many years' duration (Fig. 37) ; more rarely a benign new growth of epithelial origin may develop (Cornu cutaneum, Fig. 34). Sometimes lupus exists secondarily to tubercular diseases of other tissues, more especially to old-stand- ing affections of bones or glandular fistulse, in which case the lupus nodules are generally present in cica- trices in the immediate neighbourhood of these lesions. The Diagnosis of Lupus vulgaris is not difficult if typical nodules are present, especially when the part is examined by pressing a glass or lens on it, the nodules being thereby rendered manifest by the ex- pression of the hyperaemia which conceals them. The result of exploration with a probe confirms the diag- nosis. As nodules cannot be demonstrated in all phases of the disease, its extremely chronic course is worthy 31 of special notice. Syphilis produces much more ex- tensive and deeper lesions in a much shorter time. Other points of importance are — the onset of the mal- ady generally in youth, the absence of pain and lastly, the reaction to Koch's original tuberculin, which is an absolutely certain criterion. The differential Diag>nosis must be established from Lupus erythematosus (absence of implication of bone and of lupus ulceration), from Acne rosacea (lumpy swellings, but no lupus nodules), from Ring- worm (microscopical demonstration of fungus, no ulcers), but especially from Syphilis, as already men- tioned. This latter point is not always easy, but the inefficacy of antisyphilitic treatment, the special ten- dency for syphilis to attack bones, and the typical reaction of lupus to tuberculin, generally decide the question. The Prognosis as regards life is favourable, apart from the occurrence of general tubercular in- fection, but as regards cure it is absolutely unfavour- able in extensive cases. Permanently successful re- sults have hitherto been attained only in recent, limited cases suitable for excision. We have, however, in late years obtained, by the use of Finsen's light, permanent cures even in severe cases of lupus which have hitherto been considered of the most dire nature, owing to the hideous disfigurement so often produced by them. The results of Treatment depend in the first instance on early diagnosis. If the lupus infiltration is so circumscribed that it can be removed in toto without excessive loss of substance, radical extirpation is to be recommended just as if one were dealing with a malig- 32 Jacobi's Dermochromes. Plate XXII. No. 39. Lupus vulgaris serpiginosus. jacobi's Dermochronies. Plate XXIII. No. 40. Lupus vulgaris ; Elephantiasis consecutiva. No. 41. Lupus vulgaris; Mutilatio. nant tumour; the loss of substance must be remedied by suture or by grafting. In more extensive lupus, or when the subcutaneous tissue and lymphatic vessels are extensively involved, this procedure gives less cer- tain and less beautiful results. By scraping, scarifica- tion, galvano-caustic, or galvano-cautery, or by hot- air treatment (which, however, often causes cheloid scars), either alone or combined with caustics, appar- ently good results may for a time be obtained, but recurrences almost invariably take place. The best caustic is arsenic in the form of arsenical paste, but it cannot well be employed over large surfaces on account of pain and intoxication; the same remark applies to pyrogallol in ointments from 2 to 10 per cent, in strength. Both remedies have a selective action — i.e., they spare the sound and destroy the diseased tissue, but neither protects from relapses. Solid nitrate of silver, especially with the addition of nitrate of potassium to harden the nitrate stick, is of service for boring into nodules covered with epithelium, or may, in strong solutions, be used for ulcers, but its effects are generally too superficial. Chloride of zinc and caustic potash are deeply penetrative and energetic remedies, but they destroy also sound tissue. Lupus ulcers may heal well under 1 per thousand corrosive sublimate, or 2 per cent, permanganate of potash dress- ings, but the results are not permanent. Lupus of mucous membranes can be advantageously destroyed by cauterization with lactic acid, or by thermo- or galvano- cautery. The injection of tuber- culin, or of tuberculin and resorcin, cannot effect the cure of lupus. All the foregoing methods produce definite cure only in a small number of cases and after very pro- longed use. Better results appear sometimes to be attained by treatment with Rontgen rays until scab- bing is produced; but this method has not hitherto been generally adopted, on account of its very pro- longed duration and the sclerodermic changes in the skin which sometimes result from it. Undoubtedly the best results in extensive cases of lupus, both from the cosmetic and actually curative points of view, have been obtained by Finsen's treat- ment with concentrated sunlight, or by strong electric light from which the heat rays are eliminated. To judge by the results obtained by Finsen himself, the greater number of cases, even of protracted duration, which formerly would have been considered incurable may, by this means, be brought to a really perfect cure, and with the best imaginable cosmetic results, so that the possibility of completely eradicating lupus is not to be completely rejected. Unfortunately, the general adoption of the Finsen treatment has hitherto been rendered very difficult by the high price of the installation, the expense of the treatment, and by its long duration. None of the cheaper apparatus de- signed to replace Finsen's original apparatus (Lortet and Genoux, Bang, the Dermo lamp, Foveau and Trouvet) have, despite the great expectations founded upon them, succeeded in surely effecting the cure of lupus; so that up to the present the erection of public institutes provided with Finsen's original apparatus must be considered and advocated as the most potent weapon against this terrible malady. General recuperative treatment must be adopted in lupus as in tubercular affections of internal organs. Figs. 31, 32, 35, 42. Models in Freiburg Dermatological Clinic (Jolinsen). Figs. 33 and 39. Models in Neisser's Clinic in Breslau (Kroner). Fig. 34. Model in Saint Louis Hospital in Paris, No. 1059 (Baretta). Guibout's case. 34 Jacobi's Dermochromes. Plate XXIV. No. 42. Lupus vulgaris mucosae oris. No. 43. Verruca necrogenica. Fig. 38. Model in Neisser's Clinic in Breslau (Kroner). Figs. 36, 40, 41. Models in Neisser's Clinic in Breslau (Kroner). Fig. 37. Model in Saint Louis Hospital in Paris (Baretta). Besnier's ease. Male, aged fifty-one ; disease of twenty-two years' standing, only slightly treated, and especially never with thermo-cautery. Verruca Necrogenica. Post-mortem Wart. Plate XXIV., Fig. 43. Not infrequently there are present on the hands of anatomists, pathologists and post-mortem room ser- vants peculiar brown or grayish-black hard growths, with reddened and somewhat inflamed surrounding tissue. The affection, which results from the inocula- tion of tubercle bacilli, is generally quite benign and superficial ; only seldom can its transformation into lupus or extension into deeper tissues (lymphatics, ten- dons) be observed. Spontaneous cure frequently occurs. The Differential Diag-nosis has usually only to be established from common warts, in which there is no surrounding inflammatory zone ; their surface is also generally more uniform than that of post-mortem warts. The Prog-nosiS is almost always favourable. Treatment must be chiefly surgical. In very extensive cases the question of destruction by Light treatment may be worthy of consideration. Fig. 43. Model by Professor Jacobi in the Freiburg Clinic. 36 Scrophuloderma. Plate XXV., Fig. 44. The subcutaneous lymphatics— and especially the lymphatic glands— are sometimes infected as the re- sult of tuberculous disease of the skin, bones or joints ; and, in consequence, painless semi-globular nodules form, either isolated or arranged in lines, which differ in size and vary from a pale reddish to a livid colour. These become attached to the skin from beneath, then gradually soften and break down, discharging a thin, purulent fluid. The walls of the resulting abscesses collapse and flat ulcers form, which secrete a slight amount of discharge and are soon covered with scabs. Their walls are deeply eroded ; or narrow fistulae result, in the neighbourhood of which the skin is extensively undermined. Sometimes spontaneous healing occurs, with the formation of irregular, radiating scars; but in other cases treatment alone effects a cure of this extremely obstinate disorder. The Diag'nosis is usually obvious owing to the co-existence of other scrophulo-tuberculous lesions, but sometimes it may present points of difficulty in differ- entiation from syjihilitic gummata. The hardness of the infiltration and moderate degree of softening, as well as the formation of tyjiical, crateriforra, sharply- defined ulcers is to be specially noted. Finally, the 37 beneficial results — or inefficacy — of anti-syphilitic treatment settle any doubts. The Prognosis must be guarded. Treatment. — The nodules are best treated by surgical extirpation extending well into sound tissue. If extensive softening has taken place, thorough scraping and subsequent dressing with iodoform may be recommended. Fig. 44. Model in Neisser's Clinic in Breslau (Kroner). 38 Jacobi's Derinochromes. Plate XXV, No. 44. Scrophuloderma. No. 45. Tuberculide. Tuberculide. Plate XXV., Fig. 45. The justification of the term Tuberculide as applied to the majority of diseases of the skin supposed to result from the toxins of tuberculosis, or to many so-called "tuberculous exanthemata," appears to be extremely dubious. Some skin affections, however {e.g., Erythema induratum of Bazin and Lichen scrophulosorum), are veritable tuberculoses; while the condition named the "acneiform" or "necrotic" Tuberculide {Folliclis) has a hardly contestable claim to the name of Tuberculide. In this protean disease sharply defined nodules develop in the subcutaneous tissue, and over these macules, papules or vesicles form. Either absorption or superficial necrotic changes ensue, resulting in loss of substance and the gradual formation of sharply defined white scars, the surrounding tissue being at first deeply pigmented. The seats of predilection are the backs of the hands, the flexor and ulnar sides of the forearms, and the ears. The eruption may, however, appear on other parts of the body and generally does so in the form of crops of lesions appearing in groups. The course of the disease is very tedious. Other chronic tubercu- lous lesions generally co-exist. The Diag'nosis in characteristic cases is based 39 on the typical localization and evolution of the lesions. In others, it can only be established by a process of exclusion and in consideration of co-existent tubercu- lous manifestations. Treatment must in the first place be directed to the tuberculous element in the condition. No specific method of local treatment is yet known. Fig. 45. Model in Neisser's Clinic in Breslau (Kroner). 40 Jacobi's Derniochromes. Plate XXVI. N CO O en zs jr cu o u o £ -4-* D t3 0) 6 2 3 I. O a a, o u d 2 r// Lichen Scrophulosorum. Tuberculosis Milio-papulosa Aggregate. Plate XXVI., Fig. 46. On the trunk, and less frequently on the limbs of persons suffering from tuberculosis of the skin, bones or glands, there develop (usually unnoticed by the patient) numerous yellow or yellowish-red, acuminate, small papules, sometimes in groups, at other times scattered indiscriminately. These papules, after last- ing for some time, develop a small scale on their sur- face, and if present in larger numbers, coalesce to form scaly, rough, yellowish-brown patches (Fig. 46). The eruption, which generally occurs in young persons, causes no subjective symptoms; only seldom does the transformation of the papules into pustules or acnei- form pimples occur. The disease is undoubtedly of tuberculous nature, as shown by reaction to tuberculin, the anatomical structure of the miliary tubercles, and the discovery of bacilli in them; but it is caused by bacilli of slight virulence. The intensity of the erup- tion varies according to the condition of the under- lying tubercular disease. The Diag-nosis can be determined with ease on the existence of the typical papules and the eo-exist- 41 ence of a tubercular basis, or ultimately on the occur- rence of reaction to (the original) tuberculin. The Differential Diag-nosls need only be established from the small papular syphilide, which can be eliminated by the failure of antisyphilitic treatment. The Prog'nosis is favourable. Treatment must first be directed towards com- bating the original tuberculosis, and may be assisted by inunctions of cod-liver oil, or preferably, by weak chrysarobin ointment, which soon brings about a cure, without leaving any traces. Fig. 46. Model in Freiburg Clinic (Johnsen). 42 Erythema Induratum Scrophulosorum. (Bazin). Plate XXVI., Fig. 47. In young scrofulo-tubercular subjects, more fre- quently in the female than in the male sex, there are sometimes present on the legs hard, red or bluish-red, densely infiltrated nodules, which develop unnoticed, as they cause neither pain nor itching ; these sometimes break and discharge their strikingly yellow-coloured contents. Either after or without rupture the nodules, which are of extremely long and persistent duration, are slowly absorbed, leaving behind deep pigmenta- tion, while at the same time new lesions may develop. They are situated in the true skin and subcutaneous tissue; their margins are well defined; infiltrated areas as large as the palm of the hand may result from their extension and confluence. There is an undoubted con- nection between this disease (which is of greater fre- quency than is generally recognised) and tuberculosis, but the existence of tubercle bacilli in it has not yet been demonstrated. Deeper invasions of tissue do not occur. Treatment must first be directed to the tuber- 43 eular origin of the disease. Local treatment is gen- erally unnecessary and futile. Fig. 47. Model in Freiburg Clinic (Vogelbaclier). 44 [acobi's Dennochromes. Plate XXVIIA. 3 T3 O o o d Z Sporotrichosis of Beurmann. Plate XXVIIa; Figs. 49o and 496. (From Ikonographia Dermatologica — Rebman Company, Neiv York) Beurmann and his associates have made special studies to enable them to more fully establish and de- fine the changes caused in the skin by colonies of a certain filary fungus, called sporotriclius. They have found two distinct types of sporotrichosis. In the first form, sporotrichosis gummosa dissemi- nata tuberculoides (Fig. 49a), multiple, deep, subcu- taneous nodules develop by a slow, painless process, which gradually affect the skin by nodulation. They soften in the centre and discharge, through a narrow fistula, on pressure, pus which at first is tenacious, but afterward turns into a serous fluid tinged with streaks of blood. The central depressed orifice is encircled by a tough infiltration of a bluish-red tinge. There is no tendency to heal spontaneously, whilst a similarity to scrophulous gummata exists; glandular swelling is absent, likewise other tuberculoid manifestations. In the second but rarer type (Fig. 496), a painful ulcer quickly makes its appearance without, however, any appreciable rise in the temperature. The centre of this ulcer shows a marked tendency to scar forma- tion. The irregular but sharply defined edges are dotted with shaggy, papillomatous growths. From this primary ulcer lympathatic cords extend with nu- merous gummatous nodes which are partially movable and partially adherent to the derma. These finally penetrate the skin and turn into verrucous plaques somewhat resembling the primary lesion. Freshly de- veloped foci look more like acne nodules or strongly simulate the plaques of Eczema seborrhoicum. There are other, but rather rare types of Sporotri- chosis, such as the lymphangitic gummous, classic form described by Schenk-Hectoen, and also that men- tioned by Dor with multiple larger abscesses. Both types of Beurmann's Sporotrichosis show a well-marked similarity to certain forms of tuberculosis, especially to Scrophuloderma as well as to the gummous syphilis. The manner of softening, i.e., the foundation of narrow central fistulae surrounded by a broad, indu- rated zone, as well as the absence of other tuberculoid manifestations, are the noticeable features of the Spo- rotrichosis gummosa disseminata. In the second form much quicker and more far-reaching changes may be observed than is the case in tuberculosis and syphilis. The Diagnosis can only be established with cer- tainty through cultural methods. Nearly all culture media (the most reliable for this purpose is Sabour- aud's) produce from implantations of cellular tissue^ pus, secretions or scales, under medium or body-tem- perature within 5-10 days, small white or brownish cul- tures surrounded by a flat radiation which later on as- sumes a brown to black colour. Under the microscope this appears as long, about 2 fj. wide, straight or slightly curved, and at times ramified threads. Ad- hering to these are numerous egg-shaped spores of various magnitudes. In the pus itself, as also in the secretions and in the cellular tissue, it is difficult to discover these spores with the microscope. Sporotri- 446 chosis produces similar changes in animal inoculation with cultures, whilst with the pus or cellular tissue it- self no results are obtained. Fro£rnosis is favourable. Proper Treatment, consisting of internal and ex- ternal applications with Iodine preparations, will ef- fect a sure, though at times slow, cure. The alkali com- pounds of Iodine meet the requirements for internal medication. For external use wet bandages with Io- dine or Iodide of potassium and kindred lotions are indicated. Figs. 49«, 495. Models in the St. Louis Hospital in Paris (Baretta). No. 2531 and 2557. Dr. de Beurmann's cases. 44c Tuberculosis Linguae. Tuberculosis Nasi. Tuberculosis of Tongue and Nose. Plate XXVII., Figs. 48 and 49. In persons who suffer from tuberculosis of internal organs, true tuberculosis of the skin and mucous mem- brane, especially at their points of junction, is observed much less frequently than ordinary lupus. But — gen- erally as the result of direct infection by bacilli in the discharge — ulcers may form which are round or irreg- ular in shape, painful, and extend rapidly; their base is granular, bleeds easily, and is partly covered with sticky discharge, while miliary tubercular nodules may not infrequently be identified at their margins (Fig. 49). On mucous membrane the margins are, as a rule, undermined (Fig. 48). Numerous bacilli are— in contradistinction to lupus— to be found in the ulcers, which have also a much slighter tendency to heal, ex- tend with far greater rapidity, but seldom attain larger dimensions than in lupus, as the patients die sooner. The Diagnosis can generally be established with- out difficulty on the grounds of their localization, char- acteristic appearance, painfulness, and the general 46 Jacobi's Derniochronies. Plate XXVII in O ON d V a (J -t 6 tubercular symptoms. It may be confirmed by the discovery of bacilli. The differentiation from syphilis may be established by the behaviour of the lesions under antisyphilitic treatment. The ProgTlOSis is unfavourable. Treatment must have for its object the diminu- tion of pain by dusting with orthoform, anfesthesin, and similar remedies, as the general condition of the patient usually forbids the use of energetic measures. Should such, however, be permissible, attempts may be made to effect a cure with caustics, "light treat- ment," or surgical measures. Fig. 48. Model in Saint Louis Hospital in Paris, No. 1768 (Baretta). Tenneson's case. Fig. 49. Model in Saint Louis Hospital in Paris, No. 2236 (Baretta). Hallopeau's case. 46 Lepra. Leprosy. Elephantiasis Crsecorum. Plates XXVIII-XXX., Figs. 50-55. Leprosy is a general infective disease, known even in very ancient times as a contagious malady, which was very widely distributed till the Middle Ages. At the time of the Crusades, however, it was forced into the background by the advance and extension of syphilis, and now its occurrence is extraordinarily diminished, so that it exists with frequency in the tropics only, and is scattered sporadically over Europe (Norway, Russia, Greece, with a small area near Memel). We draw a distinction between tubercular leprosy and nerve leprosy, according to the localization of the causative agents of the disease — viz., the lepra bacilli discovered by Hansen and Neisser — whether in the skin or in the nervous system. Not infrequently "mixed forms" also occur. In tubercular leprosy, along with the symptoms of a general infective process — fever and prodromal ex- anthemata — nodules and infiltrated areas of varying size gradually form, over which the skin is usually brown and shiny (Fig. 50), or sometimes may present an eczematous or psoriasiform appearance. The com- monest localization (Fig. 51)— viz., on the face— pro- duces the early falling of the eyebrows and thickening of the facial folds, which go to make up the so-called 47 Jacobi's Uermochromes. Plate XXVIII. ^ 6 Treatment. — Cure can easily be obtained, when the disease affects merely the epidermis of glabrous parts, by means of bactericidal substances, or such as produce vigorous separation of the epidermis. Thus, tincture of iodine, the inunction of sulphur soap, or of Kaposi's naphthol ointment, attain this object without difficulty in the vesicular and squamous varieties, and the latter is efficacious in pityriasis rosea, which also yields easily to treatment with pastes or powders. The principal anti-mycotic remedies in use are chrysa- robin, pyrogallol, or a 1 per cent, solution of corrosive sublimate in tincture of benzoin. Tar, either pure or in the form of Wilkinson's ointment, acts very usefully. The treatment of the deep-lying ringworms is much more difficult ; in them poultices may be recommended, followed by compresses of a 1 per cent, solution of acetate of aluminium or resorcin. In later stages chrysarobin, Brooke's paste, or corrosive sublimate, may prove of good service. Epilation must always be practised, and must be a preliminary to the treatment of ringworm of the scalp; afterward inunction of chrysarobin, painting with tars, solutions of corrosive sublimate or tincture of iodine, ointments of sulphur or croton oil, may all be tried. Lastly, "Light treat- ment" may effect a cure, although often only after a very long time. Fig. 56. Model in Neisser's Clinic in Breslau (Kroner). Figs. 57, 59, 62. Models in Neisser's Clinic in I?reslau (Kroner). Fig. 58. Model by Professor Jacobi in the Freiburg Clinic. Fig. 60. Model in Lassar's Clinic in Berlin (Kasten). Fig. 61. Model in Saint Louis Hospital in Paris, No. 1051 (Baretta). Vidal's case. Fig. 63. Model in Neisser's Clinic in Breslau (Kroner). 54 Erythrasma. Plate XXXIV., Fig 64. Erythrasma shows itself as accurately marginated patches of brown or brownish-red colour, with convex outlines and finely desquamative surface, the per- ipheral portions of which are slightly reddened. They occur principally on the inner sides of the thighs close to the genitals, on the scrotum, labia majora and perinaeum, and on the adjacent portion of the abdomen ; they may also attack the armpits and thence spread to the chest and trunk. It is caused by a mycelium, the Microsporon minutissimum, and it is always very superficially situated in the epidermis. The disease is obstinate, although absolutely harmless. The Diagnosis is easily made on the grounds of its localization, colour and fine desquamation. The Treatment is similar to that of the super- ficial forms of ringworm. Fig. 64. Model in Riehl's Clmic in Vienna (Henning). 55 I Jacobi's Dennochromcs. FUte XXXV, Xo. 65. Pityriasis versicolor. Pityriasis Versicolor. Plate XXXV., Fig. 65. Pityriasis versicolor occurs more especially in per- sons who sweat freely, and therefore very frequently in the phthisical. It shows itself as small yellow or brownish spots, which sometimes are arranged in con- fluent patches, and are caused by the invasion of the epidermis by the Microsporon furfur. The individual spots are very superficial, only slightly elevated, and rarely somewhat reddened at the edge. The branny desquamation is most marked when the spots are lightly rubbed; there is never coarse scaling. If the part is scratched, the entire diseased corneal layer is removed in the form of a thin pellicle, and the nearly normal subjacent skin is exposed. The disease chiefly affects the trunk, whence it sometimes spreads over the limbs and neck ; the face, palms and soles are, how- ever, always free. Subjective symptoms are, as a rule, completely absent, so that the malady is often unnoticed. The Diagnosis can be made with facility from the yellow colour and localization of the disease, and by the possibility of removing the spots by scratching. It can be confirmed by the detection under the micro- scope of the network of mycelium and numerous clumps of brightly refractive spores. 56 The Prog-nosis is favourable. Treatment easily produces temporary favour- able results, but a permanent cure is obtained only with difficulty. All antimycotic remedies may be used with benefit, as may inunctions of sulphur soap, paint- ing with alkaline spirit of soap, sometimes with the addition of 1 per cent, of naphthol ; or baths followed by lotions of corrosive sublimate, naphthol, etc., may be used. The best results we have obtained have been with the treatment recommended by Besnier, consist- ing of the alternate inunction of salves containing 1 to 3 per cent, of resorcin and salicylic acid, and 5 to 15 per cent, of sulphur. Fig. 65. Model in Neisser's Clinic in Breslau (Kroner). 57 'I Jacobi's Dermochronies. Plate XXXV : en (U Ch I. oi Uh t^ d 2 3 6 2 I! Favus. Plate XXXVI., Figs. 66 and 67. Favus is most commonly present on the scalp in children, and is characterized by the formation of so- called "favTis cups" (or scutula); these are saucer- like, yellow or sulphur coloured, hollowed discs, which are composed of thickly welded masses of Achorion Schonleinei — the causative fungus of the disease — mixed with detritus and epithelium, covered with a thin coat of the horny layer, and perforated in the centre by a hair (Fig. 66). After the scutulum is removed, a shallow depression is perceptible, which, as the result of the exposure of the rete Malpighii, is moist and glistening. After some time has elapsed the favus cups coalesce to form whitish, mortar-like masses (Favus confertus), which in some cases involve the greater part of the scalp, and only show the mode of formation of the composite patches by some scat- tered cups at their margin. Over the affected areas the hairs are lustreless, as if powdered, and the disease exhales a musty, mouse-like odour. Its course on the scalp is extremely chronic, and in the majority of cases, terminates in cicatricial atrophy, as the result of pressure by the fa^'us cups, with permanent alopecia of the affected parts. The affection occurs more frequently on the scalp than on the body, where circles first appear, either 58 covered with scales, or showing vesicles at their mar- gin, and these exactly resemble the lesions produced by trichophytia ; only after protracted duration do they exhibit one or more seutula in the centre (Fig. 67). On the skin of the body the disease is not at all obstinate, and recovers without leaving any marks. In rare cases the favus fungus may penetrate deeply, and evoke a condition analogous to kerion. The nails may also suffer in the same way as in ringworm; occasionally cup-like lesions are found embedded in the nail substance. Recent investigations have proved, contrary to the views of Quincke, Unna and others, that favus is in all probability caused l)y one form of fungus only, which may assume different developmental forms on different media. Animals {e.g., cats and mice), which are susceptible to invasion by favus, are often the starting-point of the disease in man. The Diag'nosis is generally easy in presence of the favus cups, which become of an intense yellow hue when moistened with alcohol, or after microscopical demonstration of the fungus. The powdery appear- ance of the hairs and the musty odour are also points of importance. Even after favus has terminated, the cicatricial atrophy of the scalp may establish a retro- spective diagnosis. The Prog^iiosis is favourable on the body, but on the scalp it must be very guarded, as permanent alopecia is usually the ultimate result of the disease. Treatment has for its first object the removal of the seutula, which may be effected by an oil-cap; then energetic epilation must be instituted, and in very extensive cases this may be done by the application 59 Jacobi's Dermochromes. Flate XXXVU. No. 68. Psoriasis vulgaris guttata et ostracea. No. 69. Psoriasis vulgaris. of the calotte under an anaesthetic. Afterward regular washing with soap and the subsequent use of ehrysaro- bin, tincture of iodine, sublimate spirit or ointment, or naphthol may be recommended. Tar, ichthyol, and tumenol are used with good success. Treatment by X-rays appears to yield excellent results, but must be employed with the greatest caution on account of the risk of X-ray burns. Fig. 66. Model in Saint Louis Hospital, Paris, No. 548 (Bar- etta). Besnier. Fig. 67. Model in Neisser's Clinic in Breslau (Kroner). 60 Psoriasis Vulgaris. Plates XXXVII.-XLI., Figs. 68-76. By Psoriasis we understand a chronic, nearly always incurable, disease of the skin, the cause of which is unknown — but is very probably of fungous origin — and in which relapsing outbreaks of eruption alternate with intervals of more or less freedom. The primary lesions are typical and consist of small points, the size of a pin's head, which soon become covered with firmly adherent scales. As they develop and spread, all the different forms of Psoriasis guttata (Fig. 68), nummularis, etc., arise; when healing occurs in the centre, Psoriasis annularis results, and when neigh- bouring circular patches run together the condition is called Psoriasis gyrata vel figurata (Fig. 70). The localization, chiefly on the extensor sides of the ex- tremities and on the scalp (Fig. 71), is characteristic of psoriasis, as is the production of small, punctiform, bleeding points in the exposed, moist, red and shiny rete Malpighii, after the scales are rubbed off. Lastly, the absence of any dense infiltration is typical, in con- tradistinction to other similar diseases, especially scaly syphilides. Deviations from the general rule as to distribution occur, however, not infrequently and there is no part of the skin which may not occasionally be the seat of the eruption (Fig. 75). Even on the palms and soles psoriasis may exist, not only in uni- versal attacks, but also in localized cases, so that it 61 I Jacobi's Dermochromes. Plate XXXVIII. mgM^Bm V*T"' XT^ ■:^r'\^;■■ ^ •y'Tf -r. ^ '.'-i '\ No. ;o. Psoriasis gyrata et serpiginosa. lacobi's Dermochromes. Plate XXXIX. 3 > t/i o t/3 r4 6 2 Oh > '55 O t/1 o 2 is highly desirable to discontinue the use of the name Psoriasis palmaris et plantaris as designating papulo- squamous syphilides of the palms and soles (Fig. 76). Mucous membranes are hardly ever involved in psori- asis. The so-called Psoriasis Tmicosoe oris has no relationship to true psoriasis, and is better named Leucoplakia. Very marked changes may be observed in the ex- tremely chronic course of psoriasis without any treat- ment, a circumstance which greatly prejudices our judgment as to the value of all therapeutic measures. Frequently eczematous complications occur. Consid- erable differences may be observed not only in the shape and size, but also in other attributes of the psoriatic lesions; thus the characters and thickness of the scales vary greatly, and thick mortar-like or oyster-shell-like masses may be present side by side with comparatively thin scales; while all shades of colour may coexist, from a pure glistening mother-of- pearl white to a dark, grayish-yellow or gray tint (Figs. 68, 69, 74). In the same way the intensity and width of the red band which bounds the scales vary; sometimes it is of a yellow rather than a red colour, while on dependent parts a more livid tint may pre- dominate. The seats of predilection are, as already stated, the backs of the elbows, fronts of the knees and the scalp, but in other cases the disease is much more widely distributed and may involve the greater part of the integument. In acute cases scarcely any region may remain unaffected (Fig. 75), and in these circum- stances severe general symptoms may develop, whereas in localized cases the general health is unaltered. It is a generally recognised fact that psoriatics are fre- quently robust, well-nourished individuals. In the chronic forms trifling itching is, as a rule, the only 62 subjective symptom present, but in acute and extensive outbreaks a troublesome feeling of thirst is often com- plained of. When psoriasis is localized on the hands and feet there occur, besides other changes in the nails, marked thickening of the nail substance, with opacity and sep- aration from the nail-bed, which begins at the per- ipheral end (Figs. 72, 73). In severe cases the nails may even be completely shed. The Pz*Og'ilosis is so far favourable that only in exceptional cases is there any deterioration in the gen- eral health, and individual eruptions can be cured. A definite, final cure of psoriasis is, however, impossible. Differential Diagnosis.— Syi^hilis, eczema seborrhoicum, lupus erythematosus, true eczema and ringworm must first be considered. Ringworm may be eliminated by the absence of fungus and its acuter evolution. In contradistinction to lupus erythematosus, psoriasis never leaves scars, and does not invade sebaceous follicles. Eczema sebor- rhoicum corporis {Lichen cirmonscriptus of Villan) generally displays smaller and more fatty scales with brighter yellowish-red coloration, and its typical dis- tribution is on the chest and back. The differentiation from simple eczema is more difficult, chiefly because combinations of the two maladies occur. As a rule the localization and the fact that true psoriasis never weeps, as well as the determination of the elementary lesions of either disease, suffice to establish a diagnosis. Syphilis attacks most frequently flexor surfaces, and its papulo-squamous lesions — which only need to be considered here — are accompanied by dense infiltra- tion. In syphilis, too, itching is absent, but in dubious cases the effects of treatment will be decisive. 63 Jacobi's Deriiiochronies. Plate XL. No. 'J2,- Psoriasis vulgaris unguium. No, 74. Psoriasis vulgaris rupioides. [I Jacobi's Dertnochromes. Plate XLI. No. 75, 76. Psoriasis vulgaris. Treatment may be either by internal or ex- ternal means. The most important internal remedy is arsenic, which, if properly employed, almost always brings about the recovery of psoriasis spots, but with deep pigmentation. It may be used in the form of "Asiatic pills," or of subcutaneous or intramuscular injections of the liquor sodii arseniatis. Iodine is not so certain a remedy, but is efficacious in a number of cases, provided it is prescribed in the form of iodide of potassium and in full doses. Other drugs (thyroid gland, etc.) have been proved to be uncertain in action or quite futile. The first object of external treatment is the removal, after maceration, of the scaly masses. Baths, soaping and washing, salicylic ointment and super-fatty soaps, alcohol sprays or compresses, with frequent ablutions, soon produce the desired effect. Reducing and slightly irritating remedies must be applied after the removal of the scales. Chrysarobin stands in the first rank, and may be used in the form of weak ointments (2 to 5 per cent.) once or twice daily until slight irritation of the skin is caused. The effect of chrysarobin seems to depend on the variable quality of the drug. Only those preparations which produce, after protracted applica- tion, a dermatitis, will be found of importance in the treatment ,of psoriasis. As the drug varies greatly in quality and consequent effect, it is well to use only preparations which, after prolonged use, cause some degree of dermatitis. Chrysarobin ought not to be used for the face and scalp, on account of the ugly discoloration of the skin and hair it produces, as well as of its irritating effect on the conjunctiva. If chry- sarobin irritation sets in, or even threatens to do so, the remedy must be at once discontinued and treatment by indifferent soothing ointments, pastes or tars sub- stituted. Chrysarobin stains the normal skin a dark- CA bluish or brownish-red colour, in the midst of which the diseased parts appear pale, and chrysarobin stain- ing only disappears when recovery is complete. The drug may be applied to localized spots dissolved in chloroform (10 per cent.), traumaticin being afterward painted over them. Pyrogallol produces similar, but not such satisfac- tory, results ; it may be employed in the form of a 5 per cent, ointment, but ought never to be used over more than one-fifth of the surface of the body at a time, on account of the risk of poisoning. Tar is employed, principally in the form of tar baths, tar oil or tincture of tar, and is specially recommended for psoriasis of the scalp. Similar but milder in its action is the liquor carbonis detergens, which is ap- plicable to uncovered parts, owing to its slight smell and colourlessness. A 10 per cent, white precipitate ointment, to which 10 to 20 per cent, of liquor carbonis may be added, is in common use for the treatment of the face. Specially obstinate psoriasis spots often dis- appear under eugallol — a pyrogallol derivative — which is applied mixed with 2 parts of acetone, and covered with zinc paste or dusting-powder. It can, however, only be used for single small patches. Eegular hot baths with sulphur, ordinary warm-water bathing or hot-air baths, help other treatment; sea- baths are often deleterious. If eczema is present, it must first be cured before the treatment of the psor- iasis is undertaken. Radium, uviol and X-rays are also recommended. Figs. 68, 71. Models in Neisser's Clinic in Breslau (Kroner). Figs. 69, 72, 73. 74. Models in Neisser's Clinic, Breslau (Kroner). Fig. 70. Model in Lessers Clinic in Berlin (Kolbow). Fig. 75. Model in Saint Louis Hospital, Paris, No. 1670 (Baretta). Du Castel. Fig. 76. Model in Neisser's Clinic in Breslau (Kroner). A man, thirty-five years of age, who, in the nonrse of a rather e.xtonsive eruption, had manifestations on the palms and soles. 65 'II Jacobi's Deniiochromes. Plate XLII. No. ". Lichen planus. No. 78. Lichen planus atrophicus. Lichen Planus. Plates XLII.-XLIV., Figs. 77-81. Under the term Lichen are included those diseases, the primary lesion of which is represented by a small papule which undergoes no further development. Properly speaking, therefore, only two affections come into consideration — viz.. Lichen ruber planus, and Lichen acuminatus. The latter is a very rare disease, first observed by Hebra, in which numerous, red, pointed papules occur, tipped by horny caps, which may run together to form rough, grater-like patches. As the disease spreads the nails are involved, the hair falls, and the earliest described cases proved fatal, with all the characteristics of a severe general malady. It is uncertain whether this type of disease still exists, or whether its serious results are now warded off by the arsenical treatment introduced by Hebra. The great majority of lichen cases now observed are examples of Lichen planus, the elementary lesions of which consist of minute papules, sometimes as large as a hempseed, but occasionally larger; they are waxy- looking and shiny, and of bright-red colour; they are generally smooth on the surface, accurately delimi- tated and polygonal, while sometimes they are crested with a firmly adherent scale. When numerous papules run together the skin presents peculiar, raised patches. Involution is accompanied by deep pigmentation, and 66 often begins in the centre, while the process spreads at the margin, so that the skin assumes the appear- ance of shagreened leather. Intense itching is the most prominent subjective symptom; it gives rise to scratching and thus to narrow linear bands, which appear to be made up of lichen papules in close appo- sition. Lichen papules also may exist, arranged in the most diverse manners, sometimes being in rings, or in net-like patterns, or in circles (Lichen annularis, Fig. 79). After long duration a peculiar warty appear- ance may be assumed, especially upon the legs (Lichen verrucosus, Fig. 80). The disease, which is a very chronic one, generally occurs in successive outbreaks, and disappears very slowly, sometimes leaving atrophy of the parts occupied by papules (Lichen atrophicus, Fig. 78). The affection is frequently localized on the flexor surfaces of the extremities (Fig. 77), but any part of the body may be attacked, even the mucous membranes (Fig. 81), on which the lesions appear as whitish, silvery, glistening patches with thickened epithelium. Their occurrence on the penis is note- worthy, either alone or in conjunction with a general- ized eruption. Very rarely lichen papules become vesicular. The Etiolog'y of lichen is not yet definitely estab- lished, but many exciting causes of vegetable nature (fungi) have been assumed to exist. The Diagnosis can be made without any diffi- culty if typical lichen papules are present. The DifiEerential Diagfi^osis must first be made from the small papular syphilide — sometimes unfortunately called Lichen syphiliticus — which may, however, be distinguished by the coppery colour char- 67 Jacobi's Dermochromes. Plate XLIII. D (A o u 3 > 3 C 6 CO d t/5 3 C 03 C 1) 6 Z I I Jacobi's Dermochromes. Plate XLIV. a, o V 3 t/3 3 rt u 1-1 o acteristic of syphilitic eruptions, by the absence of itching, and by the presence of concomitant manifesta- tions of syphilis. When large tracts of skin are in- volved by lichen, difficulties may arise as to diagnosis from psoriasis; but in the latter disease there are no typical lichen papules and none of the scratch-mark phenomena described, whereas the typical, large, mother-of-pearl lamellar scales are present. The diagnosis may be difficult when the soles and palms are involved, as lichen causes large callosities in these situations. The primary lesions must, therefore, be looked for and the existence of itching considered in establishing a diagnosis between lichen on the one hapd and ichthyosis or psoriasis on the other. The Prog-nosis is, on the whole, favourable, but relapses and recrudescences are not infrequent during treatment. Fatal cases of Lichen acuminatus of Hebra are no longer observed. Treatment. — Most important is the internal ad- ministration of arsenic, either in the form of "Asiatic pills," or by subcutaneous or intramuscular injection of the liquor sodii arseniatis; but recovery only sets in after comparatively large doses have been admin- istered. The first object of external treatment is to allay itching by the use of tarry applications. Chry- sarobin, pyrogallol, mercurial plaster, or Unna's sub- limate and carbolic acid plaster-mull, act well in com- bination with warm baths. In stubborn cases light treatment (X-rays and ultraviolet rays) has proved beneficial. Figs. 77, 79. Models in St. Louis Hospital in Paris, Nos. 1398, 1554 (Baretta). Hallopeau. Figs. 78, 80. Models in Neisser's Clinic in Breslau (Kroner). Fig. 81. Model in Lassar's Clinic in Berlin (Kasten). 68 Leucoplakia. Plate XLIV., Fig. 82. On the tongue, especially at the margins, on the buccal mucous membrane in contact with the teeth, at the angles of the mouth, and on the mucous lining of the lips, roundish, often confluent patches are fre- quently present, especially in persons who smoke and drink to excess, over which the epithelium is thickened and opaque. They pursue an extremely chronic course, they are slightly, if at all, raised and exhibit little or no inflammation at the edge. In many cases there is a history of antecedent syphilis, but the affection can certainly not be regarded as specific, inasmuch as it also occurs in non-syphilitic subjects, and is absolutely uninfluenced by anti-syphilitic treatment. Epithe- lioma may develop on leucoplakial patches as the re- stilt of long-continued irritation. There is usually very little pain. The Diag'nosis is easy in typical cases, as the long duration, the localization and the absence of in- flammatory phenomena permit of easy distinction from syphilitic plaques. Lichen planus of the mucous mem- brane of the mouth is always accompanied by lichen elsewhere. The "geographical tongue" is congenital, and soon alters in character. C9 The Prognosis is, on the whole, favourable, ex- cept in the rare cases in which carcinoma develops on a leucoplakial basis. Treatment can only be followed by good results in the early stages. Apart from local treatment by chromic and lactic acids, papayotin or salicylic alcohol, lotions of decoction of bilberry are recommended. Obviously, smoking and indulgence in alcohol must be interdicted. Fig. 83. Model in Saint Louis Hospital in Paris, No. 1573 (Baretta). Fournier. 7d 6/ UC SOUTHERN REGIONAL LIBRARY FACILITY D 000 827 543 V ■■:,' ■^■■"' •"■''■'■ ''.^-^ ' ', V '.I "i''!i ',"yv.','-'-i'''--'>' ..I'm >,;;;■,■,■(•.;,'