Epitome of skin diseases, with formulae, for students and practitioners

Front matter

V

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V

Preface To The Second American Edition

In preparing this edition of our "Epitome" for publication in the United States, we have increased the matter to about three times its original amount. The kindly appreciation manifested for the work by the American profession has stimulated us to spare no pains in rendering it more worthy of their approbation, and in its enlarged form we believe that it will be found of enhanced value. About two-thirds of the work is newly written, and we may direct attention particularly to the section regarding the Pathology of the Skin, which has been entirely recast, and now contains a concise account of all the important changes taking place in the dermal textures in disease. The clinical descriptions of diseases also have been amplified and occasionally remodelled. Lastly, we may say that in adding material to the book we have selected such as bears on the practical side of

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VI PREFACE TO SECOND AMERICAN EDITION.

Dermatology, to the exclusion of that which is as yet hypothetical or merely of interest to the curious student. The favorable reception accorded to the work on both sides of the Atlantic would seem to show that it has realized the object with which it was prepared — to afford assistance to the student in his early study of dermatology, and to serve as a manual for ready reference by the practitioner in his daily practice. For this latter purpose it has been specially adapted, by means of the references made in the sections on treatment to the formulae at the end.

TILBURY FOX, THOMAS COLCOTT FOX.

14 Harley Street, London, W., January 1, 1879.

CO 1ST TENTS.

Part I. Paqb

General Observations on Skin Diseases . . 13

SECTION I. The Mode of Observing Skin Diseases

1. As to the General Character of Skin Eruptions . . 13

2. As to the Mode of Examining Skin Diseases . . 14

3. As regards Complications ...... 17

4. Modifications of Eruptions ...... 18

SECTION II. The Pathology of the Skin

1. Elementary" Lesions ....... 21

2. Secondary Changes ....... 32

3. General Observations on the Pathology of the Skin . 34

SECTION III. Classification or Diagnostic Chart of Skin Diseases

1. Eruptions occurring in Connection with the Acute

Specific or Zymotic Diseases .

2. Eruptions connected with Diathetic Conditions

3. Local Inflammations .....

4. Hypertrophic and Atrophic Diseases .

5. New Formations

6. Hemorrhagic Disorders ....

44 45 45 46 46 46

Vlll CONTENTS.

7. Neuroses

8. Pigmentary Alterations ...

9. Parasitic Diseases ....

10. Diseases of the Glands and Appendages .

11. Peculiarities of Skin Diseases in the United States

12. Classification and Nomenclature of American Derma-

tological Association 50

PAGE

46 46 47

47 48

PART II. The Description and Treatment of Skin Diseases

Acne 69

Alopecia, or Baldness 75

Anthrax, or Carbuncle .....<. 76 Area, see Alopecia.

Atrophia Cutis .77

Bakers' Itch 79

Baldness, see Alopecia.

Barbadoes Leg, see Bucnemia.

Boils, see Furunculi.

Bricklayers' Itch ........ 79

Bromide Eruption 79

Bucnemia Tropica, see Elephantiasis Arabum.

Cacotrophia folliculorum ...... 81

Cancer, see Epithelioma and Rodent Ulcer. Carbuncle, see Anthrax.

Chloasma, see Tinea versicolor.

Contents

IX

Comedones

Condylomata .

PART III. Cutaneous Pharmacopoeia

PARE

Baths 199

Caustics 200

Sedatives . 202

Absorbent Powders 205

Stimulants and Absorbents ...... 205

Plasters . . 208

Mixtures 208

Pills 210

Remedies for Scabies and Phtliiriasis .... 211

Remedies for Vegetable Parasitic Diseases . . . 212

Diet in Skin Diseases 214

EPITOME OF SKIN DISEASES.

PAET I.

THE GENERAL PRINCIPLES OF CUTANEOUS

MEDICINE.

Section I. The Mode Of Observing Skin Diseases

In order to pursue the clinical study, and to prosecute the treatment, of maladies of the skin with the best chances ot success, attention should be primarily directed to one or two important considerations ; relating, on the one hand, to the general character of cutaneous changes, and, on the other, to the mode of examining patients attacked by these diseases, as well as to some general facts concerning the complications and modifications of the disorders themselves.

First. As to the General Character of Skin Diseases

Really, there is nothing specialin the pathological changes occurring in the textures in these disorders. When the student approaches the study of cutaneous maladies, he is apt to imagine that he is about to encounter a new set of pathological phenomena, different from those with which he has been made acquainted in morbid alterations in other parts of the body, which in reality is not true. Recent researches in cutaneous pathology have cleared the way to a more correct knowledge of the changes taking place in the skin in disease, and, as a consequence, it is becoming more 2

14 MODE OF OBSERVING SKIN DISEASES.

and more apparent that these morbid processes are identical with those occurring elsewhere in the body ; whilst a proposition to group skin diseases according to their pathological affinities, upon a plan like to that on which other maladies are classified, is now seriously entertained. It is a noteworthy and satisfactory circumstance that the student of to-day, who is compelled to acquire pathological knowledge over a wide field, is beginning to discover that his study of skin diseases is rendered comparatively easy, because of the complete similarity which has now been demonstrated to exist between the facts of general and of skin pathology. The reader does not find himself dealing with strange topics or data, but recognizes familiar appearances, changes, and causes in morbid action, when he turns from his study of the diseased states of other organs to deal especially with those of the integument in its several parts. It is all-important, then, to understand that there is nothing essentially peculiar in the principles of cutaneous pathology.

The misconception which has so long prevailed on this point, it is not difficult to account for. The student has been bewildered and often misled by the prominence given to the mere external form and aspect of eruptions, whilst the multitudinous names, too, which have from time to time been coined with great prolixity as designations for the infinite varieties of these external appearances, have been so unlike those applied to diseased states in other parts of the body, that they have materially supported the belief in an essential difference and peculiarity in the nature of cutaneous disorders.

Secondly. As to the Mode of Examining Shin Diseases— In examining eruptions with the object of ascertaining their specific characters, error is frequently committed in attempting to decide upon these characters from a too partial or superficial examination of the phenomena they disclose to

MODE OP OBSERVING SKIN DISEASES. 15

the senses of the practitioner, and without due inquiry into their antecedents. Many persons are wont to content themselves with making a diagnosis at sight, judging from mere aspect alone. In many cases, without doubt, the nature of the disease under scrutiny can be correctly made out at once by an expert, simply from inspection, even when that is of a very partial kind, wherever the eruption assumes from the outset, and preserves throughout its course, its typical characters. But in other instances, on the contrary, it is difficult or impossible to make an accurate diagnosis without careful inspection of many parts of the disease in several localities in a given patient, and an inquiry into the previous history of its course. For many skin diseases have definite stages, and at the time of observation these may vary considerably in different parts of the body. The typical phenomena of a given eruption may be only in progress of development here, or be lost there, or modified by scratching in another locality. But an examination of the disease in several regions of the body will often disclose the existence of its earlier characters as well as the later changes, by means of which the general nature of the disease may be determined. Typical features may be discovered, in some cases, in a region of the body which, perhaps, comes last under inspection, when they have been absent in several other parts examined. But sometimes it is necessary to go carefully into the history of the case to discover the evidence of the existence of diagnostic features which formerly existed, though lost at the time of actual observation by the practitioner. Further, in reference to the necessity of a thorough examin'ation of patients suffering from cutaneous troubles for the purpose of diagnosis, it is important to add that parts, or stages of different maladies often resemble one another, and may convey a very imperfect picture of a disorder. To avoid error then the diagnosis should be based upon a careful estimation of the phenomena or features presented by any given disease as a

16 MODE OP OBSERVING SKIN DISEASES.

whole, and not upon the data afforded by any particular portion of the history, or distribution, of that disease.

The foregoing observations may be summed up in two cardinal principles, or to put the matter in another form, we may say, from what has been mentioned about the mode of examination of cases of skin disease, that there are two important rules which should be observed in attempting to make a proper diagnosis of a disease of the skin : —

The first rule is this : —

All diseased places, or as many as possible, should be carefully examined, and not one only, or one here and there: for the simple reason that the eruption may be at very different stages of development, and therefore present diverse aspects, in different localities upon the same patient.

The second rule is as follows : —

Where in any given case the earlier stages are not present so as to be recognizable, careful inquiry should be made by interrogation of the patient, as to the changes that have occurred before the disease came under observation, with the view of determining its nature.

The object of the examination prescribed by the first of these two rules is to trace out the origin and course of the disease, and to link together the various stages into a complete history which will correspond in its clinical features with an authoritative standard description of the disease, whatever it may be. During this examination special attention should be directed to the character of the newest developments of the eruption with the intention of determining the " initial or elementary lesion," as it is called (to be presently referred to), or if there really be no new spots of eruption, the observer should carefully note the features presented by the extending edges of patches, which always constitute the most recently developed parts of the disease, and which, therefore, often portray the primary lesion. Complications are also more likely to be recognized by attention to this point.

MODE OF OBSERVING SKIN DISEASES. It

The use of the second of the two rules has been cursorily referred to in a previous paragraph, but requires further discussion.

Very frequently no fresh developments of the eruption are taking place at the time of observation, and no extension of a given patch has occurred for some time. The malady has in fact become chronic and indolent, and moreover has lost its typical features oftentimes. The only way of making a diagnosis under these circumstances is by observing this second rule. For example, eczema is characterized mainly by a peculiar discharge, but the discharging stage, frequently, has passed before the case comes under medical observation, and the affection may present a dry and scaly appearance and be readily mistaken for psoriasis — a not infrequent error. Again, a disease essentially papular may have become inflamed and encrusted, and its true nature may therefore be overlooked, unless its history be carefully inquired into.

By the observance of these two rules the student ascertains what is the elementary lesion, as well as the characters of the several stages of different eruptions; and he should form with these materials a picture of the malady and so make an accurate diagnosis, just as the child with his dissected puzzle puts together the animal or landscape bit by bit to form the desired whole.

Thirdly. As regards Complications. — It should never be forgotten that two or more eruptions may occur together. When this is the case the different features of the concurring diseases will be mingled in varying proportion, and the observer will find himself dealing with characters and phenomena which, theoretically at least, he has learned are exhibited by different maladies. Examples of such commingling are to be found in the common coexistence in the same patient of urticaria and scabies, of syphilitic rash and chloasma, lichen

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18 MODE OP OBSERVING SKIN DISEASES.

and urticaria, of ecthyma and scabies, of purpura and urticaria, of eczema and scabies or fur •an cuius, and so on. The possibility of the coexistence of two diseases should never be lost sight of. Multiformity of eruption is, however, by no means sufficient evidence, although it is suggestive, of the coexistence of two or more distinct diseases, because certain uncomplicated diseases of the skin possess this feature. Practically it may be said, however, that there are only three diseases, which are essentially multiform in eruptive character. They are scabies, eczema, and syphilis. Supposing, therefore, that scabies, eczema, and syphilitic disease can be said to be absent, multiformity of eruption usually indicates the coexistence of two or more distinct eruptions.

Fourthly. As regards Modifications of Eruptions

There are many influences which modify the aspect and the general character and behavior of skin diseases, which should be taken into account in dealing with their treatment. It is not only necessary that the physician should recognize any particular kind and form of skin eruption, but that he should appreciate the part played by a number of concomitant conditions in each individual, which modify the character and the duration of the particular disease present. There are various diatheses, special states of the blood, of nerve influence, and of tissue change, which specially tend to induce an unusual amount of inflammatory action, or favor undue cell activity or pus formation, or disorder of sensation, and the like, to which due consideration must be given. The evil influences of such conditions must be dealt with, so as to pave the way for the due action of curative measures directed against the disease more directly.

A few useful particulars or hints may not inappropriately be given here. Diseases of the skin are made to spread or take on an inflammatory character, and changes in the skin are exaggerated, by exposure to irritating agencies, such as

MODE OP OBSERVING SKIN DISEASES. 19

heat, cold, scratching, and by the contact of acrid substances of all kinds, as the handling of lime, sugar, and soda respectively, by bricklayers, grocers, and washerwomen. So, too, an inflammatory aspect is given to eruptions by acridities in the blood, as in gouty or rheumatic subjects, in dyspeptics ; and in those in whom the bile acids, sugar, or retained effete matters are present in undue amount in the blood. Eruptions in strumous subjects are attended by an amount of pus formation which is unusual in non-strumous subjects. Undue chronicity is occasioned, oftentimes, by the existence of nervous or general debility : for nature then lacks the normal recuperative power which it always tries to exert in aid of the cure of disease.

The questions of age, sex, occupation, mode of life, and the general medical history of the patient have to be considered, and will be incidentally referred to in other places. Attention to the four indications already discussed will, however, be found of essential importance in the successful study, or in determining the treatment, of a skin disease. It may be observed, however, as regards age, that one essential difference between the cutaneous diseases of the young, as compared with those occurring in the middle-aged and old, consists in the fact that the former are often the result of imperfect digestion and assimilation, whereas the latter are induced by mal-influences connected with the habits and occupations and wear and tear of adult life, and degeneration of structure in the old, and are modified by a number of functional and organic diseases of internal organs, which are conspicuous by their absence in the young. The modifying influence exerted upon skin troubles by the strumous diathesis, however, is infinitely more common in the young.

Section II. The Pathology Of The Skin

Recent research in the field of dermatological pathology has advanced this branch of medical science to a reputable position ; and dermatologists are beginning to describe with no little accuracy, and with an increasing general agreement amongst themselves, the minute tissue changes that go on in the various disorders of the skin, and to define with more approach to the truth the exact anatomical limits and locality within which these morbid processes begin and go on. It has been the custom, since, indeed, the days of Plenck and Willan, to divide diseases of the skin according to their general aspects or naked-eye features, such as lumpiness, and redness, or pimples, vesicles, etc, and it has hitherto been found convenient to make certain groups according to these various types of -aspect, or " elementary lesions" as they are called. But some better method will assuredly be devised before very long, and probably it will have a pathological basis ; for the old Willanian system, however useful, cannot be regarded — taking account, as it does, only of the mere outward aspect or appearance of eruptions — as anything but a tentative arrangement, roughly outlining the physical characters of cutaneous disorders. An accurate knowledge of elementary lesions, however, is still needed by all students of dermatology preliminary to the fuller study of the subject. We shall, therefore, first describe these primary lesions, and then proceed to make a few general remarks upon the nature of the changes that individually occur in the different component textures of the skin.

ELEMENTARY LESIONS.

These elementary lesions, as before indicated, are the types of external form and aspect presented by eruptions of the skin. These are nine in number, bearing the designations respectively of macules, or stains ; hyperemia, or redness ; pomphi, or wheals ; papules, or pimples ; vesicules, or little bladders ; bullce, or blebs (*". e., bladders larger than vesicles) ; pustules, or pustules , squamce, or scales ; and tubercula, or tubercles (little solid lumps). These several lesions we shall now briefly describe in detail.

Maculae or Stains For all practical purposes these

may be said to be of four kinds, viz., pigmentary, chemical, parasitic, and hemorrhagic.

I. Pigmentary stains are usually due to the presence in the rete mucosum, and more particularly in the lower strata of its cells, of altered coloring matter of the blood in the form of pigment granules, or minute dark particles. They may be divided into two groups, viz., primary and secondary maculae. The primary or idiopathic pigmentary stains are few, and consist chiefly of such things as freckles and the discolorations left after hyperemia induced by local irritants of various kinds. The majority of pigmentary maculae belong to the group of secondary stainings, that is to say, they do not constitute the sole, or primary, or main condition present, but follow in the course of other morbid states of importance. They, for instance, occur in and are secondary to syphilitic eruption, and in association, in like manner, with certain cachexia, such as Addison's disease and leprosy. They are left behind by such eruptions as lichen planus, and the vitiligo of Willan (xanthelasmoidea of ourselves). They are sometimes strictly physiological in character, as seen in the bronzing of the forehead, and other parts of the surface, in connection with pregnancy and uterine activity of other forms. Maculae of this kind are not raised, they are unaffected by pressure, and are not the seat of any morbid sensation. There may be an entire absence of pigment, when the skin, of course, looks white.

II. Chemical stains are seen in the instances of discolorations from iodine, silver compounds, bile products, and the like.

III. Parasitic maculae are usually of a fawn color, and are caused by the presence of fungous elements growing between the cuticular cells, as seen in tinea versicolor.

IV. Hemorrhagic stains are due to the actual extravasation of blood, or the escape of its coloring matter alone, into the skin textures, and the varying hue is accounted for by the changes which have taken place in the transuded material, as typically portrayed in an ordinary bruise. Purpura is the chief disease in which extravasation of blood into the skin occurs, but an hemorrhagic aspect is assumed by variola, by herpes, by lichen planus, the bites of insects, and the petechice of febrile states.

Hyperaemia or Redness may be active (arterial) or passive (venous). Active hyperemia consists of redness removable by pressure. It may be punctiform, patchy, or consist of circles. It mostly is accompanied by swelling from effusion of serosity, and the escape of leucocytes ; by disordered sensation (pruritus and burning); by a slight rise in temperature ; and it is followed by desquamation. It is caused by local irritants, by changes in the blood, and by excitation of the nerves. It may occasionally exist alone as the sole disease, as in the erythemas ; or, as is usually the case, it may be a stage or part in the development of more complicated changes, as in the inflammatory disorders of the skin. All active morbid alteration in the skin is attended by hyperemia, more or less pronounced. Passive congestion of the skin may be said to be the result of some cause retarding the flow of the blood through the veins towards the heart, or, in fact, to be of mechanical origin.

Pomphi, or Wheals, are raised hyperasmic swellings, which vary much in size and shape. They have a palish centre, and a red areola in varying proportions. They very rapidly form, to as rapidly disappear. Attended by a certain feeling of heat in the part together with tingling or itching, they are typically portrayed in the sting of the common nettle, with which every one is familar. The fugitive and capricious character of the wheal is the most characteristic feature in its behavior. The wheal is significant of urticaria. The wheal may be oval, or round, or linear, or band-like in form ; the latter generally are the result of scratching in a particular direction, and when so produced are said to be factitious. In children they are often quite small, resembling bug-bites, and are followed by the deposit of lymph in the form of minute, solid, pale papules, which may run on into slight vesicles, as the "lichen urticatus" of children, which is a phase of urticaria. Wheals are caused by sudden irritation with immediate contraction of the capillaries, but this contraction is speedily followed by free dilatation and escape of serosity into the tissues, which accounts for the redness and the swelling; but the vessels beyond the area of dilatation, that is, away from the immediate seat of the irritation inducing the wheal, are probably in a state of spasm ; as soon as this gives way the wheal begins to disappear, and as this happens speedily, the wheal is essentially fugitive. During the formation of the wheal the serosity finds its way to the rete cells, and more particularly the lax tissue of the papules outside the vessels. It exerts, as it augments in amount, some pressure by its distending influence, and as the greatest effect is felt about the centre or apex of the wheal, the paleness at the corresponding point on its surface, which is in strong contrast with that of the bulk of the wheal, is most likely due to the emptying of the capillaries at this point by this pressure, and the masking of them by this fluid. This is proved by the gradual reappearance of the pink blush over the centre of the wheal as the effusion and swelling lessen, the white aspect going and the red reappearing pari passu with the absorption of the fluid and the diminution in the tension of the tissues. Some think that the pale centre is due to spasm of the vessels, but facts are clearly against this view. In exceptional cases the effusion is so decided and rapid that the serosity uplifts the cuticle, and produces a vesicle or bulla ; but this is not a common occurrence. In other rare instances the effusion of serosity is very great and deep, so that large tuberose swellings are induced. These are more or less fugitive in character, and are attended by heat and itching, but naturally where much fluid is transuded, it takes longer to become absorbed.

Wheals cannot be said to be inflammatory in character, because no new products are produced in connection with their formation. They are rather developed as a consequence of an alteration of the calibre of the vessels, induced by disordered nervous influence. It is a vaso-motor, and not a local, tissue disorder.

Papulae or Pimples These are small, circumscribed,

more or less firm elevatious of the surface. The word pimple sufficiently expresses their general character. Papules are of several kinds, however, and are produced by a variety of causes ; for instance, they may result from the presence of effused serosity in small amount, or lymph, or a new growth in the derma itself; or by swelling, thickening, or plugging the follicles. They vary in size somewhat, and in color, according to the amount of congestion by which they are attended. If very vascular they are small, red, and soft ; if due to the presence of solid material in the textures, they are paler, and, of course, firmer. It is important to distinguish true from what may be termed false papules. True papules are such as assume and retain the aspect of papules from the beginning to the end of their career. In other cases what seems to be a papule — but which is false, as it were, to its character at the time of observation — may be in reality an early stage in the formation of a vesicle or pustule. That is to say, when in the development of a vesicle there is but slight effusion, the dermic structures are raised into papules ; but this is succeeded, as the fluid increases in amount and the inflammation progresses, by uplifting of the cuticle, the formation of pus, and other changes. It is manifestly wrong to designate the papular stage of a vesicle as a true papule. It is a potential vesicle, as seen in eczema, hydroa, etc. It is of no little moment to remark the distinction here pointed out in diagnosing cutaneous eruptions. Patches may be and often are formed by the aggregation of pimples. Papules are often attended by itching.

True papules may, clinically, be conveniently regarded as of six chief kinds : —

a. They may be due to hyperemia of the papillae, forming bright red points, as in strophulus, or the papules of certain of the acute specific diseases.

b. They may consist of turgescent and erected follicles, the hair, the sweat, or the sebaceous, as in cases of follicular hyperemia, induced by scratching, and in slight acne and the early stage of miliaria respectively.

c. They may be caused by the deposit of lymph, or by cell infiltration about the walls of the follicles, as in lichen planus.

d. They may be actual lymph formations, or cell growths in the derma proper, as in lichen, prurigo, and syphilis.

e. They are caused by collections of sebum or epithelium, or both, in the follicular orifices, as in pityriasis pilaris, in which the hair follicles are plugged by epithelial exuviae, or in the acne sebacee cornee, in which the sebaceous glands are plugged, rasplike, by sebum.

f. Papules are sometimes the result of mere hypertrophy of normal tissue, as in papillary warts.

It will be noted that papules may be situated on three chief sites, viz. : the corium, the hair follicles, or at the sweat ducts, as in miliaria.

Vesicles These have hitherto been described as little

bladders, varying in size from a pin-head to small split peas, and caused by uplifting of the cuticle by serous fluid poured out by the vessels of the papilla? ; and, further, as either single or loculated in structure. But this definition, and especially the former portion, must now be regarded as affording "an altogether too limited representation of pathological facts.

The part of the skin tissue distended into vesicles, and the nature of the fluid which causes the distension, vary essentially in different cases, but it may be stated that there are three principal kinds of vesicles : —

a. Serous or inflammatory vesicles.

b. Sweat vesicles, or vesicles formed in connection with the sweat ducts ; and —

c. Lymphatic vesicles.

a. Serous or inflammatory vesicles are the commonest, by far. They rise above the level of the surrounding skin, and tend to burst and discharge their contents and dry away. Some vesicles burst with difficulty, as in herpes, in fact, these often never rupture. Sometimes their contents become opalescent or opaque, which is due to the admixture of pus with the serosity, thus giving rise to vesico-pustules, which form yellowish crusts, when their contents dry up. These vesicles may be acuminated as in scabies, but usually they are more or less globular, as in eczema, or hydroa. They may be oval, and perhaps at one period of their course umbilicated, as in varicella. Sometimes they are isolated, as in scabies and hydroa; at other times aggregated together into patches, as in eczema, or grouped in circular form as in herpes. They are usually attended by burning or itching. Such are their gross characters. In regard to their mode of formation and anatomical structure, it may be said that inflammatory vesicles answer to the ordinary ^description of vesicles, that is to say, they are due to the escape of serosity from the papillary and subpapillary vessels, which finds its way to the surface and uplifts the tissue which bars its exit. This may in its escape not disturb the rete tissue much, but find its way chiefly between the horny and mucous layers, raising the former up into vesiculation, as in pemphigus, and mild cases of eczema, probably, in which this condition is associated with oedema and cell infiltration of the derma ; or in its passage through the rete the fluid may cause more or less stretching of these cells into fibres, which then form the walls of little loculi in which the fluid is contained, and in which, when the disease is inflammatory, cellproducts make their appearance by migration from the corium vessels, as is the case in variola, herpes, pustular eczema, etc. The inflammatory vesicle, therefore, may be single, as in pemphigus, or, as in most of the cases, compound, as in the common vesicular affections.