Atlas of skin diseases

Front matter

Col 6

THE BRITISH ASSOCIATION OF DERMATOLOGY

THE WILLAN LIBRARY

Preface

An Atlas of Skin Diseases lias long seemed to me an urgent need in American Medical Literature. The difficulties attending the study of these affections are numerous. To know cutaneous diseases it is necessary to see them, and to be familiar with their several varieties, and also with the various stages through which they pass in their evolution. Only in a great city, where hospitals and special dispensaries afford facilities for observation and comparison, can we find an adequate field for their investigation. The vast majority of the profession, however, are so situated as to be beyond the reach of clinical material, and are thus in a great measure debarred from becoming acquainted with these diseases. Accurate delineations of typical examples cannot fail to aid in their recognition, for, whatever the peculiarities incident to certain stages, the main features remain unchangeable. Faithful copies of nature must always prove of invaluable assistance to the student.

It is now generally conceded, by those who have had the opportunity of extended observation in this specialty of medicine, that the same diseases are more or less dissimilar in external form as they occur in one country or in another. This statement is abundantly verified by comparing the cutaneous diseases of the United States with those of Europe. It has been shown, I trust, in my Treatise upon Diseases of the Skin, that a number of affections manifest themselves with us in quite other forms than those seen abroad. It is to give to the profession a series of illustrations representing the Dermatology of our country, that the present work has been undertaken.

The Atlas will contain representations of all those diseases which the practitioner is liable to encounter. The commoner affections, as, for example, Eczema and Syphiloderma, will each receive as many plates as may be necessary to show the varieties.

The cases will be selected, with a view to their being strictly characteristic examples of the disease, from the ample material afforded by the Clinic for Diseases of the Skin in the Hospital of the University of Pennsylvania, and the Dispensary for Skin Diseases, Philadelphia. Through the courtesy of the medical staff of the Philadelphia Hospital, I am also enabled to draw upon the resources of this vast Institution.

The portraits, many of them already completed, will in every instance be painted with extreme care and chromo-lithographed with particular regard to accuracy of color. No labor will be spared to render the work of the highest order. With each illustration will be given the history of the case, including a full descrip¬ tion of the lesions present, and such remarks upon the nature of the affection, its diagnosis and treatment, as may seem called for. For a more comprehensive account of the disease, as well as for the details of treatment, the reader is referred to my Treatise.

In order that no unnecessary delay may occur in the production of the Atlas, it has been decided to publish the plates in the order in which suitable cases for representation offer, without reference to their simi¬ larity of nature or to the relative positions they will occupy in the work. Each portrait with its accom¬ panying text will be complete in itself. The plates will be designated by letters of the alphabet, placed beneath the names of the diseases ; the text may be known by corresponding letters at the foot of each leaf. Upon the completion of the work, the plates and text may be arranged for binding according to a classifica¬ tion which will be furnished.

The reputation of Messrs. Faber and Moras, as artists in connection with medical subjects, is in itself’ sufficient to guarantee excellence in their respective productions.

I have endeavored to produce a work that will merit the approval of the profession, and hope that it may receive their generous support.

L. A. D.

Philadelphia, I4I6 Spruce St.

Contents

PLATE

A

ECZEMA (ERYTHEMATOSUM)

II Pemphigus

R

, HERPES ZOSTER

JJ

ECTHYMA

CLASSIFICATION*

ANOMALIC SECRETIONIS

PLATE

W SEBOllRHCEA

EXSUDATIONES

CC ERYTHEMA MULTIFORME (papulosum)

V ERYTHEMA NODOSUM

A ECZEMA (erytiiematosum)

X ECZEMA ( papulosum)

T ECZEMA (vesiculosum)

Y ECZEMA (pustulosum)

I ECZEMA (squamosum)

HH ECZEMA (rcbrum)

P ECZEMA (rubrum)

GG ECZEMA (rubrum)

R HERPES ZOSTER

II PEMPHIGUS

E ACNE ROSACEA H SYCOSIS NON-PARASITICA

Z IMPETIGO CONTAGIOSA

JJ ECTHYMA FF PSORIASIS B PSORIASIS

HCMORRHAGIC

K PURPURA (simplex)

HYPERTROPHIC

PLATE

F ICHTHYOSIS (simplex)

ATROPHIC

M VITILIGO N ALOPECIA AREATA

NEOPLASMATA

C LUPUS ERYTHEMATOSUS

BB LUPUS VULGARIS

J SYPHILODERMA (erythematosum)

AA SYPHILODERMA (papulosum)

L SYPHILODERMA (papulosum et pustulosum)

U SYPHILODERMA (pustulosum)

D SYPHILODERMA (pustulosum)

DD SYPHILODERMA (tuberculosum)

PARASITC

O TINEA FAVOSA

EE TINEA TRICIIOPHYTINA (circinata et tonsurans S TINEA SYCOSIS

G TINEA VERSICOLOR

Q SCABIES

* This arrangement is in accordance with the Author’s views as expressed in his systematic Treatise on Diseases of the Skin.

.

H. FABER PINX AD NAT l MORAS CHROMO L1TH

[f KflA

(ERYTHEMATOSUM)

A

(erythematosum)

The case represented in the accompanying portrait is that of an Irish laboring man, forty-five years of age. He states that none of his family ever had any disease of the skin. The present affection first made its appearance fifteen months ago, manifesting itself on the face, neck, hands, and trunk. For some time previous to this eruption he had been troubled with severe dyspeptic symptoms. The cutaneous disease on this occasion remained upon him three months, when he obtained complete relief from internal remedies, of the nature of which he is not aware. He enjoyed good health until three months ago, when the present attack began. This, he relates, made its appearance in the same manner as before, with the exception that the disease developed more slowly.

In answer to careful inquiry, he informs me that the disease has never presented other features than those which now exist. There has never been any moisture. Itching and burning have been constant symptoms. During the last year he has lost considerable weight, — as much, he is quite sure, as thirty pounds. He regards himself/nevertheless, as in fair general health. Upon investigation, however, it is found that the bowels are irregular, tending to constipation, that the tongue is furred, and that he has undisguised dyspepsia. He, moreover, passes restless nights, being unable to sleep on account of the violent itching and burning sensations, which, he says, are present more or less over the whole surface.

The cutaneous disease, in addition to that seen upon the face, is noted to occupy the chest, abdomen, but¬ tocks, and thighs, in the form of numerous, small, rounded, imperfectly-developed papules, constituting eczema papulosum. The lesions upon the face may be described as follows. The whole face is involved, the disease be¬ ginning upon the forehead about the edge of the scalp, thence extending downwards over the nose, cheeks, lips, chin, ears, and neck. It is particularly well marked above the eyebrows, upon the nose, upon the cheeks, and around the mouth. The skin is of a yellowish-red and purplish color, the shade varying greatly in different localities. Upon the forehead it is light yellowish-red, and fades away, in an irregular, broken outline, as it approaches the border of the scalp. The sides of the nose and especially the cheeks are more brilliant, and are also more uniformly colored ; while the lips, chin, and region of the lower jaw exhibit a darker, violaceous hue. The various tints pass into one another, either gradually or abruptly, and give the skin a decidedly broken-up, more or less streaked, patchy appearance. The lips are marked with ill-defined streaks of red and yellow. The tissues are everywhere thickened, and are seen to be infiltrated with an exudative product. About the eyelids considerable oedema exists. The eyeballs are also bloodshot, from the rubbing to which they have been subjected. The natural lines and furrows of the skin, as, for example, those of the forehead and cheeks, are observed to present an exaggerated appearance, giving to the face a severe, somewhat bold expression. The lips are puffed, are slightly fissured, and are covered with small pieces of semi-detached, thin, dry epithelium.

The skin of the face is everywhere dry and has a harsh feel ; there is no sign of moisture. Here and there over the surface are pin-head sized and larger, thin, whitish-yellow scales and shreds of exfoliated epidermis. These are found to be either adherent or in a semi-detached state. When removed with the

A finger-nail they expose a reddish, soggy surface, the unhealthy mucous layer of the epidermis, which imme¬ diately becomes again covered with the same formation. Excoriations, the result of scratching, appearing as bright red, irregularly shaped and sized puncta and lines, are here and there present. They are especially prominent over the forehead, upon the nose, and on the neck. Upon the upper lip, the sides of the chin, and the region of the heard, where the hair has been permitted to grow, abundant, small, grayish scales are observed. The disease here is passing into the squamous stage.

Beginning at the neck, and occupying the regions of the body already pointed out, the eruption consists of numerous, disseminated, more or less excoriated, pin-head sized, bright reddish papules, — eczema papillo¬ sum. They are scattered over the parts without regularity of distribution, and are noted to be most numerous over the abdomen and upon the thighs. The palms and soles are free. The nails are healthy.

The patient complains greatly of the burning and itching sensations, which he says are almost unen¬ durable. He is obliged to rub and scratch his face and body every few moments. He compares the sensations on the face to the biting of thousands of minute insects, — a pricking, pinching sensation. These symptoms are constant, although subject to exacerbations, of which he will have many in the course of the twenty-four hours. When overheated or in bed they are always greatly aggravated.

The history as given by our patient is instructive, and is one such as may very frequently be obtained. The case, moreover, is valuable as demonstrating how two varieties of eczema may occur simultaneously upon one patient.

The case before us can scarcely be mistaken for any other affection. Its features are well expressed and are characteristic. The face is the usual seat of this variety of eczema. It manifests itself in various degrees of severity and extent. It may involve the whole of the face or only a small area of surface. Not infre¬ quently it is seen upon the forehead. The sides of the nose and the upper lip are also localities very often singly invaded. Erythematous eczema may exist alone, as the sole manifestation of eczema, or it may appear in connection with other varieties, more particularly the papular variety, as in the present instance. When confined to the face, however, it almost invariably remains erythematous throughout its entire course. Although not so common as the vesicular and papular varieties, it is nevertheless very often encountered, especially in the middle-aged and the elderly. It is of much more frequent occurrence in this country than abroad. It may be either acute or chronic ; more often it is the latter, continuing in an off-and-on manner persistently for an indefinite period.

Erythematous eczema of the face may in its first stage be mistaken for erythema simplex or for erysipelas, but a few days will in all cases suffice to establish the diagnosis. It may also be confounded with seborrhoea, especially when it happens to occur in small patches about the nose and cheeks. The variegated, patchy appearance of the skin ; the puffiness of the tissues ; the marked thickening ; the tendency to desquamation ; and the prominent symptoms of itching and burning, point unmistakably to eczema. Scratch-marks or a partially abraded surface, the result of rubbing, are always present. The color of the eruption varies from a bright to a violaceous red, depending upon the age of the patient, the stage of the disease, and the region attacked.

The treatment upon which our patient was placed was simple. It consisted in the use of an aperient tonic mixture, containing a half drachm of sulphate of magnesium, a half grain of sulphate of iron, and four ounces of water, for each dose, which he took three times daily, before meals. The bowels were by this means opened at least twice every day. Locally, a lotion containing one drachm and a half of carbolic acid, one ounce of glycerine, and one pint of water, was employed with good result. In three weeks the patient was completely relieved of his disease.

H FABER PINX AD NAT

B

F MORAS OHROMO-L1TH

PSORIASIS

The patient whose arm is represented in the accompanying plate is an American woman, twenty-four years of age, married, and the mother of two children. She is of small stature ; is slender and delicate in appearance ; and has light auburn hair and a fair complexion.

According to her statement, neither her parents nor any members of the family were ever subject to diseases of the skin of any kind. She never had any eruption during early childhood, but the present affection began twelve years ago, when she was twelve years old. It first appeared in small patches, which gradually increased in size and in number, until in a short time the greater portion of the body became invaded. During the early years of its existence, she remembers that the eruption would disappear completely from time to time, and remain away for some months, when it would relapse. It has behaved in this manner also of late years, although it has been more persistent. It has always been dry and scaly ; there has never been any moisture. It has, moreover, always presented the same general appearance.

Two years ago she was under my care with an attack similar to the present one, when she took full doses of cod-liver oil for a period of months, together with small doses of arsenic. She recovered, and remained well for ten months. She now informs me that during the time she was carrying her first child, the eruption was out upon her in great profusion, and remained so not only until she had been delivered, but also until after she had weaned the child. During her last pregnancy, the disease assumed a directly opposite course, being altogether absent during the whole of this period ; with the birth of the child, however, it again manifested itself, and has been with her since.

Her present condition is as follows. She weighs one hundred and ten pounds, this being a much lighter weight than formerly. The appetite is good; bowels regular; menses always profuse, debilitating her considerably. A diffused eruption involves the greater portion of the body, in the form of variously sized and shaped, isolated and confluent patches. The scalp is Avell covered with irregularly shaped and distributed, mostly small, reddish patches covered with abundant whitish scales. The disease is not limited to the line of the scalp, but extends over upon the forehead, and also around the ears and down the neck. Over the face, upon the forehead, eyebrows, and nose, finger-nail sized, ill-defined, reddish patches exist, which are surmounted by scanty yellowish-white, partially detached scales. Upon the back, chest, breasts, abdomen, and extremities there are numerous roundish or oval, more or less broken patches, varying in size from a small coin to the palm of the hand. The extensor surfaces of the arms, forearms, thighs, and legs show them most perfectly developed. These patches, whether upon the trunk or upon the extremities, everywhere exhibit the same general peculiarities. They are roundish in shape ; show a decided disposition to coalesce and break up into segments of circles ; are raised somewhat above the level of the surrounding skin ; are reddish in color ; and are covered with whitish scales, which are more abundant in some localities than in others.

Upon the forearms the disease, as seen in the portrait, is seated mainly upon the extensor surfaces. I he patches here have existed for some time, and of late have not been disturbed by local treatment ; the scales, therefore, have accumulated in quantity, and are more caked and abundant here than upon the body. Their

B outline is quite sharply defined against the healthy skin. They have a whitish or grayish, chalky appearance, due to the mass of scales. Their borders are reddish in color, but are also more or less covered with fine, par¬ tially loose scales.

The scales are seen to be more abundant about the peripheries of the patches, where they are heaped up in the form of an embankment, giving the patches a slightly concave shape. Although firmly seated they are not adherent, and may be detached from their beds, which, when deprived of scales, are seen to be reddish. In color they are whitish, and have a silvery, somewhat greasy, opaque, mother-of-pearl look. They are imbricated, arranged upon one another in laminae, and are irregularly fissured or divided into small spaces, corresponding with the natural lines of the skin.

The present case is a well-marked example of psoriasis. The disease inclines to manifest itself in a diffused manner over various regions of the body, either in the form of small, distinct, isolated patches, varying in size from a pea to a coin ; or, in more or less broken, irregular patches, the size of the palm and larger. In shape the patches are roundish, and are either solid, as seen in our portrait, or they are more or less clear in the centre ; occasionally they appear in the form of segments of circles or bands, caused by several or a number of circular patches having coalesced. In color they are reddish, either pinkish or dark red, according to the degree of inflammation and the activity of the process, and are always covered with whitish or grayish scales. These may be very abundant, as in the present case, or they may be, comparatively speaking, scanty, in which case the patches appear reddish rather than whitish. The disease is always dry ; it never shows signs of moisture, and in this respect differs from eczema.

It is at times accompanied with severe itching and burning ; in other cases these symptoms are absent. It is almost invariably chronic in its course, relapsing from time to time. It is one of the commonest of cutaneous diseases, and occurs in both sexes, and at all periods of life from childhood to old age. It is not contagious. The causes are usually obscure.

The seat of the disease is in the upper layers of the corium, the process consisting in a peculiar kind of inflammation, with an abundant proliferation of epithelial cells.

Psoriasis can scarcely be confounded with any other disease, when its characters, which are usually well marked, are borne in mind. It may, however, resemble eczema and the papulo-squamous syphiloderm.

The management of psoriasis must vary with the case. In the majority of instances the preparations of arsenic prove our best remedies ; at times iron and cod-liver oil are found valuable ; while in other cases, general remedies, as, for example, alkalies and diuretics, appear to exert more influence over the disease. Among external remedies, which are of the greatest service and should be employed in all cases, baths of various kinds, simple or medicated, the preparations of tar, the mercurial ointments, sulphur, sapo viridis, and solutions of caustic potassa, will be found the most useful. Psoriasis is usually an obstinate disease. Although never involving life, it often causes much distress to the patient. Relapses, varying greatly as to severity, are the rule, which are apt to occur from time to time throughout life. In many cases the prognosis is more favorable.

The treatment in the case under consideration consisted of the remedies which relieved her in the former attack, together with the local use of a tar ointment, a drachm to the ounce, to be applied twice daily. She was also directed to bathe as often as possible, and to make free use of sapo viridis, for the purpose of cleansing the patches ; furthermore, to place herself upon a nutritious diet.

ILCDIFOIJ© IKWGflUIMl^TOgaD©-

(C

LUPUS ERYTHEMATOSUS

The patient whose disease is represented in the accompanying plate is a well nourished and developed, married, American woman, twenty-five years of age. She gives the following history. The disease made its appearance fifteen months ago, in the form of a roundish patch on the left side of the nose. A few' months later it appeared in the same manner on the other side of the nose, when both patches began to spread upwards over the cheeks, towards the eyelids. A patch now showed itself on the forehead, between the eyebrow's; another made its appearance behind the ear; a third on the side of the chin. The disease has never shown any disposition to attack other portions of the body.

She states that she has always been, and is at the present time, in excellent general health, and that she has gained flesh within the past year. Her appetite is good ; her menstrual function normal ; the bowels are somewhat constipated. She has for years past been subject to cold hands and feet, even during warm weather, and of late has been annoyed with slight dandruff upon the scalp. In her early life her skin wras remarkably free of all eruptions, and, in fact, she never had any trouble before the present affection. During the past year the disease has from time to time been better and worse, but on no occasion has it evinced any disposition to disappear. On the contrary, it has been slowdy invading new regions, and at the present time is increasing. It has attained its present size by repeated attacks, which would come on at uncertain intervals, every few' weeks or months, during which time the patches would enlarge considerably.

As seen in the portrait, the disease consists of two irregularly-shaped patches, occupying either side of the face. They are symmetrical, and have coalesced about the root of the nose, forming one large continuous patch, enveloping the greater portion of the face. Beginning about the eyelids and temples, the patches ex¬ tend downwards over the cheeks and along the sides of the nose to the chin, terminating in crescentic, pointed, promontorv-like strips of disease. The configuration of the disease may be compared to a butterfly or bat with outspread wings. In addition to the chief patches, smaller ones exist upon the forehead, just above the nose ; on the tip of the nose ; and on either side of the chin. These are likewise irregularly shaped ; are isolated, as seen on the chin, or are in a state of coalition, as observed on the nose.

The line of demarcation limiting the patches is peculiar; it is everywhere distinct and clearly defined. The disease terminates abruptly against the healthy integument. The patches are very slightly elevated above the level of the surrounding skin ; passing the hand over them, they are felt to be raised even less than their appearance would indicate. In color they are of a uniform, dull bluish-red ; at times they become quite purplish, presenting a livid hue, resembling that of vascular mevus. They have a congested look. rI hey are covered writh fine, whitish or grayish scales ; which, although more or less detached from the skin, in the form of minute pieces, are very adherent. These scales are not abundant, but are nevertheless everywhere present as a thin film or coating ; they are more numerous in some localities than in others, as, upon the nose. Around the edges of the patches, just within their margin, they are more plentiful, and are heaped up in the form of a delicate border. Examined closely they are seen to be small, pin-point and pin-head in size, irregularly shaped, very thin, dry, and to consist of sebaceous matter and epithelium. Every where over the patches the

C openings of the sebaceous gland ducts are observed to be patulous, and to be the seat of disease. The skin has a dry, harsh, scaly feel, and is noted to be abnormally warm, and to be thickened and infiltrated, especially about the cheeks. ^

The affection is accompanied by burning and itching sensations, which are often very annoying. These symptoms, however, are not constant, but come on in an aggravated form when the disease is spreading. The patient remarks that the skin has never presented any other appearance than that described, except that at various times it has both looked and felt much wrnrse. It has never exhibited the least tendency to moisture, nor has it ever manifested any disposition to ulceration.

The case represented may, I think, be viewed as a typical example of the disease, although it is, perhaps, more wide-spread than is ordinarily encountered. Considering the short time of its existence, it has made exceedingly rapid strides. Usually the disease confines itself during the first few years to a smaller area, invading so large a region only with time.

Lupus Erythematosus shows itself either in the form of one or two, usually roundish, localized patches, which, enlarging upon their peripheries, increase indefinitely in size; or, in the form of a number of patches, which in like manner gradually coalesce to make one or more larger patches. The latter form of the disease is observed in our portrait. The affection is usually confined to the face, and to the particular regions attacked in the case under consideration ; it may, however, appear upon other portions of the body, as, the red of the lips, the scalp, neck, extremities, fingers, and toes. Upon the face, in the great majority of cases, it assumes the peculiar configuration represented. The color of the disease differs somewdiat in cases ; it may be pinkish, reddish, bluish-red, or purplish. The amount of scaling also varies.

The course of the disease is always chronic ; it usually increases its area by repeated attacks ; it is almost invariably better and worse from time to time. It never shows moisture or signs of ulceration ; it is, however, always succeeded by more or less atrophy. Biett very happily described the disease as “lupus qui detruit en surface ,” thereby indicating one of its chief characteristics. The subjective symptoms vary ; it may itch and burn considerably, as in our case ; or, on the other hand, these symptoms may be slight.

It is one of the rarer diseases of the skin. I have found it in this country, however, to be much commoner than lupus vulgaris. It is a disease of adult age ; it seldom makes its appearance before puberty, and in this respect differs materially from lupus vulgaris. It attacks both sexes, but women more frequently than men. The general health of patients is usually good. The causes are obscure. It is in no way related to syphilis, and is not contagious. Pathologically, it is a “ cellular new growth,” beginning usually in the sebaceous glands. If the disease be examined with the naked eye, it will be noticed that the sebaceous glands are markedly involved ; their ducts are seen to be enlarged, and plugged with altered sebaceous matter and epithelium. Under the microscope the disease is seen to consist of a deposit of small cells about the glands and in the corium ; they are highly refractive, roundish in outline, and are very persistent. In general characters they are not unlike those of lupus vulgaris and syphilis.

There is no specific treatment for the disease. Each case must be managed as experience may prove . suitable. The internal remedies most likely to be useful are cod-liver oil and iodide of potassium. Local remedies will be found the most serviceable, and in particular stimulating and caustic preparations, as, for example, sapo viridis, caustic potassa, nitrate of silver, mercurial ointments, sulphur, carbolic acid, and tar. In the present case, sapo viridis was prescribed ; the parts to be rubbed with this, together with water, for twenty minutes, twice daily ; after which, a mixture composed of equal parts of sapo viridis, tar, and alcohol, was ordered to be rubbed into the skin. The disease is always rebellious to treatment, and, moreover, inclines to relapse.

H FABER PINX AD NAT

©wmiLOiDEiisraoA

(PUSTULOSUM)

ID)

.

(pustulosum)

The patient here represented is a well-nourished man, of small stature, twenty-six years of age, who states that he has always enjoyed good general health. The history of his syphilis, as is so often the ease, is imperfect. Three years ago, — the only time that he ever had any venereal trouble, — he alleges, he con¬ tracted gonorrhoea from his wife, which was checked by the employment of injections. He denies having observed any sores about the genitalia at’ this or at any other time. Neither during the period of the gonorrhoea, nor subsequently, can he recall having had any swelling of the inguinal glands. Assured in his own mind that he had taken the disease from his wife, he at once deserted l^er, and has not seen her since ; nor, he declares most positively, has he since placed himself in a position to contract any venereal disease. No eruption or other suspicious symptoms followed the affection which he terms gonorrhoea. Four months ago, more than two and a half years after the gonorrhoea, during which period he enjoyed perfect health, he * had sore throat, but which was not serious, and got well without treatment. It is probable that the sore throat was syphilitic in its nature, and that the initial lesion of syphilis occurred one or two months before this symptom.

The first eruption he ever experienced, according to his statement, made its appearance about eight weeks ago. I saw him one week after it manifested itself, and it proved to be a well-marked example of the large acuminated pustular or acneform syphiloderm, involving the face, scalp, and the whole of the trunk. His general health was fair at this time ; and, under mercury combined with the iodide of potassium, he made, in three weeks, a rapid recovery, and passed from my notice. Six weeks after this he again presented himself, with the lesions depicted in the portrait, a typical example of the large flat pustular or ecthymaform syphiloderm. This history is interesting, as showing how one form of pustular syphiloderm may follow another.