HANDBOOK

OF

OE

DISEASES

THE

EDITED

H.
PROFESSOR

BY

OF

CLINICAL

MEDICINE

CYCLOPEDIA

IN

MUNICH

OP

EDITOR

ZIEMSSEN'S

M.D.

ZIEMSSEN,

V.

SEILN

OF

PRACTICE

THE

MEDICINE

OF

CONTRIBUTORS
PBOF.

H.

AUSPITZ,

M.D.,

VIENNA.;

E.

LESSER,

M.D,,

LEIPZIG;

BRESLAU

; PROF.
E.

M.D.,

ILLUSTRATED

E.

VEIEL,

V.
P.

M.D.,

BUDAPEST

MICHELSON,

SCKWIMMER,

AND

M.D.,

TH.

VEIEL,

PROF.

H.

V.

M.D.,

PROF.

E.

GEBER,

; PROF.
P.

G.

M.D,,

AND

NEISSER,

M.D.,

; A.

KLAUSENBURa

M.D.,
A.

UNNA,

CANNSTATT

ZIEMSSEN,

ENGRAVINGS

WOOD

EIGHTY

KCENIGSBERG

BUDAPEST

M.D.,

AND

M.D.,

BERLIN;

WITH

BABES,

M.D.,

BURG;
HAM-

WEYL,

MUNICH

COLOR

PRINTS

V^'f^
NEW
WILLIAM

YORK

WOOD

"
1885

COMPANY

Copyright

WILLIAM

"

WOOD

1885

INDUSTRIAL

PRINTING

Stettiner,
129

"

131

Crosby

Lambert

Street.

COMPANY
"
New

Co.
York

COMPANY

PUBLISHEES'

AMERICAISr

It

confidently

was

"

Medicine

at

of

In

much

be

early

an

German

the

as

present

without

include

to

the

have

appearance

it

distinguish

this

the

been

as

of

part
has

in

made

somewhat

the

or

of

of

meaning

from

for

expressly

prepared

of

for

delayed

condense

to

convenient

different

Practice

ready

be

have

to

the

lication
pub-

the

issue

year.

endeavored

volume

one

last

been

would

however,

appear,

of

Cyclopaedia

Disease

Skin

of

clearness

whole

"

on

causes

it

loss

book

volume

latter

translation,

possible,

able

until

Ziemssen's

v.

Yarious

period.

edition

the

that

completed,

was

when

expected

PREFACE.

the

size.

the

Its

ordinary

origiual
in

authors,

shape

medical

and

as

order

to

general

publications,

presentation,

and

not

precedent

for

the

as

to

commercial

venture.

It

of

book

We

be

not

may

this

trust

the

shared

by

Handbook

those

of

and

pleasure

to

the

there

for

have

our

have

we

of

size

we

to

whom

Diseases

that

state

accorded

support

generous

to

character

high
that

amiss

free

in

York,
56

"

April,
58

Lafayette

1885,
Place.

no

presentation,
thus

honor

to

by
of

the

our

profession

copy

of

"

CO.,

of

will

"

Skin."

WOOD

of

persons.

appreciation

medical

presenting

publication
thousand

many

manifesting

publications
the

WILLIAM

New

is

PuUishers.

Ziemssen's

the

be

CONTENTS.

Anatomy

Development,

and

of

Development
2

Proper,
3

of
4

the

of

Muscles

the

of

the

Skin;

of

the

Corium;

Senile

Skin;

of

Ridges

Furrows

and

Vessels;

Development,

23

Plane

Nail

"

of

of

the

of

follicle, 35
43

Root

"

-Growth

in

Glands,

51

Glands,

Small

Glands;

the

52

Function

of

Cushion
the

produce
glands

and

Fat-cushion,

Nerves
of

of

the

the

Skin,

of

paces

Lymphatic

57

"

the

Vessels,

Epidermis;

Facts
of

bearing

53

and

54

of

the

of

of

Blood-vessels;

Papillary

Passage

Ateries

of

the
60

Epidermis,
62

Nerves

"

Nerves;
of

the

the

Histology

Direction

"

the
of

Corpuscles

of

the

"

63

of

the

of

Respiratory
Sweat,

68"

ous
Sebace-

of

and

Coils
cutaneous
Sub-

Coil-glands

The

"

the

of

the

of
59

the

Coil-

Lymphatic

"

in

Lymph

the

Corpuscles,

Coil-glands,

65"

dermis;
Epi64

Pigment

66.

Function
The

Sebaceous

of

the

Skin,

Secretion,

The

67"
70

"

Secretory
The

Function

By

Function
of

of

Heat

the

H.

"

Glands;
True

Histology

Skin,

of

Phisiology,
The

56

Tactile

"

it, 46

New-formation

"

Circulation

of the

Current

Nerves

Hair-follicle;

58

Veins

Hair-bed,

"

of

Lips;

Fat-tissue,

Vater,

41

the

Hair-

the

Coil-glands

Sweat-pores;
the

of

of

Color
of

Secretion

Coil-glands;

the

Time

the

at

Meibomian

"

the

of

Swelling

Hairs;

Coil-glands;

Circulation,

into

50
of

26

stratum
Sub-

Differences

"

Explanation

Glands,

the

Color

"

31

47

EponyPlate,

of

Hair-change,

Border

Large

Nail

29

the

tion
Significa-

"

Nail;

the

Layer

the

Type;

Small

Showing

shaped

Hair-change,

Free

and

Function

"

Fat-tissue;

"

the

Large

Histology

"

the

upon
Sebaceous

Hair;

the

in

Change

Epidermis;

20

Prickle-layer

"

40"

Bed-hair,
a

of

34

Layer;

Papillary

"

Hair-change

Direction

33"

Hair-follicle,

Hair;

Minora

Button
32"

11
the

Hair-cone,

Epidermis,

Papillary

Nail-fold,

of

Thickness

the

the

Papillary

and

Spindle

Adult,

Nail

28"

Diagonal

"

Function

Hand,
of

"

Table

"

or

True

Pi'imitive

"

18
the

Development

Matrix,
30

the

of

the
27

the

of

Exist,

not

of

Hair-follicle,

the

Hair;

Development;

55

Direct

the

the

Labia

the

Fat,

in

of

Hair-change

Coil-glands,

the
of

Fat-tissue;

Ju4ce-s

Vessels;

of

Sweat-pore,

"

the

Fall

Adult;

and

Hairs,

Papillary

"

"

the

"

Nail,

Hair-follicles;

of

Clinical

Coil-glands;

"

36

the

of

Regions

Coating

45

of

Glands

Glands;

hairy

Hair,

Explanation

Hair-follicles

Tysonian

three

Histology

the

of

22

of

Muscles

the

Layers

Layer,
Palm

Hairs;

Nail-bed

the

the

Histology

Skin

of

of

"

Cleavage,

Muscles;

Fields

does
13

Horny

"

of

and

Growth

Straight

Bed-hair,

the

of

the

the

Nails

Nail;

17

Layer

the

Cutis

the

of

Hair,

and

Histology

Whole,

the

of

Membrane
as

Skin;

work

Layer;

10"

Cornification

of

Development
the

Hair;
of

of

Histological
of

of

the

the

Basal

Horny

Individual

of

Root-sheath;

Form

Process

Adult;

and

Oblique

Changes

Birth;

the

the

Tension

Papillae,

Epidermis

the

Unna.

of

Direction

to

Frame-

Papillary

the

the

G.

Involuntary

"

Arrector

Corium;

Keratohyalin,

for

the

Elastic

of
of

the

Layer;

Band;

the

Layer;

of

Blood-vessels

Nail;

Yellow

External

Hair;

for
the

of

the

the

between
the

Form

Stratification

of

Lunula;

Papillary

12"

Granular

"

Keratohyalin

of

chium,

the

Color-reactions

Important

most

"

14

Layer,

Prickle

of

and

of
5

Tissue,

of

between

Significance

Muscles

Elastic

Paul

Development

"

Cleavability

Voluntary

Development

Changes;

Papillae; Morphological

"

Tensors

Connection

Tissue

Relation

Arrectoi-es;

Oblique

Tissue

Dr.

.By

Subcutaneous

"

Fibrillary

Furrows

Functional

"

Substance

Corium;

the

Whole,

Corium;

Membranes;

Temperature,
of

as

the

Skin;

Cement

"

Muscular

Skin;

Skin
of

Texture

"

Folds

"

Corium,

the

Ziemssen.

von

Skin;

Regulation;

The
the

Secretion
Function

"

VI

CONTENTS.

the Skin

of

of the
Power

as a Sensory Organ;
Body; the Disturbances

of the

General

and

Skin

Pathology

its

Function
of the

of the

General

Skin

as

Protecting Organ

Functions

of

the

Skin, 71"

for the

The

face
Sur-

Absorptive

Limits, 72.

Therapeutics

and

Nosology

the

Skin,

76"

The

78

The

of

Skin,

the

Heinrich

By

Auspitz.

Disturbances
in General, and
Inflammatory
of the Skin, 79" The
SuperficialInflammations
more
of the Skin, 86" The Inflammatory Nutritive
of
Disturbance
Deeply Spreading Inflammations
the Skin in its Relation
to Venous-lymphatic Stasis; Chronic
Inflammation
of the Skin; Terminations
of the Skin, 87
of Inflammation
The
of the
Inflammatory Nutritive Disturbance
to Angioneurotic and
Neuritic
Skin in its Relation
Review
of the Individual
Processes, 92
of the Skin, 97
Forms
of Inflammation
The Non-inflammatory Nutritive Disturbances
of the
due
Skin
98
to Independent Stasis-Processes,
of the
Hemorrhagic Nutritive Disturbances
The Disturbances
of Innervation
Skin, 100
(Idioneuroses)of the Skin, 101 The Developmental
Anomalies
of the Skin in General, 102
Anomalies
of Development of the Skin of an
lial
Epitheof the Skin of Connective-Tissu
Origin and Type (Epidermidoses),103" The Developmental Anomalies
110
The Mycotic Diseases
of the Skin; General
Origin and Type (Chorioblastoses),
and
the Skin,
Semeiology of the Skin; Anthemata
on
Synanthemata; their Distribution
General
113
Etiology of Diseases of the Skin, their Relations to the General
Oi'ganism, 120
Remarks
General
of Skin Diseases,
on
Diagnosis, Course, and Prognosis, 129 Classification
General

that

the Skin

of

of the

in Particular,

"

Nutritive

"

"

"

"

"

"

"

"

"

"

"

131

Genei-al

"

An^mi^,

Hyper^mi^,

of Skin

Treatment

Diseases, 140.

Hemorrhages

and

of

Skin, By

the

Prof.

Ernst

Schwimmer.

147
Fluxion
Active
or
Hyperaemiae from
Hyperaemiae; (a) Erythema; (6)
Anaemias
of the
Hyperasmise from Engorgement or Venous
Hypersemiae, 152
Definition
and Varieties
Skin, 154
Hemorrhages of the Skin, 156 History, 157
oPPurpura,
Maculosus
Morbus
158
Haemorrhagicus, s. Purpura Hemorrhagica (Werlhofii),159 Purpura
161
Scorbutica; Scurvy, 160
Diagnosis; Etiology, 162" Prognosis; Treatment,
Anatomy,

Hyperasmise,
Roseola, 149

"

"

"

"

"

"

"

"

"

"

164.

Dermatitides

Superficiales,

Dermatitis Ambustionis
Ambustionis, Burns, 165
Ambustionis
Bullosa; Dermatitis
Escharotica, 166

Dermatitis

"

bustionis

Dermatitis
CongelationisErythematosa;
Dermatitis
Congelationis Escharotica, 169

Dermatitis

Catarrh

Virilium; E.
Eczema;
chr.

Manum

ac.

et

et Perinaei

et

Skin, 170
E.

Pedum;

174"
Capillitii,

E. chr.

Genitalium

of the

E.

chr.

Ani, 176

"

"

"

Eczema;

Acute

E.

ac.

Dermatitis

Faciei; E.

Eczema
ac.
Universale, 173
Faciei, 175" E. chi-. Mammee;
"

E. chr.

of the

Folds

Th.

Veiel.

AmErythematosa; Dermatitis
gelations;
Dermatitis
Congelationis,Contitis
Congelationis Bullosa; Derma-

Traumatica

"

Causticis; Eczema,

Dr.

By

....

of

the

Venenis

et

Genitalium

ac.

Intertrigo; Chronic
E.

chr. Umbilici; E.
Joints, E. chr. Cruris; E.

Pedis; Pathological Anatomy, 177

Prognosis;
Etiology, 178 Diagnosis, 179
Chronic
Local
Eczema,
Remedies, 181
Remedies; Acute
Eczema, 182

chr. Manus

et

Treatment;

Internal

"

"

"

"

"

E. of the Nostrils and upper

Lip; E.
and
E. of the Genitals
Anus,
Auditory Canal; E. Mammas;
and Feet; E. of the Legs, 189
E. of the Hands
188
Impetigo; Impetigo Contagiosa (Tilbury
Fox) s. Parasitaria
(Caposi);Impetigo Herpetiformis (Hebra), s. Herpes Vegetans (Auspitz),
and
toms,
SympPyaemicus (Neumann), 180" Lupus Erythematosus; Definition; Course
s. Herpes
194.
191" Etiology; Diagnosis, 193" Prognosis; Treatment,
184"

of the

E. of

the

Lips;

Scalp;

E. of

the

E.

Faciei; E. of the Eyelids, 187"

External

"

"

Deep-Spreading
A.

Acute

Inflammations
Deep-Spreading

of

the

Skin.

Inflammations,

By

Prof.

E.

Gebeb"

and
Course, 198" Complications of Erysipelas,203" Etiology,
Erysipelas, 197" Symptoms
204
Phlegmon; Definition; Etiology, 208
Anatomy; Diagnosis; Prognosis; Treatment, 206
and Course, 209" Gangrene foudroyant, 210" Anatomy;
Prognosis, 211" Diag"Symptoms
"

"

CONTENTS.

Vll

213
Definition; Symptoms
Furunculus, 212
Carbunculus,
Prognosis; Diagnosis; Treatment, 214
and
Diagnosis; Treatment,
Etiology; Anatomy;
Course, 215
Evil, Biskra Bouton, Delhi Boil,etc., 218" Treatment, 219.

nosis; Treatment,

and

"

"

Anatomy;

216

"

Deep-Spkeading

Cheonic

B.

Inflammations,

and
Course, 220
Symptomatology
Sclerema
Neonatorum
Pi'Ognosis; Treatment, 224
22G
Arabum
s.
Pachydermia; Symptomatology,

Sclerodermia;

Ernst

"

Symptoms
217
Aleppo
"

Schwimmee.
"

"

"

"

"

230.

Treatment.

"

of

I.,

E.

De.

By

Lessee.

234
Localization; Anatomy,
tions;
Etiology; Course, 235
Diagnosis; ComplicaIchthyosis FoUicularis, 236" Ichthyosis Congenita, 237" Etiology, 238"

Ichthyosis, 233
Therapy,

"

"

236"

Verruca, 239"

Clavus;

Callus, 238"

Paet

Epideemis.

the

of

Anomalies

"

Ecthyma,

"

Pkof.

By

214

222
Diagnosis;
Etiology, 223
Anatomy,
225
Elephantiasis
; Symptomatology,
229
Etiology; Prognosis and
Anatomy,

"

"

Anomalies

Course; Etiology, 213

Anthrax,

"

"

Epideemis.

the

Cornu

Cutaneum,

Paet

240"

II.,

Condyloma,

By

241.

A.

De.

Weyl.

Planus,
Treatment, 250" Lichen
Diagnosis,249
Etiology, 245
Anatomy, 247
Lichen
Circinatus, 257
Treatment, 257
Diagnosis, 256
Acneique; Lichen
Exfoliativa
Generalis, 258
Etiology; Diagnosis; Treatment, 258
Pityriasisrubra; Dermatitis
Dermatitis
Exfoliativa
261
Dermatitis
Acuta, 259
Diagnosis; Treatment,
Anatomy, 260
Infantum
Exfoliativa
Diagnosis ; Treatment, 262
Pityriasis Rosea
(v. Rittershain),261
Diagnosis; Treatment, 263
Etiology;
(Gibert),262
Pemphigus (Eruption of Vesicles),263
266
268
Diagnosis ; Treatment, 267
Cheiropompholyx;
Diagnosis;
Anatomy,
Anatomy,
ology;
EtiTreatment, 269
Impetigo Herpetiformis (Hebra); Herpes Gestationis, 269 Anatomy;
Psoriasis, 243
254

"

"

"

Anatomy;

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

Treatment,

"Cheonic

270.

Infectious

General

Diseases

of

By

Peof.

A.

ISTeissee,M.D.

Tuberculosis, Scrofulosis,Lupus; General

Pathology,
288" Diagnosis, 289"
Diagnosis, 287" Scrofuloderma.
Treatment, 290
Lupus, 291
Lupus xuaculosus; Lupus exfoliativus; Lupus exulcerans, 292
Lupus serpiginosus,293
Lupus of the Face, 294
Lupus of the Upper Lip; L. of the Auricle;
L. of the Trunk
and the Extremities; L. of the Genitals; L. of the Mucous
L. on the Neck, 295
Membranes;
Course, 296
Prognosis; Etiology; Diagnosis, 297 Differential Diagnosis, 298
The Sartian
culosa;
Treatment, 300
Disease, 304
Leprosy, Lepra; Special Pathology; Lepra TuberMotor
of Sensibility,
Lepra Cutanea, 306
Lepra Nervorum, 309
Paralyses; Disturbances
311
eral
GenCourse; Prognosis; Pathological Anatomy, 315
Trophic Disturbances, 312
Pathology, 316
Diagnosis; Treatment, 327
Glanders, 348
Trachoma;
Syphilis, 328
Yaws, Framboesia
Tropica, 351 Parangi; Rhinoscleroma, 354 Actinomycosis, 356
nosis,
DiagGranuloma
o57
Fungoides, 358
Postscript,360.
275"

Introductory Remarks,

Skin,

the

Tuberculosis

of

the

271

"

Skin, 286"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

of

Neuroses
362
the

"

"

"

"

Neueoses

"

"

"

"

"

the

of

Central

Skin,

Peof.

-By

Eenst

Schwimmee.

361"
Sensibility,

Hypersesthesia of the Skin; Anaesthesia; Peripheral Anassthesia,

Anaesthesia; Parsesthesia; Neuralgia Cutis, 363
Pruritus
Cutaneus, Itching of

Skin; Pruritus

"

Cutaneus

Id iopathicus s. Prurigo sine

Symptomaticus; Pruritus Cutaneus
Papulis, 364" Diagnosis; Treatment, 366" Vaso-motor
forme,
MultiSensory Neuroses; Erythema
368" Diagnosis; Erythema
Iris et Circinatum, and
Herpes Iris et Circinatus, 371"
Pathogenesis of the Polymorphous Erythemata, 372" The Erythemata in Consequence of Disturbances
of Digestion; Medicinal
Erythemata, 373" The Fever Erythemata, 374" Prognosis;
375" Erythema
376" Diagnosis ; Treatment
Treatment,
Nodosum,
; Urticaria, Nettlerash,
377, Diagnosis, 378" Etiology, 879" Prognosis, 380" Treatment, 381" Neurotic
and
neurotic
TrophoDisturbances; Prurigo; Symptoms and Course of Prurigo, 382" Anatomical
Changes,
384" Diagnosis; Etiology, 385" Prognosis, 386" Treatment, 387"
Herpes, 388" Herpes facialis

VIU

CONTENTS.

labialis

(Hebi-a);Herpes
Zoster

Z. Nuchse

"

(Willan),389" Herpes Praeputialis,

Progenitalis(Hebra), 390
Hei-pes
and
Z. Facialis, 393
Symptomatology
Pathogenesis, 391" Zoster Capillitii;

Zona;

or

"

CoUaris; Z. Brachialis; Z. Pectoralis; Z. Abdominalis;

8.

of

Herpes, 394" Prognosis; Treatment,

397
Trophoneurotic Dermatitis, 398

395

Motor

"

"

Anomalies

in

Geowth

the

Perforans

Z.

Pedis, 396

"

Femoralis;

Etiology

Decubitus

Acutus,

Disturbances, 399.

Color

and

Malum

"

op

Hair,

the

By

Paul

Michelson,

M.D.

On

in the Growth
of the Hair,
Experiments Relative to the General
Etiology of Anomalies
Hereditaria, 403
Hypertrichosis, 403
Hypertrichosis Indoles
Etiology and Anatomy,
407
Hypertrichosis Acquisita (s.Transitoria); Treatment, 408
Atrophy and Dystrophy of the
Hair; Alopecia Congenita, 409
Alopecia Universalis
Congenita; Alopecia Localis (s. Areata)
410
Alopecia Symptomatica; Alopecia Senilis and Praesenilis, 411
Congenita; Anatomy,
Alopecia Pityrodes (Capillitiiand
Universalis); Alopecia Pityrodes Capillitii;
Anatomy;
Diagnosis,414
Prognosis; Anatomy;
Symptoms and Course, 412
Etiology, 415" Treatment,
418
416" Alopecia Pityrodes tJniversalis,
Alopecia Simplex; Alopecia Areata; Symptoms and
Course, 420
Anatomy;
Etiology,424
Treatment, 425
Diagnosis; Prognosis, 423
Alopecia
Affections
of the Cerebrum
the Peripheral Nerves,
or
Neurotica; Alopecia after traumatic
of the Nervous
with
Diseases
426
Alopecia in Connection
System due to Internal Causes, 437
Anomalies
in the Coloration
Concluding Remarks;
Expansions and Fissures of the Hairs, 428
401

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

of the

Hair, 432

in Connection
General

Wasting
Several

in

Color

of

the

Whitening,

Decoloration

Hair, 434

"

of

the

433"
Hair

Patchy Whitening

ening
Whitafter
of the

Skin,

the

Nsevus,

"

"

438

By

E.

Lesser,

M.D.

"

Pigment

"

Glands

"

and

their

"

Function,

By

Ernst

Veiel,

M.D.

of

"

"

Diminished

"

Retentio

Sebi;

Comedo,

464

467

Disseminata,

Acne

Rosacea

Changes

By

....

Etiology; Diagnosis, 473"

Rosacea, 473"
Morbid

"

"

Sycosis,

and

Prognosis;

"

Milium, 465
Diagnosis; Treatment; 'Atheroma,
garis,
VulAcne, Acne
Simplex, Acne
Diagnosis; Treatment;
Diagnosis; Treatment, 469.
Treatment;

"

Cyst, 466

Sebaceous

Steatoma,

Morbid

the

System;

Sebacea, etc., 458

Secretion; Hypersecretion, Seborrhoea, Steatorrhoea, Acne
461
Localis, 459" Diagnosis; Prognosis; Treatment,
Universalis; Seborrhoea
Anomalies
of Excretion;
Arrested
Asteatosis, 463
or
Secretion, Oligo-steatosis,

Anomalies

Acne

Nervous

the

Sudden

of the Skin
in Addison's
Appendix; Alterations
Partial
Albinisfti,447
Atrophy, 445
Leucopathia
Pigment Atrophy after Syphilis,Pigment Syphilis, 452.

437

Sebaceous

the

Seborrhoea

Acne

of

Cseruleae, 444

Acquisita s. Vitiligo,448
op

of

Decoloration; the

436.

Treatment,

Color

the

Disease; Maculae

Anomalies

of

Diseases; Change

Hypertrophy,

Pigment

Presenile

and

Alterations

with

Hairs, 435"

Anomalies

Senile

"

475

Anatomy,

Nail

the

of

"

Treatment,

Veiel,

M.D.

Sycosis,474^Diagnosis; Etiology;

476.

Bed,

its

and

Treatment;

Th.

By

Prof.

E.

Geber,

M.D.

nation;
Course, and TermiSymptoms, Course,
and Termination;
Treatment, 484" Deformitas
Unguium ; Degeneratio Unguium; Discoloratio
and
Chemical
Traumatic
and
Vegetable Parasites, 486"
Injuries; Animal
Unguium, 485
ment,
Onychia Maligna, 488" Etiology; TreatTreatment;
Paronychia Traumatica, 487" Treatment;
Excessive

Formation

Treatment,

of

480"

Nail

Substance,

Defective

Etiology, 479" Symptoms,

the Nail; Etiology,483"

477"

Formation

of

"

489.

Anomalies

of

the

Sudoriparous

Glands

and

their

Function,

By
Inflammation

of the

Differential

Sweat

Glands; Etiology, 490"

Diagnosis, 491"

Treatment;

Prof.

E.

Geber,

Symptoms, Course,
Anatomy;
Hypertrophy and Atrophy of

and
the

M.D.
nation;
TermiSweat

CONTENTS.

Glands, 493

Sweat

Etiology,492

Hypertrophy;

Glands;

Functional

"

IX

Course, and

Symptoms,

"

Termination;

Atrophy of the
Hyperhidrosis Ephidrosis;

Glands;

of the Sweat

Disturbances

"

Sudamina;
Miliaria, 497
Definition;
Course, and Termination;
Symptoms,
Etiology,
498
and
Course
Diagnosis; Treatment;
Ephidrosis;
Termination,
Diagnosis; Differential
Treatment
of
Hyperhidrosis in Axilla,500
Ephidrosis Pedum;
Ephidrosis Vola Manus, 499
of
the Perspira503
and
501
Anhidrosis,
Qualitative
Changes
tion;
Hypohidrosis
Hyperhidrosis,
Hasmathidrosis, Bloody Sweat, 505
Osmidrosis,
Parhidrosis, 503
Chromidrosis, 504
Urhidrosis, Urinous Perspiration,507.
Bromidrosis, Foetid Perspiration,506
494

"

"

"

"

"

"

"

"

"

"

"

The

Diseases

Parasitic

of

Skin, By A. Weyl,

the

and

M.D.,

Prof.

M.D.

E. Geber,

Favus; Dermatomy(Dermatomycoses) (Weyl), 508

Treatment, 515
Dermatomycosis TrichophyDiagnosis;
Achorina,
Anatomy,
522
Pityriasis
tina, 516
Anatomy,
Diagnosis,523 Treatment; Dermatomycosis Furfuracea;
525" Diagnosis; Treatment;
Treatment, 527
Erythrasma, 526
Versicolor, 524
Anatomy,
Parasites
due
The Skin Diseases
to Animal
Stationaiy Parasites; Scabies; Itch;
(Geber),528
and Course
of Scabies, 533"
Symptoms
History of the Itch Mite, 530
Definition; Natural
536
Hominis, 537
Treatment,
Prophylaxis; Demodex
(Acarus) FoUiculorum
Diagnosis, 535
and Course, 542
Pediculus
Treatment;
Capitis s. Cervicalis; Symptoms
Pediculosis, 540
and Course, 543
ment,
Vestimenti
Pediculus
s. Corporis s. Human.;
Diagnosis; TreatSymptoms
Pubis
544
Phthiriasis Inguinalis s. Pubis, Pediculus
(Linne),Morpion, Crab Louse,
sitical
ParaPulex
Irritans; the Flea of Man; Temporary Parasites; Animals
544
Treatment, 545
in a Mature
Gamasidse, 546
Ixodes, Ticks;
Condition; Sarcoptes Scabiei Communis;
Pulex
flies;
Cimex
Penetrans; Tabanidae, GadLectularia, the Bed-bug, 547
Lectularius, Acanthia
in an
Parasitical
Immature
Condition;
Culex
Pipiens,Gnat; Hirudinea, 548 Animals
Cutis; Di stoma Hepaticum, Large
CysticercusCellulosse Cutis, 549 Diagnosis; Echinococcus
Guinea
Filaria Sanguinis
Filaria Medinensis
or
Liver
Worm;
(Gmelin), Medina
Fluke, 550
Hominis, 551
Craw-craw, 552
Oxyuris Vermicularis; the Larvae of Diptera,553 Accidental
and Course;
Parasites; Dermatodectes;
Symptoms
Leptus Autumnalis, Harvest
Bug, 554
Clothilia Inquilina,556.
Treatment; Kriptoptes Monunguiculosis (Acarus Hordei), 555
Skin

due

Diseases

Parasites

Vegetable

to

513

cosis

514

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

The

New-Formations
Introduction

Skin,

the

of

Connective

B*yProf.

Schwimmer

and

V.

Babes, M.D.

(Schwimmer); the Cicatrices

Quality of the Cicatrices; Symptoms
of the Cicatrices, 563
Keloid
tomical
AnaTreatment, 564
(Cheloid,Chelis); Symptoms, 565
Alterations, 568
Causes; Treatment;
Fibrosus, Fibroid, Desmoid;
Fibroma, Tumor
and
Related
of some
ment;
Causes; TreatFofms, 570
Development of Fibromas
Diagnosis, 574
Xanthoma
Xanthoma
(Xanthelasma Vitiligoidea);
Symptoms; Xanthoma
planum, 575
Tuberosum
et
Tuberculosum
Treatment;
Rhinoscleroma;
Etiology, 576 Anatomy, 578
;
582
Parablastic
581" Treatment,
which
Tumors
Symptoms, 579
Anatomy,
Diagnosis, 580
the Conditions
to
Stasis (Babes); Lipoma, 583
present in themselves
Diagnosis;^
necessary
of the Skin, C;34 Tumors
with
Predominent
Rudiments
Myxoma
Participationof Vascular
Endothelial
of the Skin, 589" Melano(Babes); The
Neoplasms of the Skin, 3G3" Sarcoma
Sarcoma
of the Skin, 598" Angioma
of the Skin; Vascular
Nsevi in General
and Simple AngiThe
600
Cavernous
of the Skin, 602
omata,
of the Skin, 604
Angioma
Lymphangioma
Tumors
of the Skin, 606" The Myoma
of the Skin (Leiomyoma
Appertaining to the Archiblast
Cutis),607.

of the

(Babes),557

Skin; Kinds

of

"

and

Cicatrices

Tissue

E.

their

New-Formations

Production, 561"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

"

Neuroma,

Adenoma,

Epithelioma

Molluscum,

Carcinoma

and

By
Neuroma,

611"

Termination;
Sebaceum,
Molluscum;
623"

Nature

Treatment,

616"

of

Neuroma,

614"

Sweat-Gland

612"

Adenoma

Tumor,

Prof.

Diagnosis; Etiology, 613"

of the

Skin, 615"

Sebaceous

the

Geber,

Symptoms,
Gland

Skin,

of

E.

Tumor

M.D.

Course, and
or

Adenoma

Adenoma

Sudoriparous s. Glomiforme, 619" Epithelioma

Termination, 621" Differential Diagnosis, 622 -Anatomy,

Symptoms, Course, and

Etiology; Prognosis; Treatment,

625"

Cancer

of

the

Skin; Historical, 626"

Definition;

CONTENTS.

627

Etiology,

"

Health;

Continuous

Symptoms,
640
"

Heredity;
and

Specific,

Course,

642
"

Irritations,
and

Prognosis

"

(Carcinoma
of

Cancer

Conditions;
Papillary

the

tory,
Inflamma-

Chemical,

Constitutional

Diseases;

"

Melanodes);
of

Certain

631

Climatic
638

Termination,

JMechanical,

Traumatism;

Sex;

"

Local

Telluric

Cancer

Pigment

Genitalia,

630

Age,

Other

Skin,

632

Anatomy,
of

Cancer

Localization,

the

"

Skin

"

Treatment,

(Carcinoma
Cancer

641
"

643

644.

Histogenesis,

Obesity;
636
"

Papillare),
of

the

External

ANATOMY

AND

DEVELOPMENT

BY

DE.

PAUL

Translated

Development

the

skin.

called
and

It

the

of

develops

skin-plate,

and

from

separated
is

(which

of

shape

it,

and

light,

the

by

but

layer

the

corium

which

at

birth, of young

at

this

time

continuous
in

even

tissue

the

of

of

right

according

distinctions.

epidermis

and

layer only

to

to

and

the

regard

it

Besnier).

(corium).

circumstance

of

Substance

the

distinct

teaches
The

of

from

the

is, however,
to

recognize
tissue

us

that, in consequence

of the

the

cutaneous
sub-

corium.

the

The

half

second

cutis

the

of foetal
from

as

consequence

As

the

the

judicious
only

two

owes

its

of

in

connective
certain

by
we

of

recognition

have

would

tissue
neither

make

macroscopically

the

papillary layer,

young

layers

has
of

subcutaneous
to

even

proper

in

apparatus,

cutis

the

formed,
trans-

once

characterized

is

nerve

more

subcutaneous

in

slowly, growing

its richness
and

terminal

at

papillary layer, consists,

its cells.

work,

epidermis

defined

is

sequence
con-

superficial portion

most

density,

in

proper

the

in

becomes

becomes

the

fibrillaB, while
and

layer

to

first very

at

The

between

cutis

presence

It

until

subsequent

fibrillary frame-

as

condition

thickness

inner

layer

wholly

few

month,

afterwards

belongs

of round

entirely

sharply

of

therefore

third

it and

inner

what

cells,

an

more

This

appear.
the

very

considerable

from

the

nerves

tissue, with

its

it

between

finally

of

becomes

into

immature

an

the

between

boundary-line

however,

In

fibrillary tissue,

border.

Eemak

life still consists

substance.

foundation

real

which

mesoblast

foetal

structure)

foundation

greatly

of

its substance,

in

and

Embryology

cutis
the

in

collagenous

circulation
to

the

distinct

fat

granulation

arrangement

same

(hypoderm,
these

the

adult, differs
the

peculiarities
least

forms

already acquired

the

time

same

appearance

vessels,

deposition

and

large quantities

remains

their

then

upwards;

of

double-contoured
of

the

of

the

constitutes

corium

month

Embryologically,

of the

corium,

the

ALEXANDER.

little intercellular

entirely

never

life, fibrillae making

below

an

but
of

deposition

tissue.
outer

at

geneticallly

T.

The

"

second

TJl^l^A.

W.

superficial layer

appearance

Whole.

in the

spindle-shaped cells, with

of the

at

as

from

Dr.

by

Shin

the

G.

the
as

of

skin, the
a

distinct

appreciable

de-

2i

ANATOMY

AifD

positionof fat in it,a distinct border-line

equallyimportant border of the cutis proper
of the microscope.
only by means
Does

corium

entire
into

this mode
of the

growth

skin

the
to

increase

grow

of

coi-ium

development give
from

matures

from

within

within.

It

by cell-division

in thickness

Subcutaneous

The

extent

more

than

any

other

even

towards

the

And
much

third

the

naked

C.

eye, while
be made

Wilson, in

We

can

the
out

one-sided

only say that the

this is

more

of

perfectly natural, since the vessels grow

probable that the skin in all its parts continues

new

intercellular

of foetal life is due

subcutaneous

substance

than

that

entirelyto depositsupon

its marked
its surface.

tissue is,however, not

develftpment,but

portion of

to

papillarylayercan

to believe, with Holt

epidermis ? Assuredly not.

the formation

of the skin to attain its full

is visible

right

outwards.

and

"

the

is,however,

during the second

Tissue.

us

towards

outwardly

DEVELOPMENT.

even

during

only the earliest portion

foetal life it increases in

the skin, and

that in consequence
of the steadyand
birth, the fat graduallydecreases in quantity,

regulardepositof fat-tissue in it. After

remains
in exceptionalabundance
and finally
only at certain points of predilection.
the eyelids,
the ear (except the lobule),the external
as
Other portionsof the skin, such
auditory canal, the nose, etc. ; in short,portionsof the skin which are either firmlyattached
time muscular, are free from
fat in
are
or
unusually movable or pliableand at the same
very

In addition

to the

fat,the subcutaneous

tissue contains
all the largerbloodvessels,
destined for the corium.
In certain parts of it are
lymphatics,and nerve-trunks
of post-foetal
found the mysteriouscorpusclesof Vater (seebelow), and during the course
bursae
formed
of
such
the chin,
mucous
are
over
as
bone,
projectingpoints
development
lower
the
the
the
line
of
of
Adami,
olecranon, on
jaw, pomum
patella,
junction of
angle
etc.
with
the
When
the fat disappearsfrom the panniculus,the subcutaneous
the sacrum
coccyx,
tissue becomes
connective-tissue
an
extremely loose network, the coarser
with those of the cutis proper and in many
bundles of which are continuous
placesalso with
of the enthose of the underlying fasciae and periostea. At such points,the connection
tire
with the underlying tissues is a very firm one, as on the head, the palms and
corium
and legs,the neck, scrotum, penis,and the eyelids,
On the trunk, the arms
soles,etc.
is established only by means
of loose connective
tissue
the other hand, the connection
on
of vessels and nerves, for which
the skin is
reason
and the ingoing and outgoing bundles
freelymovable over the underlying tissues.
tissue has therefore,on
the whole, a purely mechanical
subcutaneous
The
ance.
importbetween
the body and the corium, and serves
It effects the connection
a
as
place
of depositfor the fat.
Development of the Cutis Proper. The further development of the cutis proper is
effected simply by the continuous
depositionof collagenoussubstance, by which its cells
The form and direction of this depositionis,however,
and
more
widely
separated.
more
are
is very definite and
different in each part of the body. The
not accidental,but
skin, as the outer covering of the entire body, is forced to follow it in its great increase in
This exerts a directinginfluence
bulk, and istherefore kept in a state of permanent tension.
skin is still in the cellular stage.
of
its
while
the
axes
even
the
cells,
longitudinal
upon
the cells nearest
selves
them, to arrange themIn addition, the in-growing vessels influence
As
the
trunk
and
both
their
tremities
exwe
own
regard
independent paths.
along
may
the
relation
thick
the
in
them
of
circular
of the embryo as short,
cylinders,
growth of the skin to that in a longitudinaldirection is about as 3(^) : %, presupposing a
of the individual sections of
axes
similar linear extent of the longitudinaland transverse
of the skin, yieldingto the stronger
of the spindle-cells
the body. The longitudinalaxes
the adult.

"

"

themselves

traction,will consequentlyarrange
the trunk

extremities.

and

foetus of two

tissue should
fibrillary
by the bundles

of

This

It does not

months.

followed

at

then

rightanglesto

the

the

case

found

indeed

I have

be

to

remarkable

seem

place in mainly

also take

DEVELOPMENT.

AJSID

ANATOMY

the

that

longitudinalaxis of
the fingerof a
on
secondarydeposition
This

lines.

transverse

is still

course

of the extension

In consequence
in lengthwhich now

of fibrillseafter birth.

of the

beginsto preponderate,
growth
into
transverse
lines
a
or
of
these
from
are
a
spiral
longitudinalcourse.
changed
many
the
of
elbow, hip, and knee
These alterations take place mainly in the neighborhood
tion
positionof the body (Langer). Other changes in the direcjoint,on account of the new
of alterations in
of the fibrillation occur
during infantile growth, in consequence
the partsunder the skin (disappearance
of the fat-cushion,increase in size of the muscles).
results a typicalarrangement of the bundles of fibrillaefor each
In the adult, there finally
of
the
body.
region
flexed extremities

of the Coriitm.

Texture
the
bundles

of the

organs

fibres of

of

would

after birth and

really be only

bears

the

without

points

FibrillaryTissue.

skin

is

tension
of

like

body
coriuni

the

attachment, and

its

to

that

It follows

"

is

there

But

their ultimate

have

relations

in the

origin

We

fascise.

the

skin

no

fasciae,in which
the skin,

with

the

At

Besides,

adhesions.

linear

on

is interfered

all the

the

it passes
at those points where
spinous processes of the vertebrae, the
to flat surfaces
points of adhesion

nearly

more

to

correct

regard the

tissue

septa of the subcutaneous

of the

corium

; a

constant

can

and

of the

at

and

above-mentioned

of the

tissue,and

ilia,etc.
of

Only

the

skin

the

skin

passing

as

beginning

of

to

more

fibres,which

appearance
a

limited
trunks

nervous

imagine

one

certain

corium

contrary,

points,
such, it lies

of

numerous

head, the

the

the entire

over

face
sur-

universal, everywhere

an

elastic
tight-fitting

points, by punctate

of the skin

such

certain

of

as

at these

and

spring from

at the

the

or

adhesions

bony prominences, cartilages,and tendons,

certain

over

crests

This
place meanwhile.
produces, it is true, the
which
fibres,a simple view of the matter
possesses

general notion

only

fibrillarybundles

cellular

termination

with

larger vascular

found

are

is

general mobility

Its

the

closes
in-

all the

the

case
on

the

palms of the hands, and soles of the feet. Starting from these points, it extends
in extent, being comparatively movable, and under
of the body, 1^ sq. meter
sack nor
neither
Here
it resembles
a
a
cushion, but
varying tension.
garment.

uniformly

means

opinion that

find that

structures.

underlying

by

for the

ground

no

cushion.
As
a true
aponeurosis,it resembles
in consequence
underlying structures, but slightlymovable
accumulation
of fat, especiallyon
thickened
by an abundant

firmly united

over

sack.

repetition of the muscular

entirelydistinct

two

where

the

the

as

tioned
above-men-

fasciae.

But

it

arising free in the connectiveor

less

follow

obliquely to
the

same

large uninterrupted

advantage

in

enabling

the

course,

one

surface

taking

stretches
to

obtain

of
a

subject.

stretches of fibres in all partsof

light,we find that these coarse
other
thus
of
in
rows
directions,
inclosingcontinuous
body cross
running
This
At certain points these
assume
a
typicallydiagonaldirection.
oblong rhombi.
arrangement explainswhy in most parts of the skin not a round hole, but linear clefts
awl.
are
produced by the puncture of a round
and
direction
ning
When, as is usuallythe case, ine fibres runCleavage.
Cleavahility
of
in one
direction are much
than those running in other directions,
more
numerous
only linear clefts are produced by the awl, and the skin is,as Langer calls it,completely
of fibres running in different
But
cleavable.
when, on the other hand, the number
directions is about equal,the application
of the round
awl produces triangularor ragged
holes. 'In that case
dition
an
incomplete or indefinite cleavageis said to prevail. Such a conthe
is found, e. g., on the forehead and on many
the
of
the
on
skull,
scalp,
points
etc.
below
the
chin, the epigastric
olecranon,
region,
made
tained
close togetherin rows,
Langer ascerBy arranging the punctures, which were
and
found
the direction of the stretches of fibres characteristic of each region,
If

the

we

look at it in this
others

"

AISTATOMY

that

as

above

rule such

fibres

descending

behind, forwards

and

AND

and

DEVELOPMENT.

in the form

the trunk

on

downwards,

of

girdles,obliquelyfrom

around
specially

run

the

extremities, for

shorter distances.

longer or

He also found that the tension of bundles of fibres could never

of the Skin.
directlyovercome
by flexion and extension of the joints,because they always run
the bundles of fibres are never
or
transversely
obliquelyover these parts. For this reason
in
the
meshes
movements
the
stretch
the
of
on
put
ordinary
joints. The rhomboidal
side
of the
and
the
bundles
of
fibres
the
extended
on
opposite
laterally,
are, however,
not
jointare crowded together. In this way are produced
only the permanent folds of
which
the extensor
surfaces of the joints,but also the furrows
skin on
and wrinkles
the forehead, eyelids,
scrotum, and around the mouth, as the result of frequent
occur
on
muscular
traction, and it is evident that the direction of all these folds will roughly
representthe direction of the fibres in that particularportionof the skin in which they
Folds

"

be

are

found.

with the folds of emaciation, whicn

the result Ox an
is also the case
are
excess
merly
forremaining after the disappearanceof the cushion of fat; as the fibres were
not extended
the folds which are subsequently
longitudinally,
spread out laterally,
This useful avoidance
of too
formed, of course, correspond to their originaldirection.
tension
tissue
of
the
of
and
of
of
skin
on
one
an
excess
side,
a
collagenous
great degree
the
in
the
of
movements
of
other
is
natural
the
side,
on
ordinary
joints a
consequence
direction
tissue
with
that
of a
rhomboidal
tion
the
meshes
the fact
may be changed by tracexerted mainly in a diagonalline.
We
avail ourselves of this possior
bility,
pressure
when
to use
we
a familiar illustration,
apply an elastic bandage cut on the bias out
In placeswith a well-marked
the square.
direction of cleavage,the
of tissue woven
on
This

of skin

line
preponderating

part has attained

of tension

its full

of the meshes
In

growth.

of the tissue is

placeswhere

permanent one after the

cleavageis not well-marked, e. g.,

the

of the tissue of the

corium
subsequentlyundergoes permanent
changes in the contents and in the bulk of the
These should be carefully
viscera.
tion
distinguishedfrom transient alterations in the direcof tension and cleavage. Similar changes in the arrangement of the meshes of the
also often met
with in certain pathologicalconditions, such as cutaneous
corium
are
subcutaneous
in parts with
and
abscesses, etc., even
deep-seated tumors,
complete

on

the

the texture

abdomen,

of

alterations,in consequence

cleavage.
of the Skin.

Furrows
however
bundles

short

similar

the

but

the

the

folds of the
mark

furrows

of fibres with

telling,between
the

"While

"

slight,coarse

underlying
of the

prominences

are

those

always associated
Such

structures.

which

spots
are

are

the

with

an

furrows

of

excess

sue,
tis-

closely united

very

utiHzed

in

by

fortune-

of the hand, the dimples on the cheeks

and chin, and
and their bony
points of the crests of the ilia, the sacrum,

palm
the

larger depressionsover

skin
of

some

projections.
careful

A
ones

which

distinction

occur

over

Voluntary Muscles
on

the

head

and

possessed by
in the

fibrous

neck

other

must

the

the

human

animals.

network

body, but

of the Skin.
of

of

It is
the

"

We

must

between
are

most

these

produced

also allude

by striated

effect the

furrows

coarse

highly developed

subject,in strong

skin, and

to the active

with

contrast

muscles

large class

which

of mimic

on

and
the

those

palms

much

of

the

voluntary mobility found

the

abundance

radiate

of

finer
hands.

only

skin-muscles

obliquelyfrom

below

movements.

croscopica
The frame-work
of the corium
in the adult consists miHistologyof the Corium.
of a fibrillary
connective tissue with but few cells,the individual
bundles
ing
which, in excised portionsof the skin, run in gracefulwavy lines,whereas in the livstretched
condition.
strands
in
must
all
the
of
fibres
a slightly
as
imagine
subjectwe
"

of

be made

also

whole

AND

ANATOMY

cells

The

found

are

everywhere

while

in
else

in the
greatestnumber
are
scanty.
equally
they

cells lie upon the bundles

the finer bundles
between

of fibres

are

We

of fibres.

the first in contact

from

extensive

the most

depositof

immediate
The

itself has

the
no

larger vessels,
The
capillaries.

plates,which send out flat processes

regard this cellular covering as an almost

must

of fibrillaD,
in which
dimensions.
with

each

other

are

the small

number

of the

According to this view, the

not entirelyisolated by even

collagenoussubstance, and their lines of union

nitrate of silver

capable of

vicinityof

corium

flat nucleated

as

complete carpet,surrounding the bundles

cells is compensated for by their enormous
cells which

DEVELOPMENT.

must

large extent

fore
there-

It cannot

of surface.

over
a
stainingby
presentsa certain degree of improbabilityin the case of certain
products,such as keloids and other fibromata poorly supplied with cells ; at
pathological
this
as
rate,
investigation,
subjectneeds a new
regards the corium.
any
and largerspaces remain
Certain minute
between
the bundles
of fibres clothed with
their endothelial sheaths, which
represent in their finest ramifications the beginnings of
In the normal
condition
the lymphatic channels.
they are of extreme
tenuity,but
dimensions
considerable
at
arrest
of the circulation of lymph, and
readilyassume
every
has of these lymphatic
at every parenchymatous congestion. The exact notion which
one
the questionwhether
not the cellular carpet
roots will depend, in the first place,upon
or
the just as little settled question
is everywhere continuous, and in the second place on

be

that this view

be denied

substance

of the cement

of the corium.

of the Corium.

The existence
of such a substance
both
is demanded
by hisof
the bundles
physiologists. Fleraming describes it as an ill-defined mass, in which
The familiar
fibrillae are
transverse
of fibres,which
enveloped as in a cloud.
rings of the bundles
said to be due
to its contraction.
are
are
easilyproduced artificially,
According to this view, the
be
roots
more
fissures of the cement-substance."
would,
perhaps,
accurately defined as
lymphatic
has already been physiologicallymade
This substance
of by Langer to explain the decided
traction
reuse

Substance

Cement

"

tologistsand

"

of the

frame-work
the

and

which
the

often
other

Tomsa

occurs.

elements

thinks

of the skin

While

we

are,

instructed
therefore,sufiiciently

basis of the

of
greatextensibility

(primary tension) in the alteration of

and a
the fibres are more
nearlyparallel,

it

which

that the cement

together, and

,is the

substance
cause

holds

of. the

the

lary
fibril-

elasticity of

skin.

fresh

the anatomical
of

skin

by Langer'sinvestigationsconcerning
must
seek the larger part

the skin, and

the

rhomboidal

much

mesh-work

into

one

in

rolling
part in their complete unadequate explanation of the
it shows its complete elasticity.
of the rearrangement of the tissue,by which
cause
It is certain,according to Tomsa's
Elastic Tissue.
experiments,that the elastic
tissue plays a very insignificant
part in bringing about this rearrangement. The elastic
surround
the
fibres are
of the skin, and
very evenly scattered through the framework
When
bundles
the
elastic
framework
isolated,
completely.
shows, however,
collagenous
and it cannot, therefore,account
for that of recently
a very
slightdegree of retractility,

and

final over-extension,we

can

at

smaller

present oifer

no

"

excised

skin.

But

as

it becomes

much

less swollen

in the

alkaline

fluids of the

tissues

position
collagenoussubstance, it must necessarily,
according to the quantity and comexert a more
of the surrounding fluids,
less great,but at any rate an appreciable
or
and universal distribution must
tension upon the latter (Stirling).Its even
also bring it
to pass that impulses of traction and pressure,
exerted at certain points,must, radiating
from
a largepart of the vicinity. The
whole significance
of the elastic
these, be felt over
in
be placed
the rightlightonly by considering its relations
constituent of the skin can
tion.
of the skin, to which
to the involuntarymuscles
we
shall,therefore,next turn our atten-

than

the

t)

ANATOMY

AND

DEVELOPMENT.

trusive
Involuntary Muscles of the Skin.
Although these muscles operate in a very unobthe most
they nevertheless are among
manner,
important regulatorsof all the
functions of the skin.
They are of three kinds.
Muscular
Membranes.
muscular
branes
memThey attain their greatestsize in the
found
in the scrotum, penis,mammary
and
Here
the
bundles
areolae,
nipple.
of smooth
muscular
fibres are depositedin layersin the corium, lying almost perpendicular
to the direction of its cleavage. In the scrotum, where
of fissures run
the rows
in a
from
curved manner
the root to the raphe on either side,the bands
of smooth
muscular
fibres are arranged parallel
to the raphe, the longest below, the shortest nearer
the surface
the
On
and
areola
follow
circular
direction
a
(Tomsa).
penis,nipple,
they
nearly
at a rightangle to that of cleavage,which
is obliquelylongitudinalin the former, and
radiatingin the two latter.
Similar to these concentric muscular
shells is a radiating muscle, the smooth
lidshould be regarded as the involuntaryantagonistof the orbicumuscle of Miiller,which
laris
the skin into folds when
throw
palpebrarum. All these muscles
they contract,
which
folds indicate the direction of cleavagein that particularregion. Their
tion,
relaxa"

''^

"

"

therefore, causes

no

extension

have, therefore,less

configurationof
Arrectores.

the

to do

with

the contents

with

the so-called '^arrectores

arranged that, originatingwith several tipsfrom

inserted

become

This

hair-follicles.
be

by

regarded as

with

number

fusion

of the corium

an

of blunted

the

ends into the

of different muscular

The

than

muscular
with

branes
mem-

the external

pilorum.*' These are so

papillaryportion of the skin, they
middle portionof several adjoining

bundles

into

one

arrector

should

over
more-

since
acquiredpeculiarity,

separate muscular

of fibrillae.

bundles

skin,

It is otherwise

"

of the

bundle.

As

we

in the foetus every primary hair is provided

regard the hair-follicles (incorrectly
may

embryologicalstandpoint)as involutions of the papillarylayer(Tomsa), we find

unite two pointsof the papillarylayer,situated at different levels as
that the arrectores
corium,
time loops around
first
a part of the latter. The
forming at the same
regardsthe
effect of their contraction is therefore the approximation of these points of the papillary
layer,^. e., the erection of the hair, and the drawing inwards of a point on the surface.
is much
the
exerted upon
But the action of these muscles
more
general,and is especially
The muscles
in fact not only surrounded, but also traversed
of the corium.
contents
are
by a network of elastic fibres,and elastic threads pass out all over their surfaces which
in the general fibrous frame- work.
At both ends of the muscles, these
lose themselves
ment
in largebundles, which act as a tendon
themselves
for the attachelastic threads arrange
of the muscles to the fibrillseof the corium.
Their contraction,therefore,produces
of the entire surrounding elastic frame-work, and as in the action of involuntary
a tension
muscles large spaces are alwayssimultaneouslyshortened, the contraction of these muscles
Of course, the portions
of the corium.
produces a generalshorteningand condensation
from

an

powerfullyaffected. It is,therefore, evident that

the sebaceous gland will be relieved of its contents
(Sappey) by the erection of the hairs
bundles
of the corium
of the follicle (Hesse), The
the opening of the funnel
and
situated above the arrector
are
directlycompressed by it,and as they in part belong to
(Tomsa).
over
a large surface
bundles, this tension is transmitted
ascending transverse
the

of skin nearest

But

as

probablynot
Relation

most

are

parts of the skin the direction

in many

cleavage, i.

muscles

e.,
so

the

direction

important as

of the Arrector

of the

the hairs

principalbundles

the general tension

to

of

the Hair.

"

of

correspondsto

of the elastic frame- work

Tomsa

is

that

fibres, this remote

of the

action

first alluded

that
right in insisting

we

is
to.

should

ANATOMY

selves, upon

its bottom

as

is turned, and

papillaryend

AND

fulcrum,

DEVELOPMENT.

the

is also in

hair-follicle

nearest

towards

their

which

position. Although this explanation

is correct as applied to regions with a thick covering of hair, it is by no
means
adapted
to those parts of the body in which
the hairs are widely separated from
each other, as a
glance at Fig. J teaches ; but the same
Fig. 1 also shows that the retraction of the
arrectores
must
at
the
once
papillarylayerby
produce a lesseningof the quantity of blood
which

fixed

in the terminal

loops of the vascular plexus.

general compression of the skin begins,therefore, at its periphery ; the papillary
The view that the arrectores have no
layer becomes
pale and anaemic.
absolutely
unalterable relation to the hair-follicles is supported by the fact that many
hairs have no
muscles
of
such
those
attached to their follicles,
as
are
viz.,
regions
richlysupplied with
The

other

smooth

and

It is evident

striated muscles.

that these muscles, such

as

the musculi

palpebrarum, may perform all the functions of general tensors of the corium.
On the other hand, in many
Diagonal Muscles of the Corium.
parts of the skin,
of smooth
muscles
particularlyin those with indefinite cleavage, a large number
are
found ascending obliquelyin the corium, which
an
importance entirelyanalogous
possess
to that of the arrectores
form
as
regards their action on the corium, but which
no
to the small follicles of the downy hairs of these parts.
attachments
In looking over
the facts alreadybrought forward, it
Ohlique Tensors of the Corium.
to group
most
convenient
seems
together,in contrast to the muscular
membranes, the
horizontal tensors, the arrectores
of the hairs, and the free diagonal skin-muscles, under
the common
of "ohlique tensors of the conMm,^*withoutregardto whether
name
they have
not.
It is possiblethat the firm hair-follicle plays for the
a fixed point on
a hair-follicle or
obliquemuscles only the role of certain long projectionsfor the striated muscles which pass
over
them, that of furnishingnew
pointsof originfor them. The real beginning and end ofthe
is
shin
the
elastic tissue,and through it the entire corium..
tensors
the
Just as
oUique
of
the elastic tissue automaticallyprevents an over-filling
of the lymph-spaces with tissuefluid,by exercisingan elastic compression upon the more
readilyswellingcollagenous
scattered through the elastic frame-work
are
substance, the skin-muscles
capable with its
to the much
aid of exerting a compressing force in response
delicate stimulus
of
more
In the first place,the secretion of the sebaceous
wards
outsensitive nerves.
is
pushed
glands
into the funnel
and blood
and lymph are pressed out of the
of the hair-follicle,
into the
of the papillarylayerand the upper
capillaries
part of the corium downwards
much
secretion of the coil-glands
of it as has already reached
The
or
as
largervessels.
the coils themselves, A^Jiich
the excretory duct must
also be forced outwards
; but upon
"

"

lie in the lower

but

only a
of the

Tension

by

third

the muscular

temperature.
scrotum,

relaxation
intense

As

corium

and

below

the

muscles, they

cannot

exert

an

pressing,
ex-

retaininginfluence.
Skin

apparatus

moderate
to

of the

be

can

Function
and

the

of Temperature.
"

elastic frame-work

beautifullyseen

condition

in the

is

tension

largelyunder

of the skin
the control

effected
of the

large muscles of the tunica dartos of the

temperature,complete
correspondsto a medium
to
of a hot bath), and a high grade of contraction
testicle
retraction
of
the
the scrotum
against
by
on

the

of tension

greater heat {e.g., that

cold, manifested

The

case

of

opening of the inguinal canal, and in hairy portions of skin by the well-known
in
of the elastic -transmission
that by means
"goose-skin.^' It will be readilyunderstood
be regulated
all directions the effects of external
and internal changes in temperature may
in view of
with extreme
which
has all the greater significance,
delicacy a circumstance

"the

"

apparatus of
slightlydeveloped.

the fact that the muscular

but

very

between

Connection

Functional

DEVELOPMENT.

AND

AJSTATOMY

the blood-vessels

which

Frame-worh

Elastic

ascend

into the corium

Muscles.

and

The

"

is

elastic

tributes
kind of inhibitoryapparatus which, in general,equably disa
in
the oblique skin muscles contained
and
helps
specially
traction,
pressure
of the blood on the other, and in
circulation
the
the
secretion
one
hand,
on
regulate
is therefore

frame-work

and

it to

this way

to

the

influence

of the

movements

interchange of

the

fluids,nutrition, and

gases.
of the Skin.

Thickness

occupies
push it outwards

abscesses

skin
and

and
of
the

from

papillary layer, which

feebly developed
highly developed
feet

In the

space.

break

and

is stillvery

infantile skin, the corium

This

fact
it.

through

for the

accounts

The

corium

(as much
The

negroes.

in

the

adult

with

which

offers

lies in

almost

without.

furuncular
much

greater

immediate

is

with

contact

the

subcutaneous

tissue.

face, tlie ears, penis, scrotum, perineum, areola of the

the entire back, the buttocks, and the palms of the hands

three
of

mode

and

the

over

as

within

Its thickness

of

the subcutaneous

thin, whereas
ease

tolerablyconstant, varying between

An
is found
in the
and two
one-half
mm.
exceptionallyslight development of the corium
the eyelids,the external
auditory canal, the free border of the lips,the glans penis, prepuce,
In these places,the corium
is simply a thickening of the
of the labia majora.
inner surface
to attacks

resistance
one

"

considerable

tissue

mm.

life has

in

It attains

thickness).

influence

important

an

in

remarkable

degree

It is but

nipple, and

of

causing this; the corium

and

soles

very
of

development
becomes

the
in

cially
espe-

(Krause).
constantly exposed to wind and weather
senile changes in the corium
have
been studied
He found
by I. Neumann.
them
to consist
in part of granular opacities,
in
which, at first appearing as coarse
granules, run
rows
through the corium, and give it a dull, greenish-yellow tint, and subsequently, in the shape of
finelygranular masses,
entirelysupplant the fibrillarytissue,and in part of a gelatiniform,glassy
all the nerves
and
vessels
to have
seem
swelling of the bundles of fibres,in which
perished. The
muscles
also degenerate iu the senile skin.
thick

Senile

when

is

it

Changes.

"

The

Developmeiitof tlie Papillary Layer.

"

The

the upper part of the corium

which borders on
connection
with the epidermis,
that
so

Up to the fourth foetal month, the border line

papillarylayeralone.
is perfectlystraight,
but at that time there appear, first on
the palms
and soles,linear thickenings of the epidermis,which, projectinginto the corium,
duce
progroove-likedepressionsin it,so that from this time on epidermis and corium are
dove-tailed together,as it were.
In the sixth month, the epidermis becomes
thickened
the ridgesof the corium
left standing,and penetrates into them, growwhich were
over
ing
around
the more
resistingportions. These firmer points of the surface of the
at first characterized
accumulation
corium, which
are
in them
solelyby an unusual
of young
into papillse,
and subsequently receive capillary
cells,are thus transformed
loops of their own.
They constitute the centres of nutrition nearest the epidermis,and
therefore play a prominent part in its physiology and pathology. Towards
the end
of
and the secondary papilla-formingepithelial
foetal life,the primary, ridge-like,
processes
regularityas on the hands and feet.
appear on the rest of the skin, but not with the same
At birth, the papillarylayerhas not yet attained its full development.
Fields of the Epidermis.
The
papillarylayer is therefore formed by the growing
into each other of the epidermis and corium, the active part being played by the former.
determines the form of the papillarylayerto a certain extent, owing to the
The corium
fact that it possesses many
lines and points which
remain
intact in the shape of
resisting
and
These
ridges
the situations of subsequentpapillae.
spots, which, as a rule, mark
epidermis or

between

the

papillary layer of the skin, as we call

mate
epidermis,is developed in most intino
pathologicalprocess affects either the
the

the two

"

10

AIJATOMT

blood-vessels,form
which

the

on

and

palms

them

inclose between

AND

the

DEVELOPMENT.

soles

regular,parallel,usually crooked
ridges,
of these parts. On the rest of
divided by deep epithelial
processes into distinct

well-known

fine furrows

and groups
of papillae
are
produce an irregularformation
"primaryepithelial
prolongationsare formed

the

body

rows

fields,which

the lines of direction

with

connection

of grooves
much

between

them.

earlyand

too

Although

the

to have
superficially

any

of the

tissue of the corium, the general

fibrillary
direction
of the epidermic fields produced by them
{i. e., the main diagonals of the
oblong) coincides,on the whole, with the direction of cleavageof the corium (0. Simon).
The
fields of the epidermis,which, besides on
the hands
and feet,are
wellespecially
surfaces of the extremities,and the hairy scalp,
developed on the joints,the extensor
therefore to be subjectto the generallaws of tension of the skin.
seem
Only where wellin
do
marked
an
cleavage predominates
they appear distinctly
oblong form, while on
with
indefinite
cleavagethey are square, triangular,or irregularin shape.
parts
Papillm. The papillseare very irregularlydistributed,and vary greatlyin shape
and size.
They have, as a rule, the shape of a blunt cone, being 1^ to 2 times higher
than they are broad.
Their height varies between
0.05 and 0.2 mm.,
the latter dimension
attained
the
and
soles.
There
of
in
two
on
are
rows
arranged
being
palms
they
i
nside
the
or
simple
ridges already described, frequentlyinclosing
compound papillae,
smaller papillee
between
them.
the clitoris and penis,
numerous
on
They are still more
the labia minora, and
the areola of the nipple. In many
parts of the body they are
must
Mention
also be made
of the
entirelywanting or appear only as flat elevations.
is plasticto a high degree,accommodates
fact that the surface of the corium, which
itself
structures
to all the changes of the epithelial
which
of the
penetrate it. In consequence
rendered
advance
of the epithelial
are
longer and narrower,
processes into it,the papillse
formed
of
the
while new
new
ones
are
portions of the corium by the
by
surrounding
they undergo atrophicinvolution, they become shorter and
growing epithelium. When
sink again into a level surface,as in old age.
broader, and finally
During this process,
of the part produce dendritic forms
of the surface
the natural
of the
irregularities
or
flat,mound-shaped figures,and almost comcorium, so-called compound papillae,
pletely
of
the
corium
sometimes
are
seen.
isolated,globularportions
"

Significance of the Papillce. The

Morphological
tissue of

observation.

There

perhaps
atrophy.

as

serve

which

in

each

It is true

standard

ascribe

to

every

with

of

ingrowth

an

altered, filled with

of

the

But

wandering

true, the

still very

the

for

this,and

too

thin
much

for

the

this, that it

in

part

the

variable

There
to

and

phenomenon,
growth

of

the

judging pathological

for

skin.

the

still
sole

ever,
prevails, howactivity of the

clearly made

into

the

epithelium

known
by Auspitz in 1870.
occur
epithelium does sometimes
is

always

destroyed.

tissue does

in

not

by the

might

hypertrophy

border

exerted

pressure

papillary layer

first

tissue

terms,

as

careful

more

occur

found

to

be

cally
pathologi-

,A /iendritic splitting
up

the skin, although

it may

well

of
be

of

masses

mclined

from

to local

the

it sends
opposed to all the processes which
is restricted to
coil-glands, the activityof the corium
the ingrowing epithelium from
firm to less resisting

hyperplasise. As

of the hairs

formation

downwards

case

was

of

region of the body, which

only standard
normal

test

epithelium. At an early period of the development of the sheep, it is

the head, w^hich push
here and there on
of granulations are found
the first too strongly.developed
epidermis is from
epidermis. But the human

partialloss

sti'ikingpicture of

out

the
The

papillarylayer

the

common

extremely

an

of the

stand

cells,disarranged, and

healthy epithelium by growing connective

possibleafter

matter

in such

of the

adjacent

form

connective

young

as

the

regarding

cannot

papillaeof each

between

the

in

plan,

employment

the other.

on

change

real truth

The

tissue.
that

for the

regarded only

consequently comparison

is

pathologicalconditions.

under

be

can

definite

in the

comparison

of the corium

side and

tendency

connective

of

represents only the relation

case
one

on

conditions

normal

no

papillarylayer

The

epidermis

is
means

after

of

custom

"

form, constructed

permanent

first diverts

and

ANATOMY

AND

11

DEVELOPMENT.

in many
arrests its progress
later
points,and in part afterwards
places by local hyperplasias,which
without
develop into isolated papillae(hairs),while other processes
press onwards
encountering
resistance
is very simple. The
demands
(sweat-glands). Thus far, the matter
an
only point which
does
not the epidermis become
explanation is tliat of the penetration of the epithelium. Why
thickened
in spots externally? Why
does it send its processes
inwards
?
The
for this can
be
reason
found
which
the comified
cells acquire externally; and
in fact the
only in the firmer cohesion
inward
in foetal life only after the epidermis has attained
occurs
growth of the epithelial
processes
and
considerable
thickness
later on
the
pared
coherence, and even
superpapillary epidermis, as comwith
the interpapillary, is so much
thicker
the slighter the cornification of its cells (condylomata
acuminata

et

lata).

Histologyof the Papillary Layer,

The

"

to its function

as

cushion

and

internal

structure

filter of nutriment

of the

responds
papillarylayercorepidermis. It represents
arise from the collagenous

for the

fibres of which
a delicate piece of felt,the extremely wavy
network
of the corium.
fibrillary
By virtue of this arrangement, every strain
which
reaches the corium
is transmitted
to the papillarylayer also, being meanwhile
into a tension of the latter from
all sides (Tomsa).
converted
A definite direction of
the
of
papillarylayercannot,
cleavage
Preparation is alreadymade, in
course, possess.
the uppermost layerof the connective
tissue,for the everywhere identical arrangement
of the epidermis,without
which
the latter would
protectingsubstratum
hardly be capable
of adapting itself to the variations in the tension of the corium.
The elastic fibres
also penetrateinto the papillarylayer,in which
they are just as evenly interwoven into
the collagenousbundles as in the corium.
Their principalfunction
is the transmission
of the action of the obliquetensors of the skin to the papillarylayer.
Furroios
and Ridges of the Papillary Layer. The
external surface of the papillary
layerand its connection with the epidermis is best studied after the careful maceration
of fresh skin in citric acid (formicacid), and subsequent staining with gold or osmium.
The naked papillse,
well as the interpapillary
as
and
then
show
hollows,
grooves
a
of the furrows
the ends of
one
beautifullywavy system of lines,which remind
on
"

FiG.

2." Surface

op

the

Corium

deprived

of

Epidermis,

the

fingers(seeFig. 2). That we here have to deal with a system of alternating

grooves
These
receive ridge-like
ridgesis best seen from a profileview.
grooves
projections
of the epithelial
cells between
from their under surfaces. This accounts
them, which come
for the fact that, on some
sections,the layerof epithelial
cells nearest the corium
is provided
with
coarse
dentations, while, in other places, the border-line is perfectly
straight. In the latter case, the section has fallen in the direction of these fine
and

furrows, whereas, in the former, they were

cut at right angles. In placesnot
completely
macerated, it can be plainlyseen that an epithelial
cell is welded
by its basal ridgesinto
three

or

four grooves

of the

papillarylayer,an

attachment

of hitherto

unsuspected coni-

pleteness.
A

Basal

Membrane

correspond to

does

not

exist.

connective-tissue

"

These

fibrillae.

fine grooves
of the surface do not, however,
rather channelled
are
out of a trans-

They

12

ANATOMY

parent substance,which
The

stratum.
a

membrane.

AND

spreads over

the

DEVELOPMENT.

entire

papillarylayer in

an

extremelythin

nowhere, however, indicates the existence

presence of double contours
This intermediate
also penetrates into the interior
substance, which

of
of

the

papillarylayer,and is probably identical with the so-called cement-substance, can be

removed
by trypsin,and then, with the outline of the furrows, the clear external border
fib rillseare
of the papillae
laid bare,some
also disappears,and the connective-tissue
of
them
the
form
out
like
others
of
a brush,
spreading
having
loops.
Papillary Vessels. The majority of the papillaBare the carriers of capillaryvascular loopsrunning vertically
through their centres, the main office of which is to provide
for the nutrition
of the epidermis, the respiratoryfunction
of the skin, and
the production of watery sweat.
The capillaryloop consists of an
arterial and a venous
branch, which unite a little below the apex of the papilla,and run a straightor a curved
of their contents
and the retraction of the papillse.The
course
according to the amount
waviness may
attain such a degree that the loop fills almost
the whole
of the papilla.
This allows us to infer a great variability
calibre
of the capillary
in the length and
loop
In some
in vivo.
number
of arterial branches
a
papillae,
lary.
capilempty into the venous
"

small

loop ; in

proportionof

the

instances,a

small

rare

beside the

contain a tactile corpuscleinstead

papillae
capillary
loop passes up a short distance

of

capillary
papilla

into the

corpuscle.

In close contact

with

exists between

them

the

lation
papillarylayer lies the epidermis,'although no geneticreAll the attempts which
have been made, even
quite
the origin of at least a part of the epithelial
formation
from
recently,to demonstrate
the connective
tissue,must be regarded as failures. The epidermis has its own
matrix,
the ectoderm, and
after losses of its substance, is regenerated only in case
portions of
have been preserved,in the shape of epidermis,hair-papillae,
the ectoderm
ducts of
or
glands.
of a singlelayer of polygonal cells,it presents
Development. Consistingoriginally

them.

"

in the second

month

second

row

of smaller

substitutive

cells,which

make

their appearance

While
the outer
of
layerand the corium.
layer,in consequence
to resemble
the flattening
of its cells,graduallycomes
the subsequent horny layer,the
lower one
thickened, from the third to the fifth months, into one
graduallybecomes
to
two
from
four
of cells,which
rows
containing
already be recognized as the
may
account
the
of
of fine connecting threads between
the cells.
on
prickle-layer
presence
of the corium
in the second half of foetal life entails a marked
The increased vascularity
increase in thickness
of the prickle-layer.The horny layer,however, remains
thin, and
month
has only two rows
at the seventh
of cells,the outermost
non-nucleated
scales
into the vernix
with fat, being transformed
thrown
mixed
off
and
or
gradually
caseosa,
with
the
amnii.
As
month
make
their
cells
the
as
liquor
mixing
early
eighth
granular
between
the prickleand
the horny cells,and a more
complete cornification
appearance
which
puts an end to further desquamation of the epidermis. The thickness of
occurs,
that of
the epidermis(0.15 to 0.25 mm.) is at birth considerable,in comparison with
contrast
with
it the relation of the two
the corium
we
(0.7 to 0.9 mm.), when
the period
and
This
childhood
between
disproportion ceases
layers in the adult.
between

of

puberty, as

'
soon

the first

the

epidermis increases

but

little in

It is to be hoped that the erroneous

designation
finallydisappear from scientific works.

of

thickness.

the

horny

If

layer

as

also bear

we

"

the

mind

in

epidermis

"

may

AHf)

ANATOMY

13

"

DEYELOPMENT.

are
developed from
eighth month all the hairs and coil-glands
of
notion
the
luxuriant
we
growth of this gergain some
outgrowths of the prickle-layer,
minal
due
increase is
This quantitative
almost entirely
layer at the period mentioned.
the individual
to cell-division,
epidermic cell in the adult being but little larger than
of the astounding productivityof
In this way
in the foetus.
proof is also furnished
and forty-five
times as largein
hundred
the epidermis, the general surface being one
the adult as in the foetus (Harting). During the foetal period,the cornification is not of
in all parts of the body. The horny layeris most
hardness
the same
unyieldingon the
and
of
which
the originalepithe
terminal
on
toes,
dorsal aspect of the
fingers
dermis,
phalanx
remains
late as the eighth month.
This fact
into a membrane,
condensed
as
for the development of the nail.
has a peculiarsignificance
Be^nning with the sixth
that, from this
month, the outer layersof the epidermisacquiresuch a firm coherence
of its growth in thickness
towards the surface no longer
time on, the increased difficulty
into the corium
at some
and the proliferating
epithelium is driven downwards
suffices,
this
certain
have
more
We
seen
how, during
resistingportions
already
points.
process,
of the latter are entirelysurrounded
by the growing epithelium. It now
only remains
of
It
is not enough to describe
to take a nearer
view of the forms
epithelium thus produced.
the portionsof epidermiswhich
as
penetratebetween and give form to the papillae,
"cone-shaped." It is true that, on transverse sections of the skin, the epithelialprocesses
as a rule,to be conical in shape,but
they are also often club, nail,and hump
seem,
shaped.
In horizontal
sections of the skin, however,
For)n
of the Epidermis as a Whole.
the
circular
cross-sections
fill
the
of the papillae.Their
between
they completely
spaces
it
is
the
real configuration
is,therefore,a more
complicated one ;
negativeof that of the
conical depressionsupon
its under
face.
surand, therefore,a platewith numerous
papillae,
If a vertical section cuts through a row
of such depressions,
the cut surface presents
tween
a
outgrowths, but if it falls exactlybecorrespondingseries of conical epithelial
these depression,
the epithelium,of course, presentsa straightoutline towards the
it is,therefore,possibleto
In placeswhere the papillaestand in regularrows,
corium.
toward
border
the epidermis. It is
at will sections with either a wavy
make
a straight
or
border-Kne
in
the
the epithelium
between
evident that great caution is necessary
judging
be
with safety
determined
in pathological
uous
and the corium
cases
only on a contin; it can
with horizontal sections.
seriesof perpendicularsections after comparison, if possible,
extent
Just as little can
obtain a notion of the bulk and superficial
of the epione
dermis
and over
of the height of the epithelium between
the
by single measurements
extent
of
the
and
the
Here
the
must
also
relative
first
papillary
layer
epidermis
papillae.
be determined
horizontal
on
sections,and the cross-section of the papillarylayer thus
the cubic contents
ascertained must
be multipliedby its thickness, and subtracted from
of the entire epidermis.

that from

the fifth to thp

"

'

It

growth
favored
without

is, however,
into

the

with

the

epithelial
processes

in toto, but

which

not

are

formed

by further

sprouting of single, more

epidermis
These
portions of the epidermis, after the papillarylayer has already been formed.
of

exception, while

epithelialsprouts from
new

different matter

corium

formation

of

the

penetrating into

which

papillae(on

meshes

sweat-glands and

the
the

the

hairs),which

of
hairs

continues

the
are

corium, the shape of

formed.

through

the

The
whole

process
of

prototype of the irregular growth of the epidermis in pathologicalcases

the section
corium, tumors). In such cases, according to the direction in which
'

Whence

the

ancient, inappropriate

name

rete

(Malpighi).

cones,

of

by the
highly
assume,

like

growth

the
and

life,is the physiological

(infiltrationof the
is

made,

there

are

14

AJS"ATOMT

found

dendritic

and

vsrhereas

never

do

not

growing

epithelium

from

in the

contribute

the

as

nutrition

in contact

comes

all this that

the

surrounding

complete

of

of

with

portions of the corium

bj-

cutting-off of mature

(collections of round

corium

the

to

HiiVELOPMENT.

figures. The
far

as

goes

loosely embedded

masses

pigment), which
if

conical

branching

epithelium, however,

the

AND

the

skin, may

tissue,
fibrillary
cells,blood-clots, heaps of
indeed
be completely surrounded,

them.

epithelialcone, which is frequentlygiven to

epidermis also,is inappropriate. But, as a short designation
is necessary
for those portionsof the epidermiswhich
lie over
and those which
lie
between
the papillae,
shall call them the
we
interpapillaryprickle-layer and the
superpapillaryprickle-layer."
Layers of the Epidermis. "We divide the epidermisinto three layers:1, the prickleis seated
layer;2, the granular layer; and 3, the horny layer. The innermost, which
is
which
so-called
the
the
consists
of
prickle-layer,
papillarylayer,
directlyupon
ment
paveof
epithelium,of an approximativelycubical shape,piled up in a varying number
to
cells
of
Close
of
the
corium
the
of
the
border
these
is
cells.
rows
shape
usuallycylindrical,
for which
reason
they were
formerly distinguishedfrom the rest of the pricklecells."
cylindrical
layeras
Prichle-layer. A little higher up in the epidermis,rounded and cubical cells make
in the interpapillaryspaces, and
their appearance
horizontallyflattened cells in the
characteristic a thick armor
region. All these cells have as a common
of
superpapillary
prickles,composed of fine protoplasmic
processes.
It follows

the

name

interpapillary
portion of the

"

"

''

"

"

"

Fig.

3." Epidermis
and
and
of the
papillary layer. Picrocarmin
picric acid by alcohol
staining. Decolorization
P, sweat
oh, superficial horny layer; m b, middle
layer; bh, basal
pore;
horny layer; s bh, superbasal homy
horny layer; A:,granular layer; s t, prickle layer; bst, basal prickle layer (cylindrical cellular layer); t, tactile corpuscle;
A- A, B-B,
ducts
of sweat-glands.
c p, capillary loop;
excretory
"

"

water.

The

differences

influences.
here

find

Thus
a

one

basal

vertical
is

part

flattened

are

Such

moderate,
case

in

and

is the

of the basal

as

result

mechanical

rule to demonstrable
of their

greater productivity. We

epithelium by indirect division of nuclei and cells. As

the older ones, all the
in between
necessity push themselves
and elongated in
narrowed
the
in a direction
corium,
to
parallel
of

appearance

particularlywhen
the adult.

due

cells is the

of the

prickle-cellsmust

to it.

generallythe

shapes of these prickle-cellsare

cylindrical form
new-formation

constant

the younger
cells in this

in the

the

When

presented by the
active
the

basal

mation
forthe new
prickle-layerwhen
by a long period of rest, as is

proHferation is followed
growth

of the

epithelium

is very

active,

on

the

other

le

AJS^ATOMT

Schultze

Max

real discoverer

the

was

AND

of

DEVELOPMEOT?.

the

Eanvier
melt

of the

lengthening

elastic

an

last

Bizzozero,

of

is,of

the

mainly

the

near

They

points,in profileas completely

as

attached

are

to the

of

adult, but

the

of

the

junction,

cells.

in

curved, and

isolated

On

in which

the

touching each other

according to Bizzozero.
In still other
lies close

Bpaces

cases,
to

an

leave

great length,

very

their

narrow

cells

points, as Lott

fine bristles

find

prickles

with

described,

in

or

straight
to

seem

which

vary

isolated

no

cell

one

such

them.

between

in

sometimes

the

another;

to

enough
tolerably broad protoplasmic

places often

they form

Here

alternate

has

organ."

spaces

isolated,and

are

isolated

In the

adult, other places

occasionopposite them, ally

those

melting together

at

their

ends,

and especially where

cell which
has crept into the interspinal
a wandering
epithelialcell,the prickles of this side of the cell have
disappeared for short
the

which

cells,but

adjoining

prickles

with

(see Fig. 5),while

distances

elastic

"

no

always in the skin of the foetus.

connecting bridges, which

also found

are

other

tervals,
body of the cell at tolerably regular in-

regularity, partly arranged

corners

point of

no

course,

skin

that

the

Bizzozero.
According to him, the opposing prickles
peculiar"elastic organ," which
permits a considerable

examined
often
found
in connection, places are
greatly in length. When
pricklescan be seen, but only protoplasmic threads, stretched bridge-like from
there

believed
on

prickles.

usually with pointed extremities.

partly seemingly without
lines,the

view

nodule,

surface, the pricklesappear

the

from

Seen

form

and

together

isolated cells; he

watch-wheels.

two

melted
together at their points, and Lott took
points of the opposing prickles are in contact by their sides.

the

position,maintaining that
finallyagain inclines to the

middle

the

of

prickly coat

they fitted closely into each other, like the teeth of

hand, believed that the prickles of two adjacent ceUs

opposite cell sends

Ranvier

also

remote

more

prickles freely. Finally

its

out

unite,

describes, which

the

not

running partly entirelyaround

ones,

see
prickles of
points of two

we

nearest

and

one,

going

to

over

another.

It will be
it is

oft-.-

Fig. 5." Small portion of the pricklenerve

layer, interepithelial terminal
and
intra-epithelialterminal
branches,

with

toxylin, glacial acetic

the

from

seen

acid,

osmic

ether,

which

out; in the cavity thus

formed

without

heema-

fc,prickle-

being

in and
'*^

of

It

out.

untenable
particularly

seems

that short bridges without

terminal
.

Ti

"

perhaps

is unnecessary

to

me

facts, attribute

these

"

elastic organ

an

views

and
passively,

of

j-easou
a

facultyof

the presence

fallen

has

nucleus,

ceu

the

drawn

of I,prickle-

acid,

surface;

them

of the

one

therefore, in view

must,

we

Section

cells.

nerve-bulbs; wandering

cells

that

different appearances

given above
the normal
The most
standard.
as
likelyview is to regard
the form
of the simple protoplasmic connecting bridges
These
the
as
bridges are, however, exposed
originalone.
flows around
to the influences of the lymph which
them,
to the ingrowth of nerve-threads, to immigration of white
and
less great alterations
to the more
or
blood-corpuscles,
in the situation of cells which
originally
lay close to them;

"es-

treated

these

from

seen

impossibleto accept any

imagine

superfluousfor

the intermediate
i

"

to
tively,
ac-

threads, which

in the
and

to

also

the

nodules

present such
frequentlyas long oncs which
branch;
nerve
in
their
of
^oduleS
Spitc
elongation.
the
/i,cavity
terminal nerve-bulbs;
We
must,
therefore,
regard the prickly sheathing of
its
w.
shrinking;
nucleus
by
produced
dilated
interin
^^^ ggjjg q,q g^ system of protoplasmic prOCCSSeS engaged
wandering cell, lying
uttiehigher,afragment.
spinalspace;
which
.^ ^^^.^^ movements,
permit the free circulation of
and
effect
connection, very firm,but not
its
an
organic
current
nutritive
through
the
spaces,
in the higher layersbethe
The
older
cells.
prickle-cells
inalterable between
adjacent
occur

visible; n e a, terminal
two
s t, prickle-cellswith

is

nerve-bulb

]ust

as

'

near

.1

"

"

xi.

ii

-u

j-i,

"

"

'

rounds

Attention
of

appearances

must

ladder.
of bends.

also

Such

be

paid

are

to the

due

to

semblance

nerve-threads

of

rows

which

of

nodules,

pass

under

in

figures resembling tlie

and produce optical

them,

and in the succeedinglayerof granular cells the connection

prickles,
can
is always reduced
to straightconnecting bridges. The
prickle-cells
only be
the pricklesoften breaking off rather than
with diflficulty,
yield at their points

the shorter

come

17

DEVELOPMENT.

AND

ANATOMY

isolated

the

are

of union.
the granularlayer,which usually
comes
prickle-layer
of even
four or five
in
and
consists of one
pathologicalcases
or
two, more
rarelythree,
the
race
owes
of coarselygranular cells. It is to this layeralone that the white
rows
The granulesof this layerrefract the lightvery stronglyand therefore
color of its skin.
of the
dark by transmitted, and white by reflected light. Prior to the appearance
seem
the
vessels
bloodskin
the
foetus
has
the
entire
of
a
glassytransparentappearance,
granularcells,
at
at
the
which
the
hairs
it.
of the corium
visible
Only
points
through
being
develop does the granularlayerof the inner root-sheath appear before the granular cells
of the skin, and in the foetus of six months
they shine as fine white stripesthrough the
uncolored
epidermis. Near the end of foetal life the granularlayermakes its appearance
the universal
at this point also.
At birth, aside from
hyperaemia,the entire surface is
and
the nail-bed.
In both
of
the
at
two
the
borders
white, except
lips
places
points,
surmounted
there is a normal
by a very thick, horny mass
prickle-layer
; in both the
granularlayeris absent through the whole of life.
Granular

The

"

granules, which

Langerhans
relation

to the

excretory ducts
the
V.

time

same

them,

of the

name

very
as

carefully

regarded
also, between

the

surfaces, and

mother-cells

granules

the

granular

the

in the
presence
in the mother-cells

already failed

I had

Ranvier

free state

declaimed
free

on

in the

by Kolliker

long ago

seen

them, without, however,

their

demonstrated

them

layer, were

I next

of cornification

coil-glandsand

however,

granulosum.
exist in

process

Heynold

described

Ebner

this

carefullydescribe

of cornification.

process

in the

forms

characterize

first to

the

was

to the

Next

Layer.

to do

before

drops of

as

cells of the

undermost

of

and

their

cells to be necessary

constant

diate
interme-

demonstrated

the

inner

their presence
in the
root-sheaths
of the hair.
At

vicinity of the nails,and

inner

of the

him, with
a

Auffhammer

recognizing

fluid

soon

afterwards

root-sheath, without
the

granules

of

substance, which

horny layer,and

the

fying
identistratum

he believed

which

to

gave

the

peculiarsubstance

to

to

he

"eleidin."

Keratohyalin. We
Waldeyer. He showed,
"

the influence

owe

in

our

first exact

knowledge of

oppositionto the. opinion of

this very

Eanvier,

that it swells

up

under

of alkalies and

ing,
undergoes alterations in form under pressure without meltThe granules are rendered
and could not, therefore,be fluid.
distinct by the
more
addition of glacial
acetic acid and ammonia, because they are less affected by these agents
than the substance of thje cells. They are insoluble in water, alcohol,ether, and chloroform.
The caustic alkalies and the strong mineral
and
a
acids,
pepto-glycerinextract
in the heat.
dissolve them
for substances
which
stain
They show a very greataffinity
nuclei, especiallyhaematoxylin and carmin
(picro-carmin) an afiinityeven
stronger
than that of the nuclei themselves.
be stained by hyperosmic acid.
To
They cannot
be composed of fat or fattyacids;they are
tinguished
disjudge from these reactions,they cannot
from nuclein by the fact that the latter is soluble in alkalies and
carbonate
of sodium, even
at a low
and
from
keratin
their
by
temperature,
solubilityin pepsinin them.
be found
On
the other hand, they
hydrochloric acid. No glycogen can
correspondalmost or absolutelyin their chemical behavior to hyalin,a product of degenerative
in various
tissues.
the name
hyalin
keratoWaldeyer, therefore,proposes
processes
for the substance of the granules.
"

The
border

on

keratohyalindoes
the

horny

not

layer,but

first appear
in the

middle

in the

uppermost

strata of the

rows

of

cells,those which

but only in
prickle-layer,

the

18

form

ANATOMY

AND

DEVELOPMENT.

of isolated

granules in the neighborhood of the nuclei. We can speak of real granular

staining,cells appear the entire bodies of which
only when, in ordinarymoderate
almost filled with small and largegranules. The granulesare visible even
in unstained
are
of their strong refracting
preparations,or in those treated with osmium, on account
distinct by the addition of glacialacetic acid; but only
powers, and are always rendered
stained according to the method
when
the sections have been
described above does the
granular layersuddenly appear as a dark-violet or red band, between the prickleand the
often found on top of
are
horny layers. The granules have a rounded form; small ones
lesser
of
resistance
to
The
show
the before-mentioned
ones
large
larger ones.
powers
iilled
with
when
Even
the
cells
solvents (Waldeyer).
are
completely
granules,there
free
from them.
This, however, is not sharply
always remains a slender peripheralzone
the body of the cell.
defined towards
in these cells filled with granules. The
other kinds of changes also occur
Two
first
is a decided
shorteningof the peripheralprickles. While these are becoming shorter
closer
much
time broader, the cells come
and at the same
together,and the interspinal
there
be a continuous
in
of
that
current
much
lessened
size
no
can
are
so
longer
spaces
In the interior of the cell the nucleus
fluid through them.
undergoes atrophicchanges,
seeming constricted at certain points,or assuming a mulberry pr other shape, but always
The
It is still capable,however, of being well stained.
becoming smaller.
cavityin the
its originalsize,the
cell-body,which was occupied by the nucleus, retains meanwhile
from its walls.
contractingnucleus having drawn
away
The followingchanges, therefore,take place simultaneously in the prickle-cells
as
they grow old, and that quitesuddenly; the nucleus shrinks, the cell-bodybecomes filled
with granules of different sizes,composed of keratohyalin a substance
peculiarto the
becomes
of
the
cell
the
of
differentiated,
as
a clear
cornification; peripheralzone
process
of
the
intercellular
the
border, from the remainder
cell-body,and
connecting bridges
become
much
shorter
and thicker; these changes characterize the granular layer,and
the cells are now
ready to undergo cornification.
Horny Layer. Immediately above the uppermost granular cells the first horny cells
All the strongly
make
their appearance
as
now
perfectlyclear transparent bodies.
from
have
their
interior
which
takes placevery
a
change
disappeared
granules
refracting
it
undermost
the
be
in
On
that
can
seen
hsematoxylin specimens
horny cells
quickly.
broad
clear
around
defined
with
them
stillpresminute
are
faintly
granules
ent,
spaces
very
and we
must, therefore, believe that the granulesdisappear by melting into the
of the cell-protoplasm. At the same
time the last traces of the intercellular
remainder
It is true
that these horny
also to have disappeared at this point.
seem
juic9-canals
each other, and I stated in 1875 that they still present very fine
cells do not lie flat upon
their surfaces.
But it can be very well seen, particularly
teeth (rudimentaryprickles)
on
been
which
have
the
of
on
layer
digested with pepsin and trypsin,that
horny
portions
these teeth strike upon
each other, and
isolated cells,nothing more
therefore,
on
are,
which
broken
than
mum,
remain, although reduced to a minirudimentary connectmg bridges,
From
this
it follows that the horny cells retain
dur'ingthe process of cornification.
of the connecting threads which
with each other by the persistence
their connection
were
presentfrom the beginning.
for the study of the horny layer,
The method
of digestionis a very important one
for it shows that the process of cornification does not affect the whole cell,but only its
of the
outermost
prolonged, the entire contents
layer. If the digestionbe suflBciently
of the shape of a melon
a.
cells are destroyed,and empty shells of horny substance
or
cells

"

"

"

19

DEVELOPMENT.

AND

ANATOMY

The horny layeras a whole has, therefore,

elongated,are left behind.
the
wax-cells are replacedby horny shells. Very
of a honeycomb, in which
the structure
thin (5-10 yu thick) sections of the horny layer,therefore,show, after being digested,a
without
formed
net or horny substance
contents, the strands of which are
large-meshed
united
which
close
short
are
from
two horny threads
by
together,
horny
running
very
the
sections
of
the
are
membranes,
These
cross
horny
everywhere
horny threads,
bridges.
thickness (about 1 //),
even
of the same
throughout the entire breadth of the horny layer
much

gourd, and

Somewhat

heel.

of the

thicker

sections,treated in the

cross

same

show

manner,

incised

horny cells with yellowishhorny lateral walls;here, debris of nuclei can also be found, after
in the highest part of the horny layer. It has hitherto
digestion with pepsin,even
This is, however.
been believed that the horny cells of the epidermis have no nuclei.

g,

vertical

6." Thin

Fig.
o

from

seen

tiirough

section

optical cross-sections

of

the

f resli

horny

membranes

horny

from

layer

in contact

the

by

sole

of

the

of fine

means

foot.

Complete

prickles ;

s,

digestion by tiypsin.

pieces

of

the

horny

branes
mem-

side.

the

The nuclei of the epidermis do not disapabsolutelycorrect,as I showed in 1875.

pear
and
but
and
traces
of
desiccation,
dissolved,
shrinking
crumbling,
by
being
by
of
the
in
the
On
stillbe
found
sections
them
horny layer.
therefore,
part
can,
upper
be seen
in the incised horny cells remains
half digestedin an acid solution,there can
of
the homy membrane
and the remains
like a veil between
the cell-bodystretched
of the
not

nucleus.
fact that

The

whole

rain, whereas

and

If double
sections
such

in the

substance.

horny

yet been

influence

and

partiallycut through

or

which

to

the

puzzled many

the

the

horny
the

tissue-fluid.

of

stained

are

cell-mosaic

should, however,

of

formation

The

drawn,

the

bearing

horny

cells

passively distends

red

may
be

to

cells of

obtain

good,

by picro-car-

be

obtained

on

attached, although

upon

in dilute
the

pathologicalchanges
alkaline solutions'

membrane

into

medullary

No

densest

horny

do

masses

not

consist

is

globular

cavities, etc., also occur

very
plausible explanation of this phenomenon
in the contents
of the horny cells take place under

substance.

alterations

be

may

swelling up
cell-contents, which
the

as

wish

observer.

conclusions

important

Here

alkaline

an

brilliant

most

importance

no

in tlie cornified
we

of solid horny

quently
frehas
the
stance,
sub-

of a honeycomb-like horny frame-work.

the

was

fact also

in dilute

contents

enough,

fully developed

advanced.

Ranvier

This

entirely

yellow.
are
employed,

turn

distentions, with

of the
but

cells

horny

Just

of

up

enormous

in the

'

has

this fact many

reallya swelling
shape

thin

appearance

From

the

triplestainings

quite

not

an

ones

animal
cell-membrane
an
reproduced
necessity of coloring only thin sections if

type of

the

Thus

stainings.

uniform

as

find

we

epidermis demonstrates

the

than

acids, but
of the

first to call attention

explains the
in concentrated
are

curious

to the fact

phenomenon

alkalies.

readily permeable by

cells much

more

readilythan

The
water.

that, in treating the epidermis with

that

horny
For

concentrated

the

horny

cells swell

membranes

are

this

dilute

reason

alkalies.

but

up

much

hyperosmic

more

idly
rap-

lies
slightlyaffected by alkaalkalies gain access
to the

20

ANATOMY

acid,

lower

of the

stratum

color, like that of the horny

specimen, whereas

of the
not

AND

horny layer (three

cells which

middle

DEVELOPMENT.

to

cells

five

in direct

were

thick) assumes
with

contact

layer of horny cells remains

white,

"

intenselydeep-black

an

the

acid

the surface

on

if the action

sides

and

of the acid

were

This observer
of the black
around
border
mium
osexplained the peculiar appearance
all sides into the horny layer. I
by the difficult penetration of the acid from
lower
that this explanation was
of horny layer really has
zone
unsatisfactory, and that one

intense."

too

specimens
showed
a

strong elective affinityfor osmic

a very
noteworthy attempt

makes
skin

horny layer

is

of cells above
take

on

the

that

fat

plays

conditions
of this

Table

fat, which

nornially contains

acid.

Ranvier, in the

previously deprived of its

the granular layer, which
a

It will

staining.

osmium

fat

by absolute

contain

be

seen

part in the staining of the horny

under

which

subject may

Showing

this

throw

the most

occurs

much

latest number

explain the different appearances.

explains its blackening by osmium,

of his
He

to

are

of

lightupon

Important

very
the

no

alcohol

fat,

from

on

what

which

; for the

account

follows, that

Traite
that

does

not

same

of the

"

says

the

human

the

if the

occur

the

reason

presence

technique,"

first

of water,

statement

of

row

do

not

Ranvier

cells by osmium,
is,in fact, correct, but that the
complicated nafure, and that further investigation
constitution

Color-reactions

of the

for

the

horny layer.

Horny

Layer of

the Palm

of

the Hand.

the _omy
We
finu tnat
I shall designate the superficial
layerpresents four different strata, which
layer, 3. the superbasal, 4. the basal horny layer. The basal
(or terminal) layer, 2. the middle
sions,
more
or
horny layer, to judge from its reaction with osmium, comprises two
very distinct subdiviwhich
are
always present. In the preceding table, I have distinguished these as 4 a and 4 6.
The

basal

horny

layer is the

hardest,the

connection

between

the

cells

being

somewhat

less firm

in

superbasal layer,and much

firmly constructed and harder

less

the

of

columns

two

table

the

its action

identical with

than

of osmium

fatty bodies.

upon

superficialterminal
layer is
from
seen
a study of the

The

layer.

It will be at

latter.

two

the action

that

middle

in the

so

the

21

DEVELOPMENT.

AND

ANATOMY

the

If it were,

horny layer cannot

the

upon

acid

more

next

once

would

have

he

regarded

effect whatever

no

as

after

retain their light color.

Instead
of the horny layer would
of the fat, i. e., all four divisions
of the preceding thorough refact becomes
manifest
moval
that, in consequence
this,the remarkable
sion
with
ether
for weeks
of the
fat
constantly renewed), complete inver(by treatment

removal
of

of the
turned

skin

fresh

remain
not

are

action

The

view

that

singular thing

about

with

reconciled
most

Oehl's

the

lucidum, into

stratum

the upper

three

from

osmic

intense

an

This

acid

1, 3, and

zones

fat, whereas,

assume

alcohol.

brown

of its fat is the

fact

is very

only marks

out

which

4 a,

the

on

color

whether

same,

difficult of

be

would

this

been

has

explanation, and

distribution

the

otherwise

hand, 3 and 4 b, which

after being freed from

other

of the

in
fat.

plished
accom-

be

cannot

fat in the

epidermis.

these

reactions
is evidently the splittingup of the basal horny layer,
contains
of cells,'
row
subdivisions, the lower of which
only one
in the smallest
the above-mentioned
version.
inwhich, even
space, shows

two

five,and

to

of the

epidermis deprived

upon

by absolute

or

that

place,so

light, after removal

affected by the acid,

acid

of the

by ether
The

staining takes

osmium

black

the basal
tinct
horny layer is composed of two entirelydisrender
the recognition
picro-carininand iodine-violet
necessary
the hard basal and the
middle
of a speciallayer between
softer
horny layer. This I have
shown
that it passes
called the superbasal layer,and have
face
along the sweat pores nearly to the surthem.
of the horny layer, forming rings around
Hsematoxylin has but little effect upon either
the basal or the superbasal horny layer (see table). In specimens
stained
with
ever,
haematoxylin, hownarrowed
from
the basal horny layer seems
of cells,4 b, being wanting.
This
below, the row
Just

the

as

acid

osmic

that

proves

layers, so the results of staining with

is due

appearance

by

to

fact that

the

The

the

shows
stained

same

by each

colors

as

of the

first two

middle

and
bands

white

of

which

granules which
to be

In

horny layer is blue ; if

alternatingwith blue.

the

Those

which
the

basal

horny layer,and, therefore,

It

causes.

whole

is,in fact,

surface

to the

that

the

horny

new

and

cells

stretched

thinned, and
readily penetrate into the skin.
inversion

only

longer yield
those
with

to

which

layer

follow

them.
the

layer is differently
iodine-violet,the whole
perficial
su-

higher

of variations

and
up,

show

still more

in color is due

of

row

horizontal

first to appear
that the same

is

our

cess
pro-

frequently within the

entirelymechanical

to

added

are

from

loosened

and

w^ithin

intercellular

the

Whether

to the basal

by the surface

these

Avidened, in order

spaces

mechanical

relations
But

alone
the

as

that

the fat may

suffice to

horny

are

explain

cells possess

indefinitely; when
they can
of cells higher up, and

rows

no
press
com-

light and colored bands alternate in sections stained

of the dense
ultimately leads to the formation
superficial

this reason,

For

same

layer,the outer ones

The homy
membranes

tension.

process

which
aid is furnished
If this terminal
by the factor of atmospheric desiccation.
scales.
stretched, it ruptures, and the cells are cast off in horizontal

and

4 b

formerly described
time

same

stated

after the usual

by me,

that

the stratum

"

clear
four

to

"

layer) with
six

rows

Oehl's

on

osmium

reaction, as

the

"clear''

comprised

the

two

of Oehl

recently (probably by

lucidum.

stratum

of cells, which

lucidum

his

(seetable). In spite of this fact, Ranvier

this (my former

layer containing from

The

fresh unstained

abandon

also because

it

entirely. Oehl's

it does

not

require

stratum
a

lucidum

special name,

it

should

also

being only

"

ers
layidenoversight) tified

an

lucidum

stratum

sections

by its transpai-ency above the prickle and granular layers. As my former

found
only after the unin verted osmium
special names
staining, and as such
now

the

layer,in

be further

'
This layer,4 b, was
layer (1875),but I at the

middle

decolorized,

of these

leave
undetermined.
osmium-staining, I must
cannot
this tension
continue
degree of elasticity,
it,they must again constitute a denser layer, a few

iodine-violet,and

terminal

broadest

of the

limited

be

specimen
later and

range

stained

are

the
physical necessity that, beginning with the basal horny layer, which
covers
take place externally in the other
like a dense horny cloak, changes should

necessarily become

more

softer

superbasalhorny layerbegins

whole

in it

body

of the

horny layers. For while

spread over a larger area,
must

the

deep staining with

The

themselves

show

found

horny layer,while

basal

of these

still be

can

part of the deeper-seatedgranular layer.

picro-carmin, haematoxylin, and iodine-violet,

agents.

from

passes

firm

the

here

appears

superbasal layer.

the

remains

the

agent, and, therefore, the entire layer seems

superficialfirmer horny layer, in staining with

the

attracts
clear

should

"

is that
the

tion
atten-

layer can
be

be

avoided, I

be dropped as an inexact
term, and
portion of the horny layer.

22

ANATOMY

The

thickness

AND

DEVELOPMENT.

of the entire horny layer,aside from

that

1. The

layer,is

thereforedependent upon only two factors:

after
connecting threads, and 2. their densityand elasticity

of the underlying prichlequantity of the bridge-like

their conversion

into

horny

substance.
If

take

connected

view

of these

facts, we
are
histological
alreadyin a position
of the nature
notion
of the
chemico-physiological
morphological,
cornification.
Ever
since
the
of
the
of
work
of
Langerhans on the
process
appearance
of
that
there
has
been
deal
fascination
in
the
view
factor had
a
a
granular layer,
great
in
controls
the process
the granules of this layerwhich
of cornification,
been found
since
could
either regard them as alreadyformed drops of horny substance, or at least as an
we
and keratin.
intermediate
albumin
product between
the Process
of
Keratohyalin
for
of Cornification.The former view
Signification
the
Zabludowski
for
cornification
of
the bills of birds, while Waldeyer,
was
adopted by
of the hair, the hoof of the horse, and the
who found keratohyalin also in the medulla
exists between
this
claws of ruminants, thinks it very probable that a close connection
we

to form

even

if not

"

For the internal root-sheath, he imagines

the process of cornification.
formed
reunited with the protoplasmic
keratohyalin once
graduallybecomes
it originatedor was
within which
network
deposited,and that the horny substance is
This renewed
solution of the keratohyalinin the protoplasm
the result of this union."
to
The true
cells
of the
seems
judge from the microscopic apppearances.
very probable,
only the outer layerof the cell,and
cornification
of the cells of the epidermis,however, affects
We have alreadyseen
that the contents
consists in the formation of a horny memdrane.
of the horny cells are just as readilydigestedby pepsin (and trypsin)as keratohyalinbefore
substance

and

the

''that

it has been
or

and

redissolved

in the former.

"We

cannot, therefore,say that

either

the

former

is a process which
takes place in the
cornified.Cornification'^
cells
the
and
their
to
the
is entirelyconfined
periphery of
protoplasmic

the latter is

threads.

The
of

changes which take place in the interior of

keratohyalin,are secondaryphenomena which

appearance
life in general,but not
The

thus

statement

upon cornification.
about
the epidermis is in
made

concerning keratohyalin in other

It is

epidermis,
connecting
the cells,particularlythe
have a bearing upon
cell

perfectharmony Avith our experience

supported by the capriciousness

respects.
We
sometimes
placesin which it is found.
plete
find it in
occupying a limited space just below the point of comand sometimes, long before this process
cornification (epidermis),
beginsjin higher
in which
vaccine process),
a high
places(variola,
layers(internalroot-sheath); in many
is
almost
it
the
is
cornification
or
of
on
reached,
a
nd,
entirely
wanting,
entirely,
degree
in placeswhere cornification is very incomplete. We
other hand, we find it in largemasses
should not be regarded simply
must, however, also recognizethe fact that this substance
cells
the
in
the
of
the result of a senile change
epidermis,for it does not appear in the
as
external root-sheath which
so
of
long remains unproductive. Therefore the appearance
is really
although an accessory phenomenon of the process of cornification,
Tceratohyalin,
the appearthe periphery of the cell,not vice versa,
ance
produced hy the latter,which affects
cornification
of
cells
without
the
to
leads
Peripheral
cornification.
of keratohyalin
intimated.
These
takes
ments
statewas
as
of
just
place,
keratohyalinfrequently
appearance
refer, in the first place,only to cornification of the cells of the epidermis,and it
of epithelium during the process
of other kinds
is possiblethat subsequent examinations
in the interior of the
the presence of horny material
demonstrate
of cornification may
exhibited

by this substance in
but
large quantities,

cells,perhaps as

homy

the various

frame-work.

24

ANATOMY

AND

DEVELOPMENT.

Fig. 7, III., which illustrates a longitudinalsection of a toe of six months, the

ing
{n) has alreadyattained largerdimensions, the largetransparent cells havthe
and
into
forward
nail-fold,
penetrated further backwards
pushed themselves
under
cornifled from before backwards, as can
be
the eponychium, becoming meanwhile
recognizedfrom their assuming a yellow tint when stained with picro-carmin. Granular
white
cells do not
transitional zone
no
can
appear during this process, for which reason
be recognizedmacroscopically. The nail-fold,
like the nail-bed, still retains its cubical
In

definitive nail

5"^

VSa-i

(jlartJi.
Obj.mi, Oc.

Fig.
of

7."

nail.

child
roof

of

Development

III.

3 years

f.)

6 months
old.

of nail-fdid ;

viii.

;
a

the

iv.

toe-nail."

months;

b, section

h, horny-layer

of

i.

n,

w,

b, from

roof

3d

month,

p,

eponychium

raatrLx: of nail.
vii.

magnified

of nail-fold

; n,

at

v.

nail ;

s
n

birth

; ?", upper

of

roof

nail

; p,

t,prickle-layer
m,

matrix

groove

; A;,granular

of

ii.

4)4 months

; n, rudiment

old.
vii.
layer, vi. child 3 weeks
of nail-fold; k, granular layer of

papilla

of

matrix

of nail.

everywhere arranged perpendicularlyto the

the prickle
push themselves in between
and the
The
nail-Avall
and
of
the
and
forwards.
nail-bed,
slowlyprogress
horny layers
at
out
this time alreadysent
and coilcones
numerous
epithelial
pulp of the toe have
the
of
the region
development
glands into the loose connective tissue,and the slowness of
and
of the nail becomes
more
more
striking. The nail-fold,although it has nearly
far as the condyles of the phalanx, nor
in size,no
as
doubled
longer reaches posteriorly
but is pushed
does the upper
epithelialgroove reach the pulp of the fingeranteriorly,
epithelium, the
surface

by

the

of the

outer

steadygrowth

of which

rows

corium.

The

of the

mature

phalanx

are

nail-cells

back

upon

its dorsum,

being still

held in close

con-

25

DEVELOI'MENT.

AND

ANATOMY

nective-tissue
by the eponychium. At this time the further shaping of the conThe two lateral digitalarteries
surroundings of the nail has made progress.
anastomosing vascular loops,correspondingexactlyto the
give olf two transverse
The
nail-bed is supplied by these with very
epithelialridge and the anterior groove.
of fibrilLe
The bundles
which
ones.
fine arterial capillaries,
empty into broad venous
side of the end
the periosteum of the under
which constitute the nail-bed originatefrom
phalanx (see Fig. 7, iv.),and spread out over the head of the phalanx in the form of a
the
towards
the whole
broad
fan, towards
pulp of the toe and upwards and backwards
crossed obliquelyby others, which
On
the tip of the toe these fibres are
nail-bed.
conje
at this
and thus very wide meshes
formed
the anterior part of the nail-region,
are
from
At the posteriorpart of the
and lobules of fat are
inclosed.
point,in which coil-glands
the
the
towards
of the upper side of
fibres
of
fan
bend
last
the
over
periosteum
nail-bed,

tact

the

the nail-wall

with

tissue near
the nail-border
the connective
of which
consequence
of
fibres
which
bundles
cut across
The nail-fold is surrounded
are
by

phalanx, in

less dense.

becomes
ing
in mak-

around

the horse-shoe-shaped
nail-fold,running
arrangement of the fibrous bundles of the
to comprehend : in the first place,that the anterior portion of the
enables us
corium
nail-bed is closelyunited with the anterior flattened part of the phalanx, while the posterior
the nail-fold,have
softer and more
a
yieldingfoundation,
portion,and stillmore
sent
out (seeFig. 7, v., vi., vii.),
afterwards
which
and
that the epithelial
cones
are
of the connective
all follow the course
tissue,with their apicesdirected forwards.
In Fig. 7, iv., which
shows the toe-nail of a foetus of eightmonths, the eponychium
in its entire anterior portion has yieldedto the efforts at growth of the parts around
it.
true
of
of
the
in
It still remains
broad
the
the
form
nail,
a
posteriorpart
only upon
that the front part of the tip of the finger,freed
''anterior horny plate." We
see
of horny layer. The
from
its pressure, has produced a thick mass
nail, which
ha^
alreadycrept thus far forwards under the eponychium, in the form of a very thin plate,
this mass
obtain macroscopicallythe
as
a delicate horny lamella,and
we
now
passes upon
of a free nail,no longer covered
peculiarappearance
by the eponychium, which stillhas
in front upon a transverse
free edge, however, but terminates
no
horny mass.
toe-nail
shows
the
of
child.
new-born
us
a
Fig. 6, v.,
Microscopicalexamination
shows
that the granularlayer has appeared between
the prickleand
the horny layers,
everywhere except at the border of the nail. It passes from the back of the finger

sections,and
longitudinal

at

right angles to

around
the

skin, and

are

seen

axis of the toe.

nail- wall into the hindmost

the

same

the

way

it passes

here

from

also it

in

front

This

corner

under

of the nail -fold,where

the

nail

as

far

as

it terminates.

this is unattached

In
to the

also takes place at

suddenly disappears. Epithelialproliferation
freed
from
which
sent out
numerous
cones
are
upon
pressure, by
in the direction of the pulp of the toe.
On macroscopicalexamination
characteristic
a
The
anterior transverse
torn
change is seen.
horny mass
alreadydescribed becomes
In consequence
through in the middle layers,and scales olf until the normal level is reached.
of this the nail,which has crept forwards
stands exposed in the form
over
it,now
which
ing
of that irregularedge, thin as paper
usuallyfalls a victim to soap and water durthe first few days after birth.
cones
Fig. 7, VI., representsthe toe-nail of a child three weeks old. The epithelial
of the nail-bed have grown
stilllarger. At the bottom
of the nail three or four papillte,
which
the end of foetal life,have become
were
near
faintlymarked
greatlydeveloped.
Their
growth is intimatelyassociated with the increased production of nail-substance
which
of the nail-fold.
the whole bottom
The fully-formednail has"
now
over
goes on

this time

the

nail-bed

26

in

comparison

still much

"witlithat of

thinner

nail-fold has been

The

at

AI^D

new-born

child, increased

its free

somewhat

of the

remains

ANATOMY

edge

than

elevated

by

DEVELOPMEKT.

at the

the

considerablyin thickness, but

orifice of the nail-fold.

that

growing nail, so

stillvisible in the

form

The

is

roof of the

its orifice is widened.

of the thickened

anterior lip
of the
smoothly over the prickle-layer
it.
it
additions
from
That
of
which
is
covered
nail-bed,without
portion
receiving
by
the nail produces neither granular nor
horny layer. Just as we shall see later,in studying
both
the hair, it begins to form
layersat the point at which it becomes
separated
of fcetal life can
stillbe recognizedat this
The former upper groove
from the nail below.
point (r).
The
to the contoe of a child of three years (Fig. 7, vii.)bears a close resemblance
ditions
of

the

the roof of

eponychium

are

nail still passes

The

nail-fold.

The

nail is

bed

(not representedhere) which

it has

find

the

in the

found

from

matrix

over

it,and

under

adult.

the
can

at

be

once

of the

same

thickness

gradually acquired

in

the

over

the

whole

nail-fold.

nail-

We

now

of the nail-fold ; its anterior edge projectsa little

The
recognized during life as a white crescent.

bottom

whole

now

and epithelial
same
papillae
plane
cones, lying in the
obliquelyforwards.
The
the finger,except
as
on
development of the nail on the toe is virtuallythe same
earlier on the latter than on the former, so that
that the eponychium desquamates much
the
remains
thin
toe-nail ; finally,
the finger-nail
the finger-nail
is set free sooner
than
longer than the toe-nail.
The
Individual
Nails and Hairs.
nail of the adult is a horny
Nail of the Adult.
plate,curved from rightto left,which begins with a narrowed extremityat the bottom of
it attains its definitive thickness, which, with
rare
nail-fold,in passingthrough which
entire
it
If
far
it
the
nail-bed.
left
retains
over
uncut,
beyond the
exceptions,
grows
certain
distance
the
b
of
the
narrowed
and bent
eyond
tip
latter, and terminates a
finger
left to itself,
When
downwards.
therefore,it has a natural
typicallength dependent
its original
in part upon
thickness, in part upon the cohesion of its cells. A continuous
it to far exceed
its natural
not
addition to it,a tergo,would
cause
length,if this were
the
of
does
The
attainment
the
natural
desquamation.
'^typical
^
Mength
preservedby
of a
not indicate, therefore,in uncut
nails,an arrest of growth, but the establishment
matrix

and

and

the nail-bed

both

show

directed

"

"

"

balance

between

new

formation

and

loss of tissue.

As

in the normal

arrest, there

of life without

condition

the

nail

be, of course,

of absolute
whole
can
during
pauses
A succession of
only one individual nail for each matrix, from its foetal originto death.
singleindividual nails upon one matrix is always pathological. The hairs,however, fall
out as a rule, after having preservedfor a considerable
period the condition of balance
A
and
make
hairs.
succession
of
for
individual
of the
new
typical length,
place
in
and
the
normal.
is
based
follicle
is
This
difference
the
hairs
same
one
single
upon
much
more
simple conditions of growth of the nail.
exact definition of the meaning of the
A more
The True Nail, or the Nail Plate.
that we
is essential from a pathologicalstandpoint. I propose
nail
word
apply the
nail
term
only to that which projectsbeyond the top of the finger(inanalogy with the
in fact, only the plateof the nail.
We
define this true nail (nail-plate)
as
hair-shaft),
which tahes its originfrom the entire floorof the nail-fold,
the horny mass
as far forwards
the edge of the lunula, and, hent over forward in the form of a thin curved plate,is
as
tions
pushed onward, fittingcloselyupon the ridgesof the nail-bed, without receivingcontributhe

grows

''

*'

"

"

"

"

"

from

it.

In view

of the

extent
great superficial

of the

it
nail-plate,

is very

desirable

that

we

AND

ANATOMY

27

DEVELOPMENT.

picture it to ourselves,not as
in the air
the roof of the nail-fold,but as growing straight up
all points of the matrix,
like a hair, wp find that vertical horny threads pass out from
in view
nail-fold ; but
of the general cohesion
floor of the
the whole
i. e., from
that
well
which
nail-cells one
as
of the
can
horny matter
layers
of
just
say
secreted
the
matrix.
If
in
agination
imeach
other
to
we
now
are
by
are
heaped up parallel
that
the
whole
forwards
of
the
we
see
consider the bending over
horny
mass,
from the most posteriorpart of the
the surface of the nail come
threads which pass over
from the middle, and the undermost
from
nail-fold,those which run through its middle
terminates
with the lunula.
the anterior portion of its floor,which
Changes in the
surface of the nail must, therefore, be referred to the bottom of the nail-fold,
upper
It is also evident that if we
seek
those of the under surface to the regionof the lunula.

Fig.
has

8." Schematic

broad

nail;i,ridges of
horny-layer of
fold

sections

nail-fold,the

(perionyx

the
the

of

nail-bed;

forwards

2;, dentate

nail; s

nail I call the

plane

Such

that

the

same

and
a

not,

plane

slowly moving

to

of

mass

as

as

at

and

one

is

the

time

same

by

running
usually believed,in

this which

shows

the

an

the matrix,
and

behind

obliquelyfrom

latter

artificial vertical

natural

layers of

the

of stratification."

increased

progress

produced

parallelto the

downwards,
nail.

"plane

will also correspond

more

were

more

nail.

Growth

horny

nail-fold,that the plane of stratification

of its onward

moment

Longitudinal

one;

of Stratificationof the Nail.

understand

section
former
through a thick, ii., through a thin nail. The
section
of a
b, nail-bed; s t,k, h, n, n in as in Fig. 7. iii. Transverse
of the nail; /i,clear
lower
the
part of the nail (erroneously called
processes
t,k, h, prickle, granular, horny-layer of the epithelium at the .sides of the naili.

cells which

in

and

cross-section of the

Plane

narrow

for

we

Arloing.)

shall find them

above

; n,

inside the nail for the

we

of nails,

latter

nail-bedj

If

its interior.

thoroughly understand
hent over
anteriorlyby

in the

matter

will
same

be

requires only a little reflection to

more
evenly by a narrower
horizontal, the nail thinner, and the rapidity

of the Nail.
will

be

more

ratio.

"

pushed

nail-fold

It

over

with

broader

opening

and
to
abruptly descending plane of stratification,
schematic
two
The
longitudinal sections (Fig. 8, I. and

than
thicker

usual
and

li.)through

28

ANATOMY

thick

and

thin

nail will elucidate

ridges of the nail-bed

factor

of it.

nails at

schott) or

notions
the

and

by comparing

progress

these

is,therefore, not

Correct
one

at that

same

the

AND

conditions.

The

to be identified

with

concerning
time,

DEVELOPMEJTT.

the

relative

the

growth

be formed

cannot

forward

movement

of

of

nail at different

except by either weighing

products of the thickness

of the

the

nail

upon

growth of the nail, it being only

nail

at

periods,
th^

or

of

the
one
eral
sev-

parings (Mole-

particulartime

with

its forward

time.

more

careful

consideration

of the

changes which

during
placein a nail-plate
the
a
us
groiuth at
posterior
by a gradual increase in the steepness of the plane of
part of the nail-foldis followed
stratification on the bed of the nail,in other words, a steady thickeningof the nail; while
increased growth at the anterior edge of the lunula induces a gradual thinning of the
an
normal
nails in the light of these facts,we find the
nail subsequently. If we examine
been
made
hitherto
which
have
statements
fullycorroborated, the nailwidely varying
from
of
the
anterior
estimated
the
lunula, retaining,as a rule, the same
edge
plate,
the
end
of the finger,
in some
ing
becomcases
thickness, until after it has gone beyond
even
well-stained sections,no addition is ever
made
on
thicker, although, as can be proven
This increase in thickness
due to a more
is therefore
active
to the nail by the nail-bed.
of the nail-fold,which
is characterized, as we
know, by the presgrowth at the bottom
ence
in the foetus.
of papillse,
These
three to six rows
of from
even
papillae,which are
turned
their concavities
with
forwards, and run
arranged in horse-shoe-shapedrows,
velopment.
parallelto the edge of the nail-fold,present individuallygreatlyvarying degrees of dethem
I have several times found
developed in the adult.
very slightly
In the majorityof instances,however,
PapillaryLayer ofthe Substratum
of the Nail.
substratum
the
whole
of the nail is exactly
the configurationof the papillary
over
layer
it
has
been
H.
described
Hebra.
from
behind, we first find the
as
Beginning
recently
by
of
several
of very slender
(three'to six) rows
horse-shoe-shapedsemicircle,composed
and
before by
a lenticular
papillae. Kext to this section comes
space, inclosed behind
of which
ciirved lines,the anterior border
slightly
correspondsexactlyto the anterior edge
of the lunula.
This space contains comb-like
decrease
which steadily
ridgesbearingpapillae
lunula.
in size anteriorly,
and entirely
These
not
the
do
all run
near
disappear
ridges
but
in
their
from
behind
d
ivision
to a
forwards,
symmetrically
posterior
parallel
converge
to the
point lying behind the nail-fold, those situated externallyadapting themselves
These two divisions together
curved
border of the nail-fold.
correspond to the matrix, so
that the latter in itself is by no means
a papillary,
anteriorly
homogeneous, having posteriorly
the nail-hed
character.
Further
forwards
follows as a third
a simple bed-like
with from sixtyto ninety high ridges,which
section,which begins at once
pass as far as
there
the
become
in rows
and
lost
of
the pulp of the finger,
same
height,
retaining
the
branches
which
nail-bed
the
arise
from
of
longitudinal
papillae. The ridges
carry
the posteriorand anterior vascular loops on the floor of the nail.
AVith the decided
increase in the size of
Blood-vessels of the Nail-bed and Matrix.
ihe nail-bed after birth, the vascular system of the pulp of the finger,which
originally
culation
with its dorsum, exerts a constantlyincreasinginfluence
had no connection
upon the cirtervals
The
vessels of the ridgesgive ofE to their surfaces at regularinof the nail-bed.
and
if
from
hence
which
seem
as
above,
present pecucompressed
capillaryloops
liar

its movement

forwards

teaches

that

constant

may

take

increased

"

"

appearances.
This

complicated vascular arrangement

largerarteries and veins, from

which
arise, present certain peculiarities

that the

which
are

is rendered
the
found

still more
puzzling oy the fact
and
of the matrix
nail-bed
capillaries
only in the erectile tissue of the corpora

AND

ANATOMY

the

into

that well-marked

has shown

Hoyer

cavernosa.

broad, thin-walled

very

lacuna-like

of the ridges.
capillaries
a capillary
system, extend

venous

of

it,and

the other hand, that

is capableof

which
and

on

the
nullifying

It is evident

branches
veins
that

increase

effect of

of the
of the

arteries empty directly

digital

nail-bed, in addition

in arterial tension

moderate

stases may,

generalvenous

to the arterial

their influence

each

29

DEVELOPMENT.

increase upon

system, and
here finds
the

to the

in the absence

thus localize

safety-valve,
nail-bed,the finger,
a

of the extremities.

the whole

Nail-fold.
"

The

greater part ot

tne

surface

of the nail is free, but

lateral

it is covered
be

hind
be-

tinguished
dis-

narrow
portions can
posteriorand
nail-fold. The whole coveringis,however,
horse-shoe-shaped
and the epiderof a uniform
structure, as regardsits connective-tissue substratum
mis
it. It is composed of a loose connective tissue,containing coil-glandsand fat,
over
and those
both with those of the surrounding corium
communicate
the vessels of which
the prickle,
the granular,
underneath
the nail.. The epidermis has three complete layers,
of the nail.
The
and the horny, which
everywhere uniformly extend to the substratum
nail
the
itself
it frees
from them
the lateral portionsof the fold retreat from the
more
more
the greateris the quantityof horny layerproduced by the substratum
of the
anteriorly,
nail under these lateral edges,so that on the anterior portion of the nail-bed the edges
the bare pricklelayer,but over
of
of the nail no longer slide forwards
over
a foundation

and

at both
on

sides.

two

broad

the surface of the

horny layer.
Just as, at
may be studied upon successive cross-sections of the nail.
which
small
the posterior
horny plate
entirelydisappearsanteriorly,
part of the nail-fold,a
This

condition

extends

in many
persons
This crescentic
the nail.

chum

(perionyx).
Anteriorlythe
the

corium

horny layer of lateral covering of the fold upon

residue of the foetal eponyinsignificant
horny layeris the now
from

goes

of the

the

at

once

from
Here

the

of the nail to its under

surface
upper
also the skin has all three of the layers of

pulp
finger.
to the nail from below, at first the
attach themselves
epidermis,which successively
and
the
the
last
der
pricklelayer. The last alone continues ungranular,
horny, then
without change as far as the lunula.
the nail,as the epitheliumof the nail-bed,entirely
The
in contact
small space, in which the three layersof the epidermis come'
successively
with the nail from
the
below, can be very easilyrecognized with the naked
eye upon
surface of the nail,as a yellowish-white
in
narrower
stripeconvex
anteriorly,somewhat
the middle
than at the sides,to which but littleattention has hitherto been paid. On
a
it can
be
from
careful examination
the
in
always
distinguished
transparent (or,
waxy,
of the penetrationof air into it,milky-white) free edge of the nail on the
consequence
The epitheliumof the nail bed consists enone
hand, and the red nail-bed on the other.
tirely
of pricklecells,which not only fill out the grooves
between
the ridges,but are
also
spread over the surfaces of the latter. Seated directlyupon the ridges,elongated cylindrical
cells are everywhere found, and above them
others of a flat or triangularshape. The
nail passes closely
this pricklelayer,firmlyattached to it by ridge-likeprojections
over
from its under
surface,which correspondto the grooves of the nail-bed,on a cross-section
nail
appearing as teeth (seeFig. 8, iii. ) and on the under surface of the forciblyremoved
The
of
fine
lowermost
the nail,which
as
consists of cells of
longitudinalridges.
layer
lesser density than those of the upper layers,
section as a band
appears in a transverse
somewhat
paler in color than the rest of the nail (see Fig. 8, iii.). It has therefore
frequentlybeen regardedas something peculiarto the nail-bed,as its horny layer. Such a
layer,however, is found on the nail bed only under pathologicalconditions.
surface

the

to form

30

ANATOMY

AND

DEVELOPMENT.

regionfrom the lunula to the posterioredge of the nail-bed the nuclei of the
prickle-layer
again become very deeply stained when exposed to coloringagents; there are
towards
the anterior edge of the lunula, and it passes
more
layers of cells,particularly
between
above into a brownish
the prickle-cells
and
layerof cells,a varietyintermediate
In the

the nail-cells proper.

I described
cells of the
way
and
no

in

this transition

nail

become

1875

and

more

as

follows

The

"

pricklesof

the clear mother-

distinct,while the cells become

more

flatter ; in this

From
this the very flat
stronglypunctate, darker, transitional layer is formed.
with
delicate
covered
are
teeth,
nail-cells,
shining
finally
developed. There is here
trace
of a granular layer." Waldeyer, however, believed that he could
recognize
a

the

between

of the

mother-cells

nails and

the nail-cells proper, two

globules. Eanvier claims to have

of cells which

rows

found not keratocontain

keratohyalin in very fine
hyalin,but granules of a peculiarkind in the transitional cells,which are stained brown
(not red) by picro-carmin,and are solid (askeratohyalinalso is,according to our view).
calls this the
Ranvier
substance
the matter,
onychogene." After again investigating
the brownish
I must
that the pointsw^hich cause
still maintain
lie
the
appearance
upon
than
not in their interiors,and
surfaces of the cells and
the much
are
nothing more
be seen
horizontal sections of the zone
outlined prickles. It can
of
on
more
distinctly
transition that the interior of the cells is free from granules. In the subsequent cornifithe pricklesbecome
shorter and more
cation of the peripherallayerof the cells,
indistinct,
the
to
nail-cells on thin sections.
but even
later they give a peculiarglittering
appearance
The
The yellowland.
arises whether
Color of the lunula.
these histological
questionnow
furnish
facts suffice to finally
a
satisfactory
explanation of the border of tlie
been entirelyunderstood.
has hitherto never
the nail,which
lunula
The answer
upon
In the first place,that which
call the lunula, viz.,the
must
be in the affirmative.
we
in front of the nail-fold,does not reallyend at the
which
little white crescent
appears
the
of
the
of
nail-fold,but extends on either side to the lateral edges of
covering
edge
visible only after
the nail.
Frequently,perhaps always on the toes, the lunula becomes
It
has therefore exactlythe same
relation to the
the roof of the nail-fold has been removed.
covering of the nail-fold, as regards its extent, as the matrix, i. e., the two parts
(the horse-shoe-shapedand the lenticular). The lunula is the
separatedby H. Hebra
"

"

macroscopic expression of
lunula

blood

more

the

and

lunula

the

nail-bed

than
under

the

former

any

the

is not

matrix
one

of

of the nail.
degree,due

(Henle),but

circumstances,

an

whereas

absolute

The
the

to
one.

the color

difference

in

color

of

the

fact that the latter contains

Blood

of blood

never
can

be

givesa color
readilyremoved

to

The
difference is undoubtedly due to the fact that the
by pressure.
is covered
of
nail-bed
by a transparent horny substance, whereas there are a number
in the matrix
elements
of the nail which
completely scatter the light.
absolutelyopaque
covered
and over
These
have just seen, the transitional cells,which
are
over
are, "s we
with points,which
light appear darker, and by reflected light whiter
by transmitted
the granularcells.
in fact,marks the exact boundary of the lunula.
than
Their presence,
As regardsthese physicalpointsI believe that I may
rejoicein the approval of Ranvier,
of the keratogenous
he ascribes the white color of the lunula to the
when
irregularity
of this view is furnished
confirmation
of the correctness
cells." Additional
by the superficial
the
free
of
before
the
I
described
situated
nail.
band
which
At
as
edge
just
yellow
to
the
this point the red color of the nail-bed suddenly ceases, owing
presence of the
from

the

nail-bed

"

granular cells.
Development of the

opaque

hairs.

"

The

first rudiments

of the hairs appear

on

the face in

;32

AND

ANATOMY

DEVELOPMENT.

is the most

layersthe homogeneous internal lamella

the
fibrous layer,and finally
middle, transverse
three

Differencesbetween
the

towards

skin

of the

surface

extremities.

the

Oblique and

the

The

obliquity of the

latter

far too

little

they have

because
hair-follicles,

obliquelythey lie,the

more

hair, the

distinctly does

more

there

Tlais is the
restraining apparatus.
constantly inci-easing obtu?e angle between
kind

of

follicles
hairs

call the

arrector

an

their

make

hair-rudiments

penetrate much
assume

On

is situated.

Both

root-sheath.

The

follicle.

other,

hairs

The

projects

out

even

the

hair

sides

destined

On

the

vertical
of

varieties

oblique hairs.

While

fourth

rudiments

the
as

over

the

these

the

the

of

to act

bridges

skin.

body between

In parts with

of the

and

all those

I
the

which

oblique hairs, the secondary

or

less

of the

side

the

swelling and

button-shaped
the

overcomes

embryonic

oblique

in the

mass

vicinity

protrusion of tlie external

three

tliey are

of

are

of

shape

the expression

course

the

of the

resistance

way,

hair-follicle

recognize

the

on

assumes,

swellings

button-like

the

hair-rudi-

its centre, to

which
the obtuse
angle of the hair
oblique secondary hairs of the other

on

less

"

the

cells in

appearance

all the

on

button-shaped, lateral

of the Hair-follicle. In this

on

of the

the

before

visible

are

swelling gradually

as

on

root-sheath.
"Even

root-sheath

uniform

arrector

external

Root-sheath.

the

face, and

the unilateral

and

tension

Regions

Three

the

secondary

lower

always towards

of the

cii'cular,more

of

of

those

in

both

position between

is

length of the

direction, and

pili,which

surface

on

and
in

on

bundle

parts provided with

form

proliferation at this point, and

marked

are

the

in the

It

direction.

circular

fact that the

to the

of

the External

gland.

arrector, and

the

increased

an

the

by the fatty degeneration

us,

and

vertical

is found

regions, there
of

the

and

corium

arrector

intermediate

or

corium
than the primary,
verticallyinto the already thickened
responding
oblique position during their subsequent growth only. A cor-

sebaceous

form

of the

insertion

of the

as

definite

hairs, a very

hair
An

the

less inclined

more

increase

muscular

hairs

the

and

vertical

the

layer.

more

more

enabling

one

destination

its future

the

globular swellings of the external

hair-cone, two

inents, the upper

"of

the former.

between

regional difference is also found

shaped Swelling of
Spindle and Button
of the

delicate

rudiment

hair-follicles

appearance

and

gradually

them

of

the

position of

eyebrows,

the

corium, in

tension

which

primary, I group

month

afterwards

the

the

successively appear
the term
together under

first rudiments

very

steadily with

in

room

be found.

can

secondary

the

occupied by

is

sixth

of

trace

no

the nose,

trunk, including the

increases

on

appear

lips and

the

on

therefore

unequal

more

longitudinalfibrous
"

those

of the

all those

in

distinctly
developed,then

Straight Hair-follicles. The

the

eyelashes, vibrissae, and

in the

exactly vertical

external

latter
sheath

is due

hair-

above

the

regions, lying one

:

1st, the funnel

tirely
en-

of the

of the

follicle

the openings of the sebaceous

far down
as
glands ; 2d, the region occupied by the swelling ; and
as
The
middle
follicular region (that
3d, the region of the papilla. All three have distinct functions.
in the embryo
of the swelling) is already characterized
by the two following peculiarities: the hairfollicle is thinner

There

oblique follicles.

the

point of

the

towards

otherwise

But

is different
a

in

This

cao

of six months.

recent
I

and

straight
are

the

month,
as

They

with

seen

these

ascend

regions of the vertical

in their

neighborhood

and
grow

The

vibrissa

two

and

the hairs

three, equidistant from

external

secondary

all,two

them

between

midway

of the

primary rudiments,

difference

as

regards the embryonic

oblique follicles,which
themselves

old hairs

in the

verticallydownwards,

grows

the

new

nose

two

primary

of the

embryo

of

one,
ones

course

what
some-

of still

appear,

still smaller.

stages of loosening and

all

on

find, between

origin,and
those

and

appears
well

between

first to prepare

follows

the

oblique hairs,the secondary hair-rudiments

resistance, i. e., the region of the button-shaped swellings on the primary

the sebaceous
lie in their way.
going around
glands which
course,

rudiment

at last to the

come

between

crooked

be very
Here
we

smaller, and
luore

evenly and deeply stained than in the

more

Tlie matter
they keep as close as possibleto the obtuse
angle of the primary hair.
in extent,
regions with vertical follicles. Here, as the surface of the skin increases

hair

secondary

hairs.

least

be

point of difference

is also another

In the

following

hairs, often

can
point, and the prickle-cells

this

at

pupillaryregion.

are

follicle

as

for the

is

change

new-formed

pushed

off from

far

the

as

extremely
in the

hairs
the

swollen

are

hair

In the

embryo.
here

with.

met

their
papillae,
middle

change

between

characteristic.

ends

follicular

their upward
is arrested, and
spindle-shaped,where
progress
The lower
the epithelium of this region.
from
portion

the

the
hairs

beginning
The

region, here
to

of

process

assuming

continue
of

The

grow

follicle does

parts with
on

the

the

lips

seventh

is,in short,

bulbous

shape.

usually circularly
by accretions
not

at

once

ceived
re-

col-

33

DEVELOPMENT.

AND

ANATOMY

transparent epithelium which

them, but becomes
possessed of a more
from
shai-ply differentiated
good stainings with picro-carmin,it becomes

remains

lapse behind
In

time.

the

long

ored
deeply col-

hair.
The lower
receive the loosened
portion of the
region which
and
the
its
ascending
papilla atrophies.
gradually shorter,
epithelium disappears,
have
In the eighth month, these old epithelial
disappeared and are replaced by new
ones,
processes
still seated in the middle
are
capable of being deeply stained, proceeding from the old hairs, which
cells of the middle

follicular

follicle becomes

foJlicular

These

region.

and

indented

new

old

the

making
papilla. At the same

downwards,

grow

by

follicular

lower

time, the

hairs

region

more

once

thrown

are

off

meable
per-

from

many

secondary hair rudiments.

this time

At

region
the

towards

that

the

on

the

angle of

side when

produce

lower

The

third.

epithelial
pix)cesses,
Thus
the

is

from

produced
of this

hairs

it has
a

this

of the

curious

direction

api)earance

upper

the

The

of

lateral

of

the

old

processes

the

loss

brows,
eye-

lower

licular
fol-

its contents.

of

follicular region is swollen

mass), the old hair also turns

this, aided

further

scalp and
old

by

follicle from

seated

this

from

the
the

middle

of

the

are

and
follicle,

into that
of

effect

thirds

downwards

send

the

Here
after

button-shaped

hairs, which

old

from

the old hairs

of the

point.

two

the

is that

this vertical
the

(in the form

reached

perpendicularly
which

While

alters its direction.

hair

deviation

consequence

papillae,arise almost
diverted

the

shortened

length, becoming

on

also

place

takes

axillae.

in the

and

scrotum,

its entire

ascending hair

obtuse

arrector, is to

are

back, abdomen,

first retains

at

Here, however,
towards

hairs

(eighth month), the loosening of the primary

still later

in the

near

oblique lower
projecting from

action

of

the

direction

of

the

middle

third, without

is that

consequence

point

the

the

the

end

the

lower

the

young

of foetal

life,
portion of the follicle.
ends

of all

period.

In the same
order as that in which
the primary
Hair-Change at the Time of Birth.
from
the
the
hands
face
towards
and
feet,preoriginallyappeared, proceeding
parations
the
sixth
the
month
for
which
made
from
to
are
a hair-change,
eighth
persists
to pay
after birth and takes place all over
the body. As we, as physicians,
accustomed
are
attention to this only as it occurs
the scalp,we
shall now
on
study it up to its completion
"

follicles

in this

When
normal

hair

part.
a

child has

hair-changeon
the head

very thick, long, erect, and often dark head of hair at birth, the
the fcetal
head has been postponeduntil afterhirth. This long suit of

of the foetus consists

of
microscopically

primary hairs,all seated without

in shortened
have sent downwards
and which
from their sides productive
follicles,
papillse
bed-hairs, which have
epithelial
They are not ordinarypapillaryhairs,but
processes.
been growing for two
out of the epithelium
of the middle
follicular region,the
months
the
"hair-bed.^'
Near
end of intra-uterine life, the epithelial
processes produce new
the
hairs
in
their
after
exact
of
the primary hair-rudiments,
interior,
papillary
pattern
young
and these, usuallybefore birth, but often after it,supplant the bed-hairs by loosening
from below, growing out of the follicle beside them, and finally
them
causing them
on

old

''

^^

to fall out.

The
is, therefore, a true interchange between
two
hair-change of the new-born
to investigate
the quesentirelydistinct types of hair. It would be extremely interesting
tion
whether
the hair-changeof puberty, of convalescence, and of different forms
of
similar
should
referred
in
to
also be
a
alopecia
change
type or are to be otherwise
explained.
At birth,a relative degree of baldness
Changes of the hairy Coating in the Adult.
"

is found

This is at once
body under normal conditions.
compensated for,
the head, by the development of the hairs of the scalp,and again at puberty by the
on
The
growth of the beard in the male sex.
eyebrows and lashes increase very gradually
in strength;at puberty, the hairs of the axilla3,
and
those on the mons
veneris
especially
and around
late in life those at the entrance
the anus, and finally
of the nostrils (vibrissa)
and in the external auditorycanal (tragi)follow their example. All the embryonic
over

the whole

34

ANATOMY

hairs "of the rest of the

constitute

and

late in life

body

retain

the so-called

AND

as

DEVELOPMENT.

rule their

originalsize

down

and

absence

in the

male
(lanugo). But
lengthening with pigmentation of the

sex

of

tion,
pigmenta-

there often

occurs

short hairs of the head

thickening and
of surface, and
in females
after the menopause,
over
increase in
a varying extent
an
growth of the down on the upper lip,or on the cheeks and lower lip.
the distal phalanges of the
The great development of other epithelial
structures
on
and
the
the
and
and
toes
feet seems
of
hands
soles
of
the
the
to hinder
on
fingers
palms
in
other parts of the body also,it is a law of the products of the
growth of hairs. Even
that they mutually restrict each other's growth. Thus the epithelial
ectoderm
layer of
the
hairs are
surface is least developed where
thickest, e. g., on the head, and the
finer the hairs the more
closelytogetherdo they stand.
Hairs.
The hairs,as we have seen, are as a rule implanted obliquely
Direction
the
of
in the corium.
that of the hair-root,
Their direction is dependent upon
and is,of course,
of cleavage of the skin, is under
not accidental,but, like the direction
the
control of
of which
cussion.
disis at present, however, stillunder
generallaws of growth, the investigation
a

"

Color

The color of the hair is a product of three factors, viz.,the

of the Hair.
in the hairs.
the hair pigment, and the air contained
of the hair-cells,
The
"

color

proper

former, according to its intensity,

imparts a pale blond

or

deep

red

color.

The

ish-black
brown-

part
pigment granulessurrounding the individual cells of the cortex of the hair imless brunette
The
to an
tint,varying from a pale brown
or
a more
ebony black.
former
(horn-colorproper) and the latter (pigment color) may unite to produce every
The external
cortex is almost
of the
the only one
shade of color.
layers of the hair
in giving it its color ; the presence
which is instrumental
of a moderate
quantity of air
hair
in
fact
that its central portion
color
in the cortex may
a white
give the
spiteof the
of pigment and horn-color
and
renders
the hair gray
is dark (Pincus). Want
ent,
transparcome
and if with this there is associated a largequantity of air in the cortex, the hairs bewhite and opaque
(oldage).
hairs
Black is the most universal
color of the hair, the slightlypigmented blond
the
in
in
the
casus
Cauand
and
found
Germans, Celts,Slaves,
Finns,
occasionally
only
being
and
in
the
Arminians
Semites
red
hair is found
single individuals of
only
;
among

all

races.

of
Pruner-Bey has employed the curling of the hair as a means
by the shape of the cross-section of the hair, the round
while those with an
oval or flat cross-section curl themselves
remaining straight,

Form

of the

hairs
over

Hair.

This

classification.

the surface

"

is controlled

of the skin.

The

curliest hairs

of American

are

those

aborigines,
Polynesians,and
ground between these extremes.
The
histologyof the hair and
Histologyof the Hair.
simplifiedan^ cleared up by recent investigations.
those
straightest
a

Malays.

and
The

negroes,

Aryan

race

the
cupies
oc-

middle

"

Hair

of Bushmen

follicle.The

rudiment, and

"

connective-tissue

developsfrom

that

its root-sheaths

hair-follicle arises at the

point in two

bottom

has been

of

the

much

hair

directions,partly ensheathing the epithelial

partlyindenting it centrally. In the adult, the follicle also is confined to an

ensheathing of the lower two-thirds of the hair with its coverings,being lost above the
veloped.
sebaceous glands in the papillary
layer. Below the glands,however, it is always well deIts external longitudinalfibrous layeris here reallyonly a limitingthickeningof
fibrous layer,on the other
The middle transverse
the surrounding corium.
hand, is the
and continues alone into the papilla.This layeris abundof the hair-follicle,
real foundation
process,

AND

ANATOMY

35

DEVELOPMENT.

It contains
with transversely
elongatednuclei,resembling those of muscle.
antly supplied
of the nuclei is probablyonly an eilect of
muscles, however, and the transverse
position
The internal homogeneous so-called vitreous
the transverse
tension of the growing hair.
but
of the middle fibrous layer
is
not
a condensation
membrane,
an
independent
layer really
third
lower
of
the
in
the
which
is
well
hair-follicle,
developed only
inwardly,
increasing
the end of the papillarystage
well marked
with the age of the hair, being especially
near
in the hair-change. A very exceptionaldevelopment of the vitreous layer I have often
that this layer (see
found normally in thick head-hairs, consistingin the circumstance
Fig. 9) in many closelysuperimposedspotsprojectedconcentricallyinto the epithelium
of the prickle-layer.
The cross-sections of these broad ridgesof the vitreous layerappear
in longitudinalsections of the follicle as blunt
or
pointed teeth (z)of different sizes,
sections of ring-like
which have in their interior fine points,the transverse
circular fibres.
Their presence stamps these ridgesas folds of a very much
hypertrophied vitreous layer.
fibrous layeris then also usually the seat
transverse
The adjacentportionof the middle
the papilla,
of a glassyswelling. The vitreous layerdoes not pass upwards upon
and is;
in
the
middle
third
at
o
ften
of
found
the
not
follicle.
It is
all,
developed
slightly,
very
where
in
cells
freelyproliferating
are
always feebly developed
places
epithelial
young,
and where the vessels of the follicle approach more
seated upon the hair-follicle,
closely,
and it is,on the whole, a very changeable structure,frequentlyincreasing
and decreasing.
no

^M

*-.

Fig.

Fig.

9." Senile

of the
Fig.
cleared

10." Senile
up

alterations

homoffeneous
and

of the

membrane,

alterations

of the

9.

inner

Fig.

sheath

of the

hair-follicle in head-hairs

which

project into
prlckle-layer of the

enlarged prickle-cellsof

the

lower

region

the

external

hair

follicle

', daw,

root-sheath

10.

; z, tooth-like

(so-calledexternal

dark

ridges (in transverse

tion)
sec-

(a lo).

prickle-cellsof

root-sheath)
the

middle

of

vibrissse ; haiv,

region capable

of

good

staining.

Prichle-layer
of the
of the

Hair-Follicle.

sheaths
epithelial

of the

"

roots

In

order to

ture
simplifythe complicated nomencla-

of the hair, we

will abandon

root-sheath,as it has hitherto been employed, and supply its placeby

much
better defines
ologically
an
entirelydistinct structure

it"
from

true

term

name

which

external

embry-

t%e hair-follicle"
iox it is genetically
internal root-sheath.
We
shall regard as

prickle-layer
of
the

the
a

36

ANATOMY

coveringsof

the

hair

only

AND

DEVELOPMENT.

the

epithelialstructures ivMcli rise from tliepapilla in company

tvith it.
shaftof the hair and grow onward
of the hair-follicle has an entirelydifferent character in the three
prickle-layer

luith the
The

regionsof

the follicle.

it sinks into the upper

In company
with the granular and horny layersof the epidermis
the
funnel
of the follicle. The
other two layers,however,
part,

terminate

simultaneouslyat the orifices of

prickle-layer
passes on alone through the

the sebaceous
middle

and

glands,and

lower

from

follicular

this point the

regions,retaining

its full thickness

far as the level of the papilla. At this point, however, it
as
grows
in proportionas the bulk of the papillaincreases,
and finally,
reduced
suddenly narrower,
to a singlecubical layer,reaches the neck of the papilla. If it be overstained
with picrocolor protoplasm, and
carmin
other agents which
decolorized with" weak
or
monia,
amaqua
it can
be regularlydemonstrated
in mature
hairs that the prickle-cells
of the
middle
portion of the follicle take up the coloringagent much more
greedilythan those
of the lower portion. This difference is most pronounced in the vibrissae (seeFig. 10) ;
in the beginning of the hair-changeit can
be demonstrated
in all the hairs.
A further
proof of the productivepower of this region is furnished by the frequent,almost regular
which
it pushes out horizontally
into the surrounding cutis ; this is
epithelialcones
aided by the slightdevelopment of the homogeneous membrane.
In contrast
to this we
find
the
lower region of the follicle in the mature
hair signs of senility,
such
on
always
which in the vibrissse are frequentlyswollen, and a thick homogeneous
clear prickle-cells,

membrane.
Inside

this hollow

which
remains
cylinder of the prickle-layer,
quiescent till the
with
the
hair
forwards
its
now
hair-change,
root-sheaths,and
freely
grows
the sebaceous
into
from
the
surrounded
funnel
of
the
follicle
is
glands on
already
by the
the papillalike a cap ; to speak exactly,
ordinary horny layer. Its root-end surrounds
this root consists of four caps which
each other, the first of which
cover
concentrically

period of the

(matrix of

the

and
root-sheath)

the second

(matrixof

the

arise
cuticle)

from

the

neck

papilla,the third (matrixof the cortex)and fourth (matrixof the medulla) from
the papillarylayer. All the cells directlysurrounding the papillaeof this section are
are
cells,from which cubical daughter-cells
cylindrical
constantlythrown off in order to
the hair and
its coverings. It is the same
form
the
complex of cells which formed
primitivehair-cone at the beginningof the hair.
In order to study the delicate differences between
these closely
Root of the hair.
crowded
layers of cells,it is essential to obtain a good stainingwith picro-carmin. A
longitudinalsection of the root of a thick hair from the beard (seeFig. 11) then shows
The matrix of the root-sheath* (m i i6)is externallyin contact
the followingconditions.
remains
the
with the
of
prickle-layer
composed of one row of cells. This matrix consists
three to six layersof cylindrical
of from
cells,which become
deeply stained in carmin.
nearest
descendants
characterized
Their
are
sprinkling of keratohyalin
by a moderate
the papillalike a loop, this
in the cell protoplasm, and while the entire layersurrounds
the cells become
of which
in consequence
more
substance
steadilyincreases in quantity,
in
in
in
thick
hairs
Meanwhile
swollen.
themselves
or
and more
two,
they arrange
very
which
in
direct
with
most
The
contact
of
the
are
external
cells
three layers.
root-sheath,
of the hair-follicle,
attain astonishingdimensions
the prickle-layer
Just below the level of
in longitudinal
section as thick square masses, the nuand appear
clei
the apex of the papilla,
with the exception
of which are completelyobscured by coarse
granulesof keratohyalin
of the

"

'

Formerly

internal

root-sheath.

37

DEVELOPMENT.

AND

ANATOMY

belongingto the outer layerof the cell,which is undergoingcornificaat a somewhat

lower
The inner (or the two inner)layerof the root-sheath remains
tion.
and therefore retains the former
all
stage of the formation of keratohyalinand swelling,
the longer. In this way, there is produced justabove the level of the apex of the papilla
difference in color,the external layerof the root-sheath
a striking
becoming suddenly
of

fine clear border

liiiii
IKfe

Fia. 11." Longitudinal section

sheath

of

the

follicle;gl,

follicle);i

w,

useless);
papilla ;

w, cuticle

o
m

internal

i w,

o,

root-sheath
of
m

the

h,

of tlie root

vitreous

completelyclear,while

hair

of

from

the

the beard

follicle; aw,

(better root-sheath); h e, sheath

root-sheath
m,

of

membrane

matrices

the

h, cuticle

of i w,

internal

w,

of
o

the

h, h,

hair
m

k;

layer,which

of
;
p

; as,
external
Henle

h, cortex
h, neck

external

sheath

of

the

follicle ; is, internal

(better prickle-layerof the

of Huxley (also
(useless term); h u, sheath
of the hair ; p,
of the hair ; m
k, medulla
root-sheath

of the

contains

papilla.

keratohyalin,stilltakes

on

38

ANATOMY

brilliant red

AND

DEVELOPMENT.

color.

There
be no doubt
but that the rapid cornification which
can
the
of
undergoes is due to the counter-pressureof the broad prickle-layer
the hair-follicle,
which is suddenly exerted at this point. For when
the papillaappears
somewhat
bent over
side (seeFig. 11 towards the left),
the first clear cell on
to one
the
bent side always correspondsexactlyto the angle of bending, i. e., to the spot in which
the breadth of the prickle-layer
is suddenly increased by the width of many
cells ; while
the convex
on
side,the clearingup of the cells begins a little higher up and takes place
very gradually. If we imaginethe clear external cellular cylinder of the root-sheath as
in the shape of an
completely isolated,it would terminate below in the bent follicles,
oval body cut off obliquely. This cellular cylinderrepresentsthe so-called sheath
of
Henle
[he),but is only the middle portion of the root-sheath which may be artifically
outer

row

isolated.
the

of cells

This

length of

name

the

(thesheath

of

Henle) must

therefore

be abandoned.

About

twice

papillahigherup, the inner layerof the root-sheath also becomes clearer

in a similar manner,
forming glassyflakes,and constitutes the so-called sheath of Huxley
This
is
also superfluous. After the clearingup of the internal layer,they
name
{h u).
both
become
and
like each
other as they originally
terminate
more
more
were, and
almost
third and the funnel
at the point of junction between
the middle
of the
as
one
cell
without
where they slowly crumble
evidence
of the
hair-follicle,
cell,
giving
by
away
with the horny layerof the funnel of the follicle.
connection
slightest
the surface, the two layersof the root-sheath
Seen from
present differences in the
cells : cubical cells,
shape of their cells. The outer layer shows next to the cylindrical
then hexagonal platesthe form of which is due to pressure from all sides,but mainly to
their thickness will allow them
as
These, swellingup as much
to,
centrifugalpressure.
After
become
cubical
cells.
their
nuclei
and
have
large
again
granules
disappeared,
tablets which
these are transformed into stunted rhomboidal
present an absolutelyplane
and a convex
surface towards the inner layer of the
surface towards the prickle-layer,
root-sheath.
The
latter layer presents from
below upwards : cylindricalcells,cubical
cells,next hexagonal plateswhich increase slowlyin size,and graduallydeveloping from
these blunted
rhomboids, which
inwardly have plane surfaces and outwardly pointed
in between
which
of
the arches of the
they wedge themselves
projections,
by means
the internal into
c
ells
of
the
This
of
external layer.
wedging
alreadyolder, less resisting
the external layergoes so far that in many
placesthe pointsof the rhombi, which project
into direct contact
small surfaces
over
upwards, perforatethe outer layer,and come
of the follicle. The
external layer presents perforations
with the prickle-layer
sponding
correhave long been known
to these points,which
as the holes of the layerof Henle.
reflect that on the periphery of the papillathe outer
When
we
layermust ascend more
rapidlythan the inner, on account of its excessive distention by keratohyalin,but that
intimatelyre-united in the middle portion of the follicle,it follows that
they become
at some
This takes
the inner layermust
point be arrested in its advance by the outer.
is
effected
the
above-mentioned
and
the
under
gradually
by
phenomena,
place
pressure
The
of
the
inner
in
the
outer
root-sheath,
therefore,
layer.
increasingentanglement
springs as a unit from the neck of the papilla,and immediately divides into two layers
which become
tain
temporarilydisarranged in their relations to each other, because they conre-united by
more
differentquantities of keratohyalin. But finally,being once
pressure from without, they crumble offas a ivhole at the neck of the follicle.
contains keratohyalin and
the matrix
of the root-sheath {m i w), which
Between
contain
cortex
of
the
hair
which
of
the
mother-cells
the
pigment, and also on the
(m h),
the two cuticulae,
which
of
is
found
the
matrix
there
neck of the papilla,
common
(m o)

40

ANATOMY

again divides sharplyinto

cells

The

pigmented cells of the

contain keratohyalinand

hair-cortex, the

of the

DEVELOPMENT.

the

of the medulla, which

cells

AND

hair-cortex

and

the

the exact

occupy

hair-cells proper,

from

are

non-pigmented

pilla.
apex of the pathe first inclosed

cells,and
granular pigment, are cut off as cubical cells from the cylindrical
are
fibre-cells,
by the pressure exerted upon them into long, narrow
graduallytransformed
also flattened and elongated, and which
vertical airspaces
leave many
the nuclei of which are
the
has
discovered
that
them.
hair-cells
between
are
Waldeyer
recently
younger
such as we
elsewhere find only in the connective
tissue.
composed of real fibrilla,
contrast
The
to the vertically
innermost
medullary cylinder,in marked
elongated
broadened
cells
cortical cells,consists of horizontally
epithelialcells. No true cylindrical
An
cubical epithelium {m m)
in the matrix
of the medulla.
be found
can
irregularly
characterized
hyalin,
the apex of the papilla,
covers
by the presence of large globulesof keratoin
each
cell.
much
which
found
two
of
These
become
are
or
medullary
only one
lary
more
Higher up, the meduldeeply stained in carmin than the round nuclei near them.
collect into a rouleau -like column
cells,which are at first arranged in irregular
layers,
of cells,having three or four cells in a horizontal plane. The
globules of keratohyalin
carmin
increase
less
and
less
the
color
while
in size ; afterwards
of
take
they
gradually
cell
in
vel
become
dissolved
the
to
while
the nuclei shriprotoplasm,
entirely
they seem
in

of

masses

up.

are

them, which

surrounded
of the
The

result of
in the

by

medullary

afterwards

complete system

cells shrink, and

wider,

grow

that

so

of air canals.

leave at first

in the

middle

Air does

not

narrow

follicular

air-spaces
region they

rior
penetrate into the inte-

cells.

shape
a

of the

whole

Finallythe
between

of horizontal

pressure

fcetus,and

exerted

during

plates,which
them

upon

the

the new-formation

medullary
above

from
of

layers,of the individual

the boundaries,

are

concentric

can

When

we

hair, the hair-shaft is at

medullated, and that the medulla grows into a closed

hair always has
is readilyunderstood; an uncut

Very curious, however,

cells assume,

downwards.

so

horny
a

mass,

the

non-medullated

sharply defined

layersof the hair, which

are

so

only

be

reflect

the
that

first

always nonoriginof this pressure

end.

according to the cellcharacterized

distinctly

to the action
of
assume
that, in obedience
chemicallyand morphologically. We must
have justattempted to sketch in outline)
forces (which we
regularlyworking mechanical
geneous
the different kinds of layersof the hair are developed out of the originally
always homothe papilla.
material which
covers
at present
we
can
Leaving the details of this process to subsequent investigations,
the
hair
the
is
the
overtaken
third
lower
that
in
follicle,
of
iy the more
proper
only say
the
latter
in
its
is
then
that
arrested
and a
suddenly
course,
rapidlygrowing root-sheath,
the
bear
middle
on
check is thereby suddenly brought to
hair;so that, i7i the
follicular
region,both hair and root-sheath must for a time grow with equal rapidity. A little
later,however, the hair gains the upper hand, and the root-sheath,leftbehind in the race,
somewhat
more
crumbles
slowlythan the hair-shaftgrows
offin the funnel of the follicle
the
root-sheath
The
of
more
is,in my opinion,due to
primarily
rapid growth
upwards.
the
in
be dependent upon
of
which
excessive
some
the
keratohyalin,
formation
may
way
matrix
in
to
situation of its
unfavorable
respect nutrition.
Bed-hair.
We have thus described the mature
continuouslygrowing
Papillary hair.
papillaryhair. It is always characterized by the presence of a medullary cylinder in
to the papilla,
reaches down
its interior,which
by the peculiarformation of the cuticulae
the cells
the
uniform
distribution
of the pigment around
and root-sheath,and finally
by
"

AJSrATOMY

of its cortex.
We

are

All these

AJMD

of the
consequences
varietyof hair-shaft,constructed

are
peculiarities

familiar with

another

41

DP]VELOPMENT.

direct

of the pilla.
paferent
entirelydif-

presence
in

an

medulla, and whose

ment
pighaving
the
and
strands
in
scattered
is
hut
throughout
heaps
uniformly distributed,
is
but
in
arises
a
hair-follicle,
the
This variety,
hair.
independently
hed-hair,never
there.
hair which originally
to a papillary
grew
always an annex
pearance
As it seems
adapted to give us an insight into the pathologicaldisapparticularly
advisable to carefully
and change of the hair, it seems
distinguishit from the
theoretical standpoint,indeed, a
a
papillaryhair as a specialvarietyof liair. From
and
all the piecescut off from
of
out
hair-follicle,
hair is that cylinderwhich
a
grows
With
such a conception of virtual
hair."
to
"one
this cylinder,from its originon, belong
ual
be no bed-hairs,but only a bed-hair stage of each individhairs,there can of course
From
hair, which always produces the last part of the hair, that nearest the skin.
a practical
standpoint,however, we do not have to deal with whole, virtual hairs,but partly
with such as have been pulled out, and which consist of a portion of the shaft of varying
length and of the root, and partlywith sections of the skin which show only the root
and an extremely small portionof the shaft.
venience,
These, for the sake of simplicityand conshall distinguish2iQ pajjiUaryhairs and non-papillaryhed-hairs.
we
Hair-cJiange. A comprehension of the bed-hair can be obtained by a careful study
from the fur of certain animals in
of the hair-change. The term
"hair-change" comes
which
cast off and
the old coat of hair is periodically
It is
one.
replacedby a new
therefore hardly correct to speak of a hair-changein man, who is constantlylosingsingle
But since a recognitionof the bed-hair necessitates a kind
hairs and gettingnew
ones.
of hair-change,and even
a change in the type of hair, in the human
subject,and
more,
hairas
this,actingbackwards, will lead us to a clear understanding of the periodical
maintain
the
shall
of
in
in
occurrence
a hair-change
man.
animals, we
change
The hair-change consists in the separationof the papillaryhair from
the papilla
and its ascent in the follicle,
though only as far as its middle region. Here it remains,
and growing out from it as a bed-hair.
After
being firmlyunited with the prickle-layer,
less collapsedlower portion of the folindefinite period,it sends out into the more
licle,
or
an
into
the
from
which
a
more
corium,
epithelialprocess
adjacent
rarely,
or,
young
hair is developed. This grows out of the old follicle,
a young
by the side of the bed-hair
in many
The hairinstances, but usually after having loosened and pushed it out.
arrested in the bed-hair stage or even
change may be indefinitely
permanently. In the
adult, no young papillaryhairs are produced without preceding bed-hairs.
In Fig. 12, I have representeda complete hair-changein the rapidly-growing
lashes,
eyeA, B, O show the separationof the old papillaryhair from its papilla,and its
transformation
into a bed-hair,D, E, F, G, the sending out of an epithelial
process by
and
the latter,
the development of the young
cilia. In A we see the hair-root
papillary
alreadyseparatedfrom the papilla. The latter is surrounded
by indifferent cells directly
continuous
with the prickle-layer.It has retained its originalsize,but the hair-follicle
alreadypresents a narrowing at its lower extremity,the whole epithelial
cap of the hairoff from
the papilla. Preparationhas long before been made
root having been drawn
for
the removal
of this cap by the thinning of the matrix of the root-sheath
culae,
and the cutiwhich arise from the neck of the papilla. These
coveringsare therefore the first
to suspend their growth during the hair-change,and their cornified portionsare the first
to be lifted upwards ; they are next
followed
by the outer parts of the cortex, then the
inner.
The
of
the
hair-root
is
consequentlylifted from the papillain a direction
cap
neither

manner,

is not

"

root-sheath,cuticulae
papilla,

nor

42

AI^^ATOMT

the

reverse

word,

not

DEVELOPMENT.

of that in which

it grew around
it; it is liftedoff,in the
therefore the hollow cap must
revert
to its

pushed off,and

Fig.

AJSTD

A, B, C, loosening of the
productive epithelial process

old

by

12." Complete

papillary
the

hair-bed

hair
and

Hair-Change
and

its

in

the

development

of the

young

sense

of the

originalcondition

Eyelashes.
into

transformation

true

bed-hair;

of
D, E, F, O, formation
gland; n, layer

papillary hair; t, sebaceous

"

called

formerly

cells which

of

neutral,"

internal

the

between

in Fig. 7.
as
change; g I,p, m, h, iw, aw,
its papilla; e h, button-shaped
A, separation of an old hair from
internal
cylindricalcells of
root-sheath; hey, cleared
up
of

third, capable
B,

old

distinct;

deep staining.
growing upwards;

hair

papillary

spur-like

t,

prickle-cells

productive

the

has

which

which

size

in

sends

while

vascularization

E,

first rudiment
a,

small

the

towards

O,

young

hair;
passes

old

the

udder

bed-hair,

of

entirely

dark

graniilar

lessened

end

comified
cells

of

hair, still very

size; pi, pigment;

in

the

middle

the

of

of the

end

broom-shaped

h.

for the hair-

importance

no

i, almost

fclp, papilla

into

the

much

middle

fallen

and

thickened

vitreous

cp,

e,

t r, band

of

pigment

being

hair-follicle

bed-hair; ih,

follicle,into

bed-hair

produced
from

the

p,

penetration

body,

papiUa

of

root-sheath,

external

sack-like

m.embrane;

bed-hair; riw,

the

by

hair-bed

the

much

atrophied;

cord.

productive epithelial process;

connective

is reformed

young

cilia;bh,

by
old

which

tissue

meanwhile

at
h, primitive hair-cone, cornifled
the
hair-strand; dstr,
very

of the

bh,

the

of

region

out;

(eh, 12, B), not

long

the

into

portion

lower

membrane;

productive epithelial process;

new

which

of the

artery

cilia, still hidden

young

much

follicle contracted
out

third; dcy,

sharply separated
become
changed into
hair-follicle,

bulb

hair

being pushed downwards;

the papilla descends,
while

of which

elements

F,

of the

third

t r, lower

D, bed-hair,

old

region of the
compressed

middle

I, very

dg

the

into

the

place,

this

in

(hb) ; p i,pigment;

hair;

of the
lower

root-sheath;

reached
has
papillary hair, which
root-sheath; iica, inner root-sheath

the

of

internal

of the

remains

vitreous

dg e, thickened
ascending internal

the

end
the

root-sheath,

external

and

hair-folHcle.

collapsed

capillaries of the

C, transformation

of

end

43

DEVELOPMENT.

AND

ANATOMY

formed

its apex,
much

extending
bed-hair; hb,

loosened
becoming
by the pressure
the old bed-hair, growing
free
in the

of the

old

ing
increas-

thickening

and

in C.

h, p i,as

interior;

cells in its

swollen

showing

papilla

gp,

undergoing

hb,b

thickened

of

out

hair-strand,

the

epithelial process.

the

latter

is

hair-bed

young

still

sharply

more

-defined

cilia.

old follicle, which

contracts
it;
firmly around
cilia,after the shedding of
epithelium of this cavity
cavity left after the falhng out of the bed-hair, with a button-shaped end; hb, mural
the
hair
matrix
of the bed-hair), which, while
as
proliferating, gradually applies itself to the young
(the former
cilia.
of the middle
region of the follicle;i h, young
prickle-layer

young

ho,

Such

is the shape of the end of the hair immediately

papilla{eIt,A), and it is also more
transparent,
be easilydistinguished
the mass
ferent
indiffrom
of rounded
striated,and can
longitudinally
into
which
all
the
cells
cells
without
resolved.
distinction,
are,
epithelial
the cornified end of the root-sheath
which
has alreadyadvanced
At e i, we
tain
see
a cerIn
the prickle-layer,
the middle region of the follicle presents
distance upwards.
cylindricalcells,which stand close together and become
deeply stained {d c y), while
clearer and larger(Ji
seated upon
those of the lower follicalar region are
are
a
c y), and
as

button.
epithelial

solid rounded

been

after it has

from

loosened

very thick vitreous membrane.

In B the end of the hair
button

shape, the

all sides.

ascended

still

cells of the
proliferating

middle

spur-likeend

The

lower

of

follicular

the

root-sheath

region is much

higher in

the

follicular
has

has

and
follicle,

lost its

regionpassinginto it from

also ascended

the

same

distance

contains only a
collapsed,and now
of old epithelial
in
the papillaalreadymuch
diminished
column
cells,and at its bottom
in size. The wall of the follicle presents the following conditions : while the external
tracts
layershrinks into a cord below the ascending papilla,the middle layerconlongitudinal
the ascending end of the hair.
with the papillaaround
The vitreous membrane,
become
shortened with them, is in part much
cannot
which
thickened
elastically
{dg I,B),

upwards.

and

The

has

the

in

part thrown

In

C, the end

region just below

more

into folds.
of the hair has
the

sebaceous

alreadyreached the upper

glands. The broom-like

part of the middle

fibrillation has

follicular

still further

of the walls of the follicle stream

in stillgreaternumbers
prickle-cells
has mostly disappeared,
at i lu a entirely
at
the last spur-like
r * w
;
of the wall of the follicle lying a
extremity is stillvisible,and around it the prickle-cells
little higher up still pass into the led-liair. By this term, we
now
designate the
may
the
hair-bed
the
of
to
while
name
the
of
we
hair,
give
productive portion
prickle-layer
it grows.
the middle follicular region from which
The
hair-bed is prolonged downwards
Hair-bed.
into a short process of old epithelial
cells,which is stillindented by the remains of the old papilla,and is surrounded
by
the

increased, and
into it. The

root-sheath

"

44

AND

ANATOMY

DEVELOPMENT.

layer of the follicle has therefore become still

more
atrophy, and the external layer
papillahaving undergone extreme
into
tortuous
vessels run.
has shrunken
a long cord
(st r), in which very
of the hair also merits
medulla
The
specialconsideration in the hair-change. Its
the papilla. This
before the epithelial
even
growth ceases
cap has been strippedfrom
seems
perfectlynatural, since, as we have seen, an exceptionallygreat pressure from
in the
is essential to its growth; the first cessation of this pressure
downwards
above
hair
is
followed
the
arrest
of
the
of
of
the
of
the
tion
formaloosening
by
beginning
process
a

thick

vitreous membrane.

The

middle

shortened, the

of the medulla.

For

this reason,

the latter does

not

extend

as

far

the end

as

of the

(seeA). In this situation it is pushed upwards with the hair

At this point,however,
(seeB), until the latter has reached its permanent destination.
the old medullary cord is again arrested,only cortical cells being furnished
by the hairThus
bed.
a non-medullated
cylinderis formed, directlycontinuous with the old medulfound
the hairs pulled out at this stage of
clear root-end
on
lated one, the so-called
their growth.

hair after it is loosened

"

"

shaft of the bed-hair

non-medullated

The

It

representsin

the form

in the nail.

encountered

of

Just

has

no

cylindera varietyof
as

in that

case,

the

cuticle and

also lacks

cornification which

transformation

of the

root-sheath.
have

already
prickle into the
distinct prickles,
we

of cells with
brought about by the intervention of a zone
of keratohyalin.
In D we see a thick young
and capable of
proliferating
process extending downwards
small
This is alreadyindented
being deeply stained.
papilla. The old connectiveby a
and
which
it sits is much
thickened
tissue cord upon
provided with largevessels,which
formation
of pigment. This finds its way into the epithelial
lead to an abundant
process,
into the bed-hair itself.
Unlike
the pigment of the papillary
the hair-bed, and finally
wander
hair, it forms thick lumps and columns, which
upwards in the epitheliumwith

hair-cells is
but

destitute

of fluid.

the current

and is stillmore
stillfurther downwards
epithelial
process has grown
most
indented
by the much
enlargedpapilla,which has alreadybeen pushed downwards, alcells
to the bottom
of the old follicle. Upon the papilla,
the neighboring epithelial
into a cone
have formed
themselves
is already of a horn-like transparency.
the apex of which
As yet, there is no separationinto shaft and root-sheath,and in the centre
of
At a we
the cone
of Avhich is still obscure.
t.hereis a peculiarcavity,the signification
much-distended
old cord.
The young
see
a large artery enteringthe
epithelial
process
E
is
in D and
no
longer bounded
by a vitreous membrane, but comes
directlyin contact
the young

In E

with

middle

the
In

i^

still covered
direction.

cells,which

small

by

sheath
mature

of the follicle.

This,
alreadydeveloped from the primitivehair-cone.
in
lateral
of
the
bed-hair
the
side
a
by
grown
up
entirelysurrounded
by a layerof very regularlycubical
stained
more
deeply
by carmin than the surrounding

cilia has

the root-sheath,has

The

cilia is
young
become
somewhat

pricklelayer.
0 shows

the end

of the

whole

Here the young

cilia has not only loosened
process.
pushed it out of the folicle. The new
papillaryhair passes freely
In a
in size.
through the cavitythus produced, which has already much diminished
of
short time, this cavitywill have also disappeared,in consequence
of the proliferation
which appliesitself closelyto the constantlythickeningnew
the prickle-layer
hair.
these stages of the hair-change,it will be seen
If we cast a glance over
that C and D
be
confounded
with
each
other.
It
asked
well
be
how, and in fact
might easily
may

the

bed-hair, but

45

DEVELOPMENT.

AND

ANATOMY

a
always distinguishan old retractingepithelial
process from
young
this
As
to
matter
of fact,
be
a
ought
proliferating
Theoreticallyspeaking,
easy.
however, the distinction between them is not always so readily made as in the preparations
There
is one
taken.
from which
absolutelyreliable criterion,
figuresC and D were
of the smallness
however, which it is unfortunatelyhard to avail ourselves of, on account
of the cells in question;viz.,in the young
epithelialprocess signs of division of cells

whether,

one

can

one.

in the old one.

In the
is not the case
treatment, which
proper
in animals),
old process is never
wholly drawn in (as is common
of the papillavery seldom
disappear entirely. The formation of the

visible under

be

must

subject,the

human

the remains

and

of the old one

therefore be regarded as an evidence that the remains
young
process must
cells of the latter again produce young
have become
productive. The cylindrical
lial
epitheprocess, therefore,increases in length and breadth, and
it like a cap.
tissue by growing around
connective
resisting

cells,and the whole

of the

papillaout
Much

discussion

has

carried

been

also

the

on

as

to whether

the

forms

hair grows

young

upon

call the

one.
prefer
enlarged papilla a new
papillaor upon
one,
the importance which
because, I do not attach to this new-formation
although, or even
is usuallyascribed to it,writers not yet having freed themselves
from the notion of an
is reallynothing more
than
independent growth of the papilla. The new-formation
a
epithelium of a portion of the
passive marking-out or isolation by the formative
corium, and it can, therefore,just as well take place upon an old papillalessened in size,
a

new

as

basis,as without

old

to

one.

in all

epithelialprocess always find

parts of the body, however, does the young
here in the case
and dilate the lower portion of the old sheath of the follicle,
of the
as
it often happens on the hairs of the beard that the young
ciliae. Thus
makes
an
process
for
of
the
old
follicle
become
a
fter
the
end
has
in
the
itself,
independent path
occluded;
the other hand, the reopening of the old follicle is the rule (as
on
very straightfollicles,
in the ciliaeand vibrissge).In the ciliae,
the growing hair-bed often sends out
moreover,
the
horizontal
into
the starting-points
become
of
corium, which may
epithelialcones
obliquehairs (trichiasis,
distichiasis).
Not

Growth

of the Bed-hair.

The greatest interest is,of course,

has thus far encountered
of the bed-hair, which

growth

pendent

following facts.
shaft

of the

same

kind

In the

bed-hair

is first made

addition
follicle.

long

As

transparent, I

hair

at

ascending
direct

no

direct

just

nail-cells

to the

find

place, the

be followed

the

the

as

can

first

can

of cells into

associated

"

the

on

the

as

thin

of the

at which

is still in

transformation

of the

of

sections
For

this

it enters

the

middle

cells.

with

the

continued

It is based

the

transformation
I believe

reason

be very

can

the

of
that

the
the
real

productive region of the

prickle-cells which

This

mde-

upon

prickle-cellsinto

the

as

nail.

contact

with

doubt.

transfoi-mation

easilyon

matrix

point

hair

gradual

much

have

become
in the

distinctlyseen

vibrissse.
In the

second

of the

view

In the
of the

absence
third

hair-bed

represented a
In
which

matter,
of

place, granular pigment

epithelial
process
But as
of lymph.

the

the

fourth

medullary
In the

hair

loosened

of

being absent

place, the number

the vessels
and

of the

connective-tissue
been

have

must

carried

cord

by the

into
rent
cur-

have

become

the

hair-cells

This

would

be

of the

impossible

bed-hair.

with

carry

if the

them

bed-hair

portion

simply

its matrix.
constructs

of the
hairs

can

pulled out, they always

are

transition.

from

hair-bed

to that

from
it

higher in the hair-bed, the prickle-cellsof the follicle must, in

bed-hairs

zone

non-meduUated

matter

fifth

the

entire

place,the

still

far

lymph-channels,

the

be likened

travels

hair-bed; thus

it ascends

place, when

dead

the

the

of further

and

cannot

and

and

are

hair-shaft

papillary hair.
not

The

of

papillaryhairs.

in very

limited

of the

bed-hairs

its

of

own

much

simpler pattern,

papillary hair always forms

This

does

not

exclude

the

medullary

possibility

portions of the papillary hair.

is

so

large in

many

parts that it is impossibleto

46

regard them
where

all

much

the

among

hundred

cilise of young

persons

old person,

the

on

wishes

one

their

have

that

to obtain

does

quickly

by

of course,

the

view

that

Entirely without
familiar

nail.

prickles, in order
all sides

over

the

middle
and

in the
He

the

to

loss

end

undergo

scalp
found

part consisted

of all the

In

this

at

of

ciliae

the
in

an

to insert

all the fingers

are
only bed-hairs

papillary hairs, which

bed-hairs

almost

are

topographical differences

constant

and
on

of this character.

were

the

as

I found

bed-hairs, and

almost

way

hundred

one

applicable.

tained,
ob-

never

be

cannot

conciled
re-

are

fusion

horny

of

papillary hair

other

any

source

different

skin, and

the

as

especially

This

origin.

phenomena

only

is

may

cornification,just

in the

of

masses

entirely analogous

as

ascending

from

mutual

substance

of

the

no

button-like

of the

case

believes

fact that

he

that

has long
obreadily be served

may

still uncornified

become

attached

by

prickle-layer grows

of

mass

of the

means

together from

cornification.

undergoes

whatever

arrectors

and

the

on

the

of

of

to

these

vertical

the arrector

I have

ascribed

notion

of the

follicle of the

adult,

and

so

the

great

often

be made

the

view

of

middle

out

nose,

be

never

to the

importance

an

that, in

reason

of

latter could

productivity of the
can

tached.
piliis atentirely overlooks

hairs, e. g., those

larger, and

only for the

hairs

vivid

the
much

are

arrector.

an

embryonic

of their follicles,
they give us
of the firmer
which, in the case

matter

attached

are

traction

swellings

the very spot to which

by this simple statement,

swellings,to

settled

has

spindle-shaped dilatations

by the one-sided
nature

the

of

epithelium

bed-hairs

simply cast-off papillaryhairs.

the other
hand, is the difficultyoften encountered,

on

the

Mahly

Schulin
has justly remarked
that the diverticula
from
objection refers to the hair-bed.
the first to describe, correspond to the reI was
gion,
region of the foetal hair-follicle,which

Another
the

The

which

to
prickle-cells,

fifth

chin, however,

other

practicalphysicians,

to

the

firmly implanted

so

the

and

that, on

found.

and he, therefore, estimated

(bulb-hairs),
of the

everywhere

traction.

means

fact

are

bed-hairs, it is necessary

of

Under

bed-hairs

foundation,

matter

the

on

no

These

the

or

moderate

very

be

three-fourths

large number

only

to

me

fourth
than

moi-e

five bed-hairs

thirty days, and

at

of the

bed-hairs

many

eyelid thirty papillaryhairs, fifteen transitional

and

to

the

so

near

upper

seem

about

by histologists,of comprehending
a

not

by the first method.

with

been

one

hundred

restraining apparatus.

own

even

on

one

hand, that

are,

shed, not

are

papillaryhairs

only

to exert

they

as

of

which

other

beard, and

pulled out,

of the

DEVELOPMENT.

just fallen out, particularlyin view

fiftyhairs

number

conclusion

have

of hairs

and

age

average

days,'

into the

that

the eriormous

the
five

hairs

as

larger number

one

forms, and

If

AND

ANATOMY

the

though
alplained
ex-

verticula
di-

yielding

follicular

gion,
re-

only by its greater

capacity for being stained.

Change in Type. Explanation of it. The entire hair-change,

and the
change in type, both types being connected with one
the other, there must
be a
of the hairs loosens and displaces
follicle. But as one
same
from
which
certain oppositionand competition between
the two
areas
they spring,and
exist
and
find
in
fact
the
this we
to
between
the- middle
papillaryregion of the follicle.
rections
all dithe papillaand presses from
It is primarily mechanical
; the hair-cone arises from
of the follicle,
therefore usuallyremains
which
againstthe prickle-layer
ductive.
unproin the foetus),
It must, however, where
it is possiblefor it to do so (especially
the
exert a centripetalpressure
distend the follicle externally,and
in all cases
upon
in
of
its
interior.
As
we
on
the
nutrition,
looking at
sources
see,
hair-cylinder
regards
is
represented by very fine
Fig. 1, that the subsequent subpapillaryvascular network
and by much
horizontal branches
which
largerparallel
run
Just beneath the epithelium,
The

Hair-Ghange

in

therefore,consists

branches, situated

little lower

of
exactlyin the zone
well supplied,until
so

placedunder
The

largeand
unite

"

middle

the

papillawhich

circumstances
small
to

more

horizontal

form

the

Mahly,

surround

down, which

the

follicular

indents

the

this

point,the
its

bed-hairs,

follicle is not

shows

epithelial
process

to

subpapillarynetwork,
quoted

the three follicles with

Below

that

it is

capillary
loop.
nutrition,by having
quently
subsestill
this
which
at
separated,
point are

favorable
branches

region.

in Virchow-Hirsch's

which

sends

down

Jahresbericht.

own

small

vascular

48

ANATt)MT

In the first

place, it

recognized by Pincus(t.

was

DEVELOPMENT.

singular fact that

the groups

e..

AND

of from

individual

the

to five

three

occupants of the hair-circles first

hairs,separated by large free interspaces),

not
but
also vary
greatly as regards their
only in different stages of development,
is determined
from
length, and longevity. The difference in the stages of development

thickness,

are

by the different periods

on

and
or

the

basis of the

descend, differ

The

diffei'ence

in dimensions

is

ning
begin-

readily explicable

at different
theory of the change in type, that the hair-germs which
periods ascend
and more
more
widely from each other; that the hairs, according to either local
to varying distances
the hair-bed, that they again reach
the bottom
on
other
varying degrees of completeness, that they send out in one
place thick, in an-

follicle with

produce thick or thin hairs, according as they are

epithelial processes, which
or
by broad papillae,in one plac3 rapidly displacing the bed-hair, in another

thin
narrow

quietly out of the follicle beside

and

of the

the

which

forms,

states that

"

the

on

of

entire

(his

hair

"

term

life,the

must

exert

and

occur,

altered

root-end"

of life to which
outfall
cent

-seven

corresponds
the

of the

seventy
per
of the entire length of the hair, and (in view

hair

smaller

five times

or

outfall the

normal

than

root-ends

upon

more

the

the

exactly to our bed-hair stage). He

predestined, the longer is the root-

hair, the altered

of all those
of

was

the

that

much

slower

are

thicker, and

at

the

off, or,

growth
thickness

same

but

few

time

same

in

other

of

the

bed-hair

by the

proportion given above, and

of which

root-piece is one-third

cast

are

greater proportion of the length of lifeof the hair is occupied

not thinner, but of the
the root-ends
are
of the hairs in which
is four

growing

ally,
especiactivity of these cesses
pronecessarily bring about a great variety of
influence

an

thus

must

constitution, and

temporary

Directly applicable to the theory

type only in old age.
the investigations of Pincus
of the varying condition
of the lower

in the normal

in

of

indented

uniform

scalp are

longer the

the

time

corium,

they

by

hair

the

finds that

He

piece."
of the

succeeded

hair-change

of the root

which

at

period
are

The

it.

of the

pathologicalprocesses

end

they arise.

general influences, retire

of the

by

which

at

the

as

darker.

length
third

bed-hair), a

stage.

hairs

the

words,
The

the rest of the

be found

can

Here

we

still

number

shaft,
in the

encounter

also
whether
not papillaryhairs
or
are
great gap in our knowledge, since we do not as yet know
the result arrived at
can
Only after this has been determined
pulled out during ordinary combing.
become
diseases of the hair, the relation between
perhaps of great value, viz., that in acute
by Pincus

before
hairs

and

thin

the

the thick

which,

to those

Pincus

root-ends
when

even

reversed.

is almost

the

hair

is

short

worn

The

(four

pointed hairs," applied by

inches) fall out from the scalp
"

term

or

five

therefore
the same
have
the scissors reach them, and which
significance in men
who
their hair long, is of course
wear
(under six inches) in the outfall of women
with
this limitation, it has
with
But even
useful
us
one.
already furnished

According

Pincus, at

to

conditions, under

normal

most

six inches

in

fourth

part of the

length, and

existence

of the

in

that

outfall
of

of
at

men,

the

hair

most

in

the
an

average

short
trary
arbimates.
esti-

is, under

women

fourth

as

only

or

fifth

part

the
pointed hairs," particularlyof those from
pointed
that the boundaries
between
the typically long and the cally
borders
of the hair of the scalp, shows
typinot
short hairs are
fixed, and
changed during the normal
always become
hair-change, A

consists

of

hairs."

"

hypersemia

of the

which
hairs

after

papillary circulation
the

over

time

by the young

The

others, and

thus

"

may*suddenly give the

a general change

induce

middle
in

follicular

type from

region a great preponderance

papillaiy to bed-hairs,

itself as a universal
manifests
defiuvium, i. e., a general expulsion of the
after-growth of papillary-hairs (defiuvium of convalescence).

that in the future

bed-

pleted
aspects of the subjectmay be comwhich
can
change,
always be
by a more
I reproduce in Fig. 13 a few of the principal
For this purpose
studied on the root-end.
i. represents a
types of torn-out hairs. Fig. 13 A exhibits two perfectlyregular ones.
of transition, the hair-bed which
the zone
bed-hair from the beard ; we
was
see
partially
the
of the epithelial
extracted also,and the remains
we
see
Higher
up
like
spurprocess.
cavities into which
the ends of the root-sheath
were
inserted,and, finally,
high up
the shaft the beginning of the old medullated
on
papillaryhair, the shaft being distinctly
from
the surface,its
the scalp,seen
from
broader at this point, ii. shows a bed-hair
end looking not unlike a pine-cone; the shaft is perfectlyclear,and (a proof that it is
in it. I shall call the roots of
whatever
old bed-hair)there is no medullary matter
an
the bed-hairs (as in 13 i. and
ii.)full roots, and those of the papillaryhairs hollow

We

can

only hope
exact

the clinical

classification of the

stageof the hair

medulla, which
seated ; next, in direct contact with
and then the everted edges of the cells of the cuticle,see*ti from

papillawas
higher up ;

air

place,the depressionin

it,the

the

which

see, in the first

we
(13iii.)

root

the hollow

On

(13 HI.)-

roots

49

DEVELOPMENT.

AND

ANATOMY

tains
con-

the

surface.
In 13 B
which
sheath

end

The

to it.

attached

represented,i.

are

shows

from

hair

the

head

of the outfall,and, therefore,has the loosened rootof the hair has become
clear,and is provided with an

in the

out

torn

was

irregularforms
beginning

and

rare

.-d^
"

-Ihatf

"he

h'^rtJJJ

i"eh.

13 A.

Fig.

Fig.
Hairs."

Extracted
Fig.

13 A"i.

III.

13 B

"

of the
from

beard

The

middle

B,

rare

and

irregular

13 B.

forms.

in focus.

surface

II.

Fig.

Bed-hair
Bed-hair

of such

^, types

i.

Papillary-hair
Hair
thin

the

from

ascended

head.

from

the

head

which

the

for

cap

the

m,

head

papilla

end

in focus.

Surface

of the

;
has

hu,

h, everted

fallen

out

of the

edges
; e

h, cleared

Huxley's

portion
medulla, containing air

cells of the
up

and

; /i.e, Henle's
and

showing

cuticle

narrowed

portion
a

of the
end

of

vesicular

of
the

hair
the

seen

from

the

surface.

hair, still covered

inner

dilatation

root-sheath
;

I,bubbles

with

which

has

of air in the

cortex.
II.

Hair
e

III.

m,

Hair
centre

extracted
as

in B

the

with

root

of the

the

external

root-sheath

w,

so-called

external

; i w,

so-called

internal

root-sheath

h, everted

cuticle

i.
of
hair

which
in

has

focus)

been

torn

; ni, young

in part left
off, and
medulla, containing no

behind

in the

follicle

(the

air.

atrophic cap for the papilla. The medulla

begins with a vesicle-like dilatation of its
end (em), probably produced during extraction.
We
distinguishthe two layerson the
has
outer
the
which
of
advanced
root-sheath,
higher up on the hair (h e)than the inner

50

ANATOMY

{Jiu).

The

contains

cortex

still covered

oblong

with

represents an

III.

papilla; this shows

cuticle is here
best method
of

end

extracted

the

of air,

epithelium
of the

hollow

was

drawn

examinations

ii.

has

portion

shows

is

root, which

is

ceptionally
ex-

{aw) ; (this is doubtless

undergone a vesicle-like dilatation.
of

axis

the

hollow

follicle

which

end, traversed

while

of roots

the

of

medulla

root,

irregular,tooth-like

everted, and

for these

DEVELOPMENT.

bubbles

the

pathological); here, also,the

B

AND

by

has
the

of the

cleaning them

remained

medullary

hair
with

up

in

was

the

upon

canal.
focus.

commercial

The
The

ide
perox-

hydrogen.

New-Formation

in the Adult.
The disputed questionas to whether
of Hair-follicles
still developed in the adult is by no
are
means
yet settled.
in favor of this origin of new
Gotte and Hosse have pronounced themselves
hairs from
the surface
after
the
foetal
No
of
as
a starting-point,
positiveproof
this,by a
pattern.
continuous
developmental chain, has, however, as yet been brought forward for any part
licular
folof the body, and when
reflect that in the hairy surfaces of the adult the middle
we
conditions
region is everywhere the favored point from which under normal
many
into the corium
into the old follicle,
sent downwards
are
or
laterally
processes
; this part
the general surface plays in
of the prickle-layer
the role which
to have undertaken
seems
the embryo.
This view is also supported by the insular arrangement of the hairs of the
stand
closest together,which
head which
still obtains.
When
the secondary hairs, from
around
the primary embryonic hair, a
two to four in number, have arranged themselves
circle of hair is formed
from them
during the growth of the skin which is separatedfrom
the nearest
of a circle of hair are very close
circle by a wide interspace. If the members
follicles
the
the
become
funnels pf
partiallyunited, so that several hairs
together,
may
out

come

may

"

hair-follicles

entirelynew

whether

of

one

descendants

together about
them, owing
the

largeopening. We possess, however,

were
implanted independently near

of

hair.

one

the sebaceous
to the

sebaceous

fact

that

gland.

The

former

glands, the
seen

such

which

certain

descendants

are

hair-follicles

junction
they

alone

of ascertaining

means

other, or

each
if the

case

latter,if the

the hair-bed, from

I have

is the

certain

these hairs

has
are

bryonic
post-emare

fused

taken

place below
low
developed,lies be-

of hairs

several times

in

the beard

and four times in the eyelashes.

to
be referred
The different varieties of the fall of the hair can
of the Hair.
of two principalforms.
The first consists in the gradual atrophy of the newly-sentone
out epithelial
(thiswe have already considered)which are the less able to penetrate
processes
becomes
with advancing age. Such
into the collapsedfollicle the denser
the corium
succeeded
which
are
respondingly
by corpapillaryhairs seated superficially,
processes produce thin
Fall

"

thin bed-hairs.
The frequent repetitionof this process leads to a condition
the lanugo form, and
finally
majority or all of the bed-hairs have assumed
the senile
remain
permanently in the bed-hair stage. The other form appears when
filled
changes of the skin no longer permit the follicles to collapse; they then become
In the
returned
with epithelialdetritus,before
the hairs have
to the lanugo form.
places from which the corium has disappearedalong the hairs,one can always still recognize
the external
the cords passing verticallythrough them, which
originallyformed
in which

sheath

the

of hairs.

Sebaceous
kinds

"

Under
the

the

secretion

name

of sebaceous

of which

glands

The

are

comprised
in

is consistent,fatty,and

glands
consists of
principalportion of them
develop in the prickle-layerof the hair-follicles.

in cells.
which

Glands.

of acinous

the

But

sebaceous
with

different

part still

glands

them

are

closed
in-

proper,

usually

and

AjStatomy

classed different kinds

which

well be made

may

Meibomian
the

Lips.

the

Glands.

The

"

most

and

glandsentirelyindependent of
in this place.

to

are

their

the

between

the

indentations
the

acini

bearing

praeputii,which

from

the

the

embedded

epidermis

Free

Border

in the
which

skin

unites

of
of
the

all three layers of the epidermis,

form
of long ducts lined with
cubical
epithelium. The secretion of these
perpendicular rounded
and epidermis. In this class the few Tysonian glands of the
matter

consists
of the

glans and prepuce

(Kollicker). Next

sebaceous

under

develop

are

of

into the tarsus, in the

grow

provided with

smegma

They

and

Minora

glands, which

Meibomian

free borders.

of sebaceous
glands is a mixture
also belong,
glans penis and prepuce
the

large

the hairs,a brief enumeration

of the Labia

Glands

Glands.

Tysonian

important

eyelids vertically

lids,and

of

51

development.

the term

to

sebaceous

glands

formerly erroneously ascribed

w^as

entirelyof horny layer, while

also

which
clitoris,
the

come

glands of the free borders

"

which

almost

large sebaceous

of the

of the

the

the

production

of

epithelialdepression

has no similar glandular

produces smegma,
glands of the labia minora, and, finally,

lips(Kolliker). All these glands might be comprised

orifices."

mucous

Trite Sebaceous
Glands.
The true sebaceous glands are, however, those which
are
Such
if they afterwards lose this connection.
embryologicallyconnected with hairs,even
the sebaceous glands of the inner sides of the labia majora, the largeones
of the nose
are
and the external ear, those of the nippleand areola in man,
and the caruncula lachrymalis,
which belongs to the skin (Waldeyer).
The true sebaceous glands are very earlydeveloped in the prickle-layer
of the embryonic
hair as small lateral swellings,
which are always seated above the dilatation of the
middle follicular region and which first project on the side of the obtuse angle of the
"

hair.

Even

before

the first indication

fattydegenerationof the cells in the centre

of

an

axial hair-cone

of the

swellingsfrom

is present, there
which

occurs

the sebaceous

glands
developed (Schulin). On stainingwith picro-carmin the contents of the sebaceous
turn yellow,and they can, therefore, never
glands at once
mens
escape recognitionin specithus treated.
The
sebaceous gland graduallyattains its definitive size by the enlargement
of the primary swelling,its budding, and the formation
at the
of similar ones
level of the hair-follicle. It always forms the boundary between
same
the funnel
of the
w
hich
is
from
filled
with
to
normal
and
the
middle
two
six of
follicle,
epidermis,
region,
them being attached to each hair.
structure
The minute
of the sebaceous glands is the
simplest imaginable. Upon a very thin membrana
propria there is seated a cubical
of layers,often only one, which
of
the centre
towards
epitheliumin a varying number
each acinus undergoes slow fattjdegeneration,only the periphery of each cell escaping.
In this way is produced a secretion of epidermic cells containingfat, the membranes
of
which graduallyrupture,their contents
in
being partially
expelled the form of small and
tom
largedrops of fat. This secretion passes through the short excretory duct into the botof the funnel of the follicle,
that the hair passingthrough it is well lubricated.
so
This is the true function of the sebaceous
the
glands, which might better be called
glands of the hair-follicles.
The fattydegenerationinside the gland frequentlytakes placeunsymmetrically,extending
side as far down
the basal cells upon
on
the membrana
one
ways
as
propria. This althe side nearest the largeblood-vessels,which
occurs
on
is usuallythe lower
one.
In consequence
of this the glands of the hair-follicles,
when
well stained, assume
a
On the nose, the nipple of the male, and the other
peculiarunsymmetrical appearance.
points alreadymentioned, the sebaceous
glands attain considerable dimensions
(being
sometimes
much
two mm.
in diameter) and then they sometimes
as
as
have even
as
many
as
twenty acini ("W.Krause). It may be stated that the tissue changes and chemical
memprocesses in the sebaceous glands,next to those of the small glands of the mucous
are

'^

'*

52

Alf ATOMY

branes, are

AND

DEVELOPMENT.

the

simplestand least active of all known

glands. They consist solelyin the
cells.
fattydegenerationof ordinaryepidermic epithelial
Coil-Glands.^
the corium.
of glands which
Development. By far the largestmass
tissue or emcontains, is found in the shape of globularor oval coils in the subcutaneous
bedded
in the deepestlayer of the corium
in
make
their
the
They
proper.
appearance
fifth festal month, first on the palms of the hands
and soles of the feet,in the form
of
and
in
conical
into
the
close
a
epithelial
standing very
together
growing
shape
processes
Their situation relative to the ridgesof the first-formed papillarylayeris a very
corium.
definite one.
We have alreadyseen
that at first elevated ridges of connective tissue are
separated from each other at regular intervals by epithelialprocesses, and that the
papillaeare developed upon the tops of the ridges,the epitheliumhere also penetrating
each
downwards.
Between
which
have thus been separated from
two
of papillae
rows
in
the
the
and
at
stillfurther
other,
epidermisnow
tolerablyregularintervals,
penetrates
of
of
the sixth month
which traverse the entire thickness
forms
course
long thin cones
the corium, and assume
extremities.
Just above
bulbous shape at their lower
a slightly
this blind end
there is suddenly developed in the seventh
month, the first trace of a
lumen
which
which
after
extends
towards
the
an
reaching
opening is
epidermis,
rapidly
"

formed

(from within outwards),the siueat-pore. At

developed,the

cuticula

also

makes

the

same

rate

at which

this lumen

is

At this time the lower

its appearances.
and
oped
develhooked
the coil is now
shape,

subsequent
gland has usuallyalreadyassumed a
the gland meanwhile
trast
steadilyincreasingin size. In conby an irregularrolling-up,
the development of the coil-glands
the
to the glands of the hair-follicles,
has, near
it does not afterwards
end of foetal life,reached a point beyond which
go.
Another
step in the development of the coil-glands,
Large and Small Coil- Glands.
which, however, still goes on after birth,is their continued growth in certain partsof the
body to largervarieties which present important structural differences from the ordinary
in the axillae and folds of the groins,around
the
small glands. These largeones
occur
In the axilla,
and in the areola of the nipples,and in the external auditorycanal.
anus
scattered through the layersof the skin, the large
largeand small glands are irregularly
confined
to
the
ones
hairy portions. In the groin,the small glands are seated
being
the
cellular tissue.
superficially, largeones deep down in the subcutaneous
The
circumanal
(Q-ay).On the
glands form a singlerow, li to 1^ cm. from the anus
areola also,which
contains only largeglands,they form a closed circle near
its
mammary
lie in the
secrete the cerumen,
of the auditorycanal, which
outer edge. The
coil-glands
faces.
portionas an almost continuous layer,mainly on the upper and under surcartilaginous
these
in
of
also
ties
varieclassified
with
the
Moll
the
be
must
Finally,
eyelids
glands
convoluted
tubes without
of coil-glands.They are
coils,lined
reallyonly broad
with largecylindrical
epithelialcells,and provided with strong muscles, which empty
with diminished
calibre into the follicles of the cilias. Waldeyer has demonstrated
transitional forms
between
these
modified
coil-glands and the ordinary variety,in
the caruncula
lachrymalis.
the smaller glands present tolerably
Histologically,
Histologyof the Small Glands.
The
coil
cubical
bears
uniform
a simple
epitheliumwhich is cloudy in its
appearances.
the centre
of the canal
external portion,where it shows
striation radiating towards
a
(Ranvier). Internallyit is provided with a clear border, which, according to the same

end

of the

"

"

"

"

'The

author

(sweat-gland).
is always meant.

substitutes
Where

the

the

name

former, which

(Translator'snote.)

"

Knaueldriise
I have

"

for

translated

the
"

familiar

term

"

coil-gland,"is used,

Schweissdruse
the

"

sweat-gland

AND

ANATOMY

53

DEVELOPMENT.

be thrown

ofE,and in fact viscid,clear protoplasmicdebris is found in the

glands. Upon these secretingcells are seated, externally,muscular
the canal.
I find (agreeing
around
fibres which run
with Sapparallelwith or spirally
and
but
in
to
and
W.
Ranvier,
opposition Leydig
Krause)
pey, Heynold, Horschelmann,
fibres are
in direct contact
with
the epithelium,and
that they both
that the muscular
of connective
tissue,a so-called memby a distinct membrane
togetherare surrounded
brana
of the palm of the hand, shows
the
propria. Fig. 14, taken from the coil-glands
fibres in cross-section passing in between
the epithelial
muscular
cells,and in an oblique
to the canal at certain distances
from
another.
section running parallel
This very
one
canal
that
the
the
the
also
of
before
it
into
shows, however,
coil,just
figure
excretory
passes
bears not a cylindrical,
but a cubical epithelium,arranged in layers.
duct, sometimes
not completely cemented
The cells are, moreover,
together,the cavityof the canal penetrating
in many
between
them
places,as far as the membrana
propria. According to
cells are formed
from the ectoderm, an
inner layerof epithelial
Eanvier, the muscular
into the secretingglandularcells,an outer into muscle cells.
cells being transformed
observer,may
secretion

Fig.

14."

section; Im,

of the

Cross-section
muscle

in

through

the

point

longitudinal section;

at which
e,

the

epithelium

coil passes
of the

into

coil; n,

the
nerves

duct

of

of the

coil-gland.

q m,

coil;/, fat-cells:

muscle

in cross-

pi, pigment.

pavement epithelium,arranged in two

discovered
by Heynold. Outside of
this epithelium is a thick layerof connective, tissue,v/hich borders on it by a membrana
fibres. The
propriaand has no muscular
epithelium of the coil has a clear border,
which
is not always blackened
whereas
the epithelium liningthe duct has a
by osmium,
border
which is always stained by it,probably in consequence
of its imbibition
of the
excreted fats and fattyacids.
The
duct runs
less spirally
more
or
through the corium, and loses,at its junction
with the epithelium of the surface, its connective-tissue
sheath
externallyand its cutithat for a short distance in the prickle-layer
the stronglyconcular border internally,
so
voluted
lumen
But
is surrounded
immediately beyond
only by ordinaryprickle-cells.
its lumen, much
earlier
this part of the duct, well-developedgranular cells draw near
in other portionsof the prickle-layer;
than
then basal, next
superbasalhorny cells,etc.
(seeFig. 3), so that one may say that all the layersof the epidermis sink down, in the
shape of a funnel, into those next below them, to form the wall of the canal. At the
point at which the wall of the canal is composed of basal horny cells,it shows a decided
The

rows,

duct is

the inner

composed

of which

of

ordinary cubical

an

bears

cuticle which

was

slit-like contraction.

Stueat-pore.It
"

terminates

in the

follows from

basal

the relation

and
prickle-layer,

of

that

epidermisthat it really
corkscrew-like
spiralcanal in the

the duct
the

to the

54

ANxXTOMY

epidermis which
also

to be

DEVELOPMENT.

its direct

continuation, does not belong to it alone, but

juice-spacesof the epidermis which surround
it.
It is,therefore,
sharplydistinguishthis portion of the canal under
the old name,
sweat-pore,
rest of the duct of the coil-gland,
in view of the fact that the fluids which
pass

the

to

AND

proper to
from the

seems

open

in them

upwards

not identical.

are

sweat-pore, but

have

we

The

makes

sweat

maintain

rightto

no

that

and

eventuallyfrom the coil. This is

misleading name,
sweat-glands,and have
coil-glands{3feissner).
The
Histologyof the Large Coil- Glands.

it

also the

the

its appearance
from
the

comes

why

reason

reintroduced

the

we

externallyat the
tirely)
(at least enhave wholly ignored
duct

older

and

better

term,

large glands are distinguishedfrom the

and
length, mainly by the fact that
As a rule,the widened
they presentirregulardilatations and constrictions.
portionswith
lined with one
a largelumen
are
layerof cylindrical
epithelium and also have bundles of
if they already constitute
muscular
fibres externally,
even
is often
a part of the duct, as
in the axillary
the case
them
glands ; the narrower
are
parts of the duct between
again
lined by several layersof pavement epithelium without
muscles.
The duct and
the coil
in the largecoil-gland,
therefore,cannot morphologically(nor,perhaps, physiologically)
be so simply separatedfrom each other as in the small glands.
"

small

aside

ones,

of the Coil-Glands.

Secretion
cellular

debris

with

from

of the

links
shows

and

in

trunk

the

to

that

the

mammary

presence

lubrication,
the

other

simple watery

ones

on

the

these
fluid is

The

two

regions.
with

In man,
the

as

also

are

coil-glands of the human

around

in

the

of

the

have

in the

higher

the

of the

development
which

sense

surface

the

over

of contact

br(^adest

mit,
ad-

like

etc., appear
over

preference

the

to the surfaces

To

must

we

est
skin, froni the smallanus,

coil-glands

animal, the

of contact

the

ment.
pig-

with.

met

and

entirely unwarranted,

distribution

surfaces

extremes

soles, those

palms and

development.

is associated

in it.

sor,
exten-

joint*,
of

most

this
quire
re-

of fat in all the coil-glands,and its conrecognize the periodical presence

stant
the body
has most
in the larger ones,
need
of
and, finally,during foetal life,when

we

hand,

Function

also

; we

find the
no

of

Meissner,

the

body.

That

it

same

would

one

that

the

of

anal

and

glandular apparatus
lubrication

as

between

aspects of the trunk and the extremities

larger collections of coil-glands are confined

the

that

coils

in part of albuminoid,
cid
visgranules. In the small glands

composed

pigment

flexor

the

and

intermediate

larger

chain

complete

coils is

also

standpoint, that the different

anatomical

an

the

of the

much
except in old age, when
pigment is also found
clear, but is usually darker, containing fat and

transparent,

mixtures

great many

regard the secretion

on

Tlie secretion

large glands is often

of the

secretion

"

nuclei, containing drops of fat and

always clear and

it is almost
The

their often great thickness

from

the

apparatus at the highest point of its development

seriously speak of the sweating of the foetus.

Coil-Glanas.

whole

is,on

"

We

must

return

to

the

view

is destined
apparatus of the coil-glands
the whole, better adapted to this purpose

hair-follicles is clear from

the

standpoint of anatomy

and

advocated

solelyfor
than

the

according to the

activity. On

in

1856 by
oilingof
glands of the

the

older

Krause,

more) coil-glands
there are
more
tact).
tolerablyuniformly distributed over the body (with a preferencefor the surfaces of conOn the other hand
(accordingto W. Krause), there are only about one hundred
crowded
hair-follicles with sebaceous
are
thousand
glands, of which about eightythousand
togetherupon the hairyscalpalone. Finally,no sebaceous glands are found on the palms of
without
certainlyrequirelubrication and are never
the hands and soles of the feet, which
it. The secretion of the sebaceous
glands,the greaterpart of which is still inclosed in
of the hair-follicle,
cells,is depositeddirectlyupon the cornified surface of the funnel
is placed at the disposalof the lower layersof the
whereas the secretion of the coil-glands
warrant
for ascribinga lubrication of the surface to the
epidermis. There is much more
than

two

million

(accordingto

recent

estimates

still

56

ANATOMY

Fat-tissue.

"With

AND

DEVELOPMENT.

fat of the adult,

distinguishin the subcutaneous
which
developed by a process of partialatrophy from that of the new-born
child,three
kinds of collections of fat, which
be described
according to their relations to the
may
vascular
The
''true fat-lobules"
are
system of the skin.
suppliedby large blood-vessels
of their own,
which
break up in them
to form
a close
capillarynetwork surrounding the
individual fat-cells. Flemming appliesthe term
fat-columns
to those
which
masses
lie along the largervascular
branches
but
of the subcutaneous
tissue and
are
scantily
suppliedwith capillaries."Fat-islands," finally,
are
entirelyisolated small groups of
fat-cells without
but seldom
blood-vessels of their own
in the human
subject.
; they occur
The
fat-cells are
Histology of the Fat-tissue.
developed from
ordinary, flat
of which
take up fat in fine drops. While these
branching connective-tissue cells,some
in
and
increase
number
become
the
drops
confluent,
protoplasm of the cells also grows,
and
the cells assume
fat-cells are
rounded
These
a
now
shape.
changed, by the
young
ing
continuallyenlargingdrops of fat, into large globularbodies; the protoplasm containthe nucleus
is pushed to the periphery,and
thus gradually assumes
the appearance
A real membrane
is not an
of a membrane.
essential attribute of the fat-cell;
only in
become
old fat-cells does the protoplasm sometimes
into a membrane-like
condensed
ering.
cov"

Flemming,

we

is

"

"

"

The

fat-cell presents certain peculiarities

which
globulardrop of fat of the mature
render it probable that it consists of a mixture
of fat with other products of the disintegration
of protoplasm. Thus, when
stained with picro-carmin,it often assumes
at certain
points a pale red color,and also presents more
deeply stained red granules at such
which
places. Here are also most frequentlyfound those fattycrystals
probably are formed
of
the
the
skin
after
death.
of
The
fat
during
cooling
frequentlycontains vacuoles,
drop
with

thin-fluid
The

contents.

fat-cell may
visible alteration.

mature

persistin
But

this form

real permanence

for any

length of

of its

time

without

component parts is

going
under-

able,
probany
It is therefore
rich in blood-vessels.
the fat-tissue is extraordinarily
as
particularly
and reproduction of the fat takes place. If the
probable that a constant transformation
the latter,the various forms of atrophy result.
former predominate over
In the human
subject,"serous
atrophy" is most frequentlymet with, characterized
by the disappearanceof the drop of fat alone, the cavitythus left in the interior of the
cell being filled with a serous
fluid,and the fat-ceil thus at first retains its originalsize.
a

not

in bulk and
atrophy progress, the fat-cell diminishes
finallybecomes reduced to a
cell
in
the
interior
the
near
rounding
original
protoplasm, lying
globule of fat, and surbetween
the
the nucleus.
cells
the
connective-tissue
these
During
processes,
that
free
filled
and
is
become
of
it
with very minute
fat-cells
fat,
finelypossible(?)
drops
A constant
them.
divided fat is also depositedbetween
phenomenon during the course
in the fat-cells,
and adjacent connective-tissue
of the atrophy is the appearance
cells,of
"secondary drops," which grow in the fat-cells as the primary drop disappears,usually
differingfrom it in consistence and color. They are therefore certainlynot produced by
Much
but are
its disintegration,
the result of a secondary new-formation.
more
rarely
in
which
the protovarieties
met
other
of
with:
two
the
plasm
are
atrophy
"simple atrophy,"
the
with
diminishes
fat-globule;and "atrophy with grotvth,"in
concentrically
stead
Inwhich
multiplicationof nuclei and cell-growthcoincide with the atrophic process.

If the

mass

of

being reduced to the status of the connective-tissue cell,it may either

with fibrillarjr
disappear
(asin.the skin of old people) or groups of daughter-cells
entirely
of the cell

DEVELOPM

AND

ANATOMY

5T

KNT.

disappearanceof the fat is ultimatelyfollowed

by atrophy of the surrounding capillarynetwork.
connective
tissue,only ordinary
Besides the blood-vessels and very scanty fibrillary
the fat-cells within the large lobules,in inverse
cells are found between
connective-tissue
become
proportion to the quantityof fat-cells alreadypresent,because they themselves
The
l
ike
the
in
thickness.
fat
increase
of
fat-tissue,
if
the
fat-cells
larger and
layer
contains
number
of
subcutaneous
of
the
columns
firmer connective-tissue
a large
tissue,
of
with
but is entirelydestitute
holes and juice-spaces,
lymph-channels
independent
tissue may

connective

formed.

be

The

walls.
with the coil-glands,
for the reason
the fat-tissue in connection
the
corium
of
of
the
a
which,
owing to the
latter,
portion
dependent
only
transformation.
has
of
these
a
Despite its early
peculiar
activity
glands,
undergone
of the
not
to
the
constituents
fat-tissue
does
foetal
the
in
life,
typical
belong
appearance
cushion
skin, since skin in most parts of the body may be well developed,yet without a
conditions.
of fat, under physiological
We
have alreadyseen
that the products
The Coil- Glands produce the Fat-Gushion.
of the coii-glands
consist of fat and other things (fat-formers,
fattyacids, soaps). These
all steadily
are
cular
pushed onwards towards the epidermisby the action of the smooth musAs
is
well
the
of
muscles
alternate
fibres
the coil-glands.
known,
quiteregularly
with the epithelium,so that the entire secretingepithelium comes
directlyin contact by
half its surface with the lymph-spaces around
the coils which
into the connectiveextend
The muscles are, therefore,reallydestined to further an extissue sheath of the latter.
change
reflux between
the secretingepithelialcells and
the lymph which
flows
and
In this they are aided by the above-mentioned
around
them.
arrangement of the oblique
exert
influence
of the skin, which
muscles
of
an
expulsive
only upon the contents
in
the interior of the gland,
the duct, and a retardingone
upon the glandular products
This arrangement seems
a
as
highly practicalone, because heat,
upon its circulation.
which
relaxes the vessels,calls forth, by causing a hyperaemia of the whole
papillary
time, by relaxing the oblique
layer,a profusewatery alkaline sweat, and at the same
muscles of the skin, opens wide the way for the passage of the fattyproducts of the coilglands to the surface,thus counteractingthe unpleasant effects of the alkaline tissue-fluids
of the acid and fattyproducts of the glands. On the other
upon the epidermisby means
of the skin by its oblique muscles,
hand, every increase in the tension of the framework
We

considered

have

it is

that

"

lead to

must

retention

of the secretion

of the

coils,and

thus

facilitate the

passage

of

coils into the

the naked

surrounding lymph-spaces.
We
must
at any rate imagine the lymph which
streams
from
the coils to be
away
loaded with fattyproducts. This lymph has, however, no lymphaticvessels of its own,
but is taken up in part by the few lymphatic vessels coming from the corium, but mainly
The lymph, while being thus taken up, must, of course,
trunks.
venous
by the cutaneous
left behind in the subcutaneous
be filtered in such a way that its fattyelements
tissue
are
there.
and accumulate
By this process, I explainthe storing-upof fat by the cells of the
the

products from

tissue and

subcutaneous

their conversion

into fat-cells.

tating
fattylymph, in the embryo as in the adult, exercises an irrifrom
the nearest
influence and attracts
capillaries
blood-vessels,whose venous
take up all the lymph except its fatty portions,the arterial furnishing the
branches

The

oxygen

first collection

used

in the elaboration

separatedfrom
accumulation

of

the

when

current

of the fat.

The

which,
lymph-corpuscles

of blood, collect around

the

fat-lobules.

fat-tissue is first formed, cannot, however, be

as

The

usual, become
fact of their

utilized to

explainth"

58

ANATOMY

originof

in view
the fat-tissue,

the fat which

abundant,

branches

venous
are

In

fat-cells.

and

then

AND

of the absence

placeswhere
has been

the

formed, which

often

so

of

transitional

any

budding

filtered out

their attendant

and

DEVELOPMENT.

first

at

between

ing
wander-

is less
sanguineous capillaries
remains
behind
all the larger
on

lymphatic vessels,around
these

accompany

forms

of the

vascular

which

the

"

fat-columns

Between

tracts.

the

"

"

coil-

the

glands and

fat-islands,
fat-columns, and singleclusters of fat mark
fat-layer
proper,
If the latter become
of the fat-laden lymph.
the course
exhausted, atrophy of the fatand thence
lobules (Flemming) begins,externally
of course,
inwards,
progresses concentrically
the absorbing blood-vessels.
towards
In this way
the association of coil-glands
with fat-tissue is fullyexplained.
It still remains
to cast a brief glance at the vascular
and
trunks which
nervous
from

grow

within

"jular trunks

which

into the corium.

outwards

Vessels.

Blood-

Tomsa

"

that both

has shown

supply the different

the size and

form

portionsof the corium

of the individual

with

blood,

are

vas-

subjectto

On
the extensor
surfaces of the extremities and trunk, the territories
great variations.
supplied by single arteries are much
larger than on the flexor surfaces ; the vascular
in the palms of the hands, the soles of the feet,and the face.
trunks are most numerous
Their form is dependent upon the local cleavage. While
in parts of the skin where the
not
is
the
vascular
trunks
almost
are
uniform,
cleavage
vertically
very tortuous, and run
of
the
distribution
their
and
of
crooked
branches
is of a rounded
area
upwards,
very
shape, in parts with uniform cleavagethey are crowded together,by the bundles of fibres
tightlystretched in one direction,into flat circulatoryplanes. According to Tomsa, the
best way to find such a circulatory
plane is to make
obliquesections through the corium,
and therefore at right angles to the direction of cleavage.
parallelto the hair-follicles,
Fig. 1, however, shows that the horizontal ramifications may be completelyexposed by a
time parallel
to the direction of cleavage and
section made
and at the same
of
vertically
vertical
hairs.
the
of
circulation
the
Between
there are, of
horizontal,oblique,or
planes
some
parts of the corium which are relatively
course,
poor in vessels.
in part run
The horizontal distribution of the vessels which
cally
obliquely,in part vertiat the border
between
the
principallyin two regionsof the skin
upwards occurs
the former and the papillary
corium
and the subcutaneous
tissue,and at that between
layer.
Underneath
the papillary
rial
artelayerwe find a wide-meshed
Papillary Circulation.
in
the direction
tubes, the longitudinalaxes of which run
network, composed of narrow
network
sends upward a tortuous
arterial
of the grooves of the epidermis. This
capillaryto each vascular papilla,which bends over in the shape of a loop to form the
still more
tortuous
of the papillarylayer
venous
capillary. All the venous
capillaries
network
at the
level
same
venous
again unite to form a close,narrow-meshed
capillary
that in which
this largerveins arise,which
the arterial lies,and from
as
run
through
"

"

the

corium

in the

same

direction

as

the arteries.

papillaryvascular system and the largerbranches in the corium

cutaneous
the subwith them consist only of an endothelial
tube, which is joined,near
adventitia.
and
media
tissue, by a very insignificant
They are therefore
the veins
arteries are
The
a
comparatively very
capillarynature.
narrow,

All the vessels of this

connected

mainly

of

wide.
In three
the corium.
which

places,the papillaryvessels present dilatations

In the first place,they furnish the flat vascular
lie between

their middle

and

external

sheaths

in the

and

deeper portions of

networks

of

the

the basket-like

licles
hair-fol-

plexuses

ANATOMY

AND

59

DEVELOPMENT.

oblique muscles of the skin also receive their vascular

supply from this source, and a third branch-plexus accompanies the excretory ducts of
in some
the coil-glandsdownwards.
deviations
found
Minor
are
parts of the skin.
Thus
in very short papillae
often entirelywanting, givthe ascending papillaryloops are
ing
around
to
the
the
alae
and
external
the
nasi,
on
lips,
place
irregularplexuses;
ear,
the whole
into a series of largelacunae, into
subpapillaryvascular net is transformed
which the venous
capillaries
empty from above, and the veins from below (Tomsa).
Circulation
Fat-Tissue.
Below
the papillarysystem is a
and
of the Coil-Glands
horizontal area
poorlysuppliedwith vessels,which is the broader the thicker the corium;
the fibrous bundles
have
of the corium
themselves
no
capillaries.An exceedingly
of

the sebaceous

glands.

The

"

distribution

abundant

of vessels is found

at

the border

tissue.

of the subcutaneous

the first

In

arterial trunks, to

place,independent branches are here givenoff by the small

also receive
All the coils of the coil-glands
loop for each hair-papilla.
capillary
If the coils lie close together,a common
capillaryplexusesfrom this source.
plexus is
formed
of capillaries
the vessels which form
dense networks
by their vessels. Finally,
inside the fat-lobules take their origin from
this point. The vessels of the individual
lobules also unite, when
the fat is abundant, to form horizontal nets, this usuallytaking
in the coil-glands. In this way, a
placesimultaneouslywith a correspondingoccurrence
at the lower border of the corium
vascular plexus is formed
also,which occupies a much
largerextent of surface than that of the papillarylayer.
We may regard the horizontal
distribution of the vascular
trunks
as
taking place
at
two
the
borders
of
the
divide
into
and
it
the
corium,
mainly
papillary system
may
(with ascendingloops for the papillaeand three kinds of branches in the lower portions
of the corium) and the system of the coil-glands
and fat-tissue(thevessels running upwards
to the former, and downwards
to the latter).
The horizontal form of the distribution of the vessels in the adult is due mainly to
the increase in thickness of the corium.
In the foetus and new-born
child, the obliquely
nearest
branches
the
to
vessels
off
or
verticallyascending
give
irregularly
epithelial
structures.
the
are
Only after the depositionbetween them of firm bundles of fibrillae,
horizontal terminal branches
the border of the papillarylayer crowded
near
togetherto
form a network, and with the descent of nearly all the coil-glands
to the lower border of
the corium, and the gradual atrophyof the subcutaneous
fat, the vascular territories of
the coil-glands
and the fat-tissue unite to form
the broad
subcutaneous
plexus. The
after birth, by the addition of a media
and
largervessels of this plexus graduallyassume
furnish

thick

adventitia,the characters

their indefinite

of arteries and

veins, while

character.
embryonic (capillary)

"When

the vessels above

them

tain
re-

in adult life the subcutaneous

fat

again attains considerable dimensions, the upper portionof the fat-cushion is

suppliedby the cutaneous, the lower by the musculo-fascial vessels.
Direct Passage of the Arteries into the Veins of the S/ci?i. A peculiararrangement
of vessels is found in the skin of the terminal
phalanges of the fingersand toes.
Hoyer
in man.
describes it as of a double nature
of the digitalarIn the first place,branches
teries
empty directlyinto the wide veins of the nail-bed, and in the second place,after
of the skin of the finger,
but before the
giving off branches for the fat and coil-glands
is
into
which
small
vascular
inside
numerous
papillarysystem formed, empty
coils,
they
also pass into veins.
Under
ordinary circumstances, these direct transitions evidently
circulation through the ends of the fingers
serve
as
regulatorsfor the obstructed capillary
"

and

toes, in which, aside from

and

the

insufficient

their unfavorable

development

situation,the absence

of the elastic elements

of the corium

of the muscular,
come

into

play.

60

ANATOMY

If

take

we

there is

such

no

muscular

generalview of the
thing as a functional

movements,
into

transformed

AND

doable

DEVELOPMENT.

circulation

Its distribution

etc.

in the

division of it into

only by

mechanical

skin, we

forced

are

circulation for

is uniform

from

influences.

to admit

the first,
and

This

that

tion,
secrerespiration,

becomes

latter fact is of

great
pathologicalprocesses in the skin remain confined
importance, because by it alone many
The
unusual
circulation and its annexes.
thinness of the walls of the
to the fibrillary
doubtless
and
is
of their being embedded
cutaneous
vessels
in
a consequence
subpapillary
firm papillary
the
assume
tissue;the skin-veins which rest upon a very firm basis even
of blood-sinuses
with
The
form
absence
of highly-developed
extremely thin walls.
muscles
in
the
vessels
of
the
skin
is
the
elastic frame-work,
part
compensated
by
upon
is influenced by the external temperature through the obliquetensors of the skin.
which
The very distensible capillary
pendent
probably possess the power of indeloops of the papillse
a

under

contraction

one

irritation.

nervous

Lymphatic Vessels. The absorbent lymphatic apparatus of the skin is an unsymdirection; it

secondary appendage of the vascular circulation with a centripetal
of tissue,absolutely
devoid of bloodhas one
vessels,
however, viz., that largemasses
peculiarity,
in it,*. e., the epidermisand its appendages. Eecent
embedded
are
investigations
clearness
of the
the exact course
of the lymphatic channels
have defined with satisfactory
of
authors
often
i
t
behooves
are
us
skin, but as the statements
absolutelycontradictory,
"

metrical

to ascertain

the real truth

of the matter.

partsof the skin contain juice-spaces;on this point there can

of pure unapplied anatomy is insufficient
of opinion. As the nomenclature
be no diiference
shall
all
for our
tliose
channels
as
we
designate
juice-spaces
lymphatic
purpose,
which do not possess an absolutely
lymphatic vessels lined
free outfloiointo well-marked
with endothelium, luhether they are devoid, as is usually the case, of independent walls or
are
provided ivith them; lymphatic vessels,on the other hand, are those channels from
consider from this standpoint
which a free outfoivinto the blood takes place. Let us now
of the skin.
the system of juice-spaces
of the epidermis are representedby
Juice-spacesof the epidermis. The juice-spaces
be most
T
hese
will
of
the
the interspinal
prickle-cells.
readilyunderstood by
passages
columns
standing
imagining a low hall,the roof of which is supported by innumerable
close together. Since Axel
Key and Retzius have
the lymph
succeeded
in injectingthese spaces from
that
it
is
certain
of
subcutaneous
tissue,
they
spaces
I
also
formed
once
are
lymphatic passages.
already
It is certain that all

"

observed

fat, in which
the cells with

the fat, stained

a

black

also contain

analogous to

channels

the

with

surrounded

by osmium,

(seeFig. 15).

frame

questionwhether

another
not

infiltration of these

natural

But

it is

interspinal
passages

do

soft,viscid substance, somewhat

the so-called

cement

of the

substance

endothelium.
to hold
the prickle-cells
requireno cement
togetheris clear from the descriptionof their
connecting threads.
not
more
or
a
The
question is simply whether

That

them
Fig.

adjacent

15

"

of

Juice-spaces

epidermis

with

papilla and

natural

the

tion.
fat-injec-

consistent
to be the

case.

In

treatingsections

of the

substance

epidermiswith

is found

in them.

Such

alkalies, it sometimes

seems

happens

ANATOMY

AND

61

DEVELOPMENT.

expansion of some
substance,
interspinal
and sometimes
chloroform-asphaltfail completely,and
although the interspinalspaces are well-developed.
they very rarely succeed entirely,
obstruction were
would
not
in the
These injections
encountered
always succeed if some

that the

bent

are
prickles

broken

and

majorityof

by

the

epidermiswith

injectionsof the

cases.

Fig.

16."

Lymph-passages

of three papillae,injected with

asphalt.

that the lymph which

It is a priori
flows from
them
should carry off the
a necessity
in the prickle-cells
it
is
that
there
be among
possible
products of tissue-changes
;
may
the passages.
them
But even
a readilycoagulatingsubstance, capable of obstructing
if
the
that
f
illed
with
are
soft
viscid
assume
a
interspinal
we
partially
substance,
passages
not even
then represent a simple process
the nutrition of the epidermis would
of imbibition,
for the interspinal
filaments which often
passages are also traversed by fine nerve
have a capillary
and perineuralcavity,always
them, and they both, nerve
cavityaround
of
the
the
cells
and
terminate
in
the
nuclei.
protoplasm
through
pass
substance is wanting, we
Even where an interspinal
always find depositsof lymph in
the fresh skin.
The

FiQ.

17."

beautiful

most

staining

with

gold

specimensare

of all the

lymphatic

obtained

channels

from

of the

oedematous
slightly

papillary layer

and

epidermis

skin, treated for

of

tous
slightly oedema-

skin.

short time with the boiled mixture

of

gold and

part

one

accordingto
oedematous

those in

prepuce.

recentlyrecommended
by Ranvier, four partsof chloride
In specimens thus treated, we
see
very distinctly,
of the depositsof gold, those passages which
are
preferredby
which stagnationoccurs.
Fig. 17 shows such a picturefrom
At the apex of the papilla,
of gold correspondsto each.
a thread

formic

the heaviness

the current, and

an

of

acid.

62

ANATOMY

intercellular

space, and
the surface of the corium.
to the contours

ATSTD

consequently
In

the

DEVELOPMENT.

the

upper

threads
horizontal

radiate

like

layersthese

tuft

threads

of

hair

from

divide, corresponding

of the cells,anastomose,

and then present between

the granular
be followed
distance
some
granules may
between
the horny cells.
the
Below
further, as the last juice-spaces
granular layer we
the
all
f
illed
with
see
juice-spaces
nearly
star-shapedwandering cells,which send their
in part upwards, in part downwards
branches
the cells,while they are
between
otherwise
b
ut
in
stillless
the prickle-layer
to
unable
plentifully
numerously distributed
; they are
the granular cells and therefore stick fast all through
creep into the narrow
spaces between
this layer. In contrast to the tops of the papillae
of lymph at their bases and
the streams
in the interpapillary
few in number.
In these placesonly a finelygranare
prickle-layer
ular
tion
depositof gold is found between the cells. We must, therefore,regard the circulaless energeticin this interpapillary
of the juicesas much
prickle-layer,
or, in other
the
slow reflux of the lymph takes place at these points. This conclusion
words,
may
also be reached from another circumstance.
Key and Eetzius found, as has alreadybeen
mentioned, that the sweat-pores can be filled from the cutaneous
lymph-passages by way
of those of the epidermis. We therefore have in the sweat-pores a means
of escape for
the lymph circulating
the
and
without
epidermis,
through
they are
exception situated
in the interpapillary
depressions.
Direction
in the Epidermis. The
of the Current of Lymph
lymph, therefore,
tions
flows to the epidermismainly from the apicesof the papillae,
thence spreads in all directhrough the former and returns to the corium by way of the interpapillary
depressions,
ternally
circumstances, be discharged exthrough the sweat-poresof which it may, under some
cells

of forked

rows

ends, from

which

rows

of

"

also.

The

are
papillae

confluent

near

come
by juice spaces (see Fig. 16). They beof the papilla,at which point the beginning of
passes upwards in the axis of the papillato a

uniformly traversed

very

the centre

of the

base

vessel is

usuallyfound ; this
distance of two-thirds of its height.
the sebaceous glands, the prickle-layer
of the
The excretory ducts of the coil-glands,
the
hair-follicle and the hair-bed, have the same
as
epidermis.
interepithelial
juice-spaces
of pigment in them
In the last situation the ascent
often be recognized. The hair
can
municate
papilla,reasoning from
analogy,is probably also traversed by lymph-spaces which comwith the interepithelial
of the cortex which contain pigment,
spaces of the matrix

lymphatic

and

with

those of the matrix

destitute of
The

and

pigment,
obliquemuscles of

extend

of the medulla, cuticle

in all directions

the skin and

furnish

material

room

for their

for the fabrication

all ensheathed

movements,

of their

as

and
the

root-sheath, which

are

portionsof the hair.

the coils of the

spaces, in which respect the latter differ from the

of juice-spaces. In the
by a much smaller number

lymph

far

horny
lymphcoil-glandsfloat in distended
sebaceous glands which are surrounded

as

and

in

case

that

specific
products.

lymph-spaces of various

forms

of the arrectores, these

of the
The

lakes

of

coil-glands
they supply

connective-tissue

bundles

from
; also the larger fat-lobules,
the individual fat-cells.
between

are

whose

by
lymph-sheaths very slender lymph-canals extend
complicatedSystem of juiceLymphatic Vessels. In contrast with this infinitely
sels
of real lymphatic vessels. This
system of vesspaces, the skin has only a small number
into which the juicewith blind extremities
begins in the upper third of the papillse
canals empty, as they do everywhere else,through holes (Schenk; pseudostomata: Klein)
cement
and through the porous
ridges of the endothelia (stomata). The lymphatic
continuous
vessels then unite to form
a
plexus which uniformly permeates with its not
"

^4:

ANATOMY

Others
towards

AND

of the medullated

branches
and go
are
longer,pass upwards in the papillae,
tire
corpuscles(ofMeissner),which are here scattered throughout the enThese
bodies present, in contrast
with the Pacinian
a
striking
corpuscles,
striation. According to Ranvier, their development can
be studied in the newborn
is
striation
transverse
as follows : At the apicesof some
found, due
papillaa

the tactile

skin.
transverse

child

Fig.

18

Fig.

a.

Tactile

to

DEVELOPMENT.

horizontal

bundle

cells of the mesoderm.

this

of fine terminal
While

the

186.

Corpuscles.

nerve-branches, and

nerve-branches

are

beneath

it

becoming largerand

little

heap

more

numer

of

forms
one
pushes itself in between them, and in the sixth month
Beneath
this
is
often
second
found
a
branching
bushy
corpuscle.
In the adult,
bundle
of nerves
to which
a new
heap of cells appliesitself from below.
therefore,we find tactile corpuscleswith one, two, and three lobules,each suppliedwith
nerve-branch.
a medullated
They seem
closelypressedtogether,and consist of largeflat
connective-tissue
nerve-fibres ramifying
cells,arranged like rolls of coin, with medullated
between
them.
contain the nuclei, are
The
swollen lateral edges of the cells,which
alternately
pressedagainst the outer border of the corpuscle,and this,togetherwith the
v
iew
around
the corpusle,
of the medullated
which
here and there run
nerves
profile
of
The axis of the whole column
transverse
striation.
gives the impressionof a coarse
cells is usuallyvertical (seeFig. 18 a),but is often variously
when
bent, especially
greatly
lose their medullary substance
developed (seeFig. 18 b). The final ofE-shoots from the nerves
inside the corpuscles.
ous,

lobule

heap

of cells

of the tactile

AND

ANATOMY

According to

E. Fischer

DEVELOPMENT.

(Flemming),medullated

65

spotsalternate with non-medullated

which
after repeatedlydividingand

which
the nerves
on
penetratebetween the cells,and
extremities (gold-specimens).
in bulbous
subdividing,terminate finally
branches of the sub-epidermicplexus
Nerves of the Epidermis. The non-medullated
ing,
basal cells,and give oil after repeatedlydividthe cylindrical
between
ascend vertically
to all the prickleand perhaps also unitingto form plexuses fine terminal branches
and various directions,
cells as far as the granular-layer,
which, coming from different nerves
the
of
the
and
in
cell
enter each
cells,
protoplasm
apply
pairs. They perforate
bulbs.
from without, terminatingin minute
to the nucleus
themselves
They often run
half-way or entirelyaround the nucleus, but without penetratingit (seeFigs. 19 and 5).
in the epidermisis,therefore,a double,intracellular
of termination
Their typicalmanner
the cells,but so irregularly
and often in
also found between
Terminal
bulbs are
one.
if they had only lost their more
advanced
close togetherthat it seems
such numbers
as
which
to
the
non-medullated
of
The
threads,
capillaryloops of the
layers epithelium.
go
like
these
behave
intra-epidermicnerves.
They terminate in pairs,
exactly
papillarylayer
in
the
with bulborfs extremities in the endothelial cells,
vicinityof the nuclei.
I have also succeeded
in demonstrating the terminaNerves
tions
of the Hair-Follicle.
of the hair-follicle ; here also "they end
of the sensitive nerves
in the prickle-layer
"

"

"

'

"

Fig.

19."

Termination

of the

Nerves

in the

Cells of the

Epidermis.

everywhere followed
far as the constriction of the hair-follicle below the sebaceous glands. At this point,
as
after passingthrough the follicle,
they lose their medullary substance externallyat the
homogeneous membrane, which they perforate,and then give off filaments in the pricklelayerof the follicle. The hair-follicle is therefore suppliedonly from above.
Nerves of the Coil-Glands.
The ducts of the coil-glandsalso receive nerves
from
truaiks which lie close to them
to
tactile
below
the
Ranvier,
Just
epidermis. According
plates of the shape of an ivy-leafare here met with, in which these nerves
terminate,
The
of the coils have been followed
nerves
spreadingthemselves out on the corium.
close up to them
failed to find their real
by Coyne and Herrmann, but these investigators
terminations.
Dr. Openchowsky (writtencommunication) has followed, by the goldIn good osmium
threads into the coils themselves.
method, non-medullated
preparations
I have seen
terminal nerve-bulbs
in the secretingepithelial
cells,as well as in the layers
of transitional epithelium at the beginning of the duct (seeFig. 14),but I have not yet
been able to form a positive
opinion as to their constancy and double nature.
The statement
of W. Krause, that all sensitive nerve-fibres finally
terminate
without
medullary substance and in minute enlargements,therefore,seems
justified.The larger
part of these terminal bulbs is found in the epidermic cells themselves, as far up as the
line of cornification.
The
peculiar tactile instruments,the corpusclesof Meissner and
Vater, must, therefore,perform some
garded
specialfunction,since they can no longer be reof generalsensation.
instruments
as
inside the

cells with

two

bulbs.

"

The

larger nerve-trunks

may

be

'

66

ANATOMY

AND

DEVELOPMENT.

Pigment
the

it
formed

with

both

germinal

mainly

in

in

of

of

the

the

cells
in

European

the

of

in

far
the

the

lower

the

and,

layer,
the

In

and

light

at

most,

the

known,
time

on

and

slight

ascends,

of
the
the

the

colored

are

on

coloring

of

adults

assume

different
for

this

purpose.

remains

children
than

the

careful
would

ological
physithe

hair-

with

phied
atro-

the

the
of

skin

As
the

doubtless

attempts

strongly.

granular

of

sumes
as-

ment
pigis

well

manner

throw
to

of

prickle-

the

color.

study

and

nuclei

the

itself

layer,

of

rest

areola),

from

is.

demonstrated
All

asserts

free

futile

has

cells

horny-yellow
and

follicle,

around

granular

it
normal

The

mammary

still

the

in

found

eyelids.

lowermost

the

as

darker

birth,

new-born

races

the

layer

up

the

epidermis

always
a

at
and

embryos

in

in

the

sociate
as-

since

alone,

alone

of

the

only

layer

of

of"

could

corium.

is

(scrotum,

granular
high

unpigmented

between

relationship

horny

corium

in

found
the

corium

parts

found

as

negro,

membranes

horny

pigmentation

the

is
of

color

The

color.

races

it

coloring,

in

is

races,

white

as

dark

saturated

colored

the

the

therefore,

pigment
a

hair

in

body

prickle-cells.

the

If

whole

the

pigment
we

manner,

in

Waldeyer

(?)

normal

deeply-colored

the

race,

tissue

portion

know,

'

over

the

to

white

unexplained

of

old

as

the

principally

pigments

As

of

connective

the

entirely

pathological,

cord
vessels.

allusion

an

skin

the

with

hitherto

pathological

the

connective-tissue

pigment

in

in

nor

in

with

study

our

importance

epidermis
layers

new-formed

pigmented
the

the

connective-tissue

the

and

conclude

little

but

epidermis

the

paradigm
change,

We
"

of

neither

in

skin,

Skin.

the

of
Although

skin.

utilize

more

the

PHYSIOLOaT

BY

H.

Translated

THE

A
skin.
the

EESPIRATOEY

The

excretion
of

the

Gerlach,

of

and

the

carbonic

OF

of the

acid

M.D.

takes

in

place

the

through

skin

times

part

every

According

more

of the

undoubted;

is

doubtful.

are

oxygen

thirty-seven

and

SKIN.

THE

lungs,

gas

of

absorption

hundred

one

that

to

analogous

water

absorb

DANA,

L.

FUNCTION

and

nitrogen

lungs

CHARLES

by

RESPIRATORY

process,

excretion

ZIEMSSEIS".

VON

but
A.

to

than

oxygen

the

skin.
The

of

amount

0.0089-0.0102

excreted

to

by

This
and

1,

skin

the

00^

according
at

conditions

which

by

with

compared

Aubert

at

increased

excreted

3.87

fixes

flow

the

by
daily

the

lungs,
of

amount

is

as

CO,

grammes.

of

temperature

the

augment

that

Eeinhard

Scharling.

to
and

2.23,

is increased

amount

other

excreted,

of

blood

exercise,

air, by muscular

the

skin

the

to

and

excretion

the

of

sweat.

is

Water
Is increased

of

thrown
the

specially,
in

excreted

water

eliminated

usually

off

the

by
of

amount

In

the

on

hours

in

the

surface
600

reality, however,

the

with

varies

skin

is about

twenty-four

lungs.

water

the

by

it appear

does

the

the

season,

form
in

of
the

and

vapor,
of

form

cannot

average

far

place, individual,

be

when

the

The

drops.

not

or

grammes,

only

from

double

such

that
since

determined,

etc., to

flow

amount

marked

extent.

Among
the
of

the

If

This

food

moisture,

the

these

skin.

and

etc.,

the

secretion

factors
in

water

of

depends

turn

drink,
of

is, first of all, the

the

upon

makes

the

upon

clothing,

bodily movements,

surrounding

excretion
sweat

the

condition

increases

of
the
and

distention

of

the

quality, quantity,
especially

upon

blood-vessels
and
the

of

temperature
temperature,

air.
to

its appearance.

too

great extent,

or

if

evaporation

is

prevented,

68

THE

solid

The

substances

which

and

properties,swells up,

it

have

share

some

gases and

are

vapor

endeavored

remainder

denied

or

thrown

show

to

for

of each

drop of

Erismann

has

glands than

Krause

the

that

the

It

affirmed.

of

surface

the

upon
that

shown

the

sudoriferous

only one-sixth

to

the

activity of

constantly to deliver

evaporation of the entire sudoriferous

apparatus

two-nintli

to

the

entire

perspiration.

The

of the
is

superficialarea

largelyincreased

by

of the sweatthe

spreading-

of water
be evaporated by the sweatcan
greater amount
that the surface
of the dead
Furthermore, he has shown
body ex-

one-iifth

water;

watery,

of

epidermis itself.

the

of the

the

on

"

an

other,

organ

by the

in

high

consist

must

the

degree
of

the

the

on

power,
its

other

In

livingbody.

in life has

which

increase

to

colorless and

almost

off

thrown

amount

ceases

at death, this organ

As the epidermis is not changed
skin, particularly the sweat-glands.

is

is

also that

ducts,

skin.

specialorgan

up

glands
sweat

much

estimated.

death

sweat

dermis,
epi-

and

one-eighth

separation of

sweat

";rete3

The

the

glands. That the sebaceous

is not impossible that
some

be said that an
estimate
it must
accurate
Against this view
glands and ducts is impossible; also that the evaporating surface
out

cells of

off in this way.

tlierefore,pass through

must,

of the

sudoriferous

the

lymph-spaces directlythrough

watery

Krause

be

cannot

only sufficient

consist

SWEAT.

OF

SECEETION

chieflysecreted by

the

from

secreted

is

is

sweat

skin

off.

be rubbed

then

can

THE

The

the sebum.

mechanically by rubbing, washing, etc., after the horny layer

moist
and
diaphoreticprobathes, warm
applications,
by warm
cedures,
virtue
of
its
the
of
most
epidermis,by
hygroscopic
superficial
layer

The

etc.

the

off from

thrown

and

sweat

SKIN.

THE

OF

removed

are

macerated

been

the

are

SKIN.

THE

OF

FUNCTION

SECRETORY

fluid secretions of the skin

The

has

FUNCTION

SECKETOKY

THE

or

hand,
surface.

evaporating

glandular

clear fluid,of acid

words, at
one

of

organs

alkaline

the

reaction,

and the individual.

The sweat
peculiarodor varying with the locality
contains
volatile fattyacids (formic acid, acetic acid, butyric,propionicacids, etc.),
and
also neutral fats in small amount
and
a
nd
cholesterin.
(palmitin
stearin),
There can
scarcelybe a doubt that the sudoriferous glands have an active share in
for
lubricatingthe epidermis,and that the secretion of the sebaceous glands is especially
the oleaginousneeds of the hair.
According to the generalview, the reaction of the fresh SAveat is normally acid;if a
and be kept
induced
profuse secretion is artificially
by jaborandi,or other diaphoretics,

saltytaste, and

up

for

if the

changes
decomposition
ammoniacal

secreted
of the

that

reaction

part

and

neutral

or

alkaline.

even

in this

stand

to

a long time,
nitrogenous constituents, especiallyurea,

Triimpy

of the

of the sweat

admixture
where

becomes

is allowed

sweat

with

The
case

the

reaction
there

also

being

formation

of

salts.

Luchsinger
when

reaction

time, the

some

there
It must

of
are

not

sweat-secretion
constituent

the
no

skin

from

found

examined
the

uniformly
sebaceous

the

uncleaned
acid

glands,is

forgotten,however,
increased and
artificially
and

of the fresh sweat

constantlyalkaline
The
acid
carefullycleansed of the sebum.
skin depends,accordingto Luchsinger,upon the

sebum.

be

of sweat

reaction

is first

exists in the

The

reaction

of the sweat

in the vola

manus,

constantlyalkaline.
that

Luchsinger and Triimpy examined

only the
normal.
not perfectly
Urea is a normal
Whether
proportionof about 0.1-0.2 per cent.
therefore

FUNCTION

SECRETORY

THE

OF

THE

SKEN.

g""

conditions
remains
still to be determined.
normal
take place under
Under
of nephritisscarlatinosa and
pathologicalconditions,for example, in anuria in the course
the excretion
of urea
be
cholerica,and nephritissuppurativa from nephrolithiasis,
may
increased that upon
so
evaporation of the sweat, crystalsappear upon the surface of

Tariations

the skin.
presence of other nitrogenousbodies
far been uniformly observed.

The
not

so

normal

as

constituents

of the

sweat

has

in profuse sweat
amount
Leube
found
of albumin.
Schottin found
a small
a rose-red
pigment precipitatedby alcohol, and turned bright-greenby oxalic acid.
Finally Favre
found
acid containingnitrogen (hydroticacid).
an
The inorganic salts in sweat
exist,according to Funke, in the proportion of 0.099cent
0.339
0.629
the alkaline chlorides,
are
(average
per cent). The principal ones
per
of
sodium.
In
amount
c
hlori
de
less
the
alkaline
and earthy phosphatesand
are
especially

of iron.

the oxide
The
These

variations
of water

amount

The

process

It is

The

centres

secretion

977.40
duration

(Schottin) to 995.573 (Favre).

of the sweating,the food, the

the

then

pass

nerves

latter contains

the sweat-nerves

into the

directlyto the extremities

by

certain causal conditions.

is

influence,and

analogous

in

of saliva.

sudoriferous

for the

oblongata,which
(Luchsinger).
The peripheralpaths of

mixed

are

in the

situated

generalcentre

follow the rami

nerves

of the

spinalcord

communicantes

extremities.

(Vulpian,Adamkiewicz), though

far up

as

as

containingthe spinalcentres
to the sympathetic,

Some

this is denied

fibres pass

by

tent
compe-

(Nawrocki).

observer

terminations

The

from
and

amount

sweating,etc.
periodic,being determined
dependent mainly upon nervous

the medulla

and

the

of secretion is

pointsto the

many

varies

sweat

depend upon
taken during
secretion

true

in

of water

amount

by Coyne by

of the sweat

the

gold

nerves

method.

strated
upon the sudoriferous glands have been demonWhether
they pass into the cells .and how is as

yet unknown.
Irritation of the
sweat

within

stimulate

the

mixed

distribution

secretion

changes
heat and

secretion

of the

by acting upon

after section of the

The

nerves

of

nerve

trunk

containingsweat fibres excites in animals secretion of

nerve.
Pilocarpine,muscarine, and other alkaloids
the periphery. For example, they will excite sweating
from

its centre.

is increased

through reflex and central stimulation

by
temperature and composition of the blood, especiallyby increase of its
acetiby venosity,poisoningwith strychnine,picrotoxine,camphor, ammonium
sweat

in the

cum.

glandularactivityis diminished or even

entirelysuspended by coolingthe skin,
the
of
arterial
the central
blood, separation of the glands from
cutting
supply
and apparentlyalso by too long rest.
nervous
by too long activity,
system, finally
stasis without
Simple venous
dyspnoeiccondition of the blood does not stimulate the
sweat-glands;neither does active hyperaemia up to the point of inflammation.
Similarly
in the arterial pressure
is without effect,as, for example, when
a simple increase
a large
amount
of water
is taken
into the system, unless the blood is heated by the imbibed
tion
fluid,or by a high temperature of the surrounding air, or by prevention of heat-radiaand water-evaporationfrom
The
of
the skin, or by muscular
secretion
activity.
it
sweat
is so far independent of the blood-vessels and
that
the vaso-motor
can
nerves
The

off

';^0

THE

stillbe excited

body

by

(Kendall and

increased

and

SEOKETOBT

irritation of

nerve

OF

FUNCTION

trunk

THE

SKIN.

when

even

the

Luchsinger),but it is accompanied by
powerful flow of arterial blood.

limb

is severed

dilatation of the

from

the

blood-vessels

by a
cessation of the sweat-secretion
or
even
a diminution
Atropine causes
by paralyzing
has apparentlyshown, the specific
the glandular nerves, while, as Kossbach
irritability
be excited by pilocarpine,
and can
even
of the glandularsubstance persists
although the
is ineffectual.
strongestelectrical irritation of the nerve
Medical
e. g., in the
experienceconfirms the power of atropineto check perspiration,
less
of
and
other
In
sweats
a
phthisical,rheumatic,
patients.
profuse
degree,morphine
both in physiological
acts in the same
experiment and with the sick.
manner,
do not lessen the activity
of the sweatChloroform, chloral hydrate,ether^and curare
The
existence of inhibitorysweat-nerves
in the largestdoses.
in the symglands even
pathetic
has lately(Vulpian)been announced, but not confirmed.

THE

Sebum
from

SECEETION".

SEBACEOUS

healthy individuals of a fluid fat,which, passingout insensibly

glands,lubricates the epidermis and hair, though not giving them a

consists in

the sebaceous

variations within
the
Herein, however, there are many
noticeablyoily appearance.
limits of health, especially
as
consistency too
regards increased secretion and abnormal
solid or too fluid. In these cases
notes either that the skin and hair always present
one
that
if
the nose
and vicinitygape;
the
mouths
of
the ducts
an
on
oilyappearance,
or,
the consistencyof the sebum
at the openings of the ducts in
is increased,that it appears
"

white, tallow-like

masses.

of the sebum
less fatty
shows, besides free fat, more
or
microscopicexamination
and epidermic scales.
cells,cell debris,cholesterin crystals,
The
chemical
composition of the sebum and allied secretions,the ear-wax, smegma
and
secretion
of the Meibomian
The
glands has been incompletely studied.
preputii,
and
and
oleic acid,
constituents
constant
are:
water, fats (palmitin
olein),palmitic
and phosphates
soaps, a casein-like albuminoid, cholesterin,and inorganicsalts (chlorides
of the alkalies and earths).
of sebum
of gigantic size,
C. Schmidt
examined
old and rancid accumulation
an
The

which,
31.70^;

account

on

of

its age,

did not

normal

representthe

fattyacids (butyric,valerianic,and

secretion,and

found:

1.21^; palmitin with

caproic),

trace

4.16^; epithelium and albuminate, 61.75^; mineral

Ear-wax

"

is

the external
can

be

So far

hj

mixture

of the

auditorymeatus.
recognized.

as

has been

and

salts,1.18^.

the sudoriferous

determined, the secretion of

increase of vascular

is filled with

secretions from

Microscopicallythe

The

temperature.
supply
the cells rupture after coalescence
fat-drops,

sebaceous

glands

these two

of

is continuous

sebum

of

and

elements

formed

water
of cholesterin,

and

central

layerof

of the

drops

the

of

tions
secre-

is increased

gland-cells

of fat, and

free

fat is formed.
The
analogy between the sebaceous and
and permeabilityof the membrane
contractility

Schwarz'

'

for the

colostrum

Sitzungberichte der

ii. Abthlg., Bd.

k.

S. 184.
liii.,

cells,exists also

k. Akademie

der

lacteal secretion
for
for

the

Wissenschaften

the view that the

justifies
by Strieker and
of the sebaceous
glands, so

fats, demonstrated
cells

zu

Wien,

Mathem.-naturwiss.

EZl.,

72

THE

ABSORPTIVE

POWER

OF

SKIN

THE

AND

ITS

LIMITS.

The
fatal termination
occurs
more
mal
produces death.
rapidlythe smaller the anithe more
surface
is
the
cutaneous
covered.
It
is
i
n
completely
sufficient, most
only a third of the body in order to produce death, and even
cases, to cover
varnishinga
sixth part may
prove fatal.
The symptoms are those of an acute febrile disease,which, after great diminution
in
culation
temperature, ends fatally. At first,one observes weakness, increased rapidityof the cirthese latter become
and respiration
mal
slower, the temperature falls,the ani; soon
is apathetic,
insensible to irritations;
a
nd
albuminuria, convulsions,
paralysesfollow,
and a fall of temperature to 19"-20" C. (inthe rectum) results,the CO, exhalation sinks
(even to one-half of the normal), and death takes place.
According to the recent experiments of Ellenbergerand others upon larger and less
sensitive animals, the effects of varnishing are
is the case
than
decidedly less marked
or

later
and

with

rabbits.
Senator

has

this question anew,

and has sought to determine
recentlyinvestigated
be applied to man.
whether
the results upon
animals can
The single observation
which
illustrates the deleterious effect of varnishingupon
man
is,as Senator shows, not a strong
At the installation of Pope Leo X., a poor
evidence.
his entire
boy was
gilded over
skin.
The child was
taken sick and died the followingnight. Senator rightlycontends
that this shows nothing, since we are not told what symptoms
occurred, and whether the
substances
not poisonous. The
used in gildingwere
fact of death occurring so suddenly
speaks againstits being due to the gilding,reasoningfrom the mode of death in lower
animals, since dogs survive varnishingfor several weeks.
of experiments,partlyupon
Senator has made
febrile (typhoid)and partly
a number
skin
He
to
the
non-febrile
adults.
an
applied
impermeable coating of adhesive
upon
it
to
remain
several days. This did
plaster,collodium ricinatum, or tar, and allowed
less fatal results.
Decrease
not produce any morbid
of the internal
symptoms, much
take place if coolingof the surface, from
or
temperature did not once
long exposure
of
was
ether,
evaporation
prevented.
it appears that covering the cutaneous
surface
with an impermeable coating
Hence
in
in
at least
is,
or
adults, not dangerous.
man,
bid
morCovering the entire skin with tar and tar preparationsproduces indeed some
If more
than a third of the body is covered
symptoms, but no dangerous results.
with tar, there is produced a high fever with distress,malaise,headache
; in vomiting, a
fluid is sometimes

dark-brown

thrown

up,

and

the

f osces

have

sometimes

constantly,the urine has

due

dark-brown

to the presence

of
greenish-black
appearance,
the
mined.
deterskin or lungs is not yet
these enter the blood by
Whether
tarry constituents.
in assuming that these morbid
At all cvonts, we are justified
phenomena are due
to suppressionof the perspiration,
but rather to absorptionof the constituents of
not
color ; most

the tar.

THE

ABSORPTIVE

POWER

OF

THE

SKIN

AND

ITS

LIMITS.

epidermis is that part of the skin which, lubricated by the

If
the absorptionof substances
appliedto it in solution.
the epidermis is removed, the papillaeexercise a powerful absorptivecapacity. Small
to be taken up.
But
excoriations and abrasions of the epidermisallow soluble substances
the questionwhether
and to what extent
the uninjured epidermis possesses an absorptive
settled. The practical
importanceof this matter is apparent in view
power is not yet finally
The

sebum,

horny layerof

reduces

to

the

minimum

THE

ABSORPTIVE

POWEK

OF

THE

SKIN

AND

ITS

LIMITS.

73

dailyapplicationof ointments, liniments, etc., to the skin. Physiology is not less

interested in the scientific aspectof the question.
and
As regardsthe paths of absorption,the cutis,with its rich supply of juice-spaces
favorable
still
offer
to
tissue
and
the
subcutaneous
ditions
cona
extent,
greater
lymph-vessels,
for absorption.
In experithe horny layer,presents obstacles.
The
mentation,
epidermis alone, particularly
that
ascertained
it must
be first carefully
no
excoriations,cuts, or lacerations

of the

brane
mempresent; that the openings of those canals which are covered with mucous
(vagina,urethra, prepuce) are not included in that portion of the skin examined;
that the absorptionof volatile substances by the lungs is excluded.
finally,
of the epidermis does not
structure
The histological
exclude, a priori,its permeability
forms
rupted
The
alone
to fluids and gases.
a firm
horny layer
superficial
layeronly interof the hair-follicles and sweat-glands. But
at the mouths
here, indeed, there is
an
opportunityfor fluids to enter the deeper layers of the epiderm towards the stratum
lucidum
without
callinginto play any absorptivecapacity of the glandular substance
are

itself.
V.

Wittich

has contended

stronglyof late that between the cells of the horny layer

in the septum lucidum
there are
spaces communicating with each other, and filled with
which
with
of the
substance
the juice-canals
granular cement
probably communicate
the surface and the fluids of
between
cutis,and constitute the path of communication
the body. They would also allow nourishing juicesto pass from
the papillarylayer to
the superficial
of
the
the
and
off
and
watery
epidermis,
parts
carry
gaseous constituents
of the perspiration;
it could, on the other hand, under favorable circumstances, assist in
absorptionof fluids and substances in solution.
These paths contain the star-shapedwandering cells of Biesiadecki which
reach with
their processes into the corium, and serve
for the passage of gases and easilysoluble substances
the epidermis and cutis.
between
above
The
descriptionharmonizes
completely with the phenomena of vesication
from
and
thermic
irritation.
chemical
resulting
The
filtration capacityof the epidermis is,according to Y. Wittich^s experiments,
But
its permeabilitycan
be increased
extremely small, although not entirelyabsent.
at any time by soaking the horny layerand looseningits texture.
This especially
occurs
when
substances are pressedinto the orifices of the glands and distend them.
We
will first consider the simplestcondition of absorption.
The experiments with longWater, appliedto the uninjured skin, is not absorbed.
continued
baths give indeed an increase in the body weight, but this depends in all probability
of water
water
imbibition
by the epidermis, not upon
absorption. All
upon
experiments at least in which the water of the bath contained in solution substances
could be easily
which
detected in the excretions or secretions,have given negativeresults;
used.
provided the necessary precautionswere
Most experiments have been made
with the salts of iodine. The careful experiments
of Braune
negativeresults.
gave invariably
Fleischer has latelymade
inclosed a limb in a glass
very careful experiments. He
at
vessel containing water
of a communicating
an
even
means
kept
temperature. By
the
of
after
he
determined
level
the
it
with
fluid,
a layerof oil to prevent
pipette
covering
the
skin
of
the
If
absorbed
the
fluid in the pipette
now
evaporation.
height
any water,
would
After
several hours
sink.
that Fleischer
this took place to such a small
extent
concluded
that the epidermis imbibed
absorbed.
some
water, but that none
was

74

ABSORPTIVE

THE

similarlydoes
are
simply brushed
applying to the skin
skin

The
tinctures
On

iodine

found

Eohrig

in the

OF

POWER

alcoholic

absorb

not
upon

AOT)

SKIN

solutions

ITS

LIMITS.

of various

substances if the

the skin.

various
urine

THE

watery

solutions

saliva after

and

of
by means
twenty minutes.

the

spray-apparatus,
After

one

to two

V. Wittich and I, who repeated

ferrocyanideof potassium in the urine.
this experiment with slightmodifications, constantlyobtained
negative results. It is,
therefore, doubtful at least whether absorptiontakes place after simple spraying.
the skin substances
is somewhat
different in rubbing upon
The
dissolved or
case
fat
In
oil.
then
in
takes
or
some
cases
absorption
places apparently through
suspended
and
ducts
of the glands into which
the fat is pressed. But in most
the mouths
cases
nothing is absorbed.
he found

hours

in them

contained

Fleischer

hair-follicles.

morphine

and

It cannot

and

there is not

which

obtained

negative results

with

ointments

of potassium iodide,
sometimes
positive,
negative,

sometimes

were

acid.
containingsalicylic
be doubted
How

is absorbed.

are

veratrine,while the results

ointments

with

stances
upon observations upon rabbits,that fats and the subof
absorbed to an unlimited
extent, probably at the mouths

holds the view, based

Lassar^

upon the skin in the form of an ointment

is
taken up by the skin is a questionregarding
mercury
that the greaterpart is
of opinion. Eohrig thinks

that mercury

in what

form

yet harmony

rubbed

of mercurial
Others
believe that the mercurial particles
vapor.
of the hair-follicles or sebaceous
glands (Neumann) or pass
through the mouths
the
of
the
epidermis
(Eindfleisch,
Fleischer). According to
superficial
l
ayers
through
which
is
the
oxide
of
always
V.
present in mercurial ointment,
Barensprung,
mercury,
be
absorbed
and
dissolved
This
is
active.
become
alone
can
by the free acid of the sweat,

in the

absorbed

form

enter

and

so

is absorbed.

Gases

through

and

substances

the shin

with

diffusionof

wJdch

easilybecome

considerable

volatile at

low temperature
relatively

pass

readiness.

through the epidermis takes place most easilyof all. This

with
regard to hydrogen sulphide,carbonic oxide,
experimentally
long
proven
carbonic acid gas, chlorine,prussicacid,and other gases.
Eohrig has latelyobtained positive
results in experimentswith these gases and with chloroform, illuminatinggas, etc.
He has
these gases, produce characteristic
is saturated with
a,lso shown
that baths, if the water
symptoms of poisoning.
The
absorptionof volatile substances, such as turpentine,camphor, etc., very readily
takes placethrough the intact epidermis.
of absorptionis increased by the presence of an
that the difficulty
The circumstance
of
and absorptionis aided by the removal
the
skin
is
stratum
one
importance,
"oily
upon
of ether, alcohol, or chloroform.
of this layerby means
According to my experiments,
those
of
of
the
solutions
based on
apomorphine, salicylic
acid, etc.,
pilocarpine,
Eohrig,
the skin, were
oil of turpentine,powerfully sprayedupon
absorbed
to the
in ether or
greatestextent when the skin had first been washed with soap or ether. The quantityof
that no practical
be taken up in this way, however, is so small
the substances which can
of administeringdrugs.
be attached to it as a method
can
significance
The

has

gases

been

Although it is certain

that

'

watery

solutions

Lassar, Virchow's

of

organic

Archiv, Bd.

and

67, 1.

inorganic salts

are

not

ABSOEPTIVE

THE

the

of

and,

by

can

solutions

conduction

the

upon
the

upon

AND

ITS

receives

therapeutics

yet

saline

of

centripetal

Should

taken
for

Finally,
pressure

these
in

practical
the
is

it

be

of
cannot

that

76

LIMITS.

in

compensation
ends

central

of

the

the

trine
doc-

peripheral

system

nervous

very

greatly,

substances
be

denied.

volatile

medicinal

nerves

and

substances

substances

ether,

epidermic

of

limits

and

gases

(alcohol,

substances

not

purposes

absorption

employed

established

the

diosmosis,

of

absorption

the

further

volatilized

easily
by

that

affirm

further

place.
in

though

of

action

SKIN

THE

OP

the

upon

processes.

We

also

skin,

uninjured

irritating

means

metabolic

takes

the

by

a,bsorbed

POWER

oil

of

by
dissolved

turpentine,

therapeutics

will

be

fats

when

the

or

etc.)
somewhat,

enlarged.

dissolved

or

suspended

in

ical
mechan-

skin

pended
sus-

are

GENERAL

AND

PATHOLOGY

THERAPEUTICS

OF

THE

SKIN.

BY

HEIIJTEICH

AUSPITZ,
OF

I.

The

of

in

organs
laws

pathological

process,

present

picture

another

of

history

between

of

denial

complete

pathological

The

types.

simply

organ

to those

subordination

of the

skin,

However,

each

the

ter
charac-

individual

logical
patho-

covering,

nutritive

same

the

and

the

of

general

to

general tegumentary

of

repetition

this

structure

the

as

entirely

correspond
that

the

as

SKIN.

will
in

disturbance

liver.

its

the

of

skin,

indeed,

and

individuality
suitable

most

far

so

pathology

the

skin

individualization.

an

complex

the

example,

for

organ,

The

is not

of the

THE

clear, however,

carried

highly

which

is

require

not

such

diseases

It

be

only

do

in

of

general.

can

of its functions,

OF

NOSOLOGY

features

pathological

diseases

GENERAL

VIENNA.

method

presents

its

entire

be

adopted

to

vacillation

constant

the

from

separation

general

that

be

to

appears

of

parative
com-

pathology.
find

We
that

extremity

of

and

in

deferens,

of

In

one

The

in

and

large

of

which,

in
each

glands
tissue.

are

have

situated

Certain

the

the

of

in

epithelium

tract,

in

the

example,

mucous

the

the

e.,

etc.,
a

shape

From

male

urethra

the

the

in

the

is

of

the

formed

parts.

some

or

more

vas

brane
mem-

connective-tissue

the

diac
car-

and

mucous

membrane

mucous

cells, the

round

or

cept
ex-

laminated

the

skin.

vs^herever

ciliated

present
in

appears

the

of

the

in

passages,

are

integument,

merely

(prismatioj

it is in

uteri, i.

os

cells, which

epithelial

remains

as

air

surfaces

special
part

the

respiratory

intestines,

tracts', for

of

external

the

as

there

cylindrical

external

mucous

and

stroma,

part

air, the

the

layers

same

layer,
layer

the

cylindrical
of

the

in

from

remaining

papilla9

basal

anus,

remainder

the

papillae; the

vaginal

secreting

connective

with

contact

of

horny

connective-tissue

genitals

layers

and

with

boundary

papillary

female

more

the

to

the
the

to

the

upon

stomach

the

larynx

the

provided

lingual

or

addition

in

the

consists
of

destitute

is

directly

directly

is not

merely

membrane

mucous

situated

being

latter

the

epithelium

epithelium,

pavement

not

that

its

less

is

stroma

distintly

intestinal

marked

villi.

The

covering.
itself, in

membrane
bladder

and

vagina,

part

contain

in
no

the

cous
submu-

glands.

in the

occurs

The
the

synovial membranes

and

serous

cells

from

their

from

which,

of

in the

membranes

mucous

are

independent epitheUum

true

of

secretion

with

covered

are

origin,

form

regarded

as

In the

cells.

itself in

manifests

layer, which
epithelial

of the external

castingoff

The

77

SKIN.

THE

OF

NOSOLOGY

GENERAL

of

single layer

the

of

connective-tissue

as

tion,
desquama-

epithelium,
pavement
tinguished
disare
cells, and
there

membranes

serous

skin

mucus.

is

no

papillary

structure.

inferred

It may

be

and

serous

membranes

the

former

which

compared

In

differ

not

far

so

as

with

the

other

from
essentially

skin

lay,in

layer of

the skin, and

membranes,
another

one

greatpart,in the
while

in their

between

the

basal

mucous

epithelial
layerof
in the

furthermore

follicles

connective-tissue

types.

part of the diseases of the skin is attributable

to

abnormal
congenital

anomaly in the physiologica

epidermis
this respectfrom
the anowill
be
malies
decisive
difference
a
processes,
of
delicate
with
and serous
covered
more
of the mucous
layers epithelium
membranes,
various irritants will produce varying effects,according
cells. In a similar manner,
cate,
the outer
covering is an elastic resistant membrane, as in the integment, or is a deli-

growth of the

as

the external

tissue of these

in the

found

are

layersdo

these brief hints that the chief difference

from
and

as

whole

or

in individual

layers,or
presented in

to

an

but easily-replaced
layer,as in the other membranes.
easily-ruptured
the glandular structures
relations are recognizablebetween

Similar
those

of other

those of the
We

may

organs,

kidneys.
point also

as, for

to

example, between

the

certain similarities which

of the skin

glomeruliof

the

sweat

exist between

the

skin and

glands

and
and

mucous

a thick
covering and profusepapillaryformation, for example
epithelial
palm of the hand and the tongue, and to the fact that certain simple,
in both places. It is a strikingfact, on
epithelium affections mainly occur
hyperplastic
arises from a typicalepithelium proof neoplasm which
the other hand, that that form
liferation
in the skin, as in the mucous
be
to
confined
or
(epithelioma cancroid)appears
membranes, to the papillarydevelopmentalform of the boundary, that accordingly it

with

membranes

the

between

tinctly
in which
the papillary
form is dismembrane
parts of the mucous
marked
(the oesophagus,cervical canal of the uterus, etc.).
but we will content
ourselves by emphasizing
It would
be easy to multiply analogies,
that the pathological
types in the skin differ indeed in many respects
again the statement
be attributed
from those of similar organs, but that these differences must
directlyto
to a genius loci,which
differences of form in their development and structure
pears
disapthe structure
of other organs
at once
when
approaches that of the external skin.

only in

occurs

those

"

If

we

consider

the

morbid

processes

of the

skin

as

whole, the fact

at

once

forces

that it is by no means
us
sharply-definedgroups of symptoms
easy to form such
they can be clearlydistinguishedfrom other groups by their originand method
their course, progand objective
of development, their peculiarsubjective
characteristics,
nosis,
is added
the observation
that certain
and reaction to curative agencies. Then
related to
are
irritants,coming from the outside or developing in the organism itself,
irritant
the
ous
and
time that one
these changes; at the same
same
may correspond to variThe morphology
deviation to various forms of irritant.
deviations,one and the same
is full of details,but comprehended with
of diseases of the skin constitutes a whole which
and classification of all
and it is scarcelypossibleto make
a dry enumeration
difficulty,
We
will lay stress, therefore, only on
these
changes reallyattractive to the reader.
law
the general pathological
those features in the generalpathology of the skin in which
in harmony with the processes in other organs or in contrast
whether
is clearlyexpressed,

itself upon
that

to the latter.

fl^

SKIN

The

irritants which

various

tegumentary
distinguishedfrom
Among these disturbances
which
the general term
have

which

indicated
At

termed

been

by

''

the words

the outset

organs,
which

is

THE

integument give
nutritive

rise to

various

disturbances,but

processes,
are

to be^

dolor, functio laesa,"have been ascribed.

of the skin, as well as of other
''inflammation"

calor,rubor, tumor,

will

we

OF

THAT

according to the predominance of this or that factor.

one
categoryhas always been regarded as a separategroup, for
inflammatory processes has been chosen, the causal factors of
"inflammatory irritants,"and to which certain clinical features,,
assume

that

as

something

be conceived

must

the

all be termed

may

AND

GENEEAL,

IK

PAETICULAE.

IN

act upon

organs, which
another
one

in the

8Xm.

THE

DISTUEBANCE

KUTBITIVE

INFLAMMATORY

THE

OF

NOSOLOGY

GENEEAL,

which

is

developing,changing,never

as

thing
some-

finished.
stationary,

inflammatory process in the skin is characterized :

a.
By changes in the circulatoryapparatus which may increase from distention of
and plasma through
the vessels to abnormal
exudation, to the passage of blood-corpuscles
the walls of the vessels (hyperaemiaand exudation).
b. By changes in the nutrition and growth of the tissue elements
produced thereby
and
of
nuclear
the
in
the
cells,
shape
changes
(parenchymatousinflammatory processes,
the
o
f
stationary"elements).
proliferation
apparatus (pain and
c.
By changes in the peripheral,sensory, and motor nervous
The

"

disturbance).

functional

of these factors is to be considered

Which

primary, is

still

entirelyunsettled

at

the

presentday.
If

confine

we

with

ourselves, therefore,to regarding the

the vascular,parenchymatous, and

result of certain irritants with

be able, from

clinical

which

standpoint,to

nervous

experiencehas
overlook

the

nate
inflammatory process as co-ordiit
to
and
as the
considering
processes,
made
will
we
us
acquainted,
finally

fact

that the

manner,

situation,and

spite
beginning of the action of these irritants are still entirelyin the dark, deselves
experiments. However, we will be compelled, at the outset, to ask ourthe question: is the inflammatory process, although not comprehended pathogeneclinical
a
readilydefined, sharply bounded
a whole, to be regarded at least as
as
tically
strict
definition
of
the
affirmative
not
is
a
an
unqualified
process
;
entity? The answer
have not been completely defined.
is impossibleat the presenttime, and its boundaries
Accordingly, we must add the followingexplanation:
characteristics is
a.
Every pathologicalprocess which presentsthe above-mentioned
inflammatory.
ble.
h. It is not necessary, however, that all the factors should be present or demonstraThis is true to the least extent of the nervous
symptoms, which are quiteoften absent.
Furthermore, the parenchymatous processes may often be so slightand temporary, that
into tissue diseases
and are converted
they escape observation,or they become stationary,
of a peculiarkind.
Finally,
in saying : there
With
c.
regard to the circulatoryprocesses, the clinician is justified
a
is no
change in the walls of the vessels (Oohnheim),
inflammatory process without
although these may attain but a slightgrade.
It is best to call this process (withVirchow) fluxion,and to understand
by this term
the
of
so-called
result
in
irritants,
a
which, as
inflammatory
change
all those changes

period of

the

numerous

has been

produced in

the

structure

of the walls

of

the

vessels

which, with

Strieker,we

:80

GENERAL

cular

district

redness
the

the

as

of such

centime

under

elevation

portionsof the skin between

erythema. This condition

graduallydiminish and

or, at the

most,

the

Here

corresponds

earliest trace
to

the

of

centre

of

often

pears
ap-

the collateral branches, it also involves the hitherto

spotsand

the individual

be

may
of the

indefinite,
largerpatches
then

the individual

of the entire

trace

no

produced

also

process

toms
sympremains

internal

by

causes,

membranes,

except that in the

the skin, the ramifications

mucous

the

delicate than

more

forms

certain extent, and

hyperaemicredness
is

district often

the skin, this punctate redness

by the excretory duct of the follicle.

described, which

latter,the epithelium of which

belong).

meshes

disappear. Either
desquamation.

here

correspondsentirelyto the

SKIN.

follicle of

is formed

increases to

moderate

arterial fluxion

The

THE

vascular

each

which

hypergemiathen spreadsto

If the
intact

OF

papillaryvascular

rule, a few

is formed

central

darker

as

and

circle which

vascular
as

of

(to which,

is first shown,

NOSOLOGY

epidermisof
sharply defined

of the distended vessels themselves

appear more
the process leaves behind an increased secretion of mucus.
This description
corresponds exactly to the results

of

the

secondly,that

parallelexperiment

in

animals.
If
to
a

rabbit's

and

one

minutes

few

hour

dilatation

moderate

to half

of the entire

the

of

mustard

oil,it presents within

about

elevation

of

temperature

and, under

also of

the

veins, which

phenomena

give place

to

the

condition.

normal

this also

disappears after

tissues

constitutes

but

arterial fluxion in which

and

arteries,then

hour, and

occurs,

dilute

very

redness

rosy

of the

an

tissue

swelling

The

with

is brushed

ear

half

the

three-quarters

glass,
a
disappear within
magnifying

Exceptionally

swelling

some

while.

transition

to

more

blood

of

profuse transudation

of

forms

severe

is added

to the simple

plasma
of white
time, a larger number
disappears,and, at the same
congestion,which soon
We
in callingthese
are
justified
blood-globulesappear to be mingled with the serum.
sense.
inflammatory oedema in Cohnheim's
appearances
This inflammatory oedema
complicates the majority of hypersBmiasof the skin to a
lesser or greaterextent, provided that the irritant is not too weak, or its action has not
been

too

Let

brief.
us

now

the rabbit^s
upon

that

assume

ear

or

the human

rabbit's

ear

an

irritant acts

more

for

intenselyor

skin; for example,more

concentrated

longer period upon

mustard

oil is brushed

in succession.

it several times
In the

more

the

experiment

together with

teaches

increased

the

following

rapidityof

dilatation
flow

of

of

the

arteries,veins, and

blood, and

redness, swelling,
time.
A
phenomena
disappear after some
tempei'ature of the concha, which
their appearance,
while
the flow of
hours
few
later,rosy redness, heat, and swelling again make
responding
blood in the neighborhood gradually becomes
slower, and stasis develops in the capillaries. Corcapillaries first
and

occurs

elevation

some

the

of

to this, red dots and streaks (small hemorrhages)

develop upon the ear ; in certain cases,
they burst, leave spots destitute of the epidermis and from which
finally,vesicles form which, when
At this period the microscope
or
shows, in the veins, the peculiar acbloody fluid flows.
cumulation
a serous
of
the

extravasation

the

white

of white

blood-globules along the walls

blood-globules from

the

veins

of the
and

veins

and

which

capillaries,and

is

soon

followed

capillaries.

followingare the appearances

experiment :
of the vessels,diffuse
First, filling
evidence
;

the

"

The

that

by

red-globules from

it is due

upon

the human

skin

rosy redness, which

to dilatation of the vessels ; at the same

then pain, swelling,and thickening of

pruritus,

as

the result of the

disappearsupon
time, elevation

the skin from

the

parallel

pressure,
of

occurrence

an

ture
temperaof

GENERAL

THE

OF

NOSOLOGY

SKIN.

81

but not always

occur
occasionally,
changes upon the surface of the skin
which have been called inflammatory efflorescences by pathologists.
found
in inflamed skin shortlyafter death show that the process is
The appearances
to
that in the skin of the rabbit.
in all respectsanalogous
tion.
accurate
direct knowledge, however, concerning the stageof exudaWe possess more
In this stage,the inflamed tissue in the vicinityof the vessels,i. e., the corium
its papillarylayer,is found:
proper and especially
Moistened
blood plasma.
a.
by transuded
from the vessels.
i. Infiltrated with red, and, to a largeextent, white blood-globules
itself by
which manifests
A nutritive change is thus produced in the corium
itself,
sue
tisof the connective
the followingphenomena : the protoplasm of the cellular elements

exudation, by which

^uid

which

ecchymoses
"

to be

appear

"

various

of

formation

swollen, their nuclei

becomes

division and

increased,nuclear

cell fission

fillingof the entire

thus soon
presents to the eye
cells of
the vessels with young uninuclear and multinuclear
which
free nuclei, singly
varied form, with and without
are
processes, between

to

occur

the

the
; -finally,

concealed

are

marked

more

connective-tissue
the most

extent, and

layeraround

main
During these processes the fibrous connective tissue and elastic tissue rebe
detected
in
and
distinct
can
no
abnormality
noteworthy
change,
any
The
the glands,their excretoryducts, and the adiposetissue.
epidermis,however, presents
cences
Its implicationgives rise to the development of effloresa different condition.
(anthemata)and in the first place,
nodules.
The
first change in the tissue of
1. To the formation of spots and
of the cells of the epiderthe corium, the hyperaemia,correspondsto a greatersucculence
mis,
the lowermost, youngest ones, then the so-called stratum
lucidum, the
especially
of the cells and nuclear remains of which
basal horny layer,the contours
again begin to
show more
distinctly.

in groups.
free from

and

While

the

layers of

changes in the papillarylayer spread farther, and

the cutis become

of the

of the elements
as

filled with

fluid

also

epidermis

cellular

and

increases, so

superiorlyby
boundary, formed
papillae,
pushes itself forward, and a more

its outermost
the

lary

into the

cones

For

this

epidermis
not

appear

and

tissue of the corium

the

cutis, formed

displaced or present

slightelevation of
change of color, and

The
the

may

also,the papillaeappear

reason

by the
itself less

that

it appears

the

deeper

succulence

enlarged in depth, inasmuch

wards
horny layer and interiorly its boundary tomarked
interpapilprojectionof the thickened

the

recognized.

to be

the
elongated,although the rigidboundary between
cylindricalcells of the Malpighian layer,does
sharply.
lowermost

the surface
the

be

the papillaeand
then
inflammatory transudation, the

entire

produced by this process is

change in the integument

concealed
is called

usually by
a
spot or

macula.
The
tracts

followingfurther
territories of the

or

erythema,
also

the

appear more
cells of the

advance

in the process
papillarylayer,which

tissue of the

corium

visible to the naked

whose

fluid contents

means,

occurs

the
to

individual

vascular

separate districts of

correspond
sharplydefined as individual districts of swelling,above which
Malpighian layer become swollen, without losingtheir serration,

their nuclei appear

less distinct or
in
epidermisthus develop
patcheswhich

while

now

become

divided

correspond to the

(Renaut).

Elevations

of the

irregularinfiltration of the
and
the correspondingprotrusion of the epidermis,and become
eye as inflammatory nodules, solid swellingsof the skin, *. e., as such
still inclosed in the cellular elements which are swollen by its
are

82

GENEBAL

Free

fluid,i. e.,

the

epidermis or

and
the

OF

NOSOLOGY

of serum,

largeraccumulation

within

the

THE

latter,does

not

SKIN.

blood

or

pus,

during

occur

between

the

the coriunt

nodular

stage

of

process.
the

skin

and

quantityof exudation
epidermis,the process
either has reached its height with
the diffuse hypersemic swelling,the macula, or with
then graduallyreturns
to the normal.
the formation
of the nodule, and the corium
the
exudative
of the
2. Formution
of vesicles and pustules. If
intensity
process in the^
in the hitherto
does not diminish, a process
corium
occurs
solid-lookingnodule which
holds good for all vesicular and pustularformations.
This is :
in the
The swellingand granular opacityof the cells of the Malpighian network
a.
lower layersand the slightseparationof the serrations from those of the other cells (praBpustulationaccording to Eenaut).
Then
within the projectionof the epidermisbelongi, the formation of a meshwork
ing
If

merely

has not

irritant has acted upon

moderate

exceeded

absorptivecapacityof the

the

the

of the

elements

to the nodule.
of the swollen
cells of the prickle
the stratum
occurs
lucidum, a transformation
Starting from
layer of the rete into a very bright,transparent body of the shape of a lentil lying transversely, which
is bounded
of swollen
is
laterallyby dense columns
cells;in the middle, however, a fibrous meshwork
formed
of

of which
are
composed
crossing one another in all directions,the meshes
elongated epithelium cells which, according to Unna, have undergone
filled with a moderate
of serous
amount
are
change, and the interspaces of which

by fibres and bands

flattened

compressed,
fibrinoid

sort of

transparent fluid and

formed

this into

converts

serum,

pus-corpuscles.

cavity thus

The

within

another

the

nodule, traversed

by

of efflorescence,the

form

strands

vesicle.

and

elevation,the base of which

above, this is a transparent,rounded
wall of the vesicle is more
surrounded
The
by a red, hypersemic zone.

is

trom

shows, in the middle,

occasionally

less
flat,
plate-shaped,

filled with

When

looked

less tense

or

at

occasionally

transparentdepression,

an

and
um-

bilication.
the parto escape, because
a vesicle allows
only a few drops of serum
tition
opening of the entire vesicle; if the entire
prevent the simultaneous
top is cut off,we will notice on its lower surface a whitish-yellow layer, consisting of the ruptured
strands
and loosened
of fibrinoid change.
of the network
cells of the epidermis in a condition
If

pricked

While
below

from

of the

walls

the

above, such

meshwork

papillaeto

the middle

the

side of the

vesicle

of the

portion of the vesicle rests

The
a.

the

rupture

vesicle,often with

the

the

has

process

within

alreadyand

take

its

before the exudative

at

if in

as

to

seem

flat

changed their elevation, the papillarybodies

somewhat
that the episo
pressed downwards
dermic

not
be

saucer

of the

corium.

ends either :
process of vesicular formation
With the absorptionof the contents of the vesicle without

5. With

and

vesicle have

commonly

there

then

which

the

of the walls, and

formation
run

place. During

fresh

a
an

has terminated

destruction

discharge of the

layer of cells of

acute

course,

; after

the

of itswall ; or,
of the

contents

serous

If the vesicular walls have

of crusts.

its course,

process

the

not

ruptured until

epidermiswill have

however, the walls

contents

of the

formed

often rupture

vesicle have

caped,
es-

red deep spot which

secretes
fluid,
remains
serous
a
papillarybody, covered merely with the layerof cylindricalcells,is

considerable

laid bare.

Or, finally
c, with the further
If

the

originalirritant

has

development
been

of the vesicle into

strong
sufficiently

to

effect

other

forms

marked

of efflorescence.

extravasa-

tion into the cerium

and

its

with
filling

THE

OF

NOSOLOGY

GENEEA.L

of young

largernumber

83

SKIN.

cells,the character

of

that the fluid contained

in the
the process in the epidermis is changed in such a manner
number
of
the
network
is
of
with
cellular
elements
meshes
an
increasing
mingled
young
which

cannot

which

may

distinguishedfrom

the

fat

provided with
granules.
of

contents

The

cutis and

among

of cells and

nuclei,

tus
finally
granular detri(wanderingcells,Biesiadecki),

processes

the

in the

cells collected

young

there, spheroidalaccumulations

be demonstrated, here and

also bodies
and

be

efflorescence

termed

longer

but

pustular,
cence
them, and the effloresreallymerely a
itself is termed
a pustule.
In its complete development, this forms a round, straw-yellowor grayish elevation
of the surface, usuallysurrounded
by a red zone, very little or not at all translucent, and
It is often noticed that the umbilication
the walls of which ordinarily
are
tenselydrawn.
into the pustule;
which had been presentin the vesicle is lost after the transformation
although there

is

in other cases,

the

are

no

now

serous

quantitativedifference between

umbilication

does

not

evident

become

until

the

have

contents

come
be-

purulent.
Under

microscope, the network

the

laterallyand

extensive

more

underneath
corium

netwoi-k

the
that

so

the

appears

to be

between

boundary

of the

with

pustule,compared
the basal

cell

that

of

layer of

the

the

vesicle,appears

layer
cells as the papillarylayer of the
densely filled with young
both is indistinct or entirely obliterated.

inferiorly;

furthermore

Malpighian

as

of the pustule. In one series of cases, the

developmentand retrogression
into normal
in the papillarylayeris absorbed
is converted
or
of
without
marked
connective
tissue,
granular degeneration. The degendevelopment
eration
contents
t
he
fluid
of which
gether
to
the
is then confined
dry up, and topustule itself,
crust which
form a brownish
with the fatty,granular degenerated cellular masses,
this crust, however, and
is laid bare by the burstingof the horny layer. Beneath
trally
cenlucifrom the lateral healthycells of the Malpighian layerstartingfrom the stratum
dum
(?) a new layerof cells has formed in the shape of a band between the incrusting
and the corium, its upper layers of cells being destitute of nuclei and
pustularmass
pearing
ap3.

cellular

Further

accumulated

mass

to be flattened ;

new

young

epidermishas formed,

above

which

lies the

crust,

inclosed

in a capsule. Finally, the

as
by the originalpustularwall, and thus
old pustularcoveringfalls off,the crust springslike a lentil out of its pod and pustulasomewhat
tion is completed, leaving behind
a
newly formed, young,
deeply situated
returns
to
the
normal.
Umbilication
which
the
longs
bebeneath
papillarybody
epidermis,
to the vesicular as well as the pustularforms ; indeed, a central depressionof the
in the first stagesof the exudative
surface is observed occasionally
process.
covered

This

depression is
the

between
fluid in it.

This

not

produced by the traction

occupied by the network

space

umbilication, which

Basch

v.

and

of

hairs
and

the

or

the

too

termed

I have

as

soon

tension

as

be

also

and

drying

the

produced

is the

quantity
primaiy
when

result

of the

of

proportion
dis-

exudative

umbilication, often

the

covering is tightly
occurs;
greater
umbilication
no
exists,by puncture and discharge of a small quantity of fluid.
stretched, i. e., when
the pustule begins to dry, and
from
develop, when
But a second
variety of umbilication
may
the space
the same
the primary, viz. the disproportion between
occupied by the pustule
cause
as
disappears

it may

like, but

small

and

the contents

We

will

now

which

are

now

consider

being absorbed
those

cases

in which

the

up.

nutritive

part of the corium

cannot

disturbance
remain

is

master

long continued, and the upper

changes. In these cases granular and fattydegeneration of the cellular
not only in the parts of the pustulewhich
abscess formation
belong to
occur,
and

active

more

of the
masses

the

bid
mor-

and

epider-

84

GENERAL

THE

OF

NOSOLOGY

SKIN.

mis, but also in the papillary

layersituated underneath
The

of the corium.

depth

cavityextends

abscess

from

it,indeed often extendinginto the

the top of the pustule down
into

suppurating loss of substance, an ulcer, and terminates in the

development of cicatricial,band-shaped connective tissue, above which a new-formed,
the lateral layers of the epidermis. The
delicate epidermis has formed, startingfrom
is thus developed,consistingof the flat,
cicatrix left over
after deeply-spreadingpustules
destitute of papillse,
firm tissue of the corium
extending under a delicate epidermis.
In very thin partsof the skin, for
inflammationof the shin and catarrh.
Superficial
into
the
skin
of
transition
of
in
the
mucous
membrane,
hyperaemia
points
example,
diffuse redness, as in true mucous
manifests itself by an
almost
membranes, and the
termination
in desquamation passes insensibly,in such places,into that of increased
the corium, there forms

secretion

of

mucus.

cessive
exdevelopment of the epidermis, the nuclei of the Malpighian cells atrophy from
takes the
In desquamation, then, the former
enlargement of the nuclear bodies.
process
of cell nuclei
place of the latter; a number
atrophy instead of forming keratin, thus lose the
resistance
peculiarto the latter and the diseased epidermis cells are cast oflfin an incomplete state.
membranes
also constitutes
The normal
secretion
of mucus
from
the mucous
than
nothing more
responds
a
evidently cordesquamation of the peculiarly changed upper layers of the epithelium,which
physiologically,if not chemically, with the cornification and desquamation of the
horny layer.

In disturbed

It is certain

which

have

that

in the

affection

fornn^tion, and

of mucin
not

yet reached

of the

also with

their

membrane

mucous

also

we

have

of the

early desquamation
highest development.
an

to

deal

cells of the

with

bance
distur-

epithelial
layer

membrane
associated
with congestion,and which
Every increase of the secretion of the mucous
various
is produced by an inflammatory irritant,is termed
we
a
catarrh, and
assume
cording
grades acthe desquamation of the mucin-containing epithelium cells occurs
as
merelyjwith a secretion
fluid or a more
of pus occurs
of serous
profuse formation
(purulent catarrh). But such a catarrh is
extensive
increased
secretion
of mucus
not simply an
in the epithelium cells or a more
tion
transformasubstance
tissue into mucin.
of collaginousand chondrogenous intercellular
of the connective
Its essential
cellular

consists

feature

elements, from

necessarilycontain
which
the

the

is dissolved.

mucin

the

Herein

the

increased

exudation

is not

Under

increased

all

into

of blood

the

but

rather

secretion

of

mucus,

but

I find the

mucous

for applying
justification

more

secretion
of

of

or

does
fluid

serous

feature

increased

analogous process
membranes,

also, efflorescences

catarrhal

the term

in the external

cataiTh

less
not
in
of

tion
sero-purulent exuda-

occur

such

inflammation

circumstances
occurs

upon

the
the

questioncannot
skin which

dermatitis

or

catarrh

integument.
after

those

Under

amount

essential
an

with

catarrhal

larger

the

covered
'vith tesselated
are
places which
pavement
observe
and find erosions
larger and small transparent vesicles,
suppurating surfaces left over upon their site, etc.
upon

The

circumstances

mixed

serum,

tissue.

surface.

of the skin to the

Upon

the

hypersemic vessels
of mucin,
larger amount

membranes

mucous

upon

of

the

or

stronger irritants,and especially

epithelium. Here also we often
ulcerations
with
even
superficial

be shirked whether

not alone is

no

form of superficial

anatomicallyand

cally
physiologi-

inflammations
of the mucous
sembles,
membranes, but also closelyreanalogous to superflcial
catarrh.
This clinical
in its clinical history,the symptomatology of mucous
would
flnd its expression in a clinical historypresentingas distinctlythe
relationship
character of a diffuse process, at least in a certain stage,as catarrh of the mucous
branes,
meminternal inflammatory
to external
and like this would
or
manner
respond in the same
indeed
irritants as the external periphery of the organism. These conditions
are
which
term
of
the
fulfllled by that morbid
external
we
eczema.
integument
process

GENERAL

NOSOLOGY

OF

THE

85

SKIN.

in both instances.
is entirelysimilar
On
the
reallyis,that the process histologically
of eczematous
histologicalexamination
integument teaches nothing else than that of
of course,
as
a matter
however, varying according to the differences
catarrh of mucous
membranes;
tissue layers of both organs.
of the individual
in the structure
examination
of eczema
the
anatomical
In like manner
corresponds entirely to those appearances
fact

The

"whole, the

vrhich

v^e

of the skin

which

of

case

in this

call attention

general

in the

eczema

that

or

stage, and

forms
to

entirelyunnecessary
from

of efflorescence

in inflammations

give detailed descriptionsand

this

or

that

portion of the skin,

text-books.

here
of

of similar

examinations

in the

It is therefore

process

eczema

I must

However,
in

described

general.

constantly repeated

so

are

made

the

of

appearances

have
in

to the

most

recent

long standing,

and

which
histologica1 examination
which
the following
among

Gaucher
results

"

are

author:

emphasized by the
1. Congestion

with
papillaryvessels,and infiltration of the cerium
embryonal cells.
the cells of the Malphighian layer into vesicles with
complete disappearance
and
of the nuclei
plete
com(calledby German
histologists dropsicalswelling of the cells"),
of cells in some
inter papillaryrete cones.
of central groups
destruction
be attributed
cannot
of preparato the method
3. A partialseparationof the epidermis which
tion,
and is not obsers^ed in normal
integument.
been left over
the tongue (which have
4. Ulcerations
evidentlyby the efflorescence).
upon
with the general appearances
of inflammation
in irritated
The first point is entirelyin harmony
of the

of

2. Transformation

"

skin.

viz., a quite
point corresponds to the clinical api)eai'ances of the observed
case,
had lasted some
time.
This also holds true of
swelling of the epidermis which
the fourth
point.
render
certain whether
With
point, however, perhaps investigationmay
regard to the second
identical
with
described
not
those
Renaut
the above-mentioned
are
as
by
praepustuappeai*ances
of cells in some
destruction
of central groups
The
lation.
interpapillaryrete cones, described
by
described
in connection
Gaucher
herewith, was
long ago by v. Basch and myself, in our work on
of the variolous
(1863).
the anatomy
process
third

The

oedematous

uniform

the

Perhaps

fact

of

the

is, that

matter

formation

pustular
progressive change of the epidermis
that it is distinctly
recognizablein the
destruction

skin,

in true

if instead

exudation

of

cells in the

occurs

vesicular
less
interior

transformation

readilybecause
of the

of

they

efflorescence

the

are

into

cells and

concealed
a

network

their

by

the

; but

skin

between
the pustules or upon
the entire surface
of the
suppuration
only a diffuseinflmmatory swelling and
spots
occasionallyin superficialinflammatory processes upon the skin.

cirumscribed

develop, as

the

observed

are

may yet be
of efflorescence

of

said at this time

Something

"

in the

first

presentedby
concerning the peculiarities

These present anatomicallyno

well-known
inflammation
in the first stages,viz.,
the
of
ones
beyond
appearances
But
must
cedema.
and
we
inflammatory
emphasize the fact that oedema
hyperaemia
in
it evidentlyarises from
and
that
urticaria,
prominent part
plays an essentially
spasm
i
n
districts
and
*'.
vascular
in some
angioneurotic oedema.
paralysis others,
e., as an
forms

some

place wheals.

other

By

this

paleand

means

alone

of wheals and the occurrence

of alternate
appearance
the oedematous
under
swellings(thewheals) essentially

is the external

parts around and

The disappearance of the
inflammatory congestionoccur.

red

influenced.

gradesof
Finallywe

must

pustuleswhich

develop

refer to the
from

wheals

without

residua

histological
appearances
from
or
preferably

follicles

shows

that

in certain forms
the

tissues

cellular infiltration of the

and
follicles,

in the

vicinityof the

swellingof the epidermiscells above

'

Ann.

de

Derm., 1881.

"

and

the vessels and

glands or the hair

elongationof the prickles

sebaceous

them, with

of nodules

surroundingthem

(acneand sycosis).
is always present (dilatation
of
In acne
and
perifolliculitis
sycosis,
corium

only slighter

86

GENEEAL

OF

THE

SKIN.

of wandering cells in the rete (Barthelemy'). In addition, inflammation

appearance
in the interior of the glands have
been described, and
abscess formation
by all

and
and

observers, atrophy of the sheath

onion-like

describes

also

of

NOSOLOGY

of the

hair with

separationof the latter ; Barthelemy

epidermis (sectionof atrophic excretory ducts

in the

bodies

hair-follicles).
The

event

the

differences

of opinion depend upon

the fact that some
(Koebner) regard as the primarysycosis,the process in the interior (folliculitis
barbae),others (Robinson ^) regard the perifolliculiti
as
primary, the atrophy within the hair-follicles as secondary; while Kaposi looks upon
interior of the hair-follicles as the starting-point
in acne
well as in sycosis.
as
in

examinations

My
in two

lead

in both

ways

processes

bodies, so that
as

course

such

with

believe that the

to

me

morbid

irritant may come

district around

into

first,
primarilyin the vascular

this instance

perifolliculitis
develops in

the formation

of nodules

or

even

at the

the

start and

play
glandular
its

runs

abscesses.

Or

in the interior of the glandular bodies or hair-follicles,

inasmuch
as
secondarily,
other
of
secretion
of
mechanical
kind
a
forms
or
or
growth
(parasitical)
process
the primary process in the enchyma cells of the sebaceous
glands,or in the root sheaths
In acne,
of
the
of the hair.
occlusion
(comedo formation)
excretory ducts then occurs
the
and
with formation
of abscess in the interior of
glands,
perifolliculitis.
finally
In sycosis
has developed in this manner,
the disease of the root sheaths, which
may
be followed by death of the hair shaft, and by a spread of the process outwards
into the
In this case,
connective-tissue
ingly,
accordportion of the hair-follicle and perifolliculitis.
the perifolliculitis
is a secondary process.
It will not be proper to separate these
latter forms
(retentionforms, Virchow) from the purely inflammatory ones, because
transitions always occur.
a

morbid

l.
We

have

THE

MOEE

to deal

DEEPLY

here,

with

not

those which
more

INFLAMMATIONS

SPREADING

the

OF

of irritants of

action

etc., but

THE

SKIN".

different

d'appui which

with

nature

a
point
produce erythema,
merely
deeply or extends more
deeply into the distribution of the largervascular

from

is situated
trunks

of

the corium.
In

erted
example, the effect excording
acparasites,
by
;
less
act
to
with
a
nd
the
as
are
or
as
they
greater
according they
applied
intensity,
healthy skin or to that in which nutrition and circulation have been morbidly changed.
We will find that moderate
ally
elevation of temperatureproduces an erythema which occasionexcoriation of the skin,
or
superficial
progresses to the formation of nodules or vesicles,
hut terminates
then by the formation
This
of a new
horny layerover the intact corium.
if
the
d
ermatitis.
But
of
to
the
intensity
corresponds,evidently,
superficial
process
heat assumes
for
to
act
is
allowed
time,
a
greater proportions or
symptoms of
longer
destruction of the horny layeroccur, or incompletestasis of the circulation in the corium,
if the action is so violent that congestivephenomena are not produced at all,
or, finally,
necrosis of the tissues occurs
of the
of the papillary
at once, with destruction
body, even
entire corium
served
connective tissue,*. e., effects such as are obas
deep as the subcutaneous
in the well-known
three stages of bums.
This also hold good with regard to the
action of parasitic
animals upon
the skin.
on

order to render
the

one

hand

the difference clear,we

abnormal

will consider, for

temperature

'

Ann.

de

"

New

York

Derm.,
Med.

on

the

1881.

Journ.,

1877.

other, by animal

88

NOSOLOGY

GENEKAL

regionswhicli

certain
the

heart

of

or

perhaps also
have

of the latter

We

greater distance

and

tenous

froro:

lymphatic plexuses,

the well-known

are

that

or

in the lower

stases

which

condition

limbs

is termed

acne

of

females
of

rosacea

who
the

"

regard,as

also

must

after

and
superficial

which

constitutes
have

We

of their

account

on

of their local

construction

children,

several

face, etc.

SKIN.

of the local innervation.

Examples
borne

predisposedthereto

are

unfavorable

an

THE

OF

to

to so-called chronic

inflammations

of the skin.

Avith two conditions

deal, therefore,essentially

disturbance

venous

after

also

transition

disturbance left over

example, the local circulatory
inflammations
of the
skin, and
deeply spreading

further

with

or

either with

passivehyperaemiaproduced by

ing
pre-exist-

inflammation

acute

an

that an
bring these two conditions into closer relations if we assume
to the pre-existing
disturbance, that an inflammatoryirritant acts
is in a state of passive congestion. The difiererence between
a part of the skin which
l
ies
of
in
the
both cases
question
priority.
evidently
have to settle the followingpoints:
We now
stasis itself and what relation does it bear to inflammation
1. What
produces the venous
We

of the skin.

can

active fluxion is added

upon

And

of the skin?
2.

further,

results follow the

What

combination

of

both

factors

in

one

or

the

other series

?
priority

of

Experiments have shown

produces a diminution
then

that

rapidityof

either

of serum,

transudation

incompleteobstruction

of the

colorless

the

of the

venous

and

current

(in man) tinged

or

with

flow uniformly

return

coldness

of the

parts,
hsematin, and

and small
blood-globulesthrough'the walls of the capillaries
dark
extravasations
red, punctate
being recognizedby numerous,
chiefly
in the neighborhood of the ligature.
In the integument of the human
the process in generalresults in the irregular
arm
propagationof the incomplete circulatoryobstruction, produced by ligatureof the veins,,
districts of the integument.
from the point of ligaturegraduallyto the various capillary
The opticalexpressionof this stasis is cyanosis. If the stasis continues
for some
time,
the blood plasma passes through the walls of the capillaries,
perhaps also of the smaller
creased.
inveins, but at first in very slightamount, so that the size of the limb is not strikingly
begins ; hemorrhages as large as the pointof a pin develop,
Diapedesisnow
most numerous
in the neighborhood of the point of ligature.
at the same
Around
transuded
these ecchymoses, the blood plasma, which
time, or
the
finally,

passage

of red

veins, the latter

even

earlier,assumes
The

some
a

time,

are

transition

Between
of
filling
the

due

from

these
the

These

are

haemoglobin
to

the

ligaturewhich

with

the

has been

blood

applied

and

for

constitute

plasma,
blood-globulesin substance.
are
produced evidentlyby the irregular
of the incomplete stasis of
consequence

exit of red

spots, which
blood, in

with

flow.

the

phenomena produced by ligatureof

within

latter is removed, in
The

white

capillarydistricts

integument, and

develop below
of

transudation

noticed

are

color.

to admixture
serous

return

veaous

reddish

spots,which

vermilion

questionnow

few

minutes

short time

after the

the veins

stasis upon

or

of the

occurrence

the human

obstruction.

If the

all the results of the stasis

arises, what

happens

when

the

disappear.
stasis persistsfor

longer

period?
In man,

in
experimentation

this

regard cannot

pass

beyond

certain boundaries, but

GENERAL

"we

have

sufficient
in

processes

knowledge

NOSOLOGY

this

on

OF

THE

from

point

8^

SKIN.

experiments

animals, and

on

morbid

man.

have

Experiments
has continued

shown

long, and

too

that the
is not

occlusion

of the

flow, a, when

return

venous

in

relieved,finallyresults

it

cessation

of the
complete
but is relieved before necrosis
necrosis;5, when it is long-continued,
can
occur, produces acute inflammation, not that the stasis passes into inflammation, but
it is relieved early,produces no
that it acts as a vigorousinflammatoryirritant;
c, when
oedema
and temporary cyanosis,perhaps
further phenomena than the above-mentioned
here and there a few ecchymoses.
and

circulation

in animals, similar results,"rom

As

stasis in

venous

are
standpoint,

its relations to inflammation.

and

man

clinical

Venous

with

found

stasis in

regard to

circumscribed

produced purposely or arisingspontaneously,causes

whether
territory,

cyanosis,oedema,
globules,but not of white globules;it has nothing in
therefore,with the inflammatorychange in the walls of the vessels. As in
common,
when
it has persisted
for a
animals, however, it is capable of producing inflammation
is
then
and
relieved.
longer period,
The process justdescribed is,however, less important with regard to the integument
than the other case, viz.,an incompletestasis of long duration, such as is observed in general
of hsematin

exudation

and

red

cachectic conditions, and

in unfavorable

local

conditions.
circulatory

My experiments have taught that the purely inflammatory phenomena which external irritants
of pus
are
occurs
usually less marked, and that the formation
produce under such circumstances
of serous
and
the formation
of free
more
bloody fluid,furthermore
slowly, but that the exudation
with
frequent; that an inflammatory granulation occurs
ecchymoses, are more
greater difficulty;
that

but

entire

the

tissue

presents

livid infiltration

entirelyupon pressure, and

that the inflammatory
finally,
These

the foot),in

The

found

are

appearances

under

eczema

such

in which

acne

occur

areolae

which

temperature

be made

cannot

is less

appear
to dis-

distinctlymarked;

in necrosis.
with

varicose

are

thus,

less

and rapidly.
distinctly

inflammation

the other hand, when

On

oedema, exudation
(cyanosis,

stasis

of

ulcers

in

rosacea,

of inflammation

phenomena

blue

foundation

(ulcers of

conditions, etc.

by incomplete stasis,they

extent

dark

elevation

rapidly terminates

process
in

and

the

is

after subsequentvenous
distinctly

whole, concealed

to

certain

alreadypresent,the symptoms peculiarto

of haematin

stasis,the

the

on

and

ecchymoses) appear

marked

more

the

so

much

more

inflammatory change has

been.

Ligature experiments
vermilion

spots around

which

most

the

marked

I have

made

upon

cases

experimentsupon

from

of

scarlatina,etc.,have

certainlyand

most

ecchymoses occur
erythema is situated.

this fact and

From

which

the

frogsand

intenselyin

shown
those

that

the

positions in

rabbits,it appears

that, in

stasis is followed

by slight phenomena
those associated with suppuhgematin);in higher grades,especially
ration,
into the tissue of the cutis.
But
the
by the enormous
escape of blood-globules
marked
stasis is by no means
suppuration in an inflamed part
capable of producing more
stasis in itself
which
is alreadysuppurating. There is no
doubt, therefore,that venous
has nothing to do with inflammation, i. e., with the change in the walls of the vessels
moderate

grades

(escapeof

assumed
another

time.

serum

therein.

of

inflammation, incomplete

and

There

is

no

irritant,that phenomena

doubt,

on

the

of inflammation

other
may

hand, that the

be

act
stasis may
after
stasis
developed by

like
some

^0

GENERAL

These

facts enable

NOSOLOGY

to understand

us

conditions, although
circulatory
nevertheless
process.
With

the aid of these

pictureof that
which

chronic

leads to unfavorable

which

forms

of inflammation,

any

of the

of

from

difference

main

in the

change

not

disordered

flammation
ordinaryintype of the

difficult to

be

paint a

ter,
deep-seatedcharac-

and
superficial

often

and

inflammatory process,

terminations.

Previously,however,
some

distinct

data it will
physiologico-pathological

inflammation

under

inflammatory processes

without

course

SKIN.

THE

a
skin,
prevents the resolution of the pure

often

so

that

without

not

their

run

OF

again

must

we

constitute

developingat

to inflammation

recur

transition

from

of the

pure

skin

and
itself,
chronic

to the

inflammations

to

forms

later

We
periodduring the cessation of inflammation.
of the skin, and
them
stasis-inflammations
into
stasis-catarrhs
will call them
separate
and stasis-phlegmons,
are
more
or
according as they occur
superficially
deeply seated.
ulceration of the skin, to the latter,
To
the former belong ecthyma and the superficial
and lymphangioitiscutis,and erysipelas.
phlebitis
a

examination

of ecthyma
pustules upon the leg showed
pustule: infiltration of the base of pustule, of the

The
ulcerated

pustule, and
^ving rise to
In such

nutritive

the unfavorable
forms

of

dense

between

boundary

the differentiation from

cases

with

neighborhood,
of the

obliteration

in necrosis of the

termination

other

immediate

in the
an

base, which

the

of

masses

beneath

corium
and

cells

of

appearances

of the

epidermis and

au

tlie

detritus

granular

corium.

pure forms of dermatitis lies in the fact that the

is confined
is caused
to the pustule itself,
by

of this base, while

conditions

well-known

the

tissue

pustular formations;for example,

in

this termination

is

exceptionalin
due

small-pox,pustular eczema

to

oil,etc.

croton

given by Willan:
correspondsto the definition of ecthyma originally
by a zone) pustules,each
eruption of large phlyzacical(*.e., surrounded

This
*'An

is situated

which

on

hard

elevated

hard, greenish,or dark-colored

They

in

terminates

base, and

the

of

formation

of

thick,

separate,distributed

over
a
slightarea,
contagious.'^
forms here described,
certain transition forms between
Analogous to the superficial
deep in the skin, viz.,phlebitisand lymphangioitisof
congestion and stasis also occur
arterial congestionwith
and in this complicationof superficial
the skin and erysipelas,
the
direct
i
evident between
stasis symptoms more
marked
relationships made
deeply,
and
the
which
arterial
stasis
in
diseases,
congestionis
these phlegmonous processes
pure
subordinate
accidental
or
part.
entirelyabsent or plays a
furnishes us with a typicalpictureof the stasis phlegmons.
Erysipelas

and

are

Here
cutis

crust.

are

not

the

soaked

vessels
with

extending

especiallyprofuse around
between

the

into

the

its meshes

serum,

the

fat-cells

deep

and

subcutaneous
dilated

the

sudoriparous

gaping ; their distention

larger lymphatic
and
the panniculus adiposus inflamed
found
Renaut
In the papillarylayer of the corium, the cellular
down.

observed

The

as

In
in the

the

cases

formation

cellular

of

the

development

of vesicles

infiltration

and

in

with

white
conceal

glands.

blood

; the

tissue of the

blood-globules
them, but

I have

found

lymph-corpuscles

was

are

the
not

which

also

are

lated
accumu-

lumina

of the

demonstrable.

swollen.
infiltration

of

is also

vesicles,the

present, but

less dense

corresponding changes

may

than
be

general.

erysipelas disappear as
normal, as they do in superficial

inflammatory oedema

completelyin those portionsof skin which

inflammatory processes.

almost

and

vessels

lower

filled with

are

filled with

trunks

venous

around

tissue

and

return

to the

of

GENERAL

NOSOLOGY

OF

THE

91

SKIN.

It is evident
from
the anatomical
clinical signs that in true
and
appearances
vessels)
we
-erysipelas
always have to deal with an affection of the lymphatic vessels (and bloodredness
down
subcutaneous
and
into
tissue.
While
the
a
deep
extending
rosy
is present in superficial
shows
a
erythema, erysipelatousredness
peculiarbluish-red
glisteningwith a yellowishborder, correspondingto a congestion deep down in the skin
covered by a thicker layer of tissue,and
the oedematous
swellingcorresponding to the
infiltration of the connective tissue in the depth of the skin.
serous
Erysipelasmust be regarded probably as a capillary
lymphangioitis and capillary
w
hich
be
its
can
phlebitis,
only
expansion from the banddistinguishedby
superficial
and
of
phlebitis
lymphangioitisof largervessels. As ^ matter of course,
shaped redness
results secondarilyin an
the process
affection of the upper
layers of the skin, the
layersof the cutis,and the epidermis.
papillary
There
vv^hich

to be

is much

give rise

to

said in

favor

erysipelas, must

of

be

the

view

attributed

that
to

the

infection

capillarylymphangitis and phlebitis,

by a microparasite. Very recently,

by the inoculation
produced erysipelasdirectlyin man
(Verb. d. Wiirzburger phys.-med, Ges., 1882). Tlie
erysipelasmay, indeed, be explained very plausibly in this manner.

of cocci

cultivated

anatomical

and

Fehleisen

skin

We

conclude

now

may

the

nosology of

of the

inflammation

chronic

from

tous
erysipela-

clinical

process

skin.

As

in

viously
pre-

explained,we have to deal with a case in which stasis is induced and gradually
superadded to a previous inflammatory affection. It is evident from experiment that
but
these
conditions of stasis should
not be regarded directlyas inflammatory processes,
ingly
merely as incomplete phenomena of stasis secondarilycaused by the latter,that accordthe phenomena of the real inflammatory process
actuallyhave been extinguished
In the human
in them.
skin the followingchanges occur
evidences of this improperly
as
chronic
termed
should be reallycalled
chronic
stasis in conseinflammation, which
quence
of previous inflammation.
of stasis,*. e.,
1. The
phenomena of inflammatory oedema give place to the oedema
"

'*

the escape of blood-serum

present in the connective
further
and

presentthe

course

bands,

formed

new

the veins.

tissue of the

At

the

time,

same

skin

begin
stagesof development into

various

to grow

connective-tissue

the

and

and
proliferate,

fibrous

and

cells

in their

elastic networks

blood-vessels,etc.

this condition are: infiltration and thickeningof the skin, at first

contents
which
be forced away partially
purely serous
may
upon
pressure ; a darkand
into a bluish tint, of the surface upon
which
more
a
red, graduallypassing more
in
the
formation
inasmuch
disturbance
of
new
as
a
develops secondarily
horny layers,
This
is
the
of
chronic
slow, branny desquamation occurs.
typicalhigheststage
superficial
The

clinical

from

signsof

with

of the

inflammation
terminates

in

skin, the so-called chronic

to the

return

As

eczema.

normal, although often

rule, however, the

until

not

after

long

process

duration

of

the stasis.
2.

Under

unfavorable
specially

in those
degeneration,

of

phlegmonous

inflammations.

of the connective
and

circumstances, such
which

processes
Thus, chronic

occur

eczema

tissue of the skin, togetherwith

cases

terminations

constitute

also may

result in further

ordinarilyonly as terminations
in scleroterminates
sis
occasionally
stasis processes in the sanguineous

i. e., in pachydermie.
lymphatic capillaries,
and
The pustulesof acne
variola end occasionally
in

cicatrices,while these
Here

necrobiotic

the rule

in

they appear either as necrobiosis with softeningand

(inphlegmons affectingthe layersof the skin, such as

the

formation

of

ulcers

and

deeply spreading phlegmons.

tissues in layers

necrosis of the
burns

and

in
or
congelation),

92

NOSOLOGY

GENERAI.

THE

OF

SKIN.

degenerativeprocesses with ulceration and gangrenous

eration
degenand
the
anthrax,
furuncles,
like).
phlegmons:
Under
the same
coid
muconditions, as in other regions,fattyand amyloid degeneration,
and calcification play their part in the integument.
metamorphosis, cheesy degeneration,
of circumscribed

the form

(in localized

THE

DISTURBANCE

NUTRITIVE

INFLAMMATOEY

ANGIONEUROTIC

It is

incumbent

now

upon
the

occurring upon
with

and

to the close

morbid

connection

organism, to the
of other

organs

fact

between
that many

without

an

us

to

skin, with

changes

OF

examine

large

number

has

of the skin

fluxions

IN

TO

irritant,and also

inflammatory processes

with

been

and

effected

are

RELATION

ITS

of

their connection

Attention

inflammation

external

to

SKIN

PROCESSES.

the

regard

in the latter.

local

THE

NEURITIC

AND

called

entire organism,

the

in various

the condition

of the

directlythrough

places
entire

the

agency
of inflammations
of

to the reaction

organism, its nutrition and diseases.

there are
other specialfactors which
But apart from this generalcausal nexus,
are
the character of such inflammations.
so
important that they powerfully influence the course, even
clear by a comparison of a few distinct types of skin disease
This will be made
with one
for
another,
produced by croton oil,the variola eruption,
example, acute eczema
the skin upon

and

the entire

herpes zoster.
In the beginning, all

presenthyperaemia of the skin, followed by the

nodules may pass
pustules. As is well known, eczema
be converted
into pustules;this is the case
in variola,,
into vesicles,and the latter may
and in herpes zoster, a few vesicles develop into pustules.
The
anatomical
picture is always that of the inflammatory efflorescence,starting
from
the papillarybody and its blood-vessels,with subsequent changes in the epidermis,
of a network, inclosure of serous, then of purulent contents
swelling and formation
in their centre, finally
drying of these contents, and development of new epidermis
above the papillaryborder.
of the inflammatory process
the skin
Despite the fact that the clinical course
upon
circumstances
to
the
all
anatomical
and
under
same
according
develops
nosological
pattern,nevertheless a separationof the three conceptionsof the disease is afforded by
do not depend upon
the local effect of the inflammation.
other factors which
formation

If

we

for

three

forms

of nodules, vesicles,and

retain the above

example, by

the

we
illustrations,

prolonged action

of the skin
irritant upon the structure
diffuse
extensive
and
serous
erythema,

will find that

to appear

cases

of

into

eczema,

action

duced,
pro-

of the

marked
exclusively;
formation
parts, rapid
layers of the skin,
upper

markedly

most

acute
local

and

infiltration of the diseased

of vesicles, occasionally
leadingquickly to excoriations

gradual transitton

intense

an

oil,allows the

of croton

desquamation and recovery.

variola,a typical,but slightlyvariable

On

of the

the other

period

hand,

we

find

in

vere
se-

of incubation, characterized

of the disease,without
then a prodromal febrile
any localization,
prodromal erythema which is entirelyindependent of the later position
to
of the efflorescences;
ecchymoses (variolahaemorrhagica);development
tendency
rescence
and progress of the individual pocks,not alone accordingto the types of inflammatory efflobut
also
of
of
with
the individual phases
a
formation,
typicalduration
ment,
developinfiltration of the skin between
diffuse serous
the pustules,as in
and without
finallytermination of the process ^th the drying up of the individual pustules.
eczema;

by general symptoms
stage, and

diffuse

GENERAL

"or

formation
while

infrequentlythe

of this
The peculiarity
inflammatoryprocess of

the

the circulation

of the

course

case

98

SKIN.

of
persistence

of ulcers and cicatrization without

this is not

THE

OF

NOSOLOGY

in

chronic

inflammatoryprocess,

eczema.

evidentlywith an influence foreign to

point of attack of which must be sought in

is connected

the
the firstvariety,

blood, in the walls of the blood-vessels,and the blood itself.

The

the difference
progress of the process in the integument is alone sufficient to show
the
and
that
of
the
variola
acute
between
identityof the purely
despite
eczema,
process
mere

inflammatory processes.
we

If we
pass to the third
will find in it:

of the illustrations chosen, to the so-called

one

herpeszoster,

Frequent neuralgicpains,as the prodromal stage,in the distribution of the tegumatory

of a series of inflammentary branches of a certain nerve, then the coincident occurrence
also
into
which
into
nodules upon
soon
vesicles,partly
a
hypersemic basis,
pass
other groups
ing
of vesicles accordpustules;then development and progress of one or more
of some
to the same
nerve;
type and the same
course, always along the branches
of the
finally,after the termination of the local inflammation, occasional continuance
of the skin always depend upon
neuritis of
a
neuralgia. These forms of inflammation
affection
of
its
the nerve-trunk, or an
ganglion.
If we
will arrive at the following
the three morbid
processes justmentioned, we
compare
conclusions:
in the skin runs
its course
according to a pathological
process of inflammation
which agrees with the generalsymptomatology of the inflammation
of organs
in general. Hereafter
will describe this process as simple inflammatory process of
we
the skin (dermatitis
simplex).
1.

The

schema

2. This
inflammatory process constitutes
destroyedeither by the predominance of one or
by the degree of development which the process
3.

In

terminations

addition, there
of which

inflammations

are

correspond to the

the

cannot
nosologicalentity which
other symptom of inflammation,
in individual

readies

of the

skin the

nosologicalschema

be
or

cases.

development, course,

and

of this inflammation, but in

be found
other phenomena are vividlypresented,the originof which cannot
among
the latter have increased
to such
extent
an
purely inflammatory factors,or only when
in smallof furthering the inflammatory process.
This occurs
pox
does not seem
as
capable*
and zoster.
These
forms
of inflammation
be
termed
partlyangioneurotic,
may
partlyneuritic dermatoses, according to the character of the most prominent factor.
of the skin resides in the fact that the
Their
difference from
simple inflammations
character of the general constitutional influence is such that it essentially
changes the
And
this alone is the reason
form of the inflammatory process in the skin.
ical
why a clinseparationof these three forms of inflammatory dermatoses appeared advisable.
in congestionsproduced by inflammatory
a.
Changes in vascular tonus always occur
of the muscular
irritants,and cannot develop without active or passivestimulation

which

'

coat

of the vessels within

of, and during the

and

around

course

the inflamed

part.

And

furthermore

as

quence
conse-

of the

inflammatory process, changes in the vascular

expressionin chronic disturbances of the circulation

readilydevelop and may find an

here,
absorption. But the change of vascular tonus, to which reference is made
manifests itself first by its relative independence of the inflammatoryprocess; secondly,
factors which
have given rise to it,and
by its direct connection with the etiological
the
extension
of
its
influence
the
of the irritant. The
of
action
thirdly,by
beyond
point
factor in all diseases of the skin belonging to this categorybears the peouliar
etiological
tonus

and

NOSOLOGY

GENERAL

94

of

character
that

time

agent whicli

an

have

we

the

of the skin

affections

nosologicalconception :
influences

whatsoever,
that

this

"

change

centre"^ is identical

spinalcord,

or

with

of irritation

phenomena

vaso-constrictors

of the

sought

in the small
in

ganglionicnerve
general with

questionwhether

of the

paralysis.We

or

in this

be determined

can

solution

difficult is the

doubt

cannot

active in the walls of the blood-vessels

are

thus

of the dilators may

dilatation of the vessels.

The

As the first series appears

second
series to that of

same

ing
categorycorrespond to the followupon any part of the organism
or in a reflex manner,
so
nerves, either directly
vascular branches
belonging to it. Whether
centres
in the medulla
longata
oblarge vaso-motor

of the

one

be

walls of the vessels themselves,

Equally

belonging

tonus

must

or

least,which

at

of vascular

centre

the

startingfrom a certain central

and repeatedlyattacks the
recurs

peculiarirritant acting

in the

occurs

implies at

irritant action which,

in all directions, or,

point, radiates
periphery.
All

an

This

nutrition.

toxicallyupon

acts

to deal with

SKIN.

THE

OF

effect the

same

holds

reverse

that

elements

of the

great difficulty.
have

we

to

vaso-dilators

of the skin,'and

deal
as

that

with

well
an

as

tation
irri-

objectas paralysisof the constrictors,viz.,

concerning contraction of the vessels.
to the picture of arterial active fluxion,the

true

correspond more
and at the same
time bears the stamp of a
passive congestion,
marked
in urticaria,
spasmodiccontraction of partsof the vessels,such as we find especially
it does not seem
to be too bold an hypothesis to state that we
have to deal in the first
series with

irritant effect upon

the dilators or
constrictors
irritation
of the
series with
or

second
and

parts of

should

paralysisof

an

paralysisof

the
the

constrictors,in the
dilators.

Dilatation

of the vessels may be observed at the same

time in differIt
other.
as
a sequel of the
vessels,gne form not infrequently

of the lumina

contraction

erent

to

the

also be

same

taken

consideration

into

that

the

of
contractility

the

can
capillaries

scarcelybe doubted.
the

Among

inflammations
angioneurotic

of the skin, I

place

the acute

exanthemata

in the first rank.

diseases

poisonsof generalnutrition.

Their symptoms appear

In the latter the
integument.
organs,
effects are manifested
always in the form of a peripheralangioneurosis,as dilatation of
the vessels and hyperaemiaof larger or smaller portions of the 'skin. Under
the influence
condition
continuance
of
this
febrile
and
the
of the general
change of tonus in the
walls of the vessels,those changes in the latter begin which
are
produced otherwise by
inflammatory irritants of a different kind.
In this manner
local inflammations
of the skin are begun, the further course
of which
is variable.
exanthemata
acute
the inflammatory change is also a superficial
In some
catarrhal one
and is restricted either to the development of erythema, or an inflammatory
formation
exudation
of
w
ith
and
distinctly
papules
patches of pigment,
appears more
of vesicles and pustulesoccurs, but always retains
or, in a third series,the formation
the character of superficial
inflammation.
In their

essence

in the most

The

and

are

tissues and

also upon

the

in scarlatina
of typhoid fever or
as in the roseola
are, indeed, exactly the same
first,simple hyperaemia without
change in the tissue of the corium
; further, in
any
accumulation
in certain placesecchymoses
of red blood-globules,
parts of the skin, occasional
suffusion
with blood pigment (yellowishcolor of the skin) which
latter phenomena
be attributed
may

cholera
some

these

varied

appearances

at

to the
oedematous

produced by

general morbid

swelling of the skin

an

character
is due

early renal affection.

of these
to the

infectious

inflammation

diseases.
of

the

However,

^skin proper,

the

inflammatory

unless

it has

been

"

GENERAL

'yg

is

NOSOLOGY

OF

THE

SKIN.

The addition of an internal or external

or
recurringone.
persistent
cyclically
to
is
the
of
the skin affection.
It is,therefore,
irritant,
however,
development
necessary
call
these
diseases
Not
the
to
vaso-motor.
purely
inflammatorydisturbance,but the |
wrong
tendency of the skin to respondwith such a change to irritants of the most varied and often I
character must
be regarded as the real disease ; this distinguishes
these nutritive
trifling
disturbances from the inflammations
produced by inflammatoryirritants upon normal skin.
does the vaso-motor
hypothesis agree with the
Only when looked at in this manner
is
the
catchword
fashionable
at the presenttime, is in
so
as
alone,
angioneurosis
facts;
group

"

"

no

respect sufficient.
h. The

second

diseases of the

But

trunks

nerve

which
affections,

These

excluded

been

category of

of

inflammations

the

skin which

branch

of dermatitis,is that of the neuri tic inflammations, i. e., those

simple forms

hitherto

or
are

the

produced by

centres.
"

often termed

from
dermatologists

of
trophoneuroses
the

by
because
independent position,

they requirean

off from

the

skin," have

category of dermatitides
the

factor
etiological

has

in
an

not

general.
essential

of the disease.
Here stress need merely be laid
influence upon the symptoms and course
"neuritic dermatoses," to that of "trophoneuroses,"
upon the fact that I preferthe term

because,
relation of the trophicprocesses in the skin to their innervation in general
side ;
cleared up to but a slightextent from the physiological
2. Because
the separationof this group was
adopted by me
merely for the special
be
that a morbid
can
constantlydetermined
as
objectively
process iiithe nerves
1. The

has been

reason

the causal factor.

differ in
may give rise to nutritive disturbances of the skin, which
The
inflammation
either appears and runs
ordinaryinflammations.
its course
form as in herpes zoster, or, with a less strict type of course,
in a strictly
cyclical
the inflammatory
processes presenta great varietyof form and grouping (theneuritic eryand wheals),
ly,
thirdthanthems
with their development of nodules,vesicles,
pustules,
finally,
by their tendency to further nutritive disturbances as, for example, to disturbances of
or even
absorption(oedema)and quiteoften to a diminution (atrophy)
complete extinction
of the nutrition of certain portionsof the skin. To the latter categorybelong
(necrosis)
neuritic lioderma
skin of American
alopecianeuritica,leucoderma neuauthors);
(glossy
Such

neuritides

their

course

ritica

decubitus
(morphoea,vitiligo),

The

from

classical

acutus

picture of dermatitis

of Samuel, etc.

neuritica

herpes zoster,the trophictegumentary change

of sensory
There

nerve

of

in which

cyclicalcourse
correspondsto

is furnished

by

the distribution

trunks.

transitions between the symptoms of typical

herpes zoster and
development,for example, of the hairs in consequence of neuritic
I
must
be reserved for specialconsideration.
processes, that their complete description
include all these forms
situated
reddened
because they are
an
inflamed,
always
upon
base, and present the most different and variable efflorescences under the same
generic
term erythanthema, but with the specificlimitation
neuriticum
in order to distinguish
it from the other variety
The symptomatology of the non-cyclical,
neuritic nutritive disturbances of the skin
with an atrophic character is furnished by glossyskin, an affection which occurs
sionally
occaof nerves, but only when
after injuries
no
complete solution of continuityin the
It begins with erythema, which
has occurred.
nerve
givesway to a smooth shining
thinned
of
the
integument.
appearance
those of

an

are

so

many

anomaly

of

"

"

"

"

GENERAL

OF

NOSOLOGY

THE

97

SKIN.

of neuritis
Finally,the purely necrotic process in the integument in consequence
acute decubitus
with
studied
in
the
so-called
formation
redness
be
most
a
clearly
may
the
anaesthetic
side
diseases
in
of the
of vesicles which occur
or
paralyzed
suddenly upon
in
the
sacral
without
demonstrable
brain and spinalcord, almost
always
region
any
"

pressure, and

OF

EEVIEW

If

we

into necrosis.

rapidlypasses

review

now

INDIVIDUAL

THE

the

FOEMS

pathological
processes
symptomatology and

the

and compare
with them
forms of dermatitis,we

INFLAMMATION

OF

OF

in inflammation
anatomical

THE

SKIN.

of the

skin in

general

of the individual

appearances

will find

and mildest forms, the temporary erythemata produced by

superficial
as
erythema solare and the like,and erythema of longerduration but
like erythema neonatorum.
slight
intensity,
1. The

mild

2. A
or

most

such
irritants,

somewhat

more

less intense oedema

are

prolonged duration
found

infectious

a.

in

various

rashes

of

variola, furthermore

deal

here

acute

diseases
the

in

erythemas which

with

of the

erythema

and the

of

occurrence

more

"

are

measles

roseola

impressed

of

and

typhus

with

the

scarlatina, the
and

cholera.

character

of

prodromal
We

have

to

general

severe

disease and, upon the skin, with the peculiarcharacter of the angioneuroses,
but which,
if the tegumentary processes per se are
considered, can
as
only be interpreted
simple
less inflammatory oedema.
or
hyperaemiawith more
l. In the various forms

urticaria,cnidosis).Here
oedema, but
of individual

spasm
but also

of

development

also

under
vascular

have

we

certain

with

(erythemapapulatum, pomphosis,
erythema

associated

peculiarmodifications, viz.,the

tracts, which

in simple
accessorily

of wheals

to deal

occurs

inflammations

and

most

constantlyin true

in inflammations

with

matory
inflam-

combination

with

angioneuroses,
produced

of the skin

by neuritis.
Erythema papulatum and urticaria in toxic and the
angioneurosesof the skin, as well as in neuritic dermatoses, depend
which
reallyconstitutes merely a symptom of inflammation,but no

so-called
upon
real

essential

this process,

independent

disease.
of the inflammatory process may Tdc learned in various
which
we
partlywith great
processes
may attribute,partlywith entire certainty,
irritant
intensified
form
and
its
of the inflammatory
to an
vigorousaction.
probability,
3.

The

complete development

morbid

Here
a.

may be included :
Some
of the series of

which

erosive

produced by
(eczema) and

are

inflammations

the
of

inflammations, for example, the

superficial
acarus

furthermore, the forms

follicular

of diffuse

inflammations
superficial

cences
efflores-

superficial

(miliaria,
acne,

sycosis)
;
final variola exanthem.

t. The

affections of the skin,which are distinguished

inflammatorysuperficial
of
their
character
efflorescence development from
by
simple hyperaemiato
the most
fullydeveloped pustular formation : the erythanthemata eruptions upon an
erythematous basis,to which belong,among the series of the angioneurosesof the skin,
and those produced by drugs (toxic),
the "polymorphous^' erythemas of Hebra
and,
neuritic skin diseases of an inflammatory nature.
finally,
At a later periodwe will have an opportunity
of notingthat the variability
of the form
c.

as

series of

the

manifold

well

as

certain

of the developmentand
peculiarities

course

of the

primarylesion

in all

98

GENEEAL

THE

OF

SKIN.

inflammatory irritants themselves, but from other

ence
standpoint,however, there is no differanatomo-pathological
other
inflammations
of
the
skin
of a superficial
character.
between
these and
d. Certain inflammatory dermatoses, which are called "irritative forms"
(Virchow)of
scrofula, etc. ; they appear as maculae, nodules,
dyscrasicprocesses, such as syphilis,
vesicles,pustules.

these

do not apiisefrom

NOSOLOGY

cases

factors. From
nosological

The

the

givingrise

processes

mere

an

to them

of such

are

that

character
wide-spreading

they

dermatitides, but
superficial
the
tive,
also extend their action into
deeper parts of the skin and give rise to furuncular, ulceraand destructive forms, the main pathological
sites of which are the deeperlayersof the
tissue. And, finally,
corium and the subcutaneous
all these irritative processes are associated
with further processes which
can
mental
scarcelybe termed inflammatory, but rather developare

in
longer restricted,

no

embryonal

an

their

were

symptoms, which
inflammatory

production of

elements,

which

type, and

We

peculiartype.

severe

of the connective-tissue

anomalies
of

cases, to the

formations

new
granulation-like

as

impart
them
compelled to mention
is called irritative,
presentsin
to

other affections their

scrofula,and
syphilis,
at this time

many

because

part of

that

perfectlysharp pictures

cases

the fact that it is

process.
the other
infiltration per se which
constitutes
one
or
that
the
inflammation
but
the
real
feature
is
or
viz.,
logical
anatomo-pathogranulation,
process,
is soon
which
absorbed in inflammatory proof this cellular inflltration,
course
cesses
of the

the

not

much

Too

stress

cellular

of

character,in
superflcial

more

deeply seated

but,
ulceration,destruction),
(degeneration,
infiltration without
time as a more
persistent

some

of tissue but
If

be laid upon
the essence
of

cannot

also without

necrobiotic

assumes

tions
termina-

granulationprocesses, continues for

further development into higher forms

rapid retrogression.

associate all those forms

we

ones

in

of inflammation

of the skin in which

the

inflammatory

the start upon the deeper layersof the corium of the subcutaneous
tissue,i. e., upon the layerof the larger nerve-trunks, the largerlymphatics,

irritant has acted from

connective

evident that the appearances

in
even
deeper glandular structures,it becomes
inflammation
of the skin in those anadiffer from the varieties of superficial
tomical
furnished
alone which
are
by the deeper anatomical situation. A
peculiarities
of the deeper point of attack of
essential feature is the fact that, in consequence
second
in the circulation,venous
and lymph stases,occur
more
the irritant,disturbances
readily
the

and

these

cases

of inflammation, belonging
certain of the forms
between
a direct transition
for the same
viz.,the
reason,
category and true stases-diseases of the skin ; finally,
disturbance, necrobiosis developsreadilyand rapidlyin these deeply spreading
circulatory

and

furnish

to this

diffuse
or
superficial
phlegmons (burns,pseudo-erysipelas,
localized
of
carbuncle,
anthrax,
phlegmons (furuncle,
idiopathicphlegmon
skin),
and lymphanetc.),and finallyof phlegmons directly
complicatedwith stasis (phlebitis
inflammations.

This

is true

of

of the

of
gioitis

the skin, and

"THE

erysipelas).

NON-IHFLAMMATOEY

NUTKITIVE

and

the

is

series of morbid

processes

consequent tissue changes appear

in the
from

although they possess no necessary connection

inflammatory congestionwhich inauguratesthe
Direct

mechanical

obstructions

THE

SKIS"

DUE

TO

STASIS-PROCESSES.

INDEPENDENT

There

OF

DISTURBANCES

to the

venoso-lymphaticstasis

skin, in which
the
with

start in

characteristic

inflammatory

irritants

or

manner,

with

an

disease.

circulation

are

the

most

frequent causes

of

NOSOLOGY

GENERAL

the

processes in the walls of

It
cannot
that these
be denied
lymphangioitis).
lymphatics(phlebitis,

and

veins

diseases of the vessels

are

and
(erysipelas)

directlywith

connected

99

SKIN.

occasionallyinflammatory

circulatorydisturbances, and

such

Till-:

OF

followed

occasionallyby

that,

this

the

on

chronic

form

account, these

of

gestion
passive inflammatorycon-

hypersemicprocesses are
of absorption
; for
and acute lymphangioitiserysipelas
acute

of stasis and

forms

anomalies

with
arabum
is thus connected
example, elephantiasis
not an
is an etiological,
essential one.
But this connection
from experiment and experiencethat, under
We know

favorable

circumstances, the

stasis may
act upon
the skin as an inflammatoryirritant.
venoso-lymphatic
it results in the developmentof true congestiveprocesses,
If this occurs,
arterial character, of which
at the

occurs

time

same

but

is an
erysipelas

illustration.

later,the real character

or

in the vascular

stasis and

Whether

such

an

even

of

an

irritant action

flammatio
of the process does not reside in the inand
of exudation
(transudation)

the anomalies

of the connective
with,
theretissue, etc.)immediatelyconnected
changes (sclerosis
in the development of a necrotic process (gangrene,
or
finally
etc.);and this is the
for including such diseases in one
presentingthe
group, viz.,stasis-dermatoses

the tissue

reason

characteristics

The
kind

passivedisturbance

passivestases

of circulation

degree of

As

stasis and

has been
the

of circulation

and

their form,

produce, according to

the circulation.

are

of

shown

absorptionwhich

sorption.
impairedvenoso-lymphaticab-

characterize diseases

of this

partlyincomplete,partlycomplete obstruction of
vary according to the
implicationof the lymphaticapparatus. They

above, the effects of the former

less

greater or

and

either:
Mere

which do not, however, present the vascular change

passive(stasis)
hyperaemiae
to
matory
inflammatory processes, and must, therefore,be distinguishedfrom inflamnecesssary
hypersemias.
Or they lead to transudation
of blood-serum
though the walls of the vessels into the
and
effusions the name
oedema
surrounding tissues. Pathology appliesto these serous
various
modifications
of
it.
recognizes
To the class of stasis-dermatoses
passive(venous)hypersemiasand
apart from mere
local ischaemias and also complete stasis-processes
with necrosis of the skin, as, for example^
local asphyxia,traumatic
decubitus, etc. belong in the main two forms of disease,both of
which begin with venoso-lymphaticstasis,
and terminate in part in hypertrophy, in part in
arabum, or pachydermia, the second
atrophy. The firstform is representedby elephantiasis
the
It
scleroma
of
sclerema
skin).
by
(scleroderma,
proper that in this class
appears to me
chronic
first
described
Gull
should be included
as
a
^'myxoedema,'^
by
general oedema
with pallor,dryness,atrophy of the skin and
diminution
of temperature,
membranes,
mucous
filtratio
inand psychicaldisturbance.
According to Ord and others, the oedematous
"

"

presents a marked
It must
other

be reserved

diseases mentioned
will be

mucoid

for the

stated
briefiy

above.

of stasis,viz.,with

forms
acute

the
for

clinical

giving

symptoms

of the

the

tions
defini-

above

inflammation

is not

an

which

constitute

Elephantiasisarabum
but, in the endemic

structure.

specialnosology to give
At this place the reasons

or

chronic

oedema

the

of the skin and

most

of the

does not begin as such,

typical varieties,with a symptom

subcutaneous

connective

lowed
tissue, fol-

of the
by enlargement of the lymphatic glands, occasionallyby inflammation
the
of
and finally
tive-tissue
conneclargerdeep veins and lymphatics,then by erysipelas,
thickening
The
and in the skin.
layerunderneath
deep inflammatory symptoms which

100

GENERAL

are
(erysipelas)

occur

is

Nor

Virchow's
The

not

primary part of

elephantiasisarabum

THE

SKIN.

the process,

but

primary hypertrophy

the result of

of the

skin,

nutritive

turbance.
dis-

diffuse fibroma

in

sense.

hypertrophy
absorption in

of

OF

NOSOLOGY

typical

of

occurrence

after every

of the

relapseof

connective-tissue

layer is evidentlythe result of a

demonstrable
integument, as is distinctly

the tissues of the

cedema

the

and

increase

in

thickness

of the

ance
disturbthe

by

tissue

connective

phlebitis,lymphangioitis,and erysipelas.
The
first sympgood also with regard to scleremata of the skin.
tom
of every scleroderma
is lymphatic oedema, circumscribed
diffuse
or
swelling of the
to increased
of the
tension
corresponds clinically
tegumentary tissues. This condition
of this change is
skin, diminished
cause
temperature, loss of sensibility.The immediate
entirelyunknown, but the oedema, which is always present at the onset, places it beyond
that we
doubt
have to deal with
stasis and
a
an
anomaly of absorption. On the other
of phlebitisand
hand, all symptoms
capillarylymphangioitis are absent ; there is no
in
the tissues,even
in those
forms
accumulation
of
which
run
an
erysipelasor
lymph
acute
that
the
difference between
sclerema
and elephancourse
(sclerema neonatorum), so
tiasis
These

remarks

arabum
As

is at

evident.

once

which
elephantiasis,
in
sclerema
atrophy
majority of the cases
to

opposed

all forms

acute

hold

of

typical. The
during this last stage.
But

sclerema

from

the

skin

associated

is not

always
of

the

observed

atrophy

pure

''generalatrophy" of Wilson,
with
pigmentation and

of

in

ends

hypertrophy,

connective
have

the

tissue

been

skin.

described

It must

termination

the

be

must

by

of

regarded

authors

as

merely

distinguished also

be

probably congenitalprogressiveatrophy of the

which
I have
called essential
teleangiectases,

lioderma.
In its further

foreground

and

however, the termination

course,

its

symptomatology

HEMOREHAGIC

In the

series of

chief

absence

greaterthan
simple
walls

and

the

of the

diseases

normal

intensiflcation

further

are

group

has

or

skin,

of diseases

found
in

stases

it has

mechanical

often

the

place through
pathologicalprocess.

in which
are

the

venous

in the

occurred

stasis,an

taken

of the

OF

discussed, we

mechanical

venoso-lymphatic stases

also the increased

last

DISTURBANCES

inflammatory change

of the

of inflammation

phenomena

an

inflammatory

NUTRITIVE

dermopathies

characteristic

with
in

similar

very

atrophy occupies the

of pure atrophy

in

sclerema

to that

skin.

of the

and

of

finallybecomes

walls

THE

and
walls

vessels.

of the

that,
of the

point of departure
gether
lymphatic vessels, to-

the

that

exudation

SKIN.

of

red

vessels

absent,

but

the

chief

as

other

blood-globules
on

account

This experience offers a

primary inflammatory change in

likewise

Here,

to the

in addition

feature

of

transition
the

to

vascular

of which

is

blood-globulesthrough the walls of the vessels.

passage
This group
includes in part certain traumatic
dent
hemorrhages (ecchymoses) indepenwhich
of external
irritants of the skin, in part those forms (essential
are
hemorrhages)
with general affections or other organic disturbances.
include
connected
They
purpura,
maculosus
morbus
Werlhofii,and scorbutus.
of red

GENERAL

DISTURBANCES

THE

The

the skin

of

in the distribution

SKIN.

THE

101

(iDIONEUROSES)

INNERVATION

OF

idioneuroses

term

OF

NOSOLOGY

is

OF

disturbances

those

applied exclusivelyto
which

SKIN.

of

trophic disorders are

be
disturbances
such
nutritive
associated
that
as
secondary propeculiar,except
may
cesses.
from the neuritic dermatoses,
These affections are therefore readilydistinguished
include
well as motor
well as from the angioneuroses. The idioneuroses
as
as
sensory

function

of the cutaneous

THE

to

nerves

no

neuroses.

The

neuroses

sensory

Occasionallythe

sensory

usuallywith
of the
paraesthesia

groups.

consists

of

central

associated

The

into two

of

group have nothing to do with sensory

the impressionwhich the condition of our

merely reflect
portions of it per

consciousness.
This
produce upon
and
with
'^generalsensibility,^'
regard to
se,

is called

consciousness

our

nervous

of the second

neuroses

tion
aliena-

or

diseases

The

skin.

the outside, but

individual

increase,diminution,

an

belonging to this category, which are

affections,are called hyperaesthesia,
ansesthesia,

tactile sensation.

of the normal

and

subdivided
disturbance

are

impressionsfrom
integument or of
form
of activity
the skin

neous
"^cuta-

generalsensibility."
forms

two

general sensation

of cutaneous

Disturbances

be

may

presentedto

under

consciousness

which
late
simupain. Those changes of the tegumentary nerves
irritation of a nerve-trunk
impression of a uniform, constant
and its region of distribution,are called neuralgias.
preted
interare
Secondly as the sensation of pruritus. This includes sensations which
if simultaneous, very slightirritations of the extreme
in consciousness
terminal
as
had occurred.
Pruritus
ramifications of the nerves
is evidentlycloselyassociated with
term
is applied to that disease which
the sensation of tickling. The
prurituscutaneus
itself by violent itchingwithout
other
i. e., in the form of a
manifests
disturbance,
any
First

sensations

as

neurosis.

sensory

pure

This

constitutes

to another

transition

implicationof

in the simultaneous
second

of

the

in consciousness

the muscular

of diseases of cutaneous

form

and

skin,

of the

fibres

differs from

general sensibility.This

it

only

represents the

of disease is known

form

prurigo.

as

histological changes found

Pruriginous skin presents all the well-known

a

which

neurosis

sensory

condition

of chronic

Derby and
to

other
the

the

"with the

hair

of

the

of

of the nodule
the

emotional

is
the

The

the

absence

not

nodule

been

or

the process

ruber
the

cutis

of

changes

of

As

temperature,

and

which

it is
as

form

is in

are

occurs

is
as

neurosis

occurrence

common

muscular

ple,
exam-

fibres,

connected

processes

by all observers.

of lichen

often

regarded
motor

noted

as

nodules, for

h-^althyintegument.

naturally

goose-skin

signsof inflammatory fluxion,the

followingconclusion

of the

than

more

lies at its foundation

which

prurigo has been

in

is like that

prurigo nodules

hypertrophic.

are

of

formation

prurigo, but also in other

lichen scrophulosus.

in

and

"

alone

appearances

thickening of the smooth

the

nodules

scratched

such

pruritus and

and

pi-urigo is nothing

of

attendant

arrectores

of

lichen

sheaths

root

without

or

prominently

layer above

horny

constant

with

root-sheaths

the

occurs

if it has

disturbances

contraction, and

the

"

that

view

when

skin

for example,
follicles,

Goose-skin
usual

of the

pilorum, which

Thickening
favor

in the hair follicles and

processes

papillary out-growth

arrectores

color

found

Gay

chronic

in any

irritation.

These

pilaris.
markedly

more

produced
of the

of

than

suddenly

spasmodic

The
facts

by

muscular

skin.

tify
pruritus,etc., jus-

102

the

GENERAL

is a sensory
Prurigo,like pruritus,
of
nodules,
primary development
muscular

of the smooth

OF

constant

THE

SKIN.

of the skin.

neurosis

is characterized

and

It differs from

anatomically by the hypertrophy

goose-skin.

by a few additional factors

(which is eminently a vascular

clearer

of urticaria

occurrence

prurigo of children, i. e., in the first outbreaks

skin)in the

the latter in

fibres,physiologically
by the coincident

of prurigo is rendered
interpretation

The

Pirst,by the
the

NOSOLOGY

of

spasm

of the disease.

the fact that the

Secondly, by

specificnodular eruption of prurigo is not absent in

but that there is scarcelya case
in
case
diagnosisis not made
any
ivhich the nodular
eruptionduring one or another attack is either very slightor entirely
diminution
absent, while the pruritusand eczematous
symptoms do not suffer the slightest
compared with other attacks.
otherwise

"

THE

The

nutritive

of

"

DEVELOPMENTAL

less permanent
the form

the

disturbances

changes

OF

ANOMALIES

which

in the

their restitution.

we

THE

SKIN

discussed

have

GENERAL.

often

are

followed

qualityof the tissue elements,

quantity and

skin furnishes, in this

The

IN

respect,a

by
as

distinct

more

well

or

in

as

example

in

that

secondary change of the upper layers of cells which are destitute of vessels,in the
form of chronic desquamation often left over
after erythematous and eczematous
processes.
"We will now
for a few further consideramake
of the illustration just adduced
tions.
use
in another
in that
as
Desquamation of the epidermis may also occur
manner,
disease which
known
and
is
after
birth
as
simple ichthyosis(with diffuse
developssoon
in
desquamation or
slighter
gradesbranny desquamation).In both cases, in desquamation
after inflammations
and in ichthyosis,
have
to deal with an
we
immoderately rapid and
profuse restitution of the horny layerwhich is cast off ; in the first case as the remains
of a nutritive
the expression of a developmental
case
as
disturbance, in the second
herently
latter disease is a primary one, but it resides inThe
anomaly of the tissue elements.
in the type of tissue development, i. e., in the laws of development of certain
tissue elements.
What

said of

has been

In like manner,

holds

also
ichthyosis,

the distinction

good

acquired diseases.
disturbances
and
developmental

of

nutritive

between

regard to those tissues which, on account of their

anatomical
structure, are the direct primary site of the nutritive disturbances, in our
ease
accordinglythe corium. In the case of the epidermis,indeed, the nutrition of which
depends entirelyupon the vascular underlying structures, the distinction depends upon
the structure of the latter. If the corium
is inflamed, the change in the epidermis must
also be regarded as dependent upon
and is therefore a process belonging
inflammation
the
to it. But if the corium
alone in an abnormal
is normal
and the epidermis elements
are
condition, we have to deal merely with an anomaly of development. This is different in
regard to the corium, which, having arisen from the mesoblast, includes all forms of
connective
opment.
substance, and therefore appears polymorphous in its deviations of develanomalies

The

may

also be maintained

anomalies

of

with

development

directions,according as they depend

of the

Furthermore,

or
epithelial

upon

skin, therefore,
the

anatomical

of the connective-tissue

all the accessory

glands,the hairs and nails are
as

of the

may

and

layersof

be differentiated

physiologicallaws

in two
of

velopment
de-

the skin.

parous
glandular structures, the sebaceous and sudorideveloped from the layerof epidermis,it is evident
and

104

is

GENERAL

spread

above

do

rete

rete

and

cones

ichthyosis

of
the

present

cellular new-formation
other
and

considerably elongated

very

thickening

or

in other

also

occur

the

from

diminished

of

is

tissues

the

coiled

but

In

present in the
here

and

nor

inflammatory

no

and

; in the

The-

elongated, in

dendritically,

addition,

corium

there

in size.

little

they do not branch

corium.

twisted

and

are

papillae;

on

the

glands here

sweat

formation
of cysts or hyaline cylinders, in the hair follicles pearly formation
the hair follicles (these
horny layers, out-growths from the root sheaths towards
in normal
affections
chronic
of the skin and even
integument), thickening of the
and

occlusion

there

the

grovsrth into

branching

hand, the vessels of the papillae are

of cavities

SKIN.

THE

is never
thickened, but often
of ichthyosis
papillae of the flat form

the

often

cornea

ever

cones

OF

prickle-celllayer, which

the

interpapillary
cases

KOSOLOGY

pilorum.

arrectores

horny
by the immoderate
The
structure
of the papillarybody, for example,
growth upon the underlying structure.
development of the changes in it,if they are
points clearlyto the merely mechanical
epidermis
compared with affections in which active processes are present in the young
All

the

like

be

must

evident

the

manner

to

regard
the

that

all the

twistingof

the

appearances

action
of the

affections

anomaly

papillaryvessels

the

mechanical

to the

attributed

With

thus

exerted

to pressure

the skin.

layersof
In

attributed

be

may

appearances

the

has

therewith

into the main

extended

to

nothing

with

but

with

after

the lamellae of the

each

removal

grater, this congenitalform

grade

of

of the

the secretion

this formation

AVhen
renewed

do

ichthyosisaround

of
of

around

the accumulation,

of

lichen

pilarismust

the follicles,
and

involutions, and

occurs

accumulation
with

confined

around

the

of
the

scales ; it
selves,
hairs them-

their circumference.

congenital,and is at once
constantlylooks like a
regarded evidentlyas a moderate
I apply to it the term
ichthyosis

follicles
so

which

or
follicles,

sebaceous

the

is

be

horny layersforming

scales

ichthyosis,it

readilyexplained.
pilaris,a cornification anomaly

may

lichen
hyperkeratoses also include
the
hair follicles,
and
ducts
of
the
to
excretory
exclusively
and
and
latter as a moderate
usuallytemporary thickening
The

has

their walls

thickening of

hair follicles in

glandular and

of cornification

connected

and

of pressure.

is

that the skin

be

therefore

follicularis.
In addition

to callosities and

corns,

horns

should

also

be included

among

the localized

the follicles.
hyperkeratoses,which develop free in the tissues but not around
Among keratolysesthe principalpart is played by pityriasis not that which remains
alba
of the hairy scalpand the pityriasis
the pityriasis
after congestive processes, but
is due to the laying bare of the
base of which
essentialis rubra of Devergie, the reddened
which
is
and
evidentlythe expression of a
deeper layer of the Malpighian network,
cachectic process of the integument in general.
The
are
representedby two diseases
paratypes of the cornification process, finally,
and lichen ruber.
I regard as closelyassociated,viz. : psoriasis
which
of psoriasis
The clinical symptoms
prove that this is not an inflammatory process in
"

generallytaught by the text-books.

be recognized as a hyperaenodule
the newly-appearing psoriasis
can
is lost with the increase
underneath
the
and
be
mic
finger
redness, it may
pressed away
be observed
around
trace of a red inflammatory zone
can
in the scalydeposit,so that no
The
the constantlydeveloping plaques,as in other inflammatory affections of the skin.
in
base
stasis
the
which
to
of
the
redness
venous
a
vessels,
givesplace
upon
hyperremic
the hillock of scales rests, and this it is which
gives rise to the hemorrhages after the

ihe

skin, as
The

removal

we

redness

are

of

of the scales.

NOSOLOGY

GENEKAL

"

anatomical

The

clinical

the

so
psoriasis,

far

105-

SKIN.

they

as

constant, correspond to

are

symptoms.

following

The

Increase

in

appearances

THE

OF

the

are

lesions

constant

of

thickness

in

horny layer,consisting

the

of

opaque

dry lamellae, which

are

being^

continually desquamated.
The

epidermis

the

nucleoli

and
upiier

the

in

cells,which

prickles, and

close

the

cutis

in such

the

rete

develops

cylindricalbasal
able

real

the

of

situated

thickness

the

upon
of

the

these

the

the

addition

to

cylindrical cells which

broom-like

rapid loss of the

more

Finally,

cylindrical layer upwards.

an

be

downwards

reach

of

appearance
create

the papillae.
prickle layer cannot

interpapillary

the

impression

as

observed,

nor

if several

is there

towards
cones

of

layers of

any

notice

elongation of the papillaeof the cutis.

is the

appearance

sinuosity, and

in the

distention

changes

may

of

the

vicinity of the vessels

"

All

cells from

papillae,and

of the round
increase
a long time
an
tissue.
separation of the connective

lasted

granular cells,in

true

apparently

boundary

were

in

constant

marked

more

that

the

cells

into

juxtapositionof the
the
prolongations of

manner

at

and

thickening

there

of

increase

Finally

changing

are

more

fibrillation

distinct

finally the cylindricalcells at the

layer, the prickle layer proper, and
vigorous and rapid developmental changes ; increase of nuclei
present more
marked
granular development in the
deeper layers of the prickle layer, more

granular

so-called

of

base

and

be observed

with
blood, here andonly after the psoriasisplaque has

papillaryvessels
"

but

spindle-shaped cells

in

in the

but they
psoriasis,

occur

and
papillae,

more

or

oedematous.

less in all

keratoses.
moderate
a
occurring in the epidermis in psoriasis,
apart from
corniis
of
the
epidermis cells, evidentlyan anomaly
fication
time
more
more
imperfect
rapid,but at the same
with
the increased
cornification of the epidermis cells may
be recognized, associated
nutritive changes in the prickle layer. This is expressedclinically
by the formation
of hillocks of scales out of dry opaque,
torn
and lamellated, slightlyadherent
masses
under
time the observation
that
of the horny layer. At the same
made
be
readily
may
be easilyremoved, the young
fests
cells
the
these scales,which
of
of
can
layer
epidermismaniwant
that
of cohesion, so
beneath
these cells we
at once
the cylindrical
reach
a
to shine through,and, being
layer of the rete which allows the vessels of the papillae
itself readily detached, lays bare the bleeding papillary vessels.
cornification
The
is associated accordinglywith a moderate
anomaly in psoriasis
developmental anomaly of
the younger
layersof the epidermis,and both combined
give rise to the plaques of scales
lend to the disease its peculiarstamp.
which
of disease,lichen exudativus
to psoriasisis a second form
Related
ruber of Hebra
lichen planus Wilson, which
I also include among
toses.
kerawith its variety,
the paratypical

The

main

increase

processes

growth of the young

as
a
process, inasmuch

of the

The

reasons

for this

clinical

are

as

follows

with nodular formations

standpoint there is an evident similarity
be certainly
must
But
of various kinds, which
while the initial
regarded as keratoses.
of epidermis around
form of lichen ruber always presents that accumulation
the mouths
known
of the hair follicles,
otherwise as lichen pilaris,
in psoriasis
the nodules
soon
pass
of disks.
the lichen has attained a higher grade of
But when
into a diffuse formation
that the originally
so
more
separate red nodules become
intensity,
closelyapproximated,
then the surface of such
of nodules
becomes
covered
with a layerof adherent
groups
of psoriaticskin ; the
whitish
scales,which
again gives the appearance
palms of the
hands and the soles of the feet especially
covered
become
with a thick scalyfissured calFrom

106

NOSOLOGY

GENERAL

OF

THE

SKIN.

brittle,thickened,destitute of gloss,
layersof skin, the nails become
fall
out.
the hairs become
thin, and gradually
of psoriasis
also approaches this clinical picture
In fact,the diffuse, inveterate form
the
fact that a hyperaemic condition of the papillarylayer may
of lichen ruber, from
develop in both.
and lichen ruber appear to me
to consist in
The clinical differences between
psoriasis
the
starts
from
disease
that
the
former
of
the
this,
skin, the latter
continuity
follicles.
In
of
the
hair
the
from
therefore, the process
psoriasis,
epidermis layers
while the centres of the plaques
spreads towards the periphery in segments of a circle,
pale and heal. In lichen, however, the disease spreads along the root sheaths of
grow
the
hair, i. e., perpendicularlyto the surface of the skin in an upward or downward

losityof

the upper

direction.

Connected

accumulation

of

therewith

may

fact that in the

the

be

epidermisdevelopsin the

form

of

first

case

pointed nodular
depressionof the nodule
a

mass

more

marked

; in the latter

of epidermis,a sort
advancing downwards, a central
is produced.
It is evident, then, that the primary affection in lichen ruber as in lichen pilaris
and
is not a true inflammatory efflorescence,
but merely consists
the beginning of psoriasis,
of accumulations
of epidermis the development of which has continued, and
which, by
and
and
their
thus
a
the red,
fluxion,
base,
hypersemia
produce
secondary
upon
pressure
brownish-red
color of the nodules, while the continued
predominance of the affection of
the horny layergivesrise to the final extensive scalysurfaces.
of those anomalies
I may
of secretion of
omit further details concerning the nature
the growth of the hair and nails which
are
closelyrelated to true keratoses,and also of
restrict myself,so far as regards the character of the diseases of
chromatoses, and must
the prickle layerof the epidermis,with illustrating
their nosological
character by a few
examples.
of the pricklelayer (hyperakanthosis)
The
is observed
type of simple proliferation
in
of
this
in warts
and
layer (akantholysis)
condylomata ; atrophy
pemphigus ;
I have applied the term
paratypicalgrowth (parakanthosis)
by those forms to which
akanthomata
(cancerof the skin in its various forms).
be attached to the relation of the
In all these anomalies, the chief importance must
basal cylindrical
responding
layerof the rete, to the corium, and, in a corlayer,the germinal-cell
the
of
the
level
formations
of
the
the
on
changes
papillary
produced
manner,
and
most
marked
In
warts
and
the
corium
development.
epidermis
acquire
mata,
condyloin pemphigus and
of scales
as
desquamation or accumulation
epithelioma,marked
substance
the
of
the
takes
in
never
an
horny
always
place
development
entirely
occurs,
case,

of

upon

umbilication

"

normal

manner.

So much

germinal layersof the horny layer

questionfurther arises,what is
the relation
the epidermisand the upper layerof the corium;
whether, as has been so often believed, all changes in the former should not be regarded
of the corium.
as
merely secondary,as a result of the condition of the papillae
The
have
been
histological
interpretedusuallyas meaning that all the
appearances
morbid
of the integument not alone take their departure from the
superficial
processes
papillarylayer,but are also associated with an elongation of the individual papillae
In fact, the objectiveappearances
teach us that an increase in the volume
themselves.
-of the papillae
does reallyoccur
to a slighterextent
in
(though not produced actively)
it may
be disputed whether
the keratoses, to a greaterextent in the akanthoses, and
the
on

the

one

regard to the relation

the pricklelayeron
of
between
the pricklelayerwith

hand

and

between

the

the other.

The

GENERAL

NOSOLOGY

OF

THE

107

SKIN.

But this statement

is made
also with regard to all other
actuallygrow.
they produce very slightmanifestations in the epithelium layer; the
elongated papillaeconstitute the inevitable refrain of the histological
melody, and
estimates
taken without
of their increase in length are
to
the
regard
length and
any
of the papillae
of the normal
skin at the same
structure
places.
But it is clear that the papillarylayer differs
from the remainder
of
physiologically
in
fact
that
the corium
the
have
into
cones
it.
In
the papillary
epidermis
only
grown
in the deeper part of the
course
as
layer, an inflammatory process runs
exactlythe same

papillasdo

not

when

even

processes,

'"

"

corium.

compression of

the

But
of

exudation

of

is

exceeded

other

hand,

the

But

one

we

toto, until

migration

of this

and

well

aware

juicesfrom

the vascular

the

corium

by

of cells,or

masses

rise

give

accumulation

an

to

"

the subcutaneous
that

tissue

not

enlargement in the volume

limits of the elasticityof the
fibrous tissue have
compression is no longer possible,and when, on the
accumulated
into the vicinity into the epidermis
mass

the

further

hand,

are

does

their

and
a

the connective
which

process

tissue in

the

been

on

connective

of the
vitality

into the former.

tissue

the

other

is not

possible.
epidermis depends upon the passage of
We see dailyin inflammatory processes
on

"

that

the most varied efflorescences containing serum

and pus are formed
in the tissue of
be no
epidermis by exudation
passing to them from below, and thus there can
of the corium
of its papillarylayer alone, so long as
or
questionof an increase in volume
and
the tissues lying upon
around
it have
not
lost the capacityfor the absorptior of
the

fluid.
But

granted
of

volume

of the

in this event

which
the

us
are

rete

tissue,

the increase

the

assume

in such

concealed

and

long

will

occur

and

corium

next?

must
papillae

case,

viz. : distention

Experience
that

manner

cells

or

we

the

the

teaches

cutis,may

fluid will

produce

increase' in

an

be

the
But

produced.
tions,
uniformly in all direc-

occur

of the tissue of the cutis with

that

boundary

observer

nuclei.

passage
between
the

an

of the cell

the

of
appearance
the papillaenever

But

abnormality in

into

epidermis is
geneous
apparently homo-

an

increase

in

size

on

factor is active.

that the
the

masses

masses

cutis and

other

some

infer furthermore

must

interpretedonly as

of the cutis with

tissue framework

The
which

diameter.

considerations

maybe

by

papillarylayerof the

cellular infiltration of their tissue,unless

these

corium

what

tissue

size of the

finally
presents to

of the

From
of the

as

second

tissue filled with

account

of the

in the

chieflycellular.

occurs

happened,

connective

well

as

alone in their

not
Let

that this has

the subcutaneous

oedema

growth of
growth of the

the

papillae

connective-

the vessels embedded

in it,etc.
But such an anomaly
layer of the corium, but would probably
much
more
markedly in the layers lying underneath, since the larger
appear
vascular trunks are situated in that position.
formulate
the following statement:
increase in the volume
of the
"We may
now
an
Individual
of the corium
simultaneouslyand proportionallywith a
papillae
only occurs
corresponding increase of volume in the layers of epidermis corresponding to them.
in the varieties of the class '^'epidermidoses,"
in the ^'choThis is a constant
appearance
rioblastoses
with secondary proliferation
of the epidermis,and in those conditions
of
in hypertrophic condition
irritation which
terminate
of the papillarylayer,for example,

of

development

would

not

be confined

to the upper

"

in chronic
'The

eczema.

expression

"

elongation"

in

ordinary

use

is

improper,

as

it refers

to

growth

in all directions.

108

GENERAL

"Which

forms

of the two

been

with

or

reference

made

them

to

hyperakanthoses,since
above.

mentioned

the

or

questionwhich
the most

However,

few

epidermis,plays
has hitherto

not

important points
remarks

must

be

descriptionof ptmphigus as akantholysis. For this purpose,

the inflammatory and akantholytic formation
be
of vesicles must

between

the difference

the

been

the

substantiate

to

have

upon

skin, the corium

of size is

increase

SKtN.

THE

OF

of tissue of the

in this

primary part
settled.
definitely
I will not dwell longer

the active

NOSOLOGY

pointed out.
Experience teaches

that vesicular

in

formations

general occur

upon

the skin in two

ways:
First. As

in the

graduallydevelopingchange

deep

inflammation

from

the

of the cutis,which

cells in
epithelial

leads

circumscribed

epidermis produced by

the formation

to

district,and

of meshes

or
superficial

and

chambers-

to the

fillingof these chambers

vesicular phlyctenula,which

exudation, i. e., the inflammatory vesicle or

of vesicles.
regarded
merely as a largevesicle or confluence of a number
may
As
destruction
of
sudden
the
of
a
Secondly.
layer
epidermis (theprickle
younger
to a typicalinflammatory process, but
which
is not due
is merely accompanied
cells),
accidentallyor secondarilyby congestivephenomena ; this is effected by fluid which,
from the vessels of the corium, lifts up the epidermis as a whole over
escaping en masse
a circumscribed
spot,and effects its separationfrom the surface of the corium.

by

serous

be

has been produced in this manner

and the fluid accumulated
in it are
bounded
cavity which
which
lucidum
the stratum
and horny layer are
rent,
adheby the compressed granule layer, over

The
above

and
the

by the papillarylayer of the corium, still covered

below

more

or

less with

the

remains

of

cylindricallayer.
The

formation

lost the

from

escapes

of such

vesicles is

capacity of withstanding
the

of the corium.

vessels,and
I have

the

only conceivable
mechanical

accumulates

therefore

more

applied the

if the

Malpighian

of the

pressure

blood

network

serum

has

which

markedly in various placesin the tissue

cular
akantholytic to this variety of vesi-

term

formation.

In addition, Unna
in this form
has described
of vesicles {Vierteljahresschnft fur Dermat., 1878)
and their transformation
into sausagedegeneration of the prickle cells (calledby him
fibrinoid)
like,
swollen

of the

vesicle

bands

and

membranous

(G. Simon), and

are

flat masses,
traversed

which

adhere

by degenerated

to the

nuclear

lower

surface

of the

covering

formations.

be drawn
readilythat the form of the vesicle,as it was described
may
of
inflammatory vesicles,only is produced when there is a rapid removal
the epidermis layers from
circumscribed
their base over
localities,
plete
during which comof the prickle layer and
destruction of the elements
their gradual transformation
This destruction
be
occurs.
produced by blisteringremedies, by a burn of the
may
second degree with rapid formation
of vesicles,etc.
The destruction of the pricklelayerand the vesicular formation
also be effected
may
in the resistance of the prickle layer, and
series of
a
by a pre-existingdiminution
factors favor the view that in pemphigus we
have to deal with the latter form of cachectic
condition of the epithelium.
These factors are, in brief,the following:
absent or only auxiliary.
The clinical signsof inflammatory fluxion are either entirely
the pemphigus vesicles or upon.
around
The slightredness observed here and there
The

in contrast

conclusion
with

GENERAL

their base creates

always

merely

when

the

course

skin

impression of a reactive or collateral fluxion.

desquamation of the roof of the vesicle and
spreading deeper into the papillarylayer. This

affection

extends

and

of the
and

The process
formation
of
is

even

the

parts of the skin (P. foliaceus

surfaces, devoid of epithelium or

continuous

over

Cazenave), and only the prolonged exposure

effect here
injuriousinfluences, may
of ulcers

109

SKI-NT.

the

other

formation

THE

with

epidermis without

young
case

runs

its

OF

NOSOLOGY

there

deep suppuration, and

then

the

cicatrices.

vesicular formation

varietyof

evidentlycan be explained alone by the fact that

the nutrition of the younger
layers of the Malpighian network is impaired, that they
offer but a feeble resistance to the fluid escapingthrough the walls of the vessels and, in
pushed away by the fluid and
unfavorably situated places,these younger
layersare
partly destroyed,partly pressed against the horny layer,and finallyare thinned and
This
of fluid.
ruptured by the constantlyincreasingpressure due to the accumulation
in
is
is
that
cachectic
met
with
the,fact
or
explanation supported by
pemphigus
usually
dyscrasicindividuals; that children suffering from congenital syphilispresent these
vesicular formations
most
frequently.
Finally,if we examine the relations of pemphigus foliaceus to ordinarypemphigus,
it becomes
evident that in both cases
there is a lesser or greater degree of capacityfor
resistance on the part of the epidermis,and a mechanical
to the
separationof it down
be
all
In
this
statements
vesicular
manner
horny layer.
interpreted
concerning
may
formations
after long-standing skin diseases of another
kind, for example psoriasis,
This

chronic

urticaria,chronic

This

does

develop acutely,if
Acute

eczema,

militate

not

the causal

vesicular

etc.

againstthe
factors

fact that

arise

formations, which

such

suddenly

or

vesicular

formations

occasionally

to the

skin.
spread suddenly
purely inflammatory type or
erythema and herpes iris,and the

either the

present
angioneurotic fluxion (the bullous forms of
of vesicular
forms
like),do not constitute pemphigus. However, there may be some
of inflammatoryand
characters
formations
which
the
mixed
akanthodistinctly
possess
of the skin and pemphigus.
lyticvesiculation,*'.e., of inflammation
the term
Under
parakanthoses I include those anomalies of the pricklelayerwhich
growth, in contradistinction to the simple hyperplasise.
present an atypical(paratypical)
in this category:first,
Two
diseases
the so-called
molgroups of
may be included
of the prickle-cells
into peculiarlyconstituted
luscum
contagiosum," a transformation
at the
bodies (molluscum bodies),homogeneous and vitreous in the centre, horn-like
which
have
periphery,
according to the most recent investigations
nothing in common
with colloid or amyloid degeneration.
We
have to deal in the second
group with the extension of the atypicalcondition of
to the connective-tissue
the prickle-cells
foci of an epitheas
layerof the skin, inasmuch
lioidal type develop in the latter,in the form
of irregularcell groups, which
differ from
the interpapillary
tissue of the corium
in all directions,
cone
forms, traverse the connective
and find new
centres
of growth in the involutions of the epidermis in the corium.
the standpoint of Thiersch
these
be retained, that
and "Waldeyer must
iSTevertheless,
to
formations
their
the
the
new
owe
atypicalepithelial
origin
pre-existing
epidermis,
epithelium,or its continuations in the corium.
of an atypicalcharacter
This form of epithelial
new-formation
is also distinguished
fore,
I have, theretraverse
which
the entire tissue.
by the formation of nests (alveoli)
may
appliedto this second group of parakanthosesthe term alveolar akanthomata.
As an
it is peculiar to the various
independent and definite morbid
appearance,
that

of

"

110

of

forms

and
epithelioma

in various

other
the

later among
The
forms

the
processes, especially
chorioblastoses.-

like

In

the

Moreover,
from

sarcoma

However,

we

certain

term

SKIN.

auxiliary
phenomenon it occurs
which
will discuss,
we
granulations,

skin.

As

so-called

an

neither

dropped altogether, since

combined,

or

is

"carcinoma"

the

to cauliflower

superfluouswith

warty
But

designated by it.

be

can

the alveolar

nor

need

we

be too

not

tumors.

regard

skin, both

the

to

from

histological point of view.

histogenetic and

merely

the

manner,

THE

papilloma in the future

term

apply the

may

be

individually

of akanthomata,

rigorous, and

should

papilloma"

"

term

of the

carcinoma

to

OF

NOSOLOGY

GENERAL

conception carcinoma, in general, is not

Virchow
which
attempted to make.
the

employ

may

alveolar

of

group

term

of

carcinoma

"

akanthomata.

deflnite

the

These

may

tiation
despite the sharp differen-

one,

"

skin

when

be divided

wish

we

into

to

two

designate

groups,

of

one

of the proliferating epithelial cells in the alveolar

cornitication
by marked
laminated
which
the well-known
in
bodies
of
manner
bodies
epithelial
Waldeyer),
cancer
(the
should
These
be
globes, etc., are produced.
nests, horny layer nests, pearly bodies, cholesteatoma
the other group
of Waldeyer), while
called the true epithelioma of the skin (epithelioma keratodes
is characterized

which

the

is very

this corniflcation

in which

slightlyor

at all

not

apparent, retains

the

carcinoma

"

name

of

skin."

THE

ANOMALIES

DEVELOPMENTAL

developmentalanomalies

The

THE

OF

CONNECTIVE-TISSUE

OF

SKIN

AND

ORIGIN

(CHORIOBLASTOSES.)

TYPE

of the corium

tissue in the

characterized

are

diseases of this class

the

by

fact

reach

the

that

the

ment
developstage, i. e., presents
reallyhigher types, but remains in an embryonal (cellular)
of cellular connective-tissue
elements, which
persistas such
a
profuse proliferation
(granulomaof Virchow).
with a process which
These forms of developmental anomaly have a greatsimilarity
abundant
a
nd
also
after
the
corium
an
in
irritants,
inflammatory
depends
upon
develops
termed
and
connective-tissue
is
of
cells,
inflammatory granuusually
lation.
development
young
terminates
This process, which
every inflammatory process in the connectivegrowth

connective

of the

does

not

of

tissue

and ulcers,also
layer,and constitutes the first stage in the restoration of wounds
with granulomata. In the granulationof wounds
we
clinically
similarity

presents some
have

to deal

viz., the
a

the

also with

formation

of nodules

of the

elements

embryonal
regularoutgrowth
of
the formation
nerves, and finally

to which

the

we

refer

continuance

tense

more

now

show

of the

and

similar

embryonal

connective-tissue

the

formation

into

bands

of

elements,

atypicalcharacter

of connective

with

tissue,vessels,

epithelial
coveringover the corium which, at
devoid of papillae.On the other hand, the diseases
inasmuch
but in an atypicalmanner,
as
processes,

and

the most, has become

from

this is

proud flesh,but

granulationsof

an

character

of the young

new-formation

the

becomes

characteristic.

prominent
The
diagnosisis evident
sharplyoutlined, and, on the

if the
other

other

symptoms

hand, resolution

of the

inflammatory

of the inflammation

process

occurs.

inflammatory irritant is not

But

are

it

heretofore that occasionally

mentioned
the
nizable
recogthat furthermore
the clinical signsof inflammation
distinctly,
appear less sharply
the accumuinasmuch
its course
is a tedious
as
lated
defined, that finally
occasionally
one,
appear
embryonal cells persistfor a longerperiod in the tissues,and are only made to disfrom
the
difficult
in
is
indeed
necrobiosis
such
the
differentiation
more
cases
by
;
tissue.
the
connective
anomalies
of
true granulations,
as
developmental
of the
But another
questionarises: as is well known, the presence of bacilli in some
has

been

112

and

Thoma,
have

vitreous

and
defended
fixed

him

with

Thin, maintain

escaped directlyfrom

cells into

been

with

proven

also in other

tiie coalescence
whether

of

they

tissue and

meshed

regard

cellular

It is still a

etc.

to the

the

result

of

process

as

follows

growth
represent an outrecently has again

Jarisch

depicted the gradual transformation

from,

lupus elements.

into

occur

not

alone

in

lupus and

losis,
tubercu-

tions,
proliferastages of syphilis,in scrofulous
have
been produced by
giant-cell formations

in the later

disputed question whether

granulation cells,whether
are

has

blood-globules which

which

themselves.

vessels

then

white

are

appearances

giant-cellsthat they

new-formations,

clinical relations of the various

The

of the

original cellular proliferationtheory and

the

but

describes

Lang

of the walls

SKIN.

THE

lupus elements

that the

vessels, while

degeneration

connective-tissue
It has

the

OF

NOSOLOGY

GENERAL

these

they
of

are

exuded

development

from
or

the

lymphatics

sels,
the blood-ves-

or

retrogression.

granulation tumors

to

one

another

may

be

pressed
ex-

course
granulomata of the skin which possess a clinical and anatomical
is undoubted.
These
of which
with syphilis
similar to that of lupus and the connection
of
termed
true
scrofulous
This
is
be
also
proliferations
decidedly
syphilitic
lupus.
may
infiltrations.
in the form of nodular
cerning
conFinally,there is one form of such infiltrations,
and
dark.
in
the
quired
acthe etiological
factors of which
we
are
Hereditary
entirely
other
in
such
neither
be
excluded
nor
cases
glandularenlargements
syphilismay
;
as
scrofula,and tuberculous infiltrations cannot
symptoms point to the condition known
trations
infilbe found; there can
be no questionof leprosy. And, nevertheless,the well-known
in the skin of such
children
otherwise
who
and develop steadily
are
parently
apappear
as
opposed to
healthy. We speak of lupus in such cases, but its characteristics,
of granulomata, reside less in the clinical and anatomical
the other forms
signsthan in
factor.
than a granuThis lupus is nothing more
the absence of a definite etiological
loma
the causes
and very chronic
of
with very marked
persistenceof its elements
course,
of
Willan.
the
unknown
this
is
which
are
lupus vulgaris,simplex,idiopathicus
;
of lupus true scrofulous
But although in many
cases
depositsin other tissues are
laid
of
have
stress upon
the relations
absent, nevertheless
very good observers recently
in otherwise
The common
argument that lupus occurs
lupus to tuberculosis and scrofula.
who
healthy individuals is considered of slightimport, for example by Volkmann,
which
chronic
bones
that frequentlysevere
diseases of the jointsand
sent
prepoints out
of scrofulous
morbid processes, but in which
not merely the clinical peculiarities
putation
amin
tubercular
the
resection is followed by manifest
branes
memor
deposits
synovial
in
in the medullary tissues of the bones
the sole disturbance
as
occur
or
even
transitional
and
that
mixed
otherwise
furthermore,
perfectlyhealthy individuals,
membranes
forms between
occur,
lupus and manifest tuberculosis of the skin and mucous
of
tuberculosis
from
and that lupus of the tegumentary coveringsdevelops occasionally
the bones or lymphatic glands.''
It is evident that the relationship
of lupus of vulgaristo tuberculosis and scrofula is
extent
not denied to the same
as
formerly.
the granulomata,
The second
from the first,
group of chorioblastoses is distinguished
i.
normal
than
that
the
fact
constitute
rather
they
by
heterotypes
paratypes, e., there is an abof
but
bounds
well-known
the
of
the
within
connective-tissue
elements,
outgrowth
higher forms of development and types of tissue. I apply to them the term desmomata
of the skin.
They include:
Fibromata, with predominant development of the connective tissue of the cutis and

There

are

"

"

"

subcutaneous

tissue into fibres and

bundles

of fibres.

Osteomata, with predominant development of

osseous

tissue.

THE

SKIN.

113

tissue.
predominant development of cartilaginous
tissue.
of
fatty
predominant development
predominant mucoid degeneration.
coUoidata, with predominant hyaline (vitreous,
degeneration.
colloid)

with

Chondromata,

Lipomata,
Myxomata,
Hyalomata

OF

SEMEIOLOGY

GENERAL

with
with
and

predominant fattydegeneration.
tissue.
predominant development of muscular
with predominant development of nervous
(?) tissue.
Neuromata,
Angiomata, with predominant development of vascular cysts.
condition.
Sarcomata, with predominant development of cell forms in an atypical
must
be left to specialpathology.
More detailed consideration of these tumors
of development which
terized
characmust
of those anomalies
Brief mention
be made
are
of
the
defective
connective-tissue
development
layer.
by atrophy or congenital
This includes those changes due to age, and also a probablycongenitalgeneral atrophy
has been made, viz., liodermia essentialis.
of which previousmention
The senile changes in the skin are confined to a wasting of the tissue of the cutis,
be termed
which must
shrinking,finelygranularopacity,and vitreous (hyaline)swelling,
or
morphoea
(E. Wilson). In the epidermis, however, it may result in wart-like
also in atrophy of the hair follicles and increase of pigcornification),
ment.
growths (irregular
and is merely the
is also peculiarto essential liodermia
The latter appearance
constant
pathognomonicexpressionof irregularatrophy of the skin.
with

Xanthomata,

with

Myomata,

"

"

THE

DISEASES

MYCOTIC

OF

THE

SKIN.

the dermatomycoses, are

by vegetableparasites,
distinguished
I will not enter into any details
by their peculiardevelopment and course.
concerning them.
also act as
to animal
which
In contradistinction
parasites,
disease-producers
upon
the skin, I would point to the fact that the character of the diseases in questionresides in
and that the former disappearswith the removal
of the
the depositof the parasite
itself,
of the zooparasites,
latter. This is different in the case
which are partly,
for
as
example,
after the removal
not found upon the skin at all,or
of the
only accidentally
body-lice,
the
disease
form of inflammation
a superficial
impregnated clothing,while
proper
^may
developlater.
In this categoryare included the diseases of the skin produced by vegetableorganisms,
which are divided into four groups
: mycosis favosa
; mycosis circinata (tonsurans,
or
marginatum) ; mycosis pustulosa(including
herpes tonsurans
ring-worm, eczema
and mycosis furfuracea (pityriasis
parasitical
sycosis,
impetigo parasitaria)
versicolor).
The

from

diseases caused

the others

"

II.

GENERAL

SEMEIOLOGY

OF

THEIR

THE

"

ANTHEMATA

SKIN.

DISTRIBUTION

ON

THE

AND

SYNANTHEMATA

SKIN.

important objectsof dermatology to recognizeclearlythose

general coveringwhich constitute the basis of the complicated
their
to
examine
to
forms,
pathologicaland anatomo-pathologicalsignificance,
them
t
o
mention
the
a
nd
finally
accurately,
part played by them in the forms of

It is

one

of the

most

elementarychanges in the
define

disease themselves.
For

this purpose
8

we

will discuss

the

and
subjectanalytically,

will

presentfirst the

114:

GKNEEAL

simple

most

We

would

propose the retention

the entire body in the

"

eruption

elementary changes

or

over

be termed

forms

link

the skin

in

anthemata

SKIK.

from

of the term

purely morphological

exanthem

dermatology of
anthemata/' and finallythat

"

between

THE

OF

8EMEI0L0GT

all

for the

productionof

languages; and

the groups

indiscriminatelyfor
diseases.

When

in groups,

which

morbid

in

in

of

an

If

we

do

with

been

At

to go

I may

will spare

the

as

to the

for the

In the

disease,and
with
former

maintain

the

study

will render
measure

student

much

and

"

lichen;

or

be mistaken

not
we

the

employ

for

the

the

use

pression
ex-

"vesicle"

term

further

and

character

not

may

herpes, without

or

determined

nosologically
of

name

length of

more

addition,

as

collected

origin, are

distinctly,as is done

disease, for example,

avoiding
but

remains

the

that
the

to

all

define

terms

their

limits, and

best

ruber

lichen

such

tion
by the addi-

or

entirely(which

of the

recognition of, and

groping in the labyrinth

distinct

laborious

easier, and

removal

to

employ

herpes
would

ter.
zos-

meet

them

in

will

confusion

also

appear

which

to

adhesion
of

advanced

the

the

to

the

previous

following
ture,
nomencla-

dermatologist as

able
suit-

still predominates.

the morphological
will enumerate
we
primary forms of skin
ciation
place in their appropriatepositionsthe simple anthemata, and, in assovarieties of the
these, the synanthemata which are composed of one or more

followingremarks
will

Spots (maculae)are
the skin

necting
con-

manner.

all events

definitions

"

speak of lichen

definite

defined

serve

practicaldifficulties),
nothing

corresponding

we

may
of

the

or
herpes. But this lichen or herpes is not yet the expression of
of the primary lesions,
and arrangement
merely of a definite character
diseases.
a
ample,
synanthem, for exOnly after the appellation of such

but

various

wish

with

synonymnous

Nor

constitute

lichen

or

not

as

vesicles

or

herpes, has
adjective,may it

lichen

"

herpes."

"

process,

occur

may

papules"

nodules

this results

definite

"

or

skin-

that their elementary

which

be superfluous to call attention

to the fact that these should
therefore
For
be strictlydefined.
themselves, and must
example,
"nodules"

"

exanthemata, be called ''synanthemata."

and

It will not
diseases

point.
stand-

without

changes

in the

consistence

color, density and

essential change in its elevation.

Such

^^

''

of the

surface

of

arise:

spots may
in dermatology as
erythema
congestion,h3rper8emia. They are known
roseola."
These
and
spots,which always disappearunder the pressure of the finger,
of blood within the vessels of the skin.
are
merely the expressionof an excessive amount
When
slightlyelevated (erythema
inflammatory oedema is also present,they are occasionally
then
faint
color.
and
a
yellowish
present
papulatum),
be due to arterial fluxion, and then are brightred; or they
The congestivespotsmay
arise from venous
and
their color is then
bluish-red, cyanotic. Such erydistention,
the
when
themata
known
are
as
expressionof an exanthematic
general
roseolae,
they are
develop
affection,for example, in typhus and syphilis. The erythematous rings which
1.

*'

From

''^

''

ordinarilyaround

spotsof

inflammation

are

called

of the

coloringmatter
These
haemoglobinorrhoea).
spots occur
Bes,
mechanical
the
result
of
as
incomplete
patches,
of the coloringmatter
the passage
3. From
2.

From

the passage

areolae,halos.
into the skin

of the blood
in

the form

venous

of the

of

(hsematochroyellowish,yellowish-white

stases.

puscles.
blood, together with blood-cor-

in the shape of
they occur
occur
as
plications
comstreaks,as ecchymoses and petechiaewhen they are punctate. They may
of simple inflammatory and
angioneuroticprocesses (hemorrhagicerythema),
If
in simple and papulous purpura,
or
as
hemorrhagic suffusions in erythema nodosum.
these extravasations
basis predominates,
a dyscrasic
usuallyare called petechiae.
marked
the more
4. From
development of the blood-vessels of a region of the skin.
These

extravasations

are

known

as

vibices when

GKNEEAL

usually under
thickening of

conditions
the walls

nsevi,birth

they are
tion
I

ogy

or

of
5.
a.

8EMEI0L0GT

which

of these

marks

produce
vessels.

OF

THE

with
stasis, occasionally

venous

This

115

SKIN.

includes
The

coincident

cular
partlycongenitalchanges vascalled teleangiectases,
are
if
"

latter

^partlyacquired
themselves;but if this is associated with chronic congescedema
of
the surrounding skin, they constitute the symptomatolinflammatory
of authors.
rosacea
erythema angiectaticum,the acne
From
changes in pigmentation (parachromasiae). These occur:
As the remains
of previouschanges in the skin, especially
orrhagic
inflammatory and hemat first bluish-red, then greenish-yelare
low,
processes in the form of patches which
confined

then
t. As

ones.

"

to the vessels

brown.
excessive

either of the normal

accumulation

of

the

normal

yellowish-brown pigment

coloring matter

scattered

in the

(hyperchromasiae),

lowermost

of
cell-layer
tissue of the corium; either congenital as
Malpighian network, or
naevus
spilusand pigmentosus, or acquired,as chloasma, lentigines,
ephelides.
Or of black pigment in melanosis
cutis and
certain diseases of the internal organs.
the entire organism in the cachexia
or
of malarial
fever, argyria,Addison^s
disease,
finallyin tattooingof the skin.
Or of yellow (bile)
pigment in biliaryeffusions into the skin with jaundice.
of a yellowish(sulphuryellow)mass
in
Finally,this class includes the accumulation
the

in

the skin, the character

of which

the

has not

yet been determined;

in xanthoma

(xanthelasma,

vitiligoidea).
As

the absence

albinismus

totalis and

or
either congenital as
disappearance of pigment (achromasise),
leucodermia.
Such a loss of color
or
partialis,
acquired as vitiligo,
in the skin occasionally
is called '^'morphoea"by writers, especially
when
the spots are
round, and surrounded
by a violet rim.
As
a
rule, the patches previouslymentioned
are
circumscribed, and the following
diffuse plaques or regions which
not
changes are distinguishedby more
are
distinctly
ways
circumscribed,or at least,merge readilyinto one another, and are of largersize,but alflat. The
term
them
in
to
is
patch
applicable
part. They are
only
usually
the terminal
forms
of pathologicalprocesses upon
which
they impress their stamp so
line with the morbid
themselves.
stronglythat they may be placed in the same
processes
These
include:
6.
skin
The
liodermia, also called glossy skin.
thin,
appears
drier.
smooth, tense,less elastic,shining,slightlyreddened, and usuallysomewhat
This
most
change occurs
frequentlyas the result of neuritic processes; also from unknown,,
but probably congenitalcauses.
The latter disease has been described by different writers
under various names.
Finger has also described a '^liodermia syphilitica.
7. A condition
of dryness and loss of gloss in the skin, which
is caused by diminished
secretion
mia.
xeroderof the sebaceous or sudoriparousglands. This condition I term
in the
When
due to diminution
of the secnetion of sweat, it is observed especially
it
due
is
to
of
the
when
diminished
in
other
of
the
secretion
of
skin,
palms
hands;
parts
is
increased
sebum, an
usuallypresent.
desquamation of dry scales
The term pityriasis
is appliedto the increase of the normal
desquamation in the form
of constantlyproduced branny scales,constituting
an
abnormality of cornification (keratolysis).
c.

"

^'

'^

lysis,
Pityriasisoccurs
simplex or alba, a simple keratoonly in two forms : as pityriasis
which is independent of the sebaceous
rubra (essentialis),
glands,and as pityriasis
also described
dermatitis
which
is an
exfoliativa,^'
by recent writers as
independent
morbid
of
the
hitherto
unknown
entire
skin
of
origin.
process
"

116

Finally,this category

8.

This

of stasis.

generalprocess

and

usuallyin

terminates

tion
infiltra-

cedematous

lardaceous

of the skin, which

sclerema

or

SKIN.

THE

board-like

the

includes

of the skin, viz.,dermatosclerosis

to

OF

8EMEIOLOGY

GENERAL

be

must

attributed

atrophiccondition

an

similar

to liodermia.

in appearance

of
prickle-cells

the

among

the surface, which

the skin above

of

elevations

Papules are
e., accumulation

the

contain

epidermis. They

free

no

fluid,i.
under

produced

are

conditions:

various

papules constitute largeror smaller

connected
but are
not
circumscribed
with the follicles,
are
elevations,which
necessarily
infiltration into the epidermis cells themselves;they are more
less
or
produced by serous
either pointed or depressed at the middle.
Central
of a bright-red color,solid, and
the excretory duct of a follicle terminates
depressionsare observed when
accidentally
acne
or
or
sycosis)at the top of the papule.
pathognomonically (in
h. By excessive cornification of the layers of epidermis lining the sheaths of the
of the horny layer at the point of transition of
accumulation
roots of the hair and an
If marked
the follicle into the surface of the skin.
hypersemia is present in the cutis
at the same
time, the papules will have a reddish
color; if the hypersemia is absent, or
formation
of scales,a whitish color.
marked
into
there is more
They are not converted
vesicles and pustuleslike the inflammatory nodules.
the downy hairs of the skin, as the
c.
especially
By an elevation of the hair-follicles,
contraction

result of muscular
goose

be

In this class may

definition

In the

the others

the

by
of

mouths

This

is

times

applied at

to indicate

express
the

"lichen

with

is necessary,

the

at

times

nodules

to the

"

as

of

red

in any

under

color, which

and

the

colorless

which

second

nodules

is

and

lichen

term

form

of

vesicles

of which

the

lividus, etc.

but

synanthem,

papules

the

the

of

commonly

is

of

in the

individual

In order

The

pustules.

nodules.

the

above

definition

are

often

transformed

this

the
For

term

will contrast
other

of
lichen

example,

in

disseminatus

confusion,

into

bulary
voca-

accumulation

an

speak of lichen

to check

stratum

tiation
differen-

dermatological

develop from

disease, we

distinguished

epidermis

confusing abuse, and

most

formation

isolated

are

into

and

subjected to

that

accumulation

an

the nodules

diseases

been

stated

converted

not

are

blood, of lichen

we

will

tain
re-

it with:

primary

forms

"

lichen
urticatus
with
(inflammatory nodules
an
pustules, wheals). This includes
are
tropicus," and
agrius of Willan, which
merely foi-ms of eczema,
areola), "lichen
"

lividus"

or

"

"

be

may

(ichthyosissebacea), lichen
Tubercles

those

are

(granulation).The

same

of

to the

of

author.

prurigo, which
contracture

applied properly to
ruber

nodules

small

of the

nodules

I attribute

which

"

lichen

non-red

and

pustules,and

term

"

haemorrhagicus

"

Non-inflammatory

The
tus

certain

have

we

produced by

are

"

lichen

vesicles

has

diseases,

to

that

term

oedematous

b.

others
for such

however,

use,

suffusion

they

that

the

from

(vesiclesand
and

includes

appropriatelythe synanthem

most

papules given above,

fact

employed

Inflammatory

a.

"

placed

and
hair-follicles,

the

commonly

epidermis.

to

of
the

this group

of
is

order

This

contracture.

or

"lichen.^'

termed

at

Such

prurigo.

skin and

from

in the skin.

By inflammatory processes

a.

lichen

are

not

converted

arrectores

into

pilorum.

pilariscongeni-

scrof ulosus.

produced by

are

musculi

pilarisacquisitus, lichen

Hebra, finally lichen

which

likewise

of the

cellular infiltration of the cutis

size may

decisive
not, as heretofore,be considered
large
the
elevations
of
since
with
papule or tubercle,
lupus, which have
generallyas tubercles,are distinguishedby their small size so long as
long been known
and pathologicalcharacteristics
they do not coalesce. The differences in the anatomical

regard to the

of both
The

forms
term

term

constitute
*'

or

sufficient

granuloma'^

or

reason

for their differentiation.

"granulation tumor,'' introduced

by Virchow,

is

really

GENERAL

OF

8EMEI0L0GT

for

purelyanatomo-pathologicalone

THE

infiltration

an

lit

SKUST.

of the

cells which

cutis with

main
re-

embryonal stage. It would be desirable to form a transition stagebetween

of infiltration,
and the developed morbid
the tubercle, the primary lesion of these forms
tuberculosis
of the skin.
The tubercle does not
such as lupus, syphilis,
conditions
persistas a pure elementary form, but from it are developed a series of complicated
in

an

formations.

transitional

lular
be called granulations or granulomata, i. e., celWheals
into diseases.
specialindividualization
solid elevations above the surface of a flat shape, from the size
are
(pomphiges,urticarise)
of a pea to that of a dollar,often confluent;they are produced by cedematous
swellingas
irritation.
flat
elevations
of
of
constitute
result
the
angioneurotic
Morphologically,they
in
which
the middle, and grow
redder
are
irregularshape,
a round, oval, or
usuallypale
white (ansemic)areolse around
red
towards the periphery. Here and there are observed
The individual wheals
wheals.
develop and disappear rapidly,and leave no traces of
the local process.
They are associated generallywith violent pruritus,and are observed
in
urticaria.
most
frequently
the surface, containing a free accumulation
Vesicles are elevations above
of serous
transitional

These

formations

infiltrations of the

may

cutis without

fluid.
It

that this form

explained above

was

well

as

by

as

process,
fluid coming

from

epidermisby

of anthemata

mechanical

below.

thus

akantholyticvesicles,and

the

Vesicles

produced by the
horny layer of

the

of the

kind

latter

with

contrasted

be

could

separation of

have

flammatory
in-

the

called

been

vesicles.

inflammatory
Occasionallythe vesicles of both kinds have hemorrhagic contents; they may be
large or small, tense or loose,of shorter or longer duration; they may remain isolated or
coalesce.
ering
They are either converted into pustules(the inflammatory ones)or their covis stillcovered with the youngest layerof rete cells,
bursts and leaves a spot which
and readilyacquires new
the papillaeare
skin, or they give rise to an erosion in which
which
the entire epidermis must
laid bare, and over
be newly formed.
the development of inflammatory vesicles (vesi"herpes" is meant
By the term
cles,
We
retain the term herpes
pustules) in groups, with an acute and cyclicalcourse.
of synanthem, i. e:, as an interveninglink between
individual efflorescences
as
a form
and
forms
of disease,and
the individuality
of the latter may
be readilyretained
(vesicles)
adjective.
by the addition of some
By
the

strict adherence

vesicular
a.

The

h. The

c.

The
a.

The

h. For
course,
For
a

non-

the

above

differentiation

definition,a

chronic

formation

herpes,

the acute
in
the

made

readilybetween

of vesicles

akantholytic formation

of vesicles

synanthem

inflammatory

as

in chronic

occur

pemphigus.

in groups,

various

in

of

flammatory
simple, in-

the

stigmatoses, etc.
the result of of dyscrasic processes,
for

form, is then

formation

not

retained

for the

vesicles,occurring

example, syphilis.

following

processes:

in

and

groups

running

cal
cycli-

herpes zoster.

inflammatory

acute

in the

diseases

the acute

are

known

formation

as

inflammatory

cyclical course,

Pustules

as

maybe

herpes and

inflammatory,

impetiginosus,first
,

to
of

do
non-cyclical formationof vesicles,which
of the skin; for example, in eczema,
processes

term

For

course,

c.

formation

of vesicles, occurring in groups

and running a cyclical
herpes praeputialis,progenitalis, facialis, phlyctaenoides,

formation

in ery than thema

described

elevations

by

me,

above

of

vesicles

neuriticum,

which

the

and

is
etiologically

surface

and running
pustules, occurring in groups
and
essentialis;finally, the herpes

toxicum,

with

still undetermined.

purulent

contents

accumulated

free

118

GENERAL

8EMEIOLOGY

OF

SKIN.

THE

in

the

epidermis. They always develop from

Their
papules of an inflammatory character.

from
vesicles,and, therefore, indirectly
anatomical

has

structure

been

discussed

above.
The
on

term
a

is

ecthyma

applied to

hard, elevated,red

dark-colored

crusts,and
This pustularformation,

or

conditions

constitutional
is

the

then

present,and
Under

or

in

one

eruption of largepustules,each
terminates

in the

in the

development

formation
of

new

the basis of stasis,occurs

upon

hand, incomplete stasis,on

produce,
frequently,therefore,when

most

on

an

base, and

obstruction

an

to the

of

of which

ated
is situ-

dark, hard,

ish
green-

skin.
in

all

in which

cases

the

the other hand,

return

inflammation;
produced by
mechanical
causes),

flow of blood,

mechanical

causes
(heartdisease,varicosities from
addition, inflammatory irritants act upon such parts of

the

skin.

the term

erythanthema I refer to all those symptom-groups upon

of various primary forms, such
characterized
-which are
by the combination
with a variable arrangement upon
occur
vesicles,pustules,wheals, which
a

the skin
ules,
nod-

as

reddened

(inflammatory)base.
Observation
of

teaches

that

the

morphological

same

combinations

may

occur

as

the

result
of angioneuroticirritants (toxic
to us,
as
a
directlyknown
medicinal
exanthemata) and also of neuritic processes.
The
of disease,
erythanthemata are referred to in the nosology,accordingto the cause
as
erythanthema essentiale (Hebra's erythema multiforme),erythanthema toxicum, and
erythanthema neuriticum.
the primary and elementary changes in the skin here mentioned, are associated
With
few more
a
elementary forms, which, in part, are simple,direct effects of mechanical
in
opment,
injuries, part are the sequelaeof these primary lesions,their terminal stages of develtheir remains, and are called secondary efflorescences.
or
To this class belong:
fissures and rents
The erosions (less
(rhagades),and ulcers.
properlyexcoriations),
result

three

These

causes

forms

of loss of substance

may

arise from

the most

distinguishedfrom

varied mechanical, chemical,

another
one
pathologicalprocesses.
They are
merely by
the
losses
substance.
Of
chief
of
of
stance
the depth and form
importance is the circumthe epidermis alone, and then whether" the horny layer or the prickle
whether
redness
Either
without a solution of
superficial
layer has been affected by the lesion.
continuityis produced, or a destruction of the upper skin in the shape of a circle or line
fluid or blood
in substance, if
of serous
with exudation
of blood-coloring
matter, or even
the irritant has acted as far as the papillarylayer. Ehagades, fissures with
steep edges,
if the horny layeris especially
thick or very tightly drawn
arise in this manner
may
(palm of the hand and skin of the external ear) or deep erosions may be produced.
stance
even
If the injury has destroyedin part the papillarylayer itself,
deeper losses of subof cicatrices. Ulcers of the skin which
with subsequentformation
occur
naturally
heal by cicatricial development alone, constitute a varietyof such losses of substance
constitute
the terminal
in morbidly changed tissues and
which
stage of their
occur
metamorphosis.
retrogressive
loosened from the
the lamellae of the horny layerwhich
are
Scales (squamae) are
in
form
of small branny platesbecause new
physiologically the
epidermis. This occurs
cells of the younger
layer are constantlyundergoing cornification and casting the old
If this shedding process increases,we speak of scalingor branny scalingwhen
off.
ones
smaller plates,and of desquamation when
largerwhite platesof the horny layerare cast
the
in the disease
known
latter as the
as
first varietyoccurs
"pityriasis,"
off. The
or

120

GENERAL

in this direction.

An

ETIOLOGY

unbiassed

that the actual demonstration

the

branches
in

and

zoster

neuritic

as

leprosy,as

conditions

turn

in

direction

well

skin

in those

as

other

of the

of the

skin

and

in but

few

furnished
and

we

teaches

anthemata

with

diseases,viz.,in
have

herpes
together

classed

direction

connective

connective

command

our

of the

that linear tracts

that this

subcutaneous

fibres of the

at

diseases which

proof has long been

different parts of the body

of tension

SKIN.

distribution

is afforded

The

the direction

upon

of the

nerves

dermatoses.

different
the

of the

THE

observations

in the

connection

OF

of all the

view

of

DISEASES

OF

assume

depends

upon

tissue,the latter in

tissue in and

below

the

ment
integu-

of the part in

question (Langer).
This
time an expressionof the general laws of developregularityis at the same
ment
of the body, which
the one
hand in the direction of greatesttension,and
occurs
on
the other hand is dependent upon the points of fixation of the fibres upon
the bones

on

and

fasciae.
In

addition
of the

tension
the

direction

of the

fibres of the

connective

produced thereby,the positionand

blood-vessels,and

and

nerves

to the

skin

even

tissue

direction

the arrangement

of the

and

the

of the main

varying

trunks

glands depend

of
the

upon

laws.

same

We

may say, therefore,that the law of arrangement and distribution of the anthemata
the skin, in accordance
with the generallaws of development of the human
body,

upon

depends
not

the

upon
the

upon

depend

upon

of the

of the connective-tissue

and

nerves

the fibrillation and

ETIOLOGY

GENERAL

ni.

direction

trunks

OF

vessels,the
tension

DISEASES

OF

GENERAL

The
fact

it is not

but
direction,
to

may

also

sensations
entire

the

reason

of the

direction

growing layerof

SKIN,

THE

tension

THEIR

of the

skin,but

of which

selves
them-

connective

RELATIONS

tissue.

TO

THE

ORGANISM.

distinguishedfrom
to

the

positionand

the nutrition

the other

of the

organs

of

the
in

organism mainly

body by
one

the

definite

it subserves

of the vegetaland animal

sphere
yes all, functions
many,
Under
certain circumstances, therefore,a disease of the skin
in the

disturbance

of the

respiratory
process

body, in

the

secretion

fiuids of the

tissues,in the peripheraland central innervation

touch
due to them, in the distribution
of blood

of

body,

for this

that

mean

of

osmosis

that

subservient

equal extent.

almost

an

is

generalintegument

that

fibres and

and
pressure
in the production and

the list of

causes

pathology thought to find

questionsin its domain.
Charles
Lorry, the real

maintenance

here

an

founder

heat necessary

of the

of disease presents

very

opportunityfor

to

over

life,etc.

varying picture.

the settlement

and

of all

and

the
the

And.

ISTo wonder
puted
possibledis-

division of
a
dermatopathology, first made
morbid
the result of a general
diseases of the skin into those which
are
tomatic),
process (sympand
those in which
the integument suffers independently (idiopathic),
and
herein he has been followed by all dermatopathologists
up to the present time, whatever
their principleof classification may
have been.
will now
consider these etiological
We
relations more
in detail.
1. It has always been held that the so-called acute exanthemata, likewise the various
affections of the skin in typhoid fever,cholera, glanders,syphilis,
and tuberculosis
scrofulosis,
furuncular
certain
of
the
morbid
substances,hemorrhages into
deposit
;
processes,
the skin and
subcutaneous
and
the like,in diabetes,gout, rheumatism
tissue,eczema
;:
of

GENERAL

seborrhoea,acne,

urticaria

alopecia,eczema,

leuksemic

and

scorbutic

disease

DISEASES

OF

ETIOLOGY

of the

in

ansemia

and

blood

THE

OF

121

SKEST.

and

chlorosis,furthermore

the like,must

be

regarded as

in

diseases

of nutrition.
2.

In

addition, a

series of

observations

tend

to

act as the direct cause

of skin
organs of the body may
of the central and peripheralnervous
mention
: affections

neuritic

the
the

dermatoses,

and

affections

of the

show

that

diseases
As

diseases.

centres

individual

illustrations

system, which

vaso-motor

of

which

I may

correspond to
correspond to

angioneurosesof the skin.

circulatoryorgans, which are followed mainly by stasis dermatoses.

Diseases of the organs of the vegetalsystem, the gastro-intestinal
tract, liver,spleen,
the most
varied forms
of skin diseases may be
kidneys,suprarenal capsules,to which
due, such as erythanthemata, urticaria,pruritus,etc.
the integument (eryDiseases of the genitalsystem, the sequela of which
thanthema
upon
diseases of the glands,changes in color),for example, chloasma
uterinum,
in the female sex.
play a great part,particularly
3. Those
physiologicalagencies which, under certain circumstances, may act as a
of disease upon the organism in general,or upon
cause
parts of it,naturallyact also as
factors in diseases of the skin.
etiological
This includes heredity,in part of individual diseases as such, for example, ichthyosis,
birth-marks, psoriasis,
scrofula,perhaps also gout and rheumatism,
prurigo,syphilis,
in part the disposition
to certain diseases as to loss of hair or its excessive growth, to certain
glandular and pigmentary anomalies of the skin, to catarrh of the skin, etc.
mate,
Furthermore, age, sex, occupation, food, dwelling,etc.,in single individuals,clitelluric
conditions
in
and
and
(endemic
temperature, meteorological
general
vidual
pandemic diseases of the skin). It must be left to specialpathology to utilize these indito deal merely with the
factors- in the specialforms
of disease,since we
have
to the effects on the integument.
general relations of the causes
We
shall therefore mention
catarrhs and
brieflywith regard to age : that superficial
of sebum
excoriations,also accumulations
are
frequent in nurslings,that urticaria may
occur
during the first year of life as a premonition of subsequent prurigo,that scrofula
first years of life.
also makes
its appearance,
as
a rule, during the
Psoriasis usuallyappears
after the first decennium, acne
rosacea
during the second
decennium
life suffers from atrophy of the skin, constant
pruritus,and new; advanced
Diseases

formations
As

acne,

of the

of various

far

kinds.

regards sex, those diseases are

with
directlyor in a reflex manner
as

more

the

nected
frequent in females which are conchloasma,
:
genital system
pruritus,

etc.

With

should be made
of a few substances and
regard to occupation,specialmention
manipulations which give rise to diseases of the skin ; either erythemas and eczemas
when
mild
the substances
are
irritants,deeper spreading dermatitides when
they are
concentrated.
The
more
occupation of sugar refiners (grocer'sitch), of shoemakers
and
(formationof callus upon the skin of the thigh from hammering), of washer-women
in lime and
of
is
kid-glove makers, of workers
metals,
bakers, etc.,
as
important an
factor as in those diseases of the skin which
in tar, anilin,or paper
etiological
occur
factories.
Some
upon

the

progress

skin of

conditions.

has

been

made

general conditions

in thft last few

such

as

years

in

climate, the

of the

effects

soil,temperature, the

spheric
atmo-

our

knowledge

122

GENERAL

ETIOLOGY

OF

DISEASES

OF

THE

SKIN.

Wliite

has formulated
with
the following conclusions
:
regard to America
do not occur
in America
ruber
Prurigo, pellagra,lichen exsudativus
(?).
due
to uncleanliness, especiallyto animal
diseases
2. Skin
parasites, are more
1

America

than

3.

Some
or

4.

which

diseases

milder

(lupus,syphiloderma

United

of

causes

doubts

one

the

physico-chemicalor
have

to deal not

abnormal

increase

innocuous
To

in

development

mechanical

Europe

affections

those

or

diminution

or

above

belong

enumeration

act

quent
infre-

more

in which

they

which

will

thus

But

constitute

in the

direct external

attention

may

upon
to the

act

the

parasiticorganisms

and

detailed

as

to this

often

with

substances

fact,that

merely

which

are

irritants.

which

consideration

whether
injuries,

be drawn

may

of action, so that

amount

alone

transition

be considered.

now

of the latter from

nature.

directlywith the
perhaps also eruptions

producers of disease,not

as

the skin, and

themselves, for example, water,

Their

are

countries

injuriousirritants,but
qualitatively

alone with

this class also

the skin.

in

(?),leprosy).

factors mentioned
physiological
but
also
directlyupon
organ,
idiopathicdiseases of the skin

No

4.

we

constitutional
in

Certain

The

than

States

the entire

of

with

associated

are

the

in

course

diseases
those connected
of the skin, especiallyof the glands, and
in Europe (seborrhoea, acne,
than
frequent in America
system, are more
from
heat, herpes, urticaria, and pruritus).

nervous

infrequent

Europe.

severe

inin

endemic

are

in

act

may

irritants upon

as

be reserved

must

for the

special

part.
There
been

are

few

answered

questions in the etiologyof

in a generallyharmonious

diseases of the skin which

hitherto

These

manner.

have

not

be formulated

may

in the

followingmanner
:
1. Apart from
the recognizedconnection
individual diseases of the skin and
between
gout and rheumatism, is there an independent group of skin diseases which, with the
same
be
certaintythat, for example, syphilitic
eruptionsare attributed to syphilis,
may
called arthritic (Bazin),i. e., directly
arthritic tj^e of constitution
due to an
or
duced
proin the latter alone by accidental external irritants ? And
furthermore
:
2. Is there an independent group
skin diseases which
must
of chronic
be attributed
to an herpetic(Bazin) or dartrous (Hardy) character
of the entire organism ?
Both questionsmust
of the supportersof these
be answered
in the negative. None
hypotheticaldiseases is able to give an objectivepictureof the symptoms, in the same
is readilydone
manner
as
anaemia,
by the text-books with regard to scrofula,syphilis,
chlorosis,etc., although these in realityare merely abstractions.
In

fact, the chief advocates

another.

one

of
in

"

While

herpetisme"

certain

hemoiThages
a

certain

"

arthritic

because

extent

This

for

the

crasis

"

upon

doctrine

"We refer to the

morbid
that

"

is

Bazin,

simply denied

strenuously opposed

are

by Hardy,

both

believe

in

the

peculiar connection
the

of

to

ence
exist-

between

mentioned,

the
there

dermatosis
is

and

the

scarcely any

constitutional
other

disease,

symptom

of

an

skin.

of diatheses
of

those

has

always been

skin diseases

somewhat

associated

with

difficult

it may

"

consequences
eveti

be

which

have

said

mystical.
depositfor the

conception that the skin should be regarded as a place of

to the
produced in the body by the diatheses,and furthermore
chronic skin diseases,being cured upon the surface, will be driven back

substances

the

and

diatheses, Hardy

**

exception

the treatment

made

these

arthritisme

Arthritismus
be accepted
dartre," but in entirely different senses.
may
have
long been recognized as nosological entities ;
gout and rheumatism
the presence
of uric acid deposits in the skin
in gout, and
the occurrence
of
be made
together with rheumatic
pains (purpura rheumatica), may
responsible
or

in them

although, with

of
"

since

sense,

furthermore,
to

Bazin's

fear
into

GENERAL

""

"

vital

We

organs.
that it stillholds sway
more

ETIOLOGY

would

in the

THE

123

SKIN.

it not

of many.

will be struck

withstand

cannot

of the relations between

generalsurvey

OF

this entire series of ideas, were

simply discard

minds

excluding everything that

After

DISEASES

OF

exact

if we take a
investigation,
diseases of the organism

the skin and

diseases of

the followingfacts:
for;n as
changes in the skin which appear in one and the same
factors.
The
"the result of various etiological
elementary lesions may be produced by
be produced by the bite of
Pustules may
"different irritants of the most varied kinds.
the
inflammation
of
trunk
of
and
a
nerve
an
insect,by
by iodine poisoning,although
the
and
the
and termination.
same
on
course
whole, the same
structure,
they may present
morbific
which
constitutional
Various
termed
when
are
influences,
they arise
irritants when
from
the outside, may
in the organism itself,and chronic
they come
or

of other

we

organs,

There

with

numerous

are

exercise such

influence

an

the skin that its nutrition,power

upon

to perform the various functions

influences, its ability

of resistance to external

devolvingupon

it may

be

more

or

the advocates of the diathesis theory

as
impaired. But this fact is not manifested
but
diseases
of
definite
a
character,
imagine by
by a series of constantly recurring
of
frequentlychanging combinations, which present in general the
symptoms, though
"character of enfeebled
nutrition,atrophy, and occasionally
even
paratrophy of irregular
nutrition.
development or anomalous
As by certain physiological
conditions, for example, old age, the skin may be made
to assume
a
changed condition (senileatrophy),which we recognize as dryness with
accumulation
of pigment, fallingout and atrophy of the hair, pruritus
vitreous swelling,
skin
the
also
so
etc.,
senilis,
maybe affected in a similar manner
by all those constitutional
malarial
which
diseases
diseases,scrofula and tuberculosis,diabetes
produce cachexia, by
and syphilis. The changes produced thereby will vary someand leukaamia, carcinoma
what
lose the character
according to the conditions from which they develop,but they never
of lowered
nutrition, imperfect restoration of tissue, functional
weakness,
less

"

"

cachexia.
As

the

in

integument

irritant,and
slightest
of the

retention
and

mixed

With
^nd

mucous
as

these

skin falls into

the

individuals

associated

chronic

layersof

skin

"

great sensitiveness
forms

of these

to irritants and

eczemata

obstinate

gradually become

develop.
anomalies

of cornification

tabescentium
(pityriasis
excretoryducts (lichen
and scrophulosorum,xeroderma) and
acantholyticaffections of the upper
disturbances
of innervation
ticorum).
(pemphigus), finally
(pruritus,prurigo cachec-

It is evident

-called

of

The

paratypicaleczemata

are

scrophulosorum),cachectic

cachecticorum

condition

disease.

eczematous

certain
these

changes of nutrition very often

know
in the
inflammatory process which we
that
Not
the skin is constantlyeczematous
in such
of such individuals
membranes
react by catarrh to the
catarrhs are characterized
by specialobstinacy,so in these

eczema.

the

that, as

but

cases,

chronic

chronic
superficial

chronic

as

certain

membranes,

mucous

pictureof

presentthe

that

arthritides

^'

conditions

this series of skin

and

'^dartres"

by

of the

glands and

diseases

Bazin

and

their

reallydoes not
Hardy, but to

positionin pathology,which
independentand.peculiar

we

cannot

differ much
which

from

those

they attribute

concede

an

to them.

The subjectof disturbances

of the external integument
of innervation
and
the influence
of
recentlyto have undergone thorough investigation,

appears
the

very

nervous

124:

GENERAL

system

the nutritive

upon

The

of the skin

disturbances

THE

to

seems

SKIN.

at the

be,

present time,

the

dermatopathologicaltheme.

favored

most

OF

DISEASES

OF

ETIOLOGY

since the

directlyconcerned,

is also

blood-vessels

the

part played by

muscular

These

the vaso-motor

nerves.
must,
regulated by
There
are
tant
imporregard to nutritive disturbances.
the centrifugalinfluence transmitted
for believingthat it is not exclusively
reasons
but another
influence
also
the
therefore
and
vaso-motors,
motor
the
centrifugal
by
nerves,
It
is
the
tissues.
that
this
of
the
nutrition
influences
which
probable
directly
very
the
fibres.
nerve
is
transmitted
influence
centripetal
along
sensory
centrifugal

in

action

of the vessels is

the walls

first with

therefore,be considered

The
rises.What
question now
generalassumptions ?
In the first place,with
regard

muscular

of the

coat

condition

medium

when

dilatation

occurs.

The

of the

lumen

arises,What

questionnext

constrictors

the

condition
soon

be the

must

as

the

as

and

when

point of departure of

taining
main-

gical
physiolo-

of the

spasm
to the opposite conditions

and

occurs,

the action of the

vaso-motors:

regarded
(tonus),will give place,as

paralysisof

all these

to

regard

in the normal

be

must

tension

of

is disturbed, to

condition

of the

to the influence

vessels,which

with

pathologicaldata

the

are

dilators,

narrowing

such

irritants

present time, the ganglia of the sympathetic and

produce
medulla
centres,
oblongata,perhaps also the entire spinalcord, are regarded as vaso-motor
in

and

the

addition, certain parts of

in the

centres

medulla

produced directlyby

the

At

result ?

the above

to

brain
and

(Eulenberg

agents of

noxious

said to be

are

chemical

or

with

connected

Irritation

Landois).

the vaso-motor

of these

centres

may

in
circulating

vegetablenature

be

the

periphery in a reflex manner.

manifested
which
of the capillaries
are
physiologically
changes
the
of
and
of blood (blushing
skin),in the blood prespallor
sure,
by changes in the amount
the rapidityof circulation and the temperature, also constitute the type of all the
changes of vascular tonus.
pathological
or

economy,

from

occurs

such

Perroud^

persistedfor

for

occur

example,

stress must

in

dilatation

of the

of the

with
justifiable

Disturbances
disturbance
with

mations,
not give rise to the so-called neuro-paralyticinflamof the lungs
injury to the trigeminus, inflammation

if the

glands

regard

veins

are

to the

of vaso-motor

under

tied
of the

innervation.

temperature at

the

to

can

beginning
^

be

diminution

on

from

manometric
in the
be

chorda

that

It would
and

irritation

tympani, produces

in Wharton's

pressure

vaso-motors

of temperature,
atrophy.
Finally,

salivary glands

the

arteries,so

excluded.

of the

the

addition, these

the

duct

hypothesis of

is,
an

therefore, that

seem,

perhaps

inference

an

is

sudoriparous glands of the skin.

and

will not

innervation

There

the

blood

the influence

sebaceous

with

even

beings,which

In

progressive muscular

is derived

which

in human

disturbances.

wig's experiments

nerve,

artery also appears

is not

by nutritive

paralysis,and

the pressure

afferent

neuro-paralytichypersemia

elevation, indeed

C. Lud

of

submaxillary

even

of

cases

being followed

of the skin, though this does not

vaso-motor

of

the

time, greater than

active

also

results

the

be laid upon

same

of

without

not
infrequently without
partialmyelitis, infantile

peripheralend of
hypersecretion of saliva
at the

after

eye

number

long time

of the

the secretion

of the

vagi, etc.

collected

has

does

vaso-motors

inflammation

as

of both

after section

conditions

of the

irritation

Abnormal

had

the

in the lumen

Those

no

imply
doubt

of inflammation

explainthe

chief forms

of nutritive

processes have no connection

that the arterial redness and the elevation

that these

of the skin, and

Charcot, LeQons, p. 137.

the

venous

disten-

GENEKAL

tion in stasis,must
to the influence

There

be attributed

forms

are

for

changes

to

It follows

as

that
be

must

time

and

in the lumina

the

of the vessels and

is exhausted

of

neuritic

of the

with

disturbance

recognized in
distinctly
then imparts to the process
skin

skin

of the

these

again

this effect.

of the vascular

addition

to the inflammatio

peculiar
appearance,

into

independent forms
regarded either
(for example, blushing, pallor)or as the beginnings and
(inflammatory hyperaemia), or finallyas part-symptoms
angioneuroses

pure

simple hypersemias

physiologicalfunctions

of inflammation

ISfS

SKIN.

be

may

attempt to convert

every

part-symptoms

neuralgic or

THE

of inflammation, however, in which

long

useless, because

merely increased

OF

their influence

But

disturbance
; this vaso-motor
that of an angioneurosis.

of disease

DISEASES

OF

of the vaso-motors.

continues

tonus

ETIOLOGY

be

thereby must

meant

processes.

trophicfibres

of the part played in diseases of the skin by the

pass to the consideration
their course
which
in or with the cerebro-spinal
but which, I
run
nerves,

repeat, have

not

We

now

hitherto

irritant

appliedat any

disorders

in the tract

*'.e., upon
of sensory

the extreme

been

isolated

anatomically.

of the distribution

part
suppliedby it.
periphery,and

Such

irritant

which

applied
and produce trophic disturbances
centrifugally
The production of trophic disorders of the

is therefore

fact,however

undoubted

an

pathologicalproofs have
We

have

furnished

and

in

the traumatic

add

the

appearances

also been

illustrations
forms

of

above

"glossy skin"

an

trophic

of the skin,

directlyaffects the peripheraldistribution

by a dermatitis, and on the other hand an
but also
spread,not alone centripetally,
in the skin.
skin

through

be inclined

may

in various

in the

fact that

result in

to

of

elements

nerve

interpretthem.

Anatomo-

diseases.

hemiatrophia

of American

the agency

facialis of
As

surgeons.

in

Romberg,

additional

herpes zoster,

examples

we

will

in

and Boeck
(sclerosisof the spinal cord, spinal
leprosy by Danielsen
meningitis,atrophy of the medulla), also by Tschirjew (cellproliferation in the cervical segment of
the central canal and atrophy of the cells of the posteriorhorns
of the spinal cord), etc.
In pemphigus
sclerosis
of the posteriorroots
Babesiu
has recently demonstrated
and
Goll's columns
and
atrophy of the anterior horn.

With

the

described

we

adduced

known

long

a
may
sensory nerve
irritant applied to the surface

an

in the skin, may be followed

to a sensory
nerve-trunk
may

nerves

It is

of

here mentioned

pathological
appearances

experiments. Experiments made, by

results

or, at

spinalcord

were

the

most, had

due

to avoid

the animals

merely
noxious

follows such

inflammation

an

shown

Charcot

that

and

diseases

to anaesthesia

associated

are

Brown-Sequard
of the

skin

pathological

some

had

given negative

after destruction

of the

and

of
paralysisand the consequent inability
influences. According to Charcot, the case
isdifferent when
inating
injury of the spinalcord ; then trophicdisturbances term-

their appearance
in gangrene
make
Babesiu
and Irsai have recentlymade

upon the skin.

direct experiments upon animals, and after
produced a vesicular eruption and atrophy of the

spinalcord have
skin upon
the same
side,but only after the lapse of a few days, *. e., only after the
development of a myelitis; after a few days these symptoms disappeared.
Eecent
the relation of skin
on
experiments aim to throw lightin another manner
diseases to the nervous
system. They attempt to prove that in certain dermatoses, in

unilateral

which
the

injury of

the

clinical symptoms

nerves

In

are

of

affection

nervous

present nevertheless

and

this connection, I will refer

of diseases of the skin and

must
to

the

of the gray

be

do

not

regarded

occur,
as

the

important article by
axis of the

changes

anatomical

in

of the former.

cause

Jarisch

spinalcord.

on

the

cidence
coin-

126

GENERAL

following is the history of the

The
A

pruritus,

with

and

trunk
feet

and

was

vesicles

few

other

in

limbs, while

upper
a

reported by him

case

suffered

had
sixty-one years, who
to hospital with
admitted

aet.

woman,

THE

SKIN.

five years

previously from a vesicular emptiom

and vesicles
eruption of nodules
covering the face^

an

places merely

abdomen

the

upon

OF

DISEASES

OF

ETIOLOGY

vesicular

visible.

were

formation
bed-sores

Then

upon

the

of

soles

The autopsy showed

the patient died.
developed, from which
changes in the spinal cord from the third cervical to the eight dorsal vertebrae, in which
substance
degeneration of the ganglion cells and sclerosis of the gray
granulation and

pneumonia

the

the sacrum
and
upon
interstitial nephritis, and

also

coarse
were

demonstrated.

This
a.

the

from

clinical

That

the

h. That

skin

of the gray substance

of the spinal cord
in
in
those
vertebrae,
places which, according-

affection

an

eighth dorsal
skin

of the

trophic centres

the

:
recognizedistinctly

to

us

to deal with

cervical to the

third

Charcot,

to

historyenables

have

we

affection

are

appeared

over

situated ;
a

surface

corresponding exactly to

this

localization ;
it

That

c.
a

of the

Not

causal connection

and
psoriasis,

In two

as

expressionof
great
and

affection

an

has

reserve

the skin

expressed

disease is here

examined

has
of

one

seven

of

cases

acquired syphilis^

hereditaryand

lupus erythematosus.

the lapse of
with
died of general atrophy after
hereditary syphilis who
atrophy of the ganglion cells of the spinal cord and swelling of the basement

Jarisch

substance

gray

cerebral
into

of

with

soles of the feet,

and

sacrum

the

spinalaffection

circumscribed
as
spots in the commissure
positively to call inflammatory; in two other

of which

without

the

well

venture

of the

between

the
as

children

weeks, he found
not

upon

coincidence, as Jarisch

mere

In addition, Jarisch
one

decubitus

certain.

rendered

of

acute

have sharply defined

neuropathologists

spinalcord.

himself, but

with

associated

was

disease which

the

himself

?) ; then

of

case

spinal syphilis. The

or

dorsal

lower

cord, and

acquired syphilis,in which

cerebral

horns, which

anterior

were

writer

the

the

appearances

few
stance,
subdid

tation
interpre-

around
the vessels,hyperaemia
(crumbling masses
but
various
secondary symptoms,
acquired syphilis with

doubtful

declares
a

and

cases, there

autopsy showed

oedema

of the tissue

syphilis was

hyperaemia
of the

gray

of

the

gray

evidently present, presented

matter,
The

substance.
a

similar

rhages
hemor-

second

case

appearance

in addition
with
a
atrophy of the ganglion cells ; the third
probable diagnosis of
case,
stance
cerebral
were
syphilis, but in which
merely sclerosis of the gray subpresent, showed
symptoms
of the cord, which
could be interpretedmore
properly as a senile process or atrophy than as

and

inflammation.
The

examination

spinal symptoms
in the first
visible

morbid

of which
both
lupus erythematosus,
presented
(?)of the gray axis
part sclerosis,in part inflammation
foci in the central and lateral portions of the anterior horns, which
were

cases

vitreous

of

psoriasis and

showed

in

macroscopically.

even

Only

and

case

of the

during life,also

in

process

do the appearances
justifya conclusion of the presence of a
be termed
to syphilis,
which may
an
inflammatory tissue change. We

of these

some

due

cases

believe that

these should be included

among
in addition to the positivecase
of
syphilis,

acquiredsyphilissuffered from,

and

only the first and second

"herpes iris." The first

died with, marked

symptoms

cases

and

of

hereditary

third

cases

of

of

Bright's disease,
such as are
syphilis,

and the second

presented clinical symptoms of pronounced cerebral
abundantly reportedin literature.
With
and lupus erythematosus,the results
regard to the psoriasis
in the latter permit an interpretation
is perhaps favorable
which
it is difficult to form an opinion.
origin; concerning the psoriasis

of

the

to

their

tion
examinanervous

128

GENERAL

ETIOLOGY

DISEASES

OF

OF

THE

SKIN.

inflammatory process is observed toward the peripheryas far as the skin, together
trophicdisturbances upon the latter.
to indicate that only such
Our experienceconcerning injuriesof nerve-trunks
seems
which
of the peripheralnerve-trunks
traumata
will
produces irritation or inflammation
result in the well-known
nutritive disturbances
with the atrophic terminal
symptoms of
glossyskin, etc.
of the central nervous
examination
6. The anatomical
system in various skin diseases,
in which
affection
clinical symptoms of a central nervous
not manifested, hitherto
were
in part negativeresults,in part positive
has furnished
of such
character
that for
ones
a
the present the assumption of a primary central nervous
disease does not seem
to be well
the

with

established
The

6.

in

which

is

If

in such

cases.

examination

anatomical

furnishingproof that we
followed
secondarilyby

of the
have
the

distributions
peripheral nerve
deal with
primary affections
skin affection as a sequela,i. e.,
to

what has been actuallyproven,

what remains
reiy alone upon
which
has been based upon
the nerves
? Eeally very little

has

not

of

the

with

of

ceeded
suc-

nerves

neurosis.
tropho-

the

cal
etiologimerely the fact
and diseases of the nervous
that functional disturbances
system may produce secondary
and diseases of the skin.
functional disturbances
But
the facts and
the reasoning of
An
properly
abundance
of clinical material, poorly arranged and impathologistsare different
is adduced
eases.
as
interpreted,
proof to substantiate the neurotic nature of skin disto eczema
there is no dermatosis
which
From
is not attributed
congenitalnsevus
and
is
termed
to faulty innervation
a
by ingenious arguments
trophoneurosis,"or
trophopathy." This term has begun to exercise the pathologistsin a livelymanner
called trophoneuroses.
during the last few years, and the majorityof skin diseases are now
of the
But
this term is only justifiable
when
applied to secondarytrophic disturbances
skin as
it was
also employed
the result of nervous
diseases, and in this manner
formerly.
be passed on the attempt to apply the term
But a decided veto must
trophoneuroses
to all skin diseases (erythema, eczema,
prurigo,lichen, herpes,miliaria,pemphigus, purpura,
nsevi,acne
arabum, sclerema, leprosy,ichthyosis,atrophy of
elephantiasis
rosacea,
the skin, myxoedema, neuroma,
pigmentary and developmental anomalies). Should it
not be considered
various apparatus of the
probable that morbific factors may act upon
time, that the nervous
body at the same
symptoms in leprosy,for example, can and must
be explained by the simultaneous
action of the parasites
circulatingin the blood, not
and among
these chieflythe nerves.
alone upon
the skin, but also upon
other organs
If we
facts
to
the
with
the
tion
to
satisfied
are
neuropathologicalfoundaregard
accept
of skin diseases simply as they are and as they probably will remain, we may briefly
we

structure

"

"

''

formulate

the relation of skin

Those

skin

demonstrable
must

be differentiated

'account

nervous

from

of the difference of

but rather

Finally,the
is that

of their

diseases to the

system

nervous

as

follows

tomically
symptoms, prove their originfrom anaand they alone,
affections (centralor peripheralneuritis),
of the skin and the angioneuroses; on
simple inflammation
phoneuroses
tronow
interpretation
existing,
they should not be called

diseases which,

by

their

clinical

*'

^'neuritic dermatoses."

last questionto be solved

parasiticorigin. Animal

with
as

to the etiologyof skin diseases

vegetable organisms have long been

reference

well

as

BEMARK8

GENEEAL

recognizedas

shown
and

has
investigation

recent

of skin diseases

number

development of
development in the

Micrococci

and

Furthermore,

from

the

have

bacteria

in the

followingconditions
The

a.

But
may

and

in

order

be termed
of

been

measles, scarlatina,roetheln, variola and

fever,
typhoid fever, cholera, the bites of
pustules,splenic
demonstrated

infectious

an

that

such

infectious

exactlythe

in

diseases, like syphilis,

tuberculosis, lupus, leprosy.

of their

necessary :
characterization

an

be adhered
disease
in

occurrence

to

rigidly:
produced by micro-organisms

as

piecesof

the skin.

In

addition, the

of the paraa clear differentiation

and, if possible,
sites.
in the skin.
come

from

the outside.

affection,after the fulfilment

disease,we

parasitesin

same

consider

other organs

it necessary

of the

of the

above

conditions,

to demonstrate

body, in

addition

the
to the

rence
occur-

skin,

also in the blood.

If these conditions

even

is

economy.

constancy of their occurrence

proof that they have not

The

the existence of micro-organismsin

suspectedbefore, and in part it has
dependent directlyupon their existence

are

accurate

J). The
c.

chronic

demonstration

mere

of action has

been

opinion,two main propositionsmust

in regarding a skin
not justified
are

1. We

their mode

diseases,and

demonstrated

these diseases

vaccinia, erysipelas,
dissecting wound
snakes, scorpions, and spiders, etc.

In my

skin

this had

in which

that the

further

of various

l?"

ETC.

in detail.

Moreover,
a

factor
etiological

an

described

been

DIAGNOSIS,

ON

though

there

are

are
no

the assumption of
fulfilled,

positiveresults from

an

infectious

attempts

at

disease is

conveying

them

justifiable,
to

other

organs.

Under
these conditions, the general pathology of the skin cannot
regard
definitely
nished
furdiseases as infectious until further data are
majority of the above-mentioned
i
n
of
this
The
the
classification
of
investigation
question
by
respect.
systematic
if the etiological
is
favor
of
settled
i
n
these diseases,even
infection,
question
positively
of the disease in question is more
will depend upon the fact whether
the nature
sharply
characterized
factors.
This much
than by other nosological
is certain,that in the group
infectious diseases
must
be classed very different nosological
forms; in the firstplace,
to all of
the acute
exanthemata, then malarial diseases,then granulomata. Common
self
these is an important factor,viz.,a circulating
poisonousmicrozoon which reproducs itthe
union
of
diseases
in the organism. Nevertheless, pathology will and must
oppose
and leprosyinto one
because
like scarlatina,intermittent fever,syphilis,
nosological
group,
the anatomo-clinical
picturesof these diseases,despite their pathogenetic relat^nship,
of these affections
present insufficient analogiesto one another, and because the solidarity
in all, or even
the
of
those
to
be
demonstrable
not
lations
reclinically
majority
appears
character
and
of
which
the
based
a
disease,
are
pathological
independence
upon
relation.
but only in a singlethough important (etiological)
the

"

"

GENERAL

IV.

REMARKS

ON

DIAGNOSIS,

COURSE,

AND

PROGNOSIS.

cause
diagnosisof skin diseases in one of the most difficult subjectsto the beginner,beview'of
in
the
the
risk
of
the
nosological
neglecting
always runs
process as a whole,
complexity of details presentedby the diseased integument. A considerable share of the
The

he

130

GENERAL

to the

fault is due

REMARKS

in which

ON

DIAGNOSIS,

ETC.

the

symptomatology of skin diseases and their primary

by a diffuse system of nomenclature.
of a correct
the determination
In order to further
diagnosis,a series of diagnostic
be given to the pupils,but the teachers
doctrines and dogmas should not
themselves
to
most
would
aid the cause
the
an
assertion of simple,
by coming
agreement concerning
This
strict,and logicalconceptions in the nomenclature.
being assumed, the pupils
manner

be told in addition

may

The

1.

clinical

patient should
neglected.
the

In

2.

should

historyshould

of the
be

into chaos

converted

lesions has been

always be taken before the inspection; the statements

only with the greatest caution,but should by no means

be received

examination

be looked

at

of the

objectiveappearances,

uncovered,

even

if the

patient

if

possible,the

states

there

"

entire

ment
integunothing anywhere

is

else.^^
skin may be in a condition
of active
constitute a direct morbid
The
factor.

The

3.
not

and

passive congestion,although
act

this

of

tion
undressing and the diminumay
of temperature produced thereby often
active
the
produces
congestion; moreover,
of
individuals
is
sensitive
that
almost
some
so
integument
even
mere
tact
conevery irritant,
with a foreignbody and the like, produces sudden
and
tations
dilairregularcontractions
of the vessels of the skin (districts
and paralysis)which
of spasm
manifested
are
by alternatingred and pale patches, often even
by acute oedema (elevationof the surface
the formation
of the patches, even
of wheals).

due
or

of sight and touch, it must

By means
congestion (the red patches of which,
infiltration (here also the redness
serous

mere

4.

be determined

to

when

to

least in

at

whether

it is due

finallyto
5.

and

increase

Not

part),or

to the
or

serum

the individual

exanthemata,

coloringmatter
of the pigment.

anthemata, but

the

to the

elevation

infiltration

organism

(in

of the surface

which

of the blood,

their relation to

one

main, their

constitute

the

sum

changes of color are

by pressure),

be removed

recent, may

and

their distribution,and, in the

whole, finallytheir relation

which

or

diminution

cellular

to

whether

or

this

cannot

to

blood

another
course,

in

as

be

may

be
in

moved,
re-

done)

or

mass,

synanthemata

detail and

as

of the

objectivedata upon
amination
particularthat the exthe integument,
near

be pointed out
in
It must
diagnosismust be based.
of the expansions of the mucous
which
are
membrane,
and
also of other epithelium-bearingmembranes,
should never
be omitted.
6. The
in
far
statements
the
with regard to
are
so
as
subjectivesymptoms
important
them
harmonize
with the objectiveappearances
of the disease.
and the course
In this,
in
connection, the feelingof pruritus, particular,plays an important and pathologically
interestingpart in skin diseases. Even the absence of pruritus in certain, for example,
forms of anthemata, while entirelysimilar non-syphilitic
characterized
ones
are
syphilitic
by violent pruritus,may often be of an importance which cannot be underestimated.
The manner
in which
skin diseases develop from
anthemata
into synanthemata and
exanthemata
is as manifold
of
the
the
diseases
as
developed
pictures
themselves,and
of
forms
finallya series
are
varying
presented in their transitions from the acute into the
chronic stage or their definitive retrogression
in the residua which
they leave behind, such
as
pigmentation and cicatricial formation.
is on
the whole
favorable
than
more
Finally,the prognosis of skin diseases,which

that of other
and

treatment.

parts of
With

the
the

organism, is connected very closelywith the diagnosis,course,

of treatment, especially
with
increasingperfectionof methods

CLASSIFICATION

reference

to individual

advances

of disease,the

groups

131

DISEASES.

SKIN

OF

historyof dermatology

has

made

able
consider-

for the better.

V.

CLASSIFICATION

OF

DISEASES.

SKIN

HISTORICAL.

We

of the classification of skin diseases.

now
pass to the consideration
I have published recently/ an
In the system which
attempt has been made,

in the upper

classes,to form

qualities. There

are

natural
^

nine

*'.e., those

groups,

characterized

which
(classes),

of these

by

I will

at least

series of

now

sential
es-

mention,

groups
'^
will refer you to my
of their subdivisions down
System '' for a detailed justification
ease
to individual diseases.
I will here reiterate that the clinical unity of the groups of disand the diseases themselves
tion
in so far as they are presented as wholes to the observaand

"

ciples
determining the prinand
of classification,
that individual
general pathologicalfactors (such as the
the anatomical
and functional factors,the symptomatology in detail,
cause, localization,
and terminations) have only been placed in the front rank when
the course
they actually
coincide with the real nature
of the class,group, or disease in question.
The followingis the system :
of the

has been

pathologist
"

regarded

First

Simple inflammatory
A.

1.

as

alone

decisive

in

Class.

simplices).
(dermatitides

dermatoses

Dermatoses

inflammation
with the character of superficial
simplicescatarrhales,catarrhs of the skin).
I. Family.
inflammations
of the
Diffuse superficial
of the skin.)
Mere hyperaemia predominant :
Erythema : a. simplex.
b. papulatum.
Sero-purulentexudation predominant :

of the skin

skin.

(dermatitides

(Surfacecatarrhs

2.

Eczema

typicum.
paratypicum.

a.

b.

Varieties

rubrum.

papulatum.
vesiculosum.

rhagadiforme.
pustulosum.
squamosum.

inflammations
Family. Erosive superficial
Produced
by animal parasites:
Parasitic stigmatoses.
II.

1.

Entomoses

a.

to head

due

"
'

cal

I need

lice.

body

'^

clothes lice.

not

der

Hautkrankheiten."

prove

(stigmatoses).

lice.

"

"System

of the skin

that

Wien

this is not

basis," as Kaposi has discovered

an

Braumueller,

attempt

in his

"

to

Lectures

1881.

classifyskin diseases
"

which

have

"

upon

neuro-pathologi-

recently appeared.

due

to

DISEASES.

SKIN

OF

CLASSEFICAnON

132

bed-bugs.
fleas.

"

"

flies (culex,musquito).

"

(Bombyx
caterpillars

h. Acarinoses
to the

due

(Leptus autumnalis).
(Ixodesricinus).
hair-worm
(Acarus folliculorum).
acarus
(Acarus scabiei=Sarcoptes horn.).
barley-mite (Acarus hordei=Krithoptes [Geber]).

harvest-mite

*'

the tick

"

the

"

the

"

the

processionea).

2.

By injuriesof other kinds (the vital restorer of Baunscheidt, cupping, and the like):
Traumatic
stigmatoses.
of the skin (perifolliculoses).
inflammations
Follicular superficial
III. Family.

1.

Only

the mouths

around

et rubra

alba

Miliaria

of the follicles

be

(should perhaps

included

the

among

epidermidoses [akan-

tholyses]?)
2.

Also

of the follicles and

the excretory ducts

around

implication of the

coincident

Without

sheath

the follicles themselves.

of the

hair

hair

Acne.

implication of

coincident

With

the hair-sheaths

and

Sycosis.
IV.
1,

With

2.

With

Superficialstasis

Family.

in new-formation

the termination

inflammations

of the

skin,

of skin.

Ecthyma.

B.

in cicatrices

the termination

Cutaneous

ulcers.

deep-spreading inflammations
phlegmonosae, simple phlegmons of the skin).
with

Dermatoses
ces

I.

Family.

to burns

1.

Due

2.

Due

3.

Without

the

character

Phlegmons

of

of the skin

in

layers.

Combustio.
to

freezing:

Congelatio.
injury :
Pseudo-erysipelas(phlegmone diffusa idiopathica).
Localized
II. Family.
plegmons of the skin.
external

Furunculus.
varieties

Parasitic
Due

to the

**

Aleppo
III.
Phlebitis

(Pulex penetrans).

the

"

Anthrax

sand-flea

gadfly((Estrus).
guinea-worm (Filariamedinensis).
(carbunculus).
the

and

Biskra

boils.

Family. Stasis phlegmons

and lymphangioitis cutis.

Erysipelas.

of the skin.

simpli(dermatitides

CLASSIFICATION

OF

Second

SKIN

DISEASES.

133

Class.

AngioneuroticDermatoses.
Dermatoses

with the character

to

more

or

of

I.

1. With

Family. Infectious
fevers).
predominant catarrhal

character

Erythematous exanthemata
Eoseola

of

widespread disturbance of the vascular tonus, in addition

inflammatory nutritive disturbance.
angioneurosesof the skin (acuteexanthemata, eruptive
a

less well-marked

"

typhoid fever.

of cholera, etc.

g,

Scarlatina.
'

Papular exanthemata

Rubeola.
Morbilli.
exanthemata
Vesiculo-pustular
Varicella

infantum.

"Vaccinia.
Miliaria

(only accompanying fevers,or

crystallina

disease
2. With

also

an

independentepidemic

[?])

character
predominant phlegmonous (diphtheritic)

of the

inflammation

of the

skin.
Variola.
of glanders).
(carbuncle
of splenic
fever).
maligna (carbuncle
II. Family. Toxic angioneurosesof the skin (medicinal
exanthemata, etc.).
With
predominant inflammatory congestion:
Erythanthema toxicum.
Maliasmus
Pustula

1.

Varieties

Erythema toxicum, pellagra,acrodynia.

toxicum.
eczema
: Herpes, pemphigus, and
Pustular forms : furunculi and ecthyma toxicum.
Hemorrhagic form : Purpura toxica.
Maculo-papular forms

Vesicular

2. With

1.

bullous

predominant spasm

Urticaria
3. With

and

forms

of the vessels of the skin

toxica.

occlusion

of the vessels and

termination

in necrosis

Ergotism.
diathetic)
angioneurosesof
III. Family. Essential (idiopathic,
With
predominant inflammatory congestion:

the skin.

Erythanthema essentialis (idiopathicum).

Varieties

Maculo-papularforms :
multiforme, papulatum, circinatum, iris,annu: erythema
a.
Superficial
latum.

Deep-seated: erythema nodosum.

Vesicular, bullous, and pustularforms
h.

Herpes circinatus,iris,annulatus.

184

2.

CLASSIFICATION

DISEASES.

SKIN

OF

Herpes phlyctaenoides.
Herpes impetiginosus(impetigoherpetiformis).
and pemphigoid efflorescences upon
Eczematous
an
i
ndividuals
like.
and
the
hysterical
rheumatica.
Hemorrhagic form : purpura (poliosis)
With
predominant spasm of the vessels of the skin.
Cnidosis (urticaria
essentialis,
chronica).

3. With

dilatation

and

formation

new

of vessels

angioneuroticbasis,in

Erythema angiectaticum (acnerosacea).

Class.

Third
Neuritic
Dermatoses

produced by
I.

Neuritic

Family.

Herpes

affection

an

neuriticus

Dermatoses.

of sensory

dermatoses

with

(at the

same

time

trophic?) nerre

ments.
ele-

cyclicalcourse.

(zona,herpes zoster).

Herpes febrilis (hydroa febrilis)

(?).
II.

with a cyclical
course.
Family. Neuritic dermatoses
predominant inflammatory congestion (neuriticinflammatory processes
skin) :
Erythanthema neuriticum.

1. With

Varieties

erythema neuriticum.
: herpes,pemphigus, and
furunculi
and ecthyma neuriticum.

Maculo-papular forms
Vesicular
Pustular

2.

With

3.

and
forms

bullous
:

forms

neuriticum.

eczema

Hemorrhagic form : purpura neuritica,

predominant spasm of the vessels of the skin (neuriticoedema

Urticaria

of the

of the

skin):

neuritica.

With

predominant atrophy of the skin (neuriticatrophy):

neuritica (glossyskin).
Onychogryphosis neuritica.
Alopecia neuritica.
Liodermia

Leucodermia
4.

With

true

Neuritic

neuritica.

necrosis

of the skin

necrosis):
(neuritic

phlegmon (chronic).

Decubitus

neuriticus

(acute).
FouETH

Class.

Stasis-Dermatoses.
Dermatoses

A.

with

the character

of

passivedisturbance

so-lymphaticabsorption.
With
incomplete stasis.
and
I. Family. Stasis-hyperaemias

ansemias.

Cyanosis.
Local

ischaemia

Hemorrhage

of the skin.

of the skin from

mechanical

stasis.

of circulation

and

impairedveno-

136

CLASSIFICATION

Combined

with

motor

neurosis

OF

SKIN

DISEASES.

(spasmodic contraction

of the arrectores

pilorum).

Prurigo.
B.

Pure

motor
A

of the skin.

neuroses

singlefamily. Dermatospasm.

Ciitis anserina.
Seventh

Class.

Epidermidoses.
Anomalies
A.

Anomalies

of

of the

development of the skin

formation of horny matter

First Series.
I.
1.

Family.

Keratoses

of
and

in the

an

epithelial
originand type.
(keratonoses).

of the secretion
narrower

Hyperkeratoses.

Diffuse:

Ichthyosisdiffusa

a.

simplex.

t. histrix.
2.

Around

the follicles :

Lichen

3.

pilaris.
IchthyosisfoUicularis.
In spots,but independent of
The tegumentary horn, cornu
Callosities,
tyloma.

the follicles.
cutaneum.

Corn, clavus.
II.
1.

Parakeratoses.

Family.

Diffuse:
Psoriasis.

2.

Follicular
Lichen

ruber

and planus.
Family. Keratolyses.
: a.
Pityriasis
(alba)simplex.
I. (rubra)essentialis.
III.

Dermatitis

exfoliativa infantum.
Series.

Second

Trichoses.

I.

Family. Hypertrichoses.
Hypertrichosiscongenita.
II. Family. Paratrichoses.
Trichorrhexis

nodosa.

Trichoptilosis.
III. Family.
1. Diffuse

Atrichoses.

Diffuse

alopecia:

a.

l.
2.

simplex.
pityrodes(Pincus).

In spots :

Alopeciaareata.
Third
I.

Family.

Series.

Hyperonychoses.

Hyperonychia.
II. Family. Paraonychoses.
Onychogryphosis idiopathica.

Onychoses.

sense.

CLASSIFICATION

OF

SKIN

137

DISEASES.

III. Family.
Onycholyses.
Onycholysisidiopathica.
Fourth
I.

Family.

Seborrhoea

Steatoses.

Hypersteatoses.
oleosa.

a.

Series.

h. crustosa.

II.

Family.

Parasteatoses.

Grutum.
Milium.
Atheroma

(in addition

to acrochordon

and

nsevus

Colloid

milium

(colloiddegenerationof the

Haloid

milium

(vitreousdegenerationof the

follicularis).

parenchyma

of the sebaceous

parenchyma

of the sebacous

III.

Family. Asteatoses.
Xerodermia
(dry skin): a. congenital.
h. acquired.
Fifth

Series.

Idroses.

I.

Family. Hyperidroses.
Idiopathic
hyperidroses.
II. Family. Paridroses.
Chromidrosis.
Bromidrosis.
Haematidrosis.
Uridrosis.

Family. Anidroses.
Idiopathicanidrosis.
Dysidrosis(cheiropompholix).
III.

B.

Anomalies

of

pigment

in the skin

formation

(chromatoses).

I.

1.

Family. Hyperchromatoses.
Congenital :
Naevus pigmentosus :
Varieties : spilus.
verrucosus,

pilosus.
2.

Acquired :
Chloasma

fuscum

(uterinum),

nigrum (melasma).
Lentigines(ephelides).
II.

From

1.

Parachromatoses.

Family.

Discoloration

of the skin from

icterus,argyria.

tattooing.

From

Addison's

From

the cachexia

disease.

III. Family.
Congenital :
Albinism:

Poliosis.

of intermittent
Achromatoses.

a.

universalis.

h.

partialis.

fever,etc.

glands)and
glands).

138

H.

CLASSIFICATION'

OF

DISEASES.

SKIN

Acquired :
Vitiligo.
canities.

Premature
0.

pricklelayerof the epidermis(akanthoses).

Family. Hyperakanthoses (simpleakanthomata).
Proliferation of the pricklelayerupon the surface (warty akanthomata):
of the

Anomalies
I.

1.

Verruca.

acuminatum.

Condyloma
2.

of the

glandular coils (cutaneousadenoma) :

(sweat-glandadenoma).
Parakanthoses.
II. Family.
With transformation
of the prickle cells into so-called moUuscum
(which
corpuscles
not known
are
accurately):
Molluscum
(contagiosum of authors).
of nests in the cutis (alveolar
With formation
akanthoma) :
cornification
the
new-formed
With
distinct
of
a.
epithelium cells.
Epithelioma :
Varieties : superficial
(rodentulcer),
deep.
Proliferation

Idrotadenoma

1.

b. Without

of the new-formed

cornification

Cutaneous

carcinoma

Varieties

cells

'

"

soft.

colloid,
melanodes.

Family. Akantholyses.
Pemphigus essentialis :
III.

a.

Acute.

h. Chronic.
Varieties

buUosus.
foliaceus.

Cachectic

gangrene

of infants.
Eighth

Class.

Chorioblastoses.

Developmentalanomalies
A.

of the skin of connective-tissue

development of the connective-tisue

SingleFamily. Hyperdesmoses.

Excessive

originand type.

layer.

Macrosomia.
B.

Paratypicalgrowth of the connective-tissue

of the skin.
I. Family. Granulomata
:
Lupus esssentialis (idiopathic)
Varieties

a.

Tuberculosus.

h.

Erythematosus.

layer (Paradesmoses).

L. scleroticus.
L. exuberans.

Scrophuloderma:
Papulosum
Squamosum
Tuberculosum

and

vesiculosum

(lichenscrophulosus).

(pityriasis
scrophulosa).
(lupus scrophulosis).

CLASSIFICATION

OF

SKIN

ISft

DISEASES.

Gummosum.
Ulcerosum.
Tuberculosis

Leprosy

of the skin.

Tubercular.
Macular.
Anaesthetic.

Syphiloderma:
Maculosum.

Papulosum

and

squamosum,

Vesiculosum.
BuUosum.
Pustulosum.
Tuberculosum

(lupus syphiliticus).

Gummosum.
"

Ulcerosum.

Ehinoscleroma.
Granuloma
II.

cutis [?]).
fungoides (Lymphadenoma
Desmomata
Family.
(connective-tissue
tumors),

JFibroma

cutis.
Disseminatum.

a.

h. Keloides.
Osteoma

(new formation of bone).

'Chqndroma (new formation of cartilage).
Lipoma (fattytumor).
Myxoma (mucoid tumor).
Hyaloma (vitreousswellingof the skin).
Colloid

tumor.

Xanthoma

(fat-like
change of the skin).
formation
of muscle).
Myoma (new
formation
Neuroma
of nerves).
(new
Angioma (new formation of vessels).
a.
Phlebangioma ) Varieties : simplex.
h. Lymphangioma
)
cavernosum.

'

Sarcoma.
0.

Disappearance or congenitaldefective development

SingleFamily. Adesmoses.

1.

General

and

Liodermia

diffuse

of the connective-tissue

essentialis

(congenital[?]).

Partial:

2.

Striae

atrophicaecutis.
Ninth

Class.

Dermatomycoses.
I.

Fungoid diseases of the skin and its appendages.

Family. Mycosis scutulata (favosa,lupinosa,Favus).

Dermatomycocis favosa.
,

Trichomycosis

"

layer.

140

TREATMENT

GENERAL

OF

DISEASES.

SKIN

Onychomycosis favosa.
II. Family.
Dermatomycosis

Varieties

Mycosis
circinata

circinata

(herpestonsurans, ring-worm).

Maculo-vesiculosa.

D.

marginata (eczema marginatum)

diffusa (imbricataManson).
Trichomycosis circinata.
Onychomycosis circinata.
III. Family. Mycosis pustulosa.
Dermatomycosis pustulosa(impetigocontagiosa[?])
Trichomycosis pustulosa:
D.

D.

Varieties

Tr. barbas

parasitaria).
(sycosis
capillitii
(kerionCelsi).
IV. Family.
(pityrodes).
Mycosis furfuracea
Dermatomycosis furfuracea (pityriasis
versicolor).
Tr.

VI.

The

treatment
views

As

matters

of the skin

In

and

skin

by

TREATMENT

GENERAL

of skin diseases
with

changes
to-day,there

local remedies, with

the

DISEASES.

to

great extent

upon

the

pathological
prevailing

them.

stand

diseases, on

depends

SKIN

OF

other

is
the

general tendency to treat purely local

of internal
greatestpossibleavoidance

hand, which

are

due

to

nutritive

disorder

affections
remedies.
of

other

of the diseased internal organs

must
be carried out
body, the treatment
organs
to
principles.
generaltherapeutic
according
It goes without
saying that we are far from believing in the vicarious nature of the
of
the
the skin affection into
localization of
disease,in the possibility
driving back
the dermatologistdeny certain truths
the organism.
Nor, on the other hand, may
which
the physiology of the skin allows us to recognize. We
refer,for example, to the
local circulatory
the general circulation,and,
tracts and
undoubted
connection
between
in the skin or in individual parts,and the circulation
of blood
therefore, between the amount
in general (conditionof the heart and the peripheralresistances to circulation)
tracts.
Also to the action of cutaneous
irritants
and "in other peripheralcirculatory
that feeble cutaneous
irritants proKecent
have shown
investigations
duce
upon nutrition.
contraction
of the peripheralvessels, thus increase the force of the heart's action
Eesult: increased
and the rapidityof the current
of the blood.
temperature. On the
other hand, vigorous cutaneous
irritants produce dilatation of the peripheralvessels,and
thus diminish
the temperature. According to Eoehring, a coincident irritation of
may
the
the vagi slows
pulse and circulation,and diminishes the respiration,so that this
coolness.
constitutes a compensation to too-marked
irritants is settled beyond a doubt, but
Accordingly the action of external cutaneous
they should not be employed in skin diseases,except in the two cases in which we desire
to increase the
intensityof any local process, for example, a torpid inflammation, or
the cutaneous
irritant is employed as a caustic for the production of necrosis of
when
of

the

"

the tissues.

"

GENEEAL

further

TEEATMEXT

applicationof

SKIN

OF

%^X

DISEASES.

the

physiology of the skin to therapeuticsconsists in

divorce
from
the previous conception that the ofl"ce of
fact that we can
integument as a respiratoryorgan is so extensive and important, that an affection of
extended
surface per se endangers nutrition.
former
over
an
It also follows
that no
harm
follows the applicationof substances
which
coat
it is of salves and plasters.
skin over
this is as true of water
a great extent, and
as
ourselves

I will here
bath

in chronic

even

months.

very

feeble

diffuse
As

diseases

rule, it

individuals; in

relief of the

pains of burns

of

the

found

was

some

skin, and
that
the

cases

occurred

in extensive

restoration

in the

bath.

of

But

skin

chronic

I have

them
in

become

is effected

or

thereby.

batting and

the

like

be attributed

can

to

preparations,the exciting
In

skin

continuous
effect upon

diseases, external

therapeutics,on

the

other

employed.

were

Hebra's

the

the

local

the

that

not

the

the

constitute

cur

of

course

tolerate
last

scene

applications of oil and

a

very

curative

restricted

proportionate

to

the

quisite
re-

patient, etc.
be

procedures must

hand, furnishes

this is

prolonged
upon

the

upon

in
the

some

patients cannot

Many

and

even

in

from

influence

pruritus,or

think, therefore, that

bath, and

and

convinced

favorable

least; the foudroyant toxic symptoms

(convulsions, etc.) which
in the bath
as
burns, occurred
constantly and certainly as when

cotton

when

burns

occurred

of substance

in the

severe

effect

and

processes

nutrition

upon

large losses

that, in the large majority of cases, neither

the diminution
of pain
diseases, nor
upon

suppurative

extensive

for weeks

suppurative processes,

injurious effects

no

personal observation
of

the

of the continuous
an
observation, however, with
regard to the employment
first employed
As is well known,
this was
by Hebra.
only in severe
burns, then

make

recommended

also

the

the

standard

of

General
mainly considered.
general internal treatment,

this is indicated.
With

of skin diseases,it must

be pointed"out that, as
regard to the local treatment
the
not
and
the
diseases
We possess remedies
a rule, only
cured by them.
are
symptoms
which
will improve or cause
to disappearanthemata
of various kinds, erosions,swelling
or
dryness of the skin, changes of pigment, anomalies of cornification,etc.,but we possess
external
remedies
no
as
such, against ichthyosis,prurigo, etc.,
against eczema
regarded as diseases.

Attention

small, but

the

must

also be called

to the

fact that the number

is very great, and
the number
upon

capacityof

of external
that

remedies

is

chief secret

the
of
manipulating them
of remedies.
technical skill than
depends more
upon
I will now
glance hastilyat the most important internal and external remedies, in
order to call attention to a few points of generalimportance.
When
tions
employed in moderation, water is a remedy which is very useful for the funcof the skin (cleansing,softening,removal
of the secondary morbid
products).
When
applied too frequentlyor at too high or low a temperature, it acts as an irritant
the healthy skin, and produces eczema.
even
upon
Upon inflamed parts it acts favorablyby conveying higher or lower temperatures
presses.
(warm and cold compresses),or by producing evaporationin the form of Priessnitz' comWater
should
therefore
be
out
before
well
being applied,
compresses
wrung
ing
intervenand, as a rule, they should not be placed directlyupon the skin,but upon some
substance impervious to water.
The applicationof hydro-therapeutics
has proven
less suitable,in general,to produce
mild
procedures
recovery of local chronic
processes and, on the other hand, even
are
apt to give rise to irritative conditions of the skin. However, advantage will often
be derived in psoriasis,
prurigo, etc., from systematic packs, half -baths, and rubbings,
success

in

nervous

dermatoses

general,from

from

macerating

douches

steam

baths

with
(especially
and

steam

warm

douches.

water),in epidermidosesin

142

TREATMENT

GENEEAL

DISEASES.

SKIN

OF

substances have always been employed in skin diseases.

containing medicinal
it may
those
be stated that the addition of an alkalr
to
regard
prepared artificially,
to the bath, for example, potash, soda, borax
(perhaps with the addition of starch,,
diminishes
congestion of the skin.
Bulkley), softens the epidermis and
Sulphur is employed either as sulphide of calcium or potassium, for example, 30-50'
to the bath, or the body of the patient being
of Vlemingkx' solution being added
Grm.
with a solution of the sulphur before entering the baths.
smeared
in which
desire
The action of artificial sulphur baths upon the skin in those cases
we
to kill parasites(scabies),
etc., is similar to that of its medicinal
application. Like the
in chronic
natural sulphur waters, they produce good results occasionally
itching skin
Baths

With

diseases.
.

has

Hebra

then

placed

first smeared

patientsbeing

baths, the

tar

employed

with

t'hetar

and

in the bath.

in syphilis
for
as
a substitute
employed occasionally
or
measures
adjuvant to the ordinaryanti-syphilitic
(5.0to 30.0 for a full bath of 32-35''
of various
kinds, for example, as a hand-bath
C), or locallyin chronic dermatoses
(1:2,000to 1:500).
With
regard to natural mineral baths, specialattention must be called to the fact
that their action upon the skin is mainly macerating and solvent,they remove
secondary
i. e., they chiefly
affect the epidermis.
are
deposits,and occasionally
slightlyirritating,
The
from the bath through the human
integument is not so easy
passage of substances
If we
that
in
small quantity and that
believed.
as is commonly
grant
gases pass through
be
in
solid substances, especially a fattyemulsion, may
some
pressedthrough after long
also remember
that the living skin does not permit the passage of
inunction, we must
in contact
in the bath with
substances
from watery solutions of salts which
simply come
the intact skin, and that even
the absorptionof water by the layersof the skin is usually
Baths

of corrosive

sublimate

are

moderate.
We

now

pass

first place soap.

to the consideration

Soap

being rubbed
upon
of the constituents

in

agent

soap, made
contain no

with

water
have

free and

surface

of free alkali,which

of

employed

fattyacids and

the skin, and

on

become

good materials, always

excess

of

the

when
water, especially

for cleansing the

of

of the substances

combination

some

which

In combination
best

is

the

poor

skin.

with

water, and

alkalies,which

again undergo

in salts
A

or

combination

new

alkalies of the surface

in the

dissolved

are

of the

it
distilled,

serves

skin.
as

carefully-prepared,
simple

either
proves suflBcient,
the skin.
will macerate

cold

or

warm;

the
soda

it should

time a
stronger potash soaps, which present at the same
so-called
The
soft soap, which
is
success.
employed with more
manufactured
with tolerable purity,is a sort of ointment
now
which, when not used as a
caustic, should not produce an alkaline or burning taste on the tongue. Stronger potash
caustic,
soaps act like solutions of caustic potash, i. e., not merely macerating,but even
done
in
if they are
chronic
for
this
often
skin
a
was
employed
formerly
prolonged period ;
in
in
of
inunctions
for
Hebra
or
others,
diseases,
prurigo,etc., by
cycles soap
example,
and soap poultices. I no longer employ this plan of treatment.
I rarelyemploy combinations
of soap with other remedies, because
In like manner,
For

softer

purposes,

consistence,are

It is best

dest., 200.0
metal.

curative

to prepare

for four

baths.

the

following solution:
The

water

naust

Hydr.
be

bichlor.

distilled,the

corros.,

bath-tub

20.0; Natrii

chlor.,50.0; Aq.
of
covered, and not made

144

OF

TREATMENT

GENERAL

DISEASES.

SKIN

plastersalone remain, and may be applied to the skin for a long time
fies
it,since the oxide of lead, which is destitute of carbonic acid, saponiirritating
to
such
is
added
If
fat
a
acids.
some
plaster(empl. plumbi
easilywith the fatty
simplex, empl. diachylon simplex),the preparationacquiresthe consistence of a cerate,
in which
fat can
exercise its
and in this manner
presentsthe most perfectform possible,
the lead

Therefore

without

simplex,carefullyprepared in
equal parts of oil or fat).*
the fats

from

Apart

the metallic
of

zinc, subnitrate

parts.

fabrics

mull

recently a

with

are

almost

mixed

with

skin.

which

is

ointment

mixtures

effect upon

an

the vascular

cornification,indirectlyalso upon
the

and

of which

epidermis

with

is
of

fats

diseased

to

for extensive

suited

measures,

the

substances

bandages

as

be

to

appears

series of curative

another
to be

employed

are

constantly being improved,

in the main

appears

application of medicinal

of

form

new

with

specialpeculiarityof

The

substances

the

impregnated

method,

This

medicinal

ointment

an

action

empl. diachylon

oxides

recommended

has

Unna

varied

most

of

of

A prominent part
employed successfully
upon
and salts, especially
(in addition to those of lead)oxide
bismuth, mercury,
sulphur, iodine, narcotic substances, etc.

and

played by

which

basis,the

of the unexcelled

reason

to the consistence

and
plasters,

ointments

in

as

is the

(ung. diachylon simplex, made

water-bath

This

of the skin.

ointment

so-called Hebra's

the

of

the surface

effects upon

favorable

ployment.
em-

tar is

the

and

process
apparatus in the corium.

nervous

representative
of
It

of wood-tar, the empyreumatic constituents

employ only distilled wood tar (beech, birch
of excessive formation
or
junipertar). As a matter of experience,these produce a diminution
and
of hypergemia,especially
thus
of scales,diminution
of
chronic
infilvenous,
tration of the skin, finally
a
strikingrelief of pruritus and, in this latter respect, often
exercise the most
surprisingeffect.

coal-tar, and

is well to discard

of which

act

as

varieties

impure

irritant,and

an

to

regard their applicationas

with

should

Tar
in.
and

contain

Like

be
in

Applied

exudation, it does

tar in its

any

small

applied in very

large quantities,and

much

effective

most

especially without

fat, soap,

when

addition

they

employed

are

i. e., without

pure,

ture
admix-

of alcohol.

quantities, with

strong bristle brush, and

parts of the skin which

not act favorably, and may
even

are

upon

then

well

rubbed

congested, sensitive,

very

produce

violent

reaction.

action, but

not equal to it in efficacy,

carbolic acid, creasote, saliare
cylic
resin, chrysarobin,pyrogallicacid, naphthol, a few mercurial
rations
prepa-

acid, benzoic

(ung. praecip.album, solution of corrosive sublimate and sublimate collodion),

occasionally
sulphur (sulphur flowers,precipitatedsulphur,sulphide of calcium and
and
potassium^),
finallya few resins (balsam,peruvianus, storax liquidus,oleum roris
also

'

Experience
and

time
or

the

like, among
of the

manner
'

has

Upon
as

upon

an

the

developed
of

eczematous

many

as

increase

subjective

more

employment

of

oxide

of lead

produces toxic symptoms.

patients treated in this

hydrargyri.
acutely inflamed
skin, sulphur always produces

has

mycoses).
phuret

the

the

surfaces, never

in this

manner,

I have

This

manner.

even

for

observed

never

is true

long

lead colic
in

similar

emplastrum

well

deeper down

that

taught

extensive

over

run

its

as

of the
well

course

as
or

subjective symptoms.
objective phenomena,
diminished

markedly (scaly forms

In chronic

calcium

skin

(according

diseases
to

as

diseases

all

Vlemingkx-Schneider)

of the

rule, however,

soon

of all

kinds, Hebra

increase

an
a

the acute

as

considerably,but

of skin
of

As

the

disease

of

kinds, anomalies
has

(3 Calcis

recommended

infiltration

sulphur

and

udation,
ex-

acts

ably
admir-

inflammatory

process

the
of
a

upper

layers has

glandular
solution

tion,
secre-

of

sul-

vivae, libram; Sulf. citr., libras

to its action
alone

which

and

plants
temporarilyon

acid in

Vienna
the

of

the

like,againstthe

layer,and

horny

not

are

parasiticanimals
merely situated

organic

and

lime

within

equal parts rubbed

in

wall

made

for irritation.

acids,

potash.

silver;caustic

paste (potash and

knife-blade

products and

(nitric,hydrochloric,sulphuric, acetic

acids

mineral
of

of morbid

for the destruction

serve

with

alcohol

of adhesive
artificially

and

the

paste applied

plaster).

and chloride
of antimony);
paste, as Landolfl's paste (with chloride of bromine
with
nitrate of potash 1 : 0.4-0.2 according to Koebner).
caustic
arsenic
preparations of arsenic, Dupuytren's
powder,' Hebra's
paste,''

(moulded

in sticks

vai'ious

The

in

of zinc

Chloride
or

the

substance); nitrate

caustic

thickness

habitat

the

and

sulphur,soap,

their

caustic remedies

include:

These
chromic

with

have

it.

various

The

the

on

combination

in

or

tion
by its strong odor, in addigroup, which, is characterized
is
the
either
of
employed
successfully,
layer,
horny
continuity

last-mentioned

The

marini).

145

DISEASES.

SKIN

OF

TREATMENT

GENERAL

Esmarch's'

,*Marsden's,* and

pulv. Cosmii

paste;

Glycerin iodide;'^
sublimate, alone

Corrosive
Plenck's

with

collodion;
actual

(hydr. nitric, oxyd.) ; finally,the

Liquor Bellosti
caustic

or

solution.''

cautery, galvano-caustic and

thermo-

apparatus.

ment
treatimportant part in recent therapeuticsof the skin is played by mechanical
and
the
of Volkmann's
fastened
to
the
sharp
pyramidal
by means
spoon,
prong
lancet-needle
out
vessels
and
the
for
in
the
flat,
(Auspitz),
double-cutting
cutting
spoon
skin ; the various snapper-likeapparatus for the same
purpose, finallythe electrical
needles and combinations
of needles for the destruction
of the hair-follicles,
the latter
in
in recent times.
recommended
America
being especially
In many
skin diseases, especially
epidermidoses (ngevi,
pointed condylomata and
in many
chronic nodular and pustularformations
warts, superficial
epitheliomata),
(acne
in acne
in
certain
furthermore
and sycosis),
formations
from
the
new
starting
rosacea,
corium
treatment, either alone or
(lupus tuberculosus and erythematosus),mechanical
combined
with other medicinal
agents (for example, caustics in the pricking of lupus
and
the
constitutes
nodules,
a very
useful, occasionally(as in sycosisnon-parasilike)
sole
the
taria)
therapeuticmethod, attended with good results.

An

duas.

Coq.

bination
and

has

the

and

soap

libr. 20 ad

following composition:

kalini,Axung.
remedies,

pore,

aa

of

account

on

reman,

In chronic

tar.

libr. 12, filtra),

also sulphur ointments, mostly in com
bies
scaly eruptions of all kinds, also almost exclusively in sca-

with the exception of favus

sulphur ointment, combined

mycoses,

employed

years

font.

Aq.

c.

with

IJ Storacis

10.0; f. ung.
the

This

rapidityof

which
with

requires

liq.,Flor.
ointment

its action

in

sulf.
enables

vigorous remedies, I have

more

and

storax

soap,

according to Weinberg,

lotor,,Cretss alb. pulv., aa

me

to

slightirritation

dispense,
in the

as

5.0;

Saponis

rule, with

above-mentioned

for

which

other

pj.tho-

logicalprocesses.
'

Acid,

Arsen.

It should
with

arsenicos.,0.2;Calomelan., 20.0.
albi, 1.5; Cinnabaris
be

gum

Arsenic,

Morph.

albi, 10.0; Gummi

*Iodin., Potass,
'

Hydr.

0.25; Arsen.
iodid..

subl. corr.,

10

,3.0; Ung. rosat., 20.0.

albi, 1.0; Cinnab.

It should

factit.,35.0; ft. pulv.

be

pared
pre-

water.

mur.,

Ft. pasta.

factit.

prescribed: Arsenic,

aa

acacias,5.0.
albi, 0.25; Calomel., 0.12; Sacch.
2.5; Glycerini, 5.0.

2.5; Spir. vini, Acet.

vini

cone,

aa

alb., q.

s.

25.0; Camphor,

ut f.

pasta.

Alum,

Cerussae, aa

2.5.

146

GENERAL

With

regard

TREATMENT

internal

to

remedies, I will

arsenic, atropine, pilocarpine, and

The

internal

of carcinoma
is

There

in arsenic
and

with

success

few

words

Finally, a
A

acid

the

is often
of the

is not

play

than

hard

hard

soda

The

purposes.

or

the

Simple,

innocuous

and

This

sublimate,

is
11.

of the
form

to

The

to

and

atropine, have
of the

neuroses

been

skin.

if all

of health

health

of the

requirements
carried

are

has

cerning
con-

out, the

influence

no

on

skin.
it does

complexion, though

not

to

and

amounts

diminish

excess,

at

the

moderate

elasticityof

irritants.
suitable

for

and

washing

less

irritating

hair, rather

softer

soaps

for

soaps

constituents

contain

not

of moderate

potash

of their

quality
must

such

toilet

and

free alkali,

quantities of perfumes

should

extent

metallic

as

the

abstracts

is also true

This

be

external

water

of

of other

greater extent

merely

starch, magnesia,

as

protection against

of alcohol

the

or

any

does

not

smelling

entirely

are

skin, makes

of the

All

glycerin.

toilet

it

and

dry

washes

taining
con-

avoided.
additions

to

This

bleaching powder.

etc.,

irritants.

washes, such

corrosive

as

salts, etc.

containing

particularlytrue
be increased

by

the

roots

of the

means

greater

than

Substances
the

the

oils and

tannic
fats

is also

true

of benzoic

resin,

acid.
should

be

employed

to

greater

extent

for toilet purposes.

is

the

the

upon

Good

powders,

useful

substances

should

scalp), and

still

of sweet

use

This

as

acids, certain
acts

done

now

scalp

and

fatter

skin.

moderate

used

more

addition

The

considerable

any

mineral

Camphor

the

skin

and

Even

of the

in

only

are

depends

its nutrition.

is true

of oil-baths

12.

the

usually preferable to

are

of soaps

application

sulphur flowers,
10.

is shown

as

them

quality.
act

impairs

alcohol

than

of the

condition

upon

external

to

soft water

finely ground
often

Frequent

brittle,and

9.

treatment

skin.

saponification.

the

materially change

8.

make

to

conditions, etc.,

beauty

baths, when

warm

soaps

quality
of

thoroughness

7.

skin,

of the

in order

given

angioneuroses

general

it has

skin

the

to

foreign, irritatingsubstance.
6.

the

water.

The

5.

of the

so-called

and

highly praised in

the nutrition

is

climatic

and

of the

of resistance

its power

and

Distilled

4.

health

cold

Very

temperatures.

concerning'

ruber.

beautifying

The

non

qua

is serviceable

Water

skin

sine

in the

great part

3.

the

is

been

necessarilybeautiful.

bad.

extremely

of

the

complexion, though

Cleanliness

2.

arsenic

treatment

concerning

healthy integument

beauty

remarks

particularly ergotine, pilocarpine, and

in the

diet, residence, atmospheric

complexion

has

lichen

influences

whom

to

few

"

of alkaloids,

used

recently

arsenious

in horses

glossy.

more

number

1.

that

doubt

no

of arsenic

use

skin, lupus, psoriasis,and

eaters, and

skin

the

hypodermic

or

of the

make

merely
alkaloids.

other

few

DISEASES.

SKIN

OF

the
should

of the

use

of

with

by

regard
the

to

rational

application,at
simple pomades

the

of the

growth

application of fat
night,

of

; this

should

sponge
be

hair.

The

nutrition

(for example,
soaked

applied

in

in

the

oil upon

to the

roots

of

shafts.
be
hair.

avoided

or

sparinglyused

which

abstract

water

from

tha

SKIN

THE

OF

HEMORRHAGES

AND

k^MMM,

HYPER^MIJ;,

BY

SOHWIMMER

EEE"ST

PROF.

HYPER^MI^.

By
or

mnia

hyper

blood

its actual

or

manifestation

of
In

plethora.
vascular

blood,

and

and

extends

congestion

to

These
when

for

into

the

are

veins

capable

produces
a

of

hyperaemiae
emptying

the

of

vascular
from

congested
majority

and

veins,
of cases,

the

of

of

partial

latter

heightened

blood-pressure
of

venous

fluxion,

from

though

arterial
warranted

however,

the

of

while

the

These

division

of

since

precise
those

by science,

is

fluxion-hypersemise

the

are

more

hyperaa
correct,

arteries

always
distinction

due
of

active,

terms,

more

of

blood-supply
a

area,

only enlarged

contraction

and

propelled

are

some

skin.

physiologically

also,

The
in

smaller

or

the

is retarded.

every

blood,

and

passive hyperaemia

flow

diminished

Consequently,
of

larger

color

contents

as

integument.

corium,

passive condition,

blood,
a

the

the

the

regard

we

in
of

and

engorgement

which

increase

in

their

obstacles,

though

lumen.
an

from

hyperemia

or

system

the

accumulation

It affects

active

as

constitutes

in

only

proper,

Increased

layers

changes

to

from

surplus

condition,

arising

of
In

the

known

those

containing

active

also

congestion

every

of

leads

conditions,
and

parts

produces

alterations

the

enlargement,

an

is

either

vessels.

tissue.

and

consequence

fluxion

an

shrinkage

importance.

in

mechanical

from

strictly speaking,

vessels

from

to

undergo

result

entire

accumulation

hypercemia

hypercemia

within

connective

are

the

visible

by

inclosed

conditions,

when,

passive,

those

vessels

congestion

of

in

the

engorgement.

known

subcutaneous

causal

blood-vessels

correspond
miae

the

forms

the

rapidly

of the

those

to

according

the

to

from

single

may

resistance

arterial

between

is made

hypercemia

in

of

excessive

an

constitutes

resistance

hypercemia

or

blood

former

diminished

blood;

distinguish

hypercemia

Cutaneous

places

arterial

of

condition
either

present

blood-pressure

diminished

from

we

the

increased

an

continued

or

Excess

congestion;

cases,

of

hence

venous

transient
blood-vessels

superabundance.

or

influx

an

the

which

general

both

energy

causes

that

is meant
in

single parts,

of

to

little

an

or

results
tween
beplete
incom-

practical

distinguished

148

HYPEE^MIuE.

from

those of engorgement

by certain signs.Arterial fluxion is accompanied by increased

rapidityof circulation,which imparts a ruddier hue to the integument. In venous
gorgement,
enthe oxygen
of the blood, by reason
of retarded
circulation,is absorbed in
greater quantity,making the blood darker and giving to the skin a deep-red or bluish
A quickened arterial current
color.
will communicate
the specificheat of the blood,
which
is
increased
probably considerably
by friction with the walls of the vessels,to the
surrounding tissues,and hence the hyperaemic skin becomes warmer,
of
while, in cases
and imperfectly oxygenated blood loses its
engorgement, the slowly-flowing
heat
specific
and

the tissues to appear

symptoms of cutaneous

causes

The

cooler.

hyperaemia correspond at the outset with the indications

just given;
sign is the heightened color of the skin ; sometimes
this is combined
with an elevation of temperature. Through continuous
operation of
the underlying causes,
slightswellingoccasionally
portant
develops,and there may be an unimfunctional disturbance.
The phenomena, therefore,are in part analogousto those
Pain is often entirely
occurringin inflammation.
when the disease affects
absent, especially
surfaces,and is frequentlyfelt only as a sensation of pricking,burning,
large cutaneous
"etc. All the symptoms
mentioned
endure
for a longer
singly or in combination
may
without
shorter
to
or
time,
giving rise
any important disturbances,although they serve
for the sequelae
of hyperaemia. To this class belong the exudative
as
starting-points
and
sometimes

the earliest

hemorrhagicprocesses.
Exudation
in the

undue

i. e., to

since

the
the

pressure

be

is

hyperaemia

tension

of the

this pressure,

constantly maintained,

increased
essentially

vascular
will
may

walls

permit
further

an

by increased

is sometimes
of

escape

lead

to

plasma.

increased

an

lateral

greater than
This

pressure

their

ticity,
elas-

exudation,

growth

of

tissue,

hypertrophy.

The

hemorrhagic
i. e., without

takes

place when

eslarged vessels,under

the
if the

takes

blood-vessels, and

place, with
about

brought

in

as

increase

by

cases

action
of their

escape

cutaneous
of the

hyperaemia

heart

contents.

of the

Hemorrhagic

central

are

met

with

fluence,
when, through peripheral in-

being directlyconcerned,

cardiac

pressure,

affections

laceration

of

together with

the

of

the

integument,

diminished

of the

hemorrhagic diathesis, of pyaemia, scorbutus, etc., are

hyperaemia.

of cutaneous

We

sequelaeof
the

capillaries
which

vascular

are

ance,
resist-

altogether independent

itself either as a merely transient

tion
conditions
alterapreliminarystages of long-lastingdiseases,and that the cutaneous
clearlyproceed either from repeated attacks of the complaint, or as results of its

find,therefore,that hypersemia shows

or

as

the

passage into other affections.

The blood-vessels,
is well
as

originatein the gray substance

as
taking their departure from
vascular
branches
condition

of

nerve-centres

nerves.

being

The
affected

known,

acted
are
on
by the vaso-motor
nerves, which
spinalcord (Vulpian),but which may be regarded
lated
sympathetic ganglia. Besides these, individual,isowhich
give origin to similar
(Eckhardt,Strieker),

of the
the
exist

innervation
not

only by

of the
the

blood-vessels

sympathetic,but

is

also

very

by

extended
the

brain

one,

and

their

spinal

cord.
have
nerves
Investigations
concerning the points of exit of the vaso-motor
chiefly
in explaining the contractility
of the blood-vessels.
Through them we know
that all variations in the color and
temperature of the skin are due solelyto the agency
of the vascular nerves.
Further
inquiry has shown that vascular innervation takes place
in two
directions,since the vaso-motors
effect,not only contraction,but also dilatation.
resulted

149

HYPEB^MI^,

of the vessels,the vaso-constrictors

actingin

the former

case, and

the vaso-dilafors

in the

latter.

state

contractioa

of moderate
vascular

the

which

is

activity of the vaso-constrictors

The
that

essentiallyexpended in maintaining the blood-vessels

depends their tonus, i. e., that constant excitation

vrhich

upon

"

opposed

are

to the

and

hyperaemic

These
and

more

that

of

dilators

the
and

A.

HYPEE^.MI^

or

latter; when

of the

action

conditions

are

in

which, by overcoming the slight resistances met

The vaso-dilators,the function
of which
consists
in

apparatus normally exists,and

with, permits an equable flow of its contents.

effect which
an
enlarging the blood-vessels
many
"

in

by

of the

an

increased
skin.

the

discoloration

FLUXION"

FROM

characterized

prefer attributing to paralysisof the constrictors

equilibrium between

disturbed, and

erythematous

an

less redness

is

the

The

influence
are

OR

action

the

of

latter

the

strictors
vaso-con-

preponderates^

produced.

ACTIVE

flow of blood
color

the
of

varies

HTPER^MI^.

vessels
through the cutaneous
pale pink to blood-red,
aifected part. Thus
a hyper-

from

layersover the
redness than the sole of the foot when
larly
simideeper
integument presents
much
in
the
former
of
smaller
blood
is
because
case
a
affected,
supply
required by
the very minute
vessels pass
in the latter where
the enlarged vessels than is needed
be either diffuse or
through dense and less yielding tissue. These hyperaemiae may
follows:
as
circumscribed, and presentdefinite clinical types; these may be enumerated
according to
femic

the thickness

scrotal

of the cutaneous
a

{a) Erythema,
{a) Erythema,

E.

{h) Roseola.

buted
hypermmicum exhibits a pinkish or deep-red discoloration,distriIt runs
its
uniformly or in spots and momentarily disappearing under pressure.
acute affection and
the chronic type by changing into some
course
as
an
only assumes
allied form associated with disorders of nutrition.
The
shape and extent of erythema
to
undefined
and
it
is
include
this designationall spotty
usual
under
are
quite
irregular;
formations
of the kind just described which are largerthan a pea.
(6) Roseola {Rosalia,
Rose-rash)is allied to erythema, and consists of circular spots,
varying in size from that of a hemp-seed to that of a lentil,and lightor dark red in color.
The rash follows the course
of an acute affection,turning pale or momentarily disappearing
under
and
like
condition
either
or
as
as
a
a
erythema
hypersemic
appears
pressure,
disorder resultingfrom consecutive alteration of tissue.
long-lasting
Erythema and roseola are, therefore,two closelyrelated types,solelydistinguishable
their
different configurations;
by
both, so long as they constitute hyperaemic conditions
much
merely, are to he regarded as symptoms, and can only be spoken of as skin diseases insowithout
discoverable
and without
as
they often recur
persistently
being
cause,
developed as the result of direct action on the external integument. This explainswhy
the erythemata have been considered
as
exhibitingboth idiopathicor independent and
or
symptomatic
secondaryforms, although such a classification is forbidden by the actual
nature
of these cutaneous
affections.
When, however, we
speak of the erythemata as
symptoms, we are but returningto the views of the older dermatologists(Lorry, Biett,
Bateman) who never
thought of dividingthese diseases according to the principlelaid
down
by Hebra.
The duration
of erythema is very variable;it often lasts only a few hours, often
for weeks, in cases
where the cutaneous
again for some
days, or even
hyperaemia recurs
after
its
chief
have
subsided.
frequently,
symptoms
repeatedly
of erythema is important because the complaint,when
The locality
of
a symptom

150

HTPEK^EMI^.

certain

diseases,often manifests

generallyshows

itself

the

on

preferencefor particularpartsof

trunk

both
morbilli);it occurs
(variola,
and on
(quinine,belladonna, etc.),
emotional

disturbances.

the entire

surface

The

the

on

trunk

and

the face and

limbs

the

body.

severe

Erythema

febrile disorders

effect of certain drugs

an
of
regions,in consequence
extensively,
attacking almost
as

other hairless

forms

its appearance

of

symptom

precursory

Sometimes
it displaysitself more
''erythema universale.''^

as

in ivhich it makes

mode

as

another

characteristic of

erythema.
change
always
suddenly, and this peculiarityled
the
English writers to apply to it the term ''rash," a designation which, rendered into
scientific language, has been conferred especially
upon the erythema of small-pox.
In the delineation here given,under
the heads of color,duration, locality,
and mode
of changes undergone by the generalintegument,
traced
be
of appearance,
a correct
may
picture of hypercemicor congestiveerythema,which, as alreadyshown, is characterized by
active congestionand
caused
hy disturbed innervation of the vaso-motors
(dilatatores).
The

of color

The
them

Vienna

from

school

the

distinction

comes

has

chronic

could

which, in the light of

our

the

The

evidence.

same

action

of the vaso-motor
In

Hebra

out

from

the

congestive in

their nature
The

has

and

due

to

exudation.

standpoint

of

pathological anatomy

separated

correctness
"

of

this

standpoint

no
present knowledge of the function of the vascular nerves,
longer affords
development of erythema is only to be completely explained through the
nerves.

of the

one

as

considered

the

mode

classification

of

subjectof congestiveerythema

treatingit as
differs from

which

made

with

accordance

discuss the

regarded these erythemas

forms

only be

quickly,often

on

adopted

in connection

in the

with

the

Although
(angioneuroses).

neuroses

that of the current

our

presentwork, we shall
hypersemige,instead of
pathogeneticdoctrine

will in

manuals, yet this circumstance

no

wise interfere

adequate presentationof our theme

aspect; and, our point of view
under
which
forms
to describe the various
being thus made
plain,we proceed at once
hyperffimicerytheniais encountered.
of their very
The
elements
that surround
us
(a) Erythema Caloricum.
may, by reason
high or low temperature,give rise to hyperasmic conditions attended perhaps by swelling
cold baths may
of the cutis with more
Hot
less copious exudation.
or
produce such
or
to operate. Another
forms of erythema which quickly subside when
their causes
cease
varietyis solar erythema, a simple and brief hyperaemia,only dangerous when associated
with
are
insolation.
It affects only those parts of the body which
habituallykept
uncovered; it is dangerous when
occurringin the scalp,as it is then accompanied by
cerebral
symptoms, resembling an acute and fatal attack of meningitis.
According to medical reports from tropicalcountries, erythema is often wanting
in the severest and most rapid cases
of insolation; on the other hand, inflammatory
even
with

in its clinical

an

"

lesions.
ment
Treatetc., not seldom constitute its attendant cutaneous
erythema, erysipelas,
posed
disof erythema caloricum
should be purely expectant. Should the symptoms seem
be
to linger,cold ablutions and the applicationof rice-powderor fresh grease may
of service.
cerebral
When
symptoms, antiphlogistics
accompanied by insolation with
must

be resorted

to.

{b) Erythema
inflamed
but have

ex

The
profluviis (intertrigo).
"

by long contact with

been
decomposed by

irritants,like urine,
Women

girlswho

affected with
suffer

from

seretions

different
exposure

leucorrhcea

vaginal

to the

which

are

very

are

atmosphere

from
(especially

mucus

skin

the

not

and

cases

in
thus

reddened
themselves

converted

and

even

injurious,
into

neous
cuta-

diarrhoeic stools, etc.

genitals),

liable to be troubled

discharges,in which

be

may

the

in this way;

symptoms

likewise little
are

not

to

be

152

HTPEB^ail^.
.

Itm

ust be

supposed that

effect,through their

the

(hyperaemia).Such

produces

conditions

HYPER^MI^E

B.

centres^,as

connections, a

apparatus,which

vaso-motor

vascular

nervous

extensive

an

result of these

blood-current

in

case

ENGORGEMENT

OR

collateral branches, and

sufficient outlet

no

hence

impressions,..

contraction

or

congestion of

VENOUS

Congestions arising when any system of vessels

floioof the Uood-current
by increasing the amount
of
called hyper(Bmim from engorgement.' Such
vascular
a
the

mental

the

of the

entire

cutaneous

vessels

of brief duration.

are

FROM

rapid dilatation

the fact

becomes

opposed

resistance it has

for the

of retardation

HTPER^MI^.

stasis results

in

flow

the

to

to

regular

overcome

are

retardation

of

is

the

impeded
provided by
distinguishesthis species

is what

of

hyperaemia from that produced by fluxion.

The venous
reddishhyperaemiaspresent spots of darh-blue, grayish-blue,and even
turn pale,but do not
black, which
always completelydisappear on pressure.
Usually
these spotssoon
fade away,
yet they frequentlygive rise to more
profound disturbances
with
and
sequelaein the shape of exudations
hemorrhages. The hyperasmise from
not
in
do
the
the
active hyperaemiae,
it is
nevertheless
occur
same
as
engorgement
way
not always possible
to distinguish
two
between
the
conditions.
precisely
We therefore classify
ances
as
venous
hyperaemiaethose forms in which, through disturbin the cutaneous
anastomoses
circulation,the venous
experience an accumulation
which
becomes
of blood
outwardly apparent. Such engorgements may result from
mechanical

cosmical

from

or

influences.

produced by long-continuedpressure
elements, water

{a)

Venous

and

or

Among

the

former

friction;among

the

are

included

the symptoms

latter,those

due

to the

rounding
sur-

air.

from Mechanical

Hypermmim

Causes.

"

Whenever

continuous

pressure

is

skin, whether

by a tight bandage or closely-fitting

garments, we find in
with
the underlyingintegument a turgescence of the veins, sometimes
partialcBdema.
the lower extremities,where
the force of
This is observed with especialfrequency on
the distribution
of the blood.
If
gravitationexerts no inconsiderable influence over
blood is persistently
the reflux of venous
impeded, the veins become enlarged,and show
less twisted cords, as in persons who
or
are
obligedto stand
through the skin like more
of
Individuals
bakers,
turners,
as
habits,
clerks,
etc.).
sedentary
continually(cooks,
similar
the
of
etc., exhibit a
telangiectasia
pelvicorgans (hemorrhoids).
literary
men,
made

upon

the

Auspitz* has
in

investigated very
His

passive hyperaemia.

from
the

the cyanotic
coloring matter

out

at the

same

time

to

cinnabar-red.

of the

blood

of
ovving to the escape
is forced
coloring matter
at the
later becomes
paler, because

They proved that these dark

along with its pressed-out serum.

edges of the compressed

individual

takes
which
the subject of the discoloration
place
experiments resulted in reproducing the various deeper shades,

thoroughly

numerous

blood-vessels

part, while
tilled with

the

of

centre

serum

are

the

prevented

hues

are

The

circulating.

from

pneumonia, fracture, etc.) in

positionsduring long periods,the blood likewise
scarcelychange
where the skin
the most dependent parts. This is more
likelyto occur
In

diseases

some

which

(typhus,severe

'In

cases
course

of
are

impediment
better

of resistance
*"

On

Venous

than

to

the

blood- current,

enabled, through
are

the veins

their

which

we

know

collateral
run

that

the

connections,

arteries
to

lies close to

which

compensate

directly to their centre, the heart.

Engorgement," Vierteljahraschrift f. Dermatolog.,

1874.

patients

accumulates

their

pursue
for all

in
the

pheral
peri-

larities
irregu-

153

IIYPEE^MI^.
,

atrophy,as over the sacrum

spots will be presented.

of loss of fat or muscular

Tjones in consequence
bluish-red
dark -blue
situations
or
in which

hypostases. They constitute

the soft parts.
Costnical Influences. These

named

hyperaemiaeare

subsequent destruction of
(b) HypermmicB from
a

"

of cold water

to the action

due

of the minute

contraction

another

cold air.

or

When

subjectto

place,and prevents here

continues
to operate,but with

capillaries.If the cold

apparent, and the
engorgement become
has become
of the medium
high enough
of the

skin remains

cool

and

of

decubitus

and

with

discol orations

cutaneous

vessels takes

scapulae,
gravitation

These

cause

include

the skin is

and the

such

there

influences,
the

ing
emptysigns of
temperature

less energy,

blue until the

to

the internal
produce an equilibriumbetween
The next result is an enlargement of the vessels,which enables
and external conditions.
and the skin resumes
its normal
the retarded blood to pass off more
If
easily,
appearance.
lose
the
their
and
the cold is sufficiently
local inflammatory
intense,
sensibility,
parts
symptoms set in, which may terminate in mortification and sloughing.
this head, we
include
(c) Venous HypercBmia from Pathological Catises, Under
diseased conditions
all states of engorgement from
which
characterized
are
by a dark
or
cyanoticcolor of the skin. As alreadyremarked, this dark hue is produced by an
acid in the blood, which
of carbonic
excess
again is the result of a retarded circulation
The
distant
the affected part from the heart, and the
from pathologicalobstacles.
more
slower the passage of blood, the deeper is the cyanosisand the largerthe extent of surface
Sometimes
involved.
also the nose,
only the tipsof the fingersand toes, sometimes
This varietyof hyperemia forms
cheeks, and eyelidsexhibit this deep-blue appearance.
essential symptom of local asphyxia, the precursor of the so-called symmetrical ganan
grene
of the extremities.
"

These
oedema

cyanotic alterations

of the

glottis,the

of the

skin

most
and
speedily in diseases
where, as in croup
When
exudation
takes place in the
greatly obstructed.

occur

of air is

entrance

is
pleurisy, and tuberculosis, the same
respiratory organs, as in pneumonia,
hypersemic condition
Diseases
less rapidly.
of the heart
sometimes
developed much
give rise to cyanotic phenomena,
of the circulation
though likewise by slow degrees, the retardation
being manifested
ous
by sanguine-

engorgement

Finally,we

in the

have

great vessels.
to mention
surface

the entire cutaneous

of this disorder

"

disease

cardiac

patency of

that

is characterized

cyanosis,morbus
the foramen

by

cceruleus.

ovale; absence

dark-blue
The

color

more

of

common

incomplete closure of
septum ventriculorum;
right ventricle;origin of the
the pulmonary artery springs from the left ventricle.
aorta in the rightventricle,while
Occasionally,however, cyanosisdoes not result,despitethe existence of the anatomical
anomalies; they are then first brought to lightby an autopsy.
It is unquestionable,therefore,that cyanosisis not caused
by a mingling of arterial
and venous
blood, but can only exist when, in addition to the influences just mentioned,*
stasis takes
venous
a
place into the capillaries.This explains why cardiac cyanosia
the
under
conditions as all other venous
same
occurs
precisely
hypersemiae.
of
treatment
The
hyperaemiaafrom engorgement must usually be directed to the
removal
of the obstacles to circulation.
Medical
skill is helplessin cases
of congenital
of the heart; yet hypertrophy of the right ventricle, in
malformation
individual
contrivance
for the alleviation of cyanosis. Notwithstanding
instances, is Nature's own
congenitaldefects in the cardiac structure, cyanosisfrequentlydoes not show itself on
causes

are

origin of

the

the

skin until the

later

years

of

life.

the

Thus

aorta

in

Peter

or

the

Frank

relates that

he

saw

case

of

154

AU^MT^

cyanosisin

which

did not

OF

THE

till he

SKIN.

a girl
the symptoms of cyanosisfirst appeared
healthy parentage,
in her fifth year.
The slightest
emotional
excitement
the skin of her face to turn
causes
deep-blue,while at all other times only the end of the fingersand toes, the tip of the
and
of the lips are
borders
discolored.
Examination
of the heart reveals no
nose,

fifteen

man

years

defects

valvular

come

on

old, of

Forster

nor

fifty-seven
years

was

of age.

I know

in whom

any

disturbance

'

of its chief normal

relations.

of the highly carbonized

blood
long ago attempied
improve
it
with
increased
the
tration
adminisamount
of oxygen
an
by supplying
through
chlorate of potash, and he claims to have effected considerable amelioration
in
the condition

to

in this disease
of
individual

cases.

He

obtained

of hydrogen, 8 drops in

stillbetter

AN^MI^

This

title includes

results

from

cod-liver oil,three times

THE

OF

disorders

the

prolonged

use

of

hyperoxide

daily.

SKIN,

integument which result from a diminution

rect
corStrictlyspeaking, it would be more
the name
to use
an
oligaemiain this connection, since anasmia properly signifies
here
absolute poverty of the blood, whereas
concerned
are
we
merely with a lessening of
first denominated
its amount, which
Virchow
the
may be either partialor extensive.
which
has undergone the same
former
condition
transformation
as
ischcemia, a term
latter we
anaemia.
shall employ as denoting a decrease in the quantity of blood,
The
since such decrease exerts a specialinfluence on
the bodily relations and on
the color of
in the entire volume

those

of the

of the

circulatingfluid.

the skin.
The
lessened quantity of blood
either be the direct result of frequent losses
may
of
of insufficient formation
(hemorrhages), or it may occur
indirectlyas a consequence
in number
blood.
The blood-corpuscles
either be actuallyreduced
(oligocythasmia),
may
of white corpuscles is
or
they may undergo such a change that the relative number
result
all these alterations is
immediate
of
increased
The
considerably
(leucocythaemia).
the
of the vessels and a morbid
in
tone of the general
the insufficient nourishment
change
The
itself
outer
the
on
pale,earthy complexion,
integument.
system, which manifests
the yellowishhue of the skin, the loss of color in those parts, as the lipsand cheeks,
all characteristic
out by their roseate tinge are
which, in a state of health, are marked
anaemia.
signs of cutaneous
Cutaneous
of the tissues and lowers the physiological
anaemia impairs the nourishment
decrease
in the elements
condition of the skin, and it is easilyperceived that a continuous
must
further
essential
be
followed
tions
deviafunctional
to the normal
by
activity
"

disturbances.
Such
ditions
conhealthy standard, as well as by various incidental
and
if the
arisingfrom anaemia lead to decay of the tissues,to partialatrophy,
Hence
it follows that, although
necrosis.
"supply of blood be entirelycut off,to local death
anaemia may
occasion destruction of tissue,yet, since a negative idea is included
portant
imin its very definition,it cannot
phenomena more
give rise to any series of abnormal
than
anmmia
cutaneous
those just mentioned.
no
also,
produces
Consequently,
of nuof general disturbances
diseases of the shin ; it presentsitself only as a symptom
trition.
from

"

Any deficiencyin the quantum of

activitylessens the supply of nutritive
'

Dublin

blood

required for

material

Med.

Joum.,

to

the

the

maintenance

layersof

1863, p. 112.

the

of

cutis,so

functional
that

the

AN^MI^

results

is very imperfectlyaccomplished. The

if the abnormal
brittle state of the epidermic layers,and

of their wasted

Testoration
are

and

dry

powder

substance

transparentlamellae which
the fingers. The
between
particles
of thin

continue, the detachment

into bran-like

or

155

SKIN.

THE

OF

be

can

surface

rubbed

immediate
influences
into

fina

of the skin affected

and when
the hand
is passed over
parts
it,imcloth
the
These
tions
alterastroking
"against
grain."
by
a
all parts of the body, but most
conspicuouslyon the extremities ; one such
on
occur
thin scales,is called pityriasis. Besides
of
morbid
condition, characterized by deposits
palenessof the skin, its reduced temperature is an essential symptom of anaemia.
The palloralways proceeds from deficient injectionof the cutaneous
capillaries.It
marked
is often distinctly
plainlywhen the local
only on isolated parts,and shows more
Similar ischasmic conditions
relations give rise to a partialretention of the blood.
may
of
the
vascular
of
from
diseases
cal
walls,since,through mechanisingleportions
originate
of their calibre may take place,with paleness
pressure, as from bandaging, a narrowing
localities.
of the skin only in particular
has

in this way

dead, lustreless appearance,

like that

sensation

pallor is often

Local
with

subsequent
since

vessels

visible

on

the

growth

changes

latter, however,

the
the

in the

the

surrounding

coloring-matter of the blood.

appearance

; where

it is

connective

frequently

more

newly-formed epidermic

with

white

of profound destruction
of the general integument,
a result
as
less,
(lupus, scrofulosis,syphilis); the skin becomes
pale and blood-

witnessed

cicatricial

cicatricial

caused

tissue

surfaces"

signs of

more

the

latter

abundant,

is
a

here

completely,

and
and

there

obliteration

minute

veins

of the
become

and restored compartial new-formation

munication
pallor is also frequently influenced
by the
skin assumes
deficient,the anaemic
a
yellowish-

capillar} plexuses

When

produce

disappear

tlie

darker

shade

is

produced.

the anaemia is caused

palenessvaries greatly. When
by
and persistent
when
vascular
nutrition
is
;
imperfect,
in oligocythemiaand leucocythemia,the skin is pale,but not as yellowas in the former
as
and tuberculous
all these difhue ; and
ferent
subjects present a waxen
case
; carcinomatous
the
disease
remain
abnormal
continues.
so
long as
original
appearances
Cutaneous
stitutes
palloris not only to be regarded as a diagnosticindication,it also conaid to prognosis. In this respect,the cutaneous
an
symptoms belonging to the
exanthemata
acute
measles, and the first stage of variola) are of no small
(scarlatina,
of severe
admonished
and
internal complicationsby the pallor
are
we
frequently
value,
remark
eases,
which
attends the progress of these complaints. The
same
appliesto other disIn
all
the
and
cholera.
these
of
blood
fever
should
which
as
typhoid
supply
cases,
from it for the support of morbid
normally be retained by the integument is withdrawn
processes in the system at large,and as the condition of the latter deteriorates,the small
and visible anaemia
is the result.
vessels which nourish the skin collapse,
Hence, the
of eruptive or
decided this collapse,
other infectious maladies,
more
during the course
is the prognosis,and in this way the state of the skin alone may
the more
unfavorable
the intensity
to measure
of diseased
conditions.
serve
The fallof temperature, that other constant
dered
anaemia, is rensymptom of cutaneous
in
various ways.
As a subjectivesensation
evident
of cold it is perceived most
the
ends
The
of the
plainlyon the partsfurthest from the heart.
ears, the nose, and
Ansemic
ness
pale and cold.
fingersand toes become
patientsfrequentlycomplain of chilliin the skin, and the latter in this case
becomes
shrunken, owing to contraction of
muscular
the
fibres ; in like manner,
smooth
the cold stage of ague is accompanied by
anaemia.
transient cutaneous
Disturbed
innervation
of indignationor of
from emotions
in
of
insufficient
or
assimilation,as through hunger or fatigue,projoy,
consequence
The

duration

loss of blood, the

of cutaneous

palloris extreme

156

HEMOERHAGES

duces

not

only pallor,but
by a diminution

OF

sensation

THE

of coldness

of tactile

SKIN.

in the skin.

which
sensibility,

Sometimes

may

this is

amount

even

to

panied
accom-

positive

angesthesia.
The

treatment

of

causal conditions.

If

the

cutaneous
we

anaemia
succeed

can

must

in

always
compensating

be

conducted

for the

with

reference

loss of blood,

in

or

to

proving
im-

insufficient

both
the internal
hsematosis,we shall be enabled to remove
its superficial
manifestations.
The indications for the management
of the
general affection belong to the department of specialpathology; as to
cutaneous
of arousing the blood-vesanaemia, we will merely observe that the best means
sels
to renewed
activityis hy frictionwith pure water or alcoliolic solutions. If the bloodsupply is impeded through predominance of vascular contraction, moist heat in the form
of cataplasms, baths, etc., will prove
most
effective in relievingthe circulation
and.
restoringthe natural color and temperature of the skin.

of angemia

symptoms

and

HEMORRHAGES

OF

SKIN.

THE

The

to denote any condition

term hemorrhage is used, in a general sense
of the vessels
of the well-known
In consequence
accompanied by an escape of their contents.
firmness
and
of the vascular
elasticity
apparatus, hemorrhage is impossible except
The
in
structure
of the vessels.
alteration
defect
the
through some
or
bleeding may be
either internal or external.
of
the internal orThe former
class includes
gans
hemorrhages
visible mucous
and cavities ; the latter those proceeding from
surfaces or from the
generalintegument.

Extravasation
named
1.

and

of

millet

into

follows

as

red

or

of

or
a

several

assumes

forms, which

have

been

or

spotsare

bluish-red

as

color

largeas poppy or
; stigmata,when

hemp
they

seeds

or

the

are

as

peas,

size of

that

of

lentil.

3.

the

the effused

dark-blue

Vihices,when

2.

tissue

cutaneous

PetechicB,when
a

the

Ecchymoses,
palm of the hand
4. Ecchymomata

they appear in
they form

when

streaks.
blotches

varying from

the

size of

pea

to

; and

when
(boils),

the

hemorrhage

surface

at the cutaneous

givesrise

to

tumefaction.
These

with
hut

various

effusions into the cutaneous

the

exception of the boil, they do

not disappear under pressure
;

do

natural

tissue

rise above

and

fade

by the fact that,

of the shin ; they turn pale,
hy degrees,the skin resuming its
characterized

are

the level

away

appearance.

The
combined
must

not

hemorrhagic papule
with

exudation,

also be mentioned

and

rather

in which

the

hemorrhagic

than

true

pure

blood

vesicle

extravasations.
is effused

upon

examples of hemorrhage
That varietyof hemorrhage

are

the

surface, without

lesion

hcemidrosis, being merely

as
peculiar condition, known
which takes placethrough the excretory ducts of the sudoriparous
a sanguineous effusion
glands,belongs to the anomalies of perspiration.
of hemorrhages of
and
Condition
Hemorrhage. The causes
Symptoms of Cutaneous
lowing
results of the foltake
as
the skin are of various kinds, yet these accidents can
place
only
changes within the vascular system:
either
1. Through Rupture of the Vessels (extravasatio
per rhexin). This occurs
of the

vessels

themselves.

This

"

"

HEMORRHAGES

violence,or through

external

from

internal

some

blood-pressureand

of

increase

THE

OF

able
which givesrise to a considerand suggilintegument (suffusion

influence

effusion into the

an

16T

SKIN.

lation).
dition
con2. Through Vascular
Degeneration(extravasatio
per diabrosin). This causal
from
other
diseases
of
atheromatous
in
of
internal
or
hemorrhage
operates cases
results
it
in
cutaneous
more
hemorrhages ;
the vascular system, even
frequentlythan when
is produced by a loss of cutaneous
tissue
walls
vascular
of
the
state
similar
a
moreover,
"

due

substance

and
scrofulous,syphilitic,

to

other forms

of ulcers.

through the Vascular Walls (extravasatio

Through
per diapedesin).
the
older
who
of
some
authors,
This occurrence
was
supposed that an
recognizedby
vascular
the
but
this
idea was
ward
afterof
took
blood
walls,
actual secretion
placethrough
as
unsusceptibleof proof.
rejected
of blood-corpusclesthrough the
the passage
the first to demonstrate
Strieker^ was
The occurrence
itself was
soon
walls, and his conclusions were
fullyconfirmed.
capillary
of
the
web-membranes
it
arises
from
a
nd
the
studied
the
on
frog
nictitating
accurately
;
Transudation

3.

"

sometimes
to the walls of the
adhere
corpusclesof the capillaries
their
vascular
finelyporous structure;
latter,and here and
contractility,
penetrate
effect. Such
a
likewise,occasionally
contributing to the same
obviously,can
process,
take place only in capillaries
providedwith very delicate adventitia.
tissue give rise
Extravasations
of the above-named
descriptionsinto the cutaneous
to various alterations of color (spots),
owing to a depositionwithin the cutis either of the
the

in which

manner

there

of its individual

itself or

blood

will predominate, and

In

elements.

the former

the color of the

case,

corpuscles

tinge; in
spotswill appear of a light or dark red (purplish)
also if a certain length of time has elapsedsince the occurrence

the

the latter,however, and

hemorrhage, the discoloration will be produced by pigmentary material which has

Thus, from the hcematin
originatethose variously
separated from the blood.
the
the
colored
dark-brown
or
viz.,
ruby-red
{hmmatoidin)
yellow
crystals
{hcBmin),
which impart the familiar hues displayedupon
and the bright-red{hcematocrystallin)
the
of the
been

"

"

skin

as

of contusions.

consequence

HISTORY.

Werlhof

cutaneous
made
lineation
hemorrnages the subjectof a specialdeof typhoid
separatedthe hemorrhagic spots appearing in the course
febris petechialis,
from
dangerous febrile conditions,and called petechiae,
other,
an-

the first"who

was

Werlhof

and

other

non-febrile

which
he denominated
of purpura
's classical edifice was
almost completed

form

Werlhof

morlus

maculosus

hemor-

Wichmann

its diagnoson
tic
partlyaccepted,partly
the English dermatogists,
Bateman, Willan, and
their followers gave them the form which, until quitelately,
they have since retained.
More recently,Schwediaur*
substituted for
purpura'^ the term Deliosis,which was
ployed
emin the same
Alibert
Schonlein.
and
sense
by
This conception almost universally
prevailed,and the distinction between petechige

rhagicus.
and therapeuticalsides ; and in like
later authorities,^
until
modified by many

his views

manner

by

were

*^

'

Bd.

Sitzungsbericht d. Kais.

Akademie,

Bd.

52.

Prussak, Sitzungerber.

Bd.

56.

Hering, ibid.,

57.
*

Werlhof

Opera

Medica,

Hannoverae,

1775, and

Wichman

"Ideen

zur

Diagnostic," 1800,

L, S. 98.
3

Gauthier

Alibert

Belief onds:
:

"

"

Vorlesungen

Essai

sur

la maladie

ilber die Krankheiten

tachetee
der

hemorrhagique

de

Werlhof," Paris, 1811.

Haut," 1837, II., S. 432.

158

HEM0KEHAGE8

and

recognizedby

was
purpura
last few years.

The

majority of

botli scientific and

writers hold

recent

THE

OF

to the

SKIN.

clinical authorities,until

of

idea

within

essentially
differingforms

the

of purpura,

other
which, by Eeder,' Neumann,'^ and Kaposi,' are
regarded, apart from
varieties as only two in number, yiz.,purpura
simplex SindLpurpura
hemorrhagica. We
conceive

that this latter distinction is unnecesssary,

since cutaneous
cluded
hemorrhage is inin the very idea of a purpura
and
difference
is
in
or
a peliosis,
no
except
degree to
be traced between
the hemorrhagic purpura
and
of certain authors
simplex as
purpura
described by those authors themselves.
The
is in
following representationof purpura
with

accordance

species,since
infiltrations

this

senilis be classed as a separate

position. As little should purpura
of sanguineous
nothing sufficiently
peculiarabout the occurrence
lower extremities,chieflyof old people.

there is
the

on

DEFINITION"

By

is meant

VAKIETIES

AN"D

OF

PUEPUEA.

disease

times
accompanied iy extravasations into the shin, or someinto the mucous
livid spots or
or
membranes, which tahe the form of darh-red
of
extensive hemorrhagic effusions. It may
more
appear suddenly, *. e., without
precursory
its course
with
symptoms, or in conjunctionwith rheumatic pains and fever,and may run
be
internal
is
not
to
loithout the occurrence
or
as
an
Purpura
of
complications.
regarded
conditions
but
of
other
e
ither
as
originating
independent disorder,
only a symptom
locally,
in the blood itself.
in the vascular system, or generally,
connected
Several years ago I drew attention^ to the peculiarities
with the essential
character and diversified manifestations
of purpura,
and protested against going too far
in separatingthe varieties thus denominated.
link in a chain
to be only one
Molliere* pronounced purpura
of diseased conditions
and
the
into
internal
characterized
the
integument
by hemorrhages
organs, and included
too
n
ot
somewhat
this
infectious
disorders and
under
perhaps
hastily,
only many
name,
N^ot long afterward, Scheby
articular rheumatism, but also haemophilia and scorbutus.
that
convinced
became
Buch"
was
a
hemorrhagic purpura
frequent accompaniment
articular
that
of
affections, and
simplex,
hemorrhagica, and
purpura
purpura
founded
scorbutus are only different grades of the same
complaint. This opinion was
to
of
and
observed
which
it
series
be eswas
tablished
facts,by
striking
accurately
sought
upon a
that articular affections and scorbutus
often go together,and that
the unity of
all these affections is consequentlyto be inferred.
The
rheumatic
nature
of many
forms of purpura
first pointed out by Schonlein.
was
identical with
articular rheumatism,
because
Traube'
as
regarded rheumatic
purpura
fatal
and
him
examinations
in
had
extravasation
shown
some
cases
injection
post-mortem
while in life no
had existed.
We
shall not here discuss the
into the joints,
purpura
whether
identical
with
rheumatic
articular
rheumatism
be
peliosis,
although a
question
the two morbid
states might perhaps be shown
to exist;
relation between
close etiological

purpura

Hebra's

"

Handbuch

"

L. c,

'

"Pathologie

"Ueber

'

"

'

"

der

Hautkrankheiten,"

I., S. 622.

S. 242.

die

und

Affectionen

Nosografie du Purpura," Annales

Gelenkaff

Wien, 1881.
Haut," Pester Med, Chirur. Presse, 1873.
de Dermatolog.
Paris, 1874, p. 44 ff.

Therapie der Hautkrankheiten,"

hamorrhagischen
ectionen

bei den

hamorrh.

der

Affectionen, "Deutsch.

Arch.

f. Klin.

Med., 1874, 26. Bd.,

S. 466.
'

"

Gesammelte

Beitrage

zur

Pathologieu.

Physiologie," Berlin, 1871, II.,S. 763.

160

ual

HEMOBEHAGES

those of the
joints,especially

deal of spontaneous
a

few

days ;

The

the

at

in the

and

away,

OF

knee and

THE

SKIN".

anhle,now

sets

pain ; the oedema, however, seldom

time, the

same

of two

course

or

rheumatic

three

weeks

in, and is attended

proceedsfar,and

with

subsides

good

within

pains abate, the hemorrhagic spots fade

all the morbid
phenomena have disappeared.

either developed from

those which
are
mence
comaggravatedforms of purpura
their
of
manifest
increased
from
the
or
fever,
they
severity
degree
outset.
number
of
not
characterized
wider
diffusion
and
the
are
They
only by a greater
also
but
the
of
conditions
which
occasion
hemorrhagic spots,
lasting
by
development
may
find livid ecchymoses from the size of a pea to that
constitutional disturbances.
We now
and
of a kreuzer, and
irregularlyshaped blotches covering several square centimetres
formed
by the coalescence of individual spots. Along with these there are extravasations
actual sanguineous effusions into some
into mucous
of the
one
membranes, and sometimes
the tension of the vascular walls throughout the whole
cases
bodily cavities. In severe
gans
system is greatlyrelaxed, and hemorrhages into internal cavities and parenchymatous orIn
into
the
this
take
the
are
sanguineous effusions
place
spontaneous result.
way
into the arachnoidal
stomach, the lungs,the towels, the uterus, and even
cavity.Of course,
such complicationsmay
lead to a fatal issue,yet this is seldom
the case.
is complicated with severe
When
constitutional
by
symptoms, and marked
purpura
of cutaneous
a largeamount
extravasation,the results of great losses of blood will soon
their blood is poorly
be apparent. Such patientspresent a decidedlyanaemic appearance,
of
and
with
solid
constituents,
hydraemia supervene, through which
symptoms
supplied
be protractedand many
the complaint may
subsequent ailments be produced.
be
the disease conThe duration
cannot
In many
tinues
cases
preciselyfixed.
ofpurpura
for only a few days (eighteento twenty), in others again for several weeks, and it
more

with

has

moderate

known

been

even

to last for months

and

(") Purpura
The

of scorbutic

symptoms

this disease may

from dissolution

be

regarded as

scorbutica; Scurvy.^
and
point to the existence of a blood-dyscrasia,
morbid
of a general
state, arising
represensative

purpura
the true

of the blood, and

years.

localized

the

on

surface.

cutaneous

The

appearance

always preceded by general lassitude,with pains in

the extremities
and different joints; there is often only moderate
fever, which endures
The
time
for a longer or shorter
purpuric spots
according to the form of the disease.
thence
first
the
lower
over
a
great part of
on
extremities,
usually appear
they spread
dollar
the body, and
or
in malignant cases
as
a
increase to extravasations
as
large
discolored
ulcers
with
of
the
into
a
the hand, which
in some
as
palm
places change
sanious border.
An
they beconft
unfailing symptom is the affectionof the gums;
inflamed, painful,swollen, and subject to spontaneous hemorrhage ; the teeth loosen
and fall out easily
exudations
take place in.
effusions of blood or serous
may
; moreover,
other mucous
cases
membranes
in internal organs, where they constitute in many
a
or
of extravasations

direct

cause

skin

is

of death.

Scorbutus

is the most

hemorrhages

are

the disease is
an

the

on

much

now

epidemic form
'

only

For

one

"

dangerous form
manifestation
less

of purpura,

of the

prevalentthan

in former

the inevitable result of infectious

more

extended

remarks

on

and

the

accompanying cutaneous

generalnutritive disturbance.

scurvy,

see

times, when

it

Fortunately,
frequentlyassumed

surroundings,unwholesome
this

Manual,

XIII., vol. 2.

nourish-

HEM0EKHAGE8

THE

OF

161

SKIN.

where human
operatemost injuriously
tinction
ships').A disprisons,hospitals,
beings are crowded togetherin confined abodes (forts,
(in realitya purely topographicalone) was hence drawn between land-scurvyand
have so generallyresulted
At present,since improved sanitaryconditions
sea-scurvy.
from
of rational hygienic rules,an
the enforcement
epidemic of scurvy is comparatively
milder type.
and such sporadiccases
of a much
as
occur
are
very rare

ment, and impure air.

These

morbific

influences

AI^ATOMT.

than its
The pathological
accuratelyunderstood
anatomy o^ purpura is at least more
patho-chemicalrelations. Eayer' stated that the effusions presenteddifferent appearances
covered
the cutaneous
according to their situation among
layers,the smallest spotsbeing disin the corium, and the largestin the subcutaneous
cellular tissue.
Similar
accumulation
results were
of
arrived at by Gustav
an
Simon, who found
beneath
the
blood between
the corium
and the epidermis ; he also observed that
more
highly-coloredspotsthe deepestlayersof the epidermis appeared infiltrated with blood,
and that blood-corpuscles
Effusions
into the
were
plainlyvisible in the extravasations.
membranes,
tissue,as well as secondary hemorrhages into the skin and mucous
epithelial
the sabjectof an exhaustive
first made
were
investigation
by E. Wagner.^ According to
the
effused
blood
lies
individual
between
the
him,
layers of the cutis especiallythe
stratum
lucidum, which forms the transition to the epidermis and the boundary-line of
the Malphigian network
and
the sudoriparous
corium
; the latter,as well as the true
itself consists of a comextravasation
The
pact
glands,show no trace of extravasated blood.
red
of
embedded
in
w
hich
a
aggregation
peripherally-disposed
blood-corpusles
appear
layerof reticulated fibrin,
of hemorrhages into the tissue by
Wagner was unable to account for the occurrence
the condition of the vascular system itself,
since in several carefullyobserved instances of
the hemorrhagic diathesis the epitheliumhad remained
quiteunaltered ; consequently,he
seemed
obligedto fall back upon the suppositionof an extravasatio per diapedesin,since
this led him nearer
than any other to a real solution of the problem.
The
idea that the cause
of cutaneous
to be sought in the pathohemorrhage was
chemical
state of the liquor sanguinisis one
occurred
which
to some
of the earlier physicians.
jects
Many of these authorities claimed to have found that the blood of purpural subdeficient in coagulability,
while others opposed this view.
was
Andral and Gavaret, as also Bequerel and Eodier,* found the liquorsanguinisunaltered
in constitution,
but of lower specific
gravity,in several diathetic affections,as well as in
^

"

"

cases

of scurvy.
In

of frequent occurbeleagueredParis, during the Franco-Prussian

was
rence,
war,
scurvy
unusual
affording
opportunitiesfor a thorough study of the disease. Among the
numerous
and detailed publications
this subject,those of Chalvet
on
are
deservedlyprominent."
He observed that the blood of scorbutic subjectswas
pale and watery, that the
that of the red corpuscles
increased twofold, and
proportion of fibrin in its clot was
diminished

; while
'

it contained

amounts
only trifling

"

Traite

"

Hautkrankheiten,

des malad.

"

Archiv

''

Gazette

Schmidt's

der

de la

potash and

iron.

Peau," Paris, 1835, p. 520.

anatomisch

Heilkunde,

of

Band

medicale, 1847, Nos.

eriautert," Berlin, 1854, p. 77.

9 und
25 and

10, 1868 und

26.

Jahrbiicher, 1872, 1. Bd., S. 88.

1869.

Similar

exam-

162

HEMORRHAGES

inations

have

present state
blood

led
of

in scurvy

our

and

OF

THE

SKIN.

other

less different
or
investigatorsto more
in concluding that
knowledge we are justified
is not materiallydifferent from that
purpura

results ; but, from

the

the

composition of the

which

obtains

in other

so-called blood-diseases.
DIAGNOSIS.

The

will not
diagnosisof purpura
symptomatic picture,and if the
into account, the red

be

difficult if undertaken

alterations

cutaneous

with

the aid of the

going
fore-

arisingfrom

hemorrhages be
disease will be easily

spotscharacteristic of this
An
of other exanthemata.
phenomena occurring in the course
of
shorter
duration
in
exudation
takes place
measles, in the initial stage of
longer or
in isolated cases
of cholera (roseola
but it never
cholerica),
small-pox,and even
proceeds
to extravasation
always stronglymarked, sometimes
becoming
; the febrile symptoms are
intense, and the accompanying affections of the internal organs are of a very different
nature.
In typhus fever,the petechialextravasation
is likewise preceded for a lengthened
another
series
nature
is sufficiently
of
whose
familiar.
periodby quite
phenomena,
Equally
unlike purpura
is hemorrhagic small-pox, i. e., that peculiarprocess, dependent upon
does
variolous contagion,which
not give rise to spots and pustules,but through which
the disease,almost at a stroke, takes on
the form
of a diffuse hemorrhagic affection of
The
the skin and
membranes.
mucous
symptoms of this disorder are of a malignant
the very beginning ; high fever, violent sensorial disturbance, delirium
character
from
with
extravasation,and
alternating
profound sopor, are accompaniments of the cutaneous
much
in
their
onset
in
sudden
and
than
often resulting
are
more
overwhelming
purpura
be
have said,
as
we
easilyavoided by
fatallywithin a few days. Diagnostic errors
may,
paying due heed to the constitutional symptoms.
But
non-febrile
states may
In extravasations
even
occasionally
give rise to errors.
rhage,
from contusion, diagnosiswould
to be easy, owing to the small extent of the hemorseem
the swelling,and the increased
of
the
there
is
class
of
a
sensibility
parts; yet
of
kind
should
this
which
it
is
that
be
able
we
artificially
important
produced phenomena
almost
to recognize promptly.
Take, for example, purpura
puUcosa. It may seem
caused
ludicrous to make
mention
in this place of the cutaneous
which
are
appearances
since they are
of adventitious
by flea-bites,
origin,rather than actual products of disease
recall one
and are partlyhemorrhagic, partlyerythematous in their nature, yet we
can
and which
in which
the body was
covered with several hundred
case
flea-bites,
certainly
bore a strikingsuperficial
resemblance
to purpura.
In hospitalsand among
the very
seldom
not
such
this
as
are
presentedby patientsof a
though
spectacles
uncommun,
poor
of
class.
The
these
higher
peculiarand unmistakable
subjects,the character of
aspect
the spotswhen
by an erythematous
closelyexamined, with their central punctures surrounded
will
blush, as well as the marks of scratchingwhich are almost always perceptible,
readilydisclose the real nature of the disorder.
duly taken

differentiated from

or

livid

similar

"

ETIOLOGY.

The
which
most

causes

of purpura

rise to

either

are

direct

or

indirect,and differ in part from

in

give
hemorrhages
general; rupture and
be
since
has
anatomical
examination
cases
excluded,

atrophy
revealed

of the
no

those

vessels must

such

lesions

in

from

aspect of the extravasation,

bloody infiltration of the different cutaneous
layers,would lead us much more
of the liquor sanguinisthrough the elastic walls of the
readily to infer a transudation

purpura
and the

in the

cutaneous

vascular

system.

The

outward

HEMORRHAGES

OF

THE

163

SKEST.

vessels into the

in which
the hemorrhagic
surrounding tissue,as the only possiblemode
This
abnormal
an
explanation,however, presupposes
directlyproduced.
spots can
condition
must
of the organism, which
proceed either from an alteration in the liquor
sanguinis,or from a morbid state of the vascular apparatus ; although it is true that no
be based
either on the incomplete analysesof the blood or
explanation can
satisfactory
fore,
On the whole, thererelations of the vaso-motor
the imperfectlyunderstood
nerves.
on
incline to the opinion that a morbid
alteration in the liquorsanguinis,together
we
with an affection
nervous
of the vaso-motor
system, constitutes the pathologicalinfluence
which
determines
the production of purpura.
have alreadymentioned
In regard to a morbid
condition of the liquorsanguinis,we
have hitherto
led to no conclusions
which
would
that chemical
investigations
justifya
concerning any definite alteration of the blood ; still this is far from
positivestatement
proving that no such alteration can take place.
Anatomical
As to a diseased
state of the vascular
system, we have few reliable data.
tions
alteration in its structure
is indeed wanting ; yet there are certain condievidence
of an
must
exist whenever
in which
disease of that structure
be presupposed,which
a
give rise to hemorrhages in parts far distant from each other, and which
slightcauses
the hemorrhagic diathesis.
constitute what is known
as
of the
tone and requisite
in the normal
In this we
observe a diminution
elasticity
vaso-motor
insufficient
nutrition
of
the
vascular walls, probably dependent on
or
nerves,
state of the
must
be regarded as a local enfeebled
their paralysis
on
; such a condition
with a vaso-motor
disease.
vascular apparatus,which is synonymous
This
vaso-motor
neurosis, may be caused
disease, or, more
correctly,vaso-motor
be certain in every
either by a direct (central)or reflex irritation ; though we
cannot
be

case

to which

of purpura

agent which

leads

to

of these

it is due.

extravasation

skin

or

the vaso-motor

into the internal

neurosis

organs

and

givesrise

it
; still,

correct
seems
more
produce
and all the indications which
to regard purpura
as
a trophicaffection,
might lead us to
class it as an angioneurosispoint equallyto its acceptance as a tropho-neurosis.
to be reckoned
morbific influences of the
of purpura
are
Among the indirect causes
constant
most
varied nature ; insufficient and unsuitable nourishment
;
exposure to damp
mental
all of which
emotional
air
as
etc.,
conditions,
or
grief,
depression;
impure
may
;
nerve-centre.
also lead to changes in the vaso-motor
cutaneous
Certain
cause
saw
hemorrhage ; thus Tilbury Fox
drugs sometimes
hyperaemigeand sanguineous extravasation produced on the surface by the inhalation of

to purpura,

appears

also

all circumstances, however, the morbific

Under

in the

to

'

four

of tincture

grammes

of benzoin

Fournier

relates that the administration

of iodine

extravasated
followed
numerous
spots,
occasionally
by a peculiarkind of purpura
time
the
size
of
took
the
some
a
on
head,
appearing
patients
they
pin's
mostly
every
Similar cases
have been reported by other
medicine, and lastingfor several weeks.
the form of purpura
described in all these instances reminding us stronglyof
authorities,
the reflex urticarial eruptionsproduced by certain articles of food.
Individual
outbreaks
and especially
of purpura,
of scurvy,
have
are
we
undoubtedly attributable to the causes
of the latter disease in an almost epidemic form may
be
adduced, since the appearance
observed in ill-ventilated and overcrowded
etc., when the
habitations,as jails,
hospitals,
dietetic conditions are unfavorable, and in besiegedtowns under analogous circumstances.
Hayem, during the siege of Paris in 1871, made a careful study of the epidemic of
was

"

"
"

Lancet, 1874, No.

"

Jodisme

6.

Petechial," Annales

de

Dermatologie, Paris, 1877-78, p.

21.

164

OF

HEMORKHAGES

SKIN.

THE

prevailed. He found that the food-supplyof the inhabitants, considered

merely as to its quantity,but also and chieflywith regard to quality,exerted
most
a
important influence in bringing about the disease,since not only the meat and
far from
wine, but also the vegetablesthen obtainable in Paris, were
fresh, and hence
the potash-salts most
were
largelydeprived of those elements
indispensablyrequired
which

scurvy

then

not

"

for the

maintenance

"

of health.
PROGNOSIS.

depends upon the character of the symptoms. It is favorable in cases of simple,

hemorrhage, but when effusions take place into internal organs
uncomplicated cutaneous
if it breaks
the complaint assumes
serious aspect, especially
out repeatedlyupon
a more
The
bad
the skin and
is accompanied by high fever.
is
when
hemorrhages
prognosis
become
result.
in vital organs, as they may
fatal
The conto
occur
so
as
cause
stitution,
a
profuse
also be taken
the age, and the vital relations of the patientmust
into account,
of anaemia
and
the
be overlooked
should
when
the loss of
never
probable consequences
This

blood

is considerable.
In

the

scurvy,

rules

prospectof

been

have

based

hygiene ; nevertheless,a
epidemic cases.

recovery

is much

upon

is

always

cure

more

tary
present day, since saniintelligentcomprehension of
be effected in sporadic than in

improved

broader

and

more

likelyto

at the

TREATMENT.

Rational
procedures will nearlyalways insure us a result either partiallyor wholly
satisfactory.
of acids, especially
The empiricaluse
sulphuricacid, and of preparationsof iron and
the
older
attended
be
with success, and this must
of
now
some
was
bark, by
physicians,
since
the
t
o
indications
the
rate
invigoonly proper method,
leading
regarded as
are, first,
and restore the nutritive propertiesof the liquorsanguinis,
the vascular structure
In accordance
with these principles,
and, second, to compensate for the loss of blood.
we

the

administer, on

of the

first appearance

spots. Elixir, acid. Halleri

1.0-1.5

grm.

in sweetened
water
of largerextravasa,'
; in cases
pro die, lemon-juice,pure or dissolved
Extract
cornuti in solu'
secalis
ferri
(1.0-2.0
die).
sesquichlorati
tions. Liquor
grm.
pro
subcutaneous
to 100.0 Aq. d.) or
tion (2.0-2.5 grm.
injection(Ergotini,Aq. dest.,
by
ana

D. S., -Jto 1

5.0.

syringefultwice

is often of the

last

greatest service-.

ratanhiaa
composed of Ext.
painted with citric acid or dilute
For the debility,
chromic
acid (5.0 to 200
quinine and iron in suit,
and fresh vegetables,
diet of meat
with wine, are best adapted
able doses, and a generous
the saline ingredients of the blood, since potash and iron constitute equally
to restore
of hemorrhage into
in the composition of its corpuscles. In cases
important elements
of
wet compresses,
internal organs, cold applications
injections(when
ice-bags,
by means
of
be made
etc., according to the locality
directlyinto the affected cavities),
they can
articular pains,salicylic
acid in the usual
with rheumatic
the effusion ; in purpura
or
For

scorbutic

(5.0-10

grm.

affections

to

300.0

of the

daily),which
we
employ a

gums

of

fluid). The gums

solution,Millard).

are

wash

also

doses.

To
these

hasten

act

only by

promoted by
were

the

removal

of

the

cutaneous

increasingvascular

tension.

spots,we may resort to lotions,though

that absorption was
Tripier observed

local faradization,which, however,

largeand

scattered

on
of the skin, especially

will also facilitate

the

over

lower

all

was

extremities,constant

absorption.

unsuccessful

parts of the surface.

When

pressure

when

the

tions
extravasa-

there is marked

by

means

atony

of roller bandages

SUPERFIOIALES

DERMATITIDBS

BY

TH.

DR.

OF

shall

We
mechanical

class

in

of

their

Dermatitis

calorica.

2.

Dermatitis

traumatica.

3.

Dermatitis

venenis

Calorica

Dermatitis

they

causes,

characteristic

pain.

and

divided

are

chemical,

to thermal,

by suppuration,

by resolution,

respective

1.

due

and

eczema.

signs

infiltration

swelling, heat,
either

skin,

all the

variety present

former

also, they terminate

to

first,those

of the

catarrh

second,

and,

the

general, viz., redness,

According

CANNSTATT.

superficialinflammations,

as

influences,

Affections

TEIEL,

Like

by

or

into

inflammation

of

other

tions
inflamma-

gangrene.

causticis.

et

is subdivided

dermatitis

into

DERMATITIS

ambustionis

congelationis.

et

AMBUSTIONIS.

BUENS.

alterations

The

bums,

differ
the

them,
on,

and

length

the

the

less the

subject^s

Burns

2.

are

radiant

By

the

they

more

action

the

of

are

heat

in the

and

possessed by

heat

the

for

capacity

constitutional

caused

By

which

susceptibility

the

and

for

capacity

during

the

greater

boiling points,

1.

of time

surface

cutaneous

the

to

individual

dangerous,

the

the

on

according

is

kept

the

in

concentrated),
of

power

resistance

the

By

heat

(of the
of

fire

Dermatitis

with

contact
to

their

which
of

of

surface

lesion

is the

fluids, the

higher

larger

the

area

by

inflicted

involved,

acted
more

their
and

(children).

action

direct

According

large produced

extent

resulting
case

sun).

(including explosions

of

gunpowder,

fire-damp).
3.

at

substance

the

up,

The

patient.
{i. e.,

system
the

heated

degree, they

ambustionis

bodies.
are

divided

erythematosa,

into

bullosa, escharotica.

illuminating

gas,

and

166

DERMATITIS

A.
A

temperature of
after

the

transudation

less than

removal

of

C.

60^

the

Erythematosa.

givesrise only to
At

cause.

in addition

produced

are

Ambustionis

to

C.

60^

and

The

redness.

erythema,

an

which

soon

pears
disap-

above, inflammation

latter is

and

accompanied by

siderable
con-

pain, and lasts several days ; it is confined to the surface first acted upon, and
disappearentirelyunder pressure ; generallyalso there is slightswelling.
In the course
of a few days the cuticle peelsoff,and the redness and swellingdisappear.
There frequentlyremains
discoloration.
a trifling
Burns
of this degree result in most
from prolonged exposure
to the solar rays,
cases
from
the speedieroperationof ignitedgases and vapors.

does

or

Dermatitis

"

AMBUSTIONIS.

not

B.
A

of

temperature

inflammation.

75" to

Either

0.

100"

immediately

or

Ambustionis

gives rise
within

Bullosa.

to

as

however, after

by pressure.
corpuscles;

The

largeas

pronounced

more

transudation

and

few

ters
hours, the epidermis rises into blisfilled with a thin, limpid serum,
which,

These are
hen^s egg.
the
time, often attains
consistencyof

bullae

and

Dermatitis

"

jelly,and

is then

only forced out

epithelialdebris, fibrinous clots, and white bloodit abounds
in inflammatory lymph, as distinguishedfrom that of engorgement,
and shows but few red blood-corpuscles.
of force applied
in consequence
or
internally,
Through increased exudation of serum
in white, pulpy
from without, some
of the blisters rupture. The
then
lies
epidermis
rolls
the
of soft,white membrane,
on
bright-redcorium dotted with numerous
layers,or
The
formation
of the bullae takes place
bloody points. The pain is exceedinglysevere.
the bullas are frequentlychamthe rete Malphighii and the epidermis. Hence
bered
between
the epithelial
Ijecause
the transudation, as v. Biesiadecki
has shown, draws
out
fibres.
cells of the Malphigian layerinto slender fibres resembling the connective-tissue
the
bulla
fluid
is
and
the
itself
most
lapses,
colfavorable cases,
In the
subsequentlyabsorbed,
shrivels,and falls off,leavinga red spot covered with delicate epidermis. When
which
cicatrization takes place,is formed
spheric
the bulla is ruptured, a scab, beneath
by atmoaction upon
the exuded
fluid and shreds of epidermis,unless suppuration ensues
and protractsthe process of healing.
contains

serum

C.
A

"

Dermatitis

Ambustionis

Bscharotica.

action of a lower degree,results in the

of heat, or the continued
eschar;'this is smooth and white, or ashen-gray,yellow,brown or black;
sensation.
A secmoist or dry; of a leatheryhardness; firmlyadherent, and without
tion
of carbonized
of such an
eschar reveals tree-like ramifications,marking the course

high degree

formation

of

an

blood-vessels,which

(E. Hoffmann).

How

not

are

met

with

far downward

when
the

the

injury has

eschar

extends

been

cannot

inflicted after
be

inferred

death

from

its

gradually sloughs off. It is

encircled by an erythematous blush, and on the third to the fifth day, a purulent border
at first
The accompanying pain, which
(the line of demarcation) makes its appearance.
time
this
is generallyver}; slight,
becomes
The
severe.
occupied by
exceedingly
process
When
the latter is confined to the outer integument,
depends on the size of the eschar.
it is generallycast off in from ten to twelve days. It is usuallysucceeded
by a group of
surface.
Cicatrization
having an uneven
begins at the borders
very painfulgranulations
external

appearance.

As

the

healingproceeds,the

eschar

.108

DERMATITIS

AMBUSTIONIS.

of all kinds;/
process, arterial hemorrhages, opening of joints,thromboses, and emboli
inflammations
of the^idneys,
the
of the bowels (duodenal ulcers),
the lungs,
pleura,and
the

meninges

caused
Death
is often
quent
infrequentlysupervene.
by exhaustion, conseand protractedsuppuration. Tetanus, pyaemia,and erysipelas
theare
traumatic
accidents most
commonly encountered.
In burns
of the first degree,which
Treatment.
heal spontaneously,the only
soon
indication is to alleviate the severe
pain. Kest, cold, wet compresses
(saturninelotions),
and
immersion
best adapted to secure
this end.
are
irrigation,
Coating the sore with
of
collodion is a very painfulprocess, although, in many
cases, it prevents the formation
In
burns
of the second
blisters.
degree,besides relievingpain, we have to promote the
epidermis. It is best not to open the blisters;but if these are very tense
growth of new
and prevent the applicationof dressings,
they should be pricked at their bases with a
If
needle, and the fluid pressedout, taking care not to destroythe blisters themselves.
it
suffice
to
the epidermis has been detached
in small
circumscribed
will
portions only,
surface thicklywith iodoform, in order to form a crust under which
powder the denuded
When
the healing may
largerspaces are laid bare, they should be dressed with
go on.
the strictest antisepticprecautions. After
thorough disinfection with a five-per-cent
solution of carbolic acid, the sores
should be covered with protectivesilk dipped in a
four-per-centsolution of borax in water, and wrapped around with several folds of borax
the sloughing is still more
cotton
lint. When
extensive, carbolized gauze or salicylated
the borax lint in order to absorb the fluids,and the whole enveloped
is to be appliedover
the dressing becomes
cloth or India-rubber
in Mackintosh
silk. Whenever
soaked, it
be renewed.
the
burn of
Lister has recentlyrecommended
to
must
the direct application
of
in
of
lint dipped
carbolized oil,and over
this several layers
a 1 : 30 solution
antiseptic
be changed when
that may
saturated with the secretions,while the lint remains
gauze,
until
healing is completed. The advantages of the antisepticdressing consist in the
speedy relief from pain which it affords,and its effect in preventing the luxuriant growth
and
which so frequentlygive rise to extensive adhesions
of inflammatory granulations,
borax
the
ointment
Busch
Lister's
over
scars.
spreads
sore, and
strongly contracting
not

fever

upon

"

carbolized

it with

covers

gauze.

antisepticdressingsare not required,the lime liniment (aqua calcis,oleum

olivarum, ana) is the best application. The sore is covered with folds of linen dipped in
The
with it without
this mixture, and kept moistened
dressingneed
being disturbed.
adhesions are threatened, cautwice daily. When
terizing
oftener than once
not be renewed
or
Where

with
nitrate

or

nitrate

be detached, until
Burns

of silver is the best mode

strong solution

at last it is found

of the third

degree,when

dressings,combined,
to Eeverdin's

may

be

method.

In

after

the

extensive

of
As

employed.
to adhere

seated

on

so

firmlyas

as

not

the

fallen

eschar

to admit

the extremities,are

eschar has
burns

preventingthem.
often

best

Either

the

solid

loosens, it must
of removal.
septic
treated with anti-

according
off,with skin-grafting

of the trunk,

on

the

other hand,

the continuous

preferred. The sloughing of the eschar is thus hastened, the

is kept constantlyclean, the pain lessened,and the troublesome
sore
process of changing
the dressingentirelydispensedwith, while the mortalityfrom the disease is not increased.
witnessed no
Hebra
from keeping his eczematous
patientsin the
injuriousresults even
No. 43,
Med.
and
bath for two
hundred
successive
Zeitung,
Allg.
days {Wien.
seventy
is
not
available,
this
Diseases
of
When
and
in
his
Text-book
Skin
appliance
").
1861,
mattress
the patientsimply sits or reclines in a largebath-tub, in which is placeda common
A large
rest
to
the
on.
horse-hair cushions for
body
or
bed-comforter, with one or more
water-bath

is to be

"

DERMATITIS

linen cloth should

around

stretched

be

the cushions, having its ends

spread over

the vessel.

169

CONGELATIONI8.

At first,
the water

however, chilliness is experienced,making it necessary

of threatened

cases

with

wine
collapse,

subcutaneous

(performedby

and

fastened

in the bath is heated

other alcoholic

to raise the

stimulants

to

to 35"

cord which

is

C. ; sometimes,

temperature to 40". In
be freelyadministered,

must

Auto-transfusion
injectionsof camphor, ether, and musk.
constitutes
or transfusion
bandages around the extremities)

placing elastic

the final resort.

DERMATITIS

CONGELATIONIS.
CONGELATIONS.

Congelationsare

tion
Inflammadistinguishedfrom burns by their very tedious course.
sequelascontinue to be manifested
long after the cold has produced its
immediate
to congelationsvaries to a remarkable
effect. The predisposition
extent
in
different individuals.
The chief predisposingcondition
in both sexes
is anaemia.
Girls
will begin to complain of these troubles
when
laboring under
chlorosis, becoming
the general health
is restored.
A temperature of from 4 to
as
again exempt as soon
5" 0. will suffice to bring on
that a degree of cold below the freezing
so
congelations,
point is by no means
occur
more
They
readilyin a state of repose, especially
necessary.
than
is
when
the
about.
during sleep,
subject moving
In congelations,
in burns, we
as
distinguishthree degrees.
its

and

A.

The
the

DERMATITIS

first effect of excessive

skin; when

blood-current
cutaneous

causes

cold is

bluish-red

Such

ERYTHEMATOSA.

contraction

of the blood-vessels and palenessof

The
retardation of the
again dilated.
discoloration,which is accompanied by a circumscribed

abates, the

the cold

oedema.

CONGELATIONIS

is the mode

The

vessels

are

in which
and

chilblains

make
(perniones)

penis,that is,those

toes, nose, ears,

fingers,
in proportionto bulk, are
most
The
superficies
frequentlyattacked.
under pressure, while it is deepened as the result of warmth.
itch

continue with more

or
may
this is the case, the cedematous

smart, and

partswhich

their ance.
appearhave the largest

discoloration
Chilblains

appears
dis-

burn,

less

improvement or aggravationfor a long

swellingbecomes more
tense, the nodules
feel harder, and the epidermis coveringthe latter is thin and shining. Usually the complaint
to return
at
the
advent
the
of
cold
Some
disappearsin summer,
season.
again
the active symptoms have
degree of vascular enlargement,however, often remains when
subsided.
Blisters containingbloody serum
chilblains
in consequence
are
of
produced on
external
friction
as
or
injuries,
(scratching).These may degenerate into running
pressure
and ulceration
of the papillarybody, and
sores, with denudation
giverise to
may
and glandular inflammation.
venous
or

period.

When

B.

CONGELATIONIS

DERMATITIS

BULLOSA.

When

the action of cold has been of longer duration, blisters are formed, containing
bloody serum, and varying in size from that of a pea to that of an apple. After
these are opened, an ulceration of the underlying tissues often takes place,which
reaches
to the bone and is exceedinglyprotracted.
a

clear

or

C.

In
no

cases

of

blisters have

CONGELATIONIS

DERMATITIS

congelation,gangrene
been

formed.

The

may

affected

occur

ESCHAROTICA.

underneath

part becomes

the blood-blisters

pale,livid,cold, and

or

where

insensible^

170

and

ECZEMA.

when, for instance,the

frozen, the patientgoes

walking without complaint

for days together. The process of sloughinggenerallytakes place very slowly,while the
line of demarcation
is being formed, and often requiresto be aided artificially.
sive
Extensince the blood-vessels
congelationsnot unfrequently result in pyaemia or septiceemia,
to dischargetheir ofl"ce,
of the affected region continue
and in this way putrid substances
be admitted

may

toes

are

on

into the circulation.

should

Treatment

first of all be

prophylactic.

their

When

development is favored
len
woolby anaemia, this condition should be remedied, and the patientsbe directed to wear
with
cold
snow
or
stockings and gloves. Kecent
congelationsshould be rubbed
too rapidly. Chilblains will generallybid defiance
water, and not restored to warmth
himself
to cold.
to all remedies
When
so
long as the patient continues to expose
they
be
in
a
nd
member
should
horizontal
the
affected
are
a
inflamed,
kept
position,
wrapped in
should
be continued
cold lead-water cataplasms,and these measures
as
long as they are
agreeableto the patient. In cases of swellingand the formation of ganglia,tincture of
has proved of decided
iodine (even the colorless preparation)
benefit.
lute
Lemon-juice, dinitric
chloride
of
caustic
or
acid,
creasote,
acid,
lime,
hydrochloric
pyroligneous
mended.
lime, collodion,camphor, petroleum, and turpentine have each been likewise recomGentle pressure, appliedby means
of Martin's
elastic bandage, has often produced
or
chrysarobin is often very serviceable
good results. Sprinkling with iodoform
chilblains.
in promoting healthy granulationson ulcerated
When
tion
symptoms of irritafuscum
be
the
to
Lister's
ointment
is
borax
or
emplastrum
predominate.
preferred.
Blisters should be broken, and their bases thoroughly and
trate
repeatedlycauterized with niis
extensive
of silver,until a clean suppurating surface
presented. In
gangrene,
antisepticdressing,togetherwith vertical suspension of the extremities (Bergmann) or
the

continuous

water-bath

(Hebra),should

be resorted

Dermatitis

to.

Traumatica.

with their sequelae.

varietyare displayedall the phenomena of inflammation
from
tion
concussions,
trusses,
blows,
or
(as
tightboots),
produced by
by fricpressure
The
is
in
treatment
accordance
with
(inrowing, scratching,etc.).
generalsurgical
principles.
In this

It is

Dermatitis
this

head

included

Venenis

et Causticis.

largenumber

of

inflammations,arisingfrom the
substances either produce
upon
merely redness,swelling,vesicles,and bullae,or eruptiveblotches,or they entirelydestroy
chemical
the skin by effecting
changes, which frequentlyput an end to life itself. Such
mineral acids, caustic potash, caustic lime, arsenic,
the caustic agents (concentrated
are
The
treatment
inflammations
is similar to that already described
this
class
of
of
"tc.).
Under

are

injuriousaction of various

in connection

with

the

substances

skin.

These

burns.

ECZEMA.

Catarrh
Eczema

is

by

diseases.
"cases

of

those

statements
found

far the most

According

diseases

of Erasmus

that

of the

and
frequent,
to

come

Skin.
the
practically

hence

experience,it includes

our

under

Wilson, McCall

that, in Vienna, it constituted

treatment

"

an

more

estimate

Anderson, of Glasgow,

only sixteen

per

cent

and

importantof

most

than
which

one-third

agrees

with

Bulkley, while

of all the

cases.

Hebra

taneous
cu-

of all
the

Hebra
also

171

ECZEMA.

that twice

females
males
as
many
observation,the proportionof the sexes

iound
to

our

as

were

afEected with, the

in this

respect is

malady. According
equal. No period

about

of life is exempt,

most
although it occurs
frequentlyin childhood, when the skin is pecusoft,delicate,and susceptible.
"culiarly
is remarkably protean in its manifestations, showing itself under the most
Eczema

varied

forms.

Definition.Eczema

of the skin,
simple,non-contagious,catarrhal inflammation
acute or, more
frequently,chronic in form, beginning as an erythematous redness, or as
an
eruption,either scattered or in groups of papules,vesicles,or pustules,or of all these
less redness
and swellingof the skin, and with
or
together. It is associated with more
and
followed
the
of moisture
and
the formation
severe
burning
itching,
by
appearance
of crusts, partlyyellow and gummy,
and
brown, or by a dry scaly eruppartlygreen
tion
"

upon

red base.

Eczema
of the

is

mucous

is precisely
analogous to catarrh
membrane

consists in

more

of the
or

mucous

less increased

membrane.
secretion

Just
from

as

the

catarrh
mucous

glands and an abundant

desquamation of the peculiarlyaltered superficial
epithelial
with an increased exudation
from the overloaded
vessels of blood-serum,
layer,combined
of cell-elements
"containinga greater or less amount
(serousor purulent catarrh),so, in
there is a similar discharge of blood-serum
and
csll-elements,with a similar
"eczema,
is characmembrane
terized
shedding of the horny layer,and as chronic catarrh of the mucous
filtratio
by swelling,infiltration,and increased redness, so chronic eczema
presents inand
hyperaemia of the skin. We may convince ourselves that the process is
the same
in both cases
cous
by observing it in situations where the epidermis passes into mumembrane.

follows :
are
as
symptoms presentedin every case of eczema
in dependent
Hyperaemia active as a rule, though frequentlypassive,especially
portions of the body ^forms the initial stage (stadium erythematosum). This may pass
directlyinto desquamation, and I fullyagree with Kaposi, who maintains, in opposition
there
which
do not advance
to Auspitz, that
though
are
eczemas
beyond this stage, alto be called an erythema, especially
this process is not entitled on that account
in cases
when
it occurs
of eczema,
and is associated with intense itching.
Exudation.
This constitutes the eruptive stage. Small punctiform papules, vesireddened
base ; these may
on
a
or
"cles,
pustulesmake their appearance
dry up and pass
into the third stage,or the epidermis may
break, and the serous
or
purulent secretion
the surface
of the skin (moisteczema).
be dischargedupon
The typiDesquamation. This is the final stage of eczema
(eczema squamosum).
"cal succession
be most clearlytraced in acute eczemas.
of phenomena just described may
Eczema
is regarded as chronic :
situation.
1. When
it recurs
This, however, strictly
frequently in the same
speaking,
is only a relapsingform of the acute disease.
certain insidious secondaryprocesses have set in, such as occur
2. When
in some
cases
of chronic catarrh of the mucous
membraces.
these
diseases
Among
complicationsare
of the absorbent
apparatus, and conditions of engorgement, accompanied by atrophic
alterations in the glands and adipose tissue.
Eczema
is divided
into the followingvarieties,
another
of the
or
according as one
",bove symptoms predominates :
1. Eczema
erythematosum exhibits a diffuse or punctiform redness and swelling of
"the skin, graduallysubsiding at its circumference, sometimes
confined
to small spaces.
The
1.

"

"

"

"

172

ECZEMA.

sometimes

extending

into

passes

the

over

whole

either

It

body.

terminates

in

desquamation,

or

forms.

other

2. Eczema
papulosum (Hebra) shows itself in the form of small, round or acuminated,,
irregularly-scattered
papules, as large as a pin^s head, and attended with troublesome
apices of the papules being rubbed off by scratching,small, black points
itching. The
in their places. They are
either confined
of dried blood
to circumscribed
blotches,
appear
sometimes
which
include
the
entire
surface.
In the
or
over
dispersed
large areas,
bodily
latter case, the intolerable itching renders
this form
of
the
and
tractable
inmost
one
distressing
ends
maladies.
of cutaneous
with the papular eruption,
Usually it beginsand

is sometimes

which, however,
Eczema

3.

point of
very
so

or

an

by vesicles or pustules.
eruption of vesicles no larger than

foot.

dotted

or

in groups,

less

places where

the

distributed

sole of the

of

uniformly red,

large blisters,in

to form

hand

surface

and

numerous,

as

the

pin, on

succeeded
consists

vesiculosum

The

with

color ; these

frequently isolated.
They
epidermis is thickened, as

vesicles

individual

that

the head

or

are

generally

often

coalesce

the

palm of
tenselyfilled with a transparent,
swollen, and the accompanying
and disappear by desquamation,

are

on

yellowish fluid ; their surrounding surface is red and

The vesicles may
collapse,dry up,
itchingis intolerable.
under
the
considered
of eczema
the varietyto be afterwards
madidans
be
name
or
may
of
destruction
the
vesicles
the
by scratching,partly through
produced, partlythrough
The

their
or

spontaneous rupture.
the fingers.
4. Eczema
pustulosum
developed from

either

process.
is most

of

seat

vesiculosum

eczema

is the face, the

hands,

differs from
the preceding varieties in the
larger proportion of pus-corpuscles. It is
without
mediate
eczema
vesiculosum, or its pustules are formed
any interThis
form
than
the
vesicles.
of
eczema
are
pustules
usually larger
s.

impetiginosum
contains

fluid of its vesicles

the

fact that

usual

The

frequently found

upon

the

of

heads

children,

and

in scrofulous

individuals.

madidans
of
follows uniformly one
5. Eczema
inflammatorium,
s.
; eczema
in which
superficies,
preceding varieties,and is characterized by a moist and reddened
often
f ossee.
discernible as minute
From
this there
the ruptured vesicles and pustules are
which
dries
into
crust
of
is a free discharge of serum
or
a
a yellow
firmly-adherent
pus,
the
brownish
from
the
admixture
of
blood.
of
color,
or
or
Any part
body may be
green
and
of
but
the
bends
the
scrotum,
affected,
especially
legs (salt-rheum),
joints.
ears,
diffusa et palmaris, Wilson; eczema
6. Eczema
(psoriasis
psoriasiforme,
squamosum
arise from
of the preDevergie) constitutes the final stage of typicaleczema
; it may
any
ceding
It is characterized
itself persistfor years.
forms, but may
by red spots varying in
rubrum

the

with

extent, and
dust

of the

dry

large shreds

to

of

The

and

scaly surface.
epidermis. The

scales

affection

is

are

of

size, from

every

generallyassociated

with

grain

of

infiltration

skin.

is characterized
or
by fissures,either superficial
rhagadiforme
penetrating
the entire integument, extremely painful and often
rendering all movement
impossible.
caused
the joints,and
filtrated
are
most
by the brittleness of the inThey occur
frequently over
The
skin, which gives way on movement.
finger-endsare particularlyliable to
7.

Eczema

this form

their skin becomes

exceedingly painful fissures.

of

different

singledisease

localities

on

one

and
easily-bleeding
dry, brittle,and traversed by numerous
all
varieties
these
heretofore
but
tations
manifesare
explained,

As

they

and

may

the

same

pass

into each

individual

other, and
at the

same

are

frequentlymet

time.

with

in

173

ECZEMA.

ECZEMA.

ACUTE

either at a single
This is ushered
in by the appearance,
spot or in several places,of
with a feelingof burning and
inflammatory redness and swelling,resembling erysipelas,
shivertension, accompanied by general uneasiness, gastricderangement, sleeplessness,
above
the
and
the
the
and
normal,
even
being
bodily
rigors,
temperature
pulse
ings,
small papules or vesicles containinga clear
rapid. In about forty-eighthours, numerous
The eruption extends, scattered
turbid fluid arise on the affected surface.
or
spots, papules,

breaking out around the first crops, or the disease manifests itself de novo
sensitive during an
excessively
regions; for the entire integument becomes
irritation will suffice to call forth the above symptoms,
attack of eczema,
and the slightest
in previouslyhealthyparts. In the most
favorable cases, the vesicles and pustulesdry up
of crusts and scales,or else those
and disappear,with intense itchingand the formation
which
have
been
described
under the title of eczema
madialready
phenomena supervene
The eruptionsoften return in
dans.
The entire process occupiesfrom two to six weeks.
different localities,
and thus the disease graduallybecomes
chronic.
Moist
the same
or
in frequency are the papular and erythematous
form ; next
is the most common
eczema
varieties (eczema intertrigo).
Every portion of the skin is liable to the attacks,but they
the
i
n
most
occur
followingsituations :
frequently
or

on

vesicles

remote

(") Eczema
After
and

ears

faciei.

chill,the face begins to redden and swell, the eyelidsare puffy

are
greatlyswollen, and the lips are bloated and cannot be

the precursory

immovable, the

acutum

also

and palpationof the skin will disclose an unevenness,

often
opened. Careful examination
is
which
caused
the
under
of
illumination,
by
oblique
numerous
perceptibleonly
presence
minute
the ears, and
on
papules and vesicles. The vesicles break quite early,especially
extends
dischargetheir contents very profusely. Hearing is impaired when the eczema
to the auditorycanal.
Eecovery takes place in from three to six weeks, but small spots
for chronic facial eczema.
often left unhealed, and lay the foundation
are

(5) Eczema
Is associated

subject to

with

moist

great swelling of the penis and scrotum

while the penis usuallythrows
off
eczema,

(c) Eczema
Either

genitalium virilium

acutum

isolated vesicles appear

foot swells,and
or

acutum

et

manuum

the

latter

part

the disease at

once

is very

by

squamation
de-

pedum,.

fingersor toes, togetherwith slightredness, or

instepor back of the hand becomes highly oedematous.
The fingersare enlarged,painfullyswollen, and
covered with numerous
vesicles
which
often pass into pustules. The
corium
is frequentlydenuded
to a considerable
tent,
exand the nails may
fall off. The
pustules and crusts dry up, and the skin returns
to a healthy condition in the course
of a few weeks.
the whole

hand

on

the

the

(d) Eczema
This
localized

is

fortunatelyof

eczemas,

aflSicted with
unable
39.5"

to

0. ;

this form

endure

the

rare

of

soon

; he

eczema

contact

tongue thicklycoated

; it results from

occurrence

shall not

of

even

universale.

acutum

forget the
received
the

; face red

me

the

coalescence

of

numerous

presented by
gentleman
appearance
in a state of complete nudity,being
a

His pulse was

110 ; temp.
lightestgarment.
; scalpcovered with a scurfyerup-

and bloated

174

ECZEMA.

tion ; the whole

body scarlet,and the skin hot to the touch. The penis and scrotum
wer"
visible
in
the
bends
greatlyswollen, the latter exuding freely; vesicles were
of
plainly
the
while a moist
the joints,
The
eruptionoccupied
axillaryregion.
patientwas sleepless,
and in a state of extreme
agitation. The use of stimulants and all irritating
applications
forbidden
were
simply covered with starch-powder; and in a few
; the skin was
weeks the whole disorder had disappeared. As might be expected,this varietyof eczema
different aspects.
assumes
many

(e)Eczema
This

two

cutaneous

Intertrigo.

surfaces

in contact,and proceedsfrom the erythema

are
corpulentadults are most liable to its attacks.
in the anal fossa,beneath
folds of the genitals,
dulous
penand at the bends of the joints.In rare
instances,the inflammation
mammae,
runs
of neglect,that even
so
with their
high, in consequence
diphtheritisand gangrene,
be
developed (Oaposi).
sequelae,
may
were

occurs

of such localities. Children

intertrigo
The eruption is usuallysituated in the

and

CHEONIC

ECZEMA.

presentsthe same
changes as the acute form ; but, in addition,exhibits
In chronic
others, resultingfrom repeated attacks of inflammation.
the
eczema
skin is swollen,thickened, reddened, and darkly discolored. In protracted cases, the corium
tissue resembling furuncles which
often contains small thickeningsof the connective
are
hard to the touch, and merge
The
graduallyinto the surrounding structure.
apices of
and
scratched
most
these formations
are
are
off,
met
with on
generally
they
frequently
tissue may
The
subcutaneous
take part in the inflammator}^
the extremities.
process.
of chronic eczema
characterized
Certain cases
are
by profuse exudation, while others,and
these the most
Chronic
frequent,merely present a few scabs on the affected surface.
often gives rise to ulcers, particularly
the legs. The itching is usuallyexon
eczema
tremely
and compels the most
resolute patientto scratch.
if he is able
Even
distressing,
irresistible at night, and
to keep from
doing so in the day-time,the inclination becomes
bed.
caused
in
The
lesions
on
gettingwarm
especially
by scratching,and the intense
to
rise
increased
exudation
of plasma, which
irritation,give
an
cutaneous
stiffens the
is accompanied by an abatement
of the itching,and by a painful
This exudation
linen.
burning sensation,which, however, is hardly noticed by the patientin comparison with
The
the previous symptom.
itching is much
aggravatedby everythingwhich irritates
boils frequentlymake
their appearance
the skin. Numerous
of chronic
during the course
the
this
is
of
clear.
It
is
not
observed
eczema
cause
phenomenon
more
certainly
;
very
frequentlywhen the disease is treated with ointments than when aqueous and alcoholic
Chronic

solutions

eczema

are

There

are

proceed to

relied upon.
other varieties

of eczema,

{a)
This

dependent

on

its

locality. These

we

will

now

consider.

is most

generallyin

frequentlymet

the forms

Eczema

Chronicum

CapiUitii.

with in children, but is not

rare

affection among

adults,

impetiginosum. Its peculiar features

squamosum
sebaceous
due to the hair and the numerous
are
glands of the scalp. It attacks either
In the latter case, adjacent regions,
circumscribed
portionsonly, or the entire surface.
In eczema
and
involved.
the
also
are
as
forehead, neck,
'squamosum the scalp is
ears,
reddened
and covered with a plentifulcrop of white, greasy scales. In eczema
madidans
of

eczema

and

176

ECZEMA.

the lashes.
At

When

this condition

is of

long duration, it leads to very obstinate ectropium.

the same
time, a catarrhal conjunctivitisis almost always manifested, which
times
somediphtheritis.
developsinto blennorrhcea or even
(c) Eczema
This

CJironicum

Mammm.

is

particularly
frequently,both of the nipples,in the
apt to affect one, or, more
it also occurs,
but
'Case
gins
nursing women,
especially
primiparae;
though rarely,in virIt begins with a superficial
excoriation
of the nipple,and a slight disand males.
charge,
left undisturbed, the sore
which
soon
rapidly dries into a small scab. When
lieals spontaneously,but the constant irritation of suckling causes
it to spread over
the
the areola.
and
w^hole nipple and
The
and
fissured,
swollen,
so
nipple becomes
raw,
it
and
that
moist
out
elevated
as
a
broad, red,
spread
protuberance,only slightly
appears
The eruption is always circularly
above the level of its firmly-incrusted
areola.
disposed
the nipple. It is not unfrequently followed by mastitis.
around
fection
afAccording to Paget (St.Bartholomew's
Hospital Eeports,1874), an eczematous
of the nipples (Paget'sDisease) often precedes mammary
Later
vations,
obsercancer.
however, have shown that this is a correct statement
only so far as regards a
the
lactiferous
of
of
the
orifices
of
one
epithelioma
glands.
very superficial
of

{d)

and

The

umbilicus

here

also the

filled with

and

in corpulent individuals,
frequentlyattacked by eczema, especially
form.
The umbilical fossa is often
a circular
eruptionusuallyassumes
easilydecomposed, foetid secretion,

an

of the
is

organs,
often continues
form

of

Umbilici.

Ghronicum

is

(e) Eczema
Eczema

Eczema

anus

Ghronicum

is very often

frequentlyassociated
for several years

the

with

before

It is

et Perinmi

Genitalium

for
starting-point
hemorrhoidal

it attacks

the

the

et Ani,
same

troubles.
which
genitals,

disease of the sexual

Eczema

of the

is does

under

anus

the

an
eruption.
frequently accompanied by very painful rhagades,
and by troublesome
seriouslyinterfere with defecation,by a profuse secretion of mucus,
at night. The
itching,especially
strainingat stool often results in swelling and
prolapsus of the rectum.
Subsequently, the eruption extends
mostlj along the anal
fossa.
The
manifestations
obstinate
of perinealeczema
of a particularly
character
are
for eczema
along the line of the raphe. Next to the anus, the most frequent starting-point
where
the skin is in contact with
of the genitalsis the folds of the thigh,especially
the scrotum.
It is very seldom
that the complaint attacks the entire surface of the
furrows of eczema,
while that
penis ; usually,the dorsum exhibits only a few transverse
is covered by the eruption and
portion of the under surface which touches the scrotum
while the squamous
exudes
freely. On the scrotum, moist eczema
very often occurs,
is enlarged,has a glazed appearance,
form is more
The scrotum
and
rarelymet with.
almost
and
smells
secretes a fluid which
In
cases
abominably.
immediately
decomposes
swells so enormously that the patient believes himself
of long standing,the scrotum
to
in
have elephantiasis.The itchingis often very intense,and comes
on
(The
paroxysms.
so-called eczema
marginatum, which so frequently appears on the thighs, especially
where they touch the scrotum, is one
of the mycoses.) In females, the labia majora are
but this is quickly transformed, by scratching,
very often the seat of vesicular eczema,
madidans
it
is
into eczema
accompanied
by great swelling of the parts. The labia
;

which

acute

177

ECZEMA.

affected in the same

vaginalorifice are frequently
these localities is generallyassociated with vaginal leucorrhcea.
veneris and the surface of
eruptionoften extends over the mons
minora

and

(/j
Unlike
_ormed

or

CTironicum

Eczema

prefersthe

eczema
psoriasis,

the Folds

of

the

From
the

the

thighs and

abdomen.

Joints.

Joints. After crusts have

place,very painful fissures are produced as

patient,therefore,maintains the affected

might almost believe it to be ankylosed. The

the result of movement.

complaint in
genitalsthe

inner surface of the

taken

infiltration has

cutaneous

of

The

way.

The

position,so that one

generallyoccurs
symmetrically.

limb

in

flexed
semi-

disease in this

situation

{g)

Cruris.

Chronicum

Eczema

popularlycalled,is that in which it most frequently

important varieties of the complaint.
appears on the leg,and is one of the most practically
ing
It is often associated with varices,and may lead to hemorrhages, ulcers of the leg,thickenof the skin, oedema, and enlargement of the limb resembling elephantiasis.Dark,
the skin after healinghas taken place. The small,
discolored spotsusuallyremain upon
in
each
scattered pustules,
general punctured by a hair, and the small and often very
painful abscesses which belong to E. impetiginosum of the leg, constitute peculiar
Salt-rheum, as

features in this

the

moist

form

is

complaint.

{h) Eczema

Chronicum

Manus

injuriesof those parts.

the fingers.
on
especially
inner
the
the
surface
of
makes
its
the
disease
on
fingers,in the
Usually,
appearance
when
with
elevated
form
of sago-likevesicles,
borders, which,
opened, discharge a
the palm of the
tenacious fiuid. Owing to the thickness of the epidermis on
gummy,
for a long time, and then dry up and
often remain
hand, the vesicles in this locality
small holes,as if by a punch.
desquamate, leavingthe skin perforatedwith numerous
Old eczemas
the inner or outer surfaces of the articulations commonly result in the
on
production of painfulrhagades; and there is often very considerable infiltration of the
the back of the hand.
on
cutis,especially
in anaemic
A peculiarform of eczema
the palm of the hand, especially
occurs
on
females, as a dirty,dry, indurated, smooth
thickeningof the epidermis. The furrows
reddened
and filled with a whitish powder resembling fiour.
of the hand are
Only the
co-existence
enable
the
similar
and
of
other
this
affection
to
on
itching
eruptions
parts
be recognizedas eczema.
It may render the fingersincapableof complete extension ; in
the nails were
affected,becoming dry, brittle and fissured,traversed
my two cases, even
painful. The walls of the nails
by vertical or horizontal furroTvs,sensitive,and even
and greatlyswollen.
reddened
Eczema
of the feet givesrise to similar phenomena.
were
of the hands

Eczema

All forms

of

eczema

are

and

fingersis very

liable to

occur

PATHOLOGICAL

Acute

on

the

often

the

et Pedis.

result of

hands, but

more

ANATOMY.

tions
anatomicallyregarded, differs in no respectfrom other inflammascribed
exudation.
The
epidermis,with predominant serous
papillaein circumportionsof the skin are enlarged and lengthened through their infiltration with
cell elements
and a clear serous
fluid. The
connective-tissue
corpusclesof the papillae
become
and undergo a marked
In the
increase in size and succulence.
more
numerous
stratum
V.
Biesiadecki
has
fusiform
cells
as
shown,
abound, extending halfmucosum,
eczema,

of the

12

178

ECZEMA.

Tvay into the

papillarylayer,half-wayinto

These, in their advance, force asunder

as

far

which

the

as
serves

of

as

for the

outlet

an

vesicle hastens

the

cells of the stratum

epidermal investment.
into

the

form

epidermis. They

corium

and

deepest portionof

around

the

swollen

the former

mucosum,

structure..

and

cells
epithelial

reach
a

even,

network,

to the
escape of the exudation
cellular formation
within the

new

swell up, perhaps even

the inflammation

mucosum

The

the

the cells of the stratum

intense

more

into

surface.
The development
and the
papillae,
ficial
superto bursting,and
lose their
the more
deeply it extends

consists of serum
adipose layers. The exudation
and white blood-corpuscles.
The multiplication
of the latter causes
the vesicle to change
into a pustule. The usual reaction of the fluid is slightly
alkaline.
In chronic eczema
the microscope reveals considerable
thickening of the epidermis
and the corium, with
dark
discoloration.
The
papillaeare often so greatlyenlarged,
in moist chronic eczema
of the leg,that they are visible to the naked eye as red
especially
the
surface
pointsupon
(Bulkley).
oozing
There is also enlargement of the lymphaticsand blood-vessels ; thick depositof cells
and coloring-matter
tissue at the expense, partly,of the obliterated
; increase of connective
sebaceous
glands and hair-follicles and of the degeneratedsudoriparousglands ;.
atrophy of the fat cells,and degenerationof the nerve-fibres.
even

the

ETIOLOGY.

Is

eczema

local

resemblingthose of

or

constitutional
which

disorder, and ought the inflammatorysymptoms

caused

by external irritants to be set apart from the

latter?
of the constitutional
so
opinion,we are not justified,
long as the primary causes
my
disease still remain
undiscovered, in separatinginto distinct classes,affections
succession of phenomena.
The preanatomicallyhomogeneous, and displayingthe same
disposition
eczema

are

In

to

eczema

differs to

remarkable

extent

in

different individuals.

As

with

irritation of the stomach

gives rise to gastriccatarrh, so in
persons every trifling
others a mere
the
skin
will
outbreak
of eczema.
of
cause
an
chafing
It iscertain that debilitating
influences will increase the predisposition
to the complaint,
of catarrhs in general. Among these predisposing
conditions
as they increase it in the case
and intestinal
are:
chlorosis,rhachitis,scrofulosis,
gout, albuminuria, diabetes,dyspepsia,gastric
Like Bulkcatarrhs,dysmenorrhoea,uterine affections,
lactation,and pregnancy.
instance of the last-named
state predisposing
seen
an
ley,and unlike Hebra, I had never
under
to eczema
came
until,while actuallyengaged in writingthese lines,a woman
my
treatment
in her eighth pregnancy,
who, since her third, had been attacked with eczema
regularlyeach time in the third month, and disappearingspontaneously at the end of
her confinement.
Eczema
is often observed
to be aggravated during the menstrual
of the complaint,where
cause
a
period. Psychicalinfluences may also be the immediate
liable to the comexists.
Persons having a very delicate skin are
more
plaint.
predisposition
in this direction is also increased by repeated attacks.
Varicose
Susceptibility
in congested localities,
veins and hemorrhoids
tend directly
to the production of eczema
the legs.
the anus
as
or
at variance with the
On the subjestof heredityin this disease,I, like my father,am
its occurrence
of
of
both
instances
of
met
with
us
authors,
by
majority
having
frequent
in
descent.
This may
that
be
accounted
for
privatepracticeonly
probably
by supposing
must
the most inveterate cases
under notice, in which category hereditaryeczema
come
undoubtedly be placed. But one instance of this kind need here be cited. A girlof
He himself
sixteen was
placed under our care for eczema
by her father, a medical man.
some

17^

ECZEMA.

and

his mother,

as

also his second

examples might be multiplied.

phthisicalfamilies.

daughter, were

sufferers from
with

is observed

Eczema

the

complaint.

Similar

specialfrequencyin scrofulous

and

Foremost

the

among

external

causes

brought out by the wet-sheet packing

Sulphur and
hydropathic institutions.

and

is the

action

baths

of water

of

water.

and

vapor

Eczema

is often

administered

at

frequently produce the

related
most
to those arising
effects.
The eczemas
due to these causes
are
same
nearly
india-rubber
to
from
the
from
eczema
as
eczema
skin,
intertrigo,
clothing or
injuries
result
but
uot
from
of
children
also
The
perspiration,
only
bandages.
chafing
may
Another
from the alkaline character of their discharges.
predisposingaffection is the
sudamina
alba et rubra, hydroa) which
so
frequentlyoccur, under the form of
(miliaria
papules and watery blisters,in patientswho sweat profusely.
croton
Numerous
oil, tartar emetic, cantharides,
give rise to eczema:
drugs may
mercurial
ment,
sublimate, sulphur, blue ointmustard, hellebore,potash-alkalies,
mezereum,
belladonna
of
as a component
ointment, arnica tincture,and turpentine(especially
Since
the
introduction
adhesive
of
the
plaster,diachylon plaster,etc.).
antiseptic
in surgery,
carbolic acid eczema
has been
method
frequently observed ; it is generally
be classed
characterized
vesicles and copious exudation.
With
these may
by numerous
those chemical
substances which
affect the skin through their action on the spinalsystem
of nerves:
the mineral
acids, arsenic,vegetable juices,anilin dyes, resins, turpentine
(in house paintersand printers),
(butlersand barbers),alkalies (washersoap and water
women);
pulverized materials, as flour, cement, plaster,powerdered spices (millers,
bakers, masons,
laborers,grocers).
agricultural
the
influences
be menAmong
tending to the production of eczema
dynamic
tioned
may
heat and cold (E. solare,E. caloricum). In winter, the disorder very commonly
takes the form of chapped hands.
also result mechanicallyfrom pressure
The disease may
and friction,especially
of the
clothing,but principallyfrom
scratching,which is operativein all complaints accompanied
by itching.
The
of eczema
when
cause
tion,
followingvaccination must be sought in cutaneous irritaand not in any specific
action of the virus employed.
and psoriasis
Eczema
often observed to occur
are
simultaneously.This is also true
character

and
as

eczema

catarrh

still

more

''

''

of asthma

saline baths

"

fact not

to be wondered

at if

eczema

is

recognizedin

its true

of the skin.
DIAGNOSIS.

If the

time
symptomatology be kept in view, all the affected localities being at the same
carefullycompared with each other, its diagnosisin most cases will present no difficulty.
with the followingcomplaints:
Still,it may possiblybe confounded
1. Erysipelasis frequently mistaken
for acute
The
eczema.
latter,however, exhibits
little redness
and its fever is of a lower grade. The diminutive
or
swelling,
papules
vesicles of eczema
or
under oblique illumination,
are
or by palpation.Eczema
perceptible
of the face usuallybreaks out in several places at once, whereas
in the same
erysipelas
situation spreadsfrom a singlepoint. In erysipelas
there is usuallya dischargeof fluid,
but this proceeds from the rupture of largebullae.
2. Epithelioma in the
first stage. The
small
extent
of the epithelioma, its
and
the
absence
of
sharply-defined
sufficient
to prevent mistake.
borders,
itching,are
3. Lichen.
While the papules of eczema
into
vesicles or pustules, or dischange

180

ECZEMA.

altogether,those of lichen remain firm, solid,unaltered, and tipped with scales,

period.
of the genitalsis particularly
4. Pruritus
But
the
for eczema.
apt to be mistaken
papules, vesicles,and moist surfaces are wanting in pruritus. Its only visible signs are
the results of scratching.
with a burning sensation ; eczema
5. Herpes is attended
with
cles
itching. The vesiappear

for

considerable

are
herpes are in isolated groups ; those of eczema
densely aggregated, without
regular arrangement.
6. Miliaria crystallina. The
vesicles of eczema
crowded
are
together in confined
the breast and abdomen.
Eczema
is
on
spaces ; those of miliaria are isolated,especially
accompanied by pruritus; miliaria by stingingpain and uniformly by fever.
7. Pemphigus vulgaris. The
large bullae characteristic of pemphigus are not seen
in eczema.
foliaceus
is
tion
Pemphigus
distinguishedfrom eczema
by the extensive exfoliaand superficial
with
it
and
to
which
sence
gives rise,
soreness,
by the abscanty exudation,
of itchingand cutaneous
infiltration.
This is localized chieflyon the hands
and
and on
8. Scabies.
fingers,in the axillae,
the breast, abdomen, and penis. It does not attack the hairyscalp. The itch-vesicles are
less closelyaggregated than those of eczema.
ever,
The
principal mark of distinction,how-

of

is the

acarusrburrows.

9.* Favus

be confounded

can

which

sulphur-coloredcrusts
or

dark

and

appearance,

always results

Favus

and

only with
are
dry and

pustular varityof

the

friable.

in baldness, and

crusts

Underneath

consistence.

gummy

The

them

the hairs of the affected

Favus

eczema.

of

parts

have

eczema

is
are

moist

its
exhiba

yellow

surface.

bleached,

less,
lustre-

brittle.

skin
The
largerthan those of this disease.
sycosis it is rough and glandulous. The hairs
this
be drawn
from the pustules of sycosiswithout
can
pain ; in eczema
giving much
is not the case.
latter
the
left
untouched.
beard
is
the
disease,
generally
By
moreover,
11. Syphilis. Syphilitic
pustuleson the head may be mistaken for E. impetiginosum.
of the crusts discloses an ulceraThe
tion
pustulesare scattered over the scalp,and removal
with
and
there
is no
The pustulesare
succeeded
perpendicularborders.
by scars,
itching.
When
is seated on the palm of the hand, it is often impossibleto distinguish
eczema
it from
the infiltration is more
solid and
tends
exon
a first inspection. In syphilis
syphilis,
deeper into the tissues ; the discoloration does not disappear under pressure. Close
cles,
to be composed of numerous
examination
shows the blotches
points,papules,and tuberbecome
to
in
circles.
have
a
enlarged peripherally.
mostly arranged
They
strong tendency
there
is no
Their outline is usuallyirregular and
undulating, in most cases
sembling
itching. When
syphilisaffects the labial commissures, it produces fissures exactly rethose of eczema,
of the latter disease are
sides
but the other features
wanting. Bethe fissures,syphilisgenerallygivesrise to flat papules.
It is also
12. Seborrhoea.
Eczema
in the neighborhood of the hairs.
is often found
with itching and glandular enlargement. A red and inflamed, and frequently
attended
10.

beneath

Sycosis.

them

The

is smooth

crusts
in

of

eczema

eczema

are

in

"

moist

remains

scalp;
13.

surface
intact
eczema

Lupus

is left after the

and

often

of its natural
attacks

only
Erythematosus.

removal
color.

of

the scales,while

Seborrhoea

in seborrhoea

spreads uniformily over

the cuticle
the

entire

isolated spots.
The

scales

adhere

very

firmly, and

extend

into

the

"181

ECZEMA.

enlarged sebaceous glands. The scales

and
leaves contractingcicatrices,
In eczema,
Rubra.
14. Pityriasis
infiltration and thickening of the skin.

of

eczema
are
easilydetached.
tosus
Lupus erythemaunaccompanied by itching.
the
eruption is usuallymoist, with well-marked
rubra exhibits a uniform
Pityriasis
redness,with

is

abundance
of thin scales,like shreds of paper, and is generallyattended
with severe
an
moist.
It is characterized
burning pain. Pityriasisis never
by a profusion of thick,
scales, which, when
detached, leave a red surface dotted with bloodsilvery-shining
The
of
are
patches
psoriasis
sharply defined, and are chieflymet with on the
points.

surface

anterior

of the

The

limbs.

diseases

two

are

almost

certain

to be

confounded,

E. squamosum
and psoriasisuniversalis,
except after lengthened observation, especially
of a moist eruption renin which, besides the historyof the case, only the appearance
ders
differentiation possible. When
the hand, its diagnosisis very
eczema
occurs
on
in this situation,Hebra
and Oaposi recommend
frictions with caustic potash,
difficult;
In
there are usually small vesiin order to bring out the vesicles more
cles
clearly.
eczema,
and
the end of the fingers. Eczema
itches violently;psoriasis
not at all,
between
on
from
its
or
only moderately. Psoriasis heals from the centre of the eruption; eczema
circumference.
be confounded
The
acute
can
only with eczema
Herpes tonsurans
squamosum.
of herpes tonsurans, its blotches, sharply-defined
and
from
the
healing
centre,
its contagiousnature, the slightitchingwhich
scopic
accompanies it,and, above all,its microis leadfungi,leave no doubt as to its diagnosis. The scalp in herpes tonsurans
colored, dirty,and grayish-looking;the hairs are dry and broken.
Herpes marginatum,
the parasitic
origin of which has been demonstrated
by Kobner, Pick, and Caposi,is
identified by the sharp borders of its eruption,which heals from the centre, and its fungi.
16.

character

PROGKOSIS.

This

according
some

when

is

always

to

curable
such

the

favorable,

very

of the

cause

constitutional

conditions

as

far

so

life is concerned.

as

complaint.

If this is external

The
and

disorder,like anaemia, etc.,the outlook

uterine

diseases,varicose

veins, etc.,are

prognosis varies

avoidable, or
is

more

to blame.

if it is

favorable

than

Hereditary

always difficult of cure.

prognosisis also influenced by the localityof the complaint. Eczema
relapses
in
more
frequentlyon the hand than in any other situation,and it is very hard to cure
into mucous
It is also more
membrane.
those placeswhere the epidermis merges
tedious
when
seated on hairy parts. It is always well to be careful about
predictingits periodof
duration, but, in the great majority of cases, it can be permanently cured
is

eczema

The

TREATMENT.

Every
ever

of

case

observed

the

eczema

can

be

cured

ill result
slightest

1.

As

in

be

INTERNAL

injury to the general health, nor

removing the malady.

have

we

REMEDIES.

tional
constitumembrane, all co-existing
treatingany case of catarrh of the mucous
be taken
into consideration, so also must
and organic affections must
alone
managed. When, however, no such complicationsexist,local measures

disorders
eczema

without

from

will be sufficient.

"

182

ECZEMA.

In acute
mild

In

chronic

and

yet

internal treatment, apart from

eczema,

coolingdraughts and

occasional

an

purgative,is inapplicable.

to be

discovered.

infiltration.
external

carb.

When

drinks

same

may

Little, however, is
there

and

be

may

decoctions, mercury,

said of

ergotine.

and

iodine

for
specific

trying in many chronic cases

its use
without
expected from

worth

be

be

to

chlorosis,iron

is

daily. In long-standingcases,
good service:

with

Tinct.

ferri pom.,

Tinct.

rhei. vin

the

One-half

The

has

extensive

5.0

20.0

ana

Aq. menth.
S.

less,
use-

administered.

Liq. kal. arsenic

are

eczema

accompanying
We
prefer
followingcompound of steel

be

must

6.-9.

arsenic has done

and

The

Arsenic

treatment.

pilul.ferri

demulcent

eczema,

injurious.

even

140.0

tablespoonfulevery

natural

day.

and

and
artificial chalybeate waters
the ferruginous pyrophosphate
employed. For scrofulous subjects,cod-liver oil is indicated;where
bronchitis exists,phosphate of lime; gout requiresalkaline waters
(Vichy), etc. When
hemorrhoidal
troubles are
or
dyspepsia,constipation,
encountered, the usual remedies
be resorted to.
As to dyspepsia,I believe that it is very frequentlynot the cause,
may
but
the result of an
A well-regulated
extensive
and invigoratingdiet, from
eczema.
which
injuriousfats and acids are excluded, fresh air and moderate
exercise,are the main
for a cure.
As symptom-remedies, chloral hydrate and bromide
of potassium
requisites
be
the
which
is
often
employed
against
itching,
only aggravated by morphine and
may
in
of
the
of
tincture
use
opium. My experience
gelsemium, as recommended
by Bulkley,
has been insufficient to enable me
to pronounce
has proupon it; carbolic acid internally
duced
results in our
no
practice.

also be

springs may

2.
In
must

the local treatment

first of all

of

1.

Is the

disease acute

2.

What

stage is it in ?

When
modes

or

been

have

as

to the

chronic

the
effective,

physician

usually be perceived that quite

for in the respective
are
situations,since we must now
merely combating the symptoms.

they

of treatment

with

answered,

the

of this

management

applicationsmust
stage, and

then

it will

called

(a)
In

is by far the more

followingquestions:

which

eczema,

satisfyhimself

KEMEDIES.

LOCAL

be

different
be

tented
con-

Eczema.

Acute

form, the principalrule

carefullyavoided

until

first be

the

to

be observed

disease has

tating
is, that all irri-

entered

carefullytested upon

the chronic

small

a
portion
previouslyproved beneficial will
sometimes
entirelyfail us in preciselysimilar cases.
Rayer says that the best way of
is just as unassailable at the
dictum
which
is to let it alone
a
treatingacute eczema
presentday as when it was first uttered.
During the progress of a typicalcase, our duty
of injury to the skin,
is to alleviate the distressing
all causes
symptoms, and to remove
that is,to protectit against the pressure
and
friction of the clothingand the effects of

of the

even

their effects

affected surface.

The

same

should

which

means

have

"

heat.

With

naked

or

this view, the

wearing only

patient laboring under

light garment. Water is

universal
often

eczema

must

injurious,hence

lie in

bed

baths

and

184

ECZEMA.

adapts itself very nicelyto uneven

when
employed as a mask for the face

mull

This

useful

with

hairy parts,I

On

cotton.

applied thrice dailywith

In

in

use,

of

cases

some

moist

with

or

rag

acute

(1 100), or

is,therefore,
larly
particugenitals.

the

of moist eczema,
safety-pins
; in cases
places being each time wiped off
rax
stage, merely a watery solution of boof thymol (1 : 1,000),either of which
Later

sponge.

ointment

lead

in the

has

of the

course

in connection

to be mentioned

the

eczema,

the

small

on

afEected

hereafter
to the preparations

I resort

head

daily,the

of alumina

of acetate

(1 : 100),

the

several times

be renewed

or

is

behind

is fastened

mull

The

it must

surfaces, and
and

complaint

with chronic

eczema.

irritatingeffect,while

an

the

compound, is borne without inconvenience.

m, Sebi benzoinat., 70 (inwinter, 75); Adip. bsnzoinat., 15 (in winter, 10); Zinc,
oxydat. alb.,10.0; 01. amygd. dulc, 5.0.)
mild ointments
in three
When
are
indicated,to be rubbed
desquamation occurs,
times daily,such as vaseline,ungt. leniens,ungt. rosat., ungt. zinc. (zinc, oxydat.,1 :
the ungt. Wil1 : 50, and
especially
ungt. lenient.,20), ungt. plumb., ungt. bismuth.
soni (5 Benzoes
pulv.,5; Adip. suill.,IGO.O; digere,cola et adde Zinc, oxydat.,25.0,
ointment
M. F. ungt.). Tannin
ful.
(acid,tannic, 1 : ungt. lenient.,10) is also very usezinc salve, a

decidedlymilder

surfaces

Inflamed
the

desquamationdoes

be covered

may
not

cease

under

(b)
The

great

the
possible,

secret

of the
should

treatment

with

this treatment,
Chronic

therapeuticsof
be so managed

The

we

or

dusted
have

may

with

recourse

powder.

If

to tar.

Eczema.
chronic

the

not

as

majority of instances,however,
problem to be solved is threefold:
In

ointments

these

this

is

persistence. Whenever
pation.
keep
patientfrom his occuis impracticable.
eczema

the

to

crusts, scales,and indurations from the affected integument.

healing,if possible,of the moist surfaces.
3. To put an end to the remaining infiltration,
hypersemia,and desquamation.
of the crusts is accomplished : First,by the action of water, applied
removal
The
The
douches, vapor-baths,or ordinary immersion.
through comjyesses,
compresses,
fine linen, must
best made
of stripsof gauze
be changed frequently,otherwise
which
or
are
Hard
water
give rise to eczema.
ought not
they become very hot, and themselves
To

remove

To

effect

to be
or

the

1.

2.

used

"

has

been

the skin is irritable.

make

is best

distilled water

which

water

Ice

"

boiled.
water

or,

if this

Equal parts

is not
of

obtainable,rain-water,river-water,

Goulard's

is to be avoided, since
Wet

it last

as

to

need

may

be

salt is often

covered

bandages
longer (Hebra).
recommended
are
changing less often (Priesnitz),
hands, legs,and feet.
of the head,
Douches
are
applicableonly to eczema
ice to

lotion

common

with

even

eczema

in this

to it if

added

india-rubber

only in
and

added

to the

cloth, so

of the

scalp,

they

un.

are

necessary.
in their
parts,but are often very irritating
in
effects.
treatment, promoting,
play an important part
way
as
they do, the healing process, by dissolvingthe crusts and softening the epidermis.
There
are
patients,however, who cannot endure bathing, as it causes
very decided
many
the itching. Non-medicinal
baths
symptoms, especially
aggravation of the eczematous
If the water
is hard, holding saline substances
best suited to the majority of cases.
are
be boiled,and it will be well to add to it some
in solution,it must
mucilaginous substance.

Vapor-baths speedilysoften
Baths

taken

in the

the affected

usual

185-

ECZEMA.

as

bran

(fourpounds
alum,

springs,do
forms

more

of the

vulcanized

to

Baths
bath) or starch-flour.
sulphuret of potash,and
than good. Sulphur waters

salt,or

common

harm

combined

malady,
bandages, and

with

rubber

similar to that of water.

the

Like

medicated

with

the

natural

are

indicated

only

non-irritable,torpidcondition

glovesand

socks of the

benefit is not afforded

same

by

corrosive

"sool"

and

mate,
subli-

sulphur-

for inveterate

of the

skin.

material,have

The
effect

an

all rubber

garments, as they
great irritation.
Oils in general,cod-liver oil,and fats are better adapted than water to the loosening
suitable to hairy parts,on which
of the crusts.
The
first are
they are freely
especially
in
covered
and
which
stiff
and
with
then
with
are
j'ubbed
a
brush,
painter's
finally
poured
after
in
the
The
fats
smooth
same.
are
a woollen
surfaces)
applied
being
(for
rag dipped
thicklyspread on flannel or lint. They consist of pork -fat,mutton-suet, and the mild
off when
mentioned
ointments
under acute eczema.
Usually the crusts and scales come
the dressingsare removed.
When
this does not occur, as on hairy parts, and where the
to soap, especially
soft
abundant, we may have recourse
epidermal desquamation is more
which
dissolves
for
sensitive
the
skins,
Sarg'sliquidglycerin
epidermis
soap,
soap, or,
by its free alkali. The soft soap is rubbed on with the hand or a piece of flannel,until it
is washed
off with warm
water.
forms a lather,which
Spiritussaponato-kalinus(Hebra3)
is very useful, especi100.0; digerefiltra)
Saponis virid.,200.0; Spirit,rectificatiss.,
ally
{I},
hirsute parts,as its fluidity
enables it to penetratefurther between
the hairs.
It
on
is poured on a moistened
pieceof flannel and rubbed in. Scales and crusts are soaked in
this way for several days together,fattysubstances and soap being always used in alternation
in
the
callosities
which
often
but
hard
much
trouble
of the
not,
eczema
give
;
upon
cannot
remedies
act
since
the
diseased
All
and
the
usual
the
soles,
palms
parts.
upon
acetic
chemical
acid, hydrochloric acid, soft soap,
agents previouslyrecommended, as
friction with sand or pumice stone, scrapcaustic potash,as well as mechanical
measures,
ing
acid (Unna) which
with the sharp spoon,
etc., have been superseded by salicylic
the latter are
situated on the hand. Dr. Unna's.
the callosities. When
speedilyremoves
mull
the best applica(10-20
g
utta-perchaplaster
tion.
salicylated
per 1-5 qm.) forms
gram
from
After it has remained
four to eightdays, the hardened
moved
epidermis can be reis then substituted,either applied
ointment
along with it. A ten-per-cent salicylic
in at hourly intervals.
of bandages, or rubbed
by means
If the diseased surface has been
denuded, the second indication we have given that
has to be fulfilled in order that it may
be fitted for the
of healing the moist surface
ment
applicationof tar. In most cases, this is best accomplished by the use of diachylon ointIf these are too irritating,
mull.
the less energeticzinc-salve mull,
or lead ointment
very
are

apt to

cause

"

"

or

zinc

ointment,

may

be tried.

Lister's borax

ointment

will

be

found

serviceable

in

be insufficient,
cases.
some
they may be reinforced by washing with soft
the
manner
alreadydescribed.
Immediately after washing off the soap, the
soap, after
the diachylon ointment
When
cannot
coatingof diachylon ointment must be renewed.
Should

these

of tannin
(acid,tannic. 1 : ungt.
frequently on the face, inunctions
effectual.
Where
substances
not tolerated,the
are
fatty
speedily
prove
with Goulard's lotion,or with acetate of
affected surfaces may
be dried by bathing them
alumina
generallybe changed into the
(1 : 200 aqua). In these ways moist eczema
may
to
when
the
third
will
remain
be satisfied,
form,
requirement
by removing the
squamous
The
latter
often disappearsspontaneously,or by the use
hypersemia and desquamation.
of mild remedies, like W^ilson's zinc ointment.
This, however, is not generally the case.
then be resorted to, foremost
which ^istar
an.
Stimulating applicationsmust
among

.be employed,
lenient.

as

10) will

"

186

ECZEMA.

agent quite indispensablein

as
a purely external
remedy,
as

in

discoverable

are

follows

the treatment

be classed

readilypass into the circulation,and

for medicinal
from
various sources,
use

It is obtained

2.

empyreumaticum
liquidas. oleum
frequentlyemployed by us.
Oleum
fagi,beech-tar.

3.

Oleum

4.

Oleum

1.

Tar, however, cannot

eczema.

its volatile elements

as

urine.

the

of

coniferum

Pix

pine-tar. This, produced

in

Finland, is most

use

on

Juniperus oxycedrus.

cadinum, from
cadinum

is thinner

and

uncovered

parts,but

has

Oleum
for

rusci,birch-tar.
than

clearer
a

very

the

strong odor.

of

other kinds, and

Tar

ought

never

In

some

.hence preferable
to be

employed

individuals

impetiginous
always followed by dark urine,fever,rigors,headache, vomiting,and
ment,
Oftentimes, this idiosyncrasyis only manifested at the beginning of the treatof acute, of moist,

in the treatment

its administration
diarrhea.

which
consequence
either pure

or

eczema.

few

is

afterwards

may

is

or

an

be

continued

exceedinglypainful

diluted

with

alcohol

without
and

inconvenience.

obstinate

(pic.liq.1

Another

eruption of acne.
spir.1). In order to

troublesome
Tar

is

applied

assist it in trating,
pene01.
(Ijc. ruse. Spirit,

with ether
scalp,it is also combined
aether.,ana ; Hebra). Another
gentle mode of employing it is
very agreeable and more
best with fattysubstances
ointment.
Tar mixes
after having been
of an
in the form
alkaline soap (soap-boilers'
sulting
boiled with equal parts of common
soap) ; so long as the reit
in
to
continues
This
unites
soft,
corresponds
Ungt.
pic.liq.
compound
any
The tar
with fat, diachylon ointment, or zinc ointment, 1 : 1-20.
desirable proportion
of tar are laid on in thin layers
is rubbed in with the hand ; the tar and spirits
ointment
surfaces from
In order to prevent apposed cutaneous
with a stiffbrush.
adhering,they
of tar. Tar often produces such
are
powdered with starch flour after applying the spirits
surfaces which have healed, as to bring back their former condition
on
effect,even
an
irritating
with
In these cases, the applicationis to be combined
and exudation.
of redness
with the latter and spread on
that of diachylon ointment, the former being either mixed
mull being applied after
ointment
lead
ointment
of
in the form
or
ointment, or diachylon
and
of tar indicated,
Tar
ointments
of tar.
are
contra-indicated,
spirits
paintingwith spirits
In the first-named situation,
in eczema
of the beard, of the hair of the pubes, and on the hands.
often give rise to sycosisor eczema
the former
impetiginosum, while they are well
indicated
where the skin is brittle and disposed
are
tolerated on the scalp. Tar ointments
for

instance, to

the

such as are met with in children, the tar-soap now

of eczema,
chap. In mild cases
into
has
often
a very
use
good effect. The employment of tar must frequentlybe
coming
the
desquamation and redness disappear. A very favorable
perseveredin for weeks before
result of its action is a lesseningof the troublesome
itching.
accessory
hard places
More
energeticremedies are required for those isolated,circumscribed
with soap (Ungt. pic.liq..Sap.
soften.
The
latter may be combined
tar cannot
which
virid.,ana),or with carbolic acid (Spir.pic.liq.,50; Acid carb., 1). Excellent results are
also obtained
by rubbing with soft soap twice daily,washing it off every day in a bath.
effectual againstthese obstinate indurations
are
Still more
naphthol ointment, pyrogallio
the chrysarobinointment
acid ointment, and especially
(1 : 10 to 1 : 50 vas.). It is well to
begin with a two-per-cent chrysarobin ointment, carrying its strengthup graduallyto
the skin becomes
with a paint-brush. As soon
The applicationis made
as
ten per cent.
after the
be discontinued, and
must
reddened
inflamed, the chrysarobin ointment
or
be
of
the infilit
borne.
The
will
well
few
of
disappearance
generally
rapid
days
lapse a

to

187

ECZEMA.

The patientshould
quitemarvellous.
into
his
chrysarobin
againstgetting any
always be warned
eyes while bathing,
and painfulconjunctivitis.
since this substance produces a very severe
Ehagades are healed most speedilyby soft soap, which is painted into them twice a
be employed, tannin ointment, 1 : 10, or friction with
tar cannot
where
day. In cases
carbolized oil, 1 : 30, or white precipitate
ointment, 1 : 10, or yellow precipitate
ment,
oint1 : 10, will often promote healing; though I avoid as far as possiblethe use
of
2
recommends
solution
a
or
mercurial
1,
of naph^-per-cent
preparations. Oaposi
This agent is very serviceable in individual
thol in alcohol and water.
cases, espe_
surfaces
under
are
capitis. When
large cutaneous
ment,
treatciallyof E. squamosum
"tration from

the

of

use

isoften

ointment
chrysarobin

of the

it must,

however,

be

with

used

caution, the

urine

the

at

same

time

being

this becomes
As soon
be stopped. The
as
black, the naphthol must
carefullywatched.
violent itching is greatlyrelieved by bathing the parts with vinegar,or by ointments
of
chloral and
of
of
Ac.
or
camphor (1:8
carbo-glycerin(Bulkley),IjL
fat)
carboL, ] ;
to
Ungt. glycer.,50, which the patient rubs on while in the bath.
Against the eczema
which
emulsion
antisepticsurgicaldressingssometimes give rise,frictions with salicylic
(I^ Ac. salic. cryst.,10; Aqua destillata,50) have been highly recommended
(JSTussbaum).
in generalhaving now
The
been considered,we proceed to a
therapeuticsof eczema
few

remarks

of its localized ^manifestations.

the treatment

on

1.

constitute
pediculi

When
about

50

covered

of

grm.

with

petroleum

of ointment

OF

THE

originalcause
first to

are

cloth for

woollen

ECZEMA

the

be

SCALP.

of

eczema

rubbed

twenty-fourhours.

or

into
After

generated in its course,

are

the

scalp,which

this the crusts

are

is then
removed

kept
by

of soap, as alreadydescribed.
If moist surfaces now
spirits
remain,
they are treated with zinc or diachylon ointment (preparedwith olive oil,not with vaseline)
is washed
which
off with spiritsof soap.
Vaseline
ointments
not to be used
are
them
from
the
upon the head, as they do not saponify,and it is very difficult to remove
means

and

hair.
As
rusci

soon

the

as

exudation

has

ceased, tar is

of

to be

appliedin the form of

Ungt. popuL, 5). Should

tinctura

tar-pomade (Ungt.
these be
acid pomade, 1 : 10, is indicated.
ineffectual,pyrogallic
When
the redness disappears,
some
degree of desquamation frequently continues, which is completely removed
by
washing the scalpdailywith a 5-per-centalcoholic solution of chloral hydrate. Female
patientsshould not have their hair cut, but should be informed that a good many diseased
Jiairs will fall out during the progress of the cure.
as

above,

or

pic. liq.,1 ;

2.

The

crusts

lead ointment

dissolved

are

Moist

mull.

by wearing a

surfaces

accuratelyapplied. Afterwards,
alreadyreferred to. The disease
merges

into

mucous

we

-the

lead ointment

daytime, has

an

are

FACIEI.

mask

lined with

healed in the

have

same

to

recourse

is very diflficultof

cure

diachylonointment, or
The

way.

tar,

or

to

one

masks

with

be very
of its substitutes
must

in situations where

the

mis
epider-

membrane.

(a)
Here

ECZEMA

mull,

Eczema

applied

excellent

at

of

the

Eyelids.

night to both

eyes at once,

effect,especiallyif the ocular

and

to alternate eyes in

catarrh

is removed

by

188

ECZEMA.

solution of salicylate
of
a
instilling
:]^-per-cent
the
which
after
edges of the lids
by epilation,
(1 : 50 vaseline).
precipitate

(yS)Eczema
First

of all,the

every

nitrate of silver.

(zinc,
sulph.,1 ;
the

nasal

days,

two

The

crusts

which

dissolved

are

the

lashes

ointment

an

is treated
of

yellow

Lip.

upper

present must be cured by injections,

insufflator,of a one-per-cent solution of

by tampons

introduced

glycer.,100),and

and

the

is sometimes

Eichardson's

Sycosis of

paintedwith

are

the Nostrils

of

catarrh

with

lead.

of cotton,

dipped

into the nostrils.

Unna

in

zinc-glycerin

recommends

for

of

drainage-canulas,
wrapped around with lead ointment mull.
As soon
the crusts are
as
softened, they are painted every second day with the yellow
ointment.
The sycosis-like
of the upper
eczema
precipitate
lipis treated,until the pustules
to appear, by painting them
cease
dailywith an alcoholic solution of pyrogallic
acid (1:100), followed
by the applicationof sulphur-paste{^, Lact. sulph..Spirit.,
ana
20), twice a day, with a small sponge.
Aqua destillata,
same

purpose,

use

{y)
When

and

chaps

fissures

Eczema

the

of

Lips.

exist in this situation,the

first covered

lips are

with

zinc

of lead ointment
is not advisable on
account
of its poisonous qualities.
; the use
fissures
obstinate
with
twice
soft
As soon
the
are
a
as
painted
Very
day
soap.
if
diluted
tar
5
to
10
this should
fissures are
healed,
irritate,simply
(1 :
spirit),
or,

salve mull

to the
alcohol,is applied in the same
first-proof
way
inunction
with
lip-salve(ceratum cetacei rubrum)
when
caused by cold.
eczema
3.

The
tannin
tar

affected
ointment

OF

ECZEMA

so

as

portion of

it continues

afterwards

the

lips. Frequent
cure

of labial

CANAL.

moist,

with

the

suffice for

AUDITOEY

EXTEENAL

long
and
vaseline),

membrane,

(1 : 10

THE

red
will

the

is to

diluted

be

painted over

alcoholic

with

solution

of

(1 : 10).
4.

ECZEMA

MAMMiE.

Borax ointment, preparedby Lister's method

(I^Acid. boric, subtil, pulver.,1; CeraB'
albae,1; Paraffin.,2; 01. amygd., 2), is an excellent remedy for fissured nipplesof nursing
The
women.
off,after nursing, with borax water (1 : 25) and then
nipple is washed
covered

with

partswith

an

borax

ointment

alcoholic

spread on

solution

of

gauze.

When

nursing

tar, together with

the

use

has

ceased, painting the

of borax

ointment, will

If not, more
stimulatingapplicationsshould be employed,
generallyprove effectual.
poulticesof soft soap, or paintingwith chrysarobin(1 : 10 vaseline)(Hebra recommends
frictions with a solution of caustic potash [kalicaust. 1 : aqua 2] ).
5.

So

ECZEMA

OF

THE

GEISTITALS

AND

as

ANUS.

inflamed, it is best treated with

long as the eruption is very moist and much
lead-ointment
of
diachylon ointment, or a dressing
mull, held in place,in men,
by a
and
in women
the exudation
has
as
bandage,
by a T-bandage. As soon
suspensory
is preferableto that of tar, on account
ceased, the cautious use of chrysarobinointment
of its speedier operationwhere
be
pronounced infiltration exists. The ointment
may
heat or
graduallyincreased in strength(1 : 10). If this treatment
gives rise to much
must
be discontinued
for a few days,during which
the affected
redness, the ointment

189

ECZEMA.

the inflammatory symptoms have

powdered with starch flour. When
peared.
subsided, the ointment is again resorted to, until the thickening of the skin has disapof tar.
In
The last vestigesof the complaint are completely removed
by spirits
is often extremely rapid.
the improvement from chrysarobin
of the anus,
eczema
If the chrysarobinointment
is not well borne, we
employ, after the exuding
may
creased
which
tar
ointment
of
surfaces have healed, an
diachylon (1 : 20),
may be gradually ineffect
this
of
this has taken
eczema
in strengthto 1 : 2.
When
variety
(since
be powoften proceeds from the decomposition of sweat),the folds of the skin should
dered,
acid (I^Acid, salic, 1.0 ; AmyL, 89.0 ; Talc,
for a stilllonger time, with salicylic
of a suspensory
bandage. Against the
10.0). This must
always be retained by means
three times in succession,for a
the application,
intolerable itching,Bulkley recommends
at a time, on going to bed, of compresses
minute
dipped in water as hot as can be borne.
followed
of females, but only when
This procedure is very serviceable in the case
by the
be

parts should

use

of

diachylon ointment,
6.

Vesicular

or

OF

ECZEMA

of the

eczema

of

ointment.

other mild

some

HANDS

THE

AND

toes, fingers,
instep,and

spiritsof tar and

FEET.

back

lead ointment

of the

hand

is,as

rule,

unfortunately,however,
rhagades,is also soon
in
form
the
this
treatment.
It is
of
complaint that Unna's leadbe applied.
with which
it can
ointment
mull is of the greatestservice,owing to the ease
India-rubber
constantlyand cleansed every night and morning, soon
gloves,also,worn
Yet
I have never
known
a
case
bring about considerable improvement in dry eczema.
either
to be completely cured
of
these
the
alone
of constitutional eczema
means
by
;
plication
apother stimulatingagent is always necessary.
of tar or some
sole of the
the palm of the hand
foot are
removed
Indurations
or
on
by salicylic
ointment
or
acid, togetherwith inunctions of pyrogallic-acid
chrysarobinointment (each
of the palm is
1 : 10) ; these are
more
speedilyeffectual than tar. Superficialeczema
Carlsbad
the
latter
removable
of
rubbed
the
means
Sprudel-soap,
by
frequently
upon
hand at bed-time, and left on all night.
attacks the nails,they should
be scraped as thin as possiblewith a
When
eczema
pieceof glass,and spiritsof tar appliedbeneath them and within the ungual furrow.
must
Proliferations in the latter locality
be destroyedwith nitrate of silver. Poulticing
the nails with soft soap often has a very good effect. This
is done by cutting off the
half
india-rubber
full
of
of
them
an
over
glove,filling
fingers
soap, and drawing them
speedilycured

by

it is very likelyto
relieved by the same

the

use

relapse. Dry

eczema,

with

ECZEMA

OF

the

formation

of

the affected members.

7.
To
use

with

Dr.

H.

A. Martin, of Boston,

of the elastic rubber

The

LEG.

belongs the great merit

in the

it is

so

With them
others for this purpose.
foot is enveloped,beginning at the
the patient's
to any

of

having introduced the

eczema
leg,and of the ulcers
long-standing
cases, the patientis not

of

treatment

bandage
in
Even
frequentlyassociated.
from his occupationfor a singleday.
remarkably strong, yet soft bandages devised by

which

detained

THE

"

in the
toes.

of the

Dr.

Martin

morning
The

himself

before

binder

he

is taken

are

able
prefer-

has risen

"

off in the

evening,disinfected with carbolized water (two per cent),or with thymol water (one
per cent),and dried during the night. The exuding surface is covered in the evening
mull ; the dry placesare .lightly
with lead ointment
smeared
with fat.
If the apover

190

IMPETIGK).

plianceis unendurable,

the disease must

be

treated

according to

the

general

methods

already described.
IMPETIGO.

It would
perhaps be better to exclude this term altogetherfrom the list of cutaneous,
but it is stillused to designate two
diseases,
complaints impetigo contagiosa (Tilbury
Tox), and impetigo herpetiformis(Hebra).
"

Impetigo Gontagiosa {Tilbury Fox)

1.

Our

mention

s.

Parasitaria

(Caposi).

of this disease in the

present connection, and not as one of the mycoses,

is Justified
It appears
by the fact that its parasitical
origin is still undetermined.
most
the face, vertex, occiput,and back of the
on
frequentlyin children, and especially
hands, under the form of vesicles,from the size of a pin's head to that of a lentil,
whose bases are usuallynot inflamed, and which very soon
crusts
dry into gummy
pearing
apif
as
glued on.
These, on fallingoff,leave a smooth surface,free from scales. There is no pain or
itching. The affection is diffused by scrat'ching.
According to Caposi,the eruption is
followed
by great swellingof the submaxillary glands. The complaint often attacks
several children in the same
family and is said to be contagious. Caposi has discovered
the epidermis of the vesicle,but which is always derived from without.
a fungus beneath
Geber and Lang have also found
inclined to identifythis disease with
are
a fungus and
tonsurans
vesiculosus.
unable to detect these organisms.
herpes
Taylor and TTnna were
disease usuallydisappearsspontaneously in from
Its cure
The
is
two to six weeks.
hastened by zinc and white-precipitate
ointments.

2.

Impetigo Herpetiformis{Hebra),s. Herpes Vegetans {Auspitz),s. Herpes Pycemicus

{Neumann).
Only

nine

cases

of this disease have

thus

far been

observed

"

all of them

in

pregnant

Six out of eight resulted fatally.Hebra

commencing in the final months.
givesthe followingoutline of symptoms
filled with a yellow purulent
Eruption of pustules,arranged in groups or circularly,
which
a
red, excoriated, non-ulcerated
liquid,and drying into yellow flat scabs, under
surface is perceptible,
and which are surrounded
by a succession of new clusters and rings
of pustules.
the anterior surface of the
The pustuleswere
on
always largestand most numerous
body and the inside of the thigh,but were also observed on the upper extremities,throat,
women,

and

affected
four months, the disease had
In three or
nape of the neck, back, and face.
almost the entire surface,which
was
swollen, hot, covered with crusts, and fissured and
brane
memby pustules. The mucous
in
the
showed, in one
gray patches,depressed
case,
the
and
succumbed
Each crop of pustuleswas
centre.
patientsfinally
precededby rigors,
to exhaustion.
The etiologyof the disease is still quiteobscure.
the
such
as
Treatment, according to Caposi,consists in antiphlogisticmeasures,
continuous
soda
baths,
and
or
followed
of
cold
simple
by
application amylum
wrappings,
besides the use of means
tar dressings,
simple ointments, carbolized and plaster-of-Paris
to
control the fever and the other constitutional symptoms.
adapted

excoriated

in

placesthat

of the tongue

were

here and

there encircled

circumscribed

192

LUPUS

the disease attacks

case,

them

the cheeks

peculiarappearance,

and

EKYTHEMAT0SU8.

nose

compared by

exclusivelyand symmetrically,it imparts to

to that of a butterfly
with
outspread

Hebra

wings.
When
In the
the

hirsute

rare

parts are

afEected,the hairs fall off,owing

to

atrophy

of their follicles.

of spontaneous recovery from the discoid form

of lupus erythematosus,
and
and
of the eruption become
flat,
a shining,
pale
superficial,
atrophied

cases

borders

More deeplyspot remains behind, usuallywhite, and resembling the scar left by a burn.
the auricle and
reaching cicatricial infiltrations are not infrequentlyfound, especially
on
the

nose.

Aside

from

the

deformity,lupus erythematosus discoides generallyentails no bad

patient'sconstitution usuallyremains unaffected, and suppuration and
ulceration never
take place.
Much
more
malignant is that form of the disease entitled by Oaposi lupus erythematosus
disseminatus
s.
aggregatus. In this,the primary eruption is far more
widely
Its extension
takes place through the repeated outbreak
diffused.
of the disease in new
localities. The blotches thus produced never
after remaining for months,
coalesce,even
the
on
but,
contrary, may
spontaneouslyretrogress. Caposi and others have observed
the
not
this form
face,head, fingers,and toes, but also on the auricle,in the
only on
meatus
auditorius,on the trunk, upper extremities,palm and back of the hand, and, in
It generallyspreads by degrees. Occathe entire surface.
sionally,
rare
cases, dispersedover
acute
character.
an
however, the complaint assumes
Caposi describes this
The

results.

form

as
"

follows:'

The

acute

in the form
gradually,sometimes
process extends sometimes
nocturnal
associated
with
eruption,
osteocopicpains, exudation

morbid

febrile

of

an

in the

In one
series of cases, a severe
bling
swelling arose, resemjoints,and nocturnal headache.
confined
which, however, was
entirelyto the face. With this,there
erysipelas,
40" C, coma,
above
were
a typhoid condition, a temperature
sopor, and a dry, leathery
resulted
above
with
the
Half
the
cases
Along
fatally.
symptoms, in several
tongue.
of
noticed
at
the
skin
hundred
flat vesicles, connumerous
we
instances,
taining
points
many
in
either blood or a limpid fluid,such as are
these
seen
herpes iris;
immediately
them
the centrallydepressedformations
dried into crusts, leavingbehind
characteristic
of lupus erythematosus.
acute
*'Such
eruptions are almost peculiarto lupus erythematosus disseminatus.
with the discoid variety,but then this occur,
found in connection
but
are
rarely
They
also in the form of disseminated
patches."
such acute
Caesar Boeck," who has observed two
cases, gives a very precise picture
in the beginning the
unable
to detect
of the development of the eruption. He
was
of the spots. This
trace of a depressionor of a follicular opening in the centre
slightest
phenomenon only develops at a later stage of the complaint.
On mucous
membranes, lupus erythematosus has been observed on the lips,eyelids,
thus affected,are
covered
The
the hard palate,and cheek.
lips,when
very dry, and
sand.
found
the
of
fine
on
scales, resembling grains
Caposi
with exceedingly
grayish
bluish-white
cicatrized
beset
with
inside
of
the
cheeks
spots,
large patches
palate and
red or grayish excoriations,from mere
and with superficial
points to the size of a lentil.

Pathologie und Therapie der Hautkrankheiten," Wien,

CapoBi :
disseminatus."
Lupus erythematosus
eigenthumliche Falle von
Laegevidenskaben, vol. i.,pp. 1-28, 1881.
'

Moritz

"

Zwei

"

1880, p. 609.
Norsk.

Magazin

for

PathologicalAnatomy.
palm

of the hand, where

"

ERYTHEMATOSUS.

Neumann's

recent

sebaceous

no

of Thin, Geber,

LUPUS

glands

Caposi,and

193

clinical observation

Vidal, have

of the disease in thie

the anatomical

exist,togetherwith

that

demonstrated

the

tigations
inves-

sebaceous, as

the sudoriparousglands,perform only a secondary part

that,
as
production,
in the corium
especiallyin the papillary
ordinarily,this morbid process commences
in the deeper cutaneous
cellular tissue) with
layersor in the subcutaneous
body (rarely
in

well

its

"

"

and

dilatation

the

the

blood-vessels,and

parts most liable

during the

to be attacked

cheeks,

ears,

and

are

of other

course

backs

those

vascular

network

Hence, also,it follows

rounding
sur-

that

subject to engorgement and vascular

the
and congelations),
as
(acne rosacea

most

disorders

of the

the

that

involved.

glands only subsequentlybecomes

dilatation
nose,

of the

engorgement

fingersand

toes.

The

vascular

dilatation

leads

aggregation of cells. An
of cells,with hypersecretionof fluid,takes place in the glands. At
increased formation
tissue and a soaking of the
formation
of connective
the same
time, we meet with a new
tissue fall next into a
connective
The
cells
the
tissue with serum.
and
newly-formed
and
cicatricial
the
state of fatty
hyaloiddegeneration;then occur
atrophy of the latter,
o
f
the shrivelling the glandular follicles it incloses,and the partialobliteration of bloodvessels,
which process the central depressionsuniformly depend.
on
The epidermis exhibits a splinterystate of the horny layer,with fattydegeneration
and consequent cloudiness of the rete, passingat last into a condition of atrophy.
dieease ; it is more
quent
freEtiology. Lupus erythematosus is a comparatively rare
than
males.
It
in
and
females
between
the
twentieth
tieth
forgeneral
among
appears
at an
earlier or
later period. Its etiology is stiD quite
years, only exceptionally
of the skin which
Diseases
associated with intense hyperemia are
obscure.
are
posing
predisIn one
influences.
of Caposi'scases, the malady proceeded from a nasal seborrhoea,
it to follow erysipelas;
after small-pox;we have known
Auspitz observed it as a result of acne
the eye and
In one
"rosacea.
instance, we saw it arise in the vicinityof leech-bites near
tuberculosis,
the site of a fly-blister
behind the ear.
It frequentlycoexists with scrofulosis,
on
It is
gout, and chlorosis,and patientsvery often have an anaemic appearance.
met with quite often in subjectsotherwise perfectlyhealthy.
with difficulty,
Diagnosis. The diagnosisof this affection is generallyunattended
yet it is possibleto confound it with the following:
directlyto

copious

cell-infiltration and

to

circumscribed

"

"

1.

Lupus

Vulgaris.

which firmlyadherent
red points,
Lupus erythematosus preventssmall, superficial
on
conical processes are produced. Lupus vulgarisbegins with an
eruption of
brownish
in
of
the
substance
the
cutis.
papulesdeep
Lupus erythematosus never
passes
into softening,
results in nodes, like lupus vulgaris.
suppuration,and ulceration,and never
is
confined
and
to the cutis
the subcutaneous
Lupus erythematosus
always
cellular tissue ; deeper-lyingstructures,as the cartilages,
affected.
are
never
scales with

2.

The

and

nose

cheeks

the wall, the central

while

vascular

the formation
13

are

localities common

cicatrix,and

dilatation is often
of

pustules and

Acne

the
more

nodules.

Rosacea.

to both complaints. On the other hand,

scales,are wanting in acne
firmly-adherent
rosacea,
prominent in that disease,and is accompanied by

194

LUPUS

3.

This

runs

much

4.

The

scales in this disease

surface.
is

send

They

forth

of

are
no

Tonsurans.

Herpes

rapid course
its fungi are

more

by vesicles,and

surrounded

ERYTHEMATOUS.

and

exhibits

central

no

cicatrix ; its

patches are-

demonstrable.
microscopically

Psoriasis.
their

silverylustre,and
the

between

processes

removal

exposes

the central

and
papillae,

ing
bleed-

cicatrix

wanting.
5.

Circular

8yphilide.

its outline is
lupus erythematosus disappearsunder
pressure, and
its
and
the
is
not
redness
removed
hibits
margin exsyphilide
by pressure,
The
a hard, shining infiltration.
wall of the syphilide,
when
closelyexamined, is
to
of
be
seen
composed
singleeruptiveformations.
According to Caposi,aggregated lupus erythematosus in its earliest stage resembles
eczema
herpes iris,
impetiginosum, squamosum,
herpes tonsurans, maculosus, and even
but is distinguished
from
all of these by its speedilyformed
central,cicatricial depression.
Prognosis. ^This is favorable, so far as life is concerned, especiallyin the discoid
with dangerous acute
form is frequentlyattended
variety,while the disseminated
tions
erupand malignant complications. Still,even
result fatally. Sponthese very seldom
taneous
gering
and complete recovery
is exceedinglyrare.
Lupus erythematosus is a very linbe
and
its
and
hence
obstinate
should
always
guarded,
prognosis
complaint,
The
to duration, although cures
as
are
especially
rapidly effected in individual cases.
It is usuallysucceeded
mations
to treatment.
by cicatricial foraggregated form is least amenable
which
frequentlygive rise to troublesome telangiectasias.
in curing lupus erythematosus by internal
Treatment.
not
We
have
succeeded
The

redness

continuous.

In

of

the

"

"

potassium, arsenic,and iodide of starch have all failed in our

to strengthen the patient's
general constitution as far as
of
Where
detect
we
possible.
scrofula,tuberculosis,gout, or chlorosis,treatment
signs
of these diatheses
should be adapted to meet
the indications thus presented. When
none
be
content
with prescribinggood air and the most invigoratingdiet.
exist,we must
A long listof
These considerations tend to increase the importance of local treatment.
remedies

hands.

alone.

Yet

Iodide

I would

of

endeavor

in this intractable affection,no

have been tried and recommended
applications
worked
has proved reliable in all cases.
A remedy that has previously
of
similar cases, and this is true even
to disappointus in precisely
admirably may come
the other
the most powerful caustics.
The cauterized places,indeed, heal over, but on
outward
one

of which

hand

the

disease

of the eschar.

and
reappears
We
possess no

itself wherever

extends

that will

reaction

on

occurs

prevent the return

the borders

of the exanthem,

remedy
curative
and
over
again. Those
consequentlycan only keep on destroyingit over
c
icatrices.
to
followed
to
be
measures
are
be preferredwhich
least apt
are
by disfiguring
The followingremedies
have been of most service in our
hospitalpractice.
When
the patches of lupus erythematosus are small and circumscribed, the iodide of
(ata strengthof 1 : 5 to 15 ointment) has been productiveof excellent results. After
mercury
adherent
the affected spots have been
fat and
cleansed
from
scales,they are thickly
and

coated

with

the ointment

until the formation

by

means

of

of vesicles filled with

"weeks,though sometimes

at

later

brush.

cameFs-hair
pus,

period.

which
Then

This

usuallyoccurs
what

is allowed
in

the

course

is left of the ointment

to remain

of six
is

care-

"

fullyremoved,
In

the vesicles suffered to

and

this

cases

some

has
application

In

of the affected surface.

this

195

ERYTHEMATOUS.

LUPUS

we

way,

to be

finallyto
repeated on
frequently

have

effected many

dry

into crusts and

fall off
at least

rapid cures,

spontaneously.
a portion

without

ing
leav-

scars.

of
in the treatment
to be recommended
energeticagent, and one especially
its
account
of
valuable
This
is
on
lupus erythematosus corneus, is chloracetic acid.
is confined within
but little pain and
rapid yet not too penetratingaction, which causes
it excites in the
the slightdegree of inflammation
limits of the application,
the exact
to most
It
is
cicatrix.
of
the
decidedlypreferable
the
smoothness
a
nd
resulting
vicinity,
A

other

more

It is laid

acids.

on

with

glassrod

and

speedilyforms

white

eschar ; into this is

in the acid.

pointed glassrod dipped

larger surfaces are to be acted upon, we preferthe use of pyrogallicacid.
This is appliedin the form of an ointment
(1 : 10 vaseline)which is spread upon linen,or
acid pro 1-5 qm.), and is
in that of Unna's
gutta-perchaplastermull (15 gm. pyrogallic
brownish
until
it
has
eschar, which
a
three
four
for
superficial
or
produced
kept on
days,
it
until
undisturbed
left
and
is covered
with an iodoform
sloughs off. The
bandage
iodoform
with
dressed
iodoform
and
diseased parts are
gauze.
powdered thickly with
also
useful on small patches,
Iodoform
gutta-perchaplastermull, 10 gm. pro 1-5 qm., is
extensive
but not on
discharge.
more
surfaces,since it does not absorb the abundant
tive
not only prevents reaction in the neighborhood, but has also a decidedlycuraIodoform

bored

When

effect
The

on

the

lupus erythematosus.

result of this combined

treatment

is often surprising.
have

to the

curette, which

always
but should relyupon the deeper-reaclfcng
operationof pricking,
speedy relapses,
This is done with a sharp lancet,or, more
recommended
as
rapidly,
by Volkmann.
with an instrument
set
formed
of six lancets
as
proposed by my brother. Dr. E. Veiel,''
and
The
of
hundreds
skin
is
thousands
piercedby
closelytogether.
punctures arrayed as
if hacked
in pieces,
in
manifold
that
it
looks
lines,so
as
intersecting
densely as possible
hue.
The
of
the
difficult
knife is far more
in cases
of
and has a peculiarpale,livid
use
lupus erythematosus than in lupus vulgaris. After arrestingthe flow of blood by pressure
with
As a rule,
antisepticsponges, an applicationof iodoform powder is made.
the pricking has to be frequently repeated in order to obtain
Small
a
complete cure.
be anesthetized
surfaces may
by the use of Kichardson^s ether vaporizer; on larger ones,
be employed.
must
The
lineaires quadrilUes introduced
chloroform
scarifications
by
also
when
combined
with
the
Yidal
are
applicationof iodoform.
very effectual,
This process consists in making, with a double-edged knife, resembling a cataractincisions as close to one
another as possible,
but not quite peneneedle, several parallel
trating
the cutis; these are
at right angles,so that the entire
crossed by similar ones
surface appears
if traversed by deep furrows.
as
Caposi testifies to very favorable results from the employment of the gray emplastrum
hydrargyri,which, however, must be kept applied for a long time; according to
it
is of specialservice in the aggregated form
of the complaint. He has likewise
him,
effected numerous
cures
by frictions with spiritussaponato-kalinus. After the use of
this remedy, Neumann
the skin with white precipitateointment
covers
(1 : 8). When
When

givesrise

these

measures

fail,we

should

not

recourse

to

'

'

'

"

Archiv

klinischer

Sammlung

"On

fvir

Dermatologie

Lupus."

Gaz.

des

Vortrage," No.
und

13.

Syphilis, p. 278, 1873.

hopitaux, 22, 27, 33, 35, 1879.

196

time

ERYTHEMATOUS.

LUPUS

permits,

recommended

days

in

trial

by
succession,

sublimate

offering

proposed
an

opinion.

of

Caposi

this

until

by

the

brown

same

starch-flour

eschar
writer

As

advisable.

is

remedy

(naphth.

is
and

100,

formed),
by

Boeck,

the

to

merits

applied
or

of

as

the

experience

of

the

paste

naphthol
daily,

collodion
does

of
not

paste
for

three

mercurial

justify

us

in

INFLAMMATIONS

DEEP-SPREADING

DEEP-SPEEADING

ACUTE

A.

OF

THE

SKIN.

INFLAMMATIONS

BY

E.

PEOF.
IN

GEBEE,

KLAUSENBERG.

ERYSIPELAS.

Eetsipelas
I)Ook

the

the

will

remind

Greeks,

accurate

have

the

are

inasmuch

examination,
effect

and

point merely

in

even

Among

valuable

and
are

thin

tract,
will

acrid, spoiled,

or

the

or

the

that

us

the

who

On

the

retained

so

developing
in

verum

from

an

In

violent
it

of
other
much

from

as

deposit

dross,
hand,
of

tradition

to

E.

which

of

we

are

that

regard

suppressed

apostasis

"

digested

are

may

upon

"

can

the

and

of

surface,

any

which

tive
objecand

of
the

the

I will

gastric
of

the

bile, the
intestinal

difficulty, and

the

like

erroneous

ception
con-

fluxes, disturbed

mucous

scarcely

with

producers

functions

dispelled

as

bloody

Nor

begins
as

secretion

with

of
cause

conclusions,

often

the

entious
consci-

to

results

confound

regarded

the

which

by

Nevertheless,

the

false

disturbed

with

views,

they testify

always

disease

the

interference

excitement.

materia

there

of

result

general infection,

opposition
injury.

the
food

manner,

mental

that

assuming

of

like

is the

disease

and

regards

excretion

articles

erysipelas.

perspiration,

from

humors,

warm

of

ingestion

produce

far

are

we

manner,

expressed

centuries.

points,

To-day

erysipelas.

been

as

number
the

concise

hand-

connection

doctrinal

much
not

formerly

were

in

had

subsequent

the

natural

standpoint.

essential

Because

these

producing

conditions

of

of this

part

its

define,

acceptable,

standpoints

illustration.

following

the

to

the

symptoms,

their

another
of

to

very
or

predecessors,

our

another.

one

many

writers

they often,

as

with

like

the

of

on

purpose

correct

the

by

our

in

account

dermatological

that
be

to

and

is

the

from

sick-bed,

the

at

It

start

descriptions

observation

consideration

again presented,

proven

Arabians,

detailed

skin.

the

at

you

Latins,

as

the

of

erysipelas

of

investigations

modern
old

doctrine

present
I

ajffections

other

is

subject

The

(Vol. II.).

with

received

already

has

one

be

found

Nature

among
for

employs

peccans.
a

number

they
and

of

prominent

assume

place

chirurg., traumaticum,

clinicians

autochthonous,

an

this

medical

as

E.

spurium,

spontaneum,
or

nothum,

medical

who

have

erysipelas,

idiopathicum,
which

or

originates

198

ERYSIPELAS.

But

since

impetus has been given to the observation of the local conditions in

of erysipelas^
outbreak
the proofs are increasingthat the disease requiresa point of
every
and that thence it obtains its
entrance, which has been produced in a traumatic
manner,
in this direction
further spread; and that when
of results,
barren
investigation
proves
to the lesion remaining concealed
this is due to a slightinjury erosion
unnoticed.
or
of
My observations render such conclusions very probable. Among the 72 cases
8
erysipelaswhich occurred in this clinic, occurred during their stay in the hospital,
after buboes
and ulcera cruris, varices, and specifica;64 developed outside.
Among
these the starting-point
of the disease in a local affection could be demonstrated
51 times
decision could be reached, as the injuriesof the skin and
with certainty;6 times no
and in 5 cases
caries of the teeth did not coincide in point of time with the erysipelas,
no
be
could
offered.
explanation
of erysipelas
for the assumpno
Furthermore, as I find in the course
plausiblereason
tion
of two independent forms, I, for my part, do not hesitate to recognizebut one
ety,
variwhich is due to a solution of continuityas an excitingcause, i. e., traumatic
elas.
erysipof the internal
Whether, however, there is not a spontaneous idiopathicerysipelas
in
first
the
which
with
to
sense
Hippocrates
expressed
regard
wandering pneuorgi:.,ns,
monia,
and has since been described by Virchow, Friedreich, and others, I am
to
unable
an

"

determine

of the lack of suitable material.

account

on

Accordingly,I

mean

intoxication,and
serous
as

"

on

by
the

infiltration of the

the result

the
other

term

erysipelasof the skin a, on the

acute
progressinginflammation

hand,

tissues,associated

of local infectious action ; after

constantlyin a restitutio ad integrum.

febrile movement,

desquamation

of the

hand, general

with
and

epidermis

predominant
produced

this terminates

Its first symptoms : tired feelingin the limbs, anorexia,

pricking pain in the affected part, are manifested either before or
of the erysipelas,
and the disturbances
the part of the general
with the appearance
on
those
of the lesion may
either to an
condition
and
occur
equal extent, or those of
the
other.
the one
those
of
Usually, however, the patient
predominate over
may
conscious
of the significance
of his condition
when, in addition to the
only becomes
unpleasantlocal sensations,he is attacked by a chill. There is no objectionto regarding
these processes
the attack is indeed introduced
as
a prodromal stage,as
by them.
undoubted
those
which
of
mia
toxaeThe
make
their
are
an
now
symptoms
appearance
first
affected.
The
is
and of an inflammatory irritation in the
manifested
by
part
the relatively
high fever, which is out of proportionto the local affection,by the gastric
symptoms, coated tongue, anorexia, pain in the stomach, nausea, vomiting,constipation,
cinations,
halluor
diarrhoea,by irritation of the cerebro-spinal
system, headache, delirium, coma,
of the circulatory,
the possiblyassociated disturbances
tremor, and
tory,
respiraand
other organs.
With
regard to the affection of the skin, we notice a rosy to
of the finger,and
has either
"blood-red spot, which
the pressure
pale under
grows
from
uniform
it
either
defined
borders
starts
a trifling
excoriation,an
zigzag or
sharply
;
insignificant
pustule,or from a part which has healed, and in not very rare cases, from
from an inflammatory focus, may simulate a spona spot which, in view of its remoteness
taneous
development.
ing,
swellThe erysipelatous
patch is characterized by its strikingsensitiveness,serous
tension of the skin, shining exterior,and the tendency to superficial
spread.
in
If the transudation
occurs
swelling becomes
large amount, the cedematous
distinctly.This
greater,and the elevations and depressionsof the skin appear more

Symptoms

Course.

with

one

and

headache, burning

or

"

200

ERYSIPELAS.

known

any

It cannot

The

course.

and

cause,
be

like manner,

the reappearance

predictedat the
'mildest

start what

of

form

chill furnishes

the

signalof further trouble.

will assume
in its subsequent
erysipelas
In
by the mosl severe, and vice versa.

the

grades are often followed

generallyunable to predictthe

direction in which
the erysipelas
will
spread. As the observations at the sick-bed teach, however, a certain regularityappears:
to be imposed upon
it in so far as it accommodates
itself according to the cleavage of the
and
skin determined
is
by Langer,
partlymodified, partlystopped at the nodular points.
the hairy scalp,the palms of the hands, and
serrations
observed
are
Therefore, no
upon
soles of the feet, therefore the chin, base of the skull,and Poupart's ligament are
monly
comand for this reason
avoided by erysipelas,
is observed
at the condyles
a slow progress
of the joints,
the crests of the ilia,etc.
smaller
or
Exceptionally,erysipelas
greater leaps. If the part which has
may -make
between
remained
unaiiected
the individual
erysipelatousspots is small, no significance
is attached
to it. But matters
different
for example,
assume
a
aspect if the erysipelas,
and
then
has been
situated
the trunk
on
or
suddenly on the forearm
leg.
appears
Then
be earnestlyconsidered
it must
whether
and
both foci belong to one
the same
If it can
be proven
not.
that the process has extended
to remote
source
or
parts,leaving
the intermediate
partsfree,it is possiblethat in the diffusion of the deleterious substance,
some
parts of the tissue will allow it pass through them without being injured,while
others react more
and thus become
vigorousl}^
erysipelatous.For the present,however,,
that
the statement
advanced
of an erysipelatous
this
remote
by Volkmanr^,
appearance
of
is
the
result
This form
is known
E.
a metastatic
as
patch
deposit,cannot be denied.
If it is proven,
erraticum.
the other hand, that separate erysipelatous
foci are present
on
in two or more
spots,we have to deal with an E. duplex, triplex,and multiplex.
If intervals of complete apyrexia and
retrogressionof the inflamed tissues occur
between
the eruptionswhich
follow one
is a relapsingone
another, the erysipelas
and, if
of times in the parts in question,an
it recurs
habitual one.
The latter form
a number
the fact that its products themselves
constitute
the
acquires increased interest from
for
future
i. e., without
material
its
specialexciting cause, and for
recurrence,
any
of such an habitual erysipelas
to the patientis
changes in the tissues. The significance
the fact that he is not alone ignorant of when
evident from
he will be affected by an
quency
attack, but to his discomfiture finds them increasingfrom year to year, not alone in frein
also
to
but
twelve
a
year),
severity.
(nine
Fortunately such unfavorable terminations are rare, despitethe fact that individuals
suffered
who
from
have once
are
erysipelas
especially
predisposedto it. As a rule, the
inflammation
of the skin disappearscompletely,the exudation
is absorbed, the normal
color returns, the swellingof the lymphatic glands of the affected partsdisappears,and
after the branny or membranous
desquamation of the epidermis'has ceased, restitution
we

are

follows

in the strictest

sense.

there is an entire
mentioned
in the course
of erysipelas,
Apart
conditions.
For
local
with
the
factors
which
associated
are
noteworthy
mainly
of them
sake of completeness,some
will here be considered
very briefly.
quent
Facial erysipelas
which, as is well known, is the most freErysipelas of the Face.
But
have its starting-point
in any part of the face.
form, may
experience teaches
it arises most
commonly as the result of catarrhal,ulcerative,and other affections of
from

the variations

series of
the

"

that

'

Only recently as a companion piece to George

after a
foot desquamated literallyas a whole

"Wilson's

of the

severe

observations,

erysipelasof

the

I have

leg.

seen

the

epidermis

201

EKYSIPELA8.

scrofulous caries of the nasal bone, ulcerative

or
syphilitic
forms of
etc.,of the alae nasi,carious teeth,many
processes of the pharynx, lupus,syphilis,
otorrhoia,conjunctivalcatarrh, and morbid changes of the Meibomian
glands. We must
of the loose,large-meshed tissue
regard it as a speciallocal phenomenon that, on account
accumulates
of the cutis,a largequantity of transudation
more
readilyin the stroma, on
and the process in general
account
cf which the expressionof the face appears frightful,
the eyelidsare very cedematous
and
violent.
If the face is affected in its entirety,
more
account
of the flow of
on
closed, and the skin in the vicinityis eroded or eczematous
tears.
The
becomes
nose
shining,markedly swollen, and painful,the nostrils djy, often
to twice their size,the conchse
The lipsare thickened
impervious on account of crusts.
and
the
red
stiff,
are
bright
integument of the cheeks and temples
shining,
;
very tense,
considerable
and
often
to
infiltrated
is
a
extent,
presents vesicles. Facial erysipelas
has occurred
in the eyelidson
the destructive process which
usuallyends favorably,even
and
account
Now
of the infiltration usuallyheals without
any disfiguringcicatrices.
and suppuration of the parotid or the neighboringglands occur, but
then inflammation
Facial erysipelas
have no further consequences
apart from the prolonged duration.
only
from
its spread to the scalpor from the orbits to the meattains specialsignificance
ninges.
the nasal

membrane,

mucous

Erysipelas of the Scalp. If erysipelasaffects the hairy part of the head, this is
from
the beginning by the dull and later more
acute, but always constant
headache, which is due not alone to the tension of the cutis and galea aponeuroticaby
of blood in the cerebral vessels.
the exudation, but also to the change in the amount
"

manifested

In

irritable individuals,insomnia, delirium, etc., may

very

occur

even

in moderate

the fever is

and when
the erysias
high. But as soon
by no means
grades of erysipelas,
pelas
returns
subsides,the patientsgrow quiet,consciousness
undisturbed, the swelling
and an obstinate seborrhoea alone remains, associated
of the scalpdisappearsquiterapidly,
the entire scalp,and which
with defluvium
is usuallythe
capillorum extending over
result
hairs begin to grow
infiltration. As a rule,some
of a serous
while the others are
fallingout.
If the erysipelas
and high fever continue
undiminished, violent cerebral symptoms
slow (60)or rapid,the pupilsreact slowlyor become
; the pulse becomes
appear very soon
Maniacal
almost
immovable, and the sensorium is usuallydull.
attacks, violent jactitations
and
followed
and
The
coma
are
commonly
by
patientlies in an
occur,
sopor.
apathetic condition, mutters
incoherently,and dies with symptoms of convulsions,
of
tremor
the
muscular
and the like,if no change for the better occurs
teeth,
gnashing
within
inflammations
of the brain and
its membranes,
eight to ten days. Purulent
metastatic
meningitides,purulent phlebitides,
encephalitides,
and, m general,
process,
extension
much
of the erysipelas
found exceptionally,
are
more
rarelythan is commonly
To what
supposed. In the majority of cases, oedema of the brain is alone observed.
the
the
reflex
extent, however, the continued
or
fever,
and
intoxication,
high
irritability,
the like take part in this process has not been determined
hitherto.
of this serious condition, erysipelas
of the scalp has
On account

dreaded, and
made

with

for this

reason

even

the

surgicaloperation upon
slightest

always

been

more

this part must

be

the greatest care.

frequentlyas the result of ex^nsion of

the overwhelming majority of cases,
primary
the excitingcauses
of the latter form
serious
are
operations(removal of the mammary
glands in fat individuals),
neoplasms undergoing degeneration,fistulous tracts and caries
Erysipelas of the

the disease than

as

Trunk.

"

This

local

occurs

more

affection.

In

202

EKYSIPELA8.

of the ribs.

In the new-born, it is often observed

It must

"5ord.

always

of the

serous

be

regarded

as

after the

serious disease,on

fallingoff
account

of the

of the

pericarditis,
pleurisy)and
(peritonitis,

membranes

(lungs,heart, intestines,etc.).
of the trunk,
Among the forms of erysipelas

umbilical

flammation
frequent in-

of the other

organs

the

followingpossess

greateramount

of interest:
almost exclusively
in the new-born, is
Erysipelasof tlie Umbilicus, which occurs
all
of
irritation
the
sorts
of
umbilical wound.
caused
During puerperal
usuallyby
occurs
epidemicallyin foundling asylums and hospitals. It is
epidemicsit occasionally
At
by its wandering character, and the malignancy of its course.
signalizedespecially
the
umbilicus
this
the beginning,an irritated spot is observed
an
tous
erysipela; upon
upon
contact
the infant cries
with which
patch of varying size develops,upon the slightest
which
is moderate
is the course
out loudly. Parallel to this condition
the
run
fever,
by
of
If
increases
with
the
the
standstill
of
the
at the onset, but
a
spread
erysipelas
process.
within
does
not
occur
a few
days, the life of the child is seriously
endangered. The
children
die within three to twelve days from
loss of vitality,
anaemia, etc., on account
in the vicinity
of the continued
fever, the later suppuration of the tissues,and the gangrene
Or the erysipelas
is complicated by peritonitis,
of the umbilicus.
enteritis,pneumonia,
less
then occurs
at a later period,but is no
and the like,and the fatal termination
states that the disease is absolutely
fatal,and Steiner has seen
a
probable. Trousseau
in only two cases
out of sixty. Bednar, on the other hand, regards
favorable termination
frequent result.
recovery as the more
2. Erysipelasof the Genitals.
Upon the male and female sexual organs, apart from
result from the constitution of
certain operativeprocedures,the kinds of diseases which
the
chief
these parts serve
of erysipelas.In males, this includes the
as
excitingcauses
fistulous tracks of the urethra and
which
strictures and
the scrotum
result from
urethral
periIn such cases,
abscesses, the specific
ulcers,and various ulcerative processes.
the foreskin of the penis is considerablyswollen, and may
enlargeto such an extent that
is closed.
be reached, and the orifice of the urethra
of the penis cannot
the head
in
trickles
the
urine
is
and
the
The result is that
drops
constantly
only discharged
upon
surroundingsparts. This leads not infrequentlyto the production of extensive deeply
spreadinggangrene, which may dissect out the testicles. Eecovery occurs very soon after
standstill has taken
a
place. In adult females, erysipelasof the vulva is caused by
uncleanliness,decomposition of the secretion of the vagina and of ulcers, and in little
^rls who suffer from aphthous and follicular ulcerations on account of neglect,from the
1.

"

action

of the urine

and

faeces.

ities
of the face,that of the extremNext to erysipelas
Erysipelasof the Extremities.
is observed
most
frequently. According to Billroth (ZurichClinic, 1860-1870),
the
43 on
248 cases, 123 occurred
upon the limbs, 67 in the face, 13 on the scalp,

3.

"

among
trunk.

more
frequentlyin the lower than
majority of reports,it occurs
of exciting
the
that all kinds
fact
in the upper limbs.
This is explainednot alone by
but
also by the fact
ulcerations,etc., appear more
frequentlyon the lower limbs,
causes,
of the circulatory
slowly,
conditions,injuriesin this region heal more
that, on account
Nevertheless,
increase of the inflammatory process.
and preslht
a greater tendency to an
is certainly
Tillmanns
rightwhen he asserts that the statistics bearing on this pointdepend
of
the varying character of the material of observation at the command
in part upon
in
with
relative
observed
of
is
the
limbs
individual writers.
frequency
Erysipelas
upper

According

to

the

203

EKY8IPELA8.

one

with

connected

while
erysipelas,
legs.
The

the

tanners, servants, and

Macksmith,

the

of

course

is attended

with

sees
hospital,
physicianto

penal institution

the extremities

of
erysipelas

serious results

more

when,

treats

is,on
account

on

of the lower

physician,and
'

affections of the arm,

more
a

children's

The

like.

that

and

butchers, carriage-makers,
physicians,
nurses,
'Carpenters,

account

on

more

of

cas3s

limb

particularly

of vaccination
of
erysipelas

the average, favorable

of its extension, the

the

in adults.

It

jointsbecome

form, extensive destruction of tissue develops,

implicated,or when, as in the gangrenous
contractures
which
a,nd secondarily,
impede the functions of the limb.
effects of the
Complicationsof Erysipelas. In view of the violent and manifold
it
the
that
entire
is
conceivable
vital
conditions
of
the
on
organisms,
erysipelatous
process
"

deviations

the

from

normal

of the

disturbances

or

course,

varied

most

kind

often

velop.
de-

disease,or appear
during its
begin on
day
any
has
been
of
in
mentioned
the descriptionof
A part
the complications
continuance.
in which
will now
We
consider those forms
the symptomatology.
crotic
suppuration and neThe
simplestvarietyconsists of the unimportant
degenerationof the tissues result.
little abscesses which appear
skin, often as early
superficial
along the erysipelatous
is sufficient
the end of the first week, and spontaneous or artificial discharge of which
as
them
in one
If the erysipelas
remains for a longer time, or recurs
to cause
to heal.
spot,
connnective
tissue,
multipledepots of pus, sometimes
extending into the subcutaneous
and the cpnstitution of the patient is tolerably
develop. If they are not too numerous,
ment.
vigorous,they have no further significance
beyond the results of a slightfebrile moveand careful bandaging) within a short
They heal by surgicalinterference (incision
for those which
formations
time.
These abscess
should not be mistaken
during
appear
the
the
weeks
after
of
results
of metastasis of the skin,
as
-convalescence,or even
lapse
for a long time,
remain
unnoticed
the lymphatic glands,or other localities. These
may
with the symptoms of cold abscesses,are attended
brile
manifested
are
finally
usuallywith feand almost
without
movement,
exceptiondevelop deen in the tissues. Usually, also,
these collections of pus are followed by no evil results.
Much
more
important are the destructive processes which are the results of a too
abnormal
and
After fever and general malaise, the skin usuallybeexudation.
profuse
-comes
markedly infiltrated with oedema, very painful,discolored,and vesicles filled with
sero-bloodycontents
sprou^ out upon the surface; beneath these are concealed the first

They

'

As

with

of

institutions
the

start,

so

the

on

the

character, in which,

the

entire

on

the

It may

occur

healing of the vaccine

frequently in foundling asylums

more

hand, the number

one

hand, the spatial conditions

other

time

at

rarely after private vaccination,

very

this

of the

employed by the opponents of vaccination, use is made of the bad

is carried
erysipelas. I believe, however, that this accusation
too

predisposing factors.

many

lymph

weapons

vaccination

it is observed

since

at

may

of the

one

the first

and

upon

the

any

children

of

who

are

plication
com-

far,
and

cachectic

tute
ready communicability, constiof
day, from the completed vaccination
more

In the majority of cases, however,

it occurs
Its course
week, i. e., during the stage of maturity.
is not different
from
has developed from
that of erysipelas which
other cause, inasmuch
localized
some
it may
as
remain
to

pustule.

during the second

or
are

attack

parts of varying dimensions,

too

not

young,

the

process,

as

mortality is large (30/^^).Exhaustion

more

than

j^ide by

means

the

whole

must

body. In healthy, vigorous children, if they

favorably; in infants in public institutions the

be mentioned

as

50fc)of death, particularly after E. ambulans.

erysipelas, we
is furnished

even

rule, terminates

think

it may

by the vaccine

be

assumed

matter

that, when

employed,
of instruments, uncleanliness,

as

etc.

the

well

one

With

as

of

the

regard

most
to

the

frequent
causes

causes

(often

of vaccination

predisposition is present, the exciting

the
by morbific
agents brought from

cause

out-

204:

EKYSEPELAS.

mortification.

beginnings of
will

substance
In

cases, the gangrene

rarer

of various

other

serous

not

complicationsare
a

rare,

as

diffuse

in its further

its situation

also be

may

hard

as

of

developed therefrom.
pursued by

spread may

the

observed

be

in the

is
plastic,

as

become

the

qualityof

added

board, is

the loss of

(eyelids,
scrotum).

thus

may

deviation

course,

of

to

cause

the

udation,
ex-

the

previously
bright-redto

shred-like

death

of the

erysipelasepidemics,the phlegmonous
gin
impaired mobilityof a limb traces its ori-

many

case

alone

result of this is the

has

is in the main

and

is often

course

common

and

There

skin thereby becomes

extremely painful. The
Especiallyduring severe

which

contracture

As

on

The

one.

color,and

corium, fasciae,etc.
to

of

account

exudation, which

an

as

limited

becomes

soon

important destruction,and

causes

complications.

inasmuch

bluish-red

If it

importance

assume

erysipelatousand
in both

phlegmonous

instances,both

processes

mation,
inflamhave

to be

regarded as identical by various writers (Virchow,Tillmanns, and others).

to be well founded; so long as the cause
This
of both
assumption does not appear to me
(atleast in the majority of cases)is so different,and their characteristics vary so greatly
from one
another, I think that I may properlymaintain the separate specificnature of
in this categorythe hospitalgangrene
include
each.
We might, with equal justice,
casionally
ocalso be justifiable
to regard lymphanand it would
associated with erysipelas,
and osteo-myelitis
(Virchow)as erysipelatous
phlebitis,
gioitis,
processes.
the
to
With
generalcondition, the typhoid stage should be regarded as one
regard
of the disease
serious complications. AJ)out the time that a retrogression
of the most
the fever
and high temperathe seventh
should be expected on
day, on the average
ture
without
remain stationary,
being present on the
occasionally
any correspondingcause
rarely
part of the affection of the skin. In such cases, the pulse is accelerated, more
diarrhceal and
small and dicrotic,the tongue is dry and fissured;the passages
slow (sixty),
distended, the skin covered with a clammy sweat; the emaciation
stinking,the abdomen
In otherwise healthy individuals,improvement takes placequiteoften;
is considerable.
week.
the majority,however, die of adynamia towards the end of the second
of
mention:
the
we
more
meningitis,
frequentcomplications erysipelas
Am-ong
may
and
enteritis,nephritis,
peritonitis,
pneumonia, pleurisy,endocarditis,pericarditis,
ovitis,
synIn
be affected simultaneously.
count
general,on acby which one or more
organs
may
which
the organs
situated nearest
of erysipelas,
of the propagating character
are
for example, in erysipelas
to it are
predisposed to implication,and therefore^
specially
affected in preference;in
the peritoneum and the coils of intestines are
of the abdomen
heart and lung, etc. But this by no means
that of the chest, the serous
membranes,
cludes
exsituated more
the quitefrequent affection of organs which
are
remotely from the
come

"

"

'inflammation.
I

Etiology.
injury as an
"

and

occasional

afl'ections is not

wounds
us

be

must

causes

regard every

erysipelas.However,

appearance
a

erosion,fissure,pustule,open
the

but
productionof erysipelas,

the

therewith.

a changed
assumption that

present

to the

of

of

cause

sufficient for
associated

kind

or

concealed

simple existence

wound
of such

certain

other

unfolds

its deleterious

exciting
Experience at the sick-bed has taught us that open
before erysipelas
even
develops. Everything forces

specialprocess

occurs

which

then

effects.
The

question then is. What

erysipelas? Hebra, Kaposi, and
of

the

local

infiammation

favors its miasmatic

is the nature
others

which, when

nature, while

the

assume

of the process which lies at the bottom

of
that it is the secondarychemical
products

absorbed, produce

overwhelming

this

majorityof

zymotic disease. Roser

of the pres"
pathologists

205

ERYSIPELAS.

ent

may

They call attention to the observation that erysipelas

day favor its contagiousnature.
to
the adjacent beds, that occasionally
ported
in hospitalsspreads preferably
a single imis followed
of erysipelas
case
by entire epidemics, and that finallyseveral cases
in families.
another
Cohnheim
tagious
follow one
regards erysipelasas a miasmatic-condisease,
A

number
into

masses

investigatorshave

of

skin

the

of

all these

erysipelas. But

and

man

introduced

erysipelatousfluid, pus, and ichorous

to determine
the communicability of

animals, in order

exhaustive

experimentshave

furnished

no

harmonious

results.

attained

only a negative(Max Wolf, Stark, Hiller),not marked

indeterminate
(Belieu,
Zuelzer),or, at the most, a partialresult (Tillmanns),
(Ponfick),
in producing legitimateerysipelas
of putrid
others are said to have succeeded
by means
communication
have
at
mixtures
successful.
My attempts
entirelyun(Orth,Lukomsky).
proven
Only on one occasion after a superficial
injectionof six drops of fresh fluid,
in the vicinityabout as large as a two-dollar
I observed
a redness
piece,which developed
in a few hours with an elevation of temperature scarcelyworthy of mention, and which
undervalue
the
Nevertheless, I cannot
disappeared at the end of twenty-four hours,
the
also
but
few
supported by
undoubtedly positiveexperimental results, as they are
while

For

have

some

clinical facts.
aid of his experimental results,expressed himself
with cocci vegetations. And
erysipelas
Lukomsky,
in
s
tates
bacteria
that
the
found
of
are
spots erysipelas
subjectcarefully,

Orth, with

the

direct connection

of

vessels of the corium

and

the subcutaneous

connective

tissue

and

in
who

of

favor

studied

in the

the
this

lymphatic

at the borders

sively
exclu-

to discover
blood
unable
cocci in
capillaries.Billroth and Ehrlich were
erysipelas. According to Tillmanns, the presence of cocci is by no means
always presentin the successful
process, although these were
necessary to the erysipelatous
of erysipelas
fluid ; on the other hand, not every coccus-containingfluid provaccinations
duces
and
without
with
erysipelas. He concludes, therefore, that erysipelasoccurs
by a fluid containing cocci
fungus vegetations,and that the poison may be transmitted
free from
them.
afterwards
well as one
Fehleisen,
as
Very recentlyE. Koch, and soon
in favor of a specificpathogenic micrococcus, which
has its
have expressed themselves
tissue.
connective
habitat in the lymphatic vessels of the skin and subcutaneous
cocci
microThe
of the specificnature
of the erysipelas
proofs which have been advanced
ally
do not seem
to be sufiicient.
starts occasionto me
The observations
that erysipelas
the most
from completely healed, cicatricial parts of the skin or from
heterogeneous
thonous
inflammatory and purulent foci, on the one hand, renders the assumption of its autochfavors the view that the
originsuperfluous and, on the other hand, distinctly
cocci are not an indispensablerequisite
for its production. According to my conception,
is
deleterious
substance
under
influences,either in loco or
a
produced
speciallyirritating
it reaches the inflammatory spot from
the outside and produces erysipelas
in predisposed

in the

every

case

of

individuals.
.

Sex, age, the

season

of the

year, the weather, telluric conditions, and

the

like

are

predisposingfactors of erysipelas. With regard to the first three,

at this
series of tables gives the following results.
67 patients treated
a
Among
my
males
41
Almost
26
and
f
emales.
the
same
clinic,
(61.2^^)
proportionsare
(38.8^) were
of
to age,
General
the Vienna
reference
shown
Hospital. With
by five annual reports
usually mentioned

among

my
30-40

as

patients,17
years,

16

occurred
between

before
40-50

the

20th

years, and

year, 20 between
4

cases

between

20-30
50-60

tween
years, 10 beWith

years.

206

EETSIPELA8.

to the

regard

of the year, among

patients 9 developed in
my
showed
the
next
May
highestfigures.

season

these

I consider

But

January

cember,
De-

and

April and

while

in the

positionto

much

figuresas

small

too

to draw

any

definite conclusions.

command

ditions,
figureswith regard to the climatic and telluric conI know
from
but
experience that erysipelasappears very frequentlyin some
of the Nile).
marshy and maritime districts (the mouth
After
a few
hours, the skin of a patientwho has died of erysipelascan
Anatomy.
be,distinguishedin no respectfrom that of another corpse. The swellingwhich was
scopical
the micropresentduring life has disappeared,and the skin appears pale. But even
shows
examination
which
is
the appearances
characteristic,
scarcelyanything
If the part to be examined
or
being similar to those of a superficial
deeper dermatitis.
from the period of acme,
find most
comes
we
microscopically
constantlystartingfrom the
cellular tissue,round-cell
papillarylayerthrough the entire cutis into the subcutaneous
am

not

"

infiltrations which
vessels

or

are

either

collected in

loosened, moist, and

to Kenaut,

and

the
the

follow

the branches

largeror

smaller

later takes part in the

of
regard to the occurrence
entirely;Billroth, Lukomsky,

there thrombotic

addition, the connective

corpusclesin

condition

tissue is

of irritation.

cording
Ac-

dition
erysipelas
passes into an embryonic conOpinions are divided with

severe

hardening

cocci.

In

groups.

connective-tissue

adiposetissue in

of the dilated,here and

of the tissues.

Tillmanns,

Amidon,

Hiller

have

missed

them

Hueter,

Orth, K.

Koch

have

Ehrlich,
found

chieflyin the lymphatic

Frequently no abnormality is found

observed

them

others

and

them
vessels

have

observed

regularly, E. Koch
in the boundary zones.

in the

internal

them

and

quite often,
Fehleisen

have

they are the site of

or
a
cording
inflammatory change, acgrade
of the erysipelas.However, all these
to the occurrence
pathologicalprocesses
endocarditis, myocarditis,myositis,parenchymatous
(pneumonia, pleurisy,pericarditis,
ease,
and the like)presentabsolutely
nothing which is peculiarto the precedingdisnephritis,
like the appearances
but the changes produced thereby are
which are usuallyfound
in high continuous
fever, toxaemia, and metastases.
The
that a misnature
take
symptoms of erysipelasare of such a marked
Diagnosis.
be
of
A
of
varieties
cannot
found
in
cause
error
some
erythema
easilyoccur.
may
pruritusis then present, and there is no spread
(gyratum, urticatum),but very marked
the evidence of inflammatory infiltration.
and
then extensive
Now
per contiguum, nor
authors
render the diagnosisdifficult;
indeed, some
lymphangioitis and phlebitismay
regard erysipelassimply as capillarylymphangioitis. However, the streaked appearance
which continue even
of the redness and swelling,
during its course, render it possible
to recognizethe process.
Prognosis. Patients of a healthy constitution and in middle life will pass through a
The
outlook is also more
able
favorbetter than under the oppositeconditions.
severe
erysipelas
if the erysipelas
solution of continuity,
while important injuries,
starts from
a slight
of the
constantlysuppurating wounds, the puerperalcondition, vaccinia, and erysipelas
the erysipeWhether
in infants always render the termination
serious.
umbilicus
more
las
or
occurs
demic,
epidemically,and, in the latter event, the character of the episporadically
factors.
are
important
It is usuallystated to
The mortalityin erysipelas
depends upon specialconditions.
but
it
from
and
in
fifteen
the same
to
ten
to
one
be
changes
place.
year
year
per cent,
the
of
After
elaborate
of
Treatment.
erysipelasin Vol.
presentation the treatment
in the following remarks, especially
as
we
II.,I think that I may abbreviate somewhat
the disease,this

"

"

"

that organ

will present

variable

organs.
of

If

208

PHLEGMON.

to six

several

drops into

placesalong the periphory.

The

ran
a favorable
erysipelas
course
I am
unable
whether
in both cases,
post hoc or propter hoc.
of erysipelas
In my
is the best, if no
opinion,expectant, symptomatic treatment
because usuallythey are well
other specialindication is present. Apply cold compresses,
tolerated
for by the patient. If crustydepositsare
and eagerly asked
present at the
be
careful
that
these
must
of
removed
emollients
and in
are
we
places eruption,
by
(salves),
the
of
that
In
has
free
wounds
a
avenue
addition, the
discharge(drainage).
larger
pus
and
the
air frequentlychanged.
In high
patient should be placed in a spacious room,
fever, give quinine and also iron if the feeble condition requiresit and the condition of
the digestive
or
ceased, give lightbut good
organs permits. If the fever has diminished
nourishing food and old wine to the extent Avhich is well tolerated by the patient. This
If complications occur
the
on
plan will meet the indications in the majority of cases.
nature
to
the
must
of
the
disease.
of
these
be
treated
according
part
any organ,

to determine

but

PHLEGMON.

largemajorityof English writers disregardphlegmon as a morbid genus, or discuss

it simply under
the head of cellulitis. By the majority of French
writers,it is described
divided
have also been
authors
as
Erysip^lephlegmoneux. For a long time, German
it
pendent
indedo
not
and
into two
an
While
others
as
Yirchow,
recognize
Stromeyer,
camps.
in a different
sense.
disease, the majority of pathologistsexpress themselves
with them
Virchow
not
alone considers erysipelas
and phlegmon as
allied,but numbers
tis
thrombophlebitisand an entire series of puerperal processes, and hopes that osteomyeliA

and

infectious

will be included in the same

category.
pyelonephritis
in
concede
that
certain
erysipelasand phlegmon
willingly
respects,
my
But
such
doubtful.
and
often remain
that the diagnosismust
a parallelcourse,
the
ter
characdifferent
the
much
in
which
are
etiology,
opposed by a
largernumber,
of the symptoms
and termination, furnish so many
arguments for continuing to
For

run
cases

part, I

keep them

separate.

Definition. A
"

phlegmon

must

cellular tissue,produced in
leads to

suppuration and

mortification

regarded

be
a

as

an

acute

mechanical, chemical,

of the tissues in the

inflammation
or

thermal

of the
manner,

largeproportionof

cutaneous
sub-

which

cases.

135 times
were
excitingcauses
incised
35 superficial
wounds), 52
(139.58^). Among these were
injuries(erosionsand
deeper injuries(wounds from operation,contusions, fractures, phagedaeniculcers, and
secting
the like),21 thermal
7 bites of insects,6 diseffects (combustiones and congelationes),
such as pressure, blow, concussion,
of various injuries,
wounds, and 15 cases
maltreatment
and
continued
the immediate
cause
was
stretching,
etc., in all of which
terious
deleThe
uncleanliness
of
of
the solutions
septic
part played by specific
continuity.
with
substances
be determined
certaintyin the
(micrococci,Ogston) cannot

Etiology. Among
"

present state

of

our

341

demonstrable

cases, I find that

knowledge.

tive
parts of the body, viz.,those which possess a loose, large-meshedconnectissue,like the neck, inguinalregion,limbs, appear to be the site of severe
phlegmons

Individual

more

form

frequently and upon

slightprovocation. Whether
be readilydecided.
a special
cannot
predisposition

of males

of middle

age

and

feeble constitution.

But

the

sex,

age,

Statistics show

it is

possiblethat

and
a

constitution

largemajority

the first two

fac-

209

PHLEGMON.

are
representedby large figuresmerely
occupation,
etc.
for injuries,
frequent opportunity

tors, like

because

they afford

more

It is advisable
to discuss
the circumscribed
phlegmon
Before
regarded as a patternof the non-complicated form.
the patientexperiencesin the affected part an annoying
noticeable externally,
it becomes
feelingassociated with tension,which very often increases to decided pain after the lapse
About
this time, a slightelevation is noticed at the part,
of twelve to twenty-fourhours.
feels
and
towards the deeper parts. If the site is
hard, especially
but it is not movable
visible redness is
and the layer of epidermis is not thick, a distinctly
more
superficial,
to
and
lost
is
which
a
on
extent,
slight
pale,
graduallytoward
pressure,
grows
present,
after the
the periphery. If the part is kept quiet,complete resolution
occur
even
may
sion,
tenand
fluctuation
is
noticeable.
The
consistence has become
redness,
doughy
slight
ing
leava
nd
resolution
and swellingthen subside,the pain diminishes
occurs,
steadily,

Symptoms

and

Course.

separately, this must

as

behind

darker

"

be

coloration

of the

skin.

If

resolution

does

not

occur

within

the

periences
suppuration. The patientexdays,the process passes into well-marked
robs him
of sleep.
a
dull, hammering pain, which
increases,and
deep down
The
marked, and the oedema in the vicinity
swellingincreases,the redness becomes more
tense,
inIf
is
becomes
the inflammation
further.
more
no
effected,
improvement
spreads
and
the
is
the skin becomes
seen
thinner, extremely red,
shining through.
pus
fever develops. Perforation
!N"ot infrequentlymoderate
occurs
commonly during the
second week, when
a relatively
largequantityof foul-smellingpus, mixed with shreds of
come
beis favorable,the walls soon
connective tissue,is discharged. If the further course
appliedto the base, and the entire process terminates within one to three weeks,
united.
the granulationswhich
situated oppositeone
another become
inasmuch
are
as
for some
which persists
is
left
behind.
An infiltrated zone,
time,
In deeper but circumscribed
phlegmons, som(3 time always elapsesbefore the process
The patient,therefore,suffers for a week without being thoroughly
reaches the surface.
scribed,
In addition, the conditions differ from
conscious of his condition.
those previouslydethe symptoms are graver, and its extension, as well as complications,
inasmuch
as

next

are

two

thus

to five

favored.

comes.
serious and grave the entire process beimplicated,the more
largerthe territory
followed
fever
disturbed
and
curs
occondition,
a rule, a chill,
general
by high
violent
of
with the first evidences of a diffuse phlegmon.
The
patient comi)lains
the disease
When
pains in the affected spot, which is very red and markedly swollen.
the latter symptoms
occurs
more
are
more
superficially,
developed from the beginning,
be raised in
and the cedema
skin cannot
of the vicinity
has also spread largely. The
folds ; it appears
infiltrated.
Under
to be tightlystretched,and
feels hot and
rigidly
the
becomes
which
shows
more
severe
relatively
high fever,
pain
only slightremissions,
and continuous, and
the redness, swelling,tension, as well as the infiltration,
sively
progresIf the process
increase.
has reached
its acme,
resolution very rarelyfollows, but
of
usuallysuppuration. In this event, the pains and fever often subside for a number
to livid,
In this stage, the skin looks dark-red
days and then return undiminished.
situated
thinner, often has vesicles filled with sero-bloodycontents
grows progressively
The

As

upon
with
may

the surface,feels very

certainty.
convince

There
diffuse

If

hot

perforation

ourselves that

14

the

touch

occurs,

it has the

however,
differences,
as
phlegmons, inasmuch

are

to
now

same

between
in

the

and

allows fluctuation

to be demonstrated

the pus is evacuated

by an
constitution as in circumscribed

or

the

phlegmon.

and
in circumscribed
processes
tissues immediately surrounding the

morbid

latter the

incision,we

210

PHLEGMON.

necrotic

become

purulentfocus

losses of substance

considerable

is firm

which
as

it resolves

the
ceases

account

on

This

does

not

time

some

differences

of the
occur

turbances
circulatorydising
exclusivelydur-

afterwards.

consist in the

As

the

former

the

result,

filtration
in-

asmuch
feel,gains the upper hand toward the periphery,and, init
of
defines
the
time
extent
at
the
same
surface,
quite an

to the

over

looser and

If this is not

fact that the

of the

If

infiammation.

the

termination

is favorable,

purulent degeneration of the tissues constantly diminishes, the fever

almost
suddenly, the pus acquiresa better appearance, and the necrotic

tissue become

In

also for

Other

arise.

of the local extension

boundaries

extent,

infiltration.

suppuration,but

of

continuance

certain

cellular

the

produced by
the

over

are

shreds

of

cast off.

case, the

event, the

sometimes

phlegmon

condition

becomes

extends
so

in

much

area
more

and

also

grave

spreadsmore
because

the

deeply.
Jointsand

become
implicated.
may
and
connective
adipose tissue,
phlegmon extends deep into the subcutaneous
fever will announce
the
is beginning to do so, the general malaise and the continuous
or
of
become
But
its
entire
the
extent
the
when
affection.
of
we
cognizant
only
severity
the
and
the
and
when
worries
dition
connight,
patientconstantlyby day
deep throbbing pain
If the pus is not evacuated
at the proper
of his vital forces rapidlygrows worse.
more
or
time, it will effect an exit at one
parts of the integument. If the surface of
is laid bare, we will be astonished
the wound
by the ravages produced by the purulent

important

organs

If the

degenerationand
The
account

course

by
is

the wide

extent

of surface

disproportionately

of the anatomical

more

which

has been

complicated

conditions, the inflamed

undermined.

in subfascial

phlegmons.

On

tissue has

insufficient space to spread

of which
the patientexperiences

forciblyretained by the fascia, on account

tion
unspeakable pain, and strangulationand mortification from the abolition of the circulaof
in the tissues occur
course
during the further
very early. If pus has formed
affection,it cannot force its way to the surface, but must make a place for itself laterally
And
because this goes on
the deeper parts,thus giving rise to sinuses,etc.
and toward
the
necessitates
referred
the
to,
a very
at
long painful period until the
depth
process
In
the
of neighmean
while, a phlegmonous inflammation
boring
purulent depositis discovered.
have extended
for
in the intermuscular
jointsmay have followed, it may
spaces
the marrow
the periosteum, bones, even
distance and have affected
of the
enormous
an
the average
survive this form
bones itself. Despite this,healthy,strong individuals
on
the pus no
of phlegmon- quite well, if it is not too prolonged, for as soon
as
mulates,
longer accuwithin the cavities which
have been formed
and the pressure accordingly ceases
(thuspreventingthe absorptionof injurioussubstances at the periphery),the fever ceases,
in hand
the
of the patient improves. Hand
with this is the rapid
vital energy
and
restoration of the extensive losses of substance, since these are
soon
compensated
very
after all kinds of putrid processes by luxuriantlysproutingvegetations.
The acute
foudroyant of Maisonneuve,
purulent oedema of Pirogoff,the gangrene
be regarded as the worst form
must
of deep and diffuse phlegmons.
Introduced
at the
the
in
inflammation
sions
onset by severe
generalsymptoms,
usually extensive contuappears
torn wounds,
and only exceptionally
and unclean
arises from
smaller, insignificant
tive,
injuries. About the third or fourth day, we observe that the edges swell, are very sensilook unclean, and secrete putrid matter
instead of pus.
During the next twentyfour hours, the swellingmay
spread to such an extent that it occupies the half of one
the
skin
and
a
limb,
acquires dirty,brownish-red
color,which grows slightlypaler under
the pressure of the finger. If the process
is left to itself,the sero-purulentoedema
and

is

211

PHLEGMON.
^

while ichorous infiltration followed by gangrene

in the
and more,
spreadsmore
appears
find
to
emphysematous cracklingand
parts first affected. We are not a little astonished
If we
incise the skin, th^re
a
swashing, instead of the expected fluctuation.
vague
and
in
which
with
shreds of
mass
bubbles,
a
unrecognizable
putrid
permeated
escapes
tissue are contained.
acute
extensive
necrosis
of
In the most
the
tissues
rarely
cases,
the fifth or sixth day. If the process
on
as the
patientsusuallydie of septicgemia
occurs,
it might be expected that the affected
rilns a less rapid course,
capillary,and
venous,
while to compensate the circulatory
conditions
lymphatic vessels will gain time in the mean
necrotic shreds of tissue having been
removed
and that, the secretion and
by a
suflQcient number
of incisions,the process will become
circumscribed;but this takes place
commonly, despite the evacuation of
phlegmon is not circumscribed
very rarely. The
in the deep parts,and
all kinds of complicationssupervene,
the ichor accumulated
on
of which
the continued
account
high fever)the strength very rapidly fails.
(especially
The
icteric look, has a small frequent pulse,occasional clouding of
an
patient assumes
and either a
the sensorium, restless,furibund
complicating pneumonia, a
manner,
anaemia
the
the
and
or
or
like,
adynamia developing out of
nephritis
parenchymatous
end of his painfulexistence.
the typhoid stage make
an
If we
for the examination
secure
a
freshlyamputated limb and make
Anatomy.
will become
sensible of a resistance at the perisections through it in various places,we
phery
of the infiltration. If pressure is made
of the phlegmonous process on account
with the blade of the knife upon
the cut surface, a straw-yellowserous
fluid,mixed with
small particles,
of pusoozes
out; this is poor in cells,and contains only a smajl number
of
If
fibrin.
little
towards
flakes
further
surrounded
we
the
a
proceed
corpuscles
by
lardaceous
and
the
cut surface presentsa
centre,
dischargesa yellowishwhite,
appearance
float fat-dropsthat have
been
set free.
The
cutaneous
subthick, sero-purulentfluid in which
cellular and adipose tissue is brittle and
readilytorn.
Beginning from this
place,the gradual spread of the inflammation, the thrombosis of the vessels,the increase
of the purulent foci,the degenerationand death of the tissues,etc., can
be followed
if
incise
the
in
central
those
to
which
the
quite accurately
part. Finally, we
places
will find upon
the walls nut-colored,
phlegmon has effected the greatest ravages, we
If the phlegmon was
loosely-hangingshreds of tissues,whicn tear readilyon traction.
subfascial,the completelyexposed bone with infiltration advancing into the medullary
substance is not infrequentlypresentedto view.
etc., and, almost without
Pneumonia, or pleurisy,or pericarditis,
exception,parenchymatous
in
the
internal
found
nephritisare
organs.
shows
that in the beginning the connective
tissue is
Microscopicalexamination
saturated
fluid,loosened and infiltrated with round cells,which
mainly with serous
increase during the further course
of the affection;in addition there is cellular infiltration
and plastic
of all the tissues.
of the serous
In consequence
tory
circulainfiltration,
"

and

nutritive disturbances

therefore,we
reality,
attended

with

of infiltration and

Prognosis.
"

destruction

it

on

and
superficially
alone
not
on
life,

and

then

effect the

which

same
processes
of the parts. The

destruction

were

difference

observed

of the tissues.
in other

depends only on

In

tions
inflammathe

degree

its extension.
Since

the

even

febrile movement,
undervalue

occur

notice the

and

the

onset.

is not

very

account

may
It

simple circumscribed
readilypass into
is,however, devoid

extensive.

more

of

of

phlegmon

severe

form,

generallyproduces
we

should

not

it is situated

danger,
long as
opposite event, it becomes
dangerous to
of pus, and the
high fever, the formation

In the

of the continued

form
a

so

212

FUKUJ^CULUS.

of the tissues,but

destruction

also

on

account

of its extension

to

more

important parts of

body, thrombosis, pyaemia,septicaemia.

the
so
distinctly
by the firm infiltration,
Diagnosis. Phlegmon is characterized
of the tissues,
fever, great pain, and the specialtendency to suppuration and destruction
it for erysipelas. This will
is it possibleto mistake
that only in progressingcases
of the general character of the clinical
be prevented,however, by careful consideration
its
further
and
course.
history
The
first object is the discoveryof the
focus of disease in order to
Treatment.
soon
as
remove
as
possibleany injuriousinfluences which may be present. If this has
himself of the condition
of the patient,
been accomplished,the physicianshould satisfy
must
If
the
inflammation
treatment
has
his further
not assumed
as
accordingly.
vary
not
is
has
resolution
dimensions
and
occurred,
suppuration
possible. The best
large
for furthering this are
rest and
suitable horizontal position. I
absolute
methods
a
would warn
the
againstthe use of gray mercurial ointment, for it is still doubtful whether
it is more
ointment
the inflammation
than probable that
acts upon
as
a resolvent,while
the skin is irritated and the occurrence
of earlynecrosis thus aided.
It should be madshould never
be employed under
measures
a principlethat
irritating
any circumstances.
but
be
should
If the pains are
ice
we
never
applied,
expect to prevent supsevere,
may
puration
and
should
it
be
this
never
appliedcontinuously.
by
means,
If the inflammation
spreads and suppuration occurs, the main principleconsists in
extensive incisions,according to the condition, because the subjecmaking one or more
tive
the pains notably diminish
sensations
of the patient improve and
from the
even
of the purulent focus, the emptying of the bloodrelief of the tension in the vicinity
vessels,
If a free discharge has been
the removal
of the exudation.
and
effected and
the shreds of tissue,without
of the
being much
pulled upon, are removed
by means
This is best done by constant, or at least
scissors,we must
keep the wound
very clean.
For this purpose
in a
a drainage tube, fenestrated
very frequentwashing (irrigation).
of places,is pushed in as far as possible,
number
with
and, being brought in connection
with a disinfectingfluid.
is constantlyirrigated
It is quite
the tube of an
irrigator,
whether
carbolic
acetate of alumina
immaterial
chloride
of
acid,
acid,
salicylic
(Burow),
If
is
the
not
be
is
this
continuous
bath
lime, etc.,
practicable,
plan
employed.
may
used to equal advantage. If new
phlegmonous depositsof pus form, the incisions must
and the powers of the patientthreaten
be repeated. If, despitethis,no standstill occurs
be performed if the affection is present in a limb, without
to fail,amputation must
disease
after such operativeinterferoften improves at once
ence.
too
long delay. The
very
If high fever or
the typhoid stage is present,quinine in doses of 1-1.5 pro die
resort to opium
to
useful.
When
there is insomnia, we
produce
may
very
proves
the

"

"

sedation.
of easily
The
low general condition is best combated
by the administration
digested,
nourishing food, wine, and also iron, bark, etc.; emetics, laxatives,etc.,being entirely

avoided.
FURUNCULUS.

The

diminutive

furunculus

applied by Oelsus to a pointed swelling,asso

pain, which presents a great tendency to pass into suppuration
is characterized by a deeply situated,necrotic
and
of cellular tissue.
Even
core
look upon
his description
now
as
we
masterly and little remains for us to do beyond
enlarging on details.

ciated with

inflammation

and

was

first

213

FUKUNCULUS.

Definition.The

circumscribed

acute

an

inflammation

of

the

cutis,

vicinityof the follicles and glandular structures, which first leads

the originally
affected tissues and later to suppuration and removal

of

mortification
the

is

furuncle

"

the

startingfrom

to

of

core.

attention
of the patient is first attracted
Course.
The
Symptoms and
by slight
reddened
point. If the fingeris passed over it,it is felt to
itchingor burning of a slightly
of the next twelve to twenty-four hours, becomes
be a hard
point which, in the course
This gradually becomes
and
extensive
more
develops into a nodule.
pointed in the
and
middle
dened,
a
pustule developsat the end of the third or fourth day, situated on a redthe opening of a follicle and is perforated
infiltrated base ; it usuallysurrounds
it continues in this acute stage for one
two days, then the
or
cases
by a hair. In rarer
the pustular contents
redness diminishes, the infiltration disappears,
dry, and the entire
abortive.
efflorescence thus
becomes
Usually, however, the inflammatory swelling
Then
often
further.
find,even during the next few days,a bright-red, sharply
we
spreads
defined tumor, perhaps as largeas a pigeon^sQgg, feelingas hard as wood
of a doughy
or
little
softness in the centre, and bearing a
On
pustule or a yellowish-brown scab.
account
of the throbbing,boring pains deep down, it robs the patientof sleep,takes
even
produces fever. If no incision is made before the seventh
away the appetite,and
at one
or more
or
points with the dischargeof
eighth day, spontaneous perforationoccurs
a
purulent and sero-blood fluid,which upon lateral pressure is followed usuallyby the
In its further course
has been loosened by the exudation.
of tissue which
the walls
core
in one
to two weeks.
together,granulationsdevelop,and recovery occurs
graduallycome
The permanent results are small irregularcicatrices which in time grow
pale and become
to unrecognizability.
flattened almost
of cases
in a positionto demonstrate
we
are
directly
Etiology. In a large number
"

"

the

of the

cause

affection,for

we

convince

may

will lead

ourselves

that all the

to the

irritants which

act

formation
furuncles sooner
the skin for a long time
later.
or
upon
illustrations I will mention
friction of the skin by articles of
As one of the best known
of

tions
clothing,the tools of mechanics, etc. But the skin itself may also present the condiby which it is kept constantlyin a condition of irritation. This category includes
and also
chronic itchingeruptions (eczema, prurigo,pruritus,pemphigus pruriginosus),
first produce protracteditchingand subsequentlythose inflammatory
those agents which
of scabies,pediculosis,
furuncles
Thus
develop in consequence
dermatomyprocesses.
etc.
Inunctions
of ointments, metallic
kosis favosa, pustulosa (sycosisparasitaria),
of j)lasters
the use
(empl. diachyl.comp.) must be
salts,solutions,tinctures (iodine),

regarded
water

kinds
s.

less

no

are

cures

as

falselystated to be

the desired

of the sebaceous

glands and

of affections

folliculitis

and perhaps
barbae),

those individuals
But

the

class also includes

This

causes.

whose

furuncle

it is for

also

occurs

diseases of the intestinal

primary affection.

In

mellitus

precedes the presence

scrof ulosis,and
tuberculosis,
may

continue

until

the

often

tract

diabetes

of sugar

sometimes
In

(comedo,
that

reason

furuncles

which

in

They
sycosisvulgaris
develop in all

acne,

furuncles

often

in

occur

their presence in impure, dusty air.

with
in connection
other diseases,symptomatically,

another
for a long time
they follow one
body, we accept the view of a specialdiathesis
with

follicles

this

ominous

the crisis.

signsof

occupation necessitates

if

and

those

suffer

of

in the

life.

extend

speak

from

urine, and
and

However,

furunculosis.

until

the

appearance
even

marantic
we

largesurfaces

over

of

them

the
insipidus,

and

other cachectic

end

and
and

find

directs

of the

Patients

recovery of the
furuncles

of the

attention

conditions, the

to it.

losis
furuncu-

it preferablymaking

its

214

AJSTTHKAX.

CAEBUNCULU8,

as

appearance

avenging

an

Nemesis

the

where

patient has

sinned

much

in baccho

et

yenere.

with relative frequencyfrom the age of puberty to middle life in both

occur
evidentlyis due to the constitution of the integument, the development of
and the growth of the hair.
the glandular structures, the follicles,
I think I may
state that individuals who
To judge from
have
observations,
previous
around
of
the
skin (due to an
accumulation
a rough
thick, dark
epidermis
follicles),
hair and vigorousgrowth of hair are more
of furuncles.
predisposedto the formation
to develop epidemically when
Furunculosis
is said sometimes
variola,erysipelas,
and
phlegmons prevail.
With
the exception of the palms of the hands and soles of the feet, where furuncles
in all parts of the integument.
observed
The spots
are
very rarely(Duplay), they occur
and
the buttocks, scalp,axillae,
of predilection
are
back, neck, cheeks
eyelids.
in a positionto examine
in detail all the stages of the
We
seldom
are
Anatomy.
Furuncles
This

sexes.

"

"disease.
We

state with

may

arises from

of

degree

embolism

mation
probabilitybordering on certaintythat the inflamaround
the follicles of the sebaceous
and
capillaries

of the

glands,and that, in the

sudor.'parous
plasticinfiltration in the vicinityoccurs

course,

mortification

of the

the

tissues

with

If

at
these
ditions
conspot originallyaifected.
established,the other changes develop with a regularitypeculiarto these

once

are

further

its appearance,
this loosens the detritus of tissue and, by a propaPus makes
gation
processes.
to the necrosis of the skin, the disboth contribute
of the inflammatory irritation,
charge

of the contents, etc.

pathological
process
Prognosis.

The

Celsus

had

The

is confined

inflammation
to

very

terminates

small

spot and

spontaneously,because the
is rapidly removed.

the exudation

is absolutelymild, if uncomplicated by erysipelas

or
mon.
phlegdise",se
The
without medical interference.
alreadyremarked, it heals even
serious consideration.
furunculosis
dependent on a diathesis alone deserves more
Diagnosis. The recognitionof the disease can scarcelypresent any difficulties. Its
form, with the characteristic conical tip in the
circumscribed, sharply defined, rounded
middle
unmistakable
are
signs.
If there is any hope of abortive retrogression,
be
ice compresses
Treatment.
should
If the furuncle
the tension.
employed. They relieve the pain at least,and diminish
has developed to such an extent that the consistence is alreadydoughy, it is advisable to
use
containinglargequantitiesof resinous substances, but prepoultices. The plasters,
pared
which
without
tions
are
so
by the laity,often produce ulcerawarmly recommended
care,
"

As

"

"

to

which

an

unwished-for

should

the necrotic

be

done

by

are

one

or

evacuated

and

the pus,
the

CARBUNCULUS,

The

views

of the

entire

another.

crossingone

substances
process

aid the

which

conducted

In this

continuance
its natural

to

manner

of the

nation.
termi-

ANTHRAX.

agree in this that

of the cutis and the subcutaneous

past and present

inflammation

is present, it is best to divide the tumor,

free incisions

more

tissue and

connective

inflammation,

If fluctuation

extent.

the

carbuncle

cellular

is

an

acute

tissue,with

from several pointsleads to mortification of

and which
plasticinfiltration,
to an extensive gangrenous
character,
its
process.
and, by
progressing

cumscribed
cir-

fibrino-

sue
the affected tis-

216

CAKBUNCULUS,

parts which

other
the
is

direct

only

kept

are

suspicion of

certainty. In
etiological
conception.
spot

According
within

large as

as

the

to

with

converted

the

and

be

entire

toward

centre

death

with

follows
"

remains

swollen, and

the

With

individuals

Anatomy.

From

"

in all essential

respects

to that

the

to that

refer you

If

Diagnosis.
"

of the

part

sieve,

we

will be saved

Treatment.
At

the

onset

effected
do

by

If

the

suppuration

the

gangrenous

to the

pus,

should

the

of

If

they

but

let it lie until

is present, vertical

and

of the

entire

of pressure.
combated
by the diminution
of
frequent (three to four times pro die) introduction
clean or irrigation.
etc., keeping the wound

to

general condition

keep

the

fever

down

always
as

much

early stage by easilydigested food

demands
as

and

the

good

wine.

to

(Teguas

runcles.
of fu-

case

manifested; carbuncles
prematurely

are

different
be

old.

is so similar

clinical

observed.

pain,

toms
symp-

We

fore
there-

tense, hard,

which, if

it

softens,

perforated like
erysipelas.

not

are

tolerated

this

by

the

often

be

patient,

into

means

free escape

scurf.

is given

poisonous

We

the loss of

Burow's

must

stances
sub-

of the

consists

treatment

caust., camphor,

combat

dark

sufficiently
deep through

absorption of

further

kali

may

stage free incisions,or apply

is converted

the

this

and

greatest consideration.

possible,and

with

clearlyby surgical principles.

By

relieved, and

disease.

circumscribed,

at this

measure.

the

or

adduced

in the

as

tissue, and

and

skin

and

diseases, such

are

The

The

jacent
ad-

subject.

incisions,made

transverse

parts

can

is

even

bacilli

of the carbuncle

when

this

tension

make

the best

swelling,constitute
inflammation

the

the

this

same

is

who

even

insufficient,or

prove

possiblehemorrhage,

of

the

is indicated

to relieve

If the

clouded,

have

we

absent, appears
furuncle, phlegmon, or

or

becomes

quite rapidly from

constitutional

cellular

treatment

the

arise from

of both

carbuncle

it for

hours

jjfennig
opposite event,

more

which

structure

agreement

subcutaneous

mistaking

endeavor

paste, and

the

shreds, and, if these

method

ice compresses.

caustic

Vienna

from

The

"

we

dread

not

of necrotic

number

end,

the

few

which

size of

which

difierence

furuncle, that

that

in the

cluded
ex-

malignus.

infiltration.

blood).

in those

chapter referringto

remember

we

prominent swelling situated

contains

of the

anatomical

be

considerable, the

very

causes

certain

or

age,

to the

In

becomes

the

as

and

essential

an

firm

to the

of the

predilectionare

of advanced

after

progresses

carbuncles

good

sites of

beginning

the

prominent,

become

the

there

this may

increases, vomiting begins, the intestinal

consciousness

long time,

to observe-

that

carbunculus

one.

etiologicalfactors
hold

on

becomes

destruction

those

with

situated

(decomposition

age, however,

to

regard

especiallyin

of

happen

still others

its extension

cedema

fever

same

furunculosis

diabetes, uraemia, etc.) Even

occur

The

of toxa3mia

in

position

also

sero-bloody contents,

crust

the

for

and

local, circumscribed

exception

it may

trated
begins commonly with a slightlyinfiland
unnoticed.
pain
readilypass
may

after

spreads farther,

continuing

irritants

mentary

the

and

to furuncles

regard

brownish-red

splenic fever, the

of

no

in

are

epidermis,is elevated,

standstill'occurs

symptoms

With

Etiology.
specificpoison

the

(intestinalmycosis),

inflamed

becomes

tract

causes

we

but

associate

not

vesicle filled with

markedly
the
periphery.

are

cases

of the skin

development,

then

must

sago, which

flaccid

favorable,

process

glands
the

of
of

infiltration

bluish-red

the

affection

equal rapidityinto

should

course

The

of

splenic fever,
by flies,etc.,

opinion, we

my

violence

day, in the form

number

of

poison

grain of

In

inoculation

such

with

an

bare.

of the

transmission

ANTHRAX.

lution,
so-

vor
endea-

strength

at

an.

21T

ECTHYMA.

ECTHYMA.

ing
Accordbring the unmeaning term ecthyma into vogue.
of
is
each
an
eruption
large
phlyzacicalpustules,
ecthyma
hard
with
to
crust
dark-brown
situated on
black
a
base,
on
a
deep-seated,inflamed,
cicatrix. It is said not to be contagious,
drying, and usuallyterminating with a superficial
and
the entire body. They differentiated four varieties : E. vulisolated over
to occur
The
cachecticum.
dermatologistswho followed Willan
gare, infantile,luridum, and
acceptedthese views with rare unanimity. Alibert acceptsthe standpointof Swediaur
be replacedby phlyzacion,wherefore
he includes it among
and believes that ecthyma can
and Baerensprung stand
the herpetiform eruptions. Hebra
a purely historical
upon
and disputethe rightof existence of ecthyma as an independent morbid
foundation
genus,
and
of exanthema
it was
as
employed originallyonly in the sense
ecthylata; Kaposi
notiOn of a pustule. Startingfrom
associates with it merely the pathological
the Willanclasses ecthyma among
the furuncular
Bateman
affections.
;N"ot
definition,E. Wilson
quent
as
though it presents a clinical picturesimilar to this,but rather on account of its freassociation with furuncles, its pyogenic character,and the formation
of cicatrices,
and because both often appear to be the expressionof a lowered generalcondition.
Among
German
Auspitz has recentlyexpressedhimself emphaticallyfor the retention
specialists,
inflammations
of ecthyma, but he believes that it should be placed in the class of superficial
account
of the venous
in the family of stasis catarrhs of the skin, on
stasis of the base
with a new
and its termination
ers
coating of integument. Some English and French writthe existence of a contagiousecthyma.
assume
discussed
the historical development of ecthyma in order to show the
We
have
it
has passed,and also that its existence is not undisputed even
which
changes through
If
at the present time.
we
merely consider the etymological meaning of the word ecthyma,
be no
doubt that, in the absence of a specialpathological
there can
conception,it
cannot
be used to describe a varietyof disease.
However, dermatologicalnomenclature
in the present instance,
contains a sufficient number
of such inexpressiveterms.
But
the greater because
not even
the dilemma
is so much
able to erect a uniform
we
are
clinical history. A number
since the time of Willan have indeed placed
of authors
in the foreground, as an
ecthyma eruption, the pustule situated on a reddened
and
infiltrated base, but
the views concerning details differ to such an
extent
that some
identifyecthyma with all kinds of trivial pustular eruptions,while others state that
of gangrene
and severe
they have observed it in the course
generalsymptoms. But if
the subjectis investigated
without
bias,it will be found that there is a pustulareruption
in the Willan-Bateman
occurs
tory
inflammasporadicallyas a circumscribed
sense, which
nodule, is converted, after a few days, into a pustulewhich may attain the sise of a
Willan

to

was

the

first to

Willan-Bateman,

pea,

and, inasmuch

the

of the

top
produced.

as

the

pustule is

redness

or

infiltration increases for

some

time

at the

borders,

perforatedwithout

any definite cause, and a loss of substance is

in all parts of the body, but preferably
upon

Such
eruptiona may occur
and must
not be mistaken
for the
usuallyproduce no noteworthy disturbances,
etc., for impetigo, or the ordinaryfuruncle.
If we
pustulesof scabies,prurigo,eczema,
of eruption the term
wish to apply to this form
ecthyma which is at our disposal,
we
would
It would
undoubtedly be guiltyof a slightusurpation with regard to the name.
be admissible,however, in case
of necessity,
since we neither do an injury to any affection
would
we
nor
known,
already
produce any confusion ; this involves less contradiction,
the limbs,

"

"218

ALEPPO

when

also,than

EYIL,

the synonym

BISKRA

BOUTON,

of the French

DELHI

BOIL,

writers,furoncle

ETC.

atonique (Guersant)is employed.

to demonstrate
in every case
the irritant which produces
Although we are unable
such pustulareruptions,
nevertheless say this much, that we meet with it,often in
we
may
the integument is unclean
and not well cared for, particularly
in
large numbers, when
and also in badly nourished
and feeble individuals.
delicate, sensitive,
Sex causes
ference,
difno
but age does, as it occurs
more
frequentlyin poorlynourished children and marantic
old people ; vigorous,youthful individuals are
then
rarelyaffected by it,and even
only by a few pustules.
The eruptionis of no importance from a prognosticstandpoint,as it recovers
without

interference.

medical
So
such

as

long as

the

pustuleor crusty depositis present,it is advisable

oil,fat,etc.

If the loss of substance

has been

laid bare,

we

to

apply emollients

may

make

use

of the

ordinary dressings.

ALEPPO

first mention

The

EVIL,

BOUTON,

BISKRA

DELHI

BOIL,

occurringin

of the local affection

that

and

ETC.

around

Aleppo is made
is conveyed

the water, which

(1745)report of his travels. He

and
cityin aqueducts,has the property of producingboils (botches),
The
in the life of natives as well as foreigners,
once
usually in the face.
and
Patrick Eussel.
descriptionis furriished by the brothers Alexander
states

Pococke's

the

that it

in
to

occurs

first detailed

According to

the natives in the

several times, among
their account, the affection appears either once
or
and
not
is also not comthe
is
or
on
municable
limbs,
iace, among
contagious hereditary,
foreigners

by
It

was

vaccination

; it is not confined

learned, however, that

Aleppo, but

to

exanthem

similar

occurs

in

occurs

in the entire

vicinity.

the

the

valley of

phrates,
Eu-

part of Arabia, in Algeria

Egypt, upon Cyprus and the Sind, in the northern
(Biskraboils),Persia,around Delhi, etc.,and there extends over entire valleysand tracts
tubercule
of land.
Willemin
has therefore proposed to introduce the more
generalterm
d'Orient
terms.
instead of the many
special
of the nodules on
has been
The drinking water
cause
regarded as the immediate
and
alkaline
salt
of magnesia (Jilt),
account
of the presence
Weiss),
earthy
(Poggioli,
that the gases
salts (Massip,Netter), and
(Bysson). Some assume
organic substances
the producers of the germs
and others that the climate are
escapingfrom marshy districts,
from their vaccination
of the disease.
conclude
experiments
Flemming and Schlimmer
"that in the first stageof development, a substance
(Distoma haematobium) must be present
which
is destroyedduring the suppuration. Carter believes that the Biskra boil is a
granulation tumor
produced by a fungus, and that mycelium threads are found in the
vessels.
lymphatic
factors.
With
the etiological
the
The descriptions
of the disease are as manifold
as
that
nodules
form
ally
gradu'exceptionof the symptoms mentioned
by the Eussel brothers
later and heal within
under
a
or
inflammatory symptoms, degeneratesooner
year,
usuallyleaving behind disfiguringcicatrices no descriptionhas hitherto held its own
his predecessorof inaccuracy. While
permanently. Each traveller to the Orient accuses
the pustular exanthems,
Pruner
Kiglerregards it as a
places the Aleppo boil among
describes what, in our
furuncle.
This is contradicted by Willemin
who
judgment, is a
Persia
in
well-defined lupus. Pollak regardsthe
as
a
salak
occurring
process allied to
in

"

"

"

"

"

"

ALEPPO

but

lupus,

in

its

in

Persia

lupus.

not

DELHI

BOUTON,

the

on

observed

are

the

regards

hand,

other

like

the

and

scrofula,

syphilis,

Bertherand,

219

ETC.

BOIL,

quently,
fre-

very

disease

syphilitic

as

origin.
During

is

that

states
but

BISKRA

EVIL,

applied

in

stay

my
the

to

the

Orient,

various

most

became

convinced

exanthems,

such

as

diagnosis

the

that

furuncle,

eczema,

boil

Aleppo

of

syphilis,

lupus,

fuloderma,
scro-

etc.

In

Treatment.
be

name

and

that

of

mainly

the

by
caustics,
Pruner

of

in

order

recommends

during

the

Pollak

recommends
salt

common

if,

wound
In

this,

number

to

its

of

accordance

myself

of
the

definite

neapolitanum,

simple

cerate,

and

i.
the

have

nitric

in

the

very

open

boil

the

prolonged,

to

existence

of

and

advises

Floyd

is

varied

cicatrices.
that
of

sulphate

powdered
;

very

ence
prefer-

most

better
onset

the

at

in

the

employ

affection

employed

obtain

to

as

the

as

later,
copper.

washing
crossed

by

cauterize

the

with

incisions,
base

the

of

infernalis.
the
of

treatment

according

e.,

acid
to

become

concerning

Bruns-Volkmaun
obtained

to

lapis,

with

strewn

advisable

most

as

views

my

plan

circumstances,

empl.

with

be

order

applied

be

water

fuming

threatens

times
with

to

it

course

partly

lead

is

physicians
in

theless,
Never-

plaster"

useful,

boil,

the

shortened,

disfiguring.

butter

and

of

be

more

most

cass.

majority

ulcers

with

regards

pulp.

recovery,

compresses

suppuration,

Eigler

of

that

cannot

'^mercurial

the

proven

people

course

still

recommended

The

hasten

as

its

remains

has

the

among

treated,

which

salve

Aleppo.

cauterization

despite
a

of

prevalent
be

sarsaparilla
A

to

that

stage

has

that

nature.

inhabitants

partly

is
not

cicatrix

Eussel
states

scrofulous

should

the

even

Jilt

remedy.

opinion

it,

to

renders

find

we

effective

and

applied

interference

any

the

general,

"

whatever

to

the

curette,

satisfactory

at

least

scientific
nitrate
results.

the
bouton

200

diagnosis,
of

silver,

boil,

have

patients.
I

or

have

even

not

fined
con-

( !)

cording
Ac-

employed
merely

B.

CHRONIC

DEEP-SPREADING

INFLAMMATIONS

BY

PROF.

ER:rNrST

SOHWIMMER.

SCLERODERMIA.

The

during
cases

number
the

had

of accurate

last two

appeared

large,since

obseryations

decades,

and

in literature ten

observations

of this disease

while, according

has

to Heller's

years ago, their number

in

only

increased

markedly

statistics,
only fifty-two
is

probably nearly twice

specialworks, journals,etc.
now

reported every year

scleriapply the term sclerodermia
(scleroderma,
asis,and sclerema of the text-books)to a chronic disease which attacks individual parts of
the integument or the entire surface of the skin, developswithout any inflammatory process
and either persists
for a long time as a local disturbance
or, after slowlyspreading,results
in a rigidity
and hardness
of the skin, on
the latter entirelyloses its
account
of which
in
normal
considerable
its
further
suffers
and,
shortening.
elasticity
course,
in individual parts of the
(a) Partial sclerema, sclereme en placards. This occurs
affect the most
skin and may
varied surfaces of the body, usuallyin the form
of oval or
round
or
irregular,
elongatedpatches,stripesof a yellowishwhite or wax-like color. To
the examining fingerthey appear as an inelastic firm tissue,which
with diCicultybe
can
raised from the underlying layersinto a fold.
ing,
The affected surface itself is usuallyshinand the healthy skin surrounding the diseased parts often appears
changed by more
marked
pigmentation, or a rose-colored or bluish border, so that the former sometimes
looks as though it were
Partial sclerema
surrounded
by an elevated circumference.
as

new

Symptomatology and

are

Course.

"

We

"

occurs

in manifold

develop as

forms

and

in recent

the results of morbid

times

various

innervation,

are

local

included

nutritive
in

disturbances, which

this category.

To

these

the disorder usually

described
belongs the sclerodactylie'
by Ball, in which
the
the
at
ends
of
the
more
on
limbs,
frequentlythan the
fingers
appears symmetrically
and
toes ; this affection forms
transition
to
a
symmetrical asphyxia
gangrene.
Furthermore, the affection described
by English physicians as morphoea localis
in the direction of individual nerve
which
often occurs
trunks.
ciated
Finally,the sclerema assoit may
form
with atrophy of the affected partsof the skin. D nder whatever
appear,
the changes in those parts of the integument affected by partialsclerema
are
important,
local forms

inasmuch

as

the diseased

skin, if it shows
'

Societe

de

no

tendency

Biologie, 1871.

to

restitution,becomes

thinned,

221

BCLEKODEBMIA.

and
parchment-like,

the

atrophyof

the cutis extends

to
gradually

the

inunderlyinglayers,cluding

the muscles.

ages
trophicchanges produced by sclerema, the skin and its appendreports the case of a young man,
present not alone upon the trunk
and
limbs, but the scalp also presented several sharply defined
spots in which
of the patches
in circumscribed
the hairs appeared as white
bundles
spots; many
trunk
their
intercostal
the
the
ran
nerves.
course
on
Gibney^ reports a
along
in which
and scalp,and
in which
case
morphoea spots were
present on the trunk
Such cases
of a few years.
better
unilateral facial atrophy had occurred in the course
are
manifested
evidence of the character of the affection than those which
are
by the simple
be mistaken
formation
of spots (morphcea),
the latter may
as
readilyfor cases of vitiligo
be
must
attention
in a certain stageof the disease.
Special
paid, therefore,to certain
the
connected
with
color
of
the
skin, as belonging to the diagnosisof partial
phenomena
These
certain lilac discolorations with which
the disease begins,and upon
sclerema.
are
As in erythema iris,
which specialstress is laid by Wilson, Fox, and others.
white, rosebe distinguished
another
within
from one
the sclerotic
can
colored,and lilac-colored zones
of the disease,
and
it then
patches,but these signs become lost after long continuance
acquiresa waxy, white hue.
We
apply this term not alone to those sclerema affections
{b) General Sclerema.
of the

In consequence

Jamiesson'
will appear disturbed in various ways.
in whom
extensive patches of the kind described were

"

which

attack the entire surface,but also include

skin, in which

the

those

forms

affection is present

of extensive
the

sclerosis of the

spread and

increase of
over
a great extent, and
degree that the change is found over extensive surfaces.
affection begins generallyin a circumscribed
The
portion of the skin, but only
then spreadsinto surrounding parts,until graduremains localized for a short time and
ally
the entire integument is affected.
We
the largestpart or
even
therefore,
may,
in which
under
include such cases
the head of gena third of the integument is diseased
eral
The subjective
sclerema, as well as those in which a half or more
appears sclerotic.
sensations are described by the patientsas very annoying, muscular
action is impaired by
the tense skin, and is painful. Thirial's statement
that the skin affected in this manner
is cold and upon contact reminds
is a
of the sensation produced by a frozen cadaver
one
The
skin
cannot
be
raised
in
is
smooth
one.
as
or
folds,
apt
slightly
scaly,
usually
very
thin epidermiscells are sometimes
loosened from the dry surface,but it is hard and rigid
hollow can
that no depressionor
the finger. In
be produced upon
so
pressure with
with the nature
of the process, the cutis appears
accordance
hypertrophicin the first
and
of
the
shows
moderate
which
continues
for a short time
a
disease,
stage
swelling
only
then
all layers of the skin, in addition to the muscles
and
as
and
changes,inasmuch
which givesrise to the loss of elasticity
of the
fasciae,
graduallyatrophy a circumstance
of mobility. In sclerosis of the integument of the face, the mouth
skin and deficiency
is
the eyelidscan
with difiiculty,
moved
the
scarcelybe closed,the physiognomy assumes
of paralysis
of the face.
If the sclerosis extends
to the region of the neck
appearance
and throat, rotation of the head
to
skin of the
extent
certain
can
occur
a
only
; if the
thorax
is sclerotic,
the funcabdomen
is
and
likewise
tion
or
respiration impeded occasionally,
muscles
if
becomes
of the abdominal
; finally, the limbs are affected,their mobility
and hands is
impaired. The fingersare in a positionof semi-flexion,the use of the arms
the disease

to such

occur

"

Edinburgh

'

"Oa

the

Med.
Journ., 1880, p. 648.
Histology and Pathology of Morphcea,"

Arch,

of

Dermatol., 1879, p. 54.

222

SCLEKODEIiMIA.

interfered with
is

the
considerably,

and
possible,

the

toes

gaitbecomes

are

uncertain

bent,

as

and

neither

complete extension nor flexion

tottering. The impression created by
and
as the skin is everywhere shortened

inasmuch
patientis extremely distressing,
'Hoo
tight."
The functional activities of the skin are changed in a similar manner.
Tactile sensation
the
suffers no diminution
disorder
exists
to
in
so
as
but
sive
extena
long
slightdegree,
sclerema there are marked
I have detected a diminution
cases
changes, and in some
sensation demonstrable
The
by the eesthesiometer.
temperature sinks in some
cases,

such

becomes
tense, and literally

of
and

secretion of sweat

the

with

interfered

(mouth,

by

the

is diminished.

peculiarcondition

and

ways,
be observed

the

After

brownish.

these

the face

time,
In

the

of the
of

occurrence

in

of
erysipelas

function
if the

of the

membranes

mucous

sclerema

in

occurs

is also

their

vicinity

vagina).

nose,

The

The

tegumentary change

its

does not

prevent its affection in other

efflorescences,variola

acne

patients.

run

sclerosed skin

In

course

color of the

one

case

twice
skin

of marked

without

any

undergoes a

eruptions,herpes,etc.,
sclerema

effect

notable

saw

may

extensive

an

the primary disease.

on
change; it grows darker

and

described

of years ago, the skin had

number
bronzea
a
by me
almost
colored appearance
Some
tolerable
of
condition
a
everywhere.
patientsenjoy
in
diseases
others
observe
with
of
the
neys,
kidand
we
health;
complications
lungs, heart,
to a fatal termination
which lead finally
by amyloid degeneration.
The
of sclerema
is always very slow and tedious,and as soon
it has reached
course
as
certain stage of development, it undergoes either a retrogressionto the normal
a
or
first termination
The
leads to a terminal
of
change with an unfavorable ending.
sclerema
which
have been
recognized early and
rarelyoccurs
spontaneously,and cases
been
for
must
have
treated
be regarded as the favorable forms
a sufficient length of time
In such cases, the skin usuallyrecovers
of this affection.
slowly its lost suppleness and
mobility,the hardness and board-like stiffness diminish after a while; the patients,during
its further
state with satisfaction that the tension givesplace to greater mobility;
course,
the discoloration
improves, and the dark color begins to disappear. It rarelyhappens,
which
it had previousto the
material structure
however, that the skin acquiresthe same
a

case

disease.

ordinary termination of sclerema, however, is that which we have just described

with
symptomatology. The hard, tense, firm skin becomes continuallythinner
account
of the
increase in the symptoms of tension, it feels like parchment, and, on
an
to
to be adherent
tissues,seems
disappearanceof the underlying adiposeand muscular
conditions
and
local
of
stasis
the bones; the circulation suffers considerable
disturbance,
The
which lead to mortification of the tissues with subsequentulceration.
(asphyxia)occur
their
manipulations,
skin, the patientsare impeded in
jointsare fixed by the immovable
The

in

the

and

as

only

the

occurs,

vegetativefunctions
however, after

of the

also suffer

disturbance,

severe

of years, is unavoidable.
is attributable to the numerous

number

parenchymatous organs
the
impeded circulation,but the influence
by
not
of the disease,must
probable starting-point

of

the

morbid

be left out

fatal termination, which

amyloid degeneration

The

disturbances

variety.
Anatomy.

"

connective-tissue

The

cutis

elements.

appears

The

broadened
elastic

fibres

and

thickened

within

nutrition
is the

of consideration.

The form of this disease,described

as
atrophicor
by Wernicke
should, therefore,be regarded as the final stage of the sclerematous
a

of

innervation, which

it have

by

sclerema,
cicatrizing
process

than

new-formed

numerous

increased

rather

in

places,newly

ii24

SCLEEODEKMIA.

it cannot

extensive

to

and

nature
duct

was

be

not

change in the lymphatic yessels does occur, and that it leads

of lymphoid cells,this signifies
proliferation
nothing with regard to the

be denied

cause

that

of the

An

affection of the
which

In

disease.

entirelyunchanged,
explained in this manner.

and

three

cases

the increase of

under

lymph

my

observation, the thoracic

in the subcutaneous

system explains most readilythe

In my
in this affection.
treatise,'I have
nervous

occur

tissue could

of nutritive

sum

turbances
dis-

directlyapplied the

to adduce
those arguments which
trophoneurosisto sclerema, and have endeavored
not
this
view.
these
to
aid
alone
the
clinical history,
but
we
include,
Among
may
which
also some
discovered
anatomical
towards
marked
recently
point
changes
appearances
in the sympathetic,as well as abnormalities
in the central nervous
system. I will here
of Harley, who
mention
the observations
observed
marked
disturbances
of the
briefly
action of the heart and stomach, in addition to greatatrophy of the skin in an advanced
of sclerema, and who
of the sympathetic;
attributes all the symptoms to a paralysis
T;ase
furthermore,the observations of Westphal, who found pathologicalchanges in the brain,
and
which
showed
disease of the peripheralnerves;
the recent case
of
own,
finally,
my
The
Eulenberg, who found progressivefacial atrophy co-existingwith scleroderma.
number
of autopsiesand clinical observations
is still too small to determine
solute
with abstitutional
certaintythe pathogenesisof sclerodermia, but this is no less true of other conthe trophoneurotic nature
affections.
In the present condition of affairs,
of
term

serve

sclerema

may

be inferred

Diagnosis.
could
only be
"

It

left out

The

rather than

demonstrated.

diagnosisof the

mistaken

for

of view; for neither

other

oedema

disease

in

any

case

will meet

diseases if the essential

with

symptoms

no

difficulty.

of sclerema

are

the

mations
hypertrophy developing after local inflamof the rigid,immovable
do they show
presentthe appearance
integument, nor
its tension, rigidity,
or
peculiarshortening. Local sclerema can be differentiated no less
from
the
readily
healthy parts of the skin: the shining,tense, waxy patches surrounded
of the affection are
by a slightlyhyperaBmic zone, the slow development and persistence
in no
other disease.
In the later stages, when
found
atrophy occurs, consideration
be paid to the previoushypertrophicstage,in order to explain better the existing
must
abnormality.
In general, sclerodermia
does
not
admit
of a favorable
Prognosis; Treatment.
fatal
after
termination
but
it
leads
to
a
eases
prognosis,
generally
only
complicationwith disof internal organs.
If the latter do not develop during the course
of the skin
Sclerema
disease,continued emaciation and marantic conditions occur.
trogression
undergo remay
if it has not reached its acme;
the newly-formed
connective-tissue
elements
and
in the cutis then undergo transformation
absorbed.
Such
curative process
are
a
of
aid
but
the
the
rarelyoccurs
by
appropriateremedies which stimulate
spontaneously,
the process of absorption and are
capable of rendering the rigid skin flexible. This
holds true only of those cases
in v.^hich the mode
the constitution of the paof life and
tient
nor

"

further
The

the

proper treatment.
varied remedies
have

tributed
employed, and a certain effect has been atconsist
of
ments
ointcurative
one
method.
The
or
agenciesemployed
of iodine and mercury,
baths of all kinds
iron, soda, vapor, and sea baths),
(salt,
hydropathiccures, external use of oilyand fattysubstances,such as cod-liver oil,glycerin,
with
alcohol.
vaselin,tar oils,either pure or combined
Iron, quinine,bitter tonics,etc.,
most

to

the

been

other

'

"'

Die

neuropath, Dermatonos."

Wien,

1883.

SCLEEEMA

were

recommended.

was

is

one

none

of these

remedies

and

will

valuable

of the most
the exclusive

simultaneous

use

remedies

in the

treatment

galvanizationof the

of baths and,

the

form

curative

under
its use;
positively
retrogress
According to
mercurials, have a certain value.

sclerodermia
and

in
electricity,
finally

and
employed internally,
Of

225

NEONATOKUM.

but

my

of the constant

measures

current,

it be said that

can

all,with the exceptionof iodine

experience,the constant current
of sclerema, and

we

this does not

sympathetic,though
of tonics,according to
internally,

the

may

mend
recom-

prevent

the

necessities of the

case.

SCLEREMA

NEONATORUM.

Hardening of the skin of the new-born must be regarded as an entirelyindependent

affection,occurring during the first days of life,and probably developing during foetal
existence.

Symptomatology. The

between
the third and sixth days after
considerable part of the lower limbs is
a
integument over
dirty-brown or yellowish;it is
shining,tense, of a white or rosy-redcolor,occasionally
in
after
with
the finger,
becomes
hard throughpuffy, placesleaves a depression
out,
pressure
be raised in folds.
and cannot
Beginning in the calves,the disease soon spreads to
the thighs,extends over
the abdomen, trunk, and upper
limbs, affects the neck, throat,
and face,and in a short time, often within a few hours, or in one
to two
ease
days, the disthe entire body. The rapid fall of the temperature of the body,
has affected almost
the coldness of thfe affected parts,and feebleness of all the passivefunctions
of the organism
The
dren
mobilityis very restricted,the chilpoint to a serious general condition.
in a lethargic
to be sunk
lie feeble and rigid,with the eyes usuallyclosed,appear
account
of
the
account
ficulty
of the difrefuse
on
on
nourishment,
sleep,
partly
stupor,partly
is irregular,
the pulse very frequent,ocof suckling. The action of the heart
casionally
intermittent,not always perceptible. The respirationis also affected by the
and then stertorous
now
superficial,
rattlingis noticed,
generalcondition; it is irregular,
and
The evacuations
from
the bowels
the excretion
a low, painfulcry is heard.
occasionally
The
fatal termination
in four to ten days,under
of urine are diminished.
occurs
constant
increase of the symptoms described.
Such
a
grave clinical historyscarcelypermits a thought of recovery, and, although
cellular
we
might suppose that all new-born affected by hardening of the subcutaneous
to death, some
tissue are doomed
in diseases of children have seen
specialists
inevitably
when
the disease had affected only individual parts of the body.
recovery ensue
The cause
of this affection appears to lie in an extensive implicationof the bloodvessels.
Some
affection of the
authors regard atelectasis of the lungs, others a congenital
of the
heart,and stillothers a constitutional anomaly as the most probablestarting-point
disease.
These views are opposed, however, by the experiencethat unfavorable
hygienic
conditions,lack of a healthydwelling,good air,attentive nursing,etc., most readilyproduce
of the new-born
is observed
this disease.
On
this account, scleroedema
chiefly
the poorer classes and in foundlingasylums.
among
the deeply-spreadingchange
Anatomical
examination
enables us to follow distinctly
of all the layersof tissue of the general integument. The
wide-spread infiltration of
the subcutaneous
tissue permits it to be readilyraised,in places,from the deeper layers
of muscles
of a yelthe fasci*; and, upon
notice the exudation
and
lowish-w
section, we
fluid,consistingchieflyof drops of fat. The internal organs are
serous
also considerably
changed. While the lungs and kidneys are congested,the brain and
"

birth,when

15

we

find that the

first symptoms appear

226

ELEPHAirriASIS

membranes

serous

Treatment

attention.

only lead

with

by

to

favorable

who

born

are

develop,apply

the administration

by
mixed

Children

If the first signsof oedema

of the limbs

internal

this way,

and

and

when

the

delicate

cur
oc-

threateningaccidents
requirecareful

the asbestos-like whiteness

or

diseases which

are

nursing and

and

ness
strikinghardirritatinginunctions, aid nutrition
good substitute,give a mild wine

softeningpoulticesand
milk

day, and

external

result

feeble and

of mother's

times

several

sugar

PACHTDEBMIA.

moisture; the complicating

completelydeveloped.

often not

are

organs

can

recognizedearly.

8.

infiltrated with

appear

in the internal

AEABUM

or

endeavor

stimulants.

The

the

threateningaccidents avoided.
has once
occurred, there is hope of improvement;
finally
give place to greatervigor,and the life of

ELEPHANTIASIS

ARABUM

to diminish

stases

If

of the

in
occasionally
symptoms
of vitality
will

severe

congenitalweakness
patientthus restored.

the

S.

ances
disturbcirculatory

relieved

remission

the

the

be

can

PACHYDERMIA.

is meant
disease of theSymptomatology. Under the term elephantiasisarabum
a
connective
tissue in individual parts of the body,
layersof the skin and the subcutaneous
of the blood-vessels and lymphatrunning a chronic course, beginning with inflammation
ics,
and erysipelas;
and often leading to oedema
it is followed by an enormous,
deforming
"

of tissue.

increase

mainly the lower limbs and

characterized
forms
and
elephantiasis,
accordingly,viz.. Elephantiasiscruris,and
disease affects

The

of

two

the

integument

by

their

E.

genitalium.

genitalapparatus,

have been
localization,

ognized
rec-

described
Elephantiasisin other parts of the body was
partly as neoplastic formations, partly
of vessels.
Such
tumors
telangiectatic elephantiasis if the swelling jxresented a great abundance

as

observed

were

has

on

described

dense

fibrous

in blind

the upper

which

appendages

hang

arms,

which

and

structures

be

as

also

regarded

of the ear, and

in this form
they constitute monstrous
adjacent parts of the skin.
Rokitansky
consisting of numerous
lobes, and held together by
consist of ducts
containing blood, and terminating

traction

tumors

of which

Hebra("
by their

distinguished

may

produce

the contents

Kaposi and

extremities.

and

limbs, face, conchge

down

the vascular

tissue, and

phantiatic tumors,

the

Hautkrankheiten,

Bd.

II.,S. 114) described

development

abundant
varieties

as

of

of vascular

tumors

of

cruris,the originand development of the affection

elephantiasis
and
morbid
change characterized by the ordinarysignsof erysipelas,

combined

with

the streaked

inflammation

redness

of

the

of

the

veins.

affected

The

lymphatic

skin

becomes

vessels

or

cases

vessels,occurring upon
(tumores cavernosi).

In

of the

are

of elethe

preceded by

which

is often

inflamed, painful,shows
venous

apparatus,

and

the

neighboring lymphatic glands become thickened, swollen, and extremely painful. After
of the erysipelas,
which
is accompanied usuallyby violent fever,a slight
the termination
behind.
The
skin is slightly
remains
tense, shining,
cedematous
swelling occasionally
consistent.
In some
somewhat
tissue appears
more
cases
and the underlying coonnective
and the diseased parts present merely
without
its course
the erysipelas
runs
any sequelae,
a slightdesquamation or
change in the tissues. In the majorityof cases, however, the
mentioned
continues for some
oedema
time, and if the skin is affected by erysipelasagain
several times in succession,a tendency to persistentswellingof the lymphatic apparaor
tus
of the
the frequent recurrence
is thus produced. With
with increase of the oedema
oedema
the
becomes
external
after
either
provocation
spontaneously,or
erysipelas,
manent,
pertissue
the skin presentsa slightdepressionon
pressure, but as the subcutaneous

ELEPHANTIASIS

is

more

resistant than

in

in

yielding character

places the

hard

and

from

the occlusion

become

The

AKABUM

stiff.

These

increase

conditions

of the

stringyand

which

cedema

in volume

and frequent
developed without severe
sipelas,
eryis
absent, and it is
integument
entirely
favored by the stasis of lymph in the vessels

of the

also

are

227

PACHYDERMIA.

has

account

of which

uniform

mass

glands,on

hard, and form

S.

of the diseased

the

dilated lumina

partsconstantlybecomes

developsgraduallythat enlargement which causes

The
have been
symptoms of elephantiasis

of the vessels

with the infiltrated connective

more

tissue.

striking,and

the monstrous

thus

of

tiasis.
elephanappearance
develop within one or more
The external form of the new-formed
of tissue varies according to the parts
masses
years.
affected.
Elephantiasisof the lower limbs thus appears entirelydifferent from that of the
genitalapparatus. The swellingand thickeningof the affected limbs become
shapeless,
the contours
of the muscles disappear,and the heavy shapelessextremity reminds
of
one
the enormous
dimensions
of the leg of a rhinocerus
whence
also
the
or
name
elephant,
In a case
of M'Oall Anderson,'
elephantopus. The circumference of the limbs is not uniform.
the circumference
of the

of the foot

about

was

cm.
thigh
; in Bryant's^case
Still greaterdimensions
are

69

found

62 cm.,

to

that of the

calf 80

cm.,

and

that

the calf and

73 and 84 cm.
in circumference.
thigh were
of the genitalapparatus.
observed in elephantiasis
of the scrotum
of this character which weighed 110 pounds.
a tumor
Clot-Bey^extirpated
No less great dimensions
occurred in unusual
ties.
localiare
reportedwhen the elephantiasis
of Gussenbauer's^
Thus in a case
of elephantiasis
nasi in a boy set. 14 years, the
8.2 cm.
nose
was
long from the glabellato the tip,and 6.3 cm. broad.
The
changes in the surface of the integument are manifold; it is either smooth,
and
tense,
shining, or studded with numerous
nodules, prominences, or circumscribed
tumors
which
must
be regarded as papillaryproliferations
and secondary formations,
since all layersof the tegumentary tissue take part in the morbid
But apart
process.
from the more
marked
the surface of the
on
changes of tissue and the new-formations
such as eczema,
skin, various morbid
papular efflorescences or ulcerations,are
processes,
found upon
it. The latter assume
unfavorable
an
commonly
develop slowly
appearance,
from the surface,but soon
extend more
deeply,destroythe fascise and muscles, and erode
the osseous
tissues.
The edges of the ulcers are elevated,swollen, and form a crater-like
the deeply-spreadingloss of substance.
wall around
not
be regarded as
They must
identical with those losses of substance
which
observed
in long-continued and negare
lected
ulcers of the foot, which
often result in thickeningand enlargement of the adjacent
In placeswhere
affection.
parts of the skin and are usuallyregarded as an elephantiatic
the epidermisis unchanged, it is dry, rough, covered with thick lamellae which
are
ranged
arin layers,
next to and above one
in
a
or
another,
grayish-brown
dirty-graymass,
in ichthyosis. In some
as
places,however, the skin usuallybursts, or even the lymphatic
account
vessels are opened, on
of the severe
stasis,and an escape of a clear,milky
fluid thus occurs
(lymphorrhcBaor lymphorrhagia).
The changes occurringin the deeper layersare stillmore
worthy of note.
The
thickeningand extraordinaryenlargement of the affected partsdepends on the
increase

of the connective-tissue

cutis itself.

Accordingto
'

Journ.

'

Ibid.

Alibert's

elements

Virchow,
of Cut.

in the

subcutaneous

Die

as

constitutes
accordingly,elephantiasis

Medicine, 1869, vol. i.,p. 183 and

Vorlesung u. s. w., Bd. ii.,S. 216.

Prager Medic
Wochenschrift, 1880, No, 21.

"

stratum,

lii-ankhaften Geschwiilste," Bd.

i.,S. 311.

191.

well
a

as

in the

diffuse

con-

228

ELEPHANTIASIS

nective- tissue tumor

and

elements

which

increases
of

the

belongs

still more

the

to

present in

are

other

AKABUM

such

PACHYDEEMIA.

class of fibromata.

that

masses

in consistence

tissues,such

S.

and

size,on

new-formed

dense,

of

account

muscles, vessels, and

as

The

they form

callosity

tion
partialtransforma-

into

nerves,

tive-tissue
connec-

firm

connective-tissue

masses.

the other hand, it should

On
the

result

of conditions

transudations

analogy for

real inflammation

or

those

cases

develop,such as
the breast, etc.
fingers,

or

The

function

forgotten that
they cannot

of the vessels.

of the affected

to the

observed

are

the fibromata

that

in which, in addition

new-formations
toes

be

not

and
of stasis,

part of

the

be

At

regarded

the

most,

we

never
as

may

fibroma, circumscribed

in
occasionally

of the

some

develop

as

result

of

the

concede

the

elephantiatic
jointsof the

is thus

body

tent,
impaireidto a considerable exelephantiasisof the lower limbs
in walking, or drag themselves
often hindered
are
along with difficulty.Occasionally,
these unfortunates
confined
to bed and presenta pictureof wretched
are
misery.
almost
the scrotal integuElephantiasisof the genitalsin men
ment;
always starts from

and

often

in women,
the

upon

abolished.

from

the

Patients

labia

penis;in others, upon

considerable

size, but

who

clitoris.

and

the scrotum.
the

from

suffer

In

some

cases,

the

disease

Elephantiasisof these

appears

parts often

first

attains

genitalia(labia
the subject of operative treatment.
majora) and, being circumscribed
tumors, often form
dividuals
of observations,collected in Egypt, of inReyer has published a largenumber
sufferingfrom E. genitalium, in which the tumors
weighed forty to fifty
pounds, and the patientshad been affected with this disease for twenty years and upwards.
of satisfyingthe sexual
desire
that the impossibility
Reyer adds the statement
extend
In these tumors, which
causes
perhaps the greatestsufferingto the Arabians.
almost to the knees and
ankles, a small, navel-like depression is usuallyvisible in the
row,
furTipper third of the tumor; this presentsitself to the examining finger as a narrow
and leads either to the glans penis or the entrance
to the vagina. In other respects,
of the genitalsdoes not affect the generalhealth of the patientto
liowever, elephantiasis
and
Alibert
that the above-mentioned
patient,who
reports as a curiosity
any extent,
and
when
whose
was
removed,
by Clot-Bey,
elephantiaticscrotum,
operated upon
and ten pounds, produced two children after the disease had lasted
weighed one hundred
thirteen years, but before it had attained
its monstrous
development a proof that the
functions of the testicles had not been destroyed by the morbid
process.
at the onset of the disease,as in eryThe other subjectivesymptoms
the same,
are
turbance,
In addition
and lymphatic inflammations
to generalfebrile disof the skin.
sipelatoid
of
the
in
the
affected
tlffepatientssuffer from
and
tension, drawing,
parts
pains
the
skin
has
assumed
after
tumor
which
the
formation
of
disappeargradually
symptoms
the upper hand, and are
then followed
annoying conditions of
by the above-mentioned
increase of weight and formation
of the tumor.
small
form
The inguinalglands are
always swollen and enlarged,and occasionally
in the groins,^
tumors
sometimes
which
permit the escape of lymph.
in other
formations
also occur
In addition to the localities mentioned, elephantiatic
but
these
of
the
of
the
the
exsuch
limbs
and
the
face,
as
body,
integument
parts
upper
a

very

larger tumors

occur

on

the

female

"

"

"

'Zeitschrift
1855.

Nos.

"Inloc,

*Hendy:

der

Gesellschaft

10, 11 und

der

Aerzte.

"Ueber

ElephantiasisderGeschlechtstheile."

12.

cit.,S. 217.
"

Die

Driisenkrankheiten

von

Barbados."

From

the

English.

1788.

Wien,

ELEPHANTIASIS

cessive
of

hypertrophiesof

disease of the

the

skin

vessels,but

AEABUM

the

and

rather

8.

229

PACHYDEKMIA.

connective-tissue

of other

layersare rarelythe results

neoplasticformations,such as syphilis,

lupus, etc.
With regard to the age of the affected individuals,almost all statements
are
agreed
the twentieth
and fortieth years, and that it is very rarelyfound
that it developsbetween
outside of this period. I have under observation
suffered
a patient,
a boy of twelve, who
left
in
of
the
from severe
and
whom
an
foot,
elephantiasis
prurigo,
extending half-way
The increase of volume
is very considerable,
up the leg,developed within three years.
and the circumference
40 cm.
of the ankle-joint
measures
in the orient has long been
The opinion that this disease is observed exclusively
futed,
reand elephantiasis
the entire surface
may be regarded as a disease extending over
of the earth.
with
However, there are certain geographicallatitudes in which it occurs
districts
and
situated
in
the
some
viz.,
India,
Africa,
tropics. In
great frequency,
has
observed
in
such
numbers
in
India
it
been
of
some
that,
1857, according to an
parts
individuals
affected by it.' In
were
48,600 inhabitants, 2,133
English writer,among
in much
Africa it occurs
smaller numbers, mainly in Egypt, Tunis, and Barbary.
description of the changes in the integuhiatomy. Rayer^ gave an admirable
ment.
of tissue as the most
He regards the enormous
proliferation
important change,
tissue appear
and first emphasized the fact that the fibrillaeof connective
in a number
of
fluid
As
another
above
another.
he
the
one
serous
layersplaced
strikingfeature,
regards
abundantly present in this tissue,and which can be removed
readilyupon pressure with
fat-cells. In addition, the papillae
the finger,
well as
the profuselyembedded
as
appeared
and
discolored.
These
considerablyenlarged,the epidermis thickened
ances
appearclose
also observed
Virchow^
devoted
were
by Henle, Simon, Lebert, and others.
of
and
the
the
thus
to
the
shed
the
most
skin,
on
microscopical
anatomy
study
light
this
section
from
of
morbid
the
surface
to
the
the
Upon
bones,
peculiarities
process.
consistence in which
of waxy
skin often shows a hard, fibrous callosity
scarcelyanything
but fat and muscular
substance can
be distinguished. After prolonged duration
of the
substance
is also destroyed,and where it can
tinctly
disease, the nervous
no
longer be found disin the dead
body, anaesthetic and paralyticconditions were
present during life.
in abundance
the cut surface of the skin is
The clear yellowishfluid which
on
appears
the
external
than
which
in
air. Virchow
more
nothing
lymph
coagulates
explains this
accumulation
of lymph by the fact that in elephantiasis
the glands swell at an
early
of
activityof the lymphatic vessels. On account
period,and thus impair the functional
the vessels,these become
dilated and thus give rise to the
the stasis of lymph within
had
of this whitish-yellowfluid which
abundant
characteristic
alreadyseemed
presence
to Eayer. This primary affection of the lymphatic glands thus constitutes
an
tant
imporfrom
other
cedematous
and erysipelatoid
differential characteristic
inflammatory
The
conditions.
is very thin, in
epidermis presents a variable condition, occasionally
the papillais not distinct,the epidermisthin
When
other cases
considerablythickened.
and smooth, when
it is stronglydeveloped and branched, it will be covered
dermis
by the epiin thicker layers,and followingthe elevations,produce the previouslymentioned
The
Malpighian layeroften shows considerable increase of pigment,
ichthyoticappearance.
dilated in places. In some
the lymphatics are entirely
and the capillaries
are
cases
"

*
'

Hirsch:

"

Histor.

"

Maladies

"

Krankiiafte

Geograph.

Pathologie," Bd.

ii.,S. 477.

de la Peau."

Geschwiilste," Bd.

I., S. 300

et seq.

230

ELEPHANTIASIS

the

intact,but then

voin3

ara

8.

A.BABIJM

m^rkodly dilatad,

PACHTDEKMIA.

with

distinct

hyperplasiaof

the

tunica

adventitia.
were
sought in climatic and telluric influences by
elephantiasis
in
frequently tropicalcountries.
English physiciansparticularly
many
th3
in the air as
moisture
dividuals,
inan
factor,inasmuch
as some
especialmorbid
regarded
from
the
colds
to
the
classes,beingexposed
frequent
especially
during
rainy
poorer
of the tegumentary and
are
more
vascular
readilypredisposedto inflammations
season,
apparatus. In addition, the constitution of the soil,the ingestionof certain articles of
food, drinking water, hereditarytendency, and various other general or occasional causes
were
regarded as factors giving rise to elephantiasis.
Such vague statements
that elephantiasis
can
only be supported by the circumstance
more
frequently in tropicalcountries; but investigationfurnished a definite
appears
is certainlynot without
in a series of
morbid
factor, which
pathogenetic significance,
similar diseases,viz.,the occurrence
of Filaria sanguinisin the blood and lymph. Lewis'
the pathologicalconditions
has carefullystudied
produced by filaria and its embryos,
that in the blood and lymph capillaries
and
adhere in greater numhas shown
bers
they may
in placesto the vascular walls,there give rise to disturbances
which lead to stasis and
of the lymphatic vessels and
veins with
sequent
subembolism, and afterwards produce tumors
and
India regard this
elephantiasis.Numerous
physiciansin Brazil,Australia,
action of the filaria in producing elephantiasisas undoubted, and
must
we
grant the
validityof this factor in the tropicalform of elephantiasic.
But there are
other factors which may
be regarded as exciting causes
and which
in almost all parts of the inhabited globe.
explain the development of elephantiasis
Among these may be included all those morbid factors which produce inflammations
One of the most frequent causes
of the lymphaticapparatus and the vessels of the skin.
ulcers of the leg,
which alwaysprecedesthe outbreak of the disease. Chronic
is erysipelas
of the extremities
also give rise to these hyperplasticconditions;
continued
eczema

Etiology.

The

causes

observers

who

saw

"

furthermore,

dilatation

of

it

of the vessels,varices,thromboses, and

and

disorders
circulatory

obliterations in parts of

kinds
higher*up,
produce
may
and
also
cause
disease in a like manner.
syphilis
persistentthickeningsof the
Lupus
of which it may
acquirean elephantiatic
skin, by means
appearance.
of the scrotum; its great vascucausal factors hold good for elephantiasis
The same
larity
and the numerous
lymphatics readilypermit the development of this affection.
is always an extremely annoying
Elephantiasisarabum
Prognosis and Treatment.
the vessels situated

of various

"

affection,and

in

some

cases

even

leads

to

fatal termination.

The

inconveniences

in the use of the affected

dragging about a foreignweight, the difficulty
in
disturbances
to generaldepresthemselves
addition
in
persistent
bodily
sion
produce
parts,
of
and
formation
and melancholia.
disturbance,
thrombi,
Circulatory
inflammatory
observed pyasmia with a fatal
conditions of various kinds develop. In a few cases, Hebra
do not
from the spread of inflammations
of the veins, but such terminations
termination
in
and
of
the
accommodates
itself
to the
occur
often,
majority
cases, the organism usually
patientsenjoy a
changed conditions,as the disease always progresses
very slowly. The
longer lease of life than we often would be led to expect from the morbid conditions.
but this is only possible
also occur,
According to Hendy, cases of spontaneous recovery

experiencedfrom

earliest stages of the disease.

in the

Treatment

'

"

Oil tlie

is tried in various

ways,

partly by combating

Pathological Significance of Nematodes

He

natozon,"

the

1S74.

development
Annals

of Derm.,

of

the

1881.

232

of

ELEPHANTIASIS

the

the

of

ligature

the

condition
idea

upon

in
the
and

very

disease
limb

of

cases

and

to

induced

occasionally

for

the

long

The

one

previous

the

favorable

time
of

two

with
the

of

Silva

of

of

of

tissue
with

iliac

constant

of

occasional

remarkable

Arch,

of

Dermat.,
de

1880,

Therapeutique,

p.

10

Janvier,

six

1883.

been

sciatic
has

less
use-

of

to

nerve,

been
in

have

sixty

applications
success,

299.

had

the

Janeiro,''
of

current

by

years.

Journal

of

have
ton'
Mor-

retrogression

current

Eio

from

artery.

artery

communication

the

Aranjo,

strength

masses

femoral

portion

while

starting

disturbances,

years,

action

the

fourteen

excision

attended

was

of

volume.

and

the

ligaturing

ligature

times,

13

however,

nutritive

by

lasting

the

the

treatment

to

limb

improvement

physicians,

main
of

after

after

Moncorvo

liquefaction

current.

over

half

the

instead

lower

weeks

Drs.

elephantiasis
aided

right

six

in

which,

and

Some

cases.

nerve

in

emphasizes

which

elephantiasis.

have

the

of

diminished

sciatic

times

40

16

produced

kind,

within

ensued

recently,

of

this

of

case

elephantiasis

an

the

is

the

attacking

reports

in

PACHTDEEMIA.

8.

occurred

recovery

unchanged

elephantiasis

that

decided

artery,

remained

AEABUM

but

the

made
ment
treat-

treated

elements,
of

extended

the

ANOMALIES

EPIDERMIS.

THE

OF
PAET

I.

BY

DR

E.

LESSEE,

PRIVATDOCENT

AT

LEIPZIG.
"

Translated

by

Dr.

ADOLPH

RUPP,

Aural

Surgeon

to

the

N. Y. Eye

and

Ear

Infirmary.

ICHTHYOSIS.

is due

Ichthyosis

to

and according as the

lining of
only the epithelial

excess,

develop epidermisin
is affected over
as
a whole
a
larger or smaller area, or
follicles,it is known
as
sis
ichthyosisdiffusa and ichthyo-

congenitalpredispositionof
skin
the

the skin to

follicularis.
In

itself at
manifests
tendency to excessive epidermal formation
and
then
of
intra-uterine
the
disease
assumes
life,
comparativelyearlyperiod
ances
appearis called ichthyoThis last group
quite at variance with those ordinarilymet with.
sis
congenita.
form.
The so-called varieties of ichthyoIchthyosisdiffusa is by far the commonest
sis
diffusa are only the various stages and degrees of intensityof the same
malady.
When
the disease manifests
itself most
and rugae
furrows
mildly,only the normal
of the skin are
somewhat
than
more
ordinarilydeveloped. The epidermis is somewhat
are
thickened, but scalyformations
absent, although the normal desquamation is slightly
The
increased.
skin has a wrinkled
feels brittle and harsh and dry (xeroderma
appearance,
oping
develand dry skin of English writers). Hardened
of the epithelium now
masses
in excess,
the epidermal layer loses its integrity,and
The
scales are
formed.
furrows
furrows between
the largerand smaller scales correspondexactlywith the normal
some

cases,

the

of the skin.
As

extensive

areas

snake, this varietyhas

of the skin
led

the

are

affected,and these look like the skin of

of the

fish

or

ichthyosis(ichthyosisserpentina or
not developed in abundance, the color of the scales is a bright,pearly
cyprina). When
whiteness
(I. nitida, nacree,
more
abundant, their color is alwaya
Alibert). When
h
ue.
As
skin
the
darker, assuming a greenish-blackish
affected is also darker, and granto

use

term

234

ICHTHYOSIS.

ular
caused

pigment
by an

is often

in the scales,there

seen

of

be

can

The

doubt

no

that this discoloration

is

scales adhere

development
pigment.
quite firmly,especially
at the centre, but can
without giving rise to any bleeding,i. e., without
usuallybe removed
injuringthe papillae.
In its severest forms, irregularly
shaped hillocks of scales are developed,separated
here correspond to the normal
furrows of
by deep furrows from one another, which even
most
marked
about the joints. Passage of
As in health, these furrows are
the cuticle.
the surface or the movements
the hand
of the patient produces a noise by the rubbing
over
been
of the hillocks
and
this
has
to
the
rattle
of
the
againstone another,
compared
in
extreme
skin
scales
As
rattlesnake.
occurs
severe
pigmentation of the
cases, the
sent
preof scales are
black color.
thrown
a dark-green to almost
of, and are
Large masses
bed and clothes (ichthyosis
found in the patient's
cornea
or
hystrix,or hystricismus).
Localization.
Ichthyosispresentsa very marked
preferencefor certain parts of the
body, particularlythe extensor
aspects of the limbs and, in them, the corresponding
the
the
In
of scales occurs
of
joints.
slightgrades,the first formation
aspects
upon
extend
of
the
and
knee
The
disease
the
the extensor
elbow
over
joints.
aspect
may
in
the
surface
of the body, but then the affection is most pronounced
whole
regions just
these
less unaffected, and
to a less extent
Some
named.
are
or
places remain more
but especially
the soles of the feet and the palms of the hands,
the flexures generally,
the genitalsand the face.
face
However, Schmidt'
reported a case in which the entire surThe face
was
affected,with the exception of the face and upper region of the chest.
fusa.
difto be affected with ichthyosis
is the only region of the body that has not been
seen
in the severest
of ichthyosis the line of
Is is quite peculiar that even
forms
demarcation
between
healthy and diseased skin is abrupt.
In a series of cases, otherwise like those just described, the disease is presentonly on
In
and soles of the feet,the skin elsewhere
the palms of the hands
remaining normal.
ate
the milder
cases, the epidermis of the palms and soles is only thickened, showing a moderBut
of epithelial
its originsoon
amount
exfoliation,and here and there a fissure.
extra

"

after

birth, and

all its
the

absence

the

of external

hereditarycharacter, settle the

disease,but

when

such

influences

Of

diagnosis.
malady

as

manual

course,

it is desisted from, the

returns

labor, etc., and

manual
to

labor will

its former

above

aggravate

state.

This

existence
easilyexplained from the fact that the formation of callus is favored by
are
developed after the manner
ichthyosis. In other cases, true horny excrescences
A case
the soles of the feet has been described
of this kind affecting
of ichthyosiscornea.
In another
opment
case
reportedby Bcegehold,'besides the very considerable develby Ernst.
but
of scales on the palms and soles,there was
slightepidermal thickening over
I have observed
the importance of heredityin these, as in the ordinary cases,
the knees.
the

is
of

in

instance

one

Tjirth,was

in which, in

aggravated by

mother

and

labor,

manual

but

in this

son,

the

did not

disease

manifested

itself

disappear entirelywhen

was

done.

More

instructive

the

no

after

manual

family described by Thost* in

which
transmitted
through four generations.
ichthyosispalmaris et plantariswas
It has been demonstrated
that the ichthyoticscales consist of firmlycoherent
Anatomy.
hardened
epidermal cells,their long axis runni;igparallelwith the surface of the
work

respect is

soon

"

"'Descriptio Ichthyosis corneae," Bremen,

'

'"

"

Virch.

"

De

Corneis

Ueber

humani

Arcli., Bd.
erbliche

1830.

corporis excrescentiis," Diss. Berlin, 1819.

79, S. 545.

Ichthyosis palmaris

et

plantaris," Diss. Heidelberg, 1880.

235

'

ICHTHYOSIS.

angle. Between
granular pigment in abundance, which normally is
the lamellae of the cuticle is found
Sections of ichthyoticskin, apart from the frequent marked
tation
pigmenof rare
occurrence.
show that the horny layerhas been
and enlargement of the interpapillary
cones,
thickened, whilst the deeper layershave undergone no essential change. The
very much
is consequent upon hypertrophy of the papillary
cones
enlargement of the interpapillary
outgrowths
hair-follicles often show
The
indentations,and those familiar epithelial
bodies.
in a numarrectores
ber
from the point of insertion of the mm.
pilorum, as seen
skin diseases.
Not
of other chronic
originatingin the
rarelycysticformations
gated,
The papillceare markedly elonsudoriparousand sebaceous glands have been observed.
in
dendritic
and
of
the
blood-vessels
both
the
but without
course
branching ;
any
found.
are
and in their walls,pigment granules in great number
Excepting the pigmentation
of its superficial
layers,the corium exhibits no pathologicalalteration.
Chemical
analysisof the scales has shown a considerable increase in their inorganic
in silicicacid.
constituents,especially
tary
Etiology. Scarcelyany other skin disease affords such direct proof of its herediif
other
members
of
far
assert
that
to
nature
even
so
as
as ichthyosis. Hardy goes
found
fecting
afbe
with
this disease will certainly
the family are not found affected
ichthyosis,
the
friend of the patients. There are many
instances on record where
near
some
mother
to son, and from
transmitted
from
father to daughter, although
disease was
like
in brothers and sisters,
of
Its
transmitted
to
those
sex.
occurrence
frequent
usually
ture
without any external influences being recognized,is further proof of the hereditarynaof ichthyosis.
often ih.Q,nfemales the victims of this
It was
formerly supposed that males were more
With
one
exception,
disease,but later observations fail to detect any such difference.
climate
and
have
to be mentioned, race
no
soon
genetic influence on the disease.
of trustworthy observations.
endemically, according to a number
Ichthyosis occurs
in
in the Indian
endemic
it
This
is
marked
Buffon'
as
more
Paraguay.
being
reports
of the entire
the
Molucca
cent
where
it
affects
five
Islands,^
on
Archipelago,especially
per
fected
population. Its hereditary nature is very evident in these localities. Males are afis due to climatic
almost exclusively. I do not think that its endemic
occurrence
of
but is attributable to its hereditarynature, and this the more
so, because
peculiarities,
in
isolated
islands.
its occurrence
a
people
living
regions,
usually
among
affected with ichthyosis,
Those afterwards
Coiirse.
mal
are
alwaysborn as perfectlynorthe
end
the
second
The
first
of
the
before
of
evidences
disease
children.
rarelyappear
the
surfaces
of the extremities, especially
and then
of the knees
extensor
month
on
In the majority of cases, however, the disease manifests
itself in the course
and elbows.
its
of
life.
The
further
of the first or second
of
course
ichthyosis
depends upon
year
maximum
the
time
of
and
the
of
is
attained
about
puberty.
intensity,
development
usually
Its maximum
throughout
degree of development once attained,ichthyosisremains stationary

furrows
skin, partlymeeting the interpapillary

at

more

or

less acute

"

"

the
Cases
of actual
are
slight fluctuations.
among
recovery
In
of only two such cases
which
rarest of exceptions.I know
were
reportedby Hebra.'
ola.
one
instance,the ichthyosis
disappearedafter an attack of measles, in the other after variIts transient disappearance,
after severe
particularly
generaldisease, has often been
In many
seen.
patients a shedding process of the epidermis takes place, especially

life,apart

'

Cit.

'^

Hirsch:

'

Hebra

from

by Willan,
"

and

H'db.

"

Die

ihre Behandlung," Breslau, 1816, S. 149.

u.
Path.," I. Aufl., B. ii.,S. 470.
Leliib. d. Hautkr,," Bd. ii.,
S. 42.

Hautkrankh.

d. hist, geogr.

Kaposi:

"

236

ICHTHYOSIS

towards

the end

of summer,

leaving the

FOLLICULAKI8.

skin

less normal
or
temporarily with a more
the general health of the patient.
on
Ichthyosishas no
appearance.
Prognosis. Concerning the general health the prognosisof ichthyosisis good; but
The cases
the local malady is incurable.
reportedas recoveries due to medication were
in all probabilityincorrectlydiagnosticated. Mild
grades are of little importance,
of
their
further
the
extension.
The
intenser forms, however, are
possibility
excepting
quite serious, because of the deformity and impeded movement
they occasion when
to them.
certain regionsare affected,and the painfulrhagades common
Diagnosis. It might possiblybe mistaken for Kaposi'ssecond varietyof xeroderma,
in the
but in this disease the skin is always thinner, and above all smooth, whilst even
furrows
of the skin are
surface
mildest
of ichthyosis the
and
its
cases
exaggerated,
certain circumstances, be confounded
rough. The milder grades of ichthyosis may, under
lichen ruber, but the clinical historyand primary efflowith diffuse psoriasis
rescences
or
When
most
will guard against error.
intenselydeveloped,ichthyosiscannot
effect

"

"

be

mistaken

for any

other

disease.

Complications. Concerning complications,little can be said. Not rarely,in cases

is found
of moderate
in the flexures of joints,
eczema
severity,
probably caused by the
in
of
the
rid
to
In
and
of the crusts and
scales.
patient trying get
rubbing
scratching
velop.
observed to dean
Clinic,psoriasis
was
ichthyoticaged seventeen
years, at the Breslau
"

be done
in the way of treatment
than to alleviate the
can
Therapy. Little more
the
The
is
of
abundant
first
indication
the
removal
tions,
epidermal accumulasymptoms.
which can
be most
with
or
speedilyaccomplished
soft-soap,
frequent baths and
In
with
milder
end
frictions
cases, the same
green-soap.
may be attained by injections
the perspiration
of pilocarpine,
sures
softeningthe scales which are then cast off. Such meawill keep the skin supple,and
should then be adopted which
prevent the reaccuof scales. For attainingthis end, warm
in conjuncrank
and vapor baths
mulation
first,
tion
of ointments, whose
is
of
matter
with inunctions
indifference,
provided
composition
has proven
Internal medication
they are bland.
entirelyuseless.
"

ICHTHYOSIS

FOLLICULARIS.

is quite rare,
in which the disease is limited to the follicles,
Ichthyosisfollicularis,
of it. He
the
Guibout'
a detailed description
only author who has furnished
reallybeing
eases
improperly calls it acne sehacea cornea, and differentiates it from ichthyosis. Both disalike,however, and vary only in their localization.
are
pathologically
In the place of any further description,
I shall offer the followingreport of an exquisite
of this varietyof ichthyosis:
case
have
normal
and two brothers
His mother
S
skin; nothing
Max, aet. 6 years.
after
the boy's birth, his
two
A
week or
be ascertained
oan
concerning the father.
the bridge of his nose, and over
the
mother
noticed the skin to be harsh, especially
over
At birth the head was
graduallyattained.
edges of the auricles. Its present state was
without
only during his third year did a scanty growth begin to appear.
any hair, and
surfaces of the extremities,most markedly on the
Present condition: Over the extensor
face
besides
the
and
the
on
wrist
over
ankle,
brows, nose, and auricular edges, thin compact
scalycolumns, even as long as a millimetre, whitish or grayish in color, are seen projecting
"

"

Nouv.

Le^. clin.

sur

les mal.

de la

Peau," Paris, 1879.

ICHTHYOSIS

23T

CONGENITA.

less
of follicles. The flexor surfaces and the trunk
are
largenumber
very much
affected,and the palms and soles are entirelyfree. On the scalp,which centrallyhas a
be seen
few isolated hairs,and peripherally
a scanty growth, these epidermal spines may
and
number
The
in
hair-follicles.
of
f
rom
are
a
entirely
wanting,
eyebrows
projecting
the
the
diseased
is
marked.
affection
the
over
this region
Passing
fingers
parts
very
produces a sensation like that caused by the pricklysurface of a rose-leaf.
upon
consisted
of baths and spiritus
The treatment
applied,wheresaponis,systematically
ment,
treatimprovement speedilyfollowed, and the scalp having undergone the same
noticeable.
increased growth of hair became
an
and lichen pilaris
This form of ichthyosis
are
analogous in that excessive epidermal
around
to both diseases;but,
the follicles are common
collections in and immediately
for all this,I believe they are
distinctlyseparable,the scales of lichen pilarislacking
the cornification which characterizes those of ichthyosis.
from

ICHTHYOSIS

CONGENITA.

scalingbegins to manifest itself at an earlyperiod of intra-uterine

those
life. Although the phenomena presentedby this varietyof the disease differ from
it incorrect to describe
it as
distinct disease
met in the ordinaryform, I consider
a
the pathologicalprocesses
similar.
are
different from
ichthyosis,since in both cases
two
before
full
Children affected with ichthyosiscongenita are usuallyborn a month
or
covered
the
entire surface is
with
term.
They present a most strikingappearance:
lower
largerand smaller platesof epithelium,separated from each other by deeper and shalin all ca^s maintain
such a regularityof arThese platesand furrows
furrows.
rangement
In this form, the

as

to make

all the children

furrows

run

on
transversely;

the

look alike.

affected

On

the trunk, in most

cases,

extremities

longitudinally,
except about the joints
The
direction.
size of the platesvaries from one
transverse
where they have a more
mm.
From
external appearto several cm.,
according to the region in which they are formed.
ances,
and harsh, the
too small, inelastic,
would infer that, the skin having become
one
it
caused
to
child
at
those
where
movements
of
the
the strain
and
rupture
places
growth
of
is
confirmed
the
condition
the
skin
This
around
the
was
by
assumption
greatest.
and
natural
around
feet.
The
folds
the hands
the orifices
orifices of the body, and on
The
absent.
are
lipsare wanting, the ichthyoticskin extending to the alveolar processes.
covered
The eyelidsare also wanting, and the eyes are
junctiva.
by the swollen and everted conof epithelium can
be detected
No auricle is seen, but a hardened
mass
rowing
narThe anal orifice is on a level with the surrounding surface
the auditorycanal.
skin on
the hands
and
feet being more
and has rhagades radiatingfrom it. The
sistant,
reand bent, and the feet
is without cracks; but the fingersand toes are shortened
the

club-footed.
The

condition

in the centre

regard to this view. They are not present

zontal
they may be seen taking an almost horiwhich they resume
their normal direction.

of the hairs is important with

of the furrows, but

along the sides

they reach the scales,after

beginsto developabout the third month of intra-uterine life,it may be assumed
that only after this period the skin becomes
unyieldingfrom the production of the thick
The prehorny layer,and therefore tears in those placessubjectto the greatesttraction.
viously
and in
developed hair-follicles are naturallyabsent in the middle of these fissures,
the lateral portionstake a different direction,correspondingto the traction.
direction until

As the hair

238

CALLUS.

The

thickness

by
with this

on

epithelial
platesvaries

the

elongatedorifices of the
disease died several days after

to the intense

due

of the

of the

account

modification

and

sweat

birth.

of the

The

cases

from

five mm.,

glands.

and

they are

All the children

versed
trabom:

the self-evident fact that death

to

is

suckle,,

oral

deformity.
Etiology. Nothing is known
concerning

two

sebaceous

Apart

and

one

skin, it is impossiblefor these children

"

saw

between

of it in two

children

born

the

of

the

etiologyof
mother

same

within

invariablyfatal malady has been observed in calves.^

be expected from
treatment.
can
We may
here refer to those skin changes which
have been
in
later
a
nd
life.
or
are
circumscripta acquisita,
acquired
same

the

The

disease.
a

Okel, Sr,/

period of one year.

solutely
prognosisbeing ab-

fatal,nothing

On

the

lower

extremities,when

especiallywhen

more

much

in

appearance

there

is

only an

affected

with

here

occur

the

seat

of

chr.

eczema

falselycalled ichthyosis
due

to

varicose

ulcer, or

pacJiydermie.changes resembling ichthyosisvery

there

and

on

the

surfaces

thus

affected.

At

times

-epidermalscaling,without any hypertrophy of the papillae,

whilst at other times the papillaryhypertrophy is so marked
(thepapillse
being closely
packed together,several millimetres high, and capped by horny scales)that the surface
of a rough file. Similar
described
has the appearance
have been
affecting
appearances
the mucous
membrane
of the tongue.^ In these cases, the pathologicalchanges are entirely
local and due to an
obvious cause,
and not to a congenitalpathologicaldisposition
is assumed
to be the characteristic
of the skin to develop an excessive epidermis which
of ichthyosis. These changes of the skin, therefore,will be more
properly denominated
keratosis

of

excess

circumscripta.
CALLUS.

simply of a hypertrophy of the horny layer of

necessarilyinvolvingany of the other tissues. The horny layermay
The
attain a thickness of several millimetres, and graduallyshades off into normal
skin.
and
the
covered
the
area
exciting cause;
by callus varies in extent with the locality
be the seat of callus.
entire surface of the sole and palm may
Anatomically,only an
increase of cells in the superficial
The
rete Malepidermallayerscan be demonstrated.
manifest
pighii,the papillarybodies, and the corium never
appreciablechange.
any
the surface of the thinThe furrows and lines of the normal
skin are still recognizable
on
ner
Callus

tyloma)
(callositas,

consists

the skin, without

callosities.
The
of callus is long-continued intermittent
is from
cause
pressure
pressure.
the skin and bones, and
where little tissue exists between
by the bones, especially
secondlyfrom without by wearing apparel,but particularlyby various kinds of tools.
the localities most
The soles of the feet,but more
the palms of the hands, are
especially
in
much
favorable to the development of callus.
It occurs
more
rarely other regionsof
the foot, callus is oftthe
On
the body, and is explainedby the occupation of
patient.
On the hand, callus is variouslysituenest
formed
the heel and ball of the big toe.
ated,
on
and the occupationof the individual may
be diagnosed from the site of the callus.
I have seen
callus develop on the back of the fingersin physicianswho
practisedimmeThe

within

Cit. bei

'

Liebreich:

Lebert,
"

De

"

Ueber

Lebert, 1. c, S. 159.

Berlin, 1864, S. 108.

intra-uterina,"Diss. Halle, 1853.

Keratose,"

Ichthyosa uong.

"240

COENU

formations

These
body grows.
another
place.

are

CUTANEUM.

best

considered

as

naevi,and

will

be

described

in

shall speak only of those warts

that
We
are
always acquired,and originatein a
hypertrophicdevelopment of papillaeand epidermis, and only exceptionallymanifest
roundish
tumors, considerably
any increased pigmentation. These true warts are flat,
or
only slightlyelevated above the surface, and varying in size from a pea to a bean ; they
sometimes
form
coalesce and
the warts
are
At first
larger plaques when
numerous.
if
their surface
continues
remain
is smooth, and,
smooth.
small,
When
they
the wart
has existed for some
time, the epidermis cracks, and the wart presents
grows largerand
short brush.
surface analogous to that of a coarse
a
They then assume
a darker, blackish-green
color, which is partlydue to uncleanliness.
Anatomical
that warts consists of stronglymarked
research
shows
hypertrophyof
the papillae
thickened
of
and
The
a
correspondingdeposit
epidermis.
are
papillae
very
much
lengthened,especiallyin the central parts,but are not branched, as in acuminated
condylomata. As long as the epidermis of a wart remains intact,its surface is smooth.
less frequentlyon the face.
Warts
of tenest on the hands, and much
On other
occur
localities they are very rarelyseen, with the exception of one
form, verruca
which
senilis,
most
will be referred to shortly. Warts
with in children
are
and
frequently met
adults
almost
in
those
in
individuals
but
who
manual
solely
people,
perform
young
This
labor.
factor,as well as the localityin which they are found, goes to show that a
mechanical
irritation has at least something to do with their development.
Warts
have a tendency to drop oflE spontaneously,sooner
or
later,and do not re-appear
(verrucacaduca). But they often persistso obstinatelyand give rise to so much
deformity that their spontaneous disappearancecannot be waited for.
this description,occurring, as the name
from
Verruca
senilis differs somewhat
flat elevations with an
old
in
of
the
The
warts
indicates,only
irregular
aged.
age are
in diameter
less
border, and measure
one
cm.
more
or
or
; they are usuallyof a more
deep brown color. Their surface is never
markedly cracked, but only moderately coarse,
and
they are usually quite numerous.
They are most frequentlyseen in the face, back
structures
In old age the epithelial
have a tendency to hyperof the neck, and
back.
trophy,
and
to this their origin is due.
It is found that they present in the main an
hypertrophy of the epidermis without implicationof the papillae.
Warts
best removed
are
by scrapingwith a curette and subsequent cauterization.
Patients
with caustics
who
are
shy of an operation may have their warts removed
this purpose.
Of course,
alone, and, in my experience,fuming nitric acid will best serve
these cauterizations
must
be repeated for some
days,particularlyif the wart is large,
"

''

before

it shrivels and

falls ofE.

CUTANEUM.

CORNU

Homy

excrescences

appearance.

These

earlyattracted
cutaneous

the

horns

attention
consist

of observers, because

of circumscribed

ing
of their strik-

excessive

epidermal

formations, simulatingichthyosisin so far as they may develop either from the skin generally
tlie follicles;
from
thus being analogous to ichthyosis
dif.,and ichthyosisfollic.
or
an
and in the latter instance
enlarged sebaceous
respectively,
develop generallyfrom
is broad, they
their
base
When
Their
varies.
gland, or an erythematous cyst.
shape
not
the
of
them
short and
measuring
are
larger
irregularly
cylindricalor pyramidal,
to two
never
than one
in diameter, and the apices are
more
pointed,but have a
cm.

2il

CONDYLOMA.

longer horns are usuallytwisted, sometimes

making
cutaneous,
several turns.
originatingin follicles may, under certain conditions,be subi. e., they may develop within a closed atheromatous
cyst. The surface is not
rows
furalso transverse
there are
smooth, and usuallyhas longitudinalfurrows; sometimes
varieties.
various
shades
combination
of
both
or
a
besides,
They usuallypresent
of yellowish-brown. Their consistence is hard, though they are not as hard as the nails.
show that these horns consist of hardened
and thickened
dermal
epiMicroscopicexaminations
tend
excells,but that, at least in certain instances,extraordinarily
lengthenedpapillae
"weather-beaten

The

appearance.
The horns

The

far up into them.

ismuch
more

head

isthe favorite seat of these

more
relatively
sometimes
they are

their

Elsewhere

excrescences.

frequent
genitals. Ordinarily
but
there is but one
as
horn,
multiple,as many
twenty having been
As
individual.
observed on the same
a
rule, they develop only in elderlypeople,but I
the under lipof a girltwenty years of age.
two of these excrescences
have myselfseen
on
These growths have a tendency to fall ofE spontaneouslyafter having attained a certain
size,only,however, to form anew.
cutaneum
the whole, cornu
is very rare, and
On
Hebra, in his immense
ence,
experifrom
the deformity,and the pain at
met with only three instances (1876). Aside
their roots due to the traction or pressure of the clothing,
their removal is advisable because
with them, according to Lebert, in twelve per-centof the
is combined
cancer
epithelial
rare, but

occurrence

on

the male

cases.

If

Therapy.
"

as

well

as

excision,no

partsof the skin which form the base of the horn

itself by an operation,
a relapse
may be expected.
to have occurred.
relapseis known
those

not

are

the horn

After

moved
re-

ough
thor-

CONDYLOMA.

Condylomata are excrescences

and, though found in
therefore

of the
other

skin

oftenest

are
localities,

caused

seated

by

on

around

the

tals,
geni-

disease.

We

shall

and

venereal

of them

very briefly.
condylomata are caused by irritation exerted by gonorrhoealsecretions
membrane
skin.
the mucous
on
or
They begin as small pointed elevations which are
and enlarging rapidly,they coalesce and present various shapes. On
quitenumerous,
free surfaces,where they meet
with no resistance,they assume
a
mulberry or cauliflower
but
where
to
ingly.
accordtheir
form
is modified
they are subjected
pressure,
appearance;
treat

Acuminated

In

the sulcus coronarius

Their

cock's comb.

surfaces,at

and

anal fissure,
their appearance
is often like that of a
thin
moist from
a
dry, become
purulent discharge

first

attained a certain size,especially

when
cleanliness is neglected. This
clefts and fissures between
the individual parts
decompose in the numerous
stimulates
their further
Their
of the condyloma, and
growth.
rapidityof growth is
and
attain
considerable
size
within
few
When
a
a
they
days.
enormous,
neglected,they
attain the size of a fist or even
larger.
the genitals,
the anus,
and vicinity. Usually they
on
They are located exclusively

when

they have

secretion may

first show

themselves

where

the

skin

merges

into

mucous

membrane,

in

men

on

the

in women
the labia minora.
Thence
on
glans penis and inner surface of the prepuce,
in
to
the
other
to
the
of
they may spread,especially uncleanlypeople,
parts
genitals,
anus,
in whom
in women
this acrid secretion flows down
these regions,even
to
especially
upon
of
the inner aspect
the thigh.
Anatomically,acuminated
condylomata consist of an immense
papillaryhyperplasia,
10

242

CONDYLOMA.

papillge being

the

is
the
is

hand

other

the

and

of

and

for

give

elevations
the

on

skin

of

of

lies

in

the

folds,

the

other

lesions

and

all

the

is

papulae

therefore

general

with

ously
advantagewith

etc.

the

according

to

particularly
where

fingers

and

Very

often

form

toes,

two

large

foul

purif

situation

the

the

dylomata
con-

another

one

nary
ordi-

roundish

the

may

with

covered

from
flat

body

touch

they
they

and

the

of

between

that

form
are

number,

great

naval,

coalescence

greatly

different

regions
as

the
so

ulcerated,

or

quent
fre-

removed

removal

They

in

other

contact,
at

be
is most

the

of

with

removed

their

conditions.

in

chin,

of

when
"beds."
fluid.

orm

the

growth,

them.

upon

and

syphilitic lesions,

secondary

show
the

with

coincidently

occur

and

the

folds

with

epidermis

the

skin,

and

the

cleanliness,

require
local

the

papillary

lymphoid

numerous

they

treatment,

of

of

hypertrophy

and

hyperaemia

marked

corium

constitutional

of

we

may

for

add

they

better

condylomata,

madidantes.

ingly
accord-

applications

cells.

separation

mentioned

in

syphilis.

affections,

broad

is

syphilis.

appropriate

on

on

papillae

number

great

snare

occurring

in

their

By

assume

local

localities

varies

are

of

surfaces

the

hemorrhage.

which

found

are

the

bestowed

them

infiltration

of

eroded

care

secondary

surfaces

contact.

secretion

and

but

disturbed

should

ones

because

variety,

often

also

are

folds

often

this

conclusion

It
from

of

text-books

these

in

of

prognosis

best

are

larger

dangerous

special

corresponding

condylomata

opposing

In

for

the

through

an

Besides
the

of

flat

Sections

body

within

come

ing
cover-

absent,

size

and

the

by

galvano-caustic

papules

color,

gray

the

but

largest

of

They

opposing

cleanliness

These

or

in

even

account

on

moist,

are

character

and

of

skin

and

syphilitic

and

situated

surfaces

The

skin

the
fever

to

condylomata

The

the

of

profuse

are

vicinity.

breast,

of

folds

Their

sesquichlor.

removal

very

The

and

rise

troublesome

Small

cauterized.

reddish-gray
and

are

the

to

the

genitals

under

the

rise

condylomata

papules

f erri

subsequently

employed

rendered

relapse.

to

Liq.

even

may

malady,
give

epidermic
be

them.

entering

may

The

developed.

local

they

be

may

tendency

especially

much

very

purely

tree-like.

pus.

treatment

applications
instruments

may

of

"

their

is

neglected,

absorption

layer

blood-vessels

are

when

The

Therapy.

Broad

of

branching

and

horny

prickle-cells

number

the

However,

from

growths

the

condylomata

good.
health

and

of

layer

to

Acuminated

lengthened

thin,

the

proportionate

knife

much

very

comparatively

that
are

to

which

it would

etiologically
separate
are

be

entirely

acuminated

always

expedient

to

drop

distinct

condylomata
symptom

of

the

name

of

condyloma

formations.
as

syphilis

entirely

papillomata
and

may

be

called

ANOMALIES

EPIDERMIS.

THE

OF
PAET

II.

BY

DR

A.
OF

WEYL,
BERLIN.

PSORIASIS.'

is aichronic,usuallyrelapsing
skin

of
disease,in which profusequantities
the finger-nail,
form
or
more
upon
of
Parts
extent.
less large,reddened
elevated to a trifling
are
parts of the skin, which
remain
and
which
the skin covered by thick, white, or grayish-yellow
of
layers scales,
may
unchanged for years, with occasional desquamation of the superficialscales, are found
especiallyat the elbows, knees, scalp,glans penis. Small patches,particularlyat the
either
In other cases, there is a sudden
elbows, may be long overlooked.
appearance,
moderate
with or without
febrile disturbance, in many
parts of the body of bright-red,
PsoEiAsis

scales,which
silver-gray

can

be

removed

readilyby

"

somewhat

elevated, usually more

or

piece,and

less
which

If

the

scales

in size from

itching efflorescences,
varying
covered

twenty-pfennig
are
scraped with the finger-nailuntil the
slightfurther scratchingsuffices to make small drops of
has been injured.
This acute
form is called psoriasis
punctata ; after a
somewhat
known
as
largerpatches,
psoriasisguttata or
pea

to

are

soon

with

red

thick

shining

blood

appear,

short

duration

nummularis.

layer

rete
*.

appears,
e.y the

the

very

papilla

it increases
As

a.

of scales.

into

patches
central
lose
normal
the
often
their
and
scales,
a
increase,
present
except
parts
appearance,
annularis
or
a
circinata),.
discoloration,so that rings remain (psoriasis
slight brownish
this occurs,
the
but rings may
also develop from the union of circular patches. When
psoriaticchanges disappear at the points of contact, and curved lines in the form of
term
The
wreaths, etc., remain.
larger
psoriasisdiffusa or inveterata is used when
In addition, there is a general
patches are affected without distinct circular boundaries.
of intact skin are present.
and in some
cases
psoriasis,
very few centimetres
to
the situation and duration
of the proThe
external appearances
cess.
vary according
with
covered
Upon the scalp are found either exquisiteforms of nummular
plaques
thick white scales,or large,moderately scalycircular forms
extending beyond the boun-

244

psoKiAsis.

daries of the liair towards

the

forehead;more
rarely,pale-red,
slightly
scaly,small patches,
anaemic
individuals.
Smaller
especiallyin nervous,
patches,with a moderate
amount
The
extensor
of scales,predominate in the face.
aspects of the limbs are the sites of
predilectionof large, often diffuse plaques upon an infiltrated base, and covered with
thick, white to grayish-whitescales.
Very obstinate patches of a deep wine-red to violet
observed
color are
the
calves
of individuals
who have to stand a great deal
o
n
especially
varicose veins.

suffer from

and

All

forms

found

are

the

upon

trunk

; not

infrequently

patches on the anterior surface of the chest, particularlyin old people,are covered
with yellowish-gray,
branny scales which are fattyto the feel. The penis is usuallythe
site of small spotscovered with few scales.
The dorsal surface of the hand
and fingers
is rarely affected, but
exceptionallyan affection is observed solelyon the palm of the
thickening of the skin and a tendency to Assuring.
hand, associated with marked
The abundance
of the scales varies to an
extraordinarydegree. Their color varies
dull
from
white
to grayish-yellow;
the surface, convex,
they are usuallysmooth
upon
than
their lower surface which is generallysmooth
and
and have a smaller diameter
upon
presentssmall sharp spines (depressionsinto the hair-follicles).
"even, but occasionally
They consist of several layers,are dry, and readilybreak.
varies from
delicate pale-red or yellowish-redto
The color of the skin beneath
a
the
often
surrounds
redness
when
the process is exthe
tending.
scalyspots,especially
deep-red;
its
normal
The skin usuallypresents
consistence,and is moderately thickened
chemical
or
causes.
only in old patches or those irritated by mechanical
the psoriaticprocess always remains
In some
very slight;in a few, patches
cases,
less violent eruption of psoriasis
has reached
its
or
persistfor a long time, after a more
the

termination.

the

In

individual

third

even

febrile

covered

often suffers
with

disturbances;

painful,because
observed

the

extensive

less

or

generalcondition

has been

termination

series,more

is
occasionally

with

occurs

annoying,

The

intervals.

short

scales
the

outbreaks

from

head

patient must

reddened

and

exceptionallyin

follow

considerablyin such
to

foot.

one

another

cases,

The

general

keep to bed, movements

readilyfissures. A

tense

skin

this form

which

is very

similar

at

in which

to

break
outare

fatal
acute

rubra.
pityriasis

Although, as a rule, the

long standing, the occurrence
some

hair
of

does

fall out

not

complete,

even

incurable

of
psoriasis
is
not
alopecia
very
after

the

scalp of

unusual

in

cases.

plicated
the nails of the fingersand toes are usually impsoriasis,
at the
thickened
They are very much
secondarilyin the pathologicalprocess.
free edges,become
laminated, have deep points like a thimble, or opaque, yellowishformed
in
white
only small, destreaks;
places,irregularpieces break off,so that occasionally
for
In
matrix.
the
nails
to
a
time,
the
remnants
adhere
some
long
may,
cases,
In

inveterate,extensive

constitute

site of the process.

true
whether
doubtful

the exclusive

the mucous
branes.
mempsoriasisoccurs
upon
bluish, shining,
Bazin described as psoriasisbuccalis ivory-white,
occasionally
of the epithelium with normal
interspaces.
smooth, irregularopacities
which
often suppurate
If this callus-like process is more
extensive,deep fissures,
This affection
in the underlying tissue during mastication.
at a later period,readilyoccur
after
with
has also been observed
longsyphilis,smoking, dyspeptic symptoms,
mechanical
irritation from sharp carious teeth, in psoriasisand lichen planus.
continued

It is

more

than

'

'

for

Vierteljahrschr.f. Dermat.,

some

time.

Schwimmer.

In

case

VII.,

leukoplakia preceded

the

psoriasis

245

PS0K1A8IS.

Like warty formations

the starting-point
of carcinoma,
infrequently
the
transition
of
a
reports
psoriatic

the skin, it is not

on

Cartaz

particularlyupon the lips and tongue.

patch of a fingerinto carcinoma.
of the patches:
Laycock^ obtained the followingresults with regard to the sensibility
corresponds to the extent of the
1st,tactile sensation is diminished; 2d, this diminution
the patches themselves;4th, no
accurate
tions
observamarked
upon
process; 3d, it is most
their
diminution
and
but
is
could be made
pain
usually
concerning
temperature,
insignificant.
and youth, but not infrequentlyit occurs
Psoriasis usuallybegins in later childhood
in the first years of life,or
A

in mature

and
of psoriasis
peculiarity

febrile diseases,and

some

years.
other

dermatoses

is its

disappearance in

severe

after recovery.
its re-appearance
shrouded
of the disease are
causes

in obscurity. Neither
climate
it
to
but
be
more
development,
upon
appears
account
of
certain
in
more
on
frequentintermarriages. The
frequent
races, perhaps
organisms,
constitutional
which
series
entire
of
are
diseases,
supposed to be produced by microimmediate
mediate
thus
have been regarded as
or
predisposingfactors;
lis
syphiof the
monary
parents, tuberculosis (Wilson regards psoriasisas the analogue of pulWertheim
maintains
that he produced psoriatic
malaria, etc.
tuberculosis),
efflorescences by the injectionof penicillium
glaucum and the fungus of beer into the
nature
of the parasitic
is thoroughly convinced
of psoriasis.
vessels. Vivier
of the clinical historyof psoriasisto that of the dermatomycoses,
The similarity
herpes tonsurans, led E. Lang to the suppositionthat a fungus is the cause
particularly
in discoveringthe fungus. This is situated
of the former disease;and later he succeeded
skin (thinrete layerimmediatelyabove the papillae).
The
in Bulkley'sso-called psoriasis
solution of potash. They
fungi are readilyvisible after the addition of a five-per-cent
round
oval bodies, with a very shining membrane
and
or
are
having a double contour
clear as water, but somewhat
colorless protoplasmiccontents, almost
as
granular with
the most
powerful lenses. The diameter of these brood-cells (spores
?)is 6-8 yu in width
in length;in placesthey are constricted,or presentoutgrowths.
and often twice as much
Lang observed them grow, after the lapseof two or three hours, in potash 5.0 with
The contents
and membrane
similar
of the young
cells are
glycerinand water iia 50.0.
the free end is rounded
to those of the blood-cells;
or
enlarged. Endogenous development
in these enlarged ends.
The hyphi are rarelysegmented;
of spores appears to occur
there are links arranged like a necklace of pearls;and, exceptionally,
occasionally,
they
stained
with
includes
lateral
this
are
They
difficulty.
Lang
sprouts.
great
present
and
it
calls
the
To
cure
hyphomycetes,
epidermidophyton.
fungus among
psoriasis
permanently,
under treatment
he requiresthat the patientremain
until the affection is entirely
With
removed.
slightmodifications,his treatment is that ordinarilyemployed.
I often found the brood-cells representedby Lang in Fig.
In my own
investigations,
solution of soda, especially
1 in the epidermis cells treated with
in the younger
a
rete
cells of eczema
vesi(?les,
versicolor,etc. (I regard them as artefacts,as myelinpityriasis
like (?)exudations).I have not detected the culture products in potash and glycerin.

Etiology.
"

diet has

nor

The

the

its

slightestinfluence

"

Gaz.

"

Med.

'

Ann.

des
Tim.

Hop., 1878, p.

751.

and

Gaz., March, 1871, p. 271.

de Dermat., vol. i.,p. 287.

Vierteljahrschr.f.
lung, 308.

Dermat,

u.

Syph., 1878;

and

"Ueber

Psoriasis," Volkmann'sche

Samm-

246

PSORIASIS.

It has

individuals typicalefflorescences develop

long been observed that in psoriatic
for a long time to a mechanical
with preferencein placessubjected
or chemical
irritant.

Fia.

20." The

dates show

as

uppermost

in succession

the

with
figure represents the tattooing changed by the psoriasiseruption; the figures provided
irritated.
of the parts artificially

phases

after vesication,mustard

cupping, at points of
poultices,

pressure

from

tightarticles

248

PS0KIA8IS,

of
proliferation

the

rete and

the pr^'ection
of the interpapillary
especially
tions
prolongaA slighttrue enlargement of the papillarybody is only
produced by a very moderate swellingof the connective-tissue bundles, by the hypersemia
and extravascular production of lymphoid-cells.
His view that the primary anatomical
of the rete,
process consists of proliferation
and not of hyperaemia of the papillarybody, is based on
the followingreasons:
1, the
stands in no causal relation to the dilatation
enlargement of the interpapillary
projections
of the vessels in the papillse
when
even
outgrowths occur
no
; 3, small epithelial
mia
hyperebe perceived on account
of the deep situation,as in the external root-sheath
can
of
the hair which is the analogue of the rete ; 3, the hjrperplasia
of the rete occurred
even
two
adjacent pin's-head
plaques with the interveninghealthy skin ;
wh^n he removed
here the change in the rete extended beyond the apparent border of the two papules,so that
to

of the rete into the cutis.

FiG.

21."

Section

papillss; L, dilated

of

vessels

patch

of

psoriasis, after

filled witli

Jaraieson

MP,

the

elongated

interpapillary

cones;

C,

infiltrated

blood-globules.

parts. (Could R. measure

togetherin the deeper than in the superficial
is of such a
when
the question
papules so accuratelyduring life,especially
redness of
subjectivecharacter,as to determine where a macroscopicchange, i. e., a sligl^t
the skin, which as a rule passes graduallyinto the normal
color,has reached its limits ?
and
found
the vessels of the papillae
parts of the corium
Author.) Robinson
upper
also
dilated with profuseproliferation
around
of round-cells
them,
lymphoid cells around
the elevation of the
attributes
the ducts of the sweat-glandsand sebaceous
glands. He
to
the rete changes.
plaquesto the hyperemia and infiltration of the cutis rather than

they were

closer

the size of the

In inveterate

patchesthe

at the lower

the
Exceptionally

rete

end, and
smooth

very much
around
proliferation

often
prolongations

there
muscular

is round-cell
fibres become

become

hypertrophic.

elongatedand
the

ened
thick-

dilated vessels.

24:9'

P80KIASI8.

the recovery of psoriasis,

the enlargedinterpapillary
shrink to their
prolongations
the
vessels
become
and
the
cellular
shape,
perivascularproliferation,
narrower,

In

former
like the

exudation

serous

in the connective

after the
remains

absorptiveprocesses
site of the plaques.

at the

Jamieson

tissue,is absorbed

completed, and

are

; but

abnormal

the

tinues
hyperaemiacon-

discoloration

usually

found

cells often with three nuclei in the hyperplasticrete prolongations,

prickle-cells
extendingto the palisade-shapedcells immediatelyabove
the
as
regards
sign of active hyperplasticprocesses in the rete.
found
J. Neumann^
the palisade-shapedrete-cells present in several (up to four)
nucleus
layers; in the lowermost i^ete layersthe cells rapidlyassume
a horizontal
position,
and
nucleolus
become
of the cells with granules rapidlyincreases
enlarged,the filling
from below upwards (granularlayer) so that we often can
six rows, the pricklecount
cells are not present in abundance
cell proliferation
in the
(?),the most marked
occurs
in placesthese are connected
with one
another by offshoots,
interpapillary
prolongations,
the papillae
by which means
degenerateinto thin, thread-like prolongationsand, on the
other hand, passivecongestion
is maintained
in the coils of vessels. The papillge
are
ated
elongtwelve to fifteen times the normal
in places (?),their tissue
(?)and new-formed
infiltrated with round-cells,the coils of vessels dilated in some
in others ;
places,narrowed
and

the presence of
the papilla; this he

in the upper parts of the cutis the bundles

of connective
tissue
and the dilated vessels surrounded
by proliferatedround-cells.
fibres

are

some
hypertrophic,

hair-follicles increased
there

and

of the

lymphaticsdilated,the

their excretory ducts

filled with

broader

are

The

cells of the

horny

than

smooth

normal,
muscular

sweat-glandsand

cells.

In

some

cases

dilatation of the

around
their memsweat-glandsand round-cell proliferation
brana propria. The hair-follicles present numerous
nipple-like
outgrowths.
from 1. pityriasisor drif
Diagnosis. Psoriasis of the scalp must be distinguished
seborrhosa ; this usuallyentends over
the entire head without
distinct limits,the apparently
was

"

normal

skin

is covered

with

scales
fine,whitish-gray

pale-red,scalyplaques which

; in

rare

distinguishedfrom

cases

there

are

cumscribed,
cir-

those of psoriasis

only
by their very paleredness,slightbranny desquamation,and the usual coincidence of general
of the head.
2. Eczema
moist patches next
to scaly ones,
: in this there
are
pityriasis
the amount
of scales is small, there is a tendency to the formation
of yellowish firm
crusts ; it is not circumscribed
and presents no circular borders.
3. Lupus erythematosus
(Oazenave). The scales have an opaque gray color,usuallyare not very abundant,
in the skin ; the hairs fall out in these places,and after removal
and are
embedded
of
the scales the skin in the centre usuallyis somewhat
and
has
depressed
largepores (as if
of
whitish color are
a bluish-red or
worm-eaten); depressed,atrophic,non-scalypatches
rarelyabsent upon the head and ears, and there are bluish- violet patches covered with
thin

scales upon

the

vermilion

border

musty odor, gray crumbling crusts,dull

are

of the
look

lips. 4.

of the

Favus

hairs which

Psoriasis of the trunk

is characterized

by

its

readilybreak.

and limbs must be differentiated from 1. a squamous

sypMlide :
which
or
are
develops from brownish
copper-red,shining papules,
usually quite
less profusegrayishelevated,and, during their involution,are covered with more
or
white scales. Beneath
the scales of the syphilidethe skin is colored brown, depressed,
and
the plaque has a more
sombre
atrophic,
color,while a bright arterial redness predominates
in psoriasis.While
syphilisis characterized by various other forms of eruption
the whole is very uniform.
present at the same
time, psoriasis
on
Upon the delicate
this

Wien.

Med.

Jahrbuch,

1879, S. 67.

250

P80EIA8I8.

integument of the penis the difEerentiation of psoriasisfrom a scaly,specilQc

patch is
difficult. In some
it is also very difficult to differentiate the scaly,
cases
especially
of the palm of the hand and sole of the foot from the corresponding
tylosis-like
syphilide
psoriaticaffection. In the specific
process, the brownish-red, wall-like infiltration at the
borders
of the scalypatches is rarelyabsent.
Ehagades are not infrequentcomplications
The
of both processes.
is distinguished
scalyaffection of these parts produced by eczema
from psoriasisby the fact that, after the .removal of the scales in the former,
visible. In addition, more
the eczematous
recent
eczematous
change becomes
changes
be
often
observed upon
the lateral parts of the fingers. In some
in which
the
cases
may
of the hand, the diagnosis can
spreads to the dorsum
only be made
by the
process
of psoriaticefflorescences in other parts of the body. The diagnosisis equally
absence
of diseases of the nails,as psoriasis,
difficult in many
lichen ruber, tricocases
eczema,
clinical appearances.
of the nails present the same
phyton tonsurans
of the forearm
and lower limbs
Chronic
can
eczema
only be distingishedfrom
of the circular borders, the smaller
of these parts by the absence
inveterate psoriasis
marked
thickening of the cutis.
quantity of scales,and the more
circular form of eczema,
Scrofulous
children may
present a circumscribed
especially
This eczema
of the hand, the forearm, and face.
is distinguishedfrom
upon the dorsum
the nummular
of psoriasis
form
by its elevation,slightscaling,the deeper color of the
of distinct eczematous
changes in other parts.
plaques,and the coincident occurrence
The
scattered
as
primary efflorescences of lichen ruber, which are rarely absent
characteristic
colored
that
be misare
so
cannot
taken
nodules,
they
polygonal,shining,faintly
the
efflorescence
of
for
which
bright-red,
readilybleeding,primary
psoriasis,
begins
to scale very early. Upon the integument of the penis,however, the lichen nodules
are
in the form of small circles,
which are almost exactlylike psoriasis,
arranged occasionally
formation
of scales and the smooth
structure
of the base of psoriasis
but the abundant
are
wanting. Larger nodules of lichen planus are covered with few scales,have a granular
at the borders its composition out of individual
and
surface, are infiltrated rigidly,
be observed, while
nodules
ing
psoriasisscales profusely,has a smooth, readilybleedmay
without
its
borders
base, and at
gradually,
passes
any elevation,into the normal
skin.
is

Pityriasisrosea

distinguishedby

formation, yellowishcolor

in

the

its

more

centre, absence

scales,and its localization mainly upon

rapid course, slighterbranny scale

of the
hemorrhage after removal

of

the thorax.

only be

distinguishedfrom pityriasis rubra if the primary

psoriasiscan be found ; the former, as a rule, does not
latter
the
continue
last very long,
unchanged for years.
may
In doubtful cases
the patientsmust be examined
carefullyfrom head to foot.
should
be employed which
Treatment.
l^o measures
give rise to injuriesof the
since psoriasis
heals in this manner.
skin that heal by cicatrices,
never
Recovery may
be secured, 1, by internal,2, by local remedies.
of the measures
None
employed is capable of preventing a relapse.
I will mention
of drugs recommended,
Of the large number
only those which have
in
fresh
above
arsenic
in practice;
not
useful
which,
all,
(/.c,
yet treated)and not
proven
General

characteristic

psoriasis

can

efflorescence

of

"

extensive

very

'

with

prepared
drop tube.

Best
a

cases,

is often sufficient to effect recovery.

fresh

and

kept

in

Fowler's

well-stoppered bottle; the drops

solution,*with

should

be

double

carefullycounted

251

PSORIASIS.

the

be administered

peppermintwater, should

during or after meals,

be taken with
in three to five doses, or it may
began with six drops daily
and, if well tolerated,increased one drop every two or three days, up to twelve drops
then if recovery was
delayed,increased more
daily,
slowlyuntil twenty or even
thirty
administered.
If
to
the
h
e
were
began
daily
psoriatic
patches
disappear,
ally
gradudrops

quantityor

of

more

wine.

returned

Hebra

dose.
original

to the

conjunctivitis,
dryness in the
larger doses, signs of arsenic poisoning appear
throat, gastricdisturbances and pains and the dose should then be diminished.
During
its administration, acid, spiced articles of diet and those which
are
laxative,also beer
should be avoided ; furthermore, arsenic is contra-indicated
in chronic diarrhoea and dyspeptic
Another
of
the
of
not
so
use
though
unpleasant
frequent
symptoms.
symptom
In

"

"

arsenic is the
the

of various

occurrence

the

affected

'

Hunt
three

begins with

at this

he increases the dose

as

Arsenious

pillsdaily,given
I have

In

addition

By
avoid

at

of

herpes

zoster

during

the

of Fowler's
to

three

solution

weeks;

daily,divided in
improvement

if

once

no
or

twice

month

the

dose then
improvement begins,he remains
Attention
should
always be paid to conjunctival
at

employed by Hebra
pill. In the majorityof
''

mainly in pill form

the continued

cases,

before

(Asiaticpills
*), oneadministration

of three

but
sufficient,

in obstinate

meal, proved
pillsand continued this undiminished
In other cases
he administered
arsenic and opium.
arseniate of soda" in pillform, Biell also employed arseniate of iron.''
dose, immediately

one

the

dailydose

to twelve

to

injectionof

arsenious

acid, Lipp

"

has

endeavored

to

arsenic upon the stomach, and has observed

rapid effects
treated by me
in this manner
of the cases
showed
no
couraging
en-

injuriouseffects of

the

in such

If

was

of the subcutaneous

means

quantity for two

increased

months."

for many

development

at

of the toxic effect.

measure

acid

grainin each
cases

the

one-fifth,and repeats this increment

improvement takes place.

given until complete recovery ensues.

tenth

observed

eighteento twenty drops

remains

until

symptoms

of

of arsenic.

doses, and

occurs,

'

Hutchinson

spots.

administration

the skin ; in addition, after the cure

often remains
arsenicales)
(taches

eruptionsof

discoloration
to sepia-colored

a deep brown
psoriasis,

cases.

number

results,the injectionis often very painful,causes, moderate, occasionally

and in addition the preparation
must
suppurating infiltrations,
phlegmon-like,
alwaysbe
made

fresh."
'

Med.

"

Times

and

Gazette, Dec,

1868.

Diseases."

of Skin

Treatment

nious
According to Gorup-Besanez, " Anorg. Chemie," IV. Aufl.,S. 381, there are two forms of arseand the vitreous
or
acid, the crystalline
amorphous, produced from the former by heating and
with
whicli passes into the crystalline
form
AS2O3 is soluble in water
in the air.
difficulty(1 : 20),
modification
soluble than the crystalline. Both
the vitreous
are
more
readily soluble in
being more
hydrochloric acid and in water containing it than in pure water.
"*
To
arab., Aq., q. s. ut f. pil.No. 600.
arsenic, 3.6; Pip. nigr. pulv.,24.0 ; Gummi
5 Acid,
be mixed
carefully.
very
^
IJ Acid, arsenic, 0.06; Opii, 0.24; Sapon. med., q. s. ut f. pil.No. 16. Sig. Take two morning
*

and

evening.
*"

Sodae

arseniat., 0.1

; Extr.

hydro-alcohol,cicutae,

1.30 ;

M.

ft.

pil.24.

Sig.

One

to two

pills

daily.
'

48.

Ferri

arseniatis, 0.15

Sig. Take
8

Arch.

Vide

f.

one

Extr.

lupul.,4.0;

Pulv.

alth.,2.0; Syr. aurant.

pilldaily.

Dermat., 1869.

Huseman's

"

Arzneimittellehre," 1875, S. 831.

cort., q.

s.

ut f.

pil.No.

252

PSORIASIS.

of administration, however,

All methods
effect in

preventing relapses.

often

use

Tar

useless,and
to combine

it has

scarcelyany

local treatment

with

internallyis useless,as are also the carbolic acid

A similar danger
by Kaposi, and they may produce toxic symptoms.
pillsrecommended
is threatened
from
four drops
by the use of tincture of cantharides (Rayer), increasing
to
!).
daily thirtydrops (!
Oleum
phosphoratum, 2-5 drops t. i. d. ; copaiba balsam, 4-6 gm. daily have also
the internal

of arsenic.

are

It is,therefore,advisable
water

Of

greatervalue are the decoction of specieslignorum and the

its use
in grown
subcutaneous
injectionof pilocarpine. Campana recommends
people
nutrition
of the skin, and
and tonus
with rigidskin, marked
scaling,diminished
also
in general has deteriorated
and
other diseases are
when
the nutrition
The
present.
alkalies and tinctur. colchic. (1-4 gm.
daily),recommended
by Bazin in arthritic psoriasis,
with the external applicationof tar and
alkaline vapor
were
always combined
baths, so that definite therapeuticconclusions cannot be drawn therefrom.
recommended.

been

External

remedies

baths
As

much

are

of the

times, maceration

prolonged for

hours

certain

more

affected

skin

in

or

tub

rule,however, this

in their

is sufficient to

in natural

the

thermal

scales,and

action than

produce

internal

recovery,

waters,

or

warm

At

ones.

for

example,
sulphur baths.

effective remedies, such

merely
as
parations
prebe applied.
first be removed,
the scales must
In the applicationof tar in psoriasis,
that the
so
remedy may act directlyon the diseased skin. This can be effected by protracted baths, as
mentioned
or
above, and by rubbing the scalypartswith spiritus
saponato-kalinus'
pumice
Less advisable
stone.
are
scratching with the sharp spoon, on account of the violent
acid.
mechanical
irritation;also rubbing with ether or solutions of salicylic
Softening
acetic
of
such
solution
violent
scales
as
acid,
of the
caustics,
potash (1 : 2 to 10)
by more
the skin is very thick, particularly
and when
in
is advisable only in very obstinate cases
of the palm of the hand.
psoriasis
a

of tar, must

The

then

some
occasionally contraindicate
injuriouseffects,which
single application is so irritating that an acute dermatitis
the so-called
for a long time, but then
with advantage
tar acne

its further

of tar has

use

Sometimes
it is used

cases

removes

develops.
develops.

merely the excretory

ducts

of the

sebaceous

glands and

hairs

visible

are

as

tion.
applicaIn

black, somewhat

other

At

first,

elevated

the applications are

made
take their place. When
to large parts of the
points, but little pustules soon
from
the possibilityof toxic symptoms
should
absorption; children
always bear in mind
body, we
be preceded by the passage
The
of dark-colored
in particular are
symptoms
may
very sensitive.

vomiting, dizziness, and

develops with nausea,
inky black to olive-green color, giving a distinct
acid.
These
usually disappear in a short
symptoms

urine, fever

headache, black

watery

urine, of

odor

of tar

upon

the

time

with

the

urine.

an

Even

ointment

The

fatal

termination, especiallyin children, has

been

observed

stools; the

addition

of sulphuric

copious excretion

from

inunctions

of

of
tar

in scabies.

twice a day, by rubbing

either pure or diluted, once
or
remain
either
in bed for a number
the patientshould
stiffbrush, after which

application
may

it in with

be made

attend to his ordinary avocations

he may
after the
blankets
or
powdered with soapstoneand bandaged with flannel. As the tar adheres
flannel underclothingnext to the skin.
it is advisable to wear
very firmlyto the clothing,
for some
If the scalingcontinues
time, the old layer of tar with the scales should' be
before a fresh applicationis made.
with soap spirit
removed
of hours

under

parts have

woollen

been

15 Sapon. virid.,50.0-100.0; Alcoh.

or
Spirit.lavand., 10.0.

Cologne

rectif., 100.0; Macera

per

hor.

xxiv.

filtr.

Add.

Eau

de

253

P80EIA.SI8.

These

remaining

with
may also be combined
bath.
for hours in a warm

modified

the

scales have

removed

psoriasis.
The products of
acid, have

solution*

Vlemingkx^
been

with

In

with
(either

service;this

or

but

tarred

patient
of
applications
without
protractedbaths),after the
sive
this method
is quitepainful in extenHebra

like manner,

pumice stone;

distillation of tar and

of little

proven

advantage with protractedbaths, the

coal, such

as

is also true

of

has made

naphthalin,resineon, carbolic
the ftnaphthol recommended

recentlyby Kaposi.
proto-iodideointment must be used with
caution,
pustulardermatitis to which they give rise.
caoutchouc
has
useful.
with
Treatment
Eubber-cloth, used as a bandage
proven
of
excretion
from the skin, and these
article of clothing,does not absorb the products
or
the entire body is not devoid
of
its employment over
soften the integument. But
dermatitis
have been observed
in consequence.
of serious acute
danger, as several cases
It is useful to combine
of tar with rubber bandages.
applications
The
Priesnitz's hydropathic measures
act in a similar manner.
patientis placed in
After perspiringprofuselyfor a
wet linen cloths and then wrapped in woollen blankets.
he is rubbed
number
with
of hours, he is placed in a cold bath with douche, in which
cloths.
He is then placed in a dry pack for a little while.
of treatment
is the soft-soap
An occasionally
"With
effective but heroic method
cure.
until
rubbed
the
infiltrated
brush
of
is
soft
a
or
they bleed,
piece flannet;
spots
soap
upon
Aveek is requiredto
small portionsof the body being treated each time, so that about
a
treat the entire body in generalpsoriasis.The
patient,who is kept in woollen blankets
during the entire period of treatment, remains in them for several days longer until profuse
desquamation occurs, and he is then given the first bath.
The
therapeuticsof psoriasishas received recentlya valliable addition in chrywhich
Goa powder (from Angelim Amargoso in Bahia, Brazil).
is obtained from
sarobin,
Chrysarobin in used in the form of ointment
(5-20^),being slowly rubbed with
oil-bath.
It must
be remembered
fat for a few hours in an
warmed
that chrysarobin
discoloration
of the clothing(atfirst yellow,then blue
violet upon
causes
a
or
being
with soap) and also of the hair, and that its application
to the scalp,therefore,is
washed
is rubbed, at first once, then twice a day,
excluded.
of a brush the ointment
By means
been
patches which have
deprivedof scales,and the parts then covered
upon the psoriatic
with a flannel bandage or flannel underclothingworn
next to the skin.
If the formation
of scales continues, they must
be removed
repeatedly.
After
repeated inunctions, a punctate, later diffuse redness, and occasionally
marked
swellingappear at the pointsof applicationand in their vicinity. But almost
from the first appearance
of the redness, the psoriaticpatches come
out distinctly
by a
around
them, and while they graduallyfade
peculiarplay of colors,a brightring forms
into a pale rosy color, the neighboringpartsstillremain
If the inflammatory
very red.
redness becomes
destitute of scales and of
painfulor the psoriatic
patches have remained
is discontinued
of days, the inunction
is only repeated after
a pale color for a number
or
the inflammatory symptoms have subsided for a few days.
The

extreme

inconstant

on

Rochard

ointment'

account

of the violent

and

the

]J Calc, viv,, 500.0 ; Aq. font., q. s. ut f. pulv. sequabil. 5 Flor. sulf., 1,500.0-1,000.0;Aq.
font.,10,000.0,Coque usq. ad remanent
6,000.0,filtra. This contains CaSa, CaSs, and oxidation
ducts
proof S.
"

]"ilodin. pur., 0.7; Calomel, 1.25; Leni

igni fusis add.

Unguent, rosat.,60.0.

25i

hands

If the

after

Even

urine, nor
''

have

been

treated

by coming in contact
to wear
glovesat night.

advisable

thal

PLANUS.

LICHEN

that, after

state

with

inunctions, Koebner^

extensive

did he observe

chrysarobin,it may give rise

the eyes during the night, and

with

unable

was

to discover

to

violent

junctivitis
con-

it is,therefore,^

the

drug

in the

and
EosenLewin
symptoms of absorptionor albuminuria.
in rabbits, they detected
its use
it in the urine together with

nephritis.
Pyrogallicacid,'in a 5-10^ solution or in the form of ointment, applied once
or
is slower in its action than
twice a day with a brush to the patches of psoriasis,
chrysawith
robin, but is useful, is unattended
noteworthy inflammatorysymptoms, and does
not stain the clothingas deeply as the latter drug.
Kubbing with soap upon the affected
taken
number
baths
must
full
be
of
times
and
a
during the treatment.
Lightparts
of
the
these
at
and
discoloration
skin
be removed
occurs
brown
can
spots
by benzin; the
be repeated until scalingceases.
must
inunction
Upon the applicationof stronger
of vesicles and necrosis of the skin occurs,
the formation
attended
solutions (to20fo),
by
the
should
with
In
extensive
be
extreme
psoriasis,
drug
caution,
employed
greatpain.
i. e., not applied to too largeparts of the skin, as grave
symptoms of absorption with a
Neisser*
has
of this kind.
fatal termination
ensue.
a
case
reported
may
used
and
been
Neumann^
acid
has
by
Lang," but it acts more
Eufigallus
slowly than
also
stains the clothing. It is employed by Lang
chrysarobinand pyrogallicacid, and
of ointment.
Koebner
has observed
with oil with a strength of 10^ in the form
good
the applicationof powdered zinc, free from
ment.
results from
arsenic,in the form of ointsymptoms

of

'

In

addition, appropriatetreatment
etc., which

may

be

present.

be

must

In

few

adopted

for any

cases, entire

anaemic, dyspepticconditions,

change

of diet has had

able
favor-

effects.

LICHEN

PLANUS.

planus is characterized at the onset by very small (not one-half to one-quarter

color,
as
large as the head of a pin) polygonal,flat elevation of the skin, of a normal
in
small
with
what
a shining,somepapules,
or
slightlyyellowish. Extraordinarily
groups,
be observed, especially
the delicate integument of the
excavated
surface,can
upon
a deeper color (yellow,
penis. In a little while they become higher and broader, assume
and
thus
constitute
the
lichen
to
bluish-violet),
papules described by
cherry-red
deep
and
which
not
flat,^^
often,
smooth,
though
constantly,presenta
"Wilson as
shining,
surface
its
the
excavation
entire
of
the papule, and
This
excavation.
occupies
shallow
which
to
the
in
the
however, corresponds
middle,
only exceptionally,
deepest point is
later
At
a
of preformed tegumentary structures.
period, the little
excretory duct
somewhat
somewhat
more
larger,and occasionally
pointed,
nodules, which have become
removed
with considerable
are
with a very thin coating of scales,which
covered
become
L.chen

"

'

Paper read before the Berl. Med.

Arch., Bd. 85, S. 118.

sWien.

Med.

^Zeitschr.
"

Wien.

Verbal

Jahrb., iv.,1878, S. 78.

f. Klin.

Med.

^Volkmann'sche
^

Gesells.,1878.

Virch.

Medicin, Bd.

Blatter, 1879, 22.

Sammlung.

communication.

Wien.

Med.

i.,1879, S. 88.

Blatt.,May,

1878.

"256

has observed

the disease in

eight months old, and in two children between,

The
with regard to sex vary.
The disease seems
years old.
be much
more
are
frequent in the better classes,but its causes
unexplained.
At times, the lichen appears
to be preceded for a long time by an affection of the

Kaposi

three and
to

PLANUS.

LICHEN

four

child

statements

nails.
In

opposition to previous observers, R. Crocker,' believes that the

inflammation
the onset
is a superficial
independent of the hairprocess
In
a
nd
varieties.
two
he distinguishes
the cellular infiltration which
follicles,
one,
starts from
the upper wall of the vessel of the uppermost part of the cutis,constitutes
of the height of the papule ; the excretoryduct of a sweat-glandoften
three-quarters
passes
through the middle of the papule ; the infiltration starts abruptly from the normal
rete cells,the horny layer
parts. In the other series,the papule consists of proliferated
in the centre of the papule is very much
in the correand
sinks
like
thickened,
a funnel
spondingly
of
the horny layer,causes
the
depressedrete, which, upon the desquamation
umbilicated
The interpapillary
prolongationsprojectsomewhat
deeper than
appearance.
normal
infiltration in the papillaedoes not occur
so
abruptly as in the first case.
; the
The sweat-ducts
often appear to determine
the localization of the papules.
In the largerplaques of lichen, Neumann''
found
the chief changes in the upper
of
the
cutis.
The
of
cells
is
thickened, and there is considerable
layers
horny
layer
increase of the rete,especially
the prickle-cells,
the nuclei of which
are
granular and
swollen.
The
are
papillae
enlarged,their vascular coils broader and twisted, the adventitia proliferated
the dilated vesis much
considerable
beneath
more
sels.
; the proliferation
In the upper
the
of
connective
tissue
of
the
the
c
ells
are
cutis,
proliferated
part
in
in
islets
and
meshes.
No
in
the
hair-follicles
sebaceous
or
arranged
changes
glands.
Parenchymatous changes in the sweat-glandsdevelop early; they become
broader,
and are
surrounded
the whitish-gray
by proliferatedcells. According to Neumann,
consist of these pathologically
miliaryobjects,which are visible macroscopically,
changed
and
black pigment is found
free,
sweat-glands (?). In the later stages, rusty brown
and
in the cells of the upper
and the adventitia of the
parts of the cutis,the papillae,

Anatomy.

"

anatomical

at

vessels.
From

sections

of

the

of
proliferation

papules,I

earliest

the

conclude

vessels of the upper

that the process

layersof

the cutis,and

begins as

is followed

perivascular
by

of the nerves.
papillae,
followingthe course
lichen must
be distinguished
from papular eczema.
The
Diagnosis. Disseminated
latter
of the
conical form
is recognized by the brighter redness, greater size, more
forms,
papules,and also by its speedy conversion into the vesicular,pustular,or squamous
in recovery.
In psoriasispunctata, scales accumulate
or
rapidlyupon the reddened
ral
spots,which are very little elevated, and at the first very small plaques undergo peripheconcentric growth, while the plaques of lichen are composed of smooth, polygonal,flat,
asis
shining,but firm papules,which are very little or not at all scaly. Furthermore, psorithe
skin
with
intense
cicatricial
brown
of
is never
followed
o
r
cicatrices,
atrophy
by
for the small papular
The
latter disease is often mistaken
discoloration,as in lichen.
But
constitutional
the
is
attended
latter
almost always
by severe
symptoms
sypliilide.
and
and pains in the bones
muscles, and is rarelyattended
by pruritus. Upon close
an

infiltration of cells into the

"

'Lancet, 1881, Feb.

'

19th, p. 285.

Vierteljahrschr.f. Dermat., 1875,

"circumscr.
herpetiform.)."

"

Ueber

eine

noch

wenig gekannte

Hautkrankheit

(Dermat.

ACNEIQT]^.

LICHEN-

LICHEN

CIRCINATU8.

257

papules are pointed,round, often covered with a brownish

plaques develop,the centre is almost always depressedand copper-colored.
In addition, the tendency of syphilis
to polymorphism of eruptionsis present.
In the very rare
of generallichen in which the characteristic primary eruption
cases
cannot
be discovered,a diagnosisis often impossible.
Treatment.
According to Hebra and Wilson, arsenic is the sovereignremedy, and
its action is much
certain than in psoriasis.The method
of administration
more
is
that employed in psoriasis. Hebra
the same
twelve
to
three
Asiatic
as
pills
gave
said to elapsebefore its effect is produced. But
are
dailyin three doses ; six weeks
such largedoses are not always
since a number
of cases
have a tendency
necessary, especially
to spontaneous recovery.
Koebner
has secured recovery in a very short time by
small quantitiesof Fowler's
recommended
solution,injected subcutaneously. Wilson
in small
corrosive sublimate
doses, and Vidal extols,in addition to bitters
externally,
the external
internally,
applicationof glyceroled'Amidon, 20.0 ; tartaric acid, 1.0, and
baths with vinegar (1 litre to the bath). W.
Boeck'
recommended
oxidizingremedies
T. Fox^ recommends
chlorate of potash and nitric acid.
asafoetida
internally,
especially
and mercurials, in addition to nourishing diet.
Unna^
has
with
recently
employed,
good
inunction
of the entire body with: unguent Wilsoni, 100.0 ; acid, carb., 4.0
success,
;
corrosive sublimate, 0. 1 to 0. 3, the patient then being kept in woollen blankets for a
week.
He has seen
in six weeks (?). Prof. Koebner
under this treatment
has
recovery
of pilocarpine.
subcutaneous
recentlyemployed with success
injections
Local remedies, such
as
tar, Costar's paste (tinctureof iodine and tar, or, more
weak solutions of potash,
properly,iodine,7.5 ; colorless oil of tar, 30.0)or other irritants,
soft soap, solutions of thymol, etc., have often proved sufficient in the plaques of lichen
The
which
remain localized.
pruritus must be treated symptomatically. The internal
administration
of arsenic often ameliorates the prurituswithin a few days.

inspection,
moreover,
crust

the

; when

"

LICHEN

ACNEIQUE.

LICHEN

CIRCINATUS.

This disease is characterized by small pointedpapules,usuallyof a dull red color,the tip

tered
being covered often with a yellowishor grayish-browncrust.
The papules are either scator
irregularly
grouped in arcs or circles. In addition to these papules which appear
to correspondto the hair-follicles,
there are somewhat
elevated
red discs,scarcely
as
large
which are covered
with a slightly
as a twenty-pfennigpiece,
thin
irregular,
grayish-yellow,
The crust is clearly
defined by a steep,wall-like,
crust.
circular border.
Earelywe find pale
papules,from the tipsof which a clear drop exudes, and also pale-redspots,which look
if brushed
with a gum-like fluid. In addition, we
sometimes
find irregularly
as
defined,
somewhat
about as largeas the hand, and of a yellow to a brightyellowscaly patches,ish-brown
color ; these are
surrounded
ish
by the small, pointed red papules,and by brownof the acne-like papules is the sternal
punctate depressions. The site of predilection
and
be present also on the remaining parts of the
interscapularregion, but they may
thorax
and back.
The largeyellowplaques are
found particularly
the abdomen
and
on
thighs.
flat patches are found
Yellowish, irregular,
the legs; they scale very
on
occasionally
somewhat
little and grow
pale on pressure with the finger. In its milder grades as acne'

Ai'ch.

"Med

of
Times

"Monatshefte

17

Dermat., vol. i.,Taylor.

and

Gazette, 1873, vol. i.,p. 540.

Dermatolog., Hft. i.,1882.

fur pr.

258

like

PITYKA8I8

papules,the

RUBRA.

DERMATITIS

EXF01.IATIVA

GENERALI8.

disease is

from the twentieth to the fortieth

remarkably frequent in men
of the pruritus. Its duration
is variable,
annoying on account
last for months
but it may
In rare
it begins suddenly and spreadsrapidly.
or
cases
years.
factors. Occasionally
Etiology. Nothing is known positiyely
concerning its etiological
in
there was
other
of
the
face
with
cases
profuseperspiration,
a flat thorax
pallor
very
; the
and
In
well
built.
and
one
majority of the patientswere
vigorous
slightpsoriasis
case,
The
occasional violent epistaxis
also
observed.
were
wearing of flannel,to which the
denied
in the majority of cases.
disease has been attributed,was
The affection is very
years,

and

often

becomes

"

similar to lichen scrofulosorum, but

glandular
enlargements,etc.

it does

not

present the symptoms

of

scrofula,such

as.

it is also

distinguishedby the age at which it appears, by

of the complicationsof lichen scrofulosorum
the absence
(acne with a hemorrhagic border,
of the
scrofulous
eczema
genital region),and also by its localization,since the milder
grades of lich. scrof. affect mainly the abdomen.
R. Crocker' has found, in the scales,mycelia and spores similar to those of pityriasis
versicolor in size and shape ; in order to demonstrate
them
better, he employs ether and
chloroform.
They are situated mainly in the papules,not in the scalypatches. He regards
versicolor.
the disease as an abnormal
pityriasis
observations have never
resulted in the discovery of fungi which are similar
My own
to the Mikrosporon furfur.
Crocker's spores are very like the Torula communis, which is
found in scales of the most
varied origin.
far
the
So
disease is not contagious.
as
known,
of active remedies ; it may
The affection often resists for a long time the use
pear
disapits former status.
apparently,but in a few weeks resumes
Diagnosis. We must differentiate : 1. ordinary acne ; in lichen acneique the often
pale-redelevation,which
merely punctate crusts are situated upon a pointed,superficial,
duct
of
to
sebaceous
the
constitutes more
a
gland ; acne
excretory
correspondsapparently
of
often
broad, hard, deep-red papules
varying size,
painful on pressure,
deeply-seated,
and which usuallyhave purulent contents
also present, and
are
; in addition, comedones
observed in it. 2. Lichen scrofulosorum.
the yellowishplaques described above
are
never
circular discs with a red areola,while, in lichen,
3. Pityriasisrosea
are
: in this there
is an
the prominent feature
irregularboundary of those parts of the skin which are
of papules and
with
stained more
acne-like little nodules.
peripheralformation
deeply,
di\\rsii\ou
of
the
individual
ihQ
4. Eczema
long
papules,the polymorphism,
papillosum :
the
eruption,facilitate the diagnosis.5. Pityriasisversicolor
arrangement and localization of
and
like a membrane,
be removed
the fungus: in this disease, the patches may
be discovered without
difficulty
may
; in addition, no pointed papules are found.
Treatment.
This consists mainly of the applicationof tar, soft soap, soap spirit,
recommends
Wilkinson's
Crocker
inunctions
ointment, white precipitateointment.
9.0
15.0.
stinate
with natrium
with
In obsubsulfurosum, 1.0,
fat; or thymol, 1.0, vaseline,
;

"

"

cases,

the internal administration

PITYRIASIS

RUBRA.

of arsenic is recommended.

DERMATITIS

EXFOLIATIVA

GENERALIS.

rubra is a very rare, usuallychronic disease,with a fatal termination, in which

Pityriasis
a deep-red color
throughout, and is covered with largelamellae of scales.
In one, the face
of this disease.
Gibert (1860) gave a good descriptionof some
cases

the skin has

'

Lancet, Oct., 1881, p. 748.

PITYEIASI8

EXFOLIATIVA

DERMATITIS

RUBRA.

GENEEALI8.

259

dry, thickened, covered with whitish fine scales ; the skin in

escaped,tlie forehead was
generalfelt like parchment, the desquamationoccurred in large lamellae like the layers
removed
at one
adherent
of an
by rubbing ; the
onion, the scales were
edge, and were
skin was
The
to be reddened.
then seen
by a
pityr. rubr. was
preceded occasionally
vesicular eruption;during its course, weeping occurred only at the very tense and consequently
The
affection ended
elongated and bent.
ruptured places; the nails were
fatallyby marasmus.
Under
the term
"herpetide exfoliatrice,"Bazin' includes this affection,together
with other dermatoses, such as eczema,
psoriasis,
pemphigus, which are associated with
after enormous
profusescaling. These diseases may pass into one another, and finally,
terminate
intercurrent
disease.
production of scaliss,
fatallyfrom some
the term
dermatitis exfoliativa,
E. Wilson'' includes under
tion,
not alone a primary affecbut also the terminal stagesof various
in
which
the
sence
abprofuselyscalingdiseases,
of primary or characteristic eruptionsrenders the diagnosisimpossible.
rubra
Hebra' stated that pityriasis
is unaccompanied by any other symptom than
dark-red color,without notable infiltration,
formation
of papules or
a constant, intense
without weeping or formation
of vesicles ; it is associated with slightitching,
fissures,
and almost
always spreadsover the entire integument." The redness disappearson pressure,
givingplace to a yellowishcolor. At the placeswhich are free of scales,the skin
occasionallyhas a vitreous,glisteningred color, through which the deeper parts of
visible. The
the skin are
jectively
elevated, but subtemperature of the skin is somewhat
At the beginning,there is a branny desquamthere is a feelingof chilliness.
ation,
but later the scales become
larger. The affection begins at various parts of
the body, with deep-redscalingpatches. Alopecia and
ing
durchanges in the nails occur
until
disease.
the
The patientsmay
their occupation for years,
emaciation,
pursue
the feelingof tension in the skin, its diminished
elasticity,
secondary changes (fissures,
from
the fatal termination
phthisis,
gangrene),and impaired nutrition graduallycause
other intercurrent disease.
The
disease affects particularly
in.
males
or
some
nephritis,
the prime of life.
Hans
Hebra* reportsa case in which the autopsy revealed
tubercle of
V.
a
solitary
to
in
addition
the cerebellum,
Fleischmann.
pulmonary and intestinal tuberculosis.
states that he has found
cerebellar tubercles post-mortem on several occasions in children
who had suffered from a cutaneous
affection similar to pityriasis
rubra.
Chronic
pitryasisrubra does not always appear to begin with red, scalypatches,
since in one
the eruption was
of H. v. Hebra's
cases
preceded by an impetiginous
of
the
eczema
scalp.
Kaposi'^believes that he cured one case, and also reports that a colleague suffered
from
rubra, which terminated favorably.
pityriasis
Dermatitis
Corresponding to the chronic form of pityriasis
Exfoliativa Acuta.
rubra
is the acute, usually benign form
which
has been
described
under
various
It often occurs
with slightfebrile or general symptoms,
at first usually in
names.
the form
of round, red infiltrated discs, like circumscribed
dry, more
rarely moist
covered
with
which
becomes
soon
branny scales and itch moderately. The
eczema,
"

"

'

"Affections

"

Med.

Times

cut. arthrit.
and

et dartreuses."

1870, 1.,p. 118.

Aufl., 1862.

Gazette,

"

"

Vierteljahrschr. f. Dermat.,

"

"

Hautkrankheiten,"

Vorlesungen,"

i.

S. 393.

1876.

Lectures

1870-78.

260

PITYBIA8I8

BUBEA.

DERMATITIS

EXFOLIATIVA

GENEEALI8.

redness

the trunk
and limbs, nor
does the face escape;
spreads from the chest over
the horny layers scale off in stripesor in large lamellae, which
be
two
even
may
in length. Slight weeping
inches
in some
occur
places;in others, a few flabby
may
vesicles appear;
the tense skin occasionallyfissures on
the flexor aspects of the
The nails and hair sometimes
fall out.
to the normal
The skin returns
in a few
but

in

relapsesoccur

to the

hands,

and

number

of

In individual

cases.

the

cases,

affection

joints.
weeks,

is restricted

the

horny layersmay be drawn off like a glove.

It cannot
be determined
at present in how
far we
should
include
in this affection
of so-called erythema toxasmicum
after surgicaloperations,
cases
the scarlatina-like eruption
and in puerperalprocesses, also the scarlet eruption after typhoid
after similar causes
fever,at first circumscribed, which terminates in branny and large shredded
tion,
desquamaalso the similar exanthem
of certain drugs, such as hydrate
after the administration
of chloral,quinine,digitalis,
and also after extensive treatment
with caoutchouc.
T. Fox
observed
as
a
sequel of pityrias.rubr. that the hair-follicles presented
'

themselves

in rows
with scales in their excretoryducts.
This condition he calls pityriasis
and regards as characteristic of a preceding pityriasis
pilaris(lichenpilaris)
rubra, but a
similar appearance
is observed
extensive
a
fter
occasionally
psoriasis.
rubra
Byers^ reports a case in which pityriasis
developed in an ichthyoticgirl.
rubra as varietyof eczema;
he found that a slightexudation
Liveing'regardspityriasis
between
the layersof epidermis is never
absent.
He also observed that albuminuria
was
always present, and that an improvement in the condition of the skin correspondedto
a

diminution

in the urine.

of the albumin

J. Hutchinson*
of various

includes

under

the term

rubra
pityriasis

the

usually fatal

chronic, symmetrical,obstinate affections of the skin, which

are

tions
terminaterized
charac-

He
sumes
asdesquamation, thickening of the skin, absence of exudation.
that they are due to a degenerationof the spinalcord.
in
The anatomical
changes in pityr.rubr, were studied by H. vonHebra'
Anatomy.
In one he found a thick horny layer,a thin rete with infiltration cells,then
two cases.
tissue profuselyinfiltrated with cells and numerous
the connective
well-developedelastic
had
fibres,here and there yellowish-brownpigment in the connective tissue;the papillae
disappeared,the sweat-glandsand sebaceous glands were absent, the hair-follicles and hairs
of normal
rete were
the epidermis and
dimensions,
case
very scanty. In the second

by

marked

"

licles
hair-foland subcutaneous
connective
tissue filled with a cellular infiltration,
papillae
cells
accumulation
of pigment; small
and sweat-glandspresent in abundance, no
the
vessels and sweat-glands.
collected around
were
not separateddistinctly
B. Baxter" described the followingchanges: the rete Malpighi was
from the horny layer,as the zona
granulosa had disappearedentirely;there was
a very
gradual transition from the polygonal rete cells,which stained readily,to the flat
colorless.
which remained
scales of the stratum
Flattened, feeblystained nuclei,
corneum
in the uppermost layersof
be
the
to
could
which
even
surface,
recognized
lay parallel
thickened
The
the enormously
moderately enlarged, the
papillaewere
horny layers.
somewhat
more
deeply than norinterpapillaryprolongations of the rete extended

the

"
2

"

"
*

"

Times
and Gazette, 1873, i.,p, 487.
Ibid., 1880, ii.,p. 375.

Med.

"'

Diseases

of the

Skin," 1878.

Surgery," 1879.
Vierteljahrschr.f. Dermat., 1876.
Brit. Med.
Journ., July, 1879.
"

Lectures

on

Clinic.

EXFOLIATIVA

DEEMATITI8

the

cells of

The

mal.

muscular

almost

mainly

is due
The

the

appeared
which

and

acute

increased.

be

to

cutis at

thickened

of the

to a fluid exudation

of the chronic

causes

hair- follicles

consistence

261

INFANTUM.

before

is absorbed

varieties

are

the

According to Baxter,
ease
beginning of the dis-

death.

unknown.

is rarelyeasy.
squamation
Redness, deand in psoriasis,
dry eczemas
of scales than in pityr.rubr. and the
but in the latter there is a greateraccumulation
bleed
to
made
and
is
more
readilyin psoriasis.Circumscribed
plaques
papilla injured
not
forms
of
which
and
the
are
of pityr.rubr.
eczema
always preceded by a moist
dry
stage are often exactlyalike. The diffuse forms of pityr.rubr. chron. are distinguished
and lichen planus by the characteristic primary eruption.
from generalpsoriasis
at once
It is distinguishedfrom
pemphigus foliaceus by the absence of stinkingsecretion,the
moved.
dryness of the scales,the absence of eroded moist patches after the scales have been re-

Diagnosis.
"

The

moderate

Treatment.
and

of

indicated
Great

same

indications

of the chronic

fattysubstances

supple ; protractedbaths
are

when

rubra
pityriasis

after the

forms, but

hopeless. Applicationsof tar

pruritus,and render the skin more

is almost
the

present and

be attached

must

in the acute

form

applicationof
is

in

found

are

often diminish

albuminuria

importance
hold

chronic

infiltration of the cutis

Treatment

"

inunctions

diagnosis of

to

these

act in the

tar

same

ics
Diuret-

manner.

minished.
diis extraordinarily
perspiration
The
roborants.
a nourishing diet and
usuallypresenta tendency to spontaneous
the

recovery.

DERMATITIS

G. Bitter

EXFOLIATIVA

Rittershain'

INFANTUM

(V. RITTERSHAIN).

has observed

he described
a symptom-complex, which
as
of children, from
the age of about
large number
six days to five weeks.
They often presented quite a marked
dryness of the skin,
usuallywith branny desquamation. The disease begins generallyaround the anglesof the
mouth, with a diffuse, at first pale, later deep-colorederythema, with a tendency to
of rhagades. The
buccal
the formation
is dark-red, with
membrane
mucous
small,
losses
of
substance.
The
from
the face to the trunk
superficial
irregular,
process spreads
The
and limbs.
of fluid exudation
epidermis separates,usuallyafter a small amount
underneath
has accumulated
it,in other placescrusts form ; the upper layersof the skin
action.
be removed
The
rete has a dark,
uncovered
readilyby slight mechanical
can
flesh-red color,is shining,and dries in a few hours.
The process of exfoliation gradually
the entire body ; the thick horny layer of the hands
extends
and feet can be
over
strippedoff like a glove. Instead of drying of the rete, regenerationof the upper layers
attended with branny desquamation. The
often occurs,
duration
of the disease is
usuallyseven to ten days.
The
disease varies greatlyin severity
its course
usuallywithout fever or
; it runs
von

exfoliativa infantum, in

dermatitis

gastricdisturbances.

After

the skin has

normal
a
color, but presents a
recovery,
Furuncular
as
a
eruptions always occur
tendency to eczema.
sequel, and lead to
from
in
phlegmons, gangrene, and perhaps to a fatal termination
sepsis; this occurs
Mild
sometimes
after the lapse of about
two
scarcelyhalf the cases.
relapsesoccur
It presents greatsimilarity
to the infectious diseases,but
weeks.
is not contagious. It
and epidemically. Boys are
affected more
occurs
sporadically
frequentlythan girls.
"

Centralztg.f. Kinderheilk., 1878, Bd.

ii.

Arch.

f.

Kinderheilk., 18S0, No.

53.

262

PITTEA8IS

ROSEA.

Diagnosis. It must be differentiated from erythema neonatorum, which occurs

shortlyafter birth, while dermatitis exfoliativa develops,at the earliest,at the end of the
first week ; from erysipelas,
which is always attended
with increased temperature ; from
color and the vesicles are distinctly
pemphigus, in which the non-affected parts have a normal
"

formed.
Y.

Treatment."

Rittershain

recommends

roborants, nourishing diet, baths

E., looselyapplied clothing,applicationof dusting-powder to

to which
one

In

scales with

and

of crusts
a

decoction

one-half

and

furunculosis

of

fine almond

finelycut

and

by

circinata,Horand'

circinata.

Vienna

The

results

the eroded

obtained

were

(100.0oak-bark

places,removal
also

to 1 litre water

added

to

from

boiled

bath)

was

baths
one

to

added.

be evacuated.

must

Gibert

Good

-^litre of the decoction

PITYRIASIS

Described

'

oak-bark

and
hours, filtered,

the pus

oil.

of 25"

ROSEA

(GIBERT).

rubra maculata
pityriasis
by Bazin as pityriasis
rosea, and
the term
of it under
recentlygave a detailed account
pityriasis
school deny its separateexistence,regarding it as herpes tonsurans
as

maculosus.

beginswith mild fever,then little red patches,scarcelyas largeas a

twenty-pfennigpiece,and very slightlyor not at all elevated,appear upon the throat or
with a coherent, silverythorax ; they are covered with a few branny scales,sometimes
the patches spread concentrically,
In
the
scale.
few
central part is yellowa
days,
ish
gray
and
with the finest scales,and
covered
peripherallythe redness passes insensibly
The
affection spreadsover
the entire body, but rarelyaffects the
color.
into the normal
it
looks
like
is
If
the
face.
involved,
circumscribed, circular pityriasis
scalp
simplex,
but the hairs remain
unchanged. If two or more
enlargingcircles coalesce,the redness
Pruritus is not a
disappearsat the point of junction,and slightdesquamation occurs.
disease often

The

constant

disease

The

symptom.

lasts from

four

to

six weeks

and

recovers

ously.
spontane-

to be not infrequentafter
agents as the cause
; it appears
it
is
not
infrequent in childhood, parprofuse perspiration. According to this writer,
ticularly
in the first half of life,
in lymin boys ; accordingto Bazin,' it occurs
especially
phatic,

Horand

external

assumes

scrofulous

individuals.

small spores scarcely1 pi, rarely3 /" in

and middle layers of
size ; they are arranged in circles in the epithelium of the upper
in
and
i
n
about
the
but
the epidermis,
epithelium; rarelychains of
occasionally heaps
E. VidaP

spores
black

are

has found, in this affection,very

seen,

five

six spores have

or

diameter

of less than

//, and

look

like small

nata
circihowever, Vidal distinguishes
pityriasis
points arranged in lines. Clinically,
from pityriasis
rubra ; the latter lasts four to six weeks, begins at the middle of the
the trunk
and limbs, while pityriasis
circinata
thorax or back, spreadssymmetricallyover
The
leads
latter
to
consider
here
and
there
without
me
description
begins
symmetry.
account
of
On
with
identical
its
Vidal's pityriasis
circinata as
rosea.
pityriasis
varying
s.
size,he calls the fungus Mikrosporon anomseon
dispar. Similar micro-organisms
found in the scales of other desquamating dermatoses.
are
(cocci)

"

Ann.

d.

DermatoL,

"

International

Affections

Cutan.
Medical

Bd.

vii.,S. 325.
Artificielles,"
1862, p. 226.
Congre.-s, 1881.

264:

vigny) describes
in the
jj.in

40

(eKUPTION OF

PEMPHIGUS

the bacteria

form

of

of acute

pemphigus as a row of links, 2.5 n in length,arranged

threads consistingof two to twenty links, being 4 to

the

rosary,

length. The individual bacteria

arranged in zooglceaforn". The

bacteria

VESICLEs).

and

the threads

bacteria

are

found

are

very mobile ; he also found

in the fresh vesicles and in

the urine.
On
Ij

of the

account

midwife

who
the

as

bathed

of the

cause

infectious

The

in contact

with

children

in

pemphigus

in the

neonatorum

hot water, Bohn

too

looks upon

practiceof

cutaneous

tants
irri-

disease.

character'

the

of

repeated occurrence
the

of

is also shown

pemphigus

affected children, do

by

the fact that adults, coming

escape, although the

and
adults, the disease

general condition
seriously. In older children
give rise to
may
clinical appearances
is no
of contagious impetigo, and there
doubt
that
number
a
of impetigo contagiosaare reallylocalized contagiouspemphigus.
cases
not

affected

not

Tlie

contagious property

same

other

in many

Acute

reddened

is
a

patches,develop either

disturbances.
more

of adults
the size of

from

The

less

or

spreads over

vesicles

of

pea

to
or

filled at

vesicle,the

the latter often

and

are

than

rarer

with

purulent after a while.

the entire body. The

distinct formation

secretion, especially the pus, has been

the

acute

mentally
experi-

contagiouspemphigus

hazel-nut, usuallyupon

without

febrile

first with

Beginning
buccal

mucous

somewhat
and

clear, watery fluid,which

of

dren.
chil-

elevated,

prodromal stage

general
becomes

the trunk and

limbs, the eruption
upon
membrane
is often affected ; without

epithelialcovering of the mucous

though it may be changed into

looks red,

diphtheria-like,
readilybleeding surface.
sometimes

demonstrated

of

pustular eruptions (eczema, scabies, etc.).

pemphigus

Vesicles

of the

is
the

If the wall

membrane
a

is

moved,
re-

grayish-white,

of the vesicle is removed, the corium

when
the vesicles
as
a smooth, reddened
surface,sometimes, particularly
and
large,it is uneven
granular ; a deeper loss of substance is observed
only exceptionally. If the vesicular contents
dry into crusts, their color will be lightor
of the vesicles also varies,
The consistence
dark, according to their previouscontents.
sometimes
sometimes
flaccid.
are
tense,
they
The
It does not always terminate
of the disease varies as greatlyas its duration.
course
in adults, the
in a few weeks in recovery; even
fever
high
occasionally
produces
are

appears

very

symptoms,

severe

even

fatal termination.

in
of times in pregnant women,
pemphigus has been observed a number
tion
some
cases
accompanying the various pregnancies,and thus constitutinga natural transito herpes graviditatis
(Bulkley); also shortlyafter delivery. It has been observed
also in drinkers, a fatal termination
occurringrapidly,attended with delirium.
There
Chronic
are
varies
cases
pemphigus
considerablyin its duration and course.
time
the
at
time
that
is the
in which
for months, so
to
no
from time
eruption occurs
the relapses. The
ease
disbody entirelyfree. In other cases, long intervals elapsebetween
the greater the extent
be benign or malignant; the more
frequent the relapses,
may
of surface occupied by the vesicles,and therefore of the secretingsurfaces;the greater
has been
laid
the danger of septicinfection from
the extent
of the integument which
the
unfavorable
more
the
mouth
and
are
bare, the more
implicated
markedly
pharynx
will be the course
of the affection with regard to the life of the individual.
Chronic
pemphigus begins frequentlyunder the form of a polymorphous erythema,
Acute

"

from
oxen.

Ballard
a

cow

to

(Med. Times

and

human

being.

Gazette,
Gibier

1871, i.)reports
states

that

the

case

disease

of the
occurs

communication
in

asses,

of

pemphigus

horses, sheep, and

PEMPHIGUS

and

retains this character

for

number

(eKUPTION OF
of

265

VESICLES).

weeks; then largerand

smaller

vesicles appear

other cases, the vesicles develop upon

a
integument. Their size is very variable,
like a flaccid bag filled with
from that of a pea to such an extent that it hangs down
buccal
and
the
Even
brane,
memfluid,and as large as the hand.
pharyngeal mucous
upon
not
the
membrane
of
the
occurs
infrequently;they
separation
layers of
upper
localization of the
become
of the unfavorable
macerated
account
very rapidlyand, on
with marked
affected parts,assume
a diphtheria-like
swellingof the tongue,
appearance,
in swallowing,etc.
of
However, a cleaner appearance
salivation,foetor ex ore, difliculty
the parts and
membrane
Kleinof
occur
new
ordinarily
rapidly.
development
very
waechter
has described vesicles and eroded patches in the vagina in chronic pemphigus.
Upon the skin, recovery with the formation of cicatrices rarelyoccurs, but the rete
coloration
becomes
covered with the normal
layerof horny cells;a light to deep sepia-brown disvesicle.
More
at the site of the former
often remains
rarely,very firm papillary
proliferations
developgraduallyupon the thickened subcutaneous
(stalactite-like)
to develop. The
vesicles have continued
sites of predilection
tissue of placesin which
of such hyperplasias
the integument in and around
the axillse,
that of the genitaland
are
inguinalregions,and the dorsal surface of the foot.
Fever and more
less severe
the
or
general symptoms not infrequentlyaccompany
subside.
various eruptions,but quite frequentlythey afterwards
Pain is not very noticeable;
the patients complain merely of burning, tension, and
disagreeabletraction,
serious symptom
is the insomnia,
produced by the adherent bandages and clothing. A more
that
not
from
fact
it
is
the
of a
since, apart
infrequentlya prodromal symptom
new
eruption of vesicles,it reduces the condition of the patient to a remarkable
degree
The
and
often yields only to large doses of narcotics.
pruritus,which is extremely
is very annoying and intractable.
violent in some
cases,
A. Oazenave
has described
a
peculiar form of pemphigus which he calls foliaceus.
At first we find a few, usuallysmall flaccid vesicles,with purulent contents, which
come
bethe
after
After
of
months.
short
numerous
more
a
charge
lapse
period,the vesicles disnot even
vesicles are
their contents; occasionally
formed, and the skin is raised
roll in from the free
up in largeror smaller shreds of a yellowishor grayish color, which
of vesicles and separationof the skin form under these scales or
A new-formation
side.
crusts, and the morbid products are thus collected into
rolled,dough-like structures,
converted
into shreds.
and the patientlooks as if the skin had become
]N"ot infrequently,
the
be
found
in
entire
can
here
an
scarcelya healthy spot
body:
eroded, somewhat
indicates the circular form of the
moist or suppurating spot, the shape of which
vious
preupon
more

formerly erythematous patches.

occasionallynormal

the
or

In

less reddened,

'

"

vesicle,there accumulations

"

of scales; here crusts, there numerous

flaccid vesicles;
regionsof the skin look as if scalded, and adhere readilyto the bed-covering;
the
hair of the scalp and beard
falls out, the conjunctiva is injected,the lower
lid often
sets in, the absorptionof pus causes
occasional rise of
an
slightlyectropic. Emaciation
there
At
times
the
of
the
are
intestinal
on
tract.
Death
symptoms
temperature.
part
after a shorter or longer period.
closes the scene
The buccal and pharyngeal mucous
membranes
and the conjunctivae
do not remain
unaffected by the formation
of vesicles.
When
they develop on the epiglottisand mucous
of the larynx,the most threateningsymptoms of suffocation
membrane
be
duced.
promay
entire

'

Prag. med.

Wochenschr.,

Bd.

iii.,S. 6.

.266

vesicles).

(eruption of

PEMPHIGUS

the mucous
Yery rarely the vesicles occur
upon
genitalia. In rare cases, they develop earlier
the integument.
upon
V.
Baerensprung first observed hypertrophy of
it may
be followed
pemphigus. In like manner,

female

membrane
the

upon

of

the sebaceous

'

by

an

the

nose

or

membranes

mucous

the
than

glands as a sequel of
development of

enormous

furuncles.

Etiology. The causes

vigorousindividuals,and
for a long time.
In

in which

case

pemphigus are
cachectic symptoms

"

lungs, Jarisch

the clinical

with
fatally,

terminated

which

discovered

It

unknown.

of

"

do not

not

occurs

until

appear

infrequentlyin

the disease

diagnosisof herpes iris (pemphigus ?)

acute

decubitus

the

over

in the

anatomical

and

sacrum

spinal cord.

has

made, and

was

inflammation
He

lasted

of the

found

pic
macroscochanges
in the central,lateral,and
changes in various parts of the gray axis,particularly
The
changes consisted of inflammatory apposteriorportions of the anterior horns.
pearances
of the processes of the cells)
and
of the ganglion-cells
the fibrous
(swelling
interstitial substance.
in
Dejerine and Leloir found changes in the peripheral nerves
of
fresh
fibres
in
the
the
while
vesicles,
vicinity
pemphigus,
being degenerated
empty
^

nuclei, alone remained

sheaths, with increased

underneath

often appear upon the anaesthetic spots

anatomical
changes.

Vesicles

undergone

of

old vesicles.

leprosy,in

which

the

nerves

have

of pemphigus which
are
produced by changes
regard as reflex those cases
may
such as the cases
of recurringpemphigus
of women,
genital organs, particularly
and
in pregnancy,
the pemphigus hystericus(Hardy) of uterine anomalies.
In a child
Startin
observed
vesicles upon
the arms
and legsas the result of round
and the
worms,
Kcebner
after
calls attention to the
former
the dischargeof the worms.
disappeared
of pemphigus to herpesand urticaria and assumes
irritation of the vaso-motor
an
similarity
and
of pemphigus,
certain predisposition
of the skin as the cause
sprung
Baerennerves
a
v.
believes that it is a primary affection of the blood, like the exanthematic
cesses,
proand
that the blood is not affected in its entire mass, but only in certain vascular
when
the vesicles follow septicprodistricts.
The assumption of a toxic originis made
cesses,
ulcerative
endocarditis,uraemic poisoning
surgicalmeasures,
puerperal processes,
iodide of potassium,
^fter scarlatina,after the administration
of certain drugs (arsenic,
of potassium,salicylate
bromide
of soda).
Purulent vesicles not infrequently
occur
repeatedlyupon the lower limbs of enfeebled
We

in

the

individuals,who

Anatomy.
granulosum
-contain

no

from
cells

The
"cells.

"

from

have

inferior

of

contents

Ann,

"

Sitzungen

Gaz,

Arch.

d.

roof of

have

the

the stratum

separationof

attained

certain size,they

a
they
there are nipple-like
occasionally
projections
the vesicles,correspondingto the epithelium

greatly,containing-serum,
pus, and
941.9
water
1.0196,
parts,solid
specificgravity

epithelium

vesicles vary

matters

Charite, Vol.

x., p. 101.
d. k. k. Akad.
d. Wissensch.,

d.

In
Hop., 1876, p. 835.
f. Dermat., 1869, S. 218.

Ann.

Sitzung^Uer.d.

d.

by

occurs

the follicles.

its

When

singlechamber
of the

disease.

vesicles

lucidum.
a

surface

the

found

other

some

of the

stratum

and

dischargedfrom

Jarisch"

from

formation

the

meshes
the

bed-ridden

are

The

Charite, Vol.
k. k.

x.,

III.

Abth., Bd.

paralyticold

woman.

p. 99.

Akad., Abth.

III.,1879, S. 59.

81.

Mai, 1880.

58.1

(eEUPTION OF

PEMPHIGUS

it contained

parts ;

albumin, paraglobulin,and

serum

chlorine, sulphuricacid, phosphoric acid, carbonic

oxide

of

in all 0.84^ ashes.

magnesium,

Urea

267

VESICLES).
a

little fat.

The

ashes contained

acid, potash,soda, oxide

and

fat

also

were

of calcium,

present,but

no

free

ammonia.
The
the

rete cells which

nuclei

being

form

retained

dilated,the connective-tissue
the

connective-tissue
the

granular masses,
ducts

show
papillae

network

bundles

vesicle

the floor of the

; the

of the

vascular
In

is looser.

flattened in their upper layers,

injection,the vessels are somewhat

are

pemphigus

thickened, the

cutis

rete

filled with

and

sweat-glandsenlarged

foliaceus Neumann
cells clouded

necrotic

cells,their

'

found

by finely
excretory

dilated,the horny layerimperfect.

Tubercular

and also chronic

found
in the other organs in fatal cases
changes were
kidneys,waxy degeneration,pneumonia.
be distinguished
and children must
Diagnosis. The contagious pemphigus of the new-born
in children,though
from, 1, the ordinary,non-contagiousform, which occurs
more
pemphigus, which is confined chieflyto the palms of the hand
rarely; 2, syphilitic
and soles of the feet ; the vesicles are usuallypurulent,the skin presentsa brownish-red
infiltration upon
which
the vesicles have formed, or there is merely separationof the skin
Other
elevated
base.
an
specific
symptoms (coryza,exanthems, ansemia) are
upon
usuallypresent.
must
We
be on
cantharides
is
our
guard against simulation, for which
purpose
hieflyemployed. The shining scales of the Spanish flywhich can be detected upon the
indubitable
evidences of simulation.
wall of the vesicle and its vicinity,
are
their
of
the
without
The
with
vesicles,
cicatrices,
a
superficialposition
recovery
smooth
pigmented skin, the never-failingrelapsesdistinguish chronic
pemphigus
ulcerative processes associated with the formation
of vesicles or large
from the specific
pustules.
The
general condition of the patientmust always be taken into consideration m
of typhoid symptoms with abundant
formation
of
making a prognosis. The occurrence
in
of
the
acute
both
and
chronic
forms
vesicles is of very unfavorable
significance,
phigus.
pem-

degenerationof the
"

Treatment.

Acute

"

contagiouspemphigus

neonatorum

requiresisolation,the greatest

cleanliness,good nourishment, the preventionof disturbances

tract, the applicationof powdered substances, lukewarm
the

the

on

baths.

nal
part of the intestiAcute

simple

or

severityof the

contagious pemphigus requires,according

generaldisturbances,
with quinine, roborants, etc.
Locally we may apply
merely symptomatic treatment
and bandages with ointments.
powdered hygroscopicsubstances
most
The
important indications in chronic pemphigus are, 1, to keep the nutrition
of the patient in the best possiblecondition ; 2, to relieve the annoyances
caused by the
etc.
of
th'e
to
the
use
water-bed,
3,
vesicles,
bandages,
dusting powder,
by
prevent sep;
tic
complicationsfrom absorptionof purulent substances from the vesicles by cautiously
opening them ; 4, to prevent inanition if the mouth is affected. The first indication is
of tonics and bitters,such as iron, quinine,etc., nourishfulfilled by the administration
ing
is affected to a marked
diet,wine, and, if the mouth
extent, even
feedingby the
to

ectum.

Hutchinson

"^

hab observed

"

"Lehrb.

"

Med.

entire recovery

d. Hautkrankh.,"

Times

and

Gazette,

in several

V.

cases

of

Aufl., S. 243.

1875, Vol.

ii.,p. 4G1.

pemphigus

after

treat-

268

CHEIEOPOMPHOLYX.

with

ment

water,

sugar

ferr.

Devergie recommended
Baereusprung the internal

v.

second

the

to

sesquichloratum,6-8 drops t. i. d., in

gard
applicationof chlorate of potash. "With reeffects
the
of
authors
baths,
emphasize
injurious

arsenic.

indication,many

and
employed water advantageouslyin various ways, such as cold douches
baths, hydropathic packs, a water-bed
stay in water of the temperature
{i.e., constant
baths
with
also
Hebra
recommended
corrosive
sublimate,
desired). Devergie and
with
caustic
with
carbonate
of
also
4.0-10.0
bath,
soda,
50.0,
100.0-150.0;
potash,
per
the application
of the oil of cade and a subsequentprolonged bath.
Hillairet recommended
treatment
linimentum
calcareo-oleosum
and the applicationof cotton, *'.e., the same
as
In other cases, the applicationof dry dusting-powders is sufficient.
fecting
Disinin burns.
to meet
the fourth indication.
or
astringentgarglesmay be used profitably
Hebra

while

CHEIEOPOMPHOLYX.

Under

J. Hutchinson

this name,

described

disease the

itchingand

It

severer

forms

of which

occur

in the

and in a few (two)

chieflyin women.
begins with
burning
fingers,
days vesicles develop rapidlyand symmetricallyin the integument of the fingersand vola
Larger vesicles are also present. The feet
looking like swollen grains of sago.
manus,
but
often affected in the same
later than
A
the hands.
are
usuallysomewhat
manner,
and
the
over
pruritusoccasionally
eruption
(rash)
temporary erythematous
develop
body
without
time.
The
vesicles form
at the same
any inflammatory symptoms, and their
contents
disappearin a short time. The disease is followed at times by a peculiarchange
in the vicinityof the root.
in the nails; they are undermined
and break
ways
Eelapses alalmost
in this affection.
It occurs
occur
exclusivelyin adults, particularlyin
in vigorous persons,
nervous
individuals,"but sometimes
during and after protracted
the
at
The
vesicles
first
contents
mental
of
later acid; sulphuric
are
neutral,
activity.
acid produces a whitish precipitate.
Eobinson'
Anatomy.
gives the following descriptionof the microscopical
ances.
appearthe upper
takes place between
The collection of serum
layersof the rete Malphighi (stratum granulosum ?),and the rete-cells forming the floor of the vesicle are
of rete-cells,has a
flattened,in places elongated. The roof of the vesicle, formed
variable
There
thickness.
of
are
no
changes in the papillaryvessels. The formation
the smallest vesicles coalesce
the vesicles correspondsto the arrangement of the papillae;
into largerones
by the atrophy of the intervening cellular wall. The clear fluid con'

"

'

Thin,

The

from

British

Med.

following

hemicrania

nervous

finger. A large vesicle

tersb.
the

Med.

Journ., Dec,

must

be

regarded

was

affected

case:

as

Liveing, ibid.

abnormal

with

of cheiropompholyx:
cases
lancinatingpaintsin the inner side

x.,

S.

321). Rendu

is affected

woman

from

of

limbs, with

tension, throbbing, sensitiveness, and

during
groups,
inner

the

appear

two

to

weeks.

After

painful oedema.

symmetrically

side of the

for

to two

foot; they
three

are

days;

Soon

upon

then

the

filled at
the

the

fever, marked
burning,

Arch,

of

Derm., Vol.

suffering

woman

the

right middle

iii.,p. 291.

develops in the hands and lower

curs
erysipelas. General
diaphoresis oc-

redness
as

in

afterwards, vesicles of various

sizes,arranged chieflyin
limb, and
palm of the hand, sides of the fingers, the lower
first with

skin

becomes

Lymphangitis occasionally develops later,sometimes

*

of

by several relapses in the same

place (Behse, Pe(Ann. de Dermat., Vol. vi.,p. 201, Obs. 34) reports
time
to time with
chilliness,malaise, temp. 39-40",

at intervals

one

developed, followed

soon

Ztg., 1869, Bd.

following

1877.

serous,

later with

pale, crusts
with

purulent

form,

suppuration

and
of the

contents.

marked

glands.

They

sist
per-

desquamation.

(iIEEEA).herpes

HERPETIFOKlVnS

niPETiaO

269

GEBTATI0NI8.

of round
at a later period,
rendered
cells,the
are
by an increasingnumber
opaque,
in the papillge.The
dilated,and a round-cell infiltration occurs
papillaryvessels become
layerof horny cells becomes macerated, although the roof of the vesicle does not burst,
thus occurs.
The rete layers on the floor of
and insensible evaporationof the contents
cells in the later stages. There is no
also infiltrated with round
the vesicle are
change
connective
tissue or the sweat-glands. These
combat
in the subcutaneous
appearances
tents

and
T. Fox
E. Crocker*
by T. Fox for this affection.
sinuosityof the execretoryducts of the sweat-glands;the
there were
here and
in the papillarylayer of the rete, and
vesicles formed
connected
consisted of granular and cellular masses.
with the sweat-glands;the vesicular contents
In some
places,the coils of sweat-glandswere enlarged.
but it is distinguised
Hebra
regarded this disease as a vesicular eczema,
Diagnosis
from this disease by its restriction to the parts mentioned, and by the relapsesand more
marked
nervous
phenomena.
As the disease recovers
of the
Treatment.
spontaneously,symptomatic treatment
the

chosen
dyshidrosis

term

and

dilatation

found

marked

"

"

indicated.

pruritusis alone

IMPETIGO

HERPETIFORMIS

(HEBRA).

HERPES

GESTATIONIS.

The disease described

as
impetigo herpetiformisbelongs to the series of
by Hebra
acute
pemphigoid affections,as a connecting link between
pemphigus and the chronic
Hitherto
it
has
been
form
observed
ing
dur(pemphigus foliaceus).
exclusivelyin women
pregnancy.
Milton ^ reportsa

in which
case
during several pregnancies (in the fourth month)
bright-red,slightlyelevated plaques,from the size of a pea to a walnut, appeared upon
the inner side of the arm;
often
pointed vesicles,usuallyin groups of two to four, were
situated upon the patches. The violent pruritusgave
rise to insomnia.
The contents
of the vesicles soon
the trunk
becama
over
cloudy, and the affection rapidlyextended
Premature
and the other limbs; general malaise and great irritability
also present.
were
New
pustular eruptions developed after
delivery occurred
during the sixth month.
lar
afterwards.
E. Wilson
reported a simidelivery,but complete recovery occurred soon
'

case.

the

herpes vegetans, because here, as

formed
in some
of the affected
in certain cases
pemphigus, papillomatousproliferations
under
the
published a similar case, but without any proliferation,
spots. J. Neumann
name
herpes pyaemicus. Hebra
applied to the disease the term impetigo herpetiformis,
cles
of the clinical appearances.
Pustules develop in bunches, occasionallyvesiaccount
on
incrusted.
Under
the
with contents
these
become
which become
desquamated
cloudy;
crust the skin appears reddened, destitute of its horny layer,shining,occasionally
moist,
infiltratsd skin may
fissure in
but never
ulcerated;secondarily,the tense, somewhat
various places,especiallyaround
the joints. By the development of new
of
groups
pustulesupon other parts of the body, and the extension of the pustular process in the
neighborhood of a group alreadypresent,the affection spreads over the largerpart of
H.

Auspitz

described

fatal

case

under

term

of

'

Med.

'

Journ.

"

Arch.

f.

"

Wien.

med.

Skin

Times

and

of Cutan.

1878, T. i.,p. 632.

Med., Vol. i.,p. 311.

Gazette,

Diseases," 6th ed., p. 294.

Derm., 1869, S. 246.
Wochenschr.,

1872, No.

48; and

"Lehrbuch,"II.

Aufl., Bd.

i.,S. 654.

2T0

IMPETIGO

the
No

of

part
The

the

the

disease,

rule,

in

not

stop

during
chill,

its

the

GE8TATIONI8.

the

thorax,

the

abdomen,

membrane

mucous

of

course

often

the

thighs.

be

may

morbid

considerable

and

affected.
sive
Exten-

process.

increase

of

temperature,

affection.

normal

the

at

of

tlie buccal

septic

reached

HERPES

same

fatally.

termination

premature

or

time.

In

saw

the

one

by
of

majority
end

case

in

the

delivery,
observed

cases

several

recovery,

in
weeks

delivery.
form

mildest

described

and
in
of

'

lymphatics;
of

the

has

The

considerable

observed

The

body.
in

ordinarily

dilatation

an

of

of
the

are

internal

pemphigus

in

disease,

small

whether

increased

intimate

more

those

as

infiltration

vesicles

large

or

in

of

round

the

of

variety

this

The

vessels,

the

various
the

pustules,

of

dition
con-

nancies.
preg-

particularly
in

the

pemphigus

varies

prognosis

symptoms,
or

subsequent

is present

cells

ranged
ar-

are

general

cutis,

number.

relations

general.

febrile

the

of

red

pains;
size,

considerable

entire

returns

and

pruritus

that

gestationis.

hydroa

as

of

the

is

gravidarum
^

violent

often

over

disease

abundant

sweat-glands

The
"

extension

process,

tolerable.

with

later

Smith

by

vesicles,

limbs,

the

pemphigus

and

pregnancy,

which

upon

upon

Neumann

known

the

is

of

part

appear,

finely-vesicular
gestationis,

"

and

Etiology.
little

usually
herpes

as

latter

first

at

patient

the

cells

the

the

papules

groups,

Anatomy.
veins

and

in

usually

occurs

this

of

Bulkley'

D.

by

patches

to

out

with

terminated

disease

the

The

the

fall

begin
as

surface
even

often

etc.,

does

anterior

escapes,

has

pregnancy

as

Vienna,

It

nails

eruptions

restlessness,

If

after

integument
and

hair

pustular
insomnia,

the

especially

integnment,

(hEBEA).

HERPETIFOKMIS

of

grades
rapid

more

or

are

as

according

greatly

exudative

the
slow

of

loss

vitality.
I

have

seen

of

case

impetigo

disease

The

Treatment.

herpet.

is

affected

"

is

treatment

of

water),

'

Amer.

'

Dubl.

and

belladonna,

Journ.
Med.

of

Journ.,

"Hautkrankheiten,"

roborant,

against

the

kali

opium,

Obstetrics

and

and

Diseases

Aufi.,

S.

267.

general

by

of

Women,

eczema.

and

the

20.0;
chloral

Vol.

crusts

by

tar,

teaspoonful

to

ointments,

IV.,

indications.
the

pruritus,

one

internal

the

general

underneath

pfts

against
aq.

hydrate
of

ordinary

to

of

4.0;

pustular

therapeutics,

according

baths;

caust.,

1881.
V.

for
little

accumulation

permanent

(pic. liq., 8.0;

Bulkley
of

and

protracted

ointments,

picis alkalini,
100.0-150.0

symptomatic
is directed

treatment

External
means

merely

mistaken
very

No.

4.

etc.

by

liquor
about

272

"

CHROiilC

Trachoma, which,

9.

INFECTIOUS

has been

as

DISEASES.

alreadyindicated

by Virchow,

its place

obtain

must

in this class.
Also

10.

in

diabetic

the

proliferations
occurring in parasiticsycosis,in
of

forms

balanitis

are
diseases)

(perhapsalso

Celsi,and

kerion

those
dred
kin-

foot, the Aleppo lubo, and

into
this
incorporated
group of diseases,because
the

Madura

by right
they
due to parasites(mycelia).
representgranulation tumors
The
of
has been
to this group
name
''granulation tumors''
applied by Virchow
tumors
account
of their resemblance
to the cell masses
on
of inflammatory granulations.
In all these forms
it is mainly, but
not
the connective
tissue and similar
exclusively,
in
the
arises.
It
ends
parts from which the new
development of
development
usually
small
round
cells
with, as a rule, comparativelylargenuclei ; they
generally
numerous,
bear a certain resemblance
to the so-called lymph-cells. Virchow
proposed for them the
name
"granuloma."
The main
of the neoplasms arise ?
questionat issue whence do the cellular elements
is still the object of spiritedcontroversy. Beside
old doctrine, that the
Virchow's
cells are
derivates of the fixed tissue elements, that of Oohnheim, relative to the origin
of inflammatory cells from
has gained adherents
also
emigrated white blood-corpuscles,
in explanation of these tumor
that
the
be
most
cells ; we
likewise hold it to
probable
cells of granulation tumors
white
blood and
are
lymph corpuscleswhich,
essentially
after inflammatory alteration of the vessel walls, have emigrated and
form
the
now
material for the further growth of the tumors.
But
a
factor.
strikingadvance has been effected by the elucidation of the etiological
of the
consideration
To
Virchow
in
the etiologywas
the
not
the fundamental
point
the
of
fections
afstructures
the
under
discussion.
for
The
idea of "infectiousness"
majority
be

to

"

"

Klebs
who
created
Thus
it was
superadded subsequent to Virchow.
the name
"infection
tumors"
for granulomata ; Oohnheim
(p. 704) accepted it;
and
Ziegler united the histological
etiological
parts in his designation,"infectious
tious
i
n
We
granulationtumors."
are
fullyjustified designatingthis group as chronic infecdiseases in view of the findingof bacteria and other fungi in tuberculosis,leprosy,
tioned
actinomycosis,glanders. We preferthe latter title,as a class name, to the above-menis frequently
"infection
of tumors"
"character
the
tumors," etc., because
was

in the

absent

of acute
ulcerations,and inflammations
in
the
for
of
instance,
affection,
stages

pathologicalprocess

themselves

in the

various

in actinomycosis,etc.
syphilis,
It requires no
specialemphasis
that of contagiousdiseases.
To

be

sure,

the view

here

that

the idea of infectious,does

expressedis

not

yet demonstrable

as

if

even

The

served

by
in
justified

classification

"cellular

of

Nor
with

of

with

pointsand for
experience,and

in all

understanding

tion,
scepticalseparate considera-

itself.
lupus under

describes
rests on purely clinical principlesand
under
"malignant
(CI. VIII,); leprosy, carcinoma,
sarcoma,

"(CI. IX.); finallyhard

external

by

coincide

Hebra-Kaposi

new-formations"

This

harmonious

standpoint than

fest
mani-

forms

some

not

and clinical
But
to anatomical
it conforms
more
every single disease.
is much
better supported than
at
other
explanation.
attempt
any
I am
inclined to believe that, even
of a text-book the
for the purpose
will be better

course,

is really no

chancre

in CI.

X.,

ulcers

"cutaneous

but merely
classification,

"

or

"

ulcers

due

juxtapositionaccording

to

tions
new-forma-

flammation.
specificincomparatively
to

factors.
can

ours.

we

concur

fullywith

'the

system erected

byAuspitz, although essentially it

agrees

totally

of

the

intended

to

tissue
affections

if

But

the

enter

we

be

to

comes

the

"from
point
{i. e., granuloma

in this

be discussed

the

fully into

how

the

chapter.

system could be erected

there
anaesthetica, in which

; for

is

no

is

mention

of

based,

shall

we

(without regard

instance, how

of

"granulomas

to

the

of fact, Auspitz starts

For
as
a matter
lepra tuberculosa.
sense
the granular mfiltration, in the above-mentioned
essential
of the
feature
constitutes
the
process."
Despite- this

placed by

the

side

of

that

in

this

class

of view

this classification

which

principleson

above

and

etiology) lepra maculosa

skin,"

nective
con-

all the

skin) contains, under

more

ourselves

to ask

have

and
the subcutaneous
(anomalies of growth of the corium
B, paratypical growth, etc., paradesmoses,

VIII., chorioblastoses

Class

His

273

DISEASES.

mFEOTIOirS

CHEONIO

formation),
cited
inunited
in this class all anatomically different processes
standpoint, he furthermore
It
by syphilis,thus putting the etiological conception of disease quite into the foreground.
to designate by
the
intention
also
must
that
detailed
against
we
would
protest
a
explanation
require
for a "disease") all granulomas of the skin, that hence
we
the name
(already current
lupus
anatomical

"

"

of a lupus scrofulosis,lupus syphiliticus

(lupus leprosus, according to
with his view
with
obvious
adheres
it
that
himself
not
tenacity to-day to this
were
Auspitz
school),
Spanish
view.
formerly advanced
Against this view Kaposi already had raised objectionsfrom clinical standpoints, indicatingthe
the ulcerous
in appearance,
syphilide and the
differences
spread, treatment, etc., between
course,

could

not

agree

the

if we
admit
genuine lupus. Even
momentarily impossible,still such

place

We

cellular

histologicalexamination
a

in which

formation

agrees

also with

Of

this is true

course,

from

the

hitherto

same

for the
are

source,

to

demonstrate

firststages of the

still undeveloped ; it

terminal
masses
forms with their altogether similar necrotic
culous
(tuberstages, however, the microscopic-histolodetritus). In the intermediate
regard to the micro-organisms) between
tuberculous,
diagnosis (even without

the

with

forms."

"

able

been

not

(granulation cells). For as

he says:
The
Auspitz when

gumma

gical differential
and
leprous products
syphilitic,
succeed

has

cells,derived

material

same

to differ from

of the

some

and

cheese

several

the

similar

the

difficult,
perhaps
ground sufficient to

very

itself

"

forced

are

in

For
they are truly different morbid
stage is represented by heaps of granulation
tumors
only on the ground of the development

the

spring from
we

is not

processes.

new-formations

these

between

difference

thorough

tumor

all

relations

of

morbid

"granulation

name

which

tiimors

anatomical

further

regards the

embarrassment

Jirs^anatomical

the

accepted the class

have

of these

affections

diagnosis is often

differential

the

totally different

other

if in both

even

processes,
cells.

to each

near

so

that

temporary

microscope

attended

is seldom
often

can

be decided

difficulties.

with
with

And

what

at times

does

not

certainty by macroscopic inspection.

difference.
Syphilis has a specific
importantfactor is the etiological
the
diseases
and
also
tuberculosis.
Therefore,
virus, so
produced by them
leprosy,
most
if the
in their
have nothing in common,
even
conspicuous resemblances
appear
But

the most
has

products.
Lupus
It may

interpretas

we

be

culo-derma."

inconsistency

an

the

But

name

form

on

of the

our

is

lupus

tuberculous

part to retain
so

firmly

the

infection.

"lupus,"

name

established

and

so

instead

little liable

of
to

saying

lead

to

"

tuber-

standing
misunder-

of the skin; it is erroneous,

retain it. For us, lupus is a tuberculosis
fore,
therebecause
this term
offers no
lupus syphiliticus; all the more
advantages, very
ogy.
frequently leads to mistakes, and is directly opposed to the principlesnow
prevailing in dermatolthat

to

we

speak of

may

demonstrate
the mycotic
parts. First, we must
by the microscopicproof of organisms in the
new-formations
which may
be called the inciters of infection,on the other by the experimental
that by the inoculation of its organisms the disease may
be reprodemonstration
duced
at will in the animal
body. In the case of tuberculosis we are indeed able to fulfil
know
the parasite,
tliisrequirement in its entirety
but there is no
final
; in leprosywe
proof of its pathogenetic effect cultivation outside of the animal body and successful
inoculation of a healthy organism. In a third group
(syphilis,
glanders,frambcesia)we
Our

character

next

task is divided

of these

diseases,on

into two
the

"

one

hand

274

shall

CHRONIC

have

be

to

with

content

the

DISEASES.

INFECTIOUS

demonstration

that

the

symptomatology bears the

parasiticinfectious disease.
for all
As it is not possibleto discuss all the questionsbelonging here in connection
General
diseases, I have
brought them together in each affection under the head of
Pathology/'
task will consist in tracingthe connection
The second part of our
of the local newI believe,it will be possibletoformation
with the pathogeneticparasite. This requisite,
In general,the following axioms
fulfil exactlyas regards the leprous disease.
be
may
The local effects caused
maintained:
by the immigrated bacteria may be traced back to
indeed
two factors, which
are
very changeable in their importance for the pathological
in the several affections ; now
the other preponderating,perhaps also
now
one,
process
in every case
at all. But
the finalproduct, the effect,
not becoming obvious
one
for every
is
in themselves
the
have absolutely
bacteria
one
a specific
pathologicalprocesses
;
speciesof
of

character

"

character.
specific

no

1.

of the above-mentioned

One

factors

is

an

alteration

of the

vessel walls of the blood

the lymph sheaths inclosingthe large vessels,leading to

lymph channels, especially
in the tissue,to serve,
inflammation.
Lymph-cells, white blood-corpusclesaccumulate
in
the
of
the
The
of
tumor.
in their further
stages
building up
development,
process of
a
nd
hence
cell production in itself,therefore, is not
cannot
we
specific,
speak of a
But
the future destination
inflammation.
specific
of the cells furnished hy the vessels,,
the raw
which serve
as
material, is specific
for every form of disease and directlydependent
in
the
There
the
virus.
comes
here,
specific
qualitiesof
respective
question
upon
the acuteness
of the inflammatory cell production and
its relation to the vascular
first,
less adequate proportion ; second, especially
or
development which may proceed in more
the direct,immediate
influence on
the several cells exerted
by the immigrated bacteria.
These
of the inflammatory connective-tissue
course
modify the normal
development in a
that either an
intermediate
so
stage of the progressivecell development
specific
manner,
in
is maintained
for a very long time, or specific
degenerativeprocesses run their course
and

''

"

the cells.

only on the vessel walls, incitinginflammation, but the tissue

is still very slight,
and
itself is implicated. Our knowledge of these "tissue
processes
Of the nerves,
tissue.
relates in but
few points to the vascular connective
a
muscles,
know
and glands we
only that they have perished in certain stages. Only in a single
in syphilis)
shall have
to speak of producthe
of
we
case
primary induration
(formation
tive
fixed
connective-tissue
cells.
of
the
(The "granulation cells'' we trace
implication
have
to deal only
we
back, as above stated,to inflammatory lymphoid cells.) Otherwise
with necrobiotic
which
excited by the virus at an earlier or later period, in
are
processes
2.

virus acts not

The

"

the connective

tissue and

its vessels.

"specific" implication of the epithelium. Although the latter is

largely increased, it furnishes
frequently especiallyin the initial stages found
very
of
characteristic
tumor.
the
no
respectivegranulation-cell
signs
Thus
with an
to deal
have
we
inflammatory process in the connective
essentially
The
of this inflammatory process, however, is an abnormal
tissue.
one
course
by the
of conformation
formations.
It does not lead to new
influence of these very parasitical
nective
tissue
^but,whether
by an alteration suffered at any time by the cell material
for the nutrition of the cellular neoplasm,
itself or by the vascular development requisite
"tumor"
have
caused
it*
the
the
later
same
or
organisms which
sooner
perishes by
There

is

no

"

"

"

TUBERCULOSIS,

The
the

and

acuteness

the

of this process

the

depend directlyupon

of
qualities

the infection.

of
instigators
According to

the infectious materials,we

1.

Tuberculosis.

2.

Leprosy.
Syphilis.

3.

malignancy

275

LUPUS.

8CEOFUL08I8,

distinguishthe followinggroups.

tropica.

4. Framboesia
Glanders.

5.

Actinomycosis.
to base the
which
on
regards mycosis fungoides,we lack as yet every landmark
infectious
and
it
of
disease
to
its
structure
clinical
its
an
assumption
course,
; according
to
class.
decidedlybelongs our
On the other hand, I certainly
hold that lupus erythematosus does not belong to
The inflammatory cellular infiltrations occurring in it are inconstant, and
this group.
form
the essential feature of the pathologicalprocess ; perhaps
at any rate do not
affections.
like
belongs to the epithelial
psoriasis,
lupus erythematosus,
6.

As

I.

GEifEEAL
the

TUBERCULOSIS,

Pathology.

At

"

the

presenttime, tuberculosis,and
and the only one

with

infectious disease of man,

chronic

best-known

LUPUS.

SCROFULOSIS,

it scrofulosis,
is

demonstrated

with

certainty.
Villemin
failed

to

be

first to class

universal

tuberculosis

recognition.

as

inoculable

an

Further

inoculation

disease

infectious

experiments

transferred

to

culosis
a tuber(appropriate) organism, there is developed in it,in a typical manner,
remains
more
local,at other times spreads through the body generally.

an

sometimes

which

material
is capable of communicating
this disease.
Only specifictuberculous
those deprived of their infectious
or
quality, never
produce tuberculosis.
time

that

for the
Klebs

described

been

inoculable

and
has

has

able

form

of

of micrococcus

also

the

by

tuberculous

thick, tenacious

been

predisposition

some

classes

of

as

animals

peculiarto

reported experiments in cultivation

furnished

has
rest

"

"

the

variable

was

Non-tuberculous
It
as

ters,
mat-

shown

was

regards

at the

the

tivity
recep-

disease.

Schiiller

way,

his doctrine

by different

The experimenters introduced

into the animals
variable
the material
manner.
material
rendered
If tuberculous
certain.
possible points, so that the following result was

all

same

; but

made

were

in the most

savants

from

the

was

secure

pus,

sediment

into the anterior

specific bacteria

in

chamber
the

inoculations

cultivated

with

it.

its result.

In the
A

same

landmark

interesting experiments
separated it into
which
produced

tuberculosis

to demonstrate

and

tuberculosis

and

of the

of
eye

tissues, without

the

made
who, by leaving at
by Deutschmann,
inactive
in inoculation,
lightwine-yellow serum

tubercle.

Recently, Damsch,

urinary passages

of rabbits.

having

in the

Aufrecht
been

able

alone
to

in

living, by
has

Ebstein's
successful

described

clinic,
ulations
inoc-

ally
microscopic-

gain general recognition of his

results.

But
Robert

the

Koch,

credit of
who

elucidated
having finally

furnished

the

incontrovertible

the

nature

proof

that

of
a

tuberculosis

belongs to

bacillus
specific

is the

of tuberculosis and of scrofulosis.

berculous
proof consisted,first,iti the demonstration
of a parasiticmicro-organism in tuneoplasms. For this a new stainingprocess had to be invented which culminated
alone appropriate. The method
chieflyin the fact that alkaline solutions were
inally
origdevised by Koch
alkalescencemodified
the
found
who
was
soon
Ehrlich,
by
very
producing factor in anilin oil (or,accordingto Ziehl, in carbolic acid). His procedure
is as follows : The sections,or else the dry preparationsmade
on
coveringglass and sufcause

The

276

TUBERCULOSIS,

warmed,
ficiently

are

fuchsin

alcoholic

or

of

solution

aqneous

in

stained

LUPUS.

SCEOFULOSIS,

mixture

produced by the addition of a concentrated

solution to
a
gentiana-violet
watery, well-agitatedand filtered
anilin
oil (carbolicacid solution). In this the preparationsare
a

long time, best several liours,or a short time in heated solutions,are then
in a solution of
superfluouscolor in alcohol or water, and are then immersed
two
of
acid
with
officinal
three
of
or
nitric)
one
sulphuric (or
part
parts distilled water.
to a faint yellow,the stain being bleached
The deep blue (orred)color givesplace at once
in all parts of the tissue.
The hacilli,
however, retain the color and may notv he recognized
under
comparativeh/low power [HarinsiGkobj,7). It is better to subsequently stain
the background with anilin brown
then the blue or red
or
methylene blue, because
be more
bacilli can
easilydistinguished.The preparations,after having been dehydrated
in alcohol,are rendered transparentin oil of cloves and preservedin Canada
balsam.
The
not
the
color
of
the
bacilli
are
always permanent,
preparations
graduallyfading,probably
the acid is not thoroughly washed
because
out.
The gentian preparationsare certainly
in their color than
the fuchsin
constant
more
preparations. The color keeps
best when
the specimens (dry preparations)are not at all inclosed in Canada
balsam,
in oil of cedar (with homogeneous immersion).
but are directlyexamined
The
bacteria rendered
visible by this method
have a rod shape, hence
bacilli.
are
Their
length corresponds about to one-iourth to one-half the diameter of a red bloodcorpuscle. Their breadth differs according to the method employed ; Koch's original
methylene blue renders apparent only the exceedinglyslender bacilli,while Ehrlich's and
istic
Baumgarten's stainingprocesses color also the sheath inclosingthe bacillus. Characterof the tubercle
of the anilin brown
bacilli,in Koch's older method, is their rejection
In Ehrlich's method,
the
staining after they have alreadytaken the methylene blue.
tubercle
bacilli retain the tint present in the anilin oil and are not decolored
by acid or
subsequent methylene blue staining.
The
bacilli are found in great numbers
ivherever the tuberculous
process is of recent
in
form
then
and
rapid progress ;
they usually
closelypacked small groups
inceptioji
the
cells.
which
lie largelywithin
often arranged in bundles
Besides, there are also
border
of largecheesy patches they are
at the
free bacilli ; especially
numerous
present
of the tubercular
After the acme
in large free swarms.
eruption has been passed,the
be seen
bacilli become
can
only isolated,often as faintlycolored, probably
sparser and
If
dead
formations.
most
are
or
ously
numerpresent, the bacilii are found
giant-cells
dying
left

freed

for

from

them.

within
them
a

the

older

subsequent

tAvo to four

Here, too, those

cells in

dormant

oval

the

which

are

Subsequent examinations,
as

to the constant

the

are

recent, those

more

without

present have died or have passed into

originally
ordinarybacillus forms, we find others with
placed at regularintervals along the bacillus.
the

wherever

presence

bacilli

bacilli

Besides

state.

spores which

with

and

made,

confirmed

the

diagnosticvalue

the

correctness

of these

of Koch's

ment
state-

bacilli in tuberculous

affections.
But

even

this did not

satisfyKoch

He

himself.

said

"

It does

not
both

ever,
follow, how-

with bacilli that

phenomena
slightdegree of probabilityfor this
culous
assumption is furnished by the fact that the bacilli are found chieflywherever the tuberthe disease comes
in
its
where
to a
is
or
inception
disappearing
process
progress,
"In
standstill."
order to prove
that ttiherculosis is a parasitic disease caused
by the
immigration of the bacilli and is originallydue to their growth and increase,the bacilli
must
be isolated from the body and cultivated in pure fluids until they are freed from
from

stand

this coincidence

in causal

relation

to

of tuberculous
each

affection

other, though

no

TUBERCULOSIS,

any

by

possiblystill adhering morbid product

the introduction
be

must

shown

of natural origin."
has performed in a brilliant

task Koch

from

the animal

the isolated bacilli into animals, the

produced which experiencehas

matters

tuberculous
This

of

derived

us

and

27T

LUPUS.

8CBOFUL08I8,

same

organism, and finally,

culosis
picture of tuberinoculation
with
from

morbid

to result

absolutelyunobjectionablemanner

(despiteSpina'sdemurrer).

tinguished
disThey were
of
37-38''
temperature
by
C. ; they form minute
compact scales which can be easilydetached in toto and by appropriate
to consist only of the well-known, extremely delicate
shown
examination
are
the matter
derived
bacilli. The cultivations yieldedcorrespondingresults,whether
was
tuberculosis ; they were
continued
outside of the
for months
animal
human
from
or
to serum.
from serum
animal body, by successive transference
But
inoculations
of healthy animals
with the cultivations yielded a
in every case
positiveand constantlyuniform result a typicalinoculation tuberculosis of the animal.
In guinea-pigsthe inguinalglands swelled after two weeks, the pointsof inoculation
After from
the abdomen
on
thirtychanged into an ulcer, and the animals emaciated.
the
animals
killed.
exhibited
intense
tuberculosis
two to thirty-five
all
were
days
They
of the spleen,liver and lungs ; the inguinal glands were
greatlyswollen and cheesy,the
bronchial glands were
only slightlyswollen.
The
In the same
inoculated.
successfully
way rabbits,rats, cats, dogs, etc., were
wise
because these animals have otherexperimentswith rats and dogs are especially
interesting
shown
themselves
uncommonly resistant toward inoculations of tuberculosis.
The result of the experimentsis independent of the point of inoculation: subcutaneous
connective
of the eye, abdominal
tissue, anterior chamber
cavity,direct introduction
into the blood current, etc.
it
is
to
their
Only
exceedinglyslow growth,
necessary, owing
that the infectious matters
be brought to a spot where, protectedfrom external injury,the
bacilli have the opportunityto increase and penetrateinto the tissues,
otherwise the bacilli
habitat.
incisions
cutaneous
Small
shallow
are
a
again eliminated before they secure
wounds
are
no
appropriateto the invasion of bacteria. Similar conditions will be requisite
to insure
the adherence
of the bacilli which
the lungs. Probably,
have reached
such as stagnatingsecretions,denudation
factors favorable to the retention of the bacilli,
of its protectiveepithelium,etc., will be of assistance in effecting
the
of the mucosa
The

cultivations
an

were

made

exceedinglyslow

in sterilized,
coagulated blood

growth

which

proceeds only at

serum.
a

"

"

infection.

'^

of inoculated
tuberculosis,as
appeared,furthermore, that the rapidityof the course
the several organs,
is dependent upon the larger or
well as its extent and spread over
The
introduced.
smaller quantity of infectious matter
culosis
picture of acute miliarytuberthe body was
at once
occurred
overwhelmed, as it were, by a large
only when
Otherwise, when but few bacilli are inoculated, the proquantityof infectious germs.
cesses
of slow development or circumscribed
are
locally(noduleson the iris,opacityof
affections of the lymphatic glands),which
the cornea,
later succeeded
are
by
very much
the
disease
terminates
u
nless
with
the
local
inflection,
altogether
general
processes.
limited field the principalpoints,
to us the task of maintainingfor our
There remains
isolated
to
utilized
be
their
well
etc.
as
as
experiences
by
analogy with lepra,syphilis,
They are :
It

1. Tuberculosis
attended
kind

with

"

i. e., that

the formation

disease

of small

of sometimes

granulomata

of bacteria,the above-described

"

bacilli.

acute, sometimes
arises from

the

chronic

infection

with

course,
a

cific
spe-

2Y8

8CEOFTJLOSI8,

TUBEKCULOSIS,

2.

The

parasitestransmittingthe

and

are

transferred

more

or

infection

less

are

LUPUS.

always

directlyfrom

one

derived

from

organism

to

an

animal

another.

ganism,
or-

side
Out-

body, the bacilli or their spores may retain their infectious character
they cannot
multiply outside the animal body (exceptunder conditions
for specialculture),like the bacillus anthracis.
3. For infection,the bacillus requiresundisturbed
development at a protectedplace.
of
the
lesion
On the skin and the mucous
a
membranes,
protectiveepithelial
coveringis
The
delicate
oli,
endothelial
the
an
covering of
indispensableprerequisite.
pulmonary alvethe cells,and also the surwith the larger openings of the lymph-channels between
face
to permit entry of the bacilli into the plasmaticchannels
without
of the iris,seem
The local process at the point of infection ("primary effect^'),
mechanical
lesions.
cording
acto observations
hitherto made, is the following:
of from eight to fourteen
at the point of
After an incubation
days, a noduie forms
which
either
low
increases
without
inoculation,
rupturing or, generally,changes into a shalVery soon
(oftensimultaneously,it appears)the neighboring lymphatic
dry ulcer.
the
glands swell, and then already,as a sign of the constitutional affection,appears
weeks to rapid death.
leading in two more
great emaciation
at present as to the relation of
No certain deductions
can
unfortunatelybe drawn
the latter
the precisetime when
to
the local infection to the general disease,especially
a s
the
the
latter
local
at
whether
and
tuberculosis
a
point of
depends upon
commences,
inoculation.
Noteworthy is the almost synchronous affection at the point of inoculation
is succeeded
and that of the neighboringlymph -glands,which
by the generaleruption in
connection
between
the lastthe other organs; here again there is a regularanatomical
the
and
affected
attacked
formerly
lymphatic glands.
organs
of the development and the course
acuteness
of tuberculosis
4. The
are
dependent
of
each
A greater reinfectious
time.
material introduced
sistance
mainly upon the quantity the
classes of animals
(rats,dogs) is second in importance, but is
peculiar to some
that is,largequantinot absolute, and is overcome
by inoculations with cultivated bacilli,
ties
of the animal

for

time

but

of them.
tuberculosis
continues
to spread by heredityis still sui
question whether
t
he
bacilli
into
that
the
migrate from the maternal
judice. Theoretically, possibility
of
the
that
the
direct
bacterial
infection
the foetal organism, or
ovule or
semen
a
be admitted
in analogy with other infectious diseases (syphilis,
must
at once
lapsing
reoccurs,
is this heredity very rare, if
fever, the corpuscular disease of silk-worms)
; nor
author
this question. He
recent
follow
on
pointed out
we
Baumgarten, the most
such.
that processes now
tuberculous
not
as
as
were
acknowledged
recognized
formerly
number
under
tion
observais
of
which
there
the
scrofulous
affections
come
Besides,
large
in the living,and which
in the first months
the post-mortem table and
of life on
render
their foetal originvery probable.
On the contrary,
In our
opinion,this intra-uterine origindoes not form the rule.
affection
extra-uterine
have to deal with an
in
the great majority of the cases
we
after
birth.
occurring
cannot
in the hereditarytransmission, though we
This variation, this irregularity
in
also
it at present, finds its analogy in syphilis
understand
variola,
vaccinia,etc., in
;
does
the hereditaryinfection likewise occurs
not.
at times and at others
which
affections of
how
But
can
we
explain those frequent observations of tuberculous
hereditarily tainted
persons.
of explanationare possible: either tuberculosis itself,
modes
Two
or
a predisposition
5. The

"

^^

"

"

280

on

in

TTJBEKCULOSIS,

the vessels which

a

manner

as

become

inflamed
A

yet unknown.

by

them

localized

of a nodule
consistingof round
fibrillae. Now,
ordinary connective-tissue
in its structure

influence

of

the

the inclosed

only by

tuberculous

In

(2) on

cells and

while

its cell-forms, or

and

tuberculous

as

and

inflammation

formation

either

LUPUS.

SCK0FUL08IS,

suffer

is developed which

permeated by

this nodule

in the

tissues which

the

the

injuiy

leads to the

reticulum

of the

represents nothing peculiar

of its

manner

it takes
bacilli),
the

origin (and can be

under
course
specific
enlarges by successive
a

ognized
rec-

the

cell
beginning, it
at
and
the
accumulation
vessels gradually extend
into the mass.
But then,
periphery,
at the point of attack of the virus, namely in
i, e., very early,a modification
commences
of each singledepot. Not merely the exuding inflammatorycells,but also the
the centre
tissues deteriorate there;the cellular protoplasm coagulates,
the nuclei lose their capacity
for staining,*'.e., the cells exhibit the typical picture of a necrosis
of coagulation
(Weigert).

The

vessels and

noxa.

the basis substance

of this central

likewise implicated
depot become
developed that specificform of tissue degenerationwhich is
known
as
cheesy degeneration(inWeigert^ssense)and must be distinguishedfrom inspissated
in water.
the cheesy centre are found, however, some
Around
deficient
pus
sive
progrescells
developmental forms of the inflammatory round cells : large,bright,epithelioid
and
those
known
the
of
with
name
by
Langhans' giant-cells.(These are
large nuclei,
not
situated, as Ziegler assumes,
typicallyin the centre, but rather at the periphery of
inclined to look upon
the tubercle.) Some
are
as
Langhans^ giant-cells
fined
exclusivelyconOthers
to tuberculous
them
into
the
with
relation
of
the
bring
growth
processes.
abortive vascular new-formations, as it were, at the border
as
of
vessels,interpret them
the cheesy and
stillviable cells. With
it
to
at
most
us
Ziegler, appears
present
probable
the development of the tubercle cells and their various
to look upon
stages(like their
not as specific
in all inflammatory
origin),
processes, but as developmental forms, such as occur
Thus
it may
be that
the marneoplastic processes, in their further course.
ginal
intimate relation wfth the specificnature
position of the nuclei stands in a more
virus
of the tuberculous
(perhaps also with an incipientnecrosis of the central protoplasm
of the giant-cell).
in the

necrosis,and

Specificin

the

inflammation, and
centre

thus

is

tubercle

the

is the

manner

cause

of

which

furnished

its destruction;

the

the

cellular

material

by

way

of

^'caseation/' beginning in the

and
thence
tion
progressingperipherally. A patho-anatomical distinccaseation and other cheesy masses
is not always possible. Altough
specific
does not in every instance
always leads to caseation, the latter,inversely,

of eacli nodule

between
tuberculosis
coincide

with

tuberculosis.

furthermore, is the subsequent spread of the tuberculous

Specific,
process into the
In
"local"
of
recoveries
total absorptionor
syphilisor leprosy,
neighborhood.
by way
encapsulation are the rule ; in tuberculosis they belong
inflammatory connective-tissue
to the rare
exceptions. For instance, the typical formation of callosities around
gumarises around
is not effected ; a small-celled inflammatory zone
each tubercle ; but
mata
the infection extending into it hinders the final,fibrous
connective-tissue
formation
and
effects the opposite,progressivecaseation,that is to say, the tuberculosis migrates into
the

tissue.

At

times,

of

course,

too, justlycalls

this

destructive

process is a very slow, insidious one

;
fact that the local malignancy of culosis
tuber-

to the
attention
Baumgarten,
is greatlyoverestimated, as we
not
rarelycan demonstrate
"latent"
at
glands,etc., tuberculosis Avhich has become

in the

lungs, the lymphatic

least for years.

TUBEKCUL0SI8,
The

above

delineation

of the

LUPUS.

8CK0FUL0SIS,

281

patho-anatomicalprocess

has

gained

important

some

of the bacillus.
supports in the discover}^
1. The

bacilli

always found

are

in greatest number

the

at

peripheryof tuberculous

processes.
2.

They

largelysituated

are

believe that,as

Koch

assumes,

the contrary, I think

on

excites

within

in
the cells,especially

the bacillj are

inclosed

as

giant-cells.But I do not
foreignbodies in the giant-cells
;

that the

immigration of the bacilli into the

atypical morphological development which

the

latter

to

The

bacilli

finallylead

that

"

exudation

cells

call

we

"

giant-

cells,
3.
as

by

of the

means

In

with

tuberculosis

to defend
aim, first,

our

of the

the infectious

cells,whereby they themselves

character

of the necrotic

perish
of tissue

masses

persistentspores.

connection

will be

the death

to

but probably maintain

bacilli,

intend
to treat of lupus.
we
(and scrofulosis)
that lupous disease is a partialmanifestation

It

the view

of

tuberculosis.
At
exact

the outset

in
in

it should

material.

lupous

By anilin staining, treatment

and

of small

form

connective

roundish

tissue,never

cells.

The

numerous

the

for hives

not

with

acetic

granules, but
as

compact

micrococci

recent

more

are

appears

Schiiller has

acid

lupus nodules.

minute

most

developed lupus nodules,

the

not

am

able

furnish

to

yet

as

the bacilli of tuberculosis

as

have

not

the

been

of
recentlypublished the discovery

monstrated
de-

cocci
micro-

lupus tissue.

in the smaller
the

that I

explained here

be

of this connection, inasmuch

proof

the

from

masses,

impossible that SchuUer

wall
have

may

around

the

micrococci, especially

cells the

there

more

lupus formation

cocci, especially at the

and

penetrate as small rows

but rather loosely and
scattered.

much

ai'e

potash lye, he discovered

or

Between

difficult of
and

the

tlie

mistaken

the

the

micrococci
the

lie in

neighboring
larger,fully

In the

recognition, owing

softer

surrounding

into

to the

density of

underlying tissue, the

larger lupus nodules.

granulation of Ehrlich's

"

more

To
mast

it

me
"

cells

of micrococci.

However,

the

in

demonstration

the

tissue

of

tubercle

bacilli,which

at

best

are

only a questionof time.

difference has been found between
Despite careful examinations, no essential histological
In both
and
formations
there is a
a caseatingmiliarytubercle
a lupus nodule.
patch of round cells with epithelioidand giant-cells
; there are vessels in the peripheral
of
the
nodules
and
zone
vascular, coagulative-necrotic
a central,nonsegments
;
; both
local
in
in
the
tissue
and
the
have
the irresistible spread
common
relapses.
between
tuberculosis
in histological
structure
The
and
resemblance
lupus was
first pointed out by Virchow
(Onkol.,II.),then by Auspitz. SubsequentlyFriedlander
defined lupus directlyas a local tuberculosis of the skin.
Baumgarten, however, reaches
the conclusion
that lupus and tuberculosis should be kept apart. Although he considers
ho
in Virchow's
enumerates
the following essential
both as granulation tumors
sense,
stained

with

difficulty,
appears

to

me

differences:
1.

Caseous

2.

The

necrobiosis,always present in tuberculosis,is

absent

in

lupus.
cells is less conspicuous in lupus.
epithelioid
3. On the other hand, giant-cells
are
generallypresent in such quantity as to form
within true tuberculoua
to the sparsity
with which they are contained
contrast
a striking
nodules
(of the conjunctiva).
formation

of

'282

TUBEECULOSIS,

4. "We often find vessels in the

lupus

SCEOFTTLOSIS,

nodule

LUPUS.

which

are

absolutelylacking in

culous
tuber-

nodules.
In the older

mation
portionsof the lupus neoplasm we may perceive an increased forwhich
increase to such a degree that the entire patch
spindle-shapedelements
thereby gains the character of recent cicatricial tissue.
6. Furthermore
it should
be emphasized, in oppositionto the essential substratum
of conjunctival tuberculosis
which
manifests
itself in the form
of roundish
alwa3''S
nodules
demarcated
the
from
clearly
surroundings,that in the products of lupus the
miliarystructure plays but a subordinate part, and that the lupous infiltrations represent
rather the configuration
of an irregularly
arranged network with thickened nodal points.
7. Finallyhe claims for the lupus granule the capacityof direct suppuration which
is not possessedby tubercle.
With
these anatomical
differences enumerated
in
by Baumgarten we can concur
the
the
fourth
general. But, as above pointed out,
paragraph
non-vascularityof
5.

of

"

tubercle
yessels

must

"

receive

some

the

In the.very first stages,tubercle

is as free from
of vessels is effected
Gradually,however, the formation

limitation.

lupus granule.
in tuberculosis the development is more
a higher degree in lupus because
is
There
followed
merely a difference in degree in reference
acutely
by disintegration.
to the quantity of vessels.
Again, as regardsthe suppurativecapacityof the lupus nodule, it appears to me still
at present we
doubtful
whether
can
speak of a true primary suppuration.^'A cutaneous
never
lupus nodule
changes into a pustule,a lupous ulcer never
spreads by acute
puration,''
supbut slowly in the course
the ulcer disintegrates
of years the marginal portion around
its infiltration having been microscopically
demonstrable
before
long
symptoms
of degenerationbecome
externallyvisible. It is a characteristic of the lupous ulcer
rather to form
little puriform secretion.
is nothing but
is here called
What
pus
necrotic tissue and
detritus from
copiouslyonly
inflammatory cells which appear more
after the lupous new-formation
has perished.
to be sufficient to warrant
But Baumgarten himself adds: "1 hold the differences
a
It
anatomical
is
of
the
two
another
from
a
standpoint.
separation
purely
processes
both
between
eases;
disquestionwhether there is not an internal,*. e., a genetic connection
trunk
the
of
from
main
tuberculosis
off
as
thus, that perhaps lupus has branched
of time a certain independence and provided with
a ramification
attainingin the course
as

in both

; but

in

"

''

"

"

peculiarpermanent deviations."
be answered
This question,in our
positively.
opinion,may now
that
the combination
be
the
raised
Although clinically objectionmay
the other
still
but
tuberculosis
is
on
we
general
may,
very rarelyobserved,
to those
occurrence

sis,we
forms

"

latent

"

forms

which

likewise

general disease. On the other hand, in the

regain the clinical connecting link between

of

shall

of tuberculosis

their

run

morbid
the

two

course

group

of

lupus and

hand, point
without

termed

apparentlyso

the

scrof ulodifferent

of tuberculosis.

Experimental inoculation has unfortunatelyyielded here no incontrovertible result.

But
while Cohnof rabbits.
introduced
into the anterior chamber
were
Lupus particles
Hiiter
have
and
SchuUer
published
heim, Hansell, and others reportednegativeresults,
therewith
successful positiveexperiments and in accordance
they interpretboth diseases
in lupus.
is weaker
the sequelsof the same
tuberculous
as
poison,only that the noxa
to lose
to me
As opposed to the positiveresults of ScLiiller,the negativeones
seem
with
minimal
deal
to
have
iheir force; all the more
because in lupus we
probably
quan-

8CROFUL0SIS,

TUBERCULOSIS,

in
iities of bacteria,so that it is likely,

283

LUPUS.

experiments, that sometimes

sue
of tisnon-poisonous ineffective particles

series of inoculation

sometimes
bacterial,that is virulent particles,
may have been employed.
Schiiller reportsthe followingabout

his experiments:

not only in provoking

By inoculating into the lungs particlesof lupus tissue, I succeeded
lupus tissues micro-organisms
also, by fractional cultivation, in developing from
followed
into the lungs was
whose
inoculation
by distinct and widespread miliary tuberculosis,
arthritis with
tubercular
characteristic
secondary
into a joint incited
and the injection of which
"

tuberculosis, but

general tuberculosis.
tuberculous
cared

were

for in

These
infection

experiments
was

are

absolutely demonstrative.

guarded against by

positively healthy,

new

the strict isolation

stables,separated from

the

dental
other, possibly acci-

Any

of the animals.
others

by

The

animals

large court-yard,

of animals
with
the blood
(Besides, in other rabbits inoculated
special person.
could
tuberculosis
be
Therefore,
Lenz's
to
reproduced.)
experiments]
lupus [accordmg
of no
doubt.
Former
the question will admit
perhaps be explained by the
negative results may
micrococci.
active
diflScultyof securing appropriatelupus tissue containing specifically

and

tended

affected

by

with

to
to me
differences
between
lupus and true tuberculosis seem
Finally,the histological
the
have
in
tuberculosis
same
two
we
the
the
of
show
Indeed,
similarity
processes.
and of higher degree.
acute in course
pathologicaltissue processes as in lupus, only more
of
the inflammatory granulum
have in lupus the slower development
For this reason
we
with more
ample vascular development; thence, too, slower destruction at the centre
of
at the periphery,with the formation
of coagulation)and points of recovery
(necrosis
tissue
tissue).
(cicatricial
spindle-cell
It is
the local malignancy of lupus is no less than that of tuberculosis.
Nevertheless
is
that
tuberculosis
more
entire
the
of
the
{sensu
strictiori)
organism
implication
only by
malignant than lupus confined to the skin.
to a specific
biosis;
necroThe
singlelupus nodule, like the singletubercle,finallysuccumbs
but in a lupus patch the basis tissue is not so largelyinvolved, while in tuberculosis
In this variability
tial
we
can
it is regularlyimplicatedin the caseation.
distinguishan essenof the papular forms of syphilisas
difference
as little as in the spontaneous recovery
of the gummous
products.
opposed to the constant disintegration
It is true, caseation is characteristic of tuberculosis,but still it is merely a secondary
cited
phenomenon, caused by the continuous deleterious influence of the virus which before inthe
earlier
and
cceteris
or
the inflammation
new-formation.
Therefore,
paribus,
influence
of
the
culous
tuberof
and
the
duration
later onset of caseation
will depend on the intensity
in
noxa.'^ Schiiller is also inclined to ascribe importance to the qualityof the tissue withwhich
the tubercular
inflammation
takes place;in lupus,therefore, the condition of the
In fact, cases
cutaneous
of true tuberculosis of the skin are exceedinglyrare; even
organ.
in cutaneous
diseases developing over
tuberculous
patches in bones and lymphatic glands,
the penetratbut true lupus, ''because
tubercular
not
we
ulcers,
ing
frequentlyencounter,
from
cause.'*
stillunknown
tuberculous noxa
some
suffered a weakening of its intensity
"

"

"

It is of

interest,too, that while lupus migrates,true tuberculosis

of the skin

has

no

sive
progres-

character.
For
modified
of

an

us,

by

therefore,lupus
the

infectious
Does

small

is

one

quantity of

of the

forms

in which

tuberculosis

active virus; hence, it must

occurs

in the

skin,

also bear the clinical stamp

disease.

pictureof lupus present the character of an infectious disease ?

developmentalhistoryof every singlecase givesus littleinformation upon it. The
simultaneous
of several cases
of lupus in the same
occurrence
family has been observed
The

the clinical

284:

TUBEKCULOSIS,

LUPUS.

SCROFULOSIS,

rarely;nothing at all is on record of the infection of a healthy person

by lupus; asverdict of authorities that those affected with
regardsheredity,we have the unanimous
stress is laid
lupus neither inherit the disease nor transmit it to their children ; finally,
the fact how
of general tuberculosis
with lupus is to be obon
served.
rarely a combination
very

possibleto prove, however, that all

plausiblyexpl^ned on the basis of our

It will be
can

be most

the

clinical relations

point of view

of

above

lupus
"

as

discussed
a

modified

tuberculosis.
As a matter
of fact, generaltuberculosis
(used in the older, restricted sense) is
rarelyto be observed with lupus. But this explainsitself from the followingreasons:
and less dangerous noxa,
1. Lupus virus is for the organism a weaker
account
of
on
in which
it is localized.
the qualityof the organ
Schiiller maintains
that the microeven
organisms
virus suffer a direct impairment of their infective
representingthe tuberculous
in
because
the
skin
under
unfavorable
nutritive conditions.
more
they vegetate
power,
He

drew

from

this conclusion

the

observation

that it

more
developed from lupus tissue relatively
back
to bring their activity
articular injection)

direct
In

the

same

bacilli is very

way

Koch's

observation, that

decidedlyinfluenced

the

by
intensityof growth in the
Again, the localization of this

of the

in

was

sufficient to offer

favorable

conditions

to the microorganisms
of

growth (by

to its full power.

cultures

temperature, may

the

growth of the tubercle

possiblyexplain the ment
impair-

skin.

in the skin is a factor causing the

do not get into the
products of disintegration
investment
in sufficient quantityto produce acute general
circulation from
the cutaneous
the processes remain
tuberculosis of rapidcourse;
local,and as such not specially
injurious
to the generalorganism; just as a cheesy lymph-gland is succeeded
by generaltuberculosis
into the current
bring largerquantitiesof its cheesy masses
only when it can in some
way
in the most
florid forms
of pulmonary phthisis,
of the circulation.
(For even
general
acute miliarytuberculosis is of relatively
occurrence
rare
!)
of general tuberculosis
the cause
!
For these reasons
lupus does not become
the
not
when
cutaneous
tuberculosis
t
rue
does
even
Inversely,
always produce lupus,
the
the
of
it
to
tissues are attacked.
virus,
Then, owing
greater intensity
produce
may
ulcers.
genuine tuberculous
Lupus is always tuberculosis of the skin ; but tuberculosis
of the skin has other forms
besides lupus.
3. All the more
frequently,however, lupus is coupled with the complex of symptoms
designatedas scrofulosis.
to me
The objectionsof Kaposi, who does not recognizethis connection, do not seem
scrofulosis because, of the
to be justified.He says we have no reason
to derive lupus from
these conditions
hundreds
have seen, in but very few
of lupus patientswe
were
many
in
and
other hundreds
(cheesyinfiltration of the glands,the skin, keratitis,etc.)found,
2.

relative harmlessness

of scrofulous

in this way,

patientsno
(p.624).

trace

tuberculosis

that the

lupus can be
first point is in
of

discovered.

''

The

same

is true

culosis,''
of tuber-

by far the greatest

number
of other observers of all countries ; as to the second
objection,it is not necessary
than the so-called
that in every scrofulosis lupous skin disease should
develop,any more
in
scrofulous
is a regularoccurrence
scrofuloderma
patients.
has
of the Prague clinic with a.
the lupus material
Raudnitz
recentlyexamined
etc.

The

direct

contradiction

to

obvious
in whom
there was
lupus patientshe found only 'SOfo
and
between
relation
constant
himself
a
lupus
against
expresses
beof both affections cannot
scrofulosis, although, on the other hand, the concurrence

view

to its

etiology.

that he
so
scrofulosis,
"

In 209

In twenty-one
upon as accidental."
nine others this appeared probable.

looked

investigation
by Pontoppidan

An
basis

there

taint,in
hereditary

decided

was

that in one-half

to

two-thirds

scrofulous

demonstrable.

was

Inasmuch
on

showed

cases

285

LUPUS.

SCE0FUL08IS,

TUBERCULOSIS,

the

other
we

proven,

For

virus, when

unity of

the

as

hand, the

scrofulosis and

connection

between

tuberculosis

lupus

is

and

longer doubted,

no

to

scrofulosis .appears

and

us

as,

to be

loses.
include
lupus in the group of tubercustandpoint,
the
which
in
localized tuberculosis,
scrofulosis is nothing else but a peculiarly
it penetrated into the body, reached
and localized itself in the lymphatic
from

even

may,

clinical

which
acted as points of entry.
membranes
glands without direct injury to the mucous
Frequently enough such a scrofulosis is completely recovered from ; at any rate it remains
transferred to other
not
to the general organism as long as its products are
harmless
nated
dissemiin
and
additional
the
the
tubercular
virus
is
after
body
spread
Only
organs.
favorable
and
more
dangerous developmental
patches are established in more
The
restricted sense.
locations,the disease begins which is called tuberculosis in a more
ation
difference of tuberculosis from scrofulosis and lupus, therefore,does not lie in the variof the poisons (though perhaps in the quantity of the virus),but in the variable
Of these,
spread in the body and in the different importance of the affected organs.
most
to
is
most
the
dangerous to the
disintegration,
lung tissue,succumbing
rapidly
localized
foci of disease,
remain
and
skin, however,
organism ; neck, lymphatic glands,
usuallywithout any injuriousinfluence on the body.
In this connection
are

well

very

the most

variable

exciting
attains
cells

of

infectious

point to another
Similar

to

disease, the pathogenetic fungi of which

tuberculosis, that affection

syphilisand

disease, although in all,the

has

fungus

same

presents

demonstrated

been

we

find

Sometimes,

etc.

osseous

the

most

is

again, there

But

Again resuming

like

suppurations

and phlegmonous
they all have a common

processes,

actinomyces.

nothing

a
are

the

the results obtained, we

would

assume

even

giant-

abscess

tion,
forma-

pathologicalprocesses

caused

but

tumor,

etiologicalfactor"

the

as

perfect tumors, the granulation tissue of which

tissue, with
relativelyhigh development, approachiag that of perfect connective
Sometimes

(Weigert),

the

may

actinomycosis.

"

forms

cause.

carious

by

we

known

the

ray

chronic

fungus.

but
genetically

skin which, however, appears

in different forms :
in a more
Tuberculosis
restricted sense, with the formation

one

losis
tubercu-

of the
a.

the cutis,and
5.

Lupus,

with
a

miliarytubercles,as

less

harmful

form

part of

of ulcers

seated

in

generaltuberculosis.

of tuberculosis,usually remaining confined

to

the

skin.

Scrofuloderma ulcerosum,

arisingafter the opening of the so(Scrofuloderma papulosum of Auspitz does not, in our
opinion,belong here; it is,as Hebra correctlystates, a lichen scrof ulosorum. )
4. The infectious nature
of lupus is most
clearlyrecognized when considering the
of a singlecase;
clinical course
the gradual irresistible progress of the process into the
the local relapses,
cannot
without assuming the
be understood
neighborhood,and especially
of
of
of
i.
a
disease, e.,
reproductivegerm
pathogeneticorganisms; particularly
presence
instructive are the not uncommon
in which
cases
healthy flapsfrom the forehead, which
have been transplantedfor the formation
of an artificial nose, become
attacked by lupus
before long.
We shall not be mistaken
if we assume
that in the adjoiningand the basis tissue of
the destroyednose
an
behind, which infected the healthy
organizedvirus has remained
c.

called cold

skin.

cutaneous

abscesses.

i. e., ulceration

286

TUBEECUL08I8,

5.

Finally,direct

infection from

8CB0FUL0SIS,

without

LUPUS.

is not

in cases
in "whick
excluded, especially
for the
signsof tuberculosis and scrofulosis in other organs;
tubercular micro-organisms penetratethrough small fissures or
wounds
into the skin,
Schiiller attempts
where, if they have time to breed, they depositproducts superficially.
thus to explain the great frequency of lupus in the face, in the neighborhood of the
quent,
fredefects there are
nostrils,and of the mouth; not only that rhagades and superficial
but the inspiratorycurrent
is said to be an
the
microbes
there
auxiliaryleading
the hands, fingers,
and
on
by preference. On the extremities,too, lupus usuallyoccurs
toes,that is,pointslikewise more
exposed to external injuries. According to Raudnitz,
lupus occurred primarilyat the nose, the inner canthus, and lipin 38.3^; on the cheek,
in 27 Afc',on the trunk
and extremities,in 34.5^.
Inversely,Schiiller supposes that the
blood
in the skin, and thus
in
the
local
foci
deposit
organisms circulating
may produce
lupus.
But
tion
softening,cheesy glands and abscesses, i. e., infeceruptions of lupus over
and observed with
of the skin from
ficient
sufwithin, have been certainlydemonstrated
frequency.
there is

absence

an

of

matory
an
Patho-anatomicallythe process is: the virus causes
inflammation; but the inflamproducts,under the specificinfluence of this virus, take the course
peculiar to
after a progressivedevelopment of the inflammatory cells into epithelioid
tuberculosis
and
present, by necrosis of coagulagiant cells,they perish,with the tissue framework
tion
characteristic is the irresistible peripheralextension of this
and caseation; another
first inflammatory,then necrobiotic process.
in the connective
its course
tissue.
The process runs
exclusively
formations
The
implicationof the epithelial
occurringin lupus is quite secondary.
not rarelyassumes
which
this proliferation,
pical
atylarge dimensions in an
Histologically
But
is
of
the
nature
of
importance.
lupus has nothing whatever
manner,
proper
in the connective
to do with this epithelial
tissue,and
growth; lupus is a new-formation
the one
active growth of the epithelial
on
hand, an excitation into more
stratum,
causes,
into the connective
resistance,without which a proliferation
but, on the other, a diminished
be impossible. The
carcinomatous
have
little
tissue would
as
just
processes
essential relation to the lupous process as these
''atypical'^
epithelialproliferations.
in
and
will develop more
That carcinoma
more
rapidly
malignantly this friable granulation
in this
is
but
otherwise we can
tissue
see
natural,
nothing but an accidental combination
development of carcinoma into lupus.
"

"

"

Tuberculosis

1.

The
years.
organs.

knowledge
Their

of tubercular

occurrence

Generally,the

is

affections

uncommonly

nature

of

of these

rare

the Skin.

of the
in

cutaneous

skin

dates

comparison
affections

only from

with

the

tuberculosis

is first

last few
in

other

recognized in the

made
microscopicexamination
post-mortem.
ulcerations arise which
soon
Without
isolated,roundish-oval
precursors,
any special
of the
and
but
covered
crusts
become
with
are
moderately painful. After removal
bleeding,shallow ulcerous surface presents
granulated,slightly
crusts,a reddish-yellow,
b
ut soft ; not undermined, though displaceitself. The borders
are
infiltrated,
slightly
not smooth, but jagged and eroded, from
an
able on their base ; they are
aggregationof
the
True
of
tubercles
covered
with
ulcers,or even of
small depressions,
miliary
pus.
the greatest rarities.
the uninjured skin, are among
"

"

"288

TTJBEECULOSIS,

ulcerations

of the urethra

LUPUS.

SCBOFULOSIS,

which

appeared like a chronic gonorrhoea; also of numerous

glans,its neck, and partly on the inner layerof the prepuce,
of
which
characteristic of chancre
as
representedthe features enumerated
many
deep base and sharplysloping margins. The differentiation will be easilyfurnished
by
In the case
of. a soft chancre, it will be possibleto produce
experimental inoculation.
vilcers which
"with almost
absolute certaintyinoculation
be further transferred
in
may
In the case
generations,and having the period of incubation peculiarto soft chancre.
minute

situated

ulcers

on

the

"

of tubercular
will render
Mention

they

should

also be made

to tuberculosis

able for gummous

With

diagnosispossiblein

accurate

be due

may

of

ulcers,however, the demonstration

an

many

of the ulcerations

of the bones

of the

bacilli

doubtful
of the

or

the inoculation

of animals

instances.

skull

skull, and

belongingunder
are
important

this
as

head;

mistak-

ulcers.

rather

investment, an
symptoms and at first unchanged cutaneous
having so relaxed a feel as to be taken for a traumatic
cephalhaematoma, and
containing, when opened spontaneously or operatively,ample
After laying the abcess open
sion,
quantitiesof a characteristic cheesy pus.
by a large inciits inner surface was
found covered with numerous
fungous granulationscontaining
cheesy miliarytubercles as shown
by the microscope. These granulationscould
many
off
in
characteristic
and then
be easily
the diseased part of the cranial
a
wiped
manner,
the abcess had sprung became
evident.
bones whence
clearly
of tne abscess disThe
tinguish
laxity of the neoplasticmass, the fluidityof the contents
this tubercular process sharply from the firm infiltration produced by syphilis.
"

formed

abscess

vague

the

on

skull

''

2.

By
under

the

name

"

scrofuloderma

the direct influence

develop in

the subcutaneous

skin

its

from

this cutaneous

"

we

Scrofuloderma.
designatethose

of scrofulous

processes.
cellular tissue,where

support,graduallyblend

with

affections of the skin which

Granulation-like

masses

form

arise
which

of the
extensive detachment
they cause
overlying cutis,and after thinning of
tenuityof paper, consists only of the well-

the

of the
covering which finally,
elastic fibrous networks
elements
skin
and of very dense
of
the
preserved epithelial
leads to the production of typicalulcerations.
These subcutaneous
of granulationarise either primarilyin the subcutaneous
masses
connective
tissue or, more
frequently,as sequels above softening scrofulous lymphatic
of these proglands. Perilymphangiticabcesses at times also form the starting-point
cesses.
of these cases
The course
in every one
is a rather analogous one.
There is formed
infiltration which may be displaced
circumscribed
a moderately firm
inconvenience
under the epidermis; it is unaccompanied by pain or any other subjective
(periodede erudite). The shape is round or oval. Corresponding with an increasing
softening(periodede ramollissement)of the tumor, often the size of a pigeon'segg, the
epidermis is gradually implicated in the process ; it adheres to the tumor, becomes
thinner
and sensitive.
bluish-violet aspect,and grows
a
hyperaemic, assumes
Finally,
cold abcess
is
often after the lapseof months, the coveringover
this now
ckarlyfluctuating
white
and from a small irregular
perforated(perioded'ulceration)
opening a thin yellowishfluid is discharged which
in a state of fatty
consists mainly of white blood-corpuscles
ulcerosum.
degeneration. This completes what we call scrofuloderma
The form, size,and depth of these ulcers vary greatlyand depend upon the point of
tissue, a
originof the infiltration. If it has sprung
primarilyfrom the subcutaneous
"

"

TUBEROITLOSIS,

8CEOFUL08I8,

2S9

LUPUS.

lymphatic glands have taken part in

of a deep, sinuous ulcerous
the infiltration and softening,
we
tration
cavityfrom which long fistulas often extend into the depth. In a few rare cases the infilThe skin
and succeeding deliquescenceassume
particularly
large dimensions.
soft tissues beneath, and even
and
cartilageand bone, are attacked and destroyed,so
the nose, the palate,
in the face by the loss of the lips,
that fearful mutilations may
occur
thin
often
etc.
The
borders are
as
as
infiltrated,
moderately
paper, soft,relaxed ; they
ulcer
thin margin
from
the
base
of
the
demarcated
a condition
are
by an irregular,
the
also
inferior surface ; they are
caused by the maceration
undermined,
progressingat
that is to say, the extent of the ulcer is largerthan the opening of the originalabscess.
the margins of the skin are discolored
abcess formation
In the region of the subcutaneous
The
base of these
livid,almost violet,and shade gradually into the healthy skin.
with
thin
covered
and shows
ulcerations is uneven,
yellowish,
limp, pale granulations,
thin
brownish
which
bleed
When
the
of
masses
or
masses
secreting
dry,
easily.
pus,
in
reaccumulates
fresh
beneath
which
fluid
crusts arise,
thin,
large
yellow-colored
pus soon
quantity. There is no specialinfiltration of the base and of the margins, nor any paintion
before the excoriaand then there may be very prominent proliferations,
fulness ! Now
and ulceration of the cutaneous
investment
With this there may be developed
occur.
not only one, but several small openings. Particularly
the hand we may observe such
on
forms
which then give rise to great deformities by the deeply retracted cicatrices and the
changes in the bones which are not rare.
individual
of the processes occurring simultaneouslyin the same
is
The number
two and
six. Characteristic for all these forms is
usually limited and varies between
the torpid course
and a corresponding lack of acute inflammatory symptoms; hence
it
tion
happens that patientshave no suspicionof the originof the tumor and have their attendirected to the affection only by the evacuation of the abscess.
How
is is shown
chronic the course
by the gradual enlargement as well as by eventual
In the latter are
formed
closures.
of very
smooth, pale and flexible or, in the case
of bridges of healthy
cicatrices crossed by a network
irregularulcerations,distorted
The
skin.
most
seat of these ulcerations is on the leg,the neck, and
the face.
common
The
size varies much
and not rarelyreaches a diameter
of three to five centimetres.
affection described by us
as
Duhring includes in this category the cutaneous
acne
cachecticorum.
However, as this is an affection of scrofulouspersons and not a scrofulous
affection,we hold this classification to be inappropriate.
A more
general form is described by Van Harlingen: a woman
aged 70 had been
affected for twenty years with a disease which had begun as a slowlyincreasing
roughness
of the skin of the lower extremities and had led to reddish-brown
to ashy-graydiscoloration.
Initial nodular
efflorescences covering the entire skin gradually changed into
macular
or
ation
Examinscalypatches,nodes, and ulcers. The patientdied of exhaustion.
showed
universal cellular infiltration in the corium
which was
distributed
evenly

shallow
superficial,

ulcer results.

If

one

or

more

will witness

the formation

"

"

"

without

the formation

DiAGsrosis.

of groups.

teristic
diagnosisis based on the one hand on the above-described,characof the developing masses
of granulation,as well as on that of the
appearance
ulcerations alreadydisintegrated;
the other hand, too, on
the simultaneous
on
presence
of other processes peculiarto scrofulosis;
the eye, lymphatic glands,bones, with the
on
pale,anaemic, often bloated skin,etc.
In the differential
diagnosishave to be considered:
1. All those ulcerations, sometimes
called ecthyma, sometimes
rupia,which we,
19

"

The

290

TUBEKCULOSIS,

followingHebra^s
; for

doctrine, class

instance, the forms

of

8CKOFUL081S,

more

as

ulcers

less accidental

or

due

LUPUS.

to

large

concomitants

excoriations

of

other processes

from pedi(especially

culi

vestimentorum).
2. Especiallysyphilitic
gumma
prettycloselycorrespond to those of

scrofulous

stages of development

infiltration.

Essential

to the

which

tiation
differen-

here:

are
a.

in all its different

a

The

absence

or

in the
But

historyor in
if there
inversely,

and

tuberculosis

the
was

former

general scrofulous

abscesses

furnishes

syphilis. If syphilisbe

valuable
diagnostically

the possibility
of
syphilis,

the coincidence

absent

support.
of

syphilis

into consideration.

almost

are

of

symptoms

this

examination,

is still to be taken

b. Scrofulous

in
(syphilis

of former

presence

exclusivelyfound as
frequentlyappear

disease,while gummata

concomitant
in otherwise

phenomena of
healthy persons

late

stage).
than
The
numerous
neoplasms are generally more
gummata.
show a preponderating tendency to localize on
the forehead
latter,moreover,
and the
portionsof the skin coveringthe long bones.
scrofulous abscesses always spring from
d. The
the subcutaneous
quently
tissue, very frethe lymphatic glands. Gummous
from
infiltratien is as often cutaneous
cutaneous,
subas
to do with the glands.
and gummata have nothing whatever
of the formation
also decides;in the initial stages,
The
different appearance
e.
firmer
and
than the scrofulous mass
of granulation. In the stage of
is harder
gumma
is slighterin gumma.
In the ulcerative stage, the differences
softening,fluctuation
still more
which
does not colare
lapse
obvious; here a hard, firmly infiltrated gumma
mass,
after opening, with but very slightgummous
there an abscess with
even
secretion;
at once
relaxed borders, loose base, and equallyflabbyenvirons, which
collapseswith the
the
fluid
of
thin,
discharge
pus.
/. The ulcerous forms of syphilisare clear cut, usuallypainful ulcers,with steep,
ulcerosum, however, presentsitself as a painless
firmly infiltrated borders; scrofuloma
undermined
borders, which, besides,enlargesmuch
more
ulcer,with thin, soft,irregular,
luetic
ulcers.
the
than
serpiginous
slowly
settle the question. This agent
g. Finally,the exhibition of potassium iodide may
while
it scarcely influences
the
of
causes
the
neoplasms,
rapid absorption
gummous
c.

The

scrofulous

of the scrofulous

course

Treatment.
scrof ulosis

"

new-formation.

This consists

cod-liver oil,syrup

in
essentially
of iodide

roborant

of iron, etc.

directed

generaltreatment
The

local

treatment

is

against
gical:
chieflysur-

softeninginfiltrations with the sharp spoon; ablation

scissors,and a stimulatingdressingto the granulation
Wine
of camphor, silver nitrate ointment
of the ulcer.
of the bottom
(one to two
in powder, or dissolved in ether, or as an ointment
dusted
on
per cent),best iodoform
etc.
At any rate, as long as there is profusesuppuration,sufficient
dressing(one in fifteen),
Atomization
of iodoform-ether
be given to the pus.
(1 : 15), or
egress must
appropriatefor sinuous ulcerations which
are
camphorated iodoform ether, is especially
ally
accessible with difficulty
(inthe nasal or oral cavity). Lymphatic glands must eventufistulas scraped out.
be removed, osseous
removal

of the thinned

In the

case

borders

course

removed

with

and

knife and

of these scrofulous

granulatingsurfaces
of

caseated

of the

are

abscesses

often covered

preventsthe direct union

(with the sharp spoon).

of

with

and

we
fistulas,

must

bear

in mind

that the

which
granulationepithelium (Friedlander),
and
surfaces,
oppositewound
accordinglymust be

8CKOFUL08I8,

TUBERCULOSIS,
3.

The

encountered

forms

The
or

from

morbid
within

Lupus.
the

picture
lupus belongs to
in dermatology.
of

morbid

291

LUPUS.

most

manifold

and

changeable of

all

by direct infection from without

process consists in the fact that (either
virus at presfrom subcutaneous
foci)the skin is penetratedby a specific
ent

This
suspect,to be identified with the bacilli of tuberculosis.
tion
place by excitinginflammation, and thus gives rise to the formaThese small neoof small inflammatory patches situated along the vessel walls.
plasms,
section
little
of
on
as
tissue,
inflammatory
granulation
cal
sphericomposed
appear
nodules
(granuloma,lupus nodules),and are deposited in midst of a connective
The
infiltrated with inflammatorycells.
virus subsequently
tissue likewise diffusely
two
in
directions.
exerts its specific
qualities
of every
1, It influences the course
singlenew-formation
produced by it.
2. It causes
peripheralmigration of the neoplasms by spreadingalso into the healthy
periphery.
of every nodule
of small lymAd 1. In the centre
{i.e., a sphericalaccumulation
phoid
embedded
in a fine fibrillary
connective-tissue
cells which
are
mesh-work, and
from
the periphery) the virus produces
between
.which project sparse blood-vessels
basement
destruction
of the cells as well as of the fibrillary
necrosis
tissue;a specific
the
while
toward
the
of
nodule
caseation,^*
periphery
progressivedevelopmental
develops,a
and giant cells.
phases are found in the cells: the formation of largeepithelioid
But
these are
even
cells,
only temporary formations, because they, like the central
to the necrobiosis extending outward.
graduallysuccumb
Ad
these processes take
2. While
place in the singlelupus nodule which has been
of lupus,the virus has migrated into the
called very happilythe "primary efflorescence
the old process
is
nodules," on which
neighborhood, and there has again produced
the
nodular
all
after
as
masses
one
caseate,
and,
too,
These,
another,
perish
repeated.
not only the first-attacked portion of tissue is destroyed,but likewise its surroundings
both in width and in depth, and perish.
which coalesce with the new-formation
and
formation
of the lupus nodules
most
this
With
important point
disintegration
virus
into
the
into conunder the influence of a
sideration,
spreading
periphery other factors come
which, though in themselves of secondary importance,very materiallymodify
the clinical pictureof lupus. These
are:
of the spread of the lupus poison and the lupus nodules ^primary
1. The
manner
produced by it.
efflorescences)

still,
unknown,

virus

acts in

the

but, we

first

'^

"

"

"

"

2.

The

of
participation

the

internodular

infiltration

with

connective

tissue

inflammatorycells,or

wmch

is either limited
lead

to node-like
simple,temporary
may
times
at
others
at
circumscribed,
general,approaching elephantiasis.
hyperplasiae,
3. A special
ces
activityof the papillae,
by which eventuallypapillary,
horny excrescenare
produced.
to a slightextent, and
As regards the epithelium,however, it participates
butes
contriof
the
character
morbid
little to the specific
picture.
cutaneous
disease which
arises
a chronic
Therefore, by lupus vulgariswe understand
of small patches of infiltration into the tissue of the skin, and
from
the introduction
renewed
similar patches,while the older ones
progresses by the peripheralspread of ever
The variable participerishby slow absorption,or by necrobiosis leading to ulceration.
pation
of the connective tissue and the papillary
bodv produces different forms, on the description

to

of which

we

shall

now

enter.

292

TUBEECULOSIS,

SCKOFUL08I8,

LUPUS.

The primary eflSorescences,the lupus nodules, are perceptible

Lupus maculosus.
the
size
of
as
a millet-seed
spots
through the epidermis,which is slightlydepressed
at these placessituated
in the midst
of a cutaneous
surface which
otherwise
appears
The
color of these spots is a yellowish-brown,the intensityof which
quite normal.
be only imperceptibly lightened by pressure
can
with
the finger. The
skin above
the spot is smooth
it
is
side
or
slightly
o
n
illumination,
scaly
glossy,especially
very
;
because the normal
linear tracing is absent.
The most
characteristic feature is the consistence.
A lightpressure
with the blunt knob of a sound suffices to penetrate through
the epidermis-layer
into the cell-mass and to bury the knob
in the depth; while otherwise
the epidermis is impenetrable to a blunt instrument
even
on
strong pressure.
The lupus nodules are always situated in the connective-tissue
part of the skin, both
in healthy,formerly intact portions,and in old cicatrices in which
the color contrast
of
the yellowish-browninfiltration with the whitish scar, of course, is especially
evident.
is always the first stage of the development ; it is found, therefore,
Lupus maculosus
either as the first sign of the affection generally,or in the periphery of older foci,or as a
less circularly
or
relapsein cicatricial surfaces,usuallyin small, more
arranged groups.
No subjectiveinconveniences
connected
with the development of the lupus nodare
"

small

Lupus exfoliativus.In the further course, which is very chronic, there are now
lar
developed very numerous,
closelypacked nodules, the final result being a generallycircuthree
in
two
to
centimetres
to brownish-yellow
diameter, brownish-red
lupous surface,
in color.
central
The
oldest portion is usuallyalready in a state of regressive
morphosis
metahence darker and depressed,
(fattydegeneration,caseation,and cicatrization),
while toward the periphery the more
recent lupus efflorescences
are
lighterin color, and
Besides this closelypacked conoften united into a slightly
elevated, wall-like crown.
glomeration
of lupus nodules
do
uniform
diffuse
tration),
infilnot
a
(which, therefore,
represent
the healthy surroundings are
sprinkledwith isolated,most recent nodules.
The
deep-seatedinfiltration,
having led to the destruction of the papillarybody
of the cones
of the rete, robs the surface of such extensive patches of lupus
and flattening
of the
of its linear tracing; the surface,therefore, is glossy. Withal, the adherence
the surface is scaly,
cornified epidermis cells is impaired,hence
rough, and fissured. The
diameter
of the skin is thinned, and consequentlybecomes
transverse
easilywrinkled and
of
the
This
of
has
opmental
folded.
epidermis
desquamation
given this develquality
superficial
of lupus exfoliativus
form the name
"

Of

late I had

spread over

almost

healing
scaly,brown
or

two

opportunitiesof seeing lupus

large surfaces.
the

at any

entire

spot.

colored

determined

the

with

wrinkled

psoriatic surface

diagnosis,which

copious infiltration with

groups

lupus

many

this head, which

belonging under
were
volved
(twelve to eighteen), the affection had in-

forms
years

nodules

epidermis;
like

than

lupus.

at

Some

first

like an
even
more
sight, it looked
efflorescences, however, soon

primary

The latter demonstrated

confirmed
a very
by the microscope.
giant-cells)in the
granulation cells (with very large and numerous

was

of

layers of the cerium, and

tissue the

of

course

having led to ulceration

thigh and the whole of the glutealregion, without
The gradually enlarging affection
represented a uniformly glossy, slightly

surface, covered

abnormally

uppermost

In the

were

in the
very

papillae between

the

cones

of

the

rete.

In the

neous
subcuta-

sparse.

l^ow and then healing processes take place,i. e., melting down
Lupus exulcerans.
ous
cicatrization
without
destruction
of the epidermis,a kind of subcutaneand subsequent
the
scar-formation
intensityand acuteness
(cicatricial
atrophy). Usually, however,
are
of the necrobiotic processes in the lupous tissue,the caseation and softening,
so
great.
"

and

irritation

by

such

infiltration

wound-surface

inflammatory phenomena are superadded to

the normal
epithelialcovering is destroyed, and the disintegrating
is freelyexposed. A more
copious secretion, suppuration,"of this
that
we
now
speak of it as an ''ulcer": lupus exulso
once
ensues,
without

from

degree that

lupous

at

293

LUPUS.

SCBOFUL08I8,

TUBERCULOSIS,

vivid

more

"

cerans.

of such

is the nature

What

lupous

ulcer

The

base is

usuallycovered
If these

very thick, flat crusts.

with

yellow

be lifted and

of blood) brown, not

(by admixture
the underlying puriform fluid,consistingof pus-cellsand. detritus,removed, we
expose
the red, somewhat
irregularbase covered with flat granulations; it bleeds easilyand
shows
the same
consistence, at once
yielding to every instrument, as the singlelupus
borders
The
efflorescences.
imperceptiblyblend with the base of the ulcer ; they often
into the surroundings, the brownish-yeliow
of
several centimetres
exhibit, for a distance
like
of lupus skin, at times they are also slightlyelevated, wallcolor and
the soft consistence
and

massive
infiltration).
(by more
Lupus serpiginosus. The granulations,that is to say, the freelyexposed corium
and
connective
tissue infiltrated by lupus, now
and
subcutaneous
gradually disintegrate,
is
which
covered
connective
tissue,
are
gradually
replaced by newly forming, persisting
The
the neighborhood ; thus a further
with epithelium from
lupus
stage is reached.
ing,
healresult.
cicatrices
Such
distorted,retracting
heals, and very dense, firm, irregularly
segment of the circular ulcerating
however, is effected only in the centre, or at one
surface, namely, where the lupus poison has died, and, therefore, no longer prevents the
active in the still affected peripheralzone
But it is all the more
;
tendency to recovery.
"

(lupus serpiginosus).
tissue
the inflammatory neoplasia of the connective
the
necrosis : greatlyelevated proliferain the base of the ulcer may
tions
preponderate over
not
of granulationthen form, which
rarelymay organize into some
permanonce,
In other cases
the
with
covered
become
skin, and thus remain
unchanged for years.
Under
the
and
bleed
more
friable,
are
more
easily.
microscope
relaxed,
proliferations
less interspersedwith
or
we
distinguisha tissue built up of young connective tissue,more
it

there

But

lupus

''creeps" onward
under

some

circumstances

This

nodules.

connective-tissue

under
formation, proliferated

the

chronic

tion
irrita-

luposo or Lupus framboesioides.

springing from the base of the lupus
only
process,
ered
cov(still
lucerations,but, more
frequently,as a developmental form of lupus maculosus
formed
nective
with epidermis). In this case
are
chieflyfirm neoplasms composed of a contissue representingdifferent
tive-tissue
degrees of development of the inflammatory connecalmost
in
with
structure
identical
and
new-formation
ordinary elephantiasis.
of the

The

We

then

Framboesia

lupus poison,is termed

however, is found

same

brown

observe

or

not

brownish-red, soft

firmer

elevations

from

pea

to

in

nut

is smooth, or slightly
scaly,
development of tlie papillae
i. e., the growth of its ascending vascular
loops with corresponding dopressionof the
nodes arise which
the
rete
is
verrucose
of
especiallyprominent,
permit the recogcones
nition
the
surface
structure
the
verrucostis.
on
of
: lupus papillaris,
papillary
for years, are
not permaBut
all these neoplasms, despitetheir frequent persistence
nent.
ing
Sooner
or
later,with the interspersedlupus nodules, the connective tissue incloslikewise perishes.
them
We have thus far become
acquainted only with extension of lupus by contiguity.
disseminatus
the several foci appear
on
of
a
{discretus)when
we
Besides,
speak
lupus

size,either sphericalor
often

and

excoriated

"

like

covered

low

flower-beds

or

with

thin

crusts.

their surface
If

the

"

294

TUBEKCULOSIS,

different

patch

to the extension

the ducts

of

into the

and

then, however,

In

then,

as

exfoliations

rare

cases

of

the

mucous

show

The

the size of

case

every

lymph channels, around

along the vessels,

is very

firm

fasciae and

less

or

by lupus

on

membranes
are

not

has been

to be

seen.

junctiva,
con-

observed,

Small

whitish

livid-red,slightlythickened

warty prominences which

perficial
su-

and

the external

(mouth, pharynx, larynx,

mucous

in the

itself first

the bones.

more

readilyattacked

disease shows

''^nodules"

small

at the

cosa.
mu-

either still exhibit

have a red, easilybleeding surface.

part of the body, but attacks the face and the
with the greatest frequency. Usually the patches are isolated,not exceeding
the palm of the hand ; only in rare
it covers
the entire face, neck, and
cases

lupous

extremities

the

destroyed,giving rise to

the

themselves

into

rule

membranes

primary lupus of

epithelium

whitish, thickened

lupus, the

cases

Subsequentlythey change
the

migrates in

periosteum
Cartilaginoustissue

rule, the small brownish-red

of the

virus

in which

penetrate deeply, etc., progresses

is also

penetrated by the neoplasm.

In by far the majority of
to
skin, and thence extends
etc).

which

tissue,stopping as

the

of the bone.

necroses

and

depth,the

sudoriparous glands

penetrates the connective

Now

LUPUS.

parts of the body either simultaneously or in succession,

independently change into a lupus serpiginosus.

may

As

S0KOFULO8IS,

epithelial
coating or

process

may

occur

on

any

parts of the trunk.

form
It begins either in isolated flat macular
both
Lupus of the Face.
on
one
or
the
for a long time
unnoticed
cheeks, and usually remains
patient; or else,on the
by
in the form of lupus tumidus, tuberculosus, gradually leading to swelling and livid
nose
discoloration.
the
of cicatrices,
While
central
the
portions heal witli the formation
the
in
of
either
extension
or
spreads
neighborhood
serpiginously
peripheral
by
process
fresh
isolated groups
of nodules, involving the upper
the
and
forehead,
eyelids.
lip,
Then
follovfs a gradual confluence
isolated patches,thus leading to
of older, originally
extreme
torted,
disfigurement. The cicatrized surfaces are not only themselves irregularlydisbut they also cause
ectropionof the eyelidsand lipswhich is rendered all the more
of the surroundings.
conspicuous by the swelling,partly oedematous, partlyby lupous infiltration,
The disfigurementbecomes
still greater by the interspersed
ulcerations covered
"

with

the variable

crusts, and
After

color

the infiltration has

of the

several
in the

patches,changing
deeper subcutaneous

with
and

the age

of

the

intermuscular

spread
out
regularswellingof the livid discolored surface results,often withexternal
becomes
visible
of the deep-seatedinfiltration which
cutaneous
manifestation
at the surface only in the course
of long fistulous tracks witli irregular
of time, by means
ulcerous openings. The morbid
picture is completed by the prominence of the groiips
of glands on both sides of the face and in the submaxillaryregion,the softeningand caseation
process.

layersof tissue,a

more

fistulae and indolent ulcerations

implicatesthe skin and cause
affection
that
cutaneous
the
over
(scrofuloderma). It is especiallynoteworthy
disease.
these
character
scrofulous
of
abscess cavities bears the typical
Lupus
lupous
of the forehead
form, without
usuallypresentsa flat macular
any particulartendency to
nial
disintegration. But often it extends to the scalp (where it may lead to caries of the crabones), also to the upper eyelidswhich become
ectropic.
But
and upper lip.
the most
serious deformity is caused by lupus of the nose
which
has deposited a
of
the
and
exfoliativus
be
L.
maculosus
nose
a
Lupus
may
flat infiltration on the ala or
With
the absorption of the neoplasm the
the dorsum.
basement
tissue also perishes,and as a result there is shortening,shrinkage, mutilation.
of

"

which

sooner

"

or

later

296

TUBERCULOSIS,

of shallow

ulceration,and

SCEOFULOSIS,

LUPUS.

final cicatricial formation

isolated

patches developing over

ulcers (seeabove).
Lupus of the trunk and the

drawing the head forward; or else in

softeninglymphaticglands in connection with so-called

scrofulous

in a typicalserpiginous
usuallyoccurs
form,
of
the
Of
interest
are
greater
largeportions
body.
years,
of motilthe patches of lupus situated on the joints,which may give rise to disturbances
ity
and extension
Flexion
are
by the formation of ulcers and subsequent cicatrization.
then often very materiallyimpaired. On the hands, the bones are
likewise implicated;
firm cicatrices arise, the fingersbecome
caries and necrosis,deep ulcers and
curved,
shortened, phalanges are sequestratedand cast off,subluxations form, etc. Often enough
guished
are
we
compelled to perform amputation. Otherwise, lupus of the extremities is distinrather
involvement
the
combination
with
of
a
hyperplastic
by
tissue;we find
massive
and
diffuse
covered
with
circumscribed
tumefactions, usually
crusts,
thickenings
(dorsum of the hand); a diffuse hypertrophy of large segments (feet,legs),comparable
the form
of lupus papillaris
with elephantiasis,
is nos. verrucosus
develops;moreover,
where
surfaces
of the elbow
and knee joints,
as
the dorsum
on
frequent as on the extensor
the lupous ulcers on
the legs.
of the foot, and around
The
limb is thickened
so
the
skin
with
the
subcutaneous
to resemble
connective
a wooden
as
tissue,the soft
leg;
nodular
its surface,
on
parts,and bones is changed to a rigidmass, not firm, irregularly
here and there glossy,tense; at other points covered with thick, dirtyepidermic callosities,
and spinousoutgrowths.^'
stillother parts,set with warty excrescences
on
On the male genitalswe usuallyfind infiltration of the preLupus of the Genitals.
puce
the neighborhood (buttocks,thigh). On
to which
the lupus has migrated from
the lupous ulcerations are
of specialimportance, on
of the
the female genitals,
account
other forms
differential diagnosisfrom
of ulcers.
Their
is comparatively
occurrence

and, in the

course

of

extremities

covers

"

"

rare.

Membranes.
This form
has nearlyalways migrated to the
contiguous skin.
Lupus nodules," in as distinct an isolation as on
rather papillaryexcrescences
with
the skin, are, of course,
not recognizable;there
are
the
small
infiltrations
which
not
a
bove
whitish
are
sphericallupus
epithelialopacities
unite into patches with roundish
ginous
serpirecognizablemicroscopically.The excrescences
ulcers
into ulcers.
These
are
borders, finallybreaking down
distinguishedby
the cicatrization is retarded
because
their persistence,
by relapsesin the granulations.
Thus
there are frequentlyimmense
proliferating
granulations(frambcesialuposa) which
and
leave
late
tumid
cicatrices.
unsightly
Primary autochthonous
lupus of
disintegrate
of
the
and
of
the
is
the oral mucous
membrane,
conjunctiva
exceedingly rare.
larynx,
is certainlyoverlooked.
Still,a largeproportionof these cases
Many so-called eczemas
membrane
of the Schneiderian
are
being
probably nothing else but lupus,without our
destruction
of the
extensive
able at the time to verify such a suppositionunless more
of lupus on
marks.
the integument furnish further diagnosticlandseptum or the appearance

Lupus of

the Mucous

"

the

from

mucosa

"

in consequence
very frequentcomplicationof lupus is erysipelas,
authors
Some
claim
surfaces favoring the entry of erysipelas-cocci.
A

rapid healing of lupus by

the

of the
to

have

ulcerating
observed

erysipelatous
process.
Most
of lupus develop in childhood, between
the third and tenth
Course.
cases
In this
notice.
small
with
rule,
as
a
isolated,
which,
patches,
escape
years; they begin
for
most
at
infiltrations
remain
extremities
the
small
the
or
on
give
lupous
years,
way,
of puberty, when.
the time
and
until about
ulceration
rise to superficial
cicatrization,
"

with

rapid development occurs

of lupus is
puberty the occurrence
suddenly

to the number

In reference

simultaneouslyin

patch,
the prognosisis
or

much

are

the

placesof eruption,lupus
of disseminated

number

the process

is
in

insidious

more

extending lupus

of

affected

portions.

After

rare.

of

important development

more

ativus

destruction

either

appears
In the

foci.

in

single

one

latter case, of course,

unfavorable.

more

spread of

The

297

LUPUS.

SCROFULOSI8,

TUBERCULOSIS,

always very slow

extent or depth
and

in which

exulcerans

hence

and

extends

benign

the

than

suppurationis associated

years before
and exfoli-

many
maculosus

Lupus

ensues.

more

over

with

far
the

rapidly

more

destruction

of

the tissues.
of the disease
the influence
in most
cases,
Owing to the exceedinglychronic course
the general health is little or not at all injurious. Only the complications resulting
on
of long fistulous ulcers, the erysipelata
from the suppurationof the glands, the formation
cases
and lymphangitides,
etc., startingfrom lupus ulcers, may in a few
certainlyrare
"

"

give rise to

danger.

regards the prognosis

after therapeuticmeasures,

As
and

Very
cences

the

often

we

see

spring up
development

in the midst

spontaneously
process, local healing, both
there is danger of relapse.
takes place; but in every case
of large cicatrices (old lupus ulcers)the primary efiioresof the local

in large transplanted flapsfrom

the healthy forehead
even
currence.
lupus nodules, by immigration from the nose, is of frequent oc-

anew;

of

frequent in females than in males.

Etiology.
According to our hypothesis,lupus is nothing but tuberculosis (s.scrofof the skin, produced by the bacillus of tuberculosis.
Only the localization of the
ulosis)
involvement
of other organs,
bacillus in the skin, the relativelyrare
give rise to the
of
tuberculosis.
forms
the
other
to
of
as
opposed
peculiarity lupus
there is a difference
Qualitatively(probably)the bacilli are the same, only quantitatively
the
in
conditions
the
cooler
skin.
less
favorable
nutritive
which
is intensified by
glands. Joints,bones, even
Complications with tubercular affections of other organs
Lupus

is far

more

"

"

very

are
diseases, scrofuloderma
ulcerosum, etc. (scrofulosis)
analogous cutaneous
the
tubercular
has
force
their
absence
no
etiology.
argumentative
against
frequent;
Both
with syphilisin any direction.
diseases may
Lupus has nothing in common

run

side

with

"

by

side in the

Diagnosis.

"

In

individual.

same

the

diagnosis of lupus

the

early childhood,

before

followingmain

points have

to

be

hered
ad-

to:

A.

M.

From

the

1.

The

2.

The

From
1.

2.

3.

History:
beginning
very

in

slow, insidious

or

puberty.

course.

ObjectiveCondition :
new-formation
A
consistingof soft,friable granulation tissue,situated in the
surface.
skin or risingbut little above the level of the external
of
The formation
primary efflorescences" in the neighborhood of older foci;
scattered in the tissue are
these small, yellowish-brown,easilydepressed nodules
valuable diagnosticsign of lupus.
the most
to the broader
The tardiness of the development from the singlelupus nodule
which
inta
of
nodules
to
months
break
down
again requires
conglomeration
the

'^

an

ulcer.

298

TTJBEECULOSIS,

SCROFUL08I8,

LUPUS.

discoloration,the desquamation, and the moderate, often

however, give rise to mistakes, namely:

The

tended
exquitesuperficially

infiltration may,
1. With

chronic

DlFFEREifTIAL

likewise

and

great resistance to a
crusts, but
depositssuperficial

weeps
loss of substance, hence

Eczema

last for years

and

presents circum-

DIAGNOSIS.

is firm, dense, offers

Eczema

may

desquamatingspots.

ecribed, dark-brown,
Eczema

which

eczema

spreads as a
however, always

heals without

uniform

with

blunt

instrument.

does not

the formation

inflammatoryinfiltration
the

formation

of isolated

form

ulcers

connected

with

of cicatrices.
into

nodules

surrounding parts;lupus,
scattered in the healthy

tissue.
tion
only those rare cases enter into the considerain which
disseminated
fiat patches of lupus exfoliativus are
distributed,
more
plentifully
not to be perwhere the infiltration is so slightand extended
so
as
superficially
ceptible
to cause
difference in the level.
to the palpatingfingerand
The
no
pale-red
detached scales,under
which the
color of the psoriatic
patches,the white lustre of the easily
extensive spread,the characteristic
exposed, the more
readilybleeding corium is at once
will furnish adequate guiding
the extensor sides of the joints)
localization (especially
on
2.

With

psoriasis. Here,

of

course,

points.

the pale-red,
lupus erythematosus. Here a mistake will hardly be possible;
infiltrated
of
L.
covered
with
thin,
flat,almost imperceptibly
plaques
erythematosus
scales of fattylustre give an altogetherdifferent picturefrom
superficial
lupus vulgaris,
in spiteof the generallyidentical localization in the face.
is more
Here a mistake
and acne.
4. With
largement
rosacea
easilypossible,
owing to the enof the nose
occurringin them as in lupus. However, the differential diagnosis
firmness in the eleand rosacea, of a uniform
phantiasis
will be facilitated by the presence, in acne
the
intense
also
the
connective
more
redness,
tissue,
neoplastic
by
lous
pustuof the rapidly developing acne
character
efflorescences,
by the non-implication
of the small telangiectasiae
of the pituitary membrane,
perceptible
by the presence
It should
the
frequentlyvery profuse seborrhoea.
through the skin, and finallyby
3. With

be

speciallynoted that
neighborhood of the
depositedwithin

the

small, reddish

efflorescences

situated

on

the

cheek

in

mations
portion of the nose, are, in lupus,yellowish-brownfortissue;in acne, bright-red,prominent nodules palingunder
suppurating.
pressure and sometimes
arise whether
not
we
are
In the case
of ulcerous forms of lupus, the question may
with
cancroid
with
or
a
syphilis.
perhaps dealing
be decided
ness
hardwould
the case
by the great (ivory-like)
Eespecting epithelioma,
the
and
node
of
whitish
entire
with
lustre
of the elevated,translucent
margins
the
of
mencing
comthe
small
in
the
development
quantity secretion;by
tissue;by
nesting
of the neighboring lymphatic
advanced
at a more
age; by the involvement
that
not
be forgotten in this connection
glands; by the great painfulness. It must
all
the
Such
with lupus may
occur.
complicated cases are
a complicationof carcinoma
the

diseased
the

finds but little resistance in

mass
cancerous
dangerous because the proliferating
the lupous tissue.
But still more
lupus or syphilisf Even the
frequentlythe questionpresentsitself,
the several
when
for lupus, especially
tubercular,nodular
syphilidemay be mistaken
is
due to
the
The
of
h
owever,
chiefly
nodes are crowded
diagnosis,
difficulty
together.
in
both
ulcerous
of the round, peripherally
the similarity
extending
processes present
more

TUBERCULOSIS,

8CKOFUL08IS,

299

LUPUS.

for the nose, cheek, and face.

The
tory,
hisequal predilection
it points to syphilis
not.
In the
or
as
a rule, is comparativelyworthless, whether
former case, because
lupus coexistingwith syphilispresentsno strikingfeatures;in the
after infection that the
latter, because ulcerous syphilisoften develops so many
years
in
is
is
anamnestic
of
differential
case
data,
denied,
syphilis
credibility
very slight. The
ulcerous
and
is
based
the
between
on
syphilide
lupus
followingpoints:
diagnosis
and appearance
1. Form
of the ulcers. The margins of lupous infiltrations,
though
blending rather gradually with the
sharply demarcated, are low, soft,not infiltrated,
of the ulcer is lax, red, granulating,smooth, bleeding
The bottom
bottom
of the ulcer.
Pain
is
slight.
easily.
ulcers are
The syphilitic
very painful. The margins are thick, firm;raised wall-like
while they descend
the healthy surroundings by the deposited infiltration,
ruptly
abtoward
of the ulcer. The bottom
is irregularly
and sharplycut toward the bottom
eroded,
Hence
the crusts upon
ulcers
covered with pus and necrotic shreds of tissue.
syphilitic
thicker and more
much
are
prominent than those upon lupus ulcerations.
2. Environs
of the ulcers. In lupus we find in the neighborhood a soft, friable
which at once
tissue
yieldsto every mechanical
attempt at destruction,while
granulation
infiltration
is
hardness.
More peripherally,
the syphilitic
we
distinguishedby a peculiar
infiltrations as opposed to the small,impalpablelupus nodules
find the nodular
gummous
depositedwithin the tissues. These lupus nodules form the most valuable auxiliaryin
the diagnosis. They are presentin the largemajorityof cases; otherwise these "primary
unless the lupus is in the process of healing,appear in the periphery in the
efflorescences,^'

diseases,as well

as

to their

of several weeks'

course

3.

Origin. Lupus

observation.
as

rule exists from

childhood, while syphilis

usuallyis acquired

later.
4.
more

Course.

chronic

course

Every singlelupus node, as well as the whole morbid process,

than
syphilitic
products. The development of the gummous

has

far

forms

tion
are
syphilisis indeed chronic; but whenever ulcerous processes
present,the destrucis rapid,eroding in the space of weeks what lupus would
months
or
require
years to
Th3
losses
of substance connected
break
with ulcerous
down.
danger of permanent
philis
syit our
makes
treatment.
duty, in all doubtful cases, to begin with an antisyphilitic
The latter has no injuriousinfluence upon
lupus; while on the other hand an untreated
ulcerous
syphilismight leave irreparabledamage in its train. At any rate, the antiin itself furnishes
treatment
valuable
a
diagnosticauxiliary. Emplastrum
syphilitic
if
hydrargyri(especiallyadhesive),conjoined with the use of potassium iodide, removes
in a very short time, while lupus nodes present no
nodes
recent
syphilitic
disintegrating
appreciablealterations under the plaster.
in the case
of ulcers located on the female genitals
the diagnosisof lupus
Particularly
is often very difficult. There
of mistaking lupus for
is,on the one hand, the possibility
the ulcerous syphilide. Neither
of these diseases possesses a pathognomonic sign. Both
the
vulva.
rare
on
are
Usuallylupus occupies a greater surface and extends
equally
its
is less,and its course
to
is more
chronic
a circular form
more
deeply,
tendency assume
aided
than ulcerous syphilis. Sometimes
we
are
by the scrofulous or syphilitic
history,
and
unless we are
scrofulous.
dealingwith a patientwho is both syphilitic
Oftei^,as
treatment
has been stated,nothing remains but to try an antisyphilitic
as
a test.
On the other hand, lupous ulcers of the genitalsmay be mistaken
for the serpiginous
and phagedaenicvarietyof soft chancre.
The
from
the
diagnosis
objectivesymptoms
it is facilitated,however, by the history. The
will always be very difficult;
serpiginous
of

300

TUBERCULOSIS,

ulcus

molle

developsin

direct connection

LUPUS.

8CKOFUL08I8,

with

the soft chancre.

"Without any precedingbeginning represents an ulcer which besides,in

the first stages, exhibits a far more
than
acute, inflammatory character
lupus, even
de la vulve, is distinguished
though lupus of the genitals,
especially
scrophulidelupiforme
from all other forms by its more
rapid ulceration going hand in hand with destruction
and perforation. Eventually,inoculation
with the ulcerous secretion will decide ; that
is to say, it will be ineffectual with lupus, that from chancre will produce another
ulcer.
It must
in mind, however, that experimental inoculation
be borne
with phagedaenic
secretion
chancroidal
give rise to additional phagedaenicchancroids, hence that the
may
danger to the patientfrom the experiment,per se, is not inconsiderable.
Finally,in the
of
the
of
besides
also
of
forms
will
be found on
great majority
genitals,
lupus
lupus
cases,
other partsof the body which will be of use
in the diagnosis.
membrane
liable to be mistaken
ulcerations of the mucous
for lupous
are
Syphilitic
ulcers which
But
the ulcers of lupus are
shallow, shellthey resemble.
generallymore
shaped losses of substance with soft margins and base, the latter bleedingeasilyon touch.
Here too, the chronic course,
the peripheralextension, and the termination
of the infiltration
in absorptionor disintegration
will decide when
with
the
compared
rapidprogress
in syphilis.
Treatment.
The
will have
treatment
to aim
at two objects: first,
to stay the
development and progress of the pathogenetic virus; second, to destroythe morbid
It is necessary
to remove
those portions of tissue which
products alreadydeposited.
and which,
diseased that no firm, permanent tissue could be reproduced from them
are
so
have
left to himself, would
if the patientwere
to be destroyedby a slow process
of ulceration
if healingwere
to result; in those parts which
still firm and relatively
are
sound,
the lupous cellular
sometimes
in patches, must
be
infiltrations,
diffused, sometimes
To
caused
to be absorbed
(Volkmann).
accomplish the former
object, we employ

new-formation,

the

affection

from

the

"

"

"

medication

internal

Internal
our

treatment,

of

of the

virus.

only attain its full value if we had at

destroyingthe lupus virus. Second in order we would
which have a generallyroborant
the coninfluence on
stitution
increase
the power
of resistance of the body
would
we

course,

would

then

specific
capable of

disposala

to consider

have

the local destruction

and

the medicaments

body, by which
toward the spreading virus.
has
in the most
recent
As a sort of specific
time;j
against tuberculosis,iodoform
had
the
greatest recognition. My own
experiments
very encouraging results,
acquired
in use
Potassium
iodide has long been
against
although direct cure was not attained.
lupus; but at all events it requiresto be used for a very long time if it is to have any
Recognized of old as a specificagent is also
effect,which appears altogetherdoubtful.
of pure
the addition
cod-liver oil, with or without
iodine, creasote, etc.
(01.jecor.
1
iodi
w
ith
0.1
200
or
creasoti, gram
[gr.xv.]
asell.,
[01. morrhuae, 3 iij.];
pur.
grams
[gr.iss.]).
gram
The
Arsenic in very small doses, iron, and quininebelong to the class of roborants.
is based on well-known
therapeuticalprinciples.
generaldietetic and hygienictreatment
of the

morbid

of each
1.

must

The

not

virus, of

course,

will not

be

feasible without

the destruction

products alreadypresent.

number

The
value

of the

local removal

The
of the

methods

at

our

disposalfor

this purpose

is very

large. The

dependent upon:
be reached.
Here
lesser certaintywith which
the virus can
we
sightof the fact that the micro-organisms in question are always present

greater

lose

the

of

will be

or

TTJBEKCULOSIS,

SCEOFULOSIS,

LXJPIIS.

301

neighborhood of the obviously diseased portionsin the midst of apparently

healthy parts. The microscopicexamination, therefore, is not reliable.
2. Certain aesthetic considerations
with regard to the future appearance
of the patient,
since lupus attacks the face most
frequently.
to be that with
Startingfrom these points of view, we hold the best treatment
caustics.
with the knife (excision)
the
or
They are to be preferredto surgicaltreatment

in

the

spoon,

We

or

at least to be combined

discard

with

potash, Vienna

these methods.

paste,and Landolfi's paste,because their action

incalculablydeep also on the healthy skin and leaves dense, hard, unsightlycicatrices.
Better is Cosme^s
nabar,
(composed of white arsenic,artificial cinpaste as modified by Hebra
and fat),
because
it does
not
But
after several days'
destroythe healthy skin.
application,inflammatory swelling and great pain result. Besides, there is danger of
with the stick
causing intoxication by the arsenic contained in the paste. Cauterization
of silver nitrate has comparativelylittle effect. The healthy tissue offers sufficient resistance
to the silver,and even
in the diseased portions the caustic effect does not spread
beyond the spotspurposely touched.
The
to me
best seems
to be pyrogallicacid.
This acid destroys all lupus tissue
and
skin
the
It
healthy
altogether.
spares
penetratesinto the tissue and is better
able chemically to find the morbid
structures
than
patches in apparently normal
the eye of the observer.
The probability
of reaching the peripherally
virus
proliferating
is therefore greater,even
though this be not attained by the first application. Withal
the cicatrices forming from the ulcers due to the employment of this caustic are
very
sightly,soft,smooth, because the healthy portionswithin the lupus patch, having been
spared,are utilized in the cicatricial process.
The
danger of intoxication is minimal, because the absorptivesurfaces are too small
to bring a sufficient quantity of pyrogallic
acid at once
into the organism.
Pyrogallicacid is best applied in the form of a ten-per-centointment
spread upon
linen.
The linen rag, covered with gummed
and
tied
as
as
firmly
possiblyon the
paper
diseased surface,is changed morning and
for
three
four
or
evening
days. During this
time it will be noticed that the softeningmasses
of tissue become
graduallybrowner and
black (by the contact of the pyrogallicacid with alkaline tissues),
until by the end
finally
of the third or fourth day a black, discolored depositlies upon
the surface.
Thereby our
objecthas been reached: the diseased neoplasticfoci are destroyed to a great extent, as
far as the pyrogallicacid has been
able to penetrate. The
surrounding skin usually
shows, aside from the blackish-brown
discoloration,only an insignificant
inflammatory
of the uppermost epidermal layers be
swelling; only rarelywill a vesicular detachment
observed.
The pain, too, is slight; it begins as late as the third or fourth day, and continues
The pulpy masses
only when the mortified ulcerous surface is left uncovered.
are
then mechanically removed
much
feasible and
ointment
as
as
an
dressingapplied. We
a Lister's carbolic
employ as an after-dressing
or
form
thymol dressing,or rather one of iodoointment:
of
is
dusted
an
and
covered
with
on
ample layer
powder
ten-per-cent
iodoform
ointment, or the anointed piece of linen alone is laid over
it. Besides
the
antituberculous
action of iodoform, its disinfectant
(possiblypresent)specific
and anaesthetic
effects assert themselves.
The
cauterized
covered with skin in
portions become
to three weeks.
from one
It is only rarely,of course, that a single three-days'
tion
applicasuffices to effect a cure
must
be repeated; but in that case
the
; usuallythe course
cicatrix previouslyobtained is spared by the pyrogallicacid and merely the additional or
formerly left lupous foci are softened.
is

caustic

"^02

TUBEECULOSIS,

Alcoholic
form

of ether

for

lupus
coloph.,aa

of
8

LUPUS.

SCKOFULOSIS,

watery solutions of pyrogallicacid, as well as its employment in the

not proved equallyeffective.
The spray will be applicableonly
spray, have
the nasal cavity. Bock
employs a pyrogallusplaster:01. olivar.,Kesin..
or

grams

; Oerse

flavse,15 grams

Acid,

; Gumrai

resinse ammoniaci,
M.

pyrogallic,4 grams.

ft.

Balsami

binth,
tere-

The

venet.,
empl.
gram;
plasteracts
less painful.
uniformly than the ointment and is somewhat
In a few cases, perhaps, the employment of pyrogallicacid could
be combined
with
have to be done previousto the applicaother procedures. For instance, scraping may
tion
acid ; in the case
of thick epidermal layersit will eventuallybe necesof pyrogallic
sary
with
to soften them
them
or
with
potash soap
by energeticwashing
by painting
render
For
them
and
more
forms
of
permeable.
slightlyulcerating
potash lye,
lupus,
chrysarobinmay also be taken into consideration (1 : 4 ointment).
the direct
Starting from a similar point of view as Jarisch, Riehl recommended
of lupus had been
fined
conapplicationof iodoform for lupus. While formerly the treatment
of the lupous infiltration,
and removal
he believed that he had
to the destruction
followed by gradual absorptionand alteration of
in iodoform
found
was
a remedy which
aa

more

lupous tissues.
results.
Ulcerating
My experimentsin this direction yieldedexceedinglysatisfactory
to a thickness of about
to three millimetres
covered with iodoform
one
lupus nodes were
glycerinor collodion produces no effect),
whereupon
(simplepaintingwith iodoformed
and the infiltration disappeared.
the suppurationstopped at once
For more
was
deep-seated infiltrations the followingpreparatory treatment
employed:
freed
fat
with
from
The diseased skin, previously
by washing
painted by means
soap, was
of a charpiebrush with a solution of caustic potash (5 parts)in distilled water (10 parts)
cent,
transluand left in contact
all the diseased parts was
with it until the epidermis over
macerated, and detached; then by swabbing with charpie dipped in water the
superfluouscaustic potash was removed, and the part dried. The surface was then dusted
to two
to a thickness of one
with finelypowdered iodoform
millimetres, and bandaged
The
with wadding and
dressingwas allowed to remain for
stripsof adhesive plaster.
three to eightdays.
riino case was
had
sunk
into the depression
there any suppuration; the iodoform
skin
the
the
was
the
of
tissue;
formed
intervening
pale and pliable;
disappearance
lupus
by
In
intense
the swelling and erythema had
cases, the
largelydisappeared.
very
times.
three
two
had
to
be
or
application
repeated
venient,
The procedure,which
causes
pain only during the cauterization with potash,is conthe

inexpensive,rapid,and

With

regard

words

of

these

various

treatment

to the

Volkmann's.

of

measures

effective.

purely mechanical
He
are

says:

"

It must

be admitted

that much

I wish to
more

quote a
depends on

few
liow

The
particularagent is chosen.
deal
numerous
chapters of our art in which a great
technique and method."

employed

of the
lupus is one
matured
accurately

of treatment,

methods

than

on

which

depends upon
However, aside from
methods, the most radical is excision.
Among the mechanical
the deep cicatrices left over, and the necessityof being obligedto operatein the healthy
than other methods.
tissue, it offers no
greater security as regards permanent cure
is to follow immediately,
which
It can
be recommended
only when, owing to a plasticoperation
Similar advantages.
favorable by excision.
rendered
the conditions
more
are
an

304:

which
does
inflammatory swelling
be
can
repeated only at

treatment

soft,without

and

SAETIAN

THE

DISEASE.

not
until after several hours.
Hence
go down
intervals of two or three days. The cicatrices are

tumefaction.

the
flat

This

procedure is specially
appropriatefor isolated
periphery of largerpatches of lupus. It is also
of lupus granulationson mucous
membranes
applicablefor the first removal
; later,it is
better to substitute for it concentrated
solutions (with equal parts of distilled water),
which
penetratemore
deeply into the tissue.
nodules

in the

any

or
shape of relapses,

in the

The

by

sticks of caustic for this purpose

be hard
and
must
them
nitrate
with
melting
potassic
(lunarcaustic).

Besides,the scarification has been

Auspitz dips the point he

of iodine

(iodipur.,

had

combined

attached

with

the

to Volkmann's

firm, such

injectionof
spoon

into

as

produced

are

destructive

liquids.
glycerin solution

20 parts),previous to every insertion of the scarificator,

glycerini,
more
a
rapid healing and diminished painfulness. Schiff
attached a small rubber
pipetteto a short injectingneedle, so as to enable him to make
instantaneous
an
injectionwith every thrust.
In order to hasten the absorptionof the lupusproliferations,
a good adhesive
emplastrum
is
inunction
with
hydrargyri
employed (or regular
gray ointment), or painting
with tincture of iodine or iodized glycerin(Iodi puri, Potassii iodidi, aa 5 grams
cerini,
; Glydiseased parts are painted morning and evening for several days
10 grams). The
in succession
until crusts form, the evaporation of the iodine being prevented by the
Then
the crusts are
detached, and the procedure is repeated.
applicationof paraffinpaper.

whereby

In ulcerous
solution

of

he

part

secures

forms, besides the

strong silver nitrate

acid in
salicylic

solution,it is

20), to be

recommended

to

painted
daily.It
the
ing
powder causes
readilybleedto cicatrize rapidly.
be employed, we
must
But no matter
what method
invariablybe prepared for a prolonged
of treatment, and it will always be necessary to carefully
course
remove
relapses
and newly developed infiltrations. The
cal
patientsrequire regular,unintermitting mediit
Avell
advanced
be
to
stain
absupervisionfor years. In some
perhaps
cases,
may
very
At presentI have under
observation
from any interference.
a
lady patientwho
and hand without
has suffered for about twenty-two years from lupus of the right forearm
entire
forearm
surface
is
the
had
treatment.
The
one
lupus
having
palm of
;
any
of
When
these
w
ith
the hand is also interspersed
lupus.
closelypacked patches
patches
are
probed with the sound, the latter penetratesin all directions,without meeting any
resistance,almost as far as the dorsal surface of the metacarpus. Therefore, it must
whether
any therapeuticprocedure,by excessive destruction,would
appear questionable
than if the
not more
and earlier cripplethe mobilityof the stilluseful member
seriously
use

is said

also that

glycerin(6
acid
salicylic

the

dusting of pure
and the ulcer
wither
to
vegetations

process be left to itself.

In many
a case
even

I here

append

amputation

brief note

must

on

three times

in

be resorted

to.

on
"

THE

DISEASE

SARTIAN

Pascliachurda,
{TascJikent-Oeschwiir,
which

was

published by

in the
The

Sartian

Deutsch.
disease, an

Dr.

Heiman

medic.
endemic

in the

Gazeta

Wochensclir., No.
cutaneous

affection

"

Jaman

DscJiaragan)

lekarsha, No.

39, Warsaw,

and

printed
re-

3, 1883.
of

the

inhabitants

of Taschkent

and

its

en-

along the borders

virons, especially
ical relations by Prof. M. Rudniew.
to the

According
years,
had

the

; it

the

affection

The

rarely
the

which

from

The

the

then

redness

of the

the

case

to

rose-red

temples,
of

tlie

on

palm
of

irregular shape, sharply

places

kopeck

more

frequency,

spot, the color

several

on

of

the

order

and

the

at

same

larger.

rated,
indupersists,the skin gradually becomes
the nodules
and, when
one
approach

the

surround

ones

as

or

to that

either

develop

nodules

The

recent

them

rough,

it grows

wart.

more

Tschirtschik,
from

hairy parts, nor

on

isolated

later it

and
in

; next

round, oval, or

pin'shead

pressure,

feel, later

smooth

of

forehead

never

; it is of

either

occurs

that

disappears under

latter

; it

from

impression of

the

in which

skin

spots varies

the

prodromata

any

bluish

or

rivulet

is transmissible

eyelids

the

on

trunk:

the

begins without

It

surrounding

acquires

another, makes

foot.

dark-red, yellow,

into

of the

size

first the

At

rarely

extremities, the neck, and

lower

sole of the

changes

demarcated
time.

jaw, auricle, most

dred
hun-

parents have

time.

especiallyon

face,

the

and
and

soon

person
in

frequent

second

for four

whose

the

of

but

patho-anatom-

in Taschkent

water

Taschkent,

of

lower

upper
hand

of the

same

the

drinking

to

inhabitants

in its

elsewhere, but

domiciled

persons

origin

lips,nose,

the

on

is most

the

in

its

owes

can

other

on

Taschkent

in

disease

originate onlj' among

attacks
people ; it never

hence

also

existed

has

Sartians, the disease

of the

statement

hereditary, occurring

is

studied

Tschirtschik, has been

rivulet

of the

305

DISEASE.

SAETIAN

THE

older

in

simultaneously
circle.

With

the

cally,
periodi-

or

occurrence

and
intense as the
more
more
nodules, desquamation of the epidermis begins and becomes
recent
origin. As a rule, the nodules finallycoalesce into a diffuse
epidermis is of more
to eighteen months.
last from
two
of coppery
livid color.
This hyperplastic stage may
or

newly-formed
node

Then

the ulcerous

the

periphery, and

not

occur,

stage

secretion, which
while

the

corium

margins

granulations
epidermis, and

year

is

of
a

the

ulcerous

the

ulcer

become

the

at

progresses
restitution

ad

the

the

crusts,

the

several

covered

smooth

smooth,

treatment

disintegrationof
rarely

should

is then

under

process

granulations

process

children

in

Only

of

of the

net-like,more

or

centre, while

with

cicatrix.

At

periphery, which
of

integrum

the

skin

behind.

remain

discolorations

the

toward

centre

inappropriate

limitation

Finally the

depressed, radiating

disfigurement.
case,

of

duration

islands.

the

semifluid, sticky, grayish-yellow

If crust-formation

crusts.

Under

undermined.

spontaneous

the

to

small

place in the

favorable

course

former

cutaneous
painless,and at most causes
Relapses
frequently attacked.

most

ai-e

itching. Young
exceedingly rare

persons,
and

to

up
never

the

fiftieth
at

occur

the

seat.

According

to

of

degree

the

Rudniew,

small

cells

permanence,

develop with

destruction
The

of the

ulcer

Taschkent

shorter

Mistaking
of

obtained

chloride

granuloma,

the

papillary and

in the

to the
never

extends

membranes,

as

from

far

as

to

bone

and

which

possess
At

first

no

effect its

disintegration.

subcutaneous

reaction

without

connective

and

in

contiguous

impairing

ulcer, aside

its duration

able
consider-

we

notice

Then, along tlie dilated vessels

finelygranular protoplasm, without any

and

the

of

of the corium.

Tlie

from

the

the

ulcerous

tissue.

lupus by being spread diffuselyover

by causing

cartilage,by

elements

tissue.

epidermis layer and

distinguished

mucous

the

substance

reticular

ending in spontaneous recovery,

leprosy differs from the Taschkent

extension

occurrence

develops

and

course

Tubercular
the

up

itself
is

is

which

nuclei
delicately-outlined

very

corium

attacking the

never

in

tissue; they rise

intercellular

affection

and

copious vascularization

more

are

takes

considerable

to

life,are

of

form

the

in

or

from

and

bottom

peripherally,the

sometimes

Otherwise,

is formed

there

place; in
The

and

in

cicatrization

takes

and

uneven

are

down

bottom,

uneven

yellowish-brown

into

extends

form, which, according

nodules, develop

gives rise

of nodules

disintegrate.

may

times

gradually dries

development

the

large ulcer wich

breaking

nodules

the several

commences,

finallyrepresent

the

parts,

skin, and

by having

general nutrition.
painfulness

of

the

nodes

incurability.

it for Si/p7i.z7is
is prevented
the slow
by the history,and
course,
especially the late
of antisyphilitictreatment.
disintegration, finally the ineffectiveness
The
best results

from

of zinc

cauterization

with

Canquoin's

E. Polak, who

had

studied

the affection

48, 49), has recentlyagain declared

Haleb-node, bouton
20

paste, caustic

potassa, solid

nitrate

of

silver,and

paste.

d'Alepp, or

as

long

that the Taschkent

the Biskra

and

Delhi

ago

as

1860

ulcer is
bubo.

(Wien.
nothing

Med.
but

Zeit.,Nos.
the so-called

306

LEPRA.

LEPROSY,

II.

LEPROSY,

LEPRA.

Leprosy is a parasiticdisease
more

less circscribed

or

connective
without

tissue of the

being the

direct

According to

"

which

have

which

but

it consists in the development of

of chronic course;
inflammatory new-formations, mainly in the skin and in the
The
disease is almost
peripheralnerves.
incurable,
invariably

of death.

cause

its localization,
two

of

great groups

of old led to the erection

of two

symptoms arise, cutaneous

or
vous,
nerof leprosy forms, however,

different forms

"

rarelydevelop in complete purity.

Leprosy of the skin is called Lepra tuberculosa s. tuberosa, s. nodosa, tubercular lep
has received its titles from
the most
Leprosy of the nerves, lepra nervorum,
rosy.
inent
promL.
etc.
ancesthetica
Between
s.
the two lie the
symptoms :
glabra s. mutilans,
mixed forms ; consisting
eruptions,to which the symptoms dependmostly in cutaneous
ent
the alteration of the nerves
become
on
superadded ; more
rarelythe reverse
occurs,
the cutaneous
symptoms succeeding the pronounced L. nervorum.
SPECIAL

1.

Although

PATHOLOGY.

Lepra Tuberculosa;

Lepra

Cutanea.

it is

impossibleto ascertain the date of the infection, a series of general

phenomena appears almost constantlywhich may be termed prodromal (premonitory
from those observed in other infectious
symptoms)
symptoms not materiallydiffering
diseases.
There are gastricdisturbances,anorexia, dyspepsia; great fatigueand
associated with profuse sweats
somnolence, with intense vertigo,appear; they become
and frequentlyviolent epistaxis. But the most
times
important are attacks of pyrexia, someof an intermittent,
These symptoms,
sometimes
of quiteirregularcharacter.
curring
ocat variable intervals and in different intensity,
precede the outbreak of the
may
morbid

"

disease for months,

Those

authors

even

one

who

had

or

two

years.

frequentopportunitiesof observing the onset of the diseas

designatethe premonitory fever as a constant symptom.
The
prodromal stageis followed by the eruptivestage,initiated by an erythematous
of gradual origin and spread,i. e., more
less deep-red spots which
exanthem
have a
or
and
in the
next
for
the
extremities
darker
for
the
face,
specialpredilection
; they are
centre than at the periphery,may be of any size,and usuallyprojectuniformly above the
level of the normal
skin,
the spotsare
slightlyhyperaestheticin their first
frequently
macular
form either disappears,
a certain feelingof itching. This
leaving
stagesor cause
inconsiderable
remnants
these brownish-red
cular
of pigment, or else from
spots spring tuberin
felt
be
the
of
band-like
form
often
nodular
can
more
or
they
neoplasms
depth
;
long before, in the shape of nodular infiltrations. They sometimes
spread peripherally,
others grow
in height; contiguous neoplasms become
confluent, thus giving rise to
fore
gradual extensive infiltrations. As a rule, this process requiresmany months or years bethe macules
until the small, at first
or
change into tubercles'and diffuse infiltrations,
barelyperceptibleinfiltrations in the corium will clearlyproject above the level of the
skin in the shape of tubercular
efflorescences.
In the further

The

individual

of the disease

course

of every singlenode
new-formation

;
on

on

the

other, the

we

must

follow, on

perpetual and

the

one

hand,

the

outbreak
irrepressible

future

of the

fate

rous
lep-

additional

nodules

regions.
enlarge and appear

as

dark-red, soft formations

; for

month

3or

LEPEA.

LEPEOSY,

they remain unchanged, at most assuming a more

yellowish-browncolor. The epidermis
but
b
ecomes
is
in the
desquamates slightly,
rough,
preserved. More acute necroses
central portionsof the tubercles,leadingto softening,to gradual thinning of the covering
layers of epidermis, and thus to shallow ulcerations,are not regular,but merely
traceable to external

influences.
These ulcers are quiteindolent,have sharplycut edges,
copiousquantitiesof thin pus from their rather smooth, badly granulating
bottom.
Having a slighttendency to recovery, they cicatrize only after having existed
The originalhyperaesthesia
time.
for a long
of the tubercles
soon
givesway to a steadily
increasinganaesthesia ; the remaining thin flat cicatrices are usually entirelydevoid of
sensibility.At times, too, the tuberous eruptions vanish quite acutelywith the appearance
the region in questionof an erysipelas.
on
The parts most
affected are : face and
forehead, eyebrows, nasal and oral mucoua
and

secrete

Fig.

22,

"

After

photograph

the extremities

sent

the

me

by

Dr.

Goldschmidt,

of Funchal

(Madeira).

surfaces of the
are
: extensor
points of predilection
of the hands
and
tensor
fingers; altogetherthe exof
the
flexor
surface.
than the
Every part
body, however, may be attacked,
more
except the scalpand the glanspenis. The aflCected parts, of course, have their volume
is
limbs, for instance the fingers,
materially increased,and the mobilityof some
very
the case
when
the above-mentioned
tions
ulceraseriouslyinterfered with ; this is especially
at these particularly
establish themselves
exposed places. Quite typical,however,
is the alteration of the face : by the diffuse depositionof the leprousneoplastic
mass
are
again superimposed, broad wheals are
secondary nodes and excrescences
upon which
the frontal and
supra-orbitalregions; the cheeks
produced which bulge out especially
ulated,
protuberanceson both sides of the infiltrated and nodgraduallyform thick, pillow-like
and flattened,depressednose.
but broadened
On

membranes.
knee

and

elbow

joints,the dorsal surfaces

308

LEPRA.

LEPKOST,

The

lipis bloated and tumid, with slightectropion. Withal there is more

or
local alopeciaof the eyebrows and the beard.
The
auricles grow
thick, especially
the lobes change into sacs
the chm, itself bloated
Under
and
sprinkled with nodes.
dulous,
penof infiltrated lymphatic glands project. Through these
the voluminous
groups
slow but steadily
advancing processes a physiognomy is produced which is marked
by lack
of expression,and naturallyleads to a notable
resemblance
of ajl lepers. The
immense
the frontal and supra-orbital
the
folds hanging often
sac-like over
tumefaction, especially
eyes, have given rise to the term, facies leontina.
upper

less

The

in the

membranes
of the mouth, the nose, the palate,and
mucous
larynx,run parallelto those of the skin. Infiltration and nodein the earlystageswe meet
formation
lead to gradual thickening. Even
with ulcerations
is lessened
covered with corresponding crusts, especially
in the nose, the calibre of which
to
similar
the
on
thereby,leading
snufflinginspiration. Through
laryngeal
processes
the

alterations

pharynx

down

to the

the voice becomes

mucous

membrane

extends

also into the

harsh

But as the leprous infiltration

toneless.
cartilage,
deeper destructions are also produced ; it erodes the nasal
ulcerous
sinks in ; in the larynx it causes
vault which
losses of tissue which
lead to
absolute aphonia,and often to stenoses
which
endanger life.
With
the above are associated yellowish,flat depositsin the conjunctiva which gradually
and
extend
as
a white
more
opacityfrom one
edge into the cornea, more
reducing
its ulcerous
the visual power,
until finally
total opacityof the cornea,
or
perforationwith
loss of the lens, causes
permanent blindness.
crease
The glands,especially
those of the submaxillary,cervical,and inguinal regions,inin
first
of
the
to
at
be
in
size
tubercles
so
as
sight
conspicuous
shape
enormously
as
large as an apple.
In
characteristic only a gradto the other
reference
have to note
as
we
ual
organs,
velopment,
atrophy of the testicles. Should the disease begin before puberty, the physical deespeciallythat of the genitals (with the alteration of the voice, etc.,
The
mental
not
faculties are
these
is greatly retarded.
dependent upon
processes),
in
is
unless
condition
deteriorated
the
ensue
complications
generally good,
subjective
;
such
the
with
the
of
of
febrile
occur
as
attacks, or paroxysms
implication
pain
shape
and

"

of the

peripheral nerves.

The

extension

of the

process

takes

place

either

by

the

slow

peripheralgrowth

of

existing patches and the formation 6f isolated nodes close to older infiltrations, or else
a
larger region is attacked with an acute eruption of many neoplasticfoci. This last
modus
proceeds in the shape of an erysipelas. With considerable rise of temperature
great debilityand depression,
conjoined with headache, arthralgia,thirst and nausea,
become
the
entire extremity,
face and neck, or
an
pretty uniformly turgescent,the
time
the corresponding
skin reddened, very sensitive,at times exceedingly painful. At .the same
lymphatic glands swell and give pain. After a few days all these symptoms
the eruptions in largernumbers,
cules
observe
developing either as maabate, and then we
cession.
region is attacked several times in sucof
the
of
no
cases
erysipelatousparticipation larger portions
which
skin ; circumscribed
deep infiltrations (comparable to erythema nodosum) form,
by-and-by prove to be fresh leprousneoplasms.
ferred
reattacks of fever without
such eruptions also occur
However,
; they have been
partlyto metastatic invasions of other organs, partlyto the absorptionof softened
But at all events these pyrexial
of tubercle.
periodsare always a sign of the inmasses
or

as

In

flat infiltrations.
other

there

Often

is

the

same

309

LEPRA.

LEPBOBY,

patientsdread these paroxysms

very much, because a residual
for
weeks.
great weakness frequentlykeeps them confined to the bed
The type of the fever is not quiteconstant, now
againremittent;oftenest we
irregular,
fever is given in the historyof
find the intermittent type,owing to which fact intermittent
observed
in
For
case
a
a great many
Surinam)
instance,
(from
by myself here
patients.
the
is present; regularlyat two o'clock p.m.
at Breslau, this intermittent
character
on
at
C.
almost
normal
(103" F.),becoming
respectivedays the temperature rises to 39.5"
night. The pyrexialattacks each time go hand in hand with fresh eruptions.
This in brief is the course
of cutaneous
leprosy. We have seen that after a variable
of the generalorganism,the local processes
of
associated
with
involvement
incubation
period
in
the tissues of the eye,
the
the
skin, mucous
membranes,
develop on
glands,testicles,
in
acute progressionwithin a few years, again chronically
etc.,sometimes
extending over
decades with periodical
eruptionsseparatedby long intervals. To these are almost regularly
superadded affections of the peripheralnerves.
The leprouscharacter has not been positively
demonstrated
in the diseases of internal
found
at
the
of
frequently
autopsies
leprous patients. It requiresonly brief
organs
of the disease.

crease

The

here that, in the

mention

liver,cirrhosis with

the

of bacilli has

presence

been

strated
demon-

In the spleen(Norway), bacilli have been demonstrated

by myself and later by Cornil.
by Hansen and subsequentlyby myself.
The
of tubercular
course
leprosy in general is very unfavorable.
Although the
of death, recoveries are very rarelyobserved.
disease does not always form the direct cause
Hillis tabulates the followingcauses
of death:

Nephi-itis,

23.5^

Pulmonary

11. %

disease, including phthisis,

Diarrhoea,

10. %

Anaemia,

"Remittent

fever,"

Peritonitis
Exhaustion

2.5^

by leprous

internal

of

5. %
5. %

organs,

ulcerations

marasmus,

atrophy

leprous
;

stenoses

in

of the air passages

short, direct

lepra

consequence

leprosy,

of
38. ^
100.

The

author

also calculates from

mortuary records of his leprous material

of life of tupercularleprosypatientsis considerably
shorter than in those of the anaesthetic form
(20^ to 10^ of mortality).
better when
Experience shows that the prognosis becomes
lepersimmigrate into
countries free from
the disease.
Although the process is very rarely completely
arrested,it usuallyis evidentlyprolonged.
same

(inthe West

//.
Here

they are
of

the

Indies)that the duration

likewise
from

Lepra

nervorum

( Virchow).

prodromal symptoms precede

the outset

of

more

nervous

the

character:

obvious

great

outbreak

sensitiveness

of the

malady;

in various

parts

the

of the entire skin; dull,

body, resembling rheumatism, a sort of hyperaesthesia
often lancinating,
boring pains along the track of certain nerve-trunks, especiallythe
median, ulnar, and peronealnerves
greatlyincreases the pain; gastricsymp; pressure
toms
are

After

also often

this

mentioned.

period,lastingabout

year,

the disease

developsin

very

chronic

course.

310

LEPKOSY,

reaches
finally

it

until

of

stage

in
stability

tardiness

and

This
progress of the affection.
characteristic of the malady ; the several
Therefore

the

LEPKA.

erection

of

which

we

can

indistinctness

stages merge

hardly speak of
of development is

into each

other

evident

an
a

without

principal
any

clear

for
"prodromal" stage is reallyunjustifiable,
the premonitory symptoms are, strictly
speaking,symptoms of the actual disease.
is an inflammatory one, of rather acute onset
The
morbid
process of lepranervorum
in
connective
and rapid course,
the interstitial
tissue,leading by degrees to connectivetissue neoplasiawith correspondingatrophy of the nervous
elements.
Accordingly we shall be able to form two largergroups of symptoms:
A. Such as are directlytraceable to the affected nerve.
of this nervous
in correspondingparts of tissue in consequence
disease.
B. Such as occur
In the couKSE
of the affection,however, three periods(more or less clearlydemarcated
in a concrete
case)will be distinguishable:
1. Prodromal
stage: period of the developingneuritis.
the symptoms of nervous
disease become
2. Eruptive stage: in which
clearlyperceptible.
demarcation.

stage(completed atrophy).
symptoms occurringin each of these stages are

Permanent

3.
The

of

motor, sensory,

and

trophic

nature.
1. Direct
true

muscular

symptoms only with purely motor nerves.

paralyses. In the affections of the mixed nerves

motor

With
the

these
motor

alone

we

find

fibres remain

intact.
of the tactile sensation go hand
Disturbances
Sensory symptoms.
lost.
those of the perceptionof pain until both are totally
3. Trophic symptoms ;
Of the skin.
acute
a.
period of the
They occur
mostly in the first,more
2.

"

and

c.

nervous

with

tion
affec-

development of bullous eruptionsresembling pemphigus.

lost.
2. In pigment anomalies, the pigment being either increased
or
3. In atrophicprocesses (glossyskin, etc. ) belonging to the later period.
Of the muscles, which
atrophy,with correspondinglyimpaired motility.
Of the bones and
Joints,leadingto the loss of phalanges,etc. ; here, of course, the
insensible portionsof the body must
influence of external traumata
the absolutely
on
1. In

t.

consist

in hand

be

taken

the

into consideration.

qualities
peculiarto leprousneuritis correspond with the
text-books of neuritis in general,only in leprosy
descriptiongiven in neuro-pathological
blended
the acute and chronic forms are more
together.
the
more
Entering now
symptomalogy, we find,in the beginning of the
closelyon
and then
disease,chills,now
rigorswith fever ; furthermore, violent pain, felt usually
limb which
but in the whole
not only in the distribution of the affected nerve,
frequently
stant
conswollen
and
is slightly
erythematous. The skin is then hyperaesthetic.Still more
In the main, therefore,the

subjectivesymptoms
deep down, etc.
of
character.
and
a lancinating
of sleep.
are

of heat

Hillis holds these

lepra nervorum
leprosy.

such
The

as

the

states he

fever

formication, numbness,

torpor, a

decided

tion
sensa-

nearlyequal by day and by night,

persistent,
pains
The
patientsare greatlyreduced by the consequent loss
are

lancinatingpain to be as characteristic prodromata of

cular
eruptions form a pathognomonic initial symptom of tuberhas never
failed to observe this,although it was
very variable

attacks of

H.

as

312

LEPRA.

LEPBOSY,

pressure.
do not even
The
Like

The

patientsdo

recognizeany object placed in their hands ; often they^

they stillhave it between their fingersor not.
to pain suffer accordingly.
temperature,pressure, and sensibility

know

whether

sensations

of

not

the tactile sensation, the

muscles,

latter is also lost first

Excisions, burns, etc., therefore,are

explainsthe ulcerations

to be described

I have

In this section
because

the

on

skin, later

the bones,

on

etc.

it has been

made

mention

no

alreadyenumerated

felt

not

the

by

patients

fact which

"

in part

hereafter.

as

of

a
hyperesthesiaprecedingthe anaesthesia
symptom of the beginnning interstitial neu-

ritic process.

Anatomically, the
characteristic
about

examination
I

condition.

the presence

absence

or

of the skin

unable, from

am

of the

during

this

stage shows
(anaesthetic)

lack of material,to furnish

intra-epithelial
nerve

termini

any

no

information

recentlydescribed

by

Unna.

Trophic Disturbances.

3.

A.

Of

alterations

the sMn.
as

connection

"

Although they,

regards the
in the

time

of

details between

in

their

general

occurrence,

parallelwith

run

way,

the

sensory
is

location,spread,etc., stillthere

the two

series of symptoms.
Both are co-effects of
two
distinguish
an
earlyone, marked
by
stages
may
all
the more
of
the
to
be
described
copiousdevelopment
phenomena
; a later one, in which
fresh processes appear but rarelyand isolated
this is an
artificial division,as will
still,
in
be evident at once.
For
the beginning the disease affects an altogetherhealthybody,
in which
it can
sequently
eruptionssynchronously or in rapid succession ; while subproduce many
only isolated regionsare capableof being affected. A division into earlyand late
stages is admissible only in so far as the eruptivestagecan be separatedfrom that in which
the atrophicprocesses are fullydeveloped and remain
stable.
bullous
Without
known
external
The
a.
suddenly and so raperuptions.
noxa,
idly
any
that usuallyonly the completed process comes
under
observation,bullae appear
on
from
that of a lentil
the skin ; mostly but one, rarelyseveral at once
; their size ranges
to that of the palm of the hand
are
clear,bright yellow ; they persista
; their contents
few hours or days, break, and
form
less superficial
excoriation,which heals
a
more
or
with a correspondinglydeep cicatrization and
pigmentation (formationof sometimes
of these
dark, sometimes
non-pigmented maculae). Owing to the great resemblance
eruptionsto pemphigus vulgaris,they have been termed pemphigus leprosus.
This pemphigus I interpretas a tropho-neurosis,
dependent on the irritative effects
exerted
the (trophic)nerve-fibres by the commencing interstitial neuritis through the
on
first stagesof the
find these bullae frequentlyin the
we
developingneoplasm. Hence
the
them
find
later
much
for
this
on
we
hyperaesthetic,
reason
more
disease,
rarely;
of
the
entire
with
connected
symptoms of acute
complex
(co-ordinated)
painfulregions,
bleb
will often exhibit
neuritis.
For the same
a
place formerly covered by a
reason,
acts
nerve-trunk
anaesthesia soon, namely, when
the compression in the
simultaneously
As the anaesthesia is brought about by atrophy of
the trophicand the sensory fibres.
on
no

the

same

affection.

nervous

We

"

"

"

"

nerve-fibre,and

the

usuallyprecede

the

The

bullous

eruptionby

former.

The

pictureof ordinarypemphigus
supervening from without, in

processes
thicker

crusts, and

denser

an

bullae

irritant effect,it is clear

appear

in isolated

consequence
cicatrization.

on

the anaesthetic

cases

can

of which

that the latter must

skin much

be altered

there may

quently.
less fre-

by inflammatory
ations,
be deeper ulcer-

LEPEOSy,

813.

LEPKA.

of
these processes are erected into a specialform
Pigment Changes. Sometimes
several
they are separated and distributed among
leprosy(lepramaculosa),sometimes
chapters. Moreover, these alterations produce quite difEerent appearances in the white
J.

"

the colored

and

races.

In the main

encounter:

we

reddish
to somewhat
pigment. Yellowish-brown
above
the surface; either smooth
spotsappear; they are either quite flat or rise slightly
with branny, very insignificant
or
desquamation; either sharplydemarcated
diffusely
or
have
variable
The
into
the
size,
no
a
spots
partly
larger
surroundings.
merged
very
extensive
also
toward
the
than small coins, partly occupying more
spreading
regions;
The
its
centre
the
color
and
when
margin is
change
may
periphery,
grow pale again.
red
the
color.
then often raised to a low wall and of fresher
pigmentations perUsually
sist
able;
The
for years unchanged.
degree of pigmentation in a concrete case is very varithe light-brownmay
give way to an ashy-gray blackish tint.
of white, quiteunpigmented spots,developing either from
merly
for/5. The formation
the
normal
be
from
skin.
The
to
latter
of
or
seems
rarer
abnormally pigmented
The
occurrence.
process corresponds altogetherwith ordinary leucopathy. In regard
it should be noted by the way
that they are
to be differentiated
to these pigmentations,
above as the initial stage of the tubercular eruption.
from the spotsmentioned
I here place both forms side by side.
Following J. Hillis' description,
The

a.

Lepra
spots do

The
are

oval

in

elevated

and

at

the

at

are

and

the
to

situated

long

as

also

other

mar-

local

as

loss

of

not

They

atrophic processes,
pigment

in the

hair

They arise with-

usually situated

are

do

eruptions.

their confines.

They

of the

wall-like

disease, and

the

as

of

the

to

within

out fever.

vpith

small, gradually enlarging,

coalescing into large surfaces.

interpreted

be

lighter in color;

on

the

spots fade

The

pressure.

numerous;

precursors

lead

They
usually symmetrical in

first,later

tuberculosa.

Lepra

under

outset

sometimes

They persist
form

and

more

"

nervorum.

fade

not

shape

arrangement;
not

of abnormal

occurrence

round,

they project

the

margins.

exanthem.

erythema

is

The

affected

other

appearance

spots without
is

on

the

to

anterior

with
surface

gins;
beinto

peri-

fall from

alterations.

associated

regularly

they predominate

hairs

nonor

changes

tendency

no

pheral enlargement.

color;

with

disappear

may

local

There

red

level of the skin

They

smaller; the

come
an

above

decided

of

usually

are

pressure,

symmetrical,

not

elevated

under

the
Their

fever;
of

the

body,

sum
dor-

body.

It is necessary

to state

that most
quiteexplicitly
etc.
and
enumerated
morphgea (alba,lardacea,
)

of the cutaneous

alterations

nated
desiging
leprahave nothin common
with this disease.
This is true also of some
circumscribed
atrophiesof
the skin, which Kaposi, for instance,includes under leprosy.
ever,
(as symptoms of lepranervorum), howy. To be interpretedas atrophicconditions
are
certainlythe degenerationof the sweat-glandson the affected regions with
cessation of secretion; also the shrinking and thinningof the skin on the hands, forearms,
etc., occurringin the terminal stages; finally
the exfoliation and breaking-down of
as

as

symptoms

of

the nails.
B.
muscles

Trophic
must

Disturbances

be termed

steadilyadvancing and
motor
we

power

decreases

ascertain that there

These
in
of the Muscles.
processes running their course
in
consist
conspicuous symptoms.
a
Clinically
they
The
finally
complete loss of capacityfor action of the muscles.
with the atrophy of the muscular
tissue. Through the microscope
is here not only a simple atrophy of the contractile substance.
the

"

most

314:

LEPEA.

LEPKOST,

"but at the

time

of the interstitial connective

tissue.
The transverse
proliferations
etriation becoming less distinct,and particularly
more
delicate,we demonstrate
swelling
and increase of the nuclei of the muscle
of from
small accumulations
six to
corpuscles,
The
interstitial connective-tissue processes
eight nuclei taking the place of a singleone.
Taeginwith the aggregationof cellular elements; subsequentlywe find only more
copious
the ever
interstitial deposian
tion
wavy connective tissue between
sparser muscles, and finally
of numerous
fat-cells. According to my examinations, a fattymetamorphosis of the
muscular
The

same

substance

se

per

does

not

occur.

atrophiesin questionaffect

thenar, then

the

thenar

eminence,

cruris,the muscles

in the first placethe muscular

the

of the calf and

of the

structure

the

interossei,furthermore

deltoid

and

hyporiceps
quad-

expressiondisappears; the folds

trabeculae.
are
isolated,non-atrophiedmuscular
by
be
the
The eyes can
of
account
hand
no
closed, on the one
on
longer
pendulousness of
the
The
the other because
lower lid,on
of the disappearance of the muscles.
globe
The
itself suffers under these alterations;
tears flow, ulcerations of the cornea
occur.
lips
become
flabby,the lower one drops away from the gums and allows the saliva to escape.
The hands, incapableof any activity,
clawed
are
by the greaterpower of the flexors.
The gaitis slow, dragging; the thighs can
be lifted but slightly
forward; and the toes
always scrape along the floor.
Finallyall motion of the extremities becomes impossible,and therewith commences
an
exceedinglydeplorablecondition for the patientswhich is protractedfor years.
of motor
the essential feature is not the paralysis
nerveTherefore, in lepranervorum
ances
Nor have we to record any disturbfibres,but the atrophy of the contractile substance.
of co-ordination, although the anaesthesia of the skin, going hand
in hand with the
motor
and then simulates morbid
weakness, now
picturesresembling tabes. (Thus most
of the patientscannot
)
manipulate with the hand exceptby the aid of the sense of sight.
There is no vertigowhen
the eyes are closed.
C. Finallywe have to treat of the complex of symptoms described as lepramutilans.
In later stagesof the local processes,
and atrophy have been
after anaesthesia,analgesia,
the
there
the extensor
surfaces of
occur
on
long established,
jointsshallow, slightlysuppurating,
indolent
ulcerations.
extends
into the depth, implicates
The
disintegration
the ends of the bones at the joints,and finally
attacks the jointitself,and without
any
the joint phaof reaction the part situated periphallyfrom
particularmanifestations
are
entire hand
is cast off.
a whole
an
Indeed, in this way
finger,even
duced
proanges,
the
ulceration
the most
Or
else
remarkable
hand.
o
f
the
deformities, especially
of the

face

distorted

face.

the contraction

Mimetic

of

"

"

establishes

itself

eads to greater

or

complicationsby
In

the

conclusion

the

on

less

the
I

sole of the

mutilation

foot, and

now

repeat that
more

to

me

it appears

to do than

that

then

and

etc., startingfrom
pyaemia,erysipelas,

complete anaesthesia has

to be

of the

penetratingdestruction

extensive

foot, causes

gives

rise

to

which
serious

it.

in the

productionof

although the
trophoneurosis,

mutilation

latter is not

altogetherexcluded.
closingthe descriptionof the symptomatology, we shall againpoint out that
there is no regularsuccession of the several symptoms and symptom-groups, or at most it
be fixed only within the very widest limits.
Alf first there is a predominance of the
ean
bullous
tations);
pigmeneruptions,abnormal
symptoms of irritation (painfulness,
hyperaesthesia,
the
while
unaffected
later they are
found
isolated
regions;
on
formerly
only
the
of
first attacked
loss
of
to
atrophy
zones
are
pigment,
subjects anaesthesia,analgesia,
to mutilatingulcerations.
sweat-glands,of the adiposetissue,of the muscles, and finally
In thus

In addition

to this

\vc

315

LEPEA.

LErROSY,

the fact that the process taking placein the nerve, the chronic

have

attacks the primitive bundle

irregularly, and this explains how in the
perineuritis,
same
nerve
region some
parts are insensible,others sensible,and how of nearlyadjoining
muscles
one
atrophiesand the other is preserved." (Virchow.)
not directly
of phenomena may
be associated other
With
this group
nected
consymptoms
The
become
sexual function
with the leprosy. The
impaired.
bodily
may
heart's action
The
temperature falls,the patientshave a permanent chillysensation.
languishes.
in generalis slower than that of the tubercular
The
of lepra an^sthetica
COURSE
variety,and it leads to death from exhaustion and marasmus.
better than
The PROGNOSIS,
therefore,as regards the duration of life,is somewhat
in the tubercular form ; but the fate of the patientsis far more
deplorable.
"

Anatomy.

Pathological
to the

anatomical

As

"

alterations

is well known,

in the

Virchow

We

nerves.

the

was

fullycoincide

first to

with

tion
call atten-

Virchow's

view

nerves, in which
placethe primary pathologicalprocess in the peripheraland cutaneous
leads
to comp.ressionand
atrophy of the sensory and trophic
leprousnew-formation
of this atrophy has recentlybeen furnished
fibres. The patho-anatomicaldemonstration
existence of a parenchymatous neuritis
who
out
the
Leloir,
points
especiallyby
interstitial
the
side
of
the
neuritis, leading to total atrophy of the nerve-fibres.
by
the
on
According to him, this degenerationof the nerve-fibres depends not always directly
interstitial process, but may
also occur
primarily.
While
admit
the existence of these peripheralprocesses, there is still
all authors
some
they are to be interpretedas the primary ones, or whether
uncertaintywhether
and
a

there is not

rather

from
central affection,springing

various

authors

the brain

positivepost-mortem

and

cord.

In fact,there

demonstrations

of

changes in
nations,
are
a
Opposed
purely negativeexamispinalcord.
tlie
that I am
more
so
inclined,owing to
constancy of the peripheralchanges
not specifically
and the inconstancy(and in positive
cases
tral
leprouscharacter)of the cenform of leprosyas a disease of the peripheral
nerves.
lesions,to regard the nervous
Most frequentlyaffected are the ulnar,median, radial,musculo-cutaneous, intercostohumeral, and peroneal nerves.
On the bones we find mainly necroses
togetherwith carious processes and interstitial
absorption.
are

on

record

by

the

some

to these

Between
of mixed

observations

the two, the cutaneous

Indeed, it may

forms.

and

the

forms

nervous

be asserted

even

number

that

of

leprosy,is a whole series

hardly any pure case of
possibleto separate the cases
of

there is

cutaneous
or
purely nervous
leprosy,although it is
strictly
the
most
As
to
mixed
forms, then, we
prominent
symptoms.
according
clinically
Observation
teaches
shall have to record the cases
lying about midway between the two.
its
for
also
in
tubercular
the
that a case
instance,
position;
change
being
beginning
may
mixed
of the affection, and later becoming
by complicationwith nervous
symptoms.
f sequent one; namely, the mixed
forms are usuallyat
This varietyis also the more
anaesthetic
with subsequent disease of the nerves, more
first tubercular
rarelythe
*'

'*

"

*'

'^

forms

become

''

tubercular"

afterwards.

Leprosy prevailed already among

Hippocrates

was

acquainted

with

the Jews
the

and

the

Egyptians, as appears from

descriptions.

disease, but only from

Exodus.

'*

316

LEPKA.

LEPKOSY,

In Greece
In

it became

Thenceforth

century of

the

our

last two

centuries

before

Christ.

era.

the greater part of Europe.

was
rapid over
in the eighth century
leper houses in the seventh, in Germany
757, edicts against marriage were
published.
In

France,

The

spread

find

we

disease

crusades.

reached

It is said

Founding

of the

In the
the

the

frequent in

more

Italy, in the second

its

that

order

account

on

of

the

19,000 throughout Europe.

for the care

of the leprous.
centur}',leprosy in Europe disappeared

sixteenth

and

more

while

more,

at

time

syphilis spread epidemically.

then the geographical spread can
be almost

same

Since

countries

from

affected

with

The

new-formation

extensive

nodes

form, which

macular

Opposed

the

to

thetica,in which
tissue

or

in

skin^nd

more

tubercular

form

demonstrated

resembling that

in the

in the substance

indicated

found

the

most

introduction

frequentlyand

of the disease

(both

in the

in its most

in the

membranes,

mucous

infiltrations

diffuse

latter is considered

Virchow

new-formations
and

the external

on

to the

PATHOLOGY.

characterizingleprosyis

development

circumscribed

positivelytraced

leprosy.

GENEEAL

with

century

early as

as

of St. Lazarus

of the

course

greatest spread at the end of the eleventh

were
and
2,000 leproseriesin France

there

tubercular

of

shape

and

in the

stagepreliminaryto the nodes).

the
so-called
stands lepra nervorum,
lepra ansesin the interstitial nervous
the proliferation
nective
cona

external

cutaneous

of the cornea,

and

in the interstitial tissue of the

nodes.

with

We

such

as

are

also

familiar

penetrate into

spleen,liver,etc.

tilage
car-

The

lymphatic
intenselyattacked.
(But I should not refer
these alterations in the last-mentioned
processes. )
organs to interstitial proliferating
All these neoplasms show a correspondingstructure
; a cell-mass separatedby sparse
intermediate
tissue ; the cellular elements, in their recent condition exactlylike
fibrillary
lymph-corpuscles,graduallyincrease in size,the body of the cell reaching four or five
times its original
and
volume, the nucleus likewise undergoing material increase,and now
The
form
of
the
in
nuclei
in
cell.
cells
the
then several
are
ity
greatmajorpresent a single
is round ; the spindleshape of the mostly largeprotoplasmicbodies is found
of cases
is traversed
blood-vessels,and in the
more
by abundant
sparsely. The neoplasm, wjiich
is most
dense, is distinguishedby great
neighborhood of which the cellular accumulation
for years, but finallydisappears almost
remain
completelyby gradual
"persistence,
may
otherwise
little altered
thickened,
absorption,leaving deep-brown, pigmented, slightly
find
the
the
Before
skin.
on
large,pale,slightly
complete degeneration,we
granular
cells forming the neoplasm in this stage a peculiarphenomenon :
a speciesof vacuoles
lacunae in the compact cell-mass.
is developed, bright,spherical
In these lepra nodes, therefore,we
have to deal with a tumor
originally
composed
the cells of which
tion
duraof ordinarygranulationcells
a
a tumor
remarkably
long
possess
mation
forof
further
of life,in a certain sense
:
enlargement,
development
present stages
grate
disinteafter a period of vacuole
of giant and spindlecells ; finally,
formation,
are

glands and

the

testicles

likewise

are

very

''

'^

"

vanish.

and

at the

But

place of

of the subcutaneous
of

bundles

of

masses

which

of
we

the former

tumor,

connective

tissue remain

connective

tissue, is

find,in the

later

flat thickening and

very

behind.

This

pronounced

stages of the process,

elevation

of the skin

thickening,i. e.,
on

the

numerous

nerves,

the

between

thick

or

sition
depothe

trabeculae

The
of the nerves
the normal
at these points exceeds
tissue.
circumference
fibrillary
the
of
the
nerve-fibres,
however, is remarkswelling), quantity
considerably(spindle-shaped

of

To

face p. 316.

318

LEPBA.

LEPROSY,

found.

These

either

products of degeneration and tlien tlie granulesare irregularly

and
else the granulavariable in size
or
protoplasm of the cell,coarse
latter consists norlation is the sign of a progressiveact, the formation
of spores.
The
of oval, non-tingibleformations, two or three in number, which
ihallyin the occurrence
mal
abnorbreak the continuityof the rod like lacunse.
or
(Under, as I believe,unfavorable
these
conditions of growth, it seems
that also spherical
of
swellings
spores develop at
the ends and in the course
of the bacilli.) Characteristic,moreover,
is the presence
of a
in
comparativelybroad mucous
envelope,easilyrendered visible
dry preparationsstained
with watery anilin solution (fuchsin,gentiana violet, etc.). (Oomp. Virchow's
Arch.,
p. 526, 627.)
I have
Another
of growth, which
observed both in cultures
mode
(on blood-serum
nodes
into
the
introduced
abdominal
is
a
nd
with
the
cavity,
lepra
lengthening of
gelatin)
the bacilli into threads, which
about four times
the size of an
The
are
ordinary rod.
are

"

in the

scattered

"

formation

Cornil
of spores in these threads did not differ from
that in the short rods.
claims to have observed
structure
such threads also in organs, the anatomical
of which,
showing cavities and fissures,permitted this growth. (Comics results should not be

interpretedas threads, but merely as closelyaggregated singlebacilli.)

II. The bacillus is constantlypresent in all forms
and
varieties of leprosy in

all

countries.

Apart

from

in

investigationsof

the

lepra,there

Armauer

Hansen,

the

real discoverer

of

organism
micro-

descriptionsof the bacillus

record

are
on
lepraeby myself (material
Norway, Spain, Brazil,Koumania, Palestine,Hindostan, Dutch
Guyana, BataIlillis (British Guyana),
via); A. Hansen
(Norway), Cornil (Spain), Hillairet,John
Atkinson
B. Hernando
(North America), Majocchi and Pel(Spain),Kobner
(Brazil),

from

lizari.
examined

Hansen
Almost

"

'

yellow

the

exclusively round

and

middle

twice

is about
of the

pressure

in this lake

of

in the
Hartnack's

that

in

the

serum

immersion

formed

corpuscles
:

way
No.

9 to

at both

move

ends, in which

Similar

bodies.

other

in the

that

of

manner

di'op of distilled water

see

latter

corpuscles

lakes, surrounded

small

He

nodes.

found:

fat-granules, many
finely granular (called by him.
small
contain
are
rod-shaped bodies which
partly

with

'). Others

part taper

of the

covering glass has

following

cutaneous
freshly-excised

cells,a few
elements

yellowish-brown

by parallel lines, but

limited

juicefrom

it contains

no

by dense

bacteria.

placed

is

formed

case

also

are

on

Other
the

their thickness
found

where

accumulations

of

preparations

slide and

elements, then

in the

free

the

are

examined

the

cells;
duced
pro-

with

cut surface

of -the

In such preparathe scrapings spread in the drop.

tions
here move
also far more
rapidly.
corpuscles appear, which
cells the rodin these swollen
The greater pai't of the cells swells considerably in the water, and
if garnished with them, at first sight it
as
shaped bodies are far more
easily observed; some
appear

nodes

is

looks

scraped

much

as

if the

cells

apparent granules

But

the

with

were

accuracy

the

proof which

III. In every
of the

small

filled with

coarse

granules, but

of these observations
still lacking Avas

was

singlecase

skin, the

on

accurate

focussing

it is

seen

that

these

"

oblong rod-shaped particles.

of

mucous

we

shall

furnished

leprosy,the
membranes,

acknowledge to-day without

by me in September, 1879.

bacillus is found
the cornea,

in all

more

recent

reserve.

mations
new-for-

in the interstitial
in the cartilage,

tissue;also in the connective tissue of the spleen and liver;

and epididymis.
lymphatic glands,the testicles,
in
found
are
corresponding to the degree of the
they
quantities
organs

connective

nervous

In

before, and

as

of the

small

are

The

in
finally,

knife

larger number

the

these

affection.
With

the onset

of

symptoms

of

absorption of

the

neoplasm,

the bacilli also exhibit

319

LEPEA.

LEPEOSY,

into irregulargranules;finally,
total
correspondingsignsof degeneration;disintegration

A.

skin

bacilli of the

The

has vanished.

the new-formation

disappearance,when

present both

are

and

in the nodules

in the

diffuse

more

infiltrations.

exclusivelywithin the large round lepra cells described by

Virchow, which, separatedonly by a fine connective-tissue framework, are closelypacked.
of a pus-corpusclefive times, contain one
or
eral
sevThese cells,often exceeding the volume
cells,
(threeto twelve)largebright nuclei, greatlyresembling those of the epithelial
and very frequentlyappear crowded
unsymmetrically toward one wall of the cells.
fusely
either fill the entire protoplasm of the cells difbacilli and their descendants
The
bacilli lie almost

The

frequently,there are several small circumscribed

seven
apposed rods, l^ow and then two or
longitudinally
of a long,though not
another, presenting the appearance
or,

two

after

all directions

else,the bacilli pushing in

its

composition of foreign organisms

in those cells

rods and

over

be

can

three lie

lengthwise one
Or
straight filament.
that
each other, form such a compact pile
pecially
recognized only on close inspection. Essmooth

encounter, beside the slender

we

of from

accumulations

more

to

shorter

bacilli,numerous

finelygranular particles.

Fig.

from

Section

24."

lepra

node.

Power=Zeiss'

oil immersion

1/13, with

eye-piece

No.

4.

and adiposetisconnective
sues,
deepest cellular layer,i. e., that in the subcutaneous
the
most
recent
and smallest
unchanged lymph-cells,
contains, togetherwith many
few bacilli in the protoplasm. Gradually ascending,the cells
cells with relatively

The

tumor

enlarge.
The
from

oldest

layerstouch

stratum

of

the infiltration of the corium, the

deprived of

its

descending

rete

cones,

subepidermal conne6tive
epithelial
layer running
otherwise

but

normal

and

tissue which
in

separates
straightline "9,nd
merely stronglypigmented.
a

uppermost layer are peculiar large,round, sharply-limited

present a strong waxy lustre,but in anilin colors take
anilin preparations teach
The
stain.
that these globi
almost
deep
an
homogeneous
infiltrated
with
bacilli
their
and
cells
densely
(and
products),
very
represent merely
to
the
fiakes''
These
to degenerate.
''yellow
globi correspond
described, many
caused
of the skin, the spleen,and the testicles.
in older leprousnodes
years ago, by Hansen
see
we
traversingthe infiltration in longitudinalstreaks
Besides the largelepra-cells,
Most

in this

numerous

accumulations

which

small

connective-tissue

form

rather

untinted

cells which

largerspindles than

cells;the

latter

in the connective-tissue

and

there

are

usual, and

small

cells

here

free from

bacilli.

trabeculas

is very

The

presence
limited.

infiltrated with

bacilli

and

differingin nothing

from

of free bacilli between

the

then

gratory
micells

320

I could

However,
But

LEPRA.

LEPEOST,

demonstrate

never

entire

the

bacilli with

infiltration

of

is

certainty in
governed by the

the

blood-vessels.

the
framework
of the
arrangement
of the vessels and the cell mass
closing
in:ascendingblood and lymph vessels. This connection
is especially
them
cylindrically
clearlydisplayedby transverse oblique sections,
while the smaller
remain
vessels, extending in the centre of the infiltration,
without
any
In
the
influence
distribution.
subcutaneous
the
on
special
adipose tissue,the lobular
arrangement prevails.
B. These descriptions
the conditions
in
referringto the skin so completely cover
the mucous
affections of the mouth, palate,and larynx that their delineation
would
be
nothing but a repetition.
of the mucosa
of the larynx also taught that both the epiglottideal
0. Examination
of bacteria.
invasion
suffered
and
the thyroid cartilagehad
an
the
Starting from
connective
the
of
cells
which
tissue,
slightly-enlarged,
spindle-shaped
perichondrial
tained
concells always infiltrated with bacilli could
numerous
bacilli,chains of round
be
the cartilage-cells.
in the reticular cartilage
between
followed
Free rods were
also seen
in the tissue of the reticular cartilage. At the thyroid cartilage,
the perichondrium of
likewise contained
which
bacilli,only free bacilli immigrated into the substance of the
visible in the inner space of the capsule of the cartilageby the
cartilageand finallywere
of small globi had been
Even
here the formation
effected.
side of the nuclei.
In these
the
tissue of
connective
preparationsthe intermuscular
larynx also contained bacilli and
globi.
in the cartilage
most
D. The appearances
which
closelyresemble those of the cornea
cells directed from
of
the
made
an
was
toward
the
immigration
lymph
by
margin
opaque
"

All these

centre.

cells contained

E.

The

presence
in five

demonstrate
and

in the

were

subjects.

Once

tissue.

filled with

yellow,glossy,flakyappearance,
colors they took a uniform
tint
but

dense

F.

accumulations

Cells

they

also in

were

and

were

interstitial

the

isolated,

epididymis.

In unstained

it could

of

sections

singleamber

beads

likewise

found

in the interacinous

describes

them

also

to

testicle
in

While

the

of the canals
a

; stained

recognized that these flakes

products of degeneration.

hepatitis. Oornil

the

they had

be

their

able

was

of

still clearlyvisible,the lumina

were

compact mass.
if composed
as

of bacilli and

containingbacilli

of the liver in recent

however, also found

in the testicle
very large numbers
I found
the fungi within
the
canaliculi

canaliculi the several bacilli

of the testicle

were,

cornea."

of bacilli in

intertubular

cells of the

which

rods

minute

the lamellae of the

penetratingbetween

beautiful
in anilin

nothing

were

connective
within

tissue

the

liver

cells proper.

G.

I have

spleen and found isolated foci

in the shape
follicles,
joined to large cells.
heaps situated near
Of the kidney I have examined
but a singlespecimen. It showed
intense
degeneration with interstitial nephritis. No bacilli or specificalterations
examined

two

specimens of

of small

detected.
H.

Kobner
All the

likewise

the

of

bacilli

the

could

demonstrate

no

bacilli in the

amyloid
could

be

urine.

showed
lymphatic glands examined
very extensive infiltrations of bacilli
in
which
blood
mulated
accuperipheralzones,
macroscopicallyvisible,was
pigment, even
in quantities. The interf ollicular tracts especially
contained
largemultinuclear,
polygonal cells with bacilli.
1. In a small portion of lung were
found
the fine
cheesy necrotic patches without
but many
bacilli;
long chains of bacteria immigrated, I believe,post mortem.
K. Of specialimportance, however, is the findingof bacilli in the peripheralnerves;
in the

for

trace

therebywe
the

dualityof
examined

by

observation

with

tubercular

me

my

to
certainty

and

endeavors

old terminal

forms

the

single pathogeneticnoxa

anassthetic

In

symptoms.

to fill this gap

of

321

LEPKA.

LEPROSY,

And

disease.

of the

most

nerves
formerly
always had under
finally
perishwe need not

futile,because

were

clinical

former

that the bacilli

Just as, in my first comafter the experiencegained on the skin.

munication,
emphasize specially,
I had seen
which
I had interpreted
the "yellow masses"
in Christiania with
I was
in the fortunate
Prof. H. Heiberg, as agglomerationsof bacilli,
so
now
position,
on
by the death of a leprouspatientfrom an intercurrent acute disease,to demonstrate
the identityof the interstitial process of the peripheralnerves
recentlyaffected nerves
in the skin, and show the presence
of bacilli in the large
with the leprousnew-formation
cells between
the nerve
fibres and bundles.
raises
the
objectionthat these results
(Hansen
alterations in the tubercular
But it rests with
would be valid only for the nerve
form.
him to prove the difference he supposes
to exist. )
I hold that the theory advanced
In the same
by Leloir and Hoggan, that lepra
way
is a primary disease of the nerve-fibres and not an
interstitial inflammation
nervorum
with subsequentsecondarypressure atrophy of the nerves,
lacks adequatesupport because
had been long diseased.
which
The fact which
those authors examined
tradicts
cononly nerves

view, that accumulations

my

devoid

of force, because

these

bacilli

of

conditions

stated

are

to be absent

in

such

nerves,

is

be studied

only on recentlyaffected nerves.

to date teach, in the
investigations
spinalcord, in the muscles, and take no part in the production of the bullous (pemphigus)
eruptionsand in the affections of the bones and joints. Nor do we hold these
to be primary, direct leprous affections,
but derive them
from
the primary
processes
lesion
nerve
as
secondarysymptoms.
The bacilli are absent, besides,in all epithelial
tissues of the skin (reteMalpighii,
chanical
hairs,glands). Loss of hair and glandular atrophy are brought about in a purely methe
exercised
the
But
the
even
compression
by
by
leprous
neoplasm.
way
contains
of
the
rete
b
etween
the
new-formation
never
Malpighii
coveringlayer
bacilli;
developingin the corium and in the connective tissue of the papillarybody on the one
epidermal
hand, and the epidermal investiture on the other, there always remains the free suband as the epithelial
coveringis inaccessible from within to any invasion
zone;
L.

bacilli

The

of the bacilli,
so
IV.

are

can

absent, however,

it is from

as

far

as

without.

It is possible
to demonstrate

"

experimentallythat with
development of a migratory cell
the result of which we
term
briefly
well

as
microscopically

the presence
of the bacillus leprae
the typicalcourse
into a connective-tissue
cell suffers that alteration

as

of

"

lepracell since the time of Virchow.

this point is divisible into
Strictly,
? Virchow

had

considered

two

subquestions:

the fixed connective-tissue

1. Whence

cells

as

do the cells

the mother

nate
origi-

cells of the

As opposed to this view Avhich can

neither be proved
subsequentgranulationtumor.
maintain
that the granulationcells are emigrated white
we
disprovedwith certainty,
blood and lymph corpuscles.
2. How
does a white blood-corpuscle
develop into a lepracell ?
In replyto this question,
the results of my
I recapitulate
from
investigations
my
treatise above mentioned
( Virchow's Archiv, Bd. 84, pp. 534 and 535) as follows :
A. Examination
of the wound
granulationsspringingup on the loss of substance
caused
tubercle.
by the excision of a broad cutaneous
nor

In
The

vertical

section

the

latter is also free from

21

lower

layer appears

blood-vessels, while

very

they

rich
are

in cells in

quite

numerous

comparison
at

the

with
base

the
and

upper.
of

great

322

LEPRA.

LEPROSY,

bears

which

volume

filamentous

blood-corpuscle, with
in

of

neighborhood

the

thickness

of the -wall.

nucleus
large dark-colored
nuclei instead. At the same

which

cells

deposited in

are

generally

are

nearly fills the cell.

time

there

blood-vessels, of very

the

The

fibrin,and

are

size

Now

and

of

white

then

there

epithelioidcells,especially

numerous

variable

uncolored'.

an

the

form, and

some

spindle-

young

cells.

connective-tissue

shaped

to the

looking like coagulated

small

also several

are

relation

no

substance

basis

strikingcontrast to these small

voluminous, bright,vesicular nucleus,
(with and without sphericalspores).

cells

In

Fig.

35."

which

Section

others

are

five

contain

wound

from

six times

or

larger,with

of beautiful

masses

very

bacilli

smooth

granulations.

Also
At times it seems
if these cells lie singly or together in lacunsB of the basis substance.
as
the exceedingly
Besides
giant-cellswith three or four nuclei, with or without
bacilli,are not rare.
not bacilli viewed
well-preserved rods, we
find smaller
are
corpuscles tapering conically which
obliquely or vertically. I might add that these granulations proliferatewith uncommon
rapidity
on

leprous excision

the

wounds.

The

formation

of

crusting of

the

epidermis is long delayed through

drying granulations.
B.

Still

tubercle

conclusive

more

is under

to

appear

experiments

the

me

antiseptic precautions inserted

into

the

animals.

on

freshly extirpated

peritoneal cavity of

rabbit

(G. operated

in a coninclosed
the tubercle
nective-tissue
autopsy shows
of the
mass
: The
to the great omentum.
Microscopic examination
capsule adherent
is stained.
original tubercle has perished by necrosis ; not a single nucleus
Only the arrangement
tuting
cells formerly constiof the clearly stained
hives of bacilli still represents a picture of the tubercle
on

November

6th, killed

the
bacilli
from

basis.

are

contains

"

cells with

connective-tissue
Also

of

the

nuclei.

The

fact

in
is

That

newly

stained
V.

large bright nucleus,

formed

Everywhere
development

noteworthy
white

demonstrated

nodes).

zone

so

densely packed with

of connective

granular detritus

tissue

"

in which

we

that
trace

to the

cells in which

retardation

adjoining layer

in form

between

intermediate

and
epithelioid

completed

cells.

in the

bacilliferous

the

the

formation
ceUs

But

and
nective-tissue
inflammatory conperiphery layers of all stages of inflammation
connective-tissue
development of ordinary narrow
bright caudate
oval and elongated
considerable
number
of strikingly large, round, longitudinally

toward

centre

bacilliferous

11th). The

Externally to this is first

longer recognizable.

no

the

November

on

that

connective
fine-fibrillary

the

rods

the
as

lie either

bacilliferous

cells

with

their

compared

the

in small

bacilli

tissue

of

the

surrounding

agglomerations or

on

represented specially smooth

and

intact

rods.

be
bacilli may
(afterulceration of such

harbor

dry preparation of leprousnodular pus

are
way differingfrom ordinarypus-corpuscles

every
no

find
capsule we
singly by the side

by their size and by a

distinguish themselves
layer.
neighbor cells of the like age in the same

(inflammatory)blood-corpusclesgenerallycan

Cells in

scattered

full

of

beautifully

bacilli.
It may

lepra cell there

be

is

demonstrated
a

that

correspondingto

correspondingstate of the bacilli.

every

developmental phase of

the

323

LEPRA.

LEPROSX,

the number
and
densityof the
larger the cell,the greater become
their derivatives
iDacilli and
deposited in the protoplasm. Finallythere arise large
round, sharply limited agglomerationswhich untinted present a strong waxy lustre,but
These
in anilin colors take an almost homogeneous deep stain.
agglomerations(globi)
in
infiltration
the
the
of
the
bacillar
time^
acme
protoplasm. At the same
represent
demonstrate
to
of
chemical
it
is
a change
however,
protoplasm by
staining(by
possible
tion
decolorain gentiana violet instead of the normally obtainable
red coloration
a distinct
the vacuole
between
of the body of the cell). Finally there is a direct connection
posited
and the condition
of the bacilli,
formation
namely, the dropping out of the bacilli dein clusters in the protoplasm.
If we
as
draw the conclusions from the facts thus far enumerated, we
are
justified,
I
far as
can
see, in assuming :
The specific
form and nature of the lepracell is incited etiologically
by the immigrated
to the further conclusion
This leads in natural sequence
The
entire
bacillus.
:
specific
The

and

older

affection is
And

bacterial disease.

indeed, in

scientific

proof

doubt

opinion,no

our

is still

lacking

for

exist about

can

has

leprosy,as

this

been

if the

point,even

furnished

strictly
by

for tuberculosis

cultivations.

KocVs

That

these cultivations

to find

convinced

myself by

of successful

number

instances

of

(non-experimental)
spontaneous leprous affection

in

I succeeded

in

the introduction

producing
dogs, by
into the subcutaneous
connective
tissue,local neoplasms identical
particles
and
by the presence of bacilli in the
lepra tubercles both histologically
General

disease did not

VI.

Leprosy

the arguments
the

over

these local processes.

contagious infectious disease.

single

in animals.

of small

leprous

with

human
cells.

tumor

follow

far

advanced, by

the

This

in which

manner

is demonstrated, aside
this

from

plague formerly spread

earth.

In the

first

placeit is

dilate upon

shall not

the

the

data

accurate

of Trinidad

island

certain that

leprahas

been introduced

into islands and

countries

this disease.

from

islands of which

On

is

thus

formerly free
We

cult
diffi-

on

positive observation
In two

possibleI have

are

boiled egg albumen

and on blood-serum
gelatin. It will be more
speciesof animal appropriatefor inoculation,nor is there on record

trial cultures

there

in

were

1878,

confine

ourselves

to two

record.

on

1805, among
1813,

importations,and

remote

more

are

29,940 inhabitants,

"

32,000

"

"

120,000

"

patients

73
860

instructive
The
most
example, however, is presented by the Sandwich
On
these
Islands.
islands, distinguishedby the healthf ulness of their climate, the excellent fertility
of the soil,the fine
and vigorous physical development
of the natives, the disease
had
occurred
until 1859 only in isolated
carried

cases

1859,

German

themselves,
Since
was

then

two

on

to

immigrated

disease

the

forced

thither by landing sailors ; among

physician. Dr. Hillebrand, observed

resort

has
to

(Molokai).

statistics

Board

the

aborigines,are

affected

of

In
Health

with

who

and
isolation,

1881, the
estimate

leprosy.

number
that

the
under

came

rapidly to such
of

measures

adjoining island
of

Chinese

increased

the

an

natives

about

that
four

altogether unknown.
of leprosy on the

was
cases

treatment

extent

forwarded
of

it

first two

at
as

the

hundred

patients in Molokai

Hospital

early as
is

4,500 natives, that

1866

the

in

Honolulu.

government

patients to
eight hundred
is,one-tenth

In
islands

smaller

; the

of

all

last

the

324

The
we

native

learn

with

in the

these

spread of

climate

to about

population amounts

also that

familiar
the

LEPKA.

LEPEOSY,

islands

that

disease

while

the

publicationsof

2,000 lepers have

morals

and

character

died
of

to

this Board

of Health

Molokai.

All

at

the

natives

their

absolutely inadequate

appear

the

From

45,000,
about

years

agreed

are

infectious

an

must

last fifteen

physical development, and

explain the etiology. Stress

the

excellence

is laid

those

speciallyfavor
the

oa

of

the

dwelling

of

of the same
vessels
use
large families in small huts, the common
and
utensils,eating from
single dish, tlie fingers being employed for taking out the eatables, drinking from one
and
the same

vessel, smoking
whence

patients

authorities

however,

the

same

are

not

hold

Still not

very

the

disease

only natives

loose

isolated,but,

not

also cohabitation

; hence
even

pipe, the
only

to

morals, the
the

on

and
be

suffer

between

marriage
contagious.

the

absence

contrary,

of

the well

and

dread

any

secreted

much

as

the

the
disease,
possible by the

of
as

The

sick, etc.

natives,

often

disease,but

enough immigrated Europeans,

intimate
intercourse
longer,more
with other lepers. That such an infection does not take place in every instance can
be
in lepraas little as in similar cases
enumerated
as
a counter-argument
of syphilis.
of leprosy,in countries
Genuine
free from
the disease,however, do not exist.
cases
best
date
at
the only pathognomonic
Such,
altogetherfrom a time when
sparse, reports
of true leprosyoccurof the bacillus
All cases
not known.
was
ring
sign the demonstration
in Germany, England, France, etc., can
without
tion
exceptionbe traced either to infecfrom lepersor, more
commonly, to residence in tropicalleprouscountries.
of leprosy,so its spread and disappearancecan
Like the appearance
be traced only
not
to miasmatic
conditions.
For we
formulate
the law : The
to contagiousness,
may
in
inverse
relation to the measures
of isolation to which
the paspread of leprosystands
tients
are
subjected in the several localities. By the rigorousseclusion of lepersthis
several centuries
fact
plague was exterminated
ago in Germany and France
; and the same
taken by the government.
is repeated on isolated islands by appropriatemeasures
of patients is steadilydiminishing,since the majority
In Norway, too, the number
less
isolated
in the hospitalserected.
been
of lepershave
more
or
be
stated here that the relations of the disease prevailingat the
However, it should
present time in Norway, Spain, Livonia, etc. for instance, the rarely demonstrable
to wife, etc. )
of direct infection
occurrence
(of the hospitalattendants, from husband
be utilized in the settlement
of the present questionwithout
cannot
qualification.
In these countries we
are
undoubtedly dealingwith a weaker qualityof virus a fact
of the
disease in Europe, 15 to 25 years, as comdemonstrated
pared
by the average duration
disease

the

in whom

almost

can

generallybe

traced

to

"

"

"

"

"

with

that

Thereby

on

the

Sandwich

Islands, 3

above

indicated, which

the factors

to 5 years.
are

necessary

for

the actual

effectuation

scrupulousthe cleanliness,the
in the family,and the
isolated
the
the
the
are
more
more
patients
airy
living-rooms,
be
to spread relations
the
the
able
the
affection
will
fear
of
the
less
disease,etc.,
greater
and
in
in
which
are
are
an
universallyrecogsyphilis
present
absolutelyequal manner
nized.
of the

infection,gain still greater importance.

The

more

"

It remains

equally
given, which
an

for

us

terrible
allowed

to state that the inhabitants

and
so

rapid
swift

an

manner

extension

with
of

of the

Sandwich

syphilis,and
lepra.

Islands

for the

same

were

seized in

reasons,

above

and may be direct,or indirect when

takes place from man
to man,
only
their
Pus
transmitted.
therefore,
or
containing bacilli (spores),
spores are
will be liable to infect,but not any kind of pus coming from a leprouspatient. Whether,
in analogy with anthrax, the spores possess so great a power of resistance that they retain

The

transfer

the bacilli

326

LEPRA.

LEPROSY,

which

from

we

These

the

deduce

may

forms

same

of

of this disease which

peculiarcharacter
the other

dermatitis,on

is akin

to

pelas.
erysi-

hand, always lead to local recoveries

regions disappearanceof the tubercles,leaving brown

spots containing
abundance
of amorphous blood
an
pigment but invariablygive rise to an exacerbation
of the entire course,
with renewed
leprous eruptionsin other cutaneous
regions,that is
to say : plentiful
transportationof fungi from one region into another.
blood vascular
It is likelythat the
system participatesin this transportationof
but
thus
far
this
in
suppositionremains
erysipelas,"
unproved. Majocchi and
spores
Pellizari state that the presence of schizomycetesin the blood will manifest itself best in
the eruptiveperiod of leprosy,or, to speak more
of an
with every repetition
correctly,
eruption.
3. The above-mentioned
experiments on animals (introductionof freshlyextirpated
the fact that there are local transportubercles
into the body of rabbits and dogs) prove
tations
the participation
of bacilli and spores without
of blood-vessels.
Presumably only spores are carried from one region to another, while the local progress
of the leprousinfiltration probablytakes placeby the jDeripheral
migration of bacilli
(e.g., in the cornea).
Finally,in favor of the view that the lymphatic vascular system transportsthe spores
or
bacilli,is the extraordinaryswellingof the largelybacilliferous lymphatic glands and
their greatpainfulnessduring all the
erysipelatousaffections accompanying the errupon

the affected

"

"

"

tions.
But

is the

contagion

HEREDITARY

LEPROSY

Most

authors
life.
PROOF

NOT

speak

either

of

of

by

way

of

intrauterine

infection

is

incline to the view

Others
for

leprosy transferable

of

OR

of

hereditary,
by the
inherited disposition. In

these views

; but

more

side of direct infection in extrauterine

our

opinion,there

for the former

is

no

for that

than

factory
satiswhich

bility
only grant inherited disposition. On the other hand, we must admit the possiof an hereditarydisposition.
of heredity,and especially
statistical data.
doctrine
The
of heredity is based exclusivelyon
Against this it
be objected:
must
tables do not give such high figuresin favor of the asserted
1. These
heredityas to
of strikingnumbers.
demonstrative
by reason
appear
of another
2. But these tables and their results admit
interpretation infectiousness
the patients
without
heredity. In most of the countries in which leprosy still prevails,
the healthy population. The patientsintermarry,the
live more
less isolated from
or
children grow
by their diseased parents, relatives,and neighbors.
up surrounded
the
that
disease
The
fact
occurs
3.
rarely previous to the third to fifth
very
the
second
not
before
force againstthan
decennium, has more
year of life,in most cases
should have to assume
incubation lastingfor years,
an
for heredity. In all these cases
we
the course
of the disease itself is more
in regionsin which
even
rapid than this asserted
been
of congenitalleprosyhas never
latent stage. A case
recorded, as far as I know.
to try to explain the spread of the disease by
4. I hold it to be altogethererroneous
but point to the rapid spread of the disease
need
without
infection.
We
heredityonly,
Islands
from
2 to 4,500 in twenty-two years ; this would
be absolutely
in the Sandwich
alone.
inconceivable
by heredity
But, while the proof of a direct inheritance is still completelylacking,the assumpbe more
"tion of an inherited disposition
can
easilydefended.
of leprosy,viz.,lepra tuberculosa and lepranervorum,
freforms
For the two
are

would

"

"

'

-quentlysharply demarcated
other

form

the affection

about

brings
As

to the

sex

of the

form

of

leprosy.

in every

Cases

most

Diagnosis.

An

stages.

be

in the

the

because

utilized

year

are

the

one

the

or

sion
hereditary transmis-

frequent

after which

no

beyond

case

diagnosis of

criterion

valid

during life,of

course,

are

in

decrease.

they

form.

tubercular

leprosy in

But

it
the

doubt.

symptomatology

is all the

for the tubercular

to the

owing

attacks

tubercular

lepra ansesthetica,especiallyin

pure

the

of

in all districts and

males

more

rare,

very

decennium,

third

in the
difficulty
facilitates the diagnosis of

individual

knowledge

accurate

cases

cannot

places each

of

preponderance

diagnosis presents

difficult is the

More

these

it

as

way

in the

of bacilli which

is the demonstration
same

sections

in which

particularly.

organs

find

the tenth

numerous

The

"

of these

patients,we

the first and

between

the second, and

certain

cases

are

leprosy. In
either
disposition,
which

in

Besides, the

exclusively.
in lepra nervorum
than
in tubercular
numerous
considerablymore
explanation of this fact, I think, we
a
might assume
congenital
tissues or especiallyof the nervous
of the cutaneous
connective
tissue,

occurs

be assumed

can

that

geographically,so

almost

327

LEPKA.

LEPKOSY,

form,

localization

initial

requisitefor

more

the presence
of the

the

of bacilli,

leprous

process

peripheralnerves.

that there is no genuine leprosy in countries

in leprous
of infection, by residence
possibility
intercourse
with
must
be
lepers,
always
regions or by
present.
disease.
Treatment.
Although from year to
Leprosy is an absolutelyincurable
therapeutic propositionsare made which have proved effective in isolated cases,
year new
Once

all

for

it must

free from

otherwise

be

in mind

borne

the

the disease,that

"

of them

none

All the

have
more

Isolation

1.

of the

proved available
weight will have

of the

extirpationof

the malady.
:
prophylactic measures
hospitals; quarantine regulations against
laid

on

the

duction
intro-

disease.

Prevention

2.

patientsin

for the

to be

of the

infection

of
possibility

given by

every

single patient

for

his

surroundings.
I refer in
the
second

it

the first place to the

place,the attempt will

to their softening,which
to

seems

me

as

if the

careful, disinfectinglocal

contains

secretion of which

have
can

local treatment

bacilli and
to be

made

be done,
in

to

for

of open

treatment

tions,
ulcera-

specially
largequantities. In

in

spores

the

the tubercular

eruptions previous
instance, by chrysarobin. At any rate
remove

general had

not

hitherto

received

the attention

it deserves.
I shall

in

merely

mention

lepra ansesthetica by nerve

Change of residence to

proved

effectual.

The

reported successful (?)attempt at securing improvement

by suturing the nerve.
stretching,and even
has
a
healthy climate
non-leprous country or otherwise
and
milder
of the disease thereby usually becomes
slower.

the

course

experience refers mostly to Europeans who return to their native country after
In these cases, the improvement should
have
they
acquired the disease in tropicalzones.
and
be ascribed to the fact that the patient is again surrounded
more
by the accustomed
little
under
The
whom
I
other
conditions.
have
had
climatic
and
patient
appropriate
This

observation

for two

years

(born

in Surinam

; sick

years) shows no improvement in his condition,

therapeutic experiments.

extensive

in

from

his

fifth year

of

favorable

spite

; in

Germany
surroundings

two

and

828

SYPHILIS.

III.

SYPHILIS.

Syphilishas hitherto been held to be the infectious disease most nearly related to
in
that there is no connection
it is certainlydetermined
leprosy. But now
any direction
since
also
On
the other hand,
between
a lepermay
acquiresyphilis.
leprosyand syphilis,
that tuberculosis and leprosyrepresenta group
of diseases belongingtogether
know
we
now
from them.
theless
Neverthrough their strikingresemblance, while syphilisis farther removed
another
is not to be disputed,
the near
kinship of these three affections to one
in looking upon
feel justified
the contagion of syphilisas
that we
so
an
organized,
all
becomes
bacterial
the
This reasoningfrom
more
one.
analogy
important because
of the '^bacteria
to be still lacking. But
of syphilis" seems
the positivedemonstration
I refer more
has published investigations
to which
in detail
recentlyBirch-Hirschfeld
of their remarkable

account

on

On

examining

gummous

patches

of the

granulation

could

be

tissue

where

well

the

Wherever
reference

Then

bacteria

in

demonstrated

free

are

be made

must

gummous

of the

section, but

of

the

number

short, thick

The

The

they

are

The

not

rule, are

three

demonstration

they differ from

the

cells

above-described

examined

then

and

in

swollen

the

destroyed by concentrated
the

cocci

In the above-described

(of the brain, of the

bodies, of the
the

For

they
a

were

of the

quantity

of cocci

rows

wall

the

of

sake

to demonstrate
basal

The

blood

tissues

is very

microtome)

are

of bacteria

by

and

larger.

diplococci,

can

be

now

readily

The

best

red

color

seen;

staining

of the

this, the bacteria

beautiful

very

simple. The sections

placed for a short time

lustre.

certain

With

solution.

aqueous

the

is

which

is

nies,
colo-

again

made

were

and

of gummous

in absolute

hardened

tumors,

liver,of the supra-rena^

though
the result
was
positive, al-

child, of the

new-born

intestine). In all cases

considerably, and in several

Malpighii and

fuchsin
of

and

found

were

numerously
in

micro-organisms
the

from
of

condylomata,

diplococci; most

rete

the

portions derived

of broad
likewise

Here

surface, scraping

it,best with

of
varied

portions

strongly refractive
the

the

colonies,partly

micrococci

see

we

of bacteria

colonies

of the

exhibited

adult

an

bacteria

comparison,

of

excised

cells of

smaller

objects only the smallest

found.

were

papular syphilide.

the

of the

in caustic
simple clarifying of the sections
visible in the tissue as strongly refractive
corpuscles.

stomach, and

the

The

glycerin.

examinations

lung of

by far

was

The
segmentation, it is
besides, the
joined into chains;

Usually

colonies

Still better

become

manner

larger regions of the

over

formations.

Rivet-Leister

elements

acid.

acetic

be
also

one.

free

with

cut

agent is fuchsin in moderately concentrated

rods,
but
especially the intercellular

alcohol

rod-like

majority of micrococci
into

colonies.

likewise

are

simulating

united

small

could

circularly in the periphery of the cell.

not to be interpreted as rods or bacilli,but

distributed

in the

than

spread
neoplasm

in the

cells,exactly resembling those

were

into

roundish, oval, and

were

often

were

bacteria

described, however,

and

alcohol

faded

potassa, after which

they

round, but longitudinally oval.

of the

(hardened in absolute
in glacialacetic acid,

inclosing bacteria

the

five individuals

to

They
tissue

granulation

which

bacteria

The

chains, thus

into

indistinct

more

rarely

more

united

cocci

true, is much

cocci, as

thus

micro-organisms

border

parts of syphilomata,

aggregated

always

are

intercellular

of

cells without

completely, partly they

filled them

the

of

firmly fibrous

in the

at the

cheesy infiltrations.

cells

presence

granulation tissue

within

formations

tissue, they

in the

similar

round

majority of the

The

numerous

patches.

tumors.

spindle-shapedelements

most

were

centrally located

more

altogether absent

the

to

micro-organisms.

bacteria

spindle-shaped and

the

As a rule, they were

fully cicatrized gummous

in

as

The

the

with

compared

as

demonstrated

best

date.

relatively recent

less dense.

were
as

of

constantly found

he

tumors,

gummous
were

character

the

the

juice
gentian violet.
from

patientsufferingfor

in

cut

few

living

were

indurated

of the

surface, drying

days from

roseola

on

of

the

covering

syphiliticashowed

state;

papule

of

small, relatively

they lay chiefly in

where

broad

fresh

excised

an

papillarybody.

fresh, non-ulcerated
it

of

colonies

condyloma,

broad

tissue

in the

examined

chancre,

above-described

the

connective

by incising

the

an

It is also feasible

condyloma
glass, and
no

from

its

staining,

bacteria.

329"

SYPHILIS.

The
"very

of

demonstration

probable that

these

the

same

bacteria

micro-organisms

are

within

will be confirmed

patches

gummous

indeed

the

carriers

of the

of different

organs

renders

it

syphiliticcontagion.

believe it to be

perfectlyjustifiable
attempt to explain the relations
of the morbid
process, of the infection,of the heredity,etc., from this standpoint. Of
the details of the pathological
in
on
entering
course,
process, we miss at every step the
the
in
such questionsminutely, we
of
are
demonsti-ating
bacteria;
discussing
possibility
to
confined
from
almost
reasoning
analogy.
entirely
organisms
of specificmicroIn
still another, very
important question, the demonstration
the
of
the
I
decision:
would
mean
definite,longed-for
question
unity
bring
and dualityof the venereal chancre
poison.
that the dual theory appears to me
conviction
I shall merely give expressionto my
virus is altogetherdifferent
firmlyestablished;that therefore the syphilitic
by far more
Even
which produce the forms generallytermed
soft chancres."
from
all those noxae
between
the
and
obscure
in
the
to
relation
if solitary
source
ever
so
cases
regard
appear
and soft chancre,
the unity of syphilis
if they seem
to prove
the product of infection,even
it will have to be admitted
that, with such involved factors and strange complications
about
and extra-marital
intercourse of the sexes, no
are
as
by prostitution
brought
basis can
be gained for a positivetheory from such incalculable observations.
observation
To me
the fact appears decisive that all cases
of syphiliscoming under
out
from a soft chancre withderived from syphilitic
and not in a singlecase
are
indiyiduals,
syphilis.
The
acceptationof the mixed chancre which has been so freelyassailed,moreover,
correspondsaltogetherwith the universallyrecognized observation that vaccine plus syphilis
be transmitted
virus can
simultaneouslyand produce their respectiveeffects one
if
be remarkable
after the other, first small-poxpustules,then syphilis. It would
even
to occur
infection were
For
the sources
fewer cases
of mixed
than is actuallythe case.
of infection are
"mixed," tliat is to say, the preponderating majority are prostitutes
soft chancres."
of long standing,harbor
other ulcerations,vulgo
who, besides the syphilis
the one
These latter are transmitted
either alone
combined
with syphilis,
as
or
both of the poisonspenetrate through the point of infection.
or
virus,i. e.,
Syphilitic
parts of syphilitic
neoplasms or blood (?),must be mixed with the infectingsecretion if
is to be transmitted.
has exposed himself to the danger of
syphilis
Inversely,if a man
infection and
has not acquiredsyphilis,
we
can
particle
only conclude that no syphilitic
has gained entrance
into his system.
must
We
not
secretion with purulent secretion on
a
identifysyphilitic
syphilitic
be
value
ascribed to experimentalinoculations with secrecan
tions
Accordingly,no
person.
is not determined, whether
derived from syphilitic
of which
persons, but the nature
it contains syphilisor not.
As regards the experiments on animals, it has been ascertained that monkeys, cats,
and
others were
specially
susceptibleto soft chancres, while the attempts to inoculate
have given no
animals with syphilis
results.
positive
The transmissions
to monkeys have, in another
sis
quarter,been referred to tuberculoin their results,and can
therefore
for there is no
as
proof
yet claim no full validity,
that the neoplasms artificially
of
nature.
a
Avere
syphilitic
produced
really
inoculation syphilis
Moreover, there is on record a preliminarycommunication
on
of the iris and
of
the
Dr.
Paul
Haensell.
cornea
were
rabbit,by
Syphilitic
particles
introduced
into the anterior chamber; the thin-fluid purulent contents
of an intact gumWhether
to

these

results

interpretsyphilisas

or

not,

iacterial disease and

we

shall

^"^

"

330

SYPHILIS.

node, portions of

mous

After

subacute
man

are

mucous

period of incubation

patches,pieces of
of about

one

month, there

sclerosis before
were

it had

developed an

character;then, several days later,those stronglyvascularized

of the iris. In an animal
tumors
generallytermed gummous
after inoculation, with

sixth month

considerable

emaciation, it

nodules

which

found

ulcerated.

iritis having
which

in

died in the

that the

lungs
with small, rather
hard nodules, which
posed
interspersed
proved to be comof round
cells and
at times also giant-cells.
larger,multinuclear
epithelioid,
had
been
inoculated
with the products of this inoculation syphilis
A rabbit which
into the anterior chamber, presented the like appearances.
here is much
Compared with inoculated tuberculosis,the time of incubation
longer,
bears a much
chronic character.
Of the greatest importance,
and the whole course
more
two
of inoculated
difEerences.
First, the nodules
however, are especially
syphilisare
their
extent
whole
traversed
minute
vessels which
are
throughout
by
altogetherabsent in
inoculated
tubercles ; second, they never
fall a prey to cheesy metamorphosis, which
is
always the case with the latter.
to the monkey, which
An
Martineau
claims to have been
attempted transmission
himself
J. Neumann
declared
in favor of
successful,is still under observation.
recently
to animals.
in establishing
the doctrine of non-transmissibility
He did not succeed
the
syphilitic
poison in horses,rabbits,martens, rats, cats, or pigs ; at most, there appeared

and

liver

was

were

local symptoms

of reaction

in consequence

of the

inoculation.

cussed,
quite brieflybe stated that for the decision of the questionabove dismay
to the
as
unity and dualityof the virus,the form of the primary ulcer (''soft
hard^'
We shall again revert to this point.
or
chancre) is comparativelyimmaterial.
the
conscious
of
difficulties
Nevertheless, fully
arising from this lack of sufficient
I
and especially
material, have thought it incumbent
on
objectivedemonstrative
myself
pretation
valuable that a consistent interto approach these
more
questions. It appeared to me
if at
of the pathology of syphilisbe carried out from a singlestandpoint,even
still
hypothetical.
present
of infection,we must
bear
In the first place,in regard to the relations of the modus
of the
into the plasmatic channels
in mind
that the bacteria have to penetratedirectly
membranes
mucous
(of
organism. In the case of the external skin and the superficial
the oral cavity,on the genitals),
there are required,generally,mechanical
injurieswhich
of infection or existed previously. According to experienceto date,
arise at the moment
also that the mouths
infection through the intact epidermis is not possible. It seems
an
of the hair follicles and glands in their normal
condition do not serve
as points of entry to
in
the virus meets
fissures
if
the tissue,even
But whenever
the virus.
permeable
open
it
into
Hence
it
and
the
minute
it be the most
erosion, adheres,
organism.
penetrates
but on
does not require as the bacilli of tuberculosis do
a specially
protected locality;
the contrary, in spiteof the most
rapid and careful efforts,it can no longer be removed
This mode
of infection
from
the supposed points of infection.
holds
by direct contact
for
all
in
extra-uterine
life.
diseases
acquired
syphilitic
^ood
of the infection
Non-effectuation
(through a firm epidermis,etc. ) must, of course,
As far as we
not be identified with immunity againstthe virus.
know, this immunity
that
in
in Iceland,
does not exist
syphilisdoes not occur
(Whether the assertion
any man.
in spiteof the plentiful
nautical intercourse,corresponds to the actual conditions,
whereon
and
they are based in that case, is to be ascertained by further investigations.
of infected
with the advance
the spread of syphilishas kept equal pace
Otherwise
nations.)
It

here

"

"

"

"

331

SYPHILIS.

"such

as

of infection

mode

Another
takes

consists in direct introduction

placein intra-uterine

infections
syphilitic

by

of the virus into the blood,

of the

means

lation.
placentalcircu-

Finally,the most direct and highestimaginabledegree of infection is representedby

the maternal
for here all the
or
ovum,
genuine hereditarytransmission by the semen
the new
formative material of which
body is composed, harbors the infectious matter and
is not to be identified
semen
ovum
or
develops under its injuriesinfluence. But syphilitic
the

with the

semen

or

ovum

of

syphilitic
person.

In the former

effects,in the
specific

with

will

its

other

case

the virus is transmitted

is merely a certain
produce
will
itself perhaps
of
manifest
cachexia of the parents,which (notbeing
a specific
nature)
constitutional anomaly (ofa non-specific
in some
nature),for instance,rickets,etc.
of intra-uterine infection (i.e., the
In the two last-described modes
hereditary^*
fection.
local primary places of inno
and the syphilisacquiredin utero),of course, there are
it and

case

there

^'

As

opposed

and

the

these

to

i. e., from
locally,

form

local

life begins always

forms, syphilisacquired in extra-uterine
of
this
of
infection.
But
infection,in its appearpoint
point
ance

in which

it becomes

manifest, is subjectto the greatestvariations

depend chieflyupon the anatomical conflgurationof the point of entry. On the

which are termed
hard chancres,"
usuallythose neoplasms (syphilomata)
On
the mucous
indurations."
membranes, however, *'hard chancres"
are
primary
of superficial,
almost
to develop; there is a formation
never
seen
corroding,non-indurated
at their seat.
new-formation
ulcerations or erosions,without
(However, I
any specific
that in my estimation these soft primary affections stand in
wish to explainparticularly
its originto a specific
virus totally
relation to the soft contagiouschancre which owes
no
I am
"different,
) Only at the vaginal portion of the uterus
sure, from that of syphilis.
of the submucous
indurated
primary affections dependent on the anatomical structure
tissue
it
primary affections,
develop frequently. Of course, with such insignificant
unnoticed.
In
to
their
reference
these
that
which
course
run
they
happen
cases,
may
in whom
the
infection naturallyoccurs
and
more
on
rarelymen,
chieflyaffect women,
d'emhUe
has been spoken of.
membranes
a syphilis
mucous
(becauseit is on the genitals)
membrane
If this is to mean:
syphiliswithout a primary affection on the skin and mucous
if it is to
this doctrine may be accepted. But
discoverable
by our
fingers,
eyes and
signifythat in these cases there is absolutelyno local focus of infection present,we must
membrane,
object;for indeed it exists;although not visible to us on the skin or mucous
it is in the lymphatic glands belonging to the point of infection (cutaneous or mucous).
first discoverable
The
sign of the disease (theprimary effect,if you choose),then,
of the penetratedbacteria
lies in these very lymphatic glands in which the multiplication
which

''

skin there arise

'^

"

"

or

their germs

is effected.

Only subsequently,after a variable period of incubation, the general infection is

local foci,as it were
stillrepresenting
from within
brought about from these depositories,
the ordinarycourse
of the spreading
this end
Either the lymph channels serve
outward.
of acute
virus (alsoin leprosy,in certain
cases
miliarytuberculosis) or the
syphilitic
of the acute miliarytuberinfection of the blood produces the generaldisease (asin most
culoses)
"

"

(Weigert).
In

therefore,we have to deal (in the form acquired in extra-uterine life)

syphilis,
with a local infection,mostly with a so-called primary affection at the point of infection.
But what
significancehas this local disease in reference to the generalinfection ?
Js it the focus in which the bacteria multiply during the period of incubation, and from

332

SYPHILIS.

general saturation of the whole body takes place ? Or have we to deal witk
an
primary alteration at the point of infection
generalintoxication ; a
ing
developingonly partlyon account of the. larger quantity of the infectious material actof the local processes preceding or accompanying the
at this point,partlyon account
penetrationof the virus ?
Unfortunately,it has been impossiblehitherto to gain perfectclearness in this question.
In the last few years it has been
this scientific want,
even
attempted to satisfy
of the
with the therapeuticindications,by the excision
syphiliticprimary affections.
which

the

However,

results

the

"

"

instantaneous

are

of

operativeremoval

variable that

so

ulcer

definite conclusion

no

be reached.

can

Where,

node

appearing after suspectedcoition,no general

removed
be proved that the structure
disease followed, it must
was
actuallyof a syphilitic
I am
of opinion that this proof cannot
be brought with
nature.
certaintyfor the
of
because
the
affection,
which
a
primary
syphilitic
microscopicappearances
earlystages
and
do
characteristic
Cornil
looked
not
to me
to
seem
are
by Auspitz, Unna,
uj)on as
after

claimed

possess the value

an

for

or

them.

Where

the

excision

it could be objectedthat the operationwas

syphilis,
be
According to our view, this questioncannot

done

still followed

was

by general

late.

too

decided

fectious
positively. As in other ingeneral infection is brought about
in which
the virus penetrates into the body.
will vary with the manner
into the circulation,an
instantaneous
If it enters at once
general intoxication will
the
in
the
than when
bacteria,multiplying
result sooner
trict,
lymph spaces of the infected disIf intense inflammatory processes
reach the blood at a later date.
the
accompany
into the
development of the initial affection,the penetration of the syphilitic
germs
deeper tissues and thus into the general organism, is influenced by the inflammation
to me
injuriously).Clinical observation (in experimental inoculations and in
(itseems
local infection
has actuallytaught that the lapseof time between
known
infections)
accurately
all
of
varies
between
wide
limits.
At
there
is
lack
and generaldisease
a
events,
of
the
the intensity,
relation between
primary affection on the
course, etc.,
any constant
The
chief
one
hand, and the progress of the virus in the organism on the other hand.
importance attaches in every case to the quantity of the virus introduced.
of time

diseases, the space

Renault

(d'Alfort)upon

In these

experiments

Opposed

to

which

of wounds
of

this fact

the

had

portions of the skin.

performed

was

with

absorption of the virulent

have

been

the

in immediate

are

undisturbed.

wound,
with

the

in rabbits

potassa one,
"

In

collateral

most

by

two,

substances

I call to mind

were
or

of

means

saved

of the

at

once

vascular

with

from

the

of

effected
anthrax

others

after.

within

anthrax.

upon
a

few
to

matters

when

small

number

in which

introduced

into

severed

the

Davaine

the

of

without

surface

excision*

cauterization

vessels

circulation

any

minutes.

the

ing
gives the follow-

general circulation.
and

of

experiments

Colin

general infection

hours

trunks

are

those

vesicants, energetic friction,or

three

even

was

brought

subepidermal inoculation, a
communication

Therefore, the poison is

however,

diseases.

Davaine, who

of the animals

Some

caustic

of

results

caused

explanation of the fact.

which

the

absorption of the glanders poison, and

the

we

which

infectious

quite analogous facts in other

know

We

within

is

opened,

continues
In

an

tensive
ex-

communication

general circulation."

the fact that the

to us
that in syphilis
the greateststress is to be laid on
It appears
that it
general infection proceedsgradually,and that we cannot
say at a given moment
I
existed.
is now
present,while only a little while before nothing but a local trouble
the
the
local
in
with
hand
of
tion
affecthat
hand
therefore,
primary
believe,
development
and the great multiplicationof bacteria
taking place in it,the generaldisease is
ing
that point. The
of an induration
formation
effected from
(" hard chancre") has nothbut
The
of infection.
induration
is nothing
to do with the process
a
peculiarreac-

334

SYPHILIS.

ceptiblein
felt

all

the

on

This

palpable groups

lower

half

of

of the

glands on

the

last observation

half

upper

body, especially not

in the

of the

body,

which

could

by

no

be^

means

inguinal region.

teaches

in an
incontrovertible
that the primary lymmanner
phatic
glands are a focus of the virus equivalentto the hard chancre, and renders clear
why the extirpationof the latter alone so rarelysecured a radical result. As earlyas
1871, P. Vogt had therefore made the proposition,and Hardaway in 1877 had repeated
the glands togetherwith the sclerosis.
it,to remove
not very
Although the results were
is to be adhered
brilliant,still the proposed method
to.
His cases
under treatment
came
in a rather advanced
stageof the disease in which the virus probablyhad alreadyextended
beyond the limits of the glands.
The

removal

of

simple affair

very

facilityfrom
wound

glands

closed

it with

over

in the

glands

loose

surrounding
drainage tube

by first intention

performed

was

indurated

the

thin

the

; the

connective

inserted

was

of

that

tissue

into the
Under

deep sutures.

majority

before

of

be enucleated

can

an

the

chancre

and

together with

without

any

their

considerable

in

every

case

capsule with
hemorrhage

was

great
ring.
occur-

remaining cavity, often pretty large, and the

antisepticpressure bandage the cavities closed

cases.

Finally it must be taken into consideration that we can

hardly determine clinically
has
infection
been
effected
in
general
syphilis. Usually the view prevailsthat the
time of general infection is to be identified with the appearance
of visible symptoms (exanthem, polyadenitis). That this doctrine, in its generalapplicationat least,is erroneous
is proved by a communication
publishedby Finger, in which, in a patientrecentlyinfected,
efflorescences appeared on a previouslyirritated part of the skin two
weeks
syphilitic
before the macular
in
hence
a typicalmanner,
generaleruption developing subsequently
in that earlyperiod of syphiliswhich is usuallydesignated as the second
cubation.
period of inwhen

If

from

adhere

we

the focus
results

to the above

of

excision,on

operationweakening
of the chancre

developed view

of infection,we

the

will have

shall not
the other

general
to be

be

hand

infection.

combined

with

of the gradual poisoning of the organism

dictory
hand
surprised on the one
by the contraexcision will still appear
to us a very useful
it is at all possible,
the excision

Wherever
the

extirpationof

the

glands.
general infection,this is effected,as above mentioned, most probably
by way of the lymph channels ; this explainsthose diseases of the lymphatic glands of
the body which
followed
anatomically,while the
may be controlled step by step and
morbid
foci occurring simultaneouslyin the skin will have to be traced to the participation
As

regards the

of the blood
But

no

matter

channels.
in what

takes

way

and

at what

time

local pathologicalprocesses
place,finally
only where the bacteria settle and find rest so as

the

spread of
produced at

the infectious

substances

those points,and
there
activity.
In fact we
that from this period on (afterthe so-called second
see
incubation)there
are
less regular order, pathologicalproor
developed in all organs of the body in more
cesses
which provoke the most
manifold
But another
questionpresses into
symptoms.
the foreground :
To what
trace the fact that these products developing
factors can
we
the
of
course
t
he
jn
syphilis,
etiologicalunity of which is certain,and which in their
initial stages represent almost identical formations
(heaps of granulation cells)give rise
to such
differences in their further course
that finally
that well-known
polymorphism is
effected which
is characteristic of syphilis
and which
is capable of simulatingall possible
forms

of efflorescences ?

are

to unfold

their

335

SYPHILIS.

question has been often raised and

into
of syphilis
attempts at dividingthe course
two
morbid
Especially
great
groups
processes.

its

found

has

This

have

expressionin

the

many

periodsaccording to the

several

varying
always placed oppositeto one

been

another.

separated from the gummous

standpoint the papular were
tive
irritadivided
from
the
the condylomatous
stage). Virchow
gummous
products (Zeissl,
the
time
to
According
inflammatory or hyperplasticprocesses from the gummous.
of their appearance,
they are separatedinto symptoms of the earlyand those of the late
period,or according to the ordinary mode of expressionoriginatedby Kicord, secondary
The
This difference in time correspondswith a clinical one
:
and tertiarysymptoms.
to
are
rule
have
benign/'
a
tendency
spontaneous absorption,
early symptoms as a
prevails.
while in the late periodthe tendency to disintegration
anatomical

the

From

"

here

But
tissue

of

have

remarkable

affection,so that every

their

syphilidesof

for the

and

teimi

vessels,

hand,

know

we

opposed

to

in

that

"

case

early

syphilis,with
is correct
for the
in
not

"

which

only with

diseases

them; hence

intestinal

se

we

are

"

bones,

the

to be confounded

that

date, often

with

the

organ,
"

to

those

division

as

For

of

instance,
from

to time

the

the

the

diseases oftheperiossyphilitic
endarteritis
syphiliticadescribed

period of syphilis,is to be counted, both

two
"

malignant

earlier and

an

forms

(by
later

the

of disease
side of

which

the

we

have

above

ordinary endarteritis

implication of the system.

But

altogetherdifferent from what they do in cutaneous

Hence, to speak of a secondary and tertiary period

familiar.

most

late

the

systems

manner

in

something

mean

tliese limitations.

of the
that

late

"

and

to

Thus

organs.

and

"benign"

as

applied

different

accordingly to the

specially by itself.

reckon

we

be

the

namely

(aside from the secondary alterations in the brain), altogether

On the other
corresponding to the early syptoms of the skin.

tissue, in every

every

account,

time, and

considered

be

invariably to the

form), corresponding

also the gummous

must

measure

belongs almost

another

one

must

into

to the

membranes

mucous

syphilisof

the

and
clinicallyper
benign new-formations

the

among

to

which

by Heubner,
anatomically

and

another

taken

in reference

of tissues

group

skin

the

day of infection; however,

be

must

phenomenon
independence

certain

"

Furthermore,

it rnust

new-formations

osseous

late, at which

far earlier

time

such

of their

be taken
of

into

permanent

"

consideration, especially
frequently

nature

are
tophi, periostoses,

still

occur

demonstrable,

is

origin.

number
of the attempted divisions must
lead to the suppositionthat a
mere
of
(schematic) subdivision is reallyimpracticable. Indeed, mixed exanthemata
observations
of
anatomicallythe most divergentforms are not at all rare, and especially
efflorescences
and
are
so
tertiary"
simultaneously developing secondary
frequent
Is there actuallyany such strict separationbetween
that the questionappears justifiable:
? Is there reallyan essential differthe several forms of syphilisas authors have made
ence
the gummous
the papulous and
between
an
neoplasms, and can
explanation be
The

strict

"

*'

for the variation

found

Biiumler

(p.37)

of the
assumes

At

two

for

first the

forms
this

^'^

?
purpose

syphiliticvirus

changed qualityof
itself is the

the

of the

tissues in the

cause
stage.
neoplasms in
have to
normally reacting tissues ; however, in the development of gummata, we
virus on a normal
deal, probably,no longerwith the effect of the specific
tissue,but with
the specifically
altered reaction to any irritation of tissues modified
by the preceding
blood-poisoning." This view indeed has something very taking in it. There is nothing
if we
to prevent our
do not as yet know
assuming a modification of the tissues,even
itively
posfind like conditions
wherein
it consists;we
(acquiredimmunity) existingunquestionably
in other infectious diseases (invaccinia,etc.);even
in syphilis
we
are
acquainted
with such a modification
of the primary affection can
in the fact that the induration
but
cannot
be produced in an
individual
develop only in persons free from syphilis,

gummous
the

"

S36

SYPHILIS.

affected with

of the tissues be in this

syphilis. Inexplicablethough this modification
confirmed
observation, it is
by a thousandfold
experience.
of tissue" is effected and what
To explain how this ^'modification
is its nature, we
chemical
incidental
effect of the bacteria, of the kind with
a
might perhaps suppose
well acquainted in fermentation, decomposition,the growth of aspergillus,
which
we
are
"

"

etc.

Bumm
of

the

makes

making
if

followingremarks
earlyauto-inoculation

an

for this purpose

choose

we

focus

of infection,we

above

mentioned.

K.

On

August

33d,
of

point of
On
that

the

tenth

there

from

August

the

sufficient

If

chancre

historyof

case

the

have

we

to its

nity
opportupecially
bearer, and es-

from

observations

the
the

about

may

in illustration.

serve

couple of weeks

primary
relations

later, moist

spots

into ulcers.

indurated

smaller

two

was

possibleremoved

5th, 1881.

gradually changed

larger and

one

as

instructive

very

on

far

as

hereto

indurated

an

ulcers

quantity,

three
days the small cnist of blood
appeared perfectly intact.

inoculation

point which

place

which

prepuce

which

After

took

reference

from

spot

make

followingextract

Infection
the

on

present,
arm.

upper

The

C, set. 35.

perceived

were

often

can

in

had

were

inoculation

an

become

noticed, and
was

detached

day after the inoculation, a red spot the size of a pin's head
time
slowly increased
during the following days. At the same

made
and

with

the

the

the

on

skin

cretion
se-

right
at the

first noticed

was

at

guinal
swelling of the in-

glands occurred.
On
found

the

twentieth

; it had

day,

feel.

with
a lentil,
slightly scaly surface, was
a grayish-yellow
days the papule underwent

larger than

papule somewhat

distinctly infiltrated

The

next

few

discoloration, and thenceforward

retrogressed so that by the thirtieth day after the inoculation
had disappeared.
forty-seventh after infection)the entire formation
Simultaneously with the
of the
ulcers

on

the

inoculation

penis had

(the
gression
retro-

As the
glands and an angina occurred.
returned
with
patient left the clinic,but soon

papule, swelling of the cervical

healed

in the

time, the

mean

secondary symptoms.
In this

inoculation

the

case

suddenly the
to

the

whole

standstill.
time

therefore

about

was

at the very

process,

Such

we

processes
of the inoculation and

can

in

acteristic
healthy person ; a quite charwhen
by its disintegration,
the generalinfection commenced,
time when
came
that
the
explainonly by supposing
organism at

at first progressedas

papule developed which

for three

forming

weeks

an

thereafter

ulcer

was

not

yet infected, and

t ha

made
further progress
no
develop which of course
ensuing,owing to the immunity conferred by it.
I might here briefly
that perhaps it is incorrect to say : a syphilitic
remark
person
For
infection during the time the disease exists.
fresh
an
immunity against
possesses
the time being,it is true only that during this time no typicalprimary affection is formed;
with

but

an

inoculation

the constitutional

whether

question which
this

relation

after infection
to fresh

there

papule

disease

is not

could

then

new

invasion

of virus with

additional

infection

is

an

open

further
be negatived without
investigations.Practically
by no means
is important only in so far as physiciansand patientsbelieve in immunity
themselves
without any qualification,
and as the latter imprudently expose
can

invasions

of virus.

accept as proven only one part : the modification

v. rus.
body by the poisoning of the organism with syphilitic
It is more
however, whether we shall,with Baumler, charge
questionable,
any kind of
in their stead, again
irritation
with the production of gummous
processes, or rather,
the specific
virus.
syphilitic
Those who rejectthe view that the gummous
process is produced by the syphilitic
Of

Baumler's

view, therefore,we

effected in the tissues of the

"

"

33T

SYPHILIS.

opinion on the slighterinfectiousness in the gummous

stage.
Indeed, in this period,syphilisis more
rarelytransferred to other persons than in the
The
early papular period. But this rests only on external accidental circumstances.
in
but
few
numbers
at
and
almost
one
are
are
time,
always present
gummous
processes
to the propagation ; while the numerous
situated on parts of the body unfavorable
early
and
and the genitals,
efflorescences which
withal are distinguished
preferablyaffect the mouth
by a decided tendency to relapse,are naturallythe chief propagators of syphilis
than
the
is
a
nd
well
for
the
as
even
more
affections,
known,
primary
frequently
;
virus in

same

base
propria,

their

reason.

The

at least that gummous

masses
are
infectious,as well as the secretions
possibility
of the earlyperiod,has been recentlydemonstrated
mals.
by Haensell by inoculations on anithat Birch-Hirschfeld
the discoveryof the
has made
Moreover, I call to mind
operation
Accordingly we hold that a direct comicro-organismsdescribed by him, in gummata.
in the production of gummous
of the bacteria of syphilis
is
at
least
products
of frequentoccurrence,
stancy
although no positiveopinion can as yet be given as to the conof this fact.
If

now

ourselves attempt

we

we
syphilis,

in mind

bear

must

explanationof

an

the

of
variability

the several

forms

of

syphilitic
neoplasms without exceptionwe have
with
a
development,
heap of granulation cells,no matter
in
it may
take place. It
whatever
earlier or later,or
organ

this process occurs

is the further developmental

stages of this

lead to the

In

all

the manifold

of cells which

mass

forms

which

take

different

with

*^meet

we

abscesses,tubercular and gummous

etc."
Gummous,
therefore,does

and

and

courses

in almost

by

hard

as

interstitial

stagesof

formation

of

all

chancre,tubercles

formation

of

branes,
mem-

designatea peculiarform

means

any

first

whether

all organs

processes,
not

deal, in the

to

of

new-formation, but only that of decay.

causing this difference in the development of the syphilomata?

place,the active effect of the virus,which is :
First, an inflammatory one ;
of these inflammatory products ;
Second, one specifically
modifying the course
in
the entire organism vessels,permanent
Third, an alteration manifesting itself
What

the factors

are

is,in the

There

first

"

tissue cells,etc.

to deal with
a

effect of

those so-called constitutional

anomalies

every

specificmodification

suffered

modification

1. In

manifests

periods in

which

the

indeed

remarkable

once

in two

an

." induration

as

per

by Finger,
22

that

in

directions

forms

are

the

"

se

has to be
Here

we

taken

have

not

"

essential

an

after

difference

perfectcure)

from

the

later

all stages of
render

rare

syphilisare less variable histologically

so
tion.
nugatory any attempt at schematic classifica-

observations

still present gummous

they do
eruptions. However,
of the view
just defended
; they merely strengthen
well

Yirua

after the infection,

soon

(scrofulosis,
scurvy, etc.),but with
they are poisoned with the syphilitic

tissues when

itself at

products of

transitional

numerous

Very

the

factor

factor which

healthy tissue (*.e., before the infection and

only the

that

possesses the capacityto form

that

by

the

ITSELF.

yiRUS

Th^

independent

an

constitutional

become

inquiryinto the

with

account

tissues becomes

disease has

the

whenever
into

of the

alteration

This

of
not

reinfections

militate

(Merkel, Gascoyen) during

directlyagainst the correctness

the view
maintained
by the above authors as
tertiary syphilis the diathesis,thai general disease has disappeared, that

338

SYPHILIS.

have

syphilismay
the

lost its character

significance rather
But

how

does

of

local

of

general nutritive

disturbance, the symptoms

present having-

sequela.

the

primary syphiliticaffection look, and wherein

from
all others ?
tumor
primary syphilitic
primary induration, the hard chancre, the initial sclerosis per

lies the

essential

Eerence of the
tThe

dation-cell

The

tumor.

cells

are

derived

from

the

vessels

and

se
are

is

an
ordinary,
inflammatory,

emi^ated

which take on a specific

under
white blood-corpuscles
the influence of the
course
syphilitic
virus;that is to say, they all develop rather quickly into an elongated,squat
abundant
of protoplasm. The
mass
spindle cell with a small nucleus and relatively
vascular development is proportionalto that of the cell-mass so that the tissue represents
The
of tissue.
connective
a very high degree of the
inflammatory new-formation
wavy
but constitutes a fine,
tissuphas nothing to do with the formation of the hard infiltration,
between
of the tumor
network
the mass
bare%reoognizablc
fibrillary
consistingof closely
the cells
packOT cells;only here and there we see broader bundles interwoven between
In
remnsmts
this
of the tissue originally
the
of
cell-mass
cases
present.
great majority
reached
before
it
has
terminal
the
in
inflammation
normal
perishes
stage common
influenced
not specifically
of a fibrous connective tissue;according to our
assumption,
by the influence of the virus on the individual cells. The latter die, and at the same
time the vessels become
thrombosed
and disappear. Blood
pigment then remains for a
"

"

"

"

time.
*.

(Exceptionsoccur

e., transition to gumma;

in two
2.

directions:

Actual

1. Persistence

connective

of

cellular tumor

for years,

tissue new-formation, but also of

porary
tem-

nature.)
are
emigrated white
greatmajorityof the cells composing the granulationtumor
blood-corpuscles.In recent stages this may be clearlyrecognized in the cellular tubes
The virus probably extends in the lymph
which traverse the tissue along all the vessels.
of the vesselthus causes
the inflammation
sheaths surrounding the blood-vessels and
effected
is
the
vessel-walls
Whether
of
the
walls.
by the
finallypresent
thickening
is
fixed cellular elements
of these vessels themselves
an
or
by immigration
question.
open
It seems
the veins participate
more
largelythan the small arteries.
Besides the migratory cells,however, there exists in the syphilitic
primary ulcer also
In the mass
of the granulation
the
fixed
connective-tissue
cells.
of
a hyperplastic
process
in the tissue
be recognized; but
tumor
they cannot
they are uncommonly numerous
tissue are found at times only
in this connective
beneath
the induration, so that even
with large nuclei
these large,big, granulated, comparatively short cellular elements
cells
with their small
otherwise no spindle-shaped
elements whatever, or at most
migratory
granular nuclei. But it follows from this fact that in the case of these cells we are not
this the case, then the
Were
dealingwith immigrated and further developed elements.
be found
of the connective tissue would
by the side of the
ordinarynarrow
spindle-cells
cells
and
the
cells.
round
large
lymphoid
These hyperplasticcells I take to be altogeth^
for the hard chancre; not in
specific
find
instance
well visible after staining
them
a single
have I failed to
(they are especially
with Bismarck
in stronglyacid dahlia solutions,
uncolored
brown, while they remain
i. e., they are no mast
cells).
I am
unable
hardness
to say.
Whether
they take part in the formation of the specific
in the spindle shape of
to me
to find sufficient explanation certainly
The latter seems
the closelypacked granulationcells.

The

How

these

decided.

enlarged cells

are

might,

on

They

produced
the

one

and

what

hand,

owe

they really mean

origin to

their

can
a

direct

of

course

irritant

not

be

effect

of

tively
posithe

339

SYPHILIS.

On

poison.

with

necrosis

of tissue

the

not

are

have

color

deal

to

decision

The

with
of

kind

this

of

point is

Ehrlich, for they lack the specific

strongly acid anilin solutions (especially

cells of

mast

characteristic

their

and

protoplasm

denies primary

by Weigert, which
would

we

possible thereby.

rendered

lymph

stated, they

been

has

of the

granulation

"noxae,"

only primary

assumes

imbition

an

As

still open.

and

toto

in

theory defended

hand, according to the

other

the

"irritations"

in

dahlia). Possibly they are cells filled to repletionwith the syphiliticmicro-organisms.

tissue, with deposition of
speak of a fibrillaryhypertrophy of the connective
Auspitz and Unna
connective
substance, and hold
collagenous substance, of a solid,little alterable product of young

of the fibrillarytissue to be the

description given by the above-named

characteristic

hypertrophy

this

The

sclerosis.

in which

indurations

advanced

this

But

tissue.

connective

stained

scleroses

of the
As

to

of which

chancre

the

only

tissue
isolated

as

formed

obtains

the

to those

in size

but spindle(recently) boiled

of

intense

an

red

strips in the

narrow

compact

while

tissue,nothing

preparations

on

fibrous

of

cases,

inferior

not

specially

some

also

only

mass

color

cellular

in the

ronment
envi-

between

hard

and

small

(also more

inflammatory

have

markedly

cells in

soft

the

chancre, this

hard

tumor,

as

lies, in

opposed

stained) cells in chancroid

progressive development

; in

vanced
ad-

more

to

the

(less

; that

soft

is to

chancre, the

In the early stages of both, in a series of clinically

doubtful
by the virus of pus.
erred heretofore
when
were
performed, I have never
forming the diagnosis

in which

from

and

round

we

cells necrosed
cases

occurred

syphilitic initial

only in isolated

scleroses

fibrillaryconnective

spindle shape of all the cells forming

dense) infiltration with

same

exists

sight

closely packed and

were

difference

microscopic
in the

in hard

first

the

spindle-cells,but

fibrillaryconnective
at

of

in itself for

induration.

the

cases,

All

of

"

examined

of

trace

no

demonstrated

cords, however,

red

Such

elements

the

was

be

formation

hypertrophy

I have

one.

picro-carmin.

with

by this method.

there

could

condition

This

tumor,

but

by Unna;

described
cells.

only

not

was

connective-tissue

"

swelling is present in every

cellular

say,

there

condition

is correct

authors

excisions
of

presence

general syphilisbroke

the

hyperplastic connective-tissue
in

regularly, even

out

where

cases

Wherever

cells.

the

excision

was

these

performed

present,

were

at

time

when

"

When
the large connective-tissue
cells were
absent, no
yet noticeable.
the process
remained
local.
how
intense the infiltration,
But
these examinations
not
matter
are
to draw
definite enough to enable
be justified
a positive conclusion.
us
However, I believe I may
aside from
these
the primary affection of the lymphatic
in concluding from
investigations why
indui-ntion

"

no

was

as

"

had

w^hich

glands

result,why

curative
which

seemed

surface,

cut

tissue

that

had

which

portion

the

so

it will be

Accordingly

of the

microscopic control

In hard
formation

action

conclusion

contained
to

of the

excise

excision

that

similar

cell
of

more

connective

remaining

"

so

tissue

wound

also the

forms, i.
the

contiguous
e.,

were

an

inflammatory

of

the

layers of connective

likewise

diseased.

apparently healthy tissue,perhaps with

portions,

or

perhaps

take

into

consideration;

surface.

chancre, therefore,the action of the virus consists,on

of

of the virus
the

the

to

necessary

energetic cauterizeration

an

But
existed

forced

left behind

been

far

As

removed

are

we

the excisions
did not furnish
the desired
tively
posifrequentlydevelops in the cicatrix of the wound
the eye and
as
palpation could determine, everythingthe microscope showed
that the connective-tissue
cellin the lowest
even
layers immediately adjoining the
to

secondary infiltration
removed.

been

have

to

hyperplasia in

by first intention.

closed

had

morbid

attended
sufficiently'

been

not

the

one

cell-rtiasswhich

hand, in the

the influence
develops progressively
only
connective
but
later
(spindleshape,
tissue),
perish by
same
virus;furthermore, in the hyperplasia of the cellular connective-tissue
at

under

times

elements.
The
*'

alterations

specific"neither
The

small

of the

here

epithelium into
anywhere else.

greatest analogy with

arteries, the relation

In

nor

all later new-formations

cells which

the

of which

we

induration
to

the

of the

an

declared

absence
above

proliferative
processes

skin

early processes

there is
have

active

we

is

mainly

hold

by the endarteritis
pointed out above.

presented

have

of the

to be

of

the

nective-tissue
hyperplasiaof the conexpressionof the

to be the anatomical

340

SYPHILIS.

of the tissues.
But
there is superadded to it the second factor
completed syphilization
which
increases in importance with the longer duration
of the disease
the chemical
modification
of the tissues,a greater liability
to decay of the cell masses
produced,
anatomicallyindicated by the lesser degree of progressivedevevelopment exhibited by
the migratory cells.
The
become
cells,it is true, may
larger,epithelioidforms are
fibre-cell is no longer developed.
found, but the
The
nature
of this "modification"
by syphilizationmay consist in, first,the fact
that the cellular elements
furnished
by the body which constitute the syphiloma are
from
the start less viable and
succumb
more
quently
subsequickly to the necrosis induced
by the virus than cells furnished by a healthy body.
Secondly, however, the modification may have influenced the growth of the vessels ;
they do not participatesufficiently
by new-formation, as in a normal
organism, in the
nutrition
of the granulation tumor
the
vascular
also
shoots are
stroyed
de; perhaps
young
"

"

''

after their formation.

soon

if this

But

basis,the modification

new

of the tissues,is

established,then again

once

into action as the determining factor

intensityof the virus comes
the several syphilitic
and
it
is
mainly the changeable quantity of
processes,
in
the
and
into
organism
circulating
coming
play locallyat once.
the variable

We

already become

have

in vaccination.

Nourney

A.

very

small

incisions,whereby

was

found

that

of the
two

virus
or

infection
of the

is

virus

the

duration

introduced,

three

maximum

lesser

1. the

familiar
made

the

brought
in the

fever

and

about

organism

of the
onset

relations
diluted

with

in tuberculosis

of

the

more

immediately
to

vaccinal
virus

with

stand

into the wound

the

connection

was

of the

of the virus

expansion

inoculation

they

are

4. the

of

causes

the

virus

also

found
in

diminished.
on

the

areola

layed
being de-

in most

areola

It
tity
quan-

cases

; 3.

genetal

rapidity of the reproduction

the local

with

shaping

the

inoculation

undoubtedly depends

diminution

circumscribed

punctiform

fever, the appearance

; 2.

in causal

with

lymph,

of the inoculation

course

of the

certainly

seems

similar

quantity of the virus introduced

days by diminution
of

with

experiments

in

phenomena.

The

time is greater in the periods closer to the infection

quantitycirculatingat any one
than it is subsequently; but locallysmaller
numbers
of bacteria usuallycome
the
Hence
into action.
disseminated
more
over
are
more
earlyexanthems
numerous,
arises
the body, and acute in their onset.
Within
a few
days a small granulationtumor
with copious vascular development so that the persistence
of the neoplasm is assured for
do the cells and vessels graduallyperish so
Not until weeks
afterwards
a certain time.
The
that finally
a complete restitutio ad integrum ensues.
analogy of these formations
with
the primary affection is obvious ; in both
there are
comparatively high further
development of the several cellular elements, sufficient vessel formation, healing by
absorptionof the neoplasm without loss of substance.
of the gummous
The course
form is altogetherdifferent ! At very few placesa slow
This
accumulation
of
exudation
tardy
corpuscleswith sparse development of vessels.
which
the
of
until
the
remain
for
months
cells,
development
mass
unchanged
finally
may
was

from
the
very moderate
is implicated in this

start, perish. But

and
disintegration,

the
thus

tissue

results

in which
a

defect

the tumor

was

bedded
em-

healing only with

cicatrix,etc.
decided whether
these defects of tissue are
merely processes
positively
have to deal
of the tumor, or whether
to the necrosing mass
we
itself. In
the
virus
tissue
necrosis
the
constituents
of
of
with a simultaneous
by
primary
of tissue.
necrosis
direct
the
untenable
it
to
to
of
the case
seems
me
assume
gummata
to
new-formations
of causing even
The possibility
large gummous
regress by approIt cannot

of

be

deliquescencedue

"

"

342

SYPHILIS.

Altogether, as regards the employment of mercury, as well as that of potassium

iodide, we are absolutelyon an empiricalstandpoint. To mercury
ascribe a direct
we
effect on the virus, to iodine the power
of furtheringthe absorption of the products of
Fournier
syphilis. This view indeed is supported by clinical observation.
is
especially
its advocate, and again and
of syphilis,
again emphasizes the doctrine that the course
as
a
rule, depends on the treatment
instituted;that the production of late gummous
due
to
is
mercurial
symptoms
treatment; that syphilisas a chronic disease
inadequate
treatment.
chronic
requires a
of a third
Quite different,however, is the course
group of eruptionswhich otherwise
the
included sometimes
the late (gumare
early(or secondary),sometimes among
mous)
among
and
forms, but which, according to their course
character, can be erected into a
the processes
specialclass. I mean
progressingwith so-called
suppuration,"such as
the skin in the shape of pustular,bullous, and ulcerous
on
develop especially
forms, in
seek
their cause
the
in an
abscesses."
We
intestines as
especially
large quantity of
bacteria at once
the
hence
their
destructive
local
overwhelming
organism,
effect,as well
of
their
which
threaten
the
the
On the
as
integrity
system as a whole.
consequences
other hand, not rarelyan
of the acute
existing disease (tuberculosis,
etc.)is the cause
local processes
necrotic disintegration
of the syphiliticproducts. The
have this in
that they, if left to themselves, are
with the gummous
followed by
common
processes,
permanent losses of substance; they differ from them and approach the papular forms
and decay being effected in a
by their very rapid course, new-formation
very short space
of time, and
which
tegration.
can
finallyin that there is almost no treatment
prevent the disinand
is
of
bacteria
otherwise
so
a
(Mercury
quantity
powerlessagainst large
all this
aside
injures the organism alreadyattacked
by the syphilitic
virus.) From
of
the
it
entire
not
the
from
follows as a natural
uncommon
implication
organism
that these syphilides
fied
sequence
possess a characteristic malignancy, and that we are justiboth
from
the papular and the gummous
in separatingthis group
neoplasms. But
be remembered
at the same
time that every papule and gumma,
it must
by the supervention
of external accidents, may
more
"suppurate," i. e., necrose
rapidlythan is usually
"

*'

"

"

the

case.

Here

again

only a
or

does

it

very

the
acute

question arises
inflammation

effect,besides this
if

In

what

which

at

does the virus act ?

manner
once

preventsany attempt

inflamation, direct necrosis

ascribe

of tissue

at

Does

it produce

organization,

decided

answer

the

"specifictissue alterations."
The
actual facts are, a rapidlyprogressing infiltration with inflammatory cells fills the
At the periphery
tissue,and this infiltration perishestogetherwith the basis substance.
be preserved
here
is slower
new-formation
takes
which
the course
syphilitic
place
may
;
from the destruction going on at the centre, by appropriatemeasures.
I have
in mind
the
In other cases
here the bullous syphilidein hereditarylues
the
of
tween
the
the
coherence
manifests
itself
dissolution
of
virulence
existingbeby
intensity
below
the
the papillaand the epithelial
there
From
into
above and
project
layer.
interlocked
rhagic
of the two otherwise
"bulla the conical processes
layers. The form of hemorsyphilidewill likewise hardly find a better interpretationthan by a specialvioof the virus on the vessel walls.
lence in the activity
this head belong finally
the acute abscess formations
in internal organs {e.
Under
g.,
in hereditarysyphilis. Incidentally
the bones
of the thjTiiusgland),the joints,
they
minations,
also teach us the unity of all syphilitic
neoplasticprocesses which differ only in their terthe
forms
strict
while
of
and then in their extreme
classification,
a
permit
cannot

be

given, even

"

we

were

to

part

to

"

343

SYPHILIS.

to the

more

However,

we

know

to the

now

one,

other

clinical forms

two

of

hereditaryform transmitted by semen

The
in acquired disease.
syphilis

transitional

and

represent intermediate

the formations

majority of
belong now

steps,and

appear

to

type.

particularlymalignant syphilis;

and

other

the

in the

one

in the so-called

"

galloping
latter is characterized
by the rapid development
after infection
of destructive
rescences
(pustularand ulcerating)efflobeginning a few months
uninfluenced
and
in
succession
often
in
numbers,
which,
by our
rapid
very great
otherwise effective treatment, frequentlyenough jeopardizethe life of the patient.
of
This clinical form of '"galloping"syphilishas speciallyreceived the name
lignant
mawith ''grave
syphilis (as,for
syphilis" and therefore is not to be confounded
true

"

ovum,

"

"

"

"

It may

instance, syphilisof the brain, etc. )

this

to
gallopingsyphilis,

of

the

gummata,

of

speak

emphasized

also be

gummous

insidious

processes.
and the

development

here

that

it is erroneous,

Preciselythe

"

"

slow, indolent

course,

is lacking.

hereditary syphilisis certainlythe highest degree of infection

number
imagined, which will be evident at first sight from the insignificant

Furthermore,
could

be

foetuses
syphilitic

maintain

who

in these

Wherein,

two

in

essential characteristic

that
of

life.

are
categories,

we

to seek

the

reason

of

the

malignant,

grave

course

inculpate the quantity

place,as to the hereditaryform, I think I must
the
of the virus at once
overwhelming the organism. The idea suggests itself to make
of the disease.
weak
responsiblefor the grave character
organism, incapable of resisting,
be considered, however, as
It should
opposed to this view, that acquired syphilis,in
children but a few months
run
a malignant course.
old, does not by any means
of
the
know
to
better
I
no
explain
varying intensityof inherited
Besides,
way
in
in
to
the
which
decreases
proportion
increasingage of the parental
malignancy
syphilis,
rarily
syphilis,than by the gradually lesseningquantity (partlyspontaneously,partly tempoIn

the first

by mercurial treatment) of the virus present in the parents and transmitted to the
offspring.
the attempt to find the cause
of this unusual
course
Again, as to gallopingsyphilis,
the
be
harmonize
not
to
of
could
made
in the debilitated,non-resistant
quality
body,
with clinical experience.
No support has been offered for the view that there are specific
qualitiesof the virus
know
an
epoch in which
syphilisexhibited
(that is,qualitativedifferences).But we
the
described
form, namely, its spread throughout
as
malignant
only the character
all European countries at the end of the fifteenth century and the succeeding decades.
differences between
to the view of the qualitative
The
study of this epoch brings us nearer
"

"

the virus of that time

To

of

does not

"

one

attack

the

immunity.
It is

decades
as

of the disease,and

fact

taken

malignant

observed
root

factor

hitherto

relied

upon

"

the

varying quantity

question two points of view, not mentioned

above,
immunity against a second infection acquired by
besides, the hereditaryqualityof the disease as well as of
of this

consideration;namely,

into

to-day.
the

suffice.

in the discussion

However,
come

that of

explain this malignancy,

virus

the

and

the

also in other

among

diseases when

nations

they

and

attack

diseases

epidemics which have for

produce comparatively benign affections,appear
furInstances
are
a
people for the first time.

infectious

that

344

SYPHILIS.

nished

by the

of measles

first appearance

on

the Faroe

Islands,the introduction

of

leprosy

Islands.

into the Sandwich

iu Europe when
explainsto us the malignany of syphilison its first appearance
in the majority of instances ; they also give an
with the presentbenign course
explanationof the varying character of the disease in the several European countries.
said to prevail,
for instance, in Spain.
conditions in respectto syphilis
are
The same
which
manifests
in the
itself especially
There syphilistakes a remarkably mild course
children.
The
of
number
of hereditarily
this feature is attributed
cause
syphilitic
very small
to the immense
spread of syphilisfor generationsin all classes of the populace.
of the disease rest on
Does this enfeeblement
a
gradual decrease of the malignancy
of resistance ?
of the virus ; or on an increasingpower
tion.
Both
are
likely. It may be, too, that both conditions stand in a certain correla-

This

contrasted

of resistance
to the infection ; this
point : the power
of
its highest degree in the incapability
reach
would
being affected at all. Man
has
does not possess this immunity
a
spontaneously, but it is acquired when
person
infection then is as good as excluded, a fact
disease ; a new
passed through a syphilitic
of real reinfections against the great many
cured
of
borne out by the small number
cases
and
the
exists
in
in
This
we
even
indubitably,
syphilis
syphilis.
immunity
possess,
and
difference between
above-described
a syphilitic
tomical
a primary induration
papule, an anaof the modification
landmark
of the tissues representingthe immunity : in.the
cells which
in later forms
connective-tissue
indurated
no
ulcer, hyperplastic
longer occur
of syphilis.
in its original
If this acquiredimmunity could be transmitted
to posterity
strength,
be protectedagainst syphilis. This is not the case, any
the succeedinggenerationwould
transmitted
But a certain degree of
unmodified.
than. other acquired qualities
are
more
has alreadyled to a greaterresistance toward
has been inherited,which
modification
fected,
the effect of the (originally
unchanged) syphiliticvirus. But if this generation is inat the same
The latter is,as it were,
time a weakening of the virus.
there occurs
under less favorable nutritive conditions, and hence its qualityis weakened.
measles,
benign than the first attack, in syphilis,
(So also are reinfections always more
scarlatina,etc.)
of resistance and
Let us pictureto ourselves
these processes : increase in the power
l
ess
of
the
favorable
continued
in
the
virus
soil,
progressively
through
thereby weakening
of the malignancy in nations
generations,would easilyexplain the diminution
many
Let

us

consider

the latter

"

"

"

"

thus

affected.
diminished

of the

entire character

of

the disease of

to-dayagainst
immunity.
But
of
resistance
the
this leads not so much
increased
to an
against
syphilitic
power
virus as to a lesseningof the intensity
of the virus,because the latter has developedunder
less favorable conditions from
ulence
generationto generation. A diminished virprogressively
of the virus,therefore,is the permanent result attained by syphilistransmitted
through generations. The resistance acquiredby the singleindividual toward the effect
the disease of a German
who became
virus is of less importance. Thus
of an unmodified
virus has graduallyattained
infected in Spain is benign because, in that country, the syphilitic
the Europeans who acquirethe disease,for instance,
a greater benignancy ; while
The
of
the same
in China, suffer from
it in almost
cause
malignant way as the Chinese.
in China
this malignancy of syphilis
is ascribed by authors to the fact that the disease is
The

malignancy

that of old, therefore,could

well

be due

to the

continued

transmission

of the

345

SYPHILIS.

This
brings us to another factor to
entirelyunheeded, receiving no treatment.
virulence of the poison the inthe
fluence
concede
of
the
must
which
diminishing
capacity
we
to
in
is
the
able
a
course
of therapeutics. Just as the latter
singlecase
modify
of generations the character
of the
it likewise modifies in the course
of the disease
so

left

"

"

virus,in

the

explained.

above

manner

the immunity enjoyed by those apparently healthy

have borne
signs of syphilis,
showing any objectivelydemonstrable
in
the
the
father's
and
f
rom
children hereditarily
side,
great majority of cases
syphilitic
their
these
infection.
teaches
that
from
nurse
women
are
Experience
may
exempt
infection
without
the
of
children
healthy wet-nurses
danger, while
syphilitic
hereditarily
to deal in such cases
Have
with immunity
we
by such children is not of rare occurrence.
for

It remains

women

us

to

consider

who, without

is inclined to assume
the latter,from a gradual
? Hutchinson
disease of the women
or
poisoningof the maternal organism by the foetus. This view is based on the observation,
of tertiary(gummous) processes
occurring in later years, without any secondary or even
been
ever
present.
primary symptoms having
It is also possibleto imagine immunity without
disease,similar to the immunity
but
not
is acquired,
toward
variola which
by variola,
by vaccinia.
for

It still remains

to state

us

that the

above

relations between

mother

and

child

opposite direction,in this way, that the syphilisof a

may
to later
infection.
woman
acquired after conception may render the foetus insusceptible
it can
be brought into perfect
of syphilis,
As regards the hereditarytransmissibility
virus.
This appliesto the two modesharmony with the bacterial nature of the syphilitic
o
f
the
understand
^Hieredity'' syphilis; we
ordinarilydesignated
by it,on the one hand,
whether
the
of
father or the ovule
the infection of the first germ,
semen
a syphilitic
by
of the diseased mother, or both, *. e., "genuine heredity.'' On
the other hand, however,
intra-uterine infection of the foetus,healthyby concepwe
apply this term also to
tion,
but one
a rare
by syphilisacquired after conception by the mother
occurrence,
This
latter possibility
nevertheless
positivelyobserved.
appeared improbable to some
fixed
said
to pass
to be unable
authors because the
was
syphilitic
contagium
through
the septa between
and foetal placenta. But since Spitz has furnished
maternal
the proof
that
of relapsingfever are able to pass that way, and
since the same
the spirilla
power
in the bacilli of anthrax, nobody will, at least a vriori, deny the
has been demonstrated
similar property to the bacteria of the syphilis.
of syphilisby semen
In proof of the
and
refer to the
we
transmissibility
ovum,
This disease (pebrine,gastine)
is
analogy with the corpusculardisease of the silk-worm.
and
affection
which
found
in
the
blood
infectious,
are
hereditary
an
during
epidemic,
small
of the diseased
and in all organs
of the
caterpillar
glossycorpuscles(corpuscles
have
These
been
recognizedas schizomycetes.
cornalia)which
(remarkablylarge)cocci,
also manifest

itself in the

"

"

"

"

"

however,

occur

also within

Furthermore

we

are

the

ovum

indebted

from

which

to Pasteur

the diseased
for the

young

animals

are

experimental demonstration

oped.
develthat

heredity of the corpuscles takes place also when an affected father impregnates the
tion)
healthy mother, and the latter,remaining healthy,lays diseased eggs (paternal infecaffected
and
is
diseased
the
mother
when
also,
lays
;
eggs.
Now, what has been observed with these large cocci of pebrine is at least oonceivable
for the organisms of syphilis!
AVe have already spoken of the various degrees of intensity
of the syphilisoccurring
in fcetuses and its regular moderation
(proportionalto the increasingage of the diseasa

the

346

SYPHILIS.

in the

parents).
syphilis.
Although it

authenticated

But

few words

has

been

of this

be added

must

much

talked

tardy form

about

the form

termed

fact is that

about, the

there

tardy hereditary
is

positively

no

record.

By tardy hereditarysyphiliswe undertand

form
a
appearing with the symptoms of the late stage of syphilis(gummous
pharyngeal and nasal ulcerations, swellingsof the bones, etc.),from five to ten or
after
of the disindication
ease.
more
birth, without
having previously shown
years
any
we
might explain these cases, inasmuch
as
are
Theoretically
they
analogous
affections which, in acquired syphilis,may
to those gummous
follow the early forms
case

interval of years,

sometimes

after

an

with

transmitted
hereditarily

with

that

gummous

alteration

of the

processes.

This

relegateback, first,to
have

to create

on

which

germs

tissue which

anomaly of
syphilisof the

tissues in
pathological
of

if

foetus

of

even

we

decades.

have

always

felt forced

tissue and
semen

Hence

or

its

ovule

we

remained
to

should

have

latent,

and

in

presuppose

the

to

deal

besides,
case

of

origin in tardy syphiliswe could

which
from
the beginning would
Second, in the

specific

manner.

case

of

of infection,
in

utero
a
comparatively weak,
healthy conception,taking place
by
of a syphilis
way of the placentalinterchangeof blood, the absence of earlysymptoms
seem
manifesting itself subsequentlywould
capable of explanation. It is well known
has suggesteda similar theory of the transmission
of virus in explanatbat Hutchinson
tion
of
infection
the
mother
of choc-en-retour
an
{i.e.,
by
patre syphilitic
foetus).
of the cases
But
of so-called tardy syphilis
thus far reported can
in none
preceding
is always an
of
excluded.
There
disease (withoutearlyforms) be positively
absence
medical
observations.
For of course
little
non-syphilitichistory attested by accurate
of the patients
their relatives that the children
reliance is to be placed on the statements
or
of error
lies in disregardingthe exhave always been healthy. Another
source
ceedingly
first
in
of
life.
the
I
content
of
occurrence
syphilis
acquired
frequent
years
myself with enumerating brieflythe most frequent modes of infection : infection during
the passage
through the parturientcanal ; from the midwife ; from the wet-nurse
;
relatives by means
of kissing,
from
domestics ; from
bed, etc. ;
sleeping in the same
during vaccination ; during ritual circumcision ; by attempted rape, etc.
to all this the
add
If we
comparatively great benignancy of infantile, acquired
u
nder
especially
syphilis,
proper treatment, we shall not be surprisedthat tertiary
toms
sympthe infection could
because
no
are
longer
interpretedas tardy hereditarysyphilis,
'a

be traced.

obtain the
we
Surveying again the entire picture of syphilisfrom our standpoint,
theses
:
following
I. Infection. The bacteria enter the organism at any part of the surface of the
into the plasmatic
body where the lack of epidermis or epitheliumpermits penetration
channels.
The

virus

the circulation
II.
noticed

Then

remains
and

the

at once
enter
germs
point of infection,but some
the
of
infection.
to
point
appertaining
glands
lymphatic
stage of the first incubation, during which nothing can be

and

effect of the

then

at

the

rest in the

follows

of the presence

teria
bacteria ; but in that time increase of the bacthe
and
neighboring lymphatic
point of infection

certainlytakes place at the

formation
of the primary
glands ; finally,
;phaticglands.

affection

and

swelling of

the

primary lym-

347

SYPHILIS.

Saturation of the

III.

organism by
lymphaticglands.

in the

and

the bacteria

multiplyingin

the

tion
primary affec-

disease of thq several systems : glands, skin, mucous

Gradual
membrane, etc.
them
in the so-called
of the bacteria and harbor
glands become the depositories
latent periods.
these germs
Either
V.
are
spontaneously or by energetic,persistenttreatment
else
the
are
preserved,and,
finallydestroyed,or
germs
VI.
Relapses follow the intervals of latency,largerquantitiesof the bacteria again
IV.

The

to the circulation.

gainingaccess
The

VII.

nearer

presentin the

body.

to the

date of

infection,the largeris the number

Hence

in later

periods:

1.

Gradual

decrease

in infectiousness.

2.

Gradual

decrease

in the

3.

Rarer

VIII.

the

At

basis for the

time

same

of foci of disease.

occurrence

has been

there

chemical

graduallydeveloped,perhaps by

of the tissues which

modification

the bacteria,a

by-products of

capacityof hereditarytransmission.

but isolated

and

of the bacteria

in later

stages forms

the

forms.

gummous

bacteria

ficient
syphilisand, if used in sufthe
a
capable
preventing
development of the
long
iodide furthers
the absorptionof the neoplasms ; those of
stage. Potassium
gummous
those of the gummous
the earlystagein a slighterdegree,most
strikingly
stage.
lies
Respecting the varying malignancy of the disease,aside from constitutional anomaconsideration
enter
into
the
there
:
originallypresent,
of the virus at once
the quantity
1. Chiefly
overwhelming the organism; hence the
IX.

Mercury is
quantityand

the

dependenceof
2.

'

In

of their

virulence,

so

that

after

morphological qualitiesand
transmit

Eine

confirmed

of

experiments,

den

auf
and

of

malignancy

suffered

and

one

the

weak-

gus,
fun-

same

Pasteur, Touasaint, and

Chau-

incubation,

weeks

some

have

might

possible, by speciallyarranging the experiments, particularly

to deprive the fungi of anthrax
and
more
more

was

propagative

Entgegnung

these

into account

the virus,which

positive information.

more

they finally became

remain

powers

respective degrees of virulence

their

impfung.

(seeIX.).

treatment

quality, i. e., the variable

changing

only lately again acquired

had
previouslyfound that it
by increasing the temperature

veau

of the

the energy

on

of

of

changing quality'of

to the

reference

the

poison for
time, is

course

Possiblyalso

have

we

direct

for

to their

Pasteur

von

altogether

unchanged.

harmless.
thus

Fungi

Withal,
modified

the

even

descendants.

Koch
die Milzbrand(" Ueber
gehaltenen Vortrag," 1881) has recently

in Genf

therefore, in the doctrine

of infection,

changing virulence

of

morphologically

identical

temperature, there

is

certainly

whole

series

of

and

the

henceforth

must

we

bacteria, depending

take

external

on

conditions.
Besides
and

the

inherited

long

been

even

learned

sheep,
races

react

show
for the

which

immunity)

knowii
that

that

not

modify

the

similar

same

variations,or
diseasr-producers is

development

other

factors

even

not

species is receptive of any and every

mice,
animals, such as field and domestic
virus, and
that within

always the

hence
the
same.

it will
same

appear

(e. g., acquired

qualitiesof bacteria.

animal

every

closely related

differently on

the

disease;
or

plausiblethat

various

It has
have

we
races

different

of

human

the receptivity of the several individuals

tina,
history of leprosy, of yellow fever, scarla-

race

The

In fact, this circumstance

typhoid fever, etc., abundantly illustrate what has been set forth above.
is nothing else but what
we
continuallyobserve in the cultivation of bacteria, viz.,that even
opment
the most
retard the develinfluence
or
insignificant alterations of the experimental conditions
may
of the

organisms.

tigen Standpunkt

der

blatt,March, 1883, pp.

(Comp. the very commendable

Pilzlehre
53 et

mit

seq.)

Rucksicht

auf

essay
die

by Lichtheim,

' '

Ueber

den

gegenwar-

Infectionskrankheiteu,"in Aerztl, Vereins-

348

GLANDERS.

the

ening by

immunity

immunity

in the

due

previousdisease

to

of many

course

and

further

transmission
hereditary

of this

generations.

1^7. GLANDERS.

For

the

of
description

"

''

I refer to the
paper

malleus

glanders

by Bollingerin Vol.
A detailed discussion
because
appeared superfluous,
Bollinger
shares our
conviction, culminating in this,that in glanderswe have to deal with fixed,
i. e., organizedcontagia,and because, since the publicationof his essay, our
knowledge
of the nature
of the contagium has, unfortunately,not been widened.
III. of this Handbook.

Postscript.

I abstract

In the

solution

first

place,a

and

embedded
bacilli

"

form

certain

of bacteria

searched

was

killed

of

account

on

of
In

glanders.

treated

with

whether

these

bacilli

for in

tissue

specimens

with

concentrated

aqueous

acid, dehydrated in alcohol,

acetic

rods having about

the size of
present in the specific products. In

then

slender

were

causal

in

specific products of glanders,

lungs, spleen, liver, and nasal

stained

greatly diluted

stood

the

the

from

relation

glanders,

to

cultivation

was

to.

On

the

14th of

September, according

tuberculosis, a number

charged with

were

spleen of
on

"

in oil of cedar, there were

found
and
now
other
forms
of bacteria
tuberculosis; no

of

of the bacilli of
serum

cation
Wochenschrifta
preliminary communiHealth by Dr. Struck, which have led to the

of

Imperial Board
glanders :

methyl-blue, afterwards

determine

to

resorted

Medicinische

farcy buds, by staining sections

horse

of

the
order

the bacillus of

so-called
of

septum

the Deutsche

the labors of the

on

discoveryof

the

from

horse

the third

day there

drops which

of

glanders.

noticed

were

formed

had

has taught with reference

to the cultivation
reagent-glasses containing horse or sheep blood

particles carefullyselected

because

killed

Koch

to what

of sterilized

scattered

in the
the

on

In the

from

glanders tubercles

first two

days

majority of the glasisesnumerous

surface

of

the

developed in them,
to their

reference

the

experimenters

original relations

inclined

were

glanders by

to

these

test

to

into

reinocculation

lungs

noticed.

and
But

translucent

contained,

the covering glass, countless

above-mentioned
fine bacilli of the
on
staining them
the drop existed uniformly
in nearly all of the culture
as
vessels, and only this
had

the

were

small

These

serum.

from

changes

no

little

shown

as

size.

by

Inasmuch

teria
species of bac-

one

bacilli

animals

in

immediately

receptive of the

disease.
in order

But
material

continued

were

From
small
into

for

the

should
the transmission
be successful, that the inoculating
particles of the original charge of glanders material, the cultivations
through four generations.

objection,if

both

about

After

about

be

to

knotty cords

of

week

transition

an

to have

yielded

from

the

the

inoculation
the

month,

ulcers

improved
a

so
as

red

into

the

to the

swollen

developed, from which

glands of the throat and shoulders, so that

that

doubtful

it became

glanderous.

On

November

whether
25th

the
the

nasal
On
the
septum
surprising result.
into the pharyngeal
numerous
ca%'itythere were

most

nasal

areola, and

at

the

fine bacilli,a
and
pituitary membrane
mal
forty-eight hours the ani-

clinical picture of glanders.

horse
presented the pronounced
began to cicatrize, tho glandular swelling decreased, the animal

nodes; in the lungs, old fibrous, likewise

with

inoculated

After
apparently healthy horse.
deep ulcers
points of inoculation

extended

vessels

lymphatic

14th, and

October

on

actuallyinterpreted

post-mortem

cultivation, containing nothing but the above-described

old, otherwise
feverish; at the

of
very

after
one

appeared also
be

month

abstracted

was

shoulders

began

resulting fourth

quantity

should

the

to meet

perhaps still contained

root

of

calcified
the

lung

nodes, but, besides,

a

glanderous growth

symptoms
animal
as

some

well

after

as

inoculation

killed, and

was
on

the

the

points of

white, in part stellate

quite fresh gray nodes
about

the

size

of

an

apple"

350

GLANDERS.

bone

dried

formed

the

on

Both

fallingoff

continued

animals

On

thick

with

covered

were

yellowish-white fluid exuded

pasty and

circumference

be

followed

of
of

day, and

to

and
of

that

to

pea

the

and

of

and

at

the

turbinated
bottom

the

size of

the

size of

body

of

In

margins.
of

pea,

which

the

lungs

larger

of

eroded

nearly
ish-white
yellow-

or

vessels

could

possible
from

the

nasal

the

borders.

that

to

of

the

In

to

of

latter

lary
submaxil-

hazel-nut

couAtless
the

wise
like-

the

The

to

size

septum

whigh

epiglottiswas

found
due

were

had

was

found.

were

were

it

become

swollen, soft, and

mucosa

up

latter

were

lymphatic

yellow

ranging

were

surface

had
of

lymphatic

former,
node

The

and

beans

the

ulcer

an

nodules

confluence

from
smaller

of

areola.
In many
of the
by a reddened
consisting of a yellowish-wliite,
pasty, often fluid

surrounded

centre

of different

fluid

nodules

anterior

of

the

having

gray

of

the

at

On

patches.

or

size

the

turbid

gray,

nodes

were

The
small

The

the ulcers

cords

the shoulder.

almost

ulcers

yellow

mucosa

elevated

to that

of

seat

nodes

the

had

latter contained

of the

muscles

the

was

with

died.

one

hairs, and

purulent fluid and

inguinal glands

and

yellow

ulcers, small

In

which

millet-seed

The

ones.

dime

axillary

contained

yellow patches.

the

The

bones
the

of

lymphatic glands
inclosed

had

formed.

and

beneath

tissue contained

glands.

lymphatic

above-mentioned

the

moist

and

larger, had

connected

glands of

to the

soft, yellowish-white,

with

older

of secretion

parts beside and

were

the

13th

points of inoculation, too, cords

other

bean.

interspersedwith

extended

soft

the neck

on

their reddened

neighboring

there

products

infiltrated

was

ulcers

December

on

and
quarter-dollar

The

crusts.

ulcers

The

and

egg

the

as

the

parts.

finger which

From

far

here

demonstrate

around

hen's

patches.
as

by the side of the

corium

thickness

the

the

day

consisting of the dried

crusts

underlying

the

from

vessels

The

fluid.

detached

of

from

post-mortem yielded the following results :

all the points of inoculation, ulcers, the size of

The

nostrils

the

margins

pituitary membrane.

the

on

ulcers

had
Withal
animals
both
elevated margins.
a
discharge from
edges into thin yellowish crusts ; finally small ulcers with elevated

exhibited

and

which

sizes

mass.

which
then already
the result in the older animal
was
so
as
positive,the younger
one,
December
13th.
At the post-mortem, performed
immediately
killed on
great debility, was
found.
were
afterward, the following alterations
The
At the points of inoculation, large ulcers secreting a thin, yellowish-white fluid.
sore
on
Inasmuch

exhibited

of

dorsum

the

and

maxilla

smaller

thick

as

was

nasal

ulcers

as

which

in the

skin

far

as

of

as

the

down

formed

the

the

of

size

sores

and

hen's

right thigli,and

the

had

the

muscles.

on

From

the
them

periosteum

point
with

of

bloody
the

on

one

of the

upper

inoculation

in the
eral
Sev-

masses.

sheath.

From

lymphatic vessels,set with nodes and as

The
glands of the shoulder.
nodes, which
of

swollen

The
shoulder-glands
grayish-yellow patches. From
extended
chest after inoculation, the ulceration
rium
deeply into the coof lymphatic vessels the thickness
several cords
of a goose
quill
inclosed

soft, and

egg,

formed

which

the

covered

lay partly in, partly alongside the lymph-vessels, contained

were

to

close to this

its bottom

neck, cords

part of the

upper

had

smaller, and

somewhat

be followed

extended

dollar, and

ulcer

also found

the

on

large
The

was

were

finger, could

as

bone.

region

situated

ulcers

the

nose

frontal

of the

skin

the

of the

number

pus-like fluid.

of

small

and contained
The
latter were
several
the axillary glands.
as
large as a walnut
ish-white
yellowin the region of
The ulcers at the points of inoculation
patches the size of a millet-seed.
infiltrated with a turbid
fluid.
The
the flanks were
shallow, and the tissxie in their neighborhood was

extended

to

end

lower

of

the

in

ulcers

which

had

their seat

the

on

of a hen's egg ; it was

the circumference
The right inguinal gland had
soft,juicy, and
of smaller
dimensions.
The
color; the left inguinal gland, though similarly altered, was
tissue

therein

of

the

of

their

of

was

ulcer

as

large

sheath

the

on

size which

was

gelatinous consistence, and

were

as

extended

filled with

into
a

fist,and contained

the

the

also

necrotic

Several

turbid

reddish
taneous
subcu-

glands situated

lymphatic

subcutis.

yellowish-white

ternal
ex-

muscles

fluid.

piece of muscle

tained
con-

cavity in
the

length

digitalphalanx.
The

gray,

The

different

semi-membranosus

the

sheath

enlarged.

were

cavities

of

the

was
swollen, especially near
posterior metatarsus.

right thigh

side of the

mucosa

of

both

nostrils

partly yellow in color.

with

undulating

eroded

margins

Here

and

surfaces, had
and

bottoms

set with

was

nodules

numerous

and

ulcers

the

former

partly

there, by the deposition of the nodules, flower-bed-like

formed

covered

with

the

ulcers

fresh

due

nodules.

to

disintegration of
The

mucosa

around

the

nodules

the

ulcers

lings,
swelhad
was

of

the

largely affected.

most
red

edges

The

injected.
on

section, and

lung

of the

lymphatic glands

size,having
rather

was

and

several

glands

of

and

moister.

The

size of

anterior

were

passages

walnuts, firm, movable

mediastinal

and

found

were

latter
the

six

the

renchyma
pabronchial

The
juicy.
spleen was
sliglitly
enlarged, and its parenchyma
of the trunk
Liver, kidneys, heart, and the muscles
presented the
slight cloudy swelling.
were

enlarged, soft, and

have been quickly confirmed

investigations
PathologicalInstitution in Berlin.

V.

This

the

were

yellowish-white patches. In the lungs

and
a reddened
periphery. In the

by

These

the

portions of the nasal

uppermost

centre

gray

firmer

the

lymphatic

blackish-brown.

soft and
appearances

bones

spongy

submaxillary

interspersed with

of millet-seed

nodules

The

351

TROPICA.

FBAMBCESIA

YAWS,

work

undertaken

by

Israel at

TRACHOMA.

occupiesone of the principalplaces among

contagious diseases,in
Recently Sattler has also described micrococci (as
exceptionalconditions.
which
the pathohe interprets
well as experimentalinoculations with their cultures),
as
genetic
trachoma.
of
the
disease
of the conAnatomically,
junctiva
micro-organisms
granulating
be set down
as
a type of a
can
leucocythoma : sphericalpatches of round
cells,
of the most
delicate fibrillae,
which
extends a network
between
the
spring up between
into the depth which
tween
cones
probably represent also the septa bepenetrating
epithelial
the microscopically
recognizablegranules. The vascular dilatation and formation
spiteof

affection

some

opment
deeper,loose connective tissue is of a very high degree. The develto
be
seems
I
have
not seen
granulomata
a true
very sparse.
in its stead another denecrosis of coagulationin the small nodules, but have observed
generative
nuclei perish and
the protoplasm. The
can
no
longer be
process affecting
into the smallest particles;
the protoplasm of the cells
of them
disintegrate
stained, some
cells
outlines
of
the
that
the
of these spots makes
visible,
so
one
remaining
clears,only
of
delicate
which
has taken
the impression of a network
exceedingly
composed
fibrillae,
the place of the granuloma aggregation.
in the tissue of the granulations,
his micrococci
had described them
Sattler had seen
and with
these again
as
resemblingthe cocci of gonorrhoea,produced pure cultivations,
of mast-cells

in the

of vessels into the

in

effected trachoma

had

Krause

man.

and

absolutelynegativeresults.
Therefore, the questionof the bacteria

I have

examined

numerous

specimens

choma
of tra-

with

of trachoma

may

still be considered

an

open

one.

VI.

Framboesia
termed

by

The

YAWS,

FRAMBCESIA

TROPICA.

tropica,unknown
us, is a disease closely
resemblingsyphilis,and
among
affection.
a pseudo-venereal

authors

some

disease is endemic

to Lancereau,- it is met

with

the negroes of the west coast of Africa.

According
among
also in Senegal,Congo, Sierra Leone, and Nigritia. Milroy

dies
largerterritory. Slavers transportedit from Africa to the West Instates. Besides, it is now
all
the
inhabitants
spread among
of the Indian
on
of yaws or
archipelago,the Malays (especially
Java), under the name
it
is
the
In
Peru
known
and
of
bubas
names
by
plan.
verrugas.
In general,the black and colored races
are
more
subjectto the disease than the white
is easilyexplained by the better care
a fact which
race
of the skin and more
favorable

ascribes to it
and

even

the South

American

"

conditions

of life in the latter.

"352

FRAMB(ESIA

YAW8,

In reference
The

to the

follow the descriptionof Pontoppidan.

in the shape of
contagious disease of the skin, which
appears
of the general
risingbeneath the epidermis,without material disturbance

affection

small

nodules

health

; when

is

course

disease,I

the nodules

the

and

of the

TROPICA.

have

reached

round, elevated, as

it

the size of peas, the covering epidermis desquamates,

tumors
nummulated
acquire a thick, firmly

were

adherent, yellowishcrust, resembling a dirtyivory faro check, or

of cheese.
When
structure
the crust is detached, there

round, smooth,

ton-like
but-

dish,
reda weeping
appears
like a mucous
elevated surface,looking almost
ulcerating,
papule. If it be
if it be treated with irritant drugs, it may
or
greatlyelevated and proliferating,
approach
the appearance
of a raspberry. If the tumors
have their seat in the ano-genitalregion,
they may easilysimulate mucous
exposed to the air, the
papules ; but on parts more
face and
the extremities,for which
exhibit
a
they
preference,they always have their
s
mooth
crust.
dirty-yellow,
Eecently Charlouis has proposed the title polypapillomatropica,and I can confirm
the anatomical
the microscopicspecimens kindly forobservations
of this author
from
warded
form is identical with the f ramboesia
to me.
Anatomically, the tropical
occurring
with
in 1869
described
was
us, which
by Kaposi as "framboesia
non-syphilitica sive
and which
I myself have seen
dermatitis papillomatosacapillitii,
several times.
In both we
find broad, not very high, flesh-red excrescences
sessile on
flat base,
a
with an
bear the greatest resemblance
to dry,
raspberry-likesurface, which
uneven,
broad
syphilitic,
condylomata, and microscopically,like them, prove to be proliferations
of the rete Malpighii combined
with inflammatory processes and enlargements of
that
the corium
and the papillae. Therefore, neither the tropicalform
observed
nor
tumors.
inasmuch
to
the
class
of
have
laid
us
as
But,
we
granulation
belongs
among
the
factor
of
infection
chronic
down
with
the
from the beginning
main
teristic
characcourse
as
of affections,we
claim that this disease has the right to be
of this entire group
in this place.
considered
from
treatise the following most
essential points in the
the Charlouis'
I abstract
of
this
disease.
pathology
but

not

"

1. Framboesia

is

2.

It is inoculable

3.

The

same

infectious

an

both

on

disease.

patientand

healthy men.
by the

on

several

be attacked

can

person

the

times

disease.

from
themselves
from
or
others,
patients,inoculated with matter
But
these
develop either an ulcer resembling a soft chancre, or else a fungous tubercle.
the existingdisease
influence
inoculations do not exercise the slightest
on
the disintegrating
5. Both the socretion from
neoplasms (tubercles)and the blood
4.

from

Framboesia

the

is infectious,and

same

6. The

with

the

virus

when
8.
9.

neoplasms

at their acme;
The

their

or

whenever

stage of incubation

of the inoculation
cause

infection

of both

only by

are

direct

alike.
contact

While

locate the

is associated
the

products are infectious only in their developmental stage

they begin to dry up, infection is no longer possible.
may

Fever, accompanied by

eruption,and
10.

fixed

consequences
contagium, and can

skin.

7. The
or

is

the

with

three

gastricdisturbances
it for

generalinfection

place where

last from

some

to five months.

and

pains

ih the bones,

precedes the

time.

usuallypossibleto approximately
the nearest gland is the most
body, because

is stillrecent, it is

the virus entered

the

enlarged.
I wish

to

add

that

the

assertion

formerly made,

that

framboesia

and

syphilisare

TAWS,

identical,is

Both

erroneous.

FEAMBGESIA

353

TROPICA.

clinical observation

and

experimentalinoculation

have

the conta-

another.
That
that both diseases may exist side by side or succeed one
gium of framboesia is a bacterium will not be doubted in the presentstate of bacteriology,
to be furnished.
still remains
although the demonstration
it is recognizedas contagious.
In Domingo
Indeed, wherever the disease is known
it had spread so much
that some
all
seized
the
were
patients
by
policeand
yeai's ago
yaws
found
until
cured.
It
when
this proimmured
that
in special
was
were
hospitals
they
cedure
its
carried
diminished
and
the
disease
was
was
out,
materially
spread
rigorously
invariablytransmission from other yaws patientscould be
largelyprevented. Almost
shown

"

demonstrated

as

the

cause

of the affection.^'

tropicawe shall discuss the anatomicallyrelated

(Kaposi).
papillomatosacapillitii
dermatitis
mean
we
papillaris
capillitii
larger and smaller, many-furrowed,
By
lobulo-acinous tumors, several millimetres in height,of very firm consistence,generally
covered with thick epidermis,weeping only at some
points,and usuallysituated on the
of
the
Their size varies from that of
and
the
borders
nucha.
hairypartsof the occiput
dollar ; at times the several nodes
or
a
a quarter-dollar
even
a lentil to that of
merge
the surface of half the scalp. The
surface
which may cover
togetherinto proliferations
shows a rose-red or bluish-red color ; it is either bald, smooth, glossy,or covered with
and then it secretes a stickyviscid fluid. The hairs projecthere and
yellow crusts ; now
into
crowded
there,
wisps or isolated,from the grooves and furrows of the uneven
mass,
the greaterpart of the latter. The individual hairs could be withdrawn
but are lackingover
If
of
the
morbid
tissue
with
removed
the
are
portions
only with difficulty. some
An
abundance
of blood exudes from
scissors or knife, they creak on section.
numerous
points on the cut surface. The patientfeels no greatpain either on pressure or on
section.
Hyde states that when an incision is made into the centre,a considerable quantity
A sort of subcutaneous
of pus wells forth.
cavityforms which again and again fills
inflammation
of the deeper layers
with bloody fluid. Hyde believes the disease to be an
observed
several years.
of the scalp. The duration in the cases
was
This afEection belongs to the large class of new-formations
termed
framboesia by
which
these authors delineated only the tropical
infectious
name
Willan-Bateman, under
disease resemblingit anatomically. Besides it correspondsto the mycosis framboesioides
it under
erected by Alibert who included
syphilis.Eeally,however, it has nothing to
frambcesia
do with syphilis. Hebra
for all irregularlyverrucose
employed the name
matter
what
base they had arisen
chronic ulcers of
no
on
on
papillaryproliferations,
the foot, on lupus,on syphilitic
ulcers,etc.
In a few cases
is quiteunknown.
the beginning of the new-formation
The ETIOLOGY
followed a traumatic lesion leadingto cicatrization.
to be most
The
disease appears
nearlyrelated to those cases of sycosisin which
have formed.
But
syconoid,fig-like
proliferations
Kaposi disputesthe relationshipof
the two processes.
There is an absence of all the essential symptoms of sycosis,
i. e.,
pustulesfrom the pointsof which the hair projectedwhich could have been pulled out
with the greatestfacility
appeared impregnated with pus ;
; the root-sheath of which
there is an absence of the reddened, slightly
desquamating, almost eczematous
parts of
the beginning we
the skin.^' From
with firm nodules, of uniform
meet
consistence
In

connection

framboesia

with

framboesia

sive dermatitis

"

"

without

pus.

(Mycosis fungoides Alibert,or

Kobner, are altogetherdifferent from
23

the

beer-fungus-like
multiple papillarytumors
affection.)

this

of

354

EHIN08CLEK0MA.

Teeatmekt.

viz.,ablation
Eationallythis is purelysurgical,
is
effective.
often
plastrum hydrargyri
very

of the

"

neoplasms. Em-

PAEANGI.

Under

this

Dr.

has described

Kynsey

disease

prevailingfor years in Ceylon.

during which an ulcer developson some
part of the
body, and which is followed by a stageof invasion accompanied by fever and arthritic
pains. This is succeeded by an eruptive stagewhich may last for weeks or months, and
ends either in recovery or leads to the development of ulcerations,etc.
This affection
is contagious,being propagated by contact
with the secretions of the ulcers (even on the
intact skin); heredityis also assumed.
After one
attack there exists,it seems, immunity
infections,
fresh
Dr,
to be separatedfrom,
thinks
the
disease
is certainly
against
Kynsey
and
would
rather
with
syphilis
suppose an identity
yaws.
It

begins with

name

period of

incubation

VII.

In reference

RHINOSCLEROMA.

rhinoscleroma. Prof. A.

to the etiologyof

Frisch

v.

has made

the following

communication:
"

My

of six

; the

cases

other

rendered

six

both

bacteria

mostly found

bacteria

between

them

which, under

speciesof

have

pronounced

rod

shape, but

is about

and

one-half

in

of two.

rows

(Reichert'soil

powers
would

be at

larger

distended
who
cells in

held

once

These

immersion
to be

one

relations

lie

tissue

they

rarely found.

are

the

an

directly to the reception and

lie

all the

cells

Round

side of

by the
or

more

transitions

the

from

such

as

unusual

the

Between

walls, at times
are

of

these

distended
Vertical

nucleus

the

granulated round
then

form

by step from

the

cells increase

in

or

the

In

of micrococci

cells but
the

the

in

of

periphery,
number,

epithelium almost

and

on

in

high

spherical, and

they

that

grouping

their

cocci.
and

in the

509), believes

that

this

of the

fissures

them

be round

to

is to be

metamorphosis

(often in the

It is easy

same

tered
al-

deeper layers
or

more

careful

some

places

the

exclusively composed

those

these

of

of

centre
bacteria.

altered cells are

larger stretches

filled with

above-described

find the
of

the

which

are

arranged

appear

filled

around
the

cell;

Between

seen.

inspection.
we

cells

periphery toward

over

such

few

region in which

quintuple the size,in

and

longer visible,and

in these

that

us

find

we

no

closely-packed mass

sometimes

are

cleus,
nu-

size,but the protoplasm of which

has enis only faintlyvisible,or
tirely

quadruple

even
are

rods

convince

nodes

single cell

centre

p.

bacteria.

of which

the

radially from
tensely filled with

of rhinoscleroma

in the tissue.

(1.c,

little increased

but

have

Very frequently the

are

cells free hives

sections

distributed

which

were

very

cell to the terminal

stages of these
ordinary round
few
(two or three) rods, and exhibiting a well-stained

of cells extend

rows

found

shows

cells

the

quite probable

me

cells of double, treble,or

Close by are
granulation of the protoplasm and the nucleus

finallycells

almost

with

short.

They

width.

present most numerously and distinctly in those

cells three or four times.
licz,
Mikuordinary round

the

infiuence

granulation, and

by larger quantities of bacteria.

These

be

the

containing but

less distinct

observation

disappeared.

these

could

exceedingly

are

of the

they appear

cells in detail
to

dimension

attentive

are

of

these

rods

individual
the

arrangement
cells.

the

They

diameter

the

powers,

that

of

peculiarlydistended
It seems
regressive metamorphosis.

cells.

the

state.

interflbrillaryfissures of the

clearlyrecognized only by employing

low

it not

cocci, were

exceed

cells which
describes

field)to follow

which

fresh

in the

in the

appropriatestaining-methods,

times

are

7^). Under

permits the recognition

almost
exclusivelywithin

masses

rods

The
connective

shows

opportunity of examining

cells and

certain

longitudinal diameter

traced

the

in the

visible.

These

into

I had

cases

I found

cases,

tissue

connective

of professional
comprised twelve cases.
By the kindness
disposal excised portions of the diseased tissue,stained in alcohol,

placed at my

were

In all the

The

rhinoscleroma

investigations on

friends, there

In

the

bacteria

and

alterations

greatly distended.
can

be followed

superficiallayers

layers immediately
distended

quite singularl}'-

apparently uniformly

of

forms.

beneath
In

recent

the

step
yellowish

the

epidermis

or

unstained

365

EHIN08CLEE0MA.

sections,t.hese portions of the tissue bear the greatest resemblance

cells,with their strongly refractive and, with
sharply contoured
almost
this

homogeneous

contents,

is not

arrangement
alterations

node
cell

Not

all the

spindle shape

cells,too, bacteria
here

there

and

the

nostril

the

or

soft

mode

sections

rods

the

Should

sections

but

nothing

find

we

of

can
fibrillse,

These,

be looked

probably

be demonstrated

alterations.

described

fibrillaryconnective

into

demonstrated.

be

then

the

undergo

finallychanges

all the

examination,
with

well

as

small-

nodes

tissue.
the

as

large part
spindle-

In the

small

found

groups

necrosed.

as

upon

equally on

portions of tissue

colors

anilin

the

in

from

lips and

the

hardened

are

well-known

from

those

on

alcohol, and

in absolute

and

brown,

dyes the

blue

Methylene

manner.

blue, fuchsin, Bismarck

intensely;gentian violet,methyl

most

every

palate.

stained

are

and

could

appearance

to the

As
the

and

now

can

between

above

The

at

foci.

series of

large

tissue

cells of rhinoscleroma

round

assume

in

and

oldest

only in the

that

happen

may

I must
emphasize that
vanced
part of it. These far adwe
accideimlly strike a

fat-cells.

from

node

in every

infiltration.

inflammatory

of them

all its details

obviously found

are

periphery, it

at the

hardly be differentiated

can

in

seen

to adipose tissue; the large round,

peripheral arrangement of the rods,

likewise

vesuvin

the

pigments
employed.
give good pictures. Throughout, one-per-cent aqueous
tions,
if the sections, after being taken
out of the pigment soluParticularlydistinct picturesare obtained
tion
to a one-half-per-cent solutherein, are transferred
placed in distilled water and well washed
clarified in the
and left therein
three minutes.
If then they are
two
or
of potassium carbonate
and oil of cloves, the entire tissue becomes
in alcohol
colorless; only the bacteria
ordinary manner
solutions

retain

tissue

bacteria

of the

cultivations

node, the surface

the

has

of which

the slide,drying and

on
quantity of the characteristic

(95-104"F.), a great
delicate

whitish
the

from

The
the

rods.

The

In

is

else of

or

It follows

after

rods.

The

could

instance

2. That

these

these

bacteria, furthermore,
these

bacteria
the

cells into

me

lessening of the

tissue
and
some

the

inoculation

into

unaided

ments
filaas

eye

into

F.),progresses

the

of

nasal

more

results.
the

tached
deover

ganisms.
foreign or-

gelatin (R. Koch).

water

77"

admixture

given altogether negative

naturally does not exclude

certain

form

Only

slowly.
The

non-

possibilitythat
membrane

mucous

of

of bacteria

is constantly present.
by the peculiar arrangement

have

probably produce the above-described

most

of the

of

which

cell

they

have

in the

The

suffered

not

formation

of

invasion

any

inflammatory

irritation

wheals
around
cheesy masses
suppurative processes around
other kinds of schizomycetes.

caused

phosis
regressive metamor-

penetrated.

nucleus, gradual enlargement

final

This

metamorphosis

of the cell with

taneous
simul-

change of the cellular protoplasm

connective
fibrillary

of

bacteria, which

regressive process, I think is a further essential characteristic

the specificquality of the organisms.
on
This connective
chronic

meat-

granulation of the protoplasm, and

fluid substance.

cells which

of the

to

C.

The

accidental

distinguishthemselves

protoplasm

itself by the disappearance

into

have

by

35-40"

investigations:
of rhinosclerma

tissue

Finally,that
in all those

probably

employed

and

of

lengthening

any

smaller

or

brought into

covering glasseswere
forty-eight hours, quickly dried

any

(25" C.

be

temperature

visible

movements.

I observe

demonstrate
are

larger

obtained

hours, under

not

of
the

cells.

manifests

unfortunately

always

thus

sap

fresh

animal.

other

from

in the

the

vegetations

spontaneous

no

of

If

sharp knife, and some

ourselves, by spreading
a

present almost

few

I could

transmissible, perhaps by direct

some

1. That

round

is

with

convince

can

we

quantity

increase
plentifullyalso in blood serum
temperature
corresponding to the lower

rhinocsleroma

3.

show

no

particular difficulties.

no

twenty -four hours, thirty-six,and

stained.

inoculations
Experimental
receptivity of the test animals

tissue

there

small

bacteria

growth,

man

If

persistent spores.
rods

offer

surface,

cut

short

of the

of

slides after

sulphuric acid, and

the

staining it,that

increase

cloud.

rhinoscleroma

possibleto observe,

development

the

or

it is

chamber,

moist

of

carefully cleansed, be incised

been

cautiously scraped from

be

fluid

small

were

pigment.

the

Pure

of

tissue

takes

of the morbid
tissue must

from

place by

that
the

part of the
side

of

this

perhaps ing
dependbe interpreted as a product
process,

by these

of connective
bacteria,just as the formation
in tuberculosis, or the origin of
acute
inflammatory forms
many
certain necrotic
patches produced by bacteria, is connected
with
All

observers

emphasize

the fact

that rhinoscleroma

never

leads

356

ACTINOMYCOSIS.

to the

disintegration of the infiltrated tissue, but rather

tissue."
The nature of the process
contracting connective

"terminates
be

must

in

the

formation

interpretedas

"

of

chronic

firm

mation.
inflam-

"

The

exceedingly slow

of the disease, the formation

of nodes
in the skin, the presence
course
of
cells,finallythe occasionallyperceptible occurrence
of shallow
atrophic cutaneous
cicatrices on places formerly the seat of nodes, in
reminds
of leprosy. Nevertheless
us
many
ways
careful comparison
will convince
that both processes
us
are
altogether different,that the bacteria
bacteria

in

in the

leprous tissue play quite another

of bacteria

in the

myself have

for bacteria,and

part, and

that

had

but

the result

peculiarbodies
tissue

few

ascertained

to

the

ence
pres-

of the

cells,of
which

ox,

that these bodies

were

piece

of rhinoscleroma

ACTINOMYCOSIS.

had

discovered.

was

It

was

Bollingerwho firstfound
partlyfibrous granulation

seed, in the

size of

a hempat the
formerly enigmatical tumor
usuallybeen termed an osteo-sarcoma.

acinous

opaque

formations

which

broke

anterior
He
down

and

further
under

The

resultingmasses
again were
nothing but fields of intertwined threads
Harz proposed for these formations
club-shaped extremities radiatingfrom the centre.
the name
for
the
the
disease
the
name
actinomyces,
actinomycosis.
ray fungus ;
This disease of cattle which
is to be interpretedas based on highly organized granulation
in man,
first by Israel, and
tumors, has also been demonstrated
recentlyby

pressure.

with

merely

'

color,the
light-yellow

inclosingmany

posteriormaxilla

is confined

singleopportunity of examining
case
was
negative.

since this disease

years

of

resemblance

in this

VIII.

It is but

the

cells.

Ponfick.
Of late Johne

Isovis,because

in

has cast doubts

one

case

actinomyces fungi taken

effected by introduction

on

intra vitam
either

identityof actinomycosishominis and A.

inoculatinga calf and two pigs with the
used quitefreshly. No invasion was
and
man
abdominal
cavity or into the subcutaneous

the absolute

he did not

succeed
from

into

the

in

tissue.
The

demonstration

of the disease,as well as the etiological

relation
He
neoplasm has been furnished chieflyby Johne.
succeeded
in
disease by introducingfree granules into the subcutaneous
tissue or into the abdominal
cavity. One or two months later,smaller or largertumors
which
the
under
arose
microscope exhibited the usual structure of actinomycoticgrowths.
According to Ponfick's experiments, rabbits and dogs are not inoculable.
Experiments
with feedingwere
But it was
likewise ineffectual.
possibleto produce typicalneoplasms
in the lungs by introducing the matter
into the circulation.
As to the road hj which
and animals,
the infectious material enters the body of man
shall be able to assume,
we
with Ponfick, that any part of the external surface and the
mucous
membranes
serve
as
points of entry. Johne has called specialattention to
may
the importance of the food; he frequentlyfound in the tonsils of healthypigs bristly
and
stubble-like fibres,and beards of ears
which
covered with distinct actinomyof corn
were
ces
hollow
it is particularly
teeth, etc., which are to
vegetations. In the case of man
be considered
the foci of origin and development of the fungi. But in any case
as
the fungus requires an
into the depth of
breach of tissue in order to proliferate
open
the organism.

between

'

But

of the infectiousness

the

fungi and
producing the

I have

seen

Frisch's

the

specimens

which

seemed

to

me

to be

perfectly conclusive.

358

GRAJSrULOMA

further

relapsetook place.
be most

would

For

this form

should

here

also be made

foot, the etiologyof which

Chionyphe (Carteri).

subcutaneous

connective

and
masses

can

however,

Here
of
certain

fistulous

fungus, the

of

leptothrixfasciculatus

name

disease endemic

is attributed

An

arborescent

tissue,leads

to the formation

the

ulcerations,from

should

also be

mycelium
forms

added

the

in India, known

by Carter to the presence

mycelium spreads in the

sinuous

of tubercular
of

recesses

be lifted up.
The bones
likewise attacked
are
of this disease.
doubt the mycotic nature

and

and

subcutaneous

fungus

cutaneous

and

efflorescences,
ficial
super-

which

peculiar blackish

excavated.

Other

inflammatory infiltrations produced by

fungi into the cutaneous

the Madura

as

of

tissue,such

as

the

authors

penetration
Celsi,

kerion

of

Under
this head belong
parasiticsycosisdue to Trichophyton tonsurans.
Simon
in balanoposthomycosis
papillaryneoplasms observed by Oscar
resemble acuminated
papillomata,but differ from them by being everywhere penetrated
by anastomosing mycelia. This affection is frequentlyobserved with diabetes
the

also

which

of

appropriate/'

Mention

termed

FUNGOIDES.

mellitus.

IX.

"We

has

or

an

fungoides,but
this

an

hitherto

infectious

FUNGOIDES.

affection,but one whose

thoroughlywell-known
unexplained, and in which the character of a parasitic
It is the disease termed
disease is entirelyabsent.
by Alibert mycosis
which we, with Auspitz,designateas granuloma fungoides.
most
tuberculatum,
AYilson,eczema
aptlyrepresents
by Erasmus

to

come

now

ETIOLOGY

GRANULOMA

anatomically

remained

The

title chosen

rare

disease to those who

have

not

seen

it themselves.

to that of the palm of the

patches the size of a finger-nail
with graduallyfading borders
or
hand, sharplydemarcated
ular
; oval, round, or quiteirregskin
the
e
levated.
with
The
level
at
the
or
face
sursame
slightly
surroundinghealthy
;
and dry, similar to urticaria,desqualivid color,smooth
is of a dark red, somewhat
mating,
moist and soon
or
becoming covered with yellowish-brown crusts ; these
finally
sometimes
more
deeply
(correspondingto a moist eczema) sometimes quite superficial,
extending infiltrated spotsare generallydeprived of their epithelialcovering. They do
Revered with skin, but tumors
not again become
projectabove the level of the skin, ranging
firm and solid,often slightly
at
in size from a
to
l
obulated,
are
an
apple.
They
pea
times
with a shallow depressionin the centre ; often with a narrow
pediclebearing a

There

are

formed

flat

and moist with an intact

The surface is smooth
overlappingbody, toadstool-like.
and
thin
excoriated
serous
bloody fluid which
secretinga
epidermal covering,or else
again give rise to the formation of crusts.
may
No regulararrangement of the lesions is recognizable. All regionsof the body may

broad

be attacked.
The

symptoms
subjective

are

very

variable and

consist
frequently

in

an

intense

the only prodromal symptom.

often appears
as
of the continual
of the disease is exceedinglychronic on account

ing
itch-

sensation,which
The

course

recurrence

359

FTHSTGOroES.

GRANTTLOMA

sometimes
rapidly,
on
very slowly;sometimes
excoriations.
After
have
reached
longexisting
they
a certain size,
theygenerallyundergo spontaneousinvolution and often disappearwithout
edly.
any cicatrix,at times quiterapidlyand unexpectany particularpigmentation,without

"of new

The

tumors.

sometimes

tumors

formerly intact skin, sometimes

grow

from

implicationof the generalhealth is very variable. Aside from the trouble produced
turbed
etc.,the generalcondition often is not disby the intense itching,sleeplessness,
all
hitherto
for years.
Still a steadily
cases
increasingcachexia graduallyensues
;
observed ended
fatally. Only a singlecase observed and publishedby Bazin recovered
of an erysipelas.The prognosisin general,therefore,is unfavorable.
in consequence
shows in the corium
and the subcutaneous
connective
sue
tisMicroscopicexamination
infiltration with typicalsmall round cells,which
inclosed in a narrow
meshan
are
work of fine fibrillary
connective
tissue.
In recent cases, the vessels are the first zones
to be infiltrated.
In the beginning,the epithelium,as in all inflammatory processes, is
in active proliferation,
and
shows
cones.
Later, it atrophies and
moderately widened
infiltration
the
cellular
from
below
perishesby
spreading
upward. In spiteof the most
careful examinations, I have been unable to find any parasites.
The

The

disease,as has been stated,is

Alibert

rare.

described

it under

the

name

sis
myco-

as
fungoides.Tilbury Fox as fibroma fungoides,Kobner, in Paris, observed five cases
of the skin resembling the beer fungus; Ferdinand
Hebra, in
multiplepapillarytumors
1873, reporteda similar case
by Hans Hebra in 1875, by Geber in 1878) and a
(described
communication
recent
A more
is on
second
in 1874.
record by L. A. Duhring
one
I
know
of
two
observed at the clinic
cases
myself
(inflammatoryfungoid neoplasm).
in this city. Kaposi identifles this disease with
the one
described
by him under the
sarcomatosis
name
generalisof the skin. Finally,Auspitz and 0. Simon call it granuloma
to be interpretedas malignant proliferaare
fungoides. Simon thinks the tumors
tions

tissue in individuals

of connective
or

psoriasis.But
Another

the

view

is held
the

etc., Amicis, term

the

view

merely
not only by

mata

of internal

as

suffered

and

Italian authors.

before

from

eczema

Vidal, Hillairet,Galliard,

consider

lymphadenie cutan^e, and

expressionsof

for years

the

cutaneous

tions
erup-

diath^se

"

lymphadenique." They are led to this

with the lymphomata
and
lymphadenothe frequent presence
of an
increase in

the

organs;

of such

occurrence

tumors

in internal

the skin.

and

organs

Galliard

gives the following

of

1. Absence

Temporary

Rapid

of his

resume

case:

symptoms, erythemata, etc. Immediately small

hypertrophy of the axillarylymphatic glands.

prodromal

3. Considerable
4.

the French

disease

have

histologicalresemblance
they report also
simultaneous
as well as the
blood-corpuscles,

white

2.

by

who

is entirelyunknown.
proliferations

of these

cause

enlargement

fatal result nine

of the

weeks

cutaneous

after the

efflorescences
of the

occurrence

in extent,

indolent

in

not

first nodules.

No

nodules.

height.
ulceration

of the

nodes.
5. In

the

circumscribed

intestines,no

infiltration of the

symptoms

(as in the skin), but merely

intraglandular,intermuscular, perivascular,submucous,

and

diffuse

enormous

subserous

connective

tissue.
Amicis

formulates

his

diagnosis in the second

lympho-adenome
les

OS

du

splenique et ganglionnaire,avec
crdne; Leucocythemie, pleuriteexudative

The
of

local treatment,

pyrogallicacid.

of

his

cases:

repetitiondu
concomitante,

accordingto Vidal and

No generaltreatment

fongoide,

Dermo-lympho-adenome
meme

processus

dans

la

foie,dans

marasme.cardiaque.

0. Simon, is best conducted

of the disease is known

as

with

yet.

ments
oint-

360

GRANULOMA

FUNGOIDES.

POSTSCEIPT.

It
of

unfortunately

was

Hirsch

Aug.

this

learned
Hirsch

He

leprosy

says:
and

decidedly
fie

to

for

incontrovertibly

writes

Only

"

from
and

he

the

of

not

the

in

the

have

taken

disease

in

about

assumption,

but

opposed

though

Especially
in

isolated
has

letter)

(by
the

above-described

transferred

ung.

also

"Handbuch

II.

attention

Abtheilung,

in

Hirsch,

peruviana,

der

1872

the

may

upon

Islands
fact

hundreds
fact

of

the
to

with

the

already

instances

that

in

cases

contributed
most

and

that

possibly

that

have
in

far

the

can

one

other
the

opposed

are

as

the

mean

one

to

defend

my

theses
hypo-

two

see,

better

as

doubts

observed.

were

by

Hirsch

1850-1860

general

by

virus

only

Hillebrand
vaccination

in

leprosy

performed
vaccine

raised

decennium

forcible
diffuse

was

the

the

the

ceeding
suc-

pronounced,
and

laymen,

leprous

germs

the

were

well.

III.,

Yaws,

Pian,

p.

69

Sec.

IV.,

Button

Scurvy

(Ireland),

p.

78.

historisch-geographischen
Stuttgart,

As

which

ease.
dis-

speaks

On

doubted

views

look

must

the

foundation

Sec.

p.

these

opinion.

my

Sandwich

doubting

later,

vaccination

the

to

these,

the

on

to

of

without
to

adhere
of

for

years

The

sick

leprosy
room

few

entirely
the

Verruga

no

epidemic

not

from

Compare
v.,

but

manner.

is

supposition

of

is

and

cite

to

the

yet.

as

spread

called

small-pox

constrained
to

another,

one

there

occurred,

cases

felt

inclined

proven

the

to

thereto,

lately

Sec.

to

not

as

reference

have

hevertheless

am

now

are

supported,

heredity.'*

by

tious
infec-

of

contagion."
be

portant
im-

most
the

which

"

brought

the

believes

presented

by

cannot

of

leprosy,

on

contagiousness

fact

work

statements
section

he

the

one

excellent

valuable

Although

leprosy

of

the

the

me

one

denies

positively
is

received

to

heredity.

there

transmission

utilizing

desirable

standpoint

transmission

of

that

from

especially

conviction,

the

kind

one

been

probable,
my

concluded

debarred

contagiousness

extremely

be

to

been

am

opposite

of

"According

have

the

those

had

that

so

would

almost

namely,

of

nature

hand

This

occupies

questions,

printing

form,'

revised

investigator.

because

the

after

its

in

1883.

Pathologie."

Zweite,

voUstanding

neue

Bearbeit-

77

NEUROSES

SKIN.

THE

OE
BY

of the skin

Neuaoses

activityinducing

nervous

the cutaneous
their

course
^

Kaposi
of those

neuroses

of the
In

expansions.

the

of

which

show

Diseases

diseases,or they

are

of nerves,

prurigo in

enlarged the category

three

classes the group

diseases of innervation
of

anomalies

physiologyand

of

the

discussed

cutaneous

the

derma-

pathology permit

us

to

of the

anomalies

some

skin

objections
skin, we
according to physiologically

of nutrition

as

the

which

may

be

this

OF

SENSIBILITY.

of the

sensory
manifesting themselves

this class

either

nerves,
as

and

the

anomalies

of

qualities
appertaining
the sensory

concomitant

phenomena of other
separateforms distinguishedby the fact that they run solelyalong
and are not followed by any disturbance
of growth and (unless
clude
inwe
Neuroses
of sensibility
show disturbances
class)of nutrition.
either

'

"

Handbuch

"

Pathologie und

"

System

'

have

into

thoroughly

affections

disturbances

alterations

belonging to

der

are

Hautkrankheiten."

Stuttgart, 1876, ii.,p. 540.

Therapie der Hautkrankheiten."
Vienna, 1880, p. 704.
der Hautkrankheiten."
Vienna, 1881.

Die neuropathischen
Ibid., pp. 37 et seq.
"

run

tropho-neuroses.

consist in functional

apparatus.

functional

of innervation

pathological alterations.

Bulkley

I have

monograph,*

and

to them

the tracts

and

has collected

and

nerves,

I. NEUROSES

These

disturbances

activity; namely,

nervous

all factors

the

demonstrable

questionrespectingthe trophic nerves' is not yet decided,and

of
against basing upon it the classification of neuroses

as

upon

in which

without

attempt to discuss nervous

principles,including
justifiable

looked

'

raised

be

divide

shall

integument caused by disturbed

siders
conmotility. Hebra

common

of this view.

in favor

Since

might

nerves

sensory

recent

summarized

toneuroses, and
adduce

affections

as

its

to disturbances

vessels,diseases

nerve

of the

in sensation, nutrition, and

expresses a similar opinion. Neumann

extent.
affections to some
Auspitz '

of affections due
the

affections

are

alterations

skin and

in the

SOHWIMMER

EEE"ST

PEOF.

Dermatonosen."

Vienna,

1883.

Urban

"

Schwarzenberg.

362

NEUROSES

of increased

in the direction

thesia,the latter

as

diminished

or

is

SEXSIBILriT.

the
activity,

former

being

known

as

hyperaes-

anaesthesia.
1.

This

OF

in

condition

Hypermsthesia of the

which

the
sensibility.When
the
of
excitability
every
the perceptionof a heightening
nerves,
every intensified stimulus will cause
sensory cutaneous
of the sensibility.
Hypergesthesiaof the skin is merely a partialmanifestation
of a qualityinherent
in the entire organism ; but
connected
with
it is not necessarily
the increased sensibility
of all categoriesof sensation,for the functions of the organism
be normal, and stillthe common
ber
integument may be hyperaesthetic.A largenummay
of vaso-motor
disturbances
of the skin alone,
be traced
back to hjrperaesthesia
can
a

conductivityof the

and

even

there

is

Shin.

high degree

is intact,then, with

nerve-tracts

after intellectual irritation

we

see

of

increased

alterations in

color

of the

skin, accompanied

by sensory disturbances, such as itching,burning, and stinging.

Hyperaesthesiamanifests itself by different sensations,but its essential manifestations
are
pain and itching. Pain is a form of excited sensibility
occurringonly in the diseased
irritations
in the skin and the
with
all
of
the
terminations
occurs
nerve
nerve
; itching
membranes
to
skin
and
shall return
it
is
of
we
mucous
a symptom
numerous
diseases,
;
It differs in degree from
it more
in detail with the descriptionof prurituscutaneus.
such
the sensations known
as
as
tickling,
burning, formication, which can
parsesthesiae,
The
with central or peripheralaffections.
be brought into more
less close connection
or
often
followed
cutaneous
stimulations
the
and
are
nerves
hyperaesthesia
by
affecting
of irritation will produce
influenced
by local conditions ; in some
cases, the intensity
not
increase
in
others
this
latter
of sensation,and
phenomenon, however, is
merely an
;
Such abnormal
not
always characterized by sensory, but also by increased tactile sensation.
sensations

manifest

themselves

etc., at times shows

pruritus,
and

tactile sensation

so

that the skin

in

2.

Generally,anaesthesia
directlyconnected with an

occurs

with

affection

of she skin, etc.

gangrene
Anaesthesia may
be complete

numerous

skin

diseases ; eczema,
dermatitis,
the cutaneous
general

of
highly increased irritability
touch.
to
the
painful
appears
AncBstTiesia.

skin
of the

diseases
nervous

the
only when
system, as in

cutaneous
macular

malady is
leprosy,in

incomplete and is either central or peripheral.

a.
PeripheralancBsthesia is excited by local influences on the skin, such as abnor ma
disturbance of circulation
temperatures,certain caustic or narcotic substances, and finally
tions
(ischaemia). Cold and heat act equallyparalyzingand ansesthetizing.In certain condiwhere cold in the form of ice bags is continuouslyapplied for days,the sensibility
of the skin disappearsto such an
extent that pricking and
pinching often are no longer
anaesthesia
with the ether spray
the
the
local
On
based
is
same
perceived.
principles
affected
f
or
the
In congelations,
(Richardson) operativepurposes.
parts are anaesthetic
for some
time ; but if destruction of the skin occur, the anaesthesia becomes
permanent.
Heat acts in a similar manner:
if it be very intense and
destroy the layer of the cutis,
the papillary
body perishescompletelyand total anaesthesia results.
Narcotic agents, used locally,
often have a soothingeffect and reduce morbid
hyperately
to act there immedisesthesia ; but the agent must
so
as
be appliedto the cutis directly,
the nerve
on
expansions,as when blistered surfaces are covered with opiates. It is
to secure
injectionsof narcotics.
j)ossible
incomplete anaesthesia by subcutaneous
or

NEIJKOSES

also include

Peripheralcauses

OF

363

SE.^SIBILITY.

affections in which

the conduction

to the centre

is interrupted

injuriesof the

nerves.
by exostoses, exudations, tumors, or
is always spread over
anmsthesia
largersurfaces of the skin, because its
conditions are produced
Such
situated either in the brain or spinal cord.
are
causes
form,
after largedoses of narcotics,or by inhalations of ether or chloroeither artificially
as
central
to
tumors
to
in
the
due
or
traumata,
extravasations,
or
are
they
organ,
and injuriesof the bones of the skull-capand the vertebrae.
exostoses

h. Central

"

3.

ParcBsthesia.

of sensibility
The
midway between the two just discussed.
associated
sensations
induced
internal
irritations.
as
designated
by
paraesthesiae
Among these anomalies of sensation belong those of itching,numbness, formication,
burning, the velvetyfeeling,etc. These anomalies are not isolated sensations,and we
and
can
that, wherever
hyperaesthesia
hypaesthesiaexist, paraesthesiawill
presuppose
sensations which
The integument is the field for these abnormal
also be found.
there
manifest themselves
as
affections,and
symptoms of grave central or peripheralnervous
they are usuallymanifestations of prurituscutaneus.
This

is

are

disturbance
best

4.

Cutis.

neuralgiadesignatesthat affection of the sensory nervous

ratus
appaby pain. Neuralgia, however, presents still other symptoms
which
distinguishit from other affections running along the nerve-tracts.
Among
the pain extends.
these we allude to the direction in which
Neuralgia ordinarilykeeps
along the track of a nerve-trunk and spreadsin this direction,and it shows no uniform
but is distinguished
increase of irritation,
by a growing and lesseningof the excitement
the
which
nerve-trunk
branch
is in a normal
between
state (intermisor
(paroxysms),
sions)
it is alwaysprovoked by internal
that is,caused within the organism
; moreover,
morbid
but is not identical with
Neuralgia is closelyrelated to hyperaesthesia,
processes.
it;for both can coexist independently,and may also mutually exclude each other;the same
The
is true in regard to neuralgia and paraesthesiee.
tacks
with atlatter,in case they occur
not
at
the
time
of
the
of nervous
are
but
pain,
only
neuralgicparoxysms,
present
As earlyas 1850,' Tiirck found in neuralgiasthat anaesthesia
of them.
also irrespective
more
was
frequentthan hyperaesthesiain the corresponding portions of the skin lying
above the painfulspot,and NothnageP states that, in the first period of neuralgicdisease,
can
probably always be demonstrated, but in the later stages,anaeshyperaesthesiae
the changes in the cutanethesiae. According to Nothnagel, therefore,the pain causes
ous
in an ascending and a descending direction.
sensibility
The
vaso-motor
symptoms accompanying neuralgia may be either angiospasm or
we
angioparalysis;
frequentlyfind erythemata as sequels of neuralgia,most
cedly
pronounin trigeminalneuralgia;at times, eruptions of urticaria are noticed, especially
in
in which they are
cases
provoked by malaria, as in the typicalhemicranias,occipital
algias,
neurand
then
etc.
Now
trophicalterations in the shape of disturbances of nutrition
after neuralgia. These are:
and growth of the skin and its appendages occur
eruptions
bullae (zosterand
of vesicles and
pemphigus),superficial
erythemata, with inflammaIn

general,the

Neuralgia

which

term

is characterized

"

'

Eulenburg:

'

Virchow's

"

Lehrbuch

der

Archiv, 54 Bd.

"

Nervenkrankheiten."
"

Schmerz

und

cutane

Berlin, 1878, i.,p. 44.

"

Sensibilitatsstorung.

364

NEUROSES

OF

SENSIBILITY.

tions of the

skin,actual erysipelataremaining
to the neuralgia;moreover,
anomalies
discoloration and fallingof the hair, etc.
PRURITUS

This
on

forms,
and

an

the

on

the other, it is

hand,

invariable

an

in the

ITCHING

CUTANEUS,

one

confined

to

sebaceous

OF

THE

concomitant

of

independent affection;
accordingly,we
idiopathicform.
Pruritus

Itching is a

sensation

irritation of the

which

Cutaneus

is not

sponding
region corretions,
perspiratorysecre-

and

SKIN.

skin diseases,

numerous

of

treat

an

1.

circumscribed

pruritusin

tomatic
symp-

Symptomaticus.

clearlydefinable

in

words,

and

which, produced

of burning,
by
and
irresistible inclination to scratch.
The itchingsensation
an
tickling,
pain, causes
be produced by local or general causes.
may
and
Among the local factors are included the itching eruptions,such as eczema
prurigo,also urticaria. Some forms of psoriasis
are
ordinarilylikewise accompanied by
itching,still the eruption is often very extensive without causing any itching. The
an

cutaneous

affections

papilleeof the skin, yet differingfrom

due

the sensations

animal

acarus
scabiei,bugs, fleas,as well as some
parasites,
such as herpes tonsurans, eczema
by vegetableparasites,
marginatum, are
versicolor never,
or
always accompanied by violent itching,while pityriasis
only exceptionally
of
causes
itching. In the cicatrization of ulcers,during the formation
any
granulations,an intense itching,too, frequently appears.
as
a
Again, itching occurs
of
morbid
for
certain
diseases
some
nected
conconditions;
instance,
hepatic
symptom
general
with
fevers, such as scarlatina and
icterus;furthermore, in exanthematous
of the exanthem
and in the stage of desquamation; on
measles, both with the appearance
the other hand, in certain dyscrasicconditions such as syphilis
and scrofulous affections,
pruritusis usuallyentirelyabsent.
The
internal processes
The facts that some
during itching are difficult to trace.
acute
exanthemata
that
well as icterus cause
intense
as
itching,
pruritus is at times
under
in
inferred
found
medicinal
some
conditions, a
that,
erythemata, leave it to be
In other
noxious element gets into the blood and excites the nerve
termini in the papillae.
state as a local process independent
however, we must consider this hyperaesthetic
cases,
of some
influence on
the blood.
Such
be, perhaps, the stasis of the
a
process would
in the
in
The
found
conditions.
exudative
blood
which
is
papillarybody
usually
termini which
increased plethorawithin the efflorescences produces pressure on the nerve
but whenever
is felt as an itchingsensation,and the prurituspersists
as long as the stasis;
the morbid
of the affection or by the removal
diminishes
exudation
with the defervescence

others

of

to

caused

vesicles

some

itchingwill

or

the

nodules

by

then

decrease.

and

now

It is self-evident
for the

that, in the case

explanation of the itching can
b. Pruritus

This
will

affection

was

of the

to the

nervous

of the

s.
Prurigo
IdiopatJiicus

times

only point out that, although both

reference

parasiticaffections

on

the
violent irritation,

the

skin, some

less remote

factors

be found.

Cutaneus
in former

scratchingconsequent

often mistaken
forms

accidents,they stillare

for

of disease

sine

Papulis.

prurigo.
resemble

In

each

this connection

other

wo

closelywith

identical processes; the chief difference

circumscribed
is general or exists on
spots
not

being, that in pruritusthe itching present

without
a papular eruption,while
prurigo shows

an

itchingnodular

eruption.

366

NEUROSES

with

ritus in connection

I, too,

arsenic.
and

local
Local

have

diabetes

mellitus

pruritus,but I was unable

pruritus,besides,occurs

SENSIBILITY.

and

diabetes

repeatedlyseen

to note
as

claims

and

to have
cured both maladies
by
Bright'sdisease conjoined with general

effect from

any

pruritusof the

the

palms

of arsenic.

use

of the

hands

and

the

soles of

moderate
symptoms which ordinarilyare not persistent
Several years ago,
complicationssimilar to those just mentioned.
called attention to a peculiarform of pruritus pruritushiemalis,"occurring in
winter time.
The itchingordinarily
individuals usuallyabout
ities
some
beginsat the extremand then spreads over
who
largerparts of the body. I myself know several persons
about
winter time
for years have been in the habit of presentingthemselves
with their
cutaneous
itching and its consecutive complications,such as excoriations and eczema,
of some
think
and in whom
must
we
neuropathic factor caused by cold, judging from
the

feet, with

and

means

by no
Duhring

the

on

the

OF

lead

whole

to

"

of the

recurrence

affection

at

certain

season

and

its abatement

with

milder

weather.
The

Diagnosis

In the first place,,

pruritusoffers no difficulties when all factors are closelyobserved.
In
be
the
the patients
to
noticed.
the
of
affection
sensations
are
beginning
subjective
and
the
and
of
troublesome
skin
shows
no
itching,
inspection
complain of continuous
for
and
the
the neurosis persists
But when
alteration.
days or weeks ;
patients,forced
their skin
then
in the daytime, excobelabor
riations,
energetically,
by the itching,begin to
wheals, thin crusts, and stripesare observed as the result of scratchingat night.
In the case
of a skin affected with pruritus,therefore,the questionalways suggests itself
have to deal with a commencing
or
a
whether
long-standing disease ; in the former
we
In
in
latter already very numerous.
still
the
the
are
slight,
symptoms
objective
case,
the
skin
characterized
intense
when
whole
affection
with
a
an
itching,
by
presents
dealing
we
series of alterations,we have only to consider the differential diagnosis. In eczema
its
such
in
in
bear
modifications
alterations
to
mind
or
inflammatory changes
always have
weeping, red, scaly,crusty, or infiltrated surfaces ; in
as
point to an exudative process
affection ; in the
scabies and
by a certain fundamental
prurigo, changes determined
of pustulesand nodules, as well as
of the parasite,
the formation
former, the burrows
in
of the malady ; in the latter, alterations to be considered
more
often a definite locality
Chronic
detail in the descriptionof this disease.
urticaria,owing to the temporary
of itching,probably offers greater difficulties than the above-named
affections;
appearance
of the patients
but the intense effects of scratchingare usuallyabsent, and the statements
is in the habit
the inspectionof the skin at definite times
namely, when the exanthem
or
render
the
the
the
of
w
ith
observation
wheals,
diagnosispositive.
of appearing ^together

of

the

"

^^

"

"

"

will
Pemphigus pruriginosis
absent in pruritus.
are

Furthermore,

in many

not

fail to show

presence

of bullous

efflorescences

which

important to bear in mind the fundamental

metamorphosis, local diseases such as those of
accuratelyestimate a local or generalpruritus.

it will be

cases

affection,Bright'sdisease,diabetes, senile
the hemorrhoidal

the

vessels,etc., in order

to

Treatment.
In

all cutaneous

diseases

rubra, urticaria,this
pityriasis
disease, if the
1

"AnUndescribedFormof

treatment

puritus,psoriasis,
producing itching, such as eczema,
tive
troublesome
symptom will disappear with the causamore
appropriate to that affection is employed. Much

Pruritus."

The

Amer.

Journ.

of Dermatol.

New

York,

1874, p. 193.

NETJB0"E3

36T

SENSIBILITY.

OF

in the parasitical
cutaneous
tions
affecitchingovercome
the
destruction
etc.
the
of
animal or vegescabies,herpes tonsurans, favus,
by
table
other affections of the
parasites. But where the pruritus does not depend upon
In disease of
skin, endeavors should always be made to relieve other morbid conditions.
and liver,the alkaline
the stomach
saline springs are
able
generallyfollowed by very favor-

readilythan

in these

diseases is the

"

"

results.

In

anomalies

their choice and

of menstruation

or

chlorosis,iron

and

bitter tonics

are

cated,
indi-

degree of the malady. But despiteall

internal medication, the local treatment
must
be kept out of sight; it acts directly
never
effective than the most
diverse narcotic agents,such as opium and
soothing,and is more
its alkaloids,potassium bromide, chloral,hyoscyamus, etc.
The chief feature of local treatment
in generalpruritusis the use
of cold ablutions
and douches.
and
full
in
the
summer
baths,
Swimming
season,
may be taken in the
river,at other
While
form

of

cold-water

Steam
The

with

institutions,or

01.

in three

20 ;

Alcoh.

to

^ther.

of sodium

for half

an

carbonate, one-half
hour

or

at

more

The

cent

solution.

For

Spts. lavand., gtt. xx.

sulph.,2 ; Alcoh. rect., 150
; Bals.

its derivatives

be
or

instance
M.

puri,4; Ung. emollientis,80

tar and

in bathtubs.

to

kilo for each

one

temperature of from

bath,
20-24''

twice

five per

rectif.,150
;

at home

dailyin the form of rapid ablutions (not in the

is injuriousin pruritus),
the baths may be taken daily,

empyreumatic oils may

rusci,cadini, fagi,and carbolic acid in one

thol

When

indifferent thermal

per week, have also a favorable effect.

preparationsof tar often prove effective as inunctions
or

solutions.

and

the

twice

which

cure

patientsremain

various

carbolici,3

is used

the addition

baths, once

ointments

namely:

in the various

seasons

cold water

either pure or
in which
the
C.

application
depending gn

used

with

in the form

considerable

of

effect,

per cent solution, naph01.

cadini, 10 ; Griycerini,
Ij^
two

S.

Externally. Or, I^ Acidi

Or, I^ Naphtholi

Aq. dest.,50.

Peruviani, 2'.5.

fail

completely,as is unfortunatelysometimes the case

it loses its efficacy
after a certain
pruritus,especiallythe senile form, or whenever
I
often
have
results
from
ointments
seen
Lac.
time,
satisfactory
sulphur
sulphur.,5
with or
without tar.
Corrosive sublimate
also proves
grams ; Ung. simplic, 40 grams,
with

"

of

sometimes, both in the form

of lotions and
to baths, perhaps acaddition
as
an
cording
followingformula : Ij^Hydrarg.bichlor. corr., 3 grams ; Mur. ammon.
M. S. To be appliedto one
full bath.
Aq. font, dest.,80 grams.
depurati,10 grams;
Frictions with alcoholic liquids,in conjunction with chloroform, cologne water,
and ether, may also be tried,but they help only palliatively,
and not invariably.Chloral
of ointment
in the form
recommended
French
(5 : 40),
by some
physicians,has often
In local pruritus,according to its seat, the same
failed in my hands.
treatment
in
as
be used.
In pruritus scroti and
tions,
general pruritus may
pudendi, with the tar inuncbe applied through the day and
diachylon ointment
even
may
by night with
of the paroxysms
of pain ; but in these generally inveterate
temporary amelioration
forms the remedies require to be changed frequently,many
having but a passingeffect.
In all forms of prurituspudendalis, cleanliness is the first requisitein treatment
; the
must
ointments
always be prepared with pure and fresh fat,and the solutions must not
be too strong. The
carbolic (1 to 2 per cent) and
are
boracic
drugs to be recommended
solve in aq. ferv. Acid, salicylici,
4
acids; for instance, 1^ Acidi boracici,2.5 grams;
Alcohol,
50
100
M.
S.
rectif.,
Lotion.
Acid,
dest.,
Or, I^
grams
grams ;
; Aq.
grams.
M. S. Externally. The
borac, 5 grams ; Glycerin.,20 grams ; Spts.vini,100 grams.
sublimate lotions recommended
of water) are often useful ;
: 200
by Trousseau (0.08-0.1
paintingwith solution of silver nitrate,or even
touching with the solid stick,should be
use

to

the

368

VA8O-MOT0B

tried

only in

certain cases,

SENSORY

KEUE08E8.

in

because

bility
pruritus vulvae especially,
owing to ready irritaof the vaginal mucous
membrane,
disagreeableinflammatory conditions may ensue.
has sometimes
done
me
Hydrated alumina
good service in the followingformula :
]J Alumin.
hydrat,,5 grams ; Glycerini,01. olivar.,aa 20 grams ; XJng. moll., 40 grams.
and
M. S. Ointment.
Local douches
ablutions with tepid or cold water, vapor baths
of belladonna
with decoction of hyoscyamus, suppositories
or
opium are of but temporary
be
the
affection
can
benefit,yet
quently
dispensedwith,
rarely
being so stubborn as to fretry the patienceof the physicianand his client severely. Thymol, 1; Glycerin,

Alcohol,

20

aa

water, 600-800, in combination

proved
atropine,and

arsenic

the

patience

and

on

in my

useful

often

part

may

of the

hands.

This

clafescomprises

SENSORY

series of

of the

many

above-mentioned

edies,
rem-

mide,
hystero-nervoussubjects,potassium brobe given internally. The
main
thing is perseverence
sufferer
and the physician.

II. VASO-MOTOR

affections

NEUROSES.
in which

diseases,but in which

in the above-mentioned

less than

with

In

the disturbance
the influence

of

is
sensibility
of
participation
integument which

and

produce pathologicalconditions on the common

We have
associated with fluxionaryor inflammatory processes.
stated in connection
are
alterations caused through the innervation
with the hyperaemiasthat all pathological
of the
blood-vessels are to be designatedvaso-motor
or
angioneuroticaffections,and in the same
place we have discussed erythema hypersemicum and roseola congestivaas cognate forms.
shall discuss here only those affections which
cause
We
prolonged alterations and are
nutritive
morbid
besides
the
These
characterized,
fluxionarydisturbances,by
processes.
and
simultaneous
vascular
themselves
disease.
latter manifest
by metamorphoses of tissue
by itself forms a clinical morbid picture
Erythema hyperaBmicuro,as an angioneurosis,
to be considered.
the polymorphous erythemata now
in the same
as
way
the vaso-motor

nerves

tions
representingmerely transitional forms, there are certain affecaccepted as diseases of the skin, but only as the alterations
very
jected
prothe common
on
integument by the pathologicallychanged vessels ; they are: angiospasm and
extravasations
angioparalysiswhich, under certain conditions, are followed by erythemata and even
on

Between

these

which

cannot

the

conditions, often
well

be

skin.

patternof the forms of disease to be

erythemata and the urticaria related to

The
other

he
of

considered
the

sequence.

as

manifold

"

due

to

exudation

character

Hence, since

the

erythemata.
The
generallyshort
symptoms have directed

time

and

further

of

the

than

to

experiencehave
The

of

the
led

formed

the

latter, on

account

multiform

mata.
erytheclassing

criterion for

of the subjective
the insignificance
tent
physiciansrather to the size and excareful
servation
obbut
nature
the
of
malady
;
deeper
to take cognizance also of the concomitant
us

of the disease

the attention

subsequent phenomena.

and, therefore, he called the

pathological form, exudative

of Hebra, the exudation

duration

of the visible exudation

and

erythema multiforme; the

Symptomatology. Hebra has distinguisheda series of erythemata,

designated as caused by congestion,from the analogous slower forms which

Definitionand
he

here is

its natural

Erythema Multiforme.

1.

which

discussed
it form

and

numerous

first to attract

attention

was

the

fact that

erythema

SENSORY

VA80-M0T0R

369

NEUROSES.

always appear as a simple dermatonosis, but is often connected "with fever and
rheumatic
pains,and stands in manifold relation to inflammatory conditions of the joints,
that this cutaneous
observers found
well as of the heart and pericardium ; again,some
as
of the nervous
disturbances
disease at times is dependent upon
system.
be logicalto change the term
In view of this twofold clinical character, it would
that progressingwith fever,
disease
for
these
to
this
each
of
forms, especially
applied
^'dermatitis
exudativa."
former
Lewin'
and for this reason
has proposed to call the
and AuThe same
author has fullyaccepted the view previously
expressedby Kobner*
as
an
spitz'that erythema is to be interpreted
angioneurosis.
The opinion that erythema is a pyrexialaffection analogous to the exanthematic
to designatethe
we
conditions,has not been completelyproven even
by Lewin ; for were
various stagesof erythema as prodromal, eruptive,
and desquamative analogousto those
the
of the
to admit
infectious nature
even
we
occurring in variola or scarlatina were
of this
of the symptoms in the course
agent producing erythema, stillthe dissimilarity
disease is so marked
be brought in analogy with the typicaland cyclical
that it cannot
exists undisputed
which
of the other acute exanthemata, and the contagiousness
course
be demonstrated
of
cannot
in the former
cause
as
a
erythema.
the product of an affection appearas
Therefore, if we consider erythema multiforme
ing
with various efflorescences,
the basis of which
is the patchy redness, the erythema,
of the
it is easilyunderstood
that Auspitz,^taking the redness
the starting-point
as
all
this
to
endeavored
those
diseases
on
developing
pathological
together
process,
group
time givingthis fundamental
form the name
i.
tion
formabasis,at the same
erythanthema, e.,
lesion.
of efflorescence with an
Among these erythanerythematous fundamental
and
its varieties,
rheumatthemata Auspitz included all kinds of erythema,herpes
peliosis
vesicular eruptions (!). Less correct
with some
ica,certain unclassified forms of eczema,
such a widening of the term would produce a separationof some
types
nosographically,
from
the patho-etiological
of disease which we at presentare not yet able to disconnect
erythema, but with this
conception. We, therefore,choose the older term, multiform
that
the
eliminate
we
difference,
netic
qualifyingadjectiveexudative, in view of the pathogecondition, and preferto speak of an angioneuroticand trophoneuroticerythema.
By erythema multiforme we understand a skin disease running an acute or subacute
of patches of a vivid red or dark color which
are
course, characterized by the formation
that
seed
to
that
millet
their
size
from
of
or
a
hemp
variouslyjoinedtogether;
ranges
often transformed
of the finger; they are
of a lentil ; they temporarilypale under
pressure
all
isolated
of
the
into other efflorescences,
and may occur
on
or
only on
parts
of the
body (dorsum of hand and foot). The patchy form constitutes the starting-point
erythema. The circumscribed
hypergemia of the skin with which the affection begins
intense ; the skin, originally
flat and
lasts but a short time, becomes
gradually more
somewhat
smooth, becomes
firm, slightlyswollen, and by infiltration and increase of
formed
tissue within the several efflorescences the alteration is effected,during which
are
et
size
of
and
nodes
both nodules the
a hemp-seed
(erythema papulatum
tuberculatum)
hand.
The
to that of the open
and larger discolorations from the size of a thumb-nail
extension and
metamorphosis of the originalerythematous patches proceed irregularly;
efflorescences often arise which, being of the same
at the borders of the old spots new
does

not

"

"

24

Charite-Annalen,
"

Klinische

'

"

"

L.C., p. 72.

Ueber

und

venose

iii. Bd., 1878, p. 622.

experimentelleMittheilungen,"
Stauung."

Arch.

f.

Derm.,

1864.

1874, p. 310

et seq.

370

VASO-MOTOE

character

showing

as

SENSOKY

former, maintain

the

the

difference, the recent

some

influences
efflorescences

grouping of the
spread peripherallyand

; when
dimensions
greater

which

the several nodules

urticaria appear
forms from
one

change
them

near

in

run

into
in

color of

resolve

at the centre

continue

to

skin.

the

several efflorescences.

efflorescences

new

normal

the

the

circinatum

picture of the erythema, the coloration

vivid than the
being always more

efflorescences

which, graduallypaling,resume

ones

NEUK08E8.

is called
from

older

variable
in which

the form

Thus

develop

This

alone

annulare
erj'^thema

the

circular

lines

lines,circumvoluted, it is erythema gyratum

wave

stronger infiltrations and

places,we

numerous

efflorescences

new

urticatum.

erythema

see

havior
be-

the
s.

in
; if

resembling
Transitional

speciesof efflorescences into another may likewise be observed, namely

buUse develop from the nodules ; then it often appears
questionable
whether
this affection,presentingitself as erythema vesiculosum
and bullosum, does not
to herpes than the erythemata (comp. below : erythema iris).
approach nearer
The
localization of erythema multiforme
forms an
rence
important symptom ; its occurvesicles

when

and

the

on

of

dorsum

exact
More
phenomenon.
of
the
with
body,
part
any

foot ;

and

observers

some

hand

the

and

foot

simultaneous

without

or

found

even

portionsof the skin remained

intense

quite intact.

The

eruptions along the extremities was

ascertained that the placesof predilection
of the
of

bones

covered

are

the skin of the

of

nature

abdomen,

muscular

forehead, etc.

This

erythemata, for

the
also

on

(Lipp/ Behrend,^
The

thin

with

duration

the

and
of

believed

was

observation,however, showed

we

others).
erythema

be

the

most

erythema

constant
occur

may

affection of the dorsum

of

the

on

hand

tendon

sheaths, i.

e.,

the

extremities,

hardly furnishes any explanation of the

with
erythema on the cheeks, the nates, the
of the cheek, the pharynx, and the genitals

statement
meet

membrane

mucous

to

these
eruptions of erythema in which
of
the
rence
occurpreponderatingfrequency
speciallydetermined
by Lewin, and he
those where flat tubular
erythemata were

and

strata

that

multiforme

is very

variable.

The

nodular

eruption is

usuallyof very brief duration, and involution generallyfollows rapidly;while the nodular
chronic
of the
form
of the greater extent
representsa more
type, merely on account
and ulcerations reallyoccur,
I should not like to assert that abscess formation
affection.
to me
that all the similar statements
and it seems
(Hardy, Purdon, Breda, Oehme) refer
The ordinary average duration of erythema varies between
rather to erythema nodosum.
two weeks; only the intense and
extensive
forms
several days and one
are
or
prolonged
but even
the
beyond this time, as are those where fresh exacerbations ever recur
anew;
most
intense form
generallydisappears within six or eight weeks without leaving any
the duration of the disease is unlimited,
sequelae. "Where there is a tendency to relapses,
and it is a peculiarfact that erythema multiforme, in relapsing,
on
generallyreappears
terminations
when
Unfavorable
the placesfirst attacked.
cidents
acoccur
complicating
only
that extravasations
influence it. It may
not rarelybe observed
liable to occur
are
in the nodules; when
coexistingwith articular affections,they have often been considered
dents
acciforms of purpura
(Bohn, Legrand, Purdon), but this connection with rheumatic
is not

of

essential,and

the

extravasation

may

be

looked

upon

as

an

alteration

rectly
di-

belonging to the angioneurosis.

The
local conditions are rarely
The
complicationsof erythema are very manifold.
the
skin
with
the eruption;the sympof
importance slightitching,pricking
toms
appears
the
is
when
with
conjoined*
different, however,
are
high fever,with disease
erythema
"

Arch,
f, Dermatologie
"Ibid., 1877, p. 363.

und

Syphilis, 1871, p. 232.

VASO-MOTOB

SENSORY

371

LEUKOSES.

articular pains,hemorrhages, etc.

Formerly,such complications
accepted as belonging to the symptoms of erythema; but at the present
with
the polyday there is hardly any doubt that all these phenomena are connected
morphous
and then have erythematous
erythema; and just as the acute exanthemata
now
infectious or toxic nature
percursors, so other general diseases of an
may be conjoined
with erythema. The agent causing pleuritis,
endocarditis,meningitis,etc.,may also give
rise to the erythematous angioneuroses. -Ihave observed numerous
complicationsof this
class,and think that the erythema must not be separated from the fundamental
or
companying
acafEection.
At times erythema multiforme
its course
without
runs
being
of the

membranes,

serous

not

were

localized in the internal organs; but we

have stated above that it is inadmissible
it an affection analogous to an acute exanthem
(Lewin); the most correct
will
we

always be
quite unable

are

noxious

matters

The
as

appear

designatesuch

to

determine

to

which

have

diagnosis rests
spotsand after

itchingnor
spread into

entered

the

on
a

the formation

cases

in
idiopathicfebrile aflPections;
they represent a symptom
system.
as

to what

the

brief existence
of scales.

as

The

alterations

nodules

short

and

the

of

nodes

duration

of

skin

the cutaneous

of

which

causing

sider
con-

cases

many

extent

above-described

to

tion
explanacertain

at

neither

first

much

affection,its

time occupying larger surneighborhood, generallywithout at the same

faces,
facilitate the recognitionof the disease.
In very many
the
of
occurrence
cases,
the efflorescences on certain parts of the body, such as the dorsum
of the hand
and foot,
the diagnosis. The
violent subjectivesymptoms
of itching; the
helps to determine
transition
corium

the

into vesicles,scabs and

and

the

crusts; the uniform,

extensive

more

layersof tissue,will

to

Circinatum, and

Herpes

infiltration in the

serve
it from
underlying
eczema.
Prurigo is an affection of earlylife which is preceded by urticarial wheals, but not by
and evinces a
grouped nodules; which, besides its intense itching,runs
a chronic
course
surfaces of the extremities.
The
preference for the extensor
micropapular syphilide
to arise and
never
occurs
so
acutelythat it could be seen
disappear in the time appropriate
to the erythemata; besides,it is accompanied by other complications. Careful
observation
and thorough examination
of the case
will prevent its being mistaken
for
which
has been
variola
mentioned
an
error
by Lewin, Behrend, and Resillaud.
Before
entering on the further discussion of the multiform
erythemata, we shall
the followingcloselyrelated specialforms, namely:
enumerate

differentiate

"

2.

Erythema

Iris

et

Iris

et

Circinatus.

Erythema iris reallyrepresents a varietyof erythema multiforme, inasmuch

it is
as
but as this erythema almost
merely by the configurationof the efflorescences;
be brought into
constantlyleads to the vesicular form, and inversely the- latter can
full analogy with
the erythema, the independence of this form is justified
cally.
pathologidetermined

The

the

pointswhich this affection has

speciesof erythema above mentioned

the

following:
a.

The

occurrence

on

herpesvery rarely,namely
coexistence and

h. The

partsof

the

the dorsum

in

body

with

common

and

those of

where

which

herpes to

be

erythemata appear

of the hand

transition of

and

and

it
distinguish
discussed

very

below

from
are

frequently,but

foot.

erythema iris and

circinatus

into

herpes irisand

circinatus.
c.

The

of the year

occurrence
"

in the

of these

springand

herpeticforms
autumn

months.

as

well

as

of the

erythema

at the

same

time

3Y2

VASO-MOTOR

SENSORY

NEUROSES.

Kespecting the peculiarityof the iris form we wish to add the following:
to the spots^ as does herpesiris to the vesicles,
its name
which develop
Erythema iris owes
in a certain grouping; peripheral,
circularly
arranged efflorescences forming around
of the circles thus
The number
formed
is variable." The
terra
one
centrallylocated.
the
the
first
used
iris was
observers
of
various
account
of
tints
on
by
(^illan-Bateman)
of
and
red
various
shades
white
the
vesicles
are
present, according as
colors;
patches or
tween
The normal
skin beless intense congestionor exudation.
or
tinged by the more
appear
the patches and circles of vesicles always forms the lightercoloration,the affected
parts being darker.
of the exanthem
The
duration
depends on its intensityand extent; while some,
the
central
fluid,but the whole process
efflorescences,
dry, others fill with serous
usually
in
In
lasts at most ten or twelve
and
ends
the vesicles ensome
cases
large
complete recovery.
days
it
gree
deisolated
this
the
most
extreme
is,as
efflorescences;
by the confluence of
were,
of development of erythema iris,which
into pemchange into herpes and finally
may
phigus
iris.
and

Erythema
as

when

times
case

short

circles

of

be observed

as

series

find

we

time, vesicles

developed from the iris form

herpes circinatus are modifications
central
vesicles develop without
at
efflorescence,but they may
in
affections
causal
connection
with
iris.
In
this
no
herpes
primary
which
of red spots circularlyarranged, from
are
developed,in a
is in no way distinguishedfrom
whose further course
herpes iris.

Strange to say, a disease due

(identicalwith
herpes circinatus
parasitic affections

some

trunk

similar

scales

and

diseases

likewise

same

presenting the appeai'ance

condition.
a parasitic

erythemata

materially facilitated

here

is based

discussed
the

on

This

view

have

every

been

still there

is erroneous;

of

appearance

an

designated

of

are

factors

the

erythemata
must

we

of

never

enumerated

verified

on

the

bear
quite insignificant
astray by isolated misleading

parasitic nature; otherwise

under

and

arm

which

be led

not

circi-

erythema

suspicion of the presence of fungi was

occasionally find on the skin of the

But

at times

are

the
we

way

dermatologists likewise

some

which

show

observations, for the erythemata

of these

hand

in which

cases

by

tonsurans).

of the

in the

examination;

microscopic

parasites has

herpes

the dorsum

on

Kaposi mentions

natum.

to

erythema

the

multiforme,

nosis
diagand

is

by the configuration of the efflorescences.

usuallya non-pyrexialaffection,but sometimes

multiform
it assumes
a grave
erythemata, in which case the skin affection
type,
plays a prominent part; Wunderlich,' Gerhardt,^ and others have reported instances in
which
multipleerythemata appeared on the body with every indication of a grave typhoid
affection togetherwith high fever;the eruption subsequentlychanged into vesicles and
the whole, such
observations
On
are
presented the pictureof herpes universalis.
rare;
but while they prove the transition of erythema into varieties of herpes with
grave
eral
genhead as the pyrexialerythemata in general,
complications,they fall under the same
of which we
have spoken above.
Herpes

iris with

its related forms

is

like the

PATHOGENESIS

OF

THE

POLYMORPHOUS

ERYTHEMATA.

of disease in so
of the erythemata are to be separatedfrom
causes
excitingcauses
the
vascular
activity
far as the latter give the incentive to those influences which
change
alteration of the
The pathological
and thus lead to temporary or prolonged alterations.
either the vessels alone or the tissues in which
blood-vessels concerns
they ramify, and
The

accordinglywe
1

"

"

Under

assume

may

Remittirendes
the

same

Fieber

different disturbances
mit

caused

thereby. Temporary

Phlyktaniden-Eruption," in

title in Wien.

med.

Wochenschrift,

Arch.

1878, Nos.

d.

Heilkunde,

2"-30.

alterations

1864.

374

VASO-MOTOR

SENSORY

NEUEOSES.

communications
these
on
Harlingen/ Hutchinson," and others, have published numerous
in
about
the
of erythema
forms
particular,while other authors have written more
Of the drugs which
have been followed by
papulous, bullous, and hemorrhagic forms.
opium and its preparations,belladonna,
erythematous eruptions should be mentioned:
quinine, salicylicacid, arsenic, chloral Hydrate, calomel, and at times phenol. In
in others again in a circumscribed, patchy
like scarlatina,
some
cases, the eruptionappears
urticaria-like
exanthem
develops. It is strange, though, that the
form; at times, an
form
ent
(rash),or as nodules, afEects differdrug erythema, whether appearing in superficial
portionsof the skin, according to the drug administered;sometimes
only the trunk
the lower and the upper extremities are involved, but rarelythe
and abdomen, sometimes
which
to
the whole
cover
seems
body, and it is just this isolated occurrence
erythema
is peculiarnot to a singleremedy,
that the action of drugs,which
leads to the conclusion
but a physiological
but to an
entire series of them, is to be looked upon
as
effect,the
nerve-centres
vaso-motor
sufferinga change as in the acute exanthemata.
this term
Fever
the erythemata occurring
The
c.
Erythema. We comprise under
with it. Even
witli the febrile process in general,and with forms of eruption connected
in temporary pyrexialstates, a fugitiveredness is apt to occur
on
some
parts of the body
this appears as a permanent symptom in a series of
with the onset of the hot stage, and
it occurs
the prodromal erythema. The
most
feverish eruptions in which
as
important
form
belonging here is erythema variolosum s. roseola variolosa,a diffuse dark redness
occurring in the shape of reddish spots of brief duration on the skin of the abdomen, as
the inner side of the thighs,which
is to be regarded as the first beginning of
well as on
This erythema, at times, spares the genitals,
while the axillary
the variolar affection.
of
the
is
with
the
more
adjoiningportions
frequentlyattacked by
region,together
arms,
extensive
circumscribed
there
is
also
an
hypergemia,like a
erythema. Very frequently
the entire integument, often sparingonly the head and neck,
scarlatinoid
disease,over
the erythema attacks only the skin of the
often merely the abdomen, while in other cases
Nosoaround
the joints,
well as that of the hands and feet.
as
extremities,especially
is
this
neurosis.
vaso-motor
a
prodromal
erythema
logically,
sensory
"

have

.Hebra

had

the

same

at

time

see

that

the

disease

in

cases

and

demonstration

morbilli, the

the

pyrexial skin

co-existence

of

essentially different

two

two

disease, and

exanthemata

acute

disputed this assumption, and

Paediatricians

many

exanthemata.

acute

could
is

there

had the opporof years I have

happen. For a number
tunity
may
ence
coexistof this kind.
A probable explanation for the simultaneous
of disease, inasmuch
as
by the parasiticcauses
might be furnished
of a twofold
found
in acute
exanthemata
do not exclude
the possibility

the

bacteria

organism.
definite

Characteristic
efflorescences
for

diffusely punctate

of disease

for another

simultaneous

the

individual."

the

of the

mistaken

been
in

possibility "that

one

exanthemata

within

often

belief

coexistence

such

numerous

acute

micrococci

manner

to

occur

doubt

of two
the

held

positivelydenied

hardly any
to

has

variolosum

Erythema
observers

of the affected

for these
of each

scarlatina,and

mucous

tract,

as

combined

of the

the vesicular
it otherwise

is the

exanthemata

exanthems

(such

as

the

ous
simultane-

macular

for

pustular for variola) and

and

manifests

itself in the

various

the

themata.
exan-

forms
in diagnosing these mixed
lies,perhaps, for some
physicians, in the
difficulty
find
defective
older
records
the
for
in
we
conditions,
recognition of these rare
may
pathological
called peculiar species, as, for instance, a scarlatina
vesiculosa,
were
descriptions of diseases which
pustulosa, pemphigoidea, etc., or perhaps, a variety of morbilli which, lasting but a short time,
The

recurred

after

few

davs

'

"

with

"Medical

renewed

signs of fever

Eruptions," Arch,

St. Bartholomew's

and

showed

of Dermatology,
Hospital Reports, 1878,

changed

character

rescences.
of the efflo-

1880, p. 337.
^

In connection
:mata

with

of vaccinia, as

of variola it remains

the

erythema

as

those which

well

375

NEUROSES.

SENSOEY

VASO-MOTOE

then

and

now

for

occur

as

us

to mention

precursors

the

of

erythe-

morbilli

and

itant
prolonged pyrexialprocesses which represents a concomroseola
eruption of the primary disease,as in typhoid fever and at times in cholera
The
typhosa and choleraica.
erythema or the roseola in typhoid fever is brought about
in consequence
of an inflammatory process and appears generallyin the middle
toward
or
the end of the first week of sickness,is of pale-redcolor,the size of a hemp-seed to that
of a lentil,covers
chieflythe thorax and the extremities,and, in grave cases, is easily
into ecchymotic types. In cholera the erythema occurs
transformed
only toward the end
for a very brief time, and
of the violent symptoms, continues
disappearsas soon as the
The
cholera erythema exhibits larger spots than those
general condition moderates.
in
is
livid
and
dark in color ; Hebra
observed it in the epidemic
more
appearing
typhoid,
of 1866 at Vienna, and noticed that it occurred only sporadically
in about one
per cent

scarlatina,also the erythema

in

"

attacked.

of those

the erythemata of grave pyrexialdiseases mention

should also be made
of
of diphtheria. According to my
occurring in the course
experience,they
mostly covering the trunk, last from four to six
always appear ^s papular exanthems
with
until
fade
slightdesquamation. In affections of the genitals,
they
days,
especially
reflex phenomena.
as
blennorrhagicconditions, erythemata also occur

Among

the

forms

The
of

erythemata

the

after

lost in the

shows
run

without

which

graver

ulcerations
TJffelmann

the

he

case

'"

any

Prognosis

unfavorable.
further

course

and

at times

autopsy showed

connected

with

efflorescences
of the

bluish

the

mucous

and

serous

with
end

cutaneous

usuallydiaappear

skin ; should

pigment spots which

prognosisis presentedby the

infiltrations
the

The

alteration

less favorable

complicating diseases of
the erythemata connected

that

in which

of time.

with

is not

longer,they ordinarilyleave

course

erythemata

tract

general

brief existence
continue

case

in

erythematous nodes
makes
fatally. Hebra
on

the

mucous

erythema.

the

cences
efflores-

are

likewise

grave

membranes.
the

on

membrane

Grigorow

mucous

mention
of the

pyrexial
ence
Experibranes
mem-

of such

intestinal

'

not long ago

scribed
demembranes
which
led to
erythema attacking the skin and the mucous
and
in the mouth
termed
"ominous^'
finallyended fatally. The cases
by
intense
nodose
of
ished
are
eruptions
merely more
erythema occurringin ill-nour-

children

of

with

constitutional

disease.

The

Treatment

polymorphous erythemata is purely expectant. Many therapeuticexperiments

taught us that it is only in a small series of cases we can
secure
prompt remedial
in
effects. Ergotin, in the dose of 1 to 1.5 grams
has
few
a
day,
cases
per
brought about
I
involution
it
found
of
where
the
use
a more
speedy
erythema repeatedlyrecurred and
;
the erythema can
showed
a strong tendency to persist. Where
be traced to a pathological
the
is
mastered
reflex
affection
more
factor,
readilywith the removal of this factor.
the erythemata are connected
Where
with moderate
lutions;
we
itching,
may employ cold abin other cases, mere
dusting with starch, pure or mixed with zinc (Zinci oxidi.
of the

have

Vierteljahrsschrift f. Demiatologie. 1880, p. 109.

Deutsches
Arch.
f. klin. Med., xiv., 1876.

376

VASO-MOTOE

SENSORY

KEUEOSES.

Amyli, 50 grains);or sulphuratedzinc ointment

(Zincioxidi, Lactis sulph.,aa
2 grams;
carbolic acid (2 to 3
Ung. emoll., 30 grams). Alcoholic frictions with salicylic
or
of the former, 1 to 1.5 grams
of the latter in 100 grams
of alcohol)
often are quite
grams
should they be found to irritate the skin, their use must
be interrupted.Eryserviceable;
themata
connected with rheumatic
conditions requireno independent treatment; the attention
must
directed to the primary affection.
be chiefly
2.5 grams;

3.

Somewhat

Erythema

Nodosum.

akin

to the polymorphous erythema, but not to be identified with it in a

erythema nodosum.
It appears
and excrescences
in the shape of nodes
the size of a pea up to oval and
ties,
hemisphericaltumors as largeas the palm of the hand, chieflyoccurringon the extremiseldom
but
in
In
numbers.
the
isolated,
nearlyalways
larger
beginning,they are
dark-red, hot, and painfulon strong pressure; subsequently,they change their color, become
bluish-red,yellowishor greenish,thus looking like bruises;this explains the title
authors
dermatitis
contusiformis.
The
disease always
given to this affection by some
extends into the deeper parts of the cutis and the connective tissue;hence movements
of
the affected extremities
onset
The
of
the
is
are
painful.
malady
usuallycomplicated
with general symptoms
and very intense prodromal phenomena, and
consequently the
affection is classed as pyrexial. However, being not rarelyconnected
with inflammations
of the jointsor rheumatic
incidents,some
physicianshave been led to look upon erythema
rheumatica
the erythema multiforme
with
connected
tic
rheumanodosum, like purpura
or
Bohn
has designated
cause
symptoms, as a disease due to a common
(Durian,Legrand).
nodosum
embolic
skin
without
disease
an
erythema
furnishing any material
that small
proofsfor this assumption; he based his opinion upon Panum's
investigations,
the
and then arise within
the coincidence
of
circulation,as well as upon
coagula now
with venous
thrombi
in the lower extremities and presumably in the
erythema nodosum
observations
in some
This coincidence,
cases.
kidney (?),in accordance with his own
The
however, might only be quite accidental and has received no further confirmation.
of
coloration of the nodes would
of
rather
in
favor
exudation
blood
into
the
an
speak
tissue,as would the tension in the affected portion of the skin; stillit is difficult to trace
In our
the disease to an
embolic or hemorrhagic source.
opinion,the color is due to
is to be looked upon
transudation
affection distinct
of blood, and erythema-nodosum
as an
forms
from
to merge
sometimes
observed
the
several
are
erythema multiforme; although
differences
of the disease show certain
into each other, stillthe development and course
pathic
from multiform
view, to consider the affection an idioerythema, so that Neumann's
As the tension relaxes,slightfluctuation
one, is not to be altogetherdiscarded.
is exhibited in the node in its further course, but suppuration of the nodes never
occurs
or
quiteexceptionally(Uffelmann).
The course
of erythema nodosum
slower than that of erythema multiforme;
is much
the
the
of
disease,the development of the nodes seems
despite usuallyrapid appearance
the beginning to
to require a longer time, and
several weeks
generallyelapse from

clinical sense,

is

"

'

the

total

involution

height (41" C),

accompanying
conspicuoussymptom
"Embolische

of

the

remits
the
and

The

nodes.

much

outbreak
is seldom

sooner

of the

fever, which
than

skin

the

disease.

as
absent; still,

Hautkrankheiten,"

Jahrbuch

f.

may

articular

first

at

pains or

The

reach
the

articular

rule, there

Kinderheilkunde,

is

no

able
consider-

ditions
gastriccon-

affection

inflammation

1864, Heft

4.

is

a-

of

VASO-MOTOK

the heart

muscle,

ulcerations

SENSOEY

of th^ valves

nor

pericardium.

or

of the

In

severe
particularly

inflammations

mucous
membranes,
itis,endocarditis,with eventuallyfatal termination.
are

377

NEUE08E8.

of the
The

serous

involution

always with decrease of the tension and the pains in the skin; the
the doughy, soft tumor
becomes
changes into violet,light-yellowish;
and the skin slowlyregainsits normal
appearance.
The

anatomical

alterations

connective

show

tissue and

The
of

nodosum

erythema

which, should

they occur

for bruises
; the

is based
on

caused

swellingsdue

the

nates

to

occurs

dark

bluish

or

color

gradually

more

sistent,
con-

and

cutaneous
extending into the subThe
region of the node.
amply covered with lymph-cells.
the

above-described

elsewhere

or

contusions.

by

pleur-

of the nodes

Diagnosis

chieflyon

the

in

of blood

very full,the lymphatic vessels swollen

there extravasations
found.
are

and

membranes,

infiltration of the skin

an

exudation

are
capillaries

Here

there

cases,

Hence

dark-red

the trunk,

on

the form

of

the

bluish nodes

or

might easilybe
should

tumors

be

taken
misticed
no-

trauma

extends longitudiusuallyexhibit wheals, the tumor

nally,
but shows no circumscribed
formations
of lightercolor at the peripherythan at
the centre, and
blending with the surrounding hue of the skin. Should pyrexialconditions
the erythema and
articular pains be present, the recognitionof the
accompany
disease is facilitated.
A mistake with syphilitic
nodes is hardly possibleif attention is
membrane.
paid to the manifestations of syphilison the skin and the mucous
The painfulness of the recent erythema nodes
is so constant
in
a phenomenon
a
that,
possible
of doubt in regard to syphilis,
likewise be utilized.
case
it may
The
is

Treatment

mainly directed againstthe pain, which

of ice

water

or

with
applications,

by cold in the shape

may be best moderated
In this form of erythema
Goulard's lotion.

without

or

is indicated
generaltonic treatment
quinine,iron, wine pro re nata ; rest in bed is to
be stronglyrecommended
while the acute painfulstage continues.
For violent articular
acid treatment
is appropriate(three to five grams
pain the salicylic
d,aily).Every care
a

"

had

be

should
watch

the

in

this disease

to

4.

ranging
and

is

in size from

elevated

above

changes to
desquamation.
a

few

onset

hours

or

bean

to

chronic

of the disease
to two

one

after which

by

the

common

The

as

the roundish

the

affection

It

condition, causes
at times

characterized

firm

thumb-nail,

occurs

attentively

to the

by

efflorescences

feel,pale-redor whitish

(wheals)
in

color,

tion,
usuallyappears suddenly, is of brief duraviolent itching,and progresses without

without

or

oval elevations
circumscribed

appear

The

the
The
also

skin, which

are

peculiarburning
by the eruption

characon

the

caused

the title.

efflorescences of urticaria present manifold

their duration.

on

coloration.

swelling,is shared

slight temporary
(Urticaurens),whence
or

nettle

their extent, and

to

prodromata, at times is preceded for

ache,
days by general depression,malaise, nausea, fever, and head-

teri.jed by their above-mentioned

skin, as well

the level of the skin.

or

The

and

affection.

Urticaria, Nettlerash.

peculiarcutaneous

appropriate remedies

accompanying the cutaneous

symptoms

Urticaria

the

employ

wheals

forms
may

in the

manner

be scattered

of their
over

the

rence,
occur-

surface

378

VASO-MOTOE

without

to
the

being confluent, they may be

into
erythema or the exudation

its

duration, the

disease

has

NEUB08E8.

SENSORY

together or they may

underlying connective

close
the

also been

urticaria

called

be nodose
tissue.

febrilis

s.

bling
resem-

According

evanida, when

efflorescences

disappeared soon after the remission of the fever accompanying the

out
witheruption; as opposed to urticaria perstans s. chronica, urticatio,which
progresses
the wheals
fever and in which
different surfaces at succeeding
alternatelyoccupy

intervals.
The

is red

wheal

of the

when

the

papillarybody is hypergemic or white when it

is bloodless.
The
single efflorescences usually spread in groups, wandering from one
bloated, reddened, and
portion of the skin to another; thereby the skin appears
outlines
and
which
the manifold
resembles
hills
on
a
are
valleys
plastically
map
sented.
reprethe disease ocA peculiarform of urticaria is urticaria intermittens, in which
curs
in a series of days and weeks, always at a certain
and
then
time,
again completely
vanishes;thus, owing to the simultaneous
symptoms of fever, the urticaria appears
At times, however, urticaria occurs
of intermittent fever.
out
withmerely as a concomitant
be made
to disapfever in as definite intervals as a quotidianor tertian fever and may
pear
branes,
memby the use of quinine. In rare cases urticaria also shows itself on the mucous
color

and

Milton'

described

few

cases

in which

the

mucous

the

of the mouth,

membrane

with

as
as
common
an
integument were
eruption
pharynx,
Cases of temporary
of large wheals, which
form he therefore called giganticurticaria.
reddening,which, however, are followed by rather intense pigmentations,are rare
caria
(urtipigmentosa).
sufficient explanationof this morhas hitherto furnished
no
bid
Patliological
anatomy
table
because
to
the
examine
tion
affecno
an
gives
condition,
opportunity
post-mortem
the formation
of wheals
subsides so quickly; it is not yet decided whether
is
which
sult
brought about by a rapid transudation into the layersof the cutis or whether it is the reof a simple congestion. Vidal's investigations
speak for the former view, because
vessels corresponding to the wheals
he found the cutaneous
greatlydilated and replete
but
in
blood without
alteration
in
the
the neighborhood of the
vessel
with
walls;
any
and the lymph- vessels
in
accumulated
white
vessels
were
larger masses
blood-corpuscles
These anatomical
data furnish material explanation of the
also filled with them.
were
morbid
Every morbid factor followed by a nettlerash excites the termini of the
process.
nerves
membrane; they excite the
extending in the external skin or in the mucous
sensory
to contract, and by the succeeding
in a reflex way,
the capillaries
vaso-motor
cause
nerves
regions,thus producing the wheal which,
paresisincite the transudation in circumscribed
circumscribed
oedema.
but
else
a
accordingly,
representsnothing

and

trachea

well

covered

The

easilyformed from the wheals and

burning, stinging,itching. But there is
will be

Diagnosis
the
a

sensations

nervous

series of

other

associated

diseases

which

with

them

"

may

lead to

the

eruption

mistakes.
these

Among
a.

Lichen

This
of nodules
Bateman

belong :
urticaria

papulosa.
related to urticaria and
pathologically
hemp-seed to a lentil in size which soon

urticatus,

or

affection is
from

the

first introduced
'

term

lichen, because

the

characterized

change

efflorescences

f. Dermatol., 1877, p. 585.

Vierteljahrsschriffc

into
are

by

smaller

wheals.

smaller,

in

the

resembling gnat
"beginning
that the

the

nodules.

small

do not

itchingirritates the skin

intense

simultaneous

develop from

insect bites,and

and

379

NEUKOSE8.

8ENS0EY

VA80-M0T0R

enlarge if left alone, were

that largerefflorescences
so

urticatus,therefore,representsa mixed

Lichen

the one, sometimes

it not
often

form

tween
be-

the other

comitant
predominating. A consymptom is the intense itchingand whenever the effects of scratchingare seen, it
and prurigo. But such a diagnostic
is not impossibleto mistake it for papulous eczema
error
tions
than the affeclast long, because urticaria papulosa is always of shorter duration
cannot
in prurigo only in recent
in eczema
and
not
formed
wheals
are
named, because
disease.
in
not
b
ut
a long-standing
eruptionsor relapses,
I. Erythema.
This we
have described in its various stagesas erythema multiforme,
Its efflorescences persistthroughof them
wheals.
does it develop from
but in none
out
absence
of the severe
of the disease, there is an
the course
itching peculiar to
if slight,can
whenever
urticaria, and the desquamation, even
always be demonstrated
the nodes
Lichen
urticatus and erythema can
be mistaken
and nodules resolve.
for one
another only when
there are temporarilyno wheals in the former.
c.
Erysipelas shows a diffuse redness with considerable swelling of the skin, is a
more
prolonged disease,and is attended at most with vesicles. The process lasts a few
with subsequent marked
or
desquamation.
days
more,
of wheals
Diagnosticallyit is also of importance to ascertain whether the formation
nodules
which
caused
external
has been
irritations affecting
or
change into the former
by
the skin (drugs,electricity,
Furthermore
it should
be noted that,
insects)or not.
in prurigo eruptionsof wheals introduce the affection,so now
and then fine urticarial
as
in pemphigus
efflorescences may
urticaria
(pemphigus pruriginosus).When
appear
occurs
acutely,it should be borne in mind that it sets in preferablyby night,and that by
of the efflorescences can
day the remnants
barelybe found ; only in the chronic form we
find also during the day the excoriations due to scratching,pigment spots, and often discrete
this
latter
known
confluent
wheals
the
of
urticatio
or
affection,
name
or
by
;
chronic urticaria,is an exceedinglyannoying malady on account
of its pronounced chronic
tendency.

nodules

and wheals, sometimes

"

"

Etiology.
inducing urticaria,whether direct or indirect,in every case are such as
quite a specialeffect on the vaso-motor
system, partlyin toto, partlyon some
tions
poraffect the peripheral expansions of the cutaneous
direct causes
of it. The
nerves

The
"exert

causes

themselves, while the indirect

blood

of the

morbid

proved to produce the

to the
the disposition
Delicate

act

ones

agent. Among
appearance
cutaneous

individuals,women

and

as

irritants

the direct

of wheals
affection

after
is

on

causes
a

the skin
we

external

mere

dependent

by

include

on

children, therefore,react

the

the
those

absorptioninto
which

influence

have
;

the

been

of course,

of the
sensibility

skin.

easilyon
vigorouspersons.
Stronger irritations than simple pressure are the
effects produced by cold and electricity.Both agents in the beginningirritate the vasomotor
and induce anaemia ; fhen this changes into a quasi-paralytic
nerves
condition, with
urticaria wheals break out.
hyperaemia ; and then, according to the cutaneous
sensibility,
In an analogous manner
such as touching the skin
pungent substances produce urticaria,
with the common
nettle (Urticaurens),with Ehus
toxicodendron,and similar objects;
furthermore, stingsof insects,caterpillars,
mosquitoes,fleas,bugs, all of which provoke
less extensive surfaces according to the intensityof the
or
eruptions of wheals on more
than

influence.

robust

or

more

certain

tions
irrita-

380

VA80-M0T0K

The

indirect
Febrile

a.

wheals
to

of disease

causes

8ENS0KY

far

are

Children

conditions.

phenomenon of this
manifesting themselves

process

rheumatic

often

attacks

numerous.

more

while

sufferingfrom

teethingand

often exhibit

the second

on

NEUROSES.

seized

reflex

third

or

with

day

morbid

fever

of the affection.

urticaria,and

as

state in the

comitant
con-

shape of

Adults

ject
sub-

frequentlythe

eruption
exacerbations.
simultaneouslywith the rheumatic
b. The
ab ingestis).
In some
ingestionof various articles offood or drugs (urticaria
individuals we find a peculiaridiosyncrasy
These
againstcertain alimentary substances.
almost
such
aliments include
as
are
exclusively
partaken of as luxuries ; for instance,
caviare,mussels, pungent spices,etc.,
oysters,crabs, smoked or salted sea-fish,crayfish,
also champignons, strawberries,and other fruits ; a similar effect is produced by ordinary
alimentarysubstances and tidbits when partaken of in excess.
the balsams
Of drugs it is especially
(such as copaiba, tolu, and turpentine),and
belladonna, which may provoke, besides urticaria,also erythemata and other exanthems.
and other violent menExcitement
as
: fright,grief,
tal
c.
by moral influences,
anger,
offended
emotions.
Gibert relates of a newly married
woman
who, at a ball, was
by
unseemly insinuations,and was suddenly attacked by a confluent urticaria covering the
lar
Simineck, breast,and shoulders, which forced her to leave the place of entertainment.
tense
Not
not so very rare.
cases
are
long ago, Stampacchia' published a case of very inare

appears

urticaria connected

manifold

with

disturbances, which

nervous

had

erable
consid-

led to

could with
extremity,the causative factor of which
of
loss
child.
be
be
to
the
assumed
a
over
certainty
deep grief
d. Anomalies
in the functions of the sexual apparatus, as ivell as of the respiratory
mentioned
The
former were
and digestive
by the older physicians,who stated
organs.
often previousto the onset of menstruation, with genitalaffections,
that urticaria occurs
de Mussy^ called attention to a connection
between
after abortions,etc. Paul and Gueneau
and attacks of urticaria ; they reporta series
membrane
disease of the respiratory
mucous
asthmatic
of observations of bronchitis spastica,
or
attacks, in which the latter remitted
tract of the digestive
the
Affections of
urticaria broke out.
mucous
whenever
organs,
angesthesia

however,

also be looked

must

icterus due

to

during the

left lower

of the

passage
the

after

of the

as

upon

colic,on
gall-stone
stones

two

through

the
In

cessation of the colic.

taenia, several

of

causes

times

ductus
a

noticed

of the fact that in urticaria,besides

of

formation

the

hemorrhages, or
centres

and

attack

an

the

case,

eruption

an

of

case

every

in

its train,we

seek the seat of the

disease

must
in the

of

case

mediately
disappearedimin

of urticaria

echinococcus

an

vidual
indi-

whenever

of the liver.

tapping.

the wheals,

we

see

as

concomitants
no

deeper implicationof
peripheralnerves.
exclude

of urticaria

author,

same

and persistent
(lichen urticatus)
erythemata, but

nodules
ulcers

Litten,'in

observed

choledochus, which

second

sufferingfrom
passed in greaterquantity. In
piecesof the worm
Lerebouillet^ witnessed an eruption of urticaria with
In view

Thus

irritation.

occasions

different

also

vesicles,
the

nerve

Prognosis.
belong to the dangerous diseases, but
exceedinglyannoying malady. In children and infants the
Urticaria

'

"

Gazette

XJn

caso

does not

di Urticaria

hebdomadaire,

Charite-Annalen,

"*

Gazette

con

perturbamenti

1881, No.

7.

Berlin, 1879, p. 200.

hebdomadaire,

18S1, No.

16.

nervoei."

Annal.

de

in

its chronic

sudden

occurrence

form

it is

an

of urti-

Dermatolog., 1881, p. 150.

382

AND

NEUTKOTIC

TKOPHONEUROTIC

DISTURBANCES.

at times extraordinarily
effective in the dose of 0.001-0.002
gram
per day; of course,
atropine must be exhibited with the necessary care.
My prescriptionreads : I},Atropin.
sulph.,0.01 gram ; Glycerini,Aq. dest.,aa 2 grams ; Gummi
tragac, q. s. ft. pil.No.

proves

XX.

In
be

could
in

cases

few

used

in

which

had

extended

the

other

they
they

over

NEUROTIC

recurred

form

for

belonging

disturbances

from

three to five years.

TROPHONEUROTIC

DISTURBANCES.

this group

to

the

on

distinguishedby

are

when
the remedy was
stopped ; but where it
remained
longer time, the urticaria finally
away

period of

AND

affections

cutaneous

elements

affection

correspondingdoses

III.

The

the

cases

hand

one

manifold

depend upon disease of nervous

acting on the nutrition of the skin, on
neurotic
complications in the sensory

sphere.
scientific

It is diflBcult to furnish

proof that the nutritive disturbances are caused by

trophicnerves
deny the assumption that
; but we cannot
in
the
cutaneous
of
diseases.
Even
Cohninfluence
numerous
exert
production
an
they
in
to
reference
this
in
who
a
p
osition
sceptical
heim,
occupies very
question,says,
ing
speakindubitable
that a true and
of some
trophicinfluence of certain
cognate cases,
be disputed."
centres
cannot
and nerve
nerves
Among the conditions to be considered trophoneuroticdiseases belongs a series of
a

certain category of

nerves

^the

"

"

'

conditions, with

inflammatory

without

or

the

formation

of

efflorescences,ulcerative

but of the largenumber

of affections falling
processes, and structural affections of the skin;
shall confine ourselves only to those diseases which
under
this head, we
present at the
time

same

In the

neurotic

trophoneurotic character.

and

foreground

of

affections "stands:
trophoneurotic

PEUKIGO.

Formerly

the terms

were
prurigoand pruritus

either

looked

as

upon

synonymous,

and

every

itching
scratchingaffection
itching
and
and scabere, whence
prurigo
scabies).
(prurire
and designated
first restored prurigoto an independent position,
Willan and Bateman
as
forms
as
prurigo mitis and formicans; those occurringwithout nodules
the nodular
disease

with

associated

and

prurituslocalis

was

called

an

or

senilis.

exceptions,is still current in France and

of Hebra, has completely separated
England; only
from
disease
cutaneous
prurigo sine papulisor pruritus.
papulisas a true
prurigo cum
of prurigo
as Hebra's
description
The
English have gone so far as to assert that, inasmuch
is a different
does not refer to prurigo so called in England, prurigo of the Germans
Congress gave the
affection from prurigo of the English; but the last International
This

classification of

opportunityto

school, since

few

the

time

quasi-differences.^
of Prurigo. The disease

obliterate these
and

Symptoms
presence, mostly on
numerous

prurigo,with

Vienna

the

Course
the

discrete nodules,

'

"

"

"

extensor

having

Vorlesungen

Transactions

uber

surfaces

we

call

of the extremities

at first the color of the

prurigo

and

less

on

in

the

the trunk, of

skin, and graduallydarkening;

Berlin, 1882, i.,p. 518.

allg.Patholog."
Med.
Congress, London, 1881, III.

of the Internat.

consists

AND

NEUROTIC

TEOPHONEUKOTIC

38S

DISTURBANCES.

hemp seed in size,and occasion violent itching;after a brief

existence,they are freelyintermingledwith excoriated efflorescences. The disease appears
it is nearlyalways preceded by wheal-like
in earliest infancy, and has a chronic course;
which are never
absent, besides,in relapsesof the disease.
efflorescences,
The
prurigo nodules are distinguishedfrom the nodular eruptionsof eczema
losa,
papuinto other
erythema, and scabies,chieflyby not being spontaneously transformed
efflorescences,and the fact that throughout their whole existence they change neither
if the affection last for years, as mostly flat,
into vesicles nor
crusts, but appear, even
elevations,or perish in the subsequentlyforming infiltration of the
slightlyreddened
the disease extends greatly. The
skin in case
deeper layersof the cutis form the seat of
the nodules, and thus it happens that the intense subjectivesensations are often perceived
be seen
the integument.
before changes can
This fact probably made
on
prurigo
the
be followed in its further course,
appear identical with pruritus;but if such a case
in pruritus the skin seems
difference in the affection becomes
while
marked, and
altered at most
by excoriations,in prurigo the nodules will manifest themselves early,
and largelyincrease in number.
in prurigo is the
most
continuous
violent
The
prominent symptom
itching
which
reach
so
high a degree that the patients suffer the most unbearable
may
and cases
known
where some
driven
unfortunate
are
nervous
complications,
people were
sensations provoked by the itching are
to insanityand suicide by it. The
fold,
very maniand manifest themselves
chieflyat the places most affected;often, however, owing
in its totality,
the skin is attacked
to the fixed irritation,
even
on
parts quitefree from
sensation
becomes
of general pain and
and then the
scribed
one
discomfort, deefflorescences,
able
by the patientsin the most glowing colors,and despitethe comparativelyfavorphysical conditions as regards nutrition and assimilation,the vital processes are
as
seriouslyimpaired. Some patientsfeel tolerablywell by day, but as soon
they seek
often
sit
in
their bed at night,the unbearable
the
bed for
itchingcommences;
patients
their
skin
and
the
nodular
efflorescences
with
their
hours, tearing
nails,so
detaching
that here and there the upper
epidermal layersappear covered by crusts of dried blood.
It is not so much
the evening or night time which
the increase of the nervous
causes
the temporarilydormant
tion
irritasensation,but rather the heat of the bed which awakes
of the skin, and, when
once
aroused, permits its alleviation only with difficulty.
in which the patientshad been more
I have observed cases
weakened
and reduced
by the
continual sleepless
than
a
nights
by many
dangerous acute disease. Equally irritating
are
warm
or
close-fitting
garments, at times also increased temperature of the surrounding

they

from

are

millet to

air.

sequelsof prurigo manifest themselves on the skin by considerable alterations

its surface; for, both by the persistent
on
itching and the frequentscratching,the skin
becomes
and
firmer in its texture, dingy, lustreless,
loose exfoliations of the epidermis
The

form, which
where

and
In

skin

cover

the

entire

they are found

changed by an

and will
efflorescences,

we

old

diseased
may

Such

alterations

arise

only gradually,

that the affection has existed several years.

find an almost entire absence of the pruriginous

presuppose

prurigo we

rather to take the actual morbid

picturefor a squamous
will probably at once
ichthyosis. The experienced practitioner
recognize
but even
the differences;
the less expert will soon
be able to make
correct diagnosisif
a
he bear in mind
that prurigo presentspeculiarities
do not belong to other diswhich
eases.
If the prurigo be of long standing,the further alterations occurring are
suck
and very frequentlywe
found in chronic eczema,
as are
find besides the prurigo th"
can
eczema

or

an

be inclined

surface.

284:

AND

NEUROTIC

which

TROPHONEUKOTIC

DISTURBANCES.

is characterized

In this
by scabs, crusts, and weeping surfaces.
and
hidden
transformed
therefore,the originalmorbid
picture might appear
by
way,
the sequel. In addition to this,we
have the fact that in universal
prurigo the places
and
generallyspared by it,such as the face and nucha, are likewise attacked by eczema;
if we
be able to distinguishthe portions first
closelyexamine the skin, we shall soon
affected from those subsequentlyattacked.
The pruriginous skin, moroever,
in its darker
pigmentation
presents a peculiarity
which
is likewise provoked by the above-described
especially
by the
symjjtoms, and more
intense and continuous
fact may be observed also in inverate scabies
scratching; the same
due to the pediculusvestimenti.
or
long-standingprurigopedicularis
We must
mention
affection of
absent in an
one
more
phenomenon which is never
the
visible
and
of
the
long standing
swelling
enlargement
largerlymphatic glands ; this
tation
stands
the
of
in relation to
infiltration
the diseased surfaces and probably also to the irricaused by the scratching. We find this state of the glands much
more
frequently
in chronic
it is also present in eczema
prurigo than in prolonged scabies or eczema;
The
absent
dermatonoses.
of the scalp,but
in psoriasisor other chronic
swellingof
the glands depends on
As to the age
the gravityand
the duration
of the affection
of prurigopatients,
experienceteaches that the majority of prurigo sufferers exhibit this
the earliest period of life to adolescence
state from
and beyond.
morbid
This fact per se
indicates a specialgravityof the morbid
which
induced
has
observers,and
many
process,
incurable
to
Hebra
make
disease lasting
statement
the
the
is
that
rest,
an
prurigo
among
the
whole
of
life.
But
of the
the
of
throughout
physicians,especially
experience many
Vienna
that
cured
than
if
it is
shows
in
is
much
more
school,
prurigo
easily
earlyage
the patient has reached
under
treatment
when
cence.
adolesneglectedin this stage and comes

secondary eczema

"

Prurigo of the aged (prurigosenilis)

reallycoincides
the characteristic

because
as

For

secondary phenomenon.

excoriations

numerous

the

factor, the formation

skin swelled

female

and

male

and

few

in

nodules

by the itching. The

genitalsdescribed in

this disease
; the

latter

same

remark

older

works.

Anatomical
The
the

more

recent

anatomical

skin

find

we

in

itching,pruritus,
a primary, but
intense
itching with
as
papillarybodies of
local prurigo of the

not

occurs

very

fact

appear
applies to the

as

Changes.
subject show actual
by Neumann
fullydemonstrated

researches

and
its appendages, as has
especially
by Gay.^ The former

with cutaneous

of nodules,

into

this

disease
and

of

Derby,'
conspicuously
loosened, and surrounding them
altered, the hair thinned, the root-sheath
and the papillae,
exudation
into the corium
an
a thickening of the
papillarybody around
the hair-follicle and the sebaceous
accumulation
of
cells,with protrusionof
glands by an
the
condition of the prurigo
the rete Malpighii. These investigations
agree in so far with
nodules as the latter almost
invariablyseemed piercedby a hair and thus a priori led to
the suppositionof an alteration
of the hair as involved in the pruriginous disease.
Gay
that the thickness of the horny layer caused by the plasticprocess
showed
is very conspicuous.
In the later stage of the disease the sebaceous glandsgenerallyatrophy and the
sudoriparousglands dilate by ample cell development in their efferent ducts and in the
glandularcanal proper.
and

been

found

'

Sitzungsberichte der kaiserl.

'

Arch,

fiir

the

hairs

Academie

Dermatologie, 1871, iii.,pp.

and

zu

1 et

their follicles very

Wien.
seq.

59

Bd.

TROPHOKEUROTIC

AND

NETJEOTIO

385

DISTUKBANCE8.

Diagnosis.
The

morbid

errors

conditions

manifested

urticaria,but then merely

and

in fact

are

not

rare.

With

in

prurigo can
beginning

in the

reference

the

visible in the

burrows
of the parasiteare
to
one
shape of wavy stripes,
raised above the level of the skin ; at the end of the track
length,slightly
darker
at times be observed
colored points can
(excrementof the acari). Therefore,
those parts of the body should
be carefully
examined
where
the tracks are
usuallymost
the
frequent,*'. e., between
fingers,the genitals,the nipples, and those parts of the
the
which
trunk
around
clothes are
tightened. But in long-standing and extensive
the
b
urrows
often
are
.scabies,
parasitic
totallydestroyed,and traces of recent tracks can
be
found
but
in
such
will be assisted by the knowledge
cases
we
hardly
anywhere ;
of the secondary symptoms of the disease as occurring in scabies,as well as by the pustules
two

"

zema,
only for scabies,ec-

affection ; such diagnostic

examination
will easilyclear up
scabies,

to

the case, for the

mistaken

be
of

lines in

vesicles

and

the extremities,scratch-marks

on

those

on

parts of the skin where

pru-

the palm of the hand, and

rigogenerallydoes not appear, such as the genitals,
some
of
the
trunk.
parts
could be mistaken
for prurigo,but it rarelyoccurs
Only the papular form of eczema
the
extremities
and
affection presents
as
as
extensivelyon
besides, the former
prurigo,
manifold
forms
transitional
as
of the efflorescences,
stages,*. e., the transformation
"the nodules, crusts,pustules,and
exudations
serous
changing into crusts. It should
be
not
forgotten that eczema
presentsquite different factors from prurigo as regards
development, course, and duration; while, in the latter,trunk and face are more
or
less spared,this is not the case
with eczema
in
toes
and
intact
are
prurigo,
; fingers
but not in generaleczema
also less
; in the latter the flexor sides of the extremities are
affected.
does

Eczema,

no

Urticaria

intense,clears

up

and

spontaneouslyhere

there, prurigo

not.

be

can

only if hastilyexamined
wheals

how

matter

mistaken

for

in

prurigo

the

first

stages or

in

outbreaks

recent

for, in prurigo,nodules are always found with the urticaria

of short duration, and
at the placeswhere
besides,the wheals are
they have

developed into

nodules

they do

not

relapse,as

is the

case

with

urticaria.

Etiology.
No

to the nature
of the disease have been
as
indisputablycertain landmarks
cured
sepresentday.
The
older physicians believed that the irritating
substances
ganism,
remaining in the orthrough impaired activityof the kidneys,furnished the incentive for an outbreak
the skin of an eruptionimpregnated with these substances.
on
Skin diseases connected
with itchingwere
also regarded as the outflow of a peculiar
constitution of the blood, the so-called psoric dyscrasia. Assumptions of this kind are
just as common-place as the view that prurigo is due to emotional affections,the nervoences,
sanguine temperament, taking cold, malnutrition,pungent drinks,atmospheric influto the

etc.

Without

the

enteringfurther into the discussion

of the intense itching. Hebra
interpretation
of

which

circumscribed

presses on
the analogy of

exudation

papillarynerves
some

and

efflorescences

within
causes

which

the

of obscure
believed

causes,

the

we

shall

itching to

hair-folliclesor the

be

without

the

to

quence
conse-

glands
negativedby

sebaceous

the irritation ; but this view is

frequentlyappear

proceed

this

symptom.

886

AJSTD

NEUROTIC

therefore,lias explained the

Cazenave/
affection

TEOPnONEUROTlC

DISTrUBANOES.

matter

by relegatingthe excitingcause

of the-

of which
there appear
system, in consequence
great hyperaesthesia with its sequels; accordingly the itching is the primary, and
the nodular
Hebra^s
eruption, caused
by the scratching,the secondary trouble.
objection to this
of the nodular
view is,that the itchingalways sets in after the presence
eruption; but
of prurigo,because in chronic cases
this does not hold good for all forms
with very slight
absent nodular
and here and there even
eruption,we still hear the patientscomplain of
intense itching.
is likewise inclined to consider prurigo as a neurosis.
Wilson
Auspitz,^however,
has pleaded most
of this malady and
thoroughly in favor of the neurotic nature
finds the histological
called it a true idioneurosis.
He
alterations insufiicient by far to
explainthe itching,and reaches the conclusion that, as regards prurigo,we must adhere
to the idea of a neurosis of sensibility
just as we do in pruritus cutaneus, but with this
of the cellular hypertrophy around
in pruritus there is an absence
difference that
the
simultaneous
muscular
hypertrophy of the smooth
glandular formations, but, by the
fibres in prurigo,there is caused a sort of neurosis of contractility.
Eespecting the idea of a neurosis we fullyagree with Auspitz,but on the other hand,
and for the followingreasons
look upon
recent cases,
we
: In
prurigo as a trophoneurosis,
almost
the
nodular
of
urticaria.
The
an
invariably
we
eruption,
eruption
find,preceding
of
this
knows
well
this
prurigo quite
experienced practitioner
symptom is
;
precursor
form
of
urticaria
the
the
angioneurotic
by
distinguishedfrom
persistenceof
pure
into another
its transition
find in
the eruption and
Moreover, we
papular form.
in its texture
severe
:
prurigo that the nutritive disturbance of the skin is expressedeven
tissue ; the
it is lustreless,
faded, shows an undeveloped or ill-nourished subcutaneous
of the efflorescences with their sequelsimpart to the comand the continuance
outbreak
mon
of
the
diseased
for
this
and
a
surface,
reason
we
integument
might
appearance
admit, in a restricted sense, the idea of a diathesis such as is ascribed to prurigo by
French
by Guibout,^ a cachectic form
dermatologists. It has been most correctlynamed
ance
of disease.
Indeed, it is difficult to discard the idea that prurigo is a congenitaldisturbof nutrition which
might be called a cachexia ; which, although not leading to
stillif left to itself may persistas a grave general disease,while, on the other
marasmus,
be removed
The
it
immediate
and
can
by prolonged and attentive treatment.
hand,
demonstration
of the change in the peripheralor central nerves
has hitherto
anatomical
not been furnished ; but this proves nothing againstour
assumption.
to

the

nervous

Prognosis.
of
prognosisin general. The incurability
the
in
hand
on
one
can
prurigo
merely
many
that the patientmay
be relieved
in so far be ameliorated
by appropriatetreatment
some
length of time ; on the other hand, in the majority of cases in children,prurigo
in the latter disappear after several years*
I have
be cured.
cases
seen
numerous

The

admit

disease does not

of

cases

for
can

favorable

While

relative.

this affection,however, is

treatment.
In

adults, prurigo is to

development,

but

then

be

only

considered

with

Annales

"

System

"

Lefons cliniques

des
der

disease

dating from

infancy,rarelyof

curable.
diflQculty

maladies

de

la peau.

Hautkrankheiten."
sur

les maladies

Paris, 1844, II.

Vienna, 1881, p. 105.
de la

peau."

Paris, 1876, p. 46.

later

TEOPHONEUEOTIC

AND

NETJROTIC

38T

DISTUEBANCES.

Treatment.
The
Of

to

of

treatment
internal

prurigo may

remedies

arsenic

be

attempted by

alone

be

may

internal

tried

and

in the dose of

opinion it may do
per day graduallyincreased ; in our
local treatment, but it often fails both alone and when

external

means.

service

good

combined

grams
centi-

to two

one

auxiliary

as

with

external

(Dr. Kohn) tried carbolic acid in a larger series of

ago
affections associated with violent itching. He started with the idea that tar
cutaneous
and its preparations,
ternally.
which
externallyform valuable remedies, may also prove useful intried carbolic acid in pill form (I^ Acid,
Pulv. et
He
carbolici,5 grams;
Extr. liq.,
50), both in children and adults, startingwith from five
q. s. ft. pil.No.
made
to ten per day. According to the statements
(1.c), the remedy was serviceable in
and
of
in
without
numerous
use
proved
prurigo
cases,
any external treatment, but later
have
not
confirmed
these
results.
experiments
and then, and an Italian phyPotassium
bromide
is said to have proved useful now
sician
claims to have seen
rapid cure of prurigo by dailydoses of ten to twelve grams.
Oscar
Simon'
and Pick*
recommend
pilocarpine,0.01 gram
daily subcutaneously,
in numerous
The same
and this has given good results in my hands
be said
cases.
may
such
of ergo tin in doses of from 0.05 to 1 gram
as
Narcotics,
opium, lactuper day.
in
chloral
of
use
no
carium, hyoscyamus,
prurigo.
hydrate,chloroform, are
is greaterthan that of the really
in ordinaryuse
The number
of external remedies
phur
serviceable ones, of which
water, and the preparationsof sulwe
speciallymention:
remedies.

time

Some

Kaposi

'

"^

and

tar.

Water
as

in the form

used

be

may

the latter

undoubtedly

the

of cold lotions

baths, but

warm

or

useful of the two.

more

Tub-baths

permit

influence

the

we

recommend

the

patientsto

the water

at a mild
of
soothing
C; the longer the patients remain in such a bath the
temperature of from 32-26"
more
brings out the difference between eczema,
soothingit acts, and this fact alone clearly
and prurigo,both of which representmorbid
by intense itching.
processes distinguished
bath increases the hypersemia of the skin; in prurigo it modthe warm
In eczema,
erates
remain in the bath, the more
favorable it is for his
it. The longer the patientcan
diseases (prucondition;this also explainsthe effectiveness in many chronic cutaneous
rigo
of the prolonged baths as used for many
the rest)
years in Switzerland,where
among
the patientscan
stay in the baths from six to eighthours continuously.
Such protractedbaths, of course, may also be taken at the various thermal
spas, provided
do the iodine, iron, and
as
they do not contain strongly irritatingingredients,
As sulphur likewise exerts a favorable effect on prurigo,and as it is immasaline baths.
terial
baths
be placed first in the list with the
form we
in what
employ it,sulphur
may
In our
baths.
indifferent thermal
experience,baths are not only an excellent,but even
an
indispensableremedy for prurigo,and with it we combine the other agents, according-

submit

the

to choice

In

and

of soda,

there is
one

the simultaneous

with

in

applicability.
where

cases

carbonate

surface

affected

to

toto

or

no

two

addition

innerlichen

river

or

soft water
for

pounds
of sulphur

Gebrauch

der

"

Schmidt's

"

Berliner

fur Dermatologie, 1880, p.

Vierteijahrsschrift

den

or

Jahrbticher, 1871, iv.,p. 164.

klin. Wochenschrift,

1879, No. 49.

67.

our

for

tar

Carbolsaure."

^
"

Ueber

at

bath

an

it is best
disposal,

adult, which

preparations. An
Archiv

fiir

to mix

does not

it with

interfere

effective

remedy

Dermatologie, 1869, p.

21 9"

388

AKD

NEI7E0TIC

TEOPHOIS

DISTTTRBANCEB-

EUKOTIC

with the bath is tar, and the so-called tar baths are often of more
use
easilyincorporated
thus: The
tar bath
in prurigo than
in psoriasis.The
is taken
affected surfaces are
painted in part or in toto (the latter is to be avoided, owing to the absorptionof the tar,
with a solution of tar in ol. cadini or rusci;
with subsequent symptoms of intoxication)
the patient then gets into the bath, remaining one-half to one
oughly,
hour, then washes thorvaseline into the skin.
rubs simple ointment
and slightly
or
The
sulphur and tar remedies
may be employed in prurigo with or without baths.
bing
Patients with moderate
take,
a simple prolonged full bath, subsequentlyrubprurigo may
in some
for
tar
instance:
01.
5
Lactis
IJ
ointment;
sulphur or
sulphuris, grams;
cadini, 2.5 grams; Glycerini,10 grams;
Ung. simpl.,40 grams; M. S. ointment; or IJ
(Kaposi). Dusting the anointed parts
^aphtholi, 3 grams;
Ung. simpl. 60 grams
,

with

of starch

mixture

rice-flour facilitates the

and

intimate

of the ointment

contact

prurigo,with considerable infiltration of the skin and

the
affected
be well rubbed with soft-soap
solut.
crust-formation,
or
copious
parts may
the
to
anointed
and
with
ointment.
Vleminckx
bath,
previous
subequently
sulphur-tar
IVhen
improvement has set in, the soft soap may be omitted, and we employ only the tar
Tjaths; subsequent to each bath the skin is greased with simple cerate or fat. In
besides,the itchingis diminished
by wearing close-fitting
under-garments
patients,
many
oi tricot or flannel,as well as caoutchouc
clothing.
intense at night, the patient is to use
the baths with the
the itchingis most
When
remedies
in
the
before
other
retiring.
evening
baths have not done
above
Sublimate
near
as
me
good service as the treatment
In

the skin.

with

given.
By

this

temporary

carried out,
plan, if persistently
But

cure.

nothing

but

remedies

for

intense

more

The

we

modify
length of time,
of

method

same

always

secured

improvement

to

this treatment
and

some

have

we

cases
we
prevent relapses,and in many
the
and, in intractable forms, we
employ

unable

are

treatment

thus
in

give

the

and
do

several

patienta better chance for improvement.

form
appliesto children as well as

milder

can

to adults.

vesicular

and

part also

eruptionsbreak

in the formation

influence
The

in

vesicular and

The

type of

out

affections

the bullous

after

lesions

nerve

"

also

are

fact

trophoneuroticdiseases,
clearlydenoting the neurotic

of this efflorescence.

the vesicular affections is

HERPES.

In

1798

and

Willan

Bateman

gave

definition
of herpes
appropriate. According to
affection, characterized
by a series
size of a
the
base; they are
mostly

clear

correct

distinct

and

and

recognized
even
to-day
present definition, herpes is a cutaneous
a
slightlyreddened
of transparent vesicles on
hemp-seed, joined into groups, and follow the direction of
of a few days (eight to ten),while their
they dry in the course
must

which

be

as

our

cutaneous

some

whitish

serous

nerves;
contents

this
When
turbid; they disappear leaving pigmented spots of brief duration.
not
but
is
this
course
especially
remarkable,
times
several
typical
repeated,
process is
of far more
importance is the painfulnesswhich, however, generally
characteristic;

become

occurs

almost

Herpes

in herpes zoster.
exclusively

tonsurans

is

parasiticaffection,and

as

such

has

in

common

with

the

vesicular dis-

390

AND

NEUKOTIC

herpes zoster

likewise

may

DISTUBBAJS^CES.

TBOPHONEUBOTIC

in the
in tlie face, especially

appear

region of

the eyes

(zoster

ophthalmicus).
Herpes PrcBputialis,Progenitalis{Hetra).

2.

It

both

occurs

penis.

The

the prepuce

on

skin is but

singly
groups
the vesicles become
or

on

somewhat

reddened

turbid, they dry

the first twenty-fourto

and

be

can

the

or

times

base.

hours
thirty-six

all that

are

(the external

slightlysensitive,at

internal

itching,and
After

crust,

so

fold)and

brief existence,the

that

the

on

the several vesicles

the

herpes

glans
are

contents

is visible

in

of

only in

of the disease ; later,crusts, scales,or slightexcoriations

excoriations
somewhat
These
moist
or
spots,

found.

resembling ulcers the size of a hemp-seed, not rarelygive rise to the suspicion,especially
when
ulcers and
thus might occaisolated,that we have to deal with specific
sion
they occur
diagnosticmistakes.
This
the

form

vesicles

of

herpes occurs

other

or

(herpes vulvaris

not

excoriations

only in
found

are

but

men,
on

also in women,
more
though much
rarely: and
vulva, together with coijsiderable hyperaesthesia

the

pudendalis).

s.

In order to avoid

diagnosticerrors

and syphilitic
ulcers,
herpes progenitalis
Professional
syphilographershave
to
inoculation
in
doubtful
that
tion,
proposed
try
syphilis,
by auto-inoculacases, knowing
cannot
while
inoculated.
be
Such
produces chancre,
herpes
controllingexperiments
in isolated cases, but as a general rule they are
could be made
not necessary, if
The duration
bear in mind
of the efflorescences (herpesheals within eight to ten
we
: a.
of treatment.
tion
days without leavinga trace behind), and t. the mode
Every cauterizaof an herpeticexcoriation may produce an indurated
It is best,therefore,
surface.
and employ indifferent remedies
in doubtful cases, to delay any active treatment
lead or
zinc ointments
lead-water
with
^until
starch
time
lotions,dusting
(1 : 10),
enough has
larges,
elapsedto clear up the diagnosis. But should it be found that the diseased spot enof
and a purulent secretion takes the place of a watery exudation, the presence
ulcer will no longer be doubtful.
a specific
In most
of the patients,that the
can
determine, from the statements
cases, we
outbreak
of the efflorescences usually occurs
few days after the influence of certain
a
under
tion,
cases
onanism, pollutions).In some
irritatingconditions (coition,
my observathe occurrence
of herpes took place several times so obviouslyafter coition that a
connection
between
the genitalfunction
and the herpeticeruption seemed
indubitable,
mate
intiand the increased irritability
of the genitalnerves
could be suspected as the most
the

exercise

must
practitioner

the

between

utmost

caution.

"

"

of the

cause

Plumbe

considers
of

efflorescence.

herpes preputialisthe

diathesis; while

other

authors

outcome

have

of

disturbance

of

specially emphasized

digestion;Bazin,

its correlation

with

the

sequence
con-

specific

genitalaffections.
A

few

authors

Mauriac's' conception seems

to
ogy
genitalherpes into such an analplexus as the real pathogenetic
factor ; but he is in error
arthritic
when
he assumes
an
dispositionin support of this
view.
The neuralgiccause
in itself suffices to explain this malady, which, in the character
of the vesicular eruption,clearlydisplays its etiological
relations with the other
herpeticaffections.

regard it as

neuralgicdisease.

But

be very comprehensive ; he, like Barensprung, brought

with zoster as to look upon irritation of the sacral

"

Le9ons

sur

I'herpesneuralgique

des organes

genitaux."

Paris, 1877.

iIeueotio
The
of

and

tkophoneurotic

391

disturbances.

of herpes progenitalis
of relapsingfrequentlyis
peculiarity

herpes

as

pronounced

this observation

deserves

as

in this one,

the

and

consideration

some

3.

Herpes

cause

thereof

in

no

other

species

is not clear ; at all events,

diagnostically.

Zoster

Zona.

or

disease,extending
Symptomatology and Pathogenesis. Zoster is an acute cutaneous
with
skin along the direction of a nerve-twig; it appears
groups of vesicles,is
and
ends
less
does
not
cular
more
or
run
a typicalcourse,
by drying up of the vesipainful,
The beginningof the
local process.
contents
and temporary change into another
and feverish conditions
disease is often preceded by general malaise
lastinga few days,
and it is conjoined in some
patientswith fixed pain at some
part of the body. After
two days, we
find on the painfulspot a reddened
the lapse of one
or
patch. But often
cutaneous
the
and
the
affection,
no
patient'sattention is
precedes
generalindisposition
in
sensation
the skin.
Zoster then appears in the shape of
abnormal
attracted by some
several vesicles joined into groups, six to eight or ten in number,
looking like small
fluid ; for three or four days they
whitish or yellowishpearls,filled with a thin serous
at times they also increase,spread,or unite into largerbullas.
When
remain
stationary,
faded
and limp, the underlying
the efflorescences begin to dry up, the vesicles become
skin grows
yellowish-brown,moderately thick crusts, which
pale,and there are formed
zoster
fall off spontaneouslyin a few days. This process is not uniform, for wherever
the groups of vesicles,according to the implication of the nerve-twig,continue
occurs,
that the course
of such morbid
to develop along the latter, so
process may
occupy
in the

three

from

to six weeks.

phenomenon is often presented by violent neuralgiasradiatingin

the eruptionspreads. At times the pains are of moderate
the direction
intensity;
After sleepless
in a few cases, however, they are of a terrible character.
nights and days
of the cases
dejected and weak, emaciate (in one
passed in agony, the patientsbecome
in two
of the body decreased
weeks
under my observation the circumference
by twelve
to
considerable
time
after
and
strength
regain
centimetres), frequentlyrequire
recovery.
Often the patientsfeci compelled by the violent pains and the accompanying itching
torn
the affected portionsby scratching; but thereby the vesicles are
to ease
open, and
to
heal.
Not rarely,however, ulcers occur
which at times are
slow
form
thus ulcers
of the vesicles is an important
such external provocation,and this transformation
without
the
of
affection.
the
nature
favor
of
in
Many
physicianshad ascribed
trophic
symptom
the pain to the pressure of the vesicles on the peripheralnerve
expansionsand sought the
condition of the cutaneous
disease.
of the neuralgiain the anatomical
However,
causes
zoster
of
the
existence
be
abandoned
as
soon
as
this view had to
began to be brought into
At the present day herpes
causal relation with affection of central or peripheralnerves.
anatomical
lesions are
zoster stands as the type of a neurotic
affection,for often coarse
A

concomitant

in which

in connection

with

nature.
pathological

The

found

on

neurotic
Cases

disturbance

of zoster

it.

The

number

is

of

causes

of

authors

may be either of a
have considered
zoster

zoster

who

traumatic
a

disease

or

based

quitelarge.

referable to

traumatic

Journ.

de

cause

have

Physiolog.
,

1859.

been

described

by Kouget,' Eey-

392

AND

NEUEOTIC

TEOPHONEUEOTIC

Weir

Verneuil/ Paget/
naud/ Oppolzer,^
it

that in

about

came

in other

where

cases

no

factors,and

DISTUEBANCES.

Mitchell/
trauma

thus

and

could

the

others.

many
be

By

demonstrated,

knowledge

such
the

ence
experi-

causes

of

acquired that pathological

lesions of the central nervous
system are likewise followed by eruptionsof zoster.
its correct
nature
The
of zoster thus received
the
interpretation
only were
; for not
vesicular eruptions occurring with
the
trunk
included
in
nervous
on
this
symptoms
dermatonosis, but those groups of vesicles on all partsof the body which followed preceding
confined
to the direction of a nerve
twig. Charcot and Cotard" have
neuralgiasand were
all branches
of the cervical plexus on the right side were
in which
seen
a case
attacked
trunks were
found
swollen
by zoster, and at the autopsy the spinalganglia and the nerve
and
while the roots of the cervical nerves
the upper
and injected,
part of the medulla
appeared perfectlynormal ; and thus eruptions of zoster may break out in the most
and Hybord* have grouped togethera large series of cases
various regions. Hutchinson'
zoster
frontalis and ophthalmicus, in which, besides the neuralgias,
considerable
of
turbances
disof sightexisted.
Brown-Sequard' observed an intense eruption of zoster along
of spinalmeningitis. Barensprung's'"
of the brachial plexus in a case
the branches
case
he
had
established
1861
the
is universally
known
neurotic
nature
as
as
thoroughly
early
;
of pectoralzoster he found at the autopsy an inflammation
of zoster, and in a case
of the
the
thoracic
and
roots
of
the
from
nerves
them.
springing
posterior
spinal ganglia
tion
limitaBarensprung's assumption,that only the ganglia are affected in zoster, suffers some
by the fact that sometimes the intervertebral gangliahave been found intact,while the
spinalcord proper was altered,and the cases of tabes or of spinal sclerosis followed by
but once, still cases
zoster also help to establish this fact clinically.Zoster usuallyoccurs
record of several relapsesof this disease,and Kaposi" in particularreports a case
are
on
in which, in a comparativelyshort time, zoster relapsedfive times in the domain
of the
in
sixth
the
for
the
time
in
cervico-brachial
the
same
region; later,
plexus,always
right
likewise
zoster
the
on
occurred,
right side, while a
same
patient,a lumbo-sacro-crural
seventh, eighth and ninth outbreak of the cervico-brachial zoster in this patientfollowed
the left half of the body.
on
numerous
Examples of zoster due to disease of the ganglionicsystem are more
the central nervous
than those dependent on affections of the spinalcord ; hence
system
In frontal and
similar cases.
of many
cervical
the starting-point
is justlyconsidered
zoster, the brain and the medulla
oblongata; in that occurring on the trunk, the cord
Less
be designated the seat of the lesion.
frequent are the cases in which zoster
may
zoster

as

appears
a

and

sought

were

the

reflex neurosis.

Dr.

JeweP^

observed

sequelof a grave uterine disease,for

intense neuralgiasreceded.
1

de Paris, ^862, p. 156.

med.
Zeitung, 1866, No.
Allgem. Wien.
"

"

"L.

c.,p.

which

Ophthalm.
"

Lefons
Du

Biologie, 1873.

du systeme nerveux."
Paris, 1880, p. 29.
Oct., 1866, p. 166.
These
de Paris, 1872.
ophthalmique."
les maladies

sur

Zona

Comptes
"

48.
de

Hosp.Rep.,

rendus

Beitrage
med.

"

Wien.

"

Transactions

zur

de la Societe
Kenntniss

Wochenschr.,
of the

Amer.

des

de Biologie, 1870, p. 45.

Charite-Annalen,
Herpes Zoster."

1874,

1875-1877.

Neurological Asso.,

New

must

be

of the latter,the

167.

'

JO

zoster

remission

de la Societe
I'herpes traumatique." Memoires
Surgical Pathology." London, 1863, i.,p. 43.

"

crural

De

'

the

These

"

with

was

York, 1875.

1863.

sidered
con-

zoster

In addition

in the

sensory

39S

DISTURBANCES.

in zoster

observe

e., anaesthesia

at times

of the skin with

another

sensory disturbance
considerable
painful"

simultaneous

of the pain lies

symptom is not difficult : As the cause
lemma,
a
spinalcord, pathologicalprocess (exudationinto the neuritoward
the
new-formation, etc.)may
intercept conductivity
riphery,
pethis

explanationof

The

ness.

neuralgia,we

to

dolorosa, i.

anaesthesia

TBOPHONEUROTIO

AKD

NEHEOTIO

of the

root

of a
pressure
thus inducing ana3sthesia.

symptoms in zoster are not only of a sensory, but also of a motor nature,
for paralyticconditions outlastingthe exanthem
at times.
Broadbent
occur
reported a
of a woman
case
aged 74 years, who, without demonstrable
ing
cause, felt burning and stingand nucha ; shortlyafterwards, zoster appeared,
pains on the side of the right arm
covering the shoulder, upper and fore-arm ; a week later,there was
partialparalysisof
the arm
which remained
observed
complete paralysisof the right
permanent. Duncan
and leg,while the side of the face was
free from
of thoracic
arm
paralysis,in a case
in an
after a neuralgia lasting several days and before the vesicular
old woman,
zoster
eruptionbroke out; the zoster and the incomplete hemiplegia persistednearlythree weeks
and disappearedaltogether.
That zoster may
be denied
at the present
appear on both halves of the body cannot
The

nervous

'

"^

time.
into

Barensprung divided zoster

recognizedonly seven, viz. :
Zoster capillitii,
a.
b.
c.

d.
e.

/.
g.

''

faciei,

"

nuchae

"

brachialis,

''

pectoralis,

nine

varieties

according

to

the

locality;Hebra

collaris,

s.

"

abdominalis,

"

femoralis.

is localized on the anterior and posterior

capillitii
portionsof the scalpand.
extends
along the twigs springing from the second branch of the trigeminus. This,
does not apply to all cases
because, according to the above division,zoster ophthalmicus*
under
this head and the affected sensory twigs spring from the first branch, this
comes
in zoster eruptionsalong the frontal and
the case
being especially
supra-orbitalnerves.
On
the posteriorscalpzoster extends along the occiput to the vertex, in the direction of
the great occipital
nerve.
b. Zoster facialis. Hebra
of the
gives as the seat of this form the anastomoses
in the skin of the face.
But the facial is a purely motor
facial nerve
and as disturbances
nerve,
than those of sensibility
of motilityare
in this form
rarer
of zoster and the
neuralgias followed by herpetic eruptions,it is more
appropriateto trace the pains to
Zoster

a.

"

affection

of the

face

derived

are

British

Journ.

Zoster

and

the

Med.

not the motor

sensory, and
the
from
trigeminus, and

Medicine, London,

ophthalmicus
disease

local

been

the sensory

in the

cheek,

nerve-fibres

nose,

lips,and

in the

chin;

of

the

cornea,

1868, p. 242.
thoroughly

more

interpreted

repeatedly noticed

the

as

etc.

the appearance

sequels like
grave
fatal issue.

symptoms,
and

has

proper

iritis, ulceration
have

But

spread

.Journ., 1860.

of Cutan.

skin

fibres.

cause

studied
of

some

Baumann,
of this form

panophthalmitis,

not

especiallyby Hutchinson,
in the eye, such as photophobia,
Jefferies,Weyss, and other ophthalmologists
long ago,
disturbances

which

at

times

phlebitis in the

causes,

globe

with

besides

the

subsequent

above
ingitis
men-

394

AND

NEUROTIC

ience

the

of the

anastomoses

DISTURBANCES.

TROPHNOEHEOTIC

pair with

seventh

the

trigeminus are

affected with

algia
neur-

in facial zoster.
c.

Zoster

the cervical
and

nuchm
vertebrae

s.

collaris.

"

either

The

forward

vesicular
toward

the

from
the
eruption extends
region of
the
toward
or
clavicle,
upward
occiput

the auricle.
d.

Zoster

iracMalis.

It extends

"

vertebra

the upper margin of the

over
the flexor side of the upper
The
arm.

usuallyfrom the first cervical and the first dorsal

scapula,and spreads toward both the extensor and
groups of vesicles are not always in a continuous

line,but

broken
by interspaces;the exanthem, however, may often be observed on the
only, without affectingthe skin over the vertebrae.
Zoster pectoralis
is the name
of the eruption springingfrom below the first dore.
sal
its
skin
of
the
the
thorax
to
vertebrae.
the lumbar
vertebra;
territoryembraces
Its points of origin are
to be those vertebrae
where the zoster arises, and
assumed
its course,
those intercostal spaces
it extends.
The
intercostal
nerves
along which
are
usually implicated, and the concomitant
neuralgias generally so violent as to
lead to the suspicion of an
if the vesicles have
not yet appeared.
incipientpleuritis
zoster
I
in
observed
of
the
case
woman
a
a
Recently
pectoral
aged fiftyyears;
of
vesicles
extended
to
from
the
column
and
the
spinal
axillaryregion,
groups
sprang
in the same
costal
interspared the part of the skin covered by the arm, and then continued
time by
was
accompanied at the same
space as far as the sternal region. This case
At the present writing I
the most
violent neuralgia for six weeks, without
cessation.
treatment
have under
similar case
of pectoralzoster; it springs from
the third dorsal
a
left
the
extends
far
and
towards
the
as
covers
as
thorax,
vertebra,
nearly 10 cm. in
side
of
the
there
has been absothe
inner
offshoots
lutely
breadth; some
upper arm;
pass along
no
pain during the several weeks of its course.
the lumbar
Its points of originare
vertebrae,and the erup/. Zoster ahdominalis.
tion
line.
The pain is often so considerable
far as the median
as
spreads over the abdomen
that the activity
is interfered with, and the patients,if
muscles
of the abdominal
sometimes
attacks
of
seized
are
pain during defecation.
by
constipated,
the
takes
from
buttocks, and extends
along the thigh,
origin
g. Zoster femoralis
the
extremities
far as
as
partlyin a peripheral direction from behind forward, or along
arm

"

the

popliteal
space.
Etiology of Herpes.

phenomena of vesicular eruptionsis based on the fact that

nerves
are
frequentlyfollowed by outbreaks of vesicular efflorescences.
this experience gained at the bedside
But
too
must
not
we
far, and transform
go
of innervation, whether
into a general doctrine, for not every neuralgia or disturbance
this the case, the latter
with herpes; were
of central or peripheralorigin,is connected
tion
would be the most
frequent of diseases. Nevertheless, the dependence of vesicle formathat this interrelation is one
these conditions has been so indisputablydetermined
on
facts we possess in dermatology.
exact etiological
of the few more
the various speciesof herpes we have given some
With
pointsin the etiologyand shall
The

affections

explanationof

the

of the

merely a few short observations.

of its coincidence
As regards facial herpes the explanation
insisted years
Gerhardt'
clear.
conditions
is not sufficiently

add

'

Jenaer

Zeitschrift

f
.

with
ago

Medicin, 1865, p. 345.

or

that

without
the fibres

pyrexial
of

the

NEUROTIC

AND

395

DI8TUKBANOE8.

TBOPHONEUBOTIO

"trigeminusare irritated by the fever. If the small arteries which run with the nerves
during the cold stage, they dilate again
bony canals contract
"through narrow
and
hot
within
the
the narrow
canals on the nerve
in
following
stage
twigs which
press
lead
This
to the vesicular
view has something taking in it, but it
then
eruption.
the process only in part,for herpes facialis is not always present in feverish conditions,
"explains
and is rarely
appears with equalfrequencywithout fever, is invariablypainless,
bilateral.
In reference
in the

herpes progenitalis
we

to

genitalapparatus,and

stated in the

as

to

have

alreadystated

herpeszoster,

we

can

its

add

tion
dependence upon irritato
what
has
been
nothing

symptomatology.
Prognosis.

This

and disapfavorable;for exceptingzoster, the various forms run a rapidcourse

zoster
into
other
Transition
of
local
affections
leaving
sequelse.
appear
any
may
be observed;thus, in one
sometimes
I saw
zoster develop into general
case
ending fatally,
ter
pemphigus.' Other sequels are sensory disturbances, and ulcerations within the zosbe
in
not
Patients
efflorescences.
restricted
from
need
zoster
suffering
any way;
Should
functional disturbances
the
occur.
they may follow their avocations unless some
disease be prolonged, we have usuallyto deal with the sequelsof the affection (paralyses,
sensory distubances).
is

without

Treatment.
The former
applies to the
unpleasant symptoms; the latter to the alleviation of
the grave concomitant
conditions.
in the painlessforms of herpes
It is only necessary
^to employ indifferent substances
to protect the
labialis,progenitahs,iris,and circinatus
diseased surfaces againstdirt,friction,etc.
It is not advisable to hasten the drying of
the vesicles by removing their contents
by puncture; nor is it good practice to tear off
the crusts.
It is best to place thin layersof linen, coated with a pure fat,vaseline,or an
The

forms

of

treatment

running

their

herpesis expectant and symptomatic.

course

without

"

"

indifferent ointment, upon the vesicles.

If it be desired to use
be
mixed
ointment
with carbonate
of lead or oxide of zinc
may
of the ointment,

some

(1 :

medicament,

10 to

15).

In

the

place

also be employed, such as rice-starch flour,

dered
powrecommended
for herpesirisand circinatus,
exclusively
while for the other forms of herpes the above-named
ointments
are
more
appropriate.
of zinc or bismuth
indifferent or drying ointment
Tor herpes progenitalis
is to be rean
commended,
in doubtful
because
this will best decide whether
it is herpes or
cases
syphilis.
What
has been stated applieslikewise to herpes zoster, especially
those cases
which
free from
attacks of pain, or other incidents.
are
Physiciansfinallybecame
convinced,
after many
which
laxatives and
tormenting and energeticmodes of treatment, among
not omitted, that the pain of the disease could
venesections were
be moderated
merely
the sympby soothing and quietingremedies, and this led to the only rational method
tomatic

dusting powders
soapstone,etc. ; the latter are

may

to be

"

treatment
It is

of zoster.

barelyworthy of specialmention that against this affection the whole array of

been employed in the form
of ointments, plasters,cataplasms, and
ternally;
into
several
the
the
and, according
credited with correspondresults,
agents were
ing
real remedies, not only formerly,but even
as
of
to-day. We shall specifysome

narcotics has

value

'

"

Neuropathische Dermatouosen,"

p.

146.

'

396

MALUM

them, to be tried if desired.

diabotani, de

saponatum,
the

whole

PEKF0RAN8

Hebra

advises

Meliloto, to

the

be

PEDIS.

plasterspread

size of the

linen,such

on

diseased

as

surface to be

empL

covered,,

with pulvis opii and

of a cloth
fastened
roller bandage,
or
by means
twice within two or three days,until amelioration
or
dressingchanged once
or
cure
results;besides,narcotics internally.
Wilson
recommends
largedoses of quinine and iron, here and there even
arsenic
and
of zoster
outbreaks
others, have seen
(although some
physicians,like Hutchinson
in consequence
of its use),also potassium iodide and narcotics.
Among local apappear
plications
strewn

and

the

have
Oleum

aconiti, aa
30

been

grams;

partes a^quales;or, Tr. opii et Tr.

ferri
5 grams;
alcohol, rectif.,
furthermore,
gequales;
sesquichlor.,
partes
.05
5
bichlor.
frictions
also
with ol.
collodii,
hydrarg.
corros.,
grams;
grams;

cajuputi,chloroform, etc.
Every physicianwho has
to make

frictions with

recommended

cadini, chloroformillse,tr. aconiti,aa

trials,so

numerous

All

these

will have

to tire

not

least take

in the

been

remedies

forced

give only

the

tive
place of the sedaneuralgias,morphine
should be given in powder or hypodermically,also chloral hydrate,especially
at night,
ofE
the
often caused by the neuralgia,at the same
to ward
time bearing
as
so
sleeplessness
in mind
the local treatment
Hebra^s plasterwith opium, etc.
by cold applications,

temporary

relief.

of zoster
experiencewith cases
the patient,should
some

some

as

method

As

at

cannot

measures

disposalin the form

our

auxiliaries

it is well

to

of

narcotics.

recommend

now

In

and

intense

then

baths

and

in cases
in which
be borne for any length of
narcotics cannot
especially
disturbances
the shape of sensory
and motor
which
requireelectricity
time and patience.
much

MALUM

PERFORANS

cold

time.

frictions,

Sequelsin

often

consumes

PEDIS.

ous
by the influence of the trophicnerves
; it beginsas a cutanedisease
This
lesions.
ulcerative
affection
of
an
implies
deeper
of the epithelium which
the sole of the foot, beginning with a proliferation
sometimes
from
a
corn
springsfrom a thickening of the epidermisresembling a corn, sometimes
other, usuallytraumatic influence.
subjectedto constant pressure, at times from some
ulceration as if punched out with an
In all cases
the affection begins as a roundish
chronic
inflammation
it
of
instrument
is
the
which, if recognizedin time
a
;
consequence
forms
if
it
disease which
and properlyattended
close
a
not,
to, may
again ;
progressively
in depth, with subsequent destruction
extends
of all the soft parts,the Jointsand bones ;
it often resists the most
in its further spread it not only becomes
careful treatment, and
The
deeper,but also wider.
integument are
accompanying alterations on the common
The
manifest
alterations
characteristic
disease.
themselves by
the
of
trophoneurotic
very
excessive formation
of epidermis,change of the nails,and
profuse development of hair,
whole
both on the dorsal side of the foot and
the
lower
on
extremity. Together with
these conditions we
often find obvious pigmentations,
erythemata and eczemas, and either
to cause
diminished
increased perspiration.Owing to the local influences which seem
or
malum
originallybelieved to be a local one ; but the
perforans,the affection was
gravityof the disease,the duration of the ulceration,and the destruction of the soft
it obvious that we must
assume
more
a
deep-seatedmalady,
partsand bones soon made
to arise after injuries
ulcer of the foot has been often seen
to the spine,
for the perforating

This

is

disease caused

affection and

frequentlyin
nerve

leads

to

consequence

in animals, ulcers

of

have

peripheralnervous
been

noticed

to form

affections; after
on

the

section

soles of the feet.

of the

sciatic

Congelation

398

DECUBITUS

first pointed out

ACUTUS.

that, in hemiplegic conditions,the

of the

gangrene

that side of the

on
sequent ulceration always occur
therefore,in central apoplexies,on the side oppositeto

skin

and

the sub

paralysisexists *"
the apoplecticpatch. Besides,
in the latter,there is merely a unilateral
ulceration ; in apoplexy of the medulla
both sacral regions. The
usuallyan ulceration extending over
rapiditywith which the
ulceration occurs
is most apt to make
its
us
neuropathic nature, for it is impossisuspect
ble
to explain in any other
.such
In aposuddenly developing,deep disturbances.
way
plexy
of the medulla, the ulcer usually
begins in the middle of the sacral region,and
thence
cumscribed
spreads symmetrically toward both sides;but both in this form and in circerebral affections there is ansesthesia of the skin on the portions subject
to crustingand ulceration.
In patientssuffering
from
if the greatest
this disease,even
and attention be devoted
care
to keep the paralyzed part as
clean
as
duce
possibleand rethe pressure to a minimum,
the occurrence
of bed-sores cannot
be prevented.
Post-mortem
condition

in

the

determined.
on

that

examinations
central

the nates

and

lesions

concluded

of urine
had

from

that

from
the

seems

the

held

that

that it was

upon

in the corpus

these

the

were

bed-sore

and
as

the
the

first appears

on

deematitis

due to

circumscribed

spot

and

as

opticthalamus,
of trophic

striatum, anterior
of the

cause

is often

be
isted
ex-

lobe,

bed-sores.

associated

with

continence
in-

of the affection,while
starting-point
disease of the spinalganglia. In view of

the

was

to consider

correct

occurs

not

gangrene

cause

acute

bed-sore

posteriorcolumns of the cord, for in affections of the anterior columns,

muscular
atrophy and the essential paralysisof children, bed-sores never
Teophoneueotic

inflammatory

an

localization could

the cutaneous

posteriorlobe

is to be looked

the fact that acute

to be most

point of

in which

cases

hemorrhages

spinal cord

previouslyasserted

these observations,it

have

the

the

demonstrated

cases

three

the brain

others,however, found

Brown-Sequard

numerous

presentin

were

portionsof

lateral convolution, etc., and

Samuel

in

apparatus, but

nervous

Joffroy'concluded,

disease of these

disturbances

have

where

nates

a
e.

g.,

to

further

progressive

occur.

disease of the skin in which

leads

disease of the

an

erythema

inflammation, daring which

manifold

nutritive disturbances
set in.
Among the latter are efflorescences of all kinda
face.
suroccurring after injuries,
neuralgias,etc., and developing on an inflamed cutaneous
A peculiarform of this disturbance
In this affection the skin
is glossy
skin.
marbled
or
originally
thema.
eryappears red, smooth, and glossy,and shows either a uniform
and so
like
varnish
Some
described
skin
of
the
surface
the
as
being
physicians
tense that all unevennesses
thinner from
and folds disappear. Later, the skin becomes
to
the muscular
atrophy of the underlying cellular tissue,and this process extends down
layers. As this disease chieflyattacks the extremities, the nails usually drop off
after some
time and the cutaneous
glands perish.
This affection was
first observed
Danmark.''
Subsequently,Paget,'
by Alexander
Weir Mitchell,^and others have furnished a detailed descriptionand have especially
emphasized
its complicationwith violent neuralgiaswhich
termed
causalgia(burning
they
gia.
pains). It may be assumed that this affection is caused by a peculiarspeciesof neuralMoorhouse, Keen, and Mitchell have more
thoroughly established the neuralgic
affection of an extremity,
to the nervous
theory;their conclusion is,that, in proportion
intense and exthis peculiaratrophy of the skin associated with erythema becomes
more
'

Archives

'

Medical

and

Medical

Times, March

"

Des

de

Lesions

Medecine, 1876, Janvier.

Chirurgical Transactions, London,
des

1873, iv., p. 48.

26th, 1864.

Nerfs," Traduit

de

I'anglais par Dastre, p. 174.

tensive.

Thus

but

palmar

of the

fingersis

alone, the

nerve

region of the skin

this
the
face
sur-

intact.

remain

may

peripherallyinto the

suppliedby
largerplexus,not only the entire palm, but also
attacked
by the atrophic process, while the dorsal

only

lesion involves

if the

surface

that,for instance,in injury of the ulnar

asserts

affection extends

cutaneous
nerve;

Mitchell

39^

DISTUEBAifCES.

MOTOR

glossyskin appears in the form of an erythema nodosum, the diseased and

painfulspotsprojectingabove the surroundings in the shape of single nodes; in other
and then there occur
Now
the surface
the a"Eection begins as a frost bite.
of
on
cases
glossyskin small exceoriations or ruptures,the underlying skin pressingthe tense epidermal
layersapart. These additional complicationsincrease the previouslyexistingpainfulness,unless a remission and final improvement of the affection have been secured by
cold water).
sedative treatment
(electricity,
At

times

IV.

disturbances

Motor

changes.

In the

numerous

largenumber

vessels,surrounding them
elements
the

neither

cause

trabeculae

muscular

MOTOR

as

as

irritation

Whenever

irritation

an

stiffer,
approach
results which
this alteration

is

elements

other, the

surface

is called

cold, as

is disrobed

in

or

cold

in the blood

both

elements, and
mascles

in the

and

room.

skin, after having been

in

acts

is either direct
such

or

reflex.

that

manner

the

come
contract, the hair-follicles rise,the hairs be-

acquiresa

cutis
goose-flesh,
during bathing in cold

cool

muscles

lymph
glandular ducts, the skin possesses many
is caused
elasticity.The contractility
by

its contractility
and
acting on the muscular
affectingthe cutaneous

each

serious nutritive

terminating in its tissue,and

the efferent

cutis is stronglyexcited,the muscular

the

smooth

ministeringto

nervous

diseases of the skin, nor

important
elastic fibres

embedded
well

as

of

DISTURBANCES.

wrinkled

anserina.

The

and

appearance,

dition
con-

of
frequent cause
perature
temthe body at normal
water or when
is less distinctly
The goose-flesh
when
seen
cold, is suddenly acted upon
by intense heat,
most

exposed to
then
it
is
even
perceptible. That the contraction of the skin is not sudden, but
although
is graduallyincreasingand culminating,can
be most
clearlywitnessed in the skin of the
when
scrotum
of either of the above irritations.
There
is no
contractingin consequence
all parts of the body, but
that the contraction
is effected in the same
doubt
on
way
those
this shrinkage is not as
elements
on
providedwith sn^all muscular
readily
perceptible.
disturbance
is nearlyalways effected with a sensation of slightshivering
This motor
which
External
tations
irricause.
quite evidentlyis to be traced to a nervous
(horripilation)
the
cutaneous
which
centre
the
excites
to
surface are conducted
the
acting on
filaments
and produces contraction.
finest nerve
Eapid alternation of heat and cold most
tion
readilypermits us to observe a succession of contraction and relaxation,and this alternaof
ceases
only when there is a sort of balancing of the irritations. The correctness
be best verified by dipping a hand
i
nto
hot
and
cold
this observation
can
alternately
contractions of the cutaneous
until their activityis exwater ; the
muscles
continue
hausted.
Besides
need
in

may
a

and

be

groat

cold, sensory

impressions are

the

of
said

terror?

followed

by contractions,and one
attacked
by cutis anserina
rough surfaces,etc. The

individuals to be
categoryof nervous
piercingtones, scratching of the nail on
of moral
impressions; who does not shiver under

belong to

consequence

same

of

not

heat

On

such

occasions

we

do

not

generally observe

the

influence

sudden

whether

"

our

flesh

400

MOTOK

but

creeps/'

Among

the

by
in

reflex

central

and

of

none

the
the

centre

of

of
the

skin

with
interior

of

when

the

that
the
the

offer

body,

sensations,
of

the

disturbances

the

or

more

or

the

the

rigor,

influences

in

interrupted

lowed
fol-

are

named

instrumentality

affections,
is

ance.
disturb-

motor

enumerate

intense

the

through

reverse,

might

we

less

All

central

from

suffering

vessels,
it

and

is

this

activity
various
of

of

conditions

important

no

the

molecular
the

muscles.

like

alterations

possible

rendered

without

pass

same

with

cutaneous

periphery,

above-named

of

the

not

act

of

whom

the

tion
conduc-

diminished,

or

the

show

conditions.

above-named

Outside

the

always

the

to

to

does

beginning

Patients

system.

nervous

reading

of

are

terror

of

times

at

contraction

manner,

from

but

which,

general

disease

of

causes

affections

pyrexial

shivering

of

feeling

the

DISTIIRBAlfCES.

In

changes.
and

subsequent

of

sensibility.

the
of

muscular
of

which

we

have

altered,

ances
disturb-

motor

contraction
the
the

causes

already

the

spasm,

the

them,

becomes

nerves

which

or

displacement

influence

sudden

forms

contraction

we

discussed

is

blood

feeling

toward
of

in

detail

the

shivering;

altogether

find

ciated
asso-

in

ferent
difing
treat-

ANOMALIES
IN

AND

GROWTH

PAUL

THE

COLOR

RELATIVE

EXPERIMENTS

THE

TO

THE

GROWTH

HAIR.

M.D

MICHELSOW,
KONIGSBERG

ON

OF

(PRUSSIA).

GENERAL
OF

THE

ETIOLOGY

OF

IN

ANOMALIES

THE

HAIR.

acknowledged importance in the etiologyof anomalies in the growth of hair are,

of nutrition.
besides the inherited tendency,general disturbances
the growth of hair may
be
The
on
injuriousinfluence of unsuitable alimentation
demonstrated
fed
on
by Magendie's experiment, according to which
exclusively
dogs
Of

others

fed

recent

times, there is a progressiveincrease

cheese, and

on

hard-boiled

eggs,

became

weak

and

emaciated

and

lost their

hair.
In
of

more

alopeciain

the causation

of which

in the

trophoneuroticinfluences

are

domain
at

of those

forms

work, although very

done experimentallyin this direction.

experimentalobservation has been recentlypublishedby Brownnoteworthy
very
the offspringof guinea-pigs in which
that
noticed
he had
He
divided the
Sequard.
and
whenever
the
to
sciatic nerve
became
the
hair fell
epileptic,
epilepsybegan
improve,
the head and neck.
from the region of the epileptogenic
zone
on
Furthermore, Eulenburg observed fallingof the hair from the posteriorregion in

little has been

rabbits after chemical

irritation of the sciatic

nerve.

rabbits,the operationwas

of one
always done on the nerve
of
depilated. In no case was there even
a temporary cessation
hair production on the operatedside;on the contrary,in some
of the animals the growth
of hair proceeded even
more
rapidlyon this than on the healthy side. The irregular
in which the subsequent growth took place was
pilated
the demanner
conspicuous. Within
territory
suppliedby the injurednerve, there appeared, a short time after the
In my

side,but

experiments on

both

26

limbs

were

402

HTPEETEICHOSIS.

of

bunch
a good-sized
operation,

symmetrical spot

insular bunches

new

increased

in

side
Schiff

of hair

sprang up on both sides beside the former;

While
the law of bilateral
finallycoalesced.

extent, and

influenced

the

above-described

reparativeprocess, stillthe
completed later.

slower, and

was

stated

vigorous hairs, quite isolated at first;and at an

side,a similar bunch, but of smaller
dimensions.

other

the

on

"

that

side

the

on

which

on

the

had

sympathetic

been

Then

they gradually
viously
ob-

symmetry

restitution

divided

exactly

the

the

on

hair

grew

injured
un-

more

rapidly.
Mayer made
depilated, then

the

Sigmund

great auricular

After

nerve.

to the length of
developed along the course

following observation

the

on

side

one

and

one

one-half

excised

ears

of

from

the

months,

two

or

Both

pieces were

the

adult

an

rabbit

cervical

hairs

the

on

taneously
simul-

were

sympathetic

and

the

injured side had

the healthy side a distinct streak

on
of hair
only had
artery.
made
A parallelexperiment
by myself proceeded as follows : After both ears of a rabbit aged
had been completely depilated, I resected
the left cervical sympathetic and
eight months
a piece of
the left great auricular
At the same
time the ears
of a second
animal
nerve.
of the same
litter and
two

grown

preciselysimilar
cervical

configuration

wound

of the

while

ram.,

of the

former

median

depilatedwithout

were

animal

subjecting it to any other operation. The

by suppuration, and the rabbit emaciated
considerably

healed

during the first period after the operation.

Still after twelve

margins, small, colored

especiallytheir external
capillarygrowth progressed rapidly and uniformly on
weeks.

In the

delicate
weeks

uncolored

In

The
mixed

skin

became
size

the

ample branny
then

transferred

extensive

after

aged 25 years,

man,

rubbed

the

was

into the intact

of

palm

desquamation

of the

animals

to other

hand

twelve

and

completed

was

in

both

on

restitution

of

about

the
ten

remained

days, and

the

made

animals

on

permanently good, only a

growth during the following

the skin

epidermis.

In the

the

parts, and
The

Lassar and Bishop has

alopeciapraematura.'"

With

second

cut

were

fine

and

healthy rabbits
of the

course

hairs and

the

of

of

within

entirely bald.

end

"

this disease

with
to

were

by
of

infectiousness

affected

epidermis.

; at

had

of which

themselves

subsequently, the

sides

transferred

anointed

the

both

operated rabbit.

proving the

this ointment

perceptible on
of

found

in the

times, the experiment

of

vaseline

good fur, and

hair

be

than

in order to aid in

combings
with

with

tardier

recent

most

animal, the health

could

down

likewise

was

relied upon

of

non-mutilated

days there showed

hairs

ears,

third

week

another

week

the

of

loss

scales of the

week, they

and
a

intimately
guinea-pigs
decided

loss

portions of

hair

there

was

already quite

the
very

original test animals

were

been

were

bald

on

surfaces.

the followingexperiment : A mixture

of
part of rancid olive oil was rubbed dailyinto the
As
skin of the back of a vigorous full-grown rabbit with an excellent growth of hair.
of
the
loss
week
distinct
of
hair
the
second
of
a
the
was
experiment
beginning
earlyas
noticeable
the anointed
ished
on
parts of the animal which was kept isolated and well nourmuch
the twelfth day its hairy coveringon those spots was
reduced, the hairs
; on
fine scales,but otherwise quite
with
covered
skin
stillpresent were
The
loose.
was
very
unchanged. On the sixteenth day of the experiment,complete baldness over the anointed
growth of hair after the inunctions were
regainedits normal
part which, however, soon
stopped.
In

about

order

three

to control

these

parts of vaseline

results,I made

and

one

HYPERTRICHOSIS.

Most

of the affections described

matological,but
We
women
more

the
classify
or

or

also

an

an
cases

abnormal

less extensive

under

thp

offer
hypertrichosis

name

not

only a

der-

interest.
anthropological
of unusual

growth
portionof

of hair, whether
the

i. e., the occurrence

trichosis of man,

body, as

in

follows

one
:

or

the

other sex,

of

beard

spread

over

in
a

403

HYPEKTRICnOSIS.

I.

a.

probably
Hypertrichosis,
indoles
life,hypertrichosis

due

to

heredityor

tendency acquired during

uterine
intra-

hereditaria.

Hypertrichosisuniversalis.
of the so-called
1. The abnormal
hairy men.
pilosis
of the male body.
2. The generalprofusepilosis
'^

h.

localis.
Hjrpertrichosis
1.

The

abnormal

pilosisof

region the

skin

of

which

is

apparently

changed.
un-

skin.
on
pigmented and thickened (hypertrophic)
pilosis
pilosisdue to pathologicalinfluences actingduring extra-uterine life,
transitoria
Klebs).
(hypertrichosis
acquisita
hypertrichosis
1. By neurotic influences (hypertrichosis
neurotica).
irritations (hypertrichosis
2. By cutaneous
irritativa).
It is to be emphasized that the baldness of those parts which
normally are not even
covered with
lanugo, and are absolutelyhairless (palms of hands and soles of feet"
ungual phalanges of fingersand toes, inner preputial surface, glans penis, vermilion
is not altered by hypertrichosis.The
border of lips and upper
eyelids),
proliferation
from
preformed hair-germs.
always develops
2.

The

abnormal

II. Abnormal

"

I.
As

the

best

known

Indoles
Hypertricliosis

specimens

Fia.

familyof Shwe-Maong,

26."

Andrian

Andrian

of

homines

we
pilosi,

Jeftichjew,

Jeftichjew,
"

Hereditaria.

"the

Russian

the Kussian

the

enumerate:

East

Indian

Dog-Man.'

dog-man

"

and

his

son

Fedor,

404

HYPEKTEICnOSIS.

the

Common
to these cases
is a thick growth of hair
"hairy family of Ambras/'
the
extending over the whole body (excepting
parts mentioned), although by no means
uniform
throughout; naturallyit is particularlyconspicuous in the face, and there
also most largelydeveloped,thus givingto the type of the highestdegree of hyperseems
trichosis
and

universalis

s.

hirsuties

animal

decided

cast.

Jeftichjew'sportraitrecalls the picture of a Scotch terrier. But the features of

have also a certain resemblance
to each other,which
is caused by an essentially
hairy men
of
the
hair.
analogous arrangement
We know
from
the labors of Eschricht^
and Voigt^ that the hairy investment
with
which

the skin of the foetus

quite definite

maintains

iurrows,^'in

the

itself in the

covers

directions
of which

{''hair
there

fifth and
and

currents

sixth months

eddies

of intra-uterine

"); from

these

life

"seed

same

usuallyonly moderate individual differences,

silvestres. This growth of hair, moreover,
hairy growth
is nearly always described
as
soft, woolly, or silky,resembling wool rather than real
hair.
Ecker
has
concluded
that universal hypertrichosis
Hence
should be considered
an
and further growth of the embryonal hairy coat.
arrest of development, a persistence
The
hereditary basis of the abnormality is generally demonstrable; in the
observed
through the third generation. As a rule, we
family of Shwe-Maong, it was
also find in hairy men
congenital dental defects. This conjunction cannot be purely
it repeatedin very different and
see
accidental,for we
widely separatedregions. The
Burmese
the
of
hairy family
entirelylacked the twenty molars, of the
grandfather
course

springsalso the

are

of the homines

"

"

four

he

canines

The

of the

daughter

one,

nor

there

were

latter is likewise

without

not

are

on

any

alveolar

molars

record.

and

processes
canines.

for the absent

teeth.

Statements

to the

similar defect

hairy

His

man.

as

is also shown

jaw is quitetoothless,excepting the

upper
of the lower
are
jaw
complete; at the time of the examination
but
three years old, the upper
jaw was toothless,and there were

Eussian

then

but

of her children

tooth -formation

teeth

had

by

left canine, but

of his

son

the
the

Fedor,

four incisors in the

inferior maxilla.
in both
of irregularities
systems, the hair and the
unitedlyfrom the corneous
layer,has been repeatedly
of congenitalbaldness
observed.
with inherited
Danz," Sedgwick,* and others reportcases
hence
defect
of
the
teeth
the
defect
dental
be
cannot
looked
or
partial
complete
;
as
compensatory to the superabundant growth of hair.
upon
of the male body, developed not uniformly, but chieflyover
Generallystrong pilosis
The

simultaneous

occurrence

derived
teeth, odontogenetically

partsof the skin, as the face, chest,back,

families,and presents,as it were,
hereditaryin some

certain

For
the direction

these

of

likewise the

cases

law

dorsal

is valid that

surface

of

the

extremities,is

slighterdegree of hirsuties congenita.

the abnormal
pilosis
exactlyfollows

lines.
Eschricht-Voigt^s

partsof the skin is found in the occurrence

a
might here distinguishthree degrees: First,the
in fact merely a somewhat
of
so-called "Bartchen"
beard) young women,
(little
stronger
largelydeveloped in the situation of the beard
growth of the lanugo which is always more
the upper
In the second
than elsewhere
region,at times the chin.
lip,the masseter
trichosis confined

Anomalous

of

in

beard

With

women.

to isolated

Bartels

we

"

Muller's
Denkschr.

3B.
*

Arch,

f.

Anat., Phys., etc., Jahrg. 1837, pp. 37 et seq.

Acad.
d. Wissensch.
(Math.-naturw. Kl.), Bd.

d. Wien.

13, 1857.

Eble, I.e., p. 245.

Cited

by Darwin,

"

Variiren

d. Thiere

u.

Pflanzen," Bd.

2, p. 434.

Stuttgart,1868.

406

HYPEETEICHOSIS.

This

born with
the large nsevus
individual, named
Balke, stated that he was
spreading over the
part of the thighs and the lower portion of the trunk, in shape hke bathing-tightsand resemthe pelt of an animal
true
of the smaller
was
; the same
hairy spots (k.n.)and the larger and

upper

bHng
smaller

tumors
(g). Subsequently the altered portions of the skin had gradually become
somewhat
The skin of the large hairy
larger. Hereditary predispositioncould not be determined.
ngevus, as
well as that of the smaller
is stated by Dr. Schulz
to have
been in the main
ones,
thickened, in part
in color from
brown
of the larger
verrucose,
uneven,
very light to intenselydark
; the consistence
mammiform
and smaller
tumors,
of the tumors
soft, doughy-elastic. The integument
was
paler,
less hairy than the surroundings and
did not
srhoother, and much
to the
firmly adhere
tumors.
The
tumors
cellular tissue,could also be displacedon
being situated in the subcutaneous
the underlying
muscles.
The
rather inferior in technical
execution
photographs were
they permitted
; but
to ascertain
me
of the short (at most
three centidefinitelythat, whenever
metres
any positive arrangement
evident
in the picture, it agreed exlong, according to Dr. Schulz), dark and curly hair was
actly
with
Eschricht-Voigt'sfcetal lines of direction.

In

the Balke
combination
of a congenitalvery large
a
case, therefore,there was
of smaller
with congenitaltumors, which may be classed
ones
pilosusand a number
as
combination
has been observed
benign, i. e., fibroma molluscum
(Virchow). The same
first
Walther.
As
at
the
extent
of
the
by
sightso very striking
regards
large nsevus, a
search through the literature brought to lightseveral parallel
cases.
n86vus

'

1. The
The

Indian

Milan

gieri'scase
died

at

age

limit

of the

half months

melauodes"

would

darkly pigmented
to the

nodular

distribution

of the

All the above-mentioned

arrangement

; in

of tuberculosis.

one

6. The

the

Lancet

skin

falls

higher

lumbo-inguinal
have

the

on

either the upper

and

(The Lancet, 1. c). 2,

No. 1 (1. c).
4. RugJ. Klein, of a girl,who

Balke

case,

right thigh than

were

the

atlas''

it not

that

left,about

over

the
responding
cor-

nerve.

in

case

figured in Hebra's

case

to the

exactly correspond

hairy moles

nearly every

of the cutaneous

course

office of

(1.c, p. 30). 3. H. Hildebrandt's

described
belongs also 5, the case
by Jablokoff

of six and

the title "carcinoma

at the

by Hebra

Here

(1.c).

the

Orangutang presented

woman

mentioned

case

common
or

the

the

lower

symmetrical
bilaterally
limit

coincides

with

the

nerves.

in the region of certain nerves

largerhairy moles may also developunilaterally
of the trigeminus,figthe
the
branch
domain
of
second
n"vus
a
ured
by
occupying
A.
Ammon
Fr.
v.
(1.c).
by
is generallydescribed
The
consideration
as
qualityof the skin in the nsevi under
varying in intensityof pigmentation (gray to black),rarelyas smooth, chieflyas rough,
Smaller warty nsevi pilosi,
itants
nodular.
somewhat
thickened, verrucose,
frequent concombeside the largemoles ;
often found
of every kind of hereditaryhypertrichosis,
are
of these small
definite arrangement
naevi is generallynot
a
clearlyrecognizable. In
first
the
Hildebrandt's
case
hairy,darkly discolored surface,
(see above),in midst of
and more
insular portions of the skin appear more
densely covered
greatlythickened
That

is shown

with

hair.

naevi crinosi likewise are

congenitalor dehypertrichosis,
an
hereditarybasis ; in them, too, the arrangement of
ture.
hair corresponds to the lines of direction of the embyonal hairy investithe proliferated
this is
If this circumstance
is not everywhere equallyevident in the illustrations,
is
hair
and
short
of
curly
probablyin part owing to the fact that the real arrangement
Like

the other

yelop in the

'

1. c,

Ph.

Fr.

kinds

first years

Walther,

"

of

of life on

Ueber

die

angeborenen Fetthautgeschwulste." Landshut,

p. 282.
2

Plate

"

Comp.

X., No. 10.

Schwalbe,

"

Lehrb.

d.

Neurologie." Erlangen, 1881, p.

979.

1814, in Rayer,

40T

HYPEETRICH08IS.

recognition. By applyingmoisture

diflBcult of

often

"confusion

cleared

be

may

along the

"

*'

the hair, the

of

nap

up.

"We possess but little positiveknowledge respecting the

Etiology and Anatomy.
outside of hereditarypredisposition. The attempt to explain
of hypertrichosis,
'etiology
it as atavism
according to the doctrine of descent, lacks for the present every solid
"

basis.
Virchow

in the

to the fact that

attention

seek

to

inclined

was

wild

*'

"

neuristic

"

he

explanation,and
"

of the woods

men

the

called

particular

essential alterations

most

region of the trigeminus.

ened,
extensive proliferation
of hair on thickalreadyindicated that the more
certain
the
thickened
and pigmented skin follows
of
nerves
course
or
pigmented, or
belonging here.
closelythan the other categoriesof hypertrichosis
be the basis on which
But whatever
the anomalies
belonging to our first class
may
sidered
Condeveloped,we have to deal with a hypertrophic condition of the hair matrix.
from this point of view, there is then merely a difference in degree in the hypertrichosis
is thickened, verrucose,
surface which
spersed
or
even
on
a cutaneous
partiallyinterfor
the
latter
is
in
the
main
with fibroma
molluscum
but
a
nothing
hyperplasia
;

lie in the

It has been

more

are

skin and

of the

Note.

In

authors, following Virchow

modern

Most

"

thickened,

and

thickened

or

which

of the skin

Viertjschr.f.

and

teeth.

the

(iv.,3, pp. 370

trunk, right

irregular.

skin

spots of the

with

of
the

the

left buttock

branches

On

the

pudenda,

in

mouth

times.

many

der

sacral

of

branches

the

small

are

the

and
termingled
in-

excrescences,

pigmented cutaneous
Especially interestingis

and

"

tumors

face,
sur-

the
ered
cov-

particularlythe masterly

Haut," Berlin, 1883): Multiple

of

neuromata

the

extremities, the sacral plexuses, the

of the

muscular

trigeminus, some

lentil-sized

coloration

and

teeth

brown

tissue,multiple fibromatous
nerves

f. Kinderheilk.,
right side of the

167, p. 183)" besides

legs

brown

the

on

several

with

(" Multiple Fibrome

frontal

of the

some

adjoining parts,

the

Gerhardt, Jahrb.

back, shoulders, and

of the

to

tions
congenital altera-

scale). 2. Virchow's

and

face

papillomata

Jahrb., Bd.

skin, innumerable

the

the

molluscum

observed

case

the

sympathetic,

3.

arms.

left half of the

subcutaneous

also, intense, diffuse

external

the

and

and

etc.

nerve,

the

on

first

skin

trunks

abdominal

the

obturator

around

external

the

nerves,

vagi and

spots

Recklinghausen's

of the

soft fibromas
cutaneous

v.

and

5. Fibroma

been

the

(30-54 of Broca's

cutaneous

In the

(ref.in Schmidt's

skin, pigment

dark

description of

dark

as

hypertrichosisin
back

shall refer

we

between

Congenital warty, lightto dark

color.

same

Duckworth

Dyce

of

case

the

2.

hypertrichosishas

without

but

the

of the face.

left half

but

transitions

case
(Giom. ital. d. mal. ven., etc., 1871, ref. in
girl,hypertrichosis universalis, changes in the

is defined

Neuropathic

1.

seq.),case

author, ibid.,case

4. Same
with

second

et

and

arm

analogies and

1. Lombroso's

The

on
p. 339),sharply separate hypertrichosis
cutis.
proliferation of hair on the unchanged

geneticallyequivalent;

are

descriptionof Fedor Jeftichjew. Besides

intense
insular patches of more
pilosison
1871

the

S., 1871, p. 294). Microcephalic

u.

maxilla

inferior

(I.c,

from

manifold

are

discussion.

under

now

D.

anomalies

that there

shows

skin

pigmented,

these

opinion,however,

our

literature

cellular tissue.

the subcutaneous

along the

inguinal fold, and

side

external
in

the

twigs

spots, a larger one

pigment

skin

of

the

the

on

on

thighs,

top of

the

shoulder.

detailed

The

autopsy is

of death

cause

blackish-brown,

the
was

found

From

nodes.
their

probably of metastatic

sarcomata,
stratum

record

tuberculosis.

was

sharply defined

temporal convolutions.
as

on

mucosum

partly in

which

.spinalganglia

and

In the
Two

off-Klein

corpus

striatum

slate-colored

seat

and

cerebellum

spots in the

histological
character,Klein
origin. The

(seeabove).

case

of the

pons

interpretsthe

pigment

three

were

Varolii

and

nodes

accumulation

one

in

in the

small,
of the

the
skin

brain
was

the

cerebral
papillarylayer; here, as in the melanotic
nodes, the pigment
irregularlyscattered round cells,partly and chieflyin regularly arranged spindle-cells

occupied
were

of the Jablok

the

adventitial

unchanged.

spaces

of the

transitional

vessels

and

the

capillaries. The

408

HTPERTEICHOSI8.

II.
Abnormal

1. As

Hypertrichosis Acquisita (s. Transitoria).

trichosis from

dependent

pathologicalinfluences actingduring extra-uterine

disturbances

within

the

life is described:

tica.
hypertrichosisneurogrowth of hair
of spinalparalysis. The
in some
latter also observed manifold
cases
trophicdisturbances
of peripheralnerves,
and
these almost
occurring after gunshot wounds
constantly
among
The
but
increased growth of hair.
local hypertrichosis
also
not
was
below,
only
present
above
the gun-shot wound.
considered
the
the
of
Leyden
hypertrophy
epidermoidal
formations
Fischer's^ experience
tissue.
a compensation for the atrophy of the muscular

Thus,

Erb'

on

Schiefferdecker''

and

After

different.

is somewhat

he found,

lesions

nerve

system

nervous

reportedabnormal

as

"

increase in the

rule, that

the

hair

at first proliferated

profusely,but fell out subsequently.

2. Cases of heterotopicpilosis
after cutaneous
irritativa
irritations
hypertrichosis
not very rare.
The
are
amples
literature,however, certainlyrequires critical sifting. As exof
of hypertrichosis
irritativa we
observation
of
enumerate
proliferation
Eayer's
and
hair on parts which
had been irritated for months
of
vesicants,
by the application
of long, woolly hairs on the wrist- joint of a puerpera
Kaposi^s^report of the occurrence
after a dailyinunction
of mercury
continued
of gray ointment
for three weeks.
"

"

Note.

growth

It is

"

of hair

beard).

I have

to enumerate

customary
places

in

normally

even

left this group

of

subjective estimation
begins.
of

Treatment.

Only

"

cases

kinds

some

kinds

various

where

of

excessive

hypertrichosisan

close, vigorous, longer hair (scalp,region of the

with

because

of consideration^

out

decide

to

the

among
covered

limit

the

of

of local trichosis

the

form

it is
normal

the

altogether
ceases

too

object of

much
the

and

ter
mat-

abnormal

medical

ment.
treat-

For
the local hypertrichosis
on
hairy moles are best removed
by excision.
under
in
skin
beard-hair
comes
the
of
women
specially
(here
unchanged
development
of treatment.
and radical methods
Among the former
we
consideration)
possess palliative
by weak caustic pastes.
belong : shaving,pulling the hair with tweezers, and removal
nants
of these methods
the follicular parts of the
As none
hair-shafts,the hair remremoves
us
a
the formerly hairy spot to appear
cause
showing through the skin of brunettes
is especially
dark patch after palhativetreatment.
This defect of the method
conspicuous
of very small spots,
after simple shaving. Epilationwith tweezers, except in the case

Smaller

the

is

quitetroublesome,
The employment

the number

and

besides somewhat

of medicinal

of chemicals

painful.*
most
is relatively
depilatories

recommended

we

convinced

become

useful.

On

examining

lime
that it is especially

which

study of the formulae teaches that

This substance is preof
of
all
them
aim
calcium
at
the
formation
pared
sulphydrate.
nearly
calcium
into
most
hydrate.
the
introduction
of
sulphuretted hydrogen
simply by
even
is difficult to cover
It forms a grayish-greenmass,
by
odor of which
the disagreeable
has been

"
2

His

in favor

"

Loc.

Handbuch,"
cit.,p. 163.
klin.

Berlin,

Hebra-Kaposi,

'

I have

of hair

been

"

of old

Bd.

for

and
depilation,

unable

gradually becomes
*Comp. Galenus, De

careful

xi., 2.

Wochenschr., 1871, p.
1. c,

145.

p. 48.
to

confirm
more

compos,

the statement

deficient

in

pharmac,

that

after

long-continued pullingthe

pigment.
Lib.

1, Cap. 4, cited by Eble.

latter

growth.

AND

ATKOPHY

THE

OF

DYSTKOPHY

409*

HAEK.

(toncabeans, orris root, oil of lemon). The paste (to be preserved

in a
vessel)is spread with a horn knife to a thickness of one line,and,
of the skin, is allowed to act for five to ten minutes.
Then
according to the irritability
scraping off of the rapidlydrying paste with the edge of the horn knife, cleansingof the
of deodorants

the addition

well-closed

into the

inunction

water,

lukewarm

skin with

with

vaseline,cold

some

method
physiciansregard the electrolytic
negative pole of a galvanicbatteryis fastened
after the flexible steel points used by
is modelled

American
To

the
Fox

by
pulp

cream,

zinc ointment

or

spot.
as
a

effectual radical treatment.

an

thin needle

very

"

the

used

one

dentists for the extractioii of the

hair to be removed.

Strength of the current,

ten to sixteen elements
a zinc-carbon
positive(sponge) electrode is held
battery.
to twenty seconds are
Ten
ing
requiredfor loosenby the patientin the palm of the hand.
of an hour, thirtyto fifty
the hair in the follicle. In sittings
lastingthree-quarters
The
of the process is very slight,
the reaction on the skin
hairs are removed.
painfulness
it
is
trices
said,
exceptionally,
punctiform,
barelyvisible cicaOnly
trifling.
generallyquite
into the follicle of the

inserted

and

"

The

of

produced.
It is based on inflammation
excited in
simple of execution.
Bulkley'smethod is more
after
of
the
hair.
removal
The
hair
is
tweezers
and
the follicle
thorough
grasped with
time a small, sharp-pointed,
at the same
triangularneedle with cutting edges is inserted
While
the hair, the
into the follicle by the side of the hair.
a lightpull is given on
to a depth correspondingto the bottom
of the follicle and
needle is pressedin, advanced
are

then

several times

turned

vano-cautery,
Not

with

moistened

or

without

of the hair, by

around

destruction

average,

ATROPHY

The

into the follicles needles

of

maintenance

caustic fluid

Kaposi^ points

reason,

the

of which

quiteincalculable direction
thirtyto fiftyper cent
of the procedure necessary.

and

its axis.

object,others insert

like

the

With

how

out

alone

AND

by fire
acid).

problematicalit is to reach
produced, owing to

hairs

follicles.

G.

treated

grow

so

DYSTROPHY

OF

THE

H.

Fox

admits

again and

the

or

the

the effect is

of the several
of the

heated

(forinstance, carbolic

the

papilla
oblique

that, on

make

gal-

an

tion
repeti-

HAIR.

normal, equallydense growth of hair depends upon the fact

placed
lapse of their typicalduration of life,are continuallyre-

that the hairs, fallingafter the

by

others formed
loss and

anew;

there

is

constant

restitution.

balance

disturbance

between

expenditure and

ceipt,
re-

Every
growth, to alopecia.
An older nomenclature
distinguished: 1. Galvities ^the baldness of the aged due to
2. Defluvium capillorum a pretty uniform
loss of hair occurring over
natural causes;
of pyrexial and constituthe entire body, in consequence
tional
the whole head
over
even
or
diseases ; 3. Alopecia loss of hair from local causes
limited parts of the
and on
between

of the

after-growthleads

of the

relation to the detriment

to defective

"

"

"

skin.
ALOPECIA

Alopecia may

genita-^ormay
1

"

be

be

Pathol,

congenitaland

confined

u.

CONGENITA.

affect the entire skin

alopeciauniversalis conpatches alopecialocalis (s.areata)congenita.

may

to isolated

Therap. d. Hautkrankh.,"

"

"

p. 524.

Vienna

and

Leipzig, 1880.

410

ATEOPHY

DTSTEOPHT

OF

Universalis

Alopecia

a.

In many

AND

HAIK.

THE

Congenita.

of

congenitalbaldness, there is not a permanent arrest

but merely delayed perforation of the hair through the epidermis. In
the first and
second
bald, the scalpbecomes covered with lanugo between
the end of the second year, or still later,is replacedby hair of
and toward
cases

of

formation,

children

born

of

year
normal

life,

ness.
thick-

is at present under
observation.
In this two-year-old girl,otherwise
a
case
normal
my
with downy
hair.
only slightly covered
respect, the head is now
A girl aged
made
the following observation:
Luce
eight years had been born quite bald.
In

Such
in every

the

sixth

month,

noticed

were

small

numerous

sixth

in the

blackish-gray hairs of normal

black

point.

black

mass

regular alternation

question showed

in

Danz

two

adult

^states that he has observed

details in

patientaged

described

Schede

length

firm

of

conical

persons
several

33

two

thin

who

and

and

one

cases

themselves

ascertained
half

nodules

of

that

first hairs

were

unchanged

color

few

with

the

merous
nu-

central

needle

a
as

had

never

the

there

centimetres, besides

under
a
magnifying
glass, a
But
the hairs in
curled-up hair.^

spindle-shaped thickened

had
of

shown

girl,he

the

seen

saw

and

scalp had

the

saw

lifted with
was
top of these nodules
could be recognized
underneath, which

When

was

thickness

the

on

liuce

scalp showed

The

hairs.

downy

elevations
When

year.

either

places.

hair

teeth.

or

Eayer

also

congenitalpermanent alopeciaand reports the

years.
in the children

of

a
peasant woman,
boy of thirteen
quitetald,and no hair had developed
In addition there were
neither eyebrows nor
and nowhere
later.
could a trace
eye-lashes,
both children appeared well-formed
Otherwise
and of a developof lanugo be discovered.
ment
The parents were
correspondingto their age.
healthy and had a full growth of
hair; this was true of two other children.

years and

six months

girlof

cases

h.

I have

The

parietalbone.
bald

born

of this kind

from

of life

the

fact that

by others,

one

to

to be

limited

portion of
expected.

spot

the

congenital bald spot

slightly below

the

and

is said to

The

anomaly in the boy's family is noteworthy

brothers, the two central upper incisors are several

Nothing

the
the

"

vertex
other

"

eddy

lowed
fol-

was

top of the left

developmental
anomaly.
on

Another

two

that

seems

further
a delicate, scrofulous
was
boy without
relatives
noticed
The
in the first years
of
vigorous boy aged fourteen.
above
the right ear, at the junction of the temporal
and
few centimetres

in

have

gradually enlarged.

; its

At

hairs.

on

former,

of the oval congenital area

circumference
present the length of the bald spot is about three centimetres
The otherwise
centimetres.
unchanged scalp is covered here with

parietalregions.

the skin, it

patient

II. occurred

small

been

Alopecia Localis [s.Areata) Congenita.

cases

fifth year

in the

life

two

seen

1." is of interest

Case

had

congenitalbaldness is confined
of the growth of hair is never

If the
restitution

Case

; both

in

greatest width, one

few longer and a number
patient

our

millimetres

as

well

the pathogenesisof alopeciacongenita.

respecting

is known

abnormalities

of

the teeth

have

often

been

observed, and

in

half

of

downy

his

father

the

other

teeth.

As

in

as

longer than

and

deformities

trichosis,
hyperof

the

of congenitalalopeciain brothers and

rarely. The not infrequentoccup-ence
influences.
sisters points to hereditary
Schede
found, on a pieceof the scalpexcised from the older of the children
Anatomy.
nails

more

"

Comp.

Brunswick,
*

"

F. Hildebrant's
1830.

The

Handh.

above-described

Already mentioned,

1.

c,

p. 33.

Herausgeg.

d. Anatomie."
condition

is

von

generally termed

Weber.
lichen

Fourth

ed., p. 204.

pilaris,after Willan.

ATEOPHT

OF

DYSTEOPHT

AND

411

HAIR.

THE

his observation, the sebaceous

glands well
congenital baldness (see above)under
Kudiments
of hair existed
developed,and opening directlyon the skin by a free channel.
in the deeper layersof the cutis in the shape of short, straightor
slightlyconvoluted
structure
tubules without perceptibleinternal cavity. In their whole
(externally,
long,
nuclei
with
s
mall
roundish
c
ells
narrow
or
rod-shaped
cylindrical
polygonal
; internally,
These
tubuli were
largelychanged
they corresponded to the external root-sheath.
cells)
into microscopicatheromata
by a central bulbous conglomeration of flattened epidermis

with

cells.
Jones

Aitkens

and

found

cord-like areolar tissue with

them
was

that the cutis of the

Here

altered follicles.

were

scalpin

interspersedfat-cells

and

their

replaced by a
tween
granules. BeThe
papillae.
epidermis
case

accumulations

and there indications

of

was

of

atrophic.
,

ALOPECIA

(Loss of

hair from

SYMPTOMATICA.

local

causes

and

in circumscribed

)
spots.

alterations of the

lead to disturbances
hairy skin must necessarily
alopeciaof this character implicate only single
hairs as in acne, or a largepart of the capillitiumas occasionally
in erysipelas,
it is always
affected
the
limits
of
the
to
c
onfined
of
the
skin.
strictly
portion
of parakeratoses; but, for obvias
a concomitant
ous
Alopecia symptomatica may occur
it is met with
anatomical
in inflammatoryprocesses, in
more
particularly
reasons,
or
or
diffuse,infectious or non-infectious,acute or
superficial
deep-seated,circumscribed
clironicforms of dermatitis (forinstance, acne, eczema,
of the
variola,most
erysipelas,
in
and
ulcerous
and
tension
papular,pustular,
syphilides,
etc.). Compression
mycoses,
of the hairy skin, e. g., Taytumors, are a not infrequentcause
of regionalloss of hair.
Like its development, the prognosis"5i symptomatic alopeciais dependent
the
upon
character
and the intensityof the primary cutaneous
affection.
In all destructive diseases
the consecutive loss of hair is permanent and
ending in the formation of cicatrices,
In the treatment, too, the indications depend on the nature
incurable.
of the primary

All

in the

important

more

growth

of the hair.

Whether

the

affection.

cutaneous

ALOPECIA

SENILIS

It is often stated that in advanced

of

other parts of the

and

body,

of very advanced
believe that any

persons
we

the

age,

beard, the

AND

not

PE^SENILIS.

alone the hair

and
genitals,

'the

of the head, but

also that

eyebrows, diminishes.

the hair of these parts grow

age, we have not rarelyseen
considerable loss of hair in these parts can
by no means

In

denser,
be

monstrated
de-

of

frequent occurrence.
As has been stated in a previoussection,a proliferation
of hair on normally smooth
in advanced
portionsof the skin developsnot rarelyin both sexes
age ; with good reason,
increased
therefore,we
might speak of an occasionally
tendency to the production of
hair.
Experience teaches, however, that such a dispositionis never
displayed on the
scalp; on the contrary, the loss of the hair of the head in the aged is one of the most
whether
common
the rest of the body is thickly or lightly
signsof senile retrogression,
as

covered

with

hair.

baldness

The
in

always on

men

the

But

of the

than

in

top

of the

aged, as

in the small

rule

preceded by a whiteningof the hair,is more

quent
frebegins on a small spot,according to Pincus, almost
vertex, and spreadsvery slowlyforward, then sidewaysand backward.
region,which is seized at once, lanugo soon takes the place of

women

; it

412

the

ATEOPHT

AND

DYSTKOPHY

OF

THE

HAIE.

vigoroushairs,and in a few months it becomes

quitebald. Then it takes comparatively
until downy hairs grow
at a place closely
a long time
adjoining the former ;
this takes place,the process
but whenever
attacks the new
region with equal intensity.
In not a few persons gradual baldness occurs
early,generallyon an hereditarybasis.
This condition
is aptly termed
to both
varieties is the
alopeciapragsenilis.Common
above-described
the increase of the
progress of the affection; but in alopeciapraesenilis
in alopeciasenilis;in the former,
absolute dailyloss of hair is less than
the
moreover,
small
of
intermediate
the
but
occurs
on
a
not on the
vertex,
lanugo-formation
only
part
the
and
occiput (Pincus).
temples
The skin bared
seems
thinned, somewhat
tense, but
by alopeciasenilis or praesenilis
If the individuals are otherwise well nourished,
the underlyingbone.
on
easilydisplaceable
the hairless surface may
show a certain fattylustre.
The follicular openings,unless the
baldness is of very long standing,are still clearly
recognizableand here and there covered
with delicate downy hairs.
Senile atrophy of the scalpis preceded by alterations in the blood-vessels.
Anatomy.
A fibrous endarteritis narrows
the lumen
of the cutaneous
arteries;the ample
network, which otherwise spreadsthrough the connective-tissue portionsof the
capillary
skin and especiallysurrounds
also the hair-follicles,
partiallyperishes. This primary
involution of the blood-vessels is followed
an
atrophy comprising all the cutaneous
by
in
the
itself
epithelial
portionsby a thinning of the celllayers;the atrophy manifests
layer,in the connective tissue by a contraction corresponding to the insufficient supply
hair-follicles shrink
but their openings remain
of nutrient plasma. The
considerably,
of a funnel
comparativelywide, and their upper parts generallypresentthe appearance
filled
either
with
loose
contain the
masses
are
or
downward;
horny
they
diminishing
of the otherwise empty sac conMore rarelywe find at the bottom
finest downy hairs.
volutions
abortive attempt at hair formation.
of pigmented roundish
nuclei
The
an
rather broadened, and
muscles are usually preserved,appear
cutaneous
finelygranular
has become
from fattydegeneration. Perhaps the direction of their course
generally
horizontal,more
more
nearlyparallelto the level of the surface of the skin. The glandular
of
At
the
show
resistance.
time
when
of
the
the
skin
a
greatestpower
organs
find
the
sebaceous
we
above-described
glands
symptoms are alreadycompletelydeveloped,
more

"

"

unchanged

in size and

the number

and

process exert any material influence on

remain
undecided
of the sweat-glands. For the present it may
of lymphoid cells,
which we
bo ascribed to an accumulation
have
ISTor does the

structure.

extent

importance should
around
frequentlyfound especially
what

that

any

alteration

considerable

glands. Finallyit

the convoluted
in the

of the

nerves

bald

skin

has

must
not

be

emphasized

hitherto

been

demonstrated.
examination
of the cutis in advanced
alopecia
According to Pincus,' the anatomical
the same
results as in alopeciapityrodes (comp. below), only
givesessentially
prsesenilis
that the thinning of the median
layerof the cutis is stillgreater.
offer no
All experienced authors
hope of
acknowledge that therapeuticmeasures
success.

ALOPECIA

a.

Symptoms

and

Course.

(CAPILLITII AND

PITYEODES

"

UNIVEESALIS).

Alopecia Pityrodes Capillitii.

One

of

the most

L.

No.
,

frequent affections
3.

of the

scalp,the

most

414

ATROPHY

we
Ordinarily
may,
o
f
the
abnormal
intensity

the

on

various

AND

from

the

the

OF

of
intensity

rapidityof

regionsof

DYSTROPHY

head

HAIB.

THE

the cutaneous

desquamation, deduce

the hair

change, and
proceeds pari passu

the

of the
intensity

with

the

like

pityriasis'.

degree of

the

hair

disease.
Examination

of the scales in question has shown

that they consist largely(threeweight" Pincus)of morbidly altered, abnormallyfirm products of secretion
sebaceous glands.

fifths of their
of the

"

Kaposi (I.e.)sees

pityriasiscapitis which
no

means

only

of the skin"

give rise

to

While

by

increase

an

(Hebra,
an

reason,

"

in this fact

Hebra
of

has

the

been

sebum,

''

especially,for maintaining
termed
but

seborrhoea

the

sicca.
of

production

Lehrb.," 2d ed., Vol. I.,p. 90),the technical

erroneous

the seborrhceic

However,

"grease
term

as

drying

chosen

character
here

we

of the
have

the

upon

by

surface^

by"Hebra
might

easily

conception of the process.

formerly it was

assumed

that

existed for years, the simultaneous

Pincus.

alopeciabegan only

occurrence

of both

processes

after the
has been

pityriasishad
by

determined

As

regards the development of alopecia,it should be mentioned

that the alteration
typicallongitudinalgrowth at the start seizes all the hair of the head, but after
a few
quickly in the median part of the head than in the other
years it proceeds more
in women,
regions,the hairs of which, as may be most distinctlyseen
permanently
maintain
of
eleven
to
sixteen
an
centimetres
(four and one-half to six
average length
and one-half inches).' The clearingof the scalpin the second stageof the disease first
two
to four centimetres
broad, which begins about two
appears in the shape of a strip,
behind the anterior margin of the growth of hair; often also at the same
centimetres
tim"
at the vertex eddy, so that there are
at first two clearings,
later bald spots,correspondingto these localities (Kaposi). At the anterior margin of the hairy growth, the median
part above the glabellaresists the disease much
longer than the external parts situated
above
the frontal eminences.
Much
more
rarelythe loss of hair first manifests itself at
the frontal edge; then, too, there is generallya second centre at the vertex eddy.
The
of the scales shows no deviation, but we
aspect of the scalp after removal
can
in the beginning of the disease,a firmer attachment, a diminished
determine, often even
in the median
plicability
part of the head.
Many persons sufferingfrom alopeciapityrodesstate that they feel a
prickling
headache, conjoined with a certain sensation of heat, lastingfor hours, or even
days, in
The sensibility
the region of the vertex.
of the diseased scalpis intact.
the main
These
In a few
are
points of the morbid
picture described by Pincus.
differs
from
that
of
the
author
named.
For
our
experience
while,
particulars,
according
the perspirationat no
time
shows
to the latter,^
have
any perceptiblealteration,we
of
the
heard
increased
of
to
numerous
patientscomplain
disposition
scalp
perspire,,
of the

"

and

at times

convinced

ourselves

of the

correctness

of these

^^

statements.

be diagnosticatedas
the above-mentioned
soon
as
Diagiiosis. Alopecia pityrodes can
attachment
firmer
of the scalp shows
itself together with increased desquamation.
without
the presence
of the former
chronic
Even
pityriasis
capitis
symptom,
for
rise
the
to
of
teaches
at
that,
suspicion commencing alopecia,
experience
always gives
has existed for
least in the majority of cases, the hair becomes
thinner after the pityriasis
In order to ascertain
the beginning of alopeciaearly,Pincus advises the
several years.
hair on four successive days by means
of combing with a fine comb,
coUectioji of the falling
"

Pincus, 1. c,

2, p. 333.

AND

ATBOPHY

OF

DYSTROPHY

THE

415

HAIK.

of the proportion of the pointed hairs to the total loss. Should

eight,with an average length of the hair of thirteen centimetres, or
A moderate
quantityof
in ten, with that of five to eight centimetres, it is abnormal.
one
to be
limits
thereof
the
inasmuch
seem
need
as
loss
of hair
cause
no
absolute
disquietude,
of
the
the
decrease
in
state.
the normal
typicallength
rather extensive even
Respecting
all pointed,we can
of the female hairs,which
are
easilyconvince ourselves by measuring
and

the determination

this amount

the lost

to

one

in

ones.

that

the

senile

utilize the

alopeciasets

loss of hair, an

'

in the transverse

of the

even

here treatment

be

is

can

effective in the first stage.

made

in

as

"

but

observatioa

differential

diagnosisfrom alopeciasenilis,we can

in with rapid increase of the absolute
of
of
the loss
pointed hair, and a rapid diminution
rapid spread
there is an absence
In alopeciaprsesenilis,
hairs.
of many
graduallyfrom a small centre, not
clearing of the scalpensues
the whole median
rather uniformly over
part of the head.
is
where there
unfavorable
most
The
prognosis
Prognosis.
In

equally
eter
diam-

and
pityriasis,

the

alopeciapityrodes,,

hereditarytendency,,
second
stage,in
thicker
again; but
grow
a

In the

hairs
the hope of seeingthe thinned
general,we must renounce
condition
those hairs which have lost
frequentlyit is possibleto keep in their present
Of importance for the prognosis,morediameter.
over,
little or nothing of their transverse
the first symptoms presentthemselves;the earlier after puberty
is the age at which
sity
A criterion of the intenthis has been the case, the more
rapid as a rule is the course.
of
the
a
nd
first
the
in
the
of
the
furnished
proportion
is
pityriasis
degree
stage by
of
in
number
the
second
the
the
total loss;
short,
the pointed hairs to
falling,
stage,by
fine,lanugo-likehairs,continuallyincreasingwith the rapid progress of the alopecia.

Anatomy.
farthest

both

Pincus
with

parts;

but

on

the skin of the top of the

compared

still normally coated

the

the

the

transverse

diameter

partsthe

layer of the

cellular

vertex

skin of the

diseased

found

diseases,and

intercurrent
over

"

advanced

of

where

the disease had

occiputof persons dead of

the epidermislayerequal

cutis tissue proper, between

degree of thinning being

thinned, the

tissue,was
epidermis and subcutaneous
proportioned to the stage of the hair affection. The transverse diameter of the fatty
usuallygreateron the affected than the healthy places,and the fattylayerof
layer was
the former
explainingthe tightattachment
regularlyshowed an ample fibrous framework
he could observe no
Pincus
that
observed
cal
pathologiemphasizes
particularly
clinically.
alterations in the vessels.
opment
of hairs epilatedduring the develmicroscopicexamination
the morbid
of alopecia pityrodesfrom
regions shows nothing characteristic.
alterations which
Most of these hairs displaythe same
occur
during the normal change
of hair on those which
is the dry root deficient,
about to fall. Especiallynoticeable
are
solid club becoming pointed
in nuclei and pigment; it has either the form of a narrow
stance
below, or else it consists of ray-likediverging fibres prolongationsof the cortical subat
least
wellsets
As
of the hair shaft.
in, more
nearly spherical,
improvement
full roots are encountered, such as correspondto hairs which
have for a greater
rounded
in the bed-hair
brittleness of the shaft is
length of time remained
stage. Increased
largelyobservable,as in all processes leadingto atrophy of the hair.'*
factor is inherited tendency which may
Etiology. The most important etiological
Next
in order are numerous
manifest itself in otherwise perfectly
healthy persons.
proIt should

be added

that

"

"

^
,

Pincus, 1,

Comp.

V.

c,

2, p. 342.

Baiensprung:

"

Die

Hautkrankheiten,"

p. 112.

Erlangen,

1859.

416

AND

ATKOPHY

DYSTROPHY

OF

THE

HAIR.

causing impairment of bodilyvigor. Affections which exceptionally

succeeded
are
defluvium
by a rapid, copious, but usually well-recovered
capillorum for instance,
a grave
disease with prevailing
syphilis,
typhoid fever, an irregularpuerperium, mental
melancholia
much
are
more
frequentlyfollowed by the onset of an alopeciapityrodes
capillitii
distinguishedby a rapid transition into the second
stage. The hair affection
supervening in the later stagesof tuberculosis,carcinosis,and other processes leading to
ease
general cachexia, has all the characters of alopeciapityrodes. In the female sex, the disconderation
under
now
frequentlyforms a sequel of simple chlorosis.
The view of Hebra-Kaposi that a chronic seborrhoea is always the primary condition
and
that the alopecia occurs
only secondarily,has in our
opinion been disprovedby
effects of the same
Both processes are parallel
Pincus.
the branny desquamation
cause;
of an
of the scalp,the symptom
of
is
based
tution
constiabnormal
cornification,"
on
atrophy
nutrient
in
the
conditions
the
local
nutritive
same
as
or
anomaly of the hair
way
formation, the analogue of horn production (Auspitz).
Owing to the conformity with districts of peripheral nerve
hibited
expansions generallyexin the male, some
took
authors'
occasion
to suggest that the
by the baldness
loss of hair both in alopeciasenilis and in the various forms of premature alopeciamight
be preceded by the death of peripheralnerve
twigs. For the present this attempt at explanation
cesses

"

"

'^

lacks every anatomical

basis.
Lassar and Bishop (1.c. ) have latelyasserted,basing their
be caused

animals, that "alopeciaprsematura" could

with

opinion on
by contagion.

experiments

directed solelyagainst
therapeuticmeasures
formerly in use were
the
the
of
indicated
a
clearing
scalp
already
stage
ing
impendnumber
the
of
medicaments"
in baldness.
termination
we
recommended,
Among
was
can
distinguishthree categories;either a medication
attempted which should act
the deeper layersof the cutis,by strong irritation of the upper
alteratively
layers
upon
to have an astringentand, vaguely, roborant
which was
effect
(caustic
soaps, etc.);or one
the entire skin (tannin,quinine); or, finally,
irritatingdrugs were
on
employed which
influence on the development of hair (veratrine,
had the reputationof possessingas pecific
tincture of cantharides).
of the first stage of the
But, as has been stated above, it is preciselythe treatment
of
offers the best prospect
advise is
disease which
success.
Unfortunately,professional
capitis. For this stage Pincus believes only those
rarelysought for chronic pityriasis
agents to be appropriatewhich excite a very mild irritation on the skin ; he had the most
bicarbonate.
favorable results by the employment of sodium
Treatment.

concentration

The

until, when
nor

in
and

"

The

of the disease in which

that

rubbed

even

long and

during the night apply

cloth

with

contact
a

must

dose
the

compress

be

into the

minutes
The

slight burning.
intimate

mixture

of the
for several

may

be

specially determined
forehead

of the

gradually increased.

scalp, it is necessary
well

for every
patient ; it is diluted
ing
patient, it produces neither redden-

saturated

with

to
the

pour

In order
it

over

to

keep the

the latter

fluid, protectedby

solution

in the

evening,
ous
cap of impervi-

(gutta-percha tissue, oiled silk).

is that the color of the hair

bicarbonate
A disagreeable
incidental effect of sodium
which takes place especiallyearlyand with
acquiresan admixture of dirtyreddish-brown
greatestintensityin the case of dark hair.
tableMartineau
watery solution of chloral hydrate. Two
employs a five-per-cent
with
The
and
into the scalp
then rubbed
a sponge.
desquamation
spoonfulsare warmed
1
2

Comp',for
Comp,

instance, O. Simon,
Pincus, 1. c, 4, p. 310.

"Localization

d.

Hautkrankh.,"

p.

87, Berlin, 1873.

removed

likewise be

can

by

bichlor. corros., 0.6

In the second stage Pincus

of several years
The
"week

during the
Still

than

effective

more

the head
tannin

such

during its employment

but
the

of this salve

use

corrosive

einployed contained

ointments

tannin

of

Glycerini,Spirit.Colon., aa
in keeping the affection
succeeded
150

remedies, viz.,tannin

two

by

41 T

HAIR.

THE

solutions

weak

with

ablutions

Hydrarg.

OF

DYSTROPHY

AND

ATKOPHY

with

dense

in

fat ; two

soft brush

(inalcoholic

manifested

drawbacks

of

to 30 grams

5 grams

oil of savin

was

serious

Lassar).
abeyance for

75

(Sol.
a

space

oil of savin.

and

cleansed

was

sublimate

or

dipped

three
in

times

warm

suds.
soap-

solution,.5-30 drops in 30 grams),

(increased brittleness of

themselves

discoloration
of the epidermis, but especially
a penetrating odor,
hair, dirty grayish or brownish
etc.)that it could only exceptionally be utilized.
nausea,

headache,
In

times

recent

more

of treatment

method

introduced

has been

which

fulfils numerous

lowing
stagesof alopeciapityrodes. Its effectiveness rests on the folfrom
the scalp. 2.
three factors : 1. The scales and fat are
thoroughly removed
of the cutaneous
muscles
is stimulated.
3.
circulation of blood and the activity
without.
indicated
the
skin
from
at
time
fat is brought to the
same
Hereby are
in both

indications

The
Pure

partsinto

the three
with

of treatment

method

the

which

with

is saturated

water

lukewarm

is divided.

sufficient quantityof

flannel rag moistened

spirituous
soap (forinstance,

good glycerinsoap in spiritof wine, equal parts ; or a filtered solution of

and the
spiritus
saponat. kalin. Hebrge),
potash soap in one part of alcohol
this
of
Then
washed
with
means
an
irrigator,
a small
by
provided
rag.
scalpthoroughly
about
above
the
and
metre
first
one-half litre of
one
patient^shead,
spout,is suspended

solution of

two

partsof

then

lukewarm,
head.

"

head

The

if the hair

hours

to

one

and

one

carefullydried

is

stillsomewhat

be

half litres of cold water

with

dense

"

are

allowed

to fall upon

the

rough towel, and finally only after several

the scalp is thoroughly saturated with pure
"

olive oil.
the procedure should be employed every day,
degree of pityriasis,
for
two or three days in the week, for the other
or
we
process only
may
restricted
to irrigation
with succeedingoiling. The patient's
days a curtailed modification
attention is to be called to the fact that the loss of hair at 'first is apparentlyincreased,
the alreadyloosened hairs are removed
as
completelyin the first days of treatment.
irritation in the second
In order to exert a more
vigorous'cutaneous
stage of the
table
salt
to
saturation
about
disease,it will suffice to add to the spirituous
glycerinsoap,
to rub the scalppreviousto the oilingwith a
four per cent are dissolved
or
rag dipped

According

to the

order the

whole

"

"

in salt water.
Note.

"

influence

favorable

The

of sodium

chloride

on

the

growth

of hair has been

demonstrated

experimentally by Pincus.^
Of

medications

other

recentlyrecommended

the

pilocarpinetreatment

should

first

be mentioned.
The

action

Schmitz, who

of muriate

of

hairs

new

saw

pilocarpineon
develop on the

the
bald

growth
spot in

of
two

hair

accidentallydiscovered

was

persons

to

whom

some

by

subcutaneous

Schueller^
confirmed
injections of pilocarpine had been given for other reasons.
Schmitz's
ments
statePick gained the conviction, from
from
experiments on animals
the improvement
tained
ob; and
of alopecia pityrodes, that,
in ten cases
where
the disease
has not
reached
a
high degree
"

and

does

not

rest

on

hereditary basis, the pilocarpinetreatment

is

capable of producing

results."

27

L. c.

No.

Arch.

f.

4, p. 308.
experiment. Pathologic,etc.,Bd. xi.,pp. 88 and

89.

1879.

permanent

418

ATROPHY

The

The

remedy

dose

for each

ordered

once

The

is best

0.005

to 0.010

OF

of

THE

HAIR.

subcutaneous

gram.

For

injectionstwice

internal

use

0.005

to 0.010

week...

gram

is

daily(Pick).

introduced

pomade

DYSTROPHY

in the form

employed

is about

twice

or

AND

into

the

market

" Cie.;,
of Paris^
by Demarson-Chatelet
has acquireda certain
antipelluculaire,"
made
at my
reputation in lay circles. The chemical examination
instigationby Mr.
Gaebler showed
that sulphur was
the chief ingredient. Krause^s analysis
showed
that it
also contained
small quantities
of iron oxide and magnesia.
About
six years ago, in a case
of alopeciapityrodes under
Unna's
observation, considerable
secured
has since
improvement was
by the employment of this pomade. Unna
then employed an ordinarysulphur ointment, for instance :
under

the

of "La

name

Philodermine, pommade

Sulph. praecip.,

in all

of so-called

3 grains.

Adipis (ungt. pomadin.)

M. ft. pomade,

30 grains.

alopeciapityrodesincipiens,
coming under
cases
were
gained
greatlyimproved in a short
and
cured
continued
for
when
its
use
was
a long time."^
time,
completely
then in a coronal direction
has the hair parted every evening first in a sagittal,
Unna
at intervals of about one
centimetre, and the sulphur ointment
lightlyrubbed in along
these lines. Every third or fourth
evening the head is previouslycleansed of the remnants
of the old ointment.
As soon
the desquamation decreases
ing
accordas
markedly, differing,
the second day to at most
to the intensity
of the case, from
a week, the inunction
is
other
the
results
Should
continue
performed every
evening only.
equally good, only
two
weekly inunctions are given in the third and fourth weeks, then for one to two
but one
months
per week, thus graduallystoppingentirely.
of alopeciapityrodes
of Unna's, cure
By the use of this sulphur inunction treatment
is said to be secured not only in the first stage,but even
when
considerable thinning of tho
hair has alreadyoccurred.
cations
Finallyit should be pointed out that in treatingalopeciapityrodes,any other indimust
derived from the generalconstitution of the body
be most
carefullymet.
cases

his care,

In

and

affects

conviction

"

that

e.,

all

"

'

find the
we
Pathologicund Therapie der Hautkrankheiten
times
''the alopeciaprogressingwith seborrhoea
simultaneouslyor
I have also repeatedlyseen.
the eyebrows or the beard.
Such cases

Kaposi's

that at

i.
pityriasis
capitis,

the

"

'^

ment
state-

'

sively
exclu-

his
from
alopecia pityrodes of an hereditary character
is
the
to
now
thirty
day
(patient
beginning
present
years
present
old, the clearing of the central portion of the scalp is already quite distinct,no adequate treatment
in 1874 he allowed
When
his
has ever
been employed) a very great desquamation of fatty scales.
kers
beard to grow,
he noticed
that a flaking off similar to that of the scalp took place in the side whisIn

one

twentieth

and

of my

colleagues sufferingfrom

year, there

the goatee.

Probably these

from

was

After

cases

the beard

the

was

representa

shaved

off,the pityriasisbarbae

transition to the

rare

diminished.

disease for which

I would

pose
pro-

the term
h.

and

The development of this

accompanied by abundant

Alopecia Pityrodes

Universalis.

of alopeciais exceedinglyviolent.
Setting in
within a
desquamation of fattyscales, there ensues

form

'

Vienna, 1880, p. 568.

with
very

AND

ATROPHY

DYSTROPHY

OF

THE

41^

HAIR.

scalp. Synchronously or subsequently

the disease is at its height, the body is
other parts ; when
on
symptoms occur
definite centres
be clearly
as
now
deprived of the greaterpart of its hair. Inasmuch
may
recognizedwhere a much greaterloss of hair has taken place than elsewhere, the group
to the malignant form
of alopecia areata
of symptoms presentsa strong resemblance
that
the parts most
shows
More
even
examination,
however,
thorough
below).
(comp.
affected are in no stage of the disease completely bald, but covered with fine,colorless,
more
lanugo-likehairs,or that at least rudiments of hair are presentin the follicles ; furtheris
but
of
to
not
the vigorous hair
the periphery
the transition
sudden,
gradual.
Those regionsof the scalp for which "the ordinaryform of alopeciapityrodes exhibits a
attacked also by alopeciapityrodesuniversalis soonest and with
predilection
are, it seems,
salis
As opposed to alopecia areata, the skin in alopeciapityrodes universpecialviolence.
and
the underlying tissue with abnormal
is not thinned, not displaceable
on
facility,
with
and
it
has
is
covered
scales
is folded with greater difficulty
as
a
a
rule,
feel,
fatty
;
be easilyrecognized.
the openings of the hair-follicles can
to be of importance. The
influences seem
reference to etiology,debilitating
With
the
total
that
almost
defluvium
developing
even
following case shows
capillorumexceptionally
after exhausting general diseases may presentthe character of alopecia
pityrodes

short time
the

same

sketched

universalis

above.

Dg., silver-worker,
on

tlie hair of the

thinning of

material

between

himself

to

and

27th

the

beard;

soon
me

on

vigorous build, acquired

of

of inunctions

course

from

December,

December

30th

of

hard
chancre
in November,
1879.
Was
a
put
1879, to January, 1880. Patient states that quite suddenly,
out of his full,red1881, a quantity of hair fell in bunches
dish

the patient first presented

after,the scalp began to be very rapidly depilated.When
the 21st of February, 1881, he stated
that
he had
lost much
flesh within
the last

of the alopecia, which

felt weak.
The character
had
attacked
also the genital and
On
axillary hairs, completely corresponded to the highest degree of alopecia pityrodes universalis.
of the follicles were
with lanugo,
appeared bald, the mouths
parts of the skin which
partly studded
few

weeks

and

difficult to interpret microscopically;wherever

dark points, which
were
the latter condition
body could be squeezed by lateral pressure out of the hair-sac,which,
obtained, a comedo-like
of hair.
the microscope, proved to be a rudiment
Examination
further
showed
the cause
of

partly with
under

to be
ore
a pronounced fetor ex
largelyemployed in gilding, and

rinsing of the mouth

diet.

roborant

with

the

presence

thus

forced

potassium chlorate

After

few

months

of

discolored

to inhale

results of the microscopicexamination

alopeciapityrodesuniversalis about the
forms of alopecia.

The
in

Of the

rarer

be first described.

alterations,the hair rudiments

chin

of
cause

and

vapors

commenced

normal

former

hair

(the patient

gums

Treatment:

of salt-water

the hair

continued
the

the

fumes).

solution,inhalation

(beginning of May)

July the growth was already completly restored, and has

new-growth on the scalp is altogether dark blond, while
preserved its pi-eviousreddish blond color, but the
so.
lighter(blond) color than before and continued

other

deposit on

mercurial

side whiskers

from

atus;
appar-

again; in.

present time.

reddish.
had

was

baths,,

an

to grow

to the
was

Saline

The

The
tache
mous-

reappeared

in.

tion
epilatedhairs give as little informaof the atrophy as they do in most

found

in the above-detailed

case

should

The

degenerated hair-shaft,as represented in Fig. 3, consisted chieflj

of soft,multinuclear, stronglypigmented tissue,similar to that found
normally only in
the immediate
neighborhood of the bulb of freshlyvegetating hair. In the portion of
the rudiment
into

next

to the surface

cortical scales,but

appearance.
had not

The

their

of the skin

coherence

was

the

cells seemed

to have

been

transformed

abnormallyloose,presenting a

brush-like

inappropriateor insuflacient nutriment

fore,
suppliedto the matrix, therecaused a complete interruption
of the hair production,but merely led to

420

ATROPHY

AKD

OF

DTSTKOPHY

HAIE.

THE

incomplete comification of the cellular elements obviouslyfurnished in insuflBcient

substance.
number
by the papilla,and to a defective secretion of cement
of alopeciapityrodesuniversalis,the finest lanugo-likehairs,taken
In another case
themselves
almost without
from the spot most affected by the disease,showed
exception
provided with a well-developedmedullary cylinder. The occiputof the patient in question
When
still denselycovered with apparentlyvigoroushairs.
of these were
some
was
with the lightest
withdrawn
with tweezers, which succeeded
traction,
not
of the root-sheath
almost
the whole
followed,
rarely also the
membrane
the
hair-sac.
of
On
the
rootexternal
homogeneous
sheath
the symptoms of pathologicalcomification
could
often be
perceived.'
Alopecia pityrodesuniversalis has a generallygood prognosis.
an

Treatment.
the

"

of

case

Saline baths, roborant

medication

of the

strongdesquamation
hydrate, or weak

diet ; besides,in
with spirituous

solutions of corrosive sublimate,

soaps, chloral
douches.

ALOPECIA

and

scalp,ablutions

SIMPLEX.

which
otherwise resemoccur
ble
exceptionally
lack
morbid
but
the
capillitii,
alopeciapityrodes
desquamation of
secretion
of qualitatively
the epidermis and the increased
altered
these
For
the
of
sebum.
above
title
chosen
cases
we
masses
accept
by
Cases

of loss of hair

Pincus.
ALOPECIA

Symptoms
that

and

affection

Course.

"

of the

AEEATA.

By the term
hairy skin in

alopeciaareata
which

there

we

occurs

stand
underfirst

loosening, then a total loss of hair on chieflyroundish, rather

confluent
enlarging and finally
sharplydemarcated, graduallyperipherally
without
the
skin
in
the
time
ous
obvimean
patches,
showing any

;^

alterations.

.m.

lated
(benign) cases the loss of hair is confined to isoportions of the scalp or beard ; in the graver (malignant)
extend
to all partsof the skin covered
with hair.
cases, it may
28." Hair
ment
rudiFig.
It attacks preferablyyouthrare.
Alopecia areata is relatively
ful
from
the scalp of
in
but
those
also
of
There
are
develop
riper
persons,
may
age.
sufEering from
the
statistics
to
in
two
relative
of
the
versalis.
unino
occurrence
sexes
alopecia pityrodes
frequency
;
Hr., hair
to the writer's experience,patchy baldness
to be
according
appears
in
(described
more
thetext^.
frequentin the male sex than in the female.
Bt., part of
investment
the internal
The initial stageof the disease is accompanied in many
cases
by
the
hair-follicle.
of
the generalhealth, manifestingitself by headache,
a distinct influence
on
240 diam.
loss of appetite,
Headache
is com.
lassitude,and emaciation.
with
is
of
if
the
affection
has
its
seat
at
times
unilateral,
and,
specialfrequency
plained
in
the
the
half
head.
Various
of
corresponding
paraesthesiae
mainly
occasionally
appear
the

In

milder

man

diment
ru-

as

precursors

and

likewise

remain

evanescent
(itching,

pain with

the

See

slightest
pull on
further

confined

sensations

to

the

affected

of heat often

area

and

its immediate

associated with

the hair, etc.).

details in Monatshefte

f.

roundings
sur-

ling,
annoying prick-

pract. Dermatol., 1882, No. 4.

422

ATKOPHY

reached

certain

length and
be

even

may

happen, too,

repeated

that while

the

the hairs of other

to demonstrate

permits us
In the

then

AND

DYSTKOPIIY

had

likewise fallen.

several

times

in

OF

THE

HAIE.

Such

abortive

attempts at

eration
regenIt may
years.
the portions first affected is definitely
increasing,
the

course

of months

growth of hair on
regionsare beginning to fall,and

such

an

or

interruptedprogress

different stages of the affection.

tres
proceedsas follows: At the very beginning several centhe
of
the
in
beard
are
on
(more frequentlythe
scalpor
region
former);they steadilyenlargewithout any intercurrent attempts at restitution. At thiperiod of the development the above-mentioned
generalsymptoms set in. The continual
of
the
bald
the
consumes
spots
remaining ridgesof hair which separate
gradually
progress
ness
the several areas, thus producing the characteristic dumb-bell
and trefoil forms of baldin
the
29.
of
to
confined
the
loss
hairns
not
However,
represented Fig.
scalpor beard,
but may
or
successively
simultaneouslyaffect both, and in time but few small groups of
At the acme
of the disease,the eye lashes and brows,
^vigoroushair can stillbe found.

malignant form

of loss of hair

the

axillae and

Fig.

30."

No.

Total

130,pp.

course

the

the

the hairs of the

genitals,at times even
Many patientscomplain of frequent chills.

the affection.

trage,

the

observed

baldness
7 et

in

boy

seq.),caused

of

seventeen

by alopecia

years

(RudolfWoelk,

described

extremities

in

are

involved

Vol^mann'sSammlung

klin.

in

Vor-

areata.

free,bold expression.
strikingly
the
strong prominence of the
facial bones
due to the defective development of the subcutaneous
fat,is produced the
The patients
resemblance.
which
to
these
certain
peculiartype
gives
family
patientsa
attention
the
defect
reminded
of
their
unwelcome
are
they
perpetually
bodily
by
attract
strangers,and it cannot
surpriseus that their frame of mind is greatly
among
The

Hereby,

scanty eye

as

well

as

lashes and

by

the

broAvs

give to

delicate skin

the eye

of the

face

and

depressed.
The
of

recovery

vigorous hairs

in these grave cases

still present there

proceeds very gradually.

spring up, anywhere in the

Close to the few

midst

groups

of the bald

spots

ATROPHY

AND

OF

DYSTROPHY

423

HAIR.

THE

small islands of closelyaggregated,firmly

lanugo, new
of time, more
"embedded, normally pigmented and normally thick hair. In the course
confluence
leads
to
the
of
these
oases
of these islands develop. A gradual enlargement
surfaces
the
bald
on
"of their lateral borders, whole
; at
ridgesof hair appearing anew
ing
extendfirst they present themselves
in approximately arc-like segments, which
again
those

"or

covered

toward

with

another

one

delicate

unite into almost

circular forms.

Where

the several

curves

have

bridgesof hair branch ofE from them at an obtuse angle,and

within the large
surfaces of smaller diameter
analogous manner,
several
takes
on
bald patches. The
portions of the
same
simultaneously
place
process
depilatedskin, and by continual broadening of the marginal ridgesfrom the periphery
ment
the centre the circumference
of the bald or lanugo-tjovered
areas
toward
by the encroachis
until recovery
of those provided with more
vigoroushairs becomes ever narrower
morbid
skin
of
the
the
this
of
the
quality
limp
finallycomplete. During
stage
recovery,
is graduallylost.
Diagnosis. The losses of hair due to trichomycosiscircinata are largelyconfounded
with the patchy baldness from alopeciaareata.
that after the inflammatory process caused
It may
be admitted
by the vegetable
baldness
circumscribed
exceptionallydevelop
parasiteshas run its course, a form of
may
In such
a
in mycosis circinata which
that due to the benign alopeciaareata.
resembles
of
the skin
the historyof its development, or perhaps the presence of other portions
oase
affected by the disease in a less advanced
stage,will confirm the diagnosis. As long as
a

considerable

in turn

extent,

surround,

in

new

an

"

the

the
can

tonsurans
fungous vegetationcontinues, trichomycosis
independent of the microscopicappearances, by
generalfracture of the hair close above the level of the
be understood
only if we bear in mind the unfortunate

s.

the

is very

circinata

well characterized,

symptoms and
frequent mistakes
still existingin the

dermatitic

skin.

The

confusion

nomenclature.
The
form

of

differential

diagnosisbetween

alopeciaareata

has been

alopeciapityrodesuniversalis

discussed

and

the

malignant

above.

For instance, the

in the gravest cases.
Prognosis. Eecovery may take place even
from
suffered
the
Sohf
he
had
of
described
name
c.
symptoms of
patientby
by me (1. )
that he regained his full growth
for about sixteen years
writes me
the malignant form
two
I have
of hair about
just received information from Dr. Freyyears
ago, and
normal
of
that
even
our
muth,
Danzig,
patient Diekert
again rejoicesin an almost
had
been
for
hair
months
48 years old,
some
nearly
growth of
past. The latter,now
Still for those sufferof alopeciaareata
ing
since childhood.
entirelybald in consequence
with absolute certainty,
restitution cannot
from the malignant form
be prognosticated
and at all events
a considerable
space of time, usuallyseveral years, always elapsesuntil
the hair is completelyrecovered.
after several months, at most
to be classed as
The
cases
benign usuallyrecover
after a year ; very few of them
have a tendency to relapse. In the beginning it is
will
to be very reserved regardingthe prognosis,for only the subsequent course
necessary
will assume
show whether
the cases
The former is more
the malignant character or not.
of the bald
probable should the generalhealth be greatlyimplicated,the circumference
cutaneous
increase
of
without
intermittent
and
the
rapidly
formation,
signs
spots
lanugo
atrophy set in early.
"

'

"

"

"^

'

Volkmann's

Samml.,
Ibid., pp. G and 7.

No.

120, p. 10.

424

ATROPHY

AND

Anatomrj. E. Wagner and

portionsof the diseased

H.

Schultze

skin.

The

"

excised

otherwise
of

an

normal.

the size of

area

The

H.

examined

Schultze
dime

microscope showed

his

on

DYSTROPHY

own

(besidesthe

the

had

small

HAIR.

opportunity of examining
the

found

former
a

THE

OF

affected

skm

thinned, but

portion of the cutis from

scalpwhich had recentlybegun

signs of premature cornification

small

to

the

margin

become

of the

bald.

hairs)no

alteration.

further

in the hairs
of porrigo decalvans
first anwas
nounced
presence of vegetableparasites
gators
by Gruby (1843);and he was succeeded by others. But nearly all later investidenied the existence of Gruby's Microsporon Audouini, and it had begun
positively
be looked upon
as
a myth, when
our
presentfungi-lovingepoch helped Gruby's doctrine
in
form.
a new
life,though
a changed

The

to
to

describes

Gruby
threads

of

diseased

the

hair

surrounded

as

partly of spores.
the superficial
layers of the epidermis

by

Malaasez's

mycelium,

; it is

"

fungous

true

champignon
in

totally absent

de

the

sheath, partly consisting of

la

pelade"

hair- follicles.

takes

only in

root

Eichhorst

tered
encoun-

his fungus-spores exclusivelyin the portions corresponding

to the upper
two-thirds
of the
isolated
the hair and the internal root-sheath
there only a few
ones
follicle,chiefly between
; from
had
threads
of mycelium
migrated outward,
Malassez, like Eichhorst, saw
only spores, no
; but
while

the

spores

found

their

of

Eichhorst,
thin

two

decalvans," of
or

quite unlike

champignon

in

schizomycetes, which
with

his

alopeciaareata so extremely
probable complete identity, or at

very

like those

finds

former

else between

I have

at

once

oblong

shaft

and

been

able to convince

"

Ueber

paper
alterations may

then, H.

internal

Herpes

occur

thinks

would

he

the

assume

least

claims
its seat

to

have

between

discovered
the

"bacterium

and

hair-shaft

cuticula

root-sheath.'

myself of

tonsurans

und

the presence of vegetableparasites.

scribed
Area
Celsi/' I stated that all the de-

also in the nutritive disturbances

of the hair

due

to

other

confirmed
the correctness
of my
munications,
comessentially
and his demonstrations
of
strengthen our conviction that the examination
the epilatedhairs in alopeciaareata furnishes nothing characteristic of this disease.
Etiology. It was chieflytwo attempts at explanationwhich served as the startingWe
shall briefly
designate
point to the debate over the pathogenesisof alopeciaareata.
the
a
nd
neurotic
theories.
them
the
as
parasitic
The
former
at present. Even
number
has but a very limited
of adherents
assuming
to have been
the parasites
actuallypresent in the reported cases, the proof is still to be
not an accidental condition, but that the parasites
furnished that this was
reallywere the
of the disease.
rial
cause
Furthermore, the clinical morbid pictureundeniably exhibits matethe
deviations from
to the
recognized dermato-mycoses. No
symptoms common
of detached
accumulation
flakes of epidermis,no formation
of crusts, vesicles,pustules,
which
few
of
could perhaps be traced to
the
even
nodules; exceedingly
or
cause
cases,^
nowhere
successful
the
of
The aspect
infection;
a
experimental,inoculation.
report
be
differentiated from
that
of the skin in the last-affected peripheralportions not to
at these, but
in the first-attacked central points,and the recovery does not commence
Since

causes.

Schultze

that

furfur

shape, having

more

In my

furfur, Eichhorst

Microsporon

Microsporon

Finally, G. Thin

processes.

the

the
to

a
near
results,
relationship. H. Buchner, whose
organisms belonging to the
single case, reports some
only after cultivation
: granrecognizable,but to be found
ules

or

the

never

not

were

filiform

round

from

drawn

were

similar

has

"

at the

periphery.
the

Furthermore,
1

Judging
to the

from

the

smallest

Ziemssen, 1. c.

parasitic
theory is unable

drawing
air-bubbles

and

to

description, Thin's

frequently present

explainthe

bacterium

in this

fact that in

decalvans

bears

localityin particular.

large num-

blance
strikingresem-

DYSTROPHY

AND

AlllOPHT

OF

425

HAIR.

THE

accompanied by violent headache and other

generalsymptoms, nor does it throw lighton the pallorand thinning of the affected skin
in the sense
of a schizomycotic theory, the
Even
in the graver cases.
demonstrable
think of placingerysipelas,
ola,
variNo'
would
one
without
remain
analogy.
any
symptoms
and
areata
tive
Relaline
with
in
course.
as
the
same
alopecia
regardssymptoms
or
lepra
dictum
of 0. v. Naegeli is of
and Thin, moreover,
of Buchner
a
to the statements
cannot
take
root
and
increase on the external
that
the
schizomycetes
importance, namely,

"ber of

cases

the initial

stage of

of sufficient moisture.'

to the lack

skin, owing

the disease is

Baerensprung'sneurotic theory is the prevailingone at present.

innervation"
The proof of "inhibited
(v. Baerensprung)was thought to be found,
of the diseased portionsof the skin (comp.,however,
1st, "in the alterated sensibility"
symptoms occurringduring the stage of development; 3d, in
p. 421); 2d, in the nervous
in which consecutive loss of hair appeared
areata
with certain cases
the analogy of alopecia
demonstrable;
in other diseases,probably of a neurotic origin;4th, in the heredityoccasionally
made
to the experiments of Steinrueck, discussed
reference was
in
5th, finally,
Von

the first section of the

presentchapter.

the first to notice that

for individuals
alopeciaareata showed
a preference
Baerensprung acknowledged the correctness
with his theory by supposing
of this observation and sought to bring it into connection
assumed
him
influence
manifested
itself more
inhibited nerve
that the
by
frequently
disturbances
than
in otherwise
with certain constitutional
in connection
healthy persons.
less serious objections can
that more
I have shown
be raised againstthe neuor
rotic
theory,and that this is stillwithout any solid foundation.
Should
to be
we, in lieu of a better,still adhere to the neurotic ttheory,it seems
Hutchinson
with

was

constitution.

weakened

Von

"

"

'^

In

the disease to the vaso-motor, instead

to attribute

correct

more

could

favor of this view

present,as well as
reddening of the bald

be adduced

the

pallorand

observation

the

of the

"

"

trophic

nerves.

anaemia

of the affected skin ally

genermyself that in some
patientsa.

latelymade
by
of alopeciapersists
produced by faradization during the acme
for many
hours, but lasts for a briefer periodas improvement progresses.
the whole, the understanding of the morbid
To be sure, on
is but little
process
That
the vaso-motor
facilitated by such an
to be considered
hypothesis.
nerves
are
the regulators of the local nutritive
under
all conditions
as
processes is beyond any
But
it
is
then
that
doubt.
equally unquestionable
every pathologicalalteration goes
skin

"

with

in hand

hand

Treatment.
fact that

"

The

believers

ensued

cure

in

in this circumstance,

irritant

Kaposi

effect
uses

on

which

ethereal

in

be at

an

that, were

the

latter alone

to

be

sidered,
con-

end."*

the

parasitic
theory have thought to find support irt
remedies.
employment of antiparasitic
As the benign
there
is
but
little
spontaneously,
recovery
argumentative

after the

generally end

cases

force

disturbance, and

vaso-motor

specialpathology would

all

the

all the

great

value

because

more

has been

oils in alcoholic solutions

many

placed.
or

of these

agents also have

In

to

order

irritant alkaloids

produce

dissolved

that

this effect,

in alcohol

parts; Spirit,vin. rectificati.

Spirit,lavandul.,aa 30 parts;,
vin. gallic,90 parts; Spirit,
or, Veratrin., 0.4 parts; Spirit,
lavandul.,30 parts ; Glycerin.,
rubbed
15 parts; these are
twice daily with a bristle brush
once
or
into tha
bald spots and the skin immediately adjoining. Should
the skin become
much
redfor instance, 01. macis, 8

1 "

Die
L. c,

niederen

Pilze

u.

s.

w."

1, pp. 23-30.

Kaposi, I. c, Bd. ii.,p. 544.

Munchen,

1877, p. 48.

426

AND

ATROPHY

DYSTROPHY

OF

HAIR.

THE

applicationis to be made at longer intervals

vigor.
rapid improvement after the use of a mixture
"of tincture of capsicum and glycerin.
A still more
*fcohave found favor of late in
energeticprocedure seems
desquamate, the

"dened and

Eindfleisch

and

observed

of

with

less

equal parts

France.

Vidalhas
the hairs on the affected part of the scalp shaved
off" every two
ing
a blisterdays, when
the epidermis begins to become
as
soon
as
plaster is put upon it. This is removed
detached, and
after two
to spread after two
three
days a fresh plaster is applied. It is said the affection ceases
or
until vigorous hair begins to sprout. Then
applicationsof the plasters. This procedure is continued
"

tincture

of

cantharides

Besides, ablutions
Should
cantharides

in

After

is rubbed

with
the

decoct,
affection

be

conjunction with

the neurotic

into

fol.

the

affected

skin morning
and
evening with a tooth brush.
said to have proved advanare
tageous.
liquor ammonia
in the beard, daily shaving and the application of tinct.

jugl. and
located

the

ablutions

above

theory had

caustic

been

said to suffice.

are

advanced,

it

that

natural

was

should
electricity

be tried.
Waldenstroem

sympathetic,
said

that

case

without

the

Pick

applied galvanism

the other
hair

by placing

the hairless

upon

began to grow

in from

pole

one

In the

spot.

six weeks

the

over

two

superior cervical

in which

cases

months.

to two

the

ganglion of the

method

was

applied galvanism

tried it is
in

grave

effect.
saw

recovery

but he justlyhesitates
pilocarpine,
of
no
practice,pilocarpineproved
agent.
in
of
the
a
case
employment,
energetic (subcutaneous)
nant
malig-

occur

to ascribe the effect

in

few

after the

cases

solelyto this

In

use

of

our

despiteits long and

type.
with
method
of treatment
During the last few years we have employed a combined
also in some
hand, at
especially
; it aims, on the one
very satisfactory
grave cases
result^
of the generalhealth.
irritation of the skin ; on the other, at the invigoration
"a mild
saline baths at a temperaOur treatment
consists in the employment of five-per-cent
ture
The
baths
taken three times a
of 28-29
minutes.
are
deg. E., lastingtwenty-five
week, and while the patientis in them the affected partsof the skin are lightlyrubbed with
use,

with the salt water.

flannel rag moistened
with brush electrodes. Each

lojfaradization
no

bath is taken, friction with

more

Twice

week

sittinglasts

concentrated

ten

the affected

minutes.

skin

On

the

is irritated

days when

ity
salt solutions,according to the sensibil-

of the skin.
be used dailyin slightcases, instead
frictions may
conjoinedwith roborant diet,sometimes with iron.

These

always

ALOPECIA

of the

baths.

They

are

NEUROTICA.

together all forms of loss of hair in which the

caused
latter occurred
as
a concomitant
symptom or sequel of diseases in all probability
within
the nervous
system ; or, owing to its having been confined to
by disturbances
with them.
Howthe distribution of certain nerves,
found its explanationin connection
vation,
obserthe
of
clinical
such
on
an
strength
influence,
although appearing probable
-ever,
cannot
either anatomicallyor physiologically.
as yet be proven
Under

/.

the

above

title

we

Alopeciaafter Traumatic

There

'is on

group

Affectionsof the

Cerebrum

or

the

Peripheral Nerves.

total loss of hair affectingthe whole

record, first,

body

after traumatic

cerebral affections.
observed
in a man
a wagon,
set, 45, after a fall from
hemiplegia, unconsciousness,
One
continued.
going
day, as he was
set in gradually, but headache
Improvement
himself, he could not find any beard ; finally,the hair of the head and that of the rest of

Cooper Todd
"nd

"

delirium.

4" shave

"

AND

ATKOPHT

the

the

head

the

toe-nails
In

also

lain in bed

bald

; not

amaurosis
H.

had

region after

for

hair

of the

describes

The

Heilkunde

floor of

he

at

burning

Konigsberg

house.

got up again, he was

proved that the

be found

the

on

side after concussion

same

not

examination

whole

loss of all the hair of the

partialloss

cerebral

When

year.

could

even

unilateral

traumatic

of the face and

"

Holmes'
System of Surgery,"
day not only all the hair fell out, but

the next

the charred

through

lost all his hair.

of the eye

Schultze*

reported in

case

and

filr wissenschaftliche

Verein

fallen

unconscious

he

observed

Eavaton

recalls

by lightning,

the

singledowny

time

same

struck

427

HAIR.

THE

off.

dropped

afterwards

year

with

at the
been

forty years before, had

states, he had
but

had

1876, I presented before

who,

man

Todd

fell out.

body

in which

OF

DYSTROPHY

of hair

confined

After

old

an

that,he

yet quite bald,

patient was

lutely
abso-

body.

scalpand

face in connection

of the brain.
to

the

right temporo-frontal

affection,accompanied by hemiplegiaof the right half

and

of the left upper

extremities.

lower

a
siderable
hemiplegia
right facial paralysis continued, and a very conyear,
atrophy of the soft parts of the right half of the face and complete anaesthesia of the right
trigeminus developed. The hair-limit of the right frontal region was
displacedbackward
by au

While

the

recovered

alopecia, 8

oval

Fischer

cm.

in its

greatest diameter, terminating

noticed, after gun-shot wounds

"correspondingextremities
rule, the loss

was

such

to

preceded by
by Fischer

of the

degree that

"With the melancholic

fibres alone

with

Connection

absent

were

they occurred, when the motor

motor
fibres synchronously,were
Alopecia in

in

shallow

nerves,

the

in
or

affected

by

Diseases

of the

arc.

defluvium

partsappeared

of the hair.
great proliferation

of the skin described

//.

the

in

The

capillorum on
if shaven.

as

nutritive

the
As

disturbances

of grave nerve
lesions ;
large number
or
chiefly,
finallywhen the sensory and
a

trauma.

Nervous

8y stein

due

to Internal

Causes.

psychoses,a diffuse loss of hair has been frequently

with other symptoms of impaired general nutrition.
Besides, in
melancholiacs, local alopeciasoccasionally
develop ; they often follow prettycloselythe
distribution of certain nerves,
instance
of which, confined
to the auriculo-temporal
an
I have recentlyobserved.
nerve,
Loss of hair confined to isolated parts of the body is found, furthermore, in progressive
atrophy an affection whose trophoneurotic character has been recognized
(facial)
almost
generally,despite the objectionof a few prominent investigators(Cohnheim).*
Circumscribed
Atrophy (Virchow),which has been most frequentlyobserved on onethe left),
half of the face (chiefly
but at times also on other parts of the body, consists in
in young
of the subcutaneous
an
fat,the skin, the
atrophy of very slow course
persons
The
muscles.
affection
of
the
hair
of
the
manifests
itself
more
bones,
rarely
underlying
either in decoloration
and complete whitening, or the hairs fall out, or their growth is
The disease may
less diminished.
extend to the entire capillary
more
or
growth on the
affected part of the skin, or else it may
be confined to some
circumscribed
irregularly
often stripe-like
regions.
of the

forms

observed, associated

"

"

"

Such

loss
stripe-like

Tlie baldness
In

one

in the
case,

finger, extends
above
within

the

for which
from

L.
"

"L.

am

in the much-quoted first case

of Romberg.'
and stripe-like
triangular by Romberg,
by Virchow.
to Professor
Berthold, the atrophic patch, the breadth of a

instance, occurred

indebted

ciliary border of the upper eyelid upward

ending a little way
lost
are
sharp demarcation; eyelashes and brows
eyebrows, without
any
of the

c.
,

for

is termed

case

the middle

region of the

the affected
1

of hair

Schwan

strip. But in

case

of Hueter

and

Axmann,

the

hair

had

been

lost in the tem-

p. 225.

Vorlesungen
c.,1.

fiber

allgemeine Pathologie."

Aufl., Berlin, 1882, Bd.

1. p. 594

428

ATEOPHY

poral region
half

of the

and

the

AJSTD

side-whiskers; in

DYSTKOPHY

of

one

OF

THIi

HAIE.

Courtel, in the greater part of the beard

on

the

diseased

face.

There

be

to

seems

of circumscribed

hardly any
Here

atrophy.

doubt

that

the disease

the

described

case

by Gibney

belongs

had

set in in the third year of life,with

left inferior
maxilla.
In the ninth

discoloration
of the skin in the region of the
present distinct atrophy of the left half of the face, whitening of
side, and baldness below the left parietal bone.

some

bunches

in the

category
dirty-brownish

year,
of hair

there
on

were

the left

Falling of the hair of the head is stated by Eulenburg to be a well-known

fact in
of frequent attacks of migraine.
cases
mention
those not very rare
in which
Furthermore, we must
cases
loss of hair is
associated with symptoms of sensory irritation,
for instance, neuralgiasof the supra-orbital
the affected nerve
extends.
nerve, in the regionin which
Eulenburg'demonstrates on
of Komberg's what minute
case
a very instructive
gradationsexist between them and circumscribed
in
the
combination
of neuralgicand trophic
atrophy; how,
(progressive)
toms
sympit often depends only upon
the temporary preponderance of this or that
group of
symptoms and the judgment of the author, whether a case is designatedas supra-orbital
neuralgiawith trophic symptoms, or as circumscribed
atrophy with neuralgicmanifestations."
Finally,
areata

were

course

of

we

mention

must

found

the

on

large number

H.

Schultze's

of

case

boy

aet. 7 years,

scalp by the side of papillomato-verrucose

of cerebral

and

all affected

spinal

in whom

patches like alopecia

arranged along the

excrescences

nerves.

portions,

no
The
spot was
diseased hairs
quite bald.
partly in stripes,partly irregular with map-like outlines,but kept
strictly"along the course
and the auriculo-temporal nerves.
the supra -orbital,the great occipital,

Lanugo

present

was

on

"

were

of

Remarks.
In the cases
here collected, the descriptionof the special
more
alopeciais on the whole incomplete. Where
complete histories
are
given, the alopeciasupervening on a neurotic base shows an imperfectlymarked
course
(Auspitz);and, in our opinion,it is justin this that the aboveacyclical
type and
loss
of hair differ materiallyfrom alopeciaareata.
mentioned
of
In alopecases
regional
cia
of
the
out
neurotica there is frequentlyonly a thinning
at
hair;complete loss occurs
no
periodof the disease. Where total defluvium is reported,we find the form of the bald
spots described as altogetherirregularand the transition into the still hairy portion as
it does not appear
appropriate to efface the
quitegradual. Under these circumstances
morbid
areata
of
of
the
marked
outlines
picture
alopecia
by the incorporationof
clearly
intention
is
of
the
that occasionally
there
this material.
no
Withal,
denying
possibility
neurotic
influences
a weakening of the physicalconstitution
produced by
may predispose
The prognosisand treatment
of alopecianeurotica
to the development of alopeciaareata.
affection.
depend upon the character of the primary nervous

Concluding

"

of the

character

"

"

AND

EXPANSIONS

In manifold
on

larger

or

number

observer.

do not
cut

leading to

conditions

smaller

escape any
surface produced

shows that
power
Where
the hair-shaft.

1
2

by

See

shears,but

increased

loc.

Romberg,

nutrition

is found

HAIES.

of the hair, inspectionshows

which
in

are

is due
on

many

so

obvious that

fine,blunt
a

moderate

cc.

1. c.

2, p. 91, and

Eulenburg,

they

in a
point
ing
magnifyto a broom-shaped fissuringof
hairs,it is easy to gain an ina

is broadened, and

circumference

this appearance

Eulenburg,

disturbed

THE

of hairs certain appearances

The hair does not terminate

the barber's

the

OF

FISSUEES

Handb.,

1. c,

p. 66.

or

430

ATROPHY

AND

OF

DYSTROPHY

THE

HAIR.

was
frequentlyconvince ourselves that the total disintegration
preceded by a fisBuring of the shaft into largerlongitudinalsplinters.
As a rule, the partiallongitudinalAssuring occurs
almost
sxactlyin the middle of
the shaft, and then of course
destroysthe medullary cylinderif
the latter is present;but
at times the shaft divides
into one
the
and
one
largerpieceincluding
or
medullary cylinder,
more
can

we

smaller

ones.

The

portions of

the

shaft

which

deprived

are

of

their

cuticle,rough, fissured,or perhaps quite frayed out, form

\
T.a.

If

If

"

few

modern

portions of
disease.

the

There

hair shaft may

been
described

Fig.

shaft,

32,

-Lower

brittieness

part

trichorrhexis

n.) ; scissura
preparation

ofa

*of the

However,
scalp
hair,

nodosa

(T

from

girl of

those

provcd
been

cases

the

at

Same

able to

While

are

appears

Vegetableparasitesto

where

diam.

body

in

\i2i\fe
uevcr

aged twenty-two, suffering from

40.
Magu.
alopecia pityrodes.

parts of the

Hot

in

which

time

the presence

by symptoms

demonstrate

an

of
on

the

myco-

skin,

etiological relation

The

pilor.(S. p.)is derived

sis was
^g

found
investigators
fungi in the expanded
of the
and designatedthem
the cause
as
is no doubt that analogousmetamorphoses in the
indeed
develop on a mycotic base. They have
and figuredby v. Bserensprung in mycosis circihairs

'

nata.

hair

cellent
ex-

for

atmospheric dust; all imaginable granules

accumulate
there, and partlyare so firmlywedged in the fibrous
tissue that no method
of preparationcan
the
altogetherremove
the
ones.
more
dark, chiefly
resisting
Especiallyconspicuousare
of carbon (Fig.31, JT. p.) and the blue ultramarine
angular particles
granules.
A not
inconsiderable
quantity,comparatively,of air lodges
in all the smaller or largerfissures and cavities formed
by the
the
and
of
cortical
oration
the
causes
fibres,
spreading
dull-graycolof the expanded portionsof the shaft. In mounting the
air is displacedby the added
fluid,
specimen, this accumulated
and this takes place the more
rapidlyif the fluid is capable of
completelysevering the loose connection still existingbetween
the
several layers of the cortical substance.
This
probably
the
fact
when
hair
treated
thus affected was
that,
a
explains
with concentrated
acid under
the microscope,a number
of very
largebubbles were
disengaged,while from a healthy hair only
small
air-bubbles
that gas probably
arose.
Beigel concluded
within
the
hair
the
lary
developed
by
decomposition of the medulsubstance.
But this condition
is largelynoticed also in
hairs which
trace
have not even
of a medullary cylinder a
a
fact which
alone demonstrates
the untenabilityof the hypothesis.
traps

the

trichorrhexis

Studying this
above-described

aff cction,

roundish

present in greater number,

dull

and

lustreless

Charite-Annalen,

Bd.

nodosa.
we

the

throughout, and

vi.,1, PI. 2, Fig. 3.

become

convinced

swellings of the
growth of hair on
has a dry feel ; we

that
^

"

shaft
such

find.

AND

ATROPHY

OF

DY8TK0PHY

THE

431

HAIE.

perceptibleon many
imperfectly developed

atrophy or premature senilityare

or
hairs (cornified,
often frayed-out hair-bulb, absent
narrow,
medullary cylinder,faultilyformed cuticle). Aside from
the fissured and divided portionsof the shaft,the cohesion
On weighting a
of the hair is not materiallydecreased.
portion of the shaft,which in its external aspectdoes not
degenerated,until it breaks, the torn ends show
appear
ture
a Assuring like the points of fraconly quiteexceptionally
of a portion of the shaft deteriorated by trichorrhexis
tained
nodosa ; but similar appearances
more
are
frequentlyobwith hairs exposed to an equable flattening
pressure
such as may be exercised,perhaps,by a spring.

Ijesides,that

few

remain

words

trichorrhexis

of

symptoms

added

to be

about

the

fact that

chieflyobserved on
the hairs of the beard.
This is explainedin part by the
is nearlytwice
fact that the beard hair,which on an average
thick as the scalphair,makes the correspondinglylarger
as
roundish
swellingsappear more
conspicuous. While the
due
of the cortical substance
to the disintegration
nodules
be felt, but hardly seen
thin scalp hair can
at most
on
with the unaided
hair, owing to their
eye ; on the beard
form, size,and indefinite grayish color,they are not rarely
mistaken
for eggs of pediculi. However, the beard
even
to possess a real predisposition
to this alteration
hair seems
to
its
its
natural
thickness,
curliness,and its more
owing
flattened shape going hand in hand with the latter (Henle).
To
resume
brieflythe views laid down in the preceding
pages :
1. The

nodosa

morbid

hitherto

above-described

of the

course

has

hair-shaft

been

expansions and
not

are

fissures in the

separate diseases,but

the

expressionof an abnormal
dryness
and brittleness of the hair due to atrophy.
and division of the shaft into
2. Broom-like
fissuring,
larger longitudinal splintersare
equivalent processes ;
both are initiated by loss of the cuticle,they are often combined,
and largelymerge
into each other.
directly
3. The
region of the beard is the place of predilection
symptom

of

"

trichorrhexis

scalphair
there only on

the

is

by

no

account

nodosa,

means

of

rare,

the

but
and

smaller

its

occurrence

is less

on

Fig.

scalp
B,

conspicuous

dimensions

of the

cotton

specimen
young
32.

nodules.

hair

33."

Nodulus

Assured

laqueatusof
in its lower

fibres; F, feathers.
is derived

girl as that
Magnified 90

from

The

the

illustrated

part.
same

in

Fig.

diameters.

Therapeutically,
shaving of the hair is useless. A rational symptomatic treatment
to aim at counteractingthe pathological
dryness of the hair, and for this purpose
be recommended
the systematicoilingafter -precedingremoval
may
of the fat, described in detail under
alopeciapityrodes.*

will have

Schwimmer

ointment

rubbed

in

believes
:

Flor.

morning

that

he

zinc, 0.5 gram

and evening.

secured
;

Flor.

improvement in
sulphur.,1 gram

one

case
by the applicationof
M.
Ungt. spl., 10 grams.

ing
the followS.

To

be

432

ANOMALIES

We

add

hair, occasionally combined

The

with

hiding-places for dust

also

are

caught therein
of these

production

observed

them

Obviously

THE

once

hair

examination

knots

transform

the

to

appears

hair

of

the

laqueatiarise

with

shows

feathers, and

less remarkable

us

pubic region and

a
purely mechanical

in

into

than

is

condition

This

within

cotton

fibres and

curly scalp

the

loops form
similar

upholstered miniature
to Duncan

for the

from

strongly perspiring persons

deposit apparent

to

even

Bulkley, who

eggs

awkward

jects
ob-

nests.

of

morpiones.

combing

ranging
disar-

or

classified

Smith

observed

adhere

masses

substance

directly to

the

here

are

which

the

covered

for

and

there

barbed

like

quite resistant

are

to the

cortical

barbs, crystallized upon

influence
of profuse sweats; it

to the macerating
trichoptilosis,introduced

term

found

places by roundish, various-sized

is to be attributed
under

times

at

are

macroscopic inspection.Microscopic

surrounded,

These

aptly

very

rather

spaces

them

way

hair-shaft.

dry and

it does

mistook

peripheral layers of the cortical

the

alkalies.

and

it were.

as

noduli

sheath-like, in many
of cornifled,non-nucleated, yellowish-colored masses

acids

be

may

that

of these

some

of the

fingers.

the shaft

that

convolutions

them,

HATE.

of trichorrhexis.
The
symptom
tiny feathers, colored and uncolored

2. Axillary and
genital hairs of
nearly their entire length with an uneven

of

THE

OF

the

and

the

on

noduli

our

the

action

COLOKATION

the descriptionof other, in part only apparent, expansions

such
noduli
knotting. I have repeatedly seen
laqueati on

1. Real

excellent

by Devergie

for

similar

conditions.^
3. Walter

on
a nineteen-year-old,
formerly healthy girl,a shortening and thin,
swellings (six to thirty-six on one
regularlyarranged fusiform
hair) of

ning of the scalp hair, with

the

of about

shaft

swellings
but
not

millimetre

one

to

slight tendency

nodes

hard

the

continuity

; if the

parts the

hair

was

darkly pigmented

more

(ringed hairs ? M.).

opposed

to

broken, it

was

merely seated

were

on

the

Within

trichorrhexis, the

was

cuticle

through

never

node,

the
had
was

Pathological Society preparations from cases

contained
of
a honey -like mass

scalp hair, and

interprets this disease

Morris

pigmented, spore-likecells.

London

the

laid before

Morris

Lastly, Malcolm

4.
in which

rupture

As

fungi.

nor

these

appearance

smooth.

but

frayed out,

On

speckled

cell accumulations

neither

were

circumference.

in

brownish-white

presented a

thus

and

as

the

result

of

the

application of

some

slimy hair -oil (?).

The
loss of

COLORATION

THE

IN

ANOMALIES

of

congenitaldecoloration
pigment of the skin, will

the

OF

hair, as well

be discussed

in the

as

THE

the

chapter

HAIR.

whitening
"

Anomalies

associated
in the

with

tion
Colora-

of the Skin."
delicate

The

by

accordingto Wilson^s

"

shaft,being

by

and

brown,

to

coal-black

tensity
also on the inaffectingthe hair act injuriously
in
the
the
hair
of
lowest
even
regularchange
ment
segguished
end of its typicalduration of life,is generallydistin-

near

the

rows

all the elements

in its fibre-cells ; there

of the

uniformly
hair, and is especially

is found, besides,granular

pigment

between

of cells.

Colorless hair appears white according to physicallaws, owing to the unevenness

quantityof which is usuallycontained
its surface and the air-bubbles, a moderate
the
cells ; according to the degree of
between
every hair, partly within, partly
1

R.

Comp.

in "Handbuch
"

"

On

hair is also of greater thickness.

fainter coloration.

distributed
the several

darker

is graduallyreplaced
During puberty the color

hair, and

saturates
pigment-substance

The

into the world

comes

disturbances

of the

of the color
of the

the

measurements,

of the nutritive

Most

child

colored hair.
distinctly
faintlyyellow,through red

more

varies from

hair

human

of the

the

which

hair with

vigorous,thicker, and

more

the

Pfafif, Das
"

d.

menschliche

Haar, etc.,"2te Auflage, Leipzig, 1869, p. 72; and

v.
Maschka, p. 521.

gerichtl.Medicin," herausgegeb.

Management

of the

Skin," London,

1847, by Henle, 1. c, p. 32.

of
in

pig-

Oesterlen

ANOMALIES

ment-defect

and

THE

IN

COLORATION

various
air-contents,

shades

OF

THE

of color,from

433

HAIB.

to

gray

whiteness,

snowy

arise.
SENILE

The

AND

decoloration

gradual

stated,the alopeciainduced

PRESENILE

of the

DECOLORATION.

hair, the whitening, usually precedes, as

above

the senile alterations of the

skin; generallyit shows itself

first on the temporal,then in the beard region,and
constant
so
a
symptom is it of the
senile involution of the body that it has not without
been
termed
reason
physiological.
The decolored hairs are few in the beginning,but become
more
plentifulin the course
of years ; in the mean
intense,the stillblond

by

time, the decoloration

dark

the

beginning decoloration
at the pointed part of
pieceof hair, it produces,as
of another

hairs

of the several

hairs becomes

gray

more

longer tinged as stronglyas formerly,

first
ally
usually
manifesting itself at the lower, only exception-

or

the

even

are

shaft.

no

After

the hair-follicle has

formed

once

rule, in the further

in consequence

growth of the same,

typicalchange of hair, again

of the

or
a

a gray
substiin the tution

gray hair

(Pin-

cus).'
Upon microscopicexamination, it will
gradual decrease of the pigment-contents; in
blanched

hair, there

often

are

between

the

be found
that the process
the still faintlycolored, but

several

is based
not

completely

of cells still rather

rows

on

numerous

pigment granules.
The

hair of younger
also turn
persons may
gray in a manner
This presenile
decoloration often takes place in

canities senilis.

quite analogous to
wise
growth of hair otherfrom
the complication

free
remains
absolutelynormal, which, in many instances,
for
to
the
most
advanced
alopecia
decades, even
age."
The
of pigment in senile and
insufficiency
premature whitening is usuallyascribed
to the papilla having lost its pigment-producing
in
of which
power,
consequence
the hair-tissue is ''pushed ouf
deficient or lacking in color.
also
We
assume
might
that it is not the papillawhich
has lost the power
of producing pigment, but the haircells which have lost the capacityof imbibing it, Both
these factors,however, do not
suffice to explain

with

'

"

THE

authenticated

of which

examples

SUDDEN

have

compositor, aged thirty-four years,

delirium

tremore.

cum

Until

WHITENING,

of
especially

admitted

improvement

by terrifying pictures of the imagination.

of the head

and

beard

Brown-Sequard
few

white

hairs

of the

In

he had

morning

one

not

noticed

in his

the

reportedby competent

servers.
ob-

of
hospital July 9th, 1866, with symptoms
mented
set in (July 13th). he was
continually torthe hair
the night preceding the date named,

to

patient, formerly blond, became

discovered

which

to

began

late been

face, on

day before.

gray.

places of his dark beard, a

epilated them, but two days later he

symmetrical
He

in the same
the right three, on
again found
the left two
hairs which
were
region on
gray
The
throughout their whole
others decolored
length, besides numerous
only at their lower ends.
experiment of pulling out all the gray hairs was
several times repeated with a like result during the
five

next

'
*

is

or

six weeks.

Brown-Sequard

L. c, p. 181.
In senile canities,we

proportionateto

find among

the total

closes

the

his brief

perfectlywhite

communication

hairs

on

this

larger number

loss,or perhaps to the completely colored

hairs

subject with

of short

these

hairs than

(Pincus, ibidem).

3
It might also be investigatedwhether
the abundance
of pigment
in the senile skin is not in.
with the fact that coloring matters, originallyintended
part connected
for the hair, are again taken

into the circulation

28

and

depositedelsewhere.

434

ANOMALIES

words:

"Ces

experiences

(probablement

likewise

Raymond

mettent

COLOKATION

THE

hors

de

doute

nuit) de pollsnoirs

d'une

moins

en

reports (1.c.)a

la
en

THE

HAIR.

possibilite d'une

transformation

tres-rapide-

poils blancs."

of sudden

case

OF

observed

whitening

by himself

together with

Vulpian.
In view
the

of

well-authenticated

so

of sudden
possibility

observations,it appears

whitening,

nor

neitner

judiciousto

for its illustration to go back

necessary

doubt
to

the

older, in part exaggerated cases.

examination

Landois

of the

hairs of the patientfirst mentioned

above
of the hairs of a man
turned
had
pigment contents
over
night
gray
remained
due
to
unchanged, and that their predominating white color was
an
solely
in the hair-shaft.
excessive development of air bubbles
unanswered.
We
Despite this positivedemonstration, several questions remain
such
immediate
circumstances
neither what
know
an
produce
abnormally largeamount
wherein
the persistence
of the canities,after its sudden
of air within the hair,nor
tion,
producAccurate

showed

that

by

the

finds its

cause.

WHITENING

CONNECTION

IN

WITH

ALTERATIONS

OF

THE

NERVOUS

SYSTEM.

the sudden
nection
whitening into conbrings the premature, and especially
emotions.
We
might instance the German
expression
depressing mental
lassen
Haare
iiber etwas wachsen
Sich graue
(to worry one's self gray).
scientific basis by the fact that alienists have
This popular view has gained some
observed very rapid whitening of the hair in melancholiacs.
over,
Neuropathologists,moretions
that not only psychical,
but also several other central and peripheralalteramaintain
of the nervous
system may produce decoloration of the hair.
facial atrophy, the hair often falls out, or its growth at least is
In circumscribed

Popular

belief

with

"

*'

'

largelyreduced; in other cases, however, the disease of the hairs manifests

itself in a
only stripsof the scalp,or of the eyelashes
affectingsometimes
the entire affected region. Berger reportsa whitening of the hair
and brows; sometimes
to the paralyzed right side in post-typhoidhemiplegia.
and face confined
of the head
record of local decoloration of the hairs of the scalp,the eyebrows
Communications
are
on
of the trigeminus,especially
the suprain neuralgiasof isolated branches
and eyelashes,
orbital
also
hear
stances
of inall
these
of
we
While
decoloration,
are
cases
nerve.
permanent
with
the
the
of
hairs
in which
occurs
singleneuralgic attack,
a partial
whitening
neurotic
and again disappears. Less clear is the dependence of regionalcanities upon
more

or

less

decoloration

influences

in the

followingcase.

of
After traumatic
ophthalmitis of the left,and sympathetic inflammation
of ciliae of the right upper
observed
a group
nine-year-old,vigorous boy, Schenkel
lid of the (enucleated)left eye turn
the lashes of the upper
silvery-whitewithin

the

right eye in a
nearly all

lid,and
a

very

short

time.

canities is universally
importance of inherited tendency in the gradual presenile
if
if persons with
as
hereditaryneuropathic taint,even
recognized,and it almost seems
otherwise normally constituted,are pre-eminentlyprone to earlypoliosis.
The

OF

DECOLORATION

THE

HAIR

COLOR

Quite

by

different character

the decoloration
1

of the hair

Birch-Hirschfeld,

from

OF

the forms

Lehr.

d.

CHANGE

OF

THE

HAIR.

THE

seen
occasionally
"

DISEASES;

GENERAL

WASTING

AFTER

of

hitherto
poliosis

in connection

pathol. Anat.,"

p.

with

is presented
wasting general dis-

discussed

654, Leipzig,1876.

ANOMALIES

COLORATION

THE

EST

OF

THE

435

HAIR.

but which
usually happens that, after a rapidly developed alopecia,
subsequent growth of hair is quite or
a comparativelyshort time, the
generallypersists
the unbeen
hair
has
of
once
re-established,
If the t3rpical
almost colorless.
change
of time be replacedby pigmented ones.
colored hairs may in the course
the start, or after a transitional
from
At times, however, the after-growth shows
ported
stage of decoloration,quite a different tint from that of the former hair. We have rein the
such case
above (p.419) ; analogous observations are repeatedlyfound
one
it

Here

eases.

literature.
Of

specialinterest

The

black

the

of

fever, and

malignant
became

hair

reportedby Compagne.'

case

began

aged thirty-six years

day following was

woman

a
on

the

on

fourteenth

day

fade

to

perfectlywhite

the sixth

again, and

darker

is

after

first

the

twenty-third day

the

on

but

change

of

on

color

of

day they

seventh

the

they ha(i regained

original black.
Such

temporary disappearanceof the normal

easier of comprehension since
that a sudden
development of gas may

the hair has become

shown

has

color

of

Landois
lead to

whitening.

PATCHY

It has

alreadybeen

formed

once

thereafter

OF

WHITENING

stated

decolored

only

HAIRS.

SEVERAL

that

matrix

the

which

has

piece of hair, as

hair;

gray

THE

very

there appears here and there

segment, after the hair has

on

a rule, produces
exceptionally,however,
singlehairs a pigmented

been

formed

colorless

for

months.
for the
a very great rarity
decolored in patches.

major part

It is
to be

Eichelot

sufferingfrom
the beautiful
a

observed

of

case

hairs became

brown

of two

distance

the

chlorosis;
during the

the

girl aged seventeen,

majorityof

disease the

white from

After

inches.

of the hair

the

i^

their roots to

chlorosis

normal

was

cured,

the
color,
after-growthregained
to
the
white
extent
named.
This
last observation
were
only
be best explainedby assuming that the hair
can
matrix had interruptedits pigment-formingfunction for a
it as soon
the regular nutritive
as
time, and had resumed
But the temporary supply of
conditions had been restored.
the

so

that

hairs

colorless material

only way

in which

effected. We
Landois

for the

of
building-up

patchy decoloration

know

that it may

the

from
be due

the hair is not

observations

also to

the

*-^
_

of the several hairs is

of

Spiess and
interstitial development

Fig.

patches
transmitted

34.-- Hair

(ringed

"vfhitened

hair).

in

A, by

light;B, by reflected

light (after Landois).

of gas.
Karsch

of a laborer,
reports (1.c, p. 34) the case
aged nineteen years, in whom
hair
the
consisted
of
of
b
rown
and
white
tions
scalp
alternating
every
rings. Similar alterafound also on the hairs of the rest of the body. On
were
microscopicexamination
1

"Handb.

schweig, 1830.

d.

Anat.,"

v.

E.

Hildebrandt,

herausgegeben

von

Weber,

4.

Aufl., p. 200.

Braun-

436

ANOMALIES

of the

hair

Landois), the
(Spiess,

white

by

added

to the

reflected

fluid

the

hair after

brown

When

light.

THE

white

been

touch, that the hair-shaft

at

the white

the

on

HAIE.

dark

by

transmitted

light,and

microscope penetrating fluids

white

microscope

expanded

was

THE

spots appeared

cut

besides, the

ones;

OF

the stage of the

on

it had

COLORATION

the hair tissue, and

saturated

adjoining

IN

spot, air-bubbles

patch

assumed

confirmed
white

the

the

color

same

observation

patches, where

made

it

were

disengaged,

were

as

the

by

the

distinctly,

was

though slightly,thicker than on the brown spots.

In order
to explain the origin of ringed hair (piliannulati
Karsch), Landois (1.c,
intermittent
that
the
irritation
has
formulated
of trophicand
an
hypothesis
by
2)
motor
vaso"

''

gas takes

is formed,

hair-tissue

nerves,

within

which

periodicinterstitial development

of

place."
Treatment.

the

In

of

present state

hair.

the

canities

of canities upon

having
we

According

head

the

with
The

quantity.

pigment-forming
dispositionto

the

which

which

results

idea

"of

hair," Eble

of the

yolk of eggs,

good

for the

even

other

very exceptionalcases
affection is probable.

With

pigmentation

anointed

but

in the

the

on

oily ingredient.

for the

it lacked

which
had

treatment;

to

only

analyses (Vauquelin '),the

old chemical

an

can

be able to check

might

to

we

fundamental

curable

as

iron, and

amenable
available

be

direct influence

of such

do

of whitening
disposebrieflyof the treatment
explanation is required to show that the ^^physiological"

further

No

senilis is not

therapeuticswill

of science

is well
both

color

and

of

Pfaff

authors

know

the

hair

the

body

gave

these

contain

to

of

claim

for

of

the

whitening
dependence

little of

as

hair

the

development

supplying
known

We

function

the

forms

in which

to contained

with

those

metals

this method

as

of gas.

is due

sulphur

edies
rem-

matrix

phur,
sul-

substances

internallyand

and

iron

in

of treatment

siderable
conare

probably illusory.
The
To

this

the abnormal

due

in cobalt

occupations (bluecolor
method

The
cassise

of

extent, and

some

health

or

all other

oleum

at

best

at least

on

the

of very

growth

Clever

coloration
and

darker

temporary
bismuth)
of the

hair-dressers

stuffs

lustre

benefit.
have

hair.
secure

At

the

supplied

of the hair connected

indigo workers,

macidis, is harmless,

silver,and

copper,

hair-dyes.

hair

giving the

cinnamomeaj,

sulphur, iron,

qualityof absorbing dye

the

hair possesses

qualityis

in copper

green

by anointing with
but

insufficient

without.
industrial

some

workers).

oleum

where

it from

to

with

nuc.

the

Jugland.,

canities

has

oleum

gained

The
metallic
dye stuffs (combinations of lead,
the
on
reputation of having injurious influence

present it

seems

by it,according

that
to

the

nitrate

of silver

concentration

has

displaced

of the

solution

various
of its action, the most
shades, from
light-blond to deep black.
employed and the duration
The
by moistening the hair with a solution
application of the silver nitrate solution is to be followed
for black, the
tint is intended
to be produced;
a blond
of levigated sulphur (about 3 : 100), where
Since the toxic
of 0.5 : 800.
is to be replaced by pyrogallic acid in a concentration
latter substance
of this agent.
is to be advised
in the use
has become
caution
effect of pyrogallic acid
known,* some
of lead preparations is to be directlydiscountenanced.
The
use
in
silver nitrate, alone
assured
that dyeing the hair with
or
I am
by thoroughly reliable persons
with
combination
sulphur, has absolutely no injurious effects.
said to be inapplicable because
off too readily.
colors are
Anilin
they are washed

u.

' Annales
de Chimie, T. Iviii.,
1806, Avril, pp. 41-53; translated
Physik, 3 Bd., 3 Hft., No. 7, by Eble, 1. c, p. 63.
"

Neisser, Zeitschr.

f. klin.

Medicin, Bd.

1, Heft

1, 1879.

in Gehlen's

Journal

fiir Chemie

438

PIGMENT

HYPEETEOPHY.

togetherthose congenitalalterations of the skin in which

augmentation of pigment, but in which other
the
the
the
of
layer,may also be hypercorium,
papillarybody, the corneous
skin,
parts
sub-classes
nsevi
smooth
two
into
be
the
divided
for
nsevi
present
trophied. Hence
may
with
abnormal
in which
have to deal essentially
an
pigmentation,
we
only
(N. spilus),
in which
other parts of the skin are at the same
time
naevi (N. verrucosus),
and verrucose
this title we

Under

is

group

present,in the first place,a circumscribed

"

more

or

less

hypertrophic.

naevi may

Verrucose

be still further

subdivided

meet here with

and molluscif ormes
cornei, pilosi,
; but as we
papillosi,
and transitions,it is impossibleto strictly
combinations
carry out such

the

into

most

ngevi

manifold

division.

of naevi of the
etiology
by
acterized
nerves
(naevusunius lateris,v. Barensprung ; papilloma neuropathicum, Gerhardt),chareither
smooth
or
of formations
corresponding to the other,
by the occurrence
the cause
several cutaneous
confined to the regionof one
but strictly
or
nerves,
verrucose,
be ascribed to an intra-uterine trophoneuroticdisturbance.
of which, consequently,must
naevi representsimple pigment spots,varying in size from the head of a
The smooth
pin to the palm of the hand and even larger. Generallythey are sharplybut irregularly
surrounded
by a border which, though darker than the
demarcated, and are sometimes
be
naevi may
These
normal
skin, is still lighterthan the central portionsof the naevus.
for certain sites can
be observed.
found on any part of the body, and no predilection
They
skin and mucous
the pointsof transition between
membrane, on the
not rare
even
on
are
border of the lips,and on the glans penis. Their color is yellowish-brownor
vermilion
tint of the verrucose
attains the dark, often blackish-brown
and
brown,
hardly ever
have

We

a
finally

third one,

its

sharplydemarcated

"

that

forms.
examination

of these spots shows

that, besides

an
abnormally great
less great
there is also a more
or
deeper layerof the rete mucosum,
of pigment in the corium, and, according to Demieville's
accumulation
investigations,
of the blood-vessels
of
cells
the
in
cordlike
a
course
following
agglomerations
mostly
of pigment depositsin the adverititia of
fact which, togetherwith the frequentpresence
the vessels,renders still more
probable the direct originof the pigment from the blood.
of naevi,during extra-uterine
life
fiat pigment moles, as also the other forms
These
of
the
them.
wise
Otherto the enlargement
occupied by
territory
grow only in proportion
no
change is to be observed on these spots. The skin at these places functionates
for their
quite normally,no desquamation occurs, and the nsevi are of no consequence
bearers, aside from the disfigurementand the danger of the development of malignant

The

anatomical

pigmentationof

the

'

"

tumors.

The

second

the

group,

slightlydeveloped, they
warty surface,are

naevi,presentthe

verrucose

are

but

light to

little elevated
dark

above

blackish-brown

most

the
in

manifold
normal

color, and

appearances.

skin ; have

an

If
even,
un-

generallycovered
a
papillomatous

stronglydeveloped cases, they assume

Sometimes
separatedby deep furrows.
layer,every singleprotuberance
they present considerable hypertrophy of the corneous
in thickness.
These
forms,
being covered with a horny mass
up to several millimetres
These
circumscribed
in
described
instances
been
have
as
numerous
ichthyosis."
indeed,

with

hairs.

numerous

In

more

character, the several elevations being higher and

Pigmentflecken derHaut,"

"

"Ueber

"

Flittner,

p. 653.

"

Ein

Fall

von

umschriebener

Virch.

Arch., Bd., 81, p. 333.

Arch.
Ichthyosis cornea."

f. Dermat.

u.

Syph., 1870,

PIGMENT

439

HYPERTBOPHY.

naevi with

surrounded
stronglyhypertrophic corneous
layer are sometimes
by a narrow
which
exhibits
the skin, though thickened,
neither abnormally great pigmentatio
the formation
of horn.
covered with abnormally
nor
They are not found
gree
strong growth of hair, but generallyonly with a few lanugo hairs. In the highest deof development, in which
connective
tissue likewise participates
the subcutaneous
formations.
even
or
The
materially,there finallyarise actual tumors
elephantiasis-like
border

within

latter may

The
others
the

size of

reach

functional

true

cause

these naevi varies

the size of

disturbances, for

extremely.

instance, when

Some

small, no

are

dollar,of the palm of the hands

surface

eyelidsare

largerthan
even

whole

fected.
af-

lentil ;

regions of

of the

At
body is occupied by them.
their
quent
subseassume
slightlypigmented,
gradually
usually
dark
The
color.
are
are
mostly solitary,but sometimes
larger ones
multiple.
They do not enlarge,aside from the normal growth correspondingto the development
of the entire organism.
The anatomical
is extremely variable,hut at all events we
structure
have always to
deal only with true hyperplasise,
with heteroplastic
formations
of tissue.
never
Opposed to the forms thus far discussed is the third group, separated from them by
the etiological
that of the naevi of the nerves.
This form
factor
has become
better
known
described
it as Naevus unius lateris,
and
in analogy
through v. Barensprung, who
with zoster assumed
intra-uterine affection of the spinal ganglia. Since
for its cause
an
that time
has been reported,among
series of cases
whole
a
others, by Neumann," who
givesa complete bibliography.
In these cases
find flat or verrucose
we
naevi, often forming large tumors, the first
of which, the one-sidedness,is expressed by the name
obvious peculiarity
chosen
by v.
Barensprung. The distribution always correspondsto the regionof either the trigeminus
of one
In Neumann's
or
or
entire
cases
even
frequentlyof several spinal nerves.
one
half of the body was
darkly pigmented and partlycovered with papillaryproliferations.

body, in

birth, these

some

cases

almost

nsevi

the whole

; often

the

and

but

are

"

'

In such

the whole
find
form

of course,

cases,

central

more

part

nervous

field of distribution

look for the

system. As,

cause

in

not

coincides

with
exhibit

Two
related

the distribution

other
to

no

spinal ganglia,but in a
on
by no means
nerves
we
usually

zoster, vesicles appear

of the affected nerve, so in naevus
of the

of the

These

nerve.

altered
the

parts ; often

the

latter

generalarrangement always

naevi,too, aside from

the

normal

alterations.

forms

of local

naevi,the former

first place there

the

in

the
entirelynormal
portions of the skin between
only small islands in the otherwise normal skin, but

growth,

the

must

we

of the

pigmentation,lentiginesand ephelides,are
can
especially,
hardly be separatedfrom

of which,

very closely
In
them.

essential anatomical

differences,and in the second place,even

that lentiginesoccur
uterine
separatingthem
only during extrawhile the congenital
formations alone can be included among
life,
the naevi
will not
bear close scrutiny. For not rarelyit may be observed that pigment spots
in
appear
at precisely
the same
after-years
placeson which similar congenital anomalies are found
the most

are

no

for

weighty reason

"

"

in the parents

or

brothers

1
'

and

sisters of these persons.

This

fact cannot

Charite-Annalen, 1863, Bd. xi., Heft

3.

Oestr. Jahrb.

ii.,p. 165.

f.

Padiatrik, 1877, Bd.

be

explained in

440

HTPEKTKOPHY.

PIGMENT

other way

than

congenitaldispositionwhich did not develop until a

of ephelides,
from the fact that they develop
case
subsequentperiod. And so
with such extraordinaryfrequency in persons
with a certain color of the skin and
hair,
in drawing the conclusion
that in them
there is likewise a congenital
we
are
Justified
which
does not declare itself in after-life except after the action of external
disposition
any

by assuming

also in the

causes.

either isolated or in largenumbers.

Lentigenes occur
They have no particularplace
and
met
with
of
the
be
on
predilection
body. Of course, they are most
any part
may
less
Some are flat,
others more
or
elevated,and in that case usually
conspicuousin the face.
of dark, thick hairs.
set with a number
Lentigenes,indeed, can
only be distinguished
from
congenitalnaevi,both flat and elevated, if the beginning of the former has been
observed
during extra-uterine life. But if they are present without our knowing when
have
appeared,they cannot be distinguishedat all.
they
By ephelides,freckles,are meant those small pigment spots which seldom exceed the
size of a hemp-seed, never
hibit
singly,but always in large number, and generallyexappear
Their form
is irregular,
and the outlines are generally
a quite definite localization.
in the face, on the hands
and
slightlyserrated. They are met with almost exclusively
the
which
of
and
observed
that
are
are
on
uncovered,
is,
body
usually
parts
arms,
very
In the latter case the persons
in
rarelyon covered parts,as the penis and the buttocks.
usual
Their
placesof predilection.
ephelidesalso on the
questionhave always numerous
dark
in the
color is never
as
as
yellowish-brown,at any rate never
very dark, but chiefiy
increase of the
Anatomical
examination
shows that there is essentially
an
warty moles.
of pigment in the corium.
epidermal pigment, without any accumulation
but
at
are
never
birth,
usuallydo not develop before the sixth or
present
Ephelides
while they fade in winter so
of
life.
eighth year
They are conspicuousonly in summer,
to be barelyperceptible. In later years they generallydisappear again. They are
as
who
in brunettes, but extremely frequent in red-haired
rare
generallyhave a
persons,
of

remarkably

clear

complexion.

unquestionablethat ephelidesrest on a
which
requirefor their development
influence
certain external
of
t
he
conditions, especially
light. I believe that this is
the most natural explanationof their occurrence
chieflyin certain individuals, and of the
Hebra
has expressed
localization and the variations in intensity
accordingto the seasons.
also on
observation
under
because
himself against this view, especially
ephelidescome
for
is insufiicient,
this negativereason
not exposed to the light. But
are
parts which
In

view

of

all these

facts,it appears

to these
congenita]disposition

there
not

are

other

cases

directlyaffected

in which

by

to

me

pigment formations, but

there is

the agent

an

influence

producing

the

on

distant parts of the skin which

are

pigmentation.

regardsthe prognosis,naevi and allied formations are generallyof no importance;

in a few rare
prognosis. On the one
still,
give rise to an unfavorable
cases, they may
time
found at the same
nsevi were
have been reported in which
numerous
hand, cases
selves
the other hand, the naevi themin internal organs,"and, on
sarcomata
with melanotic
sarcomata
melanotic
likewise,
into
ally
especitumors,
malignant
usually
develop
may
As

after

the influence

"

Jablokoflf

Benzler:

and
"

Die

J.

of any

external

irritation."

Klein, Vierteljahrschr. f. Derm.

Naavi

als

Ursprungstatte

u.

melanotischer

Syph., 1879,

p. 632.

Geschwulste."

Diss.

Berlin, 1880.

PIGMENT

The
the

therefore,vrillhave

treatment,

the

441.

HYPERTBOPHT.

to

indications

fulfil two

"

the
firstly,

removal

of

of the naevi
disfigurementproduced by
of the danger of the development of malignant tumors.
There are indeed some
remedies
by which the pigmented epidermis can be removed,
after the employment
of which
the new-formed
epidermis contains at first less pigment
than the preceding. These are some
acids, the caustic alkalies,and particularly
corrosive

pigmentation,and

secondly,the ablation

account

on

and

In the

sublimate.

of flat naevi and

case

pigmentations to be discussed

ephelides,as

hereafter,the sublimate

well

as

of chloasma

is best

and

in

local

one
or
employed
per
place,or by dipping a
piece of linen the size of the spot to be decolored into the solution and keeping it there
for four hours, during which time it must
not be allowed to become
dry. This is Hebra's
Then
direction.
follows a more
less violent exfoliation of the epidermis,while the
or
nately
new-forming skin is colorless or slightlypigmented. However, this result is unfortuof short duration, and after a number
of weeks the pigmentation is again as intense
before.
A definite removal, therefore,will be possibleonly by operation. It is selfas

solution,being either painted repeatedlyover

cent

evident

that the latter

alone

course

the

will be effectual when

two

affected

the formation

of actual

tumors

has taken

place.
As regards the second
indication
preventing the formation of melanotic tumors
it would
all naevi and lentigines,
unless insuperable
reallybe most appropriateto remove
obstacles are
has a large
presented by their size;but inasmuch
as
nearly every man
"

"

number, this is of
to
no

other

The

course

such

remove

matter

formation

of

But,
impossibility.

which

manifests

notable

at any

rate, it will be imperative

enlargement, even

if there is

alarming symptom.

anomalies

pigment

thus

far considered stand opposed to a series of others which

congenitaldisposition.These are, first,the pigmentations
and pathological
conditions of the body; second, the
occurring with certain physiological
of external
and lastly,
pigmentations arisingin consequence
those remaining
irritations,
indeed

rest

on

no

kind

of

after diseases of the skin.

The

term

chloasma

gravidarum or
spotswhich
appear

chloasma

uterinum
is appliedto those pigmentations
also on other
chieflyin the face, in rarer
cases
those sufferingfrom
disturbances
or
of the geniparts of the body of pregnant women
tal
The most common
localization is in the face; the forehead and the temporal
organs.
regionsbeing most frequentlyaffected. The discoloration forms largebrown spots with
sharp irregularlimits ; on the forehead they usuallyreach close to the hairy scalp,from
which, however, they remain
separated by a narrow
light stripe; less frequently
they
and
the
the
the
the
cheeks,
around
mouth.
Often the spotsreach
parts
nose,
occupy
the size of the palm of the hand, at other times they are
smaller, and then usuallyappear
symmetrically; in the largerones there are often lightstripesor islands. In rarer
also on
other parts of the body, occasionally
cases, similar spots occur
there may
ensue
even
a darker
pigmentation of the entire surface of the body.' This discoloration imparts
to the face quitea peculiarchanged expression.
That these pigment anomalies
are
reallyconnected with the functions of the genital
is
certain.
in girlsbefore puberty,they recur
occur
apparatus perfectly
They never

occurring in

in

many

they

women

with

every pregnancy,
the menopause.

finally
disappear at
'

Rayer:

"

Trait,

des

mal.

after the
In
de la

termination

the
peau."

same

way

of which
we

see,

in

Brux., 1836, p. 388.

they fade, and

sufferings

women

^2

PIGMENT

from

uterine

some

the former

disease

trouble,the

and

HYPERTKOPHT.

affected

latter likewise

with

chloasma, that, with

the

from

recovery

disappears.

The

of these accumulations
of pigment are altogetherunknown.
proximate causes
local pigmentationsare observed in the train of certain exhausting diseases,
The
cachecticorum.
particulary
phthisispulmonum, whence they are called chloasmata
pigmentations, especiallyof the skin of the face, in congenitallysyphiliticchildren
also would
this head.
observation
These
under
belong under
forms, of course, come

Similar

both

in
To

and

men

women.

these alterations

which
known

in

is the

"

to be added

are

termed

are

chloasma

tanning"

the

pigment changes induced

caloricum, toxicum,

of parts of the

body

which

after

and

by

external

traumaticum.

tions,
irrita-

Generally
exposed to the

long and often

prolonged sojourn in the country, but
after tours across
is heightand
the sun's power
fields
of
where
especially
snow
glaciers
ened
the
reflection.
For
the
in
and
face
by
same
neck, the
country people,the
reason,
far as they are exposed,the feet and legs,often also a part of the chest, become
"arms
as
in summer
These
quitedeep brown, so dark that the color often equalsthat of a mulatto.
colorations fade again in winter.
The influence of sunlighton the development of pigment has been pointed out above
under
ephelides,and it becomes manifest, furthermore, if we simply bear in mind the
fact that the inhabitants
of the hotter zones
are
always more
darkly pigmented, while
the inhabitants of colder zones
I
in
inclined
to believe that, in
are
am
lighter color.

lightof

the sun,

this sense,

the

the

as

which, by inheritance
Besides, the

and

of the darker

color

remained
finally

face

in the

hands

races

course

may

of

be

are

looked

long ages,

upon

became

as

chloasma

caloricum,

graduallyintensified

until

it

permanently.
pigmentations of

the skin provoked by chemical

irritations are exceedingly
here only,as the best known, the pigmentations after
frequent. I shall enumerate
the employment of mustard
cantharides,iodine, and chrysarobin. A single
poultices,
of
mustard
for
be followed by an augmentation
minutes
a few
application a
poultice
may
of pigment at the point in question,which
frequentlypersistthrough life. The
may
employment of cantharidal plastermay likewise give rise to these persistentpigmentations.
The

of

chrysarobin is of a different
with the drug are
stained,
placescoming
but the pigmentation extends
the
skin
far
of
over
greater portions
; ordinarilydark
colorations appear most rapidlyin the face, around
the eyes, although it is with special
the
of remedies
made
regard to
containing chrysarobinis never
eyes that the application
to the head, or at least never
should be made.
Chrysarobinproduces a diffuse dermatitis,
the whole
extend over
face
suraccompanied by intense pigmentation,which occasionally
may
of the body, even
if but isolated portionsof it have
been
treated with this agent.
The spots to which
effect of the chrysarobinwas
the most
immediate
directed,that is,
of which
the pointsof the psoriatic,
account
the
other
efflorescences,
or
on
syphilitic,
and
islands
remain
uncolored
on
a
remedy was employed,
subsequentlyappear as light
dark
of this immunity has not yet been
The discoloration
cleared up.
ground. The cause
brownishof the skin after the employment of chrysarobinis generallya very dark
red to brown.
two weeks,
color of the skin is restored in one
or
Fortunatelythe normal
after a generaldesquamation of the epidermis.
to those pigmentationsof the
Finally,we may apply the term chloasma traumaticum
Such pigmechanical
.skin which
external
nature.
about
influences
of
are
a
brought
by
nature.

coloration
For

not

the

only the

skin

after

the

employment

into

direct

of

contact

PIGMENT

mentations

443

HYPEKTBOPHY.

arise at points exposed to a frequently repeated,but not

continuous
may
all
the
lesser
inflicted
from clothing,tools,etc.
Furthermore,
the
injuries
on

pressure
skin almost

always leave small pigmented patches or cicatrices with stronglypigmented

surroundings. (The lesions produced by parasites,and by scratching.) These pigmentatio
by their arrangement and localization,often permit us to deduce from them
if it have been long removed.
their respectivecause, even
that in the chronic cutaneous
diseases accompanied by
It need hardly be mentioned
reach
the
highest degrees (prurigo and intractable pediculi
itching these pigmentations
that is,in patientssufferingfor along time from an intense
vestimenti). In these cases
prurigo or in individuals affected for decades with clothes lice we observe pigmentations
of the skin which
impart to it almost the color of the negro.
may
A partialpigmentation of the skin is produced by a combination
of chemical
and
Baunscheidtismus.
traumatic
This
irritations,namely, by
procedure consists in the
of fine,circularly
applicationof a small scarifyingapparatus with a number
arranged
needles and friction of the wounds
with a substance
consistingin the main of croton oil.
"

"

This

leaves behind

very

neat

small

circles of brown

dots.

diseases which
Finallythere is a whole series of cutaneous
provoke an increase of
pigment, viz.,those which give rise to chronic hypersemias. It is impossibleto specially
enumerate
every disease belonging under this head, because almost every chronic dermatosis
These
produce excessive pigmentation in this manner.
hypersemias and their
may
culation
sequels,the pigmentations,appear most intenselyon parts of the body in which the cirunfavorable
takes place under
conditions, hence particularly
the legs. The
on
ulcers, or the cicatrices left by them, I should ascribe likewise
deep pigmentations around
to the fact that a chronic
condition
has
for
inflammatory
a length of time
prevailed
at these places. The
cause
provoking these ulcers is quite immaterial
as
regards the
secondary pigmentations. In these processes, however, the pigmentation does not rest
simply on an increase of pigment in the deepestlayersof the rete mucosum,
but there
almost
of pigment in the corium
which
are
derived
are
always accumulations
from
the
of the blood in former
transformation
of the coloringmatter
small
extravasations.
in this respect, viz.,lichen ruber and
However, two diseases requirespecialmention
often
brownish-black
The
syphilis.
pigmentations in the former disease are well
deep,
Also as regards syphilis,
known, and I refer to the respectivesection of this book.
it is
fact that the efflorescences on the skin very often disappear while
a well-known
leaving
the papular efflorescences,
not alone those belonging
deeply pigmented spots;particularly
to the secondary period which
heal without
of cicatrices,
the formation
but in a still
those
which
almost
tertiarypapular eruptions
higher degree
always terminate with the
In such cases
find quiteconstantlyat the place of the
formation
of cicatrices.
we
papule
in color, but gradually becomes
a slightly
depressed cicatrix which is at first dark-brown
Mention
has been made
above of the chloasma-like
perfectlywhite.
pigmentations of
syphiliticchildren, and still another alteration of pigment occurring with'
hereditarily
the so-called pigment syphilis,
will be discussed under
syphilis,
a different head.
We
of these conditions, aside from the
can
hardly speak of a treatment
tions
pigmentain syphilis
trial might be made
a
with the above
; however, occasionally
ated
enumerof pigment.
In syphilis,
of course, the most
agents for the removal
rapid absorption
be expected from
of the pigment can
an
and
appropriate general treatment
the
local applicationof emplastrum hydrargyri; but the pigmentations are
much
more
reJbellious to treatment

than

the other

symptoms.

444

PIGMENT

ANOMALIES.

APPENDIX.

ALTEEATIONS

This

OF

THE

SKIN

IN

ADDISON'S

DISEASE.

disease is likewise

accompanied by a great increase of the pigment of the skin,

series of others.
pigment hypertrophy is merely an isolated symptom among
a whole
Although this alteration in the color of the skin yieldsin importance to the other
disease, it still is a very significant
symptoms of Addison^s
it
symptom, inasmuch
as
often appears as the first conspicuoussign of the affection. With the
of
the
tion
affecprogress
the dark pigmentation of the skin likewise increases apace, until it finally
becomes
mulatto.
the
color
of
This
deep bronze-brown,
a
pigmentation,however, is generally
not uniform, but
tint is exhibited
dark
a
particularly
by all those parts of the body
which normally possess a deeper pigmentation than the rest of the skin : the face, neck
and hands, nipples,and genitals furthermore
there occur, as a rule, besides the general
;
coloringscattered over the entire surface of the body, darker spots here and there which
not sharply demarcated, but graduallyblend with their surroundings.
are
The
and
nail-beds
uncolored, which of course
conjunctivaealways remain
duces
proeffect
contrast.
a conspicuous
by
On the other hand, the mucous
membrane
of the mouth
and pharynx often participates
in the discoloration,
exhibit a
grayish spots being formed which occasionally
slightbluish tint. These spots,as a rule, develop by preferenceat points indented
by the teeth.
This affection of the mucous
of darkly pigmembranes
and the scattered occurrence
mented
would
the
the
of
aside
from
furnish a
course
skin,
generalsymptoms,
spots on
differential diagnostic landmark
from
the diffuse increase of the cutaneous
pigment
which
sometimes
in otherwise
occurs
healthy persons, and which likewise occasionally
produces an intense brown pigmentation of the whole surface of the body.
The
anatomical
examination
of the skin has shown
a
very great augmentation of
the epidermalpigment, and
also
in the more
cases
numerous
pronounced
aggregations
of pigment
in
in
the
the
cutis, especially
no
papillarybody. Otherwise
granules
changes have been found in the skin
but the

MACULE

Clinicians have
the

singer/and
ascertained
been

described under
acquainted with a peculiarexanthem
or
as
pelioma typhosum, by Trousseau and Grieof typhoid fever.
Lewin
which had usuallybeen interpreted
as
a symptom
that
stood
in no
relation with
this exanthem
syphilis,as had originally

of

name

C^RULE^.

taches

long

been

bleues, ombrees,

believed.
In

nection
pupils Guiol, Jaquemin, and Moursou, discovered the conthis
has
since
been
of
discovery
phthirii;
peculiarspots with the presence
confirmed
by numerous
observations, as for instance by 0. Simon, but especiallyby
in producing this exanthem
Duguet,^ who succeeded
experimentally.
til
These maculae caeruleae appear as roundish
oval spots,ranging in size from a lenor
to a quarter dollar and often larger,
color;
of a reddish-blue
or peculiardull, dark-blue
they are not elevated and do not disappear on pressure.
They are confined usuallyto

1868, Palot and

his

of these

"

'

Comp.

also

Brest,

arztl.

"Annal.

1882, p. 617.

Liebermeister, this Cyclopedia, Vol.

Ztschr., 1881, No.

de Derm., 1880, p. 544

ii.

14.
;

1881, p. 357, and

Comptes

rend, des

Seanc.

dela

Soc.

de

Biol.,.

446

ATROPHY.

PIGMENT

described

by

him

known

albinismus

as

his

acceptation,and

are
partialis

of

cases

vitiligowere

scl^rodermie

probably

most

of

cases

or

in
vitiligo

the present

cutaneous

rare

very

plaques.
For the present,therefore, we
distinguishtwo groups,
atrophies; the former of which is again subdivided
morphea,

as

of

cases

that

disease

en

congenitaland
into two

acquired pigment

classes,according

as

pigment atrophy implicates the entire surface of the body or merely circumscribed
universalis and partialis,
and
^leucopathiacongenita s. albinismus
portions of the skin
leucopathiaacquisitas. vitiligo.
the

"

The

best

those

affected with

Those
white

this

hairs

likewise

other

no

then

even

only

color of the iris is

of

light.

The

nystagmus.
The
majority of
without

to the

even

are

the

run

usually of

course

same

very

have

or

remarkable

in side view; but

in normal

as

iris is colorless,appearing

The

fineness.

Still not
albino's

if the

persons.

peculiar lightwhitish-yellowcolor,

of the visible blood-vessels.

the blood-vessels
blue

; if for

most

either white

are

red in consequence

blue, but

anomaly

are

silkylustre,and

it

with

affected

diseases of the skin

other
The

with

universalis

strikingappearance
present
laity.
altogetherfree from pigment, their skin is perfectly
less peror
(albinoes),
only here and there it acquiresa reddish tint from the more
ceptible
All
of the skin are
the functions
that
blood-vessels.
quite intact ; it seems

reason,

even

is albinismus

anomalies

three

of these

known

because

rarely the

very

the

meets

eye

iris appears

eye

of the

server,
ob-

gleaming through impart a red color to the iris. However, the

is nothing but a phenomenon
of interference
not due to pigment, but
lack of pigment of the iris in albinoes induces
photophobia and

albinoes

of

are

weakly constitution, but

this

rule

is

by

no

means

exception.
which

of

pigment,
pigment layer of the
We

be

to

seems

very

has

skin

shows

alterations

no

in the

demonstrated

been

skin,

except

absolute

an

sence
ab-

in

choroid, and

in the

the

retina.

of but

know

of the

examination

anatomical

The

factor
singleetiological
for in the majority of

"

rare,

^heredity. Direct
observations

we

inheritance, however,

find

it

phasized
particularlyem-

normally pigmented. SchlegeP cites a

the
from
transmitted
in which
this
was
grandfather to the grandchild.
case
Another
fact, however, proves quite indubitably that the infantile organism is affected
indeed
is still unknown
to us
which
namely, the
by an anomaly of the progenitors,
with
albinotic
and
brothers
sisters
fact that
are
extraordinaryfrequency; nay, more, that
the

that

parents
anomaly

albino

of the

were

"

the

singlealbino among
many
exceptional. I know of a family in
strictly

called
one

of but

occurrence

Moreover, the

normal.
as

should

in

Loango

and

statement

it be confirmed;

for

in

influences, its endemic

than

which

disease which

occurrence,

of

parents

same

six children

are

to

is not
course,

be

taken

into

certain

contagious and not

be explained in
can

"

"

Eble

Ein

Beitrag
:

"Die

zur

Lehre

naheren
von

den

Kenntniss
Haaren."

der

Albinos.

"

Meiningen,

Vienna, 1831, p. 167.

be

ties,
locali-

here,

consideration
caused
no

by hereditarytransmission.
^

must

albinotic,and

prevailsendemically in

that albinism

Guinea,^ might have

Lower

of the

children

1824.

by

other

ternal
ex-

way

PIGMENT

447

ATROPHY.

Albinism.

Partial
It is

generallyconceded that this is met with in the colored races, but its occurrence
However, there is no doubt that this congenitalpartial
Europeans is denied by many.
lack of pigment in wliites is by no
do not intend to deny
means
very rare, though we
that this anomaly may
in
the colored than in the white races.
perhaps be more
frequent
We have to deal now
with that congenitallack of pigment of isolated parts of the
skin which presentsitself in the form
of white spots,generallywith irregular
border,
the skin of which is otherwise
They are limited either by normally
perfectlynormal.
pigmented skin, or else they are surrounded
by a zone
containing less than the normal
amount
of pigment, so that the transition is gradual. In no case
is the skin immediately
white
the
than
normal.
In short,partial
adjoining
patches more
stronglypigmented
albinism forms
in every respecta perfectanalogue the
reverse
side," as Kaposi happily
Indeed, to complete this analogy
expresses it of the congenitalflat pigment moles.
of cases
still more,
in which the congenitalpigment atrophy, exactlylike
know
we
even
the pigment hypertrophyin nsevi of the nerves,
accuratelycorresponds with the distribution
of some
I subjoin here the descriptionand
nerve.
illustration of a very pronounced
in

'^

"

"

of this nature.

case

Fig.

Anna

K
,

descriptionof

the

aet.

of the

35.

It

ileo-hypogastricnerve.

renders

Tiie wood-cut

for soft chancre.

treatment

atrophy unnecessary.

pigment

hypogastric branch

under

19, came

corresponded

exactly to

Corresponding

to

the

the

any

distribution

conditions

further
of the

prevailingin

is not unpigmented,
but
the whole
and
the naevi of the nerves,
region of the nerve
the outer side. The transition into the
on
portions of normally pigmented skin, especially
rounds
everywhere surfaintly pigmented zone
normally pigmented skin is not quite abrupt, but a more
the non-pigmented spots. Besides, the patientpresented a second
pigment atrophy on the

herpes zoster

within

it are

right side of the neck, in the shape of

chin and jugulum, and its apex
about

triangle,the base of which

corresponded to the line between
the skin,
middle
of the sterno-cleido-mastoid, where

to the

though

not altogether unpigmented, was

still evidently less strongly pigmented
of the N. subcutaneus
parts. This latter spot corresponds to the distribution

derived

from

In the
on

the

the third

case

of

rightside

cervical

nerve.

girldead

of

of the abdomen,
'

v.

Both

alterations

phthisis,who
I have

Barensprung

'*

been
Die

had

existed

enabled

from

similar

than

the

ing
surround-

colli med.

et inf.

birth.

pigment atrophy
congenital

to examine

Giirtelkrankheit," p. 88.

the skin

anatomically,

448

and

PIGMENT

ATKOPHY.

to demonstrate

complete absence of pigment only in the central portions,while at

peripherythere was a gradual transition into the normally pigmented skin.
quently,
Specialattention should also be given to the color change of the hair. Very frethough not always, the hairs on the unpigmented spotsare likewise white.
the non-pigmented skin of the right
the hairs on
Thus, in the above-mentioned
case,
half of the mons
Veneris were
in which
white.
But
cases
are
some
rare
by no means
bunches
of hair are white from birth, while the skin bearing them
shows
noticeable
no
lack of pigment. Of course, the capillitium
at these points appears somewhat
lighteras
compared with the portionsset with darker hairs.
This phenomenon has been frequently described
as
questionable
poliosiscircumscripta,and unof
inheritance
this
of
cases
Thus,
pigment anomaly have been observed.
Seligsohn'describes a white ringleton the anterior part of the head of four brothers.
Still more
according to which a white
important is the communication
by Strieker,'^
lock on the forehead was
inherited in one familythrough six generations.In this instance
direct inheritance only was
observed, reversion of the defect of the grand -parents not occurring
in the children of healthy parents. Sex made
difference as regardsthe transmission.
no
the

ACQUISITA

LEUCOPATHIA

The

term

The

disease

S.

VITILIGO.

is
now
vitiligo
appliedmerely to acquiredpigment atrophy.
occurs
mostly in middle age, and manifests itself first in the shape of
small, regularlyround, white spots. These white patches graduallyincrease in size and
of their regularity
lose some
of outline.
more
oval, and irregularwhite
They become
in the case
of largespots
But
of
such
even
spots.
figuresarise particularly
by the confluence
mode
of origincan
due to the confluence
of several circles or ovals,this
generallybe
toward
For the limitinglines are
with great distinctness.
demonstrated
always convex
lines.
the outside, while the skin remaining pigmented is accordinglybounded
by concave

in the most
advanced
almost
cases
a largeportionof the skin, and
finally
lose its pigment.
Now, while the partialpigment atrophy is evidentlythe originalpathologicalprocess,
sometimes
stillthe surrounding parts exhibit quite noteworthy alterations,which
In the surroundings of the white
spots
more
are
even
conspicuous than the former.
intense as the
more
there ensues
increase of pigment, which becomes
progressively
an
a continuous
white patchesenlarge. The impressionconveyed is exactlyas if there were
in
direction.
the
a centrifugal
pigment
displacement of
the
the contrast between
at the periphery,
Of course, by this pigment accumulation
the
former enlarge,
non-pigmented and the pigmented places is correspondinglyintensified as
into isolated small islets,
is crowded
and finally,
when
the entire pigment, as it were,
times
these small spots appear
deep brown in color,while the rest of the body is white. Somethese pigmented islands are
situated at the most peripheral
parts of the body in
have given rise to the
which
It is these cases
and feet.
the face, at the hands
especially
In this way,

the entire skin, may

"

very

natural

is rendered
observation
Another

mistake

that

the brown

placesare

reallythe

abnormal

in the
cases
impossibleby the observation of many
in
case.
of the progressive
a
single
development
phenomenon is this,that the
very remarkable

'

Eulenburg,

"

Vichow's

"

Realencyclopadie,"Bd.i.,

Arch., Bd. 73, p. 623.

ones

"

different

decolored

p. 163.

mistake

which

stages,or by

the

patches usually

symmetrically.In this way are produced quite peculiarmarkings, as

illustration.
the adjoining

occur

Ml'

'

"

36.

Fig.

Ida

set. 16,

had

appears

clearlyin

most

449

ATKOPHY.

PIGMENT

nucha.

was

of remittent

attack

an

Till that time

the

admitted

clinic with
syphilis. More than a year ago the patient
commenced
with a white
after, the decoloration
spot at the
from
that period forward
the not
a light-colored skin,while

to the
Soon

fever.

patient had

darker,

even
portions became
symmetrical arrangement

decolored

at present being deep brown.

The
in the illustration.
places is evident

of them

some

of the decolored

everywhere are quite sharp, the darkest pigmentation of the colored parts is exactly
of white hair about one
centimetre
in diameter.
the occiput is a bunch

almost
The

at the

actly
ex-

limits
border.

At

here the fact that, in

I call to mind
appear
to the

hence,

of

reasonable
in

to

and
yitiligo,
29

the

that

this organ

course,

largenumber

symmetricallyarranged,and

circumstance

throughout

afford

as
an

anatomical
whole

are

"

equal basis

to

ascribe to this fact also the

not

to connect

them

with

that

of

cutaneous

diseases,the

rescences
efflo-

this

is due pre-eminently
peculiarity
relations of the skin
uniform
^byno means
perfectlyequal on symmetrical regions,and
It is most
them.
any morbid
process affecting
symmetrical spread of the unpigmented spots
"

the distribution

of the

nerves.

450

PIGMENT

No

ATEOPHT.

other disturbance

in the cutaneous
takes place.
activity
of the
has been
hairs in the process
of decolorarion
mentioned,
participation
This complication is exceedinglyfrequent,there being found
above.
in nearly every
of extensive vitiligo
of decolored
either isolated bunches
case
hair, or else white hairs are
decoloration of the hair is
s
cattered
Sometimes
the pigmented Ones.
irregularly
among
met
with also in slightly
advanced
a case
having but a single
cases; thus I have observed
The

white
spot on the trunk, several smaller ones
dollar,on the head, covered with white hairs.
confined

to the

hairs,an

which

occurrence

the hands, and

on

Now

might

we

one,

about

the

size of

the

leucopathyis
c
ircumscripta
acquipoliosis

then, however,

and

term

sita.
I

append

here the illustration and

descriptionof

most

characteristic

case

of this,

nature.'

l"io.

M
,

barrister,get. 23.
Some

prsematura.
after

year,

growth

white

bunch

of

scarlet

of decolored

hairs

indebted

am

of this

case.

of white
were

have

noticed
to the

been

kindness

in

hair

patient
fell out

on

the

of Dr.

on

the

anterior

occiput.
and

is stated
in

even

to

to be

childhood.

great

extent.

congenitalcanities
In
The

the

fifteenth

succeeding

at the points. Soon

fissured
succeeding years, small patches
lateral portions of the scalp. In the spring

throughout lighter in

appeared

also

observed

fever, the

been

hairs

parents there

family of both

have

the

hairs

attack
grave
of hair is stated to

afterward,

In

at.

color

and

Iq the

Michelson, of Konigsberg,

for

the

history and

tion
illustra-

of 1880, infiltration
half

than

longer

the

of

apex

Eyebrows

hair.

The

accumulation

no

right lung

Present

skin

condition

of

containing them

pigment

or

even

is

; of late

is of stout

Patient
of

the

lung.

within
build

of

the

the

never

orbits.

lastin.^

Otherwise
in the

nothing abnormal
delicate

blond, in the latter

whiskers

coloration

the

Complexion

considerably lighter than

darker

headaches,

violent

years,

in pressure

themselves

the apex
dulness
over
except some
organs
and
Moustache
and lashes dark-brown.

of white
is

the

day, chiefly manifesting

subjective feeling of health.

internal

of

451

ATROPHY.

PIGMENT

few

surrounding

periphery.

The

throughout.
small

parts

groups
; there

scalp is covered

ored
is uncommonly
scales ; its color throughout
light. The parts covered with decolclearlyless pigmented than their surroundings, but this contrast is certainlyenhanced
of the
There
is no sharp demarcation
by the visibilityof the follicular portions of the dark hairs.
decolored
The
localization
of the
hair.
vitiligospots from the adjoining parts bearing brown
The
hairs growing
by the illustration ; they are chieflyon the left half of the head.
patches is shown
normal
and firmly inserted
into the scalp.
them
are
nearly quite unpigmented, but otherwise
on
the nucha
there is
At
the decoloration, is perfectlynormal.
The skin of these patches, aside from
with
no
the
in
of
the
hairs
rest
hair,
beset
with
white
amply
on
part
supplied
a small
body,
;
spot
with

numerous

hairs

are

perceptibleabsence

of

pigment

anywhere.

Tlie

patient

states

that

his head

never

sweats.'

emphasize certain deviations from the generaltype of acquired

and of the increased
pigmentation of
leucopathy the absence of the sharp demarcation
the regionsaround
find the same
the unpigmented spots. But we
deviations,too, in those
of the rest of the skin,
decolorations of the hair occurringsimultaneouslywith vitiligo
and we
to variations in the development of
are
therefore,in ascribing them
Justified,
the afEection produced by the peculiar localization.
I hold it to be altogetherunquestionable
that these cases
their
to
the
morbid
owe
same
origin
process as the vitiligo.
is progressive,
the white spotssteadilyenlarging,so that they
The course
of vitiligo
finallymay occupy the entire skin.^ But the pigment atrophy may also stop at any
states that in a case
observed by him
this
point and remain forever stationary. Nacke
therefore
all
the
exclude
was
an
auto-observation,and we
more
may
any deception the
white spotsat one
became
while
point
again normally pigmented,
mented
unpigthey remained
rest
the
of
the
on
body and presented absolutelythe characteristic aspect of
vitiligo.But this behavior is exceptional; the spots once
having lost their pigment,
The disease has not the slightest
influence on the
generallyremain permanently white.
functions of the skin nor
the general health of the affected person.
on
I have examined
three cases
accidental discovery
an
was
anatomically; in two, the vitiligo
at the post-mortem, while in the third, a piece of skin was
excised during life. I
but absolute
can
only confirm Simon's statements, that the skin presents nothing abnormal
absence of pigment in the decolored spots, and more
less intense pigment hyperor
trophy
in the darker
portions. Remarkable
appeared to me only the very largequantity
of pigment in the corium, especially
where the brown
parts adjoined the white
is rather obscure, still some
The etiologyof vitiligo
facts which
have a bearing upon
There
it can
does not seem
be established.
to be any greater disposition
of one
the
or
other sex, but age has a decided influence. In the large majority of cases
tween
it begins bethe tenth and the thirtieth years ; much
more
rarelylater,and quiteexceptionally
I know
of but two cases
earlier.
in earlylife ^the above-mentioned
of Niicke, in
case
which the disease began in the fifth year, and
another commencing in the eighth year.
In many
instances the onset succeeds
acute disease;thus, in the cases
detailed above
some
It is true,

we

have

to

"

"

"

"

'

This

be regarded as an exception, the absence

of any further
disturbance
parts having been otherwise
regularly observed.
*
de med., de chir. et de pharm. mil., 1865,
Levy (Recueil de mem.
p. 193) has
in which
the pigment diappeared completely.
must

of

function

ini

the decolored

Berl. klin. Wochenschr.,

1881, p. 523.

seen

three

cases

452

after remittent

once

after
it

as

ATKOPHY.

PIGMENT

fever, and

is

typhoid fever. This concurrence

I have seen
merely accidental.
of vitiligo
spots. In isolated

vitiligoin

I have

indeed

cicatrix/ and

ordinary form

the

patches situated

on

the

and

form, within

also observed

whom

arrangement

pruritus preceded the

exhibited

hand
there

which

and

of

vitiligo

look

cannot

Ave

the affection is stated to

joiner,who

of the

dorsum

so

cases
a

have

that
frequentrelatively

patientsin

two

in

seen

Others

after scarlatina.

once

white

the

have

the

on

started

rest of

spots,

upon
rence
occur-

from

body

the

white

numerous

the flexor surfaces of the forearms, of

at least in

part, smaller

and

larger
at the scars
the hands
on
patientstated that the disease had
But we
stilllack any exdue to injuries
suffered while working at his trade.
planation
and arms,
localized pigment atrophy, and
how these processes lead to this peculiarly
on
the other hand to the pigment hypertrophyexistingat other points.
in the majority of cases, will be very easy, only we
must
not forget
The diagnosis,
It
statements
the
of
the
little
reliance
is
for this
on
that we can
patients.
place very
in interpreting
of the cases
that I thought myself justified
as
vitiligosome
reason
that
described
by Barensprung as partialalbinism, because the only point on which
the
based
statement
of. the patients that the spots had existed
was
diagnosis was
the
earliest infancy, while
from
description of these cases
corresponded exactly
differentiation from
disease.
The
the former
with
albinism,
however, will
partial
statements
without
the
aid
the
takes
of
patients'
; for misnearly always be easy even
are
guarded againstby the regularlyround form of the originalpatches and the
likewise quite characteristic markings produced by their confluence ; and
by the mostly
accumulations
at the
of
and
the
pigment
especially
great
arrangement,
symmetrical
the decolored
absent when
borders
which -are never
portionshave attained a certain size.
in partialalbinism ; the forms
absent
not regular,there is
All these peculiarities
are
are
not
irregular,

commenced

symmetricalarrangement,

through

of

have

pigment

into the normal

transition

always be

as

former

is

there

effected

never

any

diseases,only morphoea and

is

leprosy
scar-like qualityof the
leprosy show a slight

decrease

in

the

bility
sensi-

in them.

demonstrated

prognosisappears

zone

other

skin is often

; at all events

distinguishedby the
spots occasionallyoccurring in
and besides,a
place in vitiligo,

The

takes

never

Of

margin.

white

the

parts; and
desquamationwhich
can

at the

to be considered.

affected

The

the

and

intermediate, very slightlypigmented

an

accumulation

might

were,

The

cicatrices.

no

round

natural

sequence

from

what

has been

stated

above, and

altogetherpowerless. Only in cases where the wiiite portions have

islands are
them
between
that
far
so
nothing but small brown
present,we can
spread
the
the
for
at
least
a
pigment of
time,
dispelling
resultingdisfigurement,by
remove,
thus
to
and
the
methods
these brown
produce uniformity.
given above,
spotsaccording
time the pigmentation
here the effect is of but short duration, and after some
But even
our

treatment

reappears

is

character.

in its former

ATEOPHY

PIGMEKT

AFTER

SYPHILIS,

PIGMENT

SYPHILIS.

eases,
disin a series of cutaneous
under observation
secondary pigment atrophy comes
to discuss only the pigment atrophy after syphilitic
in this place I intend
efflorescences.
Perhaps the majority of observers are inclined to deny absolutelythe
existence of a typical pigment syphilis."
A

but

"

Hebra

"

Lehrbuch," Bd. ii.,p.

128.

454

PIGMENT

ATKOPHY.

for the cases

in which
this
even
formerly occupied by syphilitic
papules;hence I assume,
that the decoloration
is effected correspondingto
process had not been observed directly,
the absorptionof syphilitic
infiltrations.
I would
call to mind
here an obviouslysimilar
in
the
of
e
fflorescences
after
the
psoriatic
absorption
employment of chrysarobin,
process
where lightspots likewise appear correspondingto the former seat of the psoriatic
patches
which
become
doubly conspicuousby the darkening produced by the chrysarobinon the
surrounding parts. Another point in favor of this view is the pronounced intractability
of pigment syphilis. In spiteof all imaginable antisyphilitic
of treatment, the
courses
two
affection persistsone
without
or
even
disappearingquite
gradually,
being
years,
treated.

Herein, then, lies the exceedingly great diagnosticimportance of pigment syphilis.

all other distinct manifestations
the
often absent, within
are
cases, in which
many
diathesis it furnishes
first years of the syphilitic
an
absolutelycertain proof of the ence
presof the parts
of the disease,and its value is only enhanced
by the easy accessibility
In

usuallyaffected.
frequent,I

We

now

enter

And
hold

on

by foreign coloring
blood-vessels
way
to

from

the

occurrence
a

new,

the consideration

or

colorations of the skin

of those anomalous

These

matters.

within,

at least in women,
of pigment syphilis,
exceedinglyimportant diagnosticlandmark.

may

be

introduced

into

the

skin

is relatively

produced
by the

either

In the
penetratemechanically into it from without.
of the skin and argyria;in the latter,those

is effected the icteric coloration

tattooing and
The

as

it to be

the introduction

icteric color of the

mer
fordue

of

skin is

gunpowder.
produced by the impregnation

of the

skin

with

bile

contains
this substance
the blood, from
takes place whenever
cause,
any
normally present in it. Of course, the skin shares this fate with all other
not very deficient in blood and lymph
tissues of the body, at least in so far as they are
vessels.
According to the quantityof bile pigment passingfrom the blood into the skin,
of the color varies from a lightyellowishtint to an intense yellow,yellowishthe intensity
in the gravest chronic
still darker, blackish-greenshades
and even
green and olive-green,
The
viridis
and melas.
icterus
forms of icterus,and these have given rise to the names
saturation of the skin with the pigment is at first quite diffuse,only if.the icterus is of
by the microscope here and there some
very long standingit is possibleto demonstrate
particles. The most disagreeablesymptom, next to the
small, angular greenish-yellow
discoloration,and often more
annoying than the latter, is the often occurring pruritus,
in the skin by the
terminations
the
direct
irritation of the nerve
evidentlyproduced by

pigment
which

which

is not

hile

pigment.
of silver into the intestine and its transportation
Argyria is produced by the introduction
by the blood into the various organs of the body. The symptom of this disease,
is of the greatestimportance to us in this connection, the discoloration of the skin,
which
itself first by a dull, steel-gray
shows
faint bluish color appearing earliest in the face
or
the uncovered
and on the hands, that is,on
parts of the body, where it also attains the
greatestintensitysubsequently,when the entire skin has been implicated. W-hen, with
the color
of the drug, the alteration increases in intensity,
introduction
the continued
becomes

darker, and

may

finallyacquire a deep grayish-blue.This

membranes,
usuallyparticipatedin by the mucous
by the nails,though in a slighterdegree. The
color, as, for instance, in persons dyeing their hair

also

as

that

of the mouth

discoloration
and

is

conjunctiva,

hairs,too, acquirea peculiarreddish

with

solutions

of silver nitrate.

455

ATROPHY.

PIGMENT

that

the

epithelial
portions,the rete
also the glandularepithelium,are
depositionsof silver.
mncosum,
mulations
On the other hand, throughout the connective tissue portionsof the skin there are accuof the finest granulesof silver. These
depositsof silver are the most dense
immediately beneath the epidermisin the uppermost feyersof the papillarybody, and in
the membranae
strip,of a
proprigeof the sweat-glands,where they form a continuous
of the

Microscopicexamination

skin

shows

altogetherfree from

like

In
under
low powers.
violet appearance
deposits of silver in all internal organs,

with

manner

the

we

find

more

exception of

or

the

less extensive

central

nervous

system.
of silver
only either after the very long-continueduse
of
doses.
have to
as
a
we
Hence,
rule,
large
employment
nitrate,or
very
for years because
have
taken
silver nitrate internally
of chronio
deal with patientswho
mode
of originof argyriais
affections of the nervous
system, tabes, epilepsy. Another
reportedby Neumann,' the case of a physicianaffected with ulcer of the stomach, who, for
of the cesoseveral months, injectedtwo to three times dailyinto his stomach, by means
After
1.5 gm. of silver nitrate.
about
about
twelve
solution
a
containing
sound,
phageal
discoloration
to
have
said
the
indications
of
first
are
the
Furthermore,
appeared.
doses,
after the very long continued
been
observed
to the
of argyria have
applications
cases
for
dently
by hypochondriacs,eviyears especially
pharynx or tongue, such as is often employed
of the remedy being swallowed.
of small quantities
in consequence
in animals
repeatedlyto produce argyria artificially
by
Attempts have been made
but
thus
far
with
silver
with
results
nitrate,
as
always
negative
long-continued feeding
These

phenomena

after

regardsthe skin;
Opinions are

appear

shorter

in

internal organs

some

stilldivided
most

view'' appears

Eeimer's

as

to the

of these animals

silver could

be demonstrated.

chemistry of the

probable;he

processes taking place therein.

that the silver,having been reduced

assumes

being in the state of finest subdivision,is taken up by the chyle

vessels,thence transported into the blood current, and then deposited in the valours
the influence of light
It is difl"cult,however, to bring into harmony therewith
organs.
which
is
uncovered
in
view of the clinical
the
of
the
indisputable
parts,
on
staining
be
in any
reduced
silver
the
of
altered
color
can
no
longer
observation, for the
way by the
intestine,and

in the

light.
In the

state
prese:^t

Neumann'
statement

of the

of

our

knowledge, argyriamust

reports that, in a
patient,the intensityof

alone

case

the

under

be considered

an

incurable

tion.
affec-

his observation, according to the

stain decreased

in the

course

of several

years.

Finally,there
mechanical

the consideration

remains

introduction

of substances

from

of the color

changes

of the skin due

to

the

without.

largelymodified in its details,consists simply in outlining

with a fine needle the desired designby closelyadjoiningpunctures, then firmlyrubbing
bar,
into the skin thus prepared the pigment in question,indigo,powdered carbon, cinnaneedle
the
also
be
and
which
with
charged,
occasionally
may
finally
applying
carmin,
of pigment which
have
the part. The
thus penetrated
particles
a
bandage over
The

procedure,of

course

"

Medic.

Arch.

Arch.

Jahrbiicher, Bd.
d.
d.

Heilk., Bd,

iii.,
p. 369, 1877.
xvi., pp. 296 and 385.

Heilk, xvi., p. 382.

456

PIGMENT

through

the

undergo

minute

no

Tattooing
with

syphilis

with

saliva

in

occurred
make

to

as

often

tattooing,

in

The
has
In

which

largely
sprinkled

part

color

is

effect

distinct

too,

exposed

to

into

the

of

of

tattooing
naevi,

of

case

etc.,

tattooing

far

so

there

persists

forever.

employed

needle

the

and

infections

repeated

as

moistening

of

the

skin

have

for

the

in

cornea

covering

of

purpose

unfortunately

the

which

by

in

carbon

much

particles

falling
appear

due

to

pieces

minute

crowned

been

not

that

of

opacities

ture
struc-

the

to

with

do

of

coal,

bluish-black,

object

same

from

carbon

of

particles
the

v/ith

wqunds,

gunshot

probably

have

of

penetration
intentionally

made

as

tinge,
who

the

by

are

these

by

injuries
skin

habit

the

by
in

only

remain

corium

them

advantage.

accidental,

bluish

the

produced

really
of

known,

part

presented

workmen,

well

produced,

in

are

the

into

adhere.

utilize

to

with

employed

similar

burns,

powder

as

physician

pignftnt

in
is

design

the

consequence

the

attempts

while,

success,

burns.

have

the

to

epidermis

the

that

so

interest

of

pigmentations,

is

but

beneath

alterations,

numerous

annoying
witli

is

so

The

wounds

further

ATROPHY.

of

that

as

etc.

the

through

of

portions
coal,
we

often

exactly

firemen,
small

find

like

the

not

them.

who

particles

granules

black,

pure

overlying

skin
and

miners

is

skin

from

are

of

also

carbon

powder

ANOMALIES
THE

OF

AI^D

GLAI^DS

SEBACEOUS

FUITCTIOlSr.

THEIR

BY

ERIvj-ST
OF

YEIEL,

M.D.,

'

CANNSTATT.

find a series of organs

which
layers of the skin, we
These blind tubes
sacciform
epidermis into the corium.
and the sebaceous
the sweat-glands,the hair-follicles,
are
tubular formations
or
glands
of tubes which,
the sweat-glandsrepresent deep-seated convolutions
follicles. While
or
but traverse the epidermis in diminishing,
in the corium, penetrateit in gentle spirals,
situated
twists and always terminate
the
cork-screw-like
hair
and
ceous
sebaby themselves,
The sebaceous glands belong to the class of
but one
follicles form virtually
organ.
unilobular
as
or
acinous glands; in their simplest form, they occur
bilobular,
grape-like
the capillitium,
the nose, scrotum, etc.),
on
sacs, or else multilobular, mulberry-like (in
efferent
in one
terminate
or
and
duct, together with a hair-follicle,
apparently alone.
find almost invariablysmall (atrophic)
with downy hair
In the latter case, we
hair-sacs,
hid
either
in
which
remain
the
efferent
duct
lateral
of the sebaceous
a
s
appendages,
(lanugo),
hair-follicles
Sebaceous
and
from
the
are
glands
gland or project
pore.
organs
taining
appertogether;they are either equallydeveloped,in which case the efferent duct of
ceous
the sebaceous
gland terminates in the hair-follicle while stillwithin the cutis,the sebagland appearing as an appendage of the hair; or else,as on partsscantilysupplied
is merely rudimentary, so that the small atrophichair-folwith hair, the hair formation
licle
representsan appendage to the fullydeveloped sebaceous gland and its efferent
duct.
The efferent duct of such a sebaceous gland is identical with the uppermost part
of a hair-follicle. On perfectlyhairless parts, we are forced to aswith the terminus
or
sume
absolute atrophy of the accompanying hair-follicle.
an
in

Imbedded

the

several

of
representinvaginations

the

"

"

found

When

the

esteemed

completed,

of which

Dr.

Th.

with
Veiel

died, on January 7th, 1883, the manuscript for this chapter was
and
exception of the sections on "Acne
rosacea
Sycosis,"the writing

author
the
was

"

kind

enough

to

undertake.

"

458

ANOMALIES

Both

sebaceous

glands and

OF

SECKETION".

hair-follicles represent

surrounded
sacs
works;
by vascular netcells arranged like those of the epidermis.
epithelial
The uppermost cells,forming the interior liningof the sac, are
degenerating epithelial
cells infiltrated with fat globules.
In the normal
state, the cavityis filled with an oily,greasy mass, the cutaneous
fat;
the latter,under the microscope,is seen
to consist of cast-off cells (eitherwhole
and
filled with fat granules,or ruptured),of free fat globules,and crystals
of cholesterin.
This greasy mass
is frequentlyoccupied,particularly
at the ala nasi and
the auricle,
folliculorum.
by a small, eight-legged,certainlyquite harmless parasite,the acarus
Chemical
examination
shows the principalconstituents to be, approximately,five per cent
of fat,togetherwith water, an albuminoid
substance, and in the ash chieflyearthy phosphates
their interior is invested with

(Funke).
The
not

vis

tergo and

the

The

As

with

In seborrhcea,the
fluid

or

pilorum muscles, which are

tion.
secredischarging the formed
the less will the discharge
cutaneum,

forces

of the sebum

requirethe action of these forces.

of secretion,we

to the anomalies

or
(seborrhcea)

arrectores

be held to be the

fluid the consistence

more

of the secretion

of the

contraction

subject to will-power,must

more

sebum

or

to deal either with

have

less diminished

is sometimes

elaboration

of normal

an

increased

formation

and asteatosis).
(oligosteatosis

consistence,sometimes

it is

unusually

firm.

The

disturbances

of excretion,on

the whole,

tion
nothing but retention of the secrein
its
efferent
or
Virchow),
gland proper
turbances,
disduct, or in both, from narrowing or blocking of the opening. With the last named
and
of course,
both the glands
the efferent channels'are
subjectto manifold
alterations ; while in seborrhcea the glands and ducts, or at least the former, are
not
If the efferent duct is merely mechanicallyoccluded
affected.
by the hardened secretion,
of secretion through contraction
the comedo
with its sequels. Ketention
there occurs
or
obliteration of the efferent duct produces milium
or
atheroma, according
(sivegrutum)
to the seat of the contraction,whether
the opening or deeper in the gland.
near
at first nothing but the normal
contents
The
of these three forms
secretion of
are
the glands and their efferent channels (sebum,epidermis,etc.);subsequently,however,
of inflammatory and
degenerativeproducts
they may be so altered by the admixture
t
hat
the
and
entire
or
"originalcharacter
(serum,pus, blood, etc.),
by
partialabsorption,
is altogetherlost^' (Virchow).
of the contents

To

these fundamental

are

occurringeither in the

tumors,
(retention

forms

of disease it will be

best

to add

the

discussion

of

some

of the above
pictureswhich essentially
representa combination
and acne
morbid
viz.,acne
mentagra or sycosis.
simplex,acne
rosacea,
processes
of acne
The frequent participation
of the hair-'follicleand the hair in these forms
well as in the elementary forms of disease of the sebaceous glands is self-evident.
as

dermatologicalmorbid
"

A.

1.

HTPEKSECRETION

ANOMALIES
SEBORRHCEA,

OF

SECRETION.

STEATORRHCEA,

ACNE

SEBACEA,

ETC.

to the surface
quantityof the sebaceous secretion,liquid or solid,comes
skin
the
the
hairs,
remaining unchanged, excepting the
epidermis or between
occasional occurrence
of some
dilatation of the opening of the sebaceous
glands. The
all parts of the body excepting
disease is most
on
frequentin the young and may occur

An

excessive

of the

those not

suppliedwith

sebaceous

glands.

OE

ANOMALIES

Accordingto

459

SECRETION.

the state of the secretion,whether

fluid,oily,or

more

seborrhoea

sicca ; but the

firm

more

and

or
a
or
dry, we speak
crusts,
if apparently quite dry, always contain
fat.
The
sebum
drying of the exuded
is probably due to a relatively
of water
cutaneum
contained
therein, with
largeramount
individual, and
subsequent evaporation. Both forms may exist side by side on the same
also transitional forms between
them ; it is more
rhoea
appropriate,therefore, to divide seborand
local
to
its
location.
we
a
a
distinguish general
Accordingly
according

of

even

oleosa

seborrhoea

scales

even

seborrhoea.
Sehorrhma

a.

Every
nix
a

child

days

different

the

skin

from

neonatorum,
with

with

sebaceous

caseosa,

few

is born

the

this
in

are

Utiiversalis.

seborrhoea, with a covering of verquasi-physiological

accumulated
during intra-uterine life ; but after
increased
elaboration
of sebum.
to
Quite
tendency

secretion

loses the
the

described

cases

which, after removal

under

of the

vernix

the

of

name

the

caseosa,

seborrhoea
whole

universalis

body

is covered

varnished
(Kaposi). Unless the bared
deep red, glossyskin, looking as if it were
becomes
around
skin is immediately covered with some
it
the
fissured,
particularly
grease,
and anus.
mouth
After some
time the red skin is again invested with a sebaceous coating
which, unless covered with moist or greasy rags, rapidlydries into hard fissured crusts.
As a rule, the children succumb
to their painful affection,after a short
time, from
asthenia.
However, in these cases, described as seborrhoea universalis,it is certain that
not dealingwith a seborrhoea,but with
affection resembling ichthyosis,
is
we
are
an
as
shown
both by the diagnosticfactor,that in seborrhoea the skin covered by it is normal,
and by Ihe unfavorable
prognosis. Of generalseborrhoea in the adult, to the best of my
knowledge, there is on record only a singlecase described by Biett. Finallyit should be
noted that whole
races
{e.g., the negroes)are affected with a physiologicalseborrhoea
a

universalis.
5. Seborrlicea
Seborrhoea

of the hairy scalp.

of the vernix

caseosa

which

In

forms

children

it appears

as

thin, firmlyadherent

continuation

crusts, colored

to black

and
more

tion
desiccaor

less

of the firmlyattached
by atmospheric impurities. On removal
crusts,the underlying skin is found slightlymacerated, covered with a thin, smeary
coatingof sebum having a rancid odor, similar to a part of the body which has for some
If the disease be not
length of time been covered with a rubber plasteror caoutchouc.
interfered with, the crusts crumble
to piecesin most
after a longer or shorter time.
cases
No other symptoms
or
sequels are to be noted, excepting,perhaps,at first a slow
growth of hair.
In adults the disease appears in various forms, dependent on the nature
of the secretion.
In seborrhoea
oleosa capillitii,
the hair is continuallygreasy and smeary,
forming a
of
dust
and
constant
desiccation
of
the
secretion
leads
deposit
impurities. Eapid
oily
to agglutination
of the hair into largeror smaller bunches.
the formation
of epiderDry seborrhoea capillitii
presents various appearances
: whore
mis
like
flourpredominates,the scalpand hair are filled with glossy,white, flaky,sometimes
if there be a greater admixture
of sebum, a glossy white
scales,pityriasis
capitis;
depositis formed on the scalp;if the secretion be stillmore
dition
fatty the most frequentconthe scales,partlyfirmlyattached to the capillitium,
bet
the
hairs,
ween,
partlyfree
are
more
yellowish,often stained by dirt,and have a greasy feel. As additional symptoms

deep

brown

"

Localis.

"

"

460

ANOMALIES

"

might

be mentioned,

loss of

skin

it;where

lustreless and

OF

is very irritable,
sometimes

of the hair and

dusty appearance

is thick,

the crust

SECRETION.

increasd

an

slightitching.

often very able

considerfeelingof warmth; and where the

Often

the

scalphas

peculiarmouldy

smell.

Where

the secretion has become

complicated with
The

duration

dermatitis
is very

and

ragged and rancid, the

seborrhoea

capillitii
may

be

eczema.

variable,often lastingseveral

Spontaneous recovery is
The causes
unknown.
Ohlorotic
anaemic
rare.
after
are
conditions, especially
and constitutional diseases,predisposethereto;it is probably for this reason
that
grave
the female sex predominates among
these patients,
aside from the fact that wearing the
hair long discloses very slightcases
in men.
which
would
be overlooked
of seborrhoea
Blond
form
to
the
of
this
affection.
to
the
brunettes
most
are
oily
disposed
dry,
persons
Sehorrhosa of the face,likewise,must be divided into seborrhoea faciei sicca and oleosa.
The favorite localities are those possessing
number
of sebaceous glands. Here,
the greatest
the
and
of cases, especially
nose
on
too, the skin is normal, exceptingthat in a number
It is sometimes
cheek, the openings of the efferent ducts are dilated.
hyperoemic in the
dry form and the patienthas an itching,burning sensation.
almost
Seborrhoea
the nose, cheek, eyelids,and
oleosa (preferring
forehead) occurs
in
to
localities
the affected
an
exclusively the young and dark-complexioned,and imparts
oilyor fattygloss;all attempts at cleanliness are in vain, barelyan hour after the grease
dates
the excretion is slower or consoliWhere
has been soaped off,the face shines as before.
to
almost
the
skin
is
colored
dark,
more
impurities,
yellow,
atmospheric
rapidly,
by
not

years.

and

blackish.

Duhring

describes

skin of which

oilyappearance
The dry
young,
recovery

and

is reddened
and
form

which

from

of seborrhoea

specialform

and

exhibits

openings of
paralysis.

dilated

feels cold, a vaso-motor

of facial seborrhoea,which
often

grave

occurs

as

cutaneous

an

syphilidesand

processes,

spurs

dried

nasi, in which
the sebaceous

the

nose,

glands,has

the
an

frequent in older persons as in the

sequelof the variola eruptionor after the
isolated
other exhausting diseases,covers
mask
of
thick
and
less
crusts,
or
dirty
On detaching the
completely dry form.

is

immediate

parts,seldom the whole of the face, with a more

in the
which
always has a greasy feel even
to presenton the side next
crusts, they are seen
of

oleosa

as

like
of small, needleto the skin a number
secretion, correspondingto the dilated openings of the
and
like comedones
formed
soft at their extremities, are

glands. The small processes,

are
composed chieflyof fattyenchyma cells and a few horny cells.
drier and
In ordinarycases
the skin is barelyreddened; but as the crust becomes
and more
thinner
vulnerable,
the redness increases and the epidermisbecomes
greasier,
to be seborrhoea and merges
time, however, the disease ceases
bleedingeasily;at the same
in which at times one
into the slighter
forms of lupus erythematosus. These
really
cases,
seborrhoea
conHebra
does not know
what diagnosisto make, have been named
by
gestiva.^^
such
and acne;
Dry seborrhoea of the face is often complicated with comedones
other parts of the body.
on
patientsexhibit a tendency to the formation of comedones
^'^

Transition

into

of the

eczema

face,too, is not

rare.

interscapularregion, the umbilicus,

corporis.
of these parts exhibits
Seborrhoea
seborrhoea,
also
favorite
seats
of
genitalsare
has
a pronounced tendency to
no
specialpeculiarity;that of the umbilicus and genitals
provoke dermatitis, even eczemas, owing to the ready decomposition.
Seborrhoea

and

the

"

The

sternal

region, the

462

ANOMALIES

of the

ment
smeared

attained

is

crusts

with

vaseline

SECRETION.

OF

rapidly by

most

mask

of

the

or
ointment; excellent results are
mull; either kind of mask is changed every
lead-plaster
by bandages of gauze, and appliedonly after the crusts have

Unna^s

lint

stripsof

obtained

also

twelve
been

flannel

or

by

mask

hours, kept
moistened

in

with

of

place
oil

or

glycerin.
The

having

crusts

the skin cleansed

the

on

infrictions

soap

the

of these

are

spiritof

become

In

acute

female

almost

employ

parts affected

until

and

days.

there,

three

the

have

days
liquidsoaps are preferable;the
court
kaline
pharmacy, or Hebra's al-

200

......

parts.
"

100

et filtrato adde

diger. filtra

Spiritus lavendulae,

Spir. serpyll. thym., etc.)

S. Alkaline

the

of the Vienna

glycerinsoap

off

enter

we

three

here

appear

washed

sex

soap,

usuallyconsumes

eczema

is not

soap

the

and

this purpose we
times daily to the

This

days),and

two

or

soap:

Spiritus,
Misc.

fluid

Saponis viridis,

the

one

water

warm

For

ensues.

violent,and

first inunction.

the

by

of

means

applied three

dermatitis
too

(usuallyin

softened

crusts

^the alteration.

"

suspended, but

are

Elapsedsince
best

remaining

moderate

the dermatitis

and

in substance,

soap

until

seborrhoea

Should

detached

part of the treatment

second

exclusivelygreen
with

been

of fat and

20

aud

"

(or

raore

"

spiritof soap.

of the hair),
participatelargelyin the seborrhoea (falling
When
the soap
is
preferredto either of the former.
washed
off,the skin is reddened, the epidermis glossyand tense, slightlyfissured,and
desquamates as after scarlatina. While on the first day after washing off the soap it is
not desirable to apply grease, mild ointments
ung. leniens or rosatum, with or without
of zinc, as well as Wilson^s
zinc ointment
benzoated
be employed
the addition
may
irritation.
from the second day on, according to the degree of the cutaneous
In place of the soap, metallic
ointments
proto-iodideof mercury ointment, ung.
be
but
also
their
Eochardi, etc.
employed
use, to say the least,is unnecessary.
may
;
the skin is clear,the third indication has to be met : preventing the reAs soon
as
currence
and
This is done by the applicationof astringents
of the seborrhoea.
irritants,
acids ;
Kaposi proposes carbolic,boracic, and salicylic
always best in alcoholic solution.
Where

the

the

hair-follicles
is

latter form

to be

always

"

"

"

"

of the former, 0.15

Others

daily.
of

an

gram

; of the latter

of
application

addition

The

ointment.
oil

or

of

glycerin,but

pomatum, prevents the

astringents,tannin

Of

in 100

two, 3 grams

of alcohol.

grams

alcoholic solution of chloral

results,a five-per-cent
extol petroleum, capsicum, cantharides, etc., with alcohol

excellent

with

may

above

not

skin

or

ten

hair from

per cent,

or

We

or

in the

the

form

occasional

becoming too dry.

as
a
pomatum in

in solution,or

be recommended

ploy,
em-

hydrate,twice

rhoea
sebor-

capillitii.
I^ Acidi
Ung.

Piffard

powder.
there is

tannici,
pomat. sive rosati,

10 grams.

........

recommends

The

pomades

tannin

of extract

great loss of hair, I

'

and

chloride

of cinchona

frequentlyemploy

of iron in
likewise
the

100

solution,the

belong under
followingpomade.

"

former

this head.

also in
Where

]^Extr. cinch,

Peruvian,

Tinct.

canth.,

Succ.

citri,

In

oil

rubbed

1.0

himself

patient

scalp

method

treatment, I have

of

but

"

1.0

"

50.0

"

dry

from

place of the soap,

In

that the

granted
of it.
the face

patient can

will be

management

account

to

cloth.

for

taken

different

neglect his business on

the
evening,
grease being removed

with

by rubbing

1.5-2.5

daily.

twice

or

once

the treatment;

wish

not

in the

made

are

,."....

the

entirelyto

does

"

...

........

into

the above

devote
the

be

To

grams.

......

.....

Ung. pomatini,
S.

1.5

frig,par.,

Bals.

465

SECRETION.

OF

ANOMALIES

The

hair in the

or

if

required

with

frictions

liquorpotass,carbonat.,

ing,
morn-

pure

or

skin,
parts of water, according to the sensitiveness of
of the face
and
evening. The white flouryappearance
with a slightinunction
of vaseline.
In very
after the employment of this remedy ceases
fice.
sufdetachment
of
the
with
and
crust,
washing,
subsequent
slightcases, daily softening
But
in seborrhoea
of the genitalsit is advisable to dispense with fat, ointments,
diluted

is

with

from

the

applied to

to four

one

face

morning

frequent ablutions.
acid (1 : 100),as

and

(aerug.,0.15
complicated

daily ablutions

Three
well

with

of

bolic
car-

solution
recommended
by Kaposi
six-per-cent
copper
grams), followed by dusting with starch, have done me

Quite recently,I have

completely cured a
frequent -balanitis,
by covering both glans

with

solution

lead water, aqueous

the

as

25

aq.,

gram;

service.

the best

the

similar
and

seborrhcea

of

case

with

prepuce

Unna's

zinc rubber-plastermuslin.
In the
be

grave

of seborrhoea

form

in

completely wrapped

of the

in ichthyosis sebacea, the

it cannot
nurse
as
artificially,

neonatorum,
and

greased rags

fed

must

account

rhagades.
Diminished

2.

Diminished
of

groups

or

arrested

secretion

in which

symptoms

Asteatosis.
Secretion, Oligo-steatosis,

arrested

or

the

of

sebum

only

occurs

perspirationlikewise

as

concomitant

is diminished

certain

of

This

arrested.

or

leads to extraordinarydryness of the skin with detachment

combination
and
epidermis (pityriasis),
Assuring at points of flexion and extension.
manifests itself with physiological,
senile,and with pathologicalatrophy
diseases
with excessive formation
of epidermis, with ichthyosis. Both
as

child
on

of

dry

This
of the
are

scales

of

symptom
cutis ; also

also described

xeroderma.
A

and

slighterdegree
lack

of fat

be

can

substances

of greasy

(vaseline,cold
Mention

should
and

photographers,
when

secretion

of sebum

in

occurs

lichen ruber,
psoriasis,

prurigo.
The

but

of defective

the

excreted

cream,

perhaps

if the former

even

of the skin

are

often

for

once

only by supplying

of which

resembles

be

made

skin, by applications
natural

closelythe

cretion
se-

of artificial asteatosis in domestics, laundresses,

dissolved

secretion

of sebum

is not

length of time, the secretion

occupation be abandoned, several
to restore the normal

must

weeks

suffer

of

therein,

disturbed

again by alkalies,alcohol, ether,

some

necessary

fat to the

most

etc.).

others, although the

fat is at

this has continued

because

compensated
the consistence

some

etc.

Still,

alteration,

regular cultivation

of the sebaceous
activity

glands.

464

ANOMALIES

EXCKETION.

OF

B. ANOMALIES

OF

EXCRETION.

EETENTIO

The

of excretion

anomalies

are, as above stated,merely retentions of the sebaceous

grades and stagesof development: comedo, milium, and atheroma.

secretion in various

1.

The

is used

comedo

term

secretion which

The
head

even

comedo

of

pin.

point.
projectsabove

The

are

likewise

blonds

the

constitute

more

There

is

the number
with

each

frequentlymet

are

the level of the

prone

genitals.If
structure

with

to it than

size of the

seborrhcea,which

pressure
the upper

dark

in size from

be made

the

from

the

face, are

two

point to

the

the breast,

sides,there appears

part of which is cornified (flesh-worm).

youth, especiallythe time of puberty, but they
later age ; the male sex is more
commonly affected ;

at

brunettes.

black
is not

in whom

pointswhich
rarelythe

stands isolated,but
Usually the comedo
singleone projectingslightlyabove the
of comedones

baceous
se-

ened
hard-

disease of

hardly a singleperson

and

skin;it varies

favorite locations of this affection,besides

vermiform
yellowish-white,
Comedones

efferent ducts, of hardened

produced in a too solid condition or dried up and

discharge,appearing in the dilated openings as

black

the nucha, the back, and

a

Comedo.

for accumulations, in the

either

was

of defective

in consequence
or
(bluish)

SEBI.

comedo

could

disfigureor

not

be found

annoy,

; it is merely
if cated
especially
compli-

case.
occurs

also in groups

level of the

skin, a

verrucose

the latter case,

tion
conglomera-

is formed.

the efferent duct

generallyforms a cylindrical
plug filling
inspissatedsebum
dilates into
corresponding to the sebaceous gland or hair-follicle,
terminates
in
This
and
soft
small
flask
a
a bag or
usually
point.
body is inclosed
shape,
of
flakes
of
which
incloses
several similar
in a membrane,
a closely
packed layer
epidermis
in
concentric
them
lie
the
contents
of
arrangement. Between
ones, but not so solid,
the sebaceous
glands,enchyma cells in good preservationand in the various stages of
fattydegeneration,free globulesof fat, plates of cholesterin,detritus,lanugo hairs, and
not rarelyone
or
more
parasites(Demodex or Acarus folliculorum). The latter,barely
visible to the naked
eye, provided with six or eight legs,and approximately of the same
also in normal
sebaceous glands without a comedo, and bears
shape as the comedo, occurs
causal relation to any affection of the sebaceous glands. The black head of the plug
no
is produced by the retention of all sorts of atmosphericimpurities.
of these plugs : 1. The secretion may
Three
factors may contribute to the formation
of the excretion being too slightand tardy,and the
be too firm ; 2. it may diVjon account
influences may
vis a tergo lackingin consequence
impair or arrest the second
; 3. nervous
Biesiadecki
and Kaposi assume
the
arrectores
the
pilorum.
activityof
expulsivepower,
that the lanugo hairs,emerging at about half a right angle to the axis of the efferent
irritate the oppositewall of the duct and thus produce
channel of the gland, continually
of comedo.
of cells,which would explainthe structure
increased proliferation
an
we
Of the generalcauses
only know the above
leadingto the formation of comedones
or
aemia,
anstates of general debilityproducing weakness
: chlorosis,
paralysisof the nerves
of
of
e.
disturbances
menstruation, glanddigestion,
ular
important bodily functions, g.,
in BaccJio et Venere, onanism.
They are not due to excesses
(scrofulosis).
activity
The

which

farther inward,

ANOMALIES

etc.

local

ness, and

termination

the

this head

described
the

of

comedo

dischargingforces

Under

on

of the

efferent duct

by dirt,uncleanli-

spontaneousrecovery by expulsionof the plug

and suppuration (acne).
restored, inflammation
or

belong also

Kiistner

by

and

nose

are

is either

around

as

the ectasias of the efferent ducts

of the sebaceous

which

of

white

the mouth

comedones

of the new-born

to the earliness of the foetal period.

Treatment.

by

the

opening of

drugs (tar).

The
when

is occlusion

cause

465

EXCEETION.

OF

Removal

"

of the

They

sebaceous

are

in the

occur

they are

cles
folli-

points

in tion
proporof milium, open milia.
numerous

more

transition forms
is done

plug, which

shape

white

without

pain or injury

lateral pressure with two

wise
fingers; but the latter must be wrapped with linen,otherthe epidermisis easily
bruised off (Hebra). Piffard and others have devised special

blunt

instruments

answers

saddler^s

resembling a

well.

as.

The

traumatic

awl, comedo

dermatitis

expressors ; but every

it is best combated

arisingfrom

watch-key
with

iced

lead-water

applications.
After the skin has again become
ulated
normal, the sebaceous glands,etc., have to be stiminto increased activity
for some
months
the
best
for
this
means
;
are,
purpose
twice dailysoaping, rinsing,and vigorous rubbing with a rough towel, or sea-baths.
But all sorts of irritants are employed as a wash : Liq. potas.carbonat., also solution of
corrosive sublimate, at first stronger,later more
ments.
dilute,and borax and sulphur ointMilium.

2.

Isolated whitish, rounded

granules,often of a pearlylustre,usuallythe size of grits
above the skin, covered
millet-seeds,
generallyprojectinghemispherically
only with epidermis.
The
favorite sites are
those partsmost amply provided with sebaceous glands,
where
the skin is thinnest ; in other words, where the efferent ducts are
more
especially
the shortest.
While
comedo
is more
is most frequent in pera disease of youth, milium
sons
or

of middle
A

age.

milium

is situated

the follicle there is either

Milium
and

causes

shows

thin

same

layerof

the cutis

portionof the cutis

the

no

occluded

closed either at the

the sebaceous

mouth

of the efferent duct

opening or through

hair follicle,
where

as

the sebaceous

gland ; above
epidermismerely is intact.
remain
unchanged for years,

else the

or

tendency to inflammation,but
subjectivesymptoms.

no

Behind
be

in the
a

may

of the sebaceous

its entire extent, the

it forms

gland, which

secretion accumulates

may
in

round

lobulated body.
or
organizedbody : around a point situated
at the centre or external to it are formed
of concentrically
a number
arranged,progressively
'-"
The
enlarging membranes.
pearlylustre is probably due to this arrangement.
Sebum, partlyor entirelydegeneratedepithelium,free fat, and small hairs, are situated
between
these lamellaB,consistingof firmlyapposed epithelia.AVhen the sebum
is largelyfluid,a yellowishtranslucent body is formed, meliceris.
A microscopicsection
shows that the lamellae,septum-like,
divide the small tumor
into segments.
Similar

or

to

Causes

the

of the

comedo,

it

occlusion

of the mouth

representsan

of the sebaceous

follicle are

1. Those

of

medo
co-

and

wall
to

atheroma, for this opening may be closed by any comedo, the irritation of the
around the efferent duct, and then, by cicatricial contraction,
leadingto inflammation

obliteration

of the

mouth

other cicatricial formation.

quiteintact

cutis and
30

or

of the efferent channel

(Virchow).

Recently I saw the formation

epidermis,within five or six weeks

of milia

occur

2. A

in

traumatic
an

or

otherwise
.

after

superficialabrasion

of

466
the

ANOMALIES

cheek

; it

obliteration

the

seems

the abraded

within

3.

area.

The

EXCEETION.

OF

affected

occlusion

all the

may

be

openings of
congenital.

the sebaceous

glands

this affection with any other, excepting

impossible to confound
sufficient
differential characteristics will be
palpebrarum ; however,
pronounced yellow color and the more
furnished, on the one hand, by the more
plate-like
roundish
well as
which
xanthoma
of
a sharply demarcated
as
form,
presents
appearance
other
the
the
fact
that
xanthoma
is
of
the
lustre
hand,
the
absence
on
by
pearly
;
by
fold
of
milium
feels
the
to
confined
on
a
skin,
grasping
eyelid; moreover,
generally
the epidermis is slit open, in milium
does not, and when
like a foreignbody, xanthoma
It is

Diagnosis.
perhaps xanthoma
"

the

sphericalbody
The

easilyexpressed,but

is

of milium

treatment

consists

bloodless,with

incision,often

small

in xanthoma.

not

in its removal
a

lancet

into

usuallyit is sufficient
the tense epidermis,when
;

rubbed

at least

once

of milia which, however, I have

advises frictions of green

Kaposi

day.

multiple formation

In acute

gentle
at most requires
should be soaped

minute
The
wound
the globule to emerge.
lateral pressure will cause
the skin
to be covered with court-plaster.In order to preventrelapses,
and

make

to

yet

never

with,

met

soap.
3. Atheroma.

8teatoma, Selaceous

Slightlyrounded

Cyst.

hemispherical tumors, ranging

or

elastic softness to tense

from
egg and in firmness
glossydistended skin.

in size from

lentil to

with

hardness, covered

hen's

normal,

often

either in the sebaceous gland proper or in the

of sebum
Atheroma, an accumulation
cellular tissue.
has its seat partlyin the cutis,partlyin the subcutaneous
hair-follicle,
nucha
and back,
in
the
It is met
on
with most
the
face,
on
hairy scalp,
frequently
and

the

on

remains

genitals. The

normal

of the

duct

sebaceous

likewise

of stenosis of the duct

cases

efferent

gland

is either occluded

or

occur.

(most frequentlyon the

and the labia majora, but
eyelids)
; those with open follicular ducts on the nucha, back,
ent
to these places. According as the efferconfined
is exclusively
neither of these forms
The
feels soft and doughy, or elastic and tense.
channel is open or closed,the tumor
Closed

found

are

in size is extreme,

variation

few

atheromata

weeks

to

on

the

according to

scalpand

the duration
The

of years.
hair-follicles seem

number

the face

in

of the retention,which

skin extended

over

an

prise
com-

may

atheroma

of the

From
the
atrophied from pressure.
contents
evacuated
on
are
the pulpy
of the back and nucha
pressure.
open atheromata
mentions
Buch
Atheroma
almost always isolated,very rarelyin groups.
twentyoccurs
the glans penis,after an infection with
three cystsfrom a pin'shead to a pea in size,on
the walls inflame, and
In rare
spontaneous recovery by suppuracases
a soft chancre.
tion
with
and
fluid
the
of
thickening
constituents,
sometimes
also
absorption
ensues,

scalp is

hairless.

calcification.
There
and
times

is

As
no

milia.

The

rule, atheroma

doubt
This

in the sebaceous
has in the

course

that these

as

well

as

be

painless.
cystsare produced

sebaceous

in the

accumulations

explainsalso the fact that the

gland, at times in the hair-follicle. One or
of time been changed by pressure into a sac

variable thickness, the inner

accumulated

is

to

and
epithelia

to the lamellae

surface

of which

is covered

correspondingto the normal

inclosingmilia

and

comedones.

with

have
other

dones
way as cometheir seat at

tures
of these struc-

of connective

tissue of

consistingof

membrane

investiture
This

same

of the dilated organs

lamellar

sac

is the

true

ANOMALIES

OF

467

EXCRETION.

product of the inclosed thinner or thicker,granular pulp, usuallyturned rancid by the

the lesser part
By far the greaterpart of this pulp consists of epithelia,
length of time.
of fat, partlystillinclosed in the epithelia,
free.
The
of
partly
epidermisgives
presence
The fat is either of an
the characteristic pulpy form.
to these cyst-contents
oilynature
cholesterin.
When
the
the latter predominates,
or
pulp acquires a glisteningappearance.
The
admixture
of lanugo is not lacking. In some
cysts,probably transition
forms into milia, the onion-like structure
peculiarto the latter has been found.
with lipoma ;
The
diagnosis is usuallyvery easy. It can at most be confounded
where any doubt remains, an exploratorypuncture will decide.
The treatment
is exclusively
of the entire sac being
the complete extirpation
surgical,
is
the best.
small remnants
of
for
of
no
even
Simple opening or partialextirpation
use,
the investingmembrane
give rise to new
cysts. An easy method which generallysuffices
is the following:
Immediatelyat the margin of the tumor a straightincision,somewhat
longer than
the diameter of the tumor, is made.
Thereby the border of the sac is exposed and it is
the tumor
and thus loosen and enucleate it.
easy to insinuate a dull spoon underneath
Should
must
b
e
be
t
he
sac
extirpation impossible,
opened and emptied, and its inner
surface

destroyed by

left behind

after

some

caustic ; this is necessary,

too, if small

remnants

have

been

attemptedextirpation.
Acne

Acne, Acne

vulgaris,Acne

acne

process,

But

more

restricted sense,

disseminata.

tory
inflammaan
simplex,we understand
glands with the formation of nodules
and tubercles,in the centre of which is a black comedo
plug or a pustule.
efflorescence arises usuallywithout
from
The singleacne
cause
a
any demonstrable
latter
comedo
which changes to a red nodule with a black centre (acnepunctata). The
in a few days developsinto a pustulewith a variablyintense inflammatory areola (acne
pustulosa)and after the comedo plug is discharged,it heals without leavingany cicatrix.

By

in the

simplex.

generallychronic, of

if the inflammation

the

or

acne

sebaceous

is not restricted to the follicle and

cutis tissue takes part, then

inflammation,

its efferent duct, and

in the

majorityof

the

cases,

rounding
sur-

passes

largerabscesses form; they open and lead to suppuration

and
and destruction of the sebaceous
glands as well as of the connecting hair-follicle,
is
the
If
the
abscess
cicatrix
cicatrices.
resembles
scesses
leave
a
small,
pockmark ; largerableave largercicatrices. Larger abscesses have a tendency to burrow, and the contractions
and distortions lead partlyto cicatricial cords, partlyto narrow
folds with the
of pockets.
formation
the sebaceous glands exhibit a strong tendency to form
remnants
In these cutaneous
and milia so that these pockets are
often quitedotted over
with black points.
comedones
with this process
the
to
and
the extent
The pain manifested
of the
corresponds
degree
Another
of
the
inflammation.
is the chronic type
course
inflammation,usuallypainless,
of nodules (acne indurata)
which, however, may subsequently
leading to the formation
suppurate.
of acne
number
The
pustules and nodules simultaneouslypresent is very variable,
to several hundred.
from
However, as but few sebaceous glands inflame at the
a few
same
time, all stagesof development will be found side by side on the same
person.
Acne
is very frequentlycomplicatedwith other affections of the sebaceous
glands;
into

suppurationand

smaller

the

or

468

ANOMALIES

with
the

seborrhcea

of

disease,with

the head,

bloated, grayish skin

rarelyin

more

'icular tumors

whose

first a

The

of

back

In

with

milium,

The

complexion

of the

nodules

oddly intermingledon

the back

on

efferent

ducts

in the

and

are

punctata

acne

In

changes.

and

which

on

pressure

the
the

and
papillae
slightercases

; in nodules

the upper
of acne

layerof

the cutis

matory
the seat of inflam-

are

punctata, suppuration is found

only in
abscesses,the connective tissue surrounding the glands

and

hair-follicles is inflamed, with

subsequent purulent degeneration. The

suppurationpenetrates, the greater is the succeedingdestruction of

the

cases, though fortunatelymuch

grave
also atheromatous
folnucha, there occur

nearly always preserved,and

are

higher degrees of
is frequently

face

rancid white pulp.

gigantic comedo plug and then the above-mentioned
such patientshas a rancid
odor differing
from
tion.
specifically the usual exhala-

the efferent duct

and

processes.

EXCRETION".

pustules,crusts, and
fattylustre. In very

with

the face than

evacuates

face,and neck,

atheromatous

dirty; comedones,
gi'ayish

OF

glands alone

the sebaceous

and

hair follicle.

In

deeply

more

the

sebaceous

abscesses,both

must
perish.
tion;
inspissatedsecrethe latter again is due to deficient glandular activity,
the
fective
deto
because, owing
Behrend
elaboration of sebum, the secretion has time to dry in the efferent duct.
of acne
efflorescences by assuming that the swelling
explainsthe continued new-formation
the
of the inflammatory areolae around
occludes
existing acne
pustules and nodules
efferent channels
of additional, heretofore healthy glands. By this swellinghe also explains

The

or

of the inflammation

cause

the occasional

Kaposi
In

simplex occurs

thirtieth year.
that the male, Wilson

to the

that the female

states

clinic,of

irritation by the

while the efferent

deep in the follicles,
chieflyduring and after puberty, from

of pus

occurrence

Acne

apparently intact.

acne

is the mechanical

is

sex

ducts

predisposedto

more

On

males.

are

the fourteenth

acne.

the other hand, the

were
eighty-three
patients,
fifty-one
found
predominates before, the male after the thirtieth year of life. Hebra
chlorotic
anaemic
and
Chronic
digestivedisturbances,
equal frequency in both sexes.
conditions
to predisposeto acne.
seem
Auspitz repeatedlysaw acne
appear after variola.
and lack of sexual
at the time of puberty has caused excess
The
fact that acne
occurs

female

our

acne

sex

intercourse, onanism, and

consumption

habitual
any

than

more

the others.

to be looked

insomnia

of alcoholic

beveragesor

Still,acne

seems

upon

pungently seasoned

to

have

often it appears only during pregnancy,

are
hand, eunuchs
very rarelysubjectto acne.

sphere,for
other

or

Excessive

factors.
etiological

as

of

dishes

connection

some

not

are

with

the

causes

genital

during that period;on

ceases

the

type:
followingforms or varieties should be distinguishedfrom this idiopathic
1. Acne frontaliss. varioliformis
(Hebra),nodules and pustulesappearing in groups
and
contain
comedo.
The
nodules are brownish-red
no
at the edge of the scalp. The
then
sinks below the level,
crust
flat pustulesoften dry in the centre, and the minute
after the falling
leaves a scar
thus producing an
umbilicated, pock-likepustule which
taneous
that of ordinary acne
The
of this form differs from
of the crust.
course
by the simulThe

2.

Acne

this form
scars.

of efflorescences

of a larger number
appearance
these outbreaks.
between

months

cachecticorum

exhibits

forms,

acne

grave

form

of

frontalis and

over

occurs

flat,dirty-rednodules

I take it to be

Both

(Hebra)

the whole

changing

acne
acne

due

and

into

intermission

an

body

of debilitated

pustuleswhich

leave

of several

persons;

pigmented

to anaemia.

cachecticorum,

are

very

rare

and

bear

the

4:70

the

ANOMALIES

tubercles

howe.ver,is

OF

EXCEETION.

is hastened

by withdrawing the centrallylocated hairs. Idiopathic

acne,
afEection to be conquered onlyby great persistence. The internal
be directed only againstanaemic and chlorotic conditions possibly
present.
so-called blood-purifiers,
etc., are of no value, perhaps even
sarsaparilla,

stubborn

treatment

is to

Laxatives

and

aggravate the trouble.

The

has for its objectthe removal

of the acne
nodules and pustules,
In order to attain
possiblethe prevention of their new-formation.
the former
For
end, the pustulesshould be opened so as to give free egress to the pus.
this purpose we employ a narrow
lancet or the conical pyramidal awl devised by Auspitz,
which
is passed along the efferent duct
far as the pus cavity. Others endeavor
to
as
this
with
the
concentrated
carbolic
accomplish
acid, followed
objectby painting
pustules
by a coating with flexible collodion.
Any comedones
present are expressed, those
inflamed into papules are caused to mature
by coveringthem with emplastrum cinereum,
with Unna's
mercurial
plastermuslin, or else by irritant frictions. For the latter,the
of soap and liquorpotassse
most frequentapplications
alkaline spirit
carbonat.,
are, Hebra's
iodate of mercury
ointments
1 : 10, iodide of mercury
1 : 20, andunguentum
ointments
or
external

and

far

as

treatment

as

Eochardi.
chlor.
Ff, Hj'drai'g.
lodi

puri,

adde

I'o be rubbed

ung.

S.

1.5 Gm.

.......

0.5

........

igne fusis
Ung. rosat.,

Leni

M.

mit.,

in three

times

70.0

"

"

daily.

Compresseswet with solution of corrosive sublimate 1 : 100 (extremecaution !)and

paintingwith iodized glycerin,the partsbeing subsequentlycovered with rubber cloth,
are

also used

for the

solution.

ingkx's

same

All

Hebra
For acne
of the trunk
recommends
Vlempurpose.
these applicationslead to the development and
maturing of

The first-named method, covering with

efflorescences preformed in the skin.
acne
time, is painless,and hence to
emplastrum cinereum, though it requiresa little more
be preferredto the others.
Not until further development of papules is no longer manifested
lotions
be
to
stimulate
should
irritant
the
so
as
employed,
spirituous
slightly
recommended
Hebra
Of
the
for
such,
sulphur paste
by
glandular activity.
sycosis
irritation of the eyes by sulphur
occupiesthe first rank ; but in order to prevent the possible
particles
dropping into them, mucilage should be added to it. I use the following
the

formula

Lactis

sulphuris,

Alcoholis,
Aquae

rosarum,

Mucil.
To

be

acaciae,

aa

...

30 Gms.

10-20

.......

three

applied every

"

hours.

be continued
If this sulphur paste cannot
day and night until recovery has ensued,
of the sebaceous glands no longer appear, the tension and
i. e., until fresh inflammations
by greasing
rough skin of the face by day must be moderated
burning of the reddened
with

simple

some

It is of

water, with
5

To

fat

to
(vaseline),

also to

be

advantage
of glycerin.

use

rendered
for the

less
same

conspicaousby powdering

quently.
subse-

mixture

and

purpose

of benzoin

the addition

Tinct.

5 Gms.

benzoin,

Aq. rosarum,
Glycerini,
be applied two

90
5
or

three

times

daily.

"

"

ANOMALIES

order

the

Instead
of
with

this

activity
of

lotion
of
the

corrosive

months

after

the

471

EXCRETION.

is

cure

completed,

as

toilet

ing
stimulat-

water

skin.

sulphur
sublimate

which,

sand

for

the

OF

paste,
1

however,

has

recommend

autnors

many

EUinger

400-500.
been

formerly

abcesses

it

used

an

most
in

alcoholic

aqueous,

warmly

recommends

different

form,

as

tion
solu-

rubbing
sand-soap

and

pumice-soap.
In

the

case

of

deep

seated

is

advisable

to

scrape

the

lesion

with

curette.

!".

ACNE

ROSACEA

AND

SYCOSIS.

BY

TH.

YEIEL,

M.D.,

CANNSTATT.

ACNE

Definition. Patches

copper-colored,rarely lighter erythemata

or

visiblydilated

the
face, especially

the

to

without

or

bluish

of

"

skin, with

ROSACEA.

blood-vessels

and

cheek, chin, and

nose,

of

efflorescences,mostly

acne

forehead, and

having

the
fined
con-

chronic

course.

Acne

affection

the

of the

has

rosacea

and

on

is

of the

into the

prominently

comes

this account

diseases

accidental

merely

glands

foreground.

the

sebaceous

This

disease

is due

affection

Auspitz has correctlyincorporatedthe

because

to

disease

cular
vas-

among

angio-neuroticdermatoses.
the

skin

of

one

enveloping

the

merely

diffuse

This
first

diffuse
the

on

only

follicles.

redness
nose,

during

the

permanent,

in

The

that

there

of the

the

which

present

are

epidermis,

subcutaneous

communication

veins

and

never

deep

mental

alae nasi, then

toward

give

course

of

with

months
a

deeper plexus

or

the

the

cellular

between
off the

the

branches

noticeable.

generally appears

of irritants

GraduUy
years

light red, during

desquamation

perceptible

and

influence

warmth.
and

and

is

not

vessels

chin, but in the beginning

after
of
eating,
partaking
(after

skin
the

vgssels is

disease

cheeks

the

in the

and

congestion

several

of the

on

the

excitement,

it exhibits

associated

of

first manifestation

fluxions

the

in the

situation, this

dilatation

subjectivefeeling of

temperature
is

its

the

particularlythe

temporarilywith

warm

color, and

Owing

forms

conjoined with

becomes

arteries

surface

with

merges

papillarylayer.
of

to

redness, while

stimulating beverages, with

is

the

series

corium

congestivehyperaemia begins

rule, the

as

of

means

the

these facts

parallelto the

follicles.

enveloping the
a

under

superficialone,
by

wher6

in mind

bear

must

vessels situated

extends

which

is effected

As

of

plexuses

two

tissue ; the
two

this disease, we

understand

deeper

and

often

the

among

glands, however,

sebaceous

To
in

included

glands

of these

dilatation
his

been

of the

it

[heat,cold]),

vascular

dilatation

slowly spreads peripherally,

cold

skin.

the

seasons

Owing

more

to the

bluish-red

implication

ACNE

of

the

blood-vessels

form
This, the slightest
In the further
in

as

of

In
the

cutis

nose

and

in

The

supervenes.

covered

fleshy
anastomosing vessels.

Hans

Hebra

such
be

rhinophyma

the

cause

The

dilated ; pressure
glands
nodules have either a firm or

excrescences

upon the
elastic
an

acquirean extraordinarysize.
Syph., 1881) described and figured

may

Dermat.

und

rhinophyma, as

independentdisease,is to

an

extirpatedabout fortyof

found, like Biesiadecki, Hans

soft connective-tissue

while

even

occurs

these

excrescences

Hebra, Piffard,Eoki-

tubercles

months

and

Spontaneous
present, provided the

are

be removed.
It is certain that

"

is likewise

largeproportion of

almost

genitalapparatus,and
counted

be

to

the

among

acne

rosacea

in
exclusively

causes.

Still

acne

is due

cases

the

female

rosacea

to disturbances

Pregnancy

sex.

also without

appears

disturbances.
Chronic

of

forms

To

disease.

the

those
dyspepsia,especially
cause

same

of alcoholics,and

abuse

tipplersthe

in

rosacea

of the

cyanoticform
erythema

the intense

also be traced

must

it is for

this

with

acidification,
predispose to this

the connection
that

reason

acne

between
is

rosacea

acne

rosacea

and

frequent in

more

Some

localities producingdry wines.

acne

provided with extensively

or
are

unchanged (Hebra).
etc.,are altogether
cartilage,
of the disease is generallyextremely chronic, extending over
remain
disease may
stationaryin any degree of development.

in the

the

the

tubercles

pedunculated,clapper-shaped (Hebra)

The

brother

of

hypertrophy

circumscribed

appear

as

course

Etiology.

such

Simon, that they consist partlyof firm, partlyof embryonal, gelatinous

tissue,dilated blood-vessels,and enlarged sebaceous glands. The deeper

connective

recovery

My

the

eye, and

tissue, hypertrophy of

uniform

is either normal

he believes that

rosacea.

colleagueand

as

else there

or

sebum.

such

on

Gustav

tissues,such

years.

with

but

acne

of

nose

tansky, and

The

semi-solid

plexus ;

to the naked

even

connective

of the sebaceous

recently{ArcMv f.

has

separatedfrom

from

mouths

visible

of

either

occurs

cheek,

skin which

with

embellished

nose

The

rancid

evacuates
A

latter

vascular
superficial

pustules(seconddegree).

lobulated, even
or
hemispherical

of

excrescences

nodules

become

and

the skin of the

swellingof

feel.

to the

branches

nodules

acne

and

degree, finally,new-formation

third

form

the

them

betAveen

the

venous

superadded.

in young
females.
especially
suppurationof the follicles frequentlysupervene,

extends

hypersemia

The

erythematous base, dilated

scattered

rosacea

acne

is often

oleosa

is observed

inflammation

course,

acne.

seborrhoea
a
follicles,

the

enveloping

473

ROSACEA.

kind
of
with

even
pretend to diagnosticatefrom the form of
liquor,and to beer-drinkers they ascribe a largerproportion
bers,
rhinophyma with small nodules and pustules;to wine-bibvascular dilatation and red papules;and to whiskey-drinkers

of

bluish or not at all discolored noses

with oilyseborrhoea.
finally,
cold air and
affectingthe skin, especially
According to Hebra, irritations directly
With
cold-water
rosacea.
frequentchange of temperature,likewise predisposeto acne
of
is
observed.
the
acne
rosacea
too,
development
frequently
cures,
to acne
is exhibited by the tubercular syphilrosacea
Diagnosis. Great resemblance
"

ide.

of

formation

The

the simultaneous
the

presence

of

other

the absence
cicatrices,
manifestations

lupous and carcinomatous

by its slow and benign course, never

latter.

is differentiated

ulcers,crusts,and

From

of

of the

dilated

vessels,
blood-

terize
characsyphilissuflSciently

affections

of the nose,

leadingto

ulceration

acne
or

rosacea

destruction

of tissue.
The
otherwise

prognosisis favorable
it is curable

with

in

so

far

and
difficulty

as

acne

rosacea

relapses

are

never

leads

frequent.

to

general diseasej

474

SYCOSIS.

Treatment.
pregnancy,
to be treated

disease

The

"

uterine

effections,abuse

according to

evacuating

with

the

treatment

nodules

the cessation of the causes,

of alcohol,

its nature.

strable,symptomatic local
and

ceases

dyspepsia,etc.
graver degrees,or

In the

is indicated.

This

as, for

Each

instance,in

of these diseases is

where

no

consists,in the

is demon

cause

"

main, in opening

and

pustules and in maturing and curing those in

the methodically repeated applicationof the
by
process
irritants enumerated
under acne
the emplastrum cinereum, and in the
vulgaris,especially
of tuberculo-pustularthickened
case
paintingonce
noses, by cataplasms and
dailywith
alcoholic
solution
of
acid.
two
This
is
continued
treatment
until
a
pyrogallic
per-cent
and free from pustules. The task then remains of removing as far as
the skin is smooth
mode^ of
possiblethe erythema and the vascular dilatation. Even the above-mentioned
with dailyopenapplying the gray plasterin the shape of Unna's mercurial plaster-mull,
ing
of the pustules
time always opens
by rubbing with a rough cloth, which at the same
Whatever
does not yieldto the
a great part of the redness.
some
blood-vessels,removes
treatment
with sulphur paste (seeacne)which is then instituted and which is to be continued
for weeks, is removed
The
means.
by mechanical
larger visible blood-vessels
with a cataract
laid open lengthwise,
needle
are
or
a
lancet, and dressed with styptic
of formation.

This

is effected

cotton.
In the

must

else

of smaller

blood-vessels

erythema, the entire reddened surface

in the shape of parallelscarification,
shallow incisions being made
numerous
these, or
parallelto each other and across
scarification.
A fine scalpel,
the two-edged knife resemorm
bling
by the multiplepunctif
lancet devised by Vidal, and the compound scarification of Balmanno
a cataract
case

repeatedlyscarified

be

and

by

my
hemorrhage, the

the

brother

diffuse

either
sittings,

suitable for linear scarification.

Squireare

scarificator devised
arrest

in several

in

parts are

Suitable

1873, which
covered

for both

methods, however, is the

consists of six

with

lint.

the scarification leaves any visible scars.

Unfortunately,however, a collateral circulation of dilated

vessels
superficial

the

slittingof the

nor

calls for the repetitionof

sharp spoon is excellent.
highestdegreesof acne rosacea,
and

established

To

lancets.
parallel

Neither

the

removal

rhinophyma, nothing

remains

the

procedure.

For

visible vessels is often

of isolated

Bruns'

nodules

In the

in

but

plastic

operativeprocedures.
SYCOSIS.

Definition,^A chronic, non-contagious disease

"

which
smaller

and

sometimes
The
next

set with

are

the

thick

hairs,where

it leads

localized

to the

larger pustulespierced centrallyby

at those

development

hair, as well

as

parts of
of

the

to smaller

or

skin

and

nodules

of

larger,

infiltrations and abscesses.

perifollicular
form the most
nasal
mucosa
frequent seat of the disease
hairy
the
axilla
the
and
lashes,
eyebrows
pubic region,
; the hairy scalp being most
confluent

beard

rarelyaffected.
Associated

with

the

Men
with

twenty to twenty-fiveyears are most frequentlyattacked.

small red
tension and
heat, there are formed
feeling of some

of from
a

nodules, either isolated

or

more

or

less

closelyaggregated,the pointsof

which

are

forated
per-

change into small obtuse or pointedacne-like pustules. The

latter either dry up, forming a small dry crust piercedby a hair, or they burst.
By the
of the pus from
several adjoining pustules connected
confluence
purulent crusts are
the efflorescences are
formed.
When
closelypacked, inflammatory infiltrations form
in suppuration: hemi",lsoin the cutis surrounding the follicles and usuallyterminate
by

hair and

which

475

SYCOSIS.

protuberancesof

uneyen
spherical,

(These

carbuncle.

or

the skin often

simulatingthe appearance of a furuncle

minute
abscesses,emptying through many
and
adjoiningpustules
abscesses.)
closely

cuticular

carbunculoid

openings,arise from the confluence of

At the peripheryof the affected parts new
efflorescences arise,and thus the disease
graduallyspread over the entire beard and the scalp.
may
When
the hairs are pulled out at the beginningof the process, the root-sheath
is
found
to adhere to the hair in the shape of a clear hyaloidcylinder. In later stages the
appended root-sheath is opaque, and stilllater exhibits a purulent swelling. In the first
more

of the hair is followed

the withdrawal

case,

or

less turbid

looselyinserted
Should

the

of

sycosisnot

the cicatricial process

The
quite hairless scars.

and

still

the stillretained

sycosisframboesiformis
sclerosed scalpwhich

Kaposi

believes

other two,

advanced

the

more

touch.

Finallythe

be

with

moist,
hairs

loosened

there remain

flat

been

bunches

of

has

an

or

Hebra

in the

remain

by

connection
u.

off

twenty

undermined

sometimes
which

to

by

named

no
idiopathic
process
papillariscapillitii
{Archivf. Dermat.

to

cast

almost

ten

hair

and

verrucose,

are

uneven,

or

lastingfrom

occiputhas

at the

varietylocalized

inflammations

cuticular

surrounded

are

; in this form, firmly imbedded

is set with very hard tubercles and

calls it: dermatitis

sycosis and
p.

has

process

is very chronic, sometimes

course

disease

the

hairs

after which

commences,

chronic

more

the

; in the

of blood

drop

be treated, the above-mentioned

Often

bleeding on
condylomatoid proliferations,

years.
A

minute

farther

The

pus.

the hairs.

are

will form.

abscesses

drop

by

pus.
with

Syph., 1869,

382).

with eczema
diagnosisis usuallyeasy, but the disease may be confounded
(which
forms of lupus,and with parasitical
with some
the tubercular syphilide,
sycosis.
The
tubercular
syphilidepresentsthe sharp, painfulmargins,and the lardaceous fundus
of the ulcer,peculiarto it. Lupus presentsthe primary lupusnodules and rarelyconfines
itself to the hairy parts. The nodules of sycosis,
when
squeezed, often allow the pus to
of small openings ^the mouths
of the follicles. In parasitic
number
a
"escape from
The

see),with

"

will show the Trichophytontonsurans.

sycosis(herpestonsurans)microscopicexamination
Parasitic sycosisoccurs
as
red, hemispherical,
perforated tubercles,up to half a walnut
The
in size,which
hairs are
isolated in the otherwise
are
healthy skin of the beard.

lustreless and

Eczema,
cause,

skin

when
but

connection
Hebra
rise to the
small

The

affection often

etiologyof sycosisis quiteobscure

The

affectingthe
a

quiteloose.

hair

such
directly,

extending

to the

the

as

measures

sycosis.
perhaps the

believes that
disease ;

Lunger,

that the

perforatinginto

the old

that

transverse

to the fact

the

; in

some

profuse

the

cases

secretion

cause

of

parts of

may
chronic

the face.

lie in irritations
nasal

catarrh.

leads to sycosis. Frequent shavingis not

hair-follicles,

of the best curative

one

with

to the beardless

extends

presence

of

sycosis. Scrof

in the

is the
follicle,
diameter

of

follicle of two

same

development of

ulosis and

new

small

the hair is

hairs

ascribes

the

no

give

may

the
hair-follicle,

Wertheim

cause.

syphilishave

new

tion
irrita-

too large for

relatively

its

follicle.

Prognosis. Sycosisis a curable disease ; it

Relapses are not rare.
Robinson
Morbid
Anatomy.
{New YorhMed.
"

never

leads to

disturbances

of the general

health.

"

that the first inflammatoryalterations

Sept.,1877) found
and
regions,
perifollicular

Journ., Aug. and

alwaystake placein

the

476

SYCOSIS.

inyade

subsequently

only

Treatment.

the

Internal

follicle.

remedies

mild

Very
with

for
In

acne

of

are

painted

with

with

pustules

with

The

The

it

order

of

the

be

application

hairs

wet

as

in

the

until
scarified

tubercles
I

an

bined
com-

continued

method

is

spot
night

by

treatment,
is

larger

which

mature

affected

This

any
ment,
oint-

in

seated

pustules,

pus,

tannin

cataplasms,

applied.

opened,

and

possible,

as

weak

hairs

the

day

mature

be

must

or

of

mended
recom-

cloth.

close

Then

by

paste

rubber

the

shaved.

again

blood

cut

Then

and

are

and
is

It

solution

sulphur

(diachylon

is
50

the

being

pustules

alcoholic

an

compress

beard.

seated

is

paste

for

for

least

at

sulphur,

order

adapted

excellently
the

months,

three

continued
the

skin

evacuate

sulphur

night

of

folliculitis.
peri-

prefer

greatly

spoon.

the

every

must

shaving

from

sharp

application
I

rule,

the

the

abscesses
to

as

so

primarily

the

beard,

with

cataplasms.

plaster

the

Larger

scarification)

scraping

of

epilation

acid

and

pyrogallic

the
with

day

ointment

with

non-irritating

form.

longer

no

of

night

the

remove

or

tweezers

or

continued

(punctiform

with

the

emollient

an

lenient.),

solution

the

ointment

emollient

with

with

covered
to

is

sycosis

removing
twice

during

necessary

unguent,

pulled

pustules

be

detached

are

10

is

without

painted

smeared

should

it

cases

present
1

this

cured

nodules

and

50),

graver

crusts

to

(1

be

can

the

knife,

acid

pyrogallic

only

cases

the

Mm,

to

ineffectual.

are

"

opened

According

mild

tannin

shaved
the

ointment

to

morning.

every

fissured

become

skin

As

relapses.

prevent

to

be

to

Should

year.

one

beard

in

rubbed

be

after

shaving.
If

above

hair

tweezers
of

the

the

The

must

the

daily

withdrawn

be
other

affected
in

until

no

the

direction

of
the

pustules

more

vegetations

are

its

(only

the

the

epilation

the

and

growth,

same

With

epilated.

be

must

spot

remaining

treatment

condylomatoid

verrucose,

chloracetic

is

shaving

formed.

yield

rapidly

to

painting

single

with

acid.

Sycosis

by

hair

continued

omitted),

In

by

after-growth,

entire

the

fail,

procedure

of

sycosis

painting

of

other

parts

of

the

of

eyelashes

the

the

affected

spot

body
have
with

is

treated

always
yellow

had

like
the

precipitate

that

of

best

the

effects

ointment

beard.

epilation

from

(1

50

of

followed,

vaseline).

4Y8

MOKBID

nail
an

becoming
kinds
These

while

OF

of alteration

THE

ETC.

NAIL,

circumference, or else by

a
nearly normal
retaining

size of the nail,the elements

abnormal

Both

massive

more

CHANGES

materiallychanging their
designatedonychauxis or hypertrophy.

are

not

mutual

relation.

forms

The nail in which

the over-production
present essential differences.
aggregationof the nail-cells appears unshapely,thick, opaque,
curved and of a grayish-whitecolor,has a massive
glossyon the surface or spherically
is
hard
and
that
often
it can be divided
feel, heavy
so
only with the scroll-saw. When
the change affects the whole
its
it
shows
at
free
border
ward.
downa tendency to curve
nail,
manifests

itself by unusual

The appearance
is different when
the deviations
based
are
the dimensions, i. e., the longitudinalor -transverse diameter
or
Should

the relation be disturbed

itself especially
in the

diameter, it may
alterations in

reach

space.
In other cases

in width.

longitudinalaxis

fest
diameter, this will mani-

the

this deviation

nail

enlargein its vertical

generallyassociated with

is

nail

or

the nail

(Fig. 39).

Fia.

and

Should

of epidermisaccumulated
being either turned upward by the mass
curving in various ways (onychogryphosis).In its simplest
claw-like,so that, if of sufficient length,it may reach as far as
Fig. 38 representsagryphoticnail 7.5 cm. in length and 2.3 cm.

in the matrix,

the interosseous

parts.

lengthof 12 cm.,

the
direction;

form, the nail becomes

in favor of the transverse

adjoiningsoft

of

enlargement

an

upon
both.

and
spirally

curves

these

Between

two

may
kinds

wind

once

Fig.

38.
from

Fig.

38."

Nail

Fig.

39."

Nail from

great

the

toe.

little toe

(Drawn
of

woman

from

or

deviation

of

nature.)
aged 60. (Drawn

twice

around

transitions

its

occur.

39.

from

nature.)

configurationfrom accelerated growth are also changed

They are dirtyyellow,slightlylustrous or yellowish-brown,yellowishgrayishlongitudinalribs,at greateror lesser
white, have on their external surface stronglymarked
here and there horny plates. The
and
less elevated ridges,
intervals transverse more
or
in color,has an
inferior surface is usuallybrownish
irregular,
flakyexterior interrupted
by smaller or largercavities,and is crossed here and there by transverse ridge-like
projections.
Such

nails

exhibit

as

an

altered

otherwise.

Anatomy.
we

learn from
obtains

arranged
roundish

"

making longitudinaland
prettyuniform consistence

On
the

; while toward

in fan-like
or

flattened

sections

at the surface

the inferior surface there appears

layers.
round

transverse

At

cells

the

more

through gryphoticnails,
tion
only a slightdevia-

that here
a

harder

or

softer substance

layers the nail consists of small

superficial

containingdark granulesof

various

sizes.

Along

the

MORBID

CHANGES

OF

THE

479

ETC.

NAIL,

and
more
linearly,
closely
longitudinalaxis, the cells are arranged more
aggregated in
the
to
transverse
Farther
t
hose
downward
higher
ridges.
corresponding
places,especially
the
at
the cells are grouped in irregularmasses,
above-mentioned
cording
especially
ridges. Acof horn, which
to Virchow,
they contain centrallyhorizontal masses
laterally,

by

first observed
togetherinclosing the
medullary spaces
to represent sharplydemarcated
closer examination, they are
seen
homogeneous, lustrous yellow or finelygranular mass, and in them

On

him.

cavities filled with

bo found, at times,

may

epidermiscells in

"

process of cornification.
bed looks shorter, is arched

the gryphotic nail is lifted off,the

When
and

"

both
vertically,

however, descend

in the centre,

of

On removing the mass

at
epidermis usually largelyaccumulated
ward
longitudinallypointing ridges,and further backgreatlyhypertrophied,
The
latter exhibit
into view.
the papillae
too, come
large,dilated vascular loops
them.
infiltration around
Moreover, this condition will be met
a slightsmall-celled
the nail-bed and on a considerable
in no slighterdegree all over
part of the matrix.
of
the
matrix
anterior
and
the entire circumboth
the
ference
conclude
that
I
Hence
portion

often narrowed.

the surface, the

with
with

of the nail-bed
The

Etiology.
"

is the

former

The
and

the

into

the world

in

are

onychauxismay be congenitalor acquired.

far as the disposition
dates from the embryonal period,
so

in

case

state of irritation.

chronic

of

causes

in the

of life.
course
appears
but
with a relatively
nail,
larger

anomaly

child

the

born

latter

with

becomes

macrodactylus comes
only
very voluminous

rapidity. More frequentand

disproportionate
pronounced in form is this onychauxisin children affected with the various cutaneous
associated with papillaryhypertrophy(ichthyosis,
cornu
cutaneum, etc.).
the onychauxis is acquired,
i. e., traceable to
In the great majorityof cases
the

by

part in questiongrowing

with

more

eases
dis-

direct

idiopathicor symptomatic in nature.

may
time from
in front or sideconsiderable
ways
1. Trauma.
Any
pressure acting for some
extremities
short
increases
the
nutrition
of
the phalangeal
or
narrow
on
shoes),
(too
nail-bed by the augmented afflux of blood, and
provokes an over-productionof nail
be

These

factors.

causative

"

the

substance.
2.

the

wherever

Voigtel

and

bed-ridden

this head

Under

3.

knew

twisted, 6.5

of all sorts of substances

hyperplasia.

he

long

cm.

the

toe-nails, in

whose

man

the nail-bed

on

belongs also

"

skin, and

the

that

much

uncleanliness, were

of

care

narrates

the

velopment
of the nail. Nails present an excessive deis
t
hat
of
the
glected.
nenail,
especially
grossly

altogether
neglectedcare

Defectiveor

and

Q.Q

act

as

thick.

mm.

mechanical

of excessive

occurrence

tissue of
sudativus

absolute

of

cases

nail formation

of morbid

the diseases enumerated

of

causes

of chronic

onychauxis.

the last-mentioned

For

still how

Furthermore

cutaneous

in old

disease,we

and

lead to

people

eczema,

under

this head

every

physicianhas certainlyseen

rarelyhas
it should
are

not

be

he

are

seen

by
as

no

the connective

means

lichen

to be looked

ex-

upon

largenumber
formation
sequel hyperplasticmal-

emphasized that, in
rarelyliable to encounter

consequence
conditions

Therefore
the contrary, to a defective formation.
we
cause
some
be, besides the immediate
(cutaneousaffection),

pointing,on

that there must

and

eczema,

of the nails !

the nails

lation
accumu-

patients.

extension

However,
as

great

and
irritants,

inflammatoryprocesses of the corium

the cutis to the matrix of the nail (psoriasis
vulgaris,chronic
Grsecorum
and Arabum,
etc.).
ruber, elephantiasis

The

of

consequence

The

must

of
of

admit

predisposi-

480

MOEBID

CHAJS'GES

OF

THE

In favor of this view is the fact that in isolated

tion.

vulgaris
"

onychauxis arises

even

when

ETC.

NAIL,

cases

the matrix

e.

"

g., in

chron., psoriasis

eczema

of the nail is not

implicated.
1. in neuropathic

nail cells occasionally

appears :
itis,
degenerativeor irritative character,most frequentlyin spontaneous neurtrunks (glossyskin),
nerve
neuralgia,chronic myelitis,traumatic lesions of mixed

8ymptomatically hyperplasia of
,

affections of

the like.

and

Furthermore, this alteration of the

such

as

3.

which

articular rheumatism,
Partial

hyperplasiasappear
the remaining part of

cases

nails

occurs

after various

chronic

diseases,

ankylosis.

ulcerative

strives,as

the matrix

after various

2.

affections of the bones,

processes
it were,
to

at the nail-bed, in

compensate

for the

loss.

noticeable

Termination.

Nails altered

in

of hyperplasia
econspicuousby
ways.
nail has lost its elasticity,
their deformities.
A thickened
and hence will not only not contribute
toward enhancing the tactile sense, but, by the continual pressure exerted by the
to a
is diminished
often even
reduced
and
stiff unyieldingplateon its bed, this sense
Here
minimum.
is it with gryphotic nails ?
the finger tip is either entirely
How
covered, or else,owing to the upturningof the nail, it is unprotected and thus, together
with the exposed nail-bed,prone to injury.
in the mildest form, the person
If the fingernails are affected with the disease,
even
is unable to execute
is quite
fine work, and where the enlargement is at all considerable,
is
the
on
incapacitatedfor work.
Fortunately, onychogryphosis
fingers.
very rare
gether
Where
the toe nails are affected,walking is interfered with, and in advanced
cases, altotime most
impossible. One of the most frequent and at the same
unpleasant
if left
is produced by nails enlargedlaterally;
and suppurations)
effects (inflammations
shall
the lateral groove,
in.
We
i. e., grow
uncared
for, they penetrate toward
treatment
in
connection
with
the
of
return
to this form
more
hypertrophied
fully

Symptoms, Course, and

become

From

in many

"

cosmetical

consequence
becom

point,they

nails.

it
nail retains the acquired deformityunchanged, inasmuch
The fullyformed
as
of tissue.
generation
Therefore, we shall have the prospect of reundergoes no transformation
of the after-comingportion of the nail,and of its graduallyregaininga normal
the morbific agent before the matrix is
only when it is possibleto remove
appearance,
will
be likelyto follow hyperplasticones
Hence
normal
nails
irrevocablydegenerated.
lichen ruber,
the cause
has been furnished
when
by psoriasisvulgaris,chronic eczema,
will
is
that
after
little or no hope
On the other hand, there
cease
etc.
ever
onychauxis
be completelyrethe causative factors can
Grsecorum
never
moved.
as
or Arabum,
elephantiasis
influences to
the matrix
has been altered by mechanical
The same
is true when
such an extent that regression
no
longer occurs.
of the hyof removing the cause
The prognosis,therefore,depends on the possibility
perplasi
of the nail.
Treatment.
and

The

"

then

objectto

consists in

account

of its abnormal

the morbid

duct,
pro-

in its removal.

If the nail is troublesome

encumbrance

renderingharmless

be attained

must

on

first be removed, for which

the

growth,
longitudinal

scissors will suffice in

time, resort must

Only when the thickness is increased at the same
the saw.
cuttingpliersand even
If the nail has enlarged in width, it will press on the lateral furrow to
the shoe, there will
and when this is coupled with compression from

then

this

simple elongation.
often be

had

to the

variable

appear

tent,
ex-

at first

CHANGES

MORBID

OF

THE

NAIL,

481

ETC.

of the soft parts;and later,inflammation,suppuration,greatproliferation

:greatirritability
destruction of the cutis,of the tendons, of the muscles, and even
of granulations,
paronychia lateralis.
openingof the phalangealjoint,caries and necrosis of the bones
side
Usually the internal angle of the great toe is implicated in this process, rarelythe outSometimes
children of from,
of the little toe, and hardly ever
even
any other toe.
to two years show symptoms of this affection.
one
folding
The
hyperplasticbroad nail does not alone give rise to paronychia lateralis ; the inof the edge of the skin by the shoe, laceration of the fold, traumatic
lesions,and
"

various

processes may likewise cause

that described, either in its course
or

ulcerative

from
On

close

inspectionof

an

affection which

paronychia lateralis in

tumefaction, and heat of the skin.

At

the

cannot

be

ated
differenti-

termination;

same

its initial stage,we

time

the

note

the reddening,

patientexperiencespain at

the

touch.
If the causative factor be removed, the inflammation
soon
subsides,
slightest
immediate
at most a disagreeable
sensation is felt for a few days. When
relief is not
either a
obtained
and the process extends, suppurationtakes place,and there is formed
true abcess, or a diffuse suppurating wound
offensive
from
the
admixture
of the
surface,
and

decomposed
depth,

and

secretion

around

destroy the
possibl}'^

sheaths, periosteum,and
there

it.

may

be

bone.

In

either

subcutaneous
In

case

the inflammation
connective

may

extend

into the

tissue, muscles, tendinous

exceptionalinstances,with long-continuedsuppuration,
of the foot in the case
of cachectic
phalanx, and even

loss of the affected

dyscrasicpersons.
The
is less violent.
a
chronic, now
Usually,however, the course
process assumes
lead to extensivelyundermined, but rather
and then exacerbatingcharacter,and may
Such
destructions
a
by the burrowing of pus.
suppurating surface always
superficial
at its base, and
looks very irritated,is uneven
covered
laterally
by irregular
spongy,
easilybleeding granulations.With lateral pressure on such an inflamed phalanx, pus
to the surface from various points. Such
a j)aronychia
comes
may last for years.
In the beginning of the affection it is generallysufficient to remove
that part of the
nail which
threatens to grow in, besides putting into the groove fine threads of charpie,
-and orderingwide shoes to be worn
in the future.
if
the
inflammation
is
of
However,
intense,or if even
suppurationand j)roliferation
the edge of the nail are
present,it is advisable to employ the method of complicated
lateral pressure.
The
portion of the nail projectinginto the inflamed part having been
removed, the swollen edge of the skin is carefullypresseddownward, and the widened
is'filled with accuratelyinserted threads of charpieor
space thus gained at the furrow
In doing so, regard should be had that a part of the filling
to rest under
cotton.
comes
the sharp edge of the nail,in other words, that the latter do not come
into direct contact
with the irritated part of the skin.
This done, stripesof adhesive plasterare wound
at the affected part from above
around
the ungual phalanx in such a way as to commence
the border of the skin
downward, each turn being moderately stretched,so as to remove
much
This proas
as
possiblefrom the edge of the nail,that is,to crowd it downward.
cedure,
if performed with some
skill,causes
absolutelyno pain to the patient,but eases
his condition
at once
to such an extent
not only walk but even
that he can
shoes.
wear
After twelve or twenty-four hours, the dressingis taken off,the foot bathed for a short
If the patient has perseverance
time, and bandaged anew.
enough to continue this
treatment
for
several
has
weeks, he
scrupulously
good prospectsof being entirelyfreed
from
his trouble.
Various
authors add to the charpiesome
medicinal solution,caustic
potash,camphor jelly,carbolic solutions,etc.,and instead of the diachylon plasteruse
31

482

MOKBID

CHANGES

OF

THE

ETC.

NAIL,

fusci,etc.
If greatlydevelopedfungous granemplastrum hydrargyriaaconiti,lithargyri
ulations
are
present, they are cut away with scissors down to their base, and the bleeding

pointstouched

with

silver nitrate

caustic.

or

In very

exceptionalcases, nothing remains but to resort to the radical operationof

Dupuytren. For this,the pointed end of a pair of scissors in inserted under the nail
far as the limit of the affection;
then the nail is divided into two
as
parts, and, by
the
anterior
the
at
one
belonging to the diseased side with pliers,
firmlyseizing
margin
with a twisting motion, the affected furrow
and drawing it vigorouslyforward
is freed
from its irritant.
the wound
Then
surface is bandaged and treated according to surgical
laws.
Inasmuch
this operativeprocedure is always very painful,the patientmust
as
be ansesthetized.
We

must

trace the

endeavor

next

to

the fundamental

overcome

factors,which
etiological

affection,and

be difficult if the

will not

therefore

must

ungual phalanx

is carefully

inspected.
If

an

exists which

eczema

to be treated

on

to the

has extended

dermatologicalprinciples.In

ungual phalanx, this,too, will

the first place,we

must

the

remove

have
cause

of the eczema,
with diachylon ointment,
and then treat it,if it be of the moist variety,
I should
In stubborn
ized
vulcanacid, etc.
naphthol, salicylic
cases,
stronglyrecommend
seat
the
to
rubber stockings,
of
the
disease.
When
is
etc.,
eczema
according
gloves,
anti-eczematous
not
affected
the
but
the
local
treatment
an
on
on
present
phalanx,
body,
will be of little
in

eczema

We

use.

then

may

iron, which

exhibit

is well known

to be very

useful

of the anaemic, chlorotic,dysmenorrhoeic,etc.

In

psoriasis
vulgarisof

by

the usual remedies

of the nail appear

it by the use

the

"

ungual phalanx, we

of

(in consequence
only symptomatically

master

first of all

must

tar, carbolic acid, chrysarobin,etc.

this affection

overcome

Should

the

we
psoriasis),

hyperplasia

must

strive to

of arsenic.

sequels of elephantiasisGreecorum, the hope of improving the

after-growth of the nail is very slight. All our assistance will consist in keeping the
affected part clean and removing injuriousinfluences.
In

the

case

of the

It will be almost
and
etc.

the

same

papillaryhypertrophy at
"

^where,in the

most

all those

with

the terminal

favorable

case,

diseases

phalanges
"

we

associated

with

connective

tissue

ichthyosis,
^pachydermia,
verruga,

shall be able to effect

arrest

of

to any form

of

temporary

the exacerbation.
On

the other hand, when

the disease of the matrix

and

nail-bed

is due

a
syphilis,
great deal can be accomplished. During the papular stage, when weeping
ing
salt followed by dustpresent,it is well to apply chlorine water or solution of common
tion
If a change in the dressingsis desired,we
with powdered calomel.
employ solumay
The
been
destillata
lieved,
reof corrosive sublimate
:
weeping
having
25).
(0.1 aqua
wound
around
the
affected
This
should
be
of
part.
strips emplastrum hydrargyri
and
periostitis,
plaster,however, will act rapidlyand surelyalso in syphilitic
gumma,
to
rise
the
the
ostitis. Should
sive
excesphalanges give
degenerationon
spots of syphilitic
nail formation, local sublimate baths
(1 gm. for each bath) are to be particularly
the ulcerated part more
accessible,
Besides this,gray plasteror, to make
recommended.
powdered iodoform.
the morbid
traumatic
influence which
Should
causes
it be some
change, we must

is

"

'

ascertain

its nature.

If the

shoe

is at

fault,we

must

see

to it that

it is neither

too

for
made
wide ; it should be fitted to the form of the foot and allowance
narrow
nor
lacerations
Where
of the foot (Camper, la Forest).
oft-repeated
any specialsensibility
too

CHANGES

MOSBID

the

at

maintain

furrow

the

THE

OF

NAIL,

483

ETC.

irritative conditions,they should

be

guarded against by-

ute
frequentremoval of the stiff cones of epidermis. Should the occupationpossiblycontribto it (baker,
carpenter,etc. ),it is advisable to surround the end of the phalanx with
soft

wax.

II.

Defective
formationof

and
the nail, atrophy of the nail,hypoplasia

aplasiaof

the

their retarded growth may

The absence of the nails (anonychia)
be congenital
or
acquired.
On
developed fingersand toes we not rarelyencounter, togetherwith
insufficiently
defective
absence
or
complete
development, mutilation and coalescence of the nails.
More frequently
these conditions are acquired,and may affect the entire nail or only
turbance.
the expressionof a local or general disas
a part of it.
They may appear, moreover,
nails.
or

Etiology.
"

Trauma,

1.

the naii-bed

only a

backward

enumerate

we

causes

is lifted up
plateis

thin

similar

circumstances, produces sometimes

hyperplasia,

the shoe press upon the bed of the furrow so as to narrow

it,
like a wall and thus hindered
in its activity. The result will be
Should

produced.

in front,a

from

there be

the matrix

part of

nail-formation

of the

arrest

local

which, under

aplasia.Should

sometimes

that

As

The

ensue.

may

is

at the

time

same

of function

placed out

nail-formation

strong pressure

and

at the

complete
part may

even

affected

knock, blow, pinching,etc. I look upon the white spots, on the

nails of children,artisans,and hard-working day laborers,as an insufficient cornification
hindered

also be

by

of the nail-cells traceable

2. Thermic

and

to mechanical

chemical

arrest of nail-formation.

damage

may

In the

forced to handle

nails in workmen
the

development

of

the

part of

same

plete
comHigh degreesof cold may cause even
at
the
a
glance
frayed-out,
crippled
way,

strong acids teaches

to what

us

an

extent the

latter

of the nails.

Inflammationsassociated

3.

influences.

irritations.

with

suppuration

and

ulcerative

nail-bed,while it continues, the

In
processes.
otherwise

matrix

being

puration
supployed,
em-

of the tissue (panaritium),a perarrest,and with degeneration

manent
cessation of production. Hence
we
find, spread over a greater or lesser portion
nail,or one
accordingto the extent of the process, either a narrowed
showing a circular
there will be

or

oblong loss
this

defective

and

Among
disturbances
1.

of the

to

if

punched out, or complete absence of the nail. Adjoining

formation, pronounced hyperplasiais usually present. Henle has

of substance

attention

called

nail-bed

an

as

peculiaratrophy of

the nail in

of

consequence

suppuration

of the

obliteration of the furrow.

the

causes

of retarded

nail

growth

mention

we

the

followingconstitutiona

Every febrilecondition.
augmented transformation

In

fever the increased

of tissue and

hence

the

heat is

produced

at the

expense
the

consumption is greaterthan

reproduction.But as this disturbance extends over all organs and tissues,the result is
of the fever,the elaboration of nail-substance is diminished
that, during the continuance
A
patientwith a grave form of typhoidfever will certainlynot
or entirely
suspended.
nail
form
be able to
substance,and this holds true of pneumonia, peritonitis,
pericarditis,
etc.

When

the febrile condition

is associated with

the extension of the disease to the nail-bed

an

exanthem

or

cutaneous

affection,

will also

In temporary fever the defective formation

of

play a part.
the nail can only

be demonstrated

by

4^4

MOKBID

comparativemeasurements
state continues

for

the nail to

across

CHANGES

time, the

commencing

defect

THE

NAIL,

of the

by weighing

or

some

OF

clipped portions.

increase

may

ETC.

from

But

delicate

if the febrile

streak

running

furrow, partialshedding,total arrest, and finally

loss of

the nail.
AU

2.

chro7iic

nail-formation.
which

followed

are

wasting diseases of

The

new-growth

by

cachexia.

Such

this head

which

nail is

grow

morbid

the

should

long
development
on

nail

defective elaboration

and

3. Those

cutaneous

nails,may

give rise

the

in ataxia, and
(Jeffrey

under

the

in diseases associated

distorted
and

of tissue at the

nails of chronic

acquirethis

tip of

affections

nervous

certain conditions

Pechelin

defective

cause

with

nounced
pro-

embryonal duck-bill,thin,discolored,
brittle,crumbling.

or

and

also

an

being trimmed

atrophy

diseases

will

insufficient in all disturbances

of blood, and

be enumerated
of not

account

organism

becomes

usuallylike

soft and curlingat the end,

lustreless,
Under

the entire

of the

to

more

tuberculosis,
from

appearance

the

the

finger.
produce hyperplasia of
less aplasiaand complete loss

which
or

in

ichthyosis).
In generalwe
Termination.

take a nail to be imperfectly

Symptoms, Course, and
when
it
is
whitish
thin, delicate,giving the impression of a
developed
gray, lustreless,
thickened
membrane
hardness, readilybroken, and flexible. At
; possessingbut slight
"

the substance

times

is

it exfoliates

friable that

so

its thickness, thereby rendering the nail

If

wish

we

correct information

inspectthe nails
nails

and

presentmerely

equaldegree.

an

the several

about

phases of

prolongedfebrile condition.

duringsome

not affected in

are

and
longitudinally

diminished

defective cornification
ning across
eventually,to a pronounced groove
"

Some

which

of them

Others

lustre.

"

fractures

through

uneven.

in front

bounded

and

we
abnormality,
may
beginning the

in the

apparently

are

show

other nails

on

this

Even

changes to
behind

still quite normal

lustreless

narrow

as

broad

with

striprun

furroAv
wall

and,

by

the

termination

of the process.
Almost
without
exceptionthe nails of such persons present
transitions passinginto complete cessation of nail formation.
In the middle of the above-

borders, but which

groove Ave see a lack of substance, often limited by irregular
only the uppermost layers. If of higher degree,the loss of substance extends to
of the nail so that the
the lateral partsof the furrow and through the entire thickness
with defects so complete
latter is attached to the bed only by its body. Finallywe meet
in the formation
arrest
that between
rather unshapely nail there is an
the old and the new
of substance, the former being easilypushed off as a foreignbody.
of the matrix is more
In cases
of ulceration it may happen that the destruction
or
less total. Under
these circumstances, either only a small degenerated stump or no nail
substance at all is formed; the whole nail-bed remaining covered with a dry and resistant
of horn, and changing into the ordinary cutis.
mass
described

affects

Treatment.

"

The

tolerable to the
or

is otherwise

first task

place,we

together with

the

dition
subsequentcon-

nail interferes with

the

we

should

shall have
The

to look

main

after the

impaired

constitution

of the

avocation
a

factors
etiological

ences,
keep aloof any possibleinjuriousinfluchemical
effects;to cure
by appropriate

point is to

traumatic, thermic, and

processes; and, where

removal

the

covering with

advise

inflammations, and
affections,

skin diseases,dyscrasicconditions,nervous

fault,to support the

to render

frequent trimming,and
guard againstinjury.

troublesome,

causing the defective nail.

means,

be

to fulfil must

have

patient. Therefore,when

layer(wax) to
protecting
In the next

we

nutrition

of the

or

patient.

defective elaboration

of blood

ative
ulceris at

486

MOKBID

livid; in

said to become

CHANGES

convalescence

OF

THE

from

ETC.

NAIL,

febrile

conditions, -white;in paralysisof

botb upper
extremities,chalky white; in anasarca,
light white; in icterus,yellow; in
of apoplexy,dark-brown; in hectic conditions,pale; and with certain diseases
consequence
of internal organs, gray.
However, if we devote sufficient attention to all these
we
descriptions,

known

processes

become

convinced

that all the

of nail formation,

relations,i.

e.,

partly
translucency of the

on

allegeddiscolorations rest partlyon wellor

disregardof the physiological

misconstruction

on

nail substance

and

questionit had

been

the

of the

appearance

nail-bed.
IV.
In the introduction

to the alterations in

stated that

change

of

of the nail may take place also beyond the point of production. In entering on
the discussion of this possibility,
must
we
ask, in the first place,what is the nature of the
texture

factors

producing these
with

fullyformed

anomalies

various

nail.

Traumatic

1.
or

the

these

Among

chemical

and

In my

opinion,exceptingisolated

formations, only influences

anomalous

erated
enum-

without

affect the

are:

injuries.

dilute acids in various trades

occurrences

from

These

include

the

use

of tools,or

of

alkalies

hatters,etc.).
(Joiners,

Anijnal

and
a.
VegetableParasites,
Sarcoptes scabiei may give rise to the
anomalies
of shape
changes in the texture of the nail, and, secondarily,
and growth. Boeck
states that in the degeneratednail substance
the eggs and excrement
of the Sarcoptes were
to be found.
E. Bergh demonstrated
that the deviations of the
nail due to Sarcoptes
hand
are
brought about on the one
by affection of the nail-bed
and matrix, on the other by implicationof the substance.
The
collective result of this
influence is,that the nail-bed thereby becomes
hypertrophicand greatlybulged out longitudinall
in the middle.
Correspondingto the degree of this deviation of form, the
lower surface
of the nail is studded
with irregularprojectionsand hollows,
all over
often even
have
the
or
deeply excavated
conicallydepressed. The nails sometimes
form of a high, rounded, pyramidal horn, sometimes
that of a laterally
compressed
2.

manifold

most

claw, and
are

color

on

They

are

of

between

these

irregularlycurved,

the

various

and

the average
is dull
rather hard, but
nail

show

intermediate

of variable

(up to 16

forms

On

occur.

mm.)

thickness

their surface

and

breadth.

they
Their

yellowishwhite, whitish yellow,and darker in the furrows.

still can
be readily cut.
Sections through the substance

to the naked
there
eye the asbestos-like whitish, here and
fibrous appearance
of the axial portion;the pumice-like whitish
On microscopic
aspect of the surface; and the more
yellow appearance of the cortical mass.
even

grayishyellow,flakyor
examination

Bergh

burrows, skins, and

There
nails.

are

also

found

number

in the

substance

causes

nail itch mites, eggs,

of

parasites.
fliesin tropicalregionswhich

JSTone of these insects,however, is

which

of the

egg-shells,

of the

excrement

first violent

pain

and

as

much

feared

as

lay their

the
eggs under
sand-flea (Pulexpenetrans),

the

subsequent paronychia

associated with

loss of

the nail.
h.

VegetableParasites.
ungual phalanx or on some

Onycliomycosis.When
other part of the

either in the

neighborhood of

the

there is a mycosis
body accessible to the finger,
easilyimplicatedon account of the continual opportunityfor
auto-infection.
Hence
meet
with onychomycoses in disproportionately
we
quency
greater frethan as primary affections.
And
in cases
as secondary
in which
no
mycosis of
the skin can
be directly
that it has not been
demonstrated,we cannot conclude positively
present.
of the skin, the nail is

more

CHANGES

MORBID

In

OF

THE

favus and
of the skin
mycoses
their
of
that transference
fungi

only two

"demonstrated

NAIL,

487

ETC.

herpes tonsurans

"

can

changes

cause

^has it been

"

clearly

of the nail,i, e., ony-

"chomycoses.
Of

the

two

of

causes

tinea
onychomycosis,

favosa is

rarer

than

rans
trichophytontonsu-

The clinical pictureof the

the toe-nails the former is exceedinglyrare.
on
; and
affection is rather similar in the majorityof cases, the taking root of the fungi being

conspicuousin the beginning. Such nails are brittle,frayed-out,intersected

particularly
furrows
grayishyellowishwhite appearance, and
by
; they present a discolored,opaque,
under them.
lifted
the
the
"When
to
of
are
epidermisaccumulated
quantity
up according
the

for some
time, the alteration extends to the entire nail,and the
process continues
matrix being implicated,
changes of growth are also present. The nail becomes gryphotic,
here and
the surface, and being detached
there and acoff even
quiring
on
faded, dirtyyellow color,it often becomes greatlydisfiguring. In isolated cases
favus, the nail shows the sulphur yellow,circumscribed, scutcheon-like depressions

thickened,flakes
a

due

to

be mistaken
for the discolorations
peculiarto that disease ; but they should by no means
them
which
the
of
at
are
resembling
perceptible
margin
tion
punctate points of degeneramust
and which
preted
occurring after grave febrile diseases (small-pox)
always be interformation
a morbid
as
startingimmediately from the matrix.
Altogether,in forming the diagnosisof onychomycosis we must proceed with great
bear in mind
that lack of care
of the nail,as well as the sequelsof
caution, for we must
chronic
similar clinical pictures. When
etc.,
exactly
eczema,
psoriasis,
present
may
in positively
*ungi are found, the fact is beyond dispute;if not, we are not justified
cluding
conthat the disease is absent.
sections through a nail changed by the proliferation
of
Longitudinal and transverse
stance
subfungi show it to representan either totallyor partially
loosened, flaky,
disintegrating
to which
adheres a dull white or gray yellowishwhite mass.
When
the latter is
it is possible
of glycerin,
to discover under
the microscope
spread apart and clarified by means
convoluted
threads of mycelium and conidia mixed
with varying quantities
of cornified epithelial
cells. Fine sections of the nail,when carried throughthe entire thickness
and placed in caustic potash solution (1 : 50) show a more
concentric arrangement of the
fungous parts, whence the threads of mycelium extend between the nail-cells and around
them

in all directions.
G. Meissner, who

out
originentirely

discovered

of consideration

the

fungi

; while

on

the

nail,leaves the questionas

Virchow

arrives

at the conclusion

to their

that

more

fungi occurs in onychomycosis, that even several forms may be present

in one
and the same
nail.
tained,
Although the latter part of this propositioncould not be mainestablished
have
the
fact
that
both
subsequent investigations
unquestionably
Achorion
Schonleinii
and Trichophyton tonsurans
of
are
capable
producing the abovethan

one

described

form

of

alterations of the nail.

Treatment.
must

be

often

as

sublimate

carried

"

Owing

to the extreme

of the affection,
the
intractability

It
great perseverance.
and to paint it thoroughly several
possible
(0.5per cent),benzin, petroleum, etc.
out

with

is advisable
times

to trim

dailywith

the

treatment

nail

solution

close

as

of corrosive

As an appendix, we shall discuss the paronychias acute inflammations

of the tissues
underlying the nail.
1. Paronychia traumatica.
Puncture, concussion, contusion, laceration,penetra"

"

488

MORBin

tion of

foreignbodies, etc.,may
at
or
(P. centralis)

the middle
lesions

often

are

overlooked

Toward
sensation

Soon, however,

the
in

more

CHANGES

give rise
the

and
third

the

OF

sides

to

THE

NAIL,

ETC.

inflammations, with various results,either

of
(P. lateralis)

on

the

subungual tissues. The'

flammation
generalare not proportionedto the succeeding infourth
agreeable
day, the patientwill feel some
slight disincreases
phalanx which
especiallyon pressure.

in
or

terminal

circumscribed

spot becomes

reddened, swollen, warmer,

and

pecially
es-

If recovery do3S not occur

at this stage,the inflammatory
painfulto the touch.
will
its
to
site.
If
small
abscesses form
which
often
superficial,
process
vary according
evacuate
their contents
heal
and
within
flammation
a few
spontaneously
completely
days. If the inhas taken root more
the
over
deeply,swelling and rise of temperature occur
whole
ungual phalanx; violent pains are present which radiate upward toward the arm.
When
the symptoms become
violent.
more
In lateral
suppuration has commenced,
which
the latter is
paronychia we observe a projectionat the edge of tlie nail over
elevated, and the surrounding soft parts, infiltrated with serous
fluid,are crowded aside.
This form of inflammation
offers at least the advantage that the fluctuation
is soon
the suppuration is
recognized,and the patient thus easilyrelieved. However, when
situated farther back or toward the centre, the pulsatingpains become
almost
able.
unbearIn such a case
amount
of the surrounding tissue is inflamed, partly
a considerable
suffused and livid,the epidermis raised in form
of a blister,and the root of the nail
and projecting
in a rounded
shape.
opaque
The
termination
of all these inflammatory processes, which
often exhibit a phlegmonous
Sometimes
it terminates
in destruction of the
character, is always in recovery.
/

nail,of the subcutaneous

Treatment.

"

The

carried in
fingers,

pain.

When

tissue,of the muscles, tendinous

connective
limb

be

must

Cold

a sling.
suppuration has

kept

compresses
set

in,

we

at rest,and
should
should

when

be used
first

sheaths, etc.

the inflammation
to moderate

apply moist

the

heat

affects the

swellingand

to

hasten

the

process, and then open the abscess cavity. If pus is not visible under the nail,the latter
should be scraped until translucent
to confirm the diagnosis. If the presence of
so
as
is
of bistouries either from the surface or
can
we
means
established,
penetrate
by
pus
from

in front, in order

to

possiblypresent there.

body
principles.

give free exit to the pus,

The subsequent treatment

and

eventuallyremove

is based

on

any
well-known

foreign
gical

sui

and in patientsaffected with grave chronic

impaired vitality
observe a malignant affection of a part or of the whole of the
diseases,we
occasionally
tissue underlying the nail which
strable
Wardrop terms onychia maligna. Without any demonthe individual feels violent pain in the ungual phalanx. With steadyincrease
cause
of the pains,the phalanx begins to swell at some
point where heightened temperature is
at
its free anterior edge, we are surprised
nail
observable.
stir
the
When
to
we
attempt
When
the root is lifted by depressing
to see how
the root is detached
from the bed.
soon
with
discolored
the edge, it is seen
in
filled
to lie
a
cavity
pus, and its posterioredge
insinuate
the points of the scissors from
When
we
aiopears thinned, dirtygray to brown.
advanced
out
withbehind
forward
often penetratein the more
under
the nail,we can
cases
far as the anterior end of the nail-bed,and ascertain that the nail is
as
any difficulty
attached only at one
lateral portions. On inspectionof the surrounding portions
or
more
of the skin, we
struck at once
are
by the great swellingencompassing the loot of the
nail on
which
the epidermis is raised as by a blister or perhaps detached, and the cutis
of which
losses of substance which bleed readily. When
shows some
exertingbut slight
the
bottom
and
from
of the furrow
the
it,
patientexperiencesgreat pain,
pressure upon
2.

As

consequence

of

MORBID

offensive

some

described
which

This

is

entire

crowded

As

the
is

process

affection

Thus

far

it

only

has

lasting

the

regards

forming

in

the

emphasized
which

slow

the

is

the

impression

for

tissue

it

maintain

the

course,

spongy

that

maintain

rather

the

and

scrofulosis,

and

if

as

there

the

tinuance
con-

present.

are

definite

any

against
on

Cases

oligsemia,
a

over

during

movement

that

places

degeneration.

present

were

febrile

spongy

degeneration.
sometimes

depressed

ascertain

to

rough

cachexia,

but

above-

red

months.

process

numerous

of

spots
part,

more

conviction

the

the

central

the

bluish

to

small

even

many

expressed

suppuration
if

as

disease,

Eayer

with

When

dark

very

still

possible

been

not

"

As

evacuated.

sometimes

and

often

is

the

to

becomes

patient

anorexia,

protracted,

very

Etiology.

sometimes
the

blood

interspersed

and

489*

ETC.

NAIL,

perceive

we

friable,

rule

THE

with

mixed

extends

process

OF

backward,

down,

nail-bed.
of

The

is

broken

ulcerative

the

fluid

sero-purulent

swelling

mass

CHANGES

the

this

view

the

under

under

my

has

surface

the

recently

of

the

nail

me

gave

first

related

newly

ever

observation

anatomically

process

factor.

plates

Bizzioli

furnished

etc.,

causative

nail

instigation
moist

to

grene
gan-

(Billroth).
Treatment.

The

conditions

to

be

fulfilled

twofold.

are

the

By

most

scrupulous

"

cleanliness
matters

to
third

the

or

fourth

fundamental

the

of

accumulation

solution.

Lister,

pyogenic

thymol,

or

etc.

the

of

occurrence

be

must
"

applied

in

septic
such

"

with

learn

against
Burpw^s

dressing

that

touched

the

we

the

manner

guard

must

cavities
fused

and

silver

condition

of

day.

nitrate
the

Besides,

affection.

pockets
or

with

sprinkled
surrounding

wound,
we

easily

cannot

must

give

form

nitrate

strips

strengthening

the
of

of

luxuriating
lead

lead

diet,

powder,

plaster

are

and

endeavor

surfaces
and

in

renewed

are

order

every
to

combat

ANOMALIES
OF

SUDOEIPAEOUS

THE

GLA]^DS

Al^D

THEIR

rUI^CTIOTsT.

BY

PROF.

E.

GEBEE,

M.D.,

KLAUSENBURG.

glands have an independentample vascular system surrounding them, and

cell of the convolutions
influencingtheir activity.Each epithelial
specificnerveOn account
of their difficult accessibility,
our
representsan elementary secretingorgan.
knowledge of the pathological
respectsdefective.
processes of the sweat glands is in many
inflammation
with its various
Still there is no doubt that they are exposed to hypersemia,
and
the
manifold
terminations, hyperplasiaand hypoplasia,
atrophy,
hypertrophy
plastic
neothe
the
to
extent
formations.
We
shall first
same
as
largerglandular
processes,
deal with the diseases of the sweat
glands in the most restricted sense, and then with
their abnormal
activity.
The

sweat

fibres

I. INFLAMMATION

Inflammation

glands,it
process

of the sweat
in

occurs

has not

an

advanced

OF

glands is one

acute, subacute,
too

far, it may

or

THE

SWEAT

of their most
chronic

Etiology.
secondarilyby
"

or

extension

of the sweat
from

the

frequent diseases.

form, and, when

the

As in other

inflammatory

resolve,or else change into suppuration,abscess

formation, hypertrophy, atrophy,fatty,hyaline,and

Inflammation

GLANDS.

other

glands may

neighborhood,or

degeneration.
primarily,idiopathically,
other generaldiseases.
a sequelof

appear
as

irritations,
possiblewhen the pore is occluded, or when mechanical
The latter
etc., continuallyaffect the skin.
as
prurigo,scabies,pediculosis^
by eczema,
similar factors produce inflammation
other
when
the
last-described
and
the
be
case
may
from
extends
.the surrounding connective
of the skin, and the inflammation
by contiguity
The

former

tissue to the

is

sudoripara);when
gland {periadenitis

the afPection

arises after grave

mFLAMMATION

febrile

diseases

marasmic

THE

OF

SWEAT

acuta, cholera, pneumonia

typhns, polyarthritis

"

conditions
In

"

and

the

outline,the contents

their, normal

and

"

in the

train

of

cachexia, scrofula.

"

the simplest form the cells are traversed

distended.
The
canal becomes
slightly
appear
When
the process has
seems
as
a
whole,
gland,
enlarged.

Anatomy.

491

GLANDS.

become

opaque,

by

fine dust-like protoplasm,

in

narrow

proportion,and

gone further, the cells lose

the nuclei divide, and the nuclear

of leucocytes
largenumber
the vessels.
are
Later, the greatly altered cells enter
noticed, chieflyaround
the canal of the gland, w^here they disintegrate
and are pushed forward
and displacedby
the continuallyfollowingpus-corpuscles. The final result of an exudative
inflammation
of
is either complete disappearanceof all trace of a sweat
gland (abscess
sudoriparous
connective tissue corresponding to
gland),or else we find in the loosened, wide-meshed
the region of the pars reticularis cutis,partialoutlines,whose
centrallydirected lumen
cells permit their interpretation
the remnants
and possiblystill remaining epithelioid
as
of glands.
We
shall take for our
of
one
Symptoms, Course, and Termi7iation.
starting-point
the relatively
most frequent localizations which
clinical
presents a more
pronounced
ture.
picI refer to those inflammations
of the sweat glands which are not unf requentlymet
increased.

corpusclesare

In

the

adjoining connective

tissue

"

with

at

distance

of

and

one

half to three centimetres

from

the

anus.

usuallyinsignificant.Some
occasionally
recurringitching
but little importance is attached.
is presentto which
it becomes
however,
By-and-by,
skin
to
and
and
the
feels
rather
As
the inflammation
more
a burning,
warm.
frequent
changes
heaviness
violent
and
are
increases,more
ination
experienced,and on careful exampains
in the depth. In this stage,it is possibleto cause
a nodule
may be demonstrated
of the tumor
and resolution of all the inflammatory symptoms, by the avoidance
dissipation
of every movement
and the employment of ice applications. If this improvement
is not soon
brought about, the skin will become much reddened, infiltrated,
painful,and
be
felt
in
the
of
the
hard
centre
a perpendicular
cord, startingfrom a
hot;
patch may
the enlarged nodule
broader
base
toward the surface where it terminates
either in a
roundish
flattened elevation.
At this time suppuration is usuallypresent, though it
or
is not easilydemonstrable
because so deeply seated; when
we, however, insert a bistoury
into
the
there
is
thin fluid,occasionallymore
evacuated
some
as
as
tissue,
deep
possible
with crumbly particles. If the evacuation
viscid pus mixed
has been earlyenough and
of himself, a few days' treatment
often suffices to arrest the supthe patienttakes care
puration.
In the opposite event, the suppuration extends
far, and deep suppurating
tracks and
wounds
perforationof the rectum
(fistulaani). In
may arise with sinuous
is particularlyslow.
The
individuals the course
marasmic
of the surmelting down
rounding
The

first symptoms

are

"

"

tively
relaappears in the form of cold abscess,and fistulous tracks are
Sooner or later,cicatrization takes place,the characteristic of which
is

tissue then

frequent.

that the surface is drawn

rare

The deep infiltration usuallypersists

the longest,
and with
frequentrelapses.
abscesses of the sweat glands are
also met
with more
frequently

exceptionsgivesrise
Inflammations

and

in.

to

majora, in the axilla,and on the scrotum.

and
Diagnosis. It will not always be easy to distinguishinflammation
Differential
circumscribed
abscess of the sudoriparousglands from
phlegmons, furuncle, syphilitic
But the former affection begins as a deep movable
etc.
ciated
assonodule; is never
gumma,
with fever; is especially
painfulon pressure; permits the recognitionof a firm cord
extending upward; on the surface, according to the state of the overlying cutis, it
on

the labia

"

492

HYPEETKOPHY

sometimes

AND

roundish

ATEOPHY

SWEAT

THE

OF

projectionwhen

the

GLANDS.

cutis is

cutaneous
looselyjoinedto the subare
firmly connected; it
to suppurate at the base; the suppuration often ce5.ses remarkably soon
commences
after being punctured; it leaves a retracted cicatrix and a deeply imbedded
tion
infiltraof its slow absorption,often givesrise to repeatedrelapses.
which, by reason
The treatment
Treatment.
depends on generalsurgicalprinciples. The main thing
is to remove
every injuriousinfluence,and to provide absolute rest of the part in question.
is not yet circumscribed, we may restrict ourselves to cold or
As long as the inflammation
When
the nodule becomes
ice applications.
tinuous
perceptibleand the pains are condistinctly
and serious,puncture should not be delayed,even
if fluctuation cannot be demonstrated;
when
abscess has formed, nothing remains but to expose the wound
an
by a free
and
to
it
to
heal
and
attention.
Even
cause
then
incision,
by appropriatedressings
frequent.
relapseswill be relatively
appears

as

tissue, sometimes

flattened

when

those

structures

"

II. HYPERTROPHY

A.

AND

ATROPHY

OF

THE

SWEAT

GLANDS.

Hypertrophy. Enlargement of the sweat glands is sometimes congenital,in the

general excessive development of the body, or giganticgrowth. More usually,
however, it is acquired and forms either autochthonouslyor is produced secondarily.
Etiology. The simplestform of the former mode of development is representedby
those idiopathic
occurringin connection with those of the epithelium and
hyperplasias
the papillarybody of the cutis.
Under
the same
head belong also the soft warts
(acrothymion) mentioned by Barensprung, in the substance of which, as well as beneath, we may
often find heaps of sweat glands enlarged up to one
millimetre.
The
condition
same
b
e
demonstrated
in
These
are
however,
frequently
ichthyosis.
merely
occurrences,
may
anatomical
of an
while the hypertrophies,
whose
extend
far beyond
elements
interest;
the normal
in every way of greater moment
and
tailed
deare
deservingof a more
measure,
consideration.
Without
there occurs, in the cases
cause
ing
belongany demonstrable
under this head, a proliferation
of the glandular epithelium which
shows
other
no
change than possibly
enlargement,so that the wall at first is made to bulge out and later to
projectin the shape of a finger-like
prominence. If we imagine the process continuing,
obtain a number
of smaller and
every single spur again throwing off others, etc., we
As long as the gland is capable of performlarger tubuli, like a dendritic anastomosis.
ing
its secretory activity,
ever
we
can
only look upon it as simply hypertrophic. But whenit begins an
independent existence no longeradapted to its previousfunction, it
when
its outgrowths retain the glanduacquiresthe importance either of an adenoma
lar
destructive
when
that
of
in
a
character,or
neoplasm
epithelium and stroma proliferate
case

"

of

"

favor of the former.

Besides

the following
genuine hypertrophyof the sweat glands,we must enumerate
of grave diseases,
development : 1. Increased activity. In a number
it is certain that the profuseperspiration
is attended by enlargement of the glands, as in
etc. 2. Mechanical, chemical, thermic,
cachexia, scrofula,articular rheumatism, phthisis,
causes

the

for their

and electrical irritations.

All of these factors,if continued

for

some

time, cause

greater

in the glands or in the cutis with its adnexa, and

supply of nutrition either exclusively
Acute
3. Inflammatory processes.
tions
inflammatherebyincreased formation of elements.
the sweat glands participate,
of the cutis,when
provoke only a temporary increase
the other hand, after chronic inflammations
of the cells. On
they are almost always
In
most
skin
thickened
the excretory duct
altered,
frequentlyenlarged.
by elephantiasis,

494:

FTmCTIONAL

affect

DISTUKBAJfCES

correspondinglarger or
the blood
supply by

OF

SWEAT

THE

GLANDS.

smaller

regions. Wheals, corns, cicatrices,

etc., whicli
the underlying tissue and
favor absorption,
always cause
factors we must also enumeratrophyof the sweat glands. Among etiological
ate
the diminished
For instance, on paralyzedparts of the body
activityof the nerves.
find atrophic sudoriparous glands attributable
we
not only to the
cessation of active
b
ut
to
the
also
lesion
of
the
This
will
also
be the case
nerves.
mobility,
with other
specific
affections when
these fibres have thereby been placed out of function.
nervous
Finally
after inflammatoryprocesses, degenerations,
atrophy occurs
and
metamorphoses of the
It is mainly after the various inflammatory
glandular substance.
processes of the skin
that hypertrophyis not rarelyseen
side by side with atrophy of the sweat glands.
with
Atrophic sweat
glands,unless connected
anidrosis,are altogether of no
diminish

on

pressure

moment.

III.

The

FUNCTIONAL

secretion

DISTURBANCES

OF

THE

SWEAT

GLANDS.

the activity
of the sweat glands may deviate from
the
It
be
amount
in
in
or
changed
(quantitatively)
composition
ways.
may
and possibly
in both ways.
The former manifests itself in three degrees:
(qualitatively),

normal

by

produced by

in two

the

ing
fallmeasure
quantity exceeding the physiological
(hyperhidrosis,
ephidrosis),
of it (hypohidrosis),
or
being completely absent (anidrosis).
Qualitatively
the secretion is altered by peculiar relations of the normal
constituents
(albumen,
chemical
influences
monium
(decomposition products : amsugar, bile pigment, etc. ),various
carbonate, etc.),whereby its color, odor, taste, chemical
reaction, etc., are
changed.
short

Hyperhidrosis Ephidrosis.
"

the term

By

habituallyincreased sudoral secretion,profuse

the whole
sweating,extending over
body. If it affects only a singlepart it is called
hyperhidrosislocalis or, shortly,
therefore,it is
ephidrosis. To constitute hyperhidrosis,
that within
than the
a certain
period of time, under all circumstances,more
necessary
normal
is produced. Nor
in includingunder
are
we
quantity of perspiration
justified
the profuseperspiration
cence.
hyperhidrosis
occurringin intermittent fever with the defervesThe same
critical
remittent
so-called
in
be
said
of
the
profuse,
perspiration
may
fever, typhoid fever, pneumonia, etc.
Etiology. Hyperhidrosismay be congenital,
manifestingitselfsometimes even in very
children.
the husband
Er. Wilson
mentions
and suffered from
a family in which
young
hyperhidrosisfrom the ninth to the fiftieth year, and the mother and two brothers were
we
hyperhidrosis

mean

"

affected,while the two sisters

In

by

any age.
factor in
to

far the

Although
beyond
in the normal
as
hyperhidrosis
the

whether
and

secretion

excito-sudoral

opinionas
mixed
But

inasmuch

cause

fibres effects the

the

of

nerves

to whether

they run

cases

is acquired and
hyperhidrosis

questionthat

it is

ascertain

it.

free from

were

greatestnumber

or

the sudoral
or

secretion,we
it cannot

be

may appear at
is the determining

influence

nerv^ous

shall nevertheless
determined

always be able
only one kind of
inhibitorybesides
not

whether

Vulpian assumes, there are

sympathetic. Moreover, there is still some

whether,

in the

isolated

as

the

nerves

only in

as

of

sympatheticor
merely
of
sympathetic and
company
are

also of
not

difference of

spinalorigin,

also with

motor

fibres,etc.
far from

the immediate

cause

being

able to

point to

for all,i. e.,

the

connection

regional,unilateral,and

with

the

nervous

irritation

as

there
general,hyperhidroses,

DISTTJEBANCES

FrNCTIONAL

is

barelya singlepathological
process

equal

conditions.

which

followed

are

normal

In this
not

secretion

or

OF

which

THE

SWEAT

always produces the

respect I call to mind

anidrosis.

with

Therefore, instead

specialpoints of view
with naming
content
the
and
sweat,
only where

hyperhidrosisunder

and

shall have

to

all diseases

secretion

of

remain

phenomena

same

under

lesions of the cervical part of the cord

only by hyperhidrosis
changing

even

495

GLANDS.

the

of

separatingthem
mainly
influence

nervous

but often by
locality,
of
grouping the causes
from the ephidroses,we

associated
is

Avith increased

indubitable,

note

it

particularly.
Lesions
but

of the cerebrum,

rarely; and
in the

bone, Bloch

the whole, produce disturbances

of the sudoral secretion
on
universal
casionally
ocusuallya partialhyperhidrosis.The latter becomes

if so,

of morbus

course

hemilateral

observed

Basedowii.

Adamkievicz

injurypenetratingthe temporal

an

and, in another
hyperhidrosis

profuseperspirations. Bouveret
cerebri.

After

had

similar

case

of

vulsions,
epileptiformcon-

experiencewith

gumma

of the

of ataxia

of one
cases
arm
occurring after a
profuseperspirationappeared at intervals,and in which the postmortem
showed
abscess of the cerebrum
the side oppositeto the affected arm.
an
on
Conditions
of cerebral depressionoften cause
less developed hyperhidroses.
more
or
these phenomena pointto the fact that a sudoral nervous
be present
apparatus must

cortex

reports two

cortical lesion in which

All

in the brain.
Adamkievicz
medulla

has

observed

profuse perspirationsoccurring

with

glioma

of

the

oblongata.
affections

and
then in
rarely present the picture of hyperhidrosis;
now
horns and of secondary ascendingdegeneraposterior
tion
of the cord if they are
associated
with increased
reflex irritability
and
eccentric
is
Profuse
often
observed
with
of certain nerves;
stance,
neuroses
perspiration
for inpains.
in trigeminal neuralgia,where
it may be present on both sides (rarely),
or
along
one
or
more
branches; also in occipital,
intercostal,brachial,lumbar, and sciatic neuralgias.

Spinal

tabes dorsalis,also in sclerosis of the

alterations and
Injuries,spontaneous or secondary inflammatoryprocesses, morbid
of
the
trunk
of
the
its
rise
or
most
compression
sympathetic
ganglia give
frequently
to
As
a
hyperhidrosis,chiefly unilateral.
rule, cutaneous
hyperaemia, heightened
local

temperature,turgescence

disturbance
oculo-pupillary
The

are

of the

skin, and, with

first acceptableexplanationsof these

Nitzelnadel.

These

lesions

of the

cervical medulla,

present.
processes

were

furnished

by Vulpian

and

that paralysisof the cervical

amplifiedsince Nicati has shown
the
of
in
the
first
portion
sympatheticproduces
stage hyperaemia,heightened temperature,
and hyperhidrosisof the face, that this is followed
by an intermediate
stage with
cessation of the perspiration,
to be succeeded
in the second
stage by pallorof the skin,
lowering of the temperature, and anidrosis.
In hemicrania, according to Du
Bois-Eeymond, implicationof the sympathetic
nerve
begins with the irritated condition (vascularspasm) on one side of the head, and is
followed by paresis erythema and
perspiration of the affected half of the face. In
were

"

"

however

the
(Mollendorf),

in the reverse
symptoms are said to occur
order,
sympathetic is unquestionable.
ephidrosisor hyperhidrosisappears with particulardistinctness in cases of compression
of the sympathetic. Glandular
tumors
the neck, aortic aneurisms, neoon
plasms,
carcinomatous
degenerations (Ogle),parotid tumors (Verneuil),
sometimes
even.

cases,
many
still the participation
of the

But

496

FUNCTIONAL

the infiltrationdue

DISTURBANCES

inflammation

to

of the cutis

SWEAT

THE

OF

GLANDS.

besides

(erysipelas)
cause,

hyperhidrosis,

the concomitant

of paralysis
of the sympathetic.
phenomena (oculo-pupillary)
influences affectingthe sympathetic
Under
this head
belong all the traumatic
in consequence
of diseases of the tissues or of injuriesacting from
without.
Thus, for
met
with
unilateral
has
after
been
caries
of
the
brae,
verteinstance,
hyperhidrosis
repeatedly
fractures of the clavicle (togetherwith
also after gunshot fractures,compound
of the brachial plexus). Hayem
reports a case
affectingthe lower extremitv,
paralysis
and
pigment and hair formation
where, three years after a gunshot fracture,abnormal
instructive is Ebstein-G.
continual perspiration
were
present on the leg. Particularly
in which
Frankel's case
tremity
ephidrosisof the left half of the head and trunk and upper exin
the
without
the
occurred after angina pectoris,
change
pupil. During
autopsy
there were
found
the inferior)
the ganglia of the cervical sympathetic (especially
on
roundish, brownish-black
spotsthe size of a grain of sand which
macroscopicallyvisible,
could be recognizedas cavities (varicose
situated
on
microscopicexamination
dilatations)
Their interior
of the vessels.
continuity
in
blood-corpuscles various states

in the

hyperhidrosisis
the

glossyskin

reportedby

invested

was

of

filled with

and

It is correct

P. Guttmann.

origin,in which

(Paget)of traumatic

with

distinct endothelium
similar

preservation. A
to include

under

case

this

same

of the affected
hyperhidrosis

of left
head

partis

beginning,and is followed by a^idrosis.

main
pulmonary and cardiac diseases associated with hyperhidrosisreand the occurrence
Gubler had long ago noticed the perspiration
obscure.
of deeply
of valvuflushed cheeks appearing with severe
lar
pneumonia. Since then the combination
the
often
of
heart
with
and
cardiac
even
simple palpitation
lesions,
hypertrophy,
out
unilateral
and other
by Fleischmann, Seeligmiiller,
perspirationhas been pointed
the frequent presence
the latter phenomenon, as well as from
of the
From
observers.
it may be argued with considerof the sympathetic,
able
other symptoms peculiarto paralysis
exist. The
lesion may
excessive perspirationin
probabilitythat here the same
the
i
ncreased
it
is
here,
specially
generaldebility,
only
phthisiscertainlybelongs
slight
oy
The
fatty degeneration of the
nervous
excitement, and the depressed state of mind.
is to be considered as a sequel.
glandularepitheliumfirst discovered by Virchow
In hysteriaand menstrual
anomalies, hyperhidrosisor ephidrosisis rather frequently
I think that here,too, paralysisof
at the menopause.
absent
It
is
ever
hardly
present.

likewise

The

present in

the

observations

of

sympathetic may be assumed.

refer to Aubert's results in some
shall briefly
with the preceding,we
sudoral secretion plastically
the
in
to
A.
has attempted
diseases.
cutaneous
represent
In
results.
increased
the following
and has obtained
an
ichthyosis
ingeniousmanner,
the disease has a superficial
is said to be presentwhen
seat,otherwise there
perspiration
the hemorrhagic spots suppressionof the secrewill be hyphidrosis. Purpura shows
on
tion,
fibres of the

In connection

'

while

in their circumference

The

it is increased.

is true

same

of cicatricial spots

spilushypersecretionis found

because,
perished.
accordingto A., hypertrophy of the tissues is associated with that of the sweat glands.
surfaces,etc.,hypersecreOn the hyperaemic skin around
deep-seatedabscesses,wound
the sweat

when

To

secretion

this

end

is to

In

glands have

be

suggested to fasten
ascertained, for about

it is

show

a
one

piece of
or

thin

silver
which

white

minutes,

two

themselves

instance, produced by pilocarpine

off,drawn
through a 0.5 per cent solution of
in this manner,
negative impressions obtained
healthy parts of the skin, it is possibleto get
"

naevus

on

the

nitrate, and
are

information

after

paper,
then

compared
as

lightlyto the part whose

the drops of sweat
for
the latter is carefully lifted
exposed to the light. By the

paper
and

to the

with

"

results

quality of

the

gained from
secretion.

other

DISTURBANCES

FUNCTIONAL

tion

present,while

is said to be

SWEAT

THE

OF

with

parts affected

on

497

GLANDS.

roseola

erythema balsamicum,

In prurigo,
psoriasis
vulgaris,eczema,
etc.,the secretion is normal.
herpes,
syphilitica,
completely arrested;it returns
zoster,pemphigus,the secretion is reduced, in erysipelas
on
recovery, though only after two weeks in erysipelas.
is not an indifferent secretion
Perspiration
Symptoms, Course, and Termination.
constituents
to
2.5
occurring
(0.5
despitethe small quantityof solid
per cent). When
cating
moderately and temporarily,it gives rise to an agreeablesensation by coolingand lubri"

the skin.
sion;
the perspiration
and with but slightintermisappears in excess
cachectic persons
after slight effort, and
anaemic
it annoys
and
if, as
bathes
the
skin.
In
such
causative
the
it
not
only
cases,
phthisis, continually
It is different when
when

in

factor of the

and

do

also the relation of the

know

relation

the

To

be

the

productionof perspiration.But

we

sure,

unimportant by

not

of its few

account

on

be

but
perspiration,

with

connected
but partial,

the

between

admitting that

solid constituents,still the

of the

reason

even

great loss

it. Hence

of water

and

the

find,too, that such

we

to

sweat

the

cutis is of

consumption of

tance.
impor-

material

the latter is

portant
reallyunimcannot
profuseperspiration
nervous

excitement,

even

if

patients,
alreadydebilitated

still more
by the abundant
perspiration.
primary affection,are weakened
manifests itself also by local effects. In such an
event
But the hypersecretion
the
places,is kept clean with difficulty,
skin, at the uncovered
always feels unpleasantly
delicate persons,
the epidermisis macerated.
This is true in a
cool, and, in more

by

the

stillgreaterdegree when
various
the

and

organic

epidermis,but

evaporationis hindered by the coveringof the part and the

The
latter not only attack
inorganic materials remain there.
provoke inflammatory symptoms associated with itching,chiefly
the

eczema.

The

most

strikingexample

of the consequences

of

is offered by
generalhyperhidrosis

{a)sudamina.
In

this

summer

who

eruption

very hirsute

attacks

chieflyfleshy persons

and

forced

to work

who

are

dressed

rather

in the heat

of the day ; in the

are
at
workmen, especiallyartisans whose shop is very hot, particularly
extends
the greater part
over
night. The eruption begins with violent itching,soon
of the trunk, consists of closely
aggregated nodules, vesicles,or pustules the size of a
which
in
fresh
the several efflorhead,
escences
finally
pin's
appear
crops for several days, and
into
small
This
crusts.
disease
cutaneous
dry
inflammatory
may change into a
if the injuriousfactors persistor if unsuitable
fullydeveloped moist eczema
irritating
But if care
made.
be taken that the body do not perspiremuch, if
are
appliances
every
influence be guarded againstand the skin kept dry, the efflorescences reother injurious
trogress,
and, the crusts and detached epidermis being cast off,the process is completed

warmly
winter

within

or

are

it attacks

week.

{h)Miliaria.

This

"

affection has been

regarded as

specialform

of disease which

quently
fre-

arises in the train of other, generallyfebrile,maladies.

As in the acute infectious diseases,
writers

three stagesof the process. The

distinguish
prodromalstageis characterized by malaise, loss of appetite,depressionof mind, suddenly

followed by chill

time the patientsuffers from

rigor,succeeded by heat. At the same
lapsesinto unconsciousness,has syncope, epistaxis,
a
feelingof
the
heaviness
of
the
on
in
the
back
and loins,
chest,
oppression
stomach, nausea, pain
of the fingertips,cramps in the calves,and constant jactitation.This condinumbness
severe

or

headache, often

Oii

498

FUNCTIONAL

DI8TUKBANCE8

having lasted from several hours

e., the eruption,is said to occur

to ten

tion
i.
of

nodules

vesicles

and

from

of the neck, the breast, the

but

with

intensityof

or

the

far

lentil in size appear

on
regions,the extremities,and
a

the

skin

the back,

for several days. The several efflorescences

tion
eruption has no influence on the durafollowed
after a few days by the third stage in
small scales formed
shed without
are
leavinga

fever.

the

dry up
state of the
the process, i. e., the fever and the morbid
independent of the cutaneous
system, may advance or retrogress

I could

as

is

This
and

However,

whole

of the

the

efflorescences

trace behind.

As

to

abdominal

gastricand

become

or

or

days,the second stageof the disease^

profuseperspiration.A largenumber

eleven

after

millet-seed

GLANDS.

in the face ; often fresh crops break out

The
confluent.
only exceptionally

never

which

or

SWEAT

THE

iW

ascertain,there

reliable

no

are

post-mortem

examinations

at all seasons,

affection

The

of miliaria.

occur

but

of persons

frequentlyin
to
children
and
old people
weather
no
cool rainy than in warm
dry
;
spare
age, though
neither
station.
definite
attacked
and
to
sex
nor
can
more
Nothing
are
exempt
rarely
;
ness
be learned as to predisposing
factors or causes.
Opinions differ also about the infectiouswriters hold it to be not all or but rarely
transmissible,and ascribe
of the disease ; some
and
the epidemics,
country places,rather to uncleanliness
usuallyoccurring in remote
to
Plouviez
claims
have
observed
conditions
unfavorable
generally.
hygienic
several
without eruption (suette
sans
cases
eruption)during a miliaria epidemic.
series of symptoms in order to ascertain what
the whole
review once
If we
more
is contained
in the above descriptionsessential to miliaria,what is the most prominent
of the disease given,and what it is that bears the impressionof a
factor in the course
At all
to find anything of the sort.
unable
must
confess that we
are
we
peculiarity,
miliaria
have looked
times there have been physicianswho
as
a
or
symptom
only
upon
most
its
with
the
geneous
heteroto
accidental
even
owing
occurrence,
merely as an
appearance
that
Thus
diseases.
Kreysig asks, should not the miliaryeruption,especially
with
associated
epidemic diseases, be considered a symptom, due to a consensual
of an
Others
irritation of the skin ?
independent miliaryfever
deny the possibility
two sequelsunconnected
fever
and
exanthem
the
as
look
and
miliary
altogether,
upon
the
with each other.
This is the standpoint taken
by
great majorityof clinicians at
at
difference
The
of
the present day.
present existingrefer to the immediate
points
dead

is said to

organs
lesion.

more

"

"

of miliaria.

causes

in each

twofold,

an

"
the occurrence
of the eruption
upon
a
pyfemic process." Trousseau and his school assume

to look

Ilebra is inclined

product of a
a pyaemic origin. I for my
part willinglyadmit that miliaria
but cannot
in the train of a pyaemic and of a febrile process generally,
with the
belief that it should be brought into direct causal connection

case

as

and
idiopathic

frequentlyoccurs
in the

concur

Ferd.

latter.

Definition.In
"

course

seed to

my

opinion,miliaria

eruptionappearing chieflyin

sudoral

consistingof clear,dewdrop-likevesicles from

of febrile diseases,and
a

is

is connected
pea in size;its occurrence
of the
affection as with the possibility

not

so

much

with

the kind

the

millet-

of the

damental
fun-

glandularsecretion.
A febrile state having existed for several days,a crop of
Termination.
Course
and
the
isolated vesicles breaks out, without
the above-described
any specialprodromata, on
the
circumference
of
and
the
base
the
extremities;
neck, trunk, or the inner surface of
have
recent
efflorescences always
an.
vesicles show
no
abnormality. The contents of
include
acid reaction and
only here and there a lymphoid corpuscle or an epithelial
the vesicle is fullydeveloped,it no
cell. A. Vogel has also found chlorine salts. When
the contents
is
as
it
the
that,
evaporate,the covundergoes
only change
longerenlarges;
"

predominanceof

the

mDlTCTIONAL

OF

DISTTJEBANCES

SWEAT

THE

49^

GLANDS.

ering epidermisbecomes wrinkled, and after from two to four days the entire vesicle
The
is shed without
ration
duscale which
leavinga trace.
finallydries into an insignificant
few days, but the eruption in general may
of a singleefflorescence is at most
a
last one
weeks on account of relapses. It has no influence whatever
on the course
or two
of the primary affection.
Diagnosis. Its delicate,dewdrop-like,always limpid appearance, the absence of
It may
it sufficiently.
alteration in the surrounding skin, characterize
escape notice
"

when

the efflorescences

are

to
as
insignificant

so
"

of

the

But

mistakes.

rise to

give

efflorescences

be felt better than

pustules due

The

Diagnosis.
Differential

if

always purulent,

are

that

in mind

bear

we

seen.

pyaemia and

to

that

difficult

they

quently
fre-

septicaemiamost
in

the

occur

latter the

scattered

when

both

be

observed

over

tents
con-

the

eruptions appear
body,
of the bullae in erythe irregularaspect and
occurrence
simultaneously. Similarly,
sipelas
to their correct
will leave no
doubt
as
interpretation. There may be greater
For in both diseases the erupin the case
of pemphigus or febris bullosa.
difficulty
tion
to isolated parts of the body,
confined
is preceded by fever, the efflorescences are
whole

and
of

have

similar

pemphigus

than

will not

differentiation

the

usuallyspringsfrom

that of miliaria,and

in

that

an

even

it will

that

erythematous base, that its average

the

size is

bulla

larger

tion
by an exacerbaevery relapseis heralded
conditions will coincide only by accident.

pemphigus

in miliaria these two

of the fever, while

But

termination.

and

course

be

there
is a misconceptionas
only in case
generally. In many works on skin diseases the
still insufficiently
references
forms
two
of eruption are
to
are
separated. There
miliaria
when
alba
miliaria rubra
the surrouading cutis is reddened
to
a
lactea,
;
whitish
turbid and the surrounding zone
of the vesicles are
is
when
the contents
maceration
of
the
miliaria
of
and
to a
normal
or
epidermis;
crystallina,
pale by reason
when
the inclosed fluid is clear and transparentlike water ; the former two eruptions
are
miliaria.
typicalsudamina, and the latter only is entitled to the name
It

will

regards the

occur

with

at

The

"

sudamina

for

differentiation

Treatment.
it

mistaken

be

of miliaria

best method

place where

it is

of treatment

starch, lycopodium,talcum, alone

proportionof 1

acid in the
salicylic
2.

Epliidrosis. While
"

of generalfrom
inseparability

is to leave

annoying, the drying may

:

30

or

mixed

with

be
oxide

the

eruptionalone. Should
by frequentdusting

hastened

of zinc, cream

of tartar,or

to 50.

consideringthe etiologyof hyperhidrosis,owing to the

unilateral and regionaryhyperhidrosis,
we
were
repeatedly

latter.
The
let us assume,
for instance,a lesion of
same
cause
its
to
seat
and
and
sometimes
without
able
ascertainduration,
according
sympathetic
sometimes
sometimes
will
a
diffuse,
a
partialhyperhidrosis.
produce
reason,
Excessive sweatingof the palms of the hands is one
of
a.
EpliidrosisVola Manus.
noticeable in midthe most
summer,
particularly
frequent local hypersecretions. This becomes
the abnormally increased secretion is still more
when
augmented and the factor
feels clammy and
of continual
evaporation is superadded. Such a hand sometimes
when
the perspirationtemporarilyremits.
again remarkably warm
sticky; sometimes
if the epidermis is not thickened, we notice even
On inspectingthe palm, especially
on
the lateral parts of the fingersvesicles from a pin point or poppy-seed to a lentil in size,
isolated,close together,or confluent (when they may reach the size of a cent)with clear
frequently,the vesicles have ruptured, the epidermisbeing
watery contents ; still more
fringedborder.
lackingat their centres, while the peripheryis limited by an irregularly
almost exclusively
in anaemic children and chlorotic.
Ephidrosisof the palms occurs
forced

the

to refer to

the

"

"

"

500

FUNCTIONAL

cachectic

and
dyspeptic,
both

affects

hands, but

remissions

DISTIIEBANCES

adults, in.

sometimes

and

Feet
and

only one

The

"

after but

slightexertion

make

likewise

are

much

feet sweat

soles of feet affected with

or

GLANDS.

in

It

men.

usually

remain
unchanged for years,
; it may
alternate.
Prequentlythe tip of the

may
the soles of the feet

"

SWEAT

frequently than

more

women

exacerbations

and
usuallyunheeded
i. EpiiidrosisPedum.

THE

OF

subjectto
than

more

the

or

when

even

"

affection.

same

other part of the

any

profuse perspirationare moist

the impression as if they were

porary
tem-

nose

bathed

body.

uncovered

in sweat.

On

inspection,their

due to the macerated, loosened

whitish, dull, lustreless appearance,
the hyperhidrosishas reached
is of
a higher degree and
epidermis,is striking. When

longer duration, irritation will be caused by the decomposed secretion,and by the shoes,
The simplestform of this irritation manifests itself by scattered painful
Should
the process advance, there
red spotsoften occupying the largerpart of the sole.
is formed, just as on the palms of the hands, detachment
of the epidermis of variable
still more
undermined
extent, due to the accumulated
fluid,and the epidermis becomes
the dust, etc.

if the

same

continue.

causes

Dysliidrosis(T. Fox). In two cases of excessive perspirationI

of becoming acquainted with quite a peculiaraffection of the skin.
healthy men
(collegeteacher and cattle dealer) sought my advice
"

feet.

In

the

that he had
maceration

case

been

of

unable

of the

the
for

cattle

days

some

epidermis of

dealer, the
to

wear

foot and

the whole

soles

of

the

had

an

Two
for

feet

opportunity

middle-aged

painful sweaty

were

sensitive

so

of shoe.
On
inspection the
any kind
the partialreddeningof the sole were

without
being noticeablylifted up, looked
very striking. Here and there the epidermis,
lighterin the deeper layer. On puncturing these spots,a small quantity of viscid or
fluid had more
But
that the same
undermined
the
limpid pus oozed out.
extensively
This
unmistakable.
thickened
verified
when
the
corneous
was
layer was
supposition
pushed in sideways from the first puncture. By the side of
pointsof the scissors were
these undermined
patchesof epidermis could be seen purulent elevations,pustules,or,
where the latter were
deprived of their covering,extensive denuded
spots of the rete,
from

lentil to

under

the

walnut

epidermis,and

in size.
there

At

the

peripheryof

the efflorescences
to further

stubborn

was

pus

present

purulent infiltration.

tendency
A similar process, only of slighterdegree, had been present in the second patient for six
The
epidermis,
frequent use of foot-baths, careful trimming of the undermined
years.
followed
in the usual manner
and the continual employment of diachylon ointment
were
by complete recovery in from four to six weeks.
T.

Eox

the

was

first to

was

recognizethis affection,and

of

described

this author, it is due

to

it in 1872

the retention

under

the

of excessive

dyshidrosis. According
has termed
the same
affection cheiroperspirationunder the epidermis. Hutchinson
pompholix, and Robinson, pompholix ; both explainit as a kind of pemphigus. This
if it be true that the process which
I have
view
to me
altogether erroneous,
appears
name

observed
c.

to

is the

same.

Hyperliidrosis hi
Often

occurrence.

ephidrosis,but

it is

axilla.

"

it is associated

in
perspiration

Excessive
with

diffuse

equallyfrequent alone

on

the

hyperhidrosis,at

both

sides,or

else

axilla
other

is of

times

only one.
generally numerous
on

frequent

with

some

ing
Except-

seat and
relations,i. e., the superficial
glands,
stilllack all knowledge as to
factors, we
interpretedas predisposing
Eberth
its cause.
From
the presence
of bacteria in the red axillary
perspiration
argues
failed to contheir causal connection
with hypersecretion
however,
investigations,
; my
Tince me
of the truth of this explanation.

the

which

anatomical

must

be

502

HTP0HIDR0SI8

bichlor.

coloniensis

aqua

ANHIDROSIS.

ammoniat., extr. aconiti,Colombo, 1 : aqua, 200;

350; sodium
aether.,and other diffusible and volatile fluids. All these remedies

corr.,

AJSTD

aqua,

to be applied to the perspiring spot several times

of a sponge
daily by means
slightlypressedon, allowingthem to evaporate or dry in a current of air. In perspiration
of the hands
and feet,the drugs may be employed as ingredientsof local baths.
After this procedure,especially
the alcoholic lotions,the patient experiencesimmediate
in
and
order
maintain
this as long as possible,
to
it is advisable to use
relief,
dustingThe
latter are
j)Owders.
composed of amylum tritic,oryzae, talcum venet., rad. ireos
florent. pulv., sem.
lycopod., etc., to which are added as auxiliaries zincum
oxid.,
plumb, carbon., acid, salicyl,,
folds
potass, bitart. (0.5per cent). To the interdigital
and other parts which are in contact we
of
lint
strewn
with
of
apply
one
pledgets
may
the above powders; but they must
be changed whenever
become
moist.
they
The most difficult task is to relieve profuseperspiration
of the feet.
In the slighter
degrees it is possiblethat one or other of the above procedures may suffice ; in the
are

forms

graver

is

success

this is also true

; and

rare

antiparasitics
(Thin : boracic acid). Thus far
devised by Hebra
which is unequalled,namely,
ointment.
in

To

close

In

ointment
should

the

same

remain

go to bed

the

several

the well-known

and
the

cover

dense

in continual

to about

with

contact

as

of treatment

are

the thickness
laid between

of the back
the toes.

of

As

the skin,it is desirable that the

the

patient

either wrap the foot in flannel,or, if his occupation forces him

to
foot with fresh stockingsand shoes.
After twenty-four hours, the

dressed

in another

remaining
linen

While

the

entire treatment, he should

be

the skin is

on

This
rag as before.
at the end of that time

two weeks, and

or
way for one
times a day, especially
at the transitional

scrupulouslyclean.

recommended

mode

one

employment of diachylon
clean,carefully
dried, and then enveloped
and size,which
is
rag of appropriate form

its effect,pledgetsof lint

removed, the ointment

are

foot

linen

of but

the methodical

diachylonointment

order to enhance

should

be up, to
linen rags
and

the foot is first washed

clean, rather
fitting,

spread with
knife.

this end

of the substances

know

we

the foot is dusted

between

spots and
allowed

not
patientwas
to
do
encouraged

gentlywiped off with oil,

procedure is repeated in

to take

the
foot

thickly

toes,and

bath

kept

during the

The symptoms appearing

epidermisin largeyellowishbrown
flakes thickened
by the applicationof the ointment, exposing a delicate lightpink
or
of this treatment
the ephidrosis
pale epidermis. As a rule, after a single course
for some
is it necessary to repeatthe procedure
ceases
length of time, only exceptionally

immediatelyafter

two

or

the treatment

three times

before the

B.

Complete

loss of the

spots where

deeply
been

seated

the

connective

followed

thereafter.

so

consist in exfoliation of the

objectis attained.

HYPOHIDROSIS

sudoral
sweat

AND

secretion

glands

tissue ;

or

have

on

is

ANHIDROSIS.

rare

where

excepting on

occurrence,

perishedwith

those

'

the

destruction

inflammations

of the

scribed
circum-

of the

more

glands have
(retention

by
opening
and
cysts);or on those where homoeoplasticand heteroplasticnew-formations
appear
lesions.
the perspirationis
of nerve
paralyticconditions arise in consequence
Grenerally
merely slower and less than normal ; but these factors suffice to impart to the skin a dry,
tent,
parchment-likerough feel. But we should speak of an anhidrosis only to a limited exfor

as

atrophy,degeneration,occlusion

rule

Lypohidrosis.

v.^e

are

not

dealingwith

of the

this affection,but with

and

the duct

decreased

perspiration,

QUALITATIVE

CHAJfGES

OF

THE

like hyperhidrosis,
Hypohidrosis,
may
be

congenitalor acquired.
A general diminution

be

general or

503

rARHIDRCSIS.

PEKSPIEATION,

local.

The

tendency

to it may

in a
observed
frequently
associated with hyperhyArabum
tabes dorsalis,elephantiasis
and Graedrosis,as diabetes mellitus and insipidus,
in
lichen
and
even
cachexia,
scrofulosorum, neoplastic
psoriasis,
phthisis.
corum,
But
their most
appropriateterritoryis always furnished by the various neuroses.

number

Thus

of internal

far

we

demonstrable

of the

is rather

secretion

sudoral

others in such

diseases,among

often

are

as

in possessionof but a small number

of
of the peripheral
trunks
nerve
participation

are

in paralyses due to traumatic

or
plexuses. In all these cases arrest

mechanical
of

lesions

of anhidrosis

cases

could

of the

be found

in which

; for

brachial,lumbar,

persistsuntil
perspiration

instance,
or

other

the

galvanic excitability
by the glossy
due
to
caries
of
tubular
in
the implicationof
skin, finger,etc.,
a
bone, in which, early
the nerves,
there is present pronounced hyperhidrosis. And
in proportion as the paralysis
develops,the secretion becomes less until it finallyceases.
The most
atrophy
pronounced picture of a paralyticanhidrosis is presentedby the hemiof Virchow, in which
all the tissues atrophy down
to the bones.
With
such trophoneuroti
disturbances
of the skin we
observe numerous
other neuropathicsj^mptoms,
such as oft recurringinflammatoryeruptions(eczema,herpes,and others),
earlyloss of the
hair,etc. It is evident that there is present here some
implicationof the facial nerve,
to what
but it is unknown
extent
the trigeminus is implicated,and whether
the hypoas
fact is observed in infantile spinalparaglossusdoes not likewise participate. The same
lysis,
in which
the sudoral secretion returns
with the galvanicexcitability
of the nerve,
with the recurrence
of active mobility,and the nutrition of the extremity.
fuse
Hypohidrosis or anhidrosis forms an almost constant symptom in the sequelsof difand poliomyelitis.Strauss and Bloch hold this symptom
to be of such importance
myelitis
that they use
it as a differential diagnostic
sign againstparalysisof cerebral
origin.
In affections of the sympathetic,
shall encounter
we
hypohidrosisonly in the case of
mechanical
due
to
traumatic
lesions.
But
this coincidence
irritations,
or
is not
usually
constant
to
enable
in
the
to
as
so
settling
us,
diagnosis, dispensewith other symptoms of
the neuro-paralytic
condition, such as spastic
pallor and reduced temperature
mydriasis,
of the

nerves

is restored.

no

less

established
certainly

factor is furnished

of the skin, etc.

In

general,therefore,we can say that, in

first place,to lesions of the

it is due, in the

often to those of the motor

here

and
The

prognosisand
C.

The

nerve

there to those of the

QUALITATIVE

trunks

and

posteriorhorns

treatment

CHANGES

of anhidrosis

OF

THE

far

so

as

hypohidrosisis

of

nervous

origin

anterior horns
even

of the gray substance, very

their terminal portions(Leloir),
and

and

some
parts of the sympathetic.
always depend on the primary affection.

PERSPIRATION.

PARHIDROSIS.

of obtaining
the perspiration
which
has come
to the surface in an
impossibility
condition
makes
it
difficult
to
determine
its normal
constituents.
How
absolutelypure
much
difl"cult will this be under pathological
more
conditions,where there is an increase
diminution
of the normal
admixture
of abnormal
substances.
or
an
Thus,
ingredients,
it is well known
that in anuria from nephritischolerica and scarlatinosa the excretion of
the surface of the skin is augmented to such a degree that after evaporationuric
urea
on
acid crystals
often remain
behind
extensive regions,while the quantity of the same
over

504

substance
and

CHANGES

QUALITATIVE

after

The

same

PAKH1DE0SI8.

PERSPIKATION,

is true, under

the

defervescence

of

certain conditions, of the

high fever
tile
fattyvola-

the salts.
of other

large number
sugar

grape

THE

barelyperceptibletraces during

profuse sweats.

acids and
A

sink to

may

OF

substances

have

of albumen

traces
(indiabetes),

found

been

in the form

times

at

of

in the sweat, viz. :

albumin, lactic acid,

serum

after the
cystin,bile pigment, indigo,and other chromogens. Besides, a transudation
mate
ingestionof drugs has been proved ; for instance, iodine after potassium iodide ; subliarsenious acid after arsenate
after iodide of mercury;
and arsenuretted oxide of iron, copper
of sodium

acid after benzoic

acid (H. Meissner,

It is to

that

there

be

expected

of

potassium,arsenic

acid after

after copper poisoning,hippuric

G. Meissner),tartaric acid.

arsenate

disputedby
experiments and

will
investigations

continued

show

that

stillothers.

are

anomalies
of the perspiration.
distinguishthe followingqualitative
to
(ColoredPerspiration). In general this term is understood
dark-brown
to
w
hether
it
colored
be
or
black,
red,
mean
perspiration,
yellow,
every
An exceptionis made
only in the case of the blue perspirationfor which a special
green.
title is employed
cyanhidrosis.
The originatorof the term
chromhidrosis, Le Eoy de Mericourt
(1858),published
to
under
his observation, and
that came
several cases
subsequently(1864)endeavored
histochemical
tigations
investo the profession
the altered perspiration
demonstrate
by instituting
"VYe

Chromidrosis

1.

"

"

(Ch. Robin). But owing to the

simulators
mystifications
by hysterical

with

raised

were

as

decades, several

to the
cases

fact that

(by

of

very existence of chromidrosis.

have been described
by observers

French

eminent

some

means

plumbago,

doubts
nitrate),

within

However,
whose

clinicians met

silver

the

last two

trustworthiness

does

not

of the least doubt.

admit

of seeinga case of chromhidrosis, and therefore

had no opportunity
most
credible.
It is
myself to recapitulatethe data which appear to me
menstrual
anomalies,
said to occur
chieflyin females who are sufferingfrom hysteria,
affection.
chlorgemia and anaemia, with their associated nervous
Hardly a dozen cases
in men,
and then under the most
have been observed
heterogeneous conditions (hypochondriasi
has
Blue
etc.).
perspiration thus far been most frequently
syphilis,
phthisis,
drosis
not so very rare
relatively.Chromhimet with, though the red, yellow,and black are
I have

hitherto

restrict

I must

most
often on the lower
on
any part of the body, but has been observed
may occur
The affection
eyelids,the forehead, cheek, abdomen, a^d, in men, mostly on the scrotum.
is not limited, sometimes
Its duration
in winter.
is equallyfrequentin summer
or
or
more
disappearingfor
relapses,
lastingcontinuouslyfor years, sometimes, with one
sive
extencircumscribed
small
either
It
a
on
spot or a more
days, weeks, or years.
appears
fine
dust-like
the
one
hand, by a
deposit,on
on
itself,
surface, where it manifests
On
such
the
of
places,
the other, by discoloration of the epidermis and even
lanugo.

longer or shorter, straightor circular streaks of discoloration,which can be

removed
by rubbing with oil,glycerin,or by scraping. To guard
only with difficulty
ined
the followingprocedure. The
recommends
spot to be examSpring
againstdeception.
cleansed with oil,and when
is carefully
dry, collodion is painted on in a
perfectly
is actuallypreschromhidrosis
for a few days. When
thin layerand allowed to remain
ent,
then,

we

see

it will show
Foot

itself when

believes that

the

the collodion
color

is due

is lifted
pellicle
to oxidation

glands,and

upon as the product of the sweat

it is met
Hence
influence.
the result of nervous

generallylooked

off.

of haematin, but

with

its

chromidrosis

occurrence

wherever

nervous

is

is

nently
pre-emi-

affections.

CHANGES

QUALITATIVE

THE

IN

Ch..
chromogen are not so harmonious.
of
sufficient quantity
blue perspiration,
found
a
Kobin
and
Ordonez, who examined
in thin layers
therein very minute, homogeneous corpusclesof irregularshape, which
in thicker
darker
and
had
color approaching that of indigo, but
layers were
a
acids
said
to
and
acetic
dissolve
the
are
Concentrated
n
itric,
ment
pigsulphuric,
opaque.
valent
only graduallywhen hot. Accordingly,they consider this substance to be equito that found
by Bizio in the urine in cyanuria,and derive its originfrom the
that the extract made
found
from
the.
Schwartzenbach
epithelium of the sweat ducts.
colored red by mineral
acids and green by
of alcohol was
impregnated linen by means
alkalies.

views

The

themselves.

manifest

in reference

605-

PABHEDKOSIS.

PEE8PIKATI0N,

the presence cf a substance

equivalentto
Scherer's examination
of cyanhidrosis,

this fact S. deduces

From

cyaninin blue pus. In Collmann^s

oxide
the presence of phosphoretted

to

case

of iron.

Bergmann,

in

the

the pyoshowed

of scrotal

case

hidrosis,
cyan-

epidermiscells,chains

of intimately interlaced
equallydiscolored
cultivated on paste,developed into a fungus
conidise of a mycelium fungus which, when
Experiments at impregnatingpus with the blue flakes of epidermis
resembling aspergillus.
reactions furnish any information.
failed altogether,
did the chemical
C. B.
nor
of seventy-two,,
Hoffmann
found
indigo in the blue perspirationof a paraplegicman
the
examination
of
of
red
result
two
while
cases
yieldedno
perspiration
except the presence
bacteria both in normal
Eberth
found
of an ''apparentlyamorphous mass."
and
in "yellow" perspiration;
Babesiu
likewise found
in the "red"
perspirationof the
axilla a form of fungus resemblingbacterium
prodigiosum, and states that the red color
found

of the sweat

the

on

stands

in direct relation "to the increase of this bacterium, and

that red perspiration

is transmissible.

Hcemathidrosis, Bloody Sweat.

It

until the middle

of the present century

of blood through the intact skin began to be apprecimeaning of transudation
ated,
with the sweat glands and declared to be an
by being brought into connection
anomaly of secretion (Gendrin). A priori it must appear improbable that these glands
had anything to do with the elaboration
of a fluid which, according to exact investigations,
contains red and colorless blood-corpuscles,
well as fibrin in a similar manner
as
as
blood.
The improbability
of such a secretion is materially
supportedby the' clinical facts.
2.

that

other

not

was

the

Whoever
such

"

has

persons
abnormal

Furthermore,

seen

cases

there

of so-called

exists

hemorrhages
it is established

the attack, and

hsemathidrosis

strong tendency

occur

in

on

will

to rhexis

the

case

and

membranes

mucous

nearly every

recognizethat

that

in

of the vessels,and

physical

or

number

that

as

of
rule

internal

organs.
emotions
ceded
preSome
neuralgia,

mental

that the latter is ushered

in by local processes.
is presentat the pointin quessensibility
tion,
there appears a local hypersemia,a swelling,
or
else,without any altered sensibility,
discoloration of the surroundings; then an exudation, flow, or jet-like
often even
some
of a bright red or, accordingto the admixture
of serum,
mm.
high, Hebra) stream
(2
issues
the
fluid
from
To
be
these
factors
not
all
do
clude
pale-red
sure,
altogetherexpores.
that the sweat glands take an active part therein ; stillsome
the possibility
suspicion
must
be roused by the fact that a like fluid often comes
to the
as to the causal relationship
surface at the same
time from the mucous
membranes
frequently
; that the process can
be excited by local mechanical
influences ; and that it is by no means
fined
permanently conto one
but
then
where
the
skin
is
now
more
here,
there, usually
place,
appears
delicate,e. g., the ungual phalanx, face, flexor and inner surfaces of the extremities.
authors
believe that haemathidrosis
Moreover, some
invariablyappears only on places,
other

itching or
hypersesthesia,

affected

with

furuncles

or

other

disturbance

of

inflammations, while

we

have

seen

above

that

these

506

CHANGES

QUALITATIVE

IN

THE

PEKSPIEATION,

PARHIDKOSIS.

behave

tions
anhidrotically.Ebers states that in the case under his observation small laceraof the epidermis could be seen.
It is reported,too, that hsemathidrosis, in the
seconds or minutes, and in the graver, one to two hours;
slightercases, lasts barelysome
at irregularintervals,even
that it may
often recur
throughout many decades (Ebers).
It spares neither age, state,nor
and
(thus far only three cases),
when

affected with

; but

sex

it has been

noticed

in women,

frequent
hysteria,
dysmenorrhoea,etc. Parrot, one
more

to be

rare
relatively

especiallyabout
of the most

in

men

puberty

ardent

or

defenders

admits
that it is traceable to central or peripherallocal
hasmathidrosis, even
affections,and hence chieflymet with in hysteric,dysmenorrhoeic,chloro-ansemic
of

nervous
women

in the main
or
that it
paraplegic,paralytic,
hypochondriacmen
; but maintains
e
are
nephritide. These statements
belongs to the same
category as hsematuria
posed
opmorbid
no
by others showing that in cases affected with hsemathidrosis
absolutely
We
of this miscalled
willinglyadmit that the occurrence
change could be observed.
conditions.
hgemathidrosis
with
For
is certainlyconnected
nervous
every physicianis
familiar with the fact that in hysteria,
for instance,vasculo-dilator hyperemias result from
Should
such a person
have
the slightest
causes, either directlyor in a reflex manner.
of the vessels,hemorrhages of various degreesand from
besides a predisposition
to friability
But the sweat glands,being surrounded
different organs will result easilyenough.
by a
able to escape this jjrocess which
not
will
be
is traceable
very plentifulvascular netv/ork,
in one
to a nervous
or
more
origin. Therefore, an exudation of blood may occur
organs
and affect the sweat
likely,may
glands merely by accident ; oj else,what is still more
And, indeed, this fact has
simultaneouslytake place also in other tissues and organs.
the
of
haemathidrosis
collection
of
thus far reported;
Foot's
cases
been clearlyshown
by
the
thereto
other
in
of
or
for
the majority
were
these,
hemorrhages
tendency
present.
and

look

Accordingly, I
which

is incited

hypersemiaof
by rhexis).

by

the

haemathidrosis
upon
the sympatheticand
vessels

The

the

hemorrhages
organism.

as

brought

to
appertaining

the

from

sweat

an

exudation
about

the sweat

of blood

from

in consequence

the sweat

pores

of

neuro-paralytic
glands (by diapedesisand sometimes
not deleterious

are
glands,being insignificant,

to

account
on
Perspiration. The perspiration,
Osmidrosis, Bromhidrosis, Fmtid
organic acids it contains, possesses an odor which is perceptiblein various
degrees. But whether the Laplander reallysmells of whale oil,the Malayan of olive oil,
3.

"

of the volatile

etc.,and what

may

be

the

of it,I

cause

experience. However,

in persons of the Caucasian

is said to cause
of the skin, which
even

and

race.

the

has
perspiration

It is customary to
the

on

quite

of sonal
perpenetrating odor

ascribe this to

neglected care

parts a decomposition of
perspiring

of free volatile

corresponding formation

in the absence

to determine

unable

am

sometimes

fattyacid.

There

can

be

the
no

tion
secre-

doubt

reallythe fact,but it is equallycertain that

perspirationunder all circumstances.
are
movable
the
feet
we
are
the
axillae,
or
Should
the affection occur
on
very likelyto refer the irreetc.
this
will
not
However,
shoes,
explanation
odor to the impregnatedapparel,
treatment
I
had
Thus
under
elsewhere.
a patient
the bromhidrosis
suffice when
occurs
he began to
who otherwise did not show the least traces of bromhidrosis, but whenever
sive
freely,as after eating and drinking heartilyor by active exercise,so offenperspiremore

that in most

cases

of bromhidrosis

also persons

there

an

exhalation

who

spread

Baths, cold ablutions, and

jnent.

are

this is

affected with

around

him

that

offensive

he

was

forced

continued
hydrotherapeutics

to shun
for weeks

all social intercourse.

produced

no

improve-

CHANGES

QUALITATIVE

It
the
would

the

sour

if,

of

in

had
urinse

would

that,

in

the

the

(Funke)

1.55

secretion,

easily

it

substances,

inorganic

The

the

strongly

are

of

acids

i.

e.,

(formic,

for

of

particularly

varies

the

spiration
per-

that

of
of

chlorides),

matous
parenchy-

pulp

profuse
which

is

nitrogenous

In

regard

with

conclude

may

(Favre)

very

other

augmented.

we

altered.

cholera,

generally

is

elaboration

Gm.

crystalline

know

we

the

materially

of

the

All

0.0428

whether

present

likewise

likewise

sudor

"

examinations

any

and

from

in

form

the

are

due

probably
of

butyric,

of

them

the

to

the

greatest

urhidrosis.
is

account

excretion

augmented
products,

in

is

latter

urea

in

of

urine

of

increased

skin

with,
and

on

ences.
influ-

forms

by

the

sources,

injurious

perspiration.

evaporation

state

perspiration
sweat

the

greatly

the
to

diminished

of

the

trace

termed

record

no

secretion

of

after

met

are

urinous

elaboration

volatile

impossible

which

the

former

so

far

and

urinous

of

quantity

of

(phosphate

they

that

absolutely

fatty

is

of

traces

decomposition
the

It

off.

the

is

surface

thus

quality

that,

etc.,

the

on

constituents

probability

increased

uraemia,

remains

scraped

it

thousand,

per

have

the

ing
accord-

interest

certain

of

odor

physicians

between

of

perspiration

nephritis,

we

existing

impairment

normal

ancient

the

antagonism

during

sweat,

elucidate

to

apt

the

to

urinous

The

to

general,

parturients,

"

the

by

Unfortunately

be

owing

"While
to

urinosus."

or

which

already

the

eventual

avoiding

in

differing

e.,

in

endeavor

we

by

i.

and

in

who

secondary

of

cause

those

that,

odor

odor

correctly

act

annoyance

artefact,

an

admitting

musk-like

Perspiration.

noticed

from

disagreeable

exhalations,

the

of

the

with

side

cannot

sense

seek

to

nature,
I

far

am

shall

we

penetrating

Urinous

been

rheumatics,

counteract

to

Urhidrosis,

4.

in

Accordingly,

presenting

cases

least,

at

sweet

the

peculiarly

this

Hence
in

hand

has

persons

disease.

of

cases

only

other

the

red-haired

in

form

order,

On

syphilitics,

the

patient
in

in

bronihidrosis

of

decomposition.

perspiration

in

perspiration.

the

of

quality

507

PAJEHIDEOSIS.

PEKSPIEATION,

therefore,

correct,

more

the

existence

the

of

to

of

me

in

allow

product

to

appears

bronihidrosis

THE

IN

special

urea,

the

acetic,

as

well

carbonate
and

in

the

first
and

conditions,
to

as

of
other

the

ammonium,

acids).

place
in

the

the

to

second

inevitable

generally
place

presence
aided

possibly

to

of

by

PARASITIC

THE

OF

DISEASES

THE

SKIN.
BY

A.

I. SKIN

WEYL,

M.D.,

DISEASES

DUE

TO

VEGETABLE

processes
Thus
A

few

the

same

called

only witMn the

in questionwith
in 1839

last

Schonlein'

before

years
elements

of

other

it oidium, which

M.D.

had

pustules; but

connection

has been

fungus

the discoverer

was

Schonlein, Remak
as

of the achorion

asserted

Schonlein

that

of

of favus

the favi

are

first demonstrated

Remak

the

pathological

named

after him.

disclosed.

subsequently changed
endeavored
to explore the
investigators
name

M.D.,

(DERMATOMYCOSES).

that the causal

forty years

the existence

GEBEE,

PARASITES

WEYL,

A.

It is

PEOF.

AND

into

not

the

achorion

composed of
fungus and
Schonleinii.

disease in all directions by

long before
ficial
inoculatingthe fungus on themselves, on others, and on animals, as well as by its artipropagation in suitable nutritive fluids.
The fallingof the hair was
accounted
for by Gruby''by the fact that he had seen,
the
threads
of
extend
into the roots
of the hair;thereby the
mycelium
though rarely,
and
hair was
said to soften
splitlongitudinally. SubsequentlyWedl,' after treatingit
It

was

with

not

concentrated
low
potashlye,found in the interior of the hair, a little way above and beits emergence
through the skin, threads of mycelium which, however, did not penetrate
the
G. Simon,* in his sections of the skin affected with favus, saw
far the root.
as

fungi only rarelypenetratedownward

most
cases
they extended merely as
them

to reach

'

down

"Zur

to the

between
far

as

To

root.

the

hair

the

and

the interior root sheath; in

of the hair-follicle.

opening
explain the

cutaneous

Miiller's

Pathologie der Impetigines."

Arch., 1843.

"

d. k.k.

Gesellsch.

Eautkrankheiten,"

d. Aerzte

1851, p. 380.

zu

Wien,

never

atrophy, G. Simon

Arch., 1839.

Miiller's
Ztschr.

He

1849, p. 643.

served
obas-

610

DISEASES

the favous

able than

not

was
'

he had

which
parasite

the formation

by
the

to

before
the

under
descijibed

Paris

the

fungus

interior,in

other

which

develops in

hence

their

mentagrophyte.

name

of the hair and

the hair

like

termed

Malmsten

of Sciences

the

findingof

in

another
mentagra (sycosis)
of mentagrophyte.
At about the same
the fungus in herpes tonsurans.
Gruby

the root

again surrounds

cases

it from

of scutula,and

Academy

he had found

time, Malmsten, of Stockholm, also demonstrated

named

PARASITES.

recognizeduntil late.

communicated
Gruby
Two
herpes tonsurans.
years

1844,

fungi in

VEGETABLE

TO

affection characterized

connection
etiological
In

DUE

then

penetrates into its

and
sheath, rhizophyte,

the

fungus

of

guished
distin-

herpes tonsurans^

trichophyton tonsurans.
In Germany, v. Barensprung furnished a very good description
of th^clinical
ture
picwell as of the fungi of herpes circinatus and tonsurans
but
he
denies the existence
as
;
of transmission
of a parasitic
of herpes tonsurans
sycosis.In the same
way he reportscases
'

animals

from

and

to man,

the

Before

reverse.

Letenneur
that, Fehr and especially

had

of a depilating
reported similar cases of transmission to man
eruption covered with
after the winter's
scales,occurring in spring on the neck of young cattle,particularly
stabling,and presentingthe pictureof herpes circinatus et tonsurans.
Sycosisparasitariahas received a thorough clinical and anatomical
by
description
the trichophyton in pathologically
altered nails ;
Kobner,* who also clearlydemonstrated
the stringentproof that the disease dethe first to furnish
furthermore
Kobner
scribed
was
marginatum is an affection caused by the trichophyton.
by Hebra as eczema
One of the most
disputedpointsin the dermatomycoses is the questionof the origin
and trichophyton and even
authors maintaining that both achorion
of the fungi, some
modifications
of
and
the
but
furfur
same
are
one
fungus; F. v. Hebra, an
microsporon
moist
states
that
after
and
to the former
adherent
view,
dressing,
employing
compresses
sometimes
of favus, sometimes
the occurrence
of herpes tonsurans,
observed
he had
white

"

again of

sometimes

affections at

both

the

same

time ; furthermore, that

besides

favus,

versicolor is to be looked
appeared on one patient; pityriasis
of
the
Hallier has also endeavored
earliest
of
the
same
as
fungus.
development
stage
upon
to support this view by his culture experiments,assertingthat from
m
penicillin
phyton.
trichothe
sometimes
the
sometimes
had
cultivation
secured
achorion,
by
glaucum he

rings of herpes

In

times

recent

most

received

tonsurans

the unitarian

Grawitz,*

in

defender

on

derivation

the

fungi of the
experiments.

culture

is like that
in their fructification which
parallelism
themselves
and
identical
both
all three are
morphologically
among
with
cultivated
After subepidermalinoculation
favus, herpes
pure
showed

exact

an

versicolor

*
'

*"
^

d.

Annalen

Reflexions
Virchow's

simple oidium

Grawitz
lactis,'

with

oidium

tonsurans, and
witnessed

the

lactis;
lactis.

riasis
pityoccur-

1843.

sur
I'herp. tonsur." Nantes, 1853,
Arch., 1861, Bd. xxii.

experim. Mittheilungen," Erlangen,

"Klin.

u.

Ztschr.

d. k, k. Ges.

Virchow's

"

Experimental
no

with

of the oidium

has

three

Charite, vi.,1855.

'

and

as

All

rendus, 1844.

Comptes

Comptes rendus,

well

fungi, as

skin

of the three

strength of

Arch., Bd.
results

d.

Aerzte, Vienna,

Ixx.

inoculations
in

1864.

1854.

myself.

with

oidium

lactis

produced

in

Prof.

Kobner

small

painful

tules,
pus-

DISEASES

511

PAKASITE8.

VEGETABLE

TO

DUE

reddening,then small circles of vesicles subsequentlyshowing largelyconfluent

circles,together with itching; in two or three weeks healingensued by desquamation.
versicolor.
He did not succeed in producing favus and pityriasis
The advocates of the specific
difference of the fungilikewise base their assertions on
Thus Kobner
provedthat by inoculations with trichophyton
experimentalinoculations.
he had never
affections,at no time favus or pityriasis
produced anything but trichophytinous
circles of vesicles resembling
After inoculation with achorion he saw
versicolor.
herpes circinatus which, after a brief existence,either desquamated and perishedor else
did true herpes tonsurans
led to the formation
of a central scutulum
or
parasitic
; never
versicolor
of
with
the
inoculation
from
it.
After
fungus
pityriasis
sycosis,
etc.,develop
versicolor resulted.
only pityriasis
achorion and trichophyton,
not
are
Although the various dermatophytes, especially
differentiated
as
so constituted
regards size,shape, and arrangement as to be microscopically
from each othsr, still frequentlyenough the microscopic differential diagnosiscan
of

rence

'

be

made

the

by

preparation(predominanceof

of the

general appearance

fat, quantityof bacteria,etc.). Even

fungus constituent, epithelium,

one

or

the most

other

complete

when
of the dermatophytesdoes not suffice to identifythem
morphological resemblance
forms
of
the
show
d
issimilar.
The
themselves
living
fungi
parasitically
fnnctionally
they
other
the skin, which
consist only of myceliaand conidia, appertainbesides to many
on
otherwise
free
in
which, when livingas saprophytesor
nature,
fungilivingparasitically
show more
Up to the
highlydifferentiated forms of fructification and sexual organs.
presenttime, these forms have not yet been found for the dermatophytes in question.
is to be sought in
The source
of the infection with fungous affections in many
cases
like

similar affections of animals.

or

rats; from
Aubert^

the mice

the

to the

calls attention

permit the effectual

minor

of the greater

as

favus

of the favus
well

as

is

the

frequency in boys

than

girls. Rare
districts of France; furthermore,

living in

and

the air of

from

care

narrow

warmth

are

is not

rare.

Inasmuch

thus

can

be

explainedthe

'

"

Klin.

Ann.

d.

u.

of
of

of favus

occurrence

is

of the skin, cohabitation,

the

dust

of favus
favus

deposited
could
arose

quently
freafter

changed at long intervals (Hebra),as the moisture

compresses
to soften the epidermisdeep enough to permit the further development

moist

apt

of achorion presentin the

is in generalmuch
Dermatomycosis trichophytina

"

land
Scot-

the chief nurseries

in which

cases

in

one-third

quartersplay only a secondary r61e. In

the conidia
containingfavus patients,

of the conidia

therein

are

about

wards
hospital

of
application

and

Galicia

infection,dirt,lack of cleanliness,defective

be demonstrated, and
the

where
(Bergh),^

the

States,favus

to

head

in

and

order

of
frequentoccurrence
gear during play,are
as favus is in Germany,

more

as

In the United
some

The

interchangeof the

in certain
common
incomparablymore
in Denmark
(Anderson),in Italy (Dubini),^
favus patients
are
adults; in the same
way, Poland

always due to

be present in
necessarily

fungus.

it is

favus.

very frequentdisease in mice and

children.
these to men,
especially

from

lesions must

fact that

lodgment

the head,

on
injuries

causes

Thus

to cats, and

it is transmitted

experim. Mittheilungeu," Erlangen,

wash
more

or

the air.

frequentand

more

uniformly

1864.

Dermat., 1881, p. 293.

ite of the co
of the comb
and
other
Bergh, basing on the experience that, in
on
use
ticles,
arthere is frequently no infection
with
favus
from
affected
child to its healthy brothers
one
to assume
and sisters,is inclined
to the development of the mycosis in isolated
a specialdisposition
individuals, which
perhaps may be due to some
peculiarityof the sudoral (Remak) or sebaceous
el. for 1877, p.
secretion.
("Beretning fra Almindelig Hosp.," ii. A
seq.)
*

512

DISEASESS

distributed

of children

largenumber
of such
cases

of

are

herpestonsurans

of the head

in

institutions

with

favus.

in Paris, an
France, especially
exceedingly
herpes tonsurans; London, too, has no lack
not
exactlyrare,
ing
Perhaps the continual wearthe fungus,more
plentifulthere, to take
there of gatheringsomewhat
older children

extremely rare.

are

in vogue

alumni

givesoccasion for
(1840) reports a spread of

as

Cazenave

to sixteen children

institution

PARASITES.

Germany trichophytosis
corporisis

perhaps the system

easily;

into educational

In

in Paris allows

little children

by

VEGETABLE

affected with

while

more

TO

countries.

individuals; and

of hoods
root

the various

over

DUE

within

short time.

more

extensive

the affection in

Eug.

Mahaux

'

simultaneous
one

fection
in-

educational

a like
repoi-ts

tricho-

the young
men
phytinous disease extending from year to year in its various forms among
levied for militaryexercises. Not rarelya minor
epidemic may be traced to barber shops.
in Paris it is of dailyoccurrence.
In
parasitaria;
frequentis sycosis
Correspondingly
not
i
s
An
fact
which
has
rare.
struck
Berlin, too, sycosis
parasitaria
unexplained
very
when
even
observers,is that trichophytosis,
quiteextensive on the body and beard
many
of adults, spares the hairy scalp.
is a rather frequentdisease in animals
Herpes tonsurans
(horses,
dogs, cats, and
neous
calves).According to Megnin,^ teignetondante in horses is characterized by the cutasurfaces being covered with overlapping crusts which
consist of small epithelial
above the skin; the spores are
scales;the hairs are broken off,projecting
barely 1-2 mm.
the
affected
In
calves
portions are quite smooth, the hairs not broken,
lightbrownish.
both in the follicle and in the adjoining
but fallen out in toto; the fungus proliferates
The falling
not in the hairs.
of the hair, as well as the detachment
layersof epidermis,
of whole layersof epidermis,
The
give to the herpeticsurface an ulcerated appearance.
micromill.
5
to
6
conidia
of
conidia
have
the
of
rans
tonsudiamster;
yellowish
herpes
fungi
in horses

are

of horses
trichoph}i;osis

in size.

2 to 3 micromill.

about

Gerlier^ makes

and that of cattle;the former

distinction

between

is often

epidemic,very contagious,
and stubbornlyresists treatment; the latter is not so readilytransmissible,more
easily
considerable tendency to spontaneous recovery,
it most
curable, has even
readilyextends
of man
derived from it is endemic
in cattle-raising
to the herders, and the trichophytosis
districts.
The

most

in
frequent,particularly

Northern

Germany,

and

most

international

of

versicolor. The cause

of this is obsQure, especially
because
dermatomy coses is pityriasis
of inconvenience
to which
it
it is not easilytransmissible; perhaps the small amount
interest
taken
the
the
and
as
rise,
slight
by
patients
treatment,
consequent
regards
gives
account for this,at least in part.
for fungi is made
The examination
by scrapingaway with a knife enough epidermal
only the deeper layers contain the fungus sought. The removed
scales;sometimes
The
are
masses
placedon a slide and twenty to fortyper cent potash or soda lye added.
scope
it, the preparation is brought under the microcoveringglasshaving been placedover
After the lye has been added, it
diameters
with a power of four hundred
or
more.
the thin scales are acted
is not desirable to wait too long with the examination, as when
of
clarification
the
elements
becomes
the
for a greatlength of time,
on
excessive,
fungous
should
be
examined
epilatedhairs
rendering their outlines indistinct. In the same
way
in lyeand
and their stumps which, after prolonged(oneto twenty-fourhours)maceration
beautiful
preparations.
subsequent teasinginto the finest fibrils,furnish the most
the

Recherches

le

trichophyton."

"

Ann.

"

Lyon medical, 1881, No.

de

sur

Dermat., 1880, p. 102

18.

Bruxelles

-Paris,Delahaye.

These, 1869.

513

FAVtrs.

Glycerinclarifies the specimenstoo much, but strong acetic acid, used

scales are very full of
the epithelial
be employed to advantage. When

like the

lye,can

fat

some
droplets,
dry, allovred to evaporate,and then either
anilin
potashlyeor, after treatment with acetate of potassium and rinsingin water, some
ceeded
color (as for instance methyl violet,methyl anilin)to stain the fungi ; but I rarelysuctime uniformly stained preparations.
in obtainingvery good and at the same

alcohol

ether and

are

added

to

is characterized

while

DERMATOMYCOSIS

FAVUS.

Favus

them

by

ACHORINA.

various-sized

(from a pin-headto

or

penny

larger),

roundish, sulphur yellow,dry, friable plates. These scutula, so called,have a cup-like

depressionon their surface, and besides show in their centre a pointed excavation which
of a hair ; their lower surface is irregularly
uneven,
usuallycorrespondsto the emergence
to
elevations and depressions
of the rete in which
the
and
corresponding
irregular
convex,
they are imbedded.
They are distinguished
by a peculiarmouldy smell which is often
dirt.
The affection preferablyattacks the hairy scalp,
compared with the odor of mouse
not exempt.
of younger
Its duration is usually
especially
persons, but other parts are
very prolonged and relapsesare frequent.
Favus
begins with reddish spots of round form and various size. These have at
their periphery a circle of vesicles' not always clearly
defined (herpetic
premonitory stage,
in their centre.
moderate
a
Kobner) ; soon
Usually after
branny desquamation ensues
two
from
three weeks
around
the hair an exceedinglysmall, yellow,cupped
see
or
we
sunk

crust

into the skin

"

miniature
typical

scutulum.

The

favus cup

now

grows

formly
uni-

a
so
as
a largerplate,becoming
same
This form, in which the singlescutulum
and projectingabove the skin.
superficial
remains
clearlyapart and isolated,is called favus urceolaris s. isolatus,lupinosus. This

peripheraldirection

in

to form

at the

time

more

is the

manifestation

usual

of favus

on

the trunk

or

the extremities

hairy scalp.
By the simultaneous development of the same
process on
to pass that the singlescutula touch
it finally
comes

not

rare

even

; when

recent, it is

the

on

pointsin the neighborhood,

ually
margins and eventThis form is called favus squarrosus.
coalesce.
Here, too, after a longer existence
the scutula lose the sulphur yellow color and cup-likedepressionpeculiarto the isolated
white, very dry, wrinkled and friable,
plates. The crusts become paler,to a dirtygrayisheminences.
elevated
and accumulate
in irregular,
less
ical
mechanmore
or
Through slight
interference such as scratching,whole piecesof the dry crusts fall,togetherwith the
hairs inserted in them.
The
epidermis thus exposed,at 'first reddened and somewhat
in appearance,
at times also slightly
becomes
tumefied
moist, soon
smooth, here and there
depressed,looking like an atrophiccicatrix,of a dull-graycolor.
With the development of the scutula the hairs,around which the cups mostly form,
The hair is nearlyalways peralso drawn
into the pale of the pathological
"are
process.
fectly
preserved,apparently normal in shape, but it splitsvery easilyand is readily
pulled out ; it is of a dull, gray, dry, coarse aspect,and sometimes of a reddish color.
T. Simon*

'

reports a

case

of

atrophy

of

the

several

at their

skull, particularlyin the neighborhood of the tubera

to his
transmission
of favus
Dermat., I.,p. 282) thus describes an accidental
spot the size of a silver five-franc piece the epidermis is discolored yellowish,
vesicles filled with
thickened, wrinkled, fissured ; at the edge of this spot is a circle of the prettiest

St.

Cyr (Ann.

hand

own

clear
hairs
'

On

d.

serum,
barely the size of a lentil or pea
yellowish,pin-head sized scutula, cupped

Arch.

f.

Dermat., 1870, p. 541.

33

on

in the

close
centre

examination
as

if

one

around

sees

pricked with

needle.

the

lanugo

614

FAVU8.

after favus.
parietalia,

Pififard

claims

to liave

observed

defective

intelligencein

of

consequence

favus.

Thus, if left to itself,

the formation
of favi,after the old favus

off,may

for many
finallyterminates

process
The
affected

completely
thinned

parts of the

and

and

fallen

years until the

spontaneously.
scalp are then

bald,
irretrievably

sunken, dry, of

but

smooth,

has

mass

continue

dull

much

lustre,

slightlydesquamating

places; usuallythere is

in

indication

some

of

rows
superficial
longitudinaland transverse furdividingthe skin into large irregular
fields.
Not
their

rarely,while

height,we

see

scalp,by scratchingor
secondary, eczematous

the

scutula

superadded
other
and

sometimes

lymphatic

on

the

interference,
furunculous

processes ; in such cases, owing to

of pus, there is nearlyalwayssome
of the cervical

at

are

tion
absorping
swell-

glands which

suppurate.

On

parts of the skin suppliedonly with

be
in
seen
lanugo, typical scutula can
of
specialperfection,having a diameter
about
1.5 cm.,
here larger con
but even
fluent
Fig.

41."

Favus

of the

body

McCali

with

crusts

are

not

herpetic rings, after

their

Anderson.

existence

is very
ofE, while

lacking. Generally
brief, the

scutula

soon
no
new
are
ones
drop
time
an
usually without cicatrization,but for some
abnormal
pigmentation (brownishyellow to brownish)remains.
achorion
The proliferating
does not spare the nails, but generallyonly a few are
the characteristic yellowish crusts
affected.
In some
cases
(scutula)show themselves
at the free edge of the nail, in others at the more
quently
frecentral portions,and still more
the alteration of the nail perfectly
resembles that occurringin herpes tonsurans
;
the nail becomes
turbid, intersected with longitudinaland transverse
furrows, thickened
in others.
in some
places and thinned
Onychomycosis, if left to itself,is very

formed

the

disease

terminates

intractable.
An'ATOMY.

scutulum,

"

On

sort of

sections

usually
epidermis cells ;

we

coveringof

see,

on

the

the
mass

under
surface
and
of
upper
itself consists of an enormous

of zoogloea,rod-shaped and spherical

quantityof threads and conidia, besides masses
bacteria,epidermiscells,and pus corpuscles. The size of the spores is very variable,up
micromill,
to eight micromill. ; generallythey are
to seven
round
or
oval, others are
out and constricted in the centre, another
drawn
more
part is still more
angular,and we
chains of conidia ; usuallythey contain
meet also with rosary-like
a
largepeculiar,yellowish
lustrous nucleus, others have
The
a
yeast-likeappearance.
mycelium consists
chieflyof somewhat
serpentinethreads divided into unequal segments, of variable width.

515

FAVirs.

and

with

sized

nuclei with

nuclear

loosened

of

bright,homogeneous, sometimes

contain

taper into

less numerous,
of conidia.
Here

more

or

different

or

chain

a.
or
corpuscles,
joined by anastomoses, the connection
pressure, so that they readilyseparateinto

fibres

traction

by

sometimes

threads

; the broader

contents

find bundles

we

sprouts having

lateral

numerous

granular,turbid

of

and

which

is

there

easily

isolated segments

or

conidia.

Balzer,'the achorion developsbetween the rete at

superficial
layersof the epidermisare firmlyadherent
of
the
and thus
growth
fungus are prevented from rising,

According

to

the mouth

hair-follicle ; the
the

during
the cupped

form

(godet)of

of
proliferations
further

oidium

that

the favus

in the

albicans

the

plates. (Thisformation

hair

intestinal

tract.

"

of caps

Parrot.)

to the

is

of the

hair, and

brought about
also in the

occurs

It is

only

in the

is

affected from
the root sheath ;
directlyor indirectly
the achorion
penetratesthrough the inner and later through the outer root
moreover,
into the subcutaneous
sheath even
of the
tissue,reactive inflammations
being the causes
formation.
Not
the
hairs
in
all
district
favous
scar
attacked
a
are
subsequent
by the
fungous proliferations.
I saw
hair pulled as earlyas the second day
In favus inoculated on
on
arm,
my own
conidia lie on the cuticle of the hair at a short distance from
the root ; on the fifth day
the cuticula numerous
there were
on
delicate,long threads,as well as a dense network
and in the root of the hair ; at a short distance from it,one
of fungus fibres around
hair
course

showed

club-like

The

stage
but

short time,

with

scutulum

small

made

in
equal facility

distinguishedfrom

hardly to be
as

point.

one

be

cannot

it is

expansionat

DIAGNOSIS

every stage. In the herpetic

lasts
herpes tonsurans, but this uncertainty

forms

soon

around

hair in favus, while

in trichophytosis

less distinct
or
spots,covered with scales in the centre and having more
vesicles at the periphery,soon
spread farther in the same
form, and besides,the hairs
hirsute parts are changed to a great extent into small shapelessstumps. When
the
on
scutula are
discrete on
the scalp,they may be confounded
with 1. impetigo: here the
crusts are more
of a grayishyellow color,have a fattyfeel,are
not cupped in the centre,
the

but

convex

on

corium

bleeding
preceding

When

brownish

it from
and

2.

with

varioliformis

(Hebra); this has more

ish
yellowdepression in the skin ; after their removal
and the disease belongs more
to middle
permanent pockmark-likedepression,
united into a largerconnected
the scutula of favus are
crust we must
ferentiate
dif-

or

they leave

exudation

serous

brown

life.

their surface ; when

removed, there is disclosed either a moist or slightly
the
hairs
are
glued here and there into small bunches by
; frequently
:

crusts

rather

1.

acne

fitted into

extensive

easilyrubbed

into

eczema
impetiginous

; here

the

crusts

are

more

cheese-like and
pulverulentmass,
crusts
fluid
the
under
a watery
rancid,
usuallyexudes, the hairs are intact, only glued
of scales,the skin beneath
is reddened,
together. 2. Psoriasis has flakywhitish masses
seborrhoeic fatty scales the skin is mostly of a
smooth, slightly
bleeding. 3. Beneath
greasy

furnishes
Teeatment.

emollient
thus

not

color,smooth.

normal
masses

are

In

the most
"

For

all doubtful

the

the

is more

examination
microscopic

removal

of the favus

of the superficial
of fungus we
resort to
masses
with
lukewarm
etc.
Cure
is
poultices,
washing
soapsuds,
time, but only apparently,for fresh growths of fungi soon
the hair-follicles,
and then it becomes
necessary to cause

in the shortest

springup again from

cases,

odor

information.
positive

warm
applications,

obtained

the

within

Arch,

gener.

d. Medec,

Oct., 1881.

516

DEEMATOMTCOSI8

TKIOHOPHTTINA.

the

castingoff of those layersof epidermisin which the fungus has its seat. Bazin first
with simultaneous
of corrosive sublimate
epilation,
washes, to the
application
dignity of a therapeuticmethod; for this purpose he employed tweezers and in a few
days complely epilatedthe affected parts of the head, togetherwith a larger,apparently
still healthy marginal portion. The
followed
epilationwas
by washing with
solution of corrosive sublimate
a
alcohol; in other
one-half-per-cent
containing some
elevated

Bazin

cases

and

frictions with

also used

quicklime,of each

two

tar, or
lard

parts,to

an

ointment

of crude

sixtyparts; or

carbonate

rubbing

with

of sodium

ointments

taining
con-

especiallyturpeth mineral one

part, to lard thirty parts. These
mercury,
ointments
in morning and evening; if the cutaneous
irritation becomes
rubbed
too
are
is made
violent,application
about

three

or

four weeks

for

time

some

of

cataplasms of

intervals,with subsequent use

ointment

of the

is painful,but becomes
less so with
epilation
the sublimate or the paintingwith tar, we
may
coal-tar derivatives which

at the

oil

After
potato-meal.
shorter
longer or
until the cure
is complete. At first the
every succeeding procedure. In place of

is recommenced,
epilation

and

excite

of

repeated at

also choose

time

or

ad libitum

the disinfectant

among

slightinfiammatory action
of the skin, such as benzol, phenol,thymol, creasote,naphthol,salicyl,
etc. Parasiticides
then only of value when
have
time
the
action
the skin
are
at
same
an
irritating
on
they
and thus hasten the castingoff of the upper layers;of late,chrysarobin
and
pyrogallic
acid have been superadded to the largenumber
of agents named
above.
Oroton oil induces
too violent
carbolic acid

same

of the skin to

pustularinfiammation

some

permit of

its use.

To

rub in pure

to
hardly be recommended, owing to the symptoms of toxic absorption
which it may give rise,and to its great painfulness.The disease can
be declared cured
only after several repeated tests : after a variable length of treatment
(mostlyfive
to six months
and more),the hairs are permittedto grow without
ference,
any therapeuticinterand from time to time during about six weeks the hair and scalp are carefully
with the microscope. If during this time there are
even
examined, in doubtful cases
the treatment, or
red
round
neither scutula nor
formed
stage),
scalyspots (herpetic
any
the danger of infection,is at an end.
Favus
of the rest of the body is more
easilycured than favus of the
rapidlyand more
scalp. The scutula find little support in the efferent ducts for the lanugo hairs,emollient
them
to drop off,and
the subsequent employment of frictions
soon
cause
applications
of the fungus.
with tar, etc., prevent the re-formation
the most
In favous onychomycosis,
rapidand complete removal of the nail substance
chemical
is the most
or
means
appropriatepractice.Either the nail is
by mechanical
lamellae are softened by repeated application
carefullyfiled or scraped off,or the corneous
of concentrated
potash solution or protracted soap, soda, or potash fingerbaths,
The effect of the so-called
until healthy nail substance grows forward from the matrix.
can

ointments
parasiticide

and

but short-lived.
solutions,if used alone, is generally

TRICHOPHYTINA.

DERMATOMYCOSIS

Herpes

circinatus

and

Sycosisparasitaria,Eczema

tonsurans,

Gelsi.
In accordance

trichophytinaassumes
hairs, it begins as a

its location and

with
a

small

type.
special
red

marginatum,

Kerion

Ringworm.

duration, the clinical pictureof dermatomycosis

the body, on partswhere there are onlylanugo

On

spot,somewhat

scalyin

the

centre, barelyelevated, often

618

DEEMATOMYCOSIS

tonsurans.

endemic

in

TEICHOPHYTIN^A.

According to this author, this tinea is distinguishedfrom

Europe in almost every particular;the epidermis is thrown

in concentric

lines,similar

parallel
wavy

to the sand

Fio.

dunes

terraced

by

herpes tonsurans
up in largeflakes
the tide.

42.

In Wilson's

Journal
Medicine, iv.,p. 251, we find the following notice by Turner
of Cutaneous
than
disease.
The
ichthyosis more
(Samoa) ringworm : it resembles
scales,
any other
it mainly by the fact that they are
liowever, differ from
tric
arranged in squares as well as in concenrings, and we can represent their form by liftingthe uppermost
layers of a hard cardboard
by
of a knife so as to cause
them
to curl up.
The detached
flakes of epidermis often exceed
means
oneon

Tokelau

quarter inch
The

in size.

conidia

the

layersof
or

at the

time

same

epidermis,are

only in the most superficial

in separate groups
spherical,
irregularly

exceedingly
numerous,

are

oval

or

dichotomouslybranching twigs,at

square,
times dark

lie

in color,and

often

contain

reddish-

granules. Mycelium pale or darkly granular,generallylong, straightor curved,

erously
numdichtomouslybranching,partlyseparatedby intervals,small lateral protuberances,
conidia.
The
disease
either
in
in
chains
of
The
threads
end
bulbs
or
jointed.
affects mainly partshaving little hair.
nine days there ensues
After about
Inoculation
always produces tinea imbricata.
corium
between
elevation of the epidermis with formation
of brown
and epimasses
an
dermis
with
skin.
its
the
at
the
detached
is
still
connected
margins
epidermis
partly
;
brown

Eubbing

the scales to fall and

causes

in the

is formed

and
circles form

centre

thus, while

brown

new

the

continuallyin

affection
the

there
pale corium becomes visible. Meantime
scribed,
undergoes the alterations before despot which
concentric
extends
peripherallyin circles,new

the

centre.

Tinea

imbricata

may

spread over

the

whole

body.
it rarely,
partssuch as the scalp,
and then only in the beginning,presents the appearance
of herpes circinatus.
Usually
there is formed
a slightly
reddenened, desquamatingspot,on which the color and shape
of the hair soon
dry, dull, loses its normal glossy
undergo changes. The hair becomes
breaks
under
dark
hair
becomes
we
try to pull a
color,
lighter. When
gentle touch,
the affection
when
diseased hair, either a largepart of its lower end remains
behind, or,
When

is

more

the

trichophytonhas

recent, we

obtain

taken

hair with

root

on

hirsute

thickened

grayishwhite

root sheath.

The

small

and are surrounded

and hard to remove,
difficulty
The
in the hair.
the fungus is as plentiful
as
scales
dull
with
covered
morbid
the
is
scalp thickly
gray
process spreads continually
;
which
beneath
is visible (herpes tonsurans). Usually the
less vivid redness
more
or
outlines of such a spot are
frequently
very irregularand ill defined, alongside there are
in which
small surfaces covered with fine scales resembling simple psoriasis,
only the
most
here and there discover a shapelesshair-stump enveloped in
careful attention can

discolored

hair

by grayishwhite

stumps

sheath

are

seized with

of scales in which

Only rarelythe swellingof the skin

pustular,eczematoid
eruptions. In isolated
scales.

assumes
cases

greater dimensions ; there may be

inflammatory processes
proliferating

have

been

observed

the hairless

; such

In

some

which

cases,

the simultaneous
that there is

an

described

kerion

as

Celsi.

beginning, later

The

borders

of

of different sizes and

they are
generallyare marked by irregulardiffused margins.
the depilatedpatches become
absolutelybald, the skin as
Celsi.
that they may
be taken for patches of area
Only at

discover

permit the

only in the

and

ivoryand glossyso
possibleto

been

have

cases

round

patches are

in variable numbers

rare

519

TKICHOPIIYTINA.

DEBMATOMYCOSI8

in the

environs

diagnosis.Such
of

occurrence

infectious

of such
cases

area

an

well have

may

and

herpes tonsurans

smooth
times

as

is it

hair-stumpsand heaps of scales

given rise to the assumption of
Celsi,as

area

well

as

to the assertion

area.

in most
tense
less incases
or
more
Trichophytosisof the body as well as the scalp causes
associated with febrile symptoms.
itching; it is never
In the beard, trichophytosis
genenerallypresents the same
phenomena as on the
and
these
less
when
of rather longstandmore
or
ing,
alterations,even
superficial
hairyscalp,
in the fine,light,
thin beard hair.
still unknown,
hair, and from causes

In

occur

beard

are

not

follicles become

We

rare.

elevated

then

on

see,

in the

dark,

coarse,

violent

more

surface

of small

dense, frequentlyshaved

and

deeper inflammatoryprocesses
at first generally round, the several
tents
exhibitingpurulent conpapules soon

red
shape
becomes
thickened, reddened, nodular, around
early
the hairs distinct pustulesform which
loosen the hair; if we
the loosened
soon
remove
hairs with their purulent sheath, a copiouswatery, lightyellow,gluey fluid exudes
from
from
this
fluid
dries
almost
and
forms
crusts
as
a
at
once
sieve;
(sycosis
pores
many
The originally
with
extends
parasitaria).
deep phlegmonous
very limited process soon
infiltration into the surroundings. The skin acquires
a deep red color,has a doughy feel,
the hairs are the centre of a pustule;considerable pain is present and a feelingof great
At times largerisolated sabcutaneous
tension in the skin.
abscesses are
present in the
in the centre,

or

else the skin

littleresistant tissue.
infiltrated,

Swelling of

Incisions

in the skin

cause

enormous

rhages.
hemorcapillary

the

In isolated
submaxillaryor upper cervical glands is rarelyabsent.
febrile conditions are present.
cases
Not rarelythe surface of the infiltrated parts of the skin covered
with thick crusts
becomes uneven,
there
nodular, verrucose,
acinous, papillomatous
appear mulberry-like,
between
which pustulationoccurs.
proliferations
Where

the affection

expect healing with

integrum follows.
The

has

run

its

cicatrization.

disease described

by

Hebra

course

In most

in its

with

considerable

cases,

when

intense

abscess formation,

we

must

properlytreated, restitution

ad

stages as eczema
marginatum,
as herpesinguium, likewise
by Barensprung
begins usuallyas a
and by preferencein the pudendal and inguinal regions,particutypicaltrichophytosis
larly
where the scrotum
touches the thigh. A picture
eczema
reselnbling
marginatum is
at times also produced on the neck by the trichophyton.
small circle,healingin the centre with brownish
Slowly the originally
discoloration,
extends in all or in only one
direction,so that there results either a very largecircle or,
what
is more
discolored
frequent,a brownish
large surface limited by curved lines.
The
affection spreads from
its originalsite, on
the one
hand
and upward
forward
from
the pudendal and
internal inguinalregion to the abdominal
wall, and on the
other across
the perineum to the anal and glutealregion. The
margin of the affected
raised
is
like
at
times
small
vesicles
still
but the majorit}"
a
wall,
are
visible,
parts
of these is soon
the
sudoral
secretion
these parts
more
destroyed by
on
plentiful
the coincident
of the body and
maceration
of the epidermis. Besides, as
greater
and

in its

lighterforms

more

620

DEEMATOMYCOSIS

the disease is

TKICHOPHYTINA.

usuallyobserved

tions
time, considerable alteraonly after it has existed for some
have been produced by the scratchingfinger. As a rule the itchingis so violent
that the effects of the scratchinggive rise to a picturevery similar to eczema:
number
a
of weeping spots by the side of brown
ing
bleeding crusts,togetherwith very great thickenat the periphery as in chronic infiltrated eczemata:
of the skin, especially
besides the
formation
of furuncles.
The hairs in this region are generallyintact,some
torn off
are

'"^,-,"

Fia. 18." Sycosis parasitaria, after K5bner,

by

the

finger.
scratching

further

from

Virchow's

Archiv,

Bd.

XXII.

is the great relapsingtendency of

peculiarity

the

affection.
In
of

tropicalcountries

cleanliness.

Men

are

'

by experimental inoculations
'
'

Nicholson,
"Klinische

"

frequent,and this is ascribed

succeeded
in
by it. Kobner'
etiologyof the affection,so that no

is very
attacked
particularly
the affection

the

Wilson's
Journ.
Burmese
Ringworm."
Mittheilungen," Erlangen, 1864, p. 6.

of Cutan.

Med., i.,p.

377.

to

lack

strating
demondoubt

tion
observers; it is solelythe peculiarseat of the affecHebra
and
that
the
the singular course,
maintains,
ration
macenot, as

minds

in the

remains

of

causes

epidermis and
development
prepared, the

of the
in the
thus
territory

nails

are

irritation of the corium

of

further

be

must

marginatum,
development of

eczema

and

"

fulfilled

that

the

then,

as
on

the
the

fungous elements,

first

dition
con-

favorable

which

have

without, takes place/'

the skin from

The

unbiased

which

reached

521

TRIOHOPHYTINA.

DEBMATOMTC08I8

not exempt

from

the

invasion

with

of the

trichophyton,
althoughonychomycosis
"

tions
frequency of the other cutaneous affectrichophytina,as compared
observed
the
of
Mahon
first
due to the same
concurrence
fungus, is rather rare.
often
herpes tonsurans of the head with disease of the nails. The toe nails are far more
attacked than the fingernails.
and
The
nails become
considerablythicker;their surface becomes
rough,uneven,
transverse
streaks
visible.
At
and
other
are
places,
plainly
split;
irregularlongitudinal
whole piecesof the nail substance are sprung
off,and only a larger or smaller remnant
The
affects by preference
of the nail is present at the matrix.
thickeningand friability
the several layersof the nail substance
the free edge of the nail, and here we often see
less inclined
folded apart like the leaves of a half-openbook; at times the nail is more
or
time the nail
toward
the fingertip (a slightdegree of onychogryphosis).At the same
loses its natural lustre, becomes
dull, pale yellowish,with irregularlyscattered,small
dirt accumulates, especially
Here
and
there
white
at torn portionsof the.
grayish
spots.
its entire length, and not all
The alteration does not always attack the nail over
nail.
the nails of the
If
in

extremity.
of the
splinters

same

examine

we

the

potashlye,we

Although

find

the whole

The

nail under the microscope after prolonged maceration

mycelia generallymore
plentifulthan conidia.
nail is often degenerated,still at times spontaneous recovery

of the diseased nail.

after detachment

ensues

the

diagnosis generallybe determined

onlyby the aid of the microscope.
has
described
the
affection
under
of vespajodel capillitio
name
an
(1865)
can

Dubini

of

hairy scalpwhich

and has almost

the character
closelyresembles sycosisparasitaria
plegmonous dermatitis,but which he did not believe to be parasitical.
Similar cases
have been
described
Oelsi (honeycomb),who
kerion
as
by Wilson
T. Fox who
thought the disease to be a phytiform (!)degeneration of the skin; it was
first included it in the series of affections produced by trichophyton; so did Tanturri*
and Auspitz. According to Tanturri, the disease begins with red, round
oval plates
or
which
elevated
above
covered with fine scales (herpescircinatus)
but slightly
the skin.
are
Soon these placesbecome
small points corresponding
very prominent, vivid red ; from innumerable
the
of

furunculous

or

to the efferent ducts

of the hair follicles there exudes

tenacious

or

less viscid

When
the disease
yellowishfluid and pus ; here the hairs can easilybe removed.
is recovered from, permanent alopeciaand pale discoloration of the skin remain
the
on
It
is
not
affected
the
find
When
most
to
less
places.
always easy
fungi.
intensely
grave,,
with
the disease in its external form correspondsmore
small furuncles or closelyresembles
small patches of impetiginouseczema.
cohesive

"Lehrb.," 2te Aufl., Bd. i.,p. 493.

Kobner, Virch. Arch., Bd. xxii.,among

of uail disease.
3

"

Morgagni, 1871, p.

Skin

Diseases," 1867.
130.

several

hundred

cases

of

herpes

tonsurans

saw

only

twa

622

DEEMATOMYCOSIS

Forlanini

'

TRICHOPHTTINA.

expresses himself
that kerion

He

chophyton.
againstthe causal connection of kerion Celsi with triits
stages without the presence of
may pass through all
nature.
The prorapid recovery speaksagainstthe parasitical
cess

asserts

fungus ; also that the

begins between the cuticula of the hair and the internal root sheath with exudation
as
vesicles,later the hair is altogetherlifted and separatedfrom its root, as the hair bulb
is implicated. In the further course, subcutaneous
abscesses arise through the implication
Herein
found giant-cells,
of the adjoining epidermis and the corium.
were
only
fungi ; nor were the latter present in the pus, the contents of the vesicles,
exceptionally
the crusts, the scales,and the hair itself. Experimental inoculations were
without
effect.
In but a singleexcised piece of skin one
hair was
found
with trichophyton.
solitary
is seated in the upper
Anatomy.
In herpes circinatus the trichophyton
and lower
in
the
thence
it
the
hair
cell
between
it and
rete;
penetrates
rarely
horny
layers,
along
sheath
in the hair follicle,
the internal root
the fungus forces the cuticula apart and
crowds into the hair shaft, thereby only the outlines of the hair becomes
clearlyvisible,
is destroyedby the penetrating,
while its substance
longitudinallyextending mycelium.
in deeper than the upper
end of the hair bulb; the
The fungi do not force themselves
wall of the hair follicle,
the connective-tissue
the subcutaneous
hair papilla,
connective
tissue are not attacked, and the external and the internal root sheaths are entirely
intact.
There are no symptoms of inflammation
in the skin (Taylor),
while" Thin finds the cutis
Eobinson
finds the upper part of the external
and rete in an inflammatory condition.
the corium
root sheath of the hair plentifully,
and the subcutaneous
tissue only sparsely

the

"

set with

spores,

According

to

hair sheath

and

the

extends

fungus

few

spores

around

are

root

penetrated by

are

into the hair, when

Subsequentlythe whole
finallyis destroyedby them, the
The forms
presentedby the
red patches on hairless parts the
are
simple or anastomosing
variable

as

broader

are

the root of the hair and

Balzer,'the fungus is seated

is their width
divided

at

; the
more

or

at first on

threads

the

within

normal

it.

cuticula,then

the

(mycelia)containingconidia, and thence

the

mycelia disintegrateinto segspore-bearing

ments.
the
hair, excepting
medulla, is filled with conidia, and
cuticula disappearing..
In the scales of the
trichophytonare very manifold.
than the conidia.
mer
The formyceliaare more
plentiful

threads

narrowest

with

small

exhibit

sprouts; their length is very

septa only at very long intervals,the
lateral

less short intervals,and

in each

septum there

different-sized

are

one

or

pale or glossynuclei with nuclear corpuscles; many of the mycelia,

besides,look as if sprinkledwith fattygranules. The conidia are variable in size and
membrane, pale sparse protoplasm,
shape: round or flattened,with doubly contoured
nuclear corpuscles
often a very largenucleus with yellowishlustre in which
one
more
or
The
not
discovered
with
and
be
hair-stumps,the surface of
can
only
difficulty
always.
is covered with innumerable, generallyirregularly
which
arranged conidia, are comparable
the hair are mycelia
of fungi. Within
to the favus scutulum
as
regards the number
direction of the hair. The mycelia
to the longitudinal
of conidia running parallel
and rows
But nowhere
clear and possess an indescribable varietyof forms.
here are extraordinarily
the
threads
that
enabled
I
to
what
are
see
:
composed of
was
Kaposi describes,namely
small
round
which
dumb-bell
each
of
between
two
a
body is inserted
shaped cells,
long
in
threads
united with the long cells, others only loosely
which
in some
is organically
more

"

Annal.

Arch,

of

Arch,

gener.

de

Dermat., 1880, abstract

Dermat., viii.,p. 406.
de

from

Med., 1881, r". 407.

the

Italian

specialjournal.

523

TEICHOPHTTINA.

DERMAT0MYC0SI8

alternatingwith the former, aids in representingonly a disconnected

flakes of
By the penetrationof the fungi, the square corneous
from all sides and loosened.
which the hair is composed are overgrown
kerion Oelsi
Diagnosis.
parasitaria,
^Althoughherpescircinatus,tonsurans, sycosis
is
desirable
it
them
to
of
the
various
same
are
keep
apart so as to
only
stages
process,
circinatus
is liable to be confacilitate the survey of the differential diagnosis.Herpes
founded
its
with : 1. Pityriasis
rosea
(G-ibert)
; the latter lacks the circle of vesicles,
peripheralextension is very rapid,with equallyrapid spontaneous recovery in the centre
with lightyellowishdiscoloration of the skin ; no loss of hair, no fungi,short duration
white layers
of the affection ; 2. With psoriasis
by plentiful
; the latter is distinguished
inclined
take
the
to
reddened
of scales on
on
a symmetrical
a
basis,
patches are
ment
arrangeis completelynormal
circinate syphilide; in this the centre
or
darkly
; 3. With
infiltration has a brownish
red color,is firm,
pigmented, sunken, atrophic; the peripheral
generallyscaleless or covered with smooth thin scales,without itching; 4. With orbicular
in scrofulous children,has no tendency to spread peripherally,
eczema
chiefly
; this occurs
has larger lamellar scales,attacks by preference
formation
of vesicles,
shows
never
any
the hands and face, often symmetrically.
plex,
simdistinguishedfrom pityriasis
Herpes tonsurans, when circumscribed, is easily
and
of
the
the
the
hairs,
eczema
discoloration,
fragility
by
dryness,
squamosum,
in
circumscribed
it
of
small
generally
plates.
misshapen
hair-stumps
;
appears
presence
When
more
diffuse,and associated with secondary crust formation, the distinction is

adjoinsthem,
chain

or

of elements."

"

more

difficult ; but
hairs and

even

here there is

others surrounded

no

with

lack of broken
white

and, in the

case

small sheaths of scales.

of dark

colored
hair,dis-

In persons

whose

only with the aid of the

cropped very short, the diagnosiscan often be made
microscope. Area Celsi leaves the skin smooth as ivoryand glossy,only here and there
colored small hairs clubbed at the ends.
are
very thin, slightly
be confounded
and kerion Oelsi in their slighter
degreescan easily
Sycosisparasitaria
with idiopathicsycosis,
but the former sets in with round, red, more
less
or
flakingspots,
alba with
with or without a circle of vesicles,
well as in places resembling pityriasis
as
the characteristic hair-stumps; after a brief existence,rapidlyspreadinginto the healthy
around
surroundings,it produces deep, soft,phlegmonoid infiltrations with pustulation
to
the hairs ; it forms spongy
nodules
with
cutaneous
provided
openings (corresponding
in
its
the lost hairs)
the secretion from
which is very profuse ; while idiopathic
sycosis,
slow progress, depositssmooth, often very hard infiltrations ; at times the infiltration is
hut very slightand there is hardly anythingexcept pustulation
the hairs ; there
around
is an absence of the red, circumscribed, desquamating spots. In some
cases, the nodules
of sycosis
to tuberculo-ulcerresemblance
parasitaria,
by their deep color, bear some
but
in
such
the
of
ous
cases
syphilide
usually rapid springing up
multiple sycosis
;
hair

is

tubercles,their soft,almost
hairs obviate any
the face alone, and

around
the
consistence,their quick pustulation
fluctuating
in
Lymphadenia cutanea
(mycosis fungoides)
rarelyoccurs
is distinguished
from parasitic
sycosisexistingonly on hirsute regions

mistake.

the whole
on
by multiple tubercle formation
body ; besides the former forms more
smooth, slightly
tubercles,while in the latter,irregularly
scalingor serum-discharging
and pustulationaround the hairs are rarelyabsent.
tuberous proliferations
Eczema
from ordinaryeczema
marginatum is distinguished
by its curved outlines;
surface there are frequentlylargeror smaller moist,
hesides,around the largeeczematous
alterations
places. Furthermore, in the latter both the superficial
pustular,or squamous
infiltration
of
the suband
the
(desquamation,
reddening,weeping, fissures,
great
etc.)

524

DERMATOMYCOSIS

connective

cutaneous

FURFURACEA,

PYTIRIASIS

VERSICOLOR.

tissue

are
generallydeveloped in equal intensity
; while in eczema
marginatum there is comparatively little desquamation, pale to brownish
color with
great thickening of the skin ; besides,fresh trichophytinousrings arise on previously
of the genitalregion attacks by preference the
healed, discolored portions. Eczema
whole
scrotum
and
from
there
the other parts, while in eczema
primarily
marginatum
the
and
the
lateral
form
mainly
the first site of the
thighs
only
parts of the scrotum
affection.
Eczema
infiltrated chronic eczema
in
marginatum often resembles squamous
that only the etiological
so
factors determine
every particularin its external appearance,

the difference.
Teeatmekt.
soap,
or

or

Herpes circinatus often needs nothing but energeticwashing with

repeated paintingswith tar, chrysarobin,or pyrogallicacid ointments,
"

several

of the ointments

one

with

ink

In the treatment
Even

in the most

stage of

solutions

or

(sulphateof

several

of

herpes tonsurans

favorable
months

enumerated

iron)has at times
case,

under

acted very
must

we

the treatment

not

or
psoriasis
favus;
favorably.

count

on

months,

consumes

cure

as

well

in
as

a
a

even

short

ing
painttime.

subsequent

after

apparent recovery, as a single diseased hair may effect

scalp. All the hairs on a diseased spot without exception
removed
and
it is advantageous to extend the epilation
are
to the hairs
by epilation,
even
distance.
at some
According to Bazin, epilationshould be preceded by painting the
skin with oil of cade so as to reduce the pain of the operation. The diseased hairs often
break off,leavingthe stump closely
must
be often
packed with fungi,hence the epilation
the diseased patches are
repeated. After the epilation,
performed in different sittings,
paintedor rubbed with solution of corrosive sublimate, tar,chloroform, chloral hydrate,
the hairs to be
pyrogallicacid (5 to 10 per cent),chrysarobin ointments, etc. To cause
cast off by suppurationby means
of the applicationof croton oil,I hold to be an unsuitable
be readilywithdrawn
without
procedure. Not until the hair can
breaking, when
the skin has acquired a
smooth
we
pale appearance,
permit the hair to grow
may
the reinfection

of the entire

unhindered.
The
and

same

the

treatment

is

to parasitic
applicable
sycosisand

kerion

Celsi,viz. : epilation

of the above-named

solutions and ointments

there are
employment
; where
very
phlegmonoid inflammatory symptoms, emollient cataplasmsare indicated;besides
Zeissl's sulphur paste may be used with good result where
the cutaneous
infiltration is
subcutaneous
abscesses exist they must
be incised.
While
extensive;when
parasitic
not to permitshaving,
sycosisexists,it is to be recommended
by which the fungus might
easilybe transferred into healthy follicles.
For eczema
recommends
Wilkinson^s
is to be
ointment, which
marginatum Hebra
rubbed
for six days,morning and evening, into the diseased spots, after which
they are
bandaged with flannel. ISTotbefore eight or ten days after cessation of the treatment is
the skin very
makes
bathing or washing of the parts permitted. Wilkinson's ointment
brittle,so that it is easilybroken, and therefore its applicationis often very painful.
The method
of treatment
is here likewise of
given for herpes circinatus and tonsurans
violent

use.

The

diseased nail substance

DERMATOMYCOSIS

is removed

nearlyalways connected

with

same

manner

PITYRIASIS

FURFURACEA.

versicolor is characterized
Pityriasis
in
the
centre, but easilyremoved
slightly
affection is

in the

by

brownish

with

the

moderate

as

in favus.

VERSICOLOR.

spots generallydesquamating but

fingernail without hemorrhage. The
itching.

526

EETTHEASMA.

knob-like

brightswelling,at

times

they contain isolated lustrous granules,

rows
placeswe see
oblong-ovalnuclei looking like yacuolae and containing
dark nuclear
corpuscles; some
segments are short and sausage-shaped,others
form
taper to a point at one end, on others we see at various placesindentations
nearly uniSome
threads
both sides.
rather narrow
and filled with
are
on
dark, larger or
smaller granules,while others appear altogetherpale and vacant.
ability
Diagnosis. The brownish color,as well as the slightdesquamation and ready removof the uppermost layerswith the fingernail, will easilyobviate confounding
the trunk, such as macular
with similar efflorescences on
syphilide,
pigment remnants
after other eruptions,brownish
seated
warts, and other more
deeply
pigment anomalies.
often quiteimpossiblewithout microscopicalexamination, is its differenMore
tiation
difficult,
in the inguinal and upper
femoral region from intertrigo,
in male
particularly
From
who
extensive
lichen
of
perspirevery freely.
patches
acneiquepityriasis
persons
versicolor is differentiated
brownish
than yellowish color,the absence
of
by the more
and crusts
in the periphery of a large patch. Pityriasisrosea
small nodules
rarely
to be confounded
reaches in its centre so great a discoloration
with pityriasis
color
versias
is distinguished
by the red circular border and the acute
; besides, the former
appears
in other

as

in them

of

"

course.

Treatment.

In

"

the

treatment

of

versicolor,it is
pityriasis

essential to

cause

the

rapid castingoff of the uppermost layersin which the microsporon has its seat. In
time those fungi seated
at the same
doing so, however, it is not always possibleto remove
the point of exit of the lanugo; this probably is the reason
around
color
versiwhy pityriasis
after
Frictions
with green
again spreadseven
very energetictherapeuticmeasures.
soap followed by energeticablutions in the bath, repeatedseveral days in succession, are
useful in treatment.'
of chrysarobin ten to
Furthermore, frictions with ointments
acid five to ten per cent,
twenty per cent, pyrogallicacid five to ten per cent, salicylic
thymol five per cent, sodium subsulphateten to fifteen per cent, etc. Likewise with oil
more

of cade, Wilkinson^s

ointment, and tincture of iodine.

ERYTHRASMA

Is the
name
given by v. Barensprung' to a disease confined to the inguinal and
rubra in the form
of pityriasis
axillaryregions;it is contagious,presents the appearance
attributes to the
which
he
rosette shaped, sharplydemarcated
of roundish
and
or
spots,
Oscar
minutissimum.
described
the
so-called
Burchardt,^
fungus
Microsporon
by
intermediate
between
Simon'
has endeavored
to show that the erythrasma is an
step
versicolor and herpes tonsurans.
pityriasis
While
versicolor in the inguinalregion is an almost dailyoccurrence,
pityriasis
thrasma
erydish
manifests itself more
It representsa large,dry, redrarelyin its pure forms.
brown, often copper-coloredsurface covered with branny scales; its margin often
surrounds

of

the detached
colored

more
a

them

orange
five-cent nickel.
we

or

several similar or
epidermisin a circle. Beside it are frequently
pale reddish yellow spots with irregularoutlines,barelythe size
The scales can be removed
only in the shape of a fine flour. In

find rather short, narrow

curved,
very pale,slightly
three segments.

or

(nothalf

stiff and

'

Ann.

d.

Med.

Zeit. d. Vereins

"

Localisation

der

long

very

Charit., 1862, Bd.

the width

of those in

threads

at times

versicolor),
pityriasis
composed

x.

f. Heilk.

f.

Hautkrankheiten."

Preussen, 1859, No. 29.

of two

or

527

EKYTHRASMA.

In

other

rare

flattened
attentive

they

side

of

are

Lateral

formation

of
Some

mycetes.
times

curved

heaps

of

of

has

which

they

the

in

contain

besides

spots

the

is

which

end

bacteria

of

erythrasma

mm.,

piled
often

the

reddish

of

at

and

spots

ever

threads

granules
lye

or

tV

to

the

to
neither

are

dusty

Burchardt

treatment

of

the

affection

but

found

mented.
seg-

epidermis
and

granules

become
the

meter
dia-

nor

the

Many

threads

of

the

granules,

to

nor

most

branching

distinct.
The

acid.

straight

nim.

appearance

not

are

acetic

lye.

potash

transition

give

neither

are

-^-g

longest

tinct
dis-

most
threads

same

and

question.

versicolor.

them.

near

by

upon
in

patient

the

of

the

The
and

heaps

potash

of

acted

become

threads.

outlines

brown

pityriasis

the

form

they

threads

The
the

variable,

very

that

so

irregular

into

addition

long

furfur

less,

the

the

on

of

and

follows:

as

is

length

there
In

Like

transitions

therewith,

plentiful

more

possible

all

are

accordance
and

more

versicolor,

pityriasis

we

easily
the

into
also

see

is

the

same

as

that

of

affection

pityriasis

the
the

coffeeelements
from

distinguishable
is

relapses.
The

the

schizo-

the

small

of

very
are

than

to

their

at

number

the

always

more

nearest

most

by

threads

any

seen,

lustre

strong

but

the

stand

to

seem

by

chloasma

in

the

breadth

the

lie;

urine

microsporon
of

scales

fungi

mm.

are

been

these

From
brown

^^

move

having

after

the

xt/q-^

equals

threads

granules

is

granules

which

on

shorter

distinguished

The

described

shorter,

The
cells

they

be

to

in

find,

also

lengths,

confused,

nowhere

is

filaments

reproduction
are

hook.

breadth

much

are

their

threads

long

the

different
and

dense

most

We

very

on

micromill.,

0.6

variable.

of

lines,

is

barely

only

zoogloea.

their

them

In

into

Burchardt

curved,

of

branching

is

exceedingly

wave

network

the

conidia.

in

twisted

others

is

length

visible

becomes

ing,
adjoin-

closely

rosary-like,

of

which

diameter

transverse

Their

Where

of

segmentation

greatest

narrower.

pale.

smallest.

those

The

consist

threads

larger

the

segments,

threads,

long
and

narrow

the

of

some

inspection.

cases

of

cases,

small

versicolor.

very

liable

to

THE

PARASITIC
THE

OF

SKIN

II. THE

DISEASES

DISEASES

SKIN.

DUE

TO

ANIMAL

PARASITES.

BT

PROF.

animal

The

the

of
parasites

E.

human

M.D.

GEBER,

skin inflict upon

it different

according
injuries
boring, stinging,cutting,of the ovipositor,
etc.,
for this purpose.
well as according to the force called into requisition
as
Many of them
of the glands (cimices,ixodee,etc.).
into the lesion the caustic contents
also evacuate
Others
speciesof leeches, inject with their bite poisonous
again, as for instance some
of their

to the structure

implement

for

fluids.
A

necessityin

further

the

of
acquisition

in contact
come
they must
as
only during the attack; as soon
to any
to fast long, but
unable

that

with

nourishment

the skin.

this is

Many

past,the

animal

for
do

consists
parasites

our

by remaining

so

on

in this,

the skin

retires,into the neighborhood if

if it be able to exist without

frequentrepetition
in
it
which
its
host.
case
changes
ixodse),
(fleas,
the
skin
the
not
inconsiderable
of
domicile.
uses
as
a
Another,
parasites
They
part
do this always in a manner
appropriate to the perpetuationof the species. Animals
in the upper
their habitat
which
seek each other sexuallymake
must
layersof the skin;
while others,in which
directlyinto consideration,find room
propagationdoes not come
A very peculiar circumstance
connective
tissue.
in the subcutaneous
prevails with
of

pulex penetrans,
its way
there

are

years

so

destruction.

I.
that

divide

of which

leaves its abdomen

outside

scatter
its eggs undisturbed
it may
which, when
they accidentallyget into

that

in the skin, but

We

it

the animal

The

larva

of tsenia solium

can

of the wound
over

the

when

ing
borBut

ground.

the skin, this domicile

subsist

one

or

two

or

is

more

always perishesbefore maturity.

of
parasites
such

the human

skin into three

almost

as
Stationaryparasitesare
prey
of animals
only quite exceptionallyand

never

classes:

exclusivelyon
permanently.

the human

skin, but

skin.
All the animals
Temporary parasites or occasional parasitesof the human
of this group
are
necessarilyparasitical.But they differ from each other especially
this,that one part of them has a permanent host, while another is able to change their
II.

in

in,

the female

parasitesto

equivalentto

on

distance

ingestionof the nutriment

DISEASES

tost.

In their relations to

they

do

future

certain

III. Accidental

certain

If

this

forms

essential

an

such

parasitesare

do not

as

condition

to the

speciesof cestrus).

(forinstance, hirudines, some

seek the human

skin

of their

own

tion,
voli-

be further
of these classes may
the animal
subdivided, according to whether
in
the
whether
it
is
of
or
a parasite
man
skin, and
during its entire life or only

lives upon

during

that

and
regularity,

there, injureit in the instinct of self-preservation.

once

Each

529

PAEA8ITE8.

man

of the animal

development

but

ANIMAL

TO

they are all nearlyequal,in that they prey upon him as

generally. Interestinghere is the fact that the change of the host

animals

on

with

occurs

DUE

period.
all these

tabulate

we

obtain

factors, we

the

followingtable

for the

principal

parasites.
I.

Sarcoptes scabiei hominis,

Deraodex

itch mite.

(Acarus) folliculorum

Pediculus

Pediculus

Phthirius

pubis, crab

a.

h.

Stationary Parasites.

hom.

capitis,head louse.
vestimenti,clothes

"

irritans,flea.

Pulex

n.
1. In

sexually mature

Sarcoptes scabiei
a.

I.

Culicidae

bird

3. In
Cestodes

flies :

larval
:

Nematodes

these

flea.

Chrysops

condition.

Cysticercus cellulosae,
Echinococcus,

Muscidse

sand

Tabanus,

coecutiens.
Pangonia.
colombacencis, S. pertinax.
pipiens,Simula
H. medicinalis, officin.,
and others,Haementaria
mexicana.

Trematodes

known

mite.

Culex

Hirudinse

To

ricinus, reduvius.

Sarcopsyllapenetrans,

s.

Tabanidae, Horse

tans

Parasites.

b. Argas reflexus, persicus, americanus,

lectularius,bedbug.

Cimex
Pulex

condition

Temporary

communis.

avium,

Dermanyssus
Ixodse, ticks
^

louse.

louse.

Distoma

bladder

worm.

hepaticum,

liver fluke.

Filaria

medinensis.

Filaria

sanguinis hominis.

Oxyuris vermicularis,
Leptodera.
M. domestica, cadaverina, vomitaria, and L. Caesar.
: a.
b. Sarcophila Wohlfarti
(Portschinsky),Sarcophaga cadanaria.
be added
hominivorax
: Lucil.
in America, Stomoxys calcitrans, Glossina
may
in Central

Africa

as

(Estridge : Hypoderma
(vers
humanus,
Humboldt).
"(CEstrus

macacaque

in

Cayenne), species

III. Accidental

Parasites.

and Symbiotes (Gerlach).

Species of Dermatodectes
Leptus autumnalis, harvest bug.
Kritoptes monunguiculosis.
"Clothilia inquilis,
bookworm.

34

morsi-

tse-tse,etc.
of

Cuterebra

and

Dermatobia

630

STATIONARY

I.

1. The

PARASITES.

STATIONARY

PARASITES.

hominis

by Sarcoptesscabiei

disease caused

Scabies, Itch.
Defikitiok.
disease

produced by

conditions

in the

The

is

female
and

long

permanently

History

oblong

an

0.15

itching; the

the presence of acari.

class of acarines there are

round
on

of

shape

an

disease

But

is

always

with

irritative

conjoined with

the

is

altogether impossible to
in the opposite case.
sarcoptideswhich, though parasitical,

it is otherwise

several

the human

on

contagious cutaneous

skin.

Hence

vote
de-

must

we

Sarcoptesscabiei hominis.
Itch

the

with

an

Mite.

"

convex

upper

Sarcoptesscabiei,the human
and a lower
concave
slightly

itch

mite,

surface.

broad ; the male, 0.25 mm.

long and 0.23 mm.
body is inclosed in a delicate,transparent,loosely
here and
there epidermidal deposits,scales, chitinous
prickles. The cephalothoraxhas four indentations
ceptible
per-

0.35

average

mm.

The

broad.

mm.

domiciled

itch mite, connected

epidermis.
present nosogenetic conceptions,it

to the
exclusively

Natural

is understood
(itch)

of the human

without

become

ourselves

has

our

numerous

cannot

scabies

name

intense

and

in the

to

According
imagine scabies

the

the transmission

skin

of the
of mites

presence

For

Under

"

adherent

integument and has

inclosures,spines,bristles,and
It is divided from
the
only on the sides and otherwise forms a compact whole.
abdomen
by a transverse undulating furrow.
head representsa short, anteriorly
The
rounded, posteriorly
widening,flattened,resistent,strong cone, on which the followingparts can be distinguished: The integument
the epistome surrounds
the lateral
turns back like a fold at the limit of the head and
as
of
the
mouth
In
the
median
line
the strong
and
are
cephalic
parts
(Fig.44).
upper
mandibles

movable

(b)which,
This

slightlyserrated.

first

from

seen

pair

above, terminate

of mandibles

is covered

like scissors and

above

by

upper
mandibles, is a

and
slightlyfissured in front. Laterally,
partlytouching the
into
of touch or taste,movable
an
developed
three-jointed
palpi
organ
two
with
three
bristles
or
pair of maxillse)(c). Under
provided
(first

restingon
small

kind

pairof

On
which

strong

the
are

of

spineswhich

attachment

the

pair of

base, and

the

bles,
pair of mandibroad, posteriorly
labium, we
see
two, anteriorly
uniting
make the impressionas if they represented
a
rudimentary

maxillge.

dorsum

rows

at

labium

of lower

rods of chitin,which

second

besides

are

the

of the

are

the skin is laid into several transverse

animal
small

concentric
said

to

elevations.

roundish

aid the

animal

in

At

the nucha

burrowing.

Around

folds between
are

the

short

two

points of

behind
are
bristles)
long
these Bergh has counted
Farther backward
of
come
rows
thirtythree shoulder-cones.
nails and scales which probably undergo no further change with the developnumerous
ment.
On the posteriorhalf of the abdomen
of spines,numbering ten in
four rows
are
six-leggednymphae, twelve in males, and fourteen in females.
On the ventral side the organs
deserve
of locomotion
Medially
specialmention.
the long narrow
of
chitin
is
sternum
ridge
conspicuous ; this,giving off two forked
branches
(first
pair of epimeres)in an anterior and external direction,has thereby a balland-socket
jointconnection with the first pairof feet. Behind a shallow incision follows
the second
pair of feet with the second pairof epimeres. The other pairsof feet one
in the larva before the first moult, two in others
situated beyond the furrow betweeii
are
of the limbs

bristles

"

(Bergh'sshoulder

fastened, and

"

"

"

STATIONARY

thorax

and

abdomen

the lower
of hind
carries

the anal
be

may

the

surface

claw

the two

between

legs end
sucking disk

on

openingappears

as

In

stem.
a

vertical

researches

on

are

one

five

nected
segments coninates
pairsof feet term-

two

or

with

bristles.

From

the

of the internal

number

digestive
organs,

organs are far from

Gudden's
communications
through

know

we

Fig.

44," Fructified

dilates behind
and

the second

which

intestine

anterior

terminates

that the

in

the efferent duct

the
a

of which

or

asx"ect.

250.

stomach

above-mentioned

poison

oesophagua

mite.

feet into the

the
Posteriorly

gives detailed descriptionsof

and

pair of

As

being concluded.

Abdominal

lateral lobes.

two

female

aspect
Power

stomach

of which

arms

leg has
anterior

the

sucking disk. In the female both pairs

in the male the posteriorinner pair of feet again
the centre of the posteriormargin of the abdomen
slit. To the right and left of this,the anal bristles

projectsthe long stem

in long bristles,while

Dorsal

body

Each

seen.

The
to

double

posterior
inguinalridges.
joints. The tarsus at

ball-and-socket

togetherby
in

the

on

531

PARASITES.

continues
anal

salivarygland

is directed

consists of

gastriccavitywhich

toward

into

opening.

which

becomes

the head

the

long straight

Gudden

moreover

visible with

of the mite.

the

Eespir-

The
of the skin.
atory organs are altogetherabsent in our mite which breathes by means
also lacks circulatory
with
the
f
or
and
Sarcoptes scabiei hominis
vessels,,
even
organs
highestmagnifying power nothingcan be seen but a free flow of a kind of lymph in wallless currents.
Better
in the

known

As

described
the

are

the sexual

posteriorinner

organs.
pair of feet,on

In the male

(Fig.45),we

find

the transverse ridge separating

The
has a horse-shoe
latter,which
penis holder.
shape lying in
is perforated at its convex
depression,
part for the receptionof the immission tip.
testes
regards the internal sexual apparatus,it is probable that there are posteriorly

them, the bifurcated

the

and

centre, between

532

STATIOIsrAEY

filled "with zoosperms

situated

in front

PARASITES.

which

into the seminal ducts and open

merge
In
the female, at the limit between
penis.

of the

into the

tube

common

abdomen

and cephaplaced in the form of a transverse fissure the margins of

which
are
slightlybent with a posteriorconcavity. From there the ovipositorcontinues
medially as far as the region of the posteriorinner pair of feet. The ovipositorlooks
like a nail cleft at the head and is capable of dilatation during the passage of the eggs.
Gudden
(Taf.III.,Fig. 6) also illustrates very clearlythe vagina,seminal vessels,ovaries,
etc.,situated above the anal opening. The itch mites are oviparous. The ovum
ripe
for extrusion
fissure of the ovipositorand
in the
through the transverse
emerges
broad, lies with its
shape of an oval grayishshiningbody, 0,16 ram.
long and 0.10 mm.
axis
that
of
the
longitudinal
obliquelyacross
Bourguignon, Gudden, Burchardt,
passage.
and
Bergh justlyemphasize that they have seen
eggs in process of segmentation even
within the body of the animal, for this occurs
without
exceptionin acarini and it explains

lothorax, the curved

is

vagina

the

relatively
rapid (oftenin

found

in

burrow

of

64 to 76

hours)hatching of

is variable; hitherto

mite

altogether. According to
length of life of three and

Fig.

45.

Fig.

more

the eggs.
The number
of eggs
than 21 to 26 were
met
with

approximate calculation, a female, during an

can
pointto a posterityof one-third

an
a

not

46.

half months,

average
million

individuals.
find more
than
In a singleburrow
never
one
we
couple
of Life of the Mite.
On
the
female.
sought each other for cohabitation,i. e., one male and one
the
which
from
larva
to
six
there
in
from
three
ovum
a
six-legged
days,
escapes
average
is characterized
by two bristles on the posterioredge (Bergh) and ten longerspines on
the back.
The young
larva soon
leaves its pointof originand digs either a lateral passage
it. Six days after,the first moult
distance
from
burrow
mences,
comat some
or
a new
and
lasts three, four, or more
days, when the animal possesses eight legs,four
Mode

which

"

have

bristles,and twelve
the

development

the end

of the third week.

animal

After

equallapseof

an

that

spines,so
A

week

likewise

usuallyleaves

for

some

arrives

afterward, with

time

mite

ensues

the

reaches

the

finallycommences
a

altogetherand

view

to

the

both

The
sexes

specialburrow

pairing. After

digs into

second
moult, with
stage of puberty at

sexuallymature.

leaves its habita t, and

time, the female

the burrow

the

later,it appears

capableof reproductionnow

about
male

spines.

of fourteen

oped
fullydeveldered
having wanwhere

the
fertilization,

neighborhood.

But

the
male

sometimes

it

534

STATIONARY

Where

ance.

becomes

the

women

it bears

"

epidermisis greatlydeveloped, the

succulent; but

more

PARASFTES.

vesicles

on

more

small

or

recent

part of

delicate parts of the skin

pustules either

at

point

one

"

or

the

burrow

merely

in young
and
persons
its whole
over
extent.

Usuallyduring

this process, the mite is lifted up immediatelyto the epidermis. Intermediate

between
these are those regions (penis,
nipples,etc. ) where the burrow is seated

on

reddened, plainlydeveloped tubercle.

this

positionand

burrows

there

and

burrows
scab.

or

found

ceases,

sinks

down,

This

16

As

forward.

rule,the mite

But

as

soon

as

endeavors

it leaves

to escape

its

place,the
atrophies,that part

the consequence
is that the efflorescence
and nothing remains
there but a small scale,a dried

circumstance

burrow

farther

explains the
length,they

in

cm.

fact

that, excepting

measure

no

one

than

more

case

1-3

from
tion
irritaof the

nodule, crust,

of Hebra^s
and

cm.;

who

though
that, al-

the

than
pregnant female, for instance, can lay up to fiftyeggs, more
twenty to
found
in a burrow.
twenty-fiveare never
By the time such a long burrow is finished,the young ones first hatched have already
reached
the stage of maturity and propagation. While
these are striving
to fulfil their
conditions
of the skin as theifancestors
destiny,they will produce the same
; itching,
If we bear in mind
nodules, vesicles,pustules,and burrows.
that the mites, besides
multiplying,
partlywander off,partlyare transferred by the fingernails in scratchingto
remote
how
scabies may
some
the whole
regions,we shall understand
spread over
body
from

singlepoint.

The

subjectivesymptoms

increase

in consequence
only at the

of the

spreadingof the process, and

case
placesoccupied by the parasites,
but,
the
simultaneous
the paowing to
pointsof attack, the reflex,and the irradiation,
many
tient
is forced to scratch here and there and everywhere
The followingmorbid
pictureis presented on the skin : While on the one hand the
manifest

mites

by
the

and

themselves

in the latter

their burrows

the presence

increase,as well

of the animals

scratchingwith

the

as

the nodules, vesicles,and

the other

on

hand, all

sorts

of

pustules produced

eruptions

are

caused

by

fingernails.

following order of frequency : flexor side of the wristfolds, anterior axillaryfolds, nipples
fingers,interdigital
and surroundings in women,
penis,anal region,navel, etc. Or to express ourselves more
concisely,we may say that the mites, their burrows, and the eruptionsimmediatelyproduced
by them are met with most frequentlyon those parts which are covered, protected,
Therefore
of increased afflux of blood.
shall find them
and kept in a condition
we
also
articles
where
the skin is exposed to continual
of
dress.
But
close-fitting
by
on
pressure
must
this account, when
the diagnosisof scabies is doubtful, we
fail to examine
never
such portionsof the skin exposed to pressure, according to the occupation of the patient,
The

localization

not

joint,lateral

in the

occurs

surfaces

for the

of

of mites
presence
v,^hose skin naturallyis not

the

at least

or

subjectto

points of predilectionfor

no

of efflorescences.

any
mites, and

certain

they

may

In

infants

and young
children
pressure, there are generally
be found
in the face and on the
even

continual

soles of the feet.

The
and

efflorescences

of the
which

tions
They are the affecitching eruptions. On recently
erythema or one correspondingto the scraping with
the highest points,and with remisis eroded
sion
on

scratchingoffer
we

find in

no

at all.
peculiarities

all chronic

placeswe see either a diffuse

fingernails,and an urticaria which
lichen urticatus (Hebra). Where
the irritations
of the injury becomes
place,artificial eczema,
longer time and are repeated at one and the same

attacked
the

consequences

continue

for

folliculitis.

STATIONARY

lurunculation,dermatitis,and cutaneous
of scabies.
erysipelasin consequence
But

however

variable the form

of

535

PAKASITE8,

ulcers result.

the

Biff on

states that

he has

seen

eczema
eruption erythema, urticaria,
papuit is unchangeablein that it is
largelygrouped around those regionswhich are sought by the mites with specialpreference.
But it happens occasionally
that two or more
such eruptive
territories adjoinso
blend with each other, thus resulting
in largerpatches of
eloselythat their peripheries
scabies.
The region from the nipplesto the knees is considered
of the largest,
and
one
termed
by Hebra, with justice,
particularly
pathognomonic.
"

losum, vesiculosum, pustulosum, erosions,ulcers,etc.

"

^'"^"i'","y
Fig.

In

exceptional
cases,
decades

or

years

affected with

most

mites

that

is,when

all sorts of artefacts,the

quantitiesbeing met
(Fig.
spot
48).

Diagnosis.

generallynot
is the
warmth.
hands

"

scabies

If

we

offer any
continuous

In response
to discover

for a long time

several
still
are
pointsof predilection
demarcation
is no
longer sharply limited,
everywhere,often on simple scrapingof any

patientsremain

neglected condition, though

in variable

crusted

the

in

"

48.

bear in mind

with

"

the

all the

symptoms enumerated, its recognitionwill

the patientto consult the phycauses
sician
the whole body, and increased by
itching,literally
spread over

specialdifficulties.
to

such

the burrows

What

statement,

we

of the mite.

should

for obvious

In order to

reasons

first

recognizethese, we

that

inspect
must

all the more

they representundulating,punctated lines which become
distinct by paintingwith ink followed by drying (Hebra). If they are found sufficiently
is determined
folds,the diagnosis
developed on the fingersor interdigital
ipsofacto.
the
If no burrows
are
present on
fingersor cannot be positively
recognized there,
of the mites
they must be looked for on the pointsof predilection
penis,umbilical
region,anterior axillaryfolds,nipples,or anal region. In a form of scabies, such as
the one
have taken as the starting-point
for our
we
discussion,the development of burrows
has occurred, as a rule, on
another point. If it is probable that they are
or
one
such, and a magnifying glassis at hand, we should not fail to fetch the mite out of its
If not skilful in catching the mite, it is advisable to
the two
supposed burrow.
compare
At the point where the mite is located,we
ends of the burrow.
shall either at once
see
remember

"

536

PARASITES.

STATIONAKT

body glisteningthrough
yellowish-wliite

small roundish,

case, there

layerby

will be
of

means

point of

it should

in mind

be borne

end.

knob-shaped rounded
when
mite, especially
the lancet in the
naked

the
But

present,will

be

lost with

that it adheres

that

too

the

the succulent,

at

deep,

fluid.

otherwise

the

If the mite

has

rather

tenaciouslyto the point of

body, appearing globular to the
acquirethe knack of catching mites will do

to

scissors,razor,

in toto with

neither burrows

mites

nor

may have been undertaken

then nothing is left but to

treatment

be carried

not

microscope properlyflattened between

often

in

of the

out

small, at first motionless

unable
altogether

the burrow

remove

under

is

should

lancet

be remembered

shape of

Whoever

eye.

best to

The

epidermis,and

stay at the dried, but

it does not

that

vesicle is

secured, it should

been

else the mite

Or

the
animal

epidermis
and diametrically
to the longisuperficially
tudinal
cannot
be distinguished
at either end, and

lancet inserted

axis of the burrow.

then

liftingthe

in
particulardifficulty

no

to

are

lancet, and then to examine

or

it

slides.

be found, either because

patienthas

the

or

two

removed

them

an

by

ineffectual
cal
mechani-

some

to the presence of scabies by

as
gain information
inspectingthe pointsof predilection.If there are in the regionof the anus, the genitals,
the nipples,etc.,circumscribed
eczematous
symptoms, we can assert,independentof the
otherwise largelyrelied upon, that scabies either is or was
burrows
or the pustularforms
present.
Teeatmen"t.
The indications to be met by a complete treatment
of scabies consist
means;

"

in this, that

the

mites

killed,and

are

irritative conditions, artefacts of the skin,

the

most
aim will be best reached when
we
scrupulously avoid
employ only such agents as unite specialdestruction of the
mite with the preservationof the skin.
of ethereal oils,
Of the drugs employed may be enumerated:
Sulphur, a large number
roris marini, menthge, cinnamom., etc., balsamus
ol. lavanduL, caryophyllor,
peruvian.,

removed.

But

this twofold

all caustic substances, and

styrax; tar, infusions and decoctions of black hellebore,fol. nicotian.,baccse lauri.

recent times, petroleum, naphthol, and naphthalin have been recommended.

penetrationof

In order to facilitate the

mites

and

at the

drugs are mixed

followingparagraphthe

Often

or
"

effect the

other

them.

most

reliable

hiding places of the

ployed
ere,
they are emaccording to individual preference.

artefacts,eczema,

solutions

or

with

into the

drugs

of the

cure

of ointments, mixtures,

in the form

In the

time

same

these

In

will
prescriptions

be mentioned:

Rp. Sulph, venalis, 5 to 10 gtn. ; and Butyr. recentis or Adipis, q.s. (For country and poor practice.)
Ol. lini (4 : 1). Bals. peruv.
with
alone or combined
Also: Styracisliquid.,
(10 to 20 gm.) alone
This prescription
is particularly
with
appropriate for children.
equal parts of styrax may be used.
recommends:
Acid, arsenicus, 0.05;Potass, carbon., 1; Spirit,saponat., 10; and Aqu. font.,
Clemens
time
Where
there is present at the same
gm.
Wilkinson's
in twice within
hours
twenty-four

1000

"

rub

40; Sapon. virid.,Adipis, ana

fagi,ana
the

linen, Weinberg

substituted

has

the

But

80; and

adds
years

with

"

for

solution

extensive

ointment

Greta
amount

same

of the eczema
thereby the cure
simple scabies: Naphthol, 15, cum
thereto:
Sapon. virid.,50, and Cret.

orders

an

alb.
of

as

pulv.,15gms.
styrax for the

the

to

thirty-six hours) are

long established

for this purpose.

2; Potass,

In

natural

sufficient
and

In

"

ol.

"

to

artificial

France, Helmerich's

subcarb., 1; Adipis, 8 parts.

by

cure

the

sulphur baths,
sulphur ointment

Bourguignon

has

that

itch.

three

For
as

modified

as

to four

simple

well

to

Flor.

sulph.,Ol.
order to avoid soilingof
fagi in the last prescription.
lost sight of.
Kaposi

in

naphthalin

it is advisable

Hebra:

has been
originalintention
Ung. simpl., 100 gms., and where
alb. palv., 10 gms.
I have
employed
the

Filrbringer recommends
very satisfactory results.
himself
in 60 cases
with linseed oil. He has convinced

twenty-four

artificial eczema,
modified

is

eczema

naphthol
10

to

12

inunctions

present
for

per

two

cent

(within

mend
might recomthe sulphur-sand soap prepared

cases

is largelyemployed
it in the

we

: Sulph. puriss.,
following way: Gummi

(aoabus)folliculobum

DEMODEX

tragacanth.,1;
to the

lard

has

Hardy

changed

in Helmerich's

merely

ointment

01. lavand., menth.,

proportion of the sulphur

the

(1 : 12).
is used, satisfactory
results
remedy or prescription
The
should
of employment is correct.
remedy

"Whatever
where

subcarb., 50; Sulphur, puriss., 100; Glycerin., 200; and

Potass,

1 gm.

etc.,ana

53T

hominis.

the mode

of
predilection

the sites of

and
vigorously,

the mites

will be
be

not

be first and

must

to, other parts of the skin, such as the flexor side of the elbow
painted.
mode
In the Hopital St. Louis at Paris, Hardy employ the following

which

they

anointed

for it
qualified

take

and

hour

an

with

left for awhile

terminates

treatment

According
with

to

are
(sic!)

ordinary bath

an

for half

for half

and

modified

with

black
Then

hour.

an

the above-mentioned

soap

the

too

exclusively
ply
joint,are simof

ment:
rapid treat-

off,after

rubbed

and

patientis againthoroughly

modified ointment)
(Helmerich's
bath for cleansing
purposes the

ointment

With

in this condition.

after two

Hebra

the

washed

only
in

almost

attended

Patients

obtained
rubbed

another

hours.
his school, the

Wilkinson's

patientanoints

ointment

first separately,and
points of predilection

or

any
whole

so

as

paration
any pretake the

to

body, the face remaining

After
wrapped in woollen blankets.
twelve hours, the patientrepeats the same
procedure and this completesthe cure, so that
the treatment
of the itch lasts twenty-four hours.
For
ordinary cases this procedure is
and
the
after
from
four
to
two
perfectlysatisfactory,
patientcan take a bath. But
days,
when
the itch is of long standing,the skin consequently more
faces
irritated,and larger surafter
this condition requiresa specialappropriatetreatment
present an eczema,
the body is first painted with oil,
In general eczema
employment of the itch ointment.
eczematous
and when
the weeping has ceased altogether,
For circumscribed
with tar.
The
is
it
advisable
to
ointment
in
the
use
pustular
ordinary manner.
diachylon
patches
eruptions on the hands are best treated with dailysublimate hand-baths
(1.5)lasting
free.

Then

he dresses in

one-half

from

to

Prophylaxis.
herein

concur

some

or

is

hour.

one

Some

"

only in

so

stilladvise

far

as

DEMODEX

With

then

fabric

woollen

the

without

himself

liniment

againsta
precautions

it is desirable to

second

the bed

change

reinfection.

body

We

can

linen.

HOMINIS.

FOLLICULORUM

(ACARUS)

and

lateral pressure to the skin of the nose, forehead, cheek, lip,on

the external
behind the ears, etc.,there is dischargedfrom the efferent duct of the

auditory meatus,
follicle
oil

or

consistent, soft sebaceous

glycerin,
permitsthe

lightlyrubbed

which, when

mass

recognitionof livinganimals

under

even

with

low powers

drop

of

of the

microscope.
Demodex
has

hominis

is 0.30

to 0.40

mm.

clearlydeveloped cephalic,thoracic, and

The

head

is marked

off from

the thorax

long, has
abdominal

by

an

elongated wormlike

form, and

parts.

bandlike

streak

running

on

the

terior
pos-

side,occupiesabout the fifth part of the entire length of the body, becomes broader
and thicker in an antero-posterior
direction,and the followingparts can be distinguished
it : In front and
two
are
on
pedipalpi(Fig. 49) which are freely movable,
laterally
and capable of being rolled in.
the palpi and united with them
Between
three-jointed,
by a jointis a pair of upper maxillae or mandibles movable only in a horizontal direction
at an
like scissors. Extending from
above
acute
downward, adjoining the mandibles
the
lower
maxillas
their
which
at
are
or
angle,
posteriorend, and
jaws
together
merge

538

(aCAEUs)FOLLICULOEUM

DEMODEX

be

must

backward

regarded as masticatory implements.

membranous
a narrow,
barely perceptible

into the stomachic

cavityin

the

neighborhood

HOMESTIS.

Between

these

extends

from

tube, the CBSophagus,which

of the fourth

pairof

in front
dilates

feet.

L
Fig. 49.

The
a

49."

Fig.

50.

Fig.

51.

thorax, in the

cylindernarrowed

Fib.

Fig.

"

"

Male

the

female

with

first traces

animal

each

50.

genital apparatus.

Fecundated
Shows

mature

toward

with

about

of

vagina
an

and

ovary.

embryonal

one-fourth

end, and is bordered

development.

of the entire

in front and

length,represents
by the head, and

above

Seen from the ventral surface, we

by a furrow.
horizontal
chitinous ridgesextending
on
or
doubly-contoured
which
forward
centre
the
backward
from the margin toward
and
to meet
the
elongate
adjoiningones, thereby producingon the one hand an apparent longitudinalridge in the
centre, and on the other divide the lower surface of the thorax into as many fields joined
by membranes.
Only the most posteriorpair of these epimeres does not extend as far as
Into each of the four anterior epithe margin and thus representsa kind of false rib.
meres
therefore
is inserted one
of limbs.
Each
an
equal number
pair,altogether
leg
The coxa
has a triangularform and at its jointwith
consists of coxa, tibia,and tarsus.
The tibia represents a strong cone
the epimere is movable
only in a horizontal direction.
The tarsus consists of a singlepiece
in two planes vertical to each other.
and is movable
it has largeclaw-like processes and between
these a
graduallytaperingin front; laterally
delicate flexible whip-shaped bristle. In the dorsal positionof the animal, the only
noticeable things are
two lateral strong piecesof chitin inserted in the skin, extending
the animal
from the occiputto the second pair of feet which
serve
as
a sort of carapace.
from
the first to the third pair of feet a small knob,
animals there is laterally
On some
hence three pairaltogether,
Wedl
considers to be stigmas and is inclined to bring
which
them
in connection
with
the respiratory
apparatus. I have convinced
myself on a
individuals.
male
number
of specimens that they are spinesoccurring
on
only

behind

observe

and

below

each

toward

side four

the abdomen
five

(aCAKUS) FOLLICULOKUM

DEMODEX

The

at the end.

ringed,while
delicately
At

shape of a glove finger,tapers graduallytoward the posterior,

Its length is nearly half that of the body, and its envelopeis
the back the tracingextends only to the second
pairof feet.
loAver surface the anal opening appears in the form of a small

has the

abdomen

is rounded

and

the anterior

part of

639

H0MINI8.

on

the

cleft.
longitudinal

tube, dilates in
digestivetract begins at the maxillae as a delicate narrow
to
form
the
then
stomach,
again narrowing into
region of the fourth pair of feet
with
the vaginal opening as
a
common
intestine, and terminating in the abdomen
The

the
the

"cloaca.

By careful focussingof the microscopewe can see in the female, in the regionof the
vaginalslit,a small tube dilatingposteriorly.The latter representsthe ovary and the
the male procreative
former the oviduct.
By equal precisionwe can also demonstrate
Since
the
the
animal
of
has been raised
and
a
discovery
question
(testicle
penis).
organs
the demodex
is oviparousor viviparous.
but not decided up to the present time, whether
By culture experimentsI have had the opportunityof followingthe development of the
animal

the first traces

from

oviparous.
their

As

to the formation

of the various organs, and I believe it to be

the organs of the vegetative
system are strikingin
shows
the
also in the embryo it is the masticatoryapparatus which
animal

in the mature

so
proportions,

of structure

In

the further

development follow the stumpy

completelydevelopedmasticatory
young
possesses
short
apparatus, three pair of extremities,and a short digestivetube with a relatively
the
abdomen
becomes
abdomen.
the
longer,
masticatoryapparatus grows proGradually
portionately,
have before us a
and after the fourth pair of legs has also developed,we
Until the animal
sexless nympha.
acquiresthe sexual parts it changes its exterior in
respects.
many
An interesting
is,whether the
questionwhich has engaged entomologistsuntil now
animals
and
acari folliculorum
belong to one and the same
present in men
variety.
But however
contradictoryare the experimental results and clinical observations in
and animal
follicular acari,authors are
regard to the identityor difference of the human
of man
is considerably
unanimous
in statingthat the demodex
largerthan that of animals.
first rudiments

If

we

(Fig. 51).

feet,epimeres,etc.

larva therefore

that the mode

bear in mind, moreover,

of life of the

varies with

demodex

its host,

that
to transmissibility,
as
despitethe uncertainty
great probability,
there are of sarcoptes.
several speciesof demodex
as
Microscopicsections carried through various parts of the skin of the face show that
the tail pointingupward. The number
in the follicle,
the mite rests head downward
ent
presfollicle is very variable,there being sometimes
in any one
only one, sometimes from
The
of securingthem is to force
twelve to sixteen.
simplestan" most reliable method
the ala nasi to the surface by lateral pressure.
of the follicles on
If the
the contents
we

may
there are

mass

with

assume

obtained

be then

up with
the slide,even

rubbed

quitetransparentlayer
recognizethe animals by
on

to

In the new-born
two

and

cheeks.
on

four

Henle

their

the demodex

year old child.

and Berger have

the back, Gross

the

on

mons

little oil in such

a

tyro in the

peculiarshape, with
does not

occur.

Gruby

on

that it forms

manner

of the

found

the nose,

it in the cerumen,

Veneris, and

moderate

I have

Its favorite sites are

met

use

Wilson
other

on

the abdomen,

parts of the

of the demodex
has absolutely
morbific influence on
no
presence
with the effect on animals (dogsand hogs), Remak
alone cites a case
on

the back

which

is said to have

arisen

fail

magnifying power.
it once
in a
respectively
and
lips,chin, forehead,

The

in the face and

thin,

microscope will not

through

Eemak

body.
man,

of

acne

the demodex.

in

trast
con-

tion
erup-

540

PEDICULOSIS.

As

the demodex, according to my experiencewith more

than,
individuals,I side with Wilson in that there is hardly any grown-up
person
they cannot be found, often indeed only after a long search.

hundred

two
on

regards the frequencyof

whom

PEDICULOSIS.

Stnoktms.
Willan

speaks

of

P.

this condition

Phthiriasis,Morbus

pedicularis.
Prurigo pedicularis
(Willan).
of phthiriasisbecause
he
generally charged with being an adherent
pedicularis. But if we learn from his book, under prurigo senilis,that
"

is

of

the skin

yet that these insects

is said to be favorable

to

the

of the human

occurrence

louse,

brought forth in the inhabitants of dirty,bad apartments, and

in the inmates of prisons,etc.,that the nits are deposited on the small hairs of the skin,
and that the lice are found only on the skin or on the linen, and not under the epidermis,
then we
ranks the equal of the most
must confess that Willan
reliable observers of the
his
clinical
in
to
Bateman
stories
finds the wonderful
regard
conception.
presenttime,
about affections caused
by lice astonishingand thinks that they probably rest on error,
the writers having mistaken
other insects or their larvge for lice. The doctrine of phthiriasis
is dealt with, if possible,
even
more
harshlyby the later English writers,Plumbe,
A.

E. Wilson, T. Fox, and

T. Thomson,

German

the

Among
As

of its most

one

mites

are

prominent

resembling lice
opening tumors.

Alt claims

authors

to have

are

others.

there

adherents

are

but
must

we

few
name

who

said to arise in the unbroken

found, in two

of

cases

spoke

0. H.

in favor of

phthiriasis.
According to him,

Fuchs.

skin

and

observed
phthiriasis

to

forth from

come

culiar
pe-

at the clinic in Bonn,

fore,
Therespeciesof pediculuspeculiarto this disease,which he calls P. tabescentium.
Alt says, though in harmony with the progress of science we
no
can
longer speak
kind of lice found should
of lice as originatingin the tissues of man,
stillthe peculiar
contribute towards explainingthe nature
of the disease.
of
Nearly thirtyyears later.Dr. Gaulke, of Insterburg,reporteda series of cases
so-called
genuine phthiriasis which is said to have been produced each time by the
that the lice
All these cases
said to have had this in common,
are
pediculusvestimenti.
of thousands
in cavities one-quarter inch deep or in livid red
were
present to the number
portionsof the skin having a thin covering and resembling abscesses. Inspection with
of the closed cavities,covered with a parchment-like
skin, disclosed on
a magnifying glass
When
the surface pores the size of a pin'shead, and they felt like a sac filled with shot.
not
but
to crawl in all directions,
a drop
of lice were
seen
evacuated, a number
they were
of lice could
As to the manner
of pus could be observed.
in which
so
largea number
penetrateinto the depth of the skin, Gaulke expresses the view that the pregnant animals
piercedthe skin with their anal stingin order to lay their eggs under the epidermis.
a

'

"

'

Landois, in his notable

Leonard
has arrived

at the result that not

reallysuch, that

the disease consists in

Alt's separate species

of
grave

disease

the

animals

in

"

all the
an

on
phthiriasis,"
investigations
literature
the
in
cited
were
phthiriasis
fore
vestimenti, that thereincrease of the pediculus

historico-critical
cases

of

does not exist,and that

pediculustabescentium
skin in largenumbers
questionenter the human

either open or covered pedicularulcers.

with pedicularulcers,nor
Hebra
did not meet

cause

they

were

to be found

Hebra's

always either

ars^umentation

has not

on

did he find lice under

the hair, hairy parts,or

convinced

either Landois

or

or

in

cases

and

of

there

in the skin ;

the clothes.
Gaulke.

Landois, in his

542

PEDICULrSIS.

1. Fediculus

and

breadth

of 0. 6-1

The

the male.

cervicalis.

capitiss.
head

The

mm.

is white,

glued

part of

to the lower

Within

emerge
young
to
from
seventeen

animals

are

after

not
the

over

rule, lays from

to
fifty

on

Esquimaux

louse

increases

sixtyeggs which

are

from

six

"

In

order

to

itching,the

annoying
person
lice is forced to scratch, and this

infested with

only at the pointof attack, but

scalp. However, this provokesa

extensive

rather

as

louse
head

days.
twenty days the

Coukse.

akd

the

overcome

all

female,

mm.

largerthan
is recognizableat first
blackish margins ; but

The

etc.

1-2

capable of procreating.

Symptoms

does

brown,
yellowish

the hairs and

the

which

he

Chinese

lengthof

millimetres

of the skin of its host.

negroes
remarkable
rapidity.The

with

has

man'

Its color is gray with

the head
Thus

of the head.

black, on

on

louse of

the average is a few

on
than the clothes louse, and

is smaller

louse

sightby the triangularform

it changes its color with that

head

The

"

female

inflammation

which

is

ceeded
suc-

by the eruptionof nodules and pustules.

When
of longer standing, the pustules,the
weeping spotsand their dried secretion become
more

plentiful.If

the lice have become

dom-

of a profusegrowth of hair,
glued together, felted by the
forming secretion, causing plica polonica.
all sorts of fungi,
That
etc.,may settle in such

iqiled in midst

the

latter

confused

and

are

mass

of hair, both

at the

same

is self-evident. Yet
subsequently,

Fig. 52." Male

head

time
in

by

louse.

chitinous
the

material

several
At

the young

far the

greatestnumber

Sometimes
often

even

looked

the

of

cases

nits,fastened

Fig. 53." The

of

of

plicapolonicathe

head

stages
the

the

to

of

upper

by means
hair, represent

embryonal
end

velopment
de-

of the hair

louse has left the shell.

lice

play the

neighboringglands (loAvermaxilla, neck,

and

chief

part.

nucha) swell,

Such
merly
forsuppurate, and finallybreak open.
glandular swellingswere
as
a
etc.
sign of scrofulosis,
syphilis,
According to the degree of
upon

of the skin, especially

in young
sensibility
persons, there appear,
of the hairyscalp,vesicular and pustular eruptionswhich,

in the

even

in

case

hood
neighbor-

of still further

543

PEDICULOSIS.

spread

neglect,soon
an

of the

large part

over

face, neck, and

back.

look

Many

of head lice.
of that nature as characteristic of the presence
eczema
of a process due to the presence of head
The treatment
Treatment.

upon

lice is

"

ceedingly
ex-

proceed againstthe lice. And for this we

have in petroleum such a sovereignremedy that a singleapplicationsuffices to kill the
lice completely. Owing to its disagreeableodor, it is advisable to employ it with an
artificial eczema
The
present is next to be taken in
equal quantityof Peru balsam.
in
from
to two weeks by continual
be completely healed
This can
one
hand.
generally
washing of the head
get rid of the nits if
mind

in the

of

case

oil (ol.
olivae).It is much
green
soap and
this must
and
hair is to be preserved,
be

with
the

The

women.

of caustic

solutions

is 2-3

louse

vestimenti

Pediculus

s.

and

long

mm.

eggs

potash will

detach

not

to the

Thus

soda

The

The

broad.

mm.

them.

saturated

human.

corporiss

1-1.5

firmlyfastened

so

are

of the hair with

by repeatedwashing
2.

must

In the first place,we

simple.

difficult to

more

borne
especially
hairs that

far I have

even

in
centrated
con-

always

ceeded
suc-

solution.

clothes

color

of the

tinctly
dirtygray or has a yellowish cast. The thorax is disThe
latter is sparselyset
separated from the abdomen.
with hairs,has a yellowishcolor on the margins,and has eight segments.
According to Giebel, each tibia carries at its end, on a projection,
a rod of chitin surrounded
by largebristles. In the female
size throughout, while in the male
this projection
is of the same
The
males
it is largeron the first pairof feet than on the others.
The female lays,
than the females.
smaller and less numerous
are
on
an
seventy to eighty eggs, from which the young
average, from
to eightdays, and are capable of reproducin
from
three
tion
emerge
after fifteen or eighteendays.
is

animal

On

seek the

and

infested with

inspecting
persons
convined

cult to become

intended

to

that

the

to

obtain

body merely
it is not

cases

nourishment.

that the clothes louse is

mean

to

rare

clothes lice it is not diffi-

insects live in the clothes

see

never

them

But

the

on

around

wander

skin; in greatlyneglected

there.

Some

excoriated
ulcerated
on
or
exceptionally
parts of the skin; but
that this is their first and permanent domicile.
in believing
us
justify
If we place into the cavityof a recentlyopened furuncle, the inner
met

of them
this

with

have

carefullycleansed

been

of blood

in

nor

these results and

must
or

Symptoms

aistd

the

by
aimlesslyaround
With
soon

time

in

still the

In the latter two

lipoma.

animals

fell victims

cases

to the

the

ments.
experi-

that the

the skin.
Couese.

"

If

we

would

the skin, then

a correct
"acquire

singlesuch

it settles down

and

idea of the

louse at work.

symptoms
At

first it

its proboscis
into
projects

the

proruns

dermis.
epi-

sufficient attention,the

subsides.

the direction

becomes

on

of which

arguments againsttrue phthiriasis

brought forward
ities
pediculusvestimenti can live neither in abscess cav-

it is best to observe
clothes-lice,

auced

which

conclude

under

are

not

and

twenty-fourhours that not a

atheroma
and another
in a case of extirpated
left quiteuncovered, and
cavitywas even
by others, I

walls

does

shall find
pus, several dozens of clothes lice,we
remained
alive.
The
louse
has
took
same
single
place

in

Prom

clothes

louse,

this is not

found

to be

^j^^ 54." Female

solely

of the

The

feels at the same

time a slightstinging
person
to
louse raises its abdomen
that it stands
a little so
obliquely

sting.Now

intenselyred from

the

body

the contained

of the animal
blood.

Then

begins to
the

be colored until it finally

louse

desists and

the

first

U4:

PEDICULOSIS.

act of the
a

small

procedure is at an end.
hemorrhagicpoint which
where

the

allayby scratching.
the site of the wheal
there

appear

form

small

In

individual
But
have

now

been

not

so

its consequences.
At that spot we
observe
escence),
efflorby a pale raised areola (urticaria

feels considerable

relief is not

the surface

on

But

is surrounded

attained

until

depletedof blood, *.

of the wheal

one

or

itchingwhich

the vessels of the

e., have

been

drops of

more

he

to

papillarybody

scratched

blood

endeavors

which,

at

Thus

open.

drying,

soon

crusts.

order to

the extensive itchingproduced by numerous

satisfy
lice,there will be
where
the skin has not been injured by
erythema, wheals, and excoriations even
the lice. For
it is unquestionablethat we
not
are
always able to locate correctlythe
the patient scratches likewise on parts distant from
the
itching caused by lice,whence
of
number
efflorescences.
points of attack, thus producing the disproportionately
large
If we inspectsuch a skin more
time has elapsed since
we
iind, in case some
closely,
the last attack by lice,on
circumscribed
some
spot, recent and older blood crusts of
roundish
The latter form
is
irregularform, isolated or in a certain linear arrangement.
produced by the patient,in order to scratch effectually,
as
a
setting down the thumb
fixed point,and digginglong bloody streaks with the other four fingers.
Diagnosis.
The marks
become
tion.
importantfor the diagnosisonly by their localizaFor the attentive observer must
be struck at first sightthat the scratch effects in
pediculosismainly occupy those regionsof the skin which correspond to the folds of the
is so regularthat where clothes lice are present,the attacked
clothing. This concurrence
portionsof the skin change every time with the kind of clothingworn, and often it is
the establishment
of this fact which
leads to the discoveryof the objectat fault.
Should
this condition continue for months, the clinical pictureacquiresa different
the whole body,
over
aspect,not only in so far that the scratch effects are spread diffusely
but in the mean
time the secondary efflorescences
furuncles, and
pustules,eczemas,
utaneous
ulcers
have multipliedmateriallyand left traces in the form of all sorts occicatrices and pigment spots. On
skin thus treated, therefore,we
observe all
a
may
tory
possibletransitions from the simplesterythema to the most advanced form of inflammadestruction
and retrogression.
The latter may
even
predominate to such an extent
that nearlythe whole skin looks brown
black.
or
if
take
into
consideration
that such
Moreover,
we
people belong to the poorest
will
understand
that persons sufferingthus are liable to other bodily ailments
classes,we
and generallyfall a prey to invalidism.
Recently I had in my ward a patientaffected
with various speciesof lice,who, although no
other disease could be demonstrated
in
after
him, and in spiteof the fact that he enjoyed a, for him, luxurious
(hospital)
care,
two and a half months'
from
stay in the hospital,had been unable to recover
sufficiently
his marasmus
Such
to be capable of standing even
few
minutes.
of
a
cases
supposititious
but it is questionablewhether
in
''genuine phthiriasis might indeed terminate fatally,
such a case
there is any plausiblereason
for ascribingthe unfavorable
to
termination
must
not rather assume
the presence of the lice or whether
that the neglected mode
we
formed

"

"

"

^'

of life is the sole

The
removal

TREATMENT

cause.

cousists in

keepingthe body

dermatologicalprinciplesof the

clean

(bathingand washing),and

irritative conditions.

In

order

the

on
guard
be most
against a possiblereturn of the affection,the clothing,
etc.,must
carefully
cleansed
hours.
by washing, or by keeping it at the heat of boilingwater for forty-eight
II. Phthiriasis inguinalis
s. pubis, Pediculus
pubis (Linn6),Morpion, Crab Louse.
from
The
crab louse is distinguished
the last described species
by the broader head,

to

545

PEDICULOSIS.

has a heart
joinedto the thorax by a neck-like prolongation.The abdomen
three
being very small and only
shape and is providedwith eight segments, the first
delicate and has
first pair of feet is comparatively
indicated by the stigmata. The
which

is

The

small claw at its end.

stronger towards

become

other two

a
forcepswith
stingwhich, turned inwards, becomes
broad
and
thus from
and
to
0.8 to 1.0 mm.
0.7
0.5
mm.
long
The pear shaped eggs, ten to
smaller than the female.
of a sheath
fastened
fifteen in number, are
by means
of chitin in the lowest possible
part of the hair. From
after from
six to seven
these the young
days
emerge
and become
capableof reproductionin two weeks.

The

louse

crab

veneris

generallyspreads
over
neighboringregions,downwards
mons

thence
the

to

one

and

one

end

The

tarsus.

in

male
half

is

mm.

the

frequentlyon

most

occurs

and

the tarsus and

the

sort of

the

over

thighs and

the abdomen,
beard,
chest,axillse,
legs,upwards over
and the eye-lashes. But it is not impossible
that they
with
of the regions menbe first met
on
one
tioned
may
the
children
T
his
on
(in
eye-lashes).
depends
of transmission.

the mode

on

but
frequentopportunity,

Coition

the

offers the

infection

be

may

most
Fig.

com-

55."

crab

Louse.

municated

also by the clothing,

linen,bedding, etc.
like the other lice,injures the skin only when
feeding,the
Although the phthirius,
intense.
If the patientbe questionedabout the manner
of
more
symptoms are much
told that, as soon
the itchingappears, the necessity
to insert the
we
are
as
scratching,

naik

of

appearingin the form

eczema

the

cases

The

result

of these

efforts

finallyis an extensive
stubborn
particularly

papules,vesicles,or pustules.
degenerateinto a dermatitis.
of another quiteinteresting
symptom
In

largesurfaces or
may extend over
cerulecB. We must here make mention

eczema

Macules
of

irresistible.

becomes

deeply

"

the
phthirius,

maculae

ceruleae

taches ombrees

or

sexes

infested with

with

the destruction

of the animals.

In 1868, Mourson

demonstrated

of the French.

In persons

of both

phthiriiwe not rarelyobserve steel gray spots,the size of the little

but slightlyunder
which
fade
nail,
finger
generallyaccording to the
pressure, occur
o
f
the
disturbance,
after
few
cause
no
a
lice,
locality
days, and cease altogether
disappear

and

accordingto which
salivarygland, situated on
any

further

to

"

unguentum

use

the

and

1882

due

spots are

was

causal connection

Duguet published the

the thorax, under

to

the evacuation

the

and
epidermis,

between

phthirius

results of his investigations,

of the contents
are* not

of the

connected

with

alteration of the skin.

Treatment.

And

that there

In 1880

the taches ombrees.

be denied

it cannot

But

the animal.

Since the
cinereum

it is

will produce a
generallyunable to

of mercury
in medical practice,
it is the custom
"
''
known
blue ointment
as
popularly
againstcrab lice.

employment
"

"

that two

frictions of

piecethe

size of

bean

each

suffice to kill

equallycertain

stubborn
establish

of the

that if the necessary caution be neglected,the ointment

artificial eczema,
because
the patientis
more
especially

the

death

of the

animals, and

is

likelyto

continue

tions
fric-

eczema.
itching,
ethereal oil,Peru balsam alone or in combination
with
petroleum,some
In
to
order
of
the
hatched, it is necessary to
dispose
petroleum.
subsequently
young
repeatthe procedure several times at intervals of eightto fourteen days.
on

account

the start either

35

now

due

to the

I therefore

advise to

use

from

546

TEMPOEAEY

PULEX

PAKASITE8.

IRRITANS.

THE

OF

FLEA

MAN.

flea possesses

The

a laterally
compressed body and has a brownish red color. The^
broad.
The female, on an average, is twice that
long and 1 to 2 mm.
size. The oral parts are arranged for sucking and consist of a pair of serrated soft mandibles,
a
singletongue suitable for stinging,a lower labium forming a sheath for the
The thorax is divided into three
former, and a pair of labial palpiwith four jointseach.
each
of
which
is
with
of
a pair
segments,
provided
legs. The latter increase in length
towards the posterior,
and have very strong femurs, with two claws on the
are
five-jointed
tarsus.
Eyes,respiratory
developed. The
organs, and genitalapparatus are distinctly
female lays within twenty days the same
of eggs into fissures in the flooring,
number
the
folds of the dirtywash, etc., and from these the footless,worm-like, fourteen-segmented
whitish larvae emerge after from six to eightdays. The nympha is inclosed in a coccoon.
insect does it
Only after the flea has undergone its metamorphosis into the fullymature
skin for its nutrition.
seek the human
Its bite,with which
time injects
it at the same
fluid,is barelyperceivedat the moment.
an
irritating
Graduallythere is felt a local
itchingof short duration, conjoinedwith wheals in persons with delicate skin. When
the animal is satiated,it leaves the skin and we
rounded
perceivea small hemorrhagic pointsurareola.
The
latter
while
the
in
few
dation
exua
minutes,
by hypersBmic
disappears a
of blood continues for several hours.
In neglected persons the flea bites may be
that for an instant,especially
when
exists,
coa febrile condition
presentin such largenumbers
they may simulate the pictureof morbilli,scarlatina,etc.
host.
But
The
human
flea may change to the dog and back again to its original
the dog flea never
man.
preys permanently upon

male

is 2 to 5

mm.

1. Animals

Sarcoptesscdbiei

a.

burrow

and

the females

PARASITES.

TEMPORARY

II.

Parasitical

communis.
of which

"

in

comprised all the mites which

the Sarcoptes scabiei hominis
Hence
of separatefrom the other species(S.

this head

Under

Condition.

Mature

live in canals.

are

This has been treated

belongs among them.
really
equi,suis,ovis,canis, lupi,vulpis,
etc.)in deference to
For although sarcoptologists
unanimous
that
are
man.

character
its parasitical

towards

anatomicallyand physiologically
and
several
the
immaterial
differences
between
there are
species
only quite
mites
of
the
well
when
and
veterinarians
transferred,
Sarcoptes
are
that,
aware
physicians
major burrow under the epidermis,the females construct canals, lay eggs, from which
still
the whole body
itch spread over
an
are
hatched, in short that there ensues
young
and that
that the mites are unable to adapt themselves
has shown
definitively,
experience
such an itch is always of limited duration
(never beyond six to eightweeks) and that
both

"

"

therefore

spontaneousrecovery

be looked

as

upon

temporary
This

within

certain

skin, but

only

as

such

as

are

named

cannot

liable to produce

scabies.
a

three

or

These
sarcoptesminor.
which
eruptionlastingseveral days

stillgreaterdegree of the

produce only a

I. In the

all the mites

Hence

result.

of the human
true parasites

is true in

transferred

is the uniform

four

local eczematous

days with

family of the Gamasidae

to pass from
predilection

the death
there

birds to

man.

are

mites

of

when
nates
termi-

of the animal.
two

These

of dermanyssus
species
are

D.

and
gallinae

which

D. avium.

show

They

have
male

soft skin, breathe

into

changed
legsare hairy and end
yellowishcolor,while
are

by

means

lancet-like

in two
D.

claws
is

avium

Both species
are
numerous
they escape by night into human

54rT

PARASITES.

TEMPORARY

of tracheae,and

have

dagger, in the

female

and

sucking

no

disk.

The

eyes.
into a

D.

mandibles

delicate

gallinseis

in the

stiletto.

smaller

and

The
of

grayish.

in fowls, birds, in their nests and

habitations

in

order

to

attack

in dove-cotes, whence

during sleep and

into their hiding places. In one
of my
gorged with blood to return at dawn
about
weeks.
c
aused
diffuse
four
The
D.
a
eczema
lasting
patients
gallinasihad
Eruption
always heals spontaneously.
This familycomprisesa considerable number
of periodical
c. Ixodes, Ticks.
parasite?
which are spread over
every regionof the globe. The flattened body provided with a firm
man

when

"

dorsal shield,and

us

there

into

are
great bloodthirstiness,

occur,

long probosciswhich

to

common

all.

The

barbed

maxillae

are

protrudiblemaxillarypalpiwith serrated
terminal segments curved
like a claAV. They breathe through tracheae and possess large
salivarypoison glands (?). Each of the eightlegsends in two hooked claws.
Ixodes ricinus (wood beetle)
is spread over
The
nearly the whole temperate zone.
male is up to 3 mm.
in length and half as broad, the female
is generallytwice that size.
This tick is found in woods, on pinesand bushes, where it waits for passingmen
and animals
in order to attack them.
The animals are in the habit of boring the proboscis
bly
imperceptiextent
into the skin and gorge themselves
that they swell to the size of a
to such an
castor seed; they then let go, drop to the ground and remain
there until they repeat the
operation. But if it is a female, the numerous
eggs are first safelydepositedin an
propriate
applace,a few days after which it dies.
The
tion
sensainjury inflicted by the tick is hardly perceived at first,the troublesome
the
remains
when
animal
there
is
a
ensuing
usually small
gorged. Subsequently
inflammation.
animal
be
wheal-like or circumscribed
If
the
removed
forcibly,
papular
in the wound, causing violent pain.
tears off and remains
the proboscis
must
either wait until it
In order to render the wound
harmless
as
as
we
possible,
has gorged itself and drops off,or paint its body with oil of turpentine,etc., whereby it
either perishes(closureof the stigmas)or spontaneouslyretracts
the proboscis. With
changed

besides,Ixodes

incloses the

reduvius

and

argas

reflexus which

trouble
occasionally

man.

Of

the

mentioned:
1.
should
be specially
speciesof argas occurringin the tropics
chincha
2.
and
and
americanus,
(Persia
Argas j)ersicus
Argas
(Colombia). By
Egypt),
their bite both

cause

to strangers. But

it is almost

rather

intense

they become

impossibeto

persistentpain, and the latter is even said to be fatal

plague when they get into the houses because
at will,attacking
them durthem and they bleed men
ing

veritable

eradicate

sleep.
The

literature

the Journal

of the ticks has been

de I'Anatomie

et de la

recentlymost

1883,
Physiol.,

No.

carefullycompiled by Megnin
4,

to which

in

I refer.

d. Cimex
lectularius,AcantJiia lectularia,the hed-hug. The body has an oval form,
Mandibles
broad.
and maxillae joined
wingless,brownish red, 5 mm.
long and 3 mm.
the
lower
labium.
into a tubular
surrounded
sucking apparatus,
Tongue, as a stingby
ing
inclosed
in
the
sheath.
Glandulae
odoriferae
the
metathorax.
on
apparatus,
Its usual resorts are old furniture and neglectedapartments. It is remarkable
how,
aided by its sensory apparatus (sight
smell ?),it deliberately
or
moves
along,for instance,
the ceilingof the room,
to the desired spot so
to drop directlyupon the scented
on
as
its stinginto skin, and then, in order to obobject. Its bite is affected by first inserting
"

is

54:8

PARASITES.

TEMPORARY

by evacuatingits voluminous
largerquantity of blood with greater facility,
poison
connected
reaction
with
sides
hyperasmia. The consequences
are
gland, provoking a
that, bethe slightlesion,largewheals form which itch greatlyand are not easilydistinguished
from commencing prurigo.
Pulex penetrans (Sorcopsylla
e.
AVestwood, Genus Ehynchoprion Oken). The sand
from
the 29th degree of
flea,called by the inhabitants chique pique, nigra,etc., occurs
in
Biazil
to the 30th degree of North
South
and
latitude,especially
Gruiana,and is said to
tain

"

"
parts of Africa.
The body is egg-shaped,broader and only half as large as the human
ish
flea,of a brownIn its organizationit differs but slightly
red color with a white
spot on the back.
the other animals
of the same
from
family. Pulex penetrans becomes notable only by

its mode

of life.

some

For

while

its nourishment

obtain
sand

also in

with

be met

for such
But

animals

be attacked

by

it

on

reach
any accessible mammals
of its kind, the fecundated
female waits

strives to

male
manner

so

as

to

in the

of blood during the whole time of ovulation.

objects. Children
playing in the sand may
adults it generallybores into the nail bed of the
tacked
ring. The first bite is hardly felt by the at-

offer sufficient amount

as

too, is

man,

the

after the

of its favorite

one

part,while

any

in

abdominal

toes, penetrating to its third

person, only gradually as the insect gorges

swells to the size of a pea, the spot becomes
ever

itself and

the sac-like dilated

the tension

abdomen
thus

more
painfulby
duced.
promen,
expels the eggs from the posteriorfree part of the abdoshrinks to its former
size,drops off,and dies. Under normal conditions, the lesion
medical
aid, in the absence of injurious
which
it has caused heals in a few days without
not
if
fleas are
close together
It becomes
serious when
influences.
clean,
kept
many
the
insect
with
its
view
forcible
with
to
removal,
a
(three hundred) or if,
eggs is pressed
skin
in
the
larvae present
subsequentlygive rise to
inwards, because the numerous
may
not rarely extensive
there occur
stubborn
cases
grave complications. In neglectedand
and deep phlegmons running into gangrene,
causing partly considerable losses of tissue,
the life of the patient
even
amputations at various points ; sometimes
partlynecessitating

Meantime

be

may

protect one's self from

carefullyinspectedmorning

the feet be
the

female

seriouslyjeopardized.

In order

by

the

sand

lift it out

the

to

with

flea has

If the

flea.

red hot needle

so

and

attached
that

no

sand

flea,sound

shoes

evening. People
itself,one
eggs

remain

with

should

sweaty feet

either

must

be worn,

in the wound.

wait

are

and

spared

until it falls,or

The

treatment

of

general surgicalprinciples.
managed
Gadflies. Large flies with broad emerald green body and depressed
Proboscis
head.
projectingwith six (female)or four (male)stilettoes. Mandibles
ent
presGenerallyfemales infest the largerdomestic animals, but inflict
only in the female.
also painful injuries.
man
upon
and
with four stinging-bristles
Proboscis long, projecting,
Culex
pipiens, Gnat.
g.
caustic
fluid
act
instil
which
a
the
females
they
sting,during
palpi. Only
five-jointed
and by their
into the wound.
They generally spare animals, but prefer to attack man
the

wound

is to be

on

/. Tahanidm,

"

"

bite

cause

rather

lumbacensis
in hot

on

herewith

the

lower

regions,which

h. Hirudinea.
A

itching and

violent

In connection

"

considerable number

should

some

other

speciesof Simulia (0. co-

especially
plentiful
mosquito (Simul pertinax),
Danube)
to
are
particularlyannoying
strangers.

Leuckart
of

of wheals.

the formation
be mentioned

was

these,at

and

the

the

first to include

least

during

some

the

leeches

stage (likeH.

among

the

parasites.

medicinalis, if it is

550

TliMPOKABY

palpatingfingerswill

find

only a

PARASITES.

deep-seatednodule.

small

But

if the

animal

living,the eye appreciateseither a small roundish or a larger oval tumor covered

normal
the underlying
on
tissues.
skin, having a firm elastic feel,and displaceable

is still
with

ing
Judg-

from the findingsthus far,cysticercus

of the skin is rarelyisoloted,
but almost without
It is most frequent on the back, next on the
exception is met with in large numbers.
Often while the old tumors
lateral parts of the trunk, and on the extremities.
continue,
additional ones
form for some
time.
In the beginning they cause
no
inconvenience,but
become
painfulwhen they exceed a certain size and are frequentlyexposed to pressure.
The
final result (oftenafter two or three years)of cysticerci
of the skin is obliteration,
formation.
abscess
calcification,
rarely
The recognitionof the tumor
DiAG^srosis.
be of considerable
can
portance.
imoccasionally
Often we
shall be enabled
thereby to explain other importantmorbid symptoms
If we bear in mind, as Bergmann
of cerebral affection).
case
(Chiaris,
emphasizes
that cysticerci
with justice,
are
multipleand that each tumor contains only one animal,
echinococcus
of the skin.
it will not be difficult to distinguishit from
In syphilitic
has
altered
cannot
the
skin
be
lifted
an
in folds,the
usually
easily
appearance,
gumma
and
tumor
is
the
will
furnish
moreover
on
an
sufiicient
tion
informalarger,
history
average
its
for diagnosisin general. Lipoma is characterized
continued
by
growth, the
and carcinomata
in
uneven
rough surface, togetherwith the firm feel. Sarcomata
occur
older cachectic individuals,enlarge and increase rapidly,are
often painful,and never
"

become

smaller.

Although

it is

of
to diagnosecysticerci
possible

the seat of the affection and

be

In

make

either to

advisable

most

tumors.

the former

the

case

escapingwith

of the scolex head

the skin

of
by careful examination
occurringin combination, it will
an
exploratorypuncture or to extirpateone of the
diagnosiswill be placed beyond doubt by the booklets

exclusion

by

the

of the tumors

serous

contents, and

in the

latter,by the recognition

of the animal.
h. Ecliinococcus

cutis.

although

it has

Davaine's

rejDort,among

in the

muscles

frequentlyin

dermatologicalworks
often enough

found

the

366

of echinococcus

cases

the subcutaneous

and

female

sex

after

than
but

other disturbances

patient
usuallydies
parasite
no

In

"

thus far been

some

connective
in the

male.

this

parasiteis nowhere

in the
he

human

has found

tissue.

the

According to
latter thirty
times

It is said to

Echinococcus

mentioned

skin.

of the

far

occur

skin

disagreeablesensation of heaviness and

length of time (oneto two years)and after

causes

tension.

more

the
The

it has attained

of the vesicles become

larger dimensions ; and, while the contents
turbid, fatty,or
cification.
changed into a pultaceousmass, the connective-tissue envelope undergoes atrophy, calIts superficial
seat,the projectionwithout alteration of the skin, the peculiar
facilitate the diagfluctuation,and the scintillation of the transmitted
light materially
nosis.
If the presHere, too, exploratorypuncture will furnish the best information.
ence
has been determined, extirpationof the tumor
of echinococcus
will be the most
rational procedure for its removal.
Distoma
and Ziirn (1.c) report
c.
hepaticum. Large liver fluTce. Kiichenmeister
"

on

well

three

(embryoswith
tissue.
the

authenticated
mouth

According

to this

neighborhoodof
The

of the

and

Zurich

Fox,
(Giesker,

cases

of
intestines)
distoma

source,

and

in two

site differed (once each

ear),and

equallyvariable

on

were

the

rediae
Carri^re)of incapsulated
in the

is said to have

sailors who
the

and

these animals

had

been

subcutaneous
observed

formerlylived

in

in

connective
a

woman

in

tries.
tropicalcounlower extremities,the trunk, and the region
Sometimes
continuous
symptoms.
pain was

riLARIA

tumor

it

that

presentso

thought

was

there

was

GUINEA

OK

abscess,and

an

d, posteriori,
i.\e.,
by

d. FILARIA

MEDINENSIS

MEDINA

(GMELIN),

66}

WGKM.

again the enlargement

the diagnosiswas
cases

In all the
any inconvenience.
of the distoma.
the demonstration

without

borne

was

MEDINA
(gMELIN),

MEDINENSIS

OR

GUINEA

of the
made

WORM.

with graduallytaperingposterior
extremity. The male
cylindrical,
female
long, 0.5 to 1.7 cm. thick
yellowishwhite, 60 to 80 cm.
(Leuckart). Small triangularoral opening surrounded by four small papillae.Within
the uterus several (sixto eight)millions of embryos measuring 0. 6 to 0. 7 mm.
The Medina
occurs
worm
endemicallyin tropicalregions,but only in some
stripsof
la
it
met
and
elsewhere
is
with in
Europe
country (India,Guiana, Egypt, Brazil, etc.).

Body

filiform

far

unknown,

thus

in

and

man

in

the scrotum, back,

in the vessels.
In Africa

has found

Pruner
I have

that of the

as

had

worm

far it has been

not

are

connective

the subcutaneous

well

as

Thus

animals

other

dogs, through

frequentlyin

most

there after infection.

have returned

who

persons

tissue of the
the

under
conjunctiva,
in

negro

repeatedopportunityto

see

under

It is found

lower

quently
fretively
rela-

extremities,of

tongue, in the heart

and

the liver.

the bubonic

the filaria in negroes and

have
learned
on
inquirythe
animal in marshy regionsbores into the lower extremities

with most

met

exempt.

opinion

affection

of barefoot

produced by

there

current

that the
But

persons.

this

is

also on
such parts of the skin
occurs
opposed by the fact that the worm
where it could not penetratefrom the ground, and on the other hand
likewise
it occurs
is
whose
feet are
Hence
it
it
in persons
covered.
that
most
reaches
always
probable
statement

the

stomach

and

thence

the

be

organs
decided
definitely

localization

of the

or

the

circulation,to be depositedin the connective

in the

whether

disease

in

subcutaneous

connective

transportation
by
circumscribed

the

tissue of the

negroes,

in view

tissue

skin.

of the

rounding
sur-

It cannot

pronounced

districts,regions,etc., plays

an

equally

important role.
When

the

Medina

worm

has

settled at

place

one

and

developed

maturity, it
the following:

The symptoms manifested

in such a case
are
months
certain
a
spot, where the infested person has felt for some
fluctuation
heaviness,the skin bulges out and graduallybecomes red, painful,and slight
If the process be left to itself,
there finallyensues
is demonstrable.
a perforationthe
size of a millet seed from which the punctiform head of the animal protrudesfrom
time
Thenceforth
the opening enlargesto the time when
to time.
the animal
with its brood
of embryos leaves the inflammatoryspot. When
this has taken place,the inflammatory
symptoms abate, the swellingdiminishes, and after a few weeks an irregularcicatrix up
to the size of a hazelnut
is formed.
of
However, owing to the frequentoccurrence
these swellings,
the inhabitants and the physiciansof these regionsare familiar with the
the treatment
in time.
deavor
symptoms and therefore they generallycommence
They ento seize the end of the animal
and then with gentle traction they wind
it on
a
wooden
lest it break off. Hence
when
resistance is encountered
rod, taking care
on
traction, the procedure is interrupted,and the rod with the rolled up portionof the
is left at the opening of the wound, until the removal
is finallyeffected,sometimes
worm
after several days. The
from
the
of
the
to
immigration
expulsion the
process,
six
last
from
At
to
months.
times
animal, may
one
eighteen
person
may harbor several
aims

to reach

At

circumscribed

the

animals, in which
e.

Filaria

surface.

to

the process may

Sanguinis Hominis.
case

"

last two

years.

According

to

Lewis

and

Cobbold, the sexually

552

FILAKIA

female

mature

is

MEDINA
(gMELIn),

MEDINENSIS

yellowish white,

OR

GUINEA

WORM.

10 cm.
long and 0.3 cm.
opening circular, without
extremity of the body pointed,with anal opening. Uterine tubes
Hatched
eggs measuring 12 to 30 micromillimetres.
embryos 0.2
AYucherer
in
his
first
had
attention
directed
Brazil,
(18G6),

half

that

found

in

hitherto
urine.
and

size.

the

urine

rounded,

of

described."

not

In 1872, Lewis

in the

time

Head

tissue

either from

to

hsematuric

worms''
patientactive
embryos were
Subsequentlythe same

succeeded

juices. And
chyluria,or

broad.

oral

"

in
as

finding the

the persons

filaria in this

infested

with

The

male

papillse. Posterior
filled%ith
to 0.3
to

numerous

long.

mm.

this filaria,
having

(embryos)of
discovered

in

earlystage in

them

suffered

at

'*

species
chylous

the blood,
the

same-

from

elephantiasisarabum, or from lymphectasia of the

scrotum, he began to suspect that the affections named
might bear a causal relation to
the occurrence
of the parasite. This suppositiongained in probability
when
Cobbold
enabled
to
Avas
communications
(1877)
report, through
by Bancroft,that he had found in
Australia, in a lymphatic abscess of the arm
and soon
after in a hydrocele of
one
filaria,
the spermaticcord four sexuallymature
filariae. In the same
year, too, Lewis discovered a
mature
in the blood coagulum of an Indian
worm
(Bengal)operated on for elephantiasis
scroti,so too Silva Aranjo (inhasmaturia)
and Santos (inlymphatic abscess on the arm).
Manson
To
belongs the merit of having discovered that the filaria embryos are
taken
from
the human
blood into the body of the female mosquito,where
they undergo
their development,and by the death
of the mosquitoesin stagnant and marshy water
set

are

such

free

water

as

the

filariae. Manson

mature

animals

mature

assumes

that

moreover

with

the

ingestionof

get into the human

of the
organism, and by reason
inflammation
and obliteration they cause
in the lymphatic channels
and organs, according
to the locality,
give rise to either elephantiasisarabum, chyluria,chyloushydrocele
other related affections.
or
Only isolated voices (Tilb.Fox, Genet) have been raised
In reply to these, Manson
against this view.
in a case
of elephantiasis
(1881)has demonstrated
nsevoid. scroti that from the absence of the filaria embryos in the blood, the
diminution
of the lymph corpusclesin the vessels,and the
presence of embryos in the
that it is the mature
chylous fluid,we may conclude with good reason
filarige which
the obliteration in the lymph channels around
cause
the glands (inguinal).From
the
numerous
so

carried
investigations

far in his deduction

as

to trace

out

with

to the

same

cause,

and

he even
ingenuity,
goes
besides the lactifluous form, also the

great perseverance

arabum
of the tropicswhich
with affection of
ordinarytypicalelephantiasis
commence
lymph-vesselsand intermittent fever.
be accepted in their totality,
cannot
it must
Although these deductions
always be
the first to point out that there is a
recognized that Manson, Lewis, and others were
causal connection
between
the presence
of filaria sanguinis hominis
and a number
of
of
endemic
cases
elephantiasis,
chyluria,etc.
Within
of cutaneous
the last few years, some
disease have becases
come
/. Craw-craw.
known
of the microscopicresults obtained, show
which, by reason
undoubtedly
that they are caused by nematodes.
0. !N"eill,'
in 1875, observed in negroes on the west coast of Africa a papulo-vesiculopustulareruption,called craw-craw
by the natives, which made upon him the impression
of an old scabies,owing to the violent itchingand the localization of the efflorescences
not a little surprised to dissides of the forearm). Hence
he was
and extensor
cover
(fingers
in the scrapedepidermiscoveringthe nodules, and in the sero-purulentfluid ex-

the

"

'

Lancet, 1875, No. 20, February,

with

Illustrations.

FILARIA

pressedfrom

(gMELIN),MEDINA

MEDINENSIS

depth, several activelymoving

the

in their appearance
in Brazil treated a case of craw-craw

broad, which
S.

Aranjo

and

states that he

in the lactiform

Although at
kind

associated

found

embryos

fluid,but makes

firstwe

would

no

Nielly

(1882)had

been

outside

an

feel inclined

opportunityof

GUINEA

0.2

worms,

filaria.

long

mm.

and

0.01

mm.

Two

years later,Silva Aranjo

chyluriaand elephantiasisarabum.

with
and

553

WORM.

mature

one

filaria (dead)in the

of any discoveryin the skin.

to accept for both craw-craw
affections

urine

mention

of filaria as the incitor of the disease,we

'

never

has

said to be

were

OR

shall hesitate when

observing in Brest

of the limits of France, with

we

bear

in mind

fourteen-year-old
boy who

completely analogous morbid

some

that
had

symptoms,

and here, too, scabies was

at first suspected. Niellyhas found
in the contents of the
efflorescences several nematodes, up to 0.333 mm.
vesiculo-pustular
long and 0.13 mm.
females.
He
is inclined to consider them
broad, even
of the
sexually mature
one
numerous
but thinks that he cannot
speciesof the genus Leptodera, fam. Anguillulidae,
fullydisprovethe view (Oorre)that they are a kind of filaria.
In my opinion,Nielly's
the occurrence
of the disease in France,
statements, especially
the natural-historical
o
f
the
animals, and
fullydeveloped,sexuallymature
description
of the patient after some
the complete cure
baths, as well as the fact that these anguillulae in general have a particular
life on
the skin, make
it
predilectionfor a parasitical
mentioned
by 0. N"eill a speciesof
appear very probable that both here and in the cases
at all)
has produced the cutaneous
leptodera(the animal having reallynot been examined

disease,and this,moreover,

under

vermicularis.

the influence

The

g. Oxyuris
that size. The posteriorpart of the
tumid.

This

lives

worm

"

only in

mature

body

of external

female

is 10

of the female

the intestinal tract,and

circumstances.
mm.

is like

long, the
an

inhabits

male

only half

awl, that of the

the various

it,commencing with the stomach

male

portionsof

(inthe shapeof ova),according to its phase of development.

and in proportion as
always keeps beyond the csecum,
the time for oviposition
The eggs are deposited
approaches,descends as far as the rectum.
usuallyin the faeces,but it happens,too, that the female slipsout of the anal opening,
and then lays the eggs in the neighborhood of the anus.
In
causing violent itching,
a
affected with
boy aged thirteen who suffered from oxyuris vermicularis and was
a neglectedeczema
folds,Michelson found on the scraped
intertrigoon the genito-crural
0.05
mm.
epidermis eggs containingtadpole-likeembryos,
long and 0.016 mm.
broad, as
of
well as hatched
the
extended
form.
He
of this
embryos
correctlyexplains the cause
that tiie boy had himself effected the transmission
to the
discoveryby stating
interesting
eczematous
spotsthrough the shirt-tail soiled with the fseces.
h. The Larvm
all the larvas livings
of Diptera. Even to-day we are unable to name
But
in the extensive
families of muscidae
and cestridae there is
on
man.
parasitically
whose
larvae have not been found in wounds
and
hardly any species
injuries. However,
in various ways, and the manner
the animals
effect an entrance
in which
they reach the
rather
the
characters
families
wounds
of
the
and
on
depends
species.
A considerable
house, stable,dung, and other flies)
a.
part of the muscidae (flesh,
These insects,therefore,,
possess defective maxillge and a probosciswith fleshyend lobes.
unable to injurethe skin, and are forced to nourish themselves
with the secretions,
are
etc.
In the same
way, their larvae (maggots)have only rudimentaryoral apparatus.
Consequently,the pregnant females seek to place their eggs and larvee in situations where
they easilyfind the conditions for their future development. Among these must be inThe

fecundated

female

"

Gazette

Hebdomad.,

18S3, Nos.

15 and

18, pp. 244 and

298.

554

ACCIDENTAL

eluded

seeing a

wounds.

negleeted

of them

number

The

hospital physiciannot

in wounds,

hereby from

the active motions

It is obvious

that

considerable

PARASITES.

for instance,of the

of the animals
diffuse

is the

is peculiar
and

at the

irritative conditions

inflammation, with resultingerysipelasand

Altogether different

rarely has the opportunityof

scalp. The impressionobtained

procedureof

phlegmons,

may

oestridae

those

of the
ensue

same

time

disquieting.

skin, increase
under

of the

these circumstances.

(Dermatobianoxalis, Cutere-

(LuciliaCsesar in America, Stominis calcitrans in

Africa, SarcophilaWohlf arti in Eussia, etc. ) which
place their ova or larvae under the
of their stingingapparatus. Although they also use
sij:inby means
surfaces for this
raw
their
with
for
fresh wounds.
implements
equal frequency
inflicting
purpose, they employ
In this way are
those
furuncular
inflammations
which
frequentlyvery painful
produced
At times these tumors
until the larvse escape.
continue
even
undergo suppuration and
which
disintegration
may lead to loss of the limb, etc.
gangrenous
animal itself should always bringits offspring
But it is not necessary that the mother
Sometimes
the hatched
larva works its way unaided
from the epidermis
under the skin.
of the larvae of the
into the various depths of the skin.
Thus, for instance,it is known
Hypoderma that the thread-like body bores into the opening of the follicle and
genus
into the cutis,causing various forms of destruction.
thence advances
bra, and

Hypoderma)

muscidse

and

III.

ACCIDENTAL

PARASITES.

Dermatodectes
and
(Gerlach),Psoroptes (Gervais),Dermatokoptes (Fiirstenberg),
Dermatophagus. Both speciesof mites are largerthan those of
Symbiotesor Cliorioptes

shape. These mites are characterized by the scissor-shaped

has at the ends of the
long legs. The male of Dermatodectes
the
female
long bristles on the fourth pair of feet. Symlegspedunculatedsucking disks,
biotes
sucking disks on short stems, and thicker but shorter
possesses inflated-looking
sarcoptes,but

are

of the

maxillarypalpiand

maxillse.
corneous

The

Dermatodectes

eczema

burrows

as

far

as

the

cutis,while Symbiotes remains

the

on

layer.
mites

of Dermatodectes

in the skin, but

an

same

the

in the

form

and

Symbiotesare

perishin from
of nodules

unable

three to fite

and

to maintain

days. They cause

pustulesand are easilyfound

themselves

manently
pertheir presence
after scrapingthe

by

dried contents, i. e., the crusts.

^

Harvest
bug. It is not certain thus far whether it is the sixLeptus autumnalis.
holosericum
red earth mite
or
(Hermann) the common
legged larva of Trombidium
it belongs to the family of the Trombidae.
at all events
that of Tetranychus. But
Normally its body is oval (with Hartn. eye-pieceII., obj. VII.) 0.35-58 mm.
long and
the
ventral
surface
divided
into
on
0.32 mm.
broad, and is
cephalothoraxand abdomen
The oral parts consist of a short conico-cylindrical,
furrow.
retractible
by a transverse
is formed
which
from this are
by a fusion of two maxillae.
Laterally
sucking proboscis
claws.
two strong, five-jointed
palpi which can be rolled up and bear powerful hooked
assist
mandibles
the
function
hatchet-like
of
the
On
the
Two
moreover
proboscis.
large
is a cuirass-like shield which bears two stigmataguarded by
surface of the cephalothorax
On the lower surface are the triangular
from these two simpleeyes.
bristles and laterally
of
Each
of
the
latter
is six-Jointed
and has two claws on
epimereswith three pair legs.
is large,broad, and slightly
abdomen
The
the tarsus.
striped. Sexual parts have not
been found thus far in Leptus.
"

"

"

Symptoms

Course.

akd

itching in persons
affected skin, owing to the
of

the affection

Jbody.
If

Fig.

56.

In

we

the

observe
are

hot season,
the

around

scratching,looks

cases

slightfebrile

inspectthe several eflQorescences

-Leptus

during July
especially
of

occurrence

autumnalis

an

eruption

gooseberry,elder, and
red and has on
diffusely

bright-rednodules and wheals up to

spreadsfrom the partsfirst involved

intense

more

to

who

violent

number

In

"

occasion

rarelyhave

not

we

555

PAKASITES.

ACCIDENTAL

movement

more

the size of

August,

and

associated

other

bushes.

its surface

with
The

erable
consid-

times
Somepin'shead.
of
the
over
greater portion
associated
with
it.
is generally

we
closely,

almost

can

Fig.

(harvest

the

without

exception

57

bug).

slightelevation which is conspicuousby its yellowishred color.

often
seek to lift it off with the point of a needle or to scrape it away, we
When
can
we
with the naked eye an actively
moving reddish animalcule.
see
of the affection having been ascertained,it is the first
nature
The
Treatment.
for
search
the source
of the transmission
to
to guard against
of
the
so
as
physician
duty
near
perceive

its centre

"

further

invasions.

the process
may

In such

barelylasts

few

case,

then,

days ; while

as

the

mites

otherwise

do

not

diseases

increase
of several

and

soon

weeks'

perish,
duration

occur.

I have given to the larva of

Kriptoptesmommguiculosis (Acarushordei)is the name
which
is rather frequent in barleyand is apt to annoy the mowers,
the laborers
a mite
is
of
etc.
The
creature
oval
with
white
form,
an
oblong
loading,
yellowish
occupied
0.032
The
oral
consist
the
of
and
mm.
a
on
long
(Fig.57).
protrudcolor,
parts
average
On each side of
ible tubular boring apparatus which is inclosed by serrated mandibles.
four pair of feet,two on
the cephalothorax
this are the five jointedpalpi. There
are
articulated to the epimeres. The tarsus of the first
and two on the abdomen, which
are
pair of feet terminates in a hooked claw, while the other three bear sucking disks
the second
Between
the first and
stems.
on
pair of feet are the oval swinging clubs
The
tracheal system clearly
indicate the larval condition.
which
developed. Sexual
absent.
partsentirely

556

slightest

The
The
If

PARASITES.

ACCIDENTAL

show

carefully

we

sensitive
into

The

itchy

very

its

red,

and

involution

then

of

appearance
that

Psocidas,

teacher

the

that

reports

were

insect

an

in

Archiv

In

slight

remain

they

pigment

and

heading

"

spots

the

the

for

being

behind.

is

tion
erup-

skin

becomes

three
short

present.
four

or

and

time,

"

Holzliiusen

von

cles,
folliskin

is

after

stationary
left

the

the

movement

height

follicles.

of

urticarial

case

febrile

Invasion

Eine

mouths

of

urticaria.

the

Where

such

their

reached

of

the

transition

rapid

having

mouths

beneath.

found

of

eruption

an

Virchow

"

at

Parstein

Gestacker
Clothilia

ftir

pathol.

in

Oderberg

near

spread

which

them.
the

book-lice,

the

of

sometimes

and

effects

Under

neighborhood

superadded,

being

the

dermatitis.

painful

skin

the

of

scratch

inquilina.

observe

increases,

causes

ensues,

Clothilia

the

in

around

exception

we

and

eczema,

symptoms
fresh

no

intense

temperature

inflammatory

days,

etc.,

are

in

consists

larvae
locate

to

without

almost

the

by

tendency

epidermis

the

irritation

the

and

bright

lift

to

try

caused

special

animalcules

the

disease

cutaneous

efflorescences

from

that

states

inquilina

Anatomie

living

the

of

und

it

Neumark

was

was

over

rooms

all

the

Heyden.

Physiologie,

Bd.

54,

p.

383.

by

the

clothing,

objects,
from

orthopter

an

annoyed

much

the

family

558

NEW-FOKMATIONS

OF

THE

rine life external

selves

SKEST.

influences may also create similar

injurious
as
tumors, generallyagain through some
subsequently

Such

factors which
external

manifest

them"

agency.

factors

have also been called tumor

and
this designation has been
germs,
conception of a latent embryonal tissue ; I shall apply the term tumor
or
better, tendency to tumors, only to that material which
is associated with
germ,
of which tumors
arise at any time, from any cause.
arrangements by reason
Such
tendencies
to tumors
to abnormal
direction of growth ;
might be : disposition
redundant
or
misplaced tissue material (Virchow,Waldeyer, Cohuheim, and others); a
of the energy
of growth of different tissues (Boll)
disproportion
; a peculiar vascular
diffuse
circumscribed
evil power of proliferation
or
of many
arrangement ; a
tissues,etc.
the

appliedto

The

immediate

more

cause

of the formation

in trauma, cicatricical formation,

of resistance of the
Besides
intense

these

of tumors, then, lies in external

perhapsalso

in

relaxation

of the

irritations,

physiological
power

organism.
tumors, there

disturbances, true

are

also

some

formation

tumor

in which, after
follows

the
the

closely

on

external,generally
immediate

reactive

symptoms.
to distinguishthis form
of tumor
dency.
from those of earlytenOnly one thing seems
the
for
instance a tendency to tumor, remains
Namely,
longer an abnormality,
latent in the plan of the organization(asa hereditary
its manifestation
tendency)the more
to have
seems
adapted itself to the form of the normal development of tissues and
the tumor, whenever
But in every case
it undergoes development, precisely
by
organs.
of its presentindependence, will deviate from the laws of normal
reason
organizationas
a

branch
The

stimulate
those

does

from

external

skin into

trunk.
is first

it to new-formation

placeswhere

retention

skin

in

exposed

; then

life it is

embryonal

of certain tissues in

in

influences
high degree to such injurious
to
tumor
formation
a
disposition
easiest for a displacement,
a malposition,
or
a

there will be

state of

to occur,
proliferation

as

at the transition

as

at
a

of the

membrane, where different kinds of tissue become

intimatelyunited, at
Then
often find accumulated
we
embryonal openings have closed.
by
tissue which
in an earlier stage of development for some
time
heredityabnormal
persists
or
permanently (for instance, warts). Usually, however, it is again external causes
which
incite such places to excessive proliferation,
to independentorganization,
to the
mucous

pointswhere

formation
But

of tumors.
it cannot

similar formations

be

denied

that certain external

without

influences

likewise incite the skin to

previousdisposition.
In most tumors, several of these etiological
factors obviously
concur.
in the explanation of the diffuse and the multiple tumors
cannot
Particularly
we
to the progressive
advise against the assumptionof a congenitaldisposition
formation
of
there is in the region of certain
a certain speciesof tissue.
Obviouslyin these cases
of the skin an abnormal
differentiated formations
of which tissue
arrangement by means
material accumulates
rather
tissue
of
which
in
or
locally,
capable
proliferation
grows
to
build
if
it
such a manner
tissue.
Thus
normal
for instance the epideras
were
new
mis,
the glands and follicles,
the papillae,
the cutis,the adiposetissue form generalhypertrophies
of the vessels,of the muscles,
; while the sheaths of the glands,of the nerves,
their rudiments, singlyor in combination, may
the vessels themselves
be the field for
or
multiple processes of growth.
In order to explainmetastases
emboli of tumors
tion
and their proliferation,
then, infecby fluids,by molecular portions of cells or sprouts,have been made to do service.
"

NEW-FOEMATIONS

but

this latter

formation

cannot

assumption

be

THE

OF

brought

into

569

SKIN.

harmony

with

experiencein

our

the

that the formation

of metastases
hardly deny
multiple tendency to tumors which
incited in the first instance by the irritation of a placelocally
was
predisposedsomehow
to the formation
that multiple
of tumors
(primarytumor). It is probable for this reason
limitation
into
those
tumors
without
their
and
differences
metastases,
forming
sharp
pass
lie mainly in the benignancy of the former, and the malignancy of the latter.
The tumors
of the skin have been differentiated from very widely divergentstandpoints,
the
tissue
assert
that
finer
differences and localizations of
but in generalwe
can
formation
tumor
were
neglecteduntil the most recent times.
Pathologistsagain looked
their systems, without
of the skin from
tumors
appreciatingtheir peculiarities.
upon
But meantime
it had been demonstrated
that the individual
by many investigators
stituents
connew-formation
the
skin
and
from
various
undergo
separately
composing
causes,
thus varying in their nature
and that the tumors
ferentiati
correspond likewise to the clinical difof cells.

is often

In

nothing

this case, too, we

analysis;they grouped, for instance,

deliberately
according to one portion of tissue

tissue tumors

connective

of the

too far in this

also went
However, investigators
the well-known

can

the manifestation

but

chieflyimplicated.
shall,while consideringthe place of origin,
with due regard to the infinite multiplicity
system,
every
In general,we must
transitions.
not lose sighthere of the fact
usuallyspring from one of the largertissue germs, either the
trace of the embryo itself or from the parablast
the primitive

Therefore, in the following pages

bear

and

of the forms

that the new-formations

archiblast

that is,from

"

without

from

growing

"

inwards.

together,having
appertaining

envelopesof

deposits,and
lymph-cells,and
These

of the parablast that is,the tissue

germinal welt' and forming the vessels
into the embryonal trace,where
extends
it forms vessels,
connective
tissue,and differentiates into endothelium,

its rudiment

tissue,which

the connective

the

shall discuss

In the first place,we

and

we

of
insufficiency

the

in mind

tumors

"

in the

blood-cells.

develop,accordingto

tumors

of vessel and

connective

first a thin,dense, almost

the

formative

laws of the parablast,

in the direction
parablastportion of the skin forms
stratum
vascular subepithelial
piercedby

tissue formation.

structureless

and

The

non-

lymph-spaces which enter into the rete Malpighii. The succeeding

stratum
formly
forming the papillaeis close-meshed, lax, with wide lymph-spacesand a univascular
and
elastic
substratum.
distributed,nearly independent
arrangement
areolare is indistinct,with loose fibres,juicier
and richer in cells,containThe stratum
ing
"Within it extend the deep vascular network
and independent
embryonal elements.
follow coarse-fibred,
vascular arrangements for follicles and glands. Then
wavy layers,
embedded
with largervessels and nerves
there follow
together in loose tissue. Finally,
these a firm tissue in which
fat-columns, with separatevascular apparatus,and between
and

nerve-fibres

the

run

connections

vascular

furnishes
parablast
of them

each

new-formations

constituents
1

Recent
two

skin

the

interior of the

may

in most

and
tumors

muscles

body. Lastly,the
of the skin.

From

several of these differentiated

participate.

rudiments,
the

with

arise;but

investigations, especiallythose

while
(archiblast),
nutritive

of the

envelopesfor follicles,
glands,nerves,

one

other

material, which

of

which

encompasses

become

furrowed

of

Waldeyer,

comprises
the

the

have

shown

first furrowed

adjoining elements,

later and

extend

into

that

in all

portion

rich

ova

in

we

can

tinguish
dis-

protoplasm

in protoplasm, but rich

poor
the archiblast
(parablast).

in

"560

NEW-F0KMATI0N8

Thus

there

dermia^
with

papillaeare:

the

ichthyosis, of

acuminatum,
the

Connected

papilloma,

in

mollis.

these

some

may
More

and

only

in

lipoma,

cedematosa,

these

skin.

of

framework

with

and

These
in

and

the

sheaths

lepra

and

(in

syphiloma;

arterial

wall

new-

hyaline
is

generation
de-

especially

the

ment,
develop-

also new-formation.
of

hypertrophy

an

of

early period

an

foreground

the
of

vascular

the

in myxoma

lar
muscu-

(Koster)

of

pachydermia

infiltration

or

peculiar fatty degeneration

and

channels

of the

of

the

cutaneous

inflammatory tumors)

acute

elephantiasis arabum,

follicles),in

sebaceous

plasmatic

extensively (in

found

are

of

in

in xanthelasma

endothelia),as

well

in many

as

sarcomas.

New-formation

elastic, hyalin tissue

tendinous,

of

chiefly: diffusely in

found

mations
new-for-

of

rhinoscleroma

elephantiasislymphangiectatica,

of

cases

in

abnormalities

in

also

into

come

true

forms

in rhinoscleroma.

in local

perhaps

factors

dilatation

tubercle, in lupus (around

(as new-formation

the

dilatation, but

given

are

cases

some

here:

sarcomphalus.

New-formation

fibromas

of
in

xanthoma,

and

vascular

and

arise

proliferation,with
in

pronounced

in scleroses, and

oedema

condyloma

there

their

as

some

Cellular

Hyj)erplasiaof

cylindroma.

causes

of the

glands

also

chiefly implicated

is

walls, is generally found

its innervation,

structures

fibromata;

Eecklinghausen).

angiomas,

not

vein

the

pachy-

connected

forms.

districts, congestion, especiallyin

immediate

and

of
"

parts, in

vascular

incite

especially

erysipelas

racemose

certain

system

in

soft

of

Mainly

new-formations,

vessels, and

nerves,

forms

irritations

tropho-nervous

ichthyotic

of the

wall

blood-vessel

of
in

sheaths

The

small-pox,

of

In

the

certain

cicatrices.

inflammatory

from

more

parablast:

elephantiasis, the
chronic

some

similar

hard, but

many

elephantiasis
formation

and

with

are:

marked

sclerema,

SKIN.

entire

the

from
of

polypapilloma tropicum;

neuro-papilloma

chancre,

derived

uniformly

are

of

THE

OF

circumscribed,

scleroma;

of

the

framework

cutaneous

in

scar-like

keloid, in

is

scleroses, in

rhinoscleroma.
From
any

1.

connective

of the

As

From

(Recklinghausen).

of the

endothelia

these
an

skin

uncolored

soft

"

primarily

or

in

important part

of vessels

at

proceed:
pigmented

or

endothelial

moles
arise.

sarcomata

(infectioustumors)

many

and

warts

Endothelial

angiomata

and

in xanthoma.

sarcomata,
2.

tissue
of

new-formation

proliferation also plays

rudiments

material, especiallyfrom
proliferative

embryonal

the

point

with

Sarcoma,

persistencein

embryonal

an

stage and

degeneration

of

the

mentary
rudi-

vessels.
3.
4.

process
.

to

of the
germs

-enchondromata,

are

normal
or

to

to

pigment

excessive

degeneration

formation

of

rudimentary

of vessels,

or

even

vessels.

superseding

this

cavernosum).

(as angioma
there

with

tumors

advancing

Angiomata

Finally

none

melanotic

Most

the

developed
constituents
formation

osteomata,

in

the
of

skin, parablastictumors

the

skin, which

of abnormal

lymphatic

tumors.

tissue

we

in the

must

skin.

which
therefore

Among

owe

their
ascribe

these

origin
to

placed
mis-

belong

"

NEW-FORMATIONS.

TISSUE

CONNECTIVE

BY

ER^ST

PEOF.

(Histological

1.

THE

M.D.

SOHWIMMER,
Part

by

CICATRICES

V.

BABES,

OF

THE

M.D.)

SKIN.

We
apply the word cicatrices to
develop in place of the losses of
substance
due to destruction
its papillary
of the skin and
layers;they usually show a
vessels,
traversed
less
surface
when
of
white
but
more
smooth,
or
color,
by fine bloodglossy
the
the surface appears slightlyreddened
of
cicatrix,in
or
pink. The epidermis
recent
is smoother
than the normal
cases,
surroundings owing to the obliteration of the
trix
when
the cicaefferent ducts of the glands and here and there also of the hair-follicles;
in
but
is older, its surface appears
somewhat
there
here
and
scaly,
g
lossy,
slightly
lines
and
it,too, there is an absence of the well-known
ing
stripescorrespondundulating
to the papillaryelevations
of the cutis,for there is no
reproductionof the papillae
Kinds

"those

of

Cicateices

new-formations

the

of

AifD

dense

their

or

PRODUCTioisr.

firm texture

"

which

a
destroyed to some
depth. Now and then observers have assumed
tions
formanew-formation
of the papillarybody during cicatrization,but these structures
are
of tissue consistingmerely of vascular loops resembling the papillary
taining
body, but contactile papillae
no
(0. Weber).
Sometimes
the cicatrices are at the same
level as the rest of the skin; these are called
flat cicatrices: sometimes
rise
above
the
surface of the skin and form
oblong or
they
roundish
thicker masses
of tissue;they are
when
then called hypertrophic: or
they lie
below the level of the generalintegument in the shape of depressed or shrunken
portions
of tissue,atrophic cicatrices.
and
When
extending
firmlyunited with the substratum
"beyond the underlyingconnective tissue as far as the periosteum and the bone, the cica-trix is called fixed or adherent; but if it is freelymovable, it is called a free or movable

when

skin is

cicatrix.
The
of the

development
skin; wherever

breaches

of
the

"ver

there

of cicatricial tissue
the

essential lesion of portions

some
presupposes
of the skin is excessively
augmented after
proliferating
power

continuityand losses of
skin
repairof the loss
"

has been
36

inflammation

with

substance

"

of substance

e.

of some
g., in consequence
We
observe the

occurs.

of the
subsequent disintegration

more

stroying
injury desame

where-

plentifully

562

CICATRICES

THE

accumulated
tissue

formative

serving for

and

nutritive

the maintenance

lost substance, is,with

THE

OF

material;in

SKIN.

all the

of the normal, and

now

named, the embryonal

cases

for

the

regenerationof

the

its vessels,drawn

erate
upon for the repair,in which process the modinflammation
and the absence of the physiological
resistance

irritation of the

present
representmultiple factors favoringthe restoration.
This repair,after losses of substance, is by no
effected uniformly; it is determined
means
which
the
new-formation
the
is completed in a
healing process through
by
For this reason, the healing of the lost normal
shorter or longer time.
tissue has been
classed according to various degreesdepending on the preceding lesion and the duration
of the repair,respectively
a healing per primam, per
secundam, and per tertiam intentidiffer.
will
cicatricial
formation
The
onem.
accordingly
is usuallyfound
after
HeaU7ig hy firstintention,i. e., rapidlyensuing cicatrization,
tive
sharp divisions of continuity;there the wound-margins readilycoapt,the severed connecand
vascular twigs,there is no
tissue is joinedby new
cell-proliferation
tion,
suppuramaterial reaction in the injured tissue.
and a rapid cicatrization without
Thiersch
intermediate
the
that
substance
which
demonstrated
trization
cicacorrect
causes
investigations
by
infiltrated
connective
is
tissue
the
of
the
woundfirstintention
inflammatorily
by
ends within a short time (twenty-four
of healing,which
to
surface itself.' In this mode
hours),the cicatrix itself is quiteunimportant, as there are no inflammatory
forty-eight
conditions.
Where
injury of
Healing ly second intention is healingwith inflammatory process.
of
of
the
loss
substance
is
filled up
normal
tissue,
a
destroys larger quantity
the
new-formed
tissue
from
which
have
become
time
of
after some
vessels,
by means
embryonal, of the surrounding points grow mutually anastomosing buds (granulations)?

the skin

"

which

are

enveloped by
This

exudation.

tunic of round

young

cells

tissue,however,

well
as
(leucocytes),
seems

to contribute

as

fluid and

lated
coagulittle to the manent
per-

but

into a purulent layer,the pyogenic memit disintegrates

brane,
superficially
filling;
w
hile
the
is
floated
which
as
underlyinglayer,
by degrees
pus (Thiersch),
away
cells and blood-vessels of new-formation.
In
which
carries plasma, fillswith numerous
of stellate
the depth this tissue changes into a new-forming embryonal layer,consisting
of recent vessels.
and spindlecells and a dense network
Gradually the latter contracts
in
dense
and
the wound-surfaces
becomes
less
plasma,
fibrous;
more
or
irregularly,
poorer
the
and
redder
uneven
time,
plainlydeveloped granulations. At the same
by
appear
the
effected
also
is
while
the
wound-surfaces
mass
epithelium;
by
approximationof the
farther
to projectabove the level of the skin, the epithelium is ever
of granulationsseems
advanced
from the lateral edges of the skin, the pyogenic layeryieldsunder the progressing
and
connective
tissue
and
after
more
the
a certain
to
develops
heal,
more,
tendency
without
will
out
withas
an
the
of
epidermislayer
papillse,
epithelial
layer
lapse time,
appear
surface
of
the
loss
the
former
of
substance
is
and
without
hairs,
glands,whereby
cicatricial
formation.
completely covered and becomes perceptibleas a
increased over
the
Healing iy third intention is merely a healing process somewhet

precedingas regardsduration and

depends on manifold factors which
of substance
in conditions
or

is

replaced.

with

weak

bad

diseases,the

scrofulous

Pitha-Billroth:

or

After

"

AUgemeine

extent

have

extensive

of the cicatrization.

great influence
destruction

on

the

The

cicatricial formation

manner

in which

the loss

of the skin, deep

suppuration,and
in
to
as
cachexiaa,tuberculous,
tendency
litic,
syphirecover}^,
cicatricial process is effected slowly and incompletely.
und

i.,3. Abt'eilung, B,
specielleChirurgie,"'

p. 540 et seq.

CICATKICE8

THE

OF

563

SKIN.

THE

zation
preserved,the cicatritissue shows
softer consistence;in the lastis rather rapidand the new-formed
a
named
conditions,which generally
destroythe cutis tissue to a greaterextent, the granulations
less firm, develop very imperfectly,are smooth, dry, hemorrhagic, and show
are
a slighter
tendency to adhesion ; at times again they exhibit the oppositestate, appear
succulent, hydropic,possess little power of resistance,and disintegrate
readily. If the
is
sweat
more
rapid and better,and Schroen
glands have not perished,the skinning over
wherever
has found, in the new-formed
the latter were
preserved,
layersof epidermis,
always a newly-formed stratum Malpighii. A disturbing influence on the cicatricial

"While, in

where

cases

is also exerted

process

bacteria
especially
often followed
and

thus may

However,

and

the

by

deeper layersof

the rete

local conditions, such

fungi,which

mould

as

individual

the

power
losses of substance,

we

often

constitution

in persons

usually

well

to

also

that

of the
insignificance
while

newly

to

proliferative

in

after

them,

tissue

new-formed

the

tissue thus

excessive

develop

to

cicatricial formation
of all

formed

proportion to
is

is
the

changed pathologically

proliferating
stageand

degeneration;but

carcinomatous

loss of substance.

still in its

granulation,and are
diphtheriticdegeneration,
an

tendency
(caroluxurians),
is out
which
completelydestroyed;we then find proliferation
an

so

traction,uncleanliness,

the

multiple tumors;

in the
granulations

extraordinarysize

and

its

as

causes

tendencies

with
the

see

pressure

depositedin

are

by necrosis of the young tissue,as

also give rise to generalinfection.

of the tissues,as

Malpighiiare

may undergo tuberculous, sarcomatous,

before after-formations
if cicatrization occurs
have

generallydeveloped from these cicatrices denselyfibrous tumors such as

keloid,or malignant neoplasms such as carcinomata, or sclerotic tumors such as sarcomata.
Cicatrices.
of
the
Quality
According to what has been stated,the cicatricial
is influenced partlyby internal,partlyby external factors,and it is not always
formation
has preceded it. Nevertheless
from the cicatrix the injury which
possibleto recognize
of the cicatricial formation.
which
the
there are several landmarks
recognition
permit
diseases such as syphilisand
Most readilydetermined
are
some
scrofulosis,the former
t
he
latter
horse-shoe-shaped;
by peripherally
extending,uneven,
by the characteristic,
Often
here mistakes
the seat of the
but even
are
often tumid
easilymade.
cicatrices;
morbid
cicatrix offers a guiding point for determining the former
pressed
process; a deeply dein the region of tubular bones permits the conclucicatrix above the zygoma
sion
or
the pathological
of bone
have been lost;but whether
that particles
process was
at
scrofulosis
is
times
the
of being detertrauma
mined;
caused
or
possibility
beyond
by
by a
in
will
the
the inguinalregion
the glanspenis or
a cicatrix on
permit
recognition
stellate cicatrices with contraction
of the adjoining
of the causative disease without difficulty;
clusions
portions of skin, or glossy,dark red, graduallyfading cicatrices allow the conSuch guiding pointsmay be taken
that the skin had been burnt or cauterized.
in a concrete case
of making a positivediagmust
beware
into consideration,but we
nosis.
formed, there

are

"

dermatonoses

The

which

run

serpiginouslupus, ulcerous
ending in suppuration,etc. ^bear
e.

g.,

as

do other morbid

their

only with a slow suppurative process

carcinoma, a prolonged zoster
syphilide,superficial

"

Symtoms
reason

from

of

of the
the
the

processes.
Cicatrices.

the

abundance

obliteration
normal

the

"

course

same

The

"

relation

completed

the
of vessels,gradually
of the

tint of. the

recent

skin.

vessels,and
The

to the

characteristic

cicatrix

cutaneous

its color

healingprocess

is at

surface

cicatrization

first dark
will become

will become

whitish

itself is at times

red

by
paler

or
proach
apassociated

564

OF

CICATRICES

THE

THE

SKIN.

"with certain

subjectivesymptoms. In normal cicatrization the healingof the loss of

taining
tissue,conmay proceed without incident and rather rapidly;the new-formed
blood-vessels in largenumber, shows a great tendency to hemorrhages,after external
irritations such as pressure, knocks, and blows, but as a rule they seldom reach a high
in the young
degree and cease
spontaneously. Nerve elements, which are numerous
of the skin, but during
less great sensibility
tissue,explainto some
extent the more
or
the healingstage there is no material increase in the irritability
or
painfulness. Greater
in
the
tissue
is
almost
as
long as the .granulations
sensibility
present
invariably
young
lack the protectingcovering;sometimes
this is manifested
ing
as
itching. In fact, the itchis found
wherever
there is a tendency to rapid skinning over, but often also in
badly granulatingformations of tissue with a tendency to disintegration.
to resist the irritation and
Some
unable
then
and
are
patients now
destroy the
granulationsby rubbing or pressure ; thereby the healingprocess is perhaps somewhat
substance

retarded, but the final cicatrization is not limited

over

and

has

been

completed, we
its location

accordingto

sometimes
some

find

that account.

on

some

tension

restriction to its free

When

the

skinning

in the

recentlyformed skin,
but
these irregalarities
mobility;

in

and the occasional, tumefaction, as after

the young
tissue are
gradually equalized,
large burns, carbuncle, etc., flattens. But if the cicatrization has been effected with
nection
preceding firm adhesion of the soft parts,and if healing has taken place only by conof physiologically
extremities,nucha),the
separatedparts of organs (fingers,
cicatrization has produced a lastingdeformity.
difficult-partlyby the locality
Often the healing process is rendered
Treatmeistt.
in which
the loss of substance occurred, partlyby other pathologicalfactors inherent
in
"

these disturbances.

the affected person, and here it is necessary to remove

by the most thorough possiblecleansingof the wound

This

is done

surfaces,keeping off all disease-

producing and septicsubstances, and removal of all disturbances to the circulation in the
is that the new
The immediate
neighborhood of the raw surfaces.
tions
granulaconsequence
In former times
better developed and that the healingtendency is accelerated.
are
but such
it was
customary to attain this desired objectby various ointments and plasters,
treatment
former
has
inasmuch
the
been
placed
remedies
as
are
now
obsolete,
altogetherdisformation
of granulationsis lax, irritating
method.
Where
the
by the antiseptic
agents can stillbe employed, such as copper sulphate (0.05to 0.10 : 10 to 20 gms. ), both
in solution; also silver nitrate (0.1to 0.5 : 10 of petrolatum);
in form
of ointments
or
and

either

one

of these in

more

concentrated

cent, the silver in 50 per cent solution.

In

form

as

caustic,the copper

or
syphilitic

scrofulous

in 1 to 10 per
ulcers these remedies

the wound
surfaces show a tendency
than the pure antiseptics.Where
do more
occasionally
best
in
be
to diphtheritic
iodoform,
powder, may
disintegration,
employed ; this
its
the
odor
best
results,only
gives
prevents its general
suppuration,
drug, by restricting
In gangrenous
ulcers,camphor solutions (Camphor, subactae,0.5 : Mucil. acaciae,
use.
(Bitumen fagi or oleum cadini 10 to 15 : Calcaria
150), charcoal powder, tarred gypsum

sulphur, subt. pulv. 200) should

twice daily.

be

appliedto

the surface of the

sore

and

changed

once

or

of its general applicability

; it is
antisepticagents carbolic acid stands first,on account
20 per cent) solution.
olive
5
to
and
in
5
to
oil,
Surgical
oily(glycerin,
(1
per cent)
with
the
ing
dressserviceable
made
the antisepticsvery
by combining them
therapeutics have
Corchoris
material
such
capsularis)
cotton, and jute (the bast fibre prepared from
as
gauze,
dressed
after each
surfaces
are
"with which
the wound
cleaning. Besides carbolic acid are used :
in 3 to 5 per cent
solution),thymol (1 ; alcohol and glysalicylicacid (bestas salicylateof sodium

Among

used

in aqueous

566

chelis.
(cheloid),

KELOID

painfulness.
also

occurs

but I haye

The

site of the keloid

the nucha, back, and

on

also observed

Alibert

forms

as

which

the false keloid.

he named

trunk

extremities.

of keloid ; the

to the other, i. e., the

opposed

modern

more

the

usuallythe

new-formation

The

it

and
histologists

one

he called the true keloid

clinicians have

from

finallyaccepted the
contains

or

the

cicatrices

division made

third, namely, the

cicatricial tumor.

verrucose

close connection

with

the

difficulties in the correct

the

region,but

is permanent,

hyperplasticformation

by Dieberg' which, besides the varieties of keloid named,

In

the sternal

and

spontaneousretrogression.

two
distinguished

idiopathicform,
The

is

and

numerous

symptoms

of keloid is its diagnosis,

determination

of both

for

we

often

counter
en-

morbid

account
of
processes on
of the idiopathic
and the cicatricial tumor.
Virrelationship

manifold

chow,'^in view of the observation

others again of
(cancerous),

that

tumid

some

fibromatous

or

formations

sarcomatous

and

termed
even

keloid

are

of cancroid

nature, has
syphilitic

and to
proposed to separate from keloid altogetherall growths springingfrom cicatrices,
apply this term only to the formations of spontaneous originor arisingfrom certain pathological
Microscopicexamination, however, failed to bear out this view in the
processes.
structure
not always found
the same
in keloids of sponsense
as
desired,inasmuch
was
taneous
to
origin,and according the results obtained, keloid had sometimes to be included
the

among

fibromatous, sometimes

the formation

among

the

sarcomatous

tumors.

For

in the

one

mainly composed of connective tissue,in analogy with fibroma; in

other cases
the intractability
of the affection,and
again,the great tendency to relapses,
the exceedinglyprofuse cell proliferation
of the neoplasm are factors which pointed to a
with sarcoma.
relationship
Histologicalexamination
(Langham, Warren) taught that in the idiopathicor true
keloid the papillarybody and the cones
of the rete appear intact,and
this fact is
on
based the view that this new-formation
is an
trix
while
the cicainterposed structure;
cicatricial
the
in
which
these layersappertainingto the normal
tissue are
or
tumor,
absent, permit the deduction that a normal
portion of tissue,lost through ulceration or
of connective
tissue.
Clinical is as appropriateas
suppuration,is replaced by masses
and if in a specialcase
show that the neoplasm has
we
can
differentiation,
histological
formed
in concluding that it is a true keloid, as we
are
spontaneously,we are justified
trix,
has been seen
to develop from a cicawarranted, in the opposite case, where the tumor
in callingit a cicatricial keloid.
Warren
of keloid to re-form in its original
states,in explanationof the peculiarity
case

extent

is

after removal

great distance

from

its seat, that the

that the

and

neoplasm

is

disease of the vascular

invariablyreproduced from

walls

is present for

these structures.

and a false keloid,

a true
According to these statements, the distinction between
its development cannot
the
be traced, would
be purely histological.In this sense
statement
too
not
of the above-named
it
will
be
and
so
far,
investigators
perhaps
goes
difficult to more
closelydefine the clinical diagnosisof keloid for certain cases.
Kaposi' believes that in generalwe are able to form a probable diagnosisonly, and
herein the arrangement of the tumors
at the sternum, are said
and their seat, especially
to furnish reliable auxiliaries in deciding in a concrete
of an idiopathic
the presence
case
on
formation.
I think, however, that these auxiliaries are not always sufficient for
where

Deutsche

Klinik, 1852, No.

"

Hebra-Kaposi:

Die

krankhaften

33.

Geschwiilste,"
"

Lehrb.

d.

ii.,
p. 244.

Hautkrankh.,"

1876, ii.,p. 204.

the

diagnosis,and

as

the cicatricial keloid

shall in all

cutis,we

we

certain landmarks

of the

always developsafter

external

have

that it

no

where

cases

the latter factor is absent

arise nevertheless,be

formations

567

(cHELOID),CHELIS.

KELOID

able to

declare

originof keloid, but know

irritations and injuries
of
and

the well-known

for
positively

the

of
the

istic
character-

presence

of

an

idiopathickeloid.
of
diagnosis

clinical

true keloid it should

be

over
emphasized moreacknowledge a peculiarqualityof the skin over certain
ably
regionsof the body which predisposesto these affections. Under this head belong probkeloid develops in larger numbers
in which
both those cases
spontaneously,and
tissues readilyprothose in which
certain manipulations
affectingthe deeper cutaneous
duce
to
tumors
which
scar-like
extirpationand always
only temporarilyyield
prominent,
Without
form anew.
applying the word or the conceptionof a diathesis in this connection,
disclaim the idea that certain forms of tumors
I think that we cannot
generalizeon the
traordinarily
common
integument in this way, that they are of spontaneous origin,often multiply exto
the
number
of
formations
without
and
they
according
produce,
cause,
certain gradations
in the morbid
disposition.I believe myself all the
representas it were
I
have
times
observed forms of multiplekeloid
in
this
several
more
assumption as
justified
cutaneous
be included in the series of generalizing
develop which could without difficulty
tumors, in which only the common
integument and not the remainingconstitution could

In favor of the correct

that

be called

we

must

pathological.

The
tumors

very often

generallyis
appear
that the idea of a diathesis seems

tendency to
so

also by
displayed sometimes
to suggestitself likewise in

different forms
the

case

of

of

other

of the skin, we
of keloids as well as of other tumors
regardsthe multiplicity
of myomas
has nothing at all to
indorse Virchow's
view about the multiplicity
can
: "It
is it to be conceived as the expressionof a dysdo with malignancy and heteroplasia,
nor
local phenomenon.
crasic generalaffection,but as an
essentially
Every singletumor is
the multiplicity
the product of a local irritation,
means
nothing but the extent of the
As

tumors.

irritation."

'

usuallyas isolated structures, and their favored location is the trunk,

the sternal portion. Even
where they are multiple,the extremities are generespecially
ally
in other placesthan those
spared ; I have but very rarelyobserved their occurrence
Cazenave"
who had upwards of twenty keloids,
named.
reports the case of a young woman
the
the
cords
on
on
chest,
superficial
partly
partly
lymph
(!)of the upper and fore arm.
Bazin' makes
this general remark
about
it :
Its site of predilectionis the sternal
region. It is found also on the neck, face, and limbs, and it may be said that no part
of the body is entirelyexempt."
He
also mentions
under
his observation
in
case
a
which the abdomen, the region of the hip, and the surfaces of the thighs were
covered
with numerous
keloid tumors.
Of course,
this appliesonly to cases
of spontaneous and
not the above-mentioned
cicatricial keloids which
after
occur
anywhere, especially
may
Keloids

occur

"

burns.
Cases

tumors)

have

related to
There

also

record

where

tumid
scar-like,

new-formations

of tissue

(truefibrous
fingersand toes ; but these structures,though histologically
different tumors.
keloid, represent clinically
essentially
than
are
rarelymore
twenty to thirtydistinct keloids. Wilson' observed a
are

L. c,

"

"

'

"

"

on

developed on

p. 118.

Paris, 1847, p. 603.

Abrege pratique des Maladies de

Le9ons cliniqueset tlieoriquessur

la

Diseases

1876, p. 381.

of the

Skin."

London,

peau."

les affect, cutan.

"
artiflcielles.

Paris, 1862, p. 265.

568

thirtydistinct tumors
observations
years ago I publishedsome
five separatekeloid tumors.'
in

case

Some
and

(cHELOID),CHELIS.

KELOID

lady who

Fig. 58." Keloid

op

Syphilitic

Origin

granulating superficial cutis tissue

cells partly arranged
in long spindles

g,

The

AN'ATOMiCAL

examination.

in front of the chest and

had.

from

with

the

patent

of stellate

fifteen

girl aged

was

years

case

on
one

moderately
(6); fc,keloid

; e,

vessels

nine
with

the back..
hundred

atrophic epidermis;
tissue

with

numerous

form.

ful
frequentlybeen the subjectof careduces
affects the entire parablast,
keloid innecessarily

(Babes)have

cicatrix

the

among

obliterating proliferating

or

ALTERATIONS

While

of

cheek

which

The
fact that keloid freframe- work.
quently
of the dermatic
mainly new-formation
developsafter injuriesin place of cicatrices and arises just like the cutaneous
renders it probablethat the peculiarity
of this formation
is influenced by that
cicatrix,
of its pointsof
fibres swell and

origin.

In recent cicatricial keloid

dissolve into

reproduction of the

dense

bundles

cicatricial

of

we

observe

can

how

spindle cells which

time

at the

the

the firm cicatricial

are

wall

but

monstrous

of the

same
network;
peripheral
while the central vessels appear relatively
proliferates,
sparse and narrow.
Keloids after syphilitic
ulcers (Fig.58) are distinguished
by superabundance of cells and
transition into granulations, while those of tubercular or scrofulous origin have few cells
and resemble
sclerotic connective
tissue.
In idiopathickeloid, the cicatricial groundwork
is absent; it is marked
by greater independence and deeper positionof the tissue
noticeable is the almost tendinous,
basis,whereby the papillae
left intact;particularly
are
regulartumor tissue running parallelwith the surface; hp'ewe find lymph vessels with
endothelial proliferation
which run
paralleltowards the surface,patent and vertical,but
keloids the cellular
the
probably compressed by
longitudinal
growth of the fibres. In some

blood-vessels

network

borderingthe

when
especially
them

elements

the trabeculse have become

network

of

large stellate

peculiarscar-like qualityof
'

frame-work

of the dermatic

the skin

seems

sclerotic
or

hyaline,there

or

fusiform

concurs

to furnish

f. Dermatol.,
Vierteljahresschr.

the

is often

the latter;
found

tween
be-

multiplekeloids the
to the new-formadisposition

elements.

1. c.,233.

In

with

The

tion.

on
interesting

most

followingcase,

56"

CHELI8.
(cHELOId),

KELOID

of its extent,

account

under

came

servation.
ob-

my

girlaged seventeen, of vigorous build, had a keloid reaching from the sternal region almost to^
of tubercles, partly isolated, partly
spinal column; it consisted of a large number
tissue,
confluent, in size from that of a bean to that of a hazel-nut; firmly seated in the subcutaneous
color was
The
skin, but
little movable, moderately painful on pressure.
partly that of the normal
of the
formations
and
there
here
some
seeming to be
they had a reddish
shining appearance,
massed
The tubercles, through irregularlyplaced, are
of fine vessels.
traversed by a larger number
seventh
to the
the fourth
rib, and thus nearly corresponding to the
together in the space between
in considerable
numbers
far as.
the well-developed mamma
as
of the ribs,they extend across
course
A

the

right of the

59.

Fig.

Keloid-likk

"

cells

tissue

of the

part

be

form

one

"

they

cutaneous

tissue.

Still

interestingis

of

more

admission,

rib appear

ninth

cylindrical

tumor

the

was

keloid
hb

masses;

size

of the dermatic

of firm
and

of

(Hartnack,

z, swollen

hazel-nut

frame-work

and

few

tubercles

in the

and

camera^

connective
exhibited

surrounded

was

sternal

less

prominent within
extending
processes

dorsal

portion of the trunk,

largelydeveloped, making
upward
sending processes laterally,

the

much

were

into

an

by

writers.)

maintaining the character

flatter
much
mamma,
they become
well circumscribed
throughout, with

the

time

(The

alteration
of

cylindroma

of the

"

lymph-vessels.

cylindromatous

Cylindromatous

older patient.

by hyaline swelling

While

but

can

I y,

of an

cheek

the

changed

trabeculae;

represented

of cells

axillaryregion.

lower

trabeculae

the

on

latter

The

network

swollen

the

and

between

growth.

evident

from

new-formation

tissue

lucida 7): hb, connective

where

more

the

region and the

gland,
the glands and

the mammary
into

isolated

the

region between

and

downward

tubercles,at

the

the

the

fifth and

into the

healthy skin.
confluent
isolated and
which
in their partial coalescence
tumors
They thus formed
represented the
and irregularlylobulated
the dorsal
swelling. The skin over
tumor, including
shape of a semilunar
10 cm.
in length and 8 cm.
in breadth.
As in the preceding case, the
those at its borders, measured
to the tumor, but at others it allows
points is closelyadherent
some
epidermis at some
wrinkling
is of a reddish
the lateral edges are
color throughwhen
pushed together. The entire dorsal tumor
out,
there

and

is

tumor

absence

an

were

never

trunk

form.

dull

white

of the

not

the

In

this

in

integument

common

as

general in

there

were

as

well

in discrete nodes

as

and

microscopic examination
cones,
papillary

here

in

the

skin

second

showed
there

ease

whole

of

the

While

glossy spots resembling

be called

keloid

some

afifections of

the

The

several

nodes

disease

the

patient

the

nucha, the abdomen,

the
a

skin

of the

surfaces

cicatricial

face

of the
tion,
forma-

abnormal.

which

reaching from the

the epidermis to be
thinned

duration

remarkable.

was

of keloid

in

new-formation.

entire

of the

discrete

altogethercould

tumors

and

patient

our

on

isolated

by keloid, numerous

invaded

and

skin

comedones,

numerous

with

met

appearance

delicate

condition

The
showed

of

of the

the
ran
over
capillarynetwork
neither
speciallysensitive nor painful; during the
to complain of anysubjective accidents.
had cause

isolated

and

one

as

had

trunk

appeared on both auricles

region of the knee,

to the

somewhat

thickened

immediatelyunderneath

were

in the

form

several nests

570

FIBEOSITS

TUMOE

FIBKOMA,

DESMOID.

; FIBROID,

of

granulation tissue ; then followed a dense layer of wavy elastic fibres and felted
which
constituted the bulk of the tumor.
as
a rule lyingparallel,
Beneath, surrounded
masses,
connective
tissue trabeculae in a state of great
by a dense elastic tissue,ran
then followed trabeculae of healthymuscular
fibres and slightly
sclerotic
hyalineswelling,
vessels ; a gradual transition into a reticular cartilage,
above
very rich in elastic fibres,
concludes
the picture.
The
of keloid are
in general very obscure, and, as above stated,unless we
CAUSES
of which
the skin is readilyinvolved in
in consequence
a
peculiardisposition
presuppose
lesions
such diseases,and in which
furnish the stimulus to the
irritations
local
or
slight
for its origin. I
development of this neoplasm, we can find no other plausiblelandmark
often

observed

they

the insertion

arise after incisions into the skin for the evacuation

keloids

also met

are

of

with

after the

of vesicants,leeches, after

use

In

etc.
ear-rings,

who

man

young
cauterization

had

on

the

spot.

Of

I removed

ear

fingersand

with nitric acid,many

by
after the healing of the artificial dermatitis,that is,one neoplasm from

warts, which

numerous

of abscesses ;

piercingthe

lobes for
the

hands

keloids
each

morbid

developed
suppurating
the development

liable to lead to
as
processes syphilismight be mentioned
after long-continued
ulceration.
The age has no bearingon the appearance
of this formation
affected
with
children
it
than
adults
small
more
are
rarely
;
; in
of keloids

more

advanced
The
is

age

in old

people it is exceedinglyrare.
absolutelypowerlessin keloid ; removal of the neoplasm by
by surgicalinterference,the keloid always develops anew.

or

is

TREATMENT
as

fruitless

as

tics
caus-

Less

energeticagents such as iodine, mercury, or absorbents of all kinds do not act any better.
If pains occur
in the cicatricial tumor, which
is of frequentoccurrence,
narcotics should
be given internally
chloroform, oleum hyoscyami,opium liniment, which
; or externally,
always have their symptomatic value.

TUMOR

FIBROMA,
This

tumor

of connective

DEYELOPMEisrT
in

the

form

new-formation

representsa

tissue,with
and

; but

there

in which

AKD

are

OF

SoME

the

basis substance

or

softer

FoRMS.

trabeculse

structures.

certain intermediate

consists

mainly

elements.

RELATED

connective-tissue

dense

arrangement, represent harder

soft fibromas

DESMOID.

FIBROID,

of cellular
slightparticipation

FiBROMAS

OF

of firm

FIBROSUS

Hence

forms, such

Fibroma

"

devclops

which, according
we
as

of hard

speak

can

the

their

to

and
papillary

and

verru-

the entire tumor

and
increase of epithelium ensues,
shows
a
A frequent neoplasm of the skin, histologically
malignant epithelialformations.
of the epithelium can
related to fibroma, in which
greateror less participation
be demonstrated, is formed
In
the
the
beginning the enlarged papillae
by
papilloma.
generally do not bulge out the covering layers of the skin, and the surface appears
smooth
cedematous
or
epidermisdegeneratesclose beneath the
; not until the thickened
and
corneous
rupture, do the papillomas
layer and disintegrateswith desqua^tnation
tum.ors
loosened
At
visible.
times
the
and
exhibiting
interpapillary
separate
appear
in the
still
colloid or
and
are
cedematous
even
encapsulated
strangulated
strips
being
cornified
connected
remain
the
in
other
a
cases
epithelial
corneous
by
papillomas
layer;
As has been stated,these peculiarpapillary
horns, etc.
layer,as in hard warts, cutaneous
cose

fibromas, in which

tendency

to

"

"

are
proliferations

new-formations, among
the

of
proliferations

transitional
which

the skin in

forms

between

fibromas

some
belong also, clinically,
Virchow
which
elephantiasis

and

other

cauliflower
includes

connective

tissue

growths, such
among

the

as

fibro-

TUMOK

FIBEOMA.,

well

as

mas,

from

the

sheaths,

nerve

sometimes

fibromas

in

Some

etc.

relations

indubitable

show

of

forms

pachydermia,the
papillarywarts
the

to

developing

neuromata

which

distribution

termed

be

must

system, such

nervous

nsevi,often corresponding unilaterallyto the

nerve

571

DESMOID.

; FIBROID,

new-formations
papillary

the

as

FIBE08US

as

of

the

genital
con-

peripheral

nerves.

The

soft fibroma

tissue covered

consistingoif connective

firm tumors

MoUuscum

(Fibroma areolare; F. moUuscum,

with

fibrosum)represents

normal

skin.

They appear as
barelyvisible formations the size of a pin^shead, but are usuallyas largeas a bean, and
form
large tumors, as in a case recentlyreported by Schultze, where the tumor
may
covered the greater part of the head and face ; theymay also reach a colossal size,as in a
described some
time ago by Marcacci,^ where the moUuscum,
in the shape of a scar-like
case
dimensions
such
that
thorax
and
back
seemed
neoplasm, acquired
completelyenveloped
as
hemispherical isolated or multiple
by it. Generally,however, these fibromas occur
in the cutis or provided with a usuallyshort pedicle. Where
tumors, either imbedded
met
the
scattered over
are
with, we generally find smaller formations
large tumors
The
skin
above
the
is
tumor,
though generallyunchanged,
body.
frequentlyrugous
the fibromas
and warty, and when
seated close together,the entire surface of the
are
skin acquires
At times we can
also feel in the depth tubercles
a grape-like
appearance.
of the
belonging to these formations which may be interpretedas fusiform thickenings
Some
fibromas appear as even, flat thickeningsof smaller or largerportionsof the
nerves.
tiasis
skin; they then form pure hypertrophiesof the skin a sort of pachydermiaand elephanplanum).
(fibromamoUuscum
Such a fiat form we observed on the forehead of a boy aged fourteen, in the shape of
with the surroundingsby lobular cords ; it was
connected
tumor
covered with
a whitish
about the size of a dollar.
tense immovable
skin, and was
Microscopic examination
the epidermis,which
had lost its papillae,
under
dense undulating connective
showed
a
here and there proliferating
vessels {b); the bulk of the
tissue with indistinct fibrill^,
from
there
into
extended
the
in
lobules
between
the columns
of fat, in
tumor
depth
areolar new-formation.
the shape of an ordinaryperiarterial
(a)and perineural
The soft fibromas are
usuallycongenital,spring generallyfrom the portionsof the
^

"

which
parablast

form

sheaths, i.

the interfascicular connective

e.,

the adventitia

tissue,from

of the vessels,the

the tunica

propria of the

sheaths, and

nerve

glands,at times

also,

of the subcutaneous
fat-tissue.
according to Virchow,' from the framework
They are
inflamed
The
isolated
becoming
only through external irritations.
quite painless,
with nodular protumors
easilyenucleated, are often wide-meshed, loose,sometimes
are
cesses,
and whitish;frequentlythey can
the cut surface smooth
be disentangled
as tumid
convolutions (Czerny,Kecklinghausen). In the skin coveringthe molluscum
times
somewe
filled
with
sebum
which
be
find sebaceous
that
can
glands
expressed so
they lose
a

part

should

of their contents,
be

borne

find,besides
Within
found.
and

the

as

so-called

in mind, because

fibroma

of the fibroma

there

Whether

Deutsche

Giornale
"

Die

indeed

are

the tumors

tubercular

molluscum, also those nodes

the framework

whether

where

molluscum

spring from

Zeitschr.
italiano

Lehre

von

fur

s.

formations

are

filled with

isolated
intimate

sebaceum

nerve

masses

fibres and

relations

it cannot

be

Chirurgie, 1880, 5 u, 6 Heft.

della pelle,1879, p. 131.

Geschwiilsten," Bd.

vessels

existingwith
clearly
proved.

delle malat.
den

contagiosum. This
often
we
plentiful,
of sebum
tagiosum).
(M. con-

i.,p. 221.

are

the

ally
occasionnerve

stance
sub-

572

The

firm

into
and

TUMOR

FIBKOMA,

dense

the

from

hard

or

fibroma

forms

structure; it

size of

FIBKOSUS

occurs

; FIBEOID,

new-formation
on

the trunk

DESMOID.

tissue

of connective

fibres

pacted,
com-

the extremities,usuallyisolated,

or

develop into tumors

nearly one-third metre in
seated
in
the
scribed,
cutis,are sharply circumgenerally
deep
covered with a smooth
and
when
several
formations
epidermis,
only
coalesce,the
surface acquiresa grape-likeappearance.
As they maintain
the physiological
type of
the connective tissue,these fibromas develop most readilyfromUhe
connective tissue portions
of the skin, but also with equal facility
from
the connective tissue of the muscles
and nerve
The
cut surface of
sheaths,in which latter case they are called neuromas.
The

diameter.

Fia. 60." Fibroma

partly

of succulent

pin'shead,

s,

planum

from

sweat

connective

wavy

may

are

convoluted

molluscum

vessels;

obliterated

several tumors

forehead

the

e,

atrophic epidermis;

gland; /, subcutaneous

tissue,extends

downward;

columns
and

of

fat;

aj, arteries;

superficiallayer

c,

between
and

the

iii, nerves;

singletumor has a whitish, glossyaspect, is smooth, dry, bears some

tendons, and has homogeneous layers.
The hard fibroma developsvery slowly,and as it forms, as it were,
the

cutis,it

causes

the

case,

single tumor

too

may
old.

and

his

we

become

atrophy of the
can

find

can

not

bear

an

only be
*

"

sheaths

nerve

before

b,

sisting
con-

muscle-fibres.

resemblance

from

to

of the

out

consistence.
be

with

tumor,

In

that

cleated;
completelyenu-

the

tumors

have

fibromas

called

and

relation to the nerves;

Die

or

m,

of cutis
the

stance,
particularattention to the latter circumthat the nerves
play a prominent part in the
the connective tissue tumors
forming from their sheaths
true
fibroma
a
elements,
having arisen from the original

Eecklinghausen has
showed
investigations

unmistakable

surroundings by
clearlycircumscribed, but

vascular

central

development of fibromas; for

graduallydisplacethe nervous
The grouped
neuro-fibroma.

its firm

normal

latter

multiplen Fibrome

der

the so-called true

they usuallyform
Haut,"

u.

s.

w.

irritable tumors
subcutaneous

Berlin, 1882.

thereforenodules

the

5Y4

TUMOR

FIBROMA,
The

termination

of the hard

sometimes

through

FIBROSUS

fibroma

it

or

occur

ossification

increased

abundance

hemorrhagic

fibroma

DiAGis'OSis.
in
It could

above-described

decidingwhether

blood

the

have

we

cysts,caused

by

"

FiBROMATOus

sort of softening

times, too,

vascular

of fibroma, it seems
qualities

to deal with

soft

hard

or

with molluscum
sebaceum
readilyconfounded
therefore be given to the peculiarities
enumerated

to the smooth,
fibroma, especially

63.

at

tumor;

giectatic
telan-

dilatation. Such

BLOOD

cfYST

FROM

even

THE

surface

SUBCUTANEOUS

of the

TISSUE

OF

to us,

connective

be most

should

FiG.

true

within

generation
undergoes fatty de-

cyst is representedin Fig. 63.

The

"

is manifold; sometimes
there may also
calcification;

of blood

form, with transition into

a

DESMOID.

; FIBROID,

or

leave

ficulty
dif-

no

tissue tumor.

tion
contagiosum. Atten-

in the

symptomatology of

skin, while in the formations

HAND

THE

m,

of

neomembrane

due

blood

the

the neomembrane;
P, a layer of pigment flakes beneath
layer consisting of hyaline reticular unyielding
r, a second
connective
tissue cells {g');w e, proliferated endothelia
tissue,with swollen
of a superficial blood-vessel; /, fibres of the
fibroma
of a
tissue
with
section
elongated plasmatic channels
blood-vessels; g, transverse
containing cells; 6, ectatic
fasciculus with
ectatic
connective
tissue
hyaline
plasmatic channels; gb, swollen
ft.,
cells; el, ectatic lymph channels;

cyst;

flakes

in

transversely

vessel.

cut

to disease of the sebaceous

and
mass,

such

pressure
and at the
on

formations
can

be

more

the

time

same

may

relaxation

also be associated

transformation

tissue frame-work

cause

of

the fibroma

always

sebum-like, pasty

have

We

case

stated

be

found,

will
of

ceum
seba-

the molluscum

after its contents

that

above

have

been

pressed;
ex-

expelledfrom a fibroma (through

into
fibroma
sebaceous
a
tubercle),the connectivegland
will be
will stillbe preserved,and although the formation

small amount

of the latter

of the skin.

fibroma, in which

with

easilydistinguishedfrom

should, however,
accidental

glands the efferent duct of the latter

expel the contents in the shape

will

tumor

of sebum

be

somewhat

in size.
relaxed, it will not be diminished
when
Fibromas,
as
they occur
multiple neoplasms

eye

by

the number

will

and

consistence

easilyelucidate

of the several tumors,

their nature.

Even

the

rare

on

integument, strike the

examination
the histological

the

and
forms

of

generaldisease

of the

lymph glands,in

SyH

(XANTHELASMA VmLIGOIDEA).

XANTHOMA

all the

which

lymph glands representlobulated,grape-like,

painless
diagnosisfrom the seat of these tumors and the evident enlargement
Behrend
here and there of the lymph vessels.
also pointsout the possible
cellulosae : the latter affection is exceedingly rare, the
confounding with Cysticercus
of equal size and not different as in fibroma ; they alwaysshow, moreseveral tumors
are
over,
tumors,' will permit

correct

but

of fibroma

CAUSES

youth.

In

where

such

occur

The

quite obscure, often a hereditary

assumed,
tendency was
in
the
of
the
the fibromas appear in
cases
majority
;

local irritations

cases

some

irritations cannot
of fibromas

TREATMENT

interference

are

be demonstrated

cannot
frequently

earliest
to

consistence.

firm, uniform

The

cited

as

causes,

of

but fibromas

are

seen

"

and
only be surgical,

can

or
disfigurement,

to

owing

were

be demonstrated.

spreadingof

where

cases

they

the tumors, ablation

call for

of the

plasm
neo-

is indicated, whether

by simple ligature,the knife, scissors,or the galvanoare

blood-vessels,hemorrhage should
provided with numerous
cautery. As these tumors
Should
the fibromas reach such an extent
be guarded againstduring operativeremoval.
if they could not be readilyremoved
that surgicalinterference is out of the question,
or
these dermatological
curiosities may be left alone, as
account of their multiplicity,
on
life.
rate
not
do
at
endanger
they
any
XANTHOMA

4.

Symptoms.
which
shades

The

"

from

range

partlyconfluent,which
The

involution.
has

strong tendency
as
clinically

this disease

to
a

is appliedto a form of macular

nodular
tions
formaor
integument in the shape of lightor dark yellow (the
crete,
sulphur yellow)stripes,
plates,or protuberances,partlydisand
of
no
are
subjective
present
symptoms,
incapable spontaneous

common

to

straw

VITILIGOIDEA).

xanthoma

term
the

on

occur

(XANTHELASMA

of
persistence

spread to

the affection,and

different

the

partsof the

neoplasticformation,

and

fact that in

body, justify

us

this view

is

fullyborne

some

cases

it

in

regarding

out

logical
by histo-

examination.

Eayer
which

we

the first to describe

'

was

observe

sometimes

on

this affection ; he
around
the

disease in
speaks of it as a special
eyelidsyellowish plaques which,
redness, are symmetricallyplaced on the

and

salient,soft,without causing heat or

'^slightly
GruU
described
and
this affection independent!)'^,
and
Subsequently Addison
These
the
first
it
the
to
to
name
authors,
were
vitiligoidea.
distinguish
too,
applied
two
varieties,namely, a flat and a nodular form (vitiligoidea
plana et tuberculosa).The
was
title xanthoma
given to this disease by Smith,* and xanthelasma
by Erasmus
Wilson;
has
observations
been
within
the
last
few
of
number
the
considerablyenlarged
years, so
of the most
that this affection can no longer be called rare, though it is not one
frequent
skin."'

diseases.
We
describe

retain the clinical division

in its two

xanthoma

forms

and

as

follows

and

or

'

'

Amicis,

Lehrbuch

"

Traite

Journal

des

as

the

most

or

citron

de Dermatologie et Syphiligrafie,
1883, p.
Hautkrankheiten," Berlin, 1882, p. 399,
de la peau." Paris, 1835, avec
Atlas.
malad.

Medic,

size of

thumb

of both sides,
eyes or the eyelids
also on
other portionsof the face, the

der

of Cut.

and
appropriate,

yellowspotsthe

of the

Annales

"

G-ull

planum forms yellowishwhite

larger,usuallyoccurring at the canthi
symmetrically; they are mot with
generally

1. Xanthoma

nail

of Addison

1869, iii..
p. 241.

452.

576

.skin of the cheek, nose,

vitiligoidea).

(xanthelasma

XANTHOMA

the nucha, and

in isolated

cases

even

the

on

membrane

mucous

Pye Smith* found similar spotson the palate,and at the autopsy in the
oesophagus;Legg,^ at the bifurcation of the trachea and in the capsuleof the spleen;
had developed on the
Virchow
reports a case from Graefe^s clinic,in which a xanthoma
The
several spots are
"cornea,'etc.
flat,have generallya smooth, velvety feel,and in
side lightthey appear
alterations projecting
above the level of the skin, chieflyconspicuous
as
their
isolated
sometimes
be
color.
The
recognized as composed of
by
spotscan
in those forms in which
several apposed or coalescingsmall structures,especially
the skin
The skin thus altered can
within the spotsprojectshere and there in small nodules.
be
easilylifted in folds,has a slightlydoughy feel,but does not materiallydiffer to the
fold of skin.
The several spotsare always sharplydemarcated
from
touch from a normal
exhibit any desquamation, and are not painfulto the touch.
the surroundings,never
differs from
the preceding form
tuberosum
et tuherculosimi
2. Xanthoma
by the
in
and
the
and
tubercles
several
tions
formaof
nodules
size,
appearing
varyingshape
presence
isolated or confluent tubercles the size of a hemp-seed, lentil or beans
representing
makes
the impression of a conglomeration of grapeand the massing of the formations
like,
thus closelyarranged are a rare
form of the diseases
lobulated tumors.
Xanthomas
of

mouth.

the

several

The

nodules

covered

are

pressure, are
tissue layers. These

with

smooth, soft skin, disclose

in the corium, and

imbedded

often

down

extend

to

the

firm

texture

on

deeper connective-

eyelids,but more
frequently
the most various parts of the trunk, on the extremities,
on
in the face, and in largernumbers
the elbow and knee joint,and as flattened
especially
usuallyround about the joints,
In some
the hairy scalpis not exempt, and
the palms and soles.
nodules
cases
even
on
of

the

on
only exceptionally

occur

(Kaposi,Chambard)
genitals

the

even

forms

be the seat of this

may

latter

generallyon

the other also

from

only

by

somewhat

sensations

nervous

and

which
physicians

French

to that

located

subjectiveaccidents

concomitant

The
in that

cases

present, the

nodular
the

In

form

several

differs
tions
forma-

their presence on the flexor surfaces of the joints

agreeable
restrict the mobilityof the extremity,but also provoke the most dis-

related to the nodular

nut

the

enumerated.

above
predilection

is likewise

pain spontaneously,and by

often
not

pointsof

the

formation.

new

form

general xanthomatosis, besides the nodular, the macular

of

around

hen's

the

forms
egg,

muscular

is the xanthomatous

form

isolated

and

unavoidable

the

during

tubercular

and

confluent

which, in the

few

cases

described

ranging

tumors
thus

Closely
by some

movements.
tumor

the size of

from

far observed,

was

mainly

joints.

representdiseases of one and the same

Where
both forms
developed from the former.
macular
demarcated
from
the
the
several
some
start;
are
co-exist,
generallysharply
types
tions
at times exhibit on the eyelidsthe above-mentioned, small, grape-likeelevaxanthomas
the
to
which
have
over
a tendency
spread largely
body
; but the forms of xanthoma
Both

the nodular

and

the tubercular

nature, and usuallythe tubercular

develop rather
Etiology.
liver led
factor
such

as

the nodular
"

The

and

tubercular

accidental
seek

to
physicians

some

type.

coincidence
a

connection

specialconsideration,as
age, or heredity. Chambard

deserves
sex,

xanthoma

is

form

of the cutaneous
the two

between

it is

among

PathologicalSociety of London,

Ibidem.

Virchow's

Archiv,

Bd.

disorders.

frequentlyreferred

more

found

affection with

52.

58

cases

1879.

disease of the

This
to

etiological

than

collected from

others,
the liter-

(XANTHELASMA VITILIGOIDEA).

XANTHOMA

ature, 30 females
smaller

Hutchinson

numerous

decisive as compared with

the
appear
relations
are
more
perhaps
patients.Hereditary
important.

of male

found

first attacked

xanthoma

the

by

which

number

"

number

does

not

in

several times

disease.

Church^

; otherwise

progeny

577

there

observed

are

familyin
the

examples

no

which

affection
record

on

the

grandmother

was

in two

families among
a
)vhichwould give special

etiological
importance to heredity.
The

questionwhether

depends upon different affections has likewise

to bring arthritise
repeateddiscussion;the attempt has been made
extensive
diseases
of
the
into
connection
sebaceous
with xanthoma;
diabetes,
glands
but these suppositions
stand far behind the relationship
of xanthoma
formation
with diseases

been

the

xanthoma

subjectof

of the liver,which
distinction between

has been

several times

referred to.

But

we

must

here

make

parenchymatous diseases and icterus which is especially

charged with producing xanthoma.
Among 27 reportedcases, Kaposi found icterus
15 times;Hutchinson,
36 observations,6 times; and
58 observations,
Chambard, among
among
22 times.
I myself,among
ten cases
under
observation
within
the
coming
my
last three years, only 2 of which were
extensive nodular xanthoma, have not found icterus
present

even

liver affections

as

once.

However,

observers

who bring Jaundiceinto connection

with xanthoma, admit,
disease by many
months, even
preceded the cutaneous
years, and,
in other cases, the icterus did not appear
until long after the existence of the xanthoma.
The
number
of cases
which
could be brought into connection
with icterus
is decidedly
smaller than that in which
xanthoma
observed without
was
preceding or
accompanying jaundice;hence if we are unwillingto look upon icterus as an accidental
complication of xanthoma, we can find no plausiblebasis from which to deduce any
all the more
if we
remember
that icterus is an almost dailyand xanthoma
relationship,
that

the

much

disease.

rarer

As

some

icterus often

regards the

of the

causal

connection

in this direction
examinations
connection

between

liver,the relationship
seems

with

of affections

made

disease

of the

said to

are
on

cases

in which

during life,as

and

the

tions
parenchymatousaffec-

favorable,inasmuch

more

amount

of the liver is not

liver

xanthoma

to be

to

proof.

xanthoma

large;some

But

as

the number

some

of

servations
ob-

mortem
post-

duringlife could be brought into

contradict
the presence
directly

of

Maxon's,* who found a cicatricial

the bile-ducts ;
Legg's'who found a cyst obstructing
in these cases
the liver parenchyma was
healthy. Murchison* found cirrhosis of the liver
at the autopsy of a case
in which there was
xanthoma
the eyelids;
a
on
slightmacular
while accordingto Chambard,^ in a person
affected with multiple xanthoma, in whom
this organ was
found healthy,
during life hypertrophyof the liver was
diagnosticated,
but numerous
found
imbedded
in
the
cystswere
rightlung and in the liver. Extensive
xanthomas
without
liver disease have recentlybeen published by Carry, Brachet, and
I myself, among
Monnard; these might serve as counter
proofs of many other cases.
constriction

case

of the bile-ducts,and

ten

under
found disease of the liver. We
cases
my observation,have not once
between
affections of the liver and xanthoma
therefore,that the connection

employed

in

relations.
determiningthe etiological
'

=*

Bartholomew's

HospitalReports, x., 1878.

"Pathologic. Transactions," 1873, vol. 24.

Vide

"*

Journ,

"L,

37

It is better to confess

c.

Chambard,

Annal.

of Cut. Medic.

de Dermatol.

London, 1869.

our

may
cannot

say,
be

ignorance

678

(xanthelasma VITILIGOIPEA).

XANTHOMA

regardingthe etiologyof

drag

to

in uncertain

factors
pathological

for it

price.

at any

Ahatomt.

Anatomical

"

The

structure.

with

this disease than

minute

formation

new

examinations

show

that the spots and nodules

have the

same

irritative process in the subcutaneous

tissue
affects all the elements
equally. The first investigations

alterations exhibit

of cells which

an

by Pavy/ who had found, besides the connective tissue new-formation,

o
f
fat
Geber
and Simon/
granulesand globules in its fibrous trabeculas.
on
deposition
the other hand, have defined the disease erroneouslyas a hyperplastic
ceous
development of sebamade
by us were based on Hertzka^s case, some
gland cells. The investigations
cised
exThe yellow color of this newexamined.
formation
tubercles of which
we
might be
this color is
due to the fat which is depositedin it as a granularyellow mass; but whether
believed by older observers,is by no means
also derived from bile pigment,as was
proven.
made

were

Fig.

64."

Malpighii;x,
form;

I r,

Xanthoma

lymph

reticulum

lymph vessels; V,

The
lentil to

TDBEROSUM

cells in process

vein

surrounded

division; v

tubercle

from

the

skin

of

the

elbow:

a,

concentric

by

somewhat
superficial,

bean,

multiplex.

vacuolas, containing migratory cells and

containing hypertrophic endothelium; e r, rigid reticulum;
of

lax and

plasmatic

sc,

endothelia
n, nerve;

stratum

cornum;

swollen
c,

into

rm,

ret"

semilunar

capillaries;e I,dilated

channels.

yellow flat nodules, ranging

grape-like,
section

the cut

surface

in

size from

whitish

yellow,

fibrous;
appears
juicy,finelyreticulated,collapsing,
graduallyblendingwith the surrounding tissue. The
epidermisis thinned, and usuallydevoid of papillse,
showing here and there proliferating,
at times crushed
rete Malpighii
distorted sebaceous
and sudoriparous glands. The
or
there direct
(rm) contains atrophiccells,remarkably numerous
young elements, here and
cell divisions.
The deepest cell layeris strikingly
darkly pigmented. Close beneath the
Besides there are
epidermis follow dilated lymph vessels {eI) with swollen endothelia.
small, almost or entirelyobliterated blood-vessels with similar endothelia having here and
there hyaline contents.
tric
The wall is very much
thickened, and forms a generallyconcensinuous network, whose deep communicating spaces are lined or filled with a layerof
a

are

on

Guy's Hospital Reports, 1866.

fiir Dermatol.,
Vierteljahresschr.

1872.

579

BHINOSCLEKOMA.

containingsmall yellowishfat droplets. In the interveningtrabeculae we

muscle elements.
and smooth
red flakes of pigment, hyalinefibres,
find roundish, yellowish
to a vessel is separatedfrom the surroundingsby larger
The lacunar system appertaining
lymph spaces. By the excessive development of a lacunar plasmaticchannel system {Ir),
endothelia are crushed, and this process extends to all the
the vessels (V) with proliferated
of the skin with the exceptionof the lymph vessels,so that the
constituents
normal
The
are
equallyalienated.
tunica propriaof the glands and the sheaths of the nerves
from each other by the development of similar
connective tissue trabeculae are separated
also
become
and
swell
hyaline.
gradually
formations, they
up,
the question
is likewise unable to answer
examination
as to the pathoThe histological
genetic
swollen

cells

The

relations of xanthoma.

is sometimes

the affection

fact that

generalhas suggestedthe idea that the originof xanthoma

may

to

digestivetroubles, which
cachexia;for generaldisturbances,especially

or

alterations in the liver,may be associated

of
the idea that fattydegeneration

lead to consecutive

with

quaud,'startingfrom

holds
histologically,

found

been

which

view

"

Treatment.

"

tubercles

treatment,

and

where

and

manipulation. It

depositsin the

Quin-

occurrence.

of fat in the

organism and

blood
the

be

occasionally

glandularelements

some

elements

formation

is true,

which

in xanthoma

extension, or
superficial
tumors, cannot yieldto any

are

tissue and

cosmetic

to

be

common

has
the
tegument
in-

of

is aimed

followed in part by
neoplasticproliferation

absorbent

or

alterative

only resort to

at, we
surgical
improvement
of spontaneous involution have been reported; but
of these neoplasticforms
of
to the total retrogression
as
can

few.cases

doubts
express some
and
Both the macular

might

tissue.

its

to

sis
diathe-

stilllacks confirmation.
new-formed

of the normal

the destruction
with

The

accumulation
peculiar

leads to various

factor which
predisposing

we

observed

be traceable

xanthomas

the tubercular
be

can
knife, and thus disfigurement

permanently

should

be

removed

with

the

'

overcome.

5. RHINOSCLEROMA.

The
or

tumor

inward

of this affection manifest

SYMPTOMS

wheals

which, either isolated

the nostril,covering both

around
over

or

the

either covered

mucous

membrane,

themselves

confluent,form
the

forming

by

skin of the
hard

profuseformation

of tubercles

largelobulated or grape-like
alae nasi and spreadingthence

structures.

with

The

several tubercles

are

fine vessels;thereby

normally colored skin or traversed by isolated

and glossy,
and, the hair-follicles and sebaceous
epidermis often appears smooth
of this tumor
The most strikingpeculiarity
glands having perished,dry and furrowed.
rather
hardness
is its uncommon
Hebra
moreover
a
compared it to ivory it causes
which
is
The
felt
not
the
but
severe
on
on
tubercle,
spontaneously.
only
pain
pressure
of this new-formation
it
such
to
in the above-mentioned
rence
a
occur
localitygives
be identified with any kind of similar structure
other
of
character that it cannot
on
parts
the body. Rhinoscleroma
is a pronouncedly chronic disease of slow growth and tedious
which requiresa number
of years for its full development.
course
The disease usuallybegins as a swelling
infiltration of the skin either at the
and
membrane
of the nasal septum; the several lobes
edge of the ala nasi or on the mucous
graduallyfill the cavityof the nose or cover the parts around the
enlarge,and finally
the
of
In
and broadened.
subsequentlythe ala is distended by the tumor
edge
nose;
where
the
of
the
the interior is somewhat
hindered
toward
cases
masses
growth
by
many
the

"

"

'

Bulletin

de la Societe

1878.
cliniqu'e,

580

KHmOSCLEBOMA,

greaterresistance of the tissue and the septum, the neoplasm spreads also to the upper
in continuity
with the pointof originof the tumor.
The prolipand enlargesdownward
liferation
dency
rarelygoes much beyond the median line of the upper lip,but rather has a tento extend into the depth. The
disease progresses in the free space until the lumen
of the nose
is nearlyfilled,
then it extends to the choana, and when
it has infiltrated the
from
the
unite
in
the
new-formed
the
lar
masses
depth through the alveogums
upper lip,
the
of
the
hard
and
all
normal
tissue
of
the
skin
and
cous
mudisplace
palate
process
of

membrane,

in

of the fauces

developsonly on

the upper

side,but

affected,the new-formations
It is self-evident

that

appear

the tumid

when

masses

few

the

the

of the
process
wheals under the

alveolar

find thick, hard

new-formation

extends

have

cases

been

observed

where

both

nostrils

the

of the nasal and

membrane

mucous

the

over

the lower

and
palateand extendinglaterally
not
circumstances
only the visible parts

such

under

in the

changed

to

joiningat

altered,but also the

times
we

the opening
lip and graduallynarrows
i
nto
the
cases
proliferating
pharynx, the isthmus
fissure
(Billroth).The disease usually
very narrow

to

severe
particularly

one

then

(Kaposi).' Sometimes

out

be constricted

may

At

bones.

the cheeks, and

under

from

angles of the mouth

and
(Mikulicz),'^

muscles, and

the

upper maxilla is eroded

latter and bulging them

oral cavities

were

downward.
of

the face

are

logically
patho-

way, that they perishcompletelyin the morbid

process, and
out
piercethe coveringintegument, they present either with or withsame

thin cicatricial

mucous
layer.
of this process that despitethe extending alteration brought
specialpeculiarity
about by the ascendancy of the morbid
tissue, neither inflammatory symptoms
nor
in the surroundings and at the borders of the
destruction of the tissue or ulceration occur
focus of the disease.
was
Zeissl,^however, reports a singlecase where a rhinoscleroma
of the tubercles suppurated and
time treated as a syphilitic
for some
neoplasm ; one
a

It is

later ulcerated, which

the
finally

and

bone

similar

other

cases

on

led to the
death

destruction

The

record.

of the whole

patient. To

of the

of the

ala nasi down

to the

the

best of my knowledge there are no

itself not only progresses
painlessly,

rhinoscleroma

structures merely by
course
injuriousto the local anatomical
during
not
thus
and
to
the
respiratoryorgans,
only giving rise to
obstructing the openings
ficial
important disturbances of function, but to dyspnoea,which can often be removed by artiforms of disease.
Ehinoscleroma
alone.
belongs to the rarer
means
difficulties in so far as, in its firststagesof development,
offers some
The DIAGNOSIS
is

its entire

but

it shows
disease
able to

to

greatresemblance

new-formations.
syphilitic

Weinlechner

before
time, in the year 1860, at Professor Schuh's
and had interpreted
these
ascertain its nature
correctly,
Hebra's

had

observed

clinic,without
cases

this

being

(seven)partlyas

This was
the case with most observers,until Hebra's
partlyas carcinomatous.
syphilitic,
of this affection.
The utter failure of
to
the
attention
called
peculiarities
publication
the
of
the
affection without
seat
the
of
hardness
the
tumor,
treatment,
antisyphilitic

analogous forms on the rest of

any
It could
affection.
exclude
a
specific
is never
and

so

differs

extremely hard,
frqm
altogether

Rhmophyma

"

1 "
2

^that

rhinoscleroma

neoplasm

fur klin.

sWienermed.

body, serve to diagnose the disease and to

long mistaken for carcinoma, as the latter

be

leads to ulceration

Pathologie und

Archiv

the
not

on

the

when

it extends

in the local and

nose

which

leads

Therapie der Hautkrankheiten,"

Chirurgie, 1876, iii. Heft.

Wochenschr.,

1880, No.

23.

to the mucous

membranes,

generalincidents.
to its enlargement and

3.

Aufl., p. 633.

thick-

582

EHINOSCLEKOMA.

perished.

Wide

them

is

sweat

lymph
whose

glands,

small-round-celled

with

with

depth,

similar
it

broad, often

tissue.

represents
The

in its

the

The

the

swollen
of which

Therefore

the

the

sarcomatous

series

be

can

bacilli

these

are

Frisch

of

morbid

the

diseased

would

patch

the nasal

passages

lead, and

and

"Wiener

While

Woch.,

ablation

to

med.
this

1883, Nos.

included

The

has

tumor

come
be-

ossified,proliferating;
of

here

are

the

ments.
elethere

and

partly show

nerves

connective

tumor

are

cells,

mast

many

all

tissue is

that
short

regardingthe
new-formation

it among

the

bacilli

by staining

of the

enlargement

of bacteria

four

with

times

the

elements
thinks

aniline

occur

diameter

of

could

justifiedin

rhinoscleroma

which

be

ing
assum-

theory

"

bryonal
em-

of the

bacteria

himself

colors

consequence

such

on

bacteria

them

cells to be the

peculiar to

to

inflammatory

formation

cellular

or

of

within

cells three

chronic

the

nature

related

Frisch, basing his view

yet quite clear.

which

appears

much

so

with

complete

knife

of the

; but

long

as

as

the

the

Woclienschr.
was

24 and

1882, No.
instituted

and

its

disfigurement and

insertion

of tubes

of

originalaffection,
course

the

along

the

sequelswhich

keeping

of rubber, caoutchouc,

from
proliferations

time

to time.

33.

passing through
25) who

disease

remove

surroundings

entire

of the

to

restrict ourselves, therefore, to

troublesome
extirpatingparticularly

work

the

that

re-formation

of the
must

possibleby

tissue

of the

nature

we

only

galvano-cautery, not

or

healthy

account

cicatrization

is followed

or

deglutition.*

the

operationon

this

open

cure

operationwill

produces disfigurement

either

the tumor

extirpated,thus preventing

are

favorable

is not

of respirationand

rarelypermit
prevent

in the

tumor

small-celled

spindle-shaped cellular

of

growth

the

possible,by

be called

it could

occasionallynuclei

are

in

as

are

degeneration

the

the

of his observation, Frisch

result

tissue, but also

the

tissues

"

disturbances

If it be

them

which

form
of bacteria every new
the present era
and
exi:)erimentation.
purification
process
is purely surgical,and
of rhinoscleroma
The
treatment

for when

grave

this

specialform

in the
rather

cells of

of

the

Teeatment.
be called

by

the

confirmation,

undergo

authors

in the

abounding

the

information

some

it

in distended

holds

even

As

the existence

must

other

numerous

very

demonstrated.

furnish

small

as

which

adventitia

tissue

their interfascicular
around

the

dense,

for bacteria.

consider

affection

visible

irritation

still lacks

while

tween
; be-

proliferationincreases

tissue.

tumor

In and

can

we

observations, stated

cells,and
bacterial

as

of the

made

in

(wj.

results
histological

(twelve)of

which

imbedded

sclerotic

imbedded

in

of

interspaces of

and

calcified,even

glands

sweat

be mistaken

might

cause

cellular

there

epidermis

network

connective

cartilage{^p)

and

structureless

process,

The

processes.

wide

cysticin places by proliferationand

inasmuch

rhinoscleroma,

or

grouping,

in part
degeneration {71),

and

granules

implicates, a

swelling; within

nasal

fibres,sebaceous

stages of neuritic

enormously

the

of

the

follows, especiallyaround

thickened

(e/),

alveolar

mucous

or

hypertrophic,proliferating,and
the

fibres

tissue with

much

density

part of the

almost

muscle

it

walls

here, and
peripheral jDortions,

depth

The

elastic

of

exhibitinghyaline

fibrous

immediately under

tissue ; then

(a), having

network

division.

in indirect

in

arteries

elastic

where

extend

loose

short-spindle-celled
proliferation,the

with

profuse

very

blood-vessels

embryonal

veins, capillariesand

and

filled either

are

and

almost

an

the

press,

strict

I received

antiseptic

an

treatment

article
with

by J. Lang
favorable

(Wien.
result.

med.

WHICH

TUMORS

PARABLASTIO

PRESEI^T
l^ECESSARY

OOlJ^DITIOIsrS

THE

VICTOR

SELVES
THEM-

I^
TO

STASIS.

M.D.

BABES,

1. LIPOMA.

The

lipoma of the subcutaneous

adiposetissue is applied to new formations of
new-formation
of the fat-depositing
vascular appatrue fat tissue ; probably in the main
ratus
of the arrangements for carrying off the fat.
with insufficiency
a
Obesitybecomes
diffuse tumor, hereditarylipomatosis(polysarcia),
when
these conditions
are
diffusely
term

The

present.

is

cause

hypertrophyof the
of the

adiposetissue

bones) is

conditions

Similar

frequently to

also sometimes

the

When

arise

body emaciates,

probably as

"

the

independently

he seat of

fattyexcrescences

frequent on the nates, the

Finally lipomata may occur
from

cicatrices

are

not

face, neck,

toes

(oftenwith

trophy
atrophy or hyper-

nature;

e.

of circumscribed

cases

g., many

the extremities.

there

often

subcutaneous

the

Circumscribed

hereditarytendency.

congenital.

vascular
cellular

in certain human

back, the

circumscribed

remain

expressionof abnormal

in

in

found

also be ot neurotic

may

pseudo-hypertrophyof
lipomatosis,
mata

be

of the

races

axilla3,the
of

in consequence

deposits of
But

arrangement.

tissue, often

fat

similar

in locations

which

speciesof animals; they are

abdominal
wall, the thighs, the
and

traumatic

irritations.

Forms

lipo-

"

tumors
are

very
head.

springing

rare.

Circumscribed
small

tumors, ranging in size from

lipomata usuallyform movable
quite
large ; in the latter case they are prominent, often pendulous ; the skin
is rarelythickened, brownish, generallythinned
is coarsely
; the structure

to very

covering them
lobulated
sometimes

found
soft

often

so

cases

the

lipoma

which

as

tumor

becomes

becomes
subdivided
to be almost

is firmer

evident

when

into smaller

the

investingskin

lobules ;

fluctuating,sometimes
to

more

is made

rarelythey

crepitatingunder

coarselyfibrous (lipoma fibrosum).

in naevus
lipomatodes.

distinct
particularly

are

tense.

They

are

smooth, roundish,

pressure ; in other
The
development of

584

MYXOMA

is

Lipoma

OF

THE

SKIN.

rule

sharplycircumscribed, encapsulated,
bulging out in sections,
yellow than the normal
traversed by a
adipose tissue,and frequently
broad white or grayish translucent
mesh-work.
we
Histologically
recognize in lipoma
the structure
of normal
of the tumor
is coarser
and
adipose tissue ; but the mesh-work
generallycontains fewer vessels,and the singlefat-cells are largerthan those in normal
adiposetissue.
with a calcifi
covered
Lipomata often soften into oleaginouscysts,sometimes
to the law of
capsule. Pendulous
lipomata at times change their seat in obedience
gravity.
The DIAGNOSIS
of lipoma usuallypresents no diflBculties.
Lipomata are absolutelybenign tumors.
Very large forms are often obnoxious
by
their seat, their weight, and the disfigurement; they may also ulcerate or become
grenous
gansuperficially.
Healing of the wound
generallyoccurs
only after the discharge
of necrotic shreds of tissue ; not rarelyerysipelas
sets in there.
For this reason, especial
often

care

of

as

darker

in the treatment
When

of the wound

mixed

with

; very

extensive

grave

other

The

new-formation
likewise

of

is most

of myxomatous

metastases

2.

former

is indicated.

tumors, especially
myxoma

MYXOMA

OF

tissue

mucous

frequently caused

defective efferent vascular apparatus.

But

THE

oedema
of

natural

tissue which

new

come
be-

to lipoma. The
sequence
of embryonal tissue with

formation

by new
adiposetissue as
in regardto the

such does not

in
participate

definition of Koster

cedematous

connective

simply as an oedema, a congestivealteration of a

plays herein an essential part,the greatest stress

myxoma

though

angioma, lipoma may

lipomashave been reported.

SKIN.

forms

Accordinglywe shall here remark

process.
tissue as nothing but
mucous
upon Virchow's
and

and

carries in it the condition

or

fibroma
must

or

be

the

looks

adipose tissue,
lipoma that
"

laid

for this oedema

who

"

the

on

and

velopment
de-

pendent
inde-

an

growth.
Hence
lead to

congenitaloedema

of the skin

which

condition

tissue capable of proliferation

will
a
affecting

a diffuse myxoma,
might
myxomatous pachydermia ;
diffuse
the
of
perhaps
gland. A similar tumid pachydermia
myxomas
mammary
observed by me, from hypertrophyof the cutaneous
muscular
formed, in a case

be called

this includes

tissue

whereby the
myxomatoid
be

to

seems

In

outflow

diffuse

of the tissue

formations

in

an

myxomatous

juiceswas

umbilical
condition

polypi,the simple abnormality

origin,forms

with.

interfered

of the

vascular

is,of those

fibres whose
of the

which
at the

also
or

parts where

hypertrophymight

abdomen,

myxomas
observed

lated

the

on

the

furnish

skin

is-loose

the causative

and

ences.
influ-

myxoma.
often
quite superficial,

contains

factor.

duce
prooedema

of mechanical

apparatus,

true

that

conditions

(fungusumbilici).Myx
causing congestionthrough nervous

predisposingfactor for the development of the

it forms
is rarelysolitary. In some
cases
myxoma
tumors
of
the
large,pedunculated,grape-likegelatinous
mamma,
The

Such

cicatrix

On

the labia, or

the

smooth

tum;
scro-

muscle

many
the thigh,the surface

back, the hand, the cheek, etc.,there may develop intermuscular

have been
Furthermore, myxomas
subsequentlyprojectinto the skin.
the

angle of

the

Jaw, on

the neck,

perhapsin

the forearm, the buttocks, the forehead, and

connection
the

with

lips. They

embryonal
formed

sures,
fis-

lobu-

tremulous, translucent tumors

smooth, usuallysharplycircumscribed, gelatinous,
The
and islets of vessels.
tissue of Virchow, traversed by networks
mucous

of the pure

MYXOMA

above-mentioned

characters
admixture

an

or

spindle-shaped,
of

part

the

will

of
with

vascular

in

most

elastic

much

is

elucidate

cases

The

tissue.

interstitial

mucous

network

diagnosis.

the

cells

the

of
In

substance.
while

obliterated,

often

585

SKIN.

THE

OF

tumor
and

one

another

There

the

stellate,
tumor,

same

be

to

seems

quently
fre-

is

round,

are

excessively

dilated.
Mixed

or

formes

More
In

start.
contain

skin,

of

myxomatous

of

which

above-mentioned

they
the

and

of

their

by

may

surgical

demonstrating

girl

young
with

nature,

the

from

or

forms

pure

their

by

the

skin

cellular

or

are

ally
gener-

first

at

of

the
of

was

us,

of

the

bryonal
em-

atous;
myxomand

cells,

carcinomas

interstitial

and

pedicle,

abundance

Colloid

portions.
of

degeneration

the

times
some-

participation

predominant
of

by

come
be-

walls

tumor

thin

with

examined

and

tumor,

hyaline
This

fungus

sarcomas

medullary

with

the

usually
rarely

not

fungoid

substance.
flat

they

nsevi

vessels

matous.
myxofrom

be

can

portions,

and

grouping.

Myxomas
they

distinguished
fibro-sarcomatous

rarely

Not

processes.

forms
of

adipose

structure

myxomatous

umbilici

plexus

persistent

from

extirpated

was

this

Vascular

interstitial
A

involution.

their

be

can

admixture

differentiated

by

of

the
become

mucus,

possess

myxomas).

fungus
consists

and

sometimes

are

(fibrous

myxomato-telangiectatic

vessels

myxomas

warts

chondromas,

and

albumin

by

replaced

(sarcomphalos)

spontaneous

dollar,

tissue

and

sarcomatous

undergoes

soft

above-mentioned

superficially,
or

is

lipmatous

and

fibrous

The

ulcerating

which

however,

papillomas

trabeculse

myxomatous.

size

of

lipomas

Thus

frequent.

more

substance

frequently,

the

also

much

are

intercartilaginous

are

be

mainly

multiple

treatment.

benign
injure

and
*

and,
the

if

thoroughly

organism

extirpated,
by

their

size.

relapse
They

rarely

very
form

the

subject

but
of

TUMOES

WITH

PEEDOMINAI^fT

PARTIOIPATIOIS"

YASOULAR

RTJDIMEJ^TS.

VICTOR

Undee

this head

belong the most

pigment tumors

sarcomata, most

of the

discussion

anatomy,
etiology,

of the

1.

Tumors

formed

THE

OF

BABES,

M.D.

of the skin
the soft warts, the
frequent tumors
and angiomas.
I shall restrict myself to a brief
diagnosisof these tumors.
"

and

ENDOTHELIAL

OF

NEOPLASMS

THE

SKIN.

of

embryonal rudiments, in which the endothelia of old and new

play
part,are more
frequentthan is generallyassumed.
them
endotheliomata
of the lymph-vessels,most
of the soft unAmong
belong, as
which
have
from
them, finally
pigmented and pigmented warts and sarcomas
sprung
vessels

the main

cancroid

formations

Endothelial

a.

nece)is the

and,

broad

loose
pedicle,

warts

and

sarcomatous

structures

of the bloodvessels.

of Eecklinghausen,verrucm
{lymphangio-fibroma

warts

given
nucha, back, etc. ; they
name

such, many

as

to

the

may

ordinary warts

be smooth

occur

on

molles, car-

the face, the

genitals,the

at times
grape-like,flat,hemispherical,

or

structure, brownish

which

color,often

are

hirsute,whitish

on

have

lucent,
section,trans-

sometimes

pigmented, often almost gelatinous. The covering skin is generally

ened
more
are
highlypigmented than normally ; the papilla3
usuallybroadinto
the
lateral
the
often
and
extending
depth
by
growth,
papillary
processes
haps
percutis layer represents
pearls. The most superficial
exhibiting isolated epithelial
of crowded
Then
follows a network
ish
roundembryonal tissue with dilated lymph spaces.
is
the meshes
endothelial
cells which
barely exceed leucocytes in size ; between
network
The
connective
tissue containing few vessels and nerves.
was
recognized by
filled with
Eecklinghausen as composed of lymph-vessels,the interspacesof which were
the
where
the impression
centre
cells. The
in
the
of
most
cells are
tumor,
closelypacked
in
cells.
tissue
is
that
endenoid
often
of
Laterallythey are
abounding
conveyed
dergone.
arranged in columns from the stretchingwhich the connective tissue frame- work has unsomewhat

thinned,

Toward
courses

in which

the upper
we

endothelial

and

lower

recognizethe lymph
elements.

The

limits, the
channels

tumors

cells differentiate

of the skin, filled with

start from

the

depth of

into

cones

embryonal

the cutis.

and
liferated
pro-

In most

THE

cases

OP

THE

687

SKIN.

of the
observe a metamorpliosis
stable ; often we
tissue which
replace them in the shape of
may entirely

development

the endothelia

often

shall not, with

cellular

cords

into

homogeneous fibres.
lymph spaces is best recognized in the pigmented forms, where
endothelial
while the pigment is forming. The
swell considerably
with
abundance
of
for
this reason
in the main
cells
an
neoplasms
;

from

warts, therefore,are
we

NEOPLASMS

they reroain

connective
The

ENDOTHELIAL

Eecklinghausen,call

them

fibromas.

As long as a carneous
the above-mentioned
mole
does not exceed
limits,as long as
neighboring tissue is free from any new-formation, and the neoplasm itself shows no
sign of degeneration,we may consider it a benign structure which will forever remain so;
to differentiate it
but in its histological
structure
alone there is no point which would serve
shall
from
alveolar
From
true
an
sarcoma.
a
adenoma, however, we
readilybe able to
distinguishit by the absence of an epithelialarrangement, by the character and
of the cells,by an accidental arrangement of the alveolar boundary, and in
perishableness
which
the central partsby the change of the cell-groupsinto a mass
can
no
longer be
the

called alveolar.
h. Endothelial

sarcoma

and
others)and
etc.)of the shin.

"Wagner

endothelial

When

endothelial
and alveolar sarcoma
of
(endothelioma,
sarcoma,
lymphosarcoma (lymphoma malignum, desmoid, noma,
lymph-ade-

warts, either from

chronic

irritation

or

sometimes

even

without

"demonstrable

limits,and the procause, degenerateacutely,rapidlyexceed their former

liferated
cell-masses degenerate,they have developed into a malignant tumor.
Soon the
generated
neighboringskin and the deeper tissue are implicated,and cords and tubercles of detissue form by way of the lymph-channels.
But similar tumors, at firstcircumscribed, arise also independentlydeep in the cutis or
in the subcutaneous
tissue.
In the
beginning;they are roundish, tense, connected
with the skin, at times tubercular; clinically
and anatomicallythey resemble
certain
which
first
and
then
ulcerate
as
solitary
cancers,
deep epithelial
largetubercles,
appear
adeno-carcinomas.
or
deeply; or else they are similar to circumscribed
deep adenomas
tumors
constricted at the base, which
are
smooth, tense,
Among these belong especially
ulcerated,moderately hard, on section glossy,homogeneous, lardaceous, at
superficially
times also very finelygranular or reticulated,white or reddish, in the depth medullary,
discharging turbid or even
milky fluid,then become of almost creamy consistence,more
into
caseated
networks
and
tubercles or hemorrhagic. It is probable that
rarelystiffly
them belong also subcutaneous
tubercles of similar structure,which
diffluent
are
among
in the centre and enlargerapidly;furthermore, most of the malignantmelanotic
tumors,
colossal tumors
of the lymph-glands which
well as many
break
as
through the skin.
to be distinguished
from true carcinomas
These tumors
are
rence
mainly by their usual occurtheir
in young
seat
the
in
the
of
soft
on
lids,
place
warts, by their
persons, by
their
more
sphericalform, sharper demarcation, and looser
greater homogeneousness,
with the epidermis;especially
connection
if we
exclude
from
them
such tumors
among
as

have

been

with

the

called endothelial

carcinomas

for

no

other

reason

than

that

their

tion
connec-

ings
epidermis or glands could not be demonstrated, or because the branchof the cell-nests correspondedwith those of the lymph-vessels,
and their cells showed
than other carcinomas.
the embryonal character more
endothelial
often find all possibletransitions from formations reIn
we
sembling
sarcoma,
nests to diffuse groups
of embryonal endothelial cells. In one
and
epithelial
tumor
nests filled with large flat or
the same
we
see
polygonal cells,the seat of which,
is easilyrecognized;
in lymph-vessels,
then rows
and columns
of small macro-nuclear.

588

THE

ENDOTHELIAL

NEOPLASMS

OF

THE

SKIN.

polygonal,perishablecells,or alveoli closelypacked with similar cells,separated from

another by a quite delicate, often elastic stroma.
one
Between
the cells we
find
not
rarelyfine glossyfibres and networks, as well as coagula,and homogeneous rows
of fibres
as
though formed of cells. More frequent,probably, are forms in which one
other
or
3lass of cells predominates; for instance, in which
peculiarlydendritic gland-like rows
with cylindrical
cells and concentric
nests
of flat cells are
in the majority; particularly
,

in mixed

forms

of tumor

which

have

only have originatedthere.

cases

The

penetrated the
most

skin secondarily,and in very rare

primary endothelial sarcomata
tain
concells in plasmatic channels
alveoli.
or

common

moderate
sized,homogeneous, macro-nuclear
Purely small-cellular,alveolar forms are rarer.
These
the

forms

indeed

might be separated,but owing

hardly practicable. We think we

separationseems
tumors

formed

into endothelial

transitional

many

only set apart, as

can

forms,

sarcomas,
lympho-

with their clinical and histological

cytogenous tissue,in accordance
time failingto recognizethat gradual transiat the same
tions

sarcomas

however,
Clinically,

general,will be still more

Otherwise, in

of

without

appearance,

the

to

one

as

occur.
may
all these tumors
will appear very similar.
than
the endothelial
malignant
sarcomas.

well

in the other, the tubercles

as

will

in

Lympho-sarcomas,
progressivelyenlarge

at

the expense
of the surroundings,young
tubercles will appear by the side of the old, and
coalesce with them; soon
the lymphatic glands in the neighborhood swell, usually into
with

tubercles

medullary softening;then the affection spreads by metastasis to nearly

membra
lymphatic glands of the body, to the lung, liver,serous
aes, kidneys,
etc.
Hard
and
when
removed
in time, will offer a more
favorable
forms,
superficial
prognosis than soft and deeper forms.
A peculiarneoplasm, restricted to the skin (mycosisfungoides,lymphadenoma
cutaetc.),appears in the form of various sized superficial
tumors, which are due to
neum,
structures.
of cytogenous tissue for the cutaneous
This remarka complete substitution
able
all the

skin

disease

these

give way

ulcerate

to

deeplyand

especiallyin
formation

often

the

become

beginning,

of skin, while

acquires ever

begins with nervous

symptoms and erythematas similar to leprosy;
a
ally
multiple neoplasm of fungoid medullary tumors, which usu-

new

covered
the
ones

with

several

One

crusts.

peculiarcircumstance

disappear and

tumors

perpetuallyform,

so

that

the

give

way

affection

to
on

is,that,
a

normal

the whole

finallyends fatally. At first,the tubercles are

subsequent formation; at last we find that the entire
integument has become
oedematous, and covered with countless, confluent, pendulous,
the
in diameter.
soft, ulcerating tubercles up to several centimetres
Histologically,
tumor
ments.
corresponds to our lympho-sarcomata, with all possibletransitions of their elesmall, and

It is
or

if,in

larger dimensions,

harder

those

than

questionableif
concrete

case,

and

of

these tumors
in interpreting
justified
it is not rather a peculiar granulationtumor

we

are

as

sarcomas
we

have

(Cornil),
before

us.

in a multiple affection of the body has.

disappearanceof isolated tumors
The
previouslybeen observed with multiple fibromas, and in a case of fatal xanthelasma.
in part
and lympho-sarcomas undergo are
metamorphoses which endothelial sarcomas
those connected
with molecular
deliquescenceinto lacunse, or also with fattyor mucous
in
those
to
due
degeneration, part
abnormality in vascular distribution or arrangement ;
such we may
mention
as
pigmentation, thrombosis, usually by leucocytes,hemorrhages,
A

and

similar

infarctions.

The

infarcted

tissue

undergoes

sort

of

coagulation necrosis,becomes.

590

SARCOMA

and

connected

was

there

cases,

by thin processes or preformed rows of cells. In other

appropriatetreatment
(examinationwhen quite fresh, careful
with hyperosmic acid, eosin or saffranin,also with
agitation,treatment

with

picro-carmin)a

on

cellular

network

in

connection

vessel- wall;

especially
large cells or fused
The centre
by protoplasmaticprocesses.
within them
flakes
yellowish
again occur.
cellular cord

SKIN.

THE

islets

with

found,

was

maceration

OF

which

has

become

with

cell-masses

the

protoplasmatically
sprouting
connected

are

of these cells becomes

The

hollow

and

with

the vessel-wall

homogeneous, yellowish;

cavities often

open
forms

toward

one

side into

the starting-point
of
probably
vessels.
Usually, however, there are developed in the large cells formations which could
be called pale and
often
unhesitatingly
uncommonly perishable red blood-corpuscles;
merely yellowishor reddish, hyalineroundish, coherent flakes,pigment granules,yellowish
a

discoloration
As

of the interior of the C3ll,or

in these

so

cases,

in

all recent

growing

sarcomas,

similar

abortive

formation

of vessels and

It is

these
precisely

which, by proper

and

conditions

the formation

of empty

vacuoles.

soft, especially
myxomatous, vascular, rapidly
found, pointing

are

perhaps

cells which

now

make

to

independent, though

often

of blood.
the most

up

essential

portion of the tumors,

indirect cellexclusively,

treatment, show, nearlythroughout and

division processes.

however, directlydeny
investigators,

Many

effected in tumors;
in various

and blood

believed

Ziegler

Oornil
as

is

he

Eanvier, is

analogous to

these authors
are

tissues of the

that

large number

and

other eminent

had

observers

body,

e.

witnessed

that

is
independent vessel-formation
recognizedsuch development of vessels

tissue.
For some
g., in the subcutaneous
the same
condition, but subsequently he

time

tively
posi-

this.

denied
From

while

"

of examinations
new-formation

the connective
of

but

an

convinced

embryonal

that sarcoma,

tissue;but, I must

as

add,

stated
not

by

such

it appears in the embryo

which
is the view of
tissue in which
the vessels and vascular
rudiments

tissue

embryonal

excessively
developed,and

I became
of

as

"

the latter,proliferating
in different forms,

the mode

cause

either, 1st,by the

of countless
rudimentary formation
without
into
which
vessels,
on
developing
complete
usually
proliferating
go
there occurs
vessels or may* also be isolated,and in which
connect with pre-existing
ably
proba complete or
incompletedevelopment of blood; 2d, by the parietalportionsof young
blood and lymph vessels (endothelium,
media, adventitia, perithelium)
cessively
proliferatingexin an
embryonal form, developing fasciculi and alveoli,crushing the vessel
like papilloe
into the lumen
and
transforming its free
proper or largelyproliferating
of appearance
vessels which

of the

sarcoma;

into vacuoles, semilunar

channel
formation

may

be

in
participated

I believe,moreover,

fissures,and cups.

by

muscular

and

nervous

that

the

new-

elements, particularlyof the

vessel-walls.

Fig.

66 is taken

from

sarcoma

of the neck

of

girlaged

17.

of
to consist of a network
seen
microscope,the smallest nodules were
tiated
differensubstance
stellate pale cells with largenuclei and a finelygranular intermediate
cells (Fig. 66, g z) which
here and there into fibres;also of very large roundish
them
of protoplasm. Within
occur
yellowishhyaline
partly coalesced into large masses
red
formations
the
vacuoles
and
blood-corpuscles.
resembling
containing
masses
{h)
formed
lacuna
vessels
into
thin-walled
or
into
vacuoles
of these
Some
exceedingly
open
Under

by

the

the

divergenceof tumor-cells {g z'). Besides there

likewise connected
which
are
by spindle-cells

are

with

found

such

blood-vessels
cells.

All

passed
(5)encom-

these

large

SAHCOMA

of

Fig.
them

66."

591

SKIN.

Subcutaneous

flakes

with

the

and

occur

as

Myxo-sarcoma

yellowislihyaline

occur

yellowish

into

opening

protoplasmatic

at the

thiu-walled

network

The

Neck."

the

in vacuoles.

In

one

canal; 6, small

into

which

the

has taken
proliferation

the

these

color
tissue

borders
with

and
are

It is

the

evacuated

patulous

{sp), either

few

roundish

flakes

of

(angioblasts ?), partly coalescing. Within

is formed
a lumen
containing small

limited

by spindle-cells.

the cells

are

not

larger,and
comparing sections

canals, but

flattened

in
proliferates

and

very
usually assumed

It is

intimately

that

these

in

nected
con-

ish
part roundin different

made

cavities and

tumid

similar blood

channels

sures
fis-

There

masses.

into which

vessels have

no

walls.

vascular and anaemic, so that

appears but slightly
blood
remained
unexplained. In the body of the

spaces of a different nature,

blood-vessels with endothelial

densely cellular,obliterated

brown,

blood-vessel

substance

tumor

place.
ordinary method, the tumor

dark

cellular

cells

cells,g z',there

latter

indeed, besides these, plasmaticchannels

the

large

of the tumor.

perceivethat

directions,we

are

gr z,

of these

appeared sparser,
fissures having convex
edges. On

edges of

{Iy sp)

of

h,

masses,

interstitial substance.

By

THE

their most
especially
regularlyin similar myxo-sarcomas,
aborted
rudiments
of vessels and blood.
to representpartly
sarcoma
Fig. 67 likewise representsyoung tissue from a multiple,quitesuperficial
the impression
of angiomas. One
at first sightmake
The several tumors
the skin.
excised from the living
the most recent tubercles was
patient.
in a granular,here and there fibrous
On thin sections we observe short spindle-cells

protoplasms,such
recent portions,
seem
of

OF

borders.

In

blood-pigment,and

their
here

usually lacunae
border,

neighborhood
and

there

or

there

red

with

cave
con-

lymph-vessels
are

yellowish-

blood-corpuscles.

592

SARCOMA

Fig.

67."

Assures

MuLTiPL-fl
of

the

Saecoma
tumor

into

of

Skin,

the

which

partly

tlie sarcomatous

OF

THE

Pigmented
mass

SKLN.

and

Telangiectatic

proliferates;

v, small

containing partly endothelia, partly pale red blood-corpuscles, partly pigment

tissue.
proliferated cells containing here and there some
pigment; s, sarcoma

Fio. 68." Primakt

Endothelial

Sarcoma

of

the

; the

Introitus

(Camera
vein

luclda7):

surrounded

lymph-spaces

VAOiN.a:.

lysp,

cular
vas-

by lymph-spaces
are

surrounded

by

SAECOMA

On treatment

with osmic acid,there is made

network

meshed

OF

which

alyeoh,

forms

on

593

SKIN.

THE

apparent in

^
Fig. 69.
"

Primary

Endothelioma

op

the

Vagina,

which

the tumor

of

walls

the

which

fine,dense, round-

deposited,similar

are

'

tiv,

Relapsed

as

Spindle-cklled

Sarcoma:

containing migratory cells; V, vein; /iv,,hyaline wall of a vessel entering the tumor; hv,
by hyaline degeneration of its wall (become
cylindromatous ") ; c, cutis,in its upper
tissue
running parallel with the surface and containing numerous
spaces, in the depth tendon-like
"

the

c,

dermis
atrophic epi-

pressed
entirely comlayers dilated lymph-

vessel

cells.

Then

follows

sarcoma
spindle-celled

to endothelium,
38

seemingly[fusiformelements.

By

this treatment, the

red blood-cor-

594

8AECOMA

the

puscles infiltrated into

methods
they partlymelt
then,

have

we

so

excessive

formations

both

that

explainedto

such

as

are

endothelia.

as

The

fact that this alveolar

youngest blood-corpusclesprobably indicates,

of pigment is probably to
quality. The formation
in part perhaps by
by the escape of red blood-corpuscles,

in the tissue and

formed

were

other

Here,,

the

similar in

great extent

with

yellowish color.

of the vessels as to form almost

proliferation
appearingdevoid of walls, and as fissures
of treatment, a peculiar
alveolar struccertain mode
ture

togetherwith

visible

became

structure

while

numerous,

diffuse

vessels themselves

At the same
time, by a
cups.
act
is revealed in which the spindle-cells

and

be

and

deal with

to

SKIN.

THE

still more
appear
stain the tissue

down

of the tumor, the

the whole

tissue

OF

aborted

perished.

or

extirpatedfrom the introitus vaginas of a threesituated

in
the
It
was
depth of the cutis, larger than a walnut, eggyear-oldgirl.
enucleated
be
and
could
whitish, softlyelastic,almost
movable
shaped, freely
; it was
it
examined
When
smooth.
proved to be an endothelioma.
carefully
homogeneously
vessels filled with swollen and
consists of anastomosing,thin-walled
entire tumor
The
endothelia ; the vessels appear partly compressed into obliterated cords containing
proliferated
Pig.

68

is drawn

fusiform
color.

With

was

and

tumor

Between

elements.

low

powers
years after the

the tumor

lie also

them
the

makes

few

impressionof

fixed cells of darker

narrow
a

sarcoma.
spindle-celled

place ;
appeared at the same
operationa slightlylargertumor
connected
with
the
skin,
fissured,
intimately
lardaceous, irregularly
softer,more
it
ferent
a
there some
shallow ulcers.
had here and
Microscopically presented quite difthe
; under
picture: Fig. 69. The skin over it is thinned, devoid of papillae

Three
it

from

endothelia
and
unusually dilated lymph spaces lined with proliferating
ramifications
vascular
to
the
there
extended
ing
originat(v)
epidermis
capillaries
;
up
sparse
which
elements
in the tumor, accompanied by large fusiform
partlyran parallel
Perithelial cell material
with them, partlybent off in the direction of the cutis elements.

epidermisare

is accumulated

with

The

delta between

the ramifications.

tissue running parallel

cutis layeris changed to a tendinous
superficial
Where
it
surface, but rich in largeelements prvoidedwith bushy processes.

The

most

the

borders

in the

the tumor,

latter consists
The

canals.

these elements

bend

off

largefusiform

chieflyof
blood-vessels

are

sparse

along

the vessels into the

of the tumor.

mass

arranged in cords,

elements

and, exceptingthe swollen

or

else bordering

endothelia, have

change, whereby their lumen appears greatly

hyaline (cylindromatous)
peculiar
obliterated {hv').
narrowed
or
even
{7iv),
This case
may genetically
permitsthe very probable conclusion that the spindle-cells
which
have
been
of
endothelia
unilaterally
compressed
an
d
evelopment
atypical
represent
their
of
and
rudiments
vascular
characteristics,
of
the
deprived
by proliferation
especially
were
or
germ, though
preventedfrom developing these altogether,so that the tumor
suffered

angiomatous, did
essentially

not

find

expressionin

the formation

of vessels.

of my views on cell
I may be permittedto add a few brief remarks
I conit is mainly the large cells,which
sider
1. In myxo-sarcomas,
division in sarcomas.
which
in rect
indiare
well as very similar enlarged cell-offshoots,
as
as
vessel-forming,
in substantiation

division.
In

them

we

often find vacuoles

angio-sarcoma)
(alveolar
sarcomas,
perithelial

the centre

of

develops into

the

mainly

by
the

nuclear

filaments.

large cells

situated

2.

in

endothelial wart
3. When
an
in process of division.
tissue show
the
to
cells nearest
endothelioid
spindle-cell

the alveoli which

sarcoma,

bordered

it is

are

these processes
sarcomas
4. In ordinary spindle-celled
processes of division.
vessels.
offshoots are connected with young
whose
sparse and affect spindle-cells

numerous
are

Within

SARCOMA

The

condition

mentioned

Sarcomatous

Proliferation

under

OF

well

595

SKIN.

THE

the

of

tion
embryonal vascularizain endothelioid tissue (probablyof lymphatic nature)is shown by an almost gelatinous
tumor
marcated,
extirpatedfrom the back and representedin Fig. 70. It consists of sharplydewhich
lobes ("?)
connected, racemose
gave the surface a coarselygranular
interstitial tissue (i). The lobes congranulating
sist
appearance, and of scanty, superficially
into solid or hollow columns, between
of endothelioid cells,usuallyarranged radially
which enter thin- walled capillaries
and solid delicate cords springingfrom the interstitial
distance by rows
tissue (i,).Where
of the
they enter, they are accompanied for some

3,

as

as

manner

ad'
Fig

70."

blood-vessel

figures of
into

the

most

with
occur

the

bordered

nuclear

endothelial

by

sarcoma

divisions
masses;

iv

op

tissue

; s,

e, endothelial

ab, hyaline

an
zone

Endothelial
of

sarcoma

Wart:

g,

formation

by

granulation
indirect

tissue; i, interstitial connective

vascular

tissue

surface of the tumor, the endothelioid

proliferating

division {k t), and

spindle-cells
(s)which at the

between

; e,

of the

surface; 6, superficial
elements
; fc t,

of endothelial

penetration

of vascular

offshoots

islets.

superficial,
youngest, spindle-cell
layerof the lobes.
branches
at right angles,but without
demonstrable
stained
isolated
cells
which
often
equally
(saffranin),

nuclear

tissue

division

them

occur

in

ever

In the direction
connection

with

exhibit vacuoles

cells show
denser

surface fillthe entire lobes and

numerous
masses

of the cords

them, there

(a b).

Near

processes of
deeply stained

immediately border

branch-

596

SARCOMA

OF

ing columns of red blood-corpuscles

(b).
with granulationtissue (g).
In

this case,

well

in that

THE

This

SKIN.

tissue alternates

sarcoma

here

and

there

mentioned

at the beginning of this chapter,we

can
recognizein the arrangement of the fusiform
embryonal elements, in the continuation of the vessel-buds,the tendency to the formation
of portionsof new
vessels,but which is again made nugatory by cellular individualization
and proliferation
of the buds.
In numerous
other cases, a perithelial
forms the atypicalfeature of the
proliferation
embryonal vessel-formation,and it would be quite possibleto erect different speciesof
as

as

follow the process of

sarcoma

cutaneous

in the directions mentioned

to the

sarcomata

transitions which

numerous

Most

formation

we

; but

this would

be of littlevalue

owing

occur.

at firstisolated,and

form

spherical,
gnarled,lobulated
smaller
rarelyspringingfrom the papillae.Subsequently,
deep in the cutis,more
nodules not rarelyform in the surroundings. In the beginning, the deep forms are not
to the epidermis; later they become
adherent
immovably adherent, may ulcerate superficially,
and then undergo fungous proliferation.Usually they are but looselyconnected
with the surroundings,easilyenucleated, encapsulated
within the
; not rarelythe tumor
within it are
membrane, and even
capsuleis here and there free,invested with a serous
found
smaller nodules
comas
partlyisolated by cup-shaped fissures. On the cut surface, sarwhite, sometimes translucent,at times also gelatinous,
are
homogeneous or striped,
to black, fissured
brownish
here and there infiltrated yellowishor greenish,reddish
or
sometimes
central
in
lamellae.
They
develop,mainly by
growth, to enormous
radiallyor
formed
in
not
size. They are
strable
rarely
earlyyouth without demonfrequentlycongenital,
from warts, e. g., on the lids,the extremities,or the genitals.
or
cause
mention
As peculiarforms of congenitalsarcoma
might here be made of a tumor the
size of a pea, of cartilaginous
hardness, from the finger of a three-year-old
boy ; it was
and
consisted
of
to
the
adherent
skin,
tive
connechomogeneous
hyaline
fungous, intimately
numbers
of small spindle-cells
moderate
tissue and vessel-walls,in which
were
evenly
cutaneous

sarcomas

are

tumors

imbedded.

diffuse

sarcoma

of the foot, the size of

dollar, of

bluish

translucence,

from
prominent,immovably connected with the skin, was removed
firmlydoughy, flatly
here were
The papillse
a new-born-child.
uncommonly enlarged,and the papillaryprocesses
in
tissue
which
abounded
short
cutis
w
ith
the
dense,
spindleso
diffusely
merged
In the depth, the
cells that the lower
epitheliallimit could no longer be defined.
the normal tissue.
with
formed
masses
tissue
graduallyblending
homogeneous
spindle-cell
of
the skin generIn
Sarcomas
of infancy are
adults, sarcomas
usuallymalignant.
ally
from
from
else
as
or
benign
neoplasms,
a
develop
they
stage,
early
benign
possess
warts

or

Not

benign tumors
rarely,sarcomas

warts, continued

from

be

traced

tissue.
back

of the

to traumatic
chronic

factors ;

e.

g., irritation of

and
inflammation, cicatrices,

on

onychia.

find
frequently

ulcers

can

pressure, laceration,wounds,

the toes, malignant

We

of the connective

foot ; in such

into
rapidlyproliferate

particularly
starting
degenerationof granulations,

sarcomatous
a

case

roundish

or

deep-red,f ungously overhanging

undermined
loose

or

ulcers
firm

masses

the

foot

which

the

of

spindle-cells
having a radiate
is
to
it
their
ends
at
surface
widened
recognizewith
the
toward
possible
;
arrangement
have embrywhich
in
vessels
onal
that the bundles
are
proliferation
papillary
facility
special
cells
of
times
At
rows
erated
(degenlarge
thickeningof their walls and narrowed lumen.
round-celled
traverse the proliferating
granulations,so that
rudimentary vessels)

microscope shows

to consist of round

cells,or of bundles

of

598

MELANO-SABCOMA

OF

3. MELANO-SARCOIkIA

THE

SKIN.

THE

OF

SKIN.

Sarcomata
form

with pigment degeneration,

especially
of the
frequent varietyof sarcomas, and usuallydevelop

vascular
from

rudiments.

They

pigment moles,

more

rarelyprimarily.
I have

new

endeavored

to trace

vessels which

form

blood-vessels

or

moles

pigment
pigment instead

blood

islets arises

to

great extent

of blood.

as

rule with

am

of

to

tary
embryonal rudimenthat the cavityof
the
blood-corpuscles,

opinion

formation

of

central

part of the blood islets changing into blood, the adjoining

part into an originally
membrane, here as well as in the embryo. The young
bloodhomogeneous (elastic)
at
first
much
and
than
the
are
more
old.
When
corpuscle^
pale,larger
new
perishable
blood-vessels
neously
develop in the adult, they are generallynot permanent, and the simultaformed
or
blood-corpusclessoon
disintegrate
change into pale or hyaline flakes
and are
soon
replaced by those enteringfrom the old vessels. The degenerationof this
blood-forming process here consists in an excessive development of similar formations
which, however, at once
disintegrateinto pigment. "We are already acquainted with
kinds
other
of one-sided
development of vascular rudiments ; thus the rudimentary
formation
of relatively
large vascular spaces givesrise to angiomas ; that of excessive
endothelium, to endothelioma
or
elements, to sarcomas
thelioma
peri; that of excessive parietal
And

indeed, in melano-sarcoma, several

of these

excessive

formations

are

present.
The

tendency

chemical
"

to

constitution

fading

"

form

an

of the

excessive

of

amount

latter and

its

pigment involves

also the

rapid granular deposition.

The

abnormal

stasis,the

of the

in the young
vessels of the tumor, their size,and their
blood-corpuscles
with them
tion
(Grussenbauer)
might likewise be traceable in part to the forma-

incrustation

of young
of this
blood-corpuscles
by reason
initiate
the
pigment-forming
may
process,

ment
tendency. Hypenismia of the environother
just as it causes
neoplastic
many
is supported in the main
by the locations where the pigment is
it,in the youngest forms, in enormously swollen endothelioid

This view
processes.
found.
encounter
We
cells of those small
with

channels

skin which, in other

hypertrophicendothelia,

find

we

tumor,

spaces of the

it furthermore

but

which

in the wall and

cases,

described

are

in the interior

of young

in vascular sproutsand in perithelial

and, finally,
large cells which

in

form vacuolse.
a process of indirect division and
diffuse discoloration;
but by careful treatment
we

as

plasmatic

vessels;
represent also rudimentary bloodvessels
are

of the

frequently

pigment appears also in the form of

(seeabove) even in this
may sometimes
in
before-mentioned
formations
the
stage recognize
resembling
spaces, pale,perishable
dissolved and give up their pigment
red blood-corpuscles
which
decolorized
are
or
soon
to

the

surroundings.

destitute

Such

formations

of clear demarcation, often

that, besides

pigment,in

the vascular
which

Melano-sarcomas

case

are

of

tubercles

sometimes

the side of

rudiments, other

the mode
are

by

The

are

in
giant-cells,
do not intend

alveoli
to

cells,fixed cells,may
cells,epithelial

originmentioned
which

in

found

giant-cells.We
elsewhere

often sessile

on

deny
form

prevails.
a

broad

base, fungous, or

spotted gray and

polypous; frequentlythey are
thinned
brown
discolored,
or
epidermis,
blackish;they are at first covered with similarly
and
but rarelywith kindred
sometimes
disintegrate
they ulcerate superficially
papillae;
into a viscid inky mass,
pasty in the
may be moderately firm or fleshy,often become
centre, range in size from a nut to a fist,usuallymerge into a black speckled skin, nor
in the depth. On section they appear black or spotted.
are
they sharplycircumscribed
brownish, livid brown,
hemispherical,
.

MKLA^^O-SARCOMA

OF

THE

599

SKIN.

the tubercles
blackish-bloodyjuice. Sometimes
that case
ish,
usuallybeneath pigment moles, as roundcircumscribed, but otherwise similar nodes, in the surroundings of which
we
more
rarelyfail to find blackish spots in the glandular and adiposetissue. Soon the latter
diffuse nodules.
tastases
Very frequentlythe tumor now forms medevelop into smaller, more
continue
to
I
becomes
New
nodes
as
believe,
form, usuallyspeckled
multiple.
or,
diffuse in the depth. Finallythe
and hemispherically
prominent on the surface, more
internal organ is spared. In proportionas the tumors
and no
skin is beset with them
in cells and
abound
pigment and are soft in consistence,their growth is more
rapid.
augmenting vessels containing pigment with blood, often soften
They bleed from ever
in which
structure
further
be recognized.
no
can
throughout into a black inky mass
tumor
is
forms
metastases
does this
or
as
as
as
spread
general
Hardly any
universally

smooth
and
moist, exuding
"usually
arise in the depth of the skin, and in

melano-sarcoma.

Fig. 71." Border

pigment-sarcoma
the
op
the
of
angle
mouth
(Hartn. 4 ; 4): e, relatively
tween
replacing the lower layers of the rate and atp' especially penetrating bethe cells as far as the surface:
p", pigment in the superficiallayers of the rete; h, hair-follicle on top of a papillary
"elevation
of the skin; I y, lymph-spaces
of the superficial cutis layer;
sweat-gland, the pigment being
p sd, pigmented
between
the tubes; p 6 ", pigmented
gated
eloncells
of the tumor;
connective-tissue
at the border
present both in and
vp,
papillae,in part containing plugs of pigment; in one of the papillary processes
an
epithelialpearl in colloid degeneration;

normal

epidermis;

and

c,

neighborhood

cutis; p,

black

op

pigment

t,unusually elongated sebaceous

filled with
plasmatic channels
enlarged

and

hair-follicle;ply, tumor
tissue, pigment plugs in
endothelia; pfg, pigment in the adipose

pigmented

the

lymph-spaces,

tissue

between

or

the

the fat-

cells.

In most

melano-sarcomas

the border

layerof the thinned epidermis is intenselypigmented

pigment may
proliferatethrough its entire thickness {p'),and in
the depth surrounds
its often hypertrophic
papillaryprocesses (at h); then, occupying
of
the centre
the papillae,
it forms heaps of cells in place of their vessels (vp). The pigment
in moles or sarcomas
is rarely situated in the cell network
between
the connective
tissue trabeculaa (pid).
The tumor
is preformed more
commonly as a sort of endothelial

{p),the

wart, the alveoli of which

even

are

filled

or

lined with

large,often

flat pigmented cells

(l^).

600

ANGIOMA

Giant-cells in the tissue,too, contain

alveoli

The

flakes.

OF

THE

SKIN.

in their interior

subsequentlybecome

pigment

denser, the

ever

vacuoles

or

cells within

with
them

yellowish
are

pressed
com-

into fusiform

pigment-cellsor homogeneous black masses; the numerous

young
closed by plugs of pigare
blood-vessels,formerly repletewith pale blood-corpuscles,
now
ment
with pigmented perithelia. In the sweat-glandsof the neighborand surrounded
hood
is provided with pigmented, swollen
the vascular network
endothelia, and the
is pigmented (psd).
The same
is the case
with the vascular
protoplasm of the gland-cells
network
fat-lobules (pfg).
in remote
of some
Even
have established
regionsmetastases

primarilyin

themselves
Of

the vascular

rarer
glands.
lympho-sarcomatousnature, as

melanotic

occurrence

are

in which

mainly

tissue,occurs

as

as

the
a

of the smallest fat-lobules

the

those in which

the tubes

degenerationbetween

carcinomata
epithelial

cases

well

network

in which

or

acini.

border

narrow

of

or

sweat-

in tumors

of

undergo
young vessels in adenomas
But especially
true melanotic
rare
are

besides

pigment,

pigment

exists

nective
being deposited in foci in the conpapillaryprocesses in carcinomatous

degeneration.
is

Melano-sarcoma
the

tumor,

when

even

slowly and

the tumor

of the

without

malignant tumors,

most

to arrest

so

process.

exhibitingthe

to

that
In

the

of
extirpation

only does
generalized. At
enlarged pigment moles
rare

cases

become

urgently advised.

4. ANGIOMA

"We

the

tendency
of
earlyand thorough possibleextirpation

grow
all events, the most
is to be

one

small, is unable

apply the

term

angioma

THE

OF

to tumors

of

SKIN.

embryonal rudimentary

vessels which

velop
de-

into blood-vessels.
1.

The

Vascular

Ncevi

new-formation

in General
of

of moles, the so-called vascular

prominent warts
The

true

and

vascular

and

Simple Angiomata.

most frequentlyin the form

appears
nsevi (naevi
vasculosi).These subsequentlydevelop into

embryonal

largertumid

blood-vessels

formations.

ncevi at first resemble

with indistinct outlines;they

flea-bites,

are

spread slowly;they are

of a spider
of wide vessels often in form
with the surroundings by means
connected
wine-red
later
often
(nsevus
more
vinosus),
sharplydemarcated,
they are
(naevus
aranseus)
;
spots
bright red (n. flammeus), or dark bluish-red,moderately salient,mostly uneven
risinghere and there in small grape-likeelevations,or form pea- to nut-sized,moderately
or
deeply lobulated, '^mulberry-like"tumors.
structure
tumors
of lobulated
described
The
as
forms
are
deep, subcutaneous
(Schuh);they may correspond to the adipose tissue or to the plexus of veins (lipogeor
superficial

subcutaneous, usually flat,slightlyelevated,and

tumors, from a lentil to a bean in size,

phlebogenous forms). They are congenital
bluish appearance
skin
the
s
grow to several inches
through
(naeviubcutanei),
may
in diameter, extending into the skin and into the depth; they are lobulated and erectile.
in the shape
in groups, and very rare
They are frequent in the face when single,rarer
of countless scattered miliarynodules.
pressible;
In general,these tumors
are
soft,relaxed, reddish or livid,very sanguineous,comforms);
coarselygranular (hyperplastic
or
they are more
rigid,less plethoric,
they are lobulated like fat-lobules,in very rare cases resembling a placenta.
or, finally,
The superficial
forms
The borders of the several forms are not sharplydemarcated.
of a lighterred; the deeper
flat of associated with enlargement of the papillae,
are

nous,

have

ANGIOMA

forms
even

most

THE

601

SKIN.

are
usuallytumid and darker in color. The epidermisover the tumor is smooth,
trophic
hyperatrophicor papillomatous,and is providedwith hypertrophic hair-follicles,
arrectores
forms, the papillaryvessels espepili,and thick hairs. In superficial
cially

in other cases,
dilated,often unusuallythickened
(angioma hyperplasticum);
dilatations
of
the
smallest
veins
wide, rosary-like
(angioma varicosum). In

are

there

OF

are

however, the new-formed

cases,

and

form

According

manifold

vessels

convolutions

to Billroth,the new-formation

the hair-follicles,
the

starts first from

sweat-glands,the sebaceous
and

often lead to the tumor,

neither

correspond

veins

to

laries,
capil-

to

nor

networks.

and

glands,

or

varicose veins

dilated,sometimes

capillary
plexuses of

the

Small

the fat-lobules.
extend

thence

ries
arteto the

there are
few old vessels,most
of them
being newly
surroundings;within the tumor
sequently;
maintain
this character subformed.
vessels of the new-born
The largelycellular young
influences,vascular proliferation
owing to irritation and perhaps also to nervous
in layersensues
from
time to time, and thus
of parietal
elements
formation
or
the tumor

of such

The
formation
grows.
The
vascular dilatation.

blood

intermediate

an

flows

district

vascular

slowlyin

and

an
angioma,
less swollen.
or
Anger and excitement, as
only at times, but constantlymore
Some
this condition.
undemonstrable
of the
causes,
may materiallyaugment

contractile,on

are

and
The

the

abundance

the arrectores

vessels in

new-formed

moderately

of the

account

hypertrophy of

wide, thick-walled

of muscular

parietalelements

with

well

as

tumors

of the

sels
ves-

pili.

simple angioma constitute,in

tubes

gestion,
con-

causes

the latter is not

few

the recent

anastomoses, and

forms, winding,

invested

with

swollen

it is nothing but the demonstration

In some
of blood, often associated
cases
which
enables us to guard againstconfounding the tumor
with
hyaline masses,
the thickening,mainly by concentric depoof the sweat-glands. Subsequently
adenoma
sition
and perhaps also of young
of spindle-cells
muscle-cells,may predominate so largely
that the vessels become
obliterated,the vessel-walls partlycoalesce,and there is presented
the tumor
an
resembling sarcoma,
being composed of concentric layersof
appearance
spindle-cells.In many cases the interior vascular layerssuffer a reticular or myxomatous
cell networks, and nests,probchange, while round about the vessel are dense epithelioid
ably
composed of perithelia.In other cases, the vessels have uncommonly thin walls,
Sometimes
and the roundish
blood-spacesare bordered merely by swollen endothelia.
vessels have a venous,
the young
arterial
are
character, they
rarelyan
light-redand pulsating.
tissue between
The
the new-formed
vessels often resembles
granulations,or
is composed of embryonal spindleor stellate cells ; later it often becomes
firmlyfibrous.
of the parietal
elements, probably assisted by
Through excessive embryonal proliferation
the interstitial tissue, there may be formed
sanguineous,fungous sarcomas
(angio-sarother
In
is
in
interstitial
the
tissue
and
the
cases
vesselpigment
deposited
wall,
comas).
also
in
endothelial
channels.
cells
the
filling plasmatic
large
probably
As above stated, telangiectasias
have
been
are
usually congenital; small tumors
endothelia.

with

the new-born

observed

on

for

time, and

some

surface ; the
within
grow
or

tardy
a

few

and

then
forms

days.

are

while
disappear,

soon

remain

stable.

the

rapidly,so that, in a few years,

angiomas.
The causes
of simpleangioma are

others appear

deep

Sometimes

rare.

While

The

forms

small

are
telangiectases
of
largeportions the

soon

after birth, grow

late on
the
especially
appear
monly
angioma may enlarge uncomgenerallystable,they at times
skin

may

be

covered

with

flat

racemose

the fact that

many

of them

have

those above
their seat

pointed out ; we shall moreover

size
emphaon
maxillaryfissures (Virchow'sfissural

"02

ANGIOMA

angiomata)which
serve

indicates that

their matrix.

as

trunk, and

OP

THE

SKIN.

vessel formation

supernumerary

Angioma simplexoccurs

at

these

places may

the head, next

frequentlyon

most

the

on

the extremities.

on

Not rarely,angiomas bleed considerably

from
Central
often
vessels
they retrogress
completely.

small erosions

or

ulcers.

In

rare

cases

-obliterated ; cicatricial contractions

it spreads peripherally. In other, especially
become

appear in the centre of the tumor, while

in superficial
forms, there is cystoiddegeneration of the
transformation

of the

connections.
Sometimes

These

associated

cases

obliteration

to

blood-spaceswith hyaline
or

occlusion

of the

those originating
in papillse,
cysts,particularly
may

the mole

of the inflamed
vicinity
rare

contents, probably due

becomes
tumor.

with

inflamed
Otherwise

or

gangrenous.
these tumors

are

temporary twitches

itchingor

forms pressing
are
on
hyperplastic
nerves),

of

lar
vascu-

rupture.

in the
Erysipelasmay occur
benign, and, exceptingsome
in small subcutaneous
pain (especially

troublesome

mainly on

account

of

disfigurement.
For

this latter reason,

surgicalinterference.
blood-supplyof the tumors

are
ally
usuvery frequentlythe objectof therapeutical,
shall make
specialmention here of the cuttingoff of the

angiomas
We

mation
chiefly
by excitinginflamto
more
measures
are
abandoned,
being graduallymore
give place
to removal
by the hot iron, thermo-cautery,knife, by cauterization and ligature. Small
forms may sometimes
be cured by prolonged digital
superflcial
compression,even
by the
applicationof ice. But it is best to destroy them by the galvano-cautery,platinum
needles being drawn
through the base of the tumor and subsequentlymade incandescent;
is
sometimes
ligation very effective,a needle armed with a double ligaturebeing drawn
through the base of the tumor, and tied on oppositesides. Usually,however, these cases
are
quired
equally amenable to cauterization with nitric acid (applieduntil the angioma has acetc.
the
actual
in
removal
or
a yellowish
thermo-cautery,
thorough
by
color),
;
green
the largerforms success
be expectedfrom the latter procedureonly. For angiomas on
can
the head over
fontanelles,or on the lip,the elastic ligatureshould be employed with care.
In superficial
flat forms, cauterization with nitric acid is indicated ; in extensive forms,
"

the treatment

Very

with

hot needles

angiomas

vessels may

the

"

and

extensive

imperfect. In

case

is effective,
but tedious.
must

of serious

be

the result is usually

angiomas, the ligationof large

and
piecemeal,

operated on

diffuse

hemorrhagesof

be indicated.
2.

The

and the obliteration of their vessels

^but these

chief

cause

The

Cavernous

of this formation

Angioma

coincides

of

the Skin.

simple angioma; in many

simple variety,by the co-operationof

with

that of

cavernous
angiomas have formed from the
cases,
dilatation and coalescence of the
also embryonal vessel formation),
granulation(evidently
tricial
there was
vessels (Virchow). In other cases
preformed a connective-tissue tumor or cicatissue,the atrophy of which distorted the vessels into cavernous
spaces (Rindfleisch).
Nor is Rokitansky's opinion, that there are preformed cavernous
(probablyof
spaces
devoid
of
all
into
which
blood
justification.
subsequently entered,
lymphatic nature)
of a man
affected
of origin. I have illustrated the case
But there is stillanother mode
and proliferawith generalscorbutic disease of the vessels with the formation of petechioe
tion
of the gums, in whom
smooth, violet,expanding tumors
projecting,
hemispherically
of slow growth, up to the size of a pea had appeared. They bled from the cut surface
if from
as
a fine-grained
sponge and collapsedmoderately;the cut surface then became
bluish red, with firmer, rusty brown
histologically
points. Examined
(Fig. 72), the

ANGIOMA

epidermiswas
tumor
the
(;)),

founxi

OF

THE

603

SKIN.

atrophic(ae),the papillae
elongatedonly at
cutis
superficial

most

the

borders

of the

remarkable

dilatation of
layerfinelyspongy by a
in part arranged in
plasmatic and lymph-vesselswhich were
form {ly). Then followed exceedinglydilated,in part sacculated vessels which
cavernous
tissue of the deeper cutis layers,
but the tissue
graduallyblended with a widelycavernous
young

had

the whole

on

the

is

Fig. 72."

the

thick- walled

callous

dilatation of the

Here

the direction

the

tumor.

the

of the

lymphof the

the

the

over

most
vessels

deep

of the vascular
smooth

vessel with

that there

Skin

op

of

centre

Scorbutio
the

p,

superficial cutis layers which

{I y); c, cavernous
blood-vessels.

are

elongated

Here
the

{k).

have

become

c.

which

have

Like
type in the purest form.
vessels
of
superabundant rudimentary

most
a

e,
the

finely spongy,
into

and

there
of

centre

Above

this

the

point

atrophic epidermis; sch,

of the tumor;
borders
6,
tion
especially by augmenta-

proliferatedblood-vessels

the character

assumed
modes

1. 7):

papillae at

tissue,gradually merging

tumors

cavernous

(Hartn.,

Patient

tumor;

that these represent the

these arise from

In

indistinct outlines

general disease of the blood-vessels had

Without
being inclined to doubt these

the conclusion

anastomoses.

muscle-fibres.

epidermis (sch).

prom

epidermis

proliferating bloodvessels
maintaining

thrombotic

Cavernosum

angioma

the direction

lacunas contains

of
depression

callous thickening of the

and

of

maintained

between

stroma

tumor

is

and
capillaries

of

origin,I

have

this character
vascular

circumscribed

of

and

nous
caver-

arrived

at

and
primarily,

tumors

in

vascular

general,
district.

similar formations

largecellular vascular islets as in the area vasculosa, young

When
protoplasmaticnetworks and sproutsconnected with them.
of
with advance
and irregular
from these structures
vessels form
abnormally numerous
the vascular proliferation
and probably also their union
with vascular islets,
angioma
the formation
islets or
of vacuoles is excessively
of blood
simplex results;but when
connected
in
the
vascular
developed
sprouts, so that consequently merely irregularly
endothelia and an elastic
cavernous
spaces result,the walls of which consist only of young
nous
membrane, while the archiblastic formations togethersupply the blood spaces, a cavernished
angioma results. A similar process of primarilyconnecting blood spaces is furThey

are

of the vessel-wall,or

in the
That
young

many

area

cavernous

endothelial

vasculosa

and

tumors

the
lining,

in many
arise in this
absence

hyperplasiaof the muscle-fibres,the

with vacuoles, or
of largegiant-cells

of

cavernous
manner

spaces
not
and

granulationand

absence

of

of networks

penis).

(corpuscavernosum

by the
embryonal

secondarilyis shown

hemorrhage,the

the presence
atrophic tissue,and finally
of protoplasm connecting with vessels.

604

ANGIOMA

in many

recent

The

cases.

OF

developmentof

THE

SKIN.

elastic fibres,the

crowding out

of other

ments,
ele-

the

atrophy of the muscle-fibres of the septa, pigmentation and granulation,

are
vorable
undoubtedly effected later as the result of blood stasis in the lacunae which are unfato the circulation.
this
constant
stasis
the
tumor
h
as
bluish
Through
enlarges, a
and the blood circulates slowly.
appearance,
is rarelycongenital,
but often developssoon
Angioma cavernosum
afterbirth,though
not uncommonly later.
We distinguish
diffuse and circumscribed, superficial
and deep
forms.
Fissural angiomas are most
frequentlycavernous.
Usually there appear in the
tumid
depth of the skin at first bluish transculent, smooth
or
tubercles,or lobulated
which graduallyproliferate
tumors
both outward
the
and into the depth. In other cases
has originatedsuperficially
tumor
and then spreads diffusely
as
a naevus
over
larger portions
of the skin.
Or the originally
formations, or largercircumscribed
verrucose
ficial
superinto the subcutaneous
mulberry-liketumors, or polypi,grow as such or spread downward
tissue,between

connective
into

here

the

muscles, and

into the bones.

multiplethat the differential

The

transitions

difficult.
so
simple angiomas
slowly growing,
general,tumid, bluish, pronouncedly erectile,easilycompressible,
subcutaneous
will probably be cavernous.
vascular tumors
cavernous
Superficial
especially
sometimes
notice upon
them
the lacunae or
angiomas are more
prominent; we
of them
red points. Encapsulated soft angiomata, which
as
grow very slowly,
groups
with
while hard forms have not rarelybeen confounded
presentno diagnosticdifficulties,
sometimes
with lipomas. Sarcomas, too, being
fibromas, and the lobulated ones
very
vascular, exhibit all the characteristics of an angioma. Even cysts and encephaloceles
have been mistaken
for angiomas. In doubtful cases, therefore,an exploratorypuncture
The
will be always advisable.
nostic
extirpatedtumor, however, no longerpresentsany diagdifficulty.
it gives
not rarelyis the seat of lancinatingpains; sometimes
The cavernous
tumor
the
of its points of predilection,
rise to considerable
hemorrhages ; in other cases some
moval
lips or the eyelids,may be so swollen as to hinder their functions and indicate the reare

diagnosisbecomes

In

of the tumor.
The
As

of this tumor

treatment

general rule, in these forms

the

employment
hemorrhage.

of broad

as
a

diffuse

as

that of

simple angioma.

will

case

prevent considerable

the Skin.

traumatic

times for many,

lymphatic canals or

recent

usually

in

the prepuce,

one

case

was

said to be due

of the skin, and

the
the clitoris,

with

depth

togetherwith

or

oedema

to

hypertrophyof

of loose texture, such

labia

as

the cutaneous

the subcutaneous

cle
mus-

layer of

the

velopment
to the depredisposed
especially

majora, are
tion
swellingformations associated with discoloraUsually we
considerable
lymphorrhagia after their erosion.
or
in enlarged papillse,
ampullary lymphlacunar, connected
In other cases there is present a
of the neighboring tissue.

of such diffuse,
tumid, relaxed

find here, in the

ous
cavern-

as

Tissues
fibres (Kindfleisch).

sacs,

same

scissors is advisable,in which

originhaving
spontaneous or
In these tumors, there is rather an
for cysts containing lymph.
new-formation
of lymphatic channels.
and
form has been repeatedlydescribed as elephantiasis
pachydermia lymwell

and
phangiectatica,

scrotum,

knife and

Lyynphangioma of

of

tumors
congenital

the

the whole

has only been employed in

lymphangiectasia

term

spaces,
ectasia than

on

by
forcepsand rapid suture

haemostatic

3.

The

is

removal

or

606

APPERTAINING

TUMORS

and
and

There

of the affection.

cause

sarcomas

subcutaneous,

are

ARCHIBLA8T

THE

The

lymphangioma cavernosum.
sharplycircumscribed, soft,even
adherent

enlarge moderately,are

to

the

latter tumor

loose

skin, sometimes

and
projectingflatly,

keloid-like,firm, sometimes

SKIN.

this form

into

not

THE

OF

into very vascular fibromas

associated
with telangiectasia,
i
s
lymphangiectasia

transitions from

in which

forms

also

transitions
finally

TO

tutes
usuallyconstiswellingswhich sometimes

also at the

of moderate

pointof

adhesion

extent.

tumor, which was extirpatedfrom the cheek of a girl

aged twenty, had formed
the
soft
contusion
of
parts,and had grown slowly;
years before, after a violent blow with
it constituted
a
disfiguringtumor, flat,larger than a dollar,tumidly cicatricial at the
Such

firm, hard to grasp peripherally,

softlyelastic,
especiallyat the centre, and with indistinct borders ; its
of turbid liquid. On
abundance
tissue discharged an
section, the
the
reddish brown, cicatricial,
firm.
ited
tumor
centre was
Microscopically
(Fig.73) exhibcicatrix
which
adherent
to
centre
at the
the epidermis (d);
firm hemorrhagic
was
a
cavities but partly lined with endothelium,
while the main mass
formed
wide connected
fibrous stroma
which
were
cle-fibres.
(I)containingtrabeculae of smooth musseparatedby a coarse
The blood-vessels of the tumor
were
partlyobliterated.
The neoplasm did not relapseafter extirpation.
traceable to lymThe so-called hygroma cysticum colli congenitum is probablypartly
phangiec
is
retention
most
but
frequentlyit a
cystof foetal branchial clefts,as shown
lining. In other cases, e. g., in those of Koster and Winiwarter, in which
by its epithelial
both endothelial liningand transitions into other evident lymphangiectasias
(macrochilia)
demonstrated, we are obviouslydealing with cystically
were
degeneratedlymph-spaces
which projectmainly at the lateral partsof the neck in the shape of simple or cavernous
centre, somewhat

retracted,brown, very

closelyadherent
coarselycavernous

cystswith

to

the skin

clear contents, and

which

may

reach

the size of

man^s

Weinlechner

fist.

scribed
de-

region,the

similar cystichygromata of the anal

axilla,and the extremities,but
originremained doubtful.
The diagnosisof lymphangioma is not always easy.
Simple lymphangiectasise
may
with
with deep telangiectasias
forms
or
be confounded
cavernous
lipomata. Harder
But the adhesions to the skin and the capacityof swellingwill
may simulate fibromata.
of soft lipomata. Angiomata can
differentiation
of these and of cases
be
permit the
their

excluded
The
serious
Smaller

by

of the bluish odor.

the absence

the pachydermic or the elephantiasic,

forms, especially
may become
by hindering motion, by ulceration, by lymphorrhagia, or by suppuration.
tumors, even if multiple,present no danger of any kind ; they may possiblybe
extensive

ference,
painfulor sensitive,or enlarge rapidly. Usually they are the subject of surgicalinterdiffuse
situated
the
face.
when
forms
will
on
soon
Larger, more
especially
forms and macrocavernous
chilia,
operation
; while the smaller, especially
relapseafter partial
can

way,
well

be

cured
definitely

this head,

Under

constituents

into such
as

as

form

develop from

made

TO

of the

portionsof

the median

morbid

disappearby puncture

growth. In the same

by drainage,as

followed

"

THE

ARCHIBLAST

shall group togetherall those

first rudiments
of the germ.

we

of the
from

to

alcohol.

APPERTAINING

TUMORS

from

after radical removal

cystichygromata may be
of iodine or
as
by injection

the external

and

the

OF

THE

SKIN.

new-formations
These

can

be

which

develop
properlydivided

internal blastoderm, and

portionsof the archiblast,which

are

such

mixed
earlyintimately

TO

APi'EKTAINING

TUMORS

ARCHIBLA8T

THE

OF

and
up the muscular
the muscular
system,

penetratedparablast,build

"with the
also line

In

membranes.

nervous

THE

607

SKIN.

systems,and perhaps

nervous

probably its

visceral

portion,is

rudimentarilypreformed:
THE

The

smooth

MYOMA

OF

THE

SKIN

fibres of tumors

muscular

(LEIOMYOMA CUTIs).

always differ

more

less from

or

the

normal

they are smaller or larger,sometimes contain several nuclei, their cell body is often less
homogeneous and lustrous,their nucleus is at times shorter. Nevertheless they can be
recognizedby their form and arrangement, by their peculiarbehavior towards
positively
bases, but especially
by their characteristic

acids and
brown

color with

saffranin,also

the elastic tissue of the skin

The
have

been

origin of myomas
emphasized in the

should
The

of which

Cxjtis

74." Akgioma

Fio.

luc):

firm, smooth

can

with

picrocarmin,and

isolated in connection

with

caustic potassa.

by

means

in

factors which
general is probably traceable to the same
With
of the skin, the following
regard to myomas

introduction.

three

from

Palm

the

muscular

fibres

bz, loose, stellate-celled

endothelium;

be

is

piliform

arrectores

they

of saffranin and

yellow color

functionallydifferent,extensive layersof muscles, the most

probably that forming a constituent of the vessel-wall. Then the
smooth
muscular
fibres,and finally
a third muscular
apparatus exista

skin includes

extensive

cam.

be stated

by

the fact that

op

the

Hand.

springing from

Picrocarmin

and

(a) arterial,venous,

interstitial tissue; eg, tissue of the

formic
or

acid

preparation

lymph-vessel

walls

(Hartn., Obj. 7,
(d 6); zi, swollen

capsule.

in the genitalsphere (scrotum,labia majora, penis,

depth of the skin, especially
in
and
the
face
in
the shape of a thin network
of muscular
trabeculae.
gland),
mammary
similar
trabeculas
of
this
tissue
found
in
the
I have
inconstantly
neighborhoodof
present
in the

the umbilicus, and

the anus,

such

as
a.

are

these

the

ear.

tissue that myomas

of the skin arise.
layers of muscular
which penetratethe skin from
There are, besides,myomas
neighboring muscular
parts,
of
these
such where detached
into
in
the
and
tumors
or
skin,
parts
develop
germs
finally
It is from

connected

three

with

New-formationof

remnants
smooth

of foetal formations.

muscular

fibresof the

vessel-wall

occurs

with

most

new-

608

APPERTAINING

TUMORS

formations

of vessels.

We

TO

THE

ABCHIBLAST

OF

THE

SKIN.

speak of a preponderance of the muscular ne"w-formation

large proportionof the parietalelements consists of young
smooth
muscular
fibres. Angioma racemosum,
too, may suffer uncommon
hypertrophy
of the muscular
elements
of the media during thickening of the vessel-wall.
Often,
however, the oppositecondition takes place,the muscle-fibres being crushed by sclerosis of
in
especially

where

cases

the media, which

can

fact also enters

Particularlycharacteristic

into consideration
are

in the

case

of other

vascular

tumors.

very small, subcutaneous, sharply circumscribed,

the back, Virchow) which
reach the size of a lentil

elastic tumors
on
;softly
(especially
and are conspicuous
and larger,
by their painfulness. They consist of a coil of vessels in a
condition of myomatous
of the palm of a young
degeneration. A subcutaneous
myoma
tumor
in
whom
the
had
been
noticed
in
shows
this condition in a
even
earlyinfancy,
man,
form.
The
tumor
invested
with a lamellar capwas
pronounced
easilyenucleated,smooth,
sule,
the cut surface smooth, moist, and consisted of a basement
on
substance
softlyelastic,
reddish translucency,and a dense fibrous felted network.
The histological
having a somewhat
of
the
tumor
is
in
the
illustration
reproduced
preceding
(Fig.74).
appearance
of convoluted
Immediately beneath the capsule (cg) appears a confused network
trabeculae of smooth
muscle-fibres {g m), on which nuclei are
made
evident at frequent
intervals by treatment
with saffranin,and the body of which
ders
serrate borto have
seems
The muscular
fibres are
and flat processes.
grouped around the axis of trabeculae,
clear spaces or cords of smooth
which contain minute
or
flat,coarselygranular cells {zi),
which
could be easilyrecognized as endothelia.
Immediately around these cell-cords,
the muscle-fibres were
grouped parallelto their long axis,while the periplieral
ers
fibre-laysituated
the cords
or
were
transversely,
concentrically,
radially. Between
usually
also found
in
these elements form true convolutions, and they are
detached, sometimes
from
the vessel- wall; the interstitial tissue
the interstitial tissue as trlibeculae loosened
consists otherwise
almost

of few

homogeneous
along

course
capillaries

tumor

the

stellate cells,loose connective-tissue

narrow

intermediate

from

sprang
muscular

Marcacci

an

abnormal

have

seen

similar

the

an

{h z); finallysparse plasmaticchannels and

substance.
Therefore, it is probable that the

this intermediate

portion of

trabeculae,and

substance

vascular
vessel-wall

tumors, and

rudiment

of

furnished

the

mainly
tumor

arterial nature, in which

material.

tumor
lymphangiectatic

Brigide and
by Axel

is described

Key.
networh
muscular
(myomes dartiques,BesyS. New-formations of the cutaneous
of the scrotum, the
or
multipletumors, especially
nier). They arise as diffuse,solitary,
similar tumors
When
found
at other parts of the skin, I
were
labia,and the mamma.
muscular
fibres.
that they developed from trabeculae of smooth
would assume
Rindfleisch was
the first to call attention to a form of lymphangiectatic
elephantiasis
the smooth
the dilated lymph-vessels
muscle-fibres
between
of the scrotum, in which
were
uncommonly augmented, and on the strength of this observation he ventures the
that this form is traceable to stasis,
due to the muscular
hypertrophy. In a
suggestion
of
of pachydermiain a child aet. three years examined
case
by me, the skin, especially

genitalsand lower extremities,had been from birth tense, wrinkled and warty,
the folds and warts was
The epidermisover
thinned, its papillae
brownish, translucent.
in
ened
thickthe
the
far
corneous
corresponding depressions,
layer was
thin,
apart,while,
the

prominences the cutis is gelatinously

homogeneous,
of lymph and blood capillaries,
but otherwise deficient
The
few stellate elements.
deepest part of the cutis,which is smooth,
of round
surrounded
cells. By
and
vessels
by a slightaccumulation
glands,

crowded.
papillae
containinga largenumber

and

the

in cells,with
contains

few

On

the

TDM0K8

far the

APPEKTAmiNG

greatestpart of

this

AECHIBLAST

THE

TO

OF

consists of

portion,however,

TUE

609

SKIN.

layerof closely
packed

mus-

oular trabeculse,each up to 0.3 mm.

in thickness, the whole
with
running parallel
surface of the body and about one
millimetre in thickness;they are
surrounded
by
connective-tissue
the

intensityof

which

"

resemble

the scrotum
lated

one

sheaths.

The

thickness

the process.
Better
those of the uterus.

contained

known
Forster

small

numerous

similar structures,whose

of this

layer is

circumscribed

are

describes such

muscular
superficial

nature

was

not

majus

of

in exact

forms
a

of these myomata

case, in which

tumors, and

determined

the

separate
proportion to

the skin of

largerpedicuseated
were
closely,

more

in the skin of the abdomen.

Kraemer
underwent

from
extirpated

the labium

slightcontractions

during

of the skin of the

myomas
of a man
describes the case

The
Virchow

mamma

somewhat

are

in whom

different.

numerous

formed, up to the size of a cherry,in the

dilated vessels,a preponderating mass
besides
contain,
they
tubercles had

telangiectodes).Verneuii

(myoma

which

and

had

from

the arrectores

small
superficial,

numerous

the arrectores

from

sprang

Hyperplasiaof
I

Thus

than

is
A

sequence
muscular

no

side of the

made
chiefly

muscular

fibres

the

on
breasts,
especially
sharplybordered
later became
painful. They

man,

with the vessels,and

connected
which

it would

of

few

nerves

be diflBcult to ascertain.
muscular

of the
tumors, especially

in which

trabec-

there
and

mamma,

were

which

pili.
frame-work
in

has been found

keloid of the

obviouslyit is much

to these cases

more

by

even

in other tumor-formations.

ear, in perforating
in sarcoma)
frequent (especially

lobe

those

of the

found in placeswhere
myomas
and Vaillard found on
the extensor

Arnozan
which

became

largelentil,and
painful.
independent muscular fibres.

the

spread over

The

nodules

were

entire trunk,

vascular;they

up of

seated in the skin have

neighborhoodof

into the
from

is formed

is present.

frame-worh
countless superficial
nodules

all myomas

not

partsin the

arm

size of

acquiredthe

the skin which

there;in
originated

contain

smooth

rare

muscular

cases

tumors

fibres reach

of

under

the recto- vaginal sepfrom

skin; e. g., from the pubo-rectalaponeurosis,
tum,
isolated
it
be
which
Sometimes,
too,
(detached)
prostate.
may
germs

the

entered the skin and

formed

the posterior
portionof the labia
tumor

muscular

generallyassumed.

normally

have

young

of smooth

case

this condition

found

natural

But

of many
nsevi pilosi,
numerous
Balzer
has
also
described
a case
pili.

the muscular

of the testicles,
etc. ;

tumors

and

fibres not

originof

believes that, in the

Virchow

were

muscular

striated muscle-fibres,the

ulae form

in

developed painlessly,
grew slowly,and

mainly of

consisted

found

In the first place,

reddish
superficial,
painful,
neighborhood of the nipples;

smaller, in the depth pea-sized,

reddish, not

flat,lentil-sized and
tumors

which

largemyoma

woman

young

its removal.

there.

Marcano

an

majora projecteda

describes

case

in which

round, easily
enucleated, firm

orange which had sprung from

of a branchial cleft,from
the remnant

the size of

Probablyfrom

tumors

the above-mentioned

misplaced germs,

lar
muscu-

aponeurosis.

there had formed

the lateral regionof the neck, round

tumor
fibro-muscular
on
pigeon-egg-sized
in length and beset with numerous
of the skin, three cm.
the narrow
invagination
found under both ears
Similar tumors
were
(Klebs).
a

from

about
hairs.

Myomas of the skin may be grouped according to their origin and appearance,
transitions and combinations.
"admittingthe existence of numerous
We can
distinguish:
of its muscular
elements
I. Myomas springing from the vessel-wall by proliferation
39

610

APPEKTAmmG

TUMOKS

the

with
II.

They

cutis).

{angiomyoma
relation

As

a.

derived

Neoplasms

Besnier)

of

Diffuse,

the
IV.

forms

as

In

myomatosum).

(Virchow);

muscular

deep

the

of

layer

shin

(myome

dartique,

different

to

lead

would

in

relative

finds

in

is

which

of

the

easily

in

and

their

small,

their

latter

in

symptom
in

the

in

perhaps

by

an

the

painf

ulness,

the

(essential

?)

their

permit

mamma

in

as

situation
of

contractility

of

the
the

by

"

diagnosis.

participation

spontaneous

superficial

the

on

subcutaneous,
in

former,

will

hard

or

contractility,

multiple,

especially

seat

gives

origin
soft

to

spontaneous

The

"

mainly

irritated

also

germs.

variable
similar

appear

perhaps
myoma.
but

sarcomas,

and

explanation,
forms,

superficial

the

apparatus

for

of
its

multiple,

misplaced

whose

tumors,

they

sphere,

supposition

in

originate

or

growing

Sometimes

genital

the

growth,

slow

frequency

forms,

superficial

benign,

mistaken

easily

secondarily
slowly

appearance.

the

to

their

elasticity,
The

of

telangiectatic,

polypoid,

be

may

skin

the

are

location

be

might

forms

reach
skin

especially

pachydermia

painful.

case

modes

The

fibromas.

This

latter

the

of

and

lymphangiectodes

elephantiasis

of

which

Myomas

Myomas

nerve

(ganglion

seated.

deeply

dolorosum

naevi

the

Circumscribed.

l.

nerves;

solitary,

tumors.

from

myxomatodes

their

SKIN.

a.

rise

pili

vasculor

multiple

and

tumors

THE

OF

circumscribed

irritable

arrectores

portions

Forming

h.
III.

the

of

AKCHIBLA8T

THE

usually

are

form

they

nerves

Hyperplasias

TO

most

side

of

terminal

the
the

muscular

elements.
which

Myomas
most
return

rationally
after

are

removed

extirpation.

troublesome

by

operation

on

account

with

the

of
knife

their

or

size,
the

location,

or

galvano-cautery,

painfulness
and

are

do

not

EPITHELIOMA

ADENOMA,
NEUROMA,
AND
MOLLUSCUM,
OF

CARCINOMA
SKIN.

THE
BY

E.

PROF.
IN

GEBER,

KLAUSENBERG.

NEUROMA.

develop from

in their

that the term

recommended

ViRCHOW
which

further

the

tissue

nervous

development.

true

be

neuroma

itself,and

are

is therefore

neuroma

appliedonly to

formed
a

those

of this tissue in

neoplasm

nervous

tumors

great part
of hyperplastic

character.
But

thif

definition

does

not

suffice for all

Tumors

cases.

are

frequently found

edly
which, in thoir originand the primary implication of the nervous
tissue,are undoubtbut
which
later
such
of a nervous
character,
a
acquire
fibromatous, myxomatous, or
that scarcelyany of the originaltype remains.
nature
At other times,
tissue which
ble
recognitionof the nervous
yet remains is attended with no inconsiderabe made
that the diagnosiscannot
with certainty.
so
difficulty,
think that Virchow's
should be
we
conception of neuroma
Despitethese objections,
association
order
avoid
the
of
in
to
of
different
kinds
in the
maintained,
growths
strictly
to
It
that
seems
me
a tumor, for example, of a fibrous nature,
same
group as neuromata.
in the same
that we
manner
should be called a neuro-fibroma
speak of osteo-sarcoma,

carcinomatous
the

etc
myosarcoma,
this reason,
For

growths
heteroplastic

we

will

in which

exclude
the

the

nervous

consideration
tissue

I will also exclude

the

plays

of all those
a

subordinate

homoeoplastic and
part.

so-called

scribed
painful tubercles, first dein 1812.
unessential peculiaritiesthat they
Apart from some
by William Wood
chieflyin the neighborhood of the joints of the upper and lower limbs, particularly
occur
that
manifest
cutaneous
themselves
the
smallest
at
vanced
adbranches,
an
they
upon
to
traced
back
earlier
be
but
and
that
the
an
female
sex
period,
age,
may usually
predispositionthe clinical phenomena present such a varietythat we
presentsa marked
For

similar

reasons,

"

"

will sometimes
and

even

of

find the
cavernous

at other times
of fibromata, myomata,
symptoms of neuromaca,
sometimes
angiomata. From an histological
we
can
standpoint,

612

NEUROMA.

in them

discover

entering and

either of
of

connective

other

some

have

it is

we

are

unusual

to make

always able

not

probable

more

that

the

term

in which
differentiated,
sufficiently

been

not

an

of

nerve-

find the appearances

we

ture,
cartilaginousstruc-

represents

event

termed
exclusively

Furthermore, I think

it should

which
group of cases
be permitted to

not

character

be separated

must

plexiforme of Verneuil should also not be

hitherto described, the
neuroma.
regarded
(about twenty-five)
nodular thickenings(in places)
of the hypertrophied,usuallypre-existing
nerve
plexuses
(sympathetic,frontal, and supraorbitalnerves, lumbar, sacral,brachial plexuses,etc.)
imbedded
in proliferatedconnective
when
the latter did not
were
tissue,so that even
form a circumscribed
less penduor
thickened, more
prominent tumor, but a diffusely
lous
fold of skin, its predominance threw the nervous
element
far in the background.
This relation of the two varieties of tissue does not arise graduallyin the course
of development
extent
but
exists
to
certain
the congenitalpredisof the neoplasm,
as
a
soon
as
positions
In largegrowths of this kind, we
manifested.
ourselves that
are
may satisfy
is diffuse and passes insensiblyinto the
in the large proportion of cases
the tumor
it
is
and
then incloses a nucleus
of varying size.
or
circumscribed,
tissue,
neighboring
tumor
is
found
the
is
formed
of
the
it
of
that
sum
plexiform
proliferations
Upon section,
cellular tissue,vessels,glands,etc.)or that it is derived
of the cutis (corium,subcutaneous
immediately from the nerve-fibres,but that the lamellar sheaths of the latter have
that they in part separate the individual
in such a manner
nerve-fibres entirely
proliferated
their total disappearance.
from one another, and in part cause
others have
It is,therefore,not surprisingthat P. Bruns, Czerny, Oartatz, and
and
Winiwarter
and
that
in
found,
developing nerve-fibres,
plexiformneuromata, young
as

the

neuroma

In all the

true

muscle

Iso found

that

(Virchow).

dolorosa

neuromata

diagnosisof painful

correct

represent a speciesof tumor, but the tubercles of reallynervous

and

abundance

neoplasm.

be, therefore,that

It may

tubercles, but

and

nerves

may also be absent, and in these cases

tissue growth, varying from a soft to

fibres;but such appearances

or

emerging

-cells in them.

cases

Winiwarter

has also

these

seen

nodules

neuroma

formed
trans-

into sarcomata.
In

the growths
ojainion,

my

among
Nature
of Neuroma.

and

collected under

the

twigs

of

the

"

nerves

Neuromata

of the

skin

neuroma)
(peripheral
the

or

either

been

mistaken
The

are

more

for small nodules

hyperplasticfibres

on

upon

spinal nerves,

the trunks, branches,

on

their

be

etc.

terminations

(terminal

the

sympathetic.
fascicular neuroma), exceptionally
They are composed usuallyof nerve-fibres (fibrillary,
of ganglion cells (cellular,
ganglionicneuroma). In any event, the latter rarelyoccur
the
peripheralnerves, and it has not been decided hitherto whether they have not
upon

neuroma). They

frequent

occur

should

plexiform neuroma

term

arabum,
fibromata, neuro-fibromata, elephantiasis

divided

of nerve-fibres in

of neuromata

are

on

rare

condition

of irritation.

either medullated

or

non-medullated.

The

apart from their

the result of injury;the latter constitute neuroma
fibrillare amyelinicum.
as
occurrence
all cases, however, both kinds of fibres are
found intermingled,inasmuch
In almost
as
the medullated
fibres represent an advanced
of
of
the
non-medullated
stage
development
constitute

former

neuroma

fibrillare myelinicum

(Virchow)and

are

rare,

fibres.
Both

fist,and
oval

or

varieties grow
are

very slowly,rarely acquire dimensions

usuallysingle. As a rule, they are round, though

spindleshape, with

uniform

or

lobulated

surface.

greater than
some

They

are
are

of
firm

an

child^s

elongated

and

hard

to

614

NEUKOMA.

tion is

engendered by scrofula and phthisis. The large majorityof cases, however, are
to the nerves,
due to direct injuries
such as compression,partialand total section,resection
and ligatureof the nerves, deep-seatedulceration and amputation of the limbs.
The
neuromata
within
few
weeks
is
a
a
after
develop
(if
predisposition
or
present) only
may
the lapseof years, either directly
at the site of injury or at a distance of 1-2 cm.
be

It must
with

the

nidus

form

for the

irritated end

formation

new

of
the

of the

the cicatrix has

it,and is often provided with

by uniting with

nodules

the

that, when

granulations,and

united with
a

that

assumed

Or

(Fig. 75 a).

nerves

cicatrical tissue

in

as

united
intimately

fullyformed, the

fibrous

becomes

nerve

nodule

is intimately

prolongation,which constitutes
the ends of a largenerve
trunk
the amputation neuroma
shown

to form neuroas
Fig. 75 h, and which are united with one another in such a manner
mata
of plexiform appearance.
In exceptionalinstances,I think that amputation neuromata
retraction of the muscles and vessels of the stump.
due to the combined
are
Neuromata
Symptoms, Course, and Termination.
may exist for a long time without
The interference
being noticeable and may not be notablypainful,even
upon pressure.
function is either sensory, motor, trophic,or psychicalin its nature, accordwith nervous
ing

in

"

to the location

of the

peripheralnerves,
are

often

so

chance

severe

disturbances

sensory

to

as

of recovery
The
motor

the

cause

even

patientto

after removal

are

situated with

relative

frequencyon

(hyperaesthesia,
neuralgia,hypaesthesia,
anaesthesia)
is particularly
true
of neuralgia,which
is
lead

miserable

of the tumor,

disturbances, which

existence, and
of the

account

on

presents little

rence.
tendency to recurof paresis,
paralysis,

infrequent,consist
disturbances, in
Trophic
temporary
permanent
of
the
skin, muscles, etc.,may develop either alone
eruptions,atrophy
with

one

or

are

more

contracture.

or

or

both

of the series of disorders

manifestations,I
psychical

the

This

observed.

commonly

most

these

As

tumors.

refer to the remarks

mentioned

under

above.

the head

of

the
or

form

of

in combination

With

regard to the
and will simply
etiology,

of the disease.
periodduring the course
disturbances
of the
depends not alone upon the quality
relation to the neuroma.
affected nerve, but also upon its special
Thus, a tumor situated
will produce varying symptoms accordingas it occupies its whole extent
nerve
on
a mixed
and
also according as the nerve
is situated centrally,
or
or
laterally,
peripherally,
fibres are compressed, stretched, etc.
to a standstill as soon
and come
Neuromata
as
they have reached
grow gradually
situated superficially,
mations
inflamtheir limits,viz.,the size of a child's fist. When
or
injuries
the
in
them
to
rise
similar
from
a
vicinity
inflammatorypropropagated
may give
cess
and they may then lead to cutaneous
or
phlegmonous ulcers and abscesses. More
ing,
softenthe tumors
undergo a retrogressive
metamorphosis, viz. : calcification,
frequently
in consequence
of which they feel like resistant nodules, or
and fattydegeneration,
consistence and become
a myxomatus
cysticif the process occurs
centrally. True
assume
a malignant character.
assumes
never
neuroma
The indications for treatment
Treatment.
depend upon the severityof the symptoms,
No
internal
chance
alone
offers
of successful removal.
but operative
procedure
So-called
will cause
the disappearanceof a neuroma.
remedy or external application
tate
neuromatosis precludes
thQ,idea of removing the tumors
separately. We must also hesiances,
to remove
largeand deep-seatedgrowths, if they do not produce too serious disturbadd

that
The

they may
character

occur

of the

at any
nervous

"

because

In

the

result is often

to
disproportionate

infrequent.
relapses
the
operation,the morbid
performing

also because

are

the

of
severity

the

and
operation,

not

tissue must

be

thoroughly removed,

but the

ADENOMA

it should
entire

much

spared as

tissue

healthy

off from

be

peeled
extirpationor

nerve,

THE

healthy

615

SKIN.

possible.When

as

the

OF

the

resection must

be

If the

performed.

cicatrix

or

may be restored by the new-formed

stitches (catgut)
passed through the ends

portionsof

animals, resected
whether

undecided
than

by

cm.

When

this

with

have

nerve

be done

in

been
In

man.

is little chance

of the

neuromata

interference

can

length,there

in

the

of

become

limbs

only chance.
Unfortunately,however, the
intolerable complaints.
renewed

in which

cases

intolerable

ulceration
function, relapses,

of

nerve

it

of the perineurium. In
but it is
by transplantation,

restored

restoration

laterally,
occupies the
moved
reportion of nerve
fibres which develop

; when

nerve

is small, conduction
in the

is situated

neuroma

portions of the

the excised

part is more

of the statu quo ante.

of their size,pain,
account

on

neighboringtissues,etc.,amputation

offers the

often

inunctions

cold, warmth,
narcotics, electricity,

ADENOMA

Considerations.

General
in various

"

of the

recurrence

Eelief of such

The

OF

stump givesrise to
sought in the use of
belladonna, aconite, hyoscyamus, etc.

of

THE

be

must

SKIN.

of the

glandular organs

of the

in the

growths

conditions

circumstance

integument may

proliferate

independent
they are organs capable of
rudiments
left
function
from
fcetal
life.
If the proliferation
are
or
over
occurs
merely
that
the
cells
in such a manner
and stroma develop togetherinto an indepenglandular
dent
neoplasm, and the tubuli or acini,together with the connective tissue boundary,
retain the typical
glandular structure,it will result in a perfectly
typicaladenoma.
of the skin presentthe same
characteristics with regard to development
Adenomata
and clinical historyas the other glandularformations
of an epithelial
scopical
Micronature.
that the glandular elements
sections show
constitute the greatestpart of the
due to hypertrophyof the cells,adenomata
tumor, and that, apart from those partialtumors
arise in the largemajority of cases
from hyperplasia
of the glandular cells. This
increase of the elements
lead either to a numerical
within
individual
parts of the
may
glands, or to a growth of solid offshoots of varying length and thickness, which push the
If the proliferation
extends
still farther,
surrounding connective tissue before them.
ways,

whether

these

the

become

source

of further

If the offshoots remain

similar formations.

in this condition, they become

tissue,and then atrophy after

The
cells
of

are

of affairs is different when

course

into

converted

it continues

the

obstacles,such
may

thus, for
These

longer or

as
a

secretoryelements.

glandular function

of
impermeability

time, maintain

so

shorter

In this event, the

long

as

of the

by

the

nective
growing con-

period of time.

the offshoots contain

this is not

the duct, closure

the function

detached

central lumen, and

entire tumor

or

prevented by

of its mouth,

etc.

the

portion

mechanical

The

adenoma

gland.

be

sharply circumscribed, and appear encapsulatedand usually

present a tendency to ulceration,relapse,and
of prodegeneration. The consistence is moderately firm, varying with the amount
liferated
in any
epithelium,and the size varies from a nut to a fist. They may occur
part of the body, but usually in those situations in which the correspondingmother
gland is generallyfound.
A permanent or temporary standstill in the growth of the adenoma
at
occur
may
tumors

may

pedunculated,or they may

any

its

time, often without

own

further

any

be diffuse and

known

enlargement by

cause.

the

Sometimes

peculiarityof

the
its

tumor
presents obstacles
inasmuch
as
proliferation,

to

the

616

ADENOMA

stroma,

either

massive

wall around

OF

THE

SKIN.

of

account

a
specialtendency or a reactive inflammation, forms a.
glandularportion,and thus prevents its spread in all directions.
remain
almost unchanged in the body for whole decades.
tumors
Such
may
More
in the tissue of the adenoma
frequently,however, retrogressive
changes occur
These
manifested
after its growth is checked.
are
tion
changes
macroscopicallyby diminuexamination
of size,changed consistence,color,etc.
Microscopical
usuallyshows a
on

the

in the size and

diminution

of the cellular elements, and

number

fatty,etc.). But none

(hyaline,colloid, mucous,
form, both on account
greaterconsideration than the cystic
If the

extent.

or

are

collected and
or

one

the

secreted

if morbid

products,such

the walls

Adenomata
result.

degeneration of

changes deserve
frequencyand

of its relative
the

offshoots

be discharged,

cannot

secretion,epithelium cells,etc.,'

cyst is graduallyformed, which

latter event, is often converted

into

contains

singlecavityby

septa (cysto-adenoma).

the

nutritive disturbances,
give rise to severe
far
towards
the surface of the
so
pushed

this receives insufficient nourishment

degenerationof the tumor will soon

cannot
easilybleedinggranulations,

be

on

produced.

Such

account

of

impairedcirculation,

ulcerations,when

covered

with,

readilydistinguishedfrom carcinoma.
into another varietyof tumor
is observed usually
of an adenomatous
The conversion
have
been
time
and
existed
for
which
have
a
steadilygrowing. At times
those
long
influence
other constitutional influence;
causative
the
or
able to demonstrate
irritating
are
at other

on

of

one

or

may also grow uninterruptedlyfrom the start,and thus very largetumors

all sorts of local disturbances, and by the uninterTheir mere
size may cause
rupted

integumentthat

we

gland

thick, mucous

pressure on the neighboringtissues may

If they have
to erosion of the bones, etc.

even

in

as

lose their tonus,

cavities,and, in the

more

of
disajjpearance

may

of the

contents

also

of these

sort

some

times

we

be

with

resistance
assumptionof a diminished
to the degeneration
thereby induced predisposition

be content

must

the part of the organism and

as
we
question. Insufficiently

the

discontinues
its previous
explainwhy an adenoma
become
our
irregularly
arranged and increased
should
the
when
elements
still
we
ask,
becomes
more
why
epithelium
palpable
ignorance
at one
time, the connective tissue elements at another time, undergo this or that change into
in

and
regularity

carcinoma,

glandularelements

the

fortunatelyrare

these

Eelapses may

course.

"

etc. ?

myxoma,

sarcoma,

Apart from

can

after

occur

terminations, adenoma

usuallypursues

favorable

but they are always of

imperfectextirpation,

local

nature.

Adenoma
It may

of the skin is

doubts its occurrence.

even
comparativelyrare and Virchow
the former.
sweat
more
or
frequently
glands,

affect either the sebaceous

1.

These

tumors

are

Gland

Sebaceous
found

Tumor

or

Adenoma

either in the walls of sebaceous

Sebaceum.
and

character

dermoid

cysts,or

they

during their subsequent

an
independent
develop primarilyand then
ous
sebacewill now
which
consider, may be found wherever
The latter variety,
we
course.
often
which
are
and largeglands,
numerous
glands occur, but chieflywhere relatively
back, etc.),are congregated.
nose,
injuries(scalp,
subjectto mechanical
in
though Eobin observed such a case on
is
found
The
a
singlegland,
origin rarely
more
or
parts of the body undergo
the labia.
As a rule, whole sections of glands in one

maintain

the

hyperplastic
process.

positior
.

This

renders

probablethe assumption of

congenitalpredis-

ADENOMA

The

increase of the

start from

OF

THE

617

SKIN.

of its elements, may

glandularsubstance, usuallyby proliferation

any part and, as I have

take
; the originmay

noticed, does

not

require that

the

gland

be

capable
a
glands
place
of the offshoots it must
colloid degeneration. With
or
regard to the further course
be mentioned
that they often persistfor a long time as solid,epithelioidal
projections
here and there with pearlyglobules,
until,after continued proliferation,
an
interspersed
and
the
of
cells
offshoot
number
sebaceous
the
assumes
gradually
develop
increasing
of function

character

of the mother

Sebaceous

which

in

in

are

condition of cystic

structure.

adenomata

vary

greatlyin

size.

It is not

to find them

rare

as

largeas

,.."''""

76." Transverse

section

\,
Fig.

(zricroscopical) of

sebaceous

gland

Oc. No.

adenoma.

1,

Obj.

No.

2, tube

drawn

out

(Verickj.

reportedlargerthan the size of a fist. If the tumor

raised and
started in superficial
glands,the general integument will be irregularly
diminishes
a papillaryor
This
of
the
surface
assume
nodular
irregularity
appearance.
with the progress of the proliferation.The
able
shape of the tumor itself is extremely varition.
and the growth may even
into the neighboring tissues as a diffuse infiltraextend
On
account
of the predominance of sebaceous
cells in these tumors, they have a
white
yellowish
or
dirty yellowishbrown color and are moderately firm to the feel. If
pea
has

the
of

or

hazelnut

stroma

some

is very rich

have

been

in connective

tissue,the consistence

those which
cartilage. In the smaller ones, especially
moderately long hairs or lanugo may protrude from the
but disappearin the further course
of development.

have

may

increase

developed

dilated

mouths

even

in

to that

hairy parts,

of the follicles,

618

ADENOMA

lateral pressure,

Upon

OF

THE

SKIN.

comedo-like

of the
fattyplugs may be squeezed out of some
from
others.
So much
more
epidermisemerge
importance
should be attached to the possibility
of removing such contents
since expeof the tumor
rience
teaches that neither shape, size, color nor
sufficient to jiermita
consistence
are
above may first lead us to a recognitionof sebaceous
diagnosisand the feature mentioned

ducts, while

of

dry clumps

adenoma.
cross-section

Upon
viz.: the
acinous

structure

glance,two kinds of tissue,

yellowishand presents an

may often recognize,at the first

is
connective
tissue.
The
former

we

glandular and
; the

latter is darker

and

sends

septa of various

thickness

into

the

former, dividingit into largerand smaller lobules.

In the

adjoining figure,the
It is also evident

their

parts(lobulesof

and

each

the

1 to 6

acinous

of the

structure

is formed

that

the tumor

mm.

that
diameter),

of

the skin, and

of the skin.

those which

are

normally formed

The

has

acinus

each

little group
of terminal
vesicles.
number
a
smaller
situated deep in
cells (the majority) are

portion of

takable.
glandular substance is unmissmaller
and
larger
glands and

It

basement

will also be

the

corium

or

membrane,
noticed
the

that

reticular

markedlyhypertrophiedoccupy

the entire thickness

generalintegument

the

passes

over

highestpart

of the tumor.

Fig.

Under
membrana

largerand

largedrops,
"cellsand

Part of

an

adenoma

Oc.

sebaceum.

No.

2, Object.

No.

(Verick),

within

the

(Fig.77) it is found that the cells immediately

become
and as they approach the centre
propriaare compressed laterally,
the
in
i.
borhood
neighthe
Around
centre,
e.,
presenta marked granularcloudiness.
higher

of the lumen

carbonate

77."

and

powers

into
of the excretory duct, the fat in the cells is often accumulated
with
there together
are
deposited
cholesterin and margarin crystals

large

of lime.

The

contains normal

interlobular

connective

blood-vessels.

Bock

spotswith small
neighboringsweat

tissue is infiltrated in

found

no

changes in

the

ADENOMA

this I

glands,and

atrophy or degeneration.
of
So long as adenomata
For

their extent.

from

this

small tumors

reason

found

Broca

glandsexist

the sebaceous

619

SKIN.

THE

and

; Porta

corroborate

can

OF

as

the

such, they

exist for

may

glandsin
are

of

noticeable

only

without

being

long time

condition

the largerones
and even
only on account of their pressure
give rise to annoyance
take the first step in an
and the feelingof weight. The tumors
surrounding
parts
upon
and become
diffuse.
If they
to be circumscribed
when
unfavorable
course
they cease
retain the glandularcharacter,the danger consists in the fact that they often attain very
and can be removed, therefore,with so much
dimensions
more
considerable
difficulty.
noticed

Moreover,

the

a|pply of

of the

of the excessive increase

account

on

proves insufficient and is thus

all else is the fact that the adenoma,

tumor

important than

the

converted into

growth becomes

of

to the

absolutelynecessary

and

of

source

account

on

irritants

degeneration. But more

of its tendency'to prolif-

that, inasmuch

in
proliferate

tumor
atypical

an

existence

The

etc.

sarcoma,

not

membrane

the basement

through

cells break

and

forsakes the physiological

plan of structure
"eration,

nutritive

elements, the
epithelioidal

as

the

epithelium

unrestrained

an

manner,

of

malignant character, into

long-continued ulceration is

or

metamorphosis

of the

cinoma,
car-

fore
there-

tumor, for example into

carcinoma.

If
for

reason

they

should be removed, therefore,merely as a matter of precaution.

constitute a further
circumscribed, the local disturbances

adenomata

Small sebaceous
are

largebut

extirpation.Diffuse growths should alwaysbe

to their

possible,without any regard

Vienna
as
paste,Oanquoin^sor
even
Kelapses cannot always be guardedagainst,
as

first called

Lebert

phied sudoriparousglands.
since,from

clinical

regard
microscopicalexamination
in discussingthe
show
doubts

with

the

regard

found

in the

been

existence

the

cranial bones.

may

of this form

slow

growth.

childhood.

requirea

They

Their

are

shorter

more

On

of the

account

periodto

frequent in

consistence,which

is harder

their location ; the largesize which

conditions.
the result of anatomical
These

The

tumors

have

dirty grayish white

cut surfaces look somewhat

discloses
filledwith

tubuli

similar

like those
to

bud-like
epithelium,

those

become

older

probablyto
as

be

formed
be

by hypertrocloselycriticised,

we

wish

of tumor, in view

in any part of the

Thierfelder found

of the

thus

situation and

successful.

glomiforme.

varietyshould

will
to

of the

they have

of this kind

more

are

that of sebaceous

they usuallyattain
color

but

tumor

corium

but
individuals,

than

body,

marked
twisting
(thus simulating a
their starting
point in this
their relatively
noticeable,despite

normally

gland in the deepest layers of the

have
small, sphericalglandular body),sweat gland tumors

of the blind end

degeneration.
not

reported.

glands may occur

in
the
face,neck, and back.
chiefly

diploe of

tumor

oughly
thor-

as

results,as
entirelyunsatisfactory
diagnosis. But we do not, by any means,

of the sweat

Adenomata

this

signsof

paste,etc., are
greatestof care.
s.

and

soon

furnishes

to the

have

fact that

as

clusions
possess too few data, as a rule,to draw any safe conof the growth. We
must
also admit that even
a

quiteoften
differential

the

removed
to the

sudoHparum

diagnosisof

character

convey any
which
authentic descriptions

been

the

But

standpoint,we
to

with

to the

attention

with

Adenoma

Sweat-glandTumor,

or

Landolf's

Caustics, such

II.

size

and

an

must

also

met

with

adenomata,
also be

nodular
irregular

in

is due

regarded
surface.

of the mammary

ination
glands. Microscopicalexamoccurring normally, and also solid prolongations

offshoots,which

are

isolated or pass in

an

irregular

620

ADENOMA

examination

of those

is dilated

lumen

The

the stroma.

through

manner

increase

of the

tumor.

Observation

are

lining epithelium,but

that

that this is due

shows

SKES".

pushed

capable of

threefold, and

or

those in process of development.

As a rule, sweat gland adenomata

and

THE

latter has been

which

ducts

twofold

OF

that

into the

secretion
their

this stands

background.

will convince

dimensions

in

to the increase

relation

no

in the

us

have

Careful

that

their

increased

by-

to the size of the

newly developed tubuli

favorable

and usuallygive rise to

course,
produced locallyby their size. In one case
reported by
to
account
the
of
the
and peron
severe
extirpate
growth
Hoggan, it became
necessary
sistent
the
nerves.
on
adjacent
pains produced by pressure
The
tumors
frequently
very rarelyundergo degenerationspontaneously,but more
the result of injury. Before this occurs, the previouslynormal tegumentary coveringo
the tumor
is traversed by dilated vessels,assumes
a livid red color and
gradually grows
at the point of least resistance,
and the escapthinner.
occurs
Finallya small perforation
ing
secretion
dries
into
crust.
If
the
a
continues,
slightly
serous,
purulent
process
very
the spot of degenerationbecomes
larger,the secretion purulent and an ulcer is produced
This ulcer presentslittle tendency to recovery,
with undermined
base.
edges and uneven
in blood supply. The
rather its insufficiency
structure
account of its epithelioidal
or
on
ulceration,therefore, lasts a long time, but eventuallyheals and only rarelyis it converted
into a malignant neoplasm.
forms of retrogressive
change undergone by these adenomata,
Among the numerous
of its frequency.
account
the development of cystsdeserves mention
on
of
the
In this process the epithelial
lining
glandular tubuli is converted into a
mucoid
fluid,which is retained and dilates the surrounding walls. The tumors
may exist
unchanged for years, and, as a rule, are only discovered by accident.
with considerable
is attended
The diagnosisof this varietyof adenoma
occasionally
their
in
differences
of
the
and of the
this
is
think
the
I
and
cause
description,
difficulty,
Thus
Fuehrer's
tumors.
of
and
kinds
other
for
fact that they are mistaken
descriptions
(molluscum
reallyexamples of epithelioma molluscum
figuresshow that his cases were
contagiosum, Bateman). Lotzbeck's descriptionwould lead us to infer that his case was

except those

disturbances

no

of

one

vasculosus.

naevus

But

the
the

present in
In

be exercised

greatestcaution must
to mistake
is
liability

each

case

pursue

blow, upon

of

fist.

in

this growth
differentiating

greaterbecause

the

a
sudoripar.,

tumor

from

tissue elements

same

cinoma;
car-

are

disease.
Domec

reportedby

of

so

much

After

the back

of

as

adenoma

girlsixteen years old, and

attemptsto remove

several unsuccessful

within

developed,as
a

it without

month

attained

In order to avoid such

the clinical factors,but

errors,

should

we

should

also direct

not
our

the size

operation,the growth

and attained the size of a child's head at the end

but returned
extirpated,
after
months;
being again removed, it resulted in death from cachexia due
was

the result

of several
to

tasis.
metas-

alone take into careful consideration

all

tion,
attention, in the microscopicalexamina-

well as to the central parts

as
recentlydeveloped parts of the tumor
taken
its starting-point.Offshoots of the sweat-glands
may be readilymiswhich
considered
the
were
formerly
for carcinoma, especially
as
pearlyglobules,
in adenoma; often, also,only isolated
characteristic
of carcinoma, may also be found
parts of the microscopicalpreparation reveal the malignant character of the growth by
to

which

the most

have

the absence

formed

of the membrana

of the elements,
proliferation
propria,the atypical

etc.

622

ADENOMA

always
the

detach

easy to

the

which
projections

OF

deposit from
into the

extend

THE

BKIN.

For, inasmuch

its base.

interior of the tumor,

as

forms

it is connected

slowly and

with

becomes

dry and brittle from contact with the air,it often becomes very difficult to detach little
it has a pultaceous crumbly consistence, and
pieces. When
present in greater amount
is detached
be readilyremoved
or
can
spontaneously. In this stage,the surface of epithelioma
molluscum
contain
a single,
trough-shaped depression,attainingthe size
may
of a pea at times, with sharp,irregularedges ; it is often situated centrallyand has been
the lumen
of a sebaceous
as
regarded by some
gland. Or it possesses several openings,
which
look as if produced by the point of a needle, and appear to correspond to prolongations
that have dropped out.
of medium
size,
Upon observing the borders of a tumor
we
readilydetect an aggregationof individual little nodules like those described above, so
is due
not alone to the inthat the impression is gained that the increase of the tumor
crease
in the originalsite,but in part to the addition of new
of the elements
individuals.
In this way the shape of the growth changes constantlybut, on
the average, the fully
developed nodules are rounded, moderately retracted at the base, and present, upon the
umbilication

surface, an
nodules

have

which

has

color from

been
the

in

formed

the

vessels which

described

manner

shine

above.

The

the walls, and

are
through
pale
of
the
tension
of
the
account
them.
shining on
epidermis covering
With
regard to the size of this growth, I may state that in my case of general epithelioma
in width, 1.8 cm.
in length,
1.5 cm.
molluscum, a growth on the penis measured
and 0.5 cm.
in height, and weighed 0.5 gm. immediately after removal.
But such large
growths are exceptionaland, as a rule, they do not exceed the size of a pea.
of the hairy parts of the body deserves specialconsideration.
Epithelioma molluscum
In the majority of cases
hairs are present only on the extreme
like
periphery of the noduleif
the
nodules
had
neoplasms, so that a casual glance conveys the impression as
this is not
the case
selected sites between
the hairs.
But
disappear
; the hairs do not
hand ; they persistif the walls of the follicles
until the proliferation
has obtained the upper
a

rose

somewhat

protectedfrom

are

After

the tumors

this condition

comes

pulpy
into

becomes

contents

are

view.

Such

Another
the

termination

growth.

In

reached

long period

the tubercle

occurs,

the

for

its inroads.

have

the

(a few

flaccid and

height of
months

their

to

one

retracted, and

development, they may

two years). When
or
upon

remain

in

involution

lateral
exercising

pressure,

longer extruded, but the readilybleeding papillary body

lence.
viogrowths usually drop off upon the slightestmechanical

no

finallydestruction of
nally;
inflammatory stage,nothing is noticeable exter-

consists of inflammation, ulceration, and

the

of the

beginning
consistent pap to exude from the umbilicati on
a milky fluid or
At a
Pressure
to the feel.
is bright red, oedematous, and warmer
discharges a sanguinolent,sero-purulent fluid, containing blood., pus, and molluscum
is
losses'of substance
and
corpuscles. Then
gradually increase until the tumor
occur,
cicatrix.
a
small,
irregular,
quite superficial
entirelydestroyed,leaving
is readilyrecognized; it might only
diagnosis. Epithelioma molluscum
Differential
luscum
for
lichen
be mistaken
pilaris
condyloma acuminatum, and mol(which is not persistent),
for condyloma when
will only be mistaken
fibrosum.
Epithelioma molluscum
has an
is devoid of its external deposit and
the base of the umbilication
the former
if we
is
not
It
it
from
molluscum
fibrosum
to
difficult
uneven
distinguish
appearance.
but

pressure causes
later stage the tumor

"

remember

that its surface

is

even

and

its consistence

increased.

But

the most

positive

is found

evidence
diagnostic

Anatomy.
discloses
Thin

contain

which

contents

"

whitish

the

naked

shining,lobulated

always

pressure

section
eye a transverse
imbedded
in
substance

of

section

through

tion of infiltration cells which

changes
In

affect the

the

send

are

pap-like

epitheliomamolluscum

epithelioma

aa

scattered

molluscum

through

in process

tissue stroma.

that, with the excep-

development.

of

the connective tissue,the

principal

rete.
interpapillary

are
beginningits papillae

and

expresses

connective

sections of partsin the initial stage of the disease demonstrate

FiGt. 78." Vertical

cones

lateral

corpuscles.

molluscum
to

Even

fact that

in the

62a

SKIN.

THE

OF

ADENOMA

of
proliferation

off offshoots

{h).

On

their

all dimensions

increased

in

elements

(Fig.78, a).

account

of this formation

of

At

on
a

account
later

offshoots

on

of the

stage,the
the

one

largement
en-

rete
hand

sible
enlargedsize of the individual parts on the other hand, it is often almost imposto distinguishthe startingpoints of the proliferation
(Fig. 79). "We may justly
conclude, therefore, that the lobular structure of the growth is due to the peculiar
of proliferation
and not to a falselyassumed
manner
glandular structure.
to have
found
of
cells
all
the
The
are
layersof the changed rete prolongations
liferated
proat
and increased in size,and to a certain extent arrive prematurely
maturity.
In addition molluscum
corpusclesare present,and these are often found to begin even in
the lowest layerof cylindrical
cells. In the lowermost
or less
part of the rete they are more
frequently,at one side. In
granular,and may contain a nucleus in the centre or, more
the upper prickle-cell
layer,they have a compact, homogeneous appearance, and a partly
fatty,partlymother-of-pearl
transparentand
gloss. In the horny layer,they are more
and

the

their contents

more

delicate.

Virchow, Klebs, Thin, and others, have

in

origin.

origin,but
But

while

corpusclesas parasitic
regarded the molluscum
majority of observers believe them to be of purely epithelioid
Eokitansky,Hebra, Kaposi interpretthem as parts of the sebaceous
the

624

ADENOMA

OF

THE

SKIN.

I have

cells.

colloid

what

manner

believes that

Barensprung
fluid.

that

doubt

no

questionis, in

the

latter view

are

the

root sheaths, Lukomsky,

the

glands,Vircllow and Thin regard them as derivatives of

of the wandering cells,and
Bizzozero, C. Boeck, etc.,as

products

is correct,and

rete cells converted

the

at

into

of the

altered rete

present time, the

corpuscles?

molluscum

of an imbibition of
theydevelopfrom the cells by means
due
to
they are
amyloid degeneration,and E. Yidal

Auspitzthinks

noid
albumiassumes

degeneration.

corpusclesarise
expressed the opinion that the molluscum
years ago, Eenaut
he
atypicalcornification of the rete cells. During his microscopicalexaminations

Some
from

noticed

that

process

of stratification of the

startingfrom

protoplasm occurs,

the

peri-

_^
Fig.

nucleolar

parts of

79." Vertical

the rete

section through

cells.

Eenaut

fully developed

found

that

epiuichoina

in the
into

nioxluscum.

beginning of the process an

a
hyaline metamorphosis of

first changes
is formed, which
finallyinto complete cornification.
I have become
results.
have not led to the same
microchemical
investigations
My own
terruptedly
and uninof the altered rete cells pass directly
convinced that the largernumber

eleidin-like
the cell

substance

body

and

into the condition

and
of cornification,

that

smaller

number

are

converted

changed into a
cloudy,granular
corpuscles,after
external part
of
the
zone
Only a narrow
homogeneous, transparent,hyaline substance.
The
fullydeveloped molluscum
of the body of the cell undergoes cornification.
corpusinto

molluscum

their

contents

have

ADENOMA

'cles consist,therefore,of two

THE

OF

625

SKIN.

substances,viz.,a central hyalineand

toid
keraperipheral

substance.
In

Etiology.
"

of the fact that

view

seven

among

family,and two
sufPeringfrom molluscum

of the

children

were

by Bateman, three
family,and that the

observed

cases

in this

servants

were

same

acquiredthe disease in the face from

was
contagious. Similar cases were also
At a later period,the assumptionof the contagious
reported by Carswell and J. Thomson.
after
character of the growth fell into discredit,but again received corroboration
clinical observations
of infection and successful inoculation
ported,
experiments had been rebodies
and the molluscum
as
or
were
regarded
foreign
phytoparasites.
corpuscles
which have led me, with the large majorityof dermatologists,
those reasons
I will now
adduce
the
nature
of
m
olluscum.
to deny
contagious
epithelioma
ward
In the first place,I consider as insufficient the proofswhich have been brought forof the genuinenessof the results of inoculation.
Thus, Eetzius narrates that no
mother

of

child

contact, this writer concluded

result had

two

months

after Inoculation, and

later,in the form

months

the

of

comedo

that this did not

which

; its contents
observation,which

of molluscum

found

until

occur

graduallyassumed

and

more

to contain

cum
mollus-

peculiarappearance
be explained
in accordance
can
corpuscles. This singleauthentic
with our views, is opposed by a largenumber
of negativeresults.
It has also been regarded as proof of contagion that several children of the same
family and those individuals who live in close contact,are often affected with the disease.
I will go even
further and mention
that public women
often presentthese tumors
on
responding
corof
the
parts
body.
With regard to the first point I will recall that children were
almost always attacked
when
occurred in one
But
know
with
several cases
we
family.
regard to the integument
more

obtained

been

at least three

also

that the affection

that it not alone reacts more

of the young
the remains of the foetal condition, it is

were

to irritants,
but that, on
vigorously

account

of

of the horny substance

predisposedto proliferations
and accordinglyof the epidermis. In my opinion,therefore,the fact that several
children of the same
is due mainly to the
family are attacked by epithelioma molluscum
in
them
formations.
of
the
to
tendency
integument
epidermoidal
The following
statistics have been gatheredby me
in a year and a half: Among 576
I observed

men

excluded

the molluscum

who

had

21

times, among

313

36 times.

women

If those females

of molluscum
20 cases
190
genitalaffection,there were
among
there were
consider only the professional
prostitutes,
116 females (16.65^).
the percentage was
19 cases
only 3,8. It is
Among men
among
that
this
molluscum
would
exist,
were
probable
epithelioma
great
scarcely
disproportion
contagious.
tated
Facts like these have led me
to believe that the disease developspreferablyupon irriof the skin.
Hebra
reports a case of prurigo in a boy, whose body presented
portions
several molluscum
and Schedel describe a
Cazenave
growths as large as a hazel-nut.
of the growths upon a patientsuffering
number
from prurigosenilis (?). Cases of similar
import have been observed by Kaposi and myself.
are

If, among

women.

From
molluscum
and

no

the latter,we

all these various considerations

is not found
that in

in

must

we

contagion,but in

considerable

number

of

cases

"

40

"

It is unnecessary

to

use

cause

of

epithelioma

of the rete cells to

predisposition
local irritants act

for
Prognosis. The disease has no serious significance
growthsdevelop upon visible parts of the body.
Treatment.

that the

conclude

any

as

tion,
prolifera-

causes.
exciting

the individual,unless

strong local

or

general remedial

ous
numer-

agent.

626

CANCEK

The
to

best

of treatment

means

dischargeits contents

and

OF

Historical.

The

"

Hippocrates.

the
discarding
of

one

lymph

Boerhave's

labors,first

gave

the

in order

away.

(CARCINOMA

CUTIS).

bile constituted

by
experiments

his

the way

had been recognizedas earlyas the time

give descriptionsof the disease. Boerhave,

also

rise to

pupils,by

pointed out

SKIN

to the tumor

pressure

of carcinoma

Galen

and

old view that

believed that the

THE

existence

Celsus

of
application

it to dwindle

cause

OF

(cAECINOMACUTIs).

SKLN"

is the lateral
thus

CANCER

of

THE

cancer

the

means

materia
peccans
of fermentation.

of the

disease,
Haller,

Albert

and

numerous
anatomo-physiological
of the growth and development
investigation

for the

of carcinoma.
In 1816
which

Laennec

divided neoplasms into two categories,

the first includingthose
tunaeurs
from
analogue in the natural tissues,
homologues,as distinguished
heterologues. The latter included carcinoma, which was distinguishedfrom
by the primary difference in the elementaryconstituents.

have

tumeurs

scirrhus
But

an

it

and

not

shown

was

that scirrhus

in the
infrequently
Cruveilhier

elements, i. e.,

that tumors

mentioned

was

should

absent.

of the
not

carcinoma
or

proposed that

to the presence

conclusion

and

same

be

organ
attention

often found

are

tissue.
should

To

be directed

juice. But
regarded as cancerous

this led

cancer

Clinicians therefore

in the

harmonize

when

to the

most

to
necessarily

the

restricted themselves

same

to

ual
individ-

this apparent

tradiction,
con-

primary
the false

intercellular fluid
clinical view

of the

disease and

regarded it as a tissue degeneration.

the other hand, pursued a different course.
on
Pathologists,
According to Johann
Mueller, carcinoma is neither a heteromorphousnor a heterologousstructure; its fundamental
character is found in the fact that the germinal cells do not arise
histological
from previouslydeveloped fibres,
but from a true seminium
morbi, which forms between
the cells of the tissue.
Some

Cancer

wished
pathologists

is therefore

constitutional

to retain the

disease.

not in
homologous and heterologous,
sense
regardto the formed elements, so that
with malignant. Lebert goes
homologousbecame identical with benign and heterologous
further and divides all tumors
into homoeomorphous and heteromorphous,
the latter
even
since this contains elements which
of cancer
have no analogue in
consisting
exclusively
the human
in favor of the
has been the most aggressive
organism. Adolph Hannover
existence of a peculiarvarietyof cells (so-called
cancer-cell).
But the existence of a specific
cancer-cell was
not generallyadmitted.
ical
MicroscopLaennec's

with regard to the tissue,but with

examinations
those of cancer,

showed

that

consist in

may
elementary constituents

to

tumors, whose

greatpart of

Lebert's

cancroid

generallybelieved that
their small amount
tissue

terms

clinical characteristics

and
epithelium,
and

Hannover's

carcinoma
possesses a
of intercellular fluid are free in cavities formed
the

alveoli of the

Foerster).It

undoubtedly

equivalentin
:epithelioma. It was

definite structure, and

(stroma),
analogous to

were

thus

are

their
also

that the cells with

nective
by the vascular conlungs (Kokitansky,Virchow,
cells originated
from a specific

remained
of disputewhether the
a matter
which
had
(Eokitansky,Virchow) or were
produced from epithelial
germs
no
epithelium. Virchow and Foerster also
strayedeven into placespossessingabsolutely
precisedefinition of cancroid,the characteristic of which they believed to
gave a more
blastema

consist in localized accumulations

of

ceUs
epidermoidal

within

alveoli of the

tissue.
\

diseased

CANCER

A change of

THE

OF

in 1855, when

opinionfollowed

63T

(CABCINOMACDTIS).

SKIN

Virchow

proved that

the

epidermoidcells

in general
character.
its
distinguished
by
epithelial
a
of primary cancer
are
not long undisputed. Although cases
But both opinionswere
Remak
followers
of
the
which
observed in situations in
normally no epithelium exists,
and His' exclusive theory of the germinal layersfound sufficient support for the view that
in the belief
of such a carcinoma
the elements
developed from pre-existing
epithelium,
in such situations since the
lain stationary
or
that epitheliumcells may have wandered

connective

of cancroid

the

is

tumor

developed from
sharplydefined form of

embryonic period.
A compromise
and

these

between

origin(E. Neumann,
epithelioidal
Many clinicians
the
relied chiefly
on
in the

for the

validityof
never

fibrous
alveolar

find such

Even

tissue.
sarcoma

"

in

may

number

of

pathologists

be of desmoidal

as

well

as

Perls, E. Wagner, Langhans, etc.).

the results of histological,
examinations, and
But

of the disease.

part,are

the distinction

by

dissatisfied with

course

most

made

was

cells of carcinoma

relations of desmoidal
histological

which,

we

were

views

extreme

asserted that the

clinicians,who

tissue,and stated that carcinoma

made

distinct

and

mistaken

for

by Virchow.
separationof

there

In
the

in endothelioma, in which
which

the

roundish

are

such

tumors
epithelioidal
one
another) that

cells

tumors

cells
the
are

of the

characteristic

(forthese
we

must

differences

are

the

believe

connective

tissue

(round or spindlecells)from

type,
the

plates,and in
compressed
epithelium-like,

cells form
often

ones

in the

veritable

the space
againstone
in a connective tissue stroma
left by the removal of the cells. Epithelialproliferations
presentan entirelydifferent appearance, and constitute a foreigncolony which flourishes
at the expense
of surrounding parts.
furnished absolute distinctions,we
pense
If the clinical phenomena of cancer
might diswith the aid of the microscope,but this is not the case.
Among all the symptoms
there is not a singleone, much
of cancer,
less a group of symptoms, which is pathognomonic.
I do not hesitate to admit, however, that the well-known
subjectiveand objective
symptoms are often sufficient to enable us to form a diagnosis.
as
an
atypical,
regard carcinoma
Definition.I believe, therefore, that we must
neoplasm with a predominantlymalignant course, which develops as the
epithelioidal
result of local disturbances;when
the disease spreads,it produces a change in surrounding
tissues comparable to inflammation, secondary infiltration of the adjacentlymphatic
glands,metastatic nodules in the most various organs and tissues,and finally
produces a
cachexia as the result of all these changes.
in a positionto produce carcinoma
do
as
we
Etiology. If we were
experimentally
conclusions regardinflammation, nothing would be easier than to arrive at satisfactory
ing
its origin. But the observation of its initial stage and progressive
spread is attended
with great difficulty,
the cancerous
is
chronic
and
as
a
process
very gradual one.
since
struck
Clinicians, particularly
were
long
by the often multiple
surgeons,
the
after earlyand careful extirpation,
great tendencyto recurrence,
even
occurrence,
and the heredityof carcinoma.
These features were
ous
explained,accordingly,by a cancerblastema.
a specific
ble
dyscrasia,
Only in cases in which local irritants were demonstraimmediate
of the new
as
predecessors
growth,the therebyresultinghyperaemiawas
supposed to have caused the exudation of the cystoblastema(J.Vogel).
In opposition
to this view, the largemajority of pathologists
and a no
small proportion
clinicians regard cancer
of German
In the first place,
as
a local affection.
originally
neither local nor
of the disease nor
its hereditary
involves the
nature
generalrecurrence
another

"

"

"

thin, brushed

sections show

that delicate fibrillsetraverse

"628

GANGES

necessityof
"dependupon
etc., which

OF

THE

SKIK

its constitutional

of a tumor
not
would
origin,for otherwise the return
repulullationof the tissue and the transportationof the morbific agent,
opposed by our other experience. With regard to the heredity of cancer,

the
is

it is well known

that not

the condition
local

(gAKCINOMA CUTIs).

"

of

alone

constitutional

conditions, but

hairs,nails,etc., may

the

originof the disease is testified to

by

the fact that

one
system, that
organ or anatomical
irritative conditions, and that all sorts of

local
strictly
into
A

nature

review

of the

origin
develop ?

agent

of

do

the skin,

hand, the

fibromata, etc.

be

may

"

verted
con-

it

look

we

believed

was

will lead

con.,

influence

nervous

is destitute

to decide

us

what

is, under

questionnow

that

this view

but

with

further

in favor

conditions

certain

played a

of

tne

does

it

part in the

of foundation.

favor

is due to the entrance

of an
the view that cancer
upon
in the form of a contagion,miasm, or any other specific
it is opposed to all experience that a ferment-like
stance
increasingsub-

the outside, whether

from

infectious

The

of cancer,

pro and

adduced

reasons

cancer.

time

some

development
Xor

other

it

cicatrices,
warts, adenomata,

as

color of

the

cancer.

local

For

such

"

On

usuallydevelopssingly,or, if
its development is often attributable to
of a
hypertrophic tissues and tumors

multiple,in
local

the

even

inherited.

also be

For

matter.

should

into an
amount
develop at the point of entrance
diffuse until certo the senses, that being depositedthere it does not become
tain
appreciable
local conditions have been fulfilled,
and that its product, carried into another
ism,
organis not as certain in its effects as the originalmatter.
Numerous
negative results
have

obtained

been

0.

reported.

of introduction.
of

found

Gujon

cancer

dog ^nd

made

inside

the

after the

to

experiments, and

that

two

introduced

were

developed upon
months

in inoculation

Weber

the skin of

under

in order

requireyears

of

cat, gave

under

but

three

the

successful

encephaloid

rise to

similar

experiments.

successful

the

experiment.

inoculation, twenty-fivedays

a
a

quantity of

In

death

showed

guinea pig
the experiment.

after

of
a

the

white

the

point

rat, in which

ticles
par-

large as an almond
animal
taking place two
nodule

at

occurrence

of the
proliferation

elements

the
of

site of

the

new

introduced

explainedby the continuous

or
a proliferation
per contiguum.
Another
hypothesis consists in the assumption that all kinds of mechanical, thermal,
Thus,
chemical, and other irritants,if active for a long time, may
produce cancer.
lactation
of
is
received
to
carcinoma
attributed
the
cancer
during
injuries
;
mammary
the lip to the action of the mouth
end of the article used in smoking, or to the irritating
in tobacco.
substances
contained
Pott, Earl Sr., and Desault noticed during the last
growths

may

with

mass

the

century that

be

the

as

cancerous

But

been

duced
tissue, intro-

at
proliferation

skin, a carcinoma

sternum, the

have

ones

cancerous

of tissue

cancer

of the scrotum, Which

almost

occurs

in chimney
exclusively

sweeps,

uninterruptedlyat the trade for a long

only in those who have continued
of the
time.
Eecently J. Bell, Manouvriez, and Tillmans have reported cases of cancer
testis as a result of the action of paraffinvapors and in these patientstar acne
eruptions
also present.
were
If we add that all kinds of chronic ulcers may degenerateinto carcinoma, that not alone
cinoma
tumors, but also those of decided histioidal character,may be changed into carepithelioidal
tants
that the effective irrithe influence
under
of persistent
traumatism, and finally
is observed

are

abundance

demonstrable

even

in carcinoma

of the

of data for the mechanical, irritative

internal

organs

originof cancer,

"

we

that

possess such an
it will not appear

630

CANCEE

OF

THE

to the
comes
finally,Colmheim
manner
explained in a satisfactory

I have

that

doubt

no

explanationof
plausible
another
offered

does

this

by

of all the

series of conditions

have

that all the

theories
of
been

not

hitherto

explainhow a cancer
has already used

From
we

tumors

be

may

will

none

associated

regarded by

explainwhat

with

Cohnheim

to the

occurs

and

give a more
neoplasms, but

for these he

has

the

precedinghistorico-critical
reach

must

the conviction

that

harmless

consideration

into

ulcer,an

carcinoma.

in
Nor

adenoma, fibroma,

of the theories of the

of them

none

epithelial
neoplasticgerm

be converted

from a
developsfinally
its
neoplastic
up
germ.

etc.,which

cancer,

considered

conditions

that, at the end of fiftyyears perhaps, it may

he

of
peculiarities

theory.

explanationwhatever.

no

In the first place he does not

order

conclusion

larger number

(CAECINOMA CUTIs).

SKIN

is

of
etiology
satisfactory.My own
entirely

belief,like that of the majorityof clinicians,is that every form of neoplasm requiresa
and irritants of all kinds, disturbed
specific,
predisposed base, in order that traumata
functions

of organs or systems, age, etc.,may produce them.

immediate
of cancer
of the skin we
will enumerate
causes
:
Among the more
1. Heredity. This is manifested
in two ways.
Either the cancer
is present at birth
or'it developsin after-life. The former was
but Friederich
long disputed,
reportsa case
nodule
in which
from
birth
with
to
foetus
cancerous
a woman
cancer
a
a
suffering
gave
in the cutis and subcutaneous
that in
cellular tissue above the left patella. Broca found
of seventy years.
occurred
in the course
one
large family sixteen deaths from cancer
Sibley gives the proportionof inherited cases as 1 : 10, Lebert as 1 : 12, Velpeau 1 : 8,
Cancer
and Cocke
(Eeport of the London
Hospital)1 : 7. Experience also teaches that
when
it
in
attacks
recurs
a
family,
preferablythe same
cancer,
organ or system.
the
all
various
is
2. Age.
none
so
intimatelyconnected with
Among
neoplasms,
the
carcinoma.
This fact has led not
human
the retrogressive
period of
organism as
of advanced
infrequentlyto the exaggerated notion that all malignant tumors
age are
"

"

Tanehu

carcinomatous.

The

majorityof deaths, viz.,67.55^,

statistical tables have

Other

different kinds

included
Gurlt

collected

has

including
hospitals,
age,

that among

found

as

follows

948

of

not

9,118 deaths

cancer,

there died

the age of 41 to 70 years.

that they
for the reason
similar
results,
entirely

occur,

given

from

therefore,from

cancer.

statistics of
cases

of

11,131

of the

cancer

of

cases

cancer

skin.

These

From

0-20

"

21-30

"

"

years,
"

12 cases,
19

i. e.,
"

"

1.2^%.
2.00^.

31-40

"

96

"

"

10.13^.

41-50

"

195

"

'*

20.75^.

observed

in

three Vienna

occurred, with

regard

to

CANCER

THE

OF

"

61-70

"

"

71-80

"

i. e.,

292 cases,

51 -60 years,

From

631

(CAHCINOMACUTIs).

SKIN

31.06^,

"

"

25.21^.

78

"

"

8.30^.

19

"

"

2.00^.

237
.

"

81-89

"

948

These

skin

3.

at

cancer

Sex.

of the

account

later

age is stillunknown.
hospitalsusuallyshow

advanced

frequencyof

2,946 times in

occurred

is

cancer

statistics of

The

"

an

much
inasfrom those furnished by other statistics,
of the
usuallyat 48.5 years, while that of cancer
of the occurrence
(55 to 60 years). The essential reason

certain extent

for

average age
alone is about one decade
of

on

results differ to

the

as

men,

mammary
7,479 times

and

uterine

in women,

preponderance of

sex,

In Grurlt's tables,cancer

cancer.

and

the female

in 706

cases

no

sex

tioned.
men-

was

"

But

the

among

948

cases

of

cancer

of the

anatomical

skin, 739

males

were

proportionalso is

data, inasmuch

and

209

females.

of the
supported by
be
to
male skin, with its more
more
fullydeveloped glandularapparatus,seems
posed
predisto aid the development of cancer.
tations.
and other local irri4. Traumatism;
mechanical, chemical, inflammatory, specific,
We will here reiterate that we are far from regarding local irritants as the sole
of the productionof cancer,
cause
though we are not disposed to deny their influence
is
of the skin.
dependent upon the specificpredisposition
altogether. Their effect
When
this is present,the carcinoma
may develop,after the action of the irritant,
upon a
of a compressionatrophy,in a tissue
normal
structure, and also in the vicinity
previously
infiltrated with simple,atypicalepithelial
in a tissue-system
proliferation
(Priedlander)
of
inflammation
of the latter
T
he
or
proliferation.
recognition
presentingphenomena
that
and
should not
so
we
possibility
prognostic significance,
possesses great diagnostic
be unprepared to find a cancer
developingin an ulcerative process, a degeneratingadenoma
in youthful individuals.
will we
after caries,etc., even
Nor
be surprised
(Verneuil),
that cancer
in places in which there are' permanent disturbances
in
develops preferably
the anatomical
constitution of the tissues.
that
has
observed
Every physicianprobably
the dirty gray, so-called sebum
warts situated on the temples,forehead, nose
or
back,
the nsevus
often present since early childhood,
are
etc.,which
spilusand verrucosus,
become
graduallybecome
hypertrophied and fissured in later life,ulcerate,and finally
This

as

the structure

"

cancerous.

In like

sometimes
conformity with the above assumption that cancer
cicatrix.
kind
of
this
should
But
not
all
tumors
protopathic
spontaneous
be regarded as cancerous
until they have
been examined
and
carefully
microscopically
observed
the originof the cicatrix should
In suc]i cases
mined.
clinically.
always be deter-

developsin

With
carcinoma

manner

it is in

or

regard to ordinarylupus the majority of physicians entertain no doubt that

from the true lupus tissue itself. The explanadevelop from it and even
tion
may

of this circumstance
for years, may
This leads

us

to the combination
answer

been

this
shown

is found

transform
finally

the

to
involuntarily
and

in the fact that

the

irritative condition, which

granulationcells of lupus

the consideration

transition into

one

in
question unhesitatingly
that histioid,organoid,or

another
the

of the

affirmative.

teratoid

questionraised by

of morbid

growths

For,

tumors, for

lasts

into those of carcinoma.

on

in

the

example,

Virchow

general.
one

as

I must

hand, it has

adenoma

of the

632

"

CAlfCEK

OF

THE

SKIN

axilla,which
dermoid

in
develoiDS
particularly

hand, it has also been

types of

elements

For

5.

demonstrated

and

some

etc.,have
to

women,

cysts (of the neck), etc., may

tissues

time

certain

regarded as

that the

constitutional

aid its outbreak

elements

molluscum^.
on

diseases,such

as

"We

these processes

are

and

the

other

developfrom

may
of the indifferent formative

of carcinoma.

causes

fibroma

carcinoma; and,

cancerous

the medium

direct causal relation between

recognizea

enchondroma,

sarcoma,

be associated with

through

been

(cAECESTOMA
Cims).

all

cells.

culosis,
syphilis,
scrofula,tubernot prepared,however,

carcinoma, though they

and

rapid propagation.
6. Nor do we
believe that obesity,
continuous
health, or too nutritive food can be regarded
of carcinoma.
as
causes
The proofs of such a relation are entirelywanting.
7. Telluric and climatic conditions.
that cancer
English writers have maintained
sometimes
In healthylocalities,
sometimes
in marshy regions,
develops more
frequently
and they have concluded
that the character of the soil is an excitingcause.
I consider
may

"

this

opinion,also,as entirely
unproven.

Hitherto

have

of primarycancer, and it now

remains
investigated
only the causes
developmentof the secondaryprocess, of the metastatic infiltrations
nodules.
however, there is no agreement of opinion on this point.
Unfortunately,
The
humoral
at
theory of infection was based originally
on
pathologyand assumes,
presenttime, that the juicesor a substance dissolved in them, or certain corpuscularwe

the mode
to explain
and

the

of

possess in a form of virus the infectious property of

in the locality
to which
they are carried.

elements

Gussenbauer
taken

are

that the smallest elements

derived from
the primary growth
protoplasm or nuclei of the cells and thus constitute the first stage of
of general carcinosis,
theory of infection is supported by the occurrence
assumes

in the

up

infection.

producing a secondary process,

The

the appearance
of cancerous
and their frequentabsence

nodules

outside of the vascular domain

of the

primary nodule,
expected. But thesuch as the complete immunity of cartheoryis opposed by insurmountable objections,
tilage
metastases.
from
The
entire symptomatology of the secondary affection also
is shown
by comparing it, for example, with the history of
opposes this theory, as
in

placesin which

syphilis.
The
is also
theoryof transplantation
nevertheless

readilythe
elements
within

explainsthe
fact that the

like those

in

they would

unable

in

more
a
symptoms
lymphatic glands in the

the

primary

the vessels,
but also in remote

nodule

to

naturallybe

possiblequestions,but it
It explainsmore
manner.
satisfactory
vicinityare first affected,that cellular
found

are

all

answer

alone

not

in

recent

thrombi

the ends of the

emboli)
capillaries
(capillary
be found
in the surrounding tissues.
But the exclusive
can
though no trace of cancer
of wandering cancer
from
elements
does not
development of metastases
proliferation
their
formation
this
is
if
assume
readilyexplain
we
easilyexplained,however,
rapid
;
that the transplantedelements possess the power of causinga proliferation
of similar elements
parts at

in the various tissues.

Anatomy.
of nodular

or

is

usuallyof

"

red

surface is even,
is

of the skin

either in the

occurs

It varies from

cartilaginous
hardness; in the

grayishred, dark
The

Cancer

infiltration.

or

grayishwhite

nodulated,

pale red, moist

and

the size of

appearance,

and

recent
ones

is rare,

of nodules, which

form
to

pea
it has

beginning

papillary. In
granular;in older
or

that of

pale

is traversed
cancers

it is white

walnut

or

rose-red,and

by

more,

later

of the skin the cut

or

dilated vessels.
tion
sec-

grayish white, dry,.

CANCER

OF

SKIN

THE

(CABCINOMACUTIs).

it removes
coarselygranular. The knife passedover
white
Lateral
white
mass.
tliickish,
or
yellowish
pulpy,
pressure
fibrous

633

or

small

causes

quantityof

the

appearance

of rounded,

elongated,
cylindricaldepressionsor,
plugs,in part whitish or reddish white

rr.ore

masses,

properlyspeaking.In part
which

are

loosened

by

sage-shaped
sau-

serous.

634

CANCER

OF

THE

(CAECINOMA CUTIs).

SKIN

scanty fluid. Upon the addition of a 0.5 per cent solution of salt,
sero-sanguinolent,
detritus with a few cholesa granular,molecular
microscope reveals in these masses
of epithelioid
terin crystals
here and there, and a largenumber
cells. The isolated cells
almost always presentthe pavement epitheliumtype; the nuclei and nucleoli are often
increased and occasionally
cell fission is noticed.
of the growth should begin at the adjacenthealthytissue.
Microscopicalexamination
The firstdeviation noticeable is that the cones
of the rete Malpighiigraduallybecome
larger
(Fig. 80). a. Upon close inspectionit is found that their peripheralepitheliumcells have
cells
become
and are followed toward the centre by larger cubic and rhombic
cylindrical
with
and
dentations.
or flat,
spines
Many
compressed,many-angled cells,etc.,provided
distinct nuclei,nucleoli,and occasionally
The papillaB
vacuoles.
of them
have one or more
the centre the
and the tissue of the cutis have suffered no noteworthy change. Towards
larger and send off branches.
changes increase. The sprouts of epithelium become
found large,flattened masses
of epithelium
In the more
are
developed parts, accordingly,
corium.
Here
there
of
t.
and
into
the
a
with branches
sprout
epithelium has
extending
the
result
of
inflammatory proliferation
spreadso far into the connective tissue that, as a
into a brood nest for one
converted
or
in the adjacent parts,it has been separated and
that the cylindrical
examination
of such placesshows
colonies,
c. Careful
cancer
more
but a division of the cells and nuclei
form of the cells is either rudimentary or not visible,
laminated
is often noticed;the concentrically
spheres of epidermisare rarelymet with.
and
has been established in the papillas
followed
An irritative condition,
by proliferation,
the
d. The
cancer,
corium, corresponding to the changes in the epithelial
parts of
infiltrated papillge
the swollen and
result is that sometimes
projectbeyond the surface of
of carcinoma
the skin and divide dichotomously,givingrise to the appearance
papillare.
or

the

acts uniformly
proliferation,
goes hand in hand with the epithelial
tive
cells;the connecthen this is infiltrated throughout with round

which
Or the irritation,
upon

corium, and

the
tissue

walls in

corpusclesare
condition

of

be all

There

more

numerous,

the vessels dilated,and

the elements

of

their

proliferation.
possibletransitions

from

origineither from

the

may
varietywhich takes its

simplestform

the above-described

to that

ous
deeper layersof the corium, the subcutane-

glandsof the cutis,and which spreadsinto the muscular

this varietyoften forms largenodules, of a rosy
tissue as far as the bones.
Macroscopically
which
are
to dark red appearance,
usuallymoist or juicy on cut section.
by a
the microscope the beginning of the pathological
change is manifested
Under
increase
of
cells
that
connective
in
the
a
so
gradual
round-cell
tissue,
scanty
proliferation
al parts (interpapillary
rete, sebaceous
in all the epithelioid
glands, root
is observed
more
strikingas we approach
changes become
sheaths, and sweat glands). The histological
more
cones
are
the neoplasm. The
enlarged than in the superficial
epithelial
connective

variety of

tissue,or from

the

and

present numerous
structures
epithelioidal

cancer,

dendritic

ramifications.

If the

process

has

(glandularcarcinoma),these undergo
membrana
the
such changes as to become
propriais perforatedby the
unrecognizable
;
the
tive
into
directions
which
neighboringtissues. The connecspreads in all
proliferation
of
the
sometimes
tissue stroma
rated
prolifedisappearsalmost entirelyfrom the pressure
of the irritation it is infiltrated with round
sometimes
in consequence
epithelium,
cells ; in addition the connective tissue corpusclespresent various stages of proliferation,
started

in the

the blood-vessels
The

most

are

dilated,and their walls in

distinct

of
proliferation

the

of the skin

appearances

are

condition

visible in the

epitheliumpredominatesto

such

of irritation.

cancerous
an

extent

focus
that

itself.

Here

nothing

is

the
seen

CANCEB

(CABCINOMA.
CUTIB).

SKEST

with
proliferated
epitheliumalternating

iDut the

The

irritation.

bodies

cancer

THE

OF

former

usuallyassume

rounded

tissue in various

form, but in addition

stages of

there

some

are

fications,
grouped cells,others which presentdendritic ramiirregularly
which assume
into
or
e
longatedshapes,
irregular
polygonal,
pass

of

composed
stillothers

and

connective

635

streaks.

frequentvariations of form resultingfrom the mutual relations of

the former, while continuing to proliferate,
the cancer
nests to the stroma, developswhen
of the latter. But this isolation
become
isolated and situated in the interspaces
(alveoli)
is not absolute,inasmuch
the concentric globes often maintain
their connection
with
as
One

of the most

another

one

over

extent, and in this way the connective

wide

tissue forms

interlacing

an

network.
The

alveolar structure

has been

regarded as

but it is also found

in other

forms

Not

alone

does

cells and

cancer

connective

the

bodies, but

Newly

formed

vessels

Very

cancer.

found

at

of the skin

cancers

the

run

site of

upon the progress of the tumor.

maximum
development of the
and

rapidcourse

more

plasm,
neo-

alveolare,etc.).

for the
a
supporting frame-work
lymphatics it also suppliestheir

and

often decisive influence

an

always

are

vascular

its blood-vessels

by

nutrition,and thus exercises

(adenoma, sarcoma

constitute

tissue

of this

feature
specialdiagnostic

of tumor

less amenable

are

to treatment.
To

complete the previousdetails,we

spread to all the tissues underneath

in

part to

of them.

metamorphosisof

cancerous

The
cell
and

bodies press forward

the stroma, which

cancerous

irritation

hypertrophy

cause

but
conditions.

have

we

In

the

of the skin may

cancer

tissue,thus giving rise

into

or

then

part to hypertrophy or atrophy

the interstitial spaces, causing an embryonal
tissue,or the
changes into cancerous

atrophyof

the

neighboringtissues,so

the anatomical

shows
investigation

varietyknown
that

In

carcinoma

of the skin in eral,

genvarietyof

cancer

presents a
simplex, the

carcinoma

as

of the

of

structure

considerable

that it

of

mass

stroma.

cells

of

which

cancer,

which

are

consists

infiltrated with

the tubuli of the latter

of

small

tubuli-like

always

are

This

cells.
narrower

"concentric

bodies^'

be mistaken

may
and

to

epithelioid
minimum

adenoid

imbedded

for sweat

convoluted, and

cells is

cancer

medullare, the

approximatelyequal
the stroma ; sometimes
is reduced
the stroma
predominate over
has entirelydisappeared in places. "Waldeyer also described
an
or
to

that

fibres,etc.,are finally
destroyedby fatty,
the
bones
of the skull,jaw, shins,etc.,may be perresult,
forated

considered

detailed

more

deep

substance, nerve

As

granular degeneration.
and destroyed.

that

connective

these tissues,in

in
proliferation

pressure
the adipose cells,muscular

Hitherto

mention

must

the subcutaneous

the

gland
external

variety

in

alveoli

cancer,

cells

but
more

cuboidal.

atrophic,cicatricial

In
attain

such

disappear entirelyor

almost

firm, shining connective

known

as

usual appearance
of its cellular elements.
a

carcinoma
When

and

of the

skin

(carcinomaatrophicum),the

and
entirely,

tissue with

some

occurs,

the entire

that

the

new-growth

elastic fibres.

This

stroma

''concentric

may
bodies"

is

composed of dense,
variety has long been

scirrhus.

The

rise to

cancer

dimensions, if spontaneous recovery

of the stroma

may also be changed by the exceptionalincrease

If this excessive proliferation
affects the round cells,it gives

granulosum ; when many spindlecells are present,to carcinoma

in the various
pigment granulesare present in largeamount

intercellular substance

of the cancer,

it is known

as

carcinoma

melanoticum.

comatosum.
sar-

cells
This

636

CAJSTCEK

form

is

frequency
The

its

and

rare

of

must
diagnosis

number

variations

changes.

involves
like the

in

in the

of the most
whole

layersof

this process

be made

onion

few

nodule

cancerous

tumors, for

of

Suppurationand

or

upon

ulcerative
and

in which

all old

of

cases

of the skin, either

cancer

ciated
asso-

existingseparately. It is always circumscribed,

to one
foci.
If this degenerationtakes place in
or
more
tain
parts which are predisposedto the development of certhe scalp,it may
be difficult to decide
whether
the
or

cyst, etc.

total

partialor

the connective

of cancroid

local irritation

of

or

calcification

constitute

generation
de-

rare

of

of the skin will be discussed

cancer

corpuscles,enunciated

also be traced
condition

under

of the disease.
that

Virchow, after having shown

tissue

could
some

destruction

termination''

1855

"

from

elements

or

laminated

cancer.

caption of "course
Histogenesis. In

formed

are

the

dry, and the cut section presents a white,

streaked, fibrous surface.
delicately

and
ossification,
softening,

Mucoid

they

constitute

and

in almost

example, upon
primary cancer,

startingpointis a

the

cells

situated

may

cases,

(carcinomakeratoides).The epithelium becomes

(pearlglobules,epidermic globules). Carcinomata

change just mentioned

either to

confined

rare

the

of the growth may

be the result of retrogressive
is the cornification of the cancer
cells,which
times
some-

is far advanced, feel hard

the

relatively
greater

character

appearance
degeneration is found

with

of the

account

also vary greatly; in

new-formed
vessels

may

cancers

common

alveoli

an

soft

shining,homogeneous
Fatty

on
cautiously

of vessels in the stroma

entirelyabsent, and
major portion of the stroma.
One

(CAECIlSrOMA
CUTIs).

SKIN

melanodes.

sarcoma

almost

Other

THE

OF

to the

of weakness

the

number

of tumors

theory that the

were

epidermoidal

In consequence
of some
same
source.
of the tissues the connective tissue corpuscles

and lead to the development of a primary cancer.

undergo proliferation
After this had developed, the cancer
"carriers
and producers" of the
cells,which were
immediate
to
the
disease
the
acted
to
as
v
irus,
vicinity,
specific
infecting agents
spread
the adjacent lymphaticglands, and remote
organs.
of Foerster, C. 0. Weber,
Supported by the clinical and microscopicalinvestigations
became
the
soon
Paget, Billroth,etc.,the theoryof the connective tissue originof cancer
said to

were

dominant

one.

until Thiersch, after reportingupon

Not

of the external

well observed

102

that the tumor

skin, brought proof

directed to all
elements, was
investigation
epithelial
This theory was
sustained by the following fundamental

incontrovertible.

elements

Since

of carcinoma

tumors

and

the

the time

tissue

not

were

primitivetissue

germinal layerdid not

of J. Mueller

it had

different
essentially
and
of the embryo
"

transition

views

been

regarded

were

"that

the

the tissue elements

also that the formations

of another.

into those

which

assumed

from

cancer
epithelial
proliferation
question.

the direct

sides of the

of the

as

of

cases

developed from

finest
of benign
of

also known

It

one

that

was
permit a
typicalproliferation
(adenomata,warts, etc. ) the interpapillaryrete
and also the epithelioidal
of the cutaneous
elements
glands increase without any notable
the part of the connective
therefore taken for granted that
tissue.
It was
on
implication

in certain

an

forms

of

proliferationcould
epithelioidal
or

with

the

objectionto the view

With

regard to

the

take

place under

implicationof the other

that
occurrence

cancer
epithelial

of

tissue

pathologicalconditions

develops only

primary cancer

If this

elements.

in organs

from
which

to the

is so, there

is

clusion
exno

epitheliumpre-existing
possess

no

epithelium".

638

CANCEK

Not

THE

(CAECINOIVIA
CUTIs).

SKIN

show
places in which this differentiation has entirelydisappeared^,
and in
it is very difficult or impossible to distinguishthe qualityof the individual
cells.
alone is it often impossibleto state which
are
epithelium,which are granulation

parts
which

OF

often

cells,and which
formed

will become

epithelium cancer

etc., that

and

remain

the

one

cells present such

led to

questionwhether

the other

or

manifold

they are

variety,but

character

reallyderived

as

the

even

fully

regards size,shape,

from

epithelium. AH
types of tissue are
capable of producing embryonal cells,which, under certain circumstances,may be converted
into epithelioidal
elements.
This is shown
scopic
very clearlyin the drawings of microsections furnished
by Eindfleisch,Gussenbauer, 0. 0. Weber, and others. Embryology
also furnishes a weighty support to this theory. The most recent embryological
studies have shown
that in the first period of the formation
of the ectoblast and endoblast,and also of the mesoblast derived from the latter,embryonal cells are imbedded
between
the primary epithelial
boundary lamellae,and that these, in combination
with
of the archiblastic elements, develop into connective,muscular, and nervous
some
tissues,
are

we

these conditions

readilyexplainedif we

are

blood-vessels,and blood.
tissue from
From

In this event, there

can

all these considerations,it appears

in

absolute

no

plausiblethat

more

first pass

process
that these, according to the individual

converted

be

the various

differentiation of

nective
con-

epithelium,etc.

involved in the carcinomatous

and

that

assume

into

condition

of

all the tissue elements

embryonal

cell formation,

of the affected organ,

predisposition

are

into

atypicalproliferating
epithelium,to a slightextent
into connective
tissue corpuscles,
thus
and
etc.,
give rise to the complete clinical
finally
and histological
pictureof carcinoma.
Cancer developseither upon the normal
skin
Symptoms, Course, and Termination.
that which
is changed by a pathological
In
the
or upon
latter
the
event,
plasm
neoprocess.
develop from the elements of the morbid products,i. e., those of a lupoid,
may
irritative condition, of various types of new
affection,of an idiopathic,
syphilitic
growths
it
in
the integument which
has been rendered
(adenoma, etc.),or
develop
atrophic,
may
cicatricial,
siderable
etc.,by the morbid process in question. All these features possess no incona

great

measure

"

influence
At

the

nodular

the

upon

form, and in both

Smaller

situated

course

tumors

are

cancerous

affection.

presentseither

circumscribed

it may attain dimensions

of
situated
the
usually
superficially,

cases

infiltrationor

extremely variable proportions.

are
largerones
generally

the

beginning. Although all cases pursue the same

general
growth followed by softeningand degeneration,
course, *. e., a tendency
nevertheless
there are
certain differences.
For example, superficial
as
a
rule,
cancer,
remains
in the upper layersof the cutis,requiresa disproportionately
long time for its
destructive process, and only exceptionallyinvolves the lymphatic glands, and gives
more

deeply from

of the

of the skin

beginning, cancer

to

rise to

metastases.
from

the

unrestrained

carcinoma

beginning by

in the subcutaneous
ominous

connective
On

tissue is often

this account,

panied
accom-

of the
phenomena.
varieties.
deep
Cancer
of the skin, if not situated upon parts exposed to view, may
exist a couple
of years or more
without
attractingthe attention of the patient. More observant
first notice that the little pimple does not disappear,that the crust upon
it is
patients
itching is present. More attention is paid to it
continuallyrenewed, that constant
when
the patient notices its constant
growth. The physician then observes that the
it presents an
chronic
that
its
has
elevation of
a
look,
despite long continuance
process
that
the
of
its
reveals
removal
crust
few
an
millimetres,
eroded, readilybleedscarcelya
skin has been

divided

into the

and
superficial

cancer

CANCER

size.

condition

This

continue

further, the
at least in
But

entire

be

must

process
places,in old people.

if

few

regarded as

cells retain

hardness

or

unchanged

tionate
disproporyears, and

proliferated

then absorbed, so that when

remains, surrounded

skin

the

by

been

destroyedor are surrounded

that they are
unable to develop
manner
extinct.
This occurs
quitefrequently,

their

condition
a
capacityfor proliferation,
this
When
existingbefore the atrophy occurred.
has taken place,a similar retrogressive
process may again develop or the carcinoma
may
This growth may continue for years, until the tumor
continue to increase in extent.
is
as largeas the palm of the hand.
has reached large dimensions, the parts affected usually
Before
cancer
superficial
As
the
a
rule, these develop spontaneously,inasmuch
as
undergo secondary changes.
of
with
epitheliumundergo granulardegeneration,a hyalinemetamorphosis
upper layers
of insufficient nutrition.
Such a growth is usually
subsequent necrobiosis in consequence
lamellar exfoliation
shining,like mother of pearl,dry,and of diminished consistence.
Finally,
a

of the

cells have
such

firmness

for many
In the latter event, the

may

finally
undergo progressiveor retrogressive
changes.
cells undergo granulardegeneration,and are
epithelioidal
its course,
an
atrophic portionof the
process has run
If all the cancer
elevated border.
slightly
connective
tissue in
by the constricting

639

(CARCINOMACUTIs).

SKIN

THE

surface, and that it possesses

ing, slightlyexcavated
to its small

OF

againdevelopswhich

and

occurs,

cancer

is similar to that

erosion results.

small

of the pruridegenerationis due to the fact that, in consequence

tus
generallypresent in the beginning, the neoplasm is scratched or it is injured by
instruments, etc.; the lesions due to the scratching,etc., then initiate the destructive
degeneration. In the first event, the erosion is covered with a rather firmlyadherent,
whitish gray, or yellowish
crust; in the latter event, with a brownish crust composed of
dried blood.
The removal
of the crust shows a rounded
excavation, with sharpborders;
it may remain unchanged for months.
Another

form

of

carcinomatous

ulcer

situated

in

the

corium

is first of

round

shape,later

it

irregular. The base is pale red, shining,finelygranular,hard, and secretes a

fluid containing very few cellular elements.
The
serous
edges are irregular,
scanty
the
hardness
and
if
the
imbedded
nodules degenerate.
even
present
pathognomonic
steep,
foci of degenerationdo not occur
These
with
of
but a
singlyor
regularity,
any degree
surface
contains
number
of
which
lated,
isoof
loss
of
of
a
cancerous
are
substance, some
spots
becomes

confluent.

some

Sometimes

the

cancerous

mass

imbedded

in the

corium

at the

site of ulceration

is

mal
Norentirely
destroyedby the degeneration,givingrise to a sort of spontaneous recovery.
granulationsthen form on the base of the loss of substance, and graduallya new epidermic
is formed, or by the coalescence of grayishwhite isletsof epidermis
cover
largeror
receive a new
smaller portions
tegumentary covering. As this process is repeated quite
in
of the skin, ulcerations and cicatrices are found alternatcancers
ing
superficial
frequently
with

another.

one

If the

terruptedly,
products continued uninextend
not merely to a
alone takes place very
and finally
proliferating
cancer,

recovery by destruction of the morbid

there would
be a chance that the recovery
would
circumscribed
the cicatrization not
spot. But unfortunately

spontaneous

slowly,but it
destroyed.
The
one

or

cancer

more

often

may

ceases

to

advance, is attacked

by

the

unfavorable
deeply in
course, if it spreads more
pursue a still more
thus leads secondarily
to the development of the deep-spreading

places,and

640

CAJSfCEE

variety.

Or

nodules

OF

THE

form

(CABCINOMACUTIs).

SKLN"

at the outset

in the

deep layersof the corium, the

ized
glands. This condition is characterIn the
by the presence of an extensive infiltration or one or more
large nodules.
beginning the affection is not readilyrecognized on account of its deep localization.
evident until finally
the skin is thoroughly
But, as the disease spreads,it becomes more
infiltrated and the neoplasm is palpable as a prominent, either rounded
flat tumor.
or
The
surface may be smooth, furrowed, nodular, or papillary,
is of a waxy, pale rose
to
livid red color,traversed by vessels and shining in appearance.
Whether
in the form
of
infiltration or nodules, the growth is very little or not at all movable
its base and
an
upon
is strikingly
hard. After the lapseof years, central or peripheraldegenerationusuallysets
in.
This process may develop spontaneouslyor be excited by injuries. If a crust forms
conditions are observed as in superficial
a slighterosion,the same
over
cancer, but annoying
be
pains may
experienced and hemorrhages occur
readily. But if the degeneration
it is preceded by a deep, dark red color,a doughy or elastic,
occurs
en
fluctuating
masse,
cancerous

subcutaneous

feel and

connective

increased

the

cutaneous

; this may
results varies from

temperature

ulcer which

cancerous

tissue and

in shape, has
irregular

be associated with
the size of

moderate
to that of

pea

hemorrhage.

The

walnut, is round

nodular, dirtyyellow, hard base, covered with

irregular,
necrotic shreds of tissue,and
its edges are
The surface of the ulcer
sharplydefined.
of sero-purulentmatter, which
dries and is removed
secretes a moderate
amount
soon
with difficulty.Upon
from .pin
exercisinglateral pressure, comedo-like
plugs emerge
head
openings or a yellowishwhite, fattypap mixed with pus is discharged. In the
or

occurrence.

towards
a

of this kind

bodies ; their complete and

As
the
a
rule, when

cancer

like

event, ulcerations

favorable

most

an

the surface
mushroom

to

well

as

into

as

variable

heal

permanent

extensive
is

an

destruction
event

is left to itself,
it continues

cancer

the

after

cicatrization

In

deeper parts.
the

height above

the

level of the

former

of the
to

of the
rarest

proliferate

event, it projects

surrounding parts,and

pears
ap-

is covered
with a viscid or
lobulated, compact, pale red ulceration,which
hardness.
is
in
Its
bleeds
and
fluid,
tion,
readily,
cartilaginous
decomposing secrepurulent
in
the
to
rise
irritative
tissues.
conditions,ulcerations,
etc.,
etc., give
surrounding
as

Or the

cancerous

material

which

is

spreadinginwards

does

not

retain its nutrition,

like
and degenerationkeep equal pace, and the ulcer then has a craterproliferation
tissue covered with pus and ichor.
Here
shape, its base consistingof gangrenous
and there small granulatingspots may be observed.
The descriptions
justgiven refer to carcinoma simplex and its varieties. In addition
which
there are other forms of cancer
requirespecialconsideration.
Papillary cancer
ofthe shin (carcinomapapillare).Thiersch has called attention to
of the
the differences between
due to excrescence-like proliferation
warty cancer, a cancer
base of the ulcer,and the cancerous
wart, %. e., a wart in a condition of cancerous
ration.
degeneso

that

"

he arrives at the conclusion

But
course

is

malignant

as

there is

no

reason

the

as

for

that differences may

regardingthe
be observed

the

that, because

cauliflower
papillary,

wart

in its further

of the base of the ulceration,

proliferation

first stage

both

cancerous

as

in structure

separate disease.
and

I believe,however,

clinical relations.

has existed for years, papillary

large as the palm of the hand and has a
ous
it reaches its highest development, it presentsvariWhen
broad or pedunculatedbase.
At
outer
the
from
the
initial
to
the
of
ulceration,
fullydeveloped.
stages
partsprojections
like hypertrophic papillae
are
observed, either singlyor in groups.
They are
small, hemisphericalor cylindrical,
pale or bright red, finelygranular or rough, and
From

cancer

glandular,papillarybase

of the skin may

attain

or

dimensions

wart

as

which

CANCER

situated

on

8KIN(oAEOINOMA.
CUTIS)..

THE

OF

641

Towards
the centre
of the tumor
the
reddened, moist, infiltrated base.
higher,broader, vascular,firmer; they are either singleor

outgrowths become
papillary

either covered

branched, and

dirtybrown

If these

crusts.

with

crusts

layer of epidermis or
glistening
removed, the surface

are

beneath

with

yellowishto

is

usuallyfound

are
separatedfrom one another, it is found that the
papillae
have
a common
ones
trunk, which is hard and has a
supposed solitary
tumor
This
of
the
contain
broad base.
and other parts
a smeary,
a
or
decomposed mass
foul swelling,
purulent secretion. Upon lateral pressure comedo-like plugs,mixed with

eroded

and

fissured.

If the

majorityof the

their appearance.

blood, make

or

closer

we

approachthe

site of ulceration,the greater

of

ulcers.

cancerous

of the skin is observed

Papillarycancer
and

The

are
ered
fissured,covdestroyedpapillae.At the ulcer the papillae
irregularly
them
ichor
between
with crusts,surrounded
scattered
several
small
ulcers
are
by
;
singlecrater-shapedulcer,the base and edges of which are similar to those of other

the number

upon the external

less infections and

of
genitalia

both

frequentlyupon
They pursue a slow
operations.

most

sexes.

better suited for radical

(carcinoma melanodes).

This

should

the lower
course,

lipin

and

are

males
fore
there-

be

regarded as a special
(pigmented spots in general),
its
its rapid and unfavorable
and
greater tendency to relapses. It varies in
course,
from
to
black.
The
color
pigment is depositedeither in the cells
gray or grayishbrown
cells may present an
the intercellular substance, but some
cancer
or
entirelynormal
each relapsethe growth usuallybecomes
color.
With
more
pigmented. The nodular
frequent,but the superficial
shape and multiple development are comparatively
variety
of pigment cancer
observed
also
be
(eyelids,
scrotum). It is the most infrequent
may
Pigment

disease,on

cancer

of melanotic

"

of its

account

occurrence

and

tumors

in

is therefore

'^mother

often

tissue"

mistaken

for other

varieties of

pigment

growths.
attacked
integument of the face is more
by cancer
frequently
indeed
three-fourths
generalintegument,
constituting
nearly
any
of all such cases.
induration
In this situation it usuallyappears
as
a superficial
or
as
a
nodule.
sebum
wart of old people and then preOften, also,it starts from a wart
a
sents
In placeswhich
a papillary
are
abundantly suppliedwith sebaceous
appearance.
glands (tipand wing of the nosCj chin, scalp,etc. ),it often has an acne-like beginning
and the yellowish
brown
crusts of sebum
of
upon the nodules constitute the first symptom
the importantprocess.
In very exceptionalcases
the cancer
appears in the beginningas
nodule.
a deep circumscribed
In the large majorityof cases
the further course
of cancer
of the face corresponds
to its beginning,presentingthe original
the
induration,
superficial
aggregatednodular or
the papillaryform, entirelyindependent of the size of the growlfti
the secondary
or
which
in
But
I
do not mean
to imply
occur
changes (ulcerativedestruction)
places.
that severe
and grave symptoms are more
lar
rarelyobserved, because the deep seated noduis so very infrequentin this locality. These
form
often proliferate
and
cancers
ulcerate very rapidly in the first few years (particularly
papillarycarcinoma)and we
able to tell at what
time the superficial
ulceration will change into a deepnever
are
seated destructive process.
increase in maligExperience teaches,indeed, that cancers
nancy
in this locality
in
others
their
is
slower.
as
advance, however,
They do not
;
infective power.
When
situated superficially,
of
cancerous
possess much
degeneration
the lymphatic glands scarcely
than ten per cent of the
ever
occurs, and in hardlymore
which spread deeply.
cases
Localization.

than

other

"

The

part

of the

"

41

"

642

CANCER

OF

THE

SKIN

(CABCINOMACDTia).

The

of the face and scalplies mainly,therefore,

significanceof cancer
in its tendency
and its consequent liability
of affecting
the periosteum and
spread superficially,
bones.
It also possesses a tendency to spread along various canals and cavities to
tant
imporof the ridge of the nose
has no very great significance
Thus, a cancer
organs.
so long
it remains
it spreadsthroughthe entire thickness
as
superficial
; but this changes when
of the tissues or makes
its way into the nasal cavityfrom the edge of the wing of the nose.
The cartilaginous
and osseous
and its septum are
then destroyed,
portionsof the nose
and by spreading externallyover
the upper
lipand cheek and internally
upon the nasal
the
into
and
mucous
membrane, the cancer
the horizontal
pharynx,
through
may
pass
platesof the palatalbones into the mouth, etc. Similar devastation may result when
the carcinoma
tissue.
developson the cheek and spreads through the skin and muscular
to

If the

maxilla

upper
affected,the

teeth

spread through

is infiltrated,it becomes

lost,the antrum

are

of

necrotic

Highmore

is

and, according to the part

perforated,and the process may

the orbital fissure to the orbital

cavityand even to the dura mater.

eyelids,the eyeball is in continual danger even
is situated superficially.
The upper and lower lids
though the cancer
may be destroyed
extent
that a plasticoperation must
be performed in order to relieve the
to such an
resultingectropium.
It is not very infrequent,also, to find the entire lid destroyed or the conjunctiva
involved in the process, thus causing imminent
danger to the globe. It should not be
come
forgotten,however, that the process may stop at any stage of its development, and beIf the

carcinoma

extends

to

the

extinct.
Cancer
in

of the lower

lip is

not

but
infrequent,

beginningof the disease

women.

The

infiltrated

nodule

at

or

the

near

vermilion

of its location,leading to the

account

is much

is manifested
border

more

by

; this

"

than

men

projecting infiltration or

receives

developmet of fissures.
Upon examination, the

in

common

manifold

injurieson

Nevertheless

to three

one

affected spot presents an

elapsebefore ulceration occurs.
be
mistaken
for a syphilitic
elevated, sharply defined, hard little tumor, which
may
The
lower lip is freelymovable, as is also the integument of the chin.
As the
ulcer.
directions.
It
to
it
in
all
the
mucous
membrane,
spreads
neoplasm develops, grows
years

which

becomes

infiltrated

and

swollen, and also towards

the chin, which

becomes

more

deeply into the lip,which is then

rigid. Later the process spreads more
loosened and the teeth are not so firmlyimbedded.
with
moved
are
difficulty
; the gums
The
new
growth then forms a flattened, hemisphericalprominence, possesses either
lateral pressure, discharges
a
finelygranular or papillary,fissured surface,and, upon
of
convoluted
epithelium and fat, and also a fatty
numerous
plugs, composed chiefly
resistingand

pulpy

which, in addition

mass

to

the above-mentioned

constituents, contains

pus

cells.

later period the cancerous

a
degenerationmay involve a considerable portion of
surrounding tissues,extending on the one side to the floor of the mouth, the tongue,
illa,
pharynx and larynx,and on the other side to the alveolar process of the inferior maxnecrosis.
The
caries
and
cervical
and
lymphatic
submaxillary
glands are
causing
metastatic
nodules
not
alone
the genalso implicated. In such
cases
develop
upon
eral
Death
but
in
internal
often
also
is
due
to hemorrhage, but
integument,
organs.
usuallyto marasmus.
of the external
Cancer
genitaliavaries according to its situation. The superficial
varietypredominatesupon the scrotum, in which it very often begins in the form of a
At

the

traumatic
a

or

ulcerative process, chronic

dyscrasic
of pigment,forming

considerable amount

eczema,

carcinoma

etc.

Not

it contains
infrequently

melanodes, but

even

then

it

CANCER

OF

THE

04:3

(cAECmOMA CUTIs).

SKIN

Infected
the tendency to spread superficially.
lymphaticglands or metastatic
Scrotal cancer
depositsare rarelyobserved during its course.
may extend to the thighs,
abdominal
walls.
the
of
and
the
lower
part
penis,
is also observed
cancer
quite often upon the outer layerof the prepuce,
Superficial
inner
of the
but by no means
the
often
as
so
layerand upon the glans,on account
upon
these
secretions,uncleanliness,etc. ) to which
numerous
exciting causes
parts
(irritating
are
spreads more
rapidlyin this region. If it
subjected. For this reason, also,cancer
normal
covering of the new growth is first raised
beginsin a previously
spot,the epithelial
like a vesicle or pustule,which bursts after the lapse of one
or
more
weeks, leavingan
erosion.
The process usuallydoes not receive any serious attention until the new
growth
and ulceration have extended
more
deeply as well as super"cially. It is distinguished
The cancerous
from
:
ulcer, as a rule, is
syphiliticulceration in the following manner
of very slow growth, has an irregular,
discolored,extremely painfuland very
deep-seated,
hard base, containingnecrotic tissue,and bleedingreadily
on
contact; the edges are steep
retains

and
be

sclerosed.

present, the

The

surroundingtissues

dorsal

blood-vessels

and

hard, and
strikingly
converted
are
lymphatics

are

extensive
into hard

oedema

may
strands as

painful,their size varying

tions
from a hazelnut
to the fist. Under
increasingpains the glands break down, the ulcerathe carcinomatoas
assume
character, and the vital forces are steadily
sapped. The
natum.
becomes
difficult when
the process begins in a condyloma acumimore
diagnosisof cancer
For this may grow into a papillatedtumor
as
largeas a goose egg, may ulcerate
in placesand perforatethe prepuce or corpora cavernosa
destroyingpapilloma),
(Foerster's
the
while its appearance
at the circumference
suspicionof malignancy. In
may remove
Whenever
such cases
be very carefullyobserved.
the character of the ulcer must
possible,
thick

as

the

finger,and

little pieces
should

be

the

inguinalglands become

removed

hard and

localities
suspicious

from

for purposes

of

microscopical

examination.
of the labia

wart
nodule, or a trifling
majora beginseither as a superficial
of
the
disease
varies
in
the
further
a
course
corresponding
deep-seatedinfiltration;
At times the process spreadsover the surface,extending beyond the mons
manner.
eris,
veninguinal region, and introitus vaginae. At other times it extends deeply,either in
Cancer of this
or
a circumscribed
locality,
devastatingthe vagina,perineum, and rectum.
the papillomatous,cauliflower form.
region rarelyassumes
The trunk is rarelythe site of idiopathiccancer,
the process usuallyspreading to it
the
back
the limbs.
from
the
external
It presentsno
or
or
neck,
by contigi^ity
genitals,
clinical or etiological
peculiarities.
In the majority of cases cancer
with
in connection
of the upper or lower limbs occurs
surgicaldiseases,such as caries,necrosis,fistulous canals, ulcers,etc.,or in parts which
cicatrized after the termination
have
of such
The
diseases.
deep spreading form is,
therefore,observed more
frequently,or the papillaryvarietyif the previousinflammatory
irritation has lasted a long time.
The devastations caused by the growth are very extensive,
to
render
matters
old
debilitated
individuals
attacked.
and
are
and,
usually
worse,
of the
often after chronic eczema
Paget's disease of the nipple (carcinoma)occurs
ported
part. In 1874, Paget reported fifteen cases of this kind, and others have since been reby Munro, C. Anderson, Sherwell, etc. If we study carefullythe clinical histories
of these cases, we will arrive at the conclusion that theypresentno features entitling
them
to a separateclassification.
The
Prognosis of Cancer of the Shin.
prognosisshould always be made with great
Carcinoma

or

"

caution, althoughit is not

as

unfavorable

as

when

the disease is situated

in other local-

644:

CAJJCEK

ities.
the

that

teaches
Dailyexperience

beginning of

the disease.

The

Nor

we

are

only able to limit its progress

we

expect very much

can

complete results in
of
significance
prognostic

serious

had
of the process, which
dimensions.
the
to
previous
again

(oAECmOMA CUTIs).

SKIN

and

permanent

as

THE

OF

this direction
the

are

from

it in
extirpate
ery,
recov-

extremely rare.

resides in the

cancer

been

or

its spontaneous

extinct, may

fact

that any

small

regarded
lightit up
this
takes
long as
place slowlyand over a small
extent, the patientsuffers injurymerely because the part implicatedand the surrounding
But as it progresses, the tendencyto spread deeply
inflamed tissues lose their function.
and more.
develops,and the hope of radical recovery then diminishes more
Cancers of the skin which
are
deep seated and extensive exert a deleterious influence
In the first place,important organs may
in many
degenerate,may be stenosed or
ways.
etc.
such
ulcerate,
Furthermore,
cancers
atrophiedby pressure, may
very often ulcerate
In
of
the
continued
and become
suppuration,much material,
gangrenous.
consequence
is lost;the vessels upon the surface may be ulcerwould be useful to the economy,
which
ated
which
checked
with great difficulty
and hemorrhages ensue
are
; septicinfectious
enter the blood and the vital forces are
destroyedby the disturbed sleepdue to
particles
and the fever which
the constant pain,the loss of appetite,
developsat a later period.
with
is situated in a locality
If the cancer
numerous
provided
lymph spaces, lymphatics
and venous
remote
plexuses,the adjacentlymphaticglands and then more
organs become
the seat of metastatic growths.
On account
of the malignancy of cancer, the first indication is to reTreatment.
move
and
the new
as
growth as soon
thoroughly as possible. At the present time the
recommended
to effect this object are, 1. parenchymatous injections,
2.
only measures
remnant

as

suffice to

So

"

caustics,and

of
Injection
chloride
made

of various

3. instruments

fluids

was

kinds.

first practisedby

of zinc, sulphateof zinc,etc.,by

who
Simpson (1856),

means

of sulphate of
injections

employed

30 to 50

drops of

attendingits

few

drops of

Luton
acupuncture needles.
of iodine,alcohol, etc., and Broadbent

copper, tincture
solution (1: 15) of acetic acid.

of the

a
injected

of hollow

The

latter agent has since been

Thiersch

and then Nussbaum

used
danger
followed
solution
of
chloride
of
sodium.
Of
by a
(1 : 2000),
treated in this manner
15 cases
by Nussbaum, the cancer
disappearedin four cases after
the development of suppurationand gangrene, in six the result was
moderate, and slightin
Heine also obtained good results from the injection
of 0. 1^ of hydrochloricacid.
five cases.
of parenchymatous injection
On the whole, however, the method
has been employed too
little to warrant a positive
its
value.
opinion concerning
The effect of the different caustic remedies varies greatly. Some
of them
are
quickly
by the fiuid in the tissues,and are thus effective on the surface alone ; other
precipitated
extent.
dissolved and destroythe tissues over
a wide
are
caustic potash,sulphateof copper, chromic
The solid caustics (fusednitrate of silver,
if we are
in
acid, the mitigated stick,etc.),are used in the form of a pencil,
justified
that
w
ill
the
entire
be
repeatedapplications
destroy
neoplasm. They may
expecting
plied
apwish to produce atrophy of the
to the surface in the form of a powder, when
we
cancerous
improve the granulations,diminish the ichor, and relieve the foul odor.
mass,
has recentlyrecommended
this end in view, Esmarch
the application
of half a
With
drachm
of the followingpowder : acid, arsen.
and morph. muriat. aa
0.25, calomel 2.0,

discarded

on

account

use.

of nitrate of silver
injections

and

gumm.

arab. 12.0.

Liquid caustics (fuming nitric acid, concentrated

cetic acids, solutions

of nitrate

of silver,corrosive

sulphuricacid, acetic and chlorasublimate, etc.)are employed with

646

CAI^CEE

also

be

acid

hydrochloric
and

of

Without
the

of

use

compression

place,
iron.

The

most

administration
the

ulceration.

loss

cannot

is
be

important
of

opium

eroded

employed
indication

or

either
for

morphine,

as

of

with

either

of

and

caustic

cer.
can-

number
the

as

trates
pene-

and

operation
of

cases

former.

The

individuals,

old

be

lint
the

of

relief

subcutaneously,

potash,

dipped
of

pain

in

this

internally,

like,
and
etc.

takes

hemorrhage

pieces

or

clean

thoroughly

kept

parenchymatous

i3

the

and

hypermanganate

lime,

dry
cases

individuals,

old

in

upon,

considerable

such

great

in

fluid

use

the

cachectic,

should

chloride

or

least

wound,

cutaneous

surgical
that

in

dipped

the

of

forms

following

dipped

thereby.

operated

Ulcerations

charcoal,

powdered

blood-vessel

at

if
The

injury.

anaemic,

occasioned
be

remains.

alone

in

strongly
blood

of

is

it

means

pellet
and

positiveness

with

charpie
superficial

another

considerable

not

results

the

of

causes

with

proliferating

rapidly

stated

it

insignificant

very
or

latter

which

may

be

may
the

indicated

also

cases,

finely

larger

it

by

trifling

treatment

with

When

the

to

comparison

pastes,

neglected

dressed

into

is

rise

gives

is

of

pellet

until

performed

produced

pain

CFTIS).

procedure
surface

is

deep-spreading

treated

pastes
of

account

palliative

to

be

caustic

In

the

caustic

should

The
it

the

entering

of

use

which

following
affected

cauterization

silver.

for

reserved

the
the

upon

tissue,

healthy

is

pastes

of

of

use

rubbed

afterwards

nitrate

into

on

is

immediately

solution

make

employed.

(CAECINOMA

SKIN

THE

OF

of

chloride
is

or

done

by

applied

INDEX.

Absorptive

of

power

lectularia,

Acanthia

hominis,

foUiculorum

Acarus

Accidental

limits, 72

its

Alopecia

537

symptoms

and

areata,

treatment,

435

in

skin,

the

436

of, 467

pityrodes,

413

diagnosis,

469

pityrodes,

anatomy,

469, 470

treatment,

external,

pityrodes,

from

bromine,

from

tar, 469

469

468

rosacea,

definition,

rosacea,

diagnosis,

rosacea,

etiology,

rosacea,

morbid

rosacea,

treatment,

413

treatment,

416

pityrodes

universalis,

418

preesenilis, 411

473

senilis, 411

473

senilis, morbid

473

473, 473

anatomy,

simplex,

467

with

357

diagnosis,

of

iiyperaemia

Anaesthesia

the

skin,

skin

in, 444

619

Alibert,

in, 59

of, 33

"

95

processes

Animal

parasites

Anomalies,

in

the

color

of

in

the

color

of

of

development,

diagnosis,

of

skin

of

etiology,

skin, 538

et

seq.

103

hair, 433
the

skin, 437

et

seq.

103

origin,

connective-tissue

110

566

areata,

the

of

developmental,

of

areata,

of

503

Anhidrosis,

218

anatomy,

inflammation

and

skin, 92

446

areata,

603

Angio-neurotic

universalis, 446

Evil,"

156

113

partial, 447

Albinismus

Albinoes,

skin, treatment,

103

Akanthoses,
Albinism,

hair

106

Akanthomata,

Alopecia

in

skin,

the

Angioneuroses,

the

tissue, circulation

changes

154

the

of

cavernous,

616

362

seq.

of

Angiomata,

56

tissue,

1 et

600

Angioma,

sebaceum,

"Aleppo

94

615, 616

Adipose

system,

nervous

in, 122

skin,

the

skin,

of

Anatomy

495

disease,

the

of

diseases

of

Anaemia

dermatitis,

and

sudoriparous,

Adult,

149

173

exanthemata

Addison's

diseases

skin

America,

357

nature,

Adenoma,

410

congenita,

437

356

Adamkievicz,

411

symptomatic,

474

413

anatomy,

420

simplex,

vulgaris,

eczema,

415

pityrodes,

universalis

Active

415

pitj^rodes, symptoms,

467

Actinomycosis,

414

etiology,

pityrodes, prognosis,

468

cachectioorum,

415

pityrodes, diagnosis,
470

410

anatomy,

neurotica,

definition

treatment,

Acute

409

localis, morbid

554

468

frontalis,

430

course,

localis, 410

parasites

causes,

areata,

congenita,

555

hordei,

Acne,

and

skin
547

434
433
434

Anthrax,

the

sebaceous

113

Anthemata,
214

diagnosis,

216

glands,

457

et

seq.

648

INDEX.

Anthrax,

Burns, varieties

etiology,216
morbid

anatomy,
and

symptoms

course,

215, 216

Callus, 288

Ar^yria, 454
skin, 6

and

Cancer

of, to hair, 6

diseases, 146

in skin

Arteries

Camper,
6

pilorum,
relation
Arsenic

passing directly into

veins

each

other, 59

secondary, 633"

of the

skin, definition, 627

of the

skin, etiology,637

of the

skin, pigment,

of the

skin, prognosis,643

of the

skin, symptoms
skin, treatment,

of the

glanders,349

in

rhinoscleroma,

of

syphilispoisoned by

Carbolic

355
mercury,

347

acid

Carbuncle,

Carbunculus,

Barensprung, 390
Barley mite, 555

Carcinoma

Bateman.

382

Baumler,

336

Catarrh

Caustics

Baxter, 260

Anthrax

231

skin, 84

of the

skin,

in skin

also Eczema

see

diseases, varieties
of

corium, 5

Changes, senile,in skin,

Bed-hair, 40

of, 145

602

angioma,
substance

Cement
547

course,

644-646

diseases, 144

of the

Cavernous

Bazin, 122

Bed-bugs,

of, 1 1

and

Anthrax
see

Charcot, 373

growth of, 45

Charlouis, 352

Bed-sores, 397

358
Chionyphe (Carteri),
Cheiropompholyx, 268

Biesiadecki, 177
Billroth, 202

morbid
anatomy,
treatment, 269

Birch-Hirschfeld, 328
"

Biskra
Bouton,"
Besnier, 1

218

Chelis, see. Keloid

Cheloid,

see

Keloid

Bizzozero, 16

Chilblains, 169

Black

Chloasma

heads, 464
Bleuler, 389

gravidarum,

Bloody sweat, 505

varieties

441

441

uterinum,

and

causes,

Boeck, 192

Chondromata,

Boegehold, 234

Chorioblastoses, 107, 110, 111

Chromatoses,

Bollinger,356

Chromidrosis,

Book-lice, 556

Chronic

eczema,

infectious

Bromhidrosis,

506

Chronic

Bromine

469

Cicatrices, 119

acne,

Brown-Sequard,
Bruno-Volkmann,

557

103
504
174
skin

diseases, 271

and

how
produced,
quality of, 563

645

Bulkley, 270
Burns, treatment, 168
.

442

113

Boils, 156

563
symptoms,
treatment, 564, 565

641

cutis, 626

Carnochan,
existence

in skin

see

Balzer, 522

membrane,

632

Capillarylymphangioitis, 91
91
phlebitis,
Caposi, 196

tubercle, 275, 276

leprae,317

Basal

causes,

of the

of the

cause

of

Bacteria

in, 645

skin,

skin, localization,641
skin, morbid
anatomy,
of the skin, papillarj%640

hair, 409

glanders, 348

the
Bacillus

skin, arsenic

of the

of the

of the

of

of the

636
skin, histogenesis,
of the skin, liistory,
626

pigment, 445
Auricle, lupus of, 295
Auspitz, 269
Bacilli

482

of the

Asteatosis, 463
Athei-oma, 466
Atrophy

239

treatment,

of

Arrectores

et seq.

Callositas, 238

216

treatment,

of, 165

216

561

268-

638^

64"-

INDEX.

Cimex

Deformitas

lectularius, 547

Classification

diseases, 131-140

of skin

Cleavabilityof skin, 3
Cleavage of skin, direction, 3

Degeneration

inquilina,556

"

205

Colored

folliculorum

in, 59

ambustionis

(burns),165,166

ambustionis

escharotica, 166

large,histology of, 54
large and small, 52

exfoliativa

acuta, 259

exfoliativa

generalis,258
infantum
(Rittershain's),

exfoliativa

of, 65

261, 362
traumatic, 170

57

trophoneurotic,398

hair, 34
hair, anomalies, 401

113

Dermatomycoses,

sweat, 504

Columnse

Dermatomycosis

adiposae,55

Favus

see

furf uracea,

Condylomata, 241, 243

see

Congelations, 169
Connective-tissue

new-formations,

Congestion

skin, 158, 153

of the

Coriuni, blood-vessels
Corium,

muscles

561

of, 5

texture

Cornification
and

of, 3

and

keratohyalin,23

Ranvier, 590

Corns, 239
cutaneum,

epidermis, 13

of

hairs, 30

of

nail,23

of

papillarylayer of skin,

passage
of

Discoloration

of arteries

into

veins, 59

hairs, 34
of nails, 485
Sartian, 304

Corpuscles, tactile,64

Disease,

the

Course

Distoma

hepaticum, 550
of general functions

of

skin-diseases,
139,130

Crab-lice, 544
Craw-craw,
Crusts, 119
Cutis

Disturbances

of innervation

553

Domeo,

pipiens,548
development of, 3
proper,

Cyanosis, cardiac, 153

Cysticercus cellulosse cutis, 549

cellulosse cutis, diagnosis,550
Cysts, sebaceous, 466
Czerny, 571
Danmark,

of the

of the

620

Dupuytren, 483
Dyshidrosis,500
Dystrophy of the hair, 409
Ecchymoses,
Echinococcus

156

cutis, 550

Ecthyma, 317, 318

Eczema, 170
about
genitalregions,177

398

Decubitus

acutus, 397

Defective

formation

of

acute, 173

nails,483

Developmental anomalies, general, 103

Diagnosis of skin-diseases, 139, 130
of corium, 8
Diagonal muscles
Diptera,larvae of, 553
Direction

240

cutis, 3

of

skin, 1 et seq.
of skin as a whole, 1

Direct

treatment, 239

of

of

of, 8

diagonal
histology of, 4
oblique tensors of, 8

Ringworm

skin, 570

112

Development

of, 58

substance

cement

of

tumors

Desmomata,

treatment, 170

Culex

sicolor
Pityriasisver-

trichophytina,see
Desmoid

treatment, 243

Cornu

achorina,

464

Comedo,

Cornil

hominis, 537

congelationis,varieties of, 169

producing fat-cushion,
small, histology of, 53
of

nails, 485

function, 54

nerves

of the

of

boil," the, 218

fat,55

subcutaneous

circulation

Color

197

165 et seq.
Dermatitides, superficial,
ambustionis
Dermatitis
bullosa, 166

of, 53

and

Color

Delhi

Demodex

Coil-gland,duct
Coil-glands,52

485

nails,485

et seq.

Clothes-louse, 543
Cohnheim,

of

of the skin, 86
Deep inflammations
of the skin,
Deep-spreading inflammations

Clavus, 239

Clothilia

unguium,

Deformities

acute, usual

seats

of, 173

skin, 71
skin, 107

650

im)Ex.

chronic, 174
chronic, usual

Eczema,

seats

Erysipelas,anatomy, 306
complications of, 303, 304
diagnosis,306
etiology,304-306
history,197

of, 174-176

definition, 171

diagnosis,179, 180, 181

etiology, 178
facial, 175

of the

facial,treatment, 187

of the

face, 800

marginatum, see Ringworm

of genitals,treatment,
188

of the

genitals,203
scalp,801

of hands

and

of the
of the

feet,treatment, 189

of

scalp,treatment,

of

special regions, treatment,

pathologicalanatomy,

pathology, 806
prognosis,206

187,188

177, 178

Erythema,

171

treatment, local, of acute, 183

treatment, local, of chronic, 184-187
see

fun-

Granuloma

description,171, 173

frame-work

and
9

between,
tissue

connection

muscles,

of

skin, 5
ElephantiasisArabum, etiology,330

Emaciation,

Arabum,

morbid

Arabum,

symptoms,

Arabum,

treatment, 330

folds

Endothelial

anatomy,

multiforme,

368

multiforme,

complications, 370

multiforme,

definition, 369

multiforme,

duration, 370

nodosum,

diagnosis,377

nodosum,

morbid

nodosum,

treatment,

traumatic, 151

Erythemata, medicinal, 373

polymorphous,
prognosis,375

warts, 586

Eph elides,439
Ephidrosis,494, 499
pedum,
vola

manus,

of,

form

of, 13

Excessive
499

of, 13

Eponychium,
Erb, 408
Erosions, 118

fissures

substance,

of the

477

hairs, 438

Face, lupus of, 894

of the hair, 50

Farcy-buds,

348

55
and coil-glands,
Fat, subcutaneous,
57
cushion, produced by coil-glands,

tissue,56

631

molluscum,

anatomy, 633
diagnosis, 633

molluscum,

etiology,
^635

moUuscum,

and

Falot, 444

of, 65

Epithelialanomalies, 103
Epithelioma molluscum,

Expansion

of nail

formation

Fall

juice-spacesof, 60
layers of, 14
lymph-current in, 63

83

363

Eulenberg,
500

fields

nerves

375

Erythrasma, 536
Etiology of skin diseases, 130

Epidermidoses, 103
Epidermis, development

"

treatment,

87

Entomoses,

pathogenesis of,

373-374

586

tumors,

J}76

377

psychical, 151, 153

587

sarcoma,

anatomy,

fever, 374

of
289

336

of, 4

150
profluviis,

iris,371

vesicular, 173
Elastic

149

ex

goides
and

198-200

caloricum, 150
circinatum, 371

treatment, local, 183

tuberculatum,

course,

206, 207

treatment,

treatment, internal, 181, 182

varieties

and

symptoms

prognosis, 181
symptoms,

trunk, 801
umbilicus, 308

of the

187

173

papulosum,

extremities, 308

tissue, histology of, 56

Fats in skin diseases, 145
Favus, 518
achorion

in, 515

anatomy

of, 514

diagnosis,515
treatment,
Fetid sweat,

506

515

651

INDEX.

Glands, Tysonian, 51

Fever

erythemata, 374
Fibrillary tissue of skiu,
Fibroids

diagnosis,574

Granular

hard, 572

Granulation

soft, 571

Granuloma

epidermis, 9

of the

medinensis, 551

Granulomata,

sanguinis horainic, 551, 552

Growth

Flea, the,

Gruby,
464

worms,

of

the

of

hair, 34

varieties.111
hair, anomalies, 401

424

Gubler, 496
Guibout, 236
Gull, 99

skin, 4

340-342

Gummata,
Guinea

Fox, 163, 500

551

worm,

Hsemathidrosis, 505

tropica, 351

Frambcesia

Hair, anomalies

tropica, etiology, 853

tropica, pathology, 352

tropica,treatment,

in

anomalies

color, 432

and

354

change

changes in, at
changes in, in

ridges of papillarylayer, 11
skin, 4

of the

Furuncle,

Furunculus,

color

Furunculus

see

in color

the

et

of

birth, 33

adult, 33, 34

of, from

wasting diseases,

434

dystrophy of, 409

diagnosis,214

fall

etiology, 213, 214

form

anatomy,
and

symptoms

course,

of, 50
of, 34

histologyof, 34
medullary cylinder of, 40
patchy whitening of several, 435

214

prognosis,214
213

relation

treatment, 214

root

Gadflies, 548
Gaulke, 540
Gay, 384

etiologyof
functions

skin

of

diseases,120

the

skin, disturbances

of,

of

arrectores

to, 6

of, 36

sudden

Gamasidae, 546

whitening

of, 433

434
causes,
whitening of, from nervous
Hair-bed, 43, 44
Hair-change, 41, 42
a change in type, 46
sion
clinical and
histologicaldiscus-

71

of, 47, 48

pathology

and

therapeuticsof

the

skin,

76 et seq.

primitive,31
Hair-follicle,pricklelayer of, 85, 86
Hair-cone,

semeiology, 113
of skin-diseases,
treatment
140-146
Gibert, 262

the, 34, 35
three

regions of, 32
of, 65

nerves
Hair-follicles,

Glanders, 348

new

bacilli

between,

of, 350

minora, 5

see Sebaceous
glands
sudoriparous,see Sudoriparous glands

Sweat

glands

of,in the adult, 50

straight,difference
32

Hairs, development of, 30

direction
of, 34

sebaceous,

see

formation

oblique and

of, 348

morbid
anatomy
Glands, Meibomian, 51

sweat,

401

of, 434

time

defined, 213

of labia

growth,

of, 34

decoloration

212

morbid

General

and

atrophy of, 409

Frisch, 354
and

color

seq.

Freckles, 440
Furrows

358

bed-hair, 45

of the

Fluxion, 149
Folds of emaciation, 4
Form

of

546

Flemming,
Flesh

tumors, 112

fungoides, 358
fungoides, morbid
anatomy,
359
fungoides, synonyms,
(Virchow's),110

skin, 112

of

Filaria

layer of skin, 17

570

Fibromata,
Fields

Goffroy, 398

skin, 570

of

Fibroma,

Gnats, 548

expansions

and

individual, 26
Hansen,

318

fissures

of, 428

652

INDEX.

Harting, 13
Harvest-bug,

in the
in the
Head

Hyperakanthosis, 106
Hyperhidrosis,494
axillary,500
etiology,494

554

skin, symptoms, 555

skin, treatment, 555

treatment, 501, 502

skin, 71

of

Hypohidrosis, 503
Hypertrichosis,403

Hebra, 28, 357

304

Heiman,

Hemorrhages

497

symptoms,

lice,543

Heat-function

of the

skin, 156

of the

skin, symptoms,

156, 157
of

disturbances

nutritive

Hemorrhagic

acquisita 408
acquisita, treatment, 408

et seq.

the

etiology 407
indoles hereditaria,
403

skin, 100

morbid

Henle, 80, 38

anatomy,
transitoria,408
varieties,403

Herpes circinatus, 371

Ringworm

circinatus, see

definition,388
etiology,394, 395

407

437

Hypertrophy, pigment,

facialis,389
gestationis,269, 270

Ichthyosis, 333

iris,391
labialis,389

congenita, etiology,238

pathology of, 117

etiology,335

progenitalis,390

336
follicularis,

prognosis, 395
tonsurans,

morbid

Ringworm

Idroses, 103

391

Impetigo, 190 et seq,

contagiosa,190

zoster, 391

herpetiformis,"190

zoster, symptoms,
zoster, varieties of, 393

Infectious

548

nails and hairs,36

chronic,
skin-diseases,

Inflammation

hair, 34

skin, 78, 70

of the

skin, deep, 86
skin, individual

layer

skin,

layer,thickness
Horripilation,399
Hunt,

skin, irritative forms, 98

skin, spreading,86
of the skin, varieties of, 97
of the

18

of, 22

of the

Inflammations

197
skin,deep-spreading,

et seq.

251

Hutchinson,

of,

of the

layer,color reactions,table of, 20

of

forms

97

Horns, 240, 241

Horny

skin^

371

of the

of the

papillarylayer,11

of the

of the

97

Hesse, 6
Histology of chorium,

269

of inflammation

forms

Individual

391

of

336

Idioneuroses, 17

zoster, pathology) 391

zoster, seats of, 393, 395

Hirudinea,

of, 234

anatomy

treatment,

396

treatment, 395,
vegetans, 190
zona,

of, 334

localization

388
see

235

course,

praeputialis,cQO

tonsurans,

et seq.

congenita, 337, 338

of the

268

Inflammatory

Hiiter, 206

Innervation, disturbances

113

Hyalomata,
Hydroa gestationis,270
Hyperaemia, cosmical, 153
mechanical, 153
of the

Involuntary
Ischaemia

mode

skin, 80, 147

skin, symptoms,

of the

skin, treatment, 153, 154

passive pathological,
the skin,363

148

152

of

life,533

Itch, see Scabies

Itching of

the

of the

of, 101

of skin, 6
skin, 154

muscles

of the

Itch-mite, 530, 533

of the

Hypereesthesia of

skin, superficial,79

disturbances

skin, 364

Ixodes, 547
Ixodis ricinus, 547

skin, 78, 79

654

INDEX.

of

Lymphatics
Maculae

caeruleae,444
varieties,114, 115

origin and
Madura

"

Myxoedema, 99
Myxoma, 584
Myxomata, 113

skin, 61, 63

Nsevi

foot," 358

Mahly,

46

Malum

perforans pedis, 396

prognosis, 440
of, 438

varieties

552

Manson,

Nail

Martin, 189
Mechanical

of skin

treatment

the

of

Milium,

true, 26
chemical

defective

497, 498

defective formation

109

vegetable parasites of, 486

changes

in

the

nail

and

its

bed, 477

hemorrhagicus,

maculosus

et

157, 159,

Werlhofi, 150, 160

pedicularis,see Pediculosis
Morphoea (Wilson's),113
maculosus

disturbances

of the

skin,

of

the

of, 477
skin, 382

membranes,
elastic

and

Nerve-lesions
Nerves

of the

skin

diseases,185

skin, 63

Nettlerash,377
455

Neuralgia cutis, 363

lupus of, 296
frame-work,

of the
connection

611

diagnosis, 613

corium, diagonal, 8
skin, 4

membranes,

etiology,613
nature, 613
treatment, 614

varieties,609, 610

dartiques,608

skin, 363

Neuritides, 96
Neuroma,

Mussy, 380
Mycosis f ungoides, Alibert,
Mycotic diseases, 113
skin diseases,373
Myoma, 607
Myomata, 113
Myomes

disturbances

Neurotic

Neumann,

399

101

between,

Muscular

Nail-bed,blood-vessels of, 28
Nail-substance,excessive formation
Neck, lupus of, 295

160

of

of, 485

hyperplasia of, 483

individual,26
traumatic
injuriesto, 486

seq.

of

of,treatment, 484,485

of, 485

discoloration

contagiosum,

and

and

degeneration of, 485

466

233

Muscles

of, symptoms

484

deformities

neuroses,

of, etiology,483, 484

formation

course,

465

Molluscum

Mucous

injuriesto, 486

defective formation

499

Moncorvo,

Motor

28

Nails,aplasia of, 483

Mites, 564

Morbus

et seq.

adult, 26

papillarylayer of,
plate,26

diagnosis,466

Morbid

of, 483

changes in, 477

nail of

of, 11

anatomy,

treatment,
Millard, 164

et seq.

25, 26

of, 30

morbid

skin, 598

Membranes, muscular, 6
by the skin, 74
Mercuiy absorbed
of syphilis,347
bacteria
poisons
of trachoma, 351
Micrococci
and termination, 498
Miliaria, course
498
definition,
diagnosis,499
morbid

ages,

of, 27

growth

basal, existence

treatment,

of, at different

fold,'
29

hair, 40

lunula

Melano-sarcoma

changes in, 477

bed, morbid

development of, 23

Meissner, 54
Membrane,

its

defective formation

diseases,145

the, 551

worm,

Medullary cylinder of
Meibomian
glands, 51

and

appearance

Matrix, blood-vessels of, 28

Medina

600

Naevus, 438

353

Neuromata,
Neuroses

of

113
361
sensibility,

of the

skin, 361

of the

skin, varieties,101
skin, vaso-motor, 368

of the

New-formation
New-formations

of hair
of the

follicles in the

skin, 557

adult,50

G6I"

INDEX.

Pathogenesis of skin disease, 124

Pathology and therapeuticsof the

Nielly,553
Nits, 542
nutritive

Non-inflammatory

disturbances, 98

Pediculosis, symptoms

Nosology of the skin, 76

Nothnagel, 363

pubis, 544
varieties,541, 543

difference
straight;hair-follicles,

and

between, 82
tensors of corium, 8

Pemphigus, chronic, 264

diagnosis.267
etiology,266
history,263

463
Oligo-steatosis,

morbid

O'Neill, 552

pathology of, 108

Onychauxis, etiology,479
anatomy,
symptoms, 480
eatment, 480-483

Perionyx, 29
Perspiration,see

267, 268

Sweat

Petechise, 156

Onychomycosis, 486
Openchowsky, 65
Oppolzer, 393

Phlebitis,capillary,91

Phlegmon,

208 et seq.

anatomy, 211
definition,208

Ord, 99
Orth, 205

diagnosis,212

Osmidrosis, 506

etiology, 208, 209

of the

skin, 113

morbid
anatomy,
prognosis, 211

553

Oxyuris vermicularis,

and

symptoms

Pachydermia,
Pallor

see

Elephantiasis

treatment,

skin, 155, 156

of the

circulation,58

cancer,

hair, 40

hypertrophy,

layer, furrows

and

ridges of, 11

layer,histology of, 11
layer of skin, development,
layer of the nail, 28

of the

and

rubra, diagnosis,261
morbid
anatomy,

skin, 363

rubra, treatment,

versicolor,morbid

skin, historyof, 509, 510, 511

temporary,

546

Plane

diseases, classification,

528, 529

origin of

of

diseases,128, 139

218

Primitive

Paronychia, traumatic,

Prognosis in

layer,the, 14

487

traumatic, treatment, 488

Patchy whitening of several hairs, 435
436

of

several

526

Prickle layerof hair-follicle,

35, 36

skin diseases, 508

Parhidrosis, 503

whitening

anatomy,

treatment,
versicolor,
stratification of nail,27

Polak, 305
PoUak,

skin

261

versicolor,definition,524
versicolor,diagnosis,52Q

Parasites of the skin, accidental, 554

Parasitic (animal) skin

260

rubra

tuberculosis, 879, 280

of the

(ofGibert),363

rubra, 258

Parangi, 354
Parasites

437

skin, 66

Pityriasisrosea

583

of the

641

Pincus, 48, 414, 418

Papules, originand varieties,116

Paraesthesia

209-211

course,

212

syphilis,453
9

vessels,13
tumors,

211

Phthiriasis,
see Pediculosis
Physiology of the skin, 67 et seq.
452
Pigment atrophy after syphilis,
atrophy of the skin, 444

Papillae,10
morphology of, 10
of the skin, 640
Papillarycancer

Parablastic

266

anatomy,

treatment,

478, 479

morbid

Osteomata

543

course,

540

treatment, 544
Pediculus

rliagic,100

Oblique

and

synonyms,

disturbances, non-inflammatory, 98
the
of
disturbances
skin, hemor-

Nutritive

skiu,76

seq.

hairs,treatment,

hair-cone, 31
skin

diseases,129, 130
skin, 71

Protecting function

of

Prurigo, anatomical

lesions,384

definition,382

diagnosis,385

525

et

'656

INDEX.

Prurigo, etiology,385

Root-sheath,swelling of, 32

pedicularis, see Pediculosis

Rosalia, 149

prognosis, 386

Roseola, 149

senilis,384

Rose-rash,

sine

and course,
symptoms
treatment, 387
ani, 365

Pruritus

882

Sand-flea,548
Sappey, 6

cutaneous, idiopathic,364, 365

Sarcoma

cutaneous, symptomatic,

Sarcomata, 113
Sarcoptes scabiei communis,

364

diagnosis,365
pudendi, 365

Sartian

treatment, 366-368

Psoriasis,definition and history,248

diagnosis,249
etiology,245
morbid
anatomy,
treatment, 250

546
irritans,

definition

skin, 589

disease, the

and
symptoms
treatment, 536

varieties,158

scorbutica, 160
treatment, 164, 165
Pustules, 82

Eanvier, 17
Rayer, 229
Regulation of heat,

Schultze, 16
Sclerema, 100
225, 226

neonatorum,
see

also Sclerodermia

Scleriasis,see Sclerodermia
Scleroderma, see Sclerodermia
Schlerodermia, diagnosis,224

etiology,223
general,221
morbid
anatomy, 222, 223
and coui'se, 220
symptoms
treatment, 224, 225

71

Scrofuloderma,

539

288

diagnosis,289, 290

Renaut, 81

treatment,

Respiratory function
Rete Malpighii,13

of the

skin, 67

Scrof ulosis and

Scurvy,

bacteria

in, 855
579

of, 463

treatment, 582
516

glands, functions of, 458

glands,hypersecretionof,458
glands, true, 50

diagnosis,523
morbid

anatomy, 522
symptoms, 519-522
treatment, 524
trichophyton in, 518
Rittershain, 261

cyst, 466

gland tumors, 616

glands, 50-52
of, 457 et seq.
glands, anomalies
of secretion
of ,464
glands,anomalies
arrested secreor
tion
glands,diminished

diagnosis, 580
symptoms,

secretion,the, 70
Seborrhcea

corporis,460
diagnosis,461

Robinson, 247, 248

localis,459
of the face, 460

74

prognosis,461

Rohrig,

of the

hair,36

290

Tuberculosis, 284-286

160

Sebaceous

sebi, 464

Rhinophyma, 580
Rhinoscleroma, 354

Root

533

Schonlein, 508
Schulin, 46

retrogression of, 83

Ringworm,

course,

of, 536

Scabs, 119

development of, 83

Retentio

mite

Scars, 119

and

diagnosis,162
etiology,162, 163
hemorrhagica, 159, 160
pathology, 161
prognosis,164

Remak,

546

304

Scales, 118, 119

penetrans, 548

Pupura,

of

Scabies,definition,530
diagnosis,535
natural
historyof
prophylaxis,537

105, 247

treatment, external, 252

Pulex

the, 149

papulis,364

treatment,

461, 462

657

INDEX.

Sweat, ingredientsof, 68, 69

changes in,503
qualitative

459
universalis,

Seborrhoea
70

Sebum,

Sweat-gland, see also Coil-gland

Sweat-glands,
atrophy, 493, 494

68

of

sweat,
sebaceous, 70

Semeiology,

hypertrophy, etiology,492
hypertrophy of, symptoms, 493
inflammation
of, etiology,490

113

Senator, 72
changes in the skin, 9

Senile

of

decoloration

Sensory

of

neuroses,

101

inflammation

of, 72

parasitesin, 554
parasitesof, 528 et seq.

accidental
animal

color

in the

anomalies
as

protectingorgan,

as

sensory

of, 437
71

71

organ,

diseases

infectious

chronic

Sweat^pore, 53
Sweat-pores,function of, 55
Swelling of root-sheath,32
Sycosis,definition of, 474
diagnosis,475
etiology,475
morbid

of, 271

474, 475

anatomy,

hemorrhages of, see Hemorrhages

see Ringworm
parasitaria,

in Addison's
disease,444
involuntary muscles of, 6
of, 361 et seq.
neuroses

prognosis, 475
treatment, 476

new-formations
new-formations

560
of, classification,

bacteria

of, poisoned by mercury,

of, 335
immunities
from, 344, 345
infection
of, 346, 347

and

Skin-diseases

prognosis in, 129, 130

and the generalorganism, 120, 121
classification
course

lymphatic glands in, 333

malignancy of, 343
pigment,
suppuration in,342
tardy form of, 346
unity and dualitytheories,329,330

of, 129, 130

general
treatment

of

Soap in skin-diseases,142
Spreading inflammations
Squamae, 118, 119

general,140-146
of the

skin, 86

Taenia
the

skin, 530

Steatoma, 466

diagnosis,467
treatment, 467
Steatoses, 103
5
Stirling,

Subcutaneous

tissue,2

Sudden

whitening of the hair,433

of, 490 et seq.
Sudoriparous glands,anomalies
glands,see also Sweat glands
Sulphur in skin diseases,142
of the skin, 79
inflammations
Superficial
Sweat-gland tumors, 619
42

of, 337

Tabanidffi,548
for

of color-reactians

horny layer,20

corpuscles,64

Tactile

Stasis

phlegmons, 90
Stationaryparasitesof

virus

Syphiliticvirus, 337
Syphilomata, 340-342

Table

dermatoses, 99

in, 334

452

diagnosisof, 129, 130

general etiology,120
of, 140-146

of infection

mode

of, 131-140

treatment

347

classifications

lesions,125

Skin-disease

nerve

113

Synanthemata,
Syphilis,328

of, 557

nosology of, 76
of, varieties,528, 529
pai'asites
diseases
of, 508 et seq.
parasitic
pigment of 66

Stasis

of, symytoms, 491

of, treatment, 492

inflammation

Skin, absorptivepower

tomy,
ana-

491

451

Simon,

of, morbid

inflammation

hair,433

skin, 71

functions

of, 494

disturbances

functional

skin, 68

of the

Secretory function

of, 68

secretion

analysisof, 70
Secretion

solium

in human

connective

tissue,549

Tar-acne, 469
Tar in skin- diseases,144

Taschkent-Qeschwiir,see
Tattooing,456
Temperature and tension
Temporary parasites,546
of the skin

Tension

disease

Sartian

of the

function

skin, 8

of

temperature,

8
of

Tensors

corium, oblique,8

Therapeutics of
Thickness

of

Thiersch, 109
Thin.

112

the

skin, 9

skin,general,76

et seq.

658

INDEX.

regions of

Three

Ticks,

547

Tomsa,

the

hair-follicle,33

Vessels

matrix

of

nail-bed, 28

Vibices,

158

Vidal,

Treatment

skin

of

in

Trichophyton
Trichosis,

diseases, 140-146
518

ringworm,

405, 406

True

nail, the, 26

True

sebaceous

of

the

skin, 382

275

Virchow,

100, 208

syphilitic,337
448

VitiUgo,

51

68

Tubercle

bacillus, the, 2T5, 276

302

Volkmann,

116

muscles

Voluntary

and

lupus,

relations

between,

281
,

Von

453

solution, 253

Vlemingkx's

Tuberculosis

451

diagnosis,

Triimpy,
Tubercles,

262

course,

glands,

12

156

Villemin,

Virus,

disturbances

Trophoneurotic

nail, 38

of

papillary,
351

Trachoma,
Traube,

of

of

skin, 4

354

Frisch,

282

scrofulosis, relations

between

Tuberculosis,

general pathology,
the

of

and

275

55

Warren,

239, 240

Wai-ts,

skin, 286
skin, diagnosis, 287

the

fibrosus, 570

Tumor

excreted

Wernicke,

223

Whitening

of

of

507

Urhidrosis,
Urinous

507

sweat,

217, 282

Wilson,

2, 352, 432

378

547

552

Wucherer,

pathological anatomy,
prognosis, 380,

378

372

Wunderlich,

381

381

treatment,

vitiligoidea,575

Xanthelasma

575

Xanthoma,
Van

Harlingen,
of

Vaso-motor

Vater,

hair, treatment,

547

Wood-ticks,

379

etiology,

Varieties

289

morbid
of

inflammation
of

neuroses

the

the

skin, 97

anatomy,
575

planum,

skin, 368

65

tuberosum,

Xanthomata,

113

Veill, 195
Venous

of

hyperasmia
lymphatic
stasis

of

skin, 152
Yaws,

stasis, 87
skin, 88,

the

Yellow

89

band,

Zabludowski,

Vesicles, 82

eruption of,
origin
Vessels

951

the,

239

Verruca,

of

and

corium,

nervous

73

Wood-beetle,

diagnosis,

the

Willan,

Wittich,

377

Urticaria,

from

causes,

434

108, 509

Unna,

hair

the

59

glands,

Tysonian

67

606

238

Tyloma,

by skin,

157

Werlhof,

archiblast,

of

Tumors

diseases, 141

skin

in

Water
of

17, 18, 66

Waldeyer,

284-286

see

Pemphigus

description,
58

117

Zeissl, 335
Ziegler,
Ziim,

272

550

22

30

576

578

436