title: Illustrated skin diseases : an atlas and text-book with special reference to modern diagnosis and the most approved methods of treatment
text: - - - *L. -V ^ ^ £r. v<^' ^ ■x* v ^ •Pi. V V - : w ■> ^ . 1 » t w •£. .*?*% ^ ". ^ ^ N o o ^ V 1 ^ '// C' 4^ '*j ' '■ ,$\. -V K- & ' f 'r. - ' -P .^ %> %> > - C JV _*..-_" '- * - *v > A ,: ** V % •P . X O -Pi. v- v N ^ \ ; N , i . %■ ^ ^ ^ -^ o ' v* .*' v N * - # <\V </», AV <?, O v'\ A ^ v* A 9-^' 1 * c5 ^ NT V ■Pi. C^ <5 ^ vOC> ,^ x ss- 5 V* ,^^ s^.A N .hi, -'. *° N ■<y c° Nc * ^ "^ ,<^ o o> ■ \ ^ X/- ,^ N vV "^ v 0o. O0 l ,x^ x <b«? ■& "> •M* -^ •p ^ S _,^_ ^/, t* c/ ILLUSTRATED SKIN DISEASES AN ATLAS AND TEXT-BOOK WITH SPECIAL REFERENCE TO MODERN DIAGNOSIS AND THE MOST APPROVED METHODS OF TREATMENT BY WILLIAM S, GOTTHEIL, M.D. VISITING DERMATOLOGIST TO THE CITY HOSPITAL AND TO LEBANON HOSPITAL ] CONSULTING DERMATOLOGIST TO BETH-ISRAEL HOSPITAL; FELLOW OF THE N. Y. ACADEMY OF MEDICINE; MEMBER OF THE MANHATTAN DERMATOLOGICAL SOCIETY, THE N. Y. COUNTY MEDICAL SOCIETY, AND THE AMERICAN MEDICAL ASSOCIATION, ETC. ,* ETC. SECOND EDITION, REVISED AND ENLARGED NEW YORK E. B. TREAT & COMPANY 241-243 WEST 23D STREET 1906 I LIBRARY of C0N6HESS Two Copies Received MAR 12 1907 Copyright Entry CLASS O. XXc.No. /IOC, 02- COPY B. Copyright, 1897, 1902, and 1905, by E. B. Treat & Co. PREFACE TO SECOND EDITION. In the attempt to make a general survey of a branch of medicine so young and so rapidly growing as Dermatology there are difficulties that do not occur in older and more thoroughly explored fields. In cutaneous medicine the description and differentiation of new maladies, and the correlation and grouping of older ones, are still in progress ; and the limitations and boundaries of its various subdivisions are still matters of discussion. Classification, upon whatever basis it may be made, is necessarily imperfect, for both the etiology and the pathology of many dermal mal- adies are still unsettled. Even the nomenclature presents difficulties of its own. In some cases dissimilar diseases are known by similar names, and in others the desig- nations of a single malady are varied and confusing. In the following pages the field of dermal disease has been covered only so far as it is necessarily of interest to every practitioner of medicine. The nomenclature employed is that in common use. The classification that is followed is the simple pathological one recommended by Jessner, which seems to be as good as any one at our disposal to-day. Especial stress is laid upon the Symptomatology, Diagnosis, and Treatment of the various diseases, while the less practical considerations of Eti- ology and Pathology are condensed and cursorily considered. Questions that are still matters of dispute in Dermatology have been, as far as possible, avoided. No attempt has been made in the therapeutic sections to mention all the measures and plans of treatment that have been found useful in the various diseases. The stan- dard modern methods, and more especially those that the author has himself found useful, have been recommended. It is^ hoped that the simplified and systematized arrangement of the prescriptions will be found useful. Pictorial representation, a recognized aid to the practitioner in every department of medicine, is of preeminent importance in Dermatology. Most of the symptoms are objective and visual, and the diagnosis must generally be made by the eyesight alone. It is difficult to represent in words the manifold impressions and the delicate 3 4 PREFACE. variations that are so readily appreciated through the optic nerve. Many attempts have been made to depict on paper and permanently preserve the evanescent features of dermal disease. Photography and its dependent processes are the most suitable means for that purpose ; for the artist's brush necessarily reflects his own individuality, and his work is influenced by factors so many and various as to make it unsuitable for reproduction in quantity. Colored illustrations have been intro- duced in this atlas in all cases in which they have seemed to be necessary or advisable ; but in the many instances in which color is of no importance for the recognition of disease, illustrations in black and white have been supplied. The pictures, both plate and text, have been selected with the view of exhibit- ing, as far as possible, the ordinary phases of skin disease as met with in practice. Most of them are from photographs of his own patients made by the author. Those that are not are credited to the physicians from whom they came. A few are taken from foreign sources. The anatomical illustrations are from photomicrographs. In this second edition the section on Cosmetics of the Skin and Hair has been entirely rewritten and very greatly enlarged ; for the author believes that it is the neglect of this field which has permitted it to fall to so large an extent into im- proper and non-medical hands. The number of prescriptions has been considerably increased ; and the various changes which the improvement of our knowledge of the nature, pathology, and treatment of certain dermatoses render necessary have been made. The author desires to express his thanks to Drs. T. E. Oertel and William Beurman for assistance in the preparation of the plates, and to Dr. J. F. Aitken for his hearty good will and help in the collection of material. He also desires to thank Professor Elsenberg of Warsaw, Poland, Drs. Salvador Garciadiego of Guadalajara, Mexico, A. H. Ohmann-Dumesnil of St. Louis, A. Ravogli of Cincinnati, Ludwig Weiss, F. B. Carpenter, Robert Abrahams, Henry Roth, and Louis Fischer, of New York City, for the photographs and cases that they have placed at his disposal. William S. Gottheil. January I, 1902. CONTENTS. PAGE Anatomy of the Skin 13 Physiology of the Skin 29 Classification 52 Class I. Functional Disorders.... 54 Pruritus 54 Hyperidrosis 56 Sudamina 60 Seborrhea 61 Comedo 65 Milium 67 Sebaceous Cyst 68 Asteatosis 69 Class II. Non-inflammatory Circu- latory Disturbances 71 Erythema Simplex 71 Livedo 73 Urticaria 75 Prurigo 79 Purpura 83 Class III. Inflammations 86 Morbilli 86 Rubeola 87 Scarlatina 87 Variola 89 Vaccinia 90 Varicella 91 Lichen Planus 92 Lichen Ruber 94 Favus 96 PAGE Class III. Inflammations. — Continued. Trichophytosis Capitis 101 Trichophytosis Barbae 105 Trichophytosis Corporis 108 Trichophytosis Cruris no Chromophytosis 113 Scabies 116 Phtheiriasis Capitis 120 Phtheiriasis Vestimenti 122 Phtheiriasis Pubis 1 24 Eczema 125 Erythema Multiforme 139 Herpes 140 Zoster 142 Dysidrosis 144 Pemphigus 145 Dermatitis Herpetiformis ........ 149 Impetigo Contagiosa 151 Dermatitis Exfoliativa 152 Psoriasis 153 Dermatitis 159 Erythema Nodosum 166 Erysipelas 167 Chancroid 170 Furunculosis 173 Carbunculus 175 Tuberculosis Cutis 177 Lupus Vulgaris 177 Scrofuloderma 181 Tuberculosis Cutis Verrucosa 184 Chancre » 187 Syphiloderma 190 CONTENTS. PAGE Class III. Inflammations. — Continued. Lepra 215 Mycosis Fungoides 219 Lupus Erythematosus 221 Rhinoscleroma 225 Actinomycosis 227 Hydradenitis 227 Acne 228 Rosacea 233 Folliculitis ' 236 Onychia 239 Onychomycosis 240 Class IV. Hypertrophies 241 Ichthyosis 241 Keratosis Pilaris 243 Callositas 244 Clavus 246 Cornu Cutaneum 247 Condyloma Acuminata 248 Verruca 250 Elephantiasis 251 Molluscum Contagiosum 254 Hypertrichosis 256 Onychauxis 258 Naevus Pigmentosus 259 Lentigo 261 Chloasma 262 tagf. Class V. New Growths 264 Cicatrix 264 Keloid 265 Fibroma 267 Myxoma 268 Neuroma 268 Lipoma 268 Xanthoma 269 Sarcoma 270 Myoma , 272 Angioma 273 Lymphangioma 2/6 Adenoma 276 Carcinoma 277 Class VI. Atrophies 286 Atrophia Cutis 286 Scleroderma 289 Sclerema Neonatorum 291 Albinismus 293 Vitiligo 293 Canities 295 Alopecia 298 Alopecia Areata 304 Atrophia Pilorum 307 Atrophia Unguis 309 Cosmetics of the Skin and Hair ... 311 LIST OF PLATE ILLUSTRATIONS. PLATE Facing page I. Diagrammatic Section of the Skin 13 II. Urticaria Papulosa 75 III. Lichen Planus 95 IV. Zoster Pectoralis ; Erythema Multiforme 143 V. Purpura 83 VI. Scarlatina 87 VII. Dermatitis Exfoliativa 153 VIII. Trichophytosis 109 IX. Dermatitis Venenata 163 X. Dermatitis Parenchymatosa , 165 XL Favus 99 XII. Variola; Morbilli 91 XIII. Eczema Acutum 129 XIV. Pemphigus , 145 XV. Eczema Impetiginosum 125 XVI. Eczema Palmae ; Syphiloderma Palmse 133 XVII. Psoriasis 155 XVIII. Psoriasis Circinata 157 XIX. Psoriasis Diffusa 159 XX. Syphiloderma Ulcerosum ; Cathode-ray Dermatitis 215 XXL Erysipelas 169 XXII. Impetigo Contagiosa 151 XXIII. Chromophytosis 113 XXIV. Ichthyosis Hystrix 271 XXV. Lupus Vulgaris 177 XXVI. Lupus Vulgaris 181 XXVII. Syphiloderma Papulosum ; Syphiloderma Pustulosum 201 XXVIII. Syphiloderma Tuberculo-ulcerosum 209 XXIX. Syphiloderma Papulosum 193 7 8 LIST OF PLATE ILLUSTRATIONS. plate Facingpage XXX. Gumma Subcutaneum 211 XXXI. Rupia Syphilitica 213 XXXII. Syphiloderma Maculosum; Syphiloderma Gummatosum; Glossitis Syphili- tica ; Syphiloderma Papillosum 205 XXXIII. Syphilodermata 189 XXXIV. Naevus Pigmentosus 259 XXXV. Perifolliculitis Barbae 237 XXXVI. Ichthyosis ; Keratosis Pilaris 243 XXXVII. Syphiloderma Papulosum 185 XXXVIII. Elephantiasis Arabum 253 XXXIX. Syphiloderma Pustulosum 197 XL. Vitiligo ; Lymphangioma ; Keloid ; Fibromata 265 XLI. Acne 229 XLII. Rosacea 233 XLI 1 1. Naevus Vasculosus 275 XLIV. Alopecia Areata ; Alopecia Neurotica ; Alopecia Pityrodes ; Alopecia Totalis 299 XLV. Alopecia Areata 305 XLVI. Impetigo 149 XLVII. Erythema Multiforme 1 39 XLVIII. Elephantiasis; Sarcoma Pigmentosa ; Sarcoma Cutis; Tuberculosis Cutis Verrucosa 269 XLIX. Leucoderma 293 i.. Verruca ; Alopecia Areata 251 LI. Eczema Seborrheicurn 131 LII. Zoster Sacro-cruralis 143 LIII. Scrofuloderma ; Lupus Hypertrophicus 179 LIV. Rhinoscleroma ; Chronic Eczema ; Chromophytosis of Face 225 LV. Comedo and Acne 65 LVI. Dermatitis Traumatica 3 Dermatitis Herpetiformis 161 LVII. Eczema Marginatum IIr LVIII. Eczema Seborrhoicum I2 j LIX. Psoriasis of the Nails; Onycholysis; Eczema Unguium; Leucony- china Striata j,* LX. Variola; three forms 8o LIST OF TEXT ILLUSTRATIONS. FIG. I. 2. 3- 4- 5- 6. 7- 8. 9- 10. ii. 12. 13- 14. 16. *7- 18. 19. 20. 21. 22. 23- 24. 2 5- 26. 27. 28. PAGE Epidermis, corium, and subcutaneous tissue Author 14 Arrectores pilorum, hair-sacs, etc , Pacinian corpuscles, lymph-spaces, panniculus adiposis, etc Pacinian corpuscles, nerve-trunks, etc Sebaceous glands Sweat-glands and ducts Hair and hair-follicle Hair-shaft and root Transverse section of hair and sac Hair from head of female J. F. Babcock. Cross-sections of hairs from head " " Hair from head of child " " Hair from back of hand " " Transverse section of third phalanx Toldt. Scarificator Author. Comedo extractor Needle and holder for electrolysis Dermal curette Grappling forceps Epilating forceps Spear-shaped spud Keyes's cutaneous punch Dental bur !7 18 *9 20 21 2 3  1 5i 5 1 10 LIST OF TEXT ILLUSTRATIONS. fig. PAGE 29. Seborrhea capitis Author 62 30. Comedo J. F. Aitken 66 31. Comedo gigantica Author 67 32. Sebaceous cyst 69 2,2,. Urticaria gyrata " 75 34. Urticaria factitia 76 35. Urticaria pigmentosa Elsejiberg 77 36. Prurigo Van Haren-Noman 80 37. Purpura simplex Author 84 38. Vaccinia _ " 90 39. Varicella " 91 40. Lichen planus " 92 41. Favus corporis Ehenberg 97 42. Achorion Schonleinii Joseph 98 43. Favus capitis J. F. Aitken 99 44. Hair and root-sheath affected with favus Kaposi 100 45. Trichophytosis capitis Author 102 40. 102 47. Ringworm hair Kaposi 103 48. Trichophytosis barbae Author 1 06 49. Trichophytosis corporis " 1 09 50. Dermatomycosis flexurarum " no 5 1. Pityriasis rosea J. F. Aitken in 52. Trichophytosis cruris Author 112 53 113 54. Microsporon furfur Joseph 114 55. Chromophytosis Author 114 56. Erythrasma " 1 16 57. Scabies " 117 58. Acarus scabiei Kilchenvieister and Ziim, and Neumann 118 59. Pediculus capitis Author 121 60. Phtheiriasis vestimenti Van Haren-Noman 122 6 1. Pediculus vestimenti Kiichenmeister and Zilrn 123 62. Pediculus pubis Author 1 24 63. Embryo— Pediculus pubis " t 24 64. Eczema papulosum , " 126 65. Eczema vesiculosum Van Haren-Noman 127 66. Eczema squamosum Author. ,128 LIST OF TEXT ILLUSTRATIONS. 11 FIG. PAGE 67. Eczema faciei Author 129 68. Eczema of the hands " 130 69. Eczema acutum " 131 70. Eczema crustosum " 134 71. Herpes febrilis " 141 72. Zoster patch " 143 73. Acute pemphigus " 146 74. Pemphigus vulgaris " 147 75. Impetigo contagiosa " 151 76. Psoriasis guttata Ludwig Weiss 154 77. Psoriasis diffusa Louis Fischer 155 78. Psoriasis nummularis Van Haren-Noma?i 156 79. Psoriasis gyrata Author 157 80. Dermatitis traumatica - " 160 81. Parenchymatous dermatitis " 161 82. Parenchymatous dermatitis with ulceration " 161 83. Dermatitis ambustionis bullosa " 162 84. Dermatitis venenata " 163 85. Chancroid " 170 86. Chancroidal ulceration of labia " 171 87. Ecthyma " 172 88. Furunculosis " 173 89. Carbuncle A. H. Ohmann-Dumesnil 175 90. Lupus hypertrophicus Lesser 178 91. Lupus vulgaris " 179 92. Tuberculosis cutis Author 185 93. Chancre " 187 94. Exulcerated chancre " 188 95. Chancre of the lip " 189 96. Chancre of the meatus " 190 97. General macular syphiloderm " 191 98. General papular syphiloderm " 192 99. Papular plantar syphiloderm " 193 100. FIG. PAGE 05. Superficial gummata Elsenberg 199 06. Exulcerated gumma of the knee Author 199 07. Gumma subcutanea 2 °° 08. Ulcerative syphiloderm H. Roth 201 09. Paronychia syphilitica Author 202 10. Alopecia syphilitica Lesser 202 1 1. Multiple gummata Author 204 1 2. Lepra tuberosa S. Garciadiego 216 13. Lepra mutilans Joseph 217 14. Lupus erythematosus R. Abrahams 221 15. " " " 223 16. Acne punctata Author 228 1 7. Acne pustulosa " 229 1 8. Acne bromata Elsenberg 230 19. Rhinophyma F. B. Carpetiter 234 20. Folliculitis barbae Author 237 2 1 . Folliculitis " 238 22. Callositas " 245 23. Cornu cutaneum " 247 24. Condyloma acuminata " 248 2 5- 2 49 26. Elephantiasis vulvae Van Hare7i-Noma7i 253 27. Molluscum contagiosum Author 255 28. Onychauxis Va?i JJaren-JVbman 258 29. Naevus pigmentosus Author 260 30. Keloid " 266 3 1 . Sarcoma cutis " 271 3 2 . Naevus venosus " 274 t,^. Papillary naevus " 275 34. Rodent ulcer Ludwig Weiss 278 35. Epithelioma of the penis Author 279 36. Papillary epithelioma " 280 37. Epithelioma of the lip " 281 38. Fungating epithelioma of the scalp " 282 39. Striae atrophies A. H. Ohmann-Dumesnil 287 40. Leucoderma Van Haren-Noman 294 41. Leucoderma Joseph 295 COPYRIGHT BY E. B, TREAT & CO., N. Y. PHOTOGRAVURE AND COLOR CO., N. Y. DIAGRAMMATIC SECTION OF THE SKIN PLATE I. ANATOMY OF THE SKIN. ever present i ,wi are :. ■ . hi I ■ id. ling 1 ■ - TION OF THE SI ANATOMY OF THE SKIN. THE skin is an elastic and flexible membrane covering the entire body. Its structure is complex, and varies in different parts. Certain elements are present everywhere, and are essential portions of the organ ; such are the epidermis, the corium, and the subcutaneous connective tissue. Others are found only in certain regions, and are called appendages; as the hairs, the sweat and the sebaceous glands, and the nails. It contains also blood-vessels, lymphatics, and nerve- structures. Its appearance varies in different individuals and on different portions of the body. Its texture in places feels smooth and velvety, as on the forehead and on the lumbar regions ; in others, as on the outer surface of the thighs, it is rough and uneven. Its color depends on the amount of blood contained in the surface vessels, and on the pigment deposited in the epidermic layers. This latter varies in the different races, and is always more abundant around the nipples and on the genitalia. It is marked by deep furrows over the various joints, while secondary furrows further subdivide it into minute angular fields. At the junction of the angles of these fields are the pores, minute openings which mark the mouths of the hair-follicles and the sebaceous glands. Distinct ridges, corresponding to the regu- larly arranged papillae of the cutis, are found on the palms and soles. The skin is thickest on the back, buttocks, palms, and soles, and thinnest on the eyelids and the prepuce. It is in general more or less movable on the subjacent parts ; but in some places, as over the sternum and on the glans penis, it is more closely attached to the tissues beneath. Its entire surface is covered with hair; with ordinary long hair on the hairy parts, and with the fine down known as lanugo hair on the so-called smooth parts ; only the palms and soles, the dorsal surfaces of the third phalanges of the fingers and toes, the glans penis, and the inner surface of the prepuce being hairless. Finally, at the larger openings of the body the skin is directly continuous with the mucous membranes lining the cavities into which they lead. We distinguish three layers in the skin : I. The epidermis or scarf-skin, the out- ermost layer; 2. The corium, derma, or true skin, containing the glandular, muscu- 13 14 ILLUSTRATED SKIN DISEASES. lar, vascular, and nervous structures; 3. The subcutis or subcutaneous connective tissue, containing the fat, the panniculus adiposus. We have also to consider the following special structures and appendages: 4. The blood-vessels ; 5. The lymphatics ; 6. The muscles ; 7. The nerves, with the Pacinian bodies and the tactile corpuscles; 8. The pigment; 9. The sebaceous glands; 10. The sweat-glands ; 11. The hair; 12. The. nails. J. THE EPIDERMIS. The epidermis, cuticle, or scarf-skin is composed of layers of stratified epithelium- cells united together by a small amount of cement substance, and contains neither vessels nor nerves. Its upper surface is smooth, save for the markings above ■r*jK ~ '*? h-'"' '■:-.■ It 'v 1ft 1 r i — * J&rx <r- iV •. "t'?B&.- ^* Fig. 1. — Epidermis, corium, and subcutaneous tissue: section of skin of negro. Photomicrograph, x 21. From the author's collection. mentioned; but its lower surface is studded with club-shaped processes that fit into the interpapillary spaces of the corium. It passes down into the hair-sacs, forming a portion of the root-sheaths, and it is continuous with the lining mem- ANATOMY OF THE SKIN. 15 branes of the sweat and sebaceous glands. Its average diameter is from j4 to J^ mm. ; but it varies greatly, being especially thick on the palms and soles, and very thin on the lips and the genitals. It is being constantly desquamated ; and it is regenerated as constantly by the growth of new cells from the deeper strata of its own substance. It is composed of three layers, being, from without inward : 1. The stratum corneum or horny layer. This is the outer protecting layer, and is formed of flattened, dried-out epithelial cells, structureless and without nuclei. The inner layers are somewhat rounder and more succulent, but the outer- most ones are merely dried scales. In the palms and soles the deepest cells of this layer appear brighter than the rest, and have been called the stratum lucidum (Oehl). 2. The stratum granulosum or nuclear layer. This is composed of from two to five rows of granular refractive epithelial cells, with soft protoplasm and round nuclei. They owe their appearance to the numerous highly refractive granules that they contain, composed of a substance called keratohyalin by Waldeyer, which is of importance in the process of cornification. 3. The rete Malpighii, rete mucosum, stratum spinosum, or prickle-cell layer, consisting of polygonal ceils joined to one another by fine hair-like protoplasmic processes. The upper rows of cells of this layer are flattened, but the lower ones are cylindrical, and rest upon the papilla; of the corium. 2. THE CORIUM. The corium or true skin is the most important part of the cutaneous organ. It is composed of a dense network of interlaced connective-tissue fibers, together with others of the yellow elastic variety. Comparatively thin in children, in the adult it is 2 mm. or more in diameter ; but it varies much in thickness in different parts of the body. Exposure to the weather or other irritants causes increase of its volume, and in the negro race it is naturally of exceptional thickness. It contains vessels, nerves, lymphatics, and bundles of smooth muscular fibers, and it is penetrated by the hairs and their sheaths, and the ducts of the glands. We distinguish in the corium a papillary and a reticular layer. The papillary layer or papillary body is the outer portion of the corium, and lies in contact with the rete Malpighii of the epidermis. Its surface is closely studded with nipple-shaped projections or papillae. Upon these, and dipping down into the spaces between them, lie the cells of the lowest layer of the epidermis. The papillae themselves vary much in shape and size, but their average height is Y% mm. They are most marked on the palms and soles, but most abundant on the genitalia. They contain the blood- and lymph-vessels — the vascular papillae ; and the nerve-structures — the sensory papillae. l(i ILLUSTRATED SKIN DISEASES. The reticular layer lies under the papillary layer, is directly continuous with it, and is distinguishable from it only by the more regular arrangement of the connec- tive-tissue bundles of which it is formed. These are so interlaced as to form rhombic figures, the long axes of which usually run transversely to the axis of the part covered. Curling around the bundles are the yellow elastic fibers. The elasticity of the skin is due to this peculiar arrangement. The lowest fibers of this layer are directly continuous with the connective tissue of the subcutis. 3. THE SUBCUTIS. The subcutaneous tissue lies under the corium, and is composed of connective tissue containing many elastic fibers and forming large loose meshes. Through this there run irregular bands and masses of more condensed connective tissue that unite the subcutis to the fasciae and other underlying tissues; and on the closeness of this connection depends the movability of the skin. Larger and smaller collec- tions of fat-cells are found in the meshes. The subcutis contains also large blood- vessels, lymphatics, nervous structures, sweat-glands, and the lower part of the deeper-seated hair-follicles. Where the fat in the meshes of the subcutis is collected in larger amount, the structure is known as the panniculus adiposus. This consists of masses of round or polyhedral fat-cells, closely packed in a connective-tissue network. It is most abundant in the skin of the palms and soles, the buttocks, and the female breast, but is absent in that of the ear and nose, where the skin is thin and fixed, and in that of the scrotum, where it is very muscular and movable. 4. THE BLOOD-VESSELS. The epidermis has no blood-vessels, but in the corium and the subcutis they are very numerous. They form two distinct horizontally placed plexuses, one in the corium just beneath the papillary layer, and the other at the boundary line between corium and subcutis. This latter supplies the hair papillae, the sweat- glands, and the fat masses; the former sends branches to the papillae of the cutis. The veins follow the arteries, and form a similar plexus between the corium and the subcutis. 5. THE LYMPHATICS. True lymphatic vessels are not common in the skin, though some are found in the papillae, and form a plexus at their base. The subcutis also contains some large lymph-vessels. Lymphatic spaces are, however, very numerous indeed; they form a dense network in the corium, especially in the neighborhood of the fat collections and the muscles. These spaces originate in the lower epithelial layers, beginning in the interspinal spaces between the prickle-cells. ANATOMY OF THE SKIN. 6. THE MUSCLES. The intrinsic muscles of the skin are all of the smooth involuntary kind. There are two varieties of them : I. The arrectores pilorum. These are small bundles of smooth muscular fibers running diagonally from the connective tissue of the papillary bodies to the base of Fig. 2. — Arrector pilorum, hair-sacs, etc. : section of scalp. Photomicrograph, x 35. Fronvauthor's collection. • - the hair-sacs, to which they are attached by elastic threads. Their contraction erects the hair, empties the blood and lymphatic vessels, causes pallor of the skin, and finally expresses the contents of the sebaceous glands. Cilia and vibrissa? have no arrectores. 2. Larger masses of smooth muscular fibers arranged in layers are found in certain places, notably in the skin of the scrotum, penis, around the mammilla, and in the eyelid. ; ! 7. THE NERVES. The skin contains both medullated and non-medullated nerve-fibers. The medullated fibers are branches of the deeper subcutaneous nerves, and go to the 18 ILLUSTRATED SKIN DISEASES. Pacinian bodies, the tactile corpuscles, and the end-bulbs. The non-medullated fibers form a network in the papillary layer, and send up branches which form the subepithelial plexus ; from this there ascends a congeries of minute twigs that end in or among the prickle-cells of the rete. The Pacinian bodies or corpuscles of Vater are ellipsoid whitish bodies, 2-4 mm. in size, attached to the nerves like berries on their stems. They are found espe- Fk;. 3. — Pacinian corpuscles, lymph-spaces, panniculus adiposus, etc. : section of skin of finger-tip. Photomicrograph, x 21. From the author's collection. cially in the subcutis of the palms and soles, fingers and toes. A single medullated nerve enters each one at its lower extremity, looses its sheath, and passes to the center of the body as a naked axis-cylinder. In the upper part of the Pacinian body it ter- minates in an irregular enlargement or in pointed processes. Round this central fiber lies the core, composed of connective-tissue corpuscles ; and around this again is the thick capsular envelop that forms the mass of the Pacinian body. This latter consists of a number of layers of concentric fibers, each one composed of a hya- line elastic ground substance, connective-tissue fibers, and an inner layer of endo- thelial cells. The tactile corpuscles, known also as the corpuscles of Meissner or Wagner, are ANATOMY OF THE SKIN. 19 rounded or oval bodies, yV mm. in size, lying in the sensory papillae of the corium. They consist of a mass of connective tissue, round which there winds a medullated nerve ; the axis-cylinder enters the corpuscle and is lost. They are found in the regions where sensation is keenest, and especially in the skin of the last phalanges of the fingers. Fig. 4. — Pacinian corpuscles, nerve-trunks, artery, etc. : section of skin of finger-tip. Photomicrograph, x 35. From the author's collection. The end-bulbs of Krause are rounded bodies, consisting of a mass of cells in a delicate connective-tissue envelope. The nerve-fiber penetrates the bulb, and ends in one or more clubbed extremities. The end-bulbs are found more especially in the tongue, the lips and gums, the glans penis, and the clitoris. 8. THE PIGMENT. Pigment is found in the adult only in the epidermis, its presence in the corium being always pathological. In the white races it is situated only in the deepest lay- ers of the rete Malpighii ; in the colored races it pervades all the cells up to the granular layer. It consists of granular pigment derived from the blood, and placed chiefly around the nuclei of the cells. It is more abundant in parts that are exposed to the light, in consequence of the action of the ultra-violet chemical rays. ■20 ILLUSTRATED SKIN DISEASES. 9. THE SEBACEOUS GLANDS. These are small racemose glands, situated in the corium and subcutis, and generally connected with the hairs. From 2 to 6 mm. in size, a number of them are attached "to each hair, into the upper portion of whose sacs their ducts open. They are most abundant where the hair-follicles are most numerous, and they are absent where there are no hairs, as on the palms and soles and the glans penis. They are largest on the nose, scrotum, mons veneris, labia majora, and anus. They appear as appendages of the ordinary coarse hair; but the lanugo hair-sacs are apparently diverticula in the wall of the excretory duct of the sebaceous glands. They consist of a framework composed of connective tissue and containing the vessels, nerves, and lymphatics. This is lined with a large nucleated epithelium, which is prolonged into the excretory duct of the gland, being continuous with the Fig. j. — Sebaceous glands: section of skin of scalp. Photomicrograph, x 35. From the author's collection. external root-sheath of the hair, and therefore derived from the rete. Inside this lining membrane lies a mass of fatty epithelium-cells and detritus. The sebum is a semi-liquid oleaginous material, destined to lubricate the hairs. ANATOMY OF THE SKIN. 21 It consists of fifty per cent, of fatty matter, olein, cholesterin, etc., together with the remnants and detritus of the epithelium-cells. Certain special sebaceous glands are not connected with the hairs ; they are : I. The Meibomian glands, large glands situated at the free margin of the lids. 2. Tyson's glands in the glans penis and prepuce. 3. The sebaceous glands of the labia minora. 10. THE SWEAT-GLANDS. The sweat, sudoriparous, or coil glands are simple tubular glands coiled up into a ball, and situated deep in the reticular portion of the corium and in the subcutis t^ - 7. ife3=;^ -Xm ,-'■ & /: ' w&d ' M &j? . y ■ V£j£l O? FlG. 6. — Sweat-glands and ducts : section of skin of palm. Photomicrograph, x 42. From the author's collection. 22 ILLUSTRATED SKIN DISEASJ 5. They are small, round, yellow bodies }4~3 mm. in size, and are found everywhere save on the glans penis and the margins of the lips. They are most developed and abundant on the palms and soles, being sometimes large enough to be seen with the naked eye, and numbering between two and three thousand to the square inch. They are numerous and large also in the axilla and around the anus. Their total number is estimated at from two to three millions. Each tube, uncoiled, measures about 3 mm. in size. The coils end in excretory ducts that pass straight upward through the corium, and open at funnel-shaped depressions on the surface known as pores. Each coiled tube consists of a connective-tissue framework or membrana pro- pria, with some smooth muscular fibers, and lined with a cuboidal epithelium. The excretory duct is also lined with cuboidal epithelium ; it ends at the prickle-cell layer of the epidermis, and thence onward to the surface the duct is a simple cork- screw-like passageway, without special cellular lining. The secretion of the coil glands is partly sweat, and partly an oily material that serves to lubricate the skin. An abundant vascular supply surrounds each coil. The sweat itself is a watery fluid that differs somewhat in composition in different individuals and in different parts of the same body. It has a saline taste and an alkaline reaction. It is composed almost entirely of water, containing less than two per cent, of solid matter. This latter is mostly sodium and potassium salts, urea, neutral fats, and cholesterin. J J. THE HAIR. The hairs are columnar epithelial formations, the lower parts of which are embedded in the corium and subcutis, while the upper portions project upward through the epidermis and above the surface of the skin. They are found all over the body, except on the palms and soles, the vermilion border of the lips, the backs of the distal phalanges, the glans penis and the inner surface of the prepuce, the labia minora and the inner surface of the labia majora. We recognize two varieties : the true hairs, found on the scalp, eyebrows, eyelashes, beard, axillae, genitals, and the anus of the male ; and the lanugo hair, the soft down found on the face, the trunk, etc. ; they differ from one another only in point of size. Hairs are generally implanted obliquely in the skin in consequence of the arrangement of the connective-tissue bundles of the corium, in which their roots Ire ; but the hairs of the external auditory and the nasal passages, as well as those of the lips, are implanted straight. In certain races, as the Hottentots, for example, all the hairs have a straight implantation. Hairs are both elastic and strong, being capable of greta extension and able to bear heavy weights. They grow to a certain length, which varies with different individuals and is different in different locations, and then stop and fall out; the ANATOMY OF THE SKIN. 23 rate of growth being about half an inch a month. The life of an individual hair is from two to five years ; of an eyelash, one hundred to one hundred and fifty days. Warmth and frequent cutting promote their growth. They are among the most enduring portions of the body, as is shown by the well-preserved hair of many of the mummies. Fig. 7. — Hair and hair-follicle: section of skin of scalp. Photomicrograph, x 35. From the author's collection. We distinguish as belonging to the hair: i. A shaft, being that portion which projects above the surface of the skin; 2. A root, situated in the corium and the subcutaneous connective tissue, and ending in a knobbed extremity; 3. A follicle, being the involution of the dermic layers in which the hair is placed. 1. The shaft or scapus is a long and usually straight column, tapering at its free extremity. It consists of a central portion, the medulla or marrow, composed of polyhedral cells containing fat and free pigment granules. It is often absent, especially at the extremities of the hair, and is not found in the lanugo hair. The mass of the hair, however, is made up of the cortical substance, consisting of elon- gated, flattened epithelial cells, arranged with their long axes parallel to the long 24 ILLUSTRATED SKIN DISEASES. axes of the hairs. These cells are more or less fused together, and contain gran- ular pigment. Outside of this is the cuticle, a delicate membrane investing the hair substance and binding its bundles closely together. It consists of flat, cornified epithelial cells without nuclei, overlapping one another like shingles on a roof. FlG. 8. — Hair-shaft and root. Photomicrograph, x 240. From the author's collection. 2. The root or radix is thicker than the shaft, and ends in an expansion known as the hair-bulb. In the bottom of the bulb is a cup-shaped depression which rests upon the papilla at the base of the follicle. In its structure the root is essentially ANATOMY OF THE SKIN. 25 the same as the shaft; but the cortical substance is loose and spongy, and consists of cells closely resembling those of the rete mucosum. 3. The follicle or hair-sac is a bag-like inversion of the corium. It is cylindri- cal, with a narrow mouth on the surface of the skin, and a larger rounded extremity Fig. 9. — Transverse section of hair and sac. Photomicrograph. From the author's collection. that lies in the corium or subcutis. It is essentially a continuation of the papillary layer of the corium. A little below the level of the corium is a constriction known as the neck, and here the ducts of the sebaceous glands open into the follicle. The 26 ILLUSTRATED SKIN DISEASES. follicles vary much in size in different localities, but in general they are from 2 to 6 mm. in length. They consist of a connective tissue, in which several layers may be recognized. The external layers are similar to the loose connective tissue in which the sac is situated. The outermost layer is hyaline and transparent, and is known as the vitreous follicle-sheath. At the base of the follicle rises the papilla, a small club-shaped projection about fo mm. in size, which fits into the hollow at the bottom of the hair-bulb. It is simply a modified papilla of the corium, and it contains the vessels that nourish the hair, as well as non-medullated nerve-fibers. The growth and regeneration of the hair takes place from the papilla; new elements are formed there which elongate and move up, pushing the hair before them. New hairs grow from the old papillse when the former are pulled out or lost. Fig. io. Hair from head of female. Fig. ii. Cross-sections of hairs from head. Fig. 12. Hair from the head of a child. Fig. 13. Hair from the back of hand. Human hair magnified. (After J. F. Babcock.) Between the follicle and the root of the hair are two further coats, known as root-sheaths. The external root-sheath lies next to the vitreous follicle-sheath, and is a continuation of the general rete mucosum, consisting of the same stratified epithelial cells. The internal root-sheath lies inside the preceding, surrounding the root of the hair closely. It consists of cylindrical epithelial cells, and is divided into the sheath of Huxley and the sheath of Henle. The pigment of the hair depends on the color of the corneous cells of the corti- cal substance, and on the air the medulla contains. The basis color is blond to red ; pigment in granules and diffused gives the shades from brown to black. Soap, alkalis, and especially the peroxide of hydrogen destroy the pigment; the presence of much air in'the cortical substance renders the hair white. The cilia or lashes, the vibrissas of the nostrils, and the hairs of the external ANATOMY OF THE SKIN. 27 auditory passages differ from the ordinary true hairs in their implantation, which is straight, and in the fact that they have no arrector muscles connected with their sebaceous glands. Though they are thick hairs, they remain short. 12. THE NAILS. The nails are epidermoidal structures found on the dorsal surfaces of the distal extremities of the fingers and toes. They form quadrilateral plates, curved slightly in their long diameters, and lying with their convex surface upward. Their anterior portion ends in a sharp border that overhangs the end of the last phalanx ; their posterior extremities and sides are embedded in a fold of skin. Their surface is smooth and glistening, and marked with longitudinal striae. They consist of corni- fied epithelial cells arranged in layers, similar to those of the ordinary epidermis, but fused more firmly together. This epithelium lies upon a corium that possesses certain peculiarities. Larger and smaller air- vesicles in the intercellular spaces and inside the lamellae cause the white spots so frequently observed in the nails. Fig. 14. — Transverse section of third phalanx. (After Toldt.) a, nail; i, epithelium of nail-bed; c, nail-bed; d, falx; e, bone of phalanx. The nail is divided into two distinct areas by a curved line near its posterior extremity, running parallel to the free border of the nail, and known as the lunula. The anterior area, of a pink color, rests upon the nail-bed, which is a corium cov- ered with a stratified epithelium, and represents the rete. This corium possesses no papillae, but its connective-tissue bundles are arranged in longitudinal bands con- taining the blood-vessels and the nerves. The ridges thus formed fit into corre- sponding depressions in the epithelium of the under surface of the nail itself. The posterior smaller portion is whiter, on account of the many light-refracting transi- tional epithelial cells that it contains. The corium under it is studded with papillae, like those of ordinary skin, and is known as the matrix. The posterior extremity 28 ILLUSTRATED SKIN DISEASES. of the nail is embedded in a fold of the skin, the nail-groove or falx. Here the stratum mucosum of the skin gradually passes into the epithelium of the matrix. At the lunula there is a decreased transparency of the nail, due to the presence of a broad layer of actively proliferating cells. The nail grows from the matrix, and its thickness is dependent on the breadth of that structure. The rate of growth is stated by Quain to be about 3 \, of an inch per week. The uppermost layers of the epithelial cells that compose it grow from the portion furthest back, while the lower cells are the product of the more anterior portion. Growth is continuous from behind forward. The nails are nour- ished from the subepithelial plexus of the corium of the bed, matrix, and nail-fold. They grow more rapidly in children than in adults, and in summer than in winter time. Under ordinary circumstances their growth is largely in excess of the wear to which they are subjected ; but there is a limit to it, and they cease to extend after a certain length is attained, ending in a narrowed, bent extremity. In some instances a length is attained of I x / 2 to 2 inches, and the nail is then crooked or curved upon itself. PHYSIOLOGY OF THE SKIN. The skin is an organ of great size and complexity, with functions of vital impor- tance in the body economy ; and any very extensive or permanent interference with them is deleterious to health, and may lead to death. The destruction of any very large portion of its area is fatal. The functions of the skin are varied, and are both general and special. General functions are its actions as a protecting envelop for the various other parts of the body, and its regulation of the body heat. Special functions are its activities as a breathing organ, as a secreting and excreting organ, and as an organ of sense. We shall consider them in their order. 1. The skin as a protecting organ. The corium is elastic, from the large quantity of yellow elastic connective tissue that it contains, and, with the thick panniculus adiposus, protects the various organs of the body from the effects of external vio- lence. This protection is limited, however, and the skin can be ruptured by external pressure or traumatisms, or by internal distention, as in pregnancy, oedema, or tumors. Such ruptures tend to have a definite configuration, varying in different parts of the skin, and depending upon the general arrangement of the connective-tissue bundles of the corium. The epidermis itself is a bad conductor of heat, and protects the deeper parts in some measure from the effects of heat and cold. It also prevents the too free evaporation of fluids from the body. The cholesterin fats that are formed in the cornifying surface epithelial cells act as a check to progress of micro- bic life on the surface, since they do not, like the glycerin fats, form good culture media for them. 2. The skin as a regulator of the body heat. The skin performs this function automatically, and by its means the body is enabled to withstand external tempera- tures that may vary rapidly and in fairly wide limits. When the temperature of the environment rises the muscles of the skin relax, the vessels of the papillary plexus become turgid with blood, and the surface becomes hot and red. Increased loss of heat by radiation occurs ; and the congestion of the vessels around the coil glands causes an increased production of sweat, the evaporation of which takes further heat from the skin. When the temperature falls the reverse occurs. The skin muscles 29 .'JO ILLUSTRATED SKIN DISEASES. contract under the influence of the cold, causing by the traction that they exert the erection of the obliquely implanted hairs, and giving rise to the condition known as goose-flesh or cutis anserina. The papillary vessels contract, the surface gets pale and cold, and the loss of heat by radiation and by the evaporation of sweat is reduced to a minimum 3. The skin as a breathing organ. Respiration in its true sense is a function of the skin, oxygen being taken in and both carbonic acid and water being given off. The proportions of these substances are. however, very different from those of lung respiration. The oxygen absorbed is only y^y of that taken in by the lungs, and the carbonic acid excreted amounts to only one hundred and fifty grains in twenty-four hours; both are comparatively insignificant. But the water given off by the skin is twice as great as that excreted from the lungs, being some twenty ounces daily. It passes off mostly as a vapor of whose presence we are not cognizant, the insensible perspiration ; but under certain conditions its excretion is more rapid, and it accumulates in drops as the sensible perspiration or sweat. Muscular exercise, an external high temperature, the emotions, etc., increase the production of water ; the muscles of the skin relax, the vessels fill up, and the sweat pours out. 4. The skin as a secreting organ. Both the sweat and the sebum are secretory products of the skin. The sweat is a clear, watery, saline fluid. It consists of from 97 to 99 5 per cent, of water, together with a small amount of ammonium chloride, ammonia, organic matters such as creatine, etc., and .04 per cent, of urea. Under certain pathological conditions, as in renal disease, this latter element may be increased so much as to be deposited in the form of crystals on the surface of the integument. The amount of solid matter in the perspiration depends, however, very much upon the amount of water that is ingested, and on the quantity of the secretion that is poured out. It is usually acid in reaction ; but it becomes neutral or even alkaline when produced in large quantities and for long periods of time. 