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ESSENTIALS OF DISEASES OF THE SKIN

Including the Syphilodermata

Arranged in the Form of Questions and Answers Prepared Especially
for Students of Medicine

by

HENRY W. STELWAGON, M.D., PH.D.

        *       *       *       *       *

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Besides the ordinary dictionary terms the book contains a wealth of
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ESSENTIALS OF DISEASES OF THE SKIN.

   Since the issue of the first volume of the
   #Saunders Question-Compends#,

   OVER 290,000 COPIES

   of these unrivalled publications have been sold.
   This enormous sale is indisputable evidence of
   the value of these self-helps to students and
   physicians.


Saunders' Question-Compends. No. 11.

ESSENTIALS OF DISEASES OF THE SKIN

Including the Syphilodermata

Arranged in the Form of Questions and Answers Prepared Especially
for Students of Medicine

by

HENRY W. STELWAGON, M.D., PH.D.

Professor of Dermatology in the Jefferson Medical College, Philadelphia;
Dermatologist to the Howard and Philadelphia Hospitals, etc.

Seventh Edition, Thoroughly Revised

Illustrated







Philadelphia and London
W. B. Saunders Company
1909

Set up, electrotyped, printed, 1890. Reprinted July, 1891.
Revised, reprinted, June, 1894. Reprinted March, 1897.
Revised, reprinted, August, 1899. Reprinted
September, 1901, May, 1902, September, 1903.
Revised, reprinted January, 1905.
Reprinted March, 1906. Revised,
reprinted March, 1909.

Printed in America

Press of
W. B. Saunders Company
Philadelphia




PREFACE TO SEVENTH EDITION.


In the present--seventh--edition the subject matter, especially as
regards the practical part, has been gone over carefully and the
necessary corrections and additions made. Nineteen new illustrations
have been added, a few of the old ones being eliminated. It is hoped
that the continued demand for this compend means a widening interest in
the study of diseases of the skin, sufficiently keen as to lead to the
desire for a still greater knowledge.

                                                           H.W.S.


PREFACE TO FIRST EDITION.


Much of the present volume is, in a measure, the outcome of a thorough
revision, remodelling and simplification of the various articles
contributed by the author to Pepper's System of Medicine, Buck's
Reference Handbook of the Medical Sciences, and Keating's Cyclopaedia of
the Diseases of Children. Moreover, in the endeavor to present the
subject as tersely and briefly as compatible with clear understanding,
the several standard treatises on diseases of the skin by Tilbury Fox,
Duhring, Hyde, Robinson, Anderson, and Crocker, have been freely
consulted, that of the last-named author suggesting the pictorial
presentation of the "Anatomy of the Skin." The space allotted to each
disease has been based upon relative importance. As to treatment, the
best and approved methods only--those which are founded upon the
aggregate experience of dermatologists--are referred to.

For general information a statistical table from the Transactions of the
American Dermatological Association is appended.

                                                           H.W.S.


CONTENTS.


                                               PAGE
ANATOMY OF THE SKIN                              17
    The Epidermis                                18
    The Blood-vessels                            19
    The Nervous and Vascular Papillae             20
    The Hair and Hair-follicle                   21

SYMPTOMATOLOGY                                   22
    Primary Lesions                              22
    Secondary Lesions                            23
    Distribution and Configuration               24
  Relative Frequency                             26
  Contagiousness                                 27
  Rapidity of Cure                               27
  Ointment Bases                                 27

CLASS I.--DISORDERS OF THE GLANDS                28
    Hyperidrosis                                 28
    Sudamen                                      30
    Hydrocystoma                                 31
    Anidrosis                                    31
    Bromidrosis                                  32
    Chromidrosis                                 32
    Uridrosis                                    33
    Phosphoridrosis                              33
    Seborrh[oe]a (Eczema Seborrhoicum)           33
    Comedo                                       38
    Milium                                       42
    Steatoma                                     43

CLASS II.--INFLAMMATIONS                         44
  Erythema Simplex                               44
  Erythema Intertrigo                            45
  Erythema Multiforme                            46
  Erythema Nodosum                               50
  Erythema Induratum                             51
  Urticaria                                      52
  Urticaria Pigmentosa                           56
  Dermatitis                                     58
  Dermatitis Medicamentosa                       60
  X-Ray Dermatitis                               63
  Dermatitis Factitia                            64
  Dermatitis Gangraenosa                          65
  Erysipelas                                     66
  Phlegmona Diffusa                              68
  Furunculus                                     68
  Carbunculus                                    70
  Pustula Maligna                                72
  Post-mortem Pustule                            73
  Framb[oe]sia                                   73
  Verruga Peruana                                73
  Equinia                                        74
  Miliaria                                       74
  Pompholyx                                      76
  Herpes Simplex                                 78
  Hydroa Vacciniforme                            80
  Epidermolysis Bullosa                          80
  Dermatitis Repens                              81
  Herpes Zoster                                  81
  Dermatitis Herpetiformis                       83
  Psoriasis                                      86
  Pityriasis Rosea                               95
  Dermatitis Exfoliativa                         96
  Lichen Planus                                  98
  Pityriasis Rubra Pilaris                       99
  Lichen Scrofulosus                            100
  Eczema                                        100
  Prurigo                                       118
  Acne                                          119
  Acne Rosacea                                  126
  Sycosis                                       130
  Dermatitis Papillaris Capillitii              135
  Impetigo Contagiosa                           136
  Impetigo Herpetiformis                        138
  Ecthyma                                       138
  Pemphigus                                     140

CLASS III.--HEMORRHAGES                         144
  Purpura                                       144
  Scorbutus                                     146

CLASS IV.--HYPERTROPHIES                        148
  Lentigo                                       148
  Chloasma                                      149
  Keratosis Pilaris                             151
  Keratosis Follicularis                        153
  Molluscum Epitheliale                         153
  Callositas                                    155
  Clavus                                        156
  Cornu Cutaneum                                158
  Verruca                                       160
  Naevus Pigmentosus                             162
  Ichthyosis                                    165
  Onychauxis                                    167
  Hypertrichosis                                168
  [OE]dema Neonatorum                           170
  Sclerema Neonatorum                           171
  Scleroderma                                   172
  Elephantiasis                                 174
  Dermatolysis                                  176

CLASS V.--ATROPHIES                             177
  Albinismus                                    177
  Vitiligo                                      178
  Canities                                      180
  Alopecia                                      181
  Alopecia Areata                               183
  Atrophia Pilorum Propria                      187
  Atrophia Unguis                               188
  Atrophia Cutis                                189

CLASS VI.--NEW GROWTHS                          191
  Keloid                                        191
  Fibroma                                       192
  Neuroma                                       194
  Xanthoma                                      195
  Myoma                                         196
  Angioma                                       196
  Telangiectasis                                197
  Lymphangioma                                  198
  Rhinoscleroma                                 198
  Lupus Erythematosus                           199
  Lupus Vulgaris                                203
  Tuberculosis Cutis                            209
  Ainhum                                        212
  Mycetoma                                      212
  Perforating Ulcer of the Foot                 213
  Syphilis Cutanea                              213
  Lepra                                         231
  Pellagra                                      235
  Epithelioma                                   236
  Paget's Disease of the Nipple                 240
  Sarcoma                                       241
  Granuloma Fungoides                           242

CLASS VII.--NEUROSES                            244
  Hyperaesthesia                                 244
  Dermatalgia                                   244
  Anaesthesia                                    244
  Pruritus                                      244

CLASS VIII.--PARASITIC AFFECTIONS               247
  Tinea Favosa                                  247
  Tinea Trichophytina                           251
  Tinea Imbricata                               261
  Tinea Versicolor                              262
  Erythrasma                                    265
  Actinomycosis                                 266
  Blastomycetic Dermatitis                      266
  Scabies                                       267
  Pediculosis                                   271
  Pediculosis Capitis                           272
  Pediculosis Corporis                          274
  Pediculosis Pubis                             275
  Cysticercus Cellulosae                         276
  Filaria Medinensis                            277
  Ixodes                                        277
  Leptus                                        277
  [OE]strus                                     278
  Pulex Penetrans                               278
  Cimex Lectularius                             278
  Culex                                         279
  Pulex Irritans                                279

TABLE showing Relative Frequency of the Various
  Diseases of the Skin                          280




DISEASES OF THE SKIN.

#ANATOMY OF THE SKIN.#


[Illustration: Fig. I.
  Vertical section of the skin--Diagrammatic. (_After Heitsmann._)]




                            #The Epidermis.#


[Illustration: Fig. 2.
  _c_, corneous (horny) layer; _g_, granular layer; _m_, mucous layer
  (rete Malpighii).
  The stratum lucidum is the layer just above the granular layer.
  Nerve terminations--_n_, afferent nerve; _b_, terminal nerve bulbs;
  _l_, cell of Langerhans. (_After Ranvier._)]




                           #The Blood-vessels.#


[Illustration: Fig. 3.
  _C_, epidermis; _D_, corium; _P_, papillae; _S_, sweat-gland duct.
  _v_, arterial and venous capillaries (superficial, or papillary plexus)
  of the papillae. Deep plexus is partly shown at lower margin of the
  diagram; _vs_--an intermediate plexus, an outgrowth from the deep
  plexus, supplying sweat-glands, and giving a loop to hair papilla.
  (_After Ranvier._)]




                   #The Nervous and Vascular Papillae.#


[Illustration: Fig. 4.
  _a_, a vascular papilla; _b_, a nervous papilla; _c_, a blood-vessel;
  _d_, a nerve fibre; _e_, a tactile corpuscle. (_After Biesiadecki._)]




                      #The Hair and Hair-Follicle.#


[Illustration: Fig. 5. _A_, shaft of the hair; _B_, root of the hair;
_C_, cuticle of the hair; _D_, medullary substance of the hair. _E_,
external layer of the hair-follicle; _F_, middle layer of the
hair-follicle; _G_, internal layer of the hair-follicle; _H_, papilla of
the hair; _I_, external root-sheath; _J_, outer layer of the internal
root-sheath; _K_, internal layer of the internal root-sheath. (_After
Duhring._)]




#SYMPTOMATOLOGY.#


The symptoms of cutaneous disease may be objective, subjective or both;
and in some diseases, also, there may be systemic disturbance.


#What do you mean by objective symptoms?#

Those symptoms visible to the eye or touch.


#What do you understand by subjective symptoms?#

Those which relate to sensation, such as itching, tingling, burning,
pain, tenderness, heat, anaesthesia, and hyperaesthesia.


#What do you mean by systemic symptoms?#

Those general symptoms, slight or profound, which are sometimes
associated, primarily or secondarily, with the cutaneous disease, as,
for example, the systemic disturbance in leprosy, pemphigus, and purpura
hemorrhagica.


#Into what two classes of lesions are the objective symptoms commonly
divided?#

    Primary (or elementary), and
    Secondary (or consecutive).



                          #Primary Lesions.#


#What are primary lesions?#

Those objective lesions with which cutaneous diseases begin. They may
continue as such or may undergo modification, passing into the secondary
or consecutive lesions.


#Enumerate the primary lesions.#

Macules, papules, tubercles, wheals, tumors, vesicles, blebs and
pustules.


#What are macules (maculae)?#

Variously-sized, shaped and tinted spots and discolorations, without
elevation or depression; as, for example, freckles, spots of purpura,
macules of cutaneous syphilis.


#What are papules (papulae)?#

Small, circumscribed, solid elevations, rarely exceeding the size of a
split-pea, and usually superficially seated; as, for example, the
papules of eczema, of acne, and of cutaneous syphilis.


#What are tubercles (tubercula)?#

Circumscribed, solid elevations, commonly pea-sized and usually
deep-seated; as, for example, the tubercles of syphilis, of leprosy, and
of lupus.


#What are wheals (pomphi)?#

Variously-sized and shaped, whitish, pinkish or reddish elevations, of
an evanescent character; as, for example, the lesions of urticaria, the
lesions produced by the bite of a mosquito or by the sting of a nettle.


#What are tumors (tumores)?#

Soft or firm elevations, usually large and prominent, and having their
seat in the corium and subcutaneous tissue; as, for example, sebaceous
tumors, gummata, and the lesions of fibroma.


#What are vesicles (vesiculae)?#

Pin-head to pea-sized, circumscribed epidermal elevations, containing
serous fluid; as, for example, the so-called fever-blisters, the lesions
of herpes zoster, and of vesicular eczema.


#What are blebs (bullae)?#

Rounded or irregularly-shaped, pea to egg-sized epidermic elevations,
with fluid contents; in short, they are essentially the same as vesicles
and pustules except as to size; as, for example, the blebs of pemphigus,
rhus poisoning, and syphilis.


#What are pustules (pustulae)?#

Circumscribed epidermic elevations containing pus; as, for example, the
pustules of acne, of impetigo, and of sycosis.



                        #Secondary Lesions.#


#What are secondary lesions?#

Those lesions resulting from accidental or natural change, modification
or termination of the primary lesions.


#Enumerate the secondary lesions.#

Scales, crusts, excoriations, fissures, ulcers, scars and stains.


#What are scales (squamae)?#

Dry, laminated, epidermal exfoliations; as, for example, the scales of
psoriasis, ichthyosis, and eczema.


#What are crusts (crustae)?#

Dried effete masses of exudation; as, for example, the crusts of
impetigo, of eczema, and of the pustular and ulcerating syphilodermata.


#What are excoriations (excoriationes)?#

Superficial, usually epidermal, linear or punctate loss of tissue; as,
for example, ordinary scratch-marks.


#What are fissures (rhagades)?#

Linear cracks or wounds, involving the epidermis, or epidermis and
corium; as, for example, the cracks which often occur in eczema when
seated about the joints, the cracks of chapped lips and hands.


#What are ulcers (ulcera)?#

Rounded or irregularly-shaped and sized loss of skin and subcutaneous
tissue resulting from disease; as, for example, the ulcers of syphilis
and of cancer.


#What are scars (cicatrices)?#

Connective-tissue new formations replacing loss of substance.


#What are stains?#

Discolorations left by cutaneous disease, which stains may be transitory
or permanent.



                     #Distribution and Configuration.#


#What do you mean by a patch of eruption?#

A single group or aggregation of lesions or an area of disease.


#When is an eruption said to be limited or localized?#

When it is confined to one part or region.


#When is an eruption said to be general or generalized?#

When it is scattered, uniformly or irregularly, over the entire surface.


#When is an eruption universal?#

When the whole integument is involved, without any intervening healthy
skin.


#When is an eruption said to be discrete?#

When the lesions constituting the eruption are isolated, having more or
less intervening normal skin.


#When is an eruption confluent?#

When the lesions constituting the eruption are so closely crowded that a
solid sheet results.


#When is an eruption uniform?#

When the lesions constituting the eruption are all of one type or
character.


#When is an eruption multiform?#

When the lesions constituting the eruption are of two or more types or
characters.


#When are lesions said to be aggregated?#

When they tend to form groups or closely-crowded patches.


#When are lesions disseminated?#

When they are irregularly scattered, with no tendency to form groups or
patches.


#When is a patch of eruption said to be circinate?#

When it presents a rounded form, and usually tending to clear in the
centre; as, for example, a patch of ringworm.


#When is a patch of eruption said to be annular?#

When it is ring-shaped, the central portion being clear; as, for
example, in erythema annulare.


#What meaning is conveyed by the term "iris"?#

The patch of eruption is made up of several concentric rings. Difference
of duration of the individual rings, usually slight, tends to give the
patch variegated coloration; as, for example, in erythema iris and
herpes iris.


#What meaning is conveyed by the term "marginate"?#

The sheet of eruption is sharply defined against the healthy skin; as,
for example, in erythema marginatum, eczema marginatum.


#What meaning is conveyed by the qualifying term "circumscribed"?#

The term is applied to small, usually more or less rounded, patches,
when sharply defined; as, for example, the typical patches of psoriasis.


#When is the qualifying term "gyrate" employed?#

When the patches arrange themselves in an irregular winding or
festoon-like manner; as, for instance, in some cases of psoriasis. It
results, usually, from the coalescence of several rings, the eruption
disappearing at the points of contact.


#When is an eruption said to be serpiginous?#

When the eruption spreads at the border, clearing up at the older part;
as, for instance, in the serpiginous syphiloderm.



                         #RELATIVE FREQUENCY.#


#Name the more common cutaneous diseases and state approximately their
frequency.#

Eczema, 30.4%; syphilis cutanea, 11.2%; acne, 7.3%; pediculosis, 4%;
psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies, 2.6%;
urticaria, 2.5%; pruritus, 2.1%; seborrh[oe]a, 2.1%; herpes simplex,
1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%; verruca, 1.1%;
tinea versicolor, 1%. Total: eighteen diseases, representing 81 per
cent. of all cases met with.

(These percentages are based upon statistics, public and private, of the
American Dermatological Association, covering a period of ten years. In
private practice the proportion of cases of pediculosis, scabies, favus,
and impetigo is much smaller, while acne, acne rosacea, seborrh[oe]a,
epithelioma, and lupus are relatively more frequent.)



                           #CONTAGIOUSNESS.#


#Name the more actively contagious skin diseases.#

Impetigo contagiosa, ringworm, favus, scabies and pediculosis; excluding
the exanthemata, erysipelas, syphilis and certain rare and doubtful
diseases.

[At the present time when most diseases are presumed to be due to
bacteria or parasites the belief in contagiousness, under certain
conditions, has considerably broadened.]



                          #RAPIDITY OF CURE.#


#Is the rapid cure of a skin disease fraught with any danger to the
patient?#

No. It was formerly so considered, especially by the public and general
profession, and the impression still holds to some extent, but it is not
in accord with dermatological experience.



                           #OINTMENT BASES.#


#Name the several fats in common use for ointment bases.#

Lard, petrolatum (or cosmoline or vaseline), cold cream and lanolin.


#State the relative advantages of these several bases.#

_Lard_ is the best all-around base, possessing penetrating properties
scarcely exceeded by any other fat.

_Petrolatum_ is also valuable, having little, if any, tendency to
change; it is useful as a protective, but is lacking in its power of
penetration.

_Cold Cream_ (ungt. aquae rosae) is soothing and cooling, and may often be
used when other fatty applications disagree.

_Lanolin_ is said to surpass in its power of penetration all other
bases, but this is not borne out by experience. It is an unsatisfactory
base when used alone. It should be mixed with another base in about the
proportion of 25% to 50%.

These several bases may, and often with advantage, be variously
combined.


#What is to be added to these several bases if a stiffer ointment is
required?#

Simple cerate, wax, spermaceti, or suet; or in some instances, a
pulverulent substance, such as starch, boric acid, and zinc oxide.




#CLASS I.--DISORDERS OF THE GLANDS.#


                           #Hyperidrosis.#


[Illustration: Fig. 6.
  A normal sweat-gland, highly magnified. (_After Neumann._)
  _a_, Sweat-coil: _b_, sweat-duct; _c_, lumen of duct; _d_,
  connective-tissue capsule; _e_ and _f_, arterial trunk and
  capillaries.]


#What is hyperidrosis?#

Hyperidrosis is a functional disturbance of the sweat-glands,
characterized by an increased production of sweat. This increase may be
slight or excessive, local or general.


#As a local affection, what parts are most commonly involved?#

The hands, feet, especially the palmar and plantar surfaces, the axillae
and the genitalia.


#Describe the symptoms of the local forms of hyperidrosis.#

The essential, and frequently the sole symptom, is more or less profuse
sweating.

If the hands are the parts involved, they are noted to be wet, clammy
and sometimes cold.

If involving the soles, the skin often becomes more or less macerated
and sodden in appearance, and as a result of this maceration and
continued irritation they may become inflamed, especially about the
borders of the affected parts, and present a pinkish or pinkish-red
color, having a violaceous tinge. The sweat undergoes change and becomes
offensive.


#Is hyperidrosis acute or chronic?#

Usually chronic, although it may also occur as an acute affection.


#What is the etiology of hyperidrosis?#

Debility is commonly the cause in general hyperidrosis; the local forms
are probably neurotic in origin.


#What is the prognosis?#

The disease is usually persistent and often rebellious to treatment; in
many instances a permanent cure is possible, in others palliation.
Relapses are not uncommon.


#What systemic remedies are employed in hyperidrosis?#

Ergot, belladonna, gallic acid, mineral acids, and tonics.
Constitutional treatment is rarely of benefit in the local forms of
hyperidrosis, and external applications are seldom of service in general
hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is also
well spoken of, combined, if necessary, with an astringent.


#What external remedies are employed in the local forms?#

Astringent lotions of zinc sulphate, tannin and alum, applied several
times daily, with or without the supplementary use of dusting-powders.
Weak solutions of formaldehyde, one to one hundred, are sometimes of
value.

Dusting-powders of boric acid and zinc oxide, to which may be added from
ten to thirty grains of salicylic acid to the ounce, to be used freely
and often:--

  [Rx] Pulv. ac. salicylici................. gr. x-xxx.
       Pulv. ac. borici..................... [dram]v.
       Pulv. zinci oxidi.................... [dram]iij     M.

Diachylon ointment, and an ointment containing a drachm of tannin to the
ounce; more especially applicable in hyperidrosis of the feet. The parts
are first thoroughly washed, rubbed dry with towels and dusting-powder,
and the ointment applied on strips of muslin or lint and bound on; the
dressing is renewed twice daily, the parts each time being rubbed dry
with soft towels and dusting-powder, and the treatment continued for ten
days to two weeks, after which the dusting-powder is to be used alone
for several weeks. No water is to be used after the first washing until
the ointment is discontinued. One such course will occasionally suffice,
but not infrequently a repetition is necessary.

Faradization and galvanization are sometimes serviceable. Repeated mild
exposures to the Roentgen rays have a favorable influence in some
instances.



                              #Sudamen.#
                 (_Synonym:_