UC SOUTHERN REGIONAL LIBRARY FACILITY
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THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
LOS ANGELES
GIFT OF
SAN FRANCISCO COUNTY MEDICAL SOCIETY
THE NEW SYDENHAM
SOCIETY.
INSTITUTED MDCCCLYIII.
VOLUME XXX.
ON
DISEASES OF THE SKIN,
IXCLUDIXG THE
EXANTHEMATA.
FERDINFAND HEBRA, M.D.,
PROFKSSOR FUB DEBMATOLOGTE AN DF.H UNIVKHSITAT. IIIIMARARZT DKR ABTlIErLUNO yUR IIAITKRANKIIEITKN IJI K. K. ALIO. KRAXKENII AUSE IN WIEN, ETC. ETC.
VOL. I.
TEANSLATED AXD EDITED BY
C. HILTON FAGGE, M. D.,
MEMBER OP THE ROYAL Cri.LEGE OF PHYSICIANS;
ASSISTANT-I'IIYSICIAN TO, AND LECTURER ON EXPEIIIMENTAL PIIILOSOPIIY AT
OlY'S HOSPITAL; PHYSICIAN TO THE ROYAL INFIRMARY FOR THE
DISEASES OF CHILDREN AND WOMEN.
THE NEW SYDENHAM SOCIETY, LONDON.
MDCCCLXVI.
561
PRINTED BY J. E. ADLARD,
BAETirOI.OMT-W CI.OSl!.
'^
UitTSTf
m
JlfO
AUTHOE'S PREEACE
ENGLISH EDITION.
It was with great pleasure that I acceded to the request of the Council of the New Sydenham Society, communicated to me by their courteous Secretary, Mr. Hutchinson, that I would allow my work on 'Diseases of the Skm' (which forms part of Yirchow^s ' Handbuch der speciellen Pathologie und Therapie ') to be trans- lated into the Enghsh language. Of the compUmeut paid to me by the Society in making this request I am the more sensible, because Enghsh literature is already by no means poor in treatises upon cutaneous affections. Thus, although, during the last century, this branch of medical science was cultivated with zeal both in Germany and J^^rance, it was England, the country of Willan and Bateman, wTiicETtook the largest share in what may be termed the Beformation of Dermatology. ^
In fact, not only all later English writers on diseases of the skin, but also those of every other country, have made use of the Classification of "Willan in arranging the subdivisions of their own systems, or, indeed, have even adopted this Classification without modification.
Within the last few years, in particular, several English physi- cians have pursued the study of cutaneous affections, and have suc- ceeded in adding very considerably to the general fund of knowledge in this department of medicine. Among these I must mention especially my talented friend Mr. Erasmus Wilson, as well as Dr. Anthony Todd Thomson and Dr. T. McCall Anderson. The A\ urks of these writers, whether systematic treatises, or monographs ;^ upon general dermatology, or upon particular diseases of the skin, have rendered them famous throughout the Continent as well as in
VI PREFACE.
their own country. I might name many others who have won for themselves a deserved reputation, either by excellent articles in the medical journals (Hutchinson, Addison, Gull), or by the success with which they have devoted themselves to the treatment of cuta- neous affections (Startin, HiUier, Tilbury Fox).
I have therefore felt pecuHar satisfaction in finding my work on 'Diseases of the Skin'' admitted to a place by the side of those English treatises of which I cherish so liigh an opinion. With reference to Dr. Hilton Fagge's translation, I will only say that I have found reason to express the fullest confidence in his knowledge of the subject, as well as in the zeal with which he has executed the task set before him.
I have also to mention, that there is, in some respects, a greater unity in the translation than in the original German edition. Certain parts which had been written by my colleagues have been entirely rewritten by myself.
Moreover, there are in the original several errors by which the meaning is perverted ; all these have been corrected in the present volume. Consequently, many little changes will be found, which are to be regarded as improvements. In fact, in all these points, the English translation is more correct than the German edition of my work.
Hebea.
Vienna, November, 1866.
TEANSLATOE'S PEEEACE.
In submitting to the Members of the New Sydenham Society a first volume of the translation of the important work of Professor Hebra on ' Diseases of the Skin/ I think it necessary to add a few words to the preface written by the distinguished author.
There will always be a difference of opinion as to the best course to be adopted in translating from one language into another : whether the expressions used in the original should be transplanted^ so to speak, into the fresh soil, in the hope that they may still flourish, or whether the object should be to convey the opinions of the author, in the words commonly employed by those who write in the language of the translation. It has been my aim to follow an intermediate course. But, although I believe my trans- lation to be more literal than some which have been placed in the hands of the English Medical Public, I think, in looking over the pages which foUow, that I am more likely to be blamed for depart- ing from the exact mode of expression in the German text than for adhering to it too closely.
There are, however, reasons which lead me to believe that a justi- fication may be found for this. Every sheet of the translation has been read over by Professor Hebra, and every passage in which I felt any doubt as to the faithfulness of the translation, or as to the sense of the original, was underlined by me, and has been accepted by him, or corrected so as to convey the right meaning. It is the more necessary to make this remark as there are, at least, one or two instances in which statements arc made in the original text, dia- metrically opposite to what was intended by the author. In these
Vlll PREFACE.
cases, the English edition, of course, differs ahogether from the German.
Again, I am convinced that a very literal translation is often really less accurate than a more free one. Words and forms of expression which are commonly used in a language are often intro- duced loosely and without definite meaning ; whereas, when trans- ferred to another language, they convey to the reader ideas of a precise kind which were not at all intended by the original author.
Professor Hebra has mentioned that certain chapters have been rewritten for the English edition of this work. These are Chapters V and VI, " On the Affections of the Glandular Organs of the Skin,^' and the greater part of Chapter XV, of which Herpes is the subject. Moreover, in the chapters on Morbilli and Scarlatina, certain details as to the internal diseases which occur as complications or sequelae of these exanthemata have been omitted. These omissions brins; the volume back to a size probably nearly equivalent to that of the original, for the chapters rewritten by Professor Hebra occupy a much larger space than those wliich they have replaced.
It may also be well to remark that the arrangement of the work itself differs from that adopted in the German edition. In the latter, a tabular construction is followed throughout ; there are no separate chapters j and headings in small type not rarely correspond to others at intervals of more than a hundred pages. Such a plan would, I think,"give an English reader great inconvenience ; and, therefore, the present volume has been thrown into chapters ; of which one (Chapter VII) is made up of the isolated paragraphs above referred to, all of which are thus collected together. The tabular arrangement of the original is, however, preserved in the Table of Contents.
]\Ieution is made incidentally of a fact which wiU, I think, be deemed of interest in reference to the writings of "VTillan. Pro- fessor Hebra quotes (vide note, p. 15) from a German translation of a work of Willan^s, pubhshed at Breslau in 1799. Now, the earliest treatise on diseases of the skin by the great English derma- tologist, contained in any of the large medical libraries in London, is the quarto dated 1808 ; and the only reference I have been able
PREFACE. IX
to find to any previous work of his on this subject is the state- ment that the Pothergühan gold medal had been awarded to him in the year 1790, by the Medical Society of London, for a Clas- sification of Cutaneous Affections. It would, therefore, seem that a publication which was at the time deemed worthy of translation into German has fallen into complete oblivion, having no doubt been eclipsed by the well-known later writings of its author.
In conclusion, I have only to express my great obligations to my friends. Dr. Welch, Dr. Mackenzie Bacon, and Dr. A. B. Shepherd, for having very kindly assisted me in correcting many of the proof- sheets of the present volume.
C. H. P.
Trinity Squake,
southwakk ;
Nov., 1866.
CONTENTS
FIRST VOLUME.
CHAPTER I.
On the General Pathology and Symptomatology of
|
FTANEOus Diseases |
• |
1 |
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I. Pfimary symptoms or forms of Efflorescence |
3 |
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1. The maciüe or spot |
3 |
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2. The papiile |
6 |
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3. The tubercle . |
10 |
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4. Tlie wheal |
11 |
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5, The tumour |
12 |
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6. The vesicle |
12 |
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7. The bleb |
14 |
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8. The pustule . |
15 |
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II. Seconda/ry symptoms |
17 |
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1. The excoiiation |
17 |
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2, The cutaneoiis ulcer |
18 |
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3. The fissure |
19 |
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4. The scale |
19 |
xn
CONTENTS.
5. The crust ....
6. The lamellated crust .
7. The scar .... III. On the Distribution of En(^tions over the SJcin
PAGE
20 20 21
22
CHAPTER II.
On the Diagnosis, Etiology, Treatment, and Classipica TioN OF Cutaneous Disease in general I. Diagnosis .... II. Etiology ....
III. Ti'eatment ....
IV. Classification
26
26 33 38 43
CHAPTER III.
Class I. — Hyper^müe Cutanea
A. Active Hyper8einia3 . . . .
A. Idiopathic active Hyperaemiaa . Erythema congestivum idiopathicura .
1. Erythema traumaticum
2. Erythema caloi-icum
3. Erythema ab acribus, seu venenatum
B. Symptomatic active Hypersemia^
1. Erythema infantile, seu Roseola infantilis
2. Erythema variolosum. Roseola variolosa
3. Roseola Vaccina ...
B. Passive Hyperaemise
A. Idiopathic passive Hypersemise
1. Livedo mechanica . . .
2. Livedo calorica
B. Symptomatic passive Hypersemiffi
49
50 50 51 51
52 53 53
55 56 58
60 60 61 62 63
CONTENTS.
XIU
CHAPTER IV.
Class II. — An^mi^ Cutanea .... A. Anaemia of fhe Skin, from absolute want of liloocl
A. Anaemia from haemon-liage
B. Anaemia consequent upon disease
S. Anaemia of the Skin, catised by perverted innervation
PAGE
GG
67 68 68
69
CHAPTER V.
Class III. — Anomalie Secretionis Glandulartjm Cu-
TANEARUM . . . . , .71
Functional disorders of tbe Cutaneous Glands . . 74
A. Morbid states of the Materia Perspiratoria . . 74
(a) Bromidi'osis universalis . . .75
(&) Bromidrosis localis . . . .76
B. Functional disorders of tlie Sudoripai'ous Glands . . 78
1. Quantitative changes in tbeir secretion . .78
A. Hyperidrosis . . . . . .78
a Hyperidrosis universalis . . .78
ß. Hyperidrosis localis . . . .83
B. Anidrosis . . . . . .91
2. Qualitative changes in their secretion . . .92
Chromidrosis . . . . . .93
Haematidrosis . . . . . .93
Galactidrosis . . . . . . 96
Uridrosis . . . . . .97
XIV CONTENTS.
CHAPTER VI.
C. Affections caused by morbid states of the secretion, or
by changes in the structure of the sebaceous glands . 99 I. Affections caused by the secretion of sebum in excessive
qiiantity . . . . . . .99
(i) Without impediment to its excretion . . 100
Seborrhcea ...... 100
1. SeboiThcea oleosa, seu adiposa . . . 105 (a) On parts of the body not covered with hair . 105 (fe) On parts of the body covered with hair . 107
2. Seborrhcea sicca, seu squamosa . . . 108 (a) On parts of the body not covered with hair . 109 (h) On parts of the body covered with hair . 109
General characters of seboiThcBa . . . 110
Distribution ..... 110
Seborrhcea congestiva, s. Impus erythematosus . 114 Etiology . . . . . .116
Ti-eatment . . . '. . .118
(2) With impediment to its excretion . . . 121
Comedones ..... 122
Milium, s. Gridum .... 126
Vitiligoidea ..... 127
Sebaceous warts and tumours . . . 130
Molluscum contagiosum .... 131
n. Affections in which the sebaceous secretion is diminished
in quantity ...... 137
CHAPTER VII.
Class IV. — Exudationbs Cutanea General remarks . . . . . ,
A. Acute exudative dermatoses
A. Acute, contagious, exudative dermatoses , .
B. Acute, non-contagious, exudative dennatoses
B. Chronic exudative dermatoses . • ,- ■
140 140 141 142 145 152
CONTENTS.
XV
CHAPTER VIII. A. Acute, Contagious, Exudative Dermatoses.
Morbilli ......
Symptoms ......
Irregulai' forms .....
1. Varieties in the localisation of the rasli
2. Varieties in the duration of the stadium floritionis
3. Prolongation of the period of desquamation .
4. Morbilli apyretici ....
5. Febris morbillosa sine exanthemate
0. Varieties in the appearance of the rash
7. Combinations with other
8. Complications Diagnosis
Pathological anatomy", Sequelaa Prognosis Etiology Treatment
skin-affections
PAGE
156 157 162 162 163 164 164 164 165 166 167 176 177 177 180 181 185
CHAPTER IX.
Scarlatina .... Symptoms .... Modifications ....
1. Prolongation of the period of latency
2. Irregular development of the rash
3. Irregularities in its duration or intensity
4. Irregularities in the process of desquamation
5. The " scarlatina sine exanthemate"
6. Irregulai'ities in the form of the rash .
7. Combinations with other cutaneous affections
8. Complications ....
188 189 193 193 193 194 195 195 195 197 198
XVI
CONTENTS.
Sequelae
Prognosis
Etiology
Diagnosis
Treatment
CHAPTER X
Variola Symptoms
Anomalies in its course IiTegular forms of the rash . Complications .
A. Other diseases of the skin
B. Diseases of mucous membranes c. Diseases of the eye
D, Diseases of internal organs Sequelae Diagnosis Prognosis Treatment
CHAPTER XI.
Vaccinia, or Cow-pox .... Irregular forms ....
I. Local modifications
(a) Variola Vaccina atrophica
(b) Roseola Vaccina
(c) Variola Vaccina herpetica.
(d) Variola Vaccina bullosa, Pemphigoides
(e) Variola Vaccina fiirunculosa
if) Erysipelas Vaccinae . . _
{g) Variola Vaccina ulcerosa .
(h) Gangi'cne . . . .-
CONTENTS.
XVll
II. Modifications affecting the System generally (a) YacciniolEe .... (6) Vaccinal fever
(c) Intestinal disorder
(d) Diseases of the glandular organs .
PAGE
283 283 283 284 284
CHAPTER XII. B. Acute, Non-contagious, Exudative Dermatoses.
|
The Polymorphous Erythemata . |
. 285 |
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I. Erytliema exudativum |
. 285 |
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A. Eiytliema exudativum multiform.e |
. 285 |
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B. Erytliema nodosum |
. 289 |
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Pellagra ..... |
. 293 |
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Acrodynia ..... |
, 297 |
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II. Roseola ..... |
. 299 |
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III. Urticaria ..... |
. 301 |
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Diagnosis ..... |
. 306 |
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Morbid anatomy .... |
. 307 |
|
Etiology ..... |
. 307 |
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Treatment ..... |
. 310 |
CHAPTER XIII.
|
The Dermatitides proper |
. 312 |
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A. Dermatitis idiopathiea |
. 312 |
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1. Dermatitis traumatica . |
. 312 |
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2. Dermatitis venenata . |
. 313 |
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3. Dei-matitis calorica |
. 313 |
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(a) Dermatitis ambustionis |
. 314 |
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1st degree — Erythematosa . |
. 314 |
|
2nd degree — BuUosa |
. 315 |
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3rd degree — Eschavotica |
. 316 |
XVIU
CONTENTS.
PAGE
Prognosis ..... 318
Ti-eatment . . . . .318
(6) Dermatitis congelationis . . . 322
1st degree — Erythematosa (Pernio) . 324
2nd degi-ee— Bullosa . . .325
3rd degree — Esctai'otica . . . 325
Ti-eatment . . . . .326
CHAPTER XIV.
B. Dermatitis symptomatica
I. Dermatitis ei-ythematosa . Erysipelas Symptoms . Varieties . In form . In extent In seat . Diagnosis . Pathological anatomy Etiology . Prognosis . Treatment . II. Dermatitis phlegmonosa Furunculus . Anthrax Glanders
Necrogenic pustule Pustula maligna Treatment .
330
330
330
331
333
333
334
335
337
338
339
342
342
346
347
348
351
352
354
355
CONTENTS.
XIX
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CHAPTER XV. |
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PAGE |
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The PHLYCT.ä;NOSES . . . . . . 359 |
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I. Herpes .... |
. 359 |
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History |
. 359 |
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Definition |
. 365 |
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Species |
. 366 |
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1. Hei-pes facialis, sen labialis |
. 368 |
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2. Herpes progenitalis, seu prseputialis |
. 370 |
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3. Herpes zoster . |
. 372 |
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(a) capülitii |
. 375 |
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(b) faciei |
. 375 |
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(e) nuchae . |
. 376 |
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{d) brachialis |
. 376 |
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(e) pectoralis |
. 376 |
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(/) abdominalis |
. 376 |
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((/) femoralis |
. 377 |
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4. Herpes Iris et cü-cinatus |
. 378 |
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Etiology- |
. 381 |
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Treatment |
. 382 |
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II. Miliana |
. 383 |
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Etiology |
. 390 |
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Diagnosis . |
. 391 |
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Prognosis . |
. 392 |
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Treatment . |
. 393 |
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III. Pemphigiis acutus, sen Febrilis |
. 394 |
ON
DISEASES OF THE SKIN.
CHAPTER I.
ON THE GENERAL PATHOLOGY AND SYMPTOMATOLOGY OF CUTANEOUS DISEASES.
The integument^ as an integral part of the organism^ is liable to no other morbid processes than those to which the other organs of the human body are subject. Thus, there are diseases of the skin, Avliich are caused by hypersemia, anEemia, exudation, and hsemorrhage; and we also meet with neuroses of the skin, and find it presenting new growths, or affected by hypertrophy or atrophy. The anato- mical conditions and the superficial position of tlic skin, as well as the extent of its surface do indeed in some degree modify its diseases. But of the peculiar forms thus produced, some, such as the ulcerative processes, and the parasitic growths, occur also in analogous tissues, such as the mucous membranes. And the remaining difl'erences concern chiefly the etiology and symptomatology of cutaneous aff"ec- tions, and do not consist in any essential peculiarity in the nature of the disease.
What however is altogether special to afl'ections of the skin, is their symptomatology , that is to say, the nature of the appearances by which the various pathological processes manifest themselves to our senses.
On a general survey of these appearances, it is impossible to overlook the fact that the dermatonoses present a certain uniformity in their configuration, and that they have also a definite mode of development, and of retrogression. And this leads directly to the conclusion, that the determining agent in the production of the symptoms of cutaneous disease, is not so much the general pathological
1
2 GENERAL SYMPTOMATOLOGY.
process, as the local disturbance to which it gives rise. In other words, the cause of the peculiar appearances met with in the dermatonoses, lies in the change which these diseases produce in the organs which make up the skin. For example, pustules, which do not essentially differ in form, are caused by the variolous process and by scabies, as well as by tartar emetic ointment, and by mere mechanical friction. Yesicles appear in the train of certain general diseases, which resemble perfectly those produced by the inunction of croton oil. Again, precisely similar deposits of pigment are pro- duced by external irritants, and by affections of the internal organs. And thus, from any individual appearance, we can seldom infer the cause of the disease. We have always to pass in review the whole of the symptoms, which belong to each cutaneous affection.
And yet it is indispensable to have an accurate acquaintance with each of the appearances caused in the skin by the various morbid processes to which it is liable ; and it is necessary not only to know their oric/inal form, but also to be familiar with the further changes which they undergo, with their mode of ^involution, and with their pathological anatomy.
Under the term Efflorescentice aitanea (Hautblüthen, Efflo- rescenzen, eruptions), it is usual to group together many of the symptoms of cutaneous disease, which differ altogether from other pathological appearances, in their determinate form, their position, and their course, as well as in the regularity of their development and retrogression. And it is the practice to give certain special names to the various forms of efEorescence, which are distinguished by characters of their own.
Now we have no intention of disturbing the established termi- nology and definitions of these different forms of efflorescence. On the contrary, we hold that designations once adopted should always remain fixed, and should be closely adhered to. But we shall also carefully avoid aU unnecessary and too refined distinctions, specifying those differences only, which are of an essential kind.
Some of the appearances observed in cutaneous diseases are caused
* The term involution is employed in this and other works to indicate that stage of a disease, which succeeds the full development of the pathological change, and during which the restoration of the normal condition of the part is going on. Thus, in variola, it is applied to that period which follows the com- plete formation of the pustules, and in which these become couverted into crusts. — [Ed.]
PRIMARY rORMS OF EFFLORESCENCE. 8
directly by the deposition of morbid products in the skm. These bear the name of Primary symptoms or eruptions^ Efflorescentia cutanea p-imarm. But these eruptions often afterwards undergo further development, and are subject to changes of a \italj chemical, or mechanical kind. To the appearances thus produced we apply the name of Secondary symi^toms.
Under the first head, we include (i.) the spot or macule — Macula (Fleck). (2.) The papule— Pö/j?«/ü! (Knötchen). (3.) The tubercle— Nodus seu Tuberculum (Knoten). (4.) The tumour — Phyma (Knollen). (5.) The wheal — Tomphus seu Urtica (Quaddel). (6.) The vesicle — Vesicida (Bläschen). (7.) The bleb — Bulla (Blase) ; and (8.) the pustule — Pustula (Eiterblase).
AmoDg the secondary appearances we enumerate — (i.) The excoriation — E.vcoriatlo (Hautabschürfung). (2.) The ulcer — ulcus (Geschwür). (3.) The fissure — Ehagades (Schrunde). (4.) The scale — Squama (Schuppe). (5.) The crust — Crusta (Kruste). (6.) The lamellated crust — Crusta Lamellosa (Schuppen- grind); and (7.) the cicatrix — Cicatrix (Narbe).
I. — Primary symptoms or forms of Efflorescence.
(i.) The macule or spot {JIacula, Fleck, Kelis, Tache) includes every change in the normal colour of the skin, arising from disease, and not uniformly distributed over the whole surface of the body. When the skin is universally aflected, we employ the term dis- coloration, Becoloratio, Dyschromasia — (Missfätbung) .
The colour of maculae is either one of the various shades of red^ or white, grey, yellow, green, blue, brown or black. They may either be punctiform, or may vary in size from that of a lentil to that of a bean, of a finger-nail, of a fourpenny or sixpenny-piece, a half- crown, the palm |of the hand, &c. In form, they may be divided into round, oval, elongated, circinate, and serpentine.
Their seat is sometimes in the vessels which supply the papillae of the cutis, sometimes in the pigmentary layer of the cuticle.
Various morbid processes may be concerned in the formation of maculae. They may arise either from simple hyperaemia, or from exudation into the tissue of the cutis, without elevation of its surface, or from hsemorrhage and its results, or, lastly, from anoma- lies of pigmentation.
4 GENERAL SYMPTOMATOLOGY.
All these cliaiiges iu the normal colour of the skin bear the general name of maculee; but we have for some forms of them special denominations. Thus the term Roseola (Ptöschen) is applied to red spots^ of a rounds oval^ or elongated form, in size between that of a lentil and that of a finger-nail, when the redness disappears beneath the pressure of the finger. On the other hand, when the redness does not so disappear, the name Fnrpura is used; and this is again subdivided according as the maculse are large or small, or simply punctiform — Peteehm, or in the form of strise — Vibices, or occupying large tracts of skin — Ecchymosls. Again, rashes which cover, uninterruptedly, portions of the integument as large as the palm of the hand, or larger, and which disappear beneath the pres- sure of the finger, are called '^Eryihemata (Erytheme).
Those blushes which surround the periphery of other eruptions receive the name Areola or Halo (Hof.).
Flat Teleangiectases, the so-called Nsevi vasculares, also form red spots ; but these are readily distinguished from Roseola, Erythema y or Purpura, by the presence of the distended varicose vessels which cause the disease, and which are generally visible with the naked eye. Moreover, in these affections it requires the application of a more severe and continued pressure, to make the redness even for a short time disappear.
White spots, produced by deficiency of pigment, and varying in size from that of a lentil to that of the palm of the hand, or even occupying the whole surface, are called Achroma, Vitiligo (alba levior) if acquired; Leucopathia, Albinismits, if congenital. Darker patches caused by increased deposit of pigment may be observed at the circumference of these white patches. The openings of the hair- sacs are also seen on them unaltered ; and the growth of the hairs
1 Although we fiud these terms applied throughout dermatologlcal works in pretty strict conformity with their definitions, yet it must be admitted that some names are met with, which do not answer to the rules we have laid down. A7e have examples of this in the Roseola rheumatica (a red rash, which takes the form of maculae, but which does not disappear on pressure, and, as is well known, is caused by haemorrhage), and in the Erythema papulutum, tuberculatum, atimdare, iris, gyratum, nodostim, &c., (forms of efflorescence, having a red colour and a raised surface, varying in size between that of a pea and that of a hen's e^g, of an annular shape, or resembling papules, tubercles, &c.). However, the introduction of a scientific terminology in the study of cutaneous disease, will probably be tiie work of the immediate future. I shall at least attempt to prepare the path towards its accomplishment.
PRIMARY FORMS OF EFFLORKSCENCE. 5
whicli are themselves mostly white^ remains iinafFected. These characters enable these affections to be readily distinguished from flat cicatrices.
Brown or black spots, produced by excessive deposit of pigment, have various names, (i.) Chloasmata (Pigment, ]\lother, or Livers- spots). These cover spaces as large as a half-crown-piece, or as the palm of the hand, or are even larger still. They are met with on the face, particularly on the forehead, and also on the trunk, and on the extremities, and they do not desquamate. (2.) Lentigines or Hj^lie- tides — -Sun spots (Linsenflecke, Sommersprossen). These are yellow or brown spots, of the size of a lentil, which are found in large numbers on the face and limbs. (3.) Pigment marks — ^Ncevus Spiliis (Pig- mentmaale). These are brown or black spots, generally round, scarcely or not at all elevated, and of the size of a lentil or of a fourpenny -piece. They are generally solitary, and occur chiefly on the face, back, and extremities.
Yellow, blue, and green discolorations of the surface are observed during the involution of hsemorrhagic spots ; they are always con- fined to the seat of the original heemorrhage, and may be easily recognised by the fact, that the colour is not the same over the whole of the spot. On the contrary, they have a marbled appear- ance, and generally display at the same time all the three colours which we have named.
Spots, which are simply blue, and present no other colour as well, are, if they disappear on pressure, the result of passive congestion, or blood-stasis, and occur chiefly at the distal parts of the body,
' The name Liver-spots (Leberflecke) led to, or arose from, the erroneous opinion that they were caused by hepatic diseases. For tliis idea there is no foundation whatever. Disease of tiie liver, such as atrophy, may cause deposits of bile-pigment in the skin ; but this produces a yellow or brown discoloration of the whole surface of the body.
^ Here, also, we meet with a mistake which is very widely diffused, the notion that these pigment-spots are due to the influence of the sun's rays. Careful observation, however, teaches us that this is not the case. The proof of this statement we shall furnish hereafter.
3 If the term Nsevus — mother's mark, answers to a congenital modification of the colour of certain parts of the skin, it is not strictly applicable to the appearance whicli we are now describing ; for these spots are very rarely seen in infants, and almost always show themselves first during adult life. In our Lying-in hospital, in which there are more than 7000 births every year, there is abundant opportunity to convince one's self of this fact.
6 GENERAL SYMPTOMATOLOGY.
such as the face, the hands or the feet, in cases of defective circu- lation.
A black colour affecting parts of the skin — Nigrities partialis, Panmis melanem — is met with on the face, on the areolae of the breasts, and over the linea alba of pregnaiit women, and also in the scrotum of men, where it is a local change.
Discolorations — Decolorationes, Bysclifomasia (Missfärbungen), that is to say, more or less uniform alterations in the colour of the whole surface, present various appearances. There is the pale, waxy, death-like hue (Todtenfarbe) which is seen in chlorosis, in anfcmia, and in the different cachexise. There is the yellow, green, brown, grey, or even black colour, which is due to the deposit of pigment in the skin — of biliary colouring matter in jaundice, of nitrate of silver in argyria, of an excess of the normal cutaneous pigment in melasma. And lastly, there is the more or less deep blue or bluish-black tint, which is produced by disturbance of the circulation, as in the so-called cyanosis or morbus cseruleus.
!Maculfe vary in the course which they run, and in the duration of their existence. The spots of roseola or of erythema always quickly disappear, and either leave no trace of their presence, or are followed by desquamation and deposit of pigment in the parts which were before reddened. On the other hand, spots caused by teleangiectasis are almost always permanent, and at most vary only in the depth of their red colour, and in its tint. So again the white, brown, and black maculae, which arise from deficiency or excess of pigment, very seldom undergo changes of hue, though they may spread over a larger surface. The yellow, blue, and green discolorations, which are the result of haemorrhage, have generally a duration of from one to three weeks, according to the quantity of extravasated blood. During this time they present several changes of colour, so that, from being at first bluish-red they become blue or bluish-black, then greenish-yellow, and finally quite yellow. The blue, or cyanotic colorations, correspond in duration to the causes which produce them \ and when these are removed, vanish completely without leaving behind them any indication of their presence. This is true also of the other forms of general discolora- tion of the skin.
(2.) The papule or pimple {Tabula, Knötchen, Blätterchen) . These names are applied to any morbid change in the skin, which forms a solid projection above the surface^ in size between a millet-
PRniARY FORMS OF EFFLORESCENCE. 7
seed aud a lentil,, and containing within it no fluids so far as can be seen with the naked eye.
Their colour may be that of the healthy skin, or may be of any shade of red. Papules may also be white^ brown, or black, or of a livid hue.
Their magnitude varies from that of a millet-seed — Milium, Pajonla miliares, miliform.es, to that of a lentil — Lenticnla — Papul(B lenticulares. j\Ioreover, pins-heads and hemp-seeds may also be made use of as comparative terms to indicate more accurately their size.
In form they are distinguished as pointed, Paimlce acutcB — as flat, T. plana. — conical, P.conicce — semi-globular, P. glohosa.
Papular eruptions are seated sometimes in the papillae of the cutis ; sometimes in the deeper layers of the epidermis ; sometimes, and indeed most frequently, in the follicular apparatus of the skin. Thus, in one instance, they are due to the enlargement of already existing papillae, or to the formation of new ones. In another case, they are produced by exudation into the rete mucosum, or by extravasation of blood into the same tissue. In other instances again, it is a sebaceous gland, which, having undergone degeneration, or having become distended by its secretion, causes an elevation above the surface of the skin. Lastly, and this is the most common case — the hair-sac, or rather the margin of the canal in which the hair is lodged, is the special seat of the papule. It is easy to convince one's self of this, either by obser\'ing cases of cutaneous disease with the naked eye, or by examining papules with the magnifying glass, and, after their removal, with the microscope.^
■^ My view with reference to the mode of origin of those papules (and vesicles) which are seated at the entrance of a hair-sac, is as follows. As is well known, the whole sac is filled with epidermis (the so-called root-sheath) so completely, that there .is no free space between the hair and the wall of the follicle. This part of the epidermis which is thus formed within the follicle and fills it, is uninterruptedly continuous with the external cuticle, which arises from, and covers the adjacent papillfe. Now when the vessels which supply the seba- ceous glands or the papilla of the hair, pour a drop of exudation into the in- terior of the follicle, this must of course infiltrate the epidermic cells which occupy that position. It is not, however, retained by them, but is transmitted in tlie direction determined by the mode of nutrition (in der durch den Stoff- wechsel gegeben Richtung), that is to say, outwards to the cells immediately contiguous. This process is repeated, till at last the drop of exuded matter, or the secreted fluid, reaches the horny layer of the cuticle. This resists its pres- sure, and prevents the further progress of the fluid, for its cells have less power of imbibition. Hence it becomes pushed forwards above the level of the sur-
8 GENERAL SYMPTOMATOLOGY.
The pathological processes, by which papules arise, may be reduced to the following —
(a) Abnormal growth and accumulation of e]:)idermis round the entrances of the hair-sacs. The tubular sheaths of epidermis (root-sheaths) which surround the hairs, and which normally become imperceptibly detached, are under abnormal conditions retained at the entrances of the sacs. This occurs first wdth the innermost stratum, which is in immediate contact with the hair; the next layer is then added ; and so on, till a cone of epidermis is formed, consisting of concentric rings, and either perforated by a hair in the centre, or having underneath it a more or less spirally rolled-up hair, which cannot make its escape. This forms the Lichen ^yUar'is of Willan.
{Jj) Excessive secretion of hard and altered sebum, which fills and distends the duct of the gland or of the hair-sac, and pushes before it the lamina of epidermis, which covers the duct. Thus are pro- duced the so-called white Comedones.
{c) Degeneration of the sebaceous gland, and conversion of it into a white, globular, solid body, the size of a millet-seed. This occurs in adults on the eyelids, and in the skin of the penis and scrotum, and is termed Grutum or Milium. As observed in children, it received from Willan the names Stro2)huhs albidus and S. cancUdus.
[d] Haemorrhage into the rete mucosum. The blood exudes in the form of drops, which coagulate and push forward the horny layers of the epidermis, and so produce papules. This affection is the Lichen lividus of Willan.
(e) Exudations either upon the surface of the papillae, or into the follicles in the way already described in the foot note to page 7.
(/) Hypertrophy of pre-existing sensory papillae, as, for example, in ichthyosis.
{ff) GroAvth of new papillae, resembling those of the healthy skin ; but larger, and generally pointed in form. These are met with in condylomata, in frambccsia, &c.
rounding skin ; and thus a little projection is formed wliicli encircles the hair, and is, in fact, a papide. If the process of exudation has now ceased, nothing more occurs beyond the formation of the papule ; and this quickly disappears, for the fluid exuded either evaporates or is absorbed, and the lamina of epidermis •which formed its roof, separates as a furfuraceous scale. If, liowever, the process goes a step further, and several drops of exudation are poured into the follicle, the fluid gradually becomes visible beneath the epidermis, and thus that form of eruption is produced, which goes by the name of the vesicle.
PRIMARY FORMS OP EFFLORESCENCE. 9
{h) Spasmodic contraction of the cutis (whether due to the action of the organic muscular fibres which have been discovered in its substance^ or to a contractihty inlierent in the connective tissue), by which the looselj^-imbedded hair-sacs, with their ducts, are raised above the level of tlie surface. It is in this w^ay that those papules are produced, which are of the normal colour of the skin, and which form the condition known as the Cutis anseriiia (Gänsehaut goose-skin.)
Note. — According to the nomenclature introduced by Willan, all cutaneous diseases caused by the formation of coloured papules, and occurring in adults, are placed under the head Lichen. All papular eruptions which appear in children bear the general name of StwpJm- lus: — and papules which have the same colour as the rest of the skin, are the distinguishing mark of a Prurigo. This nomenclature may appear simple and judicious ; but the presence of papules, and the peculiarities in their form and colour, cannot be applied as indi- cations sufficient in themselves for the diagnosis of a disease. Tor the determination of a cutaneous affection, its general appearance (das Gesammtbild) is just as important as for the recognition of any other internal or external malady. Moreover, as the symptoms manifest themselves not at once, but in succession, and in a definite order of development, it is necessary for the establishment of the diagnosis of a disease that its whole course should be observed. Although, therefore, we adopt the nomenclature of Willan for dis- eases of the skin, yet we employ it only to denote i\\Q\vfo7-m. So long for instance, as we regard a papular affection merely as a symptom, we give it the name of Lichen ; but if we wish to indicate any par- ticular papular eruption, it is necessary to associate with the name of Lichen, an epithet defining it more narrowly.
The duration and the course of papules vary with the patholo- gical processes to which they owe their origin. Thus those which are caused by exudation into the follicles exist as papules for a very short time only (from two to four days). Tor if the exudation conti- nues, they pass into vesicles or pustules, or even into tubercles. On the other hand, if they undergo involution, they gradually sub- side, their fluid contents disappearing by absorption or evaporation ; and a little discoid lamina of epidermis, which previously formed their roof, remains as the only indication of their position. This afterwards becomes detached as a scale. The skin beneath is then left of a normal colour, or slightly darkened by pigment ; and the
10 GENERAL SYMPTOMATOLOGY.
entrance of the hair-sac, which is again pervious, is plainly visible. Those papules which are caused by hgemorrhage have a longer duration ; and those which are due to an accumulation of sebum, or to degeneration of the sebaceous glands, remain longer still. Lastly, papules which are produced by hypertrophy of the cutaneous papillse, or by a new growth of similar structures, are altogether permanent.
BemarJv. — A morbid appearance, which has received the name of the Stigma or Umbo (Stippe, Punkt) is to be regarded as arising from the union of the two forms of efflorescence which we have been describing. It is a round, circumscribed red spot, not larger than a fourpeuny- piece, which has in its centre a minute papule. Its origin may be thus explained. The papule is caused by sweUing of the entrance of a hair-sac, in the way already described ; and the surrounding halo is produced by congestion of the vessels Avhich supply the corre- sponding sebaceous glands. The stigma is always an ephemeral, and never a permanent appearance : and it usually precedes the formation of papules, vesicles, or pustules, as is the case, for instance, in variola.
(3.) The tubercle {Tuberculum, Nodns, Knoten, Hübelchen) is any solid swelhng of the skin caused by disease, which contains no fluid, is as large as a lentil, bean, or hazel-nut, and is covered with epidermis.
In colour tubercles correspond perfectly to papules ; for they may be of the various shades of red, of the normal tint of the skin, of a li^'id hue, or .white, brown, or black.
In, magnitude they are distinguished, as mentioned above, according as they are of the size of lentils, of beans, or of hazel-nuts. Their greater size constitutes the chief difference between them and papules.
Their form is sometimes semi-globular, sometimes conical. They may also be either pointed at the summit, or flattened, in which case they may be said to be cylindrical.
The same structures of the skin, which are the seat of papules, are also concerned in the formation of tubercles. The pathological pro- cesses are also the same, with the exception of the spasmodic contrac- tion of the skin (described under the heading h). The difference con- sists simply in the fact that it is not one hair-sac only, but several adjacent ones, which are affected simultaneously; or that not one sebaceous gland only, but a whole group of them, undergoes degenera-
PRIMARY FORMS OP EFFLORESCENCE. 11
tion ; or that the quantity of exudation poured into a hair-sac^ or into a sebaceous gland, or of blood effused into the same parts, or of accumulated sebum, is so great that the appearance which is pro- duced is larger, and is therefore termed tubercular. The same thing apphes to the hypertrophies and to the new growths, only that here still larger tracts of skin are attacked, and that, in consequence, the resulting affection is also still more extensive.
The changes to which tubercles are liable are various. They may undergo complete involution, their contents being absorbed, and their covering of epidermis peeling off. They may become indurated by organization, desiccation, or calcification of their substance; they may soften and suppurate. Corresponding to these changes, the duration of tubercles is also variable; but it is in any case much longer than that of papules.
(4.) Wheals [PomjM, Urtica, Quaddeln) are solid forms of eruption, which are but shghtly raised above the surface of the skin, and of which the superficial area greatly exceeds the thickness.
Theh tint is generally red, pale red, or bluish-red. Wheals may also be of a somewhat paler colour than the healthy skin ; and in this case they are usually surrounded by a red ring.
The size of individual wheals seldom exceeds that of the thumb- nail, and they are for the most part still smaller ; but by the fusion of several which lie close together they may become bigger than the palm of the hand.
With reference to their form, it may be observed that each wheal generally resembles a segment of a sphere ; but they are sometimes flat; and they may be circinate, or may present the appearance of stripes, or have various serpentine forms.
The superficial layers of the cutis, and particularly the papillary region, and the tissues immediately adjacent to the follicles, as well as therete mucosum, are the seat of wheals.
Among the pathological processes by which they are produced the most important are exudations either into the cellular layers^ surrounding the glands, or into the superficial strata of the cutis generally. Moreover, haemorrhages, if very superficial and in large quantity, may give rise to the formation of wheals, and some main- tain also that they may be caused by spasms of the dermic structures.
^ "If the cougestiou is associated with increased exudation into the cellular layers surrounding the glands, by which these are brought into a state of tur- gescence, a wheal is the result." E-osenbaum, ' Zur Geschichte und Kritik der Leiire von den Hautkrankheiten.' Halle : 1844, p. 78.
12 GENERAL SYMPTOMATOLOGY.
It is a peculiarity of these forms of efflorescence that they are not liable to any further metamorphosis^ and that they therefore have but a short duration, and disappear without being followed even by desquamation.
(5.) The tumour (l^hjma, Knollen). This term is applied to solid swellings, in size between a walnut and a man's fist, which are covered with epidermis, and have their seat in the deeper layers of the integument.
Their colour generally resembles that of the rest of the skin j but they may also be red or brown. To indicate the size of a tumour, it is compared to a walnut, to the egg of a pigeon, hen, or goose, or to a child's or man's fist.
In form they are, for the most part, semi-globular or conical. But tumours which are globular and pedunculated, or cylindrical and flattened, are also occasionally seen. The cutis and the sub- cutaneous connective-tissue, and the sebaceous glands, are the seat of these aff'ections.
The pathological processes of which these tumours are the pro- ducts are the following : — Accumulations of sebum in very distended sebaceous glands {Tumores cystici); degeneration of these glands {MoUvscum contagiosum), M'ith massive exudations and extravasa- tions into the corium and the sub-cutaneous tissue ; and, lastly, new growths formed within the substance of the integument. Upon the nature of these processes depend both the duration of these tumours and the further changes which they undergo.
(6.) Yesicles {Vesicula, Bläschen) are elevations of the horny layer of the epidermis by transparent or milky fluid. In size they correspond to pajndes.
Their colour depends on that of their contents, and of their base. The former may be limpid or turbid, like whey, or mixed with blood. The base, again, may be of a red or of a black colour. It is, therefore, evident that the vesicles themselves may also present these tints. The further examination of the fluid which they con- tain shows that it has a neutral or alkahne reaction, and that it con- sists of a blastema containing pus cells in small numbers.
An essential characteristic of the vesicle is its size; for only those elevations of the epidermis, which are in size between a lentil and a millet-seed, hemp-seed, or pin's-head, receive this appellation. All those which are larger are reckoned as Bullse.
With reference to the form of vesicles the distinction is espe-
PRIMARY FORMS OF EFFLORESCENCE. 13
cially to be noticed, that on the summit of some of them is to be found a small depression, concave towards the surface, and forming a little saucer-shaped pit, which is called the umbilicus (Delle). ^
Most vesicles have more or less the form of a segment of a s])here [Vesicnlce glohosa) : but mention is also made of some which are conical {T'es'iadce conica).
Their seat is in the epidermis, between its mucous and horny layers ; and they ai'e found both at the apertures of the hair-sacs, and in the interfoUicular spaces. That the spiral ducts of the sweat glands may also be the seat of vesicles (as is maintained by Eosen- baum), can be demonstrated neither on the living subject nor on
^ As to the mode of origin of this appearance, authors are of different opinions. Some, and among them Eichhorn and Rokitansky, think that the umbilicus arises from the falling in of the centre of the vesicle, and its adliesion to the cutis. Others maintain that the desiccation of the contents of the vesicle beginning at its centre, causes it to shrink and to become depressed at that poinL Both tliese views are contradicted by the simple observation, that the formation of the umbilicus begins even during the development of the papule, and that it only lasts till the moment when the whole of the fluid within the vesicle has become yellow and purulent. Moreover, the umbilicus exists only in those vesicles developed from papules, which occupy parts of the surface in which hair-sacs are found ; and whether it belongs to a papule or a vesicle, it may be seen to be perforated in the centre by one or more liairs, particularly when it first makes its appearance.
My own opinion as to the mode of origin of the umbilicus, agrees perfectly with that expressed by G. Simon ('Hautkrankheiten durch anatomische Untersuchungen erläutert,' Berlin, 1851, pp. 97, 102, 131). I regard it, in fact, as a direct consequence of the mode of formation of the vesicle, which I explained when speaking of the papule.
The umbilicus is then for the most part caused by the circumstance, that the exudation which generates a papule or vesicle, and which introduces itself between the layers of the epidermis, cannot raise the cuticle so easily where this is con- tinuous with the root-sheath of the hair, as at those points where this is not the case.
Thus the formation of an umbilicus is the necessary consequence of the change in the margin of the hair-sac, which results from the development of a papule or a vesicle. The absence of an umbilicus, therefore, is a proof that the eruption does not consist in a metamorphosis of the canals leading from the hair-sacs, but has its seat in some other part of the integument.
An apparent umbilicus may indeed also arise by the circular arrangement of an efflorescence round a central point, which is healthy, and presents no erup- tion ; but such a central depression has a very different proportionate size (as compared with the raised efflorescence) from that which we find in the case of the true umbilicus. This last is never more than a small ])oint ; but the false umbilicus may be as large as a millet-seed, or even as a lentil.
]4 GENERAL SYMPTOMATOLOGY.
the dead body ; neither by observation with the naked eye, nor by microscopical investigation.
In regard to the pathological processes which are concerned in the formation of vesicles, we find that these are almost exclusively of an exudative kind. Hypersecretion of sebum may, however, give rise to an eruption which has a vesicular form, but which mostly contains a milky fluid.
The existence of vesicles in an unaltered state is never of long duration. Either the membrane bursts and allows the contents to escape, or the fluid disappears by absorption or desiccation, leaving behind it the empty skin in the form of a scale; or, lastly, the number of pus cells in the limpid fluid increases, its colour changes, it becomes yellow, puriform, viscid ; and so the vesicle is converted into a pustule.
(7.) Blebs {Bulla, Blasen) are distinguished from vesicles simply by their magnitude. The line of separation is quite arbitrary, and is generally drawn by comparing the bulla to the tubercle in size. Thus, the definition of it will be that it is an elevation of the epidermis, in size between a lentil and a gooseys egg, containing in its interior a transparent, or a yellow and purulent fluid.
As to their colour, what has been said of vesicles applies also to bullse, with this difference, that more importance is attached to the colour and nature of the contained fluid in defining the vesicle than in the case of the bleb. Thus, a large bulla may be filled with yellow purulent fluids without being termed a ])ustule, which would be the name given to a vesicle under similar circumstances.
Again, bloody serum is more frequently found in bulJse than in vesicles. But blood by itself, without admixture with serosity or pus, forms not bullse, but dark-red or black tumours (Knollen) ; for it never remains fluid when extravasated beneath such a covering of epidermis, but always coagulates.
The contents of bullfe have the same microscopical characters as those of vesicles, so long as the fluid is transparent. The chemical reaction also is always feebly alkaline or neutral, and never acid. A considerable quantity of albumen is present, especially in the larger bullee ; and sometimes the fluid also contains urea and uric acid.
On the other hand, the size and form of bullae are subject to much more considerable variations than are those of vesicles. Thus we meet with blebs of the size of lentils, beans, hazelnuts, or walnuts ; or they may be as large as the eggs of pigeons, hens, or geese, or may
PRIMARY FORMS OF EFFLORESCENCE. 15
even attain the size of the fist or the palm of the hand. "We find them semiglobular, or almost globular, and also conical ; distended or flaccid (matsch) ; with a circular or oval circumference and base ; and lastly, polygonal, indented, tailed, chciuate or half-circinate. Moreover, in describing bailee, it must not be overlooked that some of them are surrounded by a red border {Areola, Hof.), which in other instances is wanting.
In reference to their position and mode of development, it is to be remarked that they are seated in the epidermis, between its horny and mucous layers. They generally arise by the enlargement and blending together of several vesicles placed near one another. In their duration, and in the changes to which they are liable, bullae correspond exactly to vesicles.
(8.) Pustules {Pustula, Pusteln) — "Vesicula, quce pus fert, est pustula,^' was the definition given to this form of eruption by our forefathers. Thus, the purulent yellow character of the contents of an elevation of the cuticle distinguishes a pustule from a vesicle. At the present day we read as the definition of a pustule that it is a small abscess, covered only by epidermis ; and both this statement and the former one are equally correct,
A straw-colour is the fundamental tint of pustules, for the puru- lent fluid which they contain is a condition, si?ie qua non, of their existence ; but the pus may be mixed with more or less blood or sebum, which causes them to appear in the one case of a darker, in the other of a paler, yellow colour.
Yarieties in their size and form gave "VYillan, as is well knowTi, occasion to describe several kinds of pustules. At the present day one is not inclined to attach any great importance to these distinc- tions ; but I think it well to introduce them here for this reason, that one can by these special denominations most simply indicate the size of a pustule in any particular case. Omitting the Phlyctis,^ which must be referred to the vesicles, there remain three forms of pustules, namely, the Achor, the Psydracium, and the Phlyzacium.
By the achor is understood a round pustule, the size of a millet-
1 ' Die Hautkrankbeiteii und Hire Beliaudluug systematisch beschrieben,' von Robert Wiilan, &c. ; aus dem Englischen, von Fr. G. Priese, p. lo, Breslau, 1799.
In the English work ' On Cutaneous Diseases ' (vol. i, Introduction, p. 13), Willan mentions the Plilyzacium, the Psydracium, the Achor, and the Cerion, or Pavus, but not the Phlyctis. — [Ed.]
16 GENERAL SYMPTOMATOLOGY.
seed, scarcely or not at all elevated above the surface, and generally perforated by a hair. It is observed chiefly on the hairy scalp and on the face. By drying-up of the pus contained in it, there is generally produced a rough, granular, honey- coloured crust, of which the joeculiar appearance is probably due to the admixture of sebum with the pus. "Willan introduces the Favus or Cerion as a species of this affection, starting from the notion that the Favus (Tinea favosa seu lupinosa) arises from the desiccation of this kind of pustule. This however, as is well-known, is not the case.
The psydraceous pustule frequently begins as an achor, but when fully developed, is of greater size and contains a larger quantity of pus. Its margin is not circular, and is surrounded with a red areola. It dries up into crusts which have a more or less green colour. It is met with chiefly on the limbs.
The term phlyzacium is applied to pustules which are of at least the size of a pea, and which are semi-globular, and therefore have a circular base. They are filled with pus mixed with more or less blood, form brown or black crusts, and, like the psydracium, occur only on the limbs.
With reference to the umbüicus, it may be remarked that hi each of these forms this central depression is present only at the com- mencement of the pustule, and always disappears during the course of its development. For as the quantity of the contained fluid in- creases, the roof of the pustule becomes stretched; and thus the processes of epidermis by which the umbilicus is formed, and which are connected Avith the rootsheath of the hair, become softened and broken down.
Besides these forms which have received names, pustules offer many other varieties. Thus when they are developed from other kinds of eruptions, such as papules or tubercles, their base presents a more or less hard, red infiltration, which was termed by Fuchs, a fleshy pericarpium (Fleischiges pericarpium) .
The seat of pustules is of course always beneath the horny layer of the cuticle; but with regard to their being superficial to the corium, or more deeply situated within it, many differences prevail. It must not however be overlooked, that those which are developed from papules or vesicles, will naturally occupy the same position as the eruptions which preceded their formation.
The pathological process, which produces pustules can essentially be no other than that of suppuration. The element« of pus (element-
I
SECONDARY FORMS OF EFFLORESCENCE. 17
aiy granules^ nuclei^ and nucleated cells), in fact, develope them- selves in those exudations which lie beneath, and are covered only by, the epidermis, just as they do in other exudations, wherever they may be deposited. And this applies equally whether they showed themselves at first as points (Stippen), or as papules, tubercles, tumours (Knollen), vesicles, or blebs. Thus then pustules are among the forms of efflorescence, which for the most part arise from pre-existing eruptions of a diiferent character, and they therefore do not strictly deserve the name of primary symptoms, of which the distinguishing mark is that they are caused directly by the original morbid products. As, however, the exudation which precedes the occurrence of suppuration beneath the epidermis frequently escapes notice till it becomes converted into pus and thus betrays its pre- sence by its yellow colour, it often happens that pustules are the first perceptible morbid appearance, and hence one cannot help admitting them among the primary affections.
II. — Secondary Symptoms or Forms of Effiorescence.
As has been already stated, we understand by this term (Secundäre Krankheitserscheinungen) those pathological appearances which are generated in the tegumeutary tissues, not as a direct result of the disease, but by the metamorphosis, the softening, or the desiccation, by the breaking down, the fissuring, or the ulceration, or again by the organization of the morbid products deposited in the skin. The following are the appearances which fall under this head.
(i) The excoriation {Excoriatio, Hautabschürfung, Oberhautab- schürfung) presents the following characters, which also distinguish it from the ulcer. The epidermis, or at any rate the horny layer of it, is destroyed ; either the rete mucosum, or the corium, of which there is no loss of substance, is exposed ; and, lastly, healing occurs without the formation of a cicatrix.
The appearances by which excoriations manifest themselves vary, according as they follow pre-existing eruptions, or are caused by a direct destruction of the epidermis. In general, they show them- selves as red shining spots, more or less moist or bleeding, of which the margins are sharply cut off from the normal epidermis which surrounds them. These sometimes at once skin over, becoming first covered either with a brown pellicle arising from dried blastema, or
18
GENERAL SYMPTOMATOLOGY.
with a reddish-black crust formed from blood. In other cases they persist for a long time in an unaltered condition, constantly pouring- out fluid and remaining moist.
The excoriations which are consecutive to pre-existing eruptions present fresh varieties, according as they arise from the destruction and rupture of vesicles, blebs, or pustules, or are caused by the loss of the epidermis which formed the covering of papules, tuber- cles, or wlieals. In the former case they are more extensive, and are generally circular or discoid in form. They are also sharply limited by a border of healthy epidermis ; and they do not bleed, but are covered merely by a more or less fluid layer of blastema. In the latter case, they are punctiform, or at least not bigger than a lentu, and of a round or elongated form ; and they are either still bleeding, or bear a scab formed from dried-up blood.
Excoriations, which are caused by the loss of epidermis from parts of the skin previously healthy, resemble in many respects those just described, but are generally of larger extent; and the crusts which cover them have for the most part a greater thickness.
From the appearances which we have been describing, and from the part of the body which is affected, one is almost always able iu an mdividual case to indicate precisely the nature of the causes which produced excoriations. Tor in general they occur only where the horny layer of the epidermis has been separated from the mucous layer by exudation taking place heneath it, or where the cuticle has been torn from the corium or from the rete Malphigii by injuries mflicted u2ion it. In the first case the excoriation is preceded by an eruption, and the appearances already described manifest themselves. In the other case it is found upon otherwise healthy skin, and owes its origin to friction, to pressure, or to scratching with the finger nails.
(2) The cutaneous ulcer {Ulcera cutanea, Hautgeschwüre) is a term applied to a loss of substance of the corium which is caused by past disease of the skin, and in which the restoration of the tissue destroyed is either not taking place at all, or is going on very slowly, because the blastema which is thrown out does not possess the requisite properties.
The points which require observation in an ulcer are its seat, that is, the part of the skin at which it occurs ; the condition of its sur- face, of its base, and of its edges ; the state af the integument round it ; the quality of the fluid which it secretes j and its subjective
SECONDARY FORMS OP EFFLORESCENCE. 19
symptoms ; wlietlier^ that is, it causes paiu, or is, on the contrary, insensible.
In reference to their form and configuration, it may be remarked that ulcers present very great varieties, according to their position and their duration, the nature of the process which gave rise to them, and the various injurious influences which have acted upon them. The indication of these differences is, indeed, provided for by the terms Ulcera cniris, s?/j)/iilitica, c/iro/iica, inchrata, mveterata, &c. But these expressions refer to nothing more than the acci- dental condition of the sore, and are in very few cases to be regarded as names of distinct affections, possessing specific characters. To this, however, the syphilitic ulcer is an exception.
(3) Fissures {R7ia(/ades, Rhaffcidia, Rimoi cutis, Hautschrunden) are elongated aud usually linear cracks m the skin, which may affect either the cuticle alone, or the corium also, and which are some- times dry, sometimes attended with an oozing of formative fluid, or of blood. They arise when the skin is the seat of infiltration, or is abnormally brittle, in parts (such as the fingers, elbows, and knees,) which are liable to much stretching or dragging.
(4) Scales {Squama, Schuppen). These are plates of dead epi- dermis of various size, which, in consequence of morbid conditions of the skin, have become partially or altogether detached and cast off from their bed.
Their form, size, thickness, compactness, and colour, are subject to many variations. They maybe either flat or raised; they may be merely like dust or bran, or they may be as large as the palm of the hand, or they may copy the form of parts of the body, as, for example, of the fiugers. Some are as thin as goldbeater's skin; others are many lines thick ; sometimes they are soft and flexible, at other times they are dry and brittle. Lastly, they may have the same colour as the rest of the epidermis; or they may be white, yellow, brown, green, or black.
The process which gives rise to desquamation of the epidermis may affect tracts of skin of very variable extent. When it is an independent disease, that is, when it is preceded or accompanied by no other discoverable cutaneous affection, it is termed a pityriasis ; whereas the same appearance receives the name of desquamation {Desquamatio, Abschuppung) when it is the result of a previous disease of the skin. Moreover of this last, certain subdivisions are recognised* There is the Desquamatio furfur acea^ when the scales
20 GENERAL SYMPTOMATOLOGY.
are small^ and resemble meal or bran ; the Desquamatio memhrauacea, when the cuticle becomes detached in large membranous pieces ; and, lastly, the Desquamatio siloquosa ; a rare appearance, in which sac- cular elevations of the epidermis are formed by the exudation of fluid beneath them, which elevations persist as empty shells, after this fluid has escaped or has been absorbed.
(5) Crusts [Crustce, Krusten, Borken, Grinde,) are those soHd masses which are formed as a result of disease of the skin, by the drying up of exuded fluids, or of extravasated blood. They pre- sent many different appearances, according to the causes which give rise to them. Thus, serous exudations produce by their desiccation merely flat brown scabs ; whilst sebum by itself, or in admixture with pus, always dries into yellow crusts, resembling honey or gum. Again, those which are formed from pus alone, have a green hue, which is changed by the presence of blood, into a brown, or even into a black colour.
The thickness or height of a crust depends partly on its duration, and partly on the rapidity with which the exudation which gives rise to it is poui'ed out. In general, crusts become more elevated in proportion as their formation is slow and of long duration, while exudations, which take place rapidly, produce but thin scabs. Some crusts are flat ; others are raised or even conical ; and some- times they may be observed to have a conchoidal, scutiform, or alveolar appearance.
(6) Lamellated crusts {Crusta lamellosce, Schuppengrinde). As their name implies, these occupy an intermediate position between scales and crusts. They consist of layers of epidermis and of dried sebaceous secretion or inflammatory exudation, placed one over the other in strata, so that there is no great difference in the proportion of their component parts. They are easily recognised by their flat appearance ; by the colour of their surface, which is, for the most part, whitish-yellow ; by their laminated structure, and by the differ- ences in the colour of the individual layers.
Their occurrence is limited to those cases, in which small quan- tities of sebum or of exudation are deposited at the same spot, at regular intervals, between which the epidermis has time to repro- duce itself beneath the effused matters.
Examples of Crusta lamellosa, are afforded by the flat layers of sebum, from a pale yellow to a black colour, which are found on the scalps of children who are not kept clean ; by the similar appear-
SECONDARY FORMS OF EFFLORESCENCE. 31
ances in SeborrJicea capillitii, and by the yellow or brown thin plates which occur in Porrigo scutulata [Herpes tonsurans.)
(7) Scars [Cicatrices, Narben) are the structures which replace portions of skin which have undergone destruction. They are dis- tinguished from the healthy integument by their greater hardness, by their smooth, shiny aspect, and by the absence of pigment, of hair, and of glandular openings upon their surface.
Thus the growth of new tissue, which gives rise to cicatrices, makes up for the loss of substance in the skin only by regenerating its fundamental structure, the connective-tissue elements. The other tissues w^hich are peculiar to it, the papillpe, the hairs, and the seba- ceous glands, are not restored by this process.
The peculiarities in the form of certain scars depend less on the nature of the morbid process which caused the loss of substance, than on the circumstances which attended the cicatrisation. Hence it follows, that a cicatrix presents no positive marks from which one can with certainty draw conclusions as to the past disease which gave rise to it. In other words, there are no characteristic cicatrices. A scar may present the same smooth appearance whether it arose from an ulcer, a wound, a burn, or a scald, or from the application of some corrosive agent, provided only that the healing process was not accompanied by the formation of connective-tissue in excess, or that the resources of medical science kept this within proper limits. On the other hand, precisely similar injuries may lead to raised, prominent, cord-like, radiating, or funnel-shaped cica- trices, and for this some peculiarity of the loss of substance may be answerable ; or it may be the result of cicatrisation occurring (either spontaneously or from bad management,) without the uniform de- velopment of granulations.
Varieties in the colour of cicatrices are caused by their age. Those which are quite recent have, for the most part, a pale red surface, and the blood-vessels which they contain may frequently be seen through the cuticle in the form of red serpentine lines. Old cicatrices sometimes contain pigment, sometimes have a perfectly white, shining appearance.
As for the subjective symptoms to which they give rise, most cicatrices are less sensitive than the healthy skin ; but, on the other hand, there are some which are extremely j^ainful.
22 GENERAL SYMPTOMATOLOGY.
III. — 0)1 the Distribution of Eruptions over the Skin.
The forms of efflorescence, primary and secondary, which we have described in the preceding section, present many varieties in their mode of spreading and distribution, from which the affections to which they belong derive various peculiarities in their (Zeichnung) pattern.
These peculiarities (Zeichnungen) have been regarded as standing in a causal connection with the essential nature of the affection : and they have been used as names for species of diseases of the skin, whue the genera were based on the form of the primary efflores- cence. Thus, dermatologists were of opinion that changes in the mutual relations of the elements of an eruption were associated with alterations in the nature of the disease. In this they took for an example the case of plants, in which differences in the position of the leaves and flowers do, of course, characterise different species of the same genus. The comparison is, however, a bad and unsuitable one; for, in diseases of the skin, the mutual relations of the parts of an eruption are, in fact, sometimes quite accidental, and therefore variable : and sometimes they are dependent on laws which are very different from those which these writers regard as determining them. If we endeavour to ascertain these laws, we find the peculiar pattern of certain skin affections to arise partly from the anatomical arrangement of the cutaneous vessels and nerves, partly from the way in which these diseases spread, per contigiinm, from one point to another. But these conditions are very far from explaining all the peculiarities in the mutual relations of tlie parts of an efflorescence ; and, m most cases, we are obliged either to attri- bute them to chance, or to confess freely our ignorance of the laws which produce them.
If we attempt to attach more distinct conceptions to the different names employed by authors to designate the appearance and outline of cutaneous diseases, we arrive at something like the following : —
Every efflorescence, whatever may be its form, consists of ele- ments (which may of course have different characters, and do not necessarily resemble one another), ^vhich either stand each by itself, surrounded by healthy skin, or touch and blend with one another, and thus undergo modifications in their original form, which may even be alfogether lost. Thus, then, all eruptions may
DISTRIBUTION. 23
be divided into tliose which are distinct {Efflorescentiee discretce), and those which are confluent {Ef. confertd).
These names, however, are not the only ones which are used to indicate these characters. We find in books the epithets solitaniis, sparsus, intertinctus, dissemhiatus, pimctatiis, guttatics, monocarpus, &c. All these have the same signification as the word discretus, and therefore we regard them all as synonymous with it. And again, the terms confluens, aggregates, diffusus, have exactly the same meaning as confertus, when used of diseases of the skin.
It is, however, very different with those designations which are used to indicate the special features of an efflorescence (die besondere Krankheitsbilder). Thus, the term corymhosus is applied to those eruptions which form groups, such as herpes. The names orbicii' laris, circinatus, centrifugus, and ammlatus or anmilans, to those which are arranged in circles,^ as in psoriasis, roseola, erythema, &c. The epithet iris belongs to that morbid appearance which is distin- guished by concentric rings, or by a circle of which the centre is itself the seat of an efflorescence. Instances of it occur in herpes, erythema, &c. The terms gyrus, gyratus, are applied to segments of circles, Mdiicli are found either singly, or in groups, so as to have a serpentine arrangement; they are observed in psoriasis, erythema, &c. The same appearances receive the epithet serpiginosus when they belong to ulcers, or to elevated growths of new tissue, such as lupus, or the syphilitic serpiginous ulcers, &c.
Discus (Scheibe), discoides, nummularis, are terms given to those eruptions of which the appearance is like a coin, or a flat round plate, and the designation scutulatus, scutiformis, is applied to those forms of skin-affection which, though round, are not discoid or nummular, but shield-hke or saucer-shaped, that is to say, excavated in the centre. Examples of this are found in favus, psoriasis, &c.
The term circ^miscripUis, agaui, is used of those affections whose margins appear on all sides sharply cut off from the adjacent healthy skin. Marginatus, on the other hand, is employed when such a
1 It would be very desirable to indicate by distinct names, the differences in the nature of these circles. For some of them are caused by the arrangement of the individual elements of the efflorescence, which form a ring round an imaginary centre ; and for these circles we would use the epithets circinns, clrcinaUis; while the names annuhis, unmdatus, annularis, would serve for tliose which are developed from round discoid eruptions, which get well first at their centre, and thus lead to the formation of rings,
34 GENERAL SYMPTOMATOLOGY.
defined border does not surround the whole of the efflorescence, or even when it is observed only at one extremity of it, while the oppo- site end becomes gradually pale, shades off into healthy skin, and, to use a common expression, seems as if "washed out" (wie verwaschen) . Maculated rashes (fleckige Röthungen), that is to say, red patches alternating with parts of the skin which present the normal colour, receive the e^iithet variegatus, in contradistinction to those which afPect the skin uniformly, and for which the name lavigattts is used. The appellations j%2«'ö(if?/.s', agrhis, answer to no definite characters, but are applied by difi^erent authors arbitrarily, now to one, now to another form of cutaneous disease.
Certain of these epithets, again, refer to the form or to the colour, or to some other feature of the cutaneous disease, merely as it exists at the time. Such are the terms inveteratus , acwniuatns, verrn- corns, mucosus, granulatus, himidus,fungosiis, exuherans, excoriicans, rodens, exedens, sordidus, lactißtms, madescens, siccus, microcarpus, macrocarpus, amiantaceiis , prominens, lenticidaris , miliaris, tuherosus, favescens, nigricans, melanodes, alhidus, ruber, amorphus, crystallinns, eoniformis, glohulosus, pempihigodes, fimbriatus, suberinns, achatinus, eschar oticus, &c. There are others which relate to the age and sex of the patient, such as neonatorum, infantilis, puerilis, adultorum, senilis, virilis, muUebris, Others, again, indicate particular re- gions of the body, as capillitii, faciei or facialis, larvalis, cervicalis, mammarum, pectoralis, abdominalis^ extremitatum, brachialis, 2^o-l- maris, femoralis, plantaris. Moreover, some liave reference to the duration of the disease, TiS fugax, ephemerus, acutus, chronicus, vola- iicus, perstans. And others relate to its geographical distribution, such as septentrionalis, tropicus, Aquitanicns, Asturiensis, Lombardi- cus, Bothnicus, Esthonicus, Sibiriens, &c.
All these terms have for us no greater value than is implied by the sense of the words. They may pass as means of defining with greater precision the more or less accidental (and therefore not cha- racteristic) appearances which an eruption presents at the time ; but they are not to be used (as was done by Willan, and by all those who have followed his system, with or without modification) as names for the different species of a genus. In the natural history of mine- rals, of plants, and of animals, such terms are ajiplied in this way, and are rightly so applied; and it was from this source that the older dermatologists, who compared the different cutaneous eruptions to flowers and fruits, derived the principles of the nomenclature
DISTRIBUTION. 25
which they adopted for diseases of the skin. But they certainly made a mistake in doing so.
We do not, then, set the same vahie as our predecessors and con- temporaries on the usual denominations of dermatoses, in which a specific as well as a generic name is invariably employed. On the contrary, in naming a skin-affection, we content ourselves with the use of a single appellation, unless we consider the addition of an epithet necessary to define more accurately the nature of the disease. "VYe adhere, in fact, in this respect, to the nomenclature which is now generally employed for the other diseases of the human or- ganism.
Por similar reasons, we must protest against giving a general name to any cutaneous disease, merely because its presence is confined to a particular part of the skin ; for each cutaneous affection may appear on any part of the surface of the body which presents the anatomical conditions necessary for its development. And therefore, to give to a disease a name derived from its seat alone is inadmissible ; and the terms Tinea, Forrigo, Crnsta lactea, Meniagra, Pygagria, Pahnaria, &c.. should be transferred to the domain of history.
CHATTER II.
ON THE DIAGNOSIS, ETIOLOGY, TREATMENT, AND CLASSIFI- CATION OE CUTANEOUS DISEASE IN GENERAL.
I. Diagnosis.
For the recognition of a disease of the skin, no other assistance is required than a knowledge of the objective symptoms, which are visible on the surface of the bod}^ in each particular case. We do not attach any value whatever, either to the history or to tlie subjective phenomena in investigating a cutaneous affection ; for we ought to be guided in this matter only by those symptoms which are appreciable by the sight, the touch, or (sometimes) by the smell. These afford certain and infallible grounds for the establishment of a diagnosis, for they have their origin in the malady itself. They are, so to speak, the alphabet, of which the letters are traced on the skin ; and our task is but that of deciphering the writing.
To accomplish this, it is pecuharly important to have a method in the investigation of every skin affection, and not to neglect certain rules in examining the cutaneous surface when diseased.
Above all, the whole of the body should be looked at, even in cases in which the malady is nominally or really confined to one particular spot ; for it frequently happens that the disease (das Krankheitsbild) assumes quite a different aspect when regard is paid to the appearances presented by every part of the surface, from what it would have if those spots only were examined which were indi- cated by the patient as its seat. By attending to this rule, one is often enabled to find very different and much more rehable grounds for the diagnosis of cutaneous diseases than could be obtained in any other way.
It must not be objected that an examination of this kind, though it may do very well in a Hospital, cannot be carried out in private practice, and especially in the case of female patients. It is quite a mistake to make this assertion. In the first place, decency should
DIAGNOSIS. 37
never be disregarded, even in Hospital practice ; and by us at least, no procedure is adopted, at which decorum or modesty could take offence. It is quite unnecessary to conduct an examination of the skin, so as to cause any discomfort to the patient. The principal parts of the body should be looked at in succession, and in their anatomical order; the genitals and the breasts should be left un- touched; or where this is impossible, their inspection should be deferred to the last ; and then all patients will submit readily to an examination which is undertaken for their own benefit. Again full day-light, and sufficient illumination are indispensable to the thorough observation of the skin's surface. However brilliant an artificial light may be, and whether derived from candles, lamps, or gas, it always gives the skin, whether healthy or diseased, a different appearance, and generally makes it look paler than by day-light. Another point, which may be of considerable importance in ex- amining a cutaneous affection, is the warmth of the air ; for both the higher and the lower degrees of temperature modify the colour of the surface. The ordinary temperatui'e of rooms (66° Fahr.) is the most proper. For the same reason one should avoid making the diagnosis of a skin disease, either during or just after the employ- ment of a cold or warm bath by the patient.
Due regard being paid to these considerations, the examination of the case may be commenced, and in doing this, our object is not, as might be supposed, to endeavour to find some real or imaginary primary efflorescence, but rather to keep to the general appearance of the disease (das Gesammtbild), not allowing ourselves to be beguiled by any special symptom, however striking it may be. The following are the chief points which require to be noticed.
(i) In regard to the surface of the skin, it must be observed whether this is smooth, soft, even, with a greasy lustre, and free from crusts or scales, — or whether it is harsh, ready to crack, uneven, dry, and covered with scales or scabs. It has also to be noted whether the natural lines and furrows are too shallow or too deep, too near or too widely separated from each other ; what is the condition of the pores of the skin, whether or not they are plainly visible, and whether pervious or obstructed; and lastly, whether the growth of hair is normal, excessive or deficient. For these various circumstances enable us to draw certain conclusions as to the pathological changes in the different tissues which form the skin.
28 DIAGNOSIS.
Thus the healthy integument is smooth and soft to the feel^ and has a sHght greasy lustre ; and the shedding of its epidermis goes on without visible desquamation. The hnes and furrows which exist on its surface are moderately pronounced, and are about a millimetre apart. The apertures of the sebaceous and sudoriparous ducts, or the cutaneous "pores," as they are called, are at some parts not to be seen, while elsewhere they may be observed as slight depressions about two millimetres distant from each other. The amount of hair varies with the sex, and also according to the colour of the hair itself, but keeps within certain limits both as to quantity and quality.
On the other hand, when the epidermis is developed abnormally the surface of the skin may be rough, uneven, diy, chapped, or tra- versed by fissures, and covered with scales of various colours and thickness (as is the case in pityriasis, ichthyosis, prurigo, &c.). The lines and furrows also may be abnormally deep, and separated from another by hypertrophic papillse to a distance of two or three mil- limetres. Again, the openings of the follicles may be plugged with sebum, and dilated (as in seborrhsea). Lastly, the hairs may fall out or may be imperfectly developed ; or on the other hand, they may be unusually thick, and may be present in increased numbers.
(2) Again it has to be considered, with reference to the colour of the skin, whether the pigment is excessive in amount, or deficient, and whether it is irregularly distributed; whether the surface is abnormally red, either in its whole extent or in patches ; or whether lastly it deviates from the healthy colour in the direction of too great pallor.
Thus, in respect of the pigment contained in the skin, it has to be noticed whether this is uniformly distributed, or is confined to particular spots, of greater or less extent ; whether the pigmentation corresponds to that of the race of men to whom the individual belongs, and to his age, sex, residence, and occupation, as well as to the colour of his hair, the season of the year, &c. ; or whether there is any deviation from the normal condition in these respects ; and further as to the intensity of the pigmentation, whether the epider- mis has merely a yellow tinge, or is of a brown or dirty-black hue. Again the pigmentation may be defective, either universally or in parts of the surface. And in this case we have to consider whether besides the partial absence, there is not also at other points an excess of pigment. Lastly, it is to be observed whether the tracts
DIAGNOSIS. 29
which present these appearances are bald, or are on the contrary covered with hairs of a dark or white colour, corresponding to that of the surface on which they grow.
Now it is extremely difficult, to establish a norm for the pigmentation of the skin of a healthy person, for this is liable to be modified by many circumstances. But at least this much may be said, that the normal skin of individuals of our own (that is, of the Caucasian) race, generally displays an uniform pale chamois colour, and that a darker tint is observed only at certain points, such as the nipple, the labia pudenda and the scrotum.
Accordingly all irregular coloration must be regarded as morbid, whether it is circumscribed or diffused, and whether the skin is darker or paler than it should be, whether bald or covered with hair. This applies to cases of the so-called Lentigines, Ephelides, Chloasmata, Nävi sjnli et verriicosi ; and also to the Viiiligines, the Ac/iromasia, &c.
The same thing may be said also of all colorations and discolora- tions (Decoloraiiones, Byschroynasice) in which there is any consider- able deviation from the normal tint of the skin, even though the morbid condition is uniformly distributed over the whole surface of the body.
As to the cases in which the skin presents a red coloration, this of course either depends on the capillaries being more or less injected, or it arises from extravasated blood. The ])ressure of the finger is employed to settle this question. If the redness disappears on the application of pressure, which can of course be ascertained only after removal of the finger, this is a proof that the blood has not escaped from the vessels, but is merely retarded in its course and accumulated in the cutaneous capillaries. To this condition, as is well-known, the terms Hyperamia and Stasis are applied. If, on the contrary, the red spot retains its colour without alteration, however forcible the pressure which is brought to bear upon it by the finger, the redness then arises from extravasated blood, and thus the proof that hsemorrhage has occurred, is established.
RemarJc. — Beyond the determination of this point, namely, whether the reddening of the skin is caused by hypera3mia or by haemorrhage, we derive no further assistance in diagnosis from the application of pressure by the finger. For we have been unable to find any con- firmation of the statement made in almost all medical works, that when the pressure is removed the re-appearance of the red colour
30 DIAGNOSIS.
takes place^ sometimes from the centre towards the periphery, sometimes from the periphery towards the centre. This must either be simply a mistake, or must depend on differences in the form of the surface and in the mode in which the pressure M'as appKed. For if a flat yielding surface, like the inside of the thigh, be pressed on by a hard convex body, such as the finger-tip placed vertically, the centre will, of course, be subject to greater compression than the periphery. Now the more forcible the pressure on the cutaneous vessels, the longer will be the time requhed for them to fill again with blood. Hence the redness will reappear first at the periphery (which received least pressure), and last at the centre (which was the most compressed) ; in other words the redness will return from the circumference to the centre. The same thing will occur when a hard convex surface, like that of the thorax is pressed on by one which is yielding and flat or nearly so, such as the pulpy extremity of the finger. And on the other hand, pressure on a concave surface like the groin, by means of a flat one, will necessarily affect the periphery more than the centre ; and in such a case the redness will re-appear in the centre first, and later in the chcumference.
(3) Attention must next be devoted, in the investigation of cutaneous affections, to the size of the part, and to the thickness and degree of infiltration of the cutis.
Changes in the size of any tract of the skin cannot readily escape observation when looked for, particularly if they are not symmetrical, for we can then always find a standard of comparison on the opposite or healthy side of the body. To ascertain the thick- ness of the cutis, the best method of proceeding is to raise the skin into a fold, and to compare the transverse diameter of this either with that of the corresponding part on the opposite side of the patient, or on a healthy person. In this way the degree of infiltra- tion of the skin may also be estimated.
(4) Next, and most important for diagnosis is the appreciation of the appearances produced by the scratching of the patient. One becomes in this way quite independent of the statements of the patient as to the subjective sensations of itching; for no one, who does not really itch, will scratch himself to any extent. And apart from this advantage, an accurate acquaintance with the phenomena to which the irritation of scratching gives rise, affords positive or negative assistance w-hich is of the greatest value in diagnosis. For we know that certain diseases such as scabies, eczema, prurigo,
DIAGNOSIS. 31
and urticaria are always, and that others, as for example the syphilitic eruptions, are never attended with itching. And we are thus able to exclude altogether either the one or the other of these groups of diseases.
In order to give an exhaustive description of the excoriations which are produced by scratching, and chiefly by the finger nails, we have to distinguish certain varieties of them according to the degree in which the various tissues of the integument have been injured or have undergone pathological changes, and also according to the intensity presented by these appearances.
Under the first head, we have to remark, that the participation of the papillge, in the form of hypersemia of their vessels, is shown by the presence of red striae, or of difi^used redness (Erythema urticans). The follicles also become swollen by exudation in their periphery, and produce elevations above the surface, which take the form either of red papules (Lichen urticatus) or of wheals (Urticaria subcutanea). Repeated scratching gives rise to exudation on a larger scale, which penetrates between the layers of the cuticle. This next becomes raised ; vesicles with or without a red periphery or base make their appearance; and an Eczema is developed. Or if the contents of the vesicles become purulent, they then form pustules of various sizes, and thus constitute an Ecthyma.
The effect of the scratching on the epidermis is either to lacerate it and to tear it to a greater or less depth away from its bed, in other words to produce excoriations ; or merely to make the skin assume a darker colour, from increase of pigment.
In reference to these excoriations, we may be allowed to ^ establish three grades of them, which, being produced by the different degrees of force employed in scratching, enable us to draw inferences as to the intensity of the itching. When this is slight (Titillatio) the scratching is also inconsiderable, and neither long-continued nor often repeated. Hence the most superficial hard layers of the cuticle are alone injured by it, and become detached in the form of mealy dust, or of bran-Uke scales from the deeper strata, which still remain adherent. Itching of the second degree ( Formic atio) , on the other hand, being more intense leads to a severe and more protracted scratching ; and by this the whole of the horny layers of the cuticle is violently torn from the rete mucosum, of which the red moist
^ 'Zeitschrift der k. k. Gesellschaft der Aerzte.' Jahrg., 1846; i Band.j p, 332, et seq.
32 DIAGNOSIS.
surface is exposed. The consequence of tliis is that the blastema, which is poured out by the papillae for the production of epidermis, dries into a thin yellowish-brown firmly-adherent scab, just as we see a similar scab formed after the application of a blister. In the third and most violent degree of itching (Pruritus) which of course involves an incessant rubbing and scratching in which great force is employed, not only is the epdermis quite torn away from the corium, but this itself becomes injured. The minute vessels of the papillae are lacerated ; haemorrhage takes place ; and by the drying of the drop of blood which is poured out, there is formed a reddish- brown or black scab of greater or less size.
The phenomena which we have been describing are those which are observed when the scratching is practised on a skin which is not diseased. They, of course, present somewhat different features when, simultaneously with the itching, there exists also some other morbid change in the skin. It is scarcely possible to give a general sketch of the morbid appearances which are then produced ; but this much may with confidence be asserted, that eruptions which are elevated above the cutaneous surface will always be the first to be attacked, and will often be partially or completely destroyed, by the agency of the fingers in scratching, and that the intervening tracts of skin will come in for their turn only when the parts which were covered by the eruption have been brought to the level of the integument. Hence it is explicable that in prurigo the papules, in eczema the vesicles, hi psoriasis the separate red patches, with their coverings of scales, are the points which first show the effects of scratching, although the patient tears away at almost all parts of his skiu, with- out selecting any particular spot.
As for the deposits of pigment which are the result of scratching, it may be noted that these have a direct relation to the intensity of the itching. This can be most clearly demonstrated in scabies, eczema, and prurigo, in which affections no abnormal dark colora- tion of the epidermis is at first to be observed. In fact, these pigmentary deposits appear only during the progress of these dis- eases; they advance jsöfr^^;«^^« with the increase in the excoriations, and they are to be foujid only at those parts where the patient is constantly scratching liimself.
(5) ^^6 have now only to direct our attention to the other symp- toms which have not as yet been referred to. Eegard must be paid to the form, the number, the arrangement, and the position of the
ETIOLOGY. 33
primary and secondary symptoms, which have already been described. We must endeavour to ascertain what pathological process lies at the bottom of the existing cutaneous affection ; what injurious in- fluences have been in operation upon the healthy or diseased skin ; what are the age, the sex, and the occupation of the patient ; what has been his mode of life, and how he has been fed, lodged, and clothed. Our object must, in fact, be, as we said at first, to take a broad view of the case as a whole. An accurate diagnosis will with much more certainty be arrived at by the investigation of these various points than by searching merely for an accidental (jeweihg) primary efflorescence.
II. — Miology.
The causes Avhicli give rise to diseases of the skin are partly such as are internal and rooted in the organism itself, partly such as are external, and by which the integument is alone, or at least primarily or chiefly, affected. Dermatoses, therefore, have long been divided, in reference to tlieir etiology, into the symptomatic (uni- versal, deuteropathic, dermajwstases and dermexantheses) , and into the idiopathic (protopathic, local, dermatonosei) .
In regard to the first of these groups, the opinion was entertained that a common cause lay at the foundation of all, or at any rate of most, skin-affections, which was sought for in a special change in the composition of the juices. This condition was supposed to give rise only to cutaneous diseases, and was known as the Bj/s- crasia herpetica : but as its existence is extremely problematical, and as no evidence of it has as yet been brought forward, we do not feel called upon to admit it.
We do, however, know that some affections of the skin are so con- nected with certain maladies which have been shown to be blood-dis- eases, that we cannot but regard them as the effects of those diseases. We have examples of this in the acute exanthemata, in variola, mor- billi, scarlatina. There are also the rashes which occur in typhus, consisting of papules, of spots {roseola, purpura), or of vesicles (miliaria). Again, in cholera, cutaneous affections are observed as maculse (roseola), or as tubercles (erijthema papulatum et tubercu- latujn) ; in albuminuria, as purpuric spots, as pruriginous papules, and as cßdema ; in uraemia, as sebaceous secretion, containing urea and uric acid — the so-called uridrosis ; in pyaemia, as erysipelas, dermatitis, imptetigo, and in the form of pustular and furuncular
3
34 ETIOLOGY.
eruptions ; in cliolosis^ as a yellow or brown coloration of the skin ; in chlorosis, as sallowness and pallor, with infiltration of serum into the integument. In fact, in all these conditions, as well as in syphilis, scorbutus, scrofulosis, tuberculosis, the cancerous cachexia, &c., with their manifold and complex symptoms, blood-diseases are associated with changes in the skin.
Moreover, diseases of particular systems and organs are wont sympathetically to involve the integument. Thus affections of the intestinal tract, of the internal sexual organs, of the liver, the spleen, the kidneys, and of the urinary apparatus, give rise sometimes to urticaria,, sometimes to seborrhoea, eczema, or acne, sometimes to various forms of pigment-deposit. Again, diseases of the heart, blood-vessels, or lungs, produce disturbances in the circulation, which manifest themselves by increased vascular injection, and by a bright red or bluish-red coloration of the skin. Lastly, there are various physiological processes, such as menstruation and pregnancy, and also dentition, which indicate themselves by appearances of different kinds, affecting the cutaneous surface. Unfortunately, we are very seldom in a position to demonstrate the real connection between the internal affection which causes, and the skin-disease which is caused. "We see only that they occur together, that they are intimately related, that they mutually react upon each other. But we are not at the present day able to show accurately why a general disease, such as albuminuria, should give rise to a skin- affection such as prurigo; or why from a disorder of an internal organ like the uterus should be derived a dermatosis, as, for ex- ample, chloasma.
Besides these visceral affections, an influence in the generation of cutaneous diseases is exerted likewise by ordinary injurious agencies, which arise from the age of the patient, his business and mode of life, the way in which he is fed and housed, and the cli- matic conditions to which he is exposed. There are also the different contagia, of which some present themselves in association with tan- gible substances, or as inoculable fluids ; while others are only re- cognised by their effects, and are linked to no solid .or fluid matters.
Hereditary transmission, again, from parents to their offspring undoubtedly takes place in certain forms of cutaneous disease, among which are psoriasis, ichthyosis, elephantiasis Grsecorum, syphilis, &c. The cause of this is, however, to be sought, not always in a special dyscrasia, but rather in the reproduction in the offspring
ETIOLOGY. 35
of the whole habitus of the progenitor, by which also the fact is ex- plicable that children have hair of the same colour as their parents, whether this be light, red, or black. Lastly, diseases of the nervous system must not be overlooked as the causes of certain dermatoses, although with reference to this point all accurate investigation is as yet wanting. One can at most draw negative conclusions, and regard skin affections which are associated with morbid sensations, such as itching, pain, w^ant of sensibility, or anaesthesia, as the effect of per- verted innervation.
In conclusion, we must not forget to mention that even mental dis- orders and diseases (Gemiithsaffecte, Psychopathien) are said to have the power of producing certain cutaneous affections, such as urticaria.
Much more potent in the generation of diseases of the skin than the internal causes which have their seat in the organism itself, are those agencies which are external to the body, and which affect the skin directly. Thus are produced the so-called idiojjcitkic dermatoses. Even among these agents, the effects of climatic conditions, of dress, and of occupation and mode of hfe, &c., must not be overlooked ; and, apart from these, there are numberless other injurious influences, sucli as those of weather — that is to say, of heat and cold, of dryness and moisture, &c. — which cannot be escaped, being uni- versal, and affecting everybody in a greater or less degree. But there are also others among these causes of disease which depend on conditions pecuhar to the individual. Examples of these are afforded us by the different arts and trades, in which the skin is often in- jured by the handling of the necessary tools, by the exposure of the body to very high or very low temperatures, by the operation of cor- rosive substances, &c.
Man is often his own worst enemy, for he practises a number of occupations which subject him to various cutaneous affections ; and he neglects many of the precautions which would protect his skin from disease. Thus, one of the chief factors in the causation of the idiopathic dermatoses is the permanent action of pressure, or the fre- quent repetition of blows upon the integument, or the constant friction of some solid body which comes into direct contact with the skin. And under this head may be reckoned, besides many other injurious influences, the scratching of patients who suffer from the itching of cutaneous diseases.
Neglect of the skin, and that sin of omission, want of cleanliness, are well known to be fruitful causes, from which not a few cutaneous
86 ETIOLOGY.
affections derive their origin. But the same effect may in the end be produced also by the opposite proceeding, that is to say, by too frequently repeated or too energetic washing and bathing.
In enumerating the causes which produce cutaneous disease, those also must unfortunately be mentioned which, no doubt with good intentions, are employed in the practice of the healing art. As is well known, the rubefacientia and the epispastica play an important part in Hippocratic medicine. We are far too lavish with sina- pisms, vesicants, mezereum, 01. Crotonis Tighi, tartar-emetic oint- ment (Ung. Autenriethi), and issues. Even the moxa, and the actual and potential cautery are still too often used. They are generally applied with the object of effecting (by means of the powerful irritation of the skin which they produce) a derivation from some internal organ which is the seat of disease. How far this end is obtained is uncertain, and opinions about it are divided. For my own part, I think that the supposed but not proven good effects of the use of the epispastica are far outweighed by the demonstrably evil results of their application to the skin. Daily experience furnishes the proofs of the correctness of this opinion, with reference to which we shall, in another part of this work, enter into greater detail.
The epiphyta and epizoa, of which some are met with in the pro- tective horny tissues — some in the substance of the cutis itself — are frequent causes of cutaneous disease. The epiphyta, which inva- riably belong to the class of fungi (Pilze), consist of minute bodies, which measure from 0*005 — °'°5 niilHrnetres, and are termed spores {Sporidia, SponiU, Sporen) . They are either naked or enclosed in special organs {Sporangium, Theca), and they are seated on a common base (the receptaculum, or conceptaculum) . They reside either in the epidermis alone, or in the hairs as weD, or, lastly, in the nails also. The following eight species^ have, up to this time, been discovered in these tissues :
I. The Tricliophyton tonsurans. Malmsten first found this fungus in the hair. I demonstrated the fact that it occurs also in the epi- dermis," in cases of herpes tonsurans.
3. T\\QMi/cocle7'mapUc(BPolonic(E (Günsburg), and the ^n(?^o/?/^y- ton sjjoruloides (Walther), in the Phca Polonica (Weichselzopf).
' Küchenmeister. ' Die pflanzlichen Parasiten.' Leipzig, 1855, p. 30. - ' Zeitschrift der k. k. Gesellschaft der Aerzfe,' x Jahrg., 1854, Heft xii, P- 473-
ETIOLOGY. 37
3. Tlie Microsporon Audoinni (Grubj), in porrigo decalvans.
4. The Microsporon mentagraphyies (Bazin), in sycosis.
5- Tlie Microsporon furfar (Eiclistedi) in pityriasis versicolor.
6. The Ac/iorioti Schoenleinii in favus.
7. The nail-fungus: according to Meissner^ a species of Asper- gillus; in the Onychomycosis of Virchow.
8. The Oidiiim albicans — on the nipple (Küchenmeister).
The animal parasites which choose the skin as their scene of action (Tummelplatz) are divided into
I, The Bermatozoa, which cither always, or at any rate during part of their existence, dwell within the substance of the skin, and
II, The Epizoa, which merely seek their food upon the skin's surface, residing either in the appendages of the skin, namelj^ on the hairs, or in the clothing or other surroundings of persons infested by these parasites.
To the first class belong
1 . The Acarus scahiei (Krätzmilbe) or itch insect.
2. The Acarus folliculornm (Haarsackmilbe) or pimple-mite.
3. The Pulex penetrans (Sandfloh), the sand-Üea or chigue.
4. The Filaria medinensis (Peitschenwurm) or guinea-worm.
5. The Leptus aniumnalis (Ernteniilbe) or harvest-bug. In the second class we enumerate,
1 . The Pediculus (Läuse) or louse, including
(i.) The Pediculus eapilis (Kopfläuse), the common louse.
(2.) The Pedicnlns pul/is, sen Plithirins ingninalis, the crab- louse (Körper- oder Tilzläuse).
(3.) T\\QPediculusvestimeniornm, ^evihimani corporis (Kleider- läuse) the body-louse.
2. The Pulex irritans (Elohe) or flea.
3. The Cimex lectnlarius (Wanze) or bug.
4. The Culex pipiens (Mücke, Gelse) or gnat.
These parasites may give rise to cutaneous aflfections in two different ways. By nestling in the skin they irritate it, and dispose it to take on morbid action, to become hypersemic, and to present exudations, hremorrhages, degenerations of the epidermis, &c. And they also excite the sensibility of the cutaneous nerves, and thus produce itching or pain, which sensations are themselves*[additional causes of disease.
Besides these general and local agents, of which the effects are
38 TREATMENT.
known to be injurious, there are doubtless many others which have as yet escaped our observation, for we see many cutaneous affections arise without being able to point out their source. But we prefer to confess our ignorance in this matter, rather than to get out of the difficulty by referring these diseases to chills, errors of diet, mental disorders, nervous influences, or to the epidemic or endemic con- stitution, &c. ; wliich expressions are in fact quite vague and desti- tute of real meaning.
III. — Treahient.
Although in the course of the last few years great attention has, on all sides, been devoted to this department of medicine, we have unhappily made as yet but little progress towards the wished-for end, the cure of all cutaneous diseases. The cause of this lies, no doubt, partly in the fact that it has been only quite recently and during a time, very short for making exact investigations, that thera- peutical experiments have been carried on in a rational spirit, and without bias. For before one can speak of the action of a remedy in the treatment of any skin-affection two things must be ascertained : the course taken by the disease when left to itself, and the effects Avhich are produced by the remedy wlien applied to the healthy skin. Our want of success depends also, in part, on our defective knowledge of the dermatoses, and on the small extent to which the l)athological chemistry of cutaneous diseases has been cultivated. It seems to us that a very promising field for investigation is afforded by dermatology to those who are interested in this new branch of science. Unfavorable circumstances have, hoM'cver, as yet pre- vented us from exploring it ourselves ; and this task must, there- fore, be postponed to a future opportunity or left to other observers.
In the imperfection, or rather in the complete absence of any rational basis for our therapeutical procedures in the treatment of skin affections, no expedient remains but pure empiricism. Por the slight success which we have hitherto obtained we are indebted entirely to the strictly practical course which we have pursued in this respect. We have tried methods of the most varied description, Avhether they were recommended by medical men or by unprofessional persons, and we have found some belonging to the. former category less effectual than they were represented to be, while popular reme- dies, on the other hand, have often done us good service.
TREATMENT. 39
Before passing on to enumerate the different remedial agents^ we shall be permitted to allude to a few deeply-rooted prejudices which interfere even now, to some extent, and interfered still more formerly, with the employment in practice of certain methods of treatment.
The first of these prejudices which we must combat is the dread with which local applications were regarded.
Some years since we drew attention to the fact that it is quite a mistake to suppose that the action of remedies applied to the diseased or healthy skin is necessarily merely topical and not general.^ Por we need but call to mind the contagia of small- pox, syphilis, hydrophobia, and the poisons of serpents, and of the dissecting-room, which are generally introduced through the skin, to prove that it is an organ which absorbs very readily many forms of virus. And that it is equally adapted to absorb medicinal agents also, and to admit them into the circulation, even while the epidermis is intact, can be easily shown during the external use of tar, of iodine, or of the mercurial preparations.
Now, what can be demonstrated in the case of certain remedies by chemical reactions ought surely not to be denied ä priori in regard to others; and therefore we maintain the exact contrary of the principle we have alluded to, and assert that, with the exception of caustics {A.etz mittel), all remedies which are brought into prolonged contact with the skin are absorbed by it, and taken uj) into the fluids of the body.
Hence we have no fear, in applying topical remedies, of driving in cutaneous diseases, or of producing any other ill effects, for which the practitioners of the old school had various expressions. Our apprehension is rather of a too violent action upon the organism in general, especially in the case of those drugs which are liable to produce derangements of the vegetative processes. Nor have we any dread of curing skin-affections too quickly. On tlie contrary, it is the object of our warmest endeavours to find means of termi- nating these diseases as speedily as possible. Were we only in the possession of remedies which produced cures thus rapidly, we should have no anxiety with regard to the appearance from this cause (Nach schnell unterdrückten Flechten) of metastases, or of any other con- secutive diseases.
• ' Zeitschrift der k. k. Gesellschaft der Aerzte,' iii Jahrg., i Bd., 1845, P- 349-
40 TREATMENT.
There is another point also^ in which we are opposed to our prede- cessors and to many of our contemporaries^ and that is with reference to the necessity for using in the cure of chronic skin-affections remedies whicli are supposed to be purifiers of the blood [Hamaio- cathartica, Blutreinigende). We have never seen the effects which are ascribed to them by some authors, produced either by the long- continued administration of laxatives and drastics, nor by decoc- tions of woods (Holz-tränke), nor by vegetable juices. J^gain, the internal use of antimonials, baryta, graphite, anthracocali,' or sulphur; or again of cantharides, mezereum, viola tricolor, dulcamara, Roob Laffecteur,2 or sirop de Larrey/ has been invariably unattended with the hoped-for success, and therefore we cannot recommend to any one the employment of these agents. On the other hand, arsenic has proved in our hands a useful internal remedy, though we cannot praise it to the same extent as do Hunt and Romberg; and we have also seen good effects produced by the preparations of mercury, of iodine, and of iron, by the oleum Morrhuse, by the bitters, and the vegetable and mineral acids ; and, lastly, by all those remedies wliich are indicated in particular cases by the presence of dyscrasise, and which would be prescribed equally, although the general affection Avere running its course unattended by any local disease of the skin.
Externally we make use of simple baths, warm or cold as required, and of douche baths, and vapour baths ; or we add to these baths sulphur, potash, soap, common salt, or corrosive sublimate. Their temperature should be from 66°— 100° F. (15°— 30° E.) ; and their duration may vary from several days to a few minutes. Again we often employ emollient frictions with success, rubbing the whole skin or certain parts of it with oily or fatty substances (such as the ol. Amygdalse, ol. Lini, ol. OHvse, or ol. Jecoris aselli, or lard, suet, glycerine, or spermaceti). In other cases we add to these fatty matters various active substances, such as the preparations of mer- cury, zinc, lead, copper, iodine, arsenic, sulphur, &c., which remedies, so far as their solubihty permits, may also be used in watery or alcoholic solutions. Our sheet anchor, which we invariably employ
* A full account of the nature and therapeutical value of this remedy is given by Prof. Hebra, when speakiug of the treatment of psoriasis. — [Ed.]
2 "Rob de Laffecteur," is a secret remedy, of which the exact composition is unknown, but of which sarsaparilla is the principal ingredient. (V. Jourdan, ' Pharraacopee Universelle,' torn, ii, p. 419.)— [Ed.]
3 This is another medicine of the same kind as the Roob Laffecteur.— [Ed.]
TREATMENT. 41
when we wish to effect either the rapid separation of the horny hijer of the epidermis, or the removal of exudations infiltrating the cutis, or poured out beneath the cuticle, is always the soft or potash-soap. This we apply either alone, as in prurigo, eczema, psoriasis, ichthyosis, pityriasis, herpes tonsurans, favus, lupus. Sec. ; or we blend with it other medicinal agents, such as for example, sulphur in cases of scabies, tar in cases of eczema, &c.
Moreover an important part of our therapeutical resources consists in the empyreumatic oils, which result from the dry distillation of certain kinds of wood. Thus we make use of the tar which comes from the beecli (Oleum empyreumat. fagi) , of the Oleum cadinum, which is derived from the Jumperus oxi/cedrus, and of the Oleum nisei, which is obtained by distillation from the w^ood of the bircli (Betula alba), and which possesses the smell of Russia leather. The action of these is nearly identical; they differ only in their consistence, and in their smell.
For the removal from the skin of exudations, new growths, tumours and the like, caustics are employed. Passing over the actual cautery, of which, as of the knife, the application belongs to the domain of surgery, we will here concern ourselves only with the corrosives and escharotics (Aetzmittel), of which we shall refer particularly to those wliose action we have ourselves thoroughly tested.
The concentrated mineral acids, namely the strong sulphuric, nitric and hydrochloric acids, can be applied in comparatively few cases. Not only is their action inconstant and therefore unreliable ; but better effects are produced by other caustics. Moreover the disfiguring scars which follow the use of these acids often frustrate the purpose for which they were employed. The same may be said of butter of antimony, of chloride of zinc, and of other similar pre- parations. There are but few cases in ^yhich we use these substances, applying for example sulphuric acid in the removal of horny growths, and hydrochloric or nitric acid to destroy old exudations which have become organized. For experience has made us acquainted with better caustics, of which the effects can be more easily regulated, and which are followed merely by thin and smooth cicatrices. Among these we place in the foremost rank the nitrate of silver, which we use either as a solid, or in a concentrated solution (Argent, nitrat., — A qiice destillatcB, paries aqiialesj. To this sub- stance we attach a great value, because every kind of new growth
42 TREATMENT.
can be destroyed by it, without causing any further injury to the patient, and because any one, however unpractised, can apply it, without having any special experience in its use.
Next to this substance in importance is the caustic potass of the surgeons ; this may be employed either in the form of sticks, or dis- solved in two parts of water; but it demands more care in its application than the nitrate of silver ; and it also causes a more extensive loss of substance, the limits of which cannot be so accurately predetermined. Moreover its use is often followed by thick and raised (wulstig) cicatrices.
Similar effects are also produced by the Vienna paste (Wiener Aetz-Pasta), consisting of equal parts of caustic potash and quick- lime, made into a paste with alcohol at the time of its application, and left for ten or fifteen minutes in contact with the portion of skin which is to be destroyed. By the chloride of zinc paste of Canquoin (take of chloride of zinc one part, of flour four parts, of water q. s.), the same result is attained only after the lapse of four hours. And a longer time still (twenty-four hours or more) is required for the action of the paste recommended by Landolfi (consisting of chloride of bromine two drachms, of chloride of anti- mony, and chloride of zinc, of each a drachm and a half, besides chloride of gold ad Ubituni) of which the eft'ects are however more severe. All these pastes char the organic tissues with which they are brought in contact ; and they differ only in respect of the inten- sity of their action.
We may also attain similar results, though only after repeated applications, by using a ^powder containing five grains of white arsenic, and fifteen grains of artificial cinnabar, mixed with two drachms of sugar, or with the same quantity of the unguentum rosatum, as may be most convenient.
Again, the solution and paste of Plenck, consisting of corrosive sublimate, camphor, carbonate of lead, alum, spirits of wine, and vinegar in equal proportions, has been employed with success in the treatment of various growths, especially those of syphilitic origin.
Sulphate of copper, alum, pulvis sabinse frondum, corrosive
' This formula is founded upon the " Cosme'sche Pulver " of the Austrian Pharmacopoeia, of which two ingredients are liowever omitted, namely, the sanguis Braconis, and the ciiieres solearum ustarum (the ashes formed by the incineration of the soles of boots and shoes).
CLASSIFICATION. 43
sublimate, calomel, &c., are also well-known irritants, which either alone or in conjunction with other substances, may be used with advantage for the purpose of destroying, slowly, growths of various kinds.
Lastly, besides these active remedies, which are used externally or internally in different skin-aflPections, others which are indifferent and inert are also frequently prescribed, in those diseases \^hose course we cannot modify, and in which therefore the expectant method is attended with the best results. Thus, whether this or that remedy be used, is a matter of indifference, in the contagious exanthemata, as well as in all inflammatory affections of the skin which run an acute course, such as erythema, roseola, urticaria, erysipelas, herpes, miliaria, pemphigus acutus, Szc. That mode of treatment which disturbs the patient least is, in these diseases, always the best.
I Y. — Classification.
Our predecessors and contemporaries have endeavoured, according to very different principles of arrangement, or even without any such principles, to distribute cutaneous affections into classes, orders, and species. These attempts have been crowned with more or less success, and have obtained for a longer or shorter time, a partial or even a general acceptance among the profession. They have how- ever possessed the defect of isolating the diseases of the skin too completely from those of the rest of the body ; and therefore they have by no means fulfilled the requirements of a perfect derma- tological system.
In passing in review the chief works on the dermatoses which have appeared from the most remote ages to the present time, we meet with so many systems of classification, that to describe them all would be judicious or even possible, only if we were writing a historical account of these diseases. But in order not to pass over what has been hitherto effected in this branch of medical science, and to make apparent our reasons for not giving the palm to any one of these systems, we may mention cursorily some of the more important of them,
Eor this purjiose we may divide these schemes of classification into eight classes, founded on the nature of the principle which
44 CLASSIFICATION.
forms their basis_, or on the other hand on the fact that their author held himself unfettered by any logical rules.
(i) The oldest forms of classification^ those namely of Galen and Mercurialis^ were based upon the seat of the affection, that is to say, upon its anatomical distribution; and by these writers, diseases of the skin were divided simply into those which attack the hairy scalp, and those which affect the rest of the surface. It surely needs no further description to show how defective and inju- dicious is so arbitrary a distinction.
(2) Those systems on the other hand are very tempting, whicli distribute skin-diseases into the local or idiopathic, and the con- stitutional, general, or symptomatic. Lorry was the first to intro- duce this principle of classification ; but the same idea, though often under different names, has been elaborately worked out and improved by Dendy, Schönlein, Fuchs, Isensee, and others. But unfortu- nately, not only may the same cutaneous affection be produced by the most different causes, but the most varied diseases of the skin may also be caused by one and the same morbid agent. And it is not possible in every instance to draw from the form and appearance of a dermatosis, any certain inference as to its origin from a local or general cause.
(3) Next there are the anatomico-physiological systems, including those of Grimaud, Baker, Turner, and Craigie, in the last century, as well as the more modern classifications of ]loscnbaum, Erasmus "Wilson and others. These start from the opinion that it is possible to ascribe distinct names and characters to the affections of the different tissues which make up the skin; that is to say of the epidermis, of the corpus reticulare (Malpighii), of the papilla?, of the corium, and of the follicles, the vessels, the nerves, &c. But these writers forget that the integument is an organ, of which the com- ponent tissues are very rarely separately affected by disease, being on the contrary in most cases all penetrated by the morbid products, so that it is very often impossible to say whicli strata are more, and whicli less involved. These systems, therefore, are above all others, wanting in practical applicability ; and hence they have found few adherents.
(4) Xo classifications, on the other hand, have met with so many followers, as those which have for their basis the external form of the disease. Such are those which were first established by Biolanus and Plenck, and which have since been modified by Willan, Bateman, Chiarugi, Biett, Cazenave and Schedel, Gibert
CLASSIFICATION. 45
and Eieckcj and others. But although the fundamental idea of these systems is at first sight very seductive, yet it can sustain no close criticism, and is far from being verified by practice. They have in fact been the great cause of the erroneous notion, that for the recognition of a cutaneous disease, it is sufficient to determine the primary efflorescence, which existed in that particular case. It was supposed that it is thus easy to fix upon the genus, to which the skin- affection belongs; and that there is then no diffi- culty in making out the name of the disease, by seeking for the special marks which characterise each species of the dermatoses. As though for the determination of a disease, a single character is sufficient, although it be torn from its connexion with the other symptoms with which it is associated, and although all the other appearances which present themselves in the course of the case are left unobserved, and the only point investigated is whether, at its com- mencement, the affection presented a macule, a papule^ a vesicle, a bulla, a pustule, or some other of the primary forms of efflorescence ! Such a method of diagnosis reminds one only of the empirical uroscopy of our fore-fathers and certain of our contemporaries. Moreover these classifications had the further disadvantage, that they isolated diseases of the skin from the doctrines of nosology in general, that they made the morbid processes which occur in the skin, appear quite diff'erent from those which affect other parts of the body, and that they thus called into existence those erroneous conceptions of cutaneous diseases, which, even at the present time, we meet with in every direction.
No doubt the founders of these dermatological systems had floating before their eyes the Linnean classification of plants. For they sought for the characters of their genera and species in certain among the appearances of the dermatoses {Efflorescentice cutanea:, Hautbliithen) just as Linnaeus employed for the same purpose the special parts of the flower (Blumen, Blüthen). But this attempt resulted in failure.
(5) Equally unsuccessful were those who, with Ahbert at their head, and following De Candolle and Jussieu in botany, tried to introduce natural systems, as they were called, in dermatology. Their fauure arose simply from the fact that a skin-disease does not form an individual, but merely consists of changes occurring in in- dividual persons.
In forming a closer estimate of the two clauaificatious of Alibert,
46 CLASSIFICATION.
it cannot but be seen that some among the groups of dermatoses may fairly lay claim to the title of natural families. Such are the contagious exanthemata (morbilli^ scarlatina^ variola) ^ the syphiiides^ and the eczematous eruptions. But some only, not all afPectioiis of the skin admit of being thus arranged ; the basis of classification is not the same in the different groups ; and this system, even if it were practicable, would result in the isolation of dermatology. And for these reasons this method of classifying cutaneous diseases is devoid of all practical value.
(6) The course and duration of affections of the skin, their being acute or chronic, and their being attended or unattended with fever, gave to Derien and Frank a basis of arrangement, according to which they divided dermatoses into the acute and the chronic, into the exanthemata and the impetigines. Now there are certain cutaneous diseases, such as the contagious exanthemata, which are always acute; and there are others (prurigo, ichythyosis, elephan- tiasis, &c.), of which the course is invariably chronic. But there are also many affections of the integument, which sometimes termi- nate quickly, and yet are unaccompanied by fever; and there arc others, of longer duration, in which feverish symptoms are always present. Nay even the same disease may run now an acute, now a chronic, course, as we see in the case of urticaria, eczema, and impetigo. Hence it is evident that, in this respect, cutaneous diseases form no exception to what we know of the affections of other parts of the human organism. In both cases the same complaint, without alteration of its essential nature, may be either acute or chronic, either attended or unattended with fever.
(7) Other authors in constructing their schemes of classification, seem to have been struck with the difficulty, not to say impossi- bility, of carrying out logically a division of the dermatoses on either a natural or an artificial basis. Hence they have contented themselves with arranging in groups those affections of the skin which were most closely allied to one another, with imposing on them the names of classes or orders, and with describing in succession, under these different heads, the correspondmg diseases. It was in this way that the systems of Rayer, Plumbe, Devergie (his later method), Chausit (Cazenave), and others were drawn up.
(8) As curiosities we may mention, lastly, certain classifications which can be regarded only as examples of abortive attempts. Such
CLASSIFICATION. 47
are the "Fluxions" of Baume (Fluxions — (a) par cause externe, re- ßechie, deplacee, excentrique, — (b)^j«r diathese, idiopathiqiie, coraplexey ^c.J; Struve's division of the dermatoses into cryptogamese and phanerogamese ; Devergie's earlier system, by which diseases of the skin were distributed into maladies secretantes, et non secrelantes ; and Upman's classification^ according to the mutual presence as well as the mere nature of the elementary forms of eruption (as for example, into vesicles with, and vesicles without papules, &c.).
The inadequacy of the systems, which had up to that time been drawn up, and the want of uniformity between the method of clas- sifying diseases of the skin, and that applied to affections of other parts of the body, induced me, as far back as the year 1844, to propose a division of the dermatoses on a pathologico-anatomical basis, in which I adhered for the most part to the doctrines taught by Kokitansky. I have as yet found no reason to repent of the scheme which I then^ published, or to make any essential alterations in it. But I have had occasion to observe that it has been made use of, and modified by several authors in the erection of their systems. This is, indeed, easily explained by the consideration that they all have derived their knowledge from the same source as myself, namely, from Rokitansky.
I feel all the more satisfaction in being able to repeat, with but little alteration, the views which I advanced twelve years ago, be- cause my experience has been greatly enlarged since that time, by the observation of more than 80,000 cases of cutaneous disease, and because my opinions with regard to certain of the dermatoses have in many respects undergone a change. Not that I wish to represent my system as free from defects, and to maintain that no better one can possibly be at any future time proposed. Its faults and deficiencies are only too well known to me. But, in my belief, it is superior to others in this, that though artificial, it is not too refined (kiiusthches doch kein gekünsteltes), and that though it is not a natural clas- sification, it is yet in accordance with nature (obgleich kein natürliches doch ein naturgemässes) . For it places together those diseases of the skin which resemble one another in their essential nature ; and it makes no arbitrary separations between allied affec- tions.
' ' Zeitsclirift der k. k. GesellscLaft der Aerzte,' ii Jahrg., i B. 1845, PP- 35» 143, 211.
48 CLASSIFICATION.
Ill passing now to the description of our system, the first question to be answered is, why have Ave divided the diseases of the skin into twelve classes ? We freely confess that we might have contented ourselves with ten or eleven, for the separation of the eighth from the ninth class may be termed arbitrary, and even incorrect, from the histological point of view. Again, in accordance with precedent, it was not necessary to have introduced the ulcers into dermatology, or at least not as a distinct class. But the proverb says, ^^ Q?ii bene distingult bene docet j " and from the practical point of view which I have always kept before me, it appeared to me to be judicious to adopt this classification; according to which all the diseases of the skin may be reduced to twelve divisions, classes, or families, as follows —
^ Class I. — Ilj/peratnice cutanea — Hypera^mic affections of the skin. II. — Anamia cutanea — Anemic affections of the skin. III. — AnomaVue secretionis glandularum cutanearum — Morbid
conditions of the secretions of tlie cutaneous glands. IV. — Kvudatlo^ies — Exudations and exudative affections. V . — llamorrhaglce cutanea — Haemorrhages. VI. — Kypertroi^m — Hypertrophies. VII. — Atrophia — Atrophies. VIII. — Neoplamnata [Homaoplasia) — Innocent growths. IX. — Psetuloptlasmata {HeteroplasUc) — Malignant growths. X. — Ulcerationes — Ulcers. XI. — Neuroses — Neuroses. XII. — Parasita — Parasites.
The characters belonging to these classes will be given hereafter, in describing the cutaneous affections which are included under each of them.
1 For tlie denomination of the first eleven classes, or families, I have employed the name of a pathological proces'', that is to say, of a thing which, being only a conception of the mind, and invisible, can be recognised only by its effects. On the other hand, the name of the twelfth class is derived from the cause of tlie diseases which belong to it, which cause is positive, and has a real existence. But although I must thus admit the logical <lefect in the principle of classification which I have adopted, yet I have not been able to remedy it, without risking the practical usefulness of the system.
CHAPTEE III.
CLASS I.— HYPER^MI^ CUTANEA.
Diseases of the Skin, which arise from the presence of an excess of Hood in the capillary vessels of the cutis.
By a state of excessive injection of the capillary vessels of the derma, and by the impeded circulation to which this condition gives rise, many morbid appearances are produced. These may often enough be observed in the living patient alone and unattended with any demonstrable exudation or heemorrhage, so that no facts, either anatomical or physiological, are opposed to the association of these diseases into a single class, and the description of them apart from other pathological changes.
The following characters belong to the cutaneous hypergemiee in general.
a. Redness of the shin. — This presents every shade, from a bright red or rose colour to a dark, bluish-red. But it always yields to the application of pressure ; and when this is removed, the normal colour of the skin is seen, though only for an instant, after which the red colour quickly re-appears.
b. Swelling/. — This is often imperceptible, and is seldom con- siderable.
c. The temperature of the shin is not demonstrably altered in con- ditions of slight hypersemia, but in severe instances of this affec- tion it presents deviations from the norm, appreciable both by the touch, and also by the thermometer.
d. Subjective sensations, — The patient either feels no abnormal sensation, or merely a slight itching or burning.
e. The seat of the affection is either in the papillse alone, which are extremely vascular, or also in the deeper capillary net-work of the cntis, or lastly, in the capillary vessels which supply the hair sacs and glandular structures.
4
50 ACTIVE HYPERiEMIiE.
f. As regards their form, these rashes consist for the most part only of maculEBj which are either chcumscribed and of varied pattern (figurirt), or diffused ; but wheals are also sometimes present.
g. Their course is generally acute, and often of a definite type ; in some cases it is chronic, from the occurrence of repeated relapses.
h. Their duration is from a few minutes to several days.
i. Secondary or consecutive a]ipearances are, in these affections, generally wanting, but in some cases pigmentation of the epidermis, and in others slight desquamation (defurfuration) is observed.
The immediate cause of an hypersemia must be either an increased flow of blood to the part or an obstruction to the circulation, from stasis of the blood. Since each of these conditions may occur in the skin, the generally adopted division of hypersemia? into the simple or active, and the passive, mechanical or hypostatic, is neces- sary in dermatology.
A. — Active Hyper/emi^.
Symptoms, — A colour varying in tint from a pale rose to a bright blood- red, disappearing beneath the pressure of the linger ; no per- ceptible swelling; elevation of temperature; sensations of slight itching or burning : such are the phenomena which indicate these forms of hypersemia.
Subdivisions. — ^We distinguish an idiopathic from a symptomatic hypersemia. In the former case the affection is purely local, a skin disease in the strictest sense (dermatonose, Ftic/is). In the latter case it is produced by disease of other parts of the body, attacking also the skin (dermapostase, FucJis).
A. IDIOPATHIC ACTIVE HYPER^MIffi.
Under this head we shall describe all those rashes which arise from injuries affecting directly the cutaneous surface, and in which nothing occurs beyond the accumulation of blood in the part, or in which at least the hypersemia is the first and most striking morbid change.
Since the name erythema has always been given to all affections in which the skin assumes a diffuse red colour, we, will make use of the same expression. We shall take leave, however, to add to it the epithet " conr/estivum," in order to indicate more precisely the
ACTIVE IDIOPATHIC HYPER^MI^. 51
form which is to be here described, for we shall hereafter, among the exudative processes, have to speak of an erythema exudativum.
ERYTHEMA CONGESTIVUM IDIOPATHICUM.
The erythema congesthmm is characterised by the symptoms which belong to the active hypersemise of the skin, and by the absence of all phenomena pointing to disease of any other part of the organism. The extent and pattern (Zeichnung) of this rash vary according to the kind and degree of the injurious influence which produced it, and to the susceptibility of the patient.
It would, of course, lead us too far from our immediate purpose if we were to attempt to enumerate all the causes which may give rise to an active idiopathic hypersemia in the form of erythema con- gestivum. We must therefore content ourselves with mentioning tliose forms of the affection only which are either most frequently the subject of observation, or of which a knowledge is necessary, for the discrimination of other more severe skin diseases, in which they are merely temporary phenomena (Uebergangserscheinungeu).
(i.) Erythema Traumaticum.
The pressure which the skin undergoes from tightly fitting clothes or bandages, from the various postures of the body, and from rubbing or scratching, causes a reddening of the parts affected, of which the pattern varies with the form of the body which produced it. This redness, however, quickly disappears when the pressure is removed, and leaves behind no trace of its presence, unless the operation of the offending agent was either unusually intense or of long duration. Thus, we see red spots of different forms, which are produced in men] by tightly fastened belts, in women by stays, tight bands, and closely fitting garments, and in both sexes the same thing is observed at those points which bear the pressure of trusses, or of their pads or straps. Similar red patches are fomid over the sacrum or the ischial tuberosities, after lying down or sitting upright. Again, in those individuals who scratch themselves with their finger- nails, or whose skin is rubbed in other ways, we see reddenings of the skin, which are of greater or less extent, or may take the form of strias : and so long as these appearances are of short duration only.
52 ACTIVE IDIOPATHIC HYPEU^MIyfi.
and disappear totally Mdien the pressure is removed^ they are the result merely of hypersemia of the capillary vessels of the papillae.
If, however, the same irritant acts upon the skin repeatedly or continuously, the hypersemia may at length amount to stasis and exudation, or, in other instances, may lead to haemorrhage. In both cases, other cutaneous affections are called forth, which Avill be described in the proper place.
The knowledge of these appearances is necessary in itself, so that in practice they may be rightly understood, and that more importance may not be attached to them, than they deserve. Another circumstance also must always be remembered, namely, that portions of the skin which arc the seat of this kind of hypersemia, even to a trifling extent, are often observed to be specially affected by the exudative cutaneous diseases. Thus when variola breaks out in Avomen, the pustules are far more numerous round the middle of the body, and above the calves, where tightly-fastened belts and garters are worn, than on parts of the skin which have not been exposed to pressure. So again, if persons whose occupation keeps them sitting continuously on hard stools or benches, become affected with scabies, there are always found on the buttocks over the ischial tuberosities, not only numerous cuniculi, but also tubercles, vesicles and pustules. Other instances of the same kind miglit be cited.
(2.) Erj/tJiema Caloncum.
Bashes, which result from the action of heat or cold upon the skin, are to be regarded as simple hypersemise, so long as, beyond the change of colour, no other deviations from the normal state make their appearance. But when, in addition, the existence of inflammatory products in the part is shown by the presence of swelling, or by the formation of vesicles or bullte, the affection is then one of a higher degree and belongs to the domain of the exudative processes.
We may quote as an example of hypersemic eri/ihema caloncum the reddening of the surface which is produced by warm or cold air, and by hot or cold baths. When the operation of these agents is withdrawn, the colour disappears, leaving behind it no mark of its presence, in the form of either desquamation or pigmentation.
ACTIVE SYMPTOMATIC HYPERiEMJiE, 53
(3.) Erythema ah AcribuSy seu Venenatum.
As is well known, wc possess several substaucesj M'hicli by tlieir chemical properties have au irritant action upon the skiu^ and produce, as their first etfect, an engorgement of the capillaries of the cutis, in other words an hj'perfcmic erythema. Under the continued operation of these agents, however, inflammatory products are poured out, both into the cutis, thus giving rise to an exudative erythema, and also beneath the epidermis, so as to form papules, vesicles, or bullre.
\Ye are familiar with certain of these rashes produced by various mineral, vegetable, and animal matters ; for example, by the Hepar snJph'.ris, by the Semina shuqns, and by the hah's of the caterpillar of the Gastro2)acJia processionea. The form and extent of these eruptions depend on the nature of the substance which caused them and the duration of its action, and they are generally confined to the part of the skin with which it came into direct contact. But examples are by no means wanting in which an irritant acting only upon a small circumscribed spot, has given rise to a Avidely diff'used, and even universal redness of the surface.
B. SYMPTOMATIC ACTIVE HYPER-EMI.E.
In the course of general diseases of various kinds, both in those which are attended with fever and those in which there is none, we meet with rashes, of which these affections are evidently the cause. These appearances may either precede the principal malady, as in the case of the so-called roseola variolosa ; or they may accompany it, as does the strophilas volaticus ; or, lastly, they may show themselves at a time when the primary disease is undergoing involution, as is the case with the roseola vaccina, and the roseola cholerica. Even in healthy persons similar rashes are seen as a result of nervous influence or of mental disorders. Who is not acquainted with the flush, which generally affects only the cheeks, but which frequently covers all the face and neck, and even, in exceptional cases, the whole surface of the body, and which, though termed the blush of shame (Schamröthe) , is caused quite as often by anger, vexation, or confusion ?
Now although some general afi"ections are, more frequently than others, accompanied by such erythematous rashes on the skin, yet the connexion between the disease and the eruption
54 ACTIVE SYMPTOMATIC ITYPERiEMI.E.
is not so close that tlie one cannot l)e found without the other. Thus we find typhus occurring M-ithout^ as well as with, roseola. The efflorescence then is not an indispensable part of the phenomena presented by the general disease, but may be present or absent without affecting the essential characters of the latter. Indeed the course of the complaint is not even to an important extent modified by the appearance of these rashes, and it is only in certain cases that their presence is of any consequence even in rela- tion to prognosis.
An acquaintance with these forms of erythemata has however a negative value. It saves one from the common mistake of diagnosing every febrile complaint, attended with a reddening of the skin, as one of the contagious exanthemata (scarlatina, morbilli) . Such conclusions, when made too hastily, often lead to disagreeable consequences.
In reference to these symptomatic erythemata, we might content ourselves with what we have already said, and group them together under the name of erythema fugax, which is applied to them in medical works. But as some general diseases are more frequently than others attended with such rashes, and as in dermatological works many terms are mentioned, which would naturally be placed in this part of our system, it will be well for us to enumerate them in this place.
Under the name roseola [rosalia, I'uheola, rose-rash, Röthein, Kitteln, Wiebeln, Feuermasern, der rothe Hund), is understood by Willani a " rose-coloured efflorescence, variously figured, without Avheals or papules, and not contagious."
Such is "NYiUan's definition of roseola, which he divides into a roseola astiva, aiitumnalis, annnlata, infantilis, variolosa, vaccina, and miliaris. He mentions in conclusion another form also as occurring in typhus (contagious nervous fever). Other authors, such as Rayer,^ Alibert, and Fuchs,^ have thought fit to enumerate, besides these, other varieties of this affection, and describe, besides those already given, a roseola febrilis, rJieicmatica, cholerica, idio- pathica et symptomatica, saltans, &c. In addition to these nume-
1 'On Cutaneous Diseases/ by Robert Willau, M.D., 1808, vol. i, p. 433;
2 'A Theoretical and Practical Treatise on Diseases of the Skin.' By P. Rayer, M.D., 2nd Edition, translated by D. Willis, 1835, p. 192.
3 'Die krankhaften Veränderungen der Haut, &c.' Von C. H. Fuchs, GötUngen, 1840, pp. 177, 927, 1024, and 1065.
ACTIVE SYMPTOMATIC HYPER^MIJE. 55
rous species of roseola, there are also several other names which have been applied by these and other dermatologists to symptomatic hyperamise of the skni. Thus the strophulus volaticiis and inter- tinctus, the Feu des Dents of W'illan, the Nirlus of "Wilham Bat, and of Alibert, the Feu rouge of the French writers, and the ^^Eed Gown" and "Wüdfire Eash" of EngHsh physicians are clearly nothing more than transient forms of erythema, which may accompany now this, and now that complaint.
I think that I need devote a special description only to the following varieties of erythema and roseola.
(i.) Eri/tliema Infantile, seu Roseola Infantilis.
In the infantile organism, as is well known, all the manifestations of disease display a severity, which is not observed .in the case of adults. In fact quite trifling disorders of the health are in children often attended with severe (stürmisch) symptoms. Thus as a result of the so-called catarrhal, rheumatic, or gastric fever, of the process of dentition, of the presence of worms and so forth, we meet in these little patients with rashes, which are sometimes diffused over large tracts of the skin and thus resemble a scarlatina, whereas in other cases they present distinct maculoe, and then simulate the aspect of measles.
Those, therefore, who hold the opinion that, for the diagnosis of the contagious exanthemata, it is sufficient to attend to the appearances presented by the skin, will often be led into the error of regarding these transient rashes as an evidence of measles or scarlatina. But observation of the further course of the case will soon teach them the contrary ; for in the exanthematous fevers the eruption has a definite and longer duration, whereas, if it be an erythema or a roseola, it vanishes as rapidly as it appeared, lasting a few hours only, or at most a day. Moreover, these forms of rash do not, either when they break out, or while they are dis- appearing, present that regular mode of development and of retro- gression which we are accustomed to see in rubeola and in scarlet fever. Again, those symptoms are absent which, being constantly present in the exanthemata, form part of their essential characters. I refer to the severe catarrhal disease of the air-passages in measles, and the more or less intense inflammatory affection of the pharynx in scarlatina. A further aid in the diagnosis of the erythema infantile
56 ACTIVE SYJirTOMATIC HYPEUiEMIiE.
or roseola infmitilis is afforded by the circumstance that when this rash disappears it leaves behind it neither deposition of pigment nor desquamation of the epidermis.
As for the subjective symptoms of these affections^ it is to be noted that the patients frequently spealc of a feeling of increased heat, and of slight itching or pricking. These sensations are, how- ever, of but short duration, coming to an end as soon as the objective symptoms disappear.
The roseola infantilis, then, according to the description we have given, is no independent malady, and can only be regarded as a symptom accompanying other diseases. It may show itself either in the course of slight affections, which always terminate in recovery, or in the more dangerous and fatal general disorders. Moreover, it cannot be looked on as either a favorable or an un- favorable sign, in reference to the probable issue of the disease which causes it. Hence this variety of erythema or roseola possesses no special importance, so far as prognosis is concerned, nor is there anything worthy of mention in regard to its treatment. The ex- pectant method, or the employment of inert substances, is fairly applicable to this affection.
(2.) Erythema Vanolosim, Roseola Variolosa,
During the preliminary stage of variola, before the appearance of the eruption, and generally on the second day of the disease, it is not uncommon either to find the whole surface of the body covered by a diffused rash [erf/fhema), or to observe scattered spots [roseola) of a bright red colour, and in size between a lentil and a finger- nail, which appear first on the face, and afterwards on other parts of the body. The duration of this efflorescence is very short. "V^'ithin twelve or twenty-four hours the true variolous eruption gradually makes its appearance, and the earlier rash fades away as the characteristic papules become fully developed. The diagnosis of a roseola variolosa, or of an erythema variolosum, is of course impossible at the commencement of the affection, and can be made only at a later period, when the ordinary smallpox efflorescence has shown itself. The occurrence of this erythema has thus frequently been the cause of mistakes ; for, relying on the presence of a red rash, accompanied with febrile disturbance, medical men have believed that they had to do with measles, in cases in which all the characters
ACTIVE SYMPTOMATIC IIYPERJ3MI/E. 57
of variola have soon afterwards manifested themselves. A similar explanation may be given of the statement made by certain writers^ that morbillij scarlatina, and variola sometimes occur in combination, attacking simultaneously the same patient, an opinion which arose from an erroneous interpretation of this form of erythema or roseola.
I cannot refrain from availing myself of this opportunity to throw my authority, based on the experience of many thousand cases of disease, into the same scale with that of those authors who deny that more than one of the exanthemata can be present at the same time. I have, of course, seen one of these diseases (such as variola) appear after the complete termination, that is, at the end of the stage of desquamation, of another exanthem (as, for example, morbilli). But, according to certain authors, two exanthemata (morbilli and variola, scarlatina and variola, or even scarlatina and morbilli) may exist at the same time and in the same patient. Of tliis I have never been able to assure myself, and, in my opinion, no proof of it is to be obtained.
Another peculiar appearance, which precedes the eruption of variola, must also be mentioned, although the similarity between its course and that of the affections which w^e have been describing is the only reason for introducing it in this place.
Quite at the beginning of the preliminary febrile symptoms of smallpox there is in some cases observed on the abdomen, and on the inner sides of the thighs, a rash, which is sometimes a mere hyperaeraia, and disappears beneath the pressure of the finger, but which is, in other instances, of an hEemorrhagic nature, and then persists without change.
This rash invariably remains confined to a space bounded above by an imaginary line drawn transversely across the um- bilicus, at the sides by the lumbar regions, and below by a line traced across both thighs, about three fingers' breadths above the knees. It also extends further outwards in the inguinal region than lower down towards the knees ; so that, when the thighs are pressed together, the area occupied by the rash forms a triangle, w-ith its apex directed downwards. Some two or three days after its appear- ance the true smallpox eruption begins. This, as in other cases, gradually spreads over the whole surface, except that it leaves un- touched the tracts already mentioned on the abdomen and thighs. Indeed, in proportion as the development of the variolous vesicles advances, the intensity of the rash observed on these parts diminishes ;
58 ACTIVE SYMPTOMATIC HYPER.EMI^.
SO that, by the time suppuration begins, these regions have either become quite pale or present merely a deposit of pigment. In eitlier ease they are free from the shghtest trace of the smallpox efflorescence.
This erythema may show itself at any time, and affects men as well as women. But it is much more common in some epidemics of variola than in others, and it is also far more frequently ob- served in the female than in the male sex.
In relation to prognosis, again, the appearance of this rash upon the abdomen of a smallpox patient is by no means necessarily to be regarded as an unfavorable sign.
These cases do, however, more often terminate badly, than in recovery, and particularly when the affection passes beyond mere hypersemia into haemorrhage, when, in fact, a jmrpura rather than an erythema shows itself on the abdomen and on the thighs in the stadium prodromorum of variola.
(3.) lioseola Vaccina.
It is well known that inoculation, either with variolous matter (the contents of the pustules of variola vera) or with vaccine lymph (taken from the eruption found on the udders of the cow, or from the vesicles of a patient previously vaccinated), gives rise to a general disease. This often manifests itself merely by the repro- duction of vesicles similar to those which yielded the matter for inoculation. Sometimes, however, there are also produced affections of other parts of the skin, of which the most frequent is the appear- ance of simple, red, distinct spots. This rash, which is the roseola vaccina, shows itself between the thhd and the eighteenth day after inoculation, generally first upon the arms, and the size of the maculae varies from that of a fourpenny-piece to that of the palm of the hand. It often persists only during a few hours, and rarely lasts more than one day, after which it disappears without leaving behind it either deposit of pigment or desquamation. A few cases do, indeed, occur in which this rash spreads over the adjacent parts of the skin, and thus gives rise to a diffused erythema; but these are ex- ceptions. Beyond shght attacks of pyrexia, which are of short duration, no disturbance of the health of the patient is generally observed, and, therefore, any medical treatment appears to be superfluous.
It is a different affair, however, when these affections, consequent on inoculation, attain a higher degree of intensity, and when the lymphangioitis, which was the cause of the erythema or the roseola.
ACTIVE SYMPTOMATIC IIYPER^MI/E. 59
passes into äermat'ii'is. We then meet with erysipelas, infiamma- tiou of the subcutaneous areohar tissue, abscesses^ furuncles, and even gangrene^ which not unfrequently imperil the life of the patient, and are always attended by a number of severe symptoms — symptoms which, though they may be sometimes connected with it, are generally absent in cases of the simple roseola.
There are also other appearances which sometimes present them- selves on the skin after vaccination, and which, in their intensity and importance, hold an intermediate place between the roseola vaccina and the more severe forms of inflammation of the skin. These consist in the formation of papules, wheals, vesicles and buUse, and are described by certain authors^ as liehen, Mrtiearia, eczema, and jjempJiigus vaccinatoruvi. Such names are not, however, in my opinion, rightly applied to these affections, for in dermatology, as in W\Q other branches of medicine, the distinction between a disease (Krankheit) and a symptom of disease (Krankheitserscheinung) should always be observed.
As we have already stated, in giving the general characters of the active hyperaemiae, all the skin affections which are ranged under this head run an acute course, and are of short duration. Their cause varies in different cases, and there can therefore be no ques- tion of any special treatment for the forms of erythema and roseola which have been described in this place. We must confine our- selves to remedying the disease which gave rise to the rash, according to the indications which present themselves in each particular case. The erythema or roseola, as a shin-disease, calls for no treatment.
Among the hi/peramic erythemata, and roseola, I have of course been able to introduce those forms only, which in the majority of cases arise merel}" from an excessive injection of the cutaneous capillaries. There are however other varieties which are caused by exudative processes; such are the roseola typhosa, cholerica, Sfc., and the erytJiema papulatnm, nodosum, 8)C. These are placed by Willan in the same class with the others, but their proper position is obviously not here, but among the acute exudative processes of which the skin is the seat.
It is, I think, scarcely necessary for me to justify this division of the skin-affections, which were grouped together by Willan and by many
1 'Alois Bednar, die Krankheiten der Neugebornen und Säuglinge, &c.,' Vienna, Gerold, 1853. (iv Theil, s. 127.)
60 PASSIVE IIYPERiEMIJ:.
of his followers, uucler the names Roseola and Eri/thema. In the classification of the dermatoses, I have started from principles which are entirely different from those of Willan^ and with these principles the arrangement of individual diseases must of course be made to accord. Indeed when I thus distinguish the forms of erythema and roseola, caused by exudation^ from those which are merely hyperajmic, I am not, in my own opinion, making a division between diseases of the same kind; I am rather separating from one another cutaneous affections, which arise by entirely different morbid processes, and I am classifying together those of which the origin is the same.
B. — Passive Hypeh.emi^,.
Siimjptoms. — A bluish-red (li\id) or bluish-black coloration of the skin, disappearing under pressure; swelhng, which is but slight unless oedema be also present ; diminished warmth of the surface : these are the symptoms of the so-called passive hypersemirej which result from stasis of the blood (Blutstauung).
Subdivisions. — As in the active hypereemise, so also in the passive, we distinguish the idiopathic forms from those which are symptomatic.
A. IDIOPATHIC PASSIVE HYPEE^MLE.
We have seen that irritants of various kinds, if their action upon the skints surface be transient and not severe, lead to the pro- duction of the active hypersemise, and the same agents may also give rise to the passive forms of congestion, particularly if their operation be somewhat prolonged and be exerted on the larger venous trunks. Thus pressure upon any part of the skin, if it be not too severe or too long continued, will be followed by the appear- ance of a bright rose-tint of the surface (that is to say of an active hypersemic state) ; whereas even a moderate pressure, apphed directly over one of the larger superficial vems, will cause a bluish- red tint of the distal parts, or will, in other words, produce a passive hyperaemia.
These local blue colorations of the skin require to be distinguished from those which arise from internal causes, and are hence for
IDIOPATHIC PASSIVE HYPER^EML^. 61
the most part universal. These last bear^ as is well known, the name of cijanosis (Blausucht) ; and we will therefore give to the former variety the names livor cutis, livedo (Blauung), and will divide them into a livedo mcchanica, and a livedo calorica.
(i.) Livedo Meclianica, — Blueness of the skin, 'produced hy mechanical causes.
This form of afPectiou is characterised by a coloration of the skin, which varies from a leaden-grey to a reddish-blue, or bluish-black tint. It is generally confined to circumscribed parts of the surface, is observed chiefly on the extremities, and is associated with more or less oedema. When the cause which gave rise to it is removed, it gradually becomes less perceptible, and finally disappears without producing any further effects. Diminished mobihty of the parts in which the circulation is thus retarded, as well as impairment of sen- sation, or feelings of formication and itching are symptoms which sometimes accompany this afi'ectiou.
We see these affections produced in every-day life, chiefly by the action of tightly fitting articles of clothing, bandages or garters, which surround an extremity, and compress it, so that the circu- lation through the superficial veins is retarded. The blood is thus gradually made to accumulate in the smaller veins; its flow through the capillaries, and their functions are consequently interfered with, and so the condition, already described, is produced.
As is well-known, before proceeding to perform venesection, it is usual to compress one of the larger superficial veins, and under these circumstances, if the bandage be too tight or be left on too long, we have an opportunity of observing this form of coloration of the skin.
Pressure may however also be exerted upon the cutaneous veins by disease seated in the subjacent soft parts, or in the bone, as for example, by tumours, and in these cases the appearances in the skin will be the same. Moreover obstruction of the circulation, and accumulation of the blood in the distal parts of the body, may also be the result of diseases of the veins themselves, such as defects in their valves, paralysis, or a varicose condition. We see this especially in the legs of those persons who are frequently compelled to stand continuously for a long time. In old people, again, we meet
62 IDIOPATHIC PASSIVE HTPEUiEMI^.
with lividity of the hands and feet^ apart from other disease ; and it is then the result, as would appear, of deficient innervation.
(3.) Livedo Calorica. — Blueoiess of the skin , 2yroduced hy the infljience of cold.
Daily experience teaches that the skin of some people is extremely sensitive to cold. If these persons undress in a room at a tempera- ture of 63° — 68° F., and still more, if they remain for some time ex- posed to such a temperature in a state of partial or complete nudity, their veins become injected to so great a degree, that the plexuses which these form, can be seen exactly as on the skin of a corpse (sogenannte Todtenflecke) . Under such circumstances, the surface presents bluish-red or dark-blue lines, of about two centimetres in width, communicating together, and forming circles or various ser- pentine figures. These appearances are observed chiefly on the skin of the extremities, and to a less extent on that of the trunk. They yield completely to the pressure of the finger, but quickly return when it is removed ; and it is only when the patient has dressed and become warm that they finally disappear. This effect of cold is seen more often in young subjects than in those who are older, and occurs especially in the female sex.
Mention must also be made in this place of the bluish-red or dark -blue coloration of the skin which is observed in some persons on the hands and on the face, and particularly on the nose, and cheeks, after exposure for a short time to the influence of the more severe degrees of cold. The blue colour persists however only so long as the action of the cold continues, changing immediately to a natural or a bright-red tint, under the influence of a higher temperature, and this fact and the absence of sweUing, sufficiently distinguish these appearances from chilblains {Perniones, Frost- beulen) .
I cannot refrain from mentioning here a condition which is observed in some cases on the skin of the extremities, and chiefly on the hands, as an effect of cold. It consists in the appearance of distinct spots of a vermilion-red colour, seated upon a more or less livid base, and in size between a lentil and a fourpenny-piece. These red spots, combined with the blue colour of the rest of the skin, give rise to a marbled appearance, and remind one of the aspect presented by the lungs of an infant, who has breathed only
SYMPTOMATIC PASSIVE HYPERvEMI^. 63
for a short time^ and imperfectly. Can these vermihon-red spots on the skin possibly owe their origin to a similar process, to a cutaneous respiration ? We will leave this question to be answered by the physiologists, and will content ourselves with alluding to the fact.
Remark. — Although the passive hypersemise, which have been hitherto described, seem in themselves to have but little importance among the appearances caused in the skin by disease, yet an acquaint- ance with them is in some cases of no little moment. It enables us, in fact, to explain correctly many anomalous and exceptional conditions presented by cutaneous diseases, with the normal appearance of which we are familiar. We can thus understand how aifections which are generally attended with a bright red coloration of the skin, may some- times present a bluish-red hue, without change in their essential nature. AYe shall also be able to avoid the error (by which the study of cutaneous diseases has been made so complicated) of seeing in every different coloration of a familiar dermatosis a specimen of a new and distinct variety, and of immediately creating for it a new specific appellation. Thus, for example, "Willan, under the name lepra nigricans, has figured and described a disease of the lower extremities, which is evidently nothing more than a common psoriasis, seated on the legs of a person affected with varices of the superficial veins, and in which the usual bright-red colour was changed into a bluish-red or blackish-blue by the passive or me- chanical hypereemia.
B. SYMPTOMATIC PASSIVE HYPER^MI^.
The blue discolorations of the skin which come under tliis head are distinguished chiefly by the following pecuharities. They mostly affect large portions of the surface, and are seldom confined to any particular region. They have a much darker tint, and are generally of much longer duration than the idiopathic passive hy- persemise; indeed, they may persist during the ^hole life of the patient. They are also connected with affections which cause, either permanently, or at least for a time, a disturbance of the general health.
The attempt has been made to divide these affections into two varieties, according as the cause of the malady Hes in the organs of chculation, or m those of respiration. In the first case the disease
64 SYMPTOMATIC PASSIVE HYPER.EMI^.
has been termed cyanosis, or morhus cmuleus (Blausuclit) ; in the second^ pneumatelektasis (Sticksucht).
This classification has^ however^ found but few followers. The changes in the skin are in each case the same, and the determining cause can seldom, either during life or in the dead body, be so isolated as to justify the setting up of this distinction between the form of this affection due to cardiac, and that ascribed to pulmonary disease. Hence the name cyanosis may be correctly applied to any blue discoloration of the skin, which is caused by changes in the circulation, and all these terms, cyanosis, morbus caruleus, cyanopa- thia, atelectasia, ancematosis, maladie bleue (die blaue Krankheit, Blausucht, Sticksucht), are to be regarded as synonymous.
Our forefathers looked on cyanosis as a peculiar and independent disease, of which the immediate cause was either the mixing of arterial and venous blood within the walls of the vessels, or some impediment to the decarbonization of the venous blood. ^ Even in more modern works^ we find the view expressed that the blood as- sumes a " venous, cyanotic'^ appearance, when it does not meet in due proportion with pure atmospheric air. These writers based their opinion partly on the results of post-mortem examinations of the bodies of those who are stated to have fallen victims to cyanosis. Yarious congenital defects were, in fact, found in these cases : patency of \\:it foramen ovale or ductus Botalli ; perforated or de- fective septum ventriculorum ; hearts having but one ventricle; absence, narrowing, or closure of the pulmonary artery or aorta ; abnormal origin of the great vessels. The same view was, however, also supported by cases of cyanosis, in which paroxysmal attacks of dyspnoea occurred. These attacks, being followed by loss of con- sciousness, convulsions, and foaming at the mouth, as well as by blueness of the skin, affecting first the face, and j)articularly the lips, and afterwards gradually involving the whole surface, led naturally to the inference that the disease was one of a peculiar nature.
On the other hand, Rokitansky^ has fully proved, in detail, what was before taught in part by Morgagni, Ferrus, Louis, and others,
1 'Beobaclituiif^en und anatomisch path. Erörterungen über die Blausucht:' Yon Dr. M. Aberle, Prof. d. Anatomie zu Salzburg, in den Med. Jahrb. des östr. Staates, Band 46, Neue Folge Band 37, Wien, 1S44, pp. i, 142.
- ' Lehrbuch der Path. Anatomie.' Von Prof. Dr. C._-E. Bock. Leipzig, 1847, p. 231.
3 'Handbuch der Path. Anatomie,' üB. Wien, 1844, p. 511.
SYMPTOMATIC PASSIVE IIYPERiEMI^. 65
that the cause of cyanosis always lies in the impeded passage of venous blood into the heart, bj which a condition of stasis and an engorgement of the capillaries are produced. Hence both the dura- tion of the cyanosis and the degree to which it will be attended bj other symptoms of disease will vary with the causes of the obstruction to the venous blood. Among these may be the follow- ing : — Organic changes in the heart, or in the large vessels ; as, for example, extreme hypertrophy and dilatation of the heart with valvular disease, want of correspondence in size between the heart and the large vessels, &c. ; pulmonary affections, such as catarrh, emphysema, bronchiectasis, pneumonia, compression of the limgs by pleuritic exudation, &c., and, lastly, conditions of perverted innervation, which are generally dependent on diseases of the brain.
The morbid appearances in the skin, resulting from these causes, are as follows : — The surface has a leaden-gray, or even a bluish-black hue, and this is most marked at those parts (such as the lips, gums, cheeks, fingers, toes, &c.) which in healthy persons are of a peculiarly bright or blood-red colour. The temperature of the skin is lowered ; thus the thermometer sank in the hand of a cyanotic patient of F. Nasse^ to 79' 2° Fahr. (21° R.) ; and this is observed chiefly at the distal parts of the body, such as the hands, feet, and face. Cold sweats also break out in these patients, especially on the palms of the hands and the soles of the feet, and lastly, dropsical swelHngs make their appearance.
These symptoms are either constant, merely becoming aggravated from time to time as fresh attacks, attended by dyspnoea, set in ; or they appear only in paroxysms, after which they vanish without leaving behind tliem any traces of their presence.
There can obviously be no question of the treatment of cyanosis, except in so far as we are able to cope with the morbid conditions which give rise to it.
' 'Reil's Archiv,' B. x, p. 285.
CHAPTEE IV.
CLASS II.— AN^MI^ CUTANEA.
Morbid appearances of the Skin caused hy deficiency of Blood in the cutaneous Capillaries.
Although no disease of the shin, in the ordinary sense of the word, arises from deficiency in its blood-supply, yet an acquaintance with the appearances which are caused by this condition is of great importance, because it aids in the recognition of many affections of the organism in general, and also because it leads to a correct inter- pretation of certain changes, which an anaemic state of the system may produce in the aspect of a pre-existing dermatonosis.
The appearances produced by anaemia of the skin are not in all cases the same. Thus :
a. The colour of the skin will vary with the degree of physio- logical pigmentation, and with the cause which gave rise to the anaemia. If the integument contains but little pigment it will assume a waxy appearance, especially if the loss of blood be sudden ; wdiereas, when the deficient blood-supply arises gradually, and is the result of previous wasting diseases, the skin will acquire a dirty, pale-yellow tint.
On the other hand, parts of the integument which previously con- tained excess of pigment, and, in the coloured races of mankind the whole surface of the body, are made by anaemia, not paler, but darker in colour. This may be attributed to the approximation of the molecules of pigment in the epidermis, caused by the collapse of the empty blood-vessels.
h. In reference to the natural turgidity and fulness of the skin, caused by the infiltration of its tissue with fluid (Durchfeuchtuiig, Wassergehalt), it may be remarked that this condition is diminished in aneemia, both from the collapse of the vessels, and from the absorption of the interstitial moisture, and that a change in the aspect of the countenance is thereby produced.
AN^MI^. 67
c. The temperature of the surface falls when anseraia is rapidly produced, but returns to the usual height if this condition persists for some time ; and if a state of nervous excitement should become developed in consequence of repeated haemorrhages, the temperature may even rise some degrees above the normal level.^
d. The chief subjective symptom is a diminution of sensibility, sometimes amounting to anaesthesia. Some patients also suffer from cold shivering and shuddering, and others complain of a feeling of pricking, and of increased warmth of the skin.
<?. The seat of the disease can, of course, be looked for only in the vascular apparatus of the integument.
f. No particular eruptions appear as a result of deficient blood- supply to the skin ; but a profuse cold sweat may mostly be observed on the pale, colourless surface.
g. The course and duration of anaemia of the skin are various ; it may be acute and transitory, or chronic and of long persistence.
h. Secondary appearances manifest themselves on the skin of anaemic patients only when the morbid state has lasted for a con- siderable time. It may then be observed that the horny structures, such as the epidermis, hair, and nails, which are normally permeated by fluid blastema, have become drier and more brittle, while emacia- tion, and a peculiar loose state of the integument, are also produced by the absorption of the fat from the subcutaneous areolar tissue. Again, the deficient blood-supply to the skin causes not merely a pallor of the surface, but also a diminution, or a complete drying up of the secretions and of any exudations which were previously being poured out. Lastly, in consequence of the smaller amount of fluid permeating the skin, any parts of it which are hypertrophied, and also all tumours or new growths decrease in size.
Anaemia of the skin may be divided naturally into two varieties, according to its cause ; one form of it being produced by defective blood-supply, and another by perverted innervation.
A. — Anemia of the Skin, from absolute want of Blood.
There are, as is well known, two ways in which the quantity of blood in the body may be diminished ; this effect being sometimes
' 'Observations ou Bloodletting,' by Marshall Hall, M.D., 1836, p. 31.
68 ANiEMI^.
the result of haemorrhage, sometimes of certain states of disease^ attended by a slow wasting of the vital ilaid.
A. ANEMIA ARISING FROM HAEMORRHAGE.
Loss of blood, from injury to or rupture of the larger vessels^ is, usually, quickly followed by a condition of general ansemia. This manifests itself for the most part, first by pallor of the face, and especially of the lips, by coldness of the extremities, and cold sweats. These symptoms are afterwards accompanied by signs of depression of the nervous system — such as the appear- ance of mists before the eyes, failing of the senses, trembling, loss of power to maintain the body erect, nausea, sickness, &c. These phenomena constitute the condition of syncope (Ohnmacht) ; which, if the loss of blood continues, and if the nervous centres become paralysed, passes into one of apparent death (Scheintod), and ultimately into death itself — in which case the appearance of the skin remains unchanged in the dead body. The expression *' cadaveric hue," (Leichenblässe, Cadaveröses Aussehen, Todteu- farbe, &c.) has, in fact, partially lost its original meaning, and serves likewise for the description of the appearances produced in the Hving skin by ansemia. Besides the pallor of the lips and mucous membranes generally, and of the skin (the first striking symp- tom of syncope), the anaemic condition of the surface is further shown by the fact, that no blood flows from recent wounds so long as the patient is in a fainting state, although they may have bled freely before and may again bleed afterwards.
B. ANiEMIA CONSEQUENT UPON DISEASE.
All diseased states of the human organism, in which the due relation is not preserved between the renewal of the blood and its consumption, so that more of the vital fluid is expended than is during the same period reproduced, give rise at last to a condition which, besides other appearances, manifests itself in a pale, dingy, earthy, or dirty-yellow look of the skin, called by the name of ohgsemia or anaemia. Thus, in patients convalescing from pro- longed febrile complamts, we see the same pale and eai-thy appear- ance of the skin as in those who suffer from advanced tuberculosis, syphilis, scorbutus, carcinoma, chlorosis, &c. At the same time, the sl^in may generally be noticed to have a greasy feel, resulting
AN^MIiE. 69
from an increased secretion of fat by the sebaceous glands, as well as from changes in the formation of the epidermis. This con- dition and the presence of numerous white branny scales con- stitute an affection to which writers have given the names pity- riasis tabescentium, phtJdsicorum, scro^ihulosomm, &c. Another symptom, also, which has the same origin, is the falling off of the hair {Defluvium cajnUorum), which in most cases accompanies this form of ausemia.
B, — Anemia op the Skin, caused by Perverted Innervation.
Various influences may so affect the nervous system as to give rise to an anaemic condition of the skin, in addition to all sorts of other symptoms. Fear, distress, anger, indignation, frequently pro- duce pallor of the face, which arises suddenly, mostly lasts somewhat longer than the mental disturbance by which it was caused, and terminates without any further consequences in the return of the normal colour of the skin. So also fainting, whatever may be its cause, makes the whole surface of the body pale, and, as I have already stated, leads to a suspension of haemorrhage.
A knowledge of anaemia of the skin, and of the group of symp- toms to which this gives rise, affords an explanation of certain peciüiar appearances, and often enables us to interpret them in a way quite different from what has hitherto been done.
The pallor of the skin, resulting from imperfect injection of the capillaries, will, of course, whatever may be its cause, show itself not less in those who suffer besides from some cutaneous disease, than in those whose skins are otherwise healthy. But if this skin-affection be one of those which manifest themselves chiefly by a vascular injection and redness of the surface, it is clear that no trace of it will be seen, so long as the anaemia persists.
Por the same reason, on the dead body certain appearances of the skin alone remain visible. Such are those which arise from changes in the structure of the different tissues of the skhi (as, for example, the thickening of the epidermis in tylosis, ichthyosis, &c., and that of the cutis in pachydermis, keloid, elephantiasis Graecorum, &c.) ; and those which are due to the presence of morbid products (such as scales, crusts, pigmental deposits, parasitic growths, &c.) deposited on the surface of the skin, or infiltrating its tissues. The only mere reddenings of the surface, which are to be seen in the dead body, are those which are caused by extravasation of blood, or by the pre-
70 ANiEMI^.
sence of inflammatory exudation in large quantity. On the other hand, all those rashes which arise merely from hypereemia, or accompany the less severe exudative processes, disappear altogether after death.
Hence, it is not surprising that in those who have died of morbilli, scarlatina, or erysipelas, the skin presents a colour alto- gether different from that seen during life. It is also in vain that one looks in the dead body of a patient who suffered from psoriasis, eczema, or lichen, for the numberless bright-red spots which existed on the surface of his skin while he was alive. Unless their position is betrayed by the presence of scales, or of pigment, it is not possible to demonstrate the existence of these eruptions after death.
As this is what becomes in the dead subject of skin dis- eases which were present during life, we shall not be astonished to observe the same thing in the living patient, whose skin, like that of a corpse, is in an ansemic state.
Hence, when syncope suddenly occurs, we find that those derma- toses vanish which manifested their presence by reddening of the skin; and, as consciousness returns, they also reappear. For the same reason, parts of the skin which had been reddened, become pale during the last struggle for life.
A similar influence upon various forms of skin-affection is pro- duced also by the antemia caused by loss of blood, and that whether this state is developed rapidly as a result of haemorrhage, or slowly from excessive consumption of the blood in its circulation through the body. Hence, chronic skin complaints disappear when prolonged febrile diseases of the organism such as pneumonia, typhus, &c., have caused a diminution in the quantity of the vital fluid, and this occurs in proportion to the advance of the general disease. Thus it is that we find chronic dermatoses alternating with acute affections of internal organs, disappearing during the course of these complaints, and showing themselves anew while convalescence is in progress. We never observe the reverse, that is to say, that the skin disease vanishes first, and that the visceral affection occurs afterwards as a result of its disappearance. The idea that this might take place had formerly, as is well known, very many, and has unfortunately even now some, supporters, and gave rise to the doctrine of the liability to metastasis of chronic skin affection, a doctrine utterly without foundation.
CHAPTER V.
CLASS III.— ANOMALIE SECRETIONIS GLANDULARUM CUTANEARUM.
Diseases due to perverted states of the Secretions of the Cutaneous
Glands.
The affections belonging to this class are of two kinds — the first group including the various functional disorders of the cutaneous glands ; the second, their structural diseases. These last, however, concern the sebaceous glands alone, of the two varieties of secreting organs contained in the skin; for, up to the present time, the sudoriparous glands have not been shown to be subject to any such structural affections.
Now, I propose, in the first place, to describe those morbid conditions of the cutaneous glands which affect the functional activity of these organs. But before doing so I must define the position which I take up in reference to these disorders.
This is not the place to point out the important effects on the system generally which must be produced by any excess or dimi- nution in the secretory activity of the cutaneous glands. My chief object must rather be to describe those morbid conditions of the skin to which a perverted state of their functions often gives rise. Hence the present subject naturally divides itself into two parts. I must first describe the morbid changes in the secretions themselves ; and, afterwards, the cutaneous affections which result from those changes.
Before referring specially to the sweat and the sebum (the two secretions which are found in and upon the surface of the skin), it may be well that I should draw attention to the fact that these sub- stances can be regarded as existing separately from one another, only when one of the two can be plainly recognised by its own pecu- liar characters. Slight variations in their proportionate quantity can scarcely, if at all, be detected. In the healthy state the
72 AFFECTIONS OF THE GLANDULAR SECRETIONS OF THE SKIN.
jiroducts of both kinds of glands reach the surface of the integument in a more or less aeriform condition. Among other purposes, they serve to moisten, polish, and lubricate the skin. When secreted together in the normal way, they constitute a vaporous exhalation, which cannot properly be regarded as either sweat or sebaceous matter, but is really a combination of them both. With the addition of the fluids and gases which are poured forth by the vessels of the papillse themselves (independently of any glandular organs), and which pass through the epidermis, the exhalation before alluded to is what has been termed by physiologists the materia perspiratoria. The fact that the secretions of the sudoriparous and sebaceous glands are poured out simultaneously upon the surface of the skin, and there mixed together, has hitherto thrown great difficulties in the way of all attempts to determine the normal microscopical- or chemical characters of either of these products. Indeed, none of the analyses hitherto made can be supposed to be absolutely correct.
Those who have investigated the composition of these substances have adopted various methods, but have never succeeded perfectly in separating from one another the secretions of these two kinds of glands. Thenard, in his experiments, made use of shirts, saturated with perspi- ration; Auselmino collected the secretion by enclosing some part of the body in a cylindrical tube of glass ; Schottin, with a similar object, washed the surface of the skin after death. No satisfactory results, however, were obtained by any one of these procedures ; nor did any better success attend Seguin^s method of employing silk, covered on the outer surface with caoutchouc, to absorb the perspiratory secretion; or the attempts of Tunke and Favre to collect the sweat from a person placed in a vapour bath, and made to lie on a metal sur- face hollowed towards the centre. Whatever plan they may have adopted, experimenters have obtained, not the pure secretion of the sudoriparous gland«, but a mixture of this and sebum, containing also detached epidermic scales and condensed vaporous exhalations. Moreover, the artificial conditions under which such investigations are made necessarily introduce further errors into their results, by altering the quantity of the cutaneous secretions.
Thus, then, the statements of different authors with reference to the quantity and composition of the glandular secretions of the skin have only a subordinate value. This is, indeed, confessed by Ludwig, Henle, Lehmann, Valentin, Kölliker, and other physiologists.
AFFECTIONS OF THE GLANDULAR SECRETIONS OF THE SKIN. 73
As for the chemical constitution of the sweat, those who have analysed this fluid assert that it contains from 99*30 to 99*55 per cent, of water, the residue consisting of sohd matters, among which are chloride of sodium, phosphate of hme, hydroclilorate of ammonia, and traces of iron and of fatty matters. Favre, for example, gives, as the soHd substances contained in this secretion, chloride of sodium, chloride of potassium, sulphate of potass, phosphate of soda, earthy phosphates, albuminate of potass, lactate of potass, a potass-salt containing a peculiar acid (Schweisssaueres Kali), urea, and fat.
Schottin,! again, analysed the perspiration of the feet, and found in a hundred parts of this fluid 0*05 of insoluble, 0*84 of soluble matters. These consisted of —
|
Phosphate of lime |
. 0037 |
|
Phosphate of magnesia |
• 0013 |
|
Chlorine .... |
• 0279 |
|
Sulphuric acid . |
. 0049 |
|
Phosphoric acid |
. 0020 |
|
Sodium .... |
• o'25i |
|
Potassium |
. o"099 |
It is, however, necessary to bear in mind, that great variations in the quantity and quality of the cutaneous secretions occur normally even in the same individual, and still more in different persons, although apparently in good health and of simuar constitution. These variations could not be in any way taken into account in the analyses I have quoted; and this fact may be given as another reason for the great differences in the results obtained by so eminent observers, in addition to the difficulty (to which I have already referred) of isolating these secretions, and analysing them separately. Hence it appears to me that the distinctions between the different diseases of the skin, caused by morbid conditions of its glandular organs, must not be made to depend upon chemical analyses, such as those of which I have been speaking. The characters of the affection must in each case be regarded from a clinical point of view, and its definition must be based on the mode of succession of the symptoms, that is to say, upon the course of the disease.
From this stand-point, then, I shall endeavour to deal with the subject before me.
1 * De Sudore,' diss, inaug., Lipsiae, 1851.
74 AFFECTIONS OF THE MATERIA PERSPIRATORIA.
The affections produced by functional disorder of the glandular organs of the skin may be divided into three groups, according to the nature of the morbid products which present themselves. First, there are diseases of which it cannot be positively stated whether they arise from a perverted activity of the sudoriparous or of the sebaceous glands, or even of the papillse of the cutis. The substance which appears on the surface of the skin is, in these cases, what would in the normal condition be termed, as a whole, the materia persplratona. Secondly, there are affections which are attended with the formation of a watery fluid in large quantity, due principally to the action of the sweat-glands. Lastly, there are conditions in which the secretion is shown to be the product of the sebaceous glands, not only by its peculiar nature, but also by the position which it occupies.
A. — Affections produced by morbid states op the Materia Perspiratoria.
The conditions which come under this head are principally those in which our sense of smell is powerfully and disagreeably affected by exhalations possessing a specific odour, Even in the normal state each human being probably diffuses around him a special odour, although this is not strikingly perceptible to our senses. Animals, such as dogs, whose power of smell is acute, are well known to recognise their master by this sense rather than by that of sight ; and it is also a fact that persons still uncivilised, such as negroes and Indians, are able to scent friends or foes from a distance.
But even on the imperfect sense of smeU possessed by ourselves certain persons produce a disagreeable impression; and there are those who, in spite of the most scrupulous cleanliness, cannot remove the specific evil odour which clings to them. Now, it cannot be main- tained that this unpleasant smell belongs exclusively to the perspiratory secretion. On the contrary, the odours observed in these cases generally resemble those of the fatty acids, substances which are certainly formed in much larger proportion by the sebaceous than by the sudoriparous glands.
Hence, I am not disposed to ascribe to a morbid state of the sweat alone the disease which is spoken of by authors under the name of Bromidrosis {Osmidrosis, stinkender Sch weiss). I regard it
BROMIDROSIS. 75
as resulting rather from an abnormal condition of the materia per- spiratoria, that is^ of the cutaneous exhalation as a whole.
In these cases of bromidrosis the disease, as is well known, may either be universal, affecting the whole cutaneous surface, or confined to some particular part of the skin. Hence, if we would adhere to the old terminology, we must divide this complaint into a B. uni- versalis and a B. localis.
{a) Bromidrosis universalis.
Under this head are to be reckoned those cases in which there arises from the surface of the skin a fetid exhalation, of which we cannot indicate the special source, the patient being at the time in a healthy state, and the cutaneous secretion not being particularly increased in quantity, or, at any rate, not collecting in the form of drops.
If a person remains continuously in an atmosphere which is im- pregnated with any substance having a specific odour, this wül, of course, adhere mechanically to his clothes, skin, and hair. But, at the same time, he will inhale these odorous matters suspended in the air, and therefore must also exhale them through the agency of the cutaneous organs, namely, the sweat-glands, sebaceous glands, and papillae. This is proved by* what we observe in those who have, for a long period, been placed under such conditions. However fre- quently and thoroughly such persons may endeavour to cleanse them- selves, it is only after the lapse of a considerable time that they lose the subjective sensation of the peculiar smell, and cease to give off from the skin a similar odour.
There have, indeed, been physicians, who, with Heim, of Berlin, have maintained, not only that each one of the exanthemata possesses a specific smell, but also that they could detect it so constantly and with, such precision as to be in the enviable position of being able, by means of this odour, to distinguish these diseases from one another. Thus, it has been asserted that patients affected with morbilli exhale an odour like that of recently plucked feathers; that in scarlatina the smeU resembles that of new bread ; in small- pox, that of a menagerie; in the disease termed " Friesel,"^ that of decomposing straw. But the organ of smell must surely be extra-
^ This disease is fully described by Prof. Hebra under the name of " miliaria " in a later chapter of this work, among the acute, non-contagious, exudative dermatoses. — [£d.]
76 AFFECTIONS OF THE MATERIA PERSPIRATORIA.
ordinarily acute to be able to detect these odours ; and in any case they have no claim to be termed characteristic, for the substances with which they are compared by no means possess a smell so decided as to prevent the possibility of confounding them with many others.
(b) Bromidrosis localis.
Among the parts of the skin from which disagreeable odours most frequently arise must first be mentioned the axillae. In these regions, as is well known, there exist large glandular bodies, which bear a general resemblance in their structure to the sweat-glands, but have been termed by some ceruminous glands, from their being still more like those which are found in the external auditory meatus, and secrete the cerumen. The true character of these organs is doubtful, it being still a matter of dispute whether they should be reckoned among the sebaceous or rather among the sudoriparous glands.
The male and female genitals, the perinseum, the neighbourhood of the anus, the soles of the feet, and particularly the lateral surfaces of the toes, must also be mentioned as liable to give off intense odours of a similar kind.
In each of these regions the secretion of the skin has, normally, a disagreeable smell, and, under certain circumstances, may be so increased in quantity and changed in character, that its altered con- dition is, in itself, a disease. Moreover, this fluid then gives rise to an unhealthy state of the skin over which it flows ; the appearance thus produced being sometimes merely a reddening and maceration of the epidermis, or, in other words, an intertrigo ; whereas, in other cases, it amounts to an actual eruption, of a papular, vesicular, or bullous character, and, in fact, presents all the symptoms of an eczema.
So far as the bromidrosis pedum is specially concerned, this arises from the extraordinary quantity of the cutaneous secretion which is poured out, rather than from its being, when first formed, par- ticularly altered in composition. Obviously, therefore, the foetor will become more intense as the amount of this fluid increases; for if we compare the smell of the ordinary cutaneous secretion of the feet with that of the so-caUed unhealthy perspiration, we find that these odours differ, not in their quality, but merely in their intensity, which, in fact, rises and falls with the changes in the quantity of the fluid poured out. In the normal state the smell can be perceived only when the nose is brought close to the person^s foot ; under morbid conditions it is noticed even at a distance.
BROMIDROSIS. 77
But^ however much the sweat may in such a case be increased in quantity^ it will be found, on investigation, that this fluid is not in reality the only source of the evil odour given off by the cutaneous secretion. On the contrary, this smell arises from the presence of a large proportion of fatty matters, the product of sebaceous glands which exist abundantly on the sides of the toes and also on the dorsal surface of the foot. When this secretion is first formed, however, no disagreeable odour belongs to it any more than to that of the sweat-glands or to the exhalation of the papillse. The smell arises only when the fluid has remained for some time on the sur- face of the skin, and especially when it has undergone decomposition, its evaporation having been prevented by the coverings worn on the feet. As I have already stated, this secretion contains fatty matters in large quantity. These, of course, tend to undergo those changes to which all such substances are liable, consisting in the formation of the well-known series of fatty acids, among which are the caproic and the caprylic. This decomposition, which is favoured by the warmth and moisture of the parts, gives to the perspiration the smell characteristic of these acids.
These changes occur even under normal conditions, but to a far greater extent when the secretion from the feet is excessive, so as to saturate the shoes and the socks or stockings of the patient. And it is obvious that the more often these articles are soaked with per- spiration, and the longer they are worn without being changed, the more intensely will they become impregnated with tliis odour, which they will communicate to the air around.
That this is really the case any one may prove by taking a person who suffers from this complaint, removing his ordinary shoes and stockings, and making him wash his feet thorouglily several times, and lie in bed for a few days. If, at the end of this time, the smell of the things which were laid aside be compared with that of the feet, it will be found that the latter, even though they may have become covered with sweat beneath the bed-clothes, no longer give off the disagreeable odour which still adheres powerfully to the shoes and stockings.
It is clear, then, from what has been stated, that there is not, pro- perly speaking, any disease in which the secretion of the feet is fetid, but that there is an affection in which this fluid is formed in excessive quantity, and afterwards acquires an evil odour as a result of its de- composition.
78 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.
Hence there is obviously no foundation whatever for the absurd fancies which formerly prevailed as to the usefulness or injuriousness of this fetid secretion, or as to the ill-effects of its suppression, by which various other diseases were supposed to be produced.
B. — Affections caused by Functional Disorder of the Sudoriparous Glands.
(i) Quantitative Changes in this Secretion.
A. Hyperidrosis.
a. Hyperidrosis universalis.
Under the name of hyperidrosis is to be understood that con- dition of the skin in which the secretion of the sudoriparous glands appears as a fluid in the form of drops, and does not entirely pass off in a vaporous state, as is normally the case. The use of this term should, however, be restricted to those instances in which such an accumulation of the sweat occurs under conditions in which it would not naturally be observed, or, at any rate, would be but slight ; so that the excessive secretion is in itself to be regarded as morbid, and the more so because it also gives rise to certain secondary affections of the skin.
It is obvious that in this place I cannot attempt to describe those forms of hyperidrosis (Schweisssucht) due to the presence of some other disease, of which sweating is one of the regular symptoms, or in which it is often present.
Thus, I shall make no further mention of the non-febrile chronic ephidrosis of Schönlein,^ or of the colliquative sweats of phthisical patients, or of the so-called " critical" sweats which occur in acute febrile diseases, such as typhus and the exanthemata. Nor shall I give an account of the " suette de Picardie,"^ an affection which appeared in Picardy in 17 18, or of the "sudor Änglicus,"^ another of these complaints, which broke out in the army of Henry VII in 1485, and is said to have raged in England, Prance, and Germany, on five separate occasions between 1485 and 1550. I shall concern myself with hyperidrosis only from the dermatological stand-point, describing those affections alone which simply consist in a perverted
1 Scliönlein's 'Path. u. Ther., nach dessen Vorlesungen, von einigen seiner Zuhörer herausgegebeu,' vol. iii, p. 142. St. Gallen, 1841.
^ Ozanam, 'Mal. epidein.,' vol. i, p. 222. Paris et Lyons, 1835. ^ Ibid., vol. iv, p. 93.
HYPERIDROSIS UNIVERSALIS. 79
state of the perspiratory function or are caused by the local action upon the skin of sweat already secreted.
Now, it is well known that some indi\dduals perspire under cir- cumstances under which the skin of other persons remains perfectly dry, and yet that this form of hyperidrosis leads to no ill-effects on either the general health or the other functions of the body. Examples of this are far from being rare, either in medical litera- ture or in our daily experience. The persons who thus "melt" (zerfliessen) into perspiration, on the slightest bodily exertion or movement, are generally stout, well-nourished, and inchned to be fat, possessing a good digestion and an equally good appetite both for solids and fluids.
Again, there are others who likewise sweat enormously, but only under the influence of a high temperature, as when they are exposed to the rays of the sun or to some artificial source of intense heat. This is observed, for instance, in the inhabitants of southern cUmates, and also in the case of stokers, glass-blowers, and men who follow certain other occupations.
Now, in many individuals, this exalted activity on the part of the perspiratory glands leads to no morbid change in the vital condition of the skin (in dem Hautleben) ; but in others it gives rise to an efflorescence exactly similar, both in form and colour, to those eruptions which are well known to be produced by the action of various irritants. This efflorescence generally consists of small red papules, seated chiefly at the apertures of the cutaneous glands. Vesicles also are occasionally present, and these may even contain a puriform fluid, being, in reality, small pustules. All these are at first isolated from one another, and it is only when the rash has been of long duration that they coalesce, so as to form large continuous patches.
These appearances have received diff'erent names, according to the cause which gives rise to them. When they are observed on the skin of persons otherwise healthy, in whom the cutaneous sur- face is covered with drops of sweat, they are called sudamina. "When met with in southern climates they are termed calori ; and other names, all belonging to the same affection, are the "lichen tropicus'' of Willan, the " sesh" of Cleghorn, the "prickly heat" of English, antl the " Hitzblätter chen" of German writers.
In their form, extent, and seat, and also in the course which they take, these eruptions are altogether similar to those which we can
80 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.
generate artificially by the application to the skin of various irri- tants. Thus, the action of hot or cold water, in the form of baths, fomentations, or lotions, gives rise to affections to which the name " psyclracia thermalis" was formerly applied, and which more recently, when caused by the hydropathic mode of treatment, have been regarded as indicative of crises (Hautkrisen). They are, in fact, artificial forms of eczema, and with them, as I have said, the disease which I am now describing is perfectly identical.
Hence it would in reality be better to use the name eczema to designate these papular and vesicular eruptions due to hyperidrosis, some epithet, such as " sudamen," being added. Thus, they might receive the common appellation of eczema sudamen. The name sudamina^ however, has hitherto been generally given to these affec- tions, and the other terms which I have quoted have also a cer- tain claim to be noticed, being employed in various works ; I have therefore been obliged to refer to them ; but I may, finally, again remark that all these appellations — sudamina, calori, miliaria rubra, &c. — belong to one and the same eruption, which accom- panies profuse sweating.
This is shown by the fact that, when such an efflorescence has lasted for some time, the appearances presented by it are in every respect identical with those of any other form of eczema, whether originally produced by the action of some cutaneous irritant or even by a morbid condition of the system generally.
He who is acquainted with the various stages, through which an eczema passes, will recognise all of them in the so-called " suda- mina," the eruptions caused by excessive sweating. This is parti- cularly the case when the perspiration goes on without cessation both by day and night, as in those who live in tropical climates, or follow certain occupations. The same thing, however, may be ob- served also when these forms of efflorescence, being regarded as *' crises," and therefore as desirable, are aggravated by methods of treatment supposed to be judicious, but which are, in reahty, quite the contrary.
In this way it might often happen that the most severe varieties of Eczema rubrum and E. impetiginosum should be generated from
1 It is scarcely necessary to remark that this terra is generally used by English writers in a dififerent sense. The eruption consisting of transparent vesicles, commonly termed " sudamina" in this country, is described by Prof. Hebra under the name of Miliaria. — [Ed.]
HYPERIDROSIS UNIVERSALIS. 81
eruptions which were originally mere "sudamina." To produce this result we have only to excite the cutaneous glands still further, by making the patient wear warm clothing, giving him hot drinks, and keeping him in a heated atmosphere. Even the application to the skin of stimulating ointments, or the use of warm or cold baths, which likewise act as local irritants, may in these cases be sufficient to convert a simple papular or vesicular eczema into one of the more intense forms of this disease.
But if, in such a case, the temperature of the skin is no longer raised above the normal level, and if the excessive perspiration con- sequently ceases, the eruption will shortly fade; some of i\\e papules will become covered with mfnute scales of detached epidermis ; the itching will diminish, and the integument will gradually return to the healthy state, presenting at last no trace of the disease with which it was affected. But even when sudamina thus subside, instead of passing into more severe affections (as they do when irritated), the course which they take still shows their identity with the eczemata.
Authors have propounded different views with reference to the mode of development of these eruptions due to excessive sweating. Some think that the fluid, being exhaled over the whole surface of the skin by the papillae, and not merely by the sudoriparous glands, accumulates beneath the epidermis, and raises it into papules or vesicles. Others consider the mouths of the sweat-glands to be the seat of the vesicles, attributing them to the fact that the spiral ducts of these glands open very obliquely. Others, lastly, think that the sweat, when formed, is an irritant to the skin, and acts like any other irritant applied to its external surface, and they regard sudamina as the result of this action.
Careful observation of this affection shows, however, that the papules and vesicles are not caused by the action of the sweat after its secretion, but arise, if not before the perspiration occurs, at least simultaneously with its first appearance.
Thus, there are some individuals who, when affected with profuse sweating, are liable to become covered in a few hours, for instance, in the course of a single night, with an enormous quantity of sudamina. In certain persons, on the other hand, some parts of the skin are for years almost continually covered with perspiration, without any sudamina or, indeed, any eruption whatever, being formed. This is the case with most of us, so far as the skin of the axillae, nates, and genital organs is concerned. The sweat does,
6
82 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.
indeed^ like any other warm fluids act injuriously on those parts of the skin with which it comes into contact. But it is the epidermis which first suffers from this action, and only when this has been mace- rated and softened can the subjacent corium be in any way affected by it.
I am, therefore, inclined to regard sudamina as caused, not so much by the perspiration already poured out upon the surface of the skin, as by the hypersemic state of the cutis, and the consequent eleva- tion of temperature, whicli precede the secretion of that fluid. The vessels which aid in the formation of the sweat include those which supply the papillae, as well as those which enclose, in their meshes, the sudoriparous and sebaceous glands ; 'the whole network of capil- lary vessels in and beneath the skin being, in fact, concerned in the act of secretion. Hence the perspiratory fluid, being everywhere poured out in excessive quantity, and collecting beneath the epidermis, raises it in the form of papules or vesicles, while at the same time the papillae themselves become reddened and swollen.
A proof of the correctness of this view is surely furnished by the fact that the patient complains of a transient pricking sensation in the skin, while the sudamina are being developed. This could hardly be explained if the only structures concerned were the sudo- riparous glands, which certainly are not known to be very sensitive organs. But these precursory feelings of pricking and formication, often amounting even to intense itching, are sensations which are likewise observed in other affections of the cutaneous papillae. The English name, " prickly heat/^ appears to have reference to these subjective symptoms.
Treatment. — Although medical advice is not sought in very many cases of sudamina, there are yet some more severe forms of this affection which are brought under the observation of the physician, either