". r ;i40
TELEPHONE. UPLAND 26
DR. C. H. WIMPRESS
r.ON OF STREET RAILWAY UPLAND, CAL.
FOB STUDENTS AND PRACTITIONERS.
TILBURY FOX, M.D., F.R.C.P.,
PHYSICIAN TO THE DEPARTMENT FOR SKIN DISEASES IN UNIVERSITY
AUTHOR OF VARIOUS WORKS ON SKIN DISEASES, ETC.
T. C. FOX, B.A. (CANTAB.), M.R.C.S.
HENRY 0. LEA.
r. HNS, PRIKTEK.
' <ynp Sirpt
THIS little work epitomizes in a short compass
the clinical features and the essential points in the
treatment of diseases of the skin.
The book can be easily carried in the pocket
an advantage to the student ; and it is believed
that it will be of much service to him in the Hos-
pital wards and out-patient room, in his early
study of dermatology, no less than in his final
preparations for the ordinary pass examinations.
The work is also intended for ready reference
by the practitioner in daily practice. It is adapted
for this purpose on account of the particular refer-
ences made in the text, in the sections on treatment,
to particular formulae contained in the third part
of the book as suitable for use against conditions
of disease specialty defined in the text.
The work, however, in no way supersedes larger
works on the subject of skin diseases.
T. C. FOX.
14 HARI.EY STREET, CAVENDISH SQUARE,
Oct. 1st, 1876.
GENERAL OBSERVATIONS ON SKIN DISEASES ... 1
INDICATIONS FOR THE STUDY OP SKIN DISEASES :
1. As to the General Character of Skin Eruptions . . 1
2. As to the Mode of Examining Skin Diseases . . 2
3. As regards Complications . . . . . 5
4. As regards Modifications of Eruptions . ' .5
ELEMENTARY LESIONS ......... 7
CLASSIFICATION OR DIAGNOSTIC CHART OF SKIN DISEASES :
1. Eruptions occurring in Connection with the Acute
Specific or Zymotic Diseases ..... 12
2. Eruptions 12
3. Local Inflammations ....... 13
4. Hypertrophic and Atrophic Diseases . . . .13
5. New Formations ....... 14
6. Haemorrhages . . . . . . . . 14
7. Neuroses ......... 14
8. Pigmentary Alterations ...... 14
9. Parasitic Diseases ....... 14
10. Diseases of the Glands and Appendqges . . .15
THE CAUSES OF SKIN DISEASES . 16
TREATMENT (GENERAL PRINCIPLES) 25
THE DESCRIPTION A.\I> TREATMENT OF SKIN DISKASI-
Acne .......... 31
Alopecia or Baldness 33
Anthrax or Carbuncle 34
Area, tee Alopecia.
Atrophia Cutis ........ 35
Bakers' Itch 36
Baldness, gee Alopecia.
Barbadoes Leg, see Bucnemia.
Boils, see Furunculi.
Bricklayers' Itch 36
Bucnemia Tropica ........ 36
Cancer, see Epithelioma and Rodent Ulcer.
Carbuncle, see Anthrax.
Chlonsma, tee Tinea versicolor.
Condylomata . . . 38
Contagious Impetigo 38
Eczema .......... 42
Elephantiasis ......... 46
Epithelioma, or Epithelial Cancer 47
Erythema, or simple redness (hyperaemia) . . .47
Favus, see Tinea favosa.
Fibroma .......... 49
Fish Skin Disease, see Ichthyosis.
Follicular Hypersemia ....... 50
Fungi, see Tinea.
Grocers' Itch 51
Gutta rosacea, see Acne rosaoea.
Herpes *..... 52
Hydroadenitifl ........ 54
Intertrigo, see Erythema.
Itch, see Scabies.
Kerion, see Tinea kerion.
Lichen ..... ...
Lichen urticatus, see Urticaria.
Lupus ...... . .
Medicinal rashes ......
Molluscum contagiosuin .
Pediculi, see Phthiriasis.
Porrigo . . .
Prickly Heat, or Lichen Tropicus .
Pruritus, or Itching ....
Ringworm, see Tinea.
Rodent ulcer .......
Roseola . . .
Scabies or Itch ......
Scabies in Private Practice ....
Strophulus or Red Gum ....
Syphilis of the Skin
Urticaria, or Nettlerash ....
Xanthelnsma . ......
Xerodertna, see Ichthyosis.
Zoster, see Herpes.
CUTANEOUS PHARMACOPEIA 100
Astringents . . . . '. . . . .102
Absorbent Powders ....... 107
Stimulants and Absorbents ...... 107
Remedies for Scabies and Phthiriasis . . . .115
Remedies for Vegetable Parasitic Diseases . . . 116
Diet in Skin Diseases . ... 118
EPITOME OF SKIN DISEASES.
GENERAL OBSERVATIONS ON
INDICATIONS FOR THE STUDY OP SKIN DISEASES.
IN the successful clinical study and management
of skin diseases, there are one or two important con-
siderations which should never be lost sight of by
the practitioner or the student.
Firstly, as to the general character of skin erup-
tions. There is nothing really special in their
pathology. It has been a common remark that the
study of skin diseases is bewildering on account,
amongst other reasons, of the infinite variety of
forms and aspects assumed by eruptions, and the
multitudinous names given in consequence. Until
lately there certainly was much truth in such a
statement, but now researches in cutaneous patho-
logy are fast clearing the path to a more correct
knowledge of skin affections, whilst difficulties are
rapidly vanishing, especial \y by the breaking down
of those artificial distinctions which have so multi-
2 INDICATIONS FOR THE
plied varieties and terms. It is now manifest that
similar morbid processes go on in- the skin and
in other parts of the bod 3% Indeed, da\- by day it
is becoming more possible to group skin diseases
according to their pathological affinities exactly on
the same plan as other diseases. This fact in itself
testifies abundantly to the clear insight already
gained into the subject, and it also explains tin-
circumstance that the student of to-day, who is
compelled to acquire pathological knowledge in
general, discovers that the stucty of skin diseases is
rendered comparatively cas3' because of the analogy
existing between the facts of general and skin
patholog3 r . He does not find himself dealing with
strange topics or data, but recognizes familial-
appearances, changes, and causes, in morbid action.
It is most important then to understand that there
is nothing essentially special in cutaneous patho-
logical changes as compared with those which occur
in other parts.
Secondly^ as to the mode of examining skin <li.<-
eases. In diagnosing a great error is commonly
committed by attempting to recognize them from a
too partial examination of the phenomena they pre-
sent either to the senses of the practitioner or in
their histories. Practitioners and students, as the
rule, content themselves with diagnosing from sight
alone; they make a venture at the diagnosis from the
aspect alone, but only to be often signally wrong.
Without a correct diagnosis successful treatment
STUDY OP SKIN DISEASES. 3
cannot be confidently expected, but must be more
or less chance work. In some, and indeed many
cases, no doubt the nature of the disease can be made
out correctly at once from inspection, and that even
of a partial kind, inasmuch as the eruption assumes
from the outset and preserves throughout its course
its typical characters. In other instances, on the
contrary, this is difficult or impossible without
careful inspection of many parts of the disease in
several localities in a given patient, or an inquiry
into the previous history of its course ; for many
skin diseases are made up of stages, and, at the time
of observation, these may vary greatly in different
parts, and the tj'pical characters may not be dis-
tinctly recognizable or may be masked by accidental
concomitants. And further, parts only or stages of
different diseases often present a likeness to one
another and may convey a very imperfect picture of
the disease. To avoid error, then, the diagnosis
should be based upon the phenomena or features
presented by any given disease as a whole, and not
upon any particular portion of that disease.
It follows, therefore, from what has just been
said, that there are two useful rules to be observed
in making a diagnosis. The first is this :
Ail diseased places, or as many as possible, in a
patient should be carefully examined, and not one
only or one here and there, for the simple reason that
the eruption may be at very different stages of devel-
opment, and therefore present very diverse aspects
in different localities in the same patient.
4 INDICATIONS FOR THE
The object of this examination is to trace out the
origin and course of the disease, ami to link together
the various stages into a complete history which
will answer in its clinical features to an authorita-
tive standard description of the disease whatever it
may be. During this examination special attention
should be directed to the character of the ne \\e-t
developments, and, if there lc none of the kind,
to the extending edge of patches which always
constitutes the most recently developed parts of the
disease, and therefore best portrays the primary
lesion. Complications are more likely to be un-
ravelled by attention to this point.
The second rule is this :
Where the earlier stages in any given case are not
recognizable, careful inquiry should be made into
the history by interrogation of the patient as to the
changes that have occurred before the disease came
under observation, with a view to discover its nature.
Very frequently no fresh developments of the
eruption are taking place and no extension of a
patch has occurred for some time, the malady
having become chronic and indolent and having lost
its typical features ; then the only way of making a
diagnosis is by observing this second rule. For
example, an eczema is characterized mainly by a
peculiar discharge, but the discharging stage is
frequently over before the case comes under the
care of the medical man, and the disease may
present a dry and seal}* appearance, and so be
STUDY OP SKIN DISEASES. 5
mistaken for psoriasis, a fact of not unfrequent
occurrence. And again a disease esentially papular
may have become inflamed and encrusted, and its
true nature may be overlooked, unless the history
be carefully inquired into,
By the observance of these two rules, the elemen-
tary lesion and the characters of the different stages
of any given disease, are ascertained, and with these
the observer should form a picture of the malady,
and so make an accurate diagnosis, just as the child
with his dissected puzzle puts together the animal
or landscape bit by bit, to form the desired whole.
Thirdly, as regards complications. It should
never be forgotten that two or more eruptions may
occur together, and their characters be mingled in
varying proportions. Examples of this are found
in the concurrence of urticaria and eczema, of syphi-
litic rash and chloasma, of lichen and urticaria, of
ecth}-ma and scabies, of purpura and urticaria, of
eczema and scabies or furunculus, and so on. The
fact here indicated should never be lost sight of,
though, on the other hand, multiformity of eruption
is by no means sufficient evidence, yet it is sug-
gestive of the coexistence of two or more distinct
diseases ; especially if scabies and sj'philis be left
out of the question.
Fourthly, as regards modifications of eruptions.
There are many influences modifying the aspect and
general character and behavior of skin diseases,
that have to be taken into account in dealing with
6 STUDY OP SKIN DISEASES.
the treatment. It is necessary for the pli\-i<-i:m
not only to recognize any particular kind an<l form
of skin eruption, but to appreciate the part played
by various concomitant conditions in the individual,
such as diathesis, blood state, special causes induc-
ing an inflammatory character or leading to unu>u:d
pus formation or undue chronicity, and the like.
The evil influences of such conditions must be
thwarted, so as to pave the way for the proper ac-
tion of curative measures directed against the dis-
ease as a disease in the abstract.
A few useful particulars or hints may be intro-
duced here. Diseases of the skin are spread or take
on an inflammatory character, or the changes in the
skin are exaggerated, by exposure to all irritating
agencies, heat, cold, scratching, the contact of acrid
substances of all kinds, as by the handling of lime,
sugar, soda, respectively by bricklayers, grocers,
and washerwomen. So, too, an inflammatory aspect
is given to eruptions by acridities in the blood, as
in gouty or rheumatic subjects, in dyspeptics, and
in those in whom the bile acids or retained ellV-to
matters are present in undue amount in the blood.
Eruptions in strumous subjects are attended In-
more or less pus formation unusual to them under
other conditions. Undue chronicity is occasioned
oftentimes by the existence of nervous or general
debility; for nature then lacks the natural recupr-
rative power, and cannot exert it in aid of the cure.
The questions of age, sex, occupation, mode of
ELEMENTARY LESIONS. 7
life, and the general medical history of the patient,
have to be considered, and will be incidentally re-
ferred to in other places. Attention to the four
indications already discussed will, however, be found
of essential importance in the successful study or
treatment of a skin disease. It may be observed,
however, as regards age, that one essential difference
between the cutaneous diseases of young life as
compared with those occurring in the middle-aged
and old, consists in the fact that the former are
often the result of imperfect digestion and assimila-
tion, whereas the latter are induced by mal-influences
connected with the habits and occupations and wear
and tear of adult life, and degeneration of structure
in the old, and are modified by a number of func-
tional and organic diseases of internal organs, which
have not had time nor opportunity to develop in
The elementary lesions are the types of form and
aspect presented by skin eruptions. The student
is required to know these at examinations, and a
description of them will constitute a general outline
of the pathology of the skin. They are nine in
number, viz. : Maculae or stains ; redness or hyper-
ffiinia ; w heals; papules; vesicles; bullre or blebs ;
8 ELEMENTARY LESIONS.
pustules; squama; or scales ; and tubercles or large
Maculae, or Stains may be
a. Pigmentary in nature when they are due to
the presence of altered coloring matter of
the blood. The stains may be secondary to
other diseases e.g., syphilis ; or physiologi-
cal e.g., pregnancy, or associated with
certain cachexia; e.g., Addison's disease
and leprosj*. The}' may be primary or
idiopathic, and are generally left after hy-
prrrcmia caused by irritants.
b. Chemical, as in the case of stains from iodine,
silver, bile acids, etc.
c. Parasitic, due to the presence of fungus ele-
ments e. g., tinea versicolor.
d. Hffitnorrhagic e.g., purpura due to extra-
Bedness or Hyper semia may be active (arterial)
or passive (venous). Active hypera?mia consists
of redness removable by pressure. It may be punc-
tiform e.g., strophulus; or patchy e.g., roseola;
it is often accompanied by swelling from effusion
e. g., erythema papulatum; by disordered sensation
(pruritis); by slight rise in temperature; it is
often followed by desquamation, and occasionally
exudation. It is caused by local irritants, by
changes in the blood, and by excitation of the
Wlieals are raised hyperannic swellings, that
ELEMENTARY LESIONS. 9
have a palish centre, and rapidly form to as rapidly
disappear. They are typically portrayed in the
sting of the nettle. It is supposed that they are
caused by sudden dilatation of a bunch of capillary
vessels and escape of serosity. They are accom-
panied by heat and great tingling. Some suppose
the vessels beyond the point of dilatation are in a
state of spasm. "Wheals are characteristic of urti-
Papules, or pimples, are little solid raised forma-
tions in the skin. They maj" be due to hyperaemia
of the papillae forming bright red points e. g., in
strophulus ; or may consist of hypenemic, turges-
ccut, and erected follicles e. g., lichen tropicus or
prickly heat ; or due to deposit of lymph or the
like about the walls of the follicles e. g., lichen
planus; or are solid lymph formations or cell
growths in the derma proper e.g., lichen, prurigo,
syphilis ; or may be due to an epithelial collection
in the follicles e.g., pityriasis pilaris ; or may be
formed by hypertrophy of normal structure e. g.,
Vesicles are upliftings of the cuticle into minute
bladders by fluid sweat or serosity; they are
solitary or compound. Solitary vesicles may be
due to sweat between the strata of the horny
layer of the cuticle e. g., sudamina ; if larger
(bnllse) by serosity between the horny and mucous
layers of the cuticle e.g., pemphigus. All others
are compound, and the fluid is collected in loculi
10 ELEMENTARY LESIONS.
formed by the stretchecl-out cells of the ivle
e. g., variola, herpes, erysipelas, blister, eczema.
Further, in sudamina, blister, and pemphigus the
fluid is sweat or serous; in variola, eczema, and
herpes, exudation and pus cells in addition arc
present in the rete, in the papillae, and the corium,
which also gets thickened if the Inflammation
Bullae are simply large vesicles, and their struc-
ture the same. In syphilis bulhe may occur, and
then the contents become sanious, whilst ulceration
is superadded. But usually the bullrc become
tense with clear contents, then their contents get
opalescent, the bullaj become flaccid and shrivel
away, leaving only a red mark, without change in
Pnxtules are elevations of the surface by pus
rapidly formed. They are accompanied by more
inflammation than vesicles, and by a deeper a flec-
tion of the tissues, but the loculi containing pus
are similar in structure to those of vesicles. The
pustules of ectlryma are large and deep seated, and
possess painful indurated bases.
Squamae or Scales are formed of detached epi-
dermic scales. They differ from crusts, which are
formed by dried discharge. Scaliness occurs as a
secondary consequence in all inflammatory skin
diseases ; squama?, particularly as an essential part
of squamous inflammation e.y., psoriasis, pityri-
asis rubra ; and in hypertrophic conditions.
ELEMENTARY LESIONS. 11
Tuberculum is a solid fleshy lump in the skin,
formed by the growth of new tissue. It is HOMOLO-
GOUS e. g , fibroma, keloid, in which the connective
tissue is involved; or HETEROLOGOUS e.g., cancer,
There are certain " Secondary Changes" deserv-
ing of notice. They are
Crusting, in which crusts form by the drying up
of discharge either poured free upon the surface
through the inflamed derma e.g., eczema; or
from ruptured bullae e.g., rupia; or discharged
by an ulcerating surface. They may be due to
sebum collected in masses, or to fungus elements
e.g., favus. Crusts formed from the escape of
serum are thin and bright coloured ; from dried
pus, thick and }'ellow ; from dicing of bullfE, as a
rule, thin and slightly dark ; from drying of sanious
pus from ulcers, thick, dark coloured, and" heaped
up ; from collected dried sebum, flat, easily de-
tached, and greasy; in favus, pulverulent, honey-
combed, and sulphur-yellow.
Ulcer ation is usually the result of cachectic
inflammation, such as the strumous or syphilitic ;
or of new growths replacing the normal textures,
and themselves softening and decaying, as in lupus
and cancer; or it follows the softening of actual
outgrowths from the skin, as in fibroma and j^aws.
Excoriation is the exposure of the true skin
without its removal, and is due to scratching or
rubbing. Its seat is suggestive on the front of
12 CLASSIFICATION, OR DIAGNOSTIC
the forearms and the thighs of scabies, and about.
the clavicles and shoulders of phthiriasis.
Scars are left I)}- traumatic injuries; caustics;
and by certain diseases which ulcerate, such as
variola, furunculus and anthrax, pustula maligna,
strumous and s3-philitic disease. They signify
that the true skin has been removed, and replaced
by " cicatricial tissue."
CLASSIFICATION, OR DIAGNOSTIC CHART OF
The following list, or semi-chart, conveys a good
general idea of the various eruptions met with in
the skin, and regarded from a clinical point of view.
The list comprises:
1. Eruptions occurring in connection
with the acute specific or zymotic dis-
eases, including the variolous rash, roseola vario-
losa, vaccinia and roseola vaccinia, the rashes of
typhus, typhoid, rubeola, rubeola nolha, scarlatina,
glanders, and farcy, and dengue. These are impor-
tant in reference to the differential diagnosis of
2. Eruptions, the local vumife&atiaM OF T>IA-
TIIETIC STATES, comprising scrofulodermn, or scro-
fulous inflammation; xyphilodermata, or syphilitic
eruptions ; leproux eruptions ; framboesia or yaws ;
CHART OF SKIN DISEASES. 13
eruptions occurring in connection with endemic
cachexise, such as the Paranghi disease of Ceylon,
3. Local inflammations, comprising :
Erythemalous inflammation ; chief feature hyper-
ffimia, with or without some slight consequent effu-
sion of serosity.
Erythema, intertrigo, roseola, urticaria.
Catarrh a/, characterized by serous effusion into
papillary layer, running on to sero-purulent dis-
charge and crusting.
Plastic, essentially papular, due to effusion of
plastic lymph into the papillary layer, and sometimes
the deeper dermic layer.
Bullous, chief feature the development of bullae.
Herpes, pemphigus, hydroa.
Suppuratwe, essential lesion pustules, superficial
and painless, or deeply seated and painful.
Impetigo contagiosa, ecthyma, furunculus.
Squamous, characterized by hyperaemia of the
derma, and hyperplastic growth of cuticle.
Pityriasis rubra, psoriasis.
4. Hypertrophic and atrophic diseases :
Epithelial layers mainly affected.
Pityriasis, warts, corns, xeroderma, and ich-
14 CLASSIFICATION, OR DIAGNOSTIC
Connective tissues of the skin specially involved.
Keloid, fibroma, morphoea, sclerodermu.
B. A trophic.
Senile atrophy, linear atrophy, general mar.-i
5. New formations, the characteristic being
the growth of new tissue made up of granulation
cells, or altered and proliferating connective tissue
Lupus, cancer, rodent ulcer.
6. Hsemorrhagic (cutaneous), effusion of blood,
uninfluenced l>y pressure in points or patches.
7. Neuroses, in which the nerves are primarily
disordered, and there are no organic changes at the
Hyperresthesia, anaesthesia, pruritus.
8. Pigmentary alterations, consisting pri-
marily of deposits or alteration of pigment. Pig-
mentation, secondary to other diseases, is not in-
Melasma, leucopathia, xanthoderma, etc.
9. Parasitic diseases, comprising:
Scabies, phthiriasis, eruptions due to gnat
bites, fleas, etc.
Tinea favosa, tinea tonsurans, tinea circinatn,
tinea kerion, tinea versicolor, tinea sycosis,
tinea decalvans, onychomycosis.
CHART OF SKIN DISEASES. 15
10. Diseases of the glands and appendages,
divisible into :
A. Diseases of the sweat glands and follicles* as
excessive secretion (hyperidrosis) ; dimin-
ished secretion (anidrosis) ; altered secretion
(chromidrosis, osmidrosis) ; congestive and
inflammatory (miliaria, sudamina, lichen tro-
picus, strophulus, dysidrosis, hydroadenitis) ;