Table Of ContentDISEASES OF THE
SKIN
BY
JAMES H. SEQUEIRA
M.D.Lond., F.R.C.P.Lond., F.R.CS.Eng.
Physician to the Skin Department and Lecturer on Dermatology at the London
Hospital ; in charge of Queen Alexandra's Department for Light Treat-
ment ; Consulting Dermatologist to the Radium Institute ; Secretary of
the British Section of the International Association of Dermatology
and Syphilology ; Fellow (late Secretary of Dermatological
Section) of the Royal Society of Medicine ; Editor of the
British Journal of Dermatology ; formerly Physician
to the North Eastern (now Queen s) Hospital
for Children
SECOND EDITION
With 48 Plates in Colour and 238 Text Figures
CALCUTTA
BUTTERWORTH & CO. (INDIA) LTD.
8/2 Hastings St. (P.O. Box 251)
1915
PREFACE TO SECOND EDITION.
THE preparation of this Edition has been delayed by many
extraneous circumstances, and the contributions to dermato-
logical literature during the past three years have been so
extensive that the task of bringing the work up to date has
not been light. Many articles have been re-written and there
have been numerous additions. A new feature is the inclusion
of a series of micro-photographs illustrating the histology of
many common affections. Four new coloured plates have been
added, and one has been replaced. There are also sixty new
figures in the text.
I have to tender my grateful thanks for the kindly reception
given to the First Edition, and have taken advantage of many
suggestions offered in critical reviews.
Dr. H. C. Semon has been good enough to read the proof
sheets, and I tender him my hearty thanks for his care and
suggestions.
To Dr. P. Fildes I am indebted for a valuable note on the
Wassermann Reaction. Mr. F. Hocking, B.Sc, Chief Phar-
macist to the London Hospital, has kindly revised the Formulary
in the Appendix.
J. H. S.
PREFACE TO THE FIRST EDITION.
THIS book began with notes for a course of lectures delivered
in the Skin Clinic of the London Hospital in 1902, and has
gradually grown with the experience of nine years1 teaching.
The work being primarily designed for the student and in the
hope that it may also be of use to the practitioner, I have
devoted special attention to diagnosis and treatment, omitting
historical references and discussions of debated points. The
general arrangement of the chapters is on etiological lines, a system
which modern developments have rendered possible, though still
incomplete. Where such a classification has been impracticable,
the diseases are grouped according to their morphological
characters. If any apology is needed for such an arrangement,
I can only say that I have found it exceedingly useful in
teaching.
Great care has been taken in the selection of the illustrations,
which, with a few exceptions, are from my own cases. I cannot
express adequately my gratitude to Dr. Arnold Moritz for the
time and trouble he has expended over the photographs, taken
direct from patients, in three colours. From these the plates have
been made. Only those who have had experience in this kind
of work can appreciate the enormous difficulties involved. The
black and white illustrations are from photographs taken by
Mr. E. E. Wilson, late clinical photographer at the London
Hospital. For the photographs of the animal parasites I am
indebted to my former clinical assistant, Dr. T. J. Williams, and
to Dr. C. W. Daniels for the illustrations of tropical affections.
For the convenience of students and others desiring to study
more in detail particular subjects, I have appended to each
section a few references to recent articles, and especially to those
in which the literature of the subject is to be found. In a work
of this scope, no attempt has been made to give complete
bibliographies, and I trust that authors whose names are omitted
will pardon the absence of direct references to their work.
viii PREFACE
In conclusion, I have to acknowledge my indebtedness to the
writers in La Pratique Dermatologique, and in Mracek's Hand-
buch, to the text-books of Radcliffe-Crocker, Malcolm Morris
and others, to Unna's " Histopathology," and to the many friends
who have kindly sent me monographs and reprints. In the
tiresome work of reading the proof sheets and for many sugges-
tions I have to acknowledge the great assistance afforded me by
my brother, Staff-Surgeon W. S. H. Sequeira, R.N., M.B. It is
also a pleasing duty to thank my publishers for their courtesy
and generosity, especially in the matter of illustrations.
JAMES H. SEQUEIRA.
MANCHESTER SQUARE, W.
LIST OF PLATES
PLATE PAGE
1. Eczema on a Xerodermatous Skin To face 20
2. An extensive Vascular Nie vus with many Erectile
Tumours . . . . .. 36
3. Xerodermia pigmentosa 52
4. Feigned Eruption (Dermatitis artefacta) 64
5. Bullous Summer Eruption . 76
6. Scarring and Pigmentation caused by prolonged
X Ray Treatment 80
7. Acute Vesicular Eczema 100
8. Erythematous and Squamous Eczema 102
9. Eczema—Weeping Stage 104
10. Scabies 114
11. Ectothrix Ringworm . 138
12. Tinea versicolor . . .. 144
13. Favus of the Scalp 158
14. Impetigo contagiosa (streptococcal) 176
15. Follicular Impetigo of Thigh (staphylococcal) 184
16. " Corona seborrhoica" 208
17. Circinate Seborrhoide 210
18. Acne vulgaris 216
19. Lupus vulgaris 238
20. Lupus vulgaris 240
21. Lenticular Syphilide 288
22. Papulo-squamous Syphilide 290
23. Pigmentary Syphilide 296
24. Gummatous Ulcération of the Nose 300
25. Gumma of Back . 304
26. Congenital Syphilis 310
27. Copaiba Eruption 338
28. Erythema multiforme 354
29. Erythema Iris 356
30. Urticaria 366
31. Purpura 372
32. Urticaria pigmentosa 376
33. Acne rosacea 380
34. Lupus erythematosus 384
35. Lupus erythematosus 386
36. Exfoliative dermatitis 394
37. Herpes zoster 432
XIV LIST OF PLATES
PLATE PAGE
38. Herpes zoster To face 434
39. Pityriasis rosea 444
40. Psoriasis 448
41. Lichen planus 458
42. Lichen planus 460
43. Pityriasis rubra pilaris . 472
44. Pemphigus . 488
45. Epithelioma 534
46. Rodent Ulcer 538
47. Turban Tumour 542
48. Xanthelasma palpebrarum 554
DISEASES OF THE SKIN.
CHAPTER I.
HISTOLOGY OF THE NORMAL SKIN.
THE integument is composed of three layers, the epidermis or
cuticle, the dermis or corium, and the subcutaneous tissue or
hypoderm.
The epidermis is a non-vascular protective covering composed
of stratified pavement epithelial cells. It has four layers—(1)
the stratum corneum, (2) the stratum lucidum, (3) the stratum
granulosum, and (4) the stratum mucosum.
(1) The stratum comeum. The superficial part of the horny
layer consists of cells which are constantly shed. They do not
stain well with osmic acid, and owing to their loose attachment
are sometimes called the stratum disjunctum. The main part
of the stratum corneum is of variable thickness in different parts
of the body. It reaches its highest degree of development on
the palms and soles and is enormously thickened in regions
exposed to pressure. The cells are flattened and lie in lamellae.
They have no nuclei and are composed of kératine, and in the
horny plaques of the workman's hand there is a little eleidine.
There is also an epidermic fatty material which gives suppleness
to the corneous layer.
(2) The stratum lucidum lies immediately under the stratum
corneum and may be looked upon as intermediate in its structure
between the horny and granular layers. It has a homogeneous
appearance, its cells are non-nucleated and devoid of fatty
matter. Eleidine is present in the form of granules.
(3) The stratum granulosum consists of one to three or four
layers of cells, lozenge shaped in section, and containing granules
s. 1
2 DISEASES OF THE SKIN.
of eleidine, staining easily with carmine. The intercellular fibrils
of the mucous layer have disappeared.
(4) The stratum mucosum consists of several parts. The
basal layer, or stratum germinativum, stands on the basement or
hyaline membrane. It consists of cylindrical cells in one or two
layers, with large nuclei showing karyokinetic figures. In this
part of the epidermis the pigment is chiefly developed. Above
it lies the prickle cell-layer consisting of several rows of irregular
polygonal nucleated cells, united by filamentous processes. As
FIG. 1.—Vertical section of epidermis (diagrammatic).
the stratum granulosum is approached the cells become flatter
and fusiform, and finally stratiform.
Pigment. Melanin is a lipo-chrome produced by the nucleus.
Its formation is a normal function of epidermal cell-metabolism.
The corium, or cutis Vera, is composed of dense fibrous tissue
with strands of yellow elastic tissue. It contains the vessels,
lymphatics, nerves, and touch corpuscles, and the glandular
elements and the hair follicles. There are two main divisions—
(1) the papillary layer or pars papillaris, and (2) the pars
reticularis.
(1) The papillary layer consists of finger-like processes which
fit into the irregularities of the mucous layer of the epidermis.
The papillae are supplied with blood vessels, lymphatics, and fine
nerve twigs and touch corpuscles.
(2) The reticular layer is formed of bundles of connective
HISTOLOGY OF THE NORMAL SKIN. 3
tissue. It is continuous with the papillary layer, and there is
no essential difference in the structure. Elastic tissue fibres are
met with in varying quantity in this layer. It is traversed by
the vessels, nerves, and glandular structures, and by the hair
follicles.
It is now believed that the true skin does not normally
produce pigment.
The subcutaneous tissue or hypoderm consists of loose
connective tissue bundles containing masses of fat-cells in their
meshes. The sweat glands and the deep hair follicles reach the
hypoderm.
The vessels of the skin. There are two plexuses, the super-
ficial, forming loops in the papillary layer, and the deep, lying
in the subcutaneous tissue. Branches of supply pass from the
latter to the sweat glands and to the hair follicles and sebaceous
glands. Renaud has demonstrated that the distribution of the
blood vessels in the skin is mapped out into areas which are
supplied by a central deep artery and drained at the periphery
by a plexus of veins. Arterial congestion produces erythema or
redness of the central area, while venous congestion causes a
purplish reticular mottling due to distension of the peripheral
venous plexus.
The lymphatics form two plexuses following the distribution
of the blood vessels. Spaces filled with lymph are found in the
corium, and by the apices of the papillae the lymph reaches the
deeper layers of the epidermis.
The nerYes of the skin are (1) medullated nerve fibres
terminating in touch corpuscles at the apices of the papillae,
and in the Paccinian bodies in the hypoderm : (2) non-medullated
fibres, which pass through the corium and apparently end in the
stratum mucosum. There are three kinds of corpuscle connected
with the nerve terminals—(1) the corpuscles of Krause, occurring
in the conjunctivae and other sensitive mucous membranes;
(2) the Paccinian bodies, chiefly in the hypoderm, and particularly
numerous on the fingers and toes, consisting of a central nerve
fibre surrounded by a core, and with a capsule of concentric
layers ; (3) touch corpuscles, also rounded or oval bodies at the
apices of the papillae.
Huscle. Striated muscle is found in the platysma of the face
and neck. The arrectores pilorum are of smooth muscle ; they
run obliquely downwards to the root of the hair, and have the
1—2
4 DISEASES OF THE SKIN.
power of erecting the hair and of expressing sebum from the
sebaceous glands connected with it. The skin of the scrotum
also contains smooth muscle.
The sweat or coil glands are long narrow tubes extending from
the sweat pore to the subcutaneous tissue. In the epidermis
Hair Shaft
JO ( Stratum corneum—J/^-
i
Stratum lucidum
Q:
Stratum granulosum Touch
Corpuscle
UJ Stratum mucosum
—Nerve
Papillae
Sebaceous
gland
v. Pars
neticular/s
Vessel Medulla of Hair
ί
o Cortex of Hair
υ
Cuticle
Root Sheath
Hair bulb
Papilla
Fat-
FIG. 2.—Vertical section of the skin (diagrammatic).
they are coiled spirally, while in the corium they run nearly
straight and end in a coil which is copiously supplied with blood-
vessels.
The sebaceous glands are usually in relation with the hair
follicles, but on the edge of the lip and on the penis they are
independent of the hairs. They consist of acini opening into
a duct which communicates with the hair follicle. In some parts
