Book review on Skin Diseases by Douglass

Book review by Dr Jubin BHMS,MD(Hom)

Full name of the book : Skin Diseases , Their description, Etiology, Diagnosis and Treatment according to the Law of Similars.
Author : M. E. Douglas, M.D. Lecturer in Dermatology in the Southern Homoeopathic Medical College of Baltimore, Md.
Published by B Jain Publishers Private Limited, New Delhi.
Printed at J.J.Offset Printers.
Edition : 1899
Reprint Edition : 1998.

Preface 
Man is a composite being. Skin is where we notice any imperfection and relief is sought first. The physician who removes them is praised as the successful physician. Its significance is that the patient can speedily judge the effect of treatment. What not to do is an important thing to know in skin diseases. The physician must have a thorough knowledge of the general course and behaviour of skin diseases. Hahnemann’s rule is to treat the totality of symptoms complained by the patient and it is the only rule to cure the patient. The author has been prompted to prepare this work by a conviction of the existence of the urgent demand for a work on Dermatology in our school which must include the advances made and set forth the distinctive character of our therapeutics in a rational and practical manner. It has been for the medical practioneer to his daily dealings of the skin diseases and for the medical student for preparing for examinations. The author has presented in the most practical manner in the fewest possible words and avoided all controversial discussions which are of more importance to the specialist than to the general practioneer.

Contents 

• Anatomy of the skin.
• Some General Observations.
• Classification of the Elementary Lesion.
• Etiology
• Local Dermal Manifestations.
• The Eruptions of Acute Specific Diseases (Zymotic).
• Papular Inflammations.
• Eczema.
• Bullous Diseases and Anomalous forms of bullous eruptions.
• Suppurative Inflammations.
• Squamous Inflammations.
• Diathetic Diseases.
• Hypertrophic and Atrophic Affections.
• Neoplasmata.
• Cutaneous Haemorrrhages.
• Pruritus.
• Chromatogennous Diseases.
• Parasitic Diseases.
• Disorders of the Glands.
• Diseases of the Hair.
• Various lesions not classified.

Anatomy of the Skin 
To know the diseased skin it is necessary to have an accurate knowledge of skin in its different parts. Skin consists of an epithelium resting upon a connective tissue basis. Epithelium consists of many layers of cells called epidermis, the connective tissue basis is called cutis vera dermis or corium. Its surface is thrown up to a number of elevations – papillae which differ in size, form, complexity and arrangement in different regions of the body and can be simple or compound. Blood vessels are abundant forming close network capillaries and loops immediate under the epidermis and none passes into the epidermis. Lymphatics are abundant in the dermis.

Epidermis consists of two parts separated by a fairly sharp line of demarcation, an inner soft layer or Malpighian layer or stratum Malpighii, and an outer harder horny layer the stratum corneii. Differences in thickness is due the variations in the horny layer. The lowermost innermost portion of the Malpighian layer resting upon the dermis consists of a single layer of elongated or almost columnar cells placed vertically with their long axis perpendicular to the plane of dermis. The rest of the cells pf the Malpighian layer are polygonal or irregularly cubical cells. The surface of the cell is thrown into short ridges radiating irregularly from the center of the cell and projecting at the surface and edges as to give the appearance as if armed with prickles and called prickle cells. So the whole Malpighian layer is traversed by minute passages along which fluid can pass between the touching prickles.

The line of demarcation between the Malpighian layer and the horny layer is sharp and distinct. The lowermost, innermost stratum consists of single layer or of two or three layers of cells which unlike Malpighian cells abut are differentiated by form, extended horizontally so as frequently to appear fusiform in vertical sections, by the absence of prickles by their staining deeply with certain reagents such as osmic acid and especially by their cell substance being crowded with large discrete granules of a peculiar nature. Hence the stratum is called stratum granulosum.

The stratum above this is a layer of clear transparent cells which form a transparent seam called stratum lucidum between the stratum granulosum and Malpighian layer below and the horny layer above. The horny layer is variable but nearly always of considerable thickness. The upper, outer portion of the horny layer is continually shed off or rubbed in the form of flakes of variable size. The flake can no longer be recognized a cells but as scales. Every scale is a flattened mass or plate in which no nucleus is seen and which consists not of proteids and other constituents of the cell substance but almost exclusively of keratin. The lowermost portions of the horny layer are composed of elements which is recognized as cells as each contains a nucleus. The karyomitosis seen in the cells of the Malpighian layer multiply by division and there is no evidence of multiplication taking place elsewhere in the epidermis. 

The papillae in the papillary part vary in size and aspect in different parts of the skin. They are pointed or thread like about the fingers and club shaped or rounded over the general surface of the body. On the palm of the hand, about the nipple and the sole of the foot they are largest and longest being often 66 to 1 micron. They are shortest on the face. They are of 2 kinds – Nervous containing nerve fibers ending in tactile corpuscles and vascular containing blood vessels in the form of a loop. Also there are spindle shaped cells anastomosing by processes amongst the connective tissue bundles in the substance of the corium and around the vessels. The thickness of the corium varies. It is thinnest about the eyelids and prepuce, on the face, scrotum and body generally it is thicker. On the sole of foot and palm of hand it is thickest being from 2.25-228 of a millimetre. The corium is well supplied by vessels, lymphatics and nerves. Nerves accompany the blood vessels coming from below and are of 2 kinds – medullated and non-medullated. The former go with the tactile and Pacinian corpuscles and the latter form a fine network below the site in connection with the capillary plexus and are in communication with the site. Non-medullated fibres run with the capillaries which supply the vascular papillae. There is no line of demarcation between the corium above and subcutaneous tissue below.

Sweat gland : It consists of a secretory portion and a conducting portion. The coil of the sweat glands is well supplied by blood vessels in the form of capillary networks and nerves have been traced to the tubes. Though in all regions they are present in abundance in the palms of hands than in others. In the axilla they are of large size and in these they possess distinctly muscular coats.

Sebaceous gland : They are appendages of hairs and are seated in the corium and their ducts open into hair follicle at the neck in case of larger and into the surface in case of smaller follicles.
Muscles of the skin : They are of 2 kinds – Voluntary or striated and involuntary or non-striated. Voluntary are in beard, face and nose ascends to terminate in the corium between the sebaceous follicles and the hairs. Involuntary are more abundant. Over the general surface of the skin bands of fibres are detected in connection with the hair follicle and are called arrectores pili. There muscles exist as single fasciculi .045to .22 of a millimetre in immediate relation to the sebaceous glands where they occur singly or in bundles. They run from corium above to the part of the hair follicle below the glands and end in the sheath of the hair follicle.

Nails and the parts upon which they lie are same the structure as the skin in its different parts only the horny layer is more developed forming the actual nail. Posteriorly the nail is fitted into a groove, the part fitting into the recess is called the root, and the part underlying the nail represents the corium and is the matrix. Between the nail and matrix is the rete mucosum. The bed of the nail consists of the corium with the sub-connective tissue beneath and the rete above.

The epithwelial stratum of skin made of horny and mucous (rete Malpighii ) layers are the special seat of morbid processes. In parenchymatous inflammations as in small-pox the first stage is increase in rete cells and the pustule produced is formed bodily in the rete, its walls formed by altered rete cells, stretched into fibres and enclosing pus cells. In formation of bullae and vesicles rete is chiefly concerned. In non-inflammatory diseases the cells of the epidermis are found to have undergone changes or have arrested in their development as in psoriasis.

Dr. Auspitz draws the following conclusions in regard to the production of diseases from the growth inwards of and resultant changes in the papillary layer.

1. In hyperaemic and inflammatory processes the papillae are succulent and slightly swollen but no modification of form occur unless consecutiveto secondary change in the Malpighii stratum.
2. In simple and lymphatic hypertrophy of the connective tissue matrix as well as in the cell infiltrations of the corium the same law holds.
3. In keratoses or horn producing affections—ichthyosis there is no change in form or size of papillae or it is due to the pressure of the hypertrophied horny layer.
4. The papillomata (warts, condylomata, epithelioma) originate in an active neoplastic process in the rete which penetrates into the hypertrophied connective tissue matrix of the corium. The papillae of the corium has a passive role the elongation and dentritic form occasioned by hypertrophy of the epidermis and the elevation of the surface of the skin is due to hypertrophy of both.
5. An outgrowth of the connective tissue of the skin sonmetimesz occurs but neve5r dependaent ohn the pre-existing paillae.
6. The difference between several forms of papillomata, mwarts, pointed condylomata and cauliform excrescences is nil. But syphilitic condylomata differs from the specific cell infiltration of the corium.
7. Epitehlioma represents exquisitely the types of the hypertrophic growth inwards of the epidermis into the connective tissue matrix.

Cutaneous cancers originate in a morbid change in the cells of the cells of the Malpighian layer and their disordered growth in masses from their inter papillary parts.

Nature and amount of perspiration 
Perspiration 2 forms- sensible and non-sensible. Sensible remains as a fluid on the skin and insensible is discharged as watery vapour mixed with volatile matters. The proportion of insensible to sensible depends on the rapidity of secretion in reference to dryness, temperature and amount of movement to the surrounding atmosphere. Supposing the rate of secretion to be constant, the drier and hotter the air, the more rapidly the strata of air in contact with the body are renewed the greater is the amount of sensible perspiration which by evaporation converted into sensible perspiration. And when the air is cool and moist the total perspiration remains on the skin as sensible sweat. The amount of perspiration given off is affected by the condition of the atmosphere and circumstances of the body. Also by the quantity and nature of food eaten, by the amount of food drunk, character of exercise taken, by the relative activity of the other excreting organs more particularly of the kidney , by mental conditions and the like. Variations also by drugs and diseased conditions. Sweat as a whole is furnished partly by sweat glands and partly by the sebaceous glands. The secretion of the sebaceous glands appears to be fairly constant the larger variations of the total sweat depends chiefly on the varying activity of the sweat glands. When sweat is scanty, the constituents of the sebum influence largely the character of sweat. The sebum consists chiefly of fats and fatty acids and have some form of proteids the sweat glands some of fat and especially of volatile fatty acids.

Taking ordinary sweat the average amount varies from 1-2percent of which two thirds are organic substances. The chief normal constituents are

1. Sodium chloride with small quantities of organic salts.
2. Various acids of the fatty series like formic, acetic, butyric with probably propionic, caproic and caprylic. Lactic acid as a normal constituent is not present in health.
3. Neutral fats and cholesterin in palm of hand where sebaceous glands are present.
4. Urea (10 grams in 24 hours for the whole body).
5. Apparently small amount of nitrogen leaves the body or the skin as a whole but it sis supplied by sebum or epidermis.

In various diseases the sweat contains blood, albumen, urea (particularly in cholera), uric acid, calcium oxalate, sugar in diabetics, lactic acid, indigo (Or indigo yielding bodies lead to blue sweat), bile and other pigments. Ioduine and potassium iodide, succinic, tartaric and benzoic (partly as hippuric) arte found when taken as internal medicines.

Some General Observations.
Errors in diet predispose to certain affections of the skin and in many cases may aggravate the condition. Want of cleanliness is a frequent cause in skin conditions. Also abuse or frequent cause of alcohol, tobacco, stimulants and cosmetics are also causes. A man’s occupation is also a cause for his unhealthy skin. For example bakers , grocers and bricklayers to lichen about the back of hands and cooks to eczema and erythema. The medicines for internal disease also cause an eruption and is often overlooked. Belladonna, carbolic acid, Iodide of potash, antipyrine also produce eruptions. Mental shock and emotions produce eruptions. He must be a good observer and must not only on the surface but also below the skin in the form of abnormal sensations The more accurate and complete description he obtains from his patient, the more accurate diagnosis he will arrive and more successful his treatment. A positive diagnosis is not possible only by a first examination. The prognosis is not as important perhaps the diagnosis as few skin diseases are destructive to life but it is good to the patient to know that it is no danger to life. Causation is of importance and it is to be investigated for restoring the patient to health or to put him in the best possible condition for recovery. The habits, occupation , diet and dwelling places are to be carefully investigated. The treatment varies in persons of different diathesis and the age, surroundings, mode of life and all co-existing diseases must be enquired to get the totality of symptoms. Majority of skin diseases are not preceded or even accompanied by severe constitutional disturbances. 

If fever and malaise is present the acute specific diseases must be doubted. A cute lichen, erythema nodosum, secondary syphilis, acute eczema, pityriasis rubra, acute pemphigus , urticaria and zoster are not accompanied by rise of temperature. One of the great mistakes in diagnosis of skin diseases is dealing them in a piece meal manner. The dermatologist must be able to distinguish between primary and secondary phenomena. The one set are essentially points of the disease and secondary results are the results of disease. Again if searching for the earliest stage of disease when it occur in patches it is necessary to go to the edge of the disease since there presents its most recent characters. The temperament is of much value for the dermatologist. For example lymphatic are prone to eczema, impetigo, intertrigo, pustular aspect of scabies and ringworm, if rheumatic, erythema nodosum. Red-haired subjects are prone to pityriasis of scalp. Some are periodic in their occurrence. Psoriasis, eczema and syphilitic diseases are those which recur. Age is very important in skin diseases. During the first six weeks of life congenital syphilis, intertrigo and seborrhea capitis of scalp occurs In six months syphlitic pemphigus and cancer after thirty and lupus in young and adult life. Parasitic disease in young ages.

Some rules for studying skin diseases are borrowed from Fox.

1. The patient should be examined in full and not in patches as it may lead to an erroneous diagnosis.
2. Mere stages of diseases should be regarded as stages and nothing else. Disease must be dealt within their entireties. All stages are to be given equal importance.
3. A clear distinction must be made between between essentials and accidentals. For example scabies the essence is acarus in the furrow and accidentals is the follicular irritation, the ecthyma, the urticaria which occurs in many diseased conditions of skin is accidental.
4. The dermatological student must consider mere superficial appearances and changes as secondary and primary is that which occur in the deeper parts.
5. It is necessary to give primary attention to the primary anatomical seats of disease.
6. Special attention must be paid to the fact of the character of an eruption being permanent or transient or interchangeable. For example in lichen planus the characteristic lesion is red papule covered by minute scales. This is the sole lesion. It never changes to pustule or vesicle. It may change in eczema or variola. It may be capricious, appears and disappears suddenly as in urticaria.
7. The dermatologist should observe whether the eruption is uniform or multiform. Multiformity implies

a. Co-existence of two or more diseases, here the features of two or more diseases commingled. Example – purpura urticans, pemphigus pruriginosus, impetigo.
b. The existence – 1 lesions if inflammatory – if lesions of pustule present it is of scabies.
2. Degenerative – ulcers and degenerating tubercles of syphilis.

8. Certain differences in diseases in the old and young are to be found and also as the same disease in old and young. In childhood they are uncomplicated by organic diseases of internal organs and profound perversion of nutrition as gout, dyspeptic states, rheumatism etc. In the old they are with degenerative changes in the body. In children they are the result of the misuse of the pabulum supplied to the body or the direct consequence of improper diet. There is a difference in constitutional conditions – diathetic conditions are different in the child, middle aged and adult. In the young it is strumous, in the middle aged and adult syphilitic other than hereditarily transmitted are special privilege of the adult. In the aged the complicating organic diseases of internal organs, blood alterations due to malassimilation, degenerative changes as cancer and those connected with decay of nervous system as cancer. In short as regards kind the diseases of children are the result of malnutrition from deficient or bad feeding and those of adult from malassimilation and those of aged degenerative changes. As regards complications of young with strumous diathesis and of adult with functional derangements of internal organs malassimilations and with diathetitc conditions and those of aged the degenerative changes and nerve paresis.

9. There is difference in cases in skin diseases in private and hospital practice. The constitution in hospital cases are depraved of nutrition and proper food while the other suffers from overfeeding and what of hygiene. The nervous system participates in the private cases in actively helping, controlling and modifying the existing disease and this as the result of the luxury enjoyed by the rich and the busy toil of the middle classes and the effects are felt by the offspring. The old shows nervous symptoms connected with physical decay and the two extremes are marked with uncleanliness as there is less power to resist in both extremes of life.
10. There is differences in the same disease in our and other countries as well as attention must be drawn to several kinds of cutaneous eruptions in our country and abroad.
11. A close relation exists between cutaneous disorders and functional disturbances.
Dr Singer calls attention to this relation by citing examples. In urticaria there is always digestive disturbances and in idiopathic urticaria with the presence of indican in urine. In certain forms of facial acne and senile pruritus he found certain relation between the skin eruption and increased fermentation at the lower portion of the small intestine. The cutaneous troubles may be excited and intensified by internal troubles. The four organs whose derangement excites or intensifies skin mischiefs. They are stomach, liver, kidney and uterus. It is rather intensification than excitation that the practitioner ha to deal with.

12. It is important to be aware of the fact of the bias impressed upon skin diseases by various diathesis – especially the syphiltic, gouty, strumous and the nervous.
13. It is important to examine microscopically the morbid products of skin diseases. It helps to differentiate between various skin conditions like herpes, eczemas, psoriasis and tinea. Inflammatory products are absent in psoriasis while in the other three they are present, Fungus element in eczema marginatum and parasitic diseases mimics eczema and herpes.

Classification of the Elementary Lesions 
Divisions in classifying skin diseases :
1. Macules. 2. Vesicles. 3. Bullae,. 4. Pustules. 5. Papules. 6. Tubercles. 8. Scales.
9. Fissures. 10. Ulcers.
1. Macule is a small circumscribed portion of the skin, in which has occurred some alteration in its color, but without any secretion, effusion, infiltration or change in thickness or consistence. It can be red from congestion, white from loss of pigment or dark or black from increase in pigment. The principal diseases in which it occurs and the chief features are
1. Chloasma : Macule is diffuse and of brownish color and occur on forehead and cheeks.
2. Erythema : Macules of varyingmsize and of reddish color.
3. Ephelis : Macules of yellowish to a dark brown color and occur on exposed parts of the body.
4. Lentigo : Small dark brown macules scattered over the surface on covered as well as uncovered surfaces.
5. Lentigo maligna : Very dark macules from the size of a large pinhead to that of a pea later becoming infiltrating and then ulcerates.
6. Leprosy : Brownish macules of varying size.
7. Leucoderma : White or light pinkish macules surrounded by a dark border.
8. Lupus : Minute reddish- brown or ham colored.
9. Naevus : Red or purplish disappears on firm pressure.
10. Purpura : Red or purplish not disappearing on pressure.
11. Rosacea : Rosy macules.
12. Syphilis : a. Reddish macules appears in early syphilis on chest, abdomen and back. b. Macule like leucoderma in neck in young women in the early period of the disease.
13. Xanthelesma : Yellowish macules about the eyelids.

2. Vesicle is small elevation of the horny layer of epidermis, by the effusion of a serous fluid. The principal diseases in which vesicles are found are
1. Eczema : In patches, minute and closely aggregated, and rupturing in a day or two, except when the epidermis is very thick.
2. Dermatitis multiformis : Lesions of larger size and greater duration asnd with lesions of pustular nature.
3. Erysipelas : Lesions situated on a diffused inflamed base, usually on the face.
4. Erythema multiforme : Associated with macules and patches of erythema.
5. Herpes : One or more groups of three or four vesicles of moderate size and not closely packed like eczema. Lasts for a few days and dry down into a small scale or crust except on the genitals where they rupture promptly.
6. Impetigo contagiosa : Medium sized vesicles lasts a few days and dries to form crusts occurs on any part of the body.
7. Scabies : Small pointed vesicles on hands and fingers.
8. Sudamina : Minute disseminated vesicles corresponds to the sudoriparous ducts.
9. Varicella : Vesicles of variable size which may or may not be umbilicated.
10. Variola : Umbilicated vesicles succeeding papules.
11. Zoster : Vesicles of a good size follow the course of a nerve trunk and seated on inflamed patches.

3. Bulla is a larger elevation of the epidermis by a serous or sero-fibrinous effusion than a vesicle. The principal diseases in which bullae occurs are
1. Erysipelas : Bullae of erysipelas are very large vesicles seated on inflamed base.
2. Leprosy : large bullae usually solitary and appears at intervals.
3. Pemphigus : Large bullae, solitary or in crops at intervals.
4. Pustule is an elevation of the epidermis small or large by a purulent exudation. The principal diseases in which they occur are
1. Acne : Small scattered pustules results from the suppression of papules on face, back and chest.
2. Ecthyma : Scattered of a medium size.
3. Eczema : Closely aggregated of a small size.
4. Dermatitis multiformis : Pustules associated with other lesions.
5. Furuncles : A pustule seated at the apex of an inflamed, painful and slightly elevated spot.
6. Scabies : Isolated pustules especially frequent about the hands and wrists.
7. Syphilis :: Pustules succeeding papules or occurring without them.
8. Variola : Umbilicated pustules which follow vesicles and which were preceded by papules discrete or confluent.
Common features of these three lesions – vesicle, bullae and pustule is a fluid exudation – serous, sero-fibrinous or purulent which lifts up a grater or less extent of horny epidermis.

5. Papule is small solid elevation of the skin. The exudation is of a plastic character. It may disappear in a few days by absorption of the exudation or may be gradually converted into a pustule or may undergo ulceration or may even persist without alteration almost indefinitely.
1. Acne : Papules of varying size, chiefly on face, shoulders, back , chest and frequently changing to pustules.
2. Erythema multiforme : Grouped papules frequently non the extremities.
3. Eczema : Scattered or more or less closely aggregated on arms, inside of thighs and usually with scratch marks.
4. Lichen simplex : Scattered papules frequently met over the entire surface.
5. Lichen planus : Flat, umbilicated papules like papular syphilide.
6. Lupus : Persistent and gradually increasing in size and later becomes tubercles usually on the face.
7. Milium : Minute white papules on the eyelids and contagious skin.
8. Molluscum contagiosum : Umbilicated papules contains a cheesy matter which can be pressed out and pedunculated and differs from acne in this respect which is not pedunculated.
9. Prurigo : Hard and under or in the skin not much elevated easily felt than seen with little change of color and with scratch marks.
10. Rubeola : Red papules covers the entire surface with febrile symptoms.
11. Scabies : Small with other lesions and with their apices scratched off.
12. Strophulus : Red papules in infancy only.
13. Syphilis : More or less generalized reddish or copper-colored may degenerate into pustules or with fine scales.
14. Urticaria : Large papules lasts a few hours only but succeeded at short intervals by others with sharp pruritus.
15. Variola : Discrete or confluent, changes into vesicles and later into umbilicated pustules with severe general symptoms.
16. Xanthelesma : Yellowish and slightly elevated most frequent over the eyes but may occur elsewhere.

6. A tubercle is a solid elevation of the skin larger than a papule and undergoes absorption, pulsation, ulceration or indefinite prolongations. The principal diseases in which they occur are
1. Acne : Tubercles on face, back etc with inflamed bases and terminates with suppuration.
2. Fibroma : Single or multiple and scattered all over the body.
3. Framboesia : Fungous tubercles frequently of large size and very rare.
4. Keloid : Flat tubercles or flattened elevations of the skin with projecting finger like processes.
5. Lentigo maligna : Commences as macules then papules and then tubercles frequently with ulceration.
6. Leprosy : Reddish-brown tubercles on the forehead, ears and other parts of the body.
7. Lupus : Solitary or few reddish-violet tubercles of very slow increase and terminates with ulceration.
8. Morphoea : Flat, light colored tubercles followed by atrophy from one to a dozen –rarely more.
9. Rosacea hypertrophica : Confined to the nose.
10. Syphilis : Copper-colored terminating with suppuration or ulceration 

7. Scales are collections of cells in the stratum corneum collect in undue number and quantity and are loosely or firmly attached to the skin in more or less heaped up masses. When small they are loosely attached like a fine powder or meal scattered over the surface and so called farinaceous and when large thick, heaped up and firmly attached called furfuraceous. The principal diseases in which they occur are
1. Dermatitis exfoliativa : Large scales consisting of flakes of horny epidermis.
2. Eczema : Medium size, scales in the last stage of disease, and frequently preceded by exudation and crusting.
3. Ichthyosis : Adherent thick scales, the disease commences in early life and continues indefinitely.
4. Lupus ertythematosus : Very fine adhering scales situated on a reddened infiltrated base.
5. Pemphigus foliaceus : Large scales due to imperfect formation of bullae.
6. Pityriasis simplex : Fine white scales on a surface, readily exfoliating.
7. Pityriasis rubra : Fine scales on a reddened surface usually generalized.
8. Psoriasis : Thick, adherent, imbricated scales on a reddened infiltrated
surface, more or less generalized.
9. Syphilis : Small scales at the summit of papules or thicker and larger on reddened infiltrated surface more or less generalized.
10. Trichophytosis capitis : Fine scales among hairstumps on round patches.

8. Fissures are solutions of continuity and are characterized by length and depth They rarely extend deeper than horny or Malpighian layers and have a scanty exudation. The princip[al diseases in fissures occur are
1. Eczema : Especially at the flexor aspect of joints, palms of hands and soles of feet.
2. Leprosy : Especially at the extensor aspect of small joints, or between them and usually with anaesthesia.

9. Ulcers are solutions of continuity of three dimensions—namely length, breadth and depth. Their borders are sharp cut and perpendicular to the skin or sloping or overhanging. The principal diseases in which ulcers are found are
1. Carcinoma : Ulceration on the elevated surface of a carcinomatous tumor and underlying tissues hard.
2. Lupus : Ulceration follows one or more tubercles sometimes becomes carcinomatous.
3. Scrofula : Irregular and uneven, frequently with overhanging margins.
4. Syphilis : Round or ovoid with straight punched out margins.
5. Simple : Round or oval with sloping margins.

10. Tumors 
1. Carcinoma (Epithelioma) : Usually solitary, hard and terminates by ulceration.
2. Elephantiasis : Immense tumors of the genitals which rarely reaches the weight of 100 pounds.
3. Fibroma : Solitary or multiple of varying size, sessile or pedunculated without tendency to ulceration.
4. Papilloma : Warty tumors, of varying size and number.
5. Sarcomas : Soft fleshy tumors, bleed readily usually solitary , unless accompanied with melanotic deposit.
6. Steatoma : Enlarged sebaceous glands with retention of secretion.

Pathology
Like all other organs the skin presents same morbid processes like congestion, inflammation, hypertrophy, atrophy, oedemas, infiltrations, degenerations, neoplasms, pseudoplasms, nervous derangements etc and it result in the essential visible characteristics of cutaneous disease.

Etiology
Cutaneous lesions may be primarily from influences or forces from without or those which arise or exist within the body.
1. Influences from without : Temperature and climate, such as are due to traumatisms of various kinds, such as result from parasitic invasions.
a. Excessive heat or direct exposure to sun result in sudamina, lichen tropicus or to erythematous or vesicular inflammation called sunburn or the more trivial affection as freckles or ephelis.
b. Excessive cold result in absolute congelation of exposed portions on the integument followed by death and sloughing of the parts or a less degree of cold excite pernio or chilblains or chapping or fissuring of the skin and depresses the vitality promote an outbreak which would not have otherwise occurred.
c. The parasites both animal for eg scabies, pediculus or lice and leptus and vegetable for eg trichophyton, achorion,
2. Influences from within
a. Affections on the skin which are due to pre-existing lesions of some part of the nervous system as in zoster or leprosy which succeed degenerations of the cord.
b. Gastric irritation resulting from the ingestion of shell-fish results
in urticaria
c. Chronic irritation of the pelvic viscera may be the active cqause of rosacea.
d. Syphilis as the result of cutaneous manifestion of an internal dyscrasia.
e. Ill-nutrition or imperfect assimilation as scrofula or struma.
f. External lesions results from the accumulation in the blood of certain materias morbid. Most of the so called medicinal rashes are due to this. Also it is generated through imperfections in the
digestive, assimilative or excretory functions. One third of the cutaneous diseases are due to this cause.

For nutrition to be carried in certain part there must be
1. Proper state of the blood.
2. Proper condition and behaviour of the tissue to be nourished. Eg: Cancer is an example of disordered tissue life.
3. Right exercise of the controlling influence exerted by the nerves.
Diseases changes in the blood as in zymotic affections, and here the skin disease is only a part of the tissues themselves as in warts, cancer, psoriasis or in the nerves as in pruritus, herpes, pemphigus and urticaria.

Causes that produce altered states of blood current are
1. Poisons of acute specific diseases eg: small-pox.
2. Circulation of special poison animal—syphilitic, medicinal substances – arsenic, dietetic—shell fish give rise to urticaria, roseola and erythema.
3. Dietetic errors in wine drinkers, high livers, non-vegetarians leads to increase in urea and uric acid in the blood.
4. Tuberculous, scrofulous and lymphatic gives rise to impetigo and acne.
5. Gouty and rheumatic diathesis as in lichen agrius.
6. Altered and lowered nutrition from bad living, poverty and misery.
7. Accumulation of excreta in the blood from non-excretion, suppression of natural discharges, kidney disease .
8. Convalescence from severe and lowering diseases by which the body is rendered much less able to resist disease.
9. Climacteric or endemic influences often malarial in nature which acts by deteriorating the system generally.
10. Disorders of the liver and spleen leads to pigmentary deposits in various parts, jaundice and pruritus.
Local irritants leads to alterations in tissue the occupation of bricklayers, masons and washerwomen as a cause of local mischief.
Dyers and those who handle cheap clothing suffer from erythema due to the irritant action of dyes.
Certain tissue peculiarities may be inherited. Father may transmit dispositions in tissues to behave in particular ways directly to the child as a local peculiarity independent of blood state and so psoriasis, cancer, ichthyosis are hereditary.

There are 2 sources of local irritation.
1. Flannel worn next the skin which acts as a mechanical irritant by augmenting the local heat and intensifies the reflex action.
2. Scratching plays an important role in modifying skin diseases and they are accompanied by itching .To relieve itching scratching is the most natural thing to do.
1. When no eruption it creates one.
2. It augments and modifies existing eruptions.
3. When non-contagious, secretion in scratching may be transferred from place to place and if acrid, set up local inflammation and when contagious, scratching is the surest method of inoculation as in the case o contagious impetigo.
Upon the nature of the cause depends the contagious and non-contagious quality of any disease. Parasitic and acute specific diseases are contagious.
Sex has some influence as a cause of disease. Males suffer from psoriasis, sycosis, pemphigus, eczema and epithelioma. Females suffer acne, kelis and lupus especially.
Race also seem to exert influence upon the lesions on the skin.
Whatever be the cause of cutaneous diseases but it is important how the physician treats the affection.
1. Hygeine includes fresh air, wholesome food, cleanliness, exercise and seasonable clothing.
2. Then mechanical, chemical and pharmaceutical remedies and also electricity.
a. Mechanical : Elastic bandage applied to and old, infiltrated eczema of the leg.
b. Chemical : Active caustic applied to an obstinate ulcer
c. Pharmaceutical : Remedies both internally and externally.
1. Internally : Totality of the symptoms manifested in the patient giving stress that skin symptom is only as symptom of the diseased condition.
2.Externally : Formerly lotions and ointments were almost the only means of making external applications but now colloidon, gutta percha solutions (Traumaticin), mixtures of gelatin with glycerin, starch etc and other bland compounds and mixtures as excipients for drugs that we desire to bring into direst contact with the diseases parts.
d.Electricity as a destructive agent (electrolysis) or as a modifier of local nutrition or as an excitant of reflex action plays by no means humble part in the treatment of these diseases.
Homoeopathically treating the disease the physician should not be contented with mere diagnosis and naming the diseases but should study the peculiarities of each condition and the influence exerted upon the general health or condition of the patient on the special lesions in question. Keeping the first and second aphorisms of our master before us we must treat the skin conditions as different disease and treat each patient differently.

Local Dermal Manifestations
Here these are of the nature of local diseases and characterized by inflammation as the primary and essential phenomena. There are 3 leading changes in inflammatory exudation. They are resolution, organization and suppuration. The local inflammations are characterized with hyperaemia and the presence of inflammatory infiltration. They are erythemata, eczema or catarrahal inflammation, suppurative inflammation and squamous inflammation as in psoriasis.

Erythematous diseases include erythema, roseola and urticaria. They are with active hyperaemia in the longitudinal plexus of the skin and its immediate consequences – serous effusion. Febrile symptoms antecede and are relieved by the development of erythema in the exanthemata showing that local skin changes are secondary and only parts of a general disturbance is primary. Also follicular hyperaemia, pellagra and medicinal rashes are included.
Erythema includes multiforma and nodosum with description and therapeutics.
Roseola is of two groups – idiopathic and symptomatic with description, diagnosis and treatment.
Urticaria with description, Etiology, Prognosis, Diagnosis and Treatment.

The Eruptions of Acute Specific Diseases (Zymotic).
They are of contagious nature, of definite course and duration and accompanied by fever, the result of poisoning of the blood by special viruses – one of the effects of the poisoning being the development of certain characteristic eruptions on the skin.
This chapter includes variola, varicella, typhus rash, typhoid rash, Measles, scarletina, erysipelas, rubella and framboesia or yaws.

Papular Inflammations
This section includes lichen planus, lichen rubber, lichen simplex which includes circumscriptus, pilaris and agarius, Phtheiriasis, lichen scrofulosorum, Strophulus and Prurigo.

Eczema
This chapter describes in detail the classification, etiology, duration, location, treatment both local and Homoeopathic treatment.

Bullous Diseases and Anomalous forms of bullous eruptions.
Here it is included which have bullae as the primary and essential phenomena .They are herpes and pemphigus. Herpes includes zoster, labialis and progenitalis with diagnosis and indications. Pemphigus is of 2 varieties – vulgaris and foliaceus with diagnosis and treatment.
Anomalous forms include Hydroa which includes vesiculeux, vacciniforme an bulleux with its diagnosis and therapeutics.

Suppurative Inflammations or Pustular Diseases 
Includes impetigo contagiosa, Ecthyma with causes, prognosis and diagnosis and treatment, furuncles with indications of Homoeopathic medicines, Hordeolum or stye with indications of Homoeopathic medicines, Anthrax or carbuncle with diagnosis, treatment and Homoeopathic medicines and Pustula maligna or malignant pustules with indications of Homoeopathic medicines.

Squamous Inflammations
Includes Pityriasis rubra – the one by Divergie and the other by Hebra with indications of Homoeopathic medicines. Pityriasis Pilaris includes description and Sepia and Natrum ars as the principal internal remedies, Psoriasis includes description with classification according to locations, etiology, prognosis, diagnosis and treatment with indications of Homoeopathic remedies.

Diathetic Diseases 
Includes scrofuloderma with indications of Homoeopathic medicines, syphilis, etiology, diagnosis and treatment with indications of Homoeopathic medicines, condylomata, sycosis and fig-warts with treatment with Therapeutic hints with indications of Homeopathic medicines, leprosy, etiology, prognosis, treatment with indications of Homoeopathic medicines and Morvan’s disease with indications of Homoeopathic medicines.
Hypertrophic and Atrophic Affections

Hypertrophic diseases include 
1. Diseases of the epithelial layer of skin including callosities, corns and horns in which the epithelial tissue is affected.
2. Diseases involving the dermic portion in which the skin is affected  with or without the epithelium. In some cases the papillary layer is  chiefly affected but in connection with augmented portion of the  epithelium as in ichthyosis and xeroderma. In other cases the fibro-cellular tissue of the corium proper is the special seat of change are in the diseases termed scleroderma, keloid, fibroma, elephantiasis arabum and dermatolysis.
3. Diseases seated in the vascular structures including such growths as vascular naevi.  Atrophic diseases including general wasting and senile atrophy and local or linear atrophy which will be noticed together with morphoea.
Hypertrophic affections include Corns with treatment
Hypertrophy of the Papillae and Epithelium conjoined includes  horns and verrucae or warts – with description, Repertory part of verrucae or warts by Dr. Olin. M. Drake is so complete and excellent so the author has transcribed it here. It includes Cause eg: warts confinement following, small : Calc. Then locality in alphabetical order with medicines having no gradation. Then the heading Objectively considered. Subjective Symptoms, then again locality, Objectively Considered and Subjectively. Cause, Locality, Objectively considered and Subjective symptoms.

Ichthyosis –description with classification as simplex and hysterix with treatment with indications of Homoeopathic medicines.
Hypertrophic Diseases of the Corium includes Morphoea with Diagnosis, Prognosis, Etiology and Treatment with Phosphorus as the internal remedy, scleroderma – description and treatment, Scleriasis with treatment and sclerma neonatorum , keloid with description and treatment. Fibroma with diagnosis and treatment. Dermatolysis –description, Elephantiasis with treatment, Milium with treatment, Mammillitis maligna or also called Paget’s disease of the nipple, Ainhum, Naevus – description and treatment with indications of Homoeopathic remedies.
Neoplasmata or New Formations
Includes Lupus – the superficial variety lupus erythematosus, the deeper or lupus vulgaris the deeply destructive form lupus exedens with diagnosis and treatment with indications with Homoeopathic medicines.
Epithelioma – Description, Diagnosis, Prognosis and Indications of Homoeopathic medicines.
Sarcoma – Description and treatment.
Carcinoma – description, various forms like Scirrhus, encephaloma, colloma then melanoma with diagnosis and prognosis and treatment with indications by Homoeopathic medicines and lastly about Rodent ulcer its treatment.

Cutaneous Haemorrrhages
Includes general remarks – classified according to the size and shape. When small in the form of red points called petechiae, when larger and more or less linear vibices, when large in the form of bruises, ecchymosis and when the blood collects in the form of a Distinct tumor called haematomata.
The secondary forms of cutaneous haemorrhage occur in connection with typhus, measles, scarletina and variola and eruption of the several inflammatory diseases of the skin. Other conditions under which cutaneous haemorrhages arise are altered states of the blood current such as impurifications by bile products, stasis of capillaries produced in connection with heart and kidney disease. Where haemorrhage occurs as primary condition it is termed purpura – description, etiology, diagnosis and treatment with indications of Homeopathic medicines.

Pruritus
Pruritus is itching unaccompanied by organic change in the skin. The various conditions in which it occurs are described here. Also pruritus senilis, ani, praeutti, pudenda with treatment and Repertory part with Therapeutic hints ie Sensations and Location.

Chromatogennous Diseases or Alteration in the Pigmentation of the skin.
It may be divided into 3 main groups –
1. Primary or idiopathic result from the application of irritants. Scratching follows in some cases by discoloration – Phtheriasis particularly.
2. Secondary or symptomatic stainings are of 3 groups –
1. Those which follow in the wake of and occur in the same seat as certain skin eruptions.
2. Pigmentations occurring in connection with certain cachexias, the latter being associated with definite diseases of important internal organs.
3. Physiological pigmentations connected with uterine functional changes.
3. Congenital pigmentations in moles and pigmentary naevi.
Those cases in which the pigmentation of the skin is at fault the sole existing disease may be divided into 2 classes.
1. Those in which the pigment is deficient in quantity – Leucoderma or Vitiligo.
2. Those in which it is in excess – Melanoderma
They may be congenital or acquired, generals or local. Seat of change is the rete mucosum.
Vitiligo with description and treatment.
Melanoderma with description and treatment with indications.
Ephelis or sunburn with description. Verat alb, Robinia, Kali carb are useful internal remedies. Bufo indicated when the face tans quickly.

Parasitic Diseases
The parasites are of 2 kinds – animal and vegetable.
Animal parasites include Acarus scabiei or itch mite, the Pediculus or louse, The Cimex lectularius or bedbug, the Pulex irritans or flea and Pulex penetrans or chigoe.
Phtheriasis is the name applied to the affections poroduced by the invasion of 3 well known varieties of pediculus namely the head- louse, body louse and pubic or crab louse with diagnosis and treatment
Psorospermosis is a condition of the skin of varied lesion but characterized by psorosperm which is a living animal parasite which infests the humans as well as the bodies of some of the lower animals and consists of around or oval nuclei, the nucleus occupies but a small portion of the cell, the plasmic portion of which is extremely transparent and structureless.
Scabies with etiology , diagnosis and treatment with indications with Homoeopathic medicines.
Vegetable animal parasites
Favus is a parasitic disease of the skin caused by a minute vegetable fungus which affects the areas where there is hair especially the scalp of children. The fungus on which it depends is Achorion Schonleinii. Its etiology, Diagnosis and Treatment with indications of Homoeopathic remedies are given.
Trichophytosis is an affection of the skin due to the development of a minute fungus by name Trichophyton tonsurans. It bears the name ringworm. There are 4 principal varieties due to differences in location namely capitis, barbae, corporis and genito-femoralis with description, diagnosis and treatment with indications of Homoeopathic medicines.
Chromatophytosis is a parasitic affection characterized by the appearance of yellowish brown spots on the skin with etiology and treatment with indications of Homoepathic medicines.
Onymycosis is used to designate the disease of the nails due to attack on them upon them by vegetable parasites namely achorion with diagnosis and treatment.
Ingrowing toe nails with description and treatment.
Paronychia is an inflammation situated around and beneath the nail terminating in suppuration with treatment.

Disorders of the Glands
Glands include sweat and sebaceous.
Diseases of the sweat glands :
It may be functional or structural.
1. Functional diseases of the sweat glands
1. Hyperidrosis is the term applied to excessive sweating with indications of Homoeopathic medicines.
2. Anidrosis is a disorder of the function of the sweat glands with deficiency or absence of perspiration with etiology, prognosis and treatment with indications of Homoeopathic medicines.
3. Dysidrosis is acute affection of the sweat glands and ducts characterized by vesicular eruptions, usually located and confined upon the palms of hands and occasionally on the soles of the feet and in either case the sides of the fingers and toes are affected with diagnosis, prognosis, etiology and treatment.
4. Osmidrosis is a disease in which the odor of the perspiration becomes so offensive as to constitute the thing to be remedied.
5. Chromidrosis is colored perspiration – (Melanidrosis) Black and the blue (Cyanidrosis) are the same in nature but varying in hue in the two cases.
6. Haematidrosis or bloody sweating is due to the escape into the sweat glands of blood from the capillaries in its turn the result of great excitement.
2. Structural Diseases of the Sweat glands
1. Milaria and sudamina are to be considered as single diseases. Sudamina is a lesser degree of milaria in which the contents of the vesicles being acid and in milaria is amore developed condition in which contents being alkaline with remedies like Bry, Ammonium mur, Ars Alb , Ledum and Urtica urens as internal remedies
2. Lichen tropicus is an inflammatory disorder of the sweat follicles of the skin. It occurs as the result of the stimulant action of heat upon the surface. It is common in hot countries. Prickly heat is an eruption of numerous papillae of vivid red color about the size of a pin’s head without redness of the skin often with vesicles with peculiar tingling and pricking sensation which is intolerable and aggravated by flannels, heat and warm drinks.
3. Hydro-adenitis is an inflammatory state of the perspiratory follicles ending in suppuration.
4. Cystic formations or Obstructed Sweat glands with treatment.
5. Sudolorrhoea is with appearance of one or more slightly reddened , barely elevated and sharply limited patches more or less covered with a few greasy scales with treatment.
Diseases of the Sebaceous glands

Functional including 

1. Seborrhea (Increased secretion ) with chief varieties oleasa, sicca and kerativa with diagnosis and treatment with Homoeopathic medicines.
2. Asteatodes is deficiency of the sebaceous secretion and is seen in hereditary dsyphilis and in badly- nourished or uncleanly folk.
3. Allosteatodes : Alteration in the quality of secretion is the feature of the diseased condition. It may be yellow (Seborrhoea flavescens) or black (Seborrhoea nigricans)

Structural diseases including 

1. Xanthelesma : Hypertrophy of the epithelial lining and adjacent structures of the follicle with fatty degeneration is called Xanthelesma due to the yellow lamina which characterize it.
2. Retention of secretion – Comedones or comedo is the affection of the skin characterized by little black points corresponding to the opening of the sebaceous follicles with treatment.
3. Molluscum is with the development of small, umbilicated papules or tubercles from the size of a bird-shot to that of a pea and sometimes even larger with etiology, diagnosis and treatment.
4. Inflammatory affections include acne with description with indications of Homoeopathic medicine

Diseases of the hair
Diseases of the hair may be divided into
1. Diminished formation of hair may be partial or general, comparative (thinning) or absolute (Alopecia) with description, etiology, prognosis and treatment with indications of Homoeopathic medicines. It may be accidental, congenital or senile.
2. Abnormal Direction.
3. Augmented and diminished formation may be congenital of varying extent, from small localized growths to the extensive tracts covering more or less of the body. Stimulation has tendency to augment the growth if the reactive power is normal. During convalescence a freakish, reactionary growth in odd and unusual places sometimes takes place.

Various lesions not classified.
1. Pernio or chilblains is an inflammation of the skin occur as a secondary effect of cold and appears on the hands and feet with prognosis and treatment with indications of Homoeopathic medicines.
2. Actinomycosis its description and treatment.
3. Wash-leather skin – Dr. Ferrier in 1879 recorded a peculiar condition in which certain metals marked it with black lines. Dr. Emerson concludes that it does not occur in healthy and only in diseases which affect the trophic or secretory nerves of the skin like renal disease, phthisis, erysipelas and hemiplegia. Silver brings out these marks. It precede bedsores. It is of diagnostic value in testing vitality of the skin and experimental site is lumbo-sacrogluteal region.
4. Effects of Rhus tox on the skin : The toxic action is difficult to explain.
1. Its choice of victims many entirely free and many susceptible.
2. It is not necessary to even touch the plant to be severely poisoned.
3. Plant is more poisonous during the night or at any time in June or July when the sun is not shining upon it . Absence of sunlight with dampness seems to favour the exhalation of the volatile principle Toxicodendric acid in the leaves.
Symptoms found in provings are described. Many antidotes recommended are alkaline lotions especially carbolate of soda, alum crud and hypo-sulphite of soda keeps it moist with the agent in solution.
A strong infusion of red Sassafras root is strongly recommended which
applied freely to the pats and gives immediate relief. The fluid extract of serpentaria has been with much success, It is best applied by placing clothes moistened with the extract upon the affected parts without any friction. Internal remedies include Agararicus, Apis, Arnica, Belladonna, Bryonia, Croton tiglium, Graphites, Grindelia robusta, Ledum, Nymphoea, Sanguinaria, Sepia or Verbena urticoefolia.