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 CHAPTER XXVII.
THE SKIN.
It is proposed here to treat only of those diseases of the skin which
may complicate surgical cases or call for surgical treatment.
Dermatitis may be produced by chemicals, caustics, and various
irritants; the former, for instance, by the use of strong antiseptics
upon sensitive skins, and the latter as when fecal matter or urine is
poured over unprotected skin or allowed to remain in contact with it.
Ammoniacal urine will prove irritating, as will also that of diabetes.
When carbolic acid was in general use it gave rise to great trouble
upon the hands of many surgeons, while iodine, iodoform, and other
such remedies, as well as the stronger mercurial preparations, will
cause local symptoms similar to those produced by poison ivy.
This may be prevented, when the condition has occurred, by
applying soothing lotions or mild astringents, with anodynes, in dry
dusting powder or in ointment form. Cocaine in small amounts, or
preferably orthoform with menthol, may be employed in either of
these ways. When an acid discharge is expected the skin should be
protected with an ointment or with collodion or rubber cement; the
latter by drying will leave a thin film upon the surface. Thus around a
fecal fistula the skin will be irritated and more or less macerated, and
should always be thus protected when possible.
Between sixty and seventy drugs are known to produce distinct
forms of dermatitis, such as copaiba, cubebs, the various
preparations of iodine, bromine, and arsenic, some of the aniline
preparations, quinine, etc.; while the various antitoxic serums,
especially that of diphtheria, will sometimes produce a skin
disturbance. In these cases it is only necessary to recognize the
source of the trouble and remove the cause by stopping the drug.
Should dermatitis produce such restlessness as to interfere with the
physiological rest necessary for a wound or fracture an opiate should
be administered.
 DERMATITIS CALORICA.
Dermatitis calorica means the varying degrees of irritation which
may be set up by extremes of heat and cold, continuous or alternate,
as in so-called chilblains. These are often seen upon the feet, but
occur upon the hands and even the face, i. e., in places most
exposed and least supplied with blood. The lesion occurs in patches,
often with livid discoloration, and causes sensations varying from
discomfort to acute pain, almost always aggravated by warmth; while
the skin appears inflamed, though to the touch it usually seems cool.
Treatment.—Chilblains occur most frequently in the anemic and
those with uric-acid diathesis, but may be met at any
time. The constitutional treatment should not be overlooked. Much
pertains to good care of the feet, especially after exposure. After
wetting or chilling they should be dried and then rubbed with boric-
acid talcum powder, containing 1 or 2 per cent. of menthol; this may
be dusted upon the feet, before going outdoors, upon return, and
when there is discomfort.
It will often give relief to immerse the feet in warm water containing
sufficient tincture of iodine to give it a mahogany color; or the feet
may be simply dipped in this and then allowed to dry without using a
towel. The use of hydrogen dioxide diluted two or three times has
been highly commended. If this proportion of dioxide be added to
four or five parts of hot saturated solution of sodium bicarbonate the
efficacy of the measure will be much enhanced. In extreme cases
frequent use of the following formula will probably give more relief
than anything else: Carbolic acid 1 part, ichthyol and tincture
calendula each 4 parts, and glycerin 16 parts. With this the skin may
be kept constantly moistened.
The expressions of dermatitis produced by heat may vary from an
efflorescent rash to complete destruction, and will be treated of
under the following head:

BURNS AND SCALDS.

The term “burn” is applied to lesions produced by flame or dry
heat, while moist heat (i. e., boiling materials or steam) causes
injuries known as “scalds.” Between the two there is but little
essential difference, except that with the latter there is usually
loosening of the hair of the part, and sometimes much loosening of
the epidermis as well, so that it is easily detached in more or less
large patches. Whether heat is relatively feeble but prolonged, or
higher in degree and of shorter duration, the results of dry heat are
about the same. Some differences will exist according to whether the
part is exposed to actual flame or to hot or melted material,
sufficiently hot perhaps to cause complete charring or carbonization
of a part.
 Fig. 97

Burn by electric current from “live wire” carrying 1200 volts. (Original.)

Similar injuries are produced by concentrated caustics, acids, or

alkalies, while such materials as phosphorus or sulphur produce
deep burns. The burn produced by lightning is rarely deep, although
it may be extensive (Fig. 97). Persons coming in contact with live
wires sustain burns which partake much of the nature of the electric
discharge, and are sometimes of a character to deserve the term
“brush-burn.” Formerly burns were divided by Dupuytren into six or
seven degrees, but this classification is too cumbersome and
artificial to be acceptable. Morton’s classification is now everywhere
accepted, by which they are divided into three degrees: (1)
Dermatitis without vesication. (2) Vesication even to the formation of
bullæ. (3) Destruction of the skin, with or without that of the deeper
parts, which may include actual carbonization of a limb.
Burns may vary within the widest imaginable limits. To an
extensive burn of the surface may be added the features produced
by inhalation of smoke, steam, or flame; accordingly the eyes and
the mucous membrane of the nose and mouth suffer, the parts
becoming chemotic and disfigured, so as to make the individual
unrecognizable. Burns constitute one of the most painful and
distressing injuries known to the surgeon, particularly when the area
is large and the case is complicated by injuries which necessitate
more or less prolonged rest in bed. When the body is burned
completely around it is difficult to ensure rest without the use of
anodynes.
Shock is a marked feature of every serious case of burn or scald,
and albumin quickly appears in the urine in these cases. Ulceration
of the duodenum may follow extensive injuries of this kind, and is
occasionally the cause of death. It is to be attributed to a toxic action
produced by absorption of putrid material connected with the surface
sloughing process. A temporary diabetes is sometimes noted.
Laryngitis, bronchitis, and pneumonia may occur from inhalation of
steam or smoke, while the inhalation of flame may bring about a
rapid edema of the glottis, which may necessitate tracheotomy as an
early and emergency measure. It is generally stated that a burn of
the second degree, which even involves half of the surface of the
body, may prove fatal; while this is not invariably the case, it is too
frequently true, and may afford aid in prognosis.
Burns of the second degree are always followed by exudation with
formation of blebs, usually within a few hours. In the more serious
cases the exudate may be bloody. Burns of the third degree are
necessarily followed by more or less gangrene, and this fact affords
the reason for the radical treatment recommended.
Treatment.—By the time the surgeon is called to treat a burn the
first indications are usually relief of pain, and perhaps
stimulation for shock. The circumstances attending such injury
generally leave the patient in an excited mental condition, and for
several obvious reasons it would be well to use sufficient anodyne to
tranquillize and give comfort. An excellent application in emergency
cases is a saturated solution of sodium bicarbonate, or it may be
dusted over the affected surface.
The unpleasant visceral complications that follow burns are due to
absorption of decomposing fluids or tissues, so retained or so in
contact with readily absorbing surfaces as to produce a more or less
violent degree of toxemia. In this way are to be explained delirium,
convulsions, or coma, as well as the ulcerative and toxic intestinal
symptoms which constitute the distressing complications.[17] For this
reason the radical method of prevention is the best; hence whenever
there is any prospect of sloughing, or when even the epidermis is so
burned as to make it appear that it will soon separate, the best
method of treatment is to anesthetize the patient and then with a stiff
brush and antiseptic soap scrub the part and remove everything that
is at all loose, if necessary even using a wire brush, scissors, or a
razor. Beneath every sloughing area toxic absorption will go on, and
it will be far better to have fresh raw and bleeding surfaces than
those which cover sources of danger; the resultant scar will not be
any greater, while the subsequent course of the case will be
favorably influenced. Exquisitely tender surfaces thus have their
sensibility blunted, and the comfort of the patient is greatly enhanced
by thorough cleansing and sterilization; moreover, dressings will not
need to be so frequently changed. A soothing, antiseptic ointment
should be applied; there are few better than the ordinary ointment of
zinc oxide, to which may be added bismuth subnitrate and
orthoform.[18] Treatment of this kind would probably not need to be
repeated, and the duration of the trouble would be reduced to one-
quarter or one-third of the time which would otherwise be required.
When actual carbonization has occurred amputation is generally
necessary. Diluted solutions of ichthyol have proved satisfactory, and
the dressings should be covered with some impermeable material,
so as to exclude the air. Another advantage is that the amount of
subsequent discharge is limited, and thus there is less need for
frequent change of dressings. In extreme cases there is no method
which gives so much comfort and certainty as continuous immersion
in warm water; to this may be added common salt or some other
antiseptic, but the water alone is sufficient, if changed frequently. In
burns covering a great part of the body this treatment is the most
serviceable. It should be employed until the sloughs have separated
and surfaces are granulating and ready for skin grafting. This
implies, of course, immersion of the entire body in a bath-tub, the
body lying on a sheet fastened to the sides of the tub. The
advantage of brewers’ yeast dressing, when sloughs are present,
has been previously emphasized in the chapter on Ulcers and
Ulceration.
[17] The Poisons Produced in Superficial Burns.—The intoxication
which often proves fatal in from a few hours to a few days after an extensive
burn of the surface, with its attendant delirium, albuminuria, hematuria,
vomiting of blood, diarrhea, etc., is very similar to the acute intoxications
produced by bacterial products. The sympathetic nervous system is
seriously involved in both. These toxins are evidently the result of
hemolysis, and it has been shown that they are slow poisons, especially for
nerve tissue, apparently eliminated by the intestines and kidneys, which
thus suffer during the process of elimination. This is a more rational
explanation than the theories of thrombosis or of alterations in the red
corpuscles, which would not account for duodenal ulcers, necroses in the
Malpighian bodies of the spleen, etc. These poisons are formed in the burnt
area and not externally; hence, if this burnt area be removed immediate
death may be prevented, whereas if it be permitted to remain for a few
hours it may be too late. The poisons seem to be produced in the skin, as
the burning of the muscle is not followed by any such degree of intoxication.
They seem to be neither ptomain nor pyridin derivatives, but rather
resemble the poison of snake venom. Pfeiffer believes them to be derived
from the splitting up of proteids altered in composition by the heat of the
burn.
[18] Cargile membrane makes an excellent covering for burns whose
surfaces have been cleaned of sloughs and which are granulating. It adapts
itself perfectly to all irregularity of contour, may be snugly applied and not
changed until necessity requires it.

The disfigurement caused by a superficial burn will fade after a

few months. In cases where the skin has sloughed there is a
tendency to cicatricial contraction as soon as granulations begin to
form, and the tendency then is to the formation of disfiguring scars.
About the limbs the flexor muscles will always overcome the
extensors, and bridle-like deformities will be formed at flexures of the
joints. These are to be prevented so far as possible by two measures
—proper splinting and early skin grafting. About the face splints
cannot be used, but one of the grafting methods should be used.

Fig. 98

Epithelioma following ulcer due to burn. (Lexer.)

A tendency in the scars of old burns is to formation of keloid (see

below) and epithelioma. The writer has seen epitheliomatous ulcers
covering at least an area of a square foot, which had formed upon
the sites of burns received years previously. In one case of this kind
it was necessary to remove the entire upper extremity; even then the
disease recurred and finally destroyed the patient (Fig. 98).
Burns produced by caustic acids or alkalies call for appropriate
chemical antidotes at first and later essentially the same treatment
as that already mentioned. In cases of severe burn there is danger of
neglecting the ordinary rules of general treatment, which consist in
maintaining elimination and nutrition.
 FROSTBITE.
Effects similar to those produced by heat are caused also by cold,
varying from a superficial dermatitis with its surface irritation, its
possible vesication, and, later, desquamation, to complete freezing
of an extremity or a part (e. g., the nose, or the ear), which may be
followed by gangrene. Portions which are not frozen beyond the
point of restoration of vitality undergo a marked reaction and become
swollen and discolored, save in rare instances where they shrivel.
Gangrene is not so immediate a process as in a severe burn, as it
takes a number of hours, sometimes days, for the establishment of
the so-called line of demarcation, by which the dead tissue is
separated from the living. On one side of this line putrefaction goes
on rapidly, as in moist gangrene from any cause; on the other side
there is active circulatory disturbance, with phagocytosis, by which
the line becomes more marked; no portion of tissue on the distal side
of this dead line can be saved. The location of the lesion and the
exigencies of the case will indicate where amputation should be
made. (See chapter on Gangrene.)
Treatment.—A rapid restoration of warmth to the part is most
undesirable. The thawing-out process in a case of
severe freezing should be begun in cold or ice-cold water. Crude
petroleum at a temperature of 60° F. has been recommended as a
substitute for cold water, and immersion may be continuous for
several hours. A rubbing with alcohol and water may be substituted
for the cold water, and then a gradual restoration to the ordinary
temperature of the air. Unless this treatment be skilfully managed
there may be such a rapid reaction as to be painful and even
injurious. By the time there is any active exudation, or putrefaction
has begun, an absorbent dry dressing and suitable antiseptics may
be used.

DERMATITIS OF RADIO-ACTIVE ORIGIN.

The common expression of this form of skin affection is called a
burn. This is something more than its name implies, for it is
understood that the active factors are the ultraviolet rays, or the rays
beyond the color region of the spectrum; that it is not due to the heat
rays is shown by the intense burning that is frequently seen in the
Arctic regions. In the skin of the young and tender, sunburn is
sometimes followed by vesication and desquamation; ordinarily it
simply produces the latter. Any soothing ointment or solution is
usually sufficient for the treatment of sunburn, which should,
however, include avoidance of the exciting cause.
 Fig. 99

“X-ray burn,” result of nine exposures in nine days. Extensive necrosis and
sloughing, with an intractable ulcer. (From collection of Dr. G. W. Wende.)

Much more intense actinic effects are produced by the x-rays,

leading sometimes to complete destruction of the skin. These
phenomena are usually called x-ray dermatitis. They vary from local
discomfort, with itching, loss of hair on hairy surfaces, and partial
anesthesia, with later a glossy appearance, to edema of the cellular
tissue, by which anatomical outlines are effaced. The natural color of
the skin, owing to pigmentation, appears dark. If the exciting cause
be stopped before or as soon as this stage is reached complete
recovery is possible, save that hair does not always grow from the
surface which has lost it. The x-ray treatment should be pushed up
to this stage. Careful management is now necessary, especially
should any surface irritation like chafing occur. That x-ray burn, so
called, may result from x-ray exposure made some time previously
seems to be established by a case reported to me by Dr. L. L.
McArthur, of Chicago, where he had to do skin grafting upon a lesion
of this kind which did not appear until fifteen months after the last
exposure.
The stage of danger is characterized by extreme itching with
multiform eruptions in successive crops, desquamation, formation of
minute vesicles, and ulcers; or the process may be more acute and
the skin begin to slough. Small lesions will become confluent, and
large excavations may be formed. The sloughing process is usually
slow, and by it are produced ulcers characterized by extreme pain
and discomfort and a lack of tendency to heal.
These ulcers are exquisitely sensitive and applications intended
for relief are of themselves most distressing. Everything about such
an ulcer seems sluggish, while small areas which have apparently
healed break down again; healthy scabs are not formed and
granulations are extremely indolent.
Treatment.—In the treatment of these lesions, so long as they are
mild, the surgeon should confine himself to soothing
applications and rest; at the same time discontinuance of x-ray
exposures and even avoidance of light seem to be essential. Any
operator threatened with such trouble should wear thick rubber
gloves during all his work. The local treatment of this lesion is not
essentially different from that described in the chapter on Ulcers and
Ulceration, but the surfaces are often so erethistic as to demand
either anodyne applications, containing such remedies as orthoform,
anesthesin, or even cocaine, or else they need radical treatment with
a sharp spoon.
 Sloughing surfaces should be treated with brewers’ yeast until the
surface has become healthy. Picric acid in solution has been
recommended, a saturated solution being diluted seven or eight
times before using.
The writer has rarely seen any more distressing or obstinate
lesions than presented in some of these cases. In speaking of
epithelioma it has been stated that some of these ulcers are prone to
thus degenerate. It seems an extreme contradiction in physics that
the agent used so frequently in the treatment of superficial cancers
should, when used to excess, produce lesions which themselves
become cancerous. It has been the writer’s privilege to witness
amputation of all of one hand and a large part of the other, in the
case of a well-known colleague, who carried the x-ray treatment to
excess, and until he suffered to this extent. Careful and
discriminating judgment is therefore necessary in the management
of vacuum tubes.
Since radium has come into use it has been found to exercise a
deleterious effect upon the skin. The radium emanations are known
to influence living cells and tissues, and their inhibiting effect upon
the growth of larvae has been well established. The prohibitive price
of radium preparations will make these lesions rare. After exposure
there appears an erythema followed by an active dermatitis, which
so closely resembles lesions above described, in their early stages,
that one description will suffice for both. Moreover, the treatment of a
radium burn differs in no essential respects from that of an x-ray
burn.

ACUTE INFECTIONS OF THE SKIN.

Furuncle or Boil.—A furuncle is a phlegmon having its origin in a
hair follicle and involving a small area of skin
and subcutaneous tissue. The infection is produced by one of the
ordinary pyogenic organisms, which have easy access to the base of
the follicles. Sometimes these organisms are of unusual virulence,
but ordinarily there is a local condition which favors the infection,
while it may be encouraged by a general diathetic condition, such as
diabetes. The lesion is usually single, but may be multiple. Boils
appear sometimes in groups or in crops, and when the condition has
become chronic it is called furunculosis, which may be local or
general. A boil commences as a tender papule, which rapidly
enlarges into a conical swelling, sometimes of considerable size.
Around it there is an area of dusky discoloration, while the apex
becomes quite dark. Pus, travelling in the direction of least
resistance, comes more or less readily to the surface, the apex of
the boil yielding and pus finally escaping, if not evacuated by
incision, usually with a small amount of necrotic tissue, which may
be sufficiently large to justify the term “core.” With the escape of pus
the throbbing pain is much relieved. A furuncle arising in tissues
where swelling is not easily treated, as in the nose, the external
meatus, and also in the axilla and the perineum, will produce an
abnormal amount of pain.
Treatment.—The domestic treatment of boils consists of poultices,
usually made of hot flaxseed. These are always nauseous
applications, and tend to favor the development of similar trouble in
adjoining follicles. An equally comforting application can be made
with a piece of spongiopiline, or a compress, saturated in an
antiseptic solution, and covered with rubber tissues, outside of
which, if necessary, a hot-water bottle may be applied. Inasmuch as
it is tension which produces pain, early incision, which can be made
under a little freezing spray, or with cocaine, will give the greatest
relief. This may be practised even before pus has appeared. After
such incisions the same moist applications may be applied. Incisions
should be made as soon as pus is shown to be present. The
appearance of a whitish point at the apex of the furuncle will always
indicate the presence of pus beneath.
General furunculosis has almost always an underlying diathesis as
a cause, and this should be sought out and treated according to its
nature. In the absence of recognized constitutional conditions the
writer has never found anything equal to aromatic sulphuric acid,
given in 10 or 12-drop doses, with tincture of arnica in teaspoonful
doses, to be freely diluted with water.
Carbuncle.—This differs from a furuncle in the extent of the local
infection, involvement of subcutaneous tissue, and the
amount of necrosis which it produces. It is in most instances a more
serious affair, life often being destroyed by the extent of the resulting
necrosis and the amount of toxins produced. It begins as a local
process, but always with constitutional disturbance, and sometimes
even with a chill. The affected surface rapidly assumes a brawny
hardness, and the infiltration is often extensive; pain is severe and
throbbing; the surface becomes more dusky in appearance,
numerous pustules appear, development of all the features of a
serious carbuncle usually taking place in a few days. Later it begins
to soften and the skin gives way at several points, at each of which a
small drop of pus is discharged, while after removing this there may
be seen white necrotic tissue beneath. The sloughing process
extends deeply, generally to the deep fascia, and this itself
occasionally succumbs. A person may have a distinct carbuncular
lesion where the area primarily involved is not much larger than that
of a five-cent piece; on the other hand, in debilitated or dissipated
subjects, a lesion of this kind may become as large as a dinner plate,
while the sloughing process may expose the underlying bone. This is
often the case on the back of the neck and trunk. A carbuncle may
occur in any part of the body, but is usually seen on the back; when
upon a limb it generally involves the extensor surface. It is especially
serious and dangerous when occurring upon the face, as septic
thrombosis may readily extend to a cranial sinus and rapidly kill. It
was formerly believed that carbuncles of the lip always terminated
fatally; while this is not necessarily true it will indicate the
seriousness of the condition (Figs. 100 and 101).
 Fig. 100

Carbuncle of the neck. (Lexer.)

Treatment.—There are few lesions where both constitutional and

local treatment need to be more judiciously combined. Many of these
patients are diabetic, and then it assumes malignant tendencies.
Others are syphilitics or alcoholics, whom dissipation has reduced to
a condition of serious malnutrition. The urine should always be
examined for sugar and albumin, and whatever indications it may
afford carefully followed. Septic intoxication and infection may so
rapidly depress the already weakened patient as to call for
stimulants and tonics, and pain may be so severe as to justify the
use of anodynes.
The local treatment should consist of soothing applications until
the extent of the plastic exudate has declared itself, after which it
should be more radical. It is better, therefore, to excise under an
anesthetic, the area which ordinarily would require days or weeks to
slough. The most satisfactory treatment is the radical. The knife, the
scissors, and the sharp spoon constitute the best means of
combating this disease. In other respects the treatment was
discussed when dealing with septic infection. Nothing will so hasten
the sloughing and cleaning up process as brewers’ yeast. The
writer’s custom is to make a thorough excision of the affected area
and treat the part with yeast for some days. About the lip and face
the sharp spoon should take the place of the knife, but even there, if
the case be attacked early, tissue can be saved and disfigurement
reduced to a minimum. The method used by some of injecting 5 per
cent. carbolic solution is less satisfactory, although the measure
above recommended is a rather severe operation and usually
requires complete anesthesia.

Fig. 101

Anthrax carbuncle of forearm. (Lexer.)

 CHRONIC INFECTIONS OF THE SKIN.
Tuberculosis.—Most of the skin lesions formerly described as
scrofulous are now known to be expressions of
tuberculosis. So, also, are some of the papillomatous growths and
the chronic ulcers, which do not assume distinctive form.
Lupus vulgaris is perhaps the most common of these cutaneous
lesions, especially in certain parts of the world. It is seen more often
among the young than the old. The lesions begin with a papule,
which becomes the well-known lupus, smaller nodules coalescing
and forming eventually a brownish-red patch, whose borders are
somewhat elevated and scaly. This lesion usually goes on to
ulceration, particularly in those parts of the body where it is kept
moist or frequently irritated. It is in these lesions that a healing or
cicatrizing tendency is seen at one point and progressive ulceration
in another. Ulceration does not always occur, but the papule just
described sometimes undergoes spontaneous absorption, the tissue
atrophying, losing its peculiar skin functions, and the scar being
depressed and scaly.
Lupus vulgaris is to be distinguished from lupus exedens, referred
to under Epithelioma. It is often mistaken for the latter, and a
differential diagnostic table has already been given. (See p. 293.)
Verruca necrogenica, as it used to be called, is now known as
verrucose tuberculosis. It consists of cutaneous warts, surrounded
by an erythematous zone or patch, which tend to break down, and
covered with scabs, intermixed with pustules. The lesion rarely
proceeds to complete ulceration. It occurs especially upon the hands
and exposed parts of those who handle cadavers or carcasses. The
lesion is usually slow and sometimes disappears spontaneously.
On or about the mucocutaneous borders of individuals suffering
from tuberculosis there appear small ulcers, secreting a thin,
puruloid material. These are seen especially about the nose, the
mouth, the anus, and the vulva. These lesions should be regarded
as local infections from a constitutional source. They are often
sensitive, show little tendency to heal, and are sources of danger to
others. They should receive radical treatment.
 Under the term scrofuloderm are included a variety of
subcutaneous tuberculous nodules which spread and involve the
skin. They begin in the superficial lymph nodes. The overlying skin
becomes bluish and gives way, while an ulcer remains which
discharges more or less puruloid material. The edges of these ulcers
are frequently undermined for a considerable distance. These are
ordinarily chronic lesions, which sometimes undergo a spontaneous
recovery, leaving disfiguring and discolored scars, usually irregular
and more or less striped or banded.
Some of the scrofuloderms are included under the erythema
induratum of Bazin, lesions which appear mostly on the calves of the
legs of young women, consisting of deep-seated nodules, which
break down into deep ulcers, having elevated and overhanging
edges. Again, there is the so-called lichen scrofulosorum, i. e., a
papular eruption seen in the young, especially those who show other
evidences of tuberculosis. It consists of rounded groups of papules,
usually on the sides of the trunk, at first bright in color, new papules
appearing as the old ones fade. In addition there is the pustular
scrofuloderm, which crusts over, heals, and leaves small cicatrices.
In all of these lesions the tubercle bacilli can be usually
demonstrated. There are other skin lesions in which no bacilli can be
demonstrated, which are supposed to be due to the toxins generated
in tuberculous foci elsewhere. Hallopeau suggests calling all
tuberculous skin lesions tuberculides and to group them as follows:
(a) Those in which bacilli are present, bacillary tuberculides, and (b)
those arising from tuberculous toxins, toxic tuberculides.
 Fig. 102 Fig. 103

Lupus of skin (hypertrophicus et Lupus vulgaris. (Hardaway.)

exulcerans). Finally healed by excision
and plastic operation. (Lexer.)

Among the latter he describes what he calls folliculitis, i. e., small

papules, firm, at first red, then elevated, becoming nodules,
appearing on the extremities, and gradually producing crater-form
ulcers covered with black crusts, leaving small pock-like scars. This
condition is chronic, lasting years. In these patients the skin is
furfurated, showing a sluggish circulation.
Treatment.—Inasmuch as tuberculous skin lesions tend to spread
and to recur, they need radical treatment—i. e. the sharp spoon, the
scissors, and caustic. Ordinarily it is best to scrape the affected
surface, to trim away all unhealthy edges, and then to apply a strong
caustic for a brief space of time, thereby sterilizing it and searing the