SYCOSIS. 
CLINICAL LECTURE DELIVERED TO THE SENIOR CLASS. 
BY A. H. OHMANN-DUMESN1L, M.D., 
Professor of Dermatology and Syphilology in the St. Louis College of Physicians and 
Surgeons; Consulting Dermatologist to the St. Louis City and Female 
Hospitals ; Dermatologist to the Alexian Brothers 
Hospital, Pius Hospital, etc. 
[Reprinted from International Clinics, Vol. III., Second Series.] Sycosis. SYCOSIS. 
CLINICAL LECTURE DELIVERED TO THE SENIOR CLASS. 
Professor of Dermatology and Syphilology in the St. Louis College of Physicians 
and Surgeons; Consulting Dermatologist to the St. Louis City and 
Female Hospitals; Dermatologist to the Alexian Brothers 
Hospital, Pius Hospital, etc. 
A. H. OHMANN-DUMESNIL, M.D., 
The patient whom I present to-day illustrates a disease which, 
while it is not uncommon, is of the greatest interest, on account of the 
chronicity which is attached to it and because it is so rebellious to 
treatment. The man before you states that he has had the disease for 
a number of years, and, as you can plainly perceive, it is limited to the 
face, involving only those portions which are bearded. As you see, the 
upper lip, the sides of the face, the chin, and the neck all have a diffuse 
redness, and in addition you find that there are a number of yellowish 
points on a level with the skin, about the size of a large pin-head, each 
of which is perforated by a hair. The disease is one which is emi- 
nently pustular, and each pustule is penetrated by a hair, and a pecu- 
liarity of the affection is that it is found only in men, as it invades only 
the bearded face. If you attempt to make traction upon one of the 
hairs, you will find that it comes out very easily, the pustule bursts, and 
a drop of pus is exuded; whereas if' you exert pressure upon the hair 
you elicit a certain amount of pain. This condition of affairs is one 
which may be easily explained if we consider the pathology of the dis- 
ease. It is essentially a perifolliculitis. If you will recall the anat- 
omy of the hair and its follicle, you will note that the lining membrane 
of the follicle and the external sheath of the hair are continuations of 
the horny layer of the epidermis. This layer penetrates down into the 
follicle up to the papilla, but has no connection with it whatever, and 
it forms a blind pouch external to and above the papilla of the hair. 
Now, the pus which is formed, and the evidence of whose presence is 
elicited by pulling out a hair, lodges in this pouch, and it is on this 
account that we rarely find alopecia following attacks of sycosis, simply 
357 358 
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because the lining membrane of the follicle, which is continuous with 
the external sheath of the hair, is so dense that it will not permit the 
pus to burrow through it and in that way attack the papilla and de- 
stroy it; and as long as we have papillae, hair will be regenerated. It 
is also this condition which accounts for the great difficulty arising in 
curing the disease, for you will readily understand that, as the pus is so 
deeply embedded, it is a matter of some difficulty to cause remedies to 
penetrate deep down into the follicle and assert their influence in its 
depth. 
Sycosis in general has been divided into two great classes, the cocco- 
genic and the bacillogenic. In the case of the former, it is the micro- 
coccus or staphylococcus pyogenes aureus or albus which causes the 
formation of the pus, whereas in the latter it is the bacillus sycosiferus 
foetidus which causes the trouble. The former has the faculty of pene- 
trating much more deeply into the follicle than the latter, but in either 
case the penetration occurs to such a degree that it is a very difficult 
matter, on the whole, to eradicate the disease unless very energetic 
measures are used. So far as the trouble itself is concerned, you will 
find that, as a rule, it begins upon the upper lip, and very often it is 
exclusively limited to that portion of the integument. In cases of long 
standing it has a tendency to spread, the infection being brought about 
by washing, razors, ointments, and other means which tend to dissem- 
inate the micro-organisms from one portion of the skin to another. 
The patient will complain of a sensation of heat, burning, and pain in 
connection with the trouble, and very often, in addition to the forma- 
tion of pustules and general erythema of the skin, tubercular masses 
are apt to show themselves, and increase the pain and discomfort of 
the individual suffering from the disease. It is on this account that 
ointments, as a rule, are contra-indicated in the treatment of this 
trouble, especially those which have lard as a base, for, as you are 
well aware, lard when it becomes in the slightest degree decomposed 
forms a favorable breeding-ground for micro-organisms of that nature. 
The question that arises is as to the manner in which this disease 
may be engrafted. We have in the first place the infection which is 
due to razors. Men will get shaved in barber-shops, and unless razors 
are very carefully cleaned and rendered aseptic, under some circum- 
stances infection may easily occur, especially in those shops where the 
details of cleanliness are not very closely observed, and you will find 
that it is still more easy to transmit the trouble upon those occasions 
(such as Saturday night) when there is a rush of business and very 
little care is taken to have either clean razors or clean, fresh towels for SYCOSIS. 
359 
all the customers. Besides this, if an individual's integument should 
acquire a certain amount of tenderness, or should become excoriated, it 
may become infected, for, as you are well aware, the micrococcus which 
produces pus is constantly floating in the atmosphere, and it will find 
an easy lodgement in the open duct of a hair-follicle, and there com- 
mence to reproduce itself if it find favorable soil upon which to feed. 
Hence it is a matter of some surprise that more cases of this disease are 
not seen than we actually observe. You are well acquainted with the 
morphological characteristics of the pus-producing cocci, as well as 
with their cultivations. The bacillus which is peculiar to this disease 
when cultivated upon potatoes produces a growth which is whitish in 
character, but it has a greenish periphery, and it exhales a most offen- 
sive odor, this being one of the characteristics of the organism. If it 
be inoculated upon a healthy skin, it will very rapidly produce super- 
ficial suppuration of the hair-follicles, and you will find, as a rule, that 
the bacillogenic variety of sycosis is more superficial in character and 
more amenable to treatment than the coccogenic. 
Now as to the treatment. From what I have told you, you will 
sec that two prerequisites are necessary for a successful termination 
of a case: first, to see that the remedies penetrate to the site of the 
trouble; secondly, to use those remedies which are most efficient in 
destroying the cause of the trouble. For the first purpose the best 
method to be employed is probably that of depilation. It is not 
painful, and it has the advantage of emptying all the pustules, con- 
sequently opening the hair-follicles to their widest extent, and in that 
manner affording a more easy entrance to whatever remedial agents 
may be employed. Depilation should not only be employed once, but 
should be repeated as often as a hair emerges above the surface of the 
skin. So far as remedial measures are concerned, those are to be 
adopted which are eminently parasiticidal in their nature,-that is, those 
which have an influence in destroying the micro-organisms which pro- 
duce the trouble. In the present case, after depilation we will order the 
following: apply in the morning a one to five-hundred bichloride of 
mercury solution, which, although it may appear very strong, is still 
not sufficiently so to produce either inflammatory reaction or intoxica- 
tion. This is to be thoroughly applied every morning, and at night a 
thorough application also is to be made of campho-ph6nique. This 
course of treatment is to be pursued until it is judged that a sufficient 
time has elapsed, as evidenced by the appearance of the skin. This 
does not, however, terminate the treatment of the case, for it is very 
likely that a few micro-organisms are lurking in the depths of some 360 
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follicle, and unless some prophylactic means be employed we may have 
a relapse of the disease, spreading over the whole surface formerly in- 
volved, and, in addition to this, the trouble of beginning the whole 
process over again. This is not the only danger, however : there is 
another condition which requires that prophylactic means should be 
employed, and that is the circumstance that when an individual has 
once suffered from sycosis he is much more liable to be attacked by the 
disease upon a subsequent occasion, and, as I have already mentioned, 
micro-organisms are constantly floating in the air, and unless some 
measures be employed to prevent their action these nomad organisms 
might call the disease into being once more, even after a complete cure 
had been established : so that I counsel patients after an apparent cure 
to use a bichloride solution in the morning, say one in one-thousand ; 
the same for the water with which to make their lather when shaving; 
and at night to apply lanoline (pure) to the face, in order to protect it 
from any possible infection. Lanoline, or wool-fat, is one of the fats 
which, far from encouraging the cultivation of micro-organisms, has 
the faculty of destroying them, and is in itself a fair antiseptic. 
Sycosis is often called barber's itch, but it should not be confounded 
with ringworm of the beard, which it resembles to some extent, but 
from which it can be differentiated. You will find that in the latter 
disease the hair is brittle; that pain is elicited when it is pulled out; 
that the pustules are conical, elevated, and that in addition nodular 
masses appear in the skin ; that the whole integument which is at- 
tacked is painfid to the touch ; that the individual suffers darting, 
shooting pains in addition, and that subcutaneous abscesses form here 
and there. It is true these abscesses are small, but still they are 
abscesses; and as further confirmation of the condition which is pres- 
ent, you will find that when the hairs are examined microscopically 
they are infiltrated with spores of the trichophyton, that the surround- 
ings are generally also implicated, and that scrapings when examined 
microscopically will show masses of mycelia and spores. The pustules 
which are present are rather sparse in number, and the pain is due to 
the fact that the follicles have their walls pressed upon through the 
infiltration of the hairs, which themselves are brittle, brush-like at 
their extremities, and easily broken up, so that there would be very 
little difficulty in making a differential diagnosis between the two con- 
ditions. In the case of ringworm, more care should be taken in regard 
to the infection of others, for while sycosis may infect other males it is 
not so contagious as ringworm, which is apt to infect not only other 
males, but any person with whose skin the parasite comes in contact.