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PRIZE ESSAY FOR 1877 OF THE BELLEVUE 
HOSPITAL MEDICAL COLLEGE 
ALUMNI ASSOCIATION 
BY 
A. R. ROBINSON, M. B., L. R. C. P. and S., Edin., 
SPECIAL PATHOLOGIST TO THE NEW YOKE CITY ASYLUM FOB THE INSANE ; ATTENDING 
PHYSICIAN TO THE BELLEVUE BUBEAU OF OUT-DOOR POOR, CHILDREN’S 
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SOCIETY, OF THE NEW YORK DERMATOLOGICAL 
SOCIETY, AND OF THE AMERICAN DER- 
MATOLOGICAL ASSOCIATION, ETC. 
[REPRINTED FROM THE NEW YORE MEDICAL JOURNAL, 
AUGUS2 AND SEPTEMBER, 1877.] 
NEW YORK: 
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1877. SYCOSIS.' 
Syn.: Sycosis barbse (Celsus): mentagra (Plenck): dartre 
pustule use mentagre, herpes pustulosus mentagra (Alibert): 
folliculitis barbae (Kobner): acne mentagra : lichen menti. 
Definition.—Sycosis is a non-contagious inflammatory dis- 
ease of the skin, characterized by its chronic course ; its limi- 
tation to the hairy parts of the body, appearing chiefly on the 
bearded part of the face; its appearing in the form of pap- 
ules, tubercles, or pustules, and the invariable perforation of 
those by a hair. 
History.—The name sycosis appears frequently in the 
works of writers during the ancient and middle periods ; but 
though they had certainly seen cases of our sycosis, yet their 
description of the disease designated by them with that term 
bears so little analogy to the symptoms of our sycosis, that 
they undoubtedly included different diseases under this term. 
The name sycosis first appears in the works of Celsus, Paul of 
iEgina, and Aetius. 
1 Prize essay of the Alumni Association, Bellevue Hospital Medical 
College, New York, 1877. 4 
Celsus (lib. vi., cap. iii.) describes it as an “ulcus quod 
a fici similitudine av/ccoo-is Graecis nominatur, quia caro in eo 
excrescit.” The later Greeks, however (Aetius, Paul), applied 
the terms av/ca and oy/coi av/ccaSei? to eruptions seated on the 
eyelids, as well as to the sycosis of Celsus. Celsus said it 
appears principally on those parts of the skin covered with 
hairs, and especially on the bearded part of the face (“maxime 
in barba ”); but his description corresponds so little with the 
characters of our sycosis, that it is unlikel}T he was acquainted 
with the latter as a distinct disease. He distinguished two 
varieties of the disease: the one consisting of hard or round, 
and the other of moist and unequal ulcers with foetid se- 
cretion : “ Sub es vero duse sunt species. Altera ulcus durum 
et rotundum est; altera humidum et inequale. Ex duro ex- 
iguum quiddam et glutinosum exit: ex humido pus, et mali 
odoris. Fit utrumque in iis partibus quae pilis contegunter; 
sed id quod callosum et rotundum est maxime in barba: id 
vero, quod humidum, prsecipue in capillo.” 
Paul of (lib. iii., cap. iii.) described it as an erup- 
tion of “ round, red, somewhat hard, painful, and ulcerating 
tubercles of the face; and Aetius (Tetrab. ii., serm. iv., cap. 
14) mentioned it as a skin-affection, differing from acne in 
its greater tendency to ulceration, and in the nature of the 
secretion. 
Plinius (“Hat. Hist.,” lib. xxvi., cap. i.) described under the 
term “ mentagra,” instead of lichen, as previously used by the 
Greeks, a contagious disease which was brought from Asia to 
Italy in the reign of Tiberius Claudius by a Perusian knight, 
Qusestoribus Scriba, and which spread especially in Rome and 
its surroundings, and also, though in a less degree, in other 
parts .of Italy, Illyria, Gaul, and Spain. According to Plinius 
(lib. xii., Epigr. 59; lib. xi., Epigr. 98 ad Basium, de impor- 
tunis basiatoribus), it appeared especially among the rich, 
and owed its spread to certain social customs then prevalent. 
“ Causing little pain, and without danger to life, it produced 
such hideous deformities, that death would have been prefer- 
able. With many of the subjects it did not remain confined 
to the chin, but occupied the entire face except the eyes, 
spread to the neck, breast, and hands, which it covered with 5 
hideous scales. Females were not attacked by the disease. 
The treatment employed was so severe, that it produced 
cicatrices of even greater deformity than those naturally 
resulting from the disease.” 
From this description of the nature and the results of the 
disease, it is clear that the mentagra of Plinius was a very 
different disease from our sycosis, and that it was probably of 
a venereal nature. It is further evident that some forms of 
syphilis were frequently included in the description of sycosis 
by those ancient writers, since they speak of the latter as 
appearing on the anus (“nascitur in ano ”); and from the 
considerable resemblance of some condylomata to the pulp of 
a fig, it is probable that the disease referred to by them as 
occurring in that locality was syphilis, and probably a broad 
condyloma. 
Galen (“De Comp. Med.,” lib. v.), in speaking of acne, 
described fig-like tumors (“ de ficosis tumoribus ”) and other 
eruptions located on the skin (“ de lichenosis in mento tumo- 
ribus ” and “ de menti tumoribus ”); his description, however, 
is so incomplete, that, with the exception of the localization 
on the chin, it could be applied to almost any disease of the 
skin (Hebra). 
From the physicians of the Arabian school, and from those 
of the middle ages, we have no clear description of sycosis, it 
being confounded with other diseases, and especially with 
syphilis. Even such physicians of the seventeenth and eigh- 
teenth centuries as Mercurialis (<£ DeMorb, Curand.,” Yenetiis, 
1601), Lorry (“ Tract. deMorbis Cutaneis,” Parisiis, 1117), and 
Sauvages (“ Nosol. Meth.”), contributed nothing to the subject. 
Plenck (“ Doctrina de Morbis Cutaneis,” Yiennse, 1183) 
put mentagra in the class crustoe, and said : “ Est pecularis sca- 
bies circa mentum in crustas abit.” He recognized four varie- 
ties : M. venerea, leprosa, infantum, and Plinii, but, from his 
description of the different varieties, none of them correspond- 
ed to our sycosis. 
Bateman was the first writer to give us certain correct 
ideas of our sycosis; and the majority of authors since his time 
have followed him, and have applied the term to designate 
that disease for which Bateman, and also the writers of the 6 
present day, use the term, and whose characteristic nature I 
have already given you in the definition of the disease. The 
views of those different authors, including those of Bateman, 
will be given in that part of my essay devoted to a discussion 
of the etiology and nature of the disease. That disease, which 
since the time of Gruby has been called sycosis parasitaria, 
will be discussed in the part devoted to the differential diag- 
nosis of the disease. 
Symptoms.—Sycosis appears only on those parts of the 
body which are supplied with hair, and is almost always con- 
fined to the bearded part of the face ; hence the name sycosis 
menti. Sometimes the eruption is confined to the upper lip, 
at other times to the side of the chin, or a part only of the 
submaxillary region. It has been observed on other parts of 
the body as well as on the face, though its appearance else- 
where is rare. The parts most frequently attacked after the 
bearded part of the face are the eyebrows, then the scalp, 
and, lastly, the other hairy parts of the body, especially the 
axillae and pubis. I have seen but two cases of sycosis of the 
scalp, in both of which the affection was also present on the 
face. In one of the cases eczema of the scalp preceded and 
accompanied the sycosis; in the other, the sycosis invaded 
the scalp by extension ex contiguo from the beard. This lat- 
ter patient had an exceedingly severe attack of the disease, 
producing destruction of tissue, and leaving cicatrices as ex- 
tensive as in many cases of lupus. Except in such cases as 
this latter, in which the disease spreads ex contiguo from the 
bearded part of the face, sycosis of the scalp will be found 
almost always preceded by a greater or less degree of some 
form of inflammation of this region, and generally by an 
eczema. Even when seated on the face, in the majority of 
cases, it has been preceded by a chronic moist or dry eczema. 
An eczema, however, does not precede or accompany the 
eruption in every case ; sometimes only a chronic hypersemia 
is present, and in a third class of cases there is nothing abnor- 
mal to be noticed in the skin previous to the outbreak of the 
eruption, although an irritable condition of the tissues, insuf- 
ficient to produce inflammatory changes in the part, is present. 
This last statement will be defended when I discuss, later on, 7 
the cause of the disease. "When it appears primarily on the 
upper lip, it is usually preceded by a nasal catarrh, the dis- 
charge from the nose irritating the skin, and producing a con- 
gestion or an eczema, which, in its turn, is followed or accom- 
panied by sycosis. Sycosis, situated in this region, mostly 
remains limited in area, and rarely extends to the cheeks. 
Nasal catarrh—a disease which differs from eczema only in 
having its seat on a mucous membrane instead of a cutaneous 
surface—has naturally the same effect on the tissues under the 
inflamed mucous membrane ; consequently, sycosis is frequent- 
ly combined with the nasal catarrh in those parts of the nasal 
mucous membrane provided with hair. Sycosis of this re- 
gion differs from that of the beard only in the duration of 
the disease, sycosis in the nose disappearing upon cessation of 
the catarrh; or, in other words, the disease in that region is 
generally acute, disappearing upon subsidence of the catarrh, 
as, afterwards, there is not sufficient irritation to produce the 
disease; while sycosis of the beard is a chronic affection, 
continuing generally, unless properly treated, months, or even 
years. 
Sycosis of the beard is generally ushered in with severe 
local symptoms. It is preceded or accompanied by a feel- 
ing of heat, smarting, and a painful, pricking sensation, 
with swelling or intumescence of the part. Sometimes 
the attack is so severe, and the local inflammation so 
great, as to produce swelling of the lymphatic glands in 
the neck. The eruption makes its appearance in the form of 
papules and tubercles of greater or less size, ranging from 
that of a millet-seed to that of a pea, which are isolated or 
collected in groups. In acute cases, and with the first out- 
break of the eruption, the tubercles are generally seated near 
each other; but in chronic cases the local symptoms are not 
so severe, and the papules and tubercles are oftener isolated 
and fewer in number. In subsequent outbreaks new papules 
and tubercles appear, and, if seated in the same locality, may 
unite with the former ones and form connected infiltrations. 
This occurs only where the eruption is seated on parts thickly 
studded with hairs, and a considerable number of the follicles 
are affected by the inflammation. The eruption from a single 8 
outbreak rarely appears over a large surface, but generally in 
patches of limited extent; the patches in subsequent attacks 
often occupying a different portion of the face from that dur- 
ing the preceding outbreak. The papules and tubercules are 
of a red color, somewhat conical in shape when isolated, and 
generally, though not always, raised above the level of the 
skin. These papules and tubercles increase in size, pus col- 
lects on the summit, and afterward the greater part of the 
papule is gradually converted into a pustule. The length of 
time occupied in the transformation from papule or tubercle 
to pustule differs in different individuals, in the different 
outbreaks of the eruption on the same individual, and in the 
different papules and tubercles which make up a single patch. 
For instance, in scrofulous individuals the pus formation pro- 
ceeds slower than in robust individuals, though it is more 
abundant; in chronic cases the papules change slower than 
in acute attacks ; and lastly, pus collects usually more rapidly 
in the perifollicular region of stiff hairs than in that of fine 
ones. Thus it happens that, when a patient presents himself 
for consultation, papules, tubercles, and pustules are found 
present in varying proportions on the affected part; and if the 
eruption has already lasted several days, the majority will 
consist of pustules. Each papule, tubercle, and pustule, 
whether raised above the level of the skin or not, is perforated 
through its centre by a hair. The perforation of the tubercles, 
papules, and pustules, through the centre by a hair is charac- 
teristic of the disease, and it is upon the presence or absence 
of this perforation that the greatest reliance is to be made in 
forming a diagnosis between sycosis and the other diseases 
liable to be confounded with it. If perforation is not present, 
then the disease is not sycosis. This affords a ready explana- 
tion why sycosis is confined to the hairy parts of the body, as 
perforation of the papules by hairs is necessary to constitute 
the disease. When the tubercles and papules have become 
pustules, which usually occurs in from two to ten days, a scab 
forms on their summit, if not prevented by shaving or some 
emollient application, both of which would remove or pre- 
vent the formation of any scab that might otherwise form. 
The scabs in uncomplicated cases are generally thin, slight, 9 
and isolated, differing in this respect from those of impetigi- 
nous eczema, which are thick and form a large mass. Upon 
removal of the scab with the forceps, a circular funnel-shaped 
excavation is observed, having a hair exactly in the centre, 
and the base tilled with pus. On account of the inflamed 
and irritable condition of the tissues surrounding it, great 
pain is caused in the extraction of the hair during the papular 
stage of the disease ; but in that period of the pustular stage 
when the pus or serum which surrounds the follicle has 
penetrated the follicle-sheaths and separated the hair from its 
normal surroundings, or has destroyed those latter, as is gen- 
erally the case in the pustular stage, no pain arises from ex- 
traction of the hairs, as they lie loosely in the follicle. In fact, 
if not extracted, the ever-increasing accumulation of pus 
around and within the follicle, and its subsequent movement 
to the surface through the space previously occupied by the 
hair-sheaths or the tissue immediately surrounding them, final- 
ly expels the hairs, and the part heals, with or without cica- 
tricial tissue. The resulting cicatrices are sometimes flat, and 
sometimes raised above the level of the skin. If the pus has 
escaped through the opening of the follicle, the part will 
probably heal without a cicatrix forming. If, however, we do 
not extract the hair as soon as this can be done without caus- 
ing much pain, and thus allow exit to the accumulating pus, 
there is danger of destruction of the follicle, and consequent 
permanent alopecia. If the hair remains until it lies loosely 
within the follicle, there is danger of the inflammatory prod- 
ucts destroying the base of the follicle and the seat of origin 
of the hair. This condition of the hairs is met with only in 
an advanced period of the pustular stage; for during the 
papular stage the hairs are unchanged, and sit firmly within 
the follicle. 
The amount of suppuration differs greatly in different sub- 
jects. In those of a strumous constitution it is much greater 
than in robust individuals. Sometimes the amount of sup- 
puration and cell-infiltration in the skin is so great that com- 
plete destruction of the cutis, hair-follicles, sebaceous and 
sweat glands occurs, followed by cicatrices as extensive as in 
many cases of lupus. Such a destruction of tissue, however, 10 
rarely occurs, and the only evil result generally of even a long- 
continued chronic sycosis is destruction of the hair-follicle and 
sebaceous glands, with consequent permanent alopecia. Even 
this, to any considerable extent, is not a frequent occurrence; 
yet a limited number of follicles are usually destroyed if the 
suppuration has been at all extensive and epilation not per- 
formed at the proper time. When the papules are isolated, 
and no eczema is present, the inflammation is limited to the 
immediate neighborhood of the follicles. The tissue between 
the pustules is therefore sometimes natural; but, as a rule, 
there is hyperaemia or a slight dermatitis, with desquama- 
tion, especially if the pustules are not too widely separated 
from each other. In cases of long standing this condition of 
chronic dermatitis is nearly always present, and increases the 
irritability of the skin. The area of surface occupied by the 
eruption at a single outbreak varies greatly. Sometimes it is 
very limited; at other times, and more especially in acute 
cases, it can occupy the entire cheek. In chronic cases often 
only a few isolated pustules make their appearance here and 
there, unaccompanied by the heat, pain, and swelling which 
usher in acute attacks. When seated on the upper lip, the 
eruption is generally limited to a small patch, not larger than 
a ten-cent piece, situated near the middle line, and nearer the 
nasal orifices than the mouth. If the patient does not shave, 
such a patch appears red, somewhat swollen, and covered with 
a crust. Upon removal of the latter, a few papules or pustules 
are found, each perforated by a hair, and a slight discharge is 
usually present. Such a patch is generally a combination of 
eczema and sycosis, shows but little tendency to spread, and 
is exceedingly rebellious to treatment, unless the nasal catarrh, 
from which it usually has its origin, is previously cured. 
As I have already said, the papules, tubercles, and pus- 
tules are generally isolated ; but sometimes they are collected, 
and accompanied by infiltration in the intervening skin and 
subcutaneous tissue. This occurs only when the affected part 
is provided with numerous hairs, or in acute attacks accom- 
panied with considerable local inflammation. When they are 
thus united by infiltrations, papules or tubercles no longer 
arise in that region as long as the infiltration exists to any 11 
considerable extent; but new pustules arise in the infiltrated 
tissue, and the pus, passing to tlie surface, becomes dried up, 
forming brownish or yellowish scabs, perforated with hairs. 
On removal of these scabs, we find underneath, as in the case 
of the scabs formed on isolated pustules, circular, funnel- 
shaped excavations, corresponding in number to that of the 
follicles, and each excavation is perforated by a hair. This 
circular, conical excavation, containing pus at its base, and 
perforated in its centre by a hair, is found in nearly all pus- 
tules present in this disease, whether isolated or collected, 
upon removal of the pus or scab from the surface. If the hair 
has been extracted in removing the crust—a not unfrequent 
occurrence, as the hair sits lightly in the follicle in this stage 
of the disease—then naturally it will not be seen penetrating 
the excavation. With this exception, however, this perfora- 
tion by a hair is always present, and should be sought for in 
every case upon removal of the crusts or scabs, if there is any 
doubt about the correct diagnosis. Where the beard is 
allowed to grow, and the natural course of the disease is not 
interfered with, scales or scabs are always present during the 
pustular stage; but if the part is frequently shaven, their 
formation is prevented, though in other respects the symp- 
toms of the disease remain unchanged. Papules, tubercles, 
and pustules, will be present as usual, and the perforation by 
a hair will be much more easily recognized than when scabs 
are present. When the hairs are finer, isolated papules are 
present, instead of tubercles and infiltrations. “ Sometimes 
productions resembling placques muqueuses arise from the 
surface of the ulceration in the course of the disease, or the 
confluence of several deep-seated pustules may produce an ab- 
scess resembling an anthrax, having several openings on the 
surface. In other cases granulations appear on the surface, in 
the form of the caro luxurians ” (Hebra, l. c., p. 610). This 
statement of Ilebra is more appropriate for cases of parasitic 
disease of the beard than for sycosis, since it is exceedingly 
rare to see such abscesses, or any granulations bearing any 
resemblance to the pulp of a fig, in the latter disease, while 
in the former they are not uncommon. Sometimes the pus- 
tular formation, especially in strumous or ill-fed persons, is so 12 
great as to produce scabs similar to those in impetiginous 
eczema. In chronic sycosis, or, better said, in sycosis of 
long standing, there is more or less induration and thicken- 
ing of the affected part, from the products of the constantly- 
recurring inflammation. We have thus seen that the eruption 
in sycosis differs in appearance in different subjects, according 
to the general condition of the patient, whether the hairs are 
strong or fine, long or closely shaven, and whether the pap- 
ules, tubercles, and pustules, are isolated or collected. 
Sycosis is a chronic disease lasting weeks, months, or 
even years, and is prolonged by successive outbreaks of the 
eruption arising before the previous one has disappeared. 
These successive outbreaks occur generally at intervals of 
from seven to fourteen days, and the eruption follows the 
same course as the first outbreak; therefore the description I 
have already given of the primary outbreak will answer for 
that of the subsequent attacks. A successive attack does not 
always appear on the same place as its predecessor, especially 
in chronic cases, different parts of the face being often the 
seat of different outbreaks of the eruption. A notable ex- 
ception to this is the case of sycosis of the upper lip, where, 
as I have already mentioned, the disease shows no tendency 
to spread, but remains confined to its original seat for months, 
and even years. The disease in this region, however, is a com- 
bination of eczema and sycosis, the latter having its origin in 
the inflammation constituting the eczema. The eczema, in its 
turn, is produced and continued by the irritation arising from 
the nasal secretion in coryza passing over the affected surface. 
This nasal secretion irritates only a small portion of the upper 
lip, and unless some portion of the remainder of the tissue of 
the bearded part of the face is made irritable by other means, 
as shaving, cosmetics, heat-rays, etc., the tissue- will not be 
disposed to the production of sycosis, and the eruption will 
remain limited to the only spot irritated. This affords an ex- 
planation why sycosis of the upper lip usually remains con- 
fined to the limited area I have already described. 
Generally the disease is milder in summer than in winter. 
If cured, it is very liable to return in a few weeks or months, 
and especially in autumn. If recovery takes place spontane- 13 
ously, it does so by tbe cessation of tbe successive outbreaks 
by which it was prolonged, and by the gradual healing of the 
pustules, and growth of new hair from those follicles not 
destroyed by the suppurative inflammation. There is always 
complete replacement of the lost hairs by new ones, except 
where the follicles have been destroyed. 
I have given, in the foregoing pages, the natural history of 
sycosis with its usually long chronic course, sometimes lasting 
for thirty years, and its spontaneous termination in either 
complete restitution of the part to its normal condition, or in 
general or partial alopecia; and sometimes, though rarely, in 
destruction of the epidermis, cutis, hair-follicles, sebaceous 
and sweat glands, and substitution of those structures by cica- 
tricial tissue. Divested of its unusual characters, sycosis may 
therefore be briefly described as follows: It is a chronic disease, 
confined generally to the bearded part of the face; it makes 
its appearance in the form of papules or tubercles, which 
after a few days become pustules, and each papule, tubercle, 
and pustule is perforated through its centre by a hair. This 
eruption, after having completed the pustular stage, dis- 
appears, and is succeeded by a new eruption similar in all re- 
spects to the primary outbreak, and is in its turn succeeded by 
a similar eruption, and so on, so long as the disease continues 
to exist. Upon cessation of the disease the part regains its 
normal character and appearance, except a slight partial alo- 
pecia from destruction of a few hair-follicles. 
Etiology and Nature.—In giving the history of the dis- 
ease, I quoted not only the names of the writers previous to 
the time of Bateman who made use of the term sycosis, but 
also gave their descriptions and views of the nature of the 
disease referred to by them under that term. From their 
descriptions it follows that, if they included our sycosis under 
that term, they confounded it with other diseases, and espe- 
cially with syphilis, since their descriptions correspond with 
no one special disease known to dermatologists of the present 
day. Since the time of Bateman, however, the majority of 
authors agree in the use of the term sycosis, as applied to the 
disease whose symptoms I have already described. I have, 
therefore, reserved for this part of my essay a statement of 14 
the views of those writers on the nature and cause of the dis- 
ease, at the expense of leaving the part devoted to the history 
of sycosis incomplete, since I wished to discuss the correctness 
of some of them, after giving the results of my own observa- 
tions, and the views I have formed from them. I will first 
give the views of those authors, and return to a discussion of 
them, when stating the conclusions I have formed from my 
own studies. 
Bateman (“ A Practical Synopsis of Cutaneous Diseases,” 
7th ed., London, 1829, p. 403) classed it with acne, among 
the tuberculse, and accepted the two species of Celsus (Sy- 
cosis menti et capilitii). He believed it is an inflammation 
of the hair-follicles and sebaceous glands, and that it dif- 
fers from acne indurata in its seat being exclusively on the 
bearded part of the face; by the softer, more numerous, and 
clustered tubercles, and by the ulceration which they tend to 
produce; also from the porrigo of Willan, by the nature of 
the tumors, age of the patient, and absence of contagion. 
Alibert (“Precis Theorique et Pratique des Maladies de la 
Peau,” tome i., Paris, 1818, p. 263) was the first who said 
that sycosis approaches acne in its nature, and treats of it 
under the title, Dartre pustuleuse mentagre; also Herpis pus- 
tulosus mentagra. lie classed it with his species varus, which 
included the diseases of the sebaceous glands. He believed 
that the situation, the apparent similarity of cause, the course 
of the disease, and the age of the patient, show their close 
relation. He believed that it is an inflammation of the seba- 
ceous glands and hair-follicles, caused by the use of bad 
razors, or from suppressed liasmorrhoidal flow. He mentioned, 
also, that it sometimes spreads to the mucous membrane of 
the mouth, where no hair-follicles exist! 
Cazenave (“ Abrege Pratique des Maladies de la Peau,” 
4th ed., Paris, 1847, p. 312) put it in the order “ pustulae,” 
and denied its contagious nature. Before 1841 he said it fol- 
lows general inflammation of the skin, but since that time 
that it is an inflammation of the hair-follicles, and arises from 
the use of bad razors. He believed it is a pustular disease, 
and that any papules or tubercles present are secondary to 
the pustules. 15 
Rayer (“ Traite Theorique et Pratique des Maladies de la 
Peau,” tome i., 2d ed., Paris, 1835, p. 661) classed it with the 
acne eruptions, and said it arises from exposure to high tem- 
perature, and from the use of bad razors. 
Plumbe (“ A Practical Treatise on the Diseases of the 
Skin, ’ 4th ed., London, 1837, p. 91) said it is nothing more 
than acne, or follicular obstruction and its consequences, oc- 
curring on parts covered with hair, and differs from acne only 
in the existence of hair on the part, and its consequence in 
aggravating the disease. He gave a very good description of 
the disease, and was the first to recommend epilation in the 
treatment. He believed it to be an inflammation of the hair- 
follicles and sebaceous glands, and drew attention to the in- 
variable perforation of the papules by a hair. 
Bazin (“Affections Cutanees de Nature Arthrique et Dar- 
treuse,” 12th ed., Paris, 1868, p. 226) thinks there are five 
kinds of sycosis, viz.: Artificial, parasitic, syphilitic, arthritic, 
and scrofulous. He denies the existence of the microsporon 
mentagrophyta, and says the fungus found in the so-called 
parasitic sycosis is that of tinea tonsurans. The syphilitic and 
scrofulous varieties he regards as cases of pseudo-sycosis, be- 
cause the inflammation is not limited to the hair-follicles. In 
true sycosis, he says, the inflammation is limited to the hair- 
follicle, and does not extend to the subcutaneous tissue. He 
believes the predisposing cause of cases of true non-parasitic 
sycosis is either an arthritic or scrofulous condition of system, 
and the exciting causes anything that irritates the skin, as 
cosmetics, heat, shaving with dull razors, etc. 
Kiichenmeister (“ Die in und an dem Korper des lebenden 
Menschen vorkommenden Parasiten,” Leipzig, 1855) said all 
cases of sycosis are parasitic. 
Hebra (“ Lehrbuch der Haut-krankheiten,” Bd. i., zweite 
Lieferung, zweite Auflage, Erlangen, 1874, p. 605) places sy- 
cosis among the acne eruptions, of which he gives three va- 
rieties : Acne disseminata, acne mentagra seu sycosis, and acne 
rosacea. He says it is a local disease of the hair-follicles, the 
cause of which is unknown. He gives an excellent descrip- 
tion of the disease, and always denied the existence of a para- 
sitic sycosis. Last year, however, he saw a “ typical case ” of 16 
the sycosis parasitaria of authors, and it is probable he no 
longer denies its existence. 
Tilbury Fox (“ Skin-Diseases,” 2d American edition, 
New York, 1873, p. 502) calls it a parenchymatous inflamma- 
tion of the hair-follicles, with the ordinary results of long-con- 
tinued congestion. He says it is an independent morbid state 
of the actual hair-follicle itself, the cause of which is doubt- 
ful, though external irritants, as shaving and long-continued 
exposure to heat-ravs, can produce it in persons “out of 
health.” 
Nelligan (“Diseases of the Skin,” 4th American edition, 
Philadelphia, 1864, p. 275) considered all cases of sycosis as 
parasitic. 
Wilson (“ Lectures on Dermatology,” London, 1871, p. 136) 
says it is an inflammation of the hair-follicles. There are sev- 
eral varieties of the disease, and among them is observed the 
phytiform degeneration of the epithelium consequent on de- 
ranged development and nutrition of the tissue. 
Hutchinson (“ London Hospital Reports,” vol. iii., 1866, p. 
389) denies the existence of a parasitic sycosis. 
McCall Anderson (“ Eczema,” 3d ed., London, 1814, cap. 
xii.) describes under the term eczema pilare faciei appear- 
ances which correspond exactly with those of sycosis; yet he 
says it differs from the latter in being simply an extension 
of the eczema to the perifollicular region, while sycosis con- 
sists in small abscesses and tubercles. 
Baudet (“ Traite des Affections de la Peau,” Paris, 1869, 
p. 94) says it is an inflammation of the hair-follicles depending 
on an arthritic constitution. He believes that a sycotic erup- 
tion, whether arthritic or parasitic, can be converted into a 
syphilitic or a scrofulous eruption if the patient, while affected 
with sycosis, becomes syphilitic or scrofulous. 
The other French writers, as Chausit, Rayer, Duchenne, 
Dupare, Gibert, Rochard, Divergie, Giubout, etc., have con- 
tributed nothing worthy of special mention. 
Wertheim (Zeitschrift. der k. ~k. Gesellschaft der Aerzte, 
1861) made use of the microscope in studying this disease, 
but only with the object of confirming previously-conceived 
ideas of its nature and cause. He argued thus: Since a 17 
hair is always in the centre of every pustule, and pus always 
follows the extraction of such a hair, therefore the hair-folli- 
cle must be the seat of the inflammation. Every such follicle 
will therefore inclose an abscess with its sheaths, and every 
pustule is a metamorphosed hair-follicle. As sycosis appears 
but very rarely on other parts of the body than that of the 
bearded parts of the face, therefore the cause of the disease 
must be in the anatomical character of the hair-follicles of this 
region. Believing in those conjectures, he examined the 
structure of healthy hair-follicles taken from different parts of 
the body. From these studies he found that in the beard the 
hair has a greater diameter, in comparison with the diameter 
of its sheaths, than in any other part of the body. As the pus 
reaches the surface by destroying or pushing aside the exter- 
nal and internal root-sheaths, therefore, when the hair-follicle 
is inflamed, the pus has much more difficulty in reaching the 
surface when the hair is thick and the sheaths thin, than when 
the hair is thin and its compressible sheaths thick. On account 
of the resistance which a thick hair offers to the immediate 
evacuation of pus, the latter collects, and an abscess is formed. 
Kobner (“ Klinische und experijnentelle Mittheilungen 
aus der Dermatologie und Erlangen, 1864, 
p. 13) was the first to give any description of the changes 
which take place in the hair in sycosis. He names the dis- 
ease folliculitis barbae, and says it has no connection with 
acne, but is an idiopathic inflammation of the follicle, which 
inflammation is the cause of the nutrition changes which take 
place in the hair. This inflammation may be produced by 
changes of temperature as well as from chemical and mechan- 
ical irritants. He examined hairs extracted in different 
stages of the eruption, but did not make any microscopical 
examination of the diseased follicles in situ or otherwise. The 
changes outside the follicle he regards as consecutive to those 
taking place within it. He says that first the external and 
then the internal root-sheaths swell, their cells become en- 
larged, increase in number, divide, and finally are partly 
transformed into pus and detritus. The hair itself is not 
changed at first, but later it loses its connection with the fol- 
licle, the bulbi swell two or three times their normal size, and 18 
become infiltrated with a sero-purulent fluid. According to 
Kobner, the primary changes therefore take place in the ex- 
ternal and internal root-sheaths. The cause of the perifol- 
licular inflammation, he finds, lies in the anatomical construc- 
tion of the part, in its richness in blood-vessels and nerves, 
and the deep situation of the follicles. 
Since the time of Bateman, therefore, the disease has been 
regarded by almost all writers as an inflammation of the hair- 
follicles, produced by irritating agents. Wertheim and Kob- 
ner were the only writers who studied the disease with the 
aid of the microscope, but they examined only hairs extracted 
from the part affected, and not the whole tissue affected ; i. e., 
they did not examine the affected part itself. 
In my own studies upon this subject I examined portions 
of skin taken from the living subject and affected with the 
eruption in its different stages, and have followed the process 
from its commencement to its termination, either in complete 
restitution of the parts, or in greater or less destruction of the 
skin of the affected region. 
I will now describe the various pathological changes 
which take place in this disease, and show the incorrectness 
of the views of the authors I have quoted. I will first de- 
scribe the changes which take place in a case of sycosis, un- 
complicated by an eczema or dermatitis. 
The first changes which take place occur around the fol- 
licle, in the peri-follicular region. The usual changes which 
occur in vascular connective-tissue inflammations are here met 
with. An increased amount of blood is sent to the peri-follic- 
ular region, and the blood-vessels of the part become dilated 
and filled with accumulated blood-corpuscles. Some of those 
escape (pass outward), and directly pus-corpuscles (previously 
white blood-corpuscles) are found outside the vessels, espe- 
cially around the base of the follicle; but scattered corpuscles 
are found lying as high as its neck. Sometimes a rupture of 
a blood-vessel occurs very early in the disease, and a greater 
or less quantity of red blood-corpuscles appear in the neigh- 
borhood of the ruptured vessel. In one case the blood-vessel 
of the hair-papilla was ruptured, and the papilla partly filled 
with extravasated red blood-corpuscles (see Fig. 1). As occurs 19 
in any similar inflammation, the pus-corpuscles rapidly increase 
in number, either by the outwandering of more white blood- 
Fio. 1 is a section through the hair-bulb, on a level with the papilla, and represents the 
earliest stage in the disease. The blood-vessel of the papilla is ruptured, and blood- 
corpuscles have been extravasated. The cells forming the hair-root are still perfectly 
normal, but pus-corpuscles are present in the peri-follicular region. From a case of 
uncomplicated sycosis. 
corpuscles from the vessels, or from division of those already 
outside, or by both processes combined, and soon surround 
the base of the follicle; while along its sides, between the 
fundus and the neck, the blood-vessels are much dilated, 
though ordy few pus-corpuscles are found in the tissue sur- 
rounding them (see Fig. 4). With this outwandering of 
formed elements there is the usual transudation of serum, 
which penetrates the tissue and the hair-follicle ; hut, beyond 
the action of this transuded fluid upon the follicle, there is not 
any change to be observed in the latter structure in the earli- 20 
est stage of the disease. The changes, therefore, which occur 
during the early papular stage, take place primarily in the tissue 
surrounding the follicle, and show that the disease in the first 
stage is not a folliculitis, but a peri-folliculitis, pure et simple. 
As the inflammation proceeds and more pus and serum collects, 
the follicle and its sheaths become more and more affected. 
The latter become softened and more or less destroyed, and a 
portion of the surrounding pus may enter the follicle through 
the ruptured sheaths (see Fig. 2). The changes which occur 
Fio. 2 represents a little later stage than Fig. 1. A large number of pus-corpuscles were 
present around the follicle, and the follicle-sheaths are ruptured. The cells of the hair- 
bulb are commencing to break down. This section is also made through the hair-root 
on a level with the papilla, and from a case of uncomplicated sycosis. The central part 
is the papilla, the next is the hair-root, and the external connective-tissue structure the 
follicle-sheaths. 
within the follicle, prior to the rupture of its sheaths, are prin- 
cipally attributable to the increased amount of serum present. 
The cells of the external root-sheath become swollen, and some 
of the cells begin to break down. Similar changes occur simul- 
taneously in the cells of the hair-root. Here the cells form- 
ing this part of the hair are soft, contain much protoplasm, 
and are therefore easily affected by external agents. They 
swell, the protoplasm becomes granular, their margins be- 
come indistinct, and there is evidence of commencing destruc- 21 
tion. If the serum is rapidly efiused, the cell bodies and their 
connecting substance may become indistinct, and only round 
Fig. 3 is also a section from the same situation as the preceding ones, hut is from a case 
complicated with eczema. Both the papilla and the root of the hair seem to be com- 
posed of round cells. In the papilla such is the case, hut the appearance in the root of 
the hair is from the action of the serum on the cells of the part. 
bodies appear where the epithelial-like cells of the hair-root 
previously existed. This change occurs especially in cases 
■complicated with acute eczema or dermatitis. After the 
rupture of the follicle-sheaths, or even before, the cells of 
the hair-root and of the external and internal root-sheaths 
become rapidly broken up and changed by the serum which 
has entered the follicle, accompanied occasionally by the 
pus from the blood-vessels. If pus has entered them, the 
hair-root is infiltrated with a sero-purulent fluid. Very fre- 
quently, however, no pus enters the follicle, and then all the 
changes which occur in the follicle are caused by the serum 
alone. The cells of the external and internal root-sheaths 
undergo destructive changes, the cell-bodies and connecting 
substance are gradually destroyed, and a granular-looking 
mass containing roundish bodies (the nuclei of the former 
cells) is formed. This change is shown in Fig. 5, which repre- 
sents the changes always found in the whole length of the 
external root-sheath in ordinary cases of sycosis. The cells of 
the hair-root undergo exactly similar changes to that of the 
external root-slieath, and at an earlier period than that por- 
tion of the sheath seated near the surface of the skin. 
There is usually no purulent infiltration of the root; the 22 
Fig. 4 shows a later stage than Fig. 2. Pus is present in great quantity outside the fundus of the follicle, and 
the follicle-sheaths and external root-sheath are partly broken down. Toward the neck of the follicle the 
changes are less and less. The cells of the root of the hair were more granular than normal, showing the 
commencement of the retrograde metamorphosis. This drawing shows exceedingly well the primary 
changes in the disease to be a peri-folliculitis. 23 
appearance of pus-cells is deceptive; the round cells seen in 
the broken-down granular mass are the nuclei of the normal 
cells of the part. This can only be decided by sections through 
the hair-root, as examining the root of a hair extracted entire 
leads to the view that pus-cells are present in great number 
within the follicle. In this the pustular stage of the disease, 
the principal changes take place within the follicle ; and, if a 
hair is extracted in this stage, it is found that the hair-root 
and the external and internal root-sheaths are broken down, 
and no longer possess their normal characters. The external 
root-sheath and the root of the hair exhibit the changes shown 
in Fig. 5, only that the root is more changed than the sheath. 
Fig. 5 represents a later period in the pustular stage. The cells of the external root-sheath 
and the soft parts of the hair are changed in the manner described in the text. I have 
here drawn only the portion of the shaft, of a hair, but similar changes extend the entire 
length of the hair. It is in this stage, when all connection is severed between the ex- 
ternal root-sheath and the follicle-sheaths, that the hair lies loosely within the follicle, 
and can be extracted easily and without producing pain. 
The shaft of the hair being hard, and the serum consequently 
unable to act upon it, retains its normal character. As the 
disease progresses, the connective tissue around the follicle 
becomes infiltrated with pus-cells as far as the surface of the 
skin, and softened. If the hair is allowed to remain within 
the follicle until expelled by the accumulating pus, the exter- 
nal and internal root-sheaths and soft parts of the hair become 
completely destroyed, and only the hard part of the hair 
remains. 
The follicle-sheath and the connective tissue in the peri- 
follicular region are more or less destroyed, and the Malpighian 
layer becomes ruptured on a level with the upper part of the 
neck of the follicle. The pus reaches the surface by breaking 24 
through the Malpighian layer, and does not pass between the 
hair-shaft and the follicle-sheath, as mentioned by Wertheim. 
When the follicle-sheaths are destroyed, and there is free 
connection between the peri-follicular pus and the follicle, a 
portion of the pus does pass to the surface through the space 
previously occupied by the external and internal root-sheaths. 
In extracting a hair during the pustular stage, sometimes the 
follicle-sheaths accompany the hair, but generally they do not. 
The cells surrounding the hair-papilla, and from which the 
hair is formed, seem to resist the inflammatory process longer 
than the other cells of the bulb, a circumstance which explains 
why permanent alopecia is not a more frequent consequence 
of sycosis. The cavity left after the extraction of a hair in 
sycosis, in a case in which the follicle is not completely de- 
stroyed, contains pus along the entire length of its walls and 
at its base, and the follicle sheaths are more or less destroyed. 
The structures, however, forming the base of the follicle are 
not completely destroyed, the papilla remaining, from which 
a new hair will grow. In those cases in which permanent 
alopecia results', pus is present in the cavity as in the former 
case, but the follicle sheaths and the base of the follicle are 
completely destroyed, making it impossible for a new hair to 
grow, as there is no longer a papilla from which it can be 
formed. Such a cavity is represented in Fig. 6. Here all 
the follicle structures have been completely destroyed. Such 
a cavity becomes obliterated by new-formed connective tissue 
forming a cicatrix. The whole process, therefore, in simple, 
uncomplicated sycosis is, first, a peri-folliculitis, then the follicle 
elements are acted upon by the inflammatory products, and 
notably by the serum, which causes destructive changes in the 
soft parts of the hair, and in the external and internal root- 
sheaths, by which their cells are so acted upon that the cell- 
body and connecting substance are first destroyed, and a granu- 
lar mass containing round bodies, the nuclei of the fixed cells 
of the part, results. If the process continues a length of time, 
the round bodies also become destroyed, and a detritus only 
remains. In this latter stage, only the hard, corneous part of 
the hair remains of the structures which previously made up 
the hair and its sheaths. In those cases of sycosis in which 25 
Fig. 6 shows the nature of the cavity left in the skin after expulsion of a hair in the latest 
stage of the disease, and where the destructive process had proceeded so far that, the 
follicle is completely destroyed. There is no trace to be seen of any of the structures 
belonging to the follicle. Such destruction always produces permanent alopecia. 26 
the inflammation extends from the surface, as when an eczema 
is present, the changes do not differ in any essential way from 
that just described, only that the external and internal root- 
sheaths and follicle-sheaths are acted upon in their entire 
length at the same time, while in simple sycosis the sheaths 
at the root of the hair are first affected, and the inflammation 
travels upward. If a general dermatitis is present, as in ery- 
sipelas, the follicle-structures become frequently changed in 
the same manner as in sycosis ; but, as the limited peri-fol- 
licular inflammation is absent, the same clinical appearances 
are not presented. This is a proof that the changes within 
the follicle are produced from without, but it requires the peri- 
follicular inflammation to constitute sycosis. A hair will there- 
fore present different appearances, according to the stage of 
the disease at which it is extracted. If a healthy, normal hair 
is extracted, it is found that the external root-sheath does not 
accompany it. This would also be the case in the earliest 
stage of sycosis, before the follicle is affected. If, however, 
we examine a hair extracted during the pustular stage, it will 
be found covered with the root-sheaths in different stages of 
destruction, according to the duration of the disease and the 
activity of the inflammation. In an early part of the pustular 
stage the bulb is swollen, and infiltrated with a serous, and 
sometimes a sero-purulent fluid. The root-sheatlis will also 
be more or less destroyed. If the hair remains within the 
follicle until expelled by the accumulated pus, the destruction 
will have proceeded still further, the external and internal 
root-sheaths, and the soft parts of the hair, become destroyed, 
and nothing but the hard part of the hair remains intact. 
The sebaceous glands, being seated so near the hair, and being 
richly supplied with nerves and blood-vessels, may also be- 
come affected, though not at so early a stage of the disease as 
the fundus of the hair. Similar changes occur here to those in 
the cells of the external root-sheath. The endothelial cells 
become swollen, their margins indistinct, the protoplasm be- 
comes more coarsely granular, and the cells become more or 
less destroyed. An early stage of these changes is seen in 
Figs. 7 and 8. The manner in which the connective tissue 
and its cells and the different gland elements are destroyed, 27 
diflers in no respect from the process of molecular retrograde 
metamorphosis of the different tissues, as given in works on 
pathological histology, consequently is not peculiar to sycosis, 
Fig. 7 represents an early stage of the 
changes which sometimes occur in the 
sebaceous glands. They become sur- 
rounded with pus, and the endothelial 
cells undergo the hanges I have de- 
scribed. 
Fig. 8 shows the changes which occur in 
the sebaceous glands when they become 
entirely destroyed, as occurs in those 
severe cases of the disease which re- 
semble a lupns in their results. The 
gland is surrounded with pus-cells, and 
the endothelial cells become changed to 
a granular mass containing fat-drops. 
and need not be here further described. The sweat-glands, 
when affected, show similar changes, though these structures 
possess considerable immunity against external agents. In 
Fig. 9 the cells show commencing degeneration from the 
transuded serum. If, however, but little serum is present, as 
in some cases of chronic sycosis, the cells of the sweat-glands 
can remain normal even when surrounded with pus. 
The changes which I have thus far described take place in 
cases of ordinary sycosis, and the results of the inflammation, 
even when of long standing, are nothing more than a tempo- 
rary or permanent partial alopecia. In those severe cases, 
however, which resemble in their effects mild cases of lupus, 
the retrograde changes proceed further, and there is more or 28 
less destruction of the hair-follicles, sebaceous and sweat glands, 
and of the other tissues of the affected part, and healing by 
Fig. 9 gives the changes which are met with when the sweat-glands are surrounded with a 
considerable amount of serum. 
cicatricial tissue. The inflammatory changes do not differ 
much from those which take place in simple sycosis ; but 
the inflammation is more diffuse and chronic in its course. 
Pus collects in the epidermis and cutis, and those tissues are 
destroyed in the same manner as the follicle-tissue. The 
sweat-glands offer considerable resistance to the process, and 
consequently remain longer normal than the sebaceous glands 
(see Fig. 10). In Fig. 9 is shown a sebaceous gland almost 
Fig. 10 shows the resistance the sweat-glands offer to pathological processes. Pus-corpus 
cles may he present in great number, as in this case, hut, unless the quantity of serum 
is also abundant, the cells of the sweat-glands retain a long time their normal character. 
completely destroyed by the retrograde metamorphosis. The 
connective tissue shows all the changes of a retrograde process, 29 
as destruction of tlie connective-tissue bundles and the cells 
and nuclei of the part. 
We thus learn that, in sycosis, the first changes take place 
in the peri-follicular region, and that the subsequent changes 
which occur within the follicle are due to the inflammatory 
process which has its origin in the surrounding tissue. There 
is never any change whatever to be observed in the cell-ele- 
ments proper of the follicles previous to the changes taking 
place in the tissue surrounding them, i. e., the disease is pri- 
marily a peri-folliculitis. 
To constitute an idiopathic inflammation of the hair-fol-. 
licles, the primary morbid changes must take place in the ele- 
ments of the hair or its follicle. In acne the first abnormal 
changes are supposed to take place in the cells of the sebaceous 
gland, or in their secretion, and any peri-glandular inflamma- 
tion that may arise is secondary, and caused by the process 
which has taken place within the gland. If this view of the 
process in acne is correct, then the disease is, properly speak- 
ing, an affection of the sebaceous glands. In sycosis, how- 
ever, the peri-follicular inflammation is not caused by any pro- 
cess occurring within the follicle, since the elements of the 
latter are perfectly normal until invaded by the inflammation 
from without. Even then those elements do not take an ac- 
tive part in the inflammation, and increase, and divide, as 
stated by Kobner, but are simply more or less broken up and 
destroyed, in the manner I have already described, by the in- 
flammatory products from the blood-vessels passing into the 
follicle. A study of the whole process shows, therefore, that 
the disease is not primarily an inflammation, of the hair-fol- 
licles, as has been generally believed, butJ a peri-follicular 
dermatitis. 
Etiology.—Having completed the study of the nature of 
the disease, I will now proceed to discuss its cause. In the 
majority of cases, an eczema or superficial dermatitis precedes, 
and is to be regarded as a predisposing cause of, the disease. 
Sometimes, though there is no active inflammation present, 
the skin is harsh, red, and irritable. A temporary superficial 
irritation of the skin rarely, if ever, produces sycosis of the 
beard, provided the skin is otherwise in a normal condition 30 
and the health of the patient good. When the hairs are not 
deeply seated, as, for instance, on the scalp, a superficial in- 
flammation frequently extends to the follicular region, and 
produces all the changes peculiar to sycosis. In many cases 
of the disease, however, there has been no previous dermatitis, 
either of a catarrhal or other form, and even those parts of the 
skin situated between the pustules appear to he normal. In 
acute cases the eruption generally appears on limited areas, 
and is ushered in with pain and swelling of the part where 
the eruption will appear. Even when thus appearing, with 
acute symptoms, and on limited areas, a peri-folliculitis does 
not occur around every follicle situated within the atfected 
area, but only surrounds a limited number. 
In chronic sycosis the pustules are more isolated, and ap- 
pear on different parts of the heard, with the same outbreak. 
However, whether the pustules are isolated or collected, and 
whether ushered in with acute symptoms or not, they do not 
appear continuously, but periodically, that is, the eruption ap- 
pears in successive “ outbreaks,” with an interval of generally 
from seven to fourteen days between the successive attacks. I 
recall those clinical characters of the disease, as they will as- 
sist us greatly in studying the cause of the disease. In those 
cases where an eczema is present, the disease has been regarded 
by some writers as simply an extension of this disease to the 
peri-follicular region, without being influenced by anything 
which has occurred in the latter location. This is true of 
the majority of cases of blepharo-adenitis and sycosis, seated 
within the nose or on a part of the body such as the scalp, 
where the follicles lie near the surface of the skin, but such is 
rarely the cause of the disease when located in the bearded 
part of the face, where the follicles are so deeply seated. In 
the acute cases, when the eruption is on a limited area, the 
peri-folliculitis does not surround all the follicles, but only a 
few, and those often the deeply-seated ones, wThich would 
scarcely occur if the peri-folliculitis were simply an extension 
of the superficial eczematous inflammation to the deeper-lying 
tissue. In a case of sycosis of the scalp, once under my care, 
and which was preceded and accompanied by an eczema of 
this region, nearly every follicle of the affected part was sur- 31 
rounded by the inflammation, and the follicles changed. In 
this case, and in similar ones, the sycosis was caused by the 
simple extension of the eczematous inflammation, first to the 
peri-follicular region and then to the follicles, and it ceased to 
exist as soon as the eczema disappeared. The superficial situ- 
ation of the hair-follicles in this region favors an extension to 
them of the inflammation. By the use of croton oil, a sycosis 
can be produced on the scalp, in which all the changes I have 
described as taking place around and within the follicles occur. 
In chronic sycosis, where eczema is frequently present, the 
pustules are generally isolated, and few in number. If the 
disease were simply an independent extension of the eczema, it 
is probable that a greater number of pustules would be present, 
that they would be more collected, that there would be more 
general infiltration of the skin between the pustules, and, 
finally, that pus would be always found surrounding the neck 
of the follicle as early in the disease as it appears around the 
base. None of those conditions, however, are present, and the 
absence of the last-named one is proof absolute that the peri- 
folliculitis is not an independent extension downward of the 
eczema. Such a view could not be maintained one moment 
for those cases of sycosis where no eczema is present. 
There must, therefore, be some exciting cause why this in- 
flammation is limited to the peri-follicular region, and attacks 
only a limited number of follicles, and I will now endeavor to 
show that the direct cause is to be found in the irritation pro- 
duced by the stiff hairs of the beard on the irritable skin-tissue. 
In cases of chronic sycosis, the skin is in an irritable condition, 
and especially the peri-follicular region, on account of its rich 
supply of blood-vessels and nerves. Such a part, when in this 
condition, easily inflames when irritated, and in the hairs of 
the beard we have a body so stiff that they can act like so many 
spears on the morbidly-sensitive skin. That movement of 
hairs causes great pain, when the skin is inflamed or tender, is 
common experience, and when they are stiff, like those of 
the beard, they can certainly produce a peri-folliculitis when 
this region is already irritable, especially when we bear in 
mind that traction upon a hair seated in a papule which is be- 
ginning to subside is sometimes sufficient to cause active in- 32 
flammation in the latter again, and to become a pustule. The 
hairs, however, must be stiff or they cannot sufficiently irritate 
hence the rarity of a peri-folliculitis around fine hairs of the 
beard, at any period of life, and the still greater rarity of 
sycosis on those parts of the body supplied with tine hairs only. 
An eczema may, and often does, continue on those parts of the 
body, and the skin is in an irritable condition, but no peri- 
folliculitis occurs, as the hairs are not stiff enough to inflame 
the tissue. The reason, also, we have isolated pustules in sycosis 
of the beard is, that only a limited number of hairs irritate 
sufficiently to produce a peri-folliculitis. It is only the older 
and stiffer hairs of an affected part that are surrounded with 
inflammation, a proof, I think, that the exciting cause of the 
disease is the irritation produced on the irritable tissue by those 
bodies increasing the condition present sufficiently to cause 
actual inflammation. This irritation from movement of the 
hairs is not sufficient to produce inflammation in a healthy in- 
dividual with normal skin, or sycosis would be a more frequent 
disease than it is. The skin, however, does not require to be 
actually inflamed before the hairs can cause a peri-folliculitis 
around them, for, as I have already said, sycosis sometimes oc- 
curs when no dermatitis is present. It must, however, be in 
an irritable condition, and as it is more irritable at one period 
than at another, and generally at somewhat regular intervals, 
this explains the periodical outbreak of the tubercles and pap- 
ules, as at those times less irritation from the hairs is required 
to produce a peri-folliculitis. 
The fact of the rare occurrence of sycosis on those parts of 
the body covered with fine hairs, when the part is affected with 
eczema, or in an irritable condition, is sufficient proof that upon 
the nature of the hair depends the presence of the disease. 
Therefore, wdiile the inflammation around the follicles may be 
regarded as an independent extension of the inflammation from 
the seat of the eczema, it can be regarded as purely such only 
in those cases where the hairs are so fine that they cannot pro- 
duce much irritation. In this case almost all the follicles are 
affected, and especially those lying most superficially. Usually, 
however, only a limited number of follicles are affected, and 
those the deeper-lying ones, from which old and stiff* hairs are 33 
produced. Such hairs irritate the skin at the base of the fol- 
licle, and then the inflammation can extend to this region from 
the surface. 
But, when no actual inflammation is present previous to 
the appearance of the eruption, and the skin is simpty irrita- 
ble, the flrst active inflammatory changes occur around the 
follicles, and are brought about by the irritation from the stiff 
hairs. Therefore, in cases of sycosis of the beard combined 
with eczema, the inflammation may extend from the surface 
to the follicular region ; it, however, is not an independent ex- 
tension, but is caused by the irritation produced at the folli- 
cles by the stiff hairs of the part. Remove the hairs and no 
peri-folliculitis will occur, as the part will no longer be irri- 
tated. I consider, therefore, that in no other manner can the 
occurrence of sycosis on a part free of eczema, and provided 
with normal hair, be satisfactorily explained than by suppos- 
ing the skin to be in an irritable condition, and that the hair 
is capable of increasing this irritation sufficiently to produce 
a peri-folliculitis, though not a general dermatitis. When 
eczema is not present, we must seek for other causes to pro- 
duce this irritability, and they are found among the various 
mechanical and chemical irritants which predispose to the 
disease. 
Nearly all writers agree that such things as constant ex- 
posure of the face to strong rays of heat, or occupations with 
dusty and irritating substances, can, and frequently do, pro- 
duce the disease. In fact, as Tilbury says, “ any local irritant 
can produce it, if the person is out of health, by rendering 
the skin irritable.” Shaving, especially with a dull razor, 
acts in this way, as it produces great irritation of the skin, 
though Ilebra is inclined to regard shaving rather as a pro- 
phylaxis against the disease than a cause of its production. 
Ilebra, however, stands almost alone in this opinion, and the 
statement that he has met with sycosis more frequently among 
persons who never shave, such as the Polish Jews, than among 
those who shave daily, admits of easy explanation. It is 
easier to keep the skin clean when the face is shaven, than 
if the beard be allowed to grow long. Such being the case, it 
is easy to perceive that, with such a dirty class as the orthodox 34 
Polish Jews, shaving is really a prophylaxis, for, as they neither 
shave nor keep themselves clean, their skin is exposed 
to all the irritating substances which collect in their beard, 
and the continued irritation therefrom is quite sufficient to 
render the skin irritable, or produce an eczema, and finally 
sycosis. That daily shaving is necessary in the treatment is 
for the majority of cases not correct, though, if it is necessary, 
that is no proof that it is also a prophylaxis. It is only a 
prophylaxis, as I have said, in the case of uncleanly persons. 
We thus see that, among the different things which lead 
to sycosis, as eczema, exposure to strong rays of heat, dusty 
substances, shaving, irritating powders, cosmetics, etc., all act 
in the same way, producing an irritable condition of the skin, 
and the stiff hairs acting upon this irritable skin produce an 
inflammation in their immediate neighborhood, i. e., there 
arises a peri-folliculitis pilorum. Therefore, sycosis barbae is 
not a folliculitis or an independent extension of an eczema to 
the peri-follicular region, but a peri-folliculitis; neither is its 
cause to be found in the large size of the hair, as compared 
with its follicle, but simply in the size and stiffness of the 
hairs, enabling them to act like spears on the tender skin. 
Sycosis, therefore, should not be classed among the diseases of 
the hair-follicles, but as a form of dermatitis, among the 
exudative affections. 
Diagnosis.—There are but few diseases of the skin whose 
characters are more sharply defined, or that are easier to be 
diagnosed, than sycosis; yet it happens very frequently that 
other eruptions are regarded as sycosis or barbers’ itch, merely 
because they are located on the bearded part of the face. 
Such an error, of course, will not be committed by those who 
have studied the disease carefully, and are familiar with the 
characteristic signs of the eruption. It is to be borne in 
mind that sycosis is not a frequent disease, and always pre- 
sents decidedly characteristic appearances, the presence of 
which are necessary in any given eruption before the diagnosis 
sycosis can be made. On account of the rarity of the disease 
the chances are that an eruption, when seated on the face, is 
not sycosis, but some other disease of frequent occurrence in 
this region, as eczema or acne. Frequently sycosis is accom- 35 
parried by a chronic eczema; but, if so, the two diseases can 
be easily separated and diagnosed by the special characters of 
each. In sycosis, papules, tubercles, or pustules are present, 
and generally all three at the same time. They are confined 
to the hairy parts of the body, and appear almost exclusively 
on the bearded part of the face; are frequently isolated, espe- 
cially when the disease has become chronic, and each papule, 
tubercle, and pustule is perforated in the centre by a hair. 
When papules or pustules, wherever seated, and of whatever 
form, are not, or have not been, perforated in the centre by a 
hair, they belong to some other disease, since this perforation 
is an essential condition in sycosis, and is relied upon chiefly, 
when making the diagnosis. The diseases with which it is 
generally confounded are tinea barbae (sycosis parasitaria of 
some authors), acne, eczema, impetigo, lupus, and syphilis. 
The use of the term tinea sycosis, or parasitic sycosis, for an 
entirely different disease from true sycosis, and the statement 
of some authors that all cases of the disease are parasitic in 
their nature, have been productive of the greatest amount of 
confusion among physicians and of suffering to the patients. 
Acting under the belief that a given eruption, because seated 
on the face, must be sycosis, and all cases of this disease, ac- 
cording to the latest views, parasitic in origin, physicians 
have had recourse to antiparasiticides, a class of remedies 
which usually aggravate and prolong the disease, and subject 
the patient to much unnecessary suffering. 
In view of the importance of the subject, I will therefore 
enter into full details as regards the nature of this so-called 
parasitic sycosis, and endeavor to show its entire dissimilarity 
with sycosis in every respect, and consequently the impropriety 
of the term sycosis for this disease, in the hope that future 
authors in waiting upon it will treat of it under its proper 
designation, namely, that of tinea barbae. 
Gfruby (“ Comptes rendus des seances de l’Academie des 
Sciences,” 1842, p. 512) first described the disease, which has 
been called parasitic sycosis. To the fungus found by him in 
this affection he gave the name mentagraphyta, and named 
the disease itself phyfomentagra. “ The fungus,” he said, 
“ is formed within the hair, and between its root and the root- 36 
sheaths, and has its origin in the matrix of the hair and in the 
cells composing the follicle, but is never found to rise above 
the surface of the epidermis. The disease is limited to the 
hairy part of the face, and is most frequently met with upon 
the chin, upper lip, and cheeks. It covers those parts with 
white, grayish, or yellowish scales, which are slightly raised 
in the middle; their borders are angular, and pierced at all 
points by hairs. The scales are so firmly united with the 
hairs that, in removing them, some of the latter are pulled out 
at the same time.” From his whole description, and from the 
fact that subsequent observers have shown the identity of the 
fungus present in such cases with the fungus of ordinary ring- 
worm, namely, the tricojohyton tonsurans, it is plain that the 
disease described by him was not sycosis, but simply tinea 
tonsurans of the beard, a disease which is not at all rare in 
Paris, occurring, according to Kobner (“ Tiber Sycosis und 
ihre Beziehungen zur Mycosis tonsurans,” Virchow’s Archiv, 
1861, xxii. Bd., p. 46), more frequently than sycosis. Although 
Gruby and several other writers since his time (Nelligan, l. o., 
Kiichenmeister, l. c.) believed every case of sycosis to be of 
parasitic origin, the majority of observers hold to the non- 
parasitic nature of the disease, and separate it from the syco- 
sis of Gruby, retaining, however, the name of sycosis for both 
diseases. In reality, the two diseases are entirely different in 
every essential point. The sycosis of Gruby is always para- 
sitic in nature, and the fungus which produces the disease 
corresponds to that which produces ordinary ringworm—the 
tricophyton tonsurans. I consider the disease simply a tinea 
tonsurans, modified by the anatomical characters of its seat, 
and will in future, in speaking of this disease, make use of the 
term tinea barbae, as being the correct designation for it, rep- 
resenting, as it does, the true nature of the disease. The fun- 
gus in this disease passes down into the hair-follicle, then into 
the shaft of the hair, and is found in the matrix and between 
the hair and its sheaths. It is easily detected with the mi- 
croscope in recently-altered hairs, but is frequently absent in 
hairs much changed or bathed in pus, as this latter is an anti- 
parasiticide. The disease is generally preceded by a red, 
itching, or scaly spot of tinea circinata, of circumscribed or 37 
zigzag shape, upon which vesicles, tubercles, and pustules 
arise, accompanied with desquamation of skin and change in 
the character of the affected hairs. The tubercles of tinea 
barbse arise without that pricking, burning sensation which 
occurs in sycosis, and are produced continuously, and not 
periodically, as in the latter disease. The fungus not only in- 
terferes with the normal growth of the hair, but, acting as a 
foreign body, produces irritation, and, secondarily, peri-follicu- 
lar inflammation around the affected follicles. The hairs are 
affected early in the disease, becoming opaque, brittle, loose, 
and are easily extracted. The affected part is much indurated, 
and the tubercles are more voluminous than in sycosis, some- 
times reaching the size of a cherry. In the majority of the 
cases I have seen, the tubercles were large, prominent, and 
studded with numerous hairs, which lay loosely in the indu- 
rated mass. The disease begins imperceptibly, proceeds slowly 
and steadily, always increasing in extent; while sycosis begins 
with severe local symptoms, pain and swelling of the part, 
which soon subside, but reappear in a few days, accompanied 
by a new outbreak of the eruption. In sycosis, the periodically 
recurring attacks keep up the disease, but in tinea barbae the 
fungus, being always present, and the irritation therefore con- 
stant, the progress of the disease is gradual and continuous. 
In sycosis, during the papular stage, the hairs are not affected, 
and at that period of the pustular stage when the hair is sur- 
rounded with pus and its connection with the follicle-sheaths 
destroyed by the inflammation, they lie loosely in the follicle, 
so that epilation is easy and painless. In tinea barbae the tu- 
bercles are frequently isolated, and situated on different parts of 
the face or neck. When several tubercles are situated closely 
together, they form a circular mass, or are arranged in the form 
of a circle, or part of a circle ; they are more voluminous; their 
margins are sharply limited; the surface is uneven, fissured, 
and studded with loose hairs; the base is broad, firm, lies deep in 
the subcutaneous tissue, and generally cannot be raised with- 
out the coriuin. There is often a foul-smelling, sero-purulent 
secretion collected on its surface, which dries into a thick scab, 
which, when removed, takes the hairs along with it. In chronic 
sycosis the pustules are generally isolated, but in acute attacks 38 
they are seated more closely together. In nearly every case 
of tinea barboe, patches of ringworm are present on other parts 
of the body, and even, if not present, there is often a history 
of ringworm among the patient’s companions; or the disease 
has been conveyed from some animal, as a horse or mule, with 
which he came in contact. The number of cases in which 
there is no history of ringworm is only about 5 per cent, of all 
cases of this disease, and it is reasonable to suppose that this 
percentage would be still further reduced if the previous his- 
tory could be accurately ascertained. It is somewhat singular 
that in the only typical case of this affection which has come 
under Ilebra’s observation (“Lehrbuch der Hautkrankheiten,” 
ii. Bd., 3. Lieferung, Stuttgart, 18T6, p. 654) no history of 
ringworm could be obtained. Tinea barbae does not disappear 
spontaneously, but, when cured, there is no return of the dis- 
ease, unless the patient is exposed again to contagion. If all 
those characteristic signs are insufficient to enable the physi- 
cian to make the diagnosis, though it is improbable, then a 
microscopical examination of the hairs will, in competent 
hands, decide the question. It requires, however, more ex- 
perience in the use of the microscope than is generally sup- 
posed to be necessary, in order to enable the physician to de- 
cide correctly as to the presence or absence of fungi in hair 
or scales. Therefore, unless the physician is accustomed to 
the use of the microscope, it is better not to rely too much 
upon his interpretation of what he sees through that instru- 
ment, for he will very probably imagine to see fungi even if 
none are present. 
Thus, the situation, form of the patch, character of the 
tubercles, mode of origin, cause, difference of anatomical 
parts primarily affected, nature of the disease, condition of 
the hair, and derivation of the disease from some person or 
animal affected wdtli the fungus tricophyton tonsurans, ren- 
der the diagnosis easy, and show the complete dissimilarity 
of this disease in every respect to sycosis. 
Now, since the term sycosis was used to denote a special 
disease long before Gruby made his observations, no other 
disease, therefore, should be called a sycosis, unless it can be 
shown that there is a close relationship with the disease origi- 39 
nally named sycosis, or that the disease thus primarily desig- 
nated was misnamed. As regards sycosis, it is true that the 
term was ill-chosen, as it is exceedingly rare to find the erup- 
tion presenting any fig-like appearance. This appearance is. 
more common'in tinea barbae, yet it was not on this account 
that this disease received its name, hut from its supposed iden- 
tity of seat and nature of the inflammatory changes with those 
of sycosis, that it received the name sycosis with the addition 
of the adjective “ parasitic ” to designate the kind of sycosis. 
The reason for calling tinea barbae parasitic sycosis was, that 
it was looked upon as a folliculitis produced by a fungus, and, 
as the general view of the nature of sycosis was, that it is an 
inflammation of the hair-follicles, therefore the two diseases 
were considered to be similar in character and to differ only in 
their causation. If the view that both diseases are similar in 
nature and differ only in the agent producing them was cor- 
rect, then there would be some reason for the use of the term 
parasitic sycosis. For instance, eczema is sometimes a local 
disease produced by some known irritant—as, for example, 
in eczema of the upper lip, arising from the irritation pro- 
duced by a nasal discharge ; at other times the cause may be 
entirely different, yet, from the similarity of the pathological 
process in both cases, the disease receives but one name, 
which is intended to designate the eruption and not its 
cause. But, even assuming the view held by most authors of 
the present day to be correct, namely, that in both diseases 
an inflammation of the follicles always exists, that fact alone 
would not be sufficient ground for giving the two diseases a 
similar name, unless this inflammation is the essential feature- 
of the disease and of constant occurrence. In sycosis the fol- 
licular inflammation is supposed by some authors (Fox, He- 
bra) to be idiopathic or primary, and by others (Wertheim) as- 
produced by the hair-sheaths, hence secondary. In tinea bar- 
bae the inflammation is always secondary to the nutrition 
changes in the hair and its sheaths, and arises from the irri- 
tation produced by the fungus present. "We therefore see 
that only in secondary phenomena was this disease supposed 
to agree with sycosis, but we can never on such correspond- 
ence alone classify diseases so different in nature under one 40 
name. There is no more propriety in calling tinea barbae 
parasitic sycosis, even it* a follicular inflammation is generally 
present in it as well as in sycosis, and this inflammation the 
principal clinical symptom, than in calling scabies an eczema 
because an eczematous eruption is almost always present in 
the former disease, from the irritation arising through the 
presence of the acarus scabiei.1 The only justification for 
the term would be, if, as Gruby and Kiichenmeister believed, 
all cases of sycosis are parasitic in nature. This incorrect 
view, however, is not held by any living authority, since all 
writers accept the existence of a non-parasitic sycosis. 
I have thus endeavored to make clear that, even if the 
view prevalent at present that sycosis is essentially an in- 
flammation of the hair-follicles was correct, the term parasitic 
sycosis should not be used to designate a parasitic affection 
in which the changes in the hair and the peri-follicular inflam- 
mation were secondary results, and not the essential feature 
of the disease. But, as my observations have shown that sy- 
cosis itself is not a folliculitis, and that all changes which 
take place in the hair and its follicle are secondary to the in- 
flammation around the follicle, every particle of supposed 
similarity between the two diseases disappears, and we must 
conclude that the two affections are absolutely different. 
Therefore, the nature, mode of origin, course, termination, 
parts of skin affected, and, what necessarily follows from such 
great difference, the modes of treatment are all different; and, 
since the use of the term parasitic sycosis has also been the 
cause of great confusion and of erroneous ideas concerning 
the appropriate treatment, I ask, not only from a scientific 
but also from a practical standpoint, that the two diseases be 
no longer designated by the same name, and that, if the term 
sycosis be retained for the peri-folliculitis pilorum, that of 
parasitic sycosis be no longer employed, but that the parasitic 
disease of the beard be classed under its proper head as tinea 
barbae. 
11 am quite aware that Hebra places scabies in the same class as eczema, 
but outside of Germany be lias no followers in this classification, and it is 
inconsistent with the classification he gives to the other animal parasites. 
Neumann also opposes this classification of Hebra. 41 
Acne, which is a rare complication of sycosis, is a disease 
of the sebaceous glands, and consequently is not confined to 
the bearded part of the face, but appears on the forehead, 
nose, shoulders, and other parts of the body supplied with 
those structures. It is met with generally in young persons, 
does not often appear in periodical crops, and the papules or 
pustules are not perforated by a hair. This is sufficient for 
the diagnosis. 
Syphilis is known by its concomitants, the arrangement of 
its papules in the form of a circle or part of a circle, their 
dark copper color, slow development, the absence of pain, his- 
tory of the case, and the presence of syphilitic eruptions on 
other parts of the body. Syphilitic eruptions rarely occur 
exclusively on the hairy part of the face; the papules are flat- 
ter, have a shining look, and are not preceded by the burning, 
painful feeling which announces sycosis. In a pustular syph- 
ilide, the loss of substance, the destruction of the corium, the 
kidney or circular-shaped ulcers with dirty base, the history 
of the eruption, its presence on the other parts of the body, 
and the absence of pustules penetrated by a hair, will exclude 
sycosis. 
Eczema is probably more frequently confounded with sy- 
cosis than any other disease. The localization of the eczema, 
and the statement of patients that they caught the disease by 
having been shaved with a barber’s razor, are the deceptive 
motives for the incorrect diagnosis. In reality, eczema, as 
already stated, is a very frequent precursor and producer of 
sycosis, and the two diseases are often present at the same 
time and in the same region. In eczema there is either a 
moist red surface and absence of epidermis, with itching and 
“ discharge” which forms thin scabs, or there is only hyperse- 
mia, with a harsh dry skin and furfuraceous desquamation. 
The eruption is not limited to the hair-follicles, or to the parts 
provided with hair, but is also generally present on other parts 
of the face. If papules or pustules are present, they are not 
perforated by hairs. In impetiginous eczema, the duration of 
the disease, its localization, the great amount of crusting, the 
flat pustules, rapid march, the non-ulcerated surface under the 42 
crusts, and tlie absence of tubercles or papules pierced by a 
hair, show that the disease is not sycosis. 
Lupus vulgaris occurs in young persons of both sexes, 
runs a very chronic course, causes but little pain, the tubercles 
are soft, covered with slightly-adherent scales, and are not 
perforated by a hair. It occurs generally either upon the 
nose or in its immediate neighborhood, and produces more or 
less destruction of the skin, which is replaced by cicatricial 
tissue. Lupus erythematosus resembles very closely in its 
chronic course and results those severe cases of sycosis which 
produce destruction of the gland-structures and skin-tissue. 
The progress of the destruction in lupus is more gradual; the 
margins more sharply defined ; it occurs in both sexes, and 
generally commences on the parts of the face free of hair. 
There are no papules or tubercles pierced by hairs in this dis- 
ease. 
Prognosis.—The duration of untreated cases of sycosis va- 
ries very much in different persons, and in the different 
attacks in the same person : sometimes a spontaneous cure 
takes place in a few weeks, while in other cases the dis- 
ease may continue, with greater or less severity, months, or 
even years. There is often a diminution in the severity of 
the disease during summer, and a return to its former condi- 
tion in winter. Permanent, general, or partial alopecia occa- 
sionally follows untreated chronic cases, as a consequence of 
destruction of hair-follicles from the inflammation. In the 
most severe cases there may be complete destruction of the 
cutaneous tissue, hair-follicles, sebaceous and sweat glands, 
followed by cicatrices as extensive as are met with in some 
cases of lupus erythematosus. The tubercular form is more 
obstinate than the papular (Wilson, l. c.). In syphilitic and 
strumous subjects it is very obstinate (Fox, l. c.). The greater 
the amount of pustulation, the greater is the liability of the fol- 
licles being permanently destroyed. Sycosis, however, can 
always be cured, and generally within a few weeks, when 
it is subjected to appropriate treatment; although, after com- 
plete removal, it is very liable to return within a few weeks or 
months, especially in autumn, and generally in the location 
previously affected. Therefore, while we are justified in as- 43 
Buring the patient that the eruption can with certainty be 
removed, and probably within a very short period, yet a per- 
manent cure cannot be guaranteed, as the disease is so liable 
to relapse. Frequently, however, no relapse occurs, provided 
the patient avoids the exciting causes which favor its produc- 
tion. If the principal cause lies in the occupation of the 
affected individual, a relapse is certain to occur, unless he 
changes his employment. From the long-continued pus-pro- 
duction, or from too irritating applications to the affected sur- 
face, erysipelas may arise and prove a serious complication. 
This, however, is a rare occurrence, and usually the only det- 
riment resulting from even a long-continued sycosis is the 
destruction of a greater or less number of hair-follicles and 
sebaceous glands, and consequent permanent general or par- 
tial alopecia. 
Treatment.—Though sycosis can be regarded, a local dis- 
ease, having its origin in purely local conditions of the part 
affected, yet certain conditions of the general system predis- 
pose to its development, aggravate the disease when present, 
and prolong its duration. Those conditions must be taken 
into account, and receive the necessary treatment if the dis- 
ease is to be treated with reference to rapid cure and preven- 
tion of a relapse. Sycosis is in this respect similar to many 
other skin-diseases which, although local in origin and capa- 
ble of being cured by local applications alone, yet yield much 
more readily to combined local and general treatment, and the 
relapses are less frequent than when local treatment only is 
employed. The general nutrition of the patient must not be 
neglected, and any morbid condition, as rheumatism, dys- 
pepsia, syphilis, struma, demands its appropriate treatment. 
Some one of those conditions is generally present, and the 
condition of the general system, and of every organ of the 
body, should be known before commencing treatment. A 
strumous condition of the system especially aggravates the dis- 
ease, and causes an unusual amount of pus to be produced. 
It is unnecessary to enter into full particulars as to the proper 
treatment of any of those constitutional diseases, as that be- 
longs to the domain of general medicine, and every physician 
who undertakes to treat skin-diseases should have a proper 44 
knowledge of internal diseases and their therapeutics. If 
there is a rheumatic condition of system present, alkalies are 
necessary ; if the patient is anaemic, give iron, tonics, and a 
generous diet; for syphilis, mercury in some form, or iodide 
of potassium if gummata are present; and if strumous, cod- 
liver oil, and so on. Eczema, or superficial dermatitis, if 
present in the same locality, must be treated simultaneously 
with the sycosis, as the latter cannot be cured without the 
removal of the former. A knowledge of the proper treatment 
of eczema in its different phases is of much assistance to the 
physician in the treatment of sycosis, as there is a great simi- 
larity between the two diseases as regards the course of treat- 
ment to be followed. In sycosis of the upper lip it is espe- 
cially to be borne in mind that the disease is generally kept 
up by a coryza, and that it is almost impossible to cure the 
former so long as the discharge from the latter continues to 
irritate the part. Much can be accomplished in the way of 
prophylaxis in warding off a relapse of the disease by a knowl- 
edge of the special predisposing cause at work in each case. 
If the patient’s occupation plays an important part in produc- 
ing the eruption, it should be changed, if possible. Exposure 
to excessive heat or cold should be avoided, also the use of 
cosmetics, snuff, and other irritating substances. Cleanliness 
is an excellent prophylaxis in this affection. When the dis- 
ease is present, our chief reliance for its removal consists in 
local treatment, though constitutional treatment is of decided 
advantage as an adjuvant. The latter alone is never sufficient 
to effect a cure of the disease ; but local treatment, used ac- 
cording to the special indications of each case, is adequate to 
effect a cure unaided by constitutional treatment, though re- 
lapses are more liable to occur. In the acute stage we should 
endeavor to allay irritation, and wait until the swelling and 
pain subside before using active measures. Lead and opium, 
warm applications, as a sponge dipped in hot water, or poul- 
tices, should be applied. The treatment in this acute stage 
is simply that which is applicable, and is everywhere em- 
ployed, in inflammation, when we wish to allay irritation. 
Until the acute symptoms subside, this soothing treatment is 
to be continued. After thev subside we must still continue 45 
to allay irritation, for, as I have shown, an irritable condition 
of the skin is the principal predisposing cause of the eruption. 
In the chronic stage the treatment varies, exactly as in the 
case of chronic dermatitis, according to the condition of the 
part affected. To reduce irritation, produce absorption of 
effused products, and remove the existing inflammation, 
should be the object in view. If scabs are present, they must 
be removed with poultices, ointments, or oily applications, be- 
fore commencing other treatment. If the scabs are not re- 
moved it is useless to make local applications, as they do not 
reach the part you wish to influence with them. If the pa- 
tient has a long beard, and will not permit its being re- 
moved, the sycosis will be much more difficult to cure than if 
the beard is short. Its presence, however, is not an insuper- 
able object to successful treatment, though it retards the cure 
on account of the difficulty of applying remedies to the seat 
of the eruption. If there is any inflammatory thickening, ab- 
sorbent remedies are required. Those, however, which irri- 
tate, as iodine, must not be used, as they aggravate the disease 
by increasing the irritation in the part. Some preparation of 
mercury, sufficiently diluted to prevent it from producing too 
much irritation, is the most suitable remedy. If the thicken- 
ing is considerable, and of long standing, the oleate of mer- 
cury with morphine acts very efficiently. Care must be taken, 
however, not to use a very strong solution, or to apply it of- 
tener than once every three or four days, as it sometimes irri- 
tates, and, from the facility with which it is absorbed, may 
produce ptyalism. Such accidents have occurred in my prac- 
tice after very few applications of the oleate. 
Epilation, first recommended by Plumbe (1. c.), is not only 
exceedingly useful in reducing the inflammation, but is abso- 
lutely necessary in the treatment, if permanent alopecia is 
to be avoided. Some authors say they derive but little bene- 
fit from it, but I believe, if it is performed at the proper time, 
the result is most beneficial. To remove the hairs during the 
papular stage, while they are still firmly seated in the follicle, 
increases temporarily the irritation, as their extraction causes 
great pain ; but during the pustular stage they are easily ex- 
tracted, and when the operation is performed not only has the 46 
pus a free exit but the follicle is thereby frequently saved and 
permanent alopecia prevented. Though extraction during the 
papular stage causes pain and temporarily increases the irri- 
tation, yet I believe the evil resulting from the additional ir- 
ritation thus produced is more than counterbalanced by the 
good resulting from the free exit allowed to the pent-up pus 
and the removal of the irritating hairs. Fomenting the part 
with hot wrater lessens the pain produced by the operation of 
extraction. In performing the operation, but a single hair 
should be seized with the forceps at one time, and traction 
should be made in the direction of the long axis of the hair. 
Every hair perforating a papule or pustule should be extracted. 
In cases of circumscribed sycosis—that is, where the disease 
remains confined to a small spot for a long period—it is better 
to remove all the hairs from such a spot, even if the operation 
causes considerable pain. This removal of the hairs, to save 
the follicle and allow exit to the pus, is, I believe, a much bet- 
ter procedure than opening the pustules, or rather small ab- 
scesses, with a knife. 
In using ointments, the same rules are to be observed as 
in other skin-diseases. They should always be spread on cloth 
and bound on the part, as they then act more powerfully and 
efficiently than when simply rubbed in. The diachylon oint- 
ment of Ilebra is most frequently employed, and is of great 
service in curing the disease. The ointment should be applied 
twice in every twenty-four hours, and kept constantly on the 
part. 
Whether the part affected should be shaved or not is a 
disputed question. Good authorities are found to differ on 
this question, some recommending and others opposing the 
operation. Basing my views upon the nature of the disease, 
and knowing that shaving irritates the inflamed part, I be- 
lieve it is injurious, and that it is much better to cut the hairs 
close to the skin with scissors. If they are thus closely cut, 
the part is not irritated by the operation ; ointments can be 
properly applied and the hairs easily extracted. Ilebra (lc.), 
who says he has tried the different methods of treatment, is 
decidedly in favor of daily shaving and washing the part; yet, 47 
as equally good authority is found opposing it, future expe- 
rience must decide which is the proper course to pursue. 
The plan pursued at Cannstadt (“ Ueber die Behandlung 
der Sycosis in der Heilansta/t zu Cannstadt,” Blatter f. Ileil- 
wissenschaft, Jahr. 4, Nr. 11, 1873), of rubbing in a salve 
composed of two parts of ship-tar and one part of green soap 
until the hairs are easily extracted, then touching the cavity 
with acetic acid, is unnecessarily severe, and cannot be indi- 
cated in any, except perhaps chronic cases, with considerable 
induration and thickening of the cutis. 
Ointments containing sublimed sulphur, or the iodide ot 
sulphur, in varying proportions, according to the amount ot 
induration and irritability of the skin, are of service, but must 
not be made so strong as to produce irritation. 
In strumous subjects, the local application of cod-liver oil 
often acts more beneficially than ointments of either lead, sul- 
phur, or mercury. 
Hence epilation, and the application of astringent oint- 
ments, as the diachylon ointment of Hebra, with or without 
the addition of a mercurial preparation, according to the 
amount of induration present, and appropriate constitutional 
treatment, will enable the physician to cure all cases of sycosis, 
except the destructive form, within a few wreeks, providing 
the patient does not continue to expose himself to the predis- 
posing cause of the disease. 
I will not enter further into the treatment appropriate for 
the disease in its different stages and conditions, as that would 
occupy too much space, and it can be learned in any good 
work on diseases of the skin. Epilation and the treatment 
appropriate for eczema can be considered the proper treat- 
ment for sycosis. We have learned that the skin is in an 
irritable or inflamed condition previous to appearance of the 
sycosis, and that the irritation from the hairs acting upon 
this changed tissue produces the peri-folliculitis. This irrita- 
bility must be removed, as well as any actual inflammation or 
inflammatory products in the affected part. The same rules 
for treatment hold good here as in inflammation or irritability 
in any other part of the body, and the physician must know 
those rules and have a clear idea of the exact nature of the 48 
process going on in the part in the different stages and con- 
ditions of the disease. Knowing those things, he cannot fail 
to cure quickly every case of ordinary sycosis. 
All the drawings have been made by myself by means of a 
camera-lucida, and are exact reproductions of the appearances 
presented. Owing to severe illness and limited time, I have 
been unable to make as many drawings of the changes which 
take place in the pustular stage as I intended to do. I studied 
the sections, however, carefully, and have endeavored to de- 
scribe the changes. 
In conclusion, I have to express my thanks to Drs. M. H. 
Henry and L. D. Bulkley, of this city, for living material 
obtained from some of their patients, and also to the artist, 
Mr. 0. F. Ruestow, for the manner in which he has executed 
the woodcuts. 
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