CORNELL UNIVERSITY LIBRARY FROM The Estate of S.Simpson ujrYiaaa^^' University Library A practical Treatise on diseases of the 3 1924 031 248 408 oiin,anx The original of tliis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924031248408 ^^-^d«- 0^ c^aSi^-^ WILSON ON THE SKIN. ON DISEASES~OF THE SKIN. BY ERASMUS WILSON, F R. S., Author of "A System of riuman Anatomy," &c. A NEW AMERICAN, FEOM THE LAST AND IMPROVED LONDON EDITION, In one large and handsome octavo "volumej extra clolh, $2 75. Also, with fifteen Steel Plates, of which eight are exquisitely colored, $1 00. A? a practical guide to the classification, diagnosis, and treatment of the diseases of the skin, the book is complete. We know nothing, considered in this aspect, better in our lan- guage ; it is a safe authority on all the ordinary matters which, in this range of diseases, engage the practitioner's attention, and possesses the high quality — unknown, we believe, to every older manual — of being on a level with science's high-water mark — a sound book of practice. — London Medical Times. We have read this edition of Wilson on Diseases of the Skin with unusual interest, and cannot hesitate to recommend it as the most complete and satisfactory work on the subject now extant. — Medical Examiner. The " Diseases of the Skin," by Mr. Erasmus Wilson, may now be regarded as the stand- ard work in that department of medical literature. — Mcdico-Ghirurg. Review. It is extremely minute, accurate, and comprehensive, though concise ; the treatment, though succinctly, is amply indicated ; and the work will fairly contest with that of Rayer, the merit of being the bgaLon the subject which we possess. — The New York Journal of Medicine. " BY THE SAME AUTHOR — {Just IsSUed.) HEALTHY SKIlSr: A POPULAR TKBATISB ON THE SKIN AND HAIR, THEIE PEESERVATION AND MANAGEMENT. SECOND AMERICAN, FEOM THE EOUKTH AND KEVISED LONDON EDITION. WI-TH NUMEROUS I LLUST-RA-r I ONS. In one neat royal 12mo. Tolume, of about three hnndrecl pages; extra cloth, $1. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. WITH FOUR EXQUISITE COLORED PLATES, PRESENTING MORE THAN THIRTY VARIETIES OF SYPHILITIC ERUPTIONS. In one beautiful octavo volume, extra cloth, $2 25. BLANCHAED & LEA HAVE JUST ISSTTED AN ATLAS OF CUTAIEOUS DISEASES. BY J. MOORE NELIGAN, M. D., M. R. I. A., &o., In one very handsome quarto volume, extra cloth. WITH SPLENDID COLORED PLATES, PEESENTIMG NEAELY ONE HtrNDHED ELABORATE REPRESENTATIONS OF DISEASE, COLORED AFTER NATURE. Price $i 60. This beautiful volume has been prepared by the author as an accompaniment to his "Practical Treatise." No pains have been spared to render the iigures accurate and trustworthy portraits of a class of affections which, perhaps more than any other, require this mode of pictorial elucidation, and as the two works contain references from one to the other, taken together they may be said to constitute a complete manual on the pathology, diagnosis, and treatment of cutaneous affections. A compend which will very Tnuch aid the practitioner in this difficult branch of diag- nopis. Talien with the beautiful plates of the Atlaa, which are remarkable for their accu- racy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man. — Buffalo Med. Journal, Sept. 1856. Nothing is often more diflEcult than the diagnosis of disease of the skin; and hitherto the only works containing illustrations have been at rather inconvenient prices — prices, indeed, that prevented general use. The work before us will supply a want long felt, and minister to a more perfect acquaintance with the nature and treatment of a very frequent and trou- blesome form of disease. — Ohio Med. and Surg, Jbumalj July, 1856. The lithographs are so colored as to be true and faithful representations of those ninety varieties of a class of diseases whose exact diagnosis is thus made plain and easy, and which, in the absence of such aid, or a long and attentive study, is so difficult that very few practi- tioners seriously attempt it. The work is cheap, and no practitioner ambitious of a high professional status can afford to dispense with such helm.— IfdshvtUe JaumaZ of Medicine, Sept. 1866. ' One of the handsomest of the many reprints that the eminent publishing house of Elanchard & Lea have given to the medical profession of this country is the set of illustra- tions of cutaneous diseases by Dr. Neligan. As specimens of the lithographic art, we doubt whether superior can be found in any of the numerous works on skin diseases that have, from time to time, been issued from the celebrated publishing houses of the Old World. — LcmisviUe Ee/vuw, July, 1856. Neligan's Atlas of Cutaneous Diseases supplies a long existent desideratum much felt by the largest class of our profession. It presents, in quarto size, sixteen plates, each contain- ing from three to six figures, and forming in all a total of ninety distinct representations of the different species of skin affections, grouped together in genera or families. The illustra- tions have been taken from nature, and have been copied with such fidelity that they pre- sent a striking picture of life ; in which the reduced scale aptly serves to give, at a amp fanl, the remarkable peculiarities of each individual variety. And while thus the disease IS rendered more definable, there is yet no loss of proportion incurred by the necessary con- centration. Each figure is highly colored, and so truthful has the artist been that the most fastadious observer could not j ustly take exception to the correctness of the execution of the pictures under his scrutiny.— ifo««rea! Med. ChronicU. PRACTICAL TREATISE DISEASES OE THE SKIN. BV J. MOOEE KELIGAN, M.D.,M.R.I.A., HONORARY FELLOW OF THE SOCIETY OF PHYSICIANS OF SWEDEN; PHYSICIAN TO JERVIS-STREET HOSPITAL ; AND LECTURER ON PRACTICE OF MEDICINE IN THE DtTBLIN SCHOOL OF MEDICINE. Seronb '^mexitan ffibition. PHILADELPHIA: BLANCHARD AND LEA. 1857. PHILADELPHIA : T. K. AND P. iJ. COLLINS, PHINTEES. ROBERT J, GRAVES, M.D., F.R.S., M.R.I.A., THIS VOLUME IS INSCEIBED, AS A MAKK OP PROTESSIONAL RESPECT AND OF PRIVATE ESTEEM. 1* AMERICAN PUBLISHERS' NOTICE. In supplying the demand which has called for another edition of this little work, the publishers have inserted in their appropriate places references to the figures of Dr. Neligan's very handsome "Atlas of Cutaneous Dis- eases," just issued by them. - The object of the author, in the preparation of his Atlas, was to B.upply a series of illustrations adapted to the present volume, presenting those points of diagnosis which cannot be conveyed by mere description, however graphic ; the two works may therefore be regarded as constituting together a single treatise. Philadelphia, April, 1857. PREFACE. In submitting the observations contained in the following pages to the profession, the author has been influenced chiefly by a desire to offer, as an aid to the diagnosis and treatment of an important class of disd&ses, the results of an experience acquired during several years' special atten- tion to the study of cutaneous eruptions. Of late years the British medical press has abounded with monographs on other special afi'ections, but few have been published on those of the skin ; he has, therefore, thought that a concise practical treatise on them might find favor with the pro- fession. As regards the plan adopted in the construction of the •work, the only points requiring notice are the omission of the details of cases which might be cited to prove the cor- rectness of the views propounded, and the slight reference to other writers on the same subject: for both the only apology he has to ofier, is his anxious desire to condense X PREFACE. the inquiry he proposed to himself, within as narrow limits as possible, being fully aware "how great an evil a great book" is to the physician busily engaged in practice. 17 Mebeion Square, East DnBLiN, June 1, 1852. CONTENTS. CHAPTER I. Classification 13 CHAPTER II. Exanthemata 80 CHAPTER III. Yesicul^ 63 CHAPTER IV. PUSTIL^ 116 CHAPTER V. Papula 145 CHAPTER VI. Squama 1^8 CHAPTER VII. Hypertrophic 199 CHAPTER VIII. HsMOREHAai^ 226 xu CONTENTS. CHArTER IX. MaodljE ■ 2o7 CANCBODBa CHAPTER X. 246 Dermatopiiyi^ CHAPTER XI. 264 Tub Syphilides CHAPTER Xir. 281 CHAPTER Xlir. Diseases of the Appendages op iue Skin . 304 CHAPTER XIV. Therapeutics of Diseases or the Skin . 309 Index DISEASES OF THE SKIN CHAPTER I. CLASSIFICATION. There is no class of diseases which should interest the practitioner or student to a greater degree than those of the skin, 'and they are especially deserving of study in con- sequence of the difficulties 'which attend their diagnosis, and the ohstinacy with which they resist most of the re- medial measures that have been hitherto proposed for their treatment. It is only by prolonged practical experience, acquired after a careful and properly directed study of their varied characters, and an investigation into their peculiar pathology, that even a moderate degree of know- ledge of them can be obtained. In their early stages they are often simple and uncomplicated in form, and, conse- quently, easy to be recognized; but when they become chronic they are generally so changed and altered, that it is often very difficult to discover to what special class or order the peculiar form of disease under observation may belong. The skin, which covers the entire of the external sur- face of the body, has many uses in the animal economy ; and, therefore, a diseased condition of it is attended, not alone with vast inconvenience to the person affected, but is also usually accompanied by a greater or less amount of derangement of the health generally. It is the organ or medium of touch ; serves for the defence of the muscles, bones, bloodvessels, and nerves placed beneath it ; is, more- 2 14 CLASSIFICATION. over, the organ of absorption and excretion ; and, as some recent, physiological writers have well observed, agrees, in many of its functions and properties, with the mucous membrane, of which it is manifestly a continuation, — the mucous membrane protecting the internal parts of the body, while the skin protects those that are external ; there is consequently a remarkable agreement between them. In deranged conditions of the skin, the mucous membrane becomes more or less engaged ; and, in diseases which affect the mucous membrane, the functions of the skin, as regards absorption and excretion, are also affected to a greater or less degree. Owing to the great obscurity which so long enveloped the study of this class of diseases, and the late period in the history of medicine at which any attempt was made to classify them at all regularly, a great deal is left for the inquirer, even of the present day, to clear up. Yet we have abundant evidence, in the writings of the Jewish, the Egyptian, the Arabian, the Greek and the Roman legis- lators and physicians, of their existence from the remotest antiquity; and that they were very numerous, often occur- ring as scourges of mankind, is ^asily proved by a reference to the Leprosy of the Jews, and the Elephantiasis of the Greeks and of the Arabians. Of late, much has been ex- pected from the employment of the microscope in discover- ing the exact nature of diseases of the skin, but in this ex- pectation we have, as yet, been more or less disappointed. It is true, that by its aid much valuable information has been gained, as to the normal structure of the skin, yet but little addition has been hitherto made thereby to our knowledge of its diseased conditions, more particularly with reference to their diagnosis and treatment, as based on minute anatomy. There is one important fact, however, which has been attained by the use of the microscope in the investigation of the nature of diseases of the skin, namely, the discovery that, in certain affections, a vegetable production — a cryptogamic plant— is present on the cuta- neous surface, and is evidently intimately connected with their true pathology. A difference of opinion exists as to whether these vegetable growths are the cause or the con- sequence of the disease in which they have been found to CLASSIFICATION. 15 occur; but there can be no doubt now that all, or at least nearly all, dermatologists admit the truth of the discovery, and consequently believe in the existence of these vegetable growths, a new classification, containing a group or order, of which the presence of these fungi will form the essential character, must be constructed. An important point of view in which diseases of the skin must be regarded, and one that adds much to their interest, is the effect they produce upon the system generally. We sometimes find that in persons who have labored even for a long time under these affections, but little constitutional derangement is, in many cases, caused by them — so little, indeed, that it has often been doubted whether the existence of an affection of the skin, in a chronic form, tends to shorten life, or should be taken into account in coming to a conclusion as to eligibility, in a medical examination, for assurance. For my own part I believe that as long as the individual remains unaffected with any acute or inflam- matory affection, the existence of a skin disease will not, in any respect, diminish the average chances of longevity ; yet I have no doubt but that a person laboring under any general cutaneous affection, the existence of which unques- tionably deranges the functions of this extensive membrane, must be more or less liable to have the symptoms of an ordinary acute disease, such as fever or any of the internal inflammations, aggravated, and the treatment rendered more diflicult and complicated by its presence. Thus, although a chronic affection of the skin may not directly tend to shorten life, yet it may do so indirectly. As, however, these various points will be more fully considered in speaking of each eruption individually I shall not dwell on them at pre- sent, but proceed to describe the classification of diseases of the skin which I propose to adopt. No subject in the study of medicine has created more difiiculty, or for a longer period tended to retard its ad- vancement, than that of nosological arrangements. It was at one time believed to be impossible to understand the nature of diseases or their proper treatment, virithout an intimate knowledge having been previously acquired of their classification, and we therefore find that all the writers on medicine of the last, and of the commencement of the 16 CLASSIFICATION. present century, sedulously devoted themselves to devise new systems, each more complicated than the other. As regards diseases generally, it is now agreed by all that the less complicated and more simple the classification under which they are arranged, for the purposes of description or of teaching, the more advantageous is it for the acquirement of a knowledge of them ; and few, therefore, take the trou- ble of making themselves acquainted with the labored sys- tems of Cullen, Sauvages, Mason Good, or the many noso- logists of their day. Simplicity, I need scarcely say, is of equal advantage in classifying any special set of diseases, as those of the skin ; yet even in our own time it seems to me to be strangely overlooked by dermatologists; writer after writer, impelled, as it were, by an ambition to devise something novel, propounds a new classification, careless how complicated and diflScult of being comprehended it may be, provided only it diifers from those which preceded. As in the arrangement of objects of natural history, so in that of diseases, a classification may be either artificial or natural; the former being based on external appearances, or those which come directly under the cognizance of our senses, without any respect to intimate nature, structure, or properties ; while the latter has especial regard to natural qualities, as a bond of afiinity. In addition to these two, a third has been adopted by some writers on diseases of the skin, which may be called a local or regional arrangement — that is, one in which they are placed in groups, de- pendent on the part of the body upon which they are seated ; but, of course, in this system, regard must also be had to the individual character and form of the various eruptions. Of the many systems of classification of diseases of the skin which have been, from time to time, proposed, two especially of those of the earlier writers are worthy of notice, not alone as being the first which had any preten- sions to accuracy or completeness, but as forming, to a cer- tain extent, the basis of most of those which have been since propounded— I allude to the artificial system of Willan, and the natural one of Alibert. Although Willan adopted, as the groundwork of his classification, an arrangement CLASSIFICATION. 17 originally proposed by Plenck — following out the idea of Riolanus put forth nearly a century previously — of placing diseases of the skin in groups, according to their form and appearances, yet from the accuracy and appropriateness of his nomenclature, which is that now almost universally em- ployed, and the clearness with which he defined the leading features of his general divisions or orders, it is correctly^ regarded as being the first important step made to the cor- rect understanding of diseases of the skin. Alibert, in the first instance, following Turner, an Englishman, who was himself preceded by Mercurialis, adopted a regional classi- fication, dividing all eruptions into two classes, as they were situated on the head or on the trunk of the body; but this he soon abandoned for a natural system, which, though grandly conceived, did not survive its author, being found too complicated and difficult of application when attempted to be reduced to practice. In Willan's system, cutaneous diseases are divided into eight orders, characterized by the form of the eruption, viz: — Papulae. Vesiculae. Squamae. . Pustulae. Exanthemata. Tuberculse, Bullae. Maculae. The distinctive features of the eruptions, by which these orders are characterized, he defined as follows ; and here I may again remark that his nomenclature and definitions are still in use, and generally recognized as correct : — ' 1. Papula (Pimple). — A very small and accuminated ele- vation of the cuticle, with an inflamed base, not containing a fluid, nor tending to suppuration. 2. Squama (Scale). — A lamina of morbid cuticle, hard, thickened, whitish, and opaque. 3. Exanthema (Rash). — Red patches on the skin, vari- ously figured, in general confluent, and diffused irregularly over the body, leaving interstices of a natural color. 4. Bulla (Bleb). — A large portion of the cuticle detached from the skin by the interposition of a transparent, watery fluid. 5. Vesicula (Vesicle). — A small, orbicular elevation of 2* 18 CLASSIFICATION. the cuticle, containing lymph, which is Bometimes clear and colorless, but often opaque and -whitish, or pearl- colored. 6. FustuM (Pustule). — An elevation of the cuticle, with an inflamed base, containing pus. 7. Tuhercula (Tubercle). — A small, hard, superficial tu- mor, circumscribed and permanent, or proceeding very slowly to suppuration. 8. Macula (Stain). — A permanent discoloration of some portion of the skin, often with a change of its texture, but not connected with any disorder of the constitution. Alibert, in his natural arrangement, considers cutaneous diseases to resemble a tree, which he terms Varhre des der- matoses, and the branches of which constitute the various divisions or groups, which are subdivided into genera. His primary groups, which are twelve in number, he designates as follows : — Dermatoses Eczemateuses. Dermatoses V6roleuses. Exanthema- Strumeuses. teuses. Scabieuses. Teigneuses. Hdmateuses. Dartreuses. Dyschroma- Canc^reuses. teuses. Ldpreuses Het6romorphes, Biett, the immediate and most celebrated pupil of Ali- bert, soon perceiving the difficulties which the complicated system of his master, though based on the natural affinities of the various eruptions of the skin, threw in the way of their successful diagnosis, forsook it for that of Willan, which he modified and so far improved that all the artificial systems of classification which have been proposed since his time include the changes made by him. Viewed abstractedly, it is manifest that a classification of diseases of the skin which, as a natural system is sup- posed to do, takes into account not merely the form but the essential nature and pathological characters of a cuta- neous eruption, should possess many advantages, both prac- tical and theoretical, over an artificial arrangement which takes cognizance merely of the alterations of the skin which cause the eruption, or, in other words, regards solely tlie CLASSIFICATION. 19 apparent changes in the cutaneous structure of the part affected. Consequently, we find that most modern writers on the subject have bestowed their attention on the construc- tion of a perfect natural system, but hitherto, in my opinion, without success ; amongst them all there are, I think, two only at all deserving of notice, that of Erasmus Wilson in England, and of Cazenave in France. Wilson adopts, as the basis of his arrangement, the anatomy and physiology of the skin, a groundwork which, owing to the additions recently made to our knowledge of this structure by microscopic investigation, and the degree of certainty which extended observation has stamped upon it, has been well employed by him, and renders his system of classification justly entitled to be designated a natural one. He constitutes ionv primary divisions of the subject, viz : — 1. Diseases of the Derma. 2. Diseases of the Sudoriparous Glands. 3. Diseases of the Sebiparous Glands. 4. Diseases of the Hairs and Hair Follicles. Of the first, five secondary divisions are made: 1. Inflam- mation of the Derma; 2. Hypertrophy of the Papillce of the Derma ; 3. Disorders of the Vascular Tissue of the Derma; 4. Disorders of the Sensibility of the Derma; 5. Disorders of the Chromatogenous Functions of the Derma. The first of these subdivisions constitutes six groups, viz : a. Congestive Inflammation, divided into two sub-groups ; the first including those affections, in which both the mucous membranes and the Derma are inflamed, and which are attended with constitutional symptoms of a specific kind; and the second, those in which the derma alone is engaged, and in which there are no specific constitutional symptoms ; h. Effusive Inflammation ; c. Suppurative Inflammation ; d. Depositive Inflammation ; e. Squamous Inflammation ; /. Inflammation from the presence of Acari. Of the second primary divisions, three secondary are con- stituted, as the diseases are attended with, 1. Augmenta- tion^ 2, Diminution; 3. Jilteration of Secretion. Of the third, five secondary divisions are made, as the diseases of the sebiparous glands are dependent on, 1. Aug- 20 CLASSIFICATION. mentation; 2. Diminution; 3. Alteration; 4. Retention, of Secretion; and 5. In which the Gflands and adjacent Tissues are inflamed. And the fourth constitutes six seeondarij divisions : 1. Augme7ited Formation ; 2. Diminished Formation ; 3. Ab- normal Direction of the Hair; 4. Alteration of Color ; 5. Diseases of the Hairs; and, 6. Diseases of the Rair Follicles. M. Cazenave, adopting likewise an anatomical basis for his natural system, arranges diseases of the skin in eight groups : — 1. Inflammations. 5. Hemorrhages. 2. Lesions of Secretion. 6. Lesions of Sensibility. 3. Hypertrophies. 7. Foreign Bodies. 4. Deteriorations. 8. Diseases of the Appen- dages. The first group contains four Orders : 1. Non-Specific Eruptions, which may exist in an acute or chronic state ; 2. Non-Specific Eruptions, existing always in a chronic state ; 3. Acute Specific Eruptions ; 4. Chronic Specific Eruptions. The second group is divided into three Orders: 1. Lesions of the Follicular Secretions ; 2. Lesions of the Epidermic Secretions ; 3. Lesions of the Coloring Secretion. The third group, which constitutes but a single order, is defined to consist in an abnormal development of the parts afi'ected. The fourth group contains those diseases which have a tendency to destroy the parts attacked. The fifth group is characterized by the presence of blood, more or less altered, without its proper vessels. The sixth group is divided into two orders : 1. General or Local Hyperaesthesia; 2. Ansssthesia. In the seventh group are placed those diseases which seem to depend on the presence of parasitical insects or animalcules. The eighth consists of two orders : 1. Diseases of the Hair; 2. Diseases of the Nails. Both these natural systems, the most perfect that have yet been proposed, present, in some respects, great advan- tages over artificial classifications, yet, I think, for many CLASSIFICATION, 21 reasons, are not to be preferred. Could we, for example, predicate that the various eruptive diseases, placed by Wil- son or Cazenave in the group of inflammations, were inva- riably characterized by inflammatory action, we should re- ceive an important aid, not alone in diagnosis, but in treat- ment. But such is not the case in the classific9,tion of either. Both place scaly diseases of the skin in the same natural group, though in a difi"erent subdivision, with the eruptive fevers ; yet can any two classes of diseases be more different in their nature ? The former characterized by a chronic inflammation of so low a form that it is very doubt- ful whether it should be designated as inflammation at all ; while the latter are especially marked by high inflammatory action : the former tedious and slow in their progress, often lasting for years ; the latter, acute and rapid, run- ning their course in a few days : the former requiring a prolonged constitutional treatment, and the latter demand- ing immediate and active remedies. Thus an erroneous impression, acquired from a supposed natural affinity between two eruptive diseases, may lead to error, both in diagnosis and treatment. Another important objection to the employment of a natural system of classification in the study of diseases of the skin is, that, being more complicated, and not so easy of comprehension, it is more difficult to be borne in mind than an artificial arrangement, and thus great obstacles are, by its adoption, thrown in the way of the student at the very threshold of his inquiry. No artificial classification of diseases of the skin can possibly be perfect, for different persons will, of course, form different ideas of the external characteristics and features of individual eruptions ; yet it is an arrangement which seems to me to be better adapted for attaining a knowledge of the subject ; and this, after all, is the only important use of any system of classification. It is especially one more easy to be remembered. It is one which aids us considerably at the bedside, for it requires a less complex process of reasoning than a natural classifica- tion, to discover by its agency what may be the disease in any special case. It is, therefore, this which I purpose to adopt. A regional classification of eruptive diseases, although it 22 CLASSIFICATION. is not adapted for a general inquiry into affections of the skin, possesses much value in their individual study, as they often present great differences in character and even in form, and frequently require peculiar modifications in treat- ment dependent on the region on which they may occur. I have thus adopted it in a small work which I published a few years since on Eruptive Diseases of the Scalp, and also in an Essay on those which affect the face, which appeared in the eleventh volume of the New Series of the Dublin Quarterly Journal of Medical Science. Were I to propose a regional system of classification, I would suggest that cutaneous eruptions should be divided into three groups : 1. Those which occur on parts of the body constantly exposed to the air; 2. Those which appear on parts that are pro- tected from the atmosphere by clothing ; and, 3. Those which affect the hairy scalp. The first group should be sub- divided into those which occur on the face (and neck in females), and on the hands ; for as the latter, especially in several trades and occupations, are exposed to various mat- ters which cause irritation, and as the skin there differs anatomically, in some respects, from that on the face, erup- tive diseases which affect them often present different appear- ances, as they are seated on either. Vesicular eruptions, in especial, present a peculiar character when they occur upon parts of the body covered with hair, — as, for example, on the scalp. If a blister be applied to the surface of the scalp, deprived of the hair, the blister, in common language, is said not to rise ; the epidermis upon this part of the body being not only somewhat thicker than elsewhere, except on the soles of the feet and palms of the hands, but being bound down by the numerous involutions which constitute the hair follicles. When, therefore, a vascular eruption occurs upon the scalp, there is no apparent vesicle; and this, I believe, will account for that great difference of opi- nion which exists amongst writers as to the nomenclature of certain eruptive diseases of the scalp, I allude especially to the forms of Herpes. The chief improvements which have been made on Wil- lan's original classification are contained in the systems of Biett, of Cazenave and Schedel in their joint work, and of Dr. Hughes Bennett of Edinburgh. Dr. Bennett's modifica- CLASSIFICATIOlsr. 23 tion of Biett's arrangement has been published in the Edin- burgh Monthly Journal of Medical Science for April, 1850, and is, in many respects, deserving of commendation. The great difficulty in devising an artificial system of classification of cutaneous diseases depends upon the changes ■which, in the progress of the disease, all eruptions undergo, "with respect to their characteristic form and appearance. These changes are often so great that it is sometimes almost impossible to diagnose to -what order a special eruption may belong in its advanced stage, and it is therefore made to occupy a diiFerent place in diiFerent systems. For example, observers diflfer as to whether scabies, common itch, is a vesicular, a pustular, or a papular eruption. It certainly changes rapidly, in most cases, from vesicular to pustular, or the vesicles become mixed up with pustules ; but, in my opinion, it is always, in its primary stage, a vesicular eruption. In most diseases of the skin, we are, however, by careful observation, able to discover the elementary form of the eruption in the early stage of the disease : and from experience we shall always be able to diagnose, even in its most extreme changes, what the primary form was. This, of course, can only be learned by prolonged practical ex- perience. In proceeding to describe the system of classification of diseases of the skin which I intend to adopt, I wish, in limine, to disclaim any pretensions to originality. My chief object is to endeavor to simplify a subject which has often not received from the student and practitioner the attention it merits, owing to the difficulties with which complicated arrangements and ever-changing nomenclature have in- vested it. I shall therefore take advantage of the labors of those who have preceded me, and endeavor to reduce the grouping together of cutaneous eruptions to as few sub- divisions as attention to accuracy will admit. Mr. Plumbe was, I believe, the first modern writer to omit those afi'ections which are correctly termed Eruptive Fevers from the catalogue of diseases of the skin. Fabre, in his recently published Bibliothlque du Medecin-prati- cien, has followed his example, as also has Dr. Hughes Bennett in his proposed modification of Biett's system. On this subject Mr. Erasmus Wilson remarks : " It may be said 24: CLASSIFICATION. that the diseases comprised in the first sub-group [those characterized by inflammation of the derma and mucous membranes, with constitutional symptoms of a specific kind], viz : Rubeola, Scarlatina, Variola, &c., though heretofore considered and treated of as diseases of the skin, are, in reality, diseases of the system, of which the alteration in the skin is a symptom of comparatively secondary im- portance. I cheerfully assent to the validity of this argu- ment, but I am nevertheless unwilling to lose a group of diseases so rich and important to their illustration of the pathological changes wrought in and upon the skin by active inflammation." Independent of these high authorities I would, for my own part, have no hesitation in excluding eruptive fevers from being described amongst diseases of the skin ; to consider them still as such is directly opposed to the advanced position of modern pathology, and can only tend to difi"use incorrect ideas as to their essential nature. A few recent dermatologists have included amongst dis- eases of the skin some constitutional afiections, in which an eruption — of a special form always — occurs as a concomi- tant symptom, and, as regards the peculiar aflfection, is but secondary, and more or less unimportant. The diseases to which I allude are not met with in the British Islands ; they are the Frambsesia or yaws of South America and of the coast of Africa, the Radesyge of the north of Europe, and the Pellagra of Italy and of Austria. These have, I con- sider, no better claim to be classed amongst diseases of the skin than has the Plague, in consequence of its being attended with malignant pustules and boils. I shall, there- fore, omit them from my arrangement. I propose to divide cutaneous diseases into ten Groups or Orders, as follow: — 1. Exanthemata. 6. HypERiROPHiiE. 2. VBSicuLiE. 7. Hbmokrhagi^. 3. PusTULiE. 8. Macule. 4. PAPULiE. 9. Cancrodes. 5. Squamae. 10. Dermatophyte. Adding two supplementary groups, Syphilidbs and Dis- eases OF the Appendages of the Skin. CLASSIFICATION, 25 The disease contained in the Order Exanthemata are characterized by the occurrence, on a greater or less ex- tended surface of the skin, of a blush of inflammatorj red- ness, usually more or less elevated, which terminates in epidermic desquamation, in the form of fine mealy scales. The most essential character of the Order is, that the red- ness momentarily disappears on pressure with the finger. In one form of eruption, classed amongst the exanthemata, namely, erysipelas, the epidermis is very commonly raised in large blebs by serous effusion ; but this is evidently caused by the intensity of the inflammation which is present, takes place in the progress of the disease, and is not a constant or essential symptom. In general, the redness is in large uncircumscribed patches, or uninterruptedly diffused over the surface ; but in some forms it occurs in well-defined, regular spots. The essential nature of the exanthemata is, that they are inflammatory, and they seem to have their seat in the vascular rete of the derma. This Order corre- sponds with the second sub-group of the first group of the first secondary division of Wilson's Natural System, defined by him as " Inflammation of the derma, without constitu- tional symptoms of a specific kind." It contains four genera, ERYTHEMA, ERYSIPELAS, URTICARIA, ROSEOLA. The VESicuLiE are characterized by an eruption of vesi- cles or blebs, which consist in an elevation of the epidermis, varying in' size, in some forms minute (vesicles), and in some of tolerable magnitude (bullae or blebs), containing a trans- parent, serous fluid, which, with the progress of the disease, becomes opaque, and dries into thin scales or hard crusts. ' The fluid by which the elevation of the epidermis is caused in the vesiculse is at first transparent and albuminous, but after a short time becomes opaque, and often puriform. This order nearly corresponds with the second group of the first secondary division of Wilson, which he defines as "Effusive Infiammation of the Derma." It contains five genera: eczbmAj herpes, pemphigus, rupia, scabies. Wilson places scabies in a distinct sub-group, defining it to be " Inflammation of the derma, from the presence of acari." The third Order, PuSTULiE, is characterized by the erup- 3 26 CLASSIFICATIOK. tion of Pustules, — rounded elevations of the epidermis.con- taining pus, which, bursting, form scabs or thick crusts. The pustules may be of small size, and closely aggregated together, or large and isolated ; the former constituting the Psydraoia, the latter, the Phlyzaoia, of Willan ; a psydra- cious pustule being defined by him to be " a minute pustule, irregularly circumscribed, producing but a slight elevation of the cuticle, and terminating in a laminated scab," and a phlyzacious one, " of a larger size, raised on a hard, circular base of a vivid red color, and succeeded by a thick, hard, dark-colored scab." The epidermic covering of a pustule is much thicker than that of a vesicle, consequently it takes a longer time to maturate, or, in other words, to burst and form a scab or crust ; but in their advanced stage the diag- nosis between the two is sometimes not unattended with difficulty. The eruptions placed in this order correspond with those classed by Wilson in the third group of his first secondary division : " Suppurative Inflammation of the Derma." The genera are three in number : ACNE, impe- tigo, ECTHYMA. Wilson, howover, puts acne in a group, the definition of which that he gives being, " Inflammation of the glands and adjacent textures." The PAPULiE are characterized by an eruption of minute, solid elevations, — pimples, — generally reddish, but some- times of the natural color of the skin, containing neither serum nor pus, terminating in the desquamation of fine scales, and almost invariably attended with intolerable itch- ing. In some forms, the top of the pimple is of a reddish brown or black color, but this merely depends on the acci- dental presenqe of a small, dried crust of blood, usually efl"used by scratching. This Order contains two genera : LICHEN, PEURIQO. It Corresponds with the fourth group of Wilson's first secondary division, which he defines : " De- positive inflammation of the derma." The eruptive diseases contained in the Order Squam^ are characterized by the secretion of dry, laminated, whitish scales on the cutaneous surface, usually occurring in patches, often of a circular form. The scales, which are somewhat elevated above the level of the skin, readily fall off", to be again rapidly renewed ; the part which they cover is of a CLASSIFICATION. 27 smooth, glistening aspect, reddish, and dry. The Order corresponds with the fifth group of the first secondary division of Wilson's classification : " Squamous inflamma- tion of the derma." It contains two genera: PSORIASIS, PITYRIASIS. In the Order Hypertrophic, I include those diseases ■which are characterized by an hypertrophied condition of the derma or epidermis, or of both, or of the hair follicles. The term has been used much in this sense by Simon, in his " Anatomical Description of Diseases of the Skin ;" and from him I have adopted it. In its application it is nearly synonymous with the tuberculc of former artificial sys- tems of classification. The latter term, although probably not so faulty, when first employed to designate a group of cutaneous diseases, is, I think, highly objectionable at pre- sent, when it is invariably understood to designate a peculiar morbid deposit, and its application in any other sense must tend to cause confusion. Wilson, in his Natural System, has a group in which are placed those afiections that con- sist in an " hypertrophied state of the papillae of the derma;" but I propose to extend the application of the term, and to include in the Order those diseases in which the hypertrophy affects the other cutaneous structures. I shall place in it nine genera : ichthyosis, mollusoum, stearrhcea, ele- phantiasis, VERRUCA, CLAVUS, CALLOSITATES, CONDYLO- MATA, NCVI. The characteristics of the seventh Order, Hemorrhagic, scarcely require to be defined. In it there is a morbid alteration of the capillary circulation, accompanied by a changed or diseased condition of the blood, in which this fiuid, escaping from its proper vessels, is extravasated in rounded spots or patches beneath the epidermis, and also beneath the epithelium of the mucous and serous membranes. Bursting through the latter finer structure, more or less bleeding usually takes place from the surfaces of both these membranes. It contains but one genus, purpura. The Order Maculc is characterized by an alteration in the color of the skin, occurring usually in large patches, and unattended with any eruption. The natural color may be deepened, diminished, or altered in hue, and the affec- 28 CLASSIFICATION. tion lias its seat evidently in the apparatus of the skin which secretes the pigmentary matter. The Order corre- sponds with the fifth secondary division of Wilson : " Dis- orders of the Chromatogenous Function of the Derma." It contains two genera, vitiligo, which includes albmoismus, and EPHKLis. The Order Cancrodes contains those diseases of the skin in which many of their features resemble cancerous aiFec- tions. They are characterized by a degree of semi-malig- nancy, usually attended with foul ulceration of a slow and insidious nature, often with severe stinging pain, and a marked tendency to return after apparent cure, or after ex- cision, in the same or in remote parts of the cutaneous sur- face. It contains two genera: LUPUS, KELOIS. The tenth Order, DERMATOPHYTiE, I have adopted from Bennett. It includes those diseases of the skin which de- pend on, or are characterized by the presence of, parasitic plants. It contains two genera : porrigo, sycosis. Of the two supplementary Orders, the first — the Syphil- IDES — contains those eruptions of the skin which are ordina- rily termed secondary, being caused by, or consequent on, the introduction of the venereal virus or poison into the system ; and the second includes diseased conditions of the hair and nails. This classification, in the drawing up of which I have had chiefly in view an attempt to simplify what is admittedly a difiScult study, may be tabulated as follows : — CLASSIFICATION". 29 1. Exanthemata, 2. Vesicul^,- 3. Pustule, 4. Papula, . . 5. Squamje, , . 6. Hypertrophic, 7. Hemorrhagic,' 8. Maculc, . . , 9. Canceodes, . . 10. Dermatophyte,. Erythema, Erysipelas, Urtica- ria, Roseola. Eczema, Herpes, Pemphigus, Rupia, Scabies. Acne, Impetigo, Ecthyma. Lichen, Prurigo. Psoriasis, Pityriasis. Ichthyosis, Molluscum, Stear- rhcea. Elephantiasis, Ver- ruca, Clavus, Callositates, Condylomata, Nsevus. Purpura. Vitiligo, Ephelis. Lupus, Kelois. Porrigo, Sycosis. Supplementary G-roups: Syphilides. Diseases of the Appendages of the Skin. 3* 30 EXANTHEMATA. CHAPTEE II. EXANTHEMATA. The term "Exanthemata" was employed by the ancient writers on medicine to designate every variety of eruption of the skin ; but in modern days, and more especially since the time of Willan, it has been restricted to denominate a peculiar group of cutaneous diseases, — one so well defined by external appearances, that there is no difiiculty in diag- nosing any of its forms during all their stages. They are characterized by the sudden appearance, on a greater or less extended portion of the skin, of an inflammatory redness in variously shaped patches, which momentarily disappear on pressure, are usually attended with a slight elevation of the surface, and terminate in exfoliation of the epidermis. The diseases belonging to this Order are almost invariably accompanied by more or less inflammatory fever, and they thus constitute a natural group. In the treatment of them, however, we should be careful not to let this idea of inflam- mation being one of their marked characters, lead us to take too exclusive a view as to the remedial measures indi- cated ; for the attendant inflammation may be either of a low asthenic form, as it frequently is, or it may assume a highly sthenic type. In Erysipelas, one of the diseases included amongst the Exanthemata, the epidermis is often elevated by serous efi"usion into bullae, or even large blisters, which has induced some writers to describe it as a vesicular eruption; but these vesications are not a constant or necessary feature of erysipelas, and when they do occur are evidently dependent on the high degree of local inflammation which may be pre- sent. The four genera belonging to the Order are : Erythema, Erysipelas, Urticaria, Roseola. EKTTHEMA. 31 ERYTHEMA. Erythema [Inflammatory Mush) consists in an eruption of superficial, deep-red stains or patches, more or less cir- cumscribed, and slightly elevated, attended with heat and tingling, and terminating either in resolution, or with slight furfuraceous desquamation. It is non-contagious, of a mildly febrile character, and rarely a disease of much importance ; most forms of it terminating in a few days, and seldom becoming chronic. The erythematous eruption very frequently appears on the skin in the course of many acute affections, especially fevers and inflammatory diseases ; often occurs in dropsies, when it affects the depending parts of the body or those exposed to pressure ; may be produced by irritation of the cutaneous surface, as by the friction of the clothes or of the opposed surfaces of -the skin, as when it app^ears in the axillas or in the groins ; and is likewise caused on the un- covered parts of the body by exposure to harsh winds, or to the sun in travelling. The eruption may appear on any part of the cutaneous surface, but some of its forms occur with great regularity in certain regions of the skin. Several varieties of erythema nave been noticed by der- matologists, but all of them niay, I think, be described under three heads: — Erythema simplex. " papulatum. " nodosum. Erythema simplex (Atlas, PI. I. Fig. 1), under which I include the E. fugax, E. laeve, E. intertrigo, E, marginatum, and E. circinnatum of other writers, is generally a very mild form of eruption of the skin, requiring but little atten- tion, unless when it assumes a chronic character, — as in- tertrigo, when neglected, or when the causes by which it is produced are continued, not unfrequently does. It appears in the form of uncircumscribed red patches, seldom exceed- ing the size of the palm of the hand, and scarcely elevated above the surrounding skin ; it generally occurs in the course of some inflammatory disease, when, owing to the patches 32 EXANTHEMATA. suddenly disappearing, and again as suddenly re-appearing on some other part of the body, it has been termed erythema fug ax ; it also assumes the same character as indicative of or connected with derangements of the digestive organs, or obstructed menstruation. The usual seat of this sub-variety is on the face, the neck, the trunk, or the upper extremities; there is no constitutional disturbance marking its occurrence, and the only local symptom is a slight degree of heat in the part attacked. Thus, then, it would appear to be a very unimportant disease, were it not for a remark of Hippocrates, the truth of which has been confirmed by most modern ob- servers, that the occurrence of erythema fugax in fevers or acute diseases is an unfavorable sign.. This form of erythema, when it occurs in dropsical per- sons, presents a bright red, smooth, and shining aspect, whence it has been termed erythema laeve (Atlas, PI. I. Fig. 2). It usually appears in rather large patches, which spread rapidly, and, if exposed to continued pressure, may end in ulceration, and even in mortification when the vital powers are very low. The sub-variety, which has been denominated intertrigo, occurs very commonly amongst children, whose fine skin may have been chafed from any local irritation, as from the surface not being suflSciently cleansed from dirt or from the natural secretions ; it also appears in adults, especially during hot weather, in whom it is usually produced by the friction of opposed surfaces of the skin, or by rubbing of the clothes. In its commencement it is characterized by the ordinary appearances of an erythematous eruption, but afi"ecting, as it chiefly does, those parts of the cutaneous surface in which the sebaceous glands most abound, it is soon attended with a diseased exudation from both the seba- ceous and sudoriparous glands, and the parts are coated with moisture of a fetid and acrid character, which keeps up the inflammatory irritation, and may even cause troublesome ulceration. The two other sub-varieties of erythema simplex were named by Willan from the form which they assume, the one, circinnatum, which occurs in small, round, slightly elevated patches, while the other, marginatum (Atlas, PI. I. Fig. 5), is more elevated at the edges than in the centre, EEYTHEMA. 33 the margin being thug 'well-defined, — the patches are gene- rally of a deep-red hue. The former occurs, for the most part, during some inflammatory disease, with the cessation of the acute symptoms of which it usually disappears ; and the latter seems to be a form which erythema simplex fre- quently assumes in the old. Erythema papulatum (Atlas, PI. I. Fig. 3) is of frequent occurrence, especially in young persons about the age of puberty, and in females in whom the menstrual functions may have been obstructed. It appears most generally on the backs of the hands and fingers, but also occurs on the face, the neck, and other parts of the body. It is character- ized by an erythematous blush on an uncircumscribea sur- face of the skin, on which there are numerous small, round elevations, about the size of a pea, of a deeper red hue, the portions of the skin between the elevations being always of a paler or less bright color. The commencement of an attack of this variety is attended with some fever, headache, and slight nausea, and there are heat and a disagreeable sensation of tingling in the affected parts, which are also slightly sore to the touch. This form of the eruption is of no great importance, lasting usually for only a few days, and very rarely assuming a chronic character. Sometimes rather larger elevations are intermixed with the others, or they may all from the commencement assume the size of a nut or a large marble, when the variety has been named tuberculatum; it presents this character most frequently on the extremities ; the raised spots are there harder to the touch, attended with more local annoyance, and the erup- tion more frequently becomes chronic. Erythema nodosum (Atlas, PI. I. Fig. 4), is so called from the appearance which the eruption presents. It usu- ally occurs on the anterior aspect of the lower extremities, generally from the knee to the ankle. I have seen a few cases in which it was situated on the back of the arms, and- have also occasionally seen a few spots on the anterior sur- face of the body. ^It appears in distinct rounded or oblong red patches, from half an inch to even two inches in diame- ter, with a well-defined border, circumscribed, and slightly elevated in the centre, — but the elevation is more apparent 34 EXANTHEMATA. to the eye than to the finger when passed over the part. The centres of the patches or knots are of a somewhat brighter color than the borders, which have a dark red blush ; the general redness fades but slightly on pressure, which, however, causes pain, and on the pressure being re- moved the color immediately re-appears. This form of erythema is most generally met with in young girls from the age of 14 to 19 or 20, rarely appearing in males. It has been described by some as being connected with a deranged state of the menstrual functions, but in my expe- rience I have rarely seen it produced by such a cause. It is attended with more fever than any of the forms of ery- thema, being generally ushered in with nausea, sometimes even vomiting, pains in the back, loins, and head, together with loss of appetite and slight shivering. This state may continue for from twelve to twenty-four hours. The patient then feels a sensation of heat and tingling on the fronts of the legs, and on examination the characteristic eruption is seen. The knots or patches appear simultaneously over the surface, not coming out in succession, increase in size and become harder and more painful for three or four days, then deepen in color until the eighth or tenth day, when they begin to fade, and passing often through the green and yel- low stages of a bruise, disappear with slight desquamation of the epidermis in about a fortnight or three weeks from the commencement of the attack. The seat of erythema is manifestly in the vascular struc- ture of the derma, the nervous functions being but little affected; the causes by which it is produced have been already adverted to. An epidemic of erythema has been described as having- occurred in Paris in 1828-29, as a complication of a painful affection of the extremities, thence termed Acrodynia, which raged there at that period. M. Cazenave, who witnessed it in the Hopital St. Louis, de- scribes its characters as consisting in " an erythematous circle of a crimson color appearing on the soles of the feet, and on the palms of the hands, covering a space of from a third to two-thirds of an inch, and disappearing under the pressure of the finger; it presented the peculiarity that the portion of the skin which surrounded it was generally of a yellowish color, swollen and very hard, while the affected ERYTHEMA. 35 patch was manifestly depressed and very painful to the touch. These spots of erythema also appeared occasionally on the thighs, the scrotum, and in the axilla." The diagnosis of any of the forms of erythema is in very few instances attended with much difficulty. It may be mistaken for the milder forms of erysipelas, especially in their early stage, hut the hlush of erythema is of a deeper red, and less livid than that of erysipelas, is not attended with the same amount of local tumefaction, burning heat, and pain, and is marked by much less disturbance of the system generally, and . mtich less fever. That form of ery- thema simplex which has been named fugax has sometimes been mistaken for urticaria evanescens ; they are both exan- thematous eruptions ; but in the latter the eruption disap- pears and re-appears with constant rapidity, generally in the same places; while erythema fugax, though nearly equally evanescent, does not return to the same parts ; it is, too, unattended with the acute itching and annoying tingling so characteristic of urticaria, and moreover occurs in the course of some disease of the general system, while urticaria evanescens is an idiopathic aifection. Erythema papulatum has sometimes been mistaken for some of the eruptive fevers, as for measles or scarlatina ; but its local character, its appearance upon the hands, and its papular elevation, serve to distinguish it from measles, in which the eruption is of a crescentic form, of a duller red color, and attended with a catarrhal fever. As regards scarlatina, the bright redness of the efflorescence and the acute inflam- matory fever, together with the sore throat of that disease, should suffice to render the diagnosis easy. Intertrigo may be confounded with chronic eczema, occurring behind the ears, in the axillae, or in the groins ; the latter, how- ever, is a vesicular eruption in its primary stage, and as it advances is marked by the copious serous discharge, tume- faction, and deep red fissures, which so remarkably charac- terize the disease. The prognosis in any form of erythema is, of course, very favorable; all the varieties being of-a sligTit character, lasting but for a short time, and the patient recovering without any detriment to the general health. Treatment. — In the very common form of erythema sim- 36 EXANTHEMATA. plex, caused by exposure to the heat of the sun or harsh winds in travelling, nothing further is required than anoint- ing the parts affected with some mild oleaginous application, such as cold cream or fresh olive oil : a common domestic remedy, but not so eflScacious as the cream of cow's milk. When the eruption occurs in the course of any acute disease, no local application should be used except the warm bath, if it is not otherwise contra-indicated ; and where it is symp- tomatic of any derangement of the digestive organs or of any other part or function of the general system, the con- stitutional, not the local affection should be treated. In erythema laeve the parts should be carefully protected from pressure, gently sponged with the dilute solution of subace- tate of lead warmed, then well dried, dusted over with flour, and enveloped in raw cotton. When the disease appears inclined to spread, I have found linen wet with the lead- wash and covered with oiled silk, the best application. Erythema intertrigo is sometimes very obstinate, espe- cially in children, when it occurs behind the ears, as it very frequently does. As a preventive, and in the early stages, dusting the parts with very finely powdered lapis cala- minaris is often useful ; but when it becomes at all chronic, an ointment consisting of two grains of the carbonate of lead, half an ounce of white wax ointment, and half a drachm of glycerine, is better adapted. With some very chronic cases, all greasy applications seem to aggravate the disease, when I have seen it rapidly get well from the use of a lotion containing three grains of the sulphate of copper in an ounce of elder-flower water, applied on lint, kept con- stantly wet with it. In adults, intertrigo of the groins is occasionally very troublesome and sometimes obstinate, especially when the irritation is kept up by walking; the cucumber ointment of the French pharmaceutist has proved more successful in my hands in these cases than any other application : in the commencement of the eruption it gene- rally affects a cure in a few days, the affected parts having been each time previously cleansed with a moist towel, and then dried ; it should be rather thickly smeared over them three times a day. If the cucumber ointment cannot be obtamed, an ointment prepared by rubbing together two grains of acetate of zinc dissolved in a drachm of rose- ERYSIPELAS. 37 water, and an ounce of cold cream, may be substituted for it. Erythema papulatum is best treated in young persons by mild antiphlogistics, especially the saline cathartics, or emeto-cathartics. When the accompanying fever is at all well marked, and the disease occurs in robust constitutions, the use of a mixture containing two grains of tartar emetic and two ounces of sulphate of magnesia in a pint of water, of which a wine-glassful is taken every second hour until vomiting or purging be produced, is generally attended with much benefit. When it attacks old persons, or assumes the tuberculated form, tonics, as the compound tincture of bark in infusion of quassia or of calumba, are indicated; the strength also should be supported with nourishing diet, and wij:ie allowed. Should this variety of erythema be asso- ciated with deficient or obstructed menstruation, the prepa- rations of iron will in general be found beneficial, unles? the derangement be accompanied by plethora or local con- gestions, when of course an antiphlogistic plan of treatment should be adopted. Erythema nodosum, lite the form last described, is not benefited by local applications, if we except the general warm bath which may be used every second or third day. The patient should remain quiet in bed, and live low until the feverish symptoms abate ; saline antiphlogistics, the bowels having been previously freed by a mild mercurial purge, are of much service; of these, a good form is a mixture consisting of half an ounce of bitartrate of potash, a drachm of borax, two drachms of white sugar, and twenty fluid ounces of water, of which two ounces may be taken every sixth hour. While the use of the general warm bath, as above remarked, is usually productive of much benefit in this form of erythema, local baths, such as the foot-bath, generally aggravate the disease, in consequence of their determining an increased afflux of the blood to the affected parts. EEYSIPELAS. , Erysipelas {St. Anthony's Fire) is characterized by a difi'used shining redness of the skin, attended with burn- ing heat, pain, tumefaction, and a tendency to spread, and terminating in resolution with or without previous 38 EXANTHEMATA. serous effusion beneath the epidermis, in suppuration, or in gangrene. It may be conveniently considered under two gangrene divisions : — Erysipelas idiopathicum. " traumaticum. Cazenave arranges the varieties of it which have been described into three groups : True erysipelas, in which the inflammation is confined to the skin ; Phlegmonous erysipe- las, in which the disease extends more or less deeply into the sub-cutaneous areolar tissue ; and Gangrenous erysipe- las, in which the inflammation terminates in mortification. Idiopathic erysipelas (Atlas, PI. I. Fig. 6) almost inva- riably attacks the head and face, so much so that some ■writers, amongst others Dr. Watson, propose to restrict the term to that disease in which this portion of the cutaneous surface is diffusely inflamed ; but the inflammation so fre- quently spreads from these parts to the integuments of the neck and trunk, and as in some cases it appears primarily even on the extremities, I cannot agree with this proposed restriction. In one case, that of a young man, eighteen years of age, who was brought into Jervis-street Hospital in the year 1846, every part of the cutaneous surface, even to the soles of the feet, was affected with idiopathic erysipelas; it had commenced on the integuments of one side of the face after exposure to cold, and spread so rapidly that, on the fifth day, the entire of the body was engaged in the disease; he died on the second day after his admission into the hos- pital, the seventh from the appearance of the eruption. Idiopathic erysipelas is, in nearly all cases, ushered in with well-marked febrile symptoms, shivering, pain in the back and limbs, loss of appetite, thirst, bad taste in the mouth, nausea, and rapid pulse, which, however, is often very compressible; the urine is scanty and high-colored, and the bowels costive. In a few cases, more especially in very old persons, or in broken-down habits, the local symp- toms are attended with very little constitutional disturbance. The erysipelatous inflammation frequently appears first on the tonsils, when the patient complains of the symptoms of an ordinary sore throat, but, on examination, they present a darker red hue than is usually present in tonsillitis, and ERYSIPELAS. 39 they are also more swollen. Within the next twenty-four hours diffuse swelling and redness appear on some part of the cutaneous surface of the face or head, accompanied by burning heat, pain, and tension, the pain being much increased by the slightest touch, resting the inflamed part on the pillow even being often intolerable. The surface pits on pressure with the finger, which also causes the redness to fade momentarily; the affected part is bright, shining, and swollen, but smooth. With the progress of the disease the tumefaction increases much, especially where the integu- ments are loose, as in the eyelids and ears, and around the eyes, so that on the second or third day the eyes are usually quite closed by the swelling. The local inflammation generally attains its height about the sixth or seventh day, when, if vesications have appeared, they burst, and- give exit to an acrid, transparent, watery discharge, which occasionally irritates the sound skin in the neighborhood over which it may flow. These vesica- tions rarely appear before the fifth day of the eruption, and run ^ very rapid course ; they vary in size from a few lines to an inch or more in diameter. The constitutional fever, which increases with the maturation of the eruption, being most severe on the fifth or sixth day, when delirium frequently occurs, declines with the diminution of the local symptoms; the redness now begins to fade, the swelling subsidies rapidly, and the disease terminates in favorable cases with desquamation of the epidermis on the tenth or twelfth day. When the erysipelatous inflammation extends to the sub- cutaneous tissue and deeper seated structures, the disease is denominated erysipelas phlegmonodes. This form appears more frequently on the extremities than on the head or trunk of the body. The constitutional symptoms by which it is ushered in, and which accompany it, are of a more severe character, and very frequently assume a typhoid type. As regards the local characteristics, the portion of the integu- ments affected presents a dull red or livid color, is intensely painful, hot, and tense, pits more deeply on pressure, and is more tumefied. The inflammation here very seldom ter- minates in resolution, suppuration usually occurring in the areolar tissue, with death and sloughing to a greater or less 40 EXANTHEMATA. extent to this structure, occasionally ending in mortification of the part attacked. Erysipelas spreads over the cutaneous surface often with great rapidity, yet assuming a regularly progressive course, the parts on which it first appeared being those, when the disease ends in resolution, which first desquamate. Thus it sometimes occurs that the eruption is fading from the face and the swelling disappearing there, while the disease is be- ginning to show itself on the side of the head or the neck. Erysipelas is in an occasional case seen to assume a singu- larly erratic course, fading rapidly from the part on which it appeared, and suddenly attacking another portion of the skin at some distance, not spreading to it by contiguity. This has been made a distinct variety by some writers under the name of erysipelas err.aticum. Dr. Graves was the first to notice a singular fact, as regards the mode of spreading of erysipelas, that when it commences at any point of the mesial line of the body it is very apt to spread in a symme- trical manner ;' that is to say, corresponding portions of the integuments are simultaneously attacked on both- sides. In the course of erysipelas, the inflammation sometimes attacks one or more of the internal organs, as the mem- branes of the brain, the larynx and trachea, or the gastro- intestinal mucous membrane. By some this is considered to be a metastasis ; and on this supposition it has been de- scribed as a distinct variety of the eruption under the name of erysipelas metastaticum ; but in all the cases that I have seen in which any internal part of the body became thus aifected, the local erysipelatous inflammation still remained unchanged, and therefore it could not be correctly termed metastatic. Traumatio erysipelas has its origin in some local injury which may or may not have caused breach of the surface ; it more usually, however, succeeds the former ; when it spreads from an ulcerated surface it is also said to be trau- matic. In its local characteristics it corresponds in most cases with the phlegmonous form of the disease, presenting, however, more efi"usion of the liquor sanguinis into the deep- seated tissues, in consequence, seemingly, of which, vesica- tions rarely appear on the surface. The inflammation is ' Clinical Medicine, Second Edition, vol. ii. p. 327. ERYSIPELAS. 41 also more diffused, spreading rapidly from the wound, and unless checked by treatment, rarely becoming circumscribed. The parts affected, too, are more apt to become gangrenous, a not uncommon result in bad constitutions. The general symptoms of traumatic erysipelas must frequently assume a typhoid type, and are attendant on, not antecedent to, the local inflammation. In some few rare cases of this form both the local and constitutional symptoms are very mild, and do not last for a longer period than a week or ten days ; in general, however, their duration is prolonged to from a fortnight to three weeks, if death does not take place at an early date. In idiopathic erysipelas death most usually occurs from the result of inflammation attacking some internal organ ; but patients occasionally sink under this disease with the ordinary fatal symptoms of asthenic or typhus fever. The traumatic form often terminates in gangrene, or, the veins becoming inflamed, purulent deposits take place in the lungs or liver, and the individual dies of phlebitic pneumonia or hepatitis. Erysipelas may occur at any age, even in new-born chil- dren, in whom it attacks the umbilical region, from whence, spreading rapidly, it almost invariably proves fatal. Gene- ral experience seems to prove that it is more frequent in females than in males, and in adult life than in the very young or the aged. The causes of erysipelas are at times very obscure, yet in many cases its origin can be distinctly ascribed either to some local action, as in the traumatic form, or when it is produced by some direct irritant, or to some general constitutional disturbance : indeed the latter may be said to be always requisite as a predisposing cause. Thus it is often seen to arise from the same causes as those which under other circumstances produce fever : it follows exposure to cold or wet, especially when the persons sq exposed are deprived of their usual food or stimulants ; I saw several cases of erysipelas of the face and head occur- ring in car-drivers and others, who from their occupation were much exposed to the weather, at the time when the temperance movement first occurred in Ireland, and in whom the disease was evidently traceable to the want of the stimuli which they had been previously in the habit of using 4* 42 EXANTHEMATA. freely. A very fatal form of erysipelas is caused by the introduction of an animal poison into the system, as by the inoculation of morbid matter arising from wounds received during dissection, from persons laboring under phlebitis, &c. Erysipelas may be produced by a sudden violent men- tal emotion, as a fit of passion, — such cases are on record, — in which the local determination of blood probably aids in the production of this disease. In young children vac- cination is sometimes the exciting cause of erysipelas, when it usually presents an oedematous character: I witnessed a case lately which thus arose, and in which the inflammation spread from the vaccine pustule on the left arm to the fin- gers, thence proceeded up along the fingers of the opposite arm, and stopped when it reached the same height on this arm that it originated from on the other: the child recovered. As to whether erysipelas is contagious or not, a singular diiference of opinion has always existed and still exists be- tween the practitioners of the French and English school ; the former laying it down as one of the characteristic defi- nitions of the disease that it is non-contagious, and the lat- ter with almost universal consent asserting that it is mark- edly contagious. The simultaneous occurrence of the dis- ease amongst a number of persons is attempted to be ex- plained away by the French writers on the principle that such persons were predisposed to it, or that an epidemic influence, or a peculiar atmospheric condition, reigned at the time. It is unquestionable that at certain seasons or during certain years, the contagiousness of erysipelas is more manifested than at other times, but this is equally true of all other contagious diseases. The direct proofs now accu- mulated are too numerous and too certain, I think, for the question to be any longer one of doubt, and no British sur- geon would, I feel confident, undertake an operation in an hospital in which erysipelas was present. The form of ery- sipelas arising from an animal poison is decidedly the most contagious ; the medical attendants and nurses are in such cases generally infected, and they convey the disease even to others. It has been often remarked that when puerperal fever — which is manifestly due to the presence of a morbid poison in the system — prevails, wounds are very apt take on erysipelatous inflammation, and the disease spreads rapidly ERYSIPELAS, 43 by contagion ; and likewise when erysipelas occurs epidemi- cally, that puerperal fever is apt to arise. The truth of these observations has been several times confirmed in the Rotunda Lying-in Hospital, and large surgical hospitals of this city. Persons who have had an attack of erysipelas are very liable to be again aifected with it, a distinguishing feature between it and the eruptive fevers. The diagnosis of erysipelas is rarely attended with any difficulty. From erythema, which, however, some derma- tologists regard as merely a mild form of erysipelas, it is distinguished by the attendant constitutional symptoms, the smoothness of the tumefied surface, the greater degree of swelling, and the burning pain and tension. It differs from the eruptive fevers in the uniform redness which the inflamed surface exhibits ; from phlebitis, in the absence of the cord-like feel which the inflamed veins present, and in the inflammation not spreading in lines over the track of the large vessels ; and from synovites in the inflammation not being confined to, or taking its origin from, the integu- ments covering the synovial membranes — but in many cases synovitis terminates in true erysipelas. The prognosis in idiopathic erysipelas is in general favorable, unless when the disease occurs in the very old, in broken-down habits of body, or in extreme infancy. The chief indications of danger are, the attendant fever assuming a low typhoid type, or some internal organ be- coming affected. When the erysipelatous inflammation attacks the larynx and glottis, which may always be ap- prehended when it is seated on the integuments covering these parts, it usually proves rapidly fatal, owing to the tumefaction which ensues, closing up the respiratory tube. Erysipelas of the phlegmonous character is always more dangerous than when the inflammation is superficial ; and in the traumatic form, unless the -local symptoms are very mild, the prognosis is always grave. With reference to the pathology of erysipelas it is evi- dently an acute inflammation of all the structures of the skin, the vascular rete being chiefly affected. M. Bhindin has propounded the theory that the seat of the inflamma- tion is in the capillary lymphatics, and M.M. Cruveilhier 44: KXANTHEMATA. and Ribes, that it is situated in the capillary veins of the integuments. The treatment of idiopathic erysipelas may be conve- niently considered under two heads — tlie constitutional and the local. As regards the former, many different views have been propounded, the supposed indications depending on the idea formed as to the essential nature of the disease. Thus those who believe it to depend on some deranged condition of the hepatic secretion — the prevalent opinion among them being that it is caused by a deficient secretion of bile and a consequent accumulation of it in the system — treat all forms of erysipelas, no matter what may be the age or condition of the patient, by the administration of remedies calculated to promote a copious evacuation of that fluid by the alimentary canal. Others, regarding it as a highly inflammatory disease, employ de- pletion, and other active antiphlogistics ; but this plan of treatment, although it may succeed in the robust dwellers in country districts, is not at all suited for the inhabitants of towns or large cities. With some, the affection being viewed as one of asthenia, being attended with or depen- dent on diminished vital power, the use of tonics and stimulants is relied upon ; while again, others, finding that the urine is highly acid in the early stages of the disease, as it is in all febrile affections, recommend an alkaline treat- ment. Seeing that these so opposite plans of treating erysipelas are reported by those who have proposed or adopted them as being attended with almost invariable success, we are forced to the conclusion, that in the ordinary run of cases constitutional treatment is of little importance. Unques- tionably cases occur in which there are extreme inflamma- tory action and high fever, demanding the use of bleeding and antiphlogistics ;' and others in which the vital power is so low and the accompan.ying fever assumes from the onset so marked a typhoid type, that the most powerful tonics, stimulants, and nutrients are clearly indicated. My owq experience, which, however, it is right to say, has been chiefly acquired in this large and crowded city, is decidedly jn favor of the tonic and stimulant plan of treatment. I ordinarily rely on the use of bark, which I give from the EEYSU'ELAS. 45 very commencement of the disease; in the very old or debilitated combining it with tincture of serpentaria, as in the following form : — R. Tincturse Cinchonae, fl 3iv. Tincturae Serpentariae, fl 5'ij- Tincturae Croci, fl Sj- Decocti Cinchonae, fl gxj. Misce. " An ounce to be taken every sixth hour." At the same time giving wine and nourishing diet accord- ing to the circumstances of each case. The preparations of iron are by many preferred to those of bark in the treatment of this disease ; their mode of action -would appear to be similar : the tincture of the sesquichloride, in the dose of from twenty to twenty-five drops every second or third hour, has been especially re- commended by Dr. and Mr. Bell, of Edinburgh, in a paper lately published by them.^ I consider the use of purgatives in the early stages of erysipelas as decidedly objectionable : they tend to increase the debility, usually so important a characteristic feature of danger, and, determining to the mucous membrane of the alimentary canal and to the abdominal viscera, their action prevents the full development of the eruption on the cutaneous surface, — a circumstance to be especially avoid- ed in the treatment of all inflammatory diseases of the skin, — and thus gives rise to local congestions and transference of the inflammation to some internal organ. The use of biliary evacuants has been very strongly supported in an excellent practical essay published by Dr. Albert Walsh f the remedy he recommends being tartar emetic, in rather minute doses, — one grain dissolved in a quart of some emollient drink, as whey or barley water, in the twenty-four hours ; he continues its use until the erup- tion begins to fade, when he administers sulphate of quina and other tonics. Mr. Lawrence is the chief advocate in the present day for bloodletting and active antiphlogistics ; but in his views, ' Monthly Journal of Medical Science, June, 1851. 2 Dublin Quarterly Journal of Medical Science, ^'ew Series, August, 1850. 46 EXANTHEMATA. as rewards the constitutional treatment of the disease, he has very few followers. If any internal organ be attacked during erysipelas, the most active derivatives to the surface should be employed. Thus, when the membranes of the brain are engaged, sinapisms and blisters should be applied to the legs, and warm stupes to the head ; active purgatives also are now indicated, and of these the most valuable is the turpentine enema. When the inflammation seizes on the larynx, leeches, even although great debility be present, should be applied beneath the angles of the jaws, and hot stuping to the throat, with relays of sponges assiduously employed; a blister to the nape of the neck is also here a valuable remedy. The operation of tracheotomy is not applicable in such cases, for the erysipelatous inflammation spreads rapidly downwards through the respiratory tubes, causing copious effusion into their sub-mucous areolar tissue. When erysipelas affects the scalp, the hair should be im- mediately cut as close as possible, with the view of keeping the surface cool, and of permitting local remedies to be more easily applied. In the milder forms of idiopathic erysipelas, the best and only local treatment requisite consists in dusting the in- flamed parts freely with wheaten flour or finely powdered starch, which may be conveniently applied from an ordi- nary dredging-box ; the dredging should be repeated several times in the twenty-four hours. It allays the burning pain and irritation, and rflways proves highly grateful to the patient ; therapeutically it appears to act by protecting the surface from the air, and by drying up the discharge as fast as it exudes from any vesications which may have formed. When the vesications are numerous, and the dis- charge excessive, I have found the addition of a drachm of oxide of zinc and twenty grains of finely powdered carbon- ate of lead to half a pound of starch of much advantage. In using this combination the mixed powders should be well shaken each time before the parts are dusted with them, as, in consequence of their specific gravity, the zinc and lead soon sink to the bottom of the vessel in which they are kept. Anointing the inflamed surface with melted lard is by ERYSIPELAS. 47 some preferred to the use of dusting powders. Mr. Wil- son speaks highly of his experience of it, having first, he says, employed it on the recommendation of Mr. Grantham, whose method is, " to relax the skin with hot water or steam fomentations, and after each fomentation to saturate the inflamed surface with hot lard, which is afterwards covered ■with wool." When erysipelas is spreading rapidly, although superfi- cially, over the cutaneous surface, the infiammation still persisting in the parts where it first appeared, inunction with mercurial ointment has in my experience more effect than any other local application in checking its progress. The ordinary mercurial ointment, to every ounce of which a drachm of glycerine has been added, should be smeared thickly over the inflamed surface, and on the sound skin for a considerable distance beyond ; it need be applied only twice in the twenty-four hours, and if any symptoms of salivation be produced, its employment should be at once stopped. Acting as an impermeable varnish, and probably produc- ing some efiect also by the compression it causes, collodion has been successfully employed by Spengler and Rapp as a local application in erysipelas ; the parts are thickly coated with it by means of a camel's hair pencil, and it is renewed as often as may be required in consequence of its cracking and peeling ofi" when dry. When the disease aifects one of the extremities, bandaging the limb has been used with very favorable results : this practice originated with the Conti- nental school ; its action seems to depend chiefly on the equable compression exercised on the congested capillaries and cutaneous veins, whereby they are emptied of the excess of blood contained in them; but some of the good effect pro- duced is also probably due to the protection from the action of the air thereby given. Phlegmonous and traumatic erysipelas demand more active local medication than when the inflammation aff'ects the superficial layers of the integuments merely. In these forms of the' disease many rely on topical depletion by leeches, by piinctures, or by deep incision. While leeches may produce a good effect by withdrawing blood from the inflamed superficial vessel, the determination caused to parts 48 KXANTHEMATA. on which their suction power is exerted is to a certain extent productive of mischief. The same objection does not hold with regard to punctures ; their employment has been highly advocated, amongst, others, by Sir Richard Dobson, by Listen, and by Wilson ; they should be made with a lancet, all over the inflamed part, at distances of from a quarter of an inch to an inch, according to the extent of the surface engaged, and penetrate to the depth of a quarter of an inch. As soon as they have nearly ceased to bleed, a warm bran poultice may be applied. Mr. Copland Hutchinson strongly recommended free incisions, and his practice has been adopted by Lawrence, Guthrie, and others ; they should be made down to the subcutaneous fascia, and be several inches in length. When there is much deep-seated effusion of the liquor sanguinis, as is so frequently the case in traumatic erysipelas, they are decidedly productive of the best effect, and they should never be omitted when matter has formed. Nitrate of silver is used in the treatment of erysipelas with two intentions, to check tbs spread of the inflammation superficially, and to promote resolution in the parts which have been attacked. With the former view a broad line or cordon is made on the sound skin, at a short distance from the margin of the inflamed surface, by the application of a solid stick of the nitrate on the part, previously wet with pure water ; when the disease is situated on one of the ex- tremities, this line is made to surround the limb completely. Mr. Higginbottom, who amongst English surgeons is the chief advocate for the use of this agent, at first recommended the employment of the solid nitrate to the inflamed surface ; but in his observations, recently published, and which con- tain the results of his accumulated experience, he states that ho prefers a solution containing a scruple of the salt to a drachm of distilled water. He gives the following direction for its application : " The affected parts should be washed well with soap and water, then with water alone, to remove any particle of soap remaining, and then wipe dry with a soft cloth : the concentrated solution of the nitrate of silver is then to be applied two or three times over the whole in- flamed surface, and beyond it on the surrounding healthy skin, to the extent of two or three inches." In twelve hours, should the erysipelatous inflammation be unaffected, it is to URTICARIA. • 49 be again applied; when vesications exist, they should be opened previously to the application. I prefer to use the nitrate of silver in the form of ointment, a drachm to the ounce of lard ; it thus comes more coo^iletely into contact with the inflamed surface, does not dry up so rapidly, and is more easy of application to some parts of the body, as to the scalp. Sulphate of iron, both in solution and in ointment, has been recommended as a most valuable local application in erysipelas by Velpeau, but I have not seen it prove so useful as nitrate of silver ; the solution which he uses contains one part of the salt dissolved in fifteen parts of water, and the ointment consists of one part of the sulphate to three or four of lard. Blisters are sometimes employed with success to prevent the spread of erysipelatous inflammation ; they are applied at the margin of the afi'ected surface : their eff'ect appears to depend on a new action being excited in the parts, and their use seems to prove especially of service in the erratic form of the disease. The only other local remedies requir- ing notice, are creasote, which, painted over the surface, has recently proved successful in the hands of some practition- ers ; and congelation of the siirface by means of pounded ice and salt mixed in a bladder, which has been proposed by Dr. Arnott : from the use of the latter it may be appre- hended that some internal organ might be attacked. Should erysipelas assume a gangrenous tendency, in addi- tion to the internal administration of the most powerful tonics, as wine, bark, and quina, the parts ought to be enve- loped with a charcoal poultice, and afterwards dressed with Ifnt soaked in a lotion, containing from one to two ounces of the solution of chlorinated soda orchlorinated lime to the pint of distilled water. URTICARIA. TJRTTCARii {Nettle-rash) may be defined to consist in an eruption of irregularly-shaped prominent patches, or wheal- like elevations of the skin, of a yellowish-white or reddish- yellow color, which are surrounded by a diff"use redness, are often evanescent, and are attended with a burning sensation, 5 50 EXANTHEMATA. tingling, and extreme itching. It is non-contagious, and is usually accompanied by a greater or less degree of fever; and it may be either acute or chronic, in the former case lasting for a few weeks, in the latter for months or even years. The name of this disease is derived from the resem- blance which the eruption bears, both in appearance and symptoms, to that occasioned by the sting of the common nettle — Urtiea urens. Willan describes several varieties of urticaria, and numerous subdivisions of it have also been made by other dermatologists ; but I think they may all be conveniently classed under three heads : — Urticaria febrilis. " evanida. " tuberosa. An attack of Urticaria febrilis (Atlas, PI. II. Fig. 1) is ushered in with the ordinary symptoms of mild fever — shivering, headache, hot skin, thirst, loss of appetite, pains in the limbs, and in many cases vomiting. In from twelve to twenty-four hours, the cutaneous surface becomes covered with numerous patches of the characteristic eruption, the parts on which it appears having been for a short time pre- viously the seat of a burning sensation, attended with ting- ling and itching. The wheal-like elevations generally ap- pear simultaneously on various portions of the body — ;on the face, the neck, over the back, and on the anterior aspect of the arms and legs ; they often disappear suddenly, and as suddenly re-appear on some other part of the skin. They bear much resemblance to the sting of a nettle, being slightly elevated, of a bright red color, with raised yellowish spots or lines ; in most cases the itching which attends them is very intense, and accompanied by a burning sensation, and additional patches are produced on the apparently unaffected surface by the patient rubbing or scratching the part. The eruption runs its course generally in from six to eight hours, but to be succeeded by a fresh crop on the same or on differ- ent parts of the body — in most cases appearing in the even- ing, and the out-break of which is attended, as before, with tingling and itching. Febrile urticaria is thus prolonged for a week or ten days, the eruption being less extensive and URTICARIA. 51 the constitutional symptoms less marked with each succes- sive crop; the general febrile symptoms subside to a certain extent when the rash comes fully out, but are usually again somewhat aggravated each time the eruption disappears. The epidermis of the parts which have been affected desqua- mates in fine mealy scales after the disease has subsided, but no stain or mark is left behind. When the eruption does not recede and again re-appear as now described, but remains permanently on the surface on which it first presents, it assumes somewhat of a more chronic character, lasting for three or four weeks, and is termed urticaria perstans. This sub-variety is attended with milder constitutional symptoms, and with less local irritation and itching. In the variety named conferta (Atlas, PI. II. Fig. 2) the local and general symptoms are precisely similar to those of urticaria febrilis, but in general more severe ; the patches of eruption are numerous, and coalescing cover a much more extensive surface of the skin. A form of urticaria has been described under the appellation of inter- viittens, in which the appearance of successive crops of the eruption assumes a regular intermittent type, usually quoti- dian, sometimes, however, more prolonged, being tertian or quartan, or the rash may not re-appear until the end of every seventh, eighth, or ninth day — coming out in the evening, attaining its greatest intensity during the night, and disappearing almost entirely before morning. Willan mentioned as a variety of this disease, under the name of suheutanea, what was manifestly chiefly a nervous irritation, there being constant and violent itching of the cutaneous surface commencing on some spot of one of the extremities, thence extending to the entire limb, to the trunk, and finally over the whole body, with only an occasional eruption of urticaria at distant intervals. Urticaria evanida (Atlas, PI. II. Fig. 3) is a chronic form of the disease, which not unfrequently lasts for years, and although unattended with fever, renders the life of the person who suffers from it almost intolerable, from the un- ceasing painful itching by which it is characterized. The eruption appears in small, rounded, reddish-yellow eleva- tions — often two, three, or more such, closely set together, forming a wheal like that caused by the lash of a whip — 52 EXANTHEMATA. with little, if any, surrounding redness of the skin ; they may appear on any part of the hody, but are usually de- veloped by scratching, or by friction of the clothes : in fe- males they are most frequently seated around the neck, where the upper part of the dress rubs the surface, and on the arms where they are likewise caused by the friction of the sleeves of the dress. The rash generally begins to appear towards evening, and is fully developed during the night, fading away before morning. The itching it occa- sions is most intense, causing absolute suffering, and persons even of the utmost fortitude cannot refrain from scratching violently the parts affected, by which an additional eruption is caused. The wheals do not remain longer on the surface than five or six hours, but they are renewed by the least local irritation, and the disease thus continues for months with occasional intermissions, being always most severe dur- ing the summer and autumn. After it has lasted for some time the general health becomes more or less affected,' both from the constant irritation it occasions and the derange- ment of the natural functions of the skin. Urticaria tuherosa (Atlas, PI. II. Fig. 4), which is a very rare variety of the eruption, occurs in the form of distinct, rounded elevations, about the size of a small walnut, hard and firm, extending evidently into the subcutaneous areolar tissue, of a livid red color, with a yellowish raised centre. The portion of the integuments affected is stiff, tense, and painful to the touch or on motion. The tumors generally appear on the extremities, coming out during the night with pain, much itching, and some fever, and nearly disappearing before morning, leaving the patient weak, tired, and sick. It is essentially chronic in its course, and very obstinate in its duration, sometimes extending to two or three years, or even longer, with short intervals of remission. Urticaria is of more frequent occurrence in females than in males, which may be accounted for by its seldom attack- ing any but those whose skin is fine and delicate ; for the same reason, while it appears not uncommonly in infants and children, it is not a disease of advanced life. The causes by which the febrile form is produced are, in most cases, well marked, but those on which urticaria evanida and urtica- ria tuherosa depend are not so manifest. A marked con- URTICARIA. 53 nection exists between the appearance of this eruption on the cutaneous surface and derangements of the digestive organs, or rather the irritation caused in some persons by- certain indigestible articles of food. Shellfish, especially mussels, oysters, crabs, cockles, periwinkles, and shrimps, have been long noted as producing urticaria in many indivi- duals, the eruption appearing in a few hours after any of them may have been eaten. Similarly it has been seen to arise after the ingestion of pork, veal, or goose, of salted, spiced, or dried meats or fish, of cheese, of honey, of many fruits and vegetables, particularly gooseberries, cucumbers, melons, mushrooms, pickles, &c. I know two persons in both of whom urticaria appears in half-an-hour after they have eaten almonds or nuts if the brown skins had not been previously removed. In all these cases the occurrence of the eruption must be due to some individual idiosyncrasy, with the nature of which we are unacquainted. The use of certain medicines, especially of copaiba or valerian, some- times gives rise to this disease ; in one instance which I witnessed, copaiba was given to a woman who was at the time sucking her infant, and urticaria appeared both on her- self and on her child. Frank mentions his having seen it occur from drinking Selters water. In the case of a boy, aged 15, who was admitted into Jervis-street Hospital in the mouth of December, 1851, for acute pleuritis, a copious eruption of urticaria appeared over the face, the upper ex- tremities, and the trunk, on the third day after his admis- sion ; the feverish symptoms had commenced to subside, and his system had been brought under the influence of mercury the day previously. Urticaria has been often noticed as occurring in connec- tion with other febrile diseases, especially with rheumatism, and Dr. Graves has pointed out the connection which exists between rheumatism, deranged conditions of the liver, and this eruption.' In children it frequently appears at the periods of dentition, being evidently associated with the gastric irritation which then occurs. Many have described some of the forms of this disease as being caused in the female sex by deranged states of the menstrual function ; but my experience is quite opposed to this view. ' CHnical Medicine, Second Edition, vol. i. p. 446. 5* 54 EXANTHEMATA. Urticaria occasionally appears as a complication of other cutaneous eruptions, more particularly eczema, impetigo, prurigo, and lichen. The diagnosis of urticaria cannot he attended with any difiBculty, its local characteristics are so well marked. From erythema it is well distinguished by the absence of the dif- fuse redness of the cutaneous surface, and by the intense itching which accompanies it. Erythema nodosum might be mistaken for urticaria tuberosa, but the evanescent cha- racter of the latter, even in its most chronic form, suflBces to diagnose it ; the former also is marked by the presence of acute febrile symptoms. Roseola, the only other of the exanthemata which might be confounded with febrile urti- caria, is not attended with the intense itching of this disease, and also differs considerably in the color and appearance of the eruption. One of the varieties of lichen has been termed urticatus, in consequence of the troublesome sting- ing by which it is accompanied, owing to which symptom it has been occasionally mistaken for and described as a form of urticaria, but it is a distinctly papular eruption. The prognosis in any of the forms of urticaria must be favorable, as may be understood from what has been already said. A few fatal cases of the disease, it is true, have been recorded by some of the older writers, but that they were instances of this eruption uncomplicated with an internal organic affection may well be doubted. We have, however, the testimony of Willan, that a case fell under his observa- tion in which death occurred from the sudden retrocession of the eruption about the fifth day ; but the patient was a very intemperate man, and had suffered from great pain in the stomach and nausea, which were much relieved when the cutaneous eruption came out, and delirium and high fever followed its sudden disappearance. The seat of urticaria is in the superficial layers of the derma and the epidermis ; as regards its pathology ^ it seems to be chiefly an affection of the nerves of the skin. From an analysis of the urine by Dr. Douglass Maclagan of Edin- burgh, he came to the conclusion that urticaria is intimately connected with a deficiency of the organic salts of the urine — urea and uric acid, and their probable retention in the system, and the correctness of this opinion is favored UKTIOAKIA. 55 by the connection, already adverted to, •which exists between this disease and rheumatism. Treatment. — The febrile form of urticaria requires the employment of antiphlogistic purgatives, and diaphoretics, or, should the fever run very high in full habits, local or general bleeding may even be requisite. The best purga- tive is the sulphate of magnesia given in the acid infusion of roses, with an excess of acid ; thus an ounce of the salt may be dissolved in twelve fluid ounces of the acid infusion, and to it two fluid drachms of dilute sulphuric acid be added ; of this the dose is a sixth part every, third hour until the bowels are freely moved : the purgatives should be repeated every second day as long as the feverish symp- toms have not subsided. Nitre whey given at bed-time forms a good diaphoretic, or two drachms of the water of the acetate of ammonia may be added to the whey instead of the nitre. Acting on his view of the pathology of the disease. Dr. Maclagan has treated it with colchicum ; and this medicine is certainly indicated when the eruption is complicated with rheumatism. When urticaria is produced by eating any particular article of food, an active and immediate emetic, such as the sulphate of zinc, should be at once administered, and its action followed by the exhibition of a mercurial cathartic ; if the subsequent fever be well marked, bleeding may be re- quired, but only a small quantity of blood should in any case be withdrawn, as general symptoms of poisoning, with much depression, not unfrequently follow. The intermit- tent form of the disease requires to be treated constitu- tionally with tonics and antiperiodics, especially the prep&,- rations of bark, the bowels having been first freely acted on by a saline cathartic ; this variety of urticaria may oc- casionally be cut short by the administration of an emetic a few hours previously to the expected reappearance of the eruption. In urticaria evanida a lowering plan of treatment is de- cidedly contra-indicated, as the disease invariably assumes a chronic form. I have derived especial benefit in it from the use of preparations of iron, and from the administration of Dover's powder ; of the former, I generally prescribe the 56 EXANTHEMATA. compound iron mixture in doses of two ounces every morn- ing, or twenty minims of the tincture of the segqui-chlo- ride three times a day in an ounce of the infusion of quassia or caluraha, or two ounces twice daily of Bewley's aqua chalyheata : of the latter, from eight to twelve grains every night at hed-time. Under the administration of these com- bined remedies, I have seen most obstinate chronic cases of the disease yield in a few weeks ; while administering them the bowels should be kept freely open by mild saline purga- tives. Urticaria tuberosa should be treated similarly ; but in cases in jvhich the disease has been of very long stand- ing, it will occasionally only yield to the prolonged admini- stration of arsenic. When any of the forms are connected with or complicated by the presence of any other disease, the treatment ought to be modified accordingly. The itching and tingling of urticaria are somewhat allayed by the use of the warm bath, but as soon as the skin is dried afterwards, these painful sensations are augmented in con- sequence of the friction of the surface requisite to remove the moisture. In febrile urticaria I have employed, as a local application, with much effect, the following alkaline spirituous wash : — R. Carbonatis Potassse, 3ss. Aquse Florum Sambuci, fl Sxiss. Spiritus Vini Rectificati, fl §ss. Misce. Pieces of lint saturated with the lotion should be laid on the parts where the itching is most troublesome. In the chronic forms of the disease, chloroform is an excellent topical remedy for the same purpose ; an ointment^ of it, prepared by rubbing together half a drachm of chloroform and an ounce of cold cream should be smeared rather thickly over the affected surface. Lotions and ointments, contain- ing prussic acid, opiates, and other narcotics, have proved successful in the hands of others. In urticaria occurring in infants and children, the state of the digestive organs demands especial attention, and in all cases whether the teeth are appearing or not, the gums should be lanced ; in infants at the breast, the health of the nurse is in particular to be attended to ; the local irritation, ROSEOLA. 57 at this early age, may be allayed by sponging the surface of the body wth a warm infusion of chamomile. Whenever the sudden retrocession of the eruption in urticaria is attended with evidences of derangement of any internal organ, the hot bath should be used, with friction over the surface, and blisters applied to the epigastrium and the nape of the neck. As regards the diet in urticaria, the chief point to be attended to is the avoidance of the use of any food which from individual experience, has been found to produce the eruption. In. the acute forms of the disease the patient should live low ; but when it becomes chronic, the food should be nourishing, yet not rich or heating. ROSEOLA. Roseola (Rose-rash^) is by many dermatologists regarded as being merely a variety of erythema, erysipelas, or mea- sles, and its existence as a distinct eruption not admitted ; but I fully agree with Willan, that its local characteristics are suflBciently well defined" to separate it from any of these diseases, and to require a special description. The name, which has been applied to it in consequence of the peculiar rose-color which it usually presents, is to a certain extent objectionable, as this color varies much in the different stages and forms of the eruption. It consists in the appear- ance of very slightly elevated rose-red patches, of irregular shape, transient, fading at times, and again re-appearing ; non-contagious, and attended with some degree of fever. The various forms of Roseola may be classed under two heads : Roseola idiopathica. " symptomatica. An attack of Roseola idiopathica (Ailas, PI. II. Fig. 5) is usually attended with slight fever, which, however, in children is sometimes well marked and severe ; the febrile symptoms subsiding to a great extent when the eruption appears freely oh the skin. It comes out in numerous ' In Scotland erysipelas is commonly termed " The Rose," whicli has caused this eruption to be occasionally confounded with it. 58 EXANTHEMATA. reddish-yellow patches, which soon assume a roseate hue, and are irregularly distributed over the cutaneous surface ; generally appearing first on the face and neck, and spread- ing quickly thence to the trunk and the upper and lower extremities ; occasionally the eruption is confined to the face, neck, and trunk, and at times it occurs on the extremi- ties only. The rash is often very transient, disappearing completely in from twenty-four to forty-eight hours — when the feverish symptoms become aggravated, and re-appearing again within the next twelve hours ; it usually runs its course in from five to seven days, terminating with slight epider- mic desquamation. When roseola occurs in infants and children, it is not unfrequently attended with more or less tumefaction of the integuments, which precedes the appear- ance of the eruption, being most marked in those places where the rash is to come out. Two forms of the disease have been described under the names sestiva and autumnalis, from their appearing at these seasons of the year : in the former, the feverish symptoms sometimes run high, and are attended with more or less sore throat, Avhich, on inspection, is seen to be somewhat swollen and of a bright rose-red color, — the rash, too, is very generally distributed over the cutaneous surface; in the latter the eruption is of a duller hue, in smaller-sized patches, and attended with very slight fever or sore throat — this symptom, however, being often absent. When the disease attacks infants, it has by some dermatologists been described as a distinct form, and termed roseola infantilis ; it is in them usually very mild, and disappears in a few days ; but in some cases is marked by itching, as would appear from the annoyance it seems to give the little pa- tient ; it is then also more prolonged. The eruption in idiopathic roseola not unfrequently ap- pears in the form of rings or circles, of a bright rosy hue, surrounding a healthy portion of the skin which is unaltered in color ; it is then termed roseola annulata (Atlas, PI. II. Fig. 6). This is a more aggravated form of the disease, setting in with well-marked symptoms of fever, a distinct shivering fit, followed by sickness of the stomach, headache, pains in the limbs, and hot skin, preceding the appearance ROSEOLA. 59 of the eruption for from twenty-four to forty-eight hours ; oedema of the integuments is also not uncommon in this form, particularly in children — in whom the disease usually occurs — appearing especially should the eruption suddenly retro- cede. In one case which I attended in 1849, that of a boy aged six years, the entire body became enormously swollen on the sudden disappearance of the rash, so much so that both eyes were closed, and there was great difficulty of breathing and of swallowing, owing to the tumefaction of the fauces. This variety of roseola may appear on any part of the cutaneous surface, but is most frequently seen on the lower extremities, and the trunk of the body. It comes out in the form of numerous small, round, reddish patches, which, rapidly spreading by their circumference, assume the character of rings, some being quite circular, and others irregularly so ; the central portion of healthy skin, which at first is only a few lines in diameter, gra- dually extends to half-an-inch, or even two inches, the surrounding rose-red eruption being from a quarter to half- an-inch in width : sometimes two or three of the rings, meet- ing, coalesce, and may thus extend beyond one of the joints, or nearly round a limb. Heat of the skin and itching gene- rally accompany this form of roseola. Mr. Erasmus Wilson describes a variety of roseola under the name of punctata, in which the eruption, attended with fever of a subacute type, appears on the mucous membrane and skin, " on the latter, in the form of small red spots around the mouths of the follicles, then becoming diffused so as to cover the greater part of the body, reaching its height on the third day ; at first of a bright raspberry red color, afterwards acquiring a dull roseate hue, the dulness increasing with the progress of the decline ;" — the disease lasts for ten da.ys. He speaks of it as a rare disease, having seen only a few examples ; I never met with it as an idio- pathic affection, but I have seen syphilic roseola present these characteristics. Roseola symptomatica occurs in the course of, or as an accompaniment to many febrile diseases, but its charac- ters are so similar to those of the idiopathic form as not to require a distinct description. It is thus witnessed in small-pox — the eruption of which it usually precedes by 60 EXANTHEMATA. about twenty-four hours — cow-pock, fevers, acute rheuma- tism, epidemic cholera, &o., and as it may attend any of these diseases, it has been named by dermatologists R. va- riolosa, R. vaccina, R. miliaria vel febrilis, R. cholerica, &c. When the practice of inoculation prevailed, roseola is described as appearing very regularly on the second or third day of the fever of incubation, and was regarded as a 'favorable sign, indicating that the variolous eruption would be mild. In cow-pock, it occurs about the period of maturation of the vaccine pustule, spreading from it along the arm, and often appearing also on the trunk ; it is not of very frequent occurrence, is of a very mild charac- ter, and fades away in two or three days. Its appearance during either fever or acute rheumatism is rather a favorable sign than otherwise ; it does not require any special treat- ment, nor does it interfere with that of either of these dis- eases. The cholera exanthem has been described by Keir, Babington, and Rayer, all of whom witnessed it in the epi- demic of 1832 ; it accompanied the fever of re-action, and its appearance does not seem to have in any way influenced the progress of the disease. Roseola may occur at any age, but is more frequent in the young than in the old. It may be caused by any local irritation of the skin, or by any circumstance acting on the system generally, which gives rise to determination of blood to the cutaneous capillaries ; the latter is evidently the cause of the symptomatic form of the eruption. In sum- mer it is occasioned by exposure to a hot sun when the digestive organs are deranged, or by the perspiration be- ing suddenly checked ; its frequent occurrence in autumn is traceable to the gastric irritation which is at that sea- son of the year so frequently caused by the too free use of fruit and new vegetables. In children it commonly appears about the periods of first and second dentition, and is manifestly connected with the derangements of the system which then so commonly exist ; and in infa,nts it is usually occasioned by the nurse's milk disagreeing with the child. _ ; With regard to diagnosis, roseola is an important dis- ease, as it is very liable to be mistaken for either measles or scarlatina. From the former it is distinguished by the ROSEOLA. 61 color of the eruption, so diiferent when it is fully deve- loped from the dull red hue of measles, by its not assuming the crescentic or horseshoe shape, and by the absence of the catarrhal fever. From scarlatina, with which, in con- sequence of the sore throat, it is in its early stage apt to be confounded, the color of the rash, its appearing in patches or spots, and not being generally diffused over the surface, the comparatively mild character of the fever and of the attendant sore throat, and the absence of the burning heat of the skin, are sufiScient to diagnose it. The distinguishing characteristics between roseola and erythema nodosum are, the elevation, the color, and the peculiar shape of the latter ; and the chief diagnostic features be- tween it and urticaria are, the absence of the intense itching and of the wheal-like eruption. The prognosis in roseola is always favorable, the eruption being attended with but slight annoyance, disappearing generally in the course of ten days, though occasionally pro- longed for three or four weeks ; but in all cases it is a simple affection, and one attended with little or no danger, and ,in many febrile diseases its occurrence is manifestly salutary. The treatment of the disease is simple ; rest in bed or even confinement to the house, with low diet, the use of diluent drinks, and, when the eruption is well out, mild pur- gatives, being sufficient in most cases to effect a cure. Mer- curial seem better adapted than saline purgatives for the treatment of roseola — with infants and children the hydrar- gyrum cum magnesia appears especially.to agree. Should the fever run high, and the eruption be slow in coming out, the warm bath will prove of service ; it should be always used with children. When there is oedema of the surface, small doses of the spirits of nitric ether and of the water of the acetate of ammonia are prescribed with benefit. In chronic cases, or in weakly habits of the body, should the disease become chronic, vegetable tonics and the mineral acids are indicated. If much itching or heat of surface attends the eruption, it will be allayed by a weak alkaline spirituous wash, such as the following: — B. Sodae Biboratis, 5s3. Aquae Florum Sambuci, . . . fl Sxiss. Spiritus Rosmarini, fl Sss. Misce. 6 62 EXAKTHSMATA. In most cases, however, no local application, except the general warm bath, or sponging the skin with warm water, will be needed. Symptomatic roseola requires no special treatment ap^rt from the disease which it accompanies, and the employment of any which might repel the eruption from the surface should be especially guarded against. ECZEMA. 63 CHAPTER III. VESICUL^. The term Vesicul^, formerly employed to designate any cutaneous eruption, in which matter was effused beneath the cuticle, was restricted by Willan to those forms in which the effusion is a transparent fluid, contained in mi- nute, orbicular, epidermic elevations, corresponding to his definition of a vesicle ; when these elevations were of larger size, the diseases in which they occurred were placed in a distinct class, denominated by him Bullae; but with re- spect to their visible phenomena, as they differ only in magnitude, I shall include both in one class. The Order Vesiculse, then, may be defined to be characterized by an eruption of vesicles or blebs, which consist in an elevation of the epidermis varying in size, sometimes minute (vesicles), sometimes of tolerable magnitude (bullae or blebs), contain- ing a transparent, serous fluid, which, with the progress of the disease, becomes opaque, and dries into thin scales or crusts. There are five genera contained in the Order : Eczema, Herpes, Pemphigus, Rubia, Scabies. Of these the first two are attended usually with acute symptoms ; pemphigus and rubia with fever of a low type ; and scabies with local inflammatory action, but very rarely with con- stitutional derangement. In all, the fluid contained in the vesicles becomes opaque and sero-purulent with the progress of the disease, and they are then often diagnosed with dif- ficulty from pustular eruptions. ECZEMA. Eczema {Seall or Humid Tetter) is a most important and interesting disease of the skin, being of extremely frequent occurrence, at times very difficult of diagnosis — particularly in its advanced stages, and usually most re- bellious to treatment. It is characterized by the eruption of numerous minute transparent vesicles, closely set and 64: VKSICUL^. irregularly aggregated on an uncircuniscribed inflamed surface, and attended generally with burning pain and in- tense itching. It is highly inflammatory, but not conta- gious. The vesicles, which are at first perfectly transparent, become opaque on the second or third day after their appearance, — the contained fluid assuming a semi-purulent character, — and either dry up with a fine furfuraceous desquamation, or bursting, become covered with thin, yel- low crusts, from beneath which an acrid, watery exudation takes place. Eczema differs much in appearance, as it occurs on the parts of the, cutaneous surface which are ordinarily covered, or exposed, or on which hair grows, and therefore must be described more or less with reference to a regional system of classification. The forms of the disease, according to the course which they run, are naturally divided into two groups, the acute and chronic : and as regards external characteristics two varieties are well marked : — Eczema simplex. " rubrum. But it is also requisite to consider it specially, as it may be seated on the face or on the scalp : — Eczema faciei. " capitis. Eczema simplex (Atlas, PI. III. Fig. 1) is attended with scarcely any fever, slight nausea and headache occa- sionally preceding its eruption, which is accompanied by some heat and tingling of the surface. It consists in the appearance of numerous minute shining vesicles, not ex- ceedihg in size the head of a small pin, which are closely aggregated, and irregularly distributed on apparently healthy skin of the natural color, but with a magnifying glass each vesicle may be seen to be surrounded by a nar- row red areola ; in forty-eight hours the fluid contained in them becomes opaque, and on the third or fourth day they dry up and are followed by a fine mealy desquamation of the epidermis, and thus the disease may run its course in from four to six days. In most cases, however, a fresh crop of vesicles appears as soon as the first has maturated, ECZEMA. 65 and by successive crops its duration may be prolonged for as many weeks ; under such circumstances, thin yellowish crusts or scabs are formed, and a serous exudation continues to flow from the surface while the disease lasts, often in large quantity. The heat and itching are then also trouble- some, a,nd if the part be scratched or irritated, the eruption may become chronic, or may change into the second form. For a long time after the disappearance of the disease the epidermis continues to desquamate, but it leaves •no stain on the skin or other trace of its existence. This form of eczema usually appears on the backs of the hands and arms, sometimes on the scalp, but rarely on the lower extremities, on the trunk, or on the face. Eczema rubrum (AtlaS, PI. III. Fig. 2) is an acutely inflammatory disease, an attack of it being ushered in gene- rally with sharp fever, and always with much local pain, heat, and swelling of the portions of the integuments about to be aifected. Numerous pellucid, small vesicles are rapidly developed on a highly inflamed, uncircumscribed surface, of a bright red color and tumefied, over which they are irregu- larly distributed, but crowded together in patches ; the parts feel painfully tense, and cause a continued tingling rather than itching. The vesicles, becoming opaque, enlarge somewhat, look fuller, and bursting, form yellowish crusts ; in a few rare cases the disease terminates in from a fortnight to three weeks with the falling ofi" of these crusts and subse- quent epidermic desquamation. Eut in most instances, and invariably when the parts have been torn by scratching or otherwise irritated, a copious discharge of an acrid, thin, serous fluid, continues to flow from the inflamed surface, apparently without the formation of new vesicles ; the in- flammation spreads to the adjoining portions of the skin, often seemingly caused by this discharge flowing over them; bright red cracks and fissures form in the integuments, which are excoriated," thickened, much swollen, and attended with intense pain and itching, and blood flows freely should they be scratched. The serous exudation is usually in very large quantity, so great as at times to require to be continually wiped away, that from even a limited surface wetting com- pletely a large handkerchief in a few moments ; when it is not so copious it dries quickly into fine lamellar scales, a 66 VKsicnLjE. constant desquamation of which takes place. The aspect of this form of the disease, when fully developed, is highly characteristic ; the shining crimson or bright red surface, covered in parts with the ichorous discharge, and in parts with the thin film of desquamating epidermic secretion, the deeper-colored fissures and cracks, from which blood occa- sionally flows, and the tensely tumefied appearance of the whole. Eczema rubrum, when it presents the aggravated characters now described, seldom gets well in a shorter space of time than two or three months, and occasionally, becom- ing chronic, lasts for years. In some cases the local inflammation is still more acute, the discharge becomes sero-purulent or purulent, concreting into thick yellowish scabs, and scattered pustules form on the surface ; it is then termed eczema impetiginodea (Atlas, PL III. Fig. 3), from the resemblance which it presents to impetigo. This variety of 4;he eruption is generally met with in infants and children, is attended with well marked febrile symptoms, and much local pain and itching, and lasts for from three to six weeks, or occasionally, becoming chronic, for as many months ; its duration being kept up by the successive eruption of semi-purulent vesicles. When any of the forms of eczema become chronic they are usually described as a distinct variety, under the name of eczema chronioum (Atlas, PI. III. Fig. 4) ; the disease then loses its vesicular character, the integuments which are swollen, thickened, and elevated above the surrounding por- tion of the skin that may remain unaffected, assume a perma- nently dark crimson hue, with numerous deep fissures which discharge a bloody ichor, and, taking on an inflammatory action from the least constitutional excitement or local irri- tation, are painful to the touch, tense, and attended with an acrid watery discharge and extreme itching. The constitu- tion also, after a time, becomes aff'ected, the digestive organs being deranged and general debility ensuing. Eczema rubrum may be seated on any part of the body, but generally attacks a large extent of the cutaneous surface, spreading rapidly from the place where it first appears. It thus occurs on the face, the scalp, the trunk, the arms and hands, and the thighs, rarely extending to the legs or feet except in very extreme cases. It also not unfrequently is ECZEMA. 67 local, appearing merely on the scalp, the face, the fingers, the backs of the hands, the ears, around the nipples in females, or in a single patch on the lower extremities, or in the pudendal region, being in all these cases very obstinate to treatment, and apt to become chronic. Each of these local forms oi the disease has been constituted by some der- matologists into a distinct variety — an unnecessary refine- ment, as, with the exception of the first two, they present no essential differences, whether as regards diagnosis or treat- ment. The outbreak of Eczema faciei (Atlas, PI. III. Fig. 5) is preceded in young persons by a sharp attack of fever, at- tended with burning heat and soreness of the part about to be affected, which lasts for two or three days: in adults these symptoms are very trifling. Numerous minute vesicles then appear, closely crowded together, on a highly inflamed patch of the cuticular surface, characterized by acute burn- ing pain and intense itching. These vesicles do not matu- rate, but burst usually on the day or day but one after their first appearance, giving exit to an abundant irritating serous fluid, which dries inlo soft thin scales. In some few in- stances the disease does not proceed beyond this stage, the cuticle of the part affected gradually exfoliates, and recovery takes place ; but more generally the inflammation of the surface goes on increasing, fresh crops of vesicles continu- ously appear, the discharge becomes more copious and of a more acrid character, exciting irritation of those portions of the neighboring healthy skin over which it may flow, and the itching and painful tingling are most intense, scarcely allow- ing ,the patient a moment's rest, night or day. The skin which is the seat of the eruption becomes swollen as the disease advances, the epidermis exfoliates with the soft scabs, or is torn off by scratching, and deep bright red cracks appear all over the surface, from which a sanious often bloody discharge exudes. The sufferings caused by eczema, when it reaches this stage, can scq,rcely be described; suffice it to say, that they totally incapacitate adults affected with the disease from following any trade or employment. Whether eczema rubrum attacks young or old persons, when it assumes a chronic character, it is the most intract- 68 VKSICUL^ able of the eruptions which appear on the face. It not unfrequently lasts for years (in one case, regarding which I was lately consulted, it had been of upwards of twenty-five years' duration), and is rarely cured under several months' treatment. The most usual part of the face on which it appears in infants and young children is the forehead, to which it or- dinarily spreads from the scalp, and, unlike most of the other eruptive diseases, is much more obstinate there than on its primary situation. This seems to depend on the greater delicacy of the skin of the face permitting those cracks and fissures, to which the rebellious nature of the dis- ease appears to be chiefly due, to form more easily. In adults, it occurs with greater frequency on the nose and lips, but in many cases spreads also to the forehead and cheeks. SJczema capitis (Atlas, PI. III. Fig. 6) soon loses its vesicular character, and in its various stages presents so much diversity of appearance that its diagnosis is not always unattended with difficulty. The eruption is preceded by heat, tingling, and itching, which are rapidly followed by the appearance of minute vesicles, crowded together in irre- gular-shaped patches, or scattered over a large surface. The interspaces between the vesicles and the whole of the scalp on which they are seated are red and inflamed ; in most cases the vesicles are so minute as to be scarcely recogniz- able, or at least are not seen by the physician until they have burst and given exit to a copious exudation of a serous fluid, by which the roots of the hair are accreted together. In the acute forms of the disease, this serous exudation con- tinues for a long time, and is a most troublesome symptom ; but in the chronic forms — and some cases assume a chronic character almost from the first — it rapidly dries into furfura- ceous scales, which are pushed forward by the hair as it grows. The vesicles of eczema capitis usually appear first behind the ear close to the edge of the hairy scalp, from whence the disease spreads rapidly, very generally attacking the ear itself; in some cases the entire of the scalp will be covered with the eruption in a week or ten days, but in others the disease spreads very slowly. ECZEMA. 69 With the progress of the affection, the appearance of the diseased surface varies much ; sometimes it is scarcely, if at all, elevated above the healthy parts, and the eruption is only to be recognized by the watery, exudation which keeps the hairs in a constantly moist state. In other cases the scalp is raw or excoriated, and secretes a thin whitish pus, which dries into grayish brown scabs, presenting cracks or fissures, through which the inflamed surface is seen. In a third form of the disease the serous exudation dries rapidly into extremely thin membranaceous scales, which are readily removable by the slightest friction, but cause much itching. And a fourth variety is characterized by a repeated eruption of minute patches of vesicles — the patches rarely exceeding the size of a small bean — all over the scalp, which pass through the stages of eczema as witnessed on other parts of the cutaneous surface, and disappear in seven or eight days, but to be rapidly succeeded by a fresh outbreak of the disease. The hair in eczema, no matter how long the disease may have existed, remains unaltered. When in the acute forms, attended with much inflammation, ulceration of the scalp occurs, the hair, of course, falls off, but in the progress of cure it grows again in a perfectly healthy state, except that in individuals past the age of puberty the new growth of hair is often gray. Eczema occurs at all ages, from the infant at the breast to the very aged ; in new-born children it not uncommonly appears on the umbilical region, — eczema urtibilicale, — evi- dently arising from the local inflammation attendant on the separation of the remains of the funis, or from a want of due attention to cleanliness. The causes of the disease are often sufficiently apparent, but equally often it is not to be accounted for ; thus, as regards the head and face, the erup- tion occurs on the scrofulous and non-scrofulous child, on the healthy and the delicate, on the ill-fed, ill-housed, defi- ciently-clothed children of the poor, and the highly-nurtured, well-housed, warmly-clad children of the rich; in short, frequently the only cause that can be plausiby assigned for its outbreak is that scarcely understood one, constitutional. It certainly affects females more frequently than males, for the same reason that those of all ages whose skin is fine and 70 VKSIOtTLjfe. 3elicate, are more liable to the disease than those in whom the skin is coarse and hard ; in many families, too, a pecu- liar predisposition to diseases of the skin exists, and this predisposition, which appears to be hereditary, is well marked, as regards the causation of eczema. Exposure to the direct rays of the sun often produces the disease in summer, so comnionly that Sateman made a dis- tinct variety of eczema when so caused, naming it eczema solare ; a numerous class of causes, amongst which this must be includied as ode, is the action of local irritants, as of blisters, of Burgundj' pitch plasters, of croton oil and tur- pentine liniments, &c. ; thus, too, in washer-women, the eruption is produced by the Eritatioh of the alkali of the sodsi br Sosip which they use, and in house-scourers and char- women, of the potash, — in both cases the disease is termed ivasJier-women^s itch ; in grocers and makers of confection- ery, of the &ug4.r- — in them it is named grocers' itch ; in glove and clothes-cleaners it is a very usual disease arising firom thie irritation of the oil of tiirpfentine or resin which they employ ; and in the higher walks of life a not unfre- quent cause of the eruption is the too frequent use of stimu- lating soaps and cosmetic washes to the face and hands, and also the habit of washing the face, when heated, in cold ■«rater, or of not drying it sufiSciently after it has been washed. Sitting in close, heated rooms, engaged in any occupation in which the face is constantly kept stooped, as in that of writing, is also a common cause of eczema faciei. An eruption of eczema is of very frequent occurrence on the legs of old persons in whom the small superficial veins are in a varicose condition, and in them, if irritated, it is apt to degenerate into troublesome ulceration. The constitutional irritation caused by the action of mercury on the system produces in some cases — now more rai-e than formerly, when the employment of the preparation of this metal was so much abused — a very grave form of eczema ; it is usually termed eczema mercuriale, but was described as a distinct affection, under the name of Hydrar- gyria, by the late Mr. Alley of this city, in an original and highly valuable essay on the disease, published by him in the year 1810. In the majority of cases it seems to have occurred when only a very small quantity of a ECZEMA. 71 mercurial preparation had been taken. In its milder forma it resembles the acute stage of eczema rubrum, arising from other causes ; but it more frequently assumes a much more severe character when it is ushered in by fever, difficult re- spiration, dry cough j^nd tightness across the chest, Tfith a general smarting and burning feel of the skin oyeir the ^hple body. These symptoms are soon followed by an eruption of minute vesicles, which break and discharge a very fetid fluid. As the disease, increases iii severity the eruption extends oyer the face and the whole of the body, which becomes covered with incrustations ; the fever assumes a typhoid type, the difficulty of breathing increases and is ac- companied by bloody expectoration, spots of purpura appear, and death ensues, preceded by delirium or convulsions. On the first appearance of this eruption the use of mercury ought to be immediately relinquished, and the accompanying symptoms treated by the means appropriate for the indi- vidual case. The diagnosis of eczema in its advanced st9,ges, and in some of its local forms, is not una,ttended with difficulty. Eczema simplex may at its origin be mistaken for herpes, but the vesicles in the latter are larger, more distinct from each other, and occur in patches always well defi^ied, and often of small extent. When it ?ippears on the fingers the serious mistake of confounding it with scabies is not unfre- quently made, and thus much mental annqy^ince may be caused not alone to individuals but to families, owing to the dread and anxiety with which that eruption is vie.wed by all ; even at their commencement they are, however, readily to be distinguished, the vesicles in itch being solitary, large, and conical, and becoming rapidly purulent ; the tipgling, burning heat of eczema is also very different from the in- tense itching of scabies, and by careful examination the itch insect, the existence of which is an unfailing diagiiostic sign, m9.y be discovered in the latter. In fevers and other diseaseSj in which profuse sweating occurs, a vesicular ernpT tion, wiilch, from the cause by which it is produced, i^ termed sudamina, appears not unfrequeritly on the cuta- neous surface, and might be mistaken for eczema simplex ; but in it the vesicles, though of a small size, are few in number, perfectly distinct, and separated froii^ efi^ other, 72 VESICUL^, and, drying up in a few days, disappear without any serous exudation or local irritation. Eczema impetiginodes, as its name indicates, very closely resembles impetigo ; in both there is a purulent discharge, but the crusts or scabs which form on the affected part are always of a greenish hue, and the discharge purulent in the latter, while they are yellowish or yellowish-brown, and the discharge sero-purulent in the former. The chronic forms of the disease are liable to be mistaken for chronic lichen, especially for lichen agrius when seated on the hands, a serous exudation being then usually present ; but the latter eruption never loses its papular character, the portion of the integuments which is affected being raised unevenly, rough, and not marked by the cracks and fissures so cha- racteristic of chronic eczema ; and the serous exudation is small in quantity, is evidently caused by the local irritation to which the eruption gives rise, ahd only occurs occa- sionally. With psoriasis, too, chronic eczema may be con- founded by the superficial observer, in consequence of the epidermic desquamation by which it is attended, but the formation of true scales never takes place in the latter, nor the copious serous exudation in the former. The diagnostic marks between intertrigo and eczema have been noticed when describing that eruption. Eczema faciei is distin- guished from herpes, in addition to the difference in the cha- racter of the eruptions already mentioned, by the latter affecting the mouth or lips alone, while the former is not confined to any special locality. Eczema capitis may be confounded with impetigo or herpes of the scalp ; it is diagnosed from either by the co- pious serous exudation, which dries rapidly into yellowish, not greenish crusts, by the rapid and excessive formation of soft furfuraceous scales, and by the hair not being affected. For porrigo capitis it can scarcely be mistaken, but the cha- racteristic differences between the two eruptions will be more eiasily understood by deferring the mention of them until describing that disease. In eczema the prognosis varies as regards the duration of the disease with the different forms, but in very few in- stances can the affection be said to be dangerous to life; yet some do occur ; these are cases of debilitated old per- ECZEMA. 73 sons in •whom it becomes complicated with pemphigus, and whenever such a complication takes place the prognosis should be most grave. Eczema simplex, when submitted to treatment at an early stage of the eruption, very seldom becomes chronic, but it is very apt to return on exposure to any local cause, and especially "when it has been originally produced by the direct action of irritant substances. Ec- zema rubrum is always an obstinate and severe aflfection of the skin, and most rebellious to treatment, years sometimes elapsing before it can be subdued ; in such cases the general health sympathizes more or less, from the continued annoy- ance caused by the local irritation, the individual affected being not unfrequently altogether incapacitated from mental or other occupation. When the disease affects the scalp or face, it is also one of the most obstinate of the eruptions which appear on these parts. The occurrence of a general attack of eczema in the course of some chronic constitu- tional affection, particularly of the nervous system, is often not incorrectly regarded as a favorable sign. With reference to the precise anatomical seat of eczema, dermatologists are not agreed : Cazenave adopts Biett's view, that it is an inflammatory affection of the sudoripa- rous glands, but it is evident that other structures of the derma are also equally engaged. Treatment. — Eczema is essentially an inflammatory erup- tion, even in its most chronic stages, and this fact should always influence our choice of remedies, whether topical or constitutional, for its treatment. In eczema simplex occur- ring in adults, mild saline antiphlogistics with alkalies, as in the following form, are prescribed with advantage at its commencement : — B. SodsB et Potassse Tartratis, . . . .?j. Solutionis Alkalinae (Brandish), fl 3iv. Aquae destillatae, fl gxixss. Misce. "A wine-glasdful to be taken three times a day." For children, gentle mercurial purgatives are better adapted, combined with antimonials, such as James' powder, if the febrile symptoms are well marked. In the mild forms of 74 VESIOUL^. the disease, the best local treatment in the acute stage is the use of the general tepid bath, or of warm water spong- ing, the parts being thoroughly but gently dried afterwards. When the local affection is more severe, the weak lead- wash — a drachm of the solution of subacetate of lead to twelve fluid ounces of rose or elder-flower water — applied on old linen wet well with it, is an excellent application : if the eruption is seated on any part of the extremities, it is best and most efiSciently applied by means of bandages evenly put on, and kept constantly moist with the wash. In some cases of eczema moisture appears to disagree singularly, always aggravating the local symptoms ; under such circum- stances an ointment containing four grains of the carbonate of lead, or of the acetate of zinc, to an ounce of cold cream, may be used, and if there is much tingling or itching in the part, two minims of prussic acid should be added to the lattter, or six minims of chloroform to the former ointment. If simple eczema occurs, as is not unfrequently the case, in children of a scrofulous diathesis, it is very apt to become chronic ; when it does so, local remedies seem to have little effect on th6 eruption, but it yields rapidly to the internal administration of cod-liven oil, and the daily use of the tepid fresh-water bath. In the early stages of eczema rubrum general antiphlo- gistic treatment, proportionately active according to the inflammatory character of the constitutional and local symp- toms, is requisite ; in persons of full habit of body, bleeding from the arm even may be indic&ted, and in most cases, topical bleeding by leeches from the neighborhood of the affected parts is attended with much benefit ; active saline cathartics should be administered and repeated at short intervals until the febrile symptoms are subdued. The local heat, swelling, and tingling are best alleviated by gelatine baths, and at night the application of poultices, prepared by first steeping the best white bread in boiling water, squeezing it out as tlry as possible, and then moistening the pulp with the weak lead-wash above mentioned. When this form of eczema becomes chronic, it is usually most rebellious to treatment, and requires the employment of internal specific or alterative medicines to produce a KCZEMA. 75 change in tbe state of the constitution with which it is com- bined, or on which it may depend, and this is requisite even though the eruption is of small extent and local. In many cases the preparations of iodine prove most efficacious, but sometimes it is requisite to combine them with arsenic, or to give that medicine alone; in delicate constitutions, or if debility be present, the iodide of potassium is the best form ; it may be given in some tonic decoction, as follows : — R. lodidi potassii, gr. viij. Decocti ulmi (corticis recentis), fl §xij. Decocti dulcamarae, , . . . fl Siv. Misce. " A wine-glassful to be taken every night at bed-time." When thus given it is not liable to sicken the stomach, and in my experience small doses of iodine or its prepara- tions act most efficaciously in the treatment of diseased of the skin. If the use of arsenic be indicated, either from the obstinacy of the aifection or the failure of other reme- dies, five minims, very gradually increased to eight, of the liquor potassse arsenitis, or of the liquor arsenici chloridi of the last London Pharmacopoeia, may be added to each dose of the above mixture ; but whether iodine or arsenic be ad- ministered alone or in combination, their use must be con- tinued for a long time, at least for two or three months, and beneficial results are always mo^t effectually derived from the system being brought very gradually under their in- fluence. Numerous internal medicines, as well as local ap- plications, have been recommended by different writers for the treatment of chronic eczema ; of the former the most generally employed are the tincture of cantharides, anti- monials, sulphur, especially in the form of the sulphurous mineral waters, mercurials, and various vegetable tonics ; but my own experience leads me to rely on either or both of the powerful alteratives above recommended ; even in the most chronic cases I have seen the sulphurous waters — so valuable in other diseases of the skin — prove injurious, and mercurials generally disagree except with children, in whom the green iodide of mercury combined with the hydrargyrum cum creta often acts as a most valuable alterative. 76 VBSicuii^. The itching and copious secretion attendant on chronic eczema demand the employment of local sedatives and as- tringents. The compound lead-cerate of the London Phar- macopoeia, to every ounce of which two drachms of glycerine and eight minims of chloroform have been added, constitutes a most useful ointment, no matter on what part of the sur- face the eruption may be seated ; or the carbonate of lead or acetate of zinc ointment already described may be substi- tuted for it should there be much tendency to local inflam- matory action. Tannic acid, in the proportion of from four to twelve grains to the ounce of cold cream, with or without the addition of chloroform, is also an excellent application. Some recommend highly stimulating compounds for the local treatment of chronic eczema, such as anthrakokali or fuli- gokali (forms of carburet of potassium, which, when intro- duced into the practice of medicine a few years since, were highly vaunted for their remedial powers, but have now fallen into disuse), tar pitch, sulphurous preparations, &c. By dis- tilling tar with water, a mixture of impure oil of turpentine, a pyrogenous oil, and some pyretine is procured ; this liquid has been recently used and highly praised by some French dermatologists, under the name of huile de cade, as a local application, inunctions being made with it twice daily ; by the term huile de cade, however, most of the French phar- macologists understand a tarry oil obtained by the dry dis- tillation of the wood of the juniperus oxycedrus. No matter what local remedy is employed, it will be found of advantage to sponge the affected parts carefully with a weak alkaline wash — ten grains of the carbonate of soda to a pint of dis- tilled water, each time previously to its fresh application. When eczema occurs on the face or hands, the treatment as above described for its different forms is equally appli- cable, but in either situation, in consequence of the expo- sure to atmospheric vicissitudes and to various local irritants, it is usually more obstinate, and when the disease is general over the body the face is for the same reasons the last part to get well. The use of soap in washing should be inter- dicted, the weak carbonate of soda lotion warmed to blood heat being substituted for it, and especial care should be taken not to expose the surface to the action of harsh winds, ECZEMA. 77 the sun, the heat of the fire, or any cause which might pro- duce determination of blood to the affected parts. In eczema capitis the hair should be cut close to the scalp with a sharp pair of scissors — not shaved off— and kept as short as possible while the disease lasts, and for a short time after it is apparently cured. The crusts and scabs should be removed by poulticing with linseed meal, and sponging with the weak carbonate of soda solution mixed with an equal quantity of new milk, the surface being carefully dried afterwards. When the scalp is thus cleaned, in the milder and less inflammatory forms of the eruption an alkaline oint- ment, containing twelve grains of the bicarbonate of soda to the ounce of cold cream, may be applied morning and evening, the surface having been previously sponged as above directed; but if there be any tendency to inflammatory action, the car- bonate of lead or the tannic acid ointment, and the sub- acetate of lead-wash, prove more beneficial. The scalp should be kept cool, very lightly covered or exposed to the air when in the house. As regards constitutional treatment, in scrofulous habits of body, either cod-liver oil or iodide of potassium, with tonics, should be administered ; but the best alterative for children who are not scrofulous is the green iodide of mercury, as before mentioned. In all forms of eczema, when the origin of the disease can be traced to any local irritant, this of course should be care- fully guarded against, both during the progress of treatment and when a cure is effected ; in the case of persons engaged in trades, and others who cannot abandon the occupation by which the eruption was caused, the cutaneous surface should be protected as much as possible by the use of wash leather gloves. The diet of persons affected with eczema should be regulated according to the constitutional circumstances, but in children much benefit will be derived from placing them on a strictly milk and farinaceous diet. In both adults and children the bowels require to be carefully attended to, the use of mild saline purgatives, if possible the natural mineral waters, of which probably the Pullna is the best, being employed with excellent effects. In children the pro- cess of teething must be watched and the gums lanced when necessary ; and the eruption on the scalp should not be dried 7* 78 Vfisicuii^. up too suddenly if there exists a tendency to disease of the brain or of any other internal organ. HERPES. Herpes ( Tetter). — This term, though very generally used in the nomenclature of cutaneous diseases by the older medical writers, had with them no special reference : it is now employed to designate an eruption of small globular vesicles clustered together, and often regularly grouped, on inflamed patches of the skin usually of small extent and dis- tinctly separated. The eruption is preceded by heat, ting- ling, and some degree of swelling and redness in the parts on which it is about to appear, but there is no antecedent or accompanying fever unless, which is rarely the case, it is developed simultaneously over an extended surface, and even then the febrile symptoms are but slight. It is described by most English dermatologists as being non-contagious, but an accumulation of direct evidence has convinced me that one form of the eruption is propagated by contagion, no matter on what part of the cutaneous surface it may be situ- ated. The vesicles, which on their first appearance are globulitr and transparent, on the second or third day become somewhat flattened, opaque, and semi-confluent ; they then burst and give exit to a trifling serous discharge, which con- creting into a soft, thin, yellowish-brown crust, falls off and leaves a superficial ulceration that heals rapidly. The causes of herpes, when it affects the body generally, cannot be traced with certainty, btit in some of its local varieties arc often sufficienly manifest. The forms of this eruption present great variety, and have been differently named with reference both to their external phenomena and the parts on which they may appear ; this has led to numerous subdivisions of the disease in classifying it for the purposes of description, thereby tending to com- plicate the inquiry. I shall describe them all under the three following heads : — Herpes phlyctenodes. " zoster. " circinnatus. Herpes pTilyctenodea [Nirles) (Atlas, PI. IV. Fig. 1) is HERPES. 79 occasionally, more particularly when it occurs in adults, attended with slight fever, foul tongue, loss of appetite, nausea, and thirst, but the pulse is rarely quickened ; there is a deep-seated pain in the part on which the eruption is about to appear, and superficial heat and tingling. Small irregularly shaped patches of the skin become slightly swollen and red, and in about twenty-four hours afterwards an eruption of vesicles appears on them. The majority of these vesicles are of small size, but a few of them attain the magnitude of a pea; they are distinct from each other, rounded, and contain a transparent serous fluid : they occur in groups, varying in size from one to three or four inches in length or breadth, but rarely exceeding that of the palm of the hand; usually, when of large extent, constituting but a single group, which, however, is often made up of three or more smaller, by the eruption spreading over the inter- mediate sound skin. On the second day after their appear- ance the fluid in the vesicles becomes opaque or sero-puru- lent, and they burst on the third or fourth day — those that were closely aggregated together having previously become confluent, forming soft crust or brown scabs, from beneath which a thin sero-purulent matter exudes in small quantity. These scabs, falling off on or about the tenth day, leave small superficial ulcers which heal in three or four days, so that the disease rarely lasts longer than a fortnight. But it is sometimes prolonged by the eruption of a distinct patch of vesicles on the third or fourth day after the appearance of the first, and in their neighborhood; they unite with the former, and the entire thus cover a rather extended surface ; requiring, however, the same time for maturation and heal- ing, the duration extends to three or four days more. Should there be any attendant fever, it abates or disappears with the outbreak of the eruption, but the local symptoms increase until the vesicles burst, when some slight itching only re- mains. The local pain, which is often severe previously to the appearance of the eruption, is usually much alleviated then, but sometimes returns with greater intensity after the sur- face is healed, and, presenting somewhat of a neuralgic character, lasts with great obstinacy frequently for months. 80 YKSIOULiK. Occasionally in old persons or in bad constitutions, an her- petic eruption terminates in troublesome ulceration. The phlyctenoid form of herpes may appear on any part of the body; its most usual seat is on the trunk, the neck, and the arms, rarely occurring on the lower extremities. It attacks some special portions of the integuments with great regularity, and its occurrence there requires to be separately described; these are the lips and the prepuce. Herpes labialia is a slight form of the disease, deserving notice merely in consequence of the local annoyance which is occa- sioned by its situation ; the eruption, which is preceded by a certain degree of tumefaction, dryness of the skin, heat, tingling, and redness, appears at the angles of the mouth, or on the upper or lower lip, more usually on the latter, being of small extent, rarely exceeding the size of a shilling. The vesicles, which are minute, closely aggregated, and covering the entire of the inflamed surface, are at first glo- bular, transparent, and shining; within forty-eight hours the contained serum grows turbid, the vesicles become con- fluent, forming bullae of the size of a pea, and on the fourth or fifth day, soft brownish crusts appear on their surface, which fall off in two or three days more, leaving a slight degree of redness and swelling of the part, thafcrlasts for about a week. Should the crusts, however, be torn off by scratching, or irritated from their situation at the commis- sure or on the vascular portion of the lips, the surface bleeds, and a hard, dark brown scab is formed, which is slow in separation. Sometimes the herpetic eruption on the lips extends completely round the mouth, when it is a trouble- some and obstinate affection; but unless under these circum- stances it runs usually a rapid course, its duration seldom exceeding a week or ten days. A variety of herpes, similar in all respects to this, occasionally appears on the ears ; it is then termed herpes auricularis. Herpes prceputialis ha? been so namedfrom its appearing on the prepuce, being situated either upon the external cuti- cular surface or on the mucous membrane. The eruption is preceded by heat and tingling in the part, and some degree of soreness, and when it occurs on the internal aspect of the prepuce there is also more or less tumefaction ; the transparent orbicular vesicles soon appear in a small group, HERPES. 81 but distinct from each other, on a somewhat circular inflamed patch of the integument, rarely exceeding the size of a six- pence ; when they occur on the external surface, they matu- rate quickly, becoming opaque, and forming brownish crusts, ■which fall oflf on the fifth or sixth day, leaving the part on which they had been seated slightly tender and red ; but when the eruption is situated on the mucous membrane the vesicles are larger, become sero-pui'ulent, and from the con- fluence of two or three attain the size of a split pea ; the scabs which form are softer, and of a yellowish color, and, being easily rubbed off, leave a small ulcerated surface, which, from the swelling of the surrounding mucous membrane, occasionally presents a slightly excavated character, in con- sequence of which it is 'likely to be mistaken for a chancre. Herpes prseputialis sometimes becomes chronic when the disease spreads, by the appearance of successive crops of the eruption, over the entire of the prepuce, especially affecting the part where the mucous membrane and skin meet ; there is much thickening from the effusion into the sub-mucous areolar tissues, caused by the repeated attacks of inflammation ; the surface becomes hard, rugose, fissured in parts, and in parts covered with brownish crusts, from between and beneath which an unhealthy, fetid, sero-puru- lent discharge takes place, and as the glans penis cannot be uncovered, foul ulceration of it not unfrequently occurs to complicate the original disease. When the eruption is of this chronic character, it often lasts for months, and the general health becomes affected in consequence of the anx- iety and distress of mind it occasions. In females herpes phlyctenodes sometimes appears on the pudendal region, being situated at the vaginal orifice on both the skin ai^ mucous membrane ; its characters correspond precisely with those of the disease of the prepuce in males, but in consequence of the parts being more exposed to the irritation arising from local discharges and from the urine, it is generally more chronic and rebellious to treatment. By some writers it is made a distinct variety, and termed herpes pudendalis. Herpes zoster {Shingles; Ignis sacer) (Atlas, PI. IV. Fig. 2) has derived its specific name from the peculiar form which the eruption assumes, resembling, as it were, a girdle or 82 VKSICUL^. sword-belt. The constitutional and local symptoms are more severe than in the variety last described, the former often amounting to well-marked fever preceding the outbreak of the disease, attended with a distinct shivering fit and vomit- ing. Locally there are sharp stinging ,pain, burning heat, redness, and some tumefaction of the integuments in the part on which the vesicles are about to appear ; these occur of tolerable magnitude, and closely grouped together in three or four distinct but neighboring patches, each sur- rounded by an inflammatory areola, which gradually spreads, new vesicles appearing on it, and the entire constitutes a crescentic or oblique demi-zone from half-an-inch to one or two inches in breadth, seated on one side of the neck or trunk, often extending from mesial line to mesial line, by which it seems to be distinctly bounded, very rarely passing its limits. The eruption runs the same course as in herpes phlyctenodes, but the vesicles become more confluent, thus often attaining the magnitude of bullae, those which first ap- pear being always the largest ; and it is somewhat more chronic in all its stages, thes cabs being often particularly slow in separating. The local pain which precedes the appearance of the eruption in herpes zoster is not unfrequently very severe, and apparently deep-seated, seeming to shoot through the chest or abdomen if the disease is about to occur on the in- teguments of either of these regions. This pain, which to a great extent disappears when the vesicles are developed, usually returns with greater or less intensity, especially in adults or old people, when the crusts fall off, sometimes lasting even for years, and causing great suffering. At times chronic ulceration succeeds this form of herpes in bad constitutions, and this may terminate even in gangrene, and thus prove fatal. The usual seat of herpes zoster is on the thorax or ab- domen ; it also appears occasionally on the neck ; when the eruption commences over the scapula, or in the neighbor- hood of the hip, it may extend to the shoulder or thigh, including either in the semicircle which it forms, but it very rarely originates on the extremities. By Franck and Ca- zenave the disease is stated to appear more frequently on the right side of the body, but my experience agrees with HEKPES. 83 that of Reil and Wilson, that it is situated on the left in a greater number of cases. It is so extremely rare for the demi-zone of herpes to pass the median line, that amongst the ancients it was popularly believed, and the fact is mentioned by Pliny, that if the eruption surrounded the body it should prove necessarily fatal ; yet cases are recorded by modern writers, — Franck and others, — ;in -which such took place by the simultaneous development of the eruption on both sides and their extremities meeting, yet the patients recovered. Herpes circinnatus {Ringworm) (Atlas, PI. IV. Fig. 3), like the last described variety, derives its name from the shape of the groups in which the eruption appears, namely, distinct rings or circles, inclosing healthy skin in the centre. Slight pricking sensation or tingling accompanies the out- break of the disease, but it is not attended with any consti- tutional symptoms. At first, one or more small, red, circular patches, from half an inch to an inch in diameter, appear apart from each other on some portion of the integuments, on the outer border of which numerous minute, globular, transparent vesicles are developed on the second or third day; the redness then fades from the centre of each circle, which remains unaffected afterwards during the progress of the disease, but the ring of vesicles has an inflammatory border both external and internal. The vesicles, which are closely aggregated, become more or less confluent within forty-eight hours after their appearance, assume a pearly aspect, and then bursting discharge a small quantity of a serous fluid, which dries into thin brownish crusts that fall off on the eighth or ninth day, to be succeeded by a fine epidermic desquamation that lasts for some time. The dis- ease, howeiffir, rarely terminates thus, but is prolonged by the repeated eruption of fresh crops of vesicles on the outer inflammatory border, each set running in an independent course, but one similar to the first ; spreading in this man- ner from the ciccumference, the rings at times attain the size of the palm of the hand, which they rarely exceed. The circles may be few or many in number, rarely, however, more than four or five, and when of larger size, there is usually but one; they may appear simultaneously on the surface or in succession : in the latter case the disease often becomes chronic, lasting for months. 84 VBSIGULJi. Occasionally it occurs that the vesicles, instead of burst- ing and forming crusts, dry up, and are succeeded by a secretion of fine, soft scales, which continue to be exfoliated, not alone from the circumference, but from the centre of the circles. This form has been specially described by Caze- nave, who denominates it herpes squamostis (Atlas, PI. IV. Fig. 5) ; it is always chronic, and very obstinate to treat- ment. Herpes circinnatus occurs with greatest frequency on the face, neck, and scalp, being, however, occasionally situated on the chest, the shoulders, the arms, and the hands. When it appears on the face, its most usual situations are the cheeks and the forehead ; as the circles spread from, their circumference they often extend from the former to the nose, but do not pass the mesial line, and from the latter into the scalp. In its milder forms, ringworm disappears in eight or ten days, but its duration is more usually pro- longed for three or four weeks, either by the spreading of the circles or by the successive development of fresh patches of the eruption ; occasionally, as above remarked, it becomes chronic, and lasts for months, producing annoyance more from the unsightliness of its appearance, when it is situated on any of the exposed regions of the skin, than from any local uneasiness. This form of herpes, when it occurs on the scalp, requires to be specially described, as it constitutes almost a distinct variety, which might be termed herpes capitis; it resembles in many of its characteristics the herpes squamosus of Caze- nave, but that distinguished dermatologist, in consequence of the effect its presence exerts on the hair, proposes to term it herpes tonsurans. Its occurrence on the scalp at all is denied by many of the celebrated English writers on diseases of the skin, who regard the eruption about to be described as a species of porrigo ; but prolonged clinical observation, independent of their corroboration by so deserv- edly hig^ ^^ authority as M. Cazenave, has tended but to convince me of the correctness of the views I propounded some years since.' Herpes capitis (Atlas, PI. IV. Fig. 6) usually attacks children from the age of 3 to 12. It is very rare in early ' Dublin Quarterly Journal of Medical Soienoe, New Seriea, voLri. p. 88. HEUPES. 85 infancy, and I have never met with it after the age of puberty, except in one instance, in which it had commenced at the age of 13, and had lasted for more than five years before I saw the case. It is very rarely witnessed in its first stage — that of vesicle — as it then produces but little annoy- ance, and advice is, consequently, not sought for until it becomes more developed. When seen, however, at its com- mencement, it presents the appearance of a small ring of minute vesicles, not more than an eighth of an inch in dia- meter, without any redness or other marks of inflammation beyond a slight tingling — not itching. These vesicles are attended with scarcely any discharge, soon drying up and desquamating ; but as they dry up in the centre, they spread from the circumference, and the diseased spots, in the course of a few days, attain the size of a shilling. When we exa- mine them in this stage, the centre, the part where the erup- tion first appeared, is thickened, elevated above the surface of the surrounding scalp, and covered with fine scales, which are renewed rapidly on being removed. As the disease pro- ceeds, the patches extend from their periphery, still retain- ing a perfectly circular shape, and finally, after some weeks, attain the size of a crown-piece, which they rarely exceed, no matter how chronic the case may have been. Having attained this size, and ceased to spread, the entire of the diseased surface is thickened, elevated, and covered with fine, soft' scales, which the least touch removes ; this, the advanced stage of the disease,-i8 usually attended with itch- ing. Sometimes but one patch of herpes is found on the scalp, but more generally there are three, four, or more cir- cles, distinct, and at some distance from each other. As the disease advances, the hair assumes a very pecu- liar appearance, almost pathognomonic of this form of eruption of the scalp. In the early stage each hair appears to be slightly bent on itself, and turned against the grain, obstinately refusing to lie smooth ; the roots are also some- what matted together by the scaly crusts of the eruption. After some time it presents a diseased appearance, being twisted, broken, of a whitish color, and readily falling out ; so that bald patches begin to appear, over which are scattered small bundles of the altered hair, which has been described, not inaptly, as resembling tow. This condition 8 86 VESICUL^. of the hair has induced some writers to describe the affec- tion as a disease not of the scalp, but of the hair itself. The eruption does not always present the exact charac- ter now described. In the eai'ly stage — when, however, it is rarely witnessed by the medical practitioner — its ap- pearance always agrees with the description given, except that in some cases there is more inflammation than in others ; but in the advanced stages it varies much, both as regards the amount of desquamation and the appearance of the elevated patches : it is this fact which has led to so much confusion in the diagnosis and nomenclature of the disease. Yet in the most chronic or complicated cases, the circular form of the eruption, and the peculiar condition of the hair, render its diagnosis easy to even the tolerably experienced eye. Herpes capitis does not cause baldness : the altered hair falls off the diseased patches, which, when the scales dis- appear in the progress of cure, are thus left in a bald state ; but the hair eventually grows on them again, thereby con- stituting an essential difference between this affection and alopecia. The disease, unless when seen and properly treated in its early stages, soon becomes chronic and obsti- nate, and loses its inflammatory character. No constitu- tional symptoms either precede or accompany herpes of the In some very rare cases the eruption in herpes circinna- tus assumes a singular arrangement, which, in the opinion of some dermatologists, entitles it to be considered as a distinct variety, receiving the appellation of herpes iris, or rainbow ringworm (Atlas, PI. IV. Fig. 4). A small, round, inflammatory patch appears on some part of the cu- taneous surface, and around it, but separated by a narrow band of healthy integument of the natural color, is a red, slightly elevated circle, which in its turn is again surrounded by two or three other similar rings of inflamed skin : on the centre a few minute herpetic vesicles are developed in about twenty-four hours after its appearance, as also on each of the rings, but they are more numerous and more closely aggregated on them. The rings, which are usually four in number, differ in color, the inner one being of a darker red than the central patch, that next to it of a HERPES. 87 lighter shade, the third darter even than the first, and the outer ring paler than the second, being of a yellowish-red hue, fading at its outer border into the color of the sur- rounding skin. The vesicles run the same course as in the milder form of herpes phlyctenodes, the crusts, which are small and thin, falling off on the eighth or ninth day, to be followed by slight furfuraceous desquamation, which lasts for a few days longer. Herpes iris seldom occurs except in very young children and in females ; it usually appears on the backs of the fingers or of the hands, on the temples and on the prominent parts of the joints, being sometimes associated with other forms of the eruption. It may occur singly, or several patches may appear simultaneously on different parts of the body ; the only local symptoms are some trifling heat and itching, and it has no tendency to become chronic. Causes. — Herpes is a disease almost entirely confined to young persons and to those in the prime of life, very rarely appearing in the old ; among adults it affects females more commonly than males, but in children sex seems to have - no influence in the frequency of its occurrence, those of a sanguine and lymphatic temperament, and in whom the skin is fine and soft, being most liable to it. Of the excit- ing causes of herpes phlyctenodes but little is known; it seems to be occasionally developed under the influence of strong mental emotions, and it is often connected with de- ranged conditions of the digestive and biliary organs. The season of the year, too, appears to have some influence on its occurrence, for it is most frequently met with in the spring and autumn. The connection of herpes labialis with febrile states of the system is usually very evident, and especially with* those which affect the respiratory organs : thus it is an almost invariable accompaniment of catarrh, influenza, bronchitis, and pneumonia, in all of which its occurrence is a favorable symptom, whence has arisen the popular expression that the cold goes off' in this way. It is also occasioned very frequently in travelling by the direct effect of a harsh cold wind on the lips, or of the sun's rays ; the action of local irritants, too, may produce herpes here, as is often witnessed in its being caused on the upper lip by the acrid secretion from the nostrils in coryza ; this 88 VESICULJE. discharge, however, more frequently produces an eruption of eczema. Herpes praeputialis occurs only in adults, and most fre- quently in those in whom the skin of the prepuce is very sensitive; it is often caused there by the friction of the clothes ; and when it appears on the mucous membrane, or on the glans penis where I have occasionally seen it, by the irritation of the natural sebaceous secretion of the part, allowed to accumulate from want of attention to cleanliness. The connection between the occurrence of herpes on the pre- puce and stricture of the urethra is very generally admitted, but many observers believe it to be only an accidental coin- cidence ; others, with whom I agree, consider the existence of stricture to be a cause of this eruption, and the manner in which it acts may, I think, be easily explained. In persons affected with stricture, the last drops of urine are retained for some time in the urethra, the shirt is thus con- stantly wet, and the prepuce is irritated by the acrid moist- ' ure to which it is thereby so constantly exposed; hence also, in these cases, the eruption is usually seated on the verge of this fold of integument. In females herpes of the pudendum may occur at any age ; it is invariably caused by local irritation. Herpes zoster appears in adults more frequently than any of the other varieties, occurring also occasionally in old persons, in whom it sometimes becomes chronic, and termi- nates in troublesome ulceration : it seems to be generally occasioned by cold, acting on individuals suffering from hepatic derangements. In the summer and autumn of some years it would appear to be epidemic among children, and in them it is very frequently produced by sudden suppression of the perspiration. Herpes circinnatus is a disease of youth, being very rare amongst adults, and occurs with equal frequency in both sexes ; it is very common in schools, or wherever many children are congregated together, amongst whom it spreads rapidly. The popular idea that ringworm is contagious is opposed by most English dermatologists on the grounds that no other form of herpes is so, and that the disease cannot be produced by inoculation. Now, neither of these reasons is sufficient to counteract, in my mind, the amount of direct HERPES. 89 evidence which an experience of some years in the treat- ment of diseases of the skin has afforded me of the propa- gation of this form of herpes by contagion, no matter on •what part of the body it may be situated. I have else- where^ published cases illustrative of the development of the eruption on the hands of adults engaged in the applica- tion of local remedies to the scalp of children who were affected with it, and to these I could now add several others ; and I have seen too many instances of its direct communi- cation from child to child of different families, when the argument of similarity of constitution and of dietetic ar- rangements could not avail, to have any doubt on the matter ; but it must be remembered that, lik^ all other contagious diseases, some families and some children are more prone to its attacks than others. My own opinion, too, is confirmed by that of M. Cazenave, who, in his Legons sur leg Malci- dies de la Peau, and in his more recently published Traite des Maladies du Ouir Chevelu' adduces several cases from his own practice, which exhibit in a marked degree the con- tagious nature of herpes circinnatus. Diagnosis. — The characters of the eruption in herpes are so well defined that, unless when it occurs on the scalp,, it can scarcely be confounded with any other cutaneous disease. It differs from eczema in the vesicles being larger, more globular, and distributed in patches ; its erup- tion is unattended with constitutional symptoms, and in its advanced stages it is not accompanied by the copious serous exudation of that disease. When the vesicles are very confluent it may be mistaken for pemphigus, but in that affection the eruption consists of bullae, which do not in any of their stages present the pearly aspect of herpes, and are succeeded by hard, dark-brown crusts ; the bullae of pem- phigus, moreover, are usually solitary and scattered over the cutaneous surface, not distributed in groups. Herpes labialis is diiignosed by the characteristic vesicles, and by their local situation. As already remarked, the serious ' Dublin Quarterly Journal of Medical Science, New Series, vol. viii. p. 164, Note. , , „ ^ Paris 1S50, p. 197. See also Annales des Maladies de la Peau et de la Syphilis, torn. i. p. 37, et seg. 8* 90 VESICUL^. error may be committed of confounding herpes prseputialia •with chancre ; if the eruption is seen on its first appearance it is readily diagnosed by its vesicular character, but when the scab is formed, or ulceration caused by irritation, the diagnosis is often not unattended with difiSculty. The ul- ceration in herpes, however, is always superficial," never deep, and presents a smooth surface without raised edges, and not coated with a white, filmy membrane, appearances peculiar to chancre; in very doubtful cases the question may with certainty be decided, by inoculating the integu- ments of the thigh of the patient with some of the matter from the diseased surface. The same remarks as regards diagnosis, apply equally to herpes of the pudendum in females. Erythema circinnatum, or lichen circumscriptus, in theit advanced stages, present some resemblance to herpes circinnatus, but neither of these are vesicular during any period of their presence on the skin, nor do they spread from their circumference in the manner that disease does ; they are, too, attended with more thickening and elevation of the integuments on which they are situated. Herpes capitis, which corresponds with the herpes ton- surans of Cazenave, is, as I have already remarked, described by many English writers as a variety of porrigo, the yellow, cup-shaped, favus crusts so characteristic of which it, how- ever, never presents. It is diagnosed from the other erup- tive disease of the scalp by its occurring in distinct circular patches, the slight serous discharge from which dries into fine, soft scales, that are readily detached by the slightest touch, but are again very quickly renewed, and especially by the peculiar change, before described, which it produces on the hair. The prognosis in any form of herpes is favorable, as the eruption may be said almost never to endanger life, and is but very rarely productive of any injury to the general health ; it is also not so liable as many other eruptions to become chronic, unless when it occurs on the scalp. The local neuralgic pain, which not unfrequently is consequent on herpes phlyctenodes and herpes zoster, is at times both severe and obstinate, often lasting for many months. Treatment. — The phlyctenoid form of the disease very rarely requires any active constitutional remedies; in a HERPES. 91 few cases, when it occurs in young persons of a full habit of body, bleeding from the arm, or the application of leeches in the neighborhood of the eruption, is attended with benefit, but neither should be had recourse to until the eruption is fully developed : saline purgatives, — preceded, if there is any biliary derangement, by a mild mercurial, five grains of blue pill, or two of calomel combined with a grain of extract of hyoscyamus, — will, however, in nearly all cases snfiSciently meet the constitutional symptoms. In weakly individuals, tonics with antacids, — as bark with the carbonate of ammonia, — are indicated. With refer- ence to local treatment, all that is requisite during the first two or three days after the formation of the vesicles is to protect them from being irritated by rubbing or scratching ; unless there is much tingling and pain of the part, which will be relieved by smearing them over with a cerate consisting of two grains of acetate of zinc, an ounce of cold cream, and four minims of chloroform. Should there be any tendency to a copious discharge, finely powdered lapis calaminaris or starch, will be dusted over the surface with benefit. As soon as the brown scabs form, a spirituous lotion, such as the following, should be substituted for the ointment : B. Olei Limonum, m. vj. Olei Corticis Aurantii, . . . fl 3ss. Spiritus Vini rectificati, . . fl Siv. Misturse Camphorse, . . . fl Iviij. Misce. The local pain consequent on this form of herpes, or on herpes zoster, is as far as my experience enables me to come to a conclusion, but little relieved by external applications ; those usually ordered for it are narcotics and sedatives, such as preparations of opium, of aconite, of belladonna, of arnica, &c. Regarding it as being chiefly neuralgic, I have prescribed with much benefit a combination of bark with hemlock, as thus : B. Tincturse Cinchonae compositse, fl 3i.j- Succi Conii, fl 3vj. Infusi Cinchonse, fl |vij. Misce. " A tablespoonful to be taken four times a day." 92 VESICOLJt. In herpes labialis, if a strong spirituous lotion — I have found none answer so well as Uau de Cologne — be con- stantly applied to the part on which it is about to appear, as indicated by dryness, heat, swelling, and tingling, before the vesicles are formed, the further progress of the eruption may in most cases be arrested. The only local application requisite, where the disease is fully developed, is some mild oleaginous ointment, such as the cucumber cerate ; should it, however, become chronic, an ointment composed of ten grains of calomel to an ounce of simple cerate will be found useful. Persons who have once had an attack of herpes prseputialis are fully aware of the premonitory local symp- toms by which it is ushered in ; the development of the eruption may then be stayed by the continued employment of cold water, the colder the better, which can be applied by plunging the penis several times in the day into ice-cold water, and retaining it there for a minute or two ; when the vesicles are formed, no caustics or irritants should be employed, as their use is apt to be followed by troublesome ulceration ; the best local application is the black wash, or Turner's cerate, if there is much discharge when the vesicles have burst. The same treatment is adapted for herpes zoster as for the phlyctenoid form of the disease. M. Gazenave, with the view of preventing the premature rupture of the vesi- cles, recommends that the surface should be smeared with oil, and then dusted with stai'ch. The ectrotio plan of treatment, that is to say, opening each of the vesicles with a needle, and introducing into them a finely-pointed pencil of nitrate of silver, has been recommended in both these varieties of the eruption. If they are situated on an unex- posed part of the body, and not in any way connected with visceral derangements, it may be had recourse to, but it should be remembered that an indelible mark sometimes follows the application of caustic to herpes. Most cases of ringworm require no treatment in the com- mencement except the use of mild mercurial purgatives, and protection of the eruption from local irritation ; if, however, there is much heat or tingling in the part, poul- tices prepared with bread and the weak lead-wash (see page 77) are productive of much benefit ; when the scales have HERPES. 93 formed, the ointment of cold cream and acetate of zinc (see page 30) will be found an excellent application. If the disease becomes chronic, constitutional treatment is generally required for its removal, and preparations of iodine, with or without tonics, according to individual cir- cumstances, are usually the most efficacious ; as regards local applications, astringent ointments and alkaline lotions prove in most cases successful ; thus an ointment consisting of four grains of the dried sulphate of iron, an ounce of white wax ointment, and a drachm of glycerine, should be smeared over the eruption three times a day, it having been previously sponged well each time with a lotion containing ten grains of the carbonate of potash in twelve fluid ounces of rose-water ; or, in very chronic cases, a dilute citrine ointment; containing from one to two drachms ot brown citrine ointment to the ounce of prepared lead, may be substituted for that of sulphate of iron. When herpes circinnatus is inclined to spread rapidly, the progress of the eruption may be sometimes stayed by the application of strips of blis- tering plaster around the outer border of the rings, at a short distance from the inflamed surface ; their effect seems to depend on a new action being excited in the part. In herpes of the scalp the same local applications will be re- quisite as when it occurs on other parts of the body, but the hair should be kept cut close with a pair of scissors during the entire progress of the treatment, and for at least three or four weeks afterwards ; nor is it sufficient to cut the hair on the diseased part solely, but it must be removed from the entire scalp, as otherwise the eruption is apt to appear in other patches on it. In herpes capitis in chil- dren, the green iodide of mercury, prescribed as recom- mended for eczema of the scalp, has proved in my experience the best alterative remedy. Milk diet, as an important aid to treatment, should be enforced in this variety of the eruption. Herpes iris is to be treated on the same principles as the milder forms of herpes circinnatus. 94 VESICOL^. PEMPHIGUS. PEMPHiaus ( Water-blebs). — Willan described three forms of diseases of tiie skin which were characterized by the elevation of the epidermis' into bullse, namely, erysipelas, pemphigus, and pompholyx ; that the first of these was incorrectly classed by him with the others is now admitted by all dermatologists for the reasons given when describing erysipelas ; and the distinction he made between pemphigus and pompholyx — that the one is attended with constitu- tional fever and local inflammation, and the other is not — does not sufBciently separate them to constitute distinct diseases ; the latter term therefore is now very generally abandoned, and when used is considered as being synony- mous with the former. Pemphigus may be defined to con- sist in the development of oval or rounded elevations of the epidermis, containing a transparent serous fluid, which vary in size from that of a pea to that of a large nut {bullae), — at times they attain the size of an egg — each being surrounded by an inflamed areola. The contained fluid rapidly becomes opaque, and of a yellowish color, the epidermic covering, which is extremely thin, then bursts spontaneously, or is easily torn, and the eruption results in the formation of fine foliaceous crusts, or superficial excori- ations .from which a slight serous discharge flows. The bullse come out generally singly or in crops of from two to five or six, each crop disappearing in a few days with some trifling epidermic desquamation, but the duration of the disease is often indefinitely prolonged by successive eruptions. In a few cases all the bullse appear simulta- neously, when it runs its course in about a week. By some writers pemphigus has from this circumstance been classified into Pemphigus simuUaneus and Pemphigus successivus ; others arrange it in groups according to the number of the bullae, and others again with reference to the age of the person on whom the eruption appears. The division, I think, least open to objection, and most convenient for the purpose of description, is into acute and chronic : — Pemphigus acutus. " chronicus. PEMPHIGUS. 95 Acute pemphigus (Atlas, PI. V. Fig. 1) is ushered iu with well marked febrile symptoms, being preceded by shiver- ing, heat of skin, general malaise, and loss of appetite ; as well remarked by Dr. Corrigan, there are sometimes two or more shivering fits so distinct that the attack at first sight appears • to be intermittent fever.' The feverish symptoms are succeeded on the second or third day by" the appearance of a few or many bright red spots, scattered generally over the thighs and lower part of the abdomen, which are attended with heat and itching ; these spots rapidly enlarge, and a minute, transparent vesicle is developed in their centre, which in a few hours extends so as nearly to cover the pre- viously inflamed patch of integument, a border being left which forms an areola to each. The bullae thus constituted are round or oval, somewhat flattened at the summit, of a shining brilliancy, and, being irregularly distributed, resem- ble" the effect which would be produced if boiling water was dashed on the skin ; on the day after their appearance the contained fluid assumes a yellowish, opaque aspect, and within forty-eight hours the bullae usually break, giving exit to a thin, serous discharge, which continues to be secreted for a few days longer, the surface thus exposed being red and excoriated ; the discharge then accretes into a thin scab, of a yellowish color, and a foliaceous aspect, which, falling off on the sixth or seventh day from the first appearance of the eruption, is succeeded by a slight epidermic desquama- tion and yellowish stain of the surface ; the former ceases from the tenth to the fourteenth day, but the latter often lasts for an indefinite period. In the acute form of pem- phigus the eruption may occur in a single crop, but there are more usually two or three in succession, an in- terval of from twenty-four to forty-eight hours existing be- tween them, and as each set of bullae runs a similar course, the duration of the disease is then prolonged for about three weeks. Two or more bullae being occasionally developed close to each other become confluent, and thus a very large vesication is often formed. On some of the inflammatory patches, on the other hand, no elevation of the epidermis ' CyolopsEdia of Practical Medicine, vol. iii. p. 263. 96 VESICULJE. occurs ; when, however, there is more swelling of the part, and a serous exudation takes place from its surface. The feverish symptoms always ahate on the development of the eruption, and the local heat and itching are much diminished, but the appearance of each successive crop of bullae is marked by their return. In some cases the fluid contained in the bullae is absorbed when they do not break, and the disease terminates with epidermic desquamation, while in other^ superficial ulceration occurs, and then its duration is more prolonged, and indelible marks are often left on the skin. Willan termed the disease Pompholyx benignus, when the premonitory fever was very mild, and the local inflammation trifling. He also described a very rare form of the eruption under the name, Pompholyx solitarius; in it " large vesica- tions arise on some part of the body, one after another, at nearly equal intervals of time ; a disagreeable tingling is felt for several hours before the vesication arises, which is usually in the night. It enlarges rapidly, so as sometimes to contain on the following day a tea-cupful of lymph. Within forty-eight hours the cuticle breaks, the lymph is discharged, and a superficial ulceration remains. Near this another vesication arises in a day or two, and goes through the same process as the first. A third, fourth, fifth and sixth vesication will sometimes appear and proceed in like manner." This singular variety of pemphigus seems to affect women solely ; it is extremely rare, yet . Willan men- tions that he witnessed three cases of it ; Cazenave states that he saw one remarkable instance ; and Copland records its occurrence under his observation in a man. The most usual site of acute pemphigus has been already indicated, namely, on the thighs and lower part of the ab- domen, but it may affect the arms, the backs of the hands, the legs, and the thorax ; it has been also witnessed on the mucous membrane of the mouth and tongue. It most usually occurs in adult life, but infants and children are not unfrequently attacked, and a variety has been specially de- scribed by some dermatologists under the denomination of pemphigus infantilis. This corresponds with the form so admirably depicted by PEMPHIGUS. 97 the late Dr. Whitley Stokes,' as being not uncommon in Ireland, and which he termed Pemphigus gangrsenosus (popularly known as burnt-holes or eating-hive) (Atlas, PI. V. Fig. 3). By some recent writers, however, it has been regarded as a species of Rupia, but to any one who has wit- nessed it in our country districts, where it is even in the present day of not unfrequent occurrence, its agreement with the characteristic phenomena of pemphigus must be suflSciently evident.* The eruption generally appears on a child in apparently good health, but occasionally a livid suf- fusion of the surface of the body precedes its outbreak ; one or more bullae appear on the surface, and increase in size for a few days, when they burst and discharge a thin fluid, having a disagreeable smell ; " before or after breaking, the vesicles run together, the sore becomes painful with loss of substance, and a thin, fetid, ichorous discharge ; the edges of the ulcer are undermined, and it spreads quickly." The discharge daily increases in quantity, and becomes more and more fetid, the ulcers spreading rapidly, probably from its acridity, and the constitutional fever, which is evidently caused by the local irritation, is extreme ; emaciation and great debility quickly ensue, and the child dies on the tenth or twelfth day, death being often preceded by convulsions. Should recovery take place, the progress to convalescence is very tedious, and relapses not unfrequently occur, even when the ulcers are skinned over. A deep pit, like that re- sulting from smallpox, but much more extensive, is always left. The eruption appears usually very generally over the body, sometimes spreading to the meatus auditorius, when deafness follows, and to the eyes so as to destroy the sight. Pemphigus ehronieus (Atlas, PI. V. Fig. 2) is of more frequent occurrence than the acute form of the eruption, and sometimes appears as an epidemic ; of this a remark- able example is recorded by Dr. Macbride, who witnessed it in the county of Wicklow in 1766. The disease which corresponds with the Pompholyx diutinus of Willan is not attended with any febrile symptoms, yet the outbreak of the ' Dublin Medical and Physical Essays, vol. i. p. 146; Dublin, 1808. ' In the following account of the disease, Dr. Stokes' faithful and original observations are freely made use of, 9 98 VKSICULiE. eruption is preceded for some days by sickness, debility, and muscular pains. Red spots, as in the acute form, appear scattered over the skin, but the redness is of a livid color, and is not accompanied by heat or itching ; on these spots the bullae are rapidly developed, each bulla covering com- pletely the reddened surface, so that to the naked eye they appear to have no areola, but when examined with a lens, a narrow red line will be seen to surround each. The vesi- cations, which generally attain their maximum size in a single night, are much larger than in the acute form, and rarely become confluent ; they come out almost invariably in successive eruptions, a second crop sometimes not appear- ing until the one which preceded it has completely disap- peared from the surface, and thus the disease may be in- definitely prolonged. The bullae are irregularly globular, somewhat flattened at the summit, and contain a citrine-yellow, semi-transpa- rent, serous fluid, — in old persons, or in broken-down con- stitutions, the fluid is generally sanguinolent in some of the bullae ; in eight or ten hours they burst, and are succeeded by the formation of thin, blackish crusts, beneath which the surface of the skin is excoriated ; when these crusts fall off, small, unhealthy ulcers, with a foul ichorous discharge, not unfrequently succeed. If the disease is not prolonged by the development of " successive crops of buUee, which, however, is rarely the case, it may not last longer than for a month or six weeks, and the general health is but little afiected ; more usually, how- ever, a relapse takes place, the eruption seeming to lie dormant during the winter, returning again in the spring and summer, and thus, or by fresh sets of the bullae con- tinuing to be developed, its duration is prolonged for months or even years, very frequently proving fatal. In the latter case there may be seen on the cutaneous surface, at the same time, recent bullce and black crusts and atonic ulcers, the result of previous eruptions. The constitution then sympathizes, extreme debility, with low fever, ensues on the loss of rest caused by the local irritation, pain, and foul discharge ; the appetite fails, and the patient dies quite worn out. In one very chronic variety of pemphigus which attacks PEMPHIGUS. 99 old persons, the bullae form with extreme rapidity, no dis- tinct interval elapsing between the development of the suc- cessive crops ; they become confluent, burst almost as quickly as they appear, and spread so as to engage the cutaneous surface over the greater part of the body, the face in especial being affected. The bullae are succeeded by epi- dermic desquamation in large, yellowish, foliaceous scales, which partly adhering to and partly peeling from the sub- jacent integument, gives a singular aspect to the disease ; these scabs are aptly compared by Cazenave to the layers of puff-paste, and he terms the eruption in which they occur, pemphigus Ohronicus foliaceus. It is generally a very fatal form, death being preceded by dropsical effusion and diarrhoea. Chronic pemphigus may occur on any region of the body, except those parts on which hair grows ; it is more diffused than when the disease is acute, and appears more frequently on the upper extremities, the face and the thorax. It not uncommonly is complicated with other cutaneous diseases, especially with prurigo or scabies, in either of which cases the sufferings it occasions almost baffle description. The causes of pemphigus are more or less connected with constitutional derangements ; the chronic form in particular rarely occurring except in persons who have been debilitated by distress, and by insuflScient or bad diet, or in those who suffer from some chronic visceral disease, of which it seems at times to be symptomatic. Acute pemphigus is most fre- quent in children and young persons, infants even not being exempt from it, appearing rarely in adults or in the old ; while chronic pemphigus is a disease of advanced life. The eruption is occasionallly developed in children after a con- tinued exposure to the heat of the sun ; btit it much more frequently seems to depend on the effects of moisture, most of those at any age who are attacked with it being persons who have lived in damp situations ; this fact is well estab- lished in the country districts of Ireland, where it is most prevalent among the peasantry who dwell in mountainous districts, much rain falling there, and the hills being con- stantly enveloped in mists. The occurrence of the disease as an epidemic has been already adverted to; some of the 100 VESICULJE. ancient medical writers regarded it as being contagious, and Willan, by describing a variety of it under the name Pem- phigus eontagiosus, tended to perpetuate this erroneous view, one, too, which was contrary to his own opinion. The diagnosis of pemphigus, whether acute or chronic, is, in most cases, unattended with difficulty. Although the bullae resemble somewhat the vesications which occasionally accompany erysipelas, they are never situated on a diffusely inflamed portion of the skin, as occurs in that disease, nor are they attended with the constitutional fever. The diag- nostic marks between pemphigus and herpes have been given in the description of that eruption. Rupia differs from pemphigus in there being in it a broad inflammatory areola to each bulla when it is first developed, and in the peculiar appearance of the resulting scab or crust. The foliaceous form of chronic pemphigus might be mistaken for psoriasis, but the scales in the latter desquamate more freely, are smaller, of a silvery whiteness, and are never preceded by an eruption of bulls&, nor attended with a serous discharge. Prognosis. — Pemphigus in any of its forms is not un- attended with danger, notwithstanding Willan termed one variety of it Pompholyx benignus. The chief apprehensions in the acute form are, the liability to relapse when it appears in children, or about the age of puberty; and, at an earlier age, that it may assume the characters of the pemphigus gangraenosus of Stokes. The chronic form is always a most dangerous disease, few^ld persons recovering from an attack of it. The more acute the symptoms, and the more inflammatory the constitutional disturbance, the more favorable the prognosis. As regards the pathology of pemphigus, it is manifestly an atonic inflammation of the superficial layers of the derma, which terminates in serous effusion : the fluid contained in the bullae is highly albuminous, becoming nearly solid when exposed to heat. Treatment. — The acute forms of this eruption demand but little medical interference, the accompanying fever being rarely such as to require any active antiphlogistics; should it, however, continue after the bullae are fully de- PEMPHIGUS. lOi veloped, or inflammatory symptoms then appear, a small abstraction of blood from the arm may be requisite ; but in the majority of cases, rest in bed, diluent drinks, reduced diet, and mild saline purgatives will suffice. The vesica- tions should be as much as possible protected from local irritation, and, above all, from being prematurely ruptured ; •with this view they may be dusted over with flour or starch ; as soon as they have burst they may be dressed with some simple ointment, such as the cucumber or acetate of zinc cerate, or collodion may be applied over them. When acute pemphigus presents the characters described by Dr. Whitley Stokes, all debilitating plans of treatment must be carfefully avoided, good nourishing diet should be given in abundant quantity, the air be at once changed, and powdered bark, with minute doses of pulvis cretse opiatus and of the hydrar- gyrum cum creta, administered internally. On the sugges- tion of Dr. Stokes, an ointment prepared with lard and the leaves of the common figwort, Serophulafia nodosa, was used as a local application in this form of pemphigus ; he states that he derived his knowledge of its beneficial action from an inquiry into the applications which were popularly employed with success in the country districts of Ireland, in all of which he found that the leaves of this indigenous plant formed a principal ingredient ; at his recommendation it was originally introduced into the Dublin Pharmacopoeia, from the last edition of which, however, it has been omitted. It was, in fact, but a mild astringent ointment, and its chief eflicacy probably depended oiffhe protection from the action of the air which it afibrded ; a weak cerate of tannic acid — two grains to the ounce of white wax ointment — melted, and applied to the surface with a camel's-hair pencil, just as it is again about to become concrete, will be beneficially substituted for it. In chronic pemphigus the chief indications are to allay both the local and constitutional irritation, and to support the strength ; attention must also be directed to any visceral disease of which it may be symptomatic, or with which it may be complicated. I have experienced very great benefit in its treatment from the free use of opiates, 9* 102 VESICUL^. which may be given, combined with bark, as in the follow- ing form : — B. Liquoris Opii Sedativi, . . . . m. x. TinctursB Cinohonae Compositsie, m. xv. Misturse Gamphorse, fl5J. Misce; fiathaustus. " One such to be taken every sixth hour." To allay the local irritation, the parts may be covered with raw cotton or dusted with starch, or, if the itching and pain are very severe, they may be dressed with lint on which has been spread the compound lead cerate, to every ounce of which a fluid drachm of glycerine has been added. By some it has been proposed to open the buUee as soon as they appear, and to apply to the surface thus exposed a solution of nitrate of silver, containing a scruple of the salt to an ounce of distilled water; instead of the solution, Dr. Graves proposes to employ the solid nitrate for this pur- pose, and mentions a case in which its use was attended with complete success ;' the practice, however, is only ad- missible when the eruption is of small extent, and not connected with constitutional derangement. In very ob- stinate cases arsenical preparations and iodide of potassium are occasionally employed with benefit. Wine and generous diet should be allowed in all cases of chronic pemphigus, and change of air to a drier locality enforced, if possible. AVhen diarrhoea or dropsical sjknptoms occur in the course of the disease, they are to be treated on the ordinary prin- ciples. EUPIA. RCPIA is characterized by the eruption of distinctly- separated and dispersed, flattened bullae, of the size of a small nut, on an inflamed base, terminating in elevated, dark brown crusts, which, falling off, are succeeded by atonic ulcers. The bullae, which in most cases are not preceded by either local or constitutional inflammation, ■ Clinical Modioine, Second Edition, vol. ii. p. 854. KUPIA. 103 contain from the first a semi-opaque or ichorous fluid, which appears not to distend them completely ; this fluid rapidly becomes sero-purulent and more consistent, and the epidermic covering of the bullae, giving way usually on the second or third day, accretes into a wrinkled scab, more prominent in t^e centre than at the circumference. Three varieties of rupia are in general described by dermatologists, but the third of these, rupia escharotica, as has been already mentioned when describing pemphigus, is a form of that eruption, being the pemphigus gangrsenosus of Dr. Whitley Stokes — two forms, therefore, only remain to be considered here : — Rupia simplex. " prominens. In Rupia simplex (Atlas, PI. V. Fig. 4) the bullae are but few in number, often not more than two or three, and situ- ated remotely from each other ; the inflammatory areola is narrow, and scarcely raised above the level of the surround- ing integument, and the crusts, which are of a dark-brown color, only slightly elevated in the centre. The resulting ulceration is superficial, and scabs cover it in a few days ; these scabs, which are wrinkled and raised at the edges, fall oflf and are renewed several times for from one to two or three weeks, when the surface heals, a livid stain, which does not disappear for some time, remaining on the part. The duration of the disease until the falling off of the scabs is, as above remarked, from two to three weeks, unless, as occasionally occurs, it is prolonged by the formation of new bullae at the time those first developed are about to disap- pear. In some rare cases a slight degree of fever precedes the appearance of the eruption, and superficial redness, as in pemphigus, marks the spot on which each bulla is about to form. Rupia prominens (Atlas, PL V. Fig. 5) is so named from the characteristic appearance of the crusts or scabs which are formed in it. The bullae are of larger size than in rupia simplex, the patches of the cutaneous surface on which they occur are previously swollen and of a dark-red color, and the contained fluid, which is often ichorous or sanguinolent, 104: VESICUL^. sometimea as dark as chocolate, rapidly thickens and dries into a hard, wrinkled, blackish crust, surrounded by a swol- len, inflamed border. From the inner edge of this inflamed areola, unhealthy pus is secreted, which, concreting, forms additional crusts; these, pressing on the original scabs, already somewhat raised in the centre and corrugated, force them still more forwards until they eventually attain such a prominence that they bear an extraordinary resemblance to the shell of a limpet, or, in some cases, spreading from their circumference until they cover the entire of the in- flamed border by which they were surrounded, to the shell of an oyster. These crusts, which are firmly adherent and slow in falling oiT, in a few days become somewhat raised at their outer border, and permit the discharge of unhealthy pus from the excoriated surface beneath ; in the course of a week or ten days they may be readily detached, or they fall off spontaneously, when an excavated atonic ulcer, the depth of which is usually proportioned to the thickness of the scab, is seen to occupy the site of the original bulla. These ulcers are extremely indolent, pale, and bleeding on the slightest touch, and either become covered anew with the character- istic crust, which, however, does not attain the same degree or prominence as in the first instance, or, discharging an un- healthy, ichorous pus, heal slowly, leaving dark, livid stains on the skin. Rupia prominens is always a chronic disease, lasting generally for months, and its duration is often pro- longed by successive eruptions of bullfe. The usual site of either form of rupia is on the lower extremities, sometimes on the abdomen, the loins, or the thorax ; but, unless when occurring as a syphilitic eruption, it is very rarely witnessed on the upper extremities or the face. The disease may occur at any age, but it most usually affects children and old persons, being uncommon in adults. The causes by which it is produced are sufiioiently obscure, but it appears to be connected with a debilitated state of the constitution, and especially in children with the scrofulous diathesis. It is also one of the sequelae of the eruptive fevers in young persons, and in the old it not uncommonly occurs at the termination of some prolonged illness, such as fever or dysentery. Rupia is sometimes complicated with RUPIA, 105 other cutaneous diseases, more particularly scabies, ectliyma, and purpura; in the last case the bullas usually contain blood. Diagnosis. — Eupia may be confounded with either pem- phigus or ecthyma. From the former it is distinguished, even in its vesicular stage, by the bullae being solitary, never confluent, and by the raised inflammatory border ■which surrounds them ; when the scab is formed, its charac- teristic prominence serves to render the diagnosis easy. Ecthyma is an inflammatory pustular eruption, and the resulting scabs are small and flat, while rupia is distinctly vesicular at its origin, and the scabs are large and promi- nent. The moi-e serious mistake may be made of mistaking idiopathic for syphilitic rupia, which is a much more severe disease, and one requiring different treatment ; the latter is distinguished by the areola surrounding the bullae being of a dull, coppery hue ; by the bullae being much more numerous, often covering nearly the entire body, and appearing very frequently on the face ; by there being generally present at the same time syphilitic sore throat ; and by the antecedent history of the case. The prognosis in rupia is always favorable ; it is often an obstinate, but never a dangerous disease, and rarely injures the general health, unless the resulting ulcers are very numerous, and attended with much discharge, when a degree of low, irritative fever is developed by their presence. Treatment. — Constitutional remedies are chiefly to be relied on in the treatment of rupia, and these should be adapted to the indications in individual cases. Tonics, especially preparations of bark and of iron,' good food, and nourishing diet, are most usually demanded. When the disease becomes chronic, hydriodate of potash will be given with benefit in equal parts of the decoctions of elm- bark, of dulcamara, and of mezereon ; and in the case of scrofulous children, cod-liver oil should be prescribed. As regards local treatment, it is generally recommended to open the bullae at the earliest opportunity, so as to prevent, if possible, the formation of the crust ; they should then be covered with pledgets of lint, and slight pressure made on them, or they may be dusted with starch, or, what is still preferable, as the chief object is to exclude the air, collodion 106 VESICULiE. may be applied. When the crusts have formed they should be removed as quickly as possible, having been previously softened by the application of bread and water, or of linseed- meal poultices ; the'ulcers, for the first few days, should be treated with water-dressing, over which oiled silk is placed, but if they do not show a disposition to heal, stimulating ointments or lotions become requisite ; of the former, the brown citrine ointment, or one composed of equal parts of oil of turpentine and of white wax ointment, may be used ; or of the latter, if it be found, as is often the case, that greasy applications disagree, solutions of the sulphate of copper or of sulphate of iron, from six to twelve grains of ether to the ounce of distilled water, may be employed, lint soaked in them being laid on the ulcerated surface. Some of the French dermatologists report that they have derived excellent results from ointments of the iodides of mercury, — a drftchm of the green or twelve grains of the yellow iodide, to the ounce of lard. By some practitioners it is recommended to touch the ulcer every second or third day with the solid nitrate of silver, but the nitrate of copper, allowed to deliquesce, and then applied by means of a camel's hair brush, will in very obstinate cases, be found more beneficial. It must not be omitted to mention that Rayer states he found the simple practice of dusting the ulcers with finely-powdered cream of tartar very successful. SCABIES. Scabies [Itch) (Atlas, PI. VI. Figs. 1 & 2):— No little difiSculty has been at all times experienced in classifying scabies ; by some it is regarded as being papular, by others pustular, and by many modern dermatologists it has been made to constitute a division of cutaneous diseases of which it is tKfe type, — the presence of parasitic animalcules beneath the epidermis being considered by them as a necessary cha- racteristic of the eruption. There can be no doubt but that during the course of the disease pimples and pustules con- stantly occur on the skin, mingled with the vesicles, and the vesicles themselves assume a purulent aspect in a few days after they are developed, yet on careful observation it will be found that the eruption is at first always distinctly vesi- SCABIES. 107 cular, and that this character is never completely lost in any stage of the affection. The occurrence of the peculiar itch animalcule is very constant in scabies, and its existence easily demonstrable, but as cases do occur in ■which even the most experienced observers are unable to detect it, I cannot admit that its presence is necessary to and pathog- nomonic of the disease. For these reasons, then, and also because the peculiar vesicle of scabies is highly character- istic, I shall retain it amongst the vesiculee. It has always been an eruption of much interest to the physician in con- sequence of its great prevalence, the rapidity with which it spreads by contagion, and the severity of the local symptoms with which it is attended. The eruption in scabies, the development of which is unaccompanied by constitutional symptoms, is preceded by itching and tingling of the parts on which it i^ about to appear, usually the backs of the hands, the angles be- tween the fingers, and the flexures of their joints ; in about twelve hours afterwards there may be seen developed on them one or more conical vesicles, which rapidly enlarge until they not unfrequently attain the size of a small pea, being more or less solid at the base, and transparent at the apex, which is acuminate. The majority of these vesicles soon become opaque and sero-purulent, and, bursting, form yellowish scabs ; but in some of them the serous effu- sion is absorbed, and they then present a papular appear- ance, a thin, epidermic scale forming on the top of each papule. In the neighborhood of some of the vesicles may be seen, in most cases of itch, a narrow line or superficial fissure of a few lines in length, such as would be made with the point of a needle — the sillon, which terminates in a small, rounded, elevated point, of a reddish color — the cuniculus, or burrow of the itch animalcule, and from which, with a little care, it may in general be extracted. This insect — the Acarus scahiei, or, as it has been also termed, Sarcoptea hominis, being constituted jnto a new genus by Latreiile — was discovered and described as ex- isting in scabies in the twelfth century by Avenzoar ; but although its presence was evidently known to the Greek and Roman physicians, little notice of it occurs afterwards 108 VESI0ULJ5, in medical writings until the middle of the seventeenth century, when an Englishman, Mouffet, left in a posthu- mous work a singularly full and accurate description of the animalcule, especially as regards its anatomical cha- racters, and in which many of the so-called discoveries of modern days are anticipated. In our own times the na- tural history of the itch animalcule has been especially investigated by the French and German dermatologists, particularly by Renucci, Raspail, Albin-Gras, Hebra, and Bourguignon ; amongst English writers Mr. Erasmus Wil- son gives the fullest account of its habits and structure, and from his observations the following description is con- densed. Examined with the naked eye, the acarus scabiei (Atlas, PI. XVI. Fig. 1) looks white, shining, and globular in form. " There^ is no difficulty in extracting the little animal ; the Guniculus is seen without difficulty ; the end of the cunicu- lus is perceived to be a little raised, while a grayish speck is seen beneath it; as soon as this little eminence of epiderma is lifted, if the end of the needle or pin with which the ope- ration is performed be examined, the minute, white, and shining globe will probably be observed attached to the in- strument. If there be no such object, the point of the needle, placed again beneath the raised capsule of epiderma, will pretty certainly draw it forth. This facility of extract- ing the liftle creature is due to its great power of clinging to any object with which it comes in contact. When the acarus is seen running upon the surface of a plate of glass it may be perceived that its anterior margin presents a dusky tint of color, and the examination of this part of the crea- ture with the microscope brings into view a head not unlike that of a tortoise, and a pair of large and strong legs on each side of the head. These organs are encased in a mo- derately thick layer of chityne, and have consequently the reddish-brown tint of the cases of certain insects, or of the bright part of a thin layer of tortoise shell."' The general outline is sub-rotound, it being a very little longer than broad ; the ventral surface is flat, and upon it may be seen the head and eight legs ; the dorsal aspect is arched and ' Erasmus Wilson on Diseases of the Skin. Third Edition, p. 499. - SCABIES. 109 uneven, and covered by numerous spines; and twelve hair- like filaments, some long and others short, project backwards from the posterior segment of the animalcule. Mr. Wilson, from a comparison of the measurements in ten specimens, found them to vary between j^^th and TyVtIi of an inch in length, and ^J^d and ^'^th in breadth. This account refers to the female acarus, and with it are generally found some of the ova ; the male insect (Atlas, PI. XVI. Fig. 2) seems to have eluded the research of most investigators ; M, Bourguignon, writing so lately as 1847, says, " that he has never found male sexual organs in the acarus, but in every specimen he examined has seen ovaries with the ova, it appearing that connexion with a male is not requisite for the reproduction of the animalcule."' Gustav Simon, Physician to the Charky Hospital at Berlin, de- scribed the male acarus in the first edition of his Anatomical Description of Diseases of the Skin, published in 1848 ; and in 1851, it was also discovered and described by M. Lan- quetin, a pupil of M. Cazenave. It is much more minute than the female, and being always situated on the free sur- face of the skin, not taking up its abode in a cunicnlus, ac- counts for its existence being overlooked by so many careful investigators. The eruption in scabies is invariably attended with severe itching — whence the name by which the disease is com- monly known, — this, causing the sufferer from it to scratch and tear the skin with the nails, increases the local inflam- mation, which already is considerable ; fresh vesicles appear, often thickly set on the surface, and mixed with them large papulae and pustules ; a bloody serous and sero-purulent dis- charge flows from the torn integuments, in which deep fissures are also formed, and the eruption spreads rapidly, in severe cases attacking the lower extremities, the abdo- men, and the trunk, as well as the hands and arms, but being very rarely, if ever, witnessed on the face. The suffer- ings occasioned by the disease are then extreme, sleepless nights are passed often for weeks together, the itching being always much augmented by the warmth of the bed ; the con- stitution, consequently, sympathizes more or less, and in the ■ Becherclies Entomologiques et Pathologiques sur la Gale de rHomme. Paris, 1847, p. 8. 110 VESICULwS. old or the debilitated, prurigo, ecthyma, or pemphigus, com- plicates the original eruption, rendering it more intractable, and in very aged persons even fatal. In some cases of scabies the eruption is apparently alto- gether papular, but on examination with a lens it will be found that a minute vesicle surmounts each papule ; from mistaking its true character, Willan and Bateman termed this form of scabies papuUformis ; when the vesicles are perfectly transparent, and with little or no inflamed base, they denominated the disease, scabies lymphatica; and when the pustular character predominated, they constituted it a distinct variety, under the name scabies purulenta. The occurrence of the eruption in broken down constitutions is not unfrequent, and its aspects being then influenced by the physical condition of the individuals attacked, the same dermatologists arranged it in a distinct species, which they called scabies eacheotioa. Causes. — Scabies occurs at all ages, in individuals of every rank of life, and in all climates, being even more prevalent in hot countries than in cold, and there it is also a more severe disease ; it is of much more common occur- rence among the poor than amongst the higher orders, in consequence evidently of the less frequent ablutions to which their bodies are subjected, and the longer period during which their clothes are worn without being changed, for the eruption is especially a concomitant of filthy habits. That the spread of the disease from individual to individual takes place by contagioriTis undoubted, but that this is the only cause some have questioned, believing that it may be self- generated in the system ; however, such a doctrine is now nearly obsolete, and the sole difference of opinion existing on the matter at present may be said to be as to which is the contagious principle in scabies, the acarus, or the matter of the eruption. Mr. Erasmus Wilson asserts his belief, that " the vesicle is a provision of nature to protect the derma from the nearer approach of the arator, and the vesicle is formed with the judgment which usually marks nature's operations — namely, before a defensive operation would be too late." Now how the approach of the insect is to be prevented by the formation of the vesicle, I must confess 1 cannot understand ; the sillon, or tract from the SCABIES. Ill cuniculus, always terminates in a vesicle, and otservatlon shows that the development of the vesicle precedes the ap- pearance of the animalcule ; I therefore think that the con- nection between them may be more simply explained by re- garding the sillon as being the track of the acarus in making its way from the vesicle — which has been caused by the irritative inflammation occasioned by its deposition from the skin of another person, no matter how conveyed, or in the fluid of which it has been hatched — to the cuniculus or burrow for the purpose of depositing its ova. The belief of those, then, who think with that dermatologist is, that scabies, being in all cases dependent on and caused by the acarus, can alone be propagated by the deposition of this insect, or of its ova on the epidermis, and that the secre- tion from the vesicles will not of itself reproduce the disease. Direct experiment, however, proves that it may be thus propagated, but to this they answer, that when it is so, the inoculating matter employed must contain some of the ova ; but a similar argument is equally applicable to their view, namely, that when the disease has been produced in indi- viduals by the acarus being placed on the skin, it cannot be denied that the animalcule conveyed with it some of the cha- racteristic secretion. For my own part, I am of opinion that scabies will be developed in a person whose skin has been previously free from the disease by the contact of either the itch-insect or the secretion from the eruption, but I believe the latter to be the most frequent cause of the contagion, and in this way only can we account for the many cases that occur in which the disease has been produced by contact with clothes, with gloves, &c., which have lain by for some time; in one instance which I saw, a lady was attacked with scabies on the palm of her hands, and as far as obser- vation, which I freely admit is not indisputable evidence here, enabled me to judge, the contagion was conveyed to her from her servant-man, who was afiected with the disease, by means of the handles of the knives which he was in the habit of cleaning. From experiments which have been made it appears that scabies is more quickly developed in the young and in indi- viduals of a full and robust habit of body than in the old, 112 VESICUL^. or those who are of a \reak constitution; the period of incubation in the former being about four days, while in the latter it may extend to ten days or a fortnight, or even longer. The diagnosis is, in some cases of scabies, extremely difficult, and in no other cutaneous eruption is it more important that a mistake should not be made, especially as the plan of treatment adapted for it is not at all suited for those diseases with which it is likely to be confounded ; moreover, an opinion given with regard to contagion, if it prove to be incorrect, may seriously injure a physician's character. When eczema appears on the fingers or hands it is very often mistaken for scabies ; in its early stages the minuteness and number of the vesicles generally suffice to render the diagnosis facile, but when it becomes chronic, the itching with which it is attended not unfrequently may lead to error. Eczema, however, never presents the conical- shaped vesicles of scabies, the discharge from the parts affected with it is more watery, — being rarely sero-purulent except in eczema impetiginodes, — is accompanied by a mealy, epidermic desquamation, and it is rather a sensation of smarting and stinging than of true itching that attends it. The papular form of scabies may be mistaken for lichen, more particularly when the latter affects the backs of the hands ; but the complete absence of vesicles and of a sero- purulent discharge in the latter, generally suffices to prevent the mistake from being made ; the eruption, too, does not spread to the flexures between the fingers, the most usual seat of itch. Prurigo, which, like lichen, is a papular eruption, is liable to be confounded with scabies, chiefly in consequence of the severe itching with which it is attended; but it rarely affects the hands unless when it appears as a complication of that disease, its usual seat being the trunk of the body, the shoulders, and the thighs; and the small black crusts on the summits of the papulae produced by scratching are highly characteristic ; it is moreover, very rarely accompanied by any discharge. When scabies assumes the pustular character, and the individual pustules attain a large size, it might be mistaken for ecthyma, but the latter is characterized by not being attended with itch- ing, by its mode of development, and by the pustules being SCABIES. 113 usually isolated. In fine, from all the cutaneous diseases now enumerated, scabies is especially distinguished by its contagious nature, and by the presence of the acarus ; but it should be remembered that it may be complicated with any of them. Prognosis.—As this eruption can scarcely be said to prove dangerous to life, except in the rare instances already re- ferred to, the prognosis refers only to its probable duration, and this, when effective treatment is adopted, is always very short ; but if scabies be left to itself, uninterfered with by the application of remedies, it may be indefinitely prolonged, as it never seems to exhibit a tendency to wear out, or to undergo a spontaneous cure. Treatment. — If there be any well-established example of a specific in the whole Materia Medica, it is that of the action of sulphur in the treatment of scabies, and as this medicine never fails to cure the disease, it is the universally admitted remedy for it ; none other indeed would require to be alluded to, were it not that the unpleasant odor of sulphur renders its employment in some instances inadmissible. The general method of using this substance for the treatment of scabies is by the local inunctioH of ointments containing it, either alone or combined with alkalies ; in the latter form it is generally employed in the present day in France, and found to be more efficacious than when used alone ; the com- bination was first introduced by M. Helmerich, and the oint- ment, which is called after him, JPommade of Helmerich, is composed of two parts of sulphur, one of carbonate of potash, and eight of lard. The surface of the entire body, but more particularly of the affected parts, should be first washed well with a strong solution of soap, the patient then placed for a quarter of an hour in an alkaline bath, containing a pound of the carbonate of potash to twenty gallons of water, at the temperature of 92°, the skin well dried, and this sul- phuro-alkaline ointment afterwards thoroughly rubbed in; the disease may thus be effectually cured in two or three days, a single friction, preceded by the alkaline and sapona- ceous bath, being used daily. Out of upwards of 700 per- sons treated on a plan nearly similar to this at the H6pital St. Louis, in Paris, M. Bazin only met with six unsuccessful 10* 114 VKSICUL^. cases, all the rest being cured od the third day.^ M. Hardi, who succeeded M. Bazin iu the charge of the itch wards in this Hospital, has introduced a plan of using the sulphuro- alkaline ointment there, by which the period required for a complete cure is reduced to two hours. His method is as follows : " On the admission of the patient, the entire sur- face of the body is rubbed for half an hour with soft soap — savon noir; he is then placed in a bath for an hour, and the body well rubbed while in it, and at the end of that time general frictions made and continued for half an hour with Helmerich's ointment. The acarus," adds M. Hardi, "is thus killed, and the patient consequently cured." Of 400 patients thus treated, it is said that 4 only required to re- turn for further advice, and of these 2 had recontracted the disease. A question arises as to whether it is advisable to cure thus suddenly a vesicular eruption, which in some cases is attended with a rather copious discharge ; M. Devergie, a celebrated dermatologist, and one of the senior physicians to this hospital, thinks it may be dangerous to do so, but I cannot agree with him, for as scabies is not attended with any constitutional disturbance, and is never symptomatic of an internal disease, the same causes do not operate against the sudden cure of it as against that of cutaneous diseases, the discharge in which is evidently dependent on some deranged condition of the system generally. M. Devergie, however, asserts that although the contagious nature of sca- bies is destroyed by this plan of treatment, a troublesome cutaneous eruption still remains — one, too, attended with much annoyance to the patient, and often difficult of cure. When any insuperable objection exists to the employment of sulphur for the cure of scabies, other applications may be had recourse to, which, although more tedious in their action, are equally efficacious ; the use of any of them will invariably be beneficially preceded by the employment of frictions with soft soap, and of the alkaline bath. Oil of turpentine made into an ointment with eight times its weight of prepared lard, is a very certain application, but its odor to many persons is more objectionable even than that of sul- I Journal de M^deciae et de Chirurgie Pratiques, December, 1861, p. 529. SCABIES. 115 phur; this may to a great extent be removed, and its efficacy rather increased, by the addition of eight minims of oil of bitter almonds to each ounce of the lard combined with it. The ointment of sulphuric acid, of the former Dublin Phar- macopoeia, which is free from any unpleasant odor, rarely fails to cure the disease ; stavesacre and white hellebore ointments, also, have been used with success ; the former is prepared by mixing with prolonged trituration one part of the powdered seeds of the Delphinium staphisagria with four times its weight of white wax ointment and one part of glycerine, and the latter by combining two ounces of pow- dered root with half a pound of prepared lard, and adding twenty minims of oil of lemons. Inunction with simple fatty matters even, such as olive oil or lard, has been found sufficient to cure scabies, but the duration of the disease is more prolonged than when any of the above-mentioned remedies has been had recourse to. A strong objection often existing with some persons to the use of greasy applications, lotions of the sulphuret of potassium, or of chlorinated lime or soda, may be substituted for them ; of the former twenty grains, and of either of the latter a drachm to the ounce of distilled water, should be employed. With reference to internal treatment nothing more is usually requisite than the administration of saline or sul- phurous cathartics, and the use of the former should never be omitted ; in very obstinate cases the combined employ- ment of sulphur as an internal remedy and an external application is not alone attended with benefit, but often absolutely demanded. Should the local inflammation run high in young persons of robust constitution, bleeding from the arm even may be indicated, but this is very rarely requisite. In all cases of scabies constant ablutions with soap and water constitute an essential part of the treatment, and the clothes which had been worn previously should be laid aside, as from their retaining the contagious matter, the disease may be reproduced after a cure has been effected. 116 PUSTULiE. CHAPTER IV. PUSTULE. The Order Pustule includes those cutaneous diseases that are characterized by the eruption of circumscribed, rounded elevations of the epidermis, which contain pus, and are situated on an inflamed base — pustules; the pustules which may be either psydracious or phlyzacious (see page 26), burst and form scabs or thick crusts, on the falling off of which a slight, not permanent, depression or stain is left. Pustular eruptions are non-contagious, attended with more or less inflammation, usually of a sub-acute or chronic cha- racter, and their duration may be either very short or much prolonged. The local inflammatory action by which a pustule is produced affects the deeper structures of the derma as well as the epidermis, in consequence of which the sub- epidermic effusion is purulent, while in vesicular eruptions the superficial layer only of the derma being in- flamed, the effusion is serous. In its early stage a pustule can scarcely be distinguished from a papule, inasmuch as the pus on which its specific character depends does not usually appear at the apex until the second or third day ; the puru- lent secretion then gradually, increases, distending the epi- dermic covering more and more, until, finally, it gives way, when the matter is effused on the cutaneous surface, and a scab is formed ; of this process an excellent example is afforded in the case of the pustular eruption artificially pro- ■ duced by the local application of tartar emetic in the form of ointment or solution. While undergoing these changes, the pustule is said, in popular language, to be ripening. Some of the diseases included by Willan and Bateman in this order were so classed by them from an incorrect idea of their true characters ; thus scabies, for the reasons given in the last Chapter, is more properly placed among the vesiculse; variola is one of the eruptive fevers; and porrigo ACNE. 117 is not pustular in any of its stages. Acne, included by them in the division which they termed Tubercula, presents the aspects of a true pustule, according to the foregoing defini- tion. The group then comprehended three forms of cuta- neous eruptions, Acne, Impetigo, Ecthyma. ACNE. Acne consists in the eruption of psydracious pustules, Vfith a hardened base, distinct from each other, but usually aggregated in small patches on a circumscribed inflamed portion of the skin ; when they maturate, bursting and giving exit to purulent matter, which dries into thin, brown- ish crusts. The pus first appears as a minute dot at the apex of. each pimple, which is somewhat acuminate, then, gradually increasing in quantity, the pustule becomes glo- bular, and of a straw-yellow color, its base still remaining hard, red, and painful, and surrounded with an inflamed areola. At times some of the pustules, taking on an in- dolent action, little or no matter forms in them, when they present the appearance of hard, inflamed, minute tumors, about the size of a small pea and exquisitely painful to the touch, and are slow in disappearing. The seat of the inflammatory action in acne is chiefly in the sebaceous glands, and the disease is" not unfrequently produced by obstruction at their orifices causing an accumulation of the natural secretion and consequent irritation. By some modern dermatologists it has, therefore, been made to con- stitute a distinct class of cutaneous eruptions, defined by Cazenave as consisting in " a diseased condition of the follicular secretion," and by Erasmus Wilson as " an in- flammation of the sebiparous glands and adjacent tissues, with or without alteration of secretion. Acne is a disease chiefly of youth and of adult life, occurring with greatest frequency about the age of puberty, whence its name, derived from the Greek word, axfitj, vigor. The several varieties of the eruption which have been described may, I think, be reduced to two forms : — Acne simplex* '.' rosacea. 118 PUSTULE. Biett was the first to describe a rather rare cutaneous eruption as a variety of acne, terminating in acne sebacea, in which the sebaceous follicles become hypertrophied and their secretion diseased, and nearly every dermatologist since his time has adopted his views, and retained the name proposed by him ; as, however, it does not in any respect resemble acne, except in being an affection of the sebaceous follicles, it will be more correctly classed in the group of cutaneous eruptions, which I propose to term Hypertrophiie. Aene simplex (Atlas, PI. VI. Fig. 3) is a very frequent disease in young persons, especially in those in whom the cutaneous capillary circulation is active, appearing generally in the spring and autumn, and disappearing partially in summer and completely in winter ; it may consist in the eruption of only a few scattered pustules on the face, or may occur in small patches or pretty thickly disseminated over a large portion of the cutaneous surface, especially affecting those regions where the sebaceous follicles are most nume- rous. The pustules, whether few or many, are developed individually, and do not coalesce ; each of them appears first as a small, red, acuminated elevation, hard, and somewhat painful, particularly so if the skin where it occurs is thick ; within twenty-four or thirty-six hours the pustule, which has continued to enlarge, presents at its apex a yellowish point, which increases for a day or two, when the epidermis gives way or is ruptured, and pus, mixed with the curdy sebaceous secretion of the follicle which may have been involved in the local inflammation, is discharged : although each pustule has an inflamed base, there is no diffuse sur- rounding redness of the skin. Many of the pustules do not maturate, but, remaining indolent for a few days, terminate by resolution, the lymphy effusion contained in them being re-absorbed ; some slight hardness and redness, however, are left, which gradually disappear. In some persons, who are characterized for the most part by having a coarse, greasy skin, the sebaceous and hair follicles are particularly developed, and secrete copiously the thick curd-like matter which naturally exists in them ; individual follicles often become obstructed at the orifice, somewhat distended, arid present a black point at their apex ; they then exhibit the appearance described by some ACNE. 119 dermatologists as a distinct variety of acne, under the name acne punctata (Atlas, PI. VI. Fig. 4). The curd-like matter, when pressed out by the fingers, forms a round cast of the follicle in which it existed, and owing to its size and shape, and the black point at its extremity where it had been exposed to the action of the atmosphere, bears much resemblance to a small maggot, and which it is commonly believed to be. Although this popular notion is, it need scarcely be said, erroneous, Dr. Gustav Simon has discovered in the natural sebaceous secretion a minute animalcule, from the 0.085th to the 0.125th of a line (German measure- ment) in length, and about the 0.020th of a line in breadth ; it was named by him Acarus follieulorum, but has more recently been shown by Einsicht not to be an acarus, and is therefore termed by the latter Steatozoon follieulorum (Atlas, PI. XVJ. Fig. 3). The eruption in acne simplex is thus usually composed of maturating and non-maturating pustules, and of enlarged obstructed follicles characterized by black points, — the latter are constantly present on the cutaneous surface in some individuals ; it may consist in a single outbreak affecting a more or less extended surface, or it may appear in successive crops, being consequently then of more prolonged duration. No constitutional fever or other disturbance attends the dis- ease, even when it attacks many regions of the skin simul- taneously, nor, although some pustules may be attended with pain, are the local symptoms troublesome, being chiefly annoying in consequence of their being situated on the face, and therefore causing a temporary disfigurement. The du- ration of individual pustules, when they run an acute course, is from five to eight or ten days, but when they are indolent, or appear in successive crops, the disease may be prolonged for as many weeks ; in the latter case the marks left on the skin are slow in fading away. Appearing and disappearing with the seasons, being developed in spring and autumn, and receding in summer and winter, acne simplex becomes less frequent as youth changes into puberty, and with adult life either ceases altogether, or, becoming nearly permanent, is converted into the next variety to be described. The usual seat of the simple form of acne is on the face, the neck, the shoulders, and the che|t ; it occasionally occurs 120 PUSTULE. on the scalp, where it is exquisitely painful, although the pustules are few in number, and very scattered ; but it is very rare on the extremities. ^cne rosacea [Q-utta rosacea; Rosy-drop; Oarhuneled face : Brandy face) (Atlas, PI. VI. Fig. 5) is a disease of more mature life than the preceding variety ; it has espe- cially attracted the attention of the French dermatologists, by many of whom it is described as a special disease under the name of Couperose. The eruption, which is invariably seated on the face, usually becomes chronic, but in all its stages is attended with more local inflammation than acne simplex; it generally commences in the form of a red patch on the skin, on which is rapidly developed a cluster of mi- nute pustules, or rather pimples, hard, and but little ele- vated ; these enlarge gradually, but are slow to maturate, and their base becomes harder, often painful, and much in- flamed. Eventually giving way at their apex, a serous exudation, mixed with blood, oozes forth, which concretes into a hard, dry scab, and from beneath it a small quantity of a curdy pus escapes in a few days after. The hardness at the base of each pustule, however, still remains, and the rosy or crimson-violet patch of the skin, on which a varicose condition of the superficial veins is sooner or later devel- oped, is often persistent on the face for months or even years, spreading gradually over the nose, cheeks, forehead, and chin, fresh crops of similar pustules constantly appear- ing on it. When this form of acne is chronic, it assumes a very ag- gravated character, and from its unsightly appearance causes great mental annoyance ; the skin of those parts of the face on which it is situated becomes thickened and elevated, from effusion into the subcutaneous areolar tissue, caused by the repeated fresh attacks of inflammation consequent on the development of each successive crop of pustules ; it pre- sents a permanent roseate hue, which is deepened on every exciting cause, — exposure of the face to heat, indulgence in the pleasures of the table, or mental emotions ; and the sur- face is hypertrophied, rugose, and seamed with the cicatrices from pustules of previous eruptions. In its most chronic form it constitutes what has been termed acne indurata (Atlas, PI. VI. Fig. 6), but I have ACNE. 121 seen this variety of the disease not unfrequently succeed acne simplex, and even sometimes appear as an- indurated and tuberculated eruption from the first ; it might, there- fore, probably be made to constitute a distinct form of the eruption, but it has so many features similar to those of acne rosacea, and so commonly occurs apparently as an advanced stage of it, that I have thought it better to describe it as such. Acne indurata is characterized by the eruption being much elevated over the surface of the skin which is of a violaceous-crimson hue, and consists in conoidal pustules, about the size of a pea, extremely hard and tuberculated, and presenting minute points of suppuration at their apex. These pustules are not very painful to the touch ; they do not scab over, but whenever they maturate and burst, they leave a bluish cicatrix or pit resembling that of small-pox. Those that may be set closely together usually coalesce, and present then the appearance of boils, but the contained mat- ter is small in quantity, the aggregated bases extremely hard and minute, and superficial ulcers, covered with a yellowish, soft scab, form on their apex. Acne indurata, when it is an advanced stage of acne rosacea, or when it occurs as an independent disease, is invariably situated on the face, affect- ing especially the alse of the nostrils, and the most promi- nent portions of the cheeks ; when it is consequent on acne simplex it may appear on any of the regions of the body mentioned as being liable to be affected by tha;t form of the eruption. Clauses, — Acne simplex being, as already remarked, a cutaneous eruption of the period of puberty and of the prime of life, appears to be connected with the full develop- ment of the papillary circulation of the surface of the body, which at these ages usually prevails ; it is also pro- bably for the same reasons most frequently witnessed in individuals of the sanguine temperament, and when it occurs in others it is seemingly dependent on a naturally enlarged condition of the sebaceous follicles, the skin being then usually coarse, sallow, greasy, and shining. It is manifestly hereditary, and local heat, or anything which may determine to the surface, is a frequent exciting cause of the eruption in those constitutionally predisposed to it. 11 L22 PUSTULE. \.cne rosacea is frequently connected with the state of the iterine function in the female, in many cases appearing 'or the first time at the turn of life ; it also occasionally, )ut much more rarely, attacks the face of young girls ibout the period of first menstruation ; and when it does io, they are very liable to frequent returns of the eruption )n the least exciting cause. It is also a constant accom- Daniment of a deranged condition of the digestive organs, jspecially when attended with constipation ; and in many persons is evidently caused by indulgence in the pleasures )f the table, particularly a too free use of rich wines or of spirituous liquors. Prolonged or extreme mental excite- ment is also a frequent exciting cause of acne rosacea. An ittack of either form may be suddenly produced by the sup- pression of any accustomed evacuation, such as that arising from bleeding hemorrhoids ; and they are very common at- ;endants on pregnancy. Diagnosis. — The various forms of acne are in general re- jognizable without difiiculty ; the parts of the cutaneous surface which they affect, the conoidal shape of the pustules with their hardened bases, and the accompanying altered jondition of the sebaceoue follicles, being sufficiently cha- racteristic of the disease. Secondary syphilitic eruptions Doay be confounded with acne indurata and acne rosacea, From which they are distinguished by their appearing on the extremities, where acne does not occur, at the same time that they afiect the face and trunk ; by their present- ing a tubercular rather than a pustular character ; and by the diseased surface being of a dull coppery color : the se- baceous follicles, too, are unaffected. The pustules of ec- thyma differ from those of acne in being larger and flatter, scattered over the cutaneous surface generally, especially that of the extremities, and in not having any hardened bas«. Acne indurata in some cases bears much resemblance to lupus, but the latter disease presents more of a tubercu- lar character, and is always attended with destructive ulcer- ation, either superficial, or attacking the deeper structures ; in acne indurata, also, the rich crimson hue of the hyper- trophied skin, with the varicose condition of the superficial veins, and the spots of acne punctata scattered over the sur- rounding integument, are highly characteristic. ACNE. 123 Prognosis. — Acne simplex, though readily removable by treatment, unless when the pustules assume an indolent character, is very apt to return annually until after the age of 25 or 30, and persons who in their youth suffer from it are more liable than others to be affected in after-life with, either of the other forms of the disease. Both acne rosacea and acne indurata are very obstinate and rebellious to treat- ment, in some cases seeming for years to defy all remedial measures. None of the forms tend in any way to shorten life, or to injure the general health. Treatment. — When acne simplex occurs on those parts of the body which are not ordinarily exposed, medical in- terference is scarcely needed ; in persons of a sanguineous temperament and an active cutaneous circulation, saline cathartics, more especially the saline mineral waters — as those of Cheltenham, Leamington, Epsom, and Scarborough, in England ; and of Seidlitz, Marienbad, Carlsbad, and Pullna, on the Continent — will be used with benefit; or, should the disease return in a very active form every spring, a general bleeding, practised just before the period of the expected appearance of the eruption, will, in strong young persons, of either sex, sometimes prevent its outbreak. When pustules of acne simplex form on the face, the sooner they are opened, and the curdy matter they contain pressed out of them, the more rapidly they disappear. In persons predisposed to the disease, the best preventive treatment consists in the use of carbonate of soda — twenty grains to the quart of soft water — instead of soap to wash, the face, and in the application of a spirituous lotion, consisting of two drachms of oil of lemon and half a drachm of oil of rosemary in a pint of rectified spirit, immediately after the face is washed. In cases where there is much tendency to local inflammatory action, this lotion should be reduced in strength, by diluting it with twice or four times the quanllty of elder-flower water. Should the eruption accompany or appear to depend on derangement of the menstrual function, the treatment should be directed to restore it to a healthy condition, either by the use of evacuants or of tonics, accord- ing to the indications in each case. When acne simplex is general over the regions of the body which it affects, warm baths every second or third day, accompanied by friction 124 PUSTUL-ffi!. ■with a flesh-brush, should there be obstruction of the seba- ceous follicles, will be found of much service; in chronic cases, when the pustules are indolent, and there is rather deficient than increased cutaneous capillary circulation, the use of sulphurous baths — more particularly those of the natural sulphurous waters, as of Lucan, near this city, of Harrowgate in England, of Moffat in Scotland, and of Eng- hien, of Aix-la-Ohapelle, of Bareges, and of the Pyrenees, on the Continent — usually constitutes the most efficient plan of treatment. If it be possible to obtain the natural mine- ral waters for the baths, they may be artificially prepared by dissolving four ounces of sulphuret of potassium in thirty gallons of water. No remedial measures can possibly prove of service in the treatment of acne rosacea until the habits by which the dis- ease may have been occasioned are corrected, and in every case especial attention must be paid to the avoidance of all stimulating articles, both of food and drink, which occasion determination of blood to the face, such as rich meats, spices, spirituous and vinous drinks, &c., from the use of which the eruption is invariably augmented, if it had not been origin- ally produced thereby ; heated rooms, exposure of the face to the fire, continued stooping of the head, and mental ex- citement or anxiety, must be equally guarded against. When acne rosacea is seen in its early stages, or where there is much inflammatory action present, the application of from four to six leeches behind the ears, twice or three times a week at bed-time, will be found of much service, and at the same time saline cathartics should be used daily, preceded by mild mercurials, if there be any biliary derangement. The saline cathartic mineral waters are here, as in acne sim- plex, of especial service; and of them all I have found the Pullna water — which is now very generally imported — the most beneficial ; it may be given in the dose of from one to two wine-glassfuls, mixed with an equal quantity of tepid water, every morning. When they cannot be procured, one drachm of the compound saline powder, prepared as I have directed in my work on Medicines,' dissolved in half a pint of tepid water, may be substituted. The tendency to local ' Third edition, p. 107. ACNK. 125 inflammation being thus subdued, slightly stimulating appli- cations may then be used, such as ointments of the ammonio- chloride or of the nitrate of mercury, of dried sulphate of iron, of the acetate of copper, &c. ; the employment of the first of these will be found equally beneficial; it may be prepared as follows : — R. Hydrargyri Ammonio-chloridi, . gr. xij. — Jss. Cerati Simplicis, ij. Glycerihae, fl 3j- Olei Amygdalae Amarse, . . . m. iij. Misce. The ointment should be smeared thickly over the affected part at night, and washed off in the morning with a weak spiritu- ous alkaline wash, containing not more than twelve grains of the carbonate of soda to the pint of liquid, to which from half an ounce to an ounce of glycerine should be added, if the skin be hard and dry and inclined to bleed. In every stage of acne rosacea the use of soaps should be carefully eschewed, as they are all more or less irritating ; the bicar- bonate of soda may be substituted for them, and in the case of men who are compelled to shave, a saturated solution of it, mixed with an equal part of olive-oil, may be used. In chronic cases of the disease, preparations of iodine must be given internally ; two grains of the iodide of potassium, dissolved in two ounces of the decoction of fresh elm-bark, with the addition of a quarter of a grain of iodine when the disease is very obstinate, taken at bedtime, will be found perhaps the most efficacious form of administering this remedy. Should acne rosacea prove rebellious to these plans of treatment, the more active local medication proposed by some dermatologists may be tried ; such as the application daily to each inflamed follicle of a small pledget of lint dipped in a concentrated solution of sulphuret of potassium, as pro- posed by M. Duchesne-Duparc,' the contact being continued for from fifteen to twenty seconds : of a concentrated solu- tion of acetate of lead in white-wine vinegar, as recom- mended by M. Bretonneau f or of a solution of two grains of the bicyanide of mercury in an ounce of distilled water, > Nouvelle Prosopalgie: Paris, 1847, p. 69. 2 Bulletin de Th^rapeutique, tome xxxi. p. 285. 11* 126 PUSTULE. washed off in a few moments after with cold water ; an appli- cation highly spoken of by Dr. Burgess.' When aciie assumes the indurated character which has acquired for it that special denomination, it requires active treatment, both constitutionally and locally ; blood may be removed by cupping from the nape of the neck to the extent of from two to four ounces once or twice a week, according to the youth and constitution of the patient, and daily pur- gation by active saline cathartics had recourse to ; unless, which rarely occurs, the disease appears in an individual of a weak constitution, when preparations of iodine with iron will be found more beneficial. The best local application is the iodide of sulphur in the form of ointment, the strength of which may be gradually increased from fifteen grains to half a drachm to the ounce of lard. Alkaline washes should also be used as in acne rosacea, and change of air, with the inter- nal use of the sulphurous mineral waters, will be found of especial benefit. Blistering the face has been sometimes had recourse to, and it is said with success, in cases of acne in- durata which had resisted all other methods of treatment. Most of the lotions which are empirically employed in acne of the face consist of corrosive sublimate dissolved in bitter almond emulsion, in the proportion of from one to two grains to the ounce ; their use for a short time is not unfrequently attended with benefit, but if continued long they cause the skin to become hard and scaly. IMPETIGO. Impetigo {Crusted tetter). — This term, like so many others applied to designate diseases of the skin, had no determinate signification previously to the time of Willan. It is now understood to indicate a cutaneous affection, characterized by the eruption of numerous psydracious pustules, occurring singly and distinct from each other, or in groups and con- fluent, with but little surrounding inflammation ; they matu- rate rapidly, and discharge a thick purulent matter, 'which dries into a semi-transparent, greenish-yellow, irregularly shaped, persistent, solid crust. From beneath this crust, ' Eruptions of the Face, Head, and Hands: London, 1849, p, 55. IMPETIGO. 127 •when formed, purulent matter continues to be secreted, often in considerable quantity, and the duration of the disease is thus usually prolonged for some time ; the crusts are slow in separating, and when they at length fall off, a red mark or stain is left on the integuments, which, however, gradually wears away. Fresh pustules are developed in successive crops around the region of the skin originally affected, and the disease thus spreads, until it not nnfrequently involves an extended surface of' the body, which becomes covered with the characteristic, pellucid, soft, greenish crust, and from beneath which purulent matter oozes ; when the erup- tion has existed for some time, cracks and fissures form as in eczema, but they do not present the red color of that dis- ease, nor are they accompanied by the serous exudation so characteristic of it. Impetigo is a highly inflammatory erup- tion, and may run either an acute or chronic course : it is not contagious. M. Gendrin has carefully described the anatomical cha- racters of impetigo and its seat, having had an opportunity of examining it after death, — an opportunity which occurs with extreme rarity, as the disease does not prove" fatal, and as inflammatory cutaneous eruptions generally disappear in the course of mortal diseases. The following is the account which he gives of the result of his observations : " At the parts corresponding to the eruption, the skin was more ad- herent to the areolar tissue than elsewhere, nevertheless, there existed on the external surface of the derma but a slight degree of capillary injection. The cutaneous tissue was more dense than natural, and was of a reddish-yellow hue, but this morbid color only extended for a short way into the chorion. ^ On the edges of a section made through the diseased skin, *it could be observed that the small, red- dish, closely aggregated, but only slightly prominent granu- lations, which were situated beneath the crusts, were made up of minute grains about the size of the head of a pin, of a liquid and greenish-yellow, cheesy-like substance ; the sur- rounding cutaneous tissue was red, and matter similar to that which was secreted by the pustules of the eruption, and which, by drying, formed the crusts of the disease, oozed out of it when pressed between the fingers."* ' Traits des Inflammations, torn. i. 128 PUSTULE. The various forms of impetigo which have been described by dermatologists may, I think, be conveniently considered in two groups, named from the mode of development of the eruption. But as it presents certain peculiarities when it occurs on the scalp, which require to be specially noticed, I shall describe it under three heads : — Impetigo figurata. " sparsa. " capitis. Impet^o figurata (Atlas, PI. VII. Fig. 1) is so named from the disease appearing in patches of a circular or ovoid shape. It usually sets in with feverish symptoms, which both precede and accompany the eruption, never severe, but generally well-marked, consisting in malaise, headache, loss of appetite, and occasionally slight shivering ; in children the symptoms amount only to some heat of the surface, and general uneasiness ; but at times there are no premonitory signs noticeable, when the disease usually assumes rather a chronic character from the first. Small, rounded, slightly- elevated, red patches appear on the skin of the face, — where the disease is of most frequent occurrence, — of the trunk, the shoulders, the arms, the hands, or the thighs ; and on them psydracious pustules, closely set together, and more or less confluent, are rapidly developed, their appearance being preceded by much local heat and itching. The pustules attain their full magnitude, which rarely exceeds that of the head of a pin, in about forty-eight hours, when they burst and give exit to the contained purulent matter ; this, which is very liquid, dries quickly into a pale, greenish-yellow" or citrine-colored, soft crust, of a pellucid aspect, and bearing much resemblance to candied honey, so much so that Alibert, from this characteristic, named the disease melitagra. The crust generally covers completely the original red patch ; it is very friable, and through cracks which form from the motion of the part on which it may be seated, an ichorous pus oozes : this, drying rapidly, adds to the volume of the first crust, until it often acquires a considerable thickness, still, however, retaining its semi-transparency, and kept constantly moist by the discharge from beneath. Should the crusts be removed or fall off, the surface on which they IMPETIGO. 12! were seated is seen to be raw, inflamed, and secreting pus by which they are rapidly renewed. The original patches of the eruption, should there be mor than one, may remain distinct from each other, separate by healthy integument during the whole progress of th disease, but more usually those which are near become coii 'fluent, the eruption spreading by the development of isolate pustules or of successive crops on the intervening soun skin. The crusts in the more acute cases remain attache to the surface for three or four weeks, during which tim the discharge continues ; they then gradually become drier the secretion diminishes in quantity, and, unless successiv crops of pustules appear, the disease terminates by thei becoming detached in separate pieces as it were, a reddisl: , brown stain being left which is slow in disappearing ; an from which for some time an epidermic desquamation, a( companied occasionally by a slight serous oozing, take place, causing the eruption, as well remarked by Cazenavt to resemble somewhat eczema. Until the crusts commenc to dry up and fall off, a constant heat and painful tinglin in the affected parts attend the disease ; these cause childre and sometimes even adults, to tear the surface with thei nails, and thereby aggravate the malady. In some cases of impetigo figurata the symptoms, bot local and constitutional, are of a much more severe charac ter than those now described. High fever marks the oul break of the eruption, which is characterized by active ir flammation that extends to the subcutaneous areolar tissu( and affects a considerable surface of the integument, whic is red and much tumefied. In its commencement it ca scarcely be distinguished from an attack of erysipelas, — an was therefore named by V\'^illan and Bateman impetigo eri aipelatodes (Atlas, PI. VII. Fig. 3), — but on the second da the characteristic psydracious pustules appear on the ir flamed surface, when the disease runs the course above d( scribed, except that the local symptoms are throughout ( much greater severity, the discharge especially being muc more copious, and so acrid as to irritate, and cause the d( velopment of pustules on those parts of the unaffected ski over which it may flow ; there is also more or less feve present to the end, and its duration is very prolonged. 130 PUSTULE. Impetigo sparsa (Atlas, PL VII. Fig. 2) differs, as its name indicates, from the preceding form in the arrangement of the pustules, which are developed individually, and scat- tered or dispersed over the cutaneous surface, sometimes pretty thickly on the legs, where it is of most frequent oc- currence ; but it may affect any part of the body, in chil- dren being often seen on the ears, the face and the neck. When the pustules in impetigo sparsa are numerous and closely set together, as usually happens on the folds of in- tegument in the neighborhood of the joints, although they may not coalesce, which they very rarely do, the intervening skin is inflamed, red, and slightly tumid, hot, painful, and tingling. The crusts which form present the same appear- ance as in impetigo figurata, but they are distinct on each pustule, or cover the site of two or three, rarely more, and are much thinner, softer and more easily detached. The development of the eruption is attended generally with some fever, and always with an extreme degree of burning heat, sometimes almost insupportable, which remains, but in a less degree, until the crusts are about to fall off; then it re- turns, if possible, even with greater intensity, and a second crop of pustules is developed in the neighborhood of and in the intervening spaces between the first. This is in like manner followed by a third or fourth crop, and tjius the dis- ease becomes often very chronic, when the skin is hyper- trophied, fissured with red cracks caused by tearing with the nails, of a crimson tint, and discharging a thin, unhealthy, bloody pus, which dries into dark greenish-brown crusts, that at times envelope an entire limb like the bark of a tree ; when impetigo sparsa assumes this aggravated character it corresponds with the form described by Willan as impetigo scahida (Atlas, PI. VII. Fig. 4). The duration of this variety of the eruption is always much prolonged — acrid, ichorous matter, of a heavy, disagreeable odor being secreted from the surface beneath the crusts, which are very per- manent, and scattered pustules continuing to be developed in the neighborhood, often without any apparent fresh at- tack of local inflammation ; superficial ulcerations also form, and if the limbs are the parts affected they become more or less oedematous. Impetigo of either of the forms now described is very fre- IMPETIGO. 131 quenton the face of infants and young children, andbecoming chronic there presents these characteristics in their most ag- gravated form ; the features are completely changed, and the eruption covering them, as it were, with a mask, the dis- ease has been termed impetigo larvalia (Atlas, PI. VII. Fig. 5). Impetigo capitis (Atlas, PI. VIT. Fig. 6) is the only pus- tular disease which appears exclusively on the scalp. Its occurrence in children is preceded for a few days by feverish symptoms frequently attended with vomiting ; the surface of the scalp is hot and painful, and the part about to be affected presents an erythematous blush. The eruption makes its appearance either in distinct pustules of a psydra- cious character, scattered over the head, or in groups thickly set on an inflamed base. In the former case they are about the size of small peas both in circumference and elevation, and are attended with but little surrounding inflammation. On the second day of their appearance each pustule contains thick, yellow matter at the summit, but it is soon matured, when it bursts and gives exit to the contained pus, which rapidly dries into a greenish-yellow scab. This form, which to a certain extent corresponds with impetigo sparsa, termed by some dermatologists impetigo granulata, rarely assumes a chronic character, its continuance, when it has lasted for any time, being kept up by an eruption of fresh pustules on other parts of the scalp. It not unfrequently passes into the second form, which is characterized by the eruption occurring in groups of pustules. Their appearance is at- tended with more decided symptoms of inflammation both general and local, and the heat and itching are in many cases so severe that children tear the scalp and prevent the disease from presenting the truly pustular character of the first stage. The eruption usually commences on the fore- head, involving at the same time some of the hairy scalp ; the inflamed patches vary in size and form in difierent cases ; in some extending in their longest measurement not more than from half an inch to one or two inches, while in others the greatest part of the scalp is involved from the very commencement ; in nearly every instance the skin bordering on the scalp is more or less engaged in the disease, and it often appears at the same time on the ears or on some part 132 PUSTULE. of the face. The pustules are not so large aa when they occur singly; their coats are apparently thinner, and the pus which they contain is not so consistent, and is of a richer yellow color. They usually hecome confluent before they burst, and the resulting greenish-yellow — if chronic, greenish-brown — scab is consequently much more extensive. When the eruption has continued for any length of time, large quantities of bright yellow pus are secreted beneath the greenish crust, which separate in cracks to give exit to the matter, exhibiting beneath the highly inflamed raw sur- face of the scalp from which the pus is secreted. In either form of impetigo the hair is unaltered; it is usually matted together by the purulent secretion and the scabs, but it does not fall off or become changed in appear- ance, even in the most chronic cases. Impetigo capitis is not contagious ; it is met with at all ages, but most generally in early infancy, lasting for several years if not properly treated ; it very rarely appears for the first time after the age of 9 or 10, but I have seen some instances in which the eruption occurred in advanced life ; in them the disease was of the form first described. In the chronic stage of the eruption small abscesses very frequently form at the nape of the neck, close to the roots of the hair; and some of the chain of lymphatic glands, which lies behind the sterno-mastoid muscle, become en- larged, swollen, and tender, but they very rarely suppurate. Bateman described a form of cutaneous eruption as a species of impetigo, terming it impetigo rodens, and in this he has been followed by Biett and Rayer ; but the disease is evidently a lupoid ulceration of the scalp, and as such will consequently be considered in the group Cancrodes. Two other forms of the disease have been characterized by M. Devergie, aa impetigo purijluens, and impetigo pilaris; the former is attended with profuse purulent- secretion, and the latter affects those parts of the skin on which the hair grows, the pustules being frequently developed around indi- vidual hairs, which thus seem to penetrate them ; these, however, are merely accidental circumstances, and neither can be admitted as suflScient to constitute a special variety of the eruption. The impetigo sycoaiformis and impetigo IMPETIGO. 133 lupiformis of the same dermatologist are identical, the for- mer with sycosis and the latter with impetigo rodens. Causes. — Impetigo is of most frequent occurrence in infants and children ; when it affects adults, appearing only in those who have a fine transparent skin, being there- fore more common in women than in men. In old persons it is usually seated on the lower extremities, especially the thighs ; in them it is developed in the form of impetigo sparsa, and assumes a very obstinate character. The con- stitutional causes of the disease are more or less connected with the scrofulous diathesis, and in children of this temperament it commonly appears about the periods of first and second dentition, its eruption being excited then by the general perturbation of the system thereby occasioned. Anything which produces cutaneous capillary determination of blood acts as a cause of impetigo in those predisposed to it ; thus its origin may be determined by irritants applied to the surface, such as washing in very hot water — a frequent cause in infants and children— the use of hard brushes or fine tooth-combs to the hair, stimulating soaps and cosmetics, and solar heat or that from a fire — the former accounts for the frequently witnessed recurrence of the disease in summer and autumn, and the latter for its appearance on the lower extremities of old persons. Pro- longed constipation and menstrual irregularities are both frequent exciting causes of impetigo in females. Diagnosis. — Impetigo is well characterized in all its forms by its truly pustular character, and by the peculiar semi-transparent, soft, greenish-yellow, honey-like appear- ance of its crusts. From eczema impetiginodes it is often with difficulty diagnosed, and both diseases seem frequently in their advanced stages to be precisely similar; yet the copious ichorous exudation— so well described by the French term, suintement — and the epidermic desquamation, are present usually in all forms of eczema, and in impetigo fresh psydracious pustules are in general being constantly developed in the neighborhood of the eruption. From ecthyma the disease is diagnosed by the small size of the pustules, those of ecthyma being phlyzacious, and for the most part scattered singly, or in twos or threes, over the 12 134 PUSTCLiB. cutaneous surface, and the scab resulting from them is of a dull brownish yellow color : the parts usually affected are also different in the two eruptions. When pustules occur in scabies they are of a large size, and a conoidal shape, but that disease is especially distinguished from impetigo by the itching which accompanies it, burning beat, tingling and smarting, not itching, being present in the latter ; the detection of the acarus scabiei, of course, renders the diag- nosis more precise, but it should be remembered that in some cases both diseases exist together on the same person. Sycosis, from its occurrence on the face, has been at times confounded with impetigo; but it invariably affects that part on which the beard grows and its immediate neigh- borhood, is not truly pustular, and the crusts which form in it are hard, dry, and of a brown color, and, if examined under a microscope, exhibit the characters of a vegetable parasite. ■As impetigo is lihe only pustular eruption which specially affects the scalp, it can scarcely be mistaken for any other eruptive disease that appears on this part of the cutaneous surface ; the chronic form of eczema is that with which it is most likely to be corifounde,d ; in it the discharge, which is either serous or sero-purulent, dries into brownish-yellow scabs, through which the ichorous liquid forces its way, or into furfuraceous scales, while in impetigo the purulent dis- charge accretes into large, greenish-yellow crusts, by which the whole head, and even sometimes the forehead and part of the face, is in many cases covered as with a mask. Prognosis. — The only question here to be considered is the probable duration of the disease, as its existence, when uncomplicated, does not either injure the health or endanger life. In children, although apt to become chronic and obstinate if neglected, it usually yields quickly to judicious treatment, and when situated on the scalp is, in my experi- ence, more readily cured than any of th'e other eruptions peculiar to that region, if their relative duration previously to the employment of remedies be taken into account. It is in general more rebellious in adults, and when it affects the lower extremities in old persons is a most troublesome and obstinate disease, the form termed scabida by Willan not unfrequently lasting for years, notwithstanding the IMPETIGO. ]^J most careful treatment, at one time showing signs of amend- ment, but to break out with increased severity again and again. In young persons even the eruption is very apt tc return in the summer and autumn months after it has been apparently cured. At all ages the obstinacy of impetigc is in proportion- to its- previous duration. Treatment. — ^The acute stages of impetigo occurring in young persons of robust constitution require rather active antiphlogistic treatment^ the daily use of saline cathartics, and local, or even in some cases general bleeding ; the local abstraction of blood "should be by leeches applied in the neighborhood of the eruption, or behind the ears when il is situated on the face or scalp. When the disease, how- ever, attacks the old or debilitated, bleeding is very rarelj admissible, but should it be requisite in consequence of the inflammatory symptoms running high with much heat and tumefaction of the part affectedj a few leeches only should be applied, and the after-bleeding from the bites not allowed to continue ; tonics are here more generally indicated, and the use of preparations of iron, combined with vegetable tonics and saline purgatives, as somewhat in the following form, will be found highly beneficial : — R. TincturaS Ferri Sesquichloridi . . fl iss. Infusi Quassise fl Sxviij. Tincturse Calumbse fl iiss. Magnesiee Sulphatis lij. Misce. "A wine-glassful to be taken every morning." In children or adults of the scrofulous diathesis, cod-livei oil is the best tonic, and if the eruption is attended wit! scrofulous enlargement of the glands of the neck, from a sixteenth to a fourth of a grain of iodine may be dissolved in each dose of the oil, which should not exceed a dessert- spoonful three times a day for children, or a table-spoonful for adults ; as when given in large doses the local disease is apt to be aggravated, apparently from its over-stimulating action on the system. In the chronic stages of the eruption, the administration of more decidedly alterative medicines is requisite, and a mild mercurial course is often singularly efiScacious, especiallj 13& PUSTULE. when the mercury is combined with iodine and alkalies. With this view the green iodide of mercury may be given in the following form for adults, a proportionately smaller dose being prescribed for children : — R. lodidi Hydrargyri Viridis Hydrargyri cum Creta . Garbonatis Sodse Siccati Pulveris Myrrhse . . . gr. IV. gr. xij. gr. xij. Mucilaginis, quantum sufficit, ut fiant pilulaa duodecim. " One to be taken three times daily." In the more obstinate cases, some practitioners recom- mend the employment of sulphurous preparations, espe- cially in the form of the sulphur mineral waters ; and others have recourse to the use of arsenic ; of the latter, the pre- parations most suited for this disease are the arseniates of ammonia and of soda, the dose of either is from the twen- tieth to the tenth of a grain ; they may be given in decoction of dulcamara. In the- impetigo of infants and of very young children, but little constitutional treatment is necessary : for infants at the breast, should the eruption exhibit a tendency to assume a chronic character, it will be advisable to change the nurse ; and when the disease appears at the periods of dentition, the gums should be freely lanced. The state of the digestive organs must in all cases be strictly attended to, and mild purgatives, combined with alkalies, adminis- tered according to circumstances. The alkaline treatment is at this age of especial service : for children of a full habit of body the bicarbonate of soda may be prescribed in doses of from three to five grains, three times daily, in half a drachm of syrup of orange-peel and two drachms of orange- flower water, and for those of a weak or debilitated con- stitution, from one to three grains of the bicarbonate of ammonia in the same menstruum. Should diarrhoea, or symptoms of any derangement of the brain accompany the eruption of impetigo, we should be most careful not to check the disease too suddenly, more especially if it is attended with much discharge. IMPETIGO. 13 The local treatment of impetigo is of even more import ance than the constitutional, for upon its judicious appli cation, in the fii;8t instance, most frequently depends thi duration of the disease. It is especially necessary to keej constantly in view that the eruption is of an inflammatory nature, atfd that even in its most chronic stages a fresh out break of inflammation, attended with the development of i new crop of pustules, may be readily excited. The ven production of the disease in so many cases by the direct in fluence of irritants sufficiently proves this, and should wan against the use of irritating applications, which have beei often too indiscriminately recommended. In the acut( stages, no matter on what part of the cutaneous surfac( the eruption may occur, alkaline ointments are of especia service ; and should there be much local tingling and irri tation, chloroform will be beneficially combined with them, a in the following form : — B. Sodae- Bicarbonatis, gr. xx. Adipis praeparati, 3j- Chloroformi, m. iv. Misce. This ointment should be smeared pretty thickly over thi pustules night and morning, the surface having been pre viously washed with equal parts of new milk and tepid water To allay the irritation, unguents and washes, containing various preparations of lead, oxide of zinc, and of prussii acid, are recommended by different dermatologists, but . have found none of them so useful as the above. Owing t^ the moisture from the purulent discharge which is so con stantly present in impetigo, the addition of glycerine to thi local applications, so far from being attended with benefit usually proves injurious. In the chronic forms of the eruption, the crusts or scab should be always, removed carefully before the use of medi cated applications ; this is done most effectually by the em ployment of linseed-meal poultices, — wet with the weak lead wash (see page 74) when any tendency to local inflammatio; is present,— changed twice in the twenty-four hours; th parts being sponged with a warmed solution of half-a-draohi of carbonate of soda in a pint of distilled water each tim 12* 138 PUSTULE. the poultice is changed. The alkaline ointment above de- scribed may then be used ; or, should the disease be very chronic, an ointment of the dried sulphate of iron, in the proportion of from two to five grains to the ounce of cerate, employed ; this preparation even occasionally proves too stimulant, when the acetate of zinc cerate should be em- ployed instead of it. In some cases of impetigo greasy applications are found to aggravate the local symptoms, and then lotions should be substituted for them, such as twelve grains of the acetate of zinc, or six grains of the acetate of lead, or four grains of either the sulphate of copper or the sulphate of iron, dissolved in eight fluid ounces of elder- flower or of rose-water. To the use of more active local stimulants, as ointments, baths or washes of the sulphuret of potassium, of tar, of anthrakokali, of fuligokali of the huile de cade, or of caus- tics as the nitrate of silver, my experience is decidedly op- posed ; as I have generally seen their application excite an outbreak of inflammation, and the consequent spread of the disease by the development of additional pustules. When impetigo affects the scalp, the hair should always be carefully cut close, and the crusts removed by the appli- cation of poultices and the use of alkaline washes, as above directed ; afterwards the ointment of the bicarbonate of soda, and a lotion of milk and tepid water, will be employed with benefit; the green iodide of mercury, with the hydrargyrum cum creta, and the dried carbonate of soda, should be given internally. This plan of treatment seldom fails to cure the disease, even in the most chronic forms, in from six weeks to three months, provided there is a careful attendant to carry out strictly the employment of the local remedies. In any case the hair should not be permitted to grow for some time after all traces of the eruption have disappeared. Dietetic and hygienic regulations are of much importance in the treatment of impetigo, particularly of its chronic forms ; all heating and stimulating articles of food ought to be strictly prohibited, and everything which could cause de- termination of blood to the surface of the body carefully avoided. In children, the use of a purely milk and fari- naceous diet will be found to expedite the cure much. ECTHYMA. 139 ECTHYMA. Ecthyma {Papulous seall) consists in the eruption of phlyzacious pustules, on a hardened, more or less inflamed base, usually isolated, but occasionally in small patches, terminating in yellowish-brown scabs or crusts — in very chronic cases, of a livid hue — which, as they fall off, leave small ulcers that heal with superficial cicatrices. When this cutaneous disease attacks the young and the robust, it is of an inflammatory .character, but in the old and debili- tated it assumes from the first an asthenic type : in both it is non-contagious. In children it is rarely met with, still more rarely in infants, occurring most frequently in old per- sons and in adults. The pustules may appear on any part of the cutaneous surface, but they chiefly affect the extre- mities, especially the thighs ; they appear with the next degree of frequency on the skin of the trunk of the body or on the neck, being but seldom witnessed on the face or the hairy scalp. The division of ecthymain to varieties, as made by Willan, and those dermatologists who have adopted his views, de- pended either upon the age of the patient or upon accidental phenomena, having their origin in the constitution of the individual attacked. This being manifestly a bad founda- tion for a classification, though one not uncommonly fol- lowed as regards cutaneous eruptions, is now almost univer- sally abandoned, and but two forms of the disease are de- scribed by most modern writers : these I shall adopt: — Ecthyma acutum. " chronicum. The eruption of Acute ecthyma (Atlas, PI. VIII, Fig. 1) is preceded by some degree of fever, usually very slight, amounting merely to heat of the surface, thirst, and head- ache ; in about thirty-six hours afterwards, small, rounded, slightly elevated red spots appear on the skin, generally of one or both of the lower extremities, their appearance being preceded and accompanied by heat and sharp tingling of the parts about to be affected, the constitutional symptoms at the same time subsiding. These spots, which are nearly the 140 PUSTUL-fi. size of a large pea, and few in number, are scattered over the cutaneous surface distinct from each other, the interven- ing skin being healthy ; on the second day of their develop- ment the centres are raised by purulent effusion, which, increasing rapidly, covers within twelve hours the entire of each inflamed spot, thus forming the characteristic phlyza- cious pustule of the disease, surrounded by a narrow, in- flamed areola, and situated on a hardened base; occasionally two or three of the pustules, from being developed close to each other become confluent, and not unfrequently a few psydracious pustules form in the neighborhood, being evi- dently produced by an intensity of the local inflammation. This stage of the eruption is attended almost invariably with severe lancinating pain and a burning sensation, both of which are much diminished, sometimes cease completely, on the maturation of the pustules. The maturation takes place from the fpurth to the sixth day, the epidermic cover- ing giving way and the contained pus being effused ; a brownish-yellow crust or scab, occupying the site of the pus- tule, then forma rapidly, and if it be removed, a cup-shaped ulcer, with hard edges, will be brought into view. The scabs, if not interfered with, fall off sometimes in a few days, but they often do not separate for two or three weeks, and a small depression, like the pit resulting from small-pox, marks the site of each pustule. It occasionally happens that purulent matter does not form in some of the red spots, and they terminate in resolution, a reddish-brown stain, accompanied by epidermic desquamatiop, remaining for some time afterwards. The acute form of the disease thus terminates usually In from a fortnight to three weeks, but its duration is not un- frequently prolonged for five or six weeks by the develop- ment of successive crops of pustules, each crop running an independent course. The usual seat of this form of the eruption, as already remarked, is on the lower extremities, but it also appears on the shoulders, the chest, the neck, the arms, and the palms of the hands, and in a few rare cases on the face and scalp. Ecthyma chronicum (Atlas, PI. VIII. Fig. 2) is a not uncommon eruptive disease in debilitated constitutions at every age, occurring much more frequently than the acute ECTHYMA. 141 form ; it often attacks unhealthy infants and young chil- dren, and from its frequency at the very early periods of life, it was described by Willan as then constituting a dis- tinct variety, and termed by him ecthyma infantile. The eruption appears as in the acute form, but there are no pre- ceding or accompanying febrile symptoms, and the local suffering is much less — diminished, not increased, vital ac- tion characterizing it. The pustules are generally diffused over the surface, being rarely confined to any special region, and occur isolated, or in patches of two or three ; they ex- hibit a very indolent progress, maturate slowly, and form hard, dry, brownish crusts, which either adhere firmly, or, falling off in a few days, leave a superficially excavated unhealthy ulcer, that discharges a bloody purulent secretion. The matter by which some or all of the pustules are dis- tended in old persons is often sanguinolent, and the subcu- taneous areolar tissue infiltrated so as to constitute a promi- nent, hardened base, of a lurid or dingy-violet aspect, to each pustule ; these characters induced Willan to regard the eruption then as a distinct variety, and to name it ec- thyma luridum. The chronic character of the disease, as regards duration, is due to the continued development, in constant succession, of the pustules, until at length the in- teguments of almost the entire body are involved in the eruption ; the cutaneous surface then presents a most un- healthy aspect, large portions of it being covered with phly- zacious pustules in their various stages of development, hard, dark-brown scabs, superficial ulcers discharging unhealthy matter, and livid stains, the marks of spots that had healed. The constitution now, in most cases, sympathizes ; in old persons extreme debility occurs, and dropsical effusion takes place ; and the disease in this, its most aggravated form, well deserves the name applied to it by Willan — ecthyma eacheeticum. Ecthyma chronicum lasts generally for four, five, or six months, or even longer, being often complicated in its ad- vanced stages with prurigo, scabies, or chronic lichen, and being a frequent attendant on chronic organic diseases in old persons ; although it spreads to all parts of the cutaneous surface, it is most thickly disseminated over the limbs, and least so on the face or scalp. » 142 PUSTULE. Either form may appear at any age, but the acute is most common in adults, the chronic aifecting chiefly the very young and the aged ; it attacks both sexes, but after the age of puberty males are more liable to the disease than females. The causes of ecthyma are both constitutional and topical. The former are usually what may be termed hygienic and dietetic ; thus residents in damp, ill-ventilated habitations, insufficient clothing, want of due attention to cleanliness, unwholesome food, habits of dissipation, &c., produce a state of the system in which the disease is often developed ; and the direct action of substances which irritate the skin con- stitute the latter. Its association with chronic visceral disease has been noticed above ; it is also a not uncommon sequela of acute febrile disease, more particularly typhus fever and dysentery. Diagnosis. — Ecthyma is in general readily recognizable by the phlysacious character of the pustules, and the isolated manner in which they are developed. It might be con- founded with either acne or impetigo, but the characters by which it is distinguished from these eruptions have been already described when treating of them. The smaller-sized pustules bear some resemblance to those of modified small- pox, but the mode of eruption of that disease, its appear- ance first on the face and upper part of the body, and the accompanying fever, are sufficiently diagnostic marks. The pustules of secondary syphilis are, in many cases, very similar to those of ecthyma, and are with much difficulty diagnosed from the lurid form of the disease ; the latter, however, occurs seldom except in very old persons, and the presence of the usual concomitant aiFections of the throat and of the bones in secondary syphilis, together with the antecedent history of the case, mai-ks the cutaneous affec- tions produced by the venereal poison. Prognosis, — When uncomplicated, ecthyma is not a disease dangerous to life, the chronic form of the eruption is always of prolonged duration, and by its continuance the general health is more or less injured. Treatment. — In the acute stages of this eruption any in- flammatory symptoms that may exist should be subdued by the use of diluents and diaphoretics ; minute doses of tartar emetic dissolved in whey, in the proportion of half-a-grain ECTHYMA. 143 to the pint, will -be found a Bseful form, and the solution may be made to constitute the ordinary drink of the patient ; or the water of the acetate of ammonia may be given in de- coction of barley sweetened -with sugar, and flavored with lemon-juice. The state of the bowels requires careful at- tention, and tlie secretions, if unhealthy, should be regulated by the administration -of mild mercurial purgatives, com- bined with the extract of taraxacum and of colchicum, but active purgation is contra-indicated. The only topical remedy requisite is the tepid bath, and from half-a-pound to a pound of gelatine should be dissolved in each bath if there is much local irritation ; occasionally, in persons of a full habit of body, a few leeches will be applied with benefit in the neighborhood of the eruption. The first requisite in the treatment of chronic ecthyma is to remove those causes by which the state of the system with which it is so frequently connected has been produced. In infants, the nurse should if possible be changed, or, if this cannot be done, the child ought to be weaned, and fed chiefly -on asses' or goats' milk, mild alteratives, as the hy- drargyrum cum creta, combined with myrrh and dried car- bonate of soda, given, and the body warmly clad, but woollen clothing, as being apt to irritate, should not be worn next the skin. The best local application is calamine ointment, or the affected parts may be dusted with finely-powdered lapis calaminaris; emollient cataplasms or lotions generally aggravate the disease. When the eruption appears in old persons, the first and most important point is to change the air, or at least the locality in which the patient may have been residing : good and nourishing food should be given, and if there is much debility, wine or porter allowed. Should there exist any visceral organic disease, the line of treatment must be directed principally to its alleviation if possible, and topical applications employed with caution, as the sudden repulsion of the eruption would be likely not alone to aggravate it, but might be dangerous to life. Tonics, combined with alkalies and sedatives, as -in the fol- lowing form, will in general be found useful : — IJ-i PUSTUIi-E. B, Infusi Cinchonffi fl oyj. AquEe Calcis, fl sixss. TinctursB Lupulinse, Succi Conii, aa, fl 3ij. Misce. " A wine-glassful to be taken three times a day." When, however, there is much debility present, alkalies should not be given, but the mineral acids, either the nitric or hydrochloric, will then be advantageously prescribed in combination with vegetable tonics ; in the lurid form of the eruption, preparations of iron, more particularly the com- pound or aromatic iron mixture, generally prove most efiBca- cious. For local applications many astringent and mildly stimulating ointments may be employed ; a form that I have seen productive of excellent effect consists in the addition of half a drachm of oil of turpentine to the compound lead- cerate. This should be warmed and applied in the semi- fluid state, being gently smeared over the surface with a feather. The ulcers which form may be touched daily with the solution of nitrate of silver — a scruple to the ounce, or dressed with lotions of sulphate of copper or sulphate of iron — from two to five grains to the ounce of distilled water. In all forms of ecthyma the patient should be kept in the open air as much as possible, if extreme debility or accom- panying organic disease does not prevent it. During con- valescence, exposure to the sea air, and the use of the chalybeate mineral water for adults, will be found of especial service in promoting the restoration of health, and prevent- ing a relapse ; and for scrofulous children, the employment of cod-liver oil should not be omitted. PAPULA. 145 CHAPTER V. PAPULA. This group of cutaneous diseases is characterized by the eruption of minute solid elevations of the skin, — papulse or pimples, — generally reddish, but sometimes of the natural color of the part or even paler, which contain neither serum nor pus, terminate in the desquamation of fine scales, and are almost invariably attended with intolerable itching. The latter symptom is so markedly a characteristic of papular eruption that it has induced Cazenave to place them in a sub- division of his sixth group, the definition of which that he gives being " general or local hypersesthesia." By Erasmus ■ Wilson they are made to constitute a group, "styled de- positive inflammation of the derma;" but inasmuch as some forms of papular diseases are not in any of their stages ac- companied or marked by inflammatory action, and their treatment is based on indications directly opposed to the idea of inflammation having any share in their production, his definition is not, I think, sufficiently precise for a natural system of classification. ,',„t;^ Papular eruptions are non-contagious, occur at all ages and in both sexes, and affect males more frequently than females. The papulse, which are either disseminated and distinct from each other, or aggregated in patches so as to form groups, may appear on a single region of the body only, or may be diffused generally over the skin ; they vary in size from that of the head of a small pin to that of a pea, and are usually developed rapidly, generally coming out in successive crops. They terminate in resolution, with des- quamation of the epidermis in fine minute scales, which continue for some time ; but occasionally superficial ulcera- tion of the integuments occurs. By most dermatologists three forms of cutaneous disease, characterized by papular eruptions, are described as origi- nally arranged by Willan, namely. Lichen, Strophulus, and Prurigo ; but the first two are manifestly merely varieties 146 PAPULA. of the same affection, their characteristic phenomena are precisely similar, and the only difference between them is that the former occurs in infancy and childhood, and the latter at a more advanced age ; I shall, therefore, follow the example of Rayer, Gilbert, Cazenave, &c., and speaking of strophulus as a species of lichen, reduce the number of papular diseases to two, namely. Lichen and Prurigo. LICHEN. Lichen — including strophulus — may be defined to consist in the development of numerous minute papulaj of the color of the skin or of a reddish hue, aggregated in patches or disseminated over the cutaneous surface, attended with heat, tingling, or even severe itching, and terminating in super- ficial ulceration or in epidermic desquamation. A great number of forms, both of lichen and of strophulus, have been described by Willan and other writers on diseases of the skin, and named by them either from the shape, as re- gards distribution, which the eruption assumes, from the color of the papulae, from some of the attendant symptoms, from the particular structure of the portion of the integu- ment, anatomically considered, that may be affected, and from the mildness or severity of the disease. Thus there have been constituted no less than nine varieties of lichen, and five of strophulus ; they may, however, I consider^ be all conveniently considered in three divisions : — Lichen simplex. " strophulus. " agrius. Lichen simplex (Atlas, PI. VIII. Fig. 3) is at its out- break very rarely attended with any constitutional disturb- ance, in some cases slight febrile symptoms for a few days precede the eruption, especially in females, but they seldom amount to more than a feeling of malaise, which disappears immediately on the development of the papulse. These are minute, very numerous, not exceeding in size rape-seed, of a bright red color, and irregularly scattered in patches closely set together over the cutaneous surface ; they usually LICHEN, - 147 appear first on the upper extremities, and extend thence to the trunk and lower extremities, being preceded by formica- tion of the part on which they are about to occur. The eruption is attended with heat and sharp tingling, which lasts until all trace of the papulae has disappeared ; in some cases, especially in young plethoric persons, the local in- flammation runs high, when the whole of the integuments of the affected parts present a bright scarlet color, accom- panied by a sense of tension and an extreme degree of itching. Lichen simplex may be either acute or chronic ; in the former case the duration of the disease is for about a fortnight, the individual papulae are resolved in seven or eight days, but as from forty-eight to seventy-two hours elapse between their development on the different regions of the body which they attack, it is prolonged for this time. In the chronic form successive crops of papulae make their appearance as quickly as those which preceded them fade away, and thus the disease may be continued for months, or even years. The papulae in either case run the same course, attaining their greatest size on the third day, at which time they are markedly acuminate ; they then seem to remain stationary for two or three days more, when they fade some- what, are less prominent, and a minute scale appears on the apex of each ; this desquamates, and a general epidermic desquamation from the affected surface continues for three or four days in the acute, and for a longer period in the more chronic cases. In the latter, the skin after a short time becomes thickened, evidently from depositive inflamma- tion, and the diseased integument is then elevated above the level of the surrounding skin. In lichen simplex the papulae differ in size according to the region of the body on which they may occur, being always larger on those parts where the skin is softest, as on the face, the shoulders, and the anterior surface of the trunk. In the debilitated, in the aged, and in those whose skin is naturally of a dark or unhealthy aspect, the eruption is usually of a dull, livid hue, and in the former is not un- frequently complicated with crimson blotches, or stains of the integument; this form was distinctly described by Willan under the appellation of lichen lividus. In another variety, 148 PAPULA. ■which occurs usually in persons of dissipated habits, as noticed by this dermatologist, each papula in its origin en- velopes a hair, so that when arrived at its full maturation it presents a singular appearance, seeming to be pierced there- by ; he consequently termed the eruption, under the circum- stances, lichen pilaris ; it is always a very obstinate form, assuming from the first a chronic character. Occasionally in lichen simplex the papulae, instead of being dispersed over the cutaneous surface, are developed in regularly-shaped patches ; when these are circular or oval the circumference is constituted of much larger papulae than the centre, so that a distinct border to each patch is thereby formed ; this variety has been termed lichen circumscriptus (Atlas, PI. VIII. Fig. 4) ; it is of a chronic character ; the rings enlarge somewhat by the eruption of new papulae at their circumference, but its duration is rather prolonged by the development of successive patches in their neighbor- hood, as those which first appeared commence to fade. The usual seat of lichen circumscriptus is on the backs of the hands, the fore-arms, the cheeks, and the trunk of the body ; when but one patch of it exists at a time on the surface, it has been termed lichen solitarius (Atlas, PI. VIII. Fig. 6). In a few rare cases, as first noticed by Biett, the eruption of papulae assumes the appearance, as it were, of a piece of ribbon stretched on the skin, generally commencing on the chest, and passing around the arm; he named this form, lichen gyratus (Atlas, PI. VIII. Fig. 6). I do not know that it has been observed by any British or German physi- cian, but it is noticed as having been witnessed by several French dermatologists. In children and young persons, especially of the female sex, the itching is at times most extreme, and the papulae are of a much larger size than usual ; they are, moreover, occasionally to a certain degree evanescent — thus in most of their phenomena resembling urticaria, and the eruption, too, appears, as in that disease, in small patches. It is, how- ever, distinctly papular, and has been well denominated lichen urticatus. It usually occurs on the neck and side of the face, spreading in a few cases to the chest and abdomen ; is of an acute character, seldom lasting longer than a few LICHEN, 149 ■weeks, and is in general witnessed only in spring and sum- mer. Lichen strophulus {Gum).- — This is a papular eruption peculiar to the early periods of life, being rarely seen ex- cept in infants at the breast, and occurring most frequently a few days after birth. The papulae are of the natural color of the skin, of a reddish or crimson hue, ot white ; they appear most frequently on the face and up-per extrem- ities, but they also in some cases affect the body and the lower extremities. In one form, which has been termed strophulus intertinctus (Atlas, PI. IX. Fig. 1), popularly known as red gum, an eruption of Very minute t-ed papulae appears, generally a few days after birth, on the face and the backs of the hands and arms ; they are scattered over the surface, and intermingled with the^m are small erythema- tous patches ; for two or three days their color becomes more vivid, they then gradually fade away and disappear in from a week to ten days, with some slight epiderniic desqua- mation. Smart itching would seem to accompany the erup- tion from the uneasiness the infant exhibits. When lichen strophulus appears on the skin at the time the child is commencing to suffer from the irritation atten- dant on teething, the papulae, being still of a red color, are much smaller' and of a duller bue than in the last-described variety, but more numerous, and aggregated together in semi-confluent patches on the face, the chesty the upper extremities, and often also on the abdomen and legs. The eruption is then denominated strophulus confertus, and popu- larly known as tOoth-tash ; it runs a somewhat similar course, though a little more prolonged than strophulus intertinctus, and not unfrequently, more especially if the child suffers much from teething, a fresh outbreak of the rash takes place as the first is fading away. In some cases, the local and constitutional inflammatory symptoms are tolerably intense, when the patches of papulae are of a bright red color, and less disseminafed, occurring in clusters, of not more than from five to ten or twelve, developed successively on various regions of the body, as they fade from one, appear on ano- ther. This variety of the disease, which is rather uncom- 13* 150 PAPULA. mon, has been termed strophulus volatieua — wild-fire rash ; it is often of tolerably long duration. The papulae in lichen strophulus are, as has been before mentioned, occasionally of the color of the skin, or even whiter, and under such circumstances have been regarded as characterizing a distinct variety of the disease — white gum ; of it two forms have been noticed : one, — strophulus can- didus (Atlas, PL IX. Fig 2) — in which the papulae are of tolerable magnitude, not surrounded by a red areola, and generally disseminated over the cutaneous surface, but at a distance from each other ; and the other — strophulus albi- dus — in which they are of small size, and occur in a few patches, each patch having a red border ; in the former case they are usually distributed on the neck, the shoulders, the arms, and the lumbar region ; in the latter, on the face, the neck, and the chest. Both are attended, apparently, with much itching, but no constitutional disturbance, and seldom last longer than for a few weeks. lAchen agrius (Atlas, PI. IX. Fig. 3) is occasionally a sequence of lichen simplex, but more frequently presents its peculiar phenomena from the first. In- the latter case its occurrence is preceded for two or three days by smart febrile symptoms, and a remarkable burning heat and redness of the skin, so much so as at times to lead to the apprehension that scarlatina is about to set in ; the fever abates consid- erably, or altogether subsides on the appearance of the rash, which is developed in the form of numerous bright red, mi- nute,- acuminated, shining papules, clustered together on an uncircumscribed inflamed patch of the skin, often of con- siderable extent. The papules do not enlarge in size, but become more elevated from lymph being effused at their base into the subcutaneous areolar tissue, which is in conse- quence swollen and hard. An extreme degree of painful pruritus attends the development of the eruption, and is con- stantly present during the entire of its course, compelling the patient to rub and tear the skin ; the itahing, which is incessant, is much augmented by anything which increases the heat of the surface, especially the warmth of the bed, and thus renders rest or sleep in bed almost impossible. As the disease advances, the papules ulcerate at their apex, and LICHEN. 151 give exit to a sanious icbor, which concretes into thin, fria- ble, yellowish scabs : the skin becomes more and more in- flamed, thicker, dry, and rugose, and eczematous vesicles and pustules of acne or impetigo appear, minglei with the lichenous eruption, or, owing to the intense degree of local inflammation, are developed on the surrounding integument. In this extreme form of the eruption, the skin presents an hypertrophied aspect, is of a dark livid color, uneven on the surface, rugose, and fissured, and discharges a copious serosity. In the comparatively milder cases of lichen agrius, the eruption commences to fade about the-tenth or twelfth day, the subcutaneous effusion is absorbed, the local irritation diminishes, and the disease terminates in from a fortnight to three weeks with epidermic desquamation. More usually, however, its duration is prolonged for six weeks or three months, even in cases not at all aggravated, and it not unfrequently lasts four years, with occasional remissions during cold weather. This form of lichen especially afi'ects certain regions of the body, more particularly the face, where its most usual seat is on the forehead, and the backs of the hands and fingers (Atlas, PL IX. Fig. 4) ; when it occurs on the face, the swelling of the integuments is usually much greater than when it attacks other regions of the body; the features, presenting a tuberculated aspect, are completely altered in expression, and the eyes are sometimes almost entirely closed from the thickening of the upper eyelid. On the backs of the hands and fingers the eruption is in general attended with much discharge, and in some cases complicates scabies, when it causes an extreme degree of suffering. Heat seems to have a peculiar influence both in producing and aggravating lichen agrius ; it is thus not unfrequently developed in hot summer weather in this country in persons predisposed to skin diseases ; but it is in warm climates that this influence is especially witnessed, and the eruption is consequently so frequent there that it has been regarded as constituting a distinct variety, termed lichen tropicus — the prickly-heat of the East Indies. The following graphic description of the eruption, which is especially interesting as embodying his personal experience of it, is from the pen 152 pAPUii-as. of the late Dr. James Johnson. "Among the primary effects of a hot climate may be noticed the prickly-heat, a very troublesome visitor, which few Europeans escape. It is one of the miseries of a tropical life, and a most un- manageable one it is. From mos^juitoes, cock-roaches, ants, and the numerous other tribes of depredators on our per- sonal property, we have some defence by night, and in general a respite by day ; but this unwelcome guest assails us at all, and particularly the most unseasonable hours. Many a time I have been forced to spring from table, and abandon the repast which I had scarcely touched, to writhe about in the open air for a quarter of an hour : and often have I returned to the charge with no better success against my ignoble opponent ! The night affords no asylum. For some weeks after arriving in India I seldom could obtain more than an hour's sleep at one time before I was com- pelled to quit my couch with no small precipitation, and if there were any water at hand to sluice it over me, for the purpose of allaying the inexpressible irritation ! But this was productive of temporary relief only, and what was worse, a more violent paroxysm frequently succeeded. The sensations arising from prickly-heat are perfectly indescriba- ble, being compounded of pricking, itching, tingling, and many other feelings for which I have no appropriate appel- lation. It is usually but not invariably, accompanied by an eruption of vivid red pimples, not larger in general than a pin's head, which spread over the breast, arms, thighs, neck, and occasionally along the forehead close to the hair. This eruption often disappears in a great measure when we are sitting quiet, and the skin is cool ; but no sooner do we use any exercise that brings out a perspiration, or swallow any warm or stimulating fluid, such as tea, soup, or wine, than the pimples become elevated, so as to be distinctly seen and but too sensibly felt." Causes. — Lichen occurs at any age, but its different forms seem to prevail at different periods of life ; thus, as has been already remarked, lichen strophulus is a disease of early infancy, very seldom appearing after the process of first dentition is completed, and being most frequent for a month after birth, in fact few infants then escape it ; lichen agrius is most usually an eruption of adult life and of old LICHEN-. 153 age ; and lichen simplex affects young persons and those in the prime of life. The predisposing and often also the exciting causes of this eruption are very ohscure ; it is certainly witnessed most frequently in persons of a nervous temperament, with a fine, easily irritated skin, and in whom the cutaneous capillary circulation is very active, but with deficient perspiration. The occurrence of lichen strophulus in infants immediately after birth may be accounted for by the numerous local irritants to which their fine, delicate skin is then necessarily exposed, such as the effect of sudden changes of temperature, of the water and soap used in washing, of the friction employed in drying the surface afterwards, of the clothing, &c. The action of the local irritants has a decided effect in the production of lichen at all ages and in most cases ; thus it is caused on the forehead in men by the pressure of a tight hat, on the face and hands by harsh dry winds, and by solar heat or that arising from a very hot fire ; the latter is not an unfrequent cause of the eruption in some trades, such as blacksmiths, furnace-men, &c., and on the legs by the friction of worsted stockings, particularly when the veins are in a varicose condition. In certain occupations lichen is developed on the backs of the hands and on the fingers — in the same manner as other eruptions are — from the irritation of certain substances ; thus it is witnessed in grocers, bakers, washerwomen, &c,, when it is described as constituting one of the forms of the so called grocer's, baker's, or washerwoman's itch. In many cases lichen seems to be connected with derangement of the digestive organs, and its appearance on the skin in- persons who had long suffered from painful affections of the stomach or head was noticed by Bateman. and Biett as a favorable circumstance. The use of stimulating drinks, or of heating articles of food and of spices will, in some individuals, be followed by a lichenous eruption. Diagnosis.^— liichen simplex is in general easy of recog- nition, in consequence of its distinctly papular character ; the disease with which it is most likely to be confounded is prurigo, the elementary character of the eruption in both being the same ; but in the latter the papulae are larger and more globular — ^their apex being rather flattened than acu- minate, and they are gegerally of the same color as the 154 PAPULJI. part of the skin on which they appear ; the itching, also, which accompanies lichen simplex is not of the same acrid, hurning nature as that which is so characteristic of pruri- go. When the papulae begin to fade and to desquamate at their apex, the eruption might he mistaken for psoriasis guttata, from which it is distinguished by the scales being much thinner, more minute and branlike, and by the papular elevation of the surface from which they separate, as may be recognized with the aid of a lens, or felt by passing the finger over the part. From scabies and ecze- ma, lichen simplex is diagnosed by the vesicular character of both these eruptions, and the copious discharge with which they are attended. Lichen circumscriptus is liable to be confounded with herpes circinnatus, or erythema cir- cinnatum ; from both it is distingaished by the character of the eruption, papulae being never witnessed in any stage of either of these diseases. From urticaria, lichen urticatus is often with much difficulty diagnosed ; the chief distin- guishing characters are the wheal-like elevations with the paler centres, and the more decidedly evanescent nature, of the former. The only eruption with which lichen strophulus could be confounded is prurigo, but the age at which it occurs is suf- ficient to distinguish it from that disease ; moreover, in those forms of strophulus in which the papulae are red they are darker colored than in prurigo, and in the white varieties they are much paler. The more aggravated cases of lichen agrius, in their ad- vanced stages, bear much resemblance to chronic eczema rubrum, and are often with difficulty diagnosed from it ; but careful examination will scarcely ever fail in detecting the papular character of the former ; in it, too, the integuments are more swollen, thickened, and tubercular, the serous dis- charge and the epidermic desquamation considerably less, while the itching is more intense ; the peculim- red cracks and fissures from which the bloody ichor oozes are, more- over, not seen as in eczema. On the face, lichen agrius may be mistaken for acne rosacea, from which it is distin- guished by the pustular nature and deep crimson or viola- ceous hue of the latter ; they also aflect diflferent regions of the face, lichen being generally ^ituated on the forehead LICHEN. 155 and the sides of the cheeks in front of the ears and lips, while acne rosacea occurs almost invariably on the nose and the most prominent portions of the cheeks. Impetigo oc- curring on the face in adults has been confounded with lichen agrius, but the pustular character, and greenish honey-liko scabs of that eruption sufiBciently chJiraeterize it. This form of lichen is not so liable to be mistaken for psoriasis as lichen simplex, the attendant serous discharge and the characteristic itching marking especially the difference be- tween them. Lichen is a very frequent form of syphilitic eruption ; it is then characterized by the peculiar dull coppery hue it presents, by its being always of a chronic character, unat- tended with any inflammatory symptoms, either local or constitutional, by the absence generally of itching, and by the presence of the other secondary symptoms of the vene- real disease, together with the history of the individual case. In infants hereditary syphilis must be carefully distinguished from lichen strophulus ; the former rar&ly presents a papu- lar form, and it occurs in patches or coppery stains, gene- rally attended with a serous or sero-purulent discharge, on various parts of the body, but especially about the pudendal region, and on those parts of the skin on which the hair grows. Prognosis. — ^In infants and young children, the occur- rence of lichen strophulus is quite unimportant, as it gene- rally runs its course in a few days, being unattended with the least danger or injury to health, requiring notice merely in consequence of the accompanying itching, rendering the little patients fretful. In adults and old persons an eruption of lichen, though never attended with danger, is extremely troublesome, in consequence of the local annoyance and suf- fering by which it is accompanied, and the tendency more especially of lichen agrius, to become chronic ; like most other cutaneous eruptions,, the longer its duration has been, the more"rebellious is it to treatment. The disease is also more obstinate on the face or hands than when it is situated on those parts of the body that are ordinarily covered ; and the complication of other cutaneous eruptions with it invar riably renders the treaitment more diflScult. In giving a prognosis in any of the sejere forms of lichen, it should be 156 PAPULA. remembered that relapses are very liable to occur, the least exciting cause, such as even the heat of the sun in summer, being sufficient to reproduce the disease. Treatment. — In all papular eruptions a manifest indica- tion of treatment is derived from the hypersesthesia of the cutaneous structure which accompanies them in their acute as well as in their chronic stages, and this should always influence our choice of remedies, whether tonics or antiphlo- gistics, according to individual circumstances, may be re- quired. In their early stages, local applications will in general be found sufficient to check the progress of the erup- tion, unless when symptoms of inflammatory action are pre- sent, but these are usually of a trifling nature and of short duration; when, however, they have become chronic, the most active constitutional alterative treatment is required, and even under its most judicious employment they not un- commonly bafiie the physician's art for a length of time. In lichen simplex occurring in young persons of a robust constitution, restricted diet should be enforced at its com- mencement, together with rest in bed if the eruption is at all extensive, and the administration of diaphoretics, the bowels having been previously opened by a mercurial purge, provided the pstpulae are well developed on the skin : the antimonial diaphoretics, combined with guaiacum and Dover's powder, as in somewhat the following form, are usually pro- ductive of more benefit than saline diaphoretics : B. Antimonii Sulphureti praecipitati, • gr. xx. Gnaiaci Kesinse, in pulvere, . . . gr. xxiv. Pulveris Ipecacuanhse compositi, . . gr. xij. Ope mucilaginis misce et in pilulas duodecim divide. " One to be taken every sixth hour." To allay the itching and local irritation, tepid baths of fresh water may be employed daily, and the skin, having been well dried, smeared afterwards with olive oil, to every ounce of which twenty minims of chloroform have been added. When the general inflammatory symptoms are sub- dued by this treatment, if the disease exhibits any tendency to become chronic, the compound lead-cerate with glycerine may be applied to the surface, and the parts sponged twice daily with an alkaline spirituous ^ash. LICHEIT. 157 In any of the forms of lichen strophulus, medical interfer- ence is scarcely required, and especial care should be taken that no treatment, whether local or constitutional, be em- ployed by which the eruption might be repelled. If any derangements of the disgestive organs exist, they may require the use of mild alteratives or gentle mercurial purgatives, and when the eruption occurs at the period of dentition, the gums ought to be lanced freely. The annoying pruritus, which so constantly seems to accompany strophulus, is best allayed by the use of the tepid fresh-water bath with gela- tine, and the application of olive oil to the spots of eruption ; cold cream is also useful for this purpose, or the acetate of zinc cream, to every ounce of which two drops of oil of bitter almonds have been added, may be employed in more aggra- vated cases. In the early stages of lichen agrius, while the inflamma- tory symptoms are present, the treatment should be de- cidedly antiphlogistic, but unless in strong, healthy, young persons residing in the country, general bleeding is not admissible, the local abstraction of blpOd, by means of leeches^ applied in the neighborhood of the eruption, being in most cases sufficient. Even in the chronic stages of the disease, this form of local bleeding is in general attended with the best results, as it relieves the congested state of the capil- lary circulation which is present, but the leeches should never be applied on any part of the skin which is aflfected, as their bites might give rise there to troublesome ulcera- tion. At first the irritation caused by the eruption is best alle- viated by gelatine baths and soothing ointments or lotions; of the former the carbonate or acetate of lead cerate with chloroform, the compound lead cerate with glycerine, the oxide or carbonate of zinc ointment, with which oil of bitter almonds or prussic acid has been combined, or the hemlock ointment, will be used with benefit ; of the latter, the weak lead wash, to which glycerine has been added in the propor- tion of a drachm to the ounce, equal parts of camphor mix- ture and distilled vinegar, a lotion containing a drachm of succus conii, half a drachm of glycerine, and a grain of car- bonate of soda to the ounce of elder-flower water, or alka- line washes with prussic acid, as in the following form, may be employed. 158 PAPULiB. B. SodsB Biboratis, 3as._ Aqu£e Rosse fl iviij. Acidi Hydrocyanic! diluti, . . . . fl Su- Misce. If any connection can be traced between the appearance on the cutaneous surface of the eruption and disease of some internal organ, or deranged function, the remedial measures employed must be especially directed towards the alleviation of the former, and the correction of the latter. With this view saline and mercurial purgatives are generally required in most cases, and when debility exists, their employment may be conjoined advantageously with chalybeates or vege- table bitters, and the dilute mineral acid. Lichen is not unfrequently associated, in old persons, with the gouty or rheumatic diathesis, and in such cases, preparations of col- chicum, combined with the liquor potassse, or the carbonate of ammonia, should be prescribed. In the chronic stages of lichen agrius more active consti- tutional treatment is usually required, while at the same time attention is paid to any complication that may exist. Iodine and arsenic, either separately or in combination, in some of the forms described in former chapters, will be found necessary, and they may be given with tonics or diaphoretics according to individual circumstances. When there is gene- ral debility present, more especially an anemic condition of the system, iodine combined with iron in the form of the syrup, or pills of the iodide of iron is most useful. Tincture of aconite is also an excellent remedy, more especially if the hypersesthesia of the cutaneous surface is well marked, but its administration must, as in all other diseases, be carefully watched ; there is nothing to contraindicate its employment at the same time with the powerful alteratives above men- tioned. Sulphur and its preparations are highly recom- mended by many practitioners in chronic lichen, but I must confess that they have not proved so successful in my hands as they are stated to have done with others. It was at one time too much the custom to administer sulphur in nearly every form of cutaneous eruption, chiefly, I believe, in con- sequence of its being evolved so manifestly by means of the insensible perspiration ; but for this very reason its use often PRURIGO. 159 proves highly injurious, owing to the direct stimulant action it thereby exercises in diseases which are of an inflammatory nature, or which are liable to be aggravated by determina- tion of blood to the cutaneous capillaries. Most of the local applications already spoken of will be found beneficial in chronic liehen agrius, but even in the same case they must be constantly varied, aceordihg to the se- verity of the local symptoms ; when all inflammatory tend- ency has subsided, an ointment containing twenty grains of the iodide of sulphur to- an ounce of white wax ointment, to which -six minims of chloroform are added, will be found productive of excellent effect, an alkaline spirituous wash being at the same time used. PRURIGO. Prurigo. — It is very doubtful whether this disease should be termed an eruption of the skin or not, so frequently does it occur without any visible phenomena to indicate its ex- istence, the only symptoms present being obstinate intense itching, without heat, pain, or sensible elevation of the sur- face. But as in many cases it is attended with the develop- ment of papulae, it must, in an artificial arrangement of skin diseases, be classed with lichen. The papulae, when they do occur, are of a somewhat larger size, rounder and less acuminate than those of lichen ; and are of the color of the skin, or of a yellowish hue. The disease is essentially of a chronic nature, is not contagious, and is neither pre- ceded nor accompanied by constitutional symptoms ; never- theless, when it has existed for some time, the health be- comes more or less deranged, in consequence of the extreme suffering caused by the itching and local irritation attendant on it. Three forms of prurigo have in general been described by dermatologists : Prurigo mitis. Prurigo formicans, and Pru- rigo senilis ; the first two are distinguished from each other merely by the degree of severity of the symptoms, and may therefore be considered together ; the third, although de- nominated simply from its occurrence in old age only, yet requires to be noticed separately, in consequence of some of its phenomena being peculiar and characteristic. I shall 160 PAPULA. therefore describe the disease as consiating of two species, terming them, — Prurigo vulgaris. " senilis. Prurigo vulgaris (Atlas, PI. IX. Fig. 5), then, may be either mild or severe, the latter being the more frequent. The mild variety is developed by the eruption on the cuta- neous surface of scattered papulse, about the size of a millet- seed, without the least redness, inflammation, or sense of heat ; they are of the color of that part of the integument on which they may be seated, but little elevated, and scarcely to be distinguished unless with the aid of a lens, or by pass- ing the finger over the surface. The attendant pruritus is not very severe, although sufficiently sharp and stinging to cause the patient to scratch the affected parts with the nails ; the papulsB are thus torn, and a minute, blackish crust thereby formed on their apices, which gives a remarkably characteristic appearance to the affection. In the severe variety of prurigo vulgaris the disease may commence with or without the eruption of papulae, but in all cases they are usually developed in some of its stages ; when they do occur they are more numerous than in the mild form, of the same color, shape, and size, or sometimes even larger. It is, however, the remarkable cutaneous hyper- SBsthesia and consequent intense pruritus which especially mark the aggravated character of the affection, and from whence it has derived its appellation— ;/'(»"»iicaws, the sensa- tions accompanying it being often compared to those pro- duced by the sting of an ant. This comparison, however, very faintly expresses the sufferings attendant on the dis- ease : not a single spot of the skin in its entire extent but is more or less the seat of an extreme degree of itching, which compels the individual affected to tear with his nails and rub the surface all but unceasingly ; at times compara- tive cessation of the pruritus occurs, occasionally lasting for two or three hours, more usually of shorter duration, but it is again exacerbated by the most trifling exciting cause, the friction of the clothes, changes of temperature — especially the heat of the fire or the warmth of the bed, — mental emo- PKUBIQO. 161 tions, &c. In consequence of heat increasing much the local symptoms, the itching is always remarkably aggra- vated at night, rest is thus completely destroyed, sleep being rendered impossible, hour after hour is passed tearing the skin, and the sufferer is often compelled to seek relief by lying on the floor without any covering. In one case of ex- treme severity which I attended, the exacerbations and re- missions assumed a well-marked, intermittent, semi-quotidian type ; the itching commenced every afternoon at about two o'clock, and continued until six o'clock, when it gradually abated, and there was comparative ease until the same hour on the following morning ; it then returned and lasted again for the same length of time, but the night suflferings were tenfold more severe than those of the d&y ; this intermittent character of the pruritus had lasted, at the time I saw the patient, a young man of twenty-three years of age, for more than two years, and his health, both mental and bodily, was sensibly affected from the constant suffering and loss of sleep. When the disease has lasted for any time, the cutaneous surface is torn and fissured from the constant scratching ; if papulae existed, their site is marked by minute, blackish crusts or small excoriations, and the skin is thickened, un- even, and coarse, being found, on close examination, as re- marked by Wilson, " raised into small, flat elevations^ caused by the swelling of the little angular compartments between -the linear markings." The natural color of the skin is also much altered, its aspect being of a dirty brownish- yellow hue. The milder form of prurigo vulgaris seldom lasts for a longer period than two or three weeks, but the duration of the severe variety is in some cases almost indefinitely pro- longed, recovery rarely taking place in a shorter time than from four to six months. The papulae in both are developed in the first instance of the chest, the neck, the lumbar -region, the shoulder, and the outside of the thighs, from whence, when the disease lasts for more than a month or two, they spread to the arms and legs, but do not appear on the face, the scalp, or the hands, although these parts in aggravated cases are rarely free from more or less pruritus. Such of the papulae as escape being torn by the nails termi- 14* 162 PAPULA. Date in slight furfuraceous desquamation. The disease is not unfrequently complicated by the simultaneous occurrence of scabies and eczema, and in some cases of ecthyma. Prurigo senilis (AlLAS, PI. IX. Fig. 6) occurs, as its spe- cific name indicates, only in advanced life; the pruritus, which is usually of remarkable intensity, is attended always -with an eruption of papulae ; these are of larger size than in either of the forms of prurigo vulgaris, but they are few in number, more dispersed over the surface of the body, and of a dull dingy-yellow color ; soon torn with the nails, small blackish crusts appear on their apices, which also constantly bleed slightly when irritated. The chief peculiarity, how- ever, in prurigo senilis is, that it is almost invariably at- tended with the appearance of innumerable pediculi on the integuments of every part of the body — a complication never absent in the poor and in persons of filthy habits. Their presence aggravates much the other symptoms of the disease : the skin becomes of a livid color, thickened, rough, with a leathery aspect, and covered with superficial excoria- tions, and small pustules and indolent boils form in different regions of the body; the pediculi are renewed nearly aa quickly as they can be removed from the surface, which has caused a controversy as to whether they are developed from the integuments or not. By some dermatologists the occur- rence of the pediculi is considered as only an accidental circumstance, and not constituting a symptom of the disease: by others it is regarded more correctly, I think, as an essen- tial feature of the eruption, and they have, therefore, fol- lowing Alibert, denominated the form thus characterized, prurigo pedicularis. Many of the French school describe, as a distinct disease of the skin, this development of pediculi on the cutaneous surface of the body, generally terming it Phthiriasis, and dividing it into three species, as it may be general or partial — Phthiriasis corporis, Phthiriasis capitis, and Phthiriasis pubis — considering the simultaneous appearance of the pa- pulse of prurigo as only a complication ; but as I have almost invariably seen them occur together in old persons, I think it more correct to describe this singular affection as a variety of prurigo senilis. PBUBIGO. 163 Prurigo vulgaris very frequently affects some special re- gion of the skin from which it does not spread, but becom- ing chronic there causes extreme suffering, and is very obstinate. It thus attacks the scrotum in males, and the pudendal region in females : the former, termed prurigo scroti, is a very troublesome affection, being attended with a constant itching, which, instead of being relieved, is much aggravated by scratching with the nails, yet the sufferer from it cannot resist the almost unceasing inclination which exists to attempt thus to alleviate the tormenting pruritus ; the habit thence acquired can scarcely be got rid of, and even long after the apparent symptoms of the disease have disappeared, the integuments are continually fretted and torn. In females, prurigo pudendi is situated chiefly on the mucous membrane of the labia, but often extends to the entire surface, both cutaneous and mucous, of this region ; it is a most distressing and obstinate disease, and not un- commonly produces symptoms analogous to those of nym- phomania. Another frequent form of local prurigo is pru- rigo podieis ; in it a constant itching of the verge of the anus exists, and papulae, which are often not present in the other local forms of the disease, are here almost invariably developed, and sometimes attain a considerable magnitude ; occasional intermissions of the pruritus occur, but the least irritation, augmented heat of the surface, or derangement of the digestive organs, causes an exacerbated return of this tormenting sensation. Other regions of the skin are at times the seat of severe itching, and have been described, but without sufficient reason, as being then affected with prurigo ; thus dermatologists have spoken of prurigo urethra- lis, prurigo praeputialis, prurigo ^m6i«, and prurigo palma- ris: the latter has been specially mentioned by Alibert as affecting the soles of the feet, of which he states that he witnessed many examples. Causes. — Prurigo may occur at any age, but is most fre- quently seen in old persons, and more commonly in males than females : young persons are more liable to its attacks than adults, and it has been witnessed even in early infancy. That state of the constitution in which cutaneous irritability exists, as exhibited by the occurrence of troublesome ulcers from slight causes, and an inaptitude, so to say, of even 164 PAPULA. the most trifling abrasion to heal, peculiarly predisposes to its development ; there is usually in such a condition an impoverished blood circulating in the vessels, and a highly irritable nervous system. Bad or insufficient diet, want of care as to cleanliness, unhealthy habitations, sedentary oc< cupations, or confinement to the house caused by ill health, defective clothing, dissipated habits, &c^ are both predis- posing and exciting causes of prurigo. I have often thought that in gaols and workhouses, amongst the aged inhabitants of which the disease is so common, and also amongst the poor, it may be caused by the sameness of food, which, too, is often defective in nutritive qualities. Other cutaneous eruptions which are attended with local ir- ritation, more especially scabies and lichen, not uncommonly are exciting causes of this affection ; and it is in old persons a frequent accompaniment of convalescence from debili- tating diseases, particularly fever, dysentery, and chronic diarrhoea. Diagnosis. — The most characteristic symptoms of prurigo are the intense pruritus, the blackish crusts which are pro- duced on the papulae, and the alteration that takes place in the appearance of the integuments. The diseases with which it is most likely to be confounded are lichen and scabies, and the mode of diagnosing it from them has been already noticed when describing these eruptions, but, as has been before remarked, they often co-exist. Prognosis. — Prurigo, when it becomes chronic, is one of the most obstinate diseases of the skin ; in old persons sel- dom yielding to any treatment. Although prurigo vulgaris cannot be said to be attended with danger to life, yet it ren- ders life miserable, sometimes for years, and from being a constant cause of irritation, may to a certain extent, affect the mind, as is witnessed in some cases. The senile form of prurigo, although it is not in itself a mortal affection, nevertheless seldom disappears unless with life, and when it occurs as a complication of some organic or chronic disease, unquestionably hastens the fatal termination. As regards the pathology of prurigo, it is evidently chiefly a hypersesthesia of the cutaneous structure ; the changes in the state of skin which attend it being usually produced by the local irritation thereby occasioned. PRURIGO. 165 Treatment. — If this view of the pathology of the disease is correct, it is manifest constitutional remedies are most to be relied upon in its treatment, nevertheless, as in other nervous affections, topical medication should not be neglected, and is often attended with the best results. The state of the generar health should in all cases first receive attention, for, until this is regulated as far as practicable, the employ- ment of remedies more immediately directed to the disease will be found useless. With this view, mild mercurial and saline purgatives may be prescribed to correct the secretions from the digestive organs, and when there is a deficiency of bile in the discharges, as is not unfrequently the case in adults and old persons, dried carbonate of soda and extract of taraxacum should be combined with mercurials. In females, the association of the disease with derangement of the menstrual function is often witnessed, and when such exists, there is generally an anemic state of the system re- quiring the use of the preparations of iron, but they should never be prescribed except in combination with sedatives, as otherwise the stimulant action is apt to augment the pruri- tus ; the same observation applies to the employment of chalybeates in the old and debilitated, for whom they are also generally indicated in prurigo. They may be advan- tageously combined, as in the following form : — R. Misturse Ferri compositae, . . . fl Sviij. Infusi Hurauli, fl liijss. Succi Conii, fl gss. Misce. "A table- spoonful to be taken every sixth hour." Or Dover's powder may be given in rather large doses at night, preparations of iron being administered during the day. In very young persons antiphlogistics are sometimes needed as preludes to other remedies, but in no case should the strength be much weakened, as then the disease is more apt to become chronic. When prurigo has lasted for any time, or has resisted other plans of treatment, more active medicines of the class which especially influences the nerv- ous system should be prescribed ; nux vomica or its alkaloid, and tincture of aconite, thus often prove useful ; the former has succeeded in my hands when all other remedies seemed 166 PAPULA. to fail ; it may be given in the following form, a oombina- tion which will be found to promote a healthy condition of the digestive organs, and to correct the loss of tone which they exhibit usually in this disease : — B. Extract! Nucis Vomicae, gr. iij. Fellis Bovini Inspissati gr. vj. Extract! Taraxaci, gr. xxiv. Pulveris Myrrhse, gr. xviij. Misce et divide in pilulas viginti quatuor. " One to be taken three times daily." The tincture of aconite should be given in the ordinary doses, from five to eight minims of the Dublin preparation, or half that quantity of Fleming's tincture, and its efiFects carefully watched. I have also administered the succus eonii, in doses of a drachm three times a day, in an ounce of the camphor mixture with magnesia, with excellent effect in some obstinate cases of senile prurigo! Preparations of sulphur are recommended by many in the treatment of this disease, and in the very chronic forms the sulphurous mine- ral waters, as those of Lucan, of Harrov^ate, of the Pyre- nees, &c., prove of unquestionable benefit. Indeed, in all cases, change of air, if possible, to the original sources of mineral waters, the saline in the early stages, the chalybeate in the more advanced, and the sulphurous when the disease is very chronic and obstinate, so that they may be drank there is highly advisable. The local treatment is now to be spoken of: and at first nothing is requisite further than the daily use of the hot fresh-water bath, to which, if the itching is extreme, gela- tine should be added, or alkaline baths may be employed, if the eruption is well developed on the skin ; as the disease advances and becomes chronic, sulphuro-alkaline baths — three ounces of sulphuret of potassium, and an ounce of carbonate of potash to thirty gallons of hot water — will be used vith benefit ; and in senile prurigo, especially that form in which pediculi cover the body, the surface should be smeared half an hour before going into the bath with mer- curial ointment diluted with three parts of prepared lard, PBUBIGO. 167 and a drachm of glycerine added to each ounce. To allay the pruritus, various lotions and ointments have been recomr mended ; of the former, those containing the vegetable acids, such as lemon-juice, vinegar, and cherry-laurel water, are especially useful ; black-wash has also proved very service- able when the disease is local ; and lotions, containing cor- rosive sublimate, muriate of ammonia, watery extract of opium, prussic acid, preparations of lead or of sulphur, may be tried when other applications fail. From the use of chloroform in the form of ointment, as recommended in the Chapter on Urticaria, I have derived most excellent results ; in fact, latterly I have seldom had occasion to employ any other application ; but the substances mentioned above, as being used in lotions or washes, may also be applied as un- guents, and the addition of glycerine will generally be found of advantage. In very obstinate cases the chloroform may be combined with iodide of lead, as follows: — B. Iodide Plumbi, gr. xij. Unguenti Cerse Albse, .... ij. Chloroformi, m. viij. adm. xij. Glycerinse, fl Sj- Misce. When greasy applications are used, alkaline tepid baths should be employed daily to cleanse the skin, the patient remaining in the water for at least twenty minutes. Strict attention to diet ahd regimen is requisite in all cases ; stimulant food or drink being especially avoided. 168 SQUAMiE. CHAPTER VI. SQUAMiE. There is no class of diseases of the skin so well charac- terized by the apparent phenomena as that in which the formation of a scale constitutes the essential feature ; epi- dermic desquamation, as has been in the previous pages so frequently noticed, is present in many cutaneous eruptions, but that differs in many respects from the secretion and sub- sequent shedding of true scales, which consist, according to the admirable definition of Willan, of " a lamina of morbid cuticle, hard, thickened, whitish, and opaque." Although in some of the forms more or leas change from the primitive characters of the eruption takes place in the progress of the disease, it is never such as to mask their scaly nature, and the diagnosis is consequently attended with less difficulty than that of most other cutaneous affections. Squamous eruptions may be defined to consist in the secretion of dry, lammated whitish scales on the cutaneous surface, usually occurring in patches, often of a circular form, but sometimes generally diffused, and covering an extended portion of the integuments. The scales, which are somewhat elevated above the level of the surrounding skin, readily fall off, to be again rapidly renewed, and the portions of the cutaneous surface on which they are formed are of a smooth, glistening aspect, reddish and dry. Scaly diseases are essentially of a chronic, non-inflamma- tory nature, are slowly developed, and are not propagated by contagion. They may appear on any part of the body, but they chiefly affect, at least in the first instance, the extremities, whence they usually spread to other regions, being rarely confined to a single locality, with the excep- tion of pityriasis, which occasionally occurs on some sp-^cial portion of the skin. They are developed also at all seasons of the year, and are not apt, like other cutaneous diseases, PSORIASIS. 169 influenced by the atmospheric temperature, to disappear and again re-appear at certain times. The eruptions included in the order Squamae were divided by Willan into four groups — Lepra, Psoriasis, Pityriasis, and Ichthyosis — and his arrangement has been followed by many modern dermatologists; recently, however, it has been very generally admitted that Ichthyosis was incorrectly classed by him amongst scaly diseases, and doubt has been thrown on the propriety of describing psoriasis -^nd lepra as different forms, they being, moreover, evidently regarded by the ancient medical writers as constituting merely varie- ties of the same eruption. Ichthyosis cannot with any re- gard to accuracy in classification, be grouped in this class, for it is not attended with a separation — throwing ofi" scales, or desquamation, one of the most characteristic signs of this order of cutaneous eruptions ; the epidermis is in it truly hypertrophied, and I shall therefore describe it as consti- tuting one of that group of skin diseases which I have termed Hypertrophise. To even a superficial observer ^t must be evident that psoriasis and lepra have no essential differences, and they require a precisely similar plan of treatment ; regarding them, therefore, as distinct affections could only tend to complicate their study. The number of scaly dis- eases of the skin is thus reduced to two — Psoriasis, P^^- riasis. PSORIASIS. ^ Psoriasis {Dry tetter; Dry scale) — under which term it will be understood I include Lepra — is characterized by consisting in the formation on the cutaneous surface, and subsequent desquamation, of true scales, the scales being of tolerable consistence, dry and friable, of a silvery or grayish whiteness, and separating in laminae of about the size and consistence of particles of bran. The eruption appears in small, round, or irregularly-shaped spots, dis- tinct from each other, scattered over the cutaneous surface in large, circular patches, depressed in the centre, or in masses so closely aggregated and confluent as to envelop an extended portion of the skin in one vast coating of scales in consistent layers. The surface of the integument on 15 170 SQUAJI-E. which they are sitHat.eel is raised, reddish, and apparently inflamed, but unattended \?ith any discharge ; nevertheless, when the eruption has been of long duration, fissures and cracks through the dpeper-seated tissues form, from which an ichorous, bloody secretion exudes. Psoriasis has been considered by many writers : on diseases of the skin to bo a special chronic inflammation of the cutaneous structures, the specialty consisting in the development of scales ; it cannot, however, I think be regarded as an inflammatory disease, for it is not attended with heat or other local sign or symptom of inflammation, except a slight degree of itch- ing, unless when the affected surface is irritated by some cause. The eruption appears in the form of minute, slightly-ele- vated papulae, with a small scale apparent at the apex of each on careful examination, and, no matter what pheno- mena it may afterwards present, this is its primary aspect ; coming on slowly, it runs generally a most tedious course, often lasting for many years, and sometimes even for a long life. The several varieties of both psoriasis and lepra which have been described may be conveniently reduced to three : — Psoriasis guttata. " aggregata. " leprseformis. Psoriasis guttata (Atlas, PI. X. Fig. 1). — This, which is the mildest form of the disease, is unattended in any of its stages with constitutional symptoms ; a slight degree of itching of the skin occasionally precedes its appearance, but even this is not a constant sign. Numerous minute, papular elevations of the epidermis, at first not exceeding in size the point of a pin, are developed on the cutaneous surface, scat- tered irregularly but distinct from each other, except in the neighborhood of the joints, on the prominences of which they are usually more or less aggregated, On the apex of each little elevation a minute scale forms, which, at first slightly adherent, desquamates shortly after its appearance, to be succeeded by another somewhat larger and more con- sistent; this scale is shining, of a silvery whiteness, and about the thickness of thin writing paper. The raised spots PSORIASIS. 171 on wliicli the scales are situated enlarge slowly, not attain- ing the size of the head of a pin for several days, and very gradually acquiring a magnitude of from two to three lineS' in diameter, when they are of a somewhat circular shape, but irregularly circumscribed. In some parts two or more spots coalesce, and thus form small patches; rarely, however, in this form of the eruption, excefeding this size of a sixpence, except, as above remarked, near the joints, where they occa- sionally occupy a portion of the integtiment an inch or two in diameter. With the progress of the' disease the scales continue to be continuously developed, and shed as rapidly as they are secreted ; the affected spots are irregularly ele- vated, of a redish color in young persons, but of a dull brownish' hue in the old, contrasting well with the shining, grayish-white scales, and present an irritated aspect. The only annoyance accompanying the presence of the eruption on thef body, the disfigurement it occasions excepted, is a slight degree of tingling scarcely amounting to itching, caused by the separation and shedding of the scales. This form of psoriasis rarely becomes chronic; in three' or four weeks after its first appearance, the scaly desqua- mation begins to diminish^ in quantity, new spots, which continued to be developed on the sound skin amongst those which had previously existed, cease to form, the elevated' patches gradually sink to the level of the surrounding in- tegument, and the disease usually terminates in from six weeks to two months, faint reddish stain's, which alfter- a short time fade away, marking the site of the eruption. ' It may occur upon any part of the body, but is most usually situated on the chest, the back, the arms, the- face, and the scalp. , In some rare cases, as originally noticed' by Willan, the eruption is developed in the form of narrow patches or strips, consisting of the minute scaly elevations set closer to each Other than usual. These stripes or bands, which generally appear on the trunk of the body, assume a singular shape: " some of them are nearly longitudinal, some circular or semi-circular, with vermiform appendages : some are tortu- ous or serpentine, others are shaped like earth-worms or leeches ; the furrows of the cuticle, being deeper than usual, make the resemblance more striking by giving to them an 172 SQUAMA. annulated appearance."' This, which is manifestly bAly an accidental variety of psoriasis guttata, has from its peculiar aspect heen named psoriasis gyrata. Psoriasis aggregata (Atlas, PI. X. Fig. 2). — I have ventured to change the specific appellation of this form of the eruption, which by Willan and hia followers has been denominated diffusa, by Rayer confluens, and by many other dermatologists vulgaris. The latter term indicates correctly enough that it is the most common form of the disease, but does not afford any information as to its characteristics, while the first is not sufficiently specific, psoriasis guttata and psoriasis leprseformis being often as generally diffused with regard to locality over the cutaneous surface ; the name applied by Rayer is objectionable, solely because, in the English language, the word " confluent" conveys the idea of the presence of fluid. Reluctant, then, as I am to alter the nomenclature of skin diseases, although anxious to reduce in number the terms used, I have thought it well in this in- stance to do so by employing a specific denomination, which while being frequently employed to designate other diseases of the cutaneous structure, and thus not being an innovation, would be both more correct and more expressive. This form of psoriasis, developed like that last described, without constitutional disturbance, appears as numerous minute, rounded elevations of the epidermis, closely aggre- gated together in irregularly circumscribed patches, varying in size from that of a silver fourpence to that of the palm of the hand, but very irregular, both as regards shape and extent ; on these the scales are formed from the first, minute and tolerably adherent at the commencement of the disease, but gradually acquiring a greater magnitude, when they are shed and again secreted with astonishing rapidity. The scales are of the same color and consistence as in psoriasis guttata, but desquamate in rather larger pieces, their repro- duction, too, takes place much more quickly, so that they are consequently desquamated in greater quantity. With the progress of the eruption, new patches form on the inter- vening sound skin, which, sometimes coalescing with those that first appeared, increasing their size often considerably ; ' Willan on Cutaneous Diseases. London, 1808. 4to. p. 161. PS0BIA3IS. 173 the diseased surface is now distinctly raised above the level of- the surrounding integument, rather more so at the outer border than at the centre, of a dull, reddish color, and co- vered with fehining grayish-white scales. There is no dis- charge,' either sSrous or purulent, but fissures or ci-acks are generally found through the affected piarts, which present an irritated- aspect,, and through which blood occasionally exudes. This form of the disease often does ndt attain its full de- velopment for many months,' although several of the patches acquire their utmost magnitude in three or four weeks, after which time they do not increase in size, but continue to sectete the characteristic scales incessantly. Its duration is essentially chronic, lasting usually fot years if not sub- mitted to the employment of remedial measures. The disappearance of the eruption is in all cases slow and gradual, the first sign of amendment being the cessation of the development of new patches, a diminution of the scaly desquamation, and a sinking of the elevated surface to the level of the healthy iii tegument; reddish stains remain for a considerable time on the surface, even after the disease is apparently cured, and from these a fine epidermic des; quamation, though small in quantity, continues for some weeks. Either of the forms of psoriasis now described, when they become very chronic, iliay assume an extremely aggravated character, and present locAl phenomena justly entitling them to the appellation which dermatologists then usually apply to designate their severity and obstinacy to treatment — psoriasis inveterata (Atlas, Pi. X. Figs. 3 and 4). In it the various patches of the eruption coalesce, so as to cover completely the limb on which they may be situated, or even the trunk of the body ; the entire of the cutaneous surface is one mass of dry, hardened, thick scales, or rather is enveloped in a case of them which covers the integuments like a coat of mail. Through this, deep fissures are formed, generally in straight lines, but sometimes following the course of the polygonal and Hozenge-shaped linear furrows of tha epidermis, so as to give the diseased surface a Striking resemblalice to a piece of tessellated pavement. From the 15* 174 SQUAMA. fissures an ichorous and bloody pus exudes, the parts are constantly torn with the nails, itching, which is much aggra- vated by heat, being a constant accompaniment of this in- veterate form, and the entire of the affected region is a mass of leprous irritation, attended with a foul discharge, and a shower of desquamating scales flies off on the least motion, the bed of the patient presenting an appearance as if bran had been thickly strewn in it. The most usual site of psoriasis aggregate is the extre- mities, but it at times affects the entire body, being least frequent on the face, where it is always less general than on other parts of the cutaneous surface. In some cases it appears on special regions of the skin, and under such cir- cumstances has been particularly described, but the guttated form of the eruption is almost invariably present on the rest of the body at the same time. The local forms have been named, from the parts affected, psoriasis labudis, psoria- sis palpebrarum, psoriasis capitis (Atlas, PI. X. Fig. 6), psoriasis acrotalis, psoriasis prxputialis, psoriasis pudenda- lis, psoriasis palmaris, and psoriasis unffuium ; of these the two last only require to be specially noticed. Psoriasis palmaris has, in common with certain forms of lichen and eczema, been regarded as one of the varieties of the so-called baker's and grocer's itch ; it may appear on the palmar aspect of the hands, extending also to the wrists and the under surface of the fingers. In its development it is attended with more local symptoms than any other variety of the disease, inflammatory redness, accompanied by heat and itching, marking its advent; the skin on the palm of the hand then becomes swollen, irregularly elevated, and of a reddish hue, and the itching generally increases much, being at times as intense as in scabies or prurigo. Large dry whitish scales, of tolerable thickness and consist- ency, are rapidly secreted on the affected surface ; these soon desquamate, and are reformed again and again, as in the other varieties of the eruption. When it becomes chronic, the itching and heat diminish, but the integuments of the palm of the hand and of the palmar surface of the fingers become hardened, thick like leather, of a whitish-yellow color, corrugated, scaly, and fissured ; the motions are then limited and painful, the fingers cannot be completely flexed PSORIASIS, 175 or extended, and any sudden movement tears the fissured parts, and causes them to bleed. In a rare form described by Rayer, and termed by him psoriasis palmaria centrifuga, the eruption begins by the formation of a small, rounded, squamous elevation in the centre of the palm, around it a series of eccentric, raised, red circles are developed, from each of which epidermic desquamation takes place ; the eruption spreads in this manner until it covers the entire palmar aspect of the hands, which is then deeply fissured and painful, and bleeds from the slightest cause. Psoriasis attacks the backs of the hands also in some instances, and occasionally the soles of the feet. The eruption extends to the nails in most cases of chronic psoriasis of the hands, but what has been described as pso- riasis unguium is a change from their healthy condition, with or without the existence of the disease on remote parts of the body ; one or more of the nails presents a brownish- yellow, scaly elevation near its roots, which gradually becomes brittle, breaking and scaling off constantly ; it ac- quires a dirty yellowish hue, and not uncommonly the entire nail is shed, to be succeeded by the growth of another equally diseased. Psoriasis leprseformis (Atlas, PI. X. Fig. 5), which as already remarked, is the form of scaly eruption described by most derinatologists as a distinct disease, and termed by them ' Lepra,' is chiefly characterized by the development of the patches in usually a perfectly circular, but sometimes in an ovoid shape. It commences without either constitu- tional or local disturbance, in the form of numerous small, round, reddish stains, perfectly distinct from each other, and scarcely elevated above the surrounding skin, on which shining silvery-white scales soon appear. Gradually but slowly, the circles enlarge from their circumference, which is somewhat more raisjed than the centre, attaining a size varying from a few lines to one or two inches in diameter ; some of the patches coalescing, they occasionally cover an extended surface of the integument, and acquire an irregu- larly rounded shape, — this is almost invariably the case on the convex aspect of the joints and in their neighborhood, on which parts the eruption presents an appearance scarcely to be distinguished from psoriasis aggregata ; but the cir- 176 SQUAMA. cumference of the patches, no matter how large they may be, is always more elevated than the centre, which, after some time, assumes a, comparatively healthy condition, its color becoming more natural and but slight desquamation of fine epidermic scales taking place from it. From the borders, however, the constant secretion and shedding of true scales continues ; they become thicker and more solid, retaining their whitish aspect, and are sometimes imbricated on each other at the outer border of each patch ; the integument on which the eruption is situated also becomes somewhat hyper- trophied. Psoriasis lepraeformis always runs a very chronic course, not exhibiting any tendency of itself to disappear, the dis- ease being kept up more by the desquamation of scales from the patches of eruption originally formed, than by the de- velopment of new spots ; at length, when under treatment it begins to amend, the central healthy surface extends towards the circumference, upon which fewer and thinner scales are secreted ; the eruption at the same time ceases altogether to spread, and finally, only slight stains with furfuraceous epi- dermic desquamation remain, as an indication of the parts which were affected: these in most cases gradually wear away, but they sometimes last for years, and scales form on them in spring and summer, or on the least exacerbation, either from local causes or from irregularities of diet, re- lapses thus frequently occurring. A variety of this form of the eruption has been described under the name of Lepra nigriediii, in which the color of the diseased patches is du§ky-brown or livid, and the scales are very thin, soft, and of a dull, grayish-white aspect ; in all other respects it resembles psoriasis lepraeformis, and its peculiarities evidently depend on the eruption affecting old persons or those with a broken-down constitution, in whom only it is witnessed. The Lepra alphoides of Willan is a variety of psoriasis guttata, in which the spots are somewhat' larger, and the scales taore silvery-white than usual. The leproid form of psoriasis chiefly affects the extre- mities, yet it sometimes attacks the face and scalp, and the trunk of the body: I have seen it occur very exten- sively on the scalp, where the patches coalesce and envelop PSORIASIS. 177 the entire of the head in one vast crust of scales, being, however, present at the same time on other regions of the body ; on the face it is almost invariably in rather small patches distinct from each other, but most numerous on the forehead and the upper parts of the cheeks, just beneath the eyes. The spots of this form of the eruption not unfre- quently assume a somewhat symmetrical arrangement on the two halves of the body, appearing on the correspO;nding portions of the cutaneous surface at each side of the mesial line simultaneously, and in patches of nearly similar shape and size ; the same fact is also witnessed at times in the other varieties of psoriasis, but it is of more frequent occur- rence in this form of the disease. The psoriasis annulata of some dermatologists, the orhi- cularis of others, corresponds in all respects with psoriasis lepraeformis. , And the variety termed infantilis presents no peculiarity, except its occurrence at a very early age, ivhen, in consequence of the fineness of the skin, the surface is more easily irritated, and the local symptoms are, there- fore, more prominent. In all the forms of the eruption these, as has been remarked, are in general very trifling, but when any do exist, they are much aggravated by warmth, such as that caused, by the heat of the bed. The chief annoyance which psoriasis causes is the dis- figurement it occasions when situated over any of the ordi- narily exposed regions of the body ; but if the eruption has existed for any length of time, and becomes chronic, the health may be more or less aflTected from the obstruction to free cutaneous transpiration which it must produce; and thus, should any acute febrile disease attack a person affected with the eruption, the danger arising from the former may be in- creased, and the treatment rendered more difiBcult. It is probably due to this cause, also, that diuresis and diarrhoea are such frequent accompaniments of scaly diseases of the skin ; the latter complication is often very incontrollable, and the appearance of the stools at times is such as to war- rant the belief, that it is caused by an epithelial desquama- tion from the mucous membrane of the intestinal canal, analogous to the shedding of altered epidermic scales from the cutaneous surface. Causes. — Psoriasis occurs at all ages and in both sexes, 1'78 SQUAM:S!. being probably equally frequent in males and females ; its fecial causation is, like that of all cutaneous eruptions, enveloped in much obscurity. That it is sometimes produced by the action of certain irritating matters on the skin can- not be doubted ; yet we see the same local forms of psoriasis arise in persons who, from their occupatibn or position in life, are not exposed to the causes which produce it in bakers, washerwomen, shoemakers, and individuals of other trades. That squamous diseases are sometimes hereditary is also true, but their hereditary nature is of a singular character; thus, so far as my own experience would lead me to infer, the disease does not descend directly from parent to child with the same regularity as other hereditary diseases, but the predisposition frequently appears to be derived from an uncle or aunt, whose own children may bis free from the disease ; and it also seems not uncomtdonly to lie dormant in a family for a generation, and again ' r6-appear. Ip a case which I not long since attended, one son of a family was afiFected from his cbildhood with psoriasis of an invete- rate form; none of his brothers or sisters had any cutaneous eruptions, nor had his parents or grand-parents, but a pa- ternal uncle was affected with a similar diseasej and also a first cousin not the child of this uncle : it was, moreover, stated that a grand-uncle was a sufferer for years from cuta- neous eruption. A somewhat similar hereditary transmis- sion of the disease has fallen under my notice in several in- stances, namely, that while the imniediate descendants have escaped, one or more members of collateral branches have been affected. The true hereditary nature of psoriasis may therefore be doubted, and the cases which occur, and are ad- duced as proofs of it, might be accounted for in the same manner as those in which no such origin can be traced, and which are usually stated to depend on some constitutional peculiarity, not better understood now than in the days of Willan, who described it as characterized by " a slow pulse, or a languid circulation of the blood, and, what must be generally connected with it, a harsh, dry, impermeable state of the skin and cuticle." The latter part of this observa- tion has been adopted by Mr. Erasmus Wilson, who says that " the disease appears for the most part in those who are re- PSORIASIS. 179 mSirkable for a dryness of tlie skin." Yet I cannot help thinking that this is a confounding, of the effect with the cause, and that it would be rather hazardous to predicate the likelihood of psoriasis occurring to an individual because his skin was unusually dry or harsh. The other causes, or- dinarily enumerated by dermatologists as being likely to produce psoriasis, are similar to thosB . supposed to excite other diseases of the skin, such as irregularities of diet, in- sufficiency of food, the use of salted or highly-seasoned pro- visions, derangements of the digestive organs, and, in the female, deficient or excessive menstruation ; but none of these can be. supposed to act unless when original predispo- sition to the disease exists. Diagnosis. — The distinction between psoriasis and all other diseases of the skin, except pityriasis, is well marked by the presence of the characteristic scales ; several other eruptions are, as has been remarked when speaking of them, accompanied by a form of desquamation, but this is present in only certain of their stages, and the desquamation con- sists merely of the shedding of slightly altered epidermis, in minute, very thin, furfuraceous particles, not to be con- founded with a true scale; this takes place especially in chronic eczema, in herpes, and in lichen, but in the two former there is more or less serous or sero-purulent dis- charge attendant on some part of their course, and in the latter papulae are to be distinguished on careful examina- tion. When either of the two latter diseases assumes a cir- cular form, as in herpes circinnatus or lichen cireumscrip- tus, it is more apt to be confounded with psoriasis leprse- formis, -but the characteristics just noticed then serve also to aid the diagnosis, and the eruption in neither of them presents the distinctly rounded shape with the depressed centre and scaly circumference of this variety of the disease. Psoriasis very rarely occurs on the scalp, unless when the eruption^ is present at the same time on some other part of the body, and this serves to a certain extent to distinguish it from other scalp affections ; the scales, too, when they are secreted on this region, are thicker and more solid than when situated elsewhere on the cutaneous surface, and con- sequently much more so than those of any other eruption that may occur there, than which they are also more per- 180 SQUAMA. sistent, often constituting a firm, imbricated, adherent, dry crust, the outer layer of which only desquamates. Secon- dary syphilitic eruptions not unfrequently assume a scaly character, and are with diflSculty diagnosed from the ordi- nary forms of psoriasis ; the history of the case and the concomitant symptoms are the differential points to be chiefly depended on ; the color of the parts of the cutaneous surfece which are affected is, moreover, of a dull coppery or livid hue. From pityriasis the eruption is distinguished by the ab- sence in that affection of elevation of the diseased parts, which are of a yellowish or reddish -yellow color, by the scales being fine and thin, and by their being generally diffused over the cutaneous surface, not in distinct patches or spots. The chief diagnostic marks between it and ichthyosis are the thick, hardened, and rugose condition of the skin in the latter, and the non-existence of any scaly desquamation. The aggregated form of psoriasis is distinguished from the guttated variety without any diflSculty, but in some cases a distinction can scarcely be made between it and psoriasis leprseformis, a matter of but little import, as the treatment for both is in all respects similar. Prognosis. — Squamous eruptions are essentially of a chronic nature, but even when of years' duration, scarcely ever affect in any respect the general health. Developed under the influence of a peculiar constitutional state of the skin, essentially of an obstinate character, and most apt to re-appear even in months or years after they seem to have been completely cured, length of time is as important to their perfect removal as the most judiciously planned course of treatment. The physician should, therefore, in every case, be most careful not to promise a speedy cure, and always, before prescribing, explain to his patient the chronic character of the disease, and that it requires a steady per- severance in the use of remedial measures for at least two or three months before even an apparent amendment will be perceptible. The anxiety of mind which an individual labor- ing under a cutaneous eruption suffers is very great, and this, too, adds to the diflBculty of treatment. The promise of an eventual cure, though after a lengthened period, tends to alleviate this anxiety, and. prevents the repeat{9d disap- PS0BIA3IS. 181 pointment, changes of medical advisers, and trials of new plans of treatment, ■which the hope deferred, when a speedy cure has been promised, causes. Pathology. — " It is an admitted fact," writes Cazenave, " that the therapeutics of these diseases rest upon purely empirical grounds, and that, unhappily, there exists no sure guide to direct to a rational mode of cure. This statement, sufficiently true of most eruptions of the skin, is equally so of many other diseases of the. body, and it should teach us not to despise the light thrown on pathology by the expe- rience derived from therapeutics. When it is found that a certain class of remedies act beneficially on deranged condi- tions of the animal economy, concerning the true nature of which doubt exists, it cannot be termed a petitio principii to infer that such derangements have a similarity in greater or less degree to affections the nature of which is known, and which are benefited by the same class of remedies. In the treatment of scaly diseases of the skin, iodine, in some of its various combinations, and cod-liver oil are especially use- ful ; and I would, even from this therapeutic fact alone, be inclined to look upon the peculiarity of constitution in which they occur as nearly allied to the scrofulous ; in fact, that their appearance is but one of the protean forms in which scrofula may be developed. And, independently of the bene- ficial effects of iodine, if we look to the remedies ordinarily proposed as specifics for their cure — of course I speak only of those administered internally, or, so to say, constitution- ally — what are they but tonics, or alteratives, or diaphore- tics, generally employed in the treatment of scrofulous affec- tions ? Again, if we lay aside the analogy derived from therapeutics, in how many points do not scrofula an^. scaly eruptions of the skin agree ? — their hereditary nature, their slow development, the period of life at which they appear, their production by innutrition or mal-innervation of the system, their obstinacy, their liability to recur or be again reproduced, the diathesis of the individuals in whom they appear, &c. ■Treatment. — In consequence of its extreme obstinacy and usually chronic character, there is probably no eruption of the skin, for the treatment of which so many ^amei. t&ae- 16 182 SQUAMA. dies have been and still are proposed, as for psoriasis. Some trust altogether to topical medication for its cure, while others rely exclusively on the employment of constitutional remedies ; both are needed, and neither should be neglected : the former must be used when the eruption has lasted for any length of time, or where it affects an extended surface of the skin, to produce a new local action, and to remove the diseased condition of the integuments ; while the latter is required to correct any deviation from a healthy state, whether functional or organic, of the internal organs which may be present, and to alter the constitutional derangement, to the existence of which the eruption is due. Before com- mencing any plan of treatment, therefore, it is necessary to take into account the age, constitution, and diathesis of the patient, the extent of surface affected, and the previous dura- tion of the disease. In strong, healthy, plethoric young persons of either sex, when the eruption is of the guttated form, or affects only a small portion of the skin, its progress will generally be stopped, and a cure effected by the use of tolerably active saline cathartics every second or third day, preceded by a general bloodletting, and the daily use of a/resA-water bath at the temperature of 98°. In persons of a sanguine tem- perament, or of very plethoric habit of body, the bleeding may be repeated, but in all cases only a moderate quantity of blood should be drawn, for when much has been removed at a time, or the operation frequently repeated, the eruption is apt to take on an aggravated character, and to become chronic. The best cathartics that can be used are the saline purging mineral waters, such as those of PuUna, of Seidlitz, of Cheltenham, of Leamington, of Droitwich, of Kreuznach, &c. ; or, in their absence, the compound saline powder may be given in the dose of two drachms, dissolved in half a pint of lukewarm water, to which from twenty to thirty minims of the liquor potassa, or preferably, Brandish's alkaline solu- tion, and the same quantity of some aromatic tincture, as of orange-peel, should be added ; in either case the purgative should be taken in the morning early before breakfast. By these simple means, continued for five or six weeks, many of the milder cases of psoriasis may be cured, but more gene- PSOBIASIS. 183 rally, and invariably when the eruption has existed for some time before it is submitted to treatment, it is only alleviated thereby. When the disease affects old persons or individuals of a weak constitution, all debilitating remedies must be carefully eschewed ; in its early stages then stimulating diaphoretics, combined with tonics, should be employed, and the tepid bath, or tepid douche if the eruption be local, used once or twice a week when the patient's strength admits, or the hot vapor bath may in some cases be substituted with benefit for the water bath. Guaiacum and mezereon often prove the best diaphoretics in these cases of psoriasis, and they may be given in combination, as in the following form : — B. TIncturae Guaiaci Ammoniatse, . . . fl 3j. Tincturse Serpentarise, fl Jss. Mucilaginis Acacise, m. xx. Decocti Mezerei, fl 3viss. Decocti Dulcamarae, fl ij. Misce. Fiat haustns. , " One such to be taken three times a day." In scrofulous children, the progress of the disease may in its early stage be stopped and a cure efiected by the adminis- tration of cod-liver oil ; and this medicine proves also very successful in many cases of the local forms of the eruption in adults ; but with children or young persons the employ- ment of the tepid bath at the same time should not be neg- lected. In the more aggravated forms of psoriasis, however, or when the disease has become chronic, recourse must be had to the more active alteratives, some of which have acquired a sort of specific reputation for the treatment of scaly diseases ; and of all that have been used none eflfeets a cure so frequently as arsenic, whether it be given alone or its administration conjoined with the application of various local agents. In every case the beneficial action of this medicine is more decided and more speedily manifested 18i SQUAMA. when iodide or the iodide of potassium is employed at the same time, or alternated with it, and in those cases — not few in number — in which arsenic, no matter how prescribed, disagrees, the preparations of iodine su£5ce usually to cure the disease. Arsenic may be prescribed either in the fluid form or in that of pill, but, however given, the dose should be small, increased very slowly, and continued for a length- ened time, at least for several months. Of the liquid pre- parations, the liquor arsenicalis of the Pharmacopoeias, Fowler's solution — a convenient name for prescribing when it is requisite to conceal from patients or their friends that arsenical preparations are being administered — is probably the best, or the liquor araenici chloridi, De Valangin's min- eral solution — introduced into the last edition of the London Pharmacopoeia — ^may be used ; they should not be given at first in a larger dose than four minims three times a day in an ounce of decoction of dulcamara, to which, except in persons of a full habit of body, two drachms of syrup of mezereon may be added. The arseniates of ammonia or of soda may also be given in solution in water, with a little syrup, or in some vegetable infusion or decoction, in the dose of a twentieth of a grain, very gradually increased to the fifteenth of a grain, three times daily. The following form, for the administration of the arseniate of ammonia, was first proposed by Biett : — R. Ammonise Arseniatis, . . . . gr. iss. Aquse destillatse, fl liij. Spijritus Angelicas, .... fl 5vj. Misce. " One tea-spoonful, gradually increased to three, to be taken for a dose in some aromatic water." Donovan's solution of the hydriodate of arsenic and mercury, which has become oflScinal in the last edition of the Dublin Pharmabopoeia, is another liquid form that has been often employed successfully in the treatment of pso- riasis ; in consequence of its containing mercury it is espe- cially applicable for those cases in which the eruption is either a secondary symptom, or is connected with a syphi- PSORIASIS. 185 . litic taint in the system; but, from my own experience, I do not think that mercurial preparations in any form are generally applicable for scaly diseases, except in the local forms appearing in children, and I have not unfrequently seen their use followed by an aggravation of the symptoms. I have consequently, for some years back, substituted for Donovan's solution a compound in which mercury is replaced by the iodide of potassium ; this mixture may then be termed an loduretted solution of the Iodide of Potassium and Arsenic ; it is prescribed in the following form : — B. Liquoris Arsenicalis, . . . m. Ixxx. lodidi Potassii, gr. xvj. lodinii puri, gr. iv. Syrupi Florum Aurantii, . . fl gij. Solve. This solution, which is of a rich wine-yellow color, and keeps unchanged for years, contains in each fluid drachm five minims of arsenical solution, a grain of iodide of potassium, and a fourth of a grain of iodine. Forty minims of it at first may be given three times a day in simple water, or in any tonic or diaphoretic vegetable infusion or decoction, as individual circumstances may indicate, and the dose gradu- ally increased to eighty minims : it is of course, scarcely necessary to observe that this compound, as are all which contain iodine, is incompatible with vegetable preparations in which starch is present, or with the stronger acids. In cases in which from any reason it may be advisable not to prescribe arsenic, the Fowler's solution can be omitted from the above mixture, and, unless in the inveterate forms of the eruption, or when it has been of very long standing, the iodine preparations should in the first instance be tried alone. Where it is wished to prescribe arsenic in the solid form, the best preparation of it is the iodide, which may be given in pill, made with conserve of roses or with hard manna and mucilage, in doses of from the twelfth to the tenth of a grain, three times daily, very gradually increased until the fourth of a grain is taken at each time ; the arseniates of ammonia or of soda may be given in the same form. In the more re- 16* 186 SQUAMA. beliioua cases of the disease, and especially when it occurs in persons of a debilitated constitution, an excellent and favor- ite formula for the administration of this powerful agent, is what has been termed the Asiatic pills, in consequence of their being first beneficially employed in the East Indies, whence we derived our knowledge of their eflScaey ; they are prepared by rubbing together a drachm of arsenic and nine drachms of powdered black pepper, with suflSoient liquorice powder and mucilage to make 800 pills. Each of these contains about a 13th of a grain of arsenic, and one or two may be given daily. No matter what preparation of arsenic is employed, it should be administered after meals, as it is then less apt to derange the stomach, and the effect should be carefully watched : the continuance of headache, of sickness and pain in the stomach, of dryness of the fauces, or of tenderness with heat and redness of the eyes for a few days, requiring its oinission for a short time, and the adminis- tration of an active cathartic, when it may be again resumed. It generally occurs that in the treatment of scaly diseases by arsenic or by iodine, the eruption at first presents an aggravated appearance, the affected parts exhibiting an irri- tated aspect, and the scaly desquamation being much aug- mented, but these symptoms soon pass away, and signs of amendment begin to show themselves. In all cases the use of the remedies which have proved successful should be per- sisted in for some weeks after the disease is apparently cured, so as to prevent a relapse. Chronic cases of psoriasis are very frequently complicated with derangement of the digestive organ, evidenced by vari- ous dyspeptic symptoms ; the most prominent of these are nausea and vomiting, immediately after meals. This con- dition must be remedied by appropriate alterative and tonic treatment, previously to the employment of medicines, with the view of acting directly on the eruption, for if arsenic or iodine, in any form, be given while this condition is present, they will tend to increase the existing irritation, and their expected beneficial action be thereby prevented. The tepid fresh water, the douche, or the vapor bath, should be em- ployed at least once or twice a week, in addition to the use of the internal remedies now recommended. But oases of psoriasis occur which resist with obstinacy PSORIASIS. 187 the administration, even though much prolonged, of either or both of these powerful medicines, and then recourse must be had to some of the many other remedies, both constitu- tional and topical, which have at times proved useful, and have consequently found warm advocates. Sulphur and its preparations have been highly praised by many practi- tioners for their eflBicacy ; and in the very inveterate forms of the eruption occurring in languid constitutions, or when there is no determination of blood to the affected parts, nor local irritation, the sulphurous mineral waters, both taken internally and empibyed in the form of tepid bath, cure the disease when other remedies have failed ; but to derive the full benefit from them, their use should be continued for several months, otherwise the eruption is sure to reappear. When the mineral waters cannot be^jrocured, or the patient is unable to go to their sources, which is always most advis- able, sulphur may be given internally, and baths or lotions of the sulphuret of potassium used. In the local forms of the disease the iodide of sulphur ointment is a most valuable topical application, but it should be used only of moderate strength, from eight to twelve grains to the ounce of white wax ointment, and its efficacy is much increased by the addition of a drachm of glycerine to each ounce. M. Cazenave has recently administered the carbonate of ammonia, in the treatment of psoriasis, with marked success; he ^prescribes it in the dose of about two and a half grains, from one to three times a day, in a table-spoonful of syrup of sarsaparilla. " In general, the symptoms it causes are scarcely to be noticed ; some slight disturbance of the di- gestive organs, and occasionally slight heat and tingling of the skin. Yet, after an interval of time, varying usually from three to eight days, when good results follow, the scales begin to, be detached, those which succeed them are more and more fine and of a duller aspect, and the patches. on which they are situated lose their red tint and gradually fade away ; after a longer or shorter period a complete cure, and one which is often permanent, takes place."^ When carbonate of ammonia was thus administered, M. Cazenave found it to occasion diarrhoea, preceded by colic, lassitude, > Annales des Maladies de la Peau et de la Syphilis, torn. iii. p. 815. 188 SQUAM-S. sometimes headache, slight acceleration with diminished full- ness of the pulse, alternations of heat and cold of the sur- face, &c. ; these symptoms disappeared on omitting the use of the medicine for a few days, and this fact, together with their similarity to those caused by arsenic, led him to draw an analogy between the mode of operation of the two me- dicines. Amongst other constitutional plans of treatment proposed for psoriasis, bringing the system under the influence of mercury has proved successful in the hands of some prac- titioners ; it is chiefly applicable, as already remarked, to those cases in which a venereal tint exists ; but it may also be used in the milder forms of the eruption, when they do not yield to the more simple, treatment recommended above. The preparations of mercury which are preferred are those that act slowly, and rarely produce salivation, such as the red iodide or corrosive sublimate; the latter is very fre- quently prescribed in decoction of cinchona bark, a good combination, although not strictly chemical. Copland relies chiefly on the employment of emetics and purgatives at the same time, and their use is certainly at- tended with much benefit in most cases, previously to com- mencing the administration of the more active alteratives. The alkalies, especially the liquor potassse, have also been highly recommended, particularly in the local forms of the efuption, but in many cases in which I tried them the result was not satisfactory. From its original use by Biett, and the favorable notice taken of its action by Bayer, tincture of cantharidea has been rather extensively administered, especially on the Continent, in the treatment of psoriasis ; it certainly succeeds in some cases in which other remedies have failed, but its employment, even in small quantity, must be carefully watched, in consequence of the dangerous effects it is apt to produce on the urinary organs. It may be given in doses of five minims, gradually increased to fif- teea or twenty, three times a day, in at least an ounce of some emulsion or of decoction of linseed or barley. Nu- merous other medicines, especially diaphoretics, diuretics, tonics, and stimulants, have been employed in this disease, but none require mention here, with perhaps the exception of tar or pitch, which, when given internally, and at the same PS0BIA3IS. 189 time applied to the aiFected surface, is regarded by some physicians as quite a specific ; I consider it, however, much inferior in its medicinal efficacy to most of the other thera- peutic agents ■which have been now noticed. Local applications, ointments, lotions, baths, &c., have been at all times favorite methods of treating psoriasis, and many have attempted to cure the disease by their use alone ; with this view, also, it has been proposed to destroy the eruption by the free application of nitrate of silver to the affected parts, but such a proceeding tends only to aggra- vate the morbid state of the cutaneous surface, and is not altogether unattended with danger. The simple /resA-water tepid bath has proved, in my experience, the best topical remedy, I might almost say the only one needed, and it should be employed at least once a week in all forms of psoriasis ; its use tends to restore the natural secretion of the skin, and to prevent the accumulation of scales. When the eruption is local, and attended with symptoms of irrita- tion or inflammation, soothing unguents, as those containing chloroform, preparations of lead, zinc, &c., or poultices pre- pared with the lead wash, often prove highly serviceable ; and in the more chronic cases, when neither inflammation nor inflammatory irritation is present, stimulating applica- tions are occasionally required ; of these, probably the best is the iodine of sulphur ointment spoken of before, or the following, which was highly recommended by the late Dr. Anthony Todd Thompson : — R, Calbmelanos, 3 j. Unguenti Picis liquidse, . , . . 3 iv. Adipis prseparati, S j. Misce. Of other local applications it will be sufficient to enume- rate blisters, creasote, turpentine, tincture of iodine, corro- sive sublimate in lotion, black and yellow wash, citrine oint- ment, &c.; the alkalies, when applied topically, generally, I think, prove injurious. Strict attention to diet and regimen is especially requisite in the treatment of psoriasis ; a milk diet should be, if possible, enforced, except in cachectic or broken-down con- 190 SQUAMA. stitutions, and ■when from this or any other cause it cannot be altogether adopted, farinaceous articles and milk should be made as much as possible a portion of the general food, and in addition, fresh meat, plainly dressed, or poultry, should alone be allowed. From its being so much easier to carry out dietetic rules in hospital patients than with those in private or in dispensary practice, more satisfactory results are usually obtained in treating the former, and consequently, perfectly accurate conclusions as to the eflFects of remedies in the treatment of any disease, whether of the skin or not, can only be drawn from hospital experience. PITYRIASIS. Pityriasis is a scaly cutaneous disease, characterized by an abundant secretion and desquamation of minute, furfura- ceous, white, and shining scales, from slightly elevated, irregular patches of the skin, of a yellowish, reddish-yel- low, or dark-brown color, varying in extent, or from the surface of the body generally. It is attended usually with smart itching of the parts aiFected, sometimes with painful inflammatory tingling, and both are much augmented by any cause that may produce increased capillary circulation of the integuments. It is non-contagious, unaccompanied by con- stitutional symptoms, and although attended in its early stages, and in some cases throughout its entire duration, with more or less local inflammatory action, almost invari- ably runs a very chronic course. Pityriasis is, for the pur- poses of description, naturally divided into varieties, as it may aflfect the cutaneous surface generally, or some special region of the skin. Willan, who has been followed amongst others by Cazenave and Schedel, described but one local form of it — that of the scalp, and divided the eruption, when it afiected the body generally, into three varieties, according to the color which the diseased patches of integument pre- sented, namely, Pityriasis rubra, Pityriasis nigra, and Pity- riasis versicolor. Both Rayer and Erasmus Wilson consider the first of these only as being a scaly disease, and regard the other as simply alterations in the color of the skin, ac- PITTBIASIS. 191 companied by a foHaceous or mealy desquamation, and not by the separation of true scales. As, however, in both forms there is a squamous secretion, differing only in degree from the first, I prefer to regard them as sub-varieties of general pityriasis. Adopting, then, strictly the division of the disease into two forms, — general and local, — they may be termed : — Pityriasis diifusa. " localis. The early stage oi pityriasis diffusa (Atlas, PI. XI. Fig. 2) is marked by a sensation of heat and tingling on various parts of the cutaneous surface, usually on the neck, the chest, the abdomen, the back, and sometimes on the face and hands ; uncircumscribed patches of a yellowish or red- dish-yellow color, scarcely elevated above the surrounding integument, appear on the places which had been the seat of the itching, and on them minute, branny, micaceous scales soon form, at first in small quantity, but afterwards in very great abundance, desquamating freely when the spots are rubbed, or should the eruption be general, on the least movement of the body. The affected patches vary much in shape and size, being often of an irregularly rounded form separated at first by healthy skin, over which, in most cases, however, the scales gradually extend, and, becoming confluent, cover the body almost universally; the furfura- ceous desquamation is then extreme, and is attended with much itching, especially when the surface of the body is heated, and the disease assumes a very obstinate character. The skin from which the desquamation takes place — which in the commencement presents various shades of red and yellow intermixed, whence the specific appellation of pity- riasis versicolor has been applied to this form — ^gradually becomes of a lighter shade of yellow, and in many instances the secretion of scales then ceases, yellowish stains remain- ing on the surface for some time ; but in others the desqua- mation, attended with more or less itching, lasts with extra- ordinary obstinacy for months, or evenyears, after the skin has resumed its natural color. 192 SQUAMA. In some cases the eruption is more partial, being confined almost exclusively to the integuments of the thorax, usually appearing on the chest ; the spots or patches assume from the first a bright color, so marked that in the commencement they can scarcely be distinguished from erythema ; they are also attended with much heat and itching, indicating the inflammatory nature of the disease ; the characteristic scaly secretion and desquamation soon appear, however, and deter- mine its nature. This form, which is also very obstinate, has been termed pityriasis rubra; it is of much less frequent occurrence than pityriasis versicolor, but oftener witnessed than the next sub-variety. Pityriasis nigra is a very rare form of the eruption ; it does not seem to differ in any respect from pityriasis rubra, except in the color of the diseased patches, which are dark- brown or nearly black, and usually appear on one or both of the lower extremities ; according to Cazenave's observa- tions, the black tint is in some cases so superficial that, on removing the epidermis, the derma is seen beneath, of a red, shining aspect ; in others, however, the color affects the sub- epidermic layer of the derma. In both pityriasis versicolor and pityriasis nigra, the chromatogenous functions of the derma must be more or less disordered, to account for the peculiar coloration of the skin which accompanies them. As before remarked, Rayer considers the changed color as their essential characteristic, and he consequently terms the former Ohloasma, and the latter Melasma; this view has been adopted by Wilson also. Several local forms of pityriasis have been described chiefly by Rayer ; thus he notices it specially as it affects the eye-lids, pityriasis palpebrarum; the mouth and lips, pityriasis oris et labiorum; the prepuce and pudendum, pityriasis prceputialis et pudendalis; the feet and hands, pityriasis palmaris et plantaris ; and the scalp, pityriasis capitis. None of these, except the last, differ essentially from the eruption as it affects the body generally, and do not, therefore, require to be specially described ; many der- matologists, indeed, and I think with much correctness, admit the existence of but one local variety of pityriasis,^- that of the scalp. PITYRIASIS. 193 The development of pityriasis capitis (Atlas, PL XI. Fig. 3) is not accompanied by any sign of constitutional or local disturbance, but soon after its eruption it gives rise to much itching, without heat or redness of the surface. The disease consists in the secretion of numerous minute, papyraceous, dry, and shining scales, in most cases scattered over the entire of the head, without any sensible elevation of the surface, and perfectly free from moisture. I cannot describe the precise manner in which the eruption originates, as I have never seen it until the squamous secretion was fully developed, there being no symptoms to direct the patient's attention to it until then. The presence of the scales produces much itching, compelling the individual affected to scratch the head, by which they are very readily detached in large quantity, in the state of a fine powder or dandruff; their removal is rapidly succeeded by a further secretion. If the condition of the scalp in pityriasis capitis be examined, the surface is found to be closely covered with the imbricated scales, with small intervals here and there ; the skin of the unaffected parts presenting a smoother or more polished appearance than natural. On removing one of the scales we find that the spot on which it is seated is raised, and that another finer scale may be removed from it ; and it is not until after the removal of several scales, each finer than the preceding, that we arrive at the red- dened and inflamed surface of the scalp, which is somewhat depressed. The chief annoyance which it causes is itching ; the patient, in scratching himself to allay this troublesome symptom, removes large quantities of dandruff ; and in the child the irritation is often so great that the scalp is torn, becomes inflamed, eczematous vesicles appear, and the origi- nal affection is thus complicated. Although the hair in this eruption is not apparently diseased, it grows weak and thin, and falls out on the slightest cause, so that, when of long duration, baldness may result, which, except in very old persons, is, however, only temporary. Pityriasis diffusa may occur at any age, but it is most common in adults ; it seems to affect both sexes with an equal degree of frequency. Pityriasis capitis is most usually 17 194 SQUAMA. met with in infants at the breast, the frequency of its appearance decreasing with the advance of years towards puberty, at which age it is of very rare occurrence, but it again appeal's at the approach of old age. It thus seems to be most frequent when the head is least covered with •hair, and it is also most generally seen in individuals whose hair is naturally thin. The causes of pityriasis are very obscure ; in most cases it is manifestly a constitutional affection, but in some in- stances it is evidently produced by the action of local irri- tants. Thus its occurrence on the scalp may be often accounted for by the use of hard brushes or a fine tooth- comb, or from not drying the head sufficiently after it has been washed ; appearing, too, most frequently at those ages in which the scalp is least covered with hair, it may be then caused by the sudden changes of temperature to which the Surface is consequently exposed. The eruption, when general, appears to be more or less connected with some deranged state of the nervous system., especially when this state is accompanied by increased cutaneous susceptibility, and is also not unfrequently attendant on a disordered con- dition of the digestive organs. I can confirm the observa- tion of Cazenave that in some cases especially in nervous females, pityriasis capitis succeeds repeated attacks of nerv- ous headache. The use of stimulating cosmetics, whether in the form of lotion or of pomade, is a not unusual exciting cause of the eruption. Diagnosis. — Pityriasis is distinguished from psoriasis by the fineness and thinness of the scales, which are not thicker than the healthy scarf-skin, even when the disease is very chronic ; by their being desquamated in excessive quantity ; by the parts afi"ected being scarcely elevated above the surrounding integument ; by the peculiar color of the sur- face of the skin on which the eruption is situated ; and by the attendant pruritus. It might be confounded with chronic lichen or eczema, in consequence of the furfuraceous desqua- mation which attends the advanced stages of both these diseases ; pityriasis, however, is not preceded by any erup- tion, is never accompanied by any discharge, and in it the skin is never chapped nor fissured. From ichthyosis the diag- PITYRIASIS. 195 nosis is made without difficulty, the peculiar dry, hard, rugose, and, so to say, horny condition of the integuments heing sufficiently characteristic of that aifection. Pityriasis capitis is distinguished from the other eruptions which occur on this region of the body by its true scaly nature, the scales being minute, dry, papyraceous, and imbricated, though scarcely, if at all, elevated above the surface of the scalp, and readily separa,ted in the form of a fine powder or dandruif ; by there being no attendant inflanimation unless it be produced by some irritating cause ; by the absence of discharge;; by the hair being untStered, but falling out more easily than natural; and by its not being contagious; it occurSj too, most generally in advanced periods of life, being rare in childhood, adolescence, and manhood. Prognesis.^-Tri&mg an eruption as pityriasis seems to be, it is one of extreme obstinacy, and' not unfrequently, when it has continued long, causes more or less derange- ment of the general health, chiefly from the mental annoy- ance which its persistence occasions ; this is especially witnessed when it affects the scalps of females at or about the age of puberty, to whom the falling out of the hair and the continued desquamation of dandruff are a source of con- stant distress ; I have seen more than one instance in which extreme nervous and general debility was produced by this cause alone. The longer pityriasis has lasted the more difficult it is to cure, and relapses after apparently perfect recovery are very likely to occur. That the continued existence of the eruption generally over the surface of the body may not bfe altogether unattended with danger is proved by Rayer's narrative of a case in which he saw it prove fatal. Treatment. — In the treatment of pityriasis, as of many other cutaneous diseases, it is • too much the habit to resort to the indiscriminate use of active stimulants both internally and as topical applications ; I do not mean to undervalue the benefit derived from their employment in many chronic eruptions, but I must protest against the custom which for some years back has become so general, of having recourse to them in all cases without regard to the fact that a majo- rity of the affections of the skis are inflammatory in their 196 SQUAMiE. origin, and that even in their advanced stages, when all tendency to inflammatory action has apparently disappeared, local irritation or capillary excitement often causes a fresh outbreak of the eruption, or an aggravation of the symptoms. These remarks, while they are true of many cutaneous diseases, are especially applicable to that now under con- sideration, which, though much less inflammatory than many others, is extremely liable to be reproduced by the action of stimulants, — whether constitutional or local, — a fact that every one, who has had any experience in the treatment of this class of affections, must, I feel certain, have observed. When pityriasis is of the diffuse form, if it occurs in strong, healthy, young persons, a small general bleeding proves often of service in its early stages, but the with- drawal of blood is not admissible otherwise ; tepid gelatine baths should be used for at least half-an-hour daily, or every second day from the first, and purgatives be freely administered : of the latter class of medicines none prove so useful as the alkaline cathartic mineral waters, either thermal or cold, according to the age and constitution of the patient ; for example, those of Carlsbad or Marienbad ; but a combination of mild mercurials with alkalies, as in some- what the following form, should be prescribed at the same time: R. Pilulje Hydrargyri, gr. ix. Sodse Carbonatis siccati, gr. vj. Extracti Taraxaci, gr. xij. Extracti Hyoscyami, gr. iij. Misce. Fiant pilulse sex. " One to be taken every second day half-an-hour before dinner." When the mineral waters cannot be procured, a drachm of the sulphate of soda — previously deprived of its water of crystallization by exposing it to a red heat — and twenty grains of the bicarbonate of soda, dissolved in half-a-pint of tepid water, may be given in the morning after the pill. Should the eruption resist this plan of treatment, and exhibit a tendency to become chronic, alkaline baths — PITYRIASIS. 197 four ounces of the carbonate of soda, or two ounces of purified carbonate of potash, in sufficient fresh water for an ordinary bath, at the temperature of from 80° to 92° .Fahr., according to the season of the year — may be sub- stituted for those of gelatine ; and the surface of the body, previously well dried after leaving the bath, should be anointed with a pomade, composed of four ounces of pre- pared lard, well beaten up with an equal quantity of elder- flower water, then squeezed as dry as possible, and half-an ounce of glycerine added. The mercurials and alkaline saline cathartics must still be continued ; but should the eruption become essentially chronic, the more active consti- tutional alteratives, iodine and arsenic separately or com- bined, as recommended for the treatment of psoriasis, must be prescribed. In cases in which the pruritus is extreme, chloroform, added to the pomade above recommended, in the proportion of from eight to twelve minims to the ounce, will be found the most effectual application for allaying it; lotions and ointments containing prussic acid or the pre- parations of lead, have been employed usefully for the same purpose. In some of the local formg of pityriasis, the vapor douche bath is of especial service, and the constitutional treatment applicable to the general disease is also indicated. When the scalp is the part affected, the hair should be cut close — not shaved off — and so kept during the progress of the treat- ment : this is not requisite in old persons when the hair is thin on the head. In the early stages, weak alkaline oint- ments and lotions, with the addition of glycerine to either, will be found the most beneficial applications; but when the eruption is of long standing, or occurs in persons of debili- tated constitution, the tannic acid or dilute citrine ointment should be substituted for the former, the lotion being still used each time before the ointment is applied. When the eruption appears on the scalp of scrofulous children, cod- liver oil will be beneficially administered ; but for those who are not scrofulous the alterative powders of the iodide of mercury and hydrargyrum cum creta, as I have recom- mended for other diseases of the scalp, are better adapted. In very obstinate cases of any of the local forms of this eruption, more stimulating applications may be tried, such 17*- 198 SQUAMA. as ointments containing calomel or white precipitate, in the proportion of a drachm of either to the ounce of prepared lard or of white wax ointment, with the addition of glyce- rine, or lotions containing the cyanide of mercury or corro- sive sublimate; but their effects must be carefully watched, as they often cause a sudden aggravation of the symptoms. For the same reason the sulphurous mineral waters and sul- phurous baths should be used with caution, yet they unques- tionably prove at times of much benefit in chronic cases of the disease in persons of a languid circulation. Dietetic rules are most important in the treatment of pityriasis, and when the digestive organs are deranged, remedies calculated to restore their healthy tone should be employed. The food ought to be light but nourishing, as the strength must be supported, and therefore milk and farinaceous articles of diet are especially indicated : in the case of children, a strictly milk and vegetable diet should be enforced. Stimulating or heating drinks must be alto- gether prohibited, and the surface of the body kept as much as possible of a uniform temperature, extremes of heat and cold being avoided. In consequence of the liability to re- lapse, whatever treatment may be found to be successful should be continued for at least a month or six weeks after an apparent cure has been eflFected. HYPERTROPHIC. 199 CHAPTER VII. HYPERTROPHIC In the Order Hypertrophic, I purpose to include all diseases of the skin -which are specially characterized by an hypertrophied condition, attended with a morbid change from their normal state, of any or all of the anatomical elements which compose the tegumentary membrane. The aifections to be described in this division are of a chronic nature both in their development and progress, rarely ex- hibiting in any of their stages signs of constitutional dis- turbance or inflammatory action, either local or general ; yet some of them are unquestionably of constitutional ori- " gin, while others are manifestly produced by the direct - action of irritant causes. I have already mentioned the ob- jections which exist to the employment of the term " Tuber- cula," for the purpose of designating a group of diseases of the skin, or to its retention at all in cutaneous nosology ; applied formerly to include several affections, nearly all modern dermatologists who still retain it have restricted its application to some forms of- secondary syphilitic eruptions, to Lupus, and to Elephantiasis ; now of these it is evident that the first will be both more correctly classed and more conveniently described with the other syphilitic diseases which affect the skin ; the second is specially characterized by its malignant nature ; and therefore the third only can with any degree of accuracy be designated as a tubercular affection, and yet although placed by Willan and Bateman in this class, it differs essentially from their own definition of a tubercle. The appellation I propose has the advantage of not being an innovation in cutaneous nosology ; it has a place in all modern natural systems of classification of affections of the skin, as constituting a special group, and I only seek to ex- tend its signification as in any artificial arrangement may be correctly done — there being no necessity here for regard- ing the so-called natural affinities, similarity of elementary 200 HYPEBTBOPHI-ffi!. lesion or of external phenomena sufficing for the grouping of diseases. The order might certainly be made to consti- tute several groups were strict accuracy in arrangement the sole or even chief object in my inquiry ; but regarding all systems of classification as altogether secondary, and useful more for the purpose of description than for affording any aid either in diagnosis or treatment, I think it better to make as few divisions as possible. The following are the diseases I shall describe in this Chapter : Ichthyosis, Mollus- cum, Stearrhoea, Elephantiasis, Verruca, Clavus, Callositates, Condylomata, Nobvus. ICHTHYOSIS. ICHTHTOSis {Fish-skin disease) (Atlas, PI. XI. Fig. 4) is characterized by a morbid alteration and hypertrophied condition of the epidermis, by which it is converted into thick, dry, horny, adherent scales, the orifices of the hair follicles and of the sudiparous and sebiparous glands being thereby obstructed. This affection, classed by Willan and those who have adopted his views, amongst the Squamae, is, as I have stated in the last Chapter, distinctly separated from the eruptions contained in that group, by its not being attended with any desquamation of scales. Most modern writers on diseases of the skin differ as to what are the ana- tomical lesions by which it is constituted, and consequently, as to the precise position which it should occupy in nosolo- gical arrangement. Mr. Erasmus Wilson, in his earlier writings, regarded it as consisting in a hyperformation of the epidermis, but he has changed his opinion, and more re- cently announced his belief that the morbid condition of the integuments is composed of concretions of altered sebaceous substance ; repea,ted observation, aided by microscopic exa- mination, compels me, however, to differ with so eminent an authority, nor have I been able even to comprehend the grounds on which he has come to this conclusion. Dr. A. T. Thomson did not live to publish his opinions in the post- humous work which bears his name ; but that he had not been able to satisfy his mind as to the nature of the disease, is evident from the account of it given by his editor, Dr. Parkes. By Cazenave and the majority of the recent ICHTHYOSIS. 201 French dermatologists, ichthyosis is looked upon as a lesion of epidermic secretion, and is, therefore, made to constitute a distinct group, of which it is the type. Gustav Simon, ■whose views I adopt, regarding ichthyosis as an hypertrophy or increased development of the epidermis,' places it in his classification amongst the Hypertrophise. Willan and Bateman described two forms of the disease, terming the one ichthyosis simplex^ and the other ichthyosis cornea; they differ, however, merely as to the degree in ■which the epidermis is altered, and therefore cannot be cor- rectly separated from each other for the purposes of descrip- tion ; other varieties have also been constituted by different ■writers according to the appearance -vhich the altered in- teguments may present in certain cases ■ thus Wilson divides the disease into Ichthyosis squamosa, and Ichthyosis spinosa ; a form has been termed Ichthyosis hysterix by Fuchs ; and another. Ichthyosis scutellata by Schonlein. Ichthyosis may be congenital, but more usually, commenc- ing a few months after birth, lasts for life, affecting gene- rally, after a short time, the entire of the cutaneous surface, except the palms of the hands, the soles of the feet, the eyelids, the lips, and the prepuce. It consists at first of an hypertrophied condition of the epidermis, which is dry, harsh, and corrugated, the natural linear markings dividing it into distinctly separated, polygonal, and lozenge-shaped compartments. This change, except in congenital cases, in which at birth it is very general over the body, is first wit- nessed in certain regions only, namely, the ankles, the knees, the backs of the hands, the borders of the axillse, and the neck; the morbid alteration becoming gradually more aggravated on these parts, extends superficially also, affecting next the scalp, the fronts of the legs, the backs of the arms, the folds of the groins, the breasts, and the lower part of the abdomen ; by degrees, however, if the disease be unchecked by treatment, the epidermis of the entire body, with the few exceptions noticed above, becomes en- When ichthyosis is congenital, the skin of the infant at ' Die Hautkrankheiten durch anatomische Untersuchungen : Berlin. Second Edition, 1851, p. 49. 202 HYPERTROPHIC. birth ia dry, rougli, uneven, and of a grayish-brown color, but the epidermis is little hypertrophied ; this condition of it may continue for years, or even for life, accompanied by a constant mealy exfoliati( hard and firmly adherent. By exposure to the action of the atmosphere the effused matter gradually ac- quires a darker tint, presenting at length a brownish hue, and numerous cracks or fissures divide it into small packets, which often correspond with the linear markings of the skin. The portion of the integument on which the diseased secre- tion had been seated, if examined after its removal, is found to be more or less injected, not unfrequently inflamed, and the sebaceous follicles hypertrophied, with their orifices en- 214 HYPKRTROPHIiE. larged, and filled with the peculiar matter, the presence of which constitutes the disease. The crusts on the surface are rapidly renewed after their removal, and, if uninterfered with, soon form a layer three or four lines in thickness. The parts affected are the seat of sharp tingling, occasion- ally of stinging pains, accompanied by heat and itching. There is generally, also, a deranged state of the health, evidenced more especially by the condition of the digestive organs, in those persons on whose skin the disease appears, and from its occurrence most usually on the face, causing, in consequence, much disfigurement, great mental distress is occasioned. Stearrhoea flavescens, as is evident from the description now given, is an affection of the sebaceous follicles, and is, therefore, witnessed only on those regions of the skin where these glands exist, being of most frequent occurrence in the parts in which they are most numerous ; it therefore appears usually on the nose, the cheeks, the eyelids, the ears, and the scalp, but it is also seen occasionally on other portions of the integument. It runs essentially a chronic course, spreading in general but slowly from where it is first de- veloped, and, if removed by artificial means, being again quickly reproduced. Stearrhoea nigricans (Atlas, PI. XII. Fig. 3), although difi"ering from the form now described apparently only in the color of the effused diseased secretion, which is nearly jet black, deserves a special notice, in consequence of the singularity of the appearance which it presents, and its ex- treme rarity. In it the matter discharged from the follicles is of a thinner consistence than in stearrhoea flavescens, and is from the first of the same dark color, which, moreover, stains linen, or any other substance with which it may come in contact. From the few cases of the disease which. have been recorded, it would appear also to be attended with more local irritation, at times amounting to severe pain and burning heat. Its occurrence is accompanied by general constitutional disturbance, and in one case recorded by Mr. Teevan,^ which had been first under the care of Dr. Read, ' Medico-Chirurgioal Transactions, vol. zsTiii. p. 611. STKABEHCEA. 215 of Belfast, if the secretion of the diseased matter on the surface was arrested by local treatment, black vomiting, and the discharge of a black substance from the bowels and kidneys, took place immediately. The black secretion in this patient, a young lady, was analyzed by Dr. Gr. 0. Rees, and found to consist of carbon, iron, lime, albuminous mat- ter, fatty matter, and alkaline chlorides and phosphates. The instances of this peculiar aifection which have been pub- lished were seemingly even more obstinate than the second form of the disease which I have described : it was in all of them situated on the same region of the skin. The causes of any of the forms of stearrhoea are very obscure; the first is both congenital and hereditary, but the others have not been proved to be either ; they appear only in persons who have attained the age of puberty, and are very rarely witnessed in advanced life, yet I have seen one example in which stearrhoea flavescens was developed on the nose after the age of seventy ; they occur, too, with much greater frequency in females than in males, and in the former their connection with suppressed menstruation or uterine derangement, has been in some instances noticed ; but in the majority of cases their development is preceded and accompanied rather by derangements of the digestive organs. Diagnosis. — Stearrhoea simplex cannot be confounded with any other affection of the skin ; the other forms, how- ever, in consequence chiefly of their rarity, are often not recognized when they occur, and therefore occasion much doubt as to their nature. Thus, an account of five cases of what, from the description and accompanying illustrations I conceive to be stearrhoea flavescens, has been recently published by Drs. Addison and Gull,* but denominated by them Vitiligoidea plana and Vitiligoidea tuberosa, from a supposed correspondence between the affection and the in- correct definition of vitiligo, which was given by Willan ; and the case of Mr. Teevan, above referred to, was originally communicated to the Medico-Chirurgical Society of London, as.being an example of Pityriasis nigra. ' Guy's Hospital Reports, New Series, vol. vii. p. 265, 216 HYPERTROPHIC. Prognosis. — Stearrhoea flavescens and Stearrhoea nigri- cans are both most obstinate affections, and appear to be equally rebellious to all plans of treatment, but are chiefly important in consequence of the disfigurement which they occasion, being not in the least degree attended with any danger to life. In the former, I have seen the sebaceous follicles take on an active inflammatory action when caustic applications were applied to the diseased surface, and indo- lent pustules form, which, on the continuance of the irrita- tion, terminated in obstinate ulcers, with hardened elevated edges. Treatment. — The first and most important point to be attended to is the restoration of a healthy condition of the system ; this is best effected by the internal administration of alteratives, combined with alkalines, such as the hydrar- gyrum cum creta with dried carbonate of soda, or cod-liver oil with lime water, according to the circumstances of each case ; the latter combination is readily taken in milk, from one to four drachms of the oil b§ing given three times daily, in one ounce each of lime water and new milk, previously mixed. As soon as the state of the digestive organs is im- proved, or the menstrual function restored, preparations of iodine, — especially the syrup of the iodide of iron, or the iodide of potassium in some tonic vegetable decoction or infusion, — will be prescribed with benefit. Of course the employment of purgatives, when requisite, should not be omitted. The local applications that are found most useful are generally stimulating and astringent lotions and oint- ments. The affected surface should be sponged three or four times a day with the spirituous lotion recommended for acne simplex (see page 123), an ointment containing ten grains of the iodide of potassium to the ounce of cold cream being applied at night, or a solution of the iodide of iron, — two grains to the ounce of rose or elder-flower water, and dilute citrine ointment may be used. No matter what reme- dies, however, are employed, they must be continued for a very long time, and local means will be found unavailing until the general health is restored. The application of caustics I have invariably seen productive of injurious con- sequences. When the crust of effused sebaceous matter is ELEPHANTIASIS. 217 hard, dry, and adherent to the surface, it should be removed by the application of poultices or of water dressing, previ- ously to the use of topical remedies. ELEPHANTIASIS. The term Elephantiasis has been applied, both in ancient and modern days, to designate two perfectly distinct diseases of the integuments ; the one, which has been specifically denominated elephantiasis Grrceoorum,. is believed to be the true lepra or leprosy of antiquity, while the other, which, from having been first accurately described by the Arabian physicians, has been termed elephantiasis Arabum, does not bear the least analogy to it. Consistent with the scope of this work, neither of them requires or can obtain a detailed notice, inasmuch as the former is never witnessed in Euro- pean countries in the present time, and the latter is of ex- tremely rare occurrence. Elephantiasis G-rcecorum (Atlas, PI. XII. Fig. 4) is characterized by the development on the integuments of numerous globular tumors, varying in size from that of a pea to that of an apple, soft and unyielding to the touch, at first of a dusky or livid hue, but afterwards becoming brown- ish-yellow or of a bronzed tint. They occur most usually and in greatest number on the face, but may appear also on every region of the body; the skin of the part afi'ected is much hypertrophied, raised into irregular elevations, and of an unhealthy diseased appearance, causing the sufferers from the disease to present a hideous aspect, described by thos,e who have witnessed it to be revolting in the extreme, whence they have in all ages been regarded with abhorrence, as indi- viduals specially afilicted. Both mind and body share at length in the local disease, the senses become obtuse, fatuity creeps on, and all the bodily functions are deranged. Even- tually the tumors ulcerate, exude in ichorous matter, and form unhealthy, open sores ; the bones soften, and become afi'ected with caries ; mortification not unfrequently attacks the smaller joints, and death soon terminates sufferings which are extreme. This disease, which is still endemic in many countries in tropical climates, was, in the middle centuries, of common 19 218 nYPERTEOPHI^. occurrence in temperate latitudes also, hospitals being spe- cially built and endowed for the reception and isolation of those whom it attacked ; Professor Simpson, of Edinburgh, has published a most interesting and learned history of those that existed in England and Wales ;' there were several of them in Ireland also, and the name of ' Leper Hospital' is still retained for the infirmary in the city of Waterford, now happily no longer required for the reception of individuals affected with a disease similar to that for which it was ori- ginally built. In some of the more northern regions of Europe, a form, of elephantiasis Grajcorura is even in the present day of not unfrequent occurrence ; it is known in Sweden and Norway by the name of 'Spedalskhed' (Atlas, PI. XII. Fig. 5), and has been recently described and illus- trated in a magnificent work, undertaken by the desire and at the expense of the Norwegian Government, by two Dan- ish physicians, Danielssen and Boeck. Elephantiasis Grsecorum was, in former times, regarded as highly contagious, but it is more probable, judging from the accounts of it which have come down to us, that it was rather endemic than infectious, and that it was directly caused by misery, deprivation, and filth. Treatment seems to have had but little effect over it, for although isolation and hygienic measures then and in the present day checked its progress, it almost invariably re-apgeared in those whom . it had selected as its victims. Elephantiasis Arabum {Barbadoes leg). (Atlas, PI. XII. Fig. 6.) — The popular name for this singular affection indi- cates its frequency of occurrence in the West India Islands, where it is endemic, but cases of it are also witnessed in Egypt, in America, in various countries of Europe, and, as was remarked originally by Dr. Graves," are not very un- common in Ireland ; it is, however, less frequently seen now than at the time his account of it was published, twenty- six years ago. The disease consists in an extreme degree of hypertrophy, affecting one or both of the lower extremities, the scrotum, the hands or arms, and occasionally even the face, and the ' Edinburgh Medical and Surgical Journal, vols. Ivi. and Wii. • Dublin Hospital Eeports, vol. iy. p. 54. ELEPHANTIASIS. 219 mamma and pudendum in females ; the enlargement aiFects equally the skin and the subcutaneous and deep-seated areo- lar tissue, so as to produce an enormous swelling of the part attacked, one of the legs not unfrequently exceeding in mag- nitude the girth of the body. It commences usually with symptoms of local inflammation chiefly engaging the lym- phatic system, and general constitutional derangement; these attacks are of frequent occurrence, and after each, the parts engaged become more and more swollen, chiefly from effusion into the areolar texture ; but in some cases, especially in temperate climates, the enlargement comes on slowly, and gradually augments without any apparent dis- turbance of function, local or general. When the afiiection is fully developed, the integuments, which are enormously thickened, are generally of a whitish color, rough and swol- len, and present deep furrows, occasionally the seat of ulcera- tion, a thin, ichorous discharge, which concretes into hard, scaly incrustations, then issuing from them. To the great hypertrophy of the integuments is due the name of this dis- ease, but in order to distinguish it from that last described the term Pachydermia, first proposed by Fuchs, has been adopted by many modern dermatologists. When the scrotum is. the part afi'ected, as it very fre- quently is in the colored population of tropical climates, it attains at times an enormous magnitude; Hprner in his Medical Topograph^ of Brazil, narrates two instances in which the tumor situated there measured four feet in cir- cumference. The upper extremities, when attacked by the disease, do not acquire as large a size as the lower, mani- festly in consequence of their containing less areolar tissue. The palms of the hands and soles of the feet are never afi'ected. The causes of elephantiasis Arabum are altogether un- known, if we except its apparent connection with inflamma- tion of the lymphatics ; it is not contagious ; it affects both sexes equally, and occurs at all ages, but is more frequent in -adults than in children. Its much greater prevalence in hot countries, and its being more frequent there in those districts, which are characterized by, the presence of mois- ture, indicate the efl'ect of heat and damp conjoined as an exciting cause. 220 HYPERTBOPHIiK. There is no difiSculty in diagnosing this disease in its advanced stages ; in its commencement it might be mistaken for angeioleucitis; from which it appears to differ simply in its symptoms being less acute, and in its never terminating in the formation of purulent abscesses. Its duration is essentially chronic, but although its presence renders life a burden, it in very rare cases seems to prove fatal. An anatomical examination of the parts in this form of elephantiasis exhibits the derma and epidermis usually much hypertrophied, the former sometimes constituting a layer an inch in thickness, but the enlargement of the affected regions is due chiefly to the change in the areolar membrane, from the deposit sometimes of fat, but more usually of a substance almost as firm as fibrous tissue, and of a lardaceous appearance, which to the naked eye resembles the natural structure compressed. Lebert and Gustav Simon, who exa- mined the new deposit with the microscope, found it to con- sist in fibrous bundles of pure areolar tissue, fully deve- loped, or in the process of formation, with numerous fat cells in the interstices. Treatment. — In the early or inflammatory stages of ele- phantiasis Arabum, antiphlogistic treatment is clearly indi- cated, but this must be constitutional and not local ; if a limb be the part affected it should be kept at rest, and placed in the horizontal position above the level of the body. Active purging seems to have been the plan'of treatment that proved most successful in those cases which have been re- ported, and even in the chronic stages, when other remedies generally fail to prove beneficial, it has been useful. When the disease becomes chronic, iodine frictions and firm ban- daging have also been recommended, but they -usually fail to produce any manifest effect : amputation of the parts, if pos- sible, has been then advised, and ablation of the hypertro- phied scrotum has, in many instances, been resorted to with success ; but as regards the limbs, the removal of one of them has been usually followed by the development of the disease in another, thus, in a case reported by Cazenave, in which, a leg, the seat of elephantiasis, was removed, the arm became affected soon afterward. VERRUCA. 221 VERRUCA. Verruca (Warts), both in consequence of their appear- ance being familiar to all from their extreme frequency, and of their unimportance, scarcely require description ; they consist in a hypertrophied condition of a small patch of the papulae of the skin, by -which a round tumor, with a flat- tened top, varying in size from that of the head of a pin, to that of a large pea, is formed. They are of most frequent occurrence on the hands, next on the face, and are rarely •witnessed on those parts of the body which are ordinarily covered. They are generally placed singly on the integu- ments, but occasionally two or three originate close to each other, and these sometimes coalesce. Warts appear in the early periods of life, being seldom developed for the first time in adults ; they often disappear spontaneously, and even suddenly, at the approach of puberty, but sometimes, becom- ing indolent, are permanent. Some persons are peculiarly liable to warts, and the ten- dency to them seems to be hereditary ; their immediate cause has not been satisfactorily ascertained, but that it is moi'e or less connected with local irritation, and the effects of the atmosphere on the skin, is evident from their being almost altogether confined to those parts which are ordinarily exposed to the action of the air. Small growths, soft to the touch and slightly pediculated, are of frequent occurrence on the face and neck, particularly of females, and are also regarded as a variety of wart ; they appear to me to consist in the hypertrophy of a single papilla, but Mr. Erasmus Wilson believes them to be " the emptied tegumentary sacs of small sebaceous tumors." Warts are easily removed by the application of some strong caustic — strong nitric acid is, in my opinion, the best — to their apex ; the layer thereby cauterized should be pared oflF in twenty-four hours, and the caustic again applied, and this process repeated until the entire of the abnormal structure is destroyed ; when the wart is small, a single ap- plication sometimes suffices, provided a large drop of the acid is placed on the apex, and permitted to soak into its struc- ture. The soft pediculated warts are readily destroyed by 19* 222 HTPERTROPHI^. strangulatioD, by means of a hair or a thread of fine silk being tied tightly around their neck. CLAVUS. Clavi {Corns). — These excrescences, almost peculiar to the feet, being equally common, although causing a much greater degree of local uneasiness and suffering, do not re- quire more notice than warts. They consist in thickening and hardening of the epidermis of some prominent portion of the integument, usually over one or more of the joints of the toes, attended with hypertrophy of some of the papillie beneath ; the latter, which from the pressure acquire much hardness, are popularly believed to be the roots or core of the corn. They are regarded generally as being produced by pressure, but although they are kept up, and their growth increases by this mechanical cause, that they are originally occasioned thereby is, I think, disproved by their constant occurrence in the usual site on the feet of persons, .who have never worn shoes or other covering whereby pressure could be caused on the parts ; of this I have seen numerous examples. Their development also between the toes, on a portion of the integuments especially protected from any undue compression, affords an additional argument against this view ; that the extreme degree of hardness, however, which they usually present, and to which the local suffering they give rise to is chiefly due, is dependent on pressure, is proved by their being compara- tively unindurated when , situated here, whence they are termed soft corns. Corns occasionally become the seat of active inflammation when irritated by any cause, or when they have been cut too freely, and afterwards subjected too soon to compression and friction by the shoes in walking ; purulent matter then often forms beneath them, and, from its being firmly bound down by the hardened superincumbent tissues, extreme suf- fering results, followed sometimes by inflammation of the lymphatics and the formation of buboes in the groins ; they have thus ended even fatally, from the occurrence of erysi- pelas, and in some instances from tetanus coming on. Although, as above remarked, corns are almost invariably CALLOSITATES, 223 confined to the feet, they may also be developed on other parts of the body, but they then partake more of the nature of callosities; I have in a few cases seen them on the knuckles of the fingers of persons, too, in whom the hands were not exposed to any manual labor that could exert pres- sure on the parts affected. The treatment of these morbid growths consists in their ablation, by means of the knife patiently and gradually employed, until all traces of hardened tissue are removed, and afterwards protecting the parts for some time from pressure ; this is the only effectual remedy, and is the one always adopted by the self-styled chiropodists. The appli- cation of caustics never succeeds in destroying them com- pletely, but is of use in enabling the hardened^ surface to be pared off without causing hemorrhage. Corns, whether hard or soft, may generally be kept in abeyance, as -regards troublesome symptoms, by removing the superficial layers with the knife from time to time, according to the rapidity of their growth, or by rasping them with a file, the surface having been previously softened by ftiaceration in warm water. Most of the corn-plasters which are ordinarily sold in the shops cont9,in carbonate of potash, the alkali of which dissolves partially the hoyny substance which constitutes the outer layer of the growth, or, a round hole being cut in tte centre of each piece, they act by removing the pressure from the most prominent point of the corn, which is directed to be pared previously to their application. CALLOSITATES. Callositates. — Callosities consist simply in thickening of the epidermis, which becomes of more or less horny con- sistence, produced by friction or continued pressure ; they are usually witnessed on the palms of the hands or on the soles of the feet, when their cause is in general sufficiently evident. Occasionally they are attended with some degree of inflammation of the derma over which they are developed, which may result in the formation of pus, or in the effusion of a serous fluid beneath the hardened integument. They are witnessed also over-inflamed and enlarged bursse mucosa, especially on the metatarsal joint of the great toe, where 224 HYPEETROPniiE. they are manifestly produced by pressure from the boot or shoe, and their presence tends to aggravate and increase the original disease. Their treatment in the chronic stage should be the same as that for corns, but when inflammation is present, cataplasms and soothing applications should be employed, and in all cases the exciting causes should of course be removed. CONDYLOMATA. Condylomata. — Generally the result of the syphilitic poison, but at times developed in persons in whom no such taint exists, these soft, fleshy tumors appear on those parts of the integument where the skin and mucous membrane meet, at the verge of the anus, or the prepuce, at the vulva, and oceasionally, though very rarely, on the lips and nos- trils. They are of a soft consistence and a reddish-white color, varying in size from that of a pea to that of a marble, and have usually a broad base, with a flattened or rounded apex. They consist of numerous papillae in a highly vascu- lar condition, though apparently not much hypertrophied, and the epidermic covering is unchanged, except in being more vascular than in its healthy state. Various opinions have been propounded as to the nature of condylomata ; Simon and Rokitansky regard them as being a new forma- tion, consisting chiefly of areolar tissue, while Lebert be- lieves that they are epidermic or epithelial growths. They may be destroyed by the application of caustics, or strangu- lated with a ligature, which, by means of a needle, may be passed through the centre of the tumor, and then tied firmly at either side around the base. NiEVUS. N^vus {Mother mark). (Atlas, PI. XIV. Fig. 1).— Of the several varieties of this adventitious production which have been described, but one only can be regarded as a disease of the skin, namely, that which consists in a hyper- trophied condition of the capillaries of a portion of the cutaneous structure ; the others, in which the vascular system of the areolar tissue, and sometimes even of the N^vus, 225 deeper-seated parts, ia engaged, are truly surgical diseases, requiring usually surgical interference for their removal, and are consequently treated of in all works on surgery. All the forms are usually congenital, and are popularly believed to be occasioned by the effect of the mother's imagination upon the foetus in utero, an opinion shared in by the pro- fession even until modern times, and not yet altogether exploded. The variety of nsevus to be described here is character- ized by a permanent discoloration and slight elevation of the part affected, on which the niinute veins of the cutis appear dilated and slightly tortuous, becoming gorged with blood from any exciting cause, and thus the color varies at different times, being dark red, or purplish, when the circu- lation is hurried or impeded. They vary in size, sometimes consisting of a small central point, from which several minute vesicles ramify — a form termed nsevus araneus, — in other cases covering a patch of the surface from the size of a shilling to that of the palm of the hand, when they are usually irregularly circumscribed, but often roundish. They seldom enlarge much after birth, but, occasionally affecting the deeper vascular structures, they become converted into one of the other forms of the disease, which consist of erectile tissues, when they acquire a greater magnitude, and are not unfrequently attended with troublesome or even dangerous symptoms. If the nsevus which engages the cutaneous capillaries be wounded, copious hemorrhage, often difficult to check, ensues, but otherwise they are of no importance, except from the disfigurement which their presence occasions, the more especially as they are usually situated on the face. On this account attempts have been at times made to remove them by caustics and other means, but a greater deformity is thereby often occasioned; unless, therefore, they exhibit a tendency to spread much, or to be converted into one of the other forms of the disease, they should not be interfered with. 226 HEMORRHAGIC. CHAPTER VIII. HBMOREHAGIA The single disease which constitutes the order Hemor- RHAaic might perhaps be more correctly regarded as an affection of the system generally, but as its chief charac- teristic phenomena become apparent to the eye through the medium of the skin, custom has sanctioned its being described as a lesion of that structure. In cutaneous he- morrhages the blood does not escape from the surface of the body, but, being bound down by the epidermis, is effused beneath it in variously sized and differently shaped spots or patches. At times, in certain diseases, especially fevers characterized by low vital power, of which this constitutes one of the most important signs, the hemor- rhagic effusion is in the form of perfectly distinct, minute dots, termed Petechise. In other cases, occurring alone or complicating the former, it appears in irregularly circum- scribed patches, often of large extent, the blood escap- ing chiefly into the subcutaneous areolar tissue ; these are denominated Vibices or Ecehymoses, the latter term being especially applied to them when they succeed a blow or injury. And in a third form, which constitutes Purpura, the only one here to engage attention, the he- morrhage is in perfectly circular spots : intermingled with them, however, are usually several patches — vibices or ecchymoses. PURPURA. Purpura {The Purples) is characterized by the appear- ance on the integuments, generally over the whole body, of small, perfectly circular spots of the color of the blood, attended with more or less derangement of the vital func- tions. The spots vary in size from that of the head of a pin to that of a small pea ; on their first appearance the color is bright red, but augmenting slightly in extent, PUEPUBA. 227 still preserving their circular form, they gradually acquire a deep purple hue, which, as they fade away, passes through the various shades of greenish-yellow discoloration ordinarily presented by blood effused beneath the skin from a bruise. They are generally very numerous on the cutaneous surface, and often aggregated in masses on certain regions, yet per- fectly distinct from each other, except in some parts which may be exposed to pressure, where, becoming confluent, they constitute vibices or ecchymoses. Each individual spot of purpura runs its course from its first appearance until it fades away in from five or six to ten or twelve days, a slight stain remaining for some time to mark its site ; but the disease may last for many weeks, or even months, its duration depending upon the development of successive crops of the eruption, an occurrence which takes place in the mildest cases. The spots or patches are not in the least degree elevated above the cutaneous surface, their presence being caused by an extravasation of blood into the derma or beneath the epidermis from the capillaries of the skin. The appearance of purpura is most usually preceded by slight febrile symptoms and general depression, — hot skin, quick yet compressible pulse, thirst, anorexia, malaise, and headache ; but in some cases no premonitory symptoms are noticed. The circular spots are in the majority of instances present on the several mucous membranes of the body, and sometimes also on the serous, at the same time that they exist on the skin ; the blood being in them effused beneath their epithelial covering, through which structure, so much more delicate and fine than the epidermis, it commonly makes its way, and hemorrhage, often to a great extent, takes place, complicating the disease and rendering it much more dangerous. Several varieties of purpura have been described by der- matologists, all of which may, I think, be conveniently ar- ranged in two divisions : — Purpura simplex. " hemorrhagica. Purpura simplex (Atlas, PI. XIII. Fig. 1). — The spots in this form of the disease, which may be regarded as being 228 nsMORRHAGi-s:. chiefly characterized by its mildness, appear for the most part on the extremities, and are developed very suddenly, often in the course of a single night, and usually without any preceding or accompanying constitutional disturbance. Vibices or ecchymoses are seldom intermingled with them, and they are generally much dispersed over the surface, not aggregated in masses ; successive crops, rarely, however, more than two or three, appear in most cases with an in- terval of from twenty-four to forty-eight hours between each, and some spots then occur also on various regions of the body, the shoulders, the chest, the face, &c., but they are always most numerous on the extremities. The disease runs its course in from seven or eight days to a fortnight or three weeks, at the end of which time the stains it occa- sions have totally disappeared. In some cases the extravasation of blood into the derma or beneath the epidermis, instead of occurring in distinct circular spots, without any elevation of the surface, takes place in raised wheals, resembling exactly in form the erup- tion of urticaria, and accompanied often by more or less of a stinging and tingling sensation, in consequence of which it has been termed purpura urticans (Atlas, PI. XIII, Fig. 2) ; the patches, owing to their extent, are of a deeper purple color than in the ordinary form of purpura simplex, and their duration is for the same reason prolonged to five or six weeks, although they are almost invariably developed in a single crop. Purpura urticans usually occurs on the lower extremities, and most frequently in persons laboring under some organic disease, and in those who have taken much mercury ; it also appears at times in females when the men- strual function is deranged. Purpura simplex occurring in old persons, especially of the female sex, when it appears very much intermingled with large vibices and some ecchymoses, was described by Bate- man as a distinct variety, under the name of purpura senilis; it is usually confined to the arms and legs, is developed in a single crop, unattended with any constitutional or local symptoms, and is an affection of but little disturbance, not impeding the usual avocations of life, and running its course in from a week to ten days or a fortnight. PUKPUBA. 229 When any of the varieties of simple purpura now de- scribed is accompanied by hemorrhage from the mucous membranes, it then constitutes a form of the second divi- sion of ' the disease. Occasionally purpura simplex is attended with some trifling febrile symptoms, rarely ex- ceeding slight heat of skin, thirst, and anorexia, yet by some writers it has been described under the name pur- pura febrilis simplex. The duration of the simple form of the disease, as has been above remarked, seldom exceeds a few weeks, but cases occur in which successive crops are developed for from eighteen months to two years or up- wards. Purpura hemorrhagica (Atlas, PI. XIII. Fig. 3) is es- pecially characterized by the escape of blood from some of the passages of the body which are lined with mucous mem- brane; occasionally it takes place from the serous mem- branes also, when hemorrhage into the shut sacs occurs. The spots on the integuments are usually much more nume- rous, and generally acquire a larger size than in the former variety, and vibice^ and ecchymoses are more frequent; they appear on every region of the body, being most gene- rally witnessed first on the neck and shoulders, the face, and the upper extremities ; they also occur on the conjunc- tiva, on the gums, the tongue, and the inside of the cheeks, and are found after death to be as thickly dispersed over the mucous membrane of the entire digestive tract as on the external integuments. The disease is ushered in usually by much constitutional perturbation, the chief symptoms being those of general oppression ; in from twenty-four to forty-eight hours the spots begin to appear on the cutaneous surface, at first of a bright red color, but assuming a deep purple hue in about twelve hours ; they are very numerous in most cases, and are rapidly developed ; whatever region of the body is exposed to pressure, there large hemorrhagic patches are developed beneath the epidermis, and if the surface is scratched or torn, copious bleeding takes place from them ; in some cases the slightest pressure, even that caused by feeling the pulse, will produce an ecchymosed spot. Hemorrhage from the mucous membranes takes place often from the very commencement of the disease, some- 20 230 HEMORRHAGIC. times it precedes the appearance of the spots of purpura on the integuments, but more frequently does not occur for several days after they are visible. Its most usual and most manageable form is that of epistaxis, but the bleeding is also very common from the lungs, when it constitutes hemoptysis, and from the stomach and bowels, whence it is rejected by vomiting, or escapes by stool. In some cases of purpura hemorrhagica, the blood exudes from the gums in great quantity, apparently by a sort of oozing, which it is almost impossible to check, and not unfrequently proves fatal. The hemorrhage may take place also from the kidueys, the bladder, the urethra, the vagina, &c. These losses of blood are usually very great, and recurring con- stantly produce extreme depression and prostration, with a marked pallor or anemic condition of the entire surface of the body, that throws out into marked relief the purple spots and stains which are thickly scattered over it. The duration of this form of purpura is very variable ; the local hemorrhages may be checked in seven or eight days, but they are very apt to recur, and thus the disease is often prolonged for several months, the cutaneous spots and patches continuing to be developed in constant, successive crops. When it has lasted for any time, the vital powers become extremely depressed, dropsical effusion takes place into the lower extremities, and uncontrollable bloody diar- rhoea not unfrequently sets in. When the constitutional symptoms attendant on purpura hemorrhagica assume a more febrile character than has been above described, — a general redness of the surface, with burning heat, preceding the appearance of the purple spots, — the disease has been specially noticed under the de- nomination of purpura /eJn'Ks hemorrhagica. This variety is chiefly remarkable from its not unfrequently appearing as an epidemic, especially where many persons are crowded together, as in gaols, poor-houses, &c. In many cases of purpura, the cutaneous phenomena are so trifling as to be scarcely noticeable, while the hemorrhages from the mucous surfaces are excessive ; these constitute, in my experience, the most dangerous and uncontrollable cases, and death often occurs in them from extravasation of blood into some of the serous cavities. Dr. Graves described a PUBPtTRA. 231 form of the disease resembling this, in which, however, there was an exanthematous rash on the skin, resembling the red efflorescence so often seen in maculated typhus fever ; in consequence of its presence he proposed to term the affection Exanthema haemorrhagieum} Erasmus Wilson describes as a form of purpura, under the designation of purpura cacJieetiea, the occurrence of petechise and ecchymoses of the skin, " as the consequence of a reduced and debilitated state of the system, from what- ever cause the latter may arise." We frequently see instances of this kind during the latter stage of various diseases, as of dropsies, or whenever the venous circulation is obstructed. The purpura contagiosa of Bateman corre- sponds with the petechial eruption of typhus fever. Purpura may occur at any age, but it is very rarely wit- nessed in infants or very young children ; it affects both sexes also, but females are more prone to the disease than males. The hemorrhagic form is more frequent in the , young, and in those in the prime of life, while the simple variety appears generally in old age. Persons of the sanguineo-lymphatic temperament constitute unquestionably the majority of those affected with purpura, yet it is seen in all constitutions, in the strong and robust as well as in the weak and debilitated. The causes of the disease are consequently very obscure ; it was formerly believed to be always dependent on and to be a sign of general constitu- tional weakness — a view which influenced the exclusive plan of treatment recommended by Willan and his followers ; but it is now admitted to be often connected with plethora and sanguineous congestion. That low, ill-ventilated habitations, with deficient or unwholesome food, are occasionally predis- posing causes of purpura amongst the poor is undoubted, but inasmuch as it usually attacks only a single member of a family, some peculiar state of the constitution, the nature of which we are unaware of, is manifestly requisite to enable these causes to act. An exclusively meat diet, or an in- sufficiency of vegetables and milk, either of which produces the peculiar affection known as scurvy, does not seem to ' Clinical Lectures on the Practice of Medicine, Second Edition, vol. ii. p. 362. 232 HEMOERHAGI-S:. exert any influence in the causation of purpura ; in the year 1847, when scurvy -was so general in this country, in conse- quence of the failure of the potato crop, purpura was not as prevalent as usual. In some cases of the disease which 1 have seen, a hereditary tendency to it could be traced, but this is not of so decided a character or so general as in the singular instances of the hemorrhagic diathesis, occasionally witnessed, in which the slightest injury causes often uncon- trollable bleeding, death sometimes, in consequence of it, resulting from the extraction of a tooth, or even from the wound produced by the scratch of a pin. The proximate cause of purpura is manifestly atony in the capillary system of blood-vessels, combined with an abnormal fluidity of the blood. Diagnosis. — This disease is so well marked by the visible phenomena that it can scarcely be confounded with any other ; but it is necessary to distinguish the occurrence of purpura in the course of fever, or as a complication of any other afi'ection, from its existence as an individual disease. The diagnosis between it and scurvy is unattended with diffi- culty, the characteristic condition of the gums, the extensive brown and purple discoloration of the integuments, and the absence of the round purpuric stains in the latter, are suffi- ciently distinctive marks. The spots of purpura are dis- tinguished from flea-bites with which a careless observer might confound them, by the presence of a central punctum in the latter, and their almost total disappearance on firm pressure being made with the finger, the marks of purpura being thereby unaffected. Prognosis. — Even cases of purpura that, in their com- mencement, do not present symptoms of severity, are not altogether free from danger, for the simple form of the disease not unfrequently becomes converted into the hemor- rhagic, and whenever bleeding from the mucous surfaces takes places in this affection, the prognosis must be cautious. When death occurs, it is either directly or indirectly conse- quent on the loss of blood : in the former case it may be sudden, as when apoplexy results from hemorrhage into the substance of the brain or from its membranes, and in the latter, it is generally less immediate, the patient dying with the symptoms usually caused by repeated losses of blood. PURPURA. 233 The hemorrhage being profuse, or continuing unchecked by- treatment, is always an unfavorable sign, and until it ceases completely, and fresh spots no longer appear on the cutaneous, or mucous surfaces, the patient cannot be re- garded as safe. Bleeding from the gums, particularly when at all excessive, is, in my experience, one of the gravest symptoms of the disease, even although there may be but little eruption on the integuments ; I have rarely seen a case of purpura recover in which it was present to any extent. Occurring in the young, the strong, and the robust, and in the old, the weak, and the feeble, it is difficult to arrive at any correct view of the pathology of purpura. The precise condition of the circulatory apparatus, and of the blood itself, in which that fluid escapes from the vessels most remote from the centre, has not been sufficiently investigated as yet, to enable correct deductions to be drawn as to the real nature of the disease. It is true, that the blood in purpura has been chemically analyzed and microscopically examined, but the results affi3rd no further information than what had been previously gained by the unaided senses — that it is deficient in solid constituents, in consequence of which it is in most cases extremely fluid, and does not coagulate after its exudation through the mucous membranes, or should it be drawn from a vein; yet, as shown by the analysis of Frick, of Garrod, and of Parkes, the fibrine may be in excess, and the property of coagulation not deficient in purpuric blood. The appear- ances in the internal organs found after death are, the presence of purpuric spots and vibices on the mucous, and occasionally on the serous membranes, and in some cases hemorrhage into one or more of the shiit cavities. Treatment. — The treatment of purpura has been much influenced by the different opinions which have prevailed as to its true nature ; many, adopting the views propounded by Willan as to the disease being nearly allied to scurvy, and consequently being- essentially one of debility, agree also with him, " that the treatment is simple, and may be comprised in a very few words : a generous diet, the use of wine, Peruvian bark, and acids ;" others, regarding the doctrine of Parry, " that it is always of inflammatory ori- 20* 234 HEMOKRHAQIuE. gin," as correct, recommend early and free venesection as holding out the only hope of successful treatment. In very few cases of the disease, however, is the decided antiphlogistic treatment here recommended either needed or beneficial, and in still fewer will the employment of tonics and acids be necessary or advantageous. Instances unquestionably occur in which the abstraction of blood to a small extent in the very commencement of the disease will at once stop its progress ; these are cases of purpura simplex, affecting plethoric young persons of a sangui- neous temperament; but the bleeding should always be used with caution, and is rarely if ever admissible when hemorrhage occurs spontaneously to any extent from the mucous membranes. In that form of the disease which has been described as appearing on the lower extremities of old persons, whatever tends to strengthen the constitu- tion generally should not be omitted in the treatment ; but if preparations of bark, or other tonics, be administered too freely, and without the simultaneous employment of remedies calculated to remove the hemorrhagic tendency, the symptoms are often suddenly aggravated, purpuric spots are developed over the body generally, and bleeding takes place from the mucous cavities, the simple form of the disease being converted into the hemorrhagic. Some years since I published an essay' on the treatment of purpura by large doses of oil of turpentine, and illus- trated the efficacy of this remedy, when thus administered, by a report of several cases in which it proved singularly successful. Since then 1 have continued to employ it both in the simple and hemorrhagic forms of the disease, and my additional experience is fully confirmatory of the views then propounded. It must be given in doses sufficiently large to act as a purgative — from one to two ounces, according to the age and strength of the patient, for adults, and a pro- ?ortionate dose for children ; to insure its purgative action, was at first in the habit of giving it in conjbination with castor oil, but this, so far from being necessary, interferes, I think, more or less with the special effect of the turpelitine, ' Dublin Journal of Medical Science, First Series, toI. sxviii. p. 189. PUKruRA, 235 and therefore I now prescribe it combined simply with mucilage, as in the following form : — R. Olei Terebinthinae, fl |j. Mucilaginis, fl Ij- Aquae Menthse Piperitse, . , . fl 3is3. Misce. Fiat haustus. This draught may be taken once or twice daily, according to the degree of its action on the bowels, and should there be much hemorrhage from the intestinal canal, or the stomach reject the draught, the same or a larger quantity of the oil of turpentine, suspended by means of the yolk of egg in decoction of barley, may be administered as an enema. The beneficial action of the turpentine in this disease is two- fold: first, it is a diflfusible stimulant and styptic, which, when conveyed into the circulation through the digestive organs, is exhaled from the system by means chiefly of the mucous surface, as is manifested by the odor of the breath, and of the various secretions and excretions ; it is thus con- sequently brought directly into contact with the capillafy circulation, from which in this disease the hemorrhage takes place ; and, second, the free employment of purgatives in the treatment of purpura having long since been proved to be attended with most successful results, the administration of oil of turpentine to fulfil this indication is especially ser- viceable in consequence of its not being a debilitant. In cases in which from any cause — excessive debility or tendency to diarrhoea, &c. — purgatives are -contra-indicated, the turpentine may be given in smaller doses, and repeated at shorter intervals ; thus from twenty or thirty minims to a drachm may be prescribed every third or fourth hour, or three times a day, according to the amount of hemorrhage which accompanies the disease. Should there be extreme debility present, preparations of iron — those* which are astringent being preferred — or other tonics, may be admi- nistered conjointly with the turpentine ; but on the other hand, when there is much vascular excitement or general plethora, bleeding or other evacuants should be had recourse to at the same time that it is prescribed. 236 HEMORRHAGI-fi. The employment of numerous other astringents and styp- tics has been recommended for the treatment of purpura ; in cases attended with much hemorrhage from the stomach and intestines, or from the lungs, acetate of lead combined ■with opium often proves useful ; the combination may be given in pill — two grains of the former with a fourth of a grain of the latter every fourth or sixth hour. But of all this class of medicines which have been used not one has proved so beneficial as gallic acid ; it is especially of service in cases attended with profuse bleeding from the mucous surface, and may then be given in alternate doses with the oil of turpentine. Thus, a pill containing five grains of gal- lic acid made with sufficient mucilage or conserve of roses, should be administered every fourth hour, the turpentine draughts being given two hours before and after each pill. When excessive hemorrhage takes place from the mucous membrane of the gums and the inside of the mouth, it is, as before remarked, a most dangerous symptom, and the bleeding is extremely difficult to check — the most active styptics applied directly often failing to diminish it in the slightest degree. I have in such cases tried unavailingly nitrate of silver, saturated solutions of alum, of sulphate of iron, of gallic acid, &c., Rusbini's styptic, nitric acid, and even the actual cautery: pieces of lint dipped in oil of tur- pentine seem to have the most effect, but the general treat- ment above recommended can alone be then relied on. Sponging the surface of the body repeatedly during the day with cooling lotions — such as equal parts of vinegar and water, with the addition of a sixth part of rectified spirit, should there be much febrile heat — is an adjunct, too often neglected, of much value in the treatment of purpura. Acidulated drinks — ^lemonade, raspberry vinegar and water, should be always freely allowed, and the diet, though rather small as regards quantity, ought to be nutritious and tonic, but easy of digestion, consisting chiefly of milk, farinaceous food, and strong beef tea : all food and drink being taken rather cold than warm. MACULE. 237 CHAPTEE IX. MACULE. The group of cutaneous affections classed in the order MACULiB is characterized by a morbid condition of the color of the skin dependent on some deranged state of the secre- tion of the pigment cells of the derma. The change may consist in either an augmentation or a diminution of the natural color, or it may be altered in hue or totally absent ; in some, instances it affects the entire surface of the body, but more usually occurs in spots or patches that vary much in shape and extent : in either case there is no sensible ele- vation or depression of the surface. The several affections belonging to the order may be congenital, or they may be developed at any period of life: in the former case they usually consist in the total absence of coloring matter, con- stituting what has been denominated, Jilhinoismus (Atlas, PI. XIII. Fig. 6), — individuals born so being termed Albi- noes, — or there may be only a deficiency of coloring matter in large patches, a condition which is rare, but most fre- quently witnessed in the children of negroes, who are thus piebald at birth. In certain diseases, as in jaundice, in chlorosis, in malignant and in most chronic affections, a peculiar alteration in color of the tegumentary membrane takes place, and which is regarded usually as one of the most important signs of the special diathesis or constitutional de- rangement which characterizes or accompanies the disease ; but it is readily recognizable, and cannot be confounded with the pigmentary alterations of the cutaneous structure here to be considered, which do not influence in any way the general health, and are therefore to be regarded solely in consequence of the disfigurement which they occasion, in many instances a cause of greater annoyance than a real disease. These changes in color may be conveniently de- scribed in two divisions, the one, that attended with defi- 238 MACuii^. ciency of coloring matter — Vitiligo, including alhinoismus ; and the other, marked by augmentation and alteration of the natural pigment — Ephelis. VITILIGO. Vitiligo (Atlas, PI. XIII. Fig. 4) consists in a deficiency or total absence of the natural coloring matter of the skin, in consequence of which it presents a white and sometimes glistening aspect ; the term, which was adopted by Willan from Celsus, is conjectured to have been derived from the resemblance which the integuments thus afiFected bear to the flesh of calves — Vituli; and being sanctioned by usage and sufficiently expressive, I have been unwilling to change it for Leucopatfua, an appellation more strictly correct, per- haps, which is employed by many modern dermatologists. The decoloration may be limited to certain regions of the body, occurring in patches, or may be general when the ab- sence of pigment is witnessed in the hair, the eyes, &c. In the former case, the peculiar condition of the skin is often congenital, but it may be developed at any period of life ; it constitutes the Achroma vitiligo of Alibert ; the latter, the Achroma congenitale of the same author, is always con- genital; it is denominated, as before remarked, Alhinoismus. Albinoismus cannot be regarded as a disease, and therefore, not coming within the scope of this work, need not be de- scribed here ; it moreover is not within the sphere of medical art, being altogether an unalterable, and consequently an incurable afiFection. What then may be termed true vitiligo, when not congeni- tal, is developed in the form of rounded spots or patches, few or many, on some special region of the body, or on several parts at the same time ; the spots are at first usually small, not more than a few lines in diameter, and nearly circular, but they gradually augment in size — often acquiring the magnitude of the palm of the hand, and become irregular in shape. It appears most frequently on the chest, the back, the scalp, and about the genital organs, but it may occur on any part of the integuments. The portions of skin afiected present simply a white aspect, in some cases dull, VITILIGO. 239 in others bright and glistening, without any sensible eleva- tion or depression of the surface ; if hairs grow naturally on the part they also become perfectly white, no matter of what color they may have been previously, and not unfre- quently fall out after a short time, leaving a bald, colorless patch. When the hairy scalp is thus aifected, attention is at first usually attracted to it by a single lock of the hair, generally on the back part of the head or the temples, turn- ing white ; this gradually becomes larger, and at length the hairs, which have lost their color, fall out, and one of the forms of alopecia, or what has been termed a variety of porrigo decalvans, is thus constituted. The causes of this singular affection of the skin are per- fectly unknown : it occurs at all ages, and is most frequent in the prime of life, especially when it appears on the head, but it is developed on the genital region usually in old per- sons ; it is witnessed, too, in individuals of all temperaments, yet I think it is more common on the scalp of those who have dark than of those who have light hair ; it is also, in my experience, more usual on the head in females, and on . other parts of the body in males. Congenital vitiligo is rare in the white races, occurring with a much greater de- gree of frequency in negroes, infants at birth sometimes presenting a completely pied appearance. The diagnosis of vitiligo is unattended with difficulty; the longitudinal white furrows on the abdomen of females who have borne children, or of those who have had ascites, and on the breasts of nurses, might, by a superficial observer, be confounded with it, but their site and the history of the individual case are in all cases sufficient to prevent such a mistake. A form of lupus, to be hereafter described, is stated by Erasmus Wilson to be incorrectly regarded as vitiligo, and he consequently introduces this term amongst the synonymes of Lupus non-exedens, but, as will be shown in the next Chapter, the diseases are essentially different, and cannot be confounded. Prognosis. — An affection of the most trifling importance, as regards the general health, and accompanied by not the slightest local sign or symptom of irritation in its develop- ment or progress, vitiligo is, nevertheless, attended with the most serious mental suffering, especially to young persons, 240 MACULE. ■when it appears on the face or the hairy scalp, owing to the disfigurement ■which it there occasions. It is often most rebellious to treatment, and always extremely slow in exhi- biting any signs of amendment, yet, by continued attention, a cure is usually effected in time. Treatment. — Constitutional remedies should not be neg- lected in the treatment of vitiligo, but those required are simply such as will restore a healthy tone and vigor to the system : consequently, preparations of iron or of bark com- bined with iodine, cod-liver oil in scrofulous habits, cold salt- water bathing, general or local, in the form of the shower- bath or of the douche, and, above all, mental quietude, are the most essential. Topical applications, however, are chiefly to be relied on, and of these various stimulating remedies especially are employed with benefit ; tannic acid ointment, in the following form, has proved of more service than any other in my hands : — • R. Acidi Tannlci, gr- xl. Adipis prseparati, §j. Glycerinse fl Sss- Olei Rosmarini, m. viij. Misce. A portion of this ointment should be rubbed forcibly into the parts affected three times a day, the surface having, pre- viously to each application, been washed well with a satu- rated solution of common salt in water. In very chronic or obstinate cases, blisters may be applied ta the affected parts, in order to excite a new action in them, or tincture of cantharides made into an unguent, in the proportion of a drachm to the ounce of white wax ointment, rubbed in twice daily. Sulphuret of potassium, and other preparations of sulphur, in the form of lotion or ointment, employed locally, sometimes succeed when other remedies fail; but next to tannic acid I have found oil of turpentine prove most useful as a local application : a pomade may be prepared with it as follows : — B. Olei Terebinthinse, fl 5 jj- Sevi, S i> Balsami Tolutani 3 U* KPHELIS. 241 Simul liquefac lento igne, dein adde, Olei Rosmarini, m. xx. Olei Amygdalae Amarse, .... m. v. A small portion of this pomade should be rubbed into the affected spots twice or three times a day with a piece of flannel, the part having been previously well washed with an alkaline wash — a drachm of carbonate of potash to eight ounces of distilled water. EPHELIS. Ephelis. — This term, as its derivation {i,cl, ^mo$, the sun) indicates, was originally employed to designate all discolora- tions of the skin caused by the direct action of the solar rays, but latterly it has acquired a more extended signifi- cation, and may, I think, now be understood to include all those affections in which the natural pigment hue of the skin is augmented or altered. Some of these changes being con- genital and unalterable need not be described here, while others are due and can often be traced to specific causes. Ephelis may be conveniently considered as consisting of three varieties : — Ephelis lenticularis. " hepatica. " violacea. Ephelis lenticularis (Freckles). — This discoloration of the skin-'is too well known to need description ; in many persons the buff-colored or reddish-yellow spots which constitute it are congenital, when they are beyond the reach of medical art ; but in others they are developed on those regions of the body which are uncovered, by exposure to the weather, but especially to the direct action of the sun's rays. They are seldom witnessed except in those who have a very fine and fair skin and are of the sanguine temperament. Ap- pearing usually for these reasons on the skin of young per- sons of the female sex, and on those parts of the surface which are most exposed to observation, freckles cause very 21 242 MACULiE. serious annoyance, and a host of applications have been employed for their removal, which is often a matter of some difficulty; persons who are liable to them should, therefore, protect themselves as much as possible from the causes by which they are produced. The various empirical lotions which are sold for the removal of these spots, are composed chiefly of corrosive sublimate, or of the solution of the sub- acetate of lead in bitter almond emulsion, in the proportion of a fourth of a grain of the former, or six minims of the latter, to each ounce of either of them ; they are often very useful. Erasmus Wilson recommends the application of a liniment, " composed of equal parts of lime-water and olive oil," to which, if the heat of the surface is considerable, he adds " liquor plumbi in the proportion of twenty minims to the ounce." I have found the following lotion of much service : — B. Liquoris Sodaj Chlorinatse, . . . fl 5ij- Aquse Florum Sambuci, . . . . fl 5vij. Aquae Lauro-Cerasi, fl 3vj. Misce. And the application at night of a pomade, consisting of equal parts of cold cream and cucumber cerate, to every ounce of which half a drachm of the solution of chlorinated soda is added. Uphelis hepatica is characterized by the appearance of one or more patches, of tolerable extent, on some portion of the cutaneous suface ; they are of a dull yellow or buflF color, occasionally of a bronze hue; at first distinct from each other ; when more than one occurs, they gradually enlarge, and coalescing often acquire a considerable size, so that in some cases the neck, the face, the upper part of the trunk and the hands, being the parts usually affected, acquire a dark brown color. On the first appearance of the patches tliey are not unfrequently attended with some itching and tingling, and a fine mealy desquamation, increased by scratching or rubbing the surface, takes place ; but there is no sensible elevation or depression of the skin where affected. The coloration varies much in different, cases, through all the shades of gray, yellow, and brown, being often evidently dependent on the natural color of the' individual ; at times, EPHELIS. 243 ■when it is -very extensive, the contrast is so remarkable that the unaffected parts of the skin appear as if they were the seat of vitiligo. Ephelis hepatica is a very chronic affection, in most cases lasting for many months or even for years, but it is occa- sionally of short duration, and even evanescent, disappear- ing suddenly a few hours after its development. In the latter case the discolored patch or patches generally appear in females just before the coming on of the menstrual dis- charge, and fade away when it commences. It is a more frequent affection in all its forms in the female than in the male sex, being a not uncommon attendant on pregnancy and on various uterine derangements ; in both sexes it is rarely witnessed except in the prime of life, occurring, how- ever, with greater frequency in old than in young persons. A large patch of ephelis hepatica is sometimes developed on the neck or the side of the face, by the action of the rays of the sun ; and a discoloration of the skin resembling it in hue — but differing from its occurring in large, irregularly- shaped rings, surrounding comparatively healthy skin — ap- pears on the lower extremities generally of old persons who expose their legs uncovered to the fire ; the latter has been specially described by Rayer, as being very common in Paris amongst the lower orders, especially females, who sit over a charcoal fire, and is termed by him Ephilides ignSales ; in Ireland, also, it is common amongst the poor, chiefly in country districts where turf fires are used, and is vulgarly colled the Trouts. Diagnosis. — This affection is often confounded with a form of pityriasis, and, as already remarked when describing that disease, Rayer and Wilson consider pityriasis versicolor and pityriasis nigra as being nothing more than discolorations of the skin, and therefore to be classed with ephelis : my reasons for differing with them have been there given. The stains of ephelis hepatica may be confounded with those which are symptomatic of a syphilitic taint in the system, from which they are chiefly to be diagnosed by the history of each case, and the concomitant symptoms. In the treatment of this affection it is requisite, in the first place, to direct attention to the 'general health, espe- cially the state of the digestive organs, with a deranged 244 MACULE. condition of which their presence is often associated, and to use remedies calculated to restore them, if requisite, to a healthy tone ; in females, moreover, should there exist any irregularity of the menstrual function, appropriate means to correct it must be employed ; but when the patches are de- veloped in the course of pregnancy, no 'treatment ought to be had recourse to, for they usually disappear after delivery. The local applications that prove most successful are those ■which have been recommended for the last described variety of ephelis ; when, however, the discoloration of the surface is very extensive, hot baths containing the sulphuret of po- tassium, or of the natural sulphureous waters will be found of service: these mineral waters also should be used'' inter- nally, and if drank at their sources so much the better. When a single large patch of ephelis hepatica becomes chronic, repeated blisters applied over it will sometimes re- move the discoloration of the part. Ephelis violacea. — When the internal administration of the nitrate of silver has been continued for a lengthened period without prolonged intermissions, the derma becomes chemically stained with it, and the entire' surface of the body then presents a slate-colored, bluish-gray, or leaden hue, causing a frightful disfiguration, more especially as the face and those parts constantly exposed to the light are most deeply tinged. This discoloration is much less frequently witnessed now than it was some years since, when this medi- cine was so universally employed for the treatment of epi- lepsy and other nervous and convulsive diseases. The most certain way to prevent this result — one of so grave a cha- racter as almost to counterbalance any good effects which might be derived from the administration of nitrate of silver, as a medicine — is not to continue its use for a longer period than six weeks or two months, and should it be thought well to resume its employment again, to permit at least a month to elapse before doing so. This discoloration when once produced is permanent, and becomes even deeper with time, nor have any means hitherto tried for its removal had the slightest effect over it. The iodide of potassium, when applied to the skin, even some days after it may have been stained by the direct appli- cation of the nitrate of silver, effectually removes the disco- EPHELIS. 245 loration ; its use in various ways has therefore been pro- posed for the general staining of the cutaneous surface above described. Professor Melsens, of Brussels, has given it in enormous doses, half a drachm, or even more, three times daily, exposing the patient at the same time to a hot vapor bath : the iodide is thus brought to the surface, when it may be readily detected in the perspiration by the ordi- nary tests. He continues this plan of treatment for months, but in one case that I am cognizant of, which was treated by himself, the discoloration was not in the slightest degree removed. This, I think, was to be anticipated, for it is as iodine, and not as iodide of potassium that the preparation is given off by the skin after its use has been continued for some time ; I would, therefore, suggest that the patient, while under the influence of the remedy, should be placed during for from half an hour to an hour in a warm bath con- taining carbonate of potash in solution, instead of employing the hot vapor bath, as thus the iodide of potassium might be brought into direct contact with the derma. 21* 246 CANCBODES. CHAPTER X. CANCRODES. The order Cancrodes includes two diseases of the skin, ■which possess a certain degree of malignancy, inferior to that of true cancerous affections, yet in many of their fea- tures hearing much resemblance to them, especially in being usually characterized by a slow and insidious ulcerative pro- cess, often attended with severe stinging pain, and by a marked tendency to return in the same or in some other part of the skin, after they have been apparently cured, or even after the diseased portion of the integument has been ex- cised. These diseases are by most dermatologists classed amongst the Tubercula of Willan, but for the reasons already stated in the introductory remarks to the seventh chapter I have omitted this order altogether, and even were it to be retained, the affections now to be described could not, with any pretensions to accuracy, be included in it. The term Cancrodes, which I have adopted from Copland's classifica- tion of diseases of the skin,' expresses well their peculiar features above referred to, and is at the same time suffi- ciently distinctive for all purposes of arrangement. The two diseases to be described in the order are : Lupus, Kelis. LUPUS. Lupus [Eating tetter) appears on the skin usually of the face, but often on the scalp, in various forms : it is generally developed as an inflammatory affection, with more or less hypertrophy of the integuments attacked, soon terminating in ulceration, which may be either superficial or deep-seated, but is always painful, slow, and insidious, and especially characterized by a destructive tendency, whence the name — Lupus, " a wolf" — was originally applied to the disease. ' Dictionary of Practical Medicine, -vol. iii. p. 799. LUPUS, 2-17 The ulcerative process may be confined to the epidermis and the superficial layers of the derma, may extend quite through the cutaneous integument, or may even affect the deeper- seated parts, destroying the areolar tissue, muscles, carti- lages, and periosteum, laying bones bare, and' thereby caus- ing caries in them. The disease is thus naturally divided into three forms, but in general two only are described by writers on cutaneous afi"ections : the one, in which the ulcera- tive process attacks the deeper-seated tissues, being termed lupus exedens, and the other, which affects more superficial structures only, being for contrast denominated lupua non- exedens; in both, however, a similar form of ulceration, although differing in degree, occurs, and this division is, therefore, not strictly accurate. I shall describe the three forms, the leading features of which have been noticed above, under the following specific denominations : — Lupus superficialis. " serpiginosus. " devorans. Lupus superficialis (Atlas, PI. XIV. Fig. 2) commences by the development of a slight thickening or elevation of the skin, not larger than a small pea, usually on the most prominent part of one cheek ; it- presents a somewhat in- flamed appearance, is soft to the touch, rather painful if pressed firmly, and is of a very indolent nature. A thin, hard, brownish scab appears on its surface after some time, often not for months, but is seemingly not preceded by any ulceration ; when the scab is picked off with the nails, as it almost invariably is by the individual himself, the part on which it rested is seen to be superficially ulcerated, with thickened and slightly elevated edges; it is soon repro- duced, a little more consistent than before, but still of small extent, and increases very slowly in size, even when irri- tated by the use of stimulant applications or by other local causes. Generally, after several months, the dry crust or scab falls off that part of the integument on which it first appeared, while it is spreading slowly to the neighboring surface. The portion of the skin on which it had existed is white and seamed, resembling much the condition which re- sults from destruction of the superficial layers of the cuta- 248 CANCKODES. neous structure by a burn. With slow but steady progress the disease advances over the cheek, usually in one direction only, leaving its trace behind in the white seaming of the skin ; at times it becomes the seat of active inflammation, generally from being rubbed or torn with the nails, when a small, painful ulcer results, but the local symptoms are never very severe, the chief annoyance it causes being due to the unsightly deformity which it occasions on the face. The progress of this form of lupus is so slow that the re- sulting superficial cicatrix above described, which is some- what circular, does not attain a larger size than that of a shilling in from two to three years after the first appearance of the disease, — at least such was the case in two persons affected with it whom I have had under my care. Lupus superficialis, as here described, is a rare affection, and has escaped the notice of many writers on diseases of the skin; Dr. Copland gives the best account of it that I have met with, under the appellation of Lupus superficialis non-tuber culosus} Its duration may be almost indefinitely prolonged ; when it terminates in cure the scab falls off, and is not succeeded by another, but the mark on the cutaneous surface is indelible. Lupus serpiginosus (Atlas, PI. XIV. Fig. 3). — This variety of the disease — well named by Alibert, JSsthiomenos (from tcrStw, "I eat,") ambulans vel serpiginosus — is well marked by highly characteristic phenomena, which distin- guish it from either of the other forms of lupus, but it must be noticed that the specific name " superficialis" has been applied to it by some dermatologists who do not appear to have met with the variety of the disease above described under that appellation. It commences by the development of one or more small, livid, or dusky-red tumors, — the tubercles of most authors, — about the size and shape of a pea, on some portion of the integuments, usually on the face or the scalp, but not unfrequently appearing on differ- ent parts of the body at the same time ; they feel thickened and somewhat hard to the touch, with an uncircumscribed, soft, and slightly swollen base, and are rather painful on pressure, a sense of heat and itching also attending them. ' Dictionary of Traotioal Medicine, vol. iii. p. 700. LUPUS. 249 These tumors are very indolent, often remaining stationary for months, and scarcely increasing in size ; interstitial ab- sorption of the deep layers of the derma is, however, slowly going on, and at length purulent matter makes its way to the surface, generally at the most prominent part of the elevations ; ulceration then takes place, and, the pus es- caping, it is found that the surrounding integuments are more or less undermined by the process of destructive absorption which had been taking place. Additional tumors are now developed in the neighborhood of those which first appeared, and of a similar character in all respects to them: the intervening portion of integuments present an oedematous aspect, has a boggy feel, and, being first un- dermined by the ulcerative interstitial absorption, which continues its slow progress, at length gives way, and an unhealthy-looking, open ulcer, extending quite through the skin, and covered in parts by a hard, brown crust or scab, is formed. The ulcers constituted in the manner above describe^ heal slowly, leaving an uneven excavated cicatrix or pit of a white glistening color, but the disease continues to spread from the circumference, creeping on — whence the specific name — almost invariably in the form of irregular rings. The interstitial ulceration in many cases re-attacks the parts which have cicatrized, and they again may thus become for a second or third time, or even oftener, the seat of the disease, which runs the same course as at first, but each time the surface heals, the resulting cicatrix is deeper and more uneven. It not uncommonly occurs that two or more patches of the lupoid ulceration coalesce in conse- quence of the disease spreading from the circumference of each, and an extended portion of the integuments may thereby be affected. Lupus serpiginosus occurs, as already remarked, with greatest frequency on the face and scalp, often extending, too, from one to the other, and being confined to them, but it is also witnessed on both the upper and lower extremities, and occasionally on the trunk of the body ; it is usually attended with more or less local pain in all its stages, which is much aggravated at times by attacks of acute inflamma- tion, when it spreads more rapidly, but the constitution 250 CANCEODES. very rarely participates, those affected with the disease being often apparently in excellent health, even although it may have lasted for years. It is always of a chronic nature, and its duration is extremely prolonged. When it termi- nates in cure, the intra-dermoid ulceration ceases to spread ; healthy granulations, at times rather exuberant, form on the surface, and cicatrization of the affected part takes place ; the annular edges being elevated over the healthy skin, and of course much more over the cicatrized portion, and being of a bright-red color, which they retain for a long time, contrast r-emarkably with the shining white aspect of the latter : much disfigurement consequently results. Lupus devorans {noli me tangere) (Atlas, PI. XIV. Fig. 4). — This variety of the disease commences in various ways, but no matter what appearance it may present at first, it is in its progress characterized by destructive ulceration of the various structures situated beneath the skin — areolar and adipose tissues, muscles, tendons, cartilages, and peri- osteum, being equally destroyed; the bones even do not escape, for where they are laid bare caries attacks them. It may be developed, like the last- described form, by the appearance of one or more rounded, dusky-red elevations of the integument — tubercles — on the alse nasi, on the cheeks, or on the roof of the mouth, which, however, run a somewhat more rapid course than in lupus serpiginosus, are the seat of more active inflammation, and are attended with a more destructive ulcerative process, which extends to the deeper-seated structures. In other cases, one of the alse of the nostrils becomes slightly swollen, painful to the touch, and of a violet-red color ; being attended with itching it is soon scratched with the nails, a brownish crust or hard scab results, which is surrounded by an inflammatory cede- matous base, and, purulent matter forming beneath it, ulcer- ation of the destructive character peculiar to the disease commences. In a third class of cases the tip of the nose swells, and presents a dead-white color, gradually but slowly enlarging a black crust forms at the very apex, the mucous membrane of the nostrils becomes thickened, chiefly from effusion into the areolar tissue beneath it, and at length ulceration takes place. And, lastly, the thickening and subsequent ulceration first appear in the soft palate or pos- LUPUS. 251 terior nares, and, proceeding from within outwards eventually attack the septum naris, and the other cartilages of the nose. In whichever way the disease may commence, the re- sulting ulceration presents much the same characters ; its tendency is to spread from the surface inwards, not unfre- quently undermining in its progress the healthy integuments before it attacks them, and being attended with a foul, unhealthy, purulent, often ichorous discharge. The parts first affected usually cicatrize in the course of the disease, when the cicatrices present a similar appearance to what is witnessed in lupus serpiginosus, but indicate a greater loss of substance beneath. This is especially remarkable on the nose, the most usual seat of this Variety of lupus, this feature assuming then a peculiar pinched appearance, from a deficiency of some of its natural proportions. The amount of destruction caused by the ulcerative process varies much in different cases, in some removing only a small portion of the cartilages of the alse nasi, while in others the entire soft part of the nose, the alse and septum naris, and the soft palate, are destroyed, frightful deformity being thereby occasioned. As in the other forms of lupus, parts that have been cicatrized not unfrequently again become the seat of fresh ulceration, which runs a similar course to what it did at first, being then, however, more diflBcult to check. Lupus devorans most generally runs a very chronic course, its progress being slow, years often elapsing before it causes much destruction of the part it appears on ; but cases occur — happily very rarely — in which it destroys with extreme rapidity those portions of the integuments and of the neigh- boring structure it attacks ; thus, in from a month to six weeks the entire of the nose may be eaten away ; this variety of the disease has been appropriately enough termed lupus vorax. In some cases~ lupus devorans attacks the lower eyelid first, commencing by the development of a single rounded elevation of the skin, of a livid aspect ; its progress is ex- tremely slow, but in the course of years it eats away all the structures around the eyeballs, laying the orbit almost completely bare, but sparing the eye itself, which appears just as if it had been dissected out by the ulceration. This variety of the disease was first accurately described by 252 CANCKODES. Professor Jacob, who, however, regarded it as a malignant ulcer and not as a form of lupus, and it has been ever since known to the profession in this country by the name of "Jacob's ulcer" (Atlas, PI. XIV. Fig. 5)._ Rayer, who also gives an accurate account of it, believed it to be lupus, and with him my experience, derived from the prolonged observation of several cases, compels me to agree. The following graphic account of this lupoid ulceration is given by Professor Jacob:' "The edges are elevated, smooth, and glossy, with a serpentine outline, and are occasionally formed into a range of small tubercles or elevations ; the skin in the vicinity is not thickened or discolored. The part within the edges is in some places a perfectly smooth, vascular, secreting surface, having veins of considerable size ramifying over it, which veins occasionally give way, causing slight hemorrhage; in other places the surface appears covered by florid, healthy-looking granulations, firm in texture, and remaining unchanged in size and form for a great length of time. The surface sometimes heals over in patches, which are hard, smooth, and marked with venous ramifications." "The discharge from the surface is not of the description called by surgeons unhealthy or sanious, but yellow and of proper consistence ; neither is there more fetor than from the healthiest sore, if the parts be kept perfectly clean, and be dressed frequently." It is surprising how little suifering, either local or constitutional, attends this frightful affection, the duration of which may extend from early life to an advanced old age. Lupus in all its forms is a disease of youth and of the prime of life, being rare before the age of 10, and very seldom developed for the first time in old age. As regards its causes, there is abundant evidence to show that it is intimately connected with the scrofulous diathesis especially, when it is hereditary, and many cases seem to prove that a constitutional syphilitic taint also is a frequent predisposing cause of it. In the majority of instances it appears at or soon after puberty, without any manifest exciting cause, but in some it follows an injury or some other local irritant. It ' Dublin Hospital Roporta, vol. iv. p. 232. LUPUS. 253 is on the whole rather a rare disease, and is perhaps some- what more frequent in females than in males. Diagnosis. — The differential diagnosis of the various forms of lupus now described is unattended with difficulty, but some of them may be mistaken for other diseases of the skin. Lupus superficialis is of such rare occurrence that it is often not recognized when met with, yet its phenomena are highly characteristic, and it is of importance, with refer- ence both to prognosis and treatment, that it should be diag- nosed ; the peculiar cicatrization or seaming of the surface over which it has passed is its especial mark: a similar result is not met with in any other cutaneous affection. Lupus serpiginosus may be confounded with impetigo, from which it is distinguished by the destructive ulceration which attends it, by its spreading in rings, and undermining the integuments as it creeps onwards: pseudo-pustules are con- stantly developed on those parts of the skin which it attacks, but they differ from the pustules of impetigo in being flat- tened, more or less uncircumscribed, and presenting from the first a comparatively large quantity of purulent matter, with a very thin covering. This variety of lupus is in gene- ral described by dermatologists as being with difficulty diag- nosed from scrofulous ulceration of the integuments; but this is a matter of little import, for it rarely occurs except in persons of a well-marked scrofulous diathesis, and by many it is termed Esthiomanic scrofula. A somewhat simi- lar form of ulceration constitutes at times one of the phe- nomena of secondary syphilis, but it is not of the same indolent and destructive character, is attended with other symptoms which mark the presence of this poison in the system, and is always more or less amenable to specific treatment. Lupus devorans may, in its early stages, be mistaken for acne indurata, but the distinctive signs have been already pointed out in the description of that disease (see page 122). From the syphilitic affections which occur on the face it is distinguished, by its malignancy, by its slow progress, and by its not directly implicating the bony struc- tures ; but in many cases the diagnosis is made with extreme difficulty, and then the results of treatment — more especi- ally when the history of the individual case cannot be 22 254 CANCRODES. satisfactorily obtained — afford mucli aid in arriving at a conclusion. The form of lupus described above under the name of " Jacob's ulcer" is regarded by many as being nearly allied to, if not a variety of, cutaneous cancer ; by most surgical writers the. latter view is taken, and Copland regards it as a connecting link between the two diseases. But its chief characteristic phenomena, especially its tedious but onward ulcerative progresfe, not implicating the bony tissues, the freedom from pain which marks its course, the non-contami- nation of the- constitution generally, and the absence of the hypertrophied condition so characteristic of cutaneous can- cer, sufiSciently identify it, in my opinion, with the other lupoid affections. Prognosis. — \n every form of lupus, the prognosis, though favorable as regards the general health, must be more or less unfavorable with respect to the local disease, the latter being by many regarded as altogether incurable; yet, al- though most tedious and obstinate, in the majority of cases resisting even judiciously applied and appropriate treatment for years, it not nnfrequently eventually yields, the de- structive process of ulceration is arrested, and the affected parts heal. The superficial variety of lupus is the least important in all respects, but even it is most rebellious, and the diseased surface rarely takes on a healthy action until after several months of treatment, and after apparent cure it is very apt to re-appear in the old cicatrix. Lupus serpi- ginosus, when of small extent, is in some cases very amen- able to treatment; but when it affects an extended portion of the integuments is rarely cured in a shorter period than from a year to a year and a half or two years, and often after the disease is apparently perfectly removed, it breaks out afresh in one or two of the spots which had healed, when it lingers obstinately for months. Lupus devorans is both the most severe and the most obstinate of the several varieties of the disease, its destructive progress, unless when submitted to treatment at a very early period after it commences, is scarcely to be arrested, nor does it seem ever to tend to spontaneous cure : the form denominated " Jacob's ulcer" is, in my experience, perfectly incurable in all its stages. Like most other cutaneous diseases, the longer the LUPUS. 255 duration of lupus, the more difficult is it to treat success- fully. As regards the pathology of lupus, it is manifestly nearly allied to cancer, especially by its malignancy, and the ap- pellation for the group of diseases of the skin in which it is here placed has, I think, been therefore happily chosen by Dr. Copland ; yet they differ remarkably, in the latter being almost invariably marked by a general contamination of the system, which is never witnessed in the former ; this is-well evidenced by the glandular system in the neighbor- hood of the disease not becoming affected in the course of lupus, even when it has existed for years. Treatment. — The administration of constitutional reme- dies, in the treatment of lupus, is regarded by many as being useless, and the employment of local applications is solely relied on, but I agree with those who consider both to be requisite, and it is only from a prolonged perseverance in remedial measures, judiciously selected, that good results can be expected to follow in this obstinate and malignant affection. The intimate connexion that exists between the disease and scrofula being an admitted fact, -the general treatment should consist in the use of those remedies which are calculated to correct that vitiated condition of the system, and the avoidance of all medicines which experience has proved disagree with scrofulous individuals, or aggra- vate any local derangement under which they may labor. The preparations of iodine and of iron, cod-liver oil, and the vegetable- tonics, are therefore especially indicated in the treatment of the different forms of lupus, and general hygienic measures, calculated to invigorate the constitution and to remove its vitiated condition, should never be neg- lected. Iodine in some form, given in combination with tonics or alteratives, according to individual circumstances, is the remedy which, in my experience, is most to be relied on ; for the majority of cases the iodide of potassium is the preparation best adapted, but, as I have already remarked in a previous part of this work, its beneficial effects are more certainly obtained by being administered in rather small doses, continued for a long time, than if it be pre- scribed in large quantity at first — a practice which has 256 CANCBODES. been recently much folio-wed in the treatment especially of secondary syphilitic diseases. In persons in whom the constitution is unimpaired, and the muscular and adipose tissues well developed, it may he prescribed in somewhat the following form : — B. lodidi Potassii, gr. xij. Infusi Cascarillae, fl Sxij. Liquoris Taraxaoi, fl Sij- Misce. " Two table-spoonfuls to be taken three times a day." The quantity of the iodide of potassium should be in- creased by the addition of a grain to the mixture each time it is renewed, until it contains twenty-four grains, when it should be omitted for a few weeks, and again recommenced in the small dose. For weakly persons, or those of a broken- down habit of body, the iodide of iron should be substituted for the iodide of potassium, and it may be given in decoction of fresh elm-bark; when the scrofulous diathesis is very well marked, and the lupoid ulceration extensive, threaten- ing to engage the deeper seated structures, iodine itself will be advantageously combined with the iodide of potas- sium or iodide of iron : if with the former, it may be pre- scribed according to the formula at page 186, the arsenical solution being omitted. Cod-liver oil also proves an excellent remedy in the treatment of lupus, especially when the disease occurs at an early age ; from my own experience of its effects I do not think it is attended with so much advantage when given in the enormous doses recommended by some, as when administered in smaller quantity, and its use persevered in for a very long time : a teaspoonful three times a day, and increased so gradually that at the end of six months two table-spoonfuls, as frequently given, will be the amount arrived at, a dose which need not be exceeded, is the manner of administering the medicine that I have seen proved eminently successful in lupus. By some of the French dermatologists, however, many of whom speak in rather extravagant terms of its eflScacy in this disease, the dose is increased as rapidly as the stomach will admit, until LUPUd. 257 from a pint and a half to two pints are taken in the twenty-four hours. Arsenic alone, or combined with iodine, has been highly recommended by many practitioners for the treatment of lupus ; the late Dr. Anthony Todd Thompson was in the habit of relying chiefly on it in the form of the iodide of arsenic ; I have found this preparation very useful in the form described above as constituting lupus superficialis, but in the other varieties of the disease it has not proved so beneficial in my hands as iodine and the iodide of potassium. The liquor arsenici et hydrargyri hydriodatis proves of espe- cial service in those cases in which there may exist in the system an hereditary or acquired syphilitic taint. So many other medicines have been at different times, and still are, proposed for the treatment of lupus, that it would be almost impossible even to enumerate them ; a few, however, require to be shortly noticed. The animal oil of Dippel — obtained in the distillation of hartshorn shavings in close vessels — has acquired some character on the Conti- nent; it is given in doses of five or six drops, at first, gradually increased to twenty or twenty-five. The chloride of barium and chloride of calcium have both been much used; that they possess some efficacy, due certainly to their anti- scrofulous powers, has been proved by the publication of several cases in which a cure resulted from their administra- tion. Various preparations of mercury have also been tried for the treatment of lupus, and the red iodide is especially recommended by M. Rayer for those cases in which there is much hypertrophy of the integuments ; but in consequence of the injurious effects so often occasioned by the adminis- tration of mercurials to persons of the scrofulous diathesis, I cannot agree with those who advocate their use in this disease. The general hygienic measures to be adopted require merely to be alluded to ; they consist, of course, in attention to every circumstance which can fortify the constitution, and remove the depraved condition on which the presence of the local disease depends : the chief of these are, breathing a dry, pure air, the use of nourishing, unstimulating diet, residence on the .sjga-shore, and when the strength admits, cold salt- water bathing. 22* 258 CANCKODES. The local treatment of lupus has at all times attracted more attention than the constitutional, and, as before re- marked, many consider that the disease can by it alone be cured. It may be considered under two heads : first, the ablation of the affected portion of the integuments by the knife, or its destruction by caustics ; and, second, the em- ployment of astringents or other medicinal agents, calcu- lated to promote cicatrization, or excite a new action in the parts. In the superficial variety of lupus, the chief object being to prevent disfigurement by arresting the progress of the disease, the use of the knife is not admissible, for, were its employment even certain to effect a cure, the resulting eschar would occasion as much, if not greater, deformity ; for the serpiginous form it is not applicable, nor has it been recommended, except by a few surgeons, to remove the hypertrophied edges: and, therefore, it is only in lupus devorans that excision holds out any prospect of being use- ful. An almost insurmountable difficulty, as regards its application, however, is experienced in all cases in which the disease has existed for any time, owing to the manner in which the ulceration spreads, and the consequent impossi- bility of removing the entire of the parts affected ; when it is but of short duration, and the deeper-seated structures are not involved, the operation has occasionally proved use- ful, especially in "Jacob's ulcer;" but the employment of the constitutional treatment above recommended should not be neglected at the same time, as thereby alone can it be expected that the return of the disease will be prevented. The stronger caustics, from being more easy of applica- tion, and more certain than the knife in their effects on the uneven, penetrating ulceration which characterizes this form of lupus, have been more generally employed. Those chiefly used are the nitric and hydrochloric acids, the acid nitrate of mercury, caustic ammonia, chloride of zinc, chloride of gold, caustic potash, solution of the terchloride of antimony, and arsenical pastes or powders. The chloride. of zinc has many advocates, and where the edges of the ulcer are ragged and unhealthy, and the surface discharging a sanious pus, it in many cases proves useful by exciting a new action ; as much of the surface as it is wished to destroy should be touched lightly with the solid salt, and the application re- LUPUS. 259 newed every alternate day until the desired eflfect is pro- duced: the stronger acids may also be applied, in the same manner. I have generally known the employment of caustic applications prove injurious in lupus serpiginosus, yet they are highly praised by several -writers, nitrate of silver being usually preferred to any other ; in many cases that I have seen them used, the parts to which they were immediately applied healed up temporarily, but the serpiginous ulceration from the circumference continued to spread unchecked, un- dermining the surrounding integuments, generally with in- creased rapidity. In lupus superficialis, caustics, if effectu- ally applied, cause a worse disfigurement than the original diseases, which, moreover, they do not check. Under the second division of local applications may be noticed, first, those which, though not actually caustic, are highly stimulant and resolvent, such as the dilute acids, Donovan's solution, the animal oil of Dippel, lotions or oint- ments containing the chloride of zinc, nitrate of silver, caustic potash, &c. The oil of Dippel is employed very extensively on the Continent, and, it is said, with excellent effect, especially when the nose is the part affected, as a modifier of the diseased action ; it is applied by means of a camel's-hair pencil, the surface being lightly touched with it, and the application repeated several times. The solu- tion of the hydriodate of arsenic and mercury also proves most useful as a lotion in many cases of the disease ; it is especially of service in the superficial form of the affection, the crusts having been removed by poulticing previously. M. Cazenave has recently published his experience of the effects of the red iodide of mercury as a local application, from which it would appear to produce most beneficial results, especially in those cases attended with much hypertrophy. " Under the influence," says he, " of the application of the biniodide of mercury frequently repeated, I have seen after the disappearance of the sharp but fleeting local inflamma- tion produced by it, and as a consequence probably of its general action, the hypertrophied points become resolved, the tubercles to disappear, and soft, superficial, smooth cica- trices, on a level with the rest of the skin, form ; in short, I have seen the most frightful cases of lupus cured without leaving any other traces than an apparently thinned skin, 260 CANCEODES. •with white or red spots here and there, according to the length of time which had elapsed from the formation of the cicatrices."' M. Cazenave applies a thin layer of the pow- der, undiluted, to a portion only of the diseased surface at a time ; it causes severe pain and much inflammation, the former lasting for six or eight hours, and the latter for three or four days ; a thick crust is left, which falls off at the end of six, eight, or ten days, when, should there be occasion, the application may be renewed. The topical remedy which I hare found most useful in the treatment of lupus serpiginosus is the acetate of zinc ; the ulcerated surfaces should be touched with the solid salt — care being taken to use a crystal which has not effloresced — twice a day, daily or every second or third day, accord- ing to the degree of activity of the local inflammation, and a lotion containing from three to five grains to the ounce of distilled water should be used, lint wet with it being applied and the parts covered with oiled silk when practicable. In this form, as well as in lupus devorans, the local inflamma- tion, of which from time to time rather smart attacks occur, should be checked by the application of leeches as near the affected parts as possible, but sufficiently distant to prevent the bites from becoming involved in the disease, and emol- lient poultices should be used occasionally with the same intention, and to remove the hard crusts which form. No matter what local treatment be employed in the treat- ment of lupus, attention must be especially paid, when the nose or mouth is the seat of the disease, to prevent the natural outlets from becoming obstructed during the progress of cicatrization. In conclusion, I may again repeat that, as the result of considerable experience in the treatment of this obstinate and serious disease, I regard the employment of topical agents as altogether secondary ; they are unquestionably useful in modifying the diseased process that is going on, and in exciting a new action in the parts, but they must be regarded as only auxiliary to the constitutional treatment, which should engage the chief attention of the practitioner, the fact being always kept prominently in view, that it is • Annales des Maladies do la Peau et do la Syphilis, torn. iii. p. 59. 1861. KELOiS, 261 alone by the prolonged use of remedies, and diligent atten- tion to general hygienic measures, that a favorable result can be expected. KBLOiS. Kelois (C%e?oid French Codes. THI5BAPEUTICS. 319 CERATUM cucDMis {Oucumbcr Pomade).^ R. Axungise ibij. Adipis Vituli {Oalfs Suet), Sbss. Liqaefac simul, dein adde, Succi Cucumis Sativi, . fL fxxjv. "Mix and bruise them well with the hand; set aside for twenty-four hours ; then pour off the juice and replace it hj a similar quantity of fresh juice, and repeat this process ten times, adding fresh juice each time. As soon as the pomade has acquired a well-marted odor of the cucumber, melt it in a water-bath, and add an ounce of finely powdered starch, which will combine with the water and precipitate it. Allow the entire to settle, and then pour off the pomade into small vessels. To render it more white and smooth, the French pharmaciens usually prepare it for use by melting again in a water-bath, and beating it for two hours or even longer with a wooden spatula, but. when submitted to this treatment it does not keep fresh for a longer period thaa a month ; while in the former case it will keep for a year, or even longer, in a cool place." I shall now append some formulae, in addition to those contained in the preceding chapter, for ointments- which are 'ordinarily employed in the treatment of diseases of the skin. And first, I may mention that an excellent calmative oint- ment, especially useful in the cutaneous eruptions of chil- dren which are attended with heat and itching, may be pre- pared by substituting eherry-laurel- water for rose water in the above formula for cold cream. SEDATIVE OINTMENTS. B. Chloroformi, m. vj. Cerati Cucumis, Bj- Misce. R. Carbonatis Plumbi, 3ss. Cerati Galeni, ij- Chloroformi, m- iv. Misce. ' Henry and Guibourt. 320 THERAPEUTICS. R. Glycerinse, fl Sj- _ Unguenti Cerse albse, 3vij. Chloroformi, m. yiij. Cyanidi Potassii, gr- iv. Misce. The great advantage derived from the employment of chloroform, alone or in combination with other sedatives, as an external application in the treatment of cutaneous dis- eases, has been frequently referred to in the foregoing pages. In the preparation of ointments it should always be the last ingredient added, in consequence of its volatility, and for the same reason the ointment should be dispensed in bottles and not in boxes or pots. ASTRINGENT OINTMENTS. B. Carbonatis Calcis prsecipitati, . . . 3ij' Cerati Galeni, 3ij. Extracti Belladonnse, . . . . gr. xx. Glycerinse, fl 3ij- Misce. R. Oxydi Zinci, gr. xx. Cerati Galeni, Sj. Tincturse Myrrhse, fl 3ss. Misce. R. Creasoti, m. x. Adipis prseparati, lij. Pulveris Opii, gr. viij. Misce. R. Carbonatis Plumbi, gr. xij. Acidi Tannici, gr. viij. Cerati Galeni, Ij. Misce. R. R. CAMPHOR OINTMENT. Camphorse rasse et redactse, . . gr. viij. Tincturse Conii (Ed. Ph.), . . . fl 3ij. Unguenti Cerse albse, Ij. Misce. HEMLOCK OINTMENT. Fructus Conii, in pulvere subtilissimo 3ss. Unguenti Sambuci, gij. Glycerinse, fl 3j. Misce. THEBAPEUTICS. 321 A hemlock ointment thus prepared I have found very use- ful in allaying the painful sensations which attend on some forms of cutaneous eruptions. Powders are used externally, chiefly in cutaneous dis- eases attended with copious serous discharge, as in eczema, and in those accompanied hy marked local inflammatory action, as in erysipelas. They are applied to the surface by being shaken from a small bag made of fine muslin, and should be dusted over it pretty thickly. Whenever, powders of different specific gravities are employed in combination for this purpose, they should be intimately mixed, and well shaken up each time before they are applied. Forms for different compound dusting powders have been given in the preceding chapters : the following will be found useful when an active astringent is indicated, as in the superficial ulcer- ations which result in some cases of pemphigus and of ec- thyma : — B. Kramerise Pulveris gss. Garbonatis Calais prsecipitati, . . . gij- Amyli, .......... 3x. Misce. When dusting powders are employed, the affected parts s.hould be cleansed every day or every second day, by the use of gelatine or size baths, or by sponging the surface with equal parts of a weak alkaline wash and new milk warmed. This is not requisite in the treatment of erysipe- las or of erythema, in which diseases their efficacy, as has been before remarked, is partly due to their effect in exclud- ing the air. Soaps. — The use of ordinary soaps, as detergents, is seldom admissible in cutaneous diseases in consequence of their irritant properties on the skin when it is at all inflamed, and they should, therefore, never be employed except in the chronic stages of the non-inflammatory affections and in which there is no breach of the surface, and even then their effects must be carefully watched. In eruptions situ- ated on the scalp, or on other regions of the body which are ordinarily covered with hair, I have almost invariably seen them productive of injury, and, moreover, in such cases the 322 THERAPEUTICS. incrustations and scales which form are more easily and more eflfectually removed by the application of weak alka- line washes as already recommended. The employment of medicated soaps in the treatment of eruptive diseases of the skin was at one time much resorted to, particularly on the Continent, and latterly their use has been revived by Sir Henry Marsh, who speaks in very high terms of their effi- cacy, but I must confess that, in the few cases in which I tried them, they did not produce any good result; nor is it likely that a soap should prove a good form for the appli- cation of remedies in the topical medication of cutaneous affections ; for whatever substance constitutes the active in- gredient of the soap is left but a short time in contact with the skin, being almost immediately washed off ; and it would be very difficult to regulate its strength, as this must vary with the amount of water used each time in the application of the remedy. Sir Henry Marsh has recommended four different forms of soaps, which contain respectively sulphur, white precipitate, red precipitate, and corrosive sublimate, the first two in the proportion of a drachm, the third of half-a-drachm, and the fourth of ten grains to the ounce. The formula for this preparation, which originated with Dr. W. D. Moore, of this city, consists in beating up in a marble mortar, in the above proportions, white Windsor soap and the active ingredient', with half a fluid drachm of rectified spirit, a few drops of oil of roses being added as a perfume. Those remedies which are administered internally in the treatment of eruptions of the skin, with the view of acting generally on the system, require but little notice here, as they have been so fully described and several formulae given for their prescription, in the preceding chapters when treating of the individual diseases. The chief point to be kept in view in the constitutional treatment of cutaneous eruptions, one which has been before referred to, is, that they require, in most cases, a prolonged administration of the remedy which may be employed, and that, consequently, it should be given at first in rather small doses, and its strength increased afterwards very gradually and slowly. This is especially evident with respect to those powerful THERAPEUTICS. 323 alteratives, arsenic and iodine, ■which are such valuable agents in these affections, yet which often produce injurious consequences by exciting local irritation, and a tendency to local inflammatory action from being given at first in too large doses ; the same holds true of cod-liver oil and of many other medicines which are of daily use in the the- rapeutics of diseases of the skin. During the employment of any of these remedies, their administration should be occasionally omitted for a day or two, whether they cause constitutional manifestations of their eifeets or not, and the bowels freely acted on by purgatives, those of a saline na- ture being preferred if the patient's strength admit of their use. The following formulae may, in addition to those already given in the preceding chapters, serve to aid the practitioner in prescribing the medicines which are ordinarily used in the treatment of this class of affections : — DIAPUORBTIC PILLS. R. Antimonii Oxydi, gr. xc. Morphise Muriatis, gr. iss. Confectionis Rosae, quantum sufficit ut fiant pilulse xxiv. " Two to be taken every sixth hour." R. Antimonii Sulphureti prascipitati, Pulveris Ipecacuanhse compositi, . aa 5j; ■ Guaiaci Resinse, By- Theriacse, quantum sufficit ut fiant pilulae sexaginta. " One to be taken every sixth hour." ALKALINE MIXTTJEE. R. Liquoris Potassse, A 3ss. Decocti Dulcamaras, A Sxj. Tincturse Chirettse, fl 3ss. Misce. " Two table-spoonfuls to be taken three times a day." 324 THERAPEUTICS. ALKALINE CATHAKTIC DEATJGHT. R. Solutionis Alkalinse (Brandish), . . . . fl 5j. Potassse Sulphatis cum Sulphure, (Ed. Ph.) Jiss. Aquae destillatee fl Sij. Tincturae Aurantii, fl Sj- Misce. Fiat haustus. " To be taken in the morning before breakfast." DIAPHORETIC MIXTURES. R. Tincturae Guaiaci Ammoniatse, . fl Jij- Mucilaginis Gummi Tragacanthee, fl 5vj. Misturse Amygdalae, . . . . fl 3iij. Misce. " Two table-spoonfuls to be taken every sixth hour." R. Sarsaparillse Eadicis Incisse, . . . 3iss. Aquae destillatae ferventis, . . . • j. per horas duodecim in vase clauso macera, subinde agitans, dein cola, et R. Hujus infusi, . . . . fl gxij. Infusi Sassafras, Decocti mezeri, . . aa fl 3iss. Syrupi Hemidesmi, . . fl Sj. Misce. " A wine-glassful to be taken three or four times a day." ALTERATIVE MIXTURES. R. Hydrargyri Bromidi, . . . gr. ss. Decocti Dulcamarse, . • . fl iviij. Misce. " Two table-spoonfuls to be taken three times a day." This preparation may be administered in obstinate cases of secondary syphilitic eruptions ; in its action it is nearly allied to the red iodide of mercury. THERAPEUTICS. 325 B. Hydrargyrl lodidi Rubri, . . . gr. v. Spiritu3 Vini rectifioati, . , . fl 3j. tere simul dein adde, Aquse destillatas, fl |is3. lodidi Potassii, jij. Syrupi'Aurantii, fl ggg. Misce. "Twenty drops to be taken three times a day in a wine- glassful of infusion of sassafras." This is a preferable form to that of pill for the adminis- tration of the red iodide of mercury in venereal eruptions. R. Ferri Bromidi, 5j. Liquoris Arsenicalis, .... m. Ix. Syrupi Florum Aurantii, . . . fl gss. Aquae Florum Aurantii, . . . fl Jiss. Misce. ^'A tea-spoonful to be taken three times a day in a wine- glassful of decoction of fr«sh elm-bark." A useful form for the administration of arsenic in chronic «utaneous eruptions, attended with enema or much debility. Before concluding, a few words are requisite as to the hygienic measures best adapted for cutaneous diseases. As a general rule, the diet must be, of course, regulated accord- ing to the individual requirements of each case, but as these affections are usually evidences of constitutional debility, tfeough so frequently attended with tendency to local inflam- matory or irritative action, it should be nutritious but not stimulating. Restriction to an almost purely milk and fari- naceous diet is attended with the best results in the majority of instances, and should be almost invariably enforced with infants and children. Change of air to a dry, elevated posi- tion, is often of great service, but extremes of cold and heat should be avoided as much as possible. For the latter reason, the surface of the body should be kept as far as can be of an uniform temperature by attention to the clothing worn, which, however, should never be such as to check the insensible perspiration, or tend to condense it on the integu- 28 326 THERAPEUTICS. ments. That worn next the skin should be soft and unirrit ing, and therefore woollen should be avoided, soft calico, silk being preferred for under-clothing. In referring change of air, I wish to record it as the result of my ex; rience, that a residence at the sea-shore usually proves in rious in cutaneous eruptions, the fine saline particles wh float about in the atmosphere appearing to aggravate 1 disease by exciting local irritation : the. climate of those c tricts which are situated a short distance inland is, howev well adapted for persons afflicted with them. Great objections are often raised to the cure of cutanei eruptions, particularly those which are attended witl copious secretion, more especially if they have been of Ic existence, for fear of their sudden removal or the stoppi of the discharge with which they may be attended cans: some grave internal disease ; but I have never seen any consequences result when they were removed by consti tional treatment, not even in the case of infants or childi who may be teething ; on the contrary, I have invaria witnessed the general health to be much improved in respects thereby ; but the sudden cure by the employm of topical remedies only, such as caustics or powei astringents or stimulants, is certainly not advisable unl the eruption is of small extent and has been of short du tion. INDEX. AcABcs follioulorum, 119. Bcabiei, 107. Achorion Sohonleinii, 268. Aohroma congenitale, 238. vitiligo, 238. Acne, 117. indurata, 121. molluscoides, 209. punctata, 119. rosacea, 120. Bebacea, 118, 213. simplex, 118. syphilitic, 288. varioliformis, ^09. Aorodynia, 34. Albinoes, 237. Albinoismus, 237. Alibert's classification, 18. Alkaline baths, 312. cathartic draught, 324. lotion, 56, 61. sedative, 316. stimulating, 315. mixtures, 323. Alopecia, 305. Alterative mixtures, 824. Appendages of the skin, diseases of, 304. Artificial classifications, 16. Arsenic, ioduretted solution of the iodide of potassium and, 185. Asiatic pills, 186. Astringent lotions, 316. ointments, 320. Author's classification, 24. Baker's itch, 153. Baldness, 805. Bandages, 810. Barbadoes leg, 218. Baths, 311. alkaline, 312. gelatine, 312. iodine, 312. mercurial, 313. sulphur, 313. Bennett's classification, 22. Bleb, 17, 63. Brandy-face, 120. Bulla, 17. BuUse, 63. Burnt holes, 97. Callositates, 223. Camphor ointment, 320. Cancrodes, 28, 246. Cancroide, 261. Canities, 304. Cantharides, tincture of, in psori- asis, 188. Carbonate of ammonia in psoriasis, 187. Carbuncled face, 120. Cataplasms, 813. Caustic of chloride of zinc, 314. of iodine, 814. solution, compound, 314. Caustics, 314. Cazenave's classification, 20. treatment of lupus, 260. Ceratum cucumis, 319. galeni, 318. Cheloid tumor, 261. Chloasma, 192, 264. Chloride of zinc caustic, 814. Classification, 13. artificial systems of, 16. author's, 24. Alibert's, 16, 18. Bennett's, 22. 328 INDEX. Classification, Cazenave's, 20. ■Willan's, 17. Wilson's, 19. natural systems o£^ 19. regional system of, 17, 21. Clavus, I'll. Cold cream, 318. ^ Collodion in skin diseases, S09. use of, in erysipelas, 47. Condylomata, 224. syphilitic, 294. Corns, 222. soft, 222. Corrosive sublimate soap, 322. Couperose, 120. Cream, cold, 318. cucumber, 319. Crusted tetter, 12&. Cryptogamia of favas, 2S7. of sycosis, 275. Cucumber cream, 319. _ Dandruff, 193. Dermatopbytse, 28, 264. Diaphoretic mixtures, 324. pills, 323. Donovan's sol-ution, 300. Draught, alkaline cathartic, 324. Dry scale, 169. tetter, 169. Ear, herpes of, 80. Eating hive, 97. tetter,. 246^ Eochymoses, 226. Ecthyma, 139. acutum, 139. caohecticum, 141. ehronieum, 140. infantile, 141. luridum, 141. syphilitic, 290. Eczema, 63. capitis, 68. chrouioum, 66. faciei, 67. impetiginodes, 66, 133. mercuriale, 70. rnbrum, 65. simplex, 64. Bolare, 70. syphilitic, 286. umbilioale, 69. Elephantiasis, 217. Elephantiasis, Arabnm, 218. Grsecorum, 217. Eph^lides Iign6ales, 243. Ephelis, 241. Ephelis, hepatica, 242. lentioularis, 241. syphilitic, 296. yiolacea, 244. Epidemic of erythema, 34. of pemphigus, 97. Erratic erysipelas, 40. Erysipelas, 37. . ' contagiousness of, 42. erratic, 40. gangrenous, 39. idiopathiCj 38. metastatic, 40. phlegmonous, 39. symmetrical, 40. true, 38. , traumatic, 40. treatment of, 44. Erythema, 31. circiunatum, 32. fugax, 32. intertrigo, 32. Iseve, 3^ niarginaitum, 32. nodosum, 33. papulatum, 33. simplex, 31. syphilitic, 284. tuberculatum, 33. Esthiomanic scrofula, 253. Esthiomanos ambulans, 248. serpiginosus, 248. Evanescent urticaria, 51. Exanthema, 17. hemorrhagica, 231. Exanthemata, 24, 30. syphilitic, 284. Face, acne of, 120. ecaema of, 67. impetigo of, 130. Favus, 265. dissemin^, 268. en cercles, 268. Fire, sacred, 81. St. Anthony's, 37 Fish-skin disease, 20O. Flux, sebaceous, 212. Freckles, 241. INDEX. 329 Galen's cerate, 818. Gelatine baths, 312. Glycerine wash, 316. Graves on gutta percha in skin diseases, 310. Gray hair, 304. Grocer's itch, 70, 153. Gruby on mentagra, 276. Gum, 149. red, 149. ■white, 150. Gutta percha in skin diseases, 310. Gutta rosacea, 120. Hair, diseases of, 304. falling out of, 304. grayness of, 304. Hardi's treatment for the itch, 114. Heat, prickly, 151. Helmerich's itch ointment, 113. Hemlock ointment, 320. Hemorrhagise, 27, 226. Herpes, 78. auricularis, 80. capitis, 84. circinnatus, 83. iris, 86. labialis, 80. 'l phlycteuodes, 78. prseputialis, 80. pudendalis, 81. squamosus, 84. tonsurans, 84. zoster, 81. Higginbottom's treatment of erysi- pelas, 48. Huile de cade, 76. Humid tetter, 63. Hydrargyria, 70. Hypertrophise, 27, 199. syphilitic, 294. Ichthyosis, 169, 200. cornea, 201. hysterix, 201. papillary, 202. Bcutellata, 201. simplex, 201. spinosa, 201. squamosa, 201. Idiopathic erysipelas, 38. Ignis saoer, 81. Impetigo, 126. capitis, 131. 28* Impetigo, erysipelatodes, 129. figurata, 128. granulata, 131. larvailis, 131. lupiformis, 133. pilaris, 132. purifluens, 132. rodens, 132. scabida, 130. sparsa, 180. sycosiformis, 132. syphilitic, 289. Impetiginous eczema, 72, 133. Inflammatio folliculorum, 213. Inflammatory blush, 31. Intertrigo, 32. Iodine baths, 812. caustic, 314. loduretted solution of the iodide of potassium and arsenic, 185. Itch, 106. baker's, 153. grocer's, 70, 153. ^ insect, 107. washerwomen's, 70, 153. Jacob's ulcer, 252. Keloifs, 261. Leper hospitals, 218. Lepra, 169, 175, 217. alphoides, 176. nigricans, 176. syphilitic, 292. vulgaris, 175. Leprosy, 217. Leucopathia, 238. Lichen, 146. agriuB, 150. circumscriptus, 148. gyratus, 148. lividus, 147. pilaris, 148. simplex, 146. solitarius, 148. strophulus, 149. syphilitic, 291. tropicus, 151. Lips, herpes of, 80. Lotion, alkaline, 56, 61, 315. astringent, 316. glycerine, 316. S30 INDEX. Lotion, stimulant, 317. sulphurous, 317. lupoid impetigo, 132. Lupus, 246. devorans, 250. exedcns, 247. non-exedens, 247. serpiginosus, 248. superfioialis, 247. non-tubepoulosBS, 248. Torax, 251. Maclagan, Dr., on the urins in urti- caria, 54. Macula, 18. Maculae, 27, 237. syphilitio, 296. Mark, mother, 224. Marsh's soaps, 322, Melasma, 192. Melitagra, 128. Mentagra, 275. eontagioBum, 276. Mermaids, 20a. Mercurial baths, 313. eczema, 70. Mixtures, alkaline, 823. alterative, 324. diaphoretic, 324. MoUuscum, 208. aoutum, 209. chronicum, 210. coutagiosum, 209. non-contagiosum, 209. pendulum, 210.. Mother-mark, 224. HaeTus, 224. araneus, 225. Nails, diseases of, 307. ingrowing of, 307. Natural systems of classification, 19. Nettle rash, 49. Nirles, 78. Nitrate of silTer-stain, 244. Noli me tangere, 250. Ointment, camphor, 320. cucumber, 319. Helmerich's, 113. hemlock, 320. Borophularia, 101. itayesacre, 115. Ointment, ■white hellebore, 115. Ointments, 317. astringent, 203. sedative, 819. Pachydermia, 219. Papula, 17. PapulsB, 26, 145. syphilitic, 291. Papulous scall, 139. Pemphigus, 94. acutus, 95. chronicns, 97. foliaceus, 99. contagiosuB, 100. gangrsenosus, 97. infantilis, 96. simnltaneus, 94. suceessivus, 94. syphilitic, 287. Petechise, 226. Phlegmonous erysipelas, 39. Phlyzaeia, 26. Phthiriasis, 162. capitis, 162. corporis, 162. pubis, 162. Pills, Asiatic, 186. diaphoretic, 323: Pimples, 17, 26, 145. Pityriasis, 190. capitis, 193. diffusa, 191. labiorum, 192. localis, 192. nigra, 192, 215. oris, 192. - palmaris, 192. palpebrarum, 192. plantaris, 192. prseputialis, 192. pudendalis, 192. rubra, 190. versicolor, 190, 264. Plica Polonioa, 305. Pomade, cucumber, 319. Helmerich's, 113. turpentine, 240. Pompholyx, 94. benignus, 96. diutinus, 97. Bolitarius, 96. Porcupine men, 203. INDEX. 331 Pornigo, 264. decalvana, 305. favosa, 265. lupinosa, 268. Powders, 321. dusting, 321. Prepuce, herpes of, 81. Prickly heat, 151. Prurigo, 159. formicans, 160. jnitis, 159. palmaris, 163. pedicularis, 162. podicis, 163. prseputialis, 163. pubis, 168. pudendi, 163. scroti, 163. senilis, 162, urethritis, 163. ■vulgaris, 160. Psoriasis, 169. aggregata, 172. annulata, 177. capitis, 174. centrifuga, 175. confluens, 172. diffusa, 172. guttata, 170. infantilis, 177. inveterata, 173. labialis, 174. lepraeformis, 175. orbicularis, 177. palmaris, 174. centrifuga, 175. syphilitic, 293. palpebrarum, 174. preputialis, 174. pudendalis, 174. sorotalis, 174. syphilitic, 292. unguium, 175. Tulgaris, 172. Psydracia, 26. Pudendum, herpes of, 81. Purples, 226. Purpura, 226. carehectica, 231. contagiosa, 231. febrilis hemorrhagica, 230. simplex, 227. hemorrhagica, 229. genilis, 228. Purpura, simplex, 227. urticans, 228. Pustulse, 18, 116. syphilitic, 288. Pustules, 18, 26, 116. Rainbow ringworm, 86. Rash, 17. nettle, 49. rose, 57. tooth, 149. wildfire, 150. Red gum, 149. Red precipitate soap, 322. Regional classification, 17, 21. Rheumatism and urticaria, 53. Ringworm, 83. of the scalp, 84. rainbow, 86. Robin's description of porrigo, 267. Rose rash, 57. Roseola, 57. sestiva, 58. annulata, 58. autumnalis, 68. cholerioa, 60. febrilis, 60. idiopathica, 57. infantilis, 58. miliaria, 60. punctata, 59. symptomatica, 59. syphilitic, 285. vaccina, 60. variolosa, 60. Rosy drop, 120. Rupia, 102. escharotioa, 97, 103. prominens, 103. simplex, 103. syphilitic, 287. Sacred fire, 81. Sarcoptes homiuis, 107. Scabies, 106. cachectica, 110. lymphatioa, 110. papuliformis, 110. purulenta, 110. Scald head, 265 Scale, 17, 168. dry, 169. Scall, 63. 332 INDEX. Scall, head, 265. papulous, 139. Scalp, eczema of, 68. herpes of, 84. impetigo of, 131. psoriasis of, 174. ringworm of, 84. Scrophularia ointment, 101. Scrofula, esthiomanic, 253. Sebaceous flux, 212. Secondary eruptions, 281. Sedative alkaline lotions, 316. ointments, 819. Shell-fish, urticaria caused by, 53. Shingles, 81. Silver, nitrate of, stain from, 244, Skin, diseases of appendages of, 304. Soap of corrosive sublimate, 322. red precipitate, 322. sulphur, 322. white precipitate, 322. Soaps, 321. Marsh's, 322. Soft corns, 222. Solution of iodide of potassium and arsenic, 185. Spedalskhed, 218. Squama, 17. Squamse, 26, 168. syphilitic, 292. St. Anthony's fire, 37. Stains, 18. syphilitic, 296. Stavesacre ointment, 115. Stearrhoea, 212. flavescens, 213. nigricans, 214. simplex, 212. Steatozoon folliculorum, 119. Stimulant wash, 317. Stokes, Whitley, on pemphigus, 97. Strophalns, 146. albidus, 150. , candidus, 150. confertus, 149. intertinotus, 149. volatious, 150. Sudamina, 71. Sulphur baths, 313. soap, 322. Sulphurous lotion, 317. Sun bum, 241. rash, 70. Sycosis, 274. mentis, 275. Syphilide squameuse corn^e, 293. Syphilides, 28, 281. Syphilitic acne, 288. condylomata, 294. ecthyma, 290. eczema, 286. ephelis, 296. eruptions, 281. erythema, 284. exanthemata, 284. herpes, 286. hypertrophise, 294. impetigo, 289. lepra, 292. lichen, 291. maculae, 296. papulae, 291. pemphigus, 287. psoriasis, 292. pustulse, 288. roseola, 285. rupia, 287. squamae, 292. tubercles, 294. urticaria, 285. vesiculae, 286. Tetter, 78. crusted, 126. dry, 169. eating, 253. humid, 63. Therapeutics, 309. Tinea, 265. favosa, 265. Tooth-rash, 145. Topical medication, 309. Traumatic erysipelas, 40. Tropical lichen, 151. Trouts, 243. Tubercle, 17, 294. .Tubercles, syphilitic, 294. Tubercula, 199. Tumor, cheloid, 261. Turpentine pomade, 240. Ulcer, Jacob's, 252. Urticaria, 49. conferta, 51. evanida, 51. febrilis, 50. intermittens, 51. INDEX. 333 Urticaria, perstans, 51. Bubcatanea, 51. syphilitic, 285. tuberosa, 52. Velpeau's treatment of erysipelas, 49. Venereal eruptions, 281. Verrucse, 221. Vesicle, 17, 63. VesioulsB, 25, 63. syphilitic, 286. Vibioes, 226. Vitiligo, 238. Vitiligoidea plana, 215. tuberosa, 215. Warts, 221. Washerwomen's itch, 70, 168. Water-blebs, 94. White gum, 150. hellebore ointment, 114. precipitate soap, 322. Wild-fire rash, 150. Willan's classification, 17. Wilson's classification, 19. Wolf, the, 246. >'KV.„