;•!;; ■. ARMY MEDICAL LIBRARY FOUNDED 1836 A*r:zx WASHINGTON, D.C "«E TWO WEEKS FROM IAST DATE °pO 887422 / JUST PUBLISHED, AND FOR SALE BY CHARLES DESILVER, 253 MARKET STREET, PHILADELPHIA, JUlique* of Inrimt (Sngltejj ^wtn}*: CONSISTING OF OLD HEROIC BALLADS, SONGS, AND OTHER PIECES OF THE EARLIER POETS. ** COLLECTED BY THOMAS PERCY, D. D. XO WHICH IS NOW ADDED, A SUPPLEMENT OF MANY CUEIOUS HISTORICAL AND NARRATIVE BALLADS; WITH A COPIOUS GLOSSARY, AND NOTES. ILLUSTRATED WITH STEEL PLATES. 1 Vol. royal 8vO. " Th3 first time I could scrape a few shillings together I bought unto myself a copy of this beloved volume, nor do I believe I ever read a book half so frequently, or with half the enthusiasm."—Sir Walter Scott. " Percy's Reliques are the most agreeable selection perhaps which exists in any language."—Ellis. NOTICES OF THE PRESS. We welcome with peculiar pleasure this exquisite and greatly en- larged edition of one of the principal books in English literature. To be ignorant of that great standard collection is to be ignorant of the sweetest popular lyrics in the language, and to which all the publi- cations of the Percy and other societies are mere addenda. Perhaps no work in English has called forth more echoes in literature, inspired more imitations, or contributed so much to form a taste for the pure, simple ballad. Had it not been for Percy, even Scott himself might never have written his minor ballads, and Motherwell would possibly have never dipped into the strengthening tide of the vigorous simple Yolkelied, as it is termed by Germans, or the popular romance ballad. We had, previously to the receipt of this work, read Percy through in five different editions—a fact which we mention that we may state that we consider the edition before us as superior to them all. The superiority consists in the addition to the original of a number of well Belected ballads, and metrical romances. There is in these metrical romances an original and courtly tone which has never been exactly (2) reproduced by any modern poet, and which is still as well worth attain- ing as any style of poetic inspiration with which we are acquainted. We are not a friend of that hackneyed phrase "a book which no gentleman's library should be without." But we consider it as emi- nently applicable to the work now before us, and we consequently apply it in its fullest force. Not only is its editing performed in a masterly manner, but it is, as regards typographical execution and elegance of style, worthy of the highest praise. As we turn over this volume and meet with the sweet old ballads of " Syr Cauline," " The Childe of Elle," and others endeared by me- mory and the recollection of their early influence, we feel as if we should lay the pen aside, and respect them as we would subjects which awaken those inner feelings which no one cares to throw open to the world. Yes—there is in these simple old ballads a well of poesy which can only be felt and never described. They are the best literary in- heritance which we have derived from the olden time—they are born of that spirit which gave us Chaucer, and they sparkle through Shak- speare like starry points of light through the early glories of the dawn, or like fairy isles in the crimson sea of sunset. In a word, we heartily thank the publisher for giving to America the, as yet, best edition of one of England's best books.—Evening Bulletin. To praise the literary character of " Percy's Reliques," would be an attempt to "gild refined gold ;" but for the magnificent form in which the publisher has presented the work, a noble—nay, Royal octavo of near 600 pages, in the best style of typography, we can but return him the thanks of the public, and especially the scholastic portion thereof. For ourself, personally, he could scarcely have done us a greater favour than by laying us under a contribution of gratitude for this sterling volume. Our library was evidently imperfect, as must be any one, without the " Reliques of Ancient English Poetry," that never-failing fountain for the poet, the historian, and the antiquary. A valuable portion, peculiar to this edition, is the copious "Addenda," furnished with much research and skill by the editor, whose enterprise in producing these sterling additions to our poetic literature, we have been called upon more than once most heartily to commend.—Am. Courier. We would that we could imbue the reader with the satisfaction which we have felt in turning over the leaves of this fine edition of a book, the merits of which have been long confessed by every elegant scholar. This collection contains "the well of English undefiled," the spring of poetic fervor, the first rude but pure gushings of the early Anglo-Saxon muse. The quaintness and simplicity of the ballads (3) collected by Bishop Percy were rendered strangely interesting by the legendary lore which they contained. The metrical narrative has been in every country the first form in which the genius of poesy sought ut- terance and attempted those flights which exercise and improving taste afterwards rendered easy. The Minstrel was everywhere a welcome guest, and in an age when intelligence was mostly conveyed orally, and when methods of communication and interchange of thought were few, his coming was not without reason a topic of interest and excite- ment. He could sing of the achievements of foreign knights in out- landish countries beyond the seas. He could describe and praise the feats of bold crusaders among the Paynim foe, and many a wild tale of home heroes, who excelled in the foray, shone at the tournament, or maintained human rights in the merry green wood, were his to de- scribe in times of rude eloquence and lyric enthusiasm. His harp was everywhere his shield, and at the sound of his voice the fiercest war- riors became gentle, their imaginations being led away by some tender ditty of love, or their resolves heightened in stern but silent admira- tion of the description of some story of deeds of high emprise. It is not lightly, therefore, that we, who claim to be polished, to whom the clouds vouchsafe intelligence, and for whom the ever-clanking press sheds materials for information and thought—it is not lightly that we, greatly blessed with the aids of science and the achievements of mind, should disregard the reliques of the times when society was rude and man was a creature in whom physical attributes kept down intellectual. The history of ages gone by are impressive and useful lessons, and are contained in the ballad poetry of the good old times. Those metrical romances were the very marrow of the life of those for whom they were composed, and whom they held captive by their magic power for many hundred years. Bishop Percy, in collecting these poetic remains, did a service which his contemporaries freely admitted, and which those who follow will not gainsay. The book is, of itself, valuable, and its merit will readily be admitted by all who have a taste for scholarship. —Sunday Dispatch. " Percy's Reliques." This is, unquestionably, the most rare and curious collection of old ballads in the English language, and although they are rude, uncouth, and many of them coarse, yet are eminently worthy of preservation, as characteristic of a by-gone age. Nearly two hundred songs, poems, and metrical productions are here given. A large portion of these ballads were extracted from an ancient manu- script in the possession of Dr. Percy, and were originally published at the urgent solicitation of Dr. Johnson and Mr. Shenstone. " Our ancient English bards and minstrels," says Dr. Percy, "were an (4) order of men once greatly respected by our ancestors, and contributed to soften the roughness of a martial and unlettered people by their songs and by their music. Many of the best plays in the language have their story told in these rude ballads, composed centuries since. We have here the ancient and more modern ballads of Chevy Chase, Robin Hood, John Anderson my Jo, The Beggar's Daughter of Bednal Green, The Braes of Yarrow, The Children in the Wood, Robin Good Fellow, The Fairy Queen, The Birth of St. George, St. George and the Dragon, George Barnwell, Robin Hood's Death and Burial, Lord Soulis, The Life and Death of Tom Thumb, Life and Death of Richard the Third, &c, &c. There are seventeen ballads in this volume that illustrate Shak- speare. The modern ballads introduced relieve somewhat the tedious- ness of the longer narratives. Dr. Percy says: "In a polished age like the present, many of these reliques will require great allowances made for them, yet have they for the most part a pleasing simplicity, and many artless graces, which in the opinion of no mean critics (Addison, Dryden, and the witty Lord Dorset) have been thought to compensate for the want of higher beauties, and, if they do not dazzle the imagination, are frequently found to interest the heart." The volume has two steel plates, " The Grave of Robin Hood," and " Lord Soulis." The work should have a place in every library of any pre- tension.—Boston Transcript. Reliques of Ancient Englith Poetry. We suppose that the mere an- nouncement of a new edition of " Percy's Reliques" will be sufficient to fix the attention of all English scholars and lovers of old English verse. The work is a famous one—it has long been out of print, in the three volume edition. The American publisher has put it into one royal octavo of 557 beautifully printed pages, got up in very tasteful style. In every respect the issue is worthy the quality of its contents. To those who have never seen "Percy's Reliques," or even heard of it (and in the rising generations there must be many such, having taste, intelligence, and education), we would say that it is a collection of the finest old ballads, songs, and versified tales in the language, that it is the standard work on its subjects, and that it embraces much of the interesting and the beautiful, as well as of the queer and curi- ous. All the celebrated old pieces one reads of are to be found in the " Reliques," from Chevy Chase to Sir Lancelot, The Jew's Daughter, Robin Hood, The Not-Brown Mayd, Barbara Allen, and any quantity of more modern productions of note. In fact, the book is one of the most attractive compilations of poetry ever issued, irrespective of the value of its notes, essays, and glossary.—Boston Post. SYNOPSIS OF THE SYMPTOMS, DIAGNOSIS AND TREATMENT OF THE MORE COMMON AND IMPORTANT DISEASES OF THE SKIN. SIXTY COLORED FIGURES BY N. WORCESTER, M. D., PROFESSOR OF PHYSICAL DIAGNOSIS AND GENERAL PATHOLOGY, IN THE MEDICAL SCHOOL OF CLEVELAND, LATE PROFESSOR IN THE MEDICAL COLLEGE OF OHIO. PHILADELPHIA: THOMAS COWPERTHWAIT & CO. BOSTON, CHARLES C. LITTLE AND JAMES BROWN. CINCINNATI, DESILVER & BURR. 1845. Entered according to Act of Congress in the year 1844, by Desilvkr & Burr, In the Clerk's oifice of the District Court for the District of Ohio. I 8 45" f://m- no. ?1 " ^ ■•#"• / PRINT.Br> bt Shepard & Co. COLUMBIA SXKEIT, CINCINNATI. PREFACE. A concise and accurate treatise, in our language, upon Cutaneous Diseases, illustrated by well executed plates, that can be afforded at such a price as to be within the reach of all, has been needed for a long time. The design of this Synopsis, was to supply this want; and if the Author has succeeded is giving a correct description of the more common forms of these affections, illustrated by well executed plates, with the most appropriate treatment, his object has been attained. Utility and not originality has been his design ; he has drawn information from every source within his reach, and it is hoped that he has proved in this compendium that he has studied with some care, the works of Willan, Bateman, Alibert, Cazenave & Schedel, Plumbe, Thompson, Rayer, Wilson, Gibert, Erichsen, Ricord, Baumes, &c. The figures have been selected from Willan & Bateman, Thompson, Rayer, Alibert, Wilson, Erichsen, Cazenave and Ricord ; and it is believed they will be found well executed. No one has taught this much neglected branch of Medicine, that has not felt the want of such a treatise as this is intended to be; and it is the hope of the Author that it may be found to supply this deficiency. At first it was my intention to treat of the Eruptive Fevers in this Synopsis; I was deterred from doing so by the con- sideration, that the eruption in these affections is only a symptom of the general disease, that a minute account of them is contained in most of the treatises on Theory and Practice of Medicine, and that the principles of diagnosis were comparatively well understood. Cincinnati, November, 184 4. CONTENTS. Page INTRODUCTION,.................................................... 9 History of Cutaneous Diseases,.............................. 10 Classification,............................................. 12 Diagnosis,................................................ 16 Prognosis,.... -............................................'9 Causes,....................................................21 Treatment,................................................23 GROUP 1st. MOIST DISEASES. VESICUL^..........................31 Eczema,......................................-..................31 Simplex,..................................................32 Rubrum,...................................................33 Impetiginodes,............................................34 Chronic,..................................................36 Local Eczema,.............................................38 Capitis,...................................»................38 Faciei,.....................................................38 Genitalis,..................................................39 Causes of Eczema,.........................................40 Diagnosis,.................................................41 Prognosis,..................................."..............43 Treatment,................................................43 Herpes,............................-.............................49 Circinnatus,................................................50 Iris,......................................................51 Zoster,...................................................51 Phlyctaenodes,.............................................54 Diagnosis of Herpes,........................................56 Causes,....................................................58 Prognosis,.................................................59 Treatment,.................................................59 Local varieties of Herpes,...................................60 Labialis,...................................................60 Praeputialis,................................................62 Pudendalis,................................................63 Scabies,.........................................................64 Causes,....................................................67 Diagnosis,.................................................68 Treatment,................................................70 BULL^I,........... ..................................................13 Pemthigus,.......................................................'3 Chronic,..................................................76 Causes,....................................................78 Prognosis,.................................................79 Diagnosis,.................................................79 Treatment,................................................80 Rupia...........................................................|3 Escharotica,...............................................°4 Simplex,...................................................85 Causes,....................................................87 Diagnosis,.................................................88 Prognosis,.................................................°° Treatment,................................................89 vi CONTENTS, PUSTULE,..........................................................JJ Ecthyma,.......................................................™ Vulgare,...................................................94 Chronic,...................................................yiJ Causes,............,.......................................97 Diagnosis,........,........................................99 Prognosis,...............................................'00 Treatment,...............................................100 Acne...........................................................102 Sebacea,..................................................lu° Rosacea,..................................................'07 Sycosis,..................................................109 Causes,........T..........................................112 Prognosis,...............................................J14 Diagnosis,................................................114 Treatment,...............................................115 Impetigo,.......................................................120 Figurata,.................................................122 Sparsa,..................................... .............121 Scabida..................................................124 Eiysipelatodes,.......,....................................125 Larvalis,.................................................126 Causes,..........................,,...,...................129 Diagnosis,............................,....................130 Prognosis,................................................131 Treatment,..,.,.............,...............,.............131 Favus,......,.,....................,..........,......,.........135 Causes,..................................................138 Diagnosis,.............,,,....,............................140 Prognosis,................................................139 Treatment,........,..;.............................•.......141 GROUP 2nd. DRY DISEASES. EXANTHEMATA,................... .145 RosEor.A,.......................................................148 ^Estiva,.............,......................,......,.......148 Autumnalis,.....................................,........149 Annulata,.................................................149 Infantilis..................................................150 Diagnosis,.................................................150 Causes,....................................................152 Treatment,...............................................152 Urticaria,.....................................................153 Febrilis,..................................................154 Conferta,...........,.....................................154 Subcutanea,................................................155 Tuberosa,.............................,...................155 Evanida,.................................................156 Perstans,.................................................156 Causes,..................................................157 Prognosis,................................................158 Diagnosis,...............................................158 Treatment,................................................158 Erythema,.....................................................160 ... Fugax,...................................................160 Marginatum,..............................................161 Papulatum,...............................................161 Tuberculatum,............................................162 Lseve,....................................................162 Nodosum,.................................................163 Intertrigo,................................................163 Centrifugum,..............................................164 Acrodynum,..............................................165 Prognosis,.................,..............,................166 CONTENTS. vii Causes,...................................................166 Diagnosis,.................................................167 Treatment,................................................168 PAPULA.............................................................170 Lichen,........................................................171 Strophulus,...............................................172 Simplex,..................................................174 Agrius,...................................................175 Circumscriptus,............................................ 177 Gyratus,.................................................178 Pilaris,...................................................178 Lividus,..................................................179 Urticatus,.................................................179 Tropicus,.................................................180 Causes,...................................................180 Prognosis,.................................................181 Diagnosis,.................................................182 Treatment,................................................184 Prurigo,........................................................186 Mitis,....................................................187 Formicans,................................................188 Senilis,...................................................190 Pudendalis,...............................................192 Scroti,...................................................193 Causes,..................................................194 Diagnosis,................................................195 Prognosis,................................................196 Treatment,.......................................-.........197 SQUAMA,..........................................................198 Pityriasis,......................................................199 Simplex,..................................................200 Capitis,...................................................201 Causes...................................................203 Prognosis,................................................203 Diagnosis,................................................204 Treatment,...............................................204 Lepra,..........................................................206 Vulgaris,.................................................208 Alphoides,................................................209 Nigricans,................................................210 Causes,...................................................210 Diagnosis,................................................211 Prognosis,................................................211 Treatment,................................................212 Psoriasis,......................................................213 Guttata,..................................................213 Diffusa,..................................................213 Infantilis,.................................'...............216 Gyrata,...................................................217 Inveterata,................................................217 Palmaris et Plantaris,......................................218 Unguium,................................................219 Palpebrarum,..............................................220 Labialis,..................................................220 Genitalis.................................................221 Causes,...................................................221 Diagnosis,.............................................• •. 222 Prognosis,................................................222 Treatment,................................................223 Ichthyosis,.................. •..................................224 Prognosis,................................................225 Causes,...................................................225 Treatment,................................................226 Vlll CONTENTS. TUBERCUL.E........................................................227 Elephantiasis of the Greeks,....................................228 Prognosis,................................................230 Causes,...................................................230 Treatment,................................................232 Elephantiasis Arabica,..................................\.......233 Frambesia,....................................................234 Molluscum,....................................................235 Contagiosum,..............................................237 Keloides,......................................................239 Lupus,.........................................................240 Non-Exedens,.............................................241 Exedens,.................................................242 " With Hypertrophy,................................224 Causes,........ ■..........................................224 Diagnosis,.................................................225 Prognosis,................................................246 Treatment,................................................246 MACULE...........................................................249 Purpura.........................................................250 Simplex,..................................................251 Haemonhagica,............................................252 Diagnosis,................................................253 Prognosis,................................................254 Causes,...................................................254 Treatment,..............................................255 Lentigo,........................................................256 Prognosis.................................................257 Treatment,...............................................257 Ephelis,.......................................................258 Causes,...................................................259 Diagnosis...............................................259 Prognosis,.....................................77777 .*259 Njevus,........................................................260 Causes,..................................................260 Treatment,........:.................................... ,2Q0 Syphilides,............................................7.7.7 77. 262 Exanthemata,............................................'.267 Vesiculae,........................................... '' g^g guiiav..............................'..' .'.'.'.'.'.'.'.'.'.'.'.'.■.' .'.■;; 269 £ust",£e>.................................................269 Papula,...................................................270 Squamae,........................................ o~i Tuberculae,.......................................[' ' 'o^i Maculse,........................................ " '273 Causes,..................................... '' 97Q Diagnosis,................................................274 Prognosis,......................................* " ^75 Treatment,................. ' 07R FORMULARY,-.................... ............................fi DESCRIPTION OF PLATES,..........'.'.'.'.'.'.'.'.'.'.'.'.'.7.7.'.'.'.'.'.'. 7.7.7..' '.291 INTRODUCTION. When we consider the variety arid importance of cutaneous diseases, it is difficult to explain the neglect with which they are treated by practical physicians generally. They can scarcely be said to form a part of the professional education of students, in the annual courses of medical lectures in this country; it is believed that in many of our medical institutions not a single lecture is given upon the nature, classification, and treatment of this interesting class of diseases. It would have been expected that affections exposed to the sight, of very frequent occurrence, very distressing in their symptoms, capable of a very simple, beautiful and perfect classification, having in this regard, the advantage over any other class of diseases to which our species is exposed, would have engaged the earnest attention of every practical physician. When we add to this, that the diagnosis of these affections is not usually difficult, and the treatment when properly directed is very satisfactory, and that most of these B 10 INTRODUCTION. diseases, when neglected or improperly treated, have a tendency to become unmanageable and rebellious under any subsequent mode of treatment; that morbid changes take place in such cases in the skin and sub-cutaneous tissues which last for life, and by the unappeasable irritation the remainder of life is often rendered a burden, the indifference of our profession is extraordinary. The result has been that these numerous diseases have become an opprobrium to our profession, and a fruitful source of emolument to designing empiricism. History of Cutaneous Diseases.—The design of the present work will not allow us to trace far the accounts of these affections contained in the writings of the older physicians. It is difficult at the present day to determine the nature of most of the cutaneous diseases mentioned in the works of the Greek and Latin authors. The concise and vague descriptions and the terms used which probably often designated a state of the skin arising from long continuance of several different cutaneous diseases, and not the disease itself, the alterations that have taken place in the pathology and appearance of eruptions modified by changes of habits, climate, food &c. during ages, the introduction of many new affections and the probable elimination of others, render all attempts to designate with any degree of confidence the real nature of the disease intended by many of the terms handed down to us, very unsatisfactory. INTRODUCTION. 11 Still we are indebted to the ancients for many of the names of diseases that are in common use at the present time, as Impetigo, Lepra, Psora, Scabies, &c. They are now used however to designate diseases very different from their original application. It is generally conceded that cutaneous affections are more numerous now than with the ancients; their more abstemious diet, and their frequent bathings will in part account for the fact. We in vain attempt to apply the description of some ancient diseases, as that of the Jewish leprosy, to any known at the present time; we know that some eruptions, as Sycosis, have undergone considerable changes, even within the few last centuries; that the whole class of eruptive fevers have made their appearance within a comparatively recent date; that there is some doubt whether syphilis, with all its consequences and its modifications of other affections, can be traced back six centuries, and that there is good reason for believing that its character has under- gone great changes even within that time. Now in view of all these considerations, it is not to be wTondered at that many of the descriptions to be found in the works of antiquity, cannot now be recognised. Scarcely half a century has elapsed since the publication of Willan's work; and yet, notwithstanding his wonderful accuracy and precision, some difficulty has existed in ascertaining the precise disease intended in the descrip- tions of some of liis varieties; and had it not been for his beautiful and accurate delineations, and for 12 INTRODUCTION. the subsequent labors of his friend and pupil, Bateman, much more would have existed. Classification.—A great variety of plans for classi- fying cutaneous diseases has been proposed by different authors. Some have attempted to classify them by their locality, as those of the head, face, limbs, &c; others from their causes; this was one of the earliest attempts at classification, and with some modifications has been revived by Plumbe in his excellent work, and still more recently by Baumes in his elaborate ' Dermatologie,' though with great alterations. The mode of classification adopted very generally by Physicians, not only in England but upon the continent of Europe, is that of Willan, with such modifications as have necessarily arisen from subsequent investigations, and such slight changes as the fancy or judgment of authors has suggested. Willan adopted for the basis of his arrangement the elementary characteristic form of the eruption as far as it can be discovered at its full development; he classified all cutaneous diseases according to this plan, in eight different orders, viz: Exanthemata or Rashes, as Rubeola, Urticaria, &c. Vesiculje, as Herpes, Eczema, Scabies, &c. Bullae, as Pemphigus and Rupia. Pustule, as Impetigo, Acne, Mentagra, &c. Palulje, as Lichen, Prurigo. Squamae, as Lepra, Psoriasis, Pityriasis, &c Tubercul^e, as Elephantiasis, Molluscum, &c. Maculje, as Purpura, Ephelis, Naevi, &c. INTRODUCTION. 13 Of the other numerous attempts to classify these diseases, two only will be here mentioned, that of Alibert the distinguished French Professor, and that of Mr. Erasmus Wilson, of London. Alibert's first plan of classification was somewhat similar to that of Turner already mentioned, by the regions of the body; in his subsequent work all the diseases of the skin are collected in one large group, under the name of Dermatoses, which is divided into twelve small groups. Alibert constructed his celebrated tree, 'Arbre des Dermatoses,' upon which these groups are represented as branches, and these again were divided and sub- divided till they became twigs, each representing a variety of cutaneous disease. This system of classification was claimed by its author to be the "natural" system, and though very imposing, is of no practical utility, and has long since been regarded as a curiosity merely. It confounds all the natural distinctions of these diseases, unites those having no apparent or real analogy in groups, and creates great confusion by changing the entire nomenclature. In the very elaborate treatise of Wilson, he has attempted to arrange the diseases of the skin according to their physiological and anatomical characters; this he terms a " Natural System of Diseases of the skin." " The basis of the natural system of classification rests upon Anatomy and Physiology, and herein lies its strength, its simplicity, its easy application and its truth. The dermis and its appendages, its glands and follicles, 14 INTRODUCTION. are considered to be the seat of all the changes which characterize cutaneous pathology." He makes four primary divisions, viz: 1. Diseases of the Dermis. 2. Diseases of the Sudoriparous Glands. 3. Diseases of the Sebaceous Glands. 4. Diseases of the Hair and Hair Follicles. There is no doubt that this system is really a more scientific arrangement than that of Willan, and by the physician who is already acquainted with the pathology and character of the diseases of the skin it would be pre- ferred. At the same time that this is confessed, there is no comparison between the difficulty of making a diagnosis, for one unacquainted with the whole subject, by this system and that of Willan. One great design in every classification is to enable the student to ascertain most readily the name, nature, prognosis and treatment of a given disease, and there is no doubt that this can be done in one half the time by the Willanean system, opprobriously styled by the authors of other arrange- ments, the "artificial system," than by any of the more strictly scientific systems. As before said, to one acquainted with the whole subject, undoubtedly some system like that of Wilson would be preferred, but it is believed that a so much greater amount of study and attention would be required to acquire a knowledge of " Dermatoses " by this system than by the old method, that it never can come into general use. Mr. Plumbe, some years since in his original and very practical work, attempted a new system of classi- INTRODUCTION. 15 fication; " the basis of this arrangement was founded on the constitutional causes of disease, and due consideration of the organic structure and physiology of the part of the skin on which it was seated." The system was very ingenious, and more scientific than that of Willan, but has not superseded it, and nevei can, for the same reason that the Natural System of Wilson cannot. It cannot be denied that there are several very strong objections to the Willanean arrangement. It places in different orders diseases nearly allied in their nature and treatment; it groups together affections entirely distinct in their pathology, prognosis and treatment; the same disease may, during its course, run through many different orders; be at one stage exanthematic, then vesicular, then pustular, and at last squamous: it may be at first a rash, then a papule, pustule, and at last a tubercle. Notwithstanding these and many other defects, this system is the most simple, its orders are very distinct, they are few in number, and they afford great facilities for detecting and classifying a disease. With some slight modifications, it has been adopted by the most distinguished dermatologists of Europe, and will probably long continue to be the most popular, because the most useful arrangement. Several corrections have been made in the location of diseases since the time of Willan; Biett, and his pupils Cazenave and Schedel, have made some additions to the number of orders, and have thus rendered the system more philosophical; most of the 16 INTRODUCTION. orders thus added contain only a single disease and that one commonly of rare occurrence, so that for a treatise like the present, intended as a manual for the more common diseases only, the original system will answer all purposes. The great utility of the Willanean arrangement consists in the wonderful facility it affords in detecting the different diseases; and this is no mean praise. There are still many cases in which the diagnosis is difficult. Many diseases at first very different in their appearance and character, at last degenerate into a morbid condition of the skin common to a great variety of affections; these diseases frequently belong originally to different orders; one may be a vesicular, and the other a papular eruption, and yet there are stages of Eczema and Lichen when the diagnosis, especially to one not thoroughly acquainted with the whole subject, is difficult or impossible. In a great number of instances the correct decision in such a case can be readily made by inquiring whether the disease at the commencement was a dry or moist eruption; this can usually be ascertained and then diagnosis is easy. For the purposes of facilitating the diagnosis in such cases, and they are numerous, it has occurred to the author that much assistance could be derived by dividing the orders into two groups or divisions, the dry and the moist, so that when called upon to decide in any given case by asking the question in regard to the elementary form, whether it were dry or moist, nearly one half the INTRODUCTION. 17 number of diseases from which the decision is to be made, are removed at once; for some time I have been in the habit of making this inquiry in every case where there could be any hesitation, and unless I am much deceived, have derived great assistance from it in diagnosis. The group for moist diseases would include three orders, and the other group the remaining five; and they would stand thus: FIRST GROUP. SECOND GROUP. Vesicul^b. Exanthemata. Eczema. Erythema. Herpes. Roseola. Scabies. Urticaria. Miliaria. Papulje. Bullae. Lichen. Pemphigus. Prurigo. Rupia. SqUAMJE. Pustule. Lepra. Ecthyma. Psoriasis. Impetigo. Pityriasis. Acne. Ichthyosis. Mentagra. Tubercul^:. Elephantiasis Molluscum. Frambesia. Maculae. Ephelis. Naevi. Albinismus. Vitiligo. 18 INTRODUCTION. I am aware that there are objections to this arrange- ment. That some diseases at first dry, afterwards be- come moist, as Acne, Sycosis, &c, and are classed with the latter. The same impropriety exists in regarding them as pustular diseases at all; they, in their various stages, pass through more than one order, and eventu- ally become tubercular, and yet no one hesitates in con- sidering them as pustular diseases. There is usually little difficulty in making a correct diagnosis in these cases; there are numerous cases, however, where real difficulty exists in distinguishing diseases that belong to different groups, and to aid in their diagnosis is the de- sign of this division. Diagnosis.—If the same attention be paid to the principles of classification, and rules for diagnosis in cutaneous diseases, that is paid to distinguish other af- fections, and those often of far less importance, it will be found that a correct diagnosis is more readily made here than in any other class of diseases. For obvious reasons no other class of affections will admit of so complete and perfect an examination, and in no other class is an error in diagnosis so inexcusable. Complica- tions of one eruption with another, often increase the difficulty, but instances of internal diseases com- plicating each other are more numerous, and much more difficult to ascertain. The general directions for making a diagnosis may be reduced to three simple rules. 1st. Ascertain whether the eruption was originally dry or moist. INTRODUCTION. 19 2nd. Examine with great care the eruption, and in a great majority of cases some examples of the elementary form of the eruption, as the papule, vesicle, or pustule may be found either in the neighborhood of the part principally affected, or in some more recent eruptions. Almost all cutaneous diseases are successive in their appearance, which is often of great assistance in the diagnosis. 3rd. Where you cannot satisfy yourself by a careful examination, as to the elementary form of the eruption, after having ascertained the group to which it belongs, try to learn from the patient or friends the appearance of the disease at first, as whether the vesicles were from the very first filled with a clear, limpid, or with an opake and yellow fluid; whether the pimples were at first distinct, small, hard, and conical, or were flattened, soft, conglomerated, &c, &c. In most cases by observing these three general rules, not only the group, but the order to which the disease in question belongs, can be ascertained; beyond" this the diffrential diagnosis of the different diseases belonging to the same order, is commonly not difficult and often of no great practical importance. Prognosis.—It is the united testimony of those who have had the most to do with this class of diseases, and who are the best qualified to judge, that if taken in season and judiciously treated, the treatment of no other class is more satisfactory. Too much is often required from the physician. After pulmonary tubercles 20 INTRODUCTION. have proceeded to ulceration, Pneumonia to hepatization, inflammation of the eye to disorganization, a complete cure is not expected; if the tuberculization can be ar- rested, if tolerable health be restored with the functional loss of one lung, or the inflammation stopped so that one eye is uninjured, the patient is satisfied. So after any of the inflammatory cutaneous diseases have been allowed to run on till the whole texture of the skin is altered, the delicate parts, of which it is made up, as vessels, ducts, nerves, glands &c, become disorganized and unable to perform their healthy function, by long continued disease, neglect, and injudicious medication, it is unreasonable to expect perfect restoration. The power that nature possesses to adapt itself to suit exigences is proverbial, but it has limits; and when for years the system has been accustomed to a habitual discharge or secretion, it might be expected that any rude attempt to arrest it suddenly, would be followed by effects similar to those produced by interfering with any of the natural secretions; and such is found to be the case. When we consider how delicate and complicated is our whole machinery, how nicely balanced are all its operations, how accurately adapted to each other are all its various parts, we cannot but wonder at the surpris- ing power there exists for self-regulation; how after severe injury or destruction of an important part it has the means of adapting itself to the emergency, so that new frictions are overcome, due compensation made and additional labour performed. When also we consider our very imperfect knowledge of the whole subject and INTRODUCTION. 21 our very rude attempts to regulate this machinery when it has become deranged, often too from some unknown cause, we shall cease to wonder at our frequent want of success. Causes.—While we are able generally to state many circumstances which are found upon extended obser- vation to increase the number of cutaneous eruptions, we are frequently unable in an individual case to point out the proximate cause of the affection. An attempt has been made in this manual, often very unsatisfactory to be sure, to give the more frequent causes of each disease after its description; a few remarks as to the general causes might not be out of place here. Willan attributed the frequency of cutaneous diseases in England, to the want of public baths and proper attention to cleanliness; and these causes operate with still greater force in the United States; and of all the prolific causes of cutaneous disease this is unquestionably the most important in this country. Several cutaneous diseases are distinctly hereditary in their character: this is more common in the group of dry diseases, though not confined to them. A few cutaneous eruptions are distinctly contagious, though in most instances where a number of cases of the same disease occur in the same family, we are not to attribute it so much to contagion, as to the same causes affecting all the members of the same family. It is not unusual to find several members of a family 22 INTRODUCTION. simultaneously or successively attacked by other diseases as Pneumonia, Diarrhcea, &c. where we have no suspicion of any contagion. Food has a great influence in exciting eruptions of the skin. The almost universal testimony of physicians shows that the use of the flesh of swine has this effect. Fish is believed to have a similar effect. Crude and indigestible or highly seasoned food, the stimulating drinks, articles of food partially decayed, the use of fat, melted butter, gravies, &c, intemperance in the quantity of even wholesome food, are among the more frequent causes of cutaneous disease. Certain seasons of the year have a decided effect; some eruptions being worse in the warm season and others in the cold; and some of them are periodical in their return. The effect of violent passions, of long continued grief, despair, anxiety, &c. is well established as conducing to the development of this class of affections. The well authenticated cases recorded by authors arising from this cause are very numerous; and the effects of mental depression and physical suffering combined, in the poor and destitute, are too manifest to require notice. Instances in which some affection of the skin is excited by an article of diet which is wholesome to most individuals are very numerous; and indeed it is usually by this class of diseases that such idiosyncracies are manifested. The natural texture of the skin, the occupation of the individual, his age, temperament, &c. have also INTRODUCTION. 23 a great influence in modifying these affections. But we shall probably never be able to understand why the same causes, in circumstances similar, should in one produce Eczema, in another Lepra and in another Prurigo. And notwithstanding the causes of these diseases that are now enumerated by authors are so numerous and varied that they embrace the condition of almost every individual, yet we not unfrequently meet with severe cases of cutaneous disease where it requires great ingenuity to discover any cause satisfac- tory to ourselves or to the patient. Treatment.—Let the pathological nature of the cutaneous diseases be carefully studied and remedies applied as experience and reason would dictate in similar diseases of other organs, and much less complaint will be heard of their obstinacy; but frequently no attempt is made to adapt the treatment to the character or stage of the disease, and conse- quently we ought not to wTonder at the result; it is often directed by a physician incapable of giving the pathology of a single eruption; whose whole vocabulary of cutaneous diseases is confined to some four or five vulgar unmeaning names, as " Salt Rheum," " Tetter," and possibly " Herpetic Eruption;" whose whole medical ammunition for their cure consists of some half dozen remedies, administered externally and internally accord- ing to some whim or fancied specific power, as Cream of Tartar, Sarsaparilla, internally to " purify the blood;" Arsenic, Sulphur, Corrosive Sublimate prescribed inter- 24 INTRODUCTION. nally as "alterants," and externally as "stimulants;" and some irritating substances made into washes, or still Worse, mixed with more irritating rancid lard, under the form of salves and ointments, intended to be applied externally "to dry up the humor." The great reason that the treatment of cutaneous diseases has generally been attended with so little suc- cess, is that we prescribe for them too empirically, and do not pay sufficient attention either to the pathology or to the stage of the eruption. The same general principles should govern us here, as in the treatment of all other diseases; a great proportion of cutaneous eruptions are at first inflammatory; in this stage, common sense would direct general depletion by blood letting and cathartics, and local soothing, applications as cataplasms, water dressings, &c, to allay the local excitement; in short a strict, antiphlogistic course, both in medicine and regimen, should be directed. When the acute stage has passed by, the course should then be changed, and in some cases the treatment can now be beneficially reversed, and tonics or even stimilents, both general and local, be substituted for depletion. From want of due appreciation of this principle as applied to this class of diseases, it is believed that sometimes diseases, which would have run their course and disappeared, are maintained by injudicious treatment till they have become intracticable under any treatment. The antiphlogistic treatment at first very proper may be continued till the powers of the system are so reduced that the 'Vis Medicatrix Naturae' is unable INTRODUCTION. 25 to accomplish what it would have easily done had there been no interference; the soothing and relaxing local applications may be continued till the affected skin has lost the tone, its texture changed, and its recuperative power destroyed. Another principle, always to be kept in view in the treatment of cutaneous diseases, is the sort of vicarious part which they frequently seem to perform. Any attempt to suppress an obstinate cutaneous eruption by means of local remedies alone, is seldom successful, and often dangerous. This principle seems formerly to have been better understood and more fully appreciated than at present. When the Humoral Pathology was in vogue, and the doctrine of the peccant humours was acknowledged, physicians w7ere at no loss to explain the principle of this alternation of internal and external inflammation; since this doctrine has become unfashionable, the facts upon wrhich it was grounded seem to have been lost sight of; and yet explain it as we may, no facts in medicine are better established. Nothing is more common than to see examples of it; let the eruption suddenly disappear in Rubeola and Scarlatina and every nurse is aware of the danger; so in the moist diseases of childhood, especially when connected with dentition, if the eruption spon- taneously disappear or dry up, or " be driven in " by local astringents, there is great danger that its place may be sup- plied by some inflammation upon the mucous or serous membranes; and to relieve these last no remedies are so use- ful as local irritants to ;'bring out" the original eruption. D 26 INTRODUCTION. Nor is it in childhood alone that we see instances of the vicarious character of cutaneous diseases; in adult life, and especially in old age, we see instances where any attempt to cure some long continued discharge, or some irritating dry eruption, is followed by severe constitutional symptoms. In all such cases we should proceed cautiously; the general health should be attended to, and often general remedies directed for some time, before any active local treatment should be attempted. All practical physicians, who have had experience in the treatment of these affections, agree in the paramount importance of cleanliness: this is particu- larly essential in the treatment of those eruptions that belong to the first group; in many cases indeed it is found that by attention to this alone, the affection can be cured. From the great number of cutaneous diseases that occasionally arise from improper food, it would be expected, that attention to diet would have much influence in the treatnient of these affections. This is the fact; but from the great effect of a scanty and innutritious diet in producing eruptions upon the skin, we should not be led to prescribe prolonged abstinence from nutritious food, as a remedy for all cutaneous diseases. Indeed, in large cities it is found that a generous diet is all that is required, to cure some of the worst forms of disease occurring in the poor and destitute. A mild unstimulating abstemious diet in the acute stage, followed by a more generous INTRODUCTION. 27 allowance, as the activity of the symptoms abate, is found to be the general rule, in the treatment of all these diseases. Some articles of food, experience has proved, are particularly to be guarded against; as the use of pork, of all salted meats, all articles of a fatty or oily nature, most articles containing the nutritious elements in a very concentrated form, &c, though to this last there are exceptions; in some cases, a diet, con- sisting of a large amount of sugar, has been very efficacious in correcting a depraved and cachectic state of the system. As a general rule also, it is important to abstain from all the heating condiments and spices, from alcoholic drinks; and nothing in Hygiene is of greater importance, than frequent baths to cleanse and invigorate the skin. General Remedies.—It is unnecessary to go through the various classes of the Materia Medica, to show the application of each to the diseases in question ; the same principles obtain as in the treatment of other diseases. There are some classes and articles which experience has proved to be peculiarly Useful, to which it may be well to allude. Purgatives in the active stage of the eruption, and laxatives afterwards are almost always resorted to; but it is upon tonics that the chief reliance is placed in the treatment of protracted eruptions. Of these none are of so early or general application, as the bitter infusions and the mineral acids; in many cases these follow very closely upon the use of depletion with signal benefit; and not 28 INTRODUCTION. unfrequently the exhibition of the saline cathartics in bitter infusion, or with a few drops of one of the mineral acids, seems to increase their efficacy. Of all the tonics, no one at the present day, enjoys the reputation that arsenic has acquired in the treatment of chronic cutaneous diseases. Its Modus Operandi is but very imperfectly understood, but it seems to be an active stimulent to the nerves, skin, and mucous membrane of the alimentary canal. Its use is contra- dicted in all cases where there is any tendency to mucous irritation of the stomach and intestines, where there is an undue energy in the action of the heart, upon which it has a great influence, and in the active and inflammatory stage of any eruption, which it would aggravate. Erichsen says that little benefit can be hoped from its use in any case, till after the eruption has become squamous; and that before this stage, there is danger of exasperating an Eczema, Lichen, &c. In most cutaneous diseases where it acts bene- ficially, there is some evidence of increased local irritation in the eruption, evinced by redness, heat, itching, &c. before it disappears. The form in which it is usually given, is in the Asiatic Pill, in Fowler's r Pearson's Solution, or lately in the triple compound of Iodine, Mercury and Arsenic, under the name of Donovan's Solution. Much difference exists in the opinion of practical men, in regard to the dose necessary to secure its best effects. In 1812, Dr. J. R. Coxe of Philadelphia, reported a case of a lady affected with a most obstinate INTRODUCTION. 29 Lepra of long standing, who was cured by the use of fifty drops of the Mineral Solution taken at a dose, three times a day, for thirty months; and what was remarkable in her case was, that as the eruption was about disappearing, the patient was unable to bear more than five drops of the Solution, three times a day, without tumefaction of the face, nausea, loss of appetite, &c. It is generally conceded now, how- ever, that such doses are not necessary in the treatment of cutaneous diseases, and as Arsenic is an accumulative medicine they are unsafe, and that it is rarely required to carry the remedy, beyond twelve or fifteen drops daily, and then in divided doses. Remedies more purely stimulent are, in the more chronic stages of eruptions, often useful. Of these none are as efficacious as the Tine, of Cantharides and the Corrosive Sublimate. They are to be used with caution in the same cases and stages in which arsenic is found useful, and are very happily alternated with it in the treatment. A solution of the Corrosive Sublimate in some bitter decoction, as the " Lisbon diet drink, " has often proved very efficacious in the treatment of chronic cutaneous eruptions. Sulphur taken internally either in substance, or combined, as in some of the mineral waters, has a stimulant effect on the skin, and, in chronic cases, is a safe and sometimes very useful remedy. It is frequently given in two large doses; when it acts as a cathartic, it has little effect upon the skin. Within a few years much has been said of the 30 INTRODUCTION. efficacy of two new chemical preparations in cutaneous diseases. They are Anthrakokali and Fuligokali. Their mode of preparation and directions for their use will be found in the Formulary. It is difficult to ascertain, how much efficacy they may possess, in the cure of cutaneous diseases; considerable confidence is placed in them by some who have tried them; while others have found them inert. Little need be said here of the local applications. In the active and inflammatory state leeching and sedatives are indicated: in the more chronic stages, more stimulating applications succeed better. Of the sooth- ing remedies, no one is more important than some variety of the general or local warm bath; and of the stimulating applications, no one is so generally useful as some of the sulphur baths. The importance of these baths can be inferred, from the fact related by Green, that out of sixty-two patients whom he saw prescribed for by Baron Alibert one morning, fifty-five were ordered one of these baths; and that in 1835, upwards of 180,000 of these baths were administered at the Hospital of St. Louis alone, in Paris. The particular cases to which they are applicable will be given in the treatment of the several diseases. As a general rule, the sulphur vapour baths are only found useful in protracted cases, where the eruption has become squamous in its appear- ance, or in the same stage in which Erichsen recommends the exhibition of arsenic. GROUP 1st, ORDER 1st— VESICUL^l. This order is characterized by small elevations of the epidermis filled with a fluid at first clear, trans- parent and serous, which usually become opake and sero-purulent; the eruption terminating in the formation of scales or crusts. The fluid contained in the vesicle may be absorbed, or it may escape and be effused upon the skin. There are five diseases belonging to this order viz: Eczema, Miliaria, Herpes, Scabies and Varicella; any account of the last of which, does not come within the design of the present treatise. ECZEMA. Syn.—Humid Tetter ; Dartre Squammeuse of Alibert; Epidemic Itch; Crusta Lactea; Dartre Vive; &c. Eczema is a cutaneous eruption characterized by numerous small agglomerated vesicles, filled at first with clear, transparent serum, which by degrees usually 32 VESICULjE. becomes opake, milky, and sero-purulent, and is either absorbed and evaporates, or it bursts the cuticle, dries, and leaves a scale or crust. There have been many distinct general varieties of Eczema, which however may be reduced to three, viz: Eczema Simplex, Rubrum and Impitiginodes. The last two varieties are very liable to become chronic. Besides these general varieties, very many local varieties have been enumerated and described by authors, which also for practical purposes may all be reduced to three, viz: Eczema Capitis, Eczema Faciei, com- prising E. Occulorum and E. Aurium; and Eczema Genitalis, comprising E. Pubis, E. Scroti, E- Pudendalis and E. Perinei. ECZEMA SIMPLEX. Syn.—Eczema Solare; Sun Heat; Prickley Heat. This variety is characterized by the eruption of numerous, agglomerated, shining vesicles, without any red areola about them, with no appreciable inflam- mation of the skin, and with no constitutional dis- turbance. The serum of the vesicle, at first transparent, gradually becomes milky and opake, and is usually absorbed, leaving a very small, thin scale of Epidermis, not followed usually by sensible desquamation; some- times on the spot where the vesicle was, will be found a small ring of Epidermis, the centre having been detached, leaving only its circumference. This VESICULjE. 33 is the sole evidence of the vesicles; these rings are frequently found on the hand. This variety of Eczema is usually slow in its course, and commonly not accompanied by any abrasion of the surface, or any exudation, and lasts by successive eruptions for many weeks; sometimes confined to a single part, as upon the hands, arms, upon and especially between the fingers &c, or it may be nearly general. It is more common with those with delicate skin, as women and children. It is sometimes accompanied by a troublesome pruritus. ECZEMA RUBRUM. In this variety the vesicles are surrounded by a distinct red areola, the skin is inflamed, slightly rough and swollen, the redness continues after the vesicles have disappeared, attended with a sense of tension, heat and itching. In the course of a week the inflammation subsides, the serosity is absorbed if the vesicles have not been broken, and a slight desquamation takes place. Frequently, instead of this favorable termination, the inflammation continues and increases, vesicles are successively developed which break and pour out a copious, irritating and excoriating fluid; this dries, forming extensive, thin, yellowish or greenish crusts, which frequently fall off to be as often renewed, leaving an inflamed surface, sometimes slightly ulcerated. This variety may be cured after some weeks, by the E 34 VEISCUL.E. serosity gradually diminishing, and the inflammation sub- siding, leaving the skin thin, shining and red or sometimes dry and harsh; improvement in this disease always takes place from the circumference to the centre. Sudden and inexplicable relapses take place in the cure of this disease, especially where the causes which produced it at first, cannot be detected and removed; often when the patient flatters himself that he is almost well, he will , unexpectedly be taken worse, the disease will run through the same course again, and becoming chronic, be protracted for years. Sometimes also when cured upon one part of the body, it will break out on another, and occasionally the patient will sink exhausted from the irritation, loss of sleep etc., kept up by these renewed attacks. ECZEMA IMPETIGINODES. Here the inflammation is still more severe, the swelling greater, the sense of tension, heat, uneasiness and itching are more troublesome. It may commence in the preceding variety, or at the very onset, the eruption may put on the more severe characteristics of this form. The fluid, contained in the numerous crowded or confluent vesicles, is at first a little opake, or at least becomes so immediately after its appearance, and the vesicles very soon break and pour out this acrid ichorous, sero-purulent matter on the skin which increases the irritation and inflammation, and instead of drying into thin scales as in the other varieties vesiculjE. 35 of Eczema, forms thick, laminated, irregular, yellowish, greenish or grey incrustations, often very extensive. Sometimes with these crusts will be found real pustules; the disease thus partaking of the nature of both the vesiclar and pustular eruption. When the crusts fall off, the surface beneath is found inflamed and raw, which throws out a more or less copious sero-sanguinolent discharge mixed with lymph, which in its turn dries and forms scabs, to go through the same course as the last. This state of things may continue inde- finitely, the disease becoming chronic; the scabs at each successive crop may become less abundent, the exhalation of the fluid less copious, the vesicular eruption less extensive the swelling, inflammation and itching subside, and the skin gradually resume its healthy appearance and color. Under the most favorable circum- stances this variety continues several weeks, and it is always liable to become chronic and obstinate. This variety of Eczema is sometimes partial, confined to a very small space, and at other times it is very exten- sive and almost general, with constitutional symptoms corresponding in their severity with the extent of the eruption, so that in severe cases, it is accompanied by accelerated pulse, fever and vitiated secretions, very simi- lar to the Eruptive Fevers. Often all the varieties of Eczema may be distinguished in a case of E. Impetigino- des; at first the Simplex, then the Rubrum, and as the vesicles become opake and confluent, they form the thick laminated crust of E. Impetiginodes, with here and there a true pustule of Impetigo. In very severe cases of this 36 VESICULiE. variety, the skin becomes thick, rough and inflamed, so that deep cracks take place, especially over the bend of the joints, greatly increasing the pain and distress. The disease is sometimes followed by a general furfuraceous desquamation with shedding of the hair, and in some rare cases, the nails also are lost, where the hands have been the seat of the disease. Sometimes after the eruption of vesicles has ceased, the skin, especially if the lower extremities have been affected, is for a long time thin, red, glis- tening and very delicate, covered with a fine desquma- tion; in such cases it would be very difficult to make a correct diagnosis of the disease, were it not, that almost always in the neighborhood of the diseased patch, there can be found specimens of the elementary form of the eruption. This state of the skin however is unusual except where the disease has been protracted and chronic. CHRONIC ECZEMA. Either of the two last varieties of Eczema is very liable to be protracted; relapses may occur, and by successive eruptions the disease may be maintained for months, and years; in such cases the skin is affected, it becomes thick, inflamed and rough, and seems ineapable of recovering its healthy state. Crusts fall off only to be speedily renewed; when exposed the raw inflamed skin pours out a profuse exhalation VESICULiE. 37 of sero-purolent lympli, deep fissures take place in the skin, especially over the joints, and blood escapes blackening the crust; the quantity of this acrid discharge is so great, that by coming in contact extensively with the skin and inflaming it, it greatly extends the disease, and neutralizes all attempts at cure. The itching in some cases is intolerable, far worse than in the other varieties of Eczema, when the surface of the skin alone is affected. After an indefinite time, and often after the failure of the best directed therapeutical means, the inflammation abates, the exhalation is less abundant, the scabs are thinner and not so extensive, or so rapid in their formation, all the severe symptoms subside; the skin when first healed is red and delicate, but gradually assumes its natural appearance, thickness and color, though covered with a desquam- ation so nearly resembling a squamous disease, as to be with great difficulty distinguished from it, except by the history of the case. Though Eczema, especially in its chronic form, may attack any part of the skin, yet it is found to be most frequent and obstinate upon those parts supplied with numerous follicles, as the head, axilla, pubis, &c, giving rise to the several local varieties; but there is no propriety in describing every local attack of Eczema as a distinct variety, having an Eczema of the face, ears, eyes, mamma, &c, though the disease may be strictly local, and confined to one of these situations. 38 VESICULiE. ECZEMA CAPITIS. gYN#—Salt Rheum; Scald Head; Porrigo; Tinea; Milk Crust, &c. This variety is the most frequent of all, and often attacks children at the breast and during dentition; when once contracted, if great care be not taken, and in some cases notwithstanding the greatest atten- tion, it will become chronic, affecting a part or whole of the scalp; sometimes, when protracted, it extends to the hair follicles, and produces Alopecia, which in some cases is permanent, though rarely so. When obstinate, the skin is inflamed and thickened, fissures take place, the blood from which, as well as from the wounds of the little patient's nails, mixes with the exhalation and blackens the scab. The glands of the neck are often inflamed, and in some cases subcutaneous absesses occur. The disease is very rebellious, at times resisting all means directed for its cure, and lasting till after the period of dentition. It does not seem often to seriously affect the health, such children often suffering less than others from infantile diseases. ECZEMA FACIEI. This variety is often a consequent upon the preceding • from which it does not differ in any very essential VESICULiE. 39 particular. It, however, is rarely so obstinate as E. Capitis, and were it not that when it extends to the ears and eyes it is a more serious complaint, and therefore requires great attention, it would hardly be requisite to make a distinct variety of it. As in the last variety, the cervical glands swell and sometimes suppurate, especially those behind the ears, and the skin is liable to undergo the same changes as in the pre- vious varieties. When it extends to the eye, E. Occulo- rum, it is almost always very rebellious and troublesome, often persisting for months, and even years, after it has disappeared elsewhere. The follicles of the eye lashes are affected, and the lashes fall out; and the eyes are weak and inflamed for a long time. When it extends to the ear, E. Aurium, it sometimes penetrates into the meatus, causing swelling, tension, and frequently excruciating pain, terminating in small absesses. But the most troublesome local form of the disease is, ECZEMA GENITALIS. When Eczema attacks the pubis, penis, scrotum, labia or perineum the pruritus, smarting and irritation are most distressing. In males, when it attacks the genital organs, the same thickening and cracking of the skin takes place as in other parts of the body, and it is chiefly to be dreaded on account of its pruritus, obstinacy, and tendency to return when once cured. But when it attacks the genital organs in 40 VESICULiE. females, it is one of the most distressing diseases from which they suffer. It often extends to the mucous membrane of the vagina, to the perineum and inside of the thighs. The irritation, pruritus and smarting in these cases, are most aggravating, exciting vitiated and acrid discharges from the vagina, which irritating still more, cause deep fissures in the inflamed and thickened skin of the perineum, and at last excite Nympho mania with all its distressing consequences. CAUSES. Eczema is more common in children and females than in adults and males, more common in spring and summer than in cold weather. It is at times symptomatic of intestinal, or uterine mucous irritation, occurring in females with amenorrhea, dysmenorrhea and at the change of life. Besides these general and other inappreciable causes,—local irritants, as irritating plasters, handling sugar and pulverised irritating sub- stances, as lime, spices, &c, (Grocer's Itch,)—several cutaneous eruptions, as Lichen, Scabies, &c.,—and especially the remedies used in curing these diseases, as sulphur, mercury, &c.,—may be enumerated as among the most common causes of Eczema. The direct action of the sun upon a delicate skin will also at times excite the eruption, {Eczema Solare.) And though it is said to be non-contagious, yet there is reason to believe that it has been at times communicated by VESICUL^E. 41 contact, especially Eczema Genitalis. Instances have also been known where nurses have contracted the disease from a child affected with it, and a child from a nurse. DIAGNOSIS. From the great variety of appearance presented by the disease in its different stages, and from its being often complicated with other cutaneous diseases, the diagnosis of Eczema is often difficult, and can only be accomplished by the greatest attention to the history of the case, and by ascertaining the elementary form of the disease; many times when this cannot be ascertained by an examination of the present state of the eruption, the elementary form may be detected in the immediate vicinity of the seat of the disease. The means of distinguishing Eczema from Scabies will be given when upon the diagnosis of the latter disease. Eczema Impetiginodes can only be distinguished from Impetigo, by carefully examining the primitive vesicles of the one, filled at first with serum, and the pustules of the other, which never in any stage contain a clear, transparent fluid; also the thick, rough, greenish incrustations of Impetigo, and the straw-coloured, or dun, laminated scabs of Eczema, will assist in the diagnosis; the patches of Impetigo are less extensive than those of Eczema, and the latter disease never leaves a scar, except where the skin has been torn by the nails. F 42 VESICULjE. To distinguish Chronic Eczema from Lichen Agrius is often difficult, both having deep fissures, thickened skin, with an acrid sero-purulent exudation, followed by the formation of scales. The history of the case will here afford great assistance, the two diseases belonging to different groups, the one at its appearance being a dry, the other through its whole course, a moist eruption; besides, the scales in Lichen are thicker, and when removed, instead of the smooth, glistening, inflamed skin of Eczema, we perceive the papular elementary form, and very distinct roughness or harshness to the touch, with more considerable thickening of the skin; usually, upon very close examination, the elementary form of the eruption can be detected, sometimes by the touch, when it cannot by the eye. Towards the close of the disease, when the scales are thin, and little more than desquamation remains, the serous exudation having ceased, Eczema may be con- founded with Psoriasis. The history of the eruption will enable us to determine to which division or group it originally belonged; and usually in Eczema, by careful inspection, here and there a vesicle can be found. The mode of distinguishing Eczema Capitis from Favus will be given hereafter. VESICULjE, 43 PROGNOSIS. The prognosis in Eczema, as far as the life of the patient is concerned, is almost always favorable, and it is also favorable for a cure, in acute Eczema, but in the chronic form, it sometimes for years resists all the attempts we may make for a radical cure, and often when upon the very point of eradicating the disease wholly, as we hope, it suddenly breaks out afresh, with renewed violence. We are often thus disappointed in our expectations for months and even years. TREATMENT. The general treatment of Eczema must vary much to suit the stage and severity of the eruption, and the habit and age of the patient. In the first stage of the eruption, and in a young, healthy patient of good constitution, a strict anti-phlogistic treatment is required, as general and local bleeding, purgatives and abstemious diet, with diluent and cooling drinks. When the cause of the eruption can be ascertained, it should be removed. After the inflammatory stage has passed, or in an aged or debilitated patient, a different treat- ment is required. Here the milder tonics, laxatives, and alterants, with a more generous, but mild, unstim- ulating diet must be used. As tonics, any of the bitter infusions, with a few drops of one of the mineral acids, may be tried ; Sarsaparilla, Dulcamara, Humulus, 44 VESICULiE. Cascarilla, Columbo and Cinchona, have all their advocates. Besides, there is a host of other tonics that have been recommended. In very obstinate cases, especially when it has run on to the scaly stage, the internal use of Arsenic, Tine, of Cantharides, or Corrosive Sublimate, persevered in for a considerable time, .has often succeeded. It is not by general means alone, however, that we usually hope to cure Eczema; local appli- cations are still more important, and to be successful, these also should be carefully adapted to the stage of the eruption, and to the condition of the patient. In the inflammatory stage of the disease, they should be mild and soothing, as water dressings, emolient poultices, mucilaginous washes and anodynes. When this stage has gone by, more stimulant and astringent applications are required. So copious is the list of these applications, and so various the reports of their effect, that it is difficult to select the best. Dr. Thompson is very partial to the use of the Hydrocyanic Acid. A variety of stimulating preparations, as ointments and washes are mentioned in the Formulary. Perhaps no one succeeds oftener than the Citrine Ointment, diluted as is necessary, to suit the individual case. The great variety, and different nature of remedies that are occasionally successful in the treatment of Eczema, even in cases, as far as can be ascertained, similar in their stage, degree of inflammation, and in the age and condition of the patient, show the difficulty of adapting the remedy to individual cases. VESICULjE. 45 The troublesome pruritus that sometimes accompanies this eruption is often relieved by alkaline or acidulated washes, or with washes or ointments containing some sedative or narcotic, as Hydrocyanic Acid, Opium, Stramonium or Hyosciamus. General bathing is often of great service: the water niay be simple, or medicated with mucilage, some alkali, acid, tonic, common salt, astringent, or with Sulphuretted Hydrogen, according to the stage of the disease, and the condition of the patient. In very chronic cases, sea-bathing has been very effectual; so has the sulphur vapour bath; this last, however, should be tried only after pretty active depletion, and usually not oftener than once in three or four days. Of late, much has been said of the efficacy of Anthrakokali and Fuligokali in the treatment of Eczema, and other similar diseases of the skin. They are recommended to be used internally and externally; as is the case with new remedies, the reports of the success from their use are very contradictory, and it is still difficult to reconcile the statements made by those who have tried them; the amount of evidence seems to be in their favor. When any ointment is used, great care is required in its preparation, and also in its application; if it is allowed to become rancid, it is irritating and aggravates the disease. Eczema Capitis is one of the most frequent and obstinate forms of the disease. In this variety, the hair should be cut short, and the scabs removed by the application of alkaline washes and fomentations; 46 VESICUL^E. after this has been done, some of the stimulating, tonic or astringent washes and ointments, should be directed. An ointment made of the Nitrate of Silver is one of the best; others prefer an ointment containing Sulphate of Zinc, or Copper, or Iron, or the Ioduret of Sulphur, or the Corrosive Sublimate. They can be used in solution, if a wash be preferred. Hydrocyanic Acid has been highly recommended as a local application in this variety. In the treatment of all the moist diseases of the skin, too great attention cannot be paid to cleanliness; this alone will do all that is required in many cases, and it is essential in the treatment of all. When ointments are used, the parts should be gently but faithfully washed twice daily. It should be remembered that several cutaneous diseases seem to be in a measure vicarious of some other disease; this is particularly the case in Eczema; and in some cases, especially towards either extreme of life, it is not always safe to apply local remedies to suppress the eruption suddenly. During dentition many intelligent practical physicians decline interfering at all; and in all cases it is prudent to precede any active local applications by general treatment. vesicul^:. 47 SUDAMINA. Syn.—Miliaria; Febris Miliaris; Purpura Alba; Hy* droa; Hydroa-Suetta Miliare; Miliary Eruption; Mil- iary Vesicles; Papula Sudoris. Sudamina are small, distinct, isolated vesicles of a round form, and as large as the head of a pin, suddenly appearing upon the skin. This eruption has been supposed to accompany only profuse pers- piration, and some have stated that it was caused by the closure of the mouths of the perspiratory tubes. It occasionally accompanies a great variety of diseases, especially the first stage of Rubeola, Scar- latina, Variola; it is also very often found in Rheu- matism, Typhoid Fever, and inflammation of the gastro-intestinal mucous membrane. It is more com- monly seen in females and those of a delicate skin, and often appears in the puerpural state. It is not so frequent an eruption now as formerly, when the heating regimen was in vogue for the treatment of these diseases. It is usually accompanied by no peculiar general symptoms, by little or no itching or irritation. The vesicle, at first transparent, then milky and opake, dries up, and is succeeded by a scale. Eczema is the only disease with which Suda- mina can be confounded; in Eczema the vesicles are crowded and often confluent, accompanied with heat, inflaination, itching, &c„ while in Sudamina 48 VESICUL^E. the vesicles are distinct, though numerous and uninflamed. The locality of the two eruptions is different; Sudamina are most frequently found upon the chest, abdomen and neck, where Eczema is rarely found; again Sudamina are rarely seen except with some inflamma- tory disease, in this also differing from Eczema. Sudamina do not render the prognosis more grave, nor do they require any treatment distinct from that of the disease which they accompany. VESICULiE. 49 HERPES. Syn.— Tetter; Dartre; Olophlyctide of Alibert. Herpes is a non-contagious disease of the skin, usually acute in its character, characterized by the appearance of vesicles of various size, from a pin's head to that of a pea, grouped upon a circumscribed, inflamed base. These vesicles are at first transparent, but soon become opake and milky; they either break and pour out their contents upon' the skin, which dry- ing together with the cuticle, form thin, yellowish or brownish crusts, or they wither away without rupture followed by thin scales; the skin intervening be- tween these clusters of inflamed vesicles is perfectly healthy; when these crusts fall off, the surface is inflamed or slightly ulcerated, and new crusts are formed, and the disease proceeds thus, till the inflam- mation gradually subsiding, scales only succeed, as in desquamation. The constitutional symptoms are light, and the whole disease usually is accompanied by little or no fever, or acceleration of the pulse, and commonly terminates in from ten to twenty days. The vesicles sometimes are very large formed from the confluence of several smaller ones. The disease is prolonged by the eruption of successive groups, though being essentially an acute disease, it seldom lasts more than a month or six weeks at farthest. There are usually described four general varieties F 50 VESICULjE. of Herpes, viz. Herpes Circinnatus, Herpes Zoster, Herpes Iris, and Herpes Phlyctamodes. These varieties depend upon the form and arrangement of the vesicles and groups. Besides these general varieties, there have been numerous local varieties described by authors which, however, may be reduced to three, viz: Labialis, Praeputialis and Pudendalis. Herpes Circinnatus.—Ring Worm. In this variety the vesicles are small, hard, round and tense, arranged in a circular form upon an inflamed base, while the centre of the ring is usually heal- thy. It runs its course in one or two weeks, and then desquamation in fine scales takes place; often successive eruptions of vesicles occur protracting the disease. At times the vesicles are very small, and the progress of the eruption very slow, so that for a considerable time the only evidence of the disease, is an inflamed circle, with fine desquamation. Its vesicular character may however be frequently dis- covered, by squeezing a small portion of the inflamed ring between the thumb nails, when the serosity wTill be expressed. This is the least important of all the general vari- eties of Herpes; it is usually accompanied by no other symptom, than a little itching or smarting sensation. The serum at first clear, soon, as in other vesicles becomes turbid and opake, and though when the inflamed VESICULiE. 51 rings are very small, vesicles shrivel by absorption, and the scales of the detached epidermis are the sole remains of the eruption; yet generally the cuticle of of the tense vesicle bursts, and the contents escape upon the skin and dry into thin crusts. This eruption usually shows itself upon the face and neck, though no part of the body is exempt from an attack. Herpes Iris.—Rainbow Ringworm. In very rare cases, about a group of vesicles is an areola, made up of several Erythematou rings of different hues, forming a variety denominated by Bate- man on this account Herpes Iris. These rings are either three or four in number, and are them- selves, sometimes, the seat of some vesicles. It is an unimportant, transient but curious affection, unaccompanied by any constitutional symptoms; after a week or two the serum in the vesicle is absorbed, and there is a slight desquamation. Its most fre- quent localities are the face, neck, and back of the hands, and rarely the fingers of delicate females; and it is usually limited to a few patches, though at times said to be almost general upon the body. Herpes Zoster.—Shingles. This is the most severe form of Herpes, and is characterized by inflamed, irregularly rounded patches 52 VESICULiE. commonly of a bright red color, of various sizes, numerous, entirely distinct from each other, though often very nearly approximated, with the interven- ing skin healthy. The eruption generally commences at the same time both anteriorly and posteriorly upon the median line, the anterior patch being usually, the inferior, and approach each other by the eruption of successive patches, till they meet, forming a girdle around half the body. The Thorax is the most common seat of the disease, but obser- vers differ very much in their experience, in regard to the comparative frequency of the affection upon the two sides; some who have had extensive ex- perience stating it as high as nine cases out of ten on one side, and others with equal opportunities, putting it as high as three out of four on the other side. Sometimes the disease instead of commencing at two points, as mentioned above, commences at some intermediate point, and travels both ways, till it reaches the median line. The eruption at first is simply a very red patch, which early becomes covered with glistening, white globular, hard vesicles, which increase in size till they are equal to a split pea; those patches that are first to appear, are commonly covered with the largest vesicles. The serum contained in these ve- sicles is as first clear, but soon becomes milky and puru- lent, and in some cases brown or even black, often inter- spersed, here and there, with a true pustule. In three or four days after the appearance of the vesicles, they begin to VESICULjE. 53 shrivel; the serum in the smaller ones being absorbed, and the cuticle in the others being broken, allows the fluid to escape and dry upon the skin in thin, yellow, brown, or almost black scales, which, in a few days more, fall off, leaving the skin red and inflamed; sometimes when the vesicles burst, they leave troublesome ex- coriation and ulcers, which are obstinate and painful, and when healed, leave behind them cicatrices; these unpleasant consequences rarely occur, except in debilitated constitutions, and even then are usually owing to pressure upon the inflamed part from lying, and are, on this account, more common upon the back, than on any other part of the body. The disease seems most frequently to take the direction of the nerves of the part attacked. Thus when on the body it is downwards and forwards, and when it attacks the limbs, its course is longitudinal. There are exceptions however to this direction; it sometimes forms a Zone about a limb, or a half Zone about the head, face or neck. It is difficult to account for the popular prejudice so general, that where Herpes Zoster surrounds the whole body, that it is fatal; it is not founded upon experience. It probably never attacks both sides of the body at once, and instances of this when they seem to occur, should be referred to the next variety, Herpes Phlyctse- nodes. Notwithstanding the assertions of the older physicians, and the apprehensions of the vulgar, Herpes Zoster is a slight and unimportant disease; it is sometimes 54 VEISCUL-E. preceded, often accompanied, and almost always followed by a severe neuralgic pain, in and beneath the part affected; the cause of this pain is very obscure; it often persists for weeks and even months after every other symptom of the disease has disappeared. Herpes Zoster is often preceded and accompanied by some constitutional disturbance, as fever, irregular chills, furred tongue, accelerated pulse, vitiated secretions, &c, and in old persons, and in broken down constitutions, sometimes terminates in gangrene, especially in parts exposed to pressure. The causes of this affection are not known; it attacks both sexes, though more common with males; all ages, though more common with the young and plethoric; the season also seems to have some influ- ence, it being more common in summer and autumn, than in winter and spring. Some people seem peculiarly ex- posed to this disease, and in such, it sometimes seems almost periodical, occurring every summer or autumn. Herpes Phlyct^enodes. While all the other varieties of Herpes are distin- guished by the peculiar form the patch of vesicles assumes, or the locality attacked, this variety is re- markable for having no particular form or locality; it appears on every part of the body, though more com- monly upon the superior part, and is very irregular as to its form and size. It is not usually attended by any distinct constitutional symptoms, though occasionally VESICULiE. 55 preceded, for a day or two, by some anorexia, fever, thirst, pain in the back and limbs, &c. The part of the surface attacked by this eruption is the seat of an itching sensation, heat, smarting, &c, and, upon examination, a patch is found varying in size, upon which are found small, red points, seeming almost papular; in a few hours the redness becomes uniform, and the next day small, isolated, globular, transparent, hard vesicles, are visible, which increase in size, till they equal a split pea, and in some cases a sixpence; however, most of these vesicles remain minute, and some require a lens to be seen. When once established, the eruption pursues the same course as in other varieties; the serum becomes turbid and purulent, dries and usually, though not always, forms crusts which fall off in a week or two, leaving the skin discoloured; this stain will remain for weeks and months; some of the larger vesicles, however, often are the seat of slight excoriations, upon which, after the first crust falls off, another is formed, protracting the cure. There is a pain, accompanying and following this variety, similar to that of Herpes Zoster, though com- monly not so severe, and requires the same treatment. There may be one or two of these inflamed vesicular patches, or there may be many; they may be confined to a limb or part, or they may be disseminated over the whole surface; they may be simultaneous in their appearance, or they may be successive; they may be small, not exceeding an inch in diameter, or they may be many inches; they may be distant from each other, 56 VESICUL.E. or .they may be approximated, the intervening skin being always healthy. The disease may appear by itself, though very often associated with other varieties, as H. Circinnatus. Its duration is from one to three weeks, though patients are exposed to subsequent attacks, especially in the following spring or autumn; it is almost always an acute disease, and even when the eruption is successive, is rarely protracted beyond a month. Diagnosis of Herpes. The diagnosis of Herpes is not often difficult, yet it is occasionally confounded with Pemphigus, Erysipelas, Scabies, and Eczema; still the hard, globular vesicles, grouped together upon an inflamed base, few in number and isolated, the patches always distinct with the intervening skin always healthy, should ordinarily dis- tinguish Herpes from all other eruptions. In Erysipelas, the deeper and more extensive inflam- mation, the progressive march, mode of development and course, are enough to distinguish it from Herpes. Sometimes small blisters occur upon the inflamed surface in Erysipelas ; they always, however, take the form of blebs and not of vesicles. The bullae of Pemphigus are to be distinguished by their size, and the rapidity of their development, which requires only a day or two; they are scattered, irreg- ular and distinct, running their whole course in two or VESICUL.dE. 57 three days, from the small, hard, globular vesicles of Herpes, grouped upon an inflamed base, requiring a week or two to run its course. To distinguish Herpes from Eczema in all cases is more difficult, but by carefully remarking the follow- ing characters, the diagnosis can be made. In Herpes, the vesicles are commonly larger, harder, more globular, and more distinct and permanent, lasting from four to six days, commencing minute and gradually increasing; the whole disease, howTever, is acute, and rarely lasts more than a month, even when protracted by successive eruptions; in Eczema, on the contrary, the vesicles spring up suddenly, are smaller than in Herpes, but are of nearly their full size at first, seldom lasting more than three or four days, and the disease is protracted indefinitely, not only by a succession of the elementary eruption, but by excoriation and exudation. Scabies may be distinguished from Herpes by its acuminated distinct vesicles, its protracted course, its peculiar characteristic pruritus,- its contagious nature, its locality at first almost always affecting the wrist, space between the fingers, and palmar surface of the arm, and especially by the cuniculus or sulcus of the Acarus, which, when found, is of course pathognomonic of this affection. In Herpes the vesicles are larger, globular, grouped, not confined to places where the skin is delicate, and it is not contagious, running its course in a few days, and ends in desquamation or falling off of the crusts. The diagnosis of the different varieties of Herpes is G 58 VESICULjE. not difficult, being distinguishable from each other by the form and arrangement of the patches. Herpes Iris and Circinnatus are distinguished from the other varieties by their circular form, and from each other by the characteristic rings of the former, and the want of the central healthy patch of skin. Herpes Zoster generally affects the thorax, is confined to one side, made up of successive patches which are arranged in a line, and the vesicles are larger, and the pain and constitu- tional symptoms are more marked than in Herpes Phlycteenodes, which last is also characterized by the irregular form, locality and arrangement of its patches. Herpes Circinnatus and Erythema Circinnatum are distinguishable from each other, by their belonging to different groups; the moist character of the former is proved by expressing the serum between the thumb nails from the obscure vesicles. The thin, light crusts of Herpes, the elementary vesicular form, its short duration, render the confounding this disease with Favus with its thick, friable scabs, its chronic course, unnecessary; the latter disease also attacks the follicles and destroys the hair. It is not a simple, superficial inflammation of the skin. Causes. Herpes is usually an affection of youth and females with delicate skin, and is often connected with mucous irritation of the lungs, bowels, &c. It is also excited VESICULJE. 59 by exposure to cold, by long protracted depressing emotions, &c, while in many cases its cause cannot be discovered. Herpes Zoster is said by some authors to be more frequent with males than females, but this is denied by others; at all events, it more frequently seems connected with a vitiated state of the digestive organs than the other varieties, excepting perhaps, Herpes Phlyctaenodes. Prognosis. The Prognosis in Herpes depends very much upon the age and constitution of the patients. In young and healthy subjects it is an acute affection, requiring little or no treatment, and always terminating favourably; with the old, worn out and dissipated, the prospect is far worse; the inflammation tending to gangrene, un- healthy ulcerations, &c, which render the prognosis much more grave. Treatment. In most cases, little treatment is required in Herpes. Where the constitution is debilitated, and the patient is aged, tonics and alterants should be given internally, and some soothing but slightly astringent washes used externally. In the young and vigorous, a moderately anti-phlogistic course will shorten the duration of the 60 VESICUL.E. disease; generally, however, in such cases, the disease runs its course if unmolested, in two or three weeks. In Herpes Zoster, purgatives and alterants, followed by tonics, are all that is required. To allay the smarting and itching, which are some- times very troublesome, emolient poultices, water dres- sings, alkaline, mucilaginous, or narcotic washes are required. Cool, diluent drinks, light diet with laxatives, will assist. Where the disease, by successive eruptions, becomes chronic, Fowler's Solution, or the Corrosive Sublimate, or the Tine, of Cantharides, will often correct this disposition. LOCAL VARIETIES OF HERPES. Herpes Labialis. Here the eruption of vesicles appears upon the lips, often at the junction of the mucous membrane with the skin, often upon the mucous membrane alone, and some- times confined to the skin. It commences in an itching, burning, tense sensation, with heat, redness, and usually some swelling, and in the course of from four to twelve hours, vesicles make their appearance, either singly or a number in groups, and the eruption may be confined to a single vesicle, or the whole lip may be covered by them. These vesicles are globular and increase in size till they are equal to a small split pea; when there are VESICULiE. 61 a number of vesicles in a group, as is usually the case where the skin is the seat of the eruption, they often coalesce and form one or two large vesicles or bullae. The contents of these vesicles are at first clear, trans- parent, slightly saline to the taste, but soon become turbid and milky; the cuticle bursts usually in the course of a day or two, and the fluid escapes, dries, and forms a thin crust, which, if undisturbed, remains for a week or so and then falls off leaving the surface be- neath healthy; if, however, it be prematurely disturbed, another thicker scab forms upon the inflamed and bleeding surface, which is more persistent. The most common causes of Herpes Labialis are irritating applications, exposure to wind and cold while the lips are moistened by the tongue, and catarrh. Exposure to the sun, while the lips are moistened by saliva, often induces it; it also often occurs at the com- mencement or termination of fever, especially the inter- mittant, and sometimes seems critical; it also accom- panies inflammation of the mucous membrane, especially that of the nose, mouth, or lungs. It is a slight affection and requires no treatment, still if the vesicles be carefully punctured with a needle, and the lip be washed with some cold astringent lotion, as Sol. of Alum, Sulph. of Copper, Nit. of Silver, or Sulph. of Zinc, considerable annoyance can be prevented ; if, upon its first appearance, the surface be carefully protected from moisture, it will seldom prove troublesome. The junction of the mucous membrane, with the skin at the nose, ears, eyes, and in rare cases at 62 VESICULjE. the anus, is the seat of a herpetic eruption, which does not differ essentially from Herpes Labialis, except- ing in its seat; it has been denominated from its locality, Herpes Palpebrarum, H. Nasi, H. Aurium, H. Ani, &c, as the case may be; it is never a severe affection. Herpes Pr.eputialis. When Herpes attacks the junction of the mucous membrane and the skin upon the prepuce, it usually runs through the same course as when on the lips; it may be confined entirely to the skin, or to the mucous membrane, or it may attack both; when the mucous membrane is affected it is a much more troublesome matter, from the greater inflammation and greater ten- cy to excoriations. Herpes Praeputialis not unfrequently takes on a chronic form, and is then very obstinate and rebellious; the cellular tissue in such cases inflames and becomes indurated and contracted, and in hardening forms a ring about the free border of the prepuce, with excoriations, fissures, &c. In such cases circumcision is the best remedy. Herpes Praeputialis is excited in a constitution pre- disposed to such eruption by friction of the dress, by want of cleanliness, impure connection, irritating dis- charges, &c. VESICULjE, 63 Herpes Pudendalis. When Herpes attacks the vulva, it is called Pudenda- lis, but does not differ materially from the varieties al- ready described, excepting in its locality, and disposi- tion to prove obstinate and protracted by the irritating discharges from the vagina; great attention to clean- liness, and carefully protecting the inflamed surface from all irritation, are usually sufficient to effect a cure in both of these last varieties. The application of an astringent wash, especially a weak solution of Nit. of Silver, will often assist in the cure. 64 VESICULiE. SCABIES. Syn.—Itch; Gale; Psora. This disease, originally placed by Willan in his order of pustular diseases, but now with more pro- priety considered vesicular, is characterized by small, distinct, acuminated, transparent vesicles, containing a viscous serum, appearing at first where the skin is fine and delicate between the fingers, subsequently upon the wrists, upon the flexor surface of the fore- arm, at the bend of the elbow, and eventually it may attack the whole body. It is eminently a contagious disease, and all the accounts of its prevailing epi- demically, of its springing up spontaneously, and of the severe general symptoms arising from its sudden re- pression, are to be taken with great caution. It is now known to be caused by an Acarus which can always be found in genuine Scabies; and though this animal often occasions symptoms which do not disappear at its death, and the disease may thus continue long after its exciting cause has ceased to act, yet it is none the less true that the Acarus is the essential cause of the Itch. The form, size, and some of the habits of the animal have been ascertained, and his haunts discovered; he is found to be, when seen by the naked eye, a small white speck distinctly visible either upon the needle or upon the thumb nail; his motions also are readily discovered. When VESICULjE. 65 examined with a microscope, he is found to be very active, looking. like a turtle, with a head capable of being retracted within his shell, with eight legs, and with stiff hairs and spines so arranged as absolutely to prevent moving backwards, his only motion being forwards. By examining the vesicles of Scabies with great care, unless the animal has been previously killed, there will be found here and there a vesicle, either between the fingers or upon the wrist, or arm, to which a line or handle has been added, from two lines to half an inch in length, at the extremity of which, at the greatest distance from the vesicles, the animal may always be found, and easily extracted by elevating the cuticle with a needle. The animal is never found in the vesicle, but from his inability to retreat, at the end of the sulcus. The vesicles, as far as is known at present, are primitively caused by the irritation from the Acarus, but are much more numerous than the animals are proved to be, and are produced in part perhaps, by the scratching, which it is impossible to repress. The eruption of vesicles may also be maintained for an indefinite time after the Aca- rus is dead, by the application of the irritating substan- ces used for the cure of the disease; there being no doubt, that though the Scabies cannot be caused by sulphur, as asserted by Hahneman and his followers, that the eruption of vesicles may be kept up for a long time by the injudicious use of this specific. True pustules often occur during the progress of the 66 VESICULiE. disease, as the result of the irritation from the animal, the scratching, and the remedies used to cure the disease; the diagnosis thus often being difficult. When the disease is severe and of long standing, it is often difficult to discover the sulci, but by patience and perseverance several may generally be found, though it is not easy to explain in all cases the severity of the symptoms by the small number of Acari discovered, on the supposition that this animal is the sole and essential cause of the eruption; and it is not improbable that all its haunts have not been as yet discovered but it is often present where its presence cannot be demonstrated; and we must acknowledge that occasionally well marked cases of Scabies occur, that are proved to have been contracted from con- tagion, and capable of communicating the disease, that have all the other ordinary symptoms of Scabies, and yield to the approved mode of treatment, where no Acari can be found; such cases are even now rare, and when we are better acquainted with the habits of the animal, will occur still more seldom. It has been proved that the disease can be com- municated by placing the Acarus on the skin; and why it is that some individuals are not liable to contract the disease under any exposure, that physicians, and dressers in hospitals who take no precautions to pre- vent an attack, rarely suffer from this eruption, while with others it is contagious to a proverb it is dif- ficult to explain; like the essential cause of other contagious diseases, this animal seems at times verv vesicul^:. 67 fastidious in the choice of its victim; and a person may be exposed with impunity for a long time, who will at last contract the disease, without being able to discover in what manner. The usual locality of scabies, is the space between the fingers; but in mechanics, and others where the skin is hard upon the hand, the eruption is more distinct upon the wrists and arms, especially at the bend of the elbow. The form of the vesicle varies also some- what with its locality—that between the fingers be- ing acuminated, that upon the arms being more glo- bular, like herpes; where the irritation is great, pus- tules often appear, with abrasions of the skin from violent scratching. The pruritus attending this disease is intense and peculiar, and though scratching great- ly increases the irritation, it affords great immediate relief, and is accounted by the patient as a great luxury. The irritation from itching is greatly aggra- vated by the use of stimulating food, heating condi- ments, and, at times, the warmth of the bed, renders it insupportable. The itching is also wwse in the after- part of the day, and is more severe in a full pletho- ric habit, while the aged and debilitated suffer com- paratively little. Causes of Scabies. The essential cause of Scabies, is the presence of the Acarus; still, the young and delicate, with lym- 68 VESICULiE. phatic temperaments, are more exposed to it than the robust and plethoric—females more than males. Dissipation, want of cleanliness, and of proper food and clothing, also seem to predispose to it. It is of- ten communicated by clothing being infected with the disease, and patients who have once suffered, are very liable to a return, if their clothes be not faithfully dis- infected. Animals are said to be sometimes affected with this disease, and to communicate it to man; Gi- bert asserts, that several persons at the Garden of Plants took it from a goat which was affected with it. At some seasons, it would seem that the disease was more readily communicated Diagnosis. v The diagnosis, in most cases, is not difficult; the Sulcus, or Cuniculus, is found in no other cutaneous affection. When the disease attacks the space between the fingers, the vesicles are acuminated, and the apex transparent; scales are found on the affected skin, from the burrowing of the Acarus, and from the dry- ing of the vesicles. Scabies is, with some difficulty, distinguished from Eczema; in the latter disease, the vesicles are round, confluent, upon an inflamed base, transient, choosing by preference those parts of the skin where the perspiration and hair follicles are most abundant; as the head, axilla, pubis, &c, they desic- cate rapidly into crusts, are accompanied by a smarting VESICUL^. 69 sensation, and are not contagious; while in Scabies, the vesicles are distinct upon the hands and arms, acu- minated, transparent at the summit, contagious, ac- companied by a pricking, itching sensation, relieved for the time by scratching. From Prurigo, it is distinguished by being, from the commencement, a moist, and not dry, a vesicular, and not papular eruption, by being always at first where the skin is thin and delicate, by its contagiousness, not arising spontaneously, by the want of the small black characteristic scab of Prurigo, and by the peculiar itch- ing of Scabies, which is relieved by scratching, wirile it is not in Prurigo. Lichen and Scabies, though at times resembling each other, are essentially different; the one a dry and pap- ular, the other a moist and vesicular eruption. Lichen attacks usually the extensor, Scabies the flexor sur- faces; Lichen often attacking the back of the hand, never the interval between the fingers. Ecthyma often complicates Scabies, but even then the diagnosis is not difficult; the vesicles, the locality: the peculiar itching, being usually sufficient to make it out. And especially, in all doubtful cases of cutaneous dis- ease, the cuniculus is to be sought with great care, and where it can be discovered, it removes all doubt. 70 VESICULjE. Treatment. The treatment of Scabies does not usually present much difficulty; Sulphur has been found so efficacious in this disease, that it seems to be the only article in the Materia Medica deserving the name of specific for any disease. It is said to act by being eliminated from the skin in the form of Sulphurretted Hydrogen, which gas is very poisonous to the Acarus, while the Sulphur it- self is not. Gras, after numerous experiments, came to the following results: the Acarus can live in pure or salt water three hours; Goulard's solution killed it in one hour; in Olive, Almond, and Castor Oil, it lived more than two hours; in lime-water, three quarters Of an hour; in Vinegar and Alcohol, twenty minutes; in a solution of Sulphuret of Potass, twelve minutes; in a strong solution of the Hydriodate of Potass, from four to six minutes; in a solution of Arsenous Acid, four minutes; in Sulphuric Acid, diluted with three parts of water, it died in three minutes; and in concen- trated Acids and Alkalies, it died at once. It lived sixteen minutes in the vapour of burning Sulphur; and placed upon dry Sulphur at night, was found dead next day. Notwithstanding the undoubted efficacy of Sulphur in the cure of Scabies, the use of it is strongly objec- ted to by many patients; besides the constant genera- tion of Sulphurretted Hydrogen, which many patients will not endure, it is to some skins very irritating and vesicul^:. 71 will maintain a troublesome eruption long after the Acarus is dead. The Sulphurous washes are effica- cious, but not as speedily so as the Sulphur itself. Olive Oil will destroy the Acarus, and the addition of Camphor will much increase its efficacy. Many other articles have been found effectual in the treatment of this eruption; as Tobacco, Onions, Chloride of Soda, Cicuta, Hellebore, Sulphuric Acid, diluted with thirty or forty pnrts of water, the Nitrate of Silver, &c. &c. Whatever mode of treatment may be generally pre- ferred, it will be found necessary to modify it so as to adapt it to the different stages of the disease, and to the various conditions of the patient; the clothes should be disinfected, as they will communicate the disease again after it has been cured. Dr. Herman Vezin, in his treatise upon Scabies, gives a minute account of his mode of treatment, which he has found eminently successful. , The patient first takes a warm bath, with black soap, in a room of which the temperature is from 90 to 100 degrees of Fahrenheit; and he is provided then with a long woollen night gown, with sleeves, and is put into bed with two blan- kets ; the temperature of the room is maintained at the same degree day and night; he remains here twelve hours in profuse perspiration. During this time, he is said to suffer much from the heat and itching, and fresh eruptions appear upon the skin. After this, he rubs himself over his whole body with the following ointment, near a warm stove: 72 vesicul^:. R. Pulv. Suhtiliss. Sulphuris Depurat. 3j " " Radicis Hellebori Alb. 3ij " " Nitrat Potass. grs. x Saponis Nigri. 3j Adipis Suillse 3iij M. ft. Ung. The patient then wraps himself again in his gown, and lies down; in twelve hours he rubs himself in the same manner again, and after another interval of twelve hours he does the same. After twelve hours more have passed, he washes himself in warm water and black soap, as as first, and dresses himself in clean clothes. Thus, the whole process occupies only forty-eight hours. In 1364 cases, thus treated in the Hospital, it is stated that there were but three cases where the inunction required to be repeated. Four ounces of ointment were generally used in the three inunctions. No internal remedies were given and the patients were allowed their usual diet. In private practice, patients would not submit to such a course of treatment; by less active treatment, a cure can usually be effected in about two weeks by using some of the ointments or washes containing Sulphur, Mercury, Camphor, &c, and by great attention, to prevent contracting the disease again from the clothes. Gras says he " has frequently found all the Acari dead after a single friction with the Sulphuro-Alkaline oint- ment;" but though the insects are dead, vesicles con- tinue to appear for several days. As a matter of precaution, some strong aromatic or perfume, may be worn for a week or two to expel all the Acari from the dress. ORDER 2nd—BULLAE. This order of cutaneous diseases is characterized by the collection of a serous, sero-purulent, or sero- sanguineous fluid under the epidermis, differing from the vesiculae only in size. The bullae are generally of a circular form, varying in size from a split pea to an egg; and usually terminating in the formation of a crust or scab, which also varies much in thickness and shape. This order comprises only two diseases, viz: Pem- phigus and Rupia. Pemphigus. gYN#—Pompholyx; Febris Bullosa; Bullce, &c. Pemphigus is a cutaneous eruption, characterized by blisters or blebs, which are generally of a round form, and vary in size from a split pea to an inch in diameter, and where several coalesce, they form one as large as half an orange. These blebs are filled with a serous or sero-purulent fluid, which, by the rupture of the epidermis, escapes and dries, and, with the broken cuticle, forms a thin scale of the size of the blebs; K 74 BULLjE. this scale is followed by a slight ulceration, excoriation, or often by a stain only, which gradually disappears. A number of varieties of Pemphigus have been described; but recent authors have with propriety reduced them to two, the Acute and the Chronic. Pemphigus Acutus is a rare form of disease, and was not recognized by Willan or Bateman, though its occasional appearance is now proved by many observers; it is usually short in its duration, and may be con- fined to a single part, though it occasionally attacks the whole surface; those with delicate skins, as women and children, are most subject to it. The constitu- tional symptoms are frequently slight, and are some- times not remarked; at other times they are more severe, the eruption being preceded for a day or two by chilliness, fever, thirst, anorexia, head-ache, pain in the chest, abdomen, back and limbs, quick pulse, cough, &c. The blebs may be distinct and distant from each other, or grouped and confluent; they may be numerous, scat- tered here and there over the body, especially upon the lower limbs, arms, face, &c, or a single one only may ap- pear upon the body at once, preceded by considerable prickling, itching, or smarting; it is filled at first with a transparent, yellowish serum, which gradually becomes opake, and in the course of a day or two, the epidermis giving way, escapes and dries upon the surface. Another bleb makes its appearance in the vicinity of the first runs through the same course, and is in its turn suc- ceeded by another, and so on, till the disease is protracted for a week or two, constituting the Pompholyx Solitarius bullae. 75 of Willan. This course of the disease is very rare, and it usually terminates in a fortnight, though by the successive eruptions the disease may be protracted and become chronic. The first appearance of Pemphigus is in the form of Erythematous patches, like Erythema Nodosum. which in a few hours, and often almost immediately, are in part, or wholly, covered by a bleb. Not unfrequently all the Erythematous patches do not become bullous, but in such cases slight friction with the hand, or even pressure upon the patch, with the finger, is usually sufficient to raise the blebs. Sometimes the whole patch is not covered by the bleb but the centre only; its size may then be increased by pressure or friction. The blebs are not usually surrounded by a very distinct inflamed areola, except where the centre only of the patch has filled. They differ in no respect in their appearance from those excited by vesicating plasters or heat. The skin, intervening between the blebs, is entirely healthy; sometimes however a part of the body, as a limb for example, is covered by numerous confluent blebs, which, after they have gone through the inflammatory state, and have dried into scales, might be mistaken for an Eczema or Impetigo, but for the large, thin scale of the bullous disease, distinguishing it from the thin, fine scale of the one, and the thick, granulated crusts of the other. The eruption is usually successive, and all stages may often be seen in the same individual, from the slight Erythematous patch, to the dry and almost detached crust. 76 bullae. The duration of the eruption varies considerably; when it is simultaneous, it usually disappears in a week; but when successive, it may be protracted through several. Experiments, made by Rayer and others, have proved that it is not a contagious disease, and that it cannot be communicated by inoculation. Chronic Pemphigus. This is a much more common disease, and like the last, may be either partial or general. It is usually preceded by some general symptoms, as fever, thirst, irregular chills, pain in the head, back or limbs, &c. These symptoms, however, are scarcely noticed in many cases. It is a much more troublesome and painful affection than the last variety, and much less under the control of medicine. It is often complicated by inflammation of the mucous membrane, of the bowels, mouth, lungs, bladder, &c. The bullae vary in size from a split pea to an egg in diameter. They may be distinct or confluent, distant or grouped, irregular, or arranged in circles or lines like Herpes. The eruption often commences in Erythematous patches, as in the acute variety, while the succeeding blebs may be developed without being preceded by this redness. The Epidermis is raised from the skin, by serum being effused beneath it. The blebs increase in size for a day or two, then break and the contents escape, leaving inflamed surfaces, with bullae. 77 or without slight ulceration; or, if the patient be cautious not to disturb them, many of these blebs will, after a day or two, become turbid, while the epidermis, which em- prisons the fluid, will become opaque, white, and wrin- kled, and the contents evaporate and be absorbed, leaving behind only a thin brown crust, which falls off in four or five days. The disease is maintained by successive eruptions which run through the same course, so that it is not unfrequent to see, in the same indi- vidual, at the same time, every stage of the affection, from the Erythematous blush, to the dull livid stain left by the detached crust. When care has not been taken to preserve the epidermis from injury, but by friction of the dress or lying in bed, the epidermis is removed from one of these bullae; the inflamed skin is very pain- ful and sensitive, causing loss of sleep, fever, &c; and, indeed, where the health of the patient seems strong and sound at first, the successive eruptions may irri- tate and exhaust his system, till severe constitutional symptoms supervene, and he may be worn out by the protracted disease. It is rare, however, that a patient is destroyed by Pemphigus alone, and it is principally from its complications that danger is to be apprehen- ded. These complications are often severe and trouble- some. When the face is attacked, the mouth rarely escapes severe and obstinate inflammation, though Caz- nave has never seen true Pemphigus upon the mu- cous membranes; many observers, however, have been more fortunate; Alibert relates a remarkable case of a girl, where the blebs were found in the mouth, aeso- 78 BULLiE. phagus, and throughout the whole extent of the in- testinal canal. Its most severe complications are ob- stinate inflammations of these membranes: vaginal, ve- sical and bronchial irritation and inflammations are not rare, and the disease rarely proves fatal without invol- ving the mucous membrane of the Alimentary tube; effusion of serum into some of the cavities, and fatty degeneration of the liver are found in those dying from this disease. It is often complicated also with other cutaneous diseases, especially with Prurigo, and sometimes with Herpes and Eczema. When associated with Prurigo, the itching is most annoying and greatly exasperates the affection. Causes. Pemphigus is not confined to either sex, though, perhaps, more frequent in females; though authors assert that Pemphigus is more common among males than females, Joseph Frank enumerates the female sex as one of its predisposing causes. It is common to all ages; instances are on record of its being congenital. It is more common in old age than in adult life or youth. It sometimes appears first at the cessation of the menses with women. Severe afflictions, and violent passions, have at times seemed to produce it. At other times it seems to arise from improper food, from acrid substances and warm spices, taken into the stomach; especially in debilitated and broken down constitutions. BULLAE. 79 Almost all the cases, that occur in children in this country, appear after vaccination; especially where no cathartic has been taken after the subsidence of the inflammation. In many cases, however, no satisfactory cause can be assigned for the appearance of the eruption. Diagnosis. The diagnosis is, in most cases, not difficult. It is a moist eruption, thus distinguishing it, in its later stages, from the squamous eruptions. As heretofore said, when a limb only is attacked, and the eruption has passed to the squamous stage, it might be confounded with an Eczema or Impetigo. A little attention to the character of the crust will suffice to distinguish them. It has been mistaken for Herpes; the blebs are larger, and are not grouped together upon an inflamed base as in Herpes • but they are usually disseminated, and distinct, and, very commonly, with little or no inflammation of the skin. Indeed, where the elementary form of the erup- tion can be found, it ought never to be confounded with any other affection of the skin, except Rupia, the distinguishing marks of which, will be given hereafter. Prognosis. The Prognosis in acute Pemphigus is always favor- able when uncomplicated with any other affection ; but 80 BULLiE. when thus complicated, the prognosis Will depend upon these complications. Chronic Pemphigus is always a disease of more importance, not so much on its own account, as from being an index of a vitiated state of the constitution. Here the prognosis depends much upon the age, habits and general condition of the patient, and may be more or less grave, as these are unfavorable or favorable. In many cases, also, though there may be no danger, yet the disease has a tendency to return either from derangement of the digestive functions, or from some other cause, as upon the recurrence of Spring; thus, sometimes assuming a character almost periodi- cal, very difficult to be broken up. Treatment. In acute Pemphigus, little treatment is ordinarily necessary beyond laxatives, diluent drinks, rest, spare diet and cold bathing. In some cases, the inflammatory symptoms are so severe, as to require depletion by venesection and active purgatives; the blebs may be punctured with a needle and the contents be allowed to escape, care being taken not to abrade the inflamed surface; some desiccating powder may then be dusted upon the part to absorb the fluid. Attention should be paid to the condition of the general health; the secretions should be restored if suppressed, and corrected if vitiated. Diuretics often seem particularly useful, especially when the eruption is complicated with anasarca, and in many BULLiE. 81 cases connected with dysmenorrhea or amenorrhea, the eruption will disappear when this secretion is restored or regulated. When the local inflammation is severe, it should be treated by warm water dressings, fomen- tations, &c. The treatment of chronic Pemphigus is not so satis- factory. Here the anti-phlogistic treatment should be adopted with great caution; alcaline or mucilaginous baths, either warm, tepid or cold, a mild unstimulating diet, not too abstemious, residence in a healthy airy situation, with the use of laxatives, alterants and mild tonics, constitute the treatment of chronic Pemphigus. When the pain and irritation is such that the patient cannot sleep, some opiate at bed time is required; for tonics, some of the mineral acids in a bitter infusion usually answer well. The neutral salts, with a few drops of a mineral acid, or in bitter teas, are useful as laxatives. In the aged and debilitated, a generous diet, with strong tonics, as Bark or Quinine, with wine or brandy, are sometimes required. Arsenic is rarely indi- cated, but at times it unexpectedly acts like a charm; it is usually, though not always, in the latter stages that it is useful. Wilson says "when there is reason to believe that " the eruption is an effort on the part of nature, to " determine to the surface a morbid disposition, I " should strongly recommend the employment of mus- " tard baths to the whole surface of the skin, or a " stimulating liniment of some kind, such as that of " croton oil, in the proportion of a drachm to an ounce l 82 bull^:. " of olive oil, to be well rubbed into the sound parts " of the skin." When the skin has been abraded the use of some mild astringent wash, as a very weak solution of Nitrate of Silver or the Sulphate of Iron, with some absorbing powder, will give great relief and hasten the cure. bullje. 83 RUPIA. Syn.—Ulcus Atonicum; Phlyzacia of Alibert. Rupia is characterized by an eruption of large, flat, distinct bullae, similar to those of Pemphigus; they are filled at first with serum, which soon becomes opake, sanious or purulent; they have a tendency to the rapid formation of scabs, generally of a dark brown or black color, varying greatly in thickness, and followed by ulceration of greater or less depth. This eruption is usually seen in the poor, destitute, ill-fed and miserable; in patients of broken down and debilitated constitutions, exhausted by bad habits and neglect. It is not con- fined to either sex, or to any age, one variety being peculiar to infancy, another more common in old age. It makes its appearance at first in large, distinct, flattened bullae, with an inflamed base, containing a serous, ichorous fluid, which soon becomes sero-purulent, purulent or sanious, rarely well concocted, often almost black. The blebs soon wither, and crusts form, varying greatly in thickness. They are always thickest in the centre, and of a deep brown, or black color. The first scab, however, is rarely permanent, but after a few days falls off, leaving an inflamed surface with superficial ulceration. Another scab rapidly forms which remains attached longer than the previous one. The ulcer, dis- covered by the removal of the scab, is rarely deep, or of a phagedaenic character, though by the repeatedjrenewal 84 bullae. of the scab, its cure may be prolonged indefinitely; and after being healed, it leaves behind it a livid stain that is visible for a long time. Though this eruption is not confined to any part of the body, it is by far most com- mon upon the extremities, especially the lower. Three distinct varieties have been described by authors, viz: Rupia Escha?'otica, Rupia Simplex, and Rupia Prominens. Rupia Escharotica. This variety attacks children, especially while at the breast, and during dentition. The ill-fed, filthy, and neglected offspring of the poor and destitute, are most exposed to it. It appears at first in livid, slightly elevated blotches, which soon become large, flattened, irregular bullae. These are filled with a turbid or sanious serum, which soon changes to a dirty blackish color; this escapes when the cuticle gives way, and an ill-con- ditional, superficial or slightly excavated ulcer is ex- posed, which gradually increases in depth and extent. These ulcers are surrounded by an areola of violet color- ed, inflamed skin and shew no disposition to heal. The eruption is usually successive; new bullae appear to run through the same course as the last. If the con- stitution has not previously suffered, it will now sympa- thize; there is now commonly fever, restlessness and considerable pain; and at last the little sufferer is some- times worn out by the irritation, and sinks exhausted BULLAE. 85 In favorable cases, the ulcers take on a more healthy aspect and slowly heal. At other times, the ulcers be- come phagedenic, and even sloughing ; and then, if they heal at all, they leave permanent, unseemly scars. This variety resembles much, both Ecthyma and Pemphigus, and is described by Willan, under the name of Pemphi- gus Infantilis. Rupia Simplex. In this variety the blebs are commonly not large; are flattened and filled with serum and lymph, at first clear, but soon becoming turbid, purulent, and thick, which dries and forms a dark brown rough scab, thicker in the centre than at the circumference. The skin shows no evidence of inflammation at first. When the scab falls off at the end of a week or ten days, the skin is found, most frequently, excoriated, and upon it a new scab forms, sometimes very rapidly, as in the course of a few hours, which goes through the same course as the last. Many times, upon the removal of the first scab, the skin beneath is found livid, but covered with a new epidermis. The discoloration gradually fades away, leaving the skin natural, without any scar or stain. At other times the scab is renewed many times, and the disease is thus protracted indefinitely. This eruption, like the last variety, though not con- fined to any part of the body, is more common upon the lower limbs. The bullae are rarely larger than from 86 BULL.E. one-third to one-half of an inch in diameter, and are commonly unaccompanied by severe constitutional symp- toms. Rupia Prominens. This variety differs from the last, in being confined to the limbs, especially the lower, and by the greater seve- rity of all the symptoms. The blebs are larger, the ul- cerations are deeper, the crusts are thicker and more permanent, and are attended by more severe constitu- tional symptoms. The appearance of the bullae does not differ from that of Rupia Simplex at first, except in their size. The contents, at first clear, go through the same changes, becoming opake, thick, and brown, and form thick scabs, which gradually increase in thickness, the centre being most prominent. These scabs are sur- rounded by an inflamed areola, which itself becomes the seat of a similar effusion of serum and lymph, that un- dergo the same changes of color and consistence, harden- ing into a scab and elevating the preceding crust, while they increase its diameter. This scab is surrounded by an areola like the last, which goes through the same process, and thus eventually produces a peculiar, rough, conical, dark greenish or mahogany colored scab, resem- bling very much the shell of the oyster, characteristic of this variety of the disease. These singular conical crusts, with their concentric rings, are often very adhe- rent, and are detached with considerable difficulty from BULLAE. 87 the skin, and remain fixed for a long time. At other times the scabs are less adherent, and can easily be de- tached, leaving the skin ulcerated to a greater or less extent, according to the time the scab was attached. After the removal of the scab, another commonly forms with great rapidity, by the drying of the lymph and fluid poured out upon the inflamed surface. This sec- ond scab, though resembling the first, has never as perfect and symmetrical shape as the other. In old and debilitated constitutions, upon the removal of the scab, a new one does not form, but the ulcer becomes foul and unhealthy, secreting a sanious, ichorous discharge; the edges become thick, puffy, elevated and sometimes shelving; the disease is now accompanied by pain and fever, and resists every plan of treatment. These ulcers are very tender, bleeding from the slightest cause, and they sometimes go on increasing in width and depth, till the patient is exhausted and sinks. When cicatrization is accomplished, the seat of the ulcer is for a long time discolored and tender. This variety of eruption is also usually successive, though the bullae are not numerous as in the preceding varieties, there seldom being more than one or two in the same stage. Causes. As has been already said, a constitution debilitated by excesses, intemperance and protracted disease, want of 88 bullae. proper food clothing and cleanliness, and exhaustion from misery and poverty, are its frequent causes. With children, Rupia sometimes succeeds the eruptive fevers, as Scarlatina, Measles and especially Small Pox. It has been supposed that this disease never occurs except as a sequel of Syphilis. It has been proved that this idea is incorrect. It is often complicated with other cutaneous diseases, as Scabies, Pemphigus and especially with Ecthyma, with which last disease it has many points of resemblance, as noticed by Bateman, Biett, &c. As in almost all other cutaneous diseases, the causes that excite it are often inappreciable. Diagnosis. Rupia bears a greater resemblance to Pemphigus and Ecthyma, than to any other affection. The globular bullae, and the thin, delicate, brown crust of Pemphigus are commonly distinguishable from the flattened bulla? of Rupia, with their thick, rugose, conical scabs, sur- rounded by inflamed areolae, the Epidermis of which is continuous with the scab, but often already undermined by the effusion of serum and lymph which enlarge and thicken the scab already formed. From Ecthyma it is not always so easy to distinguish Rupia. The elementary form of the eruption is in the one case, from the very first pustular, in the other bullous; and even after the formation of the scab, yet by the successive eruptions of the disease, the elementary BULLAE. 89 form may usually be found. The very obstinate charac- ter of the ulcer in Rupia will sometimes assist in distin- guishing the disease; yet, it must be acknowledged that in some cases the diagnosis is not easy, and Rupia and severe cases of Ecthyma seem to be scarcely more than varieties of the same disease. The difficulty is still increased when both diseases are seen upon the same patient, as is not unfrequently the case. Prognosis. After what has been already said, it is unnecessary to add that the prognosis must depend much upon the age, constitution, habits and condition of the patient. Rupia Escharotica is more frequently fatal than either of the other varieties. In Rupia Simplex, the Prognosis is almost always favorable, and in Rupia Prominens, though frequently an obstinate disease, perseverance and patience will usually succeed in curing it. Treatment. The general treatment of Rupia is very similar to that of chronic Pemphigus. The same attention to diet, rest and good air, with baths, tonics and laxatives is required. As a general rule, a more active tonic course will be re- quired in Rupia than in Pemphigus. m 90 BULLAE. Locally, fomentations should be applied to soften and remove the scabs; beneath these, the ulcers are almost always atonic and unhealthy and require tonic or stimu- lant dressings; some of the detergent ointments, or stimulating and astringent washes answer well. Biett preferred an ointment made of the proto or deuto-Iodurets of Mercury for this purpose. Rayer dusts the surface of the ulcer with Cream of Tartar. Perhaps no application is better than a solution of Nitrate of Silver, or of the Sulphate of Copper in water. The position of the limb is very important. After the ulcer has put on a healthy appearance, it should be treated with simple dressings. In an early stage of the eruption the blebs should be punctured and dressed with simple water dressings, or, what is better, with some mild astringents, as a weak solution of Alum, Nitrate of Silver, Sulphate of Cop- per, &c. ORDER 3d—PUSTULE. This order is characterized by small distinct tumors, filled with purulent matter, upon an inflamed base. The diseases of this order usually terminate either by absorption and resolution, by the rupturing of the pus- tule and the effusion of the pus forming scabs or crusts, by ulceration, or by degenerating into a true tubercular affection of the skin. After being cured, the pustular diseases may or may not leave behind them permanent cicatrices. Besides the variolous diseases, there are three affections belonging to this order, viz. Ecthyma, Acne and Impetigo; in this connection will be described Favus also, rather in conformity with custom, than from the real pathology and appearance of the eruption, which cannot, strictly speaking, be called pustular. While some of the diseases of this order are partial, and are usually confined to a particular locality, as Favus and Acne and sometimes Impetigo, Ecthyma and often Impetigo may attack either simultaneously or successively the whole surface. In this order of cutane- ous diseases, w7hile each pustule usually dries up in the course of a few days, the disease may be protracted for an indefinite period, by successive eruptions. The eruptions belonging to this order have been divided into two divisions; the larger with an inflamed 92 PUSTULiE. base and areolae have been called Phlyzaciae; and those with smaller and more chronic pustules, with an unin- flamed base are called Psydraciae. This distinction is not of much practical importance. Ecthyma. Syn.—Furunculi Atonici; Agria; Phlyzacia, &c. This name is given by Willan to a non-contagious eruption, characterized by distinct pustules, frequently of considerable size, scattered over the body, usually not very numerous or approximated. These pustules com- monly terminate in brown scabs of considerable thick- ness, which in falling off leave a red or livid spot, last- ing for a considerable time, and sometimes are succeeded by permanent little scars. The pustules are called by Bateman Phlyzacious, and are upon red, indurated bases, with little or no inflamed areolae surrounding them; they are rarely grouped or confluent, but are usually at a considerable distance from each other; they are not necessarily confined to any one part of the body, though less common upon the head and face; and though some- times general, are usually restricted to some localities. This eruption makes its appearance by small pimples, usually few in number, wiiich very soon, often almost from the commencement, become pustular upon the summit; a brown, or dirty green scab succeeds, and if undisturbed, remains for a few days, more or less, accord- PUSTULE. 93 ing to its size, then falls off and leaves a red or livid spot, and, where the pustule has been large, a small scar. In depraved and broken down constitutions, in- stead of this termination, ulceration takes place under the scab, and is continued for an indefinite time, at last healing with a permanent scar. The more ordinary seat of this eruption seems to be on the limbs, shoulders or neck, and though not usually preceded by any severe constitutional symptoms or fever, yet there is frequently evidence of a disordered state of the system generally, and particularly of the digestive organs, indicated by de- pression, indigestion, uneasiness, sleeplessness, want of appetite, pain in the back and limbs, &c.; the worst cases of this disease are usually connected with consi- derable general derangement of the system. The duration of the disease varies from ten days to many months, according to the variety of the eruption, and the age, constitution and circumstances of the patient; it frequently accompanies, or is ingrafted upon, some other cutaneous disease, and seems sometimes to be symptomatic of some internal inflammation or de- rangement ; at times also it seems in a degree critical. Willan made four varieties of Ecthyma, viz. Ecthyma Vulgare, Ecthyma Infantile, Ecthyma Luridum, and Ecthyma Cachecticum; later dermatologists have done much to simplify the study of cutaneous diseases by re- ducing the number of Willan's varieties; at the present day, only two distinct varieties of Ecthyma are usually recognised by authors, the acute and chronic; the acute comprising only one variety of Willan, Ecthyma Vul- 94 PUSTULE. gare, and the Chronic comprehending the remaining three. For practical purposes, this division is most con- venient, though there seems to be some reason for the distinctions of Willan, all his varieties being occasion- ally met with, well characterised. Ecthyma Vulgare, or Acute Ecthyma. This variety is characterized by the eruption of round, distinct, inflamed pimples upon a hard base, usually appearing upon the neck, shoulders, or back of young people, more commonly upon females; very soon after the appearance of these pimples, upon the summit of each will be found a pustule, which in two or three days is succeeded by a brown scab; this scab, after re- maining a few days, is detached, leaving behind it a livid spot, which gradually disappears entirely. Sometimes beneath this scab, when it is detached, slight ulceration is found to have occurred, and then a superficial scar will remain permanently. This eruption commonly makes its appearance in warm weather, and is often dependent upon intestinal irritation. In this variety the pustules vary in size from one or two lines to half an inch, or even more, in diame- ter ; they are commonly few in number, distinct and dis- tant from each other, accompanied by considerable pain and tenderness, which depend much however upon the size of the pustules. The eruption is usually succes- sive, but often disappears altogether, under proper PUSTULE. 95 treatment, in from one to three weeks. There is no re- lative proportion between the degree of the inflammation of the base, and the quantity of matter contained in the pustule; many times upon a large inflamed base, a very small conical pustule will appear, and at other times a large flat pustule will appear upon a slightly inflamed base, and resemble Rupia or Pemphigus. The scabs or crusts also vary very much in thickness, at times being thick and conical, and again being thin, and often mere scales. In some of the pustules, the purulent matter is absorbed, and desquamation completes the cure. Troublesome ulceration is a rare result of this variety with an individual not reduced or with a sound con- stitution. Chronic Ecthyma. Here the pustules are commonly large, the progress slower, and the tendency to successive crops of the cha- racteristic pustule is greater than in the acute variety. Chronic Ecthyma often occurs in young children—Ec- thyma Infantile of Willan. It is found for the most part in ill clad, ill fed, and destitute children accustomed to privations, and without a proper regard to cleanliness; and under such circumstances it is very obstinate in its character, and often by successive eruptions is kept up for many months. It is commonly found associated with intestinal irritation. The pustules vary very much in size, and sometimes a very small one and one of the largest size will be found 96 PUSTULjE. in juxtaposition, though they are generally larger than in Ecthyma Vulgare; they are also much more frequently found upon the face. Ulceration is not unfrequent, and then usually a small scar remains after the eruption is cured. At times, these ulcers are very unhealthy and obstinate, and resist all means applied to heal them. As in the last variety, howTever, many of the pustules dry up without breaking, and are simply followed by desqua- mation; the colour of the base of the pustule varies, from a bright pink to a livid red, according to the consti- tution of the patient. Chronic Ecthyma often occurs also in the other ex- treme of life, in the same class of poorly clad, half starved, feeble, broken down patients, constituting Ec- thema Luridum of Willan. The pustules are here large, often flattened upon an inflamed base, with a dull, livid areolae ; they are commonly followed by ulceration, which is apt to be of an unhealthy and obstinate character; the discharge from these ulcers is frequently sanious, which desiccating, forms thick black scabs, often elevated in their centre like Rupia; the inflammation extends and involves the sub-cutaneous cellular substance, and con- siderable puffiness takes place. There is a tendency in these atonic inflammations to increase in extent, the scabs are conical and adherent, and if undisturbed, will often remain attached for weeks, in this respect also resembling Rupia ; when these\cabs are removed by violence, unhealthy ulcers with hard edges are discovered, which are often, with great dif- ficulty, covered again with crusts. These ulcers may PUSTULiE. 97 occur upon any part of the body, but are by far the most frequent upon the lower limbs. Ecthyma sometimes appears in very numerous pus- tules, is not confined to any age, and is very chronic in its course; this form of chronic Ecthyma was described as a distinct variety of Willan under the name of Ecthyma Cachecticum, but does not differ from Chronic Ecthyma generally, excepting in the greater number of the pus- tules, its occurring at every age, and also in the greater obstinacy of the eruption. The pustules are larger when the disease is not confined to old age, though there is a great variety in the size;, they are gener- ally smaller upon the trunk than uponthe extremi- ties. It is often preceded for several days by some febrile movement, anorexia, &c, and the eruption is al- most always successive, every stage of the eruption being frequently seen in the same individual, and often upon the same limb, from the first appearance of a pimple, to the desquamation. It is often accompanied during its whole course by fever, irregular pains and disordered state of the digestive organs. It seldom occurs except in debilitated and broken down constitutions, exhausted by intemperance. Causes. As already observed, Ecthyma is confined to no age, sex, or season of the year. It is often developed by irri- tating substances, applied to the skin, as Antimonial N 98 PUSTULE. Ointment, Croton Oil, &c, by the bites of insects or leeches, &c, and by the habitual handling of irritating substances, as upon the hands of grocers, masons, &c. The general causes of Ecthyma are want of proper food, clothing and cleanliness, inhabiting cold, damp, unhealthy situations; the habitual excessive use of stimulating food and drinks; every thing calculated to exhaust and deteriorate the strength of the constitution, as want of sleep, depressing passions, suppressed, irregular, or exces- sive catamenial discharges, &c. Sometimes Ecthyma attends pregnancy; and irritation of the pulmonary or intestinal mucous membrane, may be considered one of its most frequent causes. The system, after some severe disease, especially the eruptive fevers, seems to be in a peculiarly proper con- dition for the appearance of Ecthyma; the most pro- tracted and obstinate case the author ever witnessed appeared in a lady, previously healthy, as a sequel of vaccination; and after months of suffering the case proved fatal. It sometimes accompanies other cutaneous eruptions, as Impetigo, Favus, and especially Scabies; in such cases the remedies, used in the treatment of the original disease, often seem to be the cause of Ecthyma. In many cases, however, no adequate cause can be as- signed for the eruption. PUSTULjE. 99 Diagnosis. The diagnosis of Ecthyma is not difficult in most cases, and where difficulty does exist, it most frequently arises from its being complicated with some other cutaneous disease.* Ecthyma Luridum and Rupia resemble each other so much at times, as to render it difficult to make a positive diagnosis. The elementary forms of the two diseases are different, the one being pustular, the other bullous; in Ecthyma the shape of the scabs are amor- phous, and the ulceration succeeding these scabs is usually superficial; while in Rupia the scabs have a peculiar characteristic form, conical, with imbricated rings, and the ulceration is deeper. From Sycosis and Acne, the broader inflamed areola of Ecthyma, its larger pustule, its usual situation on the limbs, will serve to distinguish it from the small pustule with a tubercule base, situated upon the face and shoulders. Ecthyma is sometimes confounded with boils; in the latter the whole skin is involved and usually the sub- cutaneous cellular substance also, terminating in a small slough, while in Ecthyma the inflammation is more superficial and proceeds from without inwards. It may not, in all cases, be practicable to distinguish the pustu- lar form of Syphilitic disease from Ecthyma; generally, the history of the case, the little irritation accompanying the Syphilitic eruption, its copper colored areola, its situation upon the forehead and commissure of the nose, will enable us to come to a correct decision. 100 PUSTULiE. Prognosis. Ecthyma, uncomplicated with any other disease, and in a subject not entirely worn out, is not a dangerous disease. The prognosis in regard to a speedy cure, will, of course, depend very much upon the constitution, age, habits and situation of the patient. Treatment. To remove as far as practicable every exciting cause of the eruption, to observe a mild unstimulating diet, to correct the secretions, to have the patient removed to a dry, airy situation, and to pay strict attention to clean- liness, will cure a great proportion of cases of Ecthyma. In acute cases, the more decided anti-phlogistic treat- ment, by depletion, abstemious diet, &c., may at first be necessary; much may also be accomplished by baths; they may be tepid, cool or cold, they may be simple, mucilaginous, alkaline, salt, sulphurous, &c, according to the circumstances of the case. The diet also should vary to suit the case; with one it should be strict and abstemious, while with another it should be generous, nutritious and stimulating; the drinks in one case should be cooling and diluent, in another they should be tonic bitter or stimulating. Considerable diversity in the medical treatment is required in order to be well adapted to the different PUSTULE. 101 stages and varieties of Ecthyma. While in the acute and inflammatory form, purgatives and even venesection are required, in many cases of Ecthyma Luridum, In- fantile and Cachecticum, tonics, as the bitter infusions, mineral acids, preparations of Iron, Quinine, &c, are necessary. Great attention should be paid to the state of the bowels, as they are frequently deranged in this disease, but in the asthenic form of the eruption, the aperients should always be combined with tonics. Ec- thyma Infantile especially is often complicated with a tumid, hot state of the bowels, with vitiated secretions, and the eruption cannot be cured till the digestive organs are regulated. As an alterant, in the asthenic form of Ecthyma, the Hydriodate of Potash often succeeds well. In Ecthyma Cachecticum and Luridum, when the scabs are removed or fall off, they discover foul, unhealthy ulcers which require to be treated with stimulant, detergent ointments, or stimulating astringent washes before they will heal. The ointments of the Proto or Deuto-Ioduret of Sulphur, of the Hydriodate of Potash, of the lodurets of Mercury, the washes composed of the solution of the Nitrate of Silver, the Sulphate of Copper, Alum, or Tine, of Myrrh, &c, will answer this purpose. The Cream of Tartar dusted upon these ulcers has also been recommended and is very efficacious. The general treatment should be continued for some time after the disappearance of the eruption, so as to prevent a relapse. 102 PUSTULjE. Acne. gyN<—Varus; Couperose; Rosacea; Sycosis; lonthus; Gutta Rosea or Rosacea; Bacchia Rosacea; Dartre Pustuleuse Disseminee; Copper Nose. Since the time of Willan, by the term Acne has been understood a noncontagious eruption, characterised by small pustules, upon a conical inflamed base of greater or less size, usually of a dull red or livid, though some- times of a natural colour; after suppuration the base does not subside, but continues for some time, and often enlarging, forms small, hard, indolent, deep red, or livid tumors, which are very slow to disappear. Acne usually appears about the age of puberty in both sexes, and when once established, unless subjected to proper treat- ment, continues till the patient attains the age of twenty or twenty-five years, when it generally subsides; some times, however, it persists long after this period, till the patient is thirty or even forty years of age, and one variety is most frequent after this period of life. The most frequent seat of this eruption is the back and shoulders, and sometimes it is confined to these parts, though usually it affects the face at the same time, especially the forehead and cheeks. It is rarely confined to the face; sometimes, though not often, it attacks the upper limbs, very rarely the lower; when it attacks the arms, it is upon the extensor surface only. Acne attacks those parts which are best supplied with sebaceous PUSTULiE. 103 glands and hair follicles; and the inflammation of these organs constitute the pathology of the disease; many of the inflamed glands and follicles do not terminate in suppuration at all, but after remaining in a state of in- flammation for a longer or shorter period, the inflamma- tion subsides, and the tubercle is removed by absorption. Upon the summit of these tubercles the duct of the follicle can generally be seen; when it is visible, it is often of a dirty black color, from the exposure of the se- baceous matter to smoke and dust; in many cases the orifice seems obliterated, sometimes before, but more often, by the inflammation and suppuration; and there is perhaps some reason for the opinion, that the oblitera- tion of the duct, with the consequent accumulation of the sebaceous matter, is occasionally the exciting cause of the inflammation. Willan and Bateman made four varieties of Acne, viz. Acne Punctata, Simplex, Indurata, and Rosacea; to these, two other local varieties have since been added ; the first, Sycosis, differs from the other varieties in being confined to the follicles of the beard on the chin, upper lip, and cheeks; and Acne Sebacea is a well characterized variety, first described by Biett, and is usually confined to the face. The first three varieties are in fact only three stages of the same disease, and have been grouped together into one variety, Acne Simplex; according to this arrangement, there is one general and three local varieties, viz. Acne Simplex—and Acne Rosacea, Acne Sebacea and Sycosis, the last being confined to the 104 PUSTULiE. beard, and Acne Rosacea attacking the nose, while Acne Sebacea is found upon the face. Acne Simplex i^ characterized by the eruption of pim- ples, varying in size frOm a pin's head to a large bean, isolated, distinct, scattered over the back, neck, should- ers, face, and sometimes arms> which slowly suppurate and then dry; a desquammation usually succeeds, while the base of the pustule usually remains, for an indefinite time, in the form of a dull red or livid tumor; this at last is absorbed, but frequently leaves behind it, espe- cially where the back has been the seat of the eruption, a small white cicatrix; which is permanent. This erup- tion is unaccompanied with much pain or any consti- tutional irritation, and generally the subject, in other respects, enjoys good health. The disease seems to consist in a local inflammation, attacking the sebaceous glands, and subsequently the hair follicle of the skin; some alteration in the charac- ter of the secretion of the gland accompanies this inflam- mation, either as cause or effect, and the sebaceous mat- ter accumulates. In many cases the accumulation of sebaceous matter alone seems to excite slow inflamma- tion by distension. By examining the skin affected with this disease small black points are seen, often very num- erous, especially upon the face; often the pimples them- selves are surmounted by this black point, caused by the exposure of the accumulated secretion; if the tubercle be pressed between the two thumb nails, the sebaceous matter may be squeezed out, resembling a small grub or PUSTUL^E. 105 worm, with a black head. This constitutes Willan's variety, Acne Punctata. When the progress of the eruption is very slow, all the distended follicles and inflamed glands do not sup- purate ; and in those that have done so, the base does not disappear by resolution, but slowly increases in size and hardness, the colour remaining dull red or livid, till true tubercles or tumors of the skin are formed; these tubercles often involve the subcutaneous cellular tissue, and remain indolent for a long time while the intervening skin gradually becomes thickened; the eruption in this state forms Willan's variety of Acne Indurata. It is a very obstinate affection, and often resists every mode of treatment for months or even years; there is usually but little pain or uneasiness accompanying this eruption, ex- cept occasionally when the inflammation involves a fila- ment of nerve, and then the pain and tenderness is troublesome. The pimples are almost always distinct, though some- times several by increasing in size may seem to coalesce, and form one large tumor. From the number and size of these tubercles, and the depth of the inflammation, the skin of the part affected by this eruption becomes very much thickened and discolored, so as greatly to dis- figure the face. This eruption occasionally springs up simultaneously, though it is usually successive, and upon the same indi- vidual the disease can be seen in most of its varieties and in all its stages, from the black point of the desic- cated sebaceous matter in the follicle, to the small, white, o 106 PUSTULiE. oblong characteristic scar of Acne, through all the inter- vening degrees of pimple, pustule and hard livid tuber- cle. In severe cases of Acne, the whole affected skin becomes oily and greasy to the touch, often glistens in the light, and sometimes exhales a peculiar odor, unless great attention be paid to cleanliness. The number and extent of the tubercles of course vary much; sometimes the eruption is confined to a single part, as the face, back or shoulders, while in other cases it is very extensive, affecting, simultaneously or successively, several or many parts of the surface; the disease however, even when most severe, does not ap- parently affect the general health, but is often seen in strong, robust individuals, enjoying in all other respects excellent health. Acne Sebacea. Biett was the first to discribe another very common variety of Acne, called by him Acne Sebacea; this variety differs materially from the preceding, and its dis- tinction is now well established and admitted. From irritation, or possibly a low grade of inflammation of the sebaceous gland, or more probably from some unknown cause, the sebaceous secretion is poured out in unusual abundance, and dries into scales or thin crusts, of a dirty grey or brown color, which cover the whole of the affect- ed skin. This variety most often attacks the face, forming a PUSTULjE. 107 mask, and somewhat resembles Eczema or Impetigo, and has been, it is said, mistaken for Icthyosis. It is usually confined to the face, though it may extend to the back and breast, and in some rare cases, has been gene- ral. When first poured out, the secretion is liquid, soft and easily detached; but when it has dried, it adheres to the skin so very closely as to be with considerable difficulty separated. Beneath this crust, the skin, when exposed, is found irritated or inflamed, and occasionally this irritation goes on, till true Eczema or even Impetigo is excited by the presence of this matter. This variety may exist alone, though it is more fre- quently seen with the other varieties already described. It is rarely seen in old age, and still less frequently in children, and though very obstinate and rebellious, and sometimes lasting for years, is usually less so than Acne Indurata or Rosacea. Profuse perspiration will often de- tach many of these crusts, soon to be reproduced; and though local irritation will sometimes apparently excite it, yet in almost all cases its causes are inappreciable. Acne Rosacea. This well established and common variety usually commences upon the nose, and thence extends to the face, cheeks, forehead or neck, and in its progress is more indolent and tedious than Acne Indurata. It commonly does not occur till after the middle of life, though some individuals, especially those hereditarily predisposed to 108 PUSTULiE. it, are in youth attacked by it upon exposure to the heat of the sun, to cold wind, or when laboring under some intestinal mucous irritation or dysmenorrhea, &c. In slight cases there are only a few small pimples, but an Erythematous blush extends around them so as to involve the intervening skin; and from this, cases occur of every degree of severity, till the nose is found en- larged to twice its natural size. When the disease is allowed to go on without interruption, the part becomes congested and of a red, violet or livid color, the enlarged and varicose veins are distinctly seen coursing along in bluish lines beneath the cuticle; up to this time papular elevations are usually few, small and slow in their pro- gress, while here and there one suppurates, and the pim- ple rather increases than diminishes in size from the suppuration. The number of the papules increases, the intervening skin is affected, thickens and becomes very rough and discolored, producing great deformity. This disposition to become hypertrophied does not always exist, but the redness, occasional suppuration, and the few small tubercles with enlarged veins, constitute the whole disease. There is a great tendency in this variety to extend slowly; but it sometimes remains stationary for a long time, confined to a single part, as the nose or cheeks. It is the most obstinate of all the forms of Acne and though great fluctuations take place in its severity it is apt to continue for many years; in such chronic cases the skin at last becomes thickened and rough, and even PUSTULiE. 109 if the inflammation be subdued, and the enlarged veins diminish, so that the blood circulates naturally again, it still remains altered in its texture and appearance for life. All shades of the disease can often be seen upon the same individual, and often upon a very small space, from the simple Erythematous blush, produced by congestion, to the thickened skin with its enlarged tortuous and varicose veins, with a few small papular elevations; or even to a still later stage, with the large tubercles with here and there a pustule, the thickened rugose skin, and the deep red, violet or livid color of inveterate Gutta Rosea. As has already been said, it is a disease of adult life, and, though with many exceptions, it is generally caused by excessive eating, intemperance in the use of alcoholic drinks, &c. It is temporarily worse at evening and by a single indulgence at table. It often occurs, or at least becomes worse, in females during difficult menstruation, and at the turn of life. Sycosis. Sycosis is a pustular eruption, very analogous to the other varieties of Acne already described, differing from them principally in its locality. It is developed almost exclusively upon the upper lip, chin and cheeks of adult males, sometimes extending to the neck; females are almost entirely exempt from the disease, though cases are upon record where they have suffered from it. It 110 PUSTULE. first appears in small red pimples, which are usually more rapid in their progress than in the other varieties of Acne; commonly in three or four days, upon each papule a small pustule is seen, traversed by a hair; this pustule bursts and its thick yellow contents escape, which seem to consist of pus and vitiated sebaceous matter; this dries upon the skin, resembling very much the crusts of Impetigo. The seat of the disease seems to be in the hair follicle and in the sebacious gland beneath; and M. Gruby, of Vienna, has discovered that, within this pustule, at the root of the hair, there is sometimes found a parasitic plant, similar to that discovered in Favus. This vegeta- tion never sprouts so as to extend above the surface of the skin, but is confined to the hair follicle, and there completely surrounds the hair, forming a sheath around it. In very severe cases of Sycosis the inflammation extends beyond the skin, so as to affect the cellular tissue, and produce considerable elevations and tumors, which are often permanent, not subsiding with the in- flammation; also, after severe suppuration has taken place in the pustules, the base instead of disappearing by resolution, has a great disposition to continue, sometimes increasing in size, forming those tubercles or tumors so characteristic of Acne. Often the inflammation is so severe that the bulbs are affected, and the hair loosened, falls out, leaving the surface bald; this loss of the hair is rarely permanent the hair springing up again as soon as the disease has PUSTULJE. Ill been cured; the new hair is at first white and downy, but gradually recovers its natural appearance. The eruption is always successive; the first pimples run their course and the scabs fall off in a fornight from the commencement of the disease, while the eruption is kept up for months, and even years, by new pustules. Considerable heat, pain and especially a sense of tension accompany the disease, depending however very much upon the extent and severity of the inflammation. The duration of the eruption is various, and even when apparently cured, the patients are very subject to renew- ed attacks. When the disease yields to the remedies made use of or improves spontaneously, the successive pustules are less numerous, the crusts fall off, the inflammation abates, the swelling subsides, the tubercles are most of them absorbed, the hair reappears, and the face is left without a mark; this variety, unlike the other forms of Acne, is not commonly followed by the characteristic scar. Sometimes, however, where the inflammation has extended through the true skin and affeCted the cellular tissue, a permanent tubercle remains, or a scar shews the seat of the suppuration; but this does not occur in cases of ordinary severity. These permanent tubercles are commonly not found, except in the old and debili- tated, or in the- scrofulous, where the powers of absorption are very imperfect. The most usual cause of this distressing variety seems to be the use of a dull razor used in shaving the face, yet some trades seem to predispose to this disease, 112 PUSTULjE. especially where the face is exposed to great heat; by many it is thought to be communicated from one to another by the razor, or other shaving utensils; this idea of contagiousness, though denied by most dermatolo- gists, is supported by some very striking and well authen- ticated cases, and is readily explained if we admit its vegetable origin, as asserted by M. Gruby. At all events it not unfrequently prevails epidemically, and M. Manry states, that he has known it communicated by a razor from one individual to another in the Hospital at Rouen. Causes of Acne. The causes of Acne are very imperfectly understood. Acne Simplex usually appears about the age of puberty in both sexes, and continues a few years, commonly dis- appearing from the twentienth to the twenty-fifth year, though sometimes lasting much longer. It sometimes exists in a very severe form without there being any other indication that the patient is not in excellent health; it sometimes seems somewhat periodical in its character, disappearing wholly or partially, to be renewed the fol- lowing spring. Individuals, with a bilious or lymphathic temperament, with dark hair and smooth pliable skin, seem to suf- fer most from it. It sometimes seems to be induced by sedentary habits, by protracted watchings, by those oc- cupations where the head is bent down, by dysmenorrhea, or amenorrhea, by the use of cold drinks when the body PUSTULiE. 113 is heated, by the intemperate use of alcoholic drinks, by exposure of the face to great heat, especially when the head is low, as with cooks, blacksmiths, &c, and some- times by intestinal irritation. Masturbation especially may be mentioned as one of its frequent causes. Stu- dents and those accustomed to intellectual labor, seem also to be especially subject to it. It also is excited sometimes by depressing moral emotions, as prolonged grief, great anxiety, &c. Although some slight cases of Acne Rosacea may oc- cur before adult life, yet, severe cases of it are rarely seen before mature or declining years; it is common to both sexes, though as it frequently arises at the turn of life, it may be said to be rather more frequent with females than with males. Excess at the table, especial- ly in the use of spirituous liquors, is its most frequent cause. Suppression of any habitual discharge, as of the menses or the haemorrhoids, hereditary predisposition, want of cleanliness, the use of stimulating washes, cosmetics, &c, have been enumerated among the occa- sional causes of this variety. Sycosis sometimes seems to prevail epidemically; ex- posure to strong heat, the use of a dull razor as before mentioned, the use of irritating soap, excess at the table, stimulating drinks, and probably contagion, are the most usual causes of this variety. p 114 PUSTULE. Prognosis. Acne Simplex differs much in its prognosis according to the form in which it appears; in most cases it is cura- ble, but when it has been present for a long time, and numerous tubercles are formed, constituting the Acne Indurata of Willan, it is exceedingly rebellious, resisting for a time all efforts to cure it, but at last gradually sub- siding, till it disappears spontaneously. Acne Rosacea is always a most obstinate affection; and though it sometimes completely disappears either spontaneously, or more commonly after an attack of fever or of Erysipelas of the face, yet in most cases, we are unable to remove it entirely by any means with which we are acquainted. Sycosis usually yields to well directed treatment, though when it has been severe, the tubercles often continue through the remainder of life. Diagnosis. The conical form of the pimples, the seat of the erup- tion, the follicles distended with the sebaceous matter, the indolent course of the disease, and the permanent tubercle, or the small, oblong, white cicatrices which fol- low this affection, usually are sufficient to distinguish it from all others. The absence of severe pain and itch- ing, and of all constitutional disturbance assist in the diagnosis. PUSTULE. 115 In Ecthyma the pustules are larger, more superficial during their whole course, have thicker crusts, and do not degenerate into tubercles. From Impetigo we can distinguish Sycosis by its deeper pustulation, its slower progress, its greater obstinacy, by its locality and by the tubercles that remain after the pustules. From the pustular form of syphilitic eruption it is dis- tinguished with more difficulty. In Acne, however, the pimple is conical, small and hard, it is situated upon the cheeks, chin, nose and back; it has no tendency to ulcer- ation and loss of substance, while in syphilitic eruptions the pimples are large, flat, unequal, shining, and of a cop- per color; their most usual location is at the commis- sure of the lips, at the junction of the alae of the nos- trils with the face, and upon the forehead, though in the last situation they appear much more frequently as a papular, than as a pustular disease. In syphilitic erup- tions also the pain and itching are still less than in Acne, while they have a far greater tendency to destructive ulceration. Treatment. If the cause of the eruption can be discovered, it should be removed, and sometimes the disease will spon- taneously disappear; the state of the digestive and of the uterine organs should be attended to, and corrected if deranged; inattention to the state of these functions will often prevent any benefit from all other treatment. The different stages and varieties of Acne require differ- 116 PUSTULiE. ent treatment, In Acne Simplex, cathartics, diluent drinks, with an occasional loss of a little blood, followed by the use of the milder tonics, are all the general treat- ment usually required. The diet should be very exact and abstemious, and all violent exercise and exposure to heat should be avoided. The same course of tonics that has been so often recommended in the treatment of other eruptions should be used here; as the mineral acids in bitter infusions, the preparations of bark, &c. The patient should be particularly cautious in his drinks; the excessive use of coffee will sometimes main- tain the eruption, notwithstanding every effort made to cure it; it is hardly necessary to add that he should avoid all the heating condiments, as pepper, mustard, spices, &c, and all alcoholic drinks. Experience has also proved, even in patients who do not seem plethoric or strong, that a moderate venesection and the use of purgatives will promote the cure. Besides these general means, local applications to the face are commonly necessary. When the eruption is acute and inflammatory in its character, stimulating washes and ointments should be prescribed with cau- tion, or the skin will be irritated and the disease ren- dered worse; soothing and cooling applications will here succeed better. As a stimulating ointment, Biett often prescribed that made of the Ioduret of Sulphur, from twelve to twenty grains to the ounce of lard, and Caze- nave speaks highly of its efficacy. The solutions of Nitrate of Silver—the Sulphates of Iron and Copper—and of Arsenic of a strength adapted PUSTULE. 117 to the case, are useful for the same purpose. Probably the solution of the Corrosive Sublimate in Alcohol or Cologne Water, in the proportion of one half a grain to an ounce, gradually increased to double or quadruple that strength, is as convenient and efficacious a wash as can be used. A weak solution of Iodine, from six to ten grains to an ounce, is also a useful application, especially in dispersing the tubercles in Acne Indurata. The local application of the vapor douche, for fifteen or twenty minutes, is useful for the same purpose, and when the circulation of the skin is very inactive, its effi- cacy may be increased by the addition of some stimu- lant, as Iodine; where the tubercles of Acne Indurata are very obstinate and inflamed, the application of a leech, or the abstraction of a few drops of blood by the lancet, is often of service; and when there is reason to believe that a tubercle contains pus, it should be laid open and dressed with warm fomentations. When other means fail, we sometimes succeed, by administering empirically some articles of the Materia Medica, which experience has proved are occasionally successful in the treatment of these diseases, as Arsenic, Cantharides, Corrosive Sublimate and Iodine. These remedies do not seem so well adapted to the cure of dis- eases of this, as of several other orders, yet their effects are sometimes striking. A great number of stimulants, astringents, and sorbi- facients have been recommended as local applications in Acne Rosacea; this variety is always an obstinate and sometimes incurable disease. The most efficient appli- 118 PUSTULiE. cations are Tincture of Iodine, solution of the Sulphate of Iron in water, and of the Corrosive Sublimate in alco- hol ; in order to be of utility they should be applied with great perseverance; local bleeding may be tried at the same time, and too great attention cannot be paid to the diet, exercise, and general habits; attention should also be paid to the state of the mucous surfaces. Caustics, as saturated solution of Nitrate of Silver, the concentrated acids, the Caustic Alkali and Caustic Solution of Iodine are occasionally used with success, though in most cases they are too severe, and are occa- sionally followed by unpleasant consequences. While these local applications are made, some alterative, as Plummer's Pill, or the Blue Mass, or minute doses of Corrosive Sublimate will assist. In the treatment of Sycosis it should be remembered that the disease can be maintained indefinitely by the the use of the razor, and on this account shaving should not be allowed; the beard should be clipped by scissors, and as a hair becomes loose, it should be extracted, as it then irritates like any foreign substance. Emolient poultices applied to the inflamed part, with leeching if the inflammation is very severe, and soothing mucilagin- ous or narcotic washes, constitute the best local treat- ment for the first or inflammatory stage. Purgatives, and if the patient be robust, venesection, may also be important. After this stage has past, the vapor douche, some astringent or stimulant washes or ointments are often useful; and at this stage the internal use of some tonic, as some bitter infusion, with or without one of the PUSTULjE. 119 mineral acids, should be tried. During the whole course of treatment, too great care cannot be paid to the state of the digestive organs, and to the quantity and quality of the food. IMPETIGO. Syn.—Milk Crust; Cmsted Tetter; Psydracm; Run- ning Tetter; Dartre Crustacee; Melitagra of Alibert. By Impetigo is now understood, a non-contagious cutaneous disease, characterized by small, grouped and agglomerated pustules, not surrounded by an inflamed areola; in the course of a few days these pustules burst, and pour out a viscid secretion resembling honey, which soon dries into thick, rough, yellow or greenish crusts. This eruption is usually confined to a small part of the surface, as to the limbs, face or scalp; but at other times, by its successive eruptions, it becomes almost general. When the crusts have once formed, the disease may be prolonged indefinitely by the exudation of this viscid secretion, without the reappearance of any of the ele- mentary pustules; frequently, however, when the disease is prolonged, pustules will be constantly renewed, as at first, and the affection may thus be maintained by the successive eruptions. The individual pustules are small and superficial, and the eruption is commonly unaccompanied by any consti- tutional disturbance; but at other times, there is slight general derangement, as loss of appetite, thirst, restless- ness, constipation, &c. There is generally considerable PUSTULE. 121 heat, smarting, sense of tension, &c, in the affected part; the skin is swollen, and the neighboring lymphatics are affected, especially when the scalp is the seat of the disease. The duration of the disease varies from three or four weeks to months, though commonly it is not a very obstinate affection. When apparently cured, the patient is liable to a relapse, and the vulgar prejudice, that this eruption is at times essential to the health of the patient is not without foundation, especially in children, where attempts to dry it up by local applications are not unfre- quently followed by unpleasant consequences. When the crusts are removed prematurely, the skin beneath is found slightly ulcerated, though sometimes it is only in- flamed, smooth and shining, upon which the viscid secretion is poured out in great abundance, and by its desiccation a new crust is rapidly formed. The following varieties of Impetigo have been de- scribed by authors: Impetigo Figurata, Sparsa, Scabida, Rodens, Erysipelatodes, Larvalis and Capitis. Several of these varieties are to be distinguished from each other only by some slight peculiarity of form or appearance, and for practical purposes, their number might be reduced, but in conformity with general custom in describing this disease, the distinguishing marks of these varieties will be given. ma> Rubrum I ' .-. W -t, ' ^^ ■ Y,i-etna oftlu J?a,ct Ecz/'?//^ ^. „— ■», ->i' t Xit? ;<--' 3 Acarus Sea 1st a 6 Sc&boes ILeriM' s Circinnatum Ru/zia Tronvinens. Sycosis vMenti. Acne 14 13 12 O-."•>>' / v. « . '. "o 0> ■iSui V O , /..; t//'^, Q3.0 4-'- ^4/ ■> ( *V- yki < .-fcr 20 24 Impetigo Capitis ■:£l v*. Fauns Impetigo (rraniolafcv Capitis 25 ^f *■ Impetigo Sparsa iri-u**-- fc'Vl ■ w ^'*-?'*^*H w fM'jeetiffo Figurata -U-^V?*^ Acaras FoUiculoriem. Klauprech K Menz el's LilK /*/;»' ^ s //y M * ♦ • ****** * * w- ;■ * « ♦ ' ,» . A,. . » » » * V '■ * "__^ ......_,.. . '■JfeA*—*' X/ichen St m.fpli.z ~Pvla.ri ,v \ \ XK'^ Ss Jjich-en- Cbrcumscriplus. <*■ V'WWS '^' Fs on as is Diffusa Fsoriasis Cuttata Cry rata, 42 ^lopen of ///r Heard Color from the .Ail rate of Silt 55