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NATIONAL LIBRARY OF MEDICINE
       Bethesda, Maryland
   JUL
.   24
*J945 <p 
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BLANCHARD   &  LEA
HAVE JUST ISSUED AN
ATLAS   OF   CUTANEOUS   DISEASES.
BY J. MOORE NELIGAN,  M. D., M. R. I. A., &c,
In one very handsome quarto volume, extra cloth.
WITH  SPLENDID  COLORED  PLATES,
PRESENTING NEARLY ONE HUNDRED ELABORATE REPRESENTATIONS OF DISEASE,

                          COLORED AFTER NATURE.
Price $4 50.
  This beautiful volume has been prepared by the author as an accompaniment
to his " Practical Treatise."   No  pains have been  spared to render  the
figures accurate and trustworthy portraits of a class of affections which, perhaps
more than any other, require this mode of pictorial elucidation, and as the two
works contain references from one to the other, taken together they may be said
to constitute a complete manual on the pathology, diagnosis, and  treatment of
cutaneous affections.
  A compend which will very much aid the practitioner in this difficult branch of diag-
nosis.  Taken with the beautiful plates of the Atlas, which are remarkable for their accu-
racy and beauty of coloring, it constitutes a very valuable  addition to the library of a
practical man.—Buffalo Med. Journal, Sept. 1856.

  Nothing is often more difficult than the diagnosis of disease of the skin; and hitherto the
only works containing illustrations have been at rather inconvenient prices—prices, indeed,
that prevented general use.  The work before us will supply a want long felt, and minister
to a more perfect acquaintance with the  nature and treatment of a very frequent and trou-
blesome form of disease.—Ohio Med. and Surg. Journal, July, 1856.

  The lithographs are so colored as to be true and faithful representations of those  ninety
varieties of a class of diseases whose exact diagnosis is thus made plain and easy, and  which,
in the absence of such aid, or a long and attentive study, is so difficult that very few practi-
tioners seriously attempt it.  The work  is cheap, and no practitioner ambitious of a high
professional status can afford to dispense with such helps.—Nashville Journal of Medicine,
Sept. 1856.

  One of the handsomest of the many reprints that the eminent publishing house of
Blancbard & Lea have given to the medical profession of  this country is the set of illustra-
tions of cutaneous diseases by Dr. Neligan.  As specimens of the lithographic art, we doubt
whether superior can be found in any of the numerous works on skin diseases that have,
from time to time, been issued from the  celebrated publishing houses of the Old World.—
Louisville Review, July, 1856.

  Neligan's Atlas of Cutaneous Diseases  supplies a  long existent desideratum much felt by
the largest class of our profession. It presents, in quarto size, sixteen plates, each contain-
ing from three to six figures, and forming in all a total of ninety distinct representations of
the different species of skin affections, grouped together in genera or families.   The illustra-
tions have been taken from nature, and have been  copied with such fidelity that they pre-
sent a striking  picture of life; in which the reduced scale aptly serves to give, at  a coup
cVceil, the remarkable peculiarities of each individual variety.  And while thus the disease
is rendered more definable, there is yet no loss of proportion incurred by the necessary con-
centration.  Each figure is highly colored, and so truthful has the artist been that the most
fastidious observer could not justly take  exception to the  correctness of the execution of the
pictures under his scrutiny.—Montreal Med. Chronicle. 
                     WILSON  ON THE SKIN.


     ON  DISEASES~OF   THE  SKIN.


                BY  ERASMUS  WILSON,  F.  R. S.,

                  Author of " A System of Human Anatomy," &c.

   A NEW AMERICAN, FROM  THE LAST AND IMPROVED LONDON EDITION,

        In one large and handsome octavo volume, extra cloth, $2 7o-

  Also, an Atlas of nineteen Plates, of which twelve are exquisitely colored,

                             extra cloth, $4 25.

  As a practical guide to the classification, diagnosis, and treatment of the diseases of the
skin, the book is complete.  We know nothing, considered  in this aspect, better in our lan-
guage; it is a safe authority on all the ordinary matters which, in this range of diseases,
engage the practitioner's attention, and possesses the  high quality—unknown, we believe,
to every older manual—of being on a level with science's high-water mark—a sound book
of practice.—London  Medical Times.

  We have read this edition of Wilson on Diseases of the Skin with unusual interest, and
cannot hesitate to recommend it as the most complete and satisfactory work on the subject
now extant.—Medical Examiner.

  The "Diseases of the Skin," by Mr. Erasmus Wilson, may now be regarded as  the stand-
ard work in that department of medical literature.—Medico-Chirurg. Review.

  It is extremely minute, accurate,  and comprehensive,  though  concise: the  treatment,
though succinctly, is  amply indicated; and the work will fairly contest with that of Rayer,
the  merit of being the best  on the subject which we possess.—The New York Journal of
Medicine.
                    BY THE SAME AUTHOR—(Just Issued)



          HEALTHY    SKIN:

A POPULAR TREATISE ON THE  SKIN AND HAIR, THEIR PRESERVATION AND
                              MANAGEMENT.

     SECOND AMERICAN, FROM THE FOURTH AND REVISED LONDON EDITION.

                 WITH NUMEROUS ILLUSTRATIONS.

    In one neat royal 12mo. volume, of about three hundred pages; extra cloth, $1.
                      BY THE SAME AUTHOR.


ON  CONSTITUTIONAL  AND HEREDITARY SYPHILIS,
              SYPHILITIC  ERUPTIONS.


WITH FOUR EXQUISITE COLORED PLATES, PRESENTING  MORE  THAN THIRTY

                  VARIETIES OF SYPHILITIC ERUPTIONS.
In one beautiful octavo volume, extra cloth, $2 25. 
PRACTICAL TREATISE  /
DISEASES OE THE  SKIN.
BY
   J. MOORE NELIGAN, M.D., M.R.I.A.,

     HONORARY FELLOW OF THE SOCIETY OF PHYSICIANS OF SWEDEN)
PHYSICIAN TO JERVIS-STREET HOSPITAL J AND LECTCRER ON PRACTICE OF MEDICINE IN TnE
           DUBLIN SCHOOL OF MEDICINE.
(Erjirfc American (Edition.
     PHILADELPHIA:
BLANC HARD  AND LEA.
         1860. 
10^
W
  PHILADELPHIA:
COLLINS, PRINTER. 
    ROBERT J. GRAVES, M.D., F.R.S., M.R.I.A.,






            THIS VOLUME IS INSCRIBED,






AS  A MARK  OF  PROFESSIONAL RESPECT






          AND OF PRIVATE ESTEEM
1* 
 
AMERICAN PUBLISHERS' NOTICE.
  In supplying  the demand which  has  called for another
edition of this little work, the publishers have inserted in
their appropriate places  references to the  figures  of Dr.
Neligan's very  handsome  " Atlas  of Cutaneous Dis-
eases," just issued by them.  The object of the author, in
the  preparation  of his Atlas,  was to supply a series of
illustrations  adapted  to  the  present volume, presenting
those points of diagnosis which cannot be conveyed by mere
description, however graphic;  the two works may therefore
be regarded  as constituting together a single treatise.

  Philadelphia, March, 18G0. 
 
PREFACE.
   In submitting the observations contained in the following
 pages to the profession,  the  author  has been  influenced
 chiefly by a desire to offer, as an aid  to  the diagnosis and
 treatment of an important class of diseases, the results of
 an experience acquired during several years'  special atten-
 tion to the study of cutaneous eruptions.   Of late years the
 British medical press has abounded  with monographs  on
 other  special affections, but  few have been  published on
 those of the skin;  he has,  therefore, thought that a concise
 practical treatise  on them might find favor with  the pro-
 fession.
   As regards the  plan adopted in the construction of the
work, the only points requiring notice are the omission of
the details of cases which  might be cited  to prove  the cor-
rectness  of the views propounded, and the slight reference
to other writers on the same  subject: for both the only
apology he has to  offer, is his anxious desire  to condense 
x                      PREFACE.
the inquiry he proposed to himself, within as narrow limits
as possible, being fully aware " how great an evil a great
book" is to the physician busily engaged in practice.
  17 Mekrion Square, East Dublin,
          June 1, 1852. 
CONTENTS.
                       CHAPTER I.
Classification   ..........   13

                      CHAPTER II.
Exanthemata...........39

                      CHAPTER III.
VESICULiE...........g3
CHAPTER IV.
Pustule
11G
                       CHAPTER V.
Papulae.........          145

                      CHAPTER VI.
Squama..........      jgg

                      CHAPTER VII.
Hypertrophic   ..........  199

                      CHAPTER VIII.
Hemorrhagic..........226 
Xll
CONTENTS.
                        CHAPTER IX.
                                                      .   237
MACULjE    ....•••••

                        CHAPTER X.
                                                      .   246
Cancrodes   .......••

                        CHAPTER XI.
DERMATOPHYTE   ......••*

                       CHAPTER XII.
The Syphilides..........^&1

                       CHAPTER XIII.
Diseases of the Appendages of the Skin    .                    304

                       CHAPTER XIV.
Therapeutics of Diseases of the Skin......309
Index............  327 
                   DISEASES


          OF   THE    SKIN.




                   CHAPTER  I.

                     CLASSIFICATION.

  There is  no class of diseases which should interest  the
practitioner or student to  a greater degree  than  those of
the skin, and they are especially deserving of study in con-
sequence of  the difficulties which attend  their diagnosis,
and  the  obstinacy with which they  resist  most of the  re-
medial measures that  have  been  hitherto proposed  for their
treatment.   It is only by  prolonged practical experience,
acquired after a careful and  properly directed  study of
their varied  characters, and  an investigation  into  their
peculiar  pathology, that even a moderate  degree of know-
ledge of  them can be obtained.   In their early stages they
are often simple and  uncomplicated in form, and,  conse-
quently,  easy to be recognized; but  when  they become
chronic they  are generally so  changed  and altered, that it
is  often  very difficult to discover to what  special class or
order the peculiar  form of disease under  observation may
belong.
  The skin,  which covers  the entire of the  external sur-
face of the body, has  many uses  in the animal economy;
and, therefore, a diseased  condition of it  is  attended,  not
alone with vast inconvenience to the person affected,  but
is  also usually accompanied by a greater or less amount
of derangement of  the health  generally.   It is the organ
or medium of touch ;  serves for  the defence of the muscles,
bones, bloodvessels, and nerves  placed beneath it; is, more-
       2 . 
14
CLASSIFICATION.
over, the organ of absorption and excretion;  and, as so
recent  physiological writers  have well observed  agrees in
many of its  functions  and  properties, with  the mucous
membrane, of which  it is manifestly a continuation-tho
mucous membrane protecting the internal parts ot the Doav,,
while the skin protects those that are  external;^ there is
consequently a remarkable agreement between them,   in
deranged  conditions  of the. skin, the mucous membrane
becomes more or less engaged; and, in diseases which attect
the mucous membrane, the functions of the skin, as regards
absorption and excretion, are also affected  to a greater or
less degree.                                            ,
  Owing to the great obscurity which  so long  enveloped
the study of this class of diseases, and  the late period in
the history of medicine, at which any attempt was made to
classify them at all regularly, a  great deal is left for the
inquirer, even of  the  present day, to clear up.  Yet we
have abundant evidence, in the writings of  the Jewish, the
Egyptian, the Arabian, the Greek and the  Roman legis-
lators and physicians,  of their existence from the remotest
antiquity;  and that they were very numerous, often  occur-
ring as  scourges of mankind, is easily proved by a reference
to the Leprosy of  the  Jews, and the Elephantiasis of the
Greeks  and of the Arabians.  Of late, much has been ex-
pected from the  employment of the microscope in discover-
ing the exact nature of diseases  of the skin, but  in this
expectation we have, as yet, been more or less disappointed.
It is true, that by its  aid  much valuable information has
been gained, as to the normal  structure of the skin, yet  *
but little addition has been hitherto made thereby to our
knowledge of its diseased conditions, more particularly with
reference to their diagnosis and treatment, as based on
minute anatomy.  There is  one important fact, however,
which  has been attained by the use of the microscope in
the  investigation  of  the  nature of diseases of the  skin,
namely, the discovery that, in certain affections, a vegetable
production—a  cryptogamic plant—is present on the  cuta-
neous  surface, and is  evidently intimately connected  with
their true pathology.   A difference of opinion exists  as to
whether these vegetable growths are the cause or the con-
sequence of the disease in which they  have been found to 
CLASSIFICATION.
15
 occur ; but there can be no doubt, now that all, or at least
 nearly all, dermatologists  admit the truth of the discovery,
 and consequently believe in the existence of these vegetable
 growths, a  new classification, containing a group or  order,
 of which the presence of these  fungi will form the essential
 character, must be constructed.
   An important point of view in which diseases of the skin
 must be regarded, and one that adds much to their interest,
 is the effect they  produce  upon the system generally.  We
 sometimes find that in persons who have labored even for
 a long time under these affections, but little  constitutional
 derangement  is, in  many  cases, caused by them—so little,
 indeed, that it has often been doubted whether the existence
 of an  affection of the skin,  in a chronic form, tends to
 shorten life, or should be  taken into account in coming to
 a conclusion as to eligibility, in a  medical examination, for
 assurance.   For my own  part  I believe that as long as the
 individual remains  unaffected  with any  acute or  inflam-
 matory affection, the existence of a skin disease will not, in
 any respect,  diminish the average chances of longevity;
 yet I have no  doubt but that  a person laboring under any
 general cutaneous affection, the existence of which unques-
 tionably deranges the functions  of this extensive membrane,
 must be more  or  less liable to have  the  symptoms  of an
 ordinary acute disease, such as  fever or any of the internal
 inflammations, aggravated, and the treatment rendered more
 difficult and complicated by its presence.  Thus, although
 a  chronic affection  of the skin may not  directly tend  to
 shorten life, yet it may do so indirectly.   As, however, these
 various points will be more fully considered in speaking of
 each eruption individually, I shall not dwell on them at pre-
 sent, but proceed to  describe the classification of diseases of
 the skin which  I propose to adopt.
   No subject in the study of  medicine  has created more
 difficulty,  or for a longer  period tended  to retard its ad-
 vancement,  than  that of  nosological  arrangements.  It
was  at  one time  believed  to be impossible to  understand
the nature of diseases or  their proper treatment, without
an intimate  knowledge having  been previously  acquired of
their classification, and we  therefore find that all the writers
on medicine of the last, and of the commencement of the 
16
CLASSIFICATION.
present century, sedulously devoted themselves to devise new
systems, each more complicated than the other.   As regards
diseases generally, it is now agreed by  all  that the less
complicated and more simple the classification under which
they are arranged, for  the  purposes of description  or  ol
teaching, the more advantageous is  it for the acquirement
of a knowledge of them  ; and few, therefore, take the trou-
ble of  making themselves acquainted with the labored sys-
tems of Cullen, Sauvages, Mason Good, or the many noso-
logists of their day.   Simplicity, I  need scarcely say, is of
equal advantage in classifying any special set of diseases,
as those of the skin; yet even in our own time it seems to
me to be strangely  overlooked by dermatologists;  writer
after writer, impelled, as it were, by an ambition to devise
something novel,  propounds  a new classification, careless
how complicated and difficult  of being comprehended it may
be, provided only it differs from those which preceded.
  As in the arrangement of  objects of natural  history, so
in that of diseases, a classification may be either artificial
or natural; the former being based on external appearances,
or those which come directly under  the  cognizance of our
senses, without any respect to intimate nature, structure, or
properties; while the  latter  has especial regard to natural
qualities, as a bond of affinity.  In  addition to these two,
a third has been adopted by some writers on diseases of the
skin, which  may be called a  local or  regional arrangement
—that is, one  in which they are   placed  in groups,  de-
pendent on the  part of the body  upon which they are
seated; but, of course, in this system, regard must also  be
had to the individual character  and form of  the  various
eruptions.
  Of the many systems  of classification  of diseases of the
skin which  have  been,  from time  to time,  proposed, two
especially of those of the earlier  writers are  worthy  of
notice, not alone  as being the first  which had any preten-
sions to accuracy  or completeness, but as forming, to a cer-
tain extent, the basis of most of those  which  have been
since propounded—I allude to the artificial system of Willan
and the natural one of Alibert.   Although Willan adopted'
as the groundwork of  his  classification, an  arrangement 
CLASSIFICATION.
17
originally proposed by Plenck—following out the idea of
Riolanus put forth  nearly a century previously—of placing
diseases of the skin in groups, according  to their  form and
appearances, yet from the accuracy and appropriateness of
his nomenclature, which is that now almost universally em-
ployed, and the clearness with which he defined the leading
features of  his  general divisions or orders, it is  correctly
regarded as being the first important step made to the cor-
rect understanding of diseases of the skin.  Alibert,  in the
first instance,  following Turner, an Englishman, who was
himself preceded by Mercurialis, adopted a regional  classi-
fication, dividing all eruptions into two classes, as they were
situated on the head or on the trunk of the body; but this
he soon  abandoned  for a  natural system, which, though
grandly conceived, did  not  survive its author, being  found
too complicated and difficult of application when attempted
to be reduced to practice.
   In Willan's system, cutaneous diseases are divided  into
eight orders,  characterized  by the form of the  eruption,
viz:—
         Papulae.                     Vesiculae.
         Squamae.                    Pustulae.
         Exanthemata.                Tuberculae.
         Bullae.                      Maculae.

   The distinctive features of the eruptions, by which these
orders are characterized, he defined as follows ;  and  here I
may again remark that his nomenclature and definitions arc
still in use, and generally recognized as correct:—
   1. Papula (Pimple).—A  very small and acuminated ele-
vation of the cuticle, with an inflamed base, not containing
a fluid, not tending  to suppuration.
   2. Squama (Scale).—A lamina of morbid  cuticle, hard,
thickened, whitish,  and opaque.
   3. Exanthema (Rash).—Red patches  on the skin, vari-
ously figured, in general confluent,  and diffused irregularly
over the body,  leaving interstices of a natural color.
   4. Bulla (Bleb).—A large portion of the cuticle detached
from the skin by the interposition of a transparent, watery
fluid.
   5.  Vesirida  (Vesicle).—A small, orbicular elevation of
                           9* 
IS
CLASSIFICATION.
the cuticle,  containing  lymph, which  is  sometimes  clear
and  colorless, but  often  opaque  and  whitish, or  pearl-
colored.
  6. Pustula (Pustule).—An elevation of the cuticle, with
an inflamed  base, containing pus.
  7. Tubercula (Tubercle).—A small, hard, superficial  tu-
mor, circumscribed  and permanent, or  proceeding  very
slowly  to suppuration.
  8. Macula (Stain).—A permanent discoloration of some
portion of the skin, often with a change of its texture, but
not connected with any disorder of the constitution.
  Alibert, in his natural arrangement, considers cutaneous
diseases to resemble  a tree, which he terms Varbre des der-
matoses, and the  branches of  which constitute the various
divisions or groups, which are subdivided into genera.   His
primary groups, which are twelve in number, he designates
as follows:—
Dermatoses Eczemateuses.     Dermatoses Ve'roleuses.
     "       Exanthema-           "     Strumeuses.
     "        teuses.              "     Scabieuses.
     "       Teigneuses.            "     Hemateuses.
     "       Dartreuses.            "     Dyschroma-
     "       Cancereuses.           "        teuses.
     "       Lepreuses.             "     Hcte'romorphes.

  Biett,  the immediate and most  celebrated pupil of Ali-
bert, soon perceiving the difficulties which the complicated
system of his master, though based on the natural affinities
of the  various eruptions of the skin, threw in the way of
their successful diagnosis, forsook  it  for that of Willan,
which  he modified and so far improved that all the artificial
systems of classification which have been proposed since his
time include the changes made by him.
  Viewed abstractedly, it  is manifest that  a classification
M" diseases of the skin which, as a natural system is sup-
posed  to do, takes into account not merely the form  but
the essential nature and pathological characters of a cuta-
neous eruption, should possess many advantages, both prac-
tical and theoretic^ over  an artificial  arrangement which
takes cognizance merely of the alterations of the skin which
cause the eruption, or, in  other words, regards solely the 
CLASSIFICATION
19
apparent  changes in the cutaneous  structure of the part
affected.  Consequently, we find that most modern Avriters
en the subject have bestowed their attention on the construc-
tion of a perfect natural system, but hitherto, in my opinion,
without success;  amongst them all  there are, I  think, two
only at all deserving of notice, that of Erasmus Wilson in
England,  and of Cazenave in France.
  Wilson adopts, as  the  basis of  his  arrangement, the
anatomy and  physiology of the skin, a groundwork which,
owing to the additions recently made to  our knowledge of
this structure by microscopic investigation, and  the degree
of certainty which extended observation  has stamped upon
it, has been well employed by him, and renders  his system
of classification justly entitled to be designated a natural
one.  He constitutes four primary divisions  of the subject,
viz:—
       1.  Diseases of the Derma.
       2.  Diseases of the Sudoriparous Glands.
       3.  Diseases of the Sebiparous Glands.
       4.  Diseases of the Hairs and Hair Follicles.

  Of the first, five secondary divisions are made :  1. Inflam-
mation  of the  Derma; 2.  Hypertrophy of the  Papillse of
the Derma;  2>.%Disorders of the  Vascular Tissue of the
Derma; 4. Disorders  of the Sensibility of the  Derma; 5.
Disorders of the Chromatogenous Functions of  the Derma.
The first  of these subdivisions constitutes six groups, viz:
a. Congestive Inflammation,  divided into two sub-groups;
the first including those affections, in which both the mucous
membranes  and the Derma  are inflamed, and  which arc
attended with  constitutional symptoms of a specific kind ;
and the second, those in which the derma is alone engaged,
and in which there are wo specific constitutional symptoms ;
b. Effusive  Inflammation; e.  Suppurative  Inflammation ;
d. Depositive Inflammation ; c. Squamous Inflammation ; /.
Inflammation from the presence of Acari.
  Of  the second primary division, three secondary are con-
stituted, as the diseases  are  attended with, 1.  Augmenta-
tion;  2. Diminution;  3. Alteration of Secretion.
  Of  the  third, five  secondary divisions  are made, as the
diseases of the sebiparous glands arc dependent on, 1. Aug- 
20
CLASSIFICATION.
mentation; 2. Diminution; 3. Alteration; 4. Retention,
of Secretion ; and  5. In  which the  Glands and adjacent
Tissues are inflamed.                           m .      _.
  And the fourth  constitutes  six secondary  divisions; 1.
Augmented Formation ; 2. Diminished Formation ;  o. Ab-
normal Direction of the Hair; 4. Alteration of Color ; 5.
Diseases of the Hairs ; and, 6. Diseases of the Hair Follicles.
  M. Cazenave, adopting  likewise an  anatomical basis for
his  natural system,  arranges diseases of  the  skin in eight
groups :—
  1. Inflammations.           5.  Hemorrhages.
  2. Lesions of Secretion.      6.  Lesions of Sensibility.
  3. Hypertrophies.           7.  Foreign Bodies.
  4. Deteriorations.            8.  Diseases of the Appen-
                                 dages.

  The first group contains four  Orders: 1.  Non-Specific
Eruptions,  which  may exist in  an acute or chronic state ;
2. Non-Specific  Eruptions,  existing  always in  a chronic
state;  3. Acute Specific  Eruptions;  4.  Chronic Specific
Eruptions.
  The second group is divided into three orders; 1. Lesions
of the Follicular Secretion; 2. Lesions  of the Epidermic
Secretion ;  3. Lesions of the Coloring Secretion.
  The third group, which constitutes but  a single order, is
defined to consist in an abnormal development of the parts
affected.
  The fourth group contains those  diseases which  have a
tendency to destroy the parts attacked.
  The fifth group is characterized by the presence of blood,
more or less altered, without its proper vessels.
  The sixth group  is divided into two orders: 1. General
or Local Hyperaesthesia ; 2. Anaesthesia.
  In  the seventh group are placed  those  diseases which
seem  to depend on the presence of parasitical insects  or
animalcules.
  The eighth consists of  two  orders: 1.  Diseases  of  the
Hair; 2. Diseases of the nails.
  Both these natural systems,  the most  perfect  that have
yet been proposed,  present, in  some respects, great advan-
tages over artificial classifications, yet, I think, for many 
CLASSIFICATION
21
 reasons, arc not  to  be preferred.  Could we, for example,
 predicate  that the  various  eruptive  diseases, placed  by
 }\ ilson  or Cazenave in the group of inflammations, were
 invariably characterized by inflammatory action, we should
 receive  an important aid, not  alone  in diagnosis, but in
 treatment.  But  such is not the case in the classification of
 either.  Both place scaly diseases of the skin in the  same
 natural group, though  in a  different subdivision, with the
 eruptive fevers; yet can any two classes of diseases be more
 different in their nature ?   The former  characterized by a
 chronic inflammation of so low a form that it is very doubt-
 ful  whether it should be designated as inflammation at all;
 while the  latter are especially marked by high inflammatory
 action: the former  tedious  and  slow in  their progress,
 often lasting for years; the  latter, acute  and rapid, run-
 ning  their course in a few days:  the former requiring a
 prolonged constitutional treatment, and  the latter demand-
 ing immediate and  active  remedies.  Thus  an erroneous
^impression, acquired from a supposed natural affinity between
 two  eruptive diseases, may lead to error, both in diagnosis
 and treatment.
   Another important objection to  the  employment  of a
 natural system of classification  in  the study of diseases of
 the skin  is, that, being  more complicated, and not so easy
 of comprehension, it is more difficult  to be borne in  mind
 than an artificial arrangement, and thus great obstacles are,
 by its adoption, thrown  in  the  way of the student at the
 very threshold of his inquiry.  No artificial classification
 of diseases of  the skin can possibly be perfect, for different
 persons will, of course, form different ideas of the external
 characteristics and  features of individual eruptions;  yet it
 is an arrangement which seems  to me  to be better adapted
 for  attaining  a  knowledge of the subject; and  this,  after
 all, is the  only important use of  any system  of classification.
 It is especially one more easy to be remembered.   It is one
 which aids us  considerably at the bedside,  for it requires a
 less complex process of reasoning than a natural classifica-
 tion, to discover by its agency what may be the disease in
 any special case.   It is, therefore, this which I purpose to
 adopt.
   A regional classification of  eruptive diseases, although it 
22                 CLASSIFICATION.
is not adapted for a general inquiry into affections or
skin, possesses much value in their individual study, as tney
often present great  differences  in  character  and even  1
form, and frequently require peculiar modifications in trea -
ment dependent on the region on which they may occur.
have thus adopted it in a small work which  I published a
few years since on Eruptive Diseases of the Scalp, and also
in an Essay on those which affect the face, which appeared
in the eleventh volume  of  the  New Series of the Dublin
Quarterly Journal of Medical Science.  Were I to propose
a  regional system of classification, I would  suggest  that
cutaneous eruptions should be divided into three groups:  1.
Those which  occur on parts of the body constantly exposed
to the air ; 2. Those which  appear on parts  that  are pro-
tected from  the atmosphere  by clothing;  and, 3. Those
which affect the hairy scalp.   The first group should be sub-
divided into  those which occur  on the face (and neck  in
females), and on the  hands;  for as  the latter, especially in
several trades and occupations, are  exposed to various mat-
ters which  cause  irritation,  and  as  the skin  there differs
anatomically, in  some respects, from that on the face, erup-
tive diseases which affect them often present different appear-
ances, as they are seated on either.  Vesicular eruptions,
in especial, present  a  peculiar character when they occur
upon parts  of the body covered with hair—as, for example,
on the scalp.   If a blister be applied to the surface of the
scalp, deprived of the hair, the blister, in common language,
is said not to rise; the epidermis upon this part of the body
being not only somewhat thicker than elsewhere, except on
the soles of  the feet  and palms of the hands, but  being
bound down by the numerous involutions which constitute
the_ hair follicles.  When,  therefore, a vesicular  eruption
occurs upon  the scalp, there is  no apparent vesicle ; and
this, I believe,  will  account for that great  difference of
opinion which exists amongst writers as to the nomenclature
of certain eruptive diseases of the scalp, I allude especially
to the forms of Herpes.
   The chief improvements which have been  made on Wil-
lan s original classification are contained in the systems of
Biett^ of Cazenave and  Schedel  in  their joint work, and of
Dr. Hughes Bennett, of Edinburgh.   Dr. Bennett's modifica- 
CLASSIFICATION.
23
 tion of Biett's arrangement has been published in the Edin-
 burgh Monthly Journal of Medical Science for April, 1850,
 and is, in many respects, deserving of commendation.
   The great difficulty in devising an artificial system  of
 classification of cutaneous diseases depends upon the changes
 which, in  the progress of disease, all  eruptions undergo,
 with respect to  their characteristic form and  appearance.
 These changes are often so great that it is sometimes almost
 impossible to diagnose to what order a special eruption may
 belong in its advanced  stage, and it is therefore made  to
 occupy a different place in different systems.  For example,
 observers differ  as to whether scabies,  common itch, is a
 vesicular, a  pustular, or a papular eruption.  It certainly
 changes rapidly, in most cases, from vesicular to pustular,
 or the vesicles become mixed up with  pustules ; but, in my
 opinion, it  is  always, in its primary  stage,  a  vesicular
 eruption.  In  most diseases of the skin, we are, however,
 by careful observation, able to discover the elementary form
 of the eruption in the early stage  of the disease:  and from
 experience we shall always be able to diagnose, even in its
 most extreme changes,  what the primary form was.  This,
 of course, can only be learned by prolonged practical ex-
 perience.
   In proceeding  to describe the system of classification  of
 diseases of the skin which  I intend to adopt, I wish,  in
 limine, to disclaim any pretensions to originality.  My chief
 object is to  endeavor to simplify a subject which  has often
 not received from the student and practitioner the attention
 it merits, owing  to the  difficulties with  which complicated
 arrangements and ever-changing  nomenclature  have in-
 vested it.  I shall therefore take advantage of the labors  of
 those who have preceded me, and  endeavor to reduce the
 grouping together  of  cutaneous eruptions  to  as  few sub-
 divisions as  attention to accuracy will admit.
   Mr.  Plumbe was, I believe, the  first modern writer   to
 omit  those affections which are correctly  termed  Eruptive
 Fevers  from  the catalogue of  diseases of the skin.   Fabre,
in his recently published  Bibliotheque  du Medecin-prati-
cien,  has followed his  example, as also has  Dr. Hughes
Bennett in his proposed modification of Biett's system.   On
this subject  Mr. Erasmus Wilson remarks :  " It may be said 
24
CLASSIFICATION.
 that the diseases comprised in the first sub-group C
 characterized by inflammation of the derma and  *™>™
 membranes, with constitutional symptoms of a speciftc^mdj
 viz: Rubeola, Scarlatina, Vano a, &c,  -though ^ret^
 considered  and  treated of as diseases of the skm, are, in
 reality, diseases of the system, of which the alteration ^ in
 the skin is a symptom  of  comparatively secondary  im-
 portance.   I cheerfully assent to the validity of this argu-
 ment, but I am  nevertheless  unwilling to lose  a- group of
 diseases so  rich  and  important in their  illustration of  the
 pathological changes wrought in and upon the skin by~active
 inflammation."   Independent of  these high  authorities I
 would, for my own  part, have no hesitation  in excluding
 eruptive fevers  from being described  amongst  diseases of
 the skin; to consider them still as such is directly  opposed
 to the advanced position of modern pathology, and can only
 tend to diffuse incorrect ideas as to their essential nature.
  A few recent  dermatologists have  included  amongst dis-
 eases of the skin some constitutional affections, in which an
 eruption—of a special form always—occurs  as  a concomi-
 tant symptom, and, as regards the peculiar affection,  is but
secondary, and more  or less unimportant.  The diseases to
which I allude are not met with in the British Islands; they
are the  Frambaesia or  yaws  of South America and of the
coast of .Africa, the Radesyge of the North of Europe, and
the Pellagra of  Italy and of Austria.   These have,  I con-
siderr  no better claim to be classed amongst diseases of the
skin than has the  Plague,  in  consequence of its  being
attended with malignant pustules and boils.  I shall,  there-
fore, omit them from my arrangement.
  I propose to divide cutaneous diseases into ten Groups or
 Orders, as follows :—

  1. Exanthemata.          6. Hypertrophic.
  2. Vesiculc.              7. Hemorrhagic.
  3. Ptjstulje.               8. Macule.
  4. Papule.                9. Cancrodes.
  5. Squame.  #             io. Dermatophyte.

 Adding two supplementary  groups, Sypiiilides and Dis-
 eases of the Appendages of the Skin. 
classification.
25
   The diseases contained in the  Order Exanthemata  are
 characterized by the occurrence, on  a greater or less  ex-
 tended surface of the skin, of a blush of inflammatory red-
 ness, usually more  or  less elevated,  which terminates in
 epidermic  desquamation, in the  form of fine mealy scales.
 The most essential character of the Order is, that the red-
 ness  momentarily disappears  on pressure with the  finger.
 In one form of eruption, classed amongst the exanthemata,
 namely,  erysipelas, the  epidermis is very commonly raised
 in large blebs by serous effusion; but this is evidently caused
 by the intensity of the inflammation which is present, takes
 place in  the progress of  the disease, and is not a constant
 or essential symptom.  In general, the redness is in large
 uncircumscribed patches, or uninterruptedly diffused over
 the surface ; but in  some  forms it occurs  in well-defined,
 regular spots.  The essential nature of the exanthemata is,
 that they are inflammatory,  and they seem to have their
 seat in the vascular  rete of the  derma.  This Order corre-
 sponds with the second sub-group of the first group of  the
 first secondary division of Wilson's Natural System,  defined
 by him as  " Inflammation of the derma, without constitu-
 tional symptoms of a specific kind."  It contains four genera,
 erythema,  erysipelas,  urticaria, roseola.
   The Vesicule are characterized by an eruption of vesi-
 cles or blebs, which consist in an elevation of the epidermis,
 varying in  size, in some forms minute (vesicles), and in some
 of tolerable magnitude (bullae or blebs), containing a trans-
 parent, serous fluid, which,  with the progress of the disease,
 becomes  opaque, and dries into  thin scales or hard crusts.
 The fluid by which the elevation of the epidermis is caused
 in the vesiculae is at first transparent and albuminous, but
 after  a short time becomes  opaque,  and often puriform.
 This order  nearly corresponds with the second group of the
 first  secondary division  of Wilson, which  he  defines  as
 "Effusive Inflammation of  the  Derma."  It contains  five
genera:  eczema,  herpes,  pemphigus,  rupia,  scabies.
Wilson places scabies in a distinct sub-group, defining it to
be " Inflammation of the  derma,  from the  presence  of
acari."
  The third Order, Pustule, is characterized by the erup-
                          3 
26
CLASSIFICATION.
tion of Pustules,—rounded elevations of the epidermis con-
taining pus, which,  bursting, form scabs or  thick  crusts.
The pustules may be of small size, and closely aggregated
together, or large and isolated ;  the former constituting the
Psydracia,  the latter, the Phlyzacia, of Willan ;  a psydra-
cious pustule being defined by him to be " a minute pustule,
irregularly circumscribed, producing but a slight  elevation
of the cuticle, and terminating in a laminated scab," and a
phlyzacious  one, " of a larger size, raised on a hard, circular
base of a vivid red  color, and  succeeded by a thick, hard,
dark-colored scab."   The epidermic covering of  a pustule
is much thicker than that of a vesicle, consequently it takes
a longer time to maturate, or, in other words, to  burst and
form a scab  or crust; but in their advanced stage  the diag-
nosis  between the two  is  sometimes not unattended with
difficulty.   The  eruptions placed in this order correspond
with those classed by Wilson in  the third group of his first
secondary division:   " Suppurative  Inflammation of the
Derma."  The genera are three in number: acne, impe-
tigo, ecthyma.  Wilson, however,  puts acne in  a  group,
the definition of which that  he gives being, " Inflammation
of the glands and adjacent textures."
  The Papule are characterized by an eruption of minute,
solid  elevations,—pimples,—generally reddish,  but some-
times of the natural color of the  skin, containing neither
serum  nor  pus,  terminating in  the desquamation of fine
scales, and almost invariably attended with intolerable itch-
ing.   In some forms, the top of the pimple is of  a reddish
brown or black  color, but this merely depends on the acci-
dental presence  of a small,  dried  crust of blood, usually
effused by scratching.  This Order contains  two genera:
lichen, prurigo.  It corresponds with the fourth group of
Wilson's first secondary division, which he  defines: " De-
positive inflammation of the derma."
  The eruptive diseases contained in the Order Squame are
characterized by the secretion of dry, laminated, whitish
scales on the cutaneous surface, usually occurring in patches
often of a circular form.   The  scales,  which are somewhat
elevated above the  level of the  skin, readily fall  off, to be
again rapidly renewed; the part which they cover 'is of  a 
CLASSIFICATION.
27
 smooth, glistening aspect, reddish, and dry.  The  Order
 corresponds with the  fifth group  of  the first  secondary
 division of Wilson's classification: "Squamous inflamma-
 tion of the derma."  It contains two  genera:  psoriasis,
 pityriasis.
   In the Order  Hypertrophic, I include  those  diseases
 which are characterized  by an hypertrophied condition of
 the derma or epidermis, or of both, or of the hair follicles.
 The term has been used much in this sense by Simon, in his
 " Anatomical Description of Diseases  of  the Skin;"  and
 from him I have adopted it.  In its application it is nearly
 synonymous with the tubercule of former  artificial  sys-
 tems of classification.  The latter term, although probably
 not so faulty, when first  employed to designate a group of
 cutaneous diseases,-is, I think, highly objectionable at pre-
 sent, when it is invariably understood to designate a peculiar
 morbid deposit, and its application in any other sense must
 tend  to cause confusion.  Wilson, in his Natural System,
 has a group in which are placed those affections that con-
 sist in an "hypertrophied state of the papillae of the derma;"
 but I propose to  extend the application  of the term, and to
 include in the Order those diseases in which the hypertrophy
 affects the other  cutaneous  structures.   I  shall place in it
 nine genera; ichthyosis,  molluscum, stearrhoea,  ele-
 phantiasis,  VERRUCE,   CLAVUS,  CALLOSITATES,  CONDYLO-
 MATA,  NEVI.
   The characteristics of the seventh Order, Hemorrhagic,
 scarcely require  to  be defined.   In it  there is  a morbid
 alteration of  the capillary circulation,  accompanied by a
 changed or diseased condition of the blood, in which this
 fluid, escaping from its proper vessels, is  extravasated in
 rounded spots or patches beneath  the epidermis, and also
 beneath the epithelium of the mucous and serous membranes.
 Bursting through the latter finer  structure, more  or less
 bleeding usually takes place from the surfaces of both  these
 membranes.  It contains  but one genus, purpura.
   The Order Macule is  characterized  by  an alteration in
the color of the  skin, occurring  usually in large patches,
and unattended with any eruption.   The natural color may
be deepened,  diminished, or altered  in  hue, and  the affec- 
28
CLASSIFICATION.
 tion has  its seat evidently in the apparatus of the  skin
 which  secretes the pigmentary matter.   The  Order corre-
 sponds with the fifth secondary division of Wilson:  " Dis-
 orders of the Chromatogeneous Function of  the Derma.'
 It contains two genera, vitiligo, which includes albinoismus,
 and ephelis.
   The order Cancrodes contains those diseases of the  skin
 which in many of their features resemble cancerous affec-
 tions.  They are characterized by a degree  of semi-malig-
 nancy, usually attended with  foul  ulceration of a slow and
 insidious nature, often  with  severe stinging  pain, and  a
 marked tendency to return after apparent cure, or after ex-
 cision,  in the same or in remote parts of the cutaneous  sur-
 face.   It contains two genera : LUPUS, KELOIS.
  The  tenth Order, Dermatophyte, I have adopted from
 Bennett.   It includes those diseases of  the  skin which de-
 pend on,  or are characterized by the presence of, parasitic
 plants.  It contains two genera : porrigo, sycosis.
  Of the two supplementary Orders, the first—the Syphil-
 ides—contains those eruptions of the skin which are ordina-
rily termed secondary, being caused by, or consequent on, the
introduction of the venereal virus or poison into the system ;
and the second includes diseased conditions of the hair  and
nails.
  This classification, in the drawing up of which I have  had
chiefly  in view an attempt to simplify what is admittedly a
difficult study, may be tabulated as follows:— 
CLASSIFICATION.
29
1.  Exanthemata,

2.  Vesicule,

3.  Pustule,
4.  Papule,  .   .
5.  Squame,  .   .
6.  Hypertrophic,
 7. IlEMORRnAGIE,
 8. Macule,  .   .
 G. Cancrodes,   ;
10. Dermatophyte,
Erythema, Erysipelas, Urtica-
   ria, Roseola.
Eczema,  Herpes, Pemphigus,
   Rubia, Scabies.
Acne, Impetigo, Ecthyma.
Lichen, Prurigo.
Psoriasis, Pityriasis.
Ichthyosis,  Molluscum,  Stear-
   rhoea,  Elephantiasis,  Ver-
   ruca,  Clavus,  Callositates,
   Condylomata,  Naevus.
Purpura.
Vitiligo, Ephelis.
Lupus, Kelois.
Porrigo, Sycosis.
           Supplementary Croups:
Syphilides.
Diseases of the Appendages of the Skin.
3* 
30
exanthemata.
                  CHAPTER  II.

                    exanthemata.

  The term " Exanthemata" was employed by the ancient
writers on medicine to designate every variety of eruption
of the skin; but in modern days, and more especially since
the time of Willan, it has  been restricted to denominate a
peculiar group of cutaneous  diseases,—one so  well defined
by external appearances, that there is no difficulty in diag-
nosing any of  its forms  during  all their stages.  They are
characterized by the sudden appearance, on a greater or lesser
extended portion of  the  skin, of  an inflammatory redness
in variously shaped patches, which momentarily  disappear
on pressure, are usually  attended with a slight elevation of
the surface, and terminate in exfoliation of the epidermis.
The diseases belonging to this Order are almost invariably
accompanied by more or less inflammatory fever, and  they
thus constitute a natural group.  In the treatment of them,
however, we should be careful not  to let this idea of inflam-
mation being  one  of their  marked  characters, lead us to
take too exclusive a view as to the remedial measures  indi-
cated ; for the attendant inflammation may be either  of a
low asthenic form, as it frequently is,  or it may assume a
highly sthenic type.
  In Erysipelas, one of  the  diseases  included  amongst the
Exanthemata,  the epidermis is often  elevated by serous
effusion into bullae, or even large blisters, which has induced
some  writers  to describe  it  as a  vesicular eruption ; but
these vesications are not a constant or necessary feature of
erysipelas, and when  they do occur are evidently dependent
on the high degree of local inflammation which  may be pre-
sent.
  The four genera belonging to the Order are : Erythema,
Erysipelas, Urticaria, Roseola. 
ERYTHEMA.
31
                        ERYTHEMA.

   Erythema {Inflammatory blush) consists in  an eruption
 of superficial, deep-red  stains or  patches, more or less cir-
 cumscribed, and slightly elevated, attended with  heat and
 tingling, and terminating either in resolution, or with slight
 furfuraceous desquamation.  It is non-contagious, of a mildly
 febrile character, and rarely a disease of much importance ;
 most forms of  it terminating in  a few days,  and  seldom
 becoming chronic.
   The erythematous eruption very frequently appears on
 the skin in  the  course of many acute affections, especially
 fevers and inflammatory diseases;  often occurs  in dropsies,
 when it affects  the  depending parts of the body or those
 exposed to pressure ; may be produced by irritation of the
 cutaneous surface, as by the friction of the clothes or of the
 opposed surfaces  of the skin, as when it appears  in the
 axillae or in the  groins ;  and  is likewise caused on the un-
 covered parts of the body by exposure to harsh winds,  or to
 the sun in  travelling.   The  eruption may appear on any
 part of the  cutaneous surface, but some of its forms occur
 with great regularity in  certain regions of the skin.
   Several varieties of erythema  have been noticed by der-
 matologists, but all of  them  may, I think, be described
 under three heads :—
                    Erythema simplex.
                       "      papulatum.
                       "      nodosum.

   Erythema simplex (Atlas, PI.  I. Fig. 1), under which I
include the E. fugas, E. laeve, E. intertrigo, E. marginatum,
and E. circinnatum of other  writers, is generally a  very
mild form of eruption of  the skin, requiring but little atten-
tion, unless  when it assumes  a chronic  character,—as in-
tertrigo, when neglected, or when  the causes by which it is
produced are continued, not unfrequently does.  It appears
in the form  of uncircumscribed red patches, seldom exceed-
ing the size  of the palm of the hand, and scarcely elevated
above the surrounding skin; it generally occurs in the course
of some inflammatory disease, when, owing to the patches 
32
exanthemata.
suddenly disappearing, and again as suddenly re-appearing
on some other part of the body, it has been termed erythema
fuqax ; it also assumes the same character  as indicative ot
or connected with derangements of the digestive organs, or
obstructed menstruation.  The usual seat of this sub-variety
is on the face, the neck, the trunk, or the upper extremities ;
there is no constitutional disturbance marking its  occurrence,
and the only local symptom is a slight degree of heat in the
part attacked.   Thus,  then, it would  appear to be a very
unimportant disease, were it not for a remark of Hippocrates,
the truth of which has been confirmed by most  modern ob-
servers-, that the occurrence of erythema fugax in fevers or
acute diseases  is an unfavorable sign.
  This form of erythema, when it occurs in dropsical per-
sons,  presents a bright red,  smooth,  and  shining  aspect,
whence it has been  termed erythema Iseve  (Atlas, PL I.
Fig. 2).  It usually appears in rather  large patches, which
spread rapidly, and, if  exposed to continued pressure, may
end in ulceration, and  even  in mortification  when the vital
powers are very  low.
  The sub-variety, which  has been denominated intertrigo,
occurs very commonly  amongst children, whose fine skin
may have been chafed  from any local  irritation, as from the
surface not being sufficiently cleansed  from dirt  or from the
natural secretions;  it  also appears  in  adults, especially
during hot weather, in whom it is usually produced by the
friction of opposed  surfaces of the skin, or  by rubbing of
the clothes.  In  its commencement it is characterized by the
ordinary  appearances  of an  erythematous eruption,  but
affecting,  as it chiefly does,  those parts of the cutaneous
surface in which the  sebaceous glands most abound, it is
soon attended with a diseased exudation from both the seba-
ceous  and sudoriparous glands, and  the parts  are  coated
with moisture of a fetid and acrid character, which keeps up
the inflammatory irritation, and may even cause troublesome
ulceration.  The two other sub-varieties of erythema simplex
were named by  Willan from the form which they assume,
the one, circinnatum,, which occurs in  small, round,  slightly
elevated patches, while the other, marginatum  (Atlas,  PI.
I. Fig. 5), is more elevated at the edges than in the centre, 
ERYTHEMA.
33
the margin being thus well-defined,—the patches are gene-
rally of a deep-red hue.  The former occurs, for the most
part, during  some inflammatory disease, with the cessation
of the  acute  symptoms of which it usually disappears;  and
the latter seems  to be a form which erythema simplex fre-
quently assumes in the old.
  Erythema papulatum (Atlas, PI. I. Fig. 3) is of frequent
occurrence, especially in young persons about the age of
puberty, and in females in whom the  menstrual functions
may have been  obstructed.   It appears most generally on
the backs of  the hands and fingers, but  also occurs  on the
face, the neck, and other parts of the body.  It is character-
ized by an erythematous blush on an uncircumscribed  sur-
face of the skin,  on which there are numerous small, round
elevations, about the size of a pea, of a  deeper red hue, the
portions of the skin between the elevations being always of
a paler or less bright  color.  The commencement of an
attack of this variety is attended with some fever, headache,
and slight nausea, and there are heat  and  a disagreeable
sensation  of  tingling in the  affected parts,  which are  also
slightly sore  to the touch.  This form of the eruption is of
no great importance, lasting usually  for only a few days,
and very rarely assuming a chronic character.  Sometimes
rather  larger elevations are  intermixed with the others, or
they may all from the commencement assume the size of a
nut or a large marble, when the variety has been named
tuberculatum ; it presents this character most frequently on
the extremities;  the raised  spots are there harder to the
touch,  attended with more  local annoyance, and the erup-
tion more frequently becomes chronic.
  Erythema  nodosum  (Atlas, PI.  I. Fig. 4), is  so called
from the appearance which the eruption presents.   It usu-
ally occurs on the anterior aspect of the lower extremities,
generally from the knee  to  the ankle.  I have seen a few
cases in which it was situated on the back of the arms, and
have also occasionally seen a few spots on the  anterior sur-
face of the body.  It appears in distinct rounded or oblong
red patches, from half an inch to even two inches in diame-
ter, with a well-defined  border, circumscribed, and slightly
elevated in the centre,—but the elevation is more apparent 
34
EXANTHEMATA.
to the  eye than to the finger when passed  over the  part.
The  centres of the patches  or  knots  are  of  a somewhat
brighter  color than the borders, which  have a dark red
blush;  the general redness fades but slightly on pressure,
which,  however, causes pain, and on the pressure being re-
moved  the color immediately re-appears.   This  form of
erythema is most  generally met with  in  young girls  from
the age of 14 to 19 or  20, rarely appearing in males.  It
has  been described  by some as being  connected  with  a
deranged state of the menstrual  functions, but in my expe-
rience I have rarely seen it produced by  such  a cause.  It
is attended with more fever than any of the forms of  ery-
thema, being generally ushered  in with nausea, sometimes
even vomiting, pains in the back, loins, and  head, together
with  loss of appetite and slight shivering.   This state may
continue for from twelve to twenty-four hours.  The patient
then  feels a sensation of heat and tingling on the fronts of.
the legs,  and on examination  the characteristic eruption is
seen. The knots or patches appear simultaneously over the
surface, not coming out in succession, increase in  size  and
become harder and more painful for three  or four days, then
deepen in  color  until  the eighth or tenth day, when they
begin to fade, and passing often through the green and yel-
low stages of a bruise, disappear with slight desquamation
of the epidermis  in about  a fortnight  or  three weeks from
the commencement of the attack.
  The  seat of erythema is manifestly in the  vascular struc-
ture  of the derma, the nervous  functions being but  little
affected;  the causes by which,  it is produced have  been
already adverted to.    An epidemic of  erythema has  been
described as  having  occurred in Paris in  1828-29,  as  a
complication of a painful affection of the extremities, thence
termed Acrodynia, which raged  there at  that period.  M.
Cazenave, who witnessed it in the Hopital St. Louis, de-
scribes its characters  as consisting in "an erythematous
circle of a crimson color appearing on the soles of the feet,
and on the palms of the hands, covering  a space of from a
third to two-thirds of an inch, and disappearing under the
pressure of the finger; it presented the peculiarity that the
portion of the skin which surrounded it was generally of a
yellowish  color, swollen and very hard, while the affected 
ERYTHEMA.
35
patch was manifestly depressed and very painful  to  the
touch.   These spots of erythema also  appeared occasionally
on the thighs, the scrotum, and in the axilla."
  The diagnosis of any of the forms of erythema is in very
few  instances attended  with  much difficulty.  It  may be
mistaken for  the  milder forms  of  erysipelas, especially in
their early stage, but the blush of erythema is of a deeper
red,  and less livid than  that of  erysipelas, is  not attended
with the same amount of local  tumefaction, burning heat,
and  pain, and is marked by much  less disturbance of  the
system generally,  and much less fever.   That form of ery-
thema simplex which has been named fugax has sometimes
been mistaken for  urticaria evanescens; they are both exan-
thematous eruptions; but in the latter the eruption disap-
pears and re-appears with  constant  rapidity, generally in
the  same  places; Avhile erythema fugax, though  nearly
equally evanescent, does  not return to the  same parts  ; it
is, too, unattended  with the acute itching and annoying
tingling so characteristic of urticaria, and moreover occurs
in the  course  of some disease  of the  general system, while
urticaria evanescens is an idiopathic affection.  Erythema
papulatum has sometimes been mistaken for some of  the
eruptive fevers,  as for measles or scarlatina ;  but its local
character, its  appearance upon the hands, and  its  papular
elevation, serve  to distinguish it from measles, in which the
eruption is of a crescentic form-, of a duller red color,  and
attended  with a catarrhal  fever.  As regards scarlatina,
the bright redness of the efflorescence and the acute inflam-
matory fever, together with the sore  throat of that disease,
should  suffice to  render the  diagnosis  easy.   Intertrigo
may be confounded Avith chronic eczema, occurring  behind
the  ears, in the axillae,  or in the groins;  the latter, how-
ever, is a vesicular eruption in its primary stage, and as it
advances is marked by the copious-serous discharge, tume-
faction, and deep red fissures, Avhich so remarkably charac-
terize the disease.
   The prognosis in any form of erythema is, of course, very
favorable; all the varieties being of a slight character, lasting
but for a short time, and the patient recovering Avithout  any
detriment to the general health.
   Treatment.—In the very  common form of erythema siin- 
3b*
EXANTHEMATA.
plex, caused by exposure to the heat of the sun or harsh
winds in travelling, nothing further is required than anoint-
ing the parts affected with some mild oleaginous application,
such as cold cream or fresh olive oil:  a common domestic
remedy, but not  so efficacious as the cream of cow's milk.
When the eruption occurs in the course of any acute disease,
no local application should be  used except the warm bath,
if it is not otherwise contra-indicated ; and where it is symp-
tomatic  of any derangement  of the  digestive organs or of
any other  part or function of the general system, the  con-
stitutional, not the local affection should  be treated.   In
erythema laeve the parts should be carefully protected from
pressure, gently  sponged with  the dilute solution  of subace-
tate of lead warmed, then well  dried, dusted over with flour,
and enveloped in raw cotton.   When the  disease appears
inclined to spread, I have found lint  wet with the lead-
wash and covered Avith oiled silk, the best  application.
  Erythema  intertrigo is sometimes very obstinate, espe-
cially in children, when it occurs behind the ears, as it very
frequently  does.   As a preventive, and  in the early stages,
dusting  the  parts with very  finely poAvdered lapis cala-
minaris  is  often useful; but Avhen it becomes  at all chronic,
an  ointment  consisting  of  tAvo grains of  the carbonate of
lead, half  an ounce  of Avhite Avax ointment, and  half a
drachm  of glycerine is better adapted.  With some very
chronic  cases, all greasy applications seem to aggravate the
disease,  when I have seen it rapidly get well  from the  use
of a lotion containing three grains of the sulphate of copper
in an ounce of elder-flower water, applied on  lint, kept con-
stantly wet Avith it.  In  adults, intertrigo  of the groins is
occasionally  very  troublesome  and  sometimes  obstinate,
especially when  the  irritation is  kept up by Avalking;  the
cucumber  ointment of the French pharmaceutist has  proved
more successful in  my hands in these cases than any other
application:  in the commencement of the eruption it gene-
rally effects a cure in a feAv days, the affected parts  having
been each  time previously cleansed with a  moist towel,  and
then dried; it should.be rather thickly smeared  over them
three times a day.  If the  cucumber ointment  cannot be
obtained,  an ointment prepared  by rubbing  together  two
grains of  acetate  of  zinc dissolved in  a  drachm of rose- 
ERYSIPELAS.
37
 water, and an ounce of cold cream, may be substituted for
 it.   Erythema papulatum is best treated in young persons
 by mild antiphlogistics, especially the  saline cathartics, or
 emeto-cathartics.   When  the  accompanying fever is at all
 well marked,  and  the disease occurs in  robust constitutions,
 the use of a mixture containing two grains of tartar emetic
 and two ounces of sulphate of magnesia in a pint of water,
 of  which a wine-glassful is taken  every second  hour  until
 vomiting or purging be produced, is generally attended with
 much benefit.   When it attacks old persons, or assumes the
 tuberculated form, tonics, as the compound tincture of bark
 in  infusion of quassia or of calumba, are indicated;  the
 strength also  should be supported with  nourishing diet, and
 vvine  allowed.  Should  this variety of erythema  be  asso-
 ciated Avith deficient or obstructed menstruation,  the prepa-
 rations of iron will in general be found  beneficial, unless
 the derangement be accompanied  by plethora or local con-
 gestions, Avhen of course an antiphlogistic plan of treatment
 should be adopted.
  Erythema nodosum, like the form last described, is not
 benefited by  local applications,  if Ave  except the general
 warm  bath which  may be used every second or  third day.
 The patient should remain quiet in bed, and live Ioav  until
 the feverish  symptoms abate ; saline  antiphlogistics, the
 boAvels  having been  previously freed by a mild mercurial
 purge, are  of much  service;  of  these, a  good  form is a
 mixture consisting of half  an ounce of bitartrate of potash,
 a drachm of borax, two drachms of white sugar, and tAventy
 fluid ounces of Avater,  of  Avhich  two ounces may be taken
 every sixth hour.   While the use of the general Avarm bath,
 as above remarked, is usually productive  of much benefit
 in this form of erythema, local baths, such as the foot-bath,
generally aggravate  the  disease,  in  consequence  of their
determining an increased afflux of the blood to the affected
parts.
erysipelas.
  Erysipelas (St.  Anthony's  Fire) is characterized  by a
diffused shining redness of the skin,  attended  with burn-
ing heat, pain,  tumefaction,  and  a  tendency  to  spread,
and  terminating in  resolution with  or  Avithout  previous
                          4 
38
EXANTHEMATA,
serous effusion beneath the epidermis, in suppuration, or in
gangrene.  It may be conveniently considered under two
divisions :—
                Erysipelas idiopathicum.
                    "      traumaticum.

  Cazenave arranges the varieties  of it which have been
described into three  groups: True erysipelas, in which the
inflammation  is confined to the skin; Phlegmonous erysipe-
las, in AAThich  the disease extends more  or less deeply into
the sub-cutaneous areolar  tissue ; and Gangrenous erysipe-
las, in which  the inflammation terminates in mortification.
  Idiopathic  erysipelas (Atlas, PI. I. Fig. 6) almost inva-
riably attacks the head  and face,  so much so that some
writers, amongst others Dr. Watson, propose to restrict the
term to that disease  in which this portion of the cutaneous
surface is diffusely inflamed; but the inflammation so fre-
quently spreads from these parts to the  integuments of the
neck and trunk,  and as in  some cases it appears primarily
even on  the extremities, I  cannot agree with this proposed
restriction.   In  one case,  that  of a young man, eighteen
years of age,  who was brought into Jervis-street Hospital in
the year  1846, eArery part of the cutaneous surface, even to
the soles  of the feet, was affected with idiopathic erysipelas;
it had commenced on the integuments of one side of the face
after  exposure to cold, and spread so rapidly that, on the
fifth day, the entire of the body was engaged in the disease;
he died on  the second day after  his admission into the hos-
pital, the seventh from the appearance of the eruption.
  Idiopathic  erysipelas is, in  nearly all cases, ushered  in
with well-marked febrile symptoms, shivering, pain in the
back  and limbs, loss  of appetite,  thirst, bad  taste  in the
mouth, nausea, and rapid pulse, which, however, is often
very  compressible; the urine is scanty and  high-colored,
and the bowels costive.  In a few cases, more especially in
very old  persons, or in broken-down habits, the local symp-
toms are  attended with very little constitutional disturbance.
The erysipelatous inflammation frequently appears  first  on
the tonsils, when the patient complains  of the symptoms of
an  ordinary sore throat, but on examination, they present
a darker  red hue than is usually present in tonsillitis, and 
ERYSIPELAS.
39
they are also  more SAVollen.   Within the next twenty-four
hours diffuse swelling  and redness  appear on some part of
the cutaneous surface of the face or head, accompanied by
burning  heat, pain,  and  tension, the  pain  being  much
increased by the slightest touch, resting the  inflamed part
on the pillow even being often intolerable.  The surface  pits
on  pressure Avith the finger, which also causes the redness
to fade momentarily; the affected  part is bright,  shining,
and swollen, but smooth.   With the progress of the disease
the tumefaction increases much, especially Avhere the integu-
ments are loose, as in the eyelids and  ears, and around the
eyes, so that on the second or third day the eyes are usually
quite closed by  the swelling.
   The local inflammation generally attains its height about
the sixth or seventh day, when, if vesications have appeared,
they burst,  and give  exit  to an acrid, transparent, watery
discharge,  which occasionally  irritates  the sound skin in
the neighborhood  over Avhich it  may  Aoav.  These vesica-
tions  rarely  appear before the fifth day of  the eruption,
and run a very rapid course; they vary in size from a few
lines to an inch or more in diameter.   The constitutional
fever,  which increases with the maturation of  the eruption,
being most severe  on the fifth or sixth day, when delirium
frequently occurs, declines with the  diminution of the local
symptoms;  the redness now begins to fade, the  swelling
subsides rapidly, and the disease terminates in favorable
cases with desquamation of  the epidermis on the tenth or
twelfth day.
   When the erysipelatous inflammation extends to  the sub-
cutaneous tissue and  deeper seated structures, the  disease
is denominated erysipelas phlegmonodes. This form appears
more  frequently on the extremities than on the  head or
trunk of the body.   The constitutional symptoms by which
it is ushered in, and which accompany it, are of a more severe
character, and very frequently assume  a typhoid type.  As
regards the  local characteristics,  the portion of  the integu-
ments  affected presents a dull red or livid color, is intensely
painful, hot, and tense, pits more deeply on pressure, and is
more  tumefied.  The  inflammation  here very seldom  ter-
minates in resolution,  suppuration usually occurring in the
areolar tissue, with death and sloughing to a greater or  less 
40
EXANTHEMATA.
extent to this structure, occasionally ending in mortification
of the part attacked.
   Erysipelas spreads over the cutaneous surface often with
great rapidity, yet assuming a regularly progressive course,
the parts on which it first appeared being those, when the
disease ends in resolution, which first  desquamate.  Thus it
sometimes occurs that the eruption is  fading from the face
and the swelling disappearing there, while the disease is be-
ginning to show itself on the side of  the head or the neck.
Erysipelas is in an occasional case seen to assume a singu-
larly  erratic course, fading rapidly from the part on which
it appeared, and suddenly attacking another portion of the
skin at  some distance,  not  spreading to  it by contiguity.
This has been made a distinct variety by some writers under
the name of erysipelas  erraticum.  Dr. Graves was the first
to notice a singular fact, as  regards the mode of  spreading
of erysipelas, that when it  commences at any point of the
mesial line of the body it is very apt to spread in a symme-
trical manner ;; that is  to say, corresponding portions of the
integuments are simultaneously attacked on both sides.
  In  the course of  erysipelas, the inflammation sometimes
attacks  one  or more of the  internal  organs, as the  mem-
branes of the brain, the larynx and trachea, or the gastro-
intestinal mucous membrane.   By some this is considered
to be  a metastasis;  and on this supposition it has  been de-
scribed as a  distinct variety of the eruption under the name
of erysipelas metastaticum ; but in all the  cases that I  have
seen in Avhich any internal  part  of the body became  thus
affected, the local erysipelatous inflammation still remained
unchanged,  and therefore  could  not  be  correctly termed
metastatic.
   Traumatic erysipelas has its origin in some  local injury
which may or may not  have caused breach of the surface  ;
it  more usually, however, succeeds  the  former; when it
spreads from an ulcerated surface it is also said to be  trau-
matic. _ In its local characteristics it corresponds in most
cases  with the phlegmonous form  of the disease, presenting,
however, more effusion  of the liquor sanguinis into the deep-
seated tissues, in consequence, seemingly, of  which, vesica-
tions  rarely appear on  the  surface.   The inflammation is

         1 Clinical Medicine, second edition, vol. ii. p. 327. 
ERYSIPELAS.
41
also more diffused, spreading  rapidly from the wound, and
unless checked by treatment, rarely becoming circumscribed.
The parts affected, too, are more apt to become gangrenous,
a not uncommon  result in bad constitutions.   The  general
symptoms of traumatic erysipelas most frequently assume a
typhoid type, and are attendant on, not antecedent to, the
local inflammation.   In  some few rare  cases of this form
both the local and  constitutional symptoms are very mild,
and do not last for a longer period than  a week or ten days;
in general, however, their duration is prolonged to from a
fortnight to three Aveeks, if death does not take place at an
early date.
   In idiopathic erysipelas  death most  usually occurs from
the result of inflammation  attacking some  internal organ ;
but patients  occasionally sink under this disease with the
ordinary fatal symptoms  of asthenic or typhus fever.  The
traumatic form often terminates in gangrene, or, the veins
becoming inflamed, purulent deposits take place in the lungs
or liver, and  the  individual dies of phlebitic pneumonia  or
hepatitis.
   Erysipelas may occur at any age, even in new-born chil-
dren, in whom it attacks the umbilical region, from whence,
spreading rapidly, it almost invariably proves fatal.   Gene-
ral experience seems to prove that it is more  frequent  in
females than in males, and in adult life than  in the very
young or the aged.   The causes of erysipelas are at times
very obscure, yet in many cases its origin can be distinctly
ascribed either to some  local action, as in the  traumatic
form, or  when it  is produced  by some  direct irritant, or  to
some general constitutional  disturbance: indeed  the latter
may be  said to be always requisite as a  predisposing cause.
Thus it  is often seen to arise from the same causes as those
which under other circumstances produce fever: it follows
exposure to  cold or  wet, especially when  the  persons  so
exposed are deprived of their usual food or stimulants ; I
saw  several cases  of  erysipelas of the face and  head occur-
ring in  car drivers and others, who from their  occupation
were much exposed to the weather, at  the time  when the
temperance movement first occurred in Ireland, and in whom
the  disease  was  evidently  traceable  to the want  of the
stimuli Avhich they had been previously in the habit of using
                           4* 
42
EXANTHEMATA.
freely.  A very fatal, form of erysipelas  is caused  by the
introduction of an animal poison into the system, as  by the
inoculation of morbid matter arising from wounds received
during dissection,  from persons laboring under phlebitis,
&c.  Erysipelas may be produced by a sudden violent men-
tal emotion, as  a fit of passion,—such cases are on record,
—in which the local determination of blood probably aids
in the production of this disease.  In young children vac-
cination is sometimes the exciting cause of erysipelas, when
it usually  presents an cedematous character: I witnessed a
case lately which thus arose, and in which the inflammation
spread from the vaccine pustule on the left arm to the fin-
gers, thence proceeded up along the fingers of  the opposite
arm, and stopped when  it reached the same height on this
arm that it originated from on theother: the child recovered.
  As to whether erysipelas is contagious or not, a singular
difference  of  opinion has always existed and still exists be-
tween the practitioners of the French and English school;
the former laying it down as one of the characteristic defi-
nitions of the disease that it is non contagious,  and the lat-
ter with almost universal consent asserting that it is mark-
edly contagious.  The simultaneous occurrence of the dis-
ease amongst a number of persons is  attempted to  be ex-
plained away by the French writers on the  principle that
such persons were  predisposed  to it, or that  an  epidemic
influence,  or  a peculiar atmospheric condition, reigned at
the  time.  It  is unquestionable that  at certain seasons or
during certain years, the contagiousness of erysipelas is more
manifested than at other times, but this is equally true of
all  other contagious diseases.  The direct proofs noAV accu-
mulated are  too numerous and too  certain, I think, for the
question to be any longer one of doubt, and no British sur-
geon would, I feel confident, undertake an operation in  an
hospital in which erysipelas was present.  The  form  of ery-
sipelas arising from an animal poison is decidedly the most
contagious; the medical attendants and  nurses are in such
cases generally infected, and they convey the  disease even
to others.   It has been often remarked that Avhen puerperal
fever—which is manifestly due to the presence of a morbid
poison in the  system—prevails, wounds are very apt take on
erysipelatous inflammation, and  the disease spreads rapidly 
ERYSIPELAS.
43
 by contagion ; and likeAvise Avhen erysipelas occurs epidemi-
 cally, that puerperal fever is apt to arise.   The truth of
 these observations has been several times confirmed in the
 Rotunda Lying-in Hospital,  and large surgical hospitals of
 this city.
   Persons who  have had an attack of erysipelas are very
 liable to be again affected with  it, a distinguishing  feature
 between it and the eruptive fevers.
   The diagnosis of erysipelas  is rarely attended with any
 difficulty.   From erythema, which,  however, some  derma-
 tologists regard as  merely a mild form of erysipelas, it is
 distinguished by the attendant constitutional  symptoms,
 the smoothness  of the tumefied  surface, the greater degree
 of SAvelling, and the burning pain and tension.  It differs
 from the eruptive feArers in the uniform redness which the
 inflamed surface exhibits;  from phlebitis, in the absence of
 the cord-like feel which the inflamed veins present, and in
 the inflammation not spreading in lines over the track of
 the  large vessels ;  and from synovitis in the inflammation
 not being confined to, or taking its origin from, the  integu-
 ments covering the synovial membranes—but in many cases
 synovitis terminates in true erysipelas.
   The prognosis in  idiopathic  erysipelas  is in  general
 favorable, unless when the  disease occurs in  the very old,
 in  broken-doAvn habits  of body, or in  extreme infancy.
 The chief indications of danger are,  the attendant fever
 assuming a low typhoid type,  or some internal organ be-
 coming affected.   When the  erysipelatous  inflammation
 attacks the larynx  and glottis, which may ahvays  be ap-
 prehended when  it is seated on the integuments covering
 these parts, it  usually proves rapidly fatal, OAving  to  the
 tumefaction which ensues,  closing up the respiratory tube.
 Erysipelas of the phlegmonous character is always more
 dangerous  than when the inflammation is  superficial; and
 in the traumatic form, unless the local symptoms are very
 mild, the prognosis is always grave.
   With reference to  the pathology of  erysipelas  it  is evi-
 dently an acute  inflammation of all the  structures  of the
skin, the vascular rete being chiefly affected.   M. Blandin
has propounded  the theory that  the seat of the inflamma-
tion  is in the capillary  lymphatics, and MM. Cruveilhier 
44
EXANTHEMATA.
   and Ribes, that it  is situated in the capillary veins  of the
   integuments.
     The treatment of idiopathic  erysipelas may be  conve-
   niently  considered under  two  heads—the  constitutional
   and  the  local.  As regards the  former, many  different
   vieAvs have  been  propounded,  the  supposed  indications
   depending on  the  idea formed as to the essential nature
   of the disease.  Thus those who believe  it to depend on
   some  deranged  condition  of  the hepatic  secretion—the
   prevalent  opinion among them being that  it is caused by a
   deficient secretion  of bile and  a consequent accumulation
   of it in the system—treat all forms of erysipelas, no matter
   what may be the age or condition of the patient, by the
   administration of remedies calculated to promote a copious
   evacuation of that  fluid by the  alimentary canal.  Others,
   regarding  it as a  highly inflammatory disease, employ de-
   pletion, and other  active  antiphlogistics;  but  this plan of
   treatment, although it may succeed in the robust  dwellers
   in country districts, is not at all suited for the  inhabitants
   of towns  or large  cities.   With some, the affection being
   viewed as  one of asthenia, being attended with or depen-
   dent  on diminished  vital  power,  the use  of  tonics  and
   stimulants is relied upon; Avhile again, others, finding  that
   the urine is highly acid in the  early stages of the disease,
   as it is in all febrile affections, recommend an alkaline treat-
   ment.
     Seeing that these so opposite plans of treating erysipelas
   are reported by those who have proposed or adopted them
   as being attended  with  almost invariable success, we are
   forced to the  conclusion, that in the  ordinary run  of cases
   constitutional treatment is  of little importance.   Unques-
   tionably cases occur in which there are  extreme inflamma-
   tory action and high fever, demanding the use of bleeding
   and antiphlogistics; and others in which the vital  power is
   so low and the accompanying fever assumes from the onset
   so marked a typhoid type, that the most  powerful tonics,
   stimulants, and nutrients are clearly  indicated.  My  own
   experience, which,  however, it  is right to say, has  been
t   chiefly acquired in  this large and crowded  city, is decidedlv
   in favor  of the tonic and stimulant plan of treatment.  I
   ordinarily rely on the use of bark, which I give from the 
ERYSIPELAS.
45
 very commencement  of the disease; in  the  very old or
 debilitated combining it with tincture of serpentaria, as in
 the following form :—

       R.  Tincturae Cinchonae,.......fl 3iv.
           Tincturae Serpentariee,......fl 3iiij.
           Tincturae Croci,.........fl 3j.
           Decocti Cinchonas,........fl gxj. Misce.

            " An ounce to be taken every sixth hour."
   At the same time giving wine and nourishing diet accord-
 ing to the circumstances of each case.
   The preparations of iron are by many preferred to those
 of bark in the treatment  of this disease;  their mode of
 action would  appear to be  similar:  the  tincture  of  the
 sesquichloride,  in  the dose  of  from twenty to twenty-five
 drops every second or third hour, has been especially re-
 commended by Dr. and  Mr. Bell, of Edinburgh, in a paper
 lately published by them.1
   I consider the use of purgatives in the early stages of
 erysipelas as decidedly objectionable : they tend to increase
 the  debility, usually so  important a  characteristic feature
 of danger, and, determining  to the mucous membrane of
 the  alimentary canal  and to the abdominal viscera, their
 action prevents the full  development of the eruption on the
 cutaneous surfaces,—a circumstance to be  especially avoid-
 ed in the treatment of all inflammatory diseases of the skin,
 —and thus gives rise to local congestions and transference
 of the inflammation to some internal organ.
   The use of  biliary  evacuants has  been  very strongly
 supported in an excellent practical essay published by Dr.
 Albert Walsh ;2 the  remedy he recommends being tartar
 emetic, in  rather  minute closes,—one  grain  dissolved  in  a
 quart of some  emollient drink,  as whey or  barley  water, in
 the tAventy-four hours; he continues its use until the erup-
 tion begins to  fade, Avhen he administers sulphate  of quina
 and  other tonics.
   Mr. Lawrence is the cheif advocate in the present day
for bloodletting and active antiphlogistics; but in his views,

  1 Monthly Journal of Medical Science, June, 1851.
  2 Dublin Quarterly Journal of Medical Science, New Series, August, 1850. 
46
EXANTHEMATA.
as regards the  constitutional treatment  of the  disease, he
has very feAV followers.
   If any  internal organ be attacked during erysipelas, the
most active derivatives to the surface should be employed.
Thus,  when the  membranes  of the brain  are engaged,
sinapisms  and blisters should be applied to the legs,  and
warm stupes to the head;  active purgatives also  are now
indicated,  and of these the most valuable is the turpentine
enema.   When the  inflammation  seizes  on the  larynx,
leeches, even although great  debility be  present, should be
applied beneath the angles of the jaws, and hot stuping to
the throat, with relays  of sponges assiduously  employed;
a blister to the nape of the neck  is also here  a  valuable
remedy.   The operation of tracheotomy  is not applicable
in such cases,  for the erysipelatous inflammation  spreads
rapidly downwards through the respiratory tubes, causing
copious effusion into~their sub-mucous areolar tissue.
   When erysipelas affects the scalp, the hair should be im-
mediately  cut as close as possible, with the view  of  keeping
the surface cool, and of permitting local remedies to  be more
easily  applied.
   In the milder forms of idiopathic  erysipelas, the best  and
only local treatment requisite  consists in  dusting  the in-
flamed parts freely with wheaten flour  or finely powdered
starch, which may be conveniently applied from  an ordi-
nary dredging-box: the dredging should be repeated several
times in the twenty-four  hours.   It  allays  the  burning
pain and  irritation, and  always proves highly grateful to
the patient; therapeutically it appears to act by protecting
the surface from the air, and by drying up the discharge
as fast as  it exudes from any vesications which may have
formed.   When the vesications are numerous, and the dis-
charge excessive, I have found the addition of a drachm of
oxide of zinc and tAventy grains of  finely powdered carbon-
ate of  lead to  half a  pound of starch of  much  advantage.
In using  this  combination the  mixed  poAvders  should  be
well shaken each time before the parts are dusted with them,
as, in  consequence of their specific gravity, the zinc  and
lead soon  sink to the bottom of the  vessel in which thev are
kept.                                               J
   Anointing  the inflamed  surface  with  melted  lard is  by 
ERYSIPELAS.
47
 some preferred to the use of dusting powders.  Mr. Wil-
 son speaks highly of his experience of it, having first, he
 says, employed it on the recommendation of Mr. Grantham,
 Avhose method is, " to relax the skin Avith hot water or steam
 fomentations, and after each  fomentation to  saturate the
 inflamed surface  with hot lard, which is afterwards covered
 with avooI."
  ^ When  erysipelas is  spreading rapidly, although superfi-
 cially,  over  the  cutaneous  surface,  the  inflammation  still
 persisting in the parts where it first appeared,  inunction
 with mercurial ointment has  in  my  experience more effect
 than any other local application in checking its  progress.
 The  ordinary mercurial ointment, to every ounce of which
 a drachm of glycerine  has  been added, should be smeared
 thickly over  the  inflamed  surface, and on the sound skin
 for a considerable distance beyond; it need be  applied only
 twice in  the tAventy-four  hours, and if any symptoms of
 salivation be produced, its  employment should be at once
 stopped.
   Acting as  an impermeable varnish, and probably produc-
 ing some effect also  by the  compression it causes, collodion
 has  been successfully employed by Spengler and Rapp as
 a local application in erysipelas ; the parts are thickly coated
 Avith it by means of a camel's  hair pencil, and it is reneAved
 as often as may be required in consequence of its cracking
 and peeling off when dry.   When the disease affects one of
 the extremities, bandaging the limb has been used Avith very
 favorable results: this  practice originated with the Conti-
 nental school; its  action seems  to depend  chiefly  on  the
 equable compression  exercised on the congested  capillaries
 and cutaneous Areins, Avhereby they are emptied of the excess
 of blood contained in them ; but some of the good effect pro-
 duced is also probably due to the protection from the action
 or the air thereby given.
  Phlegmonous  and traumatic  erysipelas  demand  more
 active local medication  than Avhen the inflammation affects
 the superficial layers  of the integuments merely.   In these
forms of  the  disease many rely  on  topical depletion  by
leeches, by punctures, or by deep incision.  While leeches
may produce  a good  effect  by withdrawing blood  from  the
inflamed superficial vessel, the determination caused to parts 
48
EXANTHEMATA.
 on which their suction power is exerted is to a certain extent
 productive of mischief.   The same objection does not hold
 with regard to punctures ; their employment has been highly
 advocated, amongst  others,  by Sir Richard Dobson, by
 Liston, and by Wilson;  they should be made with a lancet,
 all over the inflamed part, at distances of from a quarter of
 an inch to an inch, according to the  extent of the surface
 engaged, and penetrate to the depth of a  quarter of an inch.
 As soon as they have  nearly ceased to bleed, a warm bran
 poultice may be applied.   Mr. Copland Hutchinson strongly
 recommended free incisions, and  his  practice  has  been
 adopted by Lawrence, Guthrie, and  others;  they  should be
 made down to the subcutaneous fascia,  and several inches
 in length. When there is much deep-seated effusion of the
 liquor sanguinis, as is so frequently the  case in traumatic
 erysipelas, they are decidedly productive of  the best effect,
 and they should never be  omitted when matter has formed.
   Nitrate of silver is used  in the treatment of erysipelas
 with  tAvo intentions, to check the spread of the inflammation
 superficially, and to promote  resolution  in the parts which
 have been attacked.  With the former view a broad line or
 cordon ismade on the sound skin, at a short distance from
 the margin of the inflamed  surface, by the application of a
 solid  stick of the nitrate  on the part, previously Avet Avith
 pure  water ; when the disease is situated on  one of the ex-
 tremities, this line is made to surround the limb completely.
 Mr. Higginbottom, who amongst English  surgeons is the
 chief advocate for the use of this agent, at first recommended
 the employment of the solid nitrate to the inflamed surface;
 but in his observations, recently published, and which con-
 tain the results of his accumulated experience, he states that
 he  prefers a solution  containing a scruple of the  salt to a
 drachm of distilled water.   He gives the following  direction
 for its application: "The affected parts should be washed
 well with soap and water,  then with water alone, to remove
 any particle of soap remaining, and  then wipe dry with a
soft cloth: the concentrated solution  of the nitrate of silver
is then to be  applied two or three times over the whole in-
flamed surface, and beyond  it on the surrounding  healthv
skin  to the extent of two or three inches."   In twetve hours
should the erysipelatous inflammation  be unaffected, it is to 
URTICARIA.
49
 be again applied; when vesications exist,  they should be
 opened previously to the application.  I prefer to use the
 nitrate of silver in the  form of ointment, a drachm to the
 ounce of lard; it thus comes more completely into contact
 with the inflamed surface, does not dry up so rapidly, and
 is more easy of application to some parts of the body, as to
 the scalp.                          *
   Sulphate of iron, both in solution and  in ointment, has
 been recommended as a most valuable  local application in
 erysipelas by Velpeau, but I have not seen it prove so useful
 as nitrate of silver ; the solution which he uses contains one
 part of the salt dissolved in fifteen parts of water,  and the
 ointment consists of one  part  of  the sulphate to three or
 four of lard.
   Blisters are sometimes employed with success to prevent
 the spread of erysipelatous inflammation ; they are applied
 at the margin of the affected surface :  their effect  appears
 to  depend on  a  new action being excited in the parts, and
 their use seems to prove especially of service in the erratic
 form of the disease.  The only other local remedies requir-
 ing notice, are creasote, which, painted over the surface, has
 recently proved successful in the hands of some practition-
 ers ; and congelation of the surface by means of pounded
 ice  and salt mixed in a bladder, which has  been proposed
 by Dr. Arnott: from the use of the latter it may be appre-
 hended that some internal organ might be attacked.
   Should erysipelas assume a gangrenous tendency, in addi-
 tion  to the internal administration  of  the most powerful
 tonics, as wine, bark, and quina, the parts ought to be enve-
 loped with a charcoal poultice, and afterwards dressed with
 lint  soaked in a  lotion, containing from  one to two ounces
 of the solution of  chlorinated soda  or chlorinated lime to
 the pint of distilled water.

                       URTICARIA.

   Urticaria  (Nettle-rash) may be defined to  consist in an
 eruption of irregularly-shaped prominent patches, or wheal-
like  elevations of the skin, of  a yellowish-white or reddish-
yellow color, which are surrounded by a diffuse redness, are
often evanescent, and are attended with a burning sensation, 
50
EXANTHEMATA.
tingling, and extreme itching.  It is non-contagious, and is
usually accompanied by a greater or less  degree of fever ;
and it may be either acute or chronic, in the former  case
lasting for a few Aveeks, in the latter for months or  even
years. The name of this disease is derived from the resem-
blance which the eruption bears, both in appearance  and
symptoms, to that occasioned by the sting of the  common
nettle— Urtica urens.  Willan describes several varieties of
urticaria,  and numerous  subdivisions of it have also  been
made by other dermatologists; but I think they may all be
conveniently classed under three heads :—

                   Urticaria febrilis.
                      "     evanida.
                      "     tuberosa.

  An attack of Urticaria febrilis (Atlas,  PI. II. Fig.  1) is
ushered in with the ordinary symptoms  of mild fever—
shivering, headache, hot skin, thirst, loss of appetite, pains
in the limbs, and in many cases \romiting.  In from  twelve
to twenty-four hours, the cutaneous surface becomes covered.
Avith numerous patches of the characteristic eruption, the
parts on which it appears  having been for a short time pre-
viously the seat of a burning sensation, attended with ting-
ling and itching.  The wheal-like elevations generally ap-
pear simultaneously on various portions of the body—on the
face, the neck, over the back, and on the anterior aspect of
the arms and legs;  they often disappear suddenly, and as
suddenly re-appear  on some other part of  the skin.  They
bear much resemblance to the sting of a nettle, being slightly
elevated, of a bright red color, with raised yellowish spots
or lines; in most cases the itching which attends them  is
very intense, and accompanied by a burning sensation, and
additional patches are produced on the apparently unaffected
surface by the patient rubbing or scratching the part.  The
eruption runs its course generally in from six to eight hours
but to be succeeded  by a fresh crop on the  same or on differ-
ent parts of the body—in most cases appearing in the even-
ing, and the outbreak of  which is attended, as before  with
tingling and itching.  Febrile urticaria is thus prolonged
for  a week or ten days, the eruption being less extensive and 
URTICARIA.
51
the constitutional symptoms  less marked with  each succes-
sive crop ; the general febrile symptoms subside to a certain
extent when the rash comes fully out, but are usually again
somewhat aggravated each time  the eruption disappears.
The epidermis of the parts which have been affected desqua-
mates in fine mealy scales after the disease  has subsided,
but no stain or mark is left behind.
   When the eruption  does not recede and again re-appear
as now described, but  remains permanently on the surface
on which it  first  presents, it  assumes somewhat of a more
chronic character, lasting for  three  or four weeks, and is
termed urticaria perstans.  This  sub-variety is attended
Avith milder constitutional symptoms,  and with  less  local
irritation and itching.  In the variety named conferta (Atlas,
PI. II. Fig. 2) the local and general symptoms are precisely
similar to those of urticaria febrilis, but in general more
severe; the  patches of eruption are numerous, and coalescing
cover a much more extensive surface of the  skin.  A form
of urticaria  has been described under the appellation of inter-
mittens, in which the  appearance of successive  crops of the
eruption assumes a regular intermittent type, usually quoti-
dian, sometimes,  however, more prolonged, being tertian or
quartan, or the rash may not re-appear until the end of
every seventh,  eighth, or ninth day—coming out in  the
evening, attaining its  greatest intensity during  the night,
and disappearing almost  entirely before morning.  Willan
mentioned as a  variety of this disease, under  the  name of
subcutanea, what was  manifestly chiefly a nervous irritation,
there being constant and violent  itching of the cutaneous
surface commencing on some spot of one of the extremities,
thence  extending to  the entire limb,  to the trunk,  and
finally over  the whole  body, with only an occasional eruption
of urticaria  at distant intervals.
   Urticaria evanida  (Atlas, PI.  II. Fig. 3)  is a chronic
form of the  disease, which not unfrequently lasts for years,
and  although unattended  with fe\rer, renders the  life of the
person Avho  suffers from it almost  intolerable,  from the un-
ceasing painful itching by which it is characterized.  The
eruption appears in small, rounded, reddish-yellow eleva-
tions—often two, three, or more such, closely  set together,
forming a wheal like that caused  by the lash  of a whip— 
52
EXANTHEMATA.
with little, if any, surrounding redness of the skin;  they
may appear on  any part of the body, but are usually de-
veloped by scratching, or by friction of the clothes: in fe-
males they  are most frequently  seated  around  the neck,
where the upper part of the dress rubs the surface, and on
the arms where they are likewise caused by the friction of
the sleeves  of the  dress.  The rash  generally  begins  to
appear towards evening, and is fully developed during the
night, fading away before morning.   The itching it occa-
sions is most intense, causing absolute suffering, and persons
even of the utmost fortitude cannot refrain from scratching
violently the parts affected, by which an additional eruption
is caused.  The wheals do not remain longer on the surface
than five or six hours, but they are  renewed  by the least
local irritation, and the disease thus  continues for months
with occasional intermissions, being always most severe dur-
ing the summer and  autumn.   After it has lasted for some
time the  general health becomes more or less affected,  both
from the constant irritation it  occasions and  the derange-
ment of the natural functions of the skin.
   Urticaria tuberosa (Atlas, PI. II. Fig. 4), which is a  very
rare variety of the eruption, occurs in the form of distinct,
rounded  elevations, about the size of a small walnut,  hard
and firm, extending evidently into the subcutaneous areolar
tissue,  of a  livid  red color, with a yellowish  raised centre.
The portion of the integuments affected is stiff, tense, and
painful to the touch or on motion.  The  tumors generally
appear on the extremities, coming out during the night with
pain, much itching, and some fever, and nearly disappearing
before  morning, leaving  the  patient weak, tired, and  sick.
It is essentially chronic in its course,  and very obstinate in
its duration, sometimes extending to two or three  years, or
even longer, with short intervals of remission.
  Urticaria is of more frequent occurrence in females than
in males, which may be accounted for by its seldom  attack-
ing any  but those whose skin is fine and delicate ; for the
same reason, while it appears  not uncommonly  in  infants
and children, it is not a disease of advanced life.  The causes
by which the febrile  form  is produced are, in most cases,
well marked, but those on which urticaria evanida and urtica-
ria tuberosa depend are  not  so manifest.  A marked con- 
URTICARIA.
53
 nection exists betAveen the appea'rance of  this eruption  on
 the  cutaneous surface and  derangements  of the digestive
 organs, or rather the irritation caused in some persons  by
 certain indigestible  articles of food.  Shellfish,  especially
 mussels, oysters,  crabs, cockles, periwinkles,  and shrimps,
 have been long noted as producing urticaria in many indivi-
 duals, the eruption  appearing  in  a few hours after any of
 them may have been eaten.   Similarly it has  been seen  to
 arise after the ingestion of pork, veal, or goose, of salted,
 spiced, or dried meats or fish, of cheese,  of honey, of many
 fruits and vegetables, particularly gooseberries, cucumbers,
 melons,  mushrooms, pickles, &c.  I know  two persons  in
 both of whom urticaria  appears in half-an-hour after they
 have eaten almonds or nuts if the brown skins had not been
 previously removed.  In all these cases the occurrence of
 the  eruption must be due to some individual idiosyncrasy,
 with the nature of Avhich we are unacquainted.   The use of
 certain medicines, especially of copaiba  or  valerian,  some-
 times gives rise to this  disease; in one instance which  I
 witnessed, copaiba was given to a woman  avIio was at the
 time suckling her infant, and urticaria appeared both on her-
 self and on her child.  Frank  mentions  his having seen  it
 occur from drinking Selters Avater.   In the case of a boy,
 aged 15, Avho was  admitted into  Jervis-street  Hospital  in
 the  month of December, 1851, for acute pleuritis, a copious
 eruption of urticaria appeared  over the face, the upper ex-
 tremities, and  the trunk, on the third  day  after his admis-
 sion ; the feverish symptoms had commenced to subside, and
 his system had been brought under the influence of mercury
 the day previously.
   Urticaria has been often  noticed as occurring in  connec-
 tion with other febrile diseases, especially Avith rheumatism,
 and  Dr. Graves has pointed out the connection which exists
 betAveen rheumatism, deranged conditions of the liver, and
 this  eruption.1  In  children it frequently  appears at the
 periods of dentition,  being  evidently  associated with the
 gastric irritation Avhich then occurs.  Many have  described
 some of  the  forms  of this  disease as being caused in the
female sex by deranged states  of the menstrual function;
but my experience is quite opposed to this Ariew.
         1  Clinical Medicine, Second Edition, vol. i. p. 446.
                           5* 
54
EXANTHEMATA.
   Urticaria occasionally appears as a complication of other
 cutaneous eruptions, more  particularly eczema, impetigo,
 prurigo, and lichen.
   The diagnosis of urticaria cannot be attended with any
 difficulty, its local characteristics are so well marked.  From
 erythema it is well distinguished by the  absence of the dif-
 fuse redness of the cutaneous surface, and by the intense
 itching which accompanies  it.  Erythema nodosum  might
 be mistaken for urticaria tuberosa, but the evanescent cha-
 racter of the latter, even in its  most chronic form, suffices
 to diagnose it; the former also  is marked by the presence
 of acute febrile symptoms.   Roseola, the only other  of the
 exanthemata which might be  confounded with febrile urti-
 caria, is not attended with the intense itching of this disease,
 and also differs considerably in the color and appearance of
 the  eruption.  One of the  varieties  of lichen has  been
 termed urticatus, in consequence of the  troublesome  sting-
 ing  by which it  is accompanied, owing  to which symptom
 it has been occasionally mistaken for and  described as  a
 form of urticaria, but it is a distinctly papular eruption.
   The prognosis in any of the  forms of urticaria must be
 favorable, as may be understood  from what has been already
 said.   A few fatal cases of the disease, it is true, have been
 recorded by some  of the older writers, but that they were
 instances  of this  eruption uncomplicated with an internal
 organic affection may well be doubted.  We have, however,
 the testimony of Willan, that  a case fell under his observa-
 tion in which death occurred from the sudden retrocession
 of the eruption about the fifth day ; but the  patient  was  a
 very intemperate man, and had  suffered from  great pain in
 the stomach and nausea, which were much relieA'ed when the
 cutaneous eruption came out, and delirium  and high fever
 followed its  sudden disappearance.
   The seat  of urticaria is in the  superficial  layers of the
 derma and the epidermis ; as regards its pathology, it seems
 to be chiefly an affection of the nerves of the skin.   From
 an analysis of the urine by Dr. Douglas Maclagan, of Edin-
burgh, he came to the conclusion that urticaria is intimately
connected with  a  deficiency  of  the  organic  salts  of the
urine—urea  and uric acid, and  their probable retention in
the system,  and  the correctness  of this opinion is favored 
URTICARIA.
55
by the connection, already adverted to, Avhich exists between
this  disease and rheumatism.
   Treatment.—The febrile form of  urticaria requires the
employment of antiphlogistic purgatives, and diaphoretics,
or, should the fever  run very high in full habits, local or
general  bleeding may even be requisite.   The  best purga-
tive  is the sulphate of magnesia given in the acid infusion
of roses, with an excess of acid; thus an ounce of the salt
may be dissolved in twelve fluid ounces of the acid infusion,
and  to it two fluid  drachms of dilute  sulphuric acid be
added; of this  the dose is  a sixth  part every third hour
until the bowels are freely moved: -the  purgatives should
be repeated every second day as long as the feverish symp-
toms have not subsided.  Nitre Avhey  given at bed-time
forms a good diaphoretic, or tAvo drachms of the water of
the acetate of ammonia may be added to the Avhey instead
of the nitre.   Acting .on his view of the pathology of the
disease, Dr. Maclagan has treated it Avith  colchicum ; and
this  medicine is certainly indicated  when the eruption is
complicated with rheumatism.
   When urticaria  is  produced by  eating any particular
article of food, an active and immediate emetic, such as the
sulphate of zinc, should  be  at  once  administered, and  its
action followed by the  exhibition of  a mercurial cathartic;
if the subsequent fever be Avell marked, bleeding may be  re-
quired, but only a small quantity of blood should in any
case be Avithdrawn, as general symptoms  of poisoning, Avith
much depression, not  unfrequently follow.  The  intermit-
tent  form  of  the  disease requires to be  treated constitu-
tionally with tonics and antiperiodics, especially the prepa-
rations  of bark, the bowels  having been  first freely acted
on by a saline cathartic; this variety of  urticaria may  oc-
casionally be  cut short by the administration of an emetic
a feAV hours previously to the expected reappearance  of the
eruption.
   In urticaria evanida a lowering plan of  treatment is de-
cidedly contra-indicated, as the disease invariably assumes
a chronic form.   I  have derived especial  benefit in it from
the use of preparations of iron, and from the administration
of Dover's poAvder ; of the former, I generally prescribe the 
56
EXANTHEMATA.
 compound iron mixture in doses of two ounces every morn-
 ing, or twenty minims of the tincture of the  sesqui-chlo-
 ride three times a day in an ounce of the infusion of quassia
 or calumba, or two  ounces  tAvice  daily of Bewley's aqua
 chalybeata: of the latter, from eight to twelve grains every
 night at bed-time.  Under the administration of these com-
 bined remedies, I have seen most obstinate chronic cases of
 the disease yield in a few Aveeks ; while administering them
 the boAvels should be kept freely open by mild saline purga-
 tives.   Urticaria tuberosa should be treated  similarly ; but
 in cases in which the disease has been of very long stand-
 ing, it Avill occasionally only yield to the prolonged adminis-
 tration of arsenic.  When any of the forms are connected
 Avith or complicated  by the  presence of any other disease,
 the treatment ought to be modified accordingly.
   The itching and tingling of urticaria are somewhat allayed
 by the use of the warm bath, but as  soon as  the skin is dried
 afterwards, these painful sensations are augmented in con-
 sequence of the friction of the surface requisite to remove
 the moisture.  In febrile urticaria  I have employed, as a
 local application, with much effect, the  following  alkaline
 spirituous wash:—
   R. Carbonatis  Potassae,........3ss.
      Aquas Florum Sambuci,......fl 5xiss.
      Spiritus Vini Rectificati,......fl gss. Misce.

   Pieces of lint saturated with the  lotion should be laid on
 the parts where the itching  is most troublesome.   In the
 chronic forms of  the  disease,  chloroform  is  an excellent
 topical  remedy for the same purpose;  an ointment  of  it,
 prepared by rubbing together half a drachm  of  chloroform
 and an ounce of cold cream should be smeared rather thickly
 over the affected surface.  Lotions  and  ointments, contain-
 ing prussic acid, opiates, and  other narcotics, have proved
 successful in the hands of others.
  In urticaria occurring in infants  and  children, the state
 of the  digestive organs demands especial attention, and in
 all cases whether  the teeth are  appearing or not, the gums
should be lanced ;  in infants at the breast, the health of the
nurse is in particular to be attended to ;  the local irritation 
ROSEOLA.
57
at this early age, may be allayed by sponging the surface of
the body Avith a warm infusion of chamomile.
  Whenever the  sudden  retrocession of the eruption  in
urticaria is attended with evidences of derangement of any
internal  organ, the hot  bath should be used, with friction
over the  surface, and blisters  applied to  the epigastrium
and the nape of the neck.
  As regards the  diet  in urticaria the  chief point to  be
attended  to is the avoidance of the use of any food which
from individual  experience,  has  been found to produce the
eruption.  In the  acute forms of the disease  the patient
should live Ioav ;  but when  it  becomes  chronic, the  food
should be nourishing, yet not rich or heating.

                        ROSEOLA.

  Roseola (Rose-rash*)  is by many dermatologists regarded
as being merely a variety  of erythema, erysipelas, or mea-
sles, and its existence as a distinct eruption not admitted;
but I fully agree with Willan,  that its local characteristics
are sufficiently well defined to separate it from any of these
diseases, and to require a special description.  The name,
which has been applied to  it in consequence of the peculiar
rose-color which  it usually presents, is to a certain  extent
objectionable, as  this color varies much in the  different
stages and forms of the eruption.   It consists in the appear-
ance of very slightly elevated rose-red patches, of irregular
shape, transient, fading  at times, and again  re-appearing;
non-contagious,  and  attended  with some  degree of fever.
The various forms of Roseola  may be classed  under tAvo
heads:
                Roseola idiopathica.
                   "    symptomatica.

  An attack of Roseola idiopathica (Atlas, PI.  II. Fig. 5)
is usually attended with slight  fever, which, however,  in
children is sometimes well marked  and severe ;  the febrile
symptoms  subsiding to  a  great  extent when the  eruption
appears  freely on  the  skin.  It comes out in numerous

  1  In Scotland erysipelas is commonly tei'med  " The Rose," which has
caused this eruption to be occasionally confounded with it. 
58
EXANTHEMATA.
 reddish-yellow patches, which soon assume  a roseate  hue,
 and are irregularly distributed over the cutaneous surface;
 generally appearing first on the face and neck, and spread-
 ing  quickly thence to  the trunk and  the  upper and lower
 extremities;  occasionally the eruption  is  confined  to the
 face, neck, and trunk, and at times it occurs on the extremi-
 ties  only.  The  rash is  often very transient, disappearing
 completely in from twenty-four to  forty-eight hours —Avhen
 the feverish symptoms become aggravated, and re-appearing
 again within the next twelve hours ; it usually runs its course
 in from five to  seven  days, terminating with slight epider-
 mic  desquamation.  When  roseola occurs  in infants  and
 children, it is not  unfrequently attended with more  or less
 tumefaction of the integuments, which precedes the appear-
 ance of the eruption, being  most  marked  in those  places
 where the rash is to come out.
   Two forms of  the disease have been described under the
 names sestiva and autumnalis, from their appearing at these
 seasons  of the year: in the former, the feverish symptoms
 sometimes  run  high, and are attended with more or  less
 sore throat, which, on  inspection, is seen to be somewhat
 swollen  and of a  bright rose-red  color,—the rash,  too, is
 very generally distributed over the cutaneous surface ;  in
 the latter the eruption is of a duller hue, in small sized
 patches, and attended with very slight fever or sore  throat
 —this symptom, however, being often absent.  When the
 disease attacks infants, it has by some dermatologists been
 described as a distinct  form, and termed roseola infantilis ;
it  is in  them usually very mild,  and disappears in  a  few
 days; but in some cases is  marked  by itching, as  would
appear from the annoyance  it seems  to give  the little pa-
tient ; it is then also more prolonged.
   The eruption in  idiopathic roseola not unfrequently ap-
pears in the form of rings or circles, of a bright rosy hue
surrounding a healthy portion of  skin which is unaltered
in  color; it is then termed roseola annulata (Atlas PI II
Fig.  6)._ This is a more aggravated form  of the'disease
setting m with  well-marked  symptoms of fever, a distinct
shivering fit, followed by sickness of the stomach, headache
pains m the limbs, and hot skin, preceding the appearance 
ROSEOLA.
59
of the eruption for from twenty-four to forty-eight hours ;
oedema of the integuments is also not uncommon in this form,
particularly in children—in whom the disease usually  occurs
—appearing especially should the  eruption suddenly retro-
cede.  In one case which I attended in 1849, that  of a boy
aged six years, the entire body became enormously SAvollen
on the sudden disappearance of the rash, so much so  that
both eyes were closed, and there  was  great difficulty of
breathing and of swallowing, owing to the tumefaction of
the  fauces.  This variety of roseola  may  appear  on  any
part of the cutaneous surface, but is  most  frequently  seen
on the loAver extremities, and the  trunk of the body.  It
comes out in  the  form of numerous small,  round, reddish
patches,  which, rapidly spreading  by their circumference,
assume the character of rings, some  being quite  circular,
and  others  irregularly so ; the central  portion  of healthy
skin, which at first is only  a  few  lines in  diameter,  gra-
dually extends  to  half-an-inch,  or even two  inches, the
surrounding rose-red  eruption being from a  quarter to half-
an-inch in width; sometimes two or three of the rings, meet-
ing,  coalesce and may thus extend beyond one of the  joints,
or nearly round a limb.  Heat of the skin and itching gene-
rally accompany this  form of roseola.
  Mr. Erasmus Wilson describes a variety of roseola under
the name of punctata, in which the  eruption, attended  with
fever of  a subacute type, appears on the mucous membrane
and  skin, " on the latter, in the form  of  small red spots
around the  mouths of the follicles, then becoming diffused
so as  to  cover the greater part of the body, reaching its
height on the  third day ; at first of a  bright raspberry red
color, aftenvards acquiring a dull roseate hue, the dulness
increasing with the progress of the decline ;"—the disease
lasts for ten days.   He speaks of it as a rare disease, having
seen only a few examples; I never met Avith it as  an idio-
pathic affection, but  I have seen syphilitic  roseola present
these characteristics.
  Roseola symptomatica occurs in the course of, or as an
accompaniment  to  many febrile  diseases,  but its charac-
ters  are  so  similar  to those  of  the idiopathic form  as not
to require a distinct  description.   It  is thus Avitnessed in
small-pox—the eruption of which it  usually  precedes by 
60
EXANTHEMATA.
about twenty-four hours—cow-pock, fevers, acute rheuma-
tism, epidemic  cholera,  &c, and  as  it may attend any of
these diseases, it has been named by dermatologists R. va-
riolosa,  R. vaccina, R. miliaria  vel febrilis, R. cholerica,
&c.  When the practice of inoculation prevailed, roseola is
described  as  appearing  very  regularly on  the  second or
third day  of the fever of incubation, and was regarded as
a favorable sign,  indicating  that the  variolous  eruption
would be  mild.  In cow-pock, it occurs  about  the period
of maturation  of  the  vaccine pustule,  spreading from it
along the  arm, and often appearing also  on the trunk ; it
is not of very frequent occurrence, is of a  very mild charac-
ter, and fades away in  two or three days. Its  appearance
during either fever or acute rheumatism is rather a favorable
sign than  otherwise ; it does not require  any special treat-
ment, nor  does it interfere Avith that of either of these dis-
eases.   The cholera exanthem has been described by Keir,
Babington, and Rayer, all of whom Avitnessed it in the epi-
demic of 1832; it accompanied the  fever of reaction, and
its appearance does not seem to have in any way influenced
the progress of the disease.
  Roseola may occur at any age, but  is  more frequent in
the young than in the old.   It may be caused by any local
irritation of the skin, or by any circumstance acting on the
system generally, which  gives rise to determination of blood
to  the cutaneous  capillaries;  the  latter is  evidently the
cause of the  symptomatic form of the eruption.  In  sum-
mer it is  occasioned by exposure to a hot sun when the
digestive organs are deranged, or by  the perspiration be-
ing suddenly checked; its  frequent  occurrence  in autumn
is  traceable to the gastric irritation which is  at that  sea-
son of the year so frequently caused by the too free use
of fruit and  new vegetables.   In   children  it commonly
appears about the periods of first and second dentition, and
is  manifestly  connected  with the  derangements of  the
system which then so commonly exist; and in infants it is
usually occasioned by the nurse's milk  disagreeing with the

  With regard to  diagnosis,  roseola is  an important dis-
ease, as it is very liable to be mistaken  for either measles
or scarlatina.   From the  former it is  distinguished by the 
ROSEOLA.
61
color of the eruption, so  different  when  it  is fully deve-
loped from the dull red hue of measles, by its not assuming
the crescentic  or  horseshoe shape,  and by the  absence of
the catarrhal fever.  From  scarlatina, with which, in con-
sequence of  the sore throat, it  is in its early stage  apt to
be  confounded, the  color of the  rash, its  appearing in
patches  or  spots,  and  not  being generally  diffused over
the surface, the comparatively mild character of the fever
and of  the  attendant sore throat, and the absence of the
burning heat of the skin, are sufficient to diagnose it.  The
distinguishing characteristics between roseola  and erythema
nodosum are,  the elevation, the color,  and  the  peculiar
shape of the latter ;  and  the chief  diagnostic features be-
tween it and  urticaria are, the absence  of the  intense
itching and of the  wheal-like eruption.
   The prognosis in roseola is always favorable, the eruption
being  attended Avith  but   slight annoyance, disappearing
generally in the course of ten days, though occasionally pro-
longed for three or four weeks ; but in all cases it is a simple
affection, and one  attended Avith little or  no danger, and in
many febrile diseases its occurrence  is manifestly salutary.
   The  treatment of the disease is  simple; rest in  bed or
even  confinement  to  the  house, with Ioav diet, the use of
diluent drinks, and when the eruption is well  out, mild pur-
gatives, being sufficient in most cases to effect  a cure.  Mer-
curial seem  better adapted  than saline purgatives for the
treatment of roseola—with infants and children the hydrar-
gyrum cum magnesia appears especially to agree.  Should
the fever run high, and the eruption be slow in coming out,
the warm bath Avill prove  of service ; it  should be  ahvays
used with children.   When there is oedema of the surface,
small doses  of the spirit  of nitric ether and of the water
of the acetate of ammonia  are prescribed Avith benefit.   In
chronic  cases,  or  in weakly habits of body, should  the
disease  become chronic, vegetable  tonics and the mineral
acids are indicated.  If much  itching or heat  of  surface
attends the eruption, it will be allayed by a  weak alkaline
spirituous wash, such as the folloAving :—
  R.  Sodae Biboratis,......5SS-
      Aquae Florum Sambuci, .   .   .   .  fl 3xiss.
   -  Spiritus Rosmarini,.....fl iss. Misce.
                           6 
62
EXANTHEMATA.
  In most cases, however, no local  application, except the
general warm bath, or  sponging the skin with warm water,
will be needed.  Symptomatic roseola requires no special
treatment apart from the disease which it accompanies, and
the employment of any  which might repel the eruption from
the surface should be especially guarded  against. 
ECZEMA.                     63
                  CHAPTER  III.

                        VESICUL^!.

   The term Vesicul^e, formerly employed to  designate
 any cutaneous eruption, in which matter was effused beneath
 the cuticle, was  restricted by  Willan to those forms  in
 which the effusion is  a transparent fluid, contained  in mi-
 nute, orbicular, epidermic "elevations,  corresponding  to  his
 definition of a vesicle; when these elevations were of larger
 size, the  diseases in which they occurred were  placed in a
 distinct class, denominated by  him Bulla?; but with  re-
 spect  to  their visible  phenomena, as  they differ only  in
 magnitude, I shall include both,in one  class.   The Order
 Vesiculae, then, may be defined  to be  characterized by an
 eruption  of vesicles or blebs, which consist  in an elevation
 of the epidermis varying in size, sometimes minute (Aresicles),
 sometimes of tolerable magnitude (bullae or blebs), contain-
 ing a transparent, serous  fluid,  which,  with the progress
 of the disease, becomes opaque, and dries into thin scales
 or crusts.  There are five genera contained in the Order:
 Eczema,  Herpes, Pemphigus,  Rupia, Scabies.   Of these
 the first  two  are attended usually Avith  acute symptoms;
 pemphigus  and rupia  with fever  of a low type; aud scabies
 with local inflammatory action,  but very rarely  with con-
 stitutional derangement.  In all, the fluid contained in the
 vesicles becomes opaque and sero-purulent with the progress
. of the disease, and they are then often diagnosed with dif-
 ficulty from pustular eruptions.

                         ECZEMA.

   Eczema  (Scall or  Humid  Tetter)  is  a most  important
 and interesting  disease  of the  skin,  being of  extremely
 frequent  occurrence, at times very difficult  of diagnosis—
 particularly in its advanced stages, and usually most re-
 bellious to  treatment.   It is characterized by the eruption
 of numerous minute  transparent vesicles, closely set and 
64                    VESICULJ3.
irregularly  aggregated  on  an uncircumscribed  inflamed
surface, and attended  generally with burning pain and in-
tense itching.  It is highly inflammatory, but non-conta-
gious.  The vesicles, which are at first perfectly transparent,
become opaque on  the second  or  third  day  after their
appearance,—the contained fluid assuming a semi-purulent
character,—and either  dry up  with a fine furfuraceous
desquamation, or, bursting,  become covered with thin, yel-
low crusts, from beneath which an acrid, watery exudation
takes place.  Eczema differs much  in appearance,  as  it
occurs on  the  parts of  the cutaneous surface which are
ordinarily  covered, or  exposed;  or  on which hair grcws,
and therefore must be described more or less with reference
to a regional system of classification.  The forms of the
disease, according  to  the  course  which  they run, are
naturally divided into  two groups, the acute and  chronic:
and  as regards external  characteristics, two  varieties are
well marked:—
                    Eczema simplex.
                       "    rubrum.

  But it is also requisite to  consider it specially, as it may
be seated on the face or on the scalp:—
                     Eczema faciei.
                        "    capitis.

  Eczema  simplex  (Atlas,  PI.  III. Fig. 1) is  attended.
with scarcely any fever,  slight nausea and headache  occa-
sionally preceding its  eruption, which is  accompanied by
some heat  and  tingling of the  surface.   It consists in the
appearance  of  numerous minute  shining vesicles, not ex-
ceeding in  size the head of  a small pin, which are closely
aggregated, and  irregularly  distributed  on   apparently
healthy skm of the  natural color, but with  a magnifying
glass each  vesicle may be seen to be surrounded by a nar-
row red areola; in forty eight hours  the fluid contained  in
them becomes opaque, and on the third or  fourth day they
dry up and  are followed by a fine mealy desquamation  of
the epidermis, and thus the  disease may run its course  in
from four to six days.   In  most cases,  however, a  fresh
crop of vesicles appears as soon as the first has maturated 
ECZEMA.
65
 and by successive crops its duration may be prolonged for
 as many weeks ;  under such circumstances,  thin yellowish
 crusts or scabs are formed, and a serous exudation continues
 to floAV from the surface while the disease  lasts, often  in
 large quantity.   The heat and itching are then also trouble-
 some, and if the part be scratched or irritated, the eruption
 may become chronic, or may change into the second form.
 For a long time after the disappearance  of the disease the
 epidermis continues to desquamate, but it leaves no stain on
 the skin or other  trace of its existence.
   This form of eczema usually appears on the backs of the
 hands and arms, sometimes on the scalp, but rarely on the
 loAver extremities, on the trunk, or on the face.
   Eczema rubrum (Atlas,  PI. III. Fig. 2)  is an  acutely
 inflammatory disease, an attack of it being ushered in gene-
 rally with sharp fever, and  ahvays  with  much local  pain,
 heat, and swelling of the portions of the  integuments about
 to be affected.   Numerous pellucid, small vesicles are rapidly
 developed on a highly inflamed, uncircumscribed surface,  of
 a bright red color and tumefied, over which they are irregu-
 larly distributed, but crowded together in  patches; the parts
 feel painfully tense, and cause a  continued  tingling rather
 than itching.    The  vesicles  becoming opaque,  enlarge
 someAvhat, look  fuller,  and bursting, form yelloAvish  crusts ;
 in a few rare cases the disease terminates in from a fortnight
 to three weeks with  the falling off of these crusts and subse-
 quent epidermic desquamation.  But in most  instances, and
 invariably when the parts  have been torn by scratching or
 othenvise  irritated,  a  copious  discharge  of an  acrid, thin,
 serous  fluid, continues to  flow from  the  inflamed surface,
 apparently without the formation of new vesicles;  the in-
 flammation spreads to  the adjoining portions of the skin,
 often seemingly caused by this discharge flowing over them;
 bright red cracks and fissures form in the integuments, which
 are excoriated, thickened, much swollen, and attended with
intense  pain and itching, and blood flows freely should they
be scratched.   The serous exudation is usually in very large
quantity, so great as at  times to require  to be continually
Aviped aAvay, that from  even  a limited surface Avetting com-
pletely a  large handkerchief in  a feAV  moments ;  when  it is
not so copious it  dries quickly into  fine  lamellar scales,  a
                           G* 
Q6
VESICUL.E.
 constant desquamation of which takes place.  The aspect
 of this form of the disease, when fully developed, is highly
 characteristic ; the  shining  crimson or bright  red  surface,
 covered in parts with the ichorous discharge, and in parts
 with the thin film of desquamating  epidermic secretion, the
 deeper-colored  fissures and cracks,  from  which blood occa-
 sionally floAvs, and the tensely tumefied appearance of the
 whole.   Eczema rubrum, when it  presents the aggravated
 characters noAv described, seldom gets well in a shorter space
 of time than two or three months, and occasionally, becom-
 ing chronic, lasts for years.
  In some cases the local inflammation is still more acute,
 the discharge becomes sero-purulent or purulent, concreting
 into thick yellowish scabs, and scattered pustules form  on
 the surface; it is then termed eczema impetiginodes (Atlas,
 PI.  III. Fig.  3), from the resemblance which it presents to
 impetigo.  This variety  of  the  eruption  is generally met
 Avith in infants and children, is  attended Avith well  marked
 febrile symptoms, and much local pain and itching, and lasts
 for  from three  to  six  Aveeks, or  occasionally,  becoming
 chronic, for as many months; its duration being kept up by
 the successive eruption of semi-purulent vesicles.
  When  any of the forms of eczema  become  chronic they
 are usually described  as a distinct variety, under the name
 of eczema chronicum  (Atlas, PI. III. Fig. 4); the disease
 then loses its vesicular character, the integuments which are
 swollen, thickened, and elevated above the surrounding por-
 tion of the skin that  may remain unaffected, assume a perma-
 nently dark crimson hue, with numerous deep fissures Avhich
 discharge a bloody ichor, and, taking on an inflammatory
 action  from the least constitutional excitement or local irri-
 tation, are painful to the  touch, tense, and attended  with an
 acrid watery discharge and extreme itching.   The constitu-
tion also, after a.time, becomes affected, the digestive organs
being  deranged and general  debility ensuing.
  Eczema rubrum may be seated on any part of the  body
but generally attacks a large extent of the cutaneous surface'
 spreading rapidly from the place where it first appears   It
thus occurs on the face, the scalp,  the trunk, the arms' and
hands, and the thighs, rarely extending to the legs or feet
 except in very extreme cases.   It  also not unfrequently is 
ECZEMA.
67
local, appearing merely on the scalp, the face, the fingers,
the backs of the hands, the  ears, around  the  nipples in
females, or in a single patch on the lower extremities, or in
the pudendal region, being in all these  cases very obstinate
to treatment, and apt to become chronic.   Each of  these
local  forms of the disease has been constituted by some der-
matologists into a distinct variety—an unnecessary refine-
ment, as, with the exception of the first  two, they present no
essential differences, whether as regards diagnosis or treat-
ment.
   The  outbreak of  Eczema faciei (Atlas, PI. III. Fig. 5)
is preceded in young persons by a sharp attack of fever, at-
tended  with burning heat and soreness  of the part about to
be  affected, which lasts for  two  or three days: in adults
these symptoms are very trifling.  Numerous minute vesicles
then appear, closely crowded together, on a highly inflamed
patch of the cuticular surface, characterized by acute burn-
ing pain and intense itching.   These vesicles do  not  matu-
rate,  but burst usually on the day or day but  one  after their
first appearance, giving exit to an abundant irritating serous
fluid,  which dries  into  soft thin scales.  In some few in-
stances the disease does not proceed beyond  this  stage, the
cuticle of the part affected gradually exfoliates, and recovery
takes place; but  more generally the inflammation  of the
surface goes  on increasing, fresh crops  of vesicles continu-
ously appear, the discharge becomes more copious and of a
more  acrid character, exciting irritation of those portions of
the neighboring healthy skin over Avhich it may Aoav, and the
itching  and painful tingling are most intense,  scarcely allow-
ing the  patient a moment's rest, night or day.  The skin
Avhich is the seat of the eruption becomes  SAVollen as the
disease  advances, the  epidermis  exfoliates with the  soft
scabs, or  is torn off by  scratching,  and deep bright red
cracks appear  all over the surface, from which  a sanious
often  bloody discharge  exudes.  The sufferings  caused by
eczema, when it reaches this stage, can scarcely be described;
suffice it to say, that they totally incapacitate  adults affected
with the disease from following any trade or  employment.
  Whether eczema rubrum attacks young or old persons,
when  it assumes a chronic character,  it is the most intract- 
68
VESICUL^.
able of the eruptions which appear on the face.   It not
unfrequently lasts for years  (in one case, regarding which
I was lately consulted, it had been of upwards of twenty-five
years' duration), and is rarely  cured under several months'
treatment.
   The most usual part  of the  face on which  it appears in
infants and young children  is the forehead, to which it or-
dinarily spreads from the scalp, and,  unlike  most of the
other eruptive diseases, is much more obstinate there than
on its primary situation.  This  seems to  depend  on the
greater delicacy of the skin of the face permitting those
cracks and fissures, to which the rebellious nature of the dis-
ease appears to be  chiefly due, to form more  easily.   In
adults, it occurs with greater frequency on the nose and lips,
but in  many cases spreads also  to the forehead and cheeks.
  Eczema capitis (Atlas, PI.  III.  Fig. 6) soon loses its
vesicular  character,  and in  its various stages presents so
much diversity of appearance that its diagnosis is not always
unattended  with difficulty.  The eruption is  preceded by
heat, tingling, and itching, which are  rapidly followed by
the appearance of minute vesicles, crowded together in irre-
gular-shaped patches, or scattered  over a large  surface.
The  interspaces between the vesicles and the whole of the
scalp on which they are seated are red and inflamed ; in most
cases the  vesicles are so minute as to be scarcely recogniz-
able, or at least are not seen by the physician until they
have burst and given exit to a copious exudation of a serous
fluid, by which the roo*ts of  the hair are accreted together.
In the acute forms of the disease, this serous exudation con-
tinues  for a long time, and is a  most  troublesome symptom;
but in  the chronic forms—and some cases assume a chronic
character  almost from the first—it rapidly dries into furfura-
ceous scales, which are pushed forwards by the hair as it
grows.
  The vesicles of eczema capitis usually appear first behind
the ear close to the  edge of the hairy scalp,  from whence
the disease spreads rapidly, very generally attacking the ear
itself;  in some cases  the entire  of the scalp will be covered
with the eruption in  a week or  ten days, but in others the
disease spreads very  slowly. 
ECZEMA.
69
  With the progress of the affection, the appearance of the
diseased surface varies much ; sometimes it is scarcely, if at
all, elevated above the healthy parts, and  the eruption is
only to be recognized by the watery exudation which keeps
the hairs in a constantly moist  state.  In other cases the
scalp is raw or excoriated, and secretes a thin whitish pus,
which dries into grayish brown  scabs, presenting cracks or
fissures, through which the inflamed surface is seen.  In a
third form of the disease the serous exudation dries rapidly
into extremely thin membranaceous scales, which are readily
removable by the slightest friction, but cause much itching.
And a fourth variety is characterized by a repeated eruption
of minute patches  of vesicles—the patches rarely exceeding
the size of a small bean—all over the scalp, which pass
through the stages of eczema as witnessed on other parts of
the cutaneous surface, and disappears in seven or eight days,
but to be rapidly succeeded by  a fresh  outbreak of the
disease.
  The hair in eczema, no matter how long the disease may
have  existed, remains unaltered.   When in the acute forms,
attended with much inflammation, ulceration  of  the scalp
occurs, the hair, of course, falls  off, but in the progress of
cure it grows again in a perfectly healthy state, except that
in individuals past the age  of puberty  the  new growth of
hair is often gray.
   Eczema occurs at all ages, from the infant at the breast
to the very aged;  in new-born children  it not  uncommonly
appears on the umbilical region,—eczema umbilicale,—evi-
dently arising from the local inflammation attendant on the
separation of the  remains of the  funis, or  from  a want of
due attention to cleanliness.   The causes of the disease are
often sufficiently apparent, but equally often it is not to be
accounted for ; thus, as regards the head and face, the erup-
tion occurs on the  scrofulous and non-scrofulous child, on
the healthy and the delicate, on the ill-fed, ill-housed, defi-
ciently-clothed children of the poor, and the highly-nurtured,
well-housed, warmly-clad  children of the  rich;  in  short,
frequently the only cause that can be plausibly assigned  for
its outbreak is that scarcely understood  one, constitutional.
It certainly affects  females more  frequently than males,  for
the same reason that those  of all ages whose skin is fine and 
70
vesicul^:.
delicate, are more  liable to the disease than those in whom
the skin is coarse and hard; in many families, too,  a pecu-
liar predisposition to  diseases  of the  skin  exists, and  this
predisposition,  which appears  to be  hereditary,  is  well
marked, as regards the causation of eczema.
  Exposure to the direct rays of the sun often produces the
disease in summer, so commonly that Bateman made a dis-
tinct variety of eczema when so caused, naming it  eczema
solare; a numerous class of causes, amongst which this must
be included  as  one, is the  action of local irritants, as  of
blisters  of Burgundy  pitch plasters, of croton  oil and  tur-
pentine  liniments, &c. ;  thus,  too, in washer-women, the
eruption is produced  by the irritation of the alkali of the
soda or soap which they use, and in house-scourers and char-
women,  of the potash,—in both cases the disease is termed
washer-women''s itch; in grocers and makers of confection-
ery, of  the sugar—in them  it  is named grocer's  itch;  in
glove and clothes-cleaners it  is a very usual disease arising
from the irritation of the oil of turpentine or resin which
they employ;  and in  the higher walks of life a not unfre-
quent cause of the eruption is the too frequent use of stimu-
lating soaps and cosmetic washes to the face and hands, and
also the habit  of washing the face, when heated,  in  cold
water,  or  of not  drying  it sufficiently  after  it  has been
washed.  Sitting in  close, heated rooms, engaged  in  any
occupation in which the face is constantly kept stooped,  as
in that of writing, is also a common cause of eczema faciei.
An eruption  of eczema is of  very frequent occurrence  on
the legs of old  persons in Avhom the  small  superficial veins
are in a varicose condition,  and in them, if irritated,  it  is
apt to degenerate into troublesome ulceration.
  The  constitutional irritation  caused  by the action  of
mercury on the system produces in some cases—now more
rare than formerly, when the employment of the preparation
of this  metal was  so  much  abused—a very grave  form  of
eczema; it is usually termed eczema mercuriale, but was
described as a distinct affection, under the name of Hydrar-
gyria,  by the  late Mr. Alley  of this city, in  an  original
and highly valuable  essay  on  the  disease, published  by
him in the  year 1810. In the majority of cases it seems
to  have occurred when  only a  very  small quanity of  a 
ECZEMA.
71
mercurial preparation had been taken.   In its milder forms
it resembles the acute stage of eczema rubrum, arising from
other causes; but it  more frequently assumes a much more
severe character when it is ushered in by fever, difficult re-
spiration, dry cough and tightness  across the chest, w7ith a
general smarting and burning feel of the skin over the whole
body.   These symptoms are  soon followed by an eruption
of minute vesicles, which break and discharge a  very fetid
fluid.  As  the  disease  increases  in severity the eruption
extends  over the face and the whole of the body, which
become covered with incrustations ;  the fever  assumes a
typhoid type, the difficulty of breathing increases and is ac-
companied by bloody expectoration, spots of purpura appear,
and death ensues, preceded by delirium or convulsions.   On
the first appearance of this eruption  the  use of mercury
ought to be immediately relinquished, and the accompanying
symptoms treated by the means  appropriate for the indi-
vidual case.
  The diagnosis of eczema in its  advanced stages, and in
some of its local forms, is not unattended with  difficulty.
Eczema simplex may at  its origin be mistaken for herpes,
but the vesicles in the latter are larger, more distinct from
each other, and occur in  patches  always well defined, and
often of small extent.   When it appears on the  fingers the
serious mistake of confounding it with scabies is  not unfre-
quently  made,  and thus much mental  annoyance  may be
caused not  alone to individuals but to families, owing to the
dread  and  anxiety Avith Avhich that eruption is  viewed by
all ;  even at their commencement they are, however, readily
to be distinguished, the vesicles in itch being solitary, large,
and  conical, and  becoming rapidly purulent; the tingling,
burning heat of eczema is  also very different from the in-
tense itching of scabies,  and by  careful examination  the
itch insect, the  existence of Avhich is an unfailing diagnostic
sign, may be discovered in the latter.   In fevers and other
diseases, in which profuse sweating occurs, a vesicular erup-
tion,  which,  from the cause by  which it is produced, is
termed sudamina, appears not unfrequently on the  cuta-
neous surface, and might be mistaken for eczema simplex;
but in it the vesicles, though of  a small  size,  are few in
number, perfectly distinct, and separated from  each other, 
72
VESICULJE.
and drying up in a  few days, disappear without any serous
exudation or local irritation.
  Eczema impetiginodes, as its name indicates, very closely
resembles impetigo; in both there is a purulent discharge,
but the crusts  or scabs which form on the affected part are
always of a greenish hue, and the discharge purulent in the
latter, while they are  yelloAvish or yellowish-brown, and the
discharge sero-purulent in  the former.   The chronic forms
of the disease are liable to be mistaken for chronic lichen,
especially for  lichen  agrius when seated on  the  hands, a
serous exudation being then usually present; but the latter
eruption  never loses  its  papular character, the portion of
the integuments which  is  affected being raised unevenly,
rough, and not marked by the cracks  and fissures so cha-
racteristic of chronic  eczema; and the  serous  exudation is
small in quantity, is evidently caused by the local irritation
to Avhich  the  eruption gives  rise, and  only  occurs occa-
sionally.   With psoriasis, too, chronic  eczema may be con-
founded  by the superficial observer, in consequence of the
epidermic desquamation  by which it is attended, but the
formation of true scales never takes place in the latter, nor
the copious serous exudation in the former.  The diagnostic
marks between intertrigo  and  eczema have  been noticed
when describing that eruption.  Eczema  faciei is distin-
guished from herpes, in addition to the difference in the cha-
racter of the  eruptions  already  mentioned, by the latter
affecting  the mouth or  lips alone, while the former is not
confined  to any special locality.
  Eczema  capitis  may be confounded  with  impetigo  or
herpes of the scalp; it is diagnosed  from either by the  co-
pious serous exudation, which dries  rapidly into yellowish,
not greenish crusts, by the  rapid and excessive formation of
soft furfuraceous scales, and by the hair not being affected.
For porrigo capitis it  can scarcely be mistaken, but the cha-
racteristic differences  between the two eruptions will be more
easily understood by  deferring the mention of them  until
describing that disease.
  In eczema the prognosis varies as regards the duration of
the disease  with the  different  forms,  but in  very feAV  in-
stances can the affection be said to be  dangerous  to life ;
yet some  do occur; these are cases of debilitated old per- 
ECZEMA.
73
sons in whom it becomes complicated with pemphigus, and
whenever such a  complication takes place  the  prognosis
should be most grave.   Eczema simplex, when submitted to
treatment  at  an early age  of the  eruption, very seldom
becomes chronic, but it is very apt to return on exposure to
any local cause, and especially when it  has been originally
produced by the direct  action of irritant substances.  Ec-
zema rubrum is always an obstinate and severe affection of
the skin, and most rebellious to treatment, years sometimes
elapsing before it can be subdued ; in such cases the general
health sympathizes more or less, from the continued annoy-
ance caused by the local irritation, the individual  affected
being not unfrequently altogether incapacitated from mental
or other occupation.  When the disease affects the scalp or
face, it is also one of the most obstinate of the  eruptions
which appear on these parts.  The occurrence of a general
attack of eczema in the course of some chronic  constitu-
tional affection, particularly of the nervous system, is often
not incorrectly regarded as a favorable sign.
   With reference to the precise anatomical seat of eczema,
dermatologists  are  not agreed:  Cazenave  adopts Biett's
view, that it is an inflammatory affection of the sudoripa-
rous glands, but it is evident  that other  structures of the
derma are also equally engaged.
   Treatment.—Eczema is essentially an inflammatory erup-
tion, even in its most chronic stages, and this fact should
ahvays influence our choice of remedies, Avhether topical or
constitutional, for its treatment.   In eczema simplex occur-
ring in  adults, mild saline antiphlogistics with alkalies, as
in the following form, are  prescribed with advantage at its
commencement:—

   R. Sodae et Potassae  Tartratis, ...    Ij.
      Solutionis Alkalinae (Brandish),  fl  3iv.
      Aquae destillatae,........fl Ixixss.  Misce.
   "A wine-glassful to  be taken three times a day."

For children, gentle mercurial purgatives are better adapted,
combined with antimonials, such  as  James' powder, if the
febrile symptoms  are well marked.   In  the mild forms of
                           7 
74
VESICULJ3.
 the disease, the best local treatment in the acute stage is
 the use of the general tepid bath, or of warm water spong-
 ing, the parts being thoroughly but gently dried afterwards.
 When the local affection is more severe, the weak lead-wash
 —a drachm of  the  solution of subacetate of  lead  to twelve
 fluid ounces of rose or elder-floAver  water—applied on old
 linen  wet well with it, is  an excellent  application : if the
 eruption is seated on any part of the extremities, it is best
 and most  efficiently applied by means of bandages evenly
 put on, and kept constantly moist with the wash.   In some
 cases  of eczema  moisture appears to disagree singularly,
 always aggravating the local symptoms ; under  such circum-
 stances an ointment containing four grains of the carbonate
 of lead, or of the acetate of zinc, to an ounce  of cold cream,
 may be used, and if there is much tingling or itching in the
 part, two  minims of prussic  acid should be added to  the
 latter, or six minims of chloroform to the former ointment.
 If simple eczema occurs, as is not unfrequently the case, in
 children of a scrofulous diathesis, it is very apt to become
 chronic; when  it does so,  local remedies seem to have little
 effect on the  eruption, but it  yields rapidly to  the  internal
 administration of cod-liver oil, and the daily use of the tepid
 fresh-water bath.
  In the early  stages of eczema rubrum general  antiphlo-
 gistic   treatment,  proportionately  active according to  the
 inflammatory character of the constitutional and local symp-
 toms,  is requisite ; in persons of full habit of body, bleeding
 from the arm even may be indicated, and in  most cases,
 topical bleeding by leeches from the neighborhood of the
 affected parts is attended with much  benefit; active saline
 cathartics should be administered and  repeated at short
 intervals until the febrile symptoms are subdued.  The local
 heat, swelling, and  tingling  are  best alleviated by gelatine
 baths,  and at night the application  of poultices,  prepared
 by first steeping the best white bread in boiling water,
squeezing it out as dry as  possible, and then moistening the
pulp with  the weak  lead-wash above mentioned.
  When this  form of eczema  becomes chronic,  it is usually
most rebellious to treatment,  and requires the  employment
of internal specific or alterative  medicines  to produce  a 
ECZEMA.
75
change in the state of the constitution with which it is com-
bined, or on which it may depend, and this is requisite even
though the eruption is of small extent and local.  In many
cases the preparations of iodine prove most efficacious, but
sometimes it is  requisite to combine them with arsenic, or
to give that medicine  alone;  in delicate constitutions, or if
debility be present, the iodide of potassium is the best form;
it may be given in some  tonic decoction, as follows:—

     R. Iodidi potassii,.....gr. viij.
        Decocti ulmi (corticis recentis),   fl Ixij.
        Decocti dulcamara?,  ....   fl siv. Misce.
   "A wine-glassful to be taken every night at bed-time."

When thus given it is  not liable to  sicken the stomach,
and in my experience small doses  of iodine or its prepara-
tions act  most efficaciously in the treatment of diseases of
the  skin.   If the use of arsenic be indicated, either from
the obstinacy of the affection or  the failure of other reme-
dies, five minims,  very gradually increased to eight, of the
liquor potassae arsenitis, or of the liquor arsenici chloridi of
the last London Pharmacopoeia, may be added to each dose
of the above mixture ; but whether iodine or arsenic be ad-
ministered alone or in combination, their use must be con-
tinued for a long time, at least for two  or three months, and
beneficial results are always  most effectually derived  from
the  system being brought  very  gradually under their  in-
fluence.  Numerous internal medicines, as well as local ap-
plications, have been recommended by different writers for
the  treatment of  chronic eczema; of  the  former the most
generally employed are the tincture  of cantharides, anti-
monials, sulphur, especially in the  form of the sulphurous
mineral waters, mercurials, and  various vegetable  tonics;
but my own experience leads me to rely on either or both of
the poAverful alteratives  above recommended;  even in the
most chronic cases I have seen the sulphurous waters—so
valuable in other diseases of the skin—prove injurious, and
mercurials generally disagree except with children, in whom
the green iodide of mercury combined with the hydrargyrum
cum creta often acts as a most valuable alterative. 
76
VESICUL^E.
   The itching and copious secretion attendant  on chronic
eczema demand the  employment of  local sedatives and as-
tringents.  The compound lead cerate of the London Phar-
macopoeia, to every ounce of which two drachms of glycerine
and eight minims of chloroform have been added,  constitutes
a most useful  ointment, no matter on what part  of  the sur-
face the  eruption may be seated ; or the carbonate  of lead
or acetate of zinc ointment already described maybe substi-
tuted for it should there be much tendency to local inflam-
matory action. Tannic acid, in the proportion of from four
to twelve grains to the ounce of cold  cream, with or without
the addition of chloroform, is also an excellent application.
Some recommend highly stimulating compounds for the local
treatment of chronic eczema, such as anthrakokali  or  fuli-
gokali (forms of carburet of potassium, Avhich, when intro-
duced into the practice of medicine a few years since, were
highly vaunted for their remedial powers, but have now fallen
into disuse), tar, pitch, sulpnurous preparations, &c.   By dis-
tilling tar with water, a mixture of impure oil of turpentine,
a pyrogenous oil, and some pyretine is procured ; this liquid
has been recently used and highly praised by some  French
dermatologists, under the name of huile de cade, as a local
application,  inunctions being made with it  twice daily; by
the term  huile de cade, however, most of the French phar-
macologists understand a tarry oil obtained by the dry dis-
tillation of the wood of the juniperus  oxycedrus.  No matter
what local remedy is employed, it will be found of advantage
to sponge the affected parts  carefully with  a iveak alkaline
wash—ten grains of the carbonate of soda to a pint of dis-
tilled water, each time previously to  its fresh application.
  When  eczema occurs on the face or hands, the treatment
as above described for  its  different  forms is equally appli-
cable, but in either situation, in  consequence of the expo-
sure to atmospheric vicissitudes and to various local irritants,
it is usually more obstinate, and when the disease is  general
over the  body  the face is for the same reasons the last part
to get well.   The use of soap  in washing  should be inter-
dicted, the weak carbonate  of soda lotion warmed to blood
heat being substituted for it, and especial  care  should be
taken not to  expose the surface to the action of harsh winds 
ECZEMA.
77
the sun, the heat of the fire, or any cause which might pro-
duce determination of blood to the affected parts.
   In eczema capitis the hair should be cut close to the scalp
with a sharp pair of  scissors—not  shaved off—and kept as
short as possible while the disease lasts, and for a short time
after it is  apparently cured.   The crusts and scabs should
be removed by poulticing with linseed meal, and  sponging
with the weak carbonate of  soda  solution  mixed with  an
equal quantity of new milk, the surface being carefully dried
afterwards.  When the scalp is thus cleaned, in the milder
and less inflammatory forms of the eruption an alkaline oint-
ment, containing twelve grains of the bicarbonate of soda to
the ounce of cold cream, may be applied morning and evening,
the surface having been previously sponged as above directed;
but if there be any tendency to inflammatory action, the car-
bonate of lead or the tannic  acid  ointment, and  the sub-
acetate of lead-wash, prove  more beneficial.   The scalp
should be kept cool, very lightly covered or exposed  to the
air when in the house. As regards constitutional treatment,
in scrofulous habits of body, either cod-liver oil or iodide of
potassium, with tonics, should  be  administered; but the best
alterative for  children who  are not  scrofulous is the  green
iodide of mercury, as before mentioned.
   In all forms of eczema, when the origin of the disease can
be traced to any local irritant, this of course should be care-
fully guarded  against, both during the progress of treatment
and when a cure is effected; in the case of persons engaged
in trades, and others who cannot  abandon the occupation by
Avhich the eruption was caused, the cutaneous surface should
be protected as much as possible  by the use of Avash leather
gloves.   The  diet of persons  affected  with eczema  should
be regulated according to the constitutional circumstances,
but in  children  much benefit  will be derived  from placing
them on a strictly milk and farinaceous diet.   In both  adults
and children the boAvels require to be carefully attended to,
the use of mild saline  purgatives, if possible the natural
mineral Avaters, of which probably  the  Pullna  is the best,
being employed with excellent effects.   In children the pro-
cess of teething must be watched  and  the gums  lanced when
necessary ; and the eruption on the scalp should not be dried 
78
VESICUL.E.
up too suddenly if there exists a tendency to disease of the
brain or of any other internal organ.

                        herpes.

  Herpes (Tetter).—This term, though very generally used
in the nomenclature of cutaneous  diseases by the older
medical writers, had with them no special reference: it is
now  employed  to designate  an eruption of small globular
vesicles clustered together, and often regularly grouped, on
inflamed patches of the skin  usually of  small extent and dis-
tinctly separated.  The  eruption is preceded by heat, ting-
ling, and some  degree of swelling and redness in the parts
on which it is about to  appear, but there is no  antecedent
or accompanying fever  unless, which is rarely  the case, it
is developed simultaneously over an  extended surface, and
even then the febrile symptoms are but slight. It is described
by most English dermatologists as being non-contagious, but
an accumulation of direct evidence has convinced me that
one form of  the  eruption is propagated by contagion, no
matter on what part of the cutaneous surface it may be situ-
ated.   The vesicles, which  on their first  appearance are
globular and transparent, on  the second or third day become
somewhat flattened, opaque,  and semi-confluent;  they then
burst and give exit to a trifling serous discharge, which, con-
creting into a soft, thin, yellowish-brown crust,  falls off and
leaves  a  superficial  ulceration that heals  rapidly.   The
causes of herpes, Avhen it affects the body generally, cannot
be traced with certainty, but  in some of  its local varieties are
often sufficiently manifest.
  The forms of this eruption present great variety, and have
been differently named with reference both to their external
phenomena and the parts on which they may appear; this
has led to numerous sub-divisions of the  disease in classifying
it for the purposes of description,  thereby tending to com-
plicate the inquiry.  I  shall describe  them  all under the
three following heads : —
                  Herpes phlyctenodes.
                    "    zoster.
                         circinnatus.
  Herpes phlyctenodes  (Nirles) (Atlas, PI. IV.  Fig. 1) is 
HERPES.
79
occasionally, more  particularly Avhen it  occurs  in  adults,
attended Avith slight  fever, foul tongue,  loss of  appetite,
nausea, and thirst, but the pulse is rarely quickened ; there
is  a deep-seated pain in the part on  which the eruption
is about to appear, and superficial  heat and tingling.  Small
irregularly  shaped patches  of the  skin become  slightly
swollen and red, and  in about twenty-four hours afterwards
an eruption of vesicles appears on them.   The majority of
these vesicles are of small size, but a feAV of them attain the
magnitude of a pea; they  are distinct  from each  other,
rounded, and contain a transparent serous fluid : they occur
in groups, varying in size from  one to three  or four inches
in length or breadth,  but rarely exceeding that of the palm
of the hand ; usually, when of large extent, constituting but
a single group, which, however, is often made up of three
or more smaller, by the eruption spreading over the inter-
mediate sound skin.   On the second  day after their appear-
ance  the fluid in the vesicles becomes opaque or  sero-puru-
lent,  and they burst on the third or fourth day—those that
were  closely aggregated  together having previously become
confluent, forming soft crusts or brown scabs, from beneath
Avhich a thin sero purulent matter exudes in small quantity.
These scabs,  falling  off on or  about the tenth  day, leave
small superficial ulcers which heal in three or four days, so
that  the disease rarely lasts longer than  a fortnight.  But
it is sometimes prolonged by the eruption  of a distinct patch
of vesicles on the third or fourth day after the appearance of
the first,  and in their neighborhood ;  they  unite with the
former, and the entire thus cover a rather extended surface;
requiring, however, the same time for maturation and heal-
ing, the duration extends to three or four days more.  Should
there be any attendant fever, it abates or disappears with
the outbreak of the eruption, but the local symptoms increase
until  the  vesicles burst, when some  slight itching only re-
mains.
   The local pain, which is often severe previously to the
appearance of the eruption, is usually much alleviated then,
but sometimes returns with greater  intensity after the  sur-
face  is healed,  and,  presenting somewhat of a neuralgic
character, lasts with great obstinacy frequently for months. 
80
VESICUL^E.
 Occasionally in old persons or in bad constitutions, an her-
 petic eruption terminates in troublesome ulceration.
   The phlyctenoid form of herpes may appear on any part
 of the body; its most usual seat is on the trunk, the neck,
 and the arms, rarely occurring on the lower extremities.  It
 attacks some special portions  of the integuments with great
 regularity, and its occurrence there requires to be separately
 described ;  these are the lips and the prepuce.   Herpes
 labialis is a slight form of the  disease, deserving  notice
 merely in consequence of the local annoyance Avhich is occa-
 sioned by its situation ; the eruption, which is  preceded by
 a certain  degree of tumefaction, dryness of the  skin, heat,
 tingling, and redness, appears at the angles of the mouth,
 or on the upper or lower lip, more  usually on  the  latter,
 being of small extent, rarely exceeding the size of a shilling.
 The vesicles,  which are  minute, closely  aggregated, and
 covering the entire of the inflamed surface, are at first glo-
 bular, transparent, and shining; within forty-eight hours
 the contained serum grows turbid, the vesicles become con
 fluent, forming bullae  of the size of a pea, and on the  fourth
 or fifth day, soft brownish crusts appear on their surface,
 which fall off in two  or three days more, leaving a slight
•degree of redness and swelling of the part, that lasts for
 about a week.   Should the crusts, however, be torn  off by
 scratching, or irritated  from their situation at  the commis-
 sures or on the vascular portion of the lips, the surface bleeds,
 and  a hard, dark brown scab is  formed, which  is slow in
 separation.  Sometimes the  herpetic  eruption on  the lips
 extends completely round the mouth, when it is a trouble-
 some and obstinate affection ; but unless under these circum-
 stances  it runs usually a rapid course, its  duration  seldom
 exceeding a week or ten days.  A variety of herpes, similar
 in all respects to this, occasionally appears  on  the ears; it
 is then termed herpes auricularis.
   Herpes prseputialis has been so named from its appearing
 on the prepuce, being situated either upon the external cuti-
 cular surface or  on the mucous membrane.  The eruption is
 preceded by heat and tingling in the part, and some degree
 of soreness, and when it occurs on the internal aspect of
 the prepuce there is  also  more  or less tumefaction;  the
 transparent  orbicular  vesicles soon appear in a small group 
HERPES.
81
but distinct from each other, on a somewhat circular inflamed
patch of the integument, rarely exceeding the size of a six-
pence ; when they occur on the external surface, they matu-
rate quickly, becoming opaque, and forming brownish crusts,
which fall off on  the fifth or sixth day, leaving the part on
which they had been seated slightly tender and red; but
when the eruption is  situated on the mucous membrane the
vesicles are larger, become sero-purulent, and from the con-
fluence of two  or three attain the size of a split pea; the
scabs which form are softer, and of a yellowish color, and
being easily rubbed off, leave a small ulcerated surface, which
from the swelling of  the  surrounding mucous membrane,
occasionally presents  a slightly excavated character, in con-
sequence of which it  is likely to be mistaken for a chancre.
Herpes  praeputialis sometimes becomes  chronic when the
disease  spreads,  by the  appearance of successive  crops of
the  eruption,  over  the  entire of the prepuce, especially
affecting the part where the mucous membrane and skin
meet;  there is much  thickening from the effusion into the
sub-mucous areolar tissues, caused  by the repeated attacks
of inflammation;  the  surface becomes hard,  rugose, fissured
in parts, and  in  parts covered with  brownish  crusts, from
betAveen and beneath which  an unhealthy, fetid, sero-puru-
lent discharge  takes  place, and as the glans penis cannot
be  uncovered, foul  ulceration of  it not unfrequently occurs
to complicate the original disease.   When  the eruption is
of this chronic character, it often lasts for months, and the
general health  becomes affected in consequence of the anx-
iety and distress  of mind it occasions.
   In females herpes phlyctenodes sometimes appears on the
pudendal region,  being situated at the vaginal orifice on both
the skin and mucous  membrane ; its characters correspond
precisely Avith those of the disease of the prepuce in males,
but in consequence of the parts  being more exposed to the
irritation arising  from local discharges and from the urine,
it  is generally more  chronic and rebellious to treatment.
By some writers it is  made a distinct variety, and termed
herpes pudendalis.
  Herpes zoster (Shingles; Ignis sacer) (Atlas, PI. IV. Fig.
2) has deriATed its specific name from the peculiar form which
the  eruption assumes, resembling, as it were, a girdle  or 
82
vesicul^e.
sword-belt.  The constitutional and local symptoms are more
severe than  in the variety last described, the former often
amounting to well-marked fever preceding the  outbreak of
the disease, attended with a distinct shivering fit and vomit-
ing.   Locally there are sharp stinging pain, burning^ heat,
redness, and some tumefaction of the integuments in  the
part on which the vesicles are about to appear; these occur
of tolerable magnitude, and closely  grouped  together in
three or  four  distinct but neighboring patches, each sur-
rounded by an inflammatory areola, which gradually spreads,
new  vesicles appearing  on  it, and the entire  constitutes  a
crescentic or oblique demi-zone  from half-an-inch to one or
two  inches in breadth,  seated on one side of the neck or
trunk, often extending  from  mesial line to mesial line, by
Avhich it seems to be  distinctly bounded, very rarely passing
its limits.   The eruption runs the same course as in herpes
phlyctenodes, but the vesicles become more confluent, thus
often attaining, the magnitude of bullae, those which first ap-
pear being always the  largest; and  it is somewhat more
chronic in all  its stages, the  scabs being often particularly
slow in separating.
  The local pain  which precedes the appearance  of  the
eruption  in herpes zoster is  not  unfrequently very severe,
and  apparently deep-seated, seeming  to shoot through  the
chest or abdomen if the disease is about to occur on the in-
teguments of either of these  regions.   This pain, which to
a great extent disappears when the vesicles are developed,
usually returns with  greater or less intensity, especially in
adults or  old  people,  when  the crusts fall off, sometimes
lasting even for years, and  causing  great suffering.  At
times chronic ulceration succeeds this  form of herpes in bad
constitutions, and this may terminate even in gangrene, and
thus prove fatal.
  The usual seat of herpes zoster is  on the thorax or ab-
domen ; it also appears occasionally on the neck; when the
eruption commences over the scapula, or in  the neighbor-
hood of the hip, it may extend to  the shoulder or thigh,
including either in the semicircle which it forms, but it very
rarely originates  on the extremities.   By Franck  and Ca-
zenave the ^ disease is stated  to appear more frequently on
the  right side of the body, but my experience  agrees with 
HERPES.
83
that of Reil and Wilson, that  it is situated  on the left
in a greater number  of cases.   It is so  extremely rare for
the  demi-zone  of herpes  to  pass the  median  line,  that
amongst the ancients it  was popularly believed, and the
fact is mentioned by Pliny, that if the eruption surrounded
the  body it should prove necessarily fatal;  yet  cases are
recorded by modern writers,—Franck and others,—in which
such took  place  by the  simultaneous  development of the
eruption on both sides and their extremities meeting, yet the
patients recovered.
   Herpes circinnatus (Ringivorm) (Atlas, PI.  IV. Fig. 3),
like the last described variety, derives  its name from the
shape of the groups in which the eruption appears, namely,
distinct rings or circles, inclosing healthy skin in the centre.
Slight pricking sensation  or  tingling accompanies-the out-
break of the disease, but it is not attended Avith any consti-
tutional symptoms. At first, one or more  small, red, circular
patches, from  half an inch to an inch in diameter, appear
apart from each other on some portion of the integuments,
on the outer border of which numerous  minute, globular,
transparent vesicles are developed on the  second or third
day ; the redness then fades from  the centre of each circle,
which remains unaffected afterwards during the progress  of
the  disease, but  the ring of vesicles has an inflammatory
border both external and internal.   The vesicles,  which are
closely  aggregated, become more  or less confluent  within
forty-eight hours after their appearance, assume  a pearly
aspect, and then bursting discharge a small quantity of a
serous fluid, which  dries into thin  brownish crusts that fall
off  on the  eighth or ninth day, to be succeeded by a fine
epidermic  desquamation that lasts  for some time.   The dis-
ease, however, rarely terminates thus, but is prolonged by
the repeated eruption of fresh crops of vesicles on the outer
inflammatory border, each set running in an independent
course, but one similar to the first; spreading in  this man-
ner  from the circumference, the rings at times attain the
size of  the palm of the hand, which  they rarely exceed.
The circles may be few or many in number, rarely, however,
more than four or five,  and when of larger size, there  is
usually but one; they may appear simultaneously on the
surface or in succession: in the latter case the disease  often
becomes chronic, lasting for months. 
84
VESICUL^E.
   Occasionally it occurs that  the vesicles, instead of burst-
ing and forming crusts, dry up, and  are succeeded by a
secretion of fine, soft scales, which continue to be exfoliated,
not alone from the circumference, but from the centre of the
circles.  This form has  been  specially described by Caze-
nave, who denominates it herpes squamosus (Atlas, PI. IV.
Fig. 5); it is always chronic,  and very obstinate to treat-
ment.
  Herpes  circinnatus occurs with greatest frequency on the
face, neck, and scalp, being, however, occasionally situated
on the chest, the shoulders, the arms, and the hands.   When
it appears  on the  face, its most usual situations are the
cheeks and the forehead;  as  the  circles  spread from their
circumference they often  extend from the  former to the
nose,  but do not pass the mesial line, and from the latter
into the scalp.  In  its milder forms, ringwrorm disappears
in eight or ten days, but its duration is  more usually pro-
longed for three or four weeks,  either by the spreading of
the circles or by the successive development of fresh patches
of the eruption ; occasionally, as  above remarked, it becomes
chronic, and  lasts for  months, producing  annoyance more
from the unsightliness of its appearance, when it is situated
on any of the exposed  regions of the skin, than from any
local uneasiness.
  This form of herpes, when it occurs on the scalp, requires
to be  specially described, as it constitutes  almost a distinct
variety, which might be termed herpes capitis ; it resembles
in many of its characteristics the herpes squamosus of Caze-
nave, but that distinguished dermatologist, in consequence
of the effect its presence exerts on the  hair, proposes to
term it herpes tonsurans.  Its occurrence  on the scalp at
all is denied by many of the celebrated English writers on
diseases of the skin, who regard the eruption about to be
described  as a species  of porrigo ;  but prolonged clinical
observation, independent of their corroboration by so deserv-
edly high an  authority as M.  Cazenave, has tended but to
convince me of the  correctness  of the views I propounded
some years since.                                r
  Herpes  capitis (Atlas PI. IV.  Fig. 6) usually attacks
children from the age of 3 to 12.   It  is very rare in early
  1 Dublin Quarterly Journal of Medical Science, New Series, vol. vi. p. 33. 
HERPES.                      85
infancy, and  I have never  met with it after the  age of
puberty, except in one instance, in which it had commenced
at the age of 13, and had lasted for more  than five years
before I saw the case.  It is very rarely Avitnessed in  its first
stage—that of vesicle—as it then produces but little annoy-
ance, and  advice  is,  consequently, not sought for until it
becomes more developed.  When seen, however, at its com-
mencement, it presents the appearance of a small ring of
minute vesicles, not more than an eighth of an inch in dia-
meter, without any redness or other marks of inflammation
beyond a slight tingling—not itching.   These vesicles are
attended with  scarcely any discharge, soon drying up  and
desquamating ; but as they dry up in the centre, they spread
from the circumference, and the diseased spots, in the course
of a few days, attain the size of a shilling.  When we exa-
mine them in this stage, the centre, the part where the erup-
tion first appeared, is thickened, elevated above the surface
of the surrounding scalp, and covered with fine scales, which
are renewed rapidly on being removed.  As the disease pro-
ceeds, the patches extend from their periphery, still  retain-
ing a perfectly circular shape, and finally, after some weeks,
attain the size of a crown-piece, which they rarely exceed,
no  matter how chronic the case may have been.   Having
attained this size, and  ceased to spread, the entire of the
diseased surface is thickened, elevated,  and  covered with
fine, soft  scales, which the least touch  removes; this, the
advanced stage of the disease, is usually attended with much
itching.  Sometimes but one patch of herpes is found on the
scalp, but more generally there are three, four, or more cir-
cles, distinct,  and at some  distance from each other.
  As the disease advances, the  hair assumes  a very pecu-
liar  appearance,  almost pathognomonic of this form of
eruption of the scalp.    In the early stage each hair appears
to be slightly bent  on itself,  and turned against the grain,
obstinately refusing to lie smooth ;  the roots are also some-
what matted together by the scaly crusts of the  eruption.
After some time it presents a  diseased appearance, being
tAvisted,  broken,  of a whitish  color,  and readily  falling
out; so that bald patches begin to  appear, over which  are
scattered small bundles of  the altered hair, which has been
described, not inaptly, as resembling tow.  This condition
                          8 
86
vesicul^;.
 of the hair has induced some writers to describe the affec-
 tion as a disease not of the scalp, but of the hair itself.
   The  eruption does not always present the exact charac-
 ters noAV described.  In the early stage—when, hoAvever,
 it is rarely witnessed by the medical  practitioner—its ap-
 pearance always agrees Avith the description given, except
 that  in some  cases  there  is  more inflammation than in
 others ;  but in the  advanced stages it varies much, both as
 regards  the  amount of desquamation  and the appearance
 of the elevated patches:  it is this fact which  has led to so
 much confusion in  the diagnosis and nomenclature of the
 disease.  Yet in the most  chronic  or complicated cases,
 the circular form of the eruption, and the peculiar condition
 of the hair, render its diagnosis easy to even the tolerably
 experienced eye.
   Herpes capitis does not cause baldness:  the  altered hair
 falls off  the  diseased patches, which, when the scales dis-
 appear in the progress of cure, are thus left in a bald state ;
 but the hair eventually grows on them  again,  thereby  con-
 stituting an essential difference  between this affection and
 alopecia.  The disease,  unless  when  seen and  properly
 treated in its early  stages, soon becomes chronic and obsti-
 nate, and loses its  inflammatory character.   No  constitu-
 tional symptoms either precede or accompany herpes of the
 scalp.
   In some very rare cases the eruption in herpes circinna-
 tus assumes  a singular arrangement, which, in the opinion
 of some  dermatologists,  entitles it to  be  considered as a
 distinct variety, receiving the  appellation of  herpes  iris,
 or rainbow ringworm (Atlas,  PI. IV. Fig. 4).  A small
 round, inflammatory patch appears on some part of the cu-
 taneous surface, and around it, but separated  by a narrow
 band of healthy integument of the natural color,  is a red,
 slightly elevated circle, which in its turn is again surrounded
by two or three other similar rings of inflamed skin : on the
 centre  a few minute herpetic   vesicles are  developed  in
about twenty four hours  after its appearance, as  also on
each of  the rings, but they are  more numerous and more
closely aggregated on them.   The rings, which are usually
lour  in  number, differ in color, the  inner one being  of a
darker red than the  central patch, that  next to  it of a 
HERPES.
87
lighter shade, the third darker even than the first, and the
outer ring  paler than the second, being of a yellowish-red
hue, fading at its outer border into the  color of the sur-
rounding skin.  The vesicles run the same course as in the
milder form of herpes phlyctenodes, the  crusts, which are
small and thin, falling off on the eighth or ninth day, to be
followed by  slight  furfuraceous desquamation, which  lasts
for a few days longer.   Herpes  iris seldom occurs  except
in very young children and in females;  it usually appears
on the backs of the fingers or on  the hands, on the temples
and on the prominent parts of the joints, being sometimes
associated with other forms of the eruption.   It may occur
singly,  or  several patches may appear simultaneously on
different parts of the body; the only local symptoms are
some trifling  heat and itching, and it has no  tendency to
become chronic.
   Causes.—Herpes is  a disease almost entirely confined to
young persons and to those in the prime of life, very rarely
appearing in the old ; among adults it affects females more
commonly  than  males, but in children  sex  seems to have
no influence in the  frequency of  its occurrence, those of a
sanguine and lymphatic  temperament, and in whom the
skin is fine and soft, being most liable to it.  Of  the excit-
ing causes of herpes  phlyctenodes but  little is known;  it
seems to be occasionally developed under the influence of
strong mental emotions,  and it is often connected with de-
ranged conditions of the  digestive and biliary organs.  The
season of the year, too, appears to have some  influence on
its  occurrence, for  it is most frequently met  with  in the
spring and autumn.  The connection of herpes labialis with
febrile states  of  the  system is usually very  evident, and
especially with those which affect  the respiratory organs:
thus it is an almost invariable accompaniment of catarrh,
iufluenza, bronchitis,  and pneumonia,  in  all of  which its
occurrence is a favorable symptom, whence  has arisen the
popular expression that the cold  goes off in this way. It
is also occasioned very frequently in travelling by the direct
effect of a harsh  cold Avind on the lips,  or  of  the sun's
rays ; the action of local irritants, too, may  produce  herpes
here,  as is  often witnessed in its being caused on  the upper
lip by the acrid secretion from the nostrils in coryza; this 
88
VESICUL^E.
discharge, however, more frequently produces an eruption of
eczema.
  Herpes preeputialis occurs only in  adults, and most fre-
quently in those in whom the skin of the prepuce is very
sensitive; it is often caused there by the friction of the
clothes;  and when it  appears on the mucous membrane,  or
on the glans penis where I have occasionally seen it, by the
irritation  of the natural sebaceous secretion of  the  part,
allowed to accumulate from want of attention to  cleanliness.
The connection between the occurrence of herpes on the pre-
puce and stricture of the urethra is very generally admitted,
but many observers believe it to be only an accidental coin-
cidence ;  others, with whom I agree, consider the existence
of stricture to be a cause of this  eruption, and  the manner
in which it  acts may, I think, be easily explained.   In
persons affected with  stricture, the last drops of urine are
retained for  some time in the urethra, the shirt  is thus con-
stantly wet, and the prepuce is irritated by the acrid moist-
ure to which  it is thereby  so  constantly exposed;  hence
also, in these  cases the eruption  is usually  seated on the
verge of this fold of integument.  In females herpes of the
pudendum may occur at any age ; it is invariably caused by
local irritation.
  Herpes zoster appears in adults more frequently than any
of the other varieties,  occurring  also occasionally in old
persons, in whom it sometimes becomes chronic, and termi-
nates in troublesome ulceration:  it seems to be generally
occasioned by cold,  acting  on individuals suffering  from
hepatic derangements.  In the summer and autumn of some
years it would appear to be epidemic among children, and in
them it is very frequently produced by sudden  suppression
of the perspiration.
  Herpes circinnatus is a disease of youth, being very rare
amongst  adults, and occurs  with equal  frequency in both
sexes; it  is very common in schools, or wherever many
children are  congregated together, amongst whom it spreads
rapidly.   The popular idea that ringworm is contagious is
opposed by most English dermatologists on the grounds that
no other  form of herpes is so, and that  the disease cannot
be produced by inoculation.  Now, neither of these reasons
is sufficient to counteract, in my mind, the amount of direct 
HERPES.
89
 evidence which an experience of some years in the treat-
 ment of diseases of the skin has afforded me of the propa-
 gation of this form  of herpes by contagion, no  matter on
 what part  of  the  body it may be  situated.  I have else-
 Avhere1  published cases illustrative of the  development of
 the eruption on the hands of adults engaged in the applica-
 tion of  local remedies to the scalp of children who were
 affected with it, and to these I could now add several others ;
 and I have seen too  many instances of its direct communi-
 cation from child  to child  of different families, when the
 argument  of similarity of constitution and  of dietetic ar-
 rangements could not avail, to have any doubt on the matter ;
 but it must be remembered that, like  all other contagious
 diseases, some families and some children are more prone to
 its attacks  than others.  My own opinion, too, is confirmed
 by that  of  M. Cazenave, who, in his Lecons sur les  Mala-
 dies de la Peau, and in his more recently published Traite
 des Maladies du Cuir  Chevelu,2 adduces several cases from
 his own  practice, which exhibit in a marked degree the con-
 tagious nature of herpes circinnatus.
   Diagnosis.—The characters of  the eruption in" herpes
 are so well  defined that, unless Avhen it occurs on the  scalp,
 it  can  scarcely be confounded  with any other  cutaneous
 disease.   It  differs from eczema  in the  vesicles  being
 larger, more globular, and distributed in patches ;  its erup-
 tion is unattended  with constitutional symptoms, and in its
 ad\Tanced stages it  is not accompanied by the copious serous
 exudation  of that disease.   When the  vesicles are  very
 confluent it may be  mistaken for  pemphigus,  but in that
 affection the eruption consists of bullae, which do not in any
 of their  stages present the pearly aspect of herpes,  and are
 succeeded  by hard, dark-brown  crusts; the  bullae  of pem-
 phigus,  moreover,  are  usually solitary and scattered over
 the cutaneous  surface,  not  distributed  in  groups.   Herpes
 labialis is diagnosed  by the characteristic vesicles, and by
 their  local  situation.   As already  remarked,  the serious

  '  Dublin Quarterly Journal of Medical Science, New Series, vol. viii. p.
 164, Note.
  B  Paris,  1850, p. 197.  See also Annales des Maladies de la Peau  el de la
Syphilis, torn. i. p. 37, el seq.
                            8* 
90
VESICUL^E.
 error may be committed of confounding herpes praaputialis
 with chancre; if the eruption is seen on its first appearance
 it is readily diagnosed by its vesicular  character, but when
 the  scab is formed, or  ulceration caused by irritation, the
 diagnosis is often not unattended Avith  difficulty.  The  ul-
 ceration in herpes, however, is  always  superficial, never
 deep, and presents  a smooth surface Avithout raised edges,
 and not coated with a Avhite, filmy membrane, appearances
 peculiar to chancre;  in very  doubtful cases the question
 may with certainty be  decided, by inoculating the  integu-
 ments of the thigh  of the patient with  some of the matter
 from the diseased surface.   The same  remarks  as regards
 diagnosis,  apply equally to herpes of the  pudendum  in
 females.  Erythema circinnatum, or lichen circumscriptus,
 in their advanced stages, present some resemblance to herpes
 circinnatus, but  neither of these are vesicular during any
 period of their presence on their skin,  nor do they spread
 from their circumference in the manner that  disease does;
 they are, too, attended  with more thickening and elevation
 of the integuments on which they are situated.
   Herpes capitis, which corresponds with the herpes ton-
 surans of Cazenave, is, as I have already  remarked, described
 by many English Avriters as a variety of  porrigo, the yellow,
 cup-shaped favus crusts  so characteristic  of which it, how-
 ever, never presents.  It is diagnosed from the other erup-
 tive disease of the scalp by its occurring in distinct circular
 patches, the slight serous discharge from which  dries into
 fine, soft scales, that  are readily detached by the slightest
 touch, but  are again very quickly renewed, and  especially
 by the peculiar change,  before described, which it produces
 on the hair.
   The prognosis in any  form of herpes  is favorable, as the
 eruption may be said almost  never to  endanger life and
 is but very rarely productive of any injury to the general
 health ; it is also not so liable  as many other eruptions to
become  chronic,  unless  when it occurs  on the scalp   The
local neuralgic pain, which not unfrequently is consequent
on herpes phlyctenodes  and herpes zoster, is at  times both
severe and obstinate, often lasting for many months
   Treatment.—The phlyctenoid  form  of the  disease very
rarely requires any active  constitutional  remedies;  in  a 
HERPES.
91
feAV cases, Avhen it occurs in young persons of a full habit of
body, bleeding from the arm, or the application  of leeches
in the  neighborhood  of  the  eruption,  is  attended  with
benefit, but neither should  be had  recourse to  until the
eruption is  fully developed : saline  purgatives,—preceded,
if there is any biliary derangement, by  a  mild  mercurial,
five grains of  blue pill, or  two of calomel combined with a
grain of extract of  hyoscyamus,—will, however, in nearly
all cases sufficiently meet the constitutional symptoms.  In
weakly individuals,  tonics with antacids,—as bark  with
the carbonate of ammonia,—are indicated.   With refer-
ence  to  local treatment,  all that is requisite  during the
first two or three days after the formation  of the  vesicles
is to  protect   them from  being  irritated  by rubbing or
scratching;  unless there is much tingling and pain of the
part,  which  will  be  relieved by smearing  them  over with
a  cerate  consisting of two grains   of acetate  of zinc, an
ounce of cold  cream,  and four  minims  of chloroform.
Should there  be any  tendency  to a copious  discharge,
finely powdered  lapis calaminaris or starch, will be dusted
over the surface with benefit.   As soon as the brown  scabs
form, a spirituous lotion,  such as the following, should be
substituted for the ointment:—
     R. Olei Limonum,.....m. vj.
        Olei Corticis Aurantii, .  .   .    fl  5ss.
        Spiritus Vini rectificati,  .   .    fl  3iv.
        Misturae Camphorae,   .  .   .    fl 5viij.  Misce.

   The local pain consequent on this form of herpes, or on
herpes zoster, is, as far as my experience enables me to come
to a conclusion, but little relieved by external applications;
those usually ordered for it are narcotics and sedatives, such
as preparations  of  opium,  of aconite,  of  belladonna, of
arnica, &c.  Regarding it  as being chiefly neuralgic, I have
prescribed with  much benefit  a combination of bark with
hemlock,  as thus :—
     R. Tincturae Cinchonae compositae,   fl 5\j-
        Succi Conii,......fl 3vj.
        Infusi Cinchonae,.....fl Svij.  Misce.
      " A tablespoonful to  be taken four times a day." 
92
VESICUL^E.
   In herpes labialis, if a strong spirituous lotion—I  have
found  none answer so  well  as  Eau de  Cologne—be con-
stantly applied to the part on which it is about to appear,
as indicated by dryness, heat, swelling, and tingling, before
the vesicles are formed,  the further progress of the eruption
may in most cases be arrested.  The only local application
requisite, where the disease is fully developed, is some mild
oleaginous  ointment, such as the cucumber cerate; should
it, however, become chronic, an  ointment composed of ten
grains of calomel  to an ounce of simple cerate will be found
useful.   Persons  who have  once had  an attack  of herpes
pracputialis are fully aware of the premonitory local symp-
toms  by  which it is  ushered in;, the  development of  the
eruption  may then  be stayed by the  continued employment
of cold water, the colder the better, which  can  be applied
by plunging the penis several times in the day into  ice-cold
water, and retaining  it  there- for  a  minute or two;  when
the vesicles are formed, no caustics  or irritants  should be
employed, as their use is apt to be followed by troublesome
ulceration ; the best local application is the black wash, or
Turner's  cerate, if there is much discharge when the  vesicles
have burst.
  The same treatment is adapted for herpes  zoster as for
the phlyctenoid form of the  disease.  M. Cazenave,  with
the view  of preventing the premature  rupture of the vesi-
cles, recommends  that the surface should be smeared  with
oil, and  then  dusted with starch.  The ectrotic plan of
treatment, that is to say, opening each of the vesicles  with
a needle, and introducing into them a finely-pointed pencil
of nitrate of silver, has been recommended in both these
varieties  of the eruption.  If they are situated on an unex-
posed part  of the  body,  and not in any way connected  with
visceral derangements,  it  may  be had recourse to, but it
should be  remembered  that  an  indelible mark  sometimes
follows the  application of caustic to herpes.
  Most cases of ringworm  require no treatment in the com-
mencement except  the use of mild  mercurial purgatives,
and protection  of the eruption  from  local irritation; if;
however,  there is much  heat or  tingling  in the part, poul-
tices prepared with bread and the weak lead-wash (see page
77) are productive of much  benefit;  when the scales have 
HERPES.
93
formed  the ointment  of cold cream and acetate of zinc
(see  page 30) will be found  an excellent application.  If
the  disease becomes  chronic, constitutional  treatment is
generally required for  its  remoA'al, and preparations  of
iodine, Avith or without tonics, according to individual cir-
cumstances, are  usually the  most efficacious ;  as regards
local applications, astringent ointments and alkaline lotions
prove in most cases successful; thus an ointment consisting
of four grains of the  dried  sulphate of  iron, an ounce of
white wax  ointment, and a drachm of glycerine, should  be
smeared over the eruption three times a day, it having been
previously sponged well  each time with a lotion containing
ten grains of the carbonate of potash in twelve fluid ounces
of rose-water;  or,  in  very  chronic  cases, a dilute citrine
ointment; containing from one to two drachms of brown citrine
ointment to the ounce  of prepared lead, may be substituted
for that of the sulphate of iron.  When herpes circinnatus is
inclined  to spread rapidly, the progress of the eruption may
be sometimes stayed by the  application of strips  of blis-
tering plaster around  the outer border  of the  rings, at a
short distance from the inflamed surface; their effect seems
to depend on a neAV action being  excited in the part.   In
herpes of the scalp the same local applications will be  re-
quisite as when it occurs in  other parts of the body, but
the  hair should be kept cut close with  a  pair  of scissors
during the entire progress of the treatment, and for at least
three or four weeks afterwards ; nor is it sufficient to  cut
the hair  on the diseased part solely, but it must  be removed
from the entire scalp, as otherwise  the eruption is  apt to
appear in other patches on it.   In  herpes capitis in chil-
dren, the green  iodide  of mercury, prescribed as recom-
mended for eczema of the scalp, has proved in my experience
the  best alterative remedy.  Milk  diet, as an important
aid to treatment, should be enforced in this variety of  the
eruption.
   Herpes iris is to be treated on the same principles as  the
milder forms of herpes circinnatus. 
94
VESICULJE.
                      PEMPHIGUS.

  Pemphigus (Water-blebs).— Willan described three forms
of diseases of the skin which  were characterized  by the
elevation of the epidermis into bullae, namely, erysipelas,
pemphigus, and pompholyx; that the  first of these  was
incorrectly classed by him with the others is now admitted
by all dermatologists for the reasons given when describing
erysipelas; and the distinction he made betAveen pemphigus
and pompholyx—that the  one  is attended with  constitu-
tional fever and local  inflammation, and the  other is not
—does not sufficiently separate them to constitute  distinct
diseases; the latter term  therefore is  now very generally
abandoned, and when used is considered as being synony-
mous with the former.  Pemphigus may be defined to con-
sist in the development of oval  or rounded elevations of
the epidermis, containing a transparent serous fluid, which
vary in size from that of a pea to that of a large nut  (bullae),
—at times they attain the  size  of an egg—each being
surrounded by  an  inflamed areola.  The  contained fluid
rapidly  becomes  opaque,  and  of  a  yellowish color, the
epidermic covering, which is extremely thin, then bursts
spontaneously, or is easily torn, and the eruption results in
the formation of fine foliaceous  crusts, or superficial excori-
ations from which a slight serous discharge  flows.   The
bullae  come out  generally singly or in  crops  of from two
to five or six, each crop disappearing in a few days with
some trifling  epidermic desquamation, but  the duration of
the disease is often indefinitely prolonged by successive
eruptions.  In  a few  cases all   the bullae  appear  simulta-
neously, when it runs its course  in about a week.  By some
writers pemphigus has from this  circumstance been classified
into Pemphigus simultaneus and Pemphigus  successivus;
others arrange it in groups according to the number of the
bullae, and others again with reference to  the age of the
person on whom the eruption  appears.   The division, I
think, least open to objection, and most convenient  for the
purpose of description, is into acute and  chronic :—
                   Pemphigus  acutus.
                       "      chronicus. 
PEMPHIGUS.
95
  Acute pemphigus (Atlas, PI.  V. Fig. 1) is ushered in
with well marked febrile symptoms, being preceded by shiver-
ing,  heat of skin, general malaise, and loss  of  appetite; as
well remarked by Dr. Corrigan, there are sometimes two or
more shivering fits so distinct that the attack  at first sight
appears to he intermittent fever.1  The  feverish symptoms
are succeeded on the second or third day by the appearance
of a few or many bright red spots, scattered generally over
the thighs and lower part of the abdomen, which are attended
with heat and itching ;  these spots rapidly enlarge, and a
minute, transparent vesicle is developed in  their  centre,
which in a few hours extends so as nearly to cover the pre-
viously inflamed patch  of integument, a border being left
which forms an areola to each.   The bullae thus constituted
are round or oval,  somewhat flattened at the  summit, of a
shining brilliancy, and, being irregularly distributed, resem-
ble the effect which would be produced if boiling water was
dashed on the skin ; on  the day after  their  appearance the
contained fluid  assumes a  yellowish,  opaque  aspect, and
within forty-eight hours the bullae usually break, giving exit
to a  thin, serous discharge, which continues to be secreted
for a few  days longer, the surface thus exposed being red
and excoriated ; the  discharge then accretes  into a thin scab,
of a yellowish color, and a  foliaceous aspect, which, falling
off on the sixth or seventh day  from the first appearance of
the eruption, is succeeded by a slight  epidermic desquama-
tion  and yellowish stain of the surface ; the former ceases
from  the  tenth to  the fourteenth day, but  the latter  often
lasts for an  indefinite period.   In  the acute form of  pem-
phigus  the  eruption may  occur  in  a  single  crop,  but
there are  more usually two or three  in succession, an in-
terval of from twenty-four to forty-eight hours existing be-
tween them, and as each set of bullae runs a similar  course,
the duration of the disease is then prolonged for about three
weeks.  Two or more bullae being occasionally developed
close to each other become confluent, and thus  a very large
vesication is often formed.  On  some of the  inflammatory
patches, on  the other hand, no elevation of the epidermis
1 Cyclopaedia of Practical Medicine, vol. iii. p. 263. 
96
vesicul^:.
occurs;  when, however, there is more swelling of the part,
and a serous exudation takes place from its surface.
  The feverish symptoms always abate on the development
of the eruption, and  the local heat and itching are much
diminished, but the appearance of each successive crop of
bullae is marked by their return.   In some cases the  fluid
contained in the bullae is absorbed when they  do  not break,
and the disease terminates with  epidermic desquamation,
while in others superficial ulceration  occurs, and  then its
duration is more prolonged, and indelible marks are often
left on the skin.
  Willan termed' the  disease Pompholyx benignus, when the
premonitory fever was very mild, and the local inflammation
trifling.   He also  described a very rare form of the  eruption
under the name, Pompholyx solitarius ;  in it " large vesica-
tions arise on some part of the body, one after another, at
nearly equal intervals  of time ;  a disagreeable  tingling is
felt for several  hours before the vesication arises,  which is
usually in the night.  It enlarges rapidly, so as sometimes
to contain  on  the following  day a tea-cupful  of lymph.
Within forty-eight hours the  cuticle  breaks, the lymph is
discharged, and a superficial ulceration remains.  Near this
another vesication arises in a day or two, and goes through
the same process as the first.   A third, fourth, fifth and
sixth vesication will  sometimes appear and proceed in like
manner."   This singular  variety  of  pemphigus seems to
affect women solely;  it  is' extremely rare, yet Willan  men-
tions that  he witnessed  three  cases of it;  Cazenave states
that he saw one remarkable instance; and Copland records
its occurrence under  his observation in a man.
   The most usual site of acute pemphigus has been already
indicated, namely, on the thighs and  lower part of the ab-
domen, but it may affect the arms, the backs of  the hands,
the legs, and the  thorax ;  it has been also witnessed on the
mucous membrane of the mouth  and  tongue.   It  most
usually occurs in adult life, but infants and children are not
unfrequently attacked, and a variety has been specially de-
scribed  by some dermatologists under the  denomination of
pemphigus infantilis.
   This corresponds with the form so admirably depicted by 
pemphigus.                   97
the late  Dr. Whitley Stokes,1 as being not uncommon in
Ireland,  and  which he termed Pemphigus  gangrsenosus
(popularly knoAvn as burnt-holes or eating-hive) (Atlas, PI.
V. Fig. 3).   By some  recent writers, however, it has been
regarded as a species of Rupia, but to anyone who has wit-
nessed it in^ our country districts, where it is even  in the
present day of not unfrequent  occurrence, its agreement
with the characteristic phenomena of pemphigus must be
sufficiently evident.2  The eruption generally appears on a
child in apparently good health, but occasionally a livid suf-
fusion  of the surface of the body precedes its outbreak ; one
or more bullae  appear  on the surface and increase  in size
for a few days, when they burst and  discharge a thin fluid,
having a disagreeable smell; "before or after breaking, the
vesicles run together, the sore becomes painful with loss of
substance,  and a thin,  fetid,  ichorous  discharge : the edges
of the  ulcer are undermined, and it spreads quickly."  The
discharge daily increases in quantity,  and becomes more and
more fetid, the ulcers  spreading rapidly, probably from its
acridity, and  the constitutional fever,  Avhich is evidently
caused by the  local irritation, is extreme ;  emaciation and
great debility quickly ensue, and the  child dies on the tenth
or twelfth day, death being often preceded by convulsions.
Should recovery take place, the progress to  convalescence is
very tedious,  and relapses not  unfrequently occur, even
when the ulcers are skinned over.  A deep  pit, like that re-
sulting from smallpox, but much more extensive, is ahvays
left.   The eruption appears usually very generally over the
body,  sometimes spreading to the meatus auditorius, when
deafness follows, and to the eyes so as to destroy the sight.
   Pemphigus chronieus (Atlas, PI. V. Fig. 2) is  of more
frequent occurrence than the acute  form  of the eruption,
and sometimes appears as an epidemic; of this a remark-
able example is recorded by Dr. Macbride, Avho witnessed
it in the county of WickloAv in  1766.  The  disease  which
corresponds Avith the Pompholyx diutinus  of Willan is not
attended with any febrile symptoms, yet the outbreak of the

   1 Dublin Medical and Physical Essnys, vol.  i- p. 146; Dublin, 1808.
   * In the following account of the disease, Dr. Stokes' faithful and original
observations are freely made use of.
                            9 
98
VESICULJE.
eruption is preceded for some days by sickness, debility, and
muscular pains.   Red  spots, as in the acute form,  appear
scattered over the skin, but the redness is of a livid color,
and is not accompanied by heat or itching; on these spots
the bullae  are rapidly developed, each bulla covering  com-
pletely the reddened surface, so that to the naked eye they
appear to  have no areola, but when  examined with a lens,
a narrow red line will be seen to surround each.  The vesi-
cations, which generally attain their maximum  size in  a
single night,  are much  larger than in the acute  form, and
rarely become confluent;  they come* out  almost  invariably
in successive eruptions, a second crop sometimes not appear-
ing until the one which preceded it has completely disap-
peared from  the surface, and thus the disease may be in-
definitely prolonged.
  The bullae are irregularly globular, somewhat flattened
at the summit, and contain a citrine-yellow, semi-transpa-
rent,  serous fluid,—in old  persons, or in broken-down con-
stitutions, the fluid is generally sanguinolent in some of the
bullae ; in eight or ten hours they burst, and are  succeeded
by the formation of thin, blackish crusts, beneath  which the
surface of the skin is excoriated ; when these crusts fall off",
small, unhealthy ulcers, with a foul ichorous discharge, not
unfrequently succeed.
  If  the disease is not prolonged by the  development of
successive crops of bulla?, Avhich, however, is rarely the case,
it may not last  longer than for  a month or six weeks,  and
the general health is but little affected; more usually, how-
ever,  a relapse  takes  place,  the eruption seeming to lie
dormant during the winter, returning again in the spring
and summer, and thus,  or  by fresh  sets of the bullae con-
tinuing to be developed,  its  duration is prolonged for months
or even years, very frequently proving fatal.  In the latter
case there may be  seen on the cutaneous  surface, at the
same  time, recent bullae and black crust and atonic  ulcers,
the result of previous  eruptions.   The  constitution  then
sympathizes, extreme debility,  with low  fever,  ensues on
the loss of rest caused by the local irritation, pain, and  foul
discharge; the appetite fails, and  the patient  dies quite
worn out.
  In  one very chronic variety of pemphigus which attacks 
PEMPHIGUS.
99
old persons, the bullae form with extreme rapidity, no dis-
tinct interval elapsing between the development of the suc-
cessive crops ; they become confluent, burst almost as quickly
as they appear,  and spread so as to engage  the cutaneous
surface over the  greater part of the body,  the face  in
especial being affected.   The bullae are succeeded by epi-
dermic  desquamation  in large, yellowish, foliaceous  scales,
Avhich partly adhering to  and partly peeling  from  the sub-
jacent integument, gives a singular aspect to the disease;
these scabs are aptly compared by Cazenave  to the layers
of  puff-paste, and he terms  the  eruption in  Avhich they
occur,  pemphigus chronicus foliaceus.  It is  generally a
very fatal form, death being preceded  by dropsical effusion
and diarrhoea.
   Chronic pemphigus may occur on any region  of the body,
except those parts on which hair grows; it is more diffused
than when the disease is acute, and appears more frequently
on  the upper extremities,  the face and the thorax.   It not
uncommonly is complicated with other cutaneous  diseases,
especially Avith prurigo or scabies, in either of  which cases
the sufferings it  occasions almost baffle  description.
   The causes of pemphigus are more or less connected with
constitutional derangements ; the chronic form in particular
rarely occurring except in persons who have been debilitated
by distress, and by insufficient or bad diet, or in those who
suffer from some chronic visceral disease, of which it seems
at times to be symptomatic.  Acute pemphigus is most fre-
quent in children and young persons, infants even not being
exempt from it,  appearing rarely in adults or  in the old;
while chronic pemphigus is a disease of advanced life.  The
eruption is occasionally developed in children after  a con-
tinued  exposure  to the heat  of the  sun ; but it much more
frequently seems to depend on the effects of moisture, most
of those at any age who are attacked Avith it  being persons
Avho have lived in damp situations; this fact is  well estab-
lished in the country districts of Ireland, where it is most
prevalent  among the peasantry who dwell in mountainous
districts, much rain falling Jthere, and  the hills  being con-
stantly enveloped in mists. "  The occurrence  of the disease
as an epidemic has been already adverted to; some  of the 
100
VESICUL^E.
ancient medical writers regarded it as being contagious, and
Willan, by describing a variety of it under the  name Pem-
phigus contagiosus, tended  to  perpetuate this erroneous
view, one, too, which was contrary to his own opinion.
  The diagnosis of pemphigus, whether  acute  or  chronic,
is, in most cases, unattended with difficulty.  Although the
bullae resemble somewhat the vesications which occasionally
accompany erysipelas, they are never situated on a  diffusely
inflamed portion of the skin, as occurs in that disease, nor
are they attended with the constitutional fever.   The diag-
nostic marks between pemphigus and  herpes  have been
given in  the description  of  that eruption.  Rupia  differs
f^om pemphigus in there  being in it a broad inflammatory
areola to each bulla when it is first developed, and  in the
peculiar appearance of the  resulting  scab or  crust.  The
foliaceous form  of chronic pemphigus  might be mistaken
for  psoriasis, but the scales in  the latter desquamate more
freely, are smaller, of a  silvery whiteness, and are  never
preceded by an eruption of bullae, nor attended with a  serous
discharge.
  Prognosis.—Pemphigus in any of its forms is  not un-
attended  with danger, notwithstanding Willan termed  one
variety of it Pompholyx benignus.  The chief apprehensions
in the acute form are, the liability to relapse Avhen it appears
in children, or about the age of puberty ;  and, at an  earlier
age, that it may assume the characters of the pemphigus
gangraenosus of Stokes.  The  chronic form is always a
most  dangerous  disease,  few old persons recovering from
an  attack of it.  The more  acute the symptoms,  and the
more inflammatory the constitutional disturbance, the more
favorable the prognosis.
  As regards the pathology of pemphigus, it is manifestly
an atonic inflammation of the superficial layers of the derma,
Avhich terminates in serous effusion: the fluid contained in
the bullae is highly albuminous, becoming nearly solid when
exposed to heat.
  Treatment.—The acute forms  of this eruption  demand
but  little  medical  interferencez  the  accompanying fever
being rarely such as to require any active antiphlogistics;
should it, however, continue after the  bullse  are fully de- 
PEMPHIGUS.
101
veloped, or inflammatory symptoms then appear, a small
abstraction of blood from the arm may be  requisite ; but
in the majority of cases, rest in bed, diluent drinks, reduced
diet,  and mild saline  purgatives  will suffice.  The vesica-
tions should be  as  much as  possible protected from local
irritation, and, above all, from being prematurely ruptured ;
with this vieAv they may be dusted over with flour or starch;
as soon as they have burst they may be  dressed with  some
simple ointment,  such  as the cucumber or acetate of zinc
cerate, or collodion may be applied over them.  When acute
pemphigus presents the characters described by Dr. Whitley
Stokes, all debilitating plans of treatment must be carefully
avoided, good nourishing  diet should be given in  abundant
quantity, the  air be at once  changed, and powdered bark,
Avith minute doses of pulvis cretse opiatus and of the hydrar-
gyrum cum creta, administered internally.  On the sugges-
tion of Dr. Stokes, an  ointment prepared Avith lard and the
leaves of the  common figwort, Scrophularia  nodosa, was
used  as  a local application in this form  of pemphigus;  he
states that he derived his knowledge of its beneficial action
from  an inquiry into the applications which Avere popularly
employed with success  in the country districts of Ireland, in
all  of Avhich he  found that the leaves  of this indigenous
plant formed a principal ingredient; at his recommendation
it Avas originally introduced into the Dublin Pharmacopoeia,
from the last edition of Avhich, however, it has been omitted.
It Avas, in fact, but a mild astringent ointment, and its chief
efficacy probably  depended on the protection from the action
of the air which  it afforded; a Aveak cerate  of tannic acid
—tAvo grains to the  ounce of Avhite Avax  ointment—melted,
and  applied to the  surface with a camel's-hair pencil, just
as it  is  again about to  become concrete, will be beneficially
substituted for it.
  In chronic pemphigus the chief indications are  to allay
both the local and constitutional irritation, and to support
the strength;  attention  must  also  be  directed to any
visceral disease of  Avhich it may  be  symptomatic, or Avith
which  it may  be complicated.   I have  experienced  very
great benefit in its treatment from the free use of opiates, 
102
VESICULiE.
which may be given, combined with bark, as in the follow-
ing form:—

R.  Liquoris Opii Sedativi, .  .  .  . m. x.
    Tincturae Cinchonae Compositae, m. xv.
    Misturae Camphorae,.....flgj. Misce; fiat haustus.
        " One such to be taken every sixth hour."

To  allay  the local irritation,  the  parts may be covered
with raw cotton or dusted with starch, or,  if the  itching
and pain are very severe, they may be dressed with lint on
which has been spread the compound lead cerate, to every
ounce of which a fluid drachm of glycerine has been added.
By some it has been proposed to open the bullae  as  soon as
they appear, and to apply to the  surface thus  exposed a
solution of nitrate of silver, containing a scruple of the salt
to an ounce of distilled water; instead of the solution, Dr.
Graves proposes to employ the solid nitrate for  this pur-
pose, and mentions a case in which  its use was attended
Avith complete success ;J  the practice, however, is only ad-
missible  when the  eruption is  of  small extent, and  not
connected  Avith  constitutional  derangement.  In very ob-
stinate cases arsenical preparations  and iodide of potassium
are occasionally employed with benefit.  Wine and generous
diet should be allowed in all  cases of chronic pemphigus,
and change of air to  a  drier locality enforced, if possible.
When diarrhoea or dropsical symptoms  occur in the  course
of the disease, they are to be treated on the  ordinary prin-
ciples.

                         RUPIA.

  Rupia  is  characterized by  the  eruption of  distinctly-
separated and dispersed, flattened  bullae, of the  size of a
small nut, on an inflamed  base, terminating  in elevated,
dark brown  crusts,  which,  falling off,  are  succeeded  by
atonic  ulcers.   The bullae, Avhich  in most  cases are not
preceded by either  local  or constitutional inflammation,
1 Clinical Medicine, second edition, vol. ii. p. 354. 
RUPIA.
103
contain from  the  first a  semi-opaque or  ichorous  fluid,
which appears not to  distend them  completely ;  this fluid
rapidly becomes  sero purulent and  more consistent, and
the epidermic  covering of the bullae, giving way usually on
the second or third day, accretes into a wrinkled scab, more
prominent in the centre than at the circumference.   Three
varieties of rupia are in general described by dermatologists,
but the third of these, rupia escharotica, as has been already
mentioned Avhen  describing pemphigus is a form of that
eruption, being the pemphigus gangraenosus of Dr. Whitley
Stokes—tAvo forms, therefore, only remain to be considered
here:—
                     Rupia simplex.
                       "   prominens.

  In Rupia simplex  (Atlas, PI. V. Fig. 4) the bullae are but
few in number, often not more than  two or three, and situ-
ated remotely  from each other ; the inflammatory areola is
narrow, and scarcely raised above the level of the surround-
ing integument, and  the crusts which  are of a dark-brown
color, only slightly elevated in the centre.   The resulting
ulceration is superficial, and scabs cover it  in a  few days ;
these scabs, which are wrinkled and raised at the  edges, fall
off  and are renewed several times for from one to  two or
three weeks, when  the- surface  heals, a  livid stain, which
does not  disappear  for some time, remaining on the part.
The duration of the  disease until the falling off of the scabs
is, as above remarked, from two to three weeks, unless, as
occasionally occurs,  it  is prolonged by  the formation  of neAV
bullae at the time those first developed are  about to disap-
pear.  In some rare cases a slight degree of fever precedes
the appearance of the  eruption, and superficial redness, as
in pemphigus, marks the spot  on which each bulla is about
to form.
  Rupia prominens  (Atlas, PI. V. Fig. 5) is so named from
the characteristic  appearance of the  crusts or scabs which
are formed in  it.   The bullae are of larger size than in rupia
simplex, the patches of the cutaneous surface on which they
occur are  previously swollen and of a dark-red color, and the
contained fluid, which is  often ichorous or  sanguinolent, 
104
VESICUL^E.
sometimes  as dark  as chocolate, rapidly thickens  and dries
into a hard, wrinkled, blackish crust, surrounded by a swol-
len, inflamed border.  From the inner edge of this inflamed
areola, unhealthy pus is secreted, Avhich, concreting, forms
additional  crusts ;  these, pressing on  the original  scabs,
already somewhat raised in the centre and corrugated, force
them still more forwards until they eventually attain such
a prominence that they bear  an extraordinary resemblance
to the shell of a limpet, or, in some  cases, spreading from
their circumference  until they cover the entire of the  in-
flamed border  by Avhich they Avere surrounded, to the shell
of an oyster.  These crusts, which are firmly adherent and
sIoav in falling off', in a few days become somewhat raised at
their outer border,  and permit the discharge of unhealthy
pus from the excoriated surface beneath ; in the  course of a
week or ten days they may be readily detached, or they fall
off spontaneously, Avhen  an excavated atonic ulcer,  the depth
of which is usually proportioned to the thickness of the scab,
is seen to occupy the site of the original bulla.  These ulcers
are extremely indolent, pale, and  bleeding on the slightest
touch, and either become covered aneAv Avith the character-
istic crust,  which, however, does not  attain the same degree
or prominence as in the  first instance, or, discharging an un-
healthy, ichorous pus, heal slowly, leaving dark, livid stains
on the skin.  Rupia prominens is always a chronic disease,
lasting generally for months, and its  duration is often pro-
longed by successive eruptions of bullae.
   The usual site of either form of  rupia is on the  loAver
extremities, sometimes  on the abdomen, the loins, or the
thorax; but, unless when occurring as a  syphilitic eruption,
it  is very rarely witnessed  on  the upper extremities or the
face.  The disease may occur at any age, but it most usually
affects children and old  persons, being uncommon  in adults.
The causes by which it  is produced are sufficiently obscure
but it appears to be connected with a debilitated state of the
constitution, and especially in  children with the scrofulous
diathesis.   It  is also one  of  the sequelae of the eruptive
fevers in young  persons, and  in the old  it not uncommonly
occurs at the termination of some prolonged illness, such a"s
fever or dysentery.  Rupia is sometimes complicated with 
RUPIA.
105
other cutaneous diseases, more particularly scabies, ecthyma,
and  purpura; in the  last case the bullae usually contain
blood.
  Diagnosis.—Rupia may be confounded with either pem-
phigus or ecthyma.  From the former  it is  distinguished,
even in its  vesicular  stage,  by the  bullae being solitary,
never  confluent,  and  by the raised  inflammatory  border
which surrounds them; Avhen  the scab is formed, its charac-
teristic  prominence  serves to  render the diagnosis easy.
Ecthyma  is an  inflammatory pustular eruption, and  the
resulting scabs are small  and flat, while rupia is distinctly
vesicular at  its origin, and the scabs  are  large and  promi-
nent.  The  more serious mistake may be made of mistaking
idiopathic for  syphilitic rupia,, which is a much more severe
disease, and one requiring different treatment; the latter is
distinguished by the areola surrounding the bullae being of a
dull, coppery hue; by the bullae being much more numerous
often covering nearly the  entire body, and appearing very
frequently on  the face; by there being generally present at
the same time syphilitic sore  throat; and by the antecedent
history of the  case.
  The prognosis in rupia is always favorable; it is often an
obstinate, but  never a dangerous disease, and rarely injures
the general  health, unless the resulting  ulcers are very
numerous, and attended Avith much discharge, when a degree
of low, irritative fever is developed by their presence.
   Treatment.—Constitutional  remedies are   chiefly to be
relied on  in the  treatment of rupia, and  these  should be
adapted to  the  indications  in individual cases.  Tonics,
especially preparations of bark and of iron, good food, and
nourishing diet,  are most usually demanded.  When  the
disease  becomes  chronic, hydriodate  of potash  will be
given with benefit in equal parts of the decoctions of elm-
bark, of dulcamara, and of mezereon ;  and in the case of
scrofulous children, cod-liver oil should be prescribed.  As
regards local  treatment,  it is  generally  recommended to
open the bullae at the earliest opportunity, so as to prevent,
if possible, the formation  of the crust; they  should then be
covered with pledgets  of  lint, and slight pressure made  on
them, or they may be  dusted with starch, or, what  is still
preferable, as  the chief object is to exclude the air, collodion 
106
VESICUL^E.
may be applied.  When the crusts have formed they should
be removed as quickly as  possible, having  been previously
softened by the application of bread and Avater, or of linseed-
meal poultices; the ulcers, for the first few days, should be
treated with Avater-dressing, over Avhich oiled  silk is placed,
but  if they do  not show a disposition to heal,  stimulating
ointments  or lotions become requisite ; of the  former, the
brown citrine ointment, or one composed of equal parts of
oil of turpentine and of Avhite wax ointment, may be used ;
or of the latter, if it be found, as is often the  case, that
greasy applications disagree, solutions  of the sulphate of
copper or of sulphate of iron,  from six to twelve grains of
either to the ounce of distilled water, may be employed, lint
soaked in them being laid on the ulcerated surface.   Some
of the French dermatologists report that they have derived
excellent results from ointments of the iodides of mercury,
—a drachm  of  the green  or  tAvelve grains of  the yelloAV
iodide, to the ounce of  lard.  By some practitioners  it is
recommended to touch the  ulcer every second or third day
with the solid nitrate of silver, but  the nitrate  of copper,
allowed to  deliquesce,  and  then applied by means  of  a
camel's-hair  brush, will in  very obstinate cases, be  found
more beneficial.   It must not  be  omitted  to  mention that
Rayer states he found the  simple practice  of dusting the
ulcers with finely-poAvdered cream of tartar very successful.

                        SCABIES.

  Scabies (Itch) (Atlas, PI. VI. Figs. 1 & 2).—No  little
difficulty has been at  all times experienced  in  classifying
scabies ; by some it is regarded as being papular, by others
pustular, and  by many  modern dermatologists it  has  been
made to constitute a division of cutaneous  diseases of which
it is the type,—the presence of parasitic animalcules beneath
the epidermis being considered by them as a necessary cha-
racteristic of the eruption.  There can be no doubt but that
during the course of the disease pimples and pustules con-
stantly occur on the skin, mingled with the vesicles, and the
vesicles themselves assume a purulent aspect in  a few days
after they are deA'eloped, yet on careful observation it will
be found that the eruption is at first always distinctly  vesi- 
SCABIES.
107
 cular, and that this character is never completely lost in any
 stage of the affection.   The occurrence of the peculiar itch
 animalcule is very  constant  in  scabies,  and its  existence
 easily demonstrable, but as  cases do occur in  which even
 the most experienced observers are unable to detect it, I
 cannot admit that its  presence is necessary to and  pathog-
 nomonic of the disease.  For  these reasons, then, and also
 because the peculiar vesicle  of scabies is highly character-
 istic, I shall retain it amongst  the vesiculae.   It has always
 been an eruption of much interest  to the physician  in con-
 sequence of  its great prevalence, the rapidity Avith which it
 spreads by contagion, and the severity of the local symptoms
 with  which it is attended.
   The eruption in  scabies,  the  development of which is
 unaccompanied  by  constitutional  symptoms,  is  preceded
 by itching and  tingling  of the parts on which  it is about
 to  appear, usually the backs of  the hands, the angles be-
 tween the  fingers, and the flexures of their joints ; in about
 twelve  hours afterwards there may be seen developed on
 them one  or  more conical vesicles, which  rapidly  enlarge
 until  they not unfrequently attain the size  of a small pea,
 being more or less solid at the  base, and transparent at the
 apex, which  is acuminate.  The  majority of these vesicles
 soon  become opaque and sero-purulent, and, bursting, form
 yellowish scabs; but in some of them the serous effusion is
 absorbed, and they then present a  papular appearance,  a
 thin,  epidermic  scale  forming on the top of each  papule.
 In the neighborhood of  some of the vesicles may be  seen,
 in most cases of itch, a narrow line  or superficial  fissure of
 a few lines in length, such as would be made with  the  point
 of a needle—the sillon, Avhich terminates in a small, rounded,
 elevated point, of a reddish color—the cuniculus, or  burrow
 of the itch animalcule, and  from which, with a little  care,
it may in general be extracted.
  This insect—the Acarus scabiei, or, as it has been also
termed, Sarcoptes hominis, being  constituted into  a new
genus by Latreille—Avas  discovered and  described  as ex-
isting in scabies  in  the twelfth century by Avenzoar; but
although its  presence  was evidently known to  the  Greek
and Roman physicians, little  notice  of it occurs afterwards 
108
vesicul^;.
in medical writings  until the  middle of  the seventeenth
century,  when  an Englishman,  Mouffet, left in a posthu-
mous Avork a  singularly full and  accurate  description of
the animalcule, especially as  regards its  anatomical cha-
racters, and in which many of the so-called discoveries of
modern days are anticipated.   In our own times the na-
tural  history of the  itch animalcule  has  been especially
investigated by the  French and  German  dermatologists,
particularly by Renucci, Raspail, Albin-Gras,  Hebra, and
Bourguignon;  amongst English writers Mr. Erasmus Wil-
son gives  the  fullest account of its  habits  and structure,
and from his observations the following  description is con-
densed.
   Examined with the naked eye, the acarus scabiei (Atlas,
PI. XVI. Fig. 1) looks white, shining, and globular in form.
" There is no difficulty in extracting  the little animal; the
cuniculus is seen without difficulty; the end of the cunicu-
lus is perceived to be a little raised, Avhile a grayish speck is
seen beneath it; as soon as this  little eminence of epiderma
is lifted, if the  end of the needle or pin with which the ope-
ration is performed  be  examined, the minute, white,  and
shining globe will probably be observed attached  to the in-
strument.  If  there  be  no such  object, the point of the
needle, placed again beneath the raised capsule of epiderma,
Avill pretty certainly draw it forth.  This facility of extract-
ing the little creature is due to its great power of clinging
to any object with which it comes in contact.   When the
acarus is seen running upon the surface of a plate of glass
it may be perceived that its anterior margin presents a dusky
tint of color, and the examination of  this  part of the crea-
ture with the microscope brings into view a head not unlike
that of a tortoise, and a pair of large and  strong legs on
each side of the head.   These organs are  encased in a mo-
derately thick  layer of chytine, and have  consequently the
reddish-brown  tint of the cases of certain  insects, or of the
bright part of  a thin layer of tortoise  shell."l   The general
outline is  sub-rotund,  it being a very little longer than
broad ; the ventral surface  is flat, and upon it may be seen
the  head and  eight legs;  the  dorsal aspect is arched and

   1 Erasmus Wilson on Diseases of the Skin.  Third Edition, p. 499. 
scabies.                    109
uneven, and covered by numerous spines; and twelve hair-
like filaments, some long and others short, project backwards
from the posterior segment of the animalcule.  Mr. Wilson,
from a comparison of the measurements in  ten  specimens,
found them to vary between x^th and  ^th of an inch in
length, and  g^gd and ^th in breadth.
   This account refers to the female acarus, and with it are
generally found some of the ova; the male insect (Atlas,
PI. XVI. Fig. 2) seems to have eluded the research of most
investigators ; M. Bourguignon, writing so  lately as 1847,
says, "that  he  has never found male sexual organs  in the
acarus, but in every specimen he examined has seen ovaries
Avith the ova, it appearing that connection with a male is not
requisite for the reproduction of the animalcule."1  Gustav
Simon,  Physician to the Charity Hospital at Berlin, de-
scribed the male acarus in the first edition of his Anatomical
Description  of Diseases of the  Skin, published in 1848 ; and
in 1851, it was also discovered and  described  by M. Lan-
quetin, a pupil of M. Cazenave.   It is much more  minute
than the female, and being always situated on the free sur-
face of the skin,  not taking up its abode in  a cuniculus, ac-
counts for its existence being overlooked by  so many  careful
investigators.
   The eruption in scabies is invariably attended with severe
itching—whence  the name by which  the  disease  is com-
monly known,—this, causing the sufferer from it to  scratch
and tear the skin with the nails, increases  the local  inflam-
mation, which already is considerable ; fresh vesicles appear,
often thickly set  on the surface, and mixed  Avith them large
papulae and pustules ; a bloody serous  and sero-purulent dis-
charge  floAVS  from  the  torn  integuments,  in  which deep
fissures are  also formed, and the eruption  spreads rapidly,
in severe cases attacking the  lower extremities, the abdo-
men, and the trunk, as well  as the  hands and arms, but
being very rarely, if ever, Avitnessed on the face.  The suffer-
ings occasioned by the disease are  then extreme, sleepless
nights are passed often for weeks together, the itching being
always much augmented by the warmth  of the bed ; the con-
stitution, consequently, sympathizes more or less, and in the
  1 Recherches Entomologiques et Pathologiques sur la Gale de 1'Homme.
Paris, 1847, p. 8. 
110
vesicul^e.
 old or the debilitated, prurigo, ecthyma, or pemphigus, com-
 plicates the original eruption, rendering it more intractable
 and in very aged persons even  fatal.
   In some cases of scabies the eruption is apparently alto-
 gether papular, but on  examination  with a  lens it will be
 found that a minute vesicle surmounts each papule:  from
 mistaking its true character, Willan  and Bateman  termed
 this form of scabies papuliformis; when the vesicles are
 perfectly transparent, and with little or no inflamed base,
 they  denominated the disease, scabies  lymphatica; andAvhen
 the pustular character  predominated, they constituted it a
 distinct variety, under  the name scabies purulenta.   The
 occurrence of the eruption in  broken down constitutions is
 not unfrequent, and its aspects being then influenced by the
 physical  condition  of the individuals attacked, the same
 dermatologists arranged it in a distinct species, which they
 called scabies cachectica.
   Causes.—Scabies  occurs  at  all  ages,  in  individuals of
 every rank of life, and in  all climates,  being even more
 prevalent in hot countries than  in cold, and there  it is also
 a more severe disease; it is of  much  more  common occur-
 rence among the poor than amongst  the higher orders, in
 consequence evidently of the less frequent ablutions to which
 their  bodies are subjected, and  the longer  period  during
 Avhich their clothes are worn without being changed, for the
 eruption is especially a concomitant of filthy habits.  That
 the spread of the disease from individual to individual takes
 place by contagion  is undoubted, but that this is the only
 cause some have questioned, believing that it  may be self-
 generated in the system; however, such a doctrine is now
 nearly obsolete, and the sole difference of opinion  existing
 on the matter at present may be said to be as to which  is
 the contagious principle  in scabies, the acarus, or the matter
 of the eruption.  Mr. Erasmus Wilson asserts his belief,
that " the  vesicle is a  provision  of nature to protect the
 derma from  the  nearer  approach  of the  arator,  and the
vesicle^ is  formed with the judgment which usually marks
nature's operations—namely, before a defensive operation
would be too late."  Now how the approach of the insect
is to  be prevented by the formation of  the  vesicle, I must
 confess I cannot understand ; the sillon,  or track from the 
SCABIES.
Ill
cuniculus, always  terminates in a vesicle, and observation
shows that the development of the vesicle precedes the ap-
pearance of the animalcule; I therefore think that the con-
nection  betAveen them may  be more simply explained by re-
garding the sillon as being the track of the acarus in making
its Avay from  the  vesicle—which  has been caused by  the
irritative  inflammation  occasioned by deposition  from  the
skin of  another person, no matter  how conveyed,  or in the
fluid  of which it  has been hatched—to  the  cuniculus  or
burrow for the purpose of depositing its  ova.   The belief
of those, then, who think  Avith that  dermatologist is, that
scabies  being  in all cases dependent on and caused by the
acarus,  can alone  be propagated by the deposition of this
insect, or of its ova on  the epidermis, and that the secre-
tion from the vesicles will not of itself reproduce the disease.
Direct experiment, however,  proves  that  it  may  be thus
propagated, but to this they answer, that Avhen it is so, the
inoculating matter employed must contain  some of the ova;
but a similar argument is equally  applicable  to their view,
namely, that when the  disease has been produced in indi-
viduals by the acarus being placed on  the skin, it cannot be
denied that the animalcule conveyed with it some of the cha-
racteristic secretion.
  For my own part, I am of the opinion that scabies will be
developed in a person Avhose  skin  has been previously free
from  the disease by the contact of either the itch-insect or
the secretion from the eruption, but I believe the latter to
be the most  frequent cause of the contagion, and in this
Avay only can we account for the many  cases that occur
in Avhich  the  disease has been produced  by contact with
clothes, with  gloves,  &c,  Avhich  have  lain  by  for  some
time; in one  instance Avhich  I  saw,  a lady Avas  attacked
with scabies on the palm of her hands, and as far  as obser-
vation, Avhich  I freely admit is not indisputable  evidence
here, enabled  me to judge, the contagion  was conveyed to
her from her servant-man, who was affected Avith the disease,
by means of the handles of the knives which he was in the
habit of cleaning.
   From experiments Avhich have been made it appears that
scabies  is more quickly developed in the young and in indi-
viduals  of a full and  robust habit  of  body than in the old, 
112
VESICUL.E.
or those who  are  of  a weak constitution;  the period of
incubation in  the  former  being about four days, while in
the latter it may extend to ten days or a fortnight, or even
longer.
  The diagnosis  is, in some cases of scabies, extremely
difficult,  and  in no other cutaneous  eruption  is it more
important that a mistake should not  be made, especially as
the plan of treatment adapted for it is not at all suited for
those diseases Avith which it is  likely to be confounded;
moreover, an  opinion  given  with regard to  contagion, if
it prove to  be incorrect, may seriously injure  a physician's
character.   When eczema appears  on the fingers  or hands
it  is very often  mistaken for scabies;  in  its early stages
the minuteness and number of the vesicles generally suffice
to render the diagnosis facile, but when it becomes chronic,
the itching with which it is attended not unfrequently may
lead to error.  Eczema, hoAvever, never presents the conical-
shaped vesicles of scabies,  the discharge  from  the  parts
affected with it is more watery,—being rarely sero-purulent
except in  eczema  impetiginodes,—is  accompanied  by a
mealy, epidermic desquamation, and it  is rather a sensation
of smarting and stinging than  of true  itching that attends
it.  The papular form of scabies may be mistaken for lichen,
more particularly when the latter  affects the back of  the
hands ;  put the complete absence of vesicles and of a sero-
purulent discharge in the latter, generally suffices to prevent
the mistake  from being made; the  eruption, too, does  not
spread to the  flexures between the fingers, the  most usual
seat of itch.   Prurigo,  which, like lichen, is  a  papular
eruption, is liable to be confounded with scabies, chiefly in
consequence of the severe itching with which it is attended;
but it rarely affects the hands unless when  it appears as a
complication of that disease,  its usual  seat being the trunk
of the body, the shoulders, and the thighs ; and the small
black crusts  on  the summits of the papulae produced by
scratching are highly characteristic; it  is, moreover, very
rarely accompanied  by  any  discharge.   When  scabies
assumes the pustular character, and the individual pustules
attain a large  size, it might  be mistaken for  ecthyma,  but
the latter is characterized by not being attended with itch-
ing? by its mode of de'velopment, and by the pustules being 
SCABIES.
vn
usually isolated.   In fine, from all  the  cutaneous diseases
noAV enumerated, scabies  is especially distinguished  by its
contagious nature, and by the  presence  of the acarus; but
it should be  remembered that it may be complicated with
any of  them.
  Prognosis.—As this eruption can scarcely be said to prove
dangerous  to life, except  in the rare instances  already re-
ferred to, the prognosis refers only to its probable duration,
and this, Avhen effective treatment is adopted, is always very
short;  but if scabies be left to itself, Uninterfered with by
the application of remedies, it may be indefinitely prolonged,
as it never seems  to exhibit  a  tendency to AYear out, or to
undergo a  spontaneous cure.
   Treatment.—If there be any well-established example of
a specific in  the Avhole Materia  Medica, it is that  of the
action of sulphur in the treatment  of scabies, and  as  this
medicine never fails  to cure the disease, it is the universally
admitted remedy for it; none other indeed Avould require to
be alluded  to, Avere it not that the unpleasant odor of sulphur
renders its employment in some instances inadmissible.  The
general method of using this  substance for the treatment of
scabies is by the local inunction of ointments containing it,
either alone or combined with alkalies ; in the latter form it
is  generally  employed  in  the  present day in France,  and
found to be more efficacious than Avhen used alone ; the com-
bination was first introduced by M. Helmerich, and the oint-
ment, which  is called  after him, Pommade  d'Helmerich, is
composed of tAvo parts of sulphur, one of carbonate of potash,
and eight  of lard.   The surface of the entire body, but
more particularly of  the affected parts, should be first washed
well with a  strong solution of soft soap, the patient then placed
for  a quarter of an  hour in an alkaline  bath, containing a
pound of the carbonate of potash to twenty gallons of Avater,
at the temperature of 92°, the  skin well  dried, and this sul-
phuro-alkaline ointment  afterwards  thoroughly  rubbed in ;
the disease may thus be effectually  cured in two or three
days, a single friction, preceded by the alkaline and sapona-
ceous bath, being used daily.    Out of upAvards of 700 per-
sons treated on a plan nearly similar to this at the Hopital
St.Louis, in Paris, M. Bazin  only met with six unsuccessful
                          10* 
ll4                   vesicul^e.
cases, all the rest being cured on the third day.1  M. Hardi,
who succeeded M. Bazin in the charge of  the itch wards in
this Hospital,  has  introduced a plan of using the sulphuro-
alkaline ointment there, by which the period required for a
complete cure is reduced to  two  hours.   His method is as
follows:  " On the  admission  of the patient, the entire sur-
face of the body is rubbed for half an hour with soft soap—
savon noir; he is then placed in a bath for an hour,  and the
body well rubbed while in it, and at  the  end of that time
general frictions made and continued for half an hour with
Helmerich's ointment.  The  acarus," adds M.  Hardi,  "is
thus killed, and the patient consequently cured.''   Of 400
patients thus treated, it  is said that 4 only required to re-
turn for further  advice, and of these 2 had recontracted the
disease.
  A question  arises as  to whether it is advisable  to cure
thus suddenly a vesicular eruption,  which  in some  cases is
attended with  a  rather copious discharge; M. Devergie,  a
celebrated dermatologist, and one of the  senior physicians
to this hospital, thinks it may be  dangerous to do so, but I
cannot agree with him, for as scabies is not attended Avith
any constitutional disturbance, and is never symptomatic of
an internal disease, the same  causes do not operate against
the sudden cure  of it as against that of  cutaneous diseases,
the  discharge in which  is evidently dependent on some
deranged condition of the system  generally.   M. Devergie,
however, asserts that although the contagious nature of sca-
bies is destroyed by this plan of treatment, a troublesome
cutaneous eruption still remains—one, too, attended Avith
much annoyance to the patient, and often difficult  of cure.
When any insuperable  objection exists to the employment
of sulphur for the cure  of scabies,  other  applications may
be had recourse  to, which, although more  tedious  in their
action, are equally efficacious;  the  use of any of them  will
invariably be  beneficially preceded by the employment of
frictions  with  soft soap,  and of the alkaline  bath.   Oil of
turpentine made into an ointment with eight times its weight
of prepared lard, is a very certain application, but  its odor
to many persons is more objectionable even than that of sul-

  1 Journal de Medecine et de ChirurgiePratiques, December, 1851, p. 529. 
SCABIES.
115  '
phur; this may to a great extent be removed, and its efficacy
rather increased, by the addition of eight  minims of oil of
bitter almonds to each ounce of the lard combined with it.
The ointment  of sulphuric acid, of the former Dublin Phar-
macopoeia, which is free  from any unpleasant  odor, rarely
fails to cure  the disease; stavesacre and Avhite hellebore
ointments, also, have been used Avith success; the former is
prepared by mixing with prolonged trituration one part of
the powdered seeds of the Delphinium staphisagria  with
four times its  weight of white wax ointment and one part of
glycerine,  and the latter by combining two ounces  of  pow-
dered root with half a pound of prepared lard, and  adding
twenty minims of oil  of lemons.  Inunction with  simple
fatty matters  even, such as olive oil or lard, has been found
sufficient to cure scabies, but the duration  of the disease is
more prolonged than  Avhen  any  of the above-mentioned
remedies has been had recourse to.
  A strong objection  often existing with  some persons to
the use of greasy applications, lotions of the sulphuret of
potassium, or of chlorinated lime or soda, may be substituted
for  them; of the former twenty grains, and of either of the
latter a drachm to the ounce  of  distilled water, should be
employed.
  With reference  to  internal  treatment  nothing more is
usually requisite than  the administration of saline or sul-
phurous cathartics, and the use of the former should never
be omitted; in very obstinate cases the combined employ-
ment of sulphur  as  an  internal  remedy and  an external
application is not alone attended  with  benefit, but often
absolutely  demanded.   Should the local inflammation run
high  in young  persons of robust constitution,  bleeding
from the arm  even may be indicated, but this is very rarely
requisite.
  In all cases of scabies constant  ablutions  with soap and
Avater constitute  an essential  part of the treatment, and
the  clothes which  had  been Avorn previously  should  be
laid aside, as from their retaining the contagious  matter,
the  disease  may  be  reproduced  after  a  cure  has  been
effected. 
v 116                    pustul-e.
                  CHAPTER  IV.

                       PUSTULE.

'  The Order Pustule  includes those cutaneous diseases
that are  characterized  by the eruption  of circumscribed,
rounded elevations of the epidermis, which contain pus, and
are situated  on an inflamed base—pustules ;  the pustules,
Avhich may be either psydracious or phlyzacious (see page
26), burst and form scabs or thick crusts, on the falling  off
of which a slight, not permanent, depression or stain is left.
Pustular  eruptions are non-contagious, attended with more
or less inflammation, usually of a sub-acute or chronic cha-
racter, and their duration may be either very short or much
prolonged.    The local  inflammatory action  by  which  a
pustule is produced  affects the deeper  structures  of the
derma as  well  as  the epidermis, in consequence of wrhich
the  sub-epidermic  effusion is  purulent, while in vesicular
eruptions the superficial layer only  of the derma being in-
flamed, the effusion is serous.   In  its early stage a pustule
can scarcely be distinguished from a papule, inasmuch as the
pus on Avhich its specific character depends does  not usually
appear at the apex until the second or third day; the puru-
lent secretion then gradually increases, distending the epi-
dermic covering more and more, until, finally,  it gives way,
when  the matter is effused on the cutaneous surface, and a
scab is formed; of.  this process an excellent example  is
afforded in the case of the pustular eruption artificially pro-
duced by the local application of tartar emetic in the form
of ointment or solution.   While undergoing these changes,
the pustule  is said,  in popular language, to  be ripening.
Some  of the  diseases included  by Willan and Bateman in
this order Avere so classed by them from an incorrect idea
of their true characters ; thus scabies, for the reasons given
in the last Chapter, is  more properly placed  among the
vesicula? ;  variola is one  of the eruptive fevers; and porrigo 
ACNE.
117  '
is not pustular in any of its stages.   Acne, included by them
in  the division which they termed Tubercula, presents the
aspects of a true pustule, according to the foregoing defini-
tion.   The group then comprehended three  forms of cuta-
neous eruptions, Acne, Impetigo, Ecthyma.

                         ACNE.

   Acne  consists in the  eruption of psydracious pustules,
with a hardened base, distinct from each other, but usually
aggregated in small  patches  on a circumscribed  inflamed
portion of the skin ;  when  they maturate, bursting and
giving exit to purulent matter, which dries into thin, brown-
ish crusts.  The pus  first appears as  a minute dot at the
apex  of each pimple, which is somewhat acuminate, then,
gradually increasing in quantity, the  pustule becomes glo-
bular, and of a straw-yellow color, its base still remaining
hard, red, and painful, and  surrounded with an  inflamed
areola.  At times  some  of the pustules, taking  on an in-
dolent action, little or no matter forms in them, when they
present the appearance  of hard, inflamed, minute tumors,
about the size of a small pea and exquisitely painful to the
touch, and are  sIoav in  disappearing.    The seat of the
inflammatory action in  acne  is  chiefly in  the  sebaceous
glands, and the disease  is not  unfrequently produced by
obstruction at their orifices causing an accumulation of the
natural secretion  and   consequent  irritation.   By  some
modern dermatologists it  has, therefore, been made to con-
stitute a distinct class of cutaneous eruptions, defined  by
Cazenave  as  consisting  in "a diseased  condition of the
follicular secretion," and by Erasmus Wilson as  "an  in-
flammation of the  sebiparous glands  and  adjacent  tissues,
with or without alteration of secretion."   Acne is a disease
chiefly of youth and  of  adult life, occurring with greater
frequency  about  the age  of puberty,  whence  its name,
derived from the Greek Avork, ax^, vigor.  The several
varieties of the eruption which have been described may, I
think, be reduced to two  forms:—
Acne simplex.
  "  rosacea. 
118
PUSTULE.
  Biett was the first to describe  a rather rare  cutaneous
eruption as  a variety of acne, terminating in acne sebacea,
in Avhich the sebaceous follicles become hypertrophied and
their  secretion diseased,  and nearly  every  dermatologist
since his time has adopted his views, and retained the name
proposed by him;  as, however, it  does not in any respect
resemble acne, except in being an affection of the sebaceous
follicles, it will be  more correctly  classed in the group  of
cutaneous eruptions, -which I propose to term Hypertrophiae.
  Acne simplex (Atlas, PI. VI. Fig. 3) is  a very frequent
disease  in young persons, especially in those  in whom  the
cutaneous capillary circulation is  active, appearing generally
in the spring  and  autumn, and  disappearing partially in
summer and completely in  winter ; it may consist in  the
eruption of only a few scattered pustules on the face, or may
occur in small patches  or pretty thickly disseminated over
a large portion of the cutaneous surface, especially affecting
those regions where the sebaceous follicles are most nume-
rous.   The  pustules, whether few or many, are  developed
individually, and do not coalesce ; each of them appears first
as a small, red, acuminated  elevation, hard, and  somewhat
painful, particularly so if the skin Avhere it  occurs is thick ;
within twenty-four or thirty-six hours the pustule, Avhich
has continued to enlarge, presents at its apex a yellowish
point, which increases for  a  day  or two, when the epidermis
gives  Avay or is ruptured, and pus, mixed  with the  curdy
sebaceous  secretion  of the  follicle Avhich may  have been
invoked in the local inflammation, is discharged ;  although
each pustule has an inflamed base,  there is no diffuse sur-
rounding redness of the skin.  Many of the pustules do not
maturate, but, remaining indolent for a feAV days, terminate
by resolution, the lymphy effusion contained  in them being
re-absorbed  ; some slight hardness and redness, however, are
left, which gradually disappear.
  In some persons, Avho are characterized for the most part
by having a coarse, greasy  skin,  the sebaceous and hair
follicles are peculiarly developed,  and secrete  copiously
the thick  curd-like matter which naturally exists in them;
individual follicles  often become obstructed  at  the orifice^
somewhat distended, and present  a black point  at their
apex;  they  then exhibit the appearance described  by some 
ACNE.
119
 dermatologists as a distinct variety of acne, under the name
 acne punctata  (Atlas, PI. VI.  Fig.  4).   The  curd-like
 matter, Avhen pressed out by the fingers, forms a round cast
 of the follicle in which it existed,  and owing to its size and
 shape, and the  black  point at its extremity where it had
 been exposed to the action of  the atmosphere, bears much
 resemblance to a small maggot, and which it  is  commonly
 believed to  be.  Although this popular notion is, it need
 scarcely be said, erroneous, Dr. Gustav Simon has discovered
 in the  natural  subaceous secretion  a  minute animalcule,
 from the 0.085th to the 0.125th of aline (German measure-
 ment) in length, and about the  0.020th of a line in breadth;
 it Avas  named by him  Acarus folliculorum, but  has more
 recently been shown by Einsicht  not to be an acarus, and
 is therefore termed by the latter Steatozoon folliculorum
 (Atlas, PI.  XVI. Fig. 3).
   The eruption in acne simplex is thus  usually composed of
 maturating and non-maturating pustules, and of enlarged
 obstructed follicles characterized by black points,—the latter
 are  constantly present on  the cutaneous  surface in some
 individuals;  it  may consist in a single  outbreak affecting a
 more or less extended surface, or it may  appear in  successive
 crops, being consequently then of  more  prolonged duration.
 No constitutional fever or other disturbance attends the dis-
 ease, even Avhen it  attacks many regions of the skin simul-
 taneously, nor  although some  pustules  may  be  attended
 with pain,  are the local symptoms troublesome, being chiefly
 annoying in consequence of their being situated on the face,
 and therefore causing a temporary disfigurement.   The du-
 ration of individual pustules, when  they run an acute course,
 is from five to eight or ten days, but when they are indolent
 or appear in successive crops, the disease may be prolonged
 for as many weeks ;  in the latter case the marks left on the
 skin are  slow in  fading away.  Appearing and disappearing
 Avith the  seasons, being developed in spring and autumn, and
 receding in summer  and winter, acne simplex becomes less
 frequent as youth changes  into puberty, and with adult life
 either ceases altogether, or becoming nearly permanent, is
 converted into the next variety to  be  described.
   The usual seat of  the simple form of  acne is on the face,
the neck, the shoulders, and the chest; it occasionally occurs 
120
PUSTULiE.
on  the  scalp, where it is  exquisitely painful, although the
pustules are  few in  number and very scattered; but it  is
very rare on the extremities.
  Acne  rosacea (Gfutta  rosacea;  Rosy-drop;  Carbuncled
face; Brandy face) (Atlas, PI. VI. Figv5) is a, disease  of
more mature  life than the preceding variety; it has espe-
cially attracted the attention of the French dermatologists,
by  many of whom it is described as a special disease under
the name of  Couperose.  The eruption*, which is invariably
seated on  the face, usually becomes chronic,  but in all its
stages is attended with more local inflammation than acne
simplex ; it generally commences in the form of a red patch
on  the skin, on which is  rapidly developed a cluster of mi-
nute pustules, or rather pimples, hard, and but little  ele-
vated ;  these  enlarge gradually, but  are sIoav to maturate,
and their base becomes harder, often painful,  and much in-
flamed.   Eventually giving way  at  their  apex,  a serous
exudation, mixed with blood, oozes forth,  which concretes
into a hard, dry scab, and  from beneath it  a small quantity
of  a curdy pus escapes in a few days after.   The hardness
at the  base of each pustule, however,  still remains, and the
rosy or crimson-violet patch of the skin, on which a varicose
condition of the superficial veins is sooner or later devel-
oped, is often persistent on the face for  months  or  even
years,  spreading gradually over the nose, cheeks, forehead,
and chin, fresh crops of  similar pustules constantly appear-
ing on it.
  When this form of acne is chronic, it assumes a  very ag-
gravated character, and from its unsightly appearance causes
great mental annoyance; the skin of those parts of the face
on which it is  situated becomes thickened and elevated, from
effusion into the subcutaneous areolar tissue, caused by the
repeated fresh attacks of  inflammation consequent on the
development of each successive crop  of pustules;  it pre-
sents a permanent roseate  hue, which is deepened on every
exciting cause,—exposure of the face to heat,  indulgence  in
the pleasures  of the table, or mental emotions ; and the  sur-
face is hypertrophied, rugose, and seamed with the cicatrices
from pustules of previous eruptions.
  In its most chronic form it  constitutes what has been
termed acne  indurata (Atlas, PI. VI. Fig. 6), but I have 
ACNE.
121
seen  this variety of the disease not unfrequently succeed
acne  simplex, and even  sometimes appear  as an indurated
and tuberculated eruption  from the first;  it might, there-
fore,  probably be made  to constitute a distinct form  of the
eruption, but it has so many features similar to those of acne
rosacea, .and so commonly occurs apparently as an advanced
stage of it, that  I  have  thought it better to describe  it  as
such.   Acne indurata is  characterized by the eruption being  -
much elevated over  the surface of the skin, which is of a
violaceous-crimson hue,  and  consists in conoidal pustules,
about the size of a pea, extremely hard and tuberculated,
and presenting minute points of suppuration at their apex.
These pustules are not very painful to the touch; they  do
not scab over, but wheneA'er they maturate and burst,  they
leave a bluish cicatrix or pit resembling that of small-pox.
Those that may be set closely together usually coalesce, and
present then the  appearance of boils, but the contained  mat-
ter is small in quantity, the aggregated bases extremely hard
and minute,  and  superficial ulcers, covered with a yellowish,
soft scab, form on their  apex.  Acne indurata, when  it  is
an advanced stage of acne rosacea, or when it occurs as an
independent disease, is invariably situated on the face, affect-
ing especially the alae of the nostrils, and  the  most promi-
nent  portions of  the cheeks ; Avhen it is consequent on  acne
simplex  it may appear on any of the regions  of  the body
mentioned as being liable to be affected by  that form of the
eruption.
   Causes.—Acne simplex being, as already  remarked,  a
cutaneous  eruption  of the period of puberty  and  of the
prime of life, appears to  be connected Avith the  full develop-
ment  of  the capillary  circulation of  the surface  of the
body, which  at these  ages usually prevails; it  is also  pro-
bably for  the same reasons most  frequently witnessed  in
individuals  of the  sanguine temperament, and  when  it
occurs in others  it  is seemingly dependent on  a naturally
enlarged condition of the sebaceous follicles, the skin being
then  usually coarse,  salloAV, greasy,  and  shining.   It  is
manifestly hereditary, and local heat, or  anything  which
may determine to the surface, is a frequent exciting cause
of the eruption in  those constitutionally predisposed to  it.
                           11 
122
PUSTULE.
Acne rosacea  is frequently connected with the state of the
uterine function  in  the  female, in many  cases  appearing
for the first  time at the turn of  life; it  also occasionally,
but  much  more  rarely,  attacks  the face of  young  girls
about the period of first menstruation;  and when it does
so, they are very liable to frequent returns of the eruption
on the least  exciting cause.   It is also a  constant accom-
paniment of  a deranged  condition of the digestive organs,
especially when  attended with constipation ; and in  many
persons is evidently caused by indulgence in the pleasures
of the table,  particularly a too free use of rich wines  or of
spirituous liquors.  Prolonged or extreme mental excite-
ment is also a frequent exciting cause of acne rosacea.   An
attack of either form maybe suddenly produced by the sup-
pression of any accustomed evacuation, such as that arising
from bleeding hemorrhoids; and they are very common at-
tendants on pregnancy.
   Diagnosis.—The various forms of acne are in general re-
cognizable  without difficulty ;  the  parts  of the  cutaneous
surface which  they affect, the conoidal shape of the pustules
with their  hardened bases, and the accompanying altered
condition of  the  sebaceous follicles, being sufficiently cha-
racteristic  of  the  disease.   Secondary syphilitic eruptions
may be confounded with acne indurata and  acne rosacea,
from which they are distinguished by their appearing  on
the extremities,  where acne  does  not occur,  at  the   same
time that they affect the face and trunk ;  by their present-
ing a tubercular rather than  a pustular character ; and by
the diseased surface being of a dull coppery color : the se-
baceous follicles, too, are unaffected.   The pustules of ec-
thyma differ from those of acne in being  larger and flatter,
scattered over the cutaneous surface generally,  especially
that of the extremities,  and  in not having  any hardened
base.  Acne indurata in some cases bears much resemblance
to lupus, but  the latter disease presents more of  a tubercu-
lar character, and is always attended with destructive  ulcer-
ation, either superficial, or attacking the  deeper structures •
in acne indurata,  also, the rich crimson hue  of the hyper-
trophied skin, with the varicose condition of the  superficial
veins, and the spots of acne punctata scattered over the sur-
rounding integument, are highly characteristic. 
ACNE.
123
   Prognosis.—Acne simplex, though readily removable by
 treatment, unless when the  pustules assume  an  indolent
 character, is very apt to return annually until after the age
 of 25 or 30, and  persons who in their youth suffer from it
 are more  liable than others to be affected in after-life with
 either of the other forms of the disease.  Both acne rosacea
 and acne  indurata are very obstinate and rebellious to treat-
 ment, in some cases seeming  for years to defy all  remedial
 measures.   None of the forms tend in any way to shorten
 life, or to injure the general health.
   Treatment.—When acne simplex  occurs  on those parts
 of the body which  are not ordinarily exposed, medical in-
 terference is scarcely needed; in persons of a sanguineous
 temperament and an active cutaneous circulation,  saline
 cathartics, more especially the saline mineral waters—as
 those  of Cheltenham, Leamington, Epsom, and Scarborough,
 in England; and of Seidlitz,  Marienbad,  Carlsbad,  and
 Pullna on the Continent—will be  used with  benefit;  or,
 should the disease return in a  very active form every spring,
 a  general bleeding,  practised  just before the period of the
 expected  appearance of the eruption, will, in strong young
 persons  of either  sex,  sometimes  prevent its  outbreak.
 When pustules of acne simplex form on the  face,  the sooner
 they are opened, and the curdy matter they contain pressed
 out of them, the more rapidly they  disappear.   In persons
 predisposed  to the  disease, the  best preventive  treatment
 consists in the use of carbonate of  soda—twenty grains to
 the  quart of soft  water—instead of  soap to wash the face,
 and in the application of a spirituous lotion, consisting of
 tAVO drachms of oil  of lemon and half a  drachm of oil of
 rosemary  in a pint of rectified spirit, immediately after the
 face is Avashed.   In  cases AA'here there is much tendency to
 local inflammatory action,  this lotion should be reduced in
 strength, by diluting it with twice or four times the quantity
 of elder-flower Avater.  Should the  eruption accompany or
 appear to depend on derangement of the menstrual function,
 the treatment should be directed to restore  it to  a healthy
 condition, either by the use of evacuants or of tonics, accord-
 ing to the indications in each case.   When  acne simplex is
general over  the regions of the body Avhich  it affects, warm
baths  every  second  or  third  day, accompanied by friction 
124                    pustule.
with a flesh-brush, should there be obstruction of the seba-
ceous follicles, will be found  of much service;  in chronic
cases, when the  pustules are indolent, and there  is rather
deficient than increased cutaneous capillary circulation, the
use of  sulphurous  baths—more  particularly those of the
natural sulphurous  waters, as of Lucan, near this city, of
Harrowgate in England, of Moffat in Scotland, and of Eng-
hien, of Aix-la-Chapelle, of Bareges, and of the Pyrenees,
on the Continent—usually constitutes the most efficient plan
of treatment.  If it be possible to obtain the natural mine-
ral waters for the baths, they may be artificially prepared
by dissolving four ounces of sulphuret of potassium  in thirty
gallons of water.
  No remedial measures can possibly prove of service in the
treatment of acne rosacea until the habits by which the dis-
ease may have been occasioned are corrected, and in every
case especial attention must be paid to the avoidance of all
stimulating articles, both of food and drink, which occasion
determination of blood to the face, such as rich meats, spices,
spirituous and vinous drinks, &c, from the  use of which the
eruption is  invariably augmented, if it had not been origin-
ally produced thereby ; heated rooms,  exposure of  the face
to the fire,  continued stooping of  the head, and mental ex-
citement or anxiety, must be equally guarded against. When
acne rosacea is seen  in its early stages, or where  there is
much inflammatory action  present, the application of from
four to six  leeches  behind  the ears, twice  or three times a
week at bed-time, will be found of much  serA'ice, and at the
same time saline  cathartics should be  used daily,  preceded
by mild mercurials, if there  is any biliary  derangement.
The saline cathartic mineral Avaters are here, as in acne sim-
plex, of especial service; and of them all I have found the
Pullna water—which is now very generally imported—the
most beneficial;  it may be  given in the dose of from one to
tAvo wine-glassfuls,  mixed with an equal quantity  of tepid
water, every morning.  When they cannot be procured, one
drachm of the compound saline powder, prepared as I have
directed in my work on Medicines,1 dissolved in half a pint
of tepid water, may be substituted.  The tendency to local
1 Third edition, p. 107. 
ACNE,
125
inflammation being thus subdued, slightly stimulating appli-
cations may then be used, such as ointments of the ammonio-
chloride or of the nitrate of mercury, of  dried sulphate of
iron, of the acetate of copper, &c.;  the employment of  the
first of these will  be found  equally beneficial ;  it may be
prepared as follows :—
   R. Hydrargyri Ammonio-chloridi,  .  gr. xij.—3ss.
      Cerati Simplicis,.....     3j.
      Glycerinae,.......fl 3j-
      Olei Amygdalae Amarae,  .  .   .  m. iij.   Misce.

The ointment should be smeared thickly 0ATer the affected part
at night, and washed off in the morning with  a weak spiritu-
ous alkaline Avash, containing not more  than tAvelve grains
of the carbonate of soda to the pint  of liquid, to which from
half an ounce to an ounce  of glycerine should be added, if
the skin be hard and dry and inclined to  bleed.   In every
stage of acne rosacea the use of soaps should be carefully
eschewed,  as they are all more or less irritating; the bicar-
bonate of soda may be substituted for them, and in the case
of men who are compelled to shave, a saturated solution of
it mixed with an equal part of  olive-oil, may be used.   In
chronic Cases of the disease, preparations of iodine must be
given internally ; two grains of the iodide of potassium, dis-
solved in two ounces of the decoction of fresh elm-bark, with
the addition of a quarter of a grain of iodine Avhen the dis-
ease is very obstinate, taken at bedtime, will be found per-
haps the most efficacious form of administering this remedy.
  Should acne rosacea  prove rebellious to  these plans of
treatment, the more active local medication proposed by some
dermatologists may be tried ; such as  the  application daily
to each inflamed follicle of a small pledget of lint dipped in
a concentrated solution of sulphuret  of potassium, as pro-
posed by M. Duchesne-Duparc,1 the contact being continued
for from fifteen to twenty seconds:  of a concentrated solu-
tion  of acetate of lead  in  white wine vinegar, as  recom-
mended by M. Bretonneau;2  or of a solution of two grains
of the bicyanide of mercury in an ounce of distilled water,

           1 Nouvelle Prosopalgic: Paris, 1847, p. 69.
           2 Bulletin de Th6rapeutique, tome xxxi. p. 1285.
                           11* 
126
pustule.
washed off in a few moments after with cold water; an appli-
cation highly spoken of by Dr. Burgess.1
   When acne assumes  the indurated character which has
acquired for it that special denomination, it requires  active
treatment, both constitutionally and locally; blood may be
remoAred by cupping from the nape of the neck to the extent
of from two to four ounces once or twice a week, according
to the youth and  constitution of the patient, and daily pur-
gation by active saline  cathartics had recourse to;  unless,
Avhich rarely occurs, the disease appears in an individual of
a weak constitution, Avhen preparations  of iodine with iron
will be found more beneficial.   The best local application is
the iodide of sulphur in the form of ointment, the strength of
which may be gradually increased from fifteen grains to half
a drachm to the ounce of lard.  Alkaline washes should also
be used as in acne rosacea, and change of air, with the inter-
nal use of the sulphurous  mineral waters, will  be found of
especial  benefit.  Blistering the  face has been sometimes
had recourse to, and it is  said Avith success, in  cases of acne
indurata which had resisted all other methods  of treatment.
   Most of the lotions which are empirically  employed in
acne of the face consist of corrosive  sublimate dissolved in
bitter  almond emulsion, in  the proportion of from  one to
two grains to the  ounce;  their use  for  a short time is  not
unfrequently  attended with benefit, but if continued long
they cause the skin to become hard and scaly.

                       IMPETIGO.

   Impetigo (Crusted tetter).—This term, like so many others
applied to designate diseases of the skin, had no determinate
signification previously  to  the  time of  Willan.  It is now
understood to indicate a cutaneous affection, characterized
by the eruption of numerous psydracious pustules, occurring
singly and distinct from each other, or in groups  and con-
fluent, with but little surrounding inflammation; they matu-
rate rapidly, and  discharge a thick purulent matter,  Avhich
dries  into a serai-transparent,  greenish-yellow, irregularly
shaped, persistent,  solid crust.   From  beneath this  crust,

   1 Eruptions of the Face, Head, and Hands: London, 1849, p. 55. 
IMPETIGO.
127
when formed, purulent matter continues to be secreted, often
in considerable quantity, and the duration of the disease is
thus usually prolonged for some time; the crusts are slow in
separating, and when they at length fall off, a red mark or
stain is left on the integuments, which, hoAvever, gradually
Avears  away.   Fresh pustules  are  developed in successive
crops around the region of the skin originally affected, and
the disease thus spreads, until  it  not unfrequently involves
an  extended surface of the  body, which becomes covered
Avith the  characteristic, pellucid, soft,  greenish crust,  and
from beneath which purulent matter oozes; when the erup-
tion has existed for some time, cracks  and fissures form as
in eczema, but they do not present the red color of that dis-
ease, nor  are they accompanied by the serous exudation so
characteristic of it.  Impetigo is a highly inflammatory erup-
tion, and  may run either an  acute or chronic course :  it is
not contagious.
   M. Gendrin  has carefully described  the anatomical  cha-
racters of impetigo and its seat, having had an opportunity
of examining it after death,—an opportunity which  occurs
Avith extreme rarity, as the disease does not prove fatal, and
as inflammatory cutaneous eruptions generally disappear in
the course of mortal diseases.  The folloAving is the account
which  he  gives of the result of his observations: "At  the
parts corresponding to the eruption, the skin Avas more ad-
herent  to the  areolar tissue than  elsewhere, nevertheless,
there existed on  the external  surface  of the derma but a
slight degree of  capillary injection.  The cutaneous tissue
Avas more  dense than natural, and was of a  reddish-yelloAv
hue, but this morbid color only extended for a short  way
into the chorion.   On the edges of a section made through
the diseased skin, it could be observed that  the small,  red-
dish, closely aggregated, but  only slightly prominent granu-
lations, which were situated  beneath the crusts, were made
up of-minute grains about the size of the head of a pin, of a
liquid and greenish-yellow, cheesy-like  substance;  the  sur-
rounding  cutaneous tissue was red, and matter similar  to
that which Avas secreted by the  pustules of the eruption, and
which, by drying, formed the  crusts of the  disease, oozed
out of it Avhen  pressed betAveen the fingers."1
Traite" des Inflammations, torn. i. 
128
PUSTULE.
  The various forms of impetigo which have been described
by dermatologists may, I think, be conveniently considered
in two groups, named from  the mode of development of the
eruption.   But as it  presents certain peculiarities when it
occurs on the scalp, which require to be specially noticed, I
shall describe it under three heads:—
                  Impetigo figurata.
                    "      sparsa.
                    "      capitis.

  Impetigo figurata  (Atlas, PI. VII. Fig. 1) is so named
from the disease appearing  in patches of a circular or ovoid
shape.  It  usually sets in  with  feverish symptoms, Avhich
both precede and accompany the eruption, never  severe, but
generally well-marked, consisting in malaise, headache, loss
of appetite, and occasionally slight shivering ; in children
the symptoms amount only  to some heat of the surface, and
general uneasiness; but at times there are no premonitory
signs noticeable, when the disease usually assumes rather a
chronic character from the  first.  Small, rounded, slightly-
elevated, red patches appear on the skin of the face,—where
the disease is of most frequent occurrence,—of the trunk,
the shoulders, the  arms, the  hands, or the thighs ; and on
them psydracious pustules, closely set  together, and more or
less confluent, are rapidly developed, their appearance being
preceded by much  local  heat and  itching.  The pustules
attain their full magnitude, which rarely exceeds that of the
head  of a pin, in about forty-eight  hours, Avhen they burst
and give exit to the contained purulent matter ;  this, which
is very liquid,  dries quickly into a pale, greenish-yellow or
citrine-colored,  soft crust, of a pellucid aspect, and bearing
much  resemblance to candied  honey, so  much  so  that
Alibert,from this characteristic, named the disease melitagra.
The crust generally covers completely the original red patch;
it is very friable, and through  cracks which form from the
motion of the part  on which it may be seated, an ichorous
pus oozes;  this, drying rapidly, adds to the volume of the
first crust,  until it often  acquires a considerable  thickness,
still,  however, retaining  its  semi-transparency,  and  kept
constantly  moist  by the  discharge  from beneath.  Should
the crusts be removed or fall off, the surface on  which they 
IMPETIGO.
129
were seated is seen to be raw, inflamed, and  secreting pus,
by which they are rapidly reneAved.
  The original patches of the eruption, should there be more
than  one, may remain distinct from each other, separated
by  healthy integument during the whole progress of the
disease, but more usually those which are near become con-
fluent, the eruption spreading by the development of isolated
pustules or of successive crops on the intervening sound
skin.   The crusts in the more acute cases remain attached
to the surface  for  three or four weeks, during which time
the discharge continues; they then gradually become drier,
the secretion diminishes  in quantity, and, unless successive
crops  of pustules appear, the  disease terminates by their
becoming detached in separate  pieces as it were, a reddish-
broAvn stain being  left Avhich is slow in disappearing; and
from which for some time  an epidermic desquamation, ac-
companied   occasionally  by a  slight  serous  oozing,  takes
place,  causing the eruption,  as well remarked by Cazenave,
to resemble somewhat eczema.   Until the crusts commence
to dry up and fall off,  a constant heat and painful tingling
in the affected parts attend the disease ; these  cause children
and sometimes even adults, to tear the surface with their
nails, and thereby aggravate the malady.
  In  some cases  of impetigo  figurata the symptoms, both
local and constitutional, are of a much more severe charac-
ter than those now described.   High fever  marks the out-
break of the eruption,  which is characterized by active in-
flammation that extends to the subcutaneous  areolar tissue,
and affects a considerable surface of the integument, Avhich
is red and  much  tumefied.   In its commencement it can
scarcely be distinguished from an attack of erysipelas,—and
Avas therefore named by Willan and Bateman impetigo ery-
sipelatodes  (Atlas, PI.  VII. Fig. 3),—but on the second day
the characteristic psydracious  pustules appear  on  the in-
flamed surface, when the disease runs the course above de-
scribed, except that the local symptoms are  throughout of
much greater severity,  the discharge especially being much
more copious, and so acrid as to irritate, and cause the de-
velopment of pustules on those parts of the unaffected skin
over which  it  may flow ; there is  also more or less fever
present to the end, and its duration is very prolonged. 
130
PUSTULE.
  Impetigo  sparse (Atlas, PI. VII.  Fig. 2) differs, as its
name indicates, from the preceding form in the arrangement
of the  pustules, which are developed individually, and scat-
tered or dispersed  over the  cutaneous surface, sometimes
pretty  thickly on the  legs,  where it is of most frequent oc-
currence ; but it  may affect any part of the body, in chil-
dren being often  seen on  the ears, the face, and the neck.
When  the pustules in impetigo sparsa are numerous and
closely set together, as  usually happens on the folds of in-
tegument  in the neighborhood of the joints, although they
may not coalesce,  which they very rarely do, the intervening
skin is  inflamed,  red, and slightly tumid, hot, painful,  and
tingling.  The crusts  which form present the same appear-
ance as in impetigo figurata,  but  they are distinct on each
pustule, or cover the site of two or three, rarely more, and
are much thinner, softer,  and more  easily detached.   The
development of the eruption is attended generally with some
fever, and always with an  extreme degree of burning heat,
sometimes almost insupportable,  which remains, but in a
less degree, until  the crusts are about to fall off; then it re-
turns, if possible,  even with greater intensity, and  a second
crop of pustules is developed  in the neighborhood of and in
the intervening spaces between the  first.   This is in like
manner followed by a  third or fourth crop, and thus the dis-
ease becomes  often very chronic, when the skin is hyper-
trophied, fissured  with red cracks caused by tearing with the
nails, of a crimson tint,  and  discharging a thin, unhealthy,
bloody pus, which dries into dark greenish-broAvn crusts that
at times envelop  an  entire limb like  the bark of a tree;
when impetigo sparsa  assumes this aggravated  character it
corresponds  Avith  the  form described by Willan as  impetigo
scabida (Atlas, PI. VII.  Fig. 4).  The  duration of this
variety of the eruption  is  always much prolonged—acrid,
ichorous matter, of a heavy, disagreeable odor being secreted
from the surface  beneath the crusts, which  are  very per-
manent, and  scattered pustules  continuing to be developed
in the  neighborhood,  often without any apparent fresh at-
tack of local inflammation;  superficial ulcerations also form,
and if the limbs are the parts affected they  become more or
less oedematous.
  Impetigo of either of the forms now described is  very fre- 
IMPETIGO.
131
quent on the face of infants and young children, and becom-
ing chronic there presents these characteristics in their most
aggravated form ; the features are completely changed, and
the eruption covering them, as it were, with a mask, the
disease has been termed impetigo larvalis  (Atlas, PI. VII.
Fig. 5).
  Impetigo  capitis (Atlas, PI. VII. Fig. 6) is  only pus-
tular  disease which appears exclusively on the scalp.  Its
occurrence in children is preceded for a few days by feverish
symptoms frequently attended  with vomiting;  the surface
of the scalp is hot and painful, and the part about to be
affected  presents an  erythematous blush.  The  eruption
makes its appearance either in distinct pustules of a psydra-
cious character, scattered over the head, or in groups thickly
set on an inflamed base.  In the former case they are about
the size of small peas both in circumference and  elevation,
and are attended with but  little surrounding  inflammation.
On the second day of their appearance each pustule contains
thick, yellow matter at the summit, but  is soon matured,
when it bursts and .gives exit  to the contained pus, which
rapidly dries into a greenish-yellow scab.   This form, which
to a certain extent corresponds with impetigo sparsa, termed
by  some dermatologists  impetigo granulata, rarely assumes
a chronic character, its  continuance, when it  has lasted for
any time, being kept up by an eruption of fresh pustules on
other parts  of the scalp.   It not unfrequently passes into
the second form, Avhich  is  characterized by the  eruption
occurring in groups of pustules.  Their appearance is  at-
tended with more  decided  symptoms of  inflammation both
general  and local, and the heat  and itching are in many
cases  so severe that children tear the scalp and prevent the
disease from presenting the truly pustular character of the
first stage.   The eruption  usually commences on the fore-
head, involving at  the same time some of the hairy scalp ;
the inflamed patches vary in size and form in different cases ;
in some extending in their  longest measurement  not  more
than from half an inch to one or two inches, while in others
the greater  part of the scalp is involved from the very
commencement; in nearly every instance the skin  bordering
on the scalp is more or  less engaged in the disease, and it
often  appears at the same time  on the ears or on some part 
132
PUSTULE.
of the face.  The pustules are not  so large as when  they
occur singly;  their coats are apparently thinner, and the
pus which  they contain  is not so consistent, and is  of  a
richer yellow color.  They usually become confluent before
they  burst, and the  resulting greenish-yellow—if chronic,
greenish-broAvn—scab is consequently much more extensive.
When the  eruption has  continued for  any length of time,
large  quantities of bright yellow pus are  secreted beneath
the greenish crusts, which separate in cracks to give exit to
the matter, exhibiting beneath the highly inflamed raw sur-
face of the scalp from which the pus is  secreted.
  In  either form of impetigo the hair is  unaltered;  it is
usually matted, together  by the purulent secretion and the
scabs, but it does not fall off  or become changed in appear-
ance,  even  in the most chronic cases.
  Impetigo capitis is not contagious;  it is  met with at all
ages,  but most generally in early infancy, lasting for several
years if not properly treated ; it very rarely appears for the
first time after the age  of 9 or  10, but I have seen some
instances in Avhich the eruption occurred in advanced  life ;
in them the disease was of the form first described.
  In  the chronic stage of the eruption  small abscesses  very
frequently  form at the nape of the neck, close  to the roots
of the hair; and some  of the chain of lymphatic glands,
which lies  behind the sterno-mastoid  muscle,  become en-
larged, swollen, and tender, but they very rarely suppurate.
  Bateman described a  form of  cutaneous eruption  as  a
species of impetigo, terming it impetigo rodens, and in this
he has been followed by Biett and Rayer ;  but  the disease
is  evidently a  lupoid  ulceration  of the scalp, and as  such
will consequently.be  considered  in  the group  Cancrodes.
Two other forms of the  disease have been characterized by
M.  Devergie;, as impetigo purifluens, and impetigo pilaris ;
the former is attended with profuse purulent secretion, and
the latter affects those parts  of the skin on which the hair
grows, the  pustules being frequently developed around  indi-
vidual hairs,  which thus seem to penetrate them;  these,
however, are  merely accidental circumstances,  and neither
can be admitted as sufficient to constitute a special variety
of the eruption.  The impetigo  sycosiformis and  impetigo 
IMPETIGO.
133
lupiformis of the same dermatologist are identical, the for-
mer Avith sycosis and the latter with impetigo rodens.
   Causes.—Impetigo  is of  most frequent  occurrence in
infants and children; when it  affects  adults,  appearing
only in those who have a fine transparent skin, being there-
fore more  common in women than in men.   In old persons
it is usually seated on the  lower  extremities, especially the
thighs; in them it is  developed in  the  form of impetigo
sparsa, and assumes a very obstinate character.   The  con-
stitutional causes of the disease are  more or less connected
with  the   scrofulous diathesis,  and in  children  of  this
temperament  it commonly appears  about  the periods of
first and second dentition, its eruption being excited then by
the general perturbation of the system thereby occasioned.
Anything which produces cutaneous  capillary determination
of blood acts as a cause of  impetigo in  those predisposed
to  it;  thus its  origin may be  determined by irritants
applied to  the surface, such as washing in very hot water—
a frequent cause in infants  and children—the use of  hard
brushes or fine-tooth  combs to  the hair, stimulating soaps
and cosmeties,  and  solar  heat  or  that  from a fire—the
former accounts for the frequently witnessed recurrence of
the disease in  summer and  autumn, and the latter  for its
appearance on the loAver extremities of old persons.   Pro-
longed constipation and menstrual  irregularities are  both
frequent exciting causes of impetigo in  females.
   Diagnosis.—^Impetigo is  Avell  characterized  in  all  its
forms  by  its truly pustular  character, and by the peculiar
semi-transparent,  soft, greenish-yellow, honey-like appear-
ance of its crusts.   From eczema impetiginodes it is often
Avith difficulty diagnosed, and both diseases seem frequently
in their advanced stages to  be  precisely similar; yet the
copious ichorous exudation—so well described by the French
term,  suintement—and the  epidermic desquamation,  are
present usually in all  forms of  eczema, and in impetigo
fresh psydracious pustules  are in general being constantly
developed  in  the   neighborhood  of  the  eruption.  From
ecthyma the disease is diagnosed by the  small size  of the
pustules, those  of  ecthyma being phlyzacious, and for the
most part  scattered  singly,  or in tAVOs or threes,  over the
                          12 
134
PUSTULE.
 cutaneous surface, and the scab .resulting from them is of a
 dull broAvnish yellow color:  the  parts  usually affected  are
 also different  in  the  tAvo eruptions.   When pustules  occur
 in scabies they are of a large size, and a conoidal shape,
 but  that disease is  especially distinguished from impetigo
 by the itching  which accompanies it,  burning heat, tingling
 and  smarting, not itching, being present in the latter;  the
 detection of the acarus scabiei, of course, renders the diag-
 nosis more precise,  but  it should  be remembered that in
 some cases both diseases exist together on the same person.
 Sycosis, from its occurrence  on the face, has been at  times
 confounded  with impetigo ;  but it invariably affects that
 part on which  the beard grows  and its immediate neigh-
 borhood, is not truly pustular, and the crusts which  form
 in it are hard, dry, and of a  brown color, and, if examined
 under a microscope, exhibit the  characters of a vegetable
 parasite.
   As impetigo  is the  only pustular  eruption which specially
 affects the scalp,  it can scarcely be mistaken for any  other
 eruptive disease that  appears on this part of the cutaneous
 surface  ; the chronic  form of eczema is that with Avhich it
 is most  likely to be confounded;  in it the discharge, Avhich
 is either serous or sero-purulent, dries into brownish-yellow
 scabs, through  which  the ichorous liquid forces its way, or
 into  furfuraceous scales, while in  impetigo the purulent dis-
 charge accretes into large, greenish-yellow crusts, by which
 the whole head, and even sometimes the forehead and part
 of the face, is in many cases covered as with a mask.
   Prognosis.—The only question here to be  considered is
 the probable duration of the  disease,  as its existence,  when
 uncomplicated, does not either injure the health or endanger
 life._  In children,  although  apt to  become  chronic  and
 obstinate if neglected, it usually yields quickly to judicious
 treatment, and when situated on the scalp is, in my experi-
ence, more readily cured than any of the other eruptions
peculiar to that region, if their relative duration previously
to the employment of remedies be taken into account.  It
is in general more rebellious in adults, and when it  affects
the lower extremities in  old persons is a most troublesome
 and  obstinate  disease, the form termed scabida by Willan
not  unfrequently  lasting  for  years, notwithstanding the 
IMPETIGO.
135
 most careful treatment, at one time showing signs of amend-
 ment, but to break out with increased severity  again and
 again.   In young persons even the eruption is very apt to
 return in the summer and autumn months after it has been
 apparently cured.   At all ages the obstinacy of impetigo
 is in proportion to its previous duration.
   Treatment.—The  acute stages of impetigo  occurring in
 young persons of  robust constitution  require rather active
 antiphlogistic  treatment, the daily  use of saline  cathartics,
 and local, or even  in some cases general bleeding; the local
 abstraction of blood  should  be  by leeches  applied  in the
 neighborhood  of the  eruption, or behind the ears when it
 is situated on the face or scalp.   When the disease, hoAv-
 ever, attacks the  old  or debilitated, bleeding is very rarely
 admissible, but should it  be requisite in consequence of the
 inflammatory symptoms running high  Avith  much heat and
 tumefaction of the part affected, a few leeches only should
 be applied, and the after-bleeding from  the bites not alloAved
 to continue ;  tonics are here more  generally indicated, and
 the  use  of preparations  of iron, combined with vegetable
 tonics and saline  purgatives, as somewhat in the following
 form, Avill be found highly beneficial: —
      B.  Tincturae Ferri Sesquichloridi   .   .  fl 3ss.
         Infusi Quassiae.......fl ^xviij.
         Tincturae Calumbae......fl siss.
         Magnesiae Sulphatis.....    Jij. Misce.
       "A AArine-glassful to be taken every morning."

   In children or adults of the scrofulous  diathesis, cod-liver
 oil is the  best tonic,  and if the eruption is attended with
 scrofulous enlargement of the glands of the neck, from a
 sixteenth to a fourth of a grain of  iodine may be dissolved
 in each dose of the oil, which should not exceed  a  dessert-
 spoonful three times a day for  children, or a table-spoonful
 for adults; as when given in large doses the local disease is
 apt  to be aggravated, apparently from its over-stimulating
 action on the  system.
  In the chronic stages of the eruption, the administration
of more  decidedly alterative  medicines is  requisite, and  a
mild mercurial course is often singularly efficacious, especially 
136
PUSTUL^E.
when the mercury is  combined  with iodine  and  alkalies.
With this view the green iodide  of mercury may be  given
in the following form for adults, a proportionately smaller
dose being prescribed for children :—

     B. Iodidi Hydrargyri Viridis .   .  .   .   gr. iv.
        Hydrargyri cum Creta.....gr. xij.
        Carbonatis Sodae Siccati  .   .  .   .   gr. xij.
        Pulveris Myrrhae.......gr. vj.
   Mucilaginis, quantum sufficit, ut fiant pilulae duodecim.
          " One to be taken three times daily."

   In the more  obstinate cases, some  practitioners recom-
mend  the employment of sulphurous  preparations,  espe-
cially in the form of the sulphur mineral AYaters ; and others
have recourse  to the use of arsenic ; of the latter, the pre-
parations most suited for this  disease are the arseniates of
ammonia and of soda, the  dose of either is from the tAven-
tieth to the tenth of a grain; they may be given in decoction
of dulcamara.
   In  the impetigo of infants and  of very  young children,
but little constitutional treatment is necessary : for infants
at the  breast, should  the  eruption  exhibit a tendency to
assume a chronic character, it will be advisable  to change
the nurse ; and when  the disease appears at the periods of
dentition, the  gums should be freely lanced.  The state of
the digestive organs must  in all cases be strictly attended
to, and mild purgatives, combined with alkalies,  adminis-
tered according to circumstances.  The alkaline treatment
is  at this age of especial service: for children of a full habit
of body the bicarbonate of soda may be prescribed in doses
of from three  to five  grains, three times  daily, in half  a
drachm of syrup of orange-peel and two drachms of orange-
flower water, and for those of a weak or  debilitated con-
stitution, from one to  three  grains  of the bicarbonate of
ammonia in the  same  menstruum.   Should  diarrhoea, or
symptoms of any derangement of the brain accompany the
eruption of impetigo, we should be most careful not to check
the disease  too suddenly, more  especially if  it is attended
with much discharge. 
IMPETIGO.
137
   The local treatment of  impetigo is of even  more import-
 ance than  the  constitutional, for upon its judicious appli-
 cation,  in  the  first  instance, most frequently depends  the
 duration of the disease.   It is especially necessary to keep
 constantly in view that the  eruption is of an  inflammatory
 nature, and that even in its most chronic stages a fresh out-
 break of inflammation, attended with the development of a
 new  crop  of pustules, may  be readily excited.   The very
 production of the disease in so many cases by  the direct in-
 fluence of irritants sufficiently proves this, and should warn
 against the use of irritating  applications, which have been
 often too  indiscriminately  recommended.  In  the acute
 stages,  no  matter on  Avhat  part of the cutaneous surface
 the eruption may occur, alkaline ointments are of especial
 service; and should  there be  much local tingling and irri-
 tation, chloroform will be beneficially combined  with them, as
 in the following form :—
      B. Sodae Bicarbonatis,.....gr. xx.
        Adipis praeparati,.....     3j.
        Chloroformi,.......m. iv. Misce.

   This  ointment should be smeared pretty thickly over the
 pustules night and  morning, the surface  having been pre-
 viously washed with  equal parts of new milk and tepid Avater.
 To allay the irritation, unguents and washes,  containing
 various preparations of lead, of oxide of zine, and  of prussic
 acid, are  recommended by different  dermatologists, but I
 have  found none of them so useful as the above.   Owing to
 the moisture from the purulent  discharge which  is so con-
 stantly present in impetigo, the addition of glycerine to the
 local  applications, so far from  being  attended  with benefit,
 usually  proves injurious.
  In  the chronic forms of  the  eruption, the crusts or scabs
 should be always removed carefully before the  use of medi-
 cated applications; this is  done most effectually by the em-
 ployment of linseed-meal poultices,—wet with the Aveak lead-
 wash  (see page  74) Avhen any tendency to local inflammation
is  present,—changed tAvice in  the tAventy-four hours;  the
parts being sponged with a warmed solution of half-a-drachm
of carbonate of soda in a pint of distilled Avater each time
                          12* 
138
PUSTULE.
the poultice is changed.   The alkaline ointment above de-
scribed  may then be  used; or, should the disease be very
chronic, an ointment  of the dried sulphate of iron, in the
proportion of from two to five grains to the ounce of cerate,
employed; this  preparation even occasionally proves too
stimulant, when  the acetate of zinc cerate should  be em-
ployed instead of it.   In  some  cases of impetigo  greasy
applications are found to aggravate the local symptoms, and
then lotions should be substituted for them, such as twelve
grains of the acetate of  zinc, or six grains of the acetate of
lead,  or four grains of either the  sulphate of copper or the
sulphate of iron, dissolved in eight fluid ounces  of elder-
flower or of rose-water.
  To the use of more active local stimulants, as ointments,
baths or washes of the sulphuret of potassium, of tar, of
anthrakokali,  of fuligokali, of the huile de cade, or of caus-
tics, as  the nitrate of silver, my experience is decidedly op-
posed ;  as I have generally seen their  application  excite an
outbreak of inflammation, and the consequent spread of the
disease by the development of additional pustules.
  When impetigo affects the scalp, the hair should always
be carefully cut close, and the crusts removed by the appli-
cation of poultices and the use of alkaline washes, as above
directed ;  afterwards the ointment of the bicarbonate of soda,
and a lotion of milk and tepid water, will be employed with
benefit; the green iodide of mercury, with the hydrargyrum
cum creta, and the dried carbonate of soda, should be given
internally.  This plan of treatment seldom fails to cure the
disease, even in the most  chronic forms, in from six weeks
to three months, provided there  is a  careful attendant to
carry out strictly the employment of  the  local remedies.
In  any case the hair should not be permitted  to groAV  for
some time after all traces of the eruption have disappeared.
  Dietetic and hygienic regulations are of much importance
in  the  treatment of  impetigo, particularly  of its  chronic
forms ; all heating and stimulating articles of food ought to
be strictly prohibited, and everything which could cause  de-
termination of blood to the surface of the body carefully
avoided.  In  children,  the use of a purely milk  and fari-
naceous diet will be found to expedite the cure much. 
ECTHYMA.
139
                       ECTHYMA.

  Ecthyma  (Papulous  scall)  consists in  the eruption  of
phlyzacious pustules, on a hardened, more  or less inflamed
base,  usually  isolated, but  occasionally in small patches,
terminating in yellowish-brown scabs  or  crusts—in very
chronic cases, of a livid hue—which, as they  fall off, leave
small ulcers  that  heal with  superficial cicatrices.   When
this cutaneous disease  attacks the young and  the robust, it
is of an inflammatory character, but  in the old and  debili-
tated it assumes from the first an  asthenic type :  in both it
is  non-contagious.  In children it  is rarely met  with, still
more  rarely in infants, occurring most frequently in old per-
sons and in adults.  The  pustules may appear on any part
of the cutaneous surface, but they chiefly affect the extre-
mities,  especially  the  thighs ;  they appear Avith the next
degree of frequency on the skin of the trunk of the body or
on the neck,  being but seldom witnessed on the face  or the
hairy scalp.
   The division of ecthyma into  varieties, as made by Willan,
and  those  dermatologists who  have adopted  his  views, de-
pended either upon the age of the patient or upon accidental
phenomena, having their  origin in the constitution  of the
individual  attacked.  This being manifestly a bad founda-
tion  for a classification,  though  one not  uncommonly fol-
lowed as regards cutaneous eruptions, is now almost univer-
sally  abandoned, and but twTo forms of the disease  are de-
scribed by most modern writers :  these  I shall adopt: —
                   Ecthyma  acutum.
                       "    chronicum.

   The eruption of Acute ecthyma (Atlas,  PI. VIII.  Fig. 1)
is  preceded by some  degree of fever, usually very  slight,
amounting merely to heat of the surface, thirst, and head-
ache ; in about thirty-six hours afterwards, small, rounded,
slightly elevated red spots appear on the skin, generally of
one or both of the lower extremities, their appearance being
preceded and accompanied by heat and sharp tingling of the
parts about to be  affected, the  constitutional  symptoms at
the same time subsiding.  These spots, which are  nearly the 
140
PUSTUL2E.
size  of a large pea, and few in number, are scattered^ over
the cutaneous surface distinct from each  other, the  inter-
vening skin being healthy; on the second day of  their de-
velopment the centres are raised by purulent effusion, which,
increasing rapidly, covers within twelve hours the  entire of
each inflamed spot, thus forming the characteristic phlyza-
cious pustule  of the disease,  surrounded  by a narrow, in-
flamed areola, and situated on a hardened base ; occasionally
two or three of the pustules, from being developed close to
each other become confluent, and not  unfrequently  a feAV
psydracious pustules  form in the neighborhood, being evi-
dently produced by an intensity of the  local inflammation.
This stage of  the eruption is attended almost invariably
with severe lancinating pain and a burning  sensation, both
of Avhich are much diminished, sometimes  cease completely,
on the maturation of the pustules.   The  maturation  takes
place from the fourth to the sixth day, the epidermic cover-
ing giving wray and the  contained  pus  being effused; a
brownish-yellow crust or seab, occupying the site of the pus-
tule, then  forms rapidly, and if it be removed,  a cup-shaped
ulcer, Avith hard  edges, will  be  brought  into view.   The
scabs, if not interfered with, fall off sometimes in a few days,
but they often do not separate for tAvo or three weeks, and
a small  depression, like the pit resulting from small-pox,
marks the  site of each pustule.   It  occasionally happens
that purulent matter does not form in some of the red  spots,
and  they  terminate  in resolution,  a reddish-brown  stain,
accompanied by epidermic desquamation, remaining for some
time afterwards.
   The acute form of the disease thus terminates usually in
from a fortnight to three weeks, but  its duration is not un-
frequently prolonged for  fi>e or  six weeks by the  develop-
ment of successive crops of pustules, each crop running an
independent  course.   The  usual  seat of  this form of the
eruption, as already  remarked, is on  the lower extremities,
but it also appears on  the shoulders, the chest, the  neck,
the arms, and the palms of the  hands, and in a few rare
cases on the face and scalp.
   Ecthyma chronicum  (Atlas, PI.  VIII. Fig. 2) is a not
uncommon  eruptive  disease in debilitated constitutions at
every age, occurring  much more  frequently than the  acute 
ECTHYMA.
141
form ;  it  often attacks unhealthy infants  and young chil-
dren, and from its frequency at the very early periods of
life, it Avas described by Willan as then constituting a dis-
tinct variety, and termed by him ecthyma infantile.   The
eruption appears  as  in the acute form, but there are no pre-
ceding  or  accompanying febrile symptoms, and the local
suffering is much less—diminished,  not increased, vital ac-
tion characterizing it.  The pustules are generally diffused
over the surface,  being rarely confined to any special region,
and occur isolated, or in patches of  two or three ;  they ex-
hibit  a very indolent progress, maturate slowly, and form
hard, dry, brownish crusts, which either adhere firmly, or,
falling  off in a  few days,  leave a superficially excavated
unhealthy ulcer, that discharges a bloody purulent secretion.
The matter  by which some or all of the pustules are dis-
tended  in old persons is often sanguinolent,  and the subcu-
taneous areolar tissue infiltrated so as to constitute a promi-
nent, hardened base, of a lurid  or  dingy-violet aspect, to
each pustule ; these characters  induced Willan to regard
the eruption then as a distinct variety, and to name  it ec-
thyma  luridum.   The chronic character of the disease, as
regards duration, is due  to  the  continued  development, in
constant succession, of the pustules, until at length the in-
teguments of almost the entire  body  are involved  in  the
eruption;  the cutaneous surface then  presents a most  un-
healthy aspect, large portions of it being covered with phly-
zacious pustules in their various stages of development, hard,
dark-brown scabs, superficial ulcers discharging unhealthy
matter, and livid stains, the marks of spots that had healed,.
The constitution  noAV, in most cases,  sympathizes; in  old
persons extreme  debility occurs, and dropsical effusions take
place ;  and the disease in  this,  its  most aggravated form,
well deserves the name applied  to  it by Willan—ecthyma
cachecticum.
   Ecthyma chronicum lasts generally for four, five, or six
months, or even  longer, being  often complicated in its ad-
vanced  stages with  prurigo, scabies, or chronic lichen, and
being a frequent attendant on chronic organic  diseases in
old persons ; although it spreads to all parts of the cutaneous
surface, it is most thickly disseminated over the limbs, and
least so on the face or scalp. 
142
PUSTULE.
  Either form may appear at any age, but the acute is most
common in adults, the chronic affecting chiefly the very
young and the aged ; it attacks both sexes, but after the  age
of puberty males are more liable to the disease than females.
  The causes of ecthyma are both constitutional and topical.
The former are usually what may be termed hygienic  and
dietetic; thus residents in damp, ill-ventilated habitations,
insufficient clothing, wrant  of  due  attention  to cleanliness,
unwholesome food, habits of dissipation, &c, produce a state
of the system in which the disease is  often developed ;  and
the direct  action of substances which irritate the skin con-
stitute the latter.   Its  association  with  chronic  visceral
disease has been noticed above; it  is also a not uncommon
sequela of acute febrile diseases, more particularly typhus
fever  and dysentery.
  Diagnosis.—Ecthyma is in general readily recognizable by
the phlyzacious character of the pustules,  and the isolated
manner in which  they are developed.   It might be  con-
founded with either acne or impetigo,  but the characters by
which it is distinguished from these  eruptions  have been
already described when treating of them.  The smaller-sized
pustules bear some resemblance to those of modified small-
pox, but the  mode of eruption of that disease, its  appear-
ance first on  the face and upper part of the body, and the
accompanying fever, are sufficiently diagnostic marks.   The
pustules  of secondary  syphilis are,  in  many cases, very
similar  to  those of ecthyma, and  are with much difficulty
diagnosed from  the  lurid form of the disease;  the latter,
however, occurs seldom except in very old persons, and the
presence of the usual concomitant affections of the throat
and of the bones  in  secondary syphilis, together with  the
antecedent history of the case, marks the  cutaneous affec-
tions  produced by  the venereal poison.
  Prognosis.—When uncomplicated, ecthyma is not a disease
dangerous to life, the chronic form of the eruption is ahvays
of prolonged duration, and  by its continuance the general
health is invariably more or less injured.
  Treatment.—In the acute stages of this  eruption any in-
flammatory symptoms that may exist  should be subdued by
the use of diluents and diaphoretics ; minute doses of tartar
emetic dissolved in whey, in the proportion of half-a-grain 
ECTHYMA.
143
to the pint, will  be found a useful form, and the solution
may be made to constitute the ordinary drink of the patient;
or the water of the acetate of ammonia may be given in de-
coction of barley sAveetened with  sugar, and  flavored  with
lemon-juice.   The  state  of the bowels requires careful at-
tention, and the secretions, if unhealthy, should be regulated
by the administration  of mild  mercurial purgatives, com-
bined Avith the extract  of taraxacum and of colchicum, but
active  purgation is contra-indicated.   The  only topical
remedy requisite  is the  tepid bath,  and from half-a-pound to
a pound of gelatine  should be dissolved in each bath if there
is much local  irritation; occasionally, in persons of a full
habit of body, a  few leeches will be applied with  benefit in
the neighborhood of the eruption.
   The  first requisite in  the treatment of chronic ecthyma
is to remove those causes by Avhich the state of the system
with which it is so frequently connected has been produced.
In  infants, the nurse should  if possible  be changed, or, if
this cannot  be done, the child ought to be weaned, and fed
chiefly on asses' or goats' milk,  mild  alteratives, as the hy-
drargyrum cum creta, combined with myrrh and dried car-
bonate of soda, given, and the body  warmly clad, but woollen
clothing, as being apt  to irritate, should not be worn next
the skin.   The best local application  is calamine  ointment,
or  the  affected parts may be dusted with  finely-powdered
lapis  calaminaris; emollient cataplasms or lotions  generally
aggravate the disease.   When the  eruption appears  in old
persons, the first  and most important point is to change the
air, or  at least the  locality in which the patient may have
been  residing: good and nourishing  food should  be  given,
and if there  is  much   debility, wine or  porter  allowed.
Should there exist any  visceral  organic disease, the line of
treatment must be  directed principally  to its  alleviation if
possible, and topical applications employed with caution, as
the sudden  repulsion of the  eruption would  be likely not
alone  £o  aggravate  it, but  might be  dangerous to  life.
Tonics, combined with alkalies and sedatives,  as in the fol-
lowing form, Avill  in  general be found useful:— 
144
PUSTULE.
       B.  Infusi Cinchonae,.........fl 3vj.
           Aquae Calcis,  ..........fl lixss.
           Tincturae Lupulinae,
           Succi Conii,.........aa, fl 5ij- Misce.
     "A wine-glassful to be taken three times a day."

  When, however, there is  much debility present, alkalies
should not  be given, but the mineral acids, either the nitric
or hydrochloric, will then be  advantageously prescribed in
combination with vegetable tonics;  in the lurid form of  the
eruption, preparations of iron, more particularly  the  com-
pound for aromatic iron mixture, generally prove most effica-
cious.  For local applications many astringent  and mildly
stimulating ointments may be employed ; a form that I have
seen productive of excellent effect consists in the addition of
half a drachm of oil of turpentine  to  the compound  lead-
cerate.   This should be warmed and applied in the semi-
fluid  state, being gently smeared over  the  surface with a
feather.  The ulcers Avhich form may be touched daily with
the solution of nitrate of silver—a scruple to the  ounce, or
dressed with lotions of sulphate of copper or sulphate of iron
—from two to five grains to the ounce of distilled  water.
  In all forms of ecthyma the patient should be kept in  the
open air as much as possible, if extreme debility or  accom-
panying organic disease does not prevent it.  During con-
valescence,  exposure to the sea air, and the  use  of  the
chalybeate  mineral water for adults, will be found of especial
service in promoting the restoration of health, and prevent-
ing a relapse;  and for scrofulous children, the employment
of cod-liver oil should not be omitted. 
PAPULA.                    145
                   CHAPTER V.

                        PAPULAE.

   This group of cutaneous diseases is characterized by *he
eruption of minute solid elevations of the skin,—papulae or
pimples,—generally reddish, but sometimes of the natural
color of the part or even paler, which contain neither serum
nor pus, terminate in the desquamation  of fine  scales, and
are almost invariably attended Avith intolerable itching.  The
latter symptom is  so markedly a characteristic  of papular
eruptions that it has induced Cazenave to place them in a sub-
division of his sixth group, the  definition of which that he
gives being "general or local hyperaesthesia." By Erasmus
Wilson they are made to  constitute  a group, "styled de-
positive inflammation of the derma ;" but inasmuch as some
forms of papular diseases are not in any of their stages ac-
companied or  marked by inflammatory action,  and their
treatment is based on indications  directly opposed to the
idea of inflammation having any share in their production,
his definition is not, I think, sufficiently precise for a natural
system of classification.
   Papular eruptions are non-contagious, occur  at all ages
and in  both  sexes, and affect males more frequently  than
females.  The papulae, which are  either disseminated and
distinct from each other, or aggregated  in patches so as to
form groups, may appear  on a  single region of  the body
only, or may be diffused generally over the skin ; they  vary
in size from that of the head of a small pin to that of a pea,
and are usually developed  rapidly, generally coming out in
successive crops.  They terminate in  resolution,  with des-
quamation of the epidermis  in  fine minute  scales, which
continues for some time ; but occasionally superficial ulcera-
tion of the integuments occurs.
   By most dermatologists three forms of cutaneous diseases,
characterized by papular eruptions, are described as origi-
nally arranged by Willan,  namely, Lichen, Strophulus, and
Prurigo;  but the first two are manifestly merely varieties
                           13 
146
PAPUL.E.
of the same  affection, their characteristic phenomena  are
precisely similar, and the only difference betAveen  them is
that the  former  occurs  in infancy and  childhood, and  the
latter at a more advanced age ; I shall, therefore, follow the
example of Bayer, Gibert, Cazenave, &c, and  speaking of
strophulus  as a species of  lichen,  reduce the  number of
papular diseases to tAvo, namely, Lichen  and  Prurigo.

                        LICHEN. .

  LicnEX—including strophulus—may be defined to consist
in the development of numerous minute papulae of the color
of the skin or of a reddish  hue, aggregated  in  patches or
disseminated over the cutaneous surface, attended with heat,
tingling, or even severe itching, and terminating in super-
ficial  ulceration  or  in epidermic desquamation.  A  great
number of forms, both  of lichen and of strophulus, have
been described by Willan and other Avriters  on diseases of
the skin, and named by them either from the shape,  as re-
gards distribution, which the  eruption assumes, from  the
color of the papulae,  from some of the attendant symptoms,
from the particular  structure of the portion  of  the integu-
ment, anatomically  considered, that may be affected,  and
from the mildness or severity of the  disease.  Thus  there
have been constituted no less than nine varieties of lichen,
and  five of strophulus ; they may,  hoAvever,  I consider, be
all conveniently  considered in three divisions:—
                    Lichen simplex.
                       "    strophulus.
                       "    agrius.

  Lichen simplex (Atlas,  PI. VIII. Fig. 3) is at its  out-
break very rarely attended with any constitutional disturb-
ance, in some cases  slight febrile symptoms  for a feAv days
precede the eruption, especially in females, but they seldom
amount to more than a feeling of malaise, which disappears
immediately on the development of the papulae.   These are
minute, very numerous,  not  exceeding in size rape-seed, of
a bright red color, and irregularly  scattered  in  patches
closely set together over the cutaneous surface ; they usually 
LICHEN.
147
 appear first on the upper extremities, and extend thence to
 the trunk and loAver extremities, being preceded by formica-
 tion  of the  part  on which they are about to occur.   The
 eruption  is attended  with  heat and sharp tingling, which
 lasts until all trace  of the papulae has disappeared; in some
 cases, especially in young  plethoric persons, the local in-
 flammation runs high, when  the whole of the integuments
 of the affected parts present  a  bright scarlet color, accom-
 panied by  a sense  of tension  and  an  extreme  degree  of
 itching.  Lichen  simplex may  be either  acute or chronic ;
 in the former case the duration  of the disease is for about a
 fortnight, the individual papulae  are resolved in seven  or
 eight  days,  but as  from forty-eight  to  seventy-two hours
 elapse between their development on the different regions of
 the  body which they attack,  it  is  prolonged for  this  time.
 In the  chronic form successive crops of  papulae make  their
 appearance as quickly as those which preceded  them fade
 away, and thus the disease may be continued for months,  or
 even years.  The papulae in either case run the same course,
 attaining their greatest size on the third day, at Avhich time
 they are  markedly  acuminate ;  they then seem  to remain
 stationary for tAvo or three days more, when they fade some-
 Avhat, are less prominent, and  a  minute scale appears on the
 apex of each ; this  desquamates, and a  general epidermic
 desquamation from  the affected surface continues for three
 or four days in the acute, and  for a longer  period in the
 more chronic cases.   In the  latter, the  skin after a short
 time becomes thickened, evidently from depositiAre inflamma-
 tion, and  the diseased integument is then  elevated above the
 level of the surrounding skin.
   In lichen simplex the papulae differ in size according to
 the region of the  body  on Avhich they  may occur, being
 always larger on those parts  where  the  skin is softest, as
 on the face,  the shoulders, and  the  anterior surface of the
 trunk.  In the debilitated, in  the  aged, and in those whose
 skin  is naturally of a dark or unhealthy aspect, the eruption
 is usually of a dull,  livid  hue, and  in the former is not un-
frequently complicated with crimson blotches, or  stains of
the integument; this form was  distinctly described by Willan
under the appellation of lichen lividus.  In another variety, 
148
PAPULJE.
which  occurs  usually in  persons  of  dissipated habits,  as
noticed by this dermatologist, each papula in  its origin en-
velops  a hair, so that when arrived at its full  maturation it
presents a singular appearance, seeming to be pierced there-
by ; he consequently termed the eruption, under the circum-
stances, lichen pilaris ; it is anvays a very obstinate  form,
assuming from the first a chronic character.
  Occasionally in lichen  simplex  the papulae, instead  of
being dispersed over  the  cutaneous surface, are developed
in regularly-shaped patches;  when these are circular or oval
the circumference is constituted of much larger papulae than
the centre, so that a distinct border to each patch is thereby
formed ; this variety has been termed lichen circumscriptus
(Atlas, PI.  VIII. Fig. 4); it is of a chronic character ; the
rings enlarge somewhat by the eruption of new papulae  at
their circumference, but its duration is rather  prolonged  by
the development  of successive patches  in their neighbor-
hood, as those which first appeared commence to fade.   The
usual seat of lichen circumscriptus  is on the  backs of the
hands, the fore-arms, the cheeks, and the trunk of the  body;
when but  one  patch of it exists at  a time on the surface, it
has been termed lichen solitarius (Atlas, PI. VIII. Fig.  5).
In a few rare  cases, as first  noticed by Biett, the  eruption
of papulae assumes the appearance, as it were, of a piece of
ribbon stretched on the skin, generally commencing on the
chest,  and passing around the arm ; he named this form,
lichen gyratus  (Atlas, PI. VIII. Fig. 6).  I  do not knoAV
that it has been observed  by any British or German  physi-
cian, but it  is noticed as having been witnessed by several
French dermatologists.
   In children and young persons,  especially of the female
sex, the itching is at times most  extreme, and the papulae
are of a much larger size than usual;  they are, moreover,
occasionally to a  certain degree evanescent—thus in most of
their phenomena resembling urticaria, and the eruption, too,
appears, as in that  disease,  in small patches.  It is, how-
ever, distinctly papular,  and  has  been well  denominated
lichen urticatus.   It usually occurs on the neck and side of
the face, spreading in a few cases to the chest  and abdomen;
is of an acute  character, seldom lasting  longer than a few 
LICHEN.
149
 weeks, and is in general witnessed only in spring and sum-
 mer.
   Lichen  strophulus (G-um).—This is a papular eruption
 peculiar to the early periods  of life, being rarely seen ex-
 cept in infants at  the breast, and occurring most frequently
 a  feAv days after birth.   The papulae are of the natural
 color of the skin, of a reddish or crimson hue, or  white ;
 they appear most  frequently on the face and upper extrem-
 ities,  but they also in some  cases  affect the  body and the
 loAver  extremities.   In one form,  which has been termed
 strophulus  intertinctus (Atlas, PI. IX. Fig. 1), popularly
 knoAvn  as  red gum, an eruption of very minute red papulae
 appears, generally a feAv days after birth, on the face and
 the backs of the hands and arms; they are scattered over
 the surface, and intermingled with them are small erythema-
 tous patches ;  for  two or three  days their color becomes
 more vivid, they then gradually fade away and disappear in
 from a week to ten days, with some slight epidermic desqua-
 mation.  Smart itching Avould seem to  accompany the erup-
 tion from the uneasiness the infant exhibits.
   When lichen strophulus appears on the skin  at the time
 the child is commencing to suffer  from the irritation atten-
 dant on  teething, the papulae, being still of a red color, are
 much smaller and  of a duller hue than in the last-described
 variety,  but more  numerous, and  aggregated together  in
 semi-confluent  patches  on the face, the  chest, the  upper
 extremities, and often also on the  abdomen and legs.   The
 eruption is then denominated strophulus confertus, and popu-
 larly known as tooth-rash; it runs a someAvhat similar course,
 though a little more prolonged than strophulus intertinctus,
 and not  unfrequently, more  especially if the child  suffers
 much from teething, a fresh outbreak of the rash takes place
 as the first is  fading aAvay.   In some cases, the local and
 constitutional inflammatory symptoms are tolerably intense,
 Avhen  the patches of papulae are of a bright red  color, and
less disseminated,  occurring in clusters, of not  more  than
from five to ten or twelve, developed successively on various
regions of the body, as they fade  from one, appearing on
another.  This variety of the disease, Avhich is rather uncom-
                          13* 
150
PAPULAE.
mon, has been termed strophulus volaticus—wild-fire rash;
it is often of tolerably long duration.
  The papulae in lichen strophulus are, as has been before
mentioned, occasionally of the  color of1 the skin, or  even
whiter, and under such  circumstances have been regarded as
characterizing a distinct variety of the disease—white gum;
of it two forms  have been noticed: one,—strophulus can-
didus (Atlas, PI. IX.  Fig. 2)—in which  the papulae are of
tolerable magnitude, not surrounded by a red areola, and
generally disseminated over the cutaneous surface, but at a
distance from  each  other;  and  the  other—strophulus albi-
dus—in which they are of small size, and occur in a few
patches, each patch having a red border ;  in the former case
they are usually distributed on the neck, the shoulders,  the
arms, and the lumbar region ; in the latter, on the face, the
neck, and the chest.  Both are  attended, apparently, with
much itching, but no constitutional disturbance, and seldom
last longer than for a few weeks.
  Lichen agrius (Atlas, PL IX. Fig. 3) is occasionally a
sequence of lichen simplex, but  more frequently presents its
peculiar phenomena from the first.  In  the  latter case its
occurrence is preceded for two or three days by smart febrile
symptoms, and a remarkable burning heat and redness of the
skin,  so much so as at times to lead to the apprehension
that scarlatina is about to  set in; the fever abates consid-
erably, or altogether subsides on the appearance of the rash,
which is developed  in the form of numerous bright red, mi-
nute, acuminated, shining papules, clustered together  on an
uncircumscribed inflamed  patch of  the  skin, often of con-
siderable extent.   The papules do  not enlarge in size,  but
become more  elevated  from lymph being effused  at their
base into the subcutaneous areolar tissue, which is in conse-
quence swollen  and hard.  An extreme degree  of painful
pruritus attends the development of  the eruption, and is con-
stantly present  during the entire of its  course,  compelling
the patient to rub and tear the skin;  the itching, which is
incessant, is much augmented by anything which  increases
the heat of the surface, especially  the warmth of  the bed,
and thus renders rest or sleep in bed almost impossible.  As
the disease advances, the papules ulcerate at their apex, and 
LICHEN.                     151
give exit to-a sanious ichor, which concretes into thin, fria-
ble, yellowish scabs: the skin becomes  more and more in-
flamed, thicker,  dry, and rugose, and eczematous vesicles
and pustules of  acne or impetigo appear, mingled with the
lichenous eruption, or, owing to the intense degree of local
inflammation, are developed on the surrounding integument.
In this extreme  form of the eruption, the skin presents an
hypertrophied aspect, is of a  dark livid color, uneven on
the surface, rugose, and fissured, and discharges a copious
serosity.
   In the  comparatively milder cases of- lichen agrius, the
eruption commences to fade about the tenth or twelfth day,
the  subcutaneous  effusion  is  absorbed, the local  irritation
diminishes,  and  the disease terminates  in from a fortnight
to three weeks with epidermic desquamation.  More usually,
however,  its duration is prolonged for six weeks or three
months, even in  cases not  at all  aggravated, and  it not
unfrequently lasts four  years,  Avith  occasional remissions
during cold weather.
   This form of lichen especially affects  certain regions of
the body, more  particularly the face, Avhere its most usual
seat is on the forehead, and the backs of the hands and
fingers (Atlas, PL IX. Fig. 4); Avhen it  occurs on the face,
the swelling of the integuments is usually much greater than
when  it attacks other regions of the body ;  the features,
presenting a tuberculated aspect, are completely altered in
expression,  and the eyes  are  sometimes almost  entirely
closed from the thickening of the upper eyelid.  On the
backs  of  the hands and fingers the eruption  is in general
attended  with much discharge, and in some cases complicates
scabies, when it causes an extreme  degree of suffering.
   Heat seems to have a peculiar influence both in producing
and aggravating lichen agrius; it is  thus not unfrequently
developed in hot summer Aveather in this country in persons
predisposed to skin  diseases;  but  it is in warm climates
that this  influence is especially Avitnessed, and the eruption
is consequently  so frequent there that it has been regarded
as constituting a distinct variety, termed lichen tropicus—
the prickly-heat of the East Indies.   The following graphic
description  of the eruption, which  is especially interesting
as embodying his  personal experience of it, is from the pen 
152
PAPULAE.
of the late Dr. James Johnson.  "Among  the primary
effects of a hot climate may be noticed the prickly-heat, a
very troublesome visitor, which feAv Europeans escape.  It
is  one of the  miseries of a tropical  life,  and a most un-
manageable one it is.   From mosquitoes, cock-roaches, ants,
and the numerous  other tribes of depredators on our per-
sonal property,  we have  some  defence by night,  and  in
general a respite by day; but this  umvelcome guest assails
us at all,  and particularly the  most  unseasonable  hours.
Many a time I have been forced  to spring from  table, and
abandon the repast which  I had scarcely touched, to writhe
about in the open air for a quarter of an hour:  and  often
have I returned to  the charge with no better success against
my ignoble opponent !   The night affords no asylum.  For
some weeks after  arriving in  India I  seldom could obtain
more than  an  hour's  sleep at  one  time before I was com-
pelled to quit my couch Avith no small precipitation,  and if
there Avere any water  at hand to sluice it over me, for the
purpose of allaying the inexpressible irritation !  But this
Avas  productive  of temporary relief only, and  what was
worse, a more  violent paroxysm frequently succeeded.  The
sensations arising from prickly-heat are perfectly indescriba-
ble, being compounded of pricking, itching, tingling, and
many other feelings for Avhich I have no appropriate  appel-
lation.  It is usually, but  not invariably,  accompanied  by
an eruption of vivid red pimples, not larger in general than
a pin's head, Avhich spread  over the  breast,  arms, thighs,
neck, and occasionally along the forehead close to the hair.
This eruption  often disappears in a great measure when  Ave
are sitting  quiet, and the skin  is cool;  but  no sooner  do  we
use any exercise that brings out a  perspiration, or SAvallow
any  warm  or  stimulating  fluid, such as tea, soup, or  Avine,
than the pimples  become elevated, so  as  to  be  distinctly
seen  and but too sensibly felt."
   Causes.—Lichen occurs at any age, but its different forms
seem to prevail at different periods  of life ;  thus,  as has
been  already  remarked, lichen strophulus is a  disease of
early infancy, very seldom appearing  after the process of
first  dentition is completed, and being most frequent for a
month after birth,  in fact few  infants then  escape it;  lichen
agrius is most usually an  eruption  of adult life and  of  old 
LICHEN.
153
age ;  and lichen simplex affects young persons and those in
the prime of life.   The  predisposing and often also the
exciting  causes of this eruption  are very  obscure;  it is
certainly witnessed most frequently in persons of a nervous
temperament, with a fine  easily irritated skin, and in Avhom
the cutaneous capillary circulation is very active, but with
deficient perspiration.   The occurrence of lichen strophulus
in infants immediately after birth  may be accounted for by
the numerous  local irritants  to which their fine,  delicate
skin is then necessarily exposed, such as the effect of sudden
changes  of temperature, of  the  water  and soap  used in
Avashing,  of the friction  employed  in drying the surface
afterwards, of the clothing, &c.   The action of local irri-
tants has  a  decided effect in  the production  of lichen at
all ages and in most cases; thus it is caused on the forehea.d
in men by the pressure of a tight hat, on the face and hands
by harsh  dry winds, and  by solar  heat or that arising from
a  very hot fire; the latter is  a not unfrequent cause of the
eruption in some trades,  such  as  blacksmiths,  furnace-men,
&c, and  on the legs by  the  friction of worsted stockings,
particularly Avhen  the veins are in a varicose condition.  In
certain occupations lichen is developed on the backs of the
hands and on the fingers—in the  same manner as  other
eruptions  are—from  the  irritation of certain substances;
thus  it is witnessed in grocers, bakers,  washerAvomen, &c,
when it is described as constituting one of the forms of the
so called grocer's, baker's, or washerwoman's itch.   In many
cases lichen seems to be connected with derangement of the
digestive  organs, and its appearance  on  the  skin in persons
Avho had long suffered from painful affections of the stomach
or  head  was noticed by Bateman  and Biett as a favorable
circumstance.  The use of stimulating drinks,  or of heating
articles of food and of spices  will, in some individuals, be
folloAved by a lichenous eruption.
   Diagnosis.—Lichen simplex is  in general easy of recog-
nition, in consequence  of its  distinctly papular character ;
the disease with which it  is most likely to be confounded is
prurigo, the  elementary character of the eruption in both
being the same; but in  the latter the papulae are larger and
more globular—their apex being rather  flattened than acu-
minate, and  they  are generally of  the  same  color as the 
154
PAPULAE.
part of the  skin  on which they appear ;  the itching, also,
which accompanies  lichen simplex is not of the same acrid,
burning nature as that which  is so characteristic of pruri-
go.  When the papulae begin  to fade and to desquamate at
their  apex,  the eruption might  be mistaken  for psoriasis
guttata, from Avhich it is distinguished  by the scales being
much  thinner, more minute  and branlike,  and  by  the
papular elevation of the surface from Avhich they separate,
as may be recognized Avith the aid  of a lens, or  felt  by
passing the  finger over the part.   From  scabies  and ecze-
ma, lichen simplex  is diagnosed by the vesicular  character
of both  these  eruptions, and  the copious discharge with
which  they are attended.  Lichen circumscriptus is liable
to be confounded Avith herpes  circinnatus, or erythema, cir-
cinnatum ; from both it is distinguished by the character of
the eruption, papulae  being never  Avitnessed in any stage of
either of- these diseases.  From urticaria, lichen urticatus is
often  with  much difficulty  diagnosed;  the  chief  distin-
guishing characters are  the  wheal like elevations with  the
paler centres, and the more decidedly evanescent nature, of
the former.
   The only  eruption with which lichen strophulus could be
confounded is prurigo, but  the age at Avhich it occurs is suf-
ficient  to distinguish it from that disease ; moreover, in those
forms of strophulus  in which  the  papulae are red they  are
darker colored than in  prurigo, and  in the white varieties
they are much paler.
   The more aggravated  cases of lichen agrius,  in their  ad-
vanced  stages, bear much resemblance to chronic  eczema
rubrum, and are often with difficulty diagnosed from it ; but
careful  examination will scarcely ever fail in detecting  the
papular character of the former; in it, too, the integuments
are more SAVollen, thickened, and tubercular, the serous dis-
charge and  the  epidermic  desquamation  considerably less,
while the  itching is nore intense; the  peculiar red  cracks
and fissures  from Avhich the bloody ichor oozes are, more-
over, not  seen  as in eczema.   On the face, lichen' agrius
may be mistaken for acne  rosacea, from which  it is distin-
guished by the pustular  nature and  deep crimson or viola-
ceous hue of the latter; they also  affect different regions of
the face,  lichen being generally situated  on the forehead 
LICHEN.
155
and the sides of the cheeks  in front of  the  ears and lips,
Avhile acne rosacea occurs almost invariably on the nose and
the most prominent portions of the cheeks.  Impetigo oc-
curring on the face in adults has been confounded Avith lichen
agrius, but the  pustular character, and  greenish honey-like
scabs  of  that  eruption  sufficiently characterize  it.  This
form of lichen  is not so  liable to be mistaken  for psoriasis
as lichen simplex, the attendant serous  discharge  and the
characteristic itching marking especially the difference be-
tAveen them.
  Lichen is a very frequent  form  of  syphilitic eruption;  it
is then characterized  by the peculiar dull coppery hue  it
presents, by its being always of a chronic character, unat-
tended Avith any inflammatory  symptoms, either local or
constitutional,  by the absence generally of itching,  and by
the presence of the other secondary symptoms of the vene-
real disease, together with the history of the individual case.
In infants hereditary syphilis must be carefully distinguished
from lichen strophulus; the former rarely presents  a papu-
lar form, and it occurs in patches  or coppery stains, gene-
rally attended with a serous  or sero-purulent discharge, on
various parts of the body, but especially about the pudendal
region, and on these parts of the skin on Avhich the  hair
groAvs.
  Prognosis.—In infants and young children, the occur-
rence of lichen strophulus is quite unimportant, as it gene-
rally  runs its course in  a feAv days, being unattended  with
the least danger or injury to  health, requiring notice merely
in consequence of the accompanying itching, rendering the
little patients fretful.   In adults and old persons an eruption
of lichen,  though never attended with danger,  is extremely
troublesome, in consequence  of the local annoyance and suf-
fering by  which it is accompanied, and the tendency, more
especially of lichen agrius,  to become chronic ; like most
other cutaneous eruptions, the longer its duration has been,
the more rebellious is it  to treatment.   The disease is also
mo*re obstinate on the face or hands than Avhen it is situated
on those parts of the body that are ordinarily coArered; and
the complication of other cutaneous eruptions with it inva-
riably renders  the treatment more difficult.  In giving a
prognosis in any of the severe forms of lichen, it should be 
156
PAPULA.
remembered that relapses are very liable to occur, the least
exciting cause, such as even the heat of the sun in summer,
being sufficient to reproduce the disease.
   Treatment.—In all papular eruptions a manifest indica-
tion of treatment is derived from the hyperaesthesia of the
cutaneous structure which accompanies  them in their  acute
as well as in their  chronic stages, and this should always
influence our choice of remedies, whether tonics or antiphlo-
gistics, according to individual  circumstances, may be re-
quired.   In their  early stages, local  applications will  in
general be found sufficient to check the progress of the erup-
tion, unless when symptoms of inflammatory action are pre-
sent, but these are usually of a trifling nature and of short
duration; when, however,  they have  become chronic, the
most active constitutional alterative treatment is required,
and even under its most judicious employment they not un-
commonly baffle the physician's  art for a length  of time.
   In lichen simplex occurring in young persons  of a robust
constitution, restricted diet should be enforced  at its com-
mencement, together with rest in bed  if the  eruption is at
all extensive,  and  the  administration of  diaphoretics,  the
bowels having been previously opened by a mercurial purge,
provided  the papulae are well developed on  the  skin :  the
antimonial diaphoretics, combined with guaiacum and Dover's
powder, as in  somewhat the folloAving form, are usually pro-
ductive of more benefit than saline diaphoretics :—
      B. Antimonii Sulphureti praecipitati,   . gr. xx.
         Guaiaci Resinae, in  pulvere,  .   .   . gr. xxiv.
         Pulveris Ipecacuanhae  compositi,    . gr. xij.
   Ope mucilaginis  misce et in  pilulas duodecim divide.
           "One to be taken every sixth  hour."

   To allay  the itching and local irritation,  tepid baths of
fresh water may be  employed  daily,  and the skin having
been well dried, smeared afterwards with  olive oil, to every
ounce of which twenty minims of  chloroform  have been
added.   When the general inflammatory symptoms are sub-
dued by this treatment, if the disease exhibits any tendency
to become chronic, the compound lead-cerate with glycerine
may be applied to the surface,  and the parts sponged twice
daily with an  akaline spirituous wash. 
LICHEN.
157
  In any of the forms of lichen strophulus, medical interfer-
ence is scarcely required, and especial care should be taken
that no treatment, whether local or  constitutional,  be  em-
ployed by which the eruption might  be repelled.   If  any
derangements of the digestive organs exist, they may  require
the use of mild alteratives  or gentle mercurial purgatives,
and when the eruption occurs at the period of dentition, the
gums ought to be lanced freely.  The annoying- pruritus,
which so constantly seems to accompany strophulus, is best
allayed by the use of the tepid  fresh-water bath w4th gela-
tine, and the application of olive oil to the spots of eruption;
cold cream is also useful for this purpose,  or the acetate of
zinc cream, to every ounce of which two drops of oil of bitter
almonds have been added, may be employed in more aggra-
vated cases.
   In the early stages of lichen  agrius, while the inflamma-
tory symptoms are present, the  treatment should  be de-
cidedly antiphlogistic, but unless in strong, healthy, young
persons residing in  the country,  general bleeding  is  not
admissible, the local abstraction of blood, by means of leeches
applied in the neighborhood of  the eruption, being in most
cases sufficient.  Even  in the chronic stages of the disease,
this form of local  bleeding is in general attended with the
best results, as it relieves the congested state of the capil-
lary circulation which  is present,  but the leeches  should
never be applied on any part of the  skin which is affected,
as their bites might give  rise there  to troublesome  ulcera-
tion.  At first the irritation caused by the eruption is best alle-
viated by gelatine baths and soothing ointments or lotions;
of the former the carbonate or  acetate of lead  cerate with
chloroform, the compound lead cerate with glycerine, the
oxide or carbonate of zinc ointment,  with which oil of bitter
almonds or prussic acid has been combined, or the hemlock
ointment, will be used with benefit; of the latter, the weak
lead wash, to which glycerine has been added in the  propor-
tion of a drachm to the ounce, equal parts of camphor mix-
ture and distilled vinegar, a lotion containing a drachm of
succus conii, half a drachm of glycerine, and a grain of car-
bonate of soda to the ounce  of  elder-flower water, or alka-
line Avashes with prussic acid, as in the following form, may
be employed. 
158
papUlje.
     B.  Sodae Biboratis,.......3^.
        Aquae Rosae,........fl Sviij. _
        Acidi Hydrocyanici diluti,  .   .   .   . fl 3y- Misce.

If any connection can be traced between the appearance  on
the cutaneous surface of the  eruption  and disease of some
internal organ, or deranged function, the remedial measures
employed must be especially directed towards the alleviation
of the former, and the correction of the  latter.   With this
view saline and mercurial purgatives are generally required
in most  cases, and when debility exists, their employment
may be conjoined advantageously with chalybeates or vege-
table bitters, and the dilute mineral acids.   Lichen is  not
unfrequently associated, in old persons, with  the gouty or
rheumatic diathesis,  and in such cases, preparations  of col-
chicum, combined Avith the liquor potassae, or the carbonate
of ammonia, should  be prescribed.
  In the chronic stages of lichen agrius more active consti-
tutional treatment is usually required, while at the same
time attention is paid to any complication  that may exist.
Iodine and  arsenic,  either  separately or in  combination, in
some of the forms described in former chapters, will be found
necessary, and they  may be given with tonics or diaphoretics
according to individual  circumstances. When there is gene-
ral  debility present,  more especially an anemic condition of
the system, iodine combined with iron in the  form of the
syrup, or pills of the iodide of iron is most useful.  Tincture
of aconite is also an  excellent remedy, more especially if the
hyperaesthesia of the cutaneous surface is well marked, but
its administration must, as in all other diseases, be carefully
Avatched; there  is nothing to contraindicate its employment
at the same time with the  powerful alteratives above men-
tioned.   Sulphur and its preparations are  highly  recom-
mended by many practitioners in chronic lichen,  but I must
confess  that they have not proved so successful in my hands
as they are stated to have done with others..  It was at one
time too much  the custom to administer  sulphur in nearly
every form of cutaneous eruption, chiefly, I believe, in con-
sequence of its being evolved so manifestly by means of the
insensible perspiration; but for this very reason its use often 
PRURIGO.
159
 proves highly injurious, owing to the direct stimulant action
 it thereby exercises in diseases which are of an inflammatory
 nature, or which are liable to be aggravated  by determina-
 tion of blood to the cutaneous capillaries.
   Most of  the  local applications  already spoken of will be
 found beneficial in chronic  lichen agrius, but even in the same
 case they must  be  consequently varied, according to the se-
 verity of the local symptoms ; when all inflammatory tend-
 ency has subsided, an ointment  containing  twenty  grains
 of the iodide of sulphur to an ounce of white  wax ointment,
 to Avhich six minims of chloroform are added, will be found
 productive  of excellent effect, an  alkaline spirituous wash
 being at the same time used.


                         PRURIGO.

   Prurigo.—It is very doubtful whether this  disease should
 be termed an eruption of the  skin or not, so frequently does
 it occur without any visible  phenomena to indicate  its ex-
 istence, the only symptoms present being obstinate intense
 itching, without heat, pain, or sensible elevation of the sur-
 face.  But  as in many cases it is attended with the develop-
 ment of papulae,  it must, in an  artificial arrangement of
 skin* diseases, be  classed  with lichen.  The  papulae, when
 they do occur, are  of  a someAvhat larger  size, rounder  and
 less  acuminate than those  of lichen ;  and are of the color of
 the skin, or of a yellowish hue.   The disease is essentially
 of a chronic  nature, is not contagious, and is neither  pre-
 ceded nor accompanied by constitutional symptoms; never-
 theless, Avhen it has existed for some time, the health be-
 comes more or less deranged,  in consequence of the extreme
 suffering caused by the itching and local irritation attendant
 on it.
   Three forms of prurigo have in general been described by
 dermatologists:  Prurigo mitis, Prurigo formicans, and Pru-
 rigo  senilis ; the first two  are  distinguished from each other
 merely by the degree of severity of the symptoms, and may
 therefore  be considered together; the third, although de-
 nominated  simply from its occurrence in old  age only, yet
requires to be noticed  separately, in consequence of some of
its phenomena being  peculiar and characteristic. I  shall 
160
PAPULA.
therefore  describe the disease as consisting of two species,
terming them,—
                    Prurigo vulgaris.
                       "    senilis.

  Prurigo vulgaris '(Atlas, PL  IX.  Fig. 5), then, may be
either mild  or severe, the latter  being the more frequent.
The mild  variety is developed by the eruption on the cuta-
neous surface of scattered papulae, about the size of a millet-
seed, without the least  redness, inflammation, or  sense of
heat; they  are of the color of that part of the integument
on which  they may be seated, but little elevated, and scarcely
to be distinguished unless with the  aid of a lens, or by pass-
ing the finger over the surface.  The attendant pruritus is
not very severe, although sufficiently sharp and stinging to
cause the patient to scratch the affected parts with the nails;
the  papulae  are  thus torn, and a minute,  blackish  crust
thereby formed  on their apices,  which gives  a remarkably
characteristic appearance to the  affection.
   In the  severe variety of prurigo vulgaris the disease may
commence with  or without the eruption of papulae, but in
all cases they are usually developed in some of its stages;
Avhen they  do occur  they are  more numerous than  in the
mild form, of the same color, shape, and size, or sometimes
even larger. It is, hpwever, the remarkable cutaneous hvper-
cesthesia  and consequent intense pruritus which  especially
mark the aggravated character of the affection,  and from
Avhence it has derived its appellation—formicans, the sensa-
tions accompanying it being often compared to those pro-
duced by the sting of  an ant.   This  comparison, however,
very faintly expresses the  sufferings attendant on the dis-
ease : not a single spot of the skin in its entire extent but
is more  or  less the seat of an extreme  degree of itching,
Avhich compels the individual affected to  tear with his nails
and rub the surface all but unceasingly ; at times compara-
tive cessation of the pruritus occurs, occasionally lasting for
two or three hours, more usually of shorter duration, but it
is again exacerbated by the most trifling exciting cause, the
friction of the clothes, changes  of temperature—especially
the heat of the fire or the warmth of the bed,—mental emo- 
PRURIGO.
161
tions,  &c.   In consequence of  heat  increasing much the
local symptoms, the itching is  always  remarkably aggra-
vated at night, rest is thus completely destroyed, sleep being
rendered impossible, hour after  hour  is passed tearing the
skin, and the sufferer is  often compelled to seek relief by
lying on the floor without any covering.   In one case of ex-
treme severity which I attended, the  exacerbations and re-
missions assumed a well-marked, intermittent, semi-quotidian
type ; the itching commenced every afternoon  at about two
o'clock, and continued until six  o'clock, when it gradually
abated, and there was comparative  ease until the same hour
on the following morning ; it then returned and lasted again
for the same length of time, but the  night sufferings  were
tenfold more severe than those of the day; this intermittent
character of the pruritus had lasted, at  the time I saw the
patient, a young man of twenty-three  years of  age, for more
than two years, and his health,  both  mentally and  bodily,
was  sensibly affected from the constant suffering and loss of
sleep.
   When the disease  has lasted for any time, the cutaneous
surface is torn and fissured from the  constant scratching;
if papulae existed, their site is marked by minute, blackish
crusts or small excoriations, and the skin is thickened, un-
even, and coarse, being found, on close examination, as re-
marked by Wilson,  " raised into small,  flat elevations, caused
by the swelling of the little angular compartments between
the  linear markings."   The natural  color of the skin is
also  much altered,  its aspect being  of a dirty  brownish
yellow hue.
   The milder form of prurigo vulgaris  seldom lasts  for a
longer period than  two or three  weeks, but the duration of
the severe variety is in some cases almost indefinitely pro-
longed, recovery  rarely taking  place in a shorter time than
from four to six months.   The papulae in  both are developed
in the first instance on  the chest, the  neck, the lumbar
region,  the  shoulder, and the outside of the  thighs,  from
whence, when the disease lasts for more than a month or
two,  they spread  to  the arms and legs, but do not appear
on the face,  the scalp, or the hands, although these parts in
aggravated cases  are rarely free  from more or less pruritus.
Such of the  papulae as escape being torn  by the nails termi-
                          14* 
162
PAPULAE.
nat'e in slight furfuraceous  desquamation.  The disease is
not unfrequently complicated by the simultaneous occurrence
of scabies and eczema, and in some cases of ecthyma.
  Prurigo senilis (Atlas, PL IX. Fig. 6) occurs, as its spe-
cific name indicates,  only in  advanced  life;  the pruritus,
which is usually of remarkable intensity, is attended always
with an eruption  of papulae  ; these are of larger size than
in either of  the forms of prurigo vulgaris, but they are few
in number, more dispersed over the surface of  the body, and
of a dull dingy-yellow color ; soon torn with the nails, small
blackish crusts appear on their apices, which also constantly
bleed slightly when  irritated.   The chief peculiarity, how-
ever, in prurigo senilis is, that  it  is  almost invariably  at-
tended with the appearance  of innumerable pediculi on the
integuments  of every part  of  the body—a  complication
never absent in the poor and in persons of filthy habits.
Their presence aggravates much the other symptoms of the
disease :  the skin becomes of a livid color, thickened, rough,
with a leathery aspect, and covered with superficial excoria-
tions, and small pustules  and indolent boils form in different
regions of the body; the pediculi are  renewed nearly  as
quickly as they can be removed from the surface, which has
caused a controversy as to whether they are developed from
the integuments or not.  By some dermatologists the occur-
rence of the pediculi is  considered as  only  an accidental
circumstance, and not constituting a symptom of the disease;
by others it is regarded more correctly, I think, as an essen-
tial feature  of  the  eruption, and  they  have,  therefore, fol-
lowing Alibert, denominated the form  thus  characterized,
prurigo pedicularis.
   Many of the French school describe,  as a distinct disease
of the skin, this  development of pediculi on the cutaneous
surface of the  body, generally terming  it Phthiriasis, and
dividing it into three species, as  it may be general or partial
—Phthiriasis corporis, Phthiriasis capitis, and  Phthiriasis
pubis—considering the simultaneous  appearance of the pa-
pulae of  prurigo as only  a complication ; but  I have almost
invariably seen them occur  together in old persons, I think
it more correct to describe this singular  affection as a variety
of prurigo senilis. 
PRURIGO.
163
  Prurigo  vulgaris very frequently affects some special re-
gion of the skin from which it does not spread, but becom-
ing chronic there causes  extreme suffering, and  is  very
obstinate.  It thus attacks the scrotum, in males,  and the
pudendal region  in  females:  the  former, termed  prurigo
scroti, is a very troublesome  affection, being attended with
a constant  itching, which, instead of being relieved,  is much
aggravated by scratching with the nails,  yet the  sufferer
from it cannot resist the almost unceasing inclination which
exists to attempt  thus to alleviate the tormenting pruritus ;
the habit thence  acquired can scarcely be got rid of, and
even  long after all apparent symptoms  of  the disease  have
disappeared, the  integuments are  continually fretted and
torn.   In  females, prurigo pudendi  is situated chiefly  on
the mucous membrane of the labia, but  often extends to the
entire surface, both  cutaneous and mucous, of this region  ;
it is a most distressing and obstinate disease, and not un-
commonly  produces  symptoms analogous to  those  of nym-
phomania.   Another frequent form of  local  prurigo is pru-
rigo podicis; in  it a constant itching  of  the verge of the
anus exists, and papulae, which are often not present in the
other local forms of the disease, are here almost invariably
developed, and-sometimes attain a considerable magnitude;
occasional  intermissions of the pruritus occur, but  the least
irritation,  augmented heat of the surface, or derangement
of the digestive organs, causes an exacerbated return of this
tormenting sensation.   Other regions  of  the skin are at
times  the seat  of severe itching, and have been  described,
but without sufficient  reason, as being then affected  with
prurigo; thus dermatologists have spoken of prurigo  urethra-
ls, prurigo prseputialis, prurigo pubis,  and prurigo palma-
ris: the latter has been specially mentioned by Alibert as
affecting the soles of the  feet, of which he  states  that  he
witnessed many examples.
   Causes.—Prurigo may occur at  any  age, but is most fre-
quently seen in old  persons,  and more commonly  in males
than  females: young persons are  more liable to its attacks
than adults, and  it has been witnessed even in early  infancy.
That state of the constitution  in which cutaneous irritability
exists, as exhibited by the occurrence of troublesome ulcers
from  slight causes,  and an inaptitude, so to  say, of even 
164
PAPULA.
the most trifling abrasion to heal, peculiarly predisposes to
its  development; there  is usually in  such a condition an
impoverished blood circulating in the vessels, and  a highly
irritable nervous system.  Bad or insufficient diet, want of
care as to cleanliness, unhealthy habitations,  sedentary oc-
cupations, or confinement to the house caused by ill health,
defective clothing, dissipated habits, &c,  are both predis-
posing and exciting  causes  of  prurigo.   I  have  often
thought that in gaols and workhouses,  amongst  the  aged
inhabitants  of which  the disease is so common, and also
amongst  the poor, it  may be caused by  the sameness of
food, which, too, is  often defective in  nutritive  qualities.
Other cutaneous eruptions which  are attended with local ir-
ritation, more especially scabies and lichen, not uncommonly
are exciting causes of this affection ; and it is in old persons
a frequent  accompaniment  of convalescence from debili-
tating  diseases, particularly fever, dysentery, and chronic
diarrhoea.
  Diagnosis.—The most characteristic symptoms of prurigo
are the intense pruritus,  the blackish crusts which are pro-
duced on the papulae, and the alteration that takes place in
the  appearance of the  integuments.  The diseases  with
Avhich  it  is most likely to  be confounded are  lichen and
scabies, and the mode of diagnosing it from them has been
already noticed when describing these eruptions, but, as  has
been before remarked, they often co-exist.
  Prognosis.—Prurigo, when it becomes chronic, is one of
the most  obstinate diseases of the skin; in old persons  sel-
dom yielding to any treatment.   Although prurigo vulgaris
cannot be said to be attended with danger to life, yet it ren-
ders life  miserable, sometimes for years, and from being a
constant cause  of irritation,  may, to a certain extent,  affect
the mind, as is witnessed  in  some cases.   The  senile form
of prurigo,, although it is not in itself a mortal  affection,
nevertheless seldom disappears unless with life, and when it
occurs as a complication of some organic or chronic disease,
unquestionably hastens the fatal termination.
  As regards the pathology of prurigo, it is evidently chiefly
a hyperaesthesia of the cutaneous  structure ; the changes in
the state of skin which attend it being usually produced by
the local irritation thereby occasioned. 
PRURIGO.
165
   Treatment.—If this view of the pathology of the disease
 is correct, it is  manifest constitutional remedies are most to
 be relied upon in its treatment, nevertheless,  as  in  other
 nervous affections, topical medication should not be neglected,
 and is often attended with the best results.  The state of
 the general health should in all cases first receive attention,
 for, until this is regulated as far as practicable, the employ-
 ment of remedies more  immediately directed to the disease
 will be found useless.  With this view, mild mercurial and
 saline purgatives may be prescribed to correct the secretions
 from the  digestive organs, and when there is a deficiency of
 bile in the discharges, as  is not  unfrequently  the case  in
 adults and old persons, dried carbonate of soda and extract
 of taraxacum should be combined with the mercurials.  In
 females, the  association  of the disease with derangement of
 the menstrual  function  is often witnessed, -and  Avhen such
 exists, there is  generally an anemic state of  the system re-
 quiring the  use of preparations  of  iron, but they should
 never be prescribed except in combination with sedatives, as
 othenvise the stimulant action  is  apt to augment the pruri-
 tus ;  the  same  observation applies to the employment  of
 chalybeates in  the old  and  debilitated, for whom  they are
 also generally indicated in prurigo.   They may be advan-
 tageously combined, as in the folloAving form:—

     B. Misturae Ferri compositae,      . fl Sviij.
        Infusi  Humuli,......fl giijss.
        Succi Conii,.......fl 3ss.  Misce.
     "A table-spoonful to  be taken every sixth hour."

   Or Dover's powder may be given in rather large doses at
night, preparations of iron being administered during the
day.   In  very young persons antiphlogistics  are sometimes
needed as preludes to other remedies, but in no case should
the strength  be  much weakened, as then the  disease is more
apt to become chronic.   When  prurigo has  lasted for any
time,  or has  resisted other plans  of treatment, more active
medicines of  the class which  especially influences the nerv-
ous system should be prescribed ; nux vomica or its alkaloid,
and tincture  of aconite, thus often prove useful; the former
has succeeded in my hands when all other remedies seemed 
163
PAPULA.
to fail;  it may be given in the following form, a combina-
tion which will be found to promote a healthy condition of
the digestive organs, and to correct the  loss of tone which
they exhibit usually in this disease :—

   B. Extracti Nucis Vomicae,.....gr. iij.
      Fellis Bovini Inspissati,.....gr. vj.
      Extracti Taraxaci,.......gr. xxiv.
      Pulveris Myrrhae,.......gr. xviij.
         Misce et divide in pilulas viginti quatuor.
           "One to be taken three times daily."

The tincture of aconite should be  given  in  the ordinary
doses, from five to eight minims of the Dublin preparation,
or half that quantity of Fleming's tincture, and its  effects
carefully watched.   I have also  administered the  succus
conii, in  doses of a drachm three  times a day, in an ounce
of the camphor mixture with magnesia, with excellent effect
in some obstinate cases of senile prurigo.   Preparations of
sulphur are recommended by many in the treatment of this
disease, and in the very chronic forms the sulphurous mine-
ral waters, as those of Lucan, of Harrowgate, of the Pyre-
nees, &c, prove of unquestionable benefit.   Indeed, in all
cases, change  of  air, if possible, to  the  original sources of
mineral waters, the saline in the early stages, the chalybeate
in the more advanced, and the sulphurous when the disease
is very chronic and obstinate,  so  that they may be drank
there, is highly advisable.
   The local treatment  is now to be spoken  of:  and at first
nothing is requisite further than the daily use of the hot
fresh-water bath, to which, if the  itching is extreme, gela-
tine should be added, or alkaline  baths  may  be employed,
if the eruption is  well developed on the skin ;  as the disease
advances and becomes chronic, sulphuro-alkaline  baths—
three ounces of sulphuret of potassium, and  an  ounce of
carbonate of potash to thirty gallons of  hot water—will be
used with benefit; and in senile prurigo, especially that form
in  which  pediculi  cover the body, the surface should be
smeared half an hour before going into the bath with mer-
curial ointment diluted with three parts of prepared lard, 
PRURIGO.
167
and a drachm of glycerine added to  each ounce.   To allay
the pruritus, various lotions and ointments have been recom-
mended ; of the former, those containing the vegetable acids,
such as leinon-juice, vinegar, and cherry-laurel  water, are
especially useful; black-Avash has also  proved very service-
able when the  disease is local;  and lotions,  containing cor-
rosive  sublimate,  muriate of ammonia,  watery  extract of
opium, prussic acid, preparations of lead or of sulphur, may
be  tried when  other  applications fail.   From the use  of
chloroform in the form of ointment, as  recommended in the
Chapter on Urticaria,  I have derived most excellent results;
in fact, latterly I have seldom had occasion  to employ any
other application ;  but the substances  mentioned above, as
being used in lotions or washes, may also be applied as un-
guents, and the addition of glycerine will  generally be found
of advantage.   In very obstinate cases the chloroform may
be combined with iodide of lead, as follows :—
   B.  Iodidi  Plumbi,......gr.  xij.
      Unguenti Cerae Albae,  ....      3j.
      Chloroform!,.......m. viij. ad m. xij.
      Glycerinae,.......fl ^j.  Misce.

When  greasy  applications  are  used, alkaline tepid baths
should be employed daily to cleanse the skin, the patient
remaining in the water for at least twenty minutes.
   Strict attention to  diet and  regimen  is requisite in all
cases; stimulant food  or drink being especially avoided. 
168                    SQUAMA.
                  CHAPTER  VI.

                        SQUAMA.

  There is no class of diseases of the skin so well charac-
terized  by the  apparent phenomena  as that in which the
formation  of  a  scale constitutes the essential feature ; epi-
dermic  desquamation, as has been in  the  previous pages so
frequently noticed, is present in many cutaneous eruptions,
but that differs in many respects from the secretion and sub-
sequent shedding of true scales, which consist, according to
the admirable definition of Willan, of " a lamina of  morbid
cuticle,  hard, thickened, whitish and opaque."  Although in
some of the forms more or less  change from the primitive
characters of the eruption takes place in the  progress of the
disease, it  is  never such as to  mask their scaly nature, and
the diagnosis is consequently attended with less difficulty
than that  of most  other  cutaneous affections.  Squamous
eruptions may be defined to consist in the  secretion of  dry,
laminated whitish scales on the cutaneous surface,  usually
occurring  in patches, often of a circular form, but sometimes
generally  diffused, and covering an extended portion of the
integuments.   The  scales,  which are  somewhat elevated
above the level of the surrounding skin, readily fall off, to
be again rapidly reneAved, and the portions of the cutaneous
surface  on which they are formed are of a smooth, glistening
aspect, reddish and dry.
  Scaly diseases are essentially of a chronic, non-inflamma-
tory nature, are slowly developed, and  are not propagated
by contagion.  They may appear on  any part of the body,
but they  chiefly affect, at least  in the first  instance, the
extremities, whence they usually spread  to other regions,
being rarely  confined to a single  locality, with the excep-
tion of pityriasis, which occasionally occurs pn some special
portion  of the skin.   They are developed also at all seasons
of the year, and are not apt, like other cutaneous diseases, 
PSORIASIS.
169
influenced by the atmospheric temperature, to disappear and
again re-appear at certain times.
  The eruptions included in the order Squamae were divided
by  Willan into four groups—Lepra,  Psoriasis,  Pityriasis,
and Ichthyosis—and his arrangement  has been folloAATed by
many  modern dermatologists; recently,  however, it has
been very generally admitted that Ichthyosis was incorrectly
classed by him  amongst scaly  diseases, and doubt has been
throAvn on the  propriety of describing psoriasis and  lepra
as different forms, they being,  moreover, evidently regarded
by  the ancient medical writers as constituting merely varie-
ties of the same eruption.   Ichthyosis cannot with  any re-
gard to accuracy in classification, be grouped in this  class,
for it is not attended with a separation—throwing off scales,
or desquamation, one of the  most characteristic signs of this
order  of cutaneous  eruptions; the epidermis is in  it  truly
hypertrophied, and  I  shall therefore  describe it  as consti-
tuting one of that group of skin diseases which I have termed
Hypertrophiae.   To even a  superficial observer it  must be
evident that psoriasis and lepra have no essential differences,
and they  require  a precisely similar plan  of treatment;
regarding  them, therefore, as  distinct affections could only
tend to complicate  their studj-.   The number of scaly dis-
eases of the skin is thus reduced  to  two—Psoriasis, Pity-
riasis.

                        PSORIASIS.

   Psoriasis  (Dry  tetter;  Dry scale)—under which  term
it Avill be understood I include Lepra—is characterized  by
consisting in the formation  on the  cutaneous surface,  and
subsequent desquamation, of true scales, the scales  being
of  tolerable consistence, dry  and friable, of a silvery or
grayish whiteness,  and separating in laminae of about the
size and consistence  of particles  of bran.  The   eruption
appears in small,  round, or  irregulaly-shaped  spots, dis-
tinct from each other, scattered^ over the cutaneous surface
in large, circular  patches,  depressed in  the  centre,  or in
masses so closely aggregated and confluent as to envelop an
extended portion of the skin  in one vast coating of  scales
in  consistent layers.   The surface of the integument on
                            15 
170
SQUAMAE.
which they are situated  is raised, reddish, and apparently
inflamed, but unattended with any discharge ; nevertheless,
Avhen the  eruption has  been of  long duration, fissures  and
cracks through the deeper-seated tissues form, from which
an  ichorous, bloody secretion exudes.   Psoriasis  has been
considered by many writers on diseases of the skin to be a
special chronic inflammation of the cutaneous structures,
the specialty consisting  in  the  deA'elopment of scales;  it
cannot, hoAvever,  I think, be regarded as an inflammatory
disease, for it  is not attended with  heat  or other local sign
or symptom of inflammation, except a slight  degree of itch-
ing, unless when  the  affected surface is irritated by some
cause.
  The eruption appears in the form of minute, slightly-ele-
vated papulae, with  a small scale apparent  at the apex of
each on careful examination, and,  no  matter what  pheno-
mena it may afterwards present, this is  its primary aspect;
coming on slowly, it runs generally a most  tedious course,
often lasting for many years, and sometimes even for a long
life.  The several varieties of both psoriasis and lepra Avhich
have been described may be conveniently reduced to three:—

                   Psoriasis guttata.
                       "    aggregata.
                       "    lepraeformis.

  Psoriasis guttata (Atlas, PL X.  Fig. 1).—This, which  is
the mildest form of the disease, is unattended in  any of its •
stages with  constitutional symptoms; a slight  degree of
itching of the skin occasionally precedes its appearance, but
even this is not a constant sign.  Numerous minute, papular
elevations of the epidermis, at first not exceeding in size the
point of a pin, are developed on the cutaneous surface, scat-
tered irregularly but distinct from each other, except in the
neighborhood  of  the joints,  on  the prominences  of  which
they are usually more or  less aggravated.   On  the apex of
each little elevation a  minute scale forms,  which, at first
slightly adherent, desquamates shortly after its appearance,
to be  succeeded by another somewhat larger  and more con-
sistent; this  scale is  shining, of a silvery  whiteness,  and
about the thickness of thin writing paper.  The raised spots 
PSORIASIS.
171
 on which the scales are situated enlarge slowly, not attain-
 ing the size of the head of a pin for several days, and very
 gradually acquiring a magnitude of from two to three lines
 in diameter, Avhen they are of a somewhat circular shape,
 but irregularly circumscribed.   In some parts two or  more
 spots coalesce, and thus form small patches, rarely, however,
 in this form of the eruption, exceeding the size of a sixpence,
 except, as above remarked, near the joints, where they  occa-
 sionally occupy a portion of the integument an inch or two
 in diameter.  With the progress of the disease  the  scales
 continue to be continuously developed, and shed as rapidly
 as they  are secreted ;  the affected spots are irregularly ele-
 vated, of  a reddish color in young persons, but of a dull
 brownish hue in the  old, contrasting  well Avith  the shining,
 grayish-Avhite scales, and present an irritated aspect.  The
 only annoyance accompanying  the presence of the eruption
 on the body, the disfigurement it occasions excepted, is a
 slight degree  of tingling scarcely amounting  to  itching,
 caused by the separation and shedding of the scales.
   This form of psoriasis  rarely becomes chronic;  in three
 or four weeks  after its first appearance, the scaly desqua-
 mation begins  to diminish in quantity, new spots Avhich
 continued to be developed on the sound skin amongst those
 which had previously existed,  cease to form, the elevated
 patches gradually sink to the  level of the surrounding in-
 tegument, and the disease usually terminates in  from six
 Aveeks to two months, faint reddish stains, which after  a
 short time fade away,  marking the site of  the eruption.  It
 may occur  upon  any part of the body, but is most usually
 situated  on the chest, the back, the arms, the face,  and the
 scalp.
   In some rare cases, as originally noticed  by Willan, the
 eruption is developed in the form of narroAV patches or stripes
 consisting of the minute scaly elevations  set closer  to each
 other than usual.   These stripes or  bands, which generally
 appear on  the trunk of the body, assume a singular shape:
 " some  of them are nearly  longitudinal,  some  circular or
semi-circular, with vermiform appendages; some  are tortu-
ous or serpentine, others are  shaped like earth-worms or
leeches ;  the furrows of the cuticle, being deeper than usual,
make the  resemblance more  striking  by giving to  them an 
172
squama.
annulated appearance."1   This, which is manifestly only an
accidental variety of psoriasis guttata, has from its peculiar
aspect been named psoriasis gyrata.
  Psoriasis aggregata  (Atlas,  PL  X.  Fig.  2).—I  have
ventured to change the specific appellation of this form of
the eruption, which by Willan and  his  followers has been
denominated diffusa, by Rayer confluens, and by many other
dermatologists vulgaris.  The latter term indicates correctly
enough that it is the most common form of the disease, but
does not afford  any information as to  its characteristics,
Avhile the first is not  sufficiently specific, psoriasis guttata
and psoriasis lepraeformis being often as generally diffused
with regard to locality over the cutaneous surface;  the name
applied by  Rayer is  objectionable,  solely  because, in the
English language, the word " confluent" conveys the idea of
the presence of fluid.   Reluctant, then,  as I am to alter the
nomenclature  of skin  diseases, although  anxious to reduce
in number the terms used,  I  have thought it well in this in-
stance to do so by employing a specific denomination, which
while being frequently employed to designate other diseases
of the cutaneous structure, and thus not  being an innovation,
would be both more correct and more expressive.
   This form of psoriasis, developed like that last described,
without  constitutional disturbance,  appears as numerous
minute, rounded  elevations of the epidermis, closely aggre-
gated together in irregularly circumscribed patches, varying
in size from that of a silver  fourpence  to that of the palm
of the hand, but  very irregular, both as regards shape and
extent; on these the scales are formed from the first, minute
and tolerably adherent at the commencement of the disease,
but gradually acquiring a greater magnitude, when they are
shed  and again  secreted  with astonishing rapidity.   The
scales are of the same color  and consistence as in psoriasis
guttata, but desquamate in rather large pieces, their  repro-
duction, too, takes place much more quickly, so that they
are consequently desquamated in greater quantity.   With
the progress of the eruption, new patches form on the inter-
vening  sound  skin, which, sometimes coalescing with  those
that first appeared, increase  their size often  considerably;

     1 Willan on Cutaneous Diseases.  London,  1808.  4to. p. 161. 
PSORIASIS.
173
the diseased surface is noAV distinctly raised above the level
of the surrounding integument, rather more so at the outer
border than at the centre,  of a  dull, reddish color, and co-
vered Avith  shining grayish-Avhite scales.  There is no dis-
charge, either serous or purulent, but fissures or cracks are
generally found  through the  affected  parts, which present
an  irritated aspect, and through which  blood  occasionally
exudes.
  This form of the disease often does not attain its full de-
velopment for many months, although several of the patches
acquire their utmost magnitude in three or four Aveeks, after
which  time they do  not increase in size, but continue to
secrete the  characteristic  scales  incessantly.   Its duration
is essentially chronic, lasting usually for years if not sub-
mitted  to  the employment of  remedial measures.  The
disappearance  of the eruption  is in all cases slow and
gradual, the first sign of amendment being the cessation of
the development  of new patches, a diminution of the scaly
desquamation,  and  a  sinking of  the elevated  surface to the
level of the healthy integument;  reddish  stains remain for
a considerable  time on the surface, even after the disease
is apparently cured, and from  these a fine epidermic des-
quamation,  though small  in quantity,  continues for some
weeks.
  Either of the forms of psoriasis now described, when they
become very chronic, may  assume an extremely aggravated
character, and present local phenomena justly entitling them
to the appellation Avhich  dermatologists  then usually apply
to designate their  severity and obstinacy to  treatment—
psoriasis inveterata (Atlas, PL  X.  Figs. 3  and 4).   In  it
the various  patches of the  eruption coalesce, so as to cover
completely the limb on which they may be situated, or even
the trunk of the  body ; the entire of the cutaneous surface
is  one  mass of dry, hardened, thick  scales, or rather  is
enveloped in a case of them which covers the  integuments
like a coat of mail.  Through this, deep fissures are formed,
generally in straight lines, but  sometimes  folloAving  the
course of the polygonal and lozenge-shaped  linear furrows
of the epidermis, so as to give the diseased surface a striking
resemblance to a piece of tessellated pavement.  From the
                          15* 
174
SQUAMAE.
 fissures an ichorous and  bloody pus  exudes, the parts  are
 constantly torn with the nails, itching, which is  much aggra-
vated by heat, being a constant accompaniment of this in-
 veterate form, and the entire of the affected region is a mass
 of leprous irritation, attended with a foul discharge, and a
 shower of  desquamation scales flies off on the least motion,
 the bed  of the patient presenting  an  appearance as if bran
 had been thickly strewn in it.
   The most  usual site of psoriasis aggregata  is the extre-
 mities,  but  it at times  affects  the entire body, being least
 frequent on the face, where it is  always  less general than
 on other parts of  the cutaneous surface.   In some cases it
 appears on special regions of the skin, and under  such  cir-
 cumstances has been particularly described, but the guttated
 .form of the  eruption is  almost invariably present on  the
 rest of the body at the same time.   The local forms have
 been named, from the parts affected, psoriasis labialis, psoria-
 sis palpebrarum, psoriasis capitis (Atlas, PL  X. Fig. 6),
 psoriasis scrotalis, psoriasis prseputialis, psoriasis pudenda-
 ls, psoriasis palmaris, and psoriasis unguium ; of these  the
 tAvo last only require to be  specially noticed.
    Psoriasis palmaris has, in common with certain forms of
- lichen and eczema, been regarded as one of the varieties of
 the so-called baker's and grocer's itch ;  it may appear on
 the palmar aspect of the hands, extending also to the wrists
 and the under surface of the fingers.  In its development
 it is attended  with more local symptoms than any other
 variety  of the  disease, inflammatory redness,  accompanied
 by heat and itching, marking its advent; the skin on the
 palm of the hand then becomes SAvollen, irregularly elevated,
 and of a reddish hue, and  the itching generally  increases
 much, being  at times as intense as in  scabies or prurigo.
 Large, dry, whitish scales, of tolerable thickness and consist-
 ency, are rapidly secreted  on  the  affected surface ; these
 soon desquamate, and are re-formed  again and again, as in
 the other varieties of the eruption. When it becomes chronic,
 the itching and heat diminish, but  the integuments of the
 palm of the hand and of the palmar surface of the fingers
 become hardened, thick like  leather, of  a whitish-yellow
 color, corrugated, scaly, and fissured; the motions are then
 limited and painful, the fingers cannot be completely flexed 
PSORIASIS.                   175
or extended, and any sudden movement  tears the fissured
parts, and causes them to bleed.   In a rare  form described
by Bayer, and termed by him psoriasis palmaris centrifuga,
the eruption begins by the formation of a small, rounded,
squamous elevation in the centre of the  palm, around it a
series of eccentric, raised, red circles  are developed, from
each  of Avhich  epidermic desquamation takes  place; the
eruption spreads in  this manner  until it covers  the  entire
palmar  aspect of the  hands, Avhich is  then  deeply fissured
and painful, and bleeds from the  slightest cause.   Psoriasis
attacks the backs of the hands also in  some instances, and
occasionally the soles  of the  feet.
   The eruption extends to the nails in most cases of chronic
psoriasis of the  hands, but Avhat has been described as pso-
riasis unguium  is a  change  from their healthy condition,
with or without  the existence of the disease on remote parts
of the body; one or more of the  nails  presents a brownish-
yellow,  scaly elevation  near  its  root,  which   gradually
extends so  as  to occupy the entire  surface;  its texture
becomes brittle,  breaking and scaling off constantly;  it ac-
quires a dirty yellowish hue,  and  not uncommonly the entire
nail  is  shed,  to be succeeded  by  the  growth of another
equally diseased.
   Psoriasis leprceformis (Atlas, PL X. Fig. 5), which, as
already remarked, is  the form of scaly eruption described
by most dermatologists as  a  distinct disease,  and termed by
them 'Lepra,' is chiefly characterized  by the development
of the patches in usually a perfectly circular, but sometimes
in an ovoid  shape.   It commences  Avithout either constitu-
tional or local disturbance, in the form of numerous small,
round, reddish stains, perfectly  distinct from each  other,
and scarcely elevated above the surrounding  skin, on Avhich
shining  silvery-white  scales  soon  appear.   Gradually, but
sloAvly, the circles enlarge from their circumference, which
is someAvhat more raised than the centre, attaining  a size
varying from a few lines to one or two inches in  diameter;
some of the patches coalescing, they occasionally cover an
extended surface of the integument, and  acquire an irregu-
larly rounded shape,—this is  almost invariably the case on
the convex aspect of the joints and in their neighborhood,
on which parts the eruption presents an appearance scarcely 
176
SQUAMJS.
to be distinguished from psoriasis aggregata ;  but the cir-
cumference  of the patches, no  matter how large they may
be, is always  more elevated  than the centre,  Avhich, after
some time, assumes  a comparatively healthy condition, its
color becoming more natural  and but slight desquamation of
fine epidermic scales taking place from it.   From the borders,
however, the constant  secretion and shedding of true scales
continues;  they become  thicker  and more solid,  retaining
their whitish aspect, and are  sometimes imbricated on each
other at the outer border of each patch;  the integument on
Avhich the eruption is situated also becomes somewhat hyper-
trophied.
  Psoriasis lepraeformis always  runs a very chronic  course,
not exhibiting any tendency  of itself to  disappear, the dis-
ease being kept up more by the desquamation of scales from
the patches of eruption originally formed, than by the de-
velopment of new spots ; at length, when  under  treatment it
begins to amend, the central healthy surface extends towards
the circumference, upon which fewer and thinner scales are
secreted; the eruption  at the same time ceases altogether to
spread, and finally, only slight  stains with furfuraceous epi-
dermic desquamation  remain, as an indication  of  the parts
which were  affected :  these in most cases gradually  wear
avVay, but they sometimes last for years,  and scales form on
them in spring and summer, or on  the least exacerbation,
either from  local causes  or  from irregularities of  diet, re-
lapses thus frequently  occurring.
  A variety of this form of the eruption has been described
under the name of Lepra nigricans, in which the  color of
the diseased patches is dusky-brown or livid,  and the scales
are very thin,  soft, and of a dull, grayish-white aspect; in
all other respects it resembles psoriasis lepraeformis, and its
peculiarities evidently depend on the eruption affecting old
persons or  those with a broken-down constitution, in whom
only it is witnessed.    The Lepra alphoides of Willan  is a
variety of psoriasis guttata, in which the spots are somewhat
larger, and the scales more silvery-white  than usual.
  The leproid form  of psoriasis chiefly  affects the extre-
mities, yet it  sometimes  attacks the face and scalp,  and
the trunk of  the body:  I have  seen it  occur  very exten-
sively on the scalp, where the patches coalesce  and envelop 
PSORIASIS.
177
the entire of the head  in  one vast  crust of scales, being,
hoAvever, present at the same time  on other regions of the
body ;  on the face it is almost invariably in rather small
patches distinct from each other, but most numerous on the
forehead and the upper parts of the cheeks, just beneath the
eyes.   The spots of this  form of the eruption not unfre-
quently assume a somewhat symmetrical arrangement on the
two halves  of  the  body,  appearing  on  the  corresponding
portions of  the cutaneous surface at each side of the mesial
line simultaneously, and in  patches of nearly similar shape
and size ; the same  fact  is also  witnessed at  times in the
other varieties  of psoriasis, but it is of more frequent occur-
rence in this form of the disease.
   The psoriasis annulata of some dermatologists, the orbi-
cularis of others, corresponds in all respects Avith  psoriasis
lepnuformis.  And the variety termed  infantilis presents
no peculiarity, except its  occurrence at a  very early age,
when,  in consequence of the fineness of the skin, the surface
is more easily irritated, and the local  symptoms are, there-
fore, more prominent.  In all  the  forms of the eruption
these,  as has been remarked, are in general very trifling, but
when any do exist, they are much aggravated by Avarmth,
such as that caused by  the heat of the bed.
   The  chief annoyance which psoriasis  causes is the dis-
figurement it occasions  Avhen situated over any of the ordi-
narily exposed regions of the body ; but if the eruption has
existed for any length  of  time, and  become chronic,  the
health may be  more or  less affected from the obstruction to
free cutaneous transpiration which it must produce; and thus
should any acute febrile disease attack a person affected Avith
the eruption, the danger arising from the former may be in-
creased, and the treatment  rendered more difficult.   It is
probably due to this cause, also, -that diuresis and diarrhoea
are such frequent accompaniments of scaly diseases of the
skin ;  the latter  complication is  often very  incontrollable,
and the appearance of the stools at times is such as to war-
rant the belief, that it is caused by an epithelial desquama-
tion from the  mucous membrane of  the intestinal  canal,
analogous to the shedding of altered epidermic scales from
the cutaneous surface.
   Causes.—Psoriasis occurs at all ages and in both sexes, 
178
SQUAMiE.
beino- probably equally frequent in males and females ;  its
specfal  causation is, like  that of  all cutaneous  eruptions,
enveloped in much obscurity.   That it is sometimes produced
by the action of certain irritating matters on the skin can-
not be doubted ; yet we see the same local forms of psoriasis
arise in persons who, from their occupation or position in life,
are not exposed to the causes which produce  it in bakers,
washerwomen, shoemakers, and individuals of other trades.
That  squamous  diseases are sometimes  hereditary is also
true, but their hereditary nature is of a singular character;
thus, so far as my oAvn experience would lead me to infer,
the disease does not descend directly from parent to  child
with the same regularity as  other hereditary diseases, but
the predisposition frequently appears to be  derived  from
an uncle or aunt, whose OAvn  children may be free from the
disease ; and it also seems not uncommonly to lie dormant
in a  family for a generation, and again re-appear.   In a
case which I not  long  since  attended, one son of a family
was affected from his childhood with psoriasis  of  an invete-
rate form ; none of his brothers or sisters had any cutaneous
eruptions, nor had his  parents or  grand-parents, but a pa-
ternal uncle was affected with a similar disease, and also a
first cousin not the child of  this  uncle :  it was,  moreover,
stated that a grand-uncle was a sufferer for years from cuta-
neous eruption.   A somewhat similar hereditary transmis-
sion of the disease has fallen under my notice in several  in-
stances, namely, that while the immediate descendants  have
escaped, one or more members  of  collateral branches  have
been affected.   The true hereditary nature of psoriasis may
therefore be doubted, and the cases which occur, and are ad-
duced as proofs of it, might  be  accounted for in the same
manner as those in which no such origin can be traced, and
Avhich are usually stated to  depend on some constitutional
peculiarity, not better  understood  noAv than in the days of
Willan,  who described it as characterized by "a slow pulse,
or a  languid circulation of the blood, and, what must  be
generally connected with it, a harsh,  dry, impermeable state
of the skin and cuticle."  The latter part of  this observa-
tion has been adopted by Mr. Erasmus Wilson, who says that
"the disease appears for the  most  part in those who are re- 
PSORIASIS,
179
 markable for a dryness of the skin."   Yet  I  cannot help
 thinking  that this is a  confounding of the  effect with the
 cause, and  that it Avould  be rather hazardous  to  predicate
 the likelihood of psoriasis occurring in an individual because
 his skin was unusually dry or  harsh.  The other causes, or-
 dinarily enumerated  by  dermatologists as being likely to
 produce psoriasis, are similar to those supposed  to  excite
 other diseases of  the skin, such as irregularities of diet, in-
 sufficiency of food, the use of salted or highly-seasoned pro-
 visions, derangements of the digestive  organs,  and, in the
 female,  deficient  or excessive menstruation ;  but none of
 these can be supposed to  act unless when original  predispo-
 sition to the disease exists.
   Diagnosis.—The distinction between psoriasis  and all
 other diseases of  the skin, except pityriasis,  is well marked
 by the  presence of the characteristic scales ;  several other
 eruptions are, as has been remarked Avhen speaking of them,
 accompanied by a form of desquamation, but this is present
 in only certain of their stages, and the desquamation con-
 sists merely of  the  shedding of slightly altered epidermis,
 in minute, very thin, furfuraceous particles,  not to be con-
 founded with a  true  scale; this  takes place especially in
 chronic  eczema, in herpes, and in  lichen, but  in the two
 former  there is more  or  less serous or sero-purulent dis-
 charge  attendant on some part of their course, and  in the
 latter papulae are to be distinguished on  careful  examina-
 tion.   When either of the two latter diseases assumes a cir-
 cular form,  as in  herpes  circinnatus or  lichen circumscrip-
 tus, it is more apt to be  confounded Avith psoriasis leprae-
 formis,  but  the  characteristics just noticed then serve also
 to aid the  diagnosis, and the  eruption  in neither of  them
 presents the distinctly rounded  shape with  the depressed
 centre and scaly circumference of this variety  of the disease.
 Psoriasis very rarely occurs  on the scalp, unless Avhen the
 eruption is  present at the same time on some other part of
 the body, and this serves to a  certain extent  to  distinguish
 it from  other scalp affections; the  scales, too,  when  they
 are secreted on  this region, are thicker and more solid than
 Avhen  situated elsewhere on the cutaneous surface,  and con-
sequently much more so than  those of  any other  eruption
that may occur  there, than which  they are also more per- 
180
SQUAMAE.
sistent, often constituting a firm, imbricated, adherent, dry
crust, the outer layer of Avhich only desquamates.  Secon-
dary syphilitic  eruptions not unfrequently assume a  scaly
character, and  are  Avith difficulty diagnosed from the ordi-
nary forms of  psoriasis ; the history of the case  and the
concomitant  symptoms are  the differential points  to  be
chiefly depended on ;  the color of the parts of the cutaneous
surface which are affected is, moreover, of a dull coppery or
livid hue.
  From  pityriasis  the eruption is distinguished by the ab-
sence in that affection of  elevation of the diseased parts,
which are of a yellowish or reddish-yellow color,  by the scales
being fine  and thin,  and by their being generally diffused
over the cutaneous  surface, not in distinct  patches or spots.
The chief diagnostic marks between it and ichthyosis are the
thick, hardened, and  rugose  condition  of  the  skin in the
latter,  and  the non-existence of any  scaly desquamation.
The  aggregated form of psoriasis is distinguished from the
guttated variety without any difficulty, but in  some cases a
distinction  can scarcely be made between it  and psoriasis
lepraeformis, a matter of but little import,  as the treatment
for both is in all respects similar.
  Prognosis.—Squamous   eruptions are  essentially  of  a
chronic nature, but, even when of years' duration, scarcely
ever affect  in any respect the  general  health.  Developed
under the influence  of a peculiar constitutional state of the
skin, essentially of  an obstinate character, and most apt to
re-appear even  in months or years after they seem to have
been completely  cured, length of time is  as  important to
their perfect  removal  as the most judiciously planned course
of treatment.  The physician should, therefore,  in  every
case, be  most  careful not  to  promise a speedy  cure, and
always, before prescribing, explain to his patient the chronic
character of  the disease, and  that it requires a steady per-
severance in  the use of remedial measures for  at  least two
or three months before even an apparent amendment will be
perceptible.  The anxiety of mind which an individual labor-
ing under  a  cutaneous eruption suffers is very great and
this, too, adds to the  difficulty of treatment.   The promise
of an eventual cure, though after a lengthened  period, tends
to alleviate this anxiety, and prevents the repeated disap- 
PSORIASIS.
181
pointment, changes  of  medical  advisers, and trials of new
plans of treatment, Avhich the hope deferred, Avhen  a speedy
cure has been promised, causes.
   Pathology.—"It  is an admitted  fact," writes Cazenave,
" that the therapeutics of  these diseases rest upon purely
empirical grounds, and  that, unhappily,  there exists no sure
guide to direct to a rational mode of cure."  This statement,
sufficiently true of most eruptions of the skin, is equally so
of many other diseases of the body, and it should teach us
not to despise the light thrown on pathology by the expe-
rience derived from  therapeutics.  When it is found that a
certain class of remedies act beneficially on deranged condi-
tions of the  animal  economy, concerning the true nature of
which doubt  exists, it cannot be  termed a petitio principis to
infer that such derangements have a similarity in greater
or less degree to  affections the nature  of Avhich  is known,
and Avhich are benefited by the same class of remedies.   In
the treatment of scaly diseases of the skin, iodine, in some of
its various combinations, and cod-liver oil are especially use-
ful ;  and I would, even from this therapeutic fact  alone, be
inclined to look upon the peculiarity of constitution in Avhich
they  occur as nearly allied  to the scrofulous; in fact, that
their appearance is  but one of  the  protean forms  in which
scrofula may be developed.  And, independently of the bene-
ficial effects of iodine,.if Ave look to the  remedies ordinarily
proposed  as specifics for their cure—of  course I speak only
of those administered internally, or, so to say, constitution-
ally—what  are they but tonics, alteratives,  or  diaphore-
tics, generally employed in the treatment of scrofulous affec-
tions ?  Again, if Ave lay aside the  analogy derived  from
therapeutics, in how many points do not scrofula and scaly
eruptions of the skin agree ?—their hereditary nature,  their
sIoav development, the period of life at which they appear,
their production  by  innutrition or mal-innervation of the
system, their  obstinacy, their liability to recur or be  again
reproduced, the diathesis of the individuals  in Avhom  they
appear, &c.
 -  Treatment.—In consequence  of its extreme obstinacy and
usually chronic character, there is probably no eruption of
the skin, for  the treatment  of Avhich  so many varied  reme-
                           16 
182
SQUAMAE.
dies have been and still are proposed, as for psoriasis.  Some
trust  altogether to  topical medication for  its cure, Avhile
others rely exclusively on the employment of constitutional
remedies; both are needed, and neither should be neglected;
the former must be used Avhen the eruption has lasted for
any length of time, or where  it affects an extended surface
of  the  skin, to  produce a new local action, and to remove
the diseased condition of  the integuments ;  while the latter
is required to  correct  any deviation  from a healthy state,
whether functional or organic, of the internal organs which
may be present, and  to alter the constitutional derangement
to the existence of Avhich  the eruption is due.  Before com-
mencing any plan of treatment, therefore, it is necessary to
take into account the age, constitution, and diathesis of the
patient, the extent of surface affected, and the previous dura-
tion of the disease.
  In  strong, healthy, plethoric young persons of either  sex,
when  the eruption is of the guttated  form, or affects only a
small  portion  of the skin, its progress Avill generally be
stopped, and  a cure effected by the  use of  tolerably active
saline cathartics every second or third day, preceded  by a
general bloodletting, and the  daily use of a fresh-Avater bath
at the temperature of 9b°.  In persons of a sanguine tem-
perament, or of  very plethoric habit of body, the  bleeding
may be repeated, but in all cases only a moderate  quantity
of blood should be draAvn,  for when much  has been  removed
at a time, or the operation frequently repeated, the  eruption
is  apt to take  on an aggravated  character, and to  become
chronic.   The best cathartics that can be used are the saline
purging mineral waters, such as those of Pullna, of Seidlitz,
of Cheltenham, of Leamington, of Droitwich, of Kreuznach,
&c.;  or, in their absence,  the compound saline poAvder may
be given in the dose of two drachms, dissolved in half a  pint
of lukewarm water, to which  from twenty to thirty minims
of the liquor potassae, or preferably, Brandish's alkaline solu-
tion, and the same quantity of some aromatic tincture, as of
orange-peel, should be added;  in either case the purgative
should be taken in the morning early before breafast.   By
these  simple means,  continued for five or six weeks, many
of the milder cases of psoriasis may be cured, but more gene- 
PSORIASIS.
183
 rally, and invariably when the eruption has existed for some
 time before it is submitted to treatment, it is only alleviated
 thereby.
   When the disease affects old persons or individuals of a
 weak constitution, all debilitating remedies must be carefully
 eschewed ; in its early stages then  stimulating diaphoretics,
 combined with  tonics, should be employed, and  the tepid
 bath,  or tepid douche if the eruption be local, used once or
 twice a week when the patient's strength admits, or the hot
 vapor bath may in some cases be  substituted  with benefit for
 the Avater  bath.  Guaiacum  and mezereon  often  prove the
 best diaphoretics in these cases of psoriasis, and  they may
 be given in combination,  as in the  folloAving  form :—

     B. Tincturae Guaiaci Ammoniatae, .  .   .  fl 5j.
        Tincturae Serpentariae,.....fl 3ss.
        Mucilaginis Acaciae,......m. xx.
        Decocti Mezerei,.......fl 3viss.
        Decocti Dulcamarae,......fl 3j.

                   Misce.  Fiat haustus.

        "One such to be taken three times a day."

   In scrofulous children,  the progress of the disease may in
 its early stage be stopped and a cure effected by the adminis-
 tration of  cod-liver oil ; and this medicine proves also very
 successful in many cases of the local forms of the eruption
 in adults ;  but with children or young  persons the employ-
 ment of the tepid bath at the same time should not be neg-
 lected.
   In the more  aggravated forms of psoriasis, however, or
 when the disease has  become chronic, recourse must be had
 to the more active alteratives, some of Avhich have acquired
 a  sort of specific reputation  for  the  treatment  of scaly
 diseases ;  and of all that have been used none effects a cure
 so frequently as arsenic,  whether it be given alone or its
administration  conjoined  with the  application of  various
local agents.  In every case the beneficial  action  of this
medicine is more decided  and  more  speedily manifested 
184
SQUAMAE.
when iodine or the iodide  of potassium is employed at the
same time, or  alternated with it,  and in those cases—not
few in number—in which arsenic, no matter how prescribed,
disagrees, the  preparations of iodine suffice usually to cure
the disease.  Arsenic may be prescribed either in the fluid
form or in that of pill, but, however given, the dose should
be small, increased very slowly, and continued for a length-
ened time,  at least for several months.   Of the liquid pre-
parations, the  liquor arsenicalis  of the  Pharmacopoeias,
Fowler's solution—a convenient name for prescribing when
it is requisite to conceal from patients or their friends that
arsenical preparations are being administered—is probably
the best, or the liquor arsenici chloridi, De Valangin's mine-
ral  solution—introduced into the last edition of the London
Pharmacopoeia—may  be used ;  they should not be given at
first in a larger dose than four minims three times a day in
an ounce of decoction of dulcamara, to  which,  except in
persons of a full habit of body, two drachms of syrup of
mezereon may be  added.   The arseniates of ammonia or of
soda may also  be given  in solution in  water,  with a little
syrup, or in some vegetable infusion or decoction, in the dose
of a twentieth of a grain, very  gradually increased  to the
fifteenth of a grain, three times  daily.  The following form,
for  the administration of the arseniate of ammonia, was first
proposed by Biett:—

     B.  Ammoniae Arseniatis, ....   gr. iss.
        Aquae destillatae,.....fl giij.
        Spiritus Angelicae,   ....   fl 3vj. Misce.

" One tea-spoonful, gradually increased to three, to be taken
           for a  dose in some aromatic water."

  Donovan's  solution of the hydriodate of  arsenic  and
mercury, which has become officinal in the  last edition of
the Dublin Pharmacopoeia, is  another liquid form that has
been often employed  successfully  in the treatment of pso-
riasis ;  in consequence of its containing mercury it is espe-
cially applicable  for those cases in which the eruption is
either a secondary symptom, or is connected with a syphi- 
PSORIASIS.
185
litic taint in the system ;  but, from  my own experience, I
do not think that mercurial  preparations in any form  are
generally applicable for scaly diseases, except in the local
forms appearing in  children, and I have not  unfrequently
seen  their use followed by an aggravation of the symptoms.
I have  consequently, for some years  back, substituted  for
Donovan's solution a compound in which mercury is replaced
by the iodide  of potassium; this  mixture may  then   be
termed an  Ioduretted  solution of the Iodide of Potassium
and Arsenic ; it is prescribed in the following form : —

         B.  Liquoris Arsenicalis,  .   .   . m. Ixxx.
            Iodidi Potassii,.....gr.  xvj.
            Iodinii puri,......gr.  iv.
            Syrupi Florum Aurantii,  .  .  fl 3ij.    Solve.

This  solution, Avhich is of a rich Avine-yellow color, and  keeps
unchanged  for  years,  contains  in each  fluid  drachm five
minims of arsenical solution, a grain of iodide of potassium,
and a fourth of a grain of iodine.   Forty minims of it  at
first may be given three times a  day in simple Avater,  or  in
any tonic or diaphoretic vegetable infusion or decoction,  as
individual circumstances may indicate, and the dose gradu-
ally increased to eighty minims  : it  is of course,  scarcely
necessary to observe that  this compound, as are all which
contain iodine, is incompatible with vegetable  preparations
in Avhich starch  is present,  or with the stronger acids.   In
cases in Avhich from  any reason it may be advisable not to
prescribe arsenic, the Fowler's solution can be omitted from
the above mixture, and, unless in  the inveterate forms  of
the eruption, or  when it has been of very long standing, the
iodine preparations  should  in the first  instance  be  tried
alone.
   Where it  is wished to prescribe arsenic in the solid  form,
the best preparation of it is the iodide, Avhich may be  given
in pill, made Avith conserve of roses or Avith hard manna and
mucilage, in doses of from the twelfth to the tenth of a grain,
three times  daily very gradually  increased until  the fourth
of a grain is taken at each time ;  the arseniates of ammonia
or of  soda may be given in  the same form.  In  the more re-
                          16* 
186
SQUAMAE.
bellious cases of the disease, and especially when it occurs in
persons of a debilitated constitution, an excellent and favor-
ite formula for the administration of this powerful agent, is
what has been termed the Asiatic pills, in consequence of
their being first  beneficially employed in the  East Indies,
Avhence we  derived our  knowledge  of their efficacy; they
are prepared by rubbing together a  drachm of arsenic and
nine drachms of  powdered black  pepper, with sufficient
liquorice  poAvder and mucilage to  make 800 pills.  Each of
these contains about a 13th of a grain of  arsenic, and one
or two  may be given daily. No matter what preparation of
arsenic is employed, it should be administered after meals,
as it is then less apt to derange the stomach, and the effects
should  be carefully watched :  the  continuance of headache,
of sickness and pain in the  stomach, of dryness of the fauces,
or of tenderness with heat  and redness of  the eyes for a few
days, requiring its omission for a short time,  and the adminis-
tration of an active cathartic, when it may be again resumed.
It generally occurs that in the treatment of scaly diseases
by arsenic  or by iodine, the  eruption at first presents an
aggravated appearance, the affected parts exhibiting an irri-
tated aspect, and the scaly desquamation being much aug-
mented by these symptoms  soon  pass away, and signs  of
amendment begin to show  themselves.  In  all cases the use
of the remedies which have proved successful should be per-
sisted in  for some weeks  after the  disease is apparently
cured,  so as to prevent a relapse.
  Chronic cases of psoriasis are very frequently complicated
Avith derangement of the digestive organ,  evidenced by vari-
ous dyspeptic symptoms;  the most prominent of these are
nausea and vomiting, immediately after meals.  This  con-
dition must be remedied by appropriate alterative and tonic
treatment, previously  to the  employment  of medicines, with
the view  of acting directly on the  eruption,  for if arsenic  or
iodine,  in any form, be given while this condition is present,
they will tend to increase  the existing irritation, and their
expected  beneficial action be thereby prevented.  The  tepid
fresh water, the  douche, or the vapor bath, should  be em-
ployed  at least once or twice a week, in addition to the use
of the  internal remedies now recommended.
  But  cases of psoriasis  occur which resist with  obstinacy 
PSORIASIS.
187
the administration, even though  much prolonged, of  either
or both of these powerful medicines, and  then recourse must
be had to some of the many other remedies, both constitu-
tional and  topical, which  have at times  proved useful,  and
have  consequently found warm  advocates.   Sulphur  and
its  preparations have been  highly praised by many practi-
tioners for their efficacy ;  and in the very inveterate forms
of the eruption occurring in languid  constitutions, or Avhen
there is no determination of blood to  the affected parts, nor
local  irritation, the sulphurous mineral  waters, both  taken
internally and  employed in  the form of tepid bath, cure the
disease when other remedies have failed ;  but to derive the
full benefit from  them, their use should be continued for
several months, otherwise the eruption is sure to re-appear.
When the mineral waters cannot be procured, or the patient'
is unable to go to their sources, Avhich is always most advis-
able,  sulphur may be given  internally, and baths or lotions
of the sulphuret of potassium used.   In the local forms of
the disease the iodide of sulphur ointment is a most valuable
topical application, but it should be used only of moderate
strength, from  eight to twelve grains to  the ounce  of white
Avax  ointment, and its efficacy is  much increased by the
addition of a drachm of glycerine to  each ounce.
   M. Cazenave has recently  administered the carbonate of
ammonia, in the treatment of psoriasis, with marked success;
he prescribes it in the dose of about  two and a half grains,
from  one to three times a day, in a table-spoonful  of syrup
of  sarsaparilla.   " In general, the symptoms  it causes are
scarcely to be  noticed; some  slight  disturbance of the di-
gestive organs, and occasionally  slight heat and tingling of
the skin.  Yet, after an interval of time, varying usually
from three to eight days, Avhen good results follow, the scales
begin to be detached, those which succeed them are more
and more  fine and of a duller  aspect, and the  patches on
Avhich they are situated  lose  their red tint and  gradually
fade away; after a longer or shorter period a complete cure,
and one Avhich is often permanent,  takes  place."1  When
carbonate  of ammonia was  thus  administered,  M. Cazenave
found it to occasion diarrhoea, preceded by colic, lassitude,

   1 Annales des Maladies de la Peau et de la Syphilis, torn. iii. p. 315. 
188
SQUAMAE.
sometimes headache, slight acceleration with diminished ful-
ness of the pulse,  alternations of heat and cold of the sur-
face, &c. ; these symptoms disappeared on omitting the use
of the medicine for a few days, and this fact, together with
their similarity to  those caused by arsenic, led him to draw
an  analogy betAveen the mode of operation of  the two me-
dicines.
  Amongst other constitutional plans of treatment proposed
for psoriasis,  bringing the system under the  influence of
mercury has  proved successful in  the  hands of some prac-
titioners ; it  is chiefly applicable,  as already  remarked, to
those cases in which a venereal taint exists; but it may also
be used in the milder forms of the eruption, when they do
not yield to the more simple treatment recommeded above.
The preparations of mercury which are preferred  are those
that act  slowly, and rarely produce  salivation, such  as the
red iodide or  corrosive sublimate ;  the  latter is  very fre-
quently prescribed in decoction of cinchona bark, a good
combination, although not strictly chemical.
  Copland relies chiefly on the employment of emetics and
purgatives at  the same time, and their use is certainly at-
tended with much benefit in most cases, previously to com-
mencing the  administration of the more  active  alteratives.
The alkalies, especially the liquor potassae, have also been
highly  recommended, particularly in the local forms of the
eruption, but in many cases in which I  tried them the result
was not satisfactory.  From  its original use by Biett, and
the favorable  notice taken  of its action by Rayer, tincture
of cantharides has been rather extensively administered,
especially on the Continent, in the treatment of psoriasis;
it certainly succeeds in some cases in which other remedies
have failed, but its  employment,  even in small  quantity,
must be carefully watched,  in consequence of the dangerous
effects  it is apt to  produce  on the  urinary organs.  It may
be given in doses of five minims, gradually increased  to fif-
teen or twenty, three times a day, in at least  an ounce of
some emulsion or of decoction of linseed or barley.   Nu-
merous  other  medicines, especially diaphoretics, diuretics,
tonics,  and stimulants, have been employed in  this disease,
but none require mention here, with perhaps the exception of
tar or  pitch, Avhich, when given internally, and at  the same
/ 
PSORIASIS.
189
time applied to the affected  surface, is regarded  by some
physicians as quite a specific;  I consider it, hoAvever, much
inferior in its medicinal efficacy to most of  the other thera-
peutic agents Avhich have been now noticed.
  Local applications,  ointments,  lotions, baths, &c, have
been at all times favorite  methods of treating psoriasis, and
many have attempted to cure the disease by their use alone;
with this vieAV, also, it has been proposed  to destroy the
eruption by the free application of nitrate of silver to the
affected parts,  but such a proceeding tends only to aggra-
vate the morbid state of the cutaneous surface, and is not
altogether unattended with danger.   The simple/resA-Avater
tepid bath has  proved, in my experience, the best topical
remedy, I might  almost  say  the  only one needed, and  it
should  be employed at least  once a week  in all  forms  of
psoriasis ; its use  tends to restore the natural  secretion of
the skin, and to prevent the accumulation of scales.  When
the eruption is local, and attended with symptoms  of irrita-
tion or inflammation, soothing unguents, as  those containing
chloroform, preparations of lead, zinc, &c,  or poultices pre-
pared with the lead wash, often  prove highly serviceable;
and in  the more chronic  cases, Avhen neither inflammation
nor  inflammatory irritation is present, stimulating applica-
tions are occasionally required ;  of these probably the best
is the iodine of sulphur  ointment spoken of before, or the
folloAving, Avhich Avas highly recommended by the  late Dr.
Anthony Todd Thompson :—

     B.   Calomelanos,........3j-
          Unguenti Picis liquidae,  ....  $iv.
          Adipis praeparati,.....3j. Misce.

   Of other local applications it  will be sufficient to enume-
rate blisters, creasote, turpentine, tincture of iodine, corro-
sive sublimate  in lotion, black and yellow wash, citrine  oint-
ment,  &c. ; the alkalies, when applied topically, generally,
I think, prove  injurious.
   Strict attention to diet and regimen is especially requisite
in the  treatment  of psoriasis;  a milk  diet should be, if
possible, enforced, except in cachectic or broken-down con- 
190
SQUAMA.
stitutions, and when from this or any other cause it cannot
be altogether adopted, farinaceous articles and milk should
be made as much as possible a portion of the general food,
and  in  addition,  fresh  meat, plainly dressed, or poultry,
should alone  be allowed.  From its being so much easier to
carry out dietetic rules  in hospital patients than Avith  those
in private or in dispensary practice, more satisfactory results
are usually obtained in treating the former, and consequently,
perfectly accurate conclusions as to  the effects of remedies
in the treatment of any disease, whether of the skin or not,
can only be drawn from hospital experience.
                       pityriasis.

  Pityriasis is a scaly cutaneous disease, characterized by
an abundant  secretion and desquamation of minute, furfura-
ceous,  white, and shining scales,  from  slightly elevated,
irregular patches  of the skin, of a yellowish, reddish-yel-
low,  or  dark-brown color, varying in extent,  or from the
surface  of the body generally.   It is attended  usually with
smart itching of the parts affected, sometimes  with  painful
inflammatory tingling, and both are much augmented by any
cause that may produce increased capillary circulation of the
integuments.    It is non-contagious, unaccompanied  by con-
stitutional  symptoms,  and although  attended  in its early
stages,  and in  some cases throughout its entire duration,
with more or  less local  inflammatory action, almost invari-
ably runs a very chronic course.  Pityriasis is, for the pur-
poses of description, naturally divided  into varieties, as  it
may affect the  cutaneous surface generally, or  some special
region of the skin.   Willan, who has been folloAved amongst
others  by Cazenave  and Schedel,  described but one local
form of it—that of the scalp, and divided the eruption, Avhen
it affected the body generally, into three varieties, according
to the  color which the diseased patches of integument pre-
sented,  namely, Pityriasis rubra, Pityriasis nigra, and Pity-
riasis versicolor.  Both  Rayer and Erasmus Wilson consider
the first of these only as being a scaly disease, and regard
the other as  simpjy alterations in the  color of the skin, ac- 
PITYRIASIS.
191
companied by a foliaceous  or  mealy desquamation, and not
by  thes  eparation  of  true scales.    As, however, in both
forms there is a squamous secretion, differing only in degree
from the first, I prefer  to regard  them as sub-varieties of
general pityriasis.   Adopting, then, strictly the  division of
the disease  into two forms,—general and local,—they may
be termed:—

                    Pityriasis diffusa.
                        "    localis.

  The early stage of pityriasis diffusa (Atlas, PL XI. Fig.
2) is marked by a sensation of heat and tingling on various
parts of  the  cutaneous  surface, usually on the  neck, the
chest, the  abdomen, the back, and sometimes on  the face
and hands; uncircumscribed patches of a  yellowish or red-
dish-yelloAv color, scarcely elevated above the surrounding
integument appear  on the places Avhich had  been the seat
of  the itching, and  on them  minute, branny, micaceous
scales  soon form, at first in small quantity, but  afterwards
in  very  great abundance, desquamating  freely  when  the
spots are rubbed, or should the eruption be general, on the
least movement of. the  body.   The affected patches vary
much in  shape and size, being often  of an irregularly rounded
form, separated at first by  healthy skin, over Avhich, in most
cases, hoAvever, the scales  gradually extend, and, becoming
confluent, cover the body  almost universally ; the furfura-
ceous desquamation is then extreme, and  is attended with
much itching,  especially Avhen  the surface of the body is
heated, and the disease assumes a very obstinate character.
The skin from Avhich the desquamation takes place—Avhich
in the  commencement presents various shades of red  and
yelloAv intermixed, Avhence  the specific  appellation of pity-
riasis versicolor has been  applied  to this  form—gradually
becomes  of a lighter shade  of yellow, and in many instances
the secretion of scales then ceases, yelloAvish stains remain-
ing on  the surface for some time ;  but in others the desqua-
mation, attended with more or  less itching lasts with extra-
ordinary  obstinacy for months, or even  years, after the skin
has resumed its natural color. 
192
SQUAMAE.
  In some cases the eruption is more partial, being confined
almost exclusively to the integuments of the thorax, usually
appearing on the chest; the spots or  patches assume from
the first a bright color, so marked that in the commencement
they can scarcely be distinguished from erythema;  they are
also attended  with much heat and  itching,  indicating  the
inflammatory nature of the disease ; the characteristic scaly
secretion and desquamation soon appear, hoAvever, and deter-
mine its  nature.  This  form, Avhich  is  also very obstinate,
has been termed pityriasis rubra ;  it is of much less frequent
occurrence  than pityriasis  versicolor, but oftener witnessed
than the next sub-variety.
  Pityriasis nigra is a  very rare  form of the eruption ; it
does not seem to differ in any respect from pityriasis rubra,
except in the color of the diseased patches, which are dark-
broAvn or nearly black, and usually appear on one or both
of the lower extremities ; according  to Cazenave's observa-
tions, the black  tint is  in some cases so superficial that, on
removing the epidermis, the derma is seen beneath,  of a red,
shining aspect; in others, however, the  color affects the sub-
epidermic layer of the derma.  In both pityriasis versicolor
and pityriasis' nigra, the chromatogenous functions  of the
derma must be more  or less disordered, to account for  the
peculiar  coloration of  the  skin which accompanies them.
As  before remarked, Rayer considers the  changed color as
their essential characteristic, and he  consequently terms the
former  Chloasma, and  the  latter  Melasma;  this view  has
been adopted by Wilson also.
  Several local forms  of pityriasis have  been  described
chiefly by Rayer; thus he  notices it specially as it  affects
the eyelids, pityriasis  palpebrarum ; the mouth and lips,
pityriasis oris  et  labiorum; the  prepuce and  pudendum,
pityriasis prseputialis et pudendalis ;  the feet  and hands,
pityriasis palmaris et plantaris ; and  the scalp, pityriasis
capitis.  None of these,  except  the  last, differ  essentially
from the eruption as it affects the body  generally, and do
not, therefore, require to be specially described; many der-
matologists, indeed, and I think with much correctness,
admit the existence of but one local variety of pityriasis,—
that of the scalp. 
PITYRIASIS.
193
  The development of pityriasas capitis (Atlas, PL XI.
Fig. 3)  is not  accompanied  by any sign of constitutional
or local disturbance, but soon after its eruption it gives rise
to much itching, without heat  or  redness  of  the surface.
The disease consists in  the secretion of numerous minute,
papyraceous, dry, and shining scales, in most cases scattered
over the entire of the head,  Avithout any sensible elevation
of the surface,  and perfectly  free from moisture.   I  cannot
describe the precise manner in which the eruption originates,
as I have never seen it until the squamous secretion was
fully developed,  there  being no  symptoms to direct  the
patient's attention  to it until  then.  The  presence of  the
scales produces much  itching, compelling the individual
affected to scratch the head, by which they are  very readily
detached in large quantity, in the state of  a fine powder or
dandruff; their removal is rapidly succeeded  by a further
secretion.  If the condition of the scalp in pityriasis  capitis
be examined, the surface is found to be closely covered with
the imbricated  scales, with small intervals  here and there;
the skin of the unaffected parts  presenting a smoother or
more polished appearance than  natural.   On removing  one
of the scales we  find that the spot on which it is seated is
raised, and  that  another finer  scale may be removed from
it;  and it is not until after the removal of several  scales,
each finer than the  preceding, that Ave  arrive at  the red-
dened and inflamed surface of the scalp, which is somewhat
depressed.  The chief annoyance which it causes is itching;
the patient, in  scratching himself to allay this  troublesome
symptom, removes large quantities  of dandruff; and in  the
child the irritation  is often so great that the scalp is torn,
becomes inflamed, eczematous vesicles appear, and the origi-
nal affection is  thus  complicated.
  Although the  hair in this  eruption is  not apparently
diseased, it  grows  weak and  thin, and falls  out on  the
slightest cause, so  that, when  of  long  duration,  baldness
may result, which, except in  very old persons, is, however,
only temporary.
  Pityriasis diffusa  may occur  at  any  age, but it is most
common  in  adults;  it seems to affect both sexes with  an
equal degree of frequency.  Pityriasis capitis is  most usually
                          17 
194
SQUAMAE.
met with in  infants  at  the breast, the  frequency of its
appearance  decreasing with the advance of years towards
puberty, at  which age it is  of  very rare occurrence, but it
again appears at the approach of old age.  It thus seems
to  be  most  frequent when  the head is least covered with
hair, and it  is -also most generally seen in individuals Avhose
hair is naturally thin.
   The causes of pityriasis are  very obscure;  in most cases
it is manifestly a constitutional affection,  but in some in-
stances it is  evidently produced by the  action of local  irri-
tants.   Thus  its occurrence  on the  scalp  may be often
accounted for by the use of hard  brushes  or a fine-tooth
comb, or from not drying the head  sufficiently after it has
been washed; appearing, too, most frequently at those ages
in Avhich the scalp is least covered Avith hair, it may be then
caused  by the  sudden changes  of temperature  to  which
the surface  is consequently exposed.  The eruption, when
general, appears to  be more or less connected with some
deranged state of the nervous system, especially when  this
state is accompanied by increased cutaneous susceptibility,
and is  also not unfrequently attendant on a disordered con-
dition of  the digestive organs.   I can confirm the observa-
tion of  Cazenave that in  some cases, especially in  nervous
females, pityriasis capitis succeeds repeated attacks of nerv-
ous headache.  The use  of stimulating cosmetics,  whether
in the form  of lotion or of pomade, is a not unusual exciting
cause of the eruption.
   Diagnosis.—Pityriasis is  distinguished from psoriasis by
the fineness  and thinness of the scales, which are not thicker
than the  healthy scarf-skin, even Avhen the disease is very
chronic; by their being desquamated in excessive quantity;
by  the  parts  affected being  scarcely  elevated above  the
surrounding integument;  by the peculiar  color of  the  sur-
face of the skin on which  the eruption is  situated ; and by
the attendant pruritus. It might be confounded with chronic
lichen or eczema, in consequence of the furfuraceous desqua-
mation  which attends the advanced stages  of both these
diseases;  pityriasis,  however, is not  preceded by any erup-
tion, is never  accompanied by  any  discharge, and in it the
skin is never chapped nor fissured. From ichthyosis the diag- 
PITYRIASIS.
195
nosis is  made without  difficulty, the  peculiar dry, hard,
rugose, and,  so  to say, horny condition of the integuments
being sufficiently characteristic of that affection.  Pityriasis
capitis is distinguished from the other eruptions which occur
on  this region  of  the  body by its true scaly nature, the
scales being  minute,  dry, papyraceous,  and  imbricated,
though scarcely, if at all, elevated above the surface of the
scalp, and readily separable in the form of a fine powder or
dandruff;  by there being no attendant inflammation unless
it be produced by some irritating cause ;  by the absence of
discharge ; by the hair  being unaltered, but falling out more
easily than natural;  and  by its not  being contagious; it
occurs, too, most generally in advanced periods of life, being
rare in childhood, adolescence, and manhood.
  Prognosis.—Trifling an eruption as pityriasis seems to
be, it is one  of extreme obstinacy, and  not unfrequently,
Avhen it has  continued long, causes more  or less derange-
ment of the  general health, chiefly from the mental annoy-
ance Avhich  its  persistence occasions ; this is especially
witnessed Avhen it  affects the scalp of females at  or about
the age of puberty, to Avhom the falling out of the hair and
the continued desquamation of dandruff are a source of con-
stant distress : I have seen more than one instance in which
extreme nervous and  general  debility Avas produced  by
this cause  alone.  The  longer pityriasis has lasted the more
difficult it  is to cure, and relapses after apparently perfect
recovery  are very  likely to occur.  That the continued
existence of  the eruption generally over the surface of the
body may not be altogether unattended  with danger is
proved  by Rayer's narrative of a  case in which he saAV it
prove fatal.
  Treatment.—In  the  treatment of pityriasis,  as of many
other cutaneous diseases, it is too much the habit to resort
to the indiscriminate use of active stimulants both internally
and as topical applications ; I do not mean  to undervalue
the benefit derived  from their employment in many chronic
eruptions, but I must protest against the custom which for
some years back has become so general, of  having recourse
to them in all cases Avithout regard to  the fact that a majo-
rity of the affections of the skin are inflammatory in their 
196
SQUAMA.
 origin, and that  even in their advanced  stages, when all
 tendency to inflammatory action has apparently disappeared,
 local irritation or capillary excitement often causes a fresh
 outbreak of the eruption, or an aggravation of the symptoms.
 These remarks, while they  are true of  many cutaneous
 diseases, are especially applicable  to that  now under  con-
 sideration,  which,  though  much  less inflammatory  than
 many others, is extremely liable to  be  reproduced by the
 action of stimulants,—whether constitutional or local,—a
 fact that every one, who  has  had any experience in  the
 treatment of this  class of affections, must,  I feel certain,
 have observed.
   When pityriasis  is of the diffuse  form, if it occurs in
 strong,  healthy, young persons, a small general bleeding
 proves often of service in its  early  stages,  but the with-
 drawal of blood is not admissible otherwise ; tepid gelatine
 baths should  be  used for at  least  half-an-hour daily, or
 every second day from the first, and purgatives  be freely
 administered : of the latter class of  medicines none prove
 so useful as the alkaline cathartic mineral waters, either
 thermal or cold, according to the age  and constitution of the
 patient;  for example, those of  Carlsbad or Marienbad ; but
 a combination of mild mercurials with alkalies, as in some-
 what the following form, should be prescribed at the same
 time:—

     B.  Pilulae Hydrargyri,.......gr. ix.
        Sodae Carbonatis siccati,.....gr. vj.
        Extracti Taraxaci,.......gr. xij.
        Extracti  Hyoscyami,......gr. iij.
                Misce.   Fiant  pilulae sex.
 " One to be taken every second day half-an-hour before
                        dinner."

  When  the mineral waters cannot be procured, a drachm
of the sulphate of soda—previously deprived of its water
of crystallization by exposing it to a red heat—and twenty
grains of the bicarbonate of soda, dissolved in a half-a-pint
of tepid  water, may be given in the morning after the  pill.
  Should the  eruption resist this  plan of treatment,  and
exhibit a tendency to become chronic,  alkaline baths— 
PITYRIASIS.
197
 four  ounces  of  the carbonate  of soda, or  two ounces of
 purified carbonate  of potash, in suffioient fresh water for
 an ordinary bath, at the temperature of from 80°  to  92°
 Fahr.,  according to the season of the year—may be sub-
 stituted for those of gelatine; and the surface of the body,
 previously  well  dried  after  leaving the  bath,  should  be
 anointed with a pomade, composed of four ounces of pre-
 pared lard, Avell  beaten  up  with an equal quantity of  elder-
 flower Avater, then squeezed as dry as possible, and half an
 ounce  of  glycerine added.  The  mercurials and alkaline
 saline  cathartics must  still be  continued ;  but  should the
 eruption become essentially chronic, the more active consti-
 tutional alteratives, iodine and arsenic separately or  com-
 bined, as recommended  for the treatment of psoriasis, must
 be prescribed.  In  cases in Avhich the pruritus  is extreme,
 chloroform, added  to the pomade above recommended,  in
 the proportion of from eight to twelve minims to the ounce,
 Avill be found the most effectual application  for allaying it ;
 lotions  and ointments containing  prussic acid  or the pre-
 parations of lead, have been employed usefully for the same
 purpose.
   In some of the local forms of pityriasis, the vapor douche
 bath  is of especial  service,  and the constitutional treatment
 applicable to the general disease is  also indicated.  When
 the scalp is the part affected, the hair should be cut close—
 not shaved off—and so kept during  the progress of the treat-
 ment :  this is not requisite in old  persons Avhen the  hair is
 thin on  the head.   In the  early stages, weak alkaline oint-
 ments and lotions,  with  the addition  of glycerine to either,
 Avill be found the most beneficial applications; but when the
 eruption is of long standing, or occurs in persons of  debili-
 tated constitution, the tannic acid or  dilute citrine ointment
 should  be substituted for the former, the lotion being still
 used each time before the ointment is applied.   When the
 eruption appears on the scalp of scrofulous children,  cod-
 liver oil will be beneficially  administered; but for those Avho
 are not scrofulous the alterative powders of the iodide of
 mercury and hydrargyrum cum creta, as I have recom-
 mended for other diseases of the scalp, are better adapted.
 In  very obstinate cases of  any  of the local forms of this
eruption, more stimulating  applications  may be tried, such
                           17* 
198
SQUAMJE.
as ointments containing calomel or white precipitate, in the
proportion of a drachm of  either to  the ounce of  prepared
lard or of white wax ointment, with  the addition  of glyce-
rine, or lotions containing the cyanide of mercury or corro-
sive sublimate; but their effect must be carefully watched,
as they often cause a sudden aggravation of the symptoms.
For the same reason the sulphurous mineral waters and sul-
phurous baths should be used-with caution, yet they unques-
tionably prove at times of  much benefit  in chronic cases of
the disease in persons of a  languid circulation.
  Dietetic  rules  are most important in the  treatment of
pityriasis, and  when  the digestive  organs are  deranged,
remedies calculated to  restore their  healthy tone should be
employed.  The food  ought  to be light but nourishing, as
the strength  must be  supported, and therefore milk  and
farinaceous articles of  diet are especially indicated : in the
case of children, a  strictly milk and vegetable diet should
be enforced.  Stimulating  or heating drinks must be  alto-
gether prohibited, and  the surface of the body kept as much
as possible of a uniform temperature, extremes of  heat and
cold being avoided.  In consequence of the liability to re-
lapse, whatever treatment  may be found  to  be successful
should be continued for at  least a month or six weeks  after
an apparent cure has been  effected. 
HYPERTROPHIC.               199
                  CHAPTER  VII.

                     HYPERTROPHIC

  In the Order Hypertrophic, I purpose to include all
diseases  of the skin which are  specially characterized by
an hypertrophied condition, attended with a morbid change
from their  normal state, of any or all of the anatomical
elements which compose the tegumentary membrane.   The
affections to be described  in this division are of a chronic
nature both in their  development  and progress, rarely ex-
hibiting  in  any of their stages signs of constitutional dis-
turbance or inflammatory  action,  either local or general;
yet some of them are unquestionably of constitutional ori-
gin, while  others  are  manifestly produced by  the direct
action of irritant causes.  I have already mentioned the ob-
jections which exist to the employment of the term  " Tuber-
cula," for the purpose of designating a group of  diseases of
the skin, or to its  retention at all in cutaneous  nosology ;
applied formerly to  include several  affections,  nearly all
modern dermatologists who still retain it have restricted its
application to some forms of secondary syphilitic eruptions,
to Lupus, and  to Elephantiasis;  now of these it is evident
that the  first will be  both more correctly classed and more
conveniently described with the  other syphilitic  diseases
which affect the skin; the second is specially characterized
by  its malignant nature; and  therefore the third  only can
Avith any degree of accuracy be designated as a  tubercular
affection, and yet although placed by Willan  and Bateman
in this class, it differs essentially from their OAvn definition  of
a tubercle.
  The appellation I propose has the advantage of not being
an  innovation in cutaneous nosology ; it has  a place in all
modern natural systems of classification of  affections of the
skin, as constituting a special group, and I  only seek to ex-
tend its  signification as  in  any artificial arrangement may
be correctly done—there being no necessity here for regard-
ing the so-called natural affinities, similarity of elementary 
200
HYPERTROPHIC
lesion or of external phenomena sufficing for the grouping
of diseases.  The order might  certainly be made to consti-
tute several groups Avere strict accuracy in arrangement the
sole or even chief object in my inquiry; but regarding all
systems of classification as altogether secondary, and useful
more for the purposes of description than for affording  any
aid either  in diagnosis or  treatment, I  think it better to
make as few divisions  as possible.   The folloAving are the
diseases I shall describe in this Chapter : Ichthyosis, Mollus-
cum, Stearrhoea, Elephantiasis, Verruca, Clavus, Callositates,
Condylomata, Naevus.

                      ICHTHYOSIS.

  Ichthyosis (Fish-skin disease) (Atlas, PL XI. Fig. 4) is
characterized by  a morbid alteration  and  hypertrophied
condition of  the  epidermis, by Avhich it is converted into
thick, dry, horny, adherent  scales, the orifices of the hair
follicles and of  the sudiparous and sebiparous glands being
thereby obstructed.  This  affection, classed by Willan  and
those who have adopted his views, amongst the Squamae, is,
as I have stated  in the last Chapter, distinctly  separated
from the eruptions contained in that group, by its not being
attended with any desquamation of  scales.  Most  modern
writers on diseases of the skin differ as to what are the ana-
tomical lesions by which it is constituted, and consequently,
as to the precise position which it should occupy in a noso-
logical  arrangement.   Mr. Erasmus Wilson, in his  earlier
writings, regarded it as  consisting in a  hyperformation of
the epidermis, but he has changed his opinion, and more re-
cently  announced his belief that the morbid condition of the
integuments is composed of concretions of altered  sebaceous
substance ; repeated observation, aided by microscopic exa-
mination, compels me, however, to differ with so eminent an
authority, nor have  I  been even  able  to  comprehend the
grounds  on which he has come to this conclusion.   Dr. A.
T. Thomson  did not live to  publish his opinions in the pos-
thumous work which bears his name ; but that he had not
been able to satisfy his  mind as  to the nature of the disease,
is evident from the account of it given  by his editor,  Dr.
Parkes.   By Cazenave and the  majority of the  recent 
ICHTHYOSIS.
201
French dermatologists, ichthyosis is looked upon as a lesion
of epidermic secretion, and is, therefore, made to constitute
a distinct group, of which it  is the type.  Gustav  Simon,
whose views I adopt, regarding ichthyosis as an hypertrophy
or increased development of the  epidermis,1 places it in his
classification amongst  the Hypertrophiae.
   Willan and Bateman described two forms of the disease,
terming the one ichthyosis simplex, and the other ichthyosis
cornea; they differ, however, merely as to  the degree  in
which  the epidermis is altered, and therefore cannot be cor-
rectly  separated from each other for the purposes of descrip-
tion ; other varieties have also been constituted by different
writers according to the appearance which the  altered in-
teguments may present in certain cases: thus Wilson divides
the disease into Ichthyosis squamosa, and Ichthyosis spinosa;
a form  has been termed Ichthyosis hysterix by Fuchs:  and
another, Ichthyosis scutellata  by Schonlein.
   Ichthyosis may be congenital,  but more  usually, commenc-
ing a few months after birth, lasts  for life, affecting gene-
rally, after a short time, the entire of the  cutaneous surface,
except  the  palms of the hands, the soles of the feet, the
eyelids, the  lips, and the prepuce.   It consists at first of an
hypertrophied  condition  of  the  epidermis,  which  is  dry,
harsh, and corrugated, the natural linear  markings dividing
it into distinctly separated, polygonal, and lozenge-shaped
compartments.   This  change, except in congenital cases, in
Avhich  at birth it is very general over the body, is first wit-
nessed  in certain  regions only,  namely, the  ankles, the
knees,  the backs of the hands, the borders  of the axillae,
and the neck;  the  morbid alteration becoming  gradually
more aggravated on these parts,  extends superficially also,
affecting next the scalp, the fronts of the legs, the backs of
the arms, the folds of the groins, the breasts,  and the lower
part of the  abdomen; by degrees,  however,  if the  disease
be  unchecked by treatment,  the  epidermis  of  the entire
body, with the few exceptions noticed above, becomes en-
gaged.
   When ichthyosis is  congenital,  the skin of the infant at

  1 Die  Hautkrnnkheiten durch anatomische Untersuchungen: Berlin.
Second Edition, 1851, p. 49. 
202
HYPERTROPHIC.
 birth is dry, rough, uneven, and  of a grayish-brown color,
 but  the epidermis is little hypertrophied;  this condition.of
 it may continue for years, or even for life, accompanied by
 a constant mealy exfoliation, without being further aggra-
 vated, constituting the mildest cases of the  affection.  More
 generally, however, the epidermis soon becomes thickened,
 hypertrophied, and of a scaly aspect, bearing at times much
 resemblance to the scales of a fish—whence the name derived
 from the Greek word, t*0i>s, a fish,  was applied to the disease;
 the surface is deeply furrowed, shining, and  of a sallow or
 greenish hue, free from  hairs, and devoid  of  any secretion
 or natural moisture; in parts the fissures occasionally extend
 quite through the hypertrophied  epidermis, and the derma
 beneath is seen to be somewhat  redder than in its healthy
 state, but  it is not  inflamed ; the superficial thickened layers
 may be  removed in scales by the nail, when the surface on
 which they rest presents also a similar appearance, but the
 epidermis  is rapidly reproduced again in the same unhealthy
 condition.
   Although, as has been mentioned, the orifices of the sudi-
 parous,  and sebiparous glands are quite obstructed, there
 are no constitutional symptoms caused thereby, the general
 health does  not appear to suffer  in  any respect, nor is the
 altered state of the integuments accompanied by heat, itch-
ing,  or any other sign  of local irritation.
   In some cases the epidermis is much more altered from
its normal condition than has been described above, pre-
senting  the  appearance of innumerable short  spines aggre-
gated together without  any intervening space, over all those
parts of the body which the disease affects; this  form  has
been termed spinosa by Wilson, but Dr. Copland, regarding
it as consisting in an hypertrophied and elongated  condition
of the papillae  of the  skin, proposes to name it papillary
ichthyosis.   The surface of  the  body  of  persons afflicted
with it presents a singular and remarkable aspect, being of
a greenish-brown color, and so hard as to feel like  horn  and
to produce a grating noise when the  hand is passed quickly
over it, yet more or less elastic and yielding when pressed;
the diseased epidermis  is firmly adherent to the derma,  and
if attempted to be torn off with the nail, the part  on which
it is situated bleeds  and is painful.   The  spiny elevations 
ICHTHYOSIS.
203
may be separated from each other, when it will be seen that
they are  of a  grayish or  yellowish-white color—the dark
tint existing only on  the  surface exposed to the air—and
that they vary in elevation from an  eighth to a quarter of
an inch ; some of  them, however, attain a much  greater
prominence than this, forming excrescences, or, as they have
been  termed, horns, fully an inch or even more in length.
On the parts of the body which are exposed to pressure, as
on the buttocks and on  the joints, callosities form, and  in
extreme cases  the  power of  motion may be  much limited.
This form of ichthyosis  is almost invariably congenital, not
attaining its complete development, however, until  at  or
about the age of puberty.
   Since this disease of the skin was  first noticed, it has at
all times attracted much  attention, owing to  the singular
condition of  the integuments  by which it is characterized ;
individuals affected with it in  an aggravated form having
been exhibited for money, in the case  of males being termed
porcupine men, and of females, mermaids, the latter from
the supposed resemblance of the skin to the scales of fishes ;
but it  has been  more aptly compared to the hide  of an
elephant or of a rhinoceros.   Not being of frequent occur-
rence, moreover, in its full development some of these cases
have been carefully described, the most celebrated probably
being that of the family  of the  Lamberts, which occurred in
the beginning of the last century, and to which I shall have
occasion again to refer  as illustrating the hereditary cha-
racter of the disease.
   Whether  ichthyosis is general or partial, the superficial
layers of  the hypertrophied epidermis are constantly  being
shed as a fine mealy desquamation, or, when softened by a
warm bath, may be rubbed off with the hand, but are  again
rapidly reneAved ; the  disease is always more marked on the
regions of the body noticed above, as the parts where it first
appears, and especially in  the  neighborhood  of the joints ;
on the scalp the epidermis is not so much thickened as else-
Avhere, yet most of the hair is shed Avhen it occurs there, and
what remains is thin and Aveak.  Although the general health
seems to be unaffected  in persons the  subject of ichthyosis,
attacks  of diarrhoea are of constant occurrence, probably
owing to the nearly complete obstruction  of the cutaneous 
204
HYPERTROPHIC
transpiration ; and  for the same  reason those parts of the
integuments which are not engaged, especially the palms of
the hands  and soles  of the feet, are constantly bedewed
with moisture : the urinary and  pulmonary  secretions are
also said to be increased  in quantity, but in four cases of
the disease which I have had under treatment this was not
so.   The affected  parts  are constantly below  the natural
temperature, and persons afflicted with the disease usually
suffer much from coldness of the  surface of the body.
  The nature of the anatomical changes which  constitute
ichthyosis have been carefully investigated, both microscopi-
cally and otherwise.   The following description of them is
given by Franz Simon: "The scales were of gray or black
color; when placed in water  they softened, and on  then
placing a section under the microscope I found that the ab-
normal structure was formed of compressed epithelial scales.
On incineration the scales left  an ash,  containing carbonate
and phosphate of lime and peroxide of iron ;  the  latter was
in such abundance as  to communicate a yellow color to the
ash.   The  ash yielded by the  incineration of the ordinary
thickened skin on the hands  and feet is perfectly white, and
contains a mere trace of peroxide of iron."1  This account,
directly opposed to the views propounded by Erasmus Wilson,
Avhich have been before referred to, is confirmed by Gluge,
who states  that on microscopic examination he  found the
scales to be composed of epidermic cells.
  Causes.—Obscure as are the causes of skin  diseases, gene-
rally speaking, there is probably not one of  which so  little
is known as to how or under what circumstances it is pro-
duced, as ichthyosis.  When  congenital, it has been ascribed,
like all the other  deviations from a normal state which are
observed occasionally in  the  foetus,  to the  effect  of the
mother's imagination while pregnant, it being popularly be-
lieved to be caused by a longing for some peculiar fish, or
by fright arising from something connected  with fish; but
it need scarcely be remarked that these causes of the disease
are altogether without foundation.  It occurs in both sexes,
but is much more frequent amongst males than females, in
the proportion, according  to Biett's observations, of one of

   1  Animal  Chemistry; Sydenham Society's Edition, vol. ii  p. 483. 
ICHTHYOSIS.
205
the latter to twenty of the former; this is well established
by the report of  those cases in Avhich ichthyosis  has been
hereditary,  as it not unfrequently is,—for example, in the
family of the Lamberts above referred to,  in which the dis-
ease Avas transmitted for several  generations from father to
child, the female  members of the family being in no instance
affected.  This hereditary transmission of ichthyosis has been
noticed in the majority of  instances, but many cases of the
disease occur in  children born of parents  healthy in all re-
spects, and  in whose families, as far as could be ascertained,
no trace of  the disease ever existed.  It is seen at all ages,
but is  usually congenital, or developed within the  first year
of life, very rarely appearing for the first time after the age
of puberty,  yet it has been  witnessed as a  primary affection
in old  persons, but ahvays in a modified form.  All the ex-
amples of ichthyosis which I have seen have been in persons,
whether  children or adults, of  a  well-marked scrofulous
diathesis.
   Diagnosis.—With no  other  disease of  the  skin  can
ichthyosis be confounded, so distinctly characterized is it by
the abnormal condition of  the epidermis:  in the cicatrices
of Avounds  and  of burns a  peculiar warty growth  is occa-
sionally developed, Avhich, having been first Avell  described
by the celebrated French  surgeon  of  the name, has been
termed the  warty ulcer of  Marjolin ; this disease presents
characters somewhat resembling  those of ichthyosis, but it
may be at once distinguished by its local  nature, occurring
only in those parts  of the integuments which have been
previously the seat of some severe injury.
   Prognosis.—Ichthyosis has  been in  all ages regarded  as
being  incurable ;  it is at all events a most grave affection,
and  one which usually lasts for years, if not for life.  When
it presents  the aggravated characters of the severe form,  as
above  described, it should be regarded as  beyond the reach
of medical  skill, but if it be submitted to treatment in its
early  stages, and while it  is yet of a comparatively  mild
form,  affecting the surface only partially, the progress of
the  disease may be  arrested, and its further development
prevented if it cannot be completely cured.
   Treatment.—From  the  extreme obstinacy and  general
incurability of ichthyosis, many plans, as  may be supposed,
                            18 
206
HYPERTROPHIC.
 have been recommended for its  treatment, both constitu-
 tionally  and topically.  The latter have  consisted chiefly
 in means to  soften and  promote  the  desquamation of  the
 altered and hardened  epidermis, and the former in the  ad-
 ministration  of the  most poAverful remedies Avhich  experi-
 ence has shown to act specially upon the skin.   Warm water
 and vapor baths, with the preceding or subsequent employ-
 ment of oleaginous and  greasy applications, constitute  the
 chief part of any method which  has proved at all successful
 in the  treatment of ichthyosis; their action is evidently due
 to a direct effect in softening the hypertrophied integument,
 and thus promoting its  separation ; but experience has shown
 that unless the state of  the  constitution on which  the  ab-
 normal secretion depends be at the same  time  changed, it
 is again rapidly reproduced in a similarly diseased condition.
 "The easiest mode," says Willan,  " of removing the scales,
 is to pick them off carefully Avith the nails from any part of
 the body Avhile it is immersed in hot Avater.   The  layer of
 cuticle which remains after this operation is harsh and dry,
 and the skin  did not in the cases I have noted recover its
 usual texture and softness ; but  the formation of the scales
 Avas prevented by a frequent use of the  Avarm bath, with
 moderate friction."   More  active  local  applications   are
 recommended by some Avriters on  the disease,  such as sul-
 phurous  baths, stimulating  lotions,   containing  corrosive
 sublimate and other preparations  of mercury, caustic pot-
 ash, &c.
  In an account recently published by Professor Banks1 of
 two cases of  the disease  which he  treated successfully, cod-
liver oil  Avas employed  topically, and  at the  same  time
 administered  internally;  at   bed-time the  patients  were
 placed in a vapor bath,  and  the  surface of  the body well
rubbed afterwards with the oil, a flannel  dress being always
worn next the skin, with the view of keeping the surface
 constantly impregnated with  it.   The use of this remedy
 was, he says, suggested to him  by the marked connection
which he has seen to exist between ichthyosis and the stru-
mous diathesis.
  The  internal  administration of  pitch was  highly recom-

1 Dublin Quarterly Journal of Medical Science, New Series, vol. xii. p.  80. 
ICHTHYOSIS.
207
 mended in this disease by Willan and Bateman,  and then-
 experience of its benefits has been confirmed, especially by
 Dr. Elliotson : they ordered it to be  made into pills with
 flour, and increased the dose gradually until  from half-an-
 ounce to an  ounce  was taken daily, and often continued for
 months.  But  both Rayer  and Biett state that although
 they gaAre this remedy a fair  trial, it failed completely in
 their hands.  The cold water treatment has also been tried
 in  the treatment of ichthyosis, but in  one case which I saw
 it did not produce  the least good effect; in this same case,
 enveloping  the affected parts  with  Avet lint,  covered with
 oiled silk, also failed.
   The following plan of treatment I have employed in four
 cases of ichthyosis, in three of which  the disease was local,
 being confined to the lower extremities in two, and engaging
 the upper also in the  third, and in these the recovery was
 complete and permanent;  in the other, the integuments of
 the body generally, except the  face, the palms of the hands,
 the soles of  the feet, and  some patches of the  trunk, were
 affected with the  disease,  which commenced  five months
 after birth,  and was  of three  years' duration Avhen I first
 saAv the child.   Here, after a year and a half of treatment,
 the epidermis  had regained a tolerably healthy condition,
 being only slightly hard and rough, but if  the  local appli-
 cations were omitted for four or five Aveeks, it again began
 to present a somewhat  thickened  appearance: this case is,
 consequently, still  under treatment.   The remedies I used
 Avere the iodide of  potassium  and iodine, from  one  to  two
 grains of the former, and  from a  sixteenth to an  eighth of
 a grain of the latter, according to the age of the  child, given
 once daily, in from one to two ounces of the decoction of
 elm bark, made with the recent inner  bark, stripped from
 the  groAving tree; and an ointment, containing twenty
 grains, gradually increased to one drachm, of the  iodide of
 potassium, a  drachm of glycerine, and an ounce of  prepared
 lard, Avith  which  the  affected parts were well  anointed
 morning and evening ; an  alkaline  bath—one  drachm of
 carbonate of soda  to  each gallon  of fresh  Avater,  at  the
 temperature  of  90° Fahr.—having been  used  for  fifteen
minutes  previously  to  each inunction, the body being well
rubbed  with  a flesh-brush  while  in  the bath.  An  inner 
208
HYPERTROPHIC
calico dress was worn constantly, and milk diet was strictly
enforced.   I have had no  opportunity, however, of trying
the effects of this  method  of treating ichthyosis in aduUs,
the four cases in which it proved so successful being children
below the age of  eight years.

                      MOLLUSCUM.

  Molluscum.—The origin of the employment of this term
to designate  a disease of the  cutaneous structure,  which
is chiefly interesting in consequence  of its extreme rarity,
has been  a matter of discussion.  Used  by Willan  and
Bateman at a time when they themselves, not having seen
the affection, obtained their knowledge of it from the account
of a case—published in 1793 by Ludwig—that occurred in
the practice of Professor  Tillesius of  Leipsig, it is most
natural to infer that its application was  derived from  the
description therein contained, in which the  small  tumors
that constitute the  disease are said to  consist in  " verrucis
mollibus sive molluscis ;"  yet nearly all the French  derma-
tologists ascribe its employment to some  imaginary resem-
blance between them and the minute excrescences that form
on the bark of  the  maple tree.   It is characterized by the
development on the skin of round, slightly umbilicated,  soft
tumors, varying in  size usually  from  that of the head of a
pin to  that of a nut, but described as occasionally acquiring
the magnitude  of a pigeon's egg;  they are of a yellow or
pinkish-white color, sessile, rarely pedunculated,  scattered
irregularly over the surface, yet  occurring not unfrequently
in small groups, of slow growth,  and unattended with either
local pain or constitutional irritation.  When pressed be-
tween the fingers, a small quantity of  a thick, whitish fluid
exudes from the minute aperture that forms the umbilicated
apex of each tumor, the exudation being evidently  altered
sebaceous secretion.  They appear on all  parts of the cuta-
neous surface, but are most frequently Avitnessed on the face,
and most  rarely on  the extremities;   their duration  is
uncertain, in some cases ulcerating and  falling off sponta-
neously, their  site  being marked by a  slight cicatrix, in
others lasting  for  life, without  undergoing  any increase in
size, but  the skin covering them  becomes  darker colored or 
MOLLUSCUM.
209
 brownish,  and  the tumors themselves acquire  a certain
 degree of  hardness.   The  internal structure of the tumors
 of molluscum is cellular, a  transverse section often exhibit-
 ing five or six divisions, each of which corresponds to a duct
 of  the sebaceous  follicle,  and contains altered  sebaceous
 matter.
   Bateman, after witnessing  some  cases  of the disease,
 described  it as consisting of tAvo varieties,  which he named
 molluscum  contagiosuni  and  molluscum non contogiosum,
 but inasmuch as  it is doubtful that the  latter, as described
 by him, Avas truly molluscum,  and  at all events as the dis-
 tinction he drew cannot  be regarded as sufficient to consti-
 tute  a specific difference, his  division must be abandoned.
 The  eruption consisting  admittedly in  a hypertrophied
 state of the sebaceous  follicles, and  being  therefore  of the
 same nature, anatomically  considered, as acne, some  recent
 French writers, especially MM. Caillault1 and Bazin,2 have
 regarded molluscum as a species of that  disease; the former
 termed it Acne molluscoides,  and  the  latter Acne varioli-
formis : the absence of local inflammation, hoAvever, clearly
 distinguishes it from  that  affection.  The best division  of
 the disease, I consider, is that proposed by Dr. Craigie,  in
 an  able essay published in  the seventy-fifth volume of the
 Edinburgh Medical and Surgical Journal, namely, into

                   Molluscum acutum.
                        "     chronicum.

  Acute molluscum (Atlas, PL XI. Fig. 5) agrees, in all
 respects, with the form which is generally regarded as  being
 contagious ;  it occurs usually on the face and neck of chil-
 dren, and from  them  is  conveyed to adults,  most invari-
 ably,  however, of the same  family.   It is developed at first
 in the form of minute papulae, scarcely noticeable, and un-
 attended with any local symptoms; these gradually increase,
 until, in from six weeks to  two months, they attain the size
 of a  small  currant, which  they resemble much  in shape,
 being somewhat pellucid, and sessile on  the portion  of in-
tegument from which they groAV.  Their duration is seldom

  1 Archives Ge'ne'rales de Meilecine, 1851, vol. xxii. pp. 46 and 316.
  2 Journal des Connaissances M6dic;iles, 1851, p. 277.
                           18*
* 
210
HYPERTROPHIC.
prolonged for more than six months, but their progress is
often more speedy, terminating either by ulceration, which
first commences at the apex, an opening being there formed
through which the  altered sebaceous matter contained  in
them  is discharged, when the small tumors collapse and
shrink away, or by an  attack of  local inflammation, when
they slough off, leaving a pit like that resulting from small-
pox.   In most cases the  molluscous  growths are developed
in successive crops.
   In  chronic  molluscum,—the  molluscum  pendulum  of
Willan (Atlas,  PL  XI.  Fig. 6),—the tumors,  which are
more  generally distributed over the surface of the  body,
attain a much larger size, and  are more frequently pedun-
culated ; they are sometimes very few in number, may even
be solitary, but occasionally several of them are developed
on different parts of the  integument at  the  same  time.
This form is most frequently witnessed in  adults, and runs
an essentially chronic course, lasting often for life if unin-
terfered with, yet with but little increase in size.    Occa-
sionally, as in the acute variety, inflammation attacks some
of the tumors and they slough off.
   The chronic  and  acute forms of  molluscum  differ espe-
cially, to use the Avords of Dr. Craigie, " in the circumstance
of the latter being  propagated by a specific matter, while
the former is, so far as is hitherto known, entirely incapable
of such communication."   This contagious property, though
its existence is   denied  by many modern  writers  on  the
disease, is, I think, too well established by the  numerous
cases which have  been recorded  by  Bateman,  Craigie,
Thompson,  Carswell, Henderson,  Willis, &c ,  to admit of
doubt.  M. Caillault, in  the  essay on the disease recently
published by him, to which  I  have  referred above, states
that he  himself  did not believe  in its contagious  nature
until it  was proved  to him in April, 1851, in one of the
Avards at the Hospital St. Louis, at Paris, fourteen children
out of thirty having taken the disease in the course of three
months from a little girl  who had been admitted with  nume-
rous molluscous tumors on  the face.   Mr. Erasmus Wilson,
Avhile denying the communicability  of molluscum  by con-
tagion,  narrates  a case  in  which  one  child of a  family
having been brought to him affected with the disease, it 
molluscum.
211
appeared in a few weeks afterwards in the mother and two
other children,  an  infant, and a  girl six  years old;  he
adds : " I quieted her  alarm relative  to contagion, but was
much struck by the fact of the almost simultaneous appear-
ance of the disease upon four members of the same family.1
I have  myself witnessed two instances in which  the  acute
form  of this  affection was  communicated by  children  to
adults, in each case members of the same family."  I have,
therefore,  no doubt in  my mind  as  to  its possessing  the
property  of being propagated by  direct contact, as from
persons sleeping together,  or in the case of children while
at play.
  As regards the causes of molluscum, in either  of its forms,
but little is known; the acute variety is most frequently met
with in children of the female sex, rarely occurring in adults
unless when it is communicated to them by children;  the
chronic form, as already remarked, is generally witnessed
after the  age of puberty, and is not unfrequently connected
with a  deranged condition of the general health, while the
former  occurs in the most  healthy individuals, the skin of
those affected, however, is usually fine and soft.
  The diagnosis of this disease is unattended with difficulty;
from warts, for  which the little tumors might be mistaken,
they are distinguished by their shape, their  softness, their
color, and the central  depression at their apex ; from fatty,
or other pendulous tumors, in addition to these  character-
istics, their sIoav development and growth aid as  diagnostic
marks.
  Prognosis.—The chronic  variety of molluscum may  last
for life without  the least injury to health or  impairment of
the  constitution, but   occasionally troublesome  symptoms
may arise from attempts  made to destroy or remove  the
tumors.  In one instance communicated to me by Dr. Lees,
the  case  of a female,  aged 18, who  was  under his care in
the  Meath .Hospital,  the application of  potassa fusa  was
followed hy erysipelas, which terminated fatally.  Acute
molluscum generally disappears spontaneously  in from four
to six months.
   Treatment.—Internal remedies do not appear to haAre any
effect over molluscum, and are therefore not required in its
           > On Diseases of the Skin, Third Edition, p 387. 
212
HYPERTROPHIC
treatment, except  such as may be calculated  to  restore a
healthy condition of the symptoms generally,  should it be
deranged.   Local applications  are not  advisable  in the
chronic variety of the  disease, but  the tumors may be
snipped off with  a sharp pair  of scissors, and  the  surface
then touched with lunar  caustic, provided the patient be in
a state  of good health, but when such is not the case this
should first be attended to.  In  the acute form, the employ-
ment of a slightly stimulating lotion, as  of sulphate of zinc
or sulphate of iron, ten grains of either to an ounce of dis-
tilled water and  a drachm of rectified  spirit,  hastens the
throwing off of the small tumors.

                      STEARRHCEA.

   Stearrhcea is  a disease of  the sebaceous follicles, char-
acterized—as  the  name atsap p?w indicates—by augmented
secretion and discharge of their  natural contents, the folli-
cles themselves and their excretory ducts being at the same
time somewhat hypertrophied.  The increased secretion may
consist merely in  an  excessive  amount of the  natural oily
matter or smegma destined for the preservation of the skin
from external irritants, or  in its discharge on the  cutaneous
surface in a vitiated condition, where it concretes and forms
a thick adherent layer, varying in color  from a rich  yellow
hue to nearly black.   The former is of very frequent occur-
rence, and can scarcely be regarded as constituting a disease,
while the  latter, a rather rare affection, is of extreme obsti-
nacy, usually resisting treatment for years.   Three varieties
of the diseases, thus constituted, require  to be noticed:—
                   Stearrhcea  simplex.
                        "    flavescens.
                        "    nigricans.

   Stearrhcea simplex  (Sebaceous flux) is marked chiefly by
an oily or greasy  state of  those parts  of  the integument in
which the sebaceous follicles are numerous, as the nose, the
cheeks, the ears,  the  scalp, and other regions where hair
grows ;  it is an accompaniment usually  of a coarse, sallow
condition  of the skin, and is generally Avitnessed  in a class
of persons who  are liable to be affected with acne, as noticed 
STEARRHCEA.
213
in the  description of  that disease.   The orifices of most of
the sebaceous follicles are usually much dilated, but others,
becoming obstructed, present the appearance regarded as
being  characteristic of acne punctata.  This state of the
cutaneous surface is  manifestly  hereditary in most cases,
and is  a constant accompaniment, or rather may be regarded
as a sign of the scrofulous diathesis;  it lasts generally during
life, appearing in youth, but being less marked in old age ;
and although indicative, cannot be considered as a cause, of
an unhealthy constitution ;  when  it exists, the natural per-
spiration is  deficient in quantity, and congestive or inflam-
matory affections of some of the  internal organs, assuming,
however, a scrofulous character, are  more  apt to occur.
   Stearrhoea flavescens (Atlas, PL XII. Fig. 1).—It is only
of late years that this affection, which is of rather rare occur-
rence,  has attracted the attention of dermatologists; Rayer
was the first to describe it under the name of sebaceous flux,
and after him it was specially noticed by Biett, Avho, regard-
ing it  correctly as dependent on a diseased condition of the
sebaceous follicles, although admitting the difference which
exists  between  it and the true  pustular  acne,  made it a
species of that eruption, under the  nature of acne sebaeea.
Erasmus Wilson gives an  illustration of the  disease in his
beautiful Portraits of Diseases of the Skin, where he terms
it Inflammatio Folliculorum, while in his octavo work he
describes it under the name I have adopted.
   It is characterized  by an exudation from the sebaceous
follicles of their  natural secretion, more or less altered, on
the surface of the skin, where it forms a yelloAvish or green-
ish-yellow  crust  or layer—in  the former case resembling
the cerumen of  the ear, of variable thickness and  consist-
ency, at times so soft as to be readily wiped off, but more
generally hard and firmly  adherent.  By exposure to the
action  of the atmosphere the  effused matter gradually ac-
quires  a darker tint, presenting at length a brownish hue,
and numerous cracks  or fissures divide it into small packets,
which  often correspond with the linear markings of the skin.
The portion  of  integument on which the diseased secre-
tion had been seated, if examined after its  removal, is found
to be more or less injected, not unfrequently inflamed, and
the sebaceous follicles hypertrophied, with their orifices en- 
214
HYPERTROPHIC
 larged, and filled with the peculiar matter, the presence of
 which constitutes the disease.  The crusts  on  the surface
 are rapidly.renewed after their removal, and, if uninterfered
 with, soon form a  layer three or four lines in  thickness.
 The parts affected are the seat of sharp tingling, occasion-
 ally of stinging pains,  accompanied by heat and itching.
 There is generally, also, a  deranged  state of the  health,
 evidenced more especially by the condition of the digestive
 organs, in those persons on whose skin the disease appears,
 and from its occurrence most usually on the face, causing,
 in  consequence, much disfigurement, great mental distress
 is occasioned.
   Stearrhcea flavescens, as is evident from the description
 now given, is an affection of  the sebaceous follicles,  and is,
 therefore, Avitnessed only on those regions of the skin where
 these glands exist, being of most frequent occurrence in the
 parts in Avhich they are most numerous : it therefore appears
 usually on the  nose, the cheeks, the eyelids, the ears,  and
 the scalp, but it is also seen occasionally on other portions
 of the integument.   It  runs essentially  a chronic course,
 spreading in general but slowly from where  it is first de-
 veloped, and  if removed by  artificial means, being  again
 quickly reproduced.
   Stearrhcea  nigricans  (Atlas,  PL  XII. Fig. 3), although
 differing from the  form now described apparently only in
 the color of the effused  diseased  secretion,  which is nearly
jet black, deserves a special notice, in consequence  of  the
 singularity of the appearance which  it presents, and its ex-
 treme rarity.   In it the matter discharged from the follicles
 is of a thinner consistence than in stearrhcea flavescens, and
 is from the first of the  same dark color, which, moreover,
 stains linen, or any other substance with which it may come
 in contact.   From the few cases  of the disease which have
 been recorded, it would appear  also to be  attended with
 more local irritation, at times amounting to  severe pain and
 burning  heat.   Its occurrence is  accompanied by general
 constitutional disturbance, and in one case recorded by Mr.
 Teevan,1 which had been first under  the care of Dr. Readj
1 Medico-Chirurgical Transactions, vol. xxviii. p. 611. 
STEARRHCEA.
215
 of Belfast, if the secretion  of the  diseased matter  on the
 surface was arrested by local treatment, black vomiting, and
 the discharge  of a black substance  from the bowels and
 kidneys, took place immediately.   The black secretion  in
 this patient, a young lady, Avas analyzed by Dr. G. 0. Rees,
 and found to consist of carbon, iron, lime, albuminous mat-
 ter, fatty matter, and alkaline chlorides and  phosphates.
 The instances of this peculiar affection which have been pub-
 lished were seemingly even more obstinate  than the  second
 form of the disease Avhich I  have described :  it was in all of
 them situated on the same region of the skin.
   The  causes of any of  the forms of stearrhcea  are very
 obscure ; the first is both congenital  and  hereditary, but
 the others have not been proved to  be  either; they appear
 only in persons Avho have attained the age of puberty, and
 are very rarely Avitnessed in advanced  life, yet  I have seen
 one example in which  stearrhcea flavescens  was developed
 on the nose after the age of seventy ; they occur, too, Avith
 much greater frequency  in  females  than  in males,  and in
 the former their connection with suppressed menstruation  or
 uterine derangement,  has been in some instances noticed ;
 but in the majority  of cases  their development  is preceded
 and accompanied rather  by  derangements of the digestive
 organs.
   Diagnosis.—Stearrhcea simplex  cannot  be  confounded
 with any other affection of the skin; the other forms, how-
 ever, in  consequence chiefly of their  rarity, are often not
 recognized when they  occur, and  therefore occasion much
 doubt as to  their nature.   Thus, an  account of five cases  of
 Avhat, from the description and accompanying illustrations
 I conceive to be stearrhcea flavescens, has been recently
published by Drs. Addison and Gull,1 but denominated by
them Vitiligoidea plana  and Vitiligoidea tuberosa, from a
supposed  correspondence  betAveen the affection  and the in-
correct  definition of vitiligo, Avhich  was given by Willan ;
and the case of Mr. Teevan, above referred to, was originally
communicated to the Medico-Chirurgical Society of London,
as being an  example of  Pityriasis nigra.

       1 Guy's Hospital Reports,  New Series, vol. vii. p. 265. 
216
HYPERTROPHIC.
  Prognosis.—Stearrhcea flavescens  and Stearrhcea nigri-
cans are both most obstinate affections, and appear to be
equally rebellious to all plans of treatment, but are chiefly
important in consequence  of the  disfigurement which they
occasion, being not in the least degree  attended with any
danger to life.  In  the former, I have  seen the sebaceous
follicles take on an  actiA'e inflammatory action when caustic
applications were applied to  the diseased surface, and indo-
lent pustules form, which, on the  continuance of the irrita-
tion, terminated in obstinate ulcers, with hardened elevated
edges.
  Treatment.—The first  and most important point to be
attended to is  the restoration of a healthy condition of the
system ;  this is best effected by the internal administration
of alteratives, combined with alkalies, such as  the  hydrar-
gyrum cum creta with dried carbonate of soda, or cod-liver
oil Avith lime water, according to the circumstances of each
case ; the latter combination is readily taken in milk, from
one to four drachms of the oil being given three times daily,
in one  ounce  each of lime water  and new milk, previously
mixed.   As soon as the state of the digestive organs is im-
proved, or the menstrual function  restored, preparations of
iodine,—especially  the  syrup of the iodide of  iron, or the
iodide  of potassium in some  tonic vegetable decoction or
infusion,—will be prescribed with benefit.   Of course the
employment of purgatives,  Avhen  requisite, should not be
omitted.   The local applications that are found most useful
are  gently  stimulating  and astringent  lotions  and  oint-
ments.   The  affected surface should be sponged  three or
four times a day with  the spirituous lotion recommended for
acne simplex  (see  page 123), an  ointment containing ten
grains of thejodide of potassium to the ounce of cold cream
being applied  at night, or a  solution of the iodide of iron,—
two grains to  the ounce of  rose or elder-flower water, and
dilute citrine ointment may be used.   No matter what reme-
dies, however, are employed, they must  be continued for a
very long time, and  local means will be found unavailing
until the general health is restored.   The application of
caustics  I have invariably seen productive of injurious con-
sequences.  When  the crust of effused sebaceous matter is 
ELEPHANTIASIS.
217
hard, dry, and adherent to the surface, it should be removed
by the application of poultices or of water dressing, previ-
ously to the use of topical remedies.

                     ELEPHANTIASIS.

  The term Elephantiasis has been applied, both in ancient
and modern days, to designate two perfectly distinct diseases
of the integuments;  the one, which has been specifically
denominated elephantiasis  Graecorum, is believed to be the
true lepra  or leprosy of antiquity, while the other,  which,
from having been first accurately described by the Arabian
physicians, has been termed elephantiasis Arabum, does not
bear the least analogy to it.   Consistent with the scope of
this work, neither  of them requires or can obtain a detailed
notice, inasmuch as the  former is  never  witnessed in Euro-
pean countries in the present time, and the latter is of ex-
tremely rare occurrence.
  Elephantiasis  Graecorum  (Atlas, PL XII.  Fig. 4) is
characterized by the development on the  integuments of
numerous  globular tumors, varying in  size from that of a
pea to that of an apple, soft and unyielding  to the touch, at
first of a dusky or livid hue, but afterwards becoming brown-
ish-yellow  or of a bronzed tint.  They occur most usually
and  in greatest number on the face, but may appear also on
every region of the body; the  skin of the part affected is
much hypertrophied, raised into irregular elevations, and of
an unhealthy diseased appearance,  causing the sufferers from
the disease to present a  hideous aspect,  described by those
Avho have witnessed it to be revolting in the extreme, whence
they have in all ages been regarded with abhorrence, as indi-
viduals specially afflicted.   Both  mind and body share at
length in the local disease, the senses become obtuse, fatuity
creeps on,  and all the bodily functions are deranged. Even-
tually the  tumors ulcerate, exude  in ichorous  matter,  and
form unhealthy, open sores;  the bones soften,  and become
affected with caries: mortification not unfrequently attacks
the  smaller joints, and death soon terminates sufferings
which  are  extreme.
   This disease, which is still endemic in many countries in
tropical climates,  Avas, in the middle centuries, of common
                           19 
218
HYPERTROPHIC
occurrence in temperate latitudes also, hospitals being spe-
cially built and  endowed  for the reception and isolation of
those whom it attacked ;  Professor Simpson, of Edinburgh,
has published a most interesting and learned history of those
that existed in England and Wales ;x there were several of
them in Ireland  also, and the name  of 'Leper Hospital' is
still retained for  the infirmary in the  city of Waterford, now
happily no longer required for the reception of individuals
affected with a disease  similar to that for which it was ori-
ginally  built.  In  some  of the more northern regions  of
Europe, a form of elephantiasis Graecorum is  even  in the
present day of not unfrequent occurrence ; it is known in
SwTeden and Norway by the name of  ' Spedalskhed' (Atlas,
PL  XII. Fig. 5), and has been recently described and illus-
trated in a magnificent Avork, undertaken by the desire and
at the expense of the Norwegian Government,  by two Dan-
ish  physicians, Danielssen and Boeck.
  Elephantiasis  Graecorum was, in former times, regarded
as highly contagious, but it is more probable, judging from
the  accounts of it which have come down to us, that it Avas
rather endemic than infectious, and that it  was directly
caused by misery, deprivation, and filth.   Treatment seems
to have had  but little effect over it, for although isolation
and hygienic measures  then and in the present day checked
its progress-, it almost invariably re-appeared in those whom
it had selected as its victims.
  Elephantiasis Arabum (Barbadoes leg). (Atlas, PL XII.
Fig. 6.)—The popular name for this  singular affection indi-
cates its frequency of occurrence in the West India Islands,
where it is endemic, but  cases of it  are also  witnessed  in
Egypt, in America, in various countries of Europe,  and,  as
was remarked originally by Dr. Graves,2 are not very un-
common in Ireland ; it is, however, less frequently seen now
than at the time his account of it was published, twenty-
six  years ago.
  The disease consists in an extreme degree of hypertrophy,
affecting one or both of the lower extremities,  the scrotum,
the  hands or arms,  and occasionally even  the face, and the

     • Edinburgh Medical and Surgical Journal, vols, hi  and lvii.
     2 Dublin Hospital Reports, vol. iv. p. 54. 
elephantiasis.
219
 mamma and pudendum in females ; the enlargement affects
 equally the skin and the subcutaneous and deep-seated areo-
 lar tissue,  so as to produce an enormous swelling of the part
 attacked, one of the legs not unfrequently exceeding in mag-
 nitude the girth of the body.  It  commences usually with
 symptoms  of local inflammation chiefly engaging the lym-
 phatic system,  and  general  constitutional derangement ;
 these attacks  are of frequent occurrence, and after each,
 the  parts  engaged become more and more swollen, chiefly
 from effusion into  the areolar texture ;  but in some cases,
 especially  in temperate climates, the enlargement comes on
 slowly, and gradually augments without any apparent dis-
 turbance of function, local or general.  When the affection
 is fully developed,  the integuments, which are enormously
 thickened, are generally of a whitish color, rough and swol-
 len, and present deep furrows, occasionally the seat of ulcera-
 tion, a thin, ichorous discharge, which concretes into hard,
 scaly incrustations, then issuing from them.   To the great
 hypertrophy of the integuments is due the name of this dis-
 ease, but in order to distinguish it from  that last described
 the term Pachydermia, first proposed by Fuchs, has been
 adopted by many modern dermatologists.
   When the scrotum is the  part affected, as it very fre-
 quently is  in the colored population of tropical climates, it
 attains  at  times an enormous magnitude;  Horner, in his
 Medical  Topography of Brazil, narrates tAvo  instances in
 which the  tumor situated there  measured four feet in cir-
 cumference.   The upper extremities, when attacked by the
 disease, do not  acquire as  large a size as the  lower, mani-
 festly in consequence of their containing less areolar tissue.
 The  palms of the  hands and soles of the feet are never
 affected.
   The causes of elephantiasis Arabum  are altogether un-
 known, if Ave except its apparent connection Avith inflamma-
 tion  of the lymphatics ; it is not contagious ; it affects both
 sexes equally, and occurs at all ages,  but is more frequent
 in adults than in children.  Its much  greater prevalence in
 hot  countries, and  its being  more frequent there in those
 districts which are characterized by the presence of mois-
 ture, indicate the effect of heat and damp  conjoined as an
exciting cause. 
220
HYPERTROPHIC.
  There is no  difficulty in  diagnosing this  disease in its
advanced stages; in its commencement it might be mistaken
for angeioleucitis; from Avhich it appears to differ simply in
its symptoms being less acute, and in its never terminating
in the formation of purulent  abscesses.   Its duration is
essentially chronic, but although its presence renders life a
burden, it in very rare cases seems to prove fatal.
  An anatomical examination of the parts in this form of
elephantiasis exhibits the derma and epidermis usually much
hypertrophied,  the former sometimes  constituting  a layer
an inch in thickness, but  the enlargement of the  affected
regions is due chiefly to the change in the areolar membrane,
from  the deposit sometimes of fat, but more usually of a
substance almost as firm as fibrous tissue, and of a lardaceous
appearance, which to the  naked eye resembles the  natural
structure compressed.  Lebert and Gustav Simon, who exa-
mined the new deposit with the microscope, found it to con-
sist in fibrous  bundles  of pure areolar tissue, fully deve-
loped, or in the  process  of formation, with  numerous  fat
cells in the interstices.
  Treatment.—In the early or inflammatory stages of ele-
phantiasis Arabum, antiphlogistic treatment is clearly indi-
cated, but this must be constitutional and not local; if a limb
be the part affected it should be kept at rest, and placed in
the horizontal position above the level of the body.  Active
purging seems  to have been the plan of treatment that
proved most successful in those cases which  have been re-
ported, and even in the chronic stages, Avhen other remedies
generally fail to prove beneficial, it has been useful.   When
the disease becomes  chronic, iodine frictions and firm ban-
daging have also been recommended, but they usually fail to
produce any manifest effect: amputation of the parts, if pos-
sible, has been  then advised, and ablation of  the hypertro-
phied scrotum has, in many instances, been resorted to with
success; but as regards the limbs, the removal  of one  of them
has been usually followed  by the development of the disease
in another, thus, in a case  reported by Cazenave, in  which a
leg, the seat of  elephantiasis, was removed, the arm became
affected soon afterward. 
VERRUCA.
221
                        VERRUCA.

  Verruca  (Warts), both in consequence of their appear-
ance being familiar to all from their extreme frequency, and
of their  unimportance,  scarcely require description ;  they
consist in a hypertrophied condition of a small patch of the
papillae of the skin, by Avhich a round tumor, with a flat-
tened top, varying in size from that of the head of a pin, to
that of a large pea, is  formed.  They are of most frequent
occurrence on  the  hands, next on  the face,  and are rarely
witnessed on those parts of the body Avhich are ordinarily
covered.   They are generally placed singly on the integu-
ments, but occasionally two or three originate close to each
other,  and these  sometimes coalesce.  Warts appear in the
early periods of  life, being  seldom deAreloped for the first
time in adults;  they often disappear spontaneously, and even
suddenly, at the approach of puberty, but sometimes, becom-
ing indolent, are  permanent.
  Some persons are peculiarly liable to warts, and the ten-
dency  to them seems  to be  hereditary ;  their  immediate
cause has not been satisfactorily ascertained, but that it is
more or  less connected  Avith local irritation,  and the effects
of the atmosphere  on the skin, is evident  from their being
almost altogether confined to those parts which are ordinarily
exposed to the  action of the air.  Small growths, soft to the
touch and slightly pediculated, are  of frequent occurrence
on the face and neck, particularly of females, and are also
regarded as a variety of Avart; they appear to me to consist
in the hypertrophy of  a single papilla, but Mr. Erasmus
Wilson believes them to be "the emptied tegumentary sacs
of small sebaceous tumors.
  Warts  are  easily removed by  the application of  some
strong caustic—strong nitric acid is, in my opinion, the best
—to their apex; the layer thereby cauterized should be
pared off in tAventy-four hours, and the caustic again applied,
and this process  repeated until  the entire of the abnormal
structure is destroyed;  Avhen  the wart is small, a single ap-
plication sometimes suffices, provided a large drop of the acid
is placed on the  apex, and permitted to soak into its struc-
ture   The soft pediculated warts  are readilv destroyed by
                           19* 
222
HYPERTROPHIC
strangulation, by means of a hair or  a thread of fine silk
being tied tightly around their neck.

                        CLAVUS.

  Clavi (Corns).—These excrescences, almost peculiar  to
the feet, being equally common, alhough causing a much
greater degree of local uneasiness  and suffering, do not  re-
quire more notice than warts.  They  consist in thickening
and hardening of the epidermis of some prominent portion
of the integuments, usually over one  or more of the joints
of the  toes,  attended with   hypertrophy  of some of the
papillae beneath ; the latter, Avhich from the pressure acquire
much hardness,  are popularly believed to be  the  roots or
core of the corn.   They are regarded generally as  being
produced by pressure, but although they are kept up, and
their  growth increased by this mechanical cause, that they
are originally occasioned thereby is, I think, disproved  by
their  constant occurrence in  the usual site  on the feet of
persons, who have never worn  shoes or other  covering
Avhereby pressure could be caused on the  parts ; of this I
have  seen  numerous  examples.   Their development also
between the toes, on a portion of the integuments especially
protected from any undue compression, affords an aditional
argument  against  this view; that the  extreme degree of
hardness,  however, which  they  usually  present, and to
Avhich the local suffering they give rise to is chiefly due, is
dependent on pressure, is proved by their being compara-
tively unindurated  when situated here, whence they are
termed soft corns.
  Corns occasionally become the  seat of active inflammation
when irritated by any cause, or  when they  have been cut
too freely, and afterwards subjected too soon  to compression
and friction by the shoes in walking;  purulent matter then
often  forms beneath-them, and, from its being firmly bound
down  by the hardened superincumbent tissues, extreme suf-
fering results, followed sometimes by inflammation of the
lymphatics  and the formation  of buboes in  the groins ;  they
have thus ended  even  fatally,  from the occurrence of erysi-
pelas, and in some instances from tetanus coming on.
  Although, as above remarked, corns  are almost invariably 
CALLOSITATES.
223
confined to the feet, they may also be developed on  other
parts of the body, but they then  partake more of the nature
of callosities ;  1  have in  a few cases seen them on  the
knuckles of the fingers of persons,  too, in whom the hands
Avere not exposed to any manual  labor that could exert pres-
sure on the parts affected.
  The treatment of these morbid growths consists  in their
ablation, by  means of the knife patiently  and gradually
employed,  until all traces of hardened  tissue are removed,
and  afterwards protecting the  parts for some time from
pressure ; this is  the only effectual remedy,  and is the  one
always  adopted by the self-styled chiropodists.   The  appli-
cation of caustics never succeeds in destroying them com-
pletely, but is of use in enabling the hardened surface to
be pared off without causing hemorrhage.  Corns,  Avhether
hard or soft, may generally be kept in abeyance, as regards
troublesome symptoms, by removing  the superficial layers
with the knife from time to time, according to  the  rapidity
of their growth, or by rasping them with a file, the surface
having  been previously  softened by maceration in  Avarm
Avater.  Most of the corn-plasters which  are  ordinarily sold
in the shops contain carbonate of potash, the  alkali of which
dissolves partially  the horny substance which constitutes
the outer layer of the growth, or, a round hole  being cut in
the centre of each piece, they  act by  removing pressure
from the most prominent point of the corn, Avhich is directed
to be pared previously to their application.

                      CALLOSITATES.

  Callositates.—Callosities* consist simply in thickening
of the epidermis,  which becomes of more or less horny con-
sistence, produced by friction or continued pressure ; they
are usually witnessed on the palms of the  hands or on  the
soles of the feet,  Avhen their cause is in general sufficiently
evident.  Occasionally they are  attended with  some degree
of inflammation of the derma over Avhich they  are developed,
which may result in the formation of  pus, or  in the effusion
of a serous fluid beneath the hardened  integument.  They
are Avitnessed also over inflamed and enlarged bursae mucosae,
especially on the metatarsal joint of  the great toe, where 
224
HYPERTROPHIC
they are manifestly produced by pressure from the  boot or
shoe, and their presence tends to aggravate and increase
the original disease.   Their treatment  in the chronic stage
should  be the same as that for corns, but Ayhen inflammation
is  present, cataplasms and  soothing applications should be
employed, and in all cases the exciting causes should of course
be removed.

                     CONDYLOMATA.

  Condylomata.—Generally  the  result of the syphilitic
poison, but at times developed in persons in whom no such
taint exists, these soft, fleshy tumors appear on those parts
of the  integument where the skin and mucous membrane
meet, at the verge of the anus, on the prepuce, at the vulva,
and 'occasionally, though very  rarely,  on the lips and nos-
trils.   They are of  a soft  consistence and  a reddish-white
color, varying in size from that of a pea to that of a marble,
and have usually a broad base, with a flattened or rounded
apex.  They consist of numerous papillae in a highly vascu-
lar  condition, though apparently not much hypertrophied,
and the epidermic covering is unchanged, except in being
more vascular than  in its healthy state.  Various opinions
have been propounded as to the nature of condylomata ;
Simon  and Rokitansky regard them as being a new forma-
tion, consisting chiefly of areolar  tissue, while Lebert  be-
lieves that they are epidermic or epithelial growths.  They
may be destroyed by the application of caustics, or strangu-
lated with a ligature,  which, by means of a needle,  may be
passed  through the centre of the tumor, and then tied firmly
at either side around the base."

                        NiEVUS.

  Nevus (Mother mark).   (Atlas, PL XIV.  Fig.  1.)—Of
the several varieties of this adventitious production which
have been described, but  one only can be  regarded as  a
disease of the skin, namely, that Avhich consists in a hyper-
trophied condition  of the  capillaries of a portion  of  the
cutaneous structure;   the  others, in  Avhich the vascular
system  of the  areolar tissue, and sometimes  even  of  the 
NCVUS.
225
deeper seated parts, is engaged, are truly surgical diseases,
requiring usually surgical interference for their removal, and
are consequently treated of in all works  on surgery.  All
the forms are usually congenital, and are popularly believed
to be occasioned by the  effect of the mother's imagination
upon the foetus  in utero, an opinion shared  in by the pro-
fession  even until  modern times,  and not yet altogether
exploded.
   The variety of naevus to be  described here is character-
ized by a permanent discoloration  and slight  elevation of
the  part  affected, on which the minute veins  of  the  cutis
appear  dilated and slightly tortuous, becoming  gorged with
blood from any  exciting cause, and  thus  the  color varies at
different times, being dark  red, or purplish, when the circu-
lation is hurried or impeded.  They vary in size, sometimes
consisting of a small central point, from which several minute
vesicles ramify—a  form termed naevus araneus,—in other
cases covering a patch  of the  surface from the size of a
shilling to that of the palm of the hand,  when  they are
usually irregularly circumscribed, but often roundish.  They
seldom  enlarge much after  birth, but, occasionally affecting
the deeper vascular structures, they become  converted into
one  of  the other  forms of the disease,  which consist  of
erectile tissues,  Avhen they acquire a greater magnitude, and
are  not unfrequently attended with  troublesome or  even
dangerous symptoms.
   If the naevus which engages the cutaneous capillaries  be
wounded,  copious  hemorrhage, often  difficult  to  check,
ensues,  but otherwise they are of  no importance,  except
from the disfigurement which their  presence  occasions, the
more especially as they are usually situated on  the  face.
On  this account  attempts have  been  at  times made  to
remove  them by caustics and other means, but a greater
deformity  is thereby often occasioned ; unless,  therefore,
they exhibit a tendency to  spread much, or to be converted
into  one of the other forms of the disease, they should not
be interfered with. 
226
HEMORRHAGIC
                 CHAPTER  VIII.

                     HEMORRHAGE.

   The single  disease which constitutes'the order Hemor-
rhagic might perhaps be more  correctly regarded as an
affection of the system generally, but as its chief charac-
teristic  phenomena become  apparent to the  eye through
the medium of the skin, custom  has sanctioned its being
described as a lesion of that structure.  In cutaneous he-
morrhages  the blood does  not escape from the surface  of
the body, but, being  bound  down  by  the  epidermis,  is
effused beneath it in variously sized  and differently shaped
spots or  patches.   At times, in certain  diseases, especially
fevers  characterized  by low  vital  power, of  which  this
constitutes  one of the  most important  signs,  the hemor-
rhagic  effusion is in  the form of  perfectly  distinct, minute
dots, termed Petechise.  In other cases, occurring alone or
complicating the former, it appears  in irregularly  circum-
scribed  patches, often of large extent,  the  blood  escap-
ing chiefly into  the subcutaneous  areolar tisiue; these
are denominated   Vibices or Ecchymoses,  the  latter term
being especially  applied  to them Avhen they succeed  a
blow or  injury.  And in  a third form, which constitutes
Purpura, the  only one here to engage  attention, the he-
morrhage is in perfectly circular spots :  intermingled with
them, however, are  usually several patches—vibices or
ecchymoses.
                       PURPURA.

  Purpura (The  Purples)  is characterized by the  appear-
ance on  the integuments, generally  over the  whole body,
of small, perfectly circular spots of the  color of the blood,
attended Avith  more or less derangement of the vital func-
tions.  The spots vary in size from  that of the head of a
pin to that of  a small  pea; on their first  appearance the
color  is  bright red, but, augmenting slightly in  extent, 
PURPURA.
227
still preserving their circular form, they gradually acquire a
deep purple hue, which, as they fade away, passes through
the various shades of greenish-yelloAV discoloration ordinarily
presented by blood effused  beneath the skin from a bruise.
They are generally very numerous on the cutaneous surface,
and often aggregated in masses on certain regions, yet per-
fectly distinct from each other, except in some parts which
may  be exposed  to pressure, where,  becoming  confluent,
they constitute vibices  or  ecchymoses.   Each individual
spot  of purpura  runs  its course  from its first appearance
until it fades away in from five or six to ten or tAvelve days,
a slight stain remaining for some time  to mark its site ;  but
the  disease  may  last for many Aveeks, or even months, its
duration depending upon the development of successive
crops of the eruption, an occurrence Avhich takes place in
the  mildest cases.  The  spots or patches are not in  the
least degree elevated  above  the cutaneous surface,  their
presence being caused by an extravasation of blood into the
derma or beneath the  epidermis from the capillaries of  the
skin.
   The appearance of purpura is most usually preceded  by
slight febrile symptoms and general depression,—hot skin,
quick yet compressible  pulse, thirst, anorexia, malaise,  and
headache; but in some cases no premonitory symptoms are
noticed.   The circular spots are in the majority of instances
present on the several mucous membranes of the body,  and
sometimes also  on the serous, at the same time  that they
exist on the skin ; the blood being in them effused beneath
their epithelial  covering, through which structure, so  much
more delicate and fine than the epidermis,  it commonly
makes its wray, and hemorrhage, often to a great  extent,
takes place, complicating the disease and rendering it much
more dangerous.
   Several varieties of purpura have been  described by der-
matologists, all of Avhich may, I think, be conveniently ar-
ranged in tAvo divisions :—
                    Purpura simplex.
                       "     hemorrhagica.

  Purpura simplex (Atlas, PL XIII.  Fig. 1).—The  spots
in  this form of the disease, which  may be regarded as being 
228
HEMORRHAGIC
chiefly characterized by its  mildness, appear  for the most
part on the extremities, and  are  developed very suddenly,
often in the course of  a single night, and usually  without
any preceding or accompanying constitutional disturbance.
Vibices or ecchymoses  are seldom intermingled with them,
and they are generally  much dispersed over the surface, not
aggregated  in masses; successive crops,  rarely, hoAvever,
more than  tAvo or three, appear.in  most  cases Avith an in-
terval  of from twenty-four  to forty-eight  hours  between
each, and some spots then occur also on various regions of
the body, the shoulders, the  chest,  the  face, &c, but they
are always  most numerous on the  extremities.  The disease
runs its course in from  seven  or eight days to a fortnight or
three weeks, at the end of Avhich time the stains  it occa-
sions have  totally disappeared.
  In some  cases the extravasation of blood into  the derma
or beneath  the epidermis, instead of occurring  in  distinct
circular spots, without any elevation of the  surface, takes
place in raised wheals,  resembling exactly in form the erup-
tion of urticaria, and accompanied often by more or less of
a stinging and  tingling sensation, in consequence of which
it has been termed purpura urticans (Atlas, PL  XIII. Fig.
2); the patches, owing to their extent, are of a deeper purple
color than  in the ordinary  form of purpura  simplex, and
their duration is for  the same reason prolonged to five or
six weeks, although they are  almost invariably developed in
a single crop.   Purpura urticans usually occurs on the lower
extremities, and most frequently in persons laboring under
some  organic  disease,  and  in those who have taken much
mercury; it also appears at times in females when the men-
strual function is deranged.
  Purpura  simplex occurring in  old persons, especially of
the female sex, when it  appears very much intermingled with
large vibices and some  ecchymoses,  was described by Bate-
man as a distinct variety, under the name of purpura senilis;
it  is usually confined to the arms and  legs, is developed in
a single crop, unattended with any constitutional  or local
symptoms,  and is an affection of  but little disturbance, not
impeding the usual avocations of life, and running its course
in from a week to ten days or a fortnight. 
PURPURA.
229
  When any of the varieties of simple purpura now de-
scribed  is  accompanied by hemorrhage  from the mucous
membranes, it then  constitutes  a form of the second divi-
sion  of  the disease.   Occasionally purpura  simplex is
attended with some trifling  febrile  symptoms, rarely ex-
ceeding slight heat  of skin,  thirst,  and anorexia, yet by
some writers it has then been described under the name pur-
pura febrilis simplex.  The  duration of the  simple  form
of the disease, as has been above remarked, seldom exceeds
a few weeks, but cases occur in Avhich successive crops are
developed  for from  eighteen  months to two years or up-
wards.
   Purpura hemorrhagica (Atlas, PL XIII. Fig. 3) is es-
pecially characterized by the escape of blood from some of
the passages of the body which are lined with mucous mem-
brane ;  occasionally it  takes place  from the serous mem-
branes also, when  hemorrhage into the shut  sacs occurs.
The spots on the integuments are usually much more nume-
rous, and generally acquire a larger size than in the former
variety,  and vibices and  ecchymoses are more frequent;
they appear on every region of the  body, being most gene-
rally witnessed first on the  neck and shoulders, the face,
and the upper extremities; they also occur on  the conjunc-
tiva, on the gums, the tongue, and the inside of the cheeks,
and are found after death  to be  as  thickly dispersed over
the mucous membrane of the entire digestive tract as on the
external integuments.
   The disease is ushered in usually by much constitutional
perturbation, the chief symptoms being those of general
oppression; in  from twenty-four to forty-eight hours the
spots begin to appear on the cutaneous surface, at first of
a  bright red color, but  assuming a deep  purple hue in
about tAvelve hours;  they are very numerous in most  cases,
and are rapidly developed; whatever region of  the body is
exposed  to pressure, there large hemorrhagic patches are
developed  beneath  the epidermis,  and if  the surface is
scratched or torn, copious bleeding takes place from them ;
in some cases the  slightest pressure, even that caused by
feeling the  pulse, will produce an ecchymosed spot.
  Hemorrhage  from the mucous membranes  takes place
often  from the very commencement  of  the disease,  some-
                          20 
230
HEMORRHAGIC
 times it precedes the appearance of the spots of purpura
 on the  integuments,  but more frequently  does not occur
 for several days after  they are visible.   Its most usual and
 most manageable form is that of epistaxis, but  the bleeding
 is also  very common  from  the lungs,  when it constitutes
 hemoptysis, and from the stomach and  bowels, wrhence it is
 rejected by vomiting, or escapes by stool.  In some cases
 of purpura hemorrhagica, the blood  exudes from the gums
 in great quantity, apparently by a sort  of oozing, which it
 is almost impossible to check,  and not unfrequently proves
 fatal.   The  hemorrhage  may take place  also  from  the
 kidneys, the bladder, the urethra, the  vagina, &c.  These
 losses of blood are usually very great,  and  recurring  con-
 stantly  produce extreme  depression and prostration, with a
 marked pallor or anemic condition of the entire surface of
 the  body,  that  throws out  into marked  relief the  purple
 spots and stains which are thickly scattered over it.
   The duration  of this form  of purpura is very variable;
 the local hemorrhages maybe checked in  seven or eight days,
 but they are very apt  to recur, and thus  the disease is often
 prolonged for several months,  the  cutaneous  spots  and
 patches continuing to be developed in constant, successive
 crops.   When it has  lasted for  any time, the vital powers
 become  extremely depressed, dropsical effusion takes place
 into  the lower extremities, and  uncontrollable bloody diar-
 rhoea not unfrequently sets in.
  When the constitutional symptoms attendant on purpura
 hemorrhagica  assume  a  more febrile character than has
 been above described,—a general redness of the surface,
 with burning heat, preceding the appearance of the purple
 spots,—the disease has been  specially noticed under the de-
 nomination of purpura febrilis  hemorrhagica.   This variety
 is chiefly remarkable  from its  not unfrequently appearing
 as an epidemic, especially where many persons are crowded
 together, as in gaols, poor-houses, &c.
  In many cases of purpura, the cutaneous phenomena are
 so trifling as to be scarcely noticeable, Avhile the hemorrhages
from the mucous surface are excessive;  these constitute, in
my experience, the most dangerous and uncontrollable cases,
and death often occurs in them from extravasation of blood
into some of the  serous cavities.  Dr.  Graves  described a 
PURPURA.
231
form of the disease  resembling  this, in which, however,
there was an exanthematous  rash  on the skin, resembling
the red  efflorescence  so  often  seen in maculated  typhus
fever: in consequence of its presence he proposed to term
the affection Exanthemata heemorrhagicum.1
   Erasmus Wilson describes  as a form of purpura, under
the  designation of purpura  cachectica, the occurrence of
petechia?, and ecchymoses of the skin, " as the consequence
of a reduced and debilitated state of the system, from what-
ever  cause  the latter may  arise."   We  frequently see
instances of this kind during  the latter stage  of  various
diseases, as of  dropsies, or  whenever the venous  circulation
is obstructed.   The purpura  contagiosa of Bateman corre-
sponds with the petechial eruption of typhus fever.
   Purpura may occur at any age, but it is very rarely wit-
nessed in infants or very young  children;  it affects both
sexes, also, but females are more prone to the disease than
males.   The hemorrhagic  form is more  frequent  in the
young, and in  those  in the prime  of life, while  the simple
variety  appears generally in  old age.  Persons  of the
sanguineo-lymphatic temperament constitute unquestionably
the  majority of those affected with purpura, yet it is seen
in all  constitutions, in the  strong  and robust  as wrell as in
the Aveak and  debilitated.  The causes of the disease are
consequently very obscure; it was formerly believed to be
always dependent on and to be a  sign of general constitu-
tional weakness—a view which influenced the exclusive plan
of treatment recommended by Willan and his followers ; but
it is noAV admitted to be often connected with plethora and
sanguineous congestion.  That low, ill-ventilated habitations,
with deficient or unwholesome food, are occasionally predis-
posing causes  of purpura amongst the poor is undoubted,
but inasmuch as it usually attacks  only a single member of
a family, some  peculiar state of the constitution, the nature
of which we are unaware of, is manifestly requisite to enable
these causes to act.   An exclusively meat diet, or an in-
sufficiency of vegetables and milk, either of which produces
the peculiar  affection  known  as scurvy, does  not seem to

  1 Clinical Lectures on the Practice of Medicine, Second  Edition, vol. ii.
p. 362. 
232
HEMORRHAGIC
exert any influence in the causation of purpura; in the year
1847, Avhen scurvy was so general in this country, in conse-
quence of the failure of the potato crop, purpura was not as
prevalent as usual.   In some cases of the disease which I
have seen, a hereditary tendency to it could be traced, but
this is not of so decided a character or so general as in the
singular instances of the hemorrhagic diathesis, occasionally
witnessed, in which the slightest injury causes often uncon-
trollable  bleeding, death sometimes, in consequence  of it,
resulting from the extraction of a tooth, or even from the
wound produced by the scratch of a pin.  The proximate
cause of purpura is manifestly atony in the capillary system
of blood-vessels, combined with an abnormal fluidity of the
blood.
  Diagnosis.—This disease is so well  marked by the visible
phenomena  that it  can scarcely be  confounded  with  any
other; but  it is necessary to  distinguish the occurrence of
purpura in the course of  fever, or as a complication of any
other affection,  from its existence as an individual disease.
The diagnosis between it and scurvy is unattended with diffi-
culty, the characteristic condition of the gums, the extensive
brown and purple discoloration of the  integuments, and the
absence of the round purpuric stains in the latter, are suffi-
ciently distinctive marks.  The  spots  of  purpura are  dis-
tinguished  from flea-bites with which a  careless observer
might confound them, by the presence of a central punctum
in the latter, and their almost total disappearance on firm
pressure being made with the finger,  the marks of purpura
being thereby unaffected.
  Prognosis.—Even  cases of purpura  that in their com-
mencement, do  not present symptoms of  severity, are  not
altogether  free from danger, for  the simple form of the
disease not unfrequently becomes converted into the hemor-
rhagic, and whenever bleeding from the mucous surfaces
takes place in this affection, the prognosis must be cautious.
When death occurs, it is  either directly or indirectly conse-
quent on the loss of blood:  in the former case it may be
sudden, as when apoplexy results from hemorrhage into the
substance of the brain or from its membranes, and in the
latter, it is generally less immediate, the patient dying with
the symptoms usually caused by repeated losses of  blood. 
PURPURA.
233
 The hemorrhage being profuse, or continuing unchecked by
 treatment,  is  always  an unfavorable sign, and  until  it
 ceases completely, and fresh spots no  longer appear on the
 cutaneous or mucous surfaces, the patient cannot be  re-
 garded as safe.   Bleeding from the gums, particularly when
 at  all excessive, is, in my experience, one  of the gravest
 symptoms of the disease, even although there may be but
 little eruption  on the  integuments;  I  have rarely seen-
 a case of purpura recover in  which it was  present to any
 extent.
   Occurring in  the young, the  strong, and the robust, and
 in the old, the  weak,  and the feeble, it is difficult to arrive
 at  any correct  view  of  the  pathology of  purpura.  The
 precise condition of  the circulatory apparatus, and of the
 blood itself, in  Avhich that fluid  escapes from  the vessels
 most remote from  the  centre, has  not been  sufficiently
 investigated as yet,  to  enable correct  deductions  to be
 drawn as to the real nature of the disease.   It is true, that
 the  blood in purpura  has been  chemically analyzed  and
 microscopically  examined, but  the results afford no further
 information than  what had been  previously gained by the
 unaided  senses—that  it  is deficient  in solid constituents,
 in consequence  of Avhich it is in most cases extremely fluid,
 and does not coagulate  after  its  exudation through  the
 mucous membranes, or  should it be  draAvn from  a vein ;
 yet, as shown by the  analysis  of  Frick, of Garrod, and of
 Parkes, the fibrine may be in  excess, and the property of
 coagulation not  deficient in purpuric  blood.  The  appear-
 ances in  the  internal organs  found  after  death are,  the
 presence of purpuric  spots  and vibices on the mucous, and
 occasionally on  the serous membranes, and  in some cases
 hemorrhage into one or more of the  shut cavities.
  Treatment.—The treatment of purpura  has been  much
 influenced by the different opinions  Avhich  have prevailed
 as to its true nature;  many adopting the vieAvs propounded
 by Willan as to the disease being nearly allied to  scurvy,
 and  consequently being essentially one of debility,  agree
 also  with  him, " that the treatment is  simple, and  may  be
 comprised in a  very  few words :  a  generous diet, the use
of wine,  Peruvian bark, and acids:" others, regarding the
doctrine of Parry, " that it is  always of inflammatory ori-
                          20* 
234
HEMORRHAGIC
gin," as correct, recommend early and free venesection
as holding out  the  only hope of successful  treatment.   In
very  few cases of  the disease, however,  is  the  decided
antiphlogistic treatment here recommended either  needed
or beneficial, and in still  fewer  will the  employment of
tonics and acids be  necessary or advantageous.  Instances
unquestionably  occur in which  the abstraction of blood to
a small extent  in the  very commencement of the  disease
will at once stop its  progress;  these  are cases of purpura
simplex,  affecting plethoric  young  persons  of  a  sangui-
neous temperament; but  the  bleeding  should  always be
used  with  caution,  and rarely if  ever admissible when
hemorrhage occurs  spontaneously  to any extent from the
mucous  membranes.  In that form of  the  disease which
has been described  as  appearing on the lower extremities
of old persons, whatever tends to  strengthen the constitu-
tion generally should not be omitted in the treatment;  but
if preparations  of bark, or other  tonics, be  administered
too  freely, and  without  the simultaneous employment of
remedies calculated to remove  the hemorrhagic  tendency,
the  symptoms are often suddenly aggravated, purpuric spots
are  developed over  the  body generally, and bleeding takes
place from the  mucous  cavities,  the  simple form  of  the
disease being converted into the hemorrhagic.
  Some years since I published an essay1 on the treatment
of purpura by  large doses of oil  of turpentine,  and illus-
trated the efficacy of this remedy, when thus  administered,
by a report of  several  cases in which  it proved  singularly
successful.   Since then I have  continued to employ it  both
in the simple and hemorrhagic forms of the disease, and my
additional experience is fully confirmatory of the  views then
propounded.  It must be given in  doses sufficiently large to
act  as a purgative—from one to two  ounces, according to
the  age and strength of the patient, for  adults, and a  pro-
portionate dose for  children ; to insure its purgative  action,
I was at first in the habit of giving it in combination  with
castor oil, but this,  so far from being  necessary,  interferes,
I think, more or less with the special effect of the turpentine,

  1 Dublin Journal of Medical Science, First Series, vol.  xxviii. p. 189. 
PURPURA.
235
and  therefore  I  now prescribe  it  combined simply  with
mucilage, as in the following form:—

       R. Olei Terebinthinae,.....fl gj.
          Mucilaginis,.......fl |j.
          Aquae  Menthae Piperitae,   .   .   .  fl giss.
                 Misce.   Fiat haustus.

  This draught may be taken once or twice daily, according
to the degree of its action on the bowels, and should there
be  much hemorrhage  from the  intestinal canal,  or  the
stomach  reject the draught, the  same or a  larger quantity
of the oil of turpentine, suspended by means of yolk of egg
in decoction of barley, may be administered as an  enema.
The beneficial action of the turpentine in this disease is two-
fold : first, it  is a  diffusible stimulant and styptic, which,
when conveyed into  the  circulation through the  digestive
organs, is exhaled from the system by means chiefly of the
mucous surface, as is manifested by the odor of  the breath,
and  of the various secretions and excretions; it is  thus con-
sequently brought  directly into contact Avith  the  capillary
circulation,  from which in this disease the hemorrhage takes
place ; and, second, the free employment of purgatives in
the treatment of  purpura having long since been proved to
be attended with most successful results, the administration
of oil of  turpentine to fulfil this indication is especially ser-
viceable in consequence of its not being a debilitant.
  In cases  in Avhich  from any  cause—excessive debility or
tendency to diarrhoea, &c.—purgatives are contra-indicated,
the turpentine  may be given in smaller doses, and repeated
at shorter intervals ;  thus from twenty or thirty minims to
a drachm may  be prescribed every third or fourth hour, or
three times a  day,  according to the  amount of hemorrhage
which accompanies the disease.   Should there  be extreme
debility  present, preparations  of iron — those  which  are
astringent being preferred—or other  tonics, may be admi-
nistered  conjointly with the turpentine; but on the other
hand, when there is  much vascular excitement or general
plethora,  bleeding or other evacuants should be had recourse
to at the  same time that it is prescribed. 
236
HEMORRHAGIC
   The employment of numerous other astringents and styp-
tics  has been  recommended for the treatment of purpura;
in cases attended with much  hemorrhage from the stomach
and intestines, or from the lungs, acetate of lead combined
with opium often  proves useful; the  combination may be
given in pill—two  grains of the former with a fourth of a
grain of the latter every fourth or sixth hour.  But of all of
this class  of medicines which have  been used not one  has
proved so beneficial as gallic acid ; it is  especially of service
in cases  attended  with  profuse  bleeding from the mucous
surface, and may then be given in  alternate doses with the
oil of turpentine.  Thus, a pill containing five grains of gal-
lic acid made Avith sufficient mucilage or conserve of roses,
should be administered every fourth hour, the  turpentine
draughts being given two hours before  and after each pill.
  When excessive  hemorrhage takes place from the mucous
membrane of the gums  and the inside of the mouth, it is
as before  remarked, a  most  dangerous symptom, and  the
bleeding  is  extremely difficult to check—the most active
styptics applied  directly often failing to diminish it in  the
slightest degree.   I have in  such cases tried unavailingly
nitrate of silver, saturated solutions of alum, of sulphate of
iron, of. gallic  acid, &c, Ruspini's styptic, nitric acid, and
even the actual cautery : pieces of lint dipped in oil  of tur-
pentine seem to have the most effect, but the general treat-
ment above recommended can alone be then relied on.
  Sponging the  surfaces of the body repeatedly  during  the
day Avith cooling  lotions—such as equal parts of vinegar and
Avater,  with the addition of a sixth  part of rectified spirit,
should there be much febrile heat—is an adjunct, too often
neglected,  of  much value in the  treatment of  purpura.
Acidulated drinks—lemonade, raspberry vinegar and water—
should be  always freely allowed, and the diet, though rather
small as regards quantity, ought to  be nutritious and tonic,
but easy of digestion, consisting chiefly of milk, farinaceous
food, and  strong beef  tea;  all food and drink being taken
rather  cold than warm. 
MACULC
237
                   CHAPTER  IX.

                        MACULC

   The  group of cutaneous affections classed in the order
Macule is characterized by a morbid condition of the color
of the skin dependent on some deranged state of the secre-
tion of  the pigment cells of the derma.   The change may
consist  in either an augmentation or a diminution of  the
natural color, or it may be altered in hue or totally absent;
in some instances it affects  the entire surface of the body,
but more usually occurs  in spots or patches that vary much
in shape and in extent: in either case there is no sensible ele-
vation or depression of the  surface.   The several affections
belonging to the order may be congenital, or they may be
developed at  any period of life:  in  the former case they
usually consist in the total absence of coloring matter, con-
stituting what has been  denominated, Albinoismus  (Atlas,
PL XIII. Fig.  5),—individuals born so being termed Albi-
noes,—or there  may be only a deficiency of coloring matter
in large patches,  a condition which  is rare, but most  fre-
quently witnessed in the children of  negroes, who are thus
piebald at  birth.   In  certain  diseases,  as in jaundice, in
chlorosis, in malignant  and in most chronic affections,  a
peculiar alteration in  color of the tegumentary membrane
takes place, and which is regarded usually as one of the most
important signs  of the special diathesis or constitutional de-
rangement which characterizes or accompanies the disease ;
but it is readily recognizable, and cannot be confounded with
the pigmentary alterations of the cutaneous  structure here
to be considered, which  do not influence in any way the
general health,  and are  therefore  to  be regarded solely in
consequence of  the  disfigurement which  they occasion, in
many instances  a  cause  of  greater annoyance than a real
disease.   These changes in  color may be  conveniently de-
scribed  in two divisions, the one, that attended with defi- 
•  238
MACULC
 ciency of coloring matter—Vitiligo, including albinoismus;
 and the other, marked by augmentation and alteration of
 the natural  pigment—Ephelis.

                        VITILIGO.

   Vitiligo  (Atlas, PL XIII. Fig. 4) consists in a deficiency
 or total absence of the natural coloring matter of the skin,
 in consequence of which it presents a white and sometimes
 glistening aspect;  the  term, which was adopted by Willan
 from Celsus, is conjectured to have been derived from the
 resemblance Avhich the integuments thus affected bear to the
 flesh of calves— Vituli; and being sanctioned by usage and
 sufficiently expressive,  I have been unwilling to  change it
 for Leucopathia, an  appellation more strictly correct, per-
 haps, which  is employed by  many modern dermatologists.
 The decoloration may be limited to certain regions of  the
 body, occurring in patches, or may be general when the ab-
 sence of pigment is witnessed in the hair, the  eyes, &c.  In
 the former case, the  peculiar condition of the skin is  often
 congenital, but it  may be developed at any period of life;
 it constitutes the Achroma vitiligo of Alibert ; the latter,
 the Acroma  congenitale of the  same author, is always con-
 genital; it is denominated, as before remarked, Albinoismus.
 Albinoismus cannot be regarded as a disease, and therefore,
 not coming within the scope  of this work,  need not be de-
 scribed here  ; it moreover is not within the sphere of medical
 art, being altogether an unalterable, and  consequently an
 incurable affection.
  What then may be termed true vitiligo, when not congeni-
 tal, is developed in the form of rounded spots or patches, few
 or many, on some special region of the body, or on several
 parts at the  same time ; the spots are at first  usually small,
 not more than a few  lines in diameter,  and  nearly circular,
 but they  gradually augment  in size—often acquiring  the
magnitude of the palm of the hand, and become irregular
in shape.    It appears  most  frequently on the  chest,  the
back,  the  scalp, and about the genital  organs, but it may
 occur on any part of the integuments.   The portions of skin
 affected present simply a white aspect,  in some cases dull, 
vitiligo.
239  .
in others bright and glistening, without any sensible eleva-
tion or depression of the surface; if hairs grow  naturally
on the part they also become perfectly white, no  matter of
what color they may have been previously, and not unfre-
quently fall out after a short time, leaving a bald, colorless
patch.  When the hairy scalp is thus affected,  attention is
at first usually attracted to it by a single lock of  the hair,
generally on the back part of the head or the temples, turn-
ing white; this gradually becomes larger, and at length the
hairs, which haAre lost  their color, fall  out, and one of the
forms of alopecia, or what  has been termed a variety of
porrigo decalvans, is thus constituted.
   The causes of  this singular affection of the skin are per-
fectly unknown: it occurs at all ages, and is most frequent
in the prime of life, especially when it appears on  the head,
but it is developed on the genital region usually in old per-
sons ; it is witnessed, too, in individuals of all temperaments,
yet I think it  is more  common on the scalp of those who
have dark  than  those who  have light  hair ; it is  also, in
my experience, more usual  on  the head in females, and on
other parts of the body in males.   Congenital vitiligo is
rare in the white races, occurring with  a much  greater de-
gree of  frequency in negroes, infants  at birth sometimes
presenting a completely pied appearance.
   The diagnosis of vitiligo  is unattended  with difficulty ;
the longitudinal white  furrows on the  abdomen of  females
who have borne children, or of  those who have  had  ascites,
and on the breasts of nurses, might, by a superficial observer,
be confounded with it, but their site and the history of the
individual case are in all cases sufficient to  prevent such a
mistake.   A form of lupus, to be hereafter described, is
stated  by Erasmus  Wilson to be incorrectly regarded as
vitiligo, and  he consequently introduces this term amongst
the synonyme3 of Lupus non-exedens, but, as will  be shown
in the next Chapter, the diseases are essentially  different,
and cannot be confounded.
  Prognosis.—An affection of the most trifling importance,
as regards the general  health,  and accompanied by  not the
slightest local sign or symptom of irritation in  its develop-
ment or progress, vitiligo is, nevertheless, attended with the
most serious  mental suffering, especially to young persons, 
.  240
MACULC
when it appears on the face or the hairy scalp, owing to the
disfigurement  which it  there occasions.  It is often most
rebellious to treatment, and always extremely slow in exhi-
biting any signs of amendment, yet, by continued attention,
a cure is usually effected in time.
   Treatment.—Constitutional remedies should not be neg-
lected in the treatment of vitiligo, but those required are
simply such as will restore a healthy tone and  vigor to the
system :  consequently, preparations of iron or of bark com-
bined with iodine, cod-liver oil in scrofulous habits,  cold salt-
water bathing, general or local, in the form of the shower
bath or of the douche, and above all, mental  quietude, are
the most essential.  Topical applications, however, are chiefly
to be relied on,  and of these  various stimulating  remedies
especially are  employed with benefit; tannic acid ointment,
in the following  form, has proved of more service  than any
other in my hands :—

     R. Acidi  Tannici,......gr. xl.
        Adipis praeparati,.....      |j.
        Glycerinae,.......fl  3ss.
        Olei Rosmarini,......m. viij.  Misce.

  A portion of this ointment should be rubbed forcibly into
the parts affected three times a day, the surface having, pre-
viously to each application, been washed well with a  satu-
rated solution of common salt in Avater.   In very chronic
or obstinate cases, blisters may be applied to the affected
parts, in order  to excite a neAV action  in them,  or  tincture
of cantharides made into an unguent, in the proportion of a
drachm to the ounce of white wax ointment, rubbed in twice
daily.   Sulphuret  of potassium, and  other preparations of
sulphur, in the form of lotion or ointment, employed locally
sometimes succeed when  other remedies fail ;  but next to
tannic acid I have found oil of turpentine prove most  useful
as a local application; a pomade may be prepared with it
as follows: —

     R. Olei Terebinthinoe,.......fl  jjj.
        Sevi,..........'  gjj#'
        Balsami Tolutani,.......jw 
ephelis.
241  •
Simul liquefac lento igne, dein adde,

       Olei Rosmarini,.......m. xx.
       Olei Amygdalae Amarae,  ....  m. v.

  A small portion of this pomade should be rubbed into the
affected spots twice or three times a  day with  a piece of
flannel, the part having been previously well washed  with
an alkaline wash—a drachm of carbonate of potash to eight
ounces of distilled water.

                        ephelis.

  Ephelis.—This term, as its derivation (fal, «jk«>$, the sun)
indicates, was originally employed to designate all discolora-
tions of the  skin  caused by the  direct  action of the solar
rays, but  latterly it has acquired a more extended  signifi-
cation, and may, I think, now be understood to include all
those affections in which the natural pigment hue of the skin
is augmented or altered.  Some of these changes being con-
genital and unalterable need  not be  described here, while
others  are due  and can often be traced to specific causes.
Ephelis may be conveniently considered as consisting of three
varieties:—

                   Ephelis lenticularis.
                      "   hepatica.
                      "   violacea.

  Ephelis lenticularis (Freckles).—This discoloration of the
skin is too well known to need description ;  in many persons
the buff-colored  or reddish-yellow spots which constitute it
are congenital, when they are beyond the reach of medical
art: but in others they  are developed  on  those regions of
the body which are uncovered, by exposure to the weather,
but especially to the direct action of the sun's rays.   They
are seldom witnessed  except in those who  have a very  fine
and fair skin and  are of the sanguine temperament.  Ap-
pearing usually for these reasons  on the skin of young per-
sons of the female sex, and on those parts of the  surface
which are most exposed to observation,  freckles  cause very
                          21 
242
MACULC
serious  annoyance, and a  host  of applications  have been
employed for their removal, which is often a matter of some
difficulty ; persons Avho are  liable to them should, therefore,
protect  themselves  as much as possible  from the causes by
which they  are produced.   The various  empirical lotions
which are sold for the removal of these spots, are composed
chiefly of corrosive sublimate, or of the  solution  of the sub-
acetate of lead in bitter almond emulsion, in the  proportion
of a fourth  of  a grain of the former, or six minims of the
latter, to each ounce of either of them ; they are  often very
useful.  Erasmus Wilson recommends the application of a
liniment, " composed of equal parts of lime-water and olive
oil," to which, if the heat of the surface  is considerable, he
adds " liquor plumbi in the proportion of twenty minims to
the ounce."   I have found the  following lotion of much
service:—

  R. Liquoris Sodae Chlorinatae,   .  .   .   fl 3y«
     Aquae  Florum Sambuci,  .    .  .   .   fl ovij.
     Aquae  Lauro-Cerasi,.....fl 3vj«   Misce.

And the application  at night of  a  pomade, consisting of
equal parts  of  cold cream  and  cucumber cerate, to every
ounce of which half a drachm of the solution of chlorinated
soda is added.
  Ephelis hepatica is characterized by the appearance of
one or more  patches, of tolerable extent, on some portion of
the cutaneous surface ; they are of a dull yellow or buff color,
occasionally of a bronze hue; at  first distinct  from  each
other;  when more than one occurs, they gradually enlarge,
and coalescing  often acquire a considerable  size, so that in
some cases the neck, the face, the upper part of the trunk
and the  hands,  being  the parts usually  affected, acquire a
dark brown  color.   On the first  appearance of the patches
they are not unfrequently attended with some itching and
tingling, and  a fine  mealy  desquamation,  increased  by
scratching or rubbing the surface,  takes  place ; but there is
no sensible elevation or depression of the  skin where affected.
The coloration varies  much in  different cases, through all
the shades of gray, yellow, and brown, being often evidently
dependent on the natural color of the individual; at times, 
EPHELIS.
243
when it is very extensive, the contrast is so remarkable that
the unaffected parts of the skin appear as if they were the
seat of vitiligo.
t  Ephelis hepatica is a very chronic affection, in most cases
lasting  for many months or even for years, but it is occa-
sionally of short duration, and even  evanescent,  disappear-
ing  suddenly  a few hours  after its  development.   In the
latter case the discolored patch or patches generally appear
in females just before the coming on of the menstrual dis-
charge, and fade away when it commences.   It  is a more
frequent affection in all its  forms in the  female than in the
male sex, being a  not uncommon attendant on  pregnancy
and on various uterine  derangements: in both sexes it  is
rarely witnessed except in the prime of life, occurring, how-
ever, with greater frequency in old than in young  persons.
A large patch of ephelis  hepatica is sometimes  developed on
the  neck  or the side of  the face, by the  action of  the rays
of the sun ; and a discoloration of the skin resembling it  in
hue—but differing  from  its  occurring in  large, irregularly-
shaped  rings, surrounding comparatively healthy skin—ap-
pears on the lower  extremities generally of old persons  who
expose their legs uncovered to  the fire:  the latter has been
specially described by Rayer, as being very common in Paris
amongst the lower orders, especially females, who sit over a
charcoal fire,  and is termed by him  Ephelides igneales ;  in
Ireland, also, it is common amongst the poor, chiefly  in
country districts Avhere turf fires are used, and is  vulgarly
called the Trouts.
   Diagnosis.—This affection is often confounded with a form
of pityriasis, and, as already remarked when describing  that
disease, Rayer and Wilson consider pityriasis versicolor and
pityriasis nigri  as  being nothing more  than  discolorations
of the skin, and therefore  to  be  classed with ephelis ; my
reasons for differing with them have been there given.   The
stains of  ephelis hepatica  may be  confounded  with those
which are symptomatic  of  a syphilitic taint in the system
from which they are chiefly to  be diagnosed by the history
of each case, and the concomitant symptoms.
  In the treatment of this affection it  is requisite, in the
first place, to direct attention  to the general  health, espe-
cially the  state of the digestive  organs,  Avith a deranged 
244
MACULC
condition of which their presence is often associated, and to
use remedies calculated  to  restore to them, if requisite, a
healthy tone :  in females, moreover, should there exist any
irregularity of the menstrual function, appropriate means to
correct it  must be employed; but when  the patches are de-
veloped in the course of  pregnancy, no treatment ought to
be had recourse to, for they usually disappear after delivery.
The local applications that prove most successful are  those
which have been recommended for the last described variety
of ephelis;  when, however,  the discoloration of the surface
is very extensive, hot baths containing the sulphuret of  po-
tassium, or of the natural sulphureous waters, will be found
of service: these mineral waters also should be used inter-
nally, and if  drank at their sources  so much the better.
When a  single  large patch of ephelis   hepatica  becomes
chronic, repeated blisters  applied over it  will sometimes re-
move the discoloration of the part.
  Ephelis violacea.—When  the internal  administration  of
the nitrate  of silver has  been continued for  a lengthened
period without prolonged  intermissions, the derma  becomes
chemically stained with  it,  and the entire surface of the
body then presents a slate-colored, bluish-gray, or leaden
hue, causing a frightful disfiguration, more especially as the
face and those parts constantly exposed to the light are most
deeply tinged.   This  discoloration is much less frequently
witnessed now than it was some years since, when this medi-
cine was so  universally employed for the treatment of epi-
lepsy and  other nervous and convulsive diseases.  The most
certain way to prevent  this result—one of so grave  a cha-
racter as almost  to counterbalance any good effects which
might be derived from the administration of nitrate of silver,
as a medicine—is not to continue its use  for a longer period
than six weeks or two months, and should it be thought well
to resume its employment again, to permit at least a month
to elapse before doing so.
  This discoloration when once produced is permanent, and
becomes even deeper with time, nor have any means hitherto
tried for its removal had  the  slightest effect over  it.   The
iodide of potassium, when applied to the skin, even some
days after it may have  been stained by the  direct  appli-
cation of the nitrate of silver, effectually  removes the  disco- 
EPHELIS.
245
loration ;  its use in various ways has therefore  been pro-
posed for the  general  staining of the  cutaneous surface
above described.   Professor Melsens, of Brussels, has given
it  in  enormous doses, half  a  drachm, or even more, three
times daily, exposing the patient at the same time to a hot
vapor bath; the iodine is thus brought to the surface, when
it  may be readily detected  in the perspiration by the ordi-
nary tests.  He continues this plan of treatment for months,
but in one case that I am  cognizant  of,  which Avas treated
by himself, the discoloration was not in the slightest degree
removed.   This,  I  think, was to be anticipated, for it is as
iodine, and not as iodide of potassium that the preparation
is  given off by the skin after its use has  been  continued for
some  time; I would, therefore, suggest  that the  patient,
Avhile under the influence of the remedy, should  be placed
during for from half an hour to an hour in a warm bath con-
taining carbonate of potash in solution, instead of employing
the hot vapor  bath, as thus the iodide  of potassium might be
brought into direct contact with the derma.
21* 
246
CANCRODES.
                   CHAPTER X.

                       CANCRODES.

  The order Cancrodes includes two diseases of the skin,
which possess a certain degree  of malignancy, inferior to
that of true cancerous affections, yet in many of their fea-
tures bearing much resemblance to them, especially in being
usually characterized by a slow and insidious ulcerative pro-
cess, often attended with severe  stinging pain, and by  a
marked tendency to return in the same or in some other part
of the skin, after they have  been apparently cured, or even
after the diseased  portion of the integument  has  been ex-
cised.  These diseases are by most dermatologists classed
amongst the Tubercula of Willan, but for the reasons already
stated in the introductory remarks to the seventh chapter I
have omitted  this  order altogether, and even  were it to be
retained, the affections now  to be  described could not, with
any pretension to  accuracy, be  included  in it.  The term
Cancrodes, which I have adopted from Copland's classifica-
tion of diseases of the skin,1 expresses well  their  peculiar
features  above referred to, and is at the same time suffi-
ciently distinctive for all purposes of arrangement.  The
two diseases to be described  in the order are:  Lupus, Kelis.

                         LUPUS.

  Lupus  (Eating tetter) appears on the skin usually of the
face, but often on the scalp,  in various forms: it is generally
developed as  an inflammatory affection, with more or  less
hypertrophy of the integuments attacked,  soon  terminating
in ulceration, which may be either superficial or deep-seated,
but is always  painful, slow, and  insidious, and especially
characterized  by a destructive tendency, whence  the name
—Lupus, "a  wolf"—was originally  applied to the disease.

          1 Dictionary of Practical Medicine, vol. iii p. 799. 
LUPUS.
247
The ulcerative process may be confined to the epidermis and
the superficial layers of the derma, may extend quite through
the cutaneous integument, or may even affect the deeper-
seated parts, destroying the areolar  tissue,  muscles, carti-
lages, and periosteum, laying bones bare, and thereby caus-
ing caries in them.   The disease is thus naturally divided
into three forms, but in general two only are described by
writers on cutaneous affections : the one, in which the ulcera-
tive process attacks the deeper-seated tissues, being termed
lupus exedens, and the other, which affects more superficial
structures only, being for contrast denominated lupus non-
exedens; in both,  however, a similar  form of ulceration,
although differing  in degree, occurs, and this  division is,
therefore, not strictly accurate.  I shall describe the three
forms, the leading features of which have been noticed above,
under the following specific denominations:—
                    Lupus superficialis.
                     "   serpiginosus.
                     "   devorans.

  Lupus superficialis (Atlas, PL XIV. Fig. 2) commences
by the  development  of a  slight thickening  or elevation of
the skin, not larger  than a small pea,  usually on the most
prominent part of one cheek ; it  presents  a somewhat in-
flamed  appearance, is soft to the touch, rather  painful if
pressed  firmly, and is of a very indolent  nature.  A thin,
hard,. broAvnish scab appears on its surface after some time,
often not for months, but is seemingly not preceded by any
ulceration ;  when the scab is picked off  with the nails, as it
almost invariably is by the individual  himself, the part on
which it rested is  seen to  be superficially ulcerated, with
thickened and  slightly elevated edges; it  is soon  repro-
duced, a little more consistent than before, but still of small
extent, and increases very slowly in size, even when irri-
tated by the use of stimulant applications or by other local
causes.   Generally, after several months, the dry crust or
scab falls off that part  of the integument on which it first
appeared, while  it is spreading slowly to the neighboring
surface.  The portion of the skin on which it had existed is
white and seamed, resembling much the condition which re-.
suits from destruction of the superficial layers of the  cuta- 
248
CANCRODES.
neous structure by a burn.  With slow but steady progress
the disease advances over the cheek, usually in one direction
only, leaving its  trace behind in the white seaming of the
skin; at times it becomes the seat of  active inflammation,
generally from being rubbed  or torn with the nails, when
a  small, painful ulcer results, but the local symptoms are
never very severe, the chief annoyance it causes being due
to the  unsightly deformity which it  occasions on the  face.
The progress of this  form of lupus  is so slow that the re-
sulting  superficial cicatrix above described, which is some-
what circular, does  not attain a larger size than that of  a
shilling in from two to three years after the first appearance
of the  disease,—at  least such was the case in two persons
affected with it whom I have under my care.
   Lupus superficialis, as  here  described,  is a rare affection,
and has escaped the notice of many writers on diseases of
the skin;  Dr. Copland gives the best account of it that  I
have met with, under the appellation of Lupus superficialis
non-tuberculosus.1   Its duration  may be almost indefinitely
prolonged; when it terminates  in cure  the scab  falls off,
and  is, not  succeeded by  another, but  the mark  on the
cutaneous surface is indelible.
   Lupus  serpiginosus (Atlas,  PL  XIV. Fig. 3).—This
variety  of the disease—well named by Alibert, Esthiomenos
(from toOta, "I eat,") ambulans vel serpiginosus—is  well
marked by highly characteristic phenomena, which distin-
guish it from either of the other  forms  of lupus, but it must
be noticed  that the specific name "superficialis" has  been
applied  to it by some dermatologists who do not appear to
have met with the variety of  the  disease above described
under that appellation.  It commences by the development
of one  or more small,  livid, or  dusky-red tumors,—the
tubercles of most authors,—about the size and shape of  a
pea, on  some portion  of the  integuments, usually on the
face or the scalp, but not unfrequently appearing on differ-
ent parts of the body at the same time ; they feel thickened
and somewhat hard to the  touch, with an uncircumscribed,
soft, and slightly swollen  base, and  are  rather painful on
pressure, a sense of heat  and itching also attending them.

         ' Dictionary of Practical Medicine, vol.  iii. p. 790. 
LUPUS.
249
These tumors are very indolent, often remaining stationary
for months, and scarcely increasing in size ; interstitial ab-
sorption of the  deep layers of the derma is, however, slowly
going on, and  at length purulent matter makes its way to
the surface, generally at the most prominent  part of the
elevations ;  ulceration then takes place,  and,  the pus es-
caping,  it  is found that the surrounding  integuments are
more  or less  undermined by  the process of destructive
absorption which had been taking place.   Additional tumors
are now developed  in the neighborhood  of those which
first appeared, and of a similar character in all respects to
them:  the intervening portion  of integument  presents an
oedematous  aspect, has a boggy feel,  and, being first un-
dermined by the ulcerative interstitial absorption, which
continues its slow progress, at length  gives way, and an
unhealthy-looking, open ulcer, extending quite  through the
skin, and covered in parts by a hard, brown crust or scab,
is  formed.
   The ulcers   constituted  in the manner  above  described
heal slowly, leaving  an uneven excavated cicatrix or pit
of a white glistening color, but  the disease continues to
spread from the circumference,  creeping  on—whence the
specific name—almost invariably in the form  of irregular
rings.   The interstitial ulceration in many cases  re-attacks
the parts which have  cicatrized, and they again may thus
become for a second or third time, or even  oftener, the seat
of the disease,  which runs the same course as at first, but
each time the surface heals, the resulting cicatrix  is deeper
and more  uneven.   It not uncommonly occurs that two or
more  patches  of the lupoid ulceration coalesce  in conse-
quence of the disease  spreading from the  circumference of
each,  and an  extended portion of the integuments  may
thereby be affected.
   Lupus  serpiginosus  occurs,  as already remarked,  with
greatest frequency on  the  face and scalp,  often extending,
too, from one to the other, and being confined to them, but
it  is also witnessed on both the  upper and lower extremities,
and occasionally on the trunk  of the  body;  it  is usually
attended with more or less local pain in all its stages, Avhich
is  much aggravated at times by attacks of  acute  inflamma-
tion, when  it  spreads more rapidly, but  the  constitution 
250
CANCRODES.
   very rarely participates, those affected with the disease being
   often apparently in excellent health,  even although it may
•  have lasted for years.   It is always  of a chronic nature,
   and  its  duration  is extremely prolonged.  When it termi-
   nates in cure, the intra-dermoid ulceration ceases to spread;
   healthy  granulations, at times rather exuberant, form  on
   the surface, and cicatrization  of  the affected part  takes
   place ;  the annular edges being elevated  over the healthy
   skin, and of course much  more over the cicatrized portion,
   and being of  a bright-red color, which  they retain  for a
   long time, contrast remarkably with the shining white aspect
   of the latter : much disfigurement consequently results.
     Lupus devorans (noli me tangere) (Atlas, PL XIV. Fig.
   4).—This variety of the  disease commences in various ways,
   but no matter what appearance it may present at first, it is
   in  its progress characterized by destructive ulceration  of
   the various structures  situated beneath the  skin—areolar
   and adipose  tissues, muscles, tendons, cartilages,  and peri-
   osteum,  being  equally  destroyed;  the bones  even do not
   escape, for where  they are laid bare  caries attacks  them.
   It  may be developed, like the last-described form, by the
   appearance of one or more rounded, dusky-red elevations
   of  the  integument—tubercles—on the alae  nasi, on the
   cheeks, or  on the  roof of the mouth, which, however, run
   a somewhat more  rapid  course than in lupus  serpiginosus,
   are the seat of more active inflammation, and  are attended
   with  a more destructive ulcerative process, which extends to
   the deeper-seated  structures.  In  other  cases, one  of the
   alae of the nostrils becomes slightly swollen, painful  to the
   touch, and of a violet-red color ; being attended with itching
   it is soon scratched with the nails, a broAvnish crust or  hard
   scab  results, which is surrounded by an inflammatory  oede-
   matous base, and, purulent matter forming beneath it, ulcer-
   ation of the destructive character peculiar  to the disease
   commences.  In  a third class of cases the tip of the  nose
   swells,  and  presents a  dead-white  color,  gradually but
   slowly enlarging, a black crust forms  at the very apex, the
   mucous membrane of the nostrils becomes thickened, chiefly
   from effusion into the areolar tissue beneath it, and at length
   ulceration  takes  place.  And, lastly, the  thickening and
   subsequent ulceration first appear in the soft palate or pos- 
LUPUS.
251
 terior nares, and, proceeding from within outwards eventually
 attack the septum naris, and the other cartilages of the nose.
   In Avhichever Avay the disease may commence, the result-
 ing  ulceration  presents  much the  same  characters;  its
 tendency is to spread from the surface inwards, not unfre-
 quently undermining in its progress the healthy integuments
 before  it attacks them,  and  being  attended with a foul,
 unhealthy, purulent, often  ichorous discharge.  The  parts
 first  affected usually cicatrize in the course of the  disease,
 when the cicatrices  present a similar appearance to what is
 witnessed in lupus serpiginosus, but indicate a greater loss
 of substance beneath.   This is especially remarkable on the
 nose, the most  usual  seat of this  variety of lupus, this
 feature assuming then a peculiar pinched appearance, from
 a deficiency of some of its natural proportions.   The amount
 of destruction caused by the ulcerative process varies  much
 in different cases, in some removing only a small portion of
 the cartilages of the alae nasi, while in others the entire soft
 part  of the  nose, the alae  and septum naris,  and the soft
 palate, are  destroyed, frightful  deformity being  thereby
 occasioned.   As in the other  forms of lupus,  parts that
 have been  cicatrized  not  unfrequently again become the
 seat of fresh ulceration, which runs a similar course  to what
 it did at first, being then, however, more difficult to check.
   Lupus  devorans most generally runs a very chronic course,
 its progress being slow, years often elapsing before it causes
 much destruction of the part it appears on ;  but cases  occur
 —happily very rarely—in  which  it destroys  with extreme
 rapidity those portions of the  integuments and of the neigh-
 boring  structure it  attacks;  thus, in from a month to  six
 weeks the entire of the nose may be eaten away; this variety
 of the disease has been appropriately enough  termed  lupus
 vorax.
   In some  cases lupus devorans  attacks the  lower eyelid
 first,  commencing by the development  of a single rounded
 elevation  of  the skin,  of a  livid aspect;  its progress  is ex-
 tremely slow, but in the  course of years it eats away all
 the structures around the  eyeball, laying the orbit almost
 completely bare, but sparing  the eye  itself, which appears
just as if  it  had been dissected out by the ulceration.  This
 variety of  the  disease was first accurately  described  by 
252
CANCRODES.
Professor Jacob, who, however, regarded it as a malignant
ulcer and not as a form of lupus, and it has been ever since
known to the profession in this country by the name  of
"Jacob's ulcer"  (Atlas, PL XIV. Fig. 5).   Rayer,  who
also  gives an accurate account of it, believed it to be lupus,
and  with him my experience, derived from the prolonged
observation  of  several cases, compels me  to agree.   The
following graphic account of this lupoid ulceration is given
by  Professor  Jacob i1  The  edges are  elevated,  smooth,
and glossy, with a serpentine outline, and are occasionally
formed into  a range  of small tubercles  or  elevations; the
skin in  the  vicinity is not thickened or discolored.   The
part Avithin  the edges is in some places a perfectly smooth,
vascular,  secreting surface,  having veins  of  considerable
size  ramifying OArer it, which veins occasionally give way,
causing  slight  hemorrhage:  in other  places  the  surface
appears covered by florid, healthy-looking granulations, firm
in texture, and remaining unchanged in size and form for a
great length of time.   The surface sometimes heals  over in
patches,  which are hard, smooth, and marked with  venous
ramifications."   "The discharge from the surface is not of
the description called by surgeons unhealthy or sanious, but
yellow and  of proper consistence; neither is  there  more
fetor than from  the  healthiest  sore, if  the parts be kept
perfectly clean, and be dressed frequently." It is surprising
how little suffering,  either local or constitutional,  attends
this  frightful affection, the duration  of  which may extend
from early life to an advanced old age.
  Lupus in  all its forms is a disease of youth  and of the
prime of life, being rare before the age of 10,  and very
seldom developed for  the first time  in old age.   As  regards
its  causes, there is abundant evidence  to  show that  it  is
intimately connected with the scrofulous diathesis, especially
when it is hereditary, and many cases seem to prove that a
constitutional syphilitic taint also is a frequent predisposing
cause of it.   In the majority of instances it  appears at  or
soon after puberty, without any manifest exciting cause, but
in some it follows an injury or some other local irritant.  It

            1 Dublin Hospital Reports, vol. iv. p. 232. 
LUPUS.
253
is on the whole rather a rare disease, and is perhaps some-
what more frequent in females than in males.
  Diagnosis.—The differential  diagnosis of  the various
forms of lupus now described is unattended with difficulty,
but some of them may be mistaken for other diseases of the
skin. Lupus superficialis is of such very rare occurrence that
it is  often not  recognized when met with; yet its phenomena
are highly characteristic, and it is of importance, with refer-
ence both to prognosis and treatment, that it should be diag-
nosed ;  the peculiar cicatrization or seaming of the surface
over Avhich it has  passed is its especial mark:  a similar
result  is not  met  with  in  any  other cutaneous  affection.
Lupus serpiginosus may be  confounded with impetigo, from
which it is distinguished by the destructive ulceration which
attends it, by its spreading  in rings, and undermining the
integuments as it creeps onwards: pseudo-pustules are con-
stantly developed on those parts of the skin which it attacks,
but they differ from the pustules of impetigo in  being flat-
tened, more or less uncircumscribed, and presenting from
the first a comparatively large quantity of purulent matter,
with a very thin covering.   This  variety of lupus is in gene-
ral described by dermatologists as being with difficulty diag-
nosed from scrofulous ulceration of the  integuments; but
this  is a matter of  little import,  for it rarely occurs except
in persons of a  well-marked scrofulous  diathesis, and  by
many it is termed Esthiomanic scrofula.   A somewhat simi-
lar form of ulceration constitutes at times one of the phe-
nomena of secondary syphilis, but it is not  of the  same
indolent  and  destructive character, is attended with other
symptoms which  mark the  presence of  this poison in the
system, and  is always more  or  less amenable to specific
treatment.   Lupus devorans  may, in its early stages,  be
mistaken for acne  indurata, but  the distinctive signs have
been already pointed out in the description of that disease
(see  page 122).   From the syphilitic affections which occur
on the face it  is distinguished, by its malignancy, by its slow
progress, and  by  its not directly implicating the bony struc-
tures ; but in many  cases the diagnosis is made with extreme
difficulty,  and then the results of treatment—more  espe-
cially when the  history of  the  individual  case  cannot  be
                           ^2 
254                   CANCRODES.
satisfactorily obtained—afford much aid in arriving at a
conclusion.
   The form of lupus described  aboAre under  the name of
" Jacob's ulcer" is regarded by many as being  nearly allied
to, if not a variety of, cutaneous cancer; by most surgical
writers the latter view is taken, and  Copland  regards it as
a  connecting link between the two diseases.   But its chief
characteristic phenomena,  especially its tedious but onward
ulcerative progress,  not implicating  the  bony  tissues, the
freedom from pain which marks its course, the non-contami-
nation of the constitution generally, and the absence of the
hypertrophied condition so characteristic  of  cutaneous can-
cer, sufficiently identify it, in my opinion, with the other
lupoid affections.
   Prognosis.—In every form of lupus, the prognosis, though
favorable as regards  the general health, must be more  or
less unfavorable with respect to the local  disease, the latter
being by many regarded  as altogether incurable; yet, al-
though most tedious  and obstinate, in the  majority of cases
resisting even judiciously applied  and  appropriate treatment
for years, it not  unfrequently eventually  yields, the de-
structive process of ulceration is  arrested, and the affected
parts heal.   The superficial  variety  of lupus  is  the  least
important in all respects, but even it is  most rebellious, and
the diseased surface  rarely takes on a  healthy action until
after several months of  treatment, and  after apparent cure
it is very apt to re-appear in the old cicatrix.   Lupus serpi-
ginosus, when of small extent, is  in some cases very amen-
able to treatment; but when it affects an extended portion
of the integuments is rarely cured in  a shorter period than
from a year to a  year and a half or two years, and often
after the disease is apparently perfectly removed, it breaks
out afresh  in one or two  of the spots which  had healed,
when it lingers obstinately for months.   Lupus devorans is
both the most severe and the most obstinate of the several
varieties of the  disease,  its  destructive progress, unless
when submitted to treatment at a very early period after it
commences, is scarcely to be arrested, nor does it seem ever
to tend to spontaneous cure: the form denominated "Jacob's
ulcer" is, in  my  experience, perfectly  incurable  in all its
stages.   Like most other cutaneous diseases, the longer the 
LUPUS.
255
duration of lupus, the more difficult is it to treat success-
fully.
   As regards the pathology of lupus, it is manifestly nearly
allied to cancer, especially by its malignancy, and the ap-
pellation for the group of diseases of the skin in which it is
here placed has, I think, been therefore happily chosen  by
Dr.  Copland;  yet they differ  remarkably, in the  latter
being almost invariably marked  by a general contamination
of the system, which is never witnessed in the former; this
is well evidenced by the glandular system in the  neighbor-
hood of the disease not becoming affected in the course of
lupus, even when it has  existed  for years.
   Treatment.—The administration of constitutional reme-
dies, in the  treatment of  lupus, is regarded  by  many  as
being useless, and the employment of local applications  is
solely relied on,  but I agree with those who consider both
to be requisite, and it is  only from a prolonged perseverance
in remedial measures, judiciously selected, that good results
can be expected  to follow  in  this obstinate  and malignant
affection.   The intimate connection that exists between the
disease and scrofula  being an  admitted fact, the general
treatment should consist in the use of those remedies which
are  calculated to correct   that vitiated  condition  of the
system, and the  avoidance of all medicines which experience
has  proved disagree with  scrofulous individuals,  or aggra-
vate  any local  derangement  under which they may labor.
The preparations of iodine and of iron, cod-liver oil, and
the vegetable tonics, are therefore especially indicated  in
the treatment of the different forms of lupus, and general
hygienic measures, calculated to invigorate the constitution
and to  remove its vitiated   condition, should never be neg-
lected.
   Iodine in some form, given in combination with tonics or
alteratives, according to  individual circumstances,  is the
remedy Avhich, in my  experience, is most to be relied on;
for the majority of  cases  the  iodide  of  potassium  is the
preparation best adapted,  but, as I  have already  remarked
in a  previous part of this work, its beneficial effects are
more certainly  obtained by being administered  in rather
small  doses, continued for a long time, than  if it  be pre-
scribed in  large quantity at  first—a practice which has 
256
CANCRODES.
been recently much followed in the treatment especially of
secondary  syphilitic  diseases.   In persons  in whom  the
constitution is  unimpaired, and the muscular  and adipose
tissues well developed, it may be prescribed in  somewhat
the following form:—

     R. Iodidi Potassii,......gr. xij.
        Infusi Cascarillae,.....fl  3xij.
        Liquoris Taraxaci,.....fl 3ij-   Misce.

   " Two table-spoonfuls to be taken three  times a day."

   The  quantity of the iodide  of potassium  should be in-
creased by the addition of a grain to the mixture each time
it is renewed, until it contains  twenty-four grains,  when it
should be omitted for a few weeks, and again recommenced
in the small dose.  For weakly persons, or those of a broken-
down habit of body, the iodide of iron should  be substituted
for the iodide of potassium, and it may be given in decoction
of  fresh elm-bark ; when the  scrofulous diathesis  is very
well marked, and the lupoid ulceration extensive, threaten-
ing to  engage the deeper seated structures, iodine  itself
will be  advantageously combined with the  iodide of potas-
sium  or iodide of iron: if Avith the former, it may be pre-
scribed according to the formula  at page 185, the arsenical
solution being omitted.
   Cod-liver oil also proves  an  excellent remedy in  the
treatment  of lupus, especially when the disease occurs at
an early age; from my own  experience of its effects I  do
not think it is attended with so much advantage when given
in  the  enormous  doses  recommended by some, as when
administered in smaller quantity, and its use persevered in
for a  very  long time: a tea spoonful three  times a day,  and
increased so gradually that  at the end of six months two
table-spoonfuls, as frequently  given,  will  be  the amount
arrived at, a dose which need not be exceeded, is the manner
of  administering  the  medicine  that  I  have  seen  prove
eminently  successful  in  lupus.   By  some of the French
dermatologists, however, many of whom  speak  in rather
extravagant terms of its  efficacy in this disease, the dose
is increased  as rapidly as  the stomach will  admit, until 
LUPUS.
257
from  a pint and a half to two pints  are taken  in  the
twenty-four hours.
  Arsenic alone, or  combined with iodine, has been highly
recommended by many practitioners for the treatment of
lupus; the  late  Dr.  Anthony Todd Thomson  was in the
habit of relying  chiefly on  it in the form of the iodide of
arsenic;  I have  found this preparation very useful in the
form described above as constituting lupus superficialis, but
in the other varieties of the disease it  has not proved so
beneficial in my hands as iodine and the iodide of potassium.
The liquor arsenici et hydrargyri hydriodatis proves of espe-
cial service in those  cases in Avhich there may exist in the
system an hereditary or acquired syphilitic taint.
  So  many other medicines have  been at different times,
and still  are, proposed  for  the treatment of lupus, that it
would be  almost  impossible  even  to enumerate them; a feAv,
however,  require to  be shortly noticed.  The animal oil of
Dippel—obtained in the dry distillation of hartshorn shav-
ings in close vessels—has acquired some  character on the
Continent; it is  given in doses of five or six drops, at first,
gradually increased to twenty or twenty-five.   The chloride
of barium and chloride of calcium have both been much used;
that they possess some efficacy, due certainly to their anti-
scrofulous powers, has  been proved by the publication of
several cases in which a cure resulted from their administra-
tion.   Various preparations of mercuy have also been tried
for the treatment of lupus,  and the red  iodide is especially
recommended by M. Rayer for those cases in which there is
much hypertrophy of the integuments ;  but in consequence
of the injurious effects so often occasioned by the adminis-
tration of mercurials to persons of the scrofulous diathesis,
I cannot agree with those who  advocate their use in this
disease.
  The general  hygienic  measures to be adopted  require
merely to be alluded to ; they consist, of course, in attention
to every circumstance which can fortify the constitution, and
remove the depraAred condition  on which the presence of the
local disease depends: the chief of these are, breathing a dry,
pure air, the use  of nourishing, unstimulating diet, residence
on the sea-shore, and when the strength  admits, cold salt-
water bathing.
                           22* 
258
flANCRODES.
  The local treatment of lupus has at all  times attracted
more attention  than the constitutional, and, as before re-
marked, many consider that the disease can by it alone be
cured.  It maybe  considered under  two heads: first, the
ablation of the affected portion of the integuments by the
knife, or its destruction by caustics;  and, second, the em-
ployment of astringents  or  other medicinal agents, calcu-
lated to promote cicatrization, or  excite a new action in the
parts.  In the superficial variety  of lupus, the chief object
being to prevent disfigurement by arresting the progress of
the disease, the use of the knife is not admissible, for, were
its employment even certain to effect  a cure, the resulting
eschar would  occasion as much, if not greater, deformity;
for the serpiginous form it is not applicable, nor has it been
recommended, except  by a few  surgeons, to remove the
hypertrophied edges:  and,  therefore, it is only in lupus
devorans that excision holds out any prospect of being use-
ful.   An almost insurmountable  difficulty, as  regards its
application, however, is experienced in  all cases in which the
disease  has existed  for any time, owing to the manner in
which the  ulceration spreads, and the consequent impossi-
bility of removing the entire of the parts affected ; when it
is but of short  duration, and the deeper-seated structures
are not involved, the operation has occasionally  proved use-
ful,  especially in "Jacob's ulcer;"  but the employment of
the constitutional treatment above recommended should not
be  neglected  at the same time, as thereby alone can it be
expected that the return of the disease will be prevented.
  The stronger caustics, from being more easy of applica-
tion, and more certain than the knife in their effects on the
uneven, penetrating ulceration which characterizes this form
of lupus, have been more generally employed.  Those chiefly
used are the nitric and hydrochloric acids,  the  acid nitrate
of mercury, caustic  ammonia, chloride of  zinc, chloride  of
gold, caustic potash, solution of the terchloride of antimony,
and  arsenical  pastes or powders.  The chloride of zinc has
many advocates, and where the edges of the ulcer are ragged
and unhealthy, and the surface discharging a sanious pus, it
in many cases proves useful  by exciting a new action ;  as
much of  the surface  as it  is wished to destroy should be
touched lightly with the solid salt, and the application re- 
LUPUS.
259
newed every alternate  day until the desired effect is  pro-
duced ; the stronger acids may also be applied, in the same
manner.  I have generally known the employment of caustic
applications prove  injurious in lupus serpiginosis, yet they
are highly praised by several writers, nitrate of silver being
usually preferred to any other ;  in many cases that I have
seen them used, the parts to which they were immediately
applied healed up temporarily, but the serpiginous ulceration
from the  circumference continued to spread unchecked, un-
dermining the surrounding integuments, generally with in-
creased rapidity.   In lupus superficialis, caustics, if effectu-
ally applied, cause a worse disfigurement than the original
disease, Avhich, moreover, they do not check.
   Under  the second division of local applications may be
noticed, first, those which, though not actually caustic, are
highly  stimulant  and resolvent, such as the  dilute acids,
Donovan's solution, the animal oil of Dippel, lotions or oint-
ments containing  the  chloride  of zinc, nitrate of  silver,
caustic potash,  &c.  The oil of Dippel  is employed very
extensively on the  Continent, and, it is said, with excellent
effect, especially when  the nose is the  part affected, as a
modifier of the  diseased  action; it is applied by means of
a camel's-hair pencil, the surface being lightly touched with
it, and the application repeated several  times.  The solu-
tion of the hydriodate of arsenic  and mercury also proves
most useful as a lotion in many cases of the disease; it  is
especially of service in the superficial form  of the affection,
the crusts having been removed by poulticing previously.
  M. Cazenave  has recently published his experience of the
effects of  the red iodide  of mercury as  a local application,
from which it would appear to produce most beneficial results,
especially in those  cases  attended with mnch hypertrophy.
" Under the influence," says he, " of the application of the
biniodide  of mercury frequently repeated, I have seen after
the disappearance of the  sharp but fleeting local inflamma-
tion produced by it, and  as a consequence probably of its
general action,  the hypertrophied  points become resolved,
the tubercles to  disappear, and soft, superficial, smooth cica-
trices, on  a level with the rest of the skin, form; in short,
I have seen the  most frightful cases of lupus cured without
leaving any other  traces  than an  apparently thinned skin, 
260
CANCRODES.
with white  or  red spots  here and there, according  to the
length of time  Avhich had elapsed from the formation of the
cicatrices." l   M. Cazenave applies a thin layer of the pow-
der, undiluted, to a portion only of the diseased surface at
a time;  it  causes severe pain and much inflammation, the
former lasting for six or eight hours, and  the latter for three
or four days ;  a thick crust is left, which falls off at the end
of  six, eight, or  ten days, when, should  there be occasion,
the application may be renewed.
   The topical remedy which I  have found  most useful in
the treatment  of  lupus serpiginosus is the acetate of zinc;
the ulcerated surfaces should be touched with the solid salt
—care being taken to use a crystal which has not effloresced
—twice a day, daily or  every second or  third day, accord-
ing to the degree of activity of  the local inflammation, and
 a lotion containing  from three to five grains to the ounce of
 distilled water should be used, lint wet with it being applied
 and the parts  covered with oiled silk when practicable.   In
 this form, as well as in lupus devorans, the local inflamma-
 tion, of  which  from  time  to time rather smart attacks occur,
 should be checked by the application of leeches  as near the
 affected parts as possible, but sufficiently distant to prevent
 the bites from becoming involved in the disease, and emol-
 lient poultices should be  used  occasionally with the same
 intention,  and to remove the hard crusts which  form.
    No matter  what local treatment be employed  in the treat-
 ment of lupus, attention must  be especially paid, when  the
 nose  or mouth  is  the  seat  of  the  disease,  to  prevent  the
 natural outlets from becoming obstructed during the progress
 of cicatrization.
    In conclusion, I  may again  repeat that,  as the result of
 considerable experience in the  treatment of this obstinate
 and  serious disease, I regard  the  employment  of  topical
 agents  as  altogether secondary; they are  unquestionably
 useful in modifying  the  diseased process that  is going  on,
 and  in  exciting a  new action  in the parts, but  they must
 be regarded as only auxiliary to the constitutional treatment,
which should engage the chief attention  of the practitioner,
the fact  being ahvays kept prominently in  view, that it is

 1 Annales des Maladies de la Peau etde la Syphilis, torn. iii. p. 59, 1851. 
KELO'lS.
261
alone by the prolonged use of remedies, and diligent atten-
tion to general hygienic measures, that a  favorable result
can be expected.


                        KELOlS.

  KeloiS (Chelo'id tumor) is an  extremely rare  disease of
the skin, Avhich was first noticed in the latter end of the last
century by Retz, and was soon afterwards fully described by
Alibert, who applied this name to it from  a fancied resem-
blance which he thought it bore to the claw of a crab  (2^,
"forfex cancrorum"):  for a similar  reason he first denomi-
nated it  Cancroide,  and also  because this latter term ex-
pressed the  analogy which he believed to exist between the
disease and  cancer ; it is for the latter reason that I have
included it with lupus, in the order Cancrodes.  It consists
in the development on the cutaneous surface of an irregular-
shaped, or somewhat oval, hard, and prominent excrescence,
slightly depressed and  uneven in the centre, the edge* being
raised and thickened;  the surface  has a  polished, shining
aspect, of a  rose or reddish-white  color, marked with bright-
red and white lines,  and corrugated  so as to present nearly
the  appearance of  an  old, much hypertrophied cicatrix.
When pressed with  the  finger it is somewhat  resilient, and
the part pressed upon becomes momentarily colorless.   The
morbid groAvth, Avhich varies in size from a few lines to an
inch or more  in diameter, is extremely adherent to the in-
teguments, roots projecting from it into the deeper layers of
the skin.  It first appears in the form of one or more small,
hard, Avartlike tumors, accompanied by itching  and  some
pain; as it  increases in size the pain becomes much aug-
mented, being of a  severe stinging  character, and in some
cases has been described as being almost unbearable.
  The cheloid tumor  is most generally solitary, being, in
the majority of cases which have been reported,  developed
on  the anterior  surface of the  thorax, either  below  the
clavicle on either  side, or on the  sternum,  but in a few in-
stances several of them have been witnessed to exist at  the
same time on  different regions of the body:  its growth is
comparatively slow,  it does not ulcerate, nor is it  painful to
the  touch, and may continue indolent for years, but in  a few 
262
CANCRODES.
cases, it has been reported to have become gradually smaller
by interstitial absorption, until it finally disappeared alto-
gether, its site being marked by a white cicatrix.
  The causes of this disease are very obscure;  in one or
two  instances  it has  been  stated to have folloAved local
injury, and  some cases have been published in  Avhich the
tumor  was  developed  on the  old cicatrix  of  a burn  or
wound, but many have with  sufficient reason questioned the
fact of these being examples  of true kelo'is.  No proof exists
of its being  hereditary, or of its occurring in persons  whose
parents had been affected with  cancer or scrofula, nor does
it appear to be connected with  any special temperament or
diathesis.   It would seem to affect both sexes nearly alike,
but it has not been observed in early life, those  who labor
under  it being  individuals   usually  of mature  age.  The
extreme rarity of the disease is  very remarkable, and  conse-
quently its nature, history, and characteristics are not well
understood,  from want  of sufficient  opportunity for their
being studied :  Wilson states that the total number of cases
recorded  amounts only to 24, of which he himself has seen
7 ; but  it has been witnessed also in Ireland,  casts and
draAvings of it existing in the Museum of the Richmond Hos-
pital in this city, although the cases have not, as far as I am
aware, been published.
  Diagnosis.—The  only affection  with  which kelois  is
likely to be  confounded is cancer ; it is  distinguished from
it by its indolent nature, its indisposition to ulcerate, the
absence of contamination of the  glandular system, and its
peculiar site.
  Prognosis.—Were  it not  for the  extremely painful sen-
sations which usually attend this affection, it would be  of
little moment,  there being  no risk  to  life, nor  local dan-
gerous symptoms likely to  be occasioned  by its presence.
The duration of the disease is almost invariably prolonged;
years elapsing  in those  cases in  which it has disappeared
spontaneously, before absorption  had commenced.
  Treatment.—Excision of the  chelo'id tumor has been pro-
posed and practised, but such a course seems  to  have been
invariably unattended with  successful  results;  the  wound
made was difficult to heal, and the  disease returned after
some time either in the cicatrix or  in the integuments of some 
KELO'iS.                    263
other region of the body.  The spontaneous cure of the
affection by absorption having  occurred in, comparatively
speaking, many cases,  should inculcate the propriety of ab-
staining from  meddlesome interference,  and teach  that
reliance ought to be placed chiefly on constitutional treat-
ment by means of alteratives and  corrigents where neces-
sary, and the local  use of mild stimulants or  sedatives  to
allay pain.  With  the latter  view I  would suggest the
employment of an ointment containing the iodide of potas-
sium and  chloroform.   Cazenave  recommends the sulphur
douche ; Wilson, the application of collodion and the tinc-
ture of  iodine; and Rayer, that  firm  and constant com-
pression should be made on the tumor Avhen  its situation
permits. 
264
DERMATOPHYTE.
                  CHAPTER  XI.

                    DERMATOPHYTE.

  The general application within the last few years of the
use of the microscope  in  investigating  diseased conditions
of animal  structures,  has  afforded  most  important  and
valuable assistance to the  morbid anatomist and pathologist,
by throwing new light  upon much that was before  obscure ;
our knowledge of cutaneous  affections has, along Avith other
subjects in  practical medicine, been advanced thereby,  and
chiefly by the discovery that in certain of them a vegetable
production—a cryptogamic plant—is present on the surface
of the skin.  It is in  consequence  of this discovery that a
necessity has arisen for constituting  the present  group or
order of diseases of the skin, and which is  termed Derma-
tophytes—from  Sip/xa, "the skin," and $vtoi>, "a plant:"—
it includes,  then, those  cutaneous affections which are depen-
dent on, or are characterized  by the  presence of parasitic
plants on the diseased surface  of  the  integuments.   By
some  the existence of these  vegetable growths is altogether
denied,  while  others  who  admit  their  existence, regard
them  as  being accidental productions,  a consequence  and
not a cause  of  the disease which  they accompany ;  the
investigations, however, of Dr.  Hughes Bennett,  of Edin-
burgh, and  of Robin,  Gruby, Lebert,  and others, on the
Continent, in my opinion,  place beyond  doubt not  only  that
these parasites are developed in  certain  diseases of the skin,
but that they constitute their essential nature.  In addition
to the two affections,  Porrigo and Sycosis, which  I shall
include  in  this order,  the presence of a cryptogamic plant
has also been recently ascertained in  Pityriasis  versicolor
(Chloasma), but I agree Avith Dr.  Bennett, in the  opinion
that  " although this disease frequently presents  epiphytes
among the  scales, it owes none  of  its essential characters
to this circumstance." 
PORRIGO.
265
                        PORRIGO.

  Porrigo (Favus; Tinea; Scall-head). (Atlas, PL XV.
Figs. 2 and  3.)—This  peculiar affection,  which,  from  its
appearing  most frequently on  the  scalp, is  generally de-
scribed as being peculiar to that region of the body, is cha-
racterized  by phenomena so distinct  from those of  all the
other eruptive diseases which are apt to occur there, that it
cannot possibly be  mistaken for any of  them.  It is deve-
loped in the form  of small, elevated, dry spots, about the
size  of a pin's head, of  a bright yellow color, seated on the
surface of the skin, which is depressed slightly by them;
each spot is distinct, hemispherical, slightly concave or cup-
shaped on  its free surface, and convex beneath, where it is
adherent to  the skin.   On removing  the small, diseased
mass, that portion  of the  scalp on  which it was  seated is
found  to be  somewhat  depressed, smooth  and shining.  A
single crust of the disease,  or favus,—as it has been termed,
from its resemblance both in color and central depression to
the superficial surface of a honeycomb,—is often  traversed
by one, and sometimes by  two hairs,  which appear to grow,
as it were, from the very centre or most depressed portion;
this  has given  rise to the  notion that the disease is one of
the bulbs of the hair, but the fact of its appearance on other
parts of the  body which are quite free  from hair affords a
sufficient refutation of this opinion.   The  eruption spreads
by additions to the outer edge or circumference of each crust,
which  thus retains  its hemispherical character, until it  ac-
quires a diameter of two or three lines, or sometimes more ;
some of the favi on the trunk at times attain fully half  an
inch in diameter; on the head, however, they rarely exceed
the size above  mentioned.   The adjacent favi, as they  in-
crease, unite with  each other, and form large, irregularly-
shaped masses, in which the original circular form of the
individual crust is in a great degree  lost; the centre also of
each is changed in appearance,  and, instead of the cup-
shaped depression, the entire surface is covered with alter-
nate elevations and depressions, or, so to speak, ridges and
furrows,  concentrically arranged.   The  eruption thus  in-
                           23 
266
DERMATOPHYTE.
creasing, the whole of the scalp, often, too, the forehead,
the neck, and parts of the trunk,  become encased  in  one
large, yellow crust, at the edges of which some favi, of the
peculiar  characteristic  appearance, are  invariably to  be
seen.
  The crusts of porrigo are of a pale sulphur-yellow color ;
they are hard and dry, and break with a short fracture, ex-
hibiting within a  mealy powder of a paler yellow than the
external  surface.   They may generally be removed  with
facility from the  scalp, but they bring away with  them  a
thin layer of epidermis, which  is firmly adherent to their
under surface, through which small  projections may be seen
with a moderate lens, sometimes with the naked eye.   These
projections,  or processes, pass into the dermis  beneath, and
when the crusts are torn forcibly away, blood issues from
the small orifices into which they were inserted.   From the
very commencement of the eruption the hair becomes altered;
much of it falls out, and the  straggling  hairs that remain
are thin, broken, weak, whitish, and readily removable  with
the crusts of the disease, in which they are firmly imbedded.
When this affection has continued for any length of time,
bald patches are left after cure, on which the hair does not
again grow; and even where  it has been cured at an earlier
stage, the hair seldom regains its  proper character, being
often weak,  thin,  and of a diseased appearance, and  of a
whitish-yellow color.   Porrigo, in its  first stage, does not
give rise to either heat  of  scalp  or  itching, and, conse-
quently, is very rarely noticed until  it is fully developed.
It usually commences on  the forehead, at the edge of the
hairy scalp,  but it spreads rapidly over the head, soon in-
volving nearly the entire surface, the healthy patches which
are left between the diseased spots being but very few, and
small in extent.   The eruption is also met with  on various
parts of the body, the trunk or extremities; but  I  have
very rarely seen it there except when it existed at the same
time on the scalp.   As the disease advances, much irritation
of the surface is  produced;  small  pustules form here  and
there in spots as yet unaffected with the eruption: the tingling
and heat are so unbearable as to compel the patient to tear
the surface with his nails, even to such a degree as to cause 
PORRIGO.
267
 ulceration; innumerable pediculi are engendered; the favus
 crusts emit an abominable odor, resembling that of mice;
 and a copious offensive discharge is secreted by the pustules
 and ulcerated spots:  in short, an  individual  affected  with
 this disease in its aggravated form  becomes a loathsome and
 disgusting object.
    I have already referred  to the  vegetable nature of this
 eruption: it is in the  spongy, friable  contents of the favi
 that its characters are best seen.  " Reduced to powder, and
 placed under the  microscope, it presents," says Robin, "a
 mixture—1. of tortuous, branching tubes, without partitions,
 empty, or containing a few molecular granules (mycelium);
 2. straight or crooked, but not tortuous  tubes, sometimes,
 but rarely, branched, containing granules or small,  rounded
 cellules, or  elongated cellules, placed end  to  end, so as to
 represent partitioned tubes, with or without jointed articula-
 tions (receptacles or sporangia, in various  states of develop-
 ment ?); 3. finally,  sporules, free,  or united into bead-like
 strings.  The mycelium is very abundant near the inner sur-
 face of the external layer, to which  it adheres.  The spongy,
 friable mass of the centre of each favus is principally formed
 of sporules and  the different tubes containing mycelium
 already described  (sporangia, or receptacles ?).  We often
 find mixed with them mycelium tubes, but in small quantity.
 All these elements pass insensibly  into each other: empty
 tubes (mycelium);  tubes containing  small, round corpuscles;
 tubes with corpuscles as large as the smaller sporules;  spo-
 rules placed end to  end, so as to resemble a hollow parti-
 tioned cylinder, with a  tendency to separate at the joints ;
 and free sporules.  Bennett has given a good drawing of
 this arrangement."'  M. Robin gives a minute description of
 the various parts of which  the fungus is composed, as well
 as faithful and well executed illustrations of this vegetable
 parasite, the correctness of which I have had repeated oppor-
 tunities of verifying within  the last  few years, and recently
 with the assistance of Dr. Lyons, Avho has devoted so much
 time and  talent to promote microscopical medical investiga-

  1 Des Vegetaux, qui croissent sur l'Homme et sur les Animaux Vivans.
par Ch. Robin.  Paris, 1847. 
268
DERMATOPHYTE.
tions in Ireland.   The botanical characters of the plant are
appended in a note.1 (Atlas, PL XVI. Figs. 5 and 6.)
  This is a rather rare affection,  appearing, however, from
the observations  of those who have written  specially upon
it, to be more common on the Continent and  in Ireland than
in England.  When I first wrote on this disease in 1848,2
my experience was drawn from a limited number of cases ;
since then, however, I have  had under my care a compara-
tively large number of  examples—twenty-three.
  It may  appear at  any time  of life, but  is very  seldom
met with  except  in childhood, from the age of 3 to  12;  it
may be developed  on almost every part of  the  body, but,
as  already  remarked, occurs with by much the greatest
frequency on the scalp, and  next to it on the back of the
trunk.  When  it appears on those  portions of the integu-
ment  which are  not  covered with  hair, the favus  crusts
acquire a larger  size, and increase more  rapidly than when
it is seated on the scalp, but it presents precisely similar
characters.
  Great confusion long existed amongst dermatologists as
to what special disease  was  understood by the term, " Por-
rigo :" the  many eruptions  which have their  seat  on the
scalp were at one time described as being merely varieties
of  a single  genus, which was indiscriminately denominated
Favus, Tinea, or  Porrigo ; this confusion has, however, been
lately much removed, and the latter appellation—the others
being synonymous  with it—is now strictly confined to the
cutaneous affection above described, aud which corresponds
with the Porrigo lupinosa of Willan.   Cazenave  divides it
into two species  characterized  by the  form in  which the
crusts  are developed,  the one he terms Favus dissemine, and
the other Favus  en cercles ;  this is, I think,  an unnecessary
refinement, tending to  complication, and presenting  no ad-
vantage  in practice.   Wilson, who denies  the  vegetable

  >  "Achobion Schonleinii.  Remah.  Orbiculare,  flavum, coriaceum,
cuti humanse presertim capitis insidens; rhizopodion molle, pellucidum,
floccosum, floccis tenuissimis, vix articulatis, ramossissimis, anastomoti-
cis(?).   Mycelium floccis crassioribus, subramosis,  distinct^ articulatis, ar-
ticulisinsequalibus, irregularibus, in sporidia abeuntibus ; sporidia rotunda,
ovalia vel irregularia, in uno vel pluribus lateribus germinantia."
  2  Eruptive Diseases of the Scalp. Dublin, 1848, 12mo. 
PORRIGO.
269
nature  of the morbid production on the  scalp, describes
favus, which is the name he adopts, as being a disease o.f the
hair-follicles.
   The causes of porrigo have given rise to much difference
of opinion, especially with  reference to its contagious  na-
ture ; the correctness of my adhesion to the views of those
who hold that it is so, which I avowed  some  years  ago in
the  little work  already referred to, has  been confirmed by
almost every day's experience since, for I have seen nume-
rous  instances of the propagation of the disease from indi-
vidual to  individual, by direct contact, in the majority of
cases from children to children, but sometimes  even from
children to adults.   The mode in  which I believe the con-
tagion to be conveyed is by the propagation of the vegetable
parasite, by means of the mycelia.   But its contagious cha-
racter has been denied by many on the grounds of the rarity
of the disease, and the failure to produce it by inoculation,
as tried by Gruby and others ;  the former of whon produced
the disease only once out of seventy-six trials on vegetables,
and  not at all on animals.   But Remak succeeded in inocu-
lating his own  arm  in August, 1842;'  and Bennett, who
had previously failed  in his own person after repeated trials,
succeeded completely in 1845, in producing the disease in
one of his class by inoculation and close contact of the favus
crusts, obtained from the head of a boy at  that time  in the
Royal Infirmary.   An account  of his experiment, and also
of Remak's, will be found in  the Northern Journal of Me-
dicine for  September, 1845, p. 202.   Now  in all these trials
to generate the plant, one important fact connected with the
natural  history of parasitical  fungi has been overlooked by
all, namely, that they require for their  growth  a peculiar
soil;  thus we find one genus is found only on snow, another
on cheese, another in yeast, different varieties on different
decaying vegetable matters, and individual genera and spe-
cies on various living animals and plants;  nay, even differ-
ent sorts on different  parts of  the same animal. .  This holds
true  with the Achorion Schonleinii;  it requires  for its  re-
production to be planted in a peculiar soil,  that is, on  an  in-
dividual whose system is in a peculiar cachectic condition; and

                1 Medicinische Zeitung, for 1842.
                          23* 
270
DERMATOPHYTE.
until it is ascertained what this exact constitution is, a single
instance of its propagation by contact—and such instances are
not uncommon—must be held as sufficient proof of its conta-
gious character.
   Some have held that this  eruption occurs in scrofulous
persons only;  others that  it  is an hereditary disease; but
neither statement is consistent with the observation of the
cases which I have seen.  It appears to have some connection
with, though I cannot say that it is caused by, poverty, filth,
wretchedness, and a weak development of the mental facul-
ties.  Unquestionably where  the disease has long existed,
the mind is weak, and the countenance presents  a somewhat
idiotic expression.
   Diagnosis.—With  no other disease of the skin can por-
rigo be  confounded, it is so distinctly characterized by the
dry, yellow, favus orusts, and  the total absence of discharge
or scaly desquamation in  any of its stages; occasionally,
pustules form,  it is true, on the surrounding integuments,
but they are evidently due to the irritative inflammation,
caused by the morbid growth on the cutaneous  surface, or
the application of acrid or stimulating unguents,  lotions, &c.
In its very early stage, when seated on the scalp, porrigo
might be mistaken for the  commencement of an  attack of
impetigo, but  the rapid development of  the pustules in the
latter soon renders the  diagnosis simple; and  it does not
present any features in common with the other eruptive dis-
eases of the scalp.  Should a doubtful case, however, occur,
any difficulty that may exist will be at once cleared up by a
microscopic  examination.
   Prognosis.—A disease of great gravity, and always re-
garded with extreme abhorrence in consequence of the dis-
agreeable symptoms Avith which it is attended, its  unsightly
aspect, and its contagious nature, porrigo nevertheless in no
respect tends to shorten life, or even to  injure the general
health, unless in so far that it almost necessitates strict con-
finement to the house and isolation.  The fatuity which is so
commonly witnessed to accompany its  advanced  stages  is
certainly to  a great  extent a consequence of its existence,
for it is not seen in any remarkable degree in individuals in
whom the affection has been of  short duration.   The effect
caused on the  growth of the hair must  also be  taken  into 
PORRIGO.
271
account in forming a prognosis, as its loss is often regarded
as one of the  most grievous consequences of "the disease ;
when the crusts cover the head completely, and their dura-
tion has been at all prolonged, the pressure produced by
them causes absorption of  the  superficial  layers  of  the
derma, and  consequent destruction of the hair-follicles, per-
manent  baldness  then  necessarily results ;  but when  the
morbid growth is removed at an  early stage, although  the
hair is most usually deteriorated and its  subsequent growth
injured,  no  ill consequences to it follow in some cases.  As
regards  the eruptive diseases of the scalp,  porrigo is  the
most obstinate and most rebellious to treatment of them all;
by many dermatologists  it  has  been regarded as  being
almost incurable, and consequently, the  most violent reme-
dies have been proposed for its treatment, but I have never
failed in curing it permanently by the simple method to be
noAV described.
   Treatment.—There  is probably no disease of the skin
which has been subjected to a greater variety of plans of
treatment, some  of them of the most  painful  character,
than  this, chiefly in consequence of its  extreme obstinacy,
and the  opposing views which have  been and are even still
held  as  to  its nature : before proceeding to speak of  the
remedies used by others, I shall  first  describe the method
which has invariably succeeded in my hands, and the efficacy
of  which has  been  now  for some years proved by  the
testimony of others.   It  consists in the simultaneous em-
ployment of constitutional remedies and local applications ;
the former,  used with the intention of correcting or altering
that vitiated condition of the system generally, to the exist-
ence of which is due the development of  the morbid growth
on a congenial soil; and the latter,  to remove the diseased
mass  constituted by the peculiar vegetable parasite, and to
prevent  its reproduction.
   A  combination of the two alteratives which experience
has proved to  be the most powerful  in the removal of cuta-
neous diseases—arsenic and iodine—has, in my experience,
effectually fulfilled the requirements of  the  constitutional
treatment.  They may be  given in the fluid form, as already-
recommended  for  the  squamous  eruptions,  combined, if
requisite, with vegetable tonics, or in  the solid state, as in 
272
DERMATOPHYTE.
the following prescription,  the  dose ordered  being  that
adapted for a child ten years old :—

       B.  Arsenici Iodidi......gr. j.
           Mannae  durae.......gr. vj.
   Mucilaginis quantum sufficit ut fiant pilulae duodecim.

          " One to be taken three times a day."

   This is the preparation which  I usually prescribe in the
treatment of porrigo; in some cases, after it has been taken
daily for five or  six weeks,  headache and dryness of the
mouth and fauces are  complained of, which quickly disap-
pear, however, on intermitting its use for a few days.  As
in the other cutaneous affections, for which these medicines
prove so valuable a remedy, their  administration  must be
persevered in for  a long period, and the dose increased very
gradually and slowly : they must also be  given  for some
time after all traces of the local affection have disappeared.
In decidedly scrofulous children,  the administration of cod-
liver oil  simultaneously with that of the iodide of arsenic
is attended with the best effects, and in cases in which from
any cause  arsenic may disagree, iodine may be given  dis-
solved in the cod-liver oil, in the proportion of the twelfth of
a grain  in each fluid drachm.  The following is an outline
of the local treatment: when the disease  is situated on the-
scalp the hair is to be cut, not shaved, as closely as  possible,
and a large  linseed-meal  poultice applied and  kept on for
twelve hours, so as to soften the crusts, and repeated for a
second or third time if necessary.  As soon as  the poultice
is removed, the head is well washed with a strong carbonate
of potash lotion—a drachm to a pint of distilled  water—and
slightly brushed with a soft hair-brush or roll  of  lint; the
scalp is then  covered with the carbonate of potash ointment
—a drachm to one ounce of prepared lard and a fluid drachm
of glycerine—spread on  lint, and  over it a closely-fitting
oil-silk cap is placed; the ointment is renewed  twice daily.
By the use of these applications  the  crusts of the eruption
are generally completely removed in  from  two to three days.
The  carbonate  of potash  ointment  is at the expiration of 
PORRIGO.
273
this time replaced by one containing the  iodide of lead, in
the proportion of half a drachm of the iodide to an ounce of
prepared lard, which is to be renewed morning and evening,
the head  being well  washed with the carbonate of potash
wash every time before the ointment is reapplied.  In some
cases  it will  be found  that  the iodide  of  lead ointment
excites a  certain degree of inflammation of the surface of
the scalp after it has been used for some days; when such
occurs it  should not be applied for a day or two, and the
lotion employed alone three or four times daily.   After this
first attack of inflammation disappears it rarely recurs again,
although the use of the ointment be  persisted in for months.
The strength of the  ointment should be increased  after a
fortnight, and if the  disease  again  appear, even to  double
that above indicated. The oil-silk cap should be kept on
the head  until  a  cure is effected;  the  advantage derived
from it is twofold; in the first stage of treatment, by keep-
ing the hard and firmly-planted  crusts of the disease in a
constant atmosphere  of warm  moisture, it softens, and thus
renders them more easily removable ; and in the after-treat-
ment the  mucedinous vegetable being retained by it in the
closest contact with the  iodide of lead and the  emanations
arising therefrom, is  more certainly destroyed,  and  its re-
production prevented.
   After continuing this  treatment for at least three weeks
or a month, all external applications should be stopped, and
the hair allowed to grow, so as to ascertain if the  fungus
will be reproduced ;  for it often lies dormant, and suddenly
shoots forth, increasing  rapidly when no longer subject to
the action of the  iodide  of lead.   Should it again  return,
the local applications must be had recourse to as before, im-
mediately on  its  appearance.   The administration  of the
iodide  of arsenic  should  be continued until we are quite
satisfied that the cure is complete.
   During the entire progress of treatment, the patient must
be  kept on a strictly milk and farinaceous diet," and the
bowels  regulated  by  the  administration  of mild mercurial
alteratives and saline  cathartics—especially the saline mine-
ral waters—when necessary.
   A most cruel, almost barbarous, method of treating por-
rigo, when it occurs on the scalp, originally proposed in the 
274
DERMATOPHYTE.
ancient days of medicine, is still followed to a great extent
on the Continent.  It consists in the application to the hairy
surface—the crusts of morbid growth having been previously
removed as much as possible by poulticing, &c.—of some
adhesive plaster, such as Burgundy or  common  pitch,  or
ammoniacum spread on strips of  stout calico, which, being
caused to adhere firmly, and left on for several days, are
torn off in a direction opposite  to that  in which  the  hair
grows, so as to remove as much of the latter  as possible ; and
they are applied again and again  until  the entire  of the
scalp is completely deprived of hair.   The sufferings occa-
sioned by this proceeding are, as  may readily be imagined,
something horrible, and the  Brothers Mahon, who strongly
advocated  its employment  in a  somewhat modified form,
mention that even death has resulted from  it.   As a reme-
dial measure, it originated in the false idea  that the disease
was an affection of the hairs solely, and  that by their total
ablation it would of necessity be cured, and in modern days
it has  been continued chiefly from a theory  which found
many supporters, that the production  of perfect  baldness
would suspend the morbid action  sufficiently long to allow
the diseased surface to return to a normal state.
  A host of powerful topical applications  have been used  in
the treatment of porrigo ; the strongest  caustics;  blisters;
ointments containing quick-lime, the sulphuret of  lime, tar-
tar emetic, arsenic, pepper, &c.;  lotions of corrosive  sub-
limate, and of other irritants and stimulants ; but inasmuch
as the method of treatment  which I have  recommended
above, has  proved invariably  successful  in my experience,
this simple enumeration of them will suffice here.
  No matter on what part of the cutaneous surface porrigo
may be developed, the  constitutional and  topical  remedies
to be employed are the same.

                        SYCOSIS.

  Sycosis (Atlas, PL  XV.  Fig. 1).—It is  conjectured  that
this term, which is of Yery ancient  origin in medicine, was
applied to designate the cutaneous affection which  is  now
understood by it, or  one nearly allied thereto, from a fan- 
SYCOSIS.
275
cied resemblance which the eruption bears to the rough
interior of a fig (<jvxov) : from the special seat of the erup-
tion it has by many modern Avriters been denominated men-
tagra, which must  therefore be  regarded as synonymous.
By Bateman the disease was classed in Willan's order of the
Tubercula, from which  it has been removed, together with
Acne, to the order  Pustulae, by those dermatologists of the
French school who have adopted an artificial arrangement of
diseases of  the skin.   Erasmus Wilson  also regards it as
being  nearly allied to Acne, and  consequently describes it
with that affection  in his group of " Diseases of the Sebi-
parous Glands."  As regards the appearance of the eruption,
in one of its stages it certainly bears much resemblance to
acne in being more or less pustular, but the pustules which
are present are, in my opinion, the result  of irritative in-
flammation, caused  by the existence of a parasitic vegetable
production,  first described by  Gruby, and, since  the  pub-
lication of his observations in 1842, by other observers also.
As the result of repeated microscopic examination, I fully
coincide with M. Gruby and Dr. Hughes Bennett, as to the
existence of this parasitic cryptogamic plant in sycosis;  I
have  therefore  placed  it with Porrigo in the group  of cuta-
neous diseases  to which the term Dermatophytae has been
applied.
   This affection, the site of which is limited to that portion
of the face on which the beard grows—the chin, the cheeks,
and the upper  lip,  rarely extending to the integuments im-
mediately adjacent—is developed at first by the appearance,
around the roots of the  hairs, of slightly inflamed-looking
elevations, on which a dry, grayish scurf soon appears ; this
increases pretty quickly, and its  presence exciting inflam-
mation, which  is much augmented by the use of the razor
in shaving,  conical pustules soon form, and mask much the
original character  of the  disease.   The eruption  escaping
notice in most cases in its early stage, has caused it to be
described as being pustular from the first;  but careful ob-
servation has convinced me that the pustules are secondary
and  that they originate from  the irritation caused by the
vegetable parasite, which must therefore be regarded as the
essential characteristic of this affection.   The crust or scurf 
276
DERMATOPHYTE.
increases very  slowly in extent, but, the attendant inflam-
mation attacking the subcutaneous structures, is accompanied
by much heat, pain, swelling, aad tension, which are further
augmented by the formation of the pustules ; these pustules
maturate slowly, and when they at length burst,  a dry, hard,
brown  scab forms, which is  very persistent, and if its re-
moval  be attempted, the surface  to which it adheres bleeds
freely and  is very painful.
  In the commencement of the disease a small portion only
of the skin is affected, and the attack is  often of short dura-
tion, the crusts and scabs falling off, and the surface pre-
senting a tolerably healthy appearance, reddish stains mark-
ing the previous site of the morbid groAvth ; but most usually
the eruption returns  after a short  time,  when it  spreads
more rapidly, and engages a  much larger extent«of surface,
the local symptoms also being more severe.   After repeated
outbreaks  thus characterized, the integuments of the  chin
become generally much hypertrophied, of a dusky-red color,
hard, and covered, in patches of a  greater  or  less extent,
Avith a thick, grayish crust pierced by the hair of the beard,
with hard,  dry, broAvn scabs, from beneath which pus exudes
here and there, and with conical, elevated pustules, many of
which, in  consequence  of their  being  developed over the
site of a hair-follicle, are perforated by  hairs.  The inflam-
matory action, when  sycosis presents these aggravated
symptoms, is usually  very  severe,  small  abscesses  some-
times form in  the subcutaneous  areolar tissue, and, engag-
ing the  hair-follicles,  the beard falls out  in patches,  and
permanent bald spots on the face  result.   Although the
disease is in the majority of  instances confined to that por-
tion of the chin on which the beard grows, in very severe
cases the upper lip  and the surface covered by  the whiskers
are also engaged, and  occasionally  it is confined to these
parts alone.
  In 1842, M. Gruby  first announced to the French  Aca-
demy of Sciences his discovery of the existence of a cryp-
togamic plant  (Atlas, PL XVI. Fig.  4), surrounding the
roots of the hair of the beard in sycosis, and he believed
that its presence constituted a previously undescribed variety
of the disease, which he proposed to term Mentagra conta- 
SYCOSIS.
277
giosum.  This parasitic vegetable does not appear above the
surface of the integuments, and thus differs altogether from
that of Porrigo.   " On examining the crusts or scabs under
the  microscope," writes M.  Gruby,  "they are seen to be
composed of epidermic cells ; but a microscopic examination
of the hair demonstrates that the entire of that part of it
which is inserted in the skin, is surrounded by cryptogamic
plants, which form a layer between the sheath of the hair
and the hair itself, so that the hair is placed, as it were, in
a cryptogamic sheath, just as a finger in a glove.  But it is
a remarkable fact that the parasitic  growths never  extend
above the surface of the cutaneous epidermis; they have
their origin in the matrix of the hair, and in the cellules
of which its sheath is composed, and they increase so as to
envelop the portion of the hair inserted in the skin.   The
sporules are almost innumerable in every part of the sheath,
and are firmly adherent both to it  and  to the hair itself,
so that it is difficult  to  separate them  without  tearing  the
sheath."1   The  stems of the  plant  are granulated  in  the
interior, and are bifurcated at angles  of from  40° to 80°.
M. Gruby has given  a  table of the distinctive characters
between the parasitic cryptogamic of porrigo and of sycosis ;
but Vogel, who corroborates his views as to the existence of
the vegetable growths—the  correctness of which has been
denied by many—regards them as being  only varieties of
the same species.
   Sycosis is a rather rare affection, and its causes are con-
sequently obscure, the only manifest one  being contagion,
the disease being propagated, as in porrigo, by the mycelia
of the parasitic vegetable ; of this an  example is recorded
by M. Foville, who  witnessed the transmission  of sycosis
to several individuals by means  of a razor which had been
used in  shaving a person affected with it.  To enable the
disease to  be communicated by contagion, we must, how-
ever, believe in the pre-existence of a peculiar constitutional
state  of the  system, as in  porrigo.   It,  of course, affects
adults  and persons  of the male  sex only; one or two in-
stances have been recorded of its having been witnessed in
females, but  it is probable some other cutaneous eruption

  1 Comptes rendus des Stances de l'Acade'mie des Sciences. 1842, p. 512.
                           24 
278
DERMATOPHYTE.
was confounded with it.  The irritation produced by shav-
ing,  and the use of acrid shaving soaps  in  persons of a
delicate skin, are usually enumerated amongst  the causes
of sycosis, but although they must be regarded as a means
of keeping up and of aggravating the disease when once it
is developed, I do not  consider  that  it can be  thus  origi-
nated ; they unquestionably often cause  other affections of
this  region of the skin, which are very often mistaken for
this disease.
  Diagnosis.—Acne, impetigo, ecthyma, furunculi, and sy-
philitic eruptions on the face, when they appear on the chin
or the lips,  are not unfrequently confounded with sycosis,
especially when they become chronic, and  indeed, by some
dermatologists, all pustular  eruptions, when seated on that
part of the face on which the beard grows,  are denominated
sycosis;  this term, however, should, I think, be restricted
to designate the disease above  described, as  being cha-
racterized by gray and yellow crusts  or scales and a  thick-
ened  and indurated condition of the integuments, and at-
tended with the development of conoidal pustules, terminat-
ing in dry, brown, adherent  scabs;  in  doubtful cases,  a
microscopic  examination of  the  roots  of the  hairs will aid
the diagnosis.
  Prognosis.—Although  seemingly not  injurious to  the
general health, sycosis is a cutaneous  disease  of much gra-
vity in consequence of its extreme obstinacy, the great suf-
fering it occasions, and the repulsive appearance which  it
gives to the face of those who suffer from it.  If submitted
to treatment in its early stages, it is in  most cases readily
cured, but it is extremely apt to return, and almost invaria-
bly in a more  severe form than  at first; when  once it has
become  chronic  it usually resists every plan  of treatment
for years, and sometimes lasts for life, or, if removed, leaves
its disfiguring traces behind, in the form of hypertrophied
livid-red patches on  the parts  which  had been affected,
and  often in the existence  of irregularly-shaped, uneven,
bald spots, on which the beard  is not reproduced.    Such
being the character of sycosis, as regards its duration and
ultimate results, it  is  of the  utmost  importance that the
disease should be carefully diagnosed  before a prognosis be
formed. 
SYCOSIS.
279
   Treatment.—The first point to be  attended to  in the
treatment of  sycosis is the state of the  general  health,
which will be found more or less deranged in most persons
affected with the disease;  and the condition of the  diges-
tive organs  especially demands attention.  To  regulate it,
mild mercurials, purgatives, alteratives, or tonics  should
be  prescribed, according to the  indication  in  each case;
and when the eruption has been of long standing, and en-
gages an extended portion of the  integument, preparations
of  iodine with the vegetable tonics and  diaphoretics should
be  administered.  As regards the local  treatment, the first
indication is to counteract, as far  as possible, the irritation
caused by the growth of the beard;  with this view  the use
of  the razor  should  from the first be altogether omitted,
and the hair kept  cut  as close  as practicable with a sharp
pair of scissors during the entire progress of the treatment.
The application  of three  or four leeches beneath the jaw
or  behind  the ears,  once  or twice a  week, during  the  in-
flammatory stages of the disease, or whenever  the affected
parts present a swollen or irritated appearance, is produc-
tive of especial benefit;  in  the  more  chronic stages,  or
when it has been of long duration, they should be used with
caution, and  their  application repeated not oftener than
twice a month.   Numerous topical remedies have been re-
commended for  the treatment of sycosis; that which I have
found most useful is a cerate containing calomel and chlo-
roform,  as  in the following  formula, applied  three  times
daily:—
     R. Calomelanos,......5ss.
         Cerati Galeni,......3j-
         Chloroformi,......m.xij.  Misce.

But in very obstinate cases, or those which resist the use of
this combination, the  iodide of  lead ointment,  as  recom-
mended for the  treatment of  porrigo, with the addition of
the quantity of chloroform above prescribed, will be  found
of much service.  Whichever  be employed, the diseased
surface should be well sponged previously to each  applica-
tion with equal parts of new milk and the weak alkaline or
lead  wash.   The ointment  of the iodide of sulphur, also, 
280                DERMATOPHYTE.
has been highly recommended by many for  the treatment
of this disease,  and in some  very obstinate  cases  I  have
found it of service.  Attention to diet and regimen is par-
ticularly demanded in all cases, the use of spirituous liquors,
and of all rich or  heating  articles  of food, being carefully
eschewed. 
THE SYPHILIDES.
281
                  CHAPTER XII.

                     THE SYPHILIDES.

   As a consequence of the absorption of the syphilitic poison
into the system during the existence of the primary or im-
mediate symptoms of the venereal disease, several secondary
affections are in most cases  developed  in a space of time,
the exact limits of which  experience has not yet enabled us
to define, but which  usually varies  from six weeks or two
months to from six to twelve months; amongst these, cuta-
neous eruptions hold  a prominent position, chiefly in conse-
quence  of their extreme frequency, and their disfiguring
effects.   The diseases of  the skin which owe their origin to
this cause present the same elementary characters as those
which are not so produced, and may assume in different cases
the form of nearly every variety of eruption  which has been
described in the preceding pages; but they  have certain
specific features by which they are readily distinguished,
and the treatment by which their removal is to be effected
consists in the  employment of remedies calculated to eradi-
cate from the system, or  counteract the effects of the con-
stitutional taint to which their existence is due.   It  is for
these reasons that most modern dermatologists have thought
it necessary to  describe the syphilitic eruptions as constitut-
ing a distinct group of cutaneous diseases.
  Secondary  syphilitic  symptoms, more especially  those
which affect the skin, may also be developed in individuals
who  have never had the primary disease, the venereal virus
being transmissible from parent to child ; thus, a cutaneous
eruption is not uncommonly witnessed soon after birth, the
origin of which may be traced to  the previous occurrence of
syphilis, whether primary or  secondary, in either parent, it
may have been even many months  previously.   Secondary
symptoms are  also by many practitioners, chiefly those  of
the English school, believed to be directly communicable by
contagion, as in the  case of the breast of a  nurse being 
282
THE SYPHILIDES.
affected by suckling an infant who has a venereal  eruption
on the mouth, by the act of kissing, &c, but the  truth  of
this view, one so  difficult to be proven, has been ably im-
pugned by M. Ricord,—an analysis of whose observations
has been given in the twelfth and thirteenth volumes of the
Dublin Quarterly Journal of Medical Science,—and his ar-
guments, fully corroborated by my own experience, incline
me to agree with the opinion that secondary symptoms are
not contagious.
  Syphilitic  cutaneous eruptions have  certain features  in
common, by which they are specially characterized, and dis-
tinguished from other diseases of the skin ;  these it will be
well to consider  shortly before speaking  of the individual
varieties.
  Since they Avere first recognized as being dependent on a
special cause, it has been noticed that although the syphilides
may differ in the  elementary form which they assume, they
invariably present a  peculiar dull tint of a brownish or  cop-
pery hue, which  is more or  less evident in all their stages,
and  also that they are  rarely accompanied by the active,
local inflammatory symptoms which so  often  attend other
cutaneous eruptions.   The shade of color by which they are
marked varies in  different cases from pale brown to a dull
copper, the difference depending  both on the  natural color
of the complexion and on the degree to which it is  affected
by the syphilitic cachexia; thus, when the secondary erup-
tions appear in a short space of time after the occurrence  of
the primary symptoms, the hue of the diseased surface  is  of
a less dull tint than when they are not developed for several
months, the venereal virus affecting  the system  more,  and
consequently producing a more decided constitutional effect,
the longer it has lain dormant in the system.   For the same
reason the more acute forms of syphilitic eruptions, or those
which  are occasionally attended with some degree  of local
inflammatory action, occur either when  the primary symp-
toms are  still present,  or shortly  after they have disap-
peared.
  Another remarkable feature which the syphilides possess
in common is a tendency for the eruption, no matter where
situated or of what form, to assume a circular or  annular 
THE SYPHILIDES.
283
shape as regards its distribution, and to spread over the sur-
face of the body in rings or crescentic-shaped patches ; this
is  especially remarkable when they are of the papular, the
squamous, and the hypertrophic types, and least manifest in
the syphilitic maculae and pustulae.
   They are also characterized by their more general occur-
rence on the exposed regions of the skin, especially on the
scalp, the forehead, the cheeks, and the alae nasi, than  on
those parts which are ordinarily covered ;  the eruption, too,
is  more thickly disseminated there.   They appear, however,
more frequently on the trunk of the  body than on the ex-
tremities, being especially developed on the back and the
shoulders.
   Lastly, syphilitic eruptions engage the more deeply-seated
cutaneous structures to a greater extent than the non-specific  .
diseases of  the skin, as is evident by the greater hypertro-
phy of  the  integuments that attends them, the firm, indu-
rated feel by which they are characterized, and the greater
elevation over the surface of those which are papular  or pus-
tular.   They are,  moreover, essentially  chronic  in their
nature ; the stains which remain on the skin after they have
been cured  are usually  very permanent; and they are even
more apt to return than the other cutaneous eruptions, which
are complicated by no special constitutional taint.
   The development of  the secondary symptoms of syphilis,
in the form  of a disease of the skin, is almost invariably
preceded and accompanied by well-marked signs of derange-
ment of the system generally.   The individual about to be
affected may have recovered in all respects from the imme-
diate consequences of the primary attack, and even a con-
siderable period of time may have elapsed, during which he
seems to be and feels in the enjoyment of his ordinary health,
when,  without any manifest exciting cause, a  degree of
cachexy is established:—the complexion becomes sallow and
earthy-looking, unwillingness to take part in any active exer-
tion, whether of mind or body, is experienced, the appetite
fails, thirst becomes constant, often extreme, pains in the mus-
cles and bones, much exacerbated at night, are complained of,
and venereal periostitis and sore throat in some cases pre-
cede and in others accompany the cutaneous eruption which 
284
THE SYPHILIDES.
  now appears—the outbreak being  in  general immediately
  preceded by a pretty smart feverish attack.   To a certain
  degree  the syphilides resemble the eruptive fevers, and by
  many writers  the analogy between them has  been made a
  subject of special observation : the similarity consists in both
  having a stage of incubation following the contagion, a period
  of febrile oppression preceding the eruption, and a charac-
  teristic fever attending its development, which ceases to a
  greater or  less extent when the  eruption  appears fully on
  the surface.
    As the scope of this work does not admit of any account
  being given of the other  secondary symptoms of the vene-
  real disease, which  usually accompany the  syphilitic cuta-
  neous  affections, and which  in  many cases  aid  much in
.  arriving at a correct diagnosis between them  and the non-
  specific affections of the skin,  I shall now proceed to  speak
  of the  special characteristics  of  the individual eruptions—
  describing them  in the  order  of  classification  which I have
  adopted, as they  present the symptoms of the groups therein
  contained.

                 SYPHILITIC EXANTHEMATA.

    The  Syphilitic Exanthemata may present the apparent
  phenomena of Erythema,  of Urticaria, or of Roseola.
    Syphilitic Erythema is characterized by the  occurrence
  in an individual  whose system  has been tainted  with the
  venereal poison of irregularly-shaped, dingy-red, or copper-
  colored patches,  more or less  circular,  but uncircumscribed,
  intermingled  with  which  generally are  numerous   small,
  rounded elevations of a darker shade; the eruption  in the
  majority of cases thus resembles  erythema papulatum, from
  which it is chiefly distinguished  by its peculiar color, and
  the other concomitant secondary symptoms which are almost
  invariably present.   The patches  of eruption are permanent,
  not fugacious,  and  although  they  fade  somewhat, do not
  disappear, even on firm pressure ; they are most usually wit-
  nessed on the forehead or  some other part of  the face, and
  on the chest and  shoulders; in some cases they are confined
  altogether to  the palms of the  hands, when  they are ex-
  tremely obstinate, recurring  again and again,  even  after 
SYPHILITIC EXANTHEMATA.         285
they have apparently yielded to treatment.   This eruption
is at times ushered in by rather smart febrile symptoms, but
in general it is not attended with any well-marked  distur-
bance of the system, nor is it accompanied by local pain,
heat, or itching.   It is rather a frequent form of syphilitic
cutaneous disease, and not  uncommonly complicates many
of the other varieties.
  Syphilitic Urticaria  is especially marked  by being at-
tended with the  characteristic burning and tingling sensa-
tions of  the ordinary disease; it resembles in shape  and
mode of development urticaria tuberosa, and like it is seated
chiefly on  the extremities, but it differs in  being of a  dull
red or violaceous tint, the centre  of each elevation being of
a coppery hue ;  it appears, too, generally during the night,
when the local annoyance it produces is also  most trouble-
some, but it  does not fade away, although it  is less promi-
nent, during the day.  It is an uncommon form of syphilitic
eruption, but when it does occur is extremely obstinate.  By
some dermatologists it is stated  that syphilitic urticaria is
not unfrequently developed on the skin as a symptom of the
primary  disease, in consequence of its  appearing while  a
blennorrhagic discharge is present; but when an eruption
of  urticaria is witnessed in such cases, it most probably
always depends  on the administration of copaiba, which has
been before noticed as being a cause of the disease.
  Syphilitic Roseola.—This  is  the most common  of  the
secondary eruptions belonging to the group; it generally
appears in from four to  six weeks after the apparent  cure of
the  primary symptoms, but sometimes  months even elapse
before its outbreak.  Cazenave and Wilson  both describe it
as occurring on  the  skin while chancres still exist on the
genital organs, and also  as a frequent concomitant of blen-
norrhagia;  but Ricord, with  whose views my experience
coincides, regards its causation in  such cases to be rather
referrible to a previous  venereal attack; at all  events, all
must admit the almost  total impossibility of arriving  at a
true history of the precedent occurrences in individuals labor-
ing under any of the symptoms of syphilis.   The eruption
is developed usually on the forehead, and the upper  part of
the face, but sometimes  on the trunk and extremities also, 
286
THE SYPHILIDES.
in the form  of small  circular patches, scarcely elevated
above the surface of the skin ; they are of a dull rose-red or
bronze hue, and fade  but slightly on pressure.   The indi-
vidual rings do not at first exceed the size of a shilling, but,
gradually increasing, two or more coalesce, so as to form
large uncircumscribed  patches, the borders  of which, how-
ever, still retain an annular character.  The outbreak of the
eruption is in general preceded by some slight febrile symp-
toms : it comes out rather rapidly on the skin, being often
fully developed in twenty-four hours; and it runs a more
acute course than most of the other syphilitic  cutaneous
affections.  Occasionally slight itching  attends it, but this
soon disappears with some superficial epidermic  desquama-
tion : in  all cases copper-colored stains for some time mark
the site of the  eruption  after it has disappeared.  As in
ordinary roseola, a similar  eruption on the throat very fre-
quently is present in the  specific form, independently of the
usual secondary venereal affection  of that part.   Syphilitic
roseola  occurs  not  unfrequently in  infants as one of  the
symptoms of  congenital syphilis.

                 SYPHILITIC VESICULE.

   The Syphilitic Vesicule may  appear in the form either
of Eczema, of Pemphigus, or of Rupia ;  by some writers it
is stated that a secondary venereal eruption, agreeing in its
local phenomena with  Herpes, also occurs, but this I have
never witnessed, and the descriptions of it which  have been
given are, I think, more applicable to eczema.
   Syphilitic Eczema is a rare variety of secondary symp-
toms, but well marked cases of it  from time to time occur,
and of these I have a most characteristic example  at present
under my care.   The eruption  appears  chiefly on the face,
the scalp, the ears, the trunk of the body, and the region of
the genital organs, rarely extending to the extremities ; the
vesicles are developed  tolerably numerous on  small, nearly
round, patches  of skin, of a reddish copper color; these
patches gradually enlarge, and additional vesicles are deve-
loped on them, but no  matter what size  they may attain by
coalescing, the outer border still  retains more or less of a 
SYPHILITIC VESICULE.
287
circular character, and the disease spreads in an annular
form, distinct rings sometimes appearing at the edges.   The
vesicles maturate slowly, and are accompanied by compara-
tively slight serous discharge; the stains, attended with some
epidermic exfoliation, remain on the surface of the skin for
a considerable period, and fresh crops of vesicles are from
time to time developed on them;  the integuments,  however,
do not become  thickened and fissured,  as  in non-specific
eczema.   In some cases, when the eruption has existed for
a long time, or is attended with more active  inflammation
than usual,  it  presents many  of the  characters of eczema
impetiginodes, but the crusts or scabs which form are dark
brown or blackish, hard, dry, and very persistent.  Syphili-
tic eczema is generally late in being developed after the dis-
appearance  of  the  primary symptoms,  several years not
uncommonly elapsing, so that if we were  to reckon, as some
do, from time, and not according to order of occurrence, it
might be classed in most  cases as  a  tertiary and not  a
secondary affection.
  Syphilitic Pemphigus is a very  rare form of venereal
eruption, which occurs more frequently, however, in new-
born children than  in adults.   It  is not preceded by any
apparent  constitutional  disturbance;  several  moderately
sized  bullae are simultaneously developed generally on the
palms of the hands  and the soles of the feet, but I have
seen  them  on the buttocks also  ; each bulla is surrounded
by  an areola  of a dull  violet tint; the contained fluid is
turbid from the first, does not  completely distend the epi-
dermis under which it is contained, and is rather slowly
absorbed, the  dark stain remaining.  After the absorption
of  the effused  serum, the spot  on which the  bulla was
situated most generally  becomes the  seat of an unhealthy
ulcer, and then  the disease almost invariably proves fatal.
   Syphilitic Rupia  presents nearly the  same characters as
the  prominent variety  of the non-specific  eruption.  The
vesicles which are rather large and flattened, are developed
in successive crops, especially affecting the face, but appear-
ing  also on nearly  every region of the body, being most
rare on the hands and  feet.  Each  bulla is surrounded at
first by a tolerably broad margin of a  dull-red or  copper 
288               THE  SYPHILIDES.

color, over which, as in ordinary rupia, the  characteristic
crust gradually extends.  The crust  is large,  remarkably
prominent, extremely hard, and very adherent to the integu-
ments ; and when removed from the surface it leaves a deep,
unevenly ulcerated pit, slow to heal, and on which a similar
crust, but usually of a  larger size,  is rapidly developed.
This form of secondary eruption  is rarely witnessed  for a
long time, often not for several years, after the cure of the
primary symptoms, and is of most frequent  occurrence in
persons advanced in life, or in those with a broken-down
habit of body ; it is therefore attended with much constitu-
tional  derangement, the  result  of  the saturation of the
system with  the syphilitic  poison.  In  extreme cases the
symptoms are of a grave  character: the greater portion of
the cutaneous surface  is thickly set with the black, promi-
nent, horny-looking crusts, giving a frightful appearance to
the countenance ; the throat is deeply ulcerated, and perios-
titic nodes exist  over  the bones of  the legs and on the
cranium;  severe nocturnal pains are present, and the indi-
vidual not uncommonly dies, a victim to syphilitic cachexia;
or, should recovery take place, the cure is  most protracted.
Cazenave  speaks of syphilitic rupia as being very rare, but
in my experience it is a rather frequent form of  secondary
venereal eruption.

                  SYPHILITIC PUSTULE.

   The Syphilitic Pustule may occur in  any  of the three
forms which characterize this group, viz., as Acne, as Im-
petigo, or as Ecthyma, and are amongst the most frequent
of the venereal secondary eruptions.
   Syphilitic Acne, which is the most  common of  the  three,
occurs usually on the ordinary sites which the disease, when
not specific,  occupies,  being  especially witnessed on  the
forehead.   The pustules  appear  distinct from  each other,
and  are very rarely surrounded  at first by  any change of
color in the skin; they are  developed in the form of hard,
inflammatory-looking papular elevations, about the  size of
a  small pea,  and of a  livid red  color;  on  the  second or
third day  after  their appearance, purulent matter forms at 
SYPHILITIC VESICULE.
289
their  apex,  which  is  somewhat  flattened, this  gradually
increases in quantity, extending into the substance  of  the
derma, and  at length the  pustule giving way at its summit,
pus is effused, which  concretes quickly into  a  hard, dry,
brown scab or crust.  During the progress of these changes
the low form of inflammation that is present  spreads to  the
integuments around the base of each pustule, which conse-
quently become  hard  and  thickened, and assume  a dull
violaceous or copper color.   After several days' duration  the
crusts become detached, leaving  a  small, rather  excavated
ulcer,  which,  however, soon, heals; the peculiar syphilitic
stain  of the surface remains for a considerable  time, and
when  it fades away,  a superficial  white stain,  somewhat
resembling the pit of smallpox, but  smaller, is witnessed on
the site of  the pustule—this is permanent.   The pustules
appear in successive crops, and thus, when the disease  has
existed for  any time, they are witnessed on  the  surface in
their  various  stages  of  development,  intermingled with
copper-colored stains or blotches, and the superficial pits
marking the former site of those which  have disappeared.
When the eruption is situated on  the trunk or the extremi-
ties, the individual pustules often acquire a considerable
magnitude, equalling in size a small bean; they are, however,
less prominent than on the face, and contain only a minute
quantity of  pus, surrounded  by a hardened, copper colored
base,  which does not undergo resolution  usually for a con-
siderable  time, the induration  remaining long  after  the
disease has been apparently cured.   Syphilitic acne may be
developed at  almost any period after the disappearance of
the primary symptoms, but is generally of early occurrence ;
it  is witnessed much  more  frequently  in adults than in
children, and  its duration is  usually prolonged for some
months.
   Syphilitic Impetigo is the least frequently met with of the
three forms of the pustular  syphilides;  it may, as regards
development, assume the  characters of the non-specific  im-
petigo figurata or sparsa; in either  case  a reddish copper
colored or violet-tinted patch appears on some part of  the
integuments,  most usually of the face, on which the psy-
dracious pustules are developed on the second or  third day. 
290
THE SYPHILIDES.
These maturate pretty quickly,  and,  giving  way, become
covered with a dark, greenish-yellow crust or scab, of more
firm consistence than in ordinary impetigo, and not present-
ing the same  pellucid  aspect;  these  crusts  are  tolerably
adherent, in the majority of cases not falling  off for from
ten days to a fortnight, when superficial ulcerations are left,
which in healing leave a cicatrix often permanent.   An out-
break of syphilitic impetigo is generally preceded  by some
slight febrile  disturbance,  and the surface on which it is
about to appear is the seat  of a somewhat  tingling  and itchy
sensation, which is alleviated on the coming out of the erup-
tion.   Its duration is seldom much prolonged, and it is wit-
nessed in children rather more frequently than in adults.
   Syphilitic Ecthyma is a  very  common form of secondary
cutaneous affection, and almost invariably indicates an ex-
treme degree  of contamination of the  system  with  the
venereal poison.  The  phlyzacious pustules  which charac-
terize it are generally few in number, and are  developed in-
dividually on scattered spots or stains, of  a livid  red  color,
and about the size of a sixpence,  or somewhat larger; these
appear distinctly separated from each other, chiefly on the
extremities,  but they also occur  on the shoulders,  the front
of the chest, the face, and occasionally on the lower part of
the abdomen, and on the scrotum.  On the second day after
the appearance of the stains, the epidermis in their  entire
extent is slightly raised by  a sero-purulent effusion; the pus-
tule thus formed acquires its full development very slowly
and becomes surrounded by a dull  copper-colored border,
which enlarges gradually until  the entire surface  acquires
nearly the size of a half crown.   After some  days the pus-
tule bursts,  and the contained  matter, exuding, dries into
a hard, dark-brown, or blackish circular crust, which is very
persistent; when it falls off, or is removed, a slightly exca-
vated, indolent ulcer is  left, which  exhibits an  extremely
slow tendency to heal, the characteristic crust of the disease
re-forming on  it again and again; when  eventually it does
heal,  a permanent, uneven cicatrix,  of  a  dull  red color at
first,  but gradually becoming white, marks the part  which
had been affected.   Little or no constitutional derangement
immediately attends the outbreak of syphilitic  ecthyma, and
the local symptoms which precede amount merely to  slight 
SYPHILITIC PAPULE.
291
itching, there being neither heat nor pain.  It is one of the
most frequent of the syphilitic eruptions in infants and young
children, and is witnessed more commonly in  old persons
than in those in the prime of life.

                   SYPHILITIC PAPULE.

  The  Syphilitic Papule  are developed ahvays  in  the
form of the non-specific Lichen simplex or Lichen agrius;
they constitute a very common secondary cutaneous erup-
tion, and occur usually at an early period after the contami-
nation of  the  system with the venereal poison, being often
present on the skin while the  primary symptoms  still exist,
or being developed in a few weeks  after they have disap-
peared.  In the former case the affection mns a much more
acute course than  in the latter.
  Lichen syphiliticum  is usually preceded by some fever
and general heat of the  skin;  the eruption comes out very
quickly, the entire cutaneous surface of the body, including
the face and the extremities, being sometimes covered with
innumerable, minute papulae, in from twenty-four to forty-
eight hours.   They are  placed so  close together, often in
patches or groups  of a  circular form, as  to  coalesce  and
present the appearance of large  elevations, Avhich require
the aid of a  lens  to prove  that they are  made  up of the
minute papulse which are so characteristic of this eruption.
At other times they are scattered over the surface perfectly
distinct from each other, when, however, though less nume-
rous,  they  are individually of larger size; in either case
they present a bright copper color.   The papulae generally
disappear in a  few weeks, with slight epidermic  desquama-
tion, as in the ordinary forms  of the disease, but the surface
remains spotted with  dull coppery stains, which  fade away
very slowly; and not uncommonly a second outbreak of the
eruption takes  place shortly after the first has commenced
to decline.  In some persons, especially those of a full habit
of body, and in infants, syphilitic lichen assumes  more of
the character of lichen agrius, the papules ulcerate at the r
apex, and a serous  exudation  takes  place, which dries into
thin, brownish-yellow scales ; much itching and well marked
constitutional disturbance attend this form of the eruption, 
292
THE SYPHILIDES.
which is also more persistent.  When either variety becomes
chronic, which, however, is rarely the case, psydracious pus-
tules  and copper-colored blotches are mingled with and
complicate the papular eruption.   Syphilitic  lichen is wit-
nessed both in infants soon after birth,  and in adults, and is
amongst  the  mildest of the syphilitic  cutaneous affections.
It is regarded by some writers as being occasionally a pri-
mary symptom, and as being not unfrequently a complication
of blennorrhagia.

                  syphilitic squame.

   The Syphilitic Squame constitute rather  a  frequent
variety of secondary eruption, rarely making  their appear-
ance for a considerable time after the removal of the primary
symptoms, and consequently indicating much  saturation of
the system, with the venereal  poison.   The scaly affection
of the skin is, in many cases/preceded by a roseolous rash,
which exists for some time before the scales are developed
on it.  It may present the form of any of the non-specific
varieties of the eruption, Psoriasis guttata, Psoriasis  aggre-
gata, and Psoriasis lepraeformis ; and consequently, a syphi-
litic psoriasis and a syphilitic  lepra are described by most
writers as distinct  affections.
   Syphilitic Psoriasis (Atlas, PL XI. Fig. 1) is not ushered
in by any decided constitutional disturbance, nor is it attended
with local irritation, but  the  usual general   symptoms of
secondary syphilis always accompany it, and serve much to
aid the  diagnosis.   The  scales, which are of a dull gray
color, are developed in distinct spots or small patches, as in
the ordinary form of  the disease, but when the  eruption is
about to  assume the aggregate  or leproid character, they
increase  in  extent pretty  quickly.   The disease  usually
comes out first on the extremities, to which, however, it is
not confined, soon appearing  on  the  face, the scalp, and
the entire trunk, especially affecting the chest and shoulders;
the surface of the  skin on which the  squamous  eruption is
seated is  of a  dull violet  or  dark coppery-red  color,  and is
elevated somewhat above the surrounding  integuments.  In
the leproid form, the edges of the circular patches are much
raised, and the centres, which are always of a more dingy 
SYPHILITIC SQUAME.
293
 hue,  depressed and free  from scales, or with a few  thin
 scattered scales  on them.   In the aggregated variety, the
 outer border  of  the patches assumes  more or less of an
 annular character, and, as Biett  has remarked, it is sepa-
 rated in  the  majority of cases from the  surrounding non-
 affected integument by a  narrow white  rim ; the  central
 portions are much more elevated  than the edges, and the
 scales on them are thicker, and of a dull gray color.  Syphi-
 litic psoriasis  differs especially from the non-specific disease,
 in not being more thickly developed around the joints than
 elsewhere on the extremities.   In some cases, when the
 eruption  has been of long persistence, it presents the tessel-
 lated pavement character described at page 174; but  fissures
 do not form in .the scales, nor is it attended with an ichorous
 discharge or  the symptoms of local irritation which  cha-
 racterize the  inveterate variety  of  the   ordinary disease.
 Syphilitic scaly eruptions are  of extreme obstinacy,  and
 their duration is invariably  much prolonged; when they
 begin to  disappear, the desquamation—which, however,  is
 never in  such quantity  as in the non-specific squamae—
 gradually diminishes, the elevated surface becomes  flatter,
 until it at length sinks to the level of the surrounding in-
 tegument, but still retains  its peculiar copper color, which
 disappears very slowly, years often elapsing  before it fades
 away completely.
   Syphilitic psoriasis  is in some cases confined to a single
 region of the body, especially the palms of the  hands, when
 it presents most of the phenomena characteristic of ordinary
 psoriasis palmaris, but the scales are thicker, of a duller hue,
 more persistent,  and the portion  of  integument on  which
 they are developed is more elevated,  drier, and of a copper
 color ; the general appearance of the palm  of the hand when
 affected with the eruption is such that  Biett termed it horny,
 the affection constituting the Syphilide squameuse  cornie of
 that dermatologist.
   The squamous  syphilides are very rarely seen in children,
 and are still more rarely developed for the first time in old
 persons, being an affection of individuals in  the prime of life,
liable to accompany either the so-called secondary or tertiary
venereal symptoms. 
294
THE SYPHILIDES.
               SYPHILITIC HYPERTROPHIE.

  In the  Syphilitic Hypertrophie a form of cutaneous
affection occurs which has no parallel among the non-specific
diseases of the skin;  custom has so completely sanctioned
the application of the term tubercle to its different varieties,
that it is almost hopeless now to think of changing this de-
nomination, and for this reason, notwithstanding the great
objections, so frequently referred to in the preceding pages,
which exist to retaining this word in the nomenclature of cu-
taneous nosology, I shall not attempt to substitue  another
for it.   Condylomata, which belong to this group of diseases
of the skin, are, as already noticed, most frequently of syphi-
litic  origin, but as, when of this nature, they'fall  altogether
within the domain  of general surgery, no further  descrip-
tion  of them than  what  has  been given at  page 224 is re-
quisite here.  For the same reason warts which result from
a venereal source will  not  be noticed.   The syphilitic tu-
bercles will therefore alone engage attention in considering
this group of cutaneous diseases as symptomatic of secondary
syphilis.
  Syphilitic tubercles are amongst the most  frequent of the
secondary symptoms of the venereal poison which affect the
skin; they may be developed in  a  very short time after the
disappearance of the primary disease, or their  occurrence
may be deferred for many months,  or even years.   The
tubercles  vary much in  size and  in their apparent pheno-
mena,  and thus constitute different varieties.   First, they
may occur in the form of large papulas, differing from  lichen
chiefly as  regards their size, being about equal to that of a
small pea;  they are rounded, hard, and elevated above.the
level of the skin, appearing in small groups, most usually of
a circular  shape, with healthy skin intervening, and not un-
frequently forming a centre to each patch.   These groups
are irregularly disseminated over  the surface of the face,
the neck, the trunk, and the extremities, especially the first;
but are often  symmetrical as regards the two sides of the
body.   The individual tubercles, which are of a violaceous
or dull coppery hue, soon secrete a thin scale at their sum-
mit,  from  beneath  Avhich,  if rubbed  off or torn with  the 
syphilitic hypertrophie.         295
nails, a slight watery exudation takes place;  this dries into
a  thin  reddish-brown, persistent  scab, which eventually
falls off, leaving a characteristic syphilitic stain that for a
long time marks the seat of the eruption.
   Second, the tubercles are of greater magnitude, varying
in size  from that of a nut to that  of  an olive, of an ovoid
shape, hard, distinctly elevated, and disseminated over the
surface ; they may occur on a single region of the body,
especially affecting the face and neck, or may be generally
distributed  over  the  surface.  In  some parts, being more
closely  set together than in others, they sometimes coalesce
and form a  tolerably large tumor, uneven on the surface,
but  distinctly circular  at  the  margin.  The tubercles  in
this variety are of  a deeper and duller shade of color than
in that first  described ; neither desquamation nor serous
exudation takes place from  them; they remain stationary
for a very long time, not  unfrequently for  years,  and  at
length,  being absorbed, often rather suddenly, the charac-
teristic stain, slow to fade  away, marks their site.
   Third, a still larger tubercle than the last appears isolated
on  some portion of the integument, most generally of the
extremities, but sometimes of the body or face ; it is rather
soft to  the  touch, slightly painful, scarcely elevated above
the surrounding skin, of a dull violaceous tint, with a bronze
or copper-colored margin.   It increases  very slowly in size,
exhibiting  an appearance as if about to suppurate, and the
margin assumes  an uncircumscribed  erythematous blush.
At length the most prominent  part  ulcerates slightly, a
thick,  blackish, adherent  crust forms on it,  which  is very
gradually detached, usually not for weeks, when the  entire
tubercle falls out, leaving an unhealthy, indolent ulcer, with
excavated edges,  painful and slow to heal.   At first rarely
more than three or four tubercles of this character  are de-
veloped on the body, but they come out in  successive crops,
so as at length to amount to a considerable number.   When
the ulcer which  they leave  heals,  a permanent depressed
cicatrix  results,  which for a long time exhibits  a rather
bright copper-red stain.  This variety of tubercle rarely ap-
pears for years after  the  primary symptoms, is generally
met with in old persons, or those of a  broken-down habit of 
296
THE SYPHILIDES.
body, and in individuals in Avhom there exists extreme syphi-
litic  cachexia.
  Fourth and last, several  tubercles,  about the size  of a
sixpence, but little elevated above the surface and rather soft
to the touch, are developed, distinct from each  other, on
some special region of the body—usually on the scrotum in
males, and the pudendal region in females, on the face, par-
ticularly on the  lips and  nose, and around the  arms;  they
are perfectly circular, and  of  a dull reddish tint.  Small
superficial ulcers soon form  on them, appearing  first at the
outer margin, these  gradually  extend,  so  as to  cover the
entire surface of the tubercle, retaining, however, their super-
ficial character,  and from  them there exudes an  extremely
fetid, sanious liquid, which irritates and inflames  the neigh-
boring integument over which it may flow.   Eventually the
discharge ceases, copper-colored crusts form, and the parts
heal  without any  marked   cicatrix.   By many  modern
writers, particularly of the French school, this form of sy-
philitic  tubercle  is regarded as constituting in some cases
one of the varieties of primary symptoms.

                  SYPHILITIC MACULE.

   Under the head of Syphilitic Macule some  of the
forms of secondary roseola  are not unfrequently described,
but  they should not be confounded with the peculiar pig-
mentary alterations of the  cutaneous structure which in
many cases accompany other  secondary eruptions, and in
some constitute the only affection of the skin present. They
resemble most in their apparent phenomena ephelis hepatica,
but differ from it in being developed in the majority of cases
on the legs, or in the region of the genital organs, occurring
only in  a few instances on the face or the trunk of the body.
They are also characterized by their color, which is distinctly
of a copper shade, at  times approaching to black, and in as-
suming from the first a well-marked circular form spreading
from the circumference in ring-like patches.  These morbid
alterations of color do not appear on the cutaneous surface
usually until several months or  even  years have elapsed
after the cure of the  primary symptoms; they are invaria-
bly attended with well-marked syphilitic cachexia, and are 
SYPHILITIC MACULE.
297
extremely obstinate  to  treatment, sometimes remaining for
life.   Syphilitic maculae  occur at all ages, both in persons
in the prime of life and  in old age, and are a not unfrequent
result of congenital  syphilis.

   Diagnosis.—Under this head little remains to be said after
the observations which have been  made  in the commence-
ment of the chapter on the general characteristics of the
secondary eruptions.  The  history  of the individual  case,
where it can be arrived at satisfactorily, which, however, in
the majority of instances is quite impossible, is the aid chiefly
to be relied on ; in doubtful cases assistance is often gained
by an examination of the glans  in males, and the external
organs  of generation in females, when the cicatrix or indu-
ration resulting from a  chancre, if it had previously existed,
will afford  satisfactory evidence; inspection  of the  throat
and back of the pharynx also should never be omitted, the
characteristic venereal  ulceration existing  there usually in
connection  with the eruption on  the skin.
   The prognosis in  secondary cutaneous  affections must be
guided  much  by the degree of syphilitic cachexia present,
by the  length  of time which  they may  have previously
existed—for in proportion to their duration is their obstinacy
__by the severity and extent of  the concomitant symptoms
in other structures  of the  body, and  by the  nature  of the
eruption itself; the latter point  has been noticed in the de-
scription of the individual  forms.
   Treatment.—As in all other  affections which have their
origin in the  absorption of the syphilitic poison into the sys-
tem, the secondary  eruptions of  the skin demand a specific
mode  of treatment, directed to  the eradication of the con-
stitutional  taint on which  they  depend.   Formerly  it was
believed that this could  alone  be effected by the action of
 mercurials, but the discovery of iodine and of its medicinal
 properties  has wrought a complete revolution in the thera-
 peutics of the consecutive symptoms of the venereal disease.
 This has in some  respects,  however, been attended with an
 evil result, that of  inducing many practitioners to discard
 mercury altogether  as a remedial agent in the  treatment of
 the syphilides, and  to trust to the employment  of such sim-
 ple measures as may be  indicated by the local and general 
298
THE SYPHILIDES.
symptoms, independently of their specific character;  or to
rely solely on the administration of preparations of iodine
to correct the constitutional contamination.  But as in nearly
every other  disease to which man  is subject, it should  be
always kept prominently in view that an exclusive system of
treatment cannot be  expected to be invariably successful,
for  the  same affection  often requires the use of even the
most opposite remedies in different individuals, or in the same
person under different circumstances.
  The remedies to be  employed  in the treatment of the
syphilides maybe conveniently considered under three heads:
the general, the specific, and the topical.
  The general treatment  consists in the  employment of
means, calculated to meet the indications  dependent on the
special symptoms Avhich may arise or be present in individual
cases.   Thus, Avhen the outbreak of an eruption is attended
with distinctly febrile symptoms or well-marked local inflam-
matory action, the employment of antiphlogistics is demanded
before the  administration of specifics can be commenced.
Under such  circumstances, in young plethoric persons, gene-
ral  bleeding will be resorted to with advantage, and topical
abstraction of blood by means of leeches is almost invariably
necessary.  Active saline  purgatives should be given  also,
and in no case should they be omitted; with very feAv excep-
tions  their  effects  are productive of the most  beneficial
results in the early stages of every syphilitic eruption: the
only instances  in which they occasionally prove  injurious
are when the syphilitic cachexia is extreme in very old per-
sons or individuals of a broken-down habit of body.  They
seem to act  chiefly by determining to the intestinal mucous
tract, and thereby diminishing  excessive cutaneous action,
the quantity of the eruption,  and consequently the  local
inflammation, being thus checked ; but they also lessen the
general febrile symptoms.  The neutral purgative salts are
best adapted to fulfil these intentions, and their administra-
tion will be  advantageously preceded by  a full dose of calo-
mel or blue  pill.
  On the other hand,  should  the vital powers be low, and
the depression  of the system very manifest, the vegetable
tonics  must be given ;  and if there are deep-seated pains
present, especially the  nocturnal pains so characteristic of 
SYPHILITIC MACULE.
299
the disease, opiates in full doses should be prescribed in
combination, or  if the suffering is extreme, their use may
precede the employment of the  tonics.  No  preparation
relieves the deep-seated pains which so frequently accom-
pany secondary  symptoms, whether  of the  skin or not, as
crude opium:  it may be given in the dose of a  grain, made
into a pill, three or four times or even oftener in the twenty-
four hours, according to circumstances.   Of the vegetable
tonics, those which determine to  the skin, such as the  elm
bark, are  especially useful, or cinchona bark or quina may
be combined with the tonic or stimulating vegetable diapho-
retics—dulcamara,  mezereon,  sarsaparilla,  guaiacum, &c;
the mineral  tonics, especially  the  stronger  acids, and iron
and its preparations, are also often highly serviceable in the
syphilides, when the employment of this class of remedies
is indicated.   The former were largely given by Biett in the
syphilitic  exanthemoid and papular secondary eruptions,
much reliance being placed by him  on  the nitric  and  sul-
phuric acids:  the latter are especially indicated when much
anemia is  present, and they are often usefully prescribed in
combination with iodine, as in the chemical compound of the
iodide of  iron, or of the iodide of iron and quina.   When
a specific eruption occurs in an individual  of  a scrofulous
diathesis,  or Avith a strumous tendency, cod-liver oil will be
administered Avith decided benefit, and should the debility be
extreme, preparations of iron are usefully given at the same
time.
  The specific treatment of the  syphilides consists in the
employment of the preparations of mercury, of gold, or of
silver, and of iodine alone  or  in  combination  with any of
them.  Mercurials are unquestionably the remedies on which
most reliance  is  to  be  placed, but  the amount of benefit to
be derived from their use depends much on the manner in
which they  are  administered, and the preparation that is
employed. They should not be given on the first appearance
of the eruption,  the more especially if its outbreak  be con-
nected Avith  general febrile symptoms—these must be previ-
ously removed by the means already referred to ; and in all
cases the  state of the  digestive organs requires special at- ■«
tention before the employment is commenced.   The several
forms of the secondary eruption serve as indications  as to 
300
THE SYPHILIDES.
 what preparation of mercury is  best suited, but it  may be
 laid down as a general rule that  those which have the pro-
 perty  of producing salivation  quickly or freely,  such as
 blue-pill, calomel,  and  the allied  compounds,  are rarely
 adapted for these consequences of the venereal disease.
   For  the scaly  and  tubular  syphilides, corrosive  sub-
 limate and the red iodide usually prove the best preparations
 of the  metal; either may be given  in  pill with  opium, in
 doses of from l-12th to l-8th of  a grain, three times daily,
 the quantity of opium being proportioned to the degree of
 the characteristic venereal pains  which may attend; or the
 former may be preferably prescribed in some vegetable de-
 coction, such  as that  of dulcamara, of elm-bark, of meze-
 reon, of sarsaparilla, &c, as in the following formula :—

     R.  Corrosivi Sublimati,.....     gr-j'
         Decocti Dulcamarae,.....fl Jiv.
         Decocti Mezerei,......fl Ixij.
         Infusi Sassafras,......fl 3viij. Misce.

     " A wine-glassful to be taken three times a day."

   When these or any other of the syphilitic eruptions be-
 come  chronic, or return frequently after  they have  been
 apparently removed, it will be necessary to have recourse
 to the administration of arsenic, in combination with the
 mercury and  iodine, and under  such circumstances Dono-
 van's  solution—the liquor  arsenici et  hydrargyri  hydrio-
 datis of the last Dublin Pharmacopoeia—proves  singularly
 beneficial.  It  is for  the chronic forms of secondary dis-
 eases of the skin that this combination is especially adapted,
 and in these  cases its therapeutical efficacy is undoubted ;
 indeed, in my hands, it has very  rarely failed  to.  effect a
 permanent  cure, but it  must be given  in  moderate doses,
 from ten to twenty minims  three times daily—the quantity
 increased very gradually, and  its use continued  for a long
 time, even after the disappearance of the eruption.  It may
 be administered in some of the  vegetable  tonic or  diapho-
retic decoctions, according  to individual circumstances.
   For the pustular and  papular  syphilides  the green iodide 
SYPHILITIC MACULE.
301
of mercury of the Dublin—the iodide of the London—Phar-
macopoeia has proved, in my experience, the best preparation
of the metal.  It may be given in pill combined with opium,
should circumstances indicate the use of that drug, in  the
dose of from half-a-grain to three grains three times daily,
but its effects must be carefully watched, as it is in some per-
sons apt  to produce salivation, even in  small doses, and in
the treatment of any form of syphilitic eruption it is most
important to administer as little mercury as possible, and to
introduce it  very gradually  into the'system; the precise
quantity requisite can only be judged by watching the effect
produced in each individual case, but the mildest action on
the mouth  is always an indication that for the time enough
has been given.   An excellent way of prescribing this pre-
paration for adults is to substitute it  for  the calomel in
Plummer's pill, and the vegetable decoctions before referred
to may be given at the same  time.
  The syphilitic exanthemata  do not require the employ-
ment of  specific remedies in  their acute stages ; but should
they exhibit a tendency to become chronic, the green iodide
of mercury is the preparation best adapted for them.   The
occurrence of maculae as a  secondary symptom indicates
the necessity for a prolonged administration of a mercurial,
and, therefore, either the bichloride or the red iodide should
be used.
  When any of the forms of syphilitic  eruption appear on
infants at the breast, it is desirable, when practicable, to in
troduce the specific medicine  into the system of the child by
means  of the nurse's milk ; but as in the majority of cases
it is essential to change the  nurse,  and it is,  consequently,
often requisite  to wean  the  infant, the hydrargyrum  cum
magnesia,, or hydrargyrum cum  cretS,, may be given in doses
of from one  to two grains daily, according to the  age,  and
with each dose from a twelfth to an  eighth of a grain of the
green iodide of  mercury may be combined when  the  erup-
tian is  extensive.
  The  preparations of gold  and of silver were at one time
proposed by the French  school as substitutes for those of
mercury; but they were found not to possess at all the same
efficacy, and they have, consequently, fallen noAV into almost
complete disuse  for the  treatment  of secondary symptoms.
                          26 
302
THE SYPHILIDES.
The former were supposed to be especially adapted for per-
sons of a scrofulous diathesis, with whom mercurials very
generally disagree, and their effects are highly spoken  of by
Legrand and Chrestien, but they have not, that I am aware,
been employed in this  country.
   Iodine or its preparations should not be trusted to  alone
with the  intention of producing a specific action in the
treatment of the secondary eruptions;  from what has been
already said, it  is evident  that their combination with mer-
curials is of especial  service,  but unless  thus prescribed,
they usually  disappoint.   In scrofulous habits, their admi-
nistration should never be  omitted—still, a mercurial must
be given with them, and  the more decided the  evidences of
scrofula are in any individual  case, so much the more must
the proportion of the iodine preparations predominate in the
treatment.  The administration  of iodide  of potassium is
attended with the best results  as  soon as the preparation of
mercury which may have been given evidences its action on
the system by the mouth being affected, and it is also  most
valuable Avhen  given  to  nurses, with the view  of treating
a venereal eruption in  an infant at the breast;  in the latter
case, it often suffices to cure the disease, whether the nurse
is  at the same time affected with secondary venereal symp-
toms or not.
   The employment of  topical  remedies in the treatment of
the syphilides is of much less importance than in the non-
specific eruptions; little more being requisite, in the majority
of cases, than the use of the tepid bath every second or third
day, to allay any local  irritation  or  inflammatory action
which may arise, and also  to restore the healthy functions
of the skin.  When ulceration occurs in the progress of any
of the secondary eruptions, the black-wash is the best appli-
cation which  can be used, if it takes place on the scalp, the
trunk or the extremities : but  on the face, an ointment con-
taining a drachm of calomel to an ounce of simple cerate is
more easily applied, and is more efficacious.  In infants, the
local symptoms are usually more severe than in adults, but
they are easily  calmed by the  employment  of a dusting
powder, containing twenty grains of the carbonate of lead,
half a drachm of the oxide of zinc, and an ounce of starch,
reduced together to a state of the minutest division ;  a tepid 
SYPHILITIC MACULE.
303
bath of fresh water, containing from two to four ounces of
size, should be at the same  time employed every night, or
every second night, according to  circumstances.  The dis-
persion of the stains in syphilitic maculae is much hastened
by inunction with mercurial ointment while the constitutional
treatment is being followed out.
  In all cases of secondary syphilitic  eruptions, as soon as
the first inflammatory symptoms, if any occur, are subdued,
the diet should be nutritious, and wine and other stimulants
should be allowed: if the syphilitic cachexia be extreme,
and much debility present, the chief points to be attended
to are, to support the strength,  and  at the  same time to
allay both  general and local irritability.   Change  of air,
especially to a dry and Avarm climate, is an aid to the treat-
ment of the utmost  importance in chronic and obstinate
cases. 
304
DISEASES  OF  THE HAIR.
                 CHAPTER  XIII.

        DISEASES OF THE APPENDAGES OF THE SKIN.

  In this Chapter I shall describe affections of the hair and
of the nails.  They constitute a class  of  morbid changes,
concerning which the  regular medical  practitioner is but
rarely consulted, and therefore a short notice of them must
here suffice, yet the former, especially, are not uncommonly
a cause of as much anxiety to those Avho suffer  from them,
as a really grave cutaneous disease.

                 DISEASES OF THE HAIR.

  The Diseases of the Hair consist in alterations of its
natural color or characters, and in its partial or total loss.
Some few cases have been  recorded  in  which  the hair has
undergone a sudden change of color  from a light to a dark
hue, or the reverse, without  any apparent cause, or after
some acute  disease ; and not unfrequently, when it is re-
produced after it has been removed for some febrile or other
affection, it grows of a much  darker color than it had been
originally; this  is usually the case  when it has been kept
cut close for any length of time in the treatment of any of
the eruptions of the scalp.   Loss of color in  the hair,—
Canities,—is one of the natural results of old age, but it
often occurs at a comparatively early period of life, either
from constitutional causes, or from extreme mental anxiety.
The effect of the latter is often well marked, and some cases
have been witnessed in which the hair has become perfectly
white in the space of a few  hours, while an individual was
laboring under  some violent emotion of the mind: these,
which  have  often furnished a theme for the  poet and the
popular writer, demand  no other notice  here than that of a
mere reference.   The most important of the constitutional
causes of canities is hereditary predisposition, and examples
of premature grayness of the hair descending through
several generations in certain families  are very numerous. 
DISEASES OF THE HAIR.
305
Blanching of the hair is sometimes associated with debility
of the vital powers, but that it is very rarely so, is evident
from the fact of  its being  so  seldom witnessed in  those
who die young of  consumptive or other lingering diseases.
   Treatment, whether topical or general, has, in my opinion,
no effect over any of the  forms of canities except that last
described, and in it the indications are manifestly to restore
the system to a state of robust health, if practicable, by the
use of such remedies  as may be appropriate for the  indi-
vidual case.  But numerous local  applications and other
means have been and still are recommended, with the view
of preventing the hair from turning gray: should it be dry
and crisp, and the surface of the scalp appear bloodless, any
gently stimulating pomade  may be  used: cutting the hair
short,  or removing it altogether by  shaving the scalp occa-
sionally, proves useful.  The preparations which are  used
for dyeing the hair are very numerous, and formulae for them
are given in all druggists' or perfumers' receipt-books.
   The occurrence of white hair  in patches on the scalp has
been already described.  (See Vitiligo.)
   The only alteration in the character  of the  hair which
can be strictly regarded as a disease is  that peculiar felting
and matting of it together which constitutes the  singular
affection that has been named Plica Polonica; but inasmuch
as it does not occur  in this country, and as, from having
never seen  a  case of  it, I can add  nothing to the account
contained in the several works in which it has been described,
I shall not notice  it further here.
   Loss of  hair,  or baldness, termed  " Alopecia" by the
ancient Avriters on medicine, would appear to have been of
much more  frequent occurrence and to  have attracted more
attention formerly than at present; it may be either partial or
general on the hairy scalp, or on the other parts of the body
which are naturally covered with hairs.  In the former case,
it Avas termed Porrigo decalvans by Willan, but  then it is
manifestly due to the occurrence of Vitiligo on these regions
of the skin, as  before described.   General baldness  is in
many persons the accompaniment of old age, being usually
associated with gray hairs, nor  can it be regarded as a dis-
ease except when it occurs in comparatively early life : some
         r                 26* 
306
DISEASES OF THE HAIR.
few cases have been recorded as being congenital, in which,
however, it was due to non-development of the hair  follicles.
Permanent baldness, as has been remarked in the preceding
pages, is also at  times a result of the  eruptive diseases of
the scalp, especially of  Porrigo, and is then a consequence
of the inflammatory action which may exist extending to
the bulbs: after most diseases of the scalp, however, although
the hair falls out, it  is reproduced.   Loss of hair, partial
or general, is also a not unfrequent sequence of fevers and
acute inflammatory affections, and of syphilis ; in the former
case it generally  grows again, but in the latter the  baldness
is usually permanent.   Loss of hair from natural causes at
an early age is,  like the premature  change of its color to
gray, hereditary  in the majority of instances, is also caused
by violent emotions of the mind, or prolonged mental anxiety,
and is connected pathologically in some individuals with
general debility,  or diminished vital action.
   Congenital and senile  baldness are  incurable, as is also
that form of it which is hereditary.  In other cases, repeated
shaving  the head, or  keeping any hair  that  may remain
constantly cut close,  and the  application of stimulating
spirituous washes, such as either of the following, sometimes
prove useful:—

       R.  Spiritus Vini Rectificati,  .   .   .   .  fl Ivj.
           Ammoniae Hydrochloratis,    ...    gr. xxx.
           Olei Rosmarini,  .......fl 5ss.
           Infusi Armoraciae compositi,    .   .   fl 3vj.
   Misce. Fiat lotio.

        R.  Tincturae Cantharidis,.....fl 3ij«
          Aquae  Florum Sambuci,    .   .  .  .   fl 3xj.
          Essentiae Rosmarini,    .  .   .  .  .   fl 5vj«
   Misce. Fiat lotio.

   The turpentine pomade, as ordered at page 240, not un-
frequently proves of service also, and  each time previously
to its application the scalp should  be washed with an  alka-
line lotion, containing a drachm of carbonate of potash to
eleven ounces of water, and one ounce of rectified spirit or 
DISEASES OF  THE NAILS.
307
of rum.   The following pomade, as recommended by Dr.
Copland,  I have frequently used with excellent effect:—

        R. Adipis praeparati,.....gij.
            Cerae Albae,.......|Ss.

Lento igne simul liquefac, tunc ab igne remove et ubi pri-
   mum lentescant,

       Balsami Peruviani veri,.....3ij.
       Olei Lavandulae,.......m.xij.

adjice, et assidue move donee refrixerint.

In all forms of alopecia the scalp should be kept warm, and
consequently wearing a wig is often of service when the hair
first begins to fall off.

                 DISEASES OF THE NAILS.

   Most of the Diseases of the Nails are of such a nature
as to demand surgical interference, and  are  consequently
described in the works of surgical writers.  Perhaps  the
most important of them all is that in which the nail of some
of the toes grows into the  surrounding  fleshy integuments,
and  by the irritation  it thus occasions, gives rise  to  the
formation of a foul, unhealthy  ulcer.   It would  not be in
accordance with the plan of this work to say anything here
of the surgical treatment requisite to cure this most obsti-
nate and  painful affection ; but I cannot avoid  remarking on
the importance of preventing the ingrowing, as it is termed
of the nails, by always cutting them straight across, parallel
with the extremity of the  toe, as when they are  cut at the
edges, the pressure of the boot or shoe not uncommonly
gives rise to this disease.   The  nails both of the hands and
feet  are also subject to inflammation attacking their matrix,
to hypertrophy, and to atrophy, and they occasionally  fall
off completely, and are not  reproduced.  This last affection,
which has been termed by  the French writers  Alopecia un-
guale, is sometimes congenital, children being born without
nails, but such cases are extremely rare.   When the nails 
308
DISEASES OF THE HAIR.
become hypertrophied, the  application to  them of caustic
potash, and the daily use of a strong lotion of carbonate of
potash is  often useful;  the nitrate of  silver is  the best
application  when the nails, being brittle,  split and  break
readily ; and it is also productive of much service should a
foul discharge continue  from  beneath  the  nail, as a conse-
quence of  previous  inflammation of  the matrix.. As  has
been remarked already, the nails at times  become engaged
in some of the eruptive diseases of the  skin, more especially
psoriasis and eczema, when, however, they require no further
treatment than that applicable to the existing affection. 
THERAPEUTICS.
309
                 CHAPTER  XIV.

        THERAPEUTICS OF  DISEASES OF THE SKIN.

  In describing the individual eruptions of the skin, I have
spoken of the  treatment adapted for each, yet there  are
some general points in therapeutics specially applicable to
this class of affections, which require a separate notice,  and
to their consideration I  purpose to devote this chapter: it
will, therefore,  consist in  a review of the remedies most
generally used  in cutaneous diseases, and the manner in
which they should be employed ; a few formulae Avhich may
prove suggestive in prescribing will also be appended.  The
remedial measures ordinarily required may for convenience
of description  be considered in two divisions—the topical
and the constitutional;  it is true that some of them, baths
for example, produce their effects by acting both locally  and
on the system generally, but as their mode of application is
external, they will be considered in the first division.
  Several objects are in general expected to be fulfilled by
the employment  of topical  medication in the treatment of
cutaneous eruptions.   It may be used with the view simply
of cleansing the  skin from  the scales or crusts which form
on the surface, so as to permit the direct application of
remedies to the diseased parts : for this purpose cataplasms,
baths,  alkaline washes and soaps are usually had  recourse
to.   It may be employed with  the intention  of  protecting
the affected portions of the integument from the action of
the air; or a directly therapeutical effect may be expected
from its application.  Some topical remedies fulfil only one
of these indications, while the  benefit derived from the use
of others depends on their mode of operation combining the
thrGG
  The treatment of diseases of the skin by the total exclu-
sion  of air has within the  last few years,  more especially
since  the discovery of collodion, been much employed  and
highly recommended by some  practitioners, while in  the
hands  of others it has  completely failed.   The  practice is 
310
THERAPEUTICS.
chiefly applicable to local eruptions, and to those which are
not attended  with much  discharge.  Its  employment  in
erysipelas has been referred to when speaking of the treat-
ment of that disease ; but it has not as yet been sufficiently
tested by experience to enable a satisfactory conclusion  as
to its therapeutical efficacy to be arrived at.   So far as re-
gards the application of  collodion to form an impermeable
covering, it has been productive rather of injury than  of
benefit in any cutaneous eruptions in which I have used it;
this appeared to me to depend chiefly on the uneven com-
pression  and contraction of the integument which  is occa-
sioned, causing much local irritation, and sometimes even a
degree of inflammation.   Such effects being due principally
to the rapidity of evaporation of the ether in which  the gun-
cotten  is dissolved, these resulting  injurious consequences
will probably be prevented by the recent proposal of Dr.
Graves1 to  employ a solution of gutta percha in chloroform
for this purpose.   Moreover, the gutta percha  forms a less
brittle, firmer, and thicker,  though still transparent, cover-
ing to the skin, and exerts an even and more complete com-
pression  on the surface ; the latter effect also being regarded
by Dr. Graves as of importance with reference to its bene-
ficial action.   In his paper on the use of this substance re-
ferred to in the note, Dr. Graves illustrates its therapeutical
efficacy by the narration of some  cases in which it proved
remarkably successful;  but whether  it will  be  of  such
general  application as he  predicts, experience  alone can
decide.
   The advantage  to be  derived  from  the application  of
Bandages to  either the  upper or lower  extremities,  when
they are  the seat of cutaneous eruptions, is too often over-
looked ;  they  fulfil to a certain extent the indication of ex-
cluding the action of the air, but they also prove beneficial
by exerting an equable amount of compression on the over-
loaded and congested vessels, as has been already noticed
when speaking of  erysipelas;  and they afford in addition a
useful means of applying medicated lotions,  as referred  to
in describing the treatment of eczema.

  1 Dr. Graves' paper on this subject, which I have had the advantage of
reading in  manuscript, is to appear in the number of the Dublin Quarterly
Journal of Medical Science for August, 1852. 
THERAPEUTICS.
311
  The various remedies which  are  employed topically for
the treatment of diseases of the skin may be applied to the
surface in the  form of  baths, cataplasms,  caustics, lotions,
ointments, powders, and  soaps.   These will now be con-
sidered in succession.
  Baths, both simple and medicated, have  at all times been
very extensively used as remedial agents in cutaneous erup-
tions, and have by many been supposed to be sufficient for
their  cure, without the administration of  any internal re-
medies.   To the reader of  the foregoing pages it must be
evident that I place but little reliance  on their efficacy, and
that I recommend a resort to their employment with the in-
tention of acting, so to say, medically on the disease  in but
few cases: yet it cannot be denied that abundant testimony
exists  to prove that persons affected for years Avith chronic
eruptions, more  particularly those of  a  scaly character,
have been cured by the prolonged use of  medicated  vapor,
steam, or water baths.   But they  are  not  at  present em-
ployed to at all the same extent that they were formerly, and
modern writers do  not  recommend baths in the  same lauda-
tory terms as those who preceded them—a proof  that their
efficacy was, to say the least, somewhat  overrated.   As  a
cleansing agent, and to promote the discharge of the healthy
functions of the skin, and a return  to its  normal state, the
fresh water tepid and warm baths are of especial service in
many cutaneous eruptions, chiefly those in  which the surface
is dry and hard, as in the exanthemata, the scaly diseases,
and ichthyosis : and when these affection are local, they are
often  advantageously employed in the form of douche; but
they seldom agree  with those cases which  are attended with
 a discharge, whether it be serous or purulent.  In addition
to  their cleansing effects  they also often prove useful, as an-
tiphlogistics, in allaying local irritation and inflammation.
Vapor baths,  being slightly stimulant, are  not indicated
until the chronic  stages of  cutaneous diseases  are fully es-
tablished, when, in consequence  of their possessing this pro-
perty, they are frequently used with advantage.  Salt water
bathing, in my experience, proves injurious in most diseases
 of the skin, for although it often appears at first to produce
 a beneficial action, the eruption usually returns afterwards
 with greater obstinacy, and is much more rebellious to treat- 
312
THERAPEUTICS.
\
ment;  but usually, and  always when the affection is of an
inflammatory tendency, it aggravates the disease: the only
cases in which I have seen it almost  invariably serviceable
are when  maculae or stains of  the  integument become per-
sistent after the removal of any of the syphilitic eruptions.
The following are formulae for some of the medicated baths
usually employed:—

                    GELATINE BATH.
   R. Gelatinii (vulgo dicti " size").....ft>vj.
     Aquae, (Caloris gradu, 75° ad 92° F.), C. xxx. Solve.

   This bath is employed with excellent effect to allay local
irritation  and itching,  and is especially useful in the cuta-
neous  diseases of children.   The temperature must be pro-
portioned to  the indications in each case.   The above  are
the quantities requisite for a bath for  the entire  body in the
case of adults.

                   ALKALINE BATHS.
R. Sodae  Carbonatis,........§viij.
 Aquae Pluviae, (Caloris gradu, 84° ad 96° F.), C. xxx. Solve.
R. Potassae Carbonatis,.......3vj.
 Aquae pluviae, (Caloris gradu, 84° ad 96° F.), C. xxx. Solve.
R.  Sodae Carbonatis,........3vj.
    Sodae  Sub-boratis,........lij.
Aquae Pluviae, (Caloris gradu, 75° ad 98° F.), C. xxx. Solve.

   These alkaline baths are often usefully employed as deter-
gents  of  the  surface  when it  becomes covered with thick
crusts of adherent scales.  They should be used with caution
when any tendency to inflammatory action exists in the skin.
They are  also of service in chronic  scaly eruptions, espe-
cially pityriasis, and in ichthyosis.

                     IODINE BATHS.
R. Iodinii,...........3ss.
    Iodidi Potassii,.........3ss.
    Glycerinae,..........fl  Jij.
    Aquae, (Caloris gradu, 86°  ad 94° F.),   C. xxx. Solve. 
THERAPEUTICS.
313
R. Iodinii,............3j.
   Liquoris Potassae,   .  .   .   .    fl gj ad fl Sij.
   AquaePluviae(Calorisgradu,86°ad96° F.),C.xxx. Solve.

R. Brominii,...........m. xx.
   Iodidi Potassii,.........gij.
   Glycerinae,.........fl 3j.
   Aquae (Caloris gradu, 86° ad 94° F.), .   C. xxx. Solve.

  Iodine baths are used in very chronic cutaneous eruptions,
when there is much hypertrophy of the integuments.  They
may also be employed in aggravated cases of prurigo.

                     SULPHUR BATHS.
R. Potassii Sulphureti,.......3iv.
   Aquae Pluvias (Caloris gradu, 86° F.),   C. xxx. Solve.

R. Potassii Sulphureti,
   Sodae Hyposulphitis,......aa 3ij.
   Aquae Pluviae (Caloris gradu, 86° F.),   C. xxx. Solve.

  Either of these  baths may be .used in the treatment of
chronic scaly diseases of the skin, but their efficacy is much
inferior to that of the natural sulphurous mineral waters.

                    MERCURIAL BATHS.
R.  Corrosivi Sublimati,.......3ij-
    Glycerinae,.........fl lij-
   Aquas Pluviae (Caloris gradu, 96° F.),    C. xxx. Solve.

R. Iodidi Hydrargyri rubri,......3j-
    Sodii Chloridi,.........3ij.
    Aquas (Caloris gradu, 96° F.),  .  .  . C. xxx. Solve.

  Mercurial baths are applicable for the  treatment of ob-
stinate syphilitic cutaneous diseases.  They have also been
used in very chronic  scaly eruptions.
   Cataplasms  are  employed chiefly to  removed  hardened
incrustations, for which purpose those prepared with linseed
meal and smeared  over with fresh lard or olive oil are best
                           27 
314
THERAPEUTICS.
adapted.  But they are also very serviceable  in  allaying
local inflammation or irritation: when used with this inten-
tion they should consist of white bread steeped well in hot
water, then squeezed dry, and moistened with some cooling
wash, as recommended before for  the treatment of eczema
and of herpes.
   Caustics are used principally with the intention  of de-
stroying the affected integuments and arresting the morbid
process in lupus, and their use in it  has  been spoken of in
the description of the treatment of that disease.   But many
practitioners  employ them also in the  chronic stages of
several cutaneous eruptions, with the  view of exciting a new
action in  those  portions of the skin on which they may be
seated : caustics have been thus used,  especially in the treat-
ment  of the eruptive diseases of the scalp and in squamous
affections ; my experience of their effects, however,  is  not in
accordance with the opinion of those who report favorably
of their application.   Besides nitrate of silver—which is
the favorite caustic in skin diseases—chloride of zinc and
caustic potash, some practitioners use a  strong solution of
iodine, which may be prepared as follows  :—

     R. Iodinii,.........3ss.
        Aquae destillatae,......3 v.
        Iodidi Potassii, quantum sufficit ut fiat solutio.

   The following formula for a compound  caustic solution is
contained in the Pharmacopoeia of the London Hospital for
Diseases of the Skin :—

     R. Zinci Chloridi,......3iv.
        Antimonii Chloridi,.....3ij«
        Pulveris Amyli,......3j«
        Glycerinae, quantum sufficit.   Misce.

   Whether caustics be resorted  to or not in the treatment
of diseases of the skin, they should never be used to the ex-
clusion of other remedial measures.
   Lotions, were  it not for the difficulty of applying them
effectually in many cases, and on certain regions of the body,
constitute the best  form for using topical medication in the 
THERAPEUTICS.
315
treatment of a great number of cutaneous eruptions.  Their
special application has been described when treating of the
individual diseases in which they are to be used, and several
formulae for their prescription  have been given.   They are
most readily applied by means of bandages kept constantly
wet Avith them ; but  as this method  is applicable for the
extremities only, when the eruption is situated on any other
portion of the integument, they may be applied on a double
fold of  old linen or lint, covered Avith a thin sheet of gutta
percha, which is preferable for this purpose to oil-silk, as it
does not keep the surface so hot, in consequence of its per-
mitting a certain^ degree of evaporation.  In the  case  of
spirituous or other cooling lotions, neither covering is of course
admissible, and then  the  linen or lint must be moistened
with the wash as often as it  becomes dry.  The addition of
glycerine to lotions is of especial  service, as in consequence
of its non-evaporating properties, it keeps the part to which
they are applied  in  a constant state  of moisture ; this is
peculiarly useful as respects alkaline lotions,  which tend to
render the surface harsh and dry,  an evil  that in many
cases would counterbalance  the  good effects that might
result from their employment.  Independently of their use
with  the intention of producing a direct medical action,
lotions and washes are also employed beneficially to cleanse
the diseased  surface,  previously to the renewed  application
of ointments, and for this  purpose  they are applied  by
means of a sponge; or should the crusts or  scales that form
be hard  and  firmly adherent, a  roll of  lint  wet with the
wash may be  brushed  over the part.   When  the ordinary
alkaline or lead lotions which are used for these purposes
are found too  irritating or astringent, they will be advan-
tageously diluted by adding  to them an  equal part of new
milk.   In  addition  to the formulae  for lotions which are
contained in the several preceding chapters, the following
may also be employed for the purposes indicated:—

             STIMULATING ALKALINE LOTIONS.
   R.  Liquoris Ammoniae.....A 3j.
      Glycerinee........A 3yj.
      Spiritus Lavandulae.....fl 3ij-
      Aquae destillatae......fl 5vj. Misce. 
316
THERAPEUTICS.
  R. Liquoris Ammoniae Carbonatis .   .   fl Ix.
      Glycerinae   ........   fl 3"ij. Misce.

  R. Sodse Carbonatis......     gr. xx.
      Spiritus Rosmarini.....fl 3*j.
      Aquae Rosae.......fl 3vij. Misce.

  These lotions  are adapted  for  all eruptive  diseases in
which  the  external application  of alkalies is  indicated;
when their chronic stage is attended with atony of the
cutaneous surface.

              SEDATIVE ALKALINE LOTIONS.
  R. Sodse Sub-boratis.....     3ij-
   Aquae Florum Sambuci
   Aquae Lauro-Cerasi

R. Sodee Bicarbonatis .   .
   Aquae Florum Aurantii
   Succi Conii  ....
fl  3xj.
fl  3vj.  Misce.

   gr. xxx.
fl  Ixj.
fl 3*j. Misce.
  Chiefly useful in eruptive diseases of a dry nature which
are attended with much itching.
GLYCERINE WASH.
R. Glycerinae........fl Sij.
   Misturae Amygdalae.....fl 3vj.
   Aquae Rosae........fl 3viij. Misce.

                ASTRINGENT LOTIONS.
R. Tincturae Acetatis Zinci  .   .   .   .  fl 3iv.
   Aquae Rosae........fl 3*viiss.  Misce.

R. Acidi Tannici.......     gr. xl.
   Aceti Gallici.......fl fss.
   Aquae destillatae......fl 3viiss. Misce.

R. Creasoti.........    m. viij.
   Tincturae Krameriae.....fl 3ij«
   Acidi Hydrocyanici.....    m. viij.
   Aquae destillatae......fl 3iv. Misce. 
THERAPEUTICS.
317
  In using  this lotion, the bottle in which it is contained
should be well shaken before it is applied to the surface.

                  SULPHUROUS LOTION.
  R.  Sodae Hypo-Sulphitis,.....    5ss.
      Potassii Sulphureti,......    3j.
      Aquas destillatae,.......fl Jxiss.
  Aquae Lauro-Cerasi,.......fl gss. Misce.

                    STIMULANT WASH.
  R.  Tincturae Nucis Vomicae,  .   .   .   .  fl £*ss.
      Essentiae Camphorae,
      Essentiae Carui,......aa, fl 3ij«
      Aquae destillatae,......fl 3vij. Misce.

  This last wash is sometimes  a useful application in the
chronic stages of lichen simplex—when the disease is very
obstinate, of prurigo, and in  inveterate psoriasis,  provided
there is no tendency to local inflammatory action.
  Ointments, under which appellation I include^ cerates and
pomades, are more  generally employed than any other form
for  the application  of topical  remedies in the treatment  of
diseases of the skin ; this is owing chiefly to the facility with
which they can be used, and the readiness with which their
strength may be increased or diminished;—both matters  of
great  practical convenience and utility:  yet  they  have the
disadvantages of being easily rubbed off, of  affording  but
little  protection to  the diseased surface,  and of soiling the
clothing  with which they may come into  contact.   In some
cutaneous  eruptions  the application  of any greasy matters
disagrees remarkably,  but this appears  to depend, in the
majority of cases, rather on some constitutional cause in the
individual affected, than in a specialty of the eruption which
may be present;  it  also seems to be  to a certain degree in-
fluenced  by the region of the skin on which  the disease  is
situated ; thus, I have seen them prove injurious more fre-
quently in the eruptions of the scalp than in those of  any
other part of the body.   With  affections which are accom-
panied by excessive serous discharge, as in most  forms  of
                           it ( 
318
THERAPEUTICS.
eczema, they also, in my experience, generally disagree more
than with any others.   We  can, however, seldom ascertain
the existence of this peculiarity except by direct trial;  but
when it  is once discovered to exist, the use of ointments
should then be carefully avoided.   Prepared axunge, in con-
sequence  of its greasy nature, does not, therefore, form a
good basis for ointments to be used in the treatment  of cu-
taneous diseases, except in cases attended with much hyper-
trophy of the integuments, as in ichthyosis, and in the chronic
stages of some obstinate eruptions which are  not accom-
panied by aopious discharges;  and the white wax ointment
—which is employed for the preparation of nearly all  the
ointments contained in the last edition of the Dublin Phar-
macopoeia—is often not well adapted for this purpose in con-
sequence  of its firmness  and consistency.  I  have,  there-
fore, latterly used in almost every  case either cold cream or
the cucumber  pomade of the French pharmaceutists,  as the
basis of whatever ointment I prescribe ;  the latter prepara-
tion, as already remarked when  speaking of the treatment
of intertrigo,  is in itself a useful local application,  possess-
ing calmative and healing properties.   As formulae for  either
of them are contained  in but very few English works  on
Materia Medica, it will be well, I think, to give them here:—

             ceratum galeni (Cold Cream).1
       R.  Olei Amygdalae,   .   .   .   .  fl Ixvj.
           Cerae Albae,.....    §iv.
           Aquae  Rosae,.....fl §xij.

   " Melt the wax in the oil with a  gentle heat, in an earthen
vessel; pour  the mixture into a marble mortar, previously
heated, and stir it constantly until it is nearly cold: then,
by  beating up the cerate briskly, incorporate  with  it the
rose water, added in small quantities at a time."

  Yellow wax may be substituted for the white wax in hospi-
tal  practice.
                       1 French Codex. 
THERAPEUTICS.
319
         ceratum cucumis (Cucumber Pomade).1

         R. Axungiae......Bbij.
            Adipis Vituli (Calfs Suet),  ftss.
Liquefac simul, dein adde,
            Succi Cucumis Sativi,   .  fl 3xxiv.

  " Mix and bruise them well with  the hand ; set aside for
twenty-four hours ; then pour off the juice and replace it by
a similar quantity of fresh juice, and repeat this process ten
times, adding fresh juice each time. As soon as the pomade
has acquired a well-marked odor of the cucumber, melt it in
a water-bath, and add an ounce of  finely powdered  starch,
which will combine with the water and precipitate it.  Allow
the entire to settle, and then pour off the pomade into small
vessels.  To render it more white and smooth, the French
pharmaciens usually prepare it for use by melting again in
a water-bath, and  beating  it for two  hours or even  longer
with a wooden spatula, but when submitted to this treatment
it does not  keep fresh for  a longer period than a month ;
while in the former case it will keep for a year, or even
longer, in a cool place."
  I shall now append  some formulae, in addition to those
contained in the preceding chapter,  for ointments which are
ordinarily employed in the treatment of diseases of the skin.
And first, I may mention that an  excellent calmative oint-
ment, especially useful in the cutaneous eruptions of chil-
dren which  are attended with heat and itching,  may be pre-
pared by substituting cherry-laurel  water for rose water in-
the above formula for cold  cream.

                  SEDATIVE OINTMENTS.
  R. Chloroformi,........m. vj.
      Cerati Cucumis,.......3j-  Misce.

  R. Carbonatis Plumbi,......3ss.
      Cerati Galeni,........3j.
      Chloroformi,........m. iv.  Misce.
1 Henry and Guibourt. 
320
THERAPEUTICS.
R. Glycerinae, .  .  .  .
   Unguenti Cerae albae,
   Chloroformi,  .   .  .
   Cyanidi Potassii .  .
A3j.
•  3vV!:
m. viij.
gr. iv.
Misce.
  The great advantage derived from the employment  of
chloroform, alone or in  combination with other sedatives,  as
an external application in the treatment of cutaneous dis-
eases, has been frequently referred to in the foregoing pages.
In the preparation of ointments it should always be the last
ingredient added, in  consequence of its volatility, and  for
the same reason the ointment should be dispensed in bottles
and not in boxes or pots.
              ASTRINGENT OINTMENTS.
R. Carbonatis Calcis praecipitati,
   Cerati Galeni, .   .
   Extracti Belladonnae
   Glycerinae,  .   .m  .
R. Oxydi Zinci,   .   .
   Cerati Galeni, .
   Tincturae Myrrhae,
R. Creasoti,........m. x.
   Adipis praeparati,.......3ij.
   Pulveris Opii,.......gr. viij.
R. Carbonatis Plumbi,.....gr. xij.
   Acidi Tannici,.......gr. viij.
   Cerati Galeni,.......Ej.
•  3ij.
.  3ij.
gr. xx.
fl 3ij.  Misce.
gr. xx.

fl 3ss. Misce.
Misce.
Misce.
CAMPHOR OINTMENT.
R. Camphorae rasae et redactae,   .   . gr. viij.
   Tincturae Conii (Ed. Ph.),  .   .   . fl 3ij.
   Unguenti Cerae albae,   ....    Sj.  Misce.
HEMLOCK OINTMENT.
R. Fructus Conii, in pulvere subtilissimo, 3ss.
   Unguenti Sambuci,.....|ij.
   Glycerinae,........fl 3j.   Misce. 
THERAPEUTICS.
321
  A hemlock ointment thus prepared I have found very use-
ful in allaying the painful  sensations which attend on some
forms of cutaneous eruptions.
  Powders  are  used externally, chiefly in cutaneous dis-
eases attended with copious serous discharge, as in eczema,
and  in  those accompanied by marked  local inflammatory
action, as in erysipelas.   They are  applied to the surface
by being shaken from a small  bag made of fine muslin, and
should be dusted over it pretty thickly.  Whenever powders
of different  specific  gravities  are employed in  combination
for this purpose, they should be intimately mixed, and well
shaken up each time before they are applied.  Forms for
different compound dusting powders  have been given in the
preceding chapters:  the following will be found useful when
an active astringent  is indicated, as in the superficial ulcer-
ations which result  in some cases of pemphigus and of ec-
thyma :—

   R. Krameriae Pulveris,......3ss.
      [Carbonatis Calcis praecipitata, .  .  .   3ij.
      Amyli,   .   .*........3*.   Misce.

   When dusting powders  are employed, the affected parts
should be cleansed every day or every second day, by the
use  of gelatine  or size baths, or by sponging the surface
with  equal  parts of  a weak  alkaline wash  and new  milk
warmed.  This is not requisite in the treatment of erysipe-
las or of erythema,  in which  diseases their efficacy, as has
been before remarked, is partly due to their effect in exclud-
ing the air.
   Soaps.—The use of ordinary soaps, as detergents, is seldom
admissible in  cutaneous diseases in consequence of  their
irritant properties on the skin when it is at  all inflamed,
and  they should,  therefore, never be employed except in
the  chronic stages of the non-inflammatory affections  and
in which there  is no breach of the surface, and  even then
their effects must  be carefully watched.   In eruptions situ-
ated on the  scalp, or on other regions of the body which are
ordinarily covered with hair, I have almost invariably seen
them productive of injury, and, moreover,  in such cases the 
\
322                 THERAPEUTICS.

incrustations and  scales which form are more easily and
more effectually removed by the application  of weak alka-
line washes as  already recommended.   The employment of
medicated soaps in the treatment of eruptive diseases of the
skin was at one time much resorted,  particularly on  the
Continent, and latterly their use has  been revived by Sir
Henry Marsh, who speaks  in very high terms  of their effi-
cacy, but  I  must confess that, in the  few cases in which I
tried them, they did not produce any good result; nor is it
likely that a soap  should  prove a good form for the appli-
cation of remedies  in the  topical medication of cutaneous
affections ;  for  whatever substance constitutes the active in-
gredient of the soap is left but a short time in  contact with
the skin, being  almost immediately washed off;  and it would
be very difficult to regulate its  strength, as this must vary
with the amount of water used each  time in the application
of the remedy.  Sir Henry Marsh  has recommended four
different forms  of soaps, which contain respectively sulphur,
white precipitate,  red  precipitate, and corrosive sublimate,
the first two in the proportion of a drachm, the third  of
half-a-drachm, and the  fourth  of ten grains  to the ounce.
The formula for their preparation,  which originated with
Dr. W. D.  Moore, of this city, consists in beating up  in
a marble mortar, in the above proportions, white Windsor
soap and the active ingredient, with half a fluid drachm of
rectified spirit, a few drops of oil of roses being added as a
perfume.

  Those remedies which are administered internally in  the
treatment of eruptions of the  skin, with the view of acting
generally on the system, require but  little notice here, as
they have  been so  fully  described  and several  formulae
given for their prescription, in the preceding chapters when
treating of the individual diseases.   The chief point to be
kept in view on the constitutional treatment of  cutaneous
eruptions, one which has been before  referred to, is, that
they require, in most cases, a prolonged administration of
the remedy which may be employed, and that, consequently,
it should be given at first in  rather  small  doses, and  its
strength increased afterwards  very  gradually and slowly.
This is  especially evident with respect to those  powerful 
THERAPEUTICS.
323
alteratives,  arsenic  and  iodine, which  are such valuable
agents in these affections, yet which often produce injurious
consequences  by exciting local irritation, and  a tendeney
to local inflammatory action from being given at first in too
large doses ;  the same holds true of cod-liver oil and  of
many other medicines which are of daily use  in  the  the-
rapeutics of diseases of the skin.   During the employment
of any of  these  remedies, their administration should be
occasionally omitted  for a day or two, whether they cause
constitutional manifestations of their effects or not, and the
bowels freely  acted on by purgatives, those of  a saline na-
ture being  preferred if the patient's strength admit of their
use.
   The following formulae may, in addition to those already
given in the preceding chapters, serve to aid the practitioner
in prescribing the medicines which are ordinarily used in the
treatment of this class of affections :—

                   DIAPHORETIC PILLS.

     R. Antimonii  Oxydi,......gr. xc.
        Morphiae Muriatis,......gr. iss.
  Confectionis Rosae, quantum sufficit ut fiant pilulae xxiv.

           " Two to be taken every sixth  hour."

   R. Antimonii Sulphureti praecipitati,
      Pulveris Ipecacuanhae compositi,  .  aa 3J;
      Guaiaci Resinae,.......3y-
Theriacae,  quantum sufficit ut fiant pilulae  sexaginta.

           " One to be taken every sixth hour."

                   ALKALINE MIXTURE.

     R.  Liquoris Potassae,......A |ss.
         Decocti Dulcamarae,.....A 3xj.
         Tincturae Chirettae,.....fl gss. Misce.
" Two table-spoonfuls  to be taken three times a day." 
324
THERAPEUTICS.
             ALKALINE CATHARTIC DRAUGHT.

  R.  Solutionis Alkalinae (Brandish),  .   .   .  • A 3j«
      Potassae Sulphatis cum Sulphure, (Ed. Ph.)  3iss.
      Aquae destillatae.........fl 3*ij.
      Tincturae Aurantii,........A 3j-
Misce.  Fiat haustus.

     " To be taken in the morning before breakfast."

                 DIAPHORETIC MIXTURES.

       R. Tincturae Guaiaci Ammoniatae,  .  A 3ij-
          Mucilaginis Gummi Tragacanthae,  fl 3vj.
          Misturae Amygdalae,    ....  A Jiij. Misce.

   " Two table-spoonfuls to be taken every sixth hour."

     R. Sarsaparillae Radicis incisse,   .   .   . 3*iss,
        Aquae destillatae ferventis, .   .   .   . Oj.

per horas duodecim in vase clauso macera, subinde agitans,
  dein cola, et

       R. Hujus infusi,   .  .  .   . fl 3xij.
          Infusi Sassafras,
          Decocti mezeri,  .   .  aa A 3iss.
          Syrupi Hemidesmi,  .   . fl 3j.         Misce.

 " A wine-glassful to be taken three or four  times a day."

                 ALTERATIVE MIXTURES.

    R. Hydrargyri Bromidi,  .   .  .  gr.  ss.
        Decocti Dulcamarae,   .   .   fl fviij.    Misce.

  "Two table-spoonfuls  to be taken three times a day."

  This preparation may be administered in  obstinate cases
of secondary syphilitic eruptions; in its action it is nearly
allied to the red iodide of mercury. 
THERAPEUTICS.
325
       R. Hydrargyri Iodidi Rubri,  .   .   .   gr. v.
          Spiritus Vini rectificati,   .   .   .   A  3j.

tere simul dein adde,

            Aquae destillatae,.....fl giss.
            Iodidi Potassii,......3ij.
            Syrupi Aurantii,.....fl gss.  Misce.

"Twenty drops to be taken three times  a day in  a wine-
             glassful of infusion of sassafras."

   This is a preferable form to that of pill for the adminis-
tration of the red iodide of mercury in venereal eruptions.

       R. Ferri Bromidi,......3j-
          Liquoris Arsenicalis,   ....   m. lx.
          Syrupi Florum Aurantii,  .  .   . fl 3"ss.
          Aquae  Florum Aurantii,   .  .   . fl §iss. Misce.

" A tea-spoonful to  be taken three times a day in  a wine-
          glassful of decoction of fresh elm-bark."

   A useful form  for the administration of arsenic in chronic
cutaneous eruptions, attended with anemia or much debility.
   Before concluding, a  few words are requisite as to the
hygienic measures best adapted for cutaneous diseases.  As
a general rule, the diet must be, of course,  regulated accord-
ing to the individual requirements of each case, but  as these
affections are usually evidences of constitutional  debility,
though so frequently attended with a tendency tolocal inflam-
matory or  irritative action, it should be nutritious but not
stimulating.  Restriction to an almost purely milk and fari-
naceous diet is attended with the best results in the majority
of instances, and should be almost invariably enforced with
infants and children.  Change of air  to a dry, elevated posi-
tion, is often of great service, but extremes of cold and heat
should be avoided  as much  as  possible.   For the  latter
reason, the  surface of the body should be kept as far as can
be of  an uniform temperature by attention to the  clothing
worn  which, however, should never be such as to check the
insensible perspiration, or  tend to condense it on the integu- 
326
THERAPEDTICS.
ments.  That worn next the skin should be soft and unirritat-
ing, and therefore woollens should be avoided, soft calico or
silk being preferred for under-clothing.   In referring to
change  of air, I wish to record it as the result of my expe-
rience, that a residence at the sea-shore usually proves inju-
rious in cutaneous eruptions, the fine saline particles which
float about in the atmosphere  appearing to aggravate the
disease  by exciting local irritation : the climate of those dis-
tricts which are situated a short distance inland is, however,
well adapted for persons  afflicted with them.
  Great objections are often raised to the cure  of cutaneous
eruptions, particularly those  which  are attended with  a
copious secretion, more especially if they have been of long
existence, for fear of their sudden removal or the stoppage
of the discharge with which they may be attended  causing
some grave internal disease; but I have never seen any ill
consequences result  when  they were removed by constitu-
tional treatment, not even in the case of infants or children
who may be teething; on the contrary, I  have  invariably
witnessed the general health to be much  improved in all
respects thereby;  but the  sudden cure by  the  employment
of topical remedies  only,  such as  caustics  or powerful
astringents or stimulants, is certainly not  advisable unless
the eruption  is of  small extent and has been of short dura-
tion. 
INDEX.
 Acarus folliculorum, 119.
       scabiei, 107.
 Achorion Schonleinii, 268.
 Achroma congenitale, 238.
       Titiligo, 238.
 Acne, 117.
       indurata, 121.
       molluscoides, 209.
       punctata, 119.
       rosacea, 120.
       sebacea, 118, 213.
       simplex, 118.
       syphilitic, 288.
       varioliformis, 209.
 Acrodynia, 34.
 Albinoes, 237.
 Albinoismus, 237.
 Alibert's classification, 18.
 Alkaline baths, 312.
       cathartic draught, 324.
       lotion, 56, 61.
         sedative, 316.
         stimulating, 315.
       mixtures, 323.
 Alopecia, 305.
 Alterative  mixtures, 324.
 Appendages of the skin, diseases of,
   304.
 Artificial classifications, 16.
 Arsenic, ioduretted  solution of the
   iodide of potassium and, 185.
 Asiatic pills, 186.
 Astringent lotions, 316.
       ointments, 320.
 Author's classification, 24.

 Baker's itch, 153.
 Baldness,  305.
Bandages,  310.
Barbadoes  leg, 218.
 Baths, 311.
       alkaline, 312.
       gelatine, 312.
       iodine, 312.
       mercurial, 313.
       sulphur, 313.
 Bennett's classification, 22.
 Bleb, 17, 63.
 Brandy-face, 120.
 Bulla, 17.
 Bullae, 63.
 Burnt holes, 97.

 Callositates, 223.
 Camphor ointment, 320.
 Cancrodes, 28, 246.
 Cancroide, 261.
 Canities, 304.
 Cantharides, tincture of,  in psori-
  asis, 188.
Carbonate  of ammonia in psoriasis,
  187.
Carbuncled face, 120.
Cataplasms, 313.
 Caustic of chloride of zinc, 314.
       of iodine, 314.    '
       solution, compound, 314.  ,
Caustics, 314.
Cazenave's classification, 20.
       treatment of lupus, 260.
Ceratum cucumis, 319.
       galeni, 318.
Cheloi'd tumor, 261.
Chloasma,  192, 264.
Chloride of zinc caustic, 314.
Classification, 13.
      artificial systems of, 16.
      author's, 24.
      Alibert's, 16, 18.
      Bennett's, 22. 
328
INDEX.
 Classification,
       Cazenave's, 20.
       Willan's, 17.
       Wilson's, 19.
       natural systems of, 19.
       regional system of, 17, 21.
 Clavus, 222.
 Cold cream, 318.
 Collodion in skin diseases, 309.
       use of, in erysipelas,  47.
 Condylomata, 224.
       syphilitic, 294.
 Corns, 222.
       soft, 222.
 Corrosive sublimate  soap, 322.
 Couperose, 120.
 Cream, cold, 318.
       cucumber, 319.
 Crusted tetter, 126.
 Cryptogamia of favus, 267.
       of sycosis, 275.
 Cucumber cream, 319.
 Dandruff,  193.
 Dermatophytae, 28, 264.
 Diaphoretic mixtures, 324
       pills, 323.
 Donovan's solution, 300.
 Draught, alkaline  cathartic, 324.
 Dry scale, 169.
       tetter,  169.
 Ear, herpes of, 80.
 Eating hive, 97.
       tetter,  246.
 Ecchymoses, 226.
 Ecthyma, 139.
       acutum, 139.
       cachecticum,  141.
       chronicum,  140.
       infantile, 141.
       luridum, 141.
       syphilitic, 290.
 Eczema, 63.
       capitis, 68.
       chronicum, 66.
       faciei, 67.
       impetiginodes, 66, 133.
       mercuriale, 70.
       rubrum, 65.
       simplex, 64.
       solare,  70.
       syphilitic, 286.
      umbilicale, 69.
Elephantiasis, 217.
 Elephantiasis,
       Arabum, 218.
       Graecorum, 217.
 Ephe'lides ligne'ales, 243.
 Ephelis, 241.
 Ephelis, hepatica, 242.
       lenticularis, 241.
       syphilitic, 296.
       violacea, 244.
 Epidemic of erythema, 34.
       of pemphigus, 97.
 Erratic erysipelas, 40.
 Erysipelas,  37.
       contagiousness of, 42.
       erratic,  40.
       gangrenous, 39.
       idiopathic, 38.
       metastatic, 40.
       phlegmonous, 39.
       symmetrical, 40.
       true, 38.
       traumatic, 40.
       treatment of, 44.
 Erythema, 31.
       circinnatum, 32.
       fugax, 32.
       intertrigo, 32.
       laeve, 32.
       marginatum, 32.
       nodosum, 33.
       papulatum, 33.
       simplex, 31.
       syphilitic, 284.
       tuberculatum, 33.
 Esthiomanic scrofula, 253.
 Esthiomanos ambulans, 248.
       serpiginosus, 248.
 Evanescent urticaria, 51.
 Exanthema, 17.
       hemorrhagica, 231
 Exanthemata, 24, 30.
       syphilitic, 284.

 Face, acne of, 120.
       eczema of, 67.
       impetigo of,  130.
 Favus, 265.
       dissemine, 268.
       en cercles, 268.
 Fire, sacred, 81.
       St. Anthony's, 37.
 Fish-skin disease, 200.
Flux, sebaceous, 212.
Freckles, 241. 
                               INI

Galen's cerate, 318.
Gelatine baths, 312.
Glycerine wash, 316.
Graves on  gutta  percha  in  skin
  diseases, 310.
Gray hair, 304.
Grocer's itch,  70,  153.
Gruby on mentagra, 276.
Gum, 149.
       red, 149.
       white, 150.
Gutta percha in skin diseases, 310.
Gutta rosacea, 120.
 Hair, diseases of, 304.
       falling out of, 304.
       grayness of, 304.
 Hardi's treatment for the itch, 114.
 Heat, prickly, 151.
 Helmerich's itch ointment, 113.
 Hemlock ointment, 320.
 Hemorrhagiae, 27, 226.
 Herpes, 78.
       auricularis, 80.
       capitis, 84.
       circinnatus, 83.
       iris, 86.
       labialis, 80.
       phlyctenodes,  78.
       praeputialis, 80.
       pudendalis, 81.
       squamosus, 84.
       tonsurans, 84.
       zoster, 81.
 Higginbottom's treatment  of  erysi-
   pelas, 48.
 Huile de cade, 76.
 Humid tetter, 63.
 Hydrargyria, 70.
 Hypertrophiae, 27, 199.
       syphilitic, 294.

 Ichthyosis, 169, 200.
       cornea,  201.
       hysterix, 201.
       papillary, 202.
       scutellata, 201.
       simplex, 201.
       spinosa, 201.
       squamosa, 201.
Idiopathic erysipelas, 38.
Ignis sacer, 81.
Impetigo, 126.
       capitis, 131.
EX.                          329

 Impetigo,
       erysipelatodes, 129.
       figurata, 128.
       granulata, 131.
       larvalis, 131.
       lupiformis, 133.
       pilaris, 132.
       purifluens, 132.
       rodens,  132.
       scabida, 130.
       sparsa, 130.
       sycosiformis, 132.
       syphilitic, 289.
 Impetiginous eczema, 72,  133.
 Inflammatio folliculorum, 213.
 Inflammatory blush, 31.
 Intertrigo, 32.
 Iodine baths, 312.
       caustic,  314.
 Ioduretted solution  of  the iodide of
  potassium and arsenic,  185.
 Itch,  106.
       baker's, 153.
       grocer's, 70, 153.
       insect, 107.
       washerwomen's,  70, 153.

Jacob's ulcer, 252.

Kelois,  261.

Leper hospitals, 218.
Lepra, 169, 175, 217.
       alphoides, 176.
       nigricans, 176.
       syphilitic, 292.
       vulgaris, 175.
Leprosy, 217.
Leucopathia, 238.
Lichen, 146.
       agrius, 150.
       circumscriptus, 148.
       gyratus, 148.
       lividus, 147.
       pilaris, 148.
       simplex, 146.
       solitarius, 148.
       strophulus, 149.
       syphilitic, 291.
      tropicus, 151.
Lips, herpes of,  80.
Lotion, alkaline, 56,  61, 315.
      astringent, 316.
      glycerine, 316.
2t 
330
INDEX.
Lotion,
       stimulant, 317.
       sulphurous, 317.
Lupoid impetigo, 132.
Lupus, 246.
       devorans, 250.
       exedens, 247.
       non-exedens,  247.
       serpiginosus,  248.
       superficialis, 247.
         non-tuberculosus, 248.
       vorax, 251.

Maclagan, Dr., on the urine in urti-
  caria, 54.
Macula, 18.
Maculae, 27, 237.
       syphilitic, 296.
Mark, mother, 224.
Marsh's soaps, 322.
Melasma, 192.
Melitagra, 128.
Mentagra, 275.
       contagiosum,  276.
Mermaids, 203.
Mercurial baths, 313.
       eczema, 70.
Mixtures, alkaline, 323.
       alterative, 324.
       diaphoretic, 324.
Molluscum, 208
       acutum, 209.
       chronicum, 210.
       contagiosum,  209.
       non-contagiosum, 209.
       pendulum, 210.
Mother-mark, 224.

Naevus, 224.
       araneus, 225.
Nails, diseases of, 307.
       ingrowing of,  307.
Natural systems of classification, 19.
Nettle rash, 49.
Nirles, 78.
Nitrate of silver-stain, 244.
Noli me tangere, 250.

Ointment, camphor, 320.
       cucumber, 319.
       Helmerich's, 113.
       hemlock, 320.
       scrophularia,  101.
       stavesacre, 115.
Ointment,
       white hellebore, 115.
Ointments, 317.
       astringent, 203.
       sedative, 319.

Pachydermia, 219.
Papula, 17.
Papulae, 26, 145.
       syphilitic, 291.
Papulous scall, 139.
Pemphigus, 94.
       acutus, 95.
       chronicus, 97.
        foliaceus, 99.
       contagiosus, 100.
gangraenosus, 97.
       infantilis, 96.
       simultaneus, 94.
       successivus, 94.
       syphilitic, 287.
Petechia?, 226.
Phlegmonous erysipelas, 39.
Phlyzacia, 26.
Phthiriasis, 162.
       capitis, 162.
       corporis, 162.
       pubis, 162.
Pills, Asiatic, 186.
       diaphoretic, 323.
Pimples, 17, 26, 145.
Pityriasis, 190.
       capitis, 193.
       diffusa, 191.
       labiorum, 192.
       localis, 192.
       nigra, 192, 215.
       oris,  192.
       palmaris, 192.
       palpebrarum, 192.
       plantaris, 192.
       praeputialis, 192.
       pudendalis, 192.
       rubra, 190.
       versicolor, 190, 264.
Plica Polonica, 305.
Pomade, cucumber, 319.
       Helmerich's, 113.
       turpentine, 240.
Pompholyx, 94.
       benignus, 96.
       diutinus, 97.
       solitarius, 96.
Porcupine men, 203. 
INDEX.
331
 Porrigo, 564.
       decalvans, 305.
       favosa,  265.
       lupinosa,  268.
 Powders, 321.
       dusting, 321.
 Prepuce, herpes of, 81.
 Prickly heat, 151.
 Prurigo, 159.
       formicans, 160.
       mitis, 159.
       palmaris, 163.
       pedicularis, 162.
       podicis, 163.
       praeputialis, 163.
       pubis, 163.
       pudendi, 163.
       scroti, 163.
       senilis,  162
       urethritis, 163.
       vulgaris, 160.
 Psoriasis, 169.
       aggregata, 172.
       annulata, 177.
       capitis, 174.
       centrifuga, 175.
       confluens, 172.
       diffusa, 172.
       guttata, 170.
       infantilis, 177.
       inveterata, 173.
       labialis, 174.
       lepraeformis,  175.
       orbicularis, 177.
       palmaris,  174.
         centrifuga, 175.
         syphilitic, 293.
       palpebrarum, 174.
       preputialis, 174.
       pudendalis, 174.
       scrotalis, 174.
       syphilitic, 292.
       unguium,  175.
       vulgaris, 172.
Psydracia, 26.
Pudendum, herpes of, 81.
Purples, 226.
Purpura, 226.
       cachectica, 231.
       contagiosa, 231.
       febrilis hemorrhagica, 230.
         simplex, 227.
       hemorrhagica, 229.
       senilis, 228.
 Purpura,
       simplex, 227.
       urticans, 228.
 Pustulae, 18, 116.
       syphilitic, 288.
 Pustules, 18, 26, 116.

 Rainbow ringworm, 86.
 Rash, 17.
       nettle, 49.
       rose, 57.
       tooth, 149.
       wildfire, 150.
 Red gum, 149.
 Red precipitate soap, 322.
 Regional classification, 17, 21.
 Rheumatism and urticaria, 53.
 Ringworm, 83.
       of the scalp, 84.
       rainbow, 86.
 Robin's  description of porrigo, 267.
 Rose rash, 57.
 Roseola, 57.
       aestiva,  58.
       annulata, 58.
       autumnalis, 58.
       cholerica, 60.
       febrilis, 60.
       idiopathica, 57.
       infantilis, 58.
       miliaria, 60.
       punctata, 59.
       symptomatica, 59.
       syphilitic, 285.
       vaccina, 60.
       variolosa, 60.
 Rosy drop, 120.
 Rupia, 102.
       escharotica, 97, 103.
       prominens, 103.
       simplex, 103.
       syphilitic, 287.

 Sacred fire, 81.
 Sarcoptes hominis, 107.
 Scabies,  106.
       cachectica, 110.
       lymphatica, 110.
       papuliformis, 110.
       purulenta, 110.
Scald head, 265.
Scale, 17, 168.
       dry, 169.
Scall, 63. 
332
INDEX.
Scall,
      head, 265.
      papulous, 139.
Scalp, eczema of, 68.
      herpes of, 84.
      impetigo of, 131.
      psoriasis of, 174.
      ringworm of, 84.
Scrophularia ointment, 101.
Scrofula, esthiomanic, 253.
Sebaceous flux, 212.
Secondary eruptions, 281.
Sedative alkaline lotions, 316.
      ointments, 319.
Shell-fish, urticaria caused by, 53.
Shingles, 81.
Silver, nitrate of, stain from, 244.
Skin, diseases of appendages of, 304.
Soap of corrosive sublimate, 322.
      red precipitate,  322.
      sulphur, 322.
      white precipitate, 322.
Soaps, 321.
      Marsh's, 322.
Soft corns, 222.
Solution of iodide  of potassium  and
  arsenic, 185.
Spedalskhed, 218.
Squama, 17.
Squamae, 26, 168.
      syphilitic, 292.
St.  Anthony's fire, 37.
Stains, 18.
      syphilitic, 286.
Stavesacre ointment, 115.
Stearrhcea, 212.
      flavescens,  213.
      nigricans, 214.
      simplex, 212.
Steatozoon folliculorum, 119.
Stimulant wash, 317.
Stokes, Whitley, on pemphigus, 97.
Strophulus, 146.
      albidus, 150.
      candidus, 150.
      confertus, 149.
      intertinctus, 149.
      volaticus, 150.
Sudamina, 71.
Sulphur baths, 313.
      soap, 322.
Sulphurous lotion, 317.
Sun burn, 241.
      rash, 70.
Sycosis, 274.
       mentis, 275.
Syphilide squameuse corne*e, 293.
Syphilides, 28, 281.
Syphilitic acne, 288.
       condylomata, 294.
       ecthyma, 290.
       eczema, 286.
       ephelis, 296.
       eruptions, 281.
       erythema, 284.
       exanthemata, 284.
       herpes, 286.
       hypertrophiae, 294.
       impetigo, 289.
       lepra, 292.
       lichen, 291.
       maculae, 296.
       papulae, 291.
       pemphigus, 287.
       psoriasis, 292.
       pustulae, 288.
       roseola, 285.
       rupia, 287.
       squamae, 292.
       tubercles, 294.
       urticaria, 285.
       vesiculae, 586.

Tetter, 78.
       crusted, 126.
       dry, 169.
       eating, 253.
       humid, 63.
Therapeutics, 309.
Tinea, 265.
       favosa, 265.
Tooth-rash, 145.
Topical medication, 309.
Traumatic erysipelas, 40.
Tropical lichen, 151.
Trouts, 243.
Tubercle, 17, 294.
Tubercles, syphilitic, 294.
Tubercula, 199.
Tumor, cheloid, 261,
Turpertine pomade, 240.

Ulcer, Jacob's, 252.
Urticaria, 49.
       conferta, 51.
       evanida, 51.
       febrilis, 50.
       intermittens, 51. 
INDEX.
333
Urticaria,
       perstans, 51.
       subcutanea, 51.
       syphilitic, 285.
       tuberosa, 52.
Velpeau's treatment of erysipelas, 49.
Venereal eruptions, 281.
Verrucae, 221.
Vesicle,  17, 63.
Vesiculae, 25, 63.
       syphilitic, 286.
Vibices,  226.
Vitiligo, 238.
Vitiligoidea plana, 215.
      tuberosa, 215.

Warts, 221.
Washerwomen's itch, 70, 153.
Water-blebs, 94.
White-gum, 150.
      hellebore ointment,  114.
      precipitate soap, 322.
Wild-fire rash, 150.
Willan's classification,  17.
Wilson's classification, 19.
Wolf, the, 246. 
 
I 
 
                         CATALOGUE
                                     OP

MEDICAL,  SURGICAL,   AND   SCIENTIFIC  WORKS,

                             PUBLISHED  BY

           BLANCHARD  &  LEA,  PHILADELPHIA.
AMERICAN JOURNAL OF THE MEDICAL  SCIENCES. — Edited  by Isaac Hats, M.D.
 Published Quarterly, each number containing about 300 large octavo pages.  Price, $5 per
 annum.  When paid for in advance, it is sent free by post, and the " Medical News aud
 Library," a monthly of 32 large 8vo. pages, is furnished gratis.  Price of the "Medical
 News," separate, $1 per annum, in advance.
ALLEN (J. M.), M.D.—The Practical Anatomist; or, The Student's Gotde in the Dissectino-
  Room.  With over 200 illustrations. In one handsome royal 12mo. volume. (Jtist Issued.)
ABEL (F. A.), F.C.S.,  and C. L. BLOXAM.—Handbook of Chemistry, Theoretical, Practical,
  and Technical, with a Recommendatory Preface by Dr. Hofmann. In one large octavo
  volume of 662 pages, with illustrations.
ASIIWELL (SAMUEL), M.D.—A Practical Treatise on the Diseases peculiar to Women.
  Illustrated by Cases derived  from Hospital and Private Practice.  Third American edition.
  In one octavo volume of 520 pages.
ARNOTT (NEILL), M. D.—Elements op Physics ; or, Natural Philosophy, General and Me-
  dical. Written for universal use, in plain or non-technical language.  A new edition, by
  Isaac Hays, M. D. Complete in one octavo volume, of 484 pages, with about two hundred
  illustrations.
BROWN (ISAAC BAKER), M.D.—On some Diseases op Women admitting op Surgical
  Treatment.  With handsome illustrations.  1 volume, 8vo., extra cloth.
BENNETT (J. HUGHES), M.D.—Ttie Pathology and Treatment of Pulmonary Tubercu-
  losis, and on the Local Medication of Pharyngeal and Laryngeal Diseases, frequently mis-
  taken for, or associated with, Phthisis.  In one handsome octavo volume, with beautiful
  wood-cuts.
BENNETT (HENRY), M.D.—A Practical Treatise on Inflammation op the Uterus, its
 Cervix and Appendages, and on its Connection with Uterine Disease. Fourth American,
 from the third and revised London edition.  To which is added (July, 1856), A Review op
 the Present State of Uterine Pathology.  In one neat octavo volume, of 500 pages, with
 wood-cuts.

BEALE (LIONEL JOHN), M. R. C. S.—The Laws of Health in Relation to Mind and Body.
 A Series of Letters from an old Practitioner to a Patient. In one handsome volume, royal
 12mo, extra cloth.

BILLING (ARCHIBALD) M. D.—The Principles of Medicine.  Second American, from the
 fifth and improved London edition. In one handsome octavo volume, extra cloth, 250 pp.

BARCLAY (A W ), M. D.—A Manual of Medical Diagnosis; being an Analysis of the Signs
 and Symptoms of Disease. In one neat octavo volume, extra cloth, of over 400 pages.
 {Now Ready.)

BUCKNILL (J. C), M. D„ and DANIEL H. TUKE, M. D.—A Manual of Psychological Medi-
 cine- containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and
 Treatment of Iusanity.  With a Plate. In one handsome octavo  volume, of 536 pages.
 {Now Ready')                                                      .j. 
2          BLANCHARD & LEA'S MEDICAL PUBLICATIONS.
BLAKISTON (PEYTON), 51. D.—Practical Observations on Certain Diseases of the Chest,
  and on the Principles of Auscultation.  In one volume, 8vo., 384 pages.
BURROWS (GEORGE), M. D.—On Disorders of the Cerebral Circulation, and on the Con-
  nection between the Affections of the Brain and Diseases of the Heart.  In one 8vo. vol.,
  with colored plates, pp. 216.
RUDD (GEORGE), M. D.—On Diseases of the Liver.  Third American, from the third and
  enlarged London edition.  In one very handsome octavo volume, with four beautifully
  colored plates, and numerous wood-cuts.  500 pages.  New edition.
BUDD (GEORGE), M.D. — On the Organic Diseases  and Functional Disorders op tub
  Siomach.  In one neat octavo volume, extra cloth.  (Now Ready.)
BUCKLER (T. H.), M.D.—On the Etiology, Pathology, and Treatment op FmRO-BRONCHina
  and Rheumatic Pneunomia. In one handsome octavo volume, extra cloth.
BUSHNAN (J. S.), M. D.—Principles op Animal and Vegetable  Physiology.  A Popular
  Treatise on the Functions and Phenomena of Organic Life.  In one handsome royal 12mo.
  volume, extra cloth, with numerous illustrations.
BLOOD AND URINE (MANUALS ON).—By John William Griffith, G. Owen Reese, and
  Alfred Markwick.  One thick volume, royal 12mo, extra cloth, with plates.  400 pages.
BRODIE (SIR BENJAMIN C), M. D.—Clinical Lectures on Surgery.  One vol., 8vo., cloth.
  350 pages.
BIRD (GOLDING), M.D— Urinary Deposits:  their Diagnosis, Pathology, and Therapeuti-
  cal Indications.  A new and enlarged American, from the last improved London edition.
  With over sixty illustrations.  In one royal 12mo. volume, extra cloth.
BARTLETT (ELISHA), M.D.—The History, Diagnosis, and Treatment of the Fevers of TnE
  United States. Fourth edition, revised, with Additions by Alonzo Clark, M.D.  In one
  handsome octavo volume, of 600 pages.  (Just Issued.)
BOWMAN (JOnN E.), M. D.—Practical Handbook of Medical Chemistry.  Second American,
  from the third and revised London edition.  In one neat volume, royal 12mo., with nume-
  rous illustrations.  288 pages.
BOWMAN (JOHN E.), M.D.—Introduction to Practical Chemistry,  including Analysis.
  Second American, from the second and revised English edition.  With numerous illustra-
  tions.  In one neat volume, royal 12mo. 350 pages.
BARLOW (GEORGE II.), M.D.—A Manual of the Practice op Medicine.  With Additions
  by D. F. Condie, M.D.  In one handsome  octavo volume, leather, of 600 pages.
CURLING (T. B.\ F. R. S.—A Practical Treatise on Diseases op the Testis, Spermatic Cord,
  and Scrotum.  Second American, from the second and enlarged English edition. With
  numerous illustrations.  In one handsome octavo volume, extra cloth.
COLOMBAT DE L'ISERE.—A  Treatise on the Diseases op Females, and on the Special
  Hygiene of their Sex.  Translated, with many Notes and Additions, by C. D. Meigs, M. D.
  Second edition, revised and improved.  In one large volume, octavo, with numerous wood-
  cuts.  720 pages.
COPLAND (JAMES), M.D.—Of the Causes, Nature, and Treatment op Palsy and Apoplexy,
  and of the Forms, Seats, Complications, and Morbid Relations of Paralytic and Apoplectic
  Diseases.  In one volume, royal 12mo., extra cloth.  326 pages 
BLANCHARD & LEA'S MEDICAL PUBLICATIONS.          3
CARSON (JOSEPH),  M. D.—Synopsis op the Course op Lectures on Materia Medica and
  pharmacy, delivered in the University of Pennsylvania.  Second edition, revised.  In one
  very neat octavo volume, of 208 pages.
',ARPENTER (WILLIAM B.), M.D.—Principles op Human Physiology; with their chief
 applications to Psychology, Pathology, Therapeutics, Hvgiene. and Forensic Medicine.  A
 new American, from the last and revised London edition.  With nearly three hundred
 illustrations.  Edited, with Additions, by Francis Gurney Smith, M.D., Professor of the
 institutes of Medicine in the Pennsvlvania Medical College, etc.  In one very large and
 beautiful octavo volume, of about 900  large pages, handsomely printed, and strongly
 bound in leather, wil.h micorl Hanrin  / r,.«* i*<-,.„ri \                                 J
bound in leather, with raised bands.  (Just Issued.)
CARPENTER (WILLIAM B.), M.D.—Principles of Comparative Physiology.  New Ameri-
  can, from the fourth and  revised London edition.  In one large and handsome octavo
  volume, with over three hundred beautiful illustrations.



CARPENTER (WILLIAM B.), M.D.—The Microscope  and its Revelations.  With an Ap-
  pendix containing the Applications of the Microscope  to Clinical Medicine, by F. G. Smith,
  M.D.  With  434 beautiful wood  engravings.  In one  large and very handsome octavo
  volume of 724 pages, extra cloth or leather.  (Now Ready.)
CARPENTER (W fLLIAM B.), M. D.—Emments (or Manual)  op Physiology, including Phy-
  siological Anatomy.  Second >"nerican, from a new and revised London edition. With
  one hundred and ninety illustrations.  In one very handsome octavo volume.
CARPENTER (WILLIAM B \ M. D.—Principles of General Physiology, including Organic
  Chemistry and Histology. With a General Sketch of the Vegetable and Animal Kingdom.
  In one large and handsome octavo volume, with several hundred illustrations. (Preparing.)
CARPENTER (WILLIAM B.), M.D— A Prize Essay on the Use of Alcoholic Liquors in
  Health and Disease.  New edition, with a Preface by D. F. Condie, M. D., and explanations
  of scientific words.  In one neat 12mo. volume.
CIIRISTTSON (ROBERT), M.D.—A Dispensatory; or, Commentary on the Pharmacopoeias
  of Great  Britain and the United States; comprising the Natural History, Description,
  Chemistry, Pharmacy, Actions, Uses, and Doses of the Articles of the Materia Medica.
  Second edition, revised and improved, with a Supplement containing the most important
  New Remedies. With copious Additions, and  two hundred  and thirteen  large  wood-
  engravings.  By R. Eglesfeld Griffith,  M.D.  In  one  very large and handsomo  octavo
  volume, of over 1000 pages.
CHELIUS (J. M.), M.D.—A System op Surgery.  Translated from the German, and accom-
  panied with additional Notes and References, by John F. South.  Complete in three very
  large octavo volumes, of nearly 2200 pages, strongly bound, with raised bands and double
  titles.
CONDIE (D. F.), M.D.—A Practical Treatise on the Diseases of Children.  Fifth edition,
  revised and augmented.  In one large volume, 8vo., of over 750 pages.  {Now Ready)


COOPER (BRANSBY B.), M. D.—Lectures on the Principles and Practice of Surgery.  Id
  one very large octavo volume, of 750 pages.


rnoPER (STR  ASTLEY P.)__A Treaw. o-i Dislocations and Fractures of the Joints.
  Kdited by Braosby B. Cooper. F.R.S., e».-.  With additional Observations by Prof J. C.
  Warren   A new American edition.  It. odv octavo volume, with numerous wood-cuts. 
4          BLANCHARD  & LEA'S MEDICAL  PUBLICATIONS.
COOPER (SIR ASTLEY P.)—On the Structure and Diseases  of the  Testis,  and on Tin
  Thymus Gland.  One vol. imperial 8vo., with 177 figures, on 29 plates.
COOPER (SIR ASTLEY P.)—On the Anatomy and Diseases op the Breast, with twenty-five
  Miscellaneous and Surgical Papers.  One large volume, imperial 8vo., with 252 figures, on
  36 plates
CHURCHILL (FLEETWOOD), M.D.—On the Theory and Practice op Midwifery.  A new
  American, from the last and. improved English edition.  Edited, with Notes and Additions,
  by D. Francis Condie, M. D., author of a " Practical Treatise on the Diseases of Children,"
  etc. With 139 illustrations.  In one very handsome octavo volume, 510 pages.
CHURCHILL (FLEETWOOD), M.D.—On the Diseases of Infants and Children. Second
  American edition, revised and enlarged by the author.  With Additions by W. V. Keating,
  M. D.  In one large and handsome volume of 700 pages.  (Now Ready.)
CHURCHILL (FLEETWOOD), M.D— Essays on the Puerperal Fever, and other Diseases
  peculiar to Women.  Selected from the writings of British authors previous to the close
  of the eighteenth century.  In one neat octavo volume, of about 450 pages.
CHURCHILL (FLEETWOOD), M. D.—On the Diseases of Women : including those of Preg-
  nancy and Childbed.  A new American edition, revised by the author.  With Notes and
  Additions, by D. Francis Condie, M. D., author of a " Practical Treatise on the Diseases of
  Children." In one handsome octavo volume, of 768 pages, with wood-cuts.  (Now Ready.)
DEWEES (W. P.), M. D.—A Comprehensive System of Midwifery.  Illustrated by occasional
  Cases and many Engravings.  Twelfth edition, with the Author's last Improvements and
  Corrections.  In one octavo volume, of 600 pages.
DEWEES (W. P.), M. D.—A Treatise on the Physical and Medical Treatment of Children.
  Tenth edition.  In one volume, octavo, 548 pages.
DEWEES (W. P.), M. D.—A Treatise on the Diseases of Females.  Tenth edition.  In on«
  volume, octavo, 532 pages, with plates.
DRUITT (ROBERT), M.R.C.S.—The Principles and Practice op Modern Surgery.  A ne-w
  American, from the improved London edition.  Edited by F. W. Sargent, M. D., author of
  " Minor Surgery," &c.  Illustrated with one hundred and ninety-three wood-engravings
  In one very handsomely-printed octavo volume, of 576 large pages.
DUNGLISON, FORBES, TWEEDIE, AND CONOLLY.—The Cyclopedia op Practical Medi
  ctne: comprising Treatises on the Nature and Treatment of Diseases. Materia Medica anc
  Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. Ac.  In four
  large super-royal octavo volumes, of 3254 double-columned pages,  strongly and hand-
  somely bound.

  *** This work contains no less than four hundred and eighteen distinct treatises, contri-
buted by sixty-eight distinguished physicians.
DUNGLISON  (ROBLEY), M. D. — Medical Lexicon; a Dictionary of Medical Science, con-
  taining a concise Explanation of the various Subjects and Terms of Physiology, Pathology,
  Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence. <tc.  With the
  French and other Synonymes;  Notices of Climate and of celebrated Mineral Waters; For-
  mulae for various Officinal, Empirical, and Dietetic Preparations, A-c.  Fifteenth edition,
  revised.  In one very thick octavo volume, of about 1000 large double-columned  pages,
  strongly bound in leather, with raised bands.   (Now Ready.) 
BLANCHARD & LEA'S  MEDICAL PUBLICATIONS.           5
DVn^ .Ih0^ (R0BLEY)> ". D.-The Practice op Medicine.  A Treatise on Special Patho-
  »ugy ana inerapeutics. Third edition.  In two large octavo volumes, of 1500 pages.



D A^LI?mN (?0BLEY). M. D.-General Therapeutics and Materia Medica; adapted for a
  flieaical lextrbook.  Sixth edition, much improved. With one hundred and eighty-seven
  iiiustertion!.  In two large and handsomely printed octavo volumes, of about 1100 pages.



DUNGLISON (ROBLEY), M.D.—New Remedies, with Formula for their Preparation and
  Administration.  Seventh Edition, with extensive Additions.  In one very lar^e octavo
  volume, of 770 pages. (Now Ready.)
DUNGLISON (ROBLEY), M.D.—Human Physiology.  Eighth edition.  Thoroughly revised
  and extensively modified and enlarged, with over 500  illustrations.  In  two large and
  handsomely printed octavo volumes, containing about 1500 pages.
DICKSON (S. II.),  M. D.—Elements  of  Medicine: a Compendious View of Pathology and
  Therapeutics,  or  the  History  and Treatment of Diseases.  In one large and handsome
  octavo volume of  750 pages, leather. (Just Issued.)
DAY (GEORGE E.). M.D.—A  Practical Treatise on the Domestic Management and more
  Important Diseases of Advanced Life.  With an Appendix on a new and successful  mode
  of treating Lumbago and other forms of Chronic Rheumatism.  One volume octavo, 226
  pages.
ELLIS (BENJAMIN), M.D.—The Medical Formulary; being a Collection of Prescriptions,
  derived from the writings and practice of many of the most eminent physicians of America
  and Europe.  Together with the usual Dietetic Preparations and Antidotes for Poisons.
  To which is added an Appendix on the Endermic use of Medicines, and on the use of Ether
  and Chloroform.  The whole  accompanied with  a few  brief Pharmaceutic  and Medical
  Observations. Tenth  edition, revised and much  extended, by  Robert  P. Thomas, M.D.,
  Professor of Materia Medica in the Philadelphia College of Pharmacy.  In one neat octavo
  volume of 296 pages.
ERTCHSEN (JOHN).—The  Science and Art of Surgery; being a Treatise on Surgical Inju-
  ries, Diseases, and Operations.  With Notes and Additions by the American editor.  Illus-
  trated with over 300 engravings on wood.  In one large and handsome octavo volume of
  nearly 900 closely printed pages.


FLINT (AUSTIN), M.D.—Physical Exploration and Diagnosis  of  Diseases affecting the
  Respiratory  Organs.  In one handsome octavo volume, extra cloth, of 636 pages.  (Now
  Ready.)


FFRGUSSON (WILLIAM), F.R. S.—A System of Practical Surgery.  Fourth American, from
  the third  and  enlarged  London edition.  In  one large and  beautifully printed  octavo
  volume of  about 700 pages, with 393 handsome illustrations.
FRICK (CHARLES), M.D.—Renal Affections: their Diagnosis and Pathology. With illus-
  trations.  One volume, royal 12mo., extra cloth.
FOWNES  (GEORGE), Ph. D. - Elementary Chemistry, Theoretical and  Practical.   With
  immerous Illustrations.  Edited, with Additions, by Robert Bridges, M  D.  In one large
  royal 12mo. volume, of over 550 pages, with 181 wood-cuts. Sheep, or extra cloth.



vTiKV FUND PRIZE ESSAYS ON CONSUMPTION.—By Edwin Lee and Edward Warren,
  M  D  In one neat octavo volume, extra cloth.   (Now Ready.) 
6           BLANCHARD & LEA'S MEDICAL PUBLICATIONS.
GRAHAM (THOMAS), F. R, S.—The Elements op Inorganic Chemistry. Including the Ap-
  plication of the Science to the Arts.  With numerous illustrations.  With Notes and Ad-
  ditions, by Robert Bridges, M.D., etc., etc.  Second American, from the second and enlarged
  London edition.  1 vol. 8vo., of over 800 pages, extra cloth.  $4.00.
Part I. (lately issued), large 8vo., 430 pages, 185 illustrations.  $1.50.
Part II. (now ready), t(  match, over 400 pages.  $2.50.
GROSS (SAMUEL D.), M. D.—A Practical Treatise on the Diseases, Injuries, and Malfor-
  mations of the Urinary Bladder, the Prostate Gland, and the Urethra.   Second edition,
  revised and much enlarged, with 184 illustrations.  In one very large and handsome octavo
  volume, of over 900 pages, extra cloth or leather.  (Just Issued.)
                                      ______                                      1
GROSS (SAMUEL D.), M.D.—A Practical Treatise on Foreign Bodies in the Air-Passages
  In one handsome octavo volume, with illustrations.
GROSS (SAMUEL D.), M. D. — Elements of Pathologic\l Anatomy ; illustrated with three
  hundred and fifty wood-cuts.  Third and revised edition.  In one large octavo volume, of
  over 900 pages, leather.
GROSS (SAMUEL D.), M.D.—A System of Surgery; Diagnostic, Pathological, Therapeutic,
  and Operative.  With very numerous engravings on wood.  (Preparing.)
OlUGE (GOTTLIEB), M.D.—An Atlas of Pathological Histology. Translated, with Notes
  and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Penn-
  sylvania.  In one volume, very large imperial quarto, with 320 figures, plain and colored,
  on twelve copper-plates.
GRIFFITH (ROBERT E.), M. D.—A Universal Formulary, containing the methods of Pre-
  paring and Administering Officinal and other Medicines.  The whole adapted to Physicians
  and Pharmaceutists.  Second edition, thoroughly revised, with  numerous Additions, by
  Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Phar-
  macy.  In one large and handsome octavo volume of over 600 pages, double columns.
GRIFFITH (ROBERT E.), M.D. — Medical Botany; or, a Description of all the more im-
  portant Plants used in Medicine, and of their properties, Uses, and Modes of Administra-
  tion.  In one large octavo volume of  704  pages, handsomely printed, with nearly 350
  illustrations on wood.
GARDNER (D. PEREIRA), M.D.—Medical Chemistry, for the use of Students and the Pro-
  fession :  being a Manual of the Science, with its  Applications to Toxicology, Physiology,
  Therapeutics, Hygiene, &c.  In one handsome royal 12mo. volume, with illustrations.
HARRISON (JOHN), M. D. — An Essay towards a Correct Theory op the Nervous System.
  In one octavo volume, 292 pages.
HUGHES (H. M.), M. D. — A Clinical Introduction to the Practice of Auscultation, and
  other Modes of Physical Diagnosis, in Diseases of the Lungs and Heart.  Second American
  from the second and improved London edition.  In one royal 12mo. volume.
HORNER (WILLIAM E.), M. D. — Special Anatomy and Histology.  Eighth edition.   Ex-
  tensively revised and  modified.  In two large octavo volumes, of more than 1000 pages,
  handsomely printed, with over 300 illustrations.
HOBLYN (RICHARD D.), A. M.—A Dictionary of the Terms used in Medicine and the Col-
  lateral Sciences.  Second and improved American edition.  Revised, with numerous Ad-
  ditions, from the second London edition, by Isaac Hays, M. D., &c.  In one large royal
  12mo. volume, of over 500 pages, double columns.  (Now Ready.)
HABERSHON (S. O.), M. D.—Pathological and Practical Observations on Diseases op the
  Alimentary Canal, OEsophagus, Stomach, Ccecum, and  Intestines.  With illustrations on
  wcod. In one handsome octavo volume.
  *** Publishing in the "Medical News and Library" for 1858. 
BLANCHARD & LEA'S MEDICAL PUBLICATIONS.           7
HAMILTON (FRANK II.)—A Treatise on Fractures and Dislocations.  In one handsome
  octavo volume.  With numerous illustrations,  (rrevarina.)
HOLLAND (SIR HENRY), M. D.—Medical Notes and Reflections.  From the third London
  edition. In one handsome octavo volume, c.ttra cloth, of about 500 pages.  (Just Issued.)
JONES (T. WHARTON), F. R. S.—The Principles and Practice of Ophthalmic Medicine and
  Surgery.  Second American, from the second and revised English edition.  With Additions
  by Edward Hartshorne, M. D.  In one very neat volume, large royal 12mo., of 500 pages,
  with 110 illustrations.


JONES (C. HANDFIELD), F. R. S., AND  EDWARD H. SIEVEKING, M. D. - A Manual op
  Pathological Anatomy.  With 397 engravings on wood.  In one handsome volume, octavo,
  of nearly 750 pages, leather.  (Lately Issued.)
KIRKES (WILLIAM  SENHOUSE), M. D., AND JAMES PAGET, F. R.S. —A Manual op
  Physiology.  Third American, from the third  and improved London  edition.  With 200
  illustrations.  In one large and handsome royal 12mo. volume.  586 pages.  (Now Ready.)
KNAPP (F.), Pn. D.—Technology; or, Chemistry applied to the Arts and to Manufactures.
  Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas
  Richardson.  First American edition, with Notes and Additions, by Professor Walter R.
  Johnson.  In two handsome octavo volumes, printed and illustrated in the highest style
  of art, with about 500 wood-engravings.
LEIIMANN  (G. C). — Physiological Chemistry.  Translated from  the second edition by
  George E.  Day, M.D.  Edited by R. E. Rogers, M.D.  With illustrations selected from
  Funkc's Atlas of Physiological Chemistry, and an Appendix of Plates.  Complete in two
  handsome  octavo volumes, extra cloth, containing 1200 pages.  With nearly 200 illustra
  tions.  (Just Issued.)

LEIIMANN  (G. C.). —Manual op Chemical Physiology. Translated from the German, with
  Notes and Additions, by J. C. Morris, M. D. With an introductory Essay  on  Vital Force,
  by Samuel Jackson, M. D.  In one handsome octavo volume, extra cloth, of 336 pages.
  With numerous illustrations.
LA  ROCHE (R.), M. D— Pneumonia; its Supposed Connection, Pathological and Etiological,
  with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of
  Malaria.  In one handsome octavo volume, extra cloth, of 500 pages.
LA ROCHE  (R), M. D— Yellow Fever,considered in its Historical, Pathological, Etiological,
  and Therapeutical  Relations.   Including a Sketch of the Disease as it has occurred in
  Philadelphia from 1699 to 1854, with an Examination of the Connections between it and
  the Fevers known under the same name in other Parts of Temperate, as well as in Tropical
  Regions.  In two large and handsome octavo volumes, of nearly 1500 pages, extra cloth.
  (Just Issued.)


LAWRENCE (W.), F. R.S.—A Treatise on Diseases op the Eye.  A new edition,  edited,
  with numerous Additions, and 243  illustrations, by Isaac Hays, M.D Surgeon to Wills'
  HospUaTetc  In one very large and handsome octavo volume of 950 pages, strongly
  bound in leather, with raised bands.


rTTDTOW n  L) M D.-A Manual of Examinations upon Anatomy, Physiology, Surgery,
  Practice of Medicine, Obstetrics.  Materia  Medica  Chemistry,  I'/iarmacy, and  Ihera-
  plutIcs  To which is added, a Medical Formulary.  Third edition, thoroughly revised and
  Sy extended and enlarged.  With 370 illustrations  In one large and handsome royal
  12mo. volume, leather, of over 800 pages. (Just Issued.)


r  xvnnnK fTTTOM\ = )  M D.—LECTURES ON THE PRINCIPLES AND METHODS OF MEDICAL  OBSEK-
  vTtion and Research. ' in one very neat royal 12mo. volume, extra cloth.  (Just Issued.) 
0           BLANCHARD  A LEA'S MEDICAL  PUBLICATIONS.
LA iXftMAND (MA—Tar. Causes. Symptoms, and Treatment of Spermatorrhea.  Translated
  at.a edited by Henry J. McDougal.  In one volume, octavo, of ^>2U pages.  Second Ame-
  rican edition.
LARDNER (DIONYSIUS), D. C. L. — Handbooks  op  Natural  Philosophy  and Astronomy.
  Revised, with numerous Additions, by the American editor.  The whole complete in three
  volumes, 12mo., of about 2000 large pages, with over 1000 figures on steel and wood.
NORLAND (W. W.), M. D.—Diseases op the Urinary Organs; a Compendium of their Diag-
  nosis, Pathology, and Treatment. With Illustrations.  In one large and handsome octavo
  volume, of about 600 pages, extra cloth.  (Now Ready, Oct., 1858.)
MEIGS (CHARLES D.), M.D.—Woman: her Diseases and their Remedies.  A Series of Lec-
  tures to his Class.  Third and improved edition.  In one large and beautifully-printed
  octavo volume.
MEIGS (CHARLES  D.), M.D. — Obstetrics:  the Science  and the Art.  Second edition,
  revised and improved.  With 131 illustrations.  In one beautifully-printed octavo volume,
  of 752 large pages.
MEIGS (CHARLES D.), M.D. — A Treatise on Acute and Chronic Diseases' of the Neck of
  the Uverus.  With numerous plates, drawn and colored from nature, in the highest style
  of art.  In one handsome octavo volume, extra cloth.
MEIGS (CHARLES D.), M.D.— On the Nature, Signs, and Treatment of Childbed Fever,
  in a Series of Letters addressed to the Students of his Class.  In one handsome octavo
  volume, extra cloth, of 365 pages.
MILLER (JAMES), F. R. S. E.—Principles of Surgery.  Fourth American, from the third
  and revised Edinburgh edition.  In one large and very beautiful volume of 700 pages, with
  240 exquisite illustrations on wood.
MILLER (JAMES), F. R. S. E.—The Practice of Surgery. Fourth American, from the third
  Edinburgh edition.  Edited, with Additions.  Illustrated by 364 engravings on wood.  In
  one large octavo volume of over 700 pages.
MALGAIGNE (J. F.). — Operative  Surgery, based on Normal and Pathological Anatomy.
  Translated from the French, by Frederick Brittan, A. B., M. D.  With numerous illustra-
  tions on wood.  In one handsome octavo volume of nearly 600 pages.
M0HR (FRANCIS), Ph. D., AND REDWOOD (THEOPHILUS).—Practical Pharmacy. Com-
  prising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and
  Laboratory.  Edited, with extensive Additions, by Prof. William  Procter, of the Philadel-
  phia College of Pharmacy.  In one handsomely-printed octavo volume, of 570 pages, with
i  over 500 engravings on wood.
llACLISE (JOSEPH).—Surgical Anatomy. Forming one volume, very large imperial quarto.
i  With sixty-eight large and splendid Plates, drawn in the best style, and beautifully colored.
j  Containing 190 Figures, many of them the  size of life.  Together with copious and expla-
I  natory letter-press.  Strongly and handsomely bound in extra cloth,  being one of the
  cheapest and best executed Surgical works as yet issued in this country.
            Copies can be sent by mail, in five parts, done up in stout covers.
MILLER (HENRY), M. D. —Principles and Practice op Obstetrics; including the Treat-
  ment of Chronic Inflammation of the Cervix  and Body of the Uterus, considered as a fre-
  quent Cause of Abortion.  With  about 100 engravings on wood.  In one very handsesie
  -.ctavo volume of over 600 pages.  (Now Ready.) 
BLANCHARD & LEA'S MEDICAL PUBLICATIONS.          t
2^   tc^k  (W.F.), M.D., Ac —An Exposition of the Signs and Symptoms op Preg-
nancy,  w ith some other Papers on Subjects connected with Midwifery.  From the second
and enlarged English edition. With two exquisite coloured plates and numerous wood-
cuts. In one very handsome octavo volume, extra cloth, of nearly 600 pa^es.
  Av     SJ0? )' S£-E"— A DlSPENSATORY AND THERAPEUTICAL REMEMBRANCER.  Comprising
  the entire lists of Materia Medica, with every Practical Formula contained in the three
  British Pharmacopoeias. In one 12mo. volume, extra cloth, of over 300 large pages.


MACKENZIE (W.), M. D. — A Practical Treatise on Diseases and Injuries op the Eye.  To
  which is prefixed an Anatomical Introduction, by T. Wharton Jones. From the fourth
  revised and enlarged London edition.  With Notes  and Additions by Addinell Hewson,
  M. D.  In one very large and handsome octavo volume, with  numerous wood-cuts and
  plates. 1028 pages, leather, raised bands.  (Just Issued.)

NEILL  (JOHN),  M. D., AND FRANCIS GURNEY SMITH, M. D.—An Analytical  Compen-
  dium of me Various Branches of Medical Science; for the Use  and Examination of Stu-
  dents.  Second edition, revised and improved. In one very large and handsomely printed
  royal 12mo. volume of over 1000 pages, with 350 illustrations on wood.  Strongly bound
  in leather, with raised bands.
NEILL (JOHN), M. D. —Outlines of the Nerves. 1 vol. 8vo., with handsome plates.  Out-
  lines of the Veins and Lymphatics, 1 vol. 8vo., handsome colored plates.
NELIGAN  (J. MOORE), M.D. — Atlas op Cutaneous Diseases.   In  one beautiful  quarto
  volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate
  representations of disease.  (Now Ready.)

NELIGAN (J. MOORE), M. D. —A Practical Treatise on Diseases op the Skin. In one neat
  royal 12mo. volume, of 334 pages.

OWEN (PROF. R.) —On the Different Forms of the Skeleton. One royal 12mo. volume,
  with numerous illustrations.
PARKER (LANGSTON).—The Modern Treatment of Syphilitic Diseases, both primary and
  Secondary; comprising the Treatment of Constitutional and Confirmed Syphilis, by a safe
  and successful method. With numerous Cases, FormulEe, and Clinical Observations.
  From the third and entirely rewritten London edition.  In one neat octavo volume.

PEREIRA  (JONATHAN), M.D.— The Elements of Materia Medica and Therapeutics.
  Third American edition, enlarged and improved by the  author; including Notices of most
  of the Medical Substances in use in the civilized world, and forming an Encyclopedia of
  Materia Medica.  Edited, with Additions, by Joseph Carson, M. D., Professor of Materia
  Medica and Pharmacy in the University of Pennsylvania.  In two very large octavo vo-
  lumes of 2100 pages, on  small type, with over 450 illustrations.  (Now Complete.)

PARRTSH (EDWARD).—An Introduction to Practical Pharmacy.  Designed as a Text-book
  for thP Stndent and as  a Guide for the Physician and Pharmaceutist.  With many For-
  mula a^ Pre^ripUoSL In one handsome octavo volume, extra cloth, of 550 pages, with
  243 illustrations.

PWASFLEE  CE R ), M.D.-Human Histology, in its Applications to Physiology and General
  Pathology.  With 434 illustrations.  In one handsome  octavo volume.  (Now Ready.)


PIRRIE (WILLIAM)^^^^^


  illustrations.______

             , ^r. i xmra n\ \T T> _TW PRINCIPLES AND PRACTICE OP OBSTETRIC MEDICINE
RAMSBOTIIAM (FRANCIS II.), "-J™^^   A new and enlarged edition, tho-
  and Surgery, in reference to the Process of Partu       y  ^      M R fa ^ ^
  roughly revised by the  author.   > itn Aoaiu     £trong]y bound in leather, with raised

  vA?a^^*uXJ™Z&^^™™}J«-mt>in tbe text'0M,tataing
  to aU near* 20<^1 large and beautiful figufcs.  (Just IssuM.)

„TrnV ,KT)WARD) M. D.-ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES.  In CD8
  ^^ro^™  volume, extra cloth, of about 250 pages.  (Just Issueil.) 
10         BLANCHARD <fc LEA'S  MEDICAL PUBLICATIONS.
RICORD (P.), M.D.—Illustrations of Syphilitic Disease.  Translated from the French, by
  Thomas F. Betton, M.D.  With the addition of a History of Syphilis, and a complete Bibli
  ography and Formulary of Remedies, collated and arranged by Paul B. Goddard, M.D.
  With fifty large quarto plates,  comprising 117 beautifully colored illustrations.  In one
  large and handsome quarto volume.
RICORD (P.), M.D.—A Treatise on the Venereal Disease.  By John Hunter, F.E.S. With
  copious Additions, by Ph. Ricord,  M.D.  Edited, with Notes,  by Freeman J. Bumstead,
  M. D.  In one handsome octavo volume, with plates.
RICORD (P.), M. D.—Letters on Syphilis, addressed to the Chief Editor of the Union Medi-
  cale.  With  an Introduction, by Amedee Latour.  Translated by W. P. Lattimore, M. D.
  In one neat  octavo volume.
ROKITANSKY (CARL).—A Manual of Pathological Anatomy. Translated from the Ger-
  man by W. E. Swaine, Edward Sieveking, M.D., C. H. Moore, and George E. Day, M.D.
  Complete, four volumes bound in two, extra cloth, of about 1200 pages.  (Just Issued.)
RIGBY (EDWARD), M. D.—A System of Midwifery. With Notes and Additional Illustra-
  tions.  Second American edition.  One volume octavo, 422 pages.
ROYLE (J. FORBES), M.D.—Materia Medica and Therapeutics; including the Preparations
  of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States.  With
  many new Medicines.  Edited by Joseph Carson, M.D., Professor of Materia Medica and
  Pharmacy  in the University of Pennsylvania.  With ninety-eight illustrations. In one
  large octavo volume of about 700 pages.
SKEY (FREDERICK C), F. R. S.—Operative Surgery.  In one very handsome octavo volume
  of over 650 pages, with about 100 wood-cuts.
SHARPEY (WILLIAM), M.D., JONES QUAIN, M. D., AND RICHARD QUAIN, F.R. S., etc.—
  Human Anatomy.  Revised, with Notes and Additions, by Joseph Leidy, M. D.  Complete
  in two large octavo volumes, of about 1300 pages.  Beautifully illustrated with over 500
  engravings on wood.
SMITH (HENRY H.), M.D., AND WILLIAM E. HORNER, M.D.—An  Anatomical  Atlas
  illustrative of the Structure of the Human Body.  In one volume, large imperial octavo,
  with about 650 beautiful figures.
SMITH (HENRY H.), M.D.—Minor Surgery; or, Hints  on the Every-day Duties of the
  Surgeon.  With 247 illustrations. Third and enlarged edition.  In one handsome royal
  12mo. volume of 456 pages
SARGENT (F. W.), M.D.—On Bandaging and other Operations op Minor Surgery.  Second
  edition, enlarged.  In one handsome royal 12mo. volume, of nearly 400 pages, with 182
  illustrations. (Just Issued.)
ETILLlS (ALFRED), M.D.—Principles of Therapeutics.  In one handsome volume.   (Pre-
 paring!)  •
BIMON (JOHN), F.R.S.—General Pathology, as conducive to the Establishment of Rational
  Principles for the Prevention and Cure of Disease.  A Course of Lectures delivered at St.
  Thomas's Hospital during the Summer Session of 1850.  In one neat octavo volume.
SMITH (W. TYLER), M. D.—On Parturition, and the Principles and Practice of Obstetrics
  In one large duodecimo volume of 400 pages.
SMITH (W. TYLER), M.D.—The Pathology and Treatment of Leucorrhcea.  With nume-
  rous illustrations.  In one very handsome octavo volume, extra cloth, of about 250 pages. 
BLANCHARD & LEA'S MEDICAL PUBLICATIONS.
11
  wuT (^MUEL), F.R.S.-The  Human Brain;  its Structure, Physiology, and Diseases
  £inn ? Dcfnptlu°n °,f the T>pical Forms of the Brain in th* Animal Kingdom  Fromth«
  Second and much enlarged London edition.  In one octavo volume, with 120 TTOod™ute.



SCHOOLER  (FRIEDRICH) Ph.D.-The Book op Nature; an Elementary Introduction to
  the Sciences of Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and
  Physiology. First American edition, with a Glossary and 'other Additions  and In^roY*
  n!^v\i^wteW^Td/ng|1Shedlt+\°?-, Translated f™i*  the sixth German edition, by
  }-l %  \ dI-   ' FC-S-' *,°- Jn-.0^ thlck volurae, small octavo, of about 700 pages, with
  Rem!lu)stratlons on "1T00d-  Sultable for the higher schools  and private student!  (Now



TAYLOR (ALFRED S.), M. D  F. R. S.-Medical Jurisprudence.  Fourth American, from the
  fifth and  improved English edition.  With Notes and References  to American Decisions
  by Edward Hartshorne, M. D.  In one large octavo volume of 700 pages.  (Now Ready.)
TAYLOR (ALFRED S.), M.D.—On Poisons, in Relation to Medical Jurisprudence and Mfdi-
  cine.  Edited, with Notes and Additions, by R. E.  Grifllth, M.D.  In  one large octavo
  volume of 688 pages.
TANNER (T. H.). M. D.—A Manual of Clinical Medicine and Physical Diagnosis. To which
  is added, The Code of Ethics of the American Medical Association.  In one neat volume,
  small 12mo., extra cloth, or flexible. (Just Issued.)
TODD (R. B.), M. D.—Clinical Lectures on Certain Diseases op the Urinary Organs, and
  on Dropsies.   In one octavo volume, extra cloth, of about 300 pages. (Just Issued.)
TODD (R. B.), M. D., AND WILLIAM BOWMAN, F. R. S.—Physiological Anatomy and Phy-
  siology op Man.  Now complete, in one very large  and handsome octavo volume, of 926
  pages, with 300 illustrations on wood.  (Just Issued,  1857.)
  J5®°" Gentlemen who have the earlier portions of this work can still complete their copies,
    if early application be made.
WATSON  (THOMAS), M. D., Ac. — Lectures on the  principles and  Practice of physic.
  A new American, from the last  London edition.  Revised, with Additions, by D. Francis
  Condie, M. D., author of a " Treatise on the Diseases of Cbildreu," &c.  In one imperial
  octavo volume, of over 1200 large pages, with nearly 200 cuts, strongly bound, with raised
  bands. (Now Ready.)
WALSHE  (W. H.), M. D.—Diseases of the Heart, Lungs, and Appendages; their Symptoms
  and Treatment.  In one handsome volume, large royal 12mo., 512 pages.
What to Observe at the Bedside and after Death, in Medical Cases.  Published under the
  authority of the London Society for Medical Observation.  In one very hand-some volume,
  royal 12mo., extra cloth.
WILDE (W. R.).—Aural Surgery, and the Nature and Treatment of Diseases of the Ear.
  In one handsome octavo volume, with illustrations.
WHITEHEAD (JAMES), F.R.C.S., Ac —The Causes and Treatment of Abortion and Ste-
  rility- being the Result of an Extended Practical Inquiry into the Physiological and
  Morbid Conditions of the Uterus.  Second American Edition. In  one volume, octavo, 368
WEST  (CHARLES), M.D.—Lectures on the Diseases of Infancx and Childhood.  Second
  American, from the second and enlarged London edition.  In one volume, octavo, of nearly
  500 pages- 
1?          BLANCHARD  & LEA'S MEDICAL PUBLICATIONS.


WEST (CHARLES), M. D.-An Inquiry into the Pathological Importance of Ulceba«ono^
  the Os Uteri.  Being the Croonian Lectures for the year 1854.  In one neat octavo vo-
  lume, extra cloth.


WEST  (CHARLES), M.D.-Lectures on the  Diseases of Women.  In two Parts.  Pari,1.,
  Diseases of the Uterus.  Part II., Diseases  of the Ovaries, &c, the Bladder, Vagina, and
  External Organs.  Complete in one octavo volume of 500 pages, extra cJotn.  (iVow Ready.)
Part II. now ready, 1 vol., 8vo., extra cloth, of about 200 pages.  Sold separate, $1.
WILSON (ERASMUS), M.D., F.R.S.—A System of Human Anatomy, General and Special.
  Fourth American, from the last English edition.  Edited by W. H. Gobrecht, M. D.  With
  400 illustrations.  Beautifully printed, in one large octavo volume, of over  600 pages.
  (Now Ready.)


WILSON (ERASMUS), M. D., F. R. S.—The Dissector's Manual; Practical and Surgical Ana-
  tomy.  Third American, from the last revised and enlarged English edition.  Modified and
  re-arranged  by William Hunt, M. D.  In one large and handsome royal  12mo. volume,
  leather, of 582 pages, with 154 illustrations.
WILSON (ERASMUS), M. D., F. R. S.—On Diseases of the Skin. Fourth American, from the
  Fourth London edition.  In one neat octavo volume, of 650 pages, extra cloth.
Also, An Atlas of Plates, of which twelve are exquisitely coloured, illustrating "Wilson oh
  the Skin."   8vo., cloth.  (Now Ready.)
WILSON (ERASMUS), M. D., F. R. S.—On Constitutional and Hereditary Syphtlusj and on
  Syphilitic Eruptions.  In one small octavo volume, beautifully printed, with four exqui-
  site coloured plates, presenting more than thirty varieties of Syphilitic Eruptions.
WILSON (ERASMUS), M. D., F. R. S.—Healthy Skin;  a Treatise on the Management of the
  Skin and Hair in Relation to Health.  Second American, from the fourth and improved
  London edition.   In one handsome royal 12mo. volume, extra cloth, with numerous illus-
  trations.  Copies may also be had in paper covers, for mailing, price 75 cents.
WILLIAMS (C. J. B.), M.D., F.R.S.—Principles of Medicine; comprising General Pathology
  and Therapeutics, and a brief General View of Etiology, Nosology, Semeiology, Diagnosis,
  Prognosis, and Hygienics.  Fifth American, from a new and enlarged London edition.
  In one octavo volume, of 500 pages.
YOU ATT (WILLIAM), V. S. —The Horse.  A new edition, with  numerous illustrations;
  together with a General History of the  Horse; a Dissertation on the American Trotting
  Horse; how Trained and Jockeyed; an account of his Remarkable Performances; and an
  Essay on the Ass and the Mule.  By J. S. Skinner, formerly Assistant Postmaster-General,
  and Editor of the Turf Register.  One large octavo voluma.


yOUATT (WILLIAM), V. S.—TnE Doo.  Edited by E. J. Lewis, M. D.  With numerous and
  beautiful illustrations. In one very handsome volume, crown Svo., crimson cloth gilt.
                     illustrate   €nteh%nt.

  Blanchard & Lea have now ready a detailed Catalogue of their publications, in Medical and
other Sciences, with Specimens of the Wood-engravings, Notices of the Press, Ac. Ac  forming
a pamphlet of eighty large octavo pages. It has been prepared without regard to'exDensn
and may be considered as one of the handsomest specimens of printing as yet executed in
this country.  Copies will be sent free, by post, on receipt of nine cents in postage stamos
  Detailed Catalogues of their publications, Miscellaneous,  Educational, Medical Ac.  fur.
nished gratis, on application. 
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