_?mi-: .f?".':<:W • : ;:.,^%7;V: ,;di:^AV.'- '^x .' 51 . ';'■.- .•W.s-,''. v,.' :. || Surgeon General's Office ^ & N< OOOQOOGQ^g- r*Z*L_....$ < CUTAIEOUS MEDICINE. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE AND DISEASES OF THE SKIN. BY ERASMUS WILSON, F.R.S. LTBEART. .> NEW YORK: WILLIAM WOOD & CO., 61 WALKER STREET. 1865. V,'147s R. CRAIGHEAD, PRINTER, 81, 83, and 85 Centre Strttt, N. Y. PREFACE. In publishing a Student's Book of Cutaneous Medicine and Diseases of the Skin, we believe that we are supplying a want in Medical Literature. Great Britain has many scientific treatises devoted to the subject; some original, the greater part founded on the works of the French or of the Germans; and an abundance of translations from foreign authors ; but we have no elementary book that the Student can call his own ; no Class-book; no book founded on British Cutaneous Medicine, that is, upon Cutaneous Diseases such as they occur in this country, and exist amongst us at the present day, and treated upon principles which long experience has shown to be the best suited to the instincts and peculiarities of the British mode of thought, and of the British medical constitution. We have endeavoured to produce such a book, and we have taken as the groundwork of our teachings, the experience of many years conscientiously devoted to the discovery of the soundest viewrs of the subject, and the soundest principles. The first progress made of late times in Cutaneous Medicine, was that instituted by our countrymen, Willan and Bateman ; and we are proud to reflect, that the system of Willan has been for many years the standard classification of Diseases of the Skin throughout Europe and America. It is the Linnaean system applied to diseases of the skin ; and no higher praise can be accorded to it. But, just as the Linnaean system called into being the system of Jussieu, and we are left in doubt which most to admire, Linnaeus or Jussieu; the Willanean system suggested the construction of a natural classification, similar to that applied by Jussieu to the vege- table kingdom. A natural classification is the want of the hour ; and a natural classification, if it could be attained, would, without doubt, be an important gain to our science. Alibert invented such a classification ; Hardy has revived it; but we must 11 PREFACE. confess that neither the classification of Alibert nor that of Hardy is such as to meet with our approval. In the present work we have framed a classification, founded on the clinical history of diseases of the skin ; we have arranged these diseases into twenty-two groups ; and we believe, that for all prac- tical purposes, the arrangement will be found sufficiently simple and comprehensive. Should it be adopted in future years as a classification worthy of being remembered, of being made the basis of study of these diseases, it may, very truly, be represented as a clinical classification. We have not left out of view the necessity for the student of being thoroughly acquainted with the skin in health, previously to undertaking the study of its diseases ; and we have preceded our chapters devoted to the twenty-two groups of diseases, by one on the Anatomy and Physiology of the Skin; and we have followed the chapter on Anatomy and Physiology, by one on the Pathology of the Skin, and the classification of its diseases. Our aim has been to simplify, to endeavour to restore to General Medicine, a department of much interest and importance, and, by furnishing the Student with a clear view of these diseases, to remove them from the narrow sphere of Specialism to the wider and nobler field of Catholic Medicine. Henrietta Street, Cavendish Square, November 1, 1864. CONTENTS. CHAPTER I. Anatomy and Physiology of the Skin ... 13 CHAPTER II. Pathology of the Skin; and Classification of Diseases of the Skin ... c, ol CHAPTER HI. I. Eczematous Affections..... g* eczema . psoriasis pityriasis lichen . ...........67 ...........94 .94 ...........95 strophulus....... 99 impetigo....... 205 scabies ••..... ino gutta rosacea........ U7 CHAPTER IV. II. Erythematous Affections...... 122 erythema......... « 123 erysipelas......... 128 urticaria.......... I37 roseola.......... 143 CHAPTER V. III. Bullous Aefections ......... 151 herpes........... 152 miliaria...........Ig3 pemphigus...........165 iv CONTENTS. CHAPTER VI. PAGB IV. Furuncular Affections........172 ECTHYMA...........172 furunculus . ..........177 hordeolum........... 181 ANTHRAX...........181 CHAPTER VII. V. Nervous Affections . ........189 hyperesthesia..........189 anesthesia........... 190 pruritus...........190 PRURIGO...........193 CHAPTER VIII. VI. Vascular Affections.........197 NEVUS VASCULOSUS.........197 HYPERTROPHIA VENARUM........199 CHAPTER IX. VII. Hemodyscrasic Affections.......204 PURPURA . ......204 CHAPTER X. VIII. Developmental and Nutritive Affections .... 213 xeroderma ........... 214 ichthyosis...........215 sauriosis...........218 cachexia cutis..........219 CHAPTER XI. IX. Hypertrophic and Atrophic Affections.....221 nevus hvpertrophicus........221 ecthyma...........223 VERRUGA........., 225 CONTENTS. V . , PAGE clavus...... 228 KE^s............231 buonemia tropica...... 236 atrophia cutis ....... 238 CHAPTER Xn. X. Alphous Affections.........241 alphos.......... 241 CHAPTER XHI. XI. Strumous Affections ........ 252 scrofuloderma..........252 lupus............253 CHAPTER XIV. XII. Carcinomatous Affections.......261 carcinoma cutis . .......261 CHAPTER XV. XIII. Zymotic Affections........265 rubeola...........270 scarlatina...........277 variola...........290 varicella...........301 vaccinia...........306 CHAPTER XVI. XIV. Syphilitic Affections........312 syphtloderma..........313 CHAPTER XVII. XV. Leprous Affections.........326 lepra vel elephantiasis........326 morph(ea...........339 VI CONTENTS. CHAPTER XVIII. PAGE XVI. Pigmentary Affections........344 melanopathia..........344 xanthopathia..........351 LENTIGO...........352 chloasma...........353 cyanopathia..........356 leucopathia..........357 CHAPTER XIX. XVII. Phytodermic Affections.......361 nosophyta...........361 CHAPTER XX. XVIII. Ungual Affections.........365 degeneratio unguium.........367 onychia...........367 CHAPTER XXI. XIX. Affections of the Hair System ...... 370 hirsuties...........370 alopecia...........372 canities...........378 fragilitas crinium.........379 trichosis vel tinea or ringworm......380 morbi sebacei..........386 FAVUS............386 KERION OR SCALLED HEAD........390 SYCOSIS............393 CHAPTER XXH. XX. Affections of the Sebiparous System.....398 epidermic hypertrophy........398 epithelial hypertrophy........398 cancroid hypertrophy........399 stearriiqsa...........4c0 CONTENTS. vii PAGE asteotodes....... HyQ allosteotodes ..... 400 comedones ...... 4.0 tumores sebipari....... ^qg tumores encystici...... 406 tubercula sebacea...... 4q9 ACNE............4iq CHAPTER XXHI. XXI. Affections of the Sudoriparous System .... 413 IDROSIS VEL EPHIDROSIS..... 413 ANIDROSIS........ 41g osmidrosis......' 41g OHROMIDROSIS....... 417 HEMIDROSIS......... 417 CHAPTER XXIV. XXII. Traumatic Affections...... 4ig malis seu maliasmus........ 4ig ambustio......... t 425 gelatio ......... 429 APPENDIX. hebra's classification of cutaneous diseases . . . . ■ 433 alphabetical index..........439 I ARRANGEMENT OF SUBJECT. The arrangement of subject adopted in this book is termed clinical, in consequence of being founded on the most salient and striking characters of each disease, whether those characters be in their nature pathological, etiological, or physiological. Taking this as our basis of arrangement, we are enabled to classify all the dis- eases of the Skin at present known into twenty-two groups, as follows : 1. Eczematous affections, 2. Erythematous affections, 3. Bullous affections, 4. furuncular affections, 5. Nervous affections, 6. Vascular affections, 7. Hjemic affections, 8. Developmental and nutritive affections, 9. Hypertrophic and atrophic affections, 10. Alphous affections, 11. Strumous affections, 12. Carcinomatous affections, 13. Zymotic affections, 14. Syphilitic affections, 15. Leprous affections, 16. Pigmentary affections, 17. Phytodermic affections, 18. Ungual affections, 19. Diseases of the hair system, 20. Diseases of the sebiparous system, 21. Diseases of the sudoriparous system, 22. Traumatic affections. X ARRANGEMENT OF SUBJECT. If we examine this classification a little more closely, we shall find that certain of these groups are composed of diseases of the GENERAL STRUCTURE OF THE DERMA ; for example,— 1. Eczematous affections, 2. Erythematous affections, 3. Bullous affections, 4. Furuncular affections. Secondly, there follows a group of diseases of the special structure of the derma, taking in the nerves, the vessels, and the contents of the vessels; thus,— 5. Nervous affections, 6. Vascular affections, 7. Haemic affections. A third group comprehends the morbid changes involved in the development, nutrition, and growth of the derma; namely, diseases of development, nutrition, and growth, as follows: 8. Developmental and nutritive affections, 9. Hypertrophic and atrophic affections. A fourth group is founded on the presence of an existing dis- position or tendency to the particular disease; in a word, diathesis ; the diathetic diseases being,— 10. Alphous affections, 11. Strumous affections, 12. Carcinomatous affections. A fifth group is founded on the dependence of the disease upon a blood-poison; diseases resulting from blood-poisons ; and the members of that group may be stated as follows:— 13. Zymotic affections, 14. Syphilitic affections, 15 Leprous affections. ARRANGEMENT OF SUBJECT. XI A sixth group is composed of diseases of the epidermis ; for example:— 16. Pigmentary affections, 17. Phytodermic affections, 18. Ungual affections. A seventh group includes the diseases of the follicles of the skin and their dependencies, namely:— 19. Diseases of the hair system, 20. Diseases of the sebiparous system, 21. Diseases of the sudoriparous system. While as an eighth group, but one very indispensable, there remain only diseases induced by injury, namely :— 22. Traumatic affections. Thus it may be shown that, although the individual groups are numerous, they admit of being collected under eight heads, as follows:— 1. Diseases of the general structure of the derma, 2. Diseases of the special structure of the derma, 3. Diseases of development, nutrition, and growth, 4. Diseases of diathesis, 5. Diseases resulting from blood-poison, 6. Diseases of the epidermis, 7. Diseases of the follicular apparatus, 8. Diseases induced by injury. And the eight groups might, upon a physiological basis, be further reduced to half that number, as follows :— 1. Dermal affections, 2. Epidermal affections, 3. Follicular affections, 4. Traumatic affections. xii ARRANGEMENT OF SUBJECT. The dermal affections, including,— a. Diseases of general structure, b. Diseases of special structure, c. Diseases of function, d. Diseases of diathesis, e. Diseases of blood-poisoning. It may be objected critically that there is a want of unity in the clinical classification ; but as unity of arrangement of cutane- ous diseases is neither possible nor practical, the sooner that objec- tion be waived the better; and the classification is none the worse in our opinion because four of the eight groups are founded on a physiological, three on an etiological, and one on a pathological basis. In the class-room or by the bedside we believe that the clinical classification will not be found wanting in its adaptability to the wants of the student and of the practitioner. THE STUDENTS BOOK OF CUTANEOUS MEDICINE. CHAPTER I. ANATOMY AND PHYSIOLOGY OF THE SKIN. The Skin is the external surface-membrane of the body, to which it serves as a covering or integument, and being common to the whole body, is sometimes called the common integument. It is firm, pliant, and elastic, adapting itself naturally to all the movements of the trunk and members, and resisting pressure and injury coming from without. Hippocrates regarded it not only as an investing and a protective covering, but also as a ligament serving to bind together the body and limbs; and Plato, pursuing the same idea, compares it in its operation to a fisherman's net. If we follow the skin from point to point, over the whole sur- face of the body, we shall find it to present some variety of character and appearance. On the head it is smooth and pale, and spotted with the numerous openings or pores which give passage to the hair. On the face it is coarse in texture, furnish- ed with hair in certain situations, more vascular than elsewhere; and at the borders of the eyelids, of the nares, and of the mouth, it exhibits the transition of the external surface-membrane into the internal surface-membrane, or mucous membrane. On the back of the neck and of the trunk, and on the outer side of the limbs, it is remarkable for its thickness and density, as compared with the front of the neck and body, and the inner side and flex- ures of the limbs. In the former situation it is more or less smooth ; in the latter, and particularly at the joints, it is marked by folds and wrinkles, which represent the lines of motion of 14 CUTANEOUS MEDICINE. the skin. In the flexures of the joints, as of the armpits, the elbows, the wrists, the groins, the ham, the fingers and toes, and in the interdigital spaces, the integument is thin, and deeply marked by the lines of motion ; while on the convexities of the joints the skin is thick and dense, and also strongly marked with the lines of motion. In certain parts of the trunk, as upon the shoulders, on the breast, in the armpits, on the mons pubis, on the scrotum, and on the perineum, there is hair, more strongly developed in the male fchan in the female. Certain parts of the skin, as of the scalp, the chin, and the pubes, are remarkable for the accumulation of subcutaneous fat; while in other parts, as of the eyelids, the penis, and the scrotum, the fat is altogether wanting. Finally, a striking modification of the skin, adapted to resistance and protection, is met with in the palm of the hand, the sole of the foot, and the ungueal extremities of the fingers and toes; in the latter situation constituting the nails. In Structure, the skin presents two layers,—the derma, or true skin (cutis vera, corium), and the epidermis, or scarf-skin, or cuticle. The derma is connected with the parts underneath by means of cellular or areolar tissue. This is its deep surface ; while, by its superficial surface, it is in close contact with the epidermis. The connection of the deep surface of the derma with the parts beneath is, in some situations, dense and close, as on the cranium, on the nose and ear, on the upper lip and chin, on the pubes and perineum. In other situations it is remark- able for its looseness, as on the eyelids, the penis and scrotum, and the convexities of joints. Where the-adhesion is close, the areas of the subcutaneous tissue are small, and filled with fat; where it is loose, the areas are large, and moistened by a serous fluid, which, under slight irritation, is apt to accumulate and give rise to oedema. The presence of loose cellular tissue, as a connecting medium of the derma, permits of a greater freedom of motion between the skin and the parts beneath, as occurs at the elbows and knees. Daniel Turner* quotes a curious case of looseness of the integument, which, as it may serve to impress > • * Daniel Turner was the author of a curious and interesting volume, entitled " A Treatise of Diseases incident to the Skin." published in 1712. As an old English author we have reason to be proud of his work; and we may remember him, moreover, by the association of his name with a very valuable remedy in cutaneous medicine,—namely, Turner's cerate, at present known as the ceratum calaminae. anatomy of the skin. 15 upon the mind of the student the physiological fact, we will here transcribe:— "Of the wonderful dilatability of this part I have heard nothing that, comes up to that in the young Spaniard Meekrin takes notice of, who, in the hospital at Amsterdam, showed him- self to Van Horn, Silvius, Piso, and other learned physicians, taking up with his left hand the skin of his right shoulder and pap, and bringing the same up to his mouth. Again, he would draw the skin of his chin down to his breast, like a beard, and presently put it upwards to the top of his head, hiding both his eyes therewith. After which, the same would return, orderly and equally, to its proper place, lying smooth, as in any other person. After the same manner, the skin of the right knee and leg he would pull, either upwards or downwards, for half a yard's length ; whilst—which was yet more remarkable—the skin of his left side would not admit of any such expansion." The Derma is composed chiefly of white fibrous tissue, which, in its deepest part, forms a strong network, with oval or circu- lar meshes; the strands or fasciculi of the network being of about half the breadth of the areas. In proceeding outwards, we find that the network becomes finer, both in respect of the fasciculi and of the meshes; and, as we approach the surface, assumes the character of a fine but dense spongy tissue. The large meshes of the under surface of the derma are filled with fatty tissue, and give passage to the blood-vessels which supply the surface of the skin, and also to the lymphatic vessels and cutaneous nerves; and the finer areas of the superficial portion support the ultimate ramifications of the vessels and nerves, together with the capillary and nervous plexuses. Looking to the constituents of its structure,- the derma is a compound tissue, consisting of a framework of white fibrous tis- sue, with which muscular tissue, and yellow elastic tissue, are intermingled; and supporting and maintaining in its areolar spaces, fatty tissue, together with arteries, veins, capillary ves- sels, lymphatics, nerves, and, as we shall see further on, hair-fol- licles and glands. The average thickness of the derma is half a line; on the back of the trunk it measures in depth about three- fourths of a line; while on the heel the measurement is more than a line, and sometimes as much as a line and a half. Viewing the two surfaces of the derma,—the superficial and 16 CUTANEOUS medicine. the deep, there appears a very manifest difference between them; the latter a coarse and firm network of white fasciculi and large open spaces, with a scanty supply of vessels and nerves; the former a fine spongy tissue, seeming to be made up almost wholly of capillary vessels and minute nerves, and bristling on the surface with minute, semi-transparent, finger-like papillas. This difference between its deeper and its superficial part has caused a distinction to be made between them, which is express- ed by the terms pars reticularis and pars papillaris, or papillary layer. The distinction is arbitrary; there is no line of division such as would constitute different layers. In structure the pars reticularis may be said to merge imperceptibly into the pars papillaris, and it is only on the actual surface that the papillary element becomes apparent. *As we ascend into the atmosphere, which is, as it were, the derma of the earth, we find it, though dense below, becoming more and more rarefied as we rise to the superficial regions; so is it also with the derma of the body. Composed of coarse tis- sues below, these tissues become finer and finer in the upper stratum, until in the most superficial of all we find, as the chief element, an imperfect areolar tissue, of the simplest composition; and finally, on the actual surface, a thin, transparent, varnish- like lamella, an organic membrane without structure of any kind, —the boundary, or limitary, or basement membrane. Elabora tion and structure seem to be exhausted; and a structureless formative element is all that remains to finish the work. The Papillary layer of the derma, or pars papillaris, is developed on its surface into minute papillas, some of which are simple, and others compound. The former are, some cylindrical, some conical, and some clavate and slightly flattened, while the compound papillas divide at the summit into two or three, and sometimes four or five simple papillas, and form a kind of tuft. In structure, a papilla is composed of an imperfectly developed areolar tissue (partly homogeneous and nucleated, and partly fibrillated), surrounded and inclosed by the structureless limitary lamella, and contains in its centre either a capillary loop or a nerve-fibre ; in the former case constituting a vascular papilla, in the latter a nervous papilla. "We are thus made aware of the existence of two kinds of papillas ; one intended for secretion, the other for sensation : and the presence of a capillary loop and a ANATOMY OF THE SKIN. 17 nervous fibril in the same papilla is an exceptional occurrence, 1 ' and would seem, when it happens, to result from the accidental fusion of two papillae of opposite kinds. The nervous papilla is further distinguished by the presence in its centre of an oval or fir-cone-shaped body, called by Wagner corpusculum tactus, and by Kolliker, from its position in the axis of the papilla, axile corpuscle; and Huxley has shown that this conical mass is a bulbous development of the termination of the neurilemma, in and upon which the nerve-fibre, after splitting up into several ultimate fibrils, is seen to end. On the general surface of the body, the papillas are disposed irregularly, and have a considerable interval between them. On certain parts, as on the nipple, the glans penis, glans clitoridis, and labia minora, they are more numerous, and are assembled more closely; while on the palm of the hand, the sole of the foot, and the bed of the nail, they are most abundant, and are collected into linear groups, which give the appearance of the fine lines characteristic of those surfaces. Weber estimated that in a square line of the palm of the hand there were 81 compound papillas, and between 150 and 200 simple ones. The papillas differ also in size; being short on the surface generally, longer on the palm and sole, and on the nipple, where they measure from -^g- to ^o of a line; and longest on the matrix of the nail, where they reach yV of a line, and on the labia majora. The longest papillas are one-half or two-thirds longer than the breadth of their base; whereas the shorter ones are as broad as, and in some instances broader than, their length. Yellow elastic tissue is mingled in considerable quantity with white fibrous tissue in the structure of the derma. It forms a network by the interlacement of its fibres, and is met with even in the papillas. Smooth or unstriped muscular fibre also forms an abundant element of its structure, in certain parts constitut- ing a muscular layer of considerable thickness, as in the instance of the dartos of the scrotum, in the areola of the nipple, and around the nipple itself; and in the superficial portion of the derma it is collected into minute fasciculi, the muscles of the hair-follicles, arrectores pili (Eylandt), which arise in the upper stratum of the corium, immediately beneath the limitary lamella, and proceed obliquely inwards to the follicles, into the outer layer of which they are inserted, just below the sebiparous gland. 2 18 CUTANEOUS MEDICINE. Dr. Lister has shown that the arrector pili is situated on the slop- ing side of the hair-follicle, and is therefore placed in the best position for protruding and erecting the hair. The presence of muscular structure in the corium explains to us the intrinsic movements of the skin; the erection of the pores in cutis anseri- na; the contractile action of the scrotum and areola mammae; ' the erection of the nipple; the hard bleached tubercles and wheals of urticaria, and probably, the crawling, and creeping sensations experienced in the skin. The term spasmus periphericus is not inaptly applied to this action. The Epidermis, or cuticle, lies in contact with the limitary surface of the derma, following all its irregularities, forming hollows for the reception of the papillas, descending into the hair- follicles and sudoriparous and sebiparous glands, and lining them throughout under the name of epithelium. Along the edges of the eyelids, at the margin of the apertures of the nares and mouth, and at the border of the external apertures of the meatus urinarius, the vulva, and the anus, the epidermis is continuous with the epithelium of the mucous membrane. The epidermis is a dense, horny, but flexible layer, secreted by the derma, and deposited upon it as a defensive covering, screen- ing it from violence by its toughness, and checking the evapora- tion of the fluids of the derma by its density. It varies con- siderably in thickness; being thin on the eyelids, on the penis and scrotum, on the back of the hands and feet, in the flexures of the joints, in the interdigital spaces, on the scalp, on the front and sides of the. trunk, on the front and inside of the arms, and on the back and inside of lower extremities; thick, on the back of the trunk and upper extremities and front of the legs, and thickest of all on the palm of the hands and sole of the feet; while, at the extremities of the fingers and toes, it is so far modi- fied in thickness and in density as to constitute the nails. As the derma is arbitrarily divided into a pars reticularis and pars papillaris, so, also, is the epidermis divided into a pars cornea, or horny portion, and a pars mucosa, or soft portion, the rete mucosum. The rete mucosum is the deep and most recently formed layer of the epidermis, that which lies in contact with the limitary layer of the corium, which is in course of develop- ment and elaboration, and, consequently, the immature part; while the horny layer is the fully-developed and mature portion ANATOMY OF THE SKIN. 19 of the epidermis, and becomes more and more dense and horny as it approaches the surface. The division of the two portions is purely arbitrary; the deepest two or three layers being regarded as rete mucosum, while the superimposed more nume- rous and condensed layers constitute the epidermis proper. In structure, the epidermis is composed of cells—of nucleated cells—which, in the rete mucosum, are polygonal in form, about g-sVo of an inch in diameter, contain a large and well defined nucleus, cell-contents, and pigment-granules, and are surrounded by a thin and imperfect cell-membrane; but which, in the horny portion, are transformed into flattened scales about four times larger than the mucous cells (^ of an inch), the nucleus of the scales having become invisible, from transparency, and the pig- ment-granules pale from chemical alteration ; the chief constitu- ent of the whilome cell being the cell-membrane, now converted, by compression and evaporation, into a thin and horny scale. The changes accompanying the maturity of the cell, and the conversion of the mucous cell into a horny lamella or scale, take place immediately above the rete mucosum. The transformation is completed long before the mid-thickness of the epidermis is reached, and, as we perceive, the change is not simply one of growth, but also of chemical transformation and metamorphosis. The cuticle is not produced as a horny albuminous mem- brane, but becomes so as the result of nutrition and develop- ment. The constant formation and growth of the epidermis, by means of the rete mucosum, is the contrivance by which a uni- form thickness of the cuticle is maintained. This layer is con- tinually undergoing wear and destruction at the surface, and the loss is as continually compensated by the regular process of formation taking place underneath. Where the formative pro- cess is most active, there the greatest thickness of epidermis is attained, as on the palm of the hands and sole of the feet. In these situations the papillas are most abundant, and the relation subsisting between the papillas and the cuticle is shown by the small ridges which represent the rows of papillas which clothe the surface. The removal of the superficial layers of the epi- dermis is also favoured by the construction of the tissue,—name- ly, of minute scales, which, as soon as they become loosened, fall away from the surface in the form of a fine dust; and, when 20 CUTANEOUS MEDICINE. their connections are softened by water, are washed away with every ablution. The rete mucosum has another claim to our interest, in being the seat of colour of the skin,—of that colour which distinguish- es the races of mankind, and has its extremes in the European and the Ethiopian. The colouring matter, or pigment, consists of minute granules, which are identical in appearance with other granules constituting the chief element of the epidermic cell, and differ from the latter only in possessing an amber or reddish- brown colour, and, possibly, a. different chemical composition. These granules, taken separately, are globular in form, and have a diameter of 2 0 j 6 0 of an inch. They are collected in greatest number around the nucleus, and are intermingled with paler granules in the cavity of the cell. The depth of colour which they occasion is due to their aggregation ; for alone, their tint of colour is very slight, even in the rete mucosum of the negro skin. As the rete mucosum is merely the young epidermis, and as it is quite evident that the epidermis is much less deeply tinted than the rete mucosum, and, in the negro, is almost white as com- pared with the latter, we are led to infer, as is probably the fact, that the pigment-granules undergo some chemical alteration or metamorphosis in the progress of development of the epidermic cell, which destroys the colouring principle, and that the develop- ment of the cell takes place in some measure at the expense of this organic element. But there is a further explanation of the whiteness of the epidermis,—namely, in the large produc- tion of albumen, which forms the chief bulk of the epidermic scale, and which would tend still further to subdue the colour of any pigment that might remain in the desiccated scale. A simple inspection of the epidermis shows another peculiar- ity of much interest,—namely, the delineation of the surface by a number of lines. These lines are furrows, and a part of the apparatus of motion of the skin, consisting of coarser lines, cor- responding with the movements of the joints, and finer lines, corresponding with the intrinsic movements of the skin. The lines of motion are transverse and divergent on the flexures and transverse and convergent on the convex side of the joints and leave between them triangular and polygonal-shaped areas • those on the side of the flexures being narrow and elongated ANATOMY OF THE NAILS. 21 and those on the convexities being broader and shorter. The lings of motion of the skin itself originate at the apertures of the hair-follicles and glands,—the pores, and radiate as from a centre, for the most part impinging upon other pores, and some- times on other radiating lines. From the larger pores there pro- ceed from six to ten radiating lines, which usually run to adjoin- ing pores, and form a number of triangular areas; and within these areas are smaller pores, with an equal number of finer lines, forming smaller areas. On the shoulder of a child five years of age we counted, in a square inch of skin, sixty large and six hundred small pores. The radiating lines from these pores were arranged in the manner just described, and had the appearance of a delicate mosaic pattern. The large pores were the centres of as many polygonal wheels, with large triangular areas; and within these areas were arranged the smaller wheels and smaller triangular spaces. The pore is therefore a centre, to which the apices of six or eight triangles converge, and the drawing toge- ther of these points serves to produce erection of the pore. On the scalp, the lines of motion form curves between the hairs, and the areas are elliptical in figure. The Nails are a modification of the epidermis adapted to the special purpose of protecting the extremities of the fingers and toes. They are situated over the expanded ends of the last phalanges, bedded upon the corium, and overlapped at their base and at the sides by a fold of the skin, constituting the late- ral and posterior wall of the nail. The nail is convex on the outer surface and concave beneath, and has two extremities,— one free ; the other, the root of the nail, being overlapped by the posterior wall to the extent of about two lines. The furrow or follicle which is so formed is the vallecula unguis. On a closer inspection, the nail presents some diversity of colour; it is pale towards the root, the pale portion being bounded in front by a semilunar line, and thence called lunula. It is pink throughout the rest of its extent, excepting at the free extremity, where it is detached from the corium. Moreover, the nail is marked by longitudinal lines, some of which are pale and others pink: the former correspond with horny longitudinal laminas situated on its under surface; the latter with plaits of the corium interposed between the horny laminse. When the nail is detached, the surface of the corium upon 22 CUTANEOUS MEDICINE. which it lies embedded—the matrix of the nail—is brought into view. The matrix is continuous at the sides with the corium of the lateral walls of the nail, and at the bottom of the vallecula with the surface of the posterior wall. . The whole of this sur- face is highly vascular; that of the posterior wall is smooth, as is also a narrow strip at the line of separation of the free extrem- ity of the nail; but the rest of the matrix is clothed with ridges and lamellated plaits or folds of the corium. • At the bottom of the vallecula are several transverse ridges corresponding with the border of the root of the nail; and these ridges are studded with papillae of considerable size. The lunula is furnished with longitudinal ridges, and beyond the semilunar line the ridges of the lunula expand into the longitudinal plaits or folds of the body of the nail. These longitudinal plaits are deepest in the middle, and shallower on each side and towards the free extrem- ity of the nail, and in the latter situation are broken 'up into irregularly-formed and elongated papillas ; finally, beyond the broken ends of the lamellae is situated the smooth strip which forms a transition to the derma of the tip of the finger or toe. The longitudinal lamellae are studded with papillas along their free borders, and these vascular fringes are the cause of the pink longitudinal lines seen through the transparent nail; while the general vascularity of the lamellae produces the deep tint of pink which distinguishes the body of the nail from that which covers the lunula. The horny nail is continuous at each side with the epidermis of the lateral wall; at the free extremity, the under surface of the nail is blended with the epidermis, which seems, as it- were, to bifurcate at this point; and along the edge of the posterior wall, the epidermis becomes attenuated, and is spread out and lost on the surface of the nail. The nail is .thicker in the middle, where the vascular lamellae of the corium are the largest, than at the sides, where they are smaller, or over the lunula, where they are absent altogether; the thickness of the nail being proportionate to the extent and activity of the vascular surface. The root of the nail is thin and soft, while the free extremity is three times thicker than the root, and has a tendency to follow in its growth the curve of the tip of the finger. The growth of the nail is effected by the synchronous forma- tion of cells upon its whole under surface, and along the border ANATOMY OF THE NAILS. 23 of the root. The cells added to its lower surface give thickness to the nail ; those deposited along the free border of its root press it forwards and give it length; and the formative action constantly in operation produces the movement forward which constitutes what is generally understood by the growth of the nails. If, for one moment, we reflect upon this process, we shall see the reason of the occasional abnormal growth of the nail, sometimes in length, but more frequently in thickness. There are few structures in anatomy more interesting than those concerned in the adhesion of the nail to its matrix, an adhesion so firm, and yet so slight as to permit of the movement of the entire nafl forwards on its bed, and by the agency of a power apparently so unequal to such an effort,—a row of minute cells, deriving their strength simply from their nutritive power and growth. We remember in our student days, wondering over the results of a similar power occurring in the vegetable world. A huge millstone lay upon the ground near the edge of a copse; a young and slender sapling, like a playful child, raised its feathery head through the hole in the middle of the stone; a few years slid by, and then the sapling was a sturdy plant that had grown to the full size of the hole in the mill- stone; it was no longer play ; the plant was inconvenienced by the pressure of the heavy mass. What would it do ? A few more years saw the remarkable issue; the plant upheaved the massive stone from the eajfth. and bore it, as it were upon its shoulders, into the air :* such is the gigantic force of nutritive power, or rather of nutritive life. The adhesion of the nail to the matrix is mainly effected by the intervention of the horny laminas of the nail and vascular plaits of the corium; they lie side by side in mutual embrace; the horny laminae, sixty or seventy in number, are secreted by the plaits of the corium, and grow by the superaddition of new cells generated by the vascu- lar structure. When left to themselves, the nails attain a certain length, and then, it is said, they cease to grow, and, like the hair, are probably shed: but the habit of paring them, common in European countries, maintains a perpetual growth. Viewed by the side of the epidermis, with which it is ana- logous, the nail will be seen to be harder, denser, whiter, less flexible, and more transparent, more nearly approaching in its characters to horn, and in fact presenting a higher condition 24 CUTANEOUS MEDICINE. of development. Like epidermis, it consists of a mucous and a horny layer; the mucous layer being composed of nucleated cells containing pigment, and in their progress towards the surface being converted into scales. The scales, however, are denser and thicker, and the nucleus firmer and larger, so as to be visible in the perfected scale, while in those of the epidermis it is with difficulty discoverable. A section of the nail shows a laminated texture like that of the epidermis, but more trans- parent and dense, together with pigment-granules which are commonly arranged in streaks. There is a difference also in regard to chemical composition ; the greater density of nail being due to the presence of a larger proportion of phosphate of lime. Thus it would appear, that in proportion to the energy of nutri- tive metamorphosis, the cell of the mucous layer is altered in its nature and composition, and is changed from a soft opaque mass, consisting of nucleus, pigment-granules, and embryonic covering, into a dense, transparent, colourless scale, without pigment or visible nucleus; in other words, that the opaque matter, the pigment matter, and the nuclear matter, are spent and exhausted in the elaboration and perfection of the horny- albuminous scale. A French physician, Dr. Beau, has made some interesting observations on the rate of growth of the nail, haying reference to its relation with the duration of illness. He finds that the nails of the hands grow four times «s fast as those of the feet, the former increasing in length at the rate of one millimetre (i of a line) a week; the latter requiring four weeks for the same amount of growth. Then, assuming the thumb nail to measure from root to free extremity eight lines, or twenty millimetres, it would take twenty weeks, or five months, to attain its complete growth ; while the nail of the great toe, measuring nine lines and a half, or twenty-four millimetres, would require for complete growth ninety-six weeks, or very nearly two years. Next, Dr. Beau remarks, that during illness, although growth in length con- tinues as usual, the material of growth is furnished less activelv, and, consequently, the nail formed during this period will be thinner than during the period of health ; and the deficiency of horny matter may be distinguished on the surface of the nail in the form of a transverse groove. If the invasion of the illness be sudden, the anterior wall of the groove will be abrupt, and vice PORES AND FOLLICLES. 25 versd; and if the return to health be rapid or gradual, the posterior border of the groove will present a corresponding incline. On these data, Dr. Beau suggests the possibility of determining the period of occurrence of an illness, and also its duration. For example, a groove crossing the thumb nail transversely, its ante- rior border measuring eight millimetres from the extremity of the root, or five from the margin of the posterior wall, would indicate an illness that commenced eight weeks before; and the breadth of the groove being two millimetres, the illness will have existed for two weeks. After five months, the groove will have become obliterated, and the thumb nail no longer an index of the malady. Then, however, the nail of the great toe may be appealed to, and will continue to be a guide for ninety-six weeks. At five months the groove has advanced only five millimetres from the edge of the root, and is just becoming apparent beyond the mar- gin of the posterior wall, while the groove itself is only half a millimetre in breadth. Dr. Beau prefers the thumb nail and great toe nail for this observation, because the appearances are more marked in them than in the rest of the nails. The development of the nail is first apparent at the completion of the third month of embryonic life. At this period the seat of the future nail is covered by ordinary epidermis, and the first preparations for the nail are shown in the gradual elevation of the boundary-wall of the matrix. A month later there exists a thin horny plate, adherent to the matrix, and covered by the epidermis. This plate progressively increases in thickness during the fifth and sixth months, and during the seventh month moves forward in length. At the sixth or seventh month after birth the foetal nail is shed, and a new permanent one takes its place. Pores and Follicles.—The skin is perforated in every part of its surface by numberless openings, which are called pores. The pores are the openings of cylindrical tubes which penetrate for a certain depth into the derma, and sometimes extend beyond its limits; and these tubes taken collectively present a surface organized like that of the skin and of an equal and possibly superior extent. We may, therefore, look upon the skin as offering for our study two surfaces,—an apparent and external surface, and a concealed or follicular surface. The cylindrical tubes are the follicles of the skin, and they are divisible into 26 CUTANEOUS MEDICINE. three groups,—hair-follicles, sebiparous follicles and glands, and sudoriparous glands. These three groups of tubules have a similar organization; they are highly vascular, have a limitary surface-layer like that of the external superficies of the corium, and are lined by a structure analogous to the epidermis; namely, the epithelium. Where they are prolonged deeply, beyond the limits of the reticular portion of the corium, they are followed to their ter- mination by a vascular plexus, by an external fibrous mem- brane derived from the corium, and are equally lined within by epithelium. Moreover, the hair-follicles are provided with minute muscles, which possess the power of erecting the hairs and protruding the summit of the follicles, and thus of giving rise to that appearance which is termed cutis auserina, or goose- skin. The hair-follicle is a simple cylinder, traversing the skin obliquely, and terminating sometimes in the substance of the corium, and sometimes, after piercing the latter, in the subcuta- neous cellular tissue, surrounded by adipose cells. From the bottom or fundus of the follicle a papilla arises, upon which the hair is formed, while the circumference of the hair is moulded by the inner wall of the follicle. The sudoriparous follicle is also a simple cylinder, more slender than the hair-follicle, but longer, also penetrating the epidermis and derma, and taking its course inwards to the larger areolar spaces of the corium, and sometimes as far as the subcutaneous areolar tissue. Having reached one or other of these situations, and surrounded by adi- pose tissue, it coils upon itself and forms a small oblong or glo- bular mass,—the sudoriparous gland. Occasionally, the follicle has been seen to bifurcate previously to rolling itself up into the coil of the gland. The sebiparous follicle is shorter than both the preceding, often dilated into the form of a pouch ; pursues a similar course through the skin, but to a lesser depth, and di- vides into branches, which, by their subdivisions and aggrega- tions, constitute a compound gland often of considerable size. The sebiparous gland in different situations presents every degree of complexity of structure', from a simple follicular pouch, to the compound structure of the mammary gland, which is nothing more than an aggregation of large sebiparous glands, modified to suit the special purpose of producing, like the sebi- ANATOMY OF THE HAIR. 27 parous gland, an oily secretion, namely, the milk. Another peculiarity of the sebiparous gland is, that it very commonly opens into a hair-follicle, particularly into the follicles of the larger hairs. Hair-follicles and Hairs.—Every part of the skin is fur- nished with hair-follicles, and organized for the production of hairs, with the exception of the palm of the hands, sole of the feet, and that occupied by the nails. But there are situations in which -also they are commonly absent; for example, the upper eyelids, the penis, and the last joints of the fingers and toes. The hairs present much variety in length and thickness, and admit of being divided into four groups ; namely, long and fine, long and stiff, short and stiff, and short and fine. The long and fine hairs are represented by the hairs of the head, which in a state of health are long, fine, and silky. The long and stiff hairs are typified by those of the beard, of the whiskers, of the axillae, of the pubes, and, in hirsute persons, the hair of the scapular region of the back, the hair of the chest, of the abdomen, and of the limbs. The short and stiff hairs are the hairs of the eye- brows, the eyelashes, the vibrissas narium, and the hairs of the meatus auditorius. The short and fine hairs include the finest hairs, the down or lanugo of infants and }roung persons, the fine hairs of the so-called hairless parts of the body, and the less fine hairs of the trunk and limbs; to which may be added the hairs of the mucous glands of the conjunctiva, the carunculas lachrymales. ' The hair is a sexual character in all animals, and is not less so in man. In both sexes it is met with pretty equally developed in certain situations; for example, on the head, the eyebrows, the edges of the eyelids, the armpits, and the pubes. But in the adult male the distribution of the hair is more extensive; for example, the beard and whiskers, on the chest, the shoulders, and thoracic portion of the back, and the abdomen; and the limbs are generally more hairy in the male than in the female. There are often a few scattered long hairs around the areola of the female; and the disposition of the hair at the pubes *is a characteristic feature of the sexes ; in the female being limited to the upper boundary of the mons Veneris, but in the male ascending in a pyramidal figure to the umbilicus. It has been inferred from the robust character of the male as compared with 28 CUTANEOUS MEDICINE. the female, the stiffness and rigidit}" of the beard and whiskers, and the general hirsuteness of the trunk and limbs, that the hair of the head was coarser in men than in women, and this idea is favoured by the habit of wearing the hair long in the one and short in the other sex. But our observations, founded on numerous microscopic measurements, are opposed to this view, and we h»ve found that the hair of the head is coarser in woman than in man. The moment of life when the body is the most universally hairy, is that of birth; it is then covered with a short fine hair or down, the lanugo,—a temporary crop, which is afterwards shed, and gives place to the permanent hair. This is the period when the arrangement of the hair upon the surface of the body may be most conveniently studied, and when some curious pheno- mena may be ascertained. The oblique position of the hair with reference to the surface is the first point to attract attention ; and in the next place it will be discovered that there is a law of arrangement of the hair, as well as of development and growth, and that the direction or set of the hair is always the same. Thus on the summit of the head is a kind of central point or corona, from which the hair radiates on all sides, with a gentle curve, sweeping from right to left behind, and from left to right in front: this constitutes the natural lay or set of the hair of the head. On the forehead, the hair sweeps from the middle line in a gentle curve to the right and to the left, forms the upper half of the eyebrow, and descends over the temple to become the central part of the whisker. At the inner angle of the eye is a facial centre of radiation, from which a vertical line of divergence descends by the side of the nose and mouth to the lower jaw, and then curves forward to the under-part of the chin. From the facial centre at the angle of the eye, the hair sweeps round with a gentle curve and is distributed over the root of the nose, along the eyelids, and over the upper part ' of the face. The rays that pass upwards and inwards meet the corresponding rays from the opposite side, and form a crest; while those that ascend meet the currents from the line of diver- gence of the forehead, and produce a second crest, which, when strongly developed, connects the eyebrows across the root of the nose. The rays that sweep across the upper eyelid form the lower half of the eyebrow, while those that pass along the lower ANATOMY OF THE HAIR. 29 eyelid are lost in the front of the whisker. From the vertical line of divergence, the currents sweep obliquely inwards and outwards, those that pass inwards clothing the side of the nose and constituting the outer and converging portion of the mus- tachio and of the beard; while those that pass outwards sweep over the cheek, and are lost in the whisker, in the middle line of the nape of the neck, and along the lower border of the jaw. The mustachio arises from the lip below the opening of the nares, and sweeps outwards; and along the margin of the central part of the lower lip another diverging stream sweeps outwards into the beard on either side. The direction of the hair upon the trunk of the body is gov- erned by a centre of radiation, situated in each axilla, and two lines of divergence, proceeding from each centre, one running forwards to the middle of the sternum, the other downwards along the flank, across the hip, and down the inner side of the thigh to the ham. The currents proceeding from these centres are directed inwards and upwards upon the chest and neck, to the line of the lower jaw, and across the side of the neck to the middle line of the back; inwards and downwards to the umbili- cus ; and from the lower half of the abdominal vertical line, inwards and upwards, also to the umbilicus. So that the umbi- licus becomes the centre of four converging currents, two from above and two from below. The currents that pass backwards from the axillary centre, and from the vertical line, sweep gently outwards and downwards to the middle line of the back. In the arm, the currents proceed from two lines of divergence; one, derived from the axillary centre, surrounds the upper part of the arm like a ring; the other takes its origin from this ring, and runs along the front of the arm in a pretty straight direc- tion, to the cleft between the thumb and forefinger on the back of the hand. From the upper border of the ring the hairs ascend to the shoulder, and sweep backwards to the middle line of the back ; from the lower. margin of the ring, and from the vertical line, they descend with a curve to the elbow; from the vertical line in the forearm, they sweep downwards in front and upwards behind, and also make their way to the elbow ; so that the elbow becomes a centre of convergence. And on the back of the hand, and of the fingers, the direction of the sweep is downwards and outwards, towards the outer border of the hand. 30 CUTANEOUS MEDICINE. The source of the currents on the lower extremity are two vertical lines of divergence; one being that which descends by the side of the abdomen, and, after crossing the hip, runs along the inner side of the thigh to the ham; the other, a line which begins at the hip and descends the outer side of the thigh, also to the ham; then passes along the outer side of the leg, and reaches the dorsum of the foot, terminating at the space between the great and second toe. The currents proceeding from these two lines pass downwards and inwards, towards the front of the thigh, and converge to the knee; those on the back of the thigh ascend towards the buttock and trunk. On the leg, where one line only exists, the diverging currents sweep around the limb and meet upon the shin; while on the foot they diverge with a sweep outwards and upwards, as on the back of the hand. The principal centres of radiation are that of the crown of the head, the inner angle of the eye, and the axilla. The principal lines of divergence are, that of the vertical centre of the forehead, the side of the nose, mouth, and chin, the pectoral line from the axillary centre, the abdominal and internal crural line, the arm- let line, the humeral line, and the external crural line. The principal centres of convergence are, that at the root of the nose, on the sternum, the umbilicus, the elbow, the buttock, and the knee; and the principal lines of convergence, the ridge of the nose, the submaxillary line, the median line of the nape of the neck and trunk of the body, and the front of the thigh. A Hair, taken separately, consists of a shaft, a point, and a root. The point is conical, and blunt at the end; and in long hair is commonly removed artificially, either by cutting or by attrition; in which case the extremity is not unfrequently ragged, and sometimes split into several fibrous ends, and sometimes into a brush-like tuft. The shaft is more or less cylindrical, some- times oval or fabiform in its outline, and sometimes unequally flattened, and varying in figure in different parts of its length. The root is the part included within the follicle ; it is more uni- formly cylindrical and somewhat thicker than the shaft, and at the extremity is dilated into an oval mass, the bulb, which is from two to three times thicker than the shaft. Furthermore, the bulb is implanted on a papilla, which rises through the fundus of the follicle. It is apparent that the hair, in the course of its growth, varies ANATOMY OF THE HAIR. 31 in its figure and dimensions; that at first it is small and pointed; that the bulb is larger than the root; that the root is cylindrical and larger than the shaft; and that the shaft is smaller than the root, and loses its cylindrical figure; the change of figure and reduction of size both being due to the same circumstance, namely, the desiccation of the hair at its escape from the follicle, and the subsequent collapse of its walls. It is the flattening of the hair by 'this process that gives rise to waving and curly hair. Sometimes the collapse of the walls of the hair occasions the formation of longitudinal grooves, and sometimes the grooves or the flattening pursue a spiral course along the hair, and produce a shorter curl, like that of the hair of the Ethiopian. While accounting for the shape of the hair, we may glance for a moment at other of its qualities ; for example, its thickness, length, and quantity. According to our admeasurements, the average thickness of the hair of the head is 1-J-0- of an inch, somewhat thicker in the female than in the male, and somewhat finer in the child than in the adult. But the hairs of the same head do not all present the same thickness: some are coarser and some finer; and a difference of diameter is also met with at different points of the same hair. In reference to colour, flaxen hair is the finest, and black the coarsest; chestnut, red, dark brown, light brown, and white, occupying an intermediate posi- tion. In the hair of different regions of the body, the range of thickness is as follows:—beard, ishr] eyebrow, -g^-; breast, ^-g-; eyelashes,j)ubes, and whiskers, -g^-g-; head and thigh, ^J-g-; ax- illa, rhr; leg, -gfo; vibrissas auris, t^. The length of the hair varies considerably in different parts of the body. The finest hairs (downy hairs, lanugo) scarcely appear above the level of the skin, while the hairs of the beard and of the head are remarkable for their length. When left to its full growth, as it is in the female, the hair of the head attains a length of twenty inches to a yard; the latter being regarded as unusually long. The quantity of hair will depend upon the degree of proxi- mity of the hair-follicles. Jahn has given us an observation, from which it would appear that, comparing the hairs of differ- ent parts of the body with the head, those of the beard are -J- less numerous ; those of the pubes, \; forearm, TV; and outer border of the hand and front of the thigh, -^. With respect to 32 CUTANEOUS MEDICINE. the head, Whitof counted, on a square inch of the scalp, of black hairs, 588; chestnut, 648; and flaxen, 728. Having our attention drawn to the same point, we found, in a square inch of scalp of a young man of twenty-five, with black hair, the pores or openings of 744 follicles; and if we take the number of square inches presented by the scalp at 120, the number of pores would amount to 89,280. Now, if we suppose each pore to give exit to a single hair, the number of hairs would be as above —nearly 90,000; but as the pore is in reality the outlet of two or more follicles, we might, in a thick head of hair, have as many as 178,560, or nearly 200,000. Hence we may reasonably infer that the number in a head of average thickness of hair would amount to 120,000. In structure, a hair is composed of three parts: of a central part, or medulla; a fibrous part, which constitutes its chief thick- ness ; and an investing part, or cuticle. The medulla is a cellular structure, consisting of nucleated cells of an oval or globular shape, with the usual constituents of cells,—granules and flu- ids. The cells are filled with fluid only in the root of the hair; in the shaft it is lost by evaporation, and the cells are conse- quently found in a state of collapse, or are more or less exten- sively occupied with air. In this state they are sometimes de- scribed as aeriferous cells. It is the refraction of the light by the air contained in the cells of the medulla that gives to it its dark appearance when seen with the microscope. The medulla in some hairs occupies a space equal to one-third the diameter of the shaft; in others it is a mere streak; and in the* short and fine hairs is wanting altogether. The fibrous portion constitutes the chief bulk of the hair, is the seat of its colour, and bestows upon it its characteristic pro- perties ; for example, its toughness and elasticity. It is com- posed of fibres resulting from the metamorphosis of the cells of the papilla or pulp; and the colouring element is distributed through it in the form of dots and streaks. The dots are the pigment-granules, while larger dots result from the aggregation of these granules; but the blackest hair, when seen through the microscope, is found to contain a larger proportion of uncoloured than of coloured material. The pigment-granules in differently coloured hair present every shade of tint, from the amber of golden hair to the deep black of dark hair. ANATOMY OF THE HAIR. 33 The cuticle of the hair is transparent and homogeneous, and marked on the surface by transverse undulating lines. These transversely disposed lines are the edges of minute quadrangu- lar scales or plates, which are derived from the surface of the papilla pili, or pulp, and overlap each other in regular succes- sion, from the bulb to the apex of the hair. The presence of the transverse lines in the form of sharp ridges is detected by the fingers when a hair is drawn between them from the point towards the root; and they are the cause of the not uncommon phenomenon of hairs burying themselves in wounds, under the nails, and between the teeth and the gums. When the cuticle of the hair is examined at its junction with the bulb, it is found to present two layers, a deep and transparent layer, and the superficial and squamous layer just described. The researches of modern physiologists, and especially of Huxley, have shown an identity of design between the structure of a hair and that of a tooth. The medulla pili is analogous to the cavitas pulpae of the tooth; the fibrous structure of the one is the dentine of the other ; the cuticle of the hair represents the enamel of the tooth; and the squamous surface of the cuti- cle, the persistent capsule (Nasmyth) of the tooth. The follicle of the hair, or hair-sac, is identical in structure with the outer skin. It has a lining of epidermis or epithelium, which rests on the structureless limitary layer of the corium; and the limitary layer is supported by two fibrous layers; the inner fibrous layer having its fibres disposed transversely, the outer longitudinally. The outer fibrous layer forms the nidus for the distribution of the vessels and nerves of the follicle, and receives the insertion of the arrectores pili muscles. The epider- mal layer lying in contact with the root of the hair by its inner surface is called the root-sheath. The root-sheath is about as thick, and often thicker, than the diameter of the hair which it incloses, and is made up of several strata of cells. The deepest cells, corresponding with the rete mucosum, have a transverse arrangement in reference to the axis of the follicle,, while the superficial cells are longitudinal; those occupying the surface possessing nuclei (Huxley), and those placed between the deep and superficial stratum having no nuclei (Henle). The fundus of the hair-follicle, or hair-sac, is slightly dilated, and occupied by the papilla or pulp of the hair. The papilla is 3 34 CUTANEOUS MEDICINE. ovate in form, the base being upwards, and the apex downwards and blended with the subcutaneous tissues. It is analogous to a dermal papilla, but without vessels or nerves, and is surrounded with small globular nucleated cells, the formative elements of the future hairs. The nucleated cells are elongated by develop- ment and metamorphosed into the fibrous structure of the hair: the imperfectly metamorphosed cells of the fundus of the papilla constitute the medulla ; while the outermost layer of the papilla is converted into the cuticle of the hair. The hair grows by the production of new cells in the papilla ; the pressure onwards of these cells by successive formation behind, and the conver- sion of the cells the most in advance into fibres. When a hair is torn from its follicle, the newly-formed fibres are seen at its end in the form of a worn-out paint-brush: the nucleated cells remain behind. Often, when a hair is forcibly pulled out, a portion of the root-sheath is drawn with it, and remains about its end, sometimes forming an irregular mass, sometimes elon- gated to a point; but more frequently curved into the shape of a bulbous hook. It is not the root of the hair that is so turned round and bent, but only the root-sheath. Growth of the hair has been noted to be more active in youth than in advanced life ; in summer than in winter; by day than by night; in hair that is cut than in hair left to its natural growth ; and in hair that is cut frequently than in that which is cut rarely. In a young person of feeble constitution, recently shaved, we found the rate of growth of the hair of the head to be nearly half an inch in the course of a month. Berthold states the rate of growth of the hair in young females between the ages of 16 and 24 to be more than half an inch per month." He observed that the beard shaved every 12 hours grew at the rate of 5i to 12 inches in the course of a year; shaved every 24 hours, it grew at the rate of 5 to 7i inches ; and shaved every 36 hours, it grew only 4 to 6£ inches. Whitof calculated that the beard grew 6£ inches in the course of a year; and that in 80 years the length would amount to 27 feet. The development of hair takes place by the protrusion in- wards of the cells of the rete mucosum in the form of a bud • the bud is elongated by growth, and assumes the shape of the future follicle; a papilla rises from the fundus of the follicle, and very soon a separation is seen to have taken place between ANATOMY OF THE HAIR. 35 the cells of the centre and those of the periphery of the mass; the former have become dark from the production of pigment, and elongated into the form of a hair; have become, in fact, the hair and the inner root-slieath ; while the peripheral cells have assumed a transverse position, and constitute the outer root- sheath. As soon as the papilla is formed and has become active, the hair inclosed in the inner root-sheath is pressed upwards to the surface, the inner root-sheath opens, and the hair is liberated. This is the mode of development of Jlie deciduous hair of the foetus, the hair that is shed immediately after birth; but before the shedding takes place, the permanent hair is already in pro- gress of formation ; a bud is protruded from the fundus of the follicle of the deciduous hair, and follows a similar course of development to that already described. When the formative process is complete, the permanent hair pushes the deciduous hair before it in its growth, and eventually takes its place. In after-years, young hairs are no longer produced by this means, but grow from the papilla of the fundus of the follicle. The protrusion inwards of the little mass of cells of the rete mucosum in the early formation of the hair, carries before it the limitary layer of the corium, and also its fibrous tissue ; and these struc- tures, at a subsequent period, become the three layers of the hair-sac. The first stages in the development of hair—namely, the pro- trusion of the cells of the rete mucosum—are perceptible at the end of the third month of embryonic life ; visible hair is present at the middle of the fifth month ; and by the end of the sixth month, hair is apparent over the whole body, with the exception of the back of the fingers and toes, the nose, and the external ear. It shows itself first on the eyebrows, next on the upper lip, around the mouth, and on the head; and by the completion of the sixth month, the hair of the head is a quarter of an inch long; that of the eyebrows two lines; and the eyelashes one line. At birth, the child is covered with a thick down, the hairs being pale, without pigment, and without medulla. They are shed during the first year. In chemical composition, hair differs from epidermis and horn, and also from albumen; its chief constituents are a compound of protein and sulphur, fat, pigment, salts of iron, manganese, 36 CUTANEOUS MEDICINE. and silica. The quantity of ash is between one and two per cent. White hair contains besides phosphate of magnesia and * lime. Sudoriparous System.—The sudoriparous tubules and glands are distributed through the skin of every part of the body, with the exception of the concha and meatus of the ear, but are most remarkable for number and for size in the axilla ; in the areola of the mamma; at the base of the scrotum and labia majora, and in the palm of the hands and sole of the feet. The glands are globular or oblong in shape; of a reddish- yellow colour; and situated at about the middle depth of the corium, sometimes in the lower stratum of the pars reticularis and sometimes in the subcutaneous cellular tissue. In the axilla they measure from half a line to a line and a half in diameter; at the base of the scrotum y^ of an inch ; and in the palm of the hand about y^g- of an inch ; the average of their size being ^V of an inch. The sudoriparous gland is simply the small mass formed by the coil of the sudoriparous tubule; and issuing from the gland, the tubule ascends to open upon the surface of the epidermis. We therefore speak of it as consisting of two parts, the gland and the excretory duct; the entire length of the tubule compos- ing the two being about a quarter of an inch. In ascending through the corium, the excretory duct is more or less flexuous ; but in passing through the thick epidermis of the palm of the hand and the sole of the foot, it forms a spiral coil of remarkable regularity, and terminates on the epidermis, by an oblique and apparently a valvular aperture. On the general surface of the skin, the excretory ducts of the sudoriparous glands,—the sudoriferous ducts,—open without any regularity; in the axilla, several of the ducts terminate by a common aperture; while on the palm of the hand and the sole of the foot they open upon the ridges of papillas, and are disposed with great order, dividing the papillas into little clumps or groups. On the palmar surface of the hand and fingers these apertures are situated at about one-sixth of a line apart, and on the plantar surface of the foot their distance apart is somewhat more than the fourth of a line. In both situations they may be seen by the naked eye as small indentations crossing the ridges transversely. SUDORIPAROUS SYSTEM. 37 In structure, the sudoriparous tubulus consists of a lining of epithelium appertaining to the epidermis, and of a limitary layer and external fibrous coat derived from the corium. In the large sudoriparous glands, as in those of the axilla, the areola of the nipple, the base of the scrotum and labia majora, around the anus, and sometimes in those of the palm and sole, there is also found a layer of smooth muscle disposed longitudinally between the limitary membrane and the fibrous coat. The epithelium is composed of several layers of nucleated cells analogous to those of the rete mucosum, but has a different physiological destination in the smaller and in the larger glands. In the former it occu- pies about two-thirds of the area of the tubulus and performs the simple office of an epithelial membrane ; in the latter it fills the entire area of the tubulus, the peripheral layers alone per- forming the office of an epithelium, while the central portion constitutes the solid element of the secretion. When the adhe- sion of the epidermis to the derma is loosened by scalding a portion of skin or by incipient decomposition, the epithelial lining of the smaller ducts may be drawn out of the tubuli by raising the epidermis gently, and separating it from the corium. At the same time it will be observed that the entrance of the tubulus into the corium is surrounded by a cone of cuticle, which is common to all the cutaneous tubuli, but is very remark- able in the palm of the hand and sole of the foot. Besides the three or four coats of the tubulus already described, the sudoriparous gland is inclosed in a delicate network of capil- lary vessels, and is imbedded in cellular and adipose tissue. It is apparently unprovided with nerves. According to Krause, the sudoriparous glands in the axilla are so numerous as to form almost a continuous layer beneath the corium ; while those of the rest of the body he estimates to number 2,381,248; and their aggregate bulk, including those of the axilla, to be 39,653 cubic inches. In calculating the length of the sudoriparous tubuli of the whole body, taking the length of the single tubulus at a quarter of an inch, we arrived at the conclusion that the entire length would amount to nearly twenty- eight miles. In pursuing this calculation, we found the number of excretory pores in a square inch of the palm of the hand to be 3,528, and on the heel 2,268. The development of the sudoriparous tubulus has been ob- 38 CUTANEOUS MEDICINE. served by Kolliker in the foot of a foetus of the fifth month, and he concludes that the sudoriparous system is complete at birth. The process is similar to that already described as the mode of development of the hairs; a bud of rete mucosum grows into the corium, pressing before it the limitary membrane; by the sixth month the bud has become an elongated cylinder, and has reached the mid-depth of the derma; and by the end of the seventh month has traversed the entire thickness of the derma, and is curved at the end in preparation for the formation of the coil. While the embryo tubulus is progressing in growth, the central cells become softened and broken up, and.are in readi- ness for excretion, while the cells of the parietes constitute the epithelial lining of the tubulus. The secretion of the sudoriparous gland is water, holding in suspension protein, fat, pigment, and nitrogen; and in solution, chloride of sodium, hydrochlorate of ammonia, salts of lactic, butyric, carbonic, acetic, and formic acids, phosphate of lime, peroxide of iron; and when the kidneys perform their office imperfectly, urea, uric acid, and urates. It is saltish to the taste, and has an acid reaction. Sebiparous System.—The sebiparous system, destined to provide a fatty secretion for the lubrication of the surface of the skin, is distributed, with a few trifling exceptions, over every part of the body, and especially to the more exposed regions, as the nose; to parts where friction occurs, as the axillae and pudendum ; around the apertures of the body, as the eyelids and anus; and the parts provided with hair. It consists of follicles and glands, which are situated in the upper stratum of the corium, in close relation with the hair-follicles. They open for the most part into the hair-follicles; sometimes they terminate on the surface of the epidermis by a common opening with the follicles of the fine hairs; and occasionally, in association with the finest hairs, they receive the opening of the hair-follicle. The smallest sebiparous glands are found in connection with the coarser hairs, and the larger glands with the finer hairs. The hairs of the head are commonly supplied with a pair of racemose glands, measuring between ^ and yV of a line in diameter. These open into the hair-follicle, one on each side, and near the superficial portion of the corium. The coarser hairs of the beard, axilla, and breast, have a little halo of three to five glands, PHYSIOLOGY OF THE SKIN. 39 each measuring from one to three-tenths of a line, opening into the upper part of their follicles; while around the follicles of the hairs of the pubes, scrotum, and labia majora, they form a rosette of four to eight glands, the glands varying in size from a quarter of a line to a line, and in consequence of their larger size, extend- ing for a greater depth into the corium. In structure, the sebiparous follicle and gland are composed of the same three coats as the sudoriparous glands and hair- follicles; namely, an external fibrous coat, derived from the corium and continuous with the fibrous coat of the hair-follicle; a middle coat, derived from the limitary layer; and an internal coat or epithelium, which is continuous with the outer root-sheath of the hair-follicle, or with the rete mucosum. The epithelium con- sists of several layers of nucleated cells, and is thicker in the larger than in the smaller ducts. The vessels of the sebiparous glands are the same as those of the hair-follicles. The development of the sebiparous follicles and glands is iden- tical with that of the hair-follicles and sudoriparous tubules: it begins by the in-growth of a bud from the rete mucosum, or from the hair-follicle; the bud lengthens into a tubule, and then ramifies, so as to constitute either a simple racemose gland, or a compound racerrlose gland. This process is first perceptible at the fourth or fifth month of foetal life; it begins in the eyebrows, and extends by degrees to the rest of the body, but is not com- pleted at the time of birth. The sebaceous secretion is a semi-solid substance, composed of disintegrated cells, fat, albumen, casein, extractive matter, and phosphate of lime. PHYSIOLOGY OF THE SKIN. The skin is a defensive covering to the body, capable of resist- ing moderate violence by virtue of its toughness and elasticity, and endowed with sensation, which gives notice to the muscular system of the approach of injury, and enables us to avoid it. The sensation of the skin is of two kinds, common and special, common sensation being that which exists throughout the general surface, and special sensation residing in the hands and in the fingers, and conferring the special sense of touch. 40 CUTANEOUS MEDICINE. The skin also possesses the singular property of maintaining a proper relation between the fluids of the body and the surround- ing atmosphere: in certain conditions of the body and of the atmosphere it exhales, and under certain other conditions it absorbs. It is therefore an organ of exhalation and absorption, acting under the control* of the general vitality of the system. Another of the functions of the skin is secretion: it is a secret- ing organ of albumen in the production of the epidermis and of the hair; it secretes, besides, the perspiratory fluid, or sweat, and the sebaceous substance. To sum its properties, we must regard it as an organ of resist- ance of injury; as an organ of sensation, of the common and of the special kind; as a supporter of the integrity of the tissues, by virtue of its exhalant and its inhalant powers; and as a con- servator of its own healthy condition, its temperature, and of the purity of the blood, by its secretory function. The special sense of touch which resides in the hands, and especially in the pulpous extremities of the fingers, is provided for by means of a special organization, the tactile papillae, and possibly also by that curious apparatus of nervous ganglia situ- ated in the subcutaneous tissue, the Pacinian corpuscles. By means of this sense we determine the qualities of surrounding objects; we are enabled to detect their resistance, their extent, and their variety of surface; to distinguish between hard and soft, smooth or rough, hot or cold. And the educated sense acquires the extraordinary power of tracing the most minute variations of form or surface; it enables the blind to read, and in some instances to detect the mysterious tactile differences of colours. The common sensation of the skin presents some interesting phenomena in reference to the sensation of different regions of the body and the appreciation of heat and cold. The most sen- sitive parts are the pulps of the fingers; the least, the middle of the internodial portion of the limbs. The experiments of Weber, made with a pair of compasses, have shown that the points applied against the skin do not produce a double impres- sion until they are separated to a certain distance apart; that on the pulp of the middle finger, the interval of separation of the points must be one-third of a line; on the palmar surface of the same finger, two lines; on the cheek, five lines; forehead PHYSIOLOGY OF THE SKIN. 41 ten lines; on the middle of the breast, twenty lines; and on the middle of the forearm and thigh, thirty lines, or upwards of two inches. He also noted, as might have been inferred, that the sensation was always most lively in the direction of the nerves of the part; for example, vertically on the forehead, and trans- versely on the cheek and neck. Other experiments made by Weber, on the power of apprecia- tion of temperature, are also interesting. If the two hands be placed in a basin of warm water, the water will seem warmest to the left hand, although the right hand is the most highly appreciative of the special sense of touch. Again, the sense of heat is shown to be materially influenced by quantity as well as by intensity: a hand plunged in water of a certain temperature may feel it too hot to be borne, while a single finger discovers nothing more than a pleasant warmth. Hence, the hand is a bad medium for testing the heat of a bath : to the finger the water in the bath may seem agreeable, to the hand it communicates the sensation of a proper heat, but to the entire skin it may prove insupportable. These experiments also tend to show that a moderate heat applied to a large surface is likely to produce a more powerful impression upon the nervous system than a greater heat upon a more limited surface. The sensation of the skin is modified very considerably by its state of health or disease: in a state of aberration from the standard of health, its sensibility may be increased or diminished, or it may be perverted; the more common examples of perverted or morbid sensibility being, heat, cold, itching, tingling, smart- ing, pricking, shooting, creeping, tickling, burning, scalding, &c. These sensations are referrible to the condition of the nervous system, and are a part of common sensation, while certain other peculiarities of sensation belong to special sense; such as, the sense of tickling in the armpits, on the flanks, and in the soles of the feet; and the erection of the nipples, under the impression of touch. The exhaling property of the skin contributes materially to the general perspiration, and is not distinguishable as a separate source of excreted fluid; it is derived from and through the epi- dermis, and also from the hair, the aeriferous cells of the latter being due to the substitution of atmospheric air for organic fluid. The absorbent property of the skin is one of the means by 42 CUTANEOUS MEDICINE. which the circle of change is maintained in the economy; and in this respect, the only difference between the inorganic and the organic mass is, that in the former the absorption and the exhalation are governed by physical laws only ; whereas, in the organic body, although governed also by physical laws, those laws are controlled and directed by the higher power of vitality. The skin is most favourably organized and disposed for the exer- cise of the phenomena of endosmosis and exosmosis,—a moist membrane interposed between a mass of fluids within and an atmosphere of fluids without, some gaseous and some aqueous. There can be no doubt that the skin imbibes largely of the oxy- gen with which it comes in contact by its Surface, and that the chief of the advantages of ablution and bathing arise from this property; moreover, in a morbid state of the skin, one of the principal of the agents of evil against which we have specially to guard, is the life-giving, but potent and stimulant, oxygen. The absorbent property of the skin is conspicuously shown when the body has been deprived of its fluids by excessive per- spiration. One of our friends, an observant man, noticed that after taking a hot-air bath, he lost a pound in weight; but that in two hours he had regained that pound of weight, although in the mean time he had neither eaten nor drunk. This pound of moisture lost was clearly replaced by the atmosphere, partly no doubt through the agency of the lungs, but in a measure also through the skin. When the body is immersed for awhile in water of a certain temperature, say 82° of Fahrenheit, and a few degrees below that point, it increases in weight by the absorption of fluid, and under certain circumstances the proofs of absorption are obtained- through the aid of chemical means. A man who had bathed in a weak solution of the ferrocyanide of potassium, showed the presence of that salt in his urine; and alkaline urine has been detected in those who have bathed in the waters of Vichy. Co- louring matters also have been discovered in the urine of persons who have been for a long time immersed in water containing such substances; and Fourcault kept birds in water, the head being free, until they vomited water from the stomach. When, instead of the moderate temperature already indicated, the temperature of the bath corresponds with or is a little over that of the body, an opposite action to that of absorption takes PHYSIOLOGY OF THE SKIN. 43 place, namely exhalation, and the body loses in weight. These experiments have also shown that in the lower temperature— that which conduces to absorption—the nervous system is tran- quillized, the action of the heart is subdued, and a sedative effect is produced; but that in the opposite circumstances—namely those that conduce to exhalation—the nervous system is excited, the heart's pulsations are more frequent than natural, and the condition of the system in general is one of irritation. The power of absorption possessed by the skin has been turned to use in various ways : emaciated and exhausted persons inca- pable of taking nourishment by the mouth have been kept alive for awhile by baths of milk and baths of broth ; medicines also have been exhibited in this way. Certain medicinal substances, such as hellebore, will act upon the system when kept in con- tact with the skin by means of a poultice; but, generally, in pursuing the iatraleplic method, or method of introducing medi- cinal substances into the blood through the agency of the skin, we have recourse to friction. The old practice of mercurial inunc- tion was founded on this property of the skin; and croton oil and preparations of strychnia will produce their characteristic effects upon the system when applied in a similar manner. These experiments make us aware of the importance.of the epidermis in resisting the admission of fo»ign substances into the system; our experiment fails on those parts of the body where the epidermis is thick, and we consequently select a spot where the epidermis is known to be thin; for example, the flex- ures of the limbs, and particularly the armpits and groins. The substances to be " rubbed in " must be in suspension or solution in water or fat; and the frictions must be continued for a consi- derable time, and repeated frequently. The epidermis is most favourable for the imbibition of these substances when softened in its tissue by saturation with fluid. When the endermic method of administration of medicines is a matter of importance, the epidermis must be removed as by a blister, and the medicinal substance sprinkled on the denuded derma. Certain substances will act on the system when pre- sented in this manner almost as quickly as they do on being taken into the stomach; and there are diseases, such as hydro- phobia, wherein this method becomes one of great value. It is only the more potent medicines that would require to be used in 44 CUTANEOUS MEDICINE. these extreme cases, and they are the best suited for the purpose; for example, strychnine, morphine, belladonna, &c. Our atten- tion is sometimes called to the absorbing power of the skin, in the instance of strangury, produced by the application of a blis- ter ; or local paralysis following the use of lead. Mr. Ceeley records a very important' and practical illustration of the absorbing power of the skin, as applied to an organic fluid, the vaccine lymph ; and the illustration is equally applicable to the absorption of animal poisons, such as that of syphilis. He says: "I have often succeeded in procuring vaccine vesicles without puncture, on the skins of children especially and young persons, by keeping lymph in contact with the skin, and exclud- ing it from the air by a coating of blood. Active lymph blend- ed with blood, casually trickling down the arm and drying in the most dependent part, will often give rise to a vesicle." In this case the coating of blood acts in a similar manner to oiled silk in a water dressing ; it confines the exhalation of the part; the exhaled fluid dissolves the vaccine lymph, and at the same time softens the epidermis to a degree the most favourable for the endosmosis that subsequently takes place. The secretions of the skin are the sebaceous matter and the sweat. The sebaceous secretion is produced on all parts of the body, with the exception of the palm of the hands and sole of the feet. It is an oily emulsion, elaborated by the cells of the epithelium of its glandular apparatus, and distributed very largely upon the surface of the epidermis. It preserves the normal moisture of the epidermis; acts as a varnish of protec- tion to parts of the body that are exposed to the atmosphere, to friction, or to the irritation of fluids, and gives brightness and beauty to the hairy vesture of man. The uses of the sebaceous matter might be best illustrated by a view of the consequences of its absence: the epidermis would become dry, parched, and broken up into scales; it would break with the movements of the body, and a state of disease be quickly established. In tem- perate climates the skin produces secretion sufficient for all the purposes required; but in extremes of climate, whether of the north or of the south, the natives are constrained to have recourse to an artificial substitute for sebaceous matter; the former to defend them from the cold, the latter from the burning heat. PHYSIOLOGY OF THE SKIN. 45 The situations in which sebaceous matter is poured out upon the skin in greatest abundance are—the head, to co-operate with and contribute to the*uses of the hair; the face, and especially the nose, to provide for the constant exposure of those parts to the severities of climate; the armpits and perineum, to assist in the defence of the skin against friction and the accumulations of fluid; and around the apertures of the body, for protection against the contact of fluid secretions. The sebaceous secretion is an oleaginous emulsion, consisting of water, stearine, oil-globules, pigment-granules, epithelial cells, and saline principles. It is variously modified in different parts of the body ; in some, as in the ear-tubes, constituting the ceru- men or ear-wax, and very remarkable for its brownish-red colour and bitter taste; in others, as in the perineum, being distin- guished by a peculiar odour, due to butyric acid. Simon states of the cerumen of the ears, that it is " an emulsive compound, which contains a soft fat, albumen, a peculiar extractive bitter matter, epithelial scales, lactate of lime, and an alkaline lactate, but no chlorides, and no phosphates soluble in water." And Esenbeck gives the following formula of chemical composition of the sebaceous substance:— 24-2 Osmazome, with traces of oil 12-6 Watery Extractive (salivary matter) 11-6 Albumen and Casein 24-2 Carbonate of Lime 2d Phosphate of Lime . 20-0 Carbonate of Magnesia 1-6 Acetate and Muriate of Soda, and Loss 3-7 100-0 The perspiratory secretion consists of the product of the sudori- parous glands, the sweat, together with the exhalation from the follicles and from the general surface of the skin. This secre- tion is undergoing constant evaporation from the cutaneous sur- face, and in a tranquil state of the body is commonly inappre- ciable to the eye : hence the term insensible perspiration ; while in an active condition of the body, it is seen oozing from the pores, bedewing the surface, and sometimes running down the skin in little rills : this is the sensible perspiration. The quantity 46 CUTANEOUS MEDICINE. of the perspiratory fluid has been variously estimated by dif- ferent observers. Lavoisier and Seguin state the mean quantity in twenty-four hours to be 33 ounces, white experiments having reference to forced perspiration have shown that the weight of the body may be reduced two, three, or four pounds in the course of an hour. The terms insensible and sensible perspiration have no other signification than that of indicating, that, although invisible, transpiration and exhalation are constantly taking place. The same amount of perspiration may at one moment be sensible, and at another insensible, by a mere alteration of the physical condition of the surrounding, atmosphere. For example, in a dry and still air, perspiration may be raised by exercise to the point of being visible, while in a current of air, the temperature and other conditions being the same, it would be evaporated so quickly as to be invisible, and a moment after, if the experi- menter were to be surrounded by an atmosphere saturated with moisture, there would be an end to evaporation, and the perspi- ration would roll down the body in big drops and rills. In estimating the quantity and importance of the perspiration in the animal economy, these modifying conditions must be borne in mind ; and it must be remembered also, that perspiration may be excited by heat, by exercise, and by certain medicines, which are thence termed diaphoretics. Amongst others of the modifiers of perspiration is the ner- vous system, as is shown in the arrest of that secretion during the hot stage of fever, and its sudden outburst in syncope, and under the influence of emotions of a depressing kind, such as fear and anxiety. Perspiration is most active during digestion, and least so immediately after a meal. The harmony of the functions of the body is illustrated in the sympathy which the secretion of perspiration maintains with other secreting organs of the system; for example, the lungs and the kidneys. In the summer time, the skin acts freely by way of perspiration, and the quantity of the urine is diminished; and in the winter these conditions are reversed; the urine is then the most abundant, the skin the least. If on a cold evening we quit a warm apartment, the perspiration im- mediately receives a check, and the kidneys are with equal suddenness prompted to action; and this is especially the case PHYSIOLOGY OF THE SKIN. 47 if the renal organs have been previously excited by alcoholic stimulants. Dr. Lining, of South Carolina, has shown by experiment, that the quantity of perspiration is more than doubled in July as compared with February, while the amount of the urine is exactly the reverse. In certain diseases also, this sympathetic equilibrium of the secretions is strikingly manifested ; for example, in the dry skin of the diabetic patient, and in the profuse night-sweats of phthisis pulmonalis. - The perspiratory secretion is an important regulator of the temperature of the body, as we see illustrated in the power which we possess of enduring a high temperature. We have ourselves remained for ten minutes in a temperature of 250° ; Blagden supported a temperature of 260° for nearly the same period; the oven of Sir Francis Chantrey, used for drying his moulds, and heated to a temperature of 350°, was constantly entered by his workmen ; and so also is the oven of Mr. Mag- nus, employed for enamelling on slate, and kept at a temperature of over 400°. Mr. Magnus once remarked to us, that the acci- dental spilling of a tumbler of water in this oven would imme- diately produce scalding. Another series of experiments has shown that in these very high temperatures, the heat of the body is very little raised above its normal standard ; the bulb of a thermometer held in the mouth of a man who had remained in a temperature of 120° for a quarter of an hour, was raised only to 105°; and when animals were destroyed by a heated temperature, their internal heat never exceeded the natural standard more than twelve or fourteen degrees. But this power of preserving a standard temperature of the body is lost as soon as the above conditions are reversed. A gentleman who visited the natural hot-vapour baths of Nero, near Pozzuoli, which in highest temperature do not exceed 122°, makes the following report of his experiment:—To reach the source, he had to pass along a narrow winding passage, seven feet in height, three in width, and one hundred and twenty yards in length. Just within the mouth of the passage, the temperature was 104° in the upper strata of the atmosphere, and 91° near the ground; further on, the air was filled with dense vapour, of 118° above, and 111° below; and over the bath it was 122° : the heat of the spring being 185°. After proceeding one-third the length of the passage, he began to feel 48 CUTANEOUS MEDICINE. a sense of oppression, and his pulse rose from seventy to eighty beats in the minute. Further on, the oppression increased: his breathing became rapid and panting; he was constrained to stoop frequently for a chestful of cooler air; he sweated pro- fusely, his head throbbed, and his pulse was 120. Continuing onward, the sensations of suffocation became insupportable; he felt as though his head would burst; his pulse became too rapid to count; he was exhausted, and becoming unconscious; and it demanded all his remaining strength and energy to stagger back into the open air. He was faint, and experienced a fulness of head, relieved by haemorrhage from the nose, and remained uncomfortable during the rest of the day, his pulse continuing to be one hundred in the minute, and his sensations of uneasi- ness considerable. So much importance is attached by some pathologists to the free transpiration of the skin, that Fourcault believed its suppres- sion to be the cause of certain chronic diseases, and particularly of scrofula and consumption; the latter disease, according to him, being the consequence of a cold and damp atmosphere, combined with want of proper exercise. To put his theory to the test of experiment, he covered the coats of animals with an impermeable varnish, and in a short time they died ; indeed, so quickly, that, as he avers, they lived for a shorter period than animals altogether deprived of their skin. Their mucous mem- branes, their serous membranes, and the nervous centres, were all found to be excessively congested after death. In a horse, the vessels of the Schneiderian membrane were loaded, and relieved themselves by a profuse discharge. Sheep suffered in a similar manner, and had also coryza; while dogs were seized with inflammation of the bowels, and congestion and enlarge- ment of the liver. The animals suffered very early from oppres- sion and difficulty of breathing, and died of asphyxia, accompa- nied with convulsions. In an animal varnished on one side only, the cutaneous capillaries of that side were found gorged with dark-coloured blood, while on the opposite side the blood was scarlet, and scanty. In the majority, the veins near the heart were found distended with black soft coagula, and in some there were coagula in the lungs. He illustrates these pheno- mena by reference to the child whose skin was gilded to give brilliancy to the f6te accompanying the election of Pope Leo the PHYSIOLOGY OF THE SKIN. 49 Tenth: the child was to represent the golden age; but its death was the result of the celebration. Fourcault also produced albu- minuria in dogs by similar means ; the first change in the urine was a diminution of its acid reaction; then albumen appeared, and the fluid became alkaline. Becquerel and Breschet conceived that if they could arrest transpiration by the skin, after the manner of Fourcault, they would produce internal fever-; but the very opposite phenomena followed their experiments. The temperature of the deep mus- cles was reduced, in the course of half an hour after the applica- tion of the varnish, from 100° to 89°; in another half-hour, to 76° ; and in another half hour the index of their thermo-electric apparatus denoted a fall in the temperature to within three degrees of the surrounding atmosphere; the latter being 63°. In one hour and a half, the temperature of the body had fallen thirty-four degrees, and the animal died. That the perspiratory secretion is not only a defence to the economy, but also a purifier of the blood, is shown by its che- mical composition. Its constituents are, water, nitrogen, animal extract, fat; carbonic acid, with carbonates of soda and lime ; lactic acid, with lactate of ammonia ; acetic acid, with acetate of soda; butyric acid, chloride of sodium, hydrochlorate of ammo- nia, phosphate of soda and lime, sulphate of soda, salts of pot- ash, and peroxide of iron. Dr. P. A. Favre sums up his che. mical researches on the composition of sweat as follows:—Its solid components, with the exception of a trace, are soluble in water; its predominant salt is chloride of sodium; alkaline sulphates exist in it in very small quantity ; alkaline and earthy phosphates are barely discoverable; lactic acid is present in the form of lactates; it possesses a peculiar nitrogenous acid, sudoric acid, resembling uric acid in its chemical nature; sudoric acid is combined with alkalies, but uric acid never occurs; urea is present; there is but little oily or albuminous matter; the latter is in combination with the alkalies; the potash is chiefly com- bined with the organic acids, the soda with the mineral acids; at the beginning of perspiration, the organic salts exceed the mineral salts, but after a time the proportions are reversed. The peculiar odour of the sweat is due to its organic constitu- ents, and partly to the presence of ammonia; and its acid reac- tion to the acetic, the lactic, and the sudoric acids. Its gaseous 50 CUTANEOUS MEDICINE. constituents are carbonic acid and nitrogen. The carbonic acid is derived chiefly from the food, and is exhaled in largest quan- tity after a meal or muscular exercise" Dalton estimates the quantity of carbon eliminated by the skin, and irrespective of varieties of food, at one-twentieth of the entire weight of the cutaneous transpiration. The nitrogen of the sweat enters the body with the food, or by absorption through the skin, in the shape of atmospheric air; during digestion, the atmospheric air undergoes decomposition, the oxygen combines with the carbon of the food to constitute carbonic acid, and the nitrogen is set free. The quantity of nitrogen is consequently the greatest during digestion, and is greater in herbivorous animals, in whom the process of digestion lasts longest, than it is in the carnivora. CHAPTER H. PATHOLOGY OF THE SKIN, AND CLASSIFICATION OF ITS DISEASES. The Skin in disease presents characters which are the direct opposites of those which distinguish its healthy state. There are characters which are apparent to the eye of the observer, and other characters which can be only fully appreciated by the suf- ferer. The characters which are obvious to the eye—the visual cha- racters—are, 1. redness; 2. unevenness or asperity from the presence of pimples; 3. asperity from the presence of vesicles; 4. asperity from the presence of large vesicles, termed bullas; 5. asperity from the presence of purulent vesicles or pustules; 6. asperity from a scale of altered epidermis; 1. asperity from enlargement and prominence of the skin, constituting tubercles; and 8, discoloration or stain. The characters which appertain to the sensations of the patient are pain in a variety of forms; for example, itching, pricking, stinging, burning, creeping, shooting, gnawing, and aching; together with flushes, chills, dryness, and stiffness. The visual characters are the pathological signs or appearances by which the disease is distinguished. They are eight in num- ber ; and upon these signs the classification of Willan is founded. The classification of Willan is, therefore, a pathological classifi- cation, and its orders or groups, eight in number, are as fol- lows:—!. Exanthemata; 2. Papulae; 3. Vesiculas ; 4. Bullas • 5. Pustulae; 6. Squamae; 7. Tuberculae; 8. Maculas. 1. Exanthemata, derived from «f*v^/», to burst forth or effloresce, or throw out blossoms like flowers, is the term applied to a vascular congestion or redness of the skin, which is one while uniform and limited in extent, as occurs in erythema, ery- sipelas, and urticaria; and another while blotchy and dispersed over the whole body, as in roseola. Willan, included in this order scarlatina and rubeola, which harmonize better with the idea of bursting into blossom, like flowers, than do erythema, 52 CUTANEOUS MEDICINE. erysipelas, and urticaria, and may be regarded as the true illus- tration of exanthemata; while the existing group would be bet- ter represented by the term erythemata, taking erythema as its type. Scarlatina and rubeola differ from the erythemata in many important respects, the chief of which is their contagious nature. We have, therefore, thought it well to make them a group by themselves, under the name of zymotic or eruptive fevers. Another affection, namely, purpura, admitted by Willan into this group, has also been rejected; the redness of purpura being due, not to congestion of vessels, but to effusion of blood into the tissues of the skin. As redness is the type of the order Exanthemata, it will be interesting to note the varieties of redness which may be present in cutaneous diseases. The redness may be scarlet, like that of arterial blood, the colour which has given a name to scarlatina. It may be crimson or raspberry-coloured, probably from a slower circulation, and the consequent intrusion of the venous change into the blood, as in rubeola ; or it may be purplish or roseate, also from tardiness of circulation, or the congestion of a different set of vessels, as in roseola. It will occur to some of my readers that in one of the erup- tions of this group, namely, urticaria, there is a development of white and anaemic tubercles and wheals in the midst of the blotches of red. This is produced by spasm of the muscular structure of the corium, which not only causes prominence of the skin, but also presses out the blood from its vessels and ren- ders it anaemic. As the spasm subsides, the prominence of the skin ceases, and the natural colour returns. In some instances the spasm is intermittent, and there is the appearance of a kind of ebb and flow of colour in the wheals, as we have several times had occasion to observe. 2. Papula.—The type of this order is a papula or pimple, which is defined by Willan to be "a very small acuminated elevation .... with an inflamed base, very seldom containing a fluid or suppurating, and commonly terminating in scurf." A careful examination of this pathological sign and a better know- ledge of the anatomy of the skin shows us, however, that the pimple is the elevation of one of the follicles of the skin, from congestion of its vessels and infiltration of the tissues immedi- ately around it. The papula, therefore, shows a deeper conges- PATHOLOGY AND CLASSIFICATION. 53 tion than that of erythema, and may exist independently of the superficial congestion, or in conjunction with it. Papulae are hard to the touch, and are commonly accompanied with con- siderable and severe itching; the severity of the pruritus being, possibly, the result of irritation of a different set of nerves to those that are involved in the more superficial congestion of the erythemata. The diseases included in the order Papulae are,—Lichen, Pru- rigo, and Strophulus. 3. Vesicul^e.—A vesicula, according to Willan, is " a small orbicular elevation of the cuticle, containing lymph, which is sometimes clear and colourless, but often opaque, and whitish or pearl-coloured. It is succeeded either by scurf or by a lami- nated scab." Anatomy teaches us that the precise situation of the vesicle is, like that of the papule, the aperture of a follicle. Sometimes the cuticle is raised evenly from the whole circumference of the pore, and the vesicle is regular in its form ; sometimes it occu- pies one lip of the pore, or more than one vesicle is developed around the circumference of the pore; and sometimes, where several vesicles are clustered together, the compound vesicle is found to possess a multilocular structure. It may be remarked that Willan's standard of observation in the definition of a vesicle, was the vesicle which is raised on the back of the hand after exposure to the sun. In this situation the vesicle is really orbicular, as he describes; but in some other positions, as be- tween the fingers, it is conical in figure; while in certain others, as on the trunk of the body, although retaining the orbicular form, it is commonly larger than elsewhere; as, for example, the vesicle of miliaria. On the palm of the hands, and palmar surface of the fingers, the cuticle resists the formation of distinct vesicles, and is raised in laminae of some extent, through which the bead-like globules of effused lymph are distinctly percep- tible. This is another example of the multilocular vesicle. A vesicle would seem to be the consequence of a similar patho- logical process to that which gives origin to the pimple. There is congestion of the vessels of the follicle in both, while in one the serous fluid or lymph which results from the congestion is retained in the tissues, and produces a pimple, and in the other is poured out upon the surface of the corium, and, lifting the 54 CUTANEOUS MEDICINE. cuticle, occasions a vesicle. And the difference seems due rather to the constitution of the patient than to the nature of the cause which excites the eruption. Two persons exercising in the sun, and exposed to the sun's rays, may the next morning find the back of the hands presenting a very different form of eruption, although the cause and the conditions were precisely the Same. In one, possessing a bilious temperament, the eruption may be distinctly papular, in a word, licheij, Solaris; while in the other, of lymphatic temperament, the eruption may be vesicular,— eczema solare; nor would it be unlikely that in a third person, say of nervous temperament, there might be neither papulae nor vesiculas, but in lieu of these, an erythema solare. The albuminous fluid which is poured out upon the skin under the influence of congestion or inflammation,'is generally transparent at its first effusion, but in a short time becomes milky and opaque. This change is very conspicuous in the vesicular eruption called miliaria: in its transparent state, from the reflection of the colour of the inflamed base, the vesicles have a red appearance, and the eruption is termed miliaria rubra; while at a later stage, when the vesicles have become milky, it is called miliaria alba. In his order Vesiculas, Willan assembled seven different dis- eases : five of these we have thought proper to reject, and have retained only eczema and miliaria. The rejected eruptions are varicella and vaccinia, which are forms pf variola; herpes, from the largeness of its vesicles, we have classed with bullas; rupia we have transferred to syphilitic eruptions, to which it properly belongs; while aphtha is an affection of the mucous membrane, and not at all of the external skin. In his definition of papula, as also of vesicula, Willan notes the termination of the pathological process in scurf, or in a laminated scab. This, it may be explained, is the natural ter- mination of a congestion or inflammation of the skin, which suspends for a while the formation of the epidermis, or which destroys the life of the epidermis, by separating it from the living tissue on which it is naturally imbedded. In a short while the separated and loosened cuticle breaks away from its attachment, and is thrown off, either as a fine desquamation or scurf, or as a coarser desquamation, namely, a laminated scab. 4. Bullae are large hemispherical vesicles and bladders, PATHOLOGY AND CLASSIFICATION. 55 thrown up upon the skin on an erythematous base. The vesicles rarely exceed the size of a small currant, and constitute the eruption termed Herpes; while the bladders or blebs are termed Pemphigus. The examples of bullae, according to Willan, are Erysipelas, Pemphigus, and Pompholyx. Erysipelas we have restored to the order Exanthemata, its vesicles being an uncertain and acci- dental character. Pemphigus and pompholyx are the same disease, and the terms have nearly the same meaning; while herpes we have taken from Vesiculas, and joined with pemphigus in the present group. The lymph which is effused into the vesicle of herpes is trans- parent at first, but rapidly becomes opalescent, and as the vesicle reaches maturity, tyellowish or purplish: in the latter state it dries up into a hard scab of a deep amber-colour or black, and remains adherent to the skin for several days. The lymph of pemphigus is more like the serum of an ordinary blister, which the entire eruption very much resembles. The effused fluid passes through the usual stages of transparency, opalescence, and amber-tinted or purplish coloration, according to the predomi- nance of the biliary or of the hasmic pigmentary principle: it is sometimes dispersed by rupture of the bleb, and sometimes dries up by evaporation, and leaves a thin cuticular scab, which is subsequently thrown off by desquamation. 5. Pustule.—When, instead of lymph or serum, the vesicle contains pus, the pathological lesion is termed a pustule. Some- times the contents of the vesicle are lymphatic at first, and after- wards become opaque and puriform; this is a sero-puslule; but when more inflammation is present, they are pustular from the beginning. The transition of a vesicle into a pustule may there- fore be taken as a sign of augmentation of inflammation ; while the original development of the eruption as a pustule must be regarded as indicative of a higher degree of inflammation, a lower vitality of the part, or a constitutional proneness to the production of pus; in other words, a pyogenic diathesis. It was customary for the older writers to distinguish four kinds of pustule; namely, Psydracium, Phlyzacium, Achor, and Favus. Psydracium is a small pustule, occurring in clusters, frequently confluent, containing lymph at first, and subsequently becoming purulent. Phlyzacium is a larger pustule with a hard 56 CUTANEOUS MEDICINE. and inflamed base. Achor is a small pustule occurring on the scalp at the apertures of the hair-follicles, and terminating in scurf. Favus also is developed around the mouth of a hair- follicle ; but the matter which it contains is distinct from pus, and is termed favous substance. We, therefore, at the present time, recognize only three forms of pustules; namely, psydracia, phlyzacia, and achores. The diseases included in the order Pustulas are Impetigo, which is an eruption of psydracious pustules, and Ecthyma, an out- break of pustules of the phlyzacious kind. Besides these, how- ever, Willan> admitted into this order three other diseases; namely, porrigo, variola, and scabies; all of which we have thought proper to reject; porrigo, because it is a misnomer and without identification ; variola, because it belongs to the zymo- tic group of eruptive fevers; and scabies, because it is an eczema. 6. Squamae.—A squama or scale, according to the definition of Willan, is " a lamina of morbid cuticle, hard, thickened, whit- ish, and opaque;" and the diseases falling within this definition are, Lepra, or, more properly, Alphos; Psoriasis, Pityriasis, and Ichthyosis. In reality, the only true squamous affection is al- phos ; psoriasis being merely a desquamating stage or form of chronic eczema; pityriasis, a furfuraceous variety of the same affection; and ichthyosis, a state of defective nutrition of the skin, in which the epidermis being imperfectly developed, breaks up over the greater part of the surface of the body into scale- like plates, corresponding with the lines of motion of the skin. The scale of alphos (lepra vulgaris, Willan) is circular in form and surmounts a slight elevation of the skin, of a reddish colour, and hard and dense to the touch. It varies in size, in correspond- ence with the elevation upon which it is formed, from one or two lines to as many inches in diameter. It is white, porous, glistening, laminated, and imbricated; and when, instead of occupying an isolated position, the disease extends over a large surface, such as an entire limb, these characters are still appreci- able, although the general form of the scale is disturbed. Upon close inspection, it is evident that the confluent or compound scale is made up of a number of small scales, each surmounting a separate little mound or tubercle. It is important, to the full understanding of what is meant by the pathological sign termed a "scale," that this description PATHOLOGY AND CLASSIFICATION. 57 should be borne in mind, in order to contrast it with the mere exfoliation of the ordinary, albeit morbid cuticle, which occurs in chronic eczema, and is termed psoriasis and' pityriasis; and in ichthyosis. The desquamation of psoriasis and pityriasis is not unfrequently furfuraceous, or branny {furfur, bran); and sometimes farinaceous, or mealy. 7. Tubercula.—A tubercle, according to Willan, is "a hard, superficial tumour, circumscribed and permanent, or proceeding very slowly to suppuration;" and he assembles under this head every disease of the skin possessing prominence and solidity, not already disposed of in his previous orders. Tubercula is consequently a kind of hochepot for the convenient packing away of a little catalogue of ailments that otherwise might be difficult to arrange; beginning with a boil, picking up acne, lupus, and elephantiasis in its way, and ending with a humble wart. The complete list is as follows:—Phyma, Acne, Sycosis, Molluscum, Lupus, Vitiligo, Elephantiasis, Frambcesia, and Verruca. The student will see at once the necessity of grouping these diseases differently, and transferring the majority of them to other heads of classification. 8. Macule.—Macula, a mark or stain, or spot, is a " perma- nent discoloration of some portion of the skin, often with a change of its texture ;" and included under this head are three divisions: Ephelis, Spilus, and Nasvus. Ephelis, or sun-stain, represents the family of discolorations of the skiff, or dyschroma- todermata; the commonest illustration of these being freckles. Spilus and naevus are the so-called mother's-marks; the spili being the marks or moles characterized by pigmentary discolo- ration ; and the nasvi, those which are due to an abnormal deve- lopment of the vessels of the skin, whether of its arterial or of its venous structure. As a rude classification of great simplicity, none can be better suited for the early training of the student than the system of Willan. Its fundamental principles are few and distinct, easily carried in the mind, easily recognized by the bedside, and easy of application under every circumstance. The invention of this classification by Plenck, and its subsequent simplification by Willan, mark an important era in the progress of cutaneous medicine, and have cleared the way for a more precise and more practical arrangement. A practical and unobjectionable classi- 58 CUTANEOUS MEDICINE. fication has engaged the thoughts of almost every dermopatho- logist who has devoted his attention to diseases of the skin, but hitherto with little success; and in the absence of a more per- fect system, we propose to adopt a classification that at least has the merit of being framed out of a practical material, and embraces every cutaneous disease at present known. If we reject pathological lesions as the foundation of a classi- fication, we may be led to ask, Which is the commonest disease of the skin ? The determination of this question naturally esta- blishes a point of commencement, and a standard of reference, while the remaining diseases may possibly fall into their proper places in a systematic arrangement, naturally, and as a matter of course. Thus, if it be shown that the commonest disease of the skin is Eczema, we may take the leading characters of eczema and establish a group of eczematous affections. Now, as eczema is a disease which is not limited to a part, or to a single tissue of the skin, but is general in its invasion and capable of attacking every region of the cutaneous surface, we may follow up eczema with three other groups, possessing a similar generality of cha- racter, and, like the eczematous group, each represented by a substantive disease: for example, Erythema, which we will take as the type of Erythematous affections; Pemphigus, which we will take as the type of Bullous affections; and Furunculus, which we will take as the type of "Furuncular affections. After these general affections, we may consider next, the affections of the nerves, the vessels, and the relation subsisting between the vessels and their contained blood: these will furnish us with three other groups; namely, Nervous affections, Vascular affec- tions, and Hasmic affections. After the tissues in general, the nerves, the vessels, and the blood, we may take disorders of deve- lopment, nutrition, and growth; and these will constitute two further groups; namely, Developmental and Nutritive affections, and Hypertrophic and Atrophic affections. We may next turn from disorders common to the skin to what may be considered as specific affections; for example, the action on the system and on the skin of zymotic poisons,—Zymotic affections; the pecu- liar disease Alphos may be taken as the type of Alphous affec- tions ; Struma will typify Strumous affections ; Syphilis, Syphi- litic affections; Cancer, Carcinomatous affections; and Elephan- tiasis, Leprous affections. Having disposed of specific affections, PATHOLOGY AND CLASSIFICATION. 59 there remain the affections of the special apparatus of the skin; namely, the hair and hair-follicles; the sebiparous apparatus; the chromatogenous apparatus; the sudoriparous apparatus; and the nails; lastly, we may add a group of Traumatic affections, and one of Phytodermic affections. This is the clas- sification which we shall venture to take as the basis of the present work. We have called it a clinical classification, as arising out of the analysis of a large number of cases of disease, and we now present it in a tabular form, as follows :— CLINICAL CLASSIFICATION. 1. Eczematous affections 13. Syphilitic affections 2. Erythematous affections 14. Carcinomatous affections 3. Bullous affections 15. Leprous affections 4. Furuncular affections 16. Affections of the hair and hair- 5. Nervous affections follicles 6. Vascular affections 17. Affections of the sebiparous ap- 7. Hsemodyscrasic affections paratus 8. Developmental and nutritive 18. Affections of the chromato- affections genous apparatus 9. Hypertrophic and Atrophic af- 19. Affections of the sudoriparous fections apparatus 10. Zymotic affections 20. Affections of the nails 11. Alphous affections 21. Traumatic affections 12. Strumous affections 22. Phytodermic affections 1. Eczematous affections.—Eczema, the commonest of the eruptions of the skin, is the type of this group ; and the diseases embraced under this head are Eczema, Psoriasis, Pityriasis, Lichen, Impetigo, Scabies, and Gutta rosacea. 2. Erythematous affections.—Erythema is the type of erythematous affections, and the diseases assembled in this group are Erythema, Urticaria, Erysipelas, and Eoseola. 3. Bullous affections, having Pemphigus for their type, include Herpes, Miliaria, and Pemphigus. 4. Furuncular affections.—Furunculus is the type of furuncular affections, and its examples, Ecthyma, Furunculus, Hordeolum, and Anthrax. * 5. Nervous affections of the skin are typified by an irri- table condition of the cutaneous nerves, giving rise commonly to itching, but sometimes to other forms of pain. The affections 60 cutaneous medicine. belonging to this group are Hyperassthesia, Anaesthesia, Pruri- tus, and Prurigo. 6. Vascular affections are represented by alterations in the distribution and size of the vessels of the skin ; the type and principal illustration of these affections being Nasvus vas- culosus, to which is added Hypertrophia venarum. 7. H^modyscrasic affections, or affections in which the relations of the blood to its vessels are abnormally altered, are represented by Purpura. 8. Developmental and Nutritive affections are typified by Xeroderma, Ichthyosis, and Cachexia cutis. 9. Hypertrophic and Atrophic affections are exempli- fied by Naevus hypertrophicus, Ecphyma, Kelis, Bucnemia tro- pica, and Atrophia cutis. 10. Zymotic affections are the diseases or fevers originating in a poisonous ferment, and attended with exanthema of the skin; in other words, the eruptive fevers. They are five in number:—Rubeola, Scarlatina, Variola, Varicella, and Vaccinia. 11. Alphous affections.—Alphos, the type of the Squamas of Willan, stands alone in this group; heretofore misnamed lepra, on account of its roughness, and psoriasis, on account of some resemblance to the squamous stage of eczema; it now resumes its proper position as an idiopathic and substantive disease. 12. Strumous affections include diseases of the skin which have their origin in struma or scrofula. The examples of these affections are Scrofuloderma and Lupus. 13. Syphilitic affections embrace all the varieties of syphilis developed on the skin,—the syphilodermata, whether they present themselves as exanthemata, papulae, pustulse, bullae, tubercula, or ulcera. Eupia is a bullous syphiloderma. 14. Carcinomatous affections include the group of cancers of the skin. 15. Leprous affections embrace the consideration of the true or ancient lepra, the elephantiasis of the Greeks, and all the varieties appertaining to this grave disease. The principal forms are included under the two following heads : Lepra and Vitiligo. 16. Affections of the Hair and hair-follicles.—The examples of disease assembled under this group are Alopecia, PATHOLOGY AND CLASSIFICATION. 61 Area, Canities, Hirsuties, Trichiasis, Trichosts, Favus, Kenon, Sycosis, Plica, Erythema folliculorum, Stearrhoea, and Narcosis folliculorum. 17. Affections of the Sebiparous apparatus.—The diseases belonging to this group are Stearrhoea, Ichthyosis sebacea, Comedones, Accumulationes sebaceae, Cornua, Tuber- cula miliaria, Tumores serosi, Tumores sebacei, and Acne. 18. Affections of the Chromatogenous apparatus.— Under this head are grouped the Dyschromatodermata; for example, Lentigo, Ephelis, Melasma, Leucosma, and Chloasma. 19. Affections of the Sudoriparous apparatus are represented by Idrosis, Anidrosis, Osmidrosis, Chromidrosis, and Hasmidrosis. 20. Affections of the Nails have their representatives in Degeneratio unguium and Onychia. 21. Traumatic affections include the injuries resulting from the bites and stings of insects, and their habitation in the skin ; together with other accidental injuries of the organ. 22. Phytodermic affections.—The dermophytic diseases are founded on a peculiar metamorphosis of the elements of the epidermic cells, by which the nascent cell is converted into a structure closely resembling a vegetable organism, and possess- ing the attributes of the mucedines. They occur chiefly in association with hair-follicles, and with one exception are bor- rowed from affections of the hair and hair-follicles; the excep- tion being chloasma, which is derived from affections of the chromatogenous apparatus. The diseases constituting this group are, Trichosis, Favus, Kerion, Sycosis, and Chloasma; and, according to some dermopathologists, also Area. We have endeavoured to show that the aims of classification are twofold, namely, in the first place, to lay down a plan by which a knowledge of diagnosis may be most easily acquired; and, secondly, to arrange a number of diseases according to a method that will facilitate the comprehension of their nature and phenomena, and conduce to their treatment with successful results. The first of these objects is amply fulfilled by the clas- sification of Willan, which is essentially a classification of dia- gnosis ; and consequently, par excellence, an educational classifi- cation ; while the second has been attempted by a number of authors, with varied success, under the name of practical or 62 cutaneous medicine. natural classification ; the most recent of these .essays being the Clinical Classification, which we have just endeavoured to explain. We discover vestiges of a pathological classification as far back as the 16th century, when we are informed by a French author, Riolan, that some physicians include all diseases of the skin under three heads; namely, alterations of smoothness, of colour, and of magnitude; whereas, this arrangement affording no place for disorders of the hair, others prefer to divide them into Pustules, Deformities, and Tubercles; pustules compre- hending all eruptions attended with roughness of the skin, whe- ther pimples, vesicles, pustules, or scales ; deformities, marks of all kinds, morbid colorations, and diseases of the hair; and tubercles, warts and condylomata. At a later period, namely, in 1776, a German author, Plenck, amplified this simple group- ing into fourteen classes, which he subdivided into 115 genera. His fourteen classes are as follows:— PLENCK'S CLASSIFICATION (1776). Maculae Callositates Pustulae Excrescentise cutanea Vesiculae Ulcera cutanea Bullae Vulnera cutanea Papulae Insecta cutanea Crustae Morbi unguium Squamae Morbi pilorum. WiTlan's classification, it will be seen, took its origin in that of Plenck, and is, in fact, the arrangement of Plenck curtailed and improved ; a selection of eight of his groups, and a rejection of six, although of these six he might very advan- tageously have retained the three last; namely, Insecta cutanea, Morbi unguium, and Morbi pilorum. Willan's classification was published in 1798, and is as follows :— WILLAN'S CLASSIFICATION (1798). Order 1.-^-Papul2e. Strophulus Prurigo Lichen. 2.—Squama Lepra Pityriasis Psoriasis Ichthyosis PATHOLOGY AND CLASSIFICATION. 63 3.—Exanthemata. Rubeola Roseola Scarlatina Urticaria Purpura Erythema Erysipelas Pemphigus 4.—Bullae. Pompholyx Impetigo Porrigo Ecthyma 5.—PuSTUI^B. Variola Scabies Varicella 6.—Vesioul.b. Miliaria Vaccinia Eczema Herpes Bupia Aptha Phyma Verruca MoUuscum Vitiligo Acne 7.—Tubercula. Sycosis Lupus Elephantiasis Frambcesia Ephelis Naevus 8.—Macul.b. Spilus, &c. The Natural Classification is founded upon a general view of the nature and cause of the disease, having for its object the development of a correct principle of treatment; hence it may also be called an Etiological and a Therapeutical classifica- tion. The earliest natural arrangement with which we are acquainted is that of Celsus, who divides diseases into such as should be treated by diet; such as should be treated by medi- cine ; and such as should be treated by surgical means. This is obviously a therapeutical classification ; but he further intro- duces into it a topographical element, and subdivides the diseases to be treated by medicine into a group of general and a group of topical affections. A natural classification of more recent times is that of Ali- bert, published in 1810, and remodelled in 1832. Alibert's classification, called the "Arbre des Dermatoses," is based on 64 CUTANEOUS medicine. the affinities or analogies which are supposed to exist between certain diseases and to lead to a method of treatment which is identical for each separate group. His groups or families, twelve in number,—the twelve branches of the "tree of the dermatoses," are as follows :— ALIBERT'S CLASSIFICATION (1810). Eczematous Syphilous Exanthematous Strumous Tineous Scabieous Dartrous Haematous Cancerous Dyschromatous Leprous Heteromorphous. Devergie, of Paris, in his excellent treatise, arranges cutane- ous diseases into groups, in accordance with their amenability to treatment; their resemblance in form; their resemblance in pathological products or accidental conditions, and their foreign origin. His groups are fourteen in number, seven cor- responding with the orders of Willan, and the remainder as fol- lows :— Parasitic affections (vegetable) Parasitic affections (animal) Scrofulous affections Syphilitic affections Exotic affections Diseases of nails Infantile diseases; especially of the hairs. The most recent author of a natural classification, Hardy, of Paris, revives the views and some of the groups of Alibert; for example, the Dartres (tetters); in other respects his arrangement takes for its groundwork an etiological and therapeutical basis. Of his ten classes, seven are founded on the cause of the disease; for example, two, special poisons,—namely, eruptive fevers and syphilis ; three, diathesis,—namely, dartres, scrofula, and cancer; one, parasites ; and one,, symptomatic of internal disease. The three remaining classes are: one, topical,—namely, local inflam- mations ; one, elementary lesion,—namely, maculae and deformi- ties; and one, exotic diseases, or diseases of foreign origin. Viewed more in detail, his classes are as follows :— PATHOLOGY AND CLASSIFICATION. 65 HARDY'S CLASSIFICATION. Maculae; deformities Dartres Local inflammations Scrofulous diseases Parasitic diseases Syphilitic diseases Eruptive fevers Cancers Symptomatic eruptions Exotic diseases. 1. Macule and Deformities; including alterations of colour, maculae, red stains, ephelis, vitiligo, lentigo, warts, mol- luscum, ichthyosis and kelis,—diseases requiring no medical treat- ment in general; but in the event of a cure being sought for, to be removed by the knife or by caustics. 2. Local inflammations : independent of any constitutional disturbance; or, if any constitutional symptoms appear at the outset of the disease, they are limited to feverishness of the slightest and most transient kind. The members of this group are: Erythema, Urticaria, Herpes, Ecthyma, Pemphigus, &c. The treatment required is very simple,—mildly antiphlogistic, local and general. 3. Parasitic diseases : purely local, and due to the presence of a parasite, animal or vegetable; for example, Scabies, Sycosis, Herpes circinatus, and Favus. The treatment is obvious;— destruction of the parasite. 4. Eruptive fevers : dependent on a general cause, the admission into the system of a virus, distinct for each variety of disease; for example, Scarlatina, Eubeola, Variola, &c. The eruption on the skin is preceded and accompanied by symptoms of constitutional disturbance of greater or less intensity. In conducting the treatment, the natural course of the disease is to be respected, and complications only attacked. 5. Symptomatic eruptions: the eruption is secondary, the treatment must therefore be directed against the primary dis- ease. The diseases belonging to this group are: Herpes labialis, the roseolous spots of typhoid fever, Sudamina, and Purpura. 6. Dartres : eruptions due to a particular state or general dis- position of the economy, called diathesis: the members of this group are—Eczema, Psoriasis, Lichen, and Pityriasis. These diseases are constitutional; the treatment consequently must be general as well as special. 7. Scrofulous affections : an important group, depend- ing on the scrofulous diathesis. The treatment must be consti- 66 CUTANEOUS MEDICINE. tutional, to control the diathesis, as well as loeally altera- tive. 8. Syphilitic affections : resulting from the syphilitic dia- thesis, a tendency not necessarily innate or hereditary, but, ordi- narily, accidental. The treatment must be the same as that which is adopted for syphilis. 9. Cancers.—The most common form of cancer affecting the skin is that which is termed cancroide. The treatment is the removal of the disease by the knife, or, by preference, by means of caustics. 10. Exotic diseases : the produce of other countries ; for example, lepra tuberculosa, pian, &c. CHAPTER III. ECZEMATOUS AFFECTIONS. Under the head of Eczematous affections, we propose to assemble:— Eczema Impetigo Psoriasis Scabies Pityriasis G-utta rosacea. Lichen Eczema, from **£«», to boil out or boil over, is the popular Greek equivalent of our own popular term " eruption" (eas fx£ff*.*Tct, ab ebulliente fervore, Grasci vulgo appellant*), and therefore means no more than a breaking or bursting forth ; the Greek term, however, is more graphic than our own, inasmuch as it suggests the association of heat, and likens the disease to water in a state of ebullition, the little bubbles formed on the surface of the water being the representatives of the vesicles of eczema. By the scientific Greek writers eczema was called Psora, in consideration of another of its properties, namely, itchiness ; the word psora being derived from ^»e/», to rub ; and the same pro- perty gave origin to the Roman term scabies; the word scabies being derived from scabere (d rxotTTu, second future of », a tree moss, and in the plural number Xetxwif was-probably used as the popular appellation of those clustered groups of pimples which at the present time we term lichen circumscriptus and lichen agrius. It doubtless took its origin from the lichens of the vege- table kingdom. The lexicons define it as a disease of trees, one author designating the olive, another the fig, as the subjects of its attack, and disputing to which the term properly belongs; Theophrastus declaring that it was the olive, while the moss on the fig he termed psora. Lichen is an eruption of papulas, resulting from congestion of the vessels of the follicles of the skin, and some degree of LICHEN. 97 infiltration into the tissues of the walls of the follicles. The pimples are conical in form, minute, more or less deeply red, transparent at the summit, and itchy, and may be compared to the normal asperity of the skin, termed cutis anserina, although from the presence of vascular congestion and infiltration, they are necessarily larger and more prominent than the latter. They are solid, and contain no fluid, the transparency of their points being due to the conical wedge of cuticle which occupies the aperture of all the follicles; and when scratched they give forth a drop of blood, followed by an oozing of a minute drop of serum. When the pimples of lichen are dispersed singly over the skin, they subside by degrees, and are followed by a slight exfo- liation, corresponding with the summit of the papule. When they occur in clusters, they are accompanied with redness, and on the decline of the redness, are succeeded by a laminated exfo- liation of the cuticle. When, however, they have been rubbed or scratched, each papule becomes covered on the summit with a small scab, which is sometimes thin and greyish, sometimes thick and amber-coloured, or brown, and sometimes, when arising from desiccated blood, almost black. The pruritus of lichen is of the hot and tingling kind, and sometimes very severe. Like eczema, lichen is non-contagious, and ft unattended with special constitutional symptoms. The varieties of lichen are founded on the manner of distribu- tion of the eruption, on its symptoms, on its cause, and on its situation. The distribution of the pimples is sometimes dispersed and general, as in lichen simplex; sometimes aggregated, as in lichen circumscriptus, lichen circinatus, and lichen gyratus. The symptoms are sometimes remarkable for the pungency of the itching and tingling, as in lichen urticatus, or for the colour of the pimples, as in lichen livid us. Heat of climate gives a dis- tinction to lichen tropicus; and situation to lichen pilaris, and to lichen strophulus. In a tabular form we should arrange the varieties of lichen as follows:— Lichen simplex Lichen strophulosus " dispersus " urticatus " circumscriptus " tropicus 1 98 CUTANEOUS MEDICINE. To which may be added as sub-varieties :— Lichen pilaris Lichen circinatus " lividus " gyratus Lichen lividus and pilaris, appertaining in chief to lichen sim- plex ; and lichen circinatus and gyratus, to lichen circumscriptus. Lichen simplex.—In the simplest form of lichen, the papu- las are more or less thickly set or dispersed over the surface of the body. They are of moderate redness, pretty uniform in size, and attended with considerable itching and tingling. When they subside, they are followed by a moderate degree of lami- nated and furfuraceous desquamation. When the eruption is scanty but general, they present more or less of a corymbose arrangement like the blotches of measles; and in some parts of the body this disposition is remarkable. It is also to be noted that in some situations the papulae are larger than in others; for example, on the face and upon the limbs. Sometimes the extent of the eruption is exactly bounded by the limits of an article of dress, as in a well-marked case of lichen simplex illus- trated in one of our Portraits of Diseases of the Skin. Lichen dispersus, vel pruriginosus.—Instead of being thrown out in crops and distributed more or less abundantly on parts or on the whole of the skin, lichen sometimes presents a dispersed character; the papulae are solitary and scattered ; the commoner seats of election being the front of the forearms, the lower part of the abdomen, the inside of the thighs, and the ankles. The papules are hard to the touch, only slightly red at first, but more conspicuous after they have been scratched, and especially remarkable for a severe and teasing itching, the erup- tion bearing no proportion in appearance to the annoyance and suffering which it occasions. This variety may be regarded as representing especially the pruritic element of lichen, while lichen simplex represents its papular character: hence, we have termed the eruption lichen pruriginosus. It is the commonest, although not the typical form of lichen, and is frequently met with as a sequel of scabies. It appears to be more than probable that this eruption is the same as that described by Willan under the name of prurigo mitis. Lichen circumscriptus is an aggregated form of the eruption, lichen. 99 in which the papulae are elevated in considerable numbers, and constitute one or more patches of a circular or oval form. The remarkable characters of the eruption are the close aggregation of the pimples, and the abrupt line by which they are separated from the adjoining skin. They are met with chiefly on the chest, the hips, and the limbs; and when they subside, the skin remains for some time rough, wrinkled, and furfuraceous. Lichen strophulosus.—The strophulus of Willan is clearly a lichenr modified by its development on the sensitive skin of infants and children, instead of the firmer and less irritable skin of the adult. The papulas are large as compared with those of the adult; they are sometimes of a vivid red colour, sometimes only reddish ; at other times whitish, with a reddish areola ; and sometimes white and smooth. They are accompanied with pru- ritus, subside in a period varying from a few days to a few weeks, and are followed by a furfuraceous desquamation of the cuticle. Willan describes five varieties of this eruption, namely, Inter- tinctus, Albidus, Confertus, Volaticus, and Candidus. Strophulus intertinctus, the fed gum or red gown,* is distin- guished by papulas of a vivid red colour, interspersed with red dots (probably congested follicles without prominence), and large erythematous patches. Sometimes, he says, there are vesi- cles on the hands and feet, but the fluid is absorbed without rup- ture. The rash occurs for the most part on the cheeks, the fore- arms, and the back of the hands; but is sometimes distributed generally over the body. Strophulus albidus is a sub-variety of strophulus intertinctus; the papulas being hard, minute, whitish, and only slightly ele- vated, and sometimes encircled by a halo of redness. They are met with chiefly on the face, neck, and breast. Strophulus confertus (rank red-gum, tooth-rash) seems to belong to eczema infantile rather than to lichen. The papulas are more extensively distributed, and less vivid in colour than those of strophulus intertinctus. They are sometimes developed in patches of large size, and sometimes the cuticle cracks, and they present the characters of intertrigo. Sometimes the eruption fades and disappears in a fortnight, and sometimes its duration is prolonged by repeated recurrence for two or three months. * Evidently a mispronunciation of " gum." 100 CUTANEOUS MEDICINE. Strophulus volaticus is a rarer form of the eruption, and belongs to the group of lichen circumscriptus. It breaks out in circular, patches or clusters of papul*, which turn brown in four days and disappear. Other patches appear in succession, and the disease acquires a duration of three or four weeks. Strophulus candidus is a hybrid that would perhaps be better omitted altogether. The papulas are large, smooth, and shining, and have no redness around their base. They would seem to be whiter, smoother, larger, and more passive than th.e papulae of strophulus albidus. They have been met with on the shoul- ders, the upper arms, and the loins ; and they disappear in about a week. Willan saw them once associated with strophulus con- fertus, appearing on the face and neck; and, in another instance, he found them on the arms of a child three years and a half old, who was cutting some double teeth, and likewise had porrigo larvalis, or, in modern language, eczema ichorosum and pustulo- sum of the face. Lichen urticatus is a natural transition from lichen strophu- losus, inasmuch as it is an eruption which belongs especially to children; begins with inflamed spots, which are succeeded by larger pimples than ordinary lichen, and is accompanied with severe pruritus. This form of lichen was first described by Bateman, and is extremely well marked ; the spots at their first appearance resemble gnat-bites or bug-bites, and remain inflamed for a day; after which the redness and pimple subside. When, however, they are rubbed or scratched, the pimple becomes more prominent, and bleached like the wheal of urticaria, and instead of subsiding, remains for several days; and if the scratch- ing be such as to remove the head of the papule, a small drop of blood escapes, and dries up into a minute black scab. As the eruption is successive, a few spots appearing each night, and occasionally also in the day, the body and limbs become spotted all over with pimples in every stage of progress. They are commonly single in their outbreak, but occasionally form, here and there, a small cluster. The term urticatus is warranted not only by the occurrence of muscular spasm in the pimple, which gives it a bleached appearance similar to that of the wheals of urticaria, but also by the severe, and frequently intense tingling and itching, which destroy sleep, and often affect seriously the child's health. The LICHEN. 101 pruritus is commonly set up by the heat of bed, and sometimes by mental emotion. The eruption is obstinate in its nature, and often lasts for many months. Lichen tropicus, or prickly heat, is the usual form of lichen as it attacks Europeans in hot climates. Dr. Winterbottom describes it as consisting " of numerous papulas, about the size of a small pin's-head, and elevated so as to produce a considerable roughness of the skin. The papulas are of a vivid red colour, and often exhibit an irregular form, two or three of them being in many places united together; but no redness or inflammation extends to the skin in the interstices of the papulae. " The eruption is diffused over those parts of the body which are usually covered, as the neck, breast, arms, legs, and inside the thighs. It does not often appear on the face, excepting on the upper part of the forehead, contiguous to the hair; neither is it ever found in the palm of the hands, sole of the feet, nor on the hairy scalp. The number of the papulae is much increased by wearing flannel, or clothes too warm and thick for the cli- mate. When perspiration is very copious, small vesicles, con- taining a limpid humour, are often intermingled with the prickly heat, more especially on the breast and about the wrists; bu/t they terminate in scales, having no disposition to ulcerate, though violently scratched. A troublesome itching attends the prickly heat, and prevents sleep during the night. There is likewise a frequent sensation of pricking, as if a number of pins were piercing the skin. This often takes place suddenly after drink- ing a dish of tea, or any Warm liquor, so as to cause the person affected to start from his seet. The eruption is in general sta- tionary, and appears equally vivid in the day and in the night. It does not leave one part and arise on another, unless the former be much exposed to cold, and the latter be heated by additional clothing, or by friction. An increase of heat, indeed, in all cases, produces a greater number of papulas. They sometimes disappear on a sudden, and return again as suddenly, without any obvious cause; but whenever the eruption continues for a length of time, the papulas throw off minute scales, and are suc- ceeded by a fresh crop, no vestiges being left in the skin. The prickly heat is in general considered as a salutary eruption; whence we are cautioned not to repel it from the skin by cold or 102 CUTANEOUS MEDICINE. other external applications. Such a repulsion cannot, however, be easily effected ; it is certainly not produced by bathing, which has been hitherto thought highly prejudicial. A vivid eruption of the prickly heat is a proof that the person affected with it is in a good state of health, although its absence does not always indicate the contrary. The sudden disappearance of it which frequently happens is rather an effect than -a cause of internal disorder, as of fever, or of any slight complaint of the stomach ; in the latter case, a temporary stimulus applied to the stomach, as by spirits, tea, or other warm liquids, has the power of restor- ing the eruption. Its appearance on the skin of persons in a state of convalescence from fevers, &c, is always a favourable sign, indicating the return of health and of vigour. "Various means have been employed to alleviate the itching and tingling of the prickly heat; the favourite remedy at Sierra Leone is the juice of lime rubbed on the skin, which, however, has no considerable effect. I have found it of most advantage to use a light cool dress, and to avoid the drinking of warm liquors." Lichen pilaris.—We have seen that lichen has its patho- logical seat in the follicles of the skin ; we are therefore prepared to find a modification of the papules bearing relation to the size or closeness of distribution of the follicles. Thus, on the trunk of the body the papulae are small; on the limbs they are coarser; while on the scalp, where the largest follicles exist, papules are almost wholly wanting. On the limbs, and particularly on the lower limbs, we sometimes meet with papules which surround the hairs at their escape from the follicles, so that the hairs have the appearance of growing out of the papules: this is lichen pilaris; and its occurrence is evidently due to a physiological cause. Lichen pilaris is therefore nothing more than a lichen simplex developed on the limbs, and especially the lower limbs, in relation with the abundant hairs and coarser follicles which are found in that region. Lichen lividus.—In peculiar states of the constitution, the circulation in the papules is so sluggish that the venous change of the blood has time to take place in the congested vessels, and the papules have consequently a purple or livid hue. This alter- ation of colour is most commonly met with in the lower extre- mities, where the papules are usually of large size; and we have LICHEN. 103 seen it in persons enjoying an average state of health, and sur- rounded by the comforts and even luxuries of life. It is not necessarily a disorder of the squalid and the ill-fed; although sometimes associated with the petechia of purpura and other indications of a cachectic habit. Lichen lividus is therefore a lichen simplex accompanied with a torpid circulation through the cutaneous vessels. Lichen circinatus is a modification of lichen circumscrip- tus, occasioned by the subsidence and dispersion of the papules in the middle of the patch; and commonly by the extension at the same time of those of the circumference. The patch is thereby converted into a ring, with a border of varying breadth, and may run on to a considerable size.* At other times the ring is broken at one point, and the extension takes place irre- gularly by the remainder of the segment; or the patch runs on in a longitudinal direction to a considerable length, and is more or less tortuous in its course. This latter is the Lichen gratus, or convoluted form of the eruption, and is a mere modification of lichen annulatus; both lichen annulatus and gyratus being simply alterations in figure of lichen circumscriptus. Diagnosis.—Lichen, being a pimple, cannot be confounded with any other pathological form; if, associated with the papu- lar eruption, there be other pathological forms present, such as erythema, vesicles, disruption of the cuticle, or exudation, the case is no longer one of lichen, but an eczema papulosum; although, a few scattered vesicles on parts of the skin, while the chief extent of the eruption is papular, is not inconsistent with the diagnosis of the eruption as one of lichen. When, with the papular eruption, there are indications of the presence of the acarus in the cuticle of the hands, the case is scabies ; and where the itching is violent and intense, the pimples are wanting, and other indications exist of an unhealthy nutrition and innervation of the skin, the disease is prurigo. * The description of papulae by Celsus harmonizes remarkably with this descrip- tion. . " There are," he says, " two kinds of papulas," that is, papular eruption; " in one, the skin is roughened, with very small pustules (i. e. pimples); is red, and slightly eroded ; the eruption being somewhat smoother in the middle than at the circumference, and spreads slowly. This kind begins for the most part as a circular eruption, and spreads by the border." 104 cutaneous medicine. Cause.—The cause of lichen is identical with that which gives rise to eczema, namely, debility ; the difference in the form of the eruption being due to constitution and temperament. Where the temperament is lymphatic, eczema will be developed; while in a bilious, and especially in a nervous temperament, the eruption will be lichen ; the essential differences between them being the difference of moist and dry; the latter being associated with irritability of the nervous system. The kinds of debility also resemble those of eczema, namely nutritive, assimilativej nervous, and local; and the remote predisposing causes: cuta- neous irritability, the sequel of scabies; deranged digestion; coldness of season and climate; errors of diet; errors of air and exercise; the eczematous diathesis ; vaccination; dentition ; and excessive lactation. With regard to strophulus, Bateman remarks that it arises from an "irritability of the skin at that period of life when the constitution" is easily " disturbed by irritation, either in the alimentary canal, the gums, or other parts." Prognosis.—Lichen is by no means serious, and is only of importance from the irritable pruritus by which it is accompa- nied, and which, by destroying rest, tends to weaken the sys- tem and to produce general disorder of the economy. It is usually a milder malady than eczema, particularly the local forms, and of shorter duration, lasting, commonly, only a few weeks, but sometimes prolonged for several months, and even for years. The time of life at which it is most frequently met with is child- hood and maturity ; but it is also observed at other periods. Lichen strophulosus is an eruption of infants, and lichen urtica- tus is chiefly met with in young children. Treatment.—The constitutional treatment requires the mild- est aperients to regulate the digestive organs and secretions, fol- lowed by bitters and the mineral acids, by chalybeates or by quinine. In chronic cases, arsenic, as prescribed for eczema, will generally effect a cure. The internal remedies recommended by Bateman for strophu- lus are, gentle laxatives, when any feverishness is present, fol- lowed by decoction of bark, or chalybeates; of the latter, he particularly favours the tartrate of iron. Doubtless had the superphosphate been in use in his day, he might have given it a preference, as being peculiarly suitable to children. To his IMPETIGO. 105 internal treatment he joins, a carefully selected diet, proper exer- cise, and the use of ablutions with tepid water, plain and with the addition of milk. He likewise expresses an old-fashioned dread of repercussion of the eruption from exposure to cold draughts of air, or the use of cold water, and he suggests that in such an event we should administer some slight cordial, such as a few drops of sal volatile, and apply a blister externally. At the present day we prefer the stimulus of mustard to that of cantharides for the skin of infants, or frictions with a mildly stimulating liniment, such as cajeput oil with soap liniment. The local treatment of lichen calls for the use of ablutions with the juniper-tar soap, tepid bathing, and anti-pruriginous and moderately stimulating lotions, such as an emulsion of bitter almonds with hydrocyanic acid, or with bichloride of mercury * and spirits of wine. But the most certain and powerful anti- pruriginous lotion is one composed of the pyroligneous oil of juniper, spirits of wine (of each an ounce), and water (six ounces). The latter remedy has been found very successful in lichen urticatus. When the lichen circumscriptus is obstinate, it may be dispersed by gentle friction with the ammonio-chloride, or nitric oxide of mercury ointment. IMPETIGO. Impetigo is a Latin term, derived, according to Pliny, ab impetu, impetu agens, acting with force, with severity, and con- veying the idea of a more energetic form of inflammation than that which accompanies the two preceding affections, eczema and lichen. Eczema, as we have seen, is essentially an exuda- tive, a lymphatic, or a moist affection, an affection in which the exuded material is a serous lymph; lichen is a dry affection, without exudation, but with an increment of pruritic irritation; while impetigo must be regarded as representing the pyogenic or purulent element. The student will easily appreciate these distinctions, and they will serve to illustrate three of the eight types of the Willanean classification. These terms are purely arbitrary, and therefore arises the greater necessity of making them definite. Eczema conveys in its meaning no idea of exudation; lichen, no idea of solidity 106 CUTANEOUS MEDICINE. and pruritus; and as little does impetigo any notion of pus- formation. Moreover, in eczema we find all the three affections combined: with exudation in one part, there are lichenous papules in another, and impetiginous pustules in a third; and to express the combination we have invented the compound terms, eczema lichenodes, or eczema papulosum, and eczema impetiginodes, or eczema pustulosum. If we turn to our authorities, we discover another argument for precision of definition. The impetigo of Celsus is through- out an eczema; he gives us no hint of any distinction founded on the presence of pus. The impetigo of Willan, although founded on the notion of pus, fails to make the pustule definite, and embraces every form of eczema in which a purulent or muco-purulent secretion prevails. Hence the necessity of repre- senting these distinctions each by a substantive malady; namely, eczema, the impersonation of sero-lymphatic exudation ; lichen, the impersonation of the solid, and dry, and itchy papule; and impetigo, the impersonation of pus, or of a purulent secretion; and establishing an identity between eczematous and vesiculous, or more properly, exudative ; between lichenous and papulous ; and between impetiginous and pustulous. There remains, however, this further and very important dis- tinction, that eczema, being the mother disease, embraces in itself all the papulas and pustulas which may chance to be associated with it; whereas, the term lichen is to be strictly limited to papulas without vesicles, exudation, or pustules; and impetigo, to pustulas without vesicles, exudation, or papules. By this arrangement we gain precision ; and we gain confidence in the use of the language of our science, a very important considera- tion. Impetigo is an inflammation of the skin, accompanied with the formation of pus, which raises the cuticle into small pustules. The redness is commonly vivid; there is some swelling; the pus is light-coloured and of the kind termed sero-purulent; but may present every tint of yellow in its hue; and dries up into a greyish or amber-coloured crust. The crust remains adherent for some days, and at its fall, leaves the skin red and shining, but without any permanent mark or scar. The eruption is non- contagious, like its congeners eczema and lichen, and is not attended with constitutional symptoms. impetigo. 107 The absence of cicatrix marks the fact of the superficial ope- ration of the inflammation, and affords us evidence that the pus is not generated at the expense of the vascular tissues of the skin, but is simply a morbid transformation of the newly-formed cells of the rete mucosum. Indeed, it would be incorrect to regard the pustule of impetigo as a true pustule, such as that of ecthyma or variola, which is the result of a destructive altera- tion of the cutaneous tissue, and consequently leaves behind it a permanent cicatrix; but as a mere modification of the serous vesicle, a vesicle, in fact, containing a sero-purulent fluid. Hence, it is no uncommon phenomenon to see one of these sero-pustules of larger size than usual, surrounded by several coherent vesi- cles, which invest it in a circle, and form together a small com- posite patch. The reading of such an appearance is briefly, an energetic burst of inflammatory actiom in the production of the primary or central pustule, and a weakening of energy in the formation of the secondary, the circumtangent, and subordinate vesicles. The pustule of impetigo is of the kind termed psydracium, and in the plural psydracia tyvx,?* v&p**i*,frigido3 guttulce), that is, a pustule or pustules produced with little heat or inflammation, commonly aggregated or confluent, and, after the discharge of their pus, pouring out " a thin watery humour, which frequently forms an irregular incrustation." Impetigo is an affection indicative of a lower grade of vitality than either eczema or lichen, and is met with most frequently in those of a cachectic habit, and particularly in children and women. It is rare as compared with the former affections, and is more commonly seen amongst the poor, and in workhouses, than in the middle rank of society. The varieties of impetigo are two in number, namely, impe tigo figurata and impetigo sparsa ; the former indicating a state of aggregation of the pustules, and the latter their dispersion. To these Willan added three others, namely, erysipelatodes, sca- bida, and rodens, of which the first and second evidently belong to eczema, and the third is a syphilitic ulceration. An impetigo capitis, admitted by ourselves, must also be transferred to eczema capitis. Impetigo figurata appears in the form of clusters of small pustules developed upon a more or less inflamed and swollen 108 CUTANEOUS MEDICINE. ground, and forming a circumscribed and often circular patch. There may be several of these patches developed on the trunk of the body or limbs ; but they are most frequently observed on the face, and particularly around the mouth. They are often chronic, and often successive in their occurrence. Impetigo sparsa is the scattered form of the eruption. The pustules appear singly or in smaller clusters than in impetigo figurata, and are dispersed over the whole body, being not unfre- quently met with on the hands and feet of children. The impetigo sparsa very commonly presents on certain parts of the body, and especially upon the hands and feet of children, the characters before referred to of a central pustule with a sur- rounding circle of confluent vesicles or phlyctenae. This form is so frequent that we have thought it deserving of a separate designation, and have named it impetigo phlyctenodes. Diagnosis.—The only pustule with which impetigo can be confounded is ecthyma; the characters of distinction, however, are sufficiently obvious. The small congregated sero-pustules of the former standing upon a slightly swollen but not much inflamed ground, are in striking contrast with the large, well- formed, deep yellow, solitary semiglobes, with inflamed and hardened base, of the latter ; the former a psydracious, the lat- ter a phlyzacious pustule; the former disappearing without leaving a trace behind, the latter leaving a cicatrized pit of greater or less permanence. Cause.—The cause of impetigo, as of the other eczematous affections, is debility ; the debility being chiefly of the nutritive kind, and the most prominent of the remote predisposing causes, general cachexia, bad ventilation and drainage, errors of diet, and the after-irritation of scabies. Prognosis.—Impetigo is not a serious affection; but as it betokens constitutional debility, a pyogenic diathesis, and a ten- dency to cachexia, might possibly lay the foundation of a more grave disturbance of health, if not speedily and effectually checked. Treatment.—The indications for treatment are the same as those which are applicable to the previous forms of eczematous affection, and the remedies of a similar class : the regulation of the digestive and secreting organs when they are found to be faulty, and the succession of bitters with the mineral acids, cha- SCABIES. 109 lybeate with the mineral acids, quinine, and where the disease assumes a chronic character, the ferro-arsenical mixture, or one of the other forms of that mineral. The local treatment should be similar to that for eczema: saturnine lotions if there be much heat, and subsequent dressing with a cerate of acetate of lead; or the benzoated ointment of oxide of zinc with spirits of wine ; lastly, in the squamous stage of the eruption, ablutions with the juniper-tar soap and slight inunction with the benzoated ointment of oxide of zinc, or one of the mercurial ointments considerably diluted (3 ij ad ^j). Where ointments are unsuitable, we must trust to lotions, and dredging with a desiccative powder, such as oxide of zinc and calamine, of each one drachm, diluted with six drachms of powder of starch. SCABIES. Scabies—derived from scabere, to scratch—is the Latin repre- sentative of Psora, our modern Eczema; but is at present used in a much more limited sense; no longer the head of a group, but, comparatively, an insignificant member. Scabies is an eczema, dependent, not upon a constitutional cause, like the preceding diseases; but upon a local and special cause—the presence in the cuticle of the acarus scabiei. The acarus scabiei'in this country, and amongst cleanly peo- ple, has its habitat only in the hands; in foreign countries it is said to be more generally distributed, and to be found in other parts. Being present, therefore, only in the hands, the erup- tion which is thrown out upon the rest of the body is the result of an irritation communicated through the nerves, in other words, a sympathetic irritation, and the kind of eruption will be influenced by the constitution and temperament of the sub- ject. In a person of nervous temperament, it may consist of redness or erythema, and papulas; in a person of lymphatic temperament, besides erythema and papulas, there will be vesi- cles also; and in a child of full habit and weakly powers there will be, in addition to erythema, papulas, and vesiculas, a crop of superficial pustules of moderately large size thrown out upon the hands and feet. The eruption is found in different parts of the body to be vari- 110 CUTANEOUS MEDICINE. ously distributed ; it is always present, and usually abundant, upon the hands; next in quantity it is found in the flexures and upon the front of the forearms; then on the lower half of the abdomen; upon the upper and inner part of the thighs; upon the penis and podex; and, in children, upon the feet. The habitat of the acarus is indicated by a furrow in the cuticle. The furrow has necessarily a ragged edge, and if it be followed with the eye, it will be seen to slip below the surface of the cuti- cle, like a tunnel, and run on for some distance further. The upper wall of the tunnel is arched, and presents a series of con- vexities that suggest the idea of a string of beads, and, at the extremity, the tunnel terminates in a kind of circular dome, and is larger than the rest of its area. The tunnel is the cuniculus or burrow of the acarus, and under the semi-globular dome at the end of the cuniculus the little animal will be found. If this part be closely inspected, there will be seen shining through the thin dome of cuticle, and corresponding with the most distant segment of the dome, a reddish-brown crescent; this crescent is the chytinous covering of the head and fore-legs of the animal, and, frequently, a whitish, pearl-like globe may be seen occupying the rest of the dome: this is the abdominal segment of the animal. The cuniculus is always more or less curved and tortuous, and frequently reaches half an inch in length. Sometimes the fur- row begins at a circular or oval space which represents the base of a destroyed vesicle, and sometimes a vesicle may be found in the course of the cuniculus ; or the cuniculus may be lifted up by a vesicle, and the acarus seen at the end of its cuniculus and within the cuticular wall of the vesicle; but it is never met "with in the vesicle itself; the vesicle being the result of the irritation caused by the burrowing of the acarus. It is common to find a vesicle in the course of the cuniculus or closely adjoining, and frequently we are led by the presence of the vesicle to seek for the furrow and tunnel just described. The cuniculus of the acarus is usually found in the more pro- tected parts of the hand, and where the cuticle has a medium thickness; for example, and first, between the fingers, along the sides of the fingers, then along the ulnar border of the hand, in the flexure of the wrists, and lastly, in the palm of the hand. On the wrists and in the palm of the hands the burrows usually take the course of the lines of mtjtion, and diverge from point SCABIES. Ill to point. In children, the palms of the hands are more fre- quently selected than other parts; and in them the cuniculi are also detected in the soles of the feet. In France and Germany the acarus is said to be found also on the penis and podex; but we have never seen a cuniculus in either of these situations in any of the patients who have come under our care. To obtain a specimen of an acarus, all that is needful is to raise the semi-globular dome of the extremity of the cuniculus with a needle-point, and insert the point of the needle into the hollow; the animalcule generally clings to the needle, and may be seen attached to it when the needle is withdrawn, and may then be transferred to a slide of glass and placed under a micro- scope, or examined with an ordinary lens. Professor Hebra told us that his plan of securing an acarus was to pinch up a piece of the cuticle enclosing the ^nd of the cuniculus with a pair of fine scissors and then transfer it to a slide; he, more- over, informed us that he selected the skin of the buttock for this operation. The acarus scabiei, under a lens of low power, has the appear- ance of a minute white and shining globe, and this appearance is increased by the habit of the animal, of depressing its head and lifting its hinder or abdominal segment when it walks. Observed with a higher power, it is seen to bear a very close resemblance to a round-shaped tortoise ; it has a carapax above and plastrum beneath, and from the anterior border of the carapax there project forwards a cylindrical head and two pairs of very strong legs or arms. The head and arms are encased in a reddish-brown chytine, and it is this chytinous base that gives the appearance of a dark crescent to the front seg- ment of the animal when seen through the transparent dome at the end of its cuniculus. On the head are several pairs of short hairs; on the back, numerous short spines, which project backwards, and on the arms, and sides of the carapax, also several pairs of long hairs; but the longest hairs are directed backwards from the posterior segment of the carapax ; the long- est of all being derived from the posterior legs. Viewed upon its under side, which is flatter than the carapax or dorsum, the head is seen to be provided with strong jaws ; the four anterior legs are found to be jointed and very strong, and disposed like the forelegs of the mole, while the four hinder legs are weak 112 CUTANEOUS MEDICINE. and diminutive, and scarcely reach to the border of the abdo- men. All the legs are besides furnished with a fistulous tarsus, and a fan-shaped and lobulated foot, provided with suckers like the foot of the house fly. The construction of the animal is adapted to its habits of bur- rowing and onward progression ; and its retreat from its burrow can only be effected by turning completely round. It is this necessity which very probably gives the varicose or beaded appearance to the tunnel of the cuniculus. Naturalists have recently discovered a difference between the sexes of the animal; the male is somewhat smaller than the female, and is adapted to a more active locomotion. He is accredited with the habit of roving about on the surface of the cuticle, while the female lives at home in her burrow, depositing and protecting her eggs. Their food would seem to^ be the softer and more vitalized deeper layers of the cuticle, the rete mucosum. The largest acarus that we have seen measured about -g^ of an inch in length by about Tfa of an inch in breadth, and was therefore not far removed from the circular form. The ova are oval in shape, and are produced in considerable numbers. The pruritus of scabies is somewhat different from that of other pruriginous complaints ; it is a kind of tickling itching, and the rubbing and scratching employed to relieve it are said to be pleasurable. King James I. has the credit of having declared that none but kings and princes should have the itch, for. the sensation of scratching was so delightful. The itching in scabies seems to depend upon the operations of the acarus, and subsides when the little creature takes its rest; it is most troublesome when the patient is warmed by exercise, and especially when the body is heated by the warmth of bed-coverings. This fact renders it probable that the opera- tions of the acarus are carried on chiefly during the night: by night, and when the patient is in bed, it is supposed to quit its burrow and wander in search of more suitable accommodation ; and this is the period also, when it is most easily transferred from one person to another: hence scabies is more certainly acquired by sleeping with an affected person than in any other way. Scabies is one of the very few contagious diseases; it is the only one that is so in the group of eczematous affections ; and it SCABIES. 113 is contagious, simply by the transfer of an acarus or some of its ova from one person to another. Sometimes the transfer is direct, as in sleeping with an infected person; sometimes it is indirect, when it passes from one individual to another through the agency of bed-clothes or body-clothes, through linen sent home from the wash, through the handling of objects belonging to a scabious person, or through using the same closet. The varieties of manifestation of scabies, we have stated to depen'd upon the constitution or temperament or age of the patient, and not upon any difference in the disease itself, or in its cause. There are consequently no real varieties of scabies. Willan and Bateman, however, describe four varieties of the disease, founded on the popular " epithets of rank, watery, pocky, and scorbutic itch," under the names of " papuliformis, lympha- tica, purulenta, and cachectica." In the first of these forms we recognize the dry pimples of lichen; in the second, the" vesicles of eczema ; in the third, simple superficial pustules ; while the fourth is intended to include those not un frequent cases in which all the forms, namely, erythema, papulae, vesiculas, pustulas, and squamas, are present together. When all these forms of eruption are present together, the papulae are found most abundantly on the back of the hands, on the forearms and flexure of the elbows, on the abdomen, and on the inner side of the thighs. The vesiculce are chiefly met with between the fingers, along the ulnar side of the hands, in front of the wrists, and on the back of the hands; in the last-men- tioned situation the vesicles are minute and semi-globular, while between the fingers they are mostly conical. Sometimes several vesicles become confluent, and when broken, give out an oozing of a viscous serous lymph; and occasionally about the wrists there are larger vesicles, in fact bullulas, or small phlyctenas. Pustuhe, when they occur, are generally developed on the back or palm of the hands. The assemblage of all these forms is most commonly observed in young children; in whom is also seen, at the same time, a hot and damp state of the hands and feet from perspiration. In the vesicular or lymphatic itch there is also, not uncommonly, a slight degree of cedematous swelling of the back of the hands. It may seem remarkable that so purely local a cause as the presence of a minute animalcule in the cuticle in simple proxi- 8 114 CUTANEOUS MEDICINE. mity with the sentient skin, should be capable of giving rise to a reflex irritation that is manifested in the most distant parts of the body; such, however, we believe to be the case; and the known physiological phenomena of the nervous system warrant the conclusion. We have in our mind the following example : a gentleman complained of pruritus of the skin between the little and ring finger of the right Ifand ; we looked at it and detected the cuniculus of an acarus ; there seemed to be but one ; he had no eruption on any other part of the hand, but he complained of a few pruritic pimples situated on the upper part of the same arm, some on the right flank, and some on the upper part of the right thigh. There was no eruption whatever on the left hand or left side of the body. Being a friend, I suggested to him the experiment of rubbing a little sulphur ointment into the site of the cuniculus between the fingers, and to do nothing for the rest of the eruption; he did so, and the general as well as the local irritation was immediately allayed. We have remarked that in some countries, and it may happen also in this country, if the animalcula be abundant, the acarus has been seen in the thin cuticle of the prepuce, and on the podex. It is supposed to reach these situations from the hands; the erup- tion common on the buttocks of children is also supposed to be derived from the hands of the nurse; again, on the mammas of nursing females, the agent of transmission is believed to be the hands of the infant. Diagnosis.—The student must familiarize himself with the discovery of the acarus, as upon this, and this alone, the dia- gnosis of scabies depends. A roughness and pimply eruption between the fingers, and upon the wrists, is always suspicious; but suspicion does not become certainty until we discover the cuniculus and its inmate. Not even does the presence of a crop Of vesicles, conical or otherwise, and oozing a viscous and colour- less lymph, afford proof of scabies without the animalcule. If we have before us a pimply eruption upon the forearms, the flex- ures of the arms, the abdomen, and the inside of the thighs, the case is in all probability scabies ; but without the proof afforded by the acarus we are unable to say more than that the disease is lichen pruriginosus, and to all appearance a scabies. It is important to remember that the acarus scabiei is capable of setting up an eruption of the skin at a distance from the part SCABIES. 115 where the irritation really exists, and that the eruption so set up may be greater or less according to the susceptibility of the patient, and that it will be greatest of all in a person of eczema- tous diathesis; on the other hand, it is to be noted that on the withdrawal of the cause of irritation, that is, upon the destruc- tion of the acarus, the eruption does not immediately subside, but in different constitutions may* linger for a longer or shorter space of time. The eruption under these circumstances may be termed secondary; and the secondary eruption of scabies is the subject of much perplexity, both of diagnosis and treatment. It is a fact, that although the cause be removed, the irritation of the skin excited by that cause may be perpetuated, and the eruption continue for several weeks or months as an independent disorder, as, in fact, a lichen pruriginosus; and the eruption is all the more likely to continue, and to be aggravated, by the use and persistence in the use of sulphur, which is the best and most reliable remedy for scabies. Under these circumstances, the diagnosis of scabies, the acarus, becomes doubly important, and in the absence of all indications of the presence of the animal- cule in the hands, we must consider the case to be, not a scabies, but a lichen pruriginosus, and treat it accordingly: by treating it as a scabies we prolong it indefinitely; by treating it as a lichen, we cure it with an equal degree of certainty. Cause.—The cause of scabies is the presence of an animal- cule, the acarus scabiei, in the cuticle; it is quite independent of any disturbance of general health; and the animalcule in general thrives better in the skin of persons enjoying moderate health, and especially of children, than it does in that of the squalid, the emaciated, and the diseased. The cause of the secondary eruption is, however, constitutional, and must be referred to those causes that give rise to eczema and lichen in general. Prognosis.—The eruption is harmless, and removable more or less easily without trespass upon the powers of the constitu- tion. Any strain upon the general health must, therefore, be referred to the presence of eczematous diathesis, and irritability of the nervous system, and not to that of the acarus. Treatment.—The treatment of scabies is expressed in a single word,—sulphur. Sulphur must be administered internally, and used externally, but with discretion. Our plan is as follows:— 116 CUTANEOUS medicine. We wash the entire skin, once or twice daily, with sulphur soap, the hands more frequently; we rub the simple sulphur oint-, ment into the hands and wrists night and morning; at night we leave it on the skin, and recommend the patient to wear gloves; in the morning, after the soap ablution, a smaller quantity of ointment suffices, which we allow to be wiped away after having been well rubbed in; and any remains of greasiness removed with sulphur powder. This plan we continue for a week, and then stop; but we recommend the continuance of the soap ablu- tion for a second week. The lichenous eruption on the rest of the body we sponge with lotions of hydrocyanic acid in emulsion of bitter almonds; with emulsion of bitter almonds, containing the bichloride of mercury, one grain to the ounce;, or we anoint with the ben- zoated ointment of oxide of zinc, with spirits of wine or spirits of camphor. And if the sulphur soap ablutions be at all irritat- ing to the skin, we substitute the juniper-tar soap. Internally, we prescribe a powder, containing sublimed sul- phur, bitartrate of potash and white sugar, of each ten grains (for a child, gr. v.), night and morning; and with the simple object of creating an atmosphere of sulphur, both internally and externally, about the patient, and presenting to the acarus a vapour destructive of its life. Moreover, as precautions when simple and easy of application cannot be over much multiplied, we recommend the sprinkling of sulphur powder in the bed of the patient, and its dispersion amongst his clothes. Strong odours, also, are destructive of the acarus, and these, particularly the essential oil of camomile, we combine with the ointment. There are many other remedies recommended for scabies, but none so good or so efficient. Reviewing our plan as above detailed, it will be observed that we advise its continuance for a week, whereas the acari are often destroyed by a second inunction; but it must be remembered that the ova remain, and if the sulphur treatment were too soon suspended, some of the ova might escape, and the disease, in a short time, be renewed. Againr the treatment neither requires isolation, nor suspension of the ordinary intercourse of life, and therefore may be tolerated for a longer period than a more violent method, or than the older treatment, which prescribed inunction of the whole body with the compound sulphur oint- GUTTA rosacea. 117 ment night and morning, and bed between blankets for several days or for a week. Sometimes a sulphur-vapour bath, or a lotion of the pentesul- phide of calcium, may be preferred to the inunction; but we know of no plan of treatment better suited to the purpose than that which we have already detailed. This treatment is founded on the presumption that the acari are limited in their presence to the hands; or, in children, the feet as well as the hands; but if it be ascertained that they are also present in other parts, then the sulphur inunction must be extended equally to them. The secondary eruption of scabies, the lichen pruriginosus, must be treated on the same principle as lichen in general: antipruri- ginous, or gently stimulating lotions; the benzoated ointment of oxide of zinc; and, internally, laxatives and mild tonics, with the mineral acids. GUTTA ROSACEA. Gutta Rosacea has heretofore been confounded with acne, under the name of acne rosacea; we shall endeavour to show that the two diseases are essentially different. Gutta rosacea is the red and pimply face of the mid-period of life, a disease of inflammatory congestion, and depending on constitutional causes; . acne is a disorder of secretion, of nutrition, of growth, and an accompaniment of youth and the development of the cutaneous tissues. Gutta* rosacea is an inflammatory congestion of the skin of the face, accompanied with erythematous patches, red spots, papulae, sometimes small and sometimes large, pustules, and tubercular thickening of the integument. It is chronic and progressive in its course, and the greater or less development of its pathological signs constitutes its varieties ; for example, gutta rosacea erythematosa, papulosa, tuberculosa, and pustulosa. Gutta rosacea makes its beginning with simple flushes of the face, which are transient; they are produced under the influence of the stimulus of food, commonly at dinner, and sometimes of emotion. These flushes, at first occasional, soon become habi- tual, and, frequently repeated, they give rise to a permanent * A drop or spot. 118 cutaneous medicine. distension of the vascular plexus of the skin, and the red face is established. This is the erythematous stage of the affection, and in conformity with the degree of congestion and the energy of the circulating power, we find certain obvious modifications. At first, and in persons of firm tissue and healthy muscular system, the cutaneous circulation is vigorous, and the colour of the skin the scarlet tint of arterial blood; after a time, months probably or years, or in a person possessing soft tissues and weakly muscular power, the circulation is languid, the blood undergoes its venous transformation in the skin, and the tint of the redness is changed to crimson, purplish, or roseate, and occa- sionally also becomes livid. It is the frequency of this altera- tion of colour that has suggested the term " rosacea," applied to the disorder; but it will be seen that the roseate hue is by no means a necessary accompaniment of the affection, and, when it exists, represents an advanced stage of the morbid process. We have previously directed attention to the deep circulation of the skin, the follicular circulation, as compared with the sur- face circulation; this difference is conspicuous in every conges- tion of the skin, and is sometimes very striking in gutta rosacea. Congestion of the follicular circulation is known by a dotted or punctated appearance in the skin (gutta rosacea punctata), each dot corresponding with a separate follicle; and the presence of these dots is the indication of a commencing development of papulae (gutta rosacea papulosa), the papulae having the same origin and structure as those of eczema or lichen. An accumu- lation of papulae at some one point produces the more extensive rising known as a tubercle (gutta rosacea tuberculosa), and the formation of pus in the summit of a papule or tubercle consti- tutes the pustular form of the disease, or gutta rosacea pustulosa. Gutta rosacea is attended with sensations of heat, burning, itching, and, in the pustular form, lancination and throbbing. When the pimples are rubbed or scratched, a little serous lymph oozes from their summit and forms a small crust; but there is never the amount of exudation which exists in eczema, and, as a consequence, never the same thickness of crust. Gutta rosacea, in a chronic form, necessarily occasions consi- derable thickening of the skin of the face, and in aggravated cases produces those unsightly blotches and tubercles which have been noted by Shakespeare:— GUTTA ROSACEA. 119 " His face is all bubukles and whelks and knobs, and flames of fire." From its occasional association with habits of intemperance, it has been termed " Bacchia," and the tubercles " grog-blossoms " and " carbuncles." And when the nose is the seat of the dis- ease, the whole organ is swollen, and the end of the nose thick- ened and hypertrophied, marked by large superficial veins, often very blue or livid, and studded with yellow pustules and ugly crusts. The characters already described bring gutta rosacea into the category of eczematous affections; namely, the kind of erup- tion ; its tendency to exudation, although in a slight degree; its development in the form of a rash or an eruption; and we may add, its dependence on constitutional causes. We have fre- quently seen it associated with eczema existing in other parts of the body, and in persons possessing the eczematous diathesis. It is essentially a chronic affection, lasting, when not restrained by treatment, for years. It has no constitutional symptoms of its own, and is obviously non-contagious. It is more frequent than would be imagined, occurring in private practice once at least in every ten patients : it is nearly six times more frequent in the female than in the male, and is commoner in the unmarried female than in the married.* Diagnosis.—Gutta rosacea may be mistaken for an eczema erythematosum and papulosum, for a lichen, or for an impetigo; but the general history of the affection will determine its iden- tity ; in a practical point of view, the blunder is not of much consequence, for the treatment is the same. With regard to acne, it is to be borne in mind that the latter disorder is one of torpid glandular action, accumulation of altered sebaceous sub- stance in the gland and its follicle, and inflammation resulting from mechanical pressure and irritation caused by the impacted matter. Moreover, it is commonly associated with other indica- tions of disordered function of the sebaceous glands and follicles, and occurs in young persons, beginning at the age of puberty. Whereas gutta rosacea is a disease of middle life, has none of the sebaceous complications referred to above, is primary instead of secondary in its inflammatory congestion, and is * Vide An Enquiry into the relative Frequency, the Duration and Cause of Dis- eases of the Skin. 120 CUTANEOUS MEDICINE. the consequence of general ailment and disorder of the economy. Cause.—The cause of gutta rosacea is similar to that of the eczematous affections already enumerated, namely, debility ; debi- lity, which is nutritive, assimilative, nervous, or local, or all, in greater or less proportion, combined. The eruption is excited by reflex irritation, originating in the nervous plexuses of the stomach and organs of digestion, and also' in the reproductive and uterine system. And the remote predisposing causes are as follows :—uterine, reproductive, and puerperal derangements; deranged menstruation; languid vital power; anxiety, fatigue, and affliction ; loss of rest; deranged digestion ; abuse of alco- holic drinks; ungenial climate; errors of air, exercise, and clothing; constitutional and organic disease ; rheumatic dia- thesis ; haemorrhage; eruptive fevers; rapid growth ; sexual excess ; excessive mental and physical labour; deficient food; adult vaccination; syphilitic cachexia, &c. A common local cause is neglect of the use of soap in the daily matinal ablution. Prognosis.—Not grave; but as the local disease implies a derangement of general health, in which digestion and nutri- tion, as well as physical comfort and mental ease are concerned, it cannot too soon be relieved; and were there wanting an addi- tional reason for prompt treatment, it might be found in the fact, that the disease is all the more difficult of removal when thoroughly confirmed by time and neglect. And this is the more apt to be the case from the fact, that gutta rosacea is too frequently looked upon as a deformity rather than a disease, and as affecting vanity rather than life. Treatment.—There is no disease more amenable to treat- ment than is gutta rosacea, when properly understood. As a disease of debility, the first indication is to improve the tone of the system and restore the general health; as a preliminary to the tonic course, the digestive organs will require to be regulated, the secretions to be set right; and when the ordinary tonics, bit- ters, mineral acids, and chalybeates, have exhausted their good effects, we may have recourse to the unfailing specific influence of arsenic. The heal treatment should be mildly stimulant and soothing, and afterwards more stimulating. Our plan is to prescribe daily, and sometimes twice daily, washing with the cold water and the GUTTA ROSACEA. 121 juniper-tar soap. If the local irritation be increased by these means, we omit the evening ablution, and apply the benzoated oxide of zinc ointment, or smear the ointment gently on the face after the evening ablution. Then, if the congestion of the :' skin be improved by this process, we follow it up by a stronger stimulant, the compound hypochloride of sulphur ointment. The ointment should be rubbed into the pimples with moderate friction at bedtime, left on the skin during the night, and washed off in the morning by the usual ablution with the juniper-tar soap and cold water. This plan is unfailing in success; but if it be found too severe, we modify it accordingly, and have recourse to milder cutaneous stimulants, such as the bichloride of mercury in emulsion of bitter almonds. CHAPTER IV. ERYTHEMATOUS AFFECTIONS. The Exanthemata of Willan are naturally divisible into two groups,—the eruptive fevers, namely, rubeola, scarlatina, and variola, of which we treat in our tenth group, under the desig- nation of Zymotic affections; and those superficial congestions of the skin which take erythema as their type,—the erythema- tous affections, and form the subject of our present chapter. The exanthemata and erythemata are the effhrescences and rashes of the skin; the former term being most appropriately ren- dered by efflorescence, a blossoming out like flowers, which the little corymbi of rubeola might be taken very fairly to repre- sent; while the latter term, erythemata, derived from epvtxitu* to redden, may be equally well rendered by the word rash, or inflammatory blush. The definition of exanthema given by Willan is, with a slight modification, applicable also to erythema; namely, " superficial red patches, variously figured, and diffused irregularly over the body, leaving interstices of a natural colour, and terminating in cuticular exfoliations." The modification relates to the words "leaving interstices of a natural colour:" these words have in view the general efflorescence of rubeola and scarlatina, and also of a member of the present group, namely, roseola; the rest of the erythemata being local, and requiring no such limitation. The leading distinction between the erythemata and the ecze- mata is the difference of relative importance of the local and constitutional disorder in the two kinds of affection. In ecze- mata the principal interest attaches to the local affection ; in ery- themata the constitutional disorder is of most consequence, the local manifestation being often a mere symptom of derange- ment of the stomach and digestive organs, and following, like the eruptive fevers, a more or less regular order of development. Thus, in several of the forms of erythema, in erysipelas, and in roseola, the beginning of the attack is announced by nausea, prostration of power, and headache: these symptoms are fol- ERYTHEMA. 123 lowed by fever; on the second or third day of the general ill- ness the rash makes its appearance, goes on increasing for four or five days, and then gradually declines. At the outbreak of the rash there is commonly a marked relief to the constitutional symptoms, and in some instances the latter quickly disappear. Hence the relation between the local affection and the constitu- tional affection is very manifest. The diseases included in the present group are: Erythema Urticaria Erysipelas Roseola ERYTHEMA. Erythema, or inflammatory blush, is a superficial inflamma- tion of the skin, more or less partial in its distribution, occur- ring in spots and patches of various size, sometimes diffused and sometimes circumscribed, and attended with more or less swell- ing and pruritus. The redness is sometimes scarlet, sometimes crimson and purplish ; and on dispersing is followed by a bluish and yellowish stain, like that of a bruise. The resolution of the inflammation is succeeded by exfoliation of the cuticle. Erythema is commonly symptomatic of some disturbance of the digestive, the nutritive, or the uterine functions, or its symp- toms are secondary and limited to a slight degree of irritative fever. Its duration varies from a few days to several weeks, and it is not contagious. The varieties of erythema are as follows:— Erythema fugax Erythema marginatum „ laeve „ tuberculatum „ circinatum „ nodosum Erythema fugax is chiefly remarkable for its evanescence; it occurs in the form of patches, which are red, hot, itchy, and slightly swollen; sometimes successive and sometimes changing their place as though by metastasis. Bateman compares the redness of the patches to that produced by pressure, and remarks upon its association with various febrile affections. He also mentions the opinion of Hippocrates that it denoted a tedious and dangerous disease. Our own experience 124 CUTANEOUS MEDICINE. associates it with disorders of the mucous membrane of the digestive, secreting, and uterine organs, and' especially the latter. Erythema fugax is sometimes more remarkable for a tendency to swell {erythema tumescens) than for its redness, and this form of the disorder is often very annoying. A little itching is felt in the part attacked; it swells quickly, and in the course of an hour has attained a considerable size. The swelling lasts for a few hours, and subsides almost as rapidly as it arose. We know a military officer who was the subject of this curious malady. The swelling would take place so suddenly that he was some- times seized with it while on duty ; occasionally it affected the integument of the eyelids; his eyes were quickly closed, and it was necessary to lead him to his quarters completely blinded. But a more painful case was that of a clergyman, in whom the disorder attacked the lips and sometimes the tongue: when it occurred in the latter situation, he was once or twice nearly suffo- cated. Erythema fugax is also associated with another curious affec- tion, namely, vicarious menstruation {erythema menstruate). A sudden flush with a little swelling appears upon some part of the skin, generally the face; a sanguineous exudation takes place, which lasts for a few days and then subsides. The exuda- tion is not continuous throughout the whole period, but inter- mittent, and during the intermission the skin has the appearance of having been scorched. We have seen three well-marked examples of this affection: the patients were young, and suffer- ing from amenorrhoea ; they were also hysterical. Erythema lmve, vel osdematosum, is a local form of erythema, depending upon the inward pressure of oedema of the subcutaneous cellular tissue. It occurs for the most part in the lower extremities, or in any depending part of the body. Some- times it is met with in the eyelids, and is mistaken for erysipelas, and not unfrequently in the lower limbs. The cuticle breaks up into a series of retiform lines; the exposed cutis exudes a serous secretion; there is considerable pruritus, and the case becomes transformed into one of eczema. Erythema lasve is a frequent accompaniment of anasarca, in which case the surface of the skin is red and shining. Another form of erythema, originating in a local cause, namely, friction; such as the friction of ill-fitting clothes, the friction of ERYTHEMA. 125 riding on horseback, the friction of one part of the body against another, or of two folds of the skin, as in fat and flabby per- sons, and in infants whose skin is naturally sensitive, is erythema intertrigo,* and the evil is increased if the integument be in a moistened state, as by the condensation of perspiration or the ' flow of secretions over the part. In lymphatic constitutions the erythema is apt to be accompanied with exudation, in the first place of a serous fluid, and subsequently of a muco-purulent secretion. The presence of exudation, however, transfers the affection from the erythematous to the eczematous group, and the case becomes one of eczema mucosum. The erythema which is apt to occur in bedridden persons, and which precedes bed- sores, is termed by Sauvages erythema parairimma, and by Plenck, erythema a decubitu. The term erythema is also applied to one stage of burn, and also to the first stage of frost-bite ; the first being called erythema ah igne, or ambustio erythematosa; the latter, erythema a gelu, or pernio erythematosa. Erythema circinatum begins in the form of circular and slightly raised patches, which increase by the circumference and fade in the centre, forming rings of various size, with borders of various breadth, being sometimes narrow and sometimes broad. The skin over which the inflammation has passed throws off its cuticle in furfuraceous desquamation, and the rings, meet- ing and crossing in their course, give rise to a variety of irregu- lar figures, consisting of broken segments of circles. This form of eruption is often met with in the course of ailments accompa- nied with perspiration, and when the patients have been kept hotly covered up with bedclothes, as in rheumatic fever. It is also seen in the spring season of the year, on the lower extremi- ties of young persons, and also associated with rheumatism. Erythema marginatum is a chronic form of erythema cir- cinatum ; the border is more raised, particularly at the periphery; the congestion is deeper tinted, often crimson or purple, and the rings broken and irregular. They are chiefly met with in elderly persons, on the extremities and loins, and, according to Willan and Bateman, are associated with some internal disorder, their occurrence being deemed an unfavourable sign. * Intertrigo, a chafe-gall, or gall from chafing; a fret 126 CUTANEOUS MEDICINE. Erythema papulatum et tuberculatum.—The two forms papulatum and tuberculatum only differ in size of the eruption, the symptoms being the same; and not unfrequently they are intermingled in the same person, or on the upper extremities assume the smaller or papulous form, and on the lower extremi- ties the larger or tuberous form. Both commence with itching and tingling, which is increased by the stimulus of meals and heat of bed; both are slightly raised at their first appearance, and subside to the level of the skin in a few days; and both are brightly red at first, become purplish by degrees, and fade away into a greenish and yellow stain. The smaller kind are met with on the face and neck, the chest, the upper extremities, and particularly in the neighbourhood of the joints and upon the back of the hands; and the larger kind are chiefly found upon the lower extremities and around the knees and ankles. Both are associated with disorder of the digestive organs, and the lat- ter with disordered menstrual function. The tuberous kind is commonly met with in female servants who have been recently introduced into London kitchens from the country : the eruption is tender to the touch, and frequently accompanied with feverish symptoms and rheumatic pains. Erythema nodosum.—Erythema nodosum only differs from the preceding in a larger development of the inflamed spots, and a somewhat more violent attack of disorder of the digestive organs and feverishness, by which it is preceded. The patches are oval in form ; are hot, painful, and tender to the touch, and appear chiefly on the lower limbs, corresponding by their long diameter with the vertical axis of the limb. Occasionally, how- ever, they are disposed transversely, and we have seen two patches so placed as to form a kind of bracelet just above the ankle. They are hard to the touch at first, and sometimes seem to sink deeply into the tissues of the limb, involving even the muscles; in a few days they become softer, and in eight or ten days subside and disappear. At the commencement they are brightly red ; as they attain maturity they become purplish, and at their decline have the green and yellow tinge of a bruise. In prominence they rise gradually to the centre, and are com- monly associated with considerable derangement of the digestive organs, and frequently with rheumatism. Diagnosis.—Redness, bright at first and subsequently becom- erythema. 127 mg purplish; slight elevation, sometimes with a tendency to sudden swelling; itching and tingling; and very slight, if any, exfoliation of the cuticle, unlike the decided desquamation of the eczematous affections; these are the signs which distinguish erythema from other disorders of the skin. Erythema papula- tum bears some resemblance to urticaria in size of prominence, in situation, and in the sensation of tingling pruritus; but there the likeness ceases ; one is permanent for several days, the other, maintained only by muscular spasm, is lost in an hour; more- over, the papules of erythema are red and the wheals of urti- caria white and bloodless. Cause.—The cause of erythema is debility, general and local; the general forms being assimilative, nutritive, and nervous; and the predisposing causes derangement of digestion, derange- ment of uterine function, variations of climate, errors of air and exercise, alternation of seasons, rheumatic diathesis, and hereditary diathesis. In a case of chronic erythema of the face, the cause was stimulation by the heat of the sun. Prognosis.—Erythema is rarely grave; but as it indicates a state of disorder of the economy, the health should be restored as quickly as possible. Treatment.—As the most frequent of the predisposing causes of erythema are those which conduce to assimilative debility, the digestive organs and the uterine system call for our especial attention. Mild purgatives, salines, and subsequently bitters with the mineral acids, will be found to be the proper remedies in the majority of cases. Where the function of the stomach is principally at fault, the trisnitrate of bismuth, with liquor cin- chonas and an infusion of orange-peel, will be useful; or the more decided tonics, quinine with sulphuric acid, or quinine with iron and citric acid. If the cutaneous disorder be associated with rheumatism, the iodide of potassium may be advantageously combined with the salines, or bitters, according to the stage of the affection. Locally, the benzoated ointment of oxide of zinc will be found useful in the more irritable forms ; and where there is oedema, an elastic cotton bandage, carefully applied. In erythema papu- losum, tuberosum, and nodosum, a spirit lotion may be used, or a lotion or cerate of Goulard's extract. In erythema intertrigo and paratrimma, the parts should be washed with the juniper- 128" cutaneous medicine. tar soap, and afterwards dressed with the benzoated ointment of oxide of zinc, combined with spirits of camphor. In erjdhema paratrimma especially, the inflamed part should be pencilled with a liniment of white of egg and spirits of wine, and after- wards dressed with the unguentum resinas flavas. For chilblains, in their erythematous state, the treatment is friction, with moderately stimulant liniments ; such as the lini- mentum camphoras, with chloroform; soap liniment and oil of cajeput; or a liniment composed of the contents of one egg, one ounce of spirits of turpentine, and one ounce of distilled vine- gar, well shaken together. ERYSIPELAS. Erysipelas, derived from tpvlpoc., rubor, and rrtxx», cutis, is a diffused inflammation of the skin and subcutaneous cellular tis- sue of a part of the body, preceded and accompanied by derange- ment of the digestive organs, and more or less severe fever. The inflammation of the skin is indicated by redness, swell- ing, burning heat and tingling, and a sense of tension and press- ure, and is remarkable for a disposition to spread; sometimes creeping onwards upon the neighbouring skin, and subsiding on the part first attacked; and sometimes vanishing suddenly on one spot to appear upon another at some distance. It is this ambulant or wandering character, and the tendency to sudden disappearance, that has gained for two of its forms the names of erralicum and metastaticum. The swelling is sometimes very moderate; at other times there is a degree of infiltration into the subcutaneous cellular tissue amounting to oedema, and with the oedema an interstitial infil- tration into the corium, producing thickening and coarseness of the skin. An advanced degree of this serous infiltration gives rise to the development on the inflamed surface of vesicles con- stituting erysipelas miliare; while larger vesicles or bullae dis- tinguish the forms known as erysipelas phlyctenodes, or bullosum, that which is marked by simple oedema being erysipelas cedema- tosum. Erysipelas has a tendency to invade by preference certain regions of the body; for example, the head and face; next in ERYSIPELAS. 129 frequency it is met with on the limbs ; and in newly-born infants it is apt to attack the umbilicus and abdomen. It also manifests a remarkable difference in respect of depth, the forms heretofore referred to being superficial, while one form is dis- tinguished for its invasion of the deep structures of the body as well as the skin, namely, erysipelas phlegmonodes. Another diversity in the forms of erysipelas has reference to its cause, the ordinary cause being constitutional, while a very dangerous form, traumatic erysipelas, has its origin in wounds, as in the erysipelas which comes on after surgical operations. Erysipelas generally runs a course of ten days, to a fortnight or three weeks; the local inflammation commonly makes its appearance on the second or third day of the constitutional dis- turbance, goes on increasing for four or five days longer, and begins to decline on the eighth or ninth day. In erysipelas phlyctenodes the bullas are formed on the fourth or fifth day, each bulla having an existence of twenty-four hours before it bursts, and erysipelas capitis reaches its height about the fourth or fifth day, and its decline at about the seventh or eighth. The termination of erysipelas usually takes place by resolu- tion : the swelling subsides, the redness disappears, the •tender- ness and pain cease, and the cuticle is separated by desquama- tion. The thin scabs formed by the desiccation of the cuticle covering the broken vesicles also desquamate in a few days. The constitutional symptoms of erysipelas are those of invasion, course, and decline. The symptoms of invasion are: chills or rigors, with flushes of heat; lassitude; pains in the back and limbs; headache and drowsiness; thirst; loss of appetite; white, coated tongue ; bitterness of mouth; nausea; often vomiting; weight and oppression at the epigastrium; consti- pation ; quick, and sometimes hard pulse, and dry skin. These symptoms' are mitigated upon the appearance of the inflamma- tion of the skin, and take on more or less of a nervous character; the pulse becomes soft and quick; the tongue is brown and dry, and there is more or less delirium. On the occurrence of the decline of the local inflammation the bad symptoms either sub- side by degrees, and a diarrhoea or lithic acid sediment shows a return of normal energy of the organic functions ; or the patient falls into a state of coma from effusion between the membranes 9 130 CUTANEOUS MEDICINE. i of the brain, or, asthenia, from exhaustion ; and gradually suc- cumbs. Not unfrequently, at the close of the fever, there is some degree of haemorrhage from the mucous membrane, sometimes from the pulmonary or alimentary mucous membrane, and some- times from the womb. The varieties of erysipelas may be arranged in two groups, general and local, as follows:— GENERAL VARIETIES. Erysipelas erraticum Erysipelas phlyctenodes „ metastaticum „ cedematodes „ miliare „ phlegmonodes LOCAL VARIETIES. Erysipelas faciei Erysipelas mammae „ capitis „ umbilicale Erysipelas erraticum is the erratic form of the disease. It is rarely accompanied with much swelling, or with the deve- lopment of vesicles. It occurs most frequently upon the head and face. Erysipelas metastaticum.—Metastasis is one of the dreaded phenomena of erysipelas, and the especial danger that is feared is metastasis or transfer of the inflammation from the skin to the brain. This danger is, of course, very much increased when the seat of the disease is the head or face. The true explanation of metastasis is that which has already been discussed in con- nection with the probabilities of repercussion of eczema; a causa morbi exists in the economy, and some organ will be the suf- ferer ; so long as the vital power is able to exert a conservative control, the disease will run its normal course in the organ already attacked, whatever it may be ; but if the vital power be very much weakened, then no human caution or contrivance can prevent the transference of the causa morbi from one organ to another, without any rational explanation being possible. The metastasis of erysipelas, says Dr. Watson, is rare; " I do not recollect to have seen it. But the extension of the inflam- mation, the supervention of delirium and coma, while the exter- nal inflammation continues, is of common occurrence." Erysipelas miliare et phlyctenodes represent two erysipelas. 131 degrees of effusion beneath the cuticle of the serous fluid already infiltrated into the tissues of the skin. In the slighter of the two, the serum is exuded in small quantity, and gives rise to vesi- cles, of the size of millet-seeds; in the other, the quantity of serum is greater, and the vesicles assume the character of phlyc- tenae, or bullas. The bullae are commonly developed on the fourth or fifth day of the fever, and go on enlarging for twenty- four hours, when they usually burst. Their contents are some- times pale and watery, and sometimes opalescent; more fre- quently they are amber-coloured, and sometimes, when there is a tendency to dyscrasis of the tissues, they are purple, from intermixture of the colouring principle of the blood with the serum. When the bullae burst, their bases become covered with thin scabs, which, at first yellow, soon become brownish, and almost black. Erysipelas cedematodes is a modification, due to the accu- mulation of serous fluid in the subcutaneous cellular tissue; it occurs most frequently in the lower extremities, and sometimes in the organs of generation. When the inflammation subsides, the fluid is gradually absorbed. Erysipelas phlegmonodes is more deeply seated, and more severe in all its phenomena, than simple erysipelas. The sub- cutaneous cellular tissue, the superficial and deep fascia, and the intermuscular fasciae, are all involved in the inflammation, which instead of being circumscribed like ordinary phlegmon, puts on the true erysipelatous^, character of spreading on all sides, and involving a considerable extent of tissue in destruction, and sometimes the greater part of a limb. It occurs most frequently in the extremities, but may attack any part of the skin; and runs on to suppuration, and commonly to gangrene of the cellu- lar tissue and fasciae. The heal signs of phlegmonous erysipelas are, redness, swell- ing, hardness, extreme tenderness, and an acute burning pain; when, at about the fifth or sixth day, suppuration is established, the pain is throbbing, an obscure fluctuation is felt, and pressure with the hand communicates a boggy sensation. When sphace- lus is set up, the colour of the skin changes to purple, or assumes a livid tint. When the case is disposed to terminate in resolu- tion, an amelioration of the symptoms takes place at the fifth or sixth day. 132 cutaneous medicine. The constitutional symptoms of erysipelas phlegmonodes are the same as those of erysipelas simplex, but more severe; deli- rium is not uncommon, the tongue is dry and brown, and there are sometimes diarrhoea and profuse perspirations. Erysipelas faciei is a serious form of the affection, as it involves parts of high organization, and clo'sely associated with the nervous system and brain. The inflammation begins at the side of the nose, and spreads rapidly over the whole face, swell- ing the features to such an extent as to be barely recognizable. The eyelids, the ears, and the lips, are greatly tumefied, and the inflammation is apt to extend to the conjunctiva, and to the mucous membrane of the nose, mouth, and throat, often involv- ing the parotid and submaxillary glands, and occasioning sup- puration among the deep tissues of the neck. The constitutional symptoms are very severe: there is violent headache, sleepless- ness, restlessness, delirium, and finally, coma. Sometimes death results from exhaustion or asthenia, and sometimes from apncea, in consequence of obstruction of the glottis by infiltration of the mucous membrane. Erysipelas of the scalp is usually the consequence of a wound (traumatic erysipelas), and occurs in about a week or ten days from the reception of the violence: the integument is cede- matous, smooth, shining, and very sensitive, and the inflamma- tion is apt to run on to suppuration and gangrene of the cellular and fibrous, tissues, and not unfrequently the inflammation is transferred to the brain. Erysipelas of the mamma is apt to assume the phleg- monoid character, in consequence of the presence of a large quantity of loose cellular tissue: suppuration takes place, with gangrene of the fibrous tissues. Erysipelas of the umbilical region occurs in young infants, from mismanagement of the umbilical cord, particularly in public institutions, and under the influence of an epidemic malaria. The inflammation spreads more or less extensively over the whole of the abdomen, and frequently extends to the organs of generation. Diagnosis.—The distinguishing characters of erysipelas are, a deeper affection of the tissues than occurs in erythema, a greater amount of tumefaction, a proneness to spread, and especially the more severe constitutional symptoms. Erysipelas phlegmonodes erysipelas. 133 is known by the hardness, which indicates a deep implication of tissues, a greater amount of pain, and the suppuration of the subcutaneous tissues. Cause.—The previous consideration of erythema has taught us that a derangement of the digestive functions may be suffi- cient to excite an inflammation in the skin; so in the present instance we must have recourse to a similar explanation in some instances of erysipelas; for example, in idiopathic and traumatic erysipelas. In other cases, erysipelas seems to be referrible to malaria, and sometimes to infection and contagion, and it is apt to prevail epidemically. Puerperal fever would seem to be one of the sources of the infection of this disease, and erysipelas and puerperal fever are reciprocally transmissible. The predisposing cause is debility, and the remote predisposing causes, those conditions that tend to lower the tone of the system and the energy of the vital powers; for example, anxiety, afflic- tion, and exhausting excesses of every kind. Some- persons seem to possess an erysipelatous diathesis, and in such persons the most trivial wound, such as a scratch with a pin or the bite of a leech, is sufficient to induce an attack. Prognosis.—Erysipelas being always serious, and often dan- gerous, demands the utmost care, and is generally of doubtful prognosis; and this is especially the case with some of its forms; for example, erysipelas faciei et capitis, and erysipelas phleg- monodes. Treatment.—The treatment of erysipelas presents the usual two indications, constitutional and local; the first being directed towards the subjugation of the fever, the second to the relief of the local affection. Erysipelas being essentially a disease of debility, of asthenia, and its progress being marked by that form of morbid inflam- mation which is termed irritability, we have to bear in mind the • necessity of sustaining the vital powers, and of putting in prac- tice a conservative plan of treatment. All that is signified in the expression " regulate the digestive organs and secretions," must be accomplished in the first instance and quickly, that no fer- menting irritant may be allowed to exist in the alimentary canal, and no torpidity of operation of the liver or kidneys complicate the future progress of the case; moreover, we gain another point by this preliminary clearance of the alimentary system; we 134 cutaneous medicine. excite a derivative action, which is an important element in the treatment, while we perform artificially that which nature would otherwise neglect. Nevertheless we must not fail to keep in mind the asthenic nature of erysipelatous inflammation, and the necessity of a strictly conservative policy in its management. The remedies the best suited to the regulation of the digestive organs and secretion, are a full dose of calomel with the com- pound extract of colocynth, say two to four grains of the former, with six to eight of the latter, and two of extract of hyoscyamuls, followed after a lapse of twelve hours with a senna or rhubarb draught. If there be any objection to calomel, half a grain of podophyllin may be substituted in its place. When the bowels have acted freely, the tendency to constipation which is apt to succeed the use of purgative medicines must be controlled by the daily exhibition of a mild aperient. The derivative action once established must be sustained; the digestive mucous mem- brane, once prompted to a natural action by remedies, must not be permitted to relapse into a sluggish state; but we must be equally cautious in avoiding any unnecessary irritation of the alimentary canal. If the fever run high, we may find it necessary to have recourse to effervescent salines, or to use the neutral salt sulphate of magnesia as our laxative; or administer the chlorate of potash, dissolved in water or barley-water, as the daily drink. One drachm of this salt may be taken in the twenty-four hours. But the moment the alimentary canal is pronounced to be free, we must be ready with our tonics : they should be com- bined with aperients, as in the combination of the sulphate of quinine with sulphate of magnesia, and they should be adminis- tered independently. We may select bitters with the mineral acids; cinchona with sulphuric acid ; or the citrate of iron and quinine. But there is one tonic which, above all others, is suit- able for erysipelas, in fact is declared to be specific, and, as far as our experience is concerned, is literally so; namely, the tinc- ture of the hydrochlorate of iron. The tincture of the sesquichloride of iron may be commenced the moment the bowels have been sufficiently relieved, and may be continued through all the stages and variations of the com- plaint. It is given in simple dilution with water, in doses of 20 minims, every two hours until the fever is subdued. Dr. Bal- ERYSIPELAS. 135 four, who recommends this plan of treatment strongly, advises that it should be administered with regularity, so as to saturate the system as speedily as possible, and he urges that it is only at the point of saturation that the remedy exerts its great cura- tive power. He finds it remove pain, lessen the heart's action, clean the tongue, and act as a diuretic; it is admissible, he says, in every stage of the fever, even in high delirium; it never produces headache; it arrests suppuration in phlegmonous erysi- pelas, and brings about a cure in less than a week. For infants he prescribes doses of two minims, and for intermediate ages a relative increase. Ammonia is a favourite remedy in erysipelas with some practi- tioners, in all its forms; the citrate and acetate as an antiphlogis- tic remedy, and the sesquicarbonate as a specific. The latter may be administered in doses of five grains every two or three hours. Sedatives are also valuable when great irritability prevails, and when they really act as sedatives, and not, as too frequently happens, as excitants of the brain and stimulants. Aconite and belladonna have gained a reputation in erysipelas, and so also have hyoscyamus, morphia, and the liquor opii sedativus. If belladonna answer the purpose, we should give it a preference, on account of its known aperient effect on the bowels when administered in very small doses, say an eighth of a grain of the extract every six or twelve hours. But on matters of detail, such as doses, the practitioner must depend on his own judgment; all we can hope to do is to lay down general principles and point out what remedies have the credit of being the best. Another department of the constitutional treatment is diet: a milk diet with farinaceous puddings; then eggs; then broths; next fish; and afterwards poultry. For drinks, toast-water and barley-water. To this, which is the ordinary antiphlogistic diet, may require to be added wine, with a view to support the vital powers of the sick person. The quantity may be six to twelve ounces of sherry or port wine in the day, according to its effect and according to the previous habits of the patient; and at pro- per intervals. The heal treatment of erysipelas is of two kinds, palliative and curative; the former being intended to relieve symptoms, namely, the heat, the tension, and the pain ; the latter to set up a new action, and supersede and alter the quality of the inflam- 136 CUTANEOUS MEDICINE. mation. The remedies suited to the first of these purposes are : sedative fomentations, dredging with flour, and inunction with lard; the second purpose is attained by pencilling the surface with a solution of nitrate of silver. As a general rule, cold and chilling applications are very objectionable; sloppy remedies are equally so; and both these inconveniences are obviated by inunction with lard, which we regard as by far the best pallia- tive treatment of this disease. The manner of employing this admirable remedy, which we consider to be as thoroughly speci- fic for outward use as is the tincture of the sesquichloride of iron for internal administration, we shall explain in the words of the surgeon* who first called our attention to it: " My plan is to relax the skin with hot water or steam fomentations, and after each fomentation to saturate the inflamed surface with, hot lard." He then covers the part with a sheet of wool, and keeps the wool in its place by means of a bandage not too tightly applied. When fomentations are used, they should be laid on by means of a fold of flannel saturated with the hot solution, and covered with oiled silk or gutta percha ; or the fotus, if substantial, as in the case of chamomile-flowers or hops, may be applied in a mus- lin bag. But these remedies are in every way inferior to the dressing with lard and cotton wool. The curative local treatment consists in blistering the inflamed surface by means of the application of a strong solutionf of nitrate of silver. Mr. Higginbottom, of Nottingham, who is the author of this plan, directs that the solution should be applied freely by the aid of a dossil of lint attached to a piece of stick, and not only to the inflamed part, but to the sound skin bordering it, to the extent of an inch or more, if the case be severe. The solution should be used more freely in bad than in slighter cases. The inflammation rarely travels beyond the limits of the caustic, and even when it does is easily controlled. Mr. Higginbottom considers the line of nitrate of silver drawn around the circum- ference of the inflammation as of very little use, and notes that on the scalp the solution rarely produces vesication. The caustic solution is equally applicable to phlegmonoid and simple erysi- pelas. After the use of the caustic solution, we are in the habit * John Grantham, of Crayford, Kent. \ Mr Higgiubottom's formula is as follows: Argenti nitratis 3viij; Acidi nitrioi diluti TTLxij; Aque distillate \ j. URTICARIA. 137 of smearing the surface with lard and covering it with cotton wool, as in ordinary lard inunction. In the vesicular form of erysipelas the bullas should be punc- tured with a needle and gently pressed with a sponge squeezed out of warm water, in order to absorb the serum and flatten the raised cuticle upon the surface of the corium. When this has been accomplished, the inunction and cotton wool may be reapplied. In erysipelas of the scalp, it is often necessary for the purpose of relieving the tension and pain, to make an incision through the inflamed tissues down to the bone, and in erysipelas phleg- monodes, one or two incisions are required to liberate the pus and sloughs, and especially to ease the pain which is created by the diffusion of pus beneath the fasciae. The incision has the double effect of giving exit to pus and sloughs, and also of emp- tying the vessels of the congested skin. After incision, the parts must be covered with a poultice and placed in a position favourable for the escape of the discharges. URTICARIA. Urticaria, or nettle-rash, derived from uriica, a nettle, is an ephemeral congestion of the skin, accompanied with a burning and tingling itching, with more or less redness, and with the development on the red ground of small elevations or wheals, which are sometimes round and oval, and sometimes in long narrow stripes. The rash is sometimes preceded by sj^mptoms indicative of considerable derangement of stomach, and some- times, in a chronic form, is wholly unaccompanied by constitu- tional symptoms. It is not contagious. The resemblance of urticaria to the effects of stinging the skin with a nettle is twofold: firstly, the hot, burning, and tingling itching is similar to that of the sting of a nettle ; and, secondly, the white elevations or wheals are due to the same cause, namely, spasm of the muscular structure of the corium. In lichen urticatus we have had the opportunity already of noticing the influence of muscular spasm of the skin in the pro- duction of papulas ; it is seen also in the spasmus periphericus, which occasions that common physiological condition of the skin, cutis anserina; and the white wheals raised upon the inte- 138 CUTANEOUS MEDICINE. gument by the lash of the whip in flogging are the result of a similar operation. In some persons the skin is so sensitive and the muscular tissue so irritable, that wheals may be produced at any moment by touching it with a feather, or lightly with the finger. We may thus sometimes trace figures and letters upon the skin, or write our name, and the figures and the writ- ing will instantly stand up in relief in the form of white wheals. We have sometimes noticed in the white wheals of urticaria an alternate contraction and relaxation of the muscular structure, which gave them the appearance of pulsation, or of an ebb and flow of blood in the capillary vessels. Urticaria is sometimes transitory and sometimes very endur- ing, lasting even for years. We have thus a kind of division of the disorder into acute and chronic. The acute forms are pre- ceded and accompanied with symptoms indicative of great derangement of stomach and its sympathetic influence on the nervous and vascular system, producing a temporary fever; while the chronic forms exhibit no traceable disorder of the ecotoomy. In the acute forms of urticaria there is generally a little swell- ing, reminding us of the swelling of erythema, and in a less degree of that of erysipelas ; and at the close of the rash there is sometimes a little oedema. But the most striking character of the rash differs essentially from anything observable in either one or other of those affections, namely, the nervous irritation that occasions the muscular spasm. In the acute forms also the skin is somewhat altered in colour at the decline of the conges- tion : it is purplish and yellowish, like a bruise; and if the conges- tion have run high, as in urticaria ab ingestis, there will probably be some degree of furfuraceous desquamation of the affected part. Its varieties are founded on its occasional febrile character; on the confluence of its wheals; on its evanescence or permanence; and on the extension of its local symptoms deeply into the skin and subcutaneous tissues, and involving a greater breadth of muscular tissue in spasmodic action. They are as follows:— ACUTE. CHRONIC. Urticaria febrilis Urticaria evanida " ab ingestis " perstans " conferta " subcutanea " tuberosa URTICARIA. 139 Urticaria febrilis is distinguished by the occurrence of symptoms denoting great irritation of the stomach ; for example, weight and fulness at the epigastrium, nausea, faintness, thirst, white tongue, quick pulse, pain in the head, and general lassi- tude and prostration. After an interval of one or two days, there is an outburst upon the skin of a number of irregular blotches, vividly red, covered with wheals, and intensely itchy. This outbreak commonly relieves the gastric symptoms; but as the cutaneous irritation subsides, the internal symptoms return. The heat and tingling and itching of the skin are always worst at night, and the internal and external symptoms are apt to alternate for a week or ten days before they decline and disappear. Willan narrates a fatal case of urticaria febri- lis ; the patient had been intemperate, and was much out of health. Urticaria ab ingestis is the name given to an attack of febrile urticaria dependent on the presence in the stomach of some irritant or deleterious article of food. The symptoms are apt to come on a few hours after having partaken of the nox- ious aliment, sometimes in the night, encouraged by the suspen- sion of digestion during sleep, and are very severe, and occa- sionall}'' fatal. They commence with a feeling of fulness and weight at the epigastrium, with nausea, faintness, giddiness, and sometimes vomiting and diarrhoea. There is a prickling in the throat, with a sense of constriction of the fauces, cough, a feel- ing of impeded respiration, and swelling of the tongue. From the mucous membrane the irritation spreads to the skin; the nose, the lips, and ears are swollen, hot, and itchy ; the features are enlarged; the rash extends to the trunk and limbs, and is particularly troublesome in the neighbourhood of the joints. The rash sometimes continues to be annoying for a day or two, but more commonly subsides after a few hours, and is followed by a furfuraceous desquamation of the cuticle. These severe symptoms are not necessarily the consequence of a highly irritating or poisonous principle present in the food; but are sometimes induced by the most harmless articles of diet; for example, rice, eggs, pork, goose, fruit, etc. A more frequent cause of urticaria is shell-fish, and particularly mussels. Willan has put on record a case evincing a disposition to periodicity on the part of the urticaria, and we have met with 140 CUTANEOUS MEDICINE. a somewhat similar instance. In Willan's case the rash recurred weekly for a considerable time ; in our own it re-appeared once at the end of a week. • Urticaria conferta.—Instead of being scattered as they commonly are, the wheals of urticaria are sometimes collected into thick clusters, and give rise to the present variety. This difference of character is chiefly due to the constitution and sus- ceptibility of the patient, and not to any difference of cause. Its symptoms bring it into the group of the acute forms, bearing some resemblance to those of urticaria febrilis. Urticaria evanida et perstans represent the chronic form of the disorder, in which there are no febrile action and no symptoms of gastric derangement, and wherein the disease con- tinues for an indefinite period of time. In the evanescent form* urticaria evanida, the rash is accompanied with tingling and itching, is apt to come out several times in the day, and is very troublesome at night. It appears also under the influence of exercise, after taking meals, and on mental emotion. After a continuance of a few hours, the rash disappears, and no trace can be discovered of its attack. In the persistent form, urticaria perstans, the general symptoms are the same, but the rash, with its crop of irritable wheals, continues for several days or weeks, and sometimes for months. The separate wheals do not remain the whole of the time, but are reproduced in succession; and the entire eruption acquires thereby the character of permanence. Urticaria subcutanea. — Under this name Willan has described an affection in which the tingling, burning, and itch- ing are present without the wheals ; or the latter are occasional and developed in a minor degree. It is not uncommon in dis- eases attended with a variety of symptoms to meet with exam- ples in which one or other of these symptoms may be in excess, while another is wanting. Under these circumstances, if the existing symptom be characteristic, we adopt it as the type of the doubtful affection. In the present variety, the sensation of tingling and stinging, and of puncturing with fine needles issu- ing from within, are characters of urticaria, while the rest of the symptoms point to some more deeply-seated morbid change in the nervous system. The affection is fortunately rare. Wil- lan remarks that it is partial, and that he had seen it only on the loins and thighs, and sometimes on'the arms ; but he con- URTICARIA. 141 ceives that it might spread over the greater part of tl»e body. Urticaria tuberosa is the result of a blending of the symp- toms of erythema tuberosum and urticaria; the deep-seated morbid alteration of the former is combined with the muscular spasm and pricking and tingling itching of the latter. The tuberous prominences are of large size, varying in diameter between half an inch and two inches; few in number, flat on the surface, hard to the touch, the hardness being felt to sink deeply into the substance of the limb, and extremely tender. They rise in a few hours, commonly in the course of the night, and when they subside they leave behind them a green and yel- low stain like that of a bruise. The disorder is rare, and is only met with in persons beyond the middle age, whose constitution is much debilitated by intemperance and chronic disease. The most marked example that we have seen was in a very fat man of gouty diathesis, who was at the same time suffering from cede- matous eczema of the lower limbs. On his thighs were several of . these tubera, and between them the greenish-yellow stains of those that had dispersed. Their outbreak during the night was accompanied with severe stinging and itching. Diagnosis.—The distinguishing signs of urticaria are, the tingling, burning, pricking, and stinging; the development of white wheals; and the evanescent character of the eruption. The papules of lichen urticatus are permanent, although their white or spasmodic stage is transient; and the tuberous eleva- tions of erythema papulatum, tuberosum, and nodosum, are never white like the wheals of urticaria, while the eruption is more permanent. Cause.—Gastric irritation is clearly established as an exciting cause of urticaria in the acute forms, and is not improbably a cause of its chronic forms. To gastric irritation as a cause of chronic urticaria may also be added irritation of any of the mucous membranes of the body, and particularly that of the uterine system. As a predisposing cause, we have detected the presence of debility, generally of the assimilative and sometimes of the nervous kind. Not unfrequently urticaria is associated with rheumatism, and we have also seen it intermittent with neu- ralgia. Dr. Maclagan having detected in the urine of a person suffering under urticaria a deficiency of urea and uric acid, has 142 CUTANEOUS MEDICINE. suggested that the disease may arise from a want of proper trans- formation of the waste tissues of the body, and the detention in the blood of the elements of the organic salts of the urine; and he notes the relation subsisting between urticaria, rheuma- tism, and purpura. Dentition also acts as a cause of urticaria in children. Prognosis.—Urticaria is not a serious disease, and the pre- monitory symptoms of the febrile forms, although violent, and for the moment dangerous, are not'difficult of relief. Chronic urticaria is very troublesome and obstinate, and is indicative of an existing debility, associated with chronic functional disturb ance. Urticaria subcutanea from its connection with nervous irritability, and urticaria tuberosa from its alliance with a broken-down state of the constitution, are necessarily of doubt- ful augury. Treatment.—Febrile urticaria requires the exhibition of an efficient purgative at first, and the subsequent administration of # effervescent salines, combined with ammonia and hydrocyanic • acid. When the feverishness has subsided and the secretions are natural, we may then have recourse to bitters, with the mineral acids and chalybeates, either alone or with quinine. In urticaria ab ingestis, it may be necessary to relieve the stomach of its load by means of an emetic; and we may select sulphate of zinc or ipecacuhan wine as the most suitable. Bear- ing in mind the faintness and extreme prostration which some- times accompany the nausea and sickness of this complaint, Willan cautions us against the use of tartarized antimony as likely to increase that kind of suffering; and Plumbe, with the same idea, suggests the administration of sulphuric ether in doses of twenty to forty minims every half-hour until reaction is restored; at the present day he would probably have given the preference to chloric ether. Chronic urticaria is to be treated by the restoration of the general health. In every instance some one or more functions are deranged, possibly unknown to the patient, and these nothing but an improvement in vital power and general vigour will set right. We have found of great service the minert.1 acids with a bitter; cinchona with sulphuric acid; quinine with sulphuric acid, and quinine with iron; while very chronic cases will yield to nothing but arsenic. ROSEOLA. 1.43 k Where any special indication presents itself, such as the gouty or rheumatic diathesis, we may call in the aid of colchicum, or in a neuralgic complication that of quinine. The heal treatment of urticaria consists in the employment of remedies which are calculated to relieve the itching, tingling, and smarting. For this purpose, we find sponging with hot water serviceable ; ablution with the juniper-tar soap; spongiug with the lotion of juniper tar; frictions with the juniper-tar oint- ment ; the use of a lotion of emulsion of bitter almonds with hydrocyanic acid; a lotion of bitter almonds, with spirits of wine and bichloride of mercury; sponging with hot vinegar; with a lotion of the sesquicarbouate of ammonia; and liniments of opodeldoc and chloroform or laudanum. When one applica- tion fails, another must be tried, until the intended effect is pro- duced. Where convenient of access, the tepid bath affords almost instantaneous relief. ROSEOLA. Roseola, or rose-rash, so named from its dull crimson or roseate hue, is distinguished not only by the colour of the efflo- rescence, but also by its manner of distribution, and by its asso- ciation with congestion of the mucous membrane of the fauces, and a moderate amount of general fever. The colour of roseola varies in degree of brightness; occasion- ally, as in some of the local forms, it is quite vivid; in the gene- ral forms it is less bright, and is influenced by the clearness or muddiness of the skin ; and in the form termed by Willan roseola autumnalis, the congested patches " are of a dark damask-rose hue." Associated with this purplish tint of colour of the rash is the tendency exhibited by some of its forms to merge into purpura, and to leave behind them a green and yellow stain, like that of a bruise, at their decline. The vascular congestion of roseola affects both the follicular and the capillary plexus of the skin; in the former case giving rise to a punctiform efflorescence; in the latter to a blotch, resembling erythema in its pathological character. The general forms of the exanthem are for the most part punctiform, and are distributed in small clusters or corymbi {roseola corymbosa), like 141 CUTANEOUS MEDICINE. those of rubeola. This corymbose distribution of the rash is a point of some importance in distinguishing roseola from rubeola; the mechanical elements of the rash are identical in the two affections, and the resemblance is often so exact as to render distinction, by the aid of the exanthem alone, a thing impossible. After the punctiform and corymbose distribution of the rash, the most frequent form is that of a ring {roseola annulata), which sometimes springs from the circumference of a corymbus, and circles it around; and sometimes, begins as a circular patch, and fades in the centre while it spreads by the circumference. In the former case the rings are narrow and fine, and may consti- tute a general exanthem; in the latter the rings are broad and local, being limited to some one region of the body, such as the lower extremities. Under the name of roseola punctata we have described a third form, in which, not the corymbi but the separate puncta afford the most conspicuous character; the congested puncta in this case being sprinkled more or less thickly over the surface of the skin, and also constituting a general form of the exanthem. Following the corymbose, the annulate, and the punctated varie- ties, comes a fourth form, pointed out by Willan; namely, a circular blotch, retaining permanently that figure ; and remarka- ble, for its deep roseate and almost purplish hue. To distinguish this form from the preceding, we shall venture to name it roseola maculosa. Next in interest to the cutaneous exanthem is that which affects the mucous membrane of the fauces. This is a dull crimson blush ; and coincident with the congestion of the fauces, there is commonly some degree of swelling and tenderness of the submaxillary glands, and often of the neighbouring lympha- tic glands. The participation of the mucous membrane, or internal skin, in the irritations of the external skin, is a patho- logical phenomenon that our physiological studies teach us to expect; and the chief point of importance deserving of note in the present instance, is the fact of a similar, but more grave congestion, occurring in rubeola, scarlatina, and variola; and we may also bear in mind that we have noted the same circum- stance already, but in a less degree, in erythema papulosum, in urticaria, and in erysipelas. The febrile symptoms of roseola are similar to those which ROSEOLA. I45 accompany the exanthematous fevers generally, but much less in degree, and often so slight as to be hardly appreciable. They consist for the most part of nausea, headache, aching in the back and limbs, restlessness, languor and lassitude, chills suc- ceeded by flushes, quick pulse, white tongue, thirst, sore throat, and arrested secretions of the skin, kidneys, and bowels. And often, in conjunction with the febrile symptoms, there occur rheumatismal pains. Moreover, it must not be omitted, in the general history of roseola, that there is no swelling or prominence of the skin, as happens in erythema, erysipelas, and urticaria; and that 'the affection, although often prevailing epidemically and endemi- cally, is not contagious. The varieties of roseola may be divided into two groups, idiopathic and symptomatic; the former being independent or primitive in origin, the latter symptomatic of other forms of disease. In a tabular arrangement they may be grouped as fol- lows :— IDIOPATHIC. SYMPTOMATIC. Roseola corymbosa Roseola variolosa „ annulata |f vaccina „ punctata }J rheumatica maculosa }} arthritica „ cholerica „ febris continuaa. Roseola corymbosa is the roseola infantilis and asstiva of Willan, the false measles, or rubeola notha, of other writers • but as the exanthem, although most common in childhood, may occur also in the adult, and, although much under the influence of seasons, may happen at any period of the year, we have thought it desirable to affix to it a designation which is charac- teristic and unalterable, and which furnishes also grounds of comparison with its other forms. Roseola corymbosa may be regarded as the typical form of the roseolous eruption, as the special form, which, from its resemblance to measles, may be mistaken for that complaint and treated as secondary measles, mild measles, false measles, or rubeola notha. It is developed on the skin as a punctiform and corymbose or rubeoloid rash, of a brighter or duller roseate hue, 10 146 CUTANEOUS MEDICINE. and distributed more or less extensively over the surface of the skin; sometimes appearing on the face and trunk only, and sometimes both on body and limbs. The exanthem is commonly preceded by slight febrile symp- toms of one or two days', and sometimes as much as a week's continuance. The rash makes its appearance in the evening or during the night, being perhaps first perceived on leaving bed in the morning, and lasts for three or four days, commonly sub- siding on the fifth. It is crimson at first, soon becomes deeper- tinted, and assumes a dull roseate hue as it fades away. Its eruption is commonly attended with a moderate amount of itch- ing and tingling; but this symptom is often absent, and in its development it follows more or less closely the path of the exanthemata, appearing first on the face, next upon the chest and trunk of the body, and lastly on the limbs ; but not unfre- quently it is found to invade the entire surface at once. Absence of regularity is one of the features of roseola as compared with rubeola: it is variable in colour, in extent, in succession, in eruption, in duration ; and it may also be men- tioned that it is liable to recur when it has seemingly wholly disappeared. In the rubeola notha of 1863-4, the exanthem was identical with that already described, but had a more decided character; the corymbi were partially papular; the congestion of the fauces was greater; there was more or less coryza; the febrile symp- toms were more acute; and the affection formed part of a rube- olous epidemic. Nevertheless, it was often doubtful whether to consider it as a roseola or a mild rubeola. Sometimes it was curiously intermingled with varioloid, sometimes with diph- theria, and sometimes with rheumatism. Roseola annulata sometimes makes its appearance as a corymbose exanthem, and the patches throw off small linear rings, or it begins from the beginning as an annular rash, and follows the course of roseola corymbosa, both in the develop- ment of its efflorescence and in general symptoms. In the latter case the rings are at first one or two lines in diameter, and increase to the dimensions of half an inch. Sometimes this form of roseola exists as a chronic affection. We had lately under treatment a delicate woman, aged twenty-one, who had been the subject of this exanthem intermittingly for several weeks. She ROSEOLA. 147 was pale and anaemic; her powers of digestion were weak, and she suffered under assimilative debility and great depression of spirits. There is, however, another form of roseola annulata which commonly attacks the lower limbs : it begins in the form of cir- cular blotches of about a quarter or half an inch in diameter, and spreads by the circumference, while the centre fades and forms an area surrounded by a broad ring. These rings attain a breadth of one or two inches, are of a bright crimson at first, and as they disappear, fade off into a greenish-yellow bruise-like tint. The constitutional symptoms are the same as those of common roseola, and the course of the local exanthem a week or ten days. We have seen this form only a few times, and then in children under puberty. Roseola punctata is a rare form of the exanthem, of which the following are the characters:—Febrile symptoms of a sub- acute type, accompanied with redness of the eyes, slight coryza, redness of the fauces, and swelling of the mucous membrane of the mouth, ushering in an exanthema at the end of three days; the exanthema appearing on the mucous membrane and skin ; on the latter, in the form of small red spots occupying 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 colour, afterwards acquiring a dull roseate hue, the dulness increasing with the progress of decline; the primary red spots resembling dull red stains as decline advances, and fading by degrees after the dis- appearance of the rash; the entire attack lasting ten days, of which three belong to the febrile period, three to the exanthema, and four to its decline; the dark stains being perceptible for some days afterwards, the rash assuming a difference of form on different parts of the surface, such differences being all referrible to roseola. Roseola maculosa, the roseola autumnalis of Willan, occurs in the form of circular patches of about the size of a shilling, and of a " dark damask-rose hue," seeming at a distance " as if stained by the juice of black cherries or mulberries." The con- stitutional symptoms are very mild, and the eruption subsides in a week or ten days, leaving behind it a slight furfuraceous desquamation. This form of roseola is chiefly met with in chil- 148 cutaneous medicine. dren, and principally upon the arms and legs. Occasionally it may take on the annular mode of extension mentioned above; in which case it would constitute a roseola annulata, with broad margin. Roseola variolosa is a blotchy redness of the skin, of roseolous hue, which sometimes accompanies the eruptive stage of variola. When inoculation for small-pox was practised, the rash was not uhfrequent; at present it is rare. It follows the usual order of eruption of the erythemata, beginning on the face; then descending to the trunk, and afterwards to the extremities. It is regarded as a not unfavourable sign when the rash is of bright colour, but less favourable when dark in its hues, and the eruptive fever runs high. It commonly has a course of three or four days. Roseola vaccina is an exanthem similar to the preceding, which accompanies sometimes the development of the vaccine vesicle, appearing on the ninth or tenth day after vaccination. The rash begins in the neighbourhood of the vaccinated spot, and spreads upon the arm and trunk, and sometimes over the greater part of the body. Its course is rarely more than two days, but it is attended with some feverishness. Roseola rheumatica et arthritica.—Rheumatism and gout are both occasionally accompanied with a roseolous rash, appearing in the form of a circular blotch {roseola maculosa), and usually on the lower extremities. Sometimes the roseola precedes the attack, and sometimes makes its invasion during the progress of the principal disorder. Roseola cholerica has been described by Rayer as a roseo- lous exanthem accompanying the progress of the Asiatic cholera. It sometimes resembled scarlatina, sometimes measles, and some- times urticaria; was associated with congestion of the fauces and the usual train of febrile symptoms; and was brightly tinted at first, but subsequently acquired a dirty pink or rose-colour. Roseola febris continue is the punctated exanthem which so commonly accompanies continued fever, and is met with in all the three varieties, typhus, typhoid, and relapsing fever. It makes its appearance at the beginning of the second week, and is scattered sometimes over the entire body, sometimes on the trunk alone, and sometimes on the limbs, particularly the back of the hands, but rarely on the face. In typhoid fever the roseola. 149 exanthem has a bright rose-colour, and disappears on pressure with the finger and after death. In typhus it is mulberry- coloured : it continues on pressure with the finger, and remains after -death, when it presents the appearance of petechial spots. The exanthem of relapsing fever also acquires very quickly a dark colour, and passes into the state of petechias. Each spot has a course of three days, and fresh spots appear every day; so that after the first three days they may be seen in all their stages—crescent, mature, and fading. Under the very objectionable name of roseola miliaris, Bate- man has noticed the occurrence of miliary vesicles or sudamina in conjunction with the roseolous spots of continued fever. These vesicles are most frequent in relapsing fever; but they appear in all the three forms, and most abundantly during the prevalence of copious perspirations. They are met with chiefly on the neck and breast, in the armpits, and on the sides of the chest. Diagnosis.—Colour, figure, and febrile symptoms, are the three leading signs by which roseola is to be distinguished from other cutaneous affections: the pink or bright crimson tint deep- ening into the hue of the damask rose, and fading often into the shadows of a bruise; the punctiform, closely-set dots grouped in clusters; the rings commonly narrow and fine, but sometimes broad ; the puncta, and the blotches; the congested fauces ; and then the fever sometimes slight and ephemeral, and sometimes severe. But even with all these symptoms before us,' it is often difficult to decide between a case of roseola and one of mild rubeola, and we are constrained to call other evidence to our aid. If there exist an epidemic of rubeola, if the patient be affected for the first time; moreover, if there be coryza and a catarrhal cough,—the case is undoubtedly rubeola. In roseola these is rarely any coryza, and still more rarely catarrh. Cause.—The cause of roseola is debility, which may be nutri- tive, nervous, or assimilative. The exciting cause is probably change of weather or seasons; alternations of heat and cold; and errors of diet. Hence we find it occurring very commonly in the spring and autumn, in the summer, and sometimes prevailing in an epidemic or endemic form. Reduced power in the system, and a relaxed and weakened state of the skin, are conditions favourable to the development of roseola; hence probably its association with diseases of debi- 150 cutaneous medicine. lity, such as rheumatism, gout, fever; and hence also the ten- dency of the exanthem to pass into the condition of purpura. Prognosis.—Roseola is by no means a serious affection either in its idiopathic form, or as a complication of more serious mala- dies. In a chronic form it indicates a general state of disorder of the economy, which we must endeavour to correct. Treatment.—Gentle laxatives, effervescent salines, light bit- ters with the mineral acids, small doses of quinine with sulphu- ric acid, mild chalybeates, constitute the pharmacopoeia of roseola, both in its idiopathic and in its chronic form. Locally, it is better left alone ; but if much irritation be present, the skin may be washed with the juniper-tar soap and tepid water. The diet should be of the antiphlogistic kind; namely, toast- water and barley-water, with or without chlorate of potash or lemon-juice, for drinks; with milk diet, farinaceous puddings, broths, eggs, fish, poultry; returning by degrees to the ordinary diet of health. CHAPTER V. bullous affections. Bullae is the type of one of Willan's orders, and presents an unmistakable character. His definition of bulla or bleb is, " a large portion of the cuticle detached from the skin by the inter- position of a transparent watery fluid." This definition applies very exactly to one of the members of the present group, namely, to pemphigus; but less well to herpes, which Willan treated as a vesicle, and admitted into the same order with eczema; and still less to miliaria, which is truly a vesicle. Herpes is a large vesicle, or small bulla; and although differing entirely in its nature both from vesicular affections and from pemphigus, seems entitled, from the possession of this special pathological form, to a place, for the present at least, in the bullous group; and the more so, as some of the varieties of herpes are really allied more closely to pemphigus than they are to herpes. And as we have broken up the order Vesiculas, by the dispersion of its different members, this is also the proper place for the consideration of the small bleb or vesicle of miliaria. The diseases constituting this group are three in number; namely — Herpes Miliaria Pemphigus Herpes is derived from the word ipirtti, "quod est," says Actu- arius, " serpere per summam cutem ;" but this is clearly an error as applied to the typical form of herpes, herpes zoster; for herpes does not creep, although some of its chronic varieties, which belong rather to pemphigus than to herpes, namely, herpes cir- cinatus and herpes iris, really do so. The term tpvis was applied by the ancients to a creeping and eating form of eruption, some- times vesicular and sometimes ulcerative, and appertaining to the strumous, the syphilitic, and the cancerous affections. Pemphigus is derived from *-£/*orr]C,, a belt. | " Zoster appellatur, et enecat, si cinxerit."—Pliny. HERPES. 155 which latter term its popular name shingles has been derived. Besides the waist, we have seen it on the flank, on the hip, on the thigh, on the shoulder, on the neck, and upon the head. On the head and face it occupied chiefly the occiput, the temple, and the forehead, while one vesicle was developed on the con- junctiva. On the limbs it takes the course of the cutaneous nerves, as of the shoulder and thigh. Bateman calls a case of the latter kind herpes proserpens. Usually the eruption of zoster takes place without any pre- monitory sign, and runs through its course without much suffer- ing, with no other pain in fact than the burning and tingling which constantly accompany it, and which have gained for it the name of zona ignea; at other times, when the neuralgic affection is severe, the internal organs are apt to suffer also from the communication of their nerves with the intercostal nerves ; thus, there may be intense shooting pains through the chest, with tumultuous action and palpitations of the heart. And sometimes the eruption is accompanied with febrile symptoms, which are as likely to arise from the ordinary cause of the erup- tion, namely, a chill, as they are from the nervous perturbation accompanying the disease. On the subsidence of the eruption, the neuralgic pains, of a very severe kind, are apt to be continued for some weeks, and to resist every kind of treatment. It has been stated that the eruption attacks one side of the body more frequently than the other. This is not the case; the two sides are equally the sub- ject of the affection. Its seat of eruption is commonly deter- mined by the direction in which' the cold which causes it is applied, and sometimes by a temporary or permanent debility of the part. We lately saw a case which had arisen from a chill in bathing, and an inordinately long walk which had strained the muscles of the hip : the eruption broke out on the weakened part. Herpes zoster enjoys no immunity from the variations that accompany most other natural phenomena, and especially those of disease. This affection may be said to have three principal symptoms ; namely, inflammation of skin, eruption of vesicles, and neuralgic pains. We have now to state that one or other of these symptoms may be occasionally absent; for example, there may be inflammation and pain without vesication; or 156 CUTANEOUS MEDICINE. there may be inflammation and vesication with a scarcely appre- ciable amount of pain. And in a fully developed zoster, some of the patches may be studded profusely with vesicles, while on others they are scanty or absent. In these cases we signify our meaning by the use of the term "arrest of development." Herpes phlyctenodes differs from herpes zoster only in situation, being identical in every other respect. Thus, when herpes attacks the trunk of the body and forms a demizone around it, the case is one of herpes zoster; but when, as we have already described, it appears upon a limb, upon the neck, or upon the head and face, it is more correct to term it herpes phlyctenodes. Herpes phlyctenodes may occur as a single patch, or as a cluster of several, on any part of the body. The patch rarely exceeds in size the palm of the hand, and it consists of an in- flamed surface studded over with vesicles, sometimes discrete and sometimes confluent: occasionally the vesicles are so small as to have suggested the term herpes miliaris; more frequently they attain the size of peas of moderate dimensions. The patches commence with a sensation of burning, tingling, and smarting; some red puncta are seen on the painful spot, a blotch of redness succeeds, and on the inflamed surface the vesi- cles are developed. Sometimes there is a deep-seated soreness and pain as well as that already described. It is rare for any constitutional symptoms to be present. Herpes labialis represents the local forms of herpes, all of which, like herpes zoster and herpes phlyctenodes, are acute forms of the affection, and have their regular course, never exceeding ten or twelve days. Some occur only once, or if the attack be repeated, it is accidental, and occurs at an uncertain period; while one of the local forms, herpes praeputialis, is inter- mittent, and breaks out at short intervals for a considerable period of time. * Herpes labialis, a frequent consequence of an inflammatory cold, or of slight febrile disturbance of the system, begins with itching, redness, heat, swelling, and painful tension of the lip and adjacent mucous membrane. On the day following the beginning of the inflammation, five or six small vesicles appear on the affected spot; some of the vesicles congregate and form small cellular bullae of the size of a split pea. On the third or HERPES. 157 fourth day the lymph of the vesicles becomes turbid and lactes- cent, and subsequently semipurulent. On the fifth or sixth day the vesicles desiccate into a brownish crust, and on the eighth or tenth day the crust falls. When the crust is interfered with during its progress, or the inflammation is aggravated by interference, a hard scab is formed, which remains adherent for a longer period than the natural crust. Herpes palpebralis, nasalis, et auricularis, are identical with herpes labialis, but usually less extensive and less severe. In herpes palpebralis the inflammation and vesicles are deve- loped on one eyelid; in herpes nasalis along the margin and upon the ala of one nostril; and in herpes auricularis upon the lobe of one of the ears and not on the other. In symptoms, course, and termination, these forms correspond with herpes labialis. Herpes pr^eputialis may occur upon the mucous or upon the cutaneous surface of the prepuce : it consists, as do the other local forms, of a blotch of redness surmounted by a small crop of vesicles, and attended with a sensation of smarting and burn- ing ; on the prepuce the blotch is rarely larger than half an inch in diameter; the vesicles found on the cutaneous surface sub- side after a few days, from the absorption of their fluid contents, and dry up into small thin brownish scabs ; but the vesicles on the mucous surface are generally broken, and produce minute excoriations, which are often slow in healing and are liable to be mistaken for syphilitic ulcerations. Herpes prasputialis presents the peculiarity of being intermit- tent, returning from time to time for several months or even years. It rarely occurs without a foregone irritation of the organ, either in the shape of a gonorrhoea or chancre ; and then seems to perpetuate a remembrance of the original disorder. We know a gentleman who, after the cure of a chancre, suffered during two years with fourteen attacks of herpes prasputialis, each attack lasting about ten day3. The last time that the erup- tion made its appearance it showed itself on the cutaneous sur- face of the derma and root of the penis of one side. Herpes pudendalis corresponds in every respect but situa- tion with herpes prasputialis; it is developed on one labium. 158 CUTANEOUS MEDICINE. CHRONIC FORMS. The chronic forms of herpes are distinguished from the acute forms by their more general distribution; by their longer duration; by a more superficial inflammation of the skin ; by a tendency to spread; by less severe local suffering; by an absence of neuralgic pain ; and by a disposition to the produc- tion of larger vesicles, and often bullas, herpes bulhsus; in a word, the chronic forms of herpes prepare us for a transition to the bullous affection pemphigus. The varieties belonging to the chronic group are herpes circinatus and herpes iris; they have no special constitutional symptoms. Herpes circinatus makes its appearance as red and slightly raised spots, which are accompanied with considerable tingling and itching, and are apt to be mistaken for the bites of insects. In a few hours the spot spreads into a blotch half an inch in diameter, and soon after increases to the diameter of an inch or two inches. When it is larger than half an inch, it is found to be slightly depressed in the centre ; and with a further increase of dimensions, the redness of the centre fades and becomes yel- lowish, and a ring is produced. In the growing disk and grow- ing ring the peripheral border is observed to be a little raised above the level of the rest of the surface, and is somewhat brighter in its tint of red: it is at this part that vesication begins, and the cuticle is raised into vesicles as large as peas upon the belt of the rings in the course of a few hours. The progress of the eruption is so rapid that that which is a sprin- kling of mere itchy spots at night, and a disturber of sleep, may, in the morning, be a crop of annular rings, each surmounted with a circle of glistening bullulas as large as moderate-sized peas. The vesicles are filled with limpid lymph, sometimes changing to opalescence and milkiness; they become wrinkled and collapsed in the course of the following day, and in a day or two more are converted into thin brownish and blackish scabs. The redness fades with the collapse of the vesicles ; the cuticle of its base exfoliates, and in a few days no trace of the patch remains. But as the eruption is successive in the development of the annuli, it may continue for ten or twelve days, or even for a longer period of time. The development and maturation of the disks and rings is HERPES. 159 accompanied with more or less tingling, itching, and smarting, and these sensations subside with the patches; but as the latter are produced in succession, and commonly during the night, the pruritus is often exceedingly annoying. The ordinary size of the annuli is two inches in diameter; sometimes they are a little larger; and when the eruption takes place suddenly, at the first outburst of the disease, they may be smaller. In a case in which the limbs and part of the trunk of the body were nearly covered with the eruption in the course of two days, the physi- cian who attended the patient remarked that it was a sight worthy of being remembered. The eruption was still trouble- some in this case, although progressing towards cure, at the end of two months. Occasionally from the beginning, but more frequently in the course of a chronic case of this disease, there are modifications of development of the eruption which are deserving of note. In the first instance there may be, scattered among the vesicu- lated rings, red blotches or disks, showing no disposition to vesi- cate ; and secondly, there may be disks of moderate size com- pletely covered by a single large bulla ; and were it not for the general history of the complaint, we might be induced to pro- nounce the case to be one of pemphigus. In the example of herpes circinatus above noticed, in which the first attack of the eruption was developed suddenly, both the rings and the vesicles were pretty uniform in size over the whole body. As the case went on, the dimensions of the patches diminished, and in place of a row of vesicles, a single,large bleb was produced; and later, when the patient's general health was improved with the aid of tonics, the effusion ceased to occur, and irritable erythe- matous disks only were apparent. Herpes iris is a lower'form of herpes than herpes circinatus. It is essentially, like some of the exhausted patches of the latter complaint, a herpes bulhsus propagated from the centre by a series of efforts, too feeble to produce a row of independent vesicles, and resulting only in the formation of annular ridges more or less distended with a serous fluid—it is, in fact, an aborted form of herpes circinatus. Herpes iris occurs very commonly on the back of the hands of elderly persons; and here the disks are small, and the central vesicle equally so. When the affection shows itself on the limbs, 160 cutaneous medicine. and in persons of reduced power, the central vesicle is an undoubted bulla, and the disk or patch may attain the dimen- sions of one or two inches in diameter. The' "process of formation of herpes iris is as follows: An inflamed spot or disk first makes its appearance ; the day follow- ing, this disk is covered by a vesicle or bleb, while a-narrow border of red appears around its circumference; on the third day the narrow border of red is raised into a vesicular ring, and the redness has crept on for another stage, forming another nar- row border of red; on the fourth and successive days, the same phenomena are repeated until the disk has attained its full size. The effusion, it will be observed, is most abundant in the central vesicle, and diminishes as the rings increase in number. The first ring is more distended than the second, the second than the third; with the third, the effusion generally ceases, and the rings developed beyond the third are simply erythematous, and distin- guished only as shades of red. The development of the disk of herpes iris undergoes some modifications: occasionally, as in the disks observed on the back of the hands and feet of elderly persons, it never reaches beyond the erythematous stage, and has been named, in consequence, erythema iris. At other times the central bulla creeps on with the enlarging erythematous line and forms a bleb, often of con- siderable size, pemphigus iris; absorbing, as it proceeds, the annular vesicles of the circumference. In the erythematous form, as seen upon the hands, there are commonly not more than three shades of colour; the centre red, the first ring whitish or yellowish, and beyond this a narrow halo of light crimson. On other parts of the body the number of rings may be increased to five or six, or even more. By watching the disks from day to day, we have observed in some cases that a new ring is pro- duced daily, so that the number of rings determines the length of duration of the patch. In one disk we counted seven white rings, representing seven days, and seven circles of fading red between them, the outermost white ring being bounded by a narrow areola of pale crimson ; while in another disk, only half an inch in diameter, there were nine different tints of colour, which, from the centre to the circumference, were as follows:— red, brown, white, deep red, lighter red, deep red, pale red, deep red, yellowish white, and crimson blush. This appearance of the HERPES. 161 eruption sufficiently warrants the designation " iris" given to it by Willan. Herpes iris has no constitutional symptoms: it is always associated with debility, as in the debility of elderly persons, and sometimes,, as in children, with nutritive debility and cachexia: It is in a cachectic state of the constitution that it more frequently takes on the pemphigoid form. Diagnosis.—The diagnosis of herpes turns upon the size of the vesicles, larger than those of eczema and miliaria, smaller than the bullas of pemphigus ; upon the burning, tingling, prick- ing, and smarting itching; upon the frequent presence of neu- ralgic pains, and upon the orderly course of the eruption. The local varieties have small vesicles,, sometimes multilocular vesi- cles ; but they are always developed upon a patch of redness, and are accompanied with the pathognomonic tingling, smarting, and burning of herpes. Herpes circinatus is recognized by its circle of vesicles or bullulas, and herpes iris by its centrifugal rings starting from a central umbo. Cause.—The cause of herpes zoster, herpes phlyctenodes, and herpes auricularis is a chill, sometimes proceeding from a cold current of air, as in the prevalence of easterly winds, or sitting in a draft when the body is heated; or sometimes from the direct application of cold, as from sitting or lying on the ground, or the wearing of damp clothes. Herpes labialis, nasalis, and palpebralis, usually proceed from irritation of the adjoining mucous membrane, and follow a feverish cold or catarrh; and herpes prasputialis and pudendi originate in some irritation of the neighbouring mucous membrane. We have never seen an instance of herpes prasputialis in which there has not previously existed a gonorrhoea, a leucorrhosa, or some syphilitic affection. The cause of herpes circinatus and iris is a debility, a lowered tone of the system, sometimes referrible to nutritive, sometimes to assimilative, and sometimes to nervous causes. We have at present under our care a patient who has suffered from herpes phlyctenodes, spring and autumn, for several years, the erup- tion being each time preceded by a bilious attack. Prognosis.—Herpes is not a grave affection and is sometimes very trivial. In the neuralgic forms the pain is often terrible, and very difficult to, conquer. The circinate form and herpes iris, as they indicate a general debility proceeding from a gcne- 11 162 CUTANEOUS MEDICINE. ral derangement of health, are of most importance in reference to the health and safety of the patient. TREATMENT.-^The treatment of herpes zoster, phlyctenodes, and the local forms, when unaccompanied with neuralgic pain, is purely local; if neuralgia be present, constitutional as well as local treatment will be requisite; and the chronic forms also call for constitutional as well as local remedies. As the acute forms of herpes are limited in extent, and have a regular course of a certain number of days' duration, all that we are called upon to do in the majority of cases is to protect the inflamed skin from pressure or friction. To this end we shall find no better means than dredging the eruption copiously with flour, and confining it there by means of a sheet of cotton wool, held in its place by strips of adhesive plaster or a ban- dage, not too tightly applied. We have also found a thick coating of the benzoated ointment of oxide of zinc, afterwards covered with a sheet of cotton wool, and retained in its place by strips of adhesive plaster, very successful. When the burning heat and tingling are very troublesome, we have obtained ease from arrowroot poultices, made by filling a muslin bag with arrowroot jelly and applying it cold ; and at other times, from folds of flannel saturated with a decoction of poppy-heads. Experiments have been made with ectrotic remedies, but their advantage has not been fully established ; the best of these is a solution of nitrate of silver in nitric ether, which we have known give considerable relief; it is a good application for all the local forms, particularly herpes prasputialis. We have some- times applied a solution of potassa fusa, in equal parts of water, with the result of immediately checking the course of the eruption. Another mode of using the nitrate of silver, is to puncture the vesicle and after absorbing the serum to touch its base with a point of the caustic; with the local forms this plan answers extremely well. In the neuralgia of herpes we must have recourse to quinine, citrate of quinine and iron, and arsenic; or if there be evidence of a rheumatic diathesis, iodide of potash; and of a gouty diathe- sis, colchicum; and as sedative remedies, to belladonna, hyoscya- mus, morphia, and chlorodyne. Locally, the treatment must be sedative and stimulant: preparations of aconite, belladonna, morphia, chloroform, cajeput, may all be used in their turn. MILIARIA. 163 i We have employed a blister without much result, and have derived the greatest advantage from the oleum juniperi pyro- lignici, combined with chloroform and tincture of aconite. The chronic forms of the eruptfon should be washed with the juniper-tar soap, and sponged with a lotion of the juniper tar, or with hydrocyanic acid in emulsion of bitter almonds, to allay the itching; and afterwards anointed with the benzoated oint- ment of oxide of zinc, with spirits of wine or spirits of camphor, or a simple camphor cerate. When the vesicles are broken and the corium excoriated, dressings of the benzoated ointment of oxide of zinc on lint should be applied. MILIARIA. Miliaria is the name which is given to an eruption of small globular vesicles of a size corresponding with that of the milium, or millet-seed. They are the consequence of a weak and exhausted state of the skin, induced by heat and per- spiration, and are commonly associated with fevers, with the puerperal state, with rheumatism, or with any ailment which renders confinement to bed for a lengthened period a necessary condition. From the latter circumstance the eruption has been termed miliaria clinica, and, from its combination with perspira- tion, the vesicles have been named sudamina. The vesicles of miliaria are larger than those of eczema, but smaller than the vesicles of herpes, and, necessarily, very much smaller than the bullas of pemphigus; nevertheless, they are frequently of a size to suggest the idea of the former, while in their origin they have some of the characters of the lattei\ They originate in a debilitated condition of the cutaneous tissues, like pemphigus ; like the latter disease also, they indicate an exhausted state of the vital power, and they are produced with little cutaneous congestion. But, unlike pemphigus, they are generally symptomatic of an independent febrile state of the constitution, and their course is acute. At their first eruption the vesicles are filled with a transparent and limpid serum, which reflects the colour of the denuded derma at their base. This gives them an appearance of redness, • and has gained for the disorder the name of Miliaria rubra. 164 CUTANEOUS MEDICINE. But in twelve or twenty-four hours the serum becomes opales- cent, whitish, and milky, and in this state the appearance of the vesicles has given origin to the term Miliaria alba. The vesicles are met with mdst frequently on the sides of the trunk of the body and upper arms; in the axillae ; on the back and on the neck; in situations, in fact, the most likely to suffer from heat and perspiration during illness. They are sometimes evolved in patches of various size, but, more commonly, are scattered singly over the surface. They appear in succession, each fresh outbreak lasting three or four days, but the eruption, as a w^hole, continuing for one or two weeks. The vesicles sometimes break, but more frequently collapse, from absorption of their contained serum; and the desiccated cuticle forms a small thin scab, which in a short time is removed by desqua- mation. Miliaria has no constitutional symptoms; but its association with fevers has suggested the term miliary fever, formerly applied to it. Indeed, there seems to be good reason for the belief that its frequency in former times, and its comparative rarity at pre- sent, are to be explained by the better method of treating fever in our own days, and the preservation of a cooler state of the body; the condition the most favourable for the production of miliaria, being a hot and perspiring state, such as would result from hot rooms, excess of bedclothes, and heating regimen and remedies. To these latter conditions in particular is to be referred the miliaria of puerperal patients. Miliaria is generally accompanied with sensations of languor, of extreme exhaustion, and a feeling of faintness; symptoms which are attributable to the perspirations, rather than to the eruption; and the perspir- ing state of the skin is also made evident by the strongly acid odour of the sick-room. Diagnosis.—The size of the vesicle is pathognomonic, as is also the absence of inflammatory congestion at its base. It is smaller than the vesicle of herpes, generally scattered, and want- ing in the burning, tingling, and pricking of the latter; while it is too small to be mistaken for pemphigus; indeed, is a vesicula and not a bulla. Cause.—Debility of cutaneous tissue, generally the conse- quence of too much heat, and a resulting excess of perspiration. Prognosis.—The prognostics of the eruption are dependent PEMPHIGUS. 165 on the illness with which it is associated, or upon the degree of power of the constitution. Treatment.—The constitutional management of miliaria must be directed to the cure of the disease with which it is asso- ciated. Its local or special treatment must have for its object, to give tone to the tissues of the skin, by means, for example, of tepid baths; of washing with tepid water and the juniper-tar soap; of sponging with a tepid solution of ammonia, of a strength sufficient to act as a mild or tonic stimulant; or with tepid vinegar and water. These are means that cannot affect injuriously the disorder in chief, but may possibly be of use to it. In a more prostrate condition of the system, we may pre- scribe the powder puff; and as the body acquires strength, we may venture to reduce still further the temperature of our local applications. PEMPHIGUS. Pemphigus is an eruption of bullas arising from a very slightly inflamed ground, and distributed more or less exten- sively over the surface of the skin. The bullas arise in the course of a few hours, with some tingling and smarting, and often without redness. They are distended with a serous fluid, burst in one or two days, and leave an excoriated surface, which soon becomes covered with a thin brownish or blackish scab. On the desquamation of the scab, the skin is left of a dull red tint, sometimes livid, and frequently stained with brownish dis- colorations. The bullas vary in bulk from the size of a pea to that of the hemisphere of a walnut, or a hen's egg; they commonly cover the whole of the inflamed disk on which they arise; and their contents, at first limpid and straw-coloured or amber-coloured, become opalescent and milky; sometimes semipurulent, and not uncommonly purple, from admixture with blood. Sometimes, instead of bursting and leaving a red and angry excoriation prone to bleed, the bullas become wrinkled and collapsed, and dry up into a thin corrugated scab, which is either greyish, light-brown, or black, according to the character of the serous contents; and sometimes the collapse is only partial, covering 166 CUTANEOUS MEDICINE. part of the base, and leaving a vesicular roll around a part of the circumference; and sometimes this last-described corrugated and collapsed form is present from the beginning, and never rises to a fully-developed bulla, but forms on desiccation a thin corru- gated scab, which being frequently oval in outline, suggests the idea of a dried leaf adhering to the skin: this appearance has given origin to the term foliaceous, applied to one of the varieties of pemphigus. The bullae of pemphigus are commonly thrown up in clusters of three or four, to twelve or even a greater number, and not unfrequently have separate bullae dispersed between the groups. Each bulla runs its course in one or two weeks; but as others appear in succession, a few fresh clusters occurring every day, or every two or three days, the eruption is prolonged for some weeks, and more commonly for several months or years. The affection is therefore essentially chronic, and differs in different persons only in degrees of chronicity; the term acute is not rea- sonably applicable to pemphigus. Occasionally the disease is limited to the production of a single bulla, pemphigus solitarius, which attains a very considerable size, often as large and even larger than a large orange. Pemphigus has been called acute, in consequence of being occasionally preceded by a little fever, and terminating in a few weeks; but in general it is chronic and lasts for a considerable period. It usually denotes a low and debilitated and cachectic state of the constitution, and is associated with bleeding from the excoriated skin; vesication of the mucous membrane of the mouth, nose, vulva, and vagina; and haemorrhage from the bowels, from the kidneys, and sometimes from the stomach and lungs. The skin in general corresponds with this morbid state, and is often dry, shrivelled, and discoloured. The local suffering attendant on pemphigus is a moderate amount of itching, tingling, and smarting on the first appearance of the eruption, and extreme soreness and sensitiveness in the state of excoriation. We have met with one case in which there was a blending of the pruritus and desquamation of eczema with the partially and irregularly formed bullae of pemphigus. This case we noted at the time of its occurrence as a pemphigoid eczema, and we find a similar case described by Hardy under the name of pemphigus pruriginosus. The cause of the affection PEMPHIGUS. 167 was identical with that of our own, namely, utero-gestation; the eruption commenced at about the sixth week of pregnancy, the patient on several occasions deriving the first notice of her state from the irritation of her skin, and continued during the whole period of gestation; and the symptoms were so severe as in one instance to result in miscarriage. Pemphigus is happily a rare affection, and more rare possibly in this country than in others. It is more frequent in women than in men, and is most common in children. Amongst the children of the poor it is apt to show itself in the form of purple and livid spots that tend to gangrene, pemphigus gangrmnosus; and amongst the ill-fed poor in Ireland, the gangrenous form sometimes prevails as an epidemic. There are few affections to which so many varieties have been assigned as pemphigus, and its synonym pompholyx; for exam- ple, pemphigus congenitus, infantilis, simultaneus, successivus, .solitarius, confluens, confertus, acutus, chronicus, pyreticus, apy- reticus, vulgaris, benignus, diutinus, contagiosus, gangrasnosus, foliaceus, pruriginosus, &c.; but for practical purposes they may all be included under the five following heads; namely,— Pemphigus vulgaris Pemphigus foliaceus „ solitarius „ pruriginosus „ gangrsenosus Pemphigus vulgaris is the common and usual form of the affection: in its milder form, and lasting only a few weeks, it has been termed pemphigus acutus and pompholyx benignus; but as we have already shown, its symptoms are not sufficient to characterize an acute disease; and all we can accord to it is that it is less chronic in some cases than it is in others, and undoubt- edly milder, benignus. Sometimes some slight febrile disorder precedes the eruption; but at other times it is unattended with any symptoms but those which belong to the depressed state of health in which the dis- order originates. The chronic form of pemphigus vulgaris is "distinguished by the prolonged continuance of the eruption, lasting sometimes for several years, and its obstinate resistance of treatment. A patient before us, a young unmarried woman, aged 26, suffering from 168 CUTANEOUS MEDICINE. this complaint for six months, had purpura which covered the lower half of the body, and was accompanied with epistaxis, seven years ago, and for the last five years she has been the subject of amenorrhcea. Pemphigus solitarius is a peculiar variety of the eruption, remarkable for the production of a single bulla, which attains to a very large size, often as big as an orange. It is preceded by a sensation of tingling and smarting, and in a few hours the bulla has attained a considerable size. At the end of two days it bursts and leaves behind it a painful excoriation, which becomes covered with a thin greyish scab. After the lapse of a few days, a second bulla appears near the seat of the former, and runs a similar course, to be followed in succession by five or six more; so that the attack is prolonged for ten days or for a fortnight. Pemphigus gangr^enosus.—Under the name of pemphigus infantilis, Willan describes an eruption which has since received from Dr. Whitley Stokes the more appropriate name of pem- phigus gangrasnosus. It occurs in children, and in Ireland some- times prevails as an epidemic among the poor. It makes its appearance in the form of small, imperfectly developed, generally flattened bullas, rising upon a purplish and livid base. The bullas are filled with a sanguinolent and sanious fluid; they burst in two or three days, and expose an ulcerating and fre- quently sloughing base; the ulcers are painful, have thin livid edges, and secrete a sanious and fetid pus; frequently they enlarge by their circumference, and when they heal, are slow and tedious in their progress towards cure. By successive erup- tions the disease is continued for some weeks; it givesrise to irritative fever, destroys rest, induces general disturoance of nutrition, and finally exhausts the power and vitality of the patient. In Ireland this eruption is popularly known as white blisters, eating hive, and burnt holes, and " death takes place about the tenth or twelfth day, often preceded by convulsions, sometimes by extreme lividity." Pemphigus foliaceus is a variety of the eruption, arising from imperfect development of the bulla; the cuticle is raised from the corium to a superficial extent, and instead of going on to the full development of a bulla, dries up into a thin corru- PEMPHIGUS. 169 gated greyish or brownish scab. When partially separated, the scabs give a ragged appearance to the skin, particularly when f they are abundant; and when they are shed, are frequently replaced by other scabs of similar formation. At first, there is a sprinkling of fully or partially-formed bullae, with the scales; but after a while, the desquamation exists alone, the skin being deeply congested and exuding a serous secretion. The foliaceous scabs are produced with such activity, that in a few hours, according to Hard}'-, the bed of the patient is filled with them. At a later period of the disease, when the skin is about returning to its natural state, there is a reappearance of the bullae Pemphigus pruriginosus is a peculiar form of the bullous eruption, associated with general redness and infiltration of the skin, and an appearance resembling chronic eczema. The above title was given to the disease by Hardy; and the case by which he illustrates the affection was one of utero-gestation: we have ourselves met with a similar case, and can confirm his observa- tion. The bullae are imperfect, frequently forming no more than a serous roll along the circumference of the patch; but they exist very numerously distributed over the surface of the body. In our own case the eruption occurred with every pregnancy, and at last grew to be insupportable. Diagnosis.—The distinctive characters of pemphigus are, its large vesicles or bullae. The large vesicles of herpes circinatus often approach in size those of pemphigus, and as we have seen, constitute a transition-link with pemphigus itself. Cause.—The cause of pemphigus is a general and local debili- ty, approaching to cachexia. We have recorded two instances which followed local injury; in one of them, a servant girl " poisoned" her hand with a red paste, with which she was cleaning brass; a few days afterwards a crop of bullas, inter- mingled with ecchymosed spots, came out on her wrist and fore- arm, and continued to trouble her from time to time for seven years. The other case was that of a medical man, who punc- tured his right hand; three or four weeks afterwards, an eruption of bullas made their appearance on his left thigh, and were repeated from time to time for eighteen months. Their outbreak was preceded by feverish symptoms; there was a scalded sen- sation in the skin, and the next morning a fully developed bulla 170 CUTANEOUS MEDICINE. would be discovered. It is often sympathetic with irritation or defective function of some part of the mucous membrane, and especially that of the uterine system. Prognosis.—As pemphigus is indicative of a serious amount of local and general debility, and as the cause of that debility is difficult of detection, and may depend upon some radical defect in the economy, the prognosis must always be doubt- ful and unsatisfactory. The ultimate result must depend upon the powers of the constitution, and these will be influ- enced very much by age, position in life, and other circum- stances. Treatment.—Treatment must be chiefly constitutional; any disorder of digestive function and secretions should be regulated, and then we must rely upon tonics; the bitters with mineral acids; cinchona with sulphuric acid; quinine; and citrate of quinine and iron. We have also derived good results from the use of arsenic. If there be feverish symptoms, we may find it necessary to have recourse to effervescent salines, with ammonia; to sulphate of magnesia, with quinine and infusion of roses; and to chlorate of potash. Locally, we should puncture the bullas as soon as they are fully developed, in order that the cuticle may fall down upon the denuded corium, and form upon it a covering of protection; then we should dress the eruption with the benzoated ointment of oxide of zinc spread on lint, and afterwards cover the dress- ing with a sheet of cotton wool. We may, if occasion arise, vary this dressing with one of ceratum calaminas, or simple cerate with which a few grains of the superacetate of lead (gr. v ad |j) have been rubbed down. If there be much sensitive- ness of the excoriated skin, we may allay it by the use of a weak solution of nitrate of silver (gr. j—iij ad f j), and dress it as above, renewing the dressing night and morning, and keeping it in its* place with adhesive strips or with a bandage. In pemphigus foliaceus and pruriginosus we shall find ablu- tions with the juniper-tar soap and warm water of great use in removing the scales and relieving irritation; and afterwards we must anoint the surface with the benzoated ointment of oxide of zinc; or if the' pruritus still be annoying, with the ointment pemphigus. 171 of the pyroligneous oil of juniper; the excoriations being dressed as above with the benzoated ointment of oxide of zinc rubbed down with spirits of wine or spirits of camphor. The diet in pemphigus should be of the nourishing kind, meat and wine, unless any contra-indication arise. 172 cutaneous medicine. CHAPTER VI. 'fi FURUNCULAR AFFECTIONS. Under the head of Furuncular affections, which properly includes Furunculus, Hordeolum, and Anthrax, we have like- wise grouped Ecthyma, as being otherwise isolated, and as pre- senting several points of affinity with furunculus; for example, it is sometimes associated in the same eruption with furunculus; it is a disease of a pyogenic character; it very commonly ulcer- ates and sloughs; is essentially a disease of low constitutional power, and evinces a tendency on the part of the constitution to cachexia. Ecthyma is a pustule; indeed is the type of the order Pustulae ofWillan, and is consequently united in that group with impe- tigo. From impetigo, however, it differs more than from furun- culus ; for impetigo is a psydracious pustule, a sero-pustule, a surface affection, developed not singly like ecthyma, but in clus- ters, with less local inflammation, and without any tendency to ulcerate. Moreover, the alliance between ecthyma and impetigo is dissolved by the union of the latter with eczema; and in con- sequence of the removal of other diseases from the same order, would be left alone unless joined with furunculus. The essential points of difference between ecthyma and furun- culus are the frank suppuration of the former, and the presence of a core of cellular tissue in the state of gangrene in the latter. ECTHYMA. Ecthyma, derived from tx.6vtn, to burst forth, is an eruption of large pustules dispersed over the body and limbs more or less extensively; rarely general, more commonly limited to a part, as to the lower extremities. The pustule is hemispherical in figure, distended with a deep yellow pus, mounted on a hard and prominent base, and surrounded by a red and highly inflamed areola. The pustule ulcerates more or less deeply; has ECTHYMA. 173 an average duration often or twelve days; dries up into a thick greyish-yellow or brownish scab, which is firmly adherent to the skin, and leaves at its fall a purplish red and pitted cicatrix. The pustules are successive, and the eruption is consequently prolonged for several weeks or months. - . The eruption begins with a little itching and tingling, and with the appearance of a small inflamed pimple; the pimple increases in size, a little pus is formed on its summit, and it is quickly converted into a round hemispherical pustule, with a hard and inflamed base. The pustule bursts in three days, and the pus, together with the plastic lymph secreted hy its base, dries up into a yellowish-grey and brown scab. If the scab be detached too soon, a small ulcer is exposed, which forms a second- ary scab, which remains attached for a considerable time, and at its fall leaves a more extensive, and a deeper pit. This is the acute course of the pustule, lasting for eight or ten days ; and the eruption is said to be acute when it is composed of pustules.of this kind, following each other in succession for three or more weeks ; but in a cachectic state of the constitution, the pustules have a chronic character; the redness is of a deeper hue or livid ; the pustule is purplish from the admixture of blood with the pus; at its rupture a painful, ulcerated, and often sloughing surface is exposed to view ; the crust formed over this ulcer is more or less black ; the edges of the sore are thin and livid; and the ulcer is slow in its progress, very painful, and of long duration. This character of the eruption is the basis of the varieties termed ecthyma luridum and ecthyma cachecticum; while in an extreme degree of cachexia there may be a gangre- nous condition of the ulcer, and a condition warranting the adoption of the term ecthyma gangrasnosum. The pyogenic tendency of ecthyma, its proneness to ulceration, to sloughing, and sometimes to gangrene, indicate a low tone and debility of the constitution, that may be associated with symp- toms of general disturbance of health and more or less fever of the hectic kind ; but there are no constitutional symptoms that can be attributed specially to ecthyma. The pyogenic condition of the system in ecthyma is indicated by the frequent presence of superficial abscesses; a disposition to suppurate in slight wounds and scratches of the skin ; and the formation of whitlows ; and the cachectic tendency of the consti- 174 CUTANEOUS MEDICINE. tution is shown by the frequent occurrence of inflammation of the lymphatic vessels and glands. The varieties of ecthyma are acute and chronic. Acute ecthyma is the ecthyma vulgare of Willan, to which Hardy adds a form almost unknown in England, ecthyma gangrasnosum. The chronic varieties are, ecthyma infantile and ecthyma cachecticum; the latter including the ecthyma luridum of Willan. In a tabu- lar form they are as follows:— ACUTE. CHRONIC. Ecthyma vulgare Ecthyma infantile " gangrenosum " cachecticum Ecthyma vulgare is the more common and simple form of the eruption,—that in which the pustules run the acute course already described, although the eruption may be prolonged by the successive appearance of pustules for two or three or more weeks, or by its continuance deserve to be considered as chronic. There is more tone and power of constitution in this than in the other forms, and the symptoms are milder in character. The pustules are for the most part developed on the extremities, par- ticularly the lower limbs, the shoulders, and the neck, and more commonly in children than in adults. Ecthyma gangrenosum is a name given by Hardy to an acute form of ecthyma, which he appears to have seen only once, and in a man exhausted by age and misery. The eruption made its appearance in the shape of phlyzacious pustules, with an areola of a brownish-red colour at first, and afterwards grey. A circular eschar, succeeded by unhealthy ulceration, formed on the second day, and was followed in five or six days by death. Hardy asks whether this may not be the rupia escharotica of authors? We think it not unlikely ; for, substituting children for the aged, it corresponds very nearly with the pemphigus gangrasnosus of Dr. Whitley Stokes, the true representative of the older rupia escharotica. Ecthyma infantile is more commonly chronic than acute, that is, its pustules are slower in their course; they are more commonly surrounded with a purplish or livid areola, and are more prone to fall into a state of unhealthy ulceration. They are met with in infants at the breast, and in ill-fed and ill- ECTHYMA. 175 nourished children. Bateman remarks that they not'only make their appearance on the extremities and trunk, but also on the scalp, and even on the face, situations in which only ecthyma cachecticum ordinarily occurs. Ecthyma cachecticum is the chronic ecthyma of the adult, as ecthyma infantile is of infants and children. Its milder cha- racters bring it under the denomination of ecthyma luridum of Willan; while in a more advanced degree of cachexia it may present every shade of dark red, purple, and livid in colour, and every variety of ulceration, sloughing, and painful irritability. Although common to every age in the adult where the powers of the constitution are reduced, it is more frequently met with amongst the elderly. There can be no doubt that many syphi- litic eruptions were treated as forms of ecthyma by Willan and Bateman, and that the prevailing cachexia noticed by them ori- ginated in syphilis. At present we are better informed as to the characters of constitutional syphilis, and less likely to fall into errors of this kind ; and in proportion to our advance in know- ledge in this respect, our examples of ecthyma have become reduced in number. Diagnosis.—The distinction of ecthyma is simple; its large well-formed pustules, scattered singly over the body, with hard and inflamed bases, are unlike everything else. The pustules of impetigo are only half pustules, sero-pustules, in fact; they are small, clustered, without hardness or much redness of base, and are commonly associated with other characters denoting eczema. The pustules of small-pox are phlyzacious, like ecthyma; but they are more numerous ; they form part of a general eruption, and they are accompanied with special constitutional symptoms. The pustules of syphilis may also be phlyzacious, and only dis- tinguishable from ecthyma by the other symptoms of that dis- ease ; indeed, a pustular syphiloderma may be an ecthyma deve- loped under the influence of the syphilitic cachexia. Cause.—The cause of ecthyma is debility, both constitutional and local; the constitutional debility in children and elderly persons being of the nutritive kind, and in adults sometimes assimilative and sometimes nervous. To this may be added local debility, or debility of tissue. In infants and young child- ren, errors of diet, dentition, and errors of hygiene, take a pro- minent position as remote predisposing causes; and in adults and 176 cutaneous medicine. elderly persons, all those causes which tend to exhaust the powers of the constitution. A child of two years of age has an attack of ecthyma with every tooth which she cuts; a lad of fifteen, of strumous habit, determined by nutritive debility, has been the subject of ecthyma of the legs for four years. All causes tend- ing to occasion cacochymia and cachexia are favourable to the production of ecthyma. Among the local causes may be enu- merated irritants of all kinds : a common one in lymphatic and weakly children is the acarus scabiei; the pustule of scabies purulenta being an ecthymatous pustule. The pustules excited by the action of tartarized antimony on the skin are phlyzacious and ecthymatous ; and Hardy calls our attention to an example of excito-sensory action manifested by the development, of a crop of ecthymatous pustules on the back, at a point opposite another crop on the front of the chest, the latter being deter- mined by the direct irritation of a blister. Prognosis.—Like other diseases manifesting a constitutional debility, a tendency to pyogenic transformation, to ulceration, and cachexia, ecthyma is grave without being serious or dan- gerous. It requires careful watching, and calls for the combina- tion of all the resources of the medical art. Treatment.—The treatment of ecthyma is constitutional and local. The constitutional treatment embraces a tonic regimen in the way of air, exercise, and diet; and tonic remedies, including bitters, mineral acids, bark, quinine, and steel. The local remedies are such as will stimulate the skin mode- rately ; for example, ablution with the juniper-tar soap and tepid water night and morning, and dressing with the benzoated oxide of zinc ointment, with calamine cerate, or with the unguen- tum resinas flavas. In a cachectic habit, an ointment of friar's balsam or camphor will be found an useful stimulant; and if there be much irritability, a weak solution of nitrate of silver may be used to pencil the inflamed surface. In a sloughing state of the ulcers, the stimulating remedies are especially called for, and the surface may be dusted over with pulvis cinchonas. Poultices and sloppy remedies of all kinds are undesirable. FURUNCULUS. 177 FURUNCULUS. The general character of the furuncular eruption is an inflam- mation, extending deeply into the skin, forming more or less prominence on the surface, and resulting in the loss of vitality of a portion of the substance of the derma. The portion of the substance of the skin so destroyed is the heart of the boil, the core {coeur), and the suppuration which follows has for its object the separation and expulsion of the core. The degree of promi- nence of the boil would seem to depend on the depth of the portion of the skin attacked; when the latter is superficial, involving parts which are looser in texture and more susceptible of distension, the prominence is greatest: but when the inflam- mation sinks deeply, the prominence is less, although the mis- chief may be considerably greater, and the case in every way more serious, being attended both with a greater amount of pain, and being much slower in its progress. This, and the extent of the skin attacked, are the prime distinctions between the furunculus and the carbuncle: in furunculus there is but one core, and the core is less deep ; in carbuncle there is more than one core, and these cores extend deeply into the derma. Thus, mere size is only a secondary feature in the diagnosis between furuncle and carbuncle; a large boil may be larger than a small carbuncle; although the carbuncle, being an aggregated boil, is generally much more extensive than the furunculus, sometimes reaching to a diameter of six or more inches. The characters of distinction between furunculus and anthrax relate to their prominence, depth, breadth, colour, number of cores, and degree of pain. Furunculus is more prominent than anthrax; but the latter extends most deeply into the skin, and involves a greater breadth of the structure of the derma. The colour of furunculus is a deep red, becoming, as the disease advances, more or less dull and bluish ; that of anthrax presents the same tints in a heightened degree, the deep red is still deeper and darker, often approaching a mahogany hue, and the bluish tint of furunculus becomes a deep purple and livid tint in anthrax. The core, which is single in furunculus, may be mul- tiplied to twenty or thirty in anthrax, until the numerous open- ings formed on its surface for the exit of the cores give it the 12 178 CUTANEOUS MEDICINE. appearance of a sieve or colander. Lastly, the pain, severe in furunculus, is more intense and more burning in anthrax. Furunculus and anthrax, together with hordeolum, or sty, which is a small boil occurring upon the edge of the eyelids, in connection with one of the meibomian glands, are grouped by Willan under the genus phyma ; the latter term