D391P 1841 I1VN INI}ia9VI JO UV11I1 TVNOI1VN 3NI3IQ3W JO A « V II 9 I 1 1VN0I1VN 3 N I 3 I 0 3 HI JO All ^ M } 41 M 'h NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA III I ^ r 1VN 3NI3IQ3W JO A II V M fl I 1 TVNOI1VN 3NI3IQ3W JO A II V II 8 II 1VNOI1VN JNI5I03W JO AH' ° /\ not' - i.-*~,C?,'X « CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA I1VN 3NI3I03W JO liVllll 1VNOI1VN 3NIDIQ3W JO UX1M 1VNOI1VN 3NI3IQ3W JO All CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL IIBR s \ ^k fxi i /& ^ : X"0 INE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA! LVN 3NI3IQ3W JO A a V a a I 1 IVNOIIVN 3NI3IQ3W JO A II V II a I T IVNOIIVN 3NI3IQ3W JO A a V %/i 1 sXIX> ! v^lK/1^1 NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAR 1VN 1NI3IQ3W JO A a V II 8 II IVNOIIVN 3NI3IQ3W JO Aavaail IVNOIIVN 3NI3IQ3W JO A8V INE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAR NE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LI B R AII Dunglison's American Medical Library. PRACTICAL REMARKS THE DISEASES OF THE SKIN, EXTERNAL SIGNS OF DISORDER, AND ON THE CONSTITUTIONAL PECULIARITIES INFANCY AND CHILDHOOD. BY WALTER C. DENDY, #» # MEMBER OF THE ROYAL COLLEGE OF SURGEONS IN LONDON J FELLOW AND HONORARY LIBRARIAN OF THE MEDICAL SOCIETY OF LONDON; HONORARY MEMBER OF THE PHYSICAL SOCIETY OF GUY'S HOSPITAL \ AND SURGEON TO THE ROYAL INFIRMARY FOR CHILDREN. ^-: LIBRARY, $ PHILADELP HI A! PUBLISHED BY A. WALDIE, 46 CARPENTER STREET. 1841. vis D3<||p CONT Classification according to character Arrangement according to causes Constitution of infants External signs of disorder Diseases of the skin Strophulus Lichen . Prurigo Crusta lactea Impetigo Roseola Erythema Eczema Urticaria Erysipelas Phlegmon Herpes . Lepra Psoriasis Crinones Verruca follicul Acne Sycosis . Porrigo . Pityriasis Icthyosis Elephantiasis Alopecia Shrivelled skin Ephidrosis Skin-bound Apthae Miliaria Ecthyma—Rup Pemphigus Anthracion Anthrax Purpura Nome CONTENTS. Page Struma ••••*""" ° * ° e« Onychia maligna......... Icterus.......... Chloasma..........' Albinism.......... Cyanosis.......... Chlorosis..........l ' Rubeola...........59 Scarlatina..........60 Varicella..........62 Variola...........63 Vaccinia . .......'" Scabies...........74 Syphilitic eruptions........76 Encausis..........77 Vesication from external irritants......79 Pernio...........ib. Paronychia..........80 Pterygion..........82 Verruca..........ib. Clavus..........'. ib. Intertrigo..........83 Rhaghades..........*'*• Condyloma..........ib- Naevus...........84 Lentigo...........85 Tinge of Argenti Nitras.......86 CLASSIFICATION ACCORDING TO CHARACTER. PAPULA—PIMPLE. A small rose-coloured accuminated tumour, with or without an inflamed base—not containing extravasated fluid—seldom suppurating—subsiding—or terminating in a film of cuticle. STROPHULUS. LICHEN. PRURIGO. EXANTHEMA—RASH. Superficial diffused redness—terminating in exfoliation of cuticle—or in vesication. ROSEOLA. ERYTHEMA. URTICARIA. RUBEOLA. SCARLATINA. ERYSIPELAS. PERNIO. VESICULA—VESICLE. Semi.globular elevation of cuticle, containing lymph—with a faint, or a deep rose- coloured base—terminating in laminated exfoliation, or brown crust. APTRiE. MILIARIA. CRUSTA LACTEA. ECZEMA. HERPES. VARICELLA. VACCINIA. VARIOLA. RUPIA. PUSTULA—PUSTULE. Elevation of cuticle, by opake or purulent fluid, with a base of rose-colour or violet— terminating in a yellow or brown crust. ECTHYMA. IMPETIGO. PORRIGO. SCABIES. STYE. PUSTULE OP ANT1M. POTASS. TARTR. 6 CLASSIFICATION ACCORDING TO CHARACTER. BULLA—BLEB. Elevation of cuticle by introfusion of serous or bloody fluid or superficial ulceration. PEMPHIGUS. POMPHOLYX. ENCAUSIS. VESICATIO LYTTiE. ECCHYMOSIS—EXTRAVASATION. Extravascular blood, beneath cuticle. PURPURA. PETECHIA. SQUAMA—SCALE. Induration or detached film of cuticle. EXFOLIATION. PITYRIASIS. PSORIASIS. LEPRA. ICTHYOSIS. CLAVUS. VERRUCA. ELEPHANTIASIS. FOLLICULOSA. Diseased secretion in the follicles. CRINONES. VERRUCA FOLLICULARIS. ACNE. SYCOSIS. MACULA—SPOT—STAIN. Discolouration of skin. MOLE. N^EVUS VASCULARIS. CHLOASMA. LENTIGO. EPHELIS. ICTERITIA. CHLOROSIS. ALBINISM. CYANOSIS. ULCUS—ULCER. Sore, with purulent secretion. PARONYCHIA. ONYCHIA MALIGNA. PTERYGION. NOME. FURUNCULUS. RHAGHADES. INTERTRIGO. CAUSTIC, —terminating in thin crust ARRANGEMENT ACCORDING TO CAUSES. DEBILITAS—ATONY. ALOPECIA. SHRIVELLED SKIN. EPHIDROSIS. CEDEMA CELLULARIS. SYPHILIS. STRUMA. ARRANGEMENT ACCORDING TO CAUSES. Diseases symptomatic chief- j ly of disorder of the alimentary j canal, marked by increased cu-"* taneous action, often by suba- cute or chronic inflammation. ("Strophulus. j Lichen. Occurring during■{ Prurigo. dentition or suckling, j Crusta lactea, L Impetigo. 'Roseola. Erythema. Eczema. Urticaria. Erysipelas. Phlegmon. Dependent chiefly i fjerpes< on gastro-enteric irri--s LeDra lation........ Original debility of^ the system...... Diseases indicative of de- bility, marked by languid cu-J taneous action, often the se- quels of acute disorder. Psoriasis. Crinones. Verruca follicularis Acne. Sycosis. „Porrigo. 'Pityriasis. Icthyosis. Elephantiasis. Alopecia. Shrivelled skin. Ephidrosis. Derangement of the chylopoietic function. f Apthse. Miliaria. Ecthyma. Rupia. Pemphigus. Anthracion. Anthrax. Purpura. Nome Struma. Onychia maligna (Chloasma 8 ARRANGEMENT ACCORDING TO CAUSES. Diseases consequent to spe- cific infection. Febrile [_ Non-febrile f Rubeola. J Scarlatina. j Varicella. L Variola. ! Vaccinia. Scabies. Syphilides. Diseases consequent to ex- ( ternal and common irritation. •> f Encausis. I Vesication from external iiri- tants. I Pernio. | Paronychia. ^ Pterygion. Verruca. Clavus. Intertrigo. Rhaghades. l_ Condyloma, SNiEvus vascularis. Lentigo. Tinge of Argenti Nitras. PREFACE. It is the duty of an author, ere he announces his book, to ask himself if its perusal will in any way increase the sum of human happiness. In the conscientious mind, an affirmative answer must ever be given with diffidence. Admiring as I do the originality of Willan, the splendour of Ali- bert, and above all, the comprehensiveness of Rayer, whose treatise is a treasure of dermatology, it will be a question why I have pre- sumed to add, while such a profusion of acknowledged learning is before us. The test of utility in a scientific work will be, not the truth of its arguments alone, but the facility with which its precepts may be reduced to practice. In medical litarature, a profusion of opinions or arguments detracts from this facility, by too often leaving the adoption of practical modes to the reluctant decision of the reader,—the very profusion thus limiting the sphere of utility. I have therefore en- deavoured, here, to improve the remarks in my former work on these subjects ; to present a book, not of argument, but of practical precepts, founded on long observation; a volume for reference rather than of elaborate study. The cutaneous pathology in this treatise essentially regards the diseases as they occur during childhood. The remarks will be, however, equally applicable to those of the adult, with this special observance, that the purity and delicacy of the constitution of the child render it peculiarly susceptible of the influence of remedy, while the contamination of system, and organic change of tissues in the adult, render the discrimination of disease and the value of remedies far more uncertain. This comparison, while it explains the combination and varieties, especially, of skin diseases, leads to one most important truth regarding our treatment—that, in the 24—e 2 dendy X PREFACE. child, in which the majority of diseases are symptomatic, a judi- cious adoption of internal treatment will frequently supersede the necessity for those topical modes so important to the adult, in whom, by protracted morbid action, disease becomes, as it were, primary, or a part of the tissue) reacting on the system. I have throughout resisted the temptation to relate a series of illustrative cases, or to adduce formal quotations from other books. This might, indeed, have rendered my own more comprehensive, perhaps more imposing, but, I presume to think, less useful than this treatise, in which is blended the experience of others, with practical deductions from my own note-books, and from clinical observations at the Royal Infirmary. I will not, therefore, apolo- gise for the plan which I have adopted, although I am sensible of the imperfection of its construction—a fault, indeed, inherent in all systems, except those of demonstrative science. Stamford Street, Blackfriara, October, 1837, PRACTICAL REMARKS DISEASES OF THE SKIN. ON THE CONSTITUTION OF INFANTS. The study of infantile pathology is replete with tender interest and instruction ; whether we regard the helplessness of the earliest spring-time of human life, or reflect on the comparative mortality of childhood. . When the physiologist begins to explain the phenomena ot or- ganic life, he selects the animal in which the organisation is the most simple ; so the constitutions of young children are the most favour- able for the "study of disease, because they are usually marked by greater simplicity, unmodified by alarm regarding the result of their disease, or by sexual influence, or by mental emotion or dis- quietude, or by the physical changes resulting from the wear and tear of body. They are, above all, uninfluenced by the alterations of structure produced by repeated and varied disease; for acute attacks if not checked very early, soon disorganise and change the normal condition of some important organs, forming thus what is termed "a weak or delicate point;" becoming often, in after life, the focus or seat of disease. There is, therefore, a greater uniformity in the symptoms ot children than in those of the adult; their pathology is uncomph- ^Tiie system of the child is capable of constant modification; hence is it so often in our power to mould and educate the body, to impart to it that degree of physical perfection at which the standard of health, as well as the requisites of beauty will be found,_to avert early disease, so often the great spring and founda- tion of idleness and immor lity. ^ 12 DENDY ON DISEASES OF THE SKIN. But in this early period of life there is a predisposition to disease in an eminent degree; arising from the peculiarity of infantile piy- siolo^y, and the sudden changes of condition. . . The vascular and nervous systems are acutely sensible ot im- pressions, indicated by a convulsive tendency, "laxit6 vibratile. The heart is soft, possessing little power, but extreme irritability; its left or arterial side being, relatively, of large size. The course of circulation is undergoing a metamorphosis in the foramen ovale, the arterial and venous ducts, and the umbilical and portal veins. Corresponding with this, we notice the extreme cplerity of lhe pulse and the breathing, the infant pulse varying from 100 to 130, the breathing being usually 35 inspirations in the minute; while in the adult the healthy pulse is 75, and the breathing 18 or 20 within the same period. The bright pink hue, or blush, of the skin, too, is a proof of arterial excitability. The brain and ganglionic masses are large in early infancy, and the nervous system is highly impressible; a properly so constantly illustrated by the facility with which crying and laughter are ex- cited, and by the rapidity with which depression and exhaustion take place. As life advances, the cerebro-spinal system predomi- nates, and diseases of irritation are more charactered by tetanic convulsion. From these peculiarities we may explain the very sudden changes of infantile disease, the rapidity with which the membrane of croup is formed—I may almost say organised,—and that almost instantaneous effusion of fluid in the cerebral cavities, the water stroke. The majority of infantile diseases bear an inflammatory charac- ter of a certain degree. I believe they are seldom attacked by neu- ralgic disorder, and that the pain from abdominal pressure is almost always an indication of chronic or subacute inflammatory action within the bowels, for the mucous membranes are the first to take on excessive action. There are, however, no membranes so readily prone to cure themselves as these, by the pouring out of their natu- ral secretion, so that in slight cases our interference is scarcely called for. I believe, too, (in opposition to the opinion of Underwood,) that this copious flow from the mucous membranes, as well as the excessive glandular secretion, driveling: and wetness of the skin, are salutary provisions to remedy this inflammatory tendency. To furnish these copious secretions, there is a corresponding capacity of the liver and other secerning glands of the body. Some of the most severe infantile disorders attacking an enfeebled frame are those which are symptomatic, or secondary; as affections of the head in pertussis, bronchitis, pneumonia, and scarlatina; of the chest, in measles, &c. &c. and all previous applications should be constantly removed from the skin ere they be ao-ain re- sorted to; unless this be done, prurigo will often degenerate into impetigo or ecthyma. Perhaps the papular form of scabies may be thus established de novo. CRUSTA LACTEA. 29 In prurigo the itching is remittent, and is very distressing to the patient. In the contagious scabies, the itching has no remission, and the scratching mostly agreeable to the child. In prurigo oint- ments are usually objectionable, while in scabies, they are the most favourable form of application. Prurigo is subject to frequent recurrence after it has been appa- rently cured. CRUSTA LACTEA. Impetigo larvalis—Impetigo mucosa—Porrigo lactea—Porrigo larvalis—Lactumen— Tinea muciflua—Teigne muqueuse—Eczema lactea—Milk scall—Infantile rash. The incipient vesicles of this disease, which frequently accom- pany strophulus, may desiccate without breaking: where, how- ever, the alimentary canal is disturbed by quantity or quality of milk or food, especially if there be added to this the irritation of dentition, the fluid in the vesicles assumes a straw coloured tinge. will often coalesce, and become surrounded by a blush : the viscid fluid escapes, and is inspissated, forming concretions of a whitish yellow or greenish tinge. The crusts lie in laminae, some over- lapping others, or intersected by narrow pink or olive coloured fissures. This process may extend till the face is reduced to one incrusted covering, resembling a mask or larva. It may extend to more remote portions of the skin, although it is usually seated in the vicinity of mucous orifices, nor does it necessarily begin, as some suppose, on the scalp. It will often vary; the discharge will abate, the crusts separate, the inflamed margins become paler, and underneath a thin dis- coloured cuticle appear, and yet this tendency to health will be suddenly averted by very trifling causes. The discharge is not offensive, nor does it, when creeping to the tarsal edges, often produce tinea ciliaris, the first degree of lippi- tudo, although epiphora will often occur more from irritation to the lachrymal gland than from any thickening of the membrane of the lachrymal passages. Irritation of the schneiderian membrane will also produce simple eoryza. Induration of the parotid, submaxillary, or cervical glands, will often occur in children with fair hair and thin skin, of languid or strumous diathesis. The disease, however, often occurs in healthy children, or those which have by no means been deficiently fed. If the disease is very extensive or acute, diarrhoea, mesenteric ob- struction, and even fatal marasmus may ensue. This disease is usually salutary, unless occurring on important parts, or to an ex- cessive degree. Treatment.—In the mild form, simply regulating the alimentary secretions by a lighter form of diet; or, perhaps, a change of breast milk and gentle laxatives. The powder (3) each night for a week. The powder (2) each following morning. If the abdomen be tumid, more decided purgation. If the general health suffers, we may 30 DENDY ON DISEASES OF THE SKIN. combine the vegetable or mineral tonics—cascarilla, calombo, or tartrate of iron. Locally, the warm water, or thin gruel: the ung. plumb, being applied to the excoriated edges. When the inflam- matory character has subsided, the ointment (2). If the crust be very dry they should be touched with cream, or ol. amygd., with a few drops of liq. potassae. If they are extremely moist (which by contact might add to the excoriation) sulphur prec, or starch pow- der, lightly strewed over the crusts. By the severe forms even of this disease, no permanent marks will be left. IMPETIGO. Psydracia—Dartre" crustac^e flavescente—Crusted tetter—Pustular or humid tetter— Scull. An incrustation of an umber, sienna brown, or olive colour, ap- pearing either in defined patches, (figurata,) or diffused over the surface, (sparsa.) The incipient psydracious pustules of impetigo appear either on an inflamed surface of two or four days' duration, or in clusters with a defined inflammatory margin, accompanied by heat and smarting, in proportion to extent and intensity of action. The pustules are slightly elevated ; in two or three days the purulent secretion bursts the cuticle ; the part then becomes red and shining, and exhibits often a cribriform appearance, the pus being evacuated through several minute orifices. If the pustules have arisen in clusters, the inspissated crust is speedily formed, and from beneath it an ichorous fluid is constantly oozing. Fresh pustules will often appear about the edges of the crusts, either disappearing early un- der the already influential treatment, or assuming a chronic and scattered form. By neglect or maltreatment the disease may extend until the whole limb is incased in one rugose covering—I. scabida. The crust will then assume a grayish brown colour, surrounded by a lake coloured margin. This form is attended by much heat and itching, and by impediment or complete obstruction to the motion of the limb. After some time the coating is permeated by deep fissures, through which the matter continues to exude, adding layers of incrustation on the previous coat; extending to the extremities, it will produce ulceration of a purple hue around the matrix of the nail, which often drops off. and is succeeded by another, misshapen, from the diseased function of the gland. The surrounding erythematous inflammation will sometimes become aggravated, producing slight vesications, (impetigo erysi- pelatoides of Willan,) and this may extend deeply into the cellular membrane— a disease of great severity. The period of the separation of the crusts will vary from two to four or five weeks; this, however, may be hastened by warm water or poultices. The healing process commences usually in IMPETIGO. 31 the centre, and radiates towards the circumference. On the dull crimson patches beneath the crusts, small elevated spots, apparently vesicular, sometimes occur; they are, however, indurated follicles. Impetigo is often combined with other forms of disease. Ecze- matous vesicles are often interspersed, (eczema impetiginodes,) which are attended by little redness, but by extreme irritation, heat, and itching. It is of some moment that we should distinguish the incipient character of these pustules and crusts, two genera of the order being contagious; viz.—porrigo and scabies. The incrustations of impetigo are more circular, thinner, browner, and less adherent than those of porrigo, and occurring much more on the extremities, and being of slower inspissation : the fluid of porrigo, too, being purulent and glutinous, that of impetigo generally ichorous. The interspersion of vesicles produces a resemblance to lymphatic sca- bies, but the vesicles of impetigo are more slow in their progress, the sensation is more heat and smarting than itching, the cuticle redder and more fissured, and the ichorous exudation more copious than in scabies. Treatment.—In mild cases, adoption of the lightest aliment. The mercurial purgative every second morning. The sulphate of potass, or the precipitated sulphur, twice in a day. If we are consulted ere the pustule has advanced to maturation, one drop of acet. aromat., on lint, or a saturated solution of lunar caustic, should be applied. In the incipient stage of mild cases, the most soothing applications are tepid water, thin gruel, a weak decoction of poppies, or a light moist bread poultice. In a more acute or inflammatory state, bleeding by leeches or venesection will be essential, minute doses of tartarised antimony, and in case of much irritation, a few drops of the Tr. hyoscyami given in lemonade twice or thrice in a day. If on the subsidence of inflam- mation the healing process is slow, it may often be aided by the lotions (') or (6), or the white precipitate ointment. In more pro- tracted cases, the alkaline, or sulphureo-gelatinous bath should be employed, or a lotion composed of acid, hydrocyan. 3J-, alcohol 3j., aq. ros. giij.; or one composed of potassae sulphuret. 3ij., aq. ros. §iv., and from five to ten grains of sulphuret of potass, may be given in milk twice in a day, with the occasional use of hydr. cum cret. According to the degree of debility, the infusions of sarsaparilla, cascarilla, calombo, or dulcamara, may be given with the muriatic acid, and syrup of orange peel. During low atmospheric tempera- ture, oiled silk should be worn on the crusted parts, to protect from cold and friction, and to soften the incrustations. The internal use of the dento-iodnret of mercury produces vesi- cles, followed by yellow or yellowish-green scaly crusts, easily mistaken for those of porrigo and impetigo. 32 DENDY ON DISEASES OF THE SKIN. DISEASES DEPENDENT CHIEFLY ON GASTRO-ENTERIC IRRITATION. The four following forms of eruption assimilate closely with re- gard to causes ; the variety being produced by the constitutional predisposition, although there are causes peculiar to each. External irritants will produce erythema. The pustules of variola and vac- cinia will excite roseola, which may in some cases become so severe as to terminate fatally. Mercury will be followed by a crop of eczema, and urticaria will rapidly appear on the administration of acids. ROSEOLA. Rose rash—Rash—False measles—Rosy efflorescence—Rubeola sine catarrho. An efflorescence of a bright rose colour diffused, or in patches on a fainter ground of pink, sometimes assuming a serpentine form resembling measles, from which it may be distinguished by its brighter hue, as also from scarlatina simplex by the slight erethism merely, which attends it. In the hotter months, the efflorescence is usually in the form of dull crimson or lake patches, of a circular or oval shape, and some- times a redder circle is formed around the patch—Roseola annulata. In the adult, roseola will sometimes be formed during acute feb- rile diseases. There is usually a premonitory languor and headache on the eve of these eruptions ; this usually subsides, or is much alleviated, on the outbreak of the rash. ERYTHEMA. Efflorescence—Maculae volaticce. A diffused, blotched, or papular redness of skin, in the form of dull crimson patches, chiefly on the breast, neck, or arms, disap- pearing on pressure. It is usually transient, although it will some- times be more severe, extending over a whole limb, and accompa- nied by oedematous swelling. It is often interspersed with distinct papulae, (eryth. papulatum,) attended by depression and quick pulse, and assumes a livid hue on its decline. It is also in some assuming the form of rose-coloured tubercular lumps, (eryth. tuberculatum,) or of a raised indurated efflorescence, attended by more heat and febrile symptoms. In young females, the fore part of the leg is sometimes studded with large rose-coloured oval patches (eryth. nodosum,) attended by much pain and erethism: this fades and becomes dusky, disappearing in about a week ; it is dependino- on sympathetic action with the changes of the uterine system. Although these rashes may be produced by external irritation or the sign of deeper seated fascial disease, they are almost invariably depending on irritation of the primae viae ; certain articles of diet ECZEMA. 33 especially unwholesome breast milk, and certain medicines, will, in some, suddenly produce them—as arrow root, rhubarb, balsam of copaiba, &c.; the rash is then of transient duration. In more slowly formed intestinal disorder it is more permanent and more severe, and yet an alleviation of the primary derange- ment. In very languid or unhealthy constitutions I have seen the efflorescence of a very deep crimson hue, or a dull, dark purple, and marked by typhoid symptoms, indicating a cachectic condition of the system ; and I may here remark of how much value is the hue of an eruption in regard to prognosis, and especially to treat- ment ; the bright efflorescence requiring the laxative and antiphlo- gistic, the livid demanding, in addition to the mildly laxative, the tonic plan of treatment. It is needless to offer a prolix catalogue of remedies for these various forms of efflorescence. In the lighter forms, gentle aperi- ents, preceded by a mild emetic of ipecacuanha, will be proper; and we should of course remember to remove the exciting cause, if possible : lancing the gums, if swollen and hot; changing the arti- cles of diet; regulating the temperature : and keeping the patient quiet, and free from excitement. If there is fever, sudorifics, the powder (2) each night—the mix- ture (7). On the subsidence of the disorder, slight tonics, as the mixture (5); and in cases of languid circulation, especially in cachectic habits, where the livid hue is observed, the powder (5) may be added. Barley water, with lemon-juice, as the common beverage. With regard to external treatment, tepid water or thin grit gruel, or, what often affords very great relief from itching, or heat, or pain, a sprinkling of starch powder. These modes of treatment will usually prevent even the severer forms from degenerating into gangrenous sores, or oozing fissures. ECZEMA. Prickly heat—Hydrargyria. Eczema usually appears in children in the form of small pearl- coloured or brownish-pink vesicles, with a very light rose-coloured base, preceded by a sense of heat or tingling. When these are seated between the fingers, especially if aggravated by scratching, it may be mistaken for scabies ; but the suddenness of eruption, the more pointed vesicle, and the sensation of smarting rather than itchino-, readily distinguish it from scabies. Ecz°ema may quickly subside, almost without desquamation, the lymph of the vesicle becoming opake, and then being absorbed; in other cases, a brownish scab will form, leaving the skin in a rugose state, and (if this becomes aggravated) producing febrile symptoms and deranged health, from irritation. Mercury and indeed cubebs, in some instances, will (perhaps by deranging the stomach) be followed by a crop of vesicles on a light 34 DENDY ON DISEASES OF THE SKIN. vermilion ground, (Ec. rubrum.) In these cases we often see a reddish-brown patch, after a short time, with a defined margin, in- terspersed occasionally with pustules. When the disease is spread- ing over the hand we have known so extensive a desquamation ot the cuticle, that it has peeled off from the hand like a glove. Its seat appears to be the cuticnlar follicles. In adults, especially from neglect, the disease often assumes a chronic form ; in children, less frequently. Treatment.—As to gentle laxatives, sudorifics, and tonics, may be similar to that for erythema. The drink should be barley water, slightly acidulated with lemon juice; or whey, with a small quan- tity of tartrate of potass dissolved in it. If there be suspicion of unhealthy breast milk, a nurse should be provided. In protracted cases I would, after the sixth year of age, advise the cautious use of dulcamara. When, on the subsidence of erup- tion, languor should long continue, the tonics should be increased and country residence be adopted. The local applications should be tepid water, or mild French roll poultice. In cases attended by symptoms of severe local irri- tation, thin almond emulsion, with a lotion of acid, hydrocyan. 3J-, aq. sambuci gviij.; the syrup of poppies should be given at night; for the disease and the symptoms react on each other, sleeplessness deranging the health, and adding thereby to the disease. In some cases the ointment (') has been very efficacious. Fric- tion should be avoided, and the linen should be frequently changed. Vesicles resembling eczema are produced from several local ap- plications in frequent use, as gum plasters, linseed, and even bread poultices, and by friction with croton oil. URTICARIA.—NETTLE RASH. Uredo—Essera—Febris urticata—Epinyctis pruriginosa. The mild form consists of white elevations, circular usually, sometimes longitudinal ; the severer, of very pale pink elevations, on a deeper rose-coloured surface. The first is unattended by feb- rile symptoms; the second is preceded and marked by the follow- ing—cephalalgia, gastrodynia, lassitude, synocha, intense itching like the sting of a nettle, aggravated by friction or heat. The erup- tion lasts six or ten days ; the cuticle then exfoliates. In rare cases the spots become tubercular, (U. tuberosa.) and I have seen them penetrate the cellular tissue, attended by still severer symptoms. The exciting causes are various: sometimes emotions of the mind, or excessive exertion, acetic acid, mushrooms, honey, the rind of encumber, strawberries, shell fish, especially muscles'and unhealthy breast milk. In cachectic habits the eruption may assume a livid hue ap- pearing more like extravasated blood, or purpura. ERYSIPELAS. 35 These varieties, and the frequent recurrence in the same patient, are proofs of peculiar susceptibility. Constant irritation will < ften produce marasmus, remittent fever, and in some cases somnolency approaching to coma. Treatment.—A mild emetic of ipecacuanha should be given early, followed by a laxative and cooling diet. The cause of the disorder should be ascertained, and the remedies relatively admi- nistered, as well as the preventives, as change of milk or food, free division of the gums. &c\ If we have twitching or convulsion ensuing from irritation, the tepid bath should be employed, and Tr. assafoet. given in warm water. In debilitated constitutions, the tonic mixture (5). In those cases interspersed with the papulae of lichen, I have pre- ferred, subsequently to laxatives, hydr. oxyd. nigr. combined with minute doses of muriatic acid. External applications are of little utility. ERYSIPELAS. Rosa volatica acuta—Ignis sacer—St. Anthony's fire. The full history of erysipelas would require a lengthened trea- tise. I shall here, as briefly as I can, divide the disease into the atonic and the acute forms, without describing its seat, or its very numerous causes, or entering on the question of contagion, or its identity with puerperal fever. Atonic.—I am writing of that erysipelas which is marked by de- ficient power from the first. This form, which often terminates in gangrene, is sometimes of intrauterine origin ; it occurs a few days after birth ; a dull crimson blush, changing to a more purple or livid hue, then often studded with livid vesications, or large bullae, which terminate in sphaceloid ulcerations. It is usually com- mencing about the abdomen and genital parts, and in new-born in- fants may have its spring in umbilical phlebitis. It is attended by a weak thready pulse, prostration, brown tongue, and dtlirium. The peritoneum will sometimes participate in the disease, and in many cases, sinuses will form, and sloughs of cellular membrane and tendon. The arrest of these formidable symptoms is marked by a white line of demarcation in the earlier stages of erysipelas gangrenosum, and the same event is indicated in the latter periods of the disease, by the secretion of pus, instead of an ichorous or sanious discharge. The treatment should be commenced by a mild laxative, fol- lowed by the carb. ammon. dissolved in orange-peel water and syrup, and minute doses of opium or morphia, every four or six hours. But if the skin is hot and dry, the liq. am. acet. should be added, and the anodyne given with more caution. If the child is a suckling, there should be a healthy substitute for the anxious mother. If not, the food should be concentrated jelly, 36 DENDY ON DISEASES OF THE SKIN. or sago, or arrow-root, or starch mucilage, or chicken jelly, or blanche-mange, with small quantities of port wine, or even a few drops of brandy. If while we have hot and dry skin we have also cerebral symp- toms supervening, as intolerance of light, screaming, or convulsion, infusion of serpentaria should be given with liq. amnion, acetat., and the forehead should be wet with ether lotion. This is a per- plexing condition, as depletion is at least an evil; if constipation occurs, the most advisable aperient is ol. ric. and ol. terebinth. combined. Local Remedies.—In the early stage, camphorated tincture ap- plied on linen rags folded, or starch powder sprinkled on the part. If the disease progresses, and is marked by distention, the following lotion :— 5< Am. subcarb. Plumb, diacetat. a gss. Aq. rosse §x. A poultice of stale beer-grounds or yeast should be applied, if the disease has terminated in sloughing, and if gangrenous erosion should be spreading, the local application of balsam of peru pen- cilled on the part twice or thrice in the day, previous to the poul- tice ; and if the fetor should be distressing, the solution of chloride of calcium should be applied carefully over the surface. Where matter, or the slough, is deeply seated and burrowing, it may be essential to make deep incisions, to allow of its escape; this is a severe mode, but it is adopted to avert a greater evil. Acute.—Skin of a bright scarlet hue and shining, preceded for about two days by heat and tingling, and fever; the pulse not usually so hard and full as in phlegmon. The disease will sometimes decline on the third or fourth day, the skin becoming yellow and desquamating. If it proceeds, vesicles or bullae form, which sometimes become purulent. In two or three days these burst, and discharge an acrid glutinous fluid. This is the superficial form. If it be commencing more deeply, we have more severity of symptoms—rigour, acute fever, and oedema- tous swelling, a purulent sanies is burrowing early among muscles or tendons, mixed with clots of thin grumous blood, altogether unlike the pus and circumscribed cell occurring in phlegmon. At this point the disease is liable,- if not energetically treated at the commencement, to assume the sphaceloid character, and will re- quire a mode of treatment adapted to this change. We sometimes observe in the acute stage that the cutaneous vessels are inflamed, and we find often purulent depositions in the serous cavities and in the lungs. Treatment.—In the milder forms, chiefly internal—mild laxa- tives, light diet, cool air, subacid and diluent drink, and saline diaphoretics, the inflamed part being sprinkled often with flour. If the blush does not subside, more profuse purgation by colocynth, calomel, or elaterium, and a frequent repetition of the effervescing saline draught, or liq. am. ac. If there is an indication of congestion PHLEGMONOUS TUMOURS. 37 about the brain or lungs, the cupping-glass should be applied on the sound skin. A blister, or the pencilling of a strong or even satu- rated solution of arg. nitrat. for about half an inch around the margin of the efflorescence will sometimes arrest its march. This latter mode may be once or twice repeated. In plethoric children leeches may be applied on the sound skin around the inflamed part. If the inflammation is deeply seated, incisions may be made, to unload the vessels and take off distention, and to evacuate the mor- bid fluids formed; over these, fomentations and thin poultices. The patient, or the inflamed limb, should be constantly kept at rest; the inflamed part, if possible, somewhat elevated, so that the blood may readily flow through the returning veins. If the diseasearises from a wound, the treatment scarcely needs variation ; but if that wound be a deep puncture, it is best to con- vert it into an incised wound by a free and deep incision, if the nature of the part admit of this. On convalescence, cascarilla, calombo, quinine, and the mineral acids, should be adapted to the degree of weakness, and the child should enjoy pure air. PHLEGMONOUS TUMOURS. These occur in various parts and tissues of the body ; either as indications of some internal or constitutional derangement, or as critical, at the decline of fever or acute disease. Their varieties being as follows :— The furuncle, or boil, is of a conical shape, its base deeply seated, its apex intensely painful, and assuming either the acute form, marked by erythism and rapid suppuration, or the chronic, of a milder character. Phyma, a phlegmonous tumour of a broader shape. Epinyctis—terminthus, a tumour of the size of a pea, livid or dusky red, acutely painful, containing a sanious fluid. Phlegmon of the submaxillary, cervical, parotid, or inguinal glands, unattended by strumous taint, and not induced by com- pression or strain. And the inflammation and suppuration of the ciliary and follicu- lar glands of the eyelid—stye, or hordeolum. The suppuration of all these tumours is salutary, and, in re- ference to the constitution, it would be well to promote that process in every case. When, however, they are seated close to important organs, as the eye, or when a gland enlarges in the neck or cheek of a female, it will be better to" attempt a discussion of them by de- pletion—leeches and cold poultices, and free purgation ; if the child is debilitated, speedily substituting a vegetable tonic, with mineral acid, and a grain or two of hyd. sub. 2 vel 3 die. To pro- mote suppuration, hot steam, fomentations constantly applied, or bread and linseed poultices, or oleum terebinthinae, warm, with linseed meal, repeated every three or four hours. 38 DENDY ON DISEASES OF THE SKIN. In the common glandular abscess, on the perception of distinct fluctuation, an early incision, as small as is consistent with perfect evacuation, should be made : this is to avoid an unsightly scar. In the phlegmonous abscess in other tissues, and when not conspicuous, the incision may be more freely mad^, and the matter expressed, and a linseed poultice applied every fifth hour for two days, then changed for one of French bread, progressively decreasing the temperature. When, however, the abscess is deeply seated, and the cellular membrane has been implicated and has sloughed, hot linseed poultices should be continued, to dislodge the membranous flakes, and obviate irritation, and a succession of suppuratiors. In the stye, if the depletory plan does not cause it to disappear soon, very warm water should be applied often on a sponge, or a poultice over the closed eye. An induration often remains in the part, es- pecially in weakly children ; this may be greatly moderated by a poultice, made of extr. belladon., French roll, and camphorated tincture. On convalescence, the country air, and the tonics I have before advised, should be adopted ; and every second or third day the powder (s). In many children there is a disposition to glandular suppuration, not of a stru mous character ; for these I would however recommend sea air and bathing, nutritious not stimulant diet, the mixture (5), or the powder (7). Tinea ciliaris—Lippitudo—Chronic stye. A chronic inflammation Jn the bulb of the eyelash, which by degrees pervades the whole ciliary circle, and, if not checked in its early stage, terminates in lippitudo, the glands of the cilia slightly discharging; in time their power of secreting hair having ceased, and leaving a permanent red circle around the eye. Treatment.—Laxatives, combined, in weakly children, with the mixture (5) or the powder (7). In the first stage, leeches in the vicinity of the lashes ; if much redness, fulness, or pain, warm water or poultices, in the second stage, U. hyd. nit. M., the inter- nal plan being continued. HERPES. Zona—Herpes miliaris—Ignis sacer—Shingles. The transparent vesicles of herpes vary from the size of a millet seed to that of a pea ; their most common mode of distribution is either as a belt around or partly around the body, (herpes zoster zona ;) or in defined clusters, (herpes phlyctaenodes';) or in circular patches around an inflamed area, the surface of which desquamates as the vesicles decline, (herpes circinnatus;) or, in the very rare instance (herpes iris) of vesicles disposed in three or four concentric circles or rings of varied and beautiful colours, and elevated above the surface of the surrounding skin. HERPES. 39 Herpes— Zoster—Ph \y ctoenodes. Its premonitory symptoms, which are not, however, essential, are for two or three days a tingling and pink blush, rigour, cephalalgia, nausea, subsiding always when the vesicle assumes the opake form, if not before, i. e. from ten to twenty hours, the blush fading in three or four days, the vesicles bursting, their fluid concreting into yellowish crusts, desiccating in five or six days, successive vesicles, however, sometimes forming for three or four weeks. Its usual seat is on the trunk, in the form of a zone—about the genital parts, around the mouth, sometimes extending to the tonsils and uvula, and also in the auditory canal. If seated near glands, they often become enlarged. It occurs most frequently in the summer, and is often dependent on checked perspiration and cold drinks. Treatment, should be commenced with a powder of calomel, a draught of potass, tartr. an hour after, potass, carb. and lemon- juice, often given in the effervescing state, light diet, repose, if there is much restlessness minute doses of liq. sedativ. added to the draught, or spt. astheris c. or Tr. valer. amm. in warm water. I have seen cases so acutely marked as to require the abstraction of blood. Locally, tepid water lightly applied, or very weak saturnine wash, or the part sprinkled with fine starch powder, or ungt. cetacei applied on singed rag. Friction to be avoided. Neglect of these precautions will convert the simple disease into one of more severity, a ragged ulcer, which spreads often very quickly, (herpes exedens.) To this should be applied the carrot poultice, or a weak nitrate of silver wash, or one of dilute solution of chloride of sodium. To the internal remedies already prescribed should be added the quinin. sulph. hi proportionate doses; and in very severe cases, the arseuiate of ammonia in distilled water, the minimum dose l-24th of a grain. Herpes is distinguished from erysipelas and pemphigus, by the smaller size of its vesicle—from eczema, by its more inflammatory base, by erythism or fever. H. circin.—H. iris—Vesicular ringworm. These two forms are more permanent, but their premonitory symptoms are very slight, often not observed, although some slight tingling for a day or two may be recollected, and some uneasiness about the stomach and bowels, with sometimes slight excitement of the system. . Treatment.—Astringent applications are required, unless heat and pain should indicate the premising of soothing fomentations, decoct, papav. and vin. opii. The solution of borate of soda, or of the sulphates of zinc or copper, or the decoction of galls. These should be applied thrice in a day, on linen rags. 40 DENDY ON DISEASES OF THE SKIN. The diet should be light and nutritious, and the bowels kept slightly relaxed by the tartr. potassae. Herpes cir. is distinguished from the rings of lepra by its more rapid changes, and from annular roseola by its vesicles. On the subsidence of all these forms the vegetable tonics should be given. LEPRA.--LEPROSY. Dartre furfurace"e arrondie—Leuce—Melas—Lepra grsecorum. A deposition of grey or whitish scales, like talc, assuming the form of circles, or segments of circles, marked by fissures of a light olive or of lake colour, surrounding a central space, which, as well as the external margin, is usually of a rose red. In the commence- ment, small reddish-white papulae arise, which are soon covered with thin scales. These spots are usually commencing about the knees, elbows, and eyebrows, and are often influenced by variation of the weather, especially on the approach of rain. In protracted cases, the disease often extends to the matrix of the nail, which is thereby curved. Lepra is attended with very little constitutional derangement. I speak of course wilhout reference to the specific form arising from syphilitic taint. In some patients the disease returns periodi- cally, I think very often in the spring and autumn, and is often aggravated by improper diet. Treatment.—In the incipient form, mild aperients and light diet, and if the vascular action is high, leeches or venesection, followed up by sulphate of magnesia, each morning, for two, three, or four weeks. In lighter cases, Plummer's pill should be given at night, and the following draught thrice in a day; it is the maximum dose for the age often. *.. Liq. potass. Mx. Liq. arsen. M iv. Syr. pap.^jss. f. h. These remedies will be more efficacious in the country than in crowded towns. Warm water or barley water should be applied twice in a day, with a sponge. Ungt. hydr. precip. alb. sjj. U. cetacei §j. as an ointment. If in three weeks the disease does not yield to this treatment, the doses of aperients should be increased, and the sulphuret of potass administered internally, and two grains of calomel each second night. The bath (4) should be employed, adding chlorid. sod. Ib.i. its temperature 98°, the child to be immersed for twenty minutes thrice in a week. I may add, if the pulse be full, the skin hot and dry, &c, we cannot hope for benefit without loss of blood. If the scales render the skin stiff and inflamed, a solution of sulphuret. potass, should be frequently used, or bran and water, or cream • and in very stubborn cases, with firm attachment of the scales' PSORIASIS. 41 liquor potassae, or dilute muriatic acid cautiously applied ; or a lotion of Tr. lyttae and aq. pistillat. If the disease resists these modes, I do not hesitate to apply a blister for thirty hours, for the purpose of producing a new tissue, at the same time continuing the internal means. If country residence can be adopted, I should advise Bath, Har- rowgate, or Leamington. On the disappearance of the disease, the vegetable or mineral tonics. PSORIASIS. Scaly tetter—Small dry seal!—Lepra alphoides—Scales of the cuticle. The effect of acuto-chronic inflammation of the vessels of the cutis, depending on peculiar action or hereditary disposition. Soon after the appearance of reddish points or lumps on the skin, small white or pearly scales, separate or in a congeries, or surround- ing a central pinkish space, appear, the surrounding skin being slightly discoloured. Lepra thus differs from psoriasis, by being more raised and annular, the centre more depressed, the scales more profuse. In other cases, the patches are of a reddish or brownish colour, interspersed with fissures, accompanied by intense itching or heat, increased by heat or friction, sometimes producing ulcera- tion and a purulent fluid, and this, concreting with the detached scales, forming a more elevated crust. Around the scales is usually a deep rose circle increased by exertion or excess; beneath the scales the skin is red and irritable. In bed the scales are often de- tached in profusion, and their friction aggravates extremely the tingling and itching. This is the usual form of psoriasis, with which the other varie- ties of squamae might be, in a practical point of view, combined. Treatment.—Equable temperature, light diet, and repose are essential; the contrasts to these, in a system predisposed, may de- velope the disease on the surface. The diseased skin should be lightly covered, and nothing but warm water applied in the first stage. In many cases these cau- tions, with free purgation and diaphoretics, assiduously given, will check or reduce inflammatory action. If this should be increasing, venesection should be employed, or leeches applied around the edges of the scaly patches. If much irritation exists, with sleepless- ness and fretting, poppy fomentations should be used, and the mix- ture (8) thrice in a day. On the subsidence of the increased action, the bath if) should be employed; but if the redness should be permanently increased by this, it should be suspended, and the following powder administered thrice in a day:— *. Sulphur, precip. 3J- Potassae supertartr. vj. Pulv. rhoei 9j. (div. in pulv. xij.) 24__o- 4 dendy 42 DENDY ON DISEASES OF THE SKIN. If there be much debility, or a violet or dark hue on the skin, the quinine may be given, in infus. cascarillae, or Tr. iodin. u.ij. ad vnj. twice in the day. . . , • In cases more protracted, I should advise the arsenical solution, or decoct, dulcam., or from three to eight grains of the following mass thrice in a day:— 5*. Pic. liquid. Farin. tritici, q. s. If the scales do not readily separate, liq. potassae or acid, muriat. may be applied, and when the effect is produced, the lotio flava will be found beneficial; or the citrine ointment, which should be always washed off before the fresh application. Regarding the psoriasis and fissures occurring about the lower lip which I believe often indicate chronic disorder about the viscera1, I have found the application of leeches on the abdomen sometimes effect a very beneficial change. FOLLICULAR TUMOURS. Grubs—Follicular wart—Acne—Sycosis. The earliest disease in the sebaceous follicles is that termed crinones or grubs, the back of the sucking infant being studded with white elevations—inspissated sebaceous matter. Friction with a coarse cloth and warm water, by the fire, and a gentle laxative will speedily remove these. I may here briefly refer to " morbus pilaris," when the capilluli on the back of an infant, by being loosened and not dislodged, excite itching and papulae. For this, poultices and extraction of the loose hairs should be employed. FOLLICULAR WART. White, hard, and rather shiny elevations of the follicle, usually occurring on the cheeks and forehead, often stationary for some time, and on derangement of the bowels becoming enlarged, of a pale pink colour, and surrounded by inflammation. A suppurative process will then commence in the cyst, and the sebaceous matter is dislodged, but it may sometimes increase to the size of a walnut, a drain of* cheesy matter continuing, which will sometimes concrete, forming crusts. The regulation of the bowels will often check and blight these tumours ; if they increase, excision must be adopted ; the wart is lifted by a pair of dissecting forceps, and excised by sharp scissors, or the cyst may be pulled out by the forceps, and the part touched with a solution of nitrate of silver. In chlorotic girls on the approach of puberty, these tumours will sometimes appear; of course attention to the functions of the uterine system will be required. ACNE.—SYCOSIS. 43 ACNE. A. simplex.—A. punctata. Chiefly occurring towards the period of puberty. Small circular elevations of the follicle, with or without the black point in the centre, which is caused by mere exposure to the air of the matter at the orifice of the follicle. They sometimes disappear spontaneously, especially at the completion of puberty, and are succeeded by slight desquamation, or fissures of the skin. They appear singly, or in clusters, sometimes surrounded by dusky discoloration. Inflammation and suppuration may however take place, especially on derangement of the alimentary canal; a yellow point, and sub- sequently a crust, being formed on the surface, the follicle becoming obliterated. In other cases the swelling will assume a more tuber" cular form, and become extended, hard, red, and painful, (A. indu- rata,) and this in a very severe degree, both from intestinal derange- ment, and also, it must be added, in amenorrhoea, and on the progress of puberty. To appropriate our remedies to these various internal causes, we must employ laxatives, mild mercurial alteratives, and decoctum sarsas. or the preparations of steel. ' In the inflammatory cases, with heat or pain, leeches, or even venesection, may be sometimes necessary, and a mild French roll poultice applied ; more frequently, however, the state is that of chronic induration. To promote the absorption of this, Iod. sulphur, gr. x to xx. U. cetacei %i. or the sebaceous points may be expressed, and the following lotion applied :— 5t.Oxym.hydr.gr.ss. Acid. mur. 3j. Aq. ros. ^vj. Misce. SYCOSIS. When follicular obstruction occurs on the hairy scalp, the inci- pient tubercles usually occur in clusters, being softer, more pointed than those of acne, and surrounded by a faint vermillion blush. They usually suppurate in five or ten days, the ulcerated surface being of an irregular, granular, fungoid appearance, somewhat re- sembling the pulp of a fig; often bleeding on pressure, and becoming spongy and overlapping, attended by an ichorous oozing, of a rancid odour. About the edges we sometimes see a slight furfura- ceous incrustation. Treatment.—If no inflammation surround the tubercles, the matter may be expressed, as in the case of acne, and the foregoing lotion applied. If there be inflammation, the liq. plumb, subac. and,crumb of roll as a poultice. If suppuration occurs, the roll poultice only ; and on the subsidence of the inflammation, the yel- low wash should be applied to the fungus. In the early and active stages, laxatives and antimonial sudorifics; in the latter, with the addition of the vegetable tonic infusions, with muriatic acid. 44 DENDY ON DISEASES OF THE SKIN- PORRIGO. P. favosa—Tinea favosa—Favus-—Tinea capitis—Scabies capitis favosa—P. lupinosa —Teigne faveusc—Honeycomb scall—Scald head. Large, flattish, light yellow pustules, rapidly becoming so from the papular form, chiefly about the ears, occiput, mouth, and fore- head, and on the scalp; the pustules soon becoming confluent, bursting, and pouring out a very glutinous secretion, which, speedi- ly concreting, forms yellow, olive, or brown crusts, rocky, or assuming a cupped form, interspersed with fissures, and sometimes containing fresh pustules ; the incrustations thus becoming cellular, like the construction of a honey-comb. It is then often exhaling a very rank odour—the origin of its name. In severe or neglected cases, the lymphatic glands in the vicinity become enlarged, and in rare instances I have seen the tongue studded with patches and vesicles. On the scalp the hair, if al- lowed, will become matted, and in a very filthy condition ; and if the hair drops off, the new hair will be flaxen, weak, and often gray. If seated near the eyes, ophthalmia of a very acute form will sometimes occur. Tinea ciliaris will be produced, and an oedema- tous state of the puncta lachrymalia, by which the tears are squeezed out over the cheek. If much protracted, this will end in ectropium —of the lower lids especially. Porrigo differs from impetigo in its more rapid change from pa- pula to pustule, and especially in its being contagious. It may, however, arise de novo. Treatment.—In the milder cases, the powder (2) each evening and morning, the laxative mixture (2) each second or third morn- ing ; and sponging with tepid water, or a soft roll poultice, will sometimes cure speedily. In strumous habits, the mixture if) should be given instead of the powder, in the morning. In more severely inflamed cases, more powerful laxatives, and even abstraction of blood by leeches, should be employed. On the subsidence of inflammatory action, flour may be sprinkled on the part for three or four days, occasionally. Subsequently, one of the following ointments or lotions. It will often be essential to change them, as one will succeed to a certain point, and the capricious ^disease will then be stationary, or retro- grade. Ungt. hydr. nit. mit. p. i. U. cetacei p. ij.:—Ungt. picis. Ungt. sulphuris. Ungt. cetacei p. seq.:—Sulphur, ioduret .gj. ad ^ss. U. cetacei §j.:—Argent. nitr. gr. vj. Aq. distillat. gvj.:—Acid. nitr. 3jss. Ol. oliv. Aq. distillat. a £ss. The bath (4) used as a lotion; or, Liq. potassae applied each night. A French roll poultice being constantly kept on the part. PORRIGO SCUTULATA. Porrigo annulare—Tinea annulare—Favus confertus—Ringworm— Pustular ringworm. Patches of very minute, slightly elevated, yellow pustules, deeply PORRIGO SCUTULATA. 45 imbedded in the skin, detached, often remote from each other, situated chiefly on the hairy scalp, or on parts, most thickly covered with down. On abrasion, circles of a brownish pink hue are formed, which gradually extend, leaving a central space free from pustules, though of a deeper colour than the surrounding skin, and slightly exfoliating. If seated on the scalp, the hair will become but slightly matted, but I have seen caries of the bone produced, by the disease deeply extending. When the hair is loosened, its colour fades, and it becomes thin and brittle. The skin beneath the crusts is red and glossy, with small purulent points. In very protracted cases, we see ridges produced on the skin in consequence of ab- sorption throughout the diseased structure. These cases will be often produced by derangement of the bowels ; sometimes the erythematous condition of scarlatina will affect the bulb of the hair, by which the hair itself becomes loos- ened, and pustules form, aggravated by the irritation of the loose hairs ; it is also extraneously produced by inoculation, or contact, and by neglect of cleanliness. There is no doubt, too, that stimu- lant articles of diet are a fertile source of this disease, as pea-soup, salt meat, as well as exposure to cold. Treatment.—On this account the constitutional treatment should be always premised, in the form of laxatives and mercurial altera- tives, and this in mild and incipient stages will sometimes effect a cure, chiefly by removing the obnoxious excitements, and allowing the vis medicatrix to influence. In other cases, the powder (2) each night, the mixture (s) each morning, combined with free use of lemonade. The local treatment should be commenced with warm water washes, and roll poultices, for three or four days; the loose hairs should then be detached by forceps ; and, if there be no inflamma- tory condition, recourse should then be had to more stimulant treatment; but patience and perseverance are much required. I append recipes of several forms; premising, that it is essential to wash off gently with soft flannel the previous applications, before employing the fresh ones. Acid, nitric. 3ss. ad 3j. Aq. dist. gi. ad ^iij.:—Cupri sulphat. pulv. rubbed in lightly. These two applications should, if they produce pain, be washed off ten minutes after their application. Liq. plumb, subac.—Acid. acet.—T. opii a Jjiij. Mist, camphorse Ibss.: U. Hydr. nit. m. §j. Camphor, £ss. Sulphur. £j.: Potassae sulphuret. gss. Aq. dist kj • Chloruret sodae solut. in aq. distill.: Sodee alicant. ^iij. Potass. sulphuret. ^iij. Aq. giij.: Acid. acet. (tepid) o. n. Ungt. hydr. n. m. mane. If the crusts are very dry, liq. potassae should be applied, and subsequently a warm poultice ; after this, the infus. gallae, to restore healthy action. In cases of several months' or years' standing, I apply a blister for 24 hours, for the purpose of changing completely the cutaneous tissue; it need not be kept open above a day or two, if it has effectually penetrated the deeper textures. 46 DENDY ON DISEASES OF THE SKIN. PORRIGO FURFURANS. A profusion of branny scales, interspersed with very minute red points, and surrounded and intersected by rose coloured margins. The constitutional remedies should here be the same as those directed in Porr. favosa; and the local applications which I have seen most efficacious are, the baths (l) or (4), Acet. dist. p. i. Aq. ros. p. iii., or Spt. rectif. o. n. et. m. Ungt. cetacei being subse- quently rubbed over the part. If the loose hairs should be firmly fixed and in profusion, the pulv. ellebori alb. should be gently rubbed in three or four times, and then ungt. picis, lukewarm; over this should be applied an oil-silk cap, to which the ointment will slightly adhere, and this being, when it is cold, withdrawn carefully, will eradicate the hairs without occasioning much pain. DISEASES INDICATIVE OF DEBILITY; MARKED BY LAN- GUID CUTANEOUS ACTION; OFTEN THE SEQ,UELiE OF ACUTE DISORDER. From original Debility of the System. PITYRIASIS. Dandriff. Even healthy children have naturally a slight exfoliation of flakes of cuticle for some days after birth, but the dandriff is the progressive desquamation of thin scales from the scalp, succeeding pink unelevated patches, chiefly attended by very slight chronic inflammation of the vessels secreting cuticle, but without the dis- charge of fluid. In neglected cases I have, however, seen the irri- tation so much increased, as to produce purulent secretion, which dries into a hard crustaceous mass, (Pityr. scabida.) In these severe cases there is often falling off of the hair, and the eyelids them- selves become diseased. This condition is reacting on the system, increasing the derangement of the health, and, although a non- contagious disease in the simple form, may by this neglect dege- nerate into contagious crusts, marked by reddish fissures ; an effect, however, which can generally be obviated by constant washing and laxatives. - On the breasts of children, about the tenth year, are often scat- tered light yellowish scales, sometimes scarcely apparent, (Pit. ver- sicolor,) an appearance sometimes resembled by the freckle, or the liver spot, (chloasma &c.) which, however, is a mere stain, without elevation. In children of a cachectic tendency, these spots will be of a dark or livid hue, (Pit. nigra—melasma,) and this will often ICTHYOSIS—ELEPHANTIASIS. 47 occur in children who have been debilitajed by living in tropical climates. If the exfoliation of the scales is not checked by warm washing, the following lotion should be gently rubbed on them. 3>. Liq. potassae gj. Aq. ros. §iv. The head to be washed with warm water and curd soap. In cases marked by much debility, the mineral acids in dec. sarsse should be given, and if the disease produces much irritation and restlessness, which will especially be the case should it extend over large portions of the skin, from I to 4 drops of liq. opii. sed. should be given once or twice a day in the food. ICTHYOSIS. Fish-skin disease. A squamous condition of the cuticle, the result of peculiar chronic inflammation of the cutaneous vessels, usually about the arms and legs. It commences with simple, dusky discoloration, attended with some degree of debility, symptoms usually for a time disregarded. As the disease advances, elevated scales appear, of a dirty hue, imparting to the touch the sensation produced by a dull file. There is sometimes a slight redness around the edges. The skin is nearly imperspirable on these diseased parts, the velamina being obstructed —decidedly so in those indurations occurring at the adult period chiefly, (icthyosis cornea.) The lamina are difficult of permanent removal, a fresh crop suc- ceeding those detached. When laxatives, sudorifics, and the warm bath have been em- ployed about a week or ten days, we should employ the bath (4), with the use of mercurial alteratives, and the liquor arsenicalis, lltij. ad vj. thrice in a day, but patience is most essential in our treatment of icthyosis, especially in crowded cities. In some cases much relief will be gained from the waters of Bath and Harrowgate, and from the following decoction : 5*. -Rad. rumicis acuti :f j.: Aq. ferv. ij. decoque dimid. et cola.: Sumr. cyath. min. ter indies. The loathsome pellagra of the plains of Lombardy, an aggra- vated form of icthyosis, assumes the appearance of black-fish skin —a livid and scaly crust. ELEPHANTIASIS. Lepra Arabum. Tubercular swelling of the corium ; appearing externally as a bard, rugose, fissured, and knotty condition of the cuticle, and assimilating closely to icthyosis, from which it differs by greater severity of symptoms; heat, pain, and surrounding redness being 48 DENDY ON DISEASES OF THE SKIN. often present, sometimes with apthous, and morbid and red condi- tion of the tongue and fauces, gastrodynia, and other marks ot con- stitutional disorder. This aggravated form of squama is very rare in children. Treatment.—Hyd. sub.; ol. ricini; ant. tart. In very stubborn cases, emp. lyttae; ol. ricini ; occasionally, mercurial alteratives, antimonial diaphoretics. Light diet. If pain is felt in the abdomen, leeches will be of service. In inveterate cases, blisters should be applied, so as to detach the scales. ALOPECIA. Athrica—Area—Porrigo decalvans—Ophiasis—Depilulio—Calvities—Baldness. Patches of baldness on the scalp, the surrounding hair growing thickly, close to the margin ; each hair, however, in the vicinity being of a cortical shape, sometimes bifurcated. If neglected, the patches will often extend to the denudation of the whole head. This baldness is a simple deficiency of vascular action in the secreting gland of the hair, unaccompanied by discharge, although the microscope may discover the slightest granular elevations. In infants, indeed, we sometimes see light patches of weak capilluli; and after fevers, the hair will become thin.and wiry, subsequently dropping off, and in extreme cases producing complete baldness. In some children affected with depilation, we see the nails shrunk and withered, and somewhat incurvated, as in phthisical patients. Treatment.—Occasional shaving of the head—Macassar oil— bear's grease—spt. camphorse—brandy, p. aeq.—decoct, foliar, nucis juglant.—lotio argent, nitr.—lot. acid. nitr.; in very stubborn cases, pulv. lyttae occasionally rubbed in. The young hair should be washed daily with strong rosemary tea. The first hair is always silky and fine, and the proof of progress in remedy is its firmer growth. In very debilitated children, we sometimes observe an extensive cuticular relaxation. SHRIVELLED SKIN. The cuticle, losing the normal attachment and support of the cellular tissue, becomes shining and puckered, and desquamates. In the same attenuated constitutions, we also find excessive sweating produced, EPHIDROSIS, perhaps unaccompanied by any acute or organic disease. These are of course decided indications of general debility, and point to the mode of treatment—concentrated nutritious diet, pure air and exercise, mild aperients, and tonics. On the contrary, we have in languid constitutions that defective MILIARIA. 49 capillary circulation, by which the skin becomes dry, cold, waxy, and unyielding; internal engorgement and effusion into the cellular membrane subsequently occurring, which effusion (of serum) speedily coagulates; in the end we have that disease termed, SKIN-BOUND. CEdeina cellularis—Indurcissement du tissu cellulaire. The child is extremely feeble, spasmodic contractions often occur, and occasionally jaundice will supervene ; invariably we have de- rangement of the alimentary canal. The treatment should consist of mercurials and diffusible stimuli, and the warm bath, and if the distention caused by the infiltration be excessive, careful incisions through the skin or acupuncture. From Derangement of the Chylopoietic Function. APTHjE. Thrush—Miliaria of the mucous membrane. Minute pearly vesicles on the mitcous membranes, extending from the lips to the anus, terminating in thin white pellicles. The simplest form of apthae is that of the suckling, (A. lactan- tium,) sometimes within a few days of birth, accompanied by erethism; the mucous membrane assumes a slight crimson hue, the papillae of the tongue are rather raised; in a day or two opake white flocculi appear, and are sooner or later detached from their superficial ulceration. By characteristic signs, as nausea, intes- tinal irritation, tenesmus, we may trace the disease in its downward course, from the mouth to the anus. In some cases, there may supervene considerable erosion of the gums and fauces. Treatment.—A healthy breast for the infant, a mild emetic of ipecacuanha, the citrate of magnesia, or the pulv. potassae c. (3) twice in a day ; and after a week or fortnight, moderate doses of the tonic mixture (s). A syrup of mel boracis and syrup, mori, ap- plied on a camel's hair brush thrice in a day. The diet should be melted jelly, blanchmange, chicken jelly, or sago, with port wine moderately and carefully given on convales- cence. Cool or temperate atmosphere. MILIARIA.1 Millet-seed eruption. Minute pearly vesicles, extensively spreading, rarely surrounded 1 The miliary fever (suette miliaire) of puerperal women appears to be an aggravated form of miliaria, under a peculiar condition of the system. 50 DENDY ON DISEASES OF THE SKIN. bv efflorescence, usually attended by transpiration of an acid odour, depending on a peculiar action of the cutaneous capillaries. It is symptomatic of some febrile excitement with debility, and may be induced by stimulating diet, and increased by unwholesome atmosphere. In some cases it may be critical or salutary, although always indicating weakness, yet by extensive irritation it may react, and thereby reproduce excitement, and sympathetically influ- ence the viscera, especially the lungs and the brain, and sometimes the urinary organs. The internal and dietetic treatment similar to that prescribed for apthae; the skin being sponged with tepid water, or thin grit gruel. ECTHYMA.—RUPIA. Atonic ulcer. In the commencement, hard elevated papulae appear, painful under pressure, with a base of bright or dull red, or dull purple. Papulae which were apparently simple, as strophulus, will in de- bilitated or cachectic systems, become thus changed; in three or four days the papulae of ecthyma become pustules, those of nipia vesicular, discharging a thick matter, which soon changes to a glu- tinous fluid. This, concreting as soon as it has oozed, forms a circular crust of a sienna brown, or brownish purple. The ulcers and crusts of ecthyma are smaller, thinner, and less deeply seated in the cutis than those of rupia ; and, altogether, rupia may be con- sidered the more severe disease. Both ecthyma and rupia have been divided into different species, which are truly indicative of diathesis or constitutional condition. Ecthyma vulgare—rupia simplex, being the mildest forms; while the terms cachecticum—luridum—escharoticum—indicate disease of greater severity and danger. The laminae of rupia are often ag- gregated superficially, so as to resemble a cone ; (R. prominens;) a character, indeed, which the crust of a burn will sometimes assume on a weakly child. The protracted and resisting nature of these diseases arises from deficient power of reparation. The simplest forms occur during lactation, (E. lactantium,) the more severe as the sequelae of acute disorder, or as an outward in- dication of marasmus, or one sign of the protean syphilis. The termination of the more malignant form will be in deep dry pits without a crust, or sloughing ulcer, or livid eschars, inter- spersed with bloody vesicles. The process of healing is slow, and may be retarded, by very slight causes. Treatment.—The slight forms in infants yield to healthy breast- milk, the mildest mercurial alteratives, and infusion of cascarilla or orange peel. Locally, a weak solution of nitrate of silver, twice in a day; occasionally a poultice of linseed and decoction of poppy, for four hours. If the ulcers are gangrenous or livid, and there is emaciation, the PEMPHIGUS. 51 tonic mixture (2) should be given thrice in a day, the-anodyne mixture (4) at night, if there is restlessness. In most malignant cases, the following should be administered: *. Acid, pyrolign. gj.: Syrup, rhaead. gss.: Aq. flor. aurant. gj. coch. i. p. ad in. ter indies, or the alkaline chlorides, in their usual forms. As a local application, cataplasms of the chloride solutions, or warm turpentine with roll. If much itching and pain are present, the following ointment will be beneficial:— &. Acid, hydrocyanic. 3j.: Plumb, acetat. gr. x.: U. cetacei £ij. M. The tepid bath occasionally employed. The diet should be nutritious and concentrated ; meat gravy, chicken jelly, 66c. Pure air, gentle exercise without fatigue. PEMPHIGUS. Pompholyx—Bulla febrilis—Pemphigoid fever. A disease usually solitary, occurring chiefly between the ages of two and seven, assimilating in its progress the form of gangrenous erysipelas. Symptoms.—Shivering, pain in the head and stomach, fever of four, five, or six days' duration, the pulse then becoming feeble and irritable, ranging from 100 to 120, the child being languid and fretful: a dull erythematous blush or spots appear, and become vesicular, the bullae being larger and more scattered than herpes, and without much inflammation ; the fluid soon becomes of a straw or dull purple colour, the pulse sinks rapidly, and the fever as- sumes the mild typhoid form, brownish white tongue, hot skin, thirst. The child dies often from five to ten days from the vesicle, but the disease may be protracted for three weeks. The bullae will sometimes extend to three or four inches in circumference, flat or table separations of the cuticle. The cutis around and be- neath the bulla becomes livid or crimson, fissured and divided into flocculi, and even exfoliation of the bones of the fingers has some- times occurred. I could adduce many cases in proof of a connection between ma- ternal puerperal fever and infantile pemphigus; the inflammatory symptoms are then of a more acute form. The sequelae of acute inflammation in children will often be marked by extensive livid vesications. Treatment.—If any abdominal tenderness exist in the very early stage, leeches may be carefully applied, followed by warm fomen- tations, moderate doses of ol. ricini each second morning, the pow- der (3) each morning, the mixture (8) thrice in the day. On the formation of the vesicles, fomentations of poppy and camomile, or the warm bath ; if very large, the bullae should be punctured, and a weak solution of argent, nitr. employed. 52 DENDY ON DISEASES OF THE SKIN. If the gangrenous ulceration spreads or assumes a dark shade, the mixture (5) or the powder (7) should be given, with jellies and rich broth, or blanchmange melted. In cases marked by excessive prostration, the sulphate of quinine, or minute doses of solut. mineral, should be watchfully administered; and, if attended by restlessness and indications of pain, the syrup, papav. should be added in the evening. The formation of bullae without fever is termed pompholyx ; the plan adopted in the early stages of pemphigus should be here em- ployed. ANTHRACION. Malignant vesicle—Persian fire. Nearly allied to pemphigus. A bulla of a reddish fluid, speedily followed by diffused inflammation, resembling that of a venomous bite, rapidly sloughing. In some cases a white line of demarcation checks its march; in others, the cellular tissue rapidly becomes disorganised, and deep caverns form beneath the skin. This is not unusual when occurring in the neck, and about the pudenda of female children. The patient dies typhoid. In these cases dissec- tion discovers black patches or melanosis about the abdominal and thoracic viscera. The treatment 1 have above alluded to should here be adopted. In addition, I think the part should be rather freely scarified, and the weak nitric acid, or nitrate of silver lotion applied, and over these a linseed poultice. This is the usual form of malignant or sloughing abscess in children : in some rare cases, the bullous vesication will not be present, and we have deep-seated inflammation, assuming somewhat the character of ANTHRAX. Carbuncle. An angry, hard, red tumour, unlike the phlegmon; the skin (if the swelling be disregarded) yielding in many points, and at length sloughing extensively, or burrowing deeply beneath the fascia, &c. These are all indications of increased action with deficient power; still, in the early stage, benefit may sometimes be derived from leeches and bread poultices. The treatment generally that recommended in the case of pem- phigus. If suppuration has occurred, deep and free incision early. Lin- seed poultices being constantly applied. PURPURA. Purples. A subcuticular extravasation of blood, not disappearing on pres- sure ; minute red points, (stigmata, P. simplex;) small purple spots P. HEMORRHAGICA. 53 (petechiae;) or large crimson or purple patches, (ecchymosis, P. haemorrhagica.) P. SIMPLEX. The spots resemble flea-bites, but they have no minute point in the centre. The disease is unaccompanied by fever, but marked by debility, languor, and fretfulness, and perspiration on even gentle exercise. In some children there is an evident predisposition to this vascular lesion on pressure, which in some few instances pervades a whole family. The treatment should be chiefly dietetic, a small quantity of food being administered at a time. For the suckling, if the milk be suspected, a more healthy breast should be obtained. The only medicines I would advise are these: the powder (2) each second night, ol. ricini on the following morning. The mix- ture (s) twice in the day. In cases of diarrhoea, the mixture (3) may be added, modifying the opiate according to the necessity. P. HEMORRHAGICA. Haemacelanosis—Hsemorrhrea petcchialis—Bloody small-pox—Bloody scurvy—Land scurvy—Petechial fever. Crimson or purple patches of varied and irregular forms, some- times interspersed with wheals (P. urticans.) These spots may be symptomatic of malignant fevers, when they indicate the worst form of adynamia, as well as extreme danger. In some cases their appearance is preceded and accompanied by full quick pulse, and other marks of a sthenic condition, (the hemorrhagic effoit,) un- attended, however, by acute fever. Then the spots will assume a florid hue, from a higher state of oxygenation, and in this form we find the internal organs especially participate, as indicated by the varieties of visceral hemorrhages, haematuria, haematemesis, hae- moptoe, epistaxis. More usually, however, the disease from its onset is marked by debility, and the ecchymoses are dark crimson or purple, and often are raised in vesicles filled with purple blood, often breaking through the cuticle. In the scorbutic diathesis, the mucous membranes may be so pervaded by this tendency that in- ternal hemorrhage may occur, proving in the end fatal, the blood becoming paler often towards dissolution. A congested condition of the hepatic system, i. e. the cava and portal vein, may perhaps throw the circulation on the capillaries, and if these partake of the general debility, which the hepatic derangement or mesenteric dis- ease may have aggravated, their tender coats immediately yield. Treatment. This should be regulated by the stage of the dis- ease and vascular power. Where indications of congestion, of local pain, or high action, especially, prevail, a small quantity of blood may be taken in the 54 DENDY ON DISEASES OF THE SKIN. recumbent position; in children, however, caution is far P10^ essential than in adults. But, above all, the restoration offt{,e healthy condition of the intestinal canal should be our aim. The first laxatives should be mercurial, to expel the unhealthy secre- tions about the biliary and pancreatic ducts, and to excite healthy action of the liver. These should be followed by the mixture (2), so that two or three evacuations may at least be obtained for three or four days; thus the laxative is a most valuable pioneer, and, indeed, becomes a tonic, by inducing a more rapid absorption of nutriment. On the cessation of pain, and subsequent to free evacuation, infus. rosae and the citrate of potass should be freely administered, and if the debility should increase, the Colombo, the quinin. sulph., and the more powerful mineral acids, or the solut. mineral. If in the latter stages blood should be constantly oozing from the gums, and other parts of the mucous epithelium, I have found the turpentine beneficial, in this form— 01. terebinth, ^ss. 01. ric. jiij. P. acac. ^iij. Aq.anelh.^iij. F. haust. This is adapted to the tenth year of age. Infusion of malt, or asses' milk, is the most appropriate beverage. The diet should always be light and nutritious, and pure air should be obtained, as soon as it is prudent to move the patient. NOME. Black thrush—Apthte nigra?—Noma—Gangrenous erosion—Phagedenic ulcer— Spreading canker, or scurvy of the gum. In children ill fed, or neglected, or having endured some acute or malignant disorder, a livid crimson hue of the gums and fauces is often observed, and a gangrenous tendency about the angles of the lips, where the cuticle sends off the epithelium. The papillae of the tongue are prominent and scarlet. The vesicles coalesce and ulcerate, and the velum, the pharynx, and larynx participate, marked often by difficult deglutition and stridulous breathing. Gray sloughs appear on the tonsils, the membrane falls in gray flocculi, or the sloughing rapidly extends, the gums become spongy, the alveolar process is exposed, and the teeth sometimes drop from their sockets. The child becomes restless, is constantly moaning, and its countenance assumes an expression of extreme suffering,-a state followed by convulsion and speedy death. Constitutional Treatment, on the commencement, should be that adopted in the case of purpura: but the tonic plan must speedily be assumed. Lemonade, or malt tea, as commou drink. The yolk of an ess; in warm rose-water, jellies, iiinglass and water, with port-wine or asses' milk. Local Treatment. If there be pain and throbbing, rnel boracis cream, and yolk of egg. If sloughing is extensive, lint dipped in bals. peru.; or, dilute muriatic acid, or chloride of lime, or soda. STRUMA. 55 It is sometimes essential to administer decided anodynes; this, however, should be done with especial care. Quinine, solut. mineral., or the mineral acids in camphor mix- ture, tartrate of iron, or charcoal administered in honey, &c, if the throat will bear it. STRUMA. Scrophula—King's evil. That peculiar taint termed scrophula may affect all the tissues of the body; the most usual points of attack being the glands, the bones, and the follicles. The subjects of struma are of light complexion, with pink cheeks and tumid lips, light hair, bluish or gray eyes, with large black pupil, bluish sclerotic coat, and slender frame. There is often some incurvation of the cylindrical bones, bulging at the extremity, sometimes with curvature and disease of the spine. The two affections to which I here allude are glandular tumour and abscess, and strumous ulcer. I have already alluded to the simple local treatment of common glandular abscess. Phlegmonous suppuration is rapid, that of a gland in a scrophulus child is a very slow process, and being so, it affords ample time often for the checking of its course, by effecting a constitutional amendment. This, however, is a work of time. When a gland, or a series of glands, becomes enlarged, it feels like a lump, or congeries of lumps, under the skin, at first of the natural hue and temperature, with slight pain on pressure. A pink spot appears after a time, which becomes soft, a partial suppuration having taken place, the rest of the gland being as hard as before. The fluid is a thin ichorous matter, with caseous flakes floating in it. On its discharge, the abscess is indisposed to heal, having pale ragged edges, somewhat everted, and often bleeding slightly on friction. In strumous children the ciliary glands are often diseased, as well as the tarsi and eyelids. The suppuration of these glands (tinea ciliaris) constantly produces, if neglected, the depilation of the eyelashes, and the red circles around the lips—lippitudo, or blear eyes. When struma affects the subcutaneous tissue, we observe light reddish tubercles, of languid progress, which, often on fresh excite- ment, suddenly soften, ulcerate, and discharge a rather viscid serum, formino- flabby sores, and, sometimes, livid crusts. These abscesses are often deeply seated, and their burrowing is marked by loose folds of integument of a doughy consistence; and, when they are more advanced, we often find bands stretching across the cavities thus formed. The walls of the ulcer are pallid and flabby, or livid • a lymphatic gland, of a pinkish white, as yet uninfluenced, being often very conspicuous, almost isolated, in the excavation. In other cases a thickened periosteum maybe observed, and around it ash-gray sloughs. 56 DENDY ON DISEASES OF THE SKIN- The cicatrices of strumous sores are usually puckered like those of burns, from the shrinking of granulations. There is doubtless in many a strumous diathesis, excitable by a variety of causes, acute disease, a long course of mercurials, ex- posure to cold, excesses, warm climate, neglect, indigence. In those so predisposed, the invigorating of the system in every way is most essential, as well as a healthy locality, pure air, exer- cise, dry feet, light nutritious food—as jellies and meat gravy—and cheerful society, early sleep and rising. The sulphureo-gelatinous bath, or the nitro-muriatic acid bath, will be beneficial in every stage of struma, adapting its strength and frequency to the occasion. On the tubercles, in the incipient state, may be rubbed the fol- lowing ointment; and when the abscess has burst, and the ulcer formed, the same may be spread on singed rag, and applied twice or thrice in a day to the sore. Hydr. iodid. 9j. ad 3j. : Ungt. cetacei 5§ij. M. I may add, that the Tr. iodinae will sometimes succeed more than the ointment, when it is pencilled on the swelling. Internally, the vegetable and mineral tonics. Iodine in the following form: 5t. lodin. gr. f. Hyd. potass, gr. jss. Aq. dist. §viij. Coch. i. vel. ij. med. ter indies ei cresce. As the common drink, malt tea, or infusion of fresh orange and lemon-peel, sweetened with barley-sugar. The citrate of magnesia may act as a mild aperient, if not, castor oil should be occasionally given. In the early stage of tinea ciliaris, leeches should be applied, and poppy fomentation. In the later stages, ungt. hydr. nitr. m., lightly pencilled on the edge of the eyelids. ONYCHIA MALIGNA. Inflammation and ulceration of the matrix and soft parts at the root of the nail, commencing in swelling, of a dull red colour, with heat, throbbing, and pain, usually attended by shivering and fever. An oozing of thin ichor soon takes place between the nail and the soft parts, and Ulceration spreads round the circular edge. The surrounding parts are tumid, and of a deep purple hue; the ulcer is unhealthy, the edges thin and flabby, covered by a dirty yellow lymph, and separated from the nail, which becomes discoloured and dead. When allowed to continue, the toe or fino-er becomes a deformed bulbous mass. This form of onychia is placed here, as it occurs only in stru- mous or cachectic habits, except (rarely) from syphilitic taint. The constitutional treatment should consist of mild laxatives__ decoct, sarsae. Hydr. oxym. gr. i. Tr. cinch, c.-gij. TT[ x. ad si. in inf. lini. ter indi CHLOASMA—EPHELIS. 57 The mixture (4) hor. somn. Locally, bread and goulard poultices; or, lotio flava; or, poultice with solut. chlorid. calc. vel sodae. If inflammation should be severe, leeches should be applied. On the healing of the sores, pulv. sarsae in aqua calcis bis indies. In very obstinate cases, escharotics must be more extensively used, to destroy the secreting surface; or a blister may be bound round the finger, thus to loosen the attachments; or the nail may be excised by a deep semicircular incision around its root: but this is seldom necessary in the cases of children. ICTERUS INFANTILIS. Icteritia—Jaundice. A dull yellow tinge, extending sometimes over the whole surface of the skin, nails, and eyes, sometimes disappearing spontaneously, at others attended by languor, fever, and wasting. It is, probably, dependent on torpor, or mechanical obstruction of the biliaryducts, and is frequently occurring during some retention of the meconium. It is possible also that the milk of a jaundiced mother may impart this disorder to her child, either directly or indirectly. Discolourations of the skin, resembling jaundice, will, however, sometimes occur as one mark of another disease. Treatment. A gentle ipecacuanha emetic once given, and the powder (2), with pure breast-milk, will soon restore more healthy action. CHLOASMA—EPHELIS. Maculae hepaticse—Pityriasis versicolor—Ephelide hepatique—Leberflectete— Liver spot. Extensive dull yellow irregular marks of the skin, seated in the corium, sometimes extending over the whole body, occasionally varying in tints, and sometimes accompanied by pricking or ting- ling. It varies much in its degree or shades, according to the more or less deranged condition of the alimentary canal; in cachectic chil- dren assuming the darker tinge (melasma.) It consists, probably, in an unhealthy secretion of the vessels of the cutis; yet, although there is usually a concomitant hepatic de- rangement, it does not seem to be a tinge of bile. Debility and languor, and impaired health, usually characterise the subjects of this discolouration. Treatment. For the suckling infant, healthy breast-milk, the nurse taking lact. sulphur. 3i. lacte ter indies. For the child, the powder (2) each night, the mixture (5) thrice in a day; to which, extr. taraxaci gr. i. ad iv., may, in cases of older children, be added. Lemonade should be freely taken. At a later period of life, the abuse of mercurials will often pro- 24__h 5 dendy 5S DENDY ON DISEASES OF THE SKIN. duce a leaden or deep yellow tinge, or bronze tint of the skin, nearly resembling the hue of chloasma. ALBINISM. A blanched, or apparently exsanguine condition of the surface of the body, the skin being of a marble whiteness, in consequence of deficiency in the constitution of the blood. The pupil is pink, from an absence of the black pigment of the eye, this occasioning blinking and weakness of sight. The hair is usually long, weak, and flaxen, or silky, and glandular swellings, about the neck especially, are prevalent. The functions of the body, as well as of the intellect, are impaired, and languor and inaptitude mark the character. Amongst the Alps of Le Valais in Switzerland, and the Pyrenees, there is a provincial defect; the "Cretins," as they are termed, being almost all conspicuous for cadaverous, or dark brown, or livid skin, flabby, wrinkled, and scaly. It is congenital, and yielding but slightly to treatment. CYANOSIS. Blue disease. A cerulean or leaden tinge, dependent on congenital defective organisation of the heart, an open state of the ventricular septum, by which the arterial and venous currents are blended. If the admission of venous blood into the aortic trunk be minute, life may continue to a certain period, under the unavoidable penalty of lassitude, coldness, and mental inactivity; it is rare that any improvement occurs. Fatigue and excitement increase the malady. CHLOROSIS. Green sickness. The pallor of young females, the skin being of a waxy white- ness, depending chiefly on the constitutional1 changes about the approach of menstruation. Of course constitutional treatment is required, the preparations of iron forming the chief remedy, attention being paid to the state of the bowels and the functions of the skin, not neglecting moral management.1 1 Albinism, cyanosis, and chlorosis, are not diseases of the skin but are alluded to as important indications of debility. RUBEOLA. 59 ON DISEASES CONSEQUENT TO SPECIFIC INFECTION. RUBEOLA. Morbili—Rugeole—Blactiae—Measles. A febrile contagious disease, (occurring once during life,) accom- panied by a characteristic efflorescence. The primary symptoms of rubeola vulgaris, which arise ten or fourteen days from exposure to a contagious atmosphere, are these—subject to exceptions—nausea, vomiting, cephalalgia, gastro- dynia, languor, red and swelled eyes, epiphora, sneezing, itching of the nose, intolerance of light, somnolency, acid perspiration, white tongue with scarlet edges, frequent dry cough. During the period of dentition these symptoms are the most severe. On the third or fourth day itching and heat of skin, on which appear small red spots, slightly raised, disappearing on pressure. These coalesce, forming red patches of different shades—circular, annular, or cres- centic. Among these we see sometimes numerous extravascular red points, not disappearing on pressure. At this point, epistaxis often occurs, and the febrile symptoms usually yield. On the fifth day of eruption, the redness fades and becomes yel- lowish, and the cuticle separates in thin scales attended by itching of skin. In some children, those with a tendency to phthisis and pulmo- nary disease, and, probably, those of an hepatic or cachectic tem- perament, the eruption is sometimes seen broader and darker in its hue (R. nigra.) Rubeola is distinguished from scarlatina and roseola by a more crimson hue; from the latter, especially, by greater severity of symptoms. The early eruption of measles and small-pox often closely re- semble each other, until the vesicular form of the latter appears. The child is more predisposed during sleep to become affected by the contagion of measles, &c., and in spring and summer; the cases being usually milder towards the autumnal season. During prevailing epidemics, as influenza, we often, too, have a prevalence of measles and other eruptions. Regarding the prophylaxis of these specific diseases, I believe that pure air, and exercise, and judicious ventilation, with attention to the bowels and diet, are the most efficacious; perhaps sulphur- ous fumigation, and even its internal exhibition, may have some influence also. Treatment. Modified by degree of inflammatory action, and accession of various local symptoms in its progress. Hio-h febrile action must be reduced by abstraction of blood, a * *5 60 DENDY ON DISEASES OF THE SKIN. mild emetic, gentle laxatives and sudorifics, the lightest diet, subacid and mucilaginous fluids, and moderately cool temperature. Determination to the brain, lungs, and bronchi, in which inflam- mation is often acute, or bowels, must of course be met by antiphlo- gistic treatment, depletion being somewhat less freely employed than in idiopathic inflammations. The warm bath is often service- able. Neglect of this will often be followed by sequelae of very severe and often formidable nature—phthisis, profuse diarrhoea, and effusions into serous cavities and the cellular membrane. On the recession of the eruption in robust children, and those not much reduced, the body may be sponged with vinegar and water, in a warm room. In cases of local congestion subsequent to measles, especially about the lungs and liver, stimulant frictions, or friction with oil or flour only, will be very efficacious; if the symptoms do not yield to this, a blister, or caustic issue, may be necessary. Caution is required in the treatment of the mucous diarrhoea often occurring at the subsidence of measles. It must not be treated by powerful astringents; it is often better, if there be pain, to apply leeches to the abdomen, and employ the warm bath. In great exhaustion however, it will sometimes be essential to give anodyne astringents, the mixture (3), to which I would add, P. rhoei gr. ss. only, night and morning. If the disease assume a typhoid form, with livid petechiae, stupor, delirium, prostration—tonics and antiseptics, as, quinine, cusparia, acid, sulph. ar. and wine will be essential. On convalescence, country air, asses' milk, light nutritious diet. SCARLATINA. Rossalia—Morbilli confluentes. A specific contagious disease, occurring once in life, consisting of diffused pink or scarlet efflorescence, preceded for a day or two by erethism or fever, usually occurring between ablactation and puberty. sc. SIMPLEX. S. benigna—Scarlet rash. Symptoms.—First stage. Languor, chilliness, restlessness, head- ach, and sometimes epistaxis. Second stage, third day.—Pink spots appear on the neck and face, (which is slightly swelled,) speedily coalescing sometimes in- terspersed with darker spots and vesicles, the papillae of the skin being sometimes erected ; the lips and pharynx and tonsils are in- flamed, the tongue partially coated, its papillae red and prominent the cerebral functions slightly impaired, with sometimes transient delirium and dreaming. In three or four days the efflorescence is continuous: but elevated points are felt, and the skin is thus in SCARLATINA ANGINOSA—S. MALIGNA. 61 some parts rough. The eruption is most severe in parts exposed to friction and heat. On the third or fourth day the eruption pales; on the sixth, the cuticle peels off, the symptomsjsubside, the tongue, from being partly coated white, becoming morbidly red and shining. Sometimes for a day or two at this period, there is some recurrence of the symptoms. Careful nursing, with the aid of cool temperature, mild laxatives and lightest diet, comprehend the chief remedial plan. SCARLATINA ANGINOSA.—S. MALIGNA. Scarlet fever. Commencing in high febrile excitement, pulse quick and wiry, nausea, headach, delirium, eyes and face flushed, jaw stiff and pain- ful, respiration quick and laborious, deglutition impeded, the fauces inflamed, (the degree measuring the danger,) and covered with ash- coloured sloughs, occasionally becoming gangrenous ulcers, a fetid sanies issuing from them over the lips; the papillae of the tongue elevated, of a deep crimson colour—even the teeth sometimes mor- bidly red ; the parotid and other glands often enlarged; hoarseness, epistaxis, coryza—(which indicates great danger)—purulent otir- rhoea, deafness. Between the second and fourth days the skin is vivid scarlet, the rash rapidly extending, the body swells, the urine is bloody; after severe shivering or shuddering, rigor, succeeded by burning fever. Dark crimson or purple spots appear, (scarlat. maligna,) with acute delirium, (meningitis,) dark brown crust on the tongue, brown sloughing of the fauces, putrid flow from the nostrils, tenderness of the belly: parts subject to pressure slough, delirium and prostration increase—convulsion—death. I believe that death has occurred where reaction was not suffi- cient to establish eruption. Dissection shows ecchymosis in the mucous linings. Under favourable circumstances, in five or seven days the rash fades, and the cuticle peels off; but there is sometimes a deceptive recession and reappearance of the rash at this time. The convalescent child is often affected with anasarcous swell- ings and effusions into serous cavities, attended with languor, and scanty turbid urine; this dropsical tendency maybe much miti- gated by dry warmth and modified temperature. Indications of cure.—To moderate febrile action with little loss of power, at the onset, by a mild emetic of ipecacuanha and laxa- tives ; by moderately cool temperature, diaphoretics, diluents, sponging with warm vinegar, tepid bath, 90°; by diminishing the morbid irritability of the heart; by digitalis and hyoscyamus in effervescing draughts, with pot. carb. and succ. limon. In the more advanced stages, vegetable tonics, contrayerva or serpentaria, with aether, capsicum, and ammonia. To obviate the septic tendency, by mineral acids, especially the oxygenated muriatic acid. The following draught will be often beneficial; (set. iv.) 62 DENDY ON DISEASES OF THE SKIN. Sod. mur. gr. x. Succ. limon. q. s. Spt. seth. nitr. TTL x. ter indies. To remove the ashy sloughs, the gargle ('), or the chloride solu- tions with honey. If, to remove local symptoms, blisters are adopted, it is best to remove them after four hours, and reapply them if required, in the vicinity, in the course of eight or ten hours. If long applied, blis- ters rapidly slough. In the malignant form it is most essential to support power. Ammonia should be freely given after the excitement has begun to subside, and in some cases it will be essential to administer wine at this period. In cases where the coryza and otirrhcea are fetid, this lotion should be used, 5<. Liq. chlor. sod. (Lab.) Jxij.: Aq. dist. ^vi, I have seen the bals. peril v. also very useful. If gargles are inadmissible, the following fumigation may be em- ployed, 9*. Sod. mur. jx.: Manganes. pulv. giv.: Pot. nitr. ^ij.: Acid, sulph. |j. The most usual sequelae of scarlatina are anasarca, ascites, hy- drocephalus, and pulmonary disorders; it is evident that on the subsidence of the eruption our efforts should be directed to obviate these, especially to guard against cold and damp, which are so often followed by effusion, the first evidence of which is usually brown and albuminous urine. Belladonna in some degree indisposes children to the influence of scarlatina. VARICELLA. Variola spuria—Variola pusillse—Bastard-pock—Glass-pock—Swine-pock—Chicken- pock—Hives. The vesicle of a specific, slightly contagious, and epidemic dis- ease, occurring once during life. After slight febrile symptoms of three or four days, small pink spots appear on the neck or breast. On the second, or morning of the third day, and sometimes on its very first appearance, it is a distinct pellucid vesicle, without an indurated base, which enlarges, and is filled with a pearly or yellowish fluid about the fourth day : it then begins to subside, becoming flaccid at the edge ; and on the fifth or sixth day brownish yellow crusts are formed. The cicatrix of the mild forms of chicken-pock, which are seated between the cuticle and the corion, produces no permanent marks; but the severe and confluent forms (the vesicle dipping deeply into the corion) are followed often by very extensive pitting. It is difficult to compare varioloid and varicelloid vesicles, and their attendant symptoms, without leaning at first to the opinion of their almost identity ; the terms conoid, lenticular, and globate, and chicken-pock, swine-pock, and hives, being chiefly distinctions of VARIOLA. 63 form and of degree. When, however, the progress is marked by the periods above stated, it is useless to refine our distinctions too much. The question of contagion is however one of importance; as varioloidea may communicate true small-pox to a person predis- posed or not defended, while varicella cannot. I shall discuss this point briefly when writing of variola. The term globate is very descriptive, varicella sometimes assum- ing the form of a vesicle a quarter of an inch in diameter, the fever being severe, successive crops of vesicles appearing and coalescing, each crop being marked by a febrile paroxysm, some inflammatory action extending to the fauces, with hoarseness and difficult deglu- tition. This is sometimes attended by convulsion. I have seen a somewhat severe form of roseola synchronous with varicella, both running a regular course. Treatment.—In mild forms, a laxative and light diet. In the more severe, attended by local inflammation, leeches should be ap- plied, but merely to subdue acute action ; without reducing the system, so that convalescence should be retarded.. VARIOLA. La petite verole—Small-pox. The characteristic vesicle1 of a specific, contagious and infec- tious fever, communicated by variolous lymph, or contact of or ex- halation from a variolous body, or infected clothes, . Potassa? sulphuret. gj. ad ^ij. Aq. ftj. M. 8<. Acid, muriat. f j. Aq. distill. Bsj. Misce §j. sing. lot. cum aq. fon- tana ^iv., et lava spongia. g.. Sulph. sublim. p. ii. Potass, pur. p. i. Adip. p. viij. ter indies utend. Internally, Sulph. lot. gr. v. ad 9j. Tartr. potass, gr. ir. ad x. Lacte ter indies sumend. In the moderate forms of scabies porcina: *. Hyd.oxyd> alb. 9j. Adip. giv. I add other forms of local remedies, because one will succeed often where others fail. *. Flor. sulph. 3v. 01. olivae 3iv. Aq. |j. Pot. subcarb. gij. Solve potass, aq. tepid. Adde 01. deinde sulph. Adde camphor. 3ij. *. Pulv. rad. veratr. a. %}. Hydr. precip. alb. 9ij. Ol. limonis 3ss. Adip. gxij. f. ungt. *. Zinci sulph. lact. sulph. bacc lauri, p. aeq. 01. q. s. ut f. ungt. p,. Potass, sulph. 3iv- Aq.dist. »j. Ac. sulph. gss. M. Bis indies utend. pro dieb. sex. 76 DENDY ON DISEASES OF THE SKIN. SYPHILITIC ERUPTIONS. Secondary Symptoms. The question regarding the syphilitic nature of infantile erup- tions is one of extreme delicacy, involving often the destruction of domestic peace ; the expression of opinion should be guarded, even if a chancre, or secondary sore, be proved an effect of parental contamination. The primary sore is seldom seen in the child, the secondary forms are not uncommon among the lower orders, assuming the character of spots, or blotches, pimples, bullae, crusts, scales, condy- lomata, which it is not easy to distinguish from eruptions on ca- chectic children. The child may be infected during its develope- ment within the womb of a diseased mother ; or in its passage through the vagina. Intra-uterine syphilis usually assumes the character of red or brown, or of extensive fawn-coloured stains. Infants are, however, sometimes born, either prematurely or not, with ragged ulcers; while others are expelled dead, with a peeling cuticle, or gangrenous extremities, perhaps not an unfrequent cause of blight, or abortion. The mother may not be apparently diseased, she may have lost the external marks for some months, and yet infect her child. How far disease may be inherent in the ovum, or the semen, involves a more subtle question. When the vagina has communicated the disease to the child, a straw-coloured discharge will often flow from the child in about a week; a few days, or even weeks, elapsing ere the eruption appears. The most common form is psoriasis or lepra, commencing in a whitish or pink spot, or pimple, which terminates in thin films; if neglected, it will become an ecthymatous ulcer, or copper-coloured, or blackish crust, surrounded by a purple margin. The scales of syphilitic lepra are very dark, and they begin to heal at the cir- cumference. The crusts will re-appear as often as they are detached. When the papulae appear about the verge of the anus, continual moisture and action prevent the formation of a crust; an indurated, irregular tubercular swelling, condyloma, being the result. These swellings will, however, sometimes form in the dry folds of the thighs. These forms of disease must always be suspected, and our diag- nosis may be almost confident, if we have, superadded, tumefaction of the nose, and a discharge of yellow, viscid, and speedily inspissat- ted mucus; and above all, if there be indications of pain in the cylindrical bones. Infantile syphilis will infect the nurse. Treatment.—If the mother be evidently infected, the ioduret of mercury should be freely given to her ; the child will be influenced thereby, through the medium of the milk ; it is true, the milk may be thus rendered less adapted for nutrition, but it is essential, unless ENCAUSIS. 77 the child is removed to another breast. In that case, and it is the safest mode, the hyd. cum. cret. should be placed on the tongue, or the gums rubbed with it night and morning; this, however, with caution, as the salivary glands may remain uninfluenced, even while an absorbent action is set up in the bones of the mouth, or the alveo- lar process, and exfoliation be the result. This effect is, however, rare. The black wash, with or without poultice, will be the best local application to the crust, ulcer, or condyloma, the other forms need only defence. The sublimate bath (3) will be beneficial. I need scarcely allude to the necessity of pure air, exercise, and nutrition. ON DISEASES CONSEQUENT TO EXTERNAL IRRITATION- ENCAUSIS. Burn and Scald. Lesion, from the contact of heated solid, fluid, or vapour; the degrees of acuteness of its symptoms, and the consequent danger, depending chiefly on the extent of the injury itself, the importance of the parts injured, the state of health, sensibility, or excitability of the patient. According to the extent of the lesion, we may divide the burn or scald into three degrees—superficial, ulcerated, and sphacelated. Superficial. This may consist in simple erythema, or redness, or inrslight vesication, accompanied by little pain, and but transient erethism. If, however, the superficial extent is large, and the injury (though .■* in itself slight) has occurred on delicate, or vital organs, as the eye or larynx, the symptoms will become relatively so severe as even to endanger life. Ulcerated. Abrasion of a more or less extensive vesication, usually attended by rigour, succeeded by flushes and other marks of' febrile action, restlessness, convulsive twitchings, sometimes by col- lapse, or by extreme constitutional irritation ; when, from exten- sive or deep ulceration; the extremities of nerves have been largely denuded this may be followed by extreme prostration, by coma, delirium', and other marks of cerebral disorder, terminating occa- sionally in death. . , Svhacelated. An eschar formed, and the parts deeply burned; the tissues being often converted into one black encrusted mass. In this case the injury has been usually so severe, that the collapse will be extreme, death taking place quickly, from a depression of nervous energy beyond the power of reaction. 78 DENDY ON DISEASES OF THE SKIN- Treatment. First Degree.—To subdue or prevent inflamma- tion by cooling applications, as cold water, liq. plumb, dilut., or flour strewed over the part; spt. rectificat. dilut., if any vesication has occurred ; adding ol. amygd., if the injury be near a joint, so that contractility may be obviated. If the burn or scald be in, or near to the eye, or the fauces, leeches shonld be applied if pain or heat rapidly increases, for the slightest injury to the glottis may be productive of severe, even fatal, result. Cooling laxatives, and the lightest diet. Second Degree.—If the injury is slight, the application of liq. calcis, and ol. amygd., or ol. lini, with attention to the state of the bowels. If an approach to collapse, brandy and ammonia must be imme- diately administered, to effect reaction of the circulation. In deep and extensive injury, the most efficacious applications are finely carded cotton wool, or fine and pure flour. The wool should be kept on the abraded surface, four, five, or six days; it forms, with the discharge, an artificial covering to the denuded nerves, thus obviating irritation; and being in itself a non-con- ductor of heat, it prevents excessive expenditure from the surface. The cicatrization is speedy, there is little or no contraction of cuticle, the new skin possessing more of its normal character than the usual cicatrix. The flour should be dredged over the surface every morning, for a few days. On the separation of the crusts, simple dressing should be applied. Excessive febrile excitement, or extreme prostration, or restless- ness, should be relieved by cooling, tonic, or anodyne remedies. In restlessness, with a tendency to coma at intervals, the Tr. benzoin, c, dropped on the part, will often procure quiet. Third Degree.—If there be collapse or prostration, the patient should be immediately placed in a warm bed. If the eschar be slight, I would adopt the plan proposed for the second degree. If the injury be destructive of the soft parts, and only then, the ol. terebinth, should be applied warm to the burnt surfaces, for two or three days. On the separation of the crusts, the abraded surface should be dressed as in the second degree. If the bone of a limb be deeply burned, the question of immedi- ate amputation, that is, when reaction is established, is one of great moment. The fever accompanying this degree is usually of a typhoid character, and the mineral acid should be early employed: if the nights are sleepless, decided anodynes must be given. The bowels should be opened by enemata, or ol. ricin. The diet should be light, but nutritious, moderately and frequently given • but if the prostration be extreme, wine or porter must be added. On the sloughing of dead substance, the arg. nitr., or chlorid. VESICATION FROM EXTERNAL IRRITANTS. 79 calc, in moderate degree of solution, should be applied on linen rags. To exuberant granulations a stronger solution of arg. nitr., or Tr. iodin. may be applied. If on the extremities, emp. saponis may be strapped round the limb, spaces being left for the discharge of matter from the sore. The glassy sore should be treated by lotions of the sulph. zinci, the spongy, and bleeding, and languid granulations, with arg. nitrat., or sulph. cupri. Contractions, or hypertrophy of the integuments, will occur, especially after their destruction by burning; in consequence of less or more blood than is due being determined to them. When contraction is extensive, or impeding the movements of the body, the diseased integument should be carefully dissected off, and a splint applied (if on a limb) during the skinning process. In cases of hypertrophied cicatrix (cheloide) compression should be adopted, or if that is not practicable, the Tr. iodin. should be pencilled on the skin every second day. VESICATION FROM EXTERNAL IRRITANTS. Lytta—Gum plasters—Linseed poultice—Severe friction or pressure—Caustic— Mercury—Cubebs—Crolon oil. Between the blister and the tender skin of children, thin gauze, or gauze paper, should be applied, or they should be removed at the third, fourth, or fifth hour. Vesication will occur, although not then visible. If ulceration is deep and spreading, with irritation, fever, or convulsion, French roll poultice should be applied ; aperients, and the anodyne mixture (8) each fourth or fifth hour. If sloughing occur, the balsam of peru may be strewed on the poultice. If fun- gous or bleeding granulations arise, the arg. nitr. should be applied; and, if they are not extensive, excision with sharp scissors or bistoury. The effect of gum plaster, or linseed poultice, will often be a pustule ; friction and pressure ring the part, i. e., produce a bulla; caustic is a slight burn, of the third form. Cubebs produce vesicles on a light vermillion ground, so also do frictions with mercurials; the biniodide of mercury, however, excites yellow vesicles, terminating in green crusts or scales. Croton will produce vesicles, and puffing of the skin. For these lesions, I would generally enjoin rest and the removing the sources of irritation, poppy fomentation, laxatives, and diapho- retic anodynes. PER1NO. Chilblain. A tumefaction of a deep dull crimson, or leaden tinge, accompa- nied by a sensation of tingling, often acutely aching and painful: usually occurring on the toes, or fingers, or heel, or outside of the 80 DENDY ON DISEASES OF THE SKIN. foot; the parts adjacent being often somewhat oedematous. The exciting cause (intense, or even moderate cold in children predis- posed) is followed by congestion of the superficial vessels, the reac- tion, to open the capillaries, producing an inflammatory condition; which will either remain in a languid chronic form, during the prevalence of cold, or become acutely inflamed, and terminate in ulceration, sometimes penetrating to the fascia and tendons, and even to the bone. Prevention. Sudden transitions of temperature avoided. The extremities defended from the air by wash-leather, or woollen socks and gloves; gentle friction in parts or systems predisposed, with liniment, saponis, lin. camphor., or spt. camphorae; regulating the functions of the bowels. Exercise. Treatment. In mild cases, simple friction and defence, as above, with the liniments. Or the following, which is often very effica- cious : 3<. Tr. lytt. ^ss.: Lin. sapon. giij.: Spt. camph. ^ss. Adding, if the itching be intense, vin. opii gss. In unhealthy and debilitated habits the following plan should be adopted:— The swelling to be covered with cerat. cetacei, over this to be laid lint or rag well wetted with the alkaline chlorides. On the occurrence of vesication, an emollient poultice, the fluid evacuated by puncture; and after the repetition of poultices for three or four days, if ulceration occurs, ungt. calaminae applied on singed rag twice in the day; the part bathed well with warm water previously to the application. If the surface of the sore be glassy, and its edges ragged, the ungt. zinci, or lot. arg. nitr. should be applied. In very stubborn and protracted ulceration, a lotion of the chlorid. calc. will be useful. Mild laxatives should be often given; and if there be restlessness, irritation, or pain, the anodyne mixture (8). PARONYCHIA. Onychia—Panaritium—Whitlow—Felon. An inflammatory tumour, usually seated near the extremity of the toe or finger, near the root of the nail. It is attended by varied degrees of pain and constitutional disturbance; its degree somewhat depending on diathesis, but chiefly on the sensibility of the tissue affected, and the depth or extent of the disease. When seated in the cutis we have the signs of slight phlegmon, heat, pain, tension, and redness, erethism or irritative fever, rapidly terminating in suppuration, marked by a semitransparent elevation of the cuticle. When seated beneath the cutis, in the cellular web, the symp- toms are more severe; the constitutional disturbance amounts to PARONYCHIA. 81 fever, often with distinct rigors; the suppurative process is slower of course in its .progress towards the surface, and often extends laterally, burrowing beneath the nail. When seated in the theca or synovial sheaths, the character of the disease is more marked; pain is deeply seated, often intense. bever is acute, the rigors severe, and often recurring at the onset. The swelling is more extensive, often spreading to the fore-arm or leg; distinct red lines marking absorbent inflammation, even to the axilla or groin. At this period convulsive action often ensues, and extreme restlessness, delirium, and other signs of cerebral disturb- ance. From the unyielding nature of the tissues, the matter which is formed does not approach the surface, but burrows along the syno- vial sheaths, or tendinous thecae, producing extensive sinuses, with thickening and loss of motion of the joints in the vicinity, some- times affecting the periosteum, and producing caries in the subja- cent bone. Causes. It is often arising spontaneously in healthy persons, without constitutional disturbance; or from gastric disorder; or it maybe critical of acute fever. External injuries, however, as con- tusion, or puncture, or acrid stimuli, or retention of extraneous substance, will often be its cause. Treatment—preventive. Extraneous substances extracted ; if from local injuries, poultices, antiphlogistic lotions of liq. plumb., spt., rect., and Tr. opii.; leeches; laxatives. If symptomatic of gastric disorder, this mode combined with remedies appropriate to the primary disorder. This mode will prevent developement. When critical of acute disorder it will be safer to allow their full developement, guarding the system from excitement, from local irritation, and debility from exhaustion. Of the Cutaneous, or Superficial. Treatment —curative. Moist warmth constantly communicated by bread or linseed poultices, or warm water. Incision, when sup- puration is complete; evacuation of matter; removal of the cuticle; ungt. calaminae, over which a warm bread poultice should be applied for three hours every morning. Of the Sub-cutaneous, or Cellular Membranous. The incision should be deeply made through the cellular mem- brane even to the periosteum; and if the pus has burrowed under the nail, a portion of that should be elevated or excised. Laxatives and diaphoretics, and anodynes at night. Of the Thecal. The sheath freely divided with the scalpel. If the bone be carious, or the tendons or thecae sloughing, poultices of bread and ol. tere- binthinae should be applied for a few days, succeeded by those of bread and water, or linseed; and these followed by the black or yellow wash. 82 DENDY ON DISEASES OF THE SKIN. If there exist a fistulous sore after a partial healing of the whit- low, the arg. nitrat. should be rubbed on the sore or inflamed parts every, or every second, morning; mild poultices being assiduously applied. In cases of exhaustion, tonics and change of air. PTERYQION. Fungous excrescence—Fleshy caruncle—Growth of the nail into the flesh. A fungous growth, arising from the soft parts contiguous to the nail; the result of inflammation, often of the deep cellular mem- branous whitlow. The nail is seldom altered in its form or size; but as the fungus increases, it tends to increase also the morbid mass by irritation. Treatment. Removal of pressure; rest; frequent warm bath- ing of the feet or hands. In slight cases, the application of arg. nitr. every second or third day, the nail being previously pared with great care, or a small triangular piece excised from the centre of its edge, so that its out- ward pressure may be lessened. If the fungus still increase in defiance of this mode, the nail should be cautiously cut through with a small sharp knife, without wounding or dividing the cuticle interposed beneath its under sur- face and the sensitive tissue beneath it; the nail may then be raised, and detached by a minute pair of forceps. The occasional administration of calomel, or byd. cm. cret. and the decoct, sarsae C. may often accelerate the effect we desire. VERRUCA. Common Wart. An irregular, rugose, or fissured tumour ; the effect of chronic in- flammation of the vessels of the cutis, in which tissue the base is seated. They often appear in clusters, and apparently spread from a sort of inoculation. They are usually inert, and free from pain; but sometimes excite an erysipelatous blush around them, or an ulcerative process, which is sometimes productive of a cure by shelling out the wart. They are occasionally absorbed. Treatment. A blister applied for thirty or forty hours. Excision, if the base be broad, and the application of caustic; or, a ligature or excision, if attached by a narrow peduncle. If very extensive, or seated near important parts, the argenti nitras should be very carefully employed. CLAVUS. Corn. An indurated and laminated condition of the cuticle, caused by external pressure: its base producing sometimes a corresponding depression in the cutis, and marked by a hard central nucleus or core, termed the "Bird's Eye." They are often aggravated by INTERTRIGO--UH AG HADES—CONDYLOMA. 83 atmospheric changes, and become acutely painful. The toes and sole are the most common seat, and if they are between the toes they are softer, from the secretion of the part. The lips of trump- eters, the fingers of harpers, and even the ear, from pressure of the ring, are sometimes affected by them. Inflammatory action, which often takes place, increases the degree of pain, but in the end ren- ders the corn softer, and may terminate in a suppuration and shell- ing out of the indurated mass. Treatment. Removal of pressure. Greatly filing the corn, and then applying a mild diachylon plaster. The most effectual mode is—immersion of the foot in warm water, paring off the in- durated laminae, and then rubbing the surface with argenti nitras for three or five minutes; the process to be repeated, on the separa- tion of the eschar, until the hardness is removed. The paring off, or excision, must be carefully performed; a ten- don may be wounded ; a small joint may be opened ; or inflamma- tion, and even fatality, be produced by too deep an incision. INTERTRIGO (Chafing.) — RHAGHADES (Chap.)—CONDYLOMA (Anal excrescence.) Intertrigo. Excoriation in the folds of the skin, chiefly in the groins, peri- neum, and neck; dependent in some degree on peculiar irritability of skin, and excited by friction, heat, or acrid moisture. These excoriations should be dusted with starch powder, or liq. plumb, sac, much diluted with elder-flower or rose water, lightly applied on soft rag, twice or thrice in a day. Manna, or magnesia, sufficient to act slightly on the bowels. Rhaghades. Fissures, often bleeding, on an irritable skin, arising from cold air or wafer—chiefly in winter. Wash-leather, or oil-silk gloves; ungt. plumbi; or cold cream. Condyloma. An indurated, flattish tumor, at the verge of the anus; usually circular at the edge of the sphincter. It is caused by irritation of the excretions from the bowels, or of ascarides within the rectum; which, if long applied, will cause the swelling to degenerate into a fissured and bleeding excrescence. Poultices; or constant tepid ablution, in the early stage. The powder if)', castor oil as a laxative; and in weakly children, the mild vegetable tonics. . If the tumour is of long duration, the local applications should be lotio flava ; or lot. arg. nitrat. 84 DENDY ON DISEASES OF THE SKIN. MACULE. NJ3VUS. Vascular nrevus—Mother's mark. A preternatural increase and free anastomosis of the vascular rete of the skin, or cellular tissue: varicose, or erectile pulsatory swellings. They are not confined to the external cuticle, but are sometimes extending into the mucous epithelium of the lips or mouth. In some cases these capillaries are widely spread and tortuous, like the legs of a spider ; in others, small, granular, defined red tumours ; in others, a bluish-red swelling, a congeries of veins; or, a crimson tumour, rapidly rising again when pressure is removed. This last, the erectile tumour, has usually a broad base, and grows slowly, unless it be irritated or bruised, when it may become rapidly enlarged. When the vessels are large, and near a considerable trunk, (aneurism by anastomosis,) they pulsate powerfully beneath the fingers, and are attended by a thrilling pur, synchronous with the heart; and for their removal may require the ligature of the arte- rial trunk from which the vessels are derived. The vascular naevus will sometimes spontaneously disappear by absorption, when it is diminutive; and ulceration will occasionally terminate in its spontaneous removal, lymph being effused to close the vessels as the ulcerative process proceeds. Treatment. Cold lotion ; pressure ; iodine ; ligature ; simple puncture; vaccination; caustic; extirpation. If naevi increase rapidly, are seated on parts subject to pressure or contusion, or ob- struct muscular action, their removal should be adopted without delay. In minute and inactive naevi, constant application of cold spring water, or liq. plumb, ac. d. on folded linen ; or pressure, by firmly binding down sheet lead on the part, if seated over a bone ; or the more speedy mode of extirpation by the knife, the haemorrage being stopped by pressure, or argenti nitras. Extirpation may prove dangerous where the tumour is seated close to a trunk, especially if connected with it by a large artery. In larger naevi, it will be essential to strangulate the tumour by ligature; or obliterate the cells by adhesive inflammation; or by destroying the tissues with caustic. If the base of the swelling be narrow, a simple ligature is the easiest mode. If the base be large, a needle, armed with a double ligature, should be passed under the base of the tumour, and the threads tied around each hemisphere, and tightened as they become loosened by ulceration; or a hare-lip pin may be passed under the naevus; NAEVUS. 85 then a needle and double ligature under that at right angles; the needle being withdrawn, the silks are then tied tightly, and twisted round the pin twice or thrice. When the part is killed, it will often be necessary to remove the ligature, especially if great pain be produced, and convulsion seem to be impending; or if the bulk of the tumour be considerable, it will be judicious in two or three days, if the strangulation is complete, to remove it by degrees, or at once, with a scalpel; if this is safely effected, the constitutional symptoms will be usually much relieved. The tissue of vascular naevi possesses a degree of insensibility which will allow ligatures, extensively applied perpendicular to their base, to remain even for months without ulceration; but ab- sorption will usually at length ensue. If the naevus do not exceed the size of a common marble, punc- ture, vaccination, or caustic may be resorted to. The puncture may be made by introducing a cataract needle obliquely beneath the skin, and then moving it about so as to de- stroy the sub-cutaneous tissue, and thus, by the effusion of lymph, obliterate the cells. It is by this obliteration, too, that vaccination is efficacious; the surface of the naevus must be studded with the punctures, that the coalescence of adhesion may completely obliterate the naevous tissue. The pustulus excited by the ungt. ant. tart, would probably pro- duce a somewhat similar effect. The caustic should not be applied in the immediate vicinity of delicate organs, as the eye, &c.; and at all times must be used with caution. Adhesive plaster is applied closely over the naevus, with an orifice less than its circumference. The kali purum is rubbed on till slight discolouration appears; plaster is then tightly pressed on the part, and suffered to remain for some days. Where the naevus is flat, one of its largest vessels may be punc- tured ; the kali purum finely pointed is passed into the orifice, and vinegar is immediately applied, to stop its escharotic progress, and prevent a scar. Laxatives should always be administered previous to the opera- tion. The child should be free from fever, and in good health, and it should have attained its third month at least. As in all other operations, where pain, restlessness, fever, or undue inflammation are produced, it will of course be essential to administer anodynes, laxatives, and diaphoretics, until the ligatures, or other sources of irritation, are removed, or drop off. When the naevus is a mere stain, it has been proposed to tattoo the skin with white lead and cinnabar. LENTIGO. Lenticula—Freckles. From exposure to the sun's rays. Small round spots, or exten- 86 DENDY ON DISEASES OF THE SKIN. sive patches of tawny yellow, almost peculiar to fair and florid com- plexions ; the hair being sandy, or auburn. Seldom occurring in parts which are covered. Treatment.—Defence from the rays of the sun. Lotions of spt. rect. or liq. potassae in aq. rosae. Nitro-muriatic acid lotion, or the sulphureo-gelatinous bath. TINGE OF ARGENTI NITRAS. From the internal use of lunar caustic. A cerulean hue gardu- ally deepening to violet, dingy purple, or even a purplish-black ; usually commencing about the face, and parts exposed to light; sometimes tinging the sclerotic, and even, though rarely, the tongue and fauces. The hue is lessened by raising the arm; although, as the blood itself is not tinged, this is probably effected by rapid ab- sorption. The discoloration does not depend on magnitude of dose so much as periods. Two, or at most, three months, should be the limit of its use. It does not always appear soon after the undue employment, but three months, and even three years have elapsed ere it has com- menced. It is removable only in a slight degree, by frequent use of the nitro-muriatic acid bath. FORMULA PULVERES. *** The upper figures denote the years of age. The lower, the number of parcels into which the mass is to be divided.—These doses are adapted to each prescription. I. III. VI. VI. IV. II. 1.+ Pulvis Aperiens.—Hydrarg. subm. gr. iij.: Pulv. jalap, gr. vj.: Rhsi, gr. xij.: Cinnarn. gr. x.: Interdum adde pulv. scamm. c. 9j. Div. 2. Pulvis Rhai Comp.—Falv. rhaei, gr. vj.: Cinnam. gr. xij.: Sod* subcarbon.gr. xij.: Hydr. cum cret. gr. x. Div.: o. n. vel 2da- n. 3. Pulvis Potassce Comp.—Potassae sulph. 9j.: Pulv. rhaei gr iv • Ipec c. gr. v.: Contrayerv. c. gr. xvj. Div.: o. n. ' 4. Pulvis Astringens.—Sodse subcarb. gr. xij.: Pulv. ipecac c er iv ■ Cretaec. gr. xvj.: Hydrarg. cum cret. gr. vj.: Interdum adde P. e.cret c cum opio, gr. vnj.: vel P. e. Kino c. gr. x. Div.: 5 vel 6 horis, caute\ t These figures are referred to in the directions for treatment. FORMULAE. 87 5. Pulv. Digitalis Comp.—Hydr. subraur. gr. iv.: Pulv. digitalis, gr. ij.: Jacobi v. gr. vj.: Sacch. alb. gr. xij.: o. n. vel 2d»- n. Div. : vel bis indies, caute. 6. Pulvis Tonic. Veget.—Palv. calomb. gr. x.: duinin. sulph. gr. ijss. : Sodae subcarb. gr. x. Div.. bis indies. 7. Pulvis Tonic. Mineral.—Ferri sulph. exsicc. gr. vij.: Potass, sulph. gr. xij.: Pulv. cascarill. gr. xvj. Div.: bis indies. MISTURiE. %* The upper figures denote the years of age. The lower, the number of dessert spoonfuls ap- propriate to each.—These doses are adapted to each prescription. I. II. IV. VI. I. II. III. VI. 1. Mistura Carminitiva.—Magnes. sulphat. 9ij.: Carbonat. 9j.: Tr. cardamom, c. ^ij. : Spt. aetheris c. Jj.: 01. anisi, 111 ij.: Syrup, violae, giij.: Infus. cinnam. Jijss. M.: 2 Yel 4 horai durante dolore. 2. Mistura Aperiens.—Magnes. sulphat. giij.: Subcarb. Jss.: Syrup. rhaei, gss. : Aq. distillat. giij. M. 3. Mistura Astringens Anodyn.—Magnes. subcarb. 9ss.: Cretae ppt.gr. xxiv. : Spt. ammon. arom. Jss.: Tr. Asafoet. gss : Syrup, papav. 2;ij.: Mucil. acac. ^iijss.: Interdum adde pulv. cretae c. cum opio, gr. xij.: vel Tr. catechu, giss. M.: 3, 4, vel 5 horis. 4. Mistura Alkalin, Anodyn.—Tr. opii 1T[x.: Liq. potass. 3j.: Spt. myrist. Jjij.: Syrup, rhoead. gij.: Mucil. acac. §iijss. M.: 4 vel 6 horis. 5. Mistura Tonic.—Acid, sulphur, arom. 3j.: Syrup, aurant. giij.: Infus. cascarill. et calomb. ^iijss. M.: ter indies. 6. Mistura Tragacanthce c.—Mucil. tragacanth. ^iijss.: Pulv. potassae nitr. 3ss. : Vin. ipecac. Hj.xl.: Tr. hyoscyam. 1t[xx.: Camphor. C. 3j.: Oxymel scill. 3j.: Syrup, tolut. ^ij.: Interdum adde liq. ant. tart. rr\,xx.: vel acid, hydrocyan. TTLiv. M.: 3 vel 4 horis. 7. Mistura Diaphoretica.—Liq. ammon. acet. ^ss.: Antimon. tart. lUxviij.: Vin. ipec. 1TLxx.: Pulv. potassae nitr. Qij.: Tr. digital. 1T[xx.: Syrup, limon. ^ss. M.: 4, 5, vel 6 horis. 8. Mistura Diaphoret. Anodyn.—Mist, camphorae. ^ij.: Tr. camphor, c. 3j.: Humuli, 3j.: Vin. ipec. H[xl. : Liq. am. acet. -Jv.: Syrup, papav. gij. M.: 4, 5, vel 6 horis. 9. Mistura Hydriodatis Potass.—Pot. hydriod. gr. viij. ad xij.: Syrup. aurant. jfss.: Aq. flor. aurant. ^ijss. M. : bis terve indies, caute. 10. Mistura Amygdalce c.—Emuls. amygd. ^iijss.: Tr. camphorae c. jij.: Spt. aetheris nit. 3ij.: Syrup, tolutan. giij. M.: 3, 4, vel 5 horis. LOTIONES. 1. Lotio Argenti Nitrat.—Argenti nitr. gr. j. ad iv.: Aquae ros. 3j. 2. Lotio Sedativa.—Liq. plumb, subac. 3ij.: Ammon. acet. Jij.: Aq. rosae|iijss. , . T. 3. Lotio Astringens.—Ammon. munat. 3j.: Liq. ammon. acet. § j.: Aq. flor. sambuc. ^ivss. 88 DENDY ON DISEASES OF THE SKIN. 4. Lotio Acidi Nitrici.—Acid. nitr. 3ss. ad 3j. : Aq. distillat. 3j. 5. Lotio Alkalina.—Liq. potass. 3jss. : Aq. flor. samb. 3j. 6. Lotio Flava.—•Hydrarg. oxym. gr. iij.: Liq. calcis, ^ijss. 7. Collyrium Sedativum.—Liq. plumb, subac. 3j.: Aq. rosae, gijss.: tepide utend. 8. Collyrium Astringens.—Z'mci sulph. gr. v.: Vin. opii, TTLxx.: Aq. rosae, |ij. 1. Gargarisma Stimidans.—Tr. capsici a. 3ss. ad 3J. : Aluminis, 9ij.: Mellis, gss.: Aq. pur. giij. 2. Gargarisma Commune.—Mel. boracis, §ss.: Tr. myrrhae, 3ij.: Acid. sulph. dil. rn_xij.: Mucilag. acac. £iij. BALNEA. 1. Bain. Acid. Nitro-muriatic.—Acid, nitric. §iij. : Acid, muriat. %'].: Warm water sufficient to reduce the bath to the acidity of distilled vinegar. 2. Balneum Alkalinum.—Potass, subcarb. ^iv. ad ^viij.: Aq. cong. xxx. 3. Balneum Sublimat.—Hydr. oxymur. gij. ad ^iv.: Aq. cong. xxx. 4. Balneum Sulphureo-gelatin.—Potass, vel sod. sulphuret. f ij. ad %W.: Icthyocoll. 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